hospital_name,last_updated_on,version,location_name,hospital_address,type_2_npi,license_number|NM,"To the best of its knowledge and belief, this hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date in the file. This hospital has included all payer-specific negotiated charges in dollars that can be expressed as a dollar amount. For payer-specific negotiated charges that cannot be expressed as a dollar amount in the machine-readable file or not knowable in advance, the hospital attests that the payer-specific negotiated charge is based on a contractual algorithm, percentage or formula that precludes the provision of a dollar amount and has provided all necessary information available to the hospital for the public to be able to derive the dollar amount, including, but not limited to, the specific fee schedule or components referenced in such percentage, algorithm or formula.",attester_name,financial_aid_policy,,,,,,,,,,,,,,,,,,,
Presbyterian Healthcare Services,4/1/2026,3.0.0,Presbyterian Hospital,"1100 Central Avenue Se, Albuquerque, NM 87106",1215913470,6022,TRUE,Laura Calkins,30% off of facility standard gross charges.,,,,,,,,,,,,,,,,,,,
description,code|1,code|1|type,code|2,code|2|type,code|3,code|3|type,code|4,code|4|type,billing_class,setting,drug_unit_of_measurement,drug_type_of_measurement,modifiers,standard_charge|gross,standard_charge|discounted_cash,payer_name,plan_name,standard_charge|negotiated_dollar,standard_charge|negotiated_percentage,standard_charge|negotiated_algorithm,median_amount,10th_percentile,90th_percentile,count,standard_charge|methodology,standard_charge|min,standard_charge|max,additional_generic_notes
Performance Measure Exclusion Modifier due to Medical Reasons,,,,,,,,,facility,both,,,1P,,,Aetna,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Performance Measure Exclusion Modifier due to Medical Reasons,,,,,,,,,facility,both,,,1P,,,Aetna,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Performance Measure Exclusion Modifier due to Medical Reasons,,,,,,,,,facility,both,,,1P,,,BCBS,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Performance Measure Exclusion Modifier due to Medical Reasons,,,,,,,,,facility,both,,,1P,,,BCBS,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Performance Measure Exclusion Modifier due to Medical Reasons,,,,,,,,,facility,both,,,1P,,,Care Improvement Plus,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Performance Measure Exclusion Modifier due to Medical Reasons,,,,,,,,,facility,both,,,1P,,,Cigna,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Performance Measure Exclusion Modifier due to Medical Reasons,,,,,,,,,facility,both,,,1P,,,Cigna,HealthSpring Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Performance Measure Exclusion Modifier due to Medical Reasons,,,,,,,,,facility,both,,,1P,,,Molina Healthcare,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Performance Measure Exclusion Modifier due to Medical Reasons,,,,,,,,,facility,both,,,1P,,,Multiplan/PHCS,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Performance Measure Exclusion Modifier due to Medical Reasons,,,,,,,,,facility,both,,,1P,,,Presbyterian Health Plan,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Performance Measure Exclusion Modifier due to Medical Reasons,,,,,,,,,facility,both,,,1P,,,Presbyterian Health Plan,Capitated Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Performance Measure Exclusion Modifier due to Medical Reasons,,,,,,,,,facility,both,,,1P,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Performance Measure Exclusion Modifier due to Medical Reasons,,,,,,,,,facility,both,,,1P,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Performance Measure Exclusion Modifier due to Medical Reasons,,,,,,,,,facility,both,,,1P,,,Presbyterian Health Plan,Medicare Managed Care - HMO,,,,,,,,,,,The modified price is presented in the standard charge value.
Performance Measure Exclusion Modifier due to Medical Reasons,,,,,,,,,facility,both,,,1P,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Performance Measure Exclusion Modifier due to Medical Reasons,,,,,,,,,facility,both,,,1P,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Performance Measure Exclusion Modifier due to Medical Reasons,,,,,,,,,facility,both,,,1P,,,UnitedHealthCare,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Performance Measure Exclusion Modifier due to Medical Reasons,,,,,,,,,facility,both,,,1P,,,UnitedHealthCare,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Performance Measure Exclusion Modifier due to Medical Reasons,,,,,,,,,facility,both,,,1P,,,UnitedHealthCare,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Performance Measure Exclusion Modifier due to Medical Reasons,,,,,,,,,facility,both,,,1P,,,Wellpoint,formerly Amerigroup Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Performance Measure Exclusion Modifier due to Medical Reasons,,,,,,,,,facility,both,,,1P,,,Western Sky Community Care,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Performance Measure Exclusion Modifier due to Medical Reasons,,,,,,,,,facility,both,,,1P,,,Zelis,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service",,,,,,,,,facility,both,,,25,,,Aetna,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service",,,,,,,,,facility,both,,,25,,,Aetna,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service",,,,,,,,,facility,both,,,25,,,BCBS,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service",,,,,,,,,facility,both,,,25,,,BCBS,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service",,,,,,,,,facility,both,,,25,,,Care Improvement Plus,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service",,,,,,,,,facility,both,,,25,,,Cigna,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service",,,,,,,,,facility,both,,,25,,,Cigna,HealthSpring Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service",,,,,,,,,facility,both,,,25,,,Molina Healthcare,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service",,,,,,,,,facility,both,,,25,,,Multiplan/PHCS,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service",,,,,,,,,facility,both,,,25,,,Presbyterian Health Plan,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service",,,,,,,,,facility,both,,,25,,,Presbyterian Health Plan,Capitated Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service",,,,,,,,,facility,both,,,25,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service",,,,,,,,,facility,both,,,25,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service",,,,,,,,,facility,both,,,25,,,Presbyterian Health Plan,Medicare Managed Care - HMO,,,,,,,,,,,The modified price is presented in the standard charge value.
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service",,,,,,,,,facility,both,,,25,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service",,,,,,,,,facility,both,,,25,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service",,,,,,,,,facility,both,,,25,,,UnitedHealthCare,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service",,,,,,,,,facility,both,,,25,,,UnitedHealthCare,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service",,,,,,,,,facility,both,,,25,,,UnitedHealthCare,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service",,,,,,,,,facility,both,,,25,,,Wellpoint,formerly Amerigroup Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service",,,,,,,,,facility,both,,,25,,,Western Sky Community Care,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service",,,,,,,,,facility,both,,,25,,,Zelis,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Professional Component,,,,,,,,,facility,both,,,26,,,Aetna,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Professional Component,,,,,,,,,facility,both,,,26,,,Aetna,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Professional Component,,,,,,,,,facility,both,,,26,,,BCBS,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Professional Component,,,,,,,,,facility,both,,,26,,,BCBS,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Professional Component,,,,,,,,,facility,both,,,26,,,Care Improvement Plus,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Professional Component,,,,,,,,,facility,both,,,26,,,Cigna,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Professional Component,,,,,,,,,facility,both,,,26,,,Cigna,HealthSpring Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Professional Component,,,,,,,,,facility,both,,,26,,,Molina Healthcare,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Professional Component,,,,,,,,,facility,both,,,26,,,Multiplan/PHCS,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Professional Component,,,,,,,,,facility,both,,,26,,,Presbyterian Health Plan,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Professional Component,,,,,,,,,facility,both,,,26,,,Presbyterian Health Plan,Capitated Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Professional Component,,,,,,,,,facility,both,,,26,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Professional Component,,,,,,,,,facility,both,,,26,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Professional Component,,,,,,,,,facility,both,,,26,,,Presbyterian Health Plan,Medicare Managed Care - HMO,,,,,,,,,,,The modified price is presented in the standard charge value.
Professional Component,,,,,,,,,facility,both,,,26,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Professional Component,,,,,,,,,facility,both,,,26,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Professional Component,,,,,,,,,facility,both,,,26,,,UnitedHealthCare,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Professional Component,,,,,,,,,facility,both,,,26,,,UnitedHealthCare,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Professional Component,,,,,,,,,facility,both,,,26,,,UnitedHealthCare,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Professional Component,,,,,,,,,facility,both,,,26,,,Wellpoint,formerly Amerigroup Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Professional Component,,,,,,,,,facility,both,,,26,,,Western Sky Community Care,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Professional Component,,,,,,,,,facility,both,,,26,,,Zelis,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Reduced Services,,,,,,,,,facility,both,,,52,,,Aetna,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Reduced Services,,,,,,,,,facility,both,,,52,,,Aetna,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Reduced Services,,,,,,,,,facility,both,,,52,,,BCBS,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Reduced Services,,,,,,,,,facility,both,,,52,,,BCBS,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Reduced Services,,,,,,,,,facility,both,,,52,,,Care Improvement Plus,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Reduced Services,,,,,,,,,facility,both,,,52,,,Cigna,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Reduced Services,,,,,,,,,facility,both,,,52,,,Cigna,HealthSpring Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Reduced Services,,,,,,,,,facility,both,,,52,,,Molina Healthcare,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Reduced Services,,,,,,,,,facility,both,,,52,,,Multiplan/PHCS,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Reduced Services,,,,,,,,,facility,both,,,52,,,Presbyterian Health Plan,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Reduced Services,,,,,,,,,facility,both,,,52,,,Presbyterian Health Plan,Capitated Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Reduced Services,,,,,,,,,facility,both,,,52,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Reduced Services,,,,,,,,,facility,both,,,52,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Reduced Services,,,,,,,,,facility,both,,,52,,,Presbyterian Health Plan,Medicare Managed Care - HMO,,,,,,,,,,,The modified price is presented in the standard charge value.
Reduced Services,,,,,,,,,facility,both,,,52,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Reduced Services,,,,,,,,,facility,both,,,52,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Reduced Services,,,,,,,,,facility,both,,,52,,,UnitedHealthCare,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Reduced Services,,,,,,,,,facility,both,,,52,,,UnitedHealthCare,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Reduced Services,,,,,,,,,facility,both,,,52,,,UnitedHealthCare,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Reduced Services,,,,,,,,,facility,both,,,52,,,Wellpoint,formerly Amerigroup Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Reduced Services,,,,,,,,,facility,both,,,52,,,Western Sky Community Care,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Reduced Services,,,,,,,,,facility,both,,,52,,,Zelis,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Distinct Procedural Service,,,,,,,,,facility,both,,,59,,,Aetna,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Distinct Procedural Service,,,,,,,,,facility,both,,,59,,,Aetna,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Distinct Procedural Service,,,,,,,,,facility,both,,,59,,,BCBS,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Distinct Procedural Service,,,,,,,,,facility,both,,,59,,,BCBS,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Distinct Procedural Service,,,,,,,,,facility,both,,,59,,,Care Improvement Plus,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Distinct Procedural Service,,,,,,,,,facility,both,,,59,,,Cigna,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Distinct Procedural Service,,,,,,,,,facility,both,,,59,,,Cigna,HealthSpring Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Distinct Procedural Service,,,,,,,,,facility,both,,,59,,,Molina Healthcare,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Distinct Procedural Service,,,,,,,,,facility,both,,,59,,,Multiplan/PHCS,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Distinct Procedural Service,,,,,,,,,facility,both,,,59,,,Presbyterian Health Plan,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Distinct Procedural Service,,,,,,,,,facility,both,,,59,,,Presbyterian Health Plan,Capitated Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Distinct Procedural Service,,,,,,,,,facility,both,,,59,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Distinct Procedural Service,,,,,,,,,facility,both,,,59,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Distinct Procedural Service,,,,,,,,,facility,both,,,59,,,Presbyterian Health Plan,Medicare Managed Care - HMO,,,,,,,,,,,The modified price is presented in the standard charge value.
Distinct Procedural Service,,,,,,,,,facility,both,,,59,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Distinct Procedural Service,,,,,,,,,facility,both,,,59,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Distinct Procedural Service,,,,,,,,,facility,both,,,59,,,UnitedHealthCare,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Distinct Procedural Service,,,,,,,,,facility,both,,,59,,,UnitedHealthCare,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Distinct Procedural Service,,,,,,,,,facility,both,,,59,,,UnitedHealthCare,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Distinct Procedural Service,,,,,,,,,facility,both,,,59,,,Wellpoint,formerly Amerigroup Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Distinct Procedural Service,,,,,,,,,facility,both,,,59,,,Western Sky Community Care,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Distinct Procedural Service,,,,,,,,,facility,both,,,59,,,Zelis,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Medical supervision by a physician: more than four concurrent anesthesia procedures,,,,,,,,,facility,both,,,AD,,,Aetna,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Medical supervision by a physician: more than four concurrent anesthesia procedures,,,,,,,,,facility,both,,,AD,,,Aetna,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Medical supervision by a physician: more than four concurrent anesthesia procedures,,,,,,,,,facility,both,,,AD,,,BCBS,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Medical supervision by a physician: more than four concurrent anesthesia procedures,,,,,,,,,facility,both,,,AD,,,BCBS,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Medical supervision by a physician: more than four concurrent anesthesia procedures,,,,,,,,,facility,both,,,AD,,,Care Improvement Plus,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Medical supervision by a physician: more than four concurrent anesthesia procedures,,,,,,,,,facility,both,,,AD,,,Cigna,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Medical supervision by a physician: more than four concurrent anesthesia procedures,,,,,,,,,facility,both,,,AD,,,Cigna,HealthSpring Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Medical supervision by a physician: more than four concurrent anesthesia procedures,,,,,,,,,facility,both,,,AD,,,Molina Healthcare,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Medical supervision by a physician: more than four concurrent anesthesia procedures,,,,,,,,,facility,both,,,AD,,,Multiplan/PHCS,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Medical supervision by a physician: more than four concurrent anesthesia procedures,,,,,,,,,facility,both,,,AD,,,Presbyterian Health Plan,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Medical supervision by a physician: more than four concurrent anesthesia procedures,,,,,,,,,facility,both,,,AD,,,Presbyterian Health Plan,Capitated Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Medical supervision by a physician: more than four concurrent anesthesia procedures,,,,,,,,,facility,both,,,AD,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Medical supervision by a physician: more than four concurrent anesthesia procedures,,,,,,,,,facility,both,,,AD,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Medical supervision by a physician: more than four concurrent anesthesia procedures,,,,,,,,,facility,both,,,AD,,,Presbyterian Health Plan,Medicare Managed Care - HMO,,,,,,,,,,,The modified price is presented in the standard charge value.
Medical supervision by a physician: more than four concurrent anesthesia procedures,,,,,,,,,facility,both,,,AD,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Medical supervision by a physician: more than four concurrent anesthesia procedures,,,,,,,,,facility,both,,,AD,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Medical supervision by a physician: more than four concurrent anesthesia procedures,,,,,,,,,facility,both,,,AD,,,UnitedHealthCare,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Medical supervision by a physician: more than four concurrent anesthesia procedures,,,,,,,,,facility,both,,,AD,,,UnitedHealthCare,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Medical supervision by a physician: more than four concurrent anesthesia procedures,,,,,,,,,facility,both,,,AD,,,UnitedHealthCare,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Medical supervision by a physician: more than four concurrent anesthesia procedures,,,,,,,,,facility,both,,,AD,,,Wellpoint,formerly Amerigroup Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Medical supervision by a physician: more than four concurrent anesthesia procedures,,,,,,,,,facility,both,,,AD,,,Western Sky Community Care,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Medical supervision by a physician: more than four concurrent anesthesia procedures,,,,,,,,,facility,both,,,AD,,,Zelis,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
"Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery",,,,,,,,,facility,both,,,AS,,,Aetna,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
"Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery",,,,,,,,,facility,both,,,AS,,,Aetna,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery",,,,,,,,,facility,both,,,AS,,,BCBS,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
"Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery",,,,,,,,,facility,both,,,AS,,,BCBS,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery",,,,,,,,,facility,both,,,AS,,,Care Improvement Plus,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery",,,,,,,,,facility,both,,,AS,,,Cigna,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
"Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery",,,,,,,,,facility,both,,,AS,,,Cigna,HealthSpring Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery",,,,,,,,,facility,both,,,AS,,,Molina Healthcare,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery",,,,,,,,,facility,both,,,AS,,,Multiplan/PHCS,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
"Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery",,,,,,,,,facility,both,,,AS,,,Presbyterian Health Plan,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
"Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery",,,,,,,,,facility,both,,,AS,,,Presbyterian Health Plan,Capitated Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery",,,,,,,,,facility,both,,,AS,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery",,,,,,,,,facility,both,,,AS,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery",,,,,,,,,facility,both,,,AS,,,Presbyterian Health Plan,Medicare Managed Care - HMO,,,,,,,,,,,The modified price is presented in the standard charge value.
"Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery",,,,,,,,,facility,both,,,AS,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery",,,,,,,,,facility,both,,,AS,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery",,,,,,,,,facility,both,,,AS,,,UnitedHealthCare,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
"Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery",,,,,,,,,facility,both,,,AS,,,UnitedHealthCare,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery",,,,,,,,,facility,both,,,AS,,,UnitedHealthCare,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery",,,,,,,,,facility,both,,,AS,,,Wellpoint,formerly Amerigroup Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery",,,,,,,,,facility,both,,,AS,,,Western Sky Community Care,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery",,,,,,,,,facility,both,,,AS,,,Zelis,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Item or service furnished to an esrd patient that is not for the treatment of esrd,,,,,,,,,facility,both,,,AY,,,Aetna,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Item or service furnished to an esrd patient that is not for the treatment of esrd,,,,,,,,,facility,both,,,AY,,,Aetna,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Item or service furnished to an esrd patient that is not for the treatment of esrd,,,,,,,,,facility,both,,,AY,,,BCBS,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Item or service furnished to an esrd patient that is not for the treatment of esrd,,,,,,,,,facility,both,,,AY,,,BCBS,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Item or service furnished to an esrd patient that is not for the treatment of esrd,,,,,,,,,facility,both,,,AY,,,Care Improvement Plus,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Item or service furnished to an esrd patient that is not for the treatment of esrd,,,,,,,,,facility,both,,,AY,,,Cigna,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Item or service furnished to an esrd patient that is not for the treatment of esrd,,,,,,,,,facility,both,,,AY,,,Cigna,HealthSpring Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Item or service furnished to an esrd patient that is not for the treatment of esrd,,,,,,,,,facility,both,,,AY,,,Molina Healthcare,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Item or service furnished to an esrd patient that is not for the treatment of esrd,,,,,,,,,facility,both,,,AY,,,Multiplan/PHCS,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Item or service furnished to an esrd patient that is not for the treatment of esrd,,,,,,,,,facility,both,,,AY,,,Presbyterian Health Plan,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Item or service furnished to an esrd patient that is not for the treatment of esrd,,,,,,,,,facility,both,,,AY,,,Presbyterian Health Plan,Capitated Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Item or service furnished to an esrd patient that is not for the treatment of esrd,,,,,,,,,facility,both,,,AY,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Item or service furnished to an esrd patient that is not for the treatment of esrd,,,,,,,,,facility,both,,,AY,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Item or service furnished to an esrd patient that is not for the treatment of esrd,,,,,,,,,facility,both,,,AY,,,Presbyterian Health Plan,Medicare Managed Care - HMO,,,,,,,,,,,The modified price is presented in the standard charge value.
Item or service furnished to an esrd patient that is not for the treatment of esrd,,,,,,,,,facility,both,,,AY,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Item or service furnished to an esrd patient that is not for the treatment of esrd,,,,,,,,,facility,both,,,AY,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Item or service furnished to an esrd patient that is not for the treatment of esrd,,,,,,,,,facility,both,,,AY,,,UnitedHealthCare,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Item or service furnished to an esrd patient that is not for the treatment of esrd,,,,,,,,,facility,both,,,AY,,,UnitedHealthCare,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Item or service furnished to an esrd patient that is not for the treatment of esrd,,,,,,,,,facility,both,,,AY,,,UnitedHealthCare,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Item or service furnished to an esrd patient that is not for the treatment of esrd,,,,,,,,,facility,both,,,AY,,,Wellpoint,formerly Amerigroup Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Item or service furnished to an esrd patient that is not for the treatment of esrd,,,,,,,,,facility,both,,,AY,,,Western Sky Community Care,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Item or service furnished to an esrd patient that is not for the treatment of esrd,,,,,,,,,facility,both,,,AY,,,Zelis,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Erythropoetic stimulating agent (esa) administered to treat anemia due to anti-cancer chemotherapy,,,,,,,,,facility,both,,,EA,,,Aetna,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Erythropoetic stimulating agent (esa) administered to treat anemia due to anti-cancer chemotherapy,,,,,,,,,facility,both,,,EA,,,Aetna,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Erythropoetic stimulating agent (esa) administered to treat anemia due to anti-cancer chemotherapy,,,,,,,,,facility,both,,,EA,,,BCBS,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Erythropoetic stimulating agent (esa) administered to treat anemia due to anti-cancer chemotherapy,,,,,,,,,facility,both,,,EA,,,BCBS,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Erythropoetic stimulating agent (esa) administered to treat anemia due to anti-cancer chemotherapy,,,,,,,,,facility,both,,,EA,,,Care Improvement Plus,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Erythropoetic stimulating agent (esa) administered to treat anemia due to anti-cancer chemotherapy,,,,,,,,,facility,both,,,EA,,,Cigna,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Erythropoetic stimulating agent (esa) administered to treat anemia due to anti-cancer chemotherapy,,,,,,,,,facility,both,,,EA,,,Cigna,HealthSpring Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Erythropoetic stimulating agent (esa) administered to treat anemia due to anti-cancer chemotherapy,,,,,,,,,facility,both,,,EA,,,Molina Healthcare,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Erythropoetic stimulating agent (esa) administered to treat anemia due to anti-cancer chemotherapy,,,,,,,,,facility,both,,,EA,,,Multiplan/PHCS,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Erythropoetic stimulating agent (esa) administered to treat anemia due to anti-cancer chemotherapy,,,,,,,,,facility,both,,,EA,,,Presbyterian Health Plan,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Erythropoetic stimulating agent (esa) administered to treat anemia due to anti-cancer chemotherapy,,,,,,,,,facility,both,,,EA,,,Presbyterian Health Plan,Capitated Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Erythropoetic stimulating agent (esa) administered to treat anemia due to anti-cancer chemotherapy,,,,,,,,,facility,both,,,EA,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Erythropoetic stimulating agent (esa) administered to treat anemia due to anti-cancer chemotherapy,,,,,,,,,facility,both,,,EA,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Erythropoetic stimulating agent (esa) administered to treat anemia due to anti-cancer chemotherapy,,,,,,,,,facility,both,,,EA,,,Presbyterian Health Plan,Medicare Managed Care - HMO,,,,,,,,,,,The modified price is presented in the standard charge value.
Erythropoetic stimulating agent (esa) administered to treat anemia due to anti-cancer chemotherapy,,,,,,,,,facility,both,,,EA,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Erythropoetic stimulating agent (esa) administered to treat anemia due to anti-cancer chemotherapy,,,,,,,,,facility,both,,,EA,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Erythropoetic stimulating agent (esa) administered to treat anemia due to anti-cancer chemotherapy,,,,,,,,,facility,both,,,EA,,,UnitedHealthCare,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Erythropoetic stimulating agent (esa) administered to treat anemia due to anti-cancer chemotherapy,,,,,,,,,facility,both,,,EA,,,UnitedHealthCare,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Erythropoetic stimulating agent (esa) administered to treat anemia due to anti-cancer chemotherapy,,,,,,,,,facility,both,,,EA,,,UnitedHealthCare,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Erythropoetic stimulating agent (esa) administered to treat anemia due to anti-cancer chemotherapy,,,,,,,,,facility,both,,,EA,,,Wellpoint,formerly Amerigroup Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Erythropoetic stimulating agent (esa) administered to treat anemia due to anti-cancer chemotherapy,,,,,,,,,facility,both,,,EA,,,Western Sky Community Care,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Erythropoetic stimulating agent (esa) administered to treat anemia due to anti-cancer chemotherapy,,,,,,,,,facility,both,,,EA,,,Zelis,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy,,,,,,,,,facility,both,,,EC,,,Aetna,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy,,,,,,,,,facility,both,,,EC,,,Aetna,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy,,,,,,,,,facility,both,,,EC,,,BCBS,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy,,,,,,,,,facility,both,,,EC,,,BCBS,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy,,,,,,,,,facility,both,,,EC,,,Care Improvement Plus,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy,,,,,,,,,facility,both,,,EC,,,Cigna,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy,,,,,,,,,facility,both,,,EC,,,Cigna,HealthSpring Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy,,,,,,,,,facility,both,,,EC,,,Molina Healthcare,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy,,,,,,,,,facility,both,,,EC,,,Multiplan/PHCS,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy,,,,,,,,,facility,both,,,EC,,,Presbyterian Health Plan,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy,,,,,,,,,facility,both,,,EC,,,Presbyterian Health Plan,Capitated Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy,,,,,,,,,facility,both,,,EC,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy,,,,,,,,,facility,both,,,EC,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy,,,,,,,,,facility,both,,,EC,,,Presbyterian Health Plan,Medicare Managed Care - HMO,,,,,,,,,,,The modified price is presented in the standard charge value.
Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy,,,,,,,,,facility,both,,,EC,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy,,,,,,,,,facility,both,,,EC,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy,,,,,,,,,facility,both,,,EC,,,UnitedHealthCare,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy,,,,,,,,,facility,both,,,EC,,,UnitedHealthCare,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy,,,,,,,,,facility,both,,,EC,,,UnitedHealthCare,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy,,,,,,,,,facility,both,,,EC,,,Wellpoint,formerly Amerigroup Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy,,,,,,,,,facility,both,,,EC,,,Western Sky Community Care,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy,,,,,,,,,facility,both,,,EC,,,Zelis,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
"Waiver of liability statement issued as required by payer policy, individual case",,,,,,,,,facility,both,,,GA,,,Aetna,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
"Waiver of liability statement issued as required by payer policy, individual case",,,,,,,,,facility,both,,,GA,,,Aetna,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Waiver of liability statement issued as required by payer policy, individual case",,,,,,,,,facility,both,,,GA,,,BCBS,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
"Waiver of liability statement issued as required by payer policy, individual case",,,,,,,,,facility,both,,,GA,,,BCBS,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Waiver of liability statement issued as required by payer policy, individual case",,,,,,,,,facility,both,,,GA,,,Care Improvement Plus,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Waiver of liability statement issued as required by payer policy, individual case",,,,,,,,,facility,both,,,GA,,,Cigna,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
"Waiver of liability statement issued as required by payer policy, individual case",,,,,,,,,facility,both,,,GA,,,Cigna,HealthSpring Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Waiver of liability statement issued as required by payer policy, individual case",,,,,,,,,facility,both,,,GA,,,Molina Healthcare,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Waiver of liability statement issued as required by payer policy, individual case",,,,,,,,,facility,both,,,GA,,,Multiplan/PHCS,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
"Waiver of liability statement issued as required by payer policy, individual case",,,,,,,,,facility,both,,,GA,,,Presbyterian Health Plan,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
"Waiver of liability statement issued as required by payer policy, individual case",,,,,,,,,facility,both,,,GA,,,Presbyterian Health Plan,Capitated Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Waiver of liability statement issued as required by payer policy, individual case",,,,,,,,,facility,both,,,GA,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Waiver of liability statement issued as required by payer policy, individual case",,,,,,,,,facility,both,,,GA,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Waiver of liability statement issued as required by payer policy, individual case",,,,,,,,,facility,both,,,GA,,,Presbyterian Health Plan,Medicare Managed Care - HMO,,,,,,,,,,,The modified price is presented in the standard charge value.
"Waiver of liability statement issued as required by payer policy, individual case",,,,,,,,,facility,both,,,GA,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Waiver of liability statement issued as required by payer policy, individual case",,,,,,,,,facility,both,,,GA,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Waiver of liability statement issued as required by payer policy, individual case",,,,,,,,,facility,both,,,GA,,,UnitedHealthCare,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
"Waiver of liability statement issued as required by payer policy, individual case",,,,,,,,,facility,both,,,GA,,,UnitedHealthCare,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Waiver of liability statement issued as required by payer policy, individual case",,,,,,,,,facility,both,,,GA,,,UnitedHealthCare,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Waiver of liability statement issued as required by payer policy, individual case",,,,,,,,,facility,both,,,GA,,,Wellpoint,formerly Amerigroup Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Waiver of liability statement issued as required by payer policy, individual case",,,,,,,,,facility,both,,,GA,,,Western Sky Community Care,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Waiver of liability statement issued as required by payer policy, individual case",,,,,,,,,facility,both,,,GA,,,Zelis,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
"Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit",,,,,,,,,facility,both,,,GY,,,Aetna,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
"Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit",,,,,,,,,facility,both,,,GY,,,Aetna,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit",,,,,,,,,facility,both,,,GY,,,BCBS,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
"Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit",,,,,,,,,facility,both,,,GY,,,BCBS,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit",,,,,,,,,facility,both,,,GY,,,Care Improvement Plus,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit",,,,,,,,,facility,both,,,GY,,,Cigna,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
"Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit",,,,,,,,,facility,both,,,GY,,,Cigna,HealthSpring Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit",,,,,,,,,facility,both,,,GY,,,Molina Healthcare,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit",,,,,,,,,facility,both,,,GY,,,Multiplan/PHCS,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
"Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit",,,,,,,,,facility,both,,,GY,,,Presbyterian Health Plan,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
"Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit",,,,,,,,,facility,both,,,GY,,,Presbyterian Health Plan,Capitated Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit",,,,,,,,,facility,both,,,GY,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit",,,,,,,,,facility,both,,,GY,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit",,,,,,,,,facility,both,,,GY,,,Presbyterian Health Plan,Medicare Managed Care - HMO,,,,,,,,,,,The modified price is presented in the standard charge value.
"Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit",,,,,,,,,facility,both,,,GY,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit",,,,,,,,,facility,both,,,GY,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit",,,,,,,,,facility,both,,,GY,,,UnitedHealthCare,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
"Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit",,,,,,,,,facility,both,,,GY,,,UnitedHealthCare,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit",,,,,,,,,facility,both,,,GY,,,UnitedHealthCare,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit",,,,,,,,,facility,both,,,GY,,,Wellpoint,formerly Amerigroup Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit",,,,,,,,,facility,both,,,GY,,,Western Sky Community Care,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit",,,,,,,,,facility,both,,,GY,,,Zelis,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Item or service expected to be denied as not reasonable and necessary,,,,,,,,,facility,both,,,GZ,,,Aetna,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Item or service expected to be denied as not reasonable and necessary,,,,,,,,,facility,both,,,GZ,,,Aetna,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Item or service expected to be denied as not reasonable and necessary,,,,,,,,,facility,both,,,GZ,,,BCBS,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Item or service expected to be denied as not reasonable and necessary,,,,,,,,,facility,both,,,GZ,,,BCBS,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Item or service expected to be denied as not reasonable and necessary,,,,,,,,,facility,both,,,GZ,,,Care Improvement Plus,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Item or service expected to be denied as not reasonable and necessary,,,,,,,,,facility,both,,,GZ,,,Cigna,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Item or service expected to be denied as not reasonable and necessary,,,,,,,,,facility,both,,,GZ,,,Cigna,HealthSpring Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Item or service expected to be denied as not reasonable and necessary,,,,,,,,,facility,both,,,GZ,,,Molina Healthcare,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Item or service expected to be denied as not reasonable and necessary,,,,,,,,,facility,both,,,GZ,,,Multiplan/PHCS,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Item or service expected to be denied as not reasonable and necessary,,,,,,,,,facility,both,,,GZ,,,Presbyterian Health Plan,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Item or service expected to be denied as not reasonable and necessary,,,,,,,,,facility,both,,,GZ,,,Presbyterian Health Plan,Capitated Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Item or service expected to be denied as not reasonable and necessary,,,,,,,,,facility,both,,,GZ,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Item or service expected to be denied as not reasonable and necessary,,,,,,,,,facility,both,,,GZ,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Item or service expected to be denied as not reasonable and necessary,,,,,,,,,facility,both,,,GZ,,,Presbyterian Health Plan,Medicare Managed Care - HMO,,,,,,,,,,,The modified price is presented in the standard charge value.
Item or service expected to be denied as not reasonable and necessary,,,,,,,,,facility,both,,,GZ,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Item or service expected to be denied as not reasonable and necessary,,,,,,,,,facility,both,,,GZ,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Item or service expected to be denied as not reasonable and necessary,,,,,,,,,facility,both,,,GZ,,,UnitedHealthCare,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Item or service expected to be denied as not reasonable and necessary,,,,,,,,,facility,both,,,GZ,,,UnitedHealthCare,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Item or service expected to be denied as not reasonable and necessary,,,,,,,,,facility,both,,,GZ,,,UnitedHealthCare,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Item or service expected to be denied as not reasonable and necessary,,,,,,,,,facility,both,,,GZ,,,Wellpoint,formerly Amerigroup Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Item or service expected to be denied as not reasonable and necessary,,,,,,,,,facility,both,,,GZ,,,Western Sky Community Care,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Item or service expected to be denied as not reasonable and necessary,,,,,,,,,facility,both,,,GZ,,,Zelis,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Administered intravenously,,,,,,,,,facility,both,,,JA,,,Aetna,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Administered intravenously,,,,,,,,,facility,both,,,JA,,,Aetna,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Administered intravenously,,,,,,,,,facility,both,,,JA,,,BCBS,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Administered intravenously,,,,,,,,,facility,both,,,JA,,,BCBS,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Administered intravenously,,,,,,,,,facility,both,,,JA,,,Care Improvement Plus,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Administered intravenously,,,,,,,,,facility,both,,,JA,,,Cigna,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Administered intravenously,,,,,,,,,facility,both,,,JA,,,Cigna,HealthSpring Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Administered intravenously,,,,,,,,,facility,both,,,JA,,,Molina Healthcare,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Administered intravenously,,,,,,,,,facility,both,,,JA,,,Multiplan/PHCS,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Administered intravenously,,,,,,,,,facility,both,,,JA,,,Presbyterian Health Plan,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Administered intravenously,,,,,,,,,facility,both,,,JA,,,Presbyterian Health Plan,Capitated Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Administered intravenously,,,,,,,,,facility,both,,,JA,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Administered intravenously,,,,,,,,,facility,both,,,JA,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Administered intravenously,,,,,,,,,facility,both,,,JA,,,Presbyterian Health Plan,Medicare Managed Care - HMO,,,,,,,,,,,The modified price is presented in the standard charge value.
Administered intravenously,,,,,,,,,facility,both,,,JA,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Administered intravenously,,,,,,,,,facility,both,,,JA,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Administered intravenously,,,,,,,,,facility,both,,,JA,,,UnitedHealthCare,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Administered intravenously,,,,,,,,,facility,both,,,JA,,,UnitedHealthCare,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Administered intravenously,,,,,,,,,facility,both,,,JA,,,UnitedHealthCare,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Administered intravenously,,,,,,,,,facility,both,,,JA,,,Wellpoint,formerly Amerigroup Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Administered intravenously,,,,,,,,,facility,both,,,JA,,,Western Sky Community Care,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Administered intravenously,,,,,,,,,facility,both,,,JA,,,Zelis,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Administered subcutaneously,,,,,,,,,facility,both,,,JB,,,Aetna,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Administered subcutaneously,,,,,,,,,facility,both,,,JB,,,Aetna,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Administered subcutaneously,,,,,,,,,facility,both,,,JB,,,BCBS,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Administered subcutaneously,,,,,,,,,facility,both,,,JB,,,BCBS,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Administered subcutaneously,,,,,,,,,facility,both,,,JB,,,Care Improvement Plus,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Administered subcutaneously,,,,,,,,,facility,both,,,JB,,,Cigna,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Administered subcutaneously,,,,,,,,,facility,both,,,JB,,,Cigna,HealthSpring Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Administered subcutaneously,,,,,,,,,facility,both,,,JB,,,Molina Healthcare,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Administered subcutaneously,,,,,,,,,facility,both,,,JB,,,Multiplan/PHCS,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Administered subcutaneously,,,,,,,,,facility,both,,,JB,,,Presbyterian Health Plan,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Administered subcutaneously,,,,,,,,,facility,both,,,JB,,,Presbyterian Health Plan,Capitated Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Administered subcutaneously,,,,,,,,,facility,both,,,JB,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Administered subcutaneously,,,,,,,,,facility,both,,,JB,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Administered subcutaneously,,,,,,,,,facility,both,,,JB,,,Presbyterian Health Plan,Medicare Managed Care - HMO,,,,,,,,,,,The modified price is presented in the standard charge value.
Administered subcutaneously,,,,,,,,,facility,both,,,JB,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Administered subcutaneously,,,,,,,,,facility,both,,,JB,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Administered subcutaneously,,,,,,,,,facility,both,,,JB,,,UnitedHealthCare,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Administered subcutaneously,,,,,,,,,facility,both,,,JB,,,UnitedHealthCare,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Administered subcutaneously,,,,,,,,,facility,both,,,JB,,,UnitedHealthCare,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Administered subcutaneously,,,,,,,,,facility,both,,,JB,,,Wellpoint,formerly Amerigroup Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Administered subcutaneously,,,,,,,,,facility,both,,,JB,,,Western Sky Community Care,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Administered subcutaneously,,,,,,,,,facility,both,,,JB,,,Zelis,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Skin substitute used as a graft,,,,,,,,,facility,both,,,JC,,,Aetna,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Skin substitute used as a graft,,,,,,,,,facility,both,,,JC,,,Aetna,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Skin substitute used as a graft,,,,,,,,,facility,both,,,JC,,,BCBS,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Skin substitute used as a graft,,,,,,,,,facility,both,,,JC,,,BCBS,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Skin substitute used as a graft,,,,,,,,,facility,both,,,JC,,,Care Improvement Plus,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Skin substitute used as a graft,,,,,,,,,facility,both,,,JC,,,Cigna,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Skin substitute used as a graft,,,,,,,,,facility,both,,,JC,,,Cigna,HealthSpring Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Skin substitute used as a graft,,,,,,,,,facility,both,,,JC,,,Molina Healthcare,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Skin substitute used as a graft,,,,,,,,,facility,both,,,JC,,,Multiplan/PHCS,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Skin substitute used as a graft,,,,,,,,,facility,both,,,JC,,,Presbyterian Health Plan,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Skin substitute used as a graft,,,,,,,,,facility,both,,,JC,,,Presbyterian Health Plan,Capitated Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Skin substitute used as a graft,,,,,,,,,facility,both,,,JC,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Skin substitute used as a graft,,,,,,,,,facility,both,,,JC,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Skin substitute used as a graft,,,,,,,,,facility,both,,,JC,,,Presbyterian Health Plan,Medicare Managed Care - HMO,,,,,,,,,,,The modified price is presented in the standard charge value.
Skin substitute used as a graft,,,,,,,,,facility,both,,,JC,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Skin substitute used as a graft,,,,,,,,,facility,both,,,JC,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Skin substitute used as a graft,,,,,,,,,facility,both,,,JC,,,UnitedHealthCare,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Skin substitute used as a graft,,,,,,,,,facility,both,,,JC,,,UnitedHealthCare,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Skin substitute used as a graft,,,,,,,,,facility,both,,,JC,,,UnitedHealthCare,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Skin substitute used as a graft,,,,,,,,,facility,both,,,JC,,,Wellpoint,formerly Amerigroup Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Skin substitute used as a graft,,,,,,,,,facility,both,,,JC,,,Western Sky Community Care,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Skin substitute used as a graft,,,,,,,,,facility,both,,,JC,,,Zelis,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Drug or biological acquired with 340b drug pricing program discount,,,,,,,,,facility,both,,,JG,,,Aetna,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Drug or biological acquired with 340b drug pricing program discount,,,,,,,,,facility,both,,,JG,,,Aetna,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Drug or biological acquired with 340b drug pricing program discount,,,,,,,,,facility,both,,,JG,,,BCBS,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Drug or biological acquired with 340b drug pricing program discount,,,,,,,,,facility,both,,,JG,,,BCBS,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Drug or biological acquired with 340b drug pricing program discount,,,,,,,,,facility,both,,,JG,,,Care Improvement Plus,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Drug or biological acquired with 340b drug pricing program discount,,,,,,,,,facility,both,,,JG,,,Cigna,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Drug or biological acquired with 340b drug pricing program discount,,,,,,,,,facility,both,,,JG,,,Cigna,HealthSpring Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Drug or biological acquired with 340b drug pricing program discount,,,,,,,,,facility,both,,,JG,,,Molina Healthcare,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Drug or biological acquired with 340b drug pricing program discount,,,,,,,,,facility,both,,,JG,,,Multiplan/PHCS,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Drug or biological acquired with 340b drug pricing program discount,,,,,,,,,facility,both,,,JG,,,Presbyterian Health Plan,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Drug or biological acquired with 340b drug pricing program discount,,,,,,,,,facility,both,,,JG,,,Presbyterian Health Plan,Capitated Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Drug or biological acquired with 340b drug pricing program discount,,,,,,,,,facility,both,,,JG,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Drug or biological acquired with 340b drug pricing program discount,,,,,,,,,facility,both,,,JG,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Drug or biological acquired with 340b drug pricing program discount,,,,,,,,,facility,both,,,JG,,,Presbyterian Health Plan,Medicare Managed Care - HMO,,,,,,,,,,,The modified price is presented in the standard charge value.
Drug or biological acquired with 340b drug pricing program discount,,,,,,,,,facility,both,,,JG,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Drug or biological acquired with 340b drug pricing program discount,,,,,,,,,facility,both,,,JG,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Drug or biological acquired with 340b drug pricing program discount,,,,,,,,,facility,both,,,JG,,,UnitedHealthCare,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Drug or biological acquired with 340b drug pricing program discount,,,,,,,,,facility,both,,,JG,,,UnitedHealthCare,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Drug or biological acquired with 340b drug pricing program discount,,,,,,,,,facility,both,,,JG,,,UnitedHealthCare,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Drug or biological acquired with 340b drug pricing program discount,,,,,,,,,facility,both,,,JG,,,Wellpoint,formerly Amerigroup Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Drug or biological acquired with 340b drug pricing program discount,,,,,,,,,facility,both,,,JG,,,Western Sky Community Care,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Drug or biological acquired with 340b drug pricing program discount,,,,,,,,,facility,both,,,JG,,,Zelis,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Drug amount discarded/not administered to any patient,,,,,,,,,facility,both,,,JW,,,Aetna,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Drug amount discarded/not administered to any patient,,,,,,,,,facility,both,,,JW,,,Aetna,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Drug amount discarded/not administered to any patient,,,,,,,,,facility,both,,,JW,,,BCBS,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Drug amount discarded/not administered to any patient,,,,,,,,,facility,both,,,JW,,,BCBS,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Drug amount discarded/not administered to any patient,,,,,,,,,facility,both,,,JW,,,Care Improvement Plus,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Drug amount discarded/not administered to any patient,,,,,,,,,facility,both,,,JW,,,Cigna,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Drug amount discarded/not administered to any patient,,,,,,,,,facility,both,,,JW,,,Cigna,HealthSpring Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Drug amount discarded/not administered to any patient,,,,,,,,,facility,both,,,JW,,,Molina Healthcare,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Drug amount discarded/not administered to any patient,,,,,,,,,facility,both,,,JW,,,Multiplan/PHCS,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Drug amount discarded/not administered to any patient,,,,,,,,,facility,both,,,JW,,,Presbyterian Health Plan,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Drug amount discarded/not administered to any patient,,,,,,,,,facility,both,,,JW,,,Presbyterian Health Plan,Capitated Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Drug amount discarded/not administered to any patient,,,,,,,,,facility,both,,,JW,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Drug amount discarded/not administered to any patient,,,,,,,,,facility,both,,,JW,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Drug amount discarded/not administered to any patient,,,,,,,,,facility,both,,,JW,,,Presbyterian Health Plan,Medicare Managed Care - HMO,,,,,,,,,,,The modified price is presented in the standard charge value.
Drug amount discarded/not administered to any patient,,,,,,,,,facility,both,,,JW,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Drug amount discarded/not administered to any patient,,,,,,,,,facility,both,,,JW,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Drug amount discarded/not administered to any patient,,,,,,,,,facility,both,,,JW,,,UnitedHealthCare,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Drug amount discarded/not administered to any patient,,,,,,,,,facility,both,,,JW,,,UnitedHealthCare,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Drug amount discarded/not administered to any patient,,,,,,,,,facility,both,,,JW,,,UnitedHealthCare,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Drug amount discarded/not administered to any patient,,,,,,,,,facility,both,,,JW,,,Wellpoint,formerly Amerigroup Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Drug amount discarded/not administered to any patient,,,,,,,,,facility,both,,,JW,,,Western Sky Community Care,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Drug amount discarded/not administered to any patient,,,,,,,,,facility,both,,,JW,,,Zelis,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Zero drug amount discarded/not administered to any patient,,,,,,,,,facility,both,,,JZ,,,Aetna,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Zero drug amount discarded/not administered to any patient,,,,,,,,,facility,both,,,JZ,,,Aetna,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Zero drug amount discarded/not administered to any patient,,,,,,,,,facility,both,,,JZ,,,BCBS,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Zero drug amount discarded/not administered to any patient,,,,,,,,,facility,both,,,JZ,,,BCBS,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Zero drug amount discarded/not administered to any patient,,,,,,,,,facility,both,,,JZ,,,Care Improvement Plus,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Zero drug amount discarded/not administered to any patient,,,,,,,,,facility,both,,,JZ,,,Cigna,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Zero drug amount discarded/not administered to any patient,,,,,,,,,facility,both,,,JZ,,,Cigna,HealthSpring Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Zero drug amount discarded/not administered to any patient,,,,,,,,,facility,both,,,JZ,,,Molina Healthcare,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Zero drug amount discarded/not administered to any patient,,,,,,,,,facility,both,,,JZ,,,Multiplan/PHCS,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Zero drug amount discarded/not administered to any patient,,,,,,,,,facility,both,,,JZ,,,Presbyterian Health Plan,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Zero drug amount discarded/not administered to any patient,,,,,,,,,facility,both,,,JZ,,,Presbyterian Health Plan,Capitated Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Zero drug amount discarded/not administered to any patient,,,,,,,,,facility,both,,,JZ,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Zero drug amount discarded/not administered to any patient,,,,,,,,,facility,both,,,JZ,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Zero drug amount discarded/not administered to any patient,,,,,,,,,facility,both,,,JZ,,,Presbyterian Health Plan,Medicare Managed Care - HMO,,,,,,,,,,,The modified price is presented in the standard charge value.
Zero drug amount discarded/not administered to any patient,,,,,,,,,facility,both,,,JZ,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Zero drug amount discarded/not administered to any patient,,,,,,,,,facility,both,,,JZ,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Zero drug amount discarded/not administered to any patient,,,,,,,,,facility,both,,,JZ,,,UnitedHealthCare,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Zero drug amount discarded/not administered to any patient,,,,,,,,,facility,both,,,JZ,,,UnitedHealthCare,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Zero drug amount discarded/not administered to any patient,,,,,,,,,facility,both,,,JZ,,,UnitedHealthCare,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Zero drug amount discarded/not administered to any patient,,,,,,,,,facility,both,,,JZ,,,Wellpoint,formerly Amerigroup Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Zero drug amount discarded/not administered to any patient,,,,,,,,,facility,both,,,JZ,,,Western Sky Community Care,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Zero drug amount discarded/not administered to any patient,,,,,,,,,facility,both,,,JZ,,,Zelis,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Requirements specified in the medical policy have been met,,,,,,,,,facility,both,,,KX,,,Aetna,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Requirements specified in the medical policy have been met,,,,,,,,,facility,both,,,KX,,,Aetna,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Requirements specified in the medical policy have been met,,,,,,,,,facility,both,,,KX,,,BCBS,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Requirements specified in the medical policy have been met,,,,,,,,,facility,both,,,KX,,,BCBS,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Requirements specified in the medical policy have been met,,,,,,,,,facility,both,,,KX,,,Care Improvement Plus,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Requirements specified in the medical policy have been met,,,,,,,,,facility,both,,,KX,,,Cigna,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Requirements specified in the medical policy have been met,,,,,,,,,facility,both,,,KX,,,Cigna,HealthSpring Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Requirements specified in the medical policy have been met,,,,,,,,,facility,both,,,KX,,,Molina Healthcare,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Requirements specified in the medical policy have been met,,,,,,,,,facility,both,,,KX,,,Multiplan/PHCS,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Requirements specified in the medical policy have been met,,,,,,,,,facility,both,,,KX,,,Presbyterian Health Plan,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Requirements specified in the medical policy have been met,,,,,,,,,facility,both,,,KX,,,Presbyterian Health Plan,Capitated Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Requirements specified in the medical policy have been met,,,,,,,,,facility,both,,,KX,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Requirements specified in the medical policy have been met,,,,,,,,,facility,both,,,KX,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Requirements specified in the medical policy have been met,,,,,,,,,facility,both,,,KX,,,Presbyterian Health Plan,Medicare Managed Care - HMO,,,,,,,,,,,The modified price is presented in the standard charge value.
Requirements specified in the medical policy have been met,,,,,,,,,facility,both,,,KX,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Requirements specified in the medical policy have been met,,,,,,,,,facility,both,,,KX,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Requirements specified in the medical policy have been met,,,,,,,,,facility,both,,,KX,,,UnitedHealthCare,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Requirements specified in the medical policy have been met,,,,,,,,,facility,both,,,KX,,,UnitedHealthCare,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Requirements specified in the medical policy have been met,,,,,,,,,facility,both,,,KX,,,UnitedHealthCare,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Requirements specified in the medical policy have been met,,,,,,,,,facility,both,,,KX,,,Wellpoint,formerly Amerigroup Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Requirements specified in the medical policy have been met,,,,,,,,,facility,both,,,KX,,,Western Sky Community Care,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Requirements specified in the medical policy have been met,,,,,,,,,facility,both,,,KX,,,Zelis,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Left side (used to identify procedures performed on the left side of the body),,,,,,,,,facility,both,,,LT,,,Aetna,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Left side (used to identify procedures performed on the left side of the body),,,,,,,,,facility,both,,,LT,,,Aetna,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Left side (used to identify procedures performed on the left side of the body),,,,,,,,,facility,both,,,LT,,,BCBS,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Left side (used to identify procedures performed on the left side of the body),,,,,,,,,facility,both,,,LT,,,BCBS,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Left side (used to identify procedures performed on the left side of the body),,,,,,,,,facility,both,,,LT,,,Care Improvement Plus,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Left side (used to identify procedures performed on the left side of the body),,,,,,,,,facility,both,,,LT,,,Cigna,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Left side (used to identify procedures performed on the left side of the body),,,,,,,,,facility,both,,,LT,,,Cigna,HealthSpring Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Left side (used to identify procedures performed on the left side of the body),,,,,,,,,facility,both,,,LT,,,Molina Healthcare,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Left side (used to identify procedures performed on the left side of the body),,,,,,,,,facility,both,,,LT,,,Multiplan/PHCS,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Left side (used to identify procedures performed on the left side of the body),,,,,,,,,facility,both,,,LT,,,Presbyterian Health Plan,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Left side (used to identify procedures performed on the left side of the body),,,,,,,,,facility,both,,,LT,,,Presbyterian Health Plan,Capitated Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Left side (used to identify procedures performed on the left side of the body),,,,,,,,,facility,both,,,LT,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Left side (used to identify procedures performed on the left side of the body),,,,,,,,,facility,both,,,LT,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Left side (used to identify procedures performed on the left side of the body),,,,,,,,,facility,both,,,LT,,,Presbyterian Health Plan,Medicare Managed Care - HMO,,,,,,,,,,,The modified price is presented in the standard charge value.
Left side (used to identify procedures performed on the left side of the body),,,,,,,,,facility,both,,,LT,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Left side (used to identify procedures performed on the left side of the body),,,,,,,,,facility,both,,,LT,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Left side (used to identify procedures performed on the left side of the body),,,,,,,,,facility,both,,,LT,,,UnitedHealthCare,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Left side (used to identify procedures performed on the left side of the body),,,,,,,,,facility,both,,,LT,,,UnitedHealthCare,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Left side (used to identify procedures performed on the left side of the body),,,,,,,,,facility,both,,,LT,,,UnitedHealthCare,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Left side (used to identify procedures performed on the left side of the body),,,,,,,,,facility,both,,,LT,,,Wellpoint,formerly Amerigroup Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Left side (used to identify procedures performed on the left side of the body),,,,,,,,,facility,both,,,LT,,,Western Sky Community Care,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Left side (used to identify procedures performed on the left side of the body),,,,,,,,,facility,both,,,LT,,,Zelis,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Positron emission tomography (pet) or pet/computed tomography (ct) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing,,,,,,,,,facility,both,,,PI,,,Aetna,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Positron emission tomography (pet) or pet/computed tomography (ct) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing,,,,,,,,,facility,both,,,PI,,,Aetna,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Positron emission tomography (pet) or pet/computed tomography (ct) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing,,,,,,,,,facility,both,,,PI,,,BCBS,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Positron emission tomography (pet) or pet/computed tomography (ct) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing,,,,,,,,,facility,both,,,PI,,,BCBS,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Positron emission tomography (pet) or pet/computed tomography (ct) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing,,,,,,,,,facility,both,,,PI,,,Care Improvement Plus,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Positron emission tomography (pet) or pet/computed tomography (ct) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing,,,,,,,,,facility,both,,,PI,,,Cigna,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Positron emission tomography (pet) or pet/computed tomography (ct) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing,,,,,,,,,facility,both,,,PI,,,Cigna,HealthSpring Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Positron emission tomography (pet) or pet/computed tomography (ct) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing,,,,,,,,,facility,both,,,PI,,,Molina Healthcare,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Positron emission tomography (pet) or pet/computed tomography (ct) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing,,,,,,,,,facility,both,,,PI,,,Multiplan/PHCS,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Positron emission tomography (pet) or pet/computed tomography (ct) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing,,,,,,,,,facility,both,,,PI,,,Presbyterian Health Plan,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Positron emission tomography (pet) or pet/computed tomography (ct) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing,,,,,,,,,facility,both,,,PI,,,Presbyterian Health Plan,Capitated Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Positron emission tomography (pet) or pet/computed tomography (ct) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing,,,,,,,,,facility,both,,,PI,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Positron emission tomography (pet) or pet/computed tomography (ct) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing,,,,,,,,,facility,both,,,PI,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Positron emission tomography (pet) or pet/computed tomography (ct) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing,,,,,,,,,facility,both,,,PI,,,Presbyterian Health Plan,Medicare Managed Care - HMO,,,,,,,,,,,The modified price is presented in the standard charge value.
Positron emission tomography (pet) or pet/computed tomography (ct) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing,,,,,,,,,facility,both,,,PI,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Positron emission tomography (pet) or pet/computed tomography (ct) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing,,,,,,,,,facility,both,,,PI,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Positron emission tomography (pet) or pet/computed tomography (ct) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing,,,,,,,,,facility,both,,,PI,,,UnitedHealthCare,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Positron emission tomography (pet) or pet/computed tomography (ct) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing,,,,,,,,,facility,both,,,PI,,,UnitedHealthCare,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Positron emission tomography (pet) or pet/computed tomography (ct) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing,,,,,,,,,facility,both,,,PI,,,UnitedHealthCare,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Positron emission tomography (pet) or pet/computed tomography (ct) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing,,,,,,,,,facility,both,,,PI,,,Wellpoint,formerly Amerigroup Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Positron emission tomography (pet) or pet/computed tomography (ct) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing,,,,,,,,,facility,both,,,PI,,,Western Sky Community Care,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Positron emission tomography (pet) or pet/computed tomography (ct) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing,,,,,,,,,facility,both,,,PI,,,Zelis,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Progressive addition lenses,,,,,,,,,facility,both,,,PL,,,Aetna,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Progressive addition lenses,,,,,,,,,facility,both,,,PL,,,Aetna,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Progressive addition lenses,,,,,,,,,facility,both,,,PL,,,BCBS,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Progressive addition lenses,,,,,,,,,facility,both,,,PL,,,BCBS,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Progressive addition lenses,,,,,,,,,facility,both,,,PL,,,Care Improvement Plus,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Progressive addition lenses,,,,,,,,,facility,both,,,PL,,,Cigna,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Progressive addition lenses,,,,,,,,,facility,both,,,PL,,,Cigna,HealthSpring Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Progressive addition lenses,,,,,,,,,facility,both,,,PL,,,Molina Healthcare,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Progressive addition lenses,,,,,,,,,facility,both,,,PL,,,Multiplan/PHCS,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Progressive addition lenses,,,,,,,,,facility,both,,,PL,,,Presbyterian Health Plan,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Progressive addition lenses,,,,,,,,,facility,both,,,PL,,,Presbyterian Health Plan,Capitated Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Progressive addition lenses,,,,,,,,,facility,both,,,PL,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Progressive addition lenses,,,,,,,,,facility,both,,,PL,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Progressive addition lenses,,,,,,,,,facility,both,,,PL,,,Presbyterian Health Plan,Medicare Managed Care - HMO,,,,,,,,,,,The modified price is presented in the standard charge value.
Progressive addition lenses,,,,,,,,,facility,both,,,PL,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Progressive addition lenses,,,,,,,,,facility,both,,,PL,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Progressive addition lenses,,,,,,,,,facility,both,,,PL,,,UnitedHealthCare,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Progressive addition lenses,,,,,,,,,facility,both,,,PL,,,UnitedHealthCare,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Progressive addition lenses,,,,,,,,,facility,both,,,PL,,,UnitedHealthCare,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Progressive addition lenses,,,,,,,,,facility,both,,,PL,,,Wellpoint,formerly Amerigroup Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Progressive addition lenses,,,,,,,,,facility,both,,,PL,,,Western Sky Community Care,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Progressive addition lenses,,,,,,,,,facility,both,,,PL,,,Zelis,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,,,facility,both,,,PLAD,,,Aetna,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,,,facility,both,,,PLAD,,,Aetna,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,,,facility,both,,,PLAD,,,BCBS,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,,,facility,both,,,PLAD,,,BCBS,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,,,facility,both,,,PLAD,,,Care Improvement Plus,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,,,facility,both,,,PLAD,,,Cigna,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,,,facility,both,,,PLAD,,,Cigna,HealthSpring Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,,,facility,both,,,PLAD,,,Molina Healthcare,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,,,facility,both,,,PLAD,,,Multiplan/PHCS,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,,,facility,both,,,PLAD,,,Presbyterian Health Plan,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,,,facility,both,,,PLAD,,,Presbyterian Health Plan,Capitated Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,,,facility,both,,,PLAD,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,,,facility,both,,,PLAD,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,,,facility,both,,,PLAD,,,Presbyterian Health Plan,Medicare Managed Care - HMO,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,,,facility,both,,,PLAD,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,,,facility,both,,,PLAD,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,,,facility,both,,,PLAD,,,UnitedHealthCare,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,,,facility,both,,,PLAD,,,UnitedHealthCare,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,,,facility,both,,,PLAD,,,UnitedHealthCare,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,,,facility,both,,,PLAD,,,Wellpoint,formerly Amerigroup Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,,,facility,both,,,PLAD,,,Western Sky Community Care,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,,,facility,both,,,PLAD,,,Zelis,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Positron emission tomography (pet) or pet/computed tomography (ct) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary's treating physician determines that the pet study is needed to inform subsequent anti-tumor strategy,,,,,,,,,facility,both,,,PS,,,Aetna,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Positron emission tomography (pet) or pet/computed tomography (ct) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary's treating physician determines that the pet study is needed to inform subsequent anti-tumor strategy,,,,,,,,,facility,both,,,PS,,,Aetna,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Positron emission tomography (pet) or pet/computed tomography (ct) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary's treating physician determines that the pet study is needed to inform subsequent anti-tumor strategy,,,,,,,,,facility,both,,,PS,,,BCBS,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Positron emission tomography (pet) or pet/computed tomography (ct) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary's treating physician determines that the pet study is needed to inform subsequent anti-tumor strategy,,,,,,,,,facility,both,,,PS,,,BCBS,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Positron emission tomography (pet) or pet/computed tomography (ct) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary's treating physician determines that the pet study is needed to inform subsequent anti-tumor strategy,,,,,,,,,facility,both,,,PS,,,Care Improvement Plus,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Positron emission tomography (pet) or pet/computed tomography (ct) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary's treating physician determines that the pet study is needed to inform subsequent anti-tumor strategy,,,,,,,,,facility,both,,,PS,,,Cigna,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Positron emission tomography (pet) or pet/computed tomography (ct) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary's treating physician determines that the pet study is needed to inform subsequent anti-tumor strategy,,,,,,,,,facility,both,,,PS,,,Cigna,HealthSpring Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Positron emission tomography (pet) or pet/computed tomography (ct) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary's treating physician determines that the pet study is needed to inform subsequent anti-tumor strategy,,,,,,,,,facility,both,,,PS,,,Molina Healthcare,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Positron emission tomography (pet) or pet/computed tomography (ct) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary's treating physician determines that the pet study is needed to inform subsequent anti-tumor strategy,,,,,,,,,facility,both,,,PS,,,Multiplan/PHCS,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Positron emission tomography (pet) or pet/computed tomography (ct) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary's treating physician determines that the pet study is needed to inform subsequent anti-tumor strategy,,,,,,,,,facility,both,,,PS,,,Presbyterian Health Plan,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Positron emission tomography (pet) or pet/computed tomography (ct) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary's treating physician determines that the pet study is needed to inform subsequent anti-tumor strategy,,,,,,,,,facility,both,,,PS,,,Presbyterian Health Plan,Capitated Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Positron emission tomography (pet) or pet/computed tomography (ct) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary's treating physician determines that the pet study is needed to inform subsequent anti-tumor strategy,,,,,,,,,facility,both,,,PS,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Positron emission tomography (pet) or pet/computed tomography (ct) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary's treating physician determines that the pet study is needed to inform subsequent anti-tumor strategy,,,,,,,,,facility,both,,,PS,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Positron emission tomography (pet) or pet/computed tomography (ct) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary's treating physician determines that the pet study is needed to inform subsequent anti-tumor strategy,,,,,,,,,facility,both,,,PS,,,Presbyterian Health Plan,Medicare Managed Care - HMO,,,,,,,,,,,The modified price is presented in the standard charge value.
Positron emission tomography (pet) or pet/computed tomography (ct) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary's treating physician determines that the pet study is needed to inform subsequent anti-tumor strategy,,,,,,,,,facility,both,,,PS,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Positron emission tomography (pet) or pet/computed tomography (ct) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary's treating physician determines that the pet study is needed to inform subsequent anti-tumor strategy,,,,,,,,,facility,both,,,PS,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Positron emission tomography (pet) or pet/computed tomography (ct) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary's treating physician determines that the pet study is needed to inform subsequent anti-tumor strategy,,,,,,,,,facility,both,,,PS,,,UnitedHealthCare,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Positron emission tomography (pet) or pet/computed tomography (ct) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary's treating physician determines that the pet study is needed to inform subsequent anti-tumor strategy,,,,,,,,,facility,both,,,PS,,,UnitedHealthCare,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Positron emission tomography (pet) or pet/computed tomography (ct) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary's treating physician determines that the pet study is needed to inform subsequent anti-tumor strategy,,,,,,,,,facility,both,,,PS,,,UnitedHealthCare,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Positron emission tomography (pet) or pet/computed tomography (ct) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary's treating physician determines that the pet study is needed to inform subsequent anti-tumor strategy,,,,,,,,,facility,both,,,PS,,,Wellpoint,formerly Amerigroup Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Positron emission tomography (pet) or pet/computed tomography (ct) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary's treating physician determines that the pet study is needed to inform subsequent anti-tumor strategy,,,,,,,,,facility,both,,,PS,,,Western Sky Community Care,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Positron emission tomography (pet) or pet/computed tomography (ct) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary's treating physician determines that the pet study is needed to inform subsequent anti-tumor strategy,,,,,,,,,facility,both,,,PS,,,Zelis,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Colorectal cancer screening test; converted to diagnostic test or other procedure,,,,,,,,,facility,both,,,PT,,,Aetna,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Colorectal cancer screening test; converted to diagnostic test or other procedure,,,,,,,,,facility,both,,,PT,,,Aetna,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Colorectal cancer screening test; converted to diagnostic test or other procedure,,,,,,,,,facility,both,,,PT,,,BCBS,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Colorectal cancer screening test; converted to diagnostic test or other procedure,,,,,,,,,facility,both,,,PT,,,BCBS,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Colorectal cancer screening test; converted to diagnostic test or other procedure,,,,,,,,,facility,both,,,PT,,,Care Improvement Plus,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Colorectal cancer screening test; converted to diagnostic test or other procedure,,,,,,,,,facility,both,,,PT,,,Cigna,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Colorectal cancer screening test; converted to diagnostic test or other procedure,,,,,,,,,facility,both,,,PT,,,Cigna,HealthSpring Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Colorectal cancer screening test; converted to diagnostic test or other procedure,,,,,,,,,facility,both,,,PT,,,Molina Healthcare,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Colorectal cancer screening test; converted to diagnostic test or other procedure,,,,,,,,,facility,both,,,PT,,,Multiplan/PHCS,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Colorectal cancer screening test; converted to diagnostic test or other procedure,,,,,,,,,facility,both,,,PT,,,Presbyterian Health Plan,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Colorectal cancer screening test; converted to diagnostic test or other procedure,,,,,,,,,facility,both,,,PT,,,Presbyterian Health Plan,Capitated Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Colorectal cancer screening test; converted to diagnostic test or other procedure,,,,,,,,,facility,both,,,PT,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Colorectal cancer screening test; converted to diagnostic test or other procedure,,,,,,,,,facility,both,,,PT,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Colorectal cancer screening test; converted to diagnostic test or other procedure,,,,,,,,,facility,both,,,PT,,,Presbyterian Health Plan,Medicare Managed Care - HMO,,,,,,,,,,,The modified price is presented in the standard charge value.
Colorectal cancer screening test; converted to diagnostic test or other procedure,,,,,,,,,facility,both,,,PT,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Colorectal cancer screening test; converted to diagnostic test or other procedure,,,,,,,,,facility,both,,,PT,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Colorectal cancer screening test; converted to diagnostic test or other procedure,,,,,,,,,facility,both,,,PT,,,UnitedHealthCare,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Colorectal cancer screening test; converted to diagnostic test or other procedure,,,,,,,,,facility,both,,,PT,,,UnitedHealthCare,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Colorectal cancer screening test; converted to diagnostic test or other procedure,,,,,,,,,facility,both,,,PT,,,UnitedHealthCare,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Colorectal cancer screening test; converted to diagnostic test or other procedure,,,,,,,,,facility,both,,,PT,,,Wellpoint,formerly Amerigroup Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Colorectal cancer screening test; converted to diagnostic test or other procedure,,,,,,,,,facility,both,,,PT,,,Western Sky Community Care,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Colorectal cancer screening test; converted to diagnostic test or other procedure,,,,,,,,,facility,both,,,PT,,,Zelis,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Investigational clinical service provided in a clinical research study that is in an approved clinical research study,,,,,,,,,facility,both,,,Q0,,,Aetna,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Investigational clinical service provided in a clinical research study that is in an approved clinical research study,,,,,,,,,facility,both,,,Q0,,,Aetna,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Investigational clinical service provided in a clinical research study that is in an approved clinical research study,,,,,,,,,facility,both,,,Q0,,,BCBS,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Investigational clinical service provided in a clinical research study that is in an approved clinical research study,,,,,,,,,facility,both,,,Q0,,,BCBS,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Investigational clinical service provided in a clinical research study that is in an approved clinical research study,,,,,,,,,facility,both,,,Q0,,,Care Improvement Plus,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Investigational clinical service provided in a clinical research study that is in an approved clinical research study,,,,,,,,,facility,both,,,Q0,,,Cigna,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Investigational clinical service provided in a clinical research study that is in an approved clinical research study,,,,,,,,,facility,both,,,Q0,,,Cigna,HealthSpring Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Investigational clinical service provided in a clinical research study that is in an approved clinical research study,,,,,,,,,facility,both,,,Q0,,,Molina Healthcare,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Investigational clinical service provided in a clinical research study that is in an approved clinical research study,,,,,,,,,facility,both,,,Q0,,,Multiplan/PHCS,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Investigational clinical service provided in a clinical research study that is in an approved clinical research study,,,,,,,,,facility,both,,,Q0,,,Presbyterian Health Plan,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Investigational clinical service provided in a clinical research study that is in an approved clinical research study,,,,,,,,,facility,both,,,Q0,,,Presbyterian Health Plan,Capitated Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Investigational clinical service provided in a clinical research study that is in an approved clinical research study,,,,,,,,,facility,both,,,Q0,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Investigational clinical service provided in a clinical research study that is in an approved clinical research study,,,,,,,,,facility,both,,,Q0,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Investigational clinical service provided in a clinical research study that is in an approved clinical research study,,,,,,,,,facility,both,,,Q0,,,Presbyterian Health Plan,Medicare Managed Care - HMO,,,,,,,,,,,The modified price is presented in the standard charge value.
Investigational clinical service provided in a clinical research study that is in an approved clinical research study,,,,,,,,,facility,both,,,Q0,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Investigational clinical service provided in a clinical research study that is in an approved clinical research study,,,,,,,,,facility,both,,,Q0,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Investigational clinical service provided in a clinical research study that is in an approved clinical research study,,,,,,,,,facility,both,,,Q0,,,UnitedHealthCare,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Investigational clinical service provided in a clinical research study that is in an approved clinical research study,,,,,,,,,facility,both,,,Q0,,,UnitedHealthCare,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Investigational clinical service provided in a clinical research study that is in an approved clinical research study,,,,,,,,,facility,both,,,Q0,,,UnitedHealthCare,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Investigational clinical service provided in a clinical research study that is in an approved clinical research study,,,,,,,,,facility,both,,,Q0,,,Wellpoint,formerly Amerigroup Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Investigational clinical service provided in a clinical research study that is in an approved clinical research study,,,,,,,,,facility,both,,,Q0,,,Western Sky Community Care,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Investigational clinical service provided in a clinical research study that is in an approved clinical research study,,,,,,,,,facility,both,,,Q0,,,Zelis,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,,,facility,both,,,REMOVED,,,Aetna,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,,,facility,both,,,REMOVED,,,Aetna,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,,,facility,both,,,REMOVED,,,BCBS,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,,,facility,both,,,REMOVED,,,BCBS,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,,,facility,both,,,REMOVED,,,Care Improvement Plus,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,,,facility,both,,,REMOVED,,,Cigna,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,,,facility,both,,,REMOVED,,,Cigna,HealthSpring Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,,,facility,both,,,REMOVED,,,Molina Healthcare,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,,,facility,both,,,REMOVED,,,Multiplan/PHCS,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,,,facility,both,,,REMOVED,,,Presbyterian Health Plan,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,,,facility,both,,,REMOVED,,,Presbyterian Health Plan,Capitated Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,,,facility,both,,,REMOVED,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,,,facility,both,,,REMOVED,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,,,facility,both,,,REMOVED,,,Presbyterian Health Plan,Medicare Managed Care - HMO,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,,,facility,both,,,REMOVED,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,,,facility,both,,,REMOVED,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,,,facility,both,,,REMOVED,,,UnitedHealthCare,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,,,facility,both,,,REMOVED,,,UnitedHealthCare,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,,,facility,both,,,REMOVED,,,UnitedHealthCare,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,,,facility,both,,,REMOVED,,,Wellpoint,formerly Amerigroup Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,,,facility,both,,,REMOVED,,,Western Sky Community Care,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,,,facility,both,,,REMOVED,,,Zelis,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities",,,,,,,,,facility,both,,,TC,,,Aetna,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities",,,,,,,,,facility,both,,,TC,,,Aetna,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities",,,,,,,,,facility,both,,,TC,,,BCBS,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities",,,,,,,,,facility,both,,,TC,,,BCBS,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities",,,,,,,,,facility,both,,,TC,,,Care Improvement Plus,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities",,,,,,,,,facility,both,,,TC,,,Cigna,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities",,,,,,,,,facility,both,,,TC,,,Cigna,HealthSpring Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities",,,,,,,,,facility,both,,,TC,,,Molina Healthcare,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities",,,,,,,,,facility,both,,,TC,,,Multiplan/PHCS,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities",,,,,,,,,facility,both,,,TC,,,Presbyterian Health Plan,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities",,,,,,,,,facility,both,,,TC,,,Presbyterian Health Plan,Capitated Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities",,,,,,,,,facility,both,,,TC,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities",,,,,,,,,facility,both,,,TC,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities",,,,,,,,,facility,both,,,TC,,,Presbyterian Health Plan,Medicare Managed Care - HMO,,,,,,,,,,,The modified price is presented in the standard charge value.
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities",,,,,,,,,facility,both,,,TC,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities",,,,,,,,,facility,both,,,TC,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities",,,,,,,,,facility,both,,,TC,,,UnitedHealthCare,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities",,,,,,,,,facility,both,,,TC,,,UnitedHealthCare,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities",,,,,,,,,facility,both,,,TC,,,UnitedHealthCare,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities",,,,,,,,,facility,both,,,TC,,,Wellpoint,formerly Amerigroup Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities",,,,,,,,,facility,both,,,TC,,,Western Sky Community Care,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities",,,,,,,,,facility,both,,,TC,,,Zelis,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,,,facility,both,,,VFC,,,Aetna,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,,,facility,both,,,VFC,,,Aetna,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,,,facility,both,,,VFC,,,BCBS,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,,,facility,both,,,VFC,,,BCBS,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,,,facility,both,,,VFC,,,Care Improvement Plus,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,,,facility,both,,,VFC,,,Cigna,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,,,facility,both,,,VFC,,,Cigna,HealthSpring Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,,,facility,both,,,VFC,,,Molina Healthcare,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,,,facility,both,,,VFC,,,Multiplan/PHCS,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,,,facility,both,,,VFC,,,Presbyterian Health Plan,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,,,facility,both,,,VFC,,,Presbyterian Health Plan,Capitated Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,,,facility,both,,,VFC,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,,,facility,both,,,VFC,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,,,facility,both,,,VFC,,,Presbyterian Health Plan,Medicare Managed Care - HMO,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,,,facility,both,,,VFC,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,,,facility,both,,,VFC,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,,,facility,both,,,VFC,,,UnitedHealthCare,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,,,facility,both,,,VFC,,,UnitedHealthCare,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,,,facility,both,,,VFC,,,UnitedHealthCare,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,,,facility,both,,,VFC,,,Wellpoint,formerly Amerigroup Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,,,facility,both,,,VFC,,,Western Sky Community Care,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
Modifier description not available,,,,,,,,,facility,both,,,VFC,,,Zelis,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
"Separate encounter, a service that is distinct because it occurred during a separate encounter",,,,,,,,,facility,both,,,XE,,,Aetna,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
"Separate encounter, a service that is distinct because it occurred during a separate encounter",,,,,,,,,facility,both,,,XE,,,Aetna,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Separate encounter, a service that is distinct because it occurred during a separate encounter",,,,,,,,,facility,both,,,XE,,,BCBS,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
"Separate encounter, a service that is distinct because it occurred during a separate encounter",,,,,,,,,facility,both,,,XE,,,BCBS,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Separate encounter, a service that is distinct because it occurred during a separate encounter",,,,,,,,,facility,both,,,XE,,,Care Improvement Plus,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Separate encounter, a service that is distinct because it occurred during a separate encounter",,,,,,,,,facility,both,,,XE,,,Cigna,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
"Separate encounter, a service that is distinct because it occurred during a separate encounter",,,,,,,,,facility,both,,,XE,,,Cigna,HealthSpring Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Separate encounter, a service that is distinct because it occurred during a separate encounter",,,,,,,,,facility,both,,,XE,,,Molina Healthcare,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Separate encounter, a service that is distinct because it occurred during a separate encounter",,,,,,,,,facility,both,,,XE,,,Multiplan/PHCS,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
"Separate encounter, a service that is distinct because it occurred during a separate encounter",,,,,,,,,facility,both,,,XE,,,Presbyterian Health Plan,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
"Separate encounter, a service that is distinct because it occurred during a separate encounter",,,,,,,,,facility,both,,,XE,,,Presbyterian Health Plan,Capitated Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Separate encounter, a service that is distinct because it occurred during a separate encounter",,,,,,,,,facility,both,,,XE,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Separate encounter, a service that is distinct because it occurred during a separate encounter",,,,,,,,,facility,both,,,XE,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Separate encounter, a service that is distinct because it occurred during a separate encounter",,,,,,,,,facility,both,,,XE,,,Presbyterian Health Plan,Medicare Managed Care - HMO,,,,,,,,,,,The modified price is presented in the standard charge value.
"Separate encounter, a service that is distinct because it occurred during a separate encounter",,,,,,,,,facility,both,,,XE,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Separate encounter, a service that is distinct because it occurred during a separate encounter",,,,,,,,,facility,both,,,XE,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Separate encounter, a service that is distinct because it occurred during a separate encounter",,,,,,,,,facility,both,,,XE,,,UnitedHealthCare,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
"Separate encounter, a service that is distinct because it occurred during a separate encounter",,,,,,,,,facility,both,,,XE,,,UnitedHealthCare,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Separate encounter, a service that is distinct because it occurred during a separate encounter",,,,,,,,,facility,both,,,XE,,,UnitedHealthCare,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Separate encounter, a service that is distinct because it occurred during a separate encounter",,,,,,,,,facility,both,,,XE,,,Wellpoint,formerly Amerigroup Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Separate encounter, a service that is distinct because it occurred during a separate encounter",,,,,,,,,facility,both,,,XE,,,Western Sky Community Care,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Separate encounter, a service that is distinct because it occurred during a separate encounter",,,,,,,,,facility,both,,,XE,,,Zelis,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
"Separate structure, a service that is distinct because it was performed on a separate organ/structure",,,,,,,,,facility,both,,,XS,,,Aetna,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
"Separate structure, a service that is distinct because it was performed on a separate organ/structure",,,,,,,,,facility,both,,,XS,,,Aetna,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Separate structure, a service that is distinct because it was performed on a separate organ/structure",,,,,,,,,facility,both,,,XS,,,BCBS,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
"Separate structure, a service that is distinct because it was performed on a separate organ/structure",,,,,,,,,facility,both,,,XS,,,BCBS,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Separate structure, a service that is distinct because it was performed on a separate organ/structure",,,,,,,,,facility,both,,,XS,,,Care Improvement Plus,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Separate structure, a service that is distinct because it was performed on a separate organ/structure",,,,,,,,,facility,both,,,XS,,,Cigna,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
"Separate structure, a service that is distinct because it was performed on a separate organ/structure",,,,,,,,,facility,both,,,XS,,,Cigna,HealthSpring Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Separate structure, a service that is distinct because it was performed on a separate organ/structure",,,,,,,,,facility,both,,,XS,,,Molina Healthcare,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Separate structure, a service that is distinct because it was performed on a separate organ/structure",,,,,,,,,facility,both,,,XS,,,Multiplan/PHCS,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
"Separate structure, a service that is distinct because it was performed on a separate organ/structure",,,,,,,,,facility,both,,,XS,,,Presbyterian Health Plan,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
"Separate structure, a service that is distinct because it was performed on a separate organ/structure",,,,,,,,,facility,both,,,XS,,,Presbyterian Health Plan,Capitated Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Separate structure, a service that is distinct because it was performed on a separate organ/structure",,,,,,,,,facility,both,,,XS,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Separate structure, a service that is distinct because it was performed on a separate organ/structure",,,,,,,,,facility,both,,,XS,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Separate structure, a service that is distinct because it was performed on a separate organ/structure",,,,,,,,,facility,both,,,XS,,,Presbyterian Health Plan,Medicare Managed Care - HMO,,,,,,,,,,,The modified price is presented in the standard charge value.
"Separate structure, a service that is distinct because it was performed on a separate organ/structure",,,,,,,,,facility,both,,,XS,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Separate structure, a service that is distinct because it was performed on a separate organ/structure",,,,,,,,,facility,both,,,XS,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Separate structure, a service that is distinct because it was performed on a separate organ/structure",,,,,,,,,facility,both,,,XS,,,UnitedHealthCare,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
"Separate structure, a service that is distinct because it was performed on a separate organ/structure",,,,,,,,,facility,both,,,XS,,,UnitedHealthCare,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Separate structure, a service that is distinct because it was performed on a separate organ/structure",,,,,,,,,facility,both,,,XS,,,UnitedHealthCare,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Separate structure, a service that is distinct because it was performed on a separate organ/structure",,,,,,,,,facility,both,,,XS,,,Wellpoint,formerly Amerigroup Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Separate structure, a service that is distinct because it was performed on a separate organ/structure",,,,,,,,,facility,both,,,XS,,,Western Sky Community Care,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Separate structure, a service that is distinct because it was performed on a separate organ/structure",,,,,,,,,facility,both,,,XS,,,Zelis,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
"Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service",,,,,,,,,facility,both,,,XU,,,Aetna,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
"Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service",,,,,,,,,facility,both,,,XU,,,Aetna,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service",,,,,,,,,facility,both,,,XU,,,BCBS,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
"Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service",,,,,,,,,facility,both,,,XU,,,BCBS,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service",,,,,,,,,facility,both,,,XU,,,Care Improvement Plus,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service",,,,,,,,,facility,both,,,XU,,,Cigna,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
"Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service",,,,,,,,,facility,both,,,XU,,,Cigna,HealthSpring Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service",,,,,,,,,facility,both,,,XU,,,Molina Healthcare,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service",,,,,,,,,facility,both,,,XU,,,Multiplan/PHCS,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
"Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service",,,,,,,,,facility,both,,,XU,,,Presbyterian Health Plan,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
"Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service",,,,,,,,,facility,both,,,XU,,,Presbyterian Health Plan,Capitated Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service",,,,,,,,,facility,both,,,XU,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service",,,,,,,,,facility,both,,,XU,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service",,,,,,,,,facility,both,,,XU,,,Presbyterian Health Plan,Medicare Managed Care - HMO,,,,,,,,,,,The modified price is presented in the standard charge value.
"Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service",,,,,,,,,facility,both,,,XU,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service",,,,,,,,,facility,both,,,XU,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service",,,,,,,,,facility,both,,,XU,,,UnitedHealthCare,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
"Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service",,,,,,,,,facility,both,,,XU,,,UnitedHealthCare,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service",,,,,,,,,facility,both,,,XU,,,UnitedHealthCare,Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service",,,,,,,,,facility,both,,,XU,,,Wellpoint,formerly Amerigroup Medicare Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service",,,,,,,,,facility,both,,,XU,,,Western Sky Community Care,Medicaid Managed Care Plan,,,,,,,,,,,The modified price is presented in the standard charge value.
"Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service",,,,,,,,,facility,both,,,XU,,,Zelis,All Commercial Plans,,,,,,,,,,,The modified price is presented in the standard charge value.
Ketorolac tromethamine inj,764,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,24434.76,12025.82,31999.97,1 through 10,percent of total billed charges,,,
Ketorolac tromethamine inj,764,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],,,,0,other,,,No services performed during 15-month lookback period.
Ketorolac tromethamine inj,764,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],7668.35,3640.11,31781.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Ketorolac tromethamine inj,764,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ketorolac tromethamine inj,764,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ketorolac tromethamine inj,764,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],10453,3426.69,17955.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Ketorolac tromethamine inj,764,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ketorolac tromethamine inj,764,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",2906.72,2310,3753.87,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Ketorolac tromethamine inj,764,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ketorolac tromethamine inj,764,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],6661.1,6661.1,9646.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Ketorolac tromethamine inj,764,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3926.42,1810.86,6038.08,106,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Ketorolac tromethamine inj,764,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],6398.98,3290.86,16987.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Ketorolac tromethamine inj,764,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],6786.12,4627.21,9753.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Ketorolac tromethamine inj,764,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Ketorolac tromethamine inj,764,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Ketorolac tromethamine inj,764,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],6590.27,350,10157.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Ketorolac tromethamine inj,764,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],26217.76,13749.22,30523.24,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Ketorolac tromethamine inj,764,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",298.52,298.52,4503.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Ketorolac tromethamine inj,764,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ketorolac tromethamine inj,764,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, glycopyrrolate, 0.1 mg",792,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, glycopyrrolate, 0.1 mg",792,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, glycopyrrolate, 0.1 mg",792,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],174.18,174.18,174.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj, glycopyrrolate, 0.1 mg",792,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, glycopyrrolate, 0.1 mg",792,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, glycopyrrolate, 0.1 mg",792,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, glycopyrrolate, 0.1 mg",792,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, glycopyrrolate, 0.1 mg",792,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, glycopyrrolate, 0.1 mg",792,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, glycopyrrolate, 0.1 mg",792,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",1817.21,1817.21,1817.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj, glycopyrrolate, 0.1 mg",792,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],5364.4,5364.4,5364.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj, glycopyrrolate, 0.1 mg",792,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, glycopyrrolate, 0.1 mg",792,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, glycopyrrolate, 0.1 mg",792,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, glycopyrrolate, 0.1 mg",792,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, glycopyrrolate, 0.1 mg",792,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, glycopyrrolate, 0.1 mg",792,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, glycopyrrolate, 0.1 mg",792,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, glycopyrrolate, 0.1 mg",792,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, glycopyrrolate, 0.1 mg",792,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
New Technology - Level 6 ($401 - $500),1506,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 6 ($401 - $500),1506,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
New Technology - Level 6 ($401 - $500),1506,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 6 ($401 - $500),1506,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 6 ($401 - $500),1506,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 6 ($401 - $500),1506,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 6 ($401 - $500),1506,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 6 ($401 - $500),1506,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 6 ($401 - $500),1506,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
New Technology - Level 6 ($401 - $500),1506,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],12060.58,12060.58,12060.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
New Technology - Level 6 ($401 - $500),1506,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 6 ($401 - $500),1506,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 6 ($401 - $500),1506,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 6 ($401 - $500),1506,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 6 ($401 - $500),1506,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 6 ($401 - $500),1506,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 6 ($401 - $500),1506,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 6 ($401 - $500),1506,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 6 ($401 - $500),1506,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
New Technology - Level 6 ($401 - $500),1506,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Endo, single, urinary tract",2040,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],,,,0,other,,,No services performed during 15-month lookback period.
"Endo, single, urinary tract",2040,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Endo, single, urinary tract",2040,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],18123.83,18123.83,18123.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Endo, single, urinary tract",2040,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Endo, single, urinary tract",2040,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Endo, single, urinary tract",2040,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],270,270,270,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Endo, single, urinary tract",2040,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],,,,0,other,,,No services performed during 15-month lookback period.
"Endo, single, urinary tract",2040,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Endo, single, urinary tract",2040,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Endo, single, urinary tract",2040,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",5837.85,5837.85,5837.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Endo, single, urinary tract",2040,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],9241.51,9241.51,9241.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Endo, single, urinary tract",2040,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],11342.39,11342.39,11346.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Endo, single, urinary tract",2040,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
"Endo, single, urinary tract",2040,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
"Endo, single, urinary tract",2040,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
"Endo, single, urinary tract",2040,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],12105.4,11858.22,12233.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Endo, single, urinary tract",2040,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],31852.29,31852.29,33840.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Endo, single, urinary tract",2040,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Endo, single, urinary tract",2040,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Endo, single, urinary tract",2040,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Ret dev, laser, ivc filter",2044,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],,,,0,other,,,No services performed during 15-month lookback period.
"Ret dev, laser, ivc filter",2044,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Ret dev, laser, ivc filter",2044,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ret dev, laser, ivc filter",2044,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ret dev, laser, ivc filter",2044,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ret dev, laser, ivc filter",2044,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ret dev, laser, ivc filter",2044,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],,,,0,other,,,No services performed during 15-month lookback period.
"Ret dev, laser, ivc filter",2044,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Ret dev, laser, ivc filter",2044,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Ret dev, laser, ivc filter",2044,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
"Ret dev, laser, ivc filter",2044,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Ret dev, laser, ivc filter",2044,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
"Ret dev, laser, ivc filter",2044,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
"Ret dev, laser, ivc filter",2044,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
"Ret dev, laser, ivc filter",2044,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
"Ret dev, laser, ivc filter",2044,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],6948.63,6948.63,6948.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ret dev, laser, ivc filter",2044,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],,,,0,other,,,No services performed during 15-month lookback period.
"Ret dev, laser, ivc filter",2044,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Ret dev, laser, ivc filter",2044,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ret dev, laser, ivc filter",2044,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cath coronary drug-delivery,2050,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],,,,0,other,,,No services performed during 15-month lookback period.
Cath coronary drug-delivery,2050,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cath coronary drug-delivery,2050,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],14037.4,14037.4,14037.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cath coronary drug-delivery,2050,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cath coronary drug-delivery,2050,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cath coronary drug-delivery,2050,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cath coronary drug-delivery,2050,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],,,,0,other,,,No services performed during 15-month lookback period.
Cath coronary drug-delivery,2050,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cath coronary drug-delivery,2050,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cath coronary drug-delivery,2050,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Cath coronary drug-delivery,2050,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cath coronary drug-delivery,2050,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Cath coronary drug-delivery,2050,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Cath coronary drug-delivery,2050,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Cath coronary drug-delivery,2050,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Cath coronary drug-delivery,2050,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cath coronary drug-delivery,2050,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],,,,0,other,,,No services performed during 15-month lookback period.
Cath coronary drug-delivery,2050,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cath coronary drug-delivery,2050,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cath coronary drug-delivery,2050,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Brachytx, non-str,Yttrium-90",2616,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],,,,0,other,,,No services performed during 15-month lookback period.
"Brachytx, non-str,Yttrium-90",2616,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Brachytx, non-str,Yttrium-90",2616,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Brachytx, non-str,Yttrium-90",2616,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Brachytx, non-str,Yttrium-90",2616,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Brachytx, non-str,Yttrium-90",2616,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Brachytx, non-str,Yttrium-90",2616,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],,,,0,other,,,No services performed during 15-month lookback period.
"Brachytx, non-str,Yttrium-90",2616,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Brachytx, non-str,Yttrium-90",2616,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Brachytx, non-str,Yttrium-90",2616,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
"Brachytx, non-str,Yttrium-90",2616,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Brachytx, non-str,Yttrium-90",2616,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
"Brachytx, non-str,Yttrium-90",2616,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
"Brachytx, non-str,Yttrium-90",2616,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
"Brachytx, non-str,Yttrium-90",2616,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
"Brachytx, non-str,Yttrium-90",2616,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],17725.47,17725.47,17725.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Brachytx, non-str,Yttrium-90",2616,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],43084.74,43084.74,43084.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Brachytx, non-str,Yttrium-90",2616,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Brachytx, non-str,Yttrium-90",2616,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Brachytx, non-str,Yttrium-90",2616,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Clinic Visits and Related Services,5012,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],15.73,11.52,246.87,27,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Clinic Visits and Related Services,5012,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,283.48,49.4,1395.36,45,percent of total billed charges,,,
Clinic Visits and Related Services,5012,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],314,123.13,1093.8,97,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Clinic Visits and Related Services,5012,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],125.5,100.4,251,106,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Clinic Visits and Related Services,5012,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Clinic Visits and Related Services,5012,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],66.42,11.86,1937.69,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Clinic Visits and Related Services,5012,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],184.22,39.65,791.78,65,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Clinic Visits and Related Services,5012,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",143.25,119.72,361.54,23,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Clinic Visits and Related Services,5012,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Clinic Visits and Related Services,5012,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",135.59,112.61,368.04,334,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Clinic Visits and Related Services,5012,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],172.38,172.38,425.49,69,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Clinic Visits and Related Services,5012,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],276.84,230.8,1092.28,108,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Clinic Visits and Related Services,5012,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],120.67,116.52,362.01,514,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Clinic Visits and Related Services,5012,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],212.2,212.2,279.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Clinic Visits and Related Services,5012,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],120.67,116.52,120.67,31,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Clinic Visits and Related Services,5012,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],347,240.8,719,552,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Clinic Visits and Related Services,5012,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],125.5,121.19,251,606,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Clinic Visits and Related Services,5012,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",174.87,111.39,334.16,36,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Clinic Visits and Related Services,5012,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Clinic Visits and Related Services,5012,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,488,11.2,1597.8,17,percent of total billed charges,,,
Level 1 Type A ED Visits,5021,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],79.85,79.85,79.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Type A ED Visits,5021,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,139.08,139.08,139.08,1 through 10,percent of total billed charges,,,
Level 1 Type A ED Visits,5021,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],183,84.13,1313.79,35,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Type A ED Visits,5021,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],84.13,84.13,86.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Type A ED Visits,5021,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Type A ED Visits,5021,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],111.63,111.63,871.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Type A ED Visits,5021,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Type A ED Visits,5021,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",74.15,74.15,74.15,23,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Type A ED Visits,5021,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Type A ED Visits,5021,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],122.17,117.78,657.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Type A ED Visits,5021,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",69.76,69.76,69.76,79,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Type A ED Visits,5021,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],183,183,183,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Type A ED Visits,5021,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],82.78,67.64,82.78,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Type A ED Visits,5021,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Type A ED Visits,5021,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Type A ED Visits,5021,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],84.13,82.45,87.5,20,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Type A ED Visits,5021,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],183,146.4,706.36,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Type A ED Visits,5021,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",68.99,68.99,108,38,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Type A ED Visits,5021,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Type A ED Visits,5021,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,146.4,146.4,146.4,1 through 10,percent of total billed charges,,,
Level 2 Type A ED Visits,5022,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],157.2,153.38,157.7,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Type A ED Visits,5022,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,187.72,150.18,518.32,39,percent of total billed charges,,,
Level 2 Type A ED Visits,5022,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],247,100,660,286,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Type A ED Visits,5022,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],150.68,31.59,156.71,126,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Type A ED Visits,5022,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],61.73,61.73,61.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Type A ED Visits,5022,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],68.89,37.64,162.64,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Type A ED Visits,5022,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],150.67,115.28,343.67,67,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Type A ED Visits,5022,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",122.54,122.54,122.54,265,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Type A ED Visits,5022,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,247,247,247,1 through 10,percent of total billed charges,,,
Level 2 Type A ED Visits,5022,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",115.28,115.28,183.97,768,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Type A ED Visits,5022,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],211.83,150,287.11,25,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Type A ED Visits,5022,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],247,106.56,507.33,56,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Type A ED Visits,5022,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],148.89,118.63,150.78,111,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Type A ED Visits,5022,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],247,247,247,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Type A ED Visits,5022,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],148.89,118.63,148.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Type A ED Visits,5022,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],150.48,31.71,156.71,348,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Type A ED Visits,5022,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],247,72.78,671.29,324,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Type A ED Visits,5022,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",114.02,114.02,114.02,299,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Type A ED Visits,5022,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Type A ED Visits,5022,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,197.6,197.6,197.6,1 through 10,percent of total billed charges,,,
Level 3 Type A ED Visits,5023,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],273.23,166.07,410.83,73,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Type A ED Visits,5023,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,608,266.07,1013.59,210,percent of total billed charges,,,
Level 3 Type A ED Visits,5023,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],797.03,329.12,1411,1622,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Type A ED Visits,5023,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],263.05,153.9,409.42,421,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Type A ED Visits,5023,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],173.36,147.14,272.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Type A ED Visits,5023,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],282.51,157.51,437.52,95,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Type A ED Visits,5023,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],476.41,184.99,863.76,430,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Type A ED Visits,5023,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",331.33,218.37,469.03,642,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Type A ED Visits,5023,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Type A ED Visits,5023,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],392.64,227.64,593.2,150,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Type A ED Visits,5023,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",308.57,183.94,434.61,3370,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Type A ED Visits,5023,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],687.61,286.3,1160.41,302,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Type A ED Visits,5023,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],260.33,207.42,400.11,604,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Type A ED Visits,5023,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],561.28,365.01,870.51,19,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Type A ED Visits,5023,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],261.77,207.42,571.89,33,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Type A ED Visits,5023,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],829,288,1211.03,1382,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Type A ED Visits,5023,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],269.64,147.14,357.89,1228,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Type A ED Visits,5023,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",305.22,191.59,451.68,685,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Type A ED Visits,5023,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Type A ED Visits,5023,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,466.4,192.45,1029.6,32,percent of total billed charges,,,
Level 4 Type A ED Visits,5024,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],594.05,311.93,978.23,179,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Type A ED Visits,5024,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,1726.92,668.95,4886.2,809,percent of total billed charges,,,
Level 4 Type A ED Visits,5024,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],1943.87,864.63,3365.83,6455,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Type A ED Visits,5024,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],611.38,401.12,976.62,1489,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Type A ED Visits,5024,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],598.62,407.83,860.64,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Type A ED Visits,5024,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],629.71,397.16,1007.34,441,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Type A ED Visits,5024,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],1336.36,473.97,3622.34,1685,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Type A ED Visits,5024,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",701.91,438.48,1157.2,1303,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Type A ED Visits,5024,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,1967.93,1967.93,3931.25,1 through 10,percent of total billed charges,,,
Level 4 Type A ED Visits,5024,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],858.23,425.01,1408.54,628,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Type A ED Visits,5024,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",589.41,334.36,994.69,6884,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Type A ED Visits,5024,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],1790.75,750.41,3815.04,1216,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Type A ED Visits,5024,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],605.84,400.35,948.41,1846,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Type A ED Visits,5024,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],1987.43,868.81,3384.21,53,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Type A ED Visits,5024,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],611.48,400.35,972.82,122,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Type A ED Visits,5024,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],2243.09,898.95,4217.49,5596,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Type A ED Visits,5024,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],624.59,390.5,993.21,4121,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Type A ED Visits,5024,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",634.11,364.55,1220.93,1304,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Type A ED Visits,5024,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],820.73,820.73,976.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Type A ED Visits,5024,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,2036.8,973.2,5370.8,157,percent of total billed charges,,,
Level 5 Type A ED Visits,5025,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],950.57,566.86,2619.12,236,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 Type A ED Visits,5025,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,2960.2,900,6851.4,445,percent of total billed charges,,,
Level 5 Type A ED Visits,5025,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],2962.97,1513.38,6450.01,3142,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 Type A ED Visits,5025,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],932.15,633.8,2581.44,991,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 Type A ED Visits,5025,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],934.53,685.3,1227.66,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 Type A ED Visits,5025,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],981.96,593.63,2680.1,321,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 Type A ED Visits,5025,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],1985.85,854.85,5912.73,906,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 Type A ED Visits,5025,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",1036.77,690.6,2598.33,699,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 Type A ED Visits,5025,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,2081.9,2081.9,2081.9,1 through 10,percent of total billed charges,,,
Level 5 Type A ED Visits,5025,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",877.21,609.48,1534.33,4739,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 Type A ED Visits,5025,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],1325.39,620.47,2013.28,444,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 Type A ED Visits,5025,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],3099.27,1357.06,5806.77,659,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 Type A ED Visits,5025,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],907.17,652.01,1752.1,1855,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 Type A ED Visits,5025,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],2802.8,1524.49,5212.4,38,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 Type A ED Visits,5025,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],955.89,659.03,2481.75,96,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 Type A ED Visits,5025,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],3246,1614.71,8668.83,3268,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 Type A ED Visits,5025,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],956.38,619.92,2604.55,3153,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 Type A ED Visits,5025,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",964.2,571.74,2808.32,719,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 Type A ED Visits,5025,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Type A ED Visits,5025,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,4840.8,2305.2,13768.32,100,percent of total billed charges,,,
Critical Care,5041,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],,,,0,other,,,No services performed during 15-month lookback period.
Critical Care,5041,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Critical Care,5041,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Critical Care,5041,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Critical Care,5041,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Critical Care,5041,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Critical Care,5041,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],,,,0,other,,,No services performed during 15-month lookback period.
Critical Care,5041,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Critical Care,5041,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Critical Care,5041,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Critical Care,5041,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Critical Care,5041,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Critical Care,5041,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Critical Care,5041,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Critical Care,5041,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Critical Care,5041,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],2581.22,2581.22,2581.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Critical Care,5041,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],,,,0,other,,,No services performed during 15-month lookback period.
Critical Care,5041,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Critical Care,5041,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Critical Care,5041,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Skin Procedures,5051,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],370,179,592,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Skin Procedures,5051,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,2686.6,2686.6,2686.6,1 through 10,percent of total billed charges,,,
Level 1 Skin Procedures,5051,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],299,225.58,534,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Skin Procedures,5051,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],379.7,193.49,637.98,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Skin Procedures,5051,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Skin Procedures,5051,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],49.3,47.6,363.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Skin Procedures,5051,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],401.99,282.67,706.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Skin Procedures,5051,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",259.41,259.41,259.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Skin Procedures,5051,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Skin Procedures,5051,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],742.68,322.73,891.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Skin Procedures,5051,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",273.48,189.84,610.92,58,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Skin Procedures,5051,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],1026.66,355.13,1634.98,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Skin Procedures,5051,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],292.99,176.47,864.87,69,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Skin Procedures,5051,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],186.05,186.05,492.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Skin Procedures,5051,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Skin Procedures,5051,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],347.7,193.5,763.5,64,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Skin Procedures,5051,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],778.74,198.18,1780,54,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Skin Procedures,5051,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",241.37,227.03,434,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Skin Procedures,5051,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Skin Procedures,5051,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Skin Procedures,5052,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],633.12,633.12,633.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Skin Procedures,5052,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,902.4,902.4,9968.52,1 through 10,percent of total billed charges,,,
Level 2 Skin Procedures,5052,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],867,372.32,1431.05,35,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Skin Procedures,5052,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],525.82,524.79,634.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Skin Procedures,5052,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Skin Procedures,5052,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],686.54,686.54,686.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Skin Procedures,5052,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],400.97,383.46,569.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Skin Procedures,5052,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",358.69,332.42,576.62,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Skin Procedures,5052,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Skin Procedures,5052,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",381.59,244.03,653.96,53,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Skin Procedures,5052,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],747,726,1008.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Skin Procedures,5052,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],634.44,378.71,637.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Skin Procedures,5052,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Skin Procedures,5052,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Skin Procedures,5052,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Skin Procedures,5052,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],628.11,390.42,661.51,24,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Skin Procedures,5052,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],1120,524.39,2157.18,30,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Skin Procedures,5052,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",342.61,309.29,382.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Skin Procedures,5052,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Skin Procedures,5052,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,306.4,306.4,306.4,1 through 10,percent of total billed charges,,,
Level 3 Skin Procedures,5053,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,3473.96,3473.96,3473.96,1 through 10,percent of total billed charges,,,
Level 3 Skin Procedures,5053,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Skin Procedures,5053,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],2548.9,1281.05,4581.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Skin Procedures,5053,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],833.75,833.75,833.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Skin Procedures,5053,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Skin Procedures,5053,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Skin Procedures,5053,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Skin Procedures,5053,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",1324.18,1324.18,1324.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Skin Procedures,5053,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Skin Procedures,5053,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],445,445,445,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Skin Procedures,5053,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",654.41,654.41,654.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Skin Procedures,5053,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],974.4,974.4,974.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Skin Procedures,5053,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Skin Procedures,5053,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Skin Procedures,5053,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Skin Procedures,5053,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],13017.19,13017.19,13017.19,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Skin Procedures,5053,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],868.25,868.25,868.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Skin Procedures,5053,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",2480.06,2480.06,2480.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Skin Procedures,5053,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Skin Procedures,5053,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Skin Procedures,5054,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Skin Procedures,5054,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Skin Procedures,5054,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],6714.57,6714.57,6714.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Skin Procedures,5054,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],1781.35,1781.35,1781.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Skin Procedures,5054,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Skin Procedures,5054,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],2217.36,2217.36,2217.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Skin Procedures,5054,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],8356.42,7599.81,12678.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Skin Procedures,5054,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Skin Procedures,5054,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Skin Procedures,5054,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",2341.79,565.07,2359.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Skin Procedures,5054,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Skin Procedures,5054,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Skin Procedures,5054,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Skin Procedures,5054,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Skin Procedures,5054,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Skin Procedures,5054,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],2275.82,1678.32,2682.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Skin Procedures,5054,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],3104.34,1199.22,7138.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Skin Procedures,5054,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Skin Procedures,5054,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Skin Procedures,5054,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 5 Skin Procedures,5055,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Skin Procedures,5055,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 5 Skin Procedures,5055,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Skin Procedures,5055,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Skin Procedures,5055,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Skin Procedures,5055,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],7565.22,7565.22,7565.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 Skin Procedures,5055,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Skin Procedures,5055,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Skin Procedures,5055,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 5 Skin Procedures,5055,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3651.5,3651.5,3651.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 Skin Procedures,5055,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],10388.86,10388.86,10388.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 Skin Procedures,5055,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],1.06,1.06,1.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 Skin Procedures,5055,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Skin Procedures,5055,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Skin Procedures,5055,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Skin Procedures,5055,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],16044.66,16044.66,16044.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 Skin Procedures,5055,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],3860.14,3860.14,4456.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 Skin Procedures,5055,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Skin Procedures,5055,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Skin Procedures,5055,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,17047.22,17047.22,17047.22,1 through 10,percent of total billed charges,,,
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],691.76,616.88,1806.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,2246.56,1653.95,5415.8,16,percent of total billed charges,,,
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],2854,1829.6,3391.42,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],691.08,685.18,696.08,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],711.53,446.93,770.96,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],1490.84,730.24,3997.92,43,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",1309.34,1309.34,1568.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",856.06,312.69,1283.58,47,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],1088.1,968.23,1355.34,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],2287.02,1508.97,3133.3,35,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],658.82,620.17,683.82,37,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],658.82,640.17,658.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],2572,643,2982.61,102,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],687.18,548.14,692.68,65,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",843.23,772.55,2553.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Excision/ Biopsy/ Incision and Drainage,5071,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,2057.6,2057.6,2057.6,1 through 10,percent of total billed charges,,,
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],1593.01,1567.16,1599.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,3293.84,2973.88,9541.04,11,percent of total billed charges,,,
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],5612,3061.31,11992.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],1486.81,1262.26,1585.29,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],1598.92,1373.92,1643.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],2910.92,2099.01,8286.24,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",1513.15,1513.15,1513.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],2492.7,1859,5427.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",1402.48,827.79,2549.25,30,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],2506.51,1862.79,5441.64,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],1517.15,1359.1,1523.34,62,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],5511.58,5511.58,5511.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],1521.15,1521.15,1521.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],1579.83,1210.33,1584.83,70,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],5621,3159,6869.41,89,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",2352.46,77.02,6801.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Excision/ Biopsy/ Incision and Drainage,5072,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,3778.4,2988.16,17222,1 through 10,percent of total billed charges,,,
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],2814.7,2814.7,2814.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,8308.1,8048.39,10279.46,1 through 10,percent of total billed charges,,,
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],9375,9375,9375,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],2899.73,2899.73,2899.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],7129.68,4042.47,9513.56,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",2338.27,2107.52,3180.72,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],4208.22,4208.22,5030.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],5785.44,5785.44,13324.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],2611.36,2336.67,2690.88,27,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],2787.14,2419.64,3037.14,26,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],11401.71,7860,12133.63,53,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",1399.19,1399.19,1399.19,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Excision/ Biopsy/ Incision and Drainage,5073,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,8020.8,5580.32,26903.8,1 through 10,percent of total billed charges,,,
Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],3533.4,3533.4,3533.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,14040.82,13120,19280.05,1 through 10,percent of total billed charges,,,
Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],7623.06,7134.74,33456.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],3631.05,3631.05,4104.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],6330.42,3857.87,6600.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],11436.55,9149.39,14414.91,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3641.08,3641.08,3641.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],5664.37,5246.74,7836.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",2677.29,2504.58,4624.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],7914.93,5667.55,12138.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],3589.62,3362.41,6110.5,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],3592.48,3592.48,3592.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],3736.55,3496.31,6353.76,37,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],16234.37,13500.44,27645.37,45,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Breast/Lymphatic Surgery and Related Procedures,5091,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,11942.02,11942.02,11942.02,1 through 10,percent of total billed charges,,,
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,62795.73,16959.4,65518.6,1 through 10,percent of total billed charges,,,
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],14752.77,11650.42,29806.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],3731.05,3731.05,3731.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],6465.42,6465.42,6465.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],14505.07,13790.94,19633.25,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],4994.58,3976.11,6308.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",5824.5,3220.46,10955.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],15132.33,13887.12,19901.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],6131.42,6110.5,12586.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],31381.31,25306.94,40564.54,24,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],6353.76,6237.08,9326.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Breast/Lymphatic Surgery and Related Procedures,5092,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,19742.71,19742.71,19742.71,1 through 10,percent of total billed charges,,,
Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],29045.77,29045.77,29045.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],10292.89,10292.89,10292.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],7070.5,7070.5,7070.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",8737.96,8737.96,8737.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],9957.57,9957.57,9957.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],33107.86,25289.15,40564.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Breast/Lymphatic Surgery and Related Procedures,5093,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Breast/Lymphatic Surgery and Related Procedures,5094,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Breast/Lymphatic Surgery and Related Procedures,5094,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Breast/Lymphatic Surgery and Related Procedures,5094,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],29688.04,29688.04,29688.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Breast/Lymphatic Surgery and Related Procedures,5094,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Breast/Lymphatic Surgery and Related Procedures,5094,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Breast/Lymphatic Surgery and Related Procedures,5094,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],24060.6,24060.6,24060.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Breast/Lymphatic Surgery and Related Procedures,5094,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Breast/Lymphatic Surgery and Related Procedures,5094,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Breast/Lymphatic Surgery and Related Procedures,5094,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Breast/Lymphatic Surgery and Related Procedures,5094,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],7285.98,7285.98,7285.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Breast/Lymphatic Surgery and Related Procedures,5094,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",13043,13043,13043,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Breast/Lymphatic Surgery and Related Procedures,5094,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Breast/Lymphatic Surgery and Related Procedures,5094,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Breast/Lymphatic Surgery and Related Procedures,5094,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Breast/Lymphatic Surgery and Related Procedures,5094,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Breast/Lymphatic Surgery and Related Procedures,5094,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],32069.14,14730.26,73254.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Breast/Lymphatic Surgery and Related Procedures,5094,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],15668.86,15668.86,15668.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Breast/Lymphatic Surgery and Related Procedures,5094,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Breast/Lymphatic Surgery and Related Procedures,5094,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Breast/Lymphatic Surgery and Related Procedures,5094,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Strapping and Cast Application,5101,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],74.64,74.64,724,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Strapping and Cast Application,5101,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Strapping and Cast Application,5101,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],305.13,305.13,305.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Strapping and Cast Application,5101,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],531.28,404.66,2498,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Strapping and Cast Application,5101,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Strapping and Cast Application,5101,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],132.84,66.42,132.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Strapping and Cast Application,5101,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],456.59,229.97,2357.04,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Strapping and Cast Application,5101,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",509.67,347.19,580.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Strapping and Cast Application,5101,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Strapping and Cast Application,5101,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",388.54,205.82,515.12,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Strapping and Cast Application,5101,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],474.93,383.46,1736.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Strapping and Cast Application,5101,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],1319.25,422.23,2064.5,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Strapping and Cast Application,5101,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],416.7,148.36,1292.88,53,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Strapping and Cast Application,5101,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],159.24,159.24,159.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Strapping and Cast Application,5101,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Strapping and Cast Application,5101,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],558.34,153.67,1551.54,50,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Strapping and Cast Application,5101,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],1884.11,702.87,3986.74,34,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Strapping and Cast Application,5101,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",601.31,442.1,661.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Strapping and Cast Application,5101,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Strapping and Cast Application,5101,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Musculoskeletal Procedures,5111,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Musculoskeletal Procedures,5111,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Musculoskeletal Procedures,5111,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],633,633,633,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Musculoskeletal Procedures,5111,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],374.2,374.2,374.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Musculoskeletal Procedures,5111,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Musculoskeletal Procedures,5111,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Musculoskeletal Procedures,5111,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Musculoskeletal Procedures,5111,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",278.4,278.4,278.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Musculoskeletal Procedures,5111,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Musculoskeletal Procedures,5111,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",261.89,261.89,261.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Musculoskeletal Procedures,5111,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],502.08,502.08,502.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Musculoskeletal Procedures,5111,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Musculoskeletal Procedures,5111,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Musculoskeletal Procedures,5111,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Musculoskeletal Procedures,5111,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Musculoskeletal Procedures,5111,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],295.44,295.44,885.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Musculoskeletal Procedures,5111,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],1536.5,1536.5,1536.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Musculoskeletal Procedures,5111,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Musculoskeletal Procedures,5111,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Musculoskeletal Procedures,5111,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Musculoskeletal Procedures,5112,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],1489.53,1489.53,1575.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Musculoskeletal Procedures,5112,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,2875.84,2491.13,11533.45,1 through 10,percent of total billed charges,,,
Level 2 Musculoskeletal Procedures,5112,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],3178.51,2419.1,5555,26,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Musculoskeletal Procedures,5112,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],1562.45,1560.52,1566.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Musculoskeletal Procedures,5112,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Musculoskeletal Procedures,5112,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],1623.86,1623.86,1623.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Musculoskeletal Procedures,5112,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],1855.11,996.7,5371.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Musculoskeletal Procedures,5112,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",1032.14,1032.14,1801.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Musculoskeletal Procedures,5112,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Musculoskeletal Procedures,5112,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",1477.23,872.65,2265.26,22,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Musculoskeletal Procedures,5112,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],1122,774,1763.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Musculoskeletal Procedures,5112,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],2672.7,2265.8,4867.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Musculoskeletal Procedures,5112,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],1510.83,1502.58,2247.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Musculoskeletal Procedures,5112,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],1416.7,1416.7,1416.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Musculoskeletal Procedures,5112,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Musculoskeletal Procedures,5112,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],1559.53,1436.02,1906.64,23,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Musculoskeletal Procedures,5112,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],3932,3177.24,6624.26,32,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Musculoskeletal Procedures,5112,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",1955.77,1440.31,2232.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Musculoskeletal Procedures,5112,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Musculoskeletal Procedures,5112,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,3958.4,3958.4,3958.4,1 through 10,percent of total billed charges,,,
Level 3 Musculoskeletal Procedures,5113,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,14140.07,14140.07,14140.07,1 through 10,percent of total billed charges,,,
Level 3 Musculoskeletal Procedures,5113,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Musculoskeletal Procedures,5113,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],5524.81,5524.81,14237.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Musculoskeletal Procedures,5113,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Musculoskeletal Procedures,5113,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Musculoskeletal Procedures,5113,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],3285.37,3285.37,3285.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Musculoskeletal Procedures,5113,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],10186.92,7339.4,16754.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Musculoskeletal Procedures,5113,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3338.66,3338.66,3338.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Musculoskeletal Procedures,5113,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Musculoskeletal Procedures,5113,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],6512.43,6512.43,6512.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Musculoskeletal Procedures,5113,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",2285.96,1932.1,6118.1,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Musculoskeletal Procedures,5113,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],7545.49,7545.49,7545.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Musculoskeletal Procedures,5113,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],2864.81,2431.89,3050.56,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Musculoskeletal Procedures,5113,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],2695.85,2695.85,2695.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Musculoskeletal Procedures,5113,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Musculoskeletal Procedures,5113,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],3162.69,2972.29,3331.82,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Musculoskeletal Procedures,5113,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],12988.08,8751.1,13954.02,28,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Musculoskeletal Procedures,5113,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",2261.06,2261.06,2261.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Musculoskeletal Procedures,5113,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Musculoskeletal Procedures,5113,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Musculoskeletal Procedures,5114,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],10133.92,10133.92,10133.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Musculoskeletal Procedures,5114,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,29579.59,29579.59,29579.59,1 through 10,percent of total billed charges,,,
Level 4 Musculoskeletal Procedures,5114,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],19526.94,10545.72,29359.33,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Musculoskeletal Procedures,5114,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],7054.68,6589.25,9252.14,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Musculoskeletal Procedures,5114,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Musculoskeletal Procedures,5114,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],7229.71,6960.24,7329.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Musculoskeletal Procedures,5114,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],13118.42,8831.29,22112.12,22,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Musculoskeletal Procedures,5114,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",18655.85,18655.85,18655.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Musculoskeletal Procedures,5114,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,9516.04,9516.04,9516.04,1 through 10,percent of total billed charges,,,
Level 4 Musculoskeletal Procedures,5114,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],9340.05,4903.66,10898.34,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Musculoskeletal Procedures,5114,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",5581.82,2812.29,9548.48,27,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Musculoskeletal Procedures,5114,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],9966.82,7571.03,12660.13,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Musculoskeletal Procedures,5114,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],6696.18,6128.91,6880.22,19,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Musculoskeletal Procedures,5114,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],12065.2,12065.2,12065.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Musculoskeletal Procedures,5114,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],6331.79,6331.79,6331.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Musculoskeletal Procedures,5114,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],6962.75,6560.3,7486.6,33,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Musculoskeletal Procedures,5114,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],29486.31,20251.59,30619.79,45,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Musculoskeletal Procedures,5114,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",6504.27,5355.54,7081.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Musculoskeletal Procedures,5114,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Musculoskeletal Procedures,5114,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,25100.7,25100.7,44285.67,1 through 10,percent of total billed charges,,,
Level 5 Musculoskeletal Procedures,5115,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],12285.47,12186.64,12827.3,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 Musculoskeletal Procedures,5115,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,32706.96,26591.42,47515.74,14,percent of total billed charges,,,
Level 5 Musculoskeletal Procedures,5115,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],41694.41,17432.74,52715.01,20,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 Musculoskeletal Procedures,5115,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],12632.26,12162.77,13023.41,35,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 Musculoskeletal Procedures,5115,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Musculoskeletal Procedures,5115,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],13116.76,12846.76,13194.08,26,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 Musculoskeletal Procedures,5115,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],25703.12,17695.22,31814.86,45,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 Musculoskeletal Procedures,5115,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",16895.21,9174.51,17167.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 Musculoskeletal Procedures,5115,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 5 Musculoskeletal Procedures,5115,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],17407.44,15798.53,18654.19,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 Musculoskeletal Procedures,5115,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",13663.88,9552.2,16575.69,39,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 Musculoskeletal Procedures,5115,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],17341.33,11300.83,34322.67,28,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 Musculoskeletal Procedures,5115,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],12143.43,11603.58,12261.03,112,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 Musculoskeletal Procedures,5115,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],8612.42,8612.42,8612.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 Musculoskeletal Procedures,5115,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],12138.45,11827.38,12242.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 Musculoskeletal Procedures,5115,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],12628.53,12162.53,12721.14,249,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 Musculoskeletal Procedures,5115,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],48456.89,39621.35,54643.33,142,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 Musculoskeletal Procedures,5115,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",15857.6,15848.47,33237.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 Musculoskeletal Procedures,5115,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Musculoskeletal Procedures,5115,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,31321.46,31321.46,31321.46,1 through 10,percent of total billed charges,,,
Level 6 Musculoskeletal Procedures,5116,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],17253.88,17253.88,17253.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 6 Musculoskeletal Procedures,5116,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,40074.47,39255.33,50674.25,1 through 10,percent of total billed charges,,,
Level 6 Musculoskeletal Procedures,5116,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],77303.67,17716.94,83438.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 6 Musculoskeletal Procedures,5116,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],17915.47,17084.11,18105.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 6 Musculoskeletal Procedures,5116,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Musculoskeletal Procedures,5116,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],18602.89,18602.89,18602.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 6 Musculoskeletal Procedures,5116,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],34784.32,24781.59,36728.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 6 Musculoskeletal Procedures,5116,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Musculoskeletal Procedures,5116,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 6 Musculoskeletal Procedures,5116,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],19201.4,19201.4,24862.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 6 Musculoskeletal Procedures,5116,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",20223.85,19260.98,23897.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 6 Musculoskeletal Procedures,5116,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],18190.39,18190.39,18190.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 6 Musculoskeletal Procedures,5116,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],17224.75,16494.08,17476.59,19,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 6 Musculoskeletal Procedures,5116,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Musculoskeletal Procedures,5116,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Musculoskeletal Procedures,5116,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],17911.69,14963.61,18110.16,36,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 6 Musculoskeletal Procedures,5116,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],60440.51,52663.68,78156.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 6 Musculoskeletal Procedures,5116,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Musculoskeletal Procedures,5116,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Musculoskeletal Procedures,5116,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,36907.27,36907.27,36907.27,1 through 10,percent of total billed charges,,,
Level 1 Airway Endoscopy,5151,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],187.07,187.07,187.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Airway Endoscopy,5151,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,306.28,306.28,396.85,1 through 10,percent of total billed charges,,,
Level 1 Airway Endoscopy,5151,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],378,378,378,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Airway Endoscopy,5151,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],125.5,125.5,125.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Airway Endoscopy,5151,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Airway Endoscopy,5151,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],245.83,245.83,479.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Airway Endoscopy,5151,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Airway Endoscopy,5151,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Airway Endoscopy,5151,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Airway Endoscopy,5151,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",275.59,275.59,275.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Airway Endoscopy,5151,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],645.34,645.34,645.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Airway Endoscopy,5151,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],302.46,302.46,332.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Airway Endoscopy,5151,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],291.12,291.12,291.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Airway Endoscopy,5151,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Airway Endoscopy,5151,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Airway Endoscopy,5151,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],318.42,275.5,318.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Airway Endoscopy,5151,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],1210,833,1255,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Airway Endoscopy,5151,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Airway Endoscopy,5151,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Airway Endoscopy,5151,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Airway Endoscopy,5153,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Airway Endoscopy,5153,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Airway Endoscopy,5153,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],3807.96,3748.87,4106.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Airway Endoscopy,5153,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],1686.84,1686.84,1922.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Airway Endoscopy,5153,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Airway Endoscopy,5153,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],3406.85,3406.85,3406.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Airway Endoscopy,5153,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Airway Endoscopy,5153,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Airway Endoscopy,5153,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Airway Endoscopy,5153,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",1617.65,1617.65,1617.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Airway Endoscopy,5153,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],2551.27,2551.27,2618.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Airway Endoscopy,5153,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],3079.84,3079.84,3079.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Airway Endoscopy,5153,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],1621.34,1621.34,1665.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Airway Endoscopy,5153,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Airway Endoscopy,5153,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Airway Endoscopy,5153,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],1679.34,1311.84,1686.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Airway Endoscopy,5153,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],7310.29,7310.29,7465.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Airway Endoscopy,5153,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Airway Endoscopy,5153,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Airway Endoscopy,5153,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Airway Endoscopy,5154,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],3471.5,3471.5,3471.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Airway Endoscopy,5154,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Airway Endoscopy,5154,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],13202.15,11793.45,13751.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Airway Endoscopy,5154,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],6212.49,6212.49,6212.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Airway Endoscopy,5154,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Airway Endoscopy,5154,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],7005.95,7005.95,7005.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Airway Endoscopy,5154,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],9816.45,9816.45,9816.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Airway Endoscopy,5154,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Airway Endoscopy,5154,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Airway Endoscopy,5154,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],5291.65,5291.65,5291.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Airway Endoscopy,5154,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4172.09,4172.09,4172.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Airway Endoscopy,5154,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],3241.95,3241.95,3241.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Airway Endoscopy,5154,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],3456.35,3314.42,6464.99,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Airway Endoscopy,5154,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],9448.97,9448.97,9448.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Airway Endoscopy,5154,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],6187.99,6187.99,6487.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Airway Endoscopy,5154,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],6743.28,3435.98,6748.27,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Airway Endoscopy,5154,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],15629.51,15629.51,15629.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Airway Endoscopy,5154,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Airway Endoscopy,5154,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Airway Endoscopy,5154,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 5 Airway Endoscopy,5155,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Airway Endoscopy,5155,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 5 Airway Endoscopy,5155,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],6747.77,6747.77,6747.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 Airway Endoscopy,5155,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Airway Endoscopy,5155,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Airway Endoscopy,5155,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],15919.17,15919.17,15919.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 Airway Endoscopy,5155,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Airway Endoscopy,5155,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",2960.89,2960.89,2960.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 Airway Endoscopy,5155,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 5 Airway Endoscopy,5155,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],12607.2,12607.2,12607.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 Airway Endoscopy,5155,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Airway Endoscopy,5155,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Airway Endoscopy,5155,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Airway Endoscopy,5155,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Airway Endoscopy,5155,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Airway Endoscopy,5155,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],6748.77,6748.77,6748.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 Airway Endoscopy,5155,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Airway Endoscopy,5155,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Airway Endoscopy,5155,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Airway Endoscopy,5155,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 ENT Procedures,5161,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 ENT Procedures,5161,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 ENT Procedures,5161,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 ENT Procedures,5161,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 ENT Procedures,5161,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 ENT Procedures,5161,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 ENT Procedures,5161,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 ENT Procedures,5161,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 ENT Procedures,5161,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 ENT Procedures,5161,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],780.01,780.01,780.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 ENT Procedures,5161,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 ENT Procedures,5161,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 ENT Procedures,5161,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 ENT Procedures,5161,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 ENT Procedures,5161,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 ENT Procedures,5161,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],805.42,310.43,3121.18,21,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 ENT Procedures,5161,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 ENT Procedures,5161,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 ENT Procedures,5161,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 ENT Procedures,5161,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 ENT Procedures,5162,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 ENT Procedures,5162,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 ENT Procedures,5162,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],9304.62,9304.62,9304.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 ENT Procedures,5162,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 ENT Procedures,5162,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 ENT Procedures,5162,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 ENT Procedures,5162,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 ENT Procedures,5162,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 ENT Procedures,5162,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 ENT Procedures,5162,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],2812.2,2812.2,2812.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 ENT Procedures,5162,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 ENT Procedures,5162,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 ENT Procedures,5162,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 ENT Procedures,5162,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 ENT Procedures,5162,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 ENT Procedures,5162,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],1513.8,1513.8,1513.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 ENT Procedures,5162,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",989.6,989.6,989.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 ENT Procedures,5162,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 ENT Procedures,5162,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 ENT Procedures,5162,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 ENT Procedures,5163,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 ENT Procedures,5163,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 ENT Procedures,5163,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],10895.6,10895.6,10895.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 ENT Procedures,5163,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 ENT Procedures,5163,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 ENT Procedures,5163,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],6674.01,6674.01,6674.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 ENT Procedures,5163,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 ENT Procedures,5163,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 ENT Procedures,5163,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 ENT Procedures,5163,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",2280.42,673.96,4512.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 ENT Procedures,5163,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],4245.99,4245.99,4245.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 ENT Procedures,5163,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],1395.7,1349.78,4016.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 ENT Procedures,5163,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 ENT Procedures,5163,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 ENT Procedures,5163,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 ENT Procedures,5163,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],1445.51,1445.51,1445.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 ENT Procedures,5163,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],6079.37,5605.07,6279.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 ENT Procedures,5163,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",2255.58,2255.58,2255.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 ENT Procedures,5163,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 ENT Procedures,5163,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 ENT Procedures,5164,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,6636.22,6636.22,6636.22,1 through 10,percent of total billed charges,,,
Level 4 ENT Procedures,5164,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 ENT Procedures,5164,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],9172.38,9172.38,10382.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 ENT Procedures,5164,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 ENT Procedures,5164,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 ENT Procedures,5164,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],11319.77,11319.77,13186.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 ENT Procedures,5164,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 ENT Procedures,5164,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 ENT Procedures,5164,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 ENT Procedures,5164,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],6543.72,6543.72,6543.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 ENT Procedures,5164,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",2234.07,2208.04,5534.53,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 ENT Procedures,5164,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],7788.3,7788.3,7788.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 ENT Procedures,5164,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],6218.93,6218.93,7737.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 ENT Procedures,5164,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 ENT Procedures,5164,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 ENT Procedures,5164,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],12918.97,10928.82,14364.18,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 ENT Procedures,5164,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",6322.36,6322.36,6322.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 ENT Procedures,5164,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 ENT Procedures,5164,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 ENT Procedures,5164,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 5 ENT Procedures,5165,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,36812.26,19157.75,37403.75,1 through 10,percent of total billed charges,,,
Level 5 ENT Procedures,5165,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 ENT Procedures,5165,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],11851.56,7399.72,15445.77,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 ENT Procedures,5165,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],5771.32,5771.32,5788.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 ENT Procedures,5165,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 ENT Procedures,5165,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],5717.78,5717.78,5982.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 ENT Procedures,5165,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],11456.85,7977.9,16326.39,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 ENT Procedures,5165,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 5 ENT Procedures,5165,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 5 ENT Procedures,5165,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],7853.21,7808.6,7919.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 ENT Procedures,5165,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",2350.23,2210.78,5850.12,46,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 ENT Procedures,5165,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],8510.24,5637.44,10182.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 ENT Procedures,5165,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],5543.24,5167.51,5563.56,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 ENT Procedures,5165,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],13297.09,13297.09,13297.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 ENT Procedures,5165,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],5545.24,5545.24,5545.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 ENT Procedures,5165,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],18586.62,15358.22,24136.89,36,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 ENT Procedures,5165,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],5763.82,5678.82,5766.82,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 ENT Procedures,5165,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",2446.9,2446.9,2446.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 ENT Procedures,5165,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 ENT Procedures,5165,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cochlear Implant Procedure,5166,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],,,,0,other,,,No services performed during 15-month lookback period.
Cochlear Implant Procedure,5166,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cochlear Implant Procedure,5166,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cochlear Implant Procedure,5166,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cochlear Implant Procedure,5166,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cochlear Implant Procedure,5166,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cochlear Implant Procedure,5166,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],,,,0,other,,,No services performed during 15-month lookback period.
Cochlear Implant Procedure,5166,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cochlear Implant Procedure,5166,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cochlear Implant Procedure,5166,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Cochlear Implant Procedure,5166,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cochlear Implant Procedure,5166,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Cochlear Implant Procedure,5166,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Cochlear Implant Procedure,5166,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Cochlear Implant Procedure,5166,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Cochlear Implant Procedure,5166,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],350.82,350.82,350.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cochlear Implant Procedure,5166,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],,,,0,other,,,No services performed during 15-month lookback period.
Cochlear Implant Procedure,5166,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cochlear Implant Procedure,5166,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cochlear Implant Procedure,5166,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Vascular Procedures,5181,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,722.31,722.31,722.31,1 through 10,percent of total billed charges,,,
Level 1 Vascular Procedures,5181,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Vascular Procedures,5181,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],12821.12,12821.12,12821.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Vascular Procedures,5181,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],10611.03,10611.03,10611.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Vascular Procedures,5181,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Vascular Procedures,5181,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],360.64,360.64,360.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Vascular Procedures,5181,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Vascular Procedures,5181,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Vascular Procedures,5181,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Vascular Procedures,5181,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",640.18,511.5,640.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Vascular Procedures,5181,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],1676.26,1676.26,1676.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Vascular Procedures,5181,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],581.29,147.69,582.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Vascular Procedures,5181,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],584.93,584.93,584.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Vascular Procedures,5181,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Vascular Procedures,5181,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Vascular Procedures,5181,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],605.09,301.63,705.65,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Vascular Procedures,5181,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],1927,1927,1927,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Vascular Procedures,5181,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4199.59,4199.59,4199.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Vascular Procedures,5181,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Vascular Procedures,5181,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,147.36,147.36,147.36,1 through 10,percent of total billed charges,,,
Level 2 Vascular Procedures,5182,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,3819.56,3819.56,10233.89,1 through 10,percent of total billed charges,,,
Level 2 Vascular Procedures,5182,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Vascular Procedures,5182,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],3283.13,3283.13,3283.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Vascular Procedures,5182,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],1370.17,1145.28,1546.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Vascular Procedures,5182,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Vascular Procedures,5182,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],1576.36,1306.36,1576.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Vascular Procedures,5182,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],6943.02,1998.97,7553.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Vascular Procedures,5182,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Vascular Procedures,5182,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Vascular Procedures,5182,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],2203.98,2077.99,2203.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Vascular Procedures,5182,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",1106.41,1106.41,1516.56,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Vascular Procedures,5182,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],1714.73,1576.98,22975.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Vascular Procedures,5182,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],1456.29,1274.94,1460.53,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Vascular Procedures,5182,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Vascular Procedures,5182,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Vascular Procedures,5182,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],3919,2884,6585.25,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Vascular Procedures,5182,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],1463.5,1145.28,1520.28,30,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Vascular Procedures,5182,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",1419.43,1419.43,1419.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Vascular Procedures,5182,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Vascular Procedures,5182,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Vascular Procedures,5183,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],3094.59,2955.64,3097.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Vascular Procedures,5183,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,11027.6,11027.6,16925.42,1 through 10,percent of total billed charges,,,
Level 3 Vascular Procedures,5183,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],8350.37,4552.76,10795.45,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Vascular Procedures,5183,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],3067.11,2285.9,3077.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Vascular Procedures,5183,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Vascular Procedures,5183,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],3187.16,2918.4,3188.4,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Vascular Procedures,5183,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],5522.94,4492.04,8643.21,24,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Vascular Procedures,5183,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",2866.71,2866.71,2866.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Vascular Procedures,5183,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Vascular Procedures,5183,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],4210.32,4210.32,4386.51,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Vascular Procedures,5183,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",2692.39,2060.79,3809.78,34,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Vascular Procedures,5183,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],5796.04,4267.58,11707.83,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Vascular Procedures,5183,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],2951.22,2751.22,2963.12,62,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Vascular Procedures,5183,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],4939.97,4939.97,4939.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Vascular Procedures,5183,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],2963.12,2963.12,2963.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Vascular Procedures,5183,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],3065.11,2697.61,3072.61,65,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Vascular Procedures,5183,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],11630,9676,13344.18,58,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Vascular Procedures,5183,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",2668.58,2663.07,4734.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Vascular Procedures,5183,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Vascular Procedures,5183,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,8992.58,5049.24,13713.3,11,percent of total billed charges,,,
Level 4 Vascular Procedures,5184,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],5325.67,5325.67,5325.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Vascular Procedures,5184,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Vascular Procedures,5184,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],14757.97,14757.97,14757.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Vascular Procedures,5184,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],5255.28,5255.28,5270.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Vascular Procedures,5184,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Vascular Procedures,5184,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],5235.96,5235.96,5235.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Vascular Procedures,5184,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],13563.96,13563.96,13563.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Vascular Procedures,5184,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",9188.99,9188.99,9188.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Vascular Procedures,5184,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Vascular Procedures,5184,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],7423.71,7423.71,7423.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Vascular Procedures,5184,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",7117.73,7117.73,7117.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Vascular Procedures,5184,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],5073.52,4049.39,5446.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Vascular Procedures,5184,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Vascular Procedures,5184,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Vascular Procedures,5184,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Vascular Procedures,5184,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],21204.23,18612.9,22915.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Vascular Procedures,5184,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],5264.21,4974.22,5289.7,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Vascular Procedures,5184,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Vascular Procedures,5184,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Vascular Procedures,5184,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,27383.16,27383.16,27383.16,1 through 10,percent of total billed charges,,,
Level 1 Endovascular Procedures,5191,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],3162.34,3015.93,6577.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Endovascular Procedures,5191,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,10253.92,3021.43,40699.44,1 through 10,percent of total billed charges,,,
Level 1 Endovascular Procedures,5191,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],14483.14,11333.77,25471.78,21,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Endovascular Procedures,5191,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],3132.23,3034.23,7930.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Endovascular Procedures,5191,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Endovascular Procedures,5191,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],3258.1,2837.49,5501.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Endovascular Procedures,5191,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],7945.59,4412.74,12321.15,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Endovascular Procedures,5191,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",5354.97,5354.97,5354.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Endovascular Procedures,5191,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Endovascular Procedures,5191,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3506.32,3501.8,4295.52,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Endovascular Procedures,5191,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],4302.51,3872.26,4335.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Endovascular Procedures,5191,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],4718.21,3556.88,5341.74,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Endovascular Procedures,5191,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],3015.76,2874.81,4601.55,49,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Endovascular Procedures,5191,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],4090.73,4090.73,4090.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Endovascular Procedures,5191,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],2878.31,2878.31,3017.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Endovascular Procedures,5191,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],13634.84,7055,16587.98,41,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Endovascular Procedures,5191,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],3135.23,2789.23,5506.99,73,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Endovascular Procedures,5191,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",23530.14,23530.14,23530.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Endovascular Procedures,5191,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Endovascular Procedures,5191,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Endovascular Procedures,5192,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Endovascular Procedures,5192,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Endovascular Procedures,5192,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],5567.94,5567.94,5567.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Endovascular Procedures,5192,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Endovascular Procedures,5192,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Endovascular Procedures,5192,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],5771.54,5771.54,5771.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Endovascular Procedures,5192,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Endovascular Procedures,5192,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Endovascular Procedures,5192,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Endovascular Procedures,5192,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],5360.53,5357.9,5360.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Endovascular Procedures,5192,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Endovascular Procedures,5192,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Endovascular Procedures,5192,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Endovascular Procedures,5192,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Endovascular Procedures,5192,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Endovascular Procedures,5192,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],10676.24,10088.03,11043.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Endovascular Procedures,5192,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Endovascular Procedures,5192,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Endovascular Procedures,5192,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Endovascular Procedures,5192,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Endovascular Procedures,5193,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],11149.92,11149.92,11149.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Endovascular Procedures,5193,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Endovascular Procedures,5193,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],44587.05,4906.72,116809.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Endovascular Procedures,5193,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],11043.74,9987.02,35750.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Endovascular Procedures,5193,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Endovascular Procedures,5193,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],10691.4,10691.4,10691.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Endovascular Procedures,5193,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Endovascular Procedures,5193,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",10330.29,10330.29,10330.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Endovascular Procedures,5193,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Endovascular Procedures,5193,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],15579,15579,15579,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Endovascular Procedures,5193,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",13406.35,10762.53,34137.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Endovascular Procedures,5193,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],16398.9,12959.37,23596.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Endovascular Procedures,5193,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],10618.98,9697.14,13073.74,24,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Endovascular Procedures,5193,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Endovascular Procedures,5193,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Endovascular Procedures,5193,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],11046.74,10091.62,16080.35,32,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Endovascular Procedures,5193,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],45685.02,34482,48074.27,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Endovascular Procedures,5193,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Endovascular Procedures,5193,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Endovascular Procedures,5193,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,37540,37540,37540,1 through 10,percent of total billed charges,,,
Level 4 Endovascular Procedures,5194,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Endovascular Procedures,5194,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Endovascular Procedures,5194,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],44804.99,44804.99,46067.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Endovascular Procedures,5194,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],17388.71,17388.71,17388.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Endovascular Procedures,5194,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Endovascular Procedures,5194,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],4769.42,4769.42,4769.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Endovascular Procedures,5194,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Endovascular Procedures,5194,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",18922.26,18922.26,18922.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Endovascular Procedures,5194,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Endovascular Procedures,5194,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",16571.37,9678.6,28041.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Endovascular Procedures,5194,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],26743.03,26743.03,26743.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Endovascular Procedures,5194,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],16653.14,15511.9,20113.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Endovascular Procedures,5194,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Endovascular Procedures,5194,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Endovascular Procedures,5194,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Endovascular Procedures,5194,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],17494.21,14112.02,20424.8,22,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Endovascular Procedures,5194,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],52629,42392.96,74335.08,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Endovascular Procedures,5194,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",10357.81,10357.81,10357.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Endovascular Procedures,5194,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Endovascular Procedures,5194,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,29096.4,29096.4,29096.4,1 through 10,percent of total billed charges,,,
Level 2 Electrophysiologic Procedures,5212,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],6917.59,6917.59,6917.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Electrophysiologic Procedures,5212,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,38491.2,38491.2,46442.96,1 through 10,percent of total billed charges,,,
Level 2 Electrophysiologic Procedures,5212,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Electrophysiologic Procedures,5212,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Electrophysiologic Procedures,5212,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Electrophysiologic Procedures,5212,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Electrophysiologic Procedures,5212,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Electrophysiologic Procedures,5212,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4947.7,4947.7,4947.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Electrophysiologic Procedures,5212,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Electrophysiologic Procedures,5212,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],11459.9,11459.9,11459.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Electrophysiologic Procedures,5212,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],7105.27,7105.27,8649.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Electrophysiologic Procedures,5212,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Electrophysiologic Procedures,5212,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Electrophysiologic Procedures,5212,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Electrophysiologic Procedures,5212,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Electrophysiologic Procedures,5212,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],7397.98,7394.49,9025.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Electrophysiologic Procedures,5212,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],26502.09,26502.09,26502.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Electrophysiologic Procedures,5212,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Electrophysiologic Procedures,5212,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Electrophysiologic Procedures,5212,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Electrophysiologic Procedures,5213,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],21988.92,21988.92,26729.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Electrophysiologic Procedures,5213,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,88910.92,88910.92,95768.05,1 through 10,percent of total billed charges,,,
Level 3 Electrophysiologic Procedures,5213,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],47380.37,44941.9,48491.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Electrophysiologic Procedures,5213,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],26854.23,23890.17,33185.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Electrophysiologic Procedures,5213,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Electrophysiologic Procedures,5213,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],25309.56,24814.42,30443.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Electrophysiologic Procedures,5213,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],60646.81,28127.1,75645.49,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Electrophysiologic Procedures,5213,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",14737.35,14737.35,14737.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Electrophysiologic Procedures,5213,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Electrophysiologic Procedures,5213,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",13844.24,13833.77,13962.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Electrophysiologic Procedures,5213,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],32850.96,29830.9,36560.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Electrophysiologic Procedures,5213,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],20850.32,18943.9,29182.35,21,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Electrophysiologic Procedures,5213,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],23065.08,18931.76,25814.12,31,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Electrophysiologic Procedures,5213,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],25977.18,25977.18,25977.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Electrophysiologic Procedures,5213,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Electrophysiologic Procedures,5213,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],102991.32,60696,103995.89,61,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Electrophysiologic Procedures,5213,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],24022.7,21775.58,29188.66,69,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Electrophysiologic Procedures,5213,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",13693.82,13693.82,13693.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Electrophysiologic Procedures,5213,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Electrophysiologic Procedures,5213,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],8334.4,8334.4,8334.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,32837.32,32837.32,32837.32,1 through 10,percent of total billed charges,,,
Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],8092.25,8092.25,8092.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],25966.45,25966.45,25966.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",11200.52,11200.52,11200.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],11035.54,11035.54,11070.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",9715.67,9715.67,14361.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],27937.9,27937.9,27937.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],7753.38,7491.14,11203.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],8062.36,7499.09,10198.9,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],34683.05,31631.61,44781.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",1798,1798,1798,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Pacemaker and Similar Procedures,5222,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],9888.64,9888.64,10289.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],7616.48,7616.48,7616.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],10386.27,10386.27,10386.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],16124.13,16124.13,16124.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",9204.64,9204.64,9204.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],13999.17,13999.17,13999.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],19207.96,19207.96,19207.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],9802.42,9415.02,17270.48,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],9505.42,9505.42,9505.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],10194.41,125.53,18574.98,36,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],33082.15,32744.6,44089.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Pacemaker and Similar Procedures,5223,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Pacemaker and Similar Procedures,5224,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],42.02,42.02,42.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Pacemaker and Similar Procedures,5224,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,20938.57,20938.57,20938.57,1 through 10,percent of total billed charges,,,
Level 4 Pacemaker and Similar Procedures,5224,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],31469.8,31469.8,31469.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Pacemaker and Similar Procedures,5224,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],20024.76,20024.76,21650.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Pacemaker and Similar Procedures,5224,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Pacemaker and Similar Procedures,5224,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],19291.68,19291.68,21825.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Pacemaker and Similar Procedures,5224,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Pacemaker and Similar Procedures,5224,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Pacemaker and Similar Procedures,5224,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Pacemaker and Similar Procedures,5224,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],27011.93,27011.93,27011.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Pacemaker and Similar Procedures,5224,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],79733.66,79733.66,79733.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Pacemaker and Similar Procedures,5224,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],17857.67,17857.67,24080.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Pacemaker and Similar Procedures,5224,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],17857.67,17857.67,17857.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Pacemaker and Similar Procedures,5224,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Pacemaker and Similar Procedures,5224,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Pacemaker and Similar Procedures,5224,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],19996.45,17865.56,24765.07,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Pacemaker and Similar Procedures,5224,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],80857.4,80845.35,80857.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Pacemaker and Similar Procedures,5224,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Pacemaker and Similar Procedures,5224,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Pacemaker and Similar Procedures,5224,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 ICD and Similar Procedures,5231,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 ICD and Similar Procedures,5231,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 ICD and Similar Procedures,5231,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],26673.87,26673.87,26673.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 ICD and Similar Procedures,5231,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 ICD and Similar Procedures,5231,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 ICD and Similar Procedures,5231,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],34292.37,34292.37,34292.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 ICD and Similar Procedures,5231,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 ICD and Similar Procedures,5231,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 ICD and Similar Procedures,5231,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 ICD and Similar Procedures,5231,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],21021.95,21021.95,21021.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 ICD and Similar Procedures,5231,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 ICD and Similar Procedures,5231,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 ICD and Similar Procedures,5231,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 ICD and Similar Procedures,5231,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 ICD and Similar Procedures,5231,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 ICD and Similar Procedures,5231,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],62613.15,62613.15,62613.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 ICD and Similar Procedures,5231,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],21858.68,21540.18,21861.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 ICD and Similar Procedures,5231,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 ICD and Similar Procedures,5231,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 ICD and Similar Procedures,5231,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 ICD and Similar Procedures,5232,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 ICD and Similar Procedures,5232,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 ICD and Similar Procedures,5232,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],84461.75,84461.75,84461.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 ICD and Similar Procedures,5232,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],30854.88,30854.88,31228.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 ICD and Similar Procedures,5232,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 ICD and Similar Procedures,5232,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],32158.64,32158.64,32158.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 ICD and Similar Procedures,5232,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 ICD and Similar Procedures,5232,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 ICD and Similar Procedures,5232,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 ICD and Similar Procedures,5232,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",37652.88,37652.88,37652.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 ICD and Similar Procedures,5232,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],39150.18,39150.18,39150.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 ICD and Similar Procedures,5232,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],46046.35,46046.35,50303.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 ICD and Similar Procedures,5232,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],30025.52,29005.41,30144.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 ICD and Similar Procedures,5232,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 ICD and Similar Procedures,5232,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 ICD and Similar Procedures,5232,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],30924.48,8128.83,31244.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 ICD and Similar Procedures,5232,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],132010.25,84362.6,135412.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 ICD and Similar Procedures,5232,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 ICD and Similar Procedures,5232,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 ICD and Similar Procedures,5232,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,60730.83,60730.83,60730.83,1 through 10,percent of total billed charges,,,
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],2560.72,2560.72,2560.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,1927.36,1927.36,3645.72,1 through 10,percent of total billed charges,,,
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],4285.58,3383.61,9765.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],987.75,613.73,1658.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],942.87,942.87,2041.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],5241.73,3807.62,7027.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4983.66,4983.66,4983.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],1501.78,1501.78,1501.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",1247.89,705.79,4681.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],1991.01,1991.01,1991.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],812.37,587.73,2013.87,37,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],684.26,684.26,684.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],4421,2536,5782.3,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],958.59,611.25,3299.23,52,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",843.07,843.07,843.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Blood Product Exchange and Related Services,5241,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,405.8,405.8,405.8,1 through 10,percent of total billed charges,,,
Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],29255.02,14359.84,33713.01,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],9929.17,9929.17,9953.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],23849.17,23849.17,23849.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",8712.33,8712.33,17079.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],4999.1,4823.46,5119.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],9743.65,7654.64,13170.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],416,307.18,2139.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],7085.81,3631.79,7831,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Blood Product Exchange and Related Services,5242,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,24656.82,22900.8,52070.4,1 through 10,percent of total billed charges,,,
Level 3 Blood Product Exchange and Related Services,5243,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],8567.86,8567.86,8567.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Blood Product Exchange and Related Services,5243,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Blood Product Exchange and Related Services,5243,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],17484,17484,17484,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Blood Product Exchange and Related Services,5243,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Blood Product Exchange and Related Services,5243,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Blood Product Exchange and Related Services,5243,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Blood Product Exchange and Related Services,5243,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Blood Product Exchange and Related Services,5243,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Blood Product Exchange and Related Services,5243,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Blood Product Exchange and Related Services,5243,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",5901.25,5901.25,5901.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Blood Product Exchange and Related Services,5243,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Blood Product Exchange and Related Services,5243,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Blood Product Exchange and Related Services,5243,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Blood Product Exchange and Related Services,5243,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Blood Product Exchange and Related Services,5243,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Blood Product Exchange and Related Services,5243,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Blood Product Exchange and Related Services,5243,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Blood Product Exchange and Related Services,5243,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Blood Product Exchange and Related Services,5243,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Blood Product Exchange and Related Services,5243,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Upper GI Procedures,5301,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],844.49,569.49,1419.99,26,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Upper GI Procedures,5301,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,3518.43,2454.95,5918.12,36,percent of total billed charges,,,
Level 1 Upper GI Procedures,5301,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],3777.93,2333.16,14741.6,56,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Upper GI Procedures,5301,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],830.99,545.52,1635.38,111,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Upper GI Procedures,5301,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Upper GI Procedures,5301,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],948.14,683.54,1294.72,89,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Upper GI Procedures,5301,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],2344.23,472.51,3827.14,76,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Upper GI Procedures,5301,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",954.39,517.44,1350.37,42,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Upper GI Procedures,5301,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Upper GI Procedures,5301,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],1350.68,1254.15,1861.28,72,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Upper GI Procedures,5301,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",773.61,544.84,983.83,312,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Upper GI Procedures,5301,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],2584.39,796.04,3838.89,64,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Upper GI Procedures,5301,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],881.49,801.53,1272.99,229,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Upper GI Procedures,5301,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],2045.07,2045.07,2219.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Upper GI Procedures,5301,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],883.9,658.9,1304.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Upper GI Procedures,5301,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],3736.19,2555.12,5488.67,385,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Upper GI Procedures,5301,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],915.02,623.03,1991.29,272,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Upper GI Procedures,5301,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",965.43,765.18,3688.25,33,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Upper GI Procedures,5301,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Upper GI Procedures,5301,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,2088.34,1870,3112,13,percent of total billed charges,,,
Level 2 Upper GI Procedures,5302,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],1766.64,1766.64,1868.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Upper GI Procedures,5302,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,4363.72,3527.05,7541.81,17,percent of total billed charges,,,
Level 2 Upper GI Procedures,5302,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],4394.4,2665.89,8302.91,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Upper GI Procedures,5302,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],1849.34,1749.34,2124.34,28,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Upper GI Procedures,5302,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Upper GI Procedures,5302,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],1923.79,1653.79,2143.39,22,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Upper GI Procedures,5302,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],3269.6,1693.97,6485.52,30,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Upper GI Procedures,5302,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",949.62,866.39,6741.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Upper GI Procedures,5302,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Upper GI Procedures,5302,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],2132.21,1656,3633,20,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Upper GI Procedures,5302,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",1246.37,773.61,2438.52,54,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Upper GI Procedures,5302,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],3819.37,2034.84,6930.78,31,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Upper GI Procedures,5302,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],1780.29,1679.77,1783.54,89,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Upper GI Procedures,5302,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],1780.29,1780.29,1780.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Upper GI Procedures,5302,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Upper GI Procedures,5302,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],1849.34,1700.34,2052.31,126,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Upper GI Procedures,5302,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],6577.63,4267,8938.88,135,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Upper GI Procedures,5302,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",765.18,765.18,4546.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Upper GI Procedures,5302,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Upper GI Procedures,5302,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,4645.76,1244.66,10892.06,1 through 10,percent of total billed charges,,,
Level 3 Upper GI Procedures,5303,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],3752.02,3752.02,3752.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Upper GI Procedures,5303,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,12989.65,12989.65,12989.65,1 through 10,percent of total billed charges,,,
Level 3 Upper GI Procedures,5303,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],12903.67,9820.97,26006.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Upper GI Procedures,5303,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],3981.95,3704.95,3982.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Upper GI Procedures,5303,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Upper GI Procedures,5303,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],3722.84,3722.84,3722.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Upper GI Procedures,5303,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],4325,3739.3,5307.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Upper GI Procedures,5303,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Upper GI Procedures,5303,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Upper GI Procedures,5303,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3921.52,3906.34,4458.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Upper GI Procedures,5303,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],2494.64,2494.64,2494.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Upper GI Procedures,5303,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],3393.69,3378.3,3578.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Upper GI Procedures,5303,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],3865.22,3865.22,3865.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Upper GI Procedures,5303,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Upper GI Procedures,5303,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Upper GI Procedures,5303,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],3682.95,3337.45,3707.95,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Upper GI Procedures,5303,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],14354.97,7551.73,16659.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Upper GI Procedures,5303,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Upper GI Procedures,5303,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Upper GI Procedures,5303,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,5103.99,5103.99,5103.99,1 through 10,percent of total billed charges,,,
Level 1 Lower GI Procedures,5311,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],896.39,845.9,1265.39,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Lower GI Procedures,5311,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,3186.68,2824.16,5735.87,72,percent of total billed charges,,,
Level 1 Lower GI Procedures,5311,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],4490.15,2342.93,10892.14,26,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Lower GI Procedures,5311,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],887.84,808.91,938,25,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Lower GI Procedures,5311,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Lower GI Procedures,5311,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],921.99,921.99,1414.53,28,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Lower GI Procedures,5311,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],2357.65,2025.2,3027.43,135,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Lower GI Procedures,5311,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",856.14,856.14,1548.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Lower GI Procedures,5311,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Lower GI Procedures,5311,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],1219.57,1219.57,1954.85,84,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Lower GI Procedures,5311,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",805.35,715.67,1618.21,121,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Lower GI Procedures,5311,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],2871.29,2711.38,4802.84,127,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Lower GI Procedures,5311,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],853.7,805.62,1308.58,145,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Lower GI Procedures,5311,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],3041.63,3041.63,3041.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Lower GI Procedures,5311,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],853.7,853.7,1310.75,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Lower GI Procedures,5311,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],3864.86,3539.86,4370.22,541,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Lower GI Procedures,5311,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],887.85,840.85,1359.11,153,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Lower GI Procedures,5311,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",919.4,796.58,2163.07,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Lower GI Procedures,5311,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Lower GI Procedures,5311,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,3390.4,3034.24,6166.2,1 through 10,percent of total billed charges,,,
Level 2 Lower GI Procedures,5312,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],1159.26,1092.2,2200.38,39,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Lower GI Procedures,5312,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,4076.59,3541.87,7303.03,148,percent of total billed charges,,,
Level 2 Lower GI Procedures,5312,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],4508.93,2948.28,10602.76,43,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Lower GI Procedures,5312,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],1150.22,1082.13,1724.33,102,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Lower GI Procedures,5312,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Lower GI Procedures,5312,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],1197.79,1192.39,2122.35,110,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Lower GI Procedures,5312,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],3110.39,2536.38,5157.52,358,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Lower GI Procedures,5312,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",1338.45,988.14,4779.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Lower GI Procedures,5312,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Lower GI Procedures,5312,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],1759.06,1668.15,2743.63,155,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Lower GI Procedures,5312,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",1257.83,848.33,1766.75,230,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Lower GI Procedures,5312,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],2876.58,2342.88,5387.67,258,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Lower GI Procedures,5312,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],1104.06,1040.19,1656.09,359,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Lower GI Procedures,5312,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],2632.77,2066.44,4652.58,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Lower GI Procedures,5312,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],1104.06,1104.06,1656.09,40,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Lower GI Procedures,5312,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],1148.75,1148.22,1754.74,479,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Lower GI Procedures,5312,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],4998.29,4626.93,7083.87,1162,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Lower GI Procedures,5312,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",1317.68,878.46,4866.06,30,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Lower GI Procedures,5312,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Lower GI Procedures,5312,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,4131.14,3753.54,5175.14,14,percent of total billed charges,,,
Level 3 Lower GI Procedures,5313,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],2696.29,2696.29,2696.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Lower GI Procedures,5313,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,5340.69,2742.84,9267.69,1 through 10,percent of total billed charges,,,
Level 3 Lower GI Procedures,5313,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],7265.19,1008.19,7462.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Lower GI Procedures,5313,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],2670.61,2670.61,2770.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Lower GI Procedures,5313,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],2573.97,2573.97,2573.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Lower GI Procedures,5313,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],2778.72,2708.72,3014.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Lower GI Procedures,5313,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],3718.56,3193.96,7058.92,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Lower GI Procedures,5313,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Lower GI Procedures,5313,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Lower GI Procedures,5313,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],3759.34,2134.5,3967.19,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Lower GI Procedures,5313,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",2202,1079.03,3058.12,21,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Lower GI Procedures,5313,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],4960.55,3140.37,5664.68,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Lower GI Procedures,5313,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],2567.89,2474.97,2567.89,37,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Lower GI Procedures,5313,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],5512.93,5512.93,8210.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Lower GI Procedures,5313,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],2567.89,2567.89,2567.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Lower GI Procedures,5313,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],8834.3,4544.42,11442.84,64,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Lower GI Procedures,5313,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],2670.61,2523.61,2673.61,33,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Lower GI Procedures,5313,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4235.11,4235.11,4235.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Lower GI Procedures,5313,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Lower GI Procedures,5313,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,3247.87,3247.87,3247.87,1 through 10,percent of total billed charges,,,
Complex GI Procedures,5331,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,7349.88,7349.88,7349.88,1 through 10,percent of total billed charges,,,
Complex GI Procedures,5331,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],,,,0,other,,,No services performed during 15-month lookback period.
Complex GI Procedures,5331,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],7366.32,7366.32,7366.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Complex GI Procedures,5331,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],5796.99,5796.99,5796.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Complex GI Procedures,5331,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complex GI Procedures,5331,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],5999.34,5999.34,5999.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Complex GI Procedures,5331,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],14877.89,14877.89,14877.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Complex GI Procedures,5331,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Complex GI Procedures,5331,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Complex GI Procedures,5331,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],4194,4194,4194,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Complex GI Procedures,5331,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4396,4396,6353.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Complex GI Procedures,5331,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],5585.71,5585.71,5596.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Complex GI Procedures,5331,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Complex GI Procedures,5331,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Complex GI Procedures,5331,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Complex GI Procedures,5331,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],5796.99,5094.63,5804.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Complex GI Procedures,5331,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],20217.72,17213.96,25234.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Complex GI Procedures,5331,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Complex GI Procedures,5331,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complex GI Procedures,5331,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,5947.61,5947.61,5947.61,1 through 10,percent of total billed charges,,,
Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],3472.57,3472.57,3474.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,11329.63,10014.2,12938.64,1 through 10,percent of total billed charges,,,
Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],17039.51,10985.25,20508.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],1292.66,977.1,3444.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],2773.98,961.96,3304.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],8848.05,4030.21,13415.75,20,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4214.24,4214.24,4214.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],4660.73,3640.66,7924.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3156.81,2742.04,5155,19,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],6746.82,3177.52,9378.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],3308.51,3062.02,3319.72,23,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],3311.31,3311.31,3311.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],14584.41,9887.5,15281.16,46,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],3319.19,652,3444.19,40,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",2796.8,456.48,3813.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Abdominal/Peritoneal/Biliary and Related Procedures,5341,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,14960.18,5370.15,23295.35,1 through 10,percent of total billed charges,,,
Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],6083.17,6083.17,6083.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],10042.43,9145.87,10937.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],8347.79,8347.79,8347.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4679.98,4679.98,6081.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],8720.41,8720.41,8720.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],5846.21,5782.8,6094.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],15345.19,14581.89,26452.19,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Abdominal/Peritoneal/Biliary and Related Procedures,5342,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Laparoscopy and Related Services,5361,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],5347.36,5345.83,9929.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Laparoscopy and Related Services,5361,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,20174.18,9463.9,26601.41,38,percent of total billed charges,,,
Level 1 Laparoscopy and Related Services,5361,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],17768.87,13454.49,22350.97,138,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Laparoscopy and Related Services,5361,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],5689.14,5193.62,7054.89,22,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Laparoscopy and Related Services,5361,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Laparoscopy and Related Services,5361,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],5905.57,5635.57,9640.16,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Laparoscopy and Related Services,5361,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],14425.42,7586.09,20592.38,113,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Laparoscopy and Related Services,5361,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",5658.94,4455.93,7009.33,24,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Laparoscopy and Related Services,5361,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Laparoscopy and Related Services,5361,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],7862.33,5919.1,8338.19,36,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Laparoscopy and Related Services,5361,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",5265.53,4181.79,6430.46,148,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Laparoscopy and Related Services,5361,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],11954.18,6395.05,15567.17,52,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Laparoscopy and Related Services,5361,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],5467.12,5086.03,8199.41,44,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Laparoscopy and Related Services,5361,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],30.94,30.94,30.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Laparoscopy and Related Services,5361,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],5470.83,5470.83,5470.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Laparoscopy and Related Services,5361,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],23709.91,15012.73,24739.86,362,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Laparoscopy and Related Services,5361,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],5684.36,5291.48,7456.52,102,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Laparoscopy and Related Services,5361,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",5315.63,4097.89,7592.79,25,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Laparoscopy and Related Services,5361,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Laparoscopy and Related Services,5361,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,22263.1,15735.15,31349.8,13,percent of total billed charges,,,
Level 2 Laparoscopy and Related Services,5362,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],9532.73,9532.73,10236.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Laparoscopy and Related Services,5362,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,16045.25,10243.2,26790.46,14,percent of total billed charges,,,
Level 2 Laparoscopy and Related Services,5362,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],19723.67,10605.64,28346.04,25,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Laparoscopy and Related Services,5362,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],10140.71,10140.71,10146.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Laparoscopy and Related Services,5362,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Laparoscopy and Related Services,5362,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],10284.48,10264.06,10601.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Laparoscopy and Related Services,5362,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],13740.39,9007.99,20688.84,48,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Laparoscopy and Related Services,5362,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4722.61,4722.61,4722.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Laparoscopy and Related Services,5362,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Laparoscopy and Related Services,5362,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],13383.03,5068.22,14648.04,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Laparoscopy and Related Services,5362,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4537.17,4401.01,6834.42,36,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Laparoscopy and Related Services,5362,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],11392.29,9019.54,18809.89,35,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Laparoscopy and Related Services,5362,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],9753.62,9077.4,9788.55,22,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Laparoscopy and Related Services,5362,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],31026.54,31026.54,31026.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Laparoscopy and Related Services,5362,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],9405.76,9405.76,9405.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Laparoscopy and Related Services,5362,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],10142.48,9439.49,10515.85,52,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Laparoscopy and Related Services,5362,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],40573.67,24762.56,44135.64,138,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Laparoscopy and Related Services,5362,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",9427.93,4925.66,42932.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Laparoscopy and Related Services,5362,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Laparoscopy and Related Services,5362,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,18578.54,16172,27240.45,1 through 10,percent of total billed charges,,,
Level 1 Urology and Related Services,5371,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Urology and Related Services,5371,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Urology and Related Services,5371,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],745.9,745.9,745.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Urology and Related Services,5371,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],241.68,241.68,241.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Urology and Related Services,5371,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Urology and Related Services,5371,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],348.92,348.92,348.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Urology and Related Services,5371,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Urology and Related Services,5371,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Urology and Related Services,5371,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Urology and Related Services,5371,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",293.9,293.9,293.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Urology and Related Services,5371,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],218.74,95.35,362.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Urology and Related Services,5371,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Urology and Related Services,5371,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Urology and Related Services,5371,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Urology and Related Services,5371,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Urology and Related Services,5371,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],393.56,393.56,393.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Urology and Related Services,5371,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Urology and Related Services,5371,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Urology and Related Services,5371,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Urology and Related Services,5371,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Urology and Related Services,5372,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Urology and Related Services,5372,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Urology and Related Services,5372,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Urology and Related Services,5372,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Urology and Related Services,5372,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Urology and Related Services,5372,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Urology and Related Services,5372,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Urology and Related Services,5372,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Urology and Related Services,5372,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Urology and Related Services,5372,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",631.02,631.02,964.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Urology and Related Services,5372,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],689,689,689,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Urology and Related Services,5372,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],4657.36,4657.36,4657.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Urology and Related Services,5372,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Urology and Related Services,5372,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Urology and Related Services,5372,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Urology and Related Services,5372,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],653,653,653,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Urology and Related Services,5372,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],2829.48,1100,2829.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Urology and Related Services,5372,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Urology and Related Services,5372,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Urology and Related Services,5372,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Urology and Related Services,5373,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],3540.73,3540.73,3540.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Urology and Related Services,5373,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,9123.68,9123.68,9123.68,1 through 10,percent of total billed charges,,,
Level 3 Urology and Related Services,5373,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],9436.47,9436.47,9436.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Urology and Related Services,5373,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],2001.39,1994.89,2002.39,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Urology and Related Services,5373,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Urology and Related Services,5373,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],1941.41,1941.41,1957.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Urology and Related Services,5373,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],6285.07,1718.37,10143.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Urology and Related Services,5373,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3633.36,3633.36,3633.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Urology and Related Services,5373,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Urology and Related Services,5373,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],4110.35,2802.99,4110.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Urology and Related Services,5373,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",1779.88,688.22,2522.87,30,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Urology and Related Services,5373,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],4226.28,3157.72,7992.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Urology and Related Services,5373,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],1925.99,1799.38,2893.11,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Urology and Related Services,5373,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],1802.71,1624.16,1925.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Urology and Related Services,5373,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Urology and Related Services,5373,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],1994.89,1755.79,2001.9,35,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Urology and Related Services,5373,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],8291.33,3799,8684.91,25,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Urology and Related Services,5373,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Urology and Related Services,5373,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Urology and Related Services,5373,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,12835.4,12835.4,12835.4,1 through 10,percent of total billed charges,,,
Level 4 Urology and Related Services,5374,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],3392.03,3390.99,3511.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Urology and Related Services,5374,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,10965.05,300,19077.8,1 through 10,percent of total billed charges,,,
Level 4 Urology and Related Services,5374,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],12694.57,9824.81,19576.09,29,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Urology and Related Services,5374,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],3358.7,2686.95,7286.16,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Urology and Related Services,5374,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Urology and Related Services,5374,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],3493.27,3223.27,3547.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Urology and Related Services,5374,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],10184.31,7193.12,16826,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Urology and Related Services,5374,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3687.18,3687.18,7205.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Urology and Related Services,5374,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Urology and Related Services,5374,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],4788.79,4092,5234.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Urology and Related Services,5374,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3304.62,2309.29,4262.28,21,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Urology and Related Services,5374,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],7268.73,2963.92,12014.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Urology and Related Services,5374,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],3232.51,3075.43,3242.69,23,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Urology and Related Services,5374,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],6609.49,6609.49,9439.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Urology and Related Services,5374,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],3079.93,3079.93,3079.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Urology and Related Services,5374,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],14421.26,11673.08,14622.16,63,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Urology and Related Services,5374,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],3361.7,3142.2,3397.2,68,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Urology and Related Services,5374,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4731.29,4145.21,14233.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Urology and Related Services,5374,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Urology and Related Services,5374,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,10131.21,5391.2,59389.69,1 through 10,percent of total billed charges,,,
Level 5 Urology and Related Services,5375,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],4794.55,4794.55,5000.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 Urology and Related Services,5375,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,13808.16,11283.5,26980.09,1 through 10,percent of total billed charges,,,
Level 5 Urology and Related Services,5375,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],17081.69,11773.26,21593.47,24,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 Urology and Related Services,5375,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],4957.06,4950.56,5098.28,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 Urology and Related Services,5375,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Urology and Related Services,5375,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],5012.02,4931.27,5146.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 Urology and Related Services,5375,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],10084.9,7651.62,17388.05,21,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 Urology and Related Services,5375,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",5237.59,4532.54,6362.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 Urology and Related Services,5375,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 5 Urology and Related Services,5375,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],6891.14,6215.5,7367.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 Urology and Related Services,5375,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4998.45,4021.71,6469.25,32,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 Urology and Related Services,5375,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],10010.63,7095.15,12351.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 Urology and Related Services,5375,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],4764.15,4565.01,4779.58,39,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 Urology and Related Services,5375,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],4766.15,4766.15,4767.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 Urology and Related Services,5375,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Urology and Related Services,5375,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],21050.2,18051.47,21563.15,60,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 Urology and Related Services,5375,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],4953.56,4731.45,7851.62,85,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 Urology and Related Services,5375,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4211.72,4211.72,6830.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 Urology and Related Services,5375,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Urology and Related Services,5375,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,19593.1,14537.17,62580.92,1 through 10,percent of total billed charges,,,
Level 6 Urology and Related Services,5376,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,20449.04,20449.04,20449.04,1 through 10,percent of total billed charges,,,
Level 6 Urology and Related Services,5376,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Urology and Related Services,5376,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],18701.81,18701.81,18701.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 6 Urology and Related Services,5376,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],9196.41,9196.41,10389.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 6 Urology and Related Services,5376,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Urology and Related Services,5376,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],17757.15,17757.15,17757.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 6 Urology and Related Services,5376,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Urology and Related Services,5376,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Urology and Related Services,5376,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 6 Urology and Related Services,5376,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],11044.32,11044.32,11044.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 6 Urology and Related Services,5376,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],9851.3,9851.3,9851.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 6 Urology and Related Services,5376,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Urology and Related Services,5376,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Urology and Related Services,5376,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Urology and Related Services,5376,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Urology and Related Services,5376,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],11485.59,11485.59,11485.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 6 Urology and Related Services,5376,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],37969.61,37969.61,37969.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 6 Urology and Related Services,5376,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Urology and Related Services,5376,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Urology and Related Services,5376,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 8 Urology and Related Services,5378,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],,,,0,other,,,No services performed during 15-month lookback period.
Level 8 Urology and Related Services,5378,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 8 Urology and Related Services,5378,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],2801.46,2801.46,2801.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 8 Urology and Related Services,5378,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 8 Urology and Related Services,5378,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 8 Urology and Related Services,5378,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],20361.02,20361.02,20361.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 8 Urology and Related Services,5378,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],,,,0,other,,,No services performed during 15-month lookback period.
Level 8 Urology and Related Services,5378,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 8 Urology and Related Services,5378,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 8 Urology and Related Services,5378,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],4938.35,4938.35,4938.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 8 Urology and Related Services,5378,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],18970.08,18970.08,18970.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 8 Urology and Related Services,5378,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 8 Urology and Related Services,5378,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 8 Urology and Related Services,5378,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 8 Urology and Related Services,5378,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 8 Urology and Related Services,5378,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],82478.33,82478.33,82478.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 8 Urology and Related Services,5378,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],19307.71,19307.71,19607.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 8 Urology and Related Services,5378,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 8 Urology and Related Services,5378,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 8 Urology and Related Services,5378,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Dialysis,5401,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],2533.39,2533.39,2533.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Dialysis,5401,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Dialysis,5401,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],2805.41,2805.41,2805.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Dialysis,5401,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dialysis,5401,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dialysis,5401,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],1654.57,1654.57,1654.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Dialysis,5401,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],,,,0,other,,,No services performed during 15-month lookback period.
Dialysis,5401,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Dialysis,5401,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Dialysis,5401,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",1996.67,1996.67,3044.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Dialysis,5401,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],2586.91,1931.6,5469.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Dialysis,5401,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Dialysis,5401,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Dialysis,5401,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Dialysis,5401,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Dialysis,5401,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],951.05,902.05,2470.62,103,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Dialysis,5401,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],19329.32,19329.32,19329.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Dialysis,5401,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3967.05,3967.05,3967.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Dialysis,5401,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dialysis,5401,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,19725.92,16830.88,22536.64,1 through 10,percent of total billed charges,,,
Level 1 Gynecologic Procedures,5411,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,617.88,218.88,1714.1,44,percent of total billed charges,,,
Level 1 Gynecologic Procedures,5411,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Gynecologic Procedures,5411,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],865.94,269.54,2081.99,50,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Gynecologic Procedures,5411,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Gynecologic Procedures,5411,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Gynecologic Procedures,5411,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],453.23,249.52,1197.19,159,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Gynecologic Procedures,5411,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Gynecologic Procedures,5411,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",350.7,263.37,477.85,26,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Gynecologic Procedures,5411,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Gynecologic Procedures,5411,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],444.62,198.61,586.87,21,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Gynecologic Procedures,5411,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",319.23,247.74,474.11,536,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Gynecologic Procedures,5411,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],782.8,255.8,1541.43,63,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Gynecologic Procedures,5411,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],404.87,335.39,786.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Gynecologic Procedures,5411,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],1030.91,795.92,2325.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Gynecologic Procedures,5411,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Gynecologic Procedures,5411,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],313.25,216.33,408.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Gynecologic Procedures,5411,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],1214,789.89,1443.51,317,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Gynecologic Procedures,5411,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",320.42,247.93,424.48,81,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Gynecologic Procedures,5411,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Gynecologic Procedures,5411,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,493.13,302.6,1681,1 through 10,percent of total billed charges,,,
Level 2 Gynecologic Procedures,5412,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Gynecologic Procedures,5412,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Gynecologic Procedures,5412,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],976.71,976.71,976.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Gynecologic Procedures,5412,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Gynecologic Procedures,5412,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Gynecologic Procedures,5412,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],1328.13,1328.13,1328.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Gynecologic Procedures,5412,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Gynecologic Procedures,5412,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",708.08,708.08,708.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Gynecologic Procedures,5412,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Gynecologic Procedures,5412,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",358.76,358.76,358.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Gynecologic Procedures,5412,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],6401.9,6401.9,6401.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Gynecologic Procedures,5412,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Gynecologic Procedures,5412,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Gynecologic Procedures,5412,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Gynecologic Procedures,5412,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Gynecologic Procedures,5412,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Gynecologic Procedures,5412,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Gynecologic Procedures,5412,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Gynecologic Procedures,5412,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Gynecologic Procedures,5412,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Gynecologic Procedures,5413,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Gynecologic Procedures,5413,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Gynecologic Procedures,5413,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Gynecologic Procedures,5413,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Gynecologic Procedures,5413,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Gynecologic Procedures,5413,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Gynecologic Procedures,5413,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Gynecologic Procedures,5413,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Gynecologic Procedures,5413,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Gynecologic Procedures,5413,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Gynecologic Procedures,5413,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Gynecologic Procedures,5413,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Gynecologic Procedures,5413,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Gynecologic Procedures,5413,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Gynecologic Procedures,5413,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Gynecologic Procedures,5413,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],3138.52,3138.52,3138.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Gynecologic Procedures,5413,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Gynecologic Procedures,5413,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Gynecologic Procedures,5413,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Gynecologic Procedures,5413,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Gynecologic Procedures,5414,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],3143.72,3143.72,3143.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Gynecologic Procedures,5414,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,11593.49,8922.4,14182.7,11,percent of total billed charges,,,
Level 4 Gynecologic Procedures,5414,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],7835.34,6230.41,12122.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Gynecologic Procedures,5414,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],2929.42,2929.42,3098.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Gynecologic Procedures,5414,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Gynecologic Procedures,5414,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],8109.85,5073.96,10839.09,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Gynecologic Procedures,5414,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Gynecologic Procedures,5414,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",2316.39,2316.39,2316.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Gynecologic Procedures,5414,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Gynecologic Procedures,5414,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],4346.19,992.05,5140.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Gynecologic Procedures,5414,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",2041.3,1773.01,2981.93,32,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Gynecologic Procedures,5414,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],6067.89,4713.07,10006.09,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Gynecologic Procedures,5414,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],2767.03,2758.28,2990.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Gynecologic Procedures,5414,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],2984.58,2984.58,2984.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Gynecologic Procedures,5414,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Gynecologic Procedures,5414,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],12544.79,9568.51,13479.46,71,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Gynecologic Procedures,5414,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],3100.02,3099.31,3105.65,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Gynecologic Procedures,5414,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",2500.33,2017.5,3500.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Gynecologic Procedures,5414,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Gynecologic Procedures,5414,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,8562.52,8562.52,8562.52,1 through 10,percent of total billed charges,,,
Level 5 Gynecologic Procedures,5415,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,11487.55,11487.55,11487.55,1 through 10,percent of total billed charges,,,
Level 5 Gynecologic Procedures,5415,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Gynecologic Procedures,5415,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],31526.72,31526.72,31526.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 Gynecologic Procedures,5415,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],7730.93,7730.93,7730.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 Gynecologic Procedures,5415,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Gynecologic Procedures,5415,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],4474.64,4474.64,4474.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 Gynecologic Procedures,5415,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],8265.71,8265.71,13166.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 Gynecologic Procedures,5415,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Gynecologic Procedures,5415,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 5 Gynecologic Procedures,5415,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],6605.45,6605.45,6605.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 Gynecologic Procedures,5415,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3477.53,3477.53,3477.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 Gynecologic Procedures,5415,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],6887.83,6887.83,6887.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 Gynecologic Procedures,5415,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],4298.88,3697.87,5539.42,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 Gynecologic Procedures,5415,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Gynecologic Procedures,5415,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Gynecologic Procedures,5415,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],18223.14,2020.56,19475.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 Gynecologic Procedures,5415,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],4807.95,4807.25,4814.69,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 Gynecologic Procedures,5415,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Gynecologic Procedures,5415,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Gynecologic Procedures,5415,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,10967.78,10967.78,10967.78,1 through 10,percent of total billed charges,,,
Level 6 Gynecologic Procedures,5416,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Gynecologic Procedures,5416,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 6 Gynecologic Procedures,5416,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Gynecologic Procedures,5416,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Gynecologic Procedures,5416,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Gynecologic Procedures,5416,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Gynecologic Procedures,5416,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Gynecologic Procedures,5416,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Gynecologic Procedures,5416,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 6 Gynecologic Procedures,5416,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],7498.96,7498.96,7498.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 6 Gynecologic Procedures,5416,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],6663.32,6663.32,6929.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 6 Gynecologic Procedures,5416,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Gynecologic Procedures,5416,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Gynecologic Procedures,5416,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Gynecologic Procedures,5416,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Gynecologic Procedures,5416,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],18505.69,18505.69,18505.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 6 Gynecologic Procedures,5416,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Gynecologic Procedures,5416,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Gynecologic Procedures,5416,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Gynecologic Procedures,5416,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Nerve Procedures,5431,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Nerve Procedures,5431,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Nerve Procedures,5431,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Nerve Procedures,5431,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Nerve Procedures,5431,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Nerve Procedures,5431,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],1980.2,1980.2,1980.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Nerve Procedures,5431,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Nerve Procedures,5431,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Nerve Procedures,5431,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Nerve Procedures,5431,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],2612.16,2612.16,2612.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Nerve Procedures,5431,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",1655.79,1655.79,1881.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Nerve Procedures,5431,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],10710.47,10710.47,10710.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Nerve Procedures,5431,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],1832.51,1832.51,1835.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Nerve Procedures,5431,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Nerve Procedures,5431,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Nerve Procedures,5431,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],7122.47,6766.35,10822.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Nerve Procedures,5431,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],1908.75,1908.75,1908.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Nerve Procedures,5431,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Nerve Procedures,5431,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Nerve Procedures,5431,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Nerve Injections,5441,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],290.23,290.23,290.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Nerve Injections,5441,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,344.28,344.28,344.28,1 through 10,percent of total billed charges,,,
Level 1 Nerve Injections,5441,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],1637.11,523,2268.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Nerve Injections,5441,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],407.27,407.27,407.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Nerve Injections,5441,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Nerve Injections,5441,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],336.16,336.16,336.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Nerve Injections,5441,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],794.27,646.05,1445.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Nerve Injections,5441,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",435.88,435.88,645.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Nerve Injections,5441,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Nerve Injections,5441,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],604.7,604.7,888.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Nerve Injections,5441,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",443.69,226.07,582.2,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Nerve Injections,5441,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],1047.46,800.23,2250.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Nerve Injections,5441,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],425.93,266.4,641.41,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Nerve Injections,5441,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Nerve Injections,5441,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Nerve Injections,5441,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],289.47,50,558.41,19,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Nerve Injections,5441,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],1251.37,262,2333.34,34,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Nerve Injections,5441,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",427.88,427.88,427.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Nerve Injections,5441,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Nerve Injections,5441,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Nerve Injections,5442,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],1666.43,1666.43,1666.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Nerve Injections,5442,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,1566.39,924.16,26373.93,1 through 10,percent of total billed charges,,,
Level 2 Nerve Injections,5442,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],5666.1,1576,12914.84,24,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Nerve Injections,5442,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],861.07,861.07,861.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Nerve Injections,5442,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Nerve Injections,5442,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],2188.68,1709.22,6741.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Nerve Injections,5442,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Nerve Injections,5442,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",1855.91,924.95,3839.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Nerve Injections,5442,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Nerve Injections,5442,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],926.37,926.37,926.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Nerve Injections,5442,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",973.16,556.05,2550.91,39,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Nerve Injections,5442,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],3227,2250.18,4382.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Nerve Injections,5442,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],1325.57,909.64,2226.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Nerve Injections,5442,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],1003.86,1003.86,1003.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Nerve Injections,5442,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],765.28,765.28,765.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Nerve Injections,5442,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],988.43,677.05,3976.15,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Nerve Injections,5442,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],2802,1396.8,8590.74,51,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Nerve Injections,5442,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",439.65,439.65,439.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Nerve Injections,5442,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Nerve Injections,5442,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Nerve Injections,5443,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Nerve Injections,5443,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Nerve Injections,5443,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Nerve Injections,5443,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Nerve Injections,5443,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Nerve Injections,5443,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Nerve Injections,5443,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Nerve Injections,5443,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Nerve Injections,5443,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Nerve Injections,5443,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",2722.13,2722.13,2722.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Nerve Injections,5443,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],378.57,378.57,378.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Nerve Injections,5443,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Nerve Injections,5443,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Nerve Injections,5443,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Nerve Injections,5443,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Nerve Injections,5443,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Nerve Injections,5443,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Nerve Injections,5443,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Nerve Injections,5443,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Nerve Injections,5443,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Neurostimulator and Related Procedures,5461,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Neurostimulator and Related Procedures,5461,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Neurostimulator and Related Procedures,5461,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Neurostimulator and Related Procedures,5461,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Neurostimulator and Related Procedures,5461,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Neurostimulator and Related Procedures,5461,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Neurostimulator and Related Procedures,5461,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Neurostimulator and Related Procedures,5461,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Neurostimulator and Related Procedures,5461,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Neurostimulator and Related Procedures,5461,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",2804.46,2804.46,2804.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Neurostimulator and Related Procedures,5461,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],3375.94,3375.94,3375.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Neurostimulator and Related Procedures,5461,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Neurostimulator and Related Procedures,5461,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Neurostimulator and Related Procedures,5461,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Neurostimulator and Related Procedures,5461,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Neurostimulator and Related Procedures,5461,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Neurostimulator and Related Procedures,5461,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Neurostimulator and Related Procedures,5461,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Neurostimulator and Related Procedures,5461,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Neurostimulator and Related Procedures,5461,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Neurostimulator and Related Procedures,5462,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Neurostimulator and Related Procedures,5462,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Neurostimulator and Related Procedures,5462,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Neurostimulator and Related Procedures,5462,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Neurostimulator and Related Procedures,5462,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Neurostimulator and Related Procedures,5462,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Neurostimulator and Related Procedures,5462,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Neurostimulator and Related Procedures,5462,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Neurostimulator and Related Procedures,5462,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Neurostimulator and Related Procedures,5462,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Neurostimulator and Related Procedures,5462,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Neurostimulator and Related Procedures,5462,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Neurostimulator and Related Procedures,5462,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Neurostimulator and Related Procedures,5462,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Neurostimulator and Related Procedures,5462,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Neurostimulator and Related Procedures,5462,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],24659.91,24659.91,24659.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Neurostimulator and Related Procedures,5462,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Neurostimulator and Related Procedures,5462,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Neurostimulator and Related Procedures,5462,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Neurostimulator and Related Procedures,5462,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],21421.69,21421.69,21421.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",12431,12431,12431,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],19457.24,19457.24,19457.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],19999.47,19999.47,19999.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],62175.49,62175.49,62175.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],20883.09,20883.09,20884.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Neurostimulator and Related Procedures,5464,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,33935.14,33935.14,33935.14,1 through 10,percent of total billed charges,,,
Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],28745.52,28745.52,28745.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],12183,12183,12183,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],29877.22,29877.22,29877.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 5 Neurostimulator and Related Procedures,5465,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],,,,0,other,,,No services performed during 15-month lookback period.
"Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],,,,0,other,,,No services performed during 15-month lookback period.
"Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",183.94,183.94,183.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
"Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
"Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
"Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
"Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
"Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],,,,0,other,,,No services performed during 15-month lookback period.
"Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Level 1 Extraocular, Repair, and Plastic Eye Procedures",5501,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Imaging without Contrast,5521,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],86.57,84.1,86.94,31,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Imaging without Contrast,5521,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,213.56,161.12,538.88,74,percent of total billed charges,,,
Level 1 Imaging without Contrast,5521,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],280.86,212,1619.91,88,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Imaging without Contrast,5521,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],87.5,80.1,281,58,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Imaging without Contrast,5521,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],86.25,86.25,86.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Imaging without Contrast,5521,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],89.04,79.24,89.24,59,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Imaging without Contrast,5521,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],181.78,129.32,654.53,213,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Imaging without Contrast,5521,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",86.64,82.78,484.11,34,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Imaging without Contrast,5521,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Imaging without Contrast,5521,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",81.5,77.87,229.35,496,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Imaging without Contrast,5521,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],117.78,87.78,125.05,104,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Imaging without Contrast,5521,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],216.8,116.56,603.83,169,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Imaging without Contrast,5521,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],82.45,80.1,83.1,358,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Imaging without Contrast,5521,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],236.06,188.77,247.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Imaging without Contrast,5521,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],83.05,53.05,275,29,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Imaging without Contrast,5521,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],85.75,61.25,86.25,493,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Imaging without Contrast,5521,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],281,212,373.24,780,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Imaging without Contrast,5521,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",118.96,78.91,246.55,51,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Imaging without Contrast,5521,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Imaging without Contrast,5521,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,197.61,185.6,964,13,percent of total billed charges,,,
Level 2 Imaging without Contrast,5522,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],104.56,101.75,184.41,115,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Imaging without Contrast,5522,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,408.12,239.4,779.55,348,percent of total billed charges,,,
Level 2 Imaging without Contrast,5522,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],425,200,882.09,89,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Imaging without Contrast,5522,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],105.56,55.56,203.56,235,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Imaging without Contrast,5522,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],105.67,105.67,105.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Imaging without Contrast,5522,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],107.55,104.66,225,232,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Imaging without Contrast,5522,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],386.74,207.4,745.42,750,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Imaging without Contrast,5522,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",135.71,132.49,272.11,43,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Imaging without Contrast,5522,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Imaging without Contrast,5522,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],142.25,138.45,409.99,392,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Imaging without Contrast,5522,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",127.66,124.63,458.8,1122,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Imaging without Contrast,5522,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],342.85,148.3,765.24,545,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Imaging without Contrast,5522,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],99.58,96.91,101.61,1221,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Imaging without Contrast,5522,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],329.21,203.28,768.18,29,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Imaging without Contrast,5522,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],100.18,97.31,182.63,99,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Imaging without Contrast,5522,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],103.56,100.8,203.6,1289,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Imaging without Contrast,5522,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],450.8,330,901.6,2915,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Imaging without Contrast,5522,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",252.54,123.27,453.81,100,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Imaging without Contrast,5522,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Imaging without Contrast,5522,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,507.2,90,1434.05,33,percent of total billed charges,,,
Level 3 Imaging without Contrast,5523,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],237.66,226.79,531.19,49,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Imaging without Contrast,5523,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,1161.28,771.55,1970.68,113,percent of total billed charges,,,
Level 3 Imaging without Contrast,5523,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],1493.76,600.71,2264.36,27,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Imaging without Contrast,5523,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],239.4,122.09,400,51,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Imaging without Contrast,5523,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],250,250,250,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Imaging without Contrast,5523,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],248.95,23.95,248.95,76,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Imaging without Contrast,5523,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],925.98,390.7,1858.73,78,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Imaging without Contrast,5523,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",487.58,381.57,487.58,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Imaging without Contrast,5523,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Imaging without Contrast,5523,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],323.34,308.56,337.21,123,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Imaging without Contrast,5523,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",458.65,275.89,458.65,335,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Imaging without Contrast,5523,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],666.35,323.34,1354.38,170,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Imaging without Contrast,5523,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],226.84,215.99,273.45,409,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Imaging without Contrast,5523,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],652.93,580.18,1239.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Imaging without Contrast,5523,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],228.31,95.96,350,31,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Imaging without Contrast,5523,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],235.4,224.64,250,397,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Imaging without Contrast,5523,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],1024.68,724.68,1278.2,944,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Imaging without Contrast,5523,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",453.66,222.75,994.57,38,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Imaging without Contrast,5523,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Imaging without Contrast,5523,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,742.71,150.6,2817.6,1 through 10,percent of total billed charges,,,
Level 4 Imaging without Contrast,5524,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],516.1,516.1,516.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Imaging without Contrast,5524,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,1226.57,1226.57,1333.04,1 through 10,percent of total billed charges,,,
Level 4 Imaging without Contrast,5524,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],2552.2,943.03,10228.05,23,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Imaging without Contrast,5524,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],533.95,533.95,735.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Imaging without Contrast,5524,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Imaging without Contrast,5524,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],554.68,544.68,814.68,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Imaging without Contrast,5524,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],1989.21,762.5,4261.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Imaging without Contrast,5524,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Imaging without Contrast,5524,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Imaging without Contrast,5524,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",275.89,275.89,802.24,29,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Imaging without Contrast,5524,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],723.45,723.45,765.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Imaging without Contrast,5524,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],449.34,416.79,2804.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Imaging without Contrast,5524,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],505.74,486.29,736.29,35,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Imaging without Contrast,5524,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],466.69,466.69,466.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Imaging without Contrast,5524,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Imaging without Contrast,5524,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],533.96,427.16,538.96,46,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Imaging without Contrast,5524,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],1834,1384,2324.32,58,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Imaging without Contrast,5524,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",1824,1634,2319.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Imaging without Contrast,5524,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Imaging without Contrast,5524,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Imaging with Contrast,5571,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],175.32,170.75,428.16,44,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Imaging with Contrast,5571,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,1139.39,421.04,4157.58,42,percent of total billed charges,,,
Level 1 Imaging with Contrast,5571,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],1126,355.8,3210.44,37,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Imaging with Contrast,5571,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],175.35,129.73,429.73,79,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Imaging with Contrast,5571,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],211.17,211.17,211.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Imaging with Contrast,5571,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],183.7,170.23,440.03,73,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Imaging with Contrast,5571,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],602.07,337.94,3797.25,119,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Imaging with Contrast,5571,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",350.2,350.2,823.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Imaging with Contrast,5571,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Imaging with Contrast,5571,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",329.41,114.86,774.77,240,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Imaging with Contrast,5571,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],250.83,223.13,582.05,91,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Imaging with Contrast,5571,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],742.2,238.13,2767.41,114,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Imaging with Contrast,5571,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],167.37,161.95,407.93,403,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Imaging with Contrast,5571,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],937.58,376.34,1058.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Imaging with Contrast,5571,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],167.37,137.93,407.93,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Imaging with Contrast,5571,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],174.06,168.84,424.24,475,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Imaging with Contrast,5571,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],754.64,554,1844.53,556,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Imaging with Contrast,5571,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",385.52,113.6,734.68,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Imaging with Contrast,5571,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Imaging with Contrast,5571,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,694.3,371.4,5860.24,1 through 10,percent of total billed charges,,,
Level 2 Imaging with Contrast,5572,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],351.62,118.7,362.45,55,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Imaging with Contrast,5572,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,2182.72,1091.4,3756.68,97,percent of total billed charges,,,
Level 2 Imaging with Contrast,5572,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],2083.12,799.34,6185.37,52,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Imaging with Contrast,5572,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],348.28,58.55,353.78,112,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Imaging with Contrast,5572,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Imaging with Contrast,5572,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],365.66,140.66,410.66,111,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Imaging with Contrast,5572,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],1543.3,858.27,2851.14,112,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Imaging with Contrast,5572,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",746.88,375.45,1844.22,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Imaging with Contrast,5572,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,368.53,368.53,368.53,1 through 10,percent of total billed charges,,,
Level 2 Imaging with Contrast,5572,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],477.72,417.72,532.44,122,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Imaging with Contrast,5572,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",702.58,385.01,784.08,287,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Imaging with Contrast,5572,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],1036.24,477.72,2160.57,177,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Imaging with Contrast,5572,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],335.77,334.91,344.49,491,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Imaging with Contrast,5572,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],902.24,902.24,917.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Imaging with Contrast,5572,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],339.91,64.91,668.39,34,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Imaging with Contrast,5572,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],348.29,230.05,521.65,660,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Imaging with Contrast,5572,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],1513.93,1234.5,1889.73,894,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Imaging with Contrast,5572,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",694.92,380.82,1473.88,30,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Imaging with Contrast,5572,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Imaging with Contrast,5572,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,2134.56,761.45,3660,13,percent of total billed charges,,,
Level 3 Imaging with Contrast,5573,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],2604.21,2377.43,2700.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Imaging with Contrast,5573,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,3745.36,1377.55,9951.75,1 through 10,percent of total billed charges,,,
Level 3 Imaging with Contrast,5573,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],19156.94,13225.43,19458.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Imaging with Contrast,5573,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],2603.65,2481.65,3024.07,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Imaging with Contrast,5573,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Imaging with Contrast,5573,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],2680.1,1138.24,2794.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Imaging with Contrast,5573,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],9149.51,6981.45,14537.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Imaging with Contrast,5573,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4791.76,4791.76,5460.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Imaging with Contrast,5573,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Imaging with Contrast,5573,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",904.51,904.51,2594.53,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Imaging with Contrast,5573,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],1534.57,1534.57,1631.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Imaging with Contrast,5573,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],1156.77,1013.4,11554.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Imaging with Contrast,5573,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],2479.25,835.82,2509.51,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Imaging with Contrast,5573,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Imaging with Contrast,5573,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Imaging with Contrast,5573,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],2574.13,1117.18,2788.43,46,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Imaging with Contrast,5573,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],3961,2942,11124.11,41,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Imaging with Contrast,5573,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",2882.7,2882.7,3259,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Imaging with Contrast,5573,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Imaging with Contrast,5573,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,3608,3608,3608,1 through 10,percent of total billed charges,,,
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],381.73,379.27,414.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,1386.24,821.56,1902.34,14,percent of total billed charges,,,
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],1164.07,756.7,1898.38,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],391.31,97.31,397.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],406.37,146.87,411.87,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],952.21,497.27,1187.06,33,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",345.09,345.09,345.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],537.52,527.58,567.58,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",325.63,325.63,402.26,45,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],776.59,206.4,1212.6,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],376.26,363.55,377.8,55,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],376.26,376.26,377.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],1703.42,521.82,1704.42,126,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],391.32,171.31,516.3,67,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",321.14,321.09,706.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Nuclear Medicine and Related Services,5591,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,1496.8,1496.8,2113.6,1 through 10,percent of total billed charges,,,
Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],500.26,500.26,526.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,1859.72,1349.76,2403.88,12,percent of total billed charges,,,
Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],1750.79,1236.18,3492.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],528.18,230.18,605.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],570.01,548.84,955.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],1162.66,1102.27,2232.97,32,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],730.03,720.03,1137.03,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",371.59,371.59,495.94,42,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],1176.51,720.03,1445,27,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],504.02,476.44,839.99,37,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],1270.01,1270.01,1270.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],504.02,504.02,534.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],524.19,329.18,622.18,54,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],2274.18,1825.44,2675.04,122,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",1457.34,1457.34,1457.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Nuclear Medicine and Related Services,5592,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,2362.4,1964.8,2510.05,1 through 10,percent of total billed charges,,,
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],2303.89,2303.89,2303.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,9427.48,9427.48,13583.36,1 through 10,percent of total billed charges,,,
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],6682.91,5945,15857.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],6595.26,6595.26,6595.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],2610.17,2610.17,2610.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",2787,2787,2787,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],1954.39,1954.39,1954.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",9813.13,9813.13,9813.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],6361.3,6361.3,6361.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],2496.09,2399.21,2595.54,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],2509.27,1780.72,2690.97,24,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],7242,5417,10723.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4889.37,4889.37,4889.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Nuclear Medicine and Related Services,5593,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],1454.47,1434.46,6547.05,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,5307.08,5209.8,12613.72,13,percent of total billed charges,,,
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],4690.75,4690.75,5322.17,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],1426.41,1126.41,6349.97,30,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],1479.54,1254.54,4186.66,37,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],3303.76,2643.01,9661.79,34,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",1447.03,1447.03,1447.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],1951.11,1900.45,5768.51,44,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",1361.2,1361.2,1361.2,73,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],2399.82,2213.66,11736.68,40,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],1379.02,1365.78,6208.5,200,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],1372.78,1109.52,6475.34,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],1420.92,1208.65,4553.64,199,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],6183.17,6019.6,9252.47,168,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",1346.37,1346.37,1346.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Nuclear Medicine and Related Services,5594,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,5586.4,351.84,12910.4,14,percent of total billed charges,,,
Level 1 Therapeutic Radiation Treatment Preparation,5611,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Therapeutic Radiation Treatment Preparation,5611,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Therapeutic Radiation Treatment Preparation,5611,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Therapeutic Radiation Treatment Preparation,5611,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Therapeutic Radiation Treatment Preparation,5611,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Therapeutic Radiation Treatment Preparation,5611,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Therapeutic Radiation Treatment Preparation,5611,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Therapeutic Radiation Treatment Preparation,5611,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Therapeutic Radiation Treatment Preparation,5611,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Therapeutic Radiation Treatment Preparation,5611,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",395.44,395.44,395.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Therapeutic Radiation Treatment Preparation,5611,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Therapeutic Radiation Treatment Preparation,5611,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Therapeutic Radiation Treatment Preparation,5611,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Therapeutic Radiation Treatment Preparation,5611,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Therapeutic Radiation Treatment Preparation,5611,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Therapeutic Radiation Treatment Preparation,5611,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],254.8,254.8,255.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Therapeutic Radiation Treatment Preparation,5611,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],981,981,981,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Therapeutic Radiation Treatment Preparation,5611,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Therapeutic Radiation Treatment Preparation,5611,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Therapeutic Radiation Treatment Preparation,5611,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Therapeutic Radiation Treatment Preparation,5612,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],273.59,273.59,273.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Therapeutic Radiation Treatment Preparation,5612,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Therapeutic Radiation Treatment Preparation,5612,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],14554.78,14554.78,14554.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Therapeutic Radiation Treatment Preparation,5612,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],4685.29,4685.29,4685.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Therapeutic Radiation Treatment Preparation,5612,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Therapeutic Radiation Treatment Preparation,5612,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],4511.81,4511.81,4511.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Therapeutic Radiation Treatment Preparation,5612,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],20314.22,20314.22,26597.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Therapeutic Radiation Treatment Preparation,5612,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Therapeutic Radiation Treatment Preparation,5612,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Therapeutic Radiation Treatment Preparation,5612,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],5301.17,5301.17,5301.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Therapeutic Radiation Treatment Preparation,5612,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",808.04,808.04,5012.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Therapeutic Radiation Treatment Preparation,5612,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],13187.68,13187.68,13187.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Therapeutic Radiation Treatment Preparation,5612,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],1397.89,1397.89,1397.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Therapeutic Radiation Treatment Preparation,5612,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],11059.49,11059.49,11059.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Therapeutic Radiation Treatment Preparation,5612,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Therapeutic Radiation Treatment Preparation,5612,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],23553.47,2098.13,41488.22,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Therapeutic Radiation Treatment Preparation,5612,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],3796.91,481.99,5646.64,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Therapeutic Radiation Treatment Preparation,5612,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3314.95,3314.95,6120.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Therapeutic Radiation Treatment Preparation,5612,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Therapeutic Radiation Treatment Preparation,5612,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Therapeutic Radiation Treatment Preparation,5613,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],2096.8,2096.8,2773.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Therapeutic Radiation Treatment Preparation,5613,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,10199.96,10199.96,10199.96,1 through 10,percent of total billed charges,,,
Level 3 Therapeutic Radiation Treatment Preparation,5613,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],10333.81,10333.81,10333.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Therapeutic Radiation Treatment Preparation,5613,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],2431.9,2203.51,3122.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Therapeutic Radiation Treatment Preparation,5613,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Therapeutic Radiation Treatment Preparation,5613,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],1914.12,1832.78,2489.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Therapeutic Radiation Treatment Preparation,5613,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],5020.91,5020.91,6015.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Therapeutic Radiation Treatment Preparation,5613,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Therapeutic Radiation Treatment Preparation,5613,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Therapeutic Radiation Treatment Preparation,5613,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",2627.79,2502.96,3114.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Therapeutic Radiation Treatment Preparation,5613,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],3526.89,3526.89,4111.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Therapeutic Radiation Treatment Preparation,5613,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],5148.8,5053.08,5607.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Therapeutic Radiation Treatment Preparation,5613,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],2542.83,1993.29,14636.77,19,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Therapeutic Radiation Treatment Preparation,5613,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],2460.38,2460.38,2460.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Therapeutic Radiation Treatment Preparation,5613,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Therapeutic Radiation Treatment Preparation,5613,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],2434.3,2073.04,3332.81,24,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Therapeutic Radiation Treatment Preparation,5613,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],8510,6871,10069.71,32,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Therapeutic Radiation Treatment Preparation,5613,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Therapeutic Radiation Treatment Preparation,5613,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Therapeutic Radiation Treatment Preparation,5613,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Radiation Therapy,5622,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Radiation Therapy,5622,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Radiation Therapy,5622,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Radiation Therapy,5622,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Radiation Therapy,5622,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Radiation Therapy,5622,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],5384.62,2431.81,8846.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Radiation Therapy,5622,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],12367.14,12367.14,12367.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Radiation Therapy,5622,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Radiation Therapy,5622,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Radiation Therapy,5622,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",5582.08,1981.44,7786.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Radiation Therapy,5622,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],9708.14,9708.14,9708.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Radiation Therapy,5622,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],2154.62,2154.62,2154.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Radiation Therapy,5622,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],989,989,989,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Radiation Therapy,5622,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Radiation Therapy,5622,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Radiation Therapy,5622,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],15628.96,6136.84,33302.86,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Radiation Therapy,5622,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],4229.4,512.2,7067.37,22,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Radiation Therapy,5622,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4910.73,4910.73,4910.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Radiation Therapy,5622,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Radiation Therapy,5622,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Radiation Therapy,5623,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],3884.18,3884.18,3884.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Radiation Therapy,5623,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,48104.96,34329.2,65942.92,1 through 10,percent of total billed charges,,,
Level 3 Radiation Therapy,5623,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],38408.93,27814.42,47947.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Radiation Therapy,5623,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],7965.97,1826.71,12372.29,23,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Radiation Therapy,5623,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Radiation Therapy,5623,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],4894.84,2662,10545.48,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Radiation Therapy,5623,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],23747.3,13776.85,50282.91,25,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Radiation Therapy,5623,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",9898.68,9013.55,17971.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Radiation Therapy,5623,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Radiation Therapy,5623,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],9284.43,1500.49,15063.62,21,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Radiation Therapy,5623,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",9311.5,4810.51,14609.39,25,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Radiation Therapy,5623,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],30336.21,12911.65,60130.43,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Radiation Therapy,5623,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],6757.01,2175.52,11330.68,84,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Radiation Therapy,5623,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],15656.17,15656.17,15656.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Radiation Therapy,5623,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],3984.38,1399.48,11750.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Radiation Therapy,5623,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],6760.37,2253.36,11830,85,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Radiation Therapy,5623,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],29440.02,12261.2,49418.64,65,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Radiation Therapy,5623,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",9686.23,6075.62,37454.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Radiation Therapy,5623,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Radiation Therapy,5623,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Radiation Therapy,5624,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],8604.99,8604.99,8604.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Radiation Therapy,5624,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Radiation Therapy,5624,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],20639.6,20639.6,34271.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Radiation Therapy,5624,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Radiation Therapy,5624,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Radiation Therapy,5624,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],1679.33,1679.33,1679.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Radiation Therapy,5624,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Radiation Therapy,5624,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Radiation Therapy,5624,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Radiation Therapy,5624,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",5984.4,5984.4,5984.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Radiation Therapy,5624,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],5227.62,5227.62,5227.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Radiation Therapy,5624,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Radiation Therapy,5624,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Radiation Therapy,5624,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Radiation Therapy,5624,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Radiation Therapy,5624,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],8093.13,8093.13,8093.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Radiation Therapy,5624,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],24979.72,24979.72,32776.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Radiation Therapy,5624,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Radiation Therapy,5624,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Radiation Therapy,5624,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 6 Radiation Therapy,5626,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],7772.79,7766.45,8632,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 6 Radiation Therapy,5626,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 6 Radiation Therapy,5626,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],7692.43,7352.5,9175.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 6 Radiation Therapy,5626,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Radiation Therapy,5626,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Radiation Therapy,5626,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],3551.44,3551.44,3551.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 6 Radiation Therapy,5626,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],26628.33,26628.33,26628.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 6 Radiation Therapy,5626,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Radiation Therapy,5626,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 6 Radiation Therapy,5626,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",9666.75,9666.75,9936.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 6 Radiation Therapy,5626,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],10388.98,10388.98,10738.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 6 Radiation Therapy,5626,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],23789.08,23789.08,23789.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 6 Radiation Therapy,5626,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],8013.33,6728.43,10560.66,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 6 Radiation Therapy,5626,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],7133.18,4838.15,8595.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 6 Radiation Therapy,5626,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Radiation Therapy,5626,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],6969.14,4103.88,11608.59,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 6 Radiation Therapy,5626,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],22893.46,15449.92,48919.29,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 6 Radiation Therapy,5626,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Radiation Therapy,5626,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 6 Radiation Therapy,5626,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Therapeutic Nuclear Medicine,5661,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],,,,0,other,,,No services performed during 15-month lookback period.
Therapeutic Nuclear Medicine,5661,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Therapeutic Nuclear Medicine,5661,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Therapeutic Nuclear Medicine,5661,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Therapeutic Nuclear Medicine,5661,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Therapeutic Nuclear Medicine,5661,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],3500.54,3500.54,3500.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Therapeutic Nuclear Medicine,5661,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],1892.83,1892.83,1892.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Therapeutic Nuclear Medicine,5661,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Therapeutic Nuclear Medicine,5661,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Therapeutic Nuclear Medicine,5661,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],3797.07,3797.07,3797.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Therapeutic Nuclear Medicine,5661,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",2662.24,2662.24,2662.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Therapeutic Nuclear Medicine,5661,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],2178.05,2178.05,2271.19,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Therapeutic Nuclear Medicine,5661,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],2436.09,2436.09,2436.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Therapeutic Nuclear Medicine,5661,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],1870.37,1870.37,1870.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Therapeutic Nuclear Medicine,5661,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],3859.92,3859.92,3859.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Therapeutic Nuclear Medicine,5661,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],3332.49,3249.54,3702.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Therapeutic Nuclear Medicine,5661,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Therapeutic Nuclear Medicine,5661,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Therapeutic Nuclear Medicine,5661,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Therapeutic Nuclear Medicine,5661,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,6386.4,6386.4,6386.4,1 through 10,percent of total billed charges,,,
Level 1 Pathology,5671,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],50.16,50.16,50.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Pathology,5671,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Pathology,5671,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],322.58,322.58,322.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Pathology,5671,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Pathology,5671,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Pathology,5671,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],136,136,136,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Pathology,5671,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Pathology,5671,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Pathology,5671,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Pathology,5671,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],97.11,97.11,97.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Pathology,5671,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Pathology,5671,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Pathology,5671,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Pathology,5671,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Pathology,5671,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Pathology,5671,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],202.03,202.03,202.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Pathology,5671,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Pathology,5671,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Pathology,5671,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Pathology,5671,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Pathology,5672,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],168.48,158.08,168.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Pathology,5672,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,449.16,449.16,449.16,1 through 10,percent of total billed charges,,,
Level 2 Pathology,5672,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],799.26,799.26,799.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Pathology,5672,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],292.4,292.4,292.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Pathology,5672,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Pathology,5672,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],173.29,173.29,173.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Pathology,5672,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],1390.79,617.93,2011,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Pathology,5672,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Pathology,5672,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Pathology,5672,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],84.47,84.47,84.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Pathology,5672,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",297.61,214.69,545.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Pathology,5672,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],596.79,596.79,596.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Pathology,5672,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],160.46,150.56,281.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Pathology,5672,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Pathology,5672,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Pathology,5672,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],726.44,581.15,726.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Pathology,5672,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],166.87,166.87,166.88,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Pathology,5672,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Pathology,5672,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Pathology,5672,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Pathology,5673,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],353.68,353.68,353.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Pathology,5673,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,3862.32,3862.32,3862.32,1 through 10,percent of total billed charges,,,
Level 3 Pathology,5673,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],1820,687.42,2287.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Pathology,5673,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],351.31,351.31,351.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Pathology,5673,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Pathology,5673,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],363.79,363.79,363.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Pathology,5673,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],3951.22,1599.31,13265.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Pathology,5673,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Pathology,5673,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Pathology,5673,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],75.35,75.35,75.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Pathology,5673,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",754.29,296.47,1515.44,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Pathology,5673,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],550.41,306.47,1662.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Pathology,5673,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],319.84,316.84,1496.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Pathology,5673,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],336.84,336.84,336.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Pathology,5673,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Pathology,5673,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],350.32,350.31,984.81,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Pathology,5673,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],1057,410,4131.59,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Pathology,5673,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",2268.05,2268.05,2268.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Pathology,5673,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Pathology,5673,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,1852,1852,1852,1 through 10,percent of total billed charges,,,
Level 4 Pathology,5674,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Pathology,5674,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Pathology,5674,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Pathology,5674,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Pathology,5674,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Pathology,5674,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Pathology,5674,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Pathology,5674,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Pathology,5674,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Pathology,5674,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Pathology,5674,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Pathology,5674,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Pathology,5674,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Pathology,5674,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Pathology,5674,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Pathology,5674,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],925,925,925,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Pathology,5674,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Pathology,5674,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Pathology,5674,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Pathology,5674,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Drug Administration,5691,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],7322.17,7322.17,7322.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Drug Administration,5691,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Drug Administration,5691,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],7391.84,2212.27,21906.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Drug Administration,5691,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],6302.54,6302.54,6302.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Drug Administration,5691,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Drug Administration,5691,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],2555.1,2555.1,2555.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Drug Administration,5691,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],6286.96,6286.96,14301.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Drug Administration,5691,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Drug Administration,5691,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Drug Administration,5691,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4696.14,4696.14,4696.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Drug Administration,5691,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],3130.39,3130.39,5763.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Drug Administration,5691,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Drug Administration,5691,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Drug Administration,5691,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Drug Administration,5691,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Drug Administration,5691,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],7776.09,100,14462.33,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Drug Administration,5691,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],2613.35,733.52,5523.44,22,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Drug Administration,5691,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Drug Administration,5691,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Drug Administration,5691,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,18887.85,18887.85,18887.85,1 through 10,percent of total billed charges,,,
Level 2 Drug Administration,5692,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],1777.45,1729.71,1875.06,42,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Drug Administration,5692,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,337.44,162.64,4609.02,25,percent of total billed charges,,,
Level 2 Drug Administration,5692,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],3901.75,1079,5445,27,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Drug Administration,5692,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],1801.81,1408.61,2116.43,78,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Drug Administration,5692,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],4717.86,4717.86,4717.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Drug Administration,5692,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],1837.13,1363.59,1946.8,52,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Drug Administration,5692,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],2900.91,82.35,3866.18,40,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Drug Administration,5692,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",104.45,104.45,104.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Drug Administration,5692,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Drug Administration,5692,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",1514.63,164.93,8572.22,60,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Drug Administration,5692,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],2489.98,2418.64,3069.82,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Drug Administration,5692,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],3707.29,1345.24,16335,42,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Drug Administration,5692,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],1960.3,1609.15,3569.99,440,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Drug Administration,5692,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],2275.29,1609.15,2820.83,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Drug Administration,5692,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Drug Administration,5692,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],1961.32,241.38,4700.92,148,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Drug Administration,5692,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],1769.88,250.25,2550.62,422,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Drug Administration,5692,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",6089.37,293.74,6089.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Drug Administration,5692,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Drug Administration,5692,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,2086.56,85.61,6695.79,1 through 10,percent of total billed charges,,,
Level 3 Drug Administration,5693,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],210.15,199.08,3237.33,24,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Drug Administration,5693,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,1824.28,482.6,9718.88,33,percent of total billed charges,,,
Level 3 Drug Administration,5693,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],5011.31,676.59,29822,104,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Drug Administration,5693,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],692.43,164.14,7780.66,103,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Drug Administration,5693,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Drug Administration,5693,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],602.24,192.79,7093.72,62,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Drug Administration,5693,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],1250.9,525.08,4085.71,96,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Drug Administration,5693,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",442.89,232.86,2364.85,27,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Drug Administration,5693,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Drug Administration,5693,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",484.44,200.04,6396.44,395,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Drug Administration,5693,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],2061.36,281.83,11385.1,56,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Drug Administration,5693,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],3671.1,921.64,29238.49,105,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Drug Administration,5693,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],755.72,189.71,11426.61,397,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Drug Administration,5693,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],1379.8,1194.9,1746.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Drug Administration,5693,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],723.39,197.28,6309.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Drug Administration,5693,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],1255.34,676,8132.14,405,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Drug Administration,5693,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],208.18,198.49,6536.26,294,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Drug Administration,5693,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",593.59,234.37,14550.58,37,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Drug Administration,5693,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Drug Administration,5693,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,547.21,449.18,36281.4,29,percent of total billed charges,,,
Level 4 Drug Administration,5694,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],2311.72,314.15,2644.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Drug Administration,5694,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,12289.04,568.48,31693.52,1 through 10,percent of total billed charges,,,
Level 4 Drug Administration,5694,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],15971.6,1065.08,66039.5,54,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Drug Administration,5694,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],2574.41,995.9,13521.65,46,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Drug Administration,5694,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Drug Administration,5694,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],462.25,268.34,2364.21,28,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Drug Administration,5694,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],9439.22,561.82,51048.46,62,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Drug Administration,5694,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",274293.52,274293.52,274293.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Drug Administration,5694,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Drug Administration,5694,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],2396.93,1281.06,19702.32,60,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Drug Administration,5694,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",675.52,288.63,8657.68,127,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Drug Administration,5694,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],5442.84,1743.05,24244.14,72,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Drug Administration,5694,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],2197.27,895.47,7800.78,164,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Drug Administration,5694,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],13448.54,13448.54,13448.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Drug Administration,5694,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],1402.92,1112.11,4127.97,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Drug Administration,5694,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],2720.58,443.66,5594.79,85,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Drug Administration,5694,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],4149.64,1940.64,36997.24,85,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Drug Administration,5694,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",334.08,334.08,26109.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Drug Administration,5694,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Drug Administration,5694,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,9248.51,4435.31,27030.4,28,percent of total billed charges,,,
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],153.82,145.58,162.67,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,487.16,149.49,641,80,percent of total billed charges,,,
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],641,212.66,641,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],154.36,146.5,154.36,34,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],158.22,148.74,183.22,54,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],339.77,243.76,391.01,274,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",226.07,226.07,226.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",212.66,212.66,212.66,169,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],209.29,209.29,331.07,92,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],339.63,226.42,345.97,124,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],147.1,137.69,147.5,166,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],297.4,283.03,310.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],146.5,137.69,147.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],152.37,143.2,153.36,208,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],624.29,480.75,641,1142,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",210.34,210.34,641,24,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Diagnostic Tests and Related Services,5721,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,512.8,128.2,512.8,1 through 10,percent of total billed charges,,,
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],291.51,291.51,307.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,775.96,718.5,959.88,16,percent of total billed charges,,,
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],732.82,484.22,1075.99,56,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],303.25,242.59,910.79,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],314.91,314.91,314.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],392.23,313.78,643.55,37,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",226.07,226.07,226.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],416.56,277.02,431.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",212.66,212.66,212.66,141,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],671.82,576.06,1007.83,21,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],291.59,276.67,292.78,36,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],1007.83,1007.83,1007.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],291.59,291.59,291.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],303.26,254.26,304.25,45,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],1055,599.25,1320.05,120,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",210.34,210.34,1052,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Diagnostic Tests and Related Services,5722,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,426.24,426.24,426.24,1 through 10,percent of total billed charges,,,
Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,2194.27,2194.27,2194.27,1 through 10,percent of total billed charges,,,
Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],7232.8,7232.8,7500.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],2655.33,1696.58,3350.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",655.25,655.25,655.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",1011.12,1011.12,1011.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],1361.28,1361.28,1361.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],677.57,677.57,819.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],2435.87,2209.11,3004.99,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",2129.78,2129.78,2129.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Diagnostic Tests and Related Services,5723,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],1000.3,968.68,1351.42,19,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,3271.04,726.36,4158.72,41,percent of total billed charges,,,
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],3445.51,2467.31,3484.36,42,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],990.76,892.76,1090.76,47,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],1028.87,995.92,1174.93,30,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],2625.44,1348.97,3281.8,88,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",1074.88,1074.88,1074.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],1360.94,1151.06,1538.66,46,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",1011.12,999.84,1011.12,229,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],3714.34,1594.11,3907.96,71,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],953.66,921.6,960.66,151,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],3145.37,1271.57,3571.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],952.66,921.6,952.66,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],990.77,941.76,991.77,238,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],4304,2956.63,4312.87,405,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",1000.11,988.96,4284,24,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Diagnostic Tests and Related Services,5724,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,1898.4,100,3492.06,1 through 10,percent of total billed charges,,,
Level 1 Minor Procedures,5731,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,429.43,47,937.08,20,percent of total billed charges,,,
Level 1 Minor Procedures,5731,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Minor Procedures,5731,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],176.86,40,251.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Minor Procedures,5731,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Minor Procedures,5731,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Minor Procedures,5731,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],146.1,91.98,212.89,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Minor Procedures,5731,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],526.46,176.29,878.41,30,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Minor Procedures,5731,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Minor Procedures,5731,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 1 Minor Procedures,5731,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],235.05,124.48,401.22,41,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Minor Procedures,5731,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",310.28,88.45,473.77,22,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Minor Procedures,5731,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],535,275.19,1228,22,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Minor Procedures,5731,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],182.21,51.36,330.26,37,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Minor Procedures,5731,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],175.67,159,234.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Minor Procedures,5731,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Minor Procedures,5731,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],164.2,44.28,329.16,38,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Minor Procedures,5731,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],278.17,119.49,511.41,119,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Minor Procedures,5731,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",924.86,245.25,1090.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 1 Minor Procedures,5731,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 1 Minor Procedures,5731,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,501.4,501.4,501.4,1 through 10,percent of total billed charges,,,
Level 2 Minor Procedures,5732,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],308.72,149.64,463.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Minor Procedures,5732,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Minor Procedures,5732,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],13965.1,13965.1,13965.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Minor Procedures,5732,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],152.88,76.44,267.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Minor Procedures,5732,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Minor Procedures,5732,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],76.76,76.76,76.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Minor Procedures,5732,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],1215.12,384.3,2113.65,27,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Minor Procedures,5732,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Minor Procedures,5732,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 2 Minor Procedures,5732,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],367.5,262.5,551.9,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Minor Procedures,5732,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",153.44,38.36,268.52,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Minor Procedures,5732,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],2375.36,2078.44,2969.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Minor Procedures,5732,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],212.94,70.7,405.9,46,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Minor Procedures,5732,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],220.5,36.75,353.5,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Minor Procedures,5732,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Minor Procedures,5732,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],229.32,39,458.64,66,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Minor Procedures,5732,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],822.6,161.99,1830.4,38,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Minor Procedures,5732,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",971.94,971.94,971.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 2 Minor Procedures,5732,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 2 Minor Procedures,5732,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Minor Procedures,5733,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],57.61,57.61,58.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Minor Procedures,5733,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,289.56,256.12,567.44,11,percent of total billed charges,,,
Level 3 Minor Procedures,5733,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],320,227.88,380.56,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Minor Procedures,5733,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],57.85,33.35,407.05,23,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Minor Procedures,5733,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Minor Procedures,5733,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],60.07,58.23,205.57,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Minor Procedures,5733,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],205.57,136.64,812.16,28,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Minor Procedures,5733,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",149.16,109.42,182.04,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Minor Procedures,5733,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Minor Procedures,5733,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",102.93,102.93,223.8,80,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Minor Procedures,5733,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],79.46,54.23,105.24,22,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Minor Procedures,5733,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],374,316.69,653.36,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Minor Procedures,5733,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],55.62,53.92,335.1,83,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Minor Procedures,5733,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],55.62,53.92,55.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Minor Procedures,5733,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Minor Procedures,5733,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],57.85,21.98,462.8,187,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Minor Procedures,5733,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],251.79,201.43,452.07,104,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Minor Procedures,5733,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",156.42,101.81,295.15,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Minor Procedures,5733,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Minor Procedures,5733,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,269.6,256,708.8,1 through 10,percent of total billed charges,,,
Level 4 Minor Procedures,5734,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],119.04,118.24,126.73,27,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Minor Procedures,5734,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,461.2,327.56,720.48,55,percent of total billed charges,,,
Level 4 Minor Procedures,5734,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],225.1,85.46,563,71,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Minor Procedures,5734,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],126.04,76.53,126.53,81,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Minor Procedures,5734,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Minor Procedures,5734,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],130.35,121.63,130.35,52,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Minor Procedures,5734,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],351.97,234.24,642.94,115,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Minor Procedures,5734,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",51.43,30.89,530.4,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Minor Procedures,5734,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 4 Minor Procedures,5734,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],43.13,26.65,246.61,58,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Minor Procedures,5734,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",50.24,23.63,156.05,150,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Minor Procedures,5734,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],421.64,272.46,713.25,82,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Minor Procedures,5734,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],120.7,96.56,121.19,257,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Minor Procedures,5734,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],380.39,379.16,428.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Minor Procedures,5734,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],120.7,112.6,120.7,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Minor Procedures,5734,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],125.53,117.11,125.53,469,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Minor Procedures,5734,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],512.55,338.24,546.44,403,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Minor Procedures,5734,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",70.87,37.04,510,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 4 Minor Procedures,5734,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 4 Minor Procedures,5734,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,499.2,362.4,1043.4,15,percent of total billed charges,,,
Level 3 Electronic Analysis of Devices,5743,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Electronic Analysis of Devices,5743,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Electronic Analysis of Devices,5743,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Electronic Analysis of Devices,5743,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Electronic Analysis of Devices,5743,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Electronic Analysis of Devices,5743,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Electronic Analysis of Devices,5743,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Electronic Analysis of Devices,5743,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Electronic Analysis of Devices,5743,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Level 3 Electronic Analysis of Devices,5743,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Electronic Analysis of Devices,5743,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Electronic Analysis of Devices,5743,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Electronic Analysis of Devices,5743,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Electronic Analysis of Devices,5743,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Electronic Analysis of Devices,5743,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Electronic Analysis of Devices,5743,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],5373.82,5373.82,5373.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Level 3 Electronic Analysis of Devices,5743,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Electronic Analysis of Devices,5743,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Electronic Analysis of Devices,5743,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Level 3 Electronic Analysis of Devices,5743,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Rehabilitation,5771,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],860.23,489.16,1241.9,19,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Rehabilitation,5771,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,2261.76,959.88,4164.8,17,percent of total billed charges,,,
Cardiac Rehabilitation,5771,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],1596.36,520.38,2290.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Rehabilitation,5771,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],838.89,122.61,1354.21,23,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Rehabilitation,5771,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Rehabilitation,5771,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],470.08,40,1402.72,20,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Rehabilitation,5771,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],1337.12,605.12,4011.36,47,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Rehabilitation,5771,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Rehabilitation,5771,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Cardiac Rehabilitation,5771,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],909.2,181.84,1852.62,23,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Rehabilitation,5771,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",352.38,100.68,553.74,34,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Rehabilitation,5771,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],2086.5,494.12,3211.78,46,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Rehabilitation,5771,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],815.29,120.3,1296.79,131,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Rehabilitation,5771,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],2379.74,2163.4,3048.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Rehabilitation,5771,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],825.23,698.82,1414.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Rehabilitation,5771,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],3526.18,957.48,6303,170,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Rehabilitation,5771,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],969.04,245.22,1471.32,249,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Rehabilitation,5771,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",99.57,99.57,99.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Rehabilitation,5771,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Rehabilitation,5771,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,2035,1315.2,2935.2,15,percent of total billed charges,,,
Resuscitation and Cardioversion,5781,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],1283.36,1283.36,1283.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Resuscitation and Cardioversion,5781,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Resuscitation and Cardioversion,5781,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],4479.62,4479.62,4479.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Resuscitation and Cardioversion,5781,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],539.25,539.25,539.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Resuscitation and Cardioversion,5781,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Resuscitation and Cardioversion,5781,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],667.16,667.16,1150.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Resuscitation and Cardioversion,5781,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],2966.43,1407.2,3835.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Resuscitation and Cardioversion,5781,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Resuscitation and Cardioversion,5781,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Resuscitation and Cardioversion,5781,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],875.35,875.35,875.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Resuscitation and Cardioversion,5781,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",1305.79,1253.79,1783.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Resuscitation and Cardioversion,5781,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],2114.82,1984.29,4882.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Resuscitation and Cardioversion,5781,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],612.74,573.68,1096.41,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Resuscitation and Cardioversion,5781,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],4052.33,4052.33,4052.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Resuscitation and Cardioversion,5781,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],612.74,612.74,612.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Resuscitation and Cardioversion,5781,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],643.15,601.63,1707.47,34,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Resuscitation and Cardioversion,5781,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],2697,2393,5463,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Resuscitation and Cardioversion,5781,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Resuscitation and Cardioversion,5781,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Resuscitation and Cardioversion,5781,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,2530.96,2530.96,2530.96,1 through 10,percent of total billed charges,,,
Pulmonary Treatment,5791,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,158.08,158.08,158.08,1 through 10,percent of total billed charges,,,
Pulmonary Treatment,5791,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Treatment,5791,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],221,221,1693.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pulmonary Treatment,5791,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],198.07,198.07,198.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pulmonary Treatment,5791,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Treatment,5791,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],301.34,301.34,578.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pulmonary Treatment,5791,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Treatment,5791,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",540.87,425.1,654.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pulmonary Treatment,5791,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Pulmonary Treatment,5791,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],260,260,260,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pulmonary Treatment,5791,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",215.94,215.94,2630.42,34,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pulmonary Treatment,5791,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],260,260,260,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pulmonary Treatment,5791,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],190.45,190.45,190.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pulmonary Treatment,5791,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Treatment,5791,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Treatment,5791,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],855.86,689.78,879.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pulmonary Treatment,5791,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],198.07,153.97,198.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pulmonary Treatment,5791,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3219.64,3219.64,3219.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pulmonary Treatment,5791,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Treatment,5791,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ventilation Initiation and Management,5801,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],,,,0,other,,,No services performed during 15-month lookback period.
Ventilation Initiation and Management,5801,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ventilation Initiation and Management,5801,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventilation Initiation and Management,5801,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventilation Initiation and Management,5801,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventilation Initiation and Management,5801,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventilation Initiation and Management,5801,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],,,,0,other,,,No services performed during 15-month lookback period.
Ventilation Initiation and Management,5801,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Ventilation Initiation and Management,5801,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Ventilation Initiation and Management,5801,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Ventilation Initiation and Management,5801,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Ventilation Initiation and Management,5801,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Ventilation Initiation and Management,5801,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Ventilation Initiation and Management,5801,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Ventilation Initiation and Management,5801,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Ventilation Initiation and Management,5801,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],2833.07,2833.07,2833.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Ventilation Initiation and Management,5801,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],,,,0,other,,,No services performed during 15-month lookback period.
Ventilation Initiation and Management,5801,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Ventilation Initiation and Management,5801,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventilation Initiation and Management,5801,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Dental Procedures,5871,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],,,,0,other,,,No services performed during 15-month lookback period.
Dental Procedures,5871,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Dental Procedures,5871,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],4700.23,4700.23,7288.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Dental Procedures,5871,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dental Procedures,5871,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dental Procedures,5871,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],150,150,150,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Dental Procedures,5871,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dental Procedures,5871,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3112.15,3112.15,3112.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Dental Procedures,5871,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Dental Procedures,5871,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",2278.01,1207.24,4533.93,29,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Dental Procedures,5871,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],7048,7048,7048,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Dental Procedures,5871,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Dental Procedures,5871,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Dental Procedures,5871,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Dental Procedures,5871,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Dental Procedures,5871,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",171.98,171.98,171.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Dental Procedures,5871,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dental Procedures,5871,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],,,,0,other,,,No services performed during 15-month lookback period.
Dental Procedures,5871,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dental Procedures,5871,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, acetaminophen (hikma)",9282,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, acetaminophen (hikma)",9282,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, acetaminophen (hikma)",9282,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, acetaminophen (hikma)",9282,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, acetaminophen (hikma)",9282,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, acetaminophen (hikma)",9282,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, acetaminophen (hikma)",9282,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, acetaminophen (hikma)",9282,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, acetaminophen (hikma)",9282,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, acetaminophen (hikma)",9282,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3325.16,3325.16,3325.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj, acetaminophen (hikma)",9282,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, acetaminophen (hikma)",9282,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, acetaminophen (hikma)",9282,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, acetaminophen (hikma)",9282,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, acetaminophen (hikma)",9282,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, acetaminophen (hikma)",9282,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, acetaminophen (hikma)",9282,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, acetaminophen (hikma)",9282,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, acetaminophen (hikma)",9282,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, acetaminophen (hikma)",9282,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, bupivacaine, nos, 0.5mg",9290,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, bupivacaine, nos, 0.5mg",9290,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, bupivacaine, nos, 0.5mg",9290,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, bupivacaine, nos, 0.5mg",9290,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, bupivacaine, nos, 0.5mg",9290,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, bupivacaine, nos, 0.5mg",9290,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, bupivacaine, nos, 0.5mg",9290,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, bupivacaine, nos, 0.5mg",9290,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, bupivacaine, nos, 0.5mg",9290,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"Inj, bupivacaine, nos, 0.5mg",9290,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],178.45,178.45,178.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Inj, bupivacaine, nos, 0.5mg",9290,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, bupivacaine, nos, 0.5mg",9290,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, bupivacaine, nos, 0.5mg",9290,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, bupivacaine, nos, 0.5mg",9290,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, bupivacaine, nos, 0.5mg",9290,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, bupivacaine, nos, 0.5mg",9290,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, bupivacaine, nos, 0.5mg",9290,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, bupivacaine, nos, 0.5mg",9290,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Inj, bupivacaine, nos, 0.5mg",9290,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Inj, bupivacaine, nos, 0.5mg",9290,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
RBC leukocytes reduced,9512,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],,,,0,other,,,No services performed during 15-month lookback period.
RBC leukocytes reduced,9512,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
RBC leukocytes reduced,9512,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],4980,4980,4980,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
RBC leukocytes reduced,9512,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
RBC leukocytes reduced,9512,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
RBC leukocytes reduced,9512,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],5056.9,5056.9,5056.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
RBC leukocytes reduced,9512,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
RBC leukocytes reduced,9512,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
RBC leukocytes reduced,9512,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
RBC leukocytes reduced,9512,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
RBC leukocytes reduced,9512,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
RBC leukocytes reduced,9512,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
RBC leukocytes reduced,9512,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
RBC leukocytes reduced,9512,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
RBC leukocytes reduced,9512,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
RBC leukocytes reduced,9512,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
RBC leukocytes reduced,9512,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],,,,0,other,,,No services performed during 15-month lookback period.
RBC leukocytes reduced,9512,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
RBC leukocytes reduced,9512,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
RBC leukocytes reduced,9512,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
RBC leukoreduced irradiated,9522,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],,,,0,other,,,No services performed during 15-month lookback period.
RBC leukoreduced irradiated,9522,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
RBC leukoreduced irradiated,9522,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],5983.46,5983.46,5983.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
RBC leukoreduced irradiated,9522,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
RBC leukoreduced irradiated,9522,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
RBC leukoreduced irradiated,9522,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
RBC leukoreduced irradiated,9522,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],,,,0,other,,,No services performed during 15-month lookback period.
RBC leukoreduced irradiated,9522,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
RBC leukoreduced irradiated,9522,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
RBC leukoreduced irradiated,9522,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],910.74,910.74,910.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
RBC leukoreduced irradiated,9522,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
RBC leukoreduced irradiated,9522,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
RBC leukoreduced irradiated,9522,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
RBC leukoreduced irradiated,9522,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
RBC leukoreduced irradiated,9522,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
RBC leukoreduced irradiated,9522,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
RBC leukoreduced irradiated,9522,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],,,,0,other,,,No services performed during 15-month lookback period.
RBC leukoreduced irradiated,9522,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
RBC leukoreduced irradiated,9522,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
RBC leukoreduced irradiated,9522,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Plate pheres leukoredu irrad,9530,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],,,,0,other,,,No services performed during 15-month lookback period.
Plate pheres leukoredu irrad,9530,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Plate pheres leukoredu irrad,9530,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],4542,3347,5078,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Plate pheres leukoredu irrad,9530,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Plate pheres leukoredu irrad,9530,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Plate pheres leukoredu irrad,9530,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],4373.09,4373.09,55520.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Plate pheres leukoredu irrad,9530,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Plate pheres leukoredu irrad,9530,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Plate pheres leukoredu irrad,9530,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Plate pheres leukoredu irrad,9530,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4003.44,4003.44,4003.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Plate pheres leukoredu irrad,9530,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],12307.27,12307.27,12307.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Plate pheres leukoredu irrad,9530,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],1523.1,1071.52,6611,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Plate pheres leukoredu irrad,9530,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Plate pheres leukoredu irrad,9530,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Plate pheres leukoredu irrad,9530,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Plate pheres leukoredu irrad,9530,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],3603.85,1522.23,6354.03,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Plate pheres leukoredu irrad,9530,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],5116,3260.9,6120,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Plate pheres leukoredu irrad,9530,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Plate pheres leukoredu irrad,9530,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Plate pheres leukoredu irrad,9530,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Clinical Diagnostic Lab Services,N800,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],23.06,6.65,95.58,36,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Clinical Diagnostic Lab Services,N800,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,275.31,31.92,682.48,49,percent of total billed charges,,,
Clinical Diagnostic Lab Services,N800,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],191.59,44.31,535,210,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Clinical Diagnostic Lab Services,N800,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],47.69,9.24,190.36,119,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Clinical Diagnostic Lab Services,N800,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],48.82,48.82,48.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Clinical Diagnostic Lab Services,N800,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],37.38,9.6,66.42,49,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Clinical Diagnostic Lab Services,N800,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],254.37,55.16,399.55,136,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Clinical Diagnostic Lab Services,N800,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",48.71,14.21,186.84,36,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Clinical Diagnostic Lab Services,N800,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Clinical Diagnostic Lab Services,N800,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],26.91,10.9,141.45,55,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Clinical Diagnostic Lab Services,N800,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",46.4,16.3,160.22,404,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Clinical Diagnostic Lab Services,N800,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],260.22,56.06,417.2,121,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Clinical Diagnostic Lab Services,N800,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],33.93,8.89,80.91,427,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Clinical Diagnostic Lab Services,N800,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],259.05,246.51,610.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Clinical Diagnostic Lab Services,N800,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],29.01,8.29,141.29,34,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Clinical Diagnostic Lab Services,N800,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],23.61,8.62,62.14,486,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Clinical Diagnostic Lab Services,N800,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],31.78,7.43,78.45,496,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Clinical Diagnostic Lab Services,N800,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",47.01,12.47,152.61,60,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Clinical Diagnostic Lab Services,N800,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Clinical Diagnostic Lab Services,N800,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,234.6,45.2,981.75,35,percent of total billed charges,,,
Therapy Services,N801,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],164.48,65.55,342.44,239,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Therapy Services,N801,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,469,176.09,1063.52,468,percent of total billed charges,,,
Therapy Services,N801,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],418,216,1445.38,83,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Therapy Services,N801,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],151.62,69.38,340.39,389,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Therapy Services,N801,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Therapy Services,N801,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],167.47,59.72,345.7,350,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Therapy Services,N801,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],456.28,178.73,932.69,1067,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Therapy Services,N801,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",315.7,164.33,630.19,94,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Therapy Services,N801,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Therapy Services,N801,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],254.05,96.57,472.64,593,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Therapy Services,N801,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",285.32,108.68,627.4,1402,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Therapy Services,N801,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],651,271.97,1463,751,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Therapy Services,N801,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],178.83,68.1,330.8,2100,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Therapy Services,N801,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],804.65,331.96,1711.81,27,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Therapy Services,N801,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],166.9,65.89,360.97,142,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Therapy Services,N801,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],167.32,70.51,342.27,2458,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Therapy Services,N801,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],189.47,83.13,426.99,3663,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Therapy Services,N801,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",259.1,90,632.47,82,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Therapy Services,N801,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Therapy Services,N801,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,712.8,263.2,1553.6,72,percent of total billed charges,,,
Other Medicine,N809,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],187.16,140.4,1066.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Medicine,N809,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,226.5,210.2,574,1 through 10,percent of total billed charges,,,
Other Medicine,N809,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],178.43,160.33,249.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Medicine,N809,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Medicine,N809,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Medicine,N809,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],172.39,137.95,225.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Medicine,N809,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],541.68,328.18,915,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Medicine,N809,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",269.76,269.76,459.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Medicine,N809,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Other Medicine,N809,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],314.27,213.84,550.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Medicine,N809,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",227.68,156.16,401.49,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Medicine,N809,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],336.76,197.24,1451.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Medicine,N809,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],186.9,129.72,284.61,30,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Medicine,N809,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],1124.39,1124.39,1124.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Medicine,N809,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],195.48,195.48,195.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Medicine,N809,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],187.96,110.11,329.46,37,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Medicine,N809,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],198.61,66.31,371.34,48,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Medicine,N809,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",47.43,47.43,47.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Medicine,N809,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Medicine,N809,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-covered Services,N900,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],205.14,127.76,317.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Non-covered Services,N900,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,647.74,282.42,1451.6,11,percent of total billed charges,,,
Non-covered Services,N900,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],505.14,505.14,505.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Non-covered Services,N900,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],149.01,149.01,149.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Non-covered Services,N900,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-covered Services,N900,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],132.01,132.01,198.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Non-covered Services,N900,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],482.77,309.27,510.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Non-covered Services,N900,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",63.51,63.51,63.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Non-covered Services,N900,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Non-covered Services,N900,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],93.55,93.55,180.19,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Non-covered Services,N900,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",261.83,114.73,386.42,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Non-covered Services,N900,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],809.6,624.58,1858.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Non-covered Services,N900,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],99.23,77.49,384.19,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Non-covered Services,N900,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Non-covered Services,N900,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Non-covered Services,N900,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],130.61,59.4,283.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Non-covered Services,N900,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],164.78,69.87,462.55,26,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Non-covered Services,N900,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",260.72,260.72,260.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Non-covered Services,N900,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-covered Services,N900,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,479.52,479.52,479.52,1 through 10,percent of total billed charges,,,
Packaged Services,N902,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],43.12,43.12,43.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Packaged Services,N902,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,318.05,318.05,318.05,1 through 10,percent of total billed charges,,,
Packaged Services,N902,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],90.34,84.63,774.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Packaged Services,N902,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Packaged Services,N902,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Packaged Services,N902,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],58.73,58.73,58.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Packaged Services,N902,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],,,,0,other,,,No services performed during 15-month lookback period.
Packaged Services,N902,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",45.86,26.92,66.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Packaged Services,N902,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Packaged Services,N902,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",51.54,26.93,72.83,68,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Packaged Services,N902,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],341.98,341.98,341.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Packaged Services,N902,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],35.09,30.59,44.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Packaged Services,N902,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Packaged Services,N902,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Packaged Services,N902,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Packaged Services,N902,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],41.79,32.11,46.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Packaged Services,N902,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],49.88,34.35,977.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Packaged Services,N902,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",59.49,59.49,59.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Packaged Services,N902,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Packaged Services,N902,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,92.8,92.8,92.8,1 through 10,percent of total billed charges,,,
Not Recognized by OPPS,N905,APC,,,,,,,facility,outpatient,,,,,,Aetna,All Commercial Plans,,76,,733.9,733.9,733.9,1 through 10,percent of total billed charges,,,
Not Recognized by OPPS,N905,APC,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 28],,,,0,other,,,No services performed during 15-month lookback period.
Not Recognized by OPPS,N905,APC,,,,,,,facility,outpatient,,,,,,Bcbs,All Commercial Plans,,,[OP Fee Schedule Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Not Recognized by OPPS,N905,APC,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Not Recognized by OPPS,N905,APC,,,,,,,facility,outpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Not Recognized by OPPS,N905,APC,,,,,,,facility,outpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Not Recognized by OPPS,N905,APC,,,,,,,facility,outpatient,,,,,,Cigna,All Commercial Plans,,,[OP Surgery  (%BC): 61] [Observation (%BC): 61] [Emergency Department (%BC): 61] [Occupational Therapy (%BC): 61] [Physical Therapy (%BC): 61] [Respiratory Services/Therapy  (%BC): 61] [Speech Therapy (%BC): 61] [All Other OP (%BC): 61],,,,0,other,,,No services performed during 15-month lookback period.
Not Recognized by OPPS,N905,APC,,,,,,,facility,outpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Not Recognized by OPPS,N905,APC,,,,,,,facility,outpatient,,,,,,Multiplan/Phcs,All Commercial Plans,,85,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
Not Recognized by OPPS,N905,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [Radiology ($): FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [Other Pharmacy ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Not Recognized by OPPS,N905,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Not Recognized by OPPS,N905,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Not Recognized by OPPS,N905,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Not Recognized by OPPS,N905,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Lesser Than Charges paid at %: 100] [OP Fee Schedule Rate: FEE SCHEDULE] [Radiology Fee Schedule: FEE SCHEDULE] [Mental Health ($): 352.57] [Mental Health-Intensive ($): 232.21] [OP High Cost Drugs ($): FEE SCHEDULE] [APC Status T ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Not Recognized by OPPS,N905,APC,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[Lesser Than Charges paid at %: 100] [OP High Cost Drugs ($): FEE SCHEDULE] [APC ($): FEE SCHEDULE] [All Other OP (%BC): 70],,,,0,other,,,No services performed during 15-month lookback period.
Not Recognized by OPPS,N905,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [Ambulance--Air ($): 4000] [Ambulance--Land ($): 400] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Not Recognized by OPPS,N905,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Lesser Than Charges paid at %: 100] [Mammography-Diagnostic Fee Schedule: FEE SCHEDULE] [Mammography-Screening Fee Schedule: FEE SCHEDULE] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy Fee Schedule: FEE SCHEDULE] [Physical Therapy Fee Schedule: FEE SCHEDULE] [Speech Therapy Fee Schedule: FEE SCHEDULE] [Mental Health-Intensive ($): 237] [Other Outpatient Implant ($): FEE SCHEDULE] [Ambulance--Air ($): FEE SCHEDULE] [Ambulance--Land ($): FEE SCHEDULE] [APC ($): 378],,,,0,other,,,No services performed during 15-month lookback period.
Not Recognized by OPPS,N905,APC,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Not Recognized by OPPS,N905,APC,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Not Recognized by OPPS,N905,APC,,,,,,,facility,outpatient,,,,,,Zelis,All Commercial Plans,,80,,,,,0,percent of total billed charges,,,No services performed during 15-month lookback period.
"DUMMY EAP FOR NSA - SUPPLIES  - $1,000 INCREMENT",1,CDM,1,HCPCS,,,,,facility,both,,,,1000,700,,,,,,,,,,,,,Gross Charge Type: Central
DUMMY EAP FOR NSA - SUPPLIES  - $500 INCREMENT,2,CDM,2,HCPCS,,,,,facility,both,,,,500,350,,,,,,,,,,,,,Gross Charge Type: Central
"DUMMY EAP FOR NSA - IMPLANTS - $1,000 INCREMENT",3,CDM,3,HCPCS,,,,,facility,both,,,,1000,700,,,,,,,,,,,,,Gross Charge Type: Central
DUMMY EAP FOR NSA - IMPLANTS - $500 INCREMENT,4,CDM,4,HCPCS,,,,,facility,both,,,,500,350,,,,,,,,,,,,,Gross Charge Type: Central
DEXRAZOXANE 500 MG IV SOLR,10528,CDM,J1190,HCPCS,55150-435-01,NDC,,,facility,both,5,EA,,3252,2276.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXRAZOXANE 500 MG IV SOLR,10528,CDM,J1190,HCPCS,55150-435-01,NDC,,,facility,both,5,EA,,3611,2527.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXRAZOXANE 500 MG IV SOLR,10528,CDM,J1190,HCPCS,55150-435-01,NDC,,,facility,both,1,EA,,435,304.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXRAZOXANE 500 MG IV SOLR,10528,CDM,J1190,HCPCS,55150-435-01,NDC,,,facility,both,5,EA,,3543,2480.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXRAZOXANE 500 MG IV SOLR,10528,CDM,J1190,HCPCS,55150-435-01,NDC,,,facility,both,1,EA,,405,283.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXRAZOXANE 500 MG IV SOLR,10528,CDM,J1190,HCPCS,55150-435-01,NDC,,,facility,both,1,EA,,561,392.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIPHTH,PERTUS(ACELL),TETANUS SYRG (INFANRIX) 25 LF UNIT-58MCG-10 LF/0.5ML IM SYRINGE",10784,CDM,90700,HCPCS,58160-810-43,NDC,,,facility,both,1,ML,,343,240.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) IV SOLN,10879,CDM,J9201,HCPCS,0409-0181-01,NDC,,,facility,both,5,ML,,231,161.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) IV SOLN,10879,CDM,J9201,HCPCS,0409-0183-01,NDC,,,facility,both,4,ML,,220,154,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) BLADDER INSTILLATION,10879,CDM,J9201,HCPCS,16714-930-01,NDC,,,facility,both,5,EA,,127,88.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) BLADDER INSTILLATION,10879,CDM,J9201,HCPCS,16714-930-01,NDC,,,facility,both,10,EA,,254,177.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) BLADDER INSTILLATION,10879,CDM,J9201,HCPCS,47335-154-40,NDC,,,facility,both,5,EA,,739,517.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) BLADDER INSTILLATION,10879,CDM,J9201,HCPCS,50742-497-53,NDC,,,facility,both,10,ML,,386,270.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) IV SOLN,10879,CDM,J9201,HCPCS,0409-0183-01,NDC,,,facility,both,2,ML,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) BLADDER INSTILLATION,10879,CDM,J9201,HCPCS,0409-0182-01,NDC,,,facility,both,5,ML,,196,137.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) BLADDER INSTILLATION,10879,CDM,J9201,HCPCS,16714-930-01,NDC,,,facility,both,5,EA,,254,177.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) IV SOLN,10879,CDM,J9201,HCPCS,0409-0181-01,NDC,,,facility,both,10,ML,,461,322.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) IV SOLN,10879,CDM,J9201,HCPCS,0409-0183-01,NDC,,,facility,both,2,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) IV SOLN,10879,CDM,J9201,HCPCS,0409-0181-01,NDC,,,facility,both,5,ML,,210,147,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) IV SOLN,10879,CDM,J9201,HCPCS,67457-617-30,NDC,,,facility,both,10,ML,,471,329.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 1 GRAM IV SOLR,10879,CDM,J9201,HCPCS,0409-0186-01,NDC,,,facility,both,5,EA,,259,181.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) IV SOLN,10879,CDM,J9201,HCPCS,0409-0181-01,NDC,,,facility,both,5,ML,,204,142.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) IV SOLN,10879,CDM,J9201,HCPCS,0409-0183-01,NDC,,,facility,both,2,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) IV SOLN,10879,CDM,J9201,HCPCS,0409-0181-01,NDC,,,facility,both,5,ML,,231,161.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) IV SOLN,10879,CDM,J9201,HCPCS,67457-617-30,NDC,,,facility,both,5,ML,,236,165.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) BLADDER INSTILLATION,10879,CDM,J9201,HCPCS,0409-0182-01,NDC,,,facility,both,2,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) IV SOLN,10879,CDM,J9201,HCPCS,0409-0183-01,NDC,,,facility,both,2,ML,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) IV SOLN,10879,CDM,J9201,HCPCS,0409-0183-01,NDC,,,facility,both,1,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) IV SOLN,10879,CDM,J9201,HCPCS,0409-0183-01,NDC,,,facility,both,4,ML,,192,134.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) IV SOLN,10879,CDM,J9201,HCPCS,0409-0183-01,NDC,,,facility,both,3,ML,,165,115.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) IV SOLN,10879,CDM,J9201,HCPCS,0409-0183-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) IV SOLN,10879,CDM,J9201,HCPCS,0409-0183-01,NDC,,,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) BLADDER INSTILLATION,10879,CDM,J9201,HCPCS,0409-0182-01,NDC,,,facility,both,20,ML,,783,548.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) IV SOLN,10879,CDM,J9201,HCPCS,0409-0181-01,NDC,,,facility,both,10,ML,,461,322.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) BLADDER INSTILLATION,10879,CDM,J9201,HCPCS,25021-235-50,NDC,,,facility,both,5,EA,,127,88.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) IV SOLN,10879,CDM,J9201,HCPCS,0409-0183-01,NDC,,,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) IV SOLN,10879,CDM,J9201,HCPCS,0409-0183-01,NDC,,,facility,both,3,ML,,136,95.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) BLADDER INSTILLATION,10879,CDM,J9201,HCPCS,0409-0181-25,NDC,,,facility,both,5,ML,,231,161.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) BLADDER INSTILLATION,10879,CDM,J9201,HCPCS,0409-0182-01,NDC,,,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) IV SOLN,10879,CDM,J9201,HCPCS,0409-0183-01,NDC,,,facility,both,2,ML,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) IV SOLN,10879,CDM,J9201,HCPCS,67457-617-30,NDC,,,facility,both,11,ML,,519,363.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) BLADDER INSTILLATION,10879,CDM,J9201,HCPCS,0409-0182-01,NDC,,,facility,both,9,ML,,353,247.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) BLADDER INSTILLATION,10879,CDM,J9201,HCPCS,47335-154-40,NDC,,,facility,both,5,EA,,1477,1033.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) IV SOLN,10879,CDM,J9201,HCPCS,0409-0183-01,NDC,,,facility,both,5,ML,,274,191.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) IV SOLN,10879,CDM,J9201,HCPCS,67457-617-30,NDC,,,facility,both,15,ML,,707,494.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) IV SOLN,10879,CDM,J9201,HCPCS,0409-0181-01,NDC,,,facility,both,5,ML,,207,144.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) IV SOLN,10879,CDM,J9201,HCPCS,0409-0183-01,NDC,,,facility,both,3,ML,,165,115.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) BLADDER INSTILLATION,10879,CDM,J9201,HCPCS,0409-0182-01,NDC,,,facility,both,10,ML,,392,274.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) BLADDER INSTILLATION,10879,CDM,J9201,HCPCS,0409-0182-01,NDC,,,facility,both,8,ML,,314,219.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) IV SOLN,10879,CDM,J9201,HCPCS,0409-0181-01,NDC,,,facility,both,5,ML,,208,145.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) IV SOLN,10879,CDM,J9201,HCPCS,0409-0183-01,NDC,,,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) IV SOLN,10879,CDM,J9201,HCPCS,0409-0181-01,NDC,,,facility,both,5,ML,,201,140.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) IV SOLN,10879,CDM,J9201,HCPCS,0409-0183-01,NDC,,,facility,both,4,ML,,205,143.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) BLADDER INSTILLATION,10879,CDM,J9201,HCPCS,0409-0182-01,NDC,,,facility,both,10,ML,,392,274.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) IV SOLN,10879,CDM,J9201,HCPCS,0409-0183-01,NDC,,,facility,both,3,ML,,164,114.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-0,NDC,,,facility,both,1,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-0,NDC,,,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0009-0082-02,NDC,,,facility,both,15,ML,,396,277.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0009-7529-04,NDC,,,facility,both,2,ML,,138,96.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0143-9702-01,NDC,,,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-0,NDC,,,facility,both,3,ML,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-1,NDC,,,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,45963-614-51,NDC,,,facility,both,10,ML,,661,462.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-1,NDC,,,facility,both,10,ML,,322,225.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0143-9701-01,NDC,,,facility,both,15,ML,,954,667.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-0,NDC,,,facility,both,3,ML,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-1,NDC,,,facility,both,10,ML,,339,237.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0009-0082-02,NDC,,,facility,both,11,ML,,359,251.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-1,NDC,,,facility,both,8,ML,,274,191.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0143-9701-01,NDC,,,facility,both,5,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-1,NDC,,,facility,both,17,ML,,568,397.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0009-7529-04,NDC,,,facility,both,2,ML,,163,114.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0143-9702-01,NDC,,,facility,both,2,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0009-0082-02,NDC,,,facility,both,2,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-1,NDC,,,facility,both,9,ML,,286,200.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-1,NDC,,,facility,both,9,ML,,316,221.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0143-9702-01,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0009-0082-02,NDC,,,facility,both,15,ML,,409,286.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0143-9702-01,NDC,,,facility,both,1,ML,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-0,NDC,,,facility,both,3,ML,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0143-9702-01,NDC,,,facility,both,4,ML,,257,179.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-0,NDC,,,facility,both,3,ML,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0143-9702-01,NDC,,,facility,both,3,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-1,NDC,,,facility,both,9,ML,,306,214.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0009-7529-04,NDC,,,facility,both,1,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0143-9701-01,NDC,,,facility,both,10,ML,,636,445.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-0,NDC,,,facility,both,2,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-0,NDC,,,facility,both,2,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-0,NDC,,,facility,both,4,ML,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-0,NDC,,,facility,both,2,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0009-0082-02,NDC,,,facility,both,15,ML,,469,328.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0009-0082-02,NDC,,,facility,both,15,ML,,474,331.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0009-0082-02,NDC,,,facility,both,15,ML,,480,336,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0143-9702-01,NDC,,,facility,both,2,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-1,NDC,,,facility,both,10,ML,,325,227.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-0,NDC,,,facility,both,4,ML,,143,100.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-0,NDC,,,facility,both,4,ML,,171,119.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0143-9702-01,NDC,,,facility,both,1,ML,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0009-0082-02,NDC,,,facility,both,15,ML,,462,323.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0143-9702-01,NDC,,,facility,both,4,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,16714-131-01,NDC,,,facility,both,5,ML,,259,181.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0143-9702-01,NDC,,,facility,both,2,ML,,133,93.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-0,NDC,,,facility,both,3,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0009-0082-02,NDC,,,facility,both,13,ML,,421,294.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0009-0082-02,NDC,,,facility,both,15,ML,,492,344.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0143-9702-01,NDC,,,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0009-0082-02,NDC,,,facility,both,19,ML,,619,433.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-0,NDC,,,facility,both,3,ML,,128,89.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0143-9702-01,NDC,,,facility,both,4,ML,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0009-0082-02,NDC,,,facility,both,15,ML,,403,282.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-0,NDC,,,facility,both,3,ML,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0009-0082-02,NDC,,,facility,both,12,ML,,393,275.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-0,NDC,,,facility,both,4,ML,,163,114.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,45963-614-51,NDC,,,facility,both,2,ML,,133,93.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0143-9702-01,NDC,,,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-1,NDC,,,facility,both,10,ML,,341,238.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-0,NDC,,,facility,both,7,ML,,274,191.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-0,NDC,,,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0009-0082-02,NDC,,,facility,both,15,ML,,470,329,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-1,NDC,,,facility,both,10,ML,,346,242.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-1,NDC,,,facility,both,11,ML,,380,266,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0143-9702-01,NDC,,,facility,both,4,ML,,261,182.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0009-0082-02,NDC,,,facility,both,15,ML,,490,343,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0009-0082-02,NDC,,,facility,both,15,ML,,475,332.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,45963-614-51,NDC,,,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-0,NDC,,,facility,both,2,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-0,NDC,,,facility,both,3,ML,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0143-9702-01,NDC,,,facility,both,2,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0009-0082-02,NDC,,,facility,both,13,ML,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-1,NDC,,,facility,both,10,ML,,320,224,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0009-0082-02,NDC,,,facility,both,13,ML,,425,297.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0009-7529-04,NDC,,,facility,both,4,ML,,288,201.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-0,NDC,,,facility,both,2,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0009-7529-03,NDC,,,facility,both,5,ML,,243,170.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,45963-614-51,NDC,,,facility,both,4,ML,,265,185.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0009-0082-02,NDC,,,facility,both,15,ML,,465,325.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-0,NDC,,,facility,both,2,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0143-9702-01,NDC,,,facility,both,3,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-0,NDC,,,facility,both,4,ML,,156,109.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0143-9702-01,NDC,,,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0143-9702-01,NDC,,,facility,both,4,ML,,250,175,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0143-9702-01,NDC,,,facility,both,3,ML,,162,113.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-0,NDC,,,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-1,NDC,,,facility,both,10,ML,,334,233.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-0,NDC,,,facility,both,4,ML,,167,116.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-1,NDC,,,facility,both,10,ML,,353,247.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0009-7529-03,NDC,,,facility,both,10,ML,,485,339.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-0,NDC,,,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0009-0082-02,NDC,,,facility,both,15,ML,,479,335.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0009-0082-02,NDC,,,facility,both,15,ML,,464,324.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-0,NDC,,,facility,both,4,ML,,148,103.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0143-9702-01,NDC,,,facility,both,2,ML,,140,98,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0009-0082-02,NDC,,,facility,both,15,ML,,472,330.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0143-9702-01,NDC,,,facility,both,4,ML,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-1,NDC,,,facility,both,5,ML,,166,116.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-0,NDC,,,facility,both,2,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-0,NDC,,,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-1,NDC,,,facility,both,5,ML,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0009-7529-03,NDC,,,facility,both,15,ML,,727,508.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-1,NDC,,,facility,both,9,ML,,309,216.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-0,NDC,,,facility,both,4,ML,,169,118.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-0,NDC,,,facility,both,3,ML,,126,88.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0143-9702-01,NDC,,,facility,both,4,ML,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0009-0082-02,NDC,,,facility,both,15,ML,,487,340.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,55150-354-01,NDC,,,facility,both,15,ML,,422,295.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-0,NDC,,,facility,both,2,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0009-0082-02,NDC,,,facility,both,14,ML,,452,316.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0009-0082-02,NDC,,,facility,both,15,ML,,488,341.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-0,NDC,,,facility,both,3,ML,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0009-0082-02,NDC,,,facility,both,15,ML,,482,337.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0009-0082-02,NDC,,,facility,both,15,ML,,391,273.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-1,NDC,,,facility,both,10,ML,,337,235.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-1,NDC,,,facility,both,9,ML,,288,201.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0143-9702-01,NDC,,,facility,both,4,ML,,290,203,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-0,NDC,,,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0009-0082-02,NDC,,,facility,both,18,ML,,590,413,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-0,NDC,,,facility,both,2,ML,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0143-9701-01,NDC,,,facility,both,10,ML,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0009-0082-02,NDC,,,facility,both,15,ML,,483,338.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-0,NDC,,,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-0,NDC,,,facility,both,2,ML,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,55150-354-01,NDC,,,facility,both,15,ML,,432,302.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0009-0082-02,NDC,,,facility,both,15,ML,,461,322.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-0,NDC,,,facility,both,3,ML,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-0,NDC,,,facility,both,4,ML,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0009-0082-02,NDC,,,facility,both,13,ML,,423,296.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,16714-131-01,NDC,,,facility,both,10,ML,,517,361.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-1,NDC,,,facility,both,10,ML,,350,245,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-1,NDC,,,facility,both,13,ML,,454,317.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0143-9702-01,NDC,,,facility,both,4,ML,,243,170.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0009-0082-02,NDC,,,facility,both,15,ML,,410,287,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0143-9702-01,NDC,,,facility,both,4,ML,,287,200.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-0,NDC,,,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,55150-354-01,NDC,,,facility,both,15,ML,,425,297.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,55150-354-01,NDC,,,facility,both,15,ML,,431,301.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0143-9702-01,NDC,,,facility,both,2,ML,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,45963-614-51,NDC,,,facility,both,3,ML,,199,139.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0009-7529-03,NDC,,,facility,both,10,ML,,484,338.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-0,NDC,,,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0009-0082-02,NDC,,,facility,both,14,ML,,446,312.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-0,NDC,,,facility,both,4,ML,,154,107.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0009-7529-04,NDC,,,facility,both,2,ML,,146,102.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,45963-614-51,NDC,,,facility,both,6,ML,,397,277.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-0,NDC,,,facility,both,3,ML,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-0,NDC,,,facility,both,1,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-1,NDC,,,facility,both,10,ML,,327,228.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0143-9701-01,NDC,,,facility,both,5,ML,,318,222.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-0,NDC,,,facility,both,4,ML,,133,93.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-1,NDC,,,facility,both,9,ML,,318,222.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-1,NDC,,,facility,both,2,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-0,NDC,,,facility,both,4,ML,,131,91.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-1,NDC,,,facility,both,17,ML,,600,420,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0143-9702-01,NDC,,,facility,both,2,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-0,NDC,,,facility,both,2,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-1,NDC,,,facility,both,12,ML,,424,296.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0009-0082-02,NDC,,,facility,both,14,ML,,459,321.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0009-0082-02,NDC,,,facility,both,11,ML,,299,209.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0143-9702-01,NDC,,,facility,both,2,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0009-0082-02,NDC,,,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-0,NDC,,,facility,both,2,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0143-9702-01,NDC,,,facility,both,3,ML,,202,141.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0143-9702-01,NDC,,,facility,both,2,ML,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,60505-6128-0,NDC,,,facility,both,1,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,10880,CDM,J9206,HCPCS,0009-0082-02,NDC,,,facility,both,2,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML IM SOLN,11021,CDM,90375,HCPCS,13533-318-05,NDC,,,facility,both,2,ML,,6262,4383.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML IM SOLN,11021,CDM,90375,HCPCS,13533-318-50,NDC,,,facility,both,20,ML,,17892,12524.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML IM SOLN,11021,CDM,90375,HCPCS,13533-318-05,NDC,,,facility,both,3,ML,,1167,816.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"VARICELLA-ZOSTER GE VAC,2 OF 2 50 MCG IM SUSR",11029,CDM,90396,HCPCS,58160-828-03,NDC,,,facility,both,1,EA,,763,534.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PNEUMOC 20-VAL CONJ-DIP CR(PF) 0.5 ML IM SYRG,11031,CDM,90677,HCPCS,0005-2000-01,NDC,,,facility,both,1,ML,,955,668.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLU VACCINE TS 2024-25 6MOS UP (PF) 45 MCG (15 MCG X 3)/0.5 ML IM SYRG,11031,CDM,90656,HCPCS,49281-424-50,NDC,,,facility,both,1,ML,,121,84.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PNEUMOCOCCAL 23-VAL PS VACCINE 25 MCG/0.5 ML INJ SYRG,11031,CDM,90732,HCPCS,0006-4837-01,NDC,,,facility,both,1,ML,,506,354.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLU VACCINE TS 2024-25 6MOS UP (PF) 45 MCG (15 MCG X 3)/0.5 ML IM SYRG,11031,CDM,90656,HCPCS,49281-424-88,NDC,,,facility,both,1,ML,,121,84.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLU VACCINE TS 2024-25 65 YR UP (PF) 180 MCG/0.5 ML IM SYRG,11031,CDM,90662,HCPCS,49281-124-88,NDC,,,facility,both,1,ML,,373,261.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"HUMAN PAPILLOMAV VAC,9-VAL(PF) 0.5 ML IM SYRG",11031,CDM,90651,HCPCS,0006-4121-01,NDC,,,facility,both,1,ML,,1089,762.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX (PF) 10 MCG IM,11031,CDM,90648,HCPCS,49281-547-58,NDC,,,facility,both,1,EA,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX (PF) 10 MCG IM,11032,CDM,90648,HCPCS,49281-547-58,NDC,,,facility,both,1,EA,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML IM SYRINGE,11032,CDM,90746,HCPCS,58160-821-43,NDC,,,facility,both,1,ML,,353,247.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLIOVIRUS VACCINE 40-8-32 UNIT/0.5 ML INJ SUSP,11032,CDM,90713,HCPCS,49281-860-10,NDC,,,facility,both,1,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPATITIS A VIRUS VACCINE (PF) 1440 ELISA UNIT/ML IM SYRG,11039,CDM,90632,HCPCS,58160-826-52,NDC,,,facility,both,1,ML,,372,260.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPATITIS A VIRUS VACCINE (PF) 1440 ELISA UNIT/ML IM SYRG,11039,CDM,90632,HCPCS,58160-826-43,NDC,,,facility,both,1,ML,,421,294.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPATITIS A VIRUS VACCINE (PF) 1440 ELISA UNIT/ML IM SYRG,11039,CDM,90632,HCPCS,58160-826-43,NDC,,,facility,both,1,ML,,372,260.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPATITIS A VIRUS VACCINE (PF) 1440 ELISA UNIT/ML IM SYRG,11039,CDM,90632,HCPCS,58160-826-52,NDC,,,facility,both,1,ML,,421,294.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPATITIS A VIRUS VACCINE (PF) 25 UNIT/0.5 ML IM MERGE (CAM USE ONLY),11040,CDM,90633,HCPCS,0006-4095-01,NDC,,,facility,both,1,ML,,228,159.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPATITIS A VIRUS VACCINE (PF) 25 UNIT/0.5 ML IM SYRG,11040,CDM,90633,HCPCS,0006-4095-02,NDC,,,facility,both,1,ML,,228,159.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPATITIS A VIRUS VACCINE (PF) 720 EL UNIT/0.5 ML IM SYRG,11040,CDM,90633,HCPCS,58160-825-52,NDC,,,facility,both,1,ML,,223,156.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPATITIS A VIRUS VACCINE (PF) 720 EL UNIT/0.5 ML IM SYRG,11040,CDM,90633,HCPCS,58160-825-43,NDC,,,facility,both,1,ML,,223,156.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPATITIS A VIRUS VACCINE (PF) 720 EL UNIT/0.5 ML IM SYRG,11040,CDM,90633,HCPCS,58160-825-43,NDC,,,facility,both,2,ML,,445,311.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPATITIS A VIRUS VACCINE (PF) 25 UNIT/0.5 ML IM MERGE (CAM USE ONLY),11040,CDM,90633,HCPCS,0006-4095-01,NDC,,,facility,both,1,ML,,228,159.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPATITIS A VIRUS VACCINE (PF) 25 UNIT/0.5 ML IM SYRG,11040,CDM,90633,HCPCS,0006-4095-02,NDC,,,facility,both,1,ML,,228,159.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPATITIS A VIRUS VACCINE (PF) 25 UNIT/0.5 ML IM MERGE (CAM USE ONLY),11040,CDM,90633,HCPCS,0006-4095-01,NDC,,,facility,both,1,ML,,234,163.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPATITIS A VIRUS VACCINE (PF) 720 EL UNIT/0.5 ML IM SYRG,11040,CDM,90633,HCPCS,58160-825-52,NDC,,,facility,both,1,ML,,229,160.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPATITIS A VIRUS VACCINE (PF) 720 EL UNIT/0.5 ML IM SYRG,11040,CDM,90633,HCPCS,58160-825-43,NDC,,,facility,both,1,ML,,229,160.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPATITIS A & B VIRUS VACCINE (PF) 720 ELISA UNIT-20 MCG/ML IM SYRINGE,11042,CDM,90636,HCPCS,58160-815-43,NDC,,,facility,both,1,ML,,545,381.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPATITIS A & B VIRUS VACCINE (PF) 720 ELISA UNIT-20 MCG/ML IM SYRINGE,11042,CDM,90636,HCPCS,58160-815-52,NDC,,,facility,both,1,ML,,545,381.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPATITIS A & B VIRUS VACCINE (PF) 720 ELISA UNIT-20 MCG/ML IM SYRINGE,11042,CDM,90636,HCPCS,58160-815-43,NDC,,,facility,both,1,ML,,572,400.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPATITIS A & B VIRUS VACCINE (PF) 720 ELISA UNIT-20 MCG/ML IM SYRINGE,11042,CDM,90636,HCPCS,58160-815-52,NDC,,,facility,both,1,ML,,572,400.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HAEMOPH B POLYSAC CONJ-MENING (PF) 7.5 MCG/0.5 ML IM,11045,CDM,90647,HCPCS,0006-4897-00,NDC,,,facility,both,1,ML,,179,125.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HAEMOPH B POLYSAC CONJ-MENING (PF) 7.5 MCG/0.5 ML IM,11045,CDM,90647,HCPCS,0006-4897-01,NDC,,,facility,both,1,ML,,184,128.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HAEMOPH B POLYSAC CONJ-MENING (PF) 7.5 MCG/0.5 ML IM,11045,CDM,90647,HCPCS,0006-4897-01,NDC,,,facility,both,1,ML,,179,125.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX (PF) 10 MCG IM,11046,CDM,90648,HCPCS,49281-545-03,NDC,,,facility,both,1,EA,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX (PF) 10 MCG IM,11046,CDM,90648,HCPCS,58160-816-03,NDC,,,facility,both,1,EA,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX (PF) 10 MCG IM,11046,CDM,90648,HCPCS,49281-547-58,NDC,,,facility,both,1,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX (PF) 10 MCG IM,11046,CDM,90648,HCPCS,49281-547-58,NDC,,,facility,both,1,EA,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX (PF) 10 MCG IM,11046,CDM,90648,HCPCS,49281-545-03,NDC,,,facility,both,1,EA,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX (PF) 10 MCG IM,11046,CDM,90648,HCPCS,58160-816-01,NDC,,,facility,both,1,EA,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX (PF) 10 MCG IM,11046,CDM,90648,HCPCS,49281-547-58,NDC,,,facility,both,1,EA,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLU VACC TV LIVE 2025(2-49YRS) 10EXP6.5-7.5 FF UNIT/0.2 ML NASL NSSY,11050,CDM,90660,HCPCS,66019-112-00,NDC,,,facility,both,1,EA,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"RABIES VACCINE,HUMAN DIPLOID (PF) 2.5 UNIT IM",11053,CDM,90675,HCPCS,49281-252-51,NDC,,,facility,both,1,EA,,1198,838.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"RABIES VACCINE,HUMAN DIPLOID (PF) 2.5 UNIT IM",11053,CDM,90675,HCPCS,49281-246-58,NDC,,,facility,both,1,EA,,1365,955.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"RABIES VACCINE, PURIFIED CHICKEN EMBRYO CELL (PF) 2.5 UNIT IM KIT",11053,CDM,90675,HCPCS,50632-013-01,NDC,,,facility,both,1,EA,,1200,840,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ROTAVIRUS VACCINE LIVE, PENTA 2 ML ORAL SUSP",11055,CDM,90680,HCPCS,0006-4047-02,NDC,,,facility,both,1,ML,,427,298.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ROTAVIRUS VACCINE LIVE, PENTA 2 ML ORAL SUSP",11055,CDM,90680,HCPCS,0006-4047-41,NDC,,,facility,both,1,ML,,444,310.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ROTAVIRUS VACCINE LIVE, PENTA 2 ML ORAL SUSP",11055,CDM,90680,HCPCS,0006-4047-41,NDC,,,facility,both,1,ML,,427,298.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ROTAVIRUS VACCINE LIVE, PENTA 2 ML ORAL SUSP",11055,CDM,90680,HCPCS,0006-4047-01,NDC,,,facility,both,1,ML,,444,310.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ROTAVIRUS VACCINE LIVE, PENTA 2 ML ORAL SUSP",11055,CDM,90680,HCPCS,0006-4047-01,NDC,,,facility,both,1,ML,,427,298.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ROTAVIRUS VACCINE LIVE, PENTA 2 ML ORAL SUSP",11055,CDM,90680,HCPCS,0006-4047-02,NDC,,,facility,both,1,ML,,444,310.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TYPHOID VI POLYSACCH VACCINE 25 MCG/0.5 ML IM SYRG,11057,CDM,90691,HCPCS,49281-790-88,NDC,,,facility,both,1,ML,,665,465.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TYPHOID VI POLYSACCH VACCINE 25 MCG/0.5 ML IM SYRG,11057,CDM,90691,HCPCS,49281-790-88,NDC,,,facility,both,1,ML,,634,443.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB 150 MG IV SOLR,11439,CDM,J9355,HCPCS,50242-132-01,NDC,,,facility,both,60,ME,,17205,12043.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 50 MG CAP,11467,CDM,Q0163,HCPCS,0904-2056-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE MALEATE 10 MG ORAL TAB,11468,CDM,Q0164,HCPCS,60687-825-11,NDC,,,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE MALEATE 10 MG ORAL TAB,11468,CDM,Q0164,HCPCS,50268-685-15,NDC,,,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE MALEATE 10 MG ORAL TAB,11468,CDM,Q0164,HCPCS,50268-685-11,NDC,,,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,11481,CDM,Q0177,HCPCS,60687-675-11,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,11481,CDM,Q0177,HCPCS,0093-5061-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,11481,CDM,Q0177,HCPCS,23155-501-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,11481,CDM,Q0177,HCPCS,60687-675-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,11481,CDM,Q0177,HCPCS,0904-6617-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,11481,CDM,Q0177,HCPCS,0904-6617-61,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC ROOM&CARE HOSPICE,11500001,CDM,115,RC,11500001,HCPCS,,,facility,both,,,,1163,814.1,,,,,,,,,,,,,Gross Charge Type: Central
HEP B-DP(ACELL)T-POLIO VACC-PF 10MCG-25LF-25MCG-10LF-40-8-32 IM SYRING,11799,CDM,90723,HCPCS,58160-811-43,NDC,,,facility,both,1,ML,,421,294.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEP B-DP(ACELL)T-POLIO VACC-PF 10MCG-25LF-25MCG-10LF-40-8-32 IM SYRING,11799,CDM,90723,HCPCS,58160-811-43,NDC,,,facility,both,1,ML,,445,311.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEP B-DP(ACELL)T-POLIO VACC-PF 10MCG-25LF-25MCG-10LF-40-8-32 IM SYRING,11799,CDM,90723,HCPCS,58160-811-52,NDC,,,facility,both,1,ML,,445,311.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC ROOM&CARE ACUTE,12000001,CDM,120,RC,12000001,HCPCS,,,facility,both,,,,1198,838.6,,,,,,,,,,,,,Gross Charge Type: Central
HC ROOM&CARE SNF SEMI,12000004,CDM,120,RC,12000004,HCPCS,,,facility,both,,,,847,592.9,,,,,,,,,,,,,Gross Charge Type: Central
HC ROOM & CARE ACUTE HOSPITAL AT HOME,12000008,CDM,161,RC,12000008,HCPCS,,,facility,both,,,,1198,838.6,,,,,,,,,,,,,Gross Charge Type: Central
HC ROOM & CARE ACUTE HOSPICE HOUSE,12000009,CDM,120,RC,12000009,HCPCS,,,facility,both,,,,1163,814.1,,,,,,,,,,,,,Gross Charge Type: Central
HC ROOM&CARE ACUTE PEDS,12300001,CDM,123,RC,12300001,HCPCS,,,facility,both,,,,1198,838.6,,,,,,,,,,,,,Gross Charge Type: Central
HC ROOM&CARE BEHAVIORAL,12400001,CDM,124,RC,12400001,HCPCS,,,facility,both,,,,1961,1372.7,,,,,,,,,,,,,Gross Charge Type: Central
IRON DEXTRAN 50 MG/ML INJ SOLN,12612,CDM,J1750,HCPCS,0023-6082-01,NDC,,,facility,both,20,ML,,2084,1458.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON DEXTRAN 50 MG/ML INJ SOLN,12612,CDM,J1750,HCPCS,0023-6082-01,NDC,,,facility,both,30,ML,,3126,2188.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON DEXTRAN 50 MG/ML INJ SOLN,12612,CDM,J1750,HCPCS,0023-6082-01,NDC,,,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON DEXTRAN 50 MG/ML INJ SOLN,12612,CDM,J1750,HCPCS,0023-6082-01,NDC,,,facility,both,30,ML,,3282,2297.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON DEXTRAN 50 MG/ML INJ SOLN,12612,CDM,J1750,HCPCS,52544-931-07,NDC,,,facility,both,20,ML,,1557,1089.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON DEXTRAN 50 MG/ML INJ SOLN,12612,CDM,J1750,HCPCS,0023-6082-01,NDC,,,facility,both,1,ML,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON DEXTRAN 50 MG/ML INJ SOLN,12612,CDM,J1750,HCPCS,52544-931-07,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON DEXTRAN 50 MG/ML INJ SOLN,12612,CDM,J1750,HCPCS,52544-931-07,NDC,,,facility,both,1,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON DEXTRAN 50 MG/ML INJ SOLN,12612,CDM,J1750,HCPCS,0023-6082-01,NDC,,,facility,both,1,ML,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON DEXTRAN 50 MG/ML INJ SOLN,12612,CDM,J1750,HCPCS,0023-6082-01,NDC,,,facility,both,20,ML,,2188,1531.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON DEXTRAN 50 MG/ML INJ SOLN,12612,CDM,J1750,HCPCS,0023-6082-01,NDC,,,facility,both,2,ML,,219,153.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON DEXTRAN 50 MG/ML INJ SOLN,12612,CDM,J1750,HCPCS,0023-6082-01,NDC,,,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON DEXTRAN 50 MG/ML INJ SOLN,12612,CDM,J1750,HCPCS,0023-6082-01,NDC,,,facility,both,2,ML,,209,146.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM  3.375 GRAM IV SOLR,12614,CDM,J2543,HCPCS,55150-120-30,NDC,,,facility,both,3,EA,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 2 MG INJ SOLR,12619,CDM,J2997,HCPCS,50242-041-10,NDC,,,facility,both,2,EA,,800,560,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 2 MG INJ SOLR,12619,CDM,J2997,HCPCS,50242-041-64,NDC,,,facility,both,2,EA,,762,533.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 2 MG INJ SOLR,12619,CDM,J2997,HCPCS,50242-041-64,NDC,,,facility,both,2,EA,,800,560,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,12675,CDM,Q0162,HCPCS,0904-7073-41,NDC,,,facility,both,4,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,12675,CDM,Q0162,HCPCS,68094-763-59,NDC,,,facility,both,4,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 8 MG ORAL TBDL,12675,CDM,Q0162,HCPCS,65862-391-10,NDC,,,facility,both,8,EA,,182,127.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,12675,CDM,Q0162,HCPCS,60687-252-40,NDC,,,facility,both,4,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,12675,CDM,Q0162,HCPCS,17856-0691-5,NDC,,,facility,both,4,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,12675,CDM,Q0162,HCPCS,16714-671-02,NDC,,,facility,both,4,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 8 MG ORAL TBDL,12675,CDM,Q0162,HCPCS,68462-158-40,NDC,,,facility,both,8,EA,,189,132.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 8 MG ORAL TBDL,12675,CDM,Q0162,HCPCS,68462-158-40,NDC,,,facility,both,4,EA,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VARICELLA-ZOSTER GE-AS01B (PF) 50 MCG/0.5 ML IM SUSR,15298,CDM,90750,HCPCS,58160-823-11,NDC,,,facility,both,1,EA,,763,534.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"VARICELLA-ZOSTER GE VAC,2 OF 2 50 MCG IM SUSR",15298,CDM,90750,HCPCS,58160-828-03,NDC,,,facility,both,1,EA,,763,534.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADJUVANT AS01B (PF)VIAL 1 OF 2 IM SUSP,15298,CDM,90750,HCPCS,58160-829-03,NDC,,,facility,both,1,ML,,763,534.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VARICELLA-ZOSTER GE-AS01B (PF) 50 MCG/0.5 ML IM SUSR,15298,CDM,90750,HCPCS,58160-823-11,NDC,,,facility,both,1,EA,,763,534.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"VARICELLA-ZOSTER GE VAC,2 OF 2 50 MCG IM SUSR",15298,CDM,90750,HCPCS,58160-828-03,NDC,,,facility,both,1,EA,,855,598.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"VARICELLA-ZOSTER GE VAC,2 OF 2 50 MCG IM SUSR",15298,CDM,90750,HCPCS,58160-828-03,NDC,,,facility,both,1,EA,,763,534.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VARICELLA-ZOSTER GE-AS01B (PF) 50 MCG/0.5 ML IM SUSR,15298,CDM,90750,HCPCS,58160-823-11,NDC,,,facility,both,1,EA,,855,598.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VARICELLA-ZOSTER GE-AS01B (PF) 50 MCG/0.5 ML IM SUSR (CAM USE ONLY),15298,CDM,90750,HCPCS,50090-3372-0,NDC,,,facility,both,1,EA,,855,598.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADJUVANT AS01B (PF)VIAL 1 OF 2 IM SUSP,15298,CDM,90750,HCPCS,58160-829-03,NDC,,,facility,both,1,ML,,763,534.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VARICELLA-ZOSTER GE-AS01B (PF) 50 MCG/0.5 ML IM SUSR,15298,CDM,90750,HCPCS,58160-819-12,NDC,,,facility,both,1,EA,,655,458.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 2 %-1:200,000 INJ SOLN",15541,CDM,J2004,HCPCS,63323-489-02,NDC,,,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 2 %-1:200,000 INJ SOLN",15542,CDM,J2004,HCPCS,63323-489-02,NDC,,,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,15921,CDM,J1815,HCPCS,0169-1833-11,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,15921,CDM,J1815,HCPCS,0169-1833-11,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),15921,CDM,J1815,HCPCS,83257-014-11,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),15921,CDM,J1815,HCPCS,0024-5926-05,NDC,,,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),15921,CDM,J1815,HCPCS,83257-014-11,NDC,,,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),15921,CDM,J1815,HCPCS,0024-5926-05,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),15921,CDM,J1815,HCPCS,0024-5926-05,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,16197,CDM,J2001,HCPCS,63323-492-04,NDC,,,facility,both,4,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,16197,CDM,J2001,HCPCS,63323-492-04,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"OCTREOTIDE,MICROSPHERES 20 MG IM SERR",16206,CDM,J2353,HCPCS,0078-0818-81,NDC,,,facility,both,30,EA,,19112,13378.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"OCTREOTIDE,MICROSPHERES 20 MG IM SERR",16206,CDM,J2353,HCPCS,0078-0818-81,NDC,,,facility,both,40,EA,,25482,17837.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"OCTREOTIDE,MICROSPHERES 30 MG IM SERR",16206,CDM,J2353,HCPCS,0078-0825-81,NDC,,,facility,both,20,EA,,12720,8904,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"OCTREOTIDE,MICROSPHERES 30 MG IM SERR",16206,CDM,J2353,HCPCS,0078-0804-61,NDC,,,facility,both,20,EA,,12720,8904,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"OCTREOTIDE,MICROSPHERES 30 MG IM SERR",16206,CDM,J2353,HCPCS,0078-0804-61,NDC,,,facility,both,30,EA,,19079,13355.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"OCTREOTIDE,MICROSPHERES 30 MG IM SERR",16206,CDM,J2353,HCPCS,0078-0825-81,NDC,,,facility,both,30,EA,,19079,13355.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"OCTREOTIDE,MICROSPHERES 30 MG IM SERR",16206,CDM,J2353,HCPCS,0078-0825-81,NDC,,,facility,both,10,EA,,2765,1935.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"OCTREOTIDE,MICROSPHERES 10 MG IM SERR",16206,CDM,J2353,HCPCS,0078-0811-81,NDC,,,facility,both,10,EA,,9725,6807.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"OCTREOTIDE,MICROSPHERES 20 MG IM SERR",16206,CDM,J2353,HCPCS,0078-0818-81,NDC,,,facility,both,20,EA,,12741,8918.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML INJECTION,16327,CDM,J3411,HCPCS,72485-507-01,NDC,,,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML INJECTION,16327,CDM,J3411,HCPCS,0641-6228-01,NDC,,,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML INJECTION,16327,CDM,J3411,HCPCS,72603-139-01,NDC,,,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML INJECTION,16327,CDM,J3411,HCPCS,72603-139-01,NDC,,,facility,both,2,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML INJECTION,16327,CDM,J3411,HCPCS,72485-507-01,NDC,,,facility,both,5,ML,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MENING VAC A,C,Y,W135 DIP (PF) 10-5 MCG/0.5 ML IM SOLN",16544,CDM,90734,HCPCS,58160-827-03,NDC,,,facility,both,1,ML,,680,476,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MENING VAC A,C,Y,W135 DIP (PF) 10-5 MCG/0.5 ML IM KIT (CAM USE ONLY)",16544,CDM,90734,HCPCS,58160-958-01,NDC,,,facility,both,1,EA,,680,476,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MENING VAC A,C,Y,W135 DIP (PF) 10-5 MCG/0.5 ML IM KIT",16544,CDM,90734,HCPCS,58160-955-09,NDC,,,facility,both,1,EA,,680,476,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MENING VAC A,C,Y,W135 DIP (PF) 10-5 MCG/0.5 ML IM SOLN",16544,CDM,90734,HCPCS,58160-827-30,NDC,,,facility,both,1,ML,,680,476,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MENING VAC A,C,Y,W135 DIP (PF) 10-5 MCG/0.5 ML IM KIT",16544,CDM,90734,HCPCS,58160-955-09,NDC,,,facility,both,1,EA,,680,476,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MENING VAC A,C,Y,W135 DIP (PF) 10-5 MCG/0.5 ML IM SOLN",16544,CDM,90734,HCPCS,58160-827-03,NDC,,,facility,both,1,ML,,680,476,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MENING VAC A,C,Y,W135 DIP (PF) 10-5 MCG/0.5 ML IM SOLN",16544,CDM,90734,HCPCS,58160-827-30,NDC,,,facility,both,1,ML,,720,504,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MENING VAC A,C,Y,W135 DIP (PF) 10-5 MCG/0.5 ML IM SOLN",16544,CDM,90734,HCPCS,58160-827-30,NDC,,,facility,both,1,ML,,680,476,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MENING VAC A,C,Y,W135 DIP (PF) 10-5 MCG/0.5 ML IM KIT (CAM USE ONLY)",16544,CDM,90734,HCPCS,58160-959-01,NDC,,,facility,both,1,ML,,680,476,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MENING VAC A,C,Y,W135 DIP (PF) 10-5 MCG/0.5 ML IM KIT (CAM USE ONLY)",16544,CDM,90734,HCPCS,58160-959-01,NDC,,,facility,both,1,ML,,680,476,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MENING VAC A,C,Y,W135 DIP (PF) 10-5 MCG/0.5 ML IM SOLN",16544,CDM,90734,HCPCS,58160-827-03,NDC,,,facility,both,1,ML,,720,504,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MENING VAC A,C,Y,W135 DIP (PF) 10-5 MCG/0.5 ML IM KIT (CAM USE ONLY)",16544,CDM,90734,HCPCS,58160-958-01,NDC,,,facility,both,1,EA,,680,476,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MENING VAC A,C,Y,W135 DIP (PF) 10-5 MCG/0.5 ML IM KIT (CAM USE ONLY)",16544,CDM,90734,HCPCS,58160-958-01,NDC,,,facility,both,1,EA,,680,476,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MENING VAC A,C,Y,W135 DIP (PF) 10-5 MCG/0.5 ML IM SOLN",16544,CDM,90734,HCPCS,58160-827-03,NDC,,,facility,both,1,ML,,720,504,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MENINGOC VAC A,C,Y,W-135 DIP (PF) 4 MCG/0.5 ML IM",16544,CDM,90734,HCPCS,49281-589-05,NDC,,,facility,both,1,ML,,612,428.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MENING VAC A,C,Y,W135 DIP (PF) 10-5 MCG/0.5 ML IM SOLN",16544,CDM,90734,HCPCS,58160-827-30,NDC,,,facility,both,1,ML,,720,504,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MENING VAC A,C,Y,W135 DIP (PF) 10-5 MCG/0.5 ML IM SOLN",16544,CDM,90734,HCPCS,58160-827-03,NDC,,,facility,both,2,ML,,720,504,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MENING VAC A,C,Y,W135 DIP (PF) 10-5 MCG/0.5 ML IM KIT",16544,CDM,90734,HCPCS,58160-955-09,NDC,,,facility,both,1,EA,,680,476,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MENING VAC A,C,Y,W135 DIP (PF) 10-5 MCG/0.5 ML IM KIT (CAM USE ONLY)",16544,CDM,90734,HCPCS,58160-959-01,NDC,,,facility,both,1,ML,,680,476,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MENING VAC A,C,Y,W135 DIP (PF) 10-5 MCG/0.5 ML IM SOLN",16544,CDM,90734,HCPCS,58160-827-03,NDC,,,facility,both,1,ML,,720,504,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MENING VAC A,C,Y,W135 DIP (PF) 10-5 MCG/0.5 ML IM SOLN",16544,CDM,90734,HCPCS,58160-827-30,NDC,,,facility,both,1,ML,,720,504,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC ROOM & CARE CHILD AWAIT PLACEMENT,16900001,CDM,169,RC,16900001,HCPCS,,,facility,both,,,,2197,1537.9,,,,,,,,,,,,,Gross Charge Type: Central
HC ROOM & CARE NURSERY,17100001,CDM,171,RC,17100001,HCPCS,,,facility,both,,,,1440,1008,,,,,,,,,,,,,Gross Charge Type: Central
HC ROOM&CARE EXT NURSERY,17200001,CDM,172,RC,17200001,HCPCS,,,facility,both,,,,2551,1785.7,,,,,,,,,,,,,Gross Charge Type: Central
HC ROOM&CARE SAC NURSERY,17300001,CDM,173,RC,17300001,HCPCS,,,facility,both,,,,3350,2345,,,,,,,,,,,,,Gross Charge Type: Central
HC ROOM&CARE NIC,17400001,CDM,174,RC,17400001,HCPCS,,,facility,both,,,,4752,3326.4,,,,,,,,,,,,,Gross Charge Type: Central
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,19464,CDM,J1817,HCPCS,0169-1833-11,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPOETIN ALFA 20000 UNIT/ML INJ SOLN,19534,CDM,J0885,HCPCS,55513-478-01,NDC,,,facility,both,10,ML,,587,410.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPOETIN ALFA 20000 UNIT/ML INJ SOLN,19534,CDM,J0885,HCPCS,55513-478-01,NDC,,,facility,both,40,ML,,2348,1643.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPOETIN ALFA 20000 UNIT/ML INJ SOLN,19534,CDM,J0885,HCPCS,55513-478-01,NDC,,,facility,both,10,ML,,199,139.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPOETIN ALFA 40000 UNIT/ML INJ SOLN,19534,CDM,J0885,HCPCS,59676-340-01,NDC,,,facility,both,40,ML,,2951,2065.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIPHTH,PERTUS(ACELL),TETANUS SYRG(BOOSTRIX) 2.5-8-5 LF-MCG-LF/0.5ML IM SYRG",19537,CDM,90715,HCPCS,58160-842-52,NDC,,,facility,both,1,ML,,247,172.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIPHTH,PERTUS(ACELL),TETANUS VIAL (BOOSTRIX*) 2.5-8-5 LF-MCG-LF/0.5ML IM SUSP",19537,CDM,90715,HCPCS,58160-842-11,NDC,,,facility,both,1,ML,,240,168,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIPHTH,PERTUS(ACELL),TETANUS SYRG(BOOSTRIX) 2.5-8-5 LF-MCG-LF/0.5ML IM SYRG",19537,CDM,90715,HCPCS,58160-842-05,NDC,,,facility,both,1,ML,,233,163.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIPHTH,PERTUS(ACELL),TETANUS VIAL (BOOSTRIX*) 2.5-8-5 LF-MCG-LF/0.5ML IM SUSP",19537,CDM,90715,HCPCS,58160-842-11,NDC,,,facility,both,1,ML,,240,168,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIPHTH,PERTUS(ACELL),TETANUS SYRG(BOOSTRIX) 2.5-8-5 LF-MCG-LF/0.5ML IM SYRG",19537,CDM,90715,HCPCS,58160-842-43,NDC,,,facility,both,1,ML,,240,168,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIPHTH,PERTUS(ACELL),TETANUS VIAL (ADACEL) 2 LF-(5-3-5MCG)-5 LF/0.5 ML IM SUSP",19537,CDM,90715,HCPCS,49281-400-10,NDC,,,facility,both,1,ML,,249,174.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIPHTH,PERTUS(ACELL),TETANUS SYRG(BOOSTRIX) 2.5-8-5 LF-MCG-LF/0.5ML IM SYRG",19537,CDM,90715,HCPCS,58160-842-52,NDC,,,facility,both,1,ML,,240,168,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIPH,PERTUS(ACEL),TET,POLIO(PF)(KINRIX) 25 LF-58 MCG-10 LF/0.5 ML IM SYRINGE",19537,CDM,90696,HCPCS,58160-812-43,NDC,,,facility,both,1,ML,,318,222.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIPHTH,PERTUS(ACELL),TETANUS SYRG(BOOSTRIX) 2.5-8-5 LF-MCG-LF/0.5ML IM SYRG",19537,CDM,90715,HCPCS,58160-842-43,NDC,,,facility,both,1,ML,,479,335.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIPHTH,PERTUS(ACELL),TETANUS SYRG(BOOSTRIX) 2.5-8-5 LF-MCG-LF/0.5ML IM SYRG",19537,CDM,90715,HCPCS,58160-842-43,NDC,,,facility,both,1,ML,,247,172.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIPHTH,PERTUS(ACELL),TETANUS SYRG (INFANRIX) 25 LF UNIT-58MCG-10 LF/0.5ML IM SYRINGE",19537,CDM,90700,HCPCS,58160-810-43,NDC,,,facility,both,1,ML,,343,240.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIPHTH,PERTUS(ACELL),TETANUS SYRG (INFANRIX) 25 LF UNIT-58MCG-10 LF/0.5ML IM SYRINGE",19537,CDM,90700,HCPCS,58160-810-43,NDC,,,facility,both,1,ML,,172,120.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIPHTH,PERTUS(ACELL),TETANUS VIAL (BOOSTRIX*) 2.5-8-5 LF-MCG-LF/0.5ML IM SUSP",19537,CDM,90715,HCPCS,58160-842-01,NDC,,,facility,both,1,ML,,240,168,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT 100 MCG/0.5 ML INJ SYRG,19694,CDM,J0881,HCPCS,55513-025-01,NDC,,,facility,both,70,ML,,651,455.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT 100 MCG/0.5 ML INJ SYRG,19694,CDM,J0881,HCPCS,55513-025-01,NDC,,,facility,both,200,ML,,4273,2991.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT  60 MCG/0.3 ML INJ SYRG,19694,CDM,J0881,HCPCS,55513-023-01,NDC,,,facility,both,60,ML,,1282,897.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT 300 MCG/0.6 ML INJ SYRG,19694,CDM,J0881,HCPCS,54868-5429-0,NDC,,,facility,both,300,ML,,4592,3214.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT 100 MCG/0.5 ML INJ SYRG,19694,CDM,J0881,HCPCS,55513-025-04,NDC,,,facility,both,30,ML,,641,448.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT 200 MCG/0.4 ML INJ SYRG,19694,CDM,J0881,HCPCS,55513-028-01,NDC,,,facility,both,200,ML,,4273,2991.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT 200 MCG/0.4 ML INJ SYRG,19694,CDM,J0881,HCPCS,55513-028-01,NDC,,,facility,both,100,ML,,2137,1495.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT 100 MCG/0.5 ML INJ SYRG,19694,CDM,J0881,HCPCS,55513-025-01,NDC,,,facility,both,30,ML,,641,448.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT 25 MCG/0.42 ML INJ SYRG,19694,CDM,J0881,HCPCS,55513-057-01,NDC,,,facility,both,60,ML,,2007,1404.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT 100 MCG/0.5 ML INJ SYRG,19694,CDM,J0881,HCPCS,55513-025-04,NDC,,,facility,both,26,ML,,556,389.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT 100 MCG/0.5 ML INJ SYRG,19694,CDM,J0881,HCPCS,55513-025-04,NDC,,,facility,both,40,ML,,855,598.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT 500 MCG/ML INJ SYRG,19694,CDM,J0881,HCPCS,55513-032-01,NDC,,,facility,both,400,ML,,8545,5981.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT 100 MCG/0.5 ML INJ SYRG,19694,CDM,J0881,HCPCS,55513-025-01,NDC,,,facility,both,26,ML,,556,389.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT 200 MCG/0.4 ML INJ SYRG,19694,CDM,J0881,HCPCS,55513-028-01,NDC,,,facility,both,150,ML,,3205,2243.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT 100 MCG/0.5 ML INJ SYRG,19694,CDM,J0881,HCPCS,55513-025-01,NDC,,,facility,both,100,ML,,2137,1495.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT 100 MCG/0.5 ML INJ SYRG,19694,CDM,J0881,HCPCS,55513-025-01,NDC,,,facility,both,60,ML,,558,390.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT 500 MCG/ML INJ SYRG,19694,CDM,J0881,HCPCS,55513-032-01,NDC,,,facility,both,100,ML,,929,650.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT  40 MCG/0.4 ML INJ SYRG,19694,CDM,J0881,HCPCS,55513-021-01,NDC,,,facility,both,40,ML,,1096,767.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT 200 MCG/0.4 ML INJ SYRG,19694,CDM,J0881,HCPCS,55513-028-01,NDC,,,facility,both,400,ML,,8545,5981.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT 200 MCG/0.4 ML INJ SYRG,19694,CDM,J0881,HCPCS,55513-028-01,NDC,,,facility,both,50,ML,,465,325.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT 300 MCG/0.6 ML INJ SYRG,19694,CDM,J0881,HCPCS,55513-111-01,NDC,,,facility,both,300,ML,,6409,4486.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT 100 MCG/0.5 ML INJ SYRG,19694,CDM,J0881,HCPCS,55513-025-01,NDC,,,facility,both,74,ML,,688,481.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT 100 MCG/0.5 ML INJ SYRG,19694,CDM,J0881,HCPCS,55513-025-01,NDC,,,facility,both,40,ML,,855,598.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT 500 MCG/ML INJ SYRG,19694,CDM,J0881,HCPCS,55513-032-01,NDC,,,facility,both,500,ML,,10682,7477.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT 100 MCG/0.5 ML INJ SYRG,19694,CDM,J0881,HCPCS,55513-025-04,NDC,,,facility,both,100,ML,,2137,1495.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHACHOLINE CHLORIDE STERILE INHALATION SOLUTION (PF) KIT,19798,CDM,J7674,HCPCS,64281-110-05,NDC,,,facility,both,100,ML,,3494,2445.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHACHOLINE CHLORIDE STERILE INHALATION SOLUTION (PF) KIT,19798,CDM,J7674,HCPCS,69374-542-06,NDC,,,facility,both,1,EA,,797,557.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 100 KIT
HC ROOM&CARE INTENSIVE,20000002,CDM,200,RC,20000002,HCPCS,,,facility,both,,,,3953,2767.1,,,,,,,,,,,,,Gross Charge Type: Central
HC ROOM&CARE PEDS INTENSIVE,20300001,CDM,203,RC,20300001,HCPCS,,,facility,both,,,,3953,2767.1,,,,,,,,,,,,,Gross Charge Type: Central
HC ROOM & CARE PROGRESSIVE,20600001,CDM,206,RC,20600001,HCPCS,,,facility,both,,,,2786,1950.2,,,,,,,,,,,,,Gross Charge Type: Central
HC ROOM & CARE CORONARY CARE,21000001,CDM,210,RC,21000001,HCPCS,,,facility,both,,,,3953,2767.1,,,,,,,,,,,,,Gross Charge Type: Central
FLU VACCINE TS 2024-25 6MOS UP (PF) 45 MCG (15 MCG X 3)/0.5 ML IM SYRG,21463,CDM,90656,HCPCS,19515-810-41,NDC,,,facility,both,1,ML,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLU VACCINE TS 2024-25 6MOS UP (PF) 45 MCG (15 MCG X 3)/0.5 ML IM SYRG,21466,CDM,90656,HCPCS,49281-424-88,NDC,,,facility,both,1,ML,,121,84.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLU VACCINE TS 2024-25 6MOS UP (PF) 45 MCG (15 MCG X 3)/0.5 ML IM SYRG,21466,CDM,90656,HCPCS,58160-884-41,NDC,,,facility,both,1,ML,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLU VACCINE TS 2025-26 6 MO UP (PF) 45 MCG (15 MCG X 3)/0.5 ML IM SYRG,21466,CDM,90656,HCPCS,19515-904-52,NDC,,,facility,both,1,ML,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLU VACCINE TS 2024-25 6MOS UP (PF) 45 MCG (15 MCG X 3)/0.5 ML IM SYRG,21466,CDM,90656,HCPCS,49281-424-50,NDC,,,facility,both,1,ML,,121,84.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLU VACCINE TS 2024-25 65 YR UP (PF) 180 MCG/0.5 ML IM SYRG,21466,CDM,90662,HCPCS,49281-124-88,NDC,,,facility,both,1,ML,,373,261.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLU VACCINE TS 2025-26 6 MO UP (PF) 45 MCG (15 MCG X 3)/0.5 ML IM SYRG,21466,CDM,90656,HCPCS,49281-425-88,NDC,,,facility,both,2,ML,,244,170.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLU VACCINE TS 2025-26 6 MO UP (PF) 45 MCG (15 MCG X 3)/0.5 ML IM SYRG,21466,CDM,90656,HCPCS,58160-912-41,NDC,,,facility,both,1,ML,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLU VACCINE TS 2024-25 6MOS UP (PF) 45 MCG (15 MCG X 3)/0.5 ML IM SYRG,21466,CDM,90656,HCPCS,70461-654-04,NDC,,,facility,both,1,ML,,190,133,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLU VACCINE TS 2025-26 6 MO UP (PF) 45 MCG (15 MCG X 3)/0.5 ML IM SYRG,21466,CDM,90656,HCPCS,49281-425-88,NDC,,,facility,both,1,ML,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLU VACCINE TS 2024-25 6MOS UP (PF) 45 MCG (15 MCG X 3)/0.5 ML IM SYRG,21466,CDM,90656,HCPCS,19515-810-41,NDC,,,facility,both,1,ML,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLU VACCINE TS 2024-25 6MOS UP (PF) 45 MCG (15 MCG X 3)/0.5 ML IM SYRG,21466,CDM,90656,HCPCS,58160-884-52,NDC,,,facility,both,1,ML,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLU VACCINE TS 2024-25 6MOS UP (PF) 45 MCG (15 MCG X 3)/0.5 ML IM SYRG,21466,CDM,90656,HCPCS,19515-810-52,NDC,,,facility,both,1,ML,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLU VACCINE TS 2025-26 6 MO UP (PF) 45 MCG (15 MCG X 3)/0.5 ML IM SYRG,21466,CDM,90656,HCPCS,49281-425-50,NDC,,,facility,both,1,ML,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLU VACCINE TS 2025-26 6 MO UP (PF) 45 MCG (15 MCG X 3)/0.5 ML IM SYRG,21466,CDM,90656,HCPCS,19515-904-41,NDC,,,facility,both,1,ML,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLU VACCINE TS 2025-26 6 MO UP (PF) 45 MCG (15 MCG X 3)/0.5 ML IM SYRG,21466,CDM,90656,HCPCS,58160-912-52,NDC,,,facility,both,1,ML,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM HYALURONATE (VISCOSUP) 10 MG/ML IATC SYRG,21630,CDM,J7321,HCPCS,8913044441,NDC,,,facility,both,1,ML,,672,470.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM HYALURONATE 30 MG/2 ML IATC SYRG,21632,CDM,J7324,HCPCS,5967636001,NDC,,,facility,both,1,ML,,1320,924,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,21732,CDM,J8540,HCPCS,0904-7266-61,NDC,,,facility,both,32,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,21732,CDM,J8540,HCPCS,0054-8175-25,NDC,,,facility,both,80,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,21732,CDM,J8540,HCPCS,49999-059-06,NDC,,,facility,both,16,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,21732,CDM,J8540,HCPCS,0054-8175-25,NDC,,,facility,both,48,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,21732,CDM,J8540,HCPCS,0054-8175-25,NDC,,,facility,both,80,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,21732,CDM,J8540,HCPCS,0054-8175-25,NDC,,,facility,both,32,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,21732,CDM,J8540,HCPCS,0054-8175-25,NDC,,,facility,both,16,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,21732,CDM,J8540,HCPCS,0054-8175-25,NDC,,,facility,both,32,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,21732,CDM,J8540,HCPCS,0054-8175-25,NDC,,,facility,both,64,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,21732,CDM,J8540,HCPCS,0054-8175-25,NDC,,,facility,both,160,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,21732,CDM,J8540,HCPCS,0054-8175-25,NDC,,,facility,both,80,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,21732,CDM,J8540,HCPCS,60687-718-11,NDC,,,facility,both,24,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,21732,CDM,J8540,HCPCS,60687-718-11,NDC,,,facility,both,40,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE HCL  2 % MM JELP,21814,CDM,J3490,HCPCS,76329-3013-5,NDC,,,facility,both,1,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ROTAVIRUS VACCINE, LIVE, 89-12 10EXP6 CCID50 /1.5 ML ORAL SUSP",21899,CDM,90681,HCPCS,58160-740-21,NDC,,,facility,both,1,ML,,599,419.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ROTAVIRUS VACCINE, LIVE, 89-12 10EXP6 CCID50 /1.5 ML ORAL SUSP",21899,CDM,90681,HCPCS,58160-740-21,NDC,,,facility,both,1,ML,,400,280,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ROTAVIRUS VACCINE, LIVE, 89-12 10EXP6 CCID50 /1.5 ML ORAL SUSP",21899,CDM,90681,HCPCS,58160-740-02,NDC,,,facility,both,1,ML,,599,419.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ROTAVIRUS VACCINE, LIVE, 89-12 10EXP6 CCID50 /1.5 ML ORAL SUSP",21899,CDM,90681,HCPCS,58160-740-02,NDC,,,facility,both,1,ML,,424,296.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ROTAVIRUS VACCINE, LIVE, 89-12 10EXP6 CCID50 /1.5 ML ORAL SUSP",21899,CDM,90681,HCPCS,58160-740-02,NDC,,,facility,both,1,ML,,635,444.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ROTAVIRUS VACCINE LIVE, PENTA 2 ML ORAL SUSP",21899,CDM,90680,HCPCS,0006-4047-01,NDC,,,facility,both,1,ML,,427,298.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ROTAVIRUS VACCINE, LIVE, 89-12 10EXP6 CCID50 /1.5 ML ORAL SUSP",21899,CDM,90681,HCPCS,58160-740-21,NDC,,,facility,both,1,ML,,635,444.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ROTAVIRUS VAC,LIVE ATT, 89-12 STRAIN G1P(8) 10EXP6 CCID50/ML ORAL SUSP",21899,CDM,90681,HCPCS,58160-851-01,NDC,,,facility,both,1,ML,,953,667.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC HUMAN BREAST MILK PROCESSING STORAGE/DISTRIBUTION ONLY,22000001,CDM,220,RC,T2101,HCPCS,,,facility,both,,,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Central
PALIPERIDONE PALMITATE 156 MG/ML IM SYRG,22574,CDM,J2426,HCPCS,50458-563-01,NDC,,,facility,both,156,ML,,6568,4597.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PALIPERIDONE PALMITATE 234 MG/1.5 ML IM SYRG,22574,CDM,J2426,HCPCS,50458-564-01,NDC,,,facility,both,234,ML,,9851,6895.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PALIPERIDONE PALMITATE 117 MG/0.75 ML IM SYRG,22574,CDM,J2426,HCPCS,50458-562-01,NDC,,,facility,both,117,ML,,4926,3448.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PALIPERIDONE PALMITATE 78 MG/0.5 ML IM SYRG,22574,CDM,J2426,HCPCS,50458-561-01,NDC,,,facility,both,78,ML,,3284,2298.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PALIPERIDONE PALMITATE 39 MG/0.25 ML IM SYRG,22574,CDM,J2426,HCPCS,50458-560-01,NDC,,,facility,both,1,ML,,1642,1149.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 250 MCG SUBQ SOLR,22614,CDM,J2796,HCPCS,55513-221-01,NDC,,,facility,both,5,EA,,382,267.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 125 MCG SUBQ SOLR,22614,CDM,J2796,HCPCS,55513-223-01,NDC,,,facility,both,13,EA,,2668,1867.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 250 MCG SUBQ SOLR,22614,CDM,J2796,HCPCS,55513-221-01,NDC,,,facility,both,19,EA,,3337,2335.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 250 MCG SUBQ SOLR,22614,CDM,J2796,HCPCS,55513-221-01,NDC,,,facility,both,2,EA,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG SUBQ SOLR,22614,CDM,J2796,HCPCS,55513-222-01,NDC,,,facility,both,20,EA,,3512,2458.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG SUBQ SOLR,22614,CDM,J2796,HCPCS,55513-222-01,NDC,,,facility,both,100,EA,,17559,12291.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 250 MCG SUBQ SOLR,22614,CDM,J2796,HCPCS,55513-221-01,NDC,,,facility,both,23,EA,,4039,2827.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG SUBQ SOLR,22614,CDM,J2796,HCPCS,55513-222-01,NDC,,,facility,both,30,EA,,2291,1603.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 250 MCG SUBQ SOLR,22614,CDM,J2796,HCPCS,55513-221-01,NDC,,,facility,both,20,EA,,3512,2458.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 125 MCG SUBQ SOLR,22614,CDM,J2796,HCPCS,55513-223-01,NDC,,,facility,both,8,EA,,1642,1149.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 250 MCG SUBQ SOLR,22614,CDM,J2796,HCPCS,55513-221-01,NDC,,,facility,both,25,EA,,4390,3073,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 125 MCG SUBQ SOLR,22614,CDM,J2796,HCPCS,55513-223-01,NDC,,,facility,both,10,EA,,2052,1436.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 125 MCG SUBQ SOLR,22614,CDM,J2796,HCPCS,55513-223-01,NDC,,,facility,both,13,EA,,2565,1795.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 125 MCG SUBQ SOLR,22614,CDM,J2796,HCPCS,55513-223-01,NDC,,,facility,both,5,EA,,447,312.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG SUBQ SOLR,22614,CDM,J2796,HCPCS,55513-222-01,NDC,,,facility,both,3,EA,,230,161,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 250 MCG SUBQ SOLR,22614,CDM,J2796,HCPCS,55513-221-01,NDC,,,facility,both,50,EA,,8780,6146,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG SUBQ SOLR,22614,CDM,J2796,HCPCS,55513-222-01,NDC,,,facility,both,97,EA,,17032,11922.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG SUBQ SOLR,22614,CDM,J2796,HCPCS,55513-222-01,NDC,,,facility,both,50,EA,,8780,6146,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 125 MCG SUBQ SOLR,22614,CDM,J2796,HCPCS,55513-223-01,NDC,,,facility,both,20,EA,,4104,2872.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 125 MCG SUBQ SOLR,22614,CDM,J2796,HCPCS,55513-223-01,NDC,,,facility,both,11,EA,,2258,1580.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 125 MCG SUBQ SOLR,22614,CDM,J2796,HCPCS,55513-223-01,NDC,,,facility,both,9,EA,,1847,1292.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BEVACIZUMAB 25 MG/ML IV SOLN,22666,CDM,J9035,HCPCS,50242-061-01,NDC,,,facility,both,160,ML,,32040,22428,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BEVACIZUMAB 25 MG/ML IV SOLN,22666,CDM,J9035,HCPCS,50242-060-01,NDC,,,facility,both,20,ML,,4005,2803.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BEVACIZUMAB 25 MG/ML IV SOLN,22666,CDM,J9035,HCPCS,50242-061-01,NDC,,,facility,both,40,ML,,8010,5607,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BEVACIZUMAB 25 MG/ML IV SOLN,22666,CDM,J9035,HCPCS,50242-060-01,NDC,,,facility,both,10,ML,,2003,1402.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BEVACIZUMAB 25 MG/ML IV SOLN,22666,CDM,J9035,HCPCS,50242-060-01,NDC,,,facility,both,30,ML,,6008,4205.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BEVACIZUMAB 25 MG/ML IV SOLN,22666,CDM,J9035,HCPCS,50242-061-01,NDC,,,facility,both,120,ML,,24030,16821,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPILIMUMAB 50 MG/10 ML (5 MG/ML) IV SOLN,22762,CDM,J9228,HCPCS,0003-2327-11,NDC,,,facility,both,50,ML,,18655,13058.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPILIMUMAB 50 MG/10 ML (5 MG/ML) IV SOLN,22762,CDM,J9228,HCPCS,0003-2327-11,NDC,,,facility,both,20,ML,,3245,2271.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPILIMUMAB 50 MG/10 ML (5 MG/ML) IV SOLN,22762,CDM,J9228,HCPCS,0003-2327-11,NDC,,,facility,both,78,ML,,29102,20371.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPILIMUMAB 200 MG/40 ML (5 MG/ML) IV SOLN,22762,CDM,J9228,HCPCS,0003-2328-22,NDC,,,facility,both,400,ML,,149238,104466.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPILIMUMAB 50 MG/10 ML (5 MG/ML) IV SOLN,22762,CDM,J9228,HCPCS,0003-2327-11,NDC,,,facility,both,25,ML,,9328,6529.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPILIMUMAB 50 MG/10 ML (5 MG/ML) IV SOLN,22762,CDM,J9228,HCPCS,0003-2327-11,NDC,,,facility,both,22,ML,,3569,2498.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPILIMUMAB 50 MG/10 ML (5 MG/ML) IV SOLN,22762,CDM,J9228,HCPCS,0003-2327-11,NDC,,,facility,both,10,ML,,1623,1136.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPILIMUMAB 50 MG/10 ML (5 MG/ML) IV SOLN,22762,CDM,J9228,HCPCS,0003-2327-11,NDC,,,facility,both,150,ML,,55965,39175.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPILIMUMAB 50 MG/10 ML (5 MG/ML) IV SOLN,22762,CDM,J9228,HCPCS,0003-2327-11,NDC,,,facility,both,19,ML,,3083,2158.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPILIMUMAB 50 MG/10 ML (5 MG/ML) IV SOLN,22762,CDM,J9228,HCPCS,0003-2327-11,NDC,,,facility,both,29,ML,,4705,3293.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPILIMUMAB 50 MG/10 ML (5 MG/ML) IV SOLN,22762,CDM,J9228,HCPCS,0003-2327-11,NDC,,,facility,both,71,ML,,26490,18543,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPILIMUMAB 50 MG/10 ML (5 MG/ML) IV SOLN,22762,CDM,J9228,HCPCS,0003-2327-11,NDC,,,facility,both,25,ML,,4056,2839.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPILIMUMAB 200 MG/40 ML (5 MG/ML) IV SOLN,22762,CDM,J9228,HCPCS,0003-2328-22,NDC,,,facility,both,25,ML,,4056,2839.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPILIMUMAB 50 MG/10 ML (5 MG/ML) IV SOLN,22762,CDM,J9228,HCPCS,0003-2327-11,NDC,,,facility,both,100,ML,,37310,26117,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPILIMUMAB 50 MG/10 ML (5 MG/ML) IV SOLN,22762,CDM,J9228,HCPCS,0003-2327-11,NDC,,,facility,both,100,ML,,37310,26117,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPILIMUMAB 50 MG/10 ML (5 MG/ML) IV SOLN,22762,CDM,J9228,HCPCS,0003-2327-11,NDC,,,facility,both,81,ML,,30221,21154.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPILIMUMAB 50 MG/10 ML (5 MG/ML) IV SOLN,22762,CDM,J9228,HCPCS,0003-2327-11,NDC,,,facility,both,31,ML,,5029,3520.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPILIMUMAB 200 MG/40 ML (5 MG/ML) IV SOLN,22762,CDM,J9228,HCPCS,0003-2328-22,NDC,,,facility,both,175,ML,,65292,45704.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPILIMUMAB 50 MG/10 ML (5 MG/ML) IV SOLN,22762,CDM,J9228,HCPCS,0003-2327-11,NDC,,,facility,both,50,ML,,18655,13058.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPILIMUMAB 50 MG/10 ML (5 MG/ML) IV SOLN,22762,CDM,J9228,HCPCS,0003-2327-11,NDC,,,facility,both,68,ML,,25371,17759.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPILIMUMAB 50 MG/10 ML (5 MG/ML) IV SOLN,22762,CDM,J9228,HCPCS,0003-2327-11,NDC,,,facility,both,90,ML,,33579,23505.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPILIMUMAB 50 MG/10 ML (5 MG/ML) IV SOLN,22762,CDM,J9228,HCPCS,0003-2327-11,NDC,,,facility,both,80,ML,,29848,20893.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPILIMUMAB 200 MG/40 ML (5 MG/ML) IV SOLN,22762,CDM,J9228,HCPCS,0003-2328-22,NDC,,,facility,both,200,ML,,74619,52233.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPILIMUMAB 200 MG/40 ML (5 MG/ML) IV SOLN,22762,CDM,J9228,HCPCS,0003-2328-22,NDC,,,facility,both,200,ML,,74619,52233.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPILIMUMAB 50 MG/10 ML (5 MG/ML) IV SOLN,22762,CDM,J9228,HCPCS,0003-2327-11,NDC,,,facility,both,32,ML,,5191,3633.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPILIMUMAB 50 MG/10 ML (5 MG/ML) IV SOLN,22762,CDM,J9228,HCPCS,0003-2327-11,NDC,,,facility,both,69,ML,,25744,18020.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALTREXONE MICROSPHERES 380 MG IM SERR,22974,CDM,J2315,HCPCS,65757-300-01,NDC,,,facility,both,380,EA,,4666,3266.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALTREXONE MICROSPHERES 380 MG IM SERR,22974,CDM,J2315,HCPCS,65757-302-02,NDC,,,facility,both,380,EA,,4666,3266.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEGARELIX 120 MG SUBQ SOLR,23523,CDM,J9155,HCPCS,55566-8403-1,NDC,,,facility,both,240,EA,,4207,2944.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEGARELIX 120 MG SUBQ SOLR,23523,CDM,J9155,HCPCS,55566-8402-0,NDC,,,facility,both,120,EA,,2104,1472.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEGARELIX 80 MG SUBQ SOLR,23523,CDM,J9155,HCPCS,55566-8303-1,NDC,,,facility,both,80,EA,,1349,944.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEGARELIX 120 MG SUBQ SOLR,23523,CDM,J9155,HCPCS,55566-8403-1,NDC,,,facility,both,120,EA,,2104,1472.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEGARELIX 80 MG SUBQ SOLR,23523,CDM,J9155,HCPCS,55566-8303-1,NDC,,,facility,both,80,EA,,1348,943.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEGARELIX 120 MG SUBQ SOLR,23523,CDM,J9155,HCPCS,55566-8402-0,NDC,,,facility,both,240,EA,,4207,2944.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,0409-0201-20,NDC,,,facility,both,140,ML,,1216,851.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,67457-533-16,NDC,,,facility,both,109,ML,,1035,724.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,0409-0201-20,NDC,,,facility,both,190,ML,,1651,1155.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN- NONSTANDARD DOSING,23955,CDM,J9171,HCPCS,43066-010-01,NDC,,,facility,both,38,ML,,227,158.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,67457-533-16,NDC,,,facility,both,150,ML,,1424,996.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,67457-533-16,NDC,,,facility,both,72,ML,,684,478.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,67457-533-16,NDC,,,facility,both,76,ML,,722,505.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN- NONSTANDARD DOSING,23955,CDM,J9171,HCPCS,43066-006-01,NDC,,,facility,both,38,ML,,333,233.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,67457-533-16,NDC,,,facility,both,129,ML,,1224,856.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN- NONSTANDARD DOSING,23955,CDM,J9171,HCPCS,67457-532-08,NDC,,,facility,both,38,ML,,457,319.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,0409-0201-20,NDC,,,facility,both,96,ML,,363,254.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,67457-533-16,NDC,,,facility,both,127,ML,,1205,843.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,67457-533-16,NDC,,,facility,both,60,ML,,570,399,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,0409-0201-20,NDC,,,facility,both,80,ML,,695,486.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,0409-0201-20,NDC,,,facility,both,127,ML,,1103,772.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,0409-0201-20,NDC,,,facility,both,152,ML,,1321,924.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,67457-533-16,NDC,,,facility,both,180,ML,,1708,1195.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,67457-533-16,NDC,,,facility,both,110,ML,,1044,730.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,67457-533-16,NDC,,,facility,both,190,ML,,1803,1262.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,67457-533-16,NDC,,,facility,both,114,ML,,1082,757.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,67457-533-16,NDC,,,facility,both,133,ML,,1262,883.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,67457-533-16,NDC,,,facility,both,80,ML,,330,231,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,67457-533-16,NDC,,,facility,both,60,ML,,248,173.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,67457-533-16,NDC,,,facility,both,70,ML,,289,202.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN- NONSTANDARD DOSING,23955,CDM,J9171,HCPCS,43066-006-01,NDC,,,facility,both,38,ML,,392,274.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,67457-533-16,NDC,,,facility,both,130,ML,,1234,863.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,67457-533-16,NDC,,,facility,both,152,ML,,1443,1010.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,67457-533-16,NDC,,,facility,both,90,ML,,854,597.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,67457-533-16,NDC,,,facility,both,64,ML,,608,425.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,67457-533-16,NDC,,,facility,both,47,ML,,194,135.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,0409-0201-20,NDC,,,facility,both,100,ML,,869,608.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN- NONSTANDARD DOSING,23955,CDM,J9171,HCPCS,43066-010-01,NDC,,,facility,both,38,ML,,330,231,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,0409-0201-20,NDC,,,facility,both,180,ML,,1564,1094.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,67457-533-16,NDC,,,facility,both,113,ML,,1073,751.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,67457-533-16,NDC,,,facility,both,21,ML,,200,140,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,0409-0201-20,NDC,,,facility,both,160,ML,,1390,973,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,67457-533-16,NDC,,,facility,both,86,ML,,816,571.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,0409-0201-20,NDC,,,facility,both,19,ML,,166,116.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,67457-533-16,NDC,,,facility,both,88,ML,,835,584.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,67457-533-16,NDC,,,facility,both,80,ML,,759,531.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,67457-533-16,NDC,,,facility,both,74,ML,,703,492.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,0409-0201-20,NDC,,,facility,both,64,ML,,556,389.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,67457-533-16,NDC,,,facility,both,131,ML,,1243,870.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,67457-533-16,NDC,,,facility,both,40,ML,,165,115.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,67457-533-16,NDC,,,facility,both,107,ML,,1016,711.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,67457-533-16,NDC,,,facility,both,20,ML,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,67457-533-16,NDC,,,facility,both,40,ML,,380,266,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,67457-533-16,NDC,,,facility,both,45,ML,,427,298.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,0409-0201-20,NDC,,,facility,both,107,ML,,930,651,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,67457-533-16,NDC,,,facility,both,106,ML,,1006,704.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,0409-0201-20,NDC,,,facility,both,40,ML,,348,243.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,67457-533-16,NDC,,,facility,both,132,ML,,1253,877.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,0409-0201-20,NDC,,,facility,both,55,ML,,478,334.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,0409-0201-20,NDC,,,facility,both,96,ML,,834,583.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,67457-533-16,NDC,,,facility,both,85,ML,,807,564.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,67457-533-16,NDC,,,facility,both,149,ML,,1414,989.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,0409-0201-20,NDC,,,facility,both,20,ML,,174,121.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,0409-0201-20,NDC,,,facility,both,131,ML,,1138,796.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,0409-0201-20,NDC,,,facility,both,114,ML,,991,693.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,0409-0201-20,NDC,,,facility,both,54,ML,,469,328.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,67457-533-16,NDC,,,facility,both,69,ML,,655,458.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,67457-533-16,NDC,,,facility,both,120,ML,,1139,797.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,67457-533-16,NDC,,,facility,both,111,ML,,1054,737.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,67457-533-16,NDC,,,facility,both,87,ML,,826,578.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,67457-533-16,NDC,,,facility,both,128,ML,,1215,850.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,67457-533-16,NDC,,,facility,both,148,ML,,1405,983.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,0409-0201-20,NDC,,,facility,both,59,ML,,513,359.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,67457-533-16,NDC,,,facility,both,70,ML,,665,465.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,67457-533-16,NDC,,,facility,both,100,ML,,949,664.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,0409-0201-20,NDC,,,facility,both,133,ML,,1156,809.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,0409-0201-20,NDC,,,facility,both,106,ML,,921,644.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,67457-533-16,NDC,,,facility,both,140,ML,,1329,930.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,67457-533-16,NDC,,,facility,both,95,ML,,902,631.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,67457-533-16,NDC,,,facility,both,160,ML,,1518,1062.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,67457-533-16,NDC,,,facility,both,67,ML,,636,445.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,0409-0201-20,NDC,,,facility,both,88,ML,,765,535.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,0409-0201-20,NDC,,,facility,both,140,ML,,529,370.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,67457-533-16,NDC,,,facility,both,200,ML,,1898,1328.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,0409-0201-20,NDC,,,facility,both,27,ML,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,67457-533-16,NDC,,,facility,both,73,ML,,693,485.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN- NONSTANDARD DOSING,23955,CDM,J9171,HCPCS,43066-006-01,NDC,,,facility,both,500,ML,,4428,3099.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,0409-0201-20,NDC,,,facility,both,120,ML,,1043,730.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,23955,CDM,J9171,HCPCS,67457-533-16,NDC,,,facility,both,20,ML,,190,133,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DENOSUMAB 60 MG/ML SUBQ SYRG,24760,CDM,J0897,HCPCS,55513-710-21,NDC,,,facility,both,60,ML,,5177,3623.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DENOSUMAB 60 MG/ML SUBQ SYRG,24760,CDM,J0897,HCPCS,55513-710-21,NDC,,,facility,both,60,ML,,4930,3451,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DENOSUMAB 60 MG/ML SUBQ SYRG,24760,CDM,J0897,HCPCS,55513-710-01,NDC,,,facility,both,60,ML,,4930,3451,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DENOSUMAB 120 MG/1.7 ML (70 MG/ML) SUBQ SOLN,24760,CDM,J0897,HCPCS,55513-730-01,NDC,,,facility,both,120,ML,,9522,6665.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DENOSUMAB 120 MG/1.7 ML (70 MG/ML) SUBQ SOLN,24760,CDM,J0897,HCPCS,55513-730-01,NDC,,,facility,both,120,ML,,9068,6347.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MENING VAC A,C,Y,W135,TET (PF) 10 MCG/0.5 ML IM SOLN",24951,CDM,90619,HCPCS,50090-6180-0,NDC,,,facility,both,1,ML,,721,504.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MENING VAC A,C,Y,W135,TET (PF) 10 MCG/0.5 ML IM SOLN",24951,CDM,90619,HCPCS,49281-590-05,NDC,,,facility,both,1,ML,,721,504.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MENING VAC A,C,Y,W135,TET (PF) 10 MCG/0.5 ML IM SOLN",24951,CDM,90619,HCPCS,49281-590-10,NDC,,,facility,both,1,ML,,721,504.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MENING VAC A,C,Y,W135,TET (PF) 10 MCG/0.5 ML IM SOLN",24951,CDM,90619,HCPCS,49281-590-58,NDC,,,facility,both,1,ML,,743,520.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MENING VAC A,C,Y,W135,TET (PF) 10 MCG/0.5 ML IM SOLN",24951,CDM,90619,HCPCS,49281-590-58,NDC,,,facility,both,1,ML,,721,504.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MENING VAC A,C,Y,W135,TET (PF) 10 MCG/0.5 ML IM SOLN",24951,CDM,90619,HCPCS,49281-590-10,NDC,,,facility,both,1,ML,,743,520.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC PROLACTA 4 CAL 10ML,25000000,CDM,250,RC,25000000,HCPCS,,,facility,both,,,,284,198.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PROLACTA 4 CAL 20ML,25000005,CDM,250,RC,25000005,HCPCS,,,facility,both,,,,426,298.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PROLACTA 6 CAL 30ML,25000006,CDM,250,RC,25000006,HCPCS,,,facility,both,,,,638,446.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PROLACTA 8 CAL 40 ML,25000007,CDM,250,RC,25000007,HCPCS,,,facility,both,,,,851,595.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PROLACTA CR 10 ML,25000008,CDM,250,RC,25000008,HCPCS,,,facility,both,,,,205,143.5,,,,,,,,,,,,,Gross Charge Type: Central
HC NC OCREVUS (OCRELIZUMAB 300MG VIAL),25000009,CDM,636,RC,J2350,HCPCS,,,facility,both,,,,0.01,0.007,,,,,,,,,,,,,Gross Charge Type: Central
HC PROLACT RTF 24 100ML,25000010,CDM,250,RC,25000010,HCPCS,,,facility,both,,,,508,355.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PROLACT RTF 26 100 ML,25000011,CDM,250,RC,25000011,HCPCS,,,facility,both,,,,725,507.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PROLACT RTF 28 100ML,25000012,CDM,250,RC,25000012,HCPCS,,,facility,both,,,,943,660.1,,,,,,,,,,,,,Gross Charge Type: Central
HC NC DUPIXENT (DUPILUMAB),25000013,CDM,250,RC,25000013,HCPCS,,,facility,both,,,,0.01,0.007,,,,,,,,,,,,,Gross Charge Type: Central
"RITUXIMAB-HYALURONIDASE,HUMAN 1400 MG/11.7 ML (120 MG/ML) SUBQ SOLN",25050,CDM,J9311,HCPCS,50242-108-01,NDC,,,facility,both,140,ML,,13985,9789.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DURVALUMAB 50 MG/ML IV SOLN,25073,CDM,J9173,HCPCS,0310-4611-50,NDC,,,facility,both,100,ML,,19204,13442.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DURVALUMAB 50 MG/ML IV SOLN,25073,CDM,J9173,HCPCS,0310-4500-12,NDC,,,facility,both,81,ML,,15555,10888.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DURVALUMAB 50 MG/ML IV SOLN,25073,CDM,J9173,HCPCS,0310-4500-12,NDC,,,facility,both,24,ML,,4609,3226.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DURVALUMAB 50 MG/ML IV SOLN,25073,CDM,J9173,HCPCS,0310-4500-12,NDC,,,facility,both,2,ML,,167,116.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DURVALUMAB 50 MG/ML IV SOLN,25073,CDM,J9173,HCPCS,0310-4500-12,NDC,,,facility,both,3,ML,,251,175.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DURVALUMAB 50 MG/ML IV SOLN,25073,CDM,J9173,HCPCS,0310-4500-12,NDC,,,facility,both,82,ML,,15747,11022.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DURVALUMAB 50 MG/ML IV SOLN,25073,CDM,J9173,HCPCS,0310-4500-12,NDC,,,facility,both,36,ML,,6914,4839.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DURVALUMAB 50 MG/ML IV SOLN,25073,CDM,J9173,HCPCS,0310-4611-50,NDC,,,facility,both,50,ML,,9602,6721.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DURVALUMAB 50 MG/ML IV SOLN,25073,CDM,J9173,HCPCS,0310-4611-50,NDC,,,facility,both,150,ML,,28805,20163.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PALONOSETRON 0.25 MG/5 ML IV INJECTION (MERGE),25138,CDM,J2469,HCPCS,0703-4094-01,NDC,,,facility,both,10,ML,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PALONOSETRON 0.25 MG/5 ML IV INJECTION (MERGE),25138,CDM,J2469,HCPCS,60505-6193-1,NDC,,,facility,both,10,ML,,605,423.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PALONOSETRON 0.25 MG/5 ML IV INJECTION (MERGE),25138,CDM,J2469,HCPCS,36000-326-01,NDC,,,facility,both,10,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FULVESTRANT 250 MG/5 ML IM SYRG,25148,CDM,J9395,HCPCS,70121-1463-2,NDC,,,facility,both,20,ML,,2655,1858.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FULVESTRANT 250 MG/5 ML IM SYRG,25148,CDM,J9395,HCPCS,43598-262-02,NDC,,,facility,both,20,ML,,864,604.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FULVESTRANT 250 MG/5 ML IM SYRG,25148,CDM,J9395,HCPCS,16714-070-02,NDC,,,facility,both,10,ML,,2296,1607.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FULVESTRANT 250 MG/5 ML IM SYRG,25148,CDM,J9395,HCPCS,0781-3532-12,NDC,,,facility,both,20,ML,,5018,3512.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FULVESTRANT 250 MG/5 ML IM SYRG,25148,CDM,J9395,HCPCS,0781-3532-12,NDC,,,facility,both,20,ML,,5017,3511.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FULVESTRANT 250 MG/5 ML IM SYRG,25148,CDM,J9395,HCPCS,16714-070-02,NDC,,,facility,both,20,ML,,4591,3213.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FULVESTRANT 250 MG/5 ML IM SYRG,25148,CDM,J9395,HCPCS,0310-0720-10,NDC,,,facility,both,20,ML,,5352,3746.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FULVESTRANT 250 MG/5 ML IM SYRG,25148,CDM,J9395,HCPCS,43598-262-23,NDC,,,facility,both,20,ML,,864,604.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FULVESTRANT 250 MG/5 ML IM SYRG,25148,CDM,J9395,HCPCS,0781-3532-01,NDC,,,facility,both,20,ML,,5018,3512.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FULVESTRANT 250 MG/5 ML IM SYRG,25148,CDM,J9395,HCPCS,16714-070-01,NDC,,,facility,both,20,ML,,4591,3213.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSAPREPITANT 150 MG IV SOLR,25167,CDM,J1453,HCPCS,0006-3061-00,NDC,,,facility,both,150,EA,,1185,829.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSAPREPITANT 150 MG IV SOLR,25167,CDM,J1453,HCPCS,0006-3061-01,NDC,,,facility,both,150,EA,,1185,829.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSAPREPITANT 150 MG IV SOLR,25167,CDM,J1453,HCPCS,0006-3941-01,NDC,,,facility,both,150,EA,,994,695.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EMICIZUMAB-KXWH 105 MG/0.7 ML SUBQ SOLN,25339,CDM,J7170,HCPCS,50242-922-01,NDC,,,facility,both,210,ML,,35039,24527.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EMICIZUMAB-KXWH 150 MG/ML SUBQ SOLN,25339,CDM,J7170,HCPCS,50242-923-01,NDC,,,facility,both,300,ML,,50055,35038.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EMICIZUMAB-KXWH 105 MG/0.7 ML SUBQ SOLN,25339,CDM,J7170,HCPCS,50242-922-01,NDC,,,facility,both,480,ML,,56061,39242.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EMICIZUMAB-KXWH 150 MG/ML SUBQ SOLN,25339,CDM,J7170,HCPCS,50242-923-01,NDC,,,facility,both,510,ML,,85093,59565.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EMICIZUMAB-KXWH 300 MG/2 ML (150 MG/ML) SUBQ SOLN,25339,CDM,J7170,HCPCS,50242-930-01,NDC,,,facility,both,600,ML,,100109,70076.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVONORGESTREL 17.5 MCG/24 HR (5 YEARS) IU IUD,25538,CDM,J7296,HCPCS,50419-424-01,NDC,,,facility,both,1,EA,,2509,1756.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVONORGESTREL 17.5 MCG/24 HR (5 YEARS) IU IUD,25538,CDM,J7296,HCPCS,50419-424-08,NDC,,,facility,both,1,EA,,2509,1756.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVONORGESTREL 17.5 MCG/24 HR (5 YEARS) IU IUD,25538,CDM,J7296,HCPCS,50419-424-01,NDC,,,facility,both,2,EA,,5018,3512.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVONORGESTREL 14 MCG/24 HOUR (3 YEARS) IU IUD,25730,CDM,J7301,HCPCS,50419-422-01,NDC,,,facility,both,1,EA,,1973,1381.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC IV INFUSION HYDRAT 31-60 MIN,26000001,CDM,260,RC,96360,HCPCS,,,facility,both,,,,599,419.3,,,,,,,,,,,,,Gross Charge Type: Central
IV INFUSION HYDRAT EA ADDL HOUR,26000002,CDM,260,RC,96361,HCPCS,,,facility,both,,,,292,204.4,,,,,,,,,,,,,Gross Charge Type: Central
IV THER/PROPHY/DX INITIAL HOUR,26000003,CDM,260,RC,96365,HCPCS,,,facility,both,,,,599,419.3,,,,,,,,,,,,,Gross Charge Type: Central
IV THER/PROPHY/DX EA ADDL HOUR,26000004,CDM,260,RC,96366,HCPCS,,,facility,both,,,,214,149.8,,,,,,,,,,,,,Gross Charge Type: Central
IV THER/PROPHY/DX ADD NEW RX,26000005,CDM,260,RC,96367,HCPCS,,,facility,both,,,,600,420,,,,,,,,,,,,,Gross Charge Type: Central
IV CONCURR ADD-ON,26000006,CDM,260,RC,96368,HCPCS,,,facility,both,,,,599,419.3,,,,,,,,,,,,,Gross Charge Type: Central
INJ THER/PROPHY/DX IM SUBQ,26000007,CDM,260,RC,96372,HCPCS,,,facility,both,,,,107,74.9,,,,,,,,,,,,,Gross Charge Type: Central
INJ THER/PROPHY/DX IV PUSH 1ST,26000008,CDM,260,RC,96374,HCPCS,,,facility,both,,,,453,317.1,,,,,,,,,,,,,Gross Charge Type: Central
INJ THER/PRO/DX IV NEW DRUG,26000009,CDM,260,RC,96375,HCPCS,,,facility,both,,,,207,144.9,,,,,,,,,,,,,Gross Charge Type: Central
HC INJ THER/PRO/DX SAME DRUG 2ND,26000010,CDM,260,RC,96376,HCPCS,,,facility,both,,,,296,207.2,,,,,,,,,,,,,Gross Charge Type: Central
HC SUBQ INFUSION THERAPY/PROPHYLAXIS INITIAL  UP TO 1 HR,26000012,CDM,260,RC,96369,HCPCS,,,facility,both,,,,630,441,,,,,,,,,,,,,Gross Charge Type: Central
HC SUBQ INFUSION THERAPY/PROPHYLAXIS ADDTL PUMP SET-UP NEW SITE,26000013,CDM,260,RC,96371,HCPCS,,,facility,both,,,,208,145.6,,,,,,,,,,,,,Gross Charge Type: Central
HC SUBQ INFUSION THERAPY/PROPHYLAXIS EA ADDTL HOUR,26000014,CDM,260,RC,96370,HCPCS,,,facility,both,,,,172,120.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PER DIEM SUPPLY ACUTE ROOM & CARE,27000001,CDM,270,RC,27000001,HCPCS,,,facility,both,,,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PER DIEM SUPPLY SPECIAL ACUTE CARE,27000002,CDM,270,RC,27000002,HCPCS,,,facility,both,,,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PER DIEM SUPPLY INTENSIVE CARE,27000003,CDM,270,RC,27000003,HCPCS,,,facility,both,,,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PER DIEM SUPPLY CORONARY CARE,27000004,CDM,270,RC,27000004,HCPCS,,,facility,both,,,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PER DIEM SUPPLY EXTENDED NURSERY,27000005,CDM,270,RC,27000005,HCPCS,,,facility,both,,,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PER DIEM SUPPLY NURSERY,27000006,CDM,270,RC,27000006,HCPCS,,,facility,both,,,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PER DIEM SUPPLY OBSERVATION,27000007,CDM,270,RC,27000007,HCPCS,,,facility,both,,,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Central
HC AVAMAX PLUS BONE CEMENT DELIVERY SYSTEM,27000008,CDM,270,RC,27000008,HCPCS,,,facility,both,,,,2164,1514.8,,,,,,,,,,,,,Gross Charge Type: Central
HC AVAMAX VERTEBRAL BALLOON TRAY,27000009,CDM,270,RC,27000009,HCPCS,,,facility,both,,,,4659,3261.3,,,,,,,,,,,,,Gross Charge Type: Central
HC AVAMAX VERTEBRAL AUGMENTATION DRILL,27000010,CDM,270,RC,27000010,HCPCS,,,facility,both,,,,480,336,,,,,,,,,,,,,Gross Charge Type: Central
HC NEEDLE ASPIRATION,27000011,CDM,270,RC,27000011,HCPCS,,,facility,both,,,,301,210.7,,,,,,,,,,,,,Gross Charge Type: Central
HC SET BLADE SHAPER SPINEOLOGY,27000012,CDM,270,RC,27000012,HCPCS,,,facility,both,,,,1649,1154.3,,,,,,,,,,,,,Gross Charge Type: Central
HC SET DILATOR SPINEOLOGY,27000013,CDM,270,RC,27000013,HCPCS,,,facility,both,,,,879,615.3,,,,,,,,,,,,,Gross Charge Type: Central
HC SET LIVER ACCESS ROSCH-UCHIDA,27000014,CDM,270,RC,27000014,HCPCS,,,facility,both,,,,999,699.3,,,,,,,,,,,,,Gross Charge Type: Central
HC TUBE FEEDING LOW PROFILE MIC,27000015,CDM,270,RC,27000015,HCPCS,,,facility,both,,,,999,699.3,,,,,,,,,,,,,Gross Charge Type: Central
HC ADAPTIC DRESSINGS ALL SIZES,27000016,CDM,270,RC,27000016,HCPCS,,,facility,both,,,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Central
HC FORTEX PTA BALLOON CATH 80MM,27000498,CDM,270,RC,27000498,HCPCS,,,facility,both,,,,281,196.7,,,,,,,,,,,,,Gross Charge Type: Central
HC RAPIDCROSS PTA BALLOON CATH 90CM,27000499,CDM,270,RC,27000499,HCPCS,,,facility,both,,,,305,213.5,,,,,,,,,,,,,Gross Charge Type: Central
HC SET EXT SM BORE 7IN BIFUSE,27000557,CDM,270,RC,27000557,HCPCS,,,facility,both,,,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Central
HC SET EXT SM BORE TRIFUSE 4IN,27000558,CDM,270,RC,27000558,HCPCS,,,facility,both,,,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Central
HC SET EXTENSION SMLLBOR QDFUSE,27000559,CDM,270,RC,27000559,HCPCS,,,facility,both,,,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Central
HC COOK ENDOBRONCHIAL BLOCKER SET,27000561,CDM,270,RC,27000561,HCPCS,,,facility,both,,,,731,511.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PLEURX-LOCKABLE DRAINAGE KIT,27000562,CDM,270,RC,27000562,HCPCS,,,facility,both,,,,132,92.4,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH SCEPTER C BLLN,27000654,CDM,272,RC,27000654,HCPCS,,,facility,both,,,,4490,3143,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH SCEPTER XC BLLN,27000655,CDM,272,RC,27000655,HCPCS,,,facility,both,,,,5452,3816.4,,,,,,,,,,,,,Gross Charge Type: Central
HC DISPOSABLE MASK SM/MED/LG,27000658,CDM,270,RC,27000658,HCPCS,,,facility,both,,,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PORTER DISPOSABLE BREATHING CIRCUIT (6FT),27000659,CDM,270,RC,27000659,HCPCS,,,facility,both,,,,160,112,,,,,,,,,,,,,Gross Charge Type: Central
HC SENSOR FORE SIGHT,27000660,CDM,270,RC,27000660,HCPCS,,,facility,both,,,,504,352.8,,,,,,,,,,,,,Gross Charge Type: Central
"HC EEF GRASS DISPOSABLE 10MM AG/AGCL DEEP-CUP ELECTRODE 39"" WIRE",27000670,CDM,270,RC,27000670,HCPCS,,,facility,both,,,,126,88.2,,,,,,,,,,,,,Gross Charge Type: Central
HC ESOPHAGEAL BALLOON CATHETER,27000672,CDM,270,RC,27000672,HCPCS,,,facility,both,,,,261,182.7,,,,,,,,,,,,,Gross Charge Type: Central
HC MARKER DELIVERY KIT,27000681,CDM,270,RC,27000681,HCPCS,,,facility,both,,,,506,354.2,,,,,,,,,,,,,Gross Charge Type: Central
HC DRESSING ALLEVYN LIFE SACRUM (SMALL) 6.75X6.875,27000705,CDM,270,RC,27000705,HCPCS,,,facility,both,,,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Central
HC DRESSING ALLEVYN LIFE SACRUM (LARGE) 8.5X9,27000706,CDM,270,RC,27000706,HCPCS,,,facility,both,,,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Central
HC SNAP CARTRIDGE 75/100/125 MM HG,27000707,CDM,270,RC,27000707,HCPCS,,,facility,both,,,,489,342.3,,,,,,,,,,,,,Gross Charge Type: Central
HC SNAP 10X10CM DRSNG KIT W/FOAM,27000708,CDM,270,RC,27000708,HCPCS,,,facility,both,,,,261,182.7,,,,,,,,,,,,,Gross Charge Type: Central
HC SNAP 15X15CM DRSNG KIT W/FOAM,27000709,CDM,270,RC,27000709,HCPCS,,,facility,both,,,,278,194.6,,,,,,,,,,,,,Gross Charge Type: Central
HC SNAP 20X20CM DRSNG KIT W/FOAM,27000710,CDM,270,RC,27000710,HCPCS,,,facility,both,,,,277,193.9,,,,,,,,,,,,,Gross Charge Type: Central
HC SNAP 14X11CM BRG DRSG KT W/FM,27000711,CDM,270,RC,27000711,HCPCS,,,facility,both,,,,308,215.6,,,,,,,,,,,,,Gross Charge Type: Central
HC SNAP 14X34CM LONG DRSNG KIT,27000712,CDM,270,RC,27000712,HCPCS,,,facility,both,,,,388,271.6,,,,,,,,,,,,,Gross Charge Type: Central
HC SNAP SM/MED/LG STRAP,27000713,CDM,270,RC,27000713,HCPCS,,,facility,both,,,,80,56,,,,,,,,,,,,,Gross Charge Type: Central
HC CERARING 2IN SLIM,27000714,CDM,270,RC,27000714,HCPCS,,,facility,both,,,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Central
HC CONTROL BOX ENPOWER,27000740,CDM,270,RC,27000740,HCPCS,,,facility,both,,,,5539,3877.3,,,,,,,,,,,,,Gross Charge Type: Central
HC CABLE ENPOWER CONNECTING,27000741,CDM,270,RC,27000741,HCPCS,,,facility,both,,,,479,335.3,,,,,,,,,,,,,Gross Charge Type: Central
HC SMART GUARD,27000774,CDM,270,RC,27000774,HCPCS,,,facility,both,,,,148,103.6,,,,,,,,,,,,,Gross Charge Type: Central
HC AEROBIKA,27000796,CDM,270,RC,27000796,HCPCS,,,facility,both,,,,213,149.1,,,,,,,,,,,,,Gross Charge Type: Central
HC RETRACTOR ABDOMINAL PANNICULUS,27000797,CDM,270,RC,27000797,HCPCS,,,facility,both,,,,293,205.1,,,,,,,,,,,,,Gross Charge Type: Central
HC GLIDESCOPE SPECTRUM LOPRO SZ1/SZ2,27000902,CDM,270,RC,27000902,HCPCS,,,facility,both,,,,272,190.4,,,,,,,,,,,,,Gross Charge Type: Central
HC GLIDESCOPE SPECTRUM LOPRO SZ3/SZ4,27000903,CDM,270,RC,27000903,HCPCS,,,facility,both,,,,236,165.2,,,,,,,,,,,,,Gross Charge Type: Central
HC CANN CAPNOLINE NASAL ETCO2,27000961,CDM,270,RC,27000961,HCPCS,,,facility,both,,,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Central
HC FEMALE EXTERNAL PUREWICK CATHETER,27001020,CDM,270,RC,27001020,HCPCS,,,facility,both,,,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Central
HC BFLEX 3.8 BRONCHOSCOPE,27001133,CDM,270,RC,27001133,HCPCS,,,facility,both,,,,4732,3312.4,,,,,,,,,,,,,Gross Charge Type: Central
HC BFLEX 5.0 BRONCHOSCOPE,27001134,CDM,270,RC,27001134,HCPCS,,,facility,both,,,,4732,3312.4,,,,,,,,,,,,,Gross Charge Type: Central
HC BFLEX 5.8 BRONCHOSCOPE,27001135,CDM,270,RC,27001135,HCPCS,,,facility,both,,,,5454,3817.8,,,,,,,,,,,,,Gross Charge Type: Central
HC THERAHONEY FLEX FOAM,27001136,CDM,270,RC,A6209,HCPCS,,,facility,both,,,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Central
HC ENLUXTRA 6X6,27001137,CDM,270,RC,A6196,HCPCS,,,facility,both,,,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Central
HC COMPRESSION WRAP COBAN 2 LITE,27001184,CDM,270,RC,27001184,HCPCS,,,facility,both,,,,70,49,,,,,,,,,,,,,Gross Charge Type: Central
HC COMPRESSION WRAP COBAN 2,27001185,CDM,270,RC,27001185,HCPCS,,,facility,both,,,,70,49,,,,,,,,,,,,,Gross Charge Type: Central
HC COMPRESSION WRAP COBAN 2XL,27001186,CDM,270,RC,27001186,HCPCS,,,facility,both,,,,70,49,,,,,,,,,,,,,Gross Charge Type: Central
HC VASHE EACH BOTTLE,27001208,CDM,270,RC,27001208,HCPCS,,,facility,both,,,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Central
HC DISPOSABLE SUCTION CUPS FOR LUCUS CPR DEVICE,27001218,CDM,270,RC,27001218,HCPCS,,,facility,both,,,,427,298.9,,,,,,,,,,,,,Gross Charge Type: Central
HC LIFESPARC PROTEKDUO 31 FR TANDEMLIFE PROCEDURE KIT,27001219,CDM,270,RC,27001219,HCPCS,,,facility,both,,,,22990,16093,,,,,,,,,,,,,Gross Charge Type: Central
HC ELBOW RESTRAINT PEDI-WRAPS SMALL,27001242,CDM,270,RC,27001242,HCPCS,,,facility,both,,,,172,120.4,,,,,,,,,,,,,Gross Charge Type: Central
HC ELBOW RESTRAINT PEDI-WRAPS LARGE,27001243,CDM,270,RC,27001243,HCPCS,,,facility,both,,,,213,149.1,,,,,,,,,,,,,Gross Charge Type: Central
HC SET TLAB TRNSJUG LIVER BX,27001261,CDM,270,RC,27001261,HCPCS,,,facility,both,,,,1862,1303.4,,,,,,,,,,,,,Gross Charge Type: Central
"HC HYPODERMIC EMG NEEDLES BIONEN 25MM (1"") X THIN 30 GAUGE ORANGE",27001270,CDM,270,RC,27001270,HCPCS,,,facility,both,,,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Central
HC KT EEG DISP NON-METAL MRI/CT LEADS 3A 26LD 1M,27001318,CDM,270,RC,27001318,HCPCS,,,facility,both,,,,493,345.1,,,,,,,,,,,,,Gross Charge Type: Central
HC MICRO G JET BUTTON 14FR FEEDING TUBE,27001324,CDM,270,RC,27001324,HCPCS,,,facility,both,,,,3369,2358.3,,,,,,,,,,,,,Gross Charge Type: Central
HC KIT TRANSFER SYS AIRTAP LC REPOSITION STANDARD 37IN X 65IN 600LB,27001344,CDM,270,RC,27001344,HCPCS,,,facility,both,,,,884,618.8,,,,,,,,,,,,,Gross Charge Type: Central
HC KIT SYS PREVALON AIRTAP 2XLARGE 46IN X 51IN 800LB,27001345,CDM,270,RC,27001345,HCPCS,,,facility,both,,,,1047,732.9,,,,,,,,,,,,,Gross Charge Type: Central
HC KIT CV SAFETY 7FRX16CM PU 3-LUM,27001346,CDM,270,RC,27001346,HCPCS,,,facility,both,,,,300,210,,,,,,,,,,,,,Gross Charge Type: Central
HC STRYKER SAGE PRIMO FIT MALE EXTERNAL CATHETER,27001349,CDM,270,RC,27001349,HCPCS,,,facility,both,,,,131,91.7,,,,,,,,,,,,,Gross Charge Type: Central
HC ORTHOSIS MULTI PODUS ALL SIZES,27001401,CDM,270,RC,27001401,HCPCS,,,facility,both,,,,442,309.4,,,,,,,,,,,,,Gross Charge Type: Central
HC SNUGGLE UPS XSMALL SMALL MED LG,27001418,CDM,270,RC,27001418,HCPCS,,,facility,both,,,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PHILIPS SQUISHON JELL PILLOW,27001419,CDM,270,RC,27001419,HCPCS,,,facility,both,,,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Central
HC FLOTRAC SENSOR,27001451,CDM,270,RC,27001451,HCPCS,,,facility,both,,,,1143,800.1,,,,,,,,,,,,,Gross Charge Type: Central
HC AG CUFFILL CUFF PRESSURE MANOMETER 10CC,27001485,CDM,270,RC,27001485,HCPCS,,,facility,both,,,,119,83.3,,,,,,,,,,,,,Gross Charge Type: Central
HC STRYKER MUL-T BLANKET PEDIATRIC/ADULT,27001511,CDM,270,RC,27001511,HCPCS,,,facility,both,,,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Central
HC KIT PREVALON AIRTAP XXL PATIENT REPOSITIONING SYSTEM 43IN X 81IN 1200LB,27001535,CDM,270,RC,27001535,HCPCS,,,facility,both,,,,1015,710.5,,,,,,,,,,,,,Gross Charge Type: Central
HC BARD INTRA-ABDOMINAL PRESSURE MONITORING KIT,27001561,CDM,270,RC,27001561,HCPCS,,,facility,both,,,,207,144.9,,,,,,,,,,,,,Gross Charge Type: Central
HC DRESSING ALLEVYN CLASSIC NON-ADHERENT 4IN X 4IN,27001562,CDM,270,RC,27001562,HCPCS,,,facility,both,,,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Central
HC CANISTER RENASYS WITH SOLIDIFIER 800ML,27001582,CDM,270,RC,27001582,HCPCS,,,facility,both,,,,173,121.1,,,,,,,,,,,,,Gross Charge Type: Central
HC SURGICEL FIBRILLAR ABSORBABLE HEMOSTAT 2IN X 4IN,27001794,CDM,270,RC,27001794,HCPCS,,,facility,both,,,,436,305.2,,,,,,,,,,,,,Gross Charge Type: Central
HC STATSEAL ADVANCED PLUS 2.2 CM 24 APPLICATIONS,27001796,CDM,270,RC,27001796,HCPCS,,,facility,both,,,,182,127.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PORT REMOVAL TRAY,27001926,CDM,270,RC,27001926,HCPCS,,,facility,both,,,,344,240.8,,,,,,,,,,,,,Gross Charge Type: Central
HC MEFIX 2 IN 11 YD,27001943,CDM,270,RC,27001943,HCPCS,,,facility,both,,,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Central
HC KT MICINTRO CAPELLA COAX 4FR W/0.18IN X45CM GUIDEWIRE/ 21GA X 7CM NEEDLE,27002001,CDM,272,RC,27002001,HCPCS,,,facility,both,,,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Central
HC SET KENDALL ECG LEADWIRE 5LD 144IN,27002031,CDM,270,RC,27002031,HCPCS,,,facility,both,,,,90,63,,,,,,,,,,,,,Gross Charge Type: Central
"HC PREVALON MOBILE AIR TRANSFER SYSTEM 39"" X 81""",27002036,CDM,270,RC,27002036,HCPCS,,,facility,both,,,,282,197.4,,,,,,,,,,,,,Gross Charge Type: Central
HC SAGE CATHETER PRIMAFIT URETHRAL ADULT FEMALE,27002068,CDM,270,RC,27002068,HCPCS,,,facility,both,,,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Central
HC AFFERA LOCATION REFERENCE PATCH KIT,27002103,CDM,270,RC,27002103,HCPCS,,,facility,both,,,,3713,2599.1,,,,,,,,,,,,,Gross Charge Type: Central
HC AIRVO AIRSPIRAL TUBE & CHAMBER KIT,27002121,CDM,270,RC,27002121,HCPCS,,,facility,both,,,,424,296.8,,,,,,,,,,,,,Gross Charge Type: Central
HC ALRM POSEY MTRS PAD 13X32IN,27002139,CDM,270,RC,27002139,HCPCS,,,facility,both,,,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Central
HC ALRM POSEY CHR PAD 13X13IN,27002140,CDM,270,RC,27002140,HCPCS,,,facility,both,,,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Central
HC OXYGEN 24HR,27100002,CDM,271,RC,27100002,HCPCS,,,facility,both,,,,477,333.9,,,,,,,,,,,,,Gross Charge Type: Central
HC OXYGEN SET UP,27100003,CDM,271,RC,27100003,HCPCS,,,facility,both,,,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Central
HC OXYGEN PER HOUR,27100004,CDM,271,RC,27100004,HCPCS,,,facility,both,,,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Central
HC NITRIC OXIDE HOURLY,27100005,CDM,271,RC,27100005,HCPCS,,,facility,both,,,,288,201.6,,,,,,,,,,,,,Gross Charge Type: Central
HC NITRIC OXIDE SET UP,27100006,CDM,271,RC,27100006,HCPCS,,,facility,both,,,,1093,765.1,,,,,,,,,,,,,Gross Charge Type: Central
HC H2O BELLOWS,27100007,CDM,271,RC,27100007,HCPCS,,,facility,both,,,,447,312.9,,,,,,,,,,,,,Gross Charge Type: Central
HC OSCILLATOR CIRCUIT 3100A,27100008,CDM,271,RC,27100008,HCPCS,,,facility,both,,,,490,343,,,,,,,,,,,,,Gross Charge Type: Central
HC AERO CHAMBER,27100009,CDM,271,RC,27100009,HCPCS,,,facility,both,,,,169,118.3,,,,,,,,,,,,,Gross Charge Type: Central
HC TEDS KNEE HIGH,27100011,CDM,271,RC,27100011,HCPCS,,,facility,both,,,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Central
HC ADAPTER FLO-SWITCH,27100012,CDM,271,RC,27100012,HCPCS,,,facility,both,,,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Central
HC ADAPTER Y TUOY-BORST,27100013,CDM,271,RC,27100013,HCPCS,,,facility,both,,,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Central
HC ADHESIVE LIQ MASSITOL HAZ,27100014,CDM,271,RC,27100014,HCPCS,,,facility,both,,,,176,123.2,,,,,,,,,,,,,Gross Charge Type: Central
HC AEROSOL THERAPY PER HOUR,27100015,CDM,271,RC,27100015,HCPCS,,,facility,both,,,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Central
HC APNEA MONITOR/DAY,27100016,CDM,271,RC,27100016,HCPCS,,,facility,both,,,,90,63,,,,,,,,,,,,,Gross Charge Type: Central
HC BAG AMBU ADULT,27100017,CDM,271,RC,27100017,HCPCS,,,facility,both,,,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Central
HC BAG AMBU,27100018,CDM,271,RC,27100018,HCPCS,,,facility,both,,,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Central
HC BAG AMBU DISP,27100019,CDM,271,RC,27100019,HCPCS,,,facility,both,,,,372,260.4,,,,,,,,,,,,,Gross Charge Type: Central
HC BAG DRAIN ABSCESS,27100020,CDM,271,RC,27100020,HCPCS,,,facility,both,,,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Central
HC BAG DRAIN LEG,27100021,CDM,271,RC,27100021,HCPCS,,,facility,both,,,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Central
HC BAG DRAIN SUCTION,27100022,CDM,271,RC,27100022,HCPCS,,,facility,both,,,,169,118.3,,,,,,,,,,,,,Gross Charge Type: Central
HC BAG HYPERINFLATION 1/2 L,27100023,CDM,271,RC,27100023,HCPCS,,,facility,both,,,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Central
HC BAG RESUSCITATION PUL DISP,27100024,CDM,271,RC,27100024,HCPCS,,,facility,both,,,,169,118.3,,,,,,,,,,,,,Gross Charge Type: Central
HC BAG URINARY,27100025,CDM,271,RC,27100025,HCPCS,,,facility,both,,,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Central
HC BAND HEMOSTASIS 14 INCH,27100026,CDM,271,RC,27100026,HCPCS,,,facility,both,,,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Central
HC DERMABOND / ETHICON,27100029,CDM,271,RC,27100029,HCPCS,,,facility,both,,,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Central
HC BELT ABDOMINAL OBESE,27100030,CDM,271,RC,27100030,HCPCS,,,facility,both,,,,164,114.8,,,,,,,,,,,,,Gross Charge Type: Central
HC ELASTIC BANDAGE,27100031,CDM,271,RC,27100031,HCPCS,,,facility,both,,,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Central
HC BELT/BELLY BAND TRANSDUCER DISPOSABLE,27100032,CDM,271,RC,27100032,HCPCS,,,facility,both,,,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Central
HC BILI CHECK CALIBRATION TIPS,27100033,CDM,271,RC,27100033,HCPCS,,,facility,both,,,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Central
HC BILIARY BRUSH BIOPSY SET,27100034,CDM,271,RC,27100034,HCPCS,,,facility,both,,,,427,298.9,,,,,,,,,,,,,Gross Charge Type: Central
HC BINDER ABDOMINAL,27100035,CDM,271,RC,27100035,HCPCS,,,facility,both,,,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Central
HC BINDER UNIVERSAL,27100036,CDM,271,RC,27100036,HCPCS,,,facility,both,,,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Central
HC BIOCLUSIVE 4X5,27100037,CDM,271,RC,27100037,HCPCS,,,facility,both,,,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Central
HC BIOPSY NEEDLE DEVICE,27100038,CDM,271,RC,27100038,HCPCS,,,facility,both,,,,294,205.8,,,,,,,,,,,,,Gross Charge Type: Central
HC BREAST FEEDING UNIT,27100040,CDM,271,RC,27100040,HCPCS,,,facility,both,,,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Central
HC BUNNY BOOT,27100041,CDM,271,RC,27100041,HCPCS,,,facility,both,,,,136,95.2,,,,,,,,,,,,,Gross Charge Type: Central
HC BURITROL,27100042,CDM,271,RC,27100042,HCPCS,,,facility,both,,,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Central
HC CAP SENSOR CO2 DETECTOR ADULT,27100043,CDM,271,RC,27100043,HCPCS,,,facility,both,,,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Central
HC CASKET INFANT 19 INCH,27100044,CDM,271,RC,27100044,HCPCS,,,facility,both,,,,400,280,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER SUCTION,27100045,CDM,271,RC,27100045,HCPCS,,,facility,both,,,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Central
HC CD MEDICAL GRADE,27100046,CDM,271,RC,27100046,HCPCS,,,facility,both,,,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Central
HC CHITO-SEAL,27100047,CDM,271,RC,27100047,HCPCS,,,facility,both,,,,253,177.1,,,,,,,,,,,,,Gross Charge Type: Central
HC CONTAINER URINE 24 HR,27100050,CDM,271,RC,27100050,HCPCS,,,facility,both,,,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Central
HC DIAL A FLOW,27100051,CDM,271,RC,27100051,HCPCS,,,facility,both,,,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Central
HC ELECTRODE GROUNDING PAD,27100052,CDM,271,RC,27100052,HCPCS,,,facility,both,,,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Central
HC ELECTRODE PACING EXTERNAL,27100053,CDM,271,RC,27100053,HCPCS,,,facility,both,,,,489,342.3,,,,,,,,,,,,,Gross Charge Type: Central
HC FEMSTOP,27100054,CDM,271,RC,27100054,HCPCS,,,facility,both,,,,478,334.6,,,,,,,,,,,,,Gross Charge Type: Central
HC HEEL PROTECTOR SAGE,27100065,CDM,271,RC,27100065,HCPCS,,,facility,both,,,,324,226.8,,,,,,,,,,,,,Gross Charge Type: Central
HC HIGHFLOW OXYGEN EA ADDT'L HOUR,27100066,CDM,271,RC,27100066,HCPCS,,,facility,both,,,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Central
HC HIGHFLOW OXYGEN INITIAL HOUR,27100067,CDM,271,RC,27100067,HCPCS,,,facility,both,,,,141,98.7,,,,,,,,,,,,,Gross Charge Type: Central
HC INCENTIVE SPIROMETER,27100068,CDM,271,RC,27100068,HCPCS,,,facility,both,,,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Central
HC INT DELIVERY SET CLOSED,27100069,CDM,271,RC,27100069,HCPCS,,,facility,both,,,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Central
HC JET VENT CARTRIDGE,27100070,CDM,271,RC,27100070,HCPCS,,,facility,both,,,,1017,711.9,,,,,,,,,,,,,Gross Charge Type: Central
HC J-LOOP IV W/INJ,27100071,CDM,271,RC,27100071,HCPCS,,,facility,both,,,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Central
HC KIT QUICKDRAW ABG 3CC 22G,27100073,CDM,271,RC,27100073,HCPCS,,,facility,both,,,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Central
HC KIT/TRAY TROCAR CATH,27100074,CDM,271,RC,27100074,HCPCS,,,facility,both,,,,158,110.6,,,,,,,,,,,,,Gross Charge Type: Central
HC K-PAD DISPOSABLE,27100075,CDM,271,RC,27100075,HCPCS,,,facility,both,,,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Central
HC LEUR LOCK MALE/FEMALE,27100076,CDM,271,RC,27100076,HCPCS,,,facility,both,,,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Central
HC MASK ANES INFANT W/VALVE,27100077,CDM,271,RC,27100077,HCPCS,,,facility,both,,,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Central
HC MASK BILI DISP EA,27100078,CDM,271,RC,27100078,HCPCS,,,facility,both,,,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Central
HC MASK NEONATE W/VALVE,27100079,CDM,271,RC,27100079,HCPCS,,,facility,both,,,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Central
HC MONITOR BLOOD PRESSURE ARTERIAL,27100080,CDM,271,RC,27100080,HCPCS,,,facility,both,,,,262,183.4,,,,,,,,,,,,,Gross Charge Type: Central
HC NELCOR OXISENSOR PEDIATRIC,27100081,CDM,271,RC,27100081,HCPCS,,,facility,both,,,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Central
HC OXYGEN PER HOUR,27100083,CDM,271,RC,27100083,HCPCS,,,facility,both,,,,20,14,,,,,,,,,,,,,Gross Charge Type: Central
HC PAD 72,27100085,CDM,271,RC,27100085,HCPCS,,,facility,both,,,,267,186.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PAD COOLING ARCTIC DISPOSABLE SM/MED/LG,27100086,CDM,271,RC,27100086,HCPCS,,,facility,both,,,,2863,2004.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PAD COOLING ARCTIC DISPOSABLE UNIVERSAL,27100087,CDM,271,RC,27100087,HCPCS,,,facility,both,,,,1140,798,,,,,,,,,,,,,Gross Charge Type: Central
HC PAD RADIATION PROTECTION,27100088,CDM,271,RC,27100088,HCPCS,,,facility,both,,,,400,280,,,,,,,,,,,,,Gross Charge Type: Central
HC PAD W/TUBING,27100089,CDM,271,RC,27100089,HCPCS,,,facility,both,,,,139,97.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PAPER FETAL MONITOR,27100090,CDM,271,RC,27100090,HCPCS,,,facility,both,,,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PELVIC EXAM COMPLETE ASST-SUPPLY,27100091,CDM,271,RC,27100091,HCPCS,,,facility,both,,,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PILLOW ABDUCTION DISP,27100092,CDM,271,RC,27100092,HCPCS,,,facility,both,,,,130,91,,,,,,,,,,,,,Gross Charge Type: Central
HC PILLOW ABDUCTION DISP LARGE,27100093,CDM,271,RC,27100093,HCPCS,,,facility,both,,,,131,91.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PRIMARY W/O CASSETTE 79C-0593,27100094,CDM,271,RC,27100094,HCPCS,,,facility,both,,,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PROTECTION MANIFOLD STATION,27100095,CDM,271,RC,27100095,HCPCS,,,facility,both,,,,249,174.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PROTECTOR HEEL SAGE,27100096,CDM,271,RC,27100096,HCPCS,,,facility,both,,,,324,226.8,,,,,,,,,,,,,Gross Charge Type: Central
HC SEAL RECTAL FECAL,27100098,CDM,271,RC,27100098,HCPCS,,,facility,both,,,,1028,719.6,,,,,,,,,,,,,Gross Charge Type: Central
HC SEAL RECTALFECAL SPEC ORDER,27100099,CDM,271,RC,27100099,HCPCS,,,facility,both,,,,1028,719.6,,,,,,,,,,,,,Gross Charge Type: Central
HC SET ADMIN CONTINUE FLOW,27100100,CDM,271,RC,27100100,HCPCS,,,facility,both,,,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Central
HC SET ANCHOR GI SCOPE,27100101,CDM,271,RC,27100101,HCPCS,,,facility,both,,,,390,273,,,,,,,,,,,,,Gross Charge Type: Central
HC SET DRSSNG OPERICARDIAL PUHRA PLEURA,27100102,CDM,271,RC,27100102,HCPCS,,,facility,both,,,,509,356.3,,,,,,,,,,,,,Gross Charge Type: Central
HC SET EZ,27100103,CDM,271,RC,27100103,HCPCS,,,facility,both,,,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Central
HC SET G-J TUBE,27100104,CDM,271,RC,27100104,HCPCS,,,facility,both,,,,840,588,,,,,,,,,,,,,Gross Charge Type: Central
HC SET IV SECONDARY,27100105,CDM,271,RC,27100105,HCPCS,,,facility,both,,,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Central
HC SET POSSIS PUMP SUPPLY,27100106,CDM,271,RC,27100106,HCPCS,,,facility,both,,,,1080,756,,,,,,,,,,,,,Gross Charge Type: Central
HC SET SECONDARY VENTED W/LL,27100107,CDM,271,RC,27100107,HCPCS,,,facility,both,,,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Central
HC SET TRANSDUCER MONITORING,27100108,CDM,271,RC,27100108,HCPCS,,,facility,both,,,,149,104.3,,,,,,,,,,,,,Gross Charge Type: Central
HC SETUP AEROSOL /HUMIDITY,27100109,CDM,271,RC,27100109,HCPCS,,,facility,both,,,,148,103.6,,,,,,,,,,,,,Gross Charge Type: Central
HC SETUP END TIDAL CARB DIOX,27100110,CDM,271,RC,27100110,HCPCS,,,facility,both,,,,160,112,,,,,,,,,,,,,Gross Charge Type: Central
HC SETUP INITIAL BIPAP SUPPLIES,27100111,CDM,271,RC,27100111,HCPCS,,,facility,both,,,,671,469.7,,,,,,,,,,,,,Gross Charge Type: Central
HC SHIELD BREAST,27100112,CDM,271,RC,27100112,HCPCS,,,facility,both,,,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Central
HC SHIELD BREAST 30,27100113,CDM,271,RC,27100113,HCPCS,,,facility,both,,,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Central
HC SHIELD BREAST PRSNL 36  NON STERILE,27100114,CDM,271,RC,27100114,HCPCS,,,facility,both,,,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Central
HC SHIELD NIPPLE,27100115,CDM,271,RC,27100115,HCPCS,,,facility,both,,,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Central
HC SLEEVE CMPR REG SCD EXP FT CUF,27100116,CDM,271,RC,27100116,HCPCS,,,facility,both,,,,146,102.2,,,,,,,,,,,,,Gross Charge Type: Central
HC SLEEVE CMPR THIGH ALL SIZES,27100117,CDM,271,RC,27100117,HCPCS,,,facility,both,,,,282,197.4,,,,,,,,,,,,,Gross Charge Type: Central
HC TUBE CHEST DRAINAGE THORAKLEX,27100118,CDM,271,RC,27100118,HCPCS,,,facility,both,,,,238,166.6,,,,,,,,,,,,,Gross Charge Type: Central
HC SLEEVE ELECTRI COOL DISPOSABLE,27100119,CDM,271,RC,27100119,HCPCS,,,facility,both,,,,236,165.2,,,,,,,,,,,,,Gross Charge Type: Central
HC SLEEVE SCD REPLACEMENT ONLY,27100120,CDM,271,RC,27100120,HCPCS,,,facility,both,,,,214,149.8,,,,,,,,,,,,,Gross Charge Type: Central
HC SLING AND SWATHE DELUX UNIL BLUE,27100121,CDM,271,RC,27100121,HCPCS,,,facility,both,,,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Central
HC SOFT BAND KERLIX,27100122,CDM,271,RC,27100122,HCPCS,,,facility,both,,,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Central
HC SPIROMETER ADULT 4000ML,27100123,CDM,271,RC,27100123,HCPCS,,,facility,both,,,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Central
HC STRAINER CALCULI,27100124,CDM,271,RC,27100124,HCPCS,,,facility,both,,,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Central
HC SUCTION UNITS KIWI DISPOSABLE,27100125,CDM,271,RC,27100125,HCPCS,,,facility,both,,,,148,103.6,,,,,,,,,,,,,Gross Charge Type: Central
HC SUPPORTER ATHLETIC ADULT SMALL,27100126,CDM,271,RC,27100126,HCPCS,,,facility,both,,,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Central
HC TEDS SCD LARGE,27100127,CDM,271,RC,27100127,HCPCS,,,facility,both,,,,270,189,,,,,,,,,,,,,Gross Charge Type: Central
HC TEDS SEQUENTIAL,27100128,CDM,271,RC,27100128,HCPCS,,,facility,both,,,,187,130.9,,,,,,,,,,,,,Gross Charge Type: Central
HC TEDS THIGH LENGTH,27100129,CDM,271,RC,27100129,HCPCS,,,facility,both,,,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Central
HC TRAP SPECIMEN,27100132,CDM,271,RC,27100132,HCPCS,,,facility,both,,,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Central
HC TRAY PERICARDIOCENTESIS,27100133,CDM,271,RC,27100133,HCPCS,,,facility,both,,,,600,420,,,,,,,,,,,,,Gross Charge Type: Central
HC TRAY UROLOGY OBSTRUCTED URETHRA URO,27100134,CDM,271,RC,27100134,HCPCS,,,facility,both,,,,959,671.3,,,,,,,,,,,,,Gross Charge Type: Central
HC TRAY UV CARGYLE NEO-SERT W/O CATH,27100135,CDM,271,RC,27100135,HCPCS,,,facility,both,,,,277,193.9,,,,,,,,,,,,,Gross Charge Type: Central
HC TUBE BLAKEMORE,27100136,CDM,271,RC,27100136,HCPCS,,,facility,both,,,,1190,833,,,,,,,,,,,,,Gross Charge Type: Central
HC TUBE CHEST DRAINAGE DOUBLE,27100137,CDM,271,RC,27100137,HCPCS,,,facility,both,,,,242,169.4,,,,,,,,,,,,,Gross Charge Type: Central
HC TUBE FEEDING 5FR 15,27100138,CDM,271,RC,27100138,HCPCS,,,facility,both,,,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Central
HC TUBE GEL IODASORB 40G,27100139,CDM,271,RC,27100139,HCPCS,,,facility,both,,,,203,142.1,,,,,,,,,,,,,Gross Charge Type: Central
HC TUBING BLOOD IV,27100140,CDM,271,RC,27100140,HCPCS,,,facility,both,,,,40,28,,,,,,,,,,,,,Gross Charge Type: Central
HC TUBING BLOOD IV,27100141,CDM,271,RC,27100141,HCPCS,,,facility,both,,,,40,28,,,,,,,,,,,,,Gross Charge Type: Central
HC TUBING BURITROL LINE 6.5,27100142,CDM,271,RC,27100142,HCPCS,,,facility,both,,,,30,21,,,,,,,,,,,,,Gross Charge Type: Central
HC TUBING EPIDURAL NOT PORT,27100143,CDM,271,RC,27100143,HCPCS,,,facility,both,,,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Central
HC TUBING FOR HOT LINE,27100144,CDM,271,RC,27100144,HCPCS,,,facility,both,,,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Central
HC URINE COLLECTOR PED,27100145,CDM,271,RC,27100145,HCPCS,,,facility,both,,,,10,7,,,,,,,,,,,,,Gross Charge Type: Central
HC VALVE DRAIN HEIMLICK,27100146,CDM,271,RC,27100146,HCPCS,,,facility,both,,,,181,126.7,,,,,,,,,,,,,Gross Charge Type: Central
HC WIRE CUTTERS,27100147,CDM,271,RC,27100147,HCPCS,,,facility,both,,,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Central
HC WND FILLIODOSORB GEL OZ,27100148,CDM,623,RC,A6261,HCPCS,,,facility,both,,,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Central
HC WNDFILL MULTIDEX PWD IODOFLEX,27100149,CDM,623,RC,A6262,HCPCS,,,facility,both,,,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Central
HC HEMOVAC 1/4,27100150,CDM,271,RC,27100150,HCPCS,,,facility,both,,,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Central
HC ELASTIC STOCKINGS THIGH,27100151,CDM,271,RC,27100151,HCPCS,,,facility,both,,,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Central
HC LINER CANISTER SUCT BOTTLE,27100154,CDM,271,RC,27100154,HCPCS,,,facility,both,,,,10,7,,,,,,,,,,,,,Gross Charge Type: Central
HC AMBU BAG,27100155,CDM,271,RC,27100155,HCPCS,,,facility,both,,,,90,63,,,,,,,,,,,,,Gross Charge Type: Central
HC DRAIN SALEM SUMP,27100156,CDM,271,RC,27100156,HCPCS,,,facility,both,,,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Central
HC VALVE SALEM SUMP,27100157,CDM,271,RC,27100157,HCPCS,,,facility,both,,,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Central
HC IV SET NITRO W/LL,27100158,CDM,271,RC,27100158,HCPCS,,,facility,both,,,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Central
HC TRANSDUCER TRUWAVE PRESSURE CABLE,27100159,CDM,271,RC,27100159,HCPCS,,,facility,both,,,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Central
HC MANIFOLD 4-VALVE,27100160,CDM,271,RC,27100160,HCPCS,,,facility,both,,,,151,105.7,,,,,,,,,,,,,Gross Charge Type: Central
HC SITZ BATH,27100161,CDM,271,RC,27100161,HCPCS,,,facility,both,,,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Central
HC BAG DRAINAGE BECKER 700L,27100168,CDM,271,RC,27100168,HCPCS,,,facility,both,,,,214,149.8,,,,,,,,,,,,,Gross Charge Type: Central
HC BLANKET UPPER BODY SM W/ STRAPS,27100169,CDM,271,RC,27100169,HCPCS,,,facility,both,,,,40,28,,,,,,,,,,,,,Gross Charge Type: Central
HC TRAY UVC ARGYLE NEO-SERT W/O CATH,27100170,CDM,271,RC,27100170,HCPCS,,,facility,both,,,,277,193.9,,,,,,,,,,,,,Gross Charge Type: Central
HC 3M BLOOD SET,27100171,CDM,271,RC,27100171,HCPCS,,,facility,both,,,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Central
HC LEUR LOCK MALE/FEMALE,27100172,CDM,271,RC,27100172,HCPCS,,,facility,both,,,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Central
HC SET ADMIN CONTINUE FLOW,27100173,CDM,271,RC,27100173,HCPCS,,,facility,both,,,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Central
HC SET SECONDARY VENTED W/LL,27100174,CDM,271,RC,27100174,HCPCS,,,facility,both,,,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Central
HC TUBING BURITROL LINE 6.5,27100175,CDM,271,RC,27100175,HCPCS,,,facility,both,,,,30,21,,,,,,,,,,,,,Gross Charge Type: Central
HC COMMODE CONTAINER HAT,27100178,CDM,271,RC,27100178,HCPCS,,,facility,both,,,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Central
HC CONTAINER URINE 24 HR,27100179,CDM,271,RC,27100179,HCPCS,,,facility,both,,,,10,7,,,,,,,,,,,,,Gross Charge Type: Central
HC STRAINER CALCULI,27100180,CDM,271,RC,27100180,HCPCS,,,facility,both,,,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PLEXIPULSE EACH,27100181,CDM,271,RC,27100181,HCPCS,,,facility,both,,,,151,105.7,,,,,,,,,,,,,Gross Charge Type: Central
HC RETRIEVAL DEVICE INSERTABLE,27100185,CDM,272,RC,C1773,HCPCS,,,facility,both,,,,1748,1223.6,,,,,,,,,,,,,Gross Charge Type: Central
HC CLEANSER SKN SPRAY 1OZ,27100228,CDM,623,RC,A6260,HCPCS,,,facility,both,,,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Central
HC SMITH & NEPHEW PICO NWPT SUPPLY (ALL SIZES),27100230,CDM,271,RC,A9272,HCPCS,,,facility,both,,,,871,609.7,,,,,,,,,,,,,Gross Charge Type: Central
HC KIT PLEURAL SGL BOTTLE DRAIN,27100231,CDM,271,RC,27100231,HCPCS,,,facility,both,,,,284,198.8,,,,,,,,,,,,,Gross Charge Type: Central
HC QUIK-CLOT 4X4 DRESSING,27100232,CDM,271,RC,27100232,HCPCS,,,facility,both,,,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH INDIGO 3 STR TIP 150 CM,27100244,CDM,271,RC,27100244,HCPCS,,,facility,both,,,,4144,2900.8,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH INDIGO 6 STR TIP 135 CM,27100245,CDM,271,RC,27100245,HCPCS,,,facility,both,,,,6490,4543,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH INDIGO 8 STR TIP 85 CM,27100246,CDM,271,RC,27100246,HCPCS,,,facility,both,,,,9818,6872.6,,,,,,,,,,,,,Gross Charge Type: Central
HC SEPARATOR INDIGO 3,27100247,CDM,271,RC,27100247,HCPCS,,,facility,both,,,,2547,1782.9,,,,,,,,,,,,,Gross Charge Type: Central
HC SEPARATOR INDIGO 6,27100248,CDM,271,RC,27100248,HCPCS,,,facility,both,,,,3845,2691.5,,,,,,,,,,,,,Gross Charge Type: Central
HC SEPARATOR INDIGO 8,27100249,CDM,271,RC,27100249,HCPCS,,,facility,both,,,,6507,4554.9,,,,,,,,,,,,,Gross Charge Type: Central
HC TUBING ASPIRATION INDIGO,27100250,CDM,271,RC,27100250,HCPCS,,,facility,both,,,,1778,1244.6,,,,,,,,,,,,,Gross Charge Type: Central
HC CANISTER PENUMBRA MAX,27100251,CDM,271,RC,27100251,HCPCS,,,facility,both,,,,1414,989.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PULMONARY AMBU BAG,27100288,CDM,271,RC,27100288,HCPCS,,,facility,both,,,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Central
HC DELIVERY SYS EVOLUT R 16FR,27100289,CDM,271,RC,27100289,HCPCS,,,facility,both,,,,6768,4737.6,,,,,,,,,,,,,Gross Charge Type: Central
HC LOADING SYS EVOLUT R 34FR,27100290,CDM,271,RC,27100290,HCPCS,,,facility,both,,,,1511,1057.7,,,,,,,,,,,,,Gross Charge Type: Central
HC POWER PULSE Y ADAPTER,27100299,CDM,271,RC,27100299,HCPCS,,,facility,both,,,,201,140.7,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH PROWLER MICRO 20CM,27100313,CDM,271,RC,27100313,HCPCS,,,facility,both,,,,3429,2400.3,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH PROWLER MICRO STRT,27100314,CDM,271,RC,27100314,HCPCS,,,facility,both,,,,3349,2344.3,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH ENVOY MPD,27100315,CDM,271,RC,27100315,HCPCS,,,facility,both,,,,1771,1239.7,,,,,,,,,,,,,Gross Charge Type: Central
HC DANDLE ROO LITE BILI WRAP SM - LG,27100319,CDM,271,RC,27100319,HCPCS,,,facility,both,,,,119,83.3,,,,,,,,,,,,,Gross Charge Type: Central
HC INFANT TRANSPORT MATTRESS,27100424,CDM,271,RC,27100424,HCPCS,,,facility,both,,,,203,142.1,,,,,,,,,,,,,Gross Charge Type: Central
HC REPOSITIONING SYS QUICK CONNECT NON STERILE PREVALON AIRTRP SYSTEM,27100425,CDM,271,RC,27100425,HCPCS,,,facility,both,,,,659,461.3,,,,,,,,,,,,,Gross Charge Type: Central
"HC COLOPLAST INTERDRY MOISTURE WICKING DRESSING 10"" X 36""",27100438,CDM,271,RC,A6250,HCPCS,,,facility,both,,,,185,129.5,,,,,,,,,,,,,Gross Charge Type: Central
HC BRIDLE NG TUBE HOLDER,27100452,CDM,271,RC,27100452,HCPCS,,,facility,both,,,,377,263.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PATIENT MONITOR NOT RETURNED,27100453,CDM,271,RC,27100453,HCPCS,,,facility,both,,,,200,140,,,,,,,,,,,,,Gross Charge Type: Central
PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML IV SUSP,27147,CDM,Q9957,HCPCS,11994-011-04,NDC,,,facility,both,4,ML,,1176,823.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML IV SUSP,27147,CDM,Q9957,HCPCS,11994-011-16,NDC,,,facility,both,4,ML,,1176,823.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML IV SUSP,27147,CDM,Q9957,HCPCS,11994-011-16,NDC,,,facility,both,3,ML,,882,617.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML IV SUSP,27147,CDM,Q9957,HCPCS,11994-011-04,NDC,,,facility,both,2,ML,,588,411.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML IV SUSP,27147,CDM,Q9957,HCPCS,11994-011-16,NDC,,,facility,both,2,ML,,588,411.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML IV SUSP,27147,CDM,Q9957,HCPCS,11994-011-01,NDC,,,facility,both,2,ML,,588,411.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML IV SUSP,27147,CDM,Q9957,HCPCS,11994-011-16,NDC,,,facility,both,1,ML,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC DUODERM 6X6 OR SACRAL,27200020,CDM,272,RC,A6235,HCPCS,,,facility,both,,,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Central
HC ELASTOMULL ELASTIC GAUZE 1 IN,27200023,CDM,272,RC,A6443,HCPCS,,,facility,both,,,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Central
HC CMPRLN STRCH COMPRSS 10CM X 5CM,27200026,CDM,272,RC,A6449,HCPCS,,,facility,both,,,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Central
CATH ATHEREC ROTA ADVNCR W/BURR,27200030,CDM,272,RC,C1724,HCPCS,,,facility,both,,,,5597,3917.9,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH ATHEREC ROTA PERIPH ROTAT,27200031,CDM,272,RC,C1724,HCPCS,,,facility,both,,,,11162,7813.4,,,,,,,,,,,,,Gross Charge Type: Central
HC BALLOON PTA C,27200032,CDM,272,RC,C1725,HCPCS,,,facility,both,,,,369,258.3,,,,,,,,,,,,,Gross Charge Type: Central
HC BALLOON EV3 .035,27200033,CDM,272,RC,C1725,HCPCS,,,facility,both,,,,541,378.7,,,,,,,,,,,,,Gross Charge Type: Central
HC BALLOON ABBOTT .035,27200034,CDM,272,RC,C1725,HCPCS,,,facility,both,,,,700,490,,,,,,,,,,,,,Gross Charge Type: Central
HC BALLOON PTA A,27200035,CDM,272,RC,C1725,HCPCS,,,facility,both,,,,744,520.8,,,,,,,,,,,,,Gross Charge Type: Central
HC BALLOON PERIPHERAL,27200036,CDM,272,RC,C1725,HCPCS,,,facility,both,,,,797,557.9,,,,,,,,,,,,,Gross Charge Type: Central
HC BALLOON ATLAS,27200038,CDM,272,RC,C1725,HCPCS,,,facility,both,,,,999,699.3,,,,,,,,,,,,,Gross Charge Type: Central
HC BALLOON PTA B,27200039,CDM,272,RC,C1725,HCPCS,,,facility,both,,,,1061,742.7,,,,,,,,,,,,,Gross Charge Type: Central
HC BALLOON PTCA,27200044,CDM,272,RC,C1725,HCPCS,,,facility,both,,,,466,326.2,,,,,,,,,,,,,Gross Charge Type: Central
HC BALLOON EV3 LONG .018,27200045,CDM,272,RC,C1725,HCPCS,,,facility,both,,,,1558,1090.6,,,,,,,,,,,,,Gross Charge Type: Central
HC BALLOON CUTTING SCIMED,27200048,CDM,272,RC,C1725,HCPCS,,,facility,both,,,,2000,1400,,,,,,,,,,,,,Gross Charge Type: Central
HC BALLOON TYSHAK BRAUN,27200049,CDM,272,RC,C1725,HCPCS,,,facility,both,,,,2033,1423.1,,,,,,,,,,,,,Gross Charge Type: Central
HC BALLOON CATH INFLAT UNIT POLAR,27200052,CDM,272,RC,C1725,HCPCS,,,facility,both,,,,4061,2842.7,,,,,,,,,,,,,Gross Charge Type: Central
HC BALLOON CATH TAMPONADE BAKRI,27200053,CDM,272,RC,C1726,HCPCS,,,facility,both,,,,816,571.2,,,,,,,,,,,,,Gross Charge Type: Central
HC BALLOON CATH DIL NON-VASC AMPLATZ,27200054,CDM,272,RC,C1726,HCPCS,,,facility,both,,,,1061,742.7,,,,,,,,,,,,,Gross Charge Type: Central
HC DRAINAGE CATHETER G,27200056,CDM,272,RC,C1729,HCPCS,,,facility,both,,,,121,84.7,,,,,,,,,,,,,Gross Charge Type: Central
HC DRAINAGE CATHETER H,27200057,CDM,272,RC,C1729,HCPCS,,,facility,both,,,,301,210.7,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH DRAIN PNEUMOTHORAX KIT A,27200058,CDM,272,RC,C1729,HCPCS,,,facility,both,,,,426,298.2,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH DRAIN PNEUMOTHORAX KIT,27200059,CDM,272,RC,C1729,HCPCS,,,facility,both,,,,445,311.5,,,,,,,,,,,,,Gross Charge Type: Central
HC DRAINAGE CATHETER B,27200060,CDM,272,RC,C1729,HCPCS,,,facility,both,,,,454,317.8,,,,,,,,,,,,,Gross Charge Type: Central
HC DRAINAGE CATHETER C,27200061,CDM,272,RC,C1729,HCPCS,,,facility,both,,,,480,336,,,,,,,,,,,,,Gross Charge Type: Central
HC DRAINAGE CATHETER A,27200062,CDM,272,RC,C1729,HCPCS,,,facility,both,,,,509,356.3,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH DRAIN CHEST TUBE PLEURAGUIDE,27200063,CDM,272,RC,C1729,HCPCS,,,facility,both,,,,511,357.7,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH DRAIN PNEUM WYNE 14FR,27200064,CDM,272,RC,C1729,HCPCS,,,facility,both,,,,609,426.3,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH DRAIN PNEUMOTHORAX KIT B,27200065,CDM,272,RC,C1729,HCPCS,,,facility,both,,,,850,595,,,,,,,,,,,,,Gross Charge Type: Central
HC DRAINAGE CATHETER F,27200066,CDM,272,RC,C1729,HCPCS,,,facility,both,,,,1748,1223.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PLEURX-PLEURAL CATH KIT,27200067,CDM,272,RC,C1729,HCPCS,,,facility,both,,,,1892,1324.4,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH EP DX QUAD NON DEFL < 19 ELE,27200068,CDM,272,RC,C1730,HCPCS,,,facility,both,,,,2439,1707.3,,,,,,,,,,,,,Gross Charge Type: Central
HC DIAG ER CATH W/20 OR MORE ELECTRODES,27200069,CDM,272,RC,C1731,HCPCS,,,facility,both,,,,2330,1631,,,,,,,,,,,,,Gross Charge Type: Central
HC EP CATHETER HALO 20 ELECTRODES,27200070,CDM,272,RC,C1731,HCPCS,,,facility,both,,,,3759,2631.3,,,,,,,,,,,,,Gross Charge Type: Central
HC EZ STEER BI-DIRECTIONAL CARTO 4MM,27200075,CDM,272,RC,C1732,HCPCS,,,facility,both,,,,6670,4669,,,,,,,,,,,,,Gross Charge Type: Central
HC THERMACOOL SF NAV CATHETER,27200076,CDM,272,RC,C1732,HCPCS,,,facility,both,,,,8120,5684,,,,,,,,,,,,,Gross Charge Type: Central
HC ABLATION CATHETER-WEBSTER,27200079,CDM,272,RC,C1733,HCPCS,,,facility,both,,,,2996,2097.2,,,,,,,,,,,,,Gross Charge Type: Central
HC EZ STEER BI DIRECTIONAL NON-CARTO 8MM,27200080,CDM,272,RC,C1733,HCPCS,,,facility,both,,,,3495,2446.5,,,,,,,,,,,,,Gross Charge Type: Central
HC EZ STEER THERMOCOOL CARTO,27200083,CDM,272,RC,C1733,HCPCS,,,facility,both,,,,6969,4878.3,,,,,,,,,,,,,Gross Charge Type: Central
HC BALLOON ARCTIC FRONT,27200084,CDM,272,RC,C1733,HCPCS,,,facility,both,,,,15972,11180.4,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH DX PERIPH,27200088,CDM,272,RC,C1751,HCPCS,,,facility,both,,,,416,291.2,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH PICC A,27200089,CDM,272,RC,C1751,HCPCS,,,facility,both,,,,509,356.3,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH PICC B,27200090,CDM,272,RC,C1751,HCPCS,,,facility,both,,,,509,356.3,,,,,,,,,,,,,Gross Charge Type: Central
CATH PICC DUAL LUMEN 1.9FRX30CM,27200091,CDM,272,RC,C1751,HCPCS,,,facility,both,,,,360,252,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH INF UNIFUSE,27200092,CDM,272,RC,C1751,HCPCS,,,facility,both,,,,668,467.6,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH CV LINE POWERLINE,27200093,CDM,272,RC,C1751,HCPCS,,,facility,both,,,,1080,756,,,,,,,,,,,,,Gross Charge Type: Central
HC TEMPORARY DIALYSIS CATHETER,27200094,CDM,272,RC,C1752,HCPCS,,,facility,both,,,,341,238.7,,,,,,,,,,,,,Gross Charge Type: Central
HC TEMP DIALYSIS CATHETER B POWER-TRIALYSIS,27200095,CDM,272,RC,C1752,HCPCS,,,facility,both,,,,660,462,,,,,,,,,,,,,Gross Charge Type: Central
HC CVIS ULTRACROSS CATH/SONICATH MDL 37-410,27200096,CDM,272,RC,C1753,HCPCS,,,facility,both,,,,2613,1829.1,,,,,,,,,,,,,Gross Charge Type: Central
HC EMBOLIZATION PRODUCT D,27200097,CDM,272,RC,C1757,HCPCS,,,facility,both,,,,509,356.3,,,,,,,,,,,,,Gross Charge Type: Central
HC EMBOLIZATION PRODUCT E,27200098,CDM,272,RC,C1757,HCPCS,,,facility,both,,,,509,356.3,,,,,,,,,,,,,Gross Charge Type: Central
HC EMBOLIZATION PRODUCT C,27200099,CDM,272,RC,C1757,HCPCS,,,facility,both,,,,999,699.3,,,,,,,,,,,,,Gross Charge Type: Central
HC EMBOLIZATION PRODUCT A,27200100,CDM,272,RC,C1757,HCPCS,,,facility,both,,,,1300,910,,,,,,,,,,,,,Gross Charge Type: Central
HC ATRIUM XPRESSWAY CATH-ASPIRATION CATH,27200102,CDM,272,RC,C1757,HCPCS,,,facility,both,,,,1261,882.7,,,,,,,,,,,,,Gross Charge Type: Central
HC AVX 50CM ULTRA,27200104,CDM,272,RC,C1757,HCPCS,,,facility,both,,,,2086,1460.2,,,,,,,,,,,,,Gross Charge Type: Central
HC THROMBECTOMY DEVICE A,27200105,CDM,272,RC,C1757,HCPCS,,,facility,both,,,,2497,1747.9,,,,,,,,,,,,,Gross Charge Type: Central
HC RHEOLYTIC CATHETER W/PUMP,27200109,CDM,272,RC,C1757,HCPCS,,,facility,both,,,,5741,4018.7,,,,,,,,,,,,,Gross Charge Type: Central
HC SOUNDSTAR/RS,27200113,CDM,272,RC,C1759,HCPCS,,,facility,both,,,,4792,3354.4,,,,,,,,,,,,,Gross Charge Type: Central
HC ACUNAV/SOUNDSTAR INTRACARDIAC ECHO CATH,27200114,CDM,272,RC,C1759,HCPCS,,,facility,both,,,,9651,6755.7,,,,,,,,,,,,,Gross Charge Type: Central
HC VASCULAR SHEATH E,27200116,CDM,272,RC,C1766,HCPCS,,,facility,both,,,,490,343,,,,,,,,,,,,,Gross Charge Type: Central
HC STEERABLE GROIN SHEATH,27200117,CDM,272,RC,C1766,HCPCS,,,facility,both,,,,5758,4030.6,,,,,,,,,,,,,Gross Charge Type: Central
HC SPRING WIRE GUIDE,27200118,CDM,272,RC,C1769,HCPCS,,,facility,both,,,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Central
HC DIAGNOSTIC GUIDE WIRE,27200120,CDM,272,RC,C1769,HCPCS,,,facility,both,,,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Central
HC GUIDEWIRE TORQUE DEVICE,27200121,CDM,272,RC,C1769,HCPCS,,,facility,both,,,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Central
HC GUIDEWIRE B,27200122,CDM,272,RC,C1769,HCPCS,,,facility,both,,,,143,100.1,,,,,,,,,,,,,Gross Charge Type: Central
GW VASC L80CM L2MM OD.018IN,27200123,CDM,272,RC,C1769,HCPCS,,,facility,both,,,,184,128.8,,,,,,,,,,,,,Gross Charge Type: Central
HC GUIDE WIRE A,27200124,CDM,272,RC,C1769,HCPCS,,,facility,both,,,,230,161,,,,,,,,,,,,,Gross Charge Type: Central
HC GUIDEWIRE C,27200127,CDM,272,RC,C1769,HCPCS,,,facility,both,,,,253,177.1,,,,,,,,,,,,,Gross Charge Type: Central
HC GUIDEWIRE G,27200128,CDM,272,RC,C1769,HCPCS,,,facility,both,,,,255,178.5,,,,,,,,,,,,,Gross Charge Type: Central
HC GUIDEWIRE H,27200130,CDM,272,RC,C1769,HCPCS,,,facility,both,,,,321,224.7,,,,,,,,,,,,,Gross Charge Type: Central
HC GUIDEWIRE D,27200131,CDM,272,RC,C1769,HCPCS,,,facility,both,,,,341,238.7,,,,,,,,,,,,,Gross Charge Type: Central
HC GLIDEWIRE,27200132,CDM,272,RC,C1769,HCPCS,,,facility,both,,,,381,266.7,,,,,,,,,,,,,Gross Charge Type: Central
HC GUIDEWIRE E,27200133,CDM,272,RC,C1769,HCPCS,,,facility,both,,,,396,277.2,,,,,,,,,,,,,Gross Charge Type: Central
HC GUIDEWIRE I,27200134,CDM,272,RC,C1769,HCPCS,,,facility,both,,,,410,287,,,,,,,,,,,,,Gross Charge Type: Central
PTCA GUIDEWIRE,27200135,CDM,272,RC,C1769,HCPCS,,,facility,both,,,,366,256.2,,,,,,,,,,,,,Gross Charge Type: Central
HC GUIDEWIRE THRUWAY 0.018 300CM,27200136,CDM,272,RC,C1769,HCPCS,,,facility,both,,,,447,312.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PULMONARY JAGWIRE,27200137,CDM,272,RC,C1769,HCPCS,,,facility,both,,,,480,336,,,,,,,,,,,,,Gross Charge Type: Central
HC GUIDEWIRE L,27200138,CDM,272,RC,C1769,HCPCS,,,facility,both,,,,509,356.3,,,,,,,,,,,,,Gross Charge Type: Central
HC GUIDEWIRE J,27200139,CDM,272,RC,C1769,HCPCS,,,facility,both,,,,521,364.7,,,,,,,,,,,,,Gross Charge Type: Central
MALLINCKRODT TAD WIRE,27200140,CDM,272,RC,C1769,HCPCS,,,facility,both,,,,576,403.2,,,,,,,,,,,,,Gross Charge Type: Central
HC V-14/18 300 CM CONTROLWIRE,27200141,CDM,272,RC,C1769,HCPCS,,,facility,both,,,,761,532.7,,,,,,,,,,,,,Gross Charge Type: Central
HC GUIDEWIRE K,27200142,CDM,272,RC,C1769,HCPCS,,,facility,both,,,,1198,838.6,,,,,,,,,,,,,Gross Charge Type: Central
HC DOPPLER PRESSURE WIRE,27200143,CDM,272,RC,C1769,HCPCS,,,facility,both,,,,2081,1456.7,,,,,,,,,,,,,Gross Charge Type: Central
HC RETRIEVAL DEVICE SNARE A,27200144,CDM,272,RC,C1773,HCPCS,,,facility,both,,,,1168,817.6,,,,,,,,,,,,,Gross Charge Type: Central
HC RETRIEVAL DEVICE SNARE B,27200145,CDM,272,RC,C1773,HCPCS,,,facility,both,,,,1485,1039.5,,,,,,,,,,,,,Gross Charge Type: Central
HC RETRIEVAL DEVICE SNARE CATH,27200146,CDM,272,RC,C1773,HCPCS,,,facility,both,,,,2277,1593.9,,,,,,,,,,,,,Gross Charge Type: Central
HC SYSEMBOLIC PROTECTION 190/300CM,27200151,CDM,272,RC,C1884,HCPCS,,,facility,both,,,,5159,3611.3,,,,,,,,,,,,,Gross Charge Type: Central
HC GUIDE CATHETER,27200152,CDM,272,RC,C1887,HCPCS,,,facility,both,,,,350,245,,,,,,,,,,,,,Gross Charge Type: Central
HC COOK CURVED SHEATH,27200153,CDM,272,RC,C1887,HCPCS,,,facility,both,,,,528,369.6,,,,,,,,,,,,,Gross Charge Type: Central
HC GW MICROCATH CARAVEL 1.9FX150CM,27200155,CDM,272,RC,C1887,HCPCS,,,facility,both,,,,1364,954.8,,,,,,,,,,,,,Gross Charge Type: Central
HC CS GUIDE CATHETER,27200156,CDM,272,RC,C1887,HCPCS,,,facility,both,,,,2396,1677.2,,,,,,,,,,,,,Gross Charge Type: Central
HC ENB LOCATABLE GUIDE,27200157,CDM,272,RC,C1887,HCPCS,,,facility,both,,,,3313,2319.1,,,,,,,,,,,,,Gross Charge Type: Central
HC VASCULAR SHEATH D,27200158,CDM,272,RC,C1892,HCPCS,,,facility,both,,,,290,203,,,,,,,,,,,,,Gross Charge Type: Central
HC TRANSSEPTAL NEEDLE,27200159,CDM,272,RC,C1893,HCPCS,,,facility,both,,,,1104,772.8,,,,,,,,,,,,,Gross Charge Type: Central
HC DIAGNOSTIC SHEATH/INTRODUCER,27200160,CDM,272,RC,C1894,HCPCS,,,facility,both,,,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Central
HC SHEATH INTRODUCER SUPER SHEATH BOSTON SC,27200162,CDM,272,RC,C1894,HCPCS,,,facility,both,,,,145,101.5,,,,,,,,,,,,,Gross Charge Type: Central
HC VASCULAR SHEATH A,27200163,CDM,272,RC,C1894,HCPCS,,,facility,both,,,,162,113.4,,,,,,,,,,,,,Gross Charge Type: Central
HC VASCULAR SHEATH B,27200165,CDM,272,RC,C1894,HCPCS,,,facility,both,,,,225,157.5,,,,,,,,,,,,,Gross Charge Type: Central
HC AVANTI 23CM SHEATH 6FR,27200166,CDM,272,RC,C1894,HCPCS,,,facility,both,,,,246,172.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PERCUTANEOUS SHEATH INTRODUCER,27200168,CDM,272,RC,C1894,HCPCS,,,facility,both,,,,285,199.5,,,,,,,,,,,,,Gross Charge Type: Central
HC CORDIS BRITE-TIP SHEATH,27200169,CDM,272,RC,C1894,HCPCS,,,facility,both,,,,289,202.3,,,,,,,,,,,,,Gross Charge Type: Central
HC SHEATH INTRODUCER COOK 14X30,27200171,CDM,272,RC,C1894,HCPCS,,,facility,both,,,,381,266.7,,,,,,,,,,,,,Gross Charge Type: Central
HC SHEATH INTRODUCER MULLINS 85CM,27200172,CDM,272,RC,C1894,HCPCS,,,facility,both,,,,477,333.9,,,,,,,,,,,,,Gross Charge Type: Central
HC SHEATH INTRODUCER COOK 16X30,27200173,CDM,272,RC,C1894,HCPCS,,,facility,both,,,,478,334.6,,,,,,,,,,,,,Gross Charge Type: Central
HC COOK BALKEN SHEATH,27200174,CDM,272,RC,C1894,HCPCS,,,facility,both,,,,528,369.6,,,,,,,,,,,,,Gross Charge Type: Central
HC VASCULAR SHEATH C,27200175,CDM,272,RC,C1894,HCPCS,,,facility,both,,,,720,504,,,,,,,,,,,,,Gross Charge Type: Central
HC DAIG SAFL SHEATH,27200176,CDM,272,RC,C1894,HCPCS,,,facility,both,,,,864,604.8,,,,,,,,,,,,,Gross Charge Type: Central
HC RAPIDO CS GUIDING CATHETER,27200178,CDM,272,RC,C1894,HCPCS,,,facility,both,,,,3594,2515.8,,,,,,,,,,,,,Gross Charge Type: Central
HC CRYOABLATION PROBE,27200179,CDM,272,RC,C2618,HCPCS,,,facility,both,,,,4327,3028.9,,,,,,,,,,,,,Gross Charge Type: Central
HC DRAINAGE CATHETER E,27200180,CDM,272,RC,C2625,HCPCS,,,facility,both,,,,554,387.8,,,,,,,,,,,,,Gross Charge Type: Central
HC SUPRAPUBIC CATHETER,27200181,CDM,272,RC,C2627,HCPCS,,,facility,both,,,,509,356.3,,,,,,,,,,,,,Gross Charge Type: Central
HC BALLOON CATH SIZING AMPLATZER,27200182,CDM,272,RC,C2628,HCPCS,,,facility,both,,,,868,607.6,,,,,,,,,,,,,Gross Charge Type: Central
HC OCCLUSION CATHETER,27200183,CDM,272,RC,C2628,HCPCS,,,facility,both,,,,2647,1852.9,,,,,,,,,,,,,Gross Charge Type: Central
HC CARTO NAVISTAR CATHETER,27200184,CDM,272,RC,C2630,HCPCS,,,facility,both,,,,7787,5450.9,,,,,,,,,,,,,Gross Charge Type: Central
HC NEEDLE CRV RF 18 GA 145 MM,27200185,CDM,272,RC,27200185,HCPCS,,,facility,both,,,,150,105,,,,,,,,,,,,,Gross Charge Type: Central
HC PEAK PLASMA BLADE,27200186,CDM,272,RC,27200186,HCPCS,,,facility,both,,,,1099,769.3,,,,,,,,,,,,,Gross Charge Type: Central
HC AVAMAX COAXIAL BONE BIOPSY SYSTEM,27200187,CDM,272,RC,27200187,HCPCS,,,facility,both,,,,440,308,,,,,,,,,,,,,Gross Charge Type: Central
HC ON CONTROL BONE BIOPSY SYSTEM,27200188,CDM,272,RC,27200188,HCPCS,,,facility,both,,,,520,364,,,,,,,,,,,,,Gross Charge Type: Central
HC MORPH ACCESSPRO SYSTEM,27200189,CDM,272,RC,27200189,HCPCS,,,facility,both,,,,1916,1341.2,,,,,,,,,,,,,Gross Charge Type: Central
HC DEFLECTABLE GUIDE CATHETER,27200190,CDM,272,RC,27200190,HCPCS,,,facility,both,,,,2913,2039.1,,,,,,,,,,,,,Gross Charge Type: Central
HC ONYX LIQUID EMBOLIC SYSTEM,27200191,CDM,272,RC,27200191,HCPCS,,,facility,both,,,,8852,6196.4,,,,,,,,,,,,,Gross Charge Type: Central
HC CONCERTO EMBOLIZATION COIL,27200192,CDM,272,RC,27200192,HCPCS,,,facility,both,,,,2497,1747.9,,,,,,,,,,,,,Gross Charge Type: Central
HC NEEDLE CERVICAL STRAIGHT 22 GA 100 MM,27200193,CDM,272,RC,27200193,HCPCS,,,facility,both,,,,142,99.4,,,,,,,,,,,,,Gross Charge Type: Central
HC NEEDLE SPINAL 22 GA X 3.5,27200194,CDM,272,RC,27200194,HCPCS,,,facility,both,,,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Central
HC NEEDLE CHIBA 22 GA X 5.0,27200195,CDM,272,RC,27200195,HCPCS,,,facility,both,,,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Central
HC NEEDLE NERVE ROOT BLOCK 22 GA X 6.0,27200196,CDM,272,RC,27200196,HCPCS,,,facility,both,,,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Central
HC NEEDLE SPINAL 22 GA X 8.0,27200197,CDM,272,RC,27200197,HCPCS,,,facility,both,,,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Central
HC NEEDLE SPINAL 23 GA X 3.5,27200198,CDM,272,RC,27200198,HCPCS,,,facility,both,,,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Central
HC NEEDLE SPINAL 23 GA X 5.0,27200199,CDM,272,RC,27200199,HCPCS,,,facility,both,,,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Central
HC NEEDLE SPINAL 25 GA X 2.5,27200200,CDM,272,RC,27200200,HCPCS,,,facility,both,,,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Central
HC NEEDLE SPINAL 25 GA X 3.5,27200201,CDM,272,RC,27200201,HCPCS,,,facility,both,,,,10,7,,,,,,,,,,,,,Gross Charge Type: Central
HC NEEDLE NERVE ROOT BLOCK 25 GA X 6.0,27200202,CDM,272,RC,27200202,HCPCS,,,facility,both,,,,129,90.3,,,,,,,,,,,,,Gross Charge Type: Central
HC NEEDLE NERVE ROOT BLOCK 25 GA X 8.0,27200203,CDM,272,RC,27200203,HCPCS,,,facility,both,,,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Central
HC CANN RF OD20GA 145 MM STR,27200204,CDM,272,RC,27200204,HCPCS,,,facility,both,,,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Central
HC NEEDLE CATH STRAIGHT 16 GA X 3.5,27200205,CDM,272,RC,27200205,HCPCS,,,facility,both,,,,290,203,,,,,,,,,,,,,Gross Charge Type: Central
HC NEEDLE CATH STRAIGHT 18 GA X 3.5,27200206,CDM,272,RC,27200206,HCPCS,,,facility,both,,,,290,203,,,,,,,,,,,,,Gross Charge Type: Central
HC GROUNDING PADS,27200207,CDM,272,RC,27200207,HCPCS,,,facility,both,,,,138,96.6,,,,,,,,,,,,,Gross Charge Type: Central
HC VERSA KATH 21 GA X 12.0,27200208,CDM,272,RC,27200208,HCPCS,,,facility,both,,,,358,250.6,,,,,,,,,,,,,Gross Charge Type: Central
HC MANO METRIC DEVICE,27200209,CDM,272,RC,27200209,HCPCS,,,facility,both,,,,504,352.8,,,,,,,,,,,,,Gross Charge Type: Central
HC REFILL KIT / IMPLANT INF PUMP,27200210,CDM,272,RC,27200210,HCPCS,,,facility,both,,,,134,93.8,,,,,,,,,,,,,Gross Charge Type: Central
HC NEEDLE RF CURVED EXTRA LONG 145 MM,27200211,CDM,272,RC,27200211,HCPCS,,,facility,both,,,,139,97.3,,,,,,,,,,,,,Gross Charge Type: Central
HC NEEDLE CANNULA RFK C15D,27200212,CDM,272,RC,27200212,HCPCS,,,facility,both,,,,227,158.9,,,,,,,,,,,,,Gross Charge Type: Central
HC SET TUBING IV LL 110 IN,27200213,CDM,272,RC,27200213,HCPCS,,,facility,both,,,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Central
HC SYRINGE UNIVERSAL FLUID DISPENSING,27200214,CDM,272,RC,27200214,HCPCS,,,facility,both,,,,504,352.8,,,,,,,,,,,,,Gross Charge Type: Central
HC TUN-L-KATH 19 GA X 12.0,27200215,CDM,272,RC,27200215,HCPCS,,,facility,both,,,,323,226.1,,,,,,,,,,,,,Gross Charge Type: Central
HC BRONCHAVEOLAR LAVAGE CATH / SUPPLIES,27200216,CDM,272,RC,27200216,HCPCS,,,facility,both,,,,396,277.2,,,,,,,,,,,,,Gross Charge Type: Central
HC DIAPHRAGM CAP,27200217,CDM,272,RC,27200217,HCPCS,,,facility,both,,,,213,149.1,,,,,,,,,,,,,Gross Charge Type: Central
HC AIRWAY LARYNGEAL DIS INTUB,27200218,CDM,272,RC,27200218,HCPCS,,,facility,both,,,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Central
HC FORCEPS BIOPSY PULM,27200219,CDM,272,RC,27200219,HCPCS,,,facility,both,,,,194,135.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PASSEY MUIR SPEAKING VALVE,27200220,CDM,272,RC,27200220,HCPCS,,,facility,both,,,,330,231,,,,,,,,,,,,,Gross Charge Type: Central
HC ANESTHESIA SUPPLY CHARGE,27200221,CDM,272,RC,27200221,HCPCS,,,facility,both,,,,341,238.7,,,,,,,,,,,,,Gross Charge Type: Central
HC SWAN GANZ CATHETER,27200223,CDM,272,RC,A4300,HCPCS,,,facility,both,,,,284,198.8,,,,,,,,,,,,,Gross Charge Type: Central
HC ACCUSTICK,27200224,CDM,272,RC,27200224,HCPCS,,,facility,both,,,,465,325.5,,,,,,,,,,,,,Gross Charge Type: Central
HC ACTICOAT 7,27200225,CDM,272,RC,A9270,HCPCS,,,facility,both,,,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Central
HC ADAPTER MALE,27200227,CDM,272,RC,27200227,HCPCS,,,facility,both,,,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Central
HC ADVISER TRANSDUCER POLE MOUNT,27200228,CDM,272,RC,27200228,HCPCS,,,facility,both,,,,454,317.8,,,,,,,,,,,,,Gross Charge Type: Central
HC AERO NEB SOLO SUPPLY,27200229,CDM,272,RC,27200229,HCPCS,,,facility,both,,,,288,201.6,,,,,,,,,,,,,Gross Charge Type: Central
HC AMNIHOOK STERILE,27200230,CDM,272,RC,27200230,HCPCS,,,facility,both,,,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Central
HC BAG COLLECTION FLEXI-SEAL  F,27200232,CDM,272,RC,27200232,HCPCS,,,facility,both,,,,283,198.1,,,,,,,,,,,,,Gross Charge Type: Central
HC BAG FOLEY PRECON,27200233,CDM,272,RC,27200233,HCPCS,,,facility,both,,,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Central
HC BALLOON CATH BIB,27200235,CDM,272,RC,C1725,HCPCS,,,facility,both,,,,2497,1747.9,,,,,,,,,,,,,Gross Charge Type: Central
HC BALLOON INTRAAORTIC,27200236,CDM,272,RC,27200236,HCPCS,,,facility,both,,,,2830,1981,,,,,,,,,,,,,Gross Charge Type: Central
HC BALLOON RIPENING CERVICAL COOK,27200237,CDM,272,RC,27200237,HCPCS,,,facility,both,,,,350,245,,,,,,,,,,,,,Gross Charge Type: Central
HC BALLOON STINGRAY,27200238,CDM,272,RC,27200238,HCPCS,,,facility,both,,,,3828,2679.6,,,,,,,,,,,,,Gross Charge Type: Central
HC BALLOON VENOGRAM MEDTRONIC,27200239,CDM,272,RC,27200239,HCPCS,,,facility,both,,,,640,448,,,,,,,,,,,,,Gross Charge Type: Central
HC BANDAGE BULKY 4X4,27200240,CDM,272,RC,27200240,HCPCS,,,facility,both,,,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Central
HC BARRIER ADHESION INTERCEED,27200241,CDM,272,RC,27200241,HCPCS,,,facility,both,,,,1041,728.7,,,,,,,,,,,,,Gross Charge Type: Central
HC BIO PATCH,27200242,CDM,272,RC,27200242,HCPCS,,,facility,both,,,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Central
HC BLAKE FLAT FULL FLUTED 10MM,27200243,CDM,272,RC,27200243,HCPCS,,,facility,both,,,,163,114.1,,,,,,,,,,,,,Gross Charge Type: Central
HC BLANKET BILI COVER S DISP,27200245,CDM,272,RC,27200245,HCPCS,,,facility,both,,,,70,49,,,,,,,,,,,,,Gross Charge Type: Central
HC BLANKET HYPO/HYPER ADULT/OR 25X64,27200246,CDM,272,RC,27200246,HCPCS,,,facility,both,,,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Central
HC BOTTLE CHEST ADULT,27200247,CDM,272,RC,27200247,HCPCS,,,facility,both,,,,306,214.2,,,,,,,,,,,,,Gross Charge Type: Central
HC BOTTLE PERFUSION REPLACEMENT,27200248,CDM,272,RC,27200248,HCPCS,,,facility,both,,,,470,329,,,,,,,,,,,,,Gross Charge Type: Central
HC CARTRIDGE STAPLE RELOAD TR45W,27200250,CDM,272,RC,27200250,HCPCS,,,facility,both,,,,439,307.3,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER AIRWAY EXCHANGE,27200251,CDM,272,RC,27200251,HCPCS,,,facility,both,,,,275,192.5,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER AIRWAY INTUB,27200252,CDM,272,RC,27200252,HCPCS,,,facility,both,,,,2859,2001.3,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER AORTIC DIAG RAD MEASURING,27200253,CDM,272,RC,27200253,HCPCS,,,facility,both,,,,632,442.4,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER ARTERIAL LINE 20G 55IN (12C,27200254,CDM,272,RC,27200254,HCPCS,,,facility,both,,,,213,149.1,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER COUDE,27200255,CDM,272,RC,27200255,HCPCS,,,facility,both,,,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER CROSSER CTO RECANALIZATION,27200256,CDM,272,RC,27200256,HCPCS,,,facility,both,,,,6655,4658.5,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER CRYO 4MM,27200257,CDM,272,RC,27200257,HCPCS,,,facility,both,,,,7650,5355,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER DIAG PCG SWAN 5FR PED,27200258,CDM,272,RC,27200258,HCPCS,,,facility,both,,,,336,235.2,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER DIAG RAD W/MARKERS,27200259,CDM,272,RC,27200259,HCPCS,,,facility,both,,,,200,140,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER DIAGNOSTIC,27200260,CDM,272,RC,27200260,HCPCS,,,facility,both,,,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER DIAGNOSTIC JKYRADIAL,27200261,CDM,272,RC,27200261,HCPCS,,,facility,both,,,,281,196.7,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER DIAGNOSTIC RADIOLOGIC,27200262,CDM,272,RC,27200262,HCPCS,,,facility,both,,,,541,378.7,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER EPIDURAL 18G,27200263,CDM,272,RC,27200263,HCPCS,,,facility,both,,,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER FLEXCATH ARCTIC FRONT,27200264,CDM,272,RC,27200264,HCPCS,,,facility,both,,,,3993,2795.1,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER FLOW DIRECTED,27200265,CDM,272,RC,27200265,HCPCS,,,facility,both,,,,567,396.9,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER FOLEY,27200266,CDM,272,RC,27200266,HCPCS,,,facility,both,,,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER FOLEY MEDIUM,27200267,CDM,272,RC,27200267,HCPCS,,,facility,both,,,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER FOLEY SILA 30CC 16FR,27200268,CDM,272,RC,27200268,HCPCS,,,facility,both,,,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER FOLEY SILA 30CC 18FR,27200269,CDM,272,RC,27200269,HCPCS,,,facility,both,,,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER FOLEY SILA 30CC 20FR,27200270,CDM,272,RC,27200270,HCPCS,,,facility,both,,,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Central
HC TUBE FEEDING DOBBHOFF,27200271,CDM,272,RC,27200271,HCPCS,,,facility,both,,,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER GUIDING PERIPHERAL,27200273,CDM,272,RC,27200273,HCPCS,,,facility,both,,,,488,341.6,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER INTRA-UTERINE PRESS,27200274,CDM,272,RC,27200274,HCPCS,,,facility,both,,,,149,104.3,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER INTRODUCER 1.9 FR NEONATAL,27200275,CDM,272,RC,27200275,HCPCS,,,facility,both,,,,204,142.8,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER IV,27200276,CDM,272,RC,27200276,HCPCS,,,facility,both,,,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER IV 14 INCH,27200277,CDM,272,RC,27200277,HCPCS,,,facility,both,,,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER IV 16 X 1 1/4,27200278,CDM,272,RC,27200278,HCPCS,,,facility,both,,,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER IV 16 X 1 1/4,27200279,CDM,272,RC,27200279,HCPCS,,,facility,both,,,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER IV 18 X 1 1/4 LATEX FREE,27200280,CDM,272,RC,27200280,HCPCS,,,facility,both,,,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER IV 18 X 1 1/4 LATEX FREE,27200281,CDM,272,RC,27200281,HCPCS,,,facility,both,,,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER IV 18 X 1 3/4 LATEX FREE,27200282,CDM,272,RC,27200282,HCPCS,,,facility,both,,,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER IV 18 X 1 3/4 LATEX FREE,27200283,CDM,272,RC,27200283,HCPCS,,,facility,both,,,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER IV 20 X 1 1/4 LATEX FREE,27200284,CDM,272,RC,27200284,HCPCS,,,facility,both,,,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER IV 20 X 1 1/4 LATEX FREE,27200285,CDM,272,RC,27200285,HCPCS,,,facility,both,,,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER IV 22 INCH,27200286,CDM,272,RC,27200286,HCPCS,,,facility,both,,,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER J-TUBE REPLACEMENT,27200287,CDM,272,RC,27200287,HCPCS,,,facility,both,,,,999,699.3,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER LATEX FREE 30CC 16FR,27200288,CDM,272,RC,27200288,HCPCS,,,facility,both,,,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER LEAD EXTRACTION LASER,27200289,CDM,272,RC,27200289,HCPCS,,,facility,both,,,,6092,4264.4,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER MULTI TRACK BRAUN,27200290,CDM,272,RC,27200290,HCPCS,,,facility,both,,,,1534,1073.8,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER OUTBACK RE ENTRY,27200291,CDM,272,RC,27200291,HCPCS,,,facility,both,,,,7188,5031.6,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER PICC 1.9 FR X 50 CM,27200292,CDM,272,RC,27200292,HCPCS,,,facility,both,,,,271,189.7,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER PICC ALL SIZES,27200293,CDM,272,RC,27200293,HCPCS,,,facility,both,,,,599,419.3,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER PIONEER PLUS,27200294,CDM,272,RC,27200294,HCPCS,,,facility,both,,,,10617,7431.9,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER POSSIS E-TRAIN 110,27200295,CDM,272,RC,27200295,HCPCS,,,facility,both,,,,2402,1681.4,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER PRO TRACK MICRO,27200296,CDM,272,RC,27200296,HCPCS,,,facility,both,,,,720,504,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER RE ENTRY CROSSBOSS,27200297,CDM,272,RC,27200297,HCPCS,,,facility,both,,,,2913,2039.1,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER RED ROBINSON 18FR,27200298,CDM,272,RC,27200298,HCPCS,,,facility,both,,,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER RE-ENTRY OUTBACK LTD,27200299,CDM,272,RC,27200299,HCPCS,,,facility,both,,,,6757,4729.9,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER ROB NEL 14 FR,27200300,CDM,272,RC,27200300,HCPCS,,,facility,both,,,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER SUCTION 10FR,27200301,CDM,272,RC,27200301,HCPCS,,,facility,both,,,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER SUCTION 14FR,27200302,CDM,272,RC,27200302,HCPCS,,,facility,both,,,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER SUCTION 5/6 FR,27200303,CDM,272,RC,27200303,HCPCS,,,facility,both,,,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER SUCTION 8FR,27200304,CDM,272,RC,27200304,HCPCS,,,facility,both,,,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER SUPPORT EV3,27200305,CDM,272,RC,27200305,HCPCS,,,facility,both,,,,700,490,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER SWAN GANZ CCO,27200306,CDM,272,RC,27200306,HCPCS,,,facility,both,,,,823,576.1,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER THORACIC,27200307,CDM,272,RC,27200307,HCPCS,,,facility,both,,,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER TROCAR,27200308,CDM,272,RC,27200308,HCPCS,,,facility,both,,,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER UMBILICAL ARTERY,27200309,CDM,272,RC,27200309,HCPCS,,,facility,both,,,,488,341.6,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER UMBILICAL VESSEL DUAL,27200310,CDM,272,RC,27200310,HCPCS,,,facility,both,,,,189,132.3,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETERIZATION INTERMITTENT,27200311,CDM,272,RC,27200311,HCPCS,,,facility,both,,,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Central
HC CAUTERY HI-TEMP FINE TIP ACCUTEMP,27200312,CDM,272,RC,27200312,HCPCS,,,facility,both,,,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Central
HC CIRCUIT BREATHING NEONATAL,27200313,CDM,272,RC,27200313,HCPCS,,,facility,both,,,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Central
HC CIRCUIT BREATHNG FLXB HT WR L51IN,27200314,CDM,272,RC,27200314,HCPCS,,,facility,both,,,,151,105.7,,,,,,,,,,,,,Gross Charge Type: Central
HC CIRCUMCISION SET DISPOSABLE,27200315,CDM,272,RC,27200315,HCPCS,,,facility,both,,,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Central
HC COAGULANT SRGICEL 1/2X2,27200316,CDM,272,RC,27200316,HCPCS,,,facility,both,,,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Central
HC COAGULANT SRGICEL 2X3,27200317,CDM,272,RC,27200317,HCPCS,,,facility,both,,,,172,120.4,,,,,,,,,,,,,Gross Charge Type: Central
HC COLLECTOR NEWBORN URIN STER,27200318,CDM,272,RC,27200318,HCPCS,,,facility,both,,,,10,7,,,,,,,,,,,,,Gross Charge Type: Central
HC COVER PROBE ULTRASOUND,27200319,CDM,272,RC,27200319,HCPCS,,,facility,both,,,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Central
HC CUP BREAST PROTECTIVE MEMBRANES,27200320,CDM,272,RC,27200320,HCPCS,,,facility,both,,,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Central
HC CUP VACUUM DISPOSAL STER,27200321,CDM,272,RC,27200321,HCPCS,,,facility,both,,,,143,100.1,,,,,,,,,,,,,Gross Charge Type: Central
HC DEVICE EZ-PAP,27200322,CDM,272,RC,27200322,HCPCS,,,facility,both,,,,302,211.4,,,,,,,,,,,,,Gross Charge Type: Central
HC DEVICE GUIDEWIRE TORQUE,27200323,CDM,272,RC,27200323,HCPCS,,,facility,both,,,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Central
HC DEVICE INFLATION GUARD DOG CO2,27200324,CDM,272,RC,27200324,HCPCS,,,facility,both,,,,1738,1216.6,,,,,,,,,,,,,Gross Charge Type: Central
HC DEVICE SAFEGUARD PRESSURE ASSISTED,27200325,CDM,272,RC,27200325,HCPCS,,,facility,both,,,,315,220.5,,,,,,,,,,,,,Gross Charge Type: Central
HC DEVICE SAFEGUARD PRESSURE ASSISTED,27200326,CDM,272,RC,27200326,HCPCS,,,facility,both,,,,315,220.5,,,,,,,,,,,,,Gross Charge Type: Central
HC DEVICE VERIFYING OPTIMESH,27200327,CDM,272,RC,27200327,HCPCS,,,facility,both,,,,999,699.3,,,,,,,,,,,,,Gross Charge Type: Central
HC DRAIN HEMOVAC 1/8,27200328,CDM,272,RC,27200328,HCPCS,,,facility,both,,,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Central
"HC DRESSING AQUACEL 3.5"" X 14""",27200329,CDM,272,RC,27200329,HCPCS,,,facility,both,,,,224,156.8,,,,,,,,,,,,,Gross Charge Type: Central
HC DRESSING AQUACEL ALGINATE ROPE 6 INCH,27200330,CDM,272,RC,A6199,HCPCS,,,facility,both,,,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Central
HC DRESSING EXUDRY SPEC ABSORP 4X6,27200332,CDM,272,RC,A6252,HCPCS,,,facility,both,,,,10,7,,,,,,,,,,,,,Gross Charge Type: Central
HC DRESSING EXUDRY SPEC ABSORP 6X9,27200333,CDM,272,RC,A6253,HCPCS,,,facility,both,,,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Central
HC DRESSING FOAM HYDRASORB 4X4,27200334,CDM,272,RC,A6209,HCPCS,,,facility,both,,,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Central
HC DRESSING FOAM HYDRASORB 4X8,27200335,CDM,272,RC,A6210,HCPCS,,,facility,both,,,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Central
HC DRESSING FOAM TIELLE 4X4,27200336,CDM,272,RC,A6212,HCPCS,,,facility,both,,,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Central
HC DRESSING FOAM TIELLE SACRAL 7X7,27200337,CDM,272,RC,A6213,HCPCS,,,facility,both,,,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Central
HC DRESSING GELFOAM,27200338,CDM,272,RC,27200338,HCPCS,,,facility,both,,,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Central
HC DRESSING HYDROCOLLOID  4X4 OR <CGF,27200339,CDM,272,RC,A6234,HCPCS,,,facility,both,,,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Central
HC DRESSING HYDROCOLLOID 4X4 OR <THIN,27200340,CDM,623,RC,A6234,HCPCS,,,facility,both,,,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Central
HC DRESSING HYDROGEL ELASTOGEL,27200341,CDM,272,RC,27200341,HCPCS,,,facility,both,,,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Central
HC DRESSING KALTOSTAT PAD,27200343,CDM,272,RC,A6196,HCPCS,,,facility,both,,,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Central
HC DRESSING POLYMEM SILVER,27200344,CDM,272,RC,A6210,HCPCS,,,facility,both,,,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Central
HC DRESSING POLYWIC PLAIN,27200345,CDM,272,RC,A6215,HCPCS,,,facility,both,,,,30,21,,,,,,,,,,,,,Gross Charge Type: Central
HC DRESSING POLYWIC SILVER,27200346,CDM,272,RC,A6215,HCPCS,,,facility,both,,,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Central
HC DRESSING RELEASE SPEC ABSORP,27200347,CDM,272,RC,27200347,HCPCS,,,facility,both,,,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Central
HC DRESSING SORBAVIEW STABILIZATION,27200348,CDM,272,RC,27200348,HCPCS,,,facility,both,,,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Central
HC DRESSING WOUND PRISMA,27200349,CDM,272,RC,A6021,HCPCS,,,facility,both,,,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Central
HC DRILL HAND 10G,27200350,CDM,272,RC,27200350,HCPCS,,,facility,both,,,,427,298.9,,,,,,,,,,,,,Gross Charge Type: Central
HC DRSG ADPTC TOUCH SILIC 3X2IN,27200351,CDM,623,RC,A6206,HCPCS,,,facility,both,,,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Central
HC DRSG ADPTC TOUCH SILIC 3X4.25IN,27200352,CDM,623,RC,A6206,HCPCS,,,facility,both,,,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Central
HC DRSG POLYMEM WOUND,27200353,CDM,272,RC,A6209,HCPCS,,,facility,both,,,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Central
HC DRSG TEGADERM SMALL (BIOCLUSIVE),27200354,CDM,272,RC,27200354,HCPCS,,,facility,both,,,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Central
HC DRSG VAC GRANUFOAM MEDIUM,27200355,CDM,272,RC,27200355,HCPCS,,,facility,both,,,,266,186.2,,,,,,,,,,,,,Gross Charge Type: Central
HC DRSG VAC GRANUFOAM SMALL,27200356,CDM,272,RC,27200356,HCPCS,,,facility,both,,,,212,148.4,,,,,,,,,,,,,Gross Charge Type: Central
HC DRSG VAC GRANUFOAM XLARGE,27200357,CDM,272,RC,27200357,HCPCS,,,facility,both,,,,442,309.4,,,,,,,,,,,,,Gross Charge Type: Central
HC DRSG WND 4.24SQIN HX SVRFBRCL ALGNT CLGN,27200358,CDM,272,RC,27200358,HCPCS,,,facility,both,,,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Central
HC DRSG WOUND MEPITEL MESH 3X4,27200359,CDM,272,RC,27200359,HCPCS,,,facility,both,,,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Central
HC DRSG WOUND MEPITEL MESH 4X8,27200360,CDM,272,RC,27200360,HCPCS,,,facility,both,,,,80,56,,,,,,,,,,,,,Gross Charge Type: Central
HC DUAL LUMEN PIG,27200361,CDM,272,RC,27200361,HCPCS,,,facility,both,,,,516,361.2,,,,,,,,,,,,,Gross Charge Type: Central
HC ELECTRODE SCALP LIFE TRAC,27200362,CDM,272,RC,27200362,HCPCS,,,facility,both,,,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Central
HC EXT IV WITH FILTER,27200363,CDM,272,RC,27200363,HCPCS,,,facility,both,,,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Central
HC EXTRACTOR KIWI OMNI CUP W/TRACTION,27200364,CDM,272,RC,27200364,HCPCS,,,facility,both,,,,547,382.9,,,,,,,,,,,,,Gross Charge Type: Central
HC FILM TRANSPARENT 2.5X3 IN,27200365,CDM,272,RC,A6257,HCPCS,,,facility,both,,,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Central
HC FILM TRANSPARENT 4X5 IN,27200366,CDM,272,RC,A6258,HCPCS,,,facility,both,,,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Central
HC FILM TRANSPARENT 6X8 IN,27200367,CDM,272,RC,A6258,HCPCS,,,facility,both,,,,10,7,,,,,,,,,,,,,Gross Charge Type: Central
HC FILTER IV,27200368,CDM,272,RC,27200368,HCPCS,,,facility,both,,,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Central
HC FOLEY BAG PRECON,27200369,CDM,272,RC,27200369,HCPCS,,,facility,both,,,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Central
HC FOLEY METER PRECON,27200370,CDM,272,RC,27200370,HCPCS,,,facility,both,,,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Central
HC FUHRMAN PLEURAL&PNEUM ALL SIZES,27200371,CDM,272,RC,27200371,HCPCS,,,facility,both,,,,509,356.3,,,,,,,,,,,,,Gross Charge Type: Central
HC GASTROSTOMY TUBE SET,27200372,CDM,272,RC,27200372,HCPCS,,,facility,both,,,,212,148.4,,,,,,,,,,,,,Gross Charge Type: Central
HC GAUZE HYROGEL,27200373,CDM,272,RC,27200373,HCPCS,,,facility,both,,,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Central
HC GAUZE NON-ELASTIC STERILE YD,27200374,CDM,272,RC,27200374,HCPCS,,,facility,both,,,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Central
HC GAUZE NON-STERILE SURGINET,27200375,CDM,272,RC,27200375,HCPCS,,,facility,both,,,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Central
HC GAUZE SALINE/HYDR ADAPTIC 3X16,27200376,CDM,272,RC,27200376,HCPCS,,,facility,both,,,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Central
HC GAUZE SALINE/HYDR ADAPTIC 3X3,27200377,CDM,272,RC,27200377,HCPCS,,,facility,both,,,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Central
HC GAUZE SALINE/HYDR ADAPTIC 3X8,27200378,CDM,272,RC,27200378,HCPCS,,,facility,both,,,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Central
HC GAUZE VASELINE/XEROFORM,27200379,CDM,272,RC,A6233,HCPCS,,,facility,both,,,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Central
HC GENERAL/SPINAL/EPIDURAL SUPPLY,27200380,CDM,272,RC,27200380,HCPCS,,,facility,both,,,,150,105,,,,,,,,,,,,,Gross Charge Type: Central
HC GLIDESCOPE RANGER 3 AND 4 DISPOSABLE,27200381,CDM,272,RC,27200381,HCPCS,,,facility,both,,,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Central
HC GLIDEWIRE EXCHANGE,27200382,CDM,272,RC,27200382,HCPCS,,,facility,both,,,,269,188.3,,,,,,,,,,,,,Gross Charge Type: Central
HC GUIDE NEEDLE RADIO-FREQUENCY,27200383,CDM,272,RC,27200383,HCPCS,,,facility,both,,,,1061,742.7,,,,,,,,,,,,,Gross Charge Type: Central
HC GUIDE WIRE STINGRAY,27200384,CDM,272,RC,27200384,HCPCS,,,facility,both,,,,999,699.3,,,,,,,,,,,,,Gross Charge Type: Central
HC GUIDEWIRE NITREX,27200385,CDM,272,RC,27200385,HCPCS,,,facility,both,,,,383,268.1,,,,,,,,,,,,,Gross Charge Type: Central
HC HYDROCOIL EMBOLIZATION,27200386,CDM,272,RC,27200386,HCPCS,,,facility,both,,,,900,630,,,,,,,,,,,,,Gross Charge Type: Central
HC INTRODUCER RADIAL 6FR,27200387,CDM,272,RC,27200387,HCPCS,,,facility,both,,,,275,192.5,,,,,,,,,,,,,Gross Charge Type: Central
HC IV PRIMARY INTERLINK AB,27200389,CDM,272,RC,27200389,HCPCS,,,facility,both,,,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Central
HC IV SECONDARY INTERLINK,27200390,CDM,272,RC,27200390,HCPCS,,,facility,both,,,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Central
HC IV SET NITRO W/LL,27200391,CDM,272,RC,27200391,HCPCS,,,facility,both,,,,40,28,,,,,,,,,,,,,Gross Charge Type: Central
HC IVAS 10G 15MM (2/15),27200392,CDM,272,RC,27200392,HCPCS,,,facility,both,,,,4327,3028.9,,,,,,,,,,,,,Gross Charge Type: Central
HC IVUS SLED,27200393,CDM,272,RC,27200393,HCPCS,,,facility,both,,,,216,151.2,,,,,,,,,,,,,Gross Charge Type: Central
HC CUP EXTRACT W/ TRACTION KIWI OMNI,27200394,CDM,272,RC,27200394,HCPCS,,,facility,both,,,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Central
HC JACKSON PRATT RESERVOIR,27200395,CDM,272,RC,27200395,HCPCS,,,facility,both,,,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER INTRAUTERINE PRESSURE ACCUTRACE,27200396,CDM,272,RC,27200396,HCPCS,,,facility,both,,,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Central
HC JACKSON PRATT ROUND/FLAT,27200397,CDM,272,RC,27200397,HCPCS,,,facility,both,,,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Central
HC KIT BREAST PUMP MEDELA,27200398,CDM,272,RC,27200398,HCPCS,,,facility,both,,,,157,109.9,,,,,,,,,,,,,Gross Charge Type: Central
HC KIT CANNISTER VACUUM W/GEL,27200399,CDM,272,RC,27200399,HCPCS,,,facility,both,,,,225,157.5,,,,,,,,,,,,,Gross Charge Type: Central
HC KIT CATH DRESSING,27200400,CDM,272,RC,27200400,HCPCS,,,facility,both,,,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Central
HC KIT CATHETER FOLEY W/BAG 16/18FR,27200402,CDM,272,RC,27200402,HCPCS,,,facility,both,,,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Central
HC KIT CENTRAL LINE FLUSH,27200403,CDM,272,RC,27200403,HCPCS,,,facility,both,,,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Central
HC KIT DRAINAGE BECKER EXTERNAL SYS,27200404,CDM,272,RC,27200404,HCPCS,,,facility,both,,,,630,441,,,,,,,,,,,,,Gross Charge Type: Central
HC KIT DRESSING WOUND TRAC GRANUFOAM LG,27200405,CDM,272,RC,27200405,HCPCS,,,facility,both,,,,285,199.5,,,,,,,,,,,,,Gross Charge Type: Central
HC KIT FEEDING ALL SIZES BUTTON RPLCT GAS,27200406,CDM,272,RC,27200406,HCPCS,,,facility,both,,,,480,336,,,,,,,,,,,,,Gross Charge Type: Central
HC KIT INDEFLATOR,27200408,CDM,272,RC,27200408,HCPCS,,,facility,both,,,,224,156.8,,,,,,,,,,,,,Gross Charge Type: Central
HC KIT MICRO PUNCTURE 3-5FR 21G,27200409,CDM,272,RC,27200409,HCPCS,,,facility,both,,,,174,121.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PHERESIS KIT NON-PHOTO,27200410,CDM,272,RC,27200410,HCPCS,,,facility,both,,,,1291,903.7,,,,,,,,,,,,,Gross Charge Type: Central
HC KIT QCARE ORAL ANTISEPTIC W/SC,27200411,CDM,272,RC,27200411,HCPCS,,,facility,both,,,,128,89.6,,,,,,,,,,,,,Gross Charge Type: Central
HC KIT RADIAL ACCESS,27200412,CDM,272,RC,27200412,HCPCS,,,facility,both,,,,360,252,,,,,,,,,,,,,Gross Charge Type: Central
HC KIT TIPS ACCESS,27200413,CDM,272,RC,27200413,HCPCS,,,facility,both,,,,1916,1341.2,,,,,,,,,,,,,Gross Charge Type: Central
HC KIT TRANSDUCER MONITORING SING LINE 84IN,27200414,CDM,272,RC,27200414,HCPCS,,,facility,both,,,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Central
HC KIT UMBILICAL DRAW,27200415,CDM,272,RC,27200415,HCPCS,,,facility,both,,,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Central
HC KIT VAS CATH/TESIO DRESSING,27200416,CDM,272,RC,27200416,HCPCS,,,facility,both,,,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Central
HC KPHYX ONE-STEP OSTEO INTRO SYSTEM SIZE 3,27200417,CDM,272,RC,27200417,HCPCS,,,facility,both,,,,3212,2248.4,,,,,,,,,,,,,Gross Charge Type: Central
HC KYPHON INFLATION SYRINGE,27200418,CDM,272,RC,27200418,HCPCS,,,facility,both,,,,720,504,,,,,,,,,,,,,Gross Charge Type: Central
HC KYPHOPAK EXPR TRAY 15/2 ADDT'L FX,27200419,CDM,272,RC,27200419,HCPCS,,,facility,both,,,,7971,5579.7,,,,,,,,,,,,,Gross Charge Type: Central
HC KYPHOPAK EXPR TRAY 15/2 FIRST FRACTURE,27200420,CDM,272,RC,27200420,HCPCS,,,facility,both,,,,11964,8374.8,,,,,,,,,,,,,Gross Charge Type: Central
HC KYPHX EXPR OSTEO INTRO DEV BEVEL/DIAMOND,27200421,CDM,272,RC,27200421,HCPCS,,,facility,both,,,,3113,2179.1,,,,,,,,,,,,,Gross Charge Type: Central
HC KYPHX EXPRESS BONE BIOPSY DEVICE SIZE 2,27200422,CDM,272,RC,27200422,HCPCS,,,facility,both,,,,520,364,,,,,,,,,,,,,Gross Charge Type: Central
HC KYPHX EXPRESS BONE BIOPSY DEVICE SIZE 3,27200423,CDM,272,RC,27200423,HCPCS,,,facility,both,,,,520,364,,,,,,,,,,,,,Gross Charge Type: Central
HC KYPHX EXPRESS BONE FILLER DEVICE SIZE 2,27200424,CDM,272,RC,27200424,HCPCS,,,facility,both,,,,460,322,,,,,,,,,,,,,Gross Charge Type: Central
HC KYPHX EXPRESS BONE FILLER DEVICE SIZE 3,27200425,CDM,272,RC,27200425,HCPCS,,,facility,both,,,,495,346.5,,,,,,,,,,,,,Gross Charge Type: Central
HC KYPHX EXPRESS INFLATABLE BONE TAMP 15/2,27200426,CDM,272,RC,27200426,HCPCS,,,facility,both,,,,3479,2435.3,,,,,,,,,,,,,Gross Charge Type: Central
HC KYPHX EXPRESS OSTEO INTRO DEVICE TROCAR,27200427,CDM,272,RC,27200427,HCPCS,,,facility,both,,,,1598,1118.6,,,,,,,,,,,,,Gross Charge Type: Central
HC KYPHX HV-R BONE CEMENT/MIXER PACK,27200428,CDM,272,RC,27200428,HCPCS,,,facility,both,,,,759,531.3,,,,,,,,,,,,,Gross Charge Type: Central
HC KYPHX ONE-STEP BEVEL DEVICE SIZE 3,27200429,CDM,272,RC,27200429,HCPCS,,,facility,both,,,,600,420,,,,,,,,,,,,,Gross Charge Type: Central
HC LOCAL/MAC/BLOCK SUPPLY,27200430,CDM,272,RC,27200430,HCPCS,,,facility,both,,,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Central
HC LOCK LEVER INTERLINK,27200431,CDM,272,RC,27200431,HCPCS,,,facility,both,,,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Central
HC MANIFOLD 3-VALVE,27200432,CDM,272,RC,27200432,HCPCS,,,facility,both,,,,132,92.4,,,,,,,,,,,,,Gross Charge Type: Central
HC MASK BI-PAP SM/MD/LG,27200433,CDM,272,RC,27200433,HCPCS,,,facility,both,,,,139,97.3,,,,,,,,,,,,,Gross Charge Type: Central
HC MECONIUM SUCTION DEVICE,27200434,CDM,272,RC,27200434,HCPCS,,,facility,both,,,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Central
HC MEDITECH INTRO SHEATH NONLASER,27200435,CDM,272,RC,27200435,HCPCS,,,facility,both,,,,291,203.7,,,,,,,,,,,,,Gross Charge Type: Central
HC MEDRAD SYRINGE,27200436,CDM,272,RC,27200436,HCPCS,,,facility,both,,,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Central
HC MEPILEX BORDER 4X4IN,27200438,CDM,623,RC,A6212,HCPCS,,,facility,both,,,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Central
HC MEPILEX BORDER 4X8IN,27200439,CDM,272,RC,A6213,HCPCS,,,facility,both,,,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Central
HC MICROPUNCTURE A,27200440,CDM,272,RC,27200440,HCPCS,,,facility,both,,,,255,178.5,,,,,,,,,,,,,Gross Charge Type: Central
HC MICROWAVE ABLATION PROBE,27200441,CDM,272,RC,27200441,HCPCS,,,facility,both,,,,5511,3857.7,,,,,,,,,,,,,Gross Charge Type: Central
HC MINI-CATH,27200443,CDM,272,RC,27200443,HCPCS,,,facility,both,,,,284,198.8,,,,,,,,,,,,,Gross Charge Type: Central
HC MONITOR CATH FOLEY SIL 10FR TMP,27200444,CDM,272,RC,27200444,HCPCS,,,facility,both,,,,130,91,,,,,,,,,,,,,Gross Charge Type: Central
HC MONITOR CATH FOLEY SIL 12FR TMP,27200445,CDM,272,RC,27200445,HCPCS,,,facility,both,,,,132,92.4,,,,,,,,,,,,,Gross Charge Type: Central
HC MONITOR CATH FOLEY SIL 14FR TMP,27200446,CDM,272,RC,27200446,HCPCS,,,facility,both,,,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Central
HC MONITOR CATH FOLEY SIL 16FR TMP,27200447,CDM,272,RC,27200447,HCPCS,,,facility,both,,,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Central
HC MONITOR CATH FOLEY SIL 18FR TMP,27200448,CDM,272,RC,27200448,HCPCS,,,facility,both,,,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Central
HC MONITOR CATH FOLEY SIL 8FR TMP,27200449,CDM,272,RC,27200449,HCPCS,,,facility,both,,,,132,92.4,,,,,,,,,,,,,Gross Charge Type: Central
HC MULLINS SHEATH,27200450,CDM,272,RC,27200450,HCPCS,,,facility,both,,,,435,304.5,,,,,,,,,,,,,Gross Charge Type: Central
HC NEEDLE BX TRANSBRONCHIAL,27200451,CDM,272,RC,27200451,HCPCS,,,facility,both,,,,294,205.8,,,,,,,,,,,,,Gross Charge Type: Central
HC NEEDLE CHIBA,27200452,CDM,272,RC,27200452,HCPCS,,,facility,both,,,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Central
HC NEEDLE HUBER,27200453,CDM,272,RC,27200453,HCPCS,,,facility,both,,,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Central
HC NEEDLE HUBER NON-CORING,27200454,CDM,272,RC,27200454,HCPCS,,,facility,both,,,,128,89.6,,,,,,,,,,,,,Gross Charge Type: Central
HC NEEDLE HUBER NON-CORING,27200455,CDM,272,RC,27200455,HCPCS,,,facility,both,,,,113,79.1,,,,,,,,,,,,,Gross Charge Type: Central
HC NEEDLE INTRODUCER OPTIMESH,27200456,CDM,272,RC,27200456,HCPCS,,,facility,both,,,,427,298.9,,,,,,,,,,,,,Gross Charge Type: Central
HC NEEDLE LUMBAR CURVED 18 GAUGE 100MM,27200457,CDM,272,RC,27200457,HCPCS,,,facility,both,,,,142,99.4,,,,,,,,,,,,,Gross Charge Type: Central
HC NEEDLE LUMBAR CURVED 20 GAUGE 100MM,27200458,CDM,272,RC,27200458,HCPCS,,,facility,both,,,,142,99.4,,,,,,,,,,,,,Gross Charge Type: Central
HC NEEDLE SPINAL 22 X 3 1/2 WH,27200459,CDM,272,RC,27200459,HCPCS,,,facility,both,,,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Central
HC DERMABOND .5CC,27200460,CDM,272,RC,27200460,HCPCS,,,facility,both,,,,40,28,,,,,,,,,,,,,Gross Charge Type: Central
HC NEEDLE SPINAL TUOHY 18 GAUGE X 5.0,27200461,CDM,272,RC,27200461,HCPCS,,,facility,both,,,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Central
HC NEEDLE SPINAL TUOHY 20 GAUGE X 3.5,27200462,CDM,272,RC,27200462,HCPCS,,,facility,both,,,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Central
HC NEEDLE SPINAL TUOHY 20 GUAGE X 6.0,27200463,CDM,272,RC,27200463,HCPCS,,,facility,both,,,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Central
HC NEEDLE TOUHY 18 GAUGE X 3 1/2 IN,27200464,CDM,272,RC,27200464,HCPCS,,,facility,both,,,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Central
HC NEPTUNE HEMOSTASIS PAD,27200465,CDM,272,RC,27200465,HCPCS,,,facility,both,,,,148,103.6,,,,,,,,,,,,,Gross Charge Type: Central
HC NIPPLE BTL W DBL CLFT PAL,27200466,CDM,272,RC,27200466,HCPCS,,,facility,both,,,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Central
HC NIPPLE BTL XCUT LF INF PGN,27200467,CDM,272,RC,27200467,HCPCS,,,facility,both,,,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Central
HC NO PORT TUBING,27200468,CDM,272,RC,27200468,HCPCS,,,facility,both,,,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Central
HC OXISENSOR TRANSDUCER,27200469,CDM,272,RC,27200469,HCPCS,,,facility,both,,,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PACK BASIC PROCEDURE,27200470,CDM,272,RC,27200470,HCPCS,,,facility,both,,,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PACK PROCEDURE DISPOSABLE,27200471,CDM,272,RC,27200471,HCPCS,,,facility,both,,,,238,166.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PACKAGE INJECTOR,27200472,CDM,272,RC,27200472,HCPCS,,,facility,both,,,,178,124.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PACKING VAGINAL,27200473,CDM,272,RC,27200473,HCPCS,,,facility,both,,,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PAD AQUACEL,27200474,CDM,272,RC,A6196,HCPCS,,,facility,both,,,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PAD CHITO-SEAL TOPICAL HEMOSTASIS 4X4C,27200475,CDM,272,RC,27200475,HCPCS,,,facility,both,,,,236,165.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PAD HEMOSTASIS CLCM ALGNT 2X2,27200476,CDM,272,RC,27200476,HCPCS,,,facility,both,,,,148,103.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PATCH EXTERNAL REFERENCE,27200477,CDM,272,RC,27200477,HCPCS,,,facility,both,,,,1997,1397.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PATCH EXTERNAL REFERENCE CARTO 3D,27200478,CDM,272,RC,27200478,HCPCS,,,facility,both,,,,1543,1080.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PATCH REFERENCE ENSITE X,27200479,CDM,272,RC,27200479,HCPCS,,,facility,both,,,,2996,2097.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PBC PRECISION SYS VERTAPLEX HV CEMENT,27200480,CDM,272,RC,27200480,HCPCS,,,facility,both,,,,1798,1258.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PENCIL CAUTERY DISP,27200481,CDM,272,RC,27200481,HCPCS,,,facility,both,,,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PERCU-STAY,27200482,CDM,272,RC,27200482,HCPCS,,,facility,both,,,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PLUG VASCULAR AMPLATZER,27200483,CDM,272,RC,27200483,HCPCS,,,facility,both,,,,2913,2039.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PORTAL OPTIMESH,27200484,CDM,272,RC,27200484,HCPCS,,,facility,both,,,,427,298.9,,,,,,,,,,,,,Gross Charge Type: Central
HC POUCH DRAINABLE/UROSTOMY,27200485,CDM,272,RC,A4432,HCPCS,,,facility,both,,,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Central
HC POUCH OSTOMY DRAINABLE EXTENDED,27200486,CDM,272,RC,27200486,HCPCS,,,facility,both,,,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Central
HC POUCH OSTOMY DRAINABLE STANDARD,27200487,CDM,272,RC,27200487,HCPCS,,,facility,both,,,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Central
HC POUCH OSTOMY URINARY,27200488,CDM,272,RC,27200488,HCPCS,,,facility,both,,,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Central
HC POUCH OSTOMY URINARY EXT WEAR,27200489,CDM,272,RC,27200489,HCPCS,,,facility,both,,,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PROBE INJECTION 7/10 FR,27200490,CDM,272,RC,27200490,HCPCS,,,facility,both,,,,990,693,,,,,,,,,,,,,Gross Charge Type: Central
HC PROBE RF ABLATION,27200491,CDM,272,RC,27200491,HCPCS,,,facility,both,,,,4077,2853.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PROTECTOR SKIN LOLLIPOP,27200492,CDM,272,RC,A6250,HCPCS,,,facility,both,,,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PTI W/TRACH TUBE,27200493,CDM,272,RC,27200493,HCPCS,,,facility,both,,,,1399,979.3,,,,,,,,,,,,,Gross Charge Type: Central
HC RED ROBIN INSERTION,27200494,CDM,272,RC,27200494,HCPCS,,,facility,both,,,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Central
HC RESPIRATORY CARE SYSTEM INFANT,27200495,CDM,272,RC,27200495,HCPCS,,,facility,both,,,,226,158.2,,,,,,,,,,,,,Gross Charge Type: Central
HC RETRACTOR ALEXIS-O DISPOSABLE,27200496,CDM,272,RC,27200496,HCPCS,,,facility,both,,,,360,252,,,,,,,,,,,,,Gross Charge Type: Central
HC RING OSTOMY ADAPT,27200497,CDM,272,RC,A4385,HCPCS,,,facility,both,,,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Central
HC SENSOR BIS QUATRO,27200498,CDM,272,RC,27200498,HCPCS,,,facility,both,,,,240,168,,,,,,,,,,,,,Gross Charge Type: Central
HC SENSOR OXYGEN FOREHEAD ADULT,27200499,CDM,272,RC,27200499,HCPCS,,,facility,both,,,,145,101.5,,,,,,,,,,,,,Gross Charge Type: Central
HC SENSOR OXYGEN INFANT SAT PROBE,27200500,CDM,272,RC,27200500,HCPCS,,,facility,both,,,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Central
HC SENSOR OXYPEDS DISP,27200501,CDM,272,RC,27200501,HCPCS,,,facility,both,,,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Central
HC SET BLOOD 3M,27200502,CDM,272,RC,27200502,HCPCS,,,facility,both,,,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Central
HC SET CATH FEM ARTERY 3 FR 8 C SNGL LUM,27200503,CDM,272,RC,27200503,HCPCS,,,facility,both,,,,263,184.1,,,,,,,,,,,,,Gross Charge Type: Central
HC SET CATH RADIAL ARTERY 2.5FR 5C SGL LUM,27200504,CDM,272,RC,27200504,HCPCS,,,facility,both,,,,179,125.3,,,,,,,,,,,,,Gross Charge Type: Central
HC SET EXTENSION,27200505,CDM,272,RC,27200505,HCPCS,,,facility,both,,,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Central
HC SET INFUSION BLD COMPONENT FIL 13 IN LON,27200506,CDM,272,RC,27200506,HCPCS,,,facility,both,,,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Central
HC SET IV EXTENSION INTERLINK Y TYPE 5IN,27200507,CDM,272,RC,27200507,HCPCS,,,facility,both,,,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Central
HC SET IV TUBING BLOOD INTERLINK Y-TYPE,27200508,CDM,272,RC,27200508,HCPCS,,,facility,both,,,,40,28,,,,,,,,,,,,,Gross Charge Type: Central
HC SET TRANSJUGULAR LIVER BIOPSY,27200509,CDM,272,RC,27200509,HCPCS,,,facility,both,,,,1773,1241.1,,,,,,,,,,,,,Gross Charge Type: Central
HC SET TUBING PUMP COOLFLOW,27200510,CDM,272,RC,27200510,HCPCS,,,facility,both,,,,321,224.7,,,,,,,,,,,,,Gross Charge Type: Central
HC SHIELD BREAST,27200511,CDM,272,RC,27200511,HCPCS,,,facility,both,,,,30,21,,,,,,,,,,,,,Gross Charge Type: Central
HC SHIELD BREAST ALL SIZES,27200512,CDM,272,RC,27200512,HCPCS,,,facility,both,,,,30,21,,,,,,,,,,,,,Gross Charge Type: Central
HC SHIELD BREAST PERSONAL FIT 24,27200513,CDM,272,RC,27200513,HCPCS,,,facility,both,,,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Central
HC SHOE POST-OP,27200514,CDM,272,RC,27200514,HCPCS,,,facility,both,,,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Central
HC SHUNT TRACKER COOK,27200515,CDM,272,RC,27200515,HCPCS,,,facility,both,,,,165,115.5,,,,,,,,,,,,,Gross Charge Type: Central
HC SLEEVE CMPR KNEE SCD EXP LRG,27200516,CDM,272,RC,27200516,HCPCS,,,facility,both,,,,209,146.3,,,,,,,,,,,,,Gross Charge Type: Central
HC SLEEVE CMPR KNEE SCD EXP MED,27200517,CDM,272,RC,27200517,HCPCS,,,facility,both,,,,130,91,,,,,,,,,,,,,Gross Charge Type: Central
HC SLEEVE CMPR KNEE SCD EXP XLG,27200518,CDM,272,RC,27200518,HCPCS,,,facility,both,,,,318,222.6,,,,,,,,,,,,,Gross Charge Type: Central
HC SLING ARM,27200519,CDM,272,RC,27200519,HCPCS,,,facility,both,,,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Central
HC SOLN IV 0.9% NACL 1L VFLX LF,27200520,CDM,272,RC,27200520,HCPCS,,,facility,both,,,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Central
HC SPECULUM DISPOSABLE,27200521,CDM,272,RC,27200521,HCPCS,,,facility,both,,,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Central
HC STAPLER PREMIUM POLLY,27200522,CDM,272,RC,27200522,HCPCS,,,facility,both,,,,1906,1334.2,,,,,,,,,,,,,Gross Charge Type: Central
HC STAPLER SKIN 35W,27200523,CDM,272,RC,27200523,HCPCS,,,facility,both,,,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Central
HC STOPCOCK 3 WAY,27200524,CDM,272,RC,27200524,HCPCS,,,facility,both,,,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Central
HC SUCT SYST ETT PED 10FR Y ADAPTER,27200525,CDM,272,RC,27200525,HCPCS,,,facility,both,,,,108,75.6,,,,,,,,,,,,,Gross Charge Type: Central
HC SURGIFOAM ABSORBABLE GELATIN SPONGE SIZE 12-7 2CM X 6CM X 0.7CM,27200526,CDM,272,RC,27200526,HCPCS,,,facility,both,,,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Central
HC SURGIPAD ABD,27200527,CDM,272,RC,A6253,HCPCS,,,facility,both,,,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Central
HC SUTURE CATAGORY 7,27200528,CDM,272,RC,27200528,HCPCS,,,facility,both,,,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Central
HC SUTURE CATEGORY 8,27200529,CDM,272,RC,27200529,HCPCS,,,facility,both,,,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Central
HC SUTURE CATEGORY 8,27200530,CDM,272,RC,27200530,HCPCS,,,facility,both,,,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Central
HC SUTURE SKIN STAPLES TW-35,27200531,CDM,272,RC,27200531,HCPCS,,,facility,both,,,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Central
HC SYRINGE INFLATION,27200532,CDM,272,RC,27200532,HCPCS,,,facility,both,,,,240,168,,,,,,,,,,,,,Gross Charge Type: Central
HC SYST FECAL FLEXI-SEAL FS,27200533,CDM,272,RC,27200533,HCPCS,,,facility,both,,,,900,630,,,,,,,,,,,,,Gross Charge Type: Central
HC SYST FEM ARCH FEMOSTOP,27200534,CDM,272,RC,27200534,HCPCS,,,facility,both,,,,512,358.4,,,,,,,,,,,,,Gross Charge Type: Central
HC SYSTEM AUTOPLEX W/VERTAPLEX HV CEMENT,27200535,CDM,272,RC,27200535,HCPCS,,,facility,both,,,,2662,1863.4,,,,,,,,,,,,,Gross Charge Type: Central
HC SYSTEM SHEATH AMPLATZER,27200536,CDM,272,RC,27200536,HCPCS,,,facility,both,,,,935,654.5,,,,,,,,,,,,,Gross Charge Type: Central
HC TAPE DRESSING 2IN X 10YD PER 18SQ INCHES,27200537,CDM,272,RC,A4452,HCPCS,,,facility,both,,,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Central
HC TAPER DILATOR COONS COOK,27200538,CDM,272,RC,27200538,HCPCS,,,facility,both,,,,132,92.4,,,,,,,,,,,,,Gross Charge Type: Central
HC TIP BOVIE TEFLON,27200539,CDM,272,RC,27200539,HCPCS,,,facility,both,,,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Central
HC TIPSUCTION YANKUER CLEAR,27200540,CDM,272,RC,27200540,HCPCS,,,facility,both,,,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Central
HC TR BAND HEMOSTASIS COMPRESSION DEVICE,27200541,CDM,272,RC,27200541,HCPCS,,,facility,both,,,,196,137.2,,,,,,,,,,,,,Gross Charge Type: Central
HC TRANSCATH DELIVERY SYSTEM ENSEMBLE,27200542,CDM,272,RC,27200542,HCPCS,,,facility,both,,,,17303,12112.1,,,,,,,,,,,,,Gross Charge Type: Central
HC KT TRUWAVE TRANSDUCER,27200543,CDM,272,RC,27200543,HCPCS,,,facility,both,,,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Central
HC TRANSDUCER NEONATAL/PEDIACTRIC DISP,27200544,CDM,272,RC,27200544,HCPCS,,,facility,both,,,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Central
HC TRANSDUCER TRIPLE CUSTOM,27200545,CDM,272,RC,27200545,HCPCS,,,facility,both,,,,228,159.6,,,,,,,,,,,,,Gross Charge Type: Central
HC TRAY AMNIOCENTESIS 20G X 3,27200546,CDM,272,RC,27200546,HCPCS,,,facility,both,,,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Central
HC TRAY BIOPSY BONE PROCEDURE 10G,27200547,CDM,272,RC,27200547,HCPCS,,,facility,both,,,,373,261.1,,,,,,,,,,,,,Gross Charge Type: Central
HC TRAY CATHETER FOLEY,27200548,CDM,272,RC,27200548,HCPCS,,,facility,both,,,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Central
HC TRAY EPIDURAL,27200549,CDM,272,RC,27200549,HCPCS,,,facility,both,,,,172,120.4,,,,,,,,,,,,,Gross Charge Type: Central
HC TRAY EPIDURAL 18 GAUGE,27200550,CDM,272,RC,27200550,HCPCS,,,facility,both,,,,149,104.3,,,,,,,,,,,,,Gross Charge Type: Central
HC TRAY EPIDURAL CUSTOM,27200551,CDM,272,RC,27200551,HCPCS,,,facility,both,,,,184,128.8,,,,,,,,,,,,,Gross Charge Type: Central
HC TRAY EXCHANGE TRANSFUSION,27200552,CDM,272,RC,27200552,HCPCS,,,facility,both,,,,466,326.2,,,,,,,,,,,,,Gross Charge Type: Central
HC TRAY IRRIGATION,27200554,CDM,272,RC,27200554,HCPCS,,,facility,both,,,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Central
HC TRAY LUMBAR CATH L30CM OD1.9FR 2,27200555,CDM,272,RC,27200555,HCPCS,,,facility,both,,,,528,369.6,,,,,,,,,,,,,Gross Charge Type: Central
HC TRAY LUMBAR PUNCTURE ADULT DIS,27200556,CDM,272,RC,27200556,HCPCS,,,facility,both,,,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Central
HC TRAY LUMBAR PUNCTURE PEDS DIS,27200557,CDM,272,RC,27200557,HCPCS,,,facility,both,,,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Central
HC TRAY PERICARDIALCENTESIS,27200558,CDM,272,RC,27200558,HCPCS,,,facility,both,,,,520,364,,,,,,,,,,,,,Gross Charge Type: Central
HC TRAY PICC CATH DRESSING,27200559,CDM,272,RC,27200559,HCPCS,,,facility,both,,,,101,70.7,,,,,,,,,,,,,Gross Charge Type: Central
HC TRAY PORT ACCESS LONG TERM,27200560,CDM,272,RC,27200560,HCPCS,,,facility,both,,,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Central
HC TRAY PROCEDURE NEO/PED,27200561,CDM,272,RC,27200561,HCPCS,,,facility,both,,,,215,150.5,,,,,,,,,,,,,Gross Charge Type: Central
HC TRAY PUNDENDAL,27200562,CDM,272,RC,27200562,HCPCS,,,facility,both,,,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Central
HC TRAY SPINAL W/O LIDOCAINE,27200563,CDM,272,RC,27200563,HCPCS,,,facility,both,,,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Central
HC TRAY THORACENTESIS DISP,27200564,CDM,272,RC,27200564,HCPCS,,,facility,both,,,,181,126.7,,,,,,,,,,,,,Gross Charge Type: Central
HC TRAY TRACH CARE DISPOSABLE,27200565,CDM,272,RC,27200565,HCPCS,,,facility,both,,,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Central
HC TRAY URETHRAL PRECONNEC 1,27200566,CDM,272,RC,27200566,HCPCS,,,facility,both,,,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Central
HC TRUEPATH CTO DEVICE,27200567,CDM,272,RC,27200567,HCPCS,,,facility,both,,,,6389,4472.3,,,,,,,,,,,,,Gross Charge Type: Central
HC TUBE CHEST DRAINAGE SGL COLL DRY SUCTION,27200568,CDM,272,RC,27200568,HCPCS,,,facility,both,,,,197,137.9,,,,,,,,,,,,,Gross Charge Type: Central
HC TUBE CHEST THAL QUICK ALL SIZES,27200569,CDM,272,RC,27200569,HCPCS,,,facility,both,,,,468,327.6,,,,,,,,,,,,,Gross Charge Type: Central
HC TUBE ENDO TRACH,27200570,CDM,272,RC,27200570,HCPCS,,,facility,both,,,,10,7,,,,,,,,,,,,,Gross Charge Type: Central
HC TUBE FEEDING KEOFEED,27200571,CDM,272,RC,27200571,HCPCS,,,facility,both,,,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Central
HC TUBE HYDROGEL,27200572,CDM,272,RC,27200572,HCPCS,,,facility,both,,,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Central
HC TUBE NASAL GASTRIC,27200573,CDM,272,RC,27200573,HCPCS,,,facility,both,,,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Central
HC TUBE TRACH ADULT,27200574,CDM,272,RC,27200574,HCPCS,,,facility,both,,,,226,158.2,,,,,,,,,,,,,Gross Charge Type: Central
HC TUBE TRACH ADULT HYPERFLEX,27200575,CDM,272,RC,27200575,HCPCS,,,facility,both,,,,424,296.8,,,,,,,,,,,,,Gross Charge Type: Central
HC TUBE TRACH COMPLEX,27200576,CDM,272,RC,27200576,HCPCS,,,facility,both,,,,850,595,,,,,,,,,,,,,Gross Charge Type: Central
HC TUBE TRACH EXT CUFFED,27200577,CDM,272,RC,27200577,HCPCS,,,facility,both,,,,348,243.6,,,,,,,,,,,,,Gross Charge Type: Central
HC TUBE TRACH HYPERFLEX ANY SIZE,27200578,CDM,272,RC,27200578,HCPCS,,,facility,both,,,,737,515.9,,,,,,,,,,,,,Gross Charge Type: Central
HC TUBE TRACH INTERMEDIATE,27200579,CDM,272,RC,27200579,HCPCS,,,facility,both,,,,341,238.7,,,,,,,,,,,,,Gross Charge Type: Central
HC TUBE TRACH NONFENESTRATED UNCUFFED,27200580,CDM,272,RC,27200580,HCPCS,,,facility,both,,,,214,149.8,,,,,,,,,,,,,Gross Charge Type: Central
HC TUBE TRACH PEDS,27200581,CDM,272,RC,27200581,HCPCS,,,facility,both,,,,239,167.3,,,,,,,,,,,,,Gross Charge Type: Central
HC TUBE TRACH SET BLUE RHINO,27200582,CDM,272,RC,27200582,HCPCS,,,facility,both,,,,1399,979.3,,,,,,,,,,,,,Gross Charge Type: Central
HC TUBE TRACH SHILEY ANY SIZE,27200583,CDM,272,RC,27200583,HCPCS,,,facility,both,,,,258,180.6,,,,,,,,,,,,,Gross Charge Type: Central
HC TUBE TRACH TTS 7.0,27200584,CDM,272,RC,27200584,HCPCS,,,facility,both,,,,405,283.5,,,,,,,,,,,,,Gross Charge Type: Central
HC TUBE TRACH TTS 8.0,27200585,CDM,272,RC,27200585,HCPCS,,,facility,both,,,,405,283.5,,,,,,,,,,,,,Gross Charge Type: Central
HC TUBE TRACH TTS SZ 6,27200586,CDM,272,RC,27200586,HCPCS,,,facility,both,,,,405,283.5,,,,,,,,,,,,,Gross Charge Type: Central
HC TUBECONNECTINGSUCTION5MM X 6FT,27200587,CDM,272,RC,27200587,HCPCS,,,facility,both,,,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Central
HC TUBIGRIP SURG SUPPLY PER YARD,27200588,CDM,272,RC,A6457,HCPCS,,,facility,both,,,,174,121.8,,,,,,,,,,,,,Gross Charge Type: Central
HC TUBING CONNECT 10 FT 5MM,27200589,CDM,272,RC,27200589,HCPCS,,,facility,both,,,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Central
HC TUBING CONNECT 6FT 5MM,27200590,CDM,272,RC,27200590,HCPCS,,,facility,both,,,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Central
HC TUBING EXTENSION HIGH PRESSURE,27200591,CDM,272,RC,27200591,HCPCS,,,facility,both,,,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Central
HC TUBING IV PRIMARY,27200592,CDM,272,RC,27200592,HCPCS,,,facility,both,,,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Central
HC TUCKER SLING VARIOUS SIZES,27200593,CDM,272,RC,27200593,HCPCS,,,facility,both,,,,156,109.2,,,,,,,,,,,,,Gross Charge Type: Central
HC TUCKER SLING VARIOUS SIZES,27200594,CDM,272,RC,27200594,HCPCS,,,facility,both,,,,156,109.2,,,,,,,,,,,,,Gross Charge Type: Central
HC URIMETER,27200595,CDM,272,RC,27200595,HCPCS,,,facility,both,,,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Central
HC VERTEPORT CEMENT CANNULA 10G,27200596,CDM,272,RC,27200596,HCPCS,,,facility,both,,,,373,261.1,,,,,,,,,,,,,Gross Charge Type: Central
HC VERTEPORT SHORT STYLET ACCESS NEEDLE,27200597,CDM,272,RC,27200597,HCPCS,,,facility,both,,,,294,205.8,,,,,,,,,,,,,Gross Charge Type: Central
HC VESSEL DILATOR,27200598,CDM,272,RC,27200598,HCPCS,,,facility,both,,,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Central
HC WAFER OSTOMY CONVEX,27200599,CDM,272,RC,A4407,HCPCS,,,facility,both,,,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Central
HC WAFER SKIN OSTOMY FLAT,27200600,CDM,272,RC,A4409,HCPCS,,,facility,both,,,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Central
HC WC SUPPLIES MINOR W/O SUTURES,27200601,CDM,272,RC,27200601,HCPCS,,,facility,both,,,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Central
HC WEDGE FOR TUCKER SLING,27200602,CDM,272,RC,27200602,HCPCS,,,facility,both,,,,457,319.9,,,,,,,,,,,,,Gross Charge Type: Central
HC WEDGE FOR TUCKER SLING,27200603,CDM,272,RC,27200603,HCPCS,,,facility,both,,,,457,319.9,,,,,,,,,,,,,Gross Charge Type: Central
HC WIPE BARRIER SKIN PROTEC/EMOLI BARD,27200604,CDM,272,RC,A5120,HCPCS,,,facility,both,,,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Central
HC WIRE PACING TEMPORARY,27200605,CDM,272,RC,C1751,HCPCS,,,facility,both,,,,427,298.9,,,,,,,,,,,,,Gross Charge Type: Central
HC WIRE ROTO SCIMED,27200606,CDM,272,RC,27200606,HCPCS,,,facility,both,,,,587,410.9,,,,,,,,,,,,,Gross Charge Type: Central
HC WIRE TIGER,27200607,CDM,272,RC,27200607,HCPCS,,,facility,both,,,,480,336,,,,,,,,,,,,,Gross Charge Type: Central
HC WND FILLMULTIDEX GEL 1 OZ,27200608,CDM,623,RC,A6261,HCPCS,,,facility,both,,,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Central
HC WOUND CARE INTER W/O SUTURES,27200609,CDM,272,RC,27200609,HCPCS,,,facility,both,,,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Central
HC WOUND CARE MAJOR W/O SUTURES,27200610,CDM,272,RC,27200610,HCPCS,,,facility,both,,,,168,117.6,,,,,,,,,,,,,Gross Charge Type: Central
HC WOUND CARE MINOR W/O SUTURES,27200611,CDM,272,RC,27200611,HCPCS,,,facility,both,,,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Central
HC SLV CMPR MR KNEE REG SCD EXP,27200612,CDM,272,RC,27200612,HCPCS,,,facility,both,,,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER SUCTION 10FR 14FR 16FR,27200613,CDM,272,RC,27200613,HCPCS,,,facility,both,,,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Central
HC CONN SUCT ARG PLAS 5 IN 1 BRB,27200614,CDM,272,RC,27200614,HCPCS,,,facility,both,,,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Central
HC DRESSING TEGADERM BIOCLUSIVE,27200615,CDM,272,RC,27200615,HCPCS,,,facility,both,,,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Central
HC STOPCOCK 3-WAY STD BORE,27200616,CDM,272,RC,27200616,HCPCS,,,facility,both,,,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER ROB NEL,27200617,CDM,272,RC,27200617,HCPCS,,,facility,both,,,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Central
HC BLOOD FILTER,27200619,CDM,272,RC,27200619,HCPCS,,,facility,both,,,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Central
HC BOTTLE CHEST ADULT,27200620,CDM,272,RC,27200620,HCPCS,,,facility,both,,,,242,169.4,,,,,,,,,,,,,Gross Charge Type: Central
HC DRESSING TELFA NON-ADHER,27200621,CDM,272,RC,27200621,HCPCS,,,facility,both,,,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Central
HC DRESSING SOFT BAND KERLIX,27200622,CDM,272,RC,27200622,HCPCS,,,facility,both,,,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Central
HC BANDAGE ELASTIC,27200623,CDM,272,RC,27200623,HCPCS,,,facility,both,,,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PREP URETHRAL BOAT,27200624,CDM,272,RC,27200624,HCPCS,,,facility,both,,,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Central
HC TOURNIQUET STERILE 24IN 30IN,27200625,CDM,272,RC,27200625,HCPCS,,,facility,both,,,,202,141.4,,,,,,,,,,,,,Gross Charge Type: Central
HC DERMABOND,27200626,CDM,272,RC,27200626,HCPCS,,,facility,both,,,,121,84.7,,,,,,,,,,,,,Gross Charge Type: Central
HC SLV MR CMPR REG KNEE SCD EXP,27200627,CDM,272,RC,27200627,HCPCS,,,facility,both,,,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PRIMARY IV TUBING,27200628,CDM,272,RC,27200628,HCPCS,,,facility,both,,,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Central
HC IV EXTENSION TUBING,27200629,CDM,272,RC,27200629,HCPCS,,,facility,both,,,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Central
HC KIT CATH STERILE INFANT,27200630,CDM,272,RC,27200630,HCPCS,,,facility,both,,,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Central
HC FEMALE CATH KIT,27200631,CDM,272,RC,27200631,HCPCS,,,facility,both,,,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Central
HC SKIN STAPLE EXTRACTOR,27200633,CDM,272,RC,27200633,HCPCS,,,facility,both,,,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Central
HC WIRE MICRO-INFUSION,27200634,CDM,272,RC,27200634,HCPCS,,,facility,both,,,,1177,823.9,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER AXIS SUREFIRE,27200635,CDM,272,RC,27200635,HCPCS,,,facility,both,,,,799,559.3,,,,,,,,,,,,,Gross Charge Type: Central
HC MICROCATHETER SUREFIRE,27200636,CDM,272,RC,27200636,HCPCS,,,facility,both,,,,1346,942.2,,,,,,,,,,,,,Gross Charge Type: Central
HC NEEDLE AVAMAX 11G,27200637,CDM,272,RC,27200637,HCPCS,,,facility,both,,,,358,250.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PROBE ABLATION MICROWAVE PMTA,27200638,CDM,272,RC,27200638,HCPCS,,,facility,both,,,,10449,7314.3,,,,,,,,,,,,,Gross Charge Type: Central
HC BIOPSY NEEDLE,27200639,CDM,272,RC,27200639,HCPCS,,,facility,both,,,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Central
HC RENTAL DIOMED LASER W/FIBER,27200640,CDM,272,RC,27200640,HCPCS,,,facility,both,,,,605,423.5,,,,,,,,,,,,,Gross Charge Type: Central
HC RENTAL OMNI GUIDE LASER 2HRS,27200641,CDM,272,RC,27200641,HCPCS,,,facility,both,,,,733,513.1,,,,,,,,,,,,,Gross Charge Type: Central
HC FEE OMNI GUIDE LASER ADDL HRS,27200642,CDM,272,RC,27200642,HCPCS,,,facility,both,,,,134,93.8,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH ANGIOPLASTY 5X40X130CML,27200645,CDM,272,RC,27200645,HCPCS,,,facility,both,,,,2816,1971.2,,,,,,,,,,,,,Gross Charge Type: Central
HC LAMINARIA,27200685,CDM,272,RC,27200685,HCPCS,,,facility,both,,,,90,63,,,,,,,,,,,,,Gross Charge Type: Central
HC NEEDLE SPINAL 27 X 4 11/16,27200686,CDM,272,RC,27200686,HCPCS,,,facility,both,,,,40,28,,,,,,,,,,,,,Gross Charge Type: Central
HC NEEDLE DISCYPHOR DIRECT REG,27200687,CDM,272,RC,27200687,HCPCS,,,facility,both,,,,799,559.3,,,,,,,,,,,,,Gross Charge Type: Central
HC AVAFLEX PLUS CURVED INJECTION NEEDLE,27200690,CDM,272,RC,27200690,HCPCS,,,facility,both,,,,1916,1341.2,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH INF PER/CENT/MIDLINE,27200691,CDM,272,RC,C1751,HCPCS,,,facility,both,,,,460,322,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER DUAL LUMEN UMBILICAL VESSEL,27200692,CDM,272,RC,27200692,HCPCS,,,facility,both,,,,189,132.3,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER UMBILICAL VESSEL,27200693,CDM,272,RC,27200693,HCPCS,,,facility,both,,,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Central
HC ICD ANTI-BACTERIAL POCKET,27200694,CDM,272,RC,27200694,HCPCS,,,facility,both,,,,2980,2086,,,,,,,,,,,,,Gross Charge Type: Central
HC PTVP ANTI-BACTERIAL POCKET,27200695,CDM,272,RC,27200695,HCPCS,,,facility,both,,,,2315,1620.5,,,,,,,,,,,,,Gross Charge Type: Central
HC WIRE RADIOFREQUENCY NYKANAN,27200696,CDM,272,RC,27200696,HCPCS,,,facility,both,,,,2830,1981,,,,,,,,,,,,,Gross Charge Type: Central
HC ELECTRODE DISPERSIVE INFANT MACROLYTE,27200697,CDM,272,RC,27200697,HCPCS,,,facility,both,,,,200,140,,,,,,,,,,,,,Gross Charge Type: Central
HC BALLOON CATH Z-MED II,27200699,CDM,272,RC,C1725,HCPCS,,,facility,both,,,,1762,1233.4,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER ULTRAFUSE SCIMED,27200700,CDM,272,RC,C1751,HCPCS,,,facility,both,,,,1055,738.5,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER MICRO CANTATA,27200703,CDM,272,RC,C1887,HCPCS,,,facility,both,,,,1203,842.1,,,,,,,,,,,,,Gross Charge Type: Central
HC DRAINAGE CHEST PEDI/INFANT,27200704,CDM,272,RC,27200704,HCPCS,,,facility,both,,,,253,177.1,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH POLYURETHANE TRIPLE LUMEN 5FR,27200705,CDM,272,RC,27200705,HCPCS,,,facility,both,,,,229,160.3,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH IV INSYTE WNGD SAFETY 24G,27200706,CDM,272,RC,27200706,HCPCS,,,facility,both,,,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Central
HC GLIDESCOPE RANGER 0 1 AND 2 DISPOSABLE,27200707,CDM,272,RC,27200707,HCPCS,,,facility,both,,,,143,100.1,,,,,,,,,,,,,Gross Charge Type: Central
HC POUCH URO ODOR PROOF W/ PLAIN BARR 9 IN,27200708,CDM,272,RC,27200708,HCPCS,,,facility,both,,,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Central
HC TUBE ET ANG TP ESCHANN 15FR,27200709,CDM,272,RC,27200709,HCPCS,,,facility,both,,,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Central
HC INTRODUCER AVANTI,27200710,CDM,272,RC,C1897,HCPCS,,,facility,both,,,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Central
HC SPECULUM DISPOSABLE,27200711,CDM,272,RC,27200711,HCPCS,,,facility,both,,,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Central
HC EXTENSION SET,27200712,CDM,272,RC,27200712,HCPCS,,,facility,both,,,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH IV 16 X 1 1/4,27200713,CDM,272,RC,27200713,HCPCS,,,facility,both,,,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH IV 18 X 1 3/4 LATEX FREE,27200714,CDM,272,RC,27200714,HCPCS,,,facility,both,,,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH IV 20 X 1 1/4 LATEX FREE,27200715,CDM,272,RC,27200715,HCPCS,,,facility,both,,,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Central
HC OXISENSOR TRANSDUCER,27200716,CDM,272,RC,27200716,HCPCS,,,facility,both,,,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Central
HC MIDSTREAM VACUTAINER,27200717,CDM,272,RC,27200717,HCPCS,,,facility,both,,,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Central
HC URIMETER,27200719,CDM,272,RC,27200719,HCPCS,,,facility,both,,,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH TRANSLUMINAL ANGIO LASER PERIPHERAL,27200726,CDM,272,RC,C1885,HCPCS,,,facility,both,,,,6989,4892.3,,,,,,,,,,,,,Gross Charge Type: Central
HC HEAMONETIC CELL SAVER,27200727,CDM,272,RC,27200727,HCPCS,,,facility,both,,,,2584,1808.8,,,,,,,,,,,,,Gross Charge Type: Central
HC DAVINCI SUPPLY,27200728,CDM,272,RC,27200728,HCPCS,,,facility,both,,,,2929,2050.3,,,,,,,,,,,,,Gross Charge Type: Central
HC HEART PUMP PERFUSIONIST SUPPLY,27200730,CDM,272,RC,27200730,HCPCS,,,facility,both,,,,8771,6139.7,,,,,,,,,,,,,Gross Charge Type: Central
HC CARTRIDGE BN CORTOSS 10CC,27200731,CDM,272,RC,27200731,HCPCS,,,facility,both,,,,4792,3354.4,,,,,,,,,,,,,Gross Charge Type: Central
HC NOZZLE DLV MIX TIPS LUER 3PK,27200732,CDM,272,RC,27200732,HCPCS,,,facility,both,,,,700,490,,,,,,,,,,,,,Gross Charge Type: Central
HC GUN CORTOSS MIX DELIVERY,27200733,CDM,272,RC,27200733,HCPCS,,,facility,both,,,,1198,838.6,,,,,,,,,,,,,Gross Charge Type: Central
HC CARTRIDGE CORTOSS BN AUG 5CC,27200734,CDM,272,RC,27200734,HCPCS,,,facility,both,,,,2330,1631,,,,,,,,,,,,,Gross Charge Type: Central
HC CORSAIR CATHETER 135,27200736,CDM,272,RC,C1887,HCPCS,,,facility,both,,,,1832,1282.4,,,,,,,,,,,,,Gross Charge Type: Central
HC COCHLEAR PROCESSOR Z185554,27200737,CDM,272,RC,27200737,HCPCS,,,facility,both,,,,16620,11634,,,,,,,,,,,,,Gross Charge Type: Central
HC COCHLEAR PROCESSOR DISCOUNTED Z185554,27200738,CDM,272,RC,27200738,HCPCS,,,facility,both,,,,8310,5817,,,,,,,,,,,,,Gross Charge Type: Central
HC STRYKER CURETTE 10G,27200739,CDM,272,RC,27200739,HCPCS,,,facility,both,,,,1806,1264.2,,,,,,,,,,,,,Gross Charge Type: Central
HC RETRIEVAL DEVICE AIRWAY,27200740,CDM,272,RC,27200740,HCPCS,,,facility,both,,,,940,658,,,,,,,,,,,,,Gross Charge Type: Central
HC AXO TRACK ACCESS KIT,27200741,CDM,272,RC,27200741,HCPCS,,,facility,both,,,,283,198.1,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER CRYO 6MM,27200742,CDM,272,RC,27200742,HCPCS,,,facility,both,,,,4427,3098.9,,,,,,,,,,,,,Gross Charge Type: Central
HC INTERLOCK COILS,27200743,CDM,272,RC,27200743,HCPCS,,,facility,both,,,,1898,1328.6,,,,,,,,,,,,,Gross Charge Type: Central
HC SENSOR OXY RECYCLED NEONAT/ADULT DISP,27200744,CDM,272,RC,27200744,HCPCS,,,facility,both,,,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Central
HC SALEM SUMP TUBE,27200751,CDM,272,RC,27200751,HCPCS,,,facility,both,,,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Central
HC FOLEY CATHETER 2 WAY,27200753,CDM,272,RC,27200753,HCPCS,,,facility,both,,,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Central
HC FEEDING TUBE - 12 FRENCH,27200757,CDM,272,RC,27200757,HCPCS,,,facility,both,,,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Central
HC DRSG DUODERM EXT THIN (TEGASORB),27200759,CDM,272,RC,27200759,HCPCS,,,facility,both,,,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Central
HC AVATEX BONE CEMENT INJECTOR,27200763,CDM,272,RC,27200763,HCPCS,,,facility,both,,,,1180,826,,,,,,,,,,,,,Gross Charge Type: Central
HC ANGIOVAC CANNULA,27200764,CDM,272,RC,27200764,HCPCS,,,facility,both,,,,34606,24224.2,,,,,,,,,,,,,Gross Charge Type: Central
HC IV CATH ALL SIZES,27200765,CDM,272,RC,27200765,HCPCS,,,facility,both,,,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH ANGIOPLASTY 4X120X130CML,27200766,CDM,272,RC,27200766,HCPCS,,,facility,both,,,,3116,2181.2,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH H1 ATHERECTMY STD,27200767,CDM,272,RC,27200767,HCPCS,,,facility,both,,,,6490,4543,,,,,,,,,,,,,Gross Charge Type: Central
HC PACIFIC EXTREME PERIPHERAL ANGIOPLASTY BALLOON CATH 250.0X5.0 MILL,27200769,CDM,272,RC,27200769,HCPCS,,,facility,both,,,,371,259.7,,,,,,,,,,,,,Gross Charge Type: Central
HC FORCEP BIOPSY DISP,27200770,CDM,272,RC,27200770,HCPCS,,,facility,both,,,,1140,798,,,,,,,,,,,,,Gross Charge Type: Central
HC GUIDE EXTENDER,27200771,CDM,272,RC,C1874,HCPCS,,,facility,both,,,,798,558.6,,,,,,,,,,,,,Gross Charge Type: Central
HC OUTBACK LTD RE-ENTRY CATHETER,27200773,CDM,272,RC,27200773,HCPCS,,,facility,both,,,,6757,4729.9,,,,,,,,,,,,,Gross Charge Type: Central
HC MARKER CATHETER,27200774,CDM,272,RC,27200774,HCPCS,,,facility,both,,,,560,392,,,,,,,,,,,,,Gross Charge Type: Central
HC PRONTO CATHETER,27200775,CDM,272,RC,C1757,HCPCS,,,facility,both,,,,900,630,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH EXTRAVASCULAR TISS ABLAT,27200776,CDM,272,RC,C1886,HCPCS,,,facility,both,,,,830,581,,,,,,,,,,,,,Gross Charge Type: Central
HC  ATLAS GOLD BALLOON,27200777,CDM,272,RC,C1725,HCPCS,,,facility,both,,,,1687,1180.9,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH TRUE BALLOON,27200778,CDM,272,RC,C1725,HCPCS,,,facility,both,,,,2830,1981,,,,,,,,,,,,,Gross Charge Type: Central
HC AVAFLEX VERTEBRAL BALLOON,27200779,CDM,272,RC,27200779,HCPCS,,,facility,both,,,,9983,6988.1,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH INQUE BALLN 28MM,27200783,CDM,272,RC,C1725,HCPCS,,,facility,both,,,,7654,5357.8,,,,,,,,,,,,,Gross Charge Type: Central
HC HYDROFERA BLUE READY 4X5,27200784,CDM,272,RC,A6210,HCPCS,,,facility,both,,,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Central
HC HYDROFERA BLUE READY 8X8,27200785,CDM,272,RC,A6211,HCPCS,,,facility,both,,,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Central
HC LUTONIX DRUG COVERED BALLOON,27200786,CDM,272,RC,C1725,HCPCS,,,facility,both,,,,5492,3844.4,,,,,,,,,,,,,Gross Charge Type: Central
HC MULTI-LUMEN CENTRAL VENOUS KIT,27200787,CDM,272,RC,27200787,HCPCS,,,facility,both,,,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Central
HC DRAGONFLY INTRAVASCULAR IMAGING,27200794,CDM,272,RC,27200794,HCPCS,,,facility,both,,,,2662,1863.4,,,,,,,,,,,,,Gross Charge Type: Central
HC RES Q WEDGE,27200795,CDM,272,RC,27200795,HCPCS,,,facility,both,,,,670,469,,,,,,,,,,,,,Gross Charge Type: Central
HC RES Q SLING,27200796,CDM,272,RC,27200796,HCPCS,,,facility,both,,,,307,214.9,,,,,,,,,,,,,Gross Charge Type: Central
HC AMPLATZER TORQUE PDA DELIVERY SYSTEM,27200797,CDM,272,RC,27200797,HCPCS,,,facility,both,,,,2450,1715,,,,,,,,,,,,,Gross Charge Type: Central
HC BRITE BLADE (ALL SIZES),27200798,CDM,272,RC,27200798,HCPCS,,,facility,both,,,,207,144.9,,,,,,,,,,,,,Gross Charge Type: Central
HC DEVICE SUT DLV LARIAT,27200802,CDM,272,RC,27200802,HCPCS,,,facility,both,,,,16473,11531.1,,,,,,,,,,,,,Gross Charge Type: Central
HC CUTTER SUT SURECUT LARIAT,27200803,CDM,272,RC,27200803,HCPCS,,,facility,both,,,,1598,1118.6,,,,,,,,,,,,,Gross Charge Type: Central
HC CANNULA SOFTIP LNG 4.3MM,27200804,CDM,272,RC,27200804,HCPCS,,,facility,both,,,,1198,838.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PULLER SUT TENSURE LARIAT,27200805,CDM,272,RC,27200805,HCPCS,,,facility,both,,,,799,559.3,,,,,,,,,,,,,Gross Charge Type: Central
HC STIFF ANGLED GLIDEWIRE 180CM .035,27200807,CDM,272,RC,C1769,HCPCS,,,facility,both,,,,141,98.7,,,,,,,,,,,,,Gross Charge Type: Central
HC GLIDECATH STRAIGHT,27200808,CDM,272,RC,27200808,HCPCS,,,facility,both,,,,299,209.3,,,,,,,,,,,,,Gross Charge Type: Central
HC KIT INTVN CLSR + .018IN L7CM,27200813,CDM,272,RC,27200813,HCPCS,,,facility,both,,,,185,129.5,,,,,,,,,,,,,Gross Charge Type: Central
HC DEV MAX30 20ML SYR MNMTR INFL,27200814,CDM,272,RC,27200814,HCPCS,,,facility,both,,,,252,176.4,,,,,,,,,,,,,Gross Charge Type: Central
HC GJ TUBE PEDS,27200816,CDM,272,RC,27200816,HCPCS,,,facility,both,,,,1646,1152.2,,,,,,,,,,,,,Gross Charge Type: Central
HC RIGHT ANGLE BOLUS/Y G-J FEEDING SET,27200817,CDM,272,RC,27200817,HCPCS,,,facility,both,,,,533,373.1,,,,,,,,,,,,,Gross Charge Type: Central
HC GENCUT CORE BIOPSY SYSTEM,27200820,CDM,272,RC,27200820,HCPCS,,,facility,both,,,,1399,979.3,,,,,,,,,,,,,Gross Charge Type: Central
HC JETSTREAM SC ATHERECTOMY CATHETER ALL SIZES,27200821,CDM,272,RC,C1724,HCPCS,,,facility,both,,,,9485,6639.5,,,,,,,,,,,,,Gross Charge Type: Central
HC BROVIAC REPAIR KIT 4.2FR,27200826,CDM,272,RC,27200826,HCPCS,,,facility,both,,,,693,485.1,,,,,,,,,,,,,Gross Charge Type: Central
HC BARD ULTRAVERSE 035 PTA DILATATION CATHETER 4MM AND 6MM DIAMETER,27200827,CDM,272,RC,27200827,HCPCS,,,facility,both,,,,460,322,,,,,,,,,,,,,Gross Charge Type: Central
HC CENTRAL LINE PLACEMENT SUPPLIES,27200829,CDM,272,RC,27200829,HCPCS,,,facility,both,,,,1955,1368.5,,,,,,,,,,,,,Gross Charge Type: Central
HC ARTERIAL LINE SUPPLIES,27200830,CDM,272,RC,27200830,HCPCS,,,facility,both,,,,1242,869.4,,,,,,,,,,,,,Gross Charge Type: Central
HC SWAN GANZ SUPPLIES,27200831,CDM,272,RC,27200831,HCPCS,,,facility,both,,,,3850,2695,,,,,,,,,,,,,Gross Charge Type: Central
HC SITZMARKS,27200836,CDM,272,RC,27200836,HCPCS,,,facility,both,,,,501,350.7,,,,,,,,,,,,,Gross Charge Type: Central
HC MULTILAYER COMPRESSION BANDAGE,27200838,CDM,272,RC,27200838,HCPCS,,,facility,both,,,,80,56,,,,,,,,,,,,,Gross Charge Type: Central
HC TCC-EZ CAST SYSTEM W/2 REG BOOTS 3-4 INCH,27200839,CDM,272,RC,27200839,HCPCS,,,facility,both,,,,435,304.5,,,,,,,,,,,,,Gross Charge Type: Central
HC TCC-EZ REGULAR BOOT MENS 6-10/WOMENS 5-11.5,27200840,CDM,272,RC,27200840,HCPCS,,,facility,both,,,,362,253.4,,,,,,,,,,,,,Gross Charge Type: Central
HC TCC EZ-LARGE BOOT MENS 10.5-13/WOMENS 11.5+ WIDE,27200841,CDM,272,RC,27200841,HCPCS,,,facility,both,,,,432,302.4,,,,,,,,,,,,,Gross Charge Type: Central
HC TCC-EZ XL BOOT 13.5-18 WIDE,27200842,CDM,272,RC,27200842,HCPCS,,,facility,both,,,,454,317.8,,,,,,,,,,,,,Gross Charge Type: Central
HC TCC-EZ LARGE CHARCOT BOOT,27200843,CDM,272,RC,27200843,HCPCS,,,facility,both,,,,495,346.5,,,,,,,,,,,,,Gross Charge Type: Central
HC TCC-EZ XL CHARCOT BOOT,27200844,CDM,272,RC,27200844,HCPCS,,,facility,both,,,,523,366.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PICC SHEATH INTRODUCER ONLY 1.4 FR,27200845,CDM,272,RC,C1894,HCPCS,,,facility,both,,,,187,130.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PLOY PICC COMPLETE KIT,27200846,CDM,272,RC,C1894,HCPCS,,,facility,both,,,,476,333.2,,,,,,,,,,,,,Gross Charge Type: Central
HC LOCATOR PLUS,27200847,CDM,272,RC,27200847,HCPCS,,,facility,both,,,,840,588,,,,,,,,,,,,,Gross Charge Type: Central
HC GELOCAST UNNA BOOT,27200848,CDM,272,RC,27200848,HCPCS,,,facility,both,,,,409,286.3,,,,,,,,,,,,,Gross Charge Type: Central
HC MEDELA STARTER SNS,27200849,CDM,272,RC,27200849,HCPCS,,,facility,both,,,,156,109.2,,,,,,,,,,,,,Gross Charge Type: Central
HC EYE EXAM KITS ROP,27200851,CDM,272,RC,27200851,HCPCS,,,facility,both,,,,161,112.7,,,,,,,,,,,,,Gross Charge Type: Central
HC DRSG OPN PORE HYDPHB NEG PRSS,27200852,CDM,272,RC,27200852,HCPCS,,,facility,both,,,,128,89.6,,,,,,,,,,,,,Gross Charge Type: Central
HC DRSG L15 X W 10CM LG S LF VAC,27200853,CDM,272,RC,27200853,HCPCS,,,facility,both,,,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Central
HC DRSG L60 X W 30CM OPN PORE,27200854,CDM,272,RC,27200854,HCPCS,,,facility,both,,,,532,372.4,,,,,,,,,,,,,Gross Charge Type: Central
HC OSTOMY BELT LRG,27200855,CDM,272,RC,27200855,HCPCS,,,facility,both,,,,10,7,,,,,,,,,,,,,Gross Charge Type: Central
HC CONNECTOR DRN Y-TYPE CA/10,27200857,CDM,272,RC,27200857,HCPCS,,,facility,both,,,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Central
HC DILATOR PLST TPRD 14F 70CM,27200858,CDM,272,RC,27200858,HCPCS,,,facility,both,,,,264,184.8,,,,,,,,,,,,,Gross Charge Type: Central
HC ESOPHAGEAL TEMP PROBE,27200859,CDM,272,RC,27200859,HCPCS,,,facility,both,,,,1997,1397.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PROTACK PIGTAIL WIRE 0.025IN DIAMETER 230CM LENGTH,27200861,CDM,272,RC,27200861,HCPCS,,,facility,both,,,,1978,1384.6,,,,,,,,,,,,,Gross Charge Type: Central
HC NRG RF TRANSSEPTAL NEEDLE 71CM,27200862,CDM,272,RC,27200862,HCPCS,,,facility,both,,,,860,602,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER BRACHYTHERAPY SEED ADMINISTRATION,27200863,CDM,272,RC,C1728,HCPCS,,,facility,both,,,,8320,5824,,,,,,,,,,,,,Gross Charge Type: Central
HC HUMMI MICRO DRAW BLOOD TRANSFER DEVICE,27200865,CDM,272,RC,27200865,HCPCS,,,facility,both,,,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Central
HC HUMMINGBIRD T CONNECTOR,27200866,CDM,272,RC,27200866,HCPCS,,,facility,both,,,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Central
HC 1CC VNTD SYRINGE W/HEP NO NEEDLE,27200867,CDM,272,RC,27200867,HCPCS,,,facility,both,,,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Central
HC 3CC VNTD SYRINGE NO HEP NO NEEDLE,27200868,CDM,272,RC,27200868,HCPCS,,,facility,both,,,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Central
HC NEEDLE ANESTHESIA EPIDURAL 17GX5 WEISS THIN WALL,27200869,CDM,272,RC,27200869,HCPCS,,,facility,both,,,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Central
HC MONGOOSE PEDIATRIC ANGIOGRAPHY CATHETER 4F 60 CM,27200870,CDM,272,RC,27200870,HCPCS,,,facility,both,,,,501,350.7,,,,,,,,,,,,,Gross Charge Type: Central
HC BOSTON SCIENTIFIC WATCHMAN ANTERIOR CURVE 14F,27200871,CDM,272,RC,27200871,HCPCS,,,facility,both,,,,3328,2329.6,,,,,,,,,,,,,Gross Charge Type: Central
HC BOSTON SCIENTIFIC WATCHMAN LAA CLOSURE DEVICE 24 MM,27200872,CDM,272,RC,C1760,HCPCS,,,facility,both,,,,45254,31677.8,,,,,,,,,,,,,Gross Charge Type: Central
HC INTRO/SHEATH FIXED NON-PEEL VISISHEATH,27200873,CDM,272,RC,C1893,HCPCS,,,facility,both,,,,900,630,,,,,,,,,,,,,Gross Charge Type: Central
HC ECKOSONIC MACH 4 ENDOVASCULAR DEVICE 135CM,27200874,CDM,272,RC,C1757,HCPCS,,,facility,both,,,,9605,6723.5,,,,,,,,,,,,,Gross Charge Type: Central
HC DEPLOYMENT CATH AND LOADER HUD,27200879,CDM,272,RC,27200879,HCPCS,,,facility,both,,,,2497,1747.9,,,,,,,,,,,,,Gross Charge Type: Central
HC KIT AIRWAY SIZING HUD,27200880,CDM,272,RC,27200880,HCPCS,,,facility,both,,,,960,672,,,,,,,,,,,,,Gross Charge Type: Central
HC VIATRAC BALLOON,27200883,CDM,272,RC,C1725,HCPCS,,,facility,both,,,,855,598.5,,,,,,,,,,,,,Gross Charge Type: Central
HC VERSACORE GUIDE WIRE,27200884,CDM,272,RC,C1769,HCPCS,,,facility,both,,,,536,375.2,,,,,,,,,,,,,Gross Charge Type: Central
HC TAD WIRE,27200890,CDM,272,RC,C1769,HCPCS,,,facility,both,,,,506,354.2,,,,,,,,,,,,,Gross Charge Type: Central
HC ARMADA 35 CATH BALLOON,27200891,CDM,272,RC,C1725,HCPCS,,,facility,both,,,,572,400.4,,,,,,,,,,,,,Gross Charge Type: Central
HC ARMADA 14 CATH BALLOON,27200892,CDM,272,RC,C1725,HCPCS,,,facility,both,,,,1043,730.1,,,,,,,,,,,,,Gross Charge Type: Central
HC ARMADA 18 PTA BALLOON,27200893,CDM,272,RC,C1725,HCPCS,,,facility,both,,,,911,637.7,,,,,,,,,,,,,Gross Charge Type: Central
HC INFLATION GUN,27200917,CDM,272,RC,27200917,HCPCS,,,facility,both,,,,1678,1174.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PULMONARY BALLOON DILATOR,27200918,CDM,272,RC,27200918,HCPCS,,,facility,both,,,,1180,826,,,,,,,,,,,,,Gross Charge Type: Central
HC EMBOSHIELD PROTECTION SYSTEM,27200946,CDM,272,RC,C1884,HCPCS,,,facility,both,,,,4161,2912.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PULMONARY INFLATION SYRINGE,27200947,CDM,272,RC,27200947,HCPCS,,,facility,both,,,,184,128.8,,,,,,,,,,,,,Gross Charge Type: Central
HC BRIDGE OCCLUSION BALLOON CATHETER,27201015,CDM,272,RC,27201015,HCPCS,,,facility,both,,,,2727,1908.9,,,,,,,,,,,,,Gross Charge Type: Central
HC BRIDGE PREP KIT,27201016,CDM,272,RC,27201016,HCPCS,,,facility,both,,,,1027,718.9,,,,,,,,,,,,,Gross Charge Type: Central
HC TIGHTRAIL ROTATING DILATOR SHEATH 11FR,27201017,CDM,272,RC,27201017,HCPCS,,,facility,both,,,,6078,4254.6,,,,,,,,,,,,,Gross Charge Type: Central
HC TIGHTRAIL SUB-C ROTATING DILATOR SHEATH 9FR,27201018,CDM,272,RC,27201018,HCPCS,,,facility,both,,,,5437,3805.9,,,,,,,,,,,,,Gross Charge Type: Central
HC BOSTON SCIENTIFIC PULM SNARE DEVICE,27201043,CDM,272,RC,27201043,HCPCS,,,facility,both,,,,466,326.2,,,,,,,,,,,,,Gross Charge Type: Central
HC CENTRAL VENOUS 2 LUM CATHETER SET 5.0 FR / 8 CM / 0.18 DIAMETER,27201063,CDM,272,RC,C1751,HCPCS,,,facility,both,,,,493,345.1,,,,,,,,,,,,,Gross Charge Type: Central
HC MEDIHONEY HCS NON-ADHESIVE DRESSING 2 X 2 (DERMASCIENCES),27201066,CDM,272,RC,A4649,HCPCS,,,facility,both,,,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Central
HC MEDIHONEY HCS NON-ADHESIVE DRESSING 4 X 4 (DERMASCIENCES),27201067,CDM,272,RC,A4649,HCPCS,,,facility,both,,,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Central
HC TOURGUIDE STEERABLE SHEETH,27201074,CDM,272,RC,C1766,HCPCS,,,facility,both,,,,1845,1291.5,,,,,,,,,,,,,Gross Charge Type: Central
HC TURKEL PNEUMOTHORAX PROC TRAY,27201076,CDM,272,RC,27201076,HCPCS,,,facility,both,,,,395,276.5,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH GUIDEZILLA 6F LONG,27201080,CDM,272,RC,C1725,HCPCS,,,facility,both,,,,1452,1016.4,,,,,,,,,,,,,Gross Charge Type: Central
HC GUIDE WIRE MAXXWIRE .035 X 180,27201083,CDM,272,RC,C1769,HCPCS,,,facility,both,,,,484,338.8,,,,,,,,,,,,,Gross Charge Type: Central
HC MERIT MEDICAL ELATION BALLOON DILATOR,27201084,CDM,272,RC,C1726,HCPCS,,,facility,both,,,,1065,745.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PLEURX-CATH ACCESS KIT,27201085,CDM,272,RC,C1729,HCPCS,,,facility,both,,,,205,143.5,,,,,,,,,,,,,Gross Charge Type: Central
HC THORACENTESIS KIT,27201086,CDM,272,RC,C1729,HCPCS,,,facility,both,,,,176,123.2,,,,,,,,,,,,,Gross Charge Type: Central
HC DEBRISOFT,27201096,CDM,272,RC,A4649,HCPCS,,,facility,both,,,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Central
HC 5MAX REPERFUSION CATHETER 6FR,27201120,CDM,272,RC,27201120,HCPCS,,,facility,both,,,,9092,6364.4,,,,,,,,,,,,,Gross Charge Type: Central
HC 3MAX REPERFUSION CATHETER 4.7FR,27201121,CDM,272,RC,27201121,HCPCS,,,facility,both,,,,6527,4568.9,,,,,,,,,,,,,Gross Charge Type: Central
HC SHEATH NEURON MAX,27201122,CDM,272,RC,27201122,HCPCS,,,facility,both,,,,1898,1328.6,,,,,,,,,,,,,Gross Charge Type: Central
HC BENCHMARK INTRACRANIAL ACCESS SYSTEM,27201123,CDM,272,RC,27201123,HCPCS,,,facility,both,,,,3161,2212.7,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH SELECT SIMV 6FR,27201124,CDM,272,RC,27201124,HCPCS,,,facility,both,,,,484,338.8,,,,,,,,,,,,,Gross Charge Type: Central
HC INZONE 2.0 DETACHMENT SYSTEM,27201148,CDM,272,RC,27201148,HCPCS,,,facility,both,,,,829,580.3,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH EXCELSION SL10 MICRO J,27201150,CDM,272,RC,27201150,HCPCS,,,facility,both,,,,3124,2186.8,,,,,,,,,,,,,Gross Charge Type: Central
HC GUIDE CATH MERCI BLLN 9F X 80CM,27201152,CDM,272,RC,27201152,HCPCS,,,facility,both,,,,3947,2762.9,,,,,,,,,,,,,Gross Charge Type: Central
HC SHEATH AXS INFINITY LS LNG 70,27201153,CDM,272,RC,27201153,HCPCS,,,facility,both,,,,1822,1275.4,,,,,,,,,,,,,Gross Charge Type: Central
HC RETRIEVER TERO XP PROVUE 4 X 20M,27201154,CDM,272,RC,27201154,HCPCS,,,facility,both,,,,18819,13173.3,,,,,,,,,,,,,Gross Charge Type: Central
"HC MARKSMAN MICRO CATHETER 3.2 > 2.8F 0.027"" DIA 160CM",27201163,CDM,272,RC,27201163,HCPCS,,,facility,both,,,,3513,2459.1,,,,,,,,,,,,,Gross Charge Type: Central
HC SOLITAIRE PLATINUM REVASC DEVICE 4 X 20MM / 4 X 40MM / 6 X 40MM,27201164,CDM,272,RC,27201164,HCPCS,,,facility,both,,,,17039,11927.3,,,,,,,,,,,,,Gross Charge Type: Central
HC APOLLO ONYX DELIVERY MICRO CATHETER 2.7F,27201165,CDM,272,RC,27201165,HCPCS,,,facility,both,,,,5629,3940.3,,,,,,,,,,,,,Gross Charge Type: Central
HC SET EPIX PROBE TUNING 5MM X 33CM,27201167,CDM,272,RC,27201167,HCPCS,,,facility,both,,,,371,259.7,,,,,,,,,,,,,Gross Charge Type: Central
HC SET EPIX VLV W DUAL BAG TUBING,27201168,CDM,272,RC,27201168,HCPCS,,,facility,both,,,,345,241.5,,,,,,,,,,,,,Gross Charge Type: Central
HC LUTONIX 035 DRUG COATED BALLOON PTA CATH 5F,27201174,CDM,272,RC,27201174,HCPCS,,,facility,both,,,,1634,1143.8,,,,,,,,,,,,,Gross Charge Type: Central
HC OSSEOFLEX STEERABLE NEEDLE 10GA,27201184,CDM,272,RC,27201184,HCPCS,,,facility,both,,,,4154,2907.8,,,,,,,,,,,,,Gross Charge Type: Central
HC OSSEOFLEX STEERABLE BALLOON 10GA,27201185,CDM,272,RC,27201185,HCPCS,,,facility,both,,,,6078,4254.6,,,,,,,,,,,,,Gross Charge Type: Central
HC OSSEOFLEX VERTEBRAL ACCESS KIT 10GA,27201186,CDM,272,RC,27201186,HCPCS,,,facility,both,,,,1918,1342.6,,,,,,,,,,,,,Gross Charge Type: Central
HC BASIXTOUCH INFLATION DEVICE,27201187,CDM,272,RC,27201187,HCPCS,,,facility,both,,,,1531,1071.7,,,,,,,,,,,,,Gross Charge Type: Central
HC OSSEOFLEX CEMENT BONE POLYMER MEDIUM/HIGH VISCOSITY,27201188,CDM,272,RC,27201188,HCPCS,,,facility,both,,,,3192,2234.4,,,,,,,,,,,,,Gross Charge Type: Central
HC OSSEOFLEX CEMENT MIXER,27201189,CDM,272,RC,27201189,HCPCS,,,facility,both,,,,1143,800.1,,,,,,,,,,,,,Gross Charge Type: Central
HC OSSEOFLEX CD-H HYDRAULIC CEMENT DELIVERY SYSTEM,27201190,CDM,272,RC,27201190,HCPCS,,,facility,both,,,,3192,2234.4,,,,,,,,,,,,,Gross Charge Type: Central
HC OSSEOFLEX HAND DRILL 10GA COMPATIBLE,27201191,CDM,272,RC,27201191,HCPCS,,,facility,both,,,,1268,887.6,,,,,,,,,,,,,Gross Charge Type: Central
HC OSSEOFLEX BONE FILLER TUBE 10GA,27201192,CDM,272,RC,27201192,HCPCS,,,facility,both,,,,1909,1336.3,,,,,,,,,,,,,Gross Charge Type: Central
HC SALIENT SURGICAL AQUAMANTYS,27201194,CDM,272,RC,27201194,HCPCS,,,facility,both,,,,1627,1138.9,,,,,,,,,,,,,Gross Charge Type: Central
HC AVECURE PROBE MINI - LARGE,27201195,CDM,272,RC,27201195,HCPCS,,,facility,both,,,,9620,6734,,,,,,,,,,,,,Gross Charge Type: Central
HC OSSEOFLEX BALLOON SB STRAIGHT 10GA 4ML,27201197,CDM,272,RC,27201197,HCPCS,,,facility,both,,,,4795,3356.5,,,,,,,,,,,,,Gross Charge Type: Central
HC KIT STABILIT MX W/ PWRCRV 10GA,27201199,CDM,272,RC,27201199,HCPCS,,,facility,both,,,,8002,5601.4,,,,,,,,,,,,,Gross Charge Type: Central
HC BAG DRAINAGE REPLACEMENT FOR DUET,27201200,CDM,272,RC,27201200,HCPCS,,,facility,both,,,,259,181.3,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH SET BACTISEAL EVD,27201201,CDM,272,RC,27201201,HCPCS,,,facility,both,,,,2457,1719.9,,,,,,,,,,,,,Gross Charge Type: Central
HC COSEAL SURGICAL SEALANT 8ML,27201210,CDM,272,RC,27201210,HCPCS,,,facility,both,,,,3072,2150.4,,,,,,,,,,,,,Gross Charge Type: Central
HC TREVO MICROCATHETER,27201211,CDM,272,RC,27201211,HCPCS,,,facility,both,,,,2438,1706.6,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH ENVOY DA MPD,27201227,CDM,272,RC,27201227,HCPCS,,,facility,both,,,,2514,1759.8,,,,,,,,,,,,,Gross Charge Type: Central
HC DRSNG BIATAIN SILICONE 3X3IN-7X7IN,27201233,CDM,272,RC,A6212,HCPCS,,,facility,both,,,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Central
HC DRSNG BIATAIN SIL LITE 2X2IN-4X4IN,27201234,CDM,272,RC,A6212,HCPCS,,,facility,both,,,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Central
HC DEVICE SEALING 10MM OD 20CML STRAIGHT NON-ABSORB BLUNT JAW BILAT F/FORCETRIAD ENERGY PLATFORM LIG,27201245,CDM,272,RC,27201245,HCPCS,,,facility,both,,,,1559,1091.3,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH SAPPHIRE II PRO,27201247,CDM,272,RC,C1725,HCPCS,,,facility,both,,,,775,542.5,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH PHENOM + DIST ACCESS,27201259,CDM,272,RC,27201259,HCPCS,,,facility,both,,,,5757,4029.9,,,,,,,,,,,,,Gross Charge Type: Central
HC CATALYST 6 132CM,27201281,CDM,272,RC,27201281,HCPCS,,,facility,both,,,,6992,4894.4,,,,,,,,,,,,,Gross Charge Type: Central
HC TREVO FAST PACK,27201282,CDM,272,RC,27201282,HCPCS,,,facility,both,,,,24128,16889.6,,,,,,,,,,,,,Gross Charge Type: Central
HC SENTINEL CEREBRAL PROTECTION SYSTEM,27201290,CDM,272,RC,C1884,HCPCS,,,facility,both,,,,12826,8978.2,,,,,,,,,,,,,Gross Charge Type: Central
HC FIBER WAVEGUIDE FEE,27201364,CDM,272,RC,27201364,HCPCS,,,facility,both,,,,968,677.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PLEURX-PATIENT STARTER KIT,27201374,CDM,272,RC,27201374,HCPCS,,,facility,both,,,,1408,985.6,,,,,,,,,,,,,Gross Charge Type: Central
HC DRSG RELIATECT W-CHG 8CMX15CM,27201375,CDM,272,RC,27201375,HCPCS,,,facility,both,,,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Central
HC DRSG RELIATECT W-CHG 10CMX25CM,27201376,CDM,272,RC,27201376,HCPCS,,,facility,both,,,,197,137.9,,,,,,,,,,,,,Gross Charge Type: Central
HC SVC FEE HOLMIUM LASER,27201396,CDM,272,RC,27201396,HCPCS,,,facility,both,,,,545,381.5,,,,,,,,,,,,,Gross Charge Type: Central
HC FIBER HOLMIUM SNGL USE 150-300,27201397,CDM,272,RC,27201397,HCPCS,,,facility,both,,,,242,169.4,,,,,,,,,,,,,Gross Charge Type: Central
HC FIBER HOLMIUM SNGL USE 300-400,27201398,CDM,272,RC,27201398,HCPCS,,,facility,both,,,,273,191.1,,,,,,,,,,,,,Gross Charge Type: Central
HC SVC FEE LITHROTRIPSY,27201399,CDM,272,RC,27201399,HCPCS,,,facility,both,,,,1936,1355.2,,,,,,,,,,,,,Gross Charge Type: Central
HC SVC FEE LITHROTRIPSY XTRA SHOCK,27201400,CDM,272,RC,27201400,HCPCS,,,facility,both,,,,495,346.5,,,,,,,,,,,,,Gross Charge Type: Central
HC EMERGENCY/AFTER HOURS,27201401,CDM,272,RC,27201401,HCPCS,,,facility,both,,,,303,212.1,,,,,,,,,,,,,Gross Charge Type: Central
HC KIT IMPELLA RP INTRODUCER,27201402,CDM,272,RC,C1894,HCPCS,,,facility,both,,,,2246,1572.2,,,,,,,,,,,,,Gross Charge Type: Central
HC INTRODUCER D VILL,27201403,CDM,272,RC,C1894,HCPCS,,,facility,both,,,,888,621.6,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH DIAMONDBACK360 1.25 135CM,27201488,CDM,272,RC,C1724,HCPCS,,,facility,both,,,,13310,9317,,,,,,,,,,,,,Gross Charge Type: Central
HC CLAMP CIRC W/BELL 1.1/1.3/1.45 CM DISP,27201489,CDM,272,RC,27201489,HCPCS,,,facility,both,,,,168,117.6,,,,,,,,,,,,,Gross Charge Type: Central
HC SVC FEE ULTRASOUND HLTHRONICS,27201532,CDM,272,RC,27201532,HCPCS,,,facility,both,,,,2904,2032.8,,,,,,,,,,,,,Gross Charge Type: Central
HC SHOCKWAVE LITHOPLASTY CATHETER,27201559,CDM,272,RC,C1761,HCPCS,,,facility,both,,,,15073,10551.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PENUMBRA ENGINE CANISTER,27201572,CDM,272,RC,27201572,HCPCS,,,facility,both,,,,1414,989.8,,,,,,,,,,,,,Gross Charge Type: Central
HC INDIGO 12 XTORQ TIP & LIGHTING ASPIRATION TUBING 12FR 100CM .014-.038 INCHES,27201573,CDM,272,RC,27201573,HCPCS,,,facility,both,,,,17407,12184.9,,,,,,,,,,,,,Gross Charge Type: Central
HC SEPARATOR 12 .110IN X 150CM WIRE,27201574,CDM,272,RC,27201574,HCPCS,,,facility,both,,,,6398,4478.6,,,,,,,,,,,,,Gross Charge Type: Central
HC CLOTTRIEVER CATHETER,27201600,CDM,272,RC,C1757,HCPCS,,,facility,both,,,,16517,11561.9,,,,,,,,,,,,,Gross Charge Type: Central
HC CLOTTRIEVER SHEATH 13F,27201601,CDM,272,RC,C1757,HCPCS,,,facility,both,,,,4811,3367.7,,,,,,,,,,,,,Gross Charge Type: Central
HC CLOTTRIEVER SHEATH 16F,27201602,CDM,272,RC,C1757,HCPCS,,,facility,both,,,,4811,3367.7,,,,,,,,,,,,,Gross Charge Type: Central
HC CONQUEST BALLON 10 X2,27201625,CDM,272,RC,C1725,HCPCS,,,facility,both,,,,719,503.3,,,,,,,,,,,,,Gross Charge Type: Central
HC INTRO DRYSEAL FLEX 33CM,27201634,CDM,272,RC,C1894,HCPCS,,,facility,both,,,,1856,1299.2,,,,,,,,,,,,,Gross Charge Type: Central
HC SHEATH DRYSEAL FLEX,27201635,CDM,272,RC,C1894,HCPCS,,,facility,both,,,,2420,1694,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH SUPREME QUAD,27201640,CDM,272,RC,C1730,HCPCS,,,facility,both,,,,1400,980,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH CLEAN THRMB 15-7FRX135CM ARGON,27201641,CDM,272,RC,27201641,HCPCS,,,facility,both,,,,4971,3479.7,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH SOFTVU OMNI .035 5FX65CM,27201655,CDM,272,RC,C1887,HCPCS,,,facility,both,,,,214,149.8,,,,,,,,,,,,,Gross Charge Type: Central
HC WIRE CATH PRFR RF NYKANEN,27201665,CDM,272,RC,27201665,HCPCS,,,facility,both,,,,2727,1908.9,,,,,,,,,,,,,Gross Charge Type: Central
HC VOLCANO VISIONS PV DIGITAL IVUS CATHETER 0.035,27201669,CDM,272,RC,C1753,HCPCS,,,facility,both,,,,3192,2234.4,,,,,,,,,,,,,Gross Charge Type: Central
HC ABRE STENT 60MM AND 100MM,27201670,CDM,272,RC,27201670,HCPCS,,,facility,both,,,,5437,3805.9,,,,,,,,,,,,,Gross Charge Type: Central
HC ABRE STENT 150MM,27201671,CDM,272,RC,27201671,HCPCS,,,facility,both,,,,6175,4322.5,,,,,,,,,,,,,Gross Charge Type: Central
HC STEERABLE BALLOON 10G 15MM,27201672,CDM,272,RC,27201672,HCPCS,,,facility,both,,,,6767,4736.9,,,,,,,,,,,,,Gross Charge Type: Central
HC BS EXALT MODEL B BRONCHOSCOPE,27201673,CDM,272,RC,27201673,HCPCS,,,facility,both,,,,1531,1071.7,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH PICC 3FR 55CM 1L POWER INJECTION,27201685,CDM,272,RC,C1751,HCPCS,,,facility,both,,,,734,513.8,,,,,,,,,,,,,Gross Charge Type: Central
HC SHEATH VIZIGO BI DIRECT GD SM CURVE,27201700,CDM,272,RC,C1766,HCPCS,,,facility,both,,,,2781,1946.7,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH DECANAV MAP,27201701,CDM,272,RC,C1732,HCPCS,,,facility,both,,,,3067,2146.9,,,,,,,,,,,,,Gross Charge Type: Central
HC CASSETTE IMPELLA IABP PRG 2.5,27201702,CDM,272,RC,27201702,HCPCS,,,facility,both,,,,3209,2246.3,,,,,,,,,,,,,Gross Charge Type: Central
HC SILICONE WATERPROOF TAPE PER 9 INCHES,27201706,CDM,272,RC,A4452,HCPCS,,,facility,both,,,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER BALLON WEDGE PRESSURE,27201712,CDM,272,RC,27201712,HCPCS,,,facility,both,,,,444,310.8,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER ATLAS GOLD BALLON 20MMX2CM,27201713,CDM,272,RC,C1725,HCPCS,,,facility,both,,,,2018,1412.6,,,,,,,,,,,,,Gross Charge Type: Central
HC CENTRAL VENOUS CATHETER SET 5.0FR/15 CM,27201714,CDM,272,RC,C1751,HCPCS,,,facility,both,,,,213,149.1,,,,,,,,,,,,,Gross Charge Type: Central
HC BRACHYTHERAPY NEEDLE,27201715,CDM,272,RC,C1715,HCPCS,,,facility,both,,,,455,318.5,,,,,,,,,,,,,Gross Charge Type: Central
HC SOUNDSTAR ECO DIAGNOSTIC ULTRASOUND CATHETER 8FR,27201726,CDM,272,RC,C1759,HCPCS,,,facility,both,,,,7706,5394.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PERIPHERAL IVL CATHETER,27201727,CDM,272,RC,C1725,HCPCS,,,facility,both,,,,11064,7744.8,,,,,,,,,,,,,Gross Charge Type: Central
HC KIT INDIGO CATHETER ASPIRATION INCLUDING TUBING,27201741,CDM,272,RC,C1887,HCPCS,,,facility,both,,,,6446,4512.2,,,,,,,,,,,,,Gross Charge Type: Central
HC INDIGO SYSTEM LIGHTNING 7,27201742,CDM,272,RC,C1757,HCPCS,,,facility,both,,,,14358,10050.6,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH OCTARAY D-CRV,27201743,CDM,272,RC,C1732,HCPCS,,,facility,both,,,,7059,4941.3,,,,,,,,,,,,,Gross Charge Type: Central
HC MEPILEX BORDER 4X10IN,27201744,CDM,272,RC,A6213,HCPCS,,,facility,both,,,,136,95.2,,,,,,,,,,,,,Gross Charge Type: Central
HC MEPILEX BORDER 4X12IN,27201745,CDM,272,RC,A6213,HCPCS,,,facility,both,,,,140,98,,,,,,,,,,,,,Gross Charge Type: Central
HC CODMAN CRANIAL ACCESS KIT,27201748,CDM,272,RC,27201748,HCPCS,,,facility,both,,,,1410,987,,,,,,,,,,,,,Gross Charge Type: Central
HC MEDTRONIC BARIUM IMPREGNATED VENTRICULAR CATHETER,27201749,CDM,272,RC,27201749,HCPCS,,,facility,both,,,,674,471.8,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER ANGIOJET ZELANTE DVT,27201751,CDM,272,RC,C1757,HCPCS,,,facility,both,,,,12353,8647.1,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER ANGIOJET SOLENT DISTA 4F,27201752,CDM,272,RC,C1757,HCPCS,,,facility,both,,,,6409,4486.3,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER ULTRASOUND OPTICROSS 0.018IN 4F X 135CM,27201753,CDM,272,RC,C1753,HCPCS,,,facility,both,,,,2156,1509.2,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER RANGER DCB 4X100MM 135CM,27201754,CDM,272,RC,C2623,HCPCS,,,facility,both,,,,5452,3816.4,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER RANGER DCB OTW 4/5 X 150MM X 150CM,27201755,CDM,272,RC,C2623,HCPCS,,,facility,both,,,,5934,4153.8,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER RANGER DCB OTW 5/6/7 X 150/200MM X 150CM,27201756,CDM,272,RC,C2623,HCPCS,,,facility,both,,,,7055,4938.5,,,,,,,,,,,,,Gross Charge Type: Central
HC MICRO CATHETER 2.3FR X 150 CM,27201761,CDM,272,RC,27201761,HCPCS,,,facility,both,,,,7055,4938.5,,,,,,,,,,,,,Gross Charge Type: Central
HC GW FIELDER FC STRT 300CM,27201770,CDM,272,RC,C1769,HCPCS,,,facility,both,,,,339,237.3,,,,,,,,,,,,,Gross Charge Type: Central
HC GW PROWATERFLEX WH J-TIP 180CM,27201771,CDM,272,RC,C1769,HCPCS,,,facility,both,,,,339,237.3,,,,,,,,,,,,,Gross Charge Type: Central
HC GW EXTENSION ASAHI GW 165CM,27201772,CDM,272,RC,C1769,HCPCS,,,facility,both,,,,366,256.2,,,,,,,,,,,,,Gross Charge Type: Central
HC GW MINAMO STRT TIP 190CM,27201773,CDM,272,RC,C1769,HCPCS,,,facility,both,,,,366,256.2,,,,,,,,,,,,,Gross Charge Type: Central
HC GW SION BLACK J-TIP 300CM,27201774,CDM,272,RC,C1769,HCPCS,,,facility,both,,,,366,256.2,,,,,,,,,,,,,Gross Charge Type: Central
HC GW MINAMO J-TIP 190/300CM,27201775,CDM,272,RC,C1769,HCPCS,,,facility,both,,,,366,256.2,,,,,,,,,,,,,Gross Charge Type: Central
HC GW SION BLUE STRT .014INX190CM,27201776,CDM,272,RC,C1769,HCPCS,,,facility,both,,,,417,291.9,,,,,,,,,,,,,Gross Charge Type: Central
HC GW SION BLUE FL J-TIP 190CM,27201777,CDM,272,RC,C1769,HCPCS,,,facility,both,,,,417,291.9,,,,,,,,,,,,,Gross Charge Type: Central
HC GW SION BLUE FL STRT 300CM,27201778,CDM,272,RC,C1769,HCPCS,,,facility,both,,,,417,291.9,,,,,,,,,,,,,Gross Charge Type: Central
HC GW GRAND SLAM J-TIP .014X 180/300CM,27201779,CDM,272,RC,C1769,HCPCS,,,facility,both,,,,444,310.8,,,,,,,,,,,,,Gross Charge Type: Central
HC GW SION BLACK STRT 190/300 CM,27201780,CDM,272,RC,C1769,HCPCS,,,facility,both,,,,444,310.8,,,,,,,,,,,,,Gross Charge Type: Central
HC GW SION BLACK J-TIP 190CM,27201781,CDM,272,RC,C1769,HCPCS,,,facility,both,,,,444,310.8,,,,,,,,,,,,,Gross Charge Type: Central
HC GW GRAND SLAM STRT .014X180CM,27201782,CDM,272,RC,C1769,HCPCS,,,facility,both,,,,444,310.8,,,,,,,,,,,,,Gross Charge Type: Central
HC GW MICROCATH CORSAIR PRO XS 2.1F,27201783,CDM,272,RC,C1887,HCPCS,,,facility,both,,,,1765,1235.5,,,,,,,,,,,,,Gross Charge Type: Central
HC GW MICROCATH CORSAIR PRO 2.6FX135,27201784,CDM,272,RC,C1887,HCPCS,,,facility,both,,,,1765,1235.5,,,,,,,,,,,,,Gross Charge Type: Central
HC GW VASC .45MMDIA 300CM STRT,27201785,CDM,272,RC,C1769,HCPCS,,,facility,both,,,,427,298.9,,,,,,,,,,,,,Gross Charge Type: Central
HC GW FIELDER XT-A 0.6G STRT 190,27201786,CDM,272,RC,C1769,HCPCS,,,facility,both,,,,446,312.2,,,,,,,,,,,,,Gross Charge Type: Central
HC GW CONFIANZA PRO 12 STRT 180CM,27201787,CDM,272,RC,C1769,HCPCS,,,facility,both,,,,446,312.2,,,,,,,,,,,,,Gross Charge Type: Central
HC GW GAIA NEXT 2 PRE-SHAPE 190CM,27201788,CDM,272,RC,C1769,HCPCS,,,facility,both,,,,446,312.2,,,,,,,,,,,,,Gross Charge Type: Central
HC GW MIRACLEBROS 6 STRT 180CM/300CM,27201789,CDM,272,RC,C1769,HCPCS,,,facility,both,,,,446,312.2,,,,,,,,,,,,,Gross Charge Type: Central
HC GW SION WH STRT 300CM,27201790,CDM,272,RC,C1769,HCPCS,,,facility,both,,,,446,312.2,,,,,,,,,,,,,Gross Charge Type: Central
HC GW RG3 CTO STRAIGHT 330CM,27201791,CDM,272,RC,C1769,HCPCS,,,facility,both,,,,446,312.2,,,,,,,,,,,,,Gross Charge Type: Central
HC GW GLADIUS MONGO STRT 190CM,27201792,CDM,272,RC,C1769,HCPCS,,,facility,both,,,,446,312.2,,,,,,,,,,,,,Gross Charge Type: Central
HC GW GLADIUS MONGO ES PRE-SHAPE 300CM,27201793,CDM,272,RC,C1769,HCPCS,,,facility,both,,,,446,312.2,,,,,,,,,,,,,Gross Charge Type: Central
HC GW GLADIUS MONGO ES STRT 300CM,27201794,CDM,272,RC,C1769,HCPCS,,,facility,both,,,,446,312.2,,,,,,,,,,,,,Gross Charge Type: Central
HC GW CONFIANZA PRO STRT 180CM,27201795,CDM,272,RC,C1769,HCPCS,,,facility,both,,,,446,312.2,,,,,,,,,,,,,Gross Charge Type: Central
HC GW FIELDER XT STRT 190CM/300CM,27201796,CDM,272,RC,C1769,HCPCS,,,facility,both,,,,446,312.2,,,,,,,,,,,,,Gross Charge Type: Central
HC GW MIRACLEBROS 3/12 STRT 300CM,27201797,CDM,272,RC,C1769,HCPCS,,,facility,both,,,,446,312.2,,,,,,,,,,,,,Gross Charge Type: Central
HC GW SUOH 03 STRAIGHT 190CM,27201798,CDM,272,RC,C1769,HCPCS,,,facility,both,,,,446,312.2,,,,,,,,,,,,,Gross Charge Type: Central
HC GW VASC .014/.018DIA 180CML,27201799,CDM,272,RC,C1769,HCPCS,,,facility,both,,,,581,406.7,,,,,,,,,,,,,Gross Charge Type: Central
HC GW ASTATO 30 STRT 180CM,27201800,CDM,272,RC,C1769,HCPCS,,,facility,both,,,,581,406.7,,,,,,,,,,,,,Gross Charge Type: Central
HC GW ASTATO XS 20 STRT 300CM,27201801,CDM,272,RC,C1769,HCPCS,,,facility,both,,,,581,406.7,,,,,,,,,,,,,Gross Charge Type: Central
HC GW MICROCATH CORSAIR PRO XS 150CM,27201802,CDM,272,RC,C1887,HCPCS,,,facility,both,,,,2727,1908.9,,,,,,,,,,,,,Gross Charge Type: Central
HC GW GLADIUS STRT 0.014/0.018INX300CM,27201803,CDM,272,RC,C1769,HCPCS,,,facility,both,,,,659,461.3,,,,,,,,,,,,,Gross Charge Type: Central
HC GW VASC .45MMDIA 300CM LGTH,27201804,CDM,272,RC,C1769,HCPCS,,,facility,both,,,,698,488.6,,,,,,,,,,,,,Gross Charge Type: Central
HC GW HALBRED STRT 0.014INX300CM,27201805,CDM,272,RC,C1769,HCPCS,,,facility,both,,,,698,488.6,,,,,,,,,,,,,Gross Charge Type: Central
HC GW CATH SASUKE GD TAPER TIP 145CM,27201807,CDM,272,RC,C1725,HCPCS,,,facility,both,,,,1531,1071.7,,,,,,,,,,,,,Gross Charge Type: Central
HC GW THRUWAY .014 STRAIGHT,27201808,CDM,272,RC,C1769,HCPCS,,,facility,both,,,,438,306.6,,,,,,,,,,,,,Gross Charge Type: Central
HC MICROCATHETER SNIPER OCCLUSION 150CM,27201812,CDM,272,RC,27201812,HCPCS,,,facility,both,,,,4330,3031,,,,,,,,,,,,,Gross Charge Type: Central
HC SYSTEM INDIGO LIGHTNING,27201813,CDM,272,RC,C1757,HCPCS,,,facility,both,,,,21966,15376.2,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER COYOTE OTW 2.5MM X 220MM X 150CM,27201817,CDM,272,RC,C1725,HCPCS,,,facility,both,,,,1085,759.5,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER SOUNDSTAR ECO ICE,27201818,CDM,272,RC,C1759,HCPCS,,,facility,both,,,,2336,1635.2,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER SHOCKWAVE C2 INTRAVASCULAR LITHOTRIPSY,27201830,CDM,272,RC,C1761,HCPCS,,,facility,both,,,,13702,9591.4,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER LIGHTNING EMBOL 16FR X 115CM,27201833,CDM,272,RC,C1757,HCPCS,,,facility,both,,,,22662,15863.4,,,,,,,,,,,,,Gross Charge Type: Central
HC KIT CATHETER THROMBECTOMY,27201837,CDM,272,RC,C1757,HCPCS,,,facility,both,,,,10903,7632.1,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER WEBSTER CS BI-DIRECT D-F 7FR X 115CM,27201838,CDM,272,RC,C2630,HCPCS,,,facility,both,,,,634,443.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PERIPHERAL ROTALINK PLUS BURR CATHETER 1.50MM X 5F,27201842,CDM,272,RC,C1760,HCPCS,,,facility,both,,,,4956,3469.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PERIPHERAL ROTALINK PLUS BURR CATHETER 1.75/2.00MM X 6/7F,27201843,CDM,272,RC,C1760,HCPCS,,,facility,both,,,,3779,2645.3,,,,,,,,,,,,,Gross Charge Type: Central
HC SURPREME ELECTROPHYSIOLOGY CATHETER 5MM CRD2 6FR X 120CM,27201844,CDM,272,RC,C1730,HCPCS,,,facility,both,,,,193,135.1,,,,,,,,,,,,,Gross Charge Type: Central
HC FLEXIBLE CRYOPROBE SINGLE USE 1.1 MM LENGTH 1150 MM W/OVERSHEATH LENGTH 817MM,27201845,CDM,272,RC,C2618,HCPCS,,,facility,both,,,,1434,1003.8,,,,,,,,,,,,,Gross Charge Type: Central
HC FLEXIBLE CRYOPROBE SINGLE USE 1.7/2.4 MM LENGTH 1150,27201846,CDM,272,RC,C2618,HCPCS,,,facility,both,,,,1071,749.7,,,,,,,,,,,,,Gross Charge Type: Central
HC SHEATH AGILIS NXT STEERABLE INTRODUCER MED CURVE,27201851,CDM,272,RC,C1766,HCPCS,,,facility,both,,,,2859,2001.3,,,,,,,,,,,,,Gross Charge Type: Central
HC SHEATH AGILIS NXT STEERABLE INTRODUCER SM CURVE,27201852,CDM,272,RC,C1766,HCPCS,,,facility,both,,,,1599,1119.3,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER OCTAPOLAR D-CRV 6FR X 92CM,27201853,CDM,272,RC,C1730,HCPCS,,,facility,both,,,,392,274.4,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER DUO-DECAPOLAR 7F,27201854,CDM,272,RC,C1731,HCPCS,,,facility,both,,,,986,690.2,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER VIEWFLEX XTRA INTRACARDIAC ECHOCARDIOGRAPHY 9F,27201855,CDM,272,RC,C1730,HCPCS,,,facility,both,,,,6825,4777.5,,,,,,,,,,,,,Gross Charge Type: Central
HC KIT DRESSING RENASYS-G GAUZE SMALL,27201865,CDM,272,RC,27201865,HCPCS,,,facility,both,,,,148,103.6,,,,,,,,,,,,,Gross Charge Type: Central
HC KIT DRESSING RENASYS-G GAUZE MEDIUM,27201866,CDM,272,RC,27201866,HCPCS,,,facility,both,,,,186,130.2,,,,,,,,,,,,,Gross Charge Type: Central
HC KIT DRESSING RENASYS-G GAUZE LARGE,27201867,CDM,272,RC,27201867,HCPCS,,,facility,both,,,,264,184.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PATCH RENASYS ADHESIVE GEL 7X10CM,27201868,CDM,272,RC,27201868,HCPCS,,,facility,both,,,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Central
HC KIT DRESSING RENASYS-F FOAM SMALL,27201869,CDM,272,RC,27201869,HCPCS,,,facility,both,,,,148,103.6,,,,,,,,,,,,,Gross Charge Type: Central
HC KIT DRESSING RENASYS-F FOAM MEDIUM,27201870,CDM,272,RC,27201870,HCPCS,,,facility,both,,,,186,130.2,,,,,,,,,,,,,Gross Charge Type: Central
HC KIT DRESSING RENASYS-F FOAM LARGE,27201871,CDM,272,RC,27201871,HCPCS,,,facility,both,,,,264,184.8,,,,,,,,,,,,,Gross Charge Type: Central
HC KIT DRESSING RENASYS-F FOAM XLARGE,27201872,CDM,272,RC,27201872,HCPCS,,,facility,both,,,,450,315,,,,,,,,,,,,,Gross Charge Type: Central
HC PORT SOFT RENASYS STAND ALONE,27201873,CDM,272,RC,27201873,HCPCS,,,facility,both,,,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Central
HC CONNECTOR Y SHAPED RENASYS,27201874,CDM,272,RC,27201874,HCPCS,,,facility,both,,,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Central
HC FOAM FILLER RENASYS NPWT 4X5X0.5IN,27201875,CDM,272,RC,27201875,HCPCS,,,facility,both,,,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Central
HC FILM TRANSPARENT RENASYS 20X30CM,27201876,CDM,272,RC,27201876,HCPCS,,,facility,both,,,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Central
HC FOAM RENASYS WHITE LARGE,27201877,CDM,272,RC,27201877,HCPCS,,,facility,both,,,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Central
HC AGNT ARISTA AH HEMOSTATIC COLL 5GM,27201880,CDM,272,RC,27201880,HCPCS,,,facility,both,,,,2902,2031.4,,,,,,,,,,,,,Gross Charge Type: Central
HC MUSTANG 0.035 BALLOON DILATION CATHETER 6.0MM X 200MM  X 35CM,27201881,CDM,272,RC,27201881,HCPCS,,,facility,both,,,,728,509.6,,,,,,,,,,,,,Gross Charge Type: Central
HC ACUNAV CATHETER ICE DIAG GE 8F X 90CM,27201887,CDM,272,RC,C1753,HCPCS,,,facility,both,,,,2411,1687.7,,,,,,,,,,,,,Gross Charge Type: Central
HC BALLOON DILATATION CATHETER 3MM X 60MM X 150CM,27201888,CDM,272,RC,C1769,HCPCS,,,facility,both,,,,912,638.4,,,,,,,,,,,,,Gross Charge Type: Central
HC SAFARI2 GUIDEWIRE XSMALL/SMALL/LARGE CURVE 0.035 IN X 275CM,27201889,CDM,272,RC,C1769,HCPCS,,,facility,both,,,,967,676.9,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH CROSSWALK,27201893,CDM,272,RC,C1887,HCPCS,,,facility,both,,,,652,456.4,,,,,,,,,,,,,Gross Charge Type: Central
HC ARGENT SURGICAL CAUTERY TIPS,27201896,CDM,272,RC,27201896,HCPCS,,,facility,both,,,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Central
HC STERADIAN SHIELD RADIATION ATTENUATION PAD,27201915,CDM,272,RC,27201915,HCPCS,,,facility,both,,,,257,179.9,,,,,,,,,,,,,Gross Charge Type: Central
HC OPTRELL MAPPING CATHETER SMALL LOOP,27201921,CDM,272,RC,C1732,HCPCS,,,facility,both,,,,6934,4853.8,,,,,,,,,,,,,Gross Charge Type: Central
HC ATTAIN HYBRID GUIDE WIRE,27201936,CDM,272,RC,C1769,HCPCS,,,facility,both,,,,522,365.4,,,,,,,,,,,,,Gross Charge Type: Central
HC MEDTRONIC STYLET KIT,27201939,CDM,272,RC,27201939,HCPCS,,,facility,both,,,,160,112,,,,,,,,,,,,,Gross Charge Type: Central
HC MEDTRONIC KIT LEAD PACING SPRINT QUATTRO,27201940,CDM,272,RC,27201940,HCPCS,,,facility,both,,,,160,112,,,,,,,,,,,,,Gross Charge Type: Central
HC INDIGO SYSTEM LIGHTNING BOLT 7,27201946,CDM,272,RC,C1757,HCPCS,,,facility,both,,,,18619,13033.3,,,,,,,,,,,,,Gross Charge Type: Central
HC MICROCATHETER TRUSELECT 0.021IN X 175CM,27201949,CDM,272,RC,C1887,HCPCS,,,facility,both,,,,2327,1628.9,,,,,,,,,,,,,Gross Charge Type: Central
HC KIT CATHETER EKOS PLUS ENDOVASCULAR SYSTEM 106CM X 8CM/16CM,27201950,CDM,272,RC,C1887,HCPCS,,,facility,both,,,,9870,6909,,,,,,,,,,,,,Gross Charge Type: Central
HC STABILIT ER SATURATE MIXING SYSTEM,27201953,CDM,272,RC,27201953,HCPCS,,,facility,both,,,,1947,1362.9,,,,,,,,,,,,,Gross Charge Type: Central
HC STABILIT MASTER SYRINGE ASSEMBLY,27201954,CDM,272,RC,27201954,HCPCS,,,facility,both,,,,1015,710.5,,,,,,,,,,,,,Gross Charge Type: Central
HC ROTAGLIDE LUBRICANT MIXTURE 20 CC VIALS,27201962,CDM,272,RC,27201962,HCPCS,,,facility,both,,,,406,284.2,,,,,,,,,,,,,Gross Charge Type: Central
HC INTRODUCER CATHETER MICROPUNCTURE ACCESS SET,27201963,CDM,272,RC,C1894,HCPCS,,,facility,both,,,,141,98.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PROBE COVER W/GUIDE,27201967,CDM,272,RC,27201967,HCPCS,,,facility,both,,,,120,84,,,,,,,,,,,,,Gross Charge Type: Central
HC ARTHROGRAM TRAY,27201968,CDM,272,RC,27201968,HCPCS,,,facility,both,,,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Central
HC RENTAL GREENLIGHT LASER,27201970,CDM,272,RC,27201970,HCPCS,,,facility,both,,,,500,350,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER SHOCKWAVE M5 IVL (CVL),27201974,CDM,272,RC,C1725,HCPCS,,,facility,both,,,,9592,6714.4,,,,,,,,,,,,,Gross Charge Type: Central
HC LEVEL 1 NORMOTHERMIC IV FLUID ADMINISTRATION SET,27201975,CDM,272,RC,27201975,HCPCS,,,facility,both,,,,321,224.7,,,,,,,,,,,,,Gross Charge Type: Central
HC FLASH MINI OSTIAL CATHETER BALLOON 3.0/3.5/4.0/4.5 X 8MM,27201976,CDM,272,RC,C1725,HCPCS,,,facility,both,,,,2781,1946.7,,,,,,,,,,,,,Gross Charge Type: Central
HC FLASH OSTIAL CATHETER BALLOON 5.0/6.0 X 12MM,27201977,CDM,272,RC,C1725,HCPCS,,,facility,both,,,,2781,1946.7,,,,,,,,,,,,,Gross Charge Type: Central
HC FLASH OSTIAL OTW CATHETER BALLON 6.0/7.0 X 12MM,27201978,CDM,272,RC,C1725,HCPCS,,,facility,both,,,,2781,1946.7,,,,,,,,,,,,,Gross Charge Type: Central
HC QDOT MICRO UNI-DIRECTIONAL CATHETER,27201979,CDM,272,RC,C1732,HCPCS,,,facility,both,,,,4028,2819.6,,,,,,,,,,,,,Gross Charge Type: Central
HC QDOT MICRO BI-DIRECTIONAL CATHETER,27201980,CDM,272,RC,C1732,HCPCS,,,facility,both,,,,4028,2819.6,,,,,,,,,,,,,Gross Charge Type: Central
HC VTE INARI SYSTEM,27201981,CDM,272,RC,C1757,HCPCS,,,facility,both,,,,26281,18396.7,,,,,,,,,,,,,Gross Charge Type: Central
HC FLEXCATH CROSS AG/VZ 71 CM,27201985,CDM,272,RC,C1893,HCPCS,,,facility,both,,,,1931,1351.7,,,,,,,,,,,,,Gross Charge Type: Central
HC SELECTSITE DEFLECTABLE CATHETER W/PRESHAPED DISTAL CURVE,27202001,CDM,272,RC,C1887,HCPCS,,,facility,both,,,,1449,1014.3,,,,,,,,,,,,,Gross Charge Type: Central
HC THERMOCOOL SF BI-DIRECTIONAL CATHETER,27202002,CDM,272,RC,C2630,HCPCS,,,facility,both,,,,4660,3262,,,,,,,,,,,,,Gross Charge Type: Central
HC HIGH DENSITY CATHETER FOCAL CATH TO GEN STERILE CBL,27202003,CDM,272,RC,27202003,HCPCS,,,facility,both,,,,1456,1019.2,,,,,,,,,,,,,Gross Charge Type: Central
HC MERIT ASPIRA PERITONEAL DRAINAGE CATHETER INSERTION TRAY PERITONEAL 15.5FR,27202010,CDM,272,RC,27202010,HCPCS,,,facility,both,,,,1708,1195.6,,,,,,,,,,,,,Gross Charge Type: Central
HC MERIT ASPIRA PERITONEAL DRAINAGE SYSTEM STARTER KIT 15.5FR 1L,27202011,CDM,272,RC,27202011,HCPCS,,,facility,both,,,,1931,1351.7,,,,,,,,,,,,,Gross Charge Type: Central
HC MERIT ASPIRA UNIVERSAL TUBING ADAPTER,27202012,CDM,272,RC,27202012,HCPCS,,,facility,both,,,,111,77.7,,,,,,,,,,,,,Gross Charge Type: Central
HC MERIT ASPIRA PLEURAL DRAINAGE CATHETER INSERTION TRAY 15.5FR,27202013,CDM,272,RC,27202013,HCPCS,,,facility,both,,,,1708,1195.6,,,,,,,,,,,,,Gross Charge Type: Central
HC MERIT ASPIRA PLEURAL DRAINAGE STARTER KIT 15.5FR 1L,27202014,CDM,272,RC,27202014,HCPCS,,,facility,both,,,,1931,1351.7,,,,,,,,,,,,,Gross Charge Type: Central
HC JADA POSTPARTUM BALLOON SYSTEM,27202016,CDM,272,RC,27202016,HCPCS,,,facility,both,,,,4144,2900.8,,,,,,,,,,,,,Gross Charge Type: Central
HC DVT INARI SYSTEM,27202017,CDM,272,RC,27202017,HCPCS,,,facility,both,,,,23100,16170,,,,,,,,,,,,,Gross Charge Type: Central
HC 365U LASER FIBER PL SINGLE USE,27202018,CDM,272,RC,27202018,HCPCS,,,facility,both,,,,195,136.5,,,,,,,,,,,,,Gross Charge Type: Central
HC MESALT RIBBON 3/4 X 39 IN,27202044,CDM,272,RC,A6260,HCPCS,,,facility,both,,,,10,7,,,,,,,,,,,,,Gross Charge Type: Central
HC ARCADIA CURVED DELIVERY CANNULA,27202045,CDM,272,RC,27202045,HCPCS,,,facility,both,,,,2480,1736,,,,,,,,,,,,,Gross Charge Type: Central
HC SHEATH STEERABLE,27202053,CDM,272,RC,C1776,HCPCS,,,facility,both,,,,2228,1559.6,,,,,,,,,,,,,Gross Charge Type: Central
HC SYSTEM LOADING NAVITOR TAVI SMALL,27202054,CDM,272,RC,27202054,HCPCS,,,facility,both,,,,1810,1267,,,,,,,,,,,,,Gross Charge Type: Central
HC SYSTEM CATHETER DELIVERY FEXNAV 5.0 VES 15 FR,27202055,CDM,272,RC,27202055,HCPCS,,,facility,both,,,,5955,4168.5,,,,,,,,,,,,,Gross Charge Type: Central
HC TOOL EPSILA EV  LEAD TRANSV/STERNAL TNL,27202056,CDM,272,RC,27202056,HCPCS,,,facility,both,,,,3564,2494.8,,,,,,,,,,,,,Gross Charge Type: Central
HC CAVACLEAR LASER SHEATH 16 FR,27202058,CDM,272,RC,C1603,HCPCS,,,facility,both,,,,9401,6580.7,,,,,,,,,,,,,Gross Charge Type: Central
HC INDIGO SYSTEM CAT7D KIT,27202059,CDM,272,RC,C1887,HCPCS,,,facility,both,,,,8049,5634.3,,,,,,,,,,,,,Gross Charge Type: Central
HC SHTH AMP TREVISIO 45D,27202060,CDM,272,RC,C1894,HCPCS,,,facility,both,,,,1958,1370.6,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER ARROW THERMODILUTION 5FR X 10MM X 80CM,27202082,CDM,272,RC,27202082,HCPCS,,,facility,both,,,,797,557.9,,,,,,,,,,,,,Gross Charge Type: Central
HC INDIGO CATHETER 12 100CM XTORQ INCLUDING LIGHTNING BOLT ASPIRATION TUBING,27202084,CDM,272,RC,27202084,HCPCS,,,facility,both,,,,22546,15782.2,,,,,,,,,,,,,Gross Charge Type: Central
HC KT MINIONE LOW PROFILE BALLON BUTTON G-TUBE 14FR X 1.5 CM,27202085,CDM,272,RC,27202085,HCPCS,,,facility,both,,,,388,271.6,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH SOFT-VU COBRA1/MP 4FR/5FR X 100CM/65CM,27202091,CDM,272,RC,C1887,HCPCS,,,facility,both,,,,162,113.4,,,,,,,,,,,,,Gross Charge Type: Central
HC SABER 0.018 PTA DILATATION CATHETER,27202092,CDM,272,RC,C1725,HCPCS,,,facility,both,,,,780,546,,,,,,,,,,,,,Gross Charge Type: Central
HC GW NITINOL GLD,27202096,CDM,272,RC,C1769,HCPCS,,,facility,both,,,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Central
HC VASCULAR SPECIALTY GUIDEWIRE,27202097,CDM,272,RC,C1769,HCPCS,,,facility,both,,,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH PERFORMA 4FR 70CM JL2,27202100,CDM,272,RC,27202100,HCPCS,,,facility,both,,,,128,89.6,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH PERFORM INF PGTL 4FR 65CM,27202101,CDM,272,RC,27202101,HCPCS,,,facility,both,,,,168,117.6,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH PERFORM INF PGTL 4FR 80CM,27202102,CDM,272,RC,27202102,HCPCS,,,facility,both,,,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH SOFTVU COBRA1 4FR 65CM,27202104,CDM,272,RC,C1887,HCPCS,,,facility,both,,,,162,113.4,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH ROYAL FLUSH PIGTAIL 5FR 100CM,27202105,CDM,272,RC,C1887,HCPCS,,,facility,both,,,,126,88.2,,,,,,,,,,,,,Gross Charge Type: Central
HC HAMILTON T1/C1/MRI EXPIRATORY VALVE SET SINGLE USE,27202106,CDM,272,RC,27202106,HCPCS,,,facility,both,,,,151,105.7,,,,,,,,,,,,,Gross Charge Type: Central
HC STYLET INTUBATION GLIDERITE 6MM TUBE LARGE,27202121,CDM,272,RC,27202121,HCPCS,,,facility,both,,,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH VARIPULSE BI-DIRECTIONAL 8.5FR,27202123,CDM,272,RC,C1732,HCPCS,,,facility,both,,,,14547,10182.9,,,,,,,,,,,,,Gross Charge Type: Central
HC CABLE VARIPULSE INTERFACE,27202124,CDM,272,RC,27202124,HCPCS,,,facility,both,,,,2296,1607.2,,,,,,,,,,,,,Gross Charge Type: Central
HC INTRODUCER CATHETER PINNACLE 4/7/8 FR X 10 CM .038,27202126,CDM,272,RC,C1894,HCPCS,,,facility,both,,,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Central
HC INTRODUCER CATHETER BRITE TIP 9/10 FR X 35/45 MM X 23 CM,27202137,CDM,272,RC,27202137,HCPCS,,,facility,both,,,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PROC WATCHMAN TRUSTEER ACCESS SYSTEM,27202145,CDM,272,RC,27202145,HCPCS,,,facility,both,,,,4455,3118.5,,,,,,,,,,,,,Gross Charge Type: Central
HC CABLE AFFERA EXTENSION CATHETER,27202153,CDM,272,RC,27202153,HCPCS,,,facility,both,,,,5940,4158,,,,,,,,,,,,,Gross Charge Type: Central
HC SET TUBING AFFERA HEXAFLOW,27202154,CDM,272,RC,27202154,HCPCS,,,facility,both,,,,905,633.5,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER SPHERE-9 AFFERA MAPPING AND ABLATION,27202155,CDM,272,RC,C1733,HCPCS,,,facility,both,,,,25410,17787,,,,,,,,,,,,,Gross Charge Type: Central
HC NANOKNIFE SINGLE ELECTRODE ACTIVATION PROBE 15 CM,27202161,CDM,272,RC,27202161,HCPCS,,,facility,both,,,,9801,6860.7,,,,,,,,,,,,,Gross Charge Type: Central
HC IODOSORB GEL TUBE 10MG,27202162,CDM,272,RC,A6261,HCPCS,,,facility,both,,,,101,70.7,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETER BALLOON DILATION AGENT PACLITAXEL 2.00/4.00 X 12MM/30MM,27202168,CDM,272,RC,C9610,HCPCS,,,facility,both,,,,13052,9136.4,,,,,,,,,,,,,Gross Charge Type: Central
HC KIT STYLET LEAD J CURVED 53 CM,27202169,CDM,272,RC,27202169,HCPCS,,,facility,both,,,,157,109.9,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH GUIDELINER CRV 6/7 FR X .07X.078IN,27202196,CDM,272,RC,C1887,HCPCS,,,facility,both,,,,1322,925.4,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH TRUE DILATION 20MMX4.5CM,27202198,CDM,272,RC,C1725,HCPCS,,,facility,both,,,,4901,3430.7,,,,,,,,,,,,,Gross Charge Type: Central
HC INTRO R2P SLNDR STR 6FR 149/119 CM,27202199,CDM,272,RC,C1887,HCPCS,,,facility,both,,,,1264,884.8,,,,,,,,,,,,,Gross Charge Type: Central
HC LEADLESS PACEMAKER SINGLE CHAMBER,27500009,CDM,275,RC,C1786,HCPCS,,,facility,both,,,,23080,16156,,,,,,,,,,,,,Gross Charge Type: Central
HC LEADLESS PACEMAKER AV MEDTRONIC DUAL CHAMBER,27500010,CDM,275,RC,C1786,HCPCS,,,facility,both,,,,29391,20573.7,,,,,,,,,,,,,Gross Charge Type: Central
HC ALLOGRAFT BONE TUBE,27800046,CDM,278,RC,C1713,HCPCS,,,facility,both,,,,409,286.3,,,,,,,,,,,,,Gross Charge Type: Central
HC TUNNELED DIALYSIS CATHETER,27800047,CDM,278,RC,C1750,HCPCS,,,facility,both,,,,1399,979.3,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH SINGLE LUMEN UVC 3.5 FR,27800048,CDM,278,RC,C1751,HCPCS,,,facility,both,,,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH TRIPLE LUMEN CVC KIT W/SHRP,27800050,CDM,272,RC,C1751,HCPCS,,,facility,both,,,,146,102.2,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH SINGLE LUMEN CVC,27800054,CDM,278,RC,C1751,HCPCS,,,facility,both,,,,358,250.6,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH CVC SET,27800056,CDM,272,RC,C1751,HCPCS,,,facility,both,,,,647,452.9,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH INF CENTRAL,27800057,CDM,278,RC,C1751,HCPCS,,,facility,both,,,,468,327.6,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH DOUBLE LUMEN SET 4.0,27800058,CDM,278,RC,C1751,HCPCS,,,facility,both,,,,528,369.6,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH CVL TUNNELED A,27800060,CDM,278,RC,C1751,HCPCS,,,facility,both,,,,1400,980,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH CVL TUNNELED B,27800061,CDM,278,RC,C1751,HCPCS,,,facility,both,,,,1694,1185.8,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH MICRO-INFUSION,27800062,CDM,278,RC,C1751,HCPCS,,,facility,both,,,,1894,1325.8,,,,,,,,,,,,,Gross Charge Type: Central
CLOSURE DEVICE,27800063,CDM,278,RC,C1760,HCPCS,,,facility,both,,,,820,574,,,,,,,,,,,,,Gross Charge Type: Central
HC CLOSURE E ANGIO-SEAL,27800064,CDM,278,RC,C1760,HCPCS,,,facility,both,,,,820,574,,,,,,,,,,,,,Gross Charge Type: Central
HC VASCULAR CLOSURE DEVICE,27800065,CDM,278,RC,C1760,HCPCS,,,facility,both,,,,1061,742.7,,,,,,,,,,,,,Gross Charge Type: Central
HC LOOP RECORDER MEDTRONIC,27800067,CDM,278,RC,C1764,HCPCS,,,facility,both,,,,11435,8004.5,,,,,,,,,,,,,Gross Charge Type: Central
HC IMPLANTABLE CV PORT C,27800071,CDM,278,RC,C1788,HCPCS,,,facility,both,,,,1957,1369.9,,,,,,,,,,,,,Gross Charge Type: Central
HC BARD CATHETER/PORT,27800072,CDM,278,RC,C1788,HCPCS,,,facility,both,,,,2035,1424.5,,,,,,,,,,,,,Gross Charge Type: Central
HC IMPLANTABLE CV PORT A,27800073,CDM,278,RC,C1788,HCPCS,,,facility,both,,,,2055,1438.5,,,,,,,,,,,,,Gross Charge Type: Central
HC IMPLANTABLE CV PORT B,27800074,CDM,278,RC,C1788,HCPCS,,,facility,both,,,,2648,1853.6,,,,,,,,,,,,,Gross Charge Type: Central
HC AMPLATZER DUCT OCCLUDER,27800075,CDM,278,RC,C1817,HCPCS,,,facility,both,,,,3524,2466.8,,,,,,,,,,,,,Gross Charge Type: Central
CARDIAC SEPTAL DEFECT IMPLANT SYSTEM,27800076,CDM,278,RC,C1817,HCPCS,,,facility,both,,,,8718,6102.6,,,,,,,,,,,,,Gross Charge Type: Central
HC INTEGRITY DRUG ELUTING STENT,27800077,CDM,278,RC,C1874,HCPCS,,,facility,both,,,,2677,1873.9,,,,,,,,,,,,,Gross Charge Type: Central
HC INTRAVASC COATED W/DEL STENT C,27800078,CDM,278,RC,C1874,HCPCS,,,facility,both,,,,7396,5177.2,,,,,,,,,,,,,Gross Charge Type: Central
WALLFLEX ESOPHAGEAL STENT W/ DEL SYSTEM,27800079,CDM,278,RC,C1874,HCPCS,,,facility,both,,,,7821,5474.7,,,,,,,,,,,,,Gross Charge Type: Central
HC WALLFLEX BILIARY STENT,27800081,CDM,278,RC,C1874,HCPCS,,,facility,both,,,,9419,6593.3,,,,,,,,,,,,,Gross Charge Type: Central
HC INTRAVASC COATED W/DEL STENT D,27800085,CDM,278,RC,C1874,HCPCS,,,facility,both,,,,12978,9084.6,,,,,,,,,,,,,Gross Charge Type: Central
HC COVERED STENT,27800087,CDM,278,RC,C1875,HCPCS,,,facility,both,,,,11237,7865.9,,,,,,,,,,,,,Gross Charge Type: Central
HC INTRAVASC NONCOATED W/DEL STENT A,27800088,CDM,278,RC,C1876,HCPCS,,,facility,both,,,,3178,2224.6,,,,,,,,,,,,,Gross Charge Type: Central
HC INTRAVASC NONCOATED W/DEL STENT B,27800089,CDM,278,RC,C1876,HCPCS,,,facility,both,,,,3178,2224.6,,,,,,,,,,,,,Gross Charge Type: Central
HC LIFESTENT VASC STENT < 100MM NON-COV,27800090,CDM,278,RC,C1876,HCPCS,,,facility,both,,,,1947,1362.9,,,,,,,,,,,,,Gross Charge Type: Central
HC BARE METAL STENT,27800091,CDM,278,RC,C1876,HCPCS,,,facility,both,,,,3980,2786,,,,,,,,,,,,,Gross Charge Type: Central
HC STENT WITH DELIVERY SYSTEM,27800093,CDM,278,RC,C1876,HCPCS,,,facility,both,,,,4792,3354.4,,,,,,,,,,,,,Gross Charge Type: Central
HC VISION STENT,27800095,CDM,278,RC,C1876,HCPCS,,,facility,both,,,,5550,3885,,,,,,,,,,,,,Gross Charge Type: Central
HC LIFESTENT VASC STENT 170MM NON-COV,27800096,CDM,278,RC,C1876,HCPCS,,,facility,both,,,,8257,5779.9,,,,,,,,,,,,,Gross Charge Type: Central
TISSUE MARKER-IMPLANTABLE (EACH),27800097,CDM,278,RC,A4648,HCPCS,,,facility,both,,,,179,125.3,,,,,,,,,,,,,Gross Charge Type: Central
HC GOLD ANCHOR FIDUCIAL MARKER,27800098,CDM,278,RC,A4648,HCPCS,,,facility,both,,,,600,420,,,,,,,,,,,,,Gross Charge Type: Central
HC IVC FILTER,27800099,CDM,278,RC,C1880,HCPCS,,,facility,both,,,,3328,2329.6,,,,,,,,,,,,,Gross Charge Type: Central
HC NEPHRO-URETERAL STENT TEMP W/ DEL SYS,27800100,CDM,278,RC,C2625,HCPCS,,,facility,both,,,,509,356.3,,,,,,,,,,,,,Gross Charge Type: Central
CATHETER VASCULAR VSD OCCLUDER,27800101,CDM,278,RC,C2628,HCPCS,,,facility,both,,,,22764,15934.8,,,,,,,,,,,,,Gross Charge Type: Central
HC INTERLOCK COILS 2D,27800102,CDM,278,RC,27800102,HCPCS,,,facility,both,,,,1918,1342.6,,,,,,,,,,,,,Gross Charge Type: Central
HC EMBOLIZATION PRODUCT J COIL DETACH CONTR,27800103,CDM,278,RC,27800103,HCPCS,,,facility,both,,,,799,559.3,,,,,,,,,,,,,Gross Charge Type: Central
HC VASCULAR PLUG,27800104,CDM,278,RC,27800104,HCPCS,,,facility,both,,,,1985,1389.5,,,,,,,,,,,,,Gross Charge Type: Central
HC EMBOLIZATION PRODUCT I DETACH FRAM COIL,27800105,CDM,278,RC,27800105,HCPCS,,,facility,both,,,,3993,2795.1,,,,,,,,,,,,,Gross Charge Type: Central
HC EMBOLIZATION PRODUCT H DETACH HELI COIL,27800106,CDM,278,RC,27800106,HCPCS,,,facility,both,,,,4327,3028.9,,,,,,,,,,,,,Gross Charge Type: Central
HC EMBOLIZATION PRODUCT K DRUG ELUTING SPHERES EACH VIAL,27800107,CDM,278,RC,27800107,HCPCS,,,facility,both,,,,6450,4515,,,,,,,,,,,,,Gross Charge Type: Central
HC MELODY VALVE PB1018,27800108,CDM,278,RC,27800108,HCPCS,,,facility,both,,,,63888,44721.6,,,,,,,,,,,,,Gross Charge Type: Central
HC LOOP RECORDER ST JUDE,27800114,CDM,278,RC,C1764,HCPCS,,,facility,both,,,,11647,8152.9,,,,,,,,,,,,,Gross Charge Type: Central
HC BRACHYTX SOURCE NON-STR HDR IR-192 PER SOURCE,27800120,CDM,278,RC,C1717,HCPCS,,,facility,both,,,,746,522.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PERIPHERAL STENT,27800123,CDM,278,RC,C1876,HCPCS,,,facility,both,,,,4228,2959.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PROPEL MINI,27800124,CDM,278,RC,27800124,HCPCS,,,facility,both,,,,5559,3891.3,,,,,,,,,,,,,Gross Charge Type: Central
HC IMPELLA 25 ALC PUMP SET US,27800127,CDM,278,RC,27800127,HCPCS,,,facility,both,,,,66550,46585,,,,,,,,,,,,,Gross Charge Type: Central
HC I-CAST BALLOON EXPANDABLE COVERED STENT,27800129,CDM,278,RC,C1874,HCPCS,,,facility,both,,,,11314,7919.8,,,,,,,,,,,,,Gross Charge Type: Central
HC TRANSLUMINAL BILIARY BIOPSY FORCEPS,27800132,CDM,278,RC,27800132,HCPCS,,,facility,both,,,,2271,1589.7,,,,,,,,,,,,,Gross Charge Type: Central
HC CAROTID WALLSTENT 8X29 5FR MR,27800133,CDM,278,RC,c1876,HCPCS,,,facility,both,,,,6374,4461.8,,,,,,,,,,,,,Gross Charge Type: Central
HC IMPELLA 5.0 ALC PUMP SET,27800134,CDM,278,RC,27800134,HCPCS,,,facility,both,,,,74536,52175.2,,,,,,,,,,,,,Gross Charge Type: Central
HC IMPELLA 3.4 ALC PUMP SET,27800135,CDM,278,RC,27800135,HCPCS,,,facility,both,,,,66550,46585,,,,,,,,,,,,,Gross Charge Type: Central
HC AMPLATZER DUCT OCCLUDER PDA 4F 90 DEG CURVE,27800137,CDM,278,RC,27800137,HCPCS,,,facility,both,,,,13644,9550.8,,,,,,,,,,,,,Gross Charge Type: Central
HC NIT-OCCLUD PDA CLOSURE SYSTEM W/FLEX SHEATH ALL SIZES,27800142,CDM,278,RC,C1760,HCPCS,,,facility,both,,,,5649,3954.3,,,,,,,,,,,,,Gross Charge Type: Central
HC CARDIOFORM SEPTAL OCCLUDER,27800144,CDM,278,RC,C1817,HCPCS,,,facility,both,,,,18233,12763.1,,,,,,,,,,,,,Gross Charge Type: Central
HC ALLOGRAFT BONE TUBE LARGE,27800145,CDM,278,RC,C1713,HCPCS,,,facility,both,,,,1060,742,,,,,,,,,,,,,Gross Charge Type: Central
HC OPTIMESH MESH POUCH LARGE,27800146,CDM,278,RC,C1781,HCPCS,,,facility,both,,,,15972,11180.4,,,,,,,,,,,,,Gross Charge Type: Central
HC MITRA CLIP SYSTEM KIT,27800149,CDM,278,RC,27800149,HCPCS,,,facility,both,,,,79860,55902,,,,,,,,,,,,,Gross Charge Type: Central
HC STENT EPIC ILIAC,27800152,CDM,278,RC,C1876,HCPCS,,,facility,both,,,,2330,1631,,,,,,,,,,,,,Gross Charge Type: Central
HC SYNERGY DRUG ELUTING STENT,27800153,CDM,278,RC,C1874,HCPCS,,,facility,both,,,,2968,2077.6,,,,,,,,,,,,,Gross Charge Type: Central
HC SURESCAN PATIENT RECHARGING SYSTEM,27800158,CDM,278,RC,27800158,HCPCS,,,facility,both,,,,2980,2086,,,,,,,,,,,,,Gross Charge Type: Central
HC VALVE IN CARTRIDGE HUD,27800166,CDM,278,RC,27800166,HCPCS,,,facility,both,,,,8819,6173.3,,,,,,,,,,,,,Gross Charge Type: Central
HC BARE CP STENT SHORT,27800167,CDM,278,RC,27800167,HCPCS,,,facility,both,,,,9152,6406.4,,,,,,,,,,,,,Gross Charge Type: Central
HC BARE CP STENT LONG,27800168,CDM,278,RC,27800168,HCPCS,,,facility,both,,,,9818,6872.6,,,,,,,,,,,,,Gross Charge Type: Central
HC COVERED CP STENT SHORT,27800169,CDM,278,RC,27800169,HCPCS,,,facility,both,,,,14242,9969.4,,,,,,,,,,,,,Gross Charge Type: Central
HC COVERED CP STENT LONG,27800170,CDM,278,RC,27800170,HCPCS,,,facility,both,,,,14775,10342.5,,,,,,,,,,,,,Gross Charge Type: Central
HC MOUNTED COVERED CP STENT SHORT,27800171,CDM,278,RC,27800171,HCPCS,,,facility,both,,,,17437,12205.9,,,,,,,,,,,,,Gross Charge Type: Central
HC MOUNTED COVERED CP STENT LONG,27800172,CDM,278,RC,27800172,HCPCS,,,facility,both,,,,17969,12578.3,,,,,,,,,,,,,Gross Charge Type: Central
HC HERCULINK STENT NON-COATED/NON-COVERED W/DELIVERY SYSTEM,27800174,CDM,278,RC,C1876,HCPCS,,,facility,both,,,,2647,1852.9,,,,,,,,,,,,,Gross Charge Type: Central
HC ABBOTT VASCULAR STENTS,27800175,CDM,278,RC,C1876,HCPCS,,,facility,both,,,,5772,4040.4,,,,,,,,,,,,,Gross Charge Type: Central
HC ABSOLUTE STENT SYSTEM NON-COATED/NON-COVERED W/DELIVERY SYSTEM,27800176,CDM,278,RC,C1876,HCPCS,,,facility,both,,,,2876,2013.2,,,,,,,,,,,,,Gross Charge Type: Central
HC OMNILINK STENT NON-COATED/NON-COVERED W/DELIVERY SYSTEM,27800177,CDM,278,RC,C1876,HCPCS,,,facility,both,,,,2317,1621.9,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH TRANSLUMINAL LASER TURBO ELITE .9MM,27800178,CDM,278,RC,C1885,HCPCS,,,facility,both,,,,13295,9306.5,,,,,,,,,,,,,Gross Charge Type: Central
HC LD DBL STENT,27800185,CDM,278,RC,27800185,HCPCS,,,facility,both,,,,2396,1677.2,,,,,,,,,,,,,Gross Charge Type: Central
HC MARIGEN MICRO 8 CM,27800186,CDM,278,RC,Q4158,HCPCS,,,facility,both,,,,1863,1304.1,,,,,,,,,,,,,Gross Charge Type: Central
HC RUBY COIL POD OCCLUSION J 60,27800187,CDM,278,RC,27800187,HCPCS,,,facility,both,,,,3713,2599.1,,,,,,,,,,,,,Gross Charge Type: Central
HC RUBY COIL CMPLX SOFT 3MM X 5CM,27800188,CDM,278,RC,27800188,HCPCS,,,facility,both,,,,2228,1559.6,,,,,,,,,,,,,Gross Charge Type: Central
HC HARMONY TRANSCATHETER PULM SYSTEM,27800189,CDM,278,RC,27800189,HCPCS,,,facility,both,,,,19635,13744.5,,,,,,,,,,,,,Gross Charge Type: Central
HC HARMONY VALVE PULMONARY TRANSCATHETER,27800190,CDM,278,RC,27800190,HCPCS,,,facility,both,,,,76230,53361,,,,,,,,,,,,,Gross Charge Type: Central
HC SMOOTH RESPONSIVE (SR),27800192,CDM,278,RC,27800192,HCPCS,,,facility,both,,,,901,630.7,,,,,,,,,,,,,Gross Charge Type: Central
HC SMOOTH SOFT TOUCH (SS),27800193,CDM,278,RC,27800193,HCPCS,,,facility,both,,,,1241,868.7,,,,,,,,,,,,,Gross Charge Type: Central
HC SMOOTH COHESIVE (SC),27800194,CDM,278,RC,27800194,HCPCS,,,facility,both,,,,1241,868.7,,,,,,,,,,,,,Gross Charge Type: Central
HC MARIGEN MICRO 4 CM,27800196,CDM,278,RC,Q4158,HCPCS,,,facility,both,,,,1578,1104.6,,,,,,,,,,,,,Gross Charge Type: Central
HC STENT PERIPHERAL ESPRIT EVROL 3.0/3.75 X 18/38 MM,27800197,CDM,278,RC,C1874,HCPCS,,,facility,both,,,,8317,5821.9,,,,,,,,,,,,,Gross Charge Type: Central
HC AMPLATZER PFO OCCLUDER,27800315,CDM,278,RC,C1817,HCPCS,,,facility,both,,,,25398,17778.6,,,,,,,,,,,,,Gross Charge Type: Central
HC SENSATION PLUS 7.5FR 40CC FIBER-OPTIC BALLOON CATH,27800316,CDM,272,RC,27800316,HCPCS,,,facility,both,,,,3288,2301.6,,,,,,,,,,,,,Gross Charge Type: Central
HC VALVE IN CARTRIDGE 9MM,27800317,CDM,278,RC,27800317,HCPCS,,,facility,both,,,,11064,7744.8,,,,,,,,,,,,,Gross Charge Type: Central
HC VLV COREVALVE EVOLUT R 34MM,27800318,CDM,278,RC,27800318,HCPCS,,,facility,both,,,,76230,53361,,,,,,,,,,,,,Gross Charge Type: Central
HC KIT VALVE SAPIEN 3 W COMMANDER 20MM,27800319,CDM,278,RC,27800319,HCPCS,,,facility,both,,,,82583,57808.1,,,,,,,,,,,,,Gross Charge Type: Central
HC STNT MINI TB CVRD,27800324,CDM,278,RC,C1874,HCPCS,,,facility,both,,,,8337,5835.9,,,,,,,,,,,,,Gross Charge Type: Central
HC STNT TB CVRD,27800325,CDM,278,RC,C1874,HCPCS,,,facility,both,,,,8337,5835.9,,,,,,,,,,,,,Gross Charge Type: Central
HC AEROSIZER STENT SIZING DEVICE,27800326,CDM,278,RC,C1874,HCPCS,,,facility,both,,,,968,677.6,,,,,,,,,,,,,Gross Charge Type: Central
HC MONITOR LINQ IMPLANT CARD,27800327,CDM,278,RC,27800327,HCPCS,,,facility,both,,,,13456,9419.2,,,,,,,,,,,,,Gross Charge Type: Central
HC STENT RESOLUTE ONYX RX,27800330,CDM,278,RC,C1874,HCPCS,,,facility,both,,,,4154,2907.8,,,,,,,,,,,,,Gross Charge Type: Central
HC ANGIOJET THROMBECTOMY CATHETER SOLENT OMNI 6FR 120CM,27800331,CDM,278,RC,C1757,HCPCS,,,facility,both,,,,5196,3637.2,,,,,,,,,,,,,Gross Charge Type: Central
HC ANGIOJET THROMBECTOMY CATHETER SOLENT PROXI 6FR 90CM,27800332,CDM,278,RC,C1757,HCPCS,,,facility,both,,,,4875,3412.5,,,,,,,,,,,,,Gross Charge Type: Central
HC ANGIOJET THROMBECTOMY CATHETER ZELANTE 8FR 105CM,27800333,CDM,278,RC,C1757,HCPCS,,,facility,both,,,,9107,6374.9,,,,,,,,,,,,,Gross Charge Type: Central
HC COIL TARGET 360 ULTRA 2MM X 3CM,27800334,CDM,278,RC,27800334,HCPCS,,,facility,both,,,,6687,4680.9,,,,,,,,,,,,,Gross Charge Type: Central
HC COIL TARGET HELLCAL ULTRA DETACHABLE 2MM X 1CM,27800335,CDM,278,RC,27800335,HCPCS,,,facility,both,,,,4571,3199.7,,,,,,,,,,,,,Gross Charge Type: Central
HC COIL TARGET XL 360 STANDARD DETACHABLE 6MM X 20CM,27800336,CDM,278,RC,27800336,HCPCS,,,facility,both,,,,8836,6185.2,,,,,,,,,,,,,Gross Charge Type: Central
HC COIL TARGET XL HELLCAL DETACHABLE 5MM X 15CM,27800337,CDM,278,RC,27800337,HCPCS,,,facility,both,,,,6322,4425.4,,,,,,,,,,,,,Gross Charge Type: Central
HC COIL TARGET 3D DETACHABLE 3MM X 6CM,27800338,CDM,278,RC,27800338,HCPCS,,,facility,both,,,,6703,4692.1,,,,,,,,,,,,,Gross Charge Type: Central
HC SYS NEUROFORM ATLAS STENT 3 X 15,27800339,CDM,278,RC,27800339,HCPCS,,,facility,both,,,,8335,5834.5,,,,,,,,,,,,,Gross Charge Type: Central
HC SYS WINGSPAN STENT 2.5 X 9MM,27800340,CDM,278,RC,27800340,HCPCS,,,facility,both,,,,17611,12327.7,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH GATEWAY PTA BLLN 1.5 X 9,27800341,CDM,278,RC,27800341,HCPCS,,,facility,both,,,,3657,2559.9,,,,,,,,,,,,,Gross Charge Type: Central
HC GLUE TRUFILL LIQ EMBOLIC 2GM,27800345,CDM,278,RC,27800345,HCPCS,,,facility,both,,,,17844,12490.8,,,,,,,,,,,,,Gross Charge Type: Central
HC IMPL PULSRIDER Y ARCH,27800346,CDM,278,RC,27800346,HCPCS,,,facility,both,,,,15125,10587.5,,,,,,,,,,,,,Gross Charge Type: Central
HC DEV PIPELINE FLX EMBOL,27800351,CDM,278,RC,27800351,HCPCS,,,facility,both,,,,33607,23524.9,,,,,,,,,,,,,Gross Charge Type: Central
HC DEV PIPELINE FLX EMBOL LONG,27800352,CDM,278,RC,27800352,HCPCS,,,facility,both,,,,36148,25303.6,,,,,,,,,,,,,Gross Charge Type: Central
HC COIL MICROFRAME,27800355,CDM,278,RC,27800355,HCPCS,,,facility,both,,,,6065,4245.5,,,,,,,,,,,,,Gross Charge Type: Central
HC MICRUSFRAME,27800356,CDM,278,RC,27800356,HCPCS,,,facility,both,,,,5729,4010.3,,,,,,,,,,,,,Gross Charge Type: Central
HC GALAXY G3,27800357,CDM,278,RC,27800357,HCPCS,,,facility,both,,,,46945,32861.5,,,,,,,,,,,,,Gross Charge Type: Central
HC STENT PK PAPYRUS,27800359,CDM,278,RC,C1874,HCPCS,,,facility,both,,,,9620,6734,,,,,,,,,,,,,Gross Charge Type: Central
HC STENT SYNERGY XD MR,27800363,CDM,278,RC,C1874,HCPCS,,,facility,both,,,,3509,2456.3,,,,,,,,,,,,,Gross Charge Type: Central
HC RENAL BALLON EXPANDABLE STENT NON COATED/NON-COVERED W/DELIVERY SYSTEM,27800365,CDM,278,RC,C1876,HCPCS,,,facility,both,,,,3369,2358.3,,,,,,,,,,,,,Gross Charge Type: Central
HC STENT VIABAHN VBX,27800367,CDM,278,RC,C1874,HCPCS,,,facility,both,,,,11975,8382.5,,,,,,,,,,,,,Gross Charge Type: Central
HC ELUVIA STENT COVERED W/DELIVERY SYSTEM 6/7 X 100/120 X 130,27800368,CDM,278,RC,C1874,HCPCS,,,facility,both,,,,9284,6498.8,,,,,,,,,,,,,Gross Charge Type: Central
HC SYSTEM LINQII INSERTABLE CARDIAC MONITOR,27800369,CDM,278,RC,C1764,HCPCS,,,facility,both,,,,14896,10427.2,,,,,,,,,,,,,Gross Charge Type: Central
HC STENT VIABAHN ENDOPROSTHESIS W/HEPARIN 6/7 MM X 25CM X 120CM,27800370,CDM,278,RC,C1874,HCPCS,,,facility,both,,,,18213,12749.1,,,,,,,,,,,,,Gross Charge Type: Central
HC STENT ENDOPROSTHESIS WITH HEPARIN 5/6MM / 2.5/5.0 CM / 120CM,27800371,CDM,278,RC,C1874,HCPCS,,,facility,both,,,,11660,8162,,,,,,,,,,,,,Gross Charge Type: Central
HC SYSTEM INDIGO SEPARATOR,27800372,CDM,278,RC,27800372,HCPCS,,,facility,both,,,,5064,3544.8,,,,,,,,,,,,,Gross Charge Type: Central
HC ABRE VENOUS SELF-EXPANDING STENT SYSTEM,27800373,CDM,278,RC,C1876,HCPCS,,,facility,both,,,,5437,3805.9,,,,,,,,,,,,,Gross Charge Type: Central
HC ABRE VENOUS SELF-EXPANDING STENT SYSTEM 12/14/16/18 MM X 150MM,27800374,CDM,278,RC,C1876,HCPCS,,,facility,both,,,,6175,4322.5,,,,,,,,,,,,,Gross Charge Type: Central
HC STENT VIABAHN ENDOPROSTHESIS W/HEPARIN 7MM X 15CM X 120CM,27800375,CDM,278,RC,C1874,HCPCS,,,facility,both,,,,12865,9005.5,,,,,,,,,,,,,Gross Charge Type: Central
HC STENT VIABAHN ENDOPROSTHESIS W/HEPARIN 8MM X 10CM X 120CM,27800376,CDM,278,RC,C1874,HCPCS,,,facility,both,,,,11550,8085,,,,,,,,,,,,,Gross Charge Type: Central
HC VALVE COREVALVE EVOLUT PRO 29MM,27800377,CDM,278,RC,27800377,HCPCS,,,facility,both,,,,69300,48510,,,,,,,,,,,,,Gross Charge Type: Central
HC KIT VALVE SAPIEN 3 W COMMANDER 29MM,27800378,CDM,278,RC,27800378,HCPCS,,,facility,both,,,,75075,52552.5,,,,,,,,,,,,,Gross Charge Type: Central
HC RUBY COIL POD OCCLUSION 4,27800379,CDM,278,RC,27800379,HCPCS,,,facility,both,,,,4927,3448.9,,,,,,,,,,,,,Gross Charge Type: Central
HC COIL EMBOLIZATION OCCLUSION 2MM X 3MM X 2.3CM,27800380,CDM,278,RC,27800380,HCPCS,,,facility,both,,,,1268,887.6,,,,,,,,,,,,,Gross Charge Type: Central
HC COIL EMBOLIZATION INTERLOCK 10MM X 50CM,27800381,CDM,278,RC,27800381,HCPCS,,,facility,both,,,,2048,1433.6,,,,,,,,,,,,,Gross Charge Type: Central
HC INTERLOCK 35 COIL 2D 6/8 MM X 20CM,27800382,CDM,278,RC,27800382,HCPCS,,,facility,both,,,,2133,1493.1,,,,,,,,,,,,,Gross Charge Type: Central
HC INTERLOCK 35 COIL 2D 10/12/15 MM X 40CM,27800383,CDM,278,RC,27800383,HCPCS,,,facility,both,,,,2467,1726.9,,,,,,,,,,,,,Gross Charge Type: Central
HC EPSILA EV QUADRIPOLAR LEAD W/SHAPED PASSIVE FIXATION,27800384,CDM,278,RC,C1896,HCPCS,,,facility,both,,,,12451,8715.7,,,,,,,,,,,,,Gross Charge Type: Central
HC TEMPERATURE MANAGEMENT DEVICE ESOPHAGEAL,27803834,CDM,278,RC,C1889,HCPCS,,,facility,both,,,,2447,1712.9,,,,,,,,,,,,,Gross Charge Type: Central
HC KIT VALVE SAPIEN 3 RESILIA,27803839,CDM,278,RC,27803839,HCPCS,,,facility,both,,,,82500,57750,,,,,,,,,,,,,Gross Charge Type: Central
HC MARIGEN 16 MM CIRCULAR,27803843,CDM,278,RC,Q4158,HCPCS,,,facility,both,,,,1441,1008.7,,,,,,,,,,,,,Gross Charge Type: Central
HC MARIGEN 1.75X1.75 CM,27803844,CDM,278,RC,Q4158,HCPCS,,,facility,both,,,,1530,1071,,,,,,,,,,,,,Gross Charge Type: Central
HC MARIGEN 3X3.5 CM,27803845,CDM,278,RC,Q4158,HCPCS,,,facility,both,,,,2108,1475.6,,,,,,,,,,,,,Gross Charge Type: Central
HC MARIGEN 3X7 CM,27803846,CDM,278,RC,Q4158,HCPCS,,,facility,both,,,,3359,2351.3,,,,,,,,,,,,,Gross Charge Type: Central
HC MARIGEN 5X7 CM,27803847,CDM,278,RC,Q4158,HCPCS,,,facility,both,,,,3998,2798.6,,,,,,,,,,,,,Gross Charge Type: Central
HC MARIGEN 3X3.5 CM FENESTRATED,27803848,CDM,278,RC,Q4158,HCPCS,,,facility,both,,,,2319,1623.3,,,,,,,,,,,,,Gross Charge Type: Central
HC MARIGEN 3X7 CM FENESTRATED,27803849,CDM,278,RC,Q4158,HCPCS,,,facility,both,,,,3695,2586.5,,,,,,,,,,,,,Gross Charge Type: Central
HC STENT EXPRESS NON-COATED/NON-COVERED W/DELIVERY SYSTEM,27803850,CDM,278,RC,C1876,HCPCS,,,facility,both,,,,3615,2530.5,,,,,,,,,,,,,Gross Charge Type: Central
HC DETOUR SYSTEM CAP ANY NUMBER OF TORUS STENT GRAFTS/ENDOCROSS DEVICE,27803852,CDM,278,RC,C1604,HCPCS,,,facility,both,,,,57751,40425.7,,,,,,,,,,,,,Gross Charge Type: Central
HC GORE VIABAHN ENDOPROSTHESIS W/HEPARIN 10MMX15CM 8FR 120CM CATH,27803853,CDM,278,RC,C1874,HCPCS,,,facility,both,,,,12834,8983.8,,,,,,,,,,,,,Gross Charge Type: Central
HC GORE VIABAHN ENDOPROSTHESIS W/ HEPARIN 10MMX10CM 8FR 120CM CATH,27803854,CDM,278,RC,C1874,HCPCS,,,facility,both,,,,11497,8047.9,,,,,,,,,,,,,Gross Charge Type: Central
HC GORE VIABAHN VBX BALLOON EXPANDABLE ENDOPROSTHESIS 6MM X 8MM X 19MM,27803855,CDM,278,RC,C1874,HCPCS,,,facility,both,,,,8605,6023.5,,,,,,,,,,,,,Gross Charge Type: Central
HC NAVITOR TRANSCATHETER AORTIC VALVE IMPLANT VISION 23 MM,27803856,CDM,278,RC,27803856,HCPCS,,,facility,both,,,,57750,40425,,,,,,,,,,,,,Gross Charge Type: Central
HC NAVITOR TRANSCATHETER AORTIC VALVE IMPLANT VISION 25 MM,27803857,CDM,278,RC,27803857,HCPCS,,,facility,both,,,,57750,40425,,,,,,,,,,,,,Gross Charge Type: Central
HC TRICLIP G4,27803860,CDM,278,RC,27803860,HCPCS,,,facility,both,,,,90090,63063,,,,,,,,,,,,,Gross Charge Type: Central
HC OCLR AMULET LA APPNDG 16MM/34 MM,27803861,CDM,278,RC,C1760,HCPCS,,,facility,both,,,,28875,20212.5,,,,,,,,,,,,,Gross Charge Type: Central
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL,28041,CDM,J1071,HCPCS,0574-0827-01,NDC,,,facility,both,300,ML,,171,119.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL,28041,CDM,J1071,HCPCS,0009-0417-01,NDC,,,facility,both,200,ML,,140,98,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL,28041,CDM,J1071,HCPCS,0143-9726-01,NDC,,,facility,both,400,ML,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL,28041,CDM,J1071,HCPCS,55150-277-01,NDC,,,facility,both,100,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL,28041,CDM,J1071,HCPCS,0143-9659-01,NDC,,,facility,both,100,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL,28041,CDM,J1071,HCPCS,0143-9659-01,NDC,,,facility,both,100,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL,28041,CDM,J1071,HCPCS,70700-289-22,NDC,,,facility,both,200,ML,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL,28041,CDM,J1071,HCPCS,0574-0827-01,NDC,,,facility,both,50,ML,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL,28041,CDM,J1071,HCPCS,72603-286-01,NDC,,,facility,both,200,ML,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL,28041,CDM,J1071,HCPCS,0574-0827-01,NDC,,,facility,both,76,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL,28041,CDM,J1071,HCPCS,0143-9726-01,NDC,,,facility,both,1700,ML,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL,28041,CDM,J1071,HCPCS,0409-6562-01,NDC,,,facility,both,150,ML,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL,28041,CDM,J1071,HCPCS,0574-0820-01,NDC,,,facility,both,76,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL,28041,CDM,J1071,HCPCS,70700-289-22,NDC,,,facility,both,100,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL,28041,CDM,J1071,HCPCS,0574-0827-01,NDC,,,facility,both,100,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL,28041,CDM,J1071,HCPCS,0409-6562-01,NDC,,,facility,both,50,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL,28041,CDM,J1071,HCPCS,0143-9659-01,NDC,,,facility,both,400,ML,,212,148.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL,28041,CDM,J1071,HCPCS,55150-277-01,NDC,,,facility,both,50,ML,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL,28041,CDM,J1071,HCPCS,0143-9659-01,NDC,,,facility,both,50,ML,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL,28041,CDM,J1071,HCPCS,0143-9726-01,NDC,,,facility,both,200,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL,28041,CDM,J1071,HCPCS,70700-289-22,NDC,,,facility,both,100,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL,28041,CDM,J1071,HCPCS,69097-802-32,NDC,,,facility,both,150,ML,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL,28041,CDM,J1071,HCPCS,0143-9659-01,NDC,,,facility,both,150,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL,28041,CDM,J1071,HCPCS,0143-9726-01,NDC,,,facility,both,300,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL,28041,CDM,J1071,HCPCS,55150-277-01,NDC,,,facility,both,150,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL,28041,CDM,J1071,HCPCS,0143-9659-01,NDC,,,facility,both,200,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL,28041,CDM,J1071,HCPCS,0143-9726-01,NDC,,,facility,both,1600,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL,28041,CDM,J1071,HCPCS,0143-9726-01,NDC,,,facility,both,1800,ML,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL,28041,CDM,J1071,HCPCS,0143-9659-01,NDC,,,facility,both,200,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL,28041,CDM,J1071,HCPCS,0143-9659-01,NDC,,,facility,both,150,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL,28041,CDM,J1071,HCPCS,0409-6562-01,NDC,,,facility,both,100,ML,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL,28041,CDM,J1071,HCPCS,0574-0827-01,NDC,,,facility,both,100,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL,28041,CDM,J1071,HCPCS,0143-9659-01,NDC,,,facility,both,400,ML,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL,28041,CDM,J1071,HCPCS,0143-9659-01,NDC,,,facility,both,50,ML,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL,28041,CDM,J1071,HCPCS,0574-0820-01,NDC,,,facility,both,124,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL,28041,CDM,J1071,HCPCS,0409-6562-01,NDC,,,facility,both,100,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL,28041,CDM,J1071,HCPCS,0574-0827-01,NDC,,,facility,both,124,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL,28041,CDM,J1071,HCPCS,0574-0827-01,NDC,,,facility,both,150,ML,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL,28041,CDM,J1071,HCPCS,0409-6562-01,NDC,,,facility,both,50,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 100 MG/ML IM OIL,28041,CDM,J1071,HCPCS,0409-6557-01,NDC,,,facility,both,100,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL,28041,CDM,J1071,HCPCS,0409-6562-01,NDC,,,facility,both,150,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL,28041,CDM,J1071,HCPCS,69097-802-32,NDC,,,facility,both,50,ML,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL,28041,CDM,J1071,HCPCS,0409-6562-01,NDC,,,facility,both,200,ML,,130,91,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL,28041,CDM,J1071,HCPCS,55150-277-01,NDC,,,facility,both,100,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL,28041,CDM,J1071,HCPCS,0574-0820-01,NDC,,,facility,both,100,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL,28041,CDM,J1071,HCPCS,0574-0820-01,NDC,,,facility,both,100,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL,28041,CDM,J1071,HCPCS,0574-0820-01,NDC,,,facility,both,200,ML,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL,28041,CDM,J1071,HCPCS,55150-277-01,NDC,,,facility,both,200,ML,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL,28041,CDM,J1071,HCPCS,0574-0827-01,NDC,,,facility,both,200,ML,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM HYALURONATE (VISCOSUP) 10 MG/ML(MW 2.4 -3.6 MILLION) IATC SYRG,29395,CDM,J7323,HCPCS,5556641001,NDC,,,facility,both,2,ML,,1277,893.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM HYALURONATE (VISCOSUP) 10 MG/ML(MW 2.4 -3.6 MILLION) IATC SYRG,29395,CDM,J7323,HCPCS,5556641003,NDC,,,facility,both,1,ML,,1277,893.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM HYALURONATE (VISCOSUP) 10 MG/ML(MW 2.4 -3.6 MILLION) IATC SYRG,29395,CDM,J7323,HCPCS,5556641001,NDC,,,facility,both,1,ML,,1277,893.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM HYALURONATE (VISCOSUP) 10 MG/ML(MW 2.4 -3.6 MILLION) IATC SYRG,29395,CDM,J7323,HCPCS,5556641000,NDC,,,facility,both,1,ML,,1277,893.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM HYALURONATE (VISCOSUP) 10 MG/ML(MW 2.4 -3.6 MILLION) IATC SYRG,29395,CDM,J7323,HCPCS,5556641000,NDC,,,facility,both,2,ML,,2554,1787.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM HYALURONATE (VISCOSUP) 10 MG/ML(MW 2.4 -3.6 MILLION) IATC SYRG,29395,CDM,J7323,HCPCS,5556641004,NDC,,,facility,both,1,ML,,1277,893.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM HYALURONATE (VISCOSUP) 10 MG/ML(MW 2.4 -3.6 MILLION) IATC SYRG,29395,CDM,J7323,HCPCS,5556641001,NDC,,,facility,both,2,ML,,2554,1787.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC VENOUS BLOOD DRAW,30000001,CDM,300,RC,36415,HCPCS,,,facility,both,,,,40,28,,,,,,,,,,,,,Gross Charge Type: Central
HC CAPILLARY BLOOD DRAW,30000002,CDM,300,RC,36416,HCPCS,,,facility,both,,,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Central
METABOLIC PANEL W/ TOTAL CA,30000003,CDM,300,RC,80048,HCPCS,,,facility,both,,,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Central
HC COMPREHEN METABOLIC PANEL,30000004,CDM,300,RC,80053,HCPCS,,,facility,both,,,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Central
URINALYSIS AUTO W/SCOPE,30000007,CDM,300,RC,81001,HCPCS,,,facility,both,,,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Central
URINALYSIS AUTO W/O SCOPE,30000008,CDM,300,RC,81003,HCPCS,,,facility,both,,,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Central
HC URINE PREGNANCY TEST,30000011,CDM,300,RC,81025,HCPCS,,,facility,both,,,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY SERUM CHOLINESTERASE,30000012,CDM,300,RC,82480,HCPCS,,,facility,both,,,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF CHROMIUM,30000014,CDM,300,RC,82495,HCPCS,,,facility,both,,,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Central
HC CREATINE MB FRACTION,30000015,CDM,300,RC,82553,HCPCS,,,facility,both,,,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Central
HC ENZYME CELL ACTIVITY,30000016,CDM,300,RC,82657,HCPCS,,,facility,both,,,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Central
HC GASTRIC ANALY W/ PH EA SPEC,30000017,CDM,300,RC,82930,HCPCS,,,facility,both,,,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Central
HC GLUC TOLER TEST (GTT) 3 SPECIM,30000018,CDM,300,RC,82951,HCPCS,,,facility,both,,,,193,135.1,,,,,,,,,,,,,Gross Charge Type: Central
HC EVAL AMNIOTIC FLUID PROTEIN,30000021,CDM,300,RC,84112,HCPCS,,,facility,both,,,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF PROTEIN SERUM,30000022,CDM,300,RC,84155,HCPCS,,,facility,both,,,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Central
HC HEMATOCRIT,30000024,CDM,300,RC,85014,HCPCS,,,facility,both,,,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Central
HEMOGLOBIN,30000025,CDM,300,RC,85018,HCPCS,,,facility,both,,,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Central
HC COMPLETE CBC W/AUTO DIFF WBC,30000026,CDM,300,RC,85025,HCPCS,,,facility,both,,,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Central
HC COMPLETE CBC AUTO W/O DIFF,30000027,CDM,300,RC,85027,HCPCS,,,facility,both,,,,40,28,,,,,,,,,,,,,Gross Charge Type: Central
MANUAL RETICULOCYTE COUNT,30000029,CDM,300,RC,85044,HCPCS,,,facility,both,,,,50,35,,,,,,,,,,,,,Gross Charge Type: Central
HC AUTOMATED LEUKOCYTE COUNT,30000031,CDM,300,RC,85048,HCPCS,,,facility,both,,,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Central
HC AUTOMATED PLATELET COUNT,30000032,CDM,300,RC,85049,HCPCS,,,facility,both,,,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Central
HC BLOOD CLOT FACTOR II TEST,30000033,CDM,300,RC,85210,HCPCS,,,facility,both,,,,442,309.4,,,,,,,,,,,,,Gross Charge Type: Central
HC BLOOD CLOT FACTOR V TEST,30000034,CDM,300,RC,85220,HCPCS,,,facility,both,,,,442,309.4,,,,,,,,,,,,,Gross Charge Type: Central
HC BLOOD CLOT FACTOR VII TEST,30000035,CDM,300,RC,85230,HCPCS,,,facility,both,,,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Central
HC BLOOD CLOT FACTOR VIII TEST,30000036,CDM,300,RC,85240,HCPCS,,,facility,both,,,,442,309.4,,,,,,,,,,,,,Gross Charge Type: Central
HC BLOOD CLOT FACTOR VIII VW FACTOR,30000037,CDM,300,RC,85245,HCPCS,,,facility,both,,,,486,340.2,,,,,,,,,,,,,Gross Charge Type: Central
HC BLOOD CLOT FACTOR VIII VW ANTIGEN,30000038,CDM,300,RC,85246,HCPCS,,,facility,both,,,,180,126,,,,,,,,,,,,,Gross Charge Type: Central
HC BLOOD CLOT FACTOR IX TEST,30000039,CDM,300,RC,85250,HCPCS,,,facility,both,,,,442,309.4,,,,,,,,,,,,,Gross Charge Type: Central
HC BLOOD CLOT FACTOR X TEST,30000040,CDM,300,RC,85260,HCPCS,,,facility,both,,,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Central
HC BLOOD CLOT FACTOR XI TEST,30000041,CDM,300,RC,85270,HCPCS,,,facility,both,,,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Central
HC BLOOD CLOT FACTOR XII TEST,30000042,CDM,300,RC,85280,HCPCS,,,facility,both,,,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Central
ANTITHROMBIN III TEST,30000044,CDM,300,RC,85300,HCPCS,,,facility,both,,,,261,182.7,,,,,,,,,,,,,Gross Charge Type: Central
BLOOD CLOT INHIBITOR C ACTIVITY,30000046,CDM,300,RC,85303,HCPCS,,,facility,both,,,,442,309.4,,,,,,,,,,,,,Gross Charge Type: Central
BLOOD CLOT INHIBITOR S FREE,30000047,CDM,300,RC,85306,HCPCS,,,facility,both,,,,180,126,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY ACTIVATED PROTEIN C,30000048,CDM,300,RC,85307,HCPCS,,,facility,both,,,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Central
HC FACTOR INHIBITOR TEST,30000049,CDM,300,RC,85335,HCPCS,,,facility,both,,,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Central
HC POC COAGULATION TIME ACTIVATED,30000050,CDM,300,RC,85347,HCPCS,,,facility,both,,,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Central
HC FIBRIN DEGRADATION QUANT,30000051,CDM,300,RC,85379,HCPCS,,,facility,both,,,,162,113.4,,,,,,,,,,,,,Gross Charge Type: Central
HC FIBRINOGEN,30000052,CDM,300,RC,85384,HCPCS,,,facility,both,,,,138,96.6,,,,,,,,,,,,,Gross Charge Type: Central
HC CLOTTING FUNCT ACTIVITY NOS,30000053,CDM,300,RC,85397,HCPCS,,,facility,both,,,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Central
HC FIBRINOLYTIC ANTIPLASMIN,30000054,CDM,300,RC,85410,HCPCS,,,facility,both,,,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Central
HC FIBRINOLYTIC PLASMINOGEN,30000055,CDM,300,RC,85415,HCPCS,,,facility,both,,,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Central
HC FIBRINOLYTIC PLASMINOGEN,30000056,CDM,300,RC,85420,HCPCS,,,facility,both,,,,289,202.3,,,,,,,,,,,,,Gross Charge Type: Central
HC HEMOGLOBIN FETAL,30000057,CDM,300,RC,85460,HCPCS,,,facility,both,,,,227,158.9,,,,,,,,,,,,,Gross Charge Type: Central
HC HEMOGLOBIN FETAL ROSETTE,30000058,CDM,300,RC,85461,HCPCS,,,facility,both,,,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Central
HC HEPARIN ASSAY,30000059,CDM,300,RC,85520,HCPCS,,,facility,both,,,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Central
HC MURAMIDASE,30000061,CDM,300,RC,85549,HCPCS,,,facility,both,,,,218,152.6,,,,,,,,,,,,,Gross Charge Type: Central
HC RBC OSMOTIC FRAGILITY,30000062,CDM,300,RC,85555,HCPCS,,,facility,both,,,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Central
HC BLOOD PLATELET AGGREGATION,30000063,CDM,300,RC,85576,HCPCS,,,facility,both,,,,496,347.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PROTHROMBIN TIME,30000065,CDM,300,RC,85610,HCPCS,,,facility,both,,,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Central
RUSSELL VIPER VENOM DILUTED,30000067,CDM,300,RC,85613,HCPCS,,,facility,both,,,,295,206.5,,,,,,,,,,,,,Gross Charge Type: Central
HC RBC SED RATE NONAUTOMATED,30000068,CDM,300,RC,85651,HCPCS,,,facility,both,,,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Central
HC RBC SED RATE AUTOMATED,30000069,CDM,300,RC,85652,HCPCS,,,facility,both,,,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Central
HC RBC SICKLE CELL TEST,30000070,CDM,300,RC,85660,HCPCS,,,facility,both,,,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Central
HC THROMBIN TIME PLASMA,30000071,CDM,300,RC,85670,HCPCS,,,facility,both,,,,169,118.3,,,,,,,,,,,,,Gross Charge Type: Central
HC THROMBOPLASTIN TIME PARTIAL (PTT) PLASMA OR WHOLE BLOOD,30000072,CDM,300,RC,85730,HCPCS,,,facility,both,,,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Central
HC BLOOD VISCOSITY EXAMINATION,30000073,CDM,300,RC,85810,HCPCS,,,facility,both,,,,136,95.2,,,,,,,,,,,,,Gross Charge Type: Central
HC AGGLUTININS FEBRILE,30000074,CDM,300,RC,86000,HCPCS,,,facility,both,,,,246,172.2,,,,,,,,,,,,,Gross Charge Type: Central
HC ALLERGEN SPECIFIC IGE QUANTITATIVE/SEMIQUANTITATIVE CRUDE ALLERGEN EXTRACT EACH,30000075,CDM,300,RC,86003,HCPCS,,,facility,both,,,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Central
HC WBC ANTIBODY IDENTIFICATION,30000076,CDM,300,RC,86021,HCPCS,,,facility,both,,,,146,102.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PLATELET ANTIBODIES,30000077,CDM,300,RC,86022,HCPCS,,,facility,both,,,,244,170.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PLATELET IMMUNOGLOB ASSAY,30000078,CDM,300,RC,86023,HCPCS,,,facility,both,,,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Central
HC ANTINUCLEAR ANTIBODIES (ANA),30000079,CDM,300,RC,86038,HCPCS,,,facility,both,,,,136,95.2,,,,,,,,,,,,,Gross Charge Type: Central
HC ANTINUCLEAR ANTIBODIES (ANA) TITER,30000080,CDM,300,RC,86039,HCPCS,,,facility,both,,,,213,149.1,,,,,,,,,,,,,Gross Charge Type: Central
HC ANTISTREPTOLYSIN O TITER,30000081,CDM,300,RC,86060,HCPCS,,,facility,both,,,,90,63,,,,,,,,,,,,,Gross Charge Type: Central
HC C-REACTIVE PROTEIN HIGH SENSIT,30000083,CDM,300,RC,86141,HCPCS,,,facility,both,,,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Central
GLYCOPROTEIN ANTIBODY,30000084,CDM,300,RC,86146,HCPCS,,,facility,both,,,,138,96.6,,,,,,,,,,,,,Gross Charge Type: Central
CARDIOLIPIN ANTIBODY EA IG CLASS,30000085,CDM,300,RC,86147,HCPCS,,,facility,both,,,,618,432.6,,,,,,,,,,,,,Gross Charge Type: Central
COLD AGGLUTININ TITER,30000087,CDM,300,RC,86157,HCPCS,,,facility,both,,,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Central
HC COMPLEMENT ANTIGEN EA COMP,30000088,CDM,300,RC,86160,HCPCS,,,facility,both,,,,279,195.3,,,,,,,,,,,,,Gross Charge Type: Central
HC COMPLEMENT/FUNCTION ACTIVITY,30000089,CDM,300,RC,86161,HCPCS,,,facility,both,,,,90,63,,,,,,,,,,,,,Gross Charge Type: Central
HC COMPLEMENT TOTAL (CH50),30000090,CDM,300,RC,86162,HCPCS,,,facility,both,,,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Central
HC CCP ANTIBODY,30000092,CDM,300,RC,86200,HCPCS,,,facility,both,,,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Central
HC DEOXYRIBONUCLEASE ANTIBODY,30000093,CDM,300,RC,86215,HCPCS,,,facility,both,,,,444,310.8,,,,,,,,,,,,,Gross Charge Type: Central
HC DNA ANTIBODY,30000094,CDM,300,RC,86225,HCPCS,,,facility,both,,,,181,126.7,,,,,,,,,,,,,Gross Charge Type: Central
HC NUCLEAR ANTIGEN ANTIBODY,30000095,CDM,300,RC,86235,HCPCS,,,facility,both,,,,279,195.3,,,,,,,,,,,,,Gross Charge Type: Central
FLUORES ANTIBODY SCREEN EA,30000096,CDM,300,RC,86255,HCPCS,,,facility,both,,,,361,252.7,,,,,,,,,,,,,Gross Charge Type: Central
HC FLUORES ANTIBODY TITER  EA ANTI,30000097,CDM,300,RC,86256,HCPCS,,,facility,both,,,,128,89.6,,,,,,,,,,,,,Gross Charge Type: Central
HC IMMUNOA TUMOR ANTIGENCA15-3,30000098,CDM,300,RC,86300,HCPCS,,,facility,both,,,,242,169.4,,,,,,,,,,,,,Gross Charge Type: Central
HC IMMUNOA TUMOR ANTIGENCA19-9,30000099,CDM,300,RC,86301,HCPCS,,,facility,both,,,,361,252.7,,,,,,,,,,,,,Gross Charge Type: Central
HC IMMUNOA TUMOR ANTIGENCA125,30000100,CDM,300,RC,86304,HCPCS,,,facility,both,,,,361,252.7,,,,,,,,,,,,,Gross Charge Type: Central
HC HETEROPHILE ANTIBODIES,30000101,CDM,300,RC,86308,HCPCS,,,facility,both,,,,144,100.8,,,,,,,,,,,,,Gross Charge Type: Central
HC IMMUNOA TUMOR ANTIGEN OTHER,30000102,CDM,300,RC,86316,HCPCS,,,facility,both,,,,229,160.3,,,,,,,,,,,,,Gross Charge Type: Central
HC IMMUNOASSAY INFECTIOUS AGENT,30000103,CDM,300,RC,86317,HCPCS,,,facility,both,,,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Central
IMMUNODIFFUSION GEL DIFF EA,30000104,CDM,300,RC,86331,HCPCS,,,facility,both,,,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Central
HC IMMUNE COMPLEX ASSAY,30000105,CDM,300,RC,86332,HCPCS,,,facility,both,,,,758,530.6,,,,,,,,,,,,,Gross Charge Type: Central
IMMUNOFIX E-PHORESIS SERUM,30000106,CDM,300,RC,86334,HCPCS,,,facility,both,,,,291,203.7,,,,,,,,,,,,,Gross Charge Type: Central
HC IMMUNFIX E-PHORSIS/URINE/CSF,30000107,CDM,300,RC,86335,HCPCS,,,facility,both,,,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Central
HC INHIBIN A,30000108,CDM,300,RC,86336,HCPCS,,,facility,both,,,,108,75.6,,,,,,,,,,,,,Gross Charge Type: Central
HC INSULIN ANTIBODIES,30000109,CDM,300,RC,86337,HCPCS,,,facility,both,,,,359,251.3,,,,,,,,,,,,,Gross Charge Type: Central
HC INTRINSIC FACTOR ANTIBODY,30000110,CDM,300,RC,86340,HCPCS,,,facility,both,,,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Central
HC ISLET CELL ANTIBODY,30000111,CDM,300,RC,86341,HCPCS,,,facility,both,,,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Central
HC CELL FUNCTION ASSAY W/STIM,30000112,CDM,300,RC,86352,HCPCS,,,facility,both,,,,346,242.2,,,,,,,,,,,,,Gross Charge Type: Central
HC LYMPHOCYTE TRANSFORMATION,30000113,CDM,300,RC,86353,HCPCS,,,facility,both,,,,414,289.8,,,,,,,,,,,,,Gross Charge Type: Central
HC MONONUCLEAR CELL ANTIGEN,30000114,CDM,300,RC,86356,HCPCS,,,facility,both,,,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Central
T CELL ABSOLUTE CD4 COUNT,30000115,CDM,300,RC,86361,HCPCS,,,facility,both,,,,398,278.6,,,,,,,,,,,,,Gross Charge Type: Central
HC MICROSOMAL ANTIBODY,30000116,CDM,300,RC,86376,HCPCS,,,facility,both,,,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Central
HC NEUTRALIZATION TEST VIRAL,30000117,CDM,300,RC,86382,HCPCS,,,facility,both,,,,170,119,,,,,,,,,,,,,Gross Charge Type: Central
HC RHEUMATOID FACTOR QUANT,30000120,CDM,300,RC,86431,HCPCS,,,facility,both,,,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Central
HC TB INTRADERMAL TEST,30000123,CDM,300,RC,86580,HCPCS,,,facility,both,,,,70,49,,,,,,,,,,,,,Gross Charge Type: Central
HC SYPHILIS TEST NON-TREP QUAL,30000124,CDM,300,RC,86592,HCPCS,,,facility,both,,,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Central
HC SYPHILIS TEST NON-TREP QUANT,30000125,CDM,300,RC,86593,HCPCS,,,facility,both,,,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Central
HC ASPERGILLUS ANTIBODY,30000126,CDM,300,RC,86606,HCPCS,,,facility,both,,,,175,122.5,,,,,,,,,,,,,Gross Charge Type: Central
HC BACTERIUM ANTIBODY NES,30000127,CDM,300,RC,86609,HCPCS,,,facility,both,,,,130,91,,,,,,,,,,,,,Gross Charge Type: Central
HC BARTONELLA ANTIBODY,30000128,CDM,300,RC,86611,HCPCS,,,facility,both,,,,100,70,,,,,,,,,,,,,Gross Charge Type: Central
HC BLASTOMYCES ANTIBODY,30000129,CDM,300,RC,86612,HCPCS,,,facility,both,,,,191,133.7,,,,,,,,,,,,,Gross Charge Type: Central
BORDETELLA ANTIBODY,30000130,CDM,300,RC,86615,HCPCS,,,facility,both,,,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Central
HC LYME DISEASE ANTIBODY CONFIRMATORY,30000131,CDM,300,RC,86617,HCPCS,,,facility,both,,,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Central
HC LYME DISEASE ANTIBODY,30000132,CDM,300,RC,86618,HCPCS,,,facility,both,,,,320,224,,,,,,,,,,,,,Gross Charge Type: Central
HC BRUCELLA ANTIBODY,30000133,CDM,300,RC,86622,HCPCS,,,facility,both,,,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Central
HC CAMPYLOBACTER ANTIBODY,30000134,CDM,300,RC,86625,HCPCS,,,facility,both,,,,70,49,,,,,,,,,,,,,Gross Charge Type: Central
HC CANDIDA ANTIBODY,30000135,CDM,300,RC,86628,HCPCS,,,facility,both,,,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Central
HC CHLAMYDIA ANTIBODY,30000136,CDM,300,RC,86631,HCPCS,,,facility,both,,,,113,79.1,,,,,,,,,,,,,Gross Charge Type: Central
HC CHLAMYDIA IGM ANTIBODY,30000137,CDM,300,RC,86632,HCPCS,,,facility,both,,,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Central
HC COCCIDIOIDES ANTIBODY,30000138,CDM,300,RC,86635,HCPCS,,,facility,both,,,,443,310.1,,,,,,,,,,,,,Gross Charge Type: Central
HC Q FEVER ANTIBODY,30000139,CDM,300,RC,86638,HCPCS,,,facility,both,,,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Central
HC CMV ANTIBODY,30000140,CDM,300,RC,86644,HCPCS,,,facility,both,,,,139,97.3,,,,,,,,,,,,,Gross Charge Type: Central
HC CMV ANTIBODY IGM,30000141,CDM,300,RC,86645,HCPCS,,,facility,both,,,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Central
HC ENCEPHALITIS ANTIBODY CALIF,30000142,CDM,300,RC,86651,HCPCS,,,facility,both,,,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Central
HC ENCEPHALITIS ANTIBODY EAST EQUIN,30000143,CDM,300,RC,86652,HCPCS,,,facility,both,,,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Central
HC ENCEPHALITIS ANTIBODY ST LOUIS,30000144,CDM,300,RC,86653,HCPCS,,,facility,both,,,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Central
HC ENCEPHALITIS ANTIBODY WESTERN,30000145,CDM,300,RC,86654,HCPCS,,,facility,both,,,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Central
HC ENTEROVIRUS ANTIBODY,30000146,CDM,300,RC,86658,HCPCS,,,facility,both,,,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Central
HC EPSTEIN-BARR EARLY ANTIGEN,30000147,CDM,300,RC,86663,HCPCS,,,facility,both,,,,128,89.6,,,,,,,,,,,,,Gross Charge Type: Central
HC EPSTEIN-BARR NUCLEAR ANTIGEN,30000148,CDM,300,RC,86664,HCPCS,,,facility,both,,,,128,89.6,,,,,,,,,,,,,Gross Charge Type: Central
HC EPSTEIN-BARR VIRAL CAPSID,30000149,CDM,300,RC,86665,HCPCS,,,facility,both,,,,128,89.6,,,,,,,,,,,,,Gross Charge Type: Central
HC EHRLICHIA ANTIBODY,30000150,CDM,300,RC,86666,HCPCS,,,facility,both,,,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Central
HC FRANCISELLA TULARENSIS,30000151,CDM,300,RC,86668,HCPCS,,,facility,both,,,,246,172.2,,,,,,,,,,,,,Gross Charge Type: Central
HC FUNGUS ANTIBODY NES,30000152,CDM,300,RC,86671,HCPCS,,,facility,both,,,,260,182,,,,,,,,,,,,,Gross Charge Type: Central
HC GIARDIA LAMBLIA ANTIBODY,30000153,CDM,300,RC,86674,HCPCS,,,facility,both,,,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Central
HC HELMINTH ANTIBODY,30000155,CDM,300,RC,86682,HCPCS,,,facility,both,,,,132,92.4,,,,,,,,,,,,,Gross Charge Type: Central
HTLV/HIV CONFIRMATORY TEST,30000156,CDM,300,RC,86689,HCPCS,,,facility,both,,,,606,424.2,,,,,,,,,,,,,Gross Charge Type: Central
HC HERPES SIMPLEX TEST NONSPECIFIC,30000157,CDM,300,RC,86694,HCPCS,,,facility,both,,,,401,280.7,,,,,,,,,,,,,Gross Charge Type: Central
HC HERPES SIMPLEX TYPE 1,30000158,CDM,300,RC,86695,HCPCS,,,facility,both,,,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Central
HC HERPES SIMPLEX TYPE 2,30000159,CDM,300,RC,86696,HCPCS,,,facility,both,,,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Central
HC HISTOPLASMA,30000160,CDM,300,RC,86698,HCPCS,,,facility,both,,,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Central
HC HIV-1/HIV-2 SINGLE RESULT,30000162,CDM,300,RC,86703,HCPCS,,,facility,both,,,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Central
HC HEP B CORE ANTIBODY TOTAL,30000163,CDM,300,RC,86704,HCPCS,,,facility,both,,,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Central
HC HEP B CORE ANTIBODY IGM,30000164,CDM,300,RC,86705,HCPCS,,,facility,both,,,,187,130.9,,,,,,,,,,,,,Gross Charge Type: Central
HC HEP B SURFACE ANTIBODY,30000165,CDM,300,RC,86706,HCPCS,,,facility,both,,,,224,156.8,,,,,,,,,,,,,Gross Charge Type: Central
HC HEP B ANTIBODY,30000166,CDM,300,RC,86707,HCPCS,,,facility,both,,,,187,130.9,,,,,,,,,,,,,Gross Charge Type: Central
HC HEP A ANTIBODY TOTAL,30000167,CDM,300,RC,86708,HCPCS,,,facility,both,,,,70,49,,,,,,,,,,,,,Gross Charge Type: Central
HC HEP A ANTIBODY IGM,30000168,CDM,300,RC,86709,HCPCS,,,facility,both,,,,121,84.7,,,,,,,,,,,,,Gross Charge Type: Central
HC INFLUENZA VIRUS ANTIBODY,30000169,CDM,300,RC,86710,HCPCS,,,facility,both,,,,129,90.3,,,,,,,,,,,,,Gross Charge Type: Central
HC LEGIONELLA ANTIBODY,30000170,CDM,300,RC,86713,HCPCS,,,facility,both,,,,132,92.4,,,,,,,,,,,,,Gross Charge Type: Central
HC LEISHMANIA ANTIBODY,30000171,CDM,300,RC,86717,HCPCS,,,facility,both,,,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Central
HC LEPTOSPIRA ANTIBODY,30000172,CDM,300,RC,86720,HCPCS,,,facility,both,,,,196,137.2,,,,,,,,,,,,,Gross Charge Type: Central
HC LYMPH CHORIOMENINGITIS,30000173,CDM,300,RC,86727,HCPCS,,,facility,both,,,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Central
HC MUMPS ANTIBODY,30000174,CDM,300,RC,86735,HCPCS,,,facility,both,,,,240,168,,,,,,,,,,,,,Gross Charge Type: Central
HC MYCOPLASMA ANTIBODY,30000175,CDM,300,RC,86738,HCPCS,,,facility,both,,,,132,92.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PARVOVIRUS ANTIBODY,30000176,CDM,300,RC,86747,HCPCS,,,facility,both,,,,143,100.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PROTOZOA ANTIBODY NOS,30000178,CDM,300,RC,86753,HCPCS,,,facility,both,,,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Central
HC RICKETTSIA ANTIBODY,30000179,CDM,300,RC,86757,HCPCS,,,facility,both,,,,128,89.6,,,,,,,,,,,,,Gross Charge Type: Central
HC RUBELLA ANTIBODY,30000180,CDM,300,RC,86762,HCPCS,,,facility,both,,,,121,84.7,,,,,,,,,,,,,Gross Charge Type: Central
HC RUBEOLA ANTIBODY,30000181,CDM,300,RC,86765,HCPCS,,,facility,both,,,,223,156.1,,,,,,,,,,,,,Gross Charge Type: Central
HC SALMONELLA ANTIBODY,30000182,CDM,300,RC,86768,HCPCS,,,facility,both,,,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Central
HC TOXOPLASMA ANTIBODY,30000183,CDM,300,RC,86777,HCPCS,,,facility,both,,,,70,49,,,,,,,,,,,,,Gross Charge Type: Central
HC TOXOPLASMA ANTIBODY IGM,30000184,CDM,300,RC,86778,HCPCS,,,facility,both,,,,70,49,,,,,,,,,,,,,Gross Charge Type: Central
TREPONEMA PALLIDUM,30000185,CDM,300,RC,86780,HCPCS,,,facility,both,,,,224,156.8,,,,,,,,,,,,,Gross Charge Type: Central
VARICELLA-ZOSTER ANTIBODY,30000186,CDM,300,RC,86787,HCPCS,,,facility,both,,,,170,119,,,,,,,,,,,,,Gross Charge Type: Central
HC WEST NILE VIRUS ANTIBODY,30000187,CDM,300,RC,86789,HCPCS,,,facility,both,,,,90,63,,,,,,,,,,,,,Gross Charge Type: Central
HC VIRUS ANTIBODY NES,30000188,CDM,300,RC,86790,HCPCS,,,facility,both,,,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Central
HC YERSINIA ANTIBODY,30000189,CDM,300,RC,86793,HCPCS,,,facility,both,,,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Central
HC THYROGLOBULIN ANTIBODY,30000190,CDM,300,RC,86800,HCPCS,,,facility,both,,,,143,100.1,,,,,,,,,,,,,Gross Charge Type: Central
HC HEPATITIS C ANTIBODY,30000191,CDM,300,RC,86803,HCPCS,,,facility,both,,,,130,91,,,,,,,,,,,,,Gross Charge Type: Central
HC RBC ANTIBODY SCREEN EA TECHNIQ,30000194,CDM,300,RC,86850,HCPCS,,,facility,both,,,,212,148.4,,,,,,,,,,,,,Gross Charge Type: Central
HC RBC ANTIBO ID EA PANEL EA TECH,30000195,CDM,300,RC,86870,HCPCS,,,facility,both,,,,478,334.6,,,,,,,,,,,,,Gross Charge Type: Central
HC COOMBS TEST DIRECT EA ANTISERUM,30000196,CDM,300,RC,86880,HCPCS,,,facility,both,,,,257,179.9,,,,,,,,,,,,,Gross Charge Type: Central
HC COOMBS TST INDIRECT EA TITER,30000198,CDM,300,RC,86886,HCPCS,,,facility,both,,,,305,213.5,,,,,,,,,,,,,Gross Charge Type: Central
HC BLOOD TYPING ABO,30000200,CDM,300,RC,86900,HCPCS,,,facility,both,,,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Central
HC BLOOD TYPING RH (D),30000201,CDM,300,RC,86901,HCPCS,,,facility,both,,,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Central
HC BLOOD TYPE ANTIGEN DONOR EA,30000202,CDM,300,RC,86902,HCPCS,,,facility,both,,,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Central
HC BLOOD TYPING RBC ANTIGENS,30000203,CDM,300,RC,86905,HCPCS,,,facility,both,,,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Central
HC COMPATIBILITY TEST SPIN,30000204,CDM,300,RC,86920,HCPCS,,,facility,both,,,,160,112,,,,,,,,,,,,,Gross Charge Type: Central
HC COMPATIBILITY TEST ELECTRIC,30000206,CDM,300,RC,86923,HCPCS,,,facility,both,,,,160,112,,,,,,,,,,,,,Gross Charge Type: Central
HC PLASMA FRESH FROZEN THAWING EA,30000207,CDM,300,RC,86927,HCPCS,,,facility,both,,,,134,93.8,,,,,,,,,,,,,Gross Charge Type: Central
HC BLOOD PRODUCT/IRRADIATION EA UNIT,30000208,CDM,300,RC,86945,HCPCS,,,facility,both,,,,111,77.7,,,,,,,,,,,,,Gross Charge Type: Central
HC POOLING BLOOD PLATELETS,30000209,CDM,300,RC,86965,HCPCS,,,facility,both,,,,174,121.8,,,,,,,,,,,,,Gross Charge Type: Central
HC CONCENTRATION FOR INFECT AGENTS,30000213,CDM,300,RC,87015,HCPCS,,,facility,both,,,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Central
HC BLOOD CULTURE FOR BACTERIA,30000214,CDM,300,RC,87040,HCPCS,,,facility,both,,,,205,143.5,,,,,,,,,,,,,Gross Charge Type: Central
HC FECES CULT OTHER PATHOGENS,30000216,CDM,300,RC,87046,HCPCS,,,facility,both,,,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Central
HC CULTURE BACTERIA OTHER SOURCES,30000217,CDM,300,RC,87070,HCPCS,,,facility,both,,,,172,120.4,,,,,,,,,,,,,Gross Charge Type: Central
HC CULT BACT AEROBIC OTHER SOURCES,30000218,CDM,300,RC,87071,HCPCS,,,facility,both,,,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Central
HC CULT BACT AEROBIC ISOLATE,30000220,CDM,300,RC,87077,HCPCS,,,facility,both,,,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Central
HC CULTURE SCREEN ONLY,30000221,CDM,300,RC,87081,HCPCS,,,facility,both,,,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Central
HC CULTURE BACT URINE,30000222,CDM,300,RC,87086,HCPCS,,,facility,both,,,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Central
HC CULTURE BACT URINE IDENT EA,30000223,CDM,300,RC,87088,HCPCS,,,facility,both,,,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Central
HC CULTURE FUNGI SKIN NAILS HAIR,30000224,CDM,300,RC,87101,HCPCS,,,facility,both,,,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Central
HC CULTURE FUNGI SOURCE NOT BLOOD,30000225,CDM,300,RC,87102,HCPCS,,,facility,both,,,,243,170.1,,,,,,,,,,,,,Gross Charge Type: Central
HC CULTURE FUNGI DEF IDENT EA ORG MOLD,30000227,CDM,300,RC,87107,HCPCS,,,facility,both,,,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Central
HC CULTURE MYCOPLASMA,30000228,CDM,300,RC,87109,HCPCS,,,facility,both,,,,174,121.8,,,,,,,,,,,,,Gross Charge Type: Central
HC CULTURE CHLAMYDIA,30000229,CDM,300,RC,87110,HCPCS,,,facility,both,,,,155,108.5,,,,,,,,,,,,,Gross Charge Type: Central
HC CULTURE ACID FACT BACILLI,30000230,CDM,300,RC,87116,HCPCS,,,facility,both,,,,242,169.4,,,,,,,,,,,,,Gross Charge Type: Central
HC CULT TYPE IMMUNOFLUORESC EA,30000231,CDM,300,RC,87140,HCPCS,,,facility,both,,,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Central
HC CULTURE TYPE IMMUNOLOGIC,30000232,CDM,300,RC,87147,HCPCS,,,facility,both,,,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Central
HC CULTURE IDENT DNA RNA PROBE,30000233,CDM,300,RC,87149,HCPCS,,,facility,both,,,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Central
HC MACROSCOPIC EXAM PARASITE,30000234,CDM,300,RC,87169,HCPCS,,,facility,both,,,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PINWORM EXAM,30000235,CDM,300,RC,87172,HCPCS,,,facility,both,,,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Central
HC TISSUE HOMOGENIZATION CULTR,30000236,CDM,300,RC,87176,HCPCS,,,facility,both,,,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Central
HC OVA AND PARASITES SMEARS,30000237,CDM,300,RC,87177,HCPCS,,,facility,both,,,,190,133,,,,,,,,,,,,,Gross Charge Type: Central
HC MICROBE SUSCEPTIBLE DIFFUSE,30000238,CDM,300,RC,87181,HCPCS,,,facility,both,,,,40,28,,,,,,,,,,,,,Gross Charge Type: Central
HC MICROBE SUSCEPTIBLE DISK,30000239,CDM,300,RC,87184,HCPCS,,,facility,both,,,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Central
HC MICROBE SUSCEPTIBLE ENZYME,30000240,CDM,300,RC,87185,HCPCS,,,facility,both,,,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Central
MICROBE SUSCEPTIBLE MICRODIL,30000241,CDM,300,RC,87186,HCPCS,,,facility,both,,,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Central
HC MICROBE SUSCEPT MACROBROTH,30000242,CDM,300,RC,87188,HCPCS,,,facility,both,,,,40,28,,,,,,,,,,,,,Gross Charge Type: Central
HC SMEAR GRAM STAIN,30000244,CDM,300,RC,87205,HCPCS,,,facility,both,,,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Central
HC SMEAR FLUORESCENT/ACID STAI,30000245,CDM,300,RC,87206,HCPCS,,,facility,both,,,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Central
HC SMEAR SPECIAL STAIN PARASITES,30000246,CDM,300,RC,87207,HCPCS,,,facility,both,,,,155,108.5,,,,,,,,,,,,,Gross Charge Type: Central
HC SMEAR COMPLEX STAIN OVA PARASIT,30000247,CDM,300,RC,87209,HCPCS,,,facility,both,,,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Central
HC SMEAR WET MOUNT SALINE/INK,30000248,CDM,300,RC,87210,HCPCS,,,facility,both,,,,50,35,,,,,,,,,,,,,Gross Charge Type: Central
KOH PREP FUNGI OVA MITES,30000249,CDM,300,RC,87220,HCPCS,,,facility,both,,,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Central
HC VIRUS INOCULATION TISSUE CULT,30000250,CDM,300,RC,87252,HCPCS,,,facility,both,,,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Central
HC VIRUS INOCULATION SHELL VIAL,30000251,CDM,300,RC,87254,HCPCS,,,facility,both,,,,140,98,,,,,,,,,,,,,Gross Charge Type: Central
HC CLOSTRIDIUM AG EIA,30000262,CDM,300,RC,87324,HCPCS,,,facility,both,,,,218,152.6,,,,,,,,,,,,,Gross Charge Type: Central
HC CRYPTOCOCCUS NEOFORM AG EIA,30000263,CDM,300,RC,87327,HCPCS,,,facility,both,,,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Central
HC CRYPTOSPORIDIUM AG EIA,30000264,CDM,300,RC,87328,HCPCS,,,facility,both,,,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Central
HC GIARDIA AG EIA,30000265,CDM,300,RC,87329,HCPCS,,,facility,both,,,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Central
HC HPYLORI STOOL EIA,30000266,CDM,300,RC,87338,HCPCS,,,facility,both,,,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Central
HC HEPATITIS B SURFACE AG EIA,30000267,CDM,300,RC,87340,HCPCS,,,facility,both,,,,169,118.3,,,,,,,,,,,,,Gross Charge Type: Central
HC HEPATITIS B SURFACE AG EIA NEUTR,30000268,CDM,300,RC,87341,HCPCS,,,facility,both,,,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Central
HC HEPATITIS BE AG EIA,30000269,CDM,300,RC,87350,HCPCS,,,facility,both,,,,169,118.3,,,,,,,,,,,,,Gross Charge Type: Central
HC HEPATITIS DELTA AG EIA,30000270,CDM,300,RC,87380,HCPCS,,,facility,both,,,,256,179.2,,,,,,,,,,,,,Gross Charge Type: Central
HC HISTOPLASMA CAPSUL AG EIA,30000271,CDM,300,RC,87385,HCPCS,,,facility,both,,,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Central
HC AG DETECT EIA MULT NOS,30000276,CDM,300,RC,87449,HCPCS,,,facility,both,,,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Central
HC LYME DIS DNA AMP PROBE,30000277,CDM,300,RC,87476,HCPCS,,,facility,both,,,,190,133,,,,,,,,,,,,,Gross Charge Type: Central
HC CHYLMD TRACH DNA AMP PROBE,30000278,CDM,300,RC,87491,HCPCS,,,facility,both,,,,209,146.3,,,,,,,,,,,,,Gross Charge Type: Central
HC CYTOMEG DNA QUANT,30000279,CDM,300,RC,87497,HCPCS,,,facility,both,,,,196,137.2,,,,,,,,,,,,,Gross Charge Type: Central
HC HEPATITIS B DNA QUANT,30000281,CDM,300,RC,87517,HCPCS,,,facility,both,,,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Central
HC HEPATITIS C DNA QUANT,30000282,CDM,300,RC,87522,HCPCS,,,facility,both,,,,279,195.3,,,,,,,,,,,,,Gross Charge Type: Central
HC HSV DNA AMP PROBE,30000283,CDM,300,RC,87529,HCPCS,,,facility,both,,,,279,195.3,,,,,,,,,,,,,Gross Charge Type: Central
HC HIV-1 DNA AMP PROBE,30000286,CDM,300,RC,87535,HCPCS,,,facility,both,,,,194,135.8,,,,,,,,,,,,,Gross Charge Type: Central
HC HIV-1 DNA QUANT,30000287,CDM,300,RC,87536,HCPCS,,,facility,both,,,,614,429.8,,,,,,,,,,,,,Gross Charge Type: Central
M TUBERCULO DNA AMP PROBE,30000288,CDM,300,RC,87556,HCPCS,,,facility,both,,,,203,142.1,,,,,,,,,,,,,Gross Charge Type: Central
HC M PNEUMON DNA AMP PROBE,30000289,CDM,300,RC,87581,HCPCS,,,facility,both,,,,203,142.1,,,,,,,,,,,,,Gross Charge Type: Central
HC N GONORRHOEAE DNA AMP PROB,30000290,CDM,300,RC,87591,HCPCS,,,facility,both,,,,154,107.8,,,,,,,,,,,,,Gross Charge Type: Central
HC DETECT AGENT DNA AMP NOS,30000291,CDM,300,RC,87798,HCPCS,,,facility,both,,,,217,151.9,,,,,,,,,,,,,Gross Charge Type: Central
HC DETECT AGENT DNA QUANT NOS,30000292,CDM,300,RC,87799,HCPCS,,,facility,both,,,,433,303.1,,,,,,,,,,,,,Gross Charge Type: Central
HC DETECT AGNT MULT DNA AMPLI,30000293,CDM,300,RC,87801,HCPCS,,,facility,both,,,,242,169.4,,,,,,,,,,,,,Gross Charge Type: Central
HC AGENT ASSAY W/OPTIC NOS,30000297,CDM,300,RC,87899,HCPCS,,,facility,both,,,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Central
HC GENOTYPE DNA HIV REVERSE T,30000298,CDM,300,RC,87901,HCPCS,,,facility,both,,,,1069,748.3,,,,,,,,,,,,,Gross Charge Type: Central
GENOTYPE DNA HEPATITIS C,30000299,CDM,300,RC,87902,HCPCS,,,facility,both,,,,1213,849.1,,,,,,,,,,,,,Gross Charge Type: Central
HC POC BILIRUBIN TOTAL TRANSCUT,30000303,CDM,300,RC,88720,HCPCS,,,facility,both,,,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Central
BODY FLUID NOT BLD CELL COUNT,30000304,CDM,300,RC,89050,HCPCS,,,facility,both,,,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Central
BODY FLUID NOT BLD W/ DIFF COUNT,30000305,CDM,300,RC,89051,HCPCS,,,facility,both,,,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Central
HC COLLECT SWEAT FOR TEST,30000307,CDM,300,RC,89230,HCPCS,,,facility,both,,,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Central
HC SEMEN ANALYS SPERM DETECTION,30000309,CDM,300,RC,89321,HCPCS,,,facility,both,,,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PROSTATE CANCER SCREEN PSA TEST,30000310,CDM,300,RC,G0103,HCPCS,,,facility,both,,,,151,105.7,,,,,,,,,,,,,Gross Charge Type: Central
HC HPV HIGH-RISK TYPES POOLED RESULT,30000800,CDM,300,RC,87624,HCPCS,,,facility,both,,,,150,105,,,,,,,,,,,,,Gross Charge Type: Central
HC MUCOPOLYSACCHARIDES ACIDE QUANT,30000943,CDM,300,RC,83864,HCPCS,,,facility,both,,,,121,84.7,,,,,,,,,,,,,Gross Charge Type: Central
HC POC PROTHROMBIN TIME,30000947,CDM,300,RC,85610,HCPCS,,,facility,both,,,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Central
HC STREP A ASSAY W/OPTIC,30000948,CDM,300,RC,87880,HCPCS,,,facility,both,,,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Central
HC POC EVAL CERVICOVAGINAL FLUID AMNIOTIC FLUID PROTEIN QUALITATIVE EACH SPECIMAN,30000949,CDM,300,RC,84112,HCPCS,,,facility,both,,,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Central
HC POC URINE PREGNANCY,30000950,CDM,300,RC,81025,HCPCS,,,facility,both,,,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Central
HC FLT3 GENE ANALYSIS,30000989,CDM,310,RC,81245,HCPCS,,,facility,both,,,,801,560.7,,,,,,,,,,,,,Gross Charge Type: Central
HC FMR1 GENE ANALYSIS EVAL DETECT ABNORMAL ALLELES,30000992,CDM,300,RC,81243,HCPCS,,,facility,both,,,,899,629.3,,,,,,,,,,,,,Gross Charge Type: Central
HC CFTR GENE FULL SEQUENCE,30000993,CDM,310,RC,81223,HCPCS,,,facility,both,,,,1703,1192.1,,,,,,,,,,,,,Gross Charge Type: Central
HC CYTOGEN ANALYSIS CONSTITUT CHROMOSMAL ABNORM GENOMIC REGIONS CGH,30000994,CDM,300,RC,81229,HCPCS,,,facility,both,,,,2535,1774.5,,,,,,,,,,,,,Gross Charge Type: Central
HC MTHFR MUTATION,30000995,CDM,300,RC,81291,HCPCS,,,facility,both,,,,657,459.9,,,,,,,,,,,,,Gross Charge Type: Central
HC RETT SYNDROME MECP2,30000996,CDM,300,RC,81302,HCPCS,,,facility,both,,,,2118,1482.6,,,,,,,,,,,,,Gross Charge Type: Central
HC RETT SYNDROME MECP2,30000997,CDM,300,RC,81304,HCPCS,,,facility,both,,,,602,421.4,,,,,,,,,,,,,Gross Charge Type: Central
HC NPM1 GENE ANALYSIS,30000998,CDM,310,RC,81310,HCPCS,,,facility,both,,,,801,560.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PRADER-WILLI OR ANGELMAN SYNDROME,30000999,CDM,300,RC,81331,HCPCS,,,facility,both,,,,450,315,,,,,,,,,,,,,Gross Charge Type: Central
HC POC TB INTRADERMAL TEST,30001020,CDM,300,RC,86580,HCPCS,,,facility,both,,,,70,49,,,,,,,,,,,,,Gross Charge Type: Central
HC POC SKIN TEST NOS ANTIGEN,30001022,CDM,300,RC,86486,HCPCS,,,facility,both,,,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Central
HC POC MONONUCLEAR CELL ANTIGEN,30001023,CDM,300,RC,86356,HCPCS,,,facility,both,,,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Central
HC POC RAPID STREP A,30001024,CDM,300,RC,87880,HCPCS,,,facility,both,,,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Central
HC KEPRA/LEVETIRACTAM/ELEPSIA,30001032,CDM,300,RC,80177,HCPCS,,,facility,both,,,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF ALUMINUM,30001033,CDM,300,RC,82108,HCPCS,,,facility,both,,,,276,193.2,,,,,,,,,,,,,Gross Charge Type: Central
HC RBC ANTIBODY ELUTION,30001034,CDM,300,RC,86860,HCPCS,,,facility,both,,,,233,163.1,,,,,,,,,,,,,Gross Charge Type: Central
HC VW MULTIMERS,30001035,CDM,300,RC,85247,HCPCS,,,facility,both,,,,200,140,,,,,,,,,,,,,Gross Charge Type: Central
HC HIV-1 INTEGRASE SEQ.,30001039,CDM,300,RC,87906,HCPCS,,,facility,both,,,,546,382.2,,,,,,,,,,,,,Gross Charge Type: Central
HC MOPATH PROCEDURE LEVEL 9,30001045,CDM,300,RC,81408,HCPCS,,,facility,both,,,,2731,1911.7,,,,,,,,,,,,,Gross Charge Type: Central
HC DRDQDRP LOCI LOW RES,30001046,CDM,300,RC,81375,HCPCS,,,facility,both,,,,999,699.3,,,,,,,,,,,,,Gross Charge Type: Central
HC C DIFF AMPLIFIED PROBE,30001053,CDM,300,RC,87493,HCPCS,,,facility,both,,,,150,105,,,,,,,,,,,,,Gross Charge Type: Central
HC TRICHINELLA ANTIBODY,30001054,CDM,300,RC,86784,HCPCS,,,facility,both,,,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Central
HC MATRIX METALLOPROTEINASE 9,30001057,CDM,300,RC,83520,HCPCS,,,facility,both,,,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY FOR PHENCYCLIDINE,30001058,CDM,300,RC,83992,HCPCS,,,facility,both,,,,249,174.3,,,,,,,,,,,,,Gross Charge Type: Central
HC ALLERGEN SPECIFIC IGG,30001063,CDM,300,RC,86001,HCPCS,,,facility,both,,,,20,14,,,,,,,,,,,,,Gross Charge Type: Central
HC OVA 1 FIVE PROTEINS (OVAR),30001065,CDM,300,RC,81503,HCPCS,,,facility,both,,,,1012,708.4,,,,,,,,,,,,,Gross Charge Type: Central
HC T CELLS TOTAL COUNT,30001066,CDM,300,RC,86359,HCPCS,,,facility,both,,,,145,101.5,,,,,,,,,,,,,Gross Charge Type: Central
HC ANTIEPILEPTICS NOT OTHERWISE SPECIFIED 1-3,30001079,CDM,300,RC,80339,HCPCS,,,facility,both,,,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Central
HC CLOT FACTOR XIII FIBRIN STAB,30001080,CDM,300,RC,85290,HCPCS,,,facility,both,,,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Central
HC CULTURE TYPING OTHER METHODS,30001081,CDM,300,RC,87158,HCPCS,,,facility,both,,,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Central
HC B CELLS TOTAL COUNT,30001087,CDM,300,RC,86355,HCPCS,,,facility,both,,,,145,101.5,,,,,,,,,,,,,Gross Charge Type: Central
HC NK CELLS TOTAL COUNT,30001088,CDM,300,RC,86357,HCPCS,,,facility,both,,,,145,101.5,,,,,,,,,,,,,Gross Charge Type: Central
HC T CELL ABSOLUTE COUNT/RATIO,30001089,CDM,300,RC,86360,HCPCS,,,facility,both,,,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Central
HC BLOOD COUNT AUTOMATED DIFFERENTIAL WBC COUNT,30001128,CDM,300,RC,85004,HCPCS,,,facility,both,,,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Central
HC FETAL CHROMOSOMAL ANEUPLOIDY GENOMIC SEQ ANALYSIS PANEL,30001144,CDM,300,RC,81420,HCPCS,,,facility,both,,,,2630,1841,,,,,,,,,,,,,Gross Charge Type: Central
HC INFECTIOUS AGENT PHENOTYPE ANALYSIS NUCLEIC ACID HIV 1 FIRST THROUGH 10 DRUGS TESTED,30001151,CDM,300,RC,87903,HCPCS,,,facility,both,,,,2073,1451.1,,,,,,,,,,,,,Gross Charge Type: Central
HC INFECTIOUS AGENT PHENOTYPE ANALYSIS NUCLEIC ACID HIV 1 EACH ADDITIONAL DRUG TESTED (LIST SEP IN ADDITION TO PRIMARY PROCEDURE),30001152,CDM,300,RC,87904,HCPCS,,,facility,both,,,,111,77.7,,,,,,,,,,,,,Gross Charge Type: Central
HC C-REACTIVE PROTEIN FOR DETECTION OF INFECTION/INFLAMMATION,30001159,CDM,300,RC,86140,HCPCS,,,facility,both,,,,20,14,,,,,,,,,,,,,Gross Charge Type: Central
HC INFECTIOUS AGENT DETECT NUCLEIC ACID (DNA/RNA) HEPATITIS B AMP PROBE TECH,30001174,CDM,300,RC,87516,HCPCS,,,facility,both,,,,151,105.7,,,,,,,,,,,,,Gross Charge Type: Central
HC INFECTIOUS AGENT DECT NUCLEIC ACID (DNA/RNA) HEPATITIS B AMP PROBE TECH INCL REVERSE TRANSCRIPTIO,30001175,CDM,300,RC,87521,HCPCS,,,facility,both,,,,151,105.7,,,,,,,,,,,,,Gross Charge Type: Central
HC HUMAN LEUKOCYTE ANTIGEN (HLA) CROSSMATCH NON-CYTOTOXIC FIRST SERUM SAMPLE OR DILUTION,30001176,CDM,300,RC,86825,HCPCS,,,facility,both,,,,463,324.1,,,,,,,,,,,,,Gross Charge Type: Central
HC INFECTIOUS AGENT DRUG SUSCEPTIBILITY PREDICTION USING REGULARLY UPDATED GENOTYPIC BIOINFORMATICS,30001180,CDM,300,RC,87900,HCPCS,,,facility,both,,,,558,390.6,,,,,,,,,,,,,Gross Charge Type: Central
HC HANDLING/CONVEYANCE OF SPECIMEN FOR TRANSFER FROM PATIENT TO A LABORATORY,30001185,CDM,300,RC,99001,HCPCS,,,facility,both,,,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Central
HC ALLERGEN SPECIFIC IGE QUANTITATIVES/SEMIQUANTITATIVE RECOMBINAT/PURIFIED COMPONENT EACH,30001209,CDM,300,RC,86008,HCPCS,,,facility,both,,,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Central
HC CLOTTING PREKALLIKREIN ASSAY,30001215,CDM,300,RC,85292,HCPCS,,,facility,both,,,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Central
HC EXOME SEQUENCE ANALYSIS,30001217,CDM,300,RC,81415,HCPCS,,,facility,both,,,,20192,14134.4,,,,,,,,,,,,,Gross Charge Type: Central
HC POC HEMOGLOBIN,30001219,CDM,300,RC,85018,HCPCS,,,facility,both,,,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Central
HC POC HEMATOCRIT ISTAT,30001240,CDM,300,RC,85014,HCPCS,,,facility,both,,,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Central
HC POC D-DIMER TRIAGE,30001241,CDM,300,RC,85379,HCPCS,,,facility,both,,,,162,113.4,,,,,,,,,,,,,Gross Charge Type: Central
HC POC BMP,30001242,CDM,300,RC,80048,HCPCS,,,facility,both,,,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Central
HC POC GRP A STREP LIAT,30001244,CDM,300,RC,87651,HCPCS,,,facility,both,,,,186,130.2,,,,,,,,,,,,,Gross Charge Type: Central
HC POC COMPLETE CBC W/AUTO DIFF WBC,30001245,CDM,300,RC,85025,HCPCS,,,facility,both,,,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Central
HC POC URINE DIPSTICK,30001246,CDM,300,RC,81003,HCPCS,,,facility,both,,,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Central
HC BLOOD COUNT RETICULOCYTES AUTO INCL 1 OR MORE CELLULAR PARAMETERS DIRECT MEASUREMENT,30001266,CDM,300,RC,85046,HCPCS,,,facility,both,,,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Central
HC DRUG ASSAY LACOSAMIDE,30001286,CDM,300,RC,80235,HCPCS,,,facility,both,,,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Central
HC DRUG ASSAY ADALIMUMAB,30001288,CDM,300,RC,80145,HCPCS,,,facility,both,,,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Central
HC DRUG ASSAY INFLIXIMAB,30001290,CDM,300,RC,80230,HCPCS,,,facility,both,,,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Central
HC DRUG ASSAY VORICONAZOLE,30001292,CDM,300,RC,80285,HCPCS,,,facility,both,,,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Central
HC CHROMOGENIC SUBSTRATE ASSAY,30001296,CDM,300,RC,85130,HCPCS,,,facility,both,,,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Central
HC COVID-19 MULTIPLE TYPES/SUBTYPES NON-CDC,30001297,CDM,300,RC,U0002,HCPCS,,,facility,both,,,,134,93.8,,,,,,,,,,,,,Gross Charge Type: Central
HC RESPIRATORY  INFECT AGENT DETECT (DNA/RNA) TYPE & SUBTYPES 2 BACTERIAL TARGETS,30001299,CDM,300,RC,0115U,HCPCS,,,facility,both,,,,802,561.4,,,,,,,,,,,,,Gross Charge Type: Central
HC ANTIBODY JC (JOHN CUNNINGHAM) VIRUS,30001300,CDM,300,RC,86711,HCPCS,,,facility,both,,,,30,21,,,,,,,,,,,,,Gross Charge Type: Central
HC INFECT AGENT DETECT DNA/RNA SARS-COV-2 AMPLIFIED PROB TECH,30001303,CDM,300,RC,87635,HCPCS,,,facility,both,,,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Central
HC ANTIBODY SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2,30001304,CDM,300,RC,86769,HCPCS,,,facility,both,,,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Central
HC CDC 2019-NCOV REAL-TIME RT-PCR DIAGNOSTIC PANEL,30001305,CDM,300,RC,U0001,HCPCS,,,facility,both,,,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Central
HC INFECT (DNA/RNA) TRICHOMONAS VAGINALIS AMPLIF PROBE TECH,30001309,CDM,300,RC,87661,HCPCS,,,facility,both,,,,169,118.3,,,,,,,,,,,,,Gross Charge Type: Central
HC NFCT DS DNA & RNA 21 TARGETS SARS-COV-2 AMP PROBE,30001325,CDM,300,RC,0225U,HCPCS,,,facility,both,,,,620,434,,,,,,,,,,,,,Gross Charge Type: Central
HC IADNA SARSCOV2 & INF A&B MULT AMPLIFIED PROBE TQ,30001332,CDM,300,RC,87636,HCPCS,,,facility,both,,,,454,317.8,,,,,,,,,,,,,Gross Charge Type: Central
HC IADNA SARSCOV2 INF A&B & RSV  MULTI AMPLIFIED PROBE TQ,30001333,CDM,300,RC,87637,HCPCS,,,facility,both,,,,472,330.4,,,,,,,,,,,,,Gross Charge Type: Central
HC BLOOD BANK PHYS SERV INVEST TRANSFUSION REACT INCL INTERP & REPORT,30001335,CDM,300,RC,86078,HCPCS,,,facility,both,,,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Central
HC POC LIAT SARS-COV-2/FLUA/FLUB,30001336,CDM,300,RC,87636,HCPCS,,,facility,both,,,,454,317.8,,,,,,,,,,,,,Gross Charge Type: Central
HC POC INFECT AGENT DETECT DNA/RNA SARS-COV-2 AMPLIFIED PROB TECH,30001337,CDM,300,RC,87635,HCPCS,,,facility,both,,,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Central
HC POC IADNA DNA/RNA RSV AMPLIFIED PROBE TECHNIQUE,30001338,CDM,300,RC,87634,HCPCS,,,facility,both,,,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Central
HC DRUG ASSAY ACETAMINOPHEN,30001339,CDM,300,RC,80143,HCPCS,,,facility,both,,,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Central
HC DRUG ASSAY SALICYLATE,30001340,CDM,300,RC,80179,HCPCS,,,facility,both,,,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Central
HC DRUG ASSAY METHOTREXATE,30001341,CDM,300,RC,80204,HCPCS,,,facility,both,,,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Central
HC JAK2 TARGETED SEQUENCE ANALYSIS,30001342,CDM,300,RC,81279,HCPCS,,,facility,both,,,,407,284.9,,,,,,,,,,,,,Gross Charge Type: Central
HC MPL GENE COMMON VARIANTS,30001343,CDM,300,RC,81338,HCPCS,,,facility,both,,,,330,231,,,,,,,,,,,,,Gross Charge Type: Central
HC TP53 GENE FULL GENE SEQUENCE,30001344,CDM,300,RC,81351,HCPCS,,,facility,both,,,,1404,982.8,,,,,,,,,,,,,Gross Charge Type: Central
HC POC BASIC METABOLIC PANEL CALCIUM IONIZED,30001350,CDM,300,RC,80047,HCPCS,,,facility,both,,,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Central
HC NEUROLOGY CSF DECT PRION PROTEIN QUALITATIVE,30001358,CDM,300,RC,0035U,HCPCS,,,facility,both,,,,1124,786.8,,,,,,,,,,,,,Gross Charge Type: Central
HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS,30001361,CDM,300,RC,81269,HCPCS,,,facility,both,,,,456,319.2,,,,,,,,,,,,,Gross Charge Type: Central
HC MYCOBACTERIAL DEF ID 1,30001362,CDM,300,RC,87118,HCPCS,,,facility,both,,,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Central
HC INFECTIOUS DISEASE BACTERIAL VAGINOSIS&VAGINITIS DNA VAG FLU ALG,30001364,CDM,300,RC,81514,HCPCS,,,facility,both,,,,562,393.4,,,,,,,,,,,,,Gross Charge Type: Central
HC NUDT15 GENE ANALYSIS COMMON VARIANTS,30001369,CDM,300,RC,81306,HCPCS,,,facility,both,,,,656,459.2,,,,,,,,,,,,,Gross Charge Type: Central
HC CYP2C9 GENE ANAKYSIS COMMON VARIANTS,30001384,CDM,300,RC,81227,HCPCS,,,facility,both,,,,394,275.8,,,,,,,,,,,,,Gross Charge Type: Central
HC IMMUNOGLOBULIN LIGHTS CHAINS FREE EACH,30001389,CDM,300,RC,83521,HCPCS,,,facility,both,,,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Central
HC GLIADIN ANTIBODY EACH IMMUNOGLOBULIN CLASS,30001390,CDM,300,RC,86258,HCPCS,,,facility,both,,,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Central
HC TISSUE TRANSGLTMNASE EA IMMUNOGLOBULIN CLASS,30001391,CDM,300,RC,86364,HCPCS,,,facility,both,,,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Central
HC ACTIN SMOOTH MUSCLE ANTIBODY EACH,30001392,CDM,300,RC,86015,HCPCS,,,facility,both,,,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Central
HC ANTINEUTROPHIL CYTOPLASMI ANTB SCREEN EA ANTIBODY,30001393,CDM,300,RC,86036,HCPCS,,,facility,both,,,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Central
HC ANTINEUTROPHIL CYTOPLASMIC ANTB TITER EACH ANTIBODY,30001394,CDM,300,RC,86037,HCPCS,,,facility,both,,,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Central
HC MITOCHONDRIAL ANTIBODY EACH,30001395,CDM,300,RC,86381,HCPCS,,,facility,both,,,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Central
HC ELASTASE PANCREATIC FECAL QUANTITATIVE,30001396,CDM,300,RC,82653,HCPCS,,,facility,both,,,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF INTERLEUKIN-6,30001397,CDM,300,RC,83529,HCPCS,,,facility,both,,,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Central
HC AQUAPORIN-4 ANTIBODY ELISA,30001398,CDM,300,RC,86051,HCPCS,,,facility,both,,,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Central
HC QUAPORIN-4 ANITBODY FLOW CYTOMETRY EACH,30001399,CDM,300,RC,86053,HCPCS,,,facility,both,,,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Central
HC MYELIN OLIGODENDROCYTE GLYCOPROTEIN ANTIBODY FLOW SYTOMETRY EACH,30013400,CDM,300,RC,86363,HCPCS,,,facility,both,,,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Central
HC VOLTAGE-GATED CALCIUM CHANNEL ANTIBODY EACH,30013401,CDM,300,RC,86596,HCPCS,,,facility,both,,,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Central
HC ENDOMYSIAL ANTIBODY EACH IMMUNOGLOBULIN CLASS,30013402,CDM,300,RC,86231,HCPCS,,,facility,both,,,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Central
HC INFECTIOUS DISEASE BACTERIAL VAGINOSIS RNA VAGINAL-FLUID ALG,30013416,CDM,300,RC,81513,HCPCS,,,facility,both,,,,305,213.5,,,,,,,,,,,,,Gross Charge Type: Central
HC POC COMPLETE CBC AUTO W/O DIFF,30013422,CDM,300,RC,85027,HCPCS,,,facility,both,,,,40,28,,,,,,,,,,,,,Gross Charge Type: Central
HC COAGULATION/FIBRINOLYSIS ASSAY WHOLE BLOOD INCL INTERP/REPORT ADDITIVE/DAY,30013423,CDM,300,RC,85396,HCPCS,,,facility,both,,,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Central
HC TRANSPLANTATION MED QUAN DONOR-DERIVED CELL FREE DNA PLASMA,30013427,CDM,300,RC,0118U,HCPCS,,,facility,both,,,,5887,4120.9,,,,,,,,,,,,,Gross Charge Type: Central
HC INFECTIOUS AGENT (DNA OR RNA) ORTHPOXVIRUS AMPLIFIED PROBE TECHNIQUE EA,30013434,CDM,300,RC,87593,HCPCS,,,facility,both,,,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Central
HC POC HEPARIN ASSAY,30013445,CDM,300,RC,85520,HCPCS,,,facility,both,,,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Central
HC POC HEPARIN PROTAMINE TOLERANCE TEST,30013446,CDM,300,RC,85530,HCPCS,,,facility,both,,,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Central
HC FMR1 GENE ANALYSIS CHARACTERIZATION OF ALLELES,30013452,CDM,300,RC,81244,HCPCS,,,facility,both,,,,330,231,,,,,,,,,,,,,Gross Charge Type: Central
HC STREPTOCOCCUS PNEUM ANTIBODY IGG SEROTYPES MLT IMMUNOASSAY QUAN,30013455,CDM,300,RC,86581,HCPCS,,,facility,both,,,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Central
HC IADNA HPV SEP RPRT HI-RISK TYP&HI-RISK POOLED RESULTS,30013456,CDM,300,RC,87626,HCPCS,,,facility,both,,,,305,213.5,,,,,,,,,,,,,Gross Charge Type: Central
HC IADNA PNEUMOCYSTIS JIROVECII AMPLIFIED PROBE TECHNIQUE,30013457,CDM,300,RC,87594,HCPCS,,,facility,both,,,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Central
HC IADNA MTB RIFAMPIN RESISTANCE AMPLIFIED PROBE TECHNIQUE,30013458,CDM,300,RC,87564,HCPCS,,,facility,both,,,,334,233.8,,,,,,,,,,,,,Gross Charge Type: Central
HC IADNA MYCOPLASMA GENITALIUM AMPLIFIED PROBE TECH,30013459,CDM,300,RC,87563,HCPCS,,,facility,both,,,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Central
HC AQUAPORIN-4 ANTIBODY CELL-BASED IMFLUOR ASSAY EA,30013460,CDM,300,RC,86052,HCPCS,,,facility,both,,,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Central
GENERAL HEALTH PANEL,30100001,CDM,301,RC,80050,HCPCS,,,facility,both,,,,434,303.8,,,,,,,,,,,,,Gross Charge Type: Central
HC ELECTROLYTE PANEL,30100002,CDM,301,RC,80051,HCPCS,,,facility,both,,,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Central
LIPID PANEL,30100003,CDM,301,RC,80061,HCPCS,,,facility,both,,,,165,115.5,,,,,,,,,,,,,Gross Charge Type: Central
HC RENAL FUNCTION PANEL,30100004,CDM,301,RC,80069,HCPCS,,,facility,both,,,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Central
ACUTE HEPATITIS PANEL,30100005,CDM,301,RC,80074,HCPCS,,,facility,both,,,,256,179.2,,,,,,,,,,,,,Gross Charge Type: Central
HC HEPATIC FUNCTION PANEL,30100006,CDM,301,RC,80076,HCPCS,,,facility,both,,,,142,99.4,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF AMIKACIN,30100011,CDM,301,RC,80150,HCPCS,,,facility,both,,,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY CARBAMAZEPINE TOTAL,30100014,CDM,301,RC,80156,HCPCS,,,facility,both,,,,229,160.3,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF CYCLOSPORINE,30100015,CDM,301,RC,80158,HCPCS,,,facility,both,,,,200,140,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF DIGOXIN,30100017,CDM,301,RC,80162,HCPCS,,,facility,both,,,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF ETHOSUXIMIDE,30100020,CDM,301,RC,80168,HCPCS,,,facility,both,,,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF GENTAMICIN,30100021,CDM,301,RC,80170,HCPCS,,,facility,both,,,,223,156.1,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF HALOPERIDOL,30100022,CDM,301,RC,80173,HCPCS,,,facility,both,,,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF LIDOCAINE,30100024,CDM,301,RC,80176,HCPCS,,,facility,both,,,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF LITHIUM,30100025,CDM,301,RC,80178,HCPCS,,,facility,both,,,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF PHENOBARBITAL,30100027,CDM,301,RC,80184,HCPCS,,,facility,both,,,,138,96.6,,,,,,,,,,,,,Gross Charge Type: Central
ASSAY OF PHENYTOIN TOTAL,30100028,CDM,301,RC,80185,HCPCS,,,facility,both,,,,187,130.9,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF PHENYTOIN FREE,30100029,CDM,301,RC,80186,HCPCS,,,facility,both,,,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF PRIMIDONE,30100030,CDM,301,RC,80188,HCPCS,,,facility,both,,,,207,144.9,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF SIROLIMUS,30100031,CDM,301,RC,80195,HCPCS,,,facility,both,,,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF TACROLIMUS,30100033,CDM,301,RC,80197,HCPCS,,,facility,both,,,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF THEOPHYLLINE,30100034,CDM,301,RC,80198,HCPCS,,,facility,both,,,,196,137.2,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF TOBRAMYCIN,30100035,CDM,301,RC,80200,HCPCS,,,facility,both,,,,252,176.4,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF TOPIRAMATE,30100036,CDM,301,RC,80201,HCPCS,,,facility,both,,,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF VANCOMYCIN,30100037,CDM,301,RC,80202,HCPCS,,,facility,both,,,,190,133,,,,,,,,,,,,,Gross Charge Type: Central
HC QUANTITATIVE ASSAY DRUG NES,30100038,CDM,301,RC,80299,HCPCS,,,facility,both,,,,241,168.7,,,,,,,,,,,,,Gross Charge Type: Central
HC ACTH STIMULATION PANEL,30100039,CDM,301,RC,80400,HCPCS,,,facility,both,,,,270,189,,,,,,,,,,,,,Gross Charge Type: Central
HC KETONE BODY QUANTITATIVE,30100042,CDM,301,RC,82010,HCPCS,,,facility,both,,,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Central
HC ACYLCARNITINES QUANT,30100044,CDM,301,RC,82017,HCPCS,,,facility,both,,,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF ACTH,30100045,CDM,301,RC,82024,HCPCS,,,facility,both,,,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF SERUM ALBUMIN,30100046,CDM,301,RC,82040,HCPCS,,,facility,both,,,,141,98.7,,,,,,,,,,,,,Gross Charge Type: Central
HC ALBUMIN OTHER SOURCE QUANTITATIVE EACH SPECIMEN,30100047,CDM,301,RC,82042,HCPCS,,,facility,both,,,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Central
HC ALBUMIN URINE (EG MICROALBUMIN) QUANTITATIVE,30100048,CDM,301,RC,82043,HCPCS,,,facility,both,,,,223,156.1,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF ALDOLASE,30100051,CDM,301,RC,82085,HCPCS,,,facility,both,,,,275,192.5,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF ALDOSTERONE,30100052,CDM,301,RC,82088,HCPCS,,,facility,both,,,,552,386.4,,,,,,,,,,,,,Gross Charge Type: Central
HC ALPHA-1-ANTITRYPSIN TOTAL,30100053,CDM,301,RC,82103,HCPCS,,,facility,both,,,,172,120.4,,,,,,,,,,,,,Gross Charge Type: Central
HC ALPHA-1-ANTITRYPSIN PHENO,30100054,CDM,301,RC,82104,HCPCS,,,facility,both,,,,270,189,,,,,,,,,,,,,Gross Charge Type: Central
ALPHA-FETOPROTEIN SERUM,30100055,CDM,301,RC,82105,HCPCS,,,facility,both,,,,242,169.4,,,,,,,,,,,,,Gross Charge Type: Central
HC AMINO ACIDS SINGLE QUANT,30100058,CDM,301,RC,82131,HCPCS,,,facility,both,,,,352,246.4,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY AMINOLEVULINIC ACID,30100059,CDM,301,RC,82135,HCPCS,,,facility,both,,,,252,176.4,,,,,,,,,,,,,Gross Charge Type: Central
HC AMINO ACIDS QUAN 6 OR MORE,30100061,CDM,301,RC,82139,HCPCS,,,facility,both,,,,1100,770,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF AMMONIA,30100062,CDM,301,RC,82140,HCPCS,,,facility,both,,,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF AMYLASE,30100064,CDM,301,RC,82150,HCPCS,,,facility,both,,,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF ANDROSTENEDIONE,30100065,CDM,301,RC,82157,HCPCS,,,facility,both,,,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Central
HC ANGIOTENSIN I ENZYME TEST,30100066,CDM,301,RC,82164,HCPCS,,,facility,both,,,,229,160.3,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF APOLIPOPROTEIN,30100067,CDM,301,RC,82172,HCPCS,,,facility,both,,,,154,107.8,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF ARSENIC,30100068,CDM,301,RC,82175,HCPCS,,,facility,both,,,,184,128.8,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF ASCORBIC ACID,30100069,CDM,301,RC,82180,HCPCS,,,facility,both,,,,296,207.2,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF BETA-2 PROTEIN,30100070,CDM,301,RC,82232,HCPCS,,,facility,both,,,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Central
HC BILE ACIDS TOTAL,30100071,CDM,301,RC,82239,HCPCS,,,facility,both,,,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Central
HC BILIRUBIN TOTAL,30100072,CDM,301,RC,82247,HCPCS,,,facility,both,,,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Central
HC BILIRUBIN DIRECT,30100073,CDM,301,RC,82248,HCPCS,,,facility,both,,,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Central
OCCULT BLOOD FECES,30100074,CDM,301,RC,82270,HCPCS,,,facility,both,,,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY TEST FOR BLOOD FECAL,30100076,CDM,301,RC,82274,HCPCS,,,facility,both,,,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Central
VITAMIN D 25 HYDROXY,30100077,CDM,301,RC,82306,HCPCS,,,facility,both,,,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF CALCITONIN,30100078,CDM,301,RC,82308,HCPCS,,,facility,both,,,,304,212.8,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF CALCIUM TOTAL,30100079,CDM,301,RC,82310,HCPCS,,,facility,both,,,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Central
HC POC ASSAY OF CALCIUM IONIZED,30100080,CDM,301,RC,82330,HCPCS,,,facility,both,,,,230,161,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF CA IN URINE TIMED,30100081,CDM,301,RC,82340,HCPCS,,,facility,both,,,,138,96.6,,,,,,,,,,,,,Gross Charge Type: Central
HC CALCULUS INFRARED SPECTROSCOPY,30100082,CDM,301,RC,82365,HCPCS,,,facility,both,,,,172,120.4,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY C-D TRANSFER MEASURE,30100083,CDM,301,RC,82373,HCPCS,,,facility,both,,,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY BLOOD CARBON DIOXIDE,30100084,CDM,301,RC,82374,HCPCS,,,facility,both,,,,90,63,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY CARBOXYHB QUANT,30100085,CDM,301,RC,82375,HCPCS,,,facility,both,,,,164,114.8,,,,,,,,,,,,,Gross Charge Type: Central
HC CARCINOEMBRYONIC ANTIGEN,30100086,CDM,301,RC,82378,HCPCS,,,facility,both,,,,184,128.8,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF CARNITINE,30100087,CDM,301,RC,82379,HCPCS,,,facility,both,,,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF CAROTENE,30100088,CDM,301,RC,82380,HCPCS,,,facility,both,,,,141,98.7,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY CATECHOLAMINES FRACTION,30100089,CDM,301,RC,82384,HCPCS,,,facility,both,,,,60,42,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF CERULOPLASMIN,30100090,CDM,301,RC,82390,HCPCS,,,facility,both,,,,158,110.6,,,,,,,,,,,,,Gross Charge Type: Central
CHEMILUMINESCENT ASSAY,30100091,CDM,301,RC,82397,HCPCS,,,facility,both,,,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Central
ASSAY OF BLOOD CHLORIDE,30100092,CDM,301,RC,82435,HCPCS,,,facility,both,,,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF URINE CHLORIDE,30100093,CDM,301,RC,82436,HCPCS,,,facility,both,,,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OTHER FLUID CHLORIDES,30100094,CDM,301,RC,82438,HCPCS,,,facility,both,,,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY BLD/SERUM CHOLESTEROL,30100095,CDM,301,RC,82465,HCPCS,,,facility,both,,,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF CITRATE,30100098,CDM,301,RC,82507,HCPCS,,,facility,both,,,,394,275.8,,,,,,,,,,,,,Gross Charge Type: Central
COLLAGEN CROSSLINKS,30100100,CDM,301,RC,82523,HCPCS,,,facility,both,,,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF COPPER,30100101,CDM,301,RC,82525,HCPCS,,,facility,both,,,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Central
HC CORTISOL FREE,30100102,CDM,301,RC,82530,HCPCS,,,facility,both,,,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Central
HC TOTAL CORTISOL,30100103,CDM,301,RC,82533,HCPCS,,,facility,both,,,,174,121.8,,,,,,,,,,,,,Gross Charge Type: Central
HC COLUMN CHROMATOGRAPHY INCL MASS SPECTROMETRY IF PERFORMED NON-DRUG ANALYTE(S) NOT ELSEWHERE SPECIFIED QUALITATIVE/QUANTITATIVE EACH SPECIMEN,30100105,CDM,301,RC,82542,HCPCS,,,facility,both,,,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF CK (CPK) TOTAL,30100107,CDM,301,RC,82550,HCPCS,,,facility,both,,,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF CPK IN BLOOD,30100108,CDM,301,RC,82552,HCPCS,,,facility,both,,,,130,91,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF CREATININE,30100109,CDM,301,RC,82565,HCPCS,,,facility,both,,,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF CREATININE OTHER SOURCE,30100110,CDM,301,RC,82570,HCPCS,,,facility,both,,,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Central
HC CREATININE CLEARANCE TEST,30100111,CDM,301,RC,82575,HCPCS,,,facility,both,,,,265,185.5,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF CRYOFIBRINOGEN,30100112,CDM,301,RC,82585,HCPCS,,,facility,both,,,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF CRYOGLOBULIN,30100113,CDM,301,RC,82595,HCPCS,,,facility,both,,,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF CYANIDE,30100114,CDM,301,RC,82600,HCPCS,,,facility,both,,,,168,117.6,,,,,,,,,,,,,Gross Charge Type: Central
VITAMIN B-12,30100115,CDM,301,RC,82607,HCPCS,,,facility,both,,,,154,107.8,,,,,,,,,,,,,Gross Charge Type: Central
HC B-12 BINDING CAPACITY,30100116,CDM,301,RC,82608,HCPCS,,,facility,both,,,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Central
HC CYSTATIN C,30100117,CDM,301,RC,82610,HCPCS,,,facility,both,,,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Central
HC DHEA,30100118,CDM,301,RC,82626,HCPCS,,,facility,both,,,,494,345.8,,,,,,,,,,,,,Gross Charge Type: Central
HC DHEA SO4,30100119,CDM,301,RC,82627,HCPCS,,,facility,both,,,,369,258.3,,,,,,,,,,,,,Gross Charge Type: Central
HC DEOXYCORTISOL,30100120,CDM,301,RC,82634,HCPCS,,,facility,both,,,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Central
VIT D 1 25-DIHYDROXY,30100122,CDM,301,RC,82652,HCPCS,,,facility,both,,,,617,431.9,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF ERYTHROPOIETIN,30100123,CDM,301,RC,82668,HCPCS,,,facility,both,,,,161,112.7,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF TOTAL ESTRADIOL,30100124,CDM,301,RC,82670,HCPCS,,,facility,both,,,,336,235.2,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF ESTROGENS,30100125,CDM,301,RC,82671,HCPCS,,,facility,both,,,,563,394.1,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF ETHYLENE GLYCOL,30100128,CDM,301,RC,82693,HCPCS,,,facility,both,,,,255,178.5,,,,,,,,,,,,,Gross Charge Type: Central
HC FATS/LIPIDS FECES QUAL,30100129,CDM,301,RC,82705,HCPCS,,,facility,both,,,,110,77,,,,,,,,,,,,,Gross Charge Type: Central
FATS/LIPIDS FECES QUANT,30100130,CDM,301,RC,82710,HCPCS,,,facility,both,,,,301,210.7,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF BLOOD FATTY ACIDS,30100131,CDM,301,RC,82725,HCPCS,,,facility,both,,,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Central
HC LONG CHAIN FATTY ACIDS,30100132,CDM,301,RC,82726,HCPCS,,,facility,both,,,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF FERRITIN,30100133,CDM,301,RC,82728,HCPCS,,,facility,both,,,,161,112.7,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF FETAL FIBRONECTIN,30100134,CDM,301,RC,82731,HCPCS,,,facility,both,,,,456,319.2,,,,,,,,,,,,,Gross Charge Type: Central
HC BLOOD FOLIC ACID SERUM,30100135,CDM,301,RC,82746,HCPCS,,,facility,both,,,,243,170.1,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF FOLIC ACID RBC,30100136,CDM,301,RC,82747,HCPCS,,,facility,both,,,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY IGA/IGD/IGG/IGM EACH,30100138,CDM,301,RC,82784,HCPCS,,,facility,both,,,,455,318.5,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF IGE,30100139,CDM,301,RC,82785,HCPCS,,,facility,both,,,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Central
HC IGG 1 2 3 OR 4 EACH,30100140,CDM,301,RC,82787,HCPCS,,,facility,both,,,,684,478.8,,,,,,,,,,,,,Gross Charge Type: Central
HC BLOOD GASES PH,30100141,CDM,301,RC,82800,HCPCS,,,facility,both,,,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Central
BLOOD GASES ANY COMBINATION,30100142,CDM,301,RC,82803,HCPCS,,,facility,both,,,,212,148.4,,,,,,,,,,,,,Gross Charge Type: Central
BLOOD GASES W/ O2 SATURATION,30100143,CDM,301,RC,82805,HCPCS,,,facility,both,,,,212,148.4,,,,,,,,,,,,,Gross Charge Type: Central
HC BLOOD GASES O2 SAT ONLY,30100144,CDM,301,RC,82810,HCPCS,,,facility,both,,,,129,90.3,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF GASTRIN,30100145,CDM,301,RC,82941,HCPCS,,,facility,both,,,,208,145.6,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF GLUCAGON,30100146,CDM,301,RC,82943,HCPCS,,,facility,both,,,,283,198.1,,,,,,,,,,,,,Gross Charge Type: Central
HC GLUCOSE FLUID NOT BLOOD,30100147,CDM,301,RC,82945,HCPCS,,,facility,both,,,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Central
ASSAY GLUCOSE BLOOD QUANT,30100148,CDM,301,RC,82947,HCPCS,,,facility,both,,,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY POCT GLUCOSE SCREEN,30100149,CDM,301,RC,82950,HCPCS,,,facility,both,,,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Central
HC GTT-ADDED SAMPLES,30100150,CDM,301,RC,82952,HCPCS,,,facility,both,,,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF G6PD ENZYME,30100151,CDM,301,RC,82955,HCPCS,,,facility,both,,,,182,127.4,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF GGT,30100153,CDM,301,RC,82977,HCPCS,,,facility,both,,,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Central
HC GLYCATED PROTEIN,30100154,CDM,301,RC,82985,HCPCS,,,facility,both,,,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Central
HC GONADOTROPIN (FSH),30100155,CDM,301,RC,83001,HCPCS,,,facility,both,,,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Central
HC GONADOTROPIN (LH),30100156,CDM,301,RC,83002,HCPCS,,,facility,both,,,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY GROWTH HORMONE (HGH),30100157,CDM,301,RC,83003,HCPCS,,,facility,both,,,,304,212.8,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF HAPTOGLOBIN QUANT,30100158,CDM,301,RC,83010,HCPCS,,,facility,both,,,,188,131.6,,,,,,,,,,,,,Gross Charge Type: Central
HC QUANTITATIVE SCREEN METALS,30100159,CDM,301,RC,83018,HCPCS,,,facility,both,,,,180,126,,,,,,,,,,,,,Gross Charge Type: Central
HC HEMOGLOBIN ELECTROPHORESIS,30100160,CDM,301,RC,83020,HCPCS,,,facility,both,,,,212,148.4,,,,,,,,,,,,,Gross Charge Type: Central
GLYCOSYLATED HEMOGLOBIN TEST,30100162,CDM,301,RC,83036,HCPCS,,,facility,both,,,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Central
HC BLOOD METHEMOGLOBIN ASSAY,30100163,CDM,301,RC,83050,HCPCS,,,facility,both,,,,129,90.3,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF PLASMA HEMOGLOBIN,30100164,CDM,301,RC,83051,HCPCS,,,facility,both,,,,180,126,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF HEMOSIDERIN QUAL,30100166,CDM,301,RC,83070,HCPCS,,,facility,both,,,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF HISTAMINE,30100167,CDM,301,RC,83088,HCPCS,,,facility,both,,,,196,137.2,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF HOMOCYSTINE,30100168,CDM,301,RC,83090,HCPCS,,,facility,both,,,,324,226.8,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF FOR HVA,30100169,CDM,301,RC,83150,HCPCS,,,facility,both,,,,254,177.8,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF 5-HIAA,30100170,CDM,301,RC,83497,HCPCS,,,facility,both,,,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF PROGESTERONE 17-D,30100171,CDM,301,RC,83498,HCPCS,,,facility,both,,,,301,210.7,,,,,,,,,,,,,Gross Charge Type: Central
HC IMMUNOASSAY NONANTIBODY,30100172,CDM,301,RC,83516,HCPCS,,,facility,both,,,,256,179.2,,,,,,,,,,,,,Gross Charge Type: Central
HC RIA NONANTIBODY,30100173,CDM,301,RC,83519,HCPCS,,,facility,both,,,,163,114.1,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF INSULIN,30100175,CDM,301,RC,83525,HCPCS,,,facility,both,,,,194,135.8,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF IRON,30100176,CDM,301,RC,83540,HCPCS,,,facility,both,,,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Central
HC IRON BINDING TEST,30100177,CDM,301,RC,83550,HCPCS,,,facility,both,,,,171,119.7,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY 17- KETOSTEROIDS TOTAL,30100178,CDM,301,RC,83586,HCPCS,,,facility,both,,,,169,118.3,,,,,,,,,,,,,Gross Charge Type: Central
ASSAY OF LACTIC ACID,30100179,CDM,301,RC,83605,HCPCS,,,facility,both,,,,188,131.6,,,,,,,,,,,,,Gross Charge Type: Central
HC LACTATE (LD) (LDH) ENZYME,30100180,CDM,301,RC,83615,HCPCS,,,facility,both,,,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF LDH ENZYMES,30100181,CDM,301,RC,83625,HCPCS,,,facility,both,,,,227,158.9,,,,,,,,,,,,,Gross Charge Type: Central
HC LACTOFERRIN FECAL (QUAL),30100182,CDM,301,RC,83630,HCPCS,,,facility,both,,,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF LEAD,30100183,CDM,301,RC,83655,HCPCS,,,facility,both,,,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Central
HC LAMELLAR BODY DENSITY,30100184,CDM,301,RC,83664,HCPCS,,,facility,both,,,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF LIPASE,30100185,CDM,301,RC,83690,HCPCS,,,facility,both,,,,184,128.8,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF LIPOPROTEIN(A),30100186,CDM,301,RC,83695,HCPCS,,,facility,both,,,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY LIPOPROTEIN PLA2,30100187,CDM,301,RC,83698,HCPCS,,,facility,both,,,,201,140.7,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF LIPOPROTEIN,30100189,CDM,301,RC,83718,HCPCS,,,facility,both,,,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF BLOOD LIPOPRO LDL,30100190,CDM,301,RC,83721,HCPCS,,,facility,both,,,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF MAGNESIUM,30100191,CDM,301,RC,83735,HCPCS,,,facility,both,,,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF MANGANESE,30100192,CDM,301,RC,83785,HCPCS,,,facility,both,,,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Central
HC MASS SPECTOMETRY AND TANDEM MASS SPECTROMETRY NON-DRUG ANALYTE(S) NOT ELSEWHERE SPECIFIED QUALITATIVE/QUANTITATIVE EACH SPECIMEN,30100193,CDM,301,RC,83789,HCPCS,,,facility,both,,,,90,63,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF MERCURY,30100194,CDM,301,RC,83825,HCPCS,,,facility,both,,,,171,119.7,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF METANEPHRINES,30100195,CDM,301,RC,83835,HCPCS,,,facility,both,,,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF CSF PROTEIN,30100197,CDM,301,RC,83873,HCPCS,,,facility,both,,,,291,203.7,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF MYOGLOBIN,30100198,CDM,301,RC,83874,HCPCS,,,facility,both,,,,292,204.4,,,,,,,,,,,,,Gross Charge Type: Central
HC NATRIURETIC PEPTIDE,30100199,CDM,301,RC,83880,HCPCS,,,facility,both,,,,162,113.4,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY NEPHELOMETRY NES,30100200,CDM,301,RC,83883,HCPCS,,,facility,both,,,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Central
HC OLIGOCLONAL BANDS,30100218,CDM,301,RC,83916,HCPCS,,,facility,both,,,,154,107.8,,,,,,,,,,,,,Gross Charge Type: Central
HC ORGANIC ACIDS TOTAL QUANT EA,30100219,CDM,301,RC,83918,HCPCS,,,facility,both,,,,134,93.8,,,,,,,,,,,,,Gross Charge Type: Central
HC ORGANIC ACID SINGLE QUANT,30100220,CDM,301,RC,83921,HCPCS,,,facility,both,,,,209,146.3,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF BLOOD OSMOLALITY,30100222,CDM,301,RC,83930,HCPCS,,,facility,both,,,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF URINE OSMOLALITY,30100223,CDM,301,RC,83935,HCPCS,,,facility,both,,,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF OXALATE,30100225,CDM,301,RC,83945,HCPCS,,,facility,both,,,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF PARATHORMONE,30100226,CDM,301,RC,83970,HCPCS,,,facility,both,,,,565,395.5,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY PH BODY FLUID NOS,30100227,CDM,301,RC,83986,HCPCS,,,facility,both,,,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY FOR CALPROTECTIN FECAL,30100228,CDM,301,RC,83993,HCPCS,,,facility,both,,,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY ALK PHOS ISOENZYMES,30100232,CDM,301,RC,84075,HCPCS,,,facility,both,,,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY ALK PHOS ISOENZYMES,30100233,CDM,301,RC,84080,HCPCS,,,facility,both,,,,334,233.8,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF PHOSPHORUS,30100235,CDM,301,RC,84100,HCPCS,,,facility,both,,,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF URINE PHOSPHORUS,30100236,CDM,301,RC,84105,HCPCS,,,facility,both,,,,10,7,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF PORPHOBILINOGEN,30100237,CDM,301,RC,84110,HCPCS,,,facility,both,,,,184,128.8,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF URINE PORPHYRINS,30100238,CDM,301,RC,84120,HCPCS,,,facility,both,,,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF FECES PORPHYRINS,30100239,CDM,301,RC,84126,HCPCS,,,facility,both,,,,292,204.4,,,,,,,,,,,,,Gross Charge Type: Central
HC POC POTASSIUM SERUM PLASMA/WHOLE BLOOD,30100240,CDM,301,RC,84132,HCPCS,,,facility,both,,,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF URINE POTASSIUM,30100241,CDM,301,RC,84133,HCPCS,,,facility,both,,,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF PREALBUMIN,30100242,CDM,301,RC,84134,HCPCS,,,facility,both,,,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF 17-HYDROXYPREG,30100244,CDM,301,RC,84143,HCPCS,,,facility,both,,,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF PROGESTERONE,30100245,CDM,301,RC,84144,HCPCS,,,facility,both,,,,213,149.1,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF PROLACTIN,30100246,CDM,301,RC,84146,HCPCS,,,facility,both,,,,281,196.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PSA SPECIFIC ANTIGEN TOTAL,30100247,CDM,301,RC,84153,HCPCS,,,facility,both,,,,199,139.3,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF PSA FREE,30100248,CDM,301,RC,84154,HCPCS,,,facility,both,,,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF PROTEIN URINE,30100249,CDM,301,RC,84156,HCPCS,,,facility,both,,,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF PROTEIN OTHER SOURCE,30100250,CDM,301,RC,84157,HCPCS,,,facility,both,,,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PAPPA SERUM,30100251,CDM,301,RC,84163,HCPCS,,,facility,both,,,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PROTEIN E-PHORESIS SERUM,30100252,CDM,301,RC,84165,HCPCS,,,facility,both,,,,218,152.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PROTEIN E-PHORESIS/URINE/CSF,30100253,CDM,301,RC,84166,HCPCS,,,facility,both,,,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Central
HC WESTERN BLOT TEST IMMUN PROBE,30100255,CDM,301,RC,84182,HCPCS,,,facility,both,,,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY RBC PROTOPORPHYRIN,30100256,CDM,301,RC,84202,HCPCS,,,facility,both,,,,317,221.9,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF PROINSULIN,30100257,CDM,301,RC,84206,HCPCS,,,facility,both,,,,242,169.4,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF VITAMIN B-6,30100258,CDM,301,RC,84207,HCPCS,,,facility,both,,,,192,134.4,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF PYRUVATE,30100259,CDM,301,RC,84210,HCPCS,,,facility,both,,,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF PYRUVATE KINASE,30100260,CDM,301,RC,84220,HCPCS,,,facility,both,,,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY NONENDOCRINE RECEPTOR,30100261,CDM,301,RC,84238,HCPCS,,,facility,both,,,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF RENIN,30100262,CDM,301,RC,84244,HCPCS,,,facility,both,,,,265,185.5,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF VITAMIN B-2,30100263,CDM,301,RC,84252,HCPCS,,,facility,both,,,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF SELENIUM,30100264,CDM,301,RC,84255,HCPCS,,,facility,both,,,,127,88.9,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF SEROTONIN,30100265,CDM,301,RC,84260,HCPCS,,,facility,both,,,,479,335.3,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF SEX HORMONE GLOBUL,30100266,CDM,301,RC,84270,HCPCS,,,facility,both,,,,134,93.8,,,,,,,,,,,,,Gross Charge Type: Central
HC POC ASSAY OF SERUM SODIUM,30100267,CDM,301,RC,84295,HCPCS,,,facility,both,,,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF URINE SODIUM,30100268,CDM,301,RC,84300,HCPCS,,,facility,both,,,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF SODIUM OTHER SOURCE,30100269,CDM,301,RC,84302,HCPCS,,,facility,both,,,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF SOMATOMEDIN,30100270,CDM,301,RC,84305,HCPCS,,,facility,both,,,,302,211.4,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF SOMATOSTATIN,30100271,CDM,301,RC,84307,HCPCS,,,facility,both,,,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Central
SPECTROPHOTOMETRY NES,30100272,CDM,301,RC,84311,HCPCS,,,facility,both,,,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Central
HC BODY FLUID SPECIF GRAV NOT URINE,30100273,CDM,301,RC,84315,HCPCS,,,facility,both,,,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Central
HC SUGARS SINGLE QUAL EA,30100274,CDM,301,RC,84376,HCPCS,,,facility,both,,,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF TESTOSTERONE FREE,30100276,CDM,301,RC,84402,HCPCS,,,facility,both,,,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF TOTAL TESTOSTERONE,30100277,CDM,301,RC,84403,HCPCS,,,facility,both,,,,261,182.7,,,,,,,,,,,,,Gross Charge Type: Central
ASSAY OF VITAMIN B-1,30100278,CDM,301,RC,84425,HCPCS,,,facility,both,,,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF THIOCYANATE,30100279,CDM,301,RC,84430,HCPCS,,,facility,both,,,,283,198.1,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF THYROGLOBULIN,30100280,CDM,301,RC,84432,HCPCS,,,facility,both,,,,301,210.7,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF TOTAL THYROXINE,30100281,CDM,301,RC,84436,HCPCS,,,facility,both,,,,133,93.1,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF FREE THYROXINE,30100282,CDM,301,RC,84439,HCPCS,,,facility,both,,,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF THYROID ACTIVITY,30100283,CDM,301,RC,84442,HCPCS,,,facility,both,,,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Central
ASSAY THYROID STIM HORMONE,30100284,CDM,301,RC,84443,HCPCS,,,facility,both,,,,70,49,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY THYROID STIM IMM GLOB,30100285,CDM,301,RC,84445,HCPCS,,,facility,both,,,,673,471.1,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF VITAMIN E,30100286,CDM,301,RC,84446,HCPCS,,,facility,both,,,,90,63,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF TRANSCORTIN,30100287,CDM,301,RC,84449,HCPCS,,,facility,both,,,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Central
HC TRANSFERASE (AST) (SGOT),30100288,CDM,301,RC,84450,HCPCS,,,facility,both,,,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Central
ALANINE AMINO (ALT) (SGPT),30100289,CDM,301,RC,84460,HCPCS,,,facility,both,,,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF TRANSFERRIN,30100290,CDM,301,RC,84466,HCPCS,,,facility,both,,,,142,99.4,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF TRIGLYCERIDES,30100291,CDM,301,RC,84478,HCPCS,,,facility,both,,,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF THYROID (T3 OR T4),30100292,CDM,301,RC,84479,HCPCS,,,facility,both,,,,101,70.7,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY TRIIODOTHYRONINE (T3) TOTAL,30100293,CDM,301,RC,84480,HCPCS,,,facility,both,,,,161,112.7,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY T3 TOTAL,30100294,CDM,301,RC,84481,HCPCS,,,facility,both,,,,313,219.1,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY T3 REVERSE,30100295,CDM,301,RC,84482,HCPCS,,,facility,both,,,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF TROPONIN QUANT,30100296,CDM,301,RC,84484,HCPCS,,,facility,both,,,,223,156.1,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF UREA NITROGEN,30100298,CDM,301,RC,84520,HCPCS,,,facility,both,,,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF URINE/UREA-N,30100299,CDM,301,RC,84540,HCPCS,,,facility,both,,,,70,49,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF BLOOD/URIC ACID,30100300,CDM,301,RC,84550,HCPCS,,,facility,both,,,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF URIC ACID OTHER SOURCE,30100301,CDM,301,RC,84560,HCPCS,,,facility,both,,,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF URINE VMA,30100302,CDM,301,RC,84585,HCPCS,,,facility,both,,,,242,169.4,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF VIP,30100303,CDM,301,RC,84586,HCPCS,,,facility,both,,,,534,373.8,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF VASOPRESSIN,30100304,CDM,301,RC,84588,HCPCS,,,facility,both,,,,254,177.8,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF VITAMIN A,30100305,CDM,301,RC,84590,HCPCS,,,facility,both,,,,222,155.4,,,,,,,,,,,,,Gross Charge Type: Central
ASSAY VITAMIN NOS,30100306,CDM,301,RC,84591,HCPCS,,,facility,both,,,,70,49,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF VITAMIN K,30100307,CDM,301,RC,84597,HCPCS,,,facility,both,,,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF ZINC,30100309,CDM,301,RC,84630,HCPCS,,,facility,both,,,,222,155.4,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF C-PEPTIDE,30100310,CDM,301,RC,84681,HCPCS,,,facility,both,,,,238,166.6,,,,,,,,,,,,,Gross Charge Type: Central
CHORIONIC GONADOTROPIN QUANT,30100311,CDM,301,RC,84702,HCPCS,,,facility,both,,,,209,146.3,,,,,,,,,,,,,Gross Charge Type: Central
HC CHORIONIC GONADOTROPIN QUANL,30100312,CDM,301,RC,84703,HCPCS,,,facility,both,,,,111,77.7,,,,,,,,,,,,,Gross Charge Type: Central
HC SUGARS SINGLE QUANTITATIVE EA SPECIMEN,30100314,CDM,301,RC,84378,HCPCS,,,facility,both,,,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Central
HC POC BLOOD GASES W/ O2 SATURATION,30100319,CDM,301,RC,82805,HCPCS,,,facility,both,,,,212,148.4,,,,,,,,,,,,,Gross Charge Type: Central
HC POC OCCULT BLOOD FECES,30100320,CDM,301,RC,82270,HCPCS,,,facility,both,,,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Central
HC POC ASSAY PH BODY FLUID NOS,30100321,CDM,301,RC,83986,HCPCS,,,facility,both,,,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Central
HC POC OCCULT BLOOD OTHER SOURCES,30100323,CDM,301,RC,82271,HCPCS,,,facility,both,,,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Central
HC POC ASSAY OF BREATH ETHANOL,30100324,CDM,301,RC,82075,HCPCS,,,facility,both,,,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Central
HC POC BLOOD GASES ANY COMBINATION,30100325,CDM,301,RC,82803,HCPCS,,,facility,both,,,,212,148.4,,,,,,,,,,,,,Gross Charge Type: Central
HC POC GLUC BLD TEST MONITORING DEVICE,30100326,CDM,301,RC,82962,HCPCS,,,facility,both,,,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Central
HC UNLISTED CHEMISTRY PROCEDURE,30100328,CDM,301,RC,84999,HCPCS,,,facility,both,,,,3653,2557.1,,,,,,,,,,,,,Gross Charge Type: Central
HC 5 NUCLEOTIDASE,30100330,CDM,301,RC,83915,HCPCS,,,facility,both,,,,186,130.2,,,,,,,,,,,,,Gross Charge Type: Central
HC BIOTINIDASE,30100331,CDM,301,RC,82261,HCPCS,,,facility,both,,,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Central
HC ANGIOTENSIN II,30100332,CDM,301,RC,82163,HCPCS,,,facility,both,,,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PROCALCITONIN (PCT),30100333,CDM,301,RC,84145,HCPCS,,,facility,both,,,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Central
HC RBC CHOLINESTERASE,30100334,CDM,301,RC,82482,HCPCS,,,facility,both,,,,174,121.8,,,,,,,,,,,,,Gross Charge Type: Central
HC DRUG SCRN QUAN MYCOPHENOLATE,30100336,CDM,301,RC,80180,HCPCS,,,facility,both,,,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Central
HC ANTIDEPRESSANTS TRICYCLIC AND OTHER CYCLICALS 3-5,30100340,CDM,301,RC,80336,HCPCS,,,facility,both,,,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Central
HC ANTIDEPRESSANTS TRICYCLIC AND OTHER CYCLICALS 1-7 CLASSES,30100341,CDM,301,RC,80337,HCPCS,,,facility,both,,,,141,98.7,,,,,,,,,,,,,Gross Charge Type: Central
HC BENZODIAZAPINES 1-12,30100342,CDM,301,RC,80346,HCPCS,,,facility,both,,,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Central
HC BENZODIAZAPINES 13 OR MORE,30100343,CDM,301,RC,80347,HCPCS,,,facility,both,,,,316,221.2,,,,,,,,,,,,,Gross Charge Type: Central
HC ANALGESICS NON-OPIOID (ACETAMINOPHEN) 1 OR 2,30100359,CDM,301,RC,80329,HCPCS,,,facility,both,,,,222,155.4,,,,,,,,,,,,,Gross Charge Type: Central
HC ALCOHOLS,30100362,CDM,301,RC,80320,HCPCS,,,facility,both,,,,141,98.7,,,,,,,,,,,,,Gross Charge Type: Central
HC ALCOHOLS BIOMARKERS 1OR 2,30100363,CDM,301,RC,80321,HCPCS,,,facility,both,,,,313,219.1,,,,,,,,,,,,,Gross Charge Type: Central
HC ALCOHOLS 3 OR MORE,30100364,CDM,301,RC,80322,HCPCS,,,facility,both,,,,128,89.6,,,,,,,,,,,,,Gross Charge Type: Central
HC AMPHETAMINES 1 OR 2,30100365,CDM,301,RC,80324,HCPCS,,,facility,both,,,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Central
HC AMPHETAMINES 3 OR 4,30100366,CDM,301,RC,80325,HCPCS,,,facility,both,,,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Central
HC AMPHETAMINES 5 OR MORE,30100367,CDM,301,RC,80326,HCPCS,,,facility,both,,,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Central
HC COCAINE,30100368,CDM,301,RC,80353,HCPCS,,,facility,both,,,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Central
HC SKELETAL MUSCLE RELAXANTS 1 OR 2,30100371,CDM,301,RC,80369,HCPCS,,,facility,both,,,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Central
HC METHADONE,30100373,CDM,301,RC,80358,HCPCS,,,facility,both,,,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Central
HC ALKALOIDS NOT OTHERWISE SPECIFIED,30100374,CDM,301,RC,80323,HCPCS,,,facility,both,,,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Central
HC OPIATES 1 OR MORE,30100375,CDM,301,RC,80361,HCPCS,,,facility,both,,,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Central
HC OPIOIDS AND OPIATE ANALOGS 1 OR 2,30100376,CDM,301,RC,80362,HCPCS,,,facility,both,,,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Central
HC OPIOIDS AND OPIATE ANALOGS 5 OR MORE,30100378,CDM,301,RC,80364,HCPCS,,,facility,both,,,,302,211.4,,,,,,,,,,,,,Gross Charge Type: Central
HC ANTIPSYCHOTICS NOT OTHERWISE SPECIFIED 1-3,30100379,CDM,301,RC,80342,HCPCS,,,facility,both,,,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY CARBAMAZEPINE FREE,30100382,CDM,301,RC,80157,HCPCS,,,facility,both,,,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF BARBITURATES,30100384,CDM,301,RC,80345,HCPCS,,,facility,both,,,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Central
HC DRUG SCREENING FENTANYL,30100385,CDM,301,RC,80354,HCPCS,,,facility,both,,,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Central
HC DRUG SCREENING BUPRENORPHINE,30100386,CDM,301,RC,80348,HCPCS,,,facility,both,,,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Central
HC DRUG SCREEN QUANT ZONISAMIDE,30100387,CDM,301,RC,80203,HCPCS,,,facility,both,,,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Central
HC 1ST TRIMESTER SEQ SC,30100388,CDM,310,RC,81508,HCPCS,,,facility,both,,,,218,152.6,,,,,,,,,,,,,Gross Charge Type: Central
HC 2ND TRIMESTER SEQ SC,30100389,CDM,310,RC,81511,HCPCS,,,facility,both,,,,617,431.9,,,,,,,,,,,,,Gross Charge Type: Central
HC OCCULT BLOOD FECES 1-3 TESTS PERFORMED FOR OTHER THAN COLORECTRAL NEOPLASM SCREENING,30100391,CDM,301,RC,82272,HCPCS,,,facility,both,,,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF CREATINE,30100394,CDM,301,RC,82540,HCPCS,,,facility,both,,,,20,14,,,,,,,,,,,,,Gross Charge Type: Central
HC DRUG TEST(S) DEFINITIVE QUAL/QUANT ALL SOURCE(S) 1-7 CLASS(ES),30100398,CDM,301,RC,G0480,HCPCS,,,facility,both,,,,302,211.4,,,,,,,,,,,,,Gross Charge Type: Central
HC CLOZAPINE,30100399,CDM,301,RC,80159,HCPCS,,,facility,both,,,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Central
HC EVEROLIMUS,30100400,CDM,301,RC,80169,HCPCS,,,facility,both,,,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Central
HC GABAPENTIN WHOLE BLOOD/SERUM/PLASMA,30100401,CDM,301,RC,80171,HCPCS,,,facility,both,,,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Central
HC LAMOTRIGINE,30100402,CDM,301,RC,80175,HCPCS,,,facility,both,,,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Central
HC OXCARBAZEPINE,30100403,CDM,301,RC,80183,HCPCS,,,facility,both,,,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Central
HC ANTIDEPRESSANTS SEROTONERGIC CLASS 1 OR 2,30100410,CDM,301,RC,80332,HCPCS,,,facility,both,,,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Central
HC ANTIDEPRESSANTS NOT OTHERWISE SPECIFIED,30100411,CDM,301,RC,80338,HCPCS,,,facility,both,,,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Central
HC CANNABINOIDS NATURAL,30100412,CDM,301,RC,80349,HCPCS,,,facility,both,,,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Central
HC OXYCODONE,30100414,CDM,301,RC,80365,HCPCS,,,facility,both,,,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PROPOXYPHENE,30100415,CDM,301,RC,80367,HCPCS,,,facility,both,,,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Central
HC SEDATIVE HYPNOTICS (NON-BENZODIAZEPINES),30100416,CDM,301,RC,80368,HCPCS,,,facility,both,,,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Central
HC STIMULANTS SYNTHETIC,30100417,CDM,301,RC,80371,HCPCS,,,facility,both,,,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Central
HC TRAMADOL,30100418,CDM,301,RC,80373,HCPCS,,,facility,both,,,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Central
HC DRUG(S)/SUBSTANCE(S) DEFINITIVE QUALITATIVE/QUANTITATIVE NOT OTHERWISE SPECIFIED 1-3,30100419,CDM,301,RC,80375,HCPCS,,,facility,both,,,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Central
HC DRUG(S)/SUBSTANCE(S) DEFINITIVE QUALITATIVE/QUANTITATIVE NOT OTHERWISE SPECIFIED 7 OR MORE,30100420,CDM,301,RC,80377,HCPCS,,,facility,both,,,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Central
HC ANTIDEPRESSANTS TRICYCLIC & OTHER CYCLICALS 1 OR 2,30100422,CDM,301,RC,80335,HCPCS,,,facility,both,,,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Central
HC VALPROIC ACID (DIPROPYLACETIC ACID) TOTAL,30100423,CDM,301,RC,80164,HCPCS,,,facility,both,,,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Central
HC VALPROIC ACID (DIPROPYLACETIC ACID) FREE,30100424,CDM,301,RC,80165,HCPCS,,,facility,both,,,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Central
HC HEROIN METABOLITE,30100425,CDM,301,RC,80356,HCPCS,,,facility,both,,,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Central
HC ANTIDEPRESSANT TRICYCLIC AND OTHER CYCLICALS 3-5,30100426,CDM,301,RC,80336,HCPCS,,,facility,both,,,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Central
HC FIBRINOLYSINS OR COAGULOPATHY SCREEN INTERP AND REPORT,30100429,CDM,301,RC,85390,HCPCS,,,facility,both,,,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Central
HC ELECTROPHORETIC TECHNIQUE NOT ELSEWHERE SPECIFIED,30100431,CDM,301,RC,82664,HCPCS,,,facility,both,,,,260,182,,,,,,,,,,,,,Gross Charge Type: Central
HC METHYLENEDIOXYAMPHETAMINES,30100433,CDM,301,RC,80359,HCPCS,,,facility,both,,,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Central
HC DIBUCAINE NUMBER,30100434,CDM,301,RC,82638,HCPCS,,,facility,both,,,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Central
HC DRUG TEST PRESUMP DIRECT OPTICAL OBS PER DATE OF SERVICE,30100435,CDM,301,RC,80305,HCPCS,,,facility,both,,,,168,117.6,,,,,,,,,,,,,Gross Charge Type: Central
HC DRUG TEST PRESUMP INSTRUMENT ASSISTED DIRECT OPTICAL OBS PER DATE OF SERVICE,30100436,CDM,301,RC,80306,HCPCS,,,facility,both,,,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Central
HC DRUG TEST PRESUMP INSTRUMENT CHEMISTRY ANALYZER CHROMATOGRAPHY/MASS SPECTROMETRY  W/WO CHROMATOGRAPHY PER DATE OF SERVICE,30100437,CDM,301,RC,80307,HCPCS,,,facility,both,,,,168,117.6,,,,,,,,,,,,,Gross Charge Type: Central
HC POTASSIUM SERUM PLASMA/WHOLE BLOOD,30100439,CDM,301,RC,84132,HCPCS,,,facility,both,,,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF SERUM SODIUM,30100440,CDM,301,RC,84295,HCPCS,,,facility,both,,,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Central
HC CRYSTAL ID FROM TISSUE OR BODY FLUID,30100441,CDM,301,RC,89060,HCPCS,,,facility,both,,,,30,21,,,,,,,,,,,,,Gross Charge Type: Central
HC DRUG SCREEN METHYLPHENIDATE,30100442,CDM,301,RC,80360,HCPCS,,,facility,both,,,,222,155.4,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF CALCIUM IONIZED,30100443,CDM,301,RC,82330,HCPCS,,,facility,both,,,,230,161,,,,,,,,,,,,,Gross Charge Type: Central
HC LUTEINIZING RELEASING FACTOR (LRH),30100444,CDM,301,RC,83727,HCPCS,,,facility,both,,,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Central
HC POC DRUG TEST PRESUMP DIRECT OPTICAL OBS PER DATE OF SERVICE,30100445,CDM,301,RC,80305,HCPCS,,,facility,both,,,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF CADMIUM,30100447,CDM,301,RC,82300,HCPCS,,,facility,both,,,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Central
HC POC CREATININE ISTAT,30100448,CDM,301,RC,82565,HCPCS,,,facility,both,,,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Central
HC POC B-HCG ISTAT,30100450,CDM,301,RC,84702,HCPCS,,,facility,both,,,,209,146.3,,,,,,,,,,,,,Gross Charge Type: Central
HC POC BNP,30100451,CDM,301,RC,83880,HCPCS,,,facility,both,,,,162,113.4,,,,,,,,,,,,,Gross Charge Type: Central
HC POC TROPONIN,30100452,CDM,301,RC,84484,HCPCS,,,facility,both,,,,223,156.1,,,,,,,,,,,,,Gross Charge Type: Central
HC POC LIVER PNL ISTAT,30100453,CDM,301,RC,80076,HCPCS,,,facility,both,,,,142,99.4,,,,,,,,,,,,,Gross Charge Type: Central
HC POC URINE PREGNANCY (HCG),30100454,CDM,301,RC,84703,HCPCS,,,facility,both,,,,111,77.7,,,,,,,,,,,,,Gross Charge Type: Central
HC POC ASSAY OF BLOOD CHLORIDE,30100455,CDM,301,RC,82435,HCPCS,,,facility,both,,,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Central
HC POC ASSAY GLUCOSE BLOOD QUANT,30100456,CDM,301,RC,82947,HCPCS,,,facility,both,,,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Central
HC POC ASSAY OF LACTIC ACID,30100457,CDM,301,RC,83605,HCPCS,,,facility,both,,,,188,131.6,,,,,,,,,,,,,Gross Charge Type: Central
HC POC ASSAY CARBOXYHB QUANT,30100459,CDM,301,RC,82375,HCPCS,,,facility,both,,,,164,114.8,,,,,,,,,,,,,Gross Charge Type: Central
HC POC DRUG TEST PRESUMP INSTRUMENT CHEM ANALYZER CHROMATOGRAPHY/MASS SPECTROMETRY  W/WO CHROMATOGRAPHY PER DOS,30100460,CDM,301,RC,80307,HCPCS,,,facility,both,,,,168,117.6,,,,,,,,,,,,,Gross Charge Type: Central
HC POC ASSAY OF UREA NITROGEN,30100461,CDM,301,RC,84520,HCPCS,,,facility,both,,,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY OF NICKEL,30100463,CDM,301,RC,83885,HCPCS,,,facility,both,,,,130,91,,,,,,,,,,,,,Gross Charge Type: Central
HC ALCOHOL SPECIMEN EXCEPT URINE & BREATH IA,30100465,CDM,301,RC,82077,HCPCS,,,facility,both,,,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Central
HC DRUG ASSAY AMIODARONE,30100466,CDM,301,RC,80151,HCPCS,,,facility,both,,,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Central
HC DRUG ASSAY FELBAMATE,30100467,CDM,301,RC,80167,HCPCS,,,facility,both,,,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Central
HC DRUG ASSAY FLECAINIDE,30100468,CDM,301,RC,80181,HCPCS,,,facility,both,,,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Central
HC DRUG ASSAY LEFLUNOMIDE,30100469,CDM,301,RC,80193,HCPCS,,,facility,both,,,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Central
HC DRUG ASSAY ITRACONAZOLE,30100470,CDM,301,RC,80189,HCPCS,,,facility,both,,,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Central
HC DRUG ASSAY CARBAMAZEPINE--10 11-EPOXIDE,30100471,CDM,301,RC,80161,HCPCS,,,facility,both,,,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Central
HC POC KETONE BODY QUANTITATIVE,30100476,CDM,301,RC,82010,HCPCS,,,facility,both,,,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Central
HC DRUG SCREENING PREGABALIN,30100477,CDM,301,RC,80366,HCPCS,,,facility,both,,,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Central
HC DRUG TEST(S) DEFINITIVE QUAL/QUANT ALL SOURCES 8-14 CLASSES,30100478,CDM,301,RC,G0481,HCPCS,,,facility,both,,,,486,340.2,,,,,,,,,,,,,Gross Charge Type: Central
HC DRUG TEST(S) DEFINITIVE QUAL/QUANT ALL SOURCES 15-21 CLASSES,30100479,CDM,301,RC,G0482,HCPCS,,,facility,both,,,,610,427,,,,,,,,,,,,,Gross Charge Type: Central
HC DRUG TEST(S) DEFINITIVE QUAL/QUANT ALL SOURCES 22+ CLASSES,30100480,CDM,301,RC,G0483,HCPCS,,,facility,both,,,,758,530.6,,,,,,,,,,,,,Gross Charge Type: Central
HC DRUG SCREENING GABAPENTIN NON BLOOD,30100483,CDM,301,RC,80355,HCPCS,,,facility,both,,,,302,211.4,,,,,,,,,,,,,Gross Charge Type: Central
HC POC BILIRUBIN TOTAL,30100484,CDM,301,RC,82247,HCPCS,,,facility,both,,,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSAY THIOPURINE S-METHYLTRANSFERASE,30100485,CDM,301,RC,84433,HCPCS,,,facility,both,,,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Central
HC ANTI-MULLERIAN HORMONE,30100486,CDM,301,RC,82166,HCPCS,,,facility,both,,,,156,109.2,,,,,,,,,,,,,Gross Charge Type: Central
HC POC ASSAY BLOOD CARBON DIOXIDE,30100487,CDM,301,RC,82374,HCPCS,,,facility,both,,,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Central
HC BETA-AMYLOID 1-42,30100488,CDM,301,RC,82234,HCPCS,,,facility,both,,,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Central
HC TAU PHOSPHORYLATED EACH,30100489,CDM,301,RC,84393,HCPCS,,,facility,both,,,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Central
HC TOTAL TAU,30100490,CDM,301,RC,84394,HCPCS,,,facility,both,,,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Central
HC POC ASSAY OF MAGNESIUM,30100491,CDM,301,RC,83735,HCPCS,,,facility,both,,,,50,35,,,,,,,,,,,,,Gross Charge Type: Central
HC POC ASSAY OF LIPASE,30100492,CDM,301,RC,83690,HCPCS,,,facility,both,,,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Central
HC TB TEST CELL IMMUN MEASURE,30200001,CDM,302,RC,86480,HCPCS,,,facility,both,,,,324,226.8,,,,,,,,,,,,,Gross Charge Type: Central
HC WEST NILE VIRUS AB IGM,30200004,CDM,302,RC,86788,HCPCS,,,facility,both,,,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Central
HC HUMAN EPIDIDYMIS PROTEIN 4,30200006,CDM,302,RC,86305,HCPCS,,,facility,both,,,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Central
HC ANTIBODY HEPATITIS DELTA AGENT,30200010,CDM,302,RC,86692,HCPCS,,,facility,both,,,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Central
HC HIV-1 ANTIGEN(S) WITH HIV-1 AND HIV-2 ANTIBODIES SINGLE RESULT BY IMMUNOASSAY TECHNIQUE QUAL/SEMIQUAL MULTIPLE-STEP METHOD,30200011,CDM,302,RC,87389,HCPCS,,,facility,both,,,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Central
HC INFECTIOUS AGENT DETECTION BY NUCLEIC ACID GASTROINTESTINAL PATHOGEN MULTIPLE TYPES/SUBTYPES 3-5 TARGETS,30200012,CDM,306,RC,87505,HCPCS,,,facility,both,,,,545,381.5,,,,,,,,,,,,,Gross Charge Type: Central
HC INFECTIOUS AGENT DETECT NUCLEIC ACID GI PTHGN INCL MULTIPLEX REVERSE TRANSCRIPT WHEN PERFORM/MULTIPLEX AMPLIFIED PROBE TECH MULTI TYPES/SUBTYPES 6-11 TARGETS,30200014,CDM,302,RC,87506,HCPCS,,,facility,both,,,,2541,1778.7,,,,,,,,,,,,,Gross Charge Type: Central
HC ACETYLCHOLINE RECEPTOR BINDING ANTIBODY,30200018,CDM,302,RC,86041,HCPCS,,,facility,both,,,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Central
HC ACETYLCHOLINE RECEPTOR MODULATING ANTIBODY,30200019,CDM,302,RC,86043,HCPCS,,,facility,both,,,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Central
HC MUSCLE-SPECIFIC KINASE ANTIBODY,30200020,CDM,302,RC,86366,HCPCS,,,facility,both,,,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Central
HC ACETYLCHOLINE RECEPTOR BLOCKING ANTIBODY,30200021,CDM,302,RC,86042,HCPCS,,,facility,both,,,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Central
HC RETICULATED PLATELET ASSAY,30500001,CDM,305,RC,85055,HCPCS,,,facility,both,,,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Central
HC CULT BACT ANAEROBIC NOT BLOOD,30600001,CDM,306,RC,87075,HCPCS,,,facility,both,,,,348,243.6,,,,,,,,,,,,,Gross Charge Type: Central
HC ASPERGILLUS AG EIA,30600003,CDM,306,RC,87305,HCPCS,,,facility,both,,,,20,14,,,,,,,,,,,,,Gross Charge Type: Central
HC ENTAMOEB HIST GROUP AG EIA,30600004,CDM,306,RC,87337,HCPCS,,,facility,both,,,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Central
HC CANDIDA DNA DIR PROBE,30600005,CDM,306,RC,87480,HCPCS,,,facility,both,,,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Central
HC ENTEROVIRUS DNA AMP PROBE,30600006,CDM,306,RC,87498,HCPCS,,,facility,both,,,,167,116.9,,,,,,,,,,,,,Gross Charge Type: Central
HC GARDNER VAG DNA DIR PROBE,30600009,CDM,306,RC,87510,HCPCS,,,facility,both,,,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Central
HHV-6 QUANTIFICATION,30600010,CDM,306,RC,87533,HCPCS,,,facility,both,,,,186,130.2,,,,,,,,,,,,,Gross Charge Type: Central
HC MRSA DNA AMP PROBE,30600011,CDM,306,RC,87641,HCPCS,,,facility,both,,,,167,116.9,,,,,,,,,,,,,Gross Charge Type: Central
STREP A DNA DIR PROBE,30600012,CDM,306,RC,87650,HCPCS,,,facility,both,,,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Central
HC STREP B DNA AMP PROBE,30600013,CDM,306,RC,87653,HCPCS,,,facility,both,,,,154,107.8,,,,,,,,,,,,,Gross Charge Type: Central
HC TRICHOMONAS VAGIN DIR PROBE,30600014,CDM,306,RC,87660,HCPCS,,,facility,both,,,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Central
HC ACID-FAST BACILLUS (AFB) ID,30600015,CDM,306,RC,87153,HCPCS,,,facility,both,,,,489,342.3,,,,,,,,,,,,,Gross Charge Type: Central
HC RESP VIRUS 3-5 TARGETS,30600016,CDM,306,RC,87631,HCPCS,,,facility,both,,,,566,396.2,,,,,,,,,,,,,Gross Charge Type: Central
HC CULTURE TYPING ID BY NUCLEIC ACID (DNA/RNA) PROBE PER CULTURE OR ISOLATE,30600018,CDM,306,RC,87150,HCPCS,,,facility,both,,,,150,105,,,,,,,,,,,,,Gross Charge Type: Central
HC INFECT AGENT DET BY NUCLEIC ACID MYCOBACT AMPL PROBE TECHNIQ,30600020,CDM,306,RC,87551,HCPCS,,,facility,both,,,,186,130.2,,,,,,,,,,,,,Gross Charge Type: Central
HC RESP VIRUS PANEL PCR,30600021,CDM,306,RC,87633,HCPCS,,,facility,both,,,,1830,1281,,,,,,,,,,,,,Gross Charge Type: Central
HC POC FLU A/B COMBO,30600022,CDM,306,RC,87502,HCPCS,,,facility,both,,,,194,135.8,,,,,,,,,,,,,Gross Charge Type: Central
HC POC FLU A/B RSV,30600023,CDM,306,RC,87631,HCPCS,,,facility,both,,,,566,396.2,,,,,,,,,,,,,Gross Charge Type: Central
HC INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA/RNA) CYTOMEGALOVIRUS AMPLIFIED PROBE,30600024,CDM,306,RC,87496,HCPCS,,,facility,both,,,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Central
HC INFECTIOUS AGENT (DNA OR RNA) CANDIDA SPECIES AMPLIFIED PROBE TECHNIQUE,30600025,CDM,306,RC,87481,HCPCS,,,facility,both,,,,154,107.8,,,,,,,,,,,,,Gross Charge Type: Central
HC INFECT AGENT DETECT NUCLEIC ACID (DNA OR RNA) CHLAMYDIA PNEUMONIAE AMPLIFIED PROBE,30600026,CDM,306,RC,87486,HCPCS,,,facility,both,,,,154,107.8,,,,,,,,,,,,,Gross Charge Type: Central
HC UNLISTED MICROBIOLOGY PROCEDURE,30600027,CDM,306,RC,87999,HCPCS,,,facility,both,,,,154,107.8,,,,,,,,,,,,,Gross Charge Type: Central
HC CNS DNA/RNA AMP PROBE MULTIPLE SUBTYPES 12-25,30600029,CDM,306,RC,87483,HCPCS,,,facility,both,,,,2065,1445.5,,,,,,,,,,,,,Gross Charge Type: Central
HC IADNA STREPTOCOCCUS GROUP A AMPLIFIED PROBE TECH,30600030,CDM,306,RC,87651,HCPCS,,,facility,both,,,,186,130.2,,,,,,,,,,,,,Gross Charge Type: Central
HC IADNA ANAPLASMA PHAGOCYTOPHILUM AMPLIFIED PROBE TECHNIQUE,30600031,CDM,306,RC,87468,HCPCS,,,facility,both,,,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Central
HC IADNA EHRLICHIA CHAFFEENSIS AMPLIFIED PROBE TECHNIQUE,30600032,CDM,306,RC,87484,HCPCS,,,facility,both,,,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Central
HC IADNA HPV SEP HIGH-RISK TYPES  & HIGH-RISK POOLED RESULT(S),30600033,CDM,306,RC,87626,HCPCS,,,facility,both,,,,305,213.5,,,,,,,,,,,,,Gross Charge Type: Central
PERTUZUMAB 420 MG/14 ML (30 MG/ML) IV SOLN,30653,CDM,J9306,HCPCS,50242-145-01,NDC,,,facility,both,420,ML,,9374,6561.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PERTUZUMAB 420 MG/14 ML (30 MG/ML) IV SOLN,30653,CDM,J9306,HCPCS,50242-145-01,NDC,,,facility,both,840,ML,,18749,13124.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PERTUZUMAB 420 MG/14 ML (30 MG/ML) IV SOLN,30653,CDM,J9306,HCPCS,50242-145-01,NDC,,,facility,both,420,ML,,9375,6562.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC URINALYSIS NONAUTO W/O SCOPE,30700001,CDM,307,RC,81002,HCPCS,,,facility,both,,,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Central
HC POC URINALYSIS NON-AUTO W/O SCOPE,30700002,CDM,307,RC,81002,HCPCS,,,facility,both,,,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Central
HC URINALYSIS VOLUME MEASURE TIMED COLLECTION EACH,30700003,CDM,307,RC,81050,HCPCS,,,facility,both,,,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Central
HC CYTOPATH FL NONGYN SMEARS,31000001,CDM,310,RC,88104,HCPCS,,,facility,both,,,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Central
HC CYTOPATH CONCENTRATE TECH,31000002,CDM,310,RC,88108,HCPCS,,,facility,both,,,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Central
HC TISSUE CULTURE LYMPHOCYTE,31000003,CDM,310,RC,88230,HCPCS,,,facility,both,,,,740,518,,,,,,,,,,,,,Gross Charge Type: Central
HC TISS CULT SKIN SOLID TISSUE BX,31000004,CDM,310,RC,88233,HCPCS,,,facility,both,,,,277,193.9,,,,,,,,,,,,,Gross Charge Type: Central
HC TISSUE CULTURE BONE MARROW,31000006,CDM,310,RC,88237,HCPCS,,,facility,both,,,,1037,725.9,,,,,,,,,,,,,Gross Charge Type: Central
HC TISSUE CULTURE SOLID TUMOR,31000007,CDM,310,RC,88239,HCPCS,,,facility,both,,,,709,496.3,,,,,,,,,,,,,Gross Charge Type: Central
HC CHROMO ANALYSIS BREAK 100 CELLS,31000008,CDM,310,RC,88249,HCPCS,,,facility,both,,,,1666,1166.2,,,,,,,,,,,,,Gross Charge Type: Central
HC CHROM ANALY SHORT 15-20 2K B,31000010,CDM,310,RC,88262,HCPCS,,,facility,both,,,,588,411.6,,,,,,,,,,,,,Gross Charge Type: Central
HC CHROM ANALYZE 20-25 CELLS,31000011,CDM,310,RC,88264,HCPCS,,,facility,both,,,,1037,725.9,,,,,,,,,,,,,Gross Charge Type: Central
HC CHROMOSOME STUDY ADDITIONAL,31000013,CDM,310,RC,88289,HCPCS,,,facility,both,,,,487,340.9,,,,,,,,,,,,,Gross Charge Type: Central
HC SURGICAL PATH GROSS,31000014,CDM,310,RC,88300,HCPCS,,,facility,both,,,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Central
HC SURG PATH GROSS AND MICROSCOP II,31000015,CDM,310,RC,88302,HCPCS,,,facility,both,,,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Central
HC SURG PATH GROSS AND MICROSC LII,31000016,CDM,310,RC,88304,HCPCS,,,facility,both,,,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Central
SURG PATH GROSS AND MICROSC IV,31000017,CDM,310,RC,88305,HCPCS,,,facility,both,,,TC,375,262.5,,,,,,,,,,,,,"Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier TC: Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities"
HC SURG PATH GROSS AND MICROSC V,31000018,CDM,310,RC,88307,HCPCS,,,facility,both,,,,338,236.6,,,,,,,,,,,,,Gross Charge Type: Central
HC SURG PATH GROSS AND MICROSC VI,31000019,CDM,310,RC,88309,HCPCS,,,facility,both,,,,375,262.5,,,,,,,,,,,,,Gross Charge Type: Central
HC DECALCIFY TISSUE,31000020,CDM,310,RC,88311,HCPCS,,,facility,both,,,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Central
HC SPECIAL STAINS GROUP 1,31000021,CDM,310,RC,88312,HCPCS,,,facility,both,,,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Central
HC HISTOCH STAINS FZN TISS ADD-ON,31000022,CDM,310,RC,88314,HCPCS,,,facility,both,,,,199,139.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PATH CONSULT INTRAOP 1 BLOC,31000025,CDM,310,RC,88331,HCPCS,,,facility,both,,,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PATH CONSULT INTRAOP ADDL,31000026,CDM,310,RC,88332,HCPCS,,,facility,both,,,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Central
INTRAOP CYTO PATH CONSULT 1ST,31000027,CDM,310,RC,88333,HCPCS,,,facility,both,,,,375,262.5,,,,,,,,,,,,,Gross Charge Type: Central
HC IMMUNOFLUORESCENCE PER SPECIMEN INITIAL SINGLE ANTIBODY STAIN PROCEDURE,31000028,CDM,310,RC,88346,HCPCS,,,facility,both,,,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Central
ELECTRON MICROSCOPY,31000029,CDM,310,RC,88348,HCPCS,,,facility,both,,,,1264,884.8,,,,,,,,,,,,,Gross Charge Type: Central
MICRODISSECTION LASER,31000030,CDM,310,RC,88380,HCPCS,,,facility,both,,,,203,142.1,,,,,,,,,,,,,Gross Charge Type: Central
HC BCR/ABL1 GENE MAJOR BP,31000032,CDM,310,RC,81206,HCPCS,,,facility,both,,,,971,679.7,,,,,,,,,,,,,Gross Charge Type: Central
HC BCR ABL1 GENE MINOR BP,31000033,CDM,310,RC,81207,HCPCS,,,facility,both,,,,796,557.2,,,,,,,,,,,,,Gross Charge Type: Central
HC BRAF GENE ANALYSIS V600 VARIANT(S),31000034,CDM,310,RC,81210,HCPCS,,,facility,both,,,,391,273.7,,,,,,,,,,,,,Gross Charge Type: Central
HC CFTR GENE COM VARIANTS,31000035,CDM,310,RC,81220,HCPCS,,,facility,both,,,,1703,1192.1,,,,,,,,,,,,,Gross Charge Type: Central
HC CFTR GENE KNOWN FAM VARIANTS,31000036,CDM,310,RC,81221,HCPCS,,,facility,both,,,,1703,1192.1,,,,,,,,,,,,,Gross Charge Type: Central
HC CFTR GENE DUP/DELET VARIANTS,31000037,CDM,310,RC,81222,HCPCS,,,facility,both,,,,1703,1192.1,,,,,,,,,,,,,Gross Charge Type: Central
HC EGFR GENE COM VARIANTS,31000038,CDM,310,RC,81235,HCPCS,,,facility,both,,,,1356,949.2,,,,,,,,,,,,,Gross Charge Type: Central
HC F2 GENE,31000039,CDM,310,RC,81240,HCPCS,,,facility,both,,,,883,618.1,,,,,,,,,,,,,Gross Charge Type: Central
HC F5 GENE,31000040,CDM,310,RC,81241,HCPCS,,,facility,both,,,,883,618.1,,,,,,,,,,,,,Gross Charge Type: Central
HC HFE GENE,31000041,CDM,310,RC,81256,HCPCS,,,facility,both,,,,1273,891.1,,,,,,,,,,,,,Gross Charge Type: Central
HC IGH GENE REARRANGE AMP METH,31000042,CDM,310,RC,81261,HCPCS,,,facility,both,,,,533,373.1,,,,,,,,,,,,,Gross Charge Type: Central
HC STR MARKERS SPECIMEN ANAL,31000043,CDM,310,RC,81265,HCPCS,,,facility,both,,,,1439,1007.3,,,,,,,,,,,,,Gross Charge Type: Central
HC ENGRAFTMENT POST TRANSPLANT,31000044,CDM,310,RC,81267,HCPCS,,,facility,both,,,,3809,2666.3,,,,,,,,,,,,,Gross Charge Type: Central
HC JAK2 GENE,31000045,CDM,310,RC,81270,HCPCS,,,facility,both,,,,371,259.7,,,,,,,,,,,,,Gross Charge Type: Central
HC KRAS GENE ANALYSIS VARIANTS IN EXON 2,31000046,CDM,310,RC,81275,HCPCS,,,facility,both,,,,573,401.1,,,,,,,,,,,,,Gross Charge Type: Central
HC MICROSATELLITE INSTABILITY,31000047,CDM,310,RC,81301,HCPCS,,,facility,both,,,,2179,1525.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PML/RARALPHA COM BREAKPOINTS,31000048,CDM,310,RC,81315,HCPCS,,,facility,both,,,,1279,895.3,,,,,,,,,,,,,Gross Charge Type: Central
HC TRG GENE REARRANGEMENT ANAL,31000049,CDM,310,RC,81342,HCPCS,,,facility,both,,,,701,490.7,,,,,,,,,,,,,Gross Charge Type: Central
HC LOW RES HLA TYPE,31000050,CDM,310,RC,81370,HCPCS,,,facility,both,,,,2024,1416.8,,,,,,,,,,,,,Gross Charge Type: Central
HC A B C LOCI LOW RES,31000052,CDM,310,RC,81372,HCPCS,,,facility,both,,,,3430,2401,,,,,,,,,,,,,Gross Charge Type: Central
HC A B C OR HLA LOW RES LOCUS,31000053,CDM,310,RC,81373,HCPCS,,,facility,both,,,,4663,3264.1,,,,,,,,,,,,,Gross Charge Type: Central
HC HLA B5701 OR B27 TEST,31000054,CDM,310,RC,81374,HCPCS,,,facility,both,,,,960,672,,,,,,,,,,,,,Gross Charge Type: Central
HC DQ OR DR LOCUS LOW RES,31000055,CDM,310,RC,81376,HCPCS,,,facility,both,,,,1243,870.1,,,,,,,,,,,,,Gross Charge Type: Central
HC HLA I & II TYPING HR,31000056,CDM,310,RC,81378,HCPCS,,,facility,both,,,,4267,2986.9,,,,,,,,,,,,,Gross Charge Type: Central
HC HLA II TYPING 1 LOC HR,31000058,CDM,310,RC,81382,HCPCS,,,facility,both,,,,4399,3079.3,,,,,,,,,,,,,Gross Charge Type: Central
HC MOPATH PROCEDURE LEVEL 3,31000059,CDM,310,RC,81402,HCPCS,,,facility,both,,,,391,273.7,,,,,,,,,,,,,Gross Charge Type: Central
HC MOPATH PROCEDURE LEVEL 4,31000060,CDM,310,RC,81403,HCPCS,,,facility,both,,,,662,463.4,,,,,,,,,,,,,Gross Charge Type: Central
HC MOPATH PROCEDURE LEVEL 5,31000061,CDM,310,RC,81404,HCPCS,,,facility,both,,,,1338,936.6,,,,,,,,,,,,,Gross Charge Type: Central
HC HLA AB SCR L PST TXP,31000063,CDM,302,RC,86828,HCPCS,,,facility,both,,,,107,74.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PRA SA CI ABS PTX-L,31000064,CDM,302,RC,86832,HCPCS,,,facility,both,,,,616,431.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PRA SA CII ABS PTX-L,31000065,CDM,302,RC,86833,HCPCS,,,facility,both,,,,561,392.7,,,,,,,,,,,,,Gross Charge Type: Central
HC IGH VARI REGIONAL MUTATION,31000067,CDM,310,RC,81263,HCPCS,,,facility,both,,,,533,373.1,,,,,,,,,,,,,Gross Charge Type: Central
HC MOPATH PROCEDURE LEVEL 7,31000071,CDM,310,RC,81406,HCPCS,,,facility,both,,,,2185,1529.5,,,,,,,,,,,,,Gross Charge Type: Central
HC MOPATH PROCEDURE LEVEL 8,31000072,CDM,310,RC,81407,HCPCS,,,facility,both,,,,2588,1811.6,,,,,,,,,,,,,Gross Charge Type: Central
HC MOPATH PROCEDURE LEVEL 2,31000073,CDM,310,RC,81401,HCPCS,,,facility,both,,,,1361,952.7,,,,,,,,,,,,,Gross Charge Type: Central
HC MOPATH PROCEDURE LEVEL 6,31000074,CDM,310,RC,81405,HCPCS,,,facility,both,,,,4238,2966.6,,,,,,,,,,,,,Gross Charge Type: Central
HC IMMHISTO/CYTO PER SPEC EA MULTI ANTIBODY,31000078,CDM,310,RC,88344,HCPCS,,,facility,both,,,,338,236.6,,,,,,,,,,,,,Gross Charge Type: Central
HC IMMHISTO/CYTO PER SPEC EA ADDL SINGLE ANTIBODY,31000079,CDM,310,RC,88341,HCPCS,,,facility,both,,,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Central
HC MORPHOMETRIC ANALYSIS IN SITU HYBRIDIZATION MANUAL PER SPECIMEN EACH ADDITIONAL SINGLE PROBE STAIN,31000080,CDM,310,RC,88369,HCPCS,,,facility,both,,,,222,155.4,,,,,,,,,,,,,Gross Charge Type: Central
HC CYTOGEN CONSTITUT CHROMOSMAL ABNORM GENOMIC REGIONS COPY NUMBER VARIANTS CGH,31000082,CDM,310,RC,81228,HCPCS,,,facility,both,,,,1092,764.4,,,,,,,,,,,,,Gross Charge Type: Central
HC SOLID ORGAN NEOPLASM GENOMIC SEQ ANALYSIS PANEL 5-50 GENES DNA ANALYSIS/COMBINED DNA & RNA ANALYSIS,31000083,CDM,310,RC,81445,HCPCS,,,facility,both,,,,1960,1372,,,,,,,,,,,,,Gross Charge Type: Central
HC HEMATOLYMPHOID NEOPLASM/DISORDER GENOMIC SEQ ANALYSIS PANEL 5-50 GENES DNA ANALYSIS/COMBINED DNA & RNA ANALYSIS,31000084,CDM,310,RC,81450,HCPCS,,,facility,both,,,,2140,1498,,,,,,,,,,,,,Gross Charge Type: Central
HC MORPHOMETRIC ANALYSIS IN SITU HYBRIDIZATION MANUAL PER SPECIMEN,31000085,CDM,310,RC,88377,HCPCS,,,facility,both,,,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Central
HC UNLISTED MOLECULAR PATHOLOGY PROCEDURE,31000086,CDM,310,RC,81479,HCPCS,,,facility,both,,,,804,562.8,,,,,,,,,,,,,Gross Charge Type: Central
HC SPECIAL STAIN GROUP II INCL INTERP AND REPORT,31000091,CDM,310,RC,88313,HCPCS,,,facility,both,,,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Central
HC SPECIAL STAIN GROUP III INCL INTERP AND REPORT,31000092,CDM,310,RC,88319,HCPCS,,,facility,both,,,,375,262.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PATHOLOGY CONSULT DURING SURGERY CYTOLOGIC EXAM EA ADDTL SITE,31000093,CDM,310,RC,88334,HCPCS,,,facility,both,,,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Central
HC SURG PATH GROSS/MIICROSCOPIC EXAM PROSTATE NEEDLE BIOPSY ANY METHOD,31000097,CDM,310,RC,88305,HCPCS,,,facility,both,,,TC,375,262.5,,,,,,,,,,,,,"Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier TC: Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities"
HC MGMT METHYLATION ANALYSIS,31000098,CDM,310,RC,81287,HCPCS,,,facility,both,,,,274,191.8,,,,,,,,,,,,,Gross Charge Type: Central
HC MLH1 GENE ANALYSIS PROMOTER METHYLATION ANALYSIS,31000099,CDM,310,RC,81288,HCPCS,,,facility,both,,,,9733,6813.1,,,,,,,,,,,,,Gross Charge Type: Central
HC IMMUNOFLUORESCENCE PER SPECIMEN EA ADDTL SINGLE ANTIBODY STAIN PROCEDURE,31000101,CDM,310,RC,88350,HCPCS,,,facility,both,,,,143,100.1,,,,,,,,,,,,,Gross Charge Type: Central
HC BRCA1 BRCA2 GENE ANALYSIS FULL SEQ ANALYSIS & FULL DUPLICATION/DELETION ANALYSIS,31000102,CDM,310,RC,81162,HCPCS,,,facility,both,,,,72001,50400.7,,,,,,,,,,,,,Gross Charge Type: Central
HC ABL1 GENE ANALYSIS VARIANTS IN KINASE DOMAIN,31000103,CDM,310,RC,81170,HCPCS,,,facility,both,,,,1205,843.5,,,,,,,,,,,,,Gross Charge Type: Central
HC CALR GENE ANALYSIS COMMON VARIANTS IN EXON 9,31000105,CDM,310,RC,81219,HCPCS,,,facility,both,,,,544,380.8,,,,,,,,,,,,,Gross Charge Type: Central
HC KIT GENE ANALYSIS TARGETED SEQ ANALYSIS,31000106,CDM,310,RC,81272,HCPCS,,,facility,both,,,,1080,756,,,,,,,,,,,,,Gross Charge Type: Central
HC KIT GENE ANALYSIS D816 VARIANT,31000107,CDM,310,RC,81273,HCPCS,,,facility,both,,,,409,286.3,,,,,,,,,,,,,Gross Charge Type: Central
HC KRAS GENE ANALYSIS VARIANT(S) ADDITIONAL VARIANT(S),31000108,CDM,310,RC,81276,HCPCS,,,facility,both,,,,647,452.9,,,,,,,,,,,,,Gross Charge Type: Central
HC NRAS GENE ANALYSIS VARIANTS IN EXON 2 AND EXON 3,31000109,CDM,310,RC,81311,HCPCS,,,facility,both,,,,970,679,,,,,,,,,,,,,Gross Charge Type: Central
HC PDGFRA GENE ANALYSIS TARGETED SEQ ANALYSIS,31000110,CDM,310,RC,81314,HCPCS,,,facility,both,,,,1088,761.6,,,,,,,,,,,,,Gross Charge Type: Central
HC HEREDITARY BRST CANCER-RELATED GEN SEQ ANALYSIS PANEL 5 OR MORE GENES INTERROGATION FOR SEQUENCE VARIANTS & COPY NUMBER VARIANTS,31000112,CDM,310,RC,81432,HCPCS,,,facility,both,,,,1529,1070.3,,,,,,,,,,,,,Gross Charge Type: Central
HC NOONAN SPECTRUM DISORDERS GENOMIC SEQ ANALYSIS PANEL INCL SEQ 12 GENES BRAF/CBL/HRAS/KRAS/MAP2K1/MAP2K2/NRAS/PTPN11/RAF1/RIT1/SHOC2/SOS1,31000117,CDM,310,RC,81442,HCPCS,,,facility,both,,,,8603,6022.1,,,,,,,,,,,,,Gross Charge Type: Central
HC ONCOLOGY (TUMOR UNKNOWN ORIGIN) MRNA GENE EXPRESS PROFIL REAL-TIME RT-PCR 92 GENES CLASSIFY MAIN CANCER TYPE/SUBTYPE USE FORMALIN-FIXED PARRIFIN-EMBEDDED TISSUE,31000125,CDM,310,RC,81540,HCPCS,,,facility,both,,,,14297,10007.9,,,,,,,,,,,,,Gross Charge Type: Central
HC ONCOLOGY (BREAST) MRNA GENE EXPRESS PROFILING REAL-TIME RT-PCR OF 21 GENES FORMALIN-FIXED PARRAFIN EMBEDDED TISSUE,31000127,CDM,310,RC,81519,HCPCS,,,facility,both,,,,10648,7453.6,,,,,,,,,,,,,Gross Charge Type: Central
HC CYP2D6 GENE ANALYSIS COMMON VARIANTS,31000128,CDM,310,RC,81226,HCPCS,,,facility,both,,,,1478,1034.6,,,,,,,,,,,,,Gross Charge Type: Central
HC HLA CLASS I TYPING HIGH RESOLUTION B5701,31000130,CDM,310,RC,81381,HCPCS,,,facility,both,,,,423,296.1,,,,,,,,,,,,,Gross Charge Type: Central
HC SOLID ORGAN/HEMATOLYMPHOID NEOPLASM/DISORDER 51 OR GREATER GENES GENOMIC SEQ ANALYSIS PANEL DNA ANALYSIS/COMBINED DNA & RNA ANALYSIS,31000132,CDM,310,RC,81455,HCPCS,,,facility,both,,,,2140,1498,,,,,,,,,,,,,Gross Charge Type: Central
HC IDH1 COMMON VARIANTS,31000133,CDM,310,RC,81120,HCPCS,,,facility,both,,,,264,184.8,,,,,,,,,,,,,Gross Charge Type: Central
HC IDH2 COMMON VARIANTS,31000134,CDM,310,RC,81121,HCPCS,,,facility,both,,,,405,283.5,,,,,,,,,,,,,Gross Charge Type: Central
HC TPMT GENE ANALYSIS COMMON VARIANTS,31000135,CDM,310,RC,81335,HCPCS,,,facility,both,,,,574,401.8,,,,,,,,,,,,,Gross Charge Type: Central
HC MOLECULAR PATHOLOGY PROCEDURE LEVEL 1,31000140,CDM,310,RC,81400,HCPCS,,,facility,both,,,,257,179.9,,,,,,,,,,,,,Gross Charge Type: Central
HC HEARING LOSS DUPLICATION/DELETION ANALYSIS PANE,31000142,CDM,310,RC,81431,HCPCS,,,facility,both,,,,1114,779.8,,,,,,,,,,,,,Gross Charge Type: Central
HC HTT GENE ANALYSIS EVAL TO DETECT ABNORMAL ALLELES,31000148,CDM,310,RC,81271,HCPCS,,,facility,both,,,,309,216.3,,,,,,,,,,,,,Gross Charge Type: Central
HC SMN1 GENE ANALYSIS DOSAGE/DELETION ANALYSIS INCL SMN2 ANALYSIS IF PERFORMED,31000149,CDM,310,RC,81329,HCPCS,,,facility,both,,,,150,105,,,,,,,,,,,,,Gross Charge Type: Central
HC PABPN1 GENE ANALYSIS EVAL TO DETECT ABNORMAL ALLELES,31000150,CDM,310,RC,81312,HCPCS,,,facility,both,,,,300,210,,,,,,,,,,,,,Gross Charge Type: Central
HC MLH1 GENE ANALYSIS FULL SEQUENCE ANALYSIS,31000152,CDM,310,RC,81292,HCPCS,,,facility,both,,,,2854,1997.8,,,,,,,,,,,,,Gross Charge Type: Central
HC MLH1 GENE ANALYSIS DUPLICATION/DELETION VARIANTS,31000153,CDM,310,RC,81294,HCPCS,,,facility,both,,,,1706,1194.2,,,,,,,,,,,,,Gross Charge Type: Central
HC CACNA1A GENE ANALYSIS FULL GENE SEQUENCE,31000155,CDM,310,RC,81185,HCPCS,,,facility,both,,,,925,647.5,,,,,,,,,,,,,Gross Charge Type: Central
HC GENETIC TESTING FOR SEVERE INHERITED CONDITIONS GENOMIC SEQUENCE ANALYSIS PANEL MUST INCLUDE SEQUENCING OF AT LEAST 15 GENES,31000156,CDM,310,RC,81443,HCPCS,,,facility,both,,,,2675,1872.5,,,,,,,,,,,,,Gross Charge Type: Central
HC INFECT DISEASE GRAM-NEG BACT ID AND DRUG RESIST DNA AMPLIFIED PROBE TECH EA TARGET,31000158,CDM,310,RC,0142U,HCPCS,,,facility,both,,,,154,107.8,,,,,,,,,,,,,Gross Charge Type: Central
HC INFECT DISEASE GRAM-POSITIVE ORG ID AND DRUG RESIST DNA BLOOD CULTURE AMPLIFIED PROBE EA TARGET,31000159,CDM,310,RC,0141U,HCPCS,,,facility,both,,,,154,107.8,,,,,,,,,,,,,Gross Charge Type: Central
HC INFECT DISEASE FUNGAL PATH ID DNA BLOOD CULTURE AMPLIFIED PROBE EA TARGET,31000160,CDM,310,RC,0140U,HCPCS,,,facility,both,,,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Central
HC MYD88 GENE ANALYSIS P.LEU265PRO VARIANT,31000161,CDM,310,RC,81305,HCPCS,,,facility,both,,,,385,269.5,,,,,,,,,,,,,Gross Charge Type: Central
HC EPILEPSY GEN SEQ ANALYSIS PANEL,31000162,CDM,310,RC,81419,HCPCS,,,facility,both,,,,5352,3746.4,,,,,,,,,,,,,Gross Charge Type: Central
HC SURG PATH GROSS/MICROSCOPIC EXAM PROSTATE NEEDLE BIOPSY ANY METHOD,31000163,CDM,310,RC,G0416,HCPCS,,,facility,both,,,,1002,701.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PATH CLINICAL CONSULT LIMITED 5-20 MINUTES,31000164,CDM,310,RC,80503,HCPCS,,,facility,both,,,,194,135.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PATH CLINICAL CONSULT MODERATELY COMPLEX 21-40 MINUTES,31000165,CDM,310,RC,80504,HCPCS,,,facility,both,,,,580,406,,,,,,,,,,,,,Gross Charge Type: Central
HC PATH CLINICAL CONSULT HIGHLY COMPLEX 41-60 MINUTES,31000166,CDM,310,RC,80505,HCPCS,,,facility,both,,,,580,406,,,,,,,,,,,,,Gross Charge Type: Central
HC PATH CLINICAL CONSULT PROLONGED SERVICE EA ADDTL 30 MINUTES,31000167,CDM,310,RC,80506,HCPCS,,,facility,both,,,,291,203.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PATHOLOGY CLIN CONSULATION SF MEDICAL DECSION MAKING 5-20 MIN,31000168,CDM,310,RC,80503,HCPCS,,,facility,both,,,,194,135.8,,,,,,,,,,,,,Gross Charge Type: Central
HC DPYD GENE ANALYSIS COMMON VARIANTS,31000169,CDM,310,RC,81232,HCPCS,,,facility,both,,,,394,275.8,,,,,,,,,,,,,Gross Charge Type: Central
HC MORPHOMETRIC ALYS ISH QUANT/SEM-QUANT COMPUTER ASSISTED TECH EA MULTI PROBE STAIN PROCEDURE,31000170,CDM,310,RC,88374,HCPCS,,,facility,both,,,,664,464.8,,,,,,,,,,,,,Gross Charge Type: Central
HC CONSULT COMPREHENSIVE W/ REVIEW OF RECORDS/SPECIMENS W/ REPRT ON REFER MATERIAL,31000171,CDM,310,RC,88325,HCPCS,,,facility,both,,,,299,209.3,,,,,,,,,,,,,Gross Charge Type: Central
HC AORTIC DYSFUNCTION/DILATION GENOMIC SEQ ANALYSIS PANEL INCL SEQ 9 GENES FBN1/TGFBR1/TGFBR2/COL3A1/MYH11/ACTA2/SLC2A10/SMAD3/MYLK,31000172,CDM,310,RC,81410,HCPCS,,,facility,both,,,,2024,1416.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PALB2 GENE ANALYSIS FULL GENE SEQUENCE,31000174,CDM,310,RC,81307,HCPCS,,,facility,both,,,,2715,1900.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PTEN GENE ANALYSIS FULL SEQUENCE ANALYSIS,31000175,CDM,310,RC,81321,HCPCS,,,facility,both,,,,2408,1685.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PTEN GENE ANALYSIS DUPLICATION/DELETION VARIANT,31000176,CDM,310,RC,81323,HCPCS,,,facility,both,,,,1205,843.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PMP22 GENE ANALYSIS FULL SEQUENCE ANALYSIS,31000177,CDM,310,RC,81325,HCPCS,,,facility,both,,,,3088,2161.6,,,,,,,,,,,,,Gross Charge Type: Central
HC HBA1/HBA2 GENE ANALYSIS FULL GENE SEQUENCE,31000178,CDM,310,RC,81259,HCPCS,,,facility,both,,,,2408,1685.6,,,,,,,,,,,,,Gross Charge Type: Central
HC TP53 GENE ANALYSIS TARGETED SEQUENCE ANALYSIS,31000179,CDM,310,RC,81352,HCPCS,,,facility,both,,,,1322,925.4,,,,,,,,,,,,,Gross Charge Type: Central
HC ONCOLOGY BREAST MRNA GENE EXPRESSION PROFILING REAL-TIME RT-PCR OF 11 GENE FORMALIN-FIXED PARAFFIN-EMBEDDED TISSUE,31000180,CDM,310,RC,81518,HCPCS,,,facility,both,,,,15543,10880.1,,,,,,,,,,,,,Gross Charge Type: Central
HC ATXN1 GENE ANALYSIS EVAL TO DETECT ABNORMAL ALLELES,31000181,CDM,310,RC,81178,HCPCS,,,facility,both,,,,579,405.3,,,,,,,,,,,,,Gross Charge Type: Central
HC ATXN2 GENE ANALYSIS EVAL TO DETECT ABNORMAL ALLELES,31000182,CDM,310,RC,81179,HCPCS,,,facility,both,,,,579,405.3,,,,,,,,,,,,,Gross Charge Type: Central
HC CACNA1A GENE ANALYSIS EVAL TO DETECT ABNORMAL ALLELES,31000183,CDM,310,RC,81184,HCPCS,,,facility,both,,,,579,405.3,,,,,,,,,,,,,Gross Charge Type: Central
HC ATXN7 GENE ANALYSIS EVAL TO DETECT ABNORMAL ALLELES,31000184,CDM,310,RC,81181,HCPCS,,,facility,both,,,,579,405.3,,,,,,,,,,,,,Gross Charge Type: Central
HC CHIMERSIM ANALYSIS POST TRANSPLANTATION SPECIMEN COMP TO BASELINE W/CELL SELECTION EACH CELL TYPE,31000185,CDM,310,RC,81268,HCPCS,,,facility,both,,,,1102,771.4,,,,,,,,,,,,,Gross Charge Type: Central
HC MSH2 GENE ANALYSIS FULL SEQUENCE ANALYSIS,31000186,CDM,310,RC,81295,HCPCS,,,facility,both,,,,2729,1910.3,,,,,,,,,,,,,Gross Charge Type: Central
HC MSH2 GENE ANALYSIS DUPLICATION/DELETION VARIANTS,31000187,CDM,310,RC,81297,HCPCS,,,facility,both,,,,1882,1317.4,,,,,,,,,,,,,Gross Charge Type: Central
HC MSH6 GENE ANALYSIS FULL SEQUENCE ANALYSIS,31000188,CDM,310,RC,81298,HCPCS,,,facility,both,,,,3366,2356.2,,,,,,,,,,,,,Gross Charge Type: Central
HC MSH6 GENE ANALYSIS DUPLICATION/DELETION VARIANTS,31000189,CDM,310,RC,81300,HCPCS,,,facility,both,,,,1751,1225.7,,,,,,,,,,,,,Gross Charge Type: Central
HC DMD DELETION ANALYSIS AND DUPLICATION ANALYSIS,31000190,CDM,310,RC,81161,HCPCS,,,facility,both,,,,1179,825.3,,,,,,,,,,,,,Gross Charge Type: Central
HC ATXN3 GENE ANALYSIS EVAL DETECT ABNORMAL ALLELES,31000191,CDM,310,RC,81180,HCPCS,,,facility,both,,,,579,405.3,,,,,,,,,,,,,Gross Charge Type: Central
HC HBB FULL GENE SEQUENCE,31000192,CDM,310,RC,81364,HCPCS,,,facility,both,,,,1408,985.6,,,,,,,,,,,,,Gross Charge Type: Central
HC G6PD GENE ANALYSIS FULL GENE SEQUENCE,31000193,CDM,310,RC,81249,HCPCS,,,facility,both,,,,2603,1822.1,,,,,,,,,,,,,Gross Charge Type: Central
HC AORTIC DYSFUNCTION OR DILATION DUPLICATION/DELETION ANALYSIS PANEL MUST INCLUDE ANALYSES FOR TGFBR1/TGFBR2/MYH11/COL3A1,31000195,CDM,310,RC,81411,HCPCS,,,facility,both,,,,5857,4099.9,,,,,,,,,,,,,Gross Charge Type: Central
HC LIVER DISEASE ANALYSIS OF 3 BIOMARKERS IA SRM PROGNOSTIC ALG RPT RISK SCORE/RISK LIVER FIBROSIS/LIVER RELATED CLIN EVENT W/I 5 YRS,31000196,CDM,310,RC,81517,HCPCS,,,facility,both,,,,765,535.5,,,,,,,,,,,,,Gross Charge Type: Central
CYTOPATH CELL ENHANCE TECH,31100002,CDM,311,RC,88112,HCPCS,,,facility,both,,,,132,92.4,,,,,,,,,,,,,Gross Charge Type: Central
CYTPTH CERV/VAG FLUID THIN AUTO,31100003,CDM,311,RC,88142,HCPCS,,,facility,both,,,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Central
CYTOPATH SMEAR OTHER SOURCE,31100004,CDM,311,RC,88160,HCPCS,,,facility,both,,,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Central
CYTP DX EVAL FNA 1ST EA SITE,31100006,CDM,311,RC,88172,HCPCS,,,facility,both,,,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Central
CYTOPATH EVAL FNA REPORT,31100007,CDM,311,RC,88173,HCPCS,,,facility,both,,,TC,136,95.2,,,,,,,,,,,,,"Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier TC: Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities"
HC CYTOPATH CERV/VAG RESCREEN AUTO THIN LAYER PREP,31100008,CDM,311,RC,88175,HCPCS,,,facility,both,,,,144,100.8,,,,,,,,,,,,,Gross Charge Type: Central
HC FLOW CYTOMETRY CELL CYCLE OR DNA ANALYSIS,31100009,CDM,311,RC,88182,HCPCS,,,facility,both,,,,479,335.3,,,,,,,,,,,,,Gross Charge Type: Central
FLOWCYTOMETRY/ TC 1 MARKER,31100010,CDM,311,RC,88184,HCPCS,,,facility,both,,,,470,329,,,,,,,,,,,,,Gross Charge Type: Central
HC FLOWCYTOMETRY/TC ADD-ON,31100011,CDM,311,RC,88185,HCPCS,,,facility,both,,,,313,219.1,,,,,,,,,,,,,Gross Charge Type: Central
CYTOGENETICS DNA PROBE,31100016,CDM,311,RC,88271,HCPCS,,,facility,both,,,,207,144.9,,,,,,,,,,,,,Gross Charge Type: Central
HC CYTOGENETICS 10-30,31100021,CDM,311,RC,88273,HCPCS,,,facility,both,,,,207,144.9,,,,,,,,,,,,,Gross Charge Type: Central
HC CYTOGENETICS 25-99,31100022,CDM,311,RC,88274,HCPCS,,,facility,both,,,,184,128.8,,,,,,,,,,,,,Gross Charge Type: Central
HC CYTOPATH EVAL OF FNA EA ADDTL EVAL EPISODE,31100026,CDM,311,RC,88177,HCPCS,,,facility,both,,,,154,107.8,,,,,,,,,,,,,Gross Charge Type: Central
HC SCRN CYTO CERVICAL/ VAGINAL THIN LAYER W/SCRN AUTO SYSTEM & MANUAL RESCRN,31100027,CDM,311,RC,G0145,HCPCS,,,facility,both,,,,110,77,,,,,,,,,,,,,Gross Charge Type: Central
CYTP URNE 3-5 PROBES EA SPEC,31200001,CDM,312,RC,88120,HCPCS,,,facility,both,,,,317,221.9,,,,,,,,,,,,,Gross Charge Type: Central
HC IMMUNOHISTOCHEMISTRY INITIAL SINGLE ANTIBODY,31200002,CDM,312,RC,88342,HCPCS,,,facility,both,,,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Central
TUMOR IMMUNOHISTOCHEM/MAN,31200004,CDM,312,RC,88360,HCPCS,,,facility,both,,,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Central
HC INSITU HYBRIDIZATION (FISH),31200005,CDM,312,RC,88365,HCPCS,,,facility,both,,,,203,142.1,,,,,,,,,,,,,Gross Charge Type: Central
HC INSITU HYBRIDIZATION MANUAL,31200007,CDM,312,RC,88368,HCPCS,,,facility,both,,,,334,233.8,,,,,,,,,,,,,Gross Charge Type: Central
HC TUMOR IMMUNOHISTOCHEM/COMPUT,31200011,CDM,312,RC,88361,HCPCS,,,facility,both,,,,330,231,,,,,,,,,,,,,Gross Charge Type: Central
HC INSITU HYBRIDIZATION (FISH) PER SPEC EA ADDTL SINGLE STAIN,31200015,CDM,312,RC,88364,HCPCS,,,facility,both,,,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Central
HC INSITU HYBRIDIZATION PER SPECIMEN EACH MULTIPLEX PROBE STAIN,31200016,CDM,312,RC,88366,HCPCS,,,facility,both,,,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Central
DARATUMUMAB 20 MG/ML IV SOLN,31544,CDM,J9145,HCPCS,57894-505-05,NDC,,,facility,both,30,ML,,3726,2608.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARATUMUMAB 20 MG/ML IV SOLN,31544,CDM,J9145,HCPCS,57894-505-05,NDC,,,facility,both,4,ML,,216,151.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARATUMUMAB 20 MG/ML IV SOLN,31544,CDM,J9145,HCPCS,57894-505-05,NDC,,,facility,both,10,ML,,1242,869.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARATUMUMAB 20 MG/ML IV SOLN,31544,CDM,J9145,HCPCS,57894-505-05,NDC,,,facility,both,6,ML,,746,522.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARATUMUMAB 20 MG/ML IV SOLN,31544,CDM,J9145,HCPCS,57894-502-05,NDC,,,facility,both,90,ML,,11178,7824.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARATUMUMAB 20 MG/ML IV SOLN,31544,CDM,J9145,HCPCS,57894-505-20,NDC,,,facility,both,40,ML,,4968,3477.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARATUMUMAB 20 MG/ML IV SOLN,31544,CDM,J9145,HCPCS,57894-505-20,NDC,,,facility,both,80,ML,,9936,6955.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARATUMUMAB 20 MG/ML IV SOLN,31544,CDM,J9145,HCPCS,57894-505-05,NDC,,,facility,both,8,ML,,432,302.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARATUMUMAB 20 MG/ML IV SOLN,31544,CDM,J9145,HCPCS,57894-505-05,NDC,,,facility,both,12,ML,,1491,1043.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DARATUMUMAB-HYALURONIDASE-FIHJ 1,800 MG-30,000 UNIT/15 ML SUBQ SOLN",31562,CDM,J9144,HCPCS,57894-503-01,NDC,,,facility,both,80,ML,,20905,14633.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DARATUMUMAB-HYALURONIDASE-FIHJ 1,800 MG-30,000 UNIT/15 ML SUBQ SOLN",31562,CDM,J9144,HCPCS,57894-503-01,NDC,,,facility,both,180,ML,,20904,14632.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DARATUMUMAB-HYALURONIDASE-FIHJ 1,800 MG-30,000 UNIT/15 ML SUBQ SOLN",31562,CDM,J9144,HCPCS,57894-503-01,NDC,,,facility,both,180,ML,,20905,14633.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LURBINECTEDIN 4 MG IV SOLR,31590,CDM,J9223,HCPCS,68727-712-01,NDC,,,facility,both,80,EA,,36615,25630.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPOETIN ALFA-EPBX 40000 UNITS/ML INJ SOLN,31664,CDM,Q5106,HCPCS,0069-1309-01,NDC,,,facility,both,40,ML,,1218,852.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN LIPOSOMAL 2 MG/ML IV INJ,31724,CDM,Q2050,HCPCS,72603-103-01,NDC,,,facility,both,1,ML,,1338,936.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN LIPOSOMAL 2 MG/ML IV INJ,31724,CDM,Q2050,HCPCS,70710-1530-1,NDC,,,facility,both,2,ML,,1685,1179.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN LIPOSOMAL 2 MG/ML IV INJ,31724,CDM,Q2050,HCPCS,70710-1530-1,NDC,,,facility,both,4,ML,,2996,2097.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN LIPOSOMAL 2 MG/ML IV INJ,31724,CDM,Q2050,HCPCS,70710-1531-1,NDC,,,facility,both,5,ML,,4681,3276.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN LIPOSOMAL 2 MG/ML IV INJ,31724,CDM,Q2050,HCPCS,70710-1530-1,NDC,,,facility,both,6,ML,,5430,3801,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN LIPOSOMAL 2 MG/ML IV INJ,31724,CDM,Q2050,HCPCS,0338-0063-01,NDC,,,facility,both,6,ML,,3401,2380.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN LIPOSOMAL 2 MG/ML IV INJ,31724,CDM,Q2050,HCPCS,70710-1530-1,NDC,,,facility,both,6,ML,,5617,3931.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN LIPOSOMAL 2 MG/ML IV INJ,31724,CDM,Q2050,HCPCS,70710-1530-1,NDC,,,facility,both,6,ML,,4868,3407.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN LIPOSOMAL 2 MG/ML IV INJ,31724,CDM,Q2050,HCPCS,47335-050-40,NDC,,,facility,both,5,ML,,6687,4680.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN LIPOSOMAL 2 MG/ML IV INJ,31724,CDM,Q2050,HCPCS,72603-103-01,NDC,,,facility,both,6,ML,,8024,5616.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN LIPOSOMAL 2 MG/ML IV INJ,31724,CDM,Q2050,HCPCS,70710-1530-1,NDC,,,facility,both,4,ML,,3745,2621.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN LIPOSOMAL 2 MG/ML IV INJ,31724,CDM,Q2050,HCPCS,72603-103-01,NDC,,,facility,both,4,ML,,5349,3744.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN LIPOSOMAL 2 MG/ML IV INJ,31724,CDM,Q2050,HCPCS,47335-049-40,NDC,,,facility,both,2,ML,,2675,1872.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN LIPOSOMAL 2 MG/ML IV INJ,31724,CDM,Q2050,HCPCS,72603-103-01,NDC,,,facility,both,2,ML,,2675,1872.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN LIPOSOMAL 2 MG/ML IV INJ,31724,CDM,Q2050,HCPCS,70710-1530-1,NDC,,,facility,both,1,ML,,407,284.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN LIPOSOMAL 2 MG/ML IV INJ,31724,CDM,Q2050,HCPCS,70710-1530-1,NDC,,,facility,both,1,ML,,937,655.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN LIPOSOMAL 2 MG/ML IV INJ,31724,CDM,Q2050,HCPCS,72603-103-01,NDC,,,facility,both,1,ML,,582,407.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN LIPOSOMAL 2 MG/ML IV INJ,31724,CDM,Q2050,HCPCS,70710-1530-1,NDC,,,facility,both,2,ML,,1873,1311.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) IV SOLN",31766,CDM,J9022,HCPCS,50242-917-01,NDC,,,facility,both,120,ML,,23792,16654.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) IV SOLN,31766,CDM,J9022,HCPCS,50242-918-01,NDC,,,facility,both,84,ML,,17763,12434.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) IV SOLN,31766,CDM,J9022,HCPCS,50242-918-01,NDC,,,facility,both,168,ML,,35526,24868.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BEVACIZUMAB-AWWB 25 MG/ML IV SOLN,31881,CDM,Q5107,HCPCS,55513-206-01,NDC,,,facility,both,10,ML,,1926,1348.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BEVACIZUMAB-AWWB 25 MG/ML IV SOLN,31881,CDM,Q5107,HCPCS,55513-206-01,NDC,,,facility,both,30,ML,,5778,4044.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BEVACIZUMAB-AWWB 25 MG/ML IV SOLN,31881,CDM,Q5107,HCPCS,55513-207-01,NDC,,,facility,both,80,ML,,15406,10784.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BEVACIZUMAB-AWWB 25 MG/ML IV SOLN,31881,CDM,Q5107,HCPCS,55513-207-01,NDC,,,facility,both,120,ML,,23109,16176.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BEVACIZUMAB-AWWB 25 MG/ML IV SOLN,31881,CDM,Q5107,HCPCS,55513-206-01,NDC,,,facility,both,30,ML,,5777,4043.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BEVACIZUMAB-AWWB 25 MG/ML IV SOLN,31881,CDM,Q5107,HCPCS,55513-206-01,NDC,,,facility,both,20,ML,,3852,2696.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BEVACIZUMAB-AWWB 25 MG/ML IV SOLN,31881,CDM,Q5107,HCPCS,55513-206-01,NDC,,,facility,both,120,ML,,23109,16176.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BEVACIZUMAB-AWWB 25 MG/ML IV SOLN,31881,CDM,Q5107,HCPCS,55513-207-01,NDC,,,facility,both,40,ML,,7703,5392.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC INSERT VENA CAVA FILTER,32000001,CDM,320,RC,37191,HCPCS,,,facility,both,,,,8290,5803,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY OF JAW < 4 VIEWS,32000004,CDM,320,RC,70100,HCPCS,,,facility,both,,,,348,243.6,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY OF JAW 4 OR MORE VIEWS,32000005,CDM,320,RC,70110,HCPCS,,,facility,both,,,,383,268.1,,,,,,,,,,,,,Gross Charge Type: Central
XRAY MASTOIDS 3> VIEWS PER SIDE,32000007,CDM,320,RC,70130,HCPCS,,,facility,both,,,,180,126,,,,,,,,,,,,,Gross Charge Type: Central
XRAY FACIAL BONES < 3 VIEWS,32000008,CDM,320,RC,70140,HCPCS,,,facility,both,,,,356,249.2,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY FACIAL BONES  3> VIEWS,32000009,CDM,320,RC,70150,HCPCS,,,facility,both,,,,433,303.1,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY NASAL BONES 3> VIEWS,32000010,CDM,320,RC,70160,HCPCS,,,facility,both,,,,287,200.9,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY EYE SOCKETS 4> VIEWS,32000011,CDM,320,RC,70200,HCPCS,,,facility,both,,,,404,282.8,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY SINUSES < 3 VIEWS,32000012,CDM,320,RC,70210,HCPCS,,,facility,both,,,,218,152.6,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY SINUSES 3> VIEWS,32000013,CDM,320,RC,70220,HCPCS,,,facility,both,,,,370,259,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY SKULL < 4 VIEWS,32000014,CDM,320,RC,70250,HCPCS,,,facility,both,,,,316,221.2,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY SKULL 4> VIEWS,32000015,CDM,320,RC,70260,HCPCS,,,facility,both,,,,385,269.5,,,,,,,,,,,,,Gross Charge Type: Central
HC FULL MOUTH XRAY OF TEETH,32000016,CDM,320,RC,70320,HCPCS,,,facility,both,,,,169,118.3,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY TMJ OPEN AND CLD UNILAT,32000017,CDM,320,RC,70328,HCPCS,,,facility,both,,,,267,186.9,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY TMJ OPEN AND CLD BILAT,32000018,CDM,320,RC,70330,HCPCS,,,facility,both,,,,370,259,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY EXAM OF NECK SOFT TISSUE,32000019,CDM,320,RC,70360,HCPCS,,,facility,both,,,,342,239.4,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY RIBS 2 VIEWS UNILAT,32000021,CDM,320,RC,71100,HCPCS,,,facility,both,,,,279,195.3,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY RIBS 3 VIEWS UNILAT INCL PA,32000022,CDM,320,RC,71101,HCPCS,,,facility,both,,,,332,232.4,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY RIBS 3 VIEWS BILAT,32000023,CDM,320,RC,71110,HCPCS,,,facility,both,,,,385,269.5,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY RIBS 3 VIEWS BILAT INCL PA,32000024,CDM,320,RC,71111,HCPCS,,,facility,both,,,,442,309.4,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY STERNUM 2 VIEWS,32000025,CDM,320,RC,71120,HCPCS,,,facility,both,,,,295,206.5,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY STERNUM 3> VIEWS,32000026,CDM,320,RC,71130,HCPCS,,,facility,both,,,,290,203,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY SPINE 1 VIEW,32000028,CDM,320,RC,72020,HCPCS,,,facility,both,,,,168,117.6,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY CERVICAL SPINE 2 OR 3 VIEWS,32000029,CDM,320,RC,72040,HCPCS,,,facility,both,,,,232,162.4,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY CERVICAL SPINE 4> VIEWS,32000030,CDM,320,RC,72050,HCPCS,,,facility,both,,,,337,235.9,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY CERV SPINE COMPL W/FLEX EXT,32000031,CDM,320,RC,72052,HCPCS,,,facility,both,,,,427,298.9,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY THORACIC SPINE 2 VIEWS,32000033,CDM,320,RC,72070,HCPCS,,,facility,both,,,,305,213.5,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY THORACIC SPINE 3 VIEWS,32000034,CDM,320,RC,72072,HCPCS,,,facility,both,,,,378,264.6,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY THOR SPINE 4> VIEWS,32000035,CDM,320,RC,72074,HCPCS,,,facility,both,,,,478,334.6,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY THORACOLUMBAR JUNCTION MINIMUM OF 2 VIEWS,32000036,CDM,320,RC,72080,HCPCS,,,facility,both,,,,280,196,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY LUMB SPINE 2 OR 3 VIEWS,32000038,CDM,320,RC,72100,HCPCS,,,facility,both,,,,326,228.2,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY LUMB SPINE 4> VIEWS,32000039,CDM,320,RC,72110,HCPCS,,,facility,both,,,,455,318.5,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY LUMB SPINE COMPL W/ BEND,32000040,CDM,320,RC,72114,HCPCS,,,facility,both,,,,578,404.6,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY LUMB SPINE FLEX EXT 2/3 VIEWS,32000041,CDM,320,RC,72120,HCPCS,,,facility,both,,,,185,129.5,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY PELVIS 1 OR 2 VIEWS,32000042,CDM,320,RC,72170,HCPCS,,,facility,both,,,,203,142.1,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY PELVIS 3> VIEWS,32000043,CDM,320,RC,72190,HCPCS,,,facility,both,,,,370,259,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY SI JOINTS 1 OR 2 VIEWS,32000044,CDM,320,RC,72200,HCPCS,,,facility,both,,,,166,116.2,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY SI JOINTS 3> VIEWS,32000045,CDM,320,RC,72202,HCPCS,,,facility,both,,,,333,233.1,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY SACRUM/COCC 2> VIEWS,32000046,CDM,320,RC,72220,HCPCS,,,facility,both,,,,305,213.5,,,,,,,,,,,,,Gross Charge Type: Central
HC CONTRAST XRAY OF CERV SPINE SI,32000047,CDM,320,RC,72240,HCPCS,,,facility,both,,,,1303,912.1,,,,,,,,,,,,,Gross Charge Type: Central
HC CONTRAST XRAY L-S SPINE SI,32000048,CDM,320,RC,72265,HCPCS,,,facility,both,,,,1270,889,,,,,,,,,,,,,Gross Charge Type: Central
HC CONTR XRAY SPINE 2> REGIONS SI,32000049,CDM,320,RC,72270,HCPCS,,,facility,both,,,,1520,1064,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY COLLAR BONE,32000053,CDM,320,RC,73000,HCPCS,,,facility,both,,,,211,147.7,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY SHOULDER BLADE,32000054,CDM,320,RC,73010,HCPCS,,,facility,both,,,,245,171.5,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY SHOULDER 1 VIEW,32000055,CDM,320,RC,73020,HCPCS,,,facility,both,,,,197,137.9,,,,,,,,,,,,,Gross Charge Type: Central
XRAY SHOULDER 2> VIEWS,32000056,CDM,320,RC,73030,HCPCS,,,facility,both,,,,225,157.5,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY SHOULDERS W/WO WEIGHT,32000057,CDM,320,RC,73050,HCPCS,,,facility,both,,,,330,231,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY HUMERUS 2> VIEWS,32000058,CDM,320,RC,73060,HCPCS,,,facility,both,,,,278,194.6,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY ELBOW 2 VIEWS,32000059,CDM,320,RC,73070,HCPCS,,,facility,both,,,,209,146.3,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY ELBOW 3> VIEWS,32000060,CDM,320,RC,73080,HCPCS,,,facility,both,,,,286,200.2,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY FOREARM 2 VIEWS,32000061,CDM,320,RC,73090,HCPCS,,,facility,both,,,,246,172.2,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY ARM INFANT 2> VIEWS,32000062,CDM,320,RC,73092,HCPCS,,,facility,both,,,,218,152.6,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY WRIST 2 VIEWS,32000063,CDM,320,RC,73100,HCPCS,,,facility,both,,,,198,138.6,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY WRIST 3> VIEWS,32000064,CDM,320,RC,73110,HCPCS,,,facility,both,,,,263,184.1,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY HAND 2 VIEWS,32000065,CDM,320,RC,73120,HCPCS,,,facility,both,,,,232,162.4,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY HAND 3> VIEWS,32000066,CDM,320,RC,73130,HCPCS,,,facility,both,,,,265,185.5,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY FINGER(S) 2> VIEWS,32000067,CDM,320,RC,73140,HCPCS,,,facility,both,,,,180,126,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY KNEE 1 OR 2 VIEWS,32000069,CDM,320,RC,73560,HCPCS,,,facility,both,,,,170,119,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY KNEE 3 VIEWS,32000070,CDM,320,RC,73562,HCPCS,,,facility,both,,,,308,215.6,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY KNEE 4> VIEWS,32000071,CDM,320,RC,73564,HCPCS,,,facility,both,,,,308,215.6,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY KNEES STANDING AP,32000072,CDM,320,RC,73565,HCPCS,,,facility,both,,,,201,140.7,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY TIB-FIB 2 VIEWS,32000073,CDM,320,RC,73590,HCPCS,,,facility,both,,,,248,173.6,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY LEG INFANT 2> VIEWS,32000074,CDM,320,RC,73592,HCPCS,,,facility,both,,,,227,158.9,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY ANKLE 2 VIEWS,32000075,CDM,320,RC,73600,HCPCS,,,facility,both,,,,199,139.3,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY ANKLE 3 VIEWS,32000076,CDM,320,RC,73610,HCPCS,,,facility,both,,,,265,185.5,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY FOOT 2 VIEWS,32000077,CDM,320,RC,73620,HCPCS,,,facility,both,,,,200,140,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY FOOT 3> VIEWS,32000078,CDM,320,RC,73630,HCPCS,,,facility,both,,,,262,183.4,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY HEEL 2> VIEWS,32000079,CDM,320,RC,73650,HCPCS,,,facility,both,,,,242,169.4,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY TOE(S) 2> VIEWS,32000080,CDM,320,RC,73660,HCPCS,,,facility,both,,,,180,126,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY ABDOMEN ACUTE SERIES,32000084,CDM,320,RC,74022,HCPCS,,,facility,both,,,,480,336,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY ESOPHAGUS,32000086,CDM,320,RC,74220,HCPCS,,,facility,both,,,,554,387.8,,,,,,,,,,,,,Gross Charge Type: Central
HC SWALLOW W/ VIDEO,32000087,CDM,320,RC,74230,HCPCS,,,facility,both,,,,508,355.6,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY UPPER GI INCL SCOUT ABDOMINAL RADIOGRAPH/DELAYED IMAGE SINGLE CONTRAST,32000088,CDM,320,RC,74240,HCPCS,,,facility,both,,,,858,600.6,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY UPPER GI INCL SCOUNT ABDOMINAL RADIOGAPH & DELAYED IMAGE DOUBLE CONTRAST STUDY INCL GLUCAGON WHEN ADMIN,32000091,CDM,320,RC,74246,HCPCS,,,facility,both,,,,987,690.9,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY SMALL BOWEL,32000094,CDM,320,RC,74250,HCPCS,,,facility,both,,,,584,408.8,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY COLON BARIUM W/WO KUB,32000095,CDM,320,RC,74270,HCPCS,,,facility,both,,,,739,517.3,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY COLON BARIUM AIR CONTR,32000096,CDM,320,RC,74280,HCPCS,,,facility,both,,,,1046,732.2,,,,,,,,,,,,,Gross Charge Type: Central
HC BE REDUCE INTUSSUSCEPTION,32000097,CDM,320,RC,74283,HCPCS,,,facility,both,,,,659,461.3,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY BILE DUCTS/PANC DURING SURG,32000098,CDM,320,RC,74300,HCPCS,,,facility,both,,,,665,465.5,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY BILE DUCT ENDOS CATHETER,32000103,CDM,320,RC,74328,HCPCS,,,facility,both,,,,629,440.3,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY PANC DUCT ENDOS CATHETER,32000104,CDM,320,RC,74329,HCPCS,,,facility,both,,,,629,440.3,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY PANC/BILE ENDOS CATHETER,32000105,CDM,320,RC,74330,HCPCS,,,facility,both,,,,629,440.3,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY GUIDE GI DILATION,32000106,CDM,320,RC,74360,HCPCS,,,facility,both,,,,583,408.1,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY GUIDE BILE DUCT DILATION,32000107,CDM,320,RC,74363,HCPCS,,,facility,both,,,,1707,1194.9,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY U T  RETROGRADE W/WO KUB,32000110,CDM,320,RC,74420,HCPCS,,,facility,both,,,,677,473.9,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY UROGRAPHY ANTEGRADE RAD S&I,32000111,CDM,320,RC,74425,HCPCS,,,facility,both,,,,514,359.8,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY BLADDER 3> VIEWS,32000112,CDM,320,RC,74430,HCPCS,,,facility,both,,,,588,411.6,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY URETH/BLADD RETROGRADE,32000113,CDM,320,RC,74450,HCPCS,,,facility,both,,,,374,261.8,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY URETH/BLADD VOIDING,32000114,CDM,320,RC,74455,HCPCS,,,facility,both,,,,758,530.6,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY GUIDE GU DILATION,32000118,CDM,320,RC,74485,HCPCS,,,facility,both,,,,1513,1059.1,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY FEMALE GENITAL TRACT,32000119,CDM,320,RC,74740,HCPCS,,,facility,both,,,,627,438.9,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY VEIN EXTR BILAT SI,32000121,CDM,320,RC,75822,HCPCS,,,facility,both,,,,974,681.8,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY VEIN INFERIOR CAVAL SI,32000122,CDM,320,RC,75825,HCPCS,,,facility,both,,,,2279,1595.3,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY VEIN SUP CAVAL SERIALO SI,32000123,CDM,320,RC,75827,HCPCS,,,facility,both,,,,2279,1595.3,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY VEIN RENAL UNILAT SI,32000124,CDM,320,RC,75831,HCPCS,,,facility,both,,,,2535,1774.5,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY VEIN RENAL BILAT SI,32000125,CDM,320,RC,75833,HCPCS,,,facility,both,,,,13400,9380,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY VEIN ADRENAL BILAT SI,32000126,CDM,320,RC,75842,HCPCS,,,facility,both,,,,2975,2082.5,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY VEIN VENOUS SINUS/JUGULAR SI,32000127,CDM,320,RC,75860,HCPCS,,,facility,both,,,,2656,1859.2,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY VEIN LIVER W/O HEMOD PERQ SI,32000128,CDM,320,RC,75887,HCPCS,,,facility,both,,,,879,615.3,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY VEIN LIVER W/ HEMODYN SI,32000129,CDM,320,RC,75889,HCPCS,,,facility,both,,,,5849,4094.3,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY VEIN LIVER W/O HEMODYN SI,32000130,CDM,320,RC,75891,HCPCS,,,facility,both,,,,4628,3239.6,,,,,,,,,,,,,Gross Charge Type: Central
HC VENOUS SAMP W/WO ANGIO CATH SI,32000131,CDM,320,RC,75893,HCPCS,,,facility,both,,,,20692,14484.4,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY TRANSCATH THER EMBOLIZ ANY METH SI,32000132,CDM,320,RC,75894,HCPCS,,,facility,both,,,,5918,4142.6,,,,,,,,,,,,,Gross Charge Type: Central
HC VASCULAR BIOPSY TRANSCATH SI,32000139,CDM,320,RC,75970,HCPCS,,,facility,both,,,,2071,1449.7,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY CHANGE DRAIN TUBE CATH SI,32000143,CDM,320,RC,75984,HCPCS,,,facility,both,,,,929,650.3,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY PERQ DRAIN FOR ABSCESS SI,32000144,CDM,320,RC,75989,HCPCS,,,facility,both,,,,757,529.9,,,,,,,,,,,,,Gross Charge Type: Central
HC FLUOROSCOPY UP TO 1 HOUR,32000145,CDM,320,RC,76000,HCPCS,,,facility,both,,,,1042,729.4,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY NOSE TO RECTUM FOR FB,32000147,CDM,320,RC,76010,HCPCS,,,facility,both,,,,209,146.3,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY ABSCESS FISTULA SINUS TRACT,32000148,CDM,320,RC,76080,HCPCS,,,facility,both,,,,776,543.2,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY SURGICAL SPECIMEN,32000149,CDM,320,RC,76098,HCPCS,,,facility,both,,,,382,267.4,,,,,,,,,,,,,Gross Charge Type: Central
HC FLUORO GUIDE VEIN DEVICE SI,32000150,CDM,320,RC,77001,HCPCS,,,facility,both,,,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Central
HC FLUORO GUIDE NEEDLE PLACEMENT,32000151,CDM,320,RC,77002,HCPCS,,,facility,both,,,,1003,702.1,,,,,,,,,,,,,Gross Charge Type: Central
HC FLUOR GUIDE NEEDLE CATH INJ SPI,32000152,CDM,320,RC,77003,HCPCS,,,facility,both,,,,485,339.5,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY FOR BONE AGE,32000155,CDM,320,RC,77072,HCPCS,,,facility,both,,,,200,140,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY FOR BONE LENGTH,32000156,CDM,320,RC,77073,HCPCS,,,facility,both,,,,501,350.7,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY FOR BONE SURVEY COMPLETE,32000158,CDM,320,RC,77075,HCPCS,,,facility,both,,,,632,442.4,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY BONE DENSITY AXIAL,32000159,CDM,320,RC,77080,HCPCS,,,facility,both,,,,453,317.1,,,,,,,,,,,,,Gross Charge Type: Central
HC THROMBLYTIC ART/VEN THERAPY,32000165,CDM,320,RC,37213,HCPCS,,,facility,both,,,,3800,2660,,,,,,,,,,,,,Gross Charge Type: Central
PERCUTANEOUS TRANSHEPATIC PORTOGRAPHY W/HEMODYNAMIC EVAL,32000169,CDM,320,RC,75885,HCPCS,,,facility,both,,,,2535,1774.5,,,,,,,,,,,,,Gross Charge Type: Central
HC UROGRAPHY INFUSION DRIP TECH OR BOLUS,32000170,CDM,320,RC,74410,HCPCS,,,facility,both,,,,750,525,,,,,,,,,,,,,Gross Charge Type: Central
HC RADIOLOGIC EXAM EYE FOR DETECTION OF FOREIGN BODY,32000173,CDM,320,RC,70030,HCPCS,,,facility,both,,,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Central
HC RADIOLOGIC EXAM SPINE ENTIRE THORACIC & LUMBAR INCL SKULL CERVICAL & SACRAL SPINE ONE VIEW,32000175,CDM,320,RC,72081,HCPCS,,,facility,both,,,,212,148.4,,,,,,,,,,,,,Gross Charge Type: Central
HC RADIOLOGIC EXAM SPINE ENTIRE THORACIC & LUMBAR INCL SKULL CERVICAL & SACRAL SPINE 2 OR 3 VIEWS,32000176,CDM,320,RC,72082,HCPCS,,,facility,both,,,,212,148.4,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY FEMUR MINIMUM 2 VIEWS,32000180,CDM,320,RC,73552,HCPCS,,,facility,both,,,,194,135.8,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY ABDOMEN 1 VIEW,32000184,CDM,320,RC,74018,HCPCS,,,facility,both,,,,237,165.9,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY ABDOMEN 2 VIEWS,32000185,CDM,320,RC,74019,HCPCS,,,facility,both,,,,307,214.9,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY ABDOMEN 3 OR MORE VIEWS,32000186,CDM,320,RC,74021,HCPCS,,,facility,both,,,,312,218.4,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY VEIN ADRENAL UNILATERAL SI,32000187,CDM,320,RC,75840,HCPCS,,,facility,both,,,,1488,1041.6,,,,,,,,,,,,,Gross Charge Type: Central
HC INTRO LONG GASTROINTESTINAL TUBE INCL MULTI FLUORO IMAGES RAD S&I,32000188,CDM,320,RC,74340,HCPCS,,,facility,both,,,,301,210.7,,,,,,,,,,,,,Gross Charge Type: Central
HC ORTHOPANTOGRAM,32000193,CDM,320,RC,70355,HCPCS,,,facility,both,,,,278,194.6,,,,,,,,,,,,,Gross Charge Type: Central
HC UNLISTED DIAGNOSTIC RADIOGRAPHIC PROCEDURE,32000194,CDM,320,RC,76499,HCPCS,,,facility,both,,,,375,262.5,,,,,,,,,,,,,Gross Charge Type: Central
HC EVASC REPAIR DESCND THORCIC AORTA CELIAC ORG RAD S&I,32000196,CDM,320,RC,75957,HCPCS,,,facility,both,,,,354,247.8,,,,,,,,,,,,,Gross Charge Type: Central
HC CISTERNOGRAPHY POSITIVE CONTRAST RS&I,32000197,CDM,320,RC,70015,HCPCS,,,facility,both,,,,3545,2481.5,,,,,,,,,,,,,Gross Charge Type: Central
HC MECHANICAL RMVL INTRALUMINAL OBSTRUCTIVE MATERIAL RAD SUPERVISION & INTERP,32000199,CDM,320,RC,75902,HCPCS,,,facility,both,,,,191,133.7,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY SHUNTOGRAM INDWELLING NONVASCULAR SHUNT RAD S&I,32000200,CDM,320,RC,75809,HCPCS,,,facility,both,,,,707,494.9,,,,,,,,,,,,,Gross Charge Type: Central
HC TBS STRUCTURAL CONDITION BONE MICROARCHITECTURE TECH PREP & TRANSMISSION DATA ALYS PFRMD ELSEWHERE,32000201,CDM,320,RC,77090,HCPCS,,,facility,both,,,,415,290.5,,,,,,,,,,,,,Gross Charge Type: Central
HC SPLENOPORTOGRAPHY RADIOLOGICAL SUPERVISION & INTERPRETATION,32000202,CDM,320,RC,75810,HCPCS,,,facility,both,,,,12111,8477.7,,,,,,,,,,,,,Gross Charge Type: Central
HC LYMPHANGIOGRAPHY PELVIC/ABDOMINAL UNILATERAL RADIOLOGICAL SUPERVISION/INTERPRETATION,32000203,CDM,320,RC,75805,HCPCS,,,facility,both,,,,12111,8477.7,,,,,,,,,,,,,Gross Charge Type: Central
HC LYMPHANGIOGRAPHY PELVIC/ABDOMINAL BILATERAL RADIOLOGICAL SUPERVISION/INTERPRETATION,32000204,CDM,320,RC,75807,HCPCS,,,facility,both,,,,13928,9749.6,,,,,,,,,,,,,Gross Charge Type: Central
HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY INCLUDING MULTIPLE SERIAL IMAGES,32000205,CDM,320,RC,74248,HCPCS,,,facility,both,,,,121,84.7,,,,,,,,,,,,,Gross Charge Type: Central
HC CINERADIOGRAPHY/VIDEORADIOGRAPHY EXCEPT WHERE SPECIFICALLY INCLUDED,32000206,CDM,320,RC,76120,HCPCS,,,facility,both,,,,697,487.9,,,,,,,,,,,,,Gross Charge Type: Central
HC MECHANICAL RMVL PRICATH OBSTR  MATRL FROM CENTRAL VENOUS DEVICE VIA SEPARATE VENOUS ACCESS RS&I,32000207,CDM,320,RC,75901,HCPCS,,,facility,both,,,,233,163.1,,,,,,,,,,,,,Gross Charge Type: Central
HC MR SAFETY IMPLANT/FOREIGN BODY ASSESS BY CLINICAL STAFF INCL ID & VERIFICATION OF IMPLANT COMPONENTS INITIAL 15 MINUTES,32000208,CDM,320,RC,76014,HCPCS,,,facility,both,,,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Central
HC MR SAFETY IMPLANT/FOREIGN BODY ASSESS BY CLINICAL STAFF INCL ID & VERIFICATION OF IMPLANT COMPONENTS EACH ADDTL 30 MINUTES,32000209,CDM,320,RC,76015,HCPCS,,,facility,both,,,,121,84.7,,,,,,,,,,,,,Gross Charge Type: Central
HC MR SAFETY DETERMINATION BY PHYSICIAN/QHP FOR SAFETY OF PROCEDURE  W/REPORT,32000210,CDM,320,RC,76016,HCPCS,,,facility,both,,,,375,262.5,,,,,,,,,,,,,Gross Charge Type: Central
HC MR SAFETY MEDICAL PHYSICS EXAM CUSTOMIZATION PLANNING/PERFORMANCE W/REPORT,32000211,CDM,320,RC,76017,HCPCS,,,facility,both,,,,1030,721,,,,,,,,,,,,,Gross Charge Type: Central
HC MR SAFETY IMPLANT ELECTRONICS PREP INCL MR-SPECIFIC PROGRAM PULSE GENERATOR/TRANSMITTER W/REPORT,32000212,CDM,320,RC,76018,HCPCS,,,facility,both,,,,391,273.7,,,,,,,,,,,,,Gross Charge Type: Central
HC MR SAFETY IMPLANT POSITIONING/IMMOBILIZATION W/REPORT,32000213,CDM,320,RC,76019,HCPCS,,,facility,both,,,,253,177.1,,,,,,,,,,,,,Gross Charge Type: Central
IRINOTECAN LIPOSOMAL 4.3 MG/ML IV DISP,32073,CDM,J9205,HCPCS,15054-0043-1,NDC,,,facility,both,107,ML,,16978,11884.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN LIPOSOMAL 4.3 MG/ML IV DISP,32073,CDM,J9205,HCPCS,15054-0043-1,NDC,,,facility,both,25,ML,,1725,1207.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN LIPOSOMAL 4.3 MG/ML IV DISP,32073,CDM,J9205,HCPCS,15054-0043-1,NDC,,,facility,both,24,ML,,1656,1159.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN LIPOSOMAL 4.3 MG/ML IV DISP,32073,CDM,J9205,HCPCS,15054-0043-1,NDC,,,facility,both,31,ML,,2139,1497.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN LIPOSOMAL 4.3 MG/ML IV DISP,32073,CDM,J9205,HCPCS,15054-0043-1,NDC,,,facility,both,121,ML,,19200,13440,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN LIPOSOMAL 4.3 MG/ML IV DISP,32073,CDM,J9205,HCPCS,15054-0043-1,NDC,,,facility,both,120,ML,,19041,13328.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN LIPOSOMAL 4.3 MG/ML IV DISP,32073,CDM,J9205,HCPCS,15054-0043-1,NDC,,,facility,both,45,ML,,7141,4998.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN LIPOSOMAL 4.3 MG/ML IV DISP,32073,CDM,J9205,HCPCS,15054-0043-1,NDC,,,facility,both,6,ML,,414,289.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN LIPOSOMAL 4.3 MG/ML IV DISP,32073,CDM,J9205,HCPCS,15054-0043-1,NDC,,,facility,both,129,ML,,20469,14328.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN LIPOSOMAL 4.3 MG/ML IV DISP,32073,CDM,J9205,HCPCS,15054-0043-1,NDC,,,facility,both,111,ML,,17613,12329.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN LIPOSOMAL 4.3 MG/ML IV DISP,32073,CDM,J9205,HCPCS,15054-0043-1,NDC,,,facility,both,86,ML,,13646,9552.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN LIPOSOMAL 4.3 MG/ML IV DISP,32073,CDM,J9205,HCPCS,15054-0043-1,NDC,,,facility,both,43,ML,,6823,4776.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN LIPOSOMAL 4.3 MG/ML IV DISP,32073,CDM,J9205,HCPCS,15054-0043-1,NDC,,,facility,both,9,ML,,621,434.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN LIPOSOMAL 4.3 MG/ML IV DISP,32073,CDM,J9205,HCPCS,15054-0043-1,NDC,,,facility,both,41,ML,,2829,1980.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN LIPOSOMAL 4.3 MG/ML IV DISP,32073,CDM,J9205,HCPCS,15054-0043-1,NDC,,,facility,both,62,ML,,9838,6886.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN LIPOSOMAL 4.3 MG/ML IV DISP,32073,CDM,J9205,HCPCS,15054-0043-1,NDC,,,facility,both,92,ML,,14598,10218.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN LIPOSOMAL 4.3 MG/ML IV DISP,32073,CDM,J9205,HCPCS,15054-0043-1,NDC,,,facility,both,104,ML,,16502,11551.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN LIPOSOMAL 4.3 MG/ML IV DISP,32073,CDM,J9205,HCPCS,15054-0043-1,NDC,,,facility,both,64,ML,,10155,7108.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN LIPOSOMAL 4.3 MG/ML IV DISP,32073,CDM,J9205,HCPCS,15054-0043-1,NDC,,,facility,both,37,ML,,2553,1787.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN LIPOSOMAL 4.3 MG/ML IV DISP,32073,CDM,J9205,HCPCS,15054-0043-1,NDC,,,facility,both,8,ML,,552,386.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN LIPOSOMAL 4.3 MG/ML IV DISP,32073,CDM,J9205,HCPCS,15054-0043-1,NDC,,,facility,both,80,ML,,12694,8885.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN LIPOSOMAL 4.3 MG/ML IV DISP,32073,CDM,J9205,HCPCS,15054-0043-1,NDC,,,facility,both,98,ML,,15550,10885,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN LIPOSOMAL 4.3 MG/ML IV DISP,32073,CDM,J9205,HCPCS,15054-0043-1,NDC,,,facility,both,18,ML,,1242,869.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN LIPOSOMAL 4.3 MG/ML IV DISP,32073,CDM,J9205,HCPCS,15054-0043-1,NDC,,,facility,both,22,ML,,1518,1062.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC X-RAY ANGIO INTER MAMM SI,32100001,CDM,321,RC,75756,HCPCS,,,facility,both,,,,12111,8477.7,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY SHOULDER ARTHROGRAM SI,32200001,CDM,322,RC,73040,HCPCS,,,facility,both,,,,718,502.6,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY WRIST ARTHROGRAM,32200002,CDM,322,RC,73115,HCPCS,,,facility,both,,,,509,356.3,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY HIP ARTHROGRAM SI,32200006,CDM,322,RC,73525,HCPCS,,,facility,both,,,,742,519.4,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY KNEE ARTHROGRAM SI,32200009,CDM,322,RC,73580,HCPCS,,,facility,both,,,,542,379.4,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY HIP UNILATERAL W/PELVIS 1 VIEW,32200010,CDM,320,RC,73501,HCPCS,,,facility,both,,,,132,92.4,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY HIP UNILATERAL W/PELVIS 2-3 VIEWS,32200011,CDM,320,RC,73502,HCPCS,,,facility,both,,,,240,168,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY HIPS BILATERAL W/PELVIS 2 VIEWS,32200013,CDM,322,RC,73521,HCPCS,,,facility,both,,,,428,299.6,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY HIPS BILATERAL W/PELVIS 3-4 VIEWS,32200014,CDM,320,RC,73522,HCPCS,,,facility,both,,,,493,345.1,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY HIPS BILATERAL W/PELVIS MINIMUM 5 VIEWS,32200015,CDM,322,RC,73523,HCPCS,,,facility,both,,,,895,626.5,,,,,,,,,,,,,Gross Charge Type: Central
HC X-RAY ANKLE ARTHROGRAPHY RAD S & I,32200016,CDM,322,RC,73615,HCPCS,,,facility,both,,,,1319,923.3,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY THOR AORTA SERIALOGRAPHY,32300001,CDM,323,RC,75605,HCPCS,,,facility,both,,,,2374,1661.8,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY ABD AORTA SERIALOGRAPHY SI,32300002,CDM,323,RC,75625,HCPCS,,,facility,both,,,,3028,2119.6,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY ABD AORTA LWR EXTR BILAT,32300003,CDM,323,RC,75630,HCPCS,,,facility,both,,,,3557,2489.9,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY ANGIO SPINAL SI,32300011,CDM,323,RC,75705,HCPCS,,,facility,both,,,,5269,3688.3,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY ANGIO EXTREMITY UNILAT SI,32300012,CDM,323,RC,75710,HCPCS,,,facility,both,,,,2790,1953,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY ANGIO EXTREMEITY BILAT SI,32300013,CDM,323,RC,75716,HCPCS,,,facility,both,,,,3611,2527.7,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY ANGIO VISCERAL SI,32300015,CDM,323,RC,75726,HCPCS,,,facility,both,,,,5269,3688.3,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY ANGIO PELVIC SI,32300016,CDM,323,RC,75736,HCPCS,,,facility,both,,,,4411,3087.7,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY ANGIO PULMON SI,32300017,CDM,323,RC,75741,HCPCS,,,facility,both,,,,2721,1904.7,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY ANGIO EACH ADDL VESSEL SI,32300018,CDM,323,RC,75774,HCPCS,,,facility,both,,,,1287,900.9,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY VEIN EXTR UNILAT SI,32300019,CDM,323,RC,75820,HCPCS,,,facility,both,,,,766,536.2,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY ANGIO F/UP THRU CATHETER,32300020,CDM,323,RC,75898,HCPCS,,,facility,both,,,,2208,1545.6,,,,,,,,,,,,,Gross Charge Type: Central
HC TRNSLUM PERIPH ARTHRE ILIAC EA,32300022,CDM,323,RC,0238T,HCPCS,,,facility,both,,,,22164,15514.8,,,,,,,,,,,,,Gross Charge Type: Central
HC SELECTIVE CATH PLACE CAROTID/INOM ART,32300023,CDM,323,RC,36223,HCPCS,,,facility,both,,,,2277,1593.9,,,,,,,,,,,,,Gross Charge Type: Central
HC SELECTIVE CATH PLACE CAROTID ART,32300024,CDM,361,RC,36224,HCPCS,,,facility,both,,,,5269,3688.3,,,,,,,,,,,,,Gross Charge Type: Central
HC SELECTIVE CATH PLACE VETEBRAL ART,32300025,CDM,361,RC,36226,HCPCS,,,facility,both,,,,5269,3688.3,,,,,,,,,,,,,Gross Charge Type: Central
HC ANGIOGRAPHY PULM UNILAT SELECT RAD S&I,32300027,CDM,323,RC,75743,HCPCS,,,facility,both,,,,3230,2261,,,,,,,,,,,,,Gross Charge Type: Central
HC PLACE CATH SUBCLAVIAN ART,32300028,CDM,323,RC,36225,HCPCS,,,facility,both,,,,2277,1593.9,,,,,,,,,,,,,Gross Charge Type: Central
HC ANGRPH PULMONARY NONSLCTV CATH/VEN NJX RS&I,32300030,CDM,323,RC,75746,HCPCS,,,facility,both,,,,4011,2807.7,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY CHEST 2 VIEWS,32400002,CDM,324,RC,71046,HCPCS,,,facility,both,,,,281,196.7,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY CHEST 4 OR MORE VIEWS,32400006,CDM,324,RC,71048,HCPCS,,,facility,both,,,,363,254.1,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY CHEST SINGLE VIEW,32400010,CDM,324,RC,71045,HCPCS,,,facility,both,,,,236,165.2,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY CHEST 3 VIEWS,32400011,CDM,324,RC,71047,HCPCS,,,facility,both,,,,323,226.1,,,,,,,,,,,,,Gross Charge Type: Central
"HUMAN PAPILLOMAV VAC,9-VAL(PF) 0.5 ML IM SYRG",32737,CDM,90651,HCPCS,0006-4121-01,NDC,,,facility,both,2,ML,,1089,762.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"HUMAN PAPILLOMAV VAC,9-VAL(PF) 0.5 ML IM SUSP",32737,CDM,90651,HCPCS,0006-4119-01,NDC,,,facility,both,1,ML,,885,619.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"HUMAN PAPILLOMAV VAC,9-VAL(PF) 0.5 ML IM SYRG",32737,CDM,90651,HCPCS,0006-4121-01,NDC,,,facility,both,1,ML,,1165,815.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"HUMAN PAPILLOMAV VAC,9-VAL(PF) 0.5 ML IM INJ MERGE (CAM USE ONLY)",32737,CDM,90651,HCPCS,0006-4121-02,NDC,,,facility,both,1,ML,,1165,815.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"HUMAN PAPILLOMAV VAC,9-VAL(PF) 0.5 ML IM SYRG",32737,CDM,90651,HCPCS,0006-4121-01,NDC,,,facility,both,1,ML,,1089,762.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"HUMAN PAPILLOMAV VAC,9-VAL(PF) 0.5 ML IM INJ MERGE (CAM USE ONLY)",32737,CDM,90651,HCPCS,0006-4121-02,NDC,,,facility,both,1,ML,,1089,762.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"HUMAN PAPILLOMAV VAC,9-VAL(PF) 0.5 ML IM SYRG",32737,CDM,90651,HCPCS,0006-4121-01,NDC,,,facility,both,1,ML,,1089,762.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"HUMAN PAPILLOMAV VAC,9-VAL(PF) 0.5 ML IM INJ MERGE (CAM USE ONLY)",32737,CDM,90651,HCPCS,0006-4121-02,NDC,,,facility,both,1,ML,,1089,762.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC MCARE ADMIN HEPATITIS B VACC,32743,CDM,771,RC,90746,HCPCS,58160-821-01,NDC,facility,both,1,ML,,353,247.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC MCARE ADMIN HEPATITIS B VACC,32743,CDM,771,RC,90744,HCPCS,58160-820-43,NDC,facility,both,1,ML,,167,116.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC MCARE ADMIN HEPATITIS B VACC,32743,CDM,771,RC,90744,HCPCS,58160-820-43,NDC,facility,both,1,ML,,171,119.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC MCARE ADMIN HEPATITIS B VACC,32743,CDM,771,RC,90746,HCPCS,58160-821-01,NDC,facility,both,1,ML,,367,256.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SYRG,32869,CDM,J3490,HCPCS,8290306546,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC RADIOPHARM THERAPY BY INTRA-ART PARTICULATE ADMIN,33000001,CDM,340,RC,79445,HCPCS,,,facility,both,,,,1265,885.5,,,,,,,,,,,,,Gross Charge Type: Central
HC APPLY INTERSTIT RADIATION COMPLEX,33000002,CDM,342,RC,77778,HCPCS,,,facility,both,,,,4095,2866.5,,,,,,,,,,,,,Gross Charge Type: Central
HC CHEMO ADMIN INTRALESIONAL UP TO AND INCL 7 LESIONS,33000003,CDM,330,RC,96405,HCPCS,,,facility,both,,,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Central
"HYALURONATE SODIUM, STABILIZED 88 MG/4 ML IATC SYRG",33038,CDM,J7327,HCPCS,5967682001,NDC,,,facility,both,1,ML,,4140,2898,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"HYALURONATE SODIUM, STABILIZED 88 MG/4 ML IATC SYRG",33038,CDM,J7327,HCPCS,5967682001,NDC,,,facility,both,1,ML,,2070,1449,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEGFILGRASTIM-JMDB (FULPHILA) 6 MG/0.6 ML SUBQ SYRG,33059,CDM,Q5108,HCPCS,67457-833-06,NDC,,,facility,both,12,ML,,11523,8066.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEGFILGRASTIM-JMDB (FULPHILA) 6 MG/0.6 ML SUBQ SYRG,33059,CDM,Q5108,HCPCS,83257-005-41,NDC,,,facility,both,12,ML,,5762,4033.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHEMO ANTINEOPL IM SUBQ,33100001,CDM,331,RC,96401,HCPCS,,,facility,both,,,,267,186.9,,,,,,,,,,,,,Gross Charge Type: Central
CHEMO HORM ANTINEOPL IM SUBQ,33100002,CDM,331,RC,96402,HCPCS,,,facility,both,,,,171,119.7,,,,,,,,,,,,,Gross Charge Type: Central
HC CHEMO ADMIN INTO CNS REQ/INCLUDE SPINAL PUNCTURE,33100003,CDM,331,RC,96450,HCPCS,,,facility,both,,,,863,604.1,,,,,,,,,,,,,Gross Charge Type: Central
HC CHEMO ADMIN INTO PLEURAL CAVITY REQ/INCLUDE THORACENTESIS,33100005,CDM,331,RC,96440,HCPCS,,,facility,both,,,,1223,856.1,,,,,,,,,,,,,Gross Charge Type: Central
HC CHEMO ADMIN INTO PERITONEAL CAVITY IMPLANTED PORT/CATHETER,33100006,CDM,331,RC,96446,HCPCS,,,facility,both,,,,1223,856.1,,,,,,,,,,,,,Gross Charge Type: Central
TESTOSTERONE ENANTHATE 200 MG/ML IM OIL,33124,CDM,J3121,HCPCS,0143-9750-01,NDC,,,facility,both,200,ML,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE ENANTHATE 200 MG/ML IM OIL,33124,CDM,J3121,HCPCS,0143-9750-01,NDC,,,facility,both,250,ML,,121,84.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE ENANTHATE 200 MG/ML IM OIL,33124,CDM,J3121,HCPCS,0143-9750-01,NDC,,,facility,both,50,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE  75 MG IMPL PLLT,33152,CDM,J3490,HCPCS,66887-004-01,NDC,,,facility,both,6,EA,,29210,20447,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC ADMIN RESPIRATORY SYNCYTIAL VIRUS MONOCLONAL ANTIBODY SEASONAL DOSE INTRAMUSCULAR INJECTION,33259,CDM,771,RC,90380,HCPCS,49281-575-00,NDC,facility,both,1,ML,,1535,1074.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC ADMIN RESPIRATORY SYNCYTIAL VIRUS MONOCLONAL ANTIBODY SEASONAL DOSE INTRAMUSCULAR INJECTION,33259,CDM,771,RC,90381,HCPCS,49281-574-88,NDC,facility,both,1,ML,,1535,1074.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC ADMIN RESPIRATORY SYNCYTIAL VIRUS MONOCLONAL ANTIBODY SEASONAL DOSE INTRAMUSCULAR INJECTION,33259,CDM,771,RC,90381,HCPCS,49281-574-88,NDC,facility,both,1,ML,,1435,1004.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC ADMIN RESPIRATORY SYNCYTIAL VIRUS MONOCLONAL ANTIBODY SEASONAL DOSE INTRAMUSCULAR INJECTION,33259,CDM,771,RC,90380,HCPCS,49281-575-00,NDC,facility,both,1,ML,,1435,1004.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SET RAD THERAPY FIELD SIMPLE,33300001,CDM,333,RC,77280,HCPCS,,,facility,both,,,,1784,1248.8,,,,,,,,,,,,,Gross Charge Type: Central
SET RAD THERAPY FIELD INTERMED,33300002,CDM,333,RC,77285,HCPCS,,,facility,both,,,,1956,1369.2,,,,,,,,,,,,,Gross Charge Type: Central
SET RAD THERAPY FIELD COMPLEX,33300003,CDM,333,RC,77290,HCPCS,,,facility,both,,,,3824,2676.8,,,,,,,,,,,,,Gross Charge Type: Central
SET RAD THERAPY FIELD 3D,33300004,CDM,333,RC,77295,HCPCS,,,facility,both,,,,9493,6645.1,,,,,,,,,,,,,Gross Charge Type: Central
RADIATION THERAPY DOSE PLAN,33300005,CDM,333,RC,77300,HCPCS,,,facility,both,,,,662,463.4,,,,,,,,,,,,,Gross Charge Type: Central
RADIOTHERAPY DOSE PLAN IMRT,33300006,CDM,333,RC,77301,HCPCS,,,facility,both,,,,4262,2983.4,,,,,,,,,,,,,Gross Charge Type: Central
SPECIAL TELETX PORT PLAN,33300010,CDM,333,RC,77321,HCPCS,,,facility,both,,,,955,668.5,,,,,,,,,,,,,Gross Charge Type: Central
RAD TX AID(S)SIMPLE,33300013,CDM,333,RC,77332,HCPCS,,,facility,both,,,,634,443.8,,,,,,,,,,,,,Gross Charge Type: Central
RAD TX AID(S) INTERMED,33300014,CDM,333,RC,77333,HCPCS,,,facility,both,,,,723,506.1,,,,,,,,,,,,,Gross Charge Type: Central
HC FIELD BLOCK DESIGN,33300015,CDM,333,RC,77334,HCPCS,,,facility,both,,,,2014,1409.8,,,,,,,,,,,,,Gross Charge Type: Central
RADIATION PHYSICS CONSULT,33300016,CDM,333,RC,77336,HCPCS,,,facility,both,,,,571,399.7,,,,,,,,,,,,,Gross Charge Type: Central
DESIGN MLC DEVICE FOR IMRT,33300017,CDM,333,RC,77338,HCPCS,,,facility,both,,,,938,656.6,,,,,,,,,,,,,Gross Charge Type: Central
RAD PHYSICS CONSULT SPECIAL,33300018,CDM,333,RC,77370,HCPCS,,,facility,both,,,,698,488.6,,,,,,,,,,,,,Gross Charge Type: Central
LIN ACC STEREOTAC RADIOSURG,33300019,CDM,333,RC,77373,HCPCS,,,facility,both,,,,7770,5439,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY PORT FILMS - 4,33300029,CDM,333,RC,77417,HCPCS,,,facility,both,,,,364,254.8,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY PORT FILMS - 3,33300030,CDM,333,RC,77417,HCPCS,,,facility,both,,,,313,219.1,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY PORT FILMS - 2,33300031,CDM,333,RC,77417,HCPCS,,,facility,both,,,,257,179.9,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY PORT FILMS - 1,33300032,CDM,333,RC,77417,HCPCS,,,facility,both,,,,273,191.1,,,,,,,,,,,,,Gross Charge Type: Central
SBRT MANAGEMENT  UP TO 5 FRACT,33300035,CDM,333,RC,77435,HCPCS,,,facility,both,,,,434,303.8,,,,,,,,,,,,,Gross Charge Type: Central
SPECIAL RADIATION TREATMENT,33300036,CDM,333,RC,77470,HCPCS,,,facility,both,,,,2853,1997.1,,,,,,,,,,,,,Gross Charge Type: Central
HC RESPIRATORY MOTION MGMT SIMULATION,33300041,CDM,333,RC,77293,HCPCS,,,facility,both,,,,1174,821.8,,,,,,,,,,,,,Gross Charge Type: Central
HC GUIDE FOR LOCALIZATION OF TARGET VOLUME FOR RADIATION TREATMENT DELIVERY KV,33300042,CDM,333,RC,77387,HCPCS,,,facility,both,,,,540,378,,,,,,,,,,,,,Gross Charge Type: Central
HC TELETHERAPY ISODOSE PLAN SIMPLE INCLUDES BASIC DOSIMETRY CALCULATION(S),33300043,CDM,333,RC,77306,HCPCS,,,facility,both,,,,627,438.9,,,,,,,,,,,,,Gross Charge Type: Central
HC TELETHERAPY ISODOSE PLAN COMPLEX INCLUDES BASIC DOSIMETRY CALCULATION(S),33300044,CDM,333,RC,77307,HCPCS,,,facility,both,,,,2655,1858.5,,,,,,,,,,,,,Gross Charge Type: Central
HC BRACHYTHERAPY ISODOSE PLAN SIMPLE INCLUDES BASIC DOSIMETRY CALCULATION(S),33300045,CDM,333,RC,77316,HCPCS,,,facility,both,,,,502,351.4,,,,,,,,,,,,,Gross Charge Type: Central
HC BRACHYTHERAPY ISODOSE PLAN COMPLEX INCLUDES BASIC DOSIMETRY CALCULATION(S),33300046,CDM,333,RC,77318,HCPCS,,,facility,both,,,,771,539.7,,,,,,,,,,,,,Gross Charge Type: Central
HC RADIATION TX DELIVERY >= 1 MEV SIMPLE,33300047,CDM,333,RC,77402,HCPCS,,,facility,both,,,,507,354.9,,,,,,,,,,,,,Gross Charge Type: Central
HC RADIATION TX DELIVERY >= 1 MEV INTERMEDIATE,33300048,CDM,333,RC,77407,HCPCS,,,facility,both,,,,534,373.8,,,,,,,,,,,,,Gross Charge Type: Central
HC RADIATION TX DELIVERY >= 1 MEV COMPLEX,33300049,CDM,333,RC,77412,HCPCS,,,facility,both,,,,1196,837.2,,,,,,,,,,,,,Gross Charge Type: Central
HC IMRT INCLUDES GUIDANCE/TRACKING SIMPLE,33300050,CDM,333,RC,77385,HCPCS,,,facility,both,,,,3669,2568.3,,,,,,,,,,,,,Gross Charge Type: Central
HC IMRT INCLUDES GUIDANCE/TRACKING COMPLEX,33300051,CDM,333,RC,77386,HCPCS,,,facility,both,,,,3758,2630.6,,,,,,,,,,,,,Gross Charge Type: Central
HC GUIDE FOR LOCALIZATION OF TARGET VOLUME FOR RADIATION TREATMENT DELIVERY BAT,33300052,CDM,333,RC,77387,HCPCS,,,facility,both,,,,540,378,,,,,,,,,,,,,Gross Charge Type: Central
HC GUIDE FOR LOCALIZATION OF TARGET VOLUME FOR RADIATION TREATMENT DELIVERY CT,33300053,CDM,333,RC,77387,HCPCS,,,facility,both,,,,722,505.4,,,,,,,,,,,,,Gross Charge Type: Central
HC REMOTE AFTERLOADING HIGH DOSE RATE RADIONUCLIDE INTERSTITIAL/INTRACAVITARY BRACHYTHERAPY INCL BASIC DOSIMETRY 1 CHANNEL,33300057,CDM,333,RC,77770,HCPCS,,,facility,both,,,,1182,827.4,,,,,,,,,,,,,Gross Charge Type: Central
HC REMOTE AFTERLOADING HIGH DOSE RATE RADIONUCLIDE INTERSTITIAL/INTRACAVITARY BRACHYTHERAPY INCL BASIC DOSIMETRY 2-12 CHANNELS,33300058,CDM,333,RC,77771,HCPCS,,,facility,both,,,,1673,1171.1,,,,,,,,,,,,,Gross Charge Type: Central
HC REMOTE AFTERLOADING HIGH DOSE RATE RADIONUCLIDE INTERSTITIAL/INTRACAVITARY BRACHYTHERAPY INCL BASIC DOSIMETRY OVER 12 CHANNELS,33300059,CDM,333,RC,77772,HCPCS,,,facility,both,,,,4627,3238.9,,,,,,,,,,,,,Gross Charge Type: Central
HC SPECIAL DOSIMETRY ONLY WHEN PRESCRIBED BY TREATING PHYS,33300061,CDM,333,RC,77331,HCPCS,,,facility,both,,,,381,266.7,,,,,,,,,,,,,Gross Charge Type: Central
CHEMO IV PUSH SINGL DRUG,33500001,CDM,335,RC,96409,HCPCS,,,facility,both,,,,493,345.1,,,,,,,,,,,,,Gross Charge Type: Central
CHEMO IV PUSH ADDL DRUG,33500002,CDM,335,RC,96411,HCPCS,,,facility,both,,,,284,198.8,,,,,,,,,,,,,Gross Charge Type: Central
CHEMO INFUS SINGL DRUG 1 HOUR,33500003,CDM,335,RC,96413,HCPCS,,,facility,both,,,,713,499.1,,,,,,,,,,,,,Gross Charge Type: Central
CHEMO INFUS SINGL DRUG EA ADD HR,33500004,CDM,335,RC,96415,HCPCS,,,facility,both,,,,239,167.3,,,,,,,,,,,,,Gross Charge Type: Central
CHEMO INFUS W/PUMP >8 HRS,33500005,CDM,335,RC,96416,HCPCS,,,facility,both,,,,671,469.7,,,,,,,,,,,,,Gross Charge Type: Central
CHEMO INFUS DIFF DRUG SEQ 1 HR,33500006,CDM,335,RC,96417,HCPCS,,,facility,both,,,,602,421.4,,,,,,,,,,,,,Gross Charge Type: Central
HC CHEMO INTRA-ARTERIAL PUSH,33500007,CDM,335,RC,96420,HCPCS,,,facility,both,,,,334,233.8,,,,,,,,,,,,,Gross Charge Type: Central
HC CHEMO ADMIN INTRA-ARTERIAL INFUS TECH INITIATION PROLONGED INFUSION > 8HRS PRTBLE/IMPLTBL PUMP,33500008,CDM,335,RC,96425,HCPCS,,,facility,both,,,,1223,856.1,,,,,,,,,,,,,Gross Charge Type: Central
HC CHEMO ADMIN INTRA-ARTERIAL INFUSION TECH EA ADDT'L HOUR,33500009,CDM,335,RC,96423,HCPCS,,,facility,both,,,,314,219.8,,,,,,,,,,,,,Gross Charge Type: Central
ROMIPLOSTIM 250 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-221-01,NDC,,,facility,both,60,EA,,459,321.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 125 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-223-01,NDC,,,facility,both,25,EA,,224,156.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 250 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-221-01,NDC,,,facility,both,35,EA,,268,187.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-222-01,NDC,,,facility,both,965,EA,,16944,11860.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 250 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-221-01,NDC,,,facility,both,180,EA,,3161,2212.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 125 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-223-01,NDC,,,facility,both,55,EA,,1129,790.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 125 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-223-01,NDC,,,facility,both,110,EA,,2258,1580.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-222-01,NDC,,,facility,both,945,EA,,16593,11615.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 125 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-223-01,NDC,,,facility,both,100,EA,,2052,1436.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-222-01,NDC,,,facility,both,935,EA,,16417,11491.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 125 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-223-01,NDC,,,facility,both,15,EA,,308,215.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 250 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-221-01,NDC,,,facility,both,250,EA,,4390,3073,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 125 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-223-01,NDC,,,facility,both,85,EA,,1745,1221.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 250 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-221-01,NDC,,,facility,both,50,EA,,382,267.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-222-01,NDC,,,facility,both,420,EA,,7375,5162.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-222-01,NDC,,,facility,both,1000,EA,,17559,12291.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-222-01,NDC,,,facility,both,40,EA,,306,214.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-222-01,NDC,,,facility,both,60,EA,,459,321.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 125 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-223-01,NDC,,,facility,both,115,EA,,2360,1652,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 125 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-223-01,NDC,,,facility,both,60,EA,,1232,862.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-222-01,NDC,,,facility,both,940,EA,,16505,11553.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 250 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-221-01,NDC,,,facility,both,190,EA,,3337,2335.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 125 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-223-01,NDC,,,facility,both,65,EA,,580,406,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 125 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-223-01,NDC,,,facility,both,95,EA,,1950,1365,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 125 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-223-01,NDC,,,facility,both,50,EA,,1026,718.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-222-01,NDC,,,facility,both,999,EA,,17559,12291.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-222-01,NDC,,,facility,both,400,EA,,3054,2137.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-222-01,NDC,,,facility,both,20,EA,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 125 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-223-01,NDC,,,facility,both,70,EA,,1437,1005.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 250 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-221-01,NDC,,,facility,both,55,EA,,420,294,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-222-01,NDC,,,facility,both,55,EA,,420,294,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 250 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-221-01,NDC,,,facility,both,75,EA,,573,401.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 125 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-223-01,NDC,,,facility,both,120,EA,,2463,1724.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 125 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-223-01,NDC,,,facility,both,60,EA,,536,375.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 250 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-221-01,NDC,,,facility,both,210,EA,,3688,2581.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-222-01,NDC,,,facility,both,65,EA,,497,347.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 125 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-223-01,NDC,,,facility,both,105,EA,,2155,1508.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 125 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-223-01,NDC,,,facility,both,20,EA,,179,125.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-222-01,NDC,,,facility,both,100,EA,,1756,1229.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 125 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-223-01,NDC,,,facility,both,51,EA,,1026,718.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 125 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-223-01,NDC,,,facility,both,30,EA,,268,187.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 125 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-223-01,NDC,,,facility,both,75,EA,,1539,1077.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-222-01,NDC,,,facility,both,500,EA,,8780,6146,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 125 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-223-01,NDC,,,facility,both,80,EA,,1642,1149.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 125 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-223-01,NDC,,,facility,both,50,EA,,447,312.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 125 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-223-01,NDC,,,facility,both,90,EA,,1847,1292.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 250 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-221-01,NDC,,,facility,both,130,EA,,2283,1598.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 125 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-223-01,NDC,,,facility,both,125,EA,,2565,1795.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 250 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-221-01,NDC,,,facility,both,40,EA,,306,214.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-222-01,NDC,,,facility,both,460,EA,,8077,5653.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 125 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-223-01,NDC,,,facility,both,55,EA,,491,343.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 250 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-221-01,NDC,,,facility,both,175,EA,,3073,2151.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 250 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-221-01,NDC,,,facility,both,195,EA,,3424,2396.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-222-01,NDC,,,facility,both,35,EA,,268,187.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-222-01,NDC,,,facility,both,980,EA,,17207,12044.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 250 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-221-01,NDC,,,facility,both,180,EA,,1375,962.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 125 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-223-01,NDC,,,facility,both,106,EA,,2155,1508.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 125 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-223-01,NDC,,,facility,both,45,EA,,924,646.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-222-01,NDC,,,facility,both,455,EA,,7989,5592.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 250 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-221-01,NDC,,,facility,both,5,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 250 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-221-01,NDC,,,facility,both,710,EA,,12467,8726.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 125 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-223-01,NDC,,,facility,both,390,EA,,3480,2436,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 125 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-223-01,NDC,,,facility,both,80,EA,,714,499.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 250 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-221-01,NDC,,,facility,both,70,EA,,1230,861,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-222-01,NDC,,,facility,both,80,EA,,611,427.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 250 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-221-01,NDC,,,facility,both,200,EA,,3512,2458.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 125 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-223-01,NDC,,,facility,both,65,EA,,1334,933.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 250 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-221-01,NDC,,,facility,both,245,EA,,4302,3011.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-222-01,NDC,,,facility,both,465,EA,,8165,5715.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-222-01,NDC,,,facility,both,45,EA,,344,240.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 125 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-223-01,NDC,,,facility,both,75,EA,,670,469,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 250 MCG SUBQ SOLR,33962,CDM,J2802,HCPCS,55513-221-01,NDC,,,facility,both,215,EA,,3775,2642.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC THYROID SINGLE UPTAKE,34000001,CDM,340,RC,78012,HCPCS,,,facility,both,,,,297,207.9,,,,,,,,,,,,,Gross Charge Type: Central
HC THYROID METS IMAGING BODY,34000006,CDM,340,RC,78018,HCPCS,,,facility,both,,,,2039,1427.3,,,,,,,,,,,,,Gross Charge Type: Central
HC ADRENAL IMAGING,34000008,CDM,340,RC,78075,HCPCS,,,facility,both,,,,1900,1330,,,,,,,,,,,,,Gross Charge Type: Central
HC LYMPH SYSTEM IMAGING,34000009,CDM,340,RC,78195,HCPCS,,,facility,both,,,,1581,1106.7,,,,,,,,,,,,,Gross Charge Type: Central
HC LIVER AND SPLEEN IMAGING STATIC,34000011,CDM,340,RC,78215,HCPCS,,,facility,both,,,,2071,1449.7,,,,,,,,,,,,,Gross Charge Type: Central
HC HEPATOBILIARY SYSTEM IMAGING,34000012,CDM,340,RC,78226,HCPCS,,,facility,both,,,,1202,841.4,,,,,,,,,,,,,Gross Charge Type: Central
HC HEPATOBIL SYST IMAGE W/DRUG,34000013,CDM,340,RC,78227,HCPCS,,,facility,both,,,,1941,1358.7,,,,,,,,,,,,,Gross Charge Type: Central
HC GASTROESOPHAGEAL REFLUX EXAM,34000014,CDM,340,RC,78262,HCPCS,,,facility,both,,,,839,587.3,,,,,,,,,,,,,Gross Charge Type: Central
HC GASTRIC EMPTYING IMAGING STUDY,34000015,CDM,340,RC,78264,HCPCS,,,facility,both,,,,1340,938,,,,,,,,,,,,,Gross Charge Type: Central
HC ACUTE GI BLOOD LOSS IMAGING,34000016,CDM,340,RC,78278,HCPCS,,,facility,both,,,,1770,1239,,,,,,,,,,,,,Gross Charge Type: Central
HC MECKELS DIVERTICULUM,34000017,CDM,340,RC,78290,HCPCS,,,facility,both,,,,970,679,,,,,,,,,,,,,Gross Charge Type: Central
HC BONE AND/OR JOINT IMAGING LIMITED AREA,34000018,CDM,340,RC,78300,HCPCS,,,facility,both,,,,1404,982.8,,,,,,,,,,,,,Gross Charge Type: Central
HC BONE AND/OR JOINT IMAGING MULTIPLE AREAS,34000019,CDM,340,RC,78305,HCPCS,,,facility,both,,,,1738,1216.6,,,,,,,,,,,,,Gross Charge Type: Central
HC BONE AND/OR JOINT IMAGING WHOLE BODY,34000020,CDM,340,RC,78306,HCPCS,,,facility,both,,,,1946,1362.2,,,,,,,,,,,,,Gross Charge Type: Central
HC BONE AND/OR JOINT IMAGING 3 PHASE STUDY,34000021,CDM,340,RC,78315,HCPCS,,,facility,both,,,,1986,1390.2,,,,,,,,,,,,,Gross Charge Type: Central
HC CARDIAC BLOOD POOL IMAGING,34000023,CDM,340,RC,78472,HCPCS,,,facility,both,,,,1695,1186.5,,,,,,,,,,,,,Gross Charge Type: Central
HC LUNG VENTILATION IMAGING,34000024,CDM,340,RC,78579,HCPCS,,,facility,both,,,,1568,1097.6,,,,,,,,,,,,,Gross Charge Type: Central
HC LUNG PERFUSION IMAGING,34000025,CDM,340,RC,78580,HCPCS,,,facility,both,,,,845,591.5,,,,,,,,,,,,,Gross Charge Type: Central
HC LUNG VENTILAT&PERFUS IMAG,34000026,CDM,340,RC,78582,HCPCS,,,facility,both,,,,1482,1037.4,,,,,,,,,,,,,Gross Charge Type: Central
HC LUNG VENTILAT&PERFUS DIFFERENTL,34000027,CDM,340,RC,78598,HCPCS,,,facility,both,,,,1326,928.2,,,,,,,,,,,,,Gross Charge Type: Central
HC BRAIN IMAGE W/FLOW 4 + VIEWS,34000028,CDM,340,RC,78606,HCPCS,,,facility,both,,,,1477,1033.9,,,,,,,,,,,,,Gross Charge Type: Central
HC CEREBROSPINAL FLUID SCAN,34000030,CDM,340,RC,78630,HCPCS,,,facility,both,,,,1523,1066.1,,,,,,,,,,,,,Gross Charge Type: Central
HC CSF SHUNT EVALUATION,34000031,CDM,340,RC,78645,HCPCS,,,facility,both,,,,877,613.9,,,,,,,,,,,,,Gross Charge Type: Central
HC K FLOW/FUNCT IMAGE W/O DRUG,34000034,CDM,340,RC,78707,HCPCS,,,facility,both,,,,1277,893.9,,,,,,,,,,,,,Gross Charge Type: Central
HC K FLOW/FUNCT IMAGE W/DRUG,34000035,CDM,340,RC,78708,HCPCS,,,facility,both,,,,1888,1321.6,,,,,,,,,,,,,Gross Charge Type: Central
HC URETERAL REFLUX STUDY,34000037,CDM,340,RC,78740,HCPCS,,,facility,both,,,,796,557.2,,,,,,,,,,,,,Gross Charge Type: Central
HC TUMOR IMAGING PLANAR WHOLE BODY SINGLE DAY IMAGING,34000038,CDM,340,RC,78802,HCPCS,,,facility,both,,,,2661,1862.7,,,,,,,,,,,,,Gross Charge Type: Central
HC TUMOR SPECT SINGLE AREA/ACQUISITION SINGLE DAY IMAGING,34000039,CDM,340,RC,78803,HCPCS,,,facility,both,,,,3804,2662.8,,,,,,,,,,,,,Gross Charge Type: Central
HC THYROID IMAGING W/ BLOOD FLOW,34000043,CDM,340,RC,78013,HCPCS,,,facility,both,,,,199,139.3,,,,,,,,,,,,,Gross Charge Type: Central
HC THYROID IMAGING W/ BLOOD FLOW W/ SNGL/MULT UPTAKE(S),34000044,CDM,340,RC,78014,HCPCS,,,facility,both,,,,308,215.6,,,,,,,,,,,,,Gross Charge Type: Central
HC SUPERVISION/HANDLING/LOADING OF RADIATION SOURCE,34000047,CDM,340,RC,77790,HCPCS,,,facility,both,,,,466,326.2,,,,,,,,,,,,,Gross Charge Type: Central
HC GASTRIC EMPTYING IMAGING STUDY W/SMALL BOWEL TRANSIT,34000048,CDM,340,RC,78265,HCPCS,,,facility,both,,,,1412,988.4,,,,,,,,,,,,,Gross Charge Type: Central
HC GASTRIC EMPTYING IMAGING STUDY W/SMALL BOWEL & COLON TRANSIT MULTI DAYS,34000049,CDM,340,RC,78266,HCPCS,,,facility,both,,,,1873,1311.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PARATHYROID IMAGING W/ TOMOGRAPHIC (SPECT),34000050,CDM,340,RC,78071,HCPCS,,,facility,both,,,,1600,1120,,,,,,,,,,,,,Gross Charge Type: Central
HC PARATHYRD PLANAR IMAG INCL SUBTRACTION W/TOMOGRAHIC (SPECT) AND CT FOR ANATOMICAL LOCALIZATION,34000051,CDM,340,RC,78072,HCPCS,,,facility,both,,,,1807,1264.9,,,,,,,,,,,,,Gross Charge Type: Central
HC LIVER IMAGING WITH VASCULAR FLOW,34000053,CDM,340,RC,78202,HCPCS,,,facility,both,,,,4055,2838.5,,,,,,,,,,,,,Gross Charge Type: Central
HC TUMOR IMAGING PLANAR SINGLE AREA SINGLE DAY IMAGING,34000055,CDM,340,RC,78800,HCPCS,,,facility,both,,,,1357,949.9,,,,,,,,,,,,,Gross Charge Type: Central
HC TUMOR SPECT W/CT SINGLE AREA/ACQUISITION SINGLE DAY IMAGING,34000057,CDM,340,RC,78830,HCPCS,,,facility,both,,,,4529,3170.3,,,,,,,,,,,,,Gross Charge Type: Central
HC TUMOR SPECT W/CT MIN 2 AREAS SINGLE DAY IMAGING OR SINGLE AREA IMAGING OVER 2 OR MORE DAYS,34000059,CDM,340,RC,78832,HCPCS,,,facility,both,,,,5138,3596.6,,,,,,,,,,,,,Gross Charge Type: Central
HC UNLISTED RESPIRATORY PROCEDURE DX NUCLEAR MED,34000060,CDM,340,RC,78599,HCPCS,,,facility,both,,,,1322,925.4,,,,,,,,,,,,,Gross Charge Type: Central
HC RADIOPHARM QUANT MEASURE SINGLE AREA,34000061,CDM,340,RC,78835,HCPCS,,,facility,both,,,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Central
HC ESOPHAGEAL MOTILITY,34000062,CDM,340,RC,78258,HCPCS,,,facility,both,,,,1340,938,,,,,,,,,,,,,Gross Charge Type: Central
YTTRIUM-90 (SIR-SPHERES) MICROSPHERES,34032,CDM,278,RC,C2616,HCPCS,99999-0404-16,NDC,facility,both,1,EA,XU,43468,30427.6,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
YTTRIUM-90 (SIR-SPHERES) MICROSPHERES,34032,CDM,278,RC,C2616,HCPCS,99999-0404-16,NDC,facility,both,1,EA,XU,42194,29535.8,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
YTTRIUM-90 (Y-90 THERASPHERE) GLASS MICROSPHERES,34032,CDM,278,RC,C2616,HCPCS,11994-016-01,NDC,facility,both,1,EA,,44379,31065.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
YTTRIUM-90 (Y-90 THERASPHERE) GLASS MICROSPHERES,34032,CDM,278,RC,C2616,HCPCS,11994-016-01,NDC,facility,both,1,EA,XU,44379,31065.3,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
YTTRIUM-90 (SIR-SPHERES) MICROSPHERES,34032,CDM,278,RC,C2616,HCPCS,99999-0404-16,NDC,facility,both,1,EA,,43468,30427.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC THYROID METS IMAGING/STUDIES,34100001,CDM,341,RC,78016,HCPCS,,,facility,both,,,,417,291.9,,,,,,,,,,,,,Gross Charge Type: Central
HC BONE MARROW IMAGING LTD,34100002,CDM,341,RC,78102,HCPCS,,,facility,both,,,,1565,1095.5,,,,,,,,,,,,,Gross Charge Type: Central
HC RED CELL SEQUESTRATION,34100003,CDM,341,RC,78140,HCPCS,,,facility,both,,,,801,560.7,,,,,,,,,,,,,Gross Charge Type: Central
HC HEART MUSC IMAGE SPECT MULT,34100006,CDM,341,RC,78452,HCPCS,,,facility,both,,,,2202,1541.4,,,,,,,,,,,,,Gross Charge Type: Central
HC TUMOR IMAGING WHOLE BODY 2 DAYS,34100007,CDM,341,RC,78804,HCPCS,,,facility,both,,,,3951,2765.7,,,,,,,,,,,,,Gross Charge Type: Central
HC BRAIN IMAGING PET PERFUSION EVALUATION,34100010,CDM,341,RC,78609,HCPCS,,,facility,both,,,,4864,3404.8,,,,,,,,,,,,,Gross Charge Type: Central
HC BONE MARROW IMAGING MULTIPLE AREAS,34100011,CDM,341,RC,78103,HCPCS,,,facility,both,,,,1800,1260,,,,,,,,,,,,,Gross Charge Type: Central
HC THYROID THERAPY,34200002,CDM,342,RC,79005,HCPCS,,,facility,both,,,,1609,1126.3,,,,,,,,,,,,,Gross Charge Type: Central
HC BRACHYTHERAPY ISODOSE PLAN INTERMEDIATE INCLUDES BASIC DOSIMETRY CALCULATION(S),34200004,CDM,333,RC,77317,HCPCS,,,facility,both,,,,657,459.9,,,,,,,,,,,,,Gross Charge Type: Central
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,34300024,CDM,343,RC,Q9969,HCPCS,,,facility,both,,,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Central
LEVONORGESTREL 20 MCG/24 HR IU IUD,34542,CDM,J7298,HCPCS,50419-423-01,NDC,,,facility,both,2,EA,,4738,3316.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVONORGESTREL 20 MCG/24 HR IU IUD,34542,CDM,J7298,HCPCS,50419-423-01,NDC,,,facility,both,1,EA,,4738,3316.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVONORGESTREL 20 MCG/24 HR IU IUD,34542,CDM,J7298,HCPCS,50419-423-01,NDC,,,facility,both,1,EA,,2369,1658.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,34546,CDM,J7512,HCPCS,59651-488-01,NDC,,,facility,both,40,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,34546,CDM,J7512,HCPCS,60687-145-11,NDC,,,facility,both,60,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,34546,CDM,J7512,HCPCS,60219-1708-1,NDC,,,facility,both,50,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,34546,CDM,J7512,HCPCS,60687-134-11,NDC,,,facility,both,20,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,34546,CDM,J7512,HCPCS,60687-145-11,NDC,,,facility,both,40,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,34546,CDM,J7512,HCPCS,60219-1708-1,NDC,,,facility,both,60,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,34546,CDM,J7512,HCPCS,60687-145-11,NDC,,,facility,both,40,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,34546,CDM,J7512,HCPCS,10135-778-01,NDC,,,facility,both,50,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,34546,CDM,J7512,HCPCS,0904-7127-61,NDC,,,facility,both,20,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,34546,CDM,J7512,HCPCS,60219-1708-1,NDC,,,facility,both,40,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,34546,CDM,J7512,HCPCS,60687-145-11,NDC,,,facility,both,20,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  5 MG ORAL TAB,34546,CDM,J7512,HCPCS,60687-122-11,NDC,,,facility,both,10,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,34546,CDM,J7512,HCPCS,59746-175-06,NDC,,,facility,both,20,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,34546,CDM,J7512,HCPCS,60687-145-11,NDC,,,facility,both,50,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,34546,CDM,J7512,HCPCS,60687-134-11,NDC,,,facility,both,40,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,34546,CDM,J7512,HCPCS,0904-7127-61,NDC,,,facility,both,60,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  5 MG ORAL TAB,34546,CDM,J7512,HCPCS,60687-122-11,NDC,,,facility,both,5,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,34546,CDM,J7512,HCPCS,0904-7127-61,NDC,,,facility,both,40,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  5 MG ORAL TAB,34546,CDM,J7512,HCPCS,60687-122-11,NDC,,,facility,both,10,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,34546,CDM,J7512,HCPCS,0904-7127-61,NDC,,,facility,both,10,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,34546,CDM,J7512,HCPCS,59651-488-01,NDC,,,facility,both,60,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,34546,CDM,J7512,HCPCS,10135-778-01,NDC,,,facility,both,40,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,34546,CDM,J7512,HCPCS,0904-7127-61,NDC,,,facility,both,100,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,34546,CDM,J7512,HCPCS,59746-175-06,NDC,,,facility,both,40,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,34546,CDM,J7512,HCPCS,59651-488-01,NDC,,,facility,both,20,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,34546,CDM,J7512,HCPCS,60687-145-11,NDC,,,facility,both,20,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,34546,CDM,J7512,HCPCS,0904-7127-61,NDC,,,facility,both,40,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AVELUMAB 20 MG/ML IV SOLN,34738,CDM,J9023,HCPCS,44087-3535-1,NDC,,,facility,both,80,ML,,14907,10434.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC CT ANGIO ABD&PELV W/WO DYE,35000001,CDM,350,RC,74174,HCPCS,,,facility,both,,,,4674,3271.8,,,,,,,,,,,,,Gross Charge Type: Central
HC CT ANGIO ABDOM W/WO DYE,35000002,CDM,350,RC,74175,HCPCS,,,facility,both,,,,3330,2331,,,,,,,,,,,,,Gross Charge Type: Central
HC CT HEART W/3D IMAGE,35000003,CDM,480,RC,75572,HCPCS,,,facility,both,,,,1618,1132.6,,,,,,,,,,,,,Gross Charge Type: Central
HC CT HEART  W/CONTRAST EVAL CHD INCL 3D IMAGE LV RV EVAL VASCULAR STRUCTURES,35000004,CDM,480,RC,75573,HCPCS,,,facility,both,,,,1618,1132.6,,,,,,,,,,,,,Gross Charge Type: Central
HC CT ANGIO HEART W/3D IMAGE,35000005,CDM,480,RC,75574,HCPCS,,,facility,both,,,,1618,1132.6,,,,,,,,,,,,,Gross Charge Type: Central
HC CT ANGIO ABD AORTA LWR EXTR BILAT,35000006,CDM,350,RC,75635,HCPCS,,,facility,both,,,,3364,2354.8,,,,,,,,,,,,,Gross Charge Type: Central
HC 3D RENDER W/O POSTPROCESS,35000007,CDM,350,RC,76376,HCPCS,,,facility,both,,,,375,262.5,,,,,,,,,,,,,Gross Charge Type: Central
HC 3D RENDERING W/POSTPROCESS,35000008,CDM,350,RC,76377,HCPCS,,,facility,both,,,,401,280.7,,,,,,,,,,,,,Gross Charge Type: Central
HC CT LIMITED OR FOLLOW-UP STUDY,35000009,CDM,350,RC,76380,HCPCS,,,facility,both,,,,413,289.1,,,,,,,,,,,,,Gross Charge Type: Central
CT GUIDE FOR STEREO LOCALIZATION,35000010,CDM,350,RC,77011,HCPCS,,,facility,both,,,,843,590.1,,,,,,,,,,,,,Gross Charge Type: Central
HC CT GUIDE NDL ASPIRATE BX,35000011,CDM,350,RC,77012,HCPCS,,,facility,both,,,,1100,770,,,,,,,,,,,,,Gross Charge Type: Central
HC CT GUIDE TISSUE ABLATION,35000012,CDM,350,RC,77013,HCPCS,,,facility,both,,,,2027,1418.9,,,,,,,,,,,,,Gross Charge Type: Central
HC 3D CT GUIDE FOR PLACEMENT OF RADIATION THERAPY FIELDS,35000014,CDM,350,RC,77014,HCPCS,,,facility,both,,,,529,370.3,,,,,,,,,,,,,Gross Charge Type: Central
HC CT HEART W/O CONTRAST W/ QUAL EVAL CORONARY CALCIUM,35000015,CDM,350,RC,75571,HCPCS,,,facility,both,,,,298,208.6,,,,,,,,,,,,,Gross Charge Type: Central
HC 4D CT GUIDE FOR PLACEMENT OF RADIATION THERAPY FIELDS,35000016,CDM,350,RC,77014,HCPCS,,,facility,both,,,,529,370.3,,,,,,,,,,,,,Gross Charge Type: Central
HC NONINVASIVE EST CORONARY FFR DERIVED SOFTWARE ANALYSIS DATA SET FROM CTA W/INTERP/REPORT BY PHY/QHP,35000019,CDM,350,RC,75580,HCPCS,,,facility,both,,,,3973,2781.1,,,,,,,,,,,,,Gross Charge Type: Central
HC CT HEAD/BRAIN W/O DYE,35100001,CDM,351,RC,70450,HCPCS,,,facility,both,,,,1071,749.7,,,,,,,,,,,,,Gross Charge Type: Central
HC CT HEAD/BRAIN W/DYE,35100002,CDM,351,RC,70460,HCPCS,,,facility,both,,,,1986,1390.2,,,,,,,,,,,,,Gross Charge Type: Central
HC CT HEAD/BRAIN W/WO DYE,35100003,CDM,351,RC,70470,HCPCS,,,facility,both,,,,2111,1477.7,,,,,,,,,,,,,Gross Charge Type: Central
HC CT ORBIT/EAR/FOSSA W/O DYE,35100004,CDM,351,RC,70480,HCPCS,,,facility,both,,,,1322,925.4,,,,,,,,,,,,,Gross Charge Type: Central
HC CT ORBIT/EAR/FOSSA W/DYE,35100005,CDM,351,RC,70481,HCPCS,,,facility,both,,,,1605,1123.5,,,,,,,,,,,,,Gross Charge Type: Central
HC CT ORBIT/EAR/FOSSA W/WO DYE,35100006,CDM,351,RC,70482,HCPCS,,,facility,both,,,,2116,1481.2,,,,,,,,,,,,,Gross Charge Type: Central
HC CT MAXILLOFACIAL W/O DYE,35100007,CDM,351,RC,70486,HCPCS,,,facility,both,,,,1036,725.2,,,,,,,,,,,,,Gross Charge Type: Central
HC CT MAXILLOFACIAL W/DYE,35100008,CDM,351,RC,70487,HCPCS,,,facility,both,,,,1595,1116.5,,,,,,,,,,,,,Gross Charge Type: Central
HC CT MAXILLOFACIAL W/WO DYE,35100009,CDM,351,RC,70488,HCPCS,,,facility,both,,,,2109,1476.3,,,,,,,,,,,,,Gross Charge Type: Central
HC CT SOFT TISSUE NECK W/O DYE,35100010,CDM,351,RC,70490,HCPCS,,,facility,both,,,,1152,806.4,,,,,,,,,,,,,Gross Charge Type: Central
HC CT SOFT TISSUE NECK W/DYE,35100011,CDM,351,RC,70491,HCPCS,,,facility,both,,,,1790,1253,,,,,,,,,,,,,Gross Charge Type: Central
HC CT SFT TSUE NCK W/WO DYE,35100012,CDM,351,RC,70492,HCPCS,,,facility,both,,,,2362,1653.4,,,,,,,,,,,,,Gross Charge Type: Central
HC CT ANGIO HEAD W/WO DYE,35100013,CDM,351,RC,70496,HCPCS,,,facility,both,,,,3284,2298.8,,,,,,,,,,,,,Gross Charge Type: Central
HC CT ANGIO NECK W/WO DYE,35100014,CDM,351,RC,70498,HCPCS,,,facility,both,,,,3284,2298.8,,,,,,,,,,,,,Gross Charge Type: Central
HC CEREBRAL PERFUSION ANALYSIS USING CT W/ CONTRAST ADMIN INCL POST-PROCESSING OF PARAMETRIC MAPS,35100015,CDM,351,RC,0042T,HCPCS,,,facility,both,,,,2660,1862,,,,,,,,,,,,,Gross Charge Type: Central
HC CT THORAX DIAGNOSTIC W/O DYE,35200001,CDM,352,RC,71250,HCPCS,,,facility,both,,,,1222,855.4,,,,,,,,,,,,,Gross Charge Type: Central
HC CT THORAX DIAGNOSTIC W/DYE,35200002,CDM,352,RC,71260,HCPCS,,,facility,both,,,,2047,1432.9,,,,,,,,,,,,,Gross Charge Type: Central
HC CT THORAX DIAGNOSTIC W/WO DYE,35200003,CDM,352,RC,71270,HCPCS,,,facility,both,,,,2471,1729.7,,,,,,,,,,,,,Gross Charge Type: Central
HC CT ANGIO CHEST W/CONTRAST INCL NONCONTRAST IMAGE,35200004,CDM,352,RC,71275,HCPCS,,,facility,both,,,,3337,2335.9,,,,,,,,,,,,,Gross Charge Type: Central
HC CT C-SPINE W/O DYE,35200005,CDM,352,RC,72125,HCPCS,,,facility,both,,,,2068,1447.6,,,,,,,,,,,,,Gross Charge Type: Central
HC CT C-SPINE W/DYE,35200006,CDM,352,RC,72126,HCPCS,,,facility,both,,,,2523,1766.1,,,,,,,,,,,,,Gross Charge Type: Central
HC CT C-SPINE W/WO DYE,35200007,CDM,352,RC,72127,HCPCS,,,facility,both,,,,2777,1943.9,,,,,,,,,,,,,Gross Charge Type: Central
HC THORACIC SPINE W/O DYE,35200008,CDM,352,RC,72128,HCPCS,,,facility,both,,,,722,505.4,,,,,,,,,,,,,Gross Charge Type: Central
HC THORACIC SPINE W/DYE,35200009,CDM,352,RC,72129,HCPCS,,,facility,both,,,,1102,771.4,,,,,,,,,,,,,Gross Charge Type: Central
HC THORACIC SPINE W/WO DYE,35200010,CDM,352,RC,72130,HCPCS,,,facility,both,,,,1235,864.5,,,,,,,,,,,,,Gross Charge Type: Central
HC CT LUMBAR SPINE W/O DYE,35200011,CDM,352,RC,72131,HCPCS,,,facility,both,,,,1609,1126.3,,,,,,,,,,,,,Gross Charge Type: Central
HC CT LUMBAR SPINE W/DYE,35200012,CDM,352,RC,72132,HCPCS,,,facility,both,,,,2349,1644.3,,,,,,,,,,,,,Gross Charge Type: Central
HC CT LUMBAR SPINE W/WO DYE,35200013,CDM,352,RC,72133,HCPCS,,,facility,both,,,,2586,1810.2,,,,,,,,,,,,,Gross Charge Type: Central
HC CT ANGIOGRAPH PELV W/WO DYE,35200014,CDM,352,RC,72191,HCPCS,,,facility,both,,,,3319,2323.3,,,,,,,,,,,,,Gross Charge Type: Central
HC CT PELVIS W/O DYE,35200015,CDM,352,RC,72192,HCPCS,,,facility,both,,,,1662,1163.4,,,,,,,,,,,,,Gross Charge Type: Central
HC CT PELVIS W/DYE,35200016,CDM,352,RC,72193,HCPCS,,,facility,both,,,,2121,1484.7,,,,,,,,,,,,,Gross Charge Type: Central
HC CT PELVIS W/WO DYE,35200017,CDM,352,RC,72194,HCPCS,,,facility,both,,,,2657,1859.9,,,,,,,,,,,,,Gross Charge Type: Central
HC CT UPPER EXTREMITY W/O DYE,35200019,CDM,352,RC,73200,HCPCS,,,facility,both,,,,1369,958.3,,,,,,,,,,,,,Gross Charge Type: Central
HC CT UPPER EXTREMITY W/DYE,35200020,CDM,352,RC,73201,HCPCS,,,facility,both,,,,1926,1348.2,,,,,,,,,,,,,Gross Charge Type: Central
HC CT UPPR EXTREMITY W/O&W/DYE,35200021,CDM,352,RC,73202,HCPCS,,,facility,both,,,,2265,1585.5,,,,,,,,,,,,,Gross Charge Type: Central
HC CT ANGIO UPR EXTRM W/WO DYE,35200022,CDM,352,RC,73206,HCPCS,,,facility,both,,,,3007,2104.9,,,,,,,,,,,,,Gross Charge Type: Central
HC CT LOWER EXT W/O DYE,35200023,CDM,352,RC,73700,HCPCS,,,facility,both,,,,1309,916.3,,,,,,,,,,,,,Gross Charge Type: Central
HC CT LOWER EXT W/DYE,35200024,CDM,352,RC,73701,HCPCS,,,facility,both,,,,1889,1322.3,,,,,,,,,,,,,Gross Charge Type: Central
HC CT LWR EXT W/WO DYE,35200025,CDM,352,RC,73702,HCPCS,,,facility,both,,,,2221,1554.7,,,,,,,,,,,,,Gross Charge Type: Central
HC CT ANGIO LWR EXT W/WO DYE,35200026,CDM,352,RC,73706,HCPCS,,,facility,both,,,,2983,2088.1,,,,,,,,,,,,,Gross Charge Type: Central
HC CT ABDOMEN W/O DYE,35200027,CDM,352,RC,74150,HCPCS,,,facility,both,,,,1409,986.3,,,,,,,,,,,,,Gross Charge Type: Central
HC CT ABDOMEN W/DYE,35200028,CDM,352,RC,74160,HCPCS,,,facility,both,,,,2163,1514.1,,,,,,,,,,,,,Gross Charge Type: Central
HC CT ABDOMEN W/WO DYE,35200029,CDM,352,RC,74170,HCPCS,,,facility,both,,,,2632,1842.4,,,,,,,,,,,,,Gross Charge Type: Central
HC CT ABD & PELVIS W/O DYE,35200030,CDM,352,RC,74176,HCPCS,,,facility,both,,,,3293,2305.1,,,,,,,,,,,,,Gross Charge Type: Central
CT ABD & PELV W/ DYE,35200031,CDM,352,RC,74177,HCPCS,,,facility,both,,,,4178,2924.6,,,,,,,,,,,,,Gross Charge Type: Central
HC CT ABD & PELV 1/> REGNS W/WO DYE,35200032,CDM,352,RC,74178,HCPCS,,,facility,both,,,,4674,3271.8,,,,,,,,,,,,,Gross Charge Type: Central
HC CT THORAX LUNG CANCER SCR C-,35200034,CDM,352,RC,71271,HCPCS,,,facility,both,,,,276,193.2,,,,,,,,,,,,,Gross Charge Type: Central
BENRALIZUMAB 30 MG/ML SUBQ ATIN,35333,CDM,J0517,HCPCS,0310-1830-30,NDC,,,facility,both,30,ML,,14769,10338.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),35402,CDM,J3490,HCPCS,25021-415-10,NDC,,,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMIDE PEROXIDE 6.5 % OTIC DROP,35402,CDM,J3490,HCPCS,63029-322-01,NDC,,,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",35402,CDM,J3490,HCPCS,0409-0007-01,NDC,,,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,35402,CDM,J3490,HCPCS,63323-202-02,NDC,,,facility,both,1,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOPERAMIDE 2 MG ORAL CAP,35402,CDM,J3490,HCPCS,51079-690-01,NDC,,,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J3490,HCPCS,63323-492-09,NDC,,,facility,both,1,ML,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,70954-316-10,NDC,,,facility,both,1,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,0143-9889-15,NDC,,,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,35402,CDM,J8540,HCPCS,0054-8175-25,NDC,,,facility,both,1,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MENING A,C,Y,W TT-N. MEN B(PF) 5-120 MCG/0.5 ML IM KIT (CAM USE ONLY)",35402,CDM,J3490,HCPCS,0069-0271-01,NDC,,,facility,both,1,EA,,817,571.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  120 MG RECT SUPP,35402,CDM,J3490,HCPCS,45802-732-30,NDC,,,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNIT/G TOP PACK,35402,CDM,J3490,HCPCS,45802-060-70,NDC,,,facility,both,1,EA,,163,114.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G POTASSIUM  5000000 UNIT INJ SOLR,35402,CDM,J2540,HCPCS,70860-126-41,NDC,,,facility,both,1,EA,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER SULFADIAZINE 1 % TOP CREA,35402,CDM,J3490,HCPCS,67877-124-05,NDC,,,facility,both,1,GM,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEGINTERFERON ALFA-2A 180 MCG/ML SUBQ SOLN,35402,CDM,J3490,HCPCS,82154-0449-1,NDC,,,facility,both,1,ML,,769,538.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG ORAL CAP,35402,CDM,J3490,HCPCS,60687-152-11,NDC,,,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COLCHICINE 0.6 MG ORAL TAB,35402,CDM,J3490,HCPCS,59651-455-01,NDC,,,facility,both,1,EA,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,68180-441-02,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,11673-660-26,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0338-0049-18,NDC,,,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,68094-494-59,NDC,,,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INHL NEBU,35402,CDM,J3490,HCPCS,487930201,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,68094-600-59,NDC,,,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL  2 MG ORAL TAB,35402,CDM,J3490,HCPCS,51079-735-01,NDC,,,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE  0.65 % NASL SPRA,35402,CDM,J3490,HCPCS,0904-3865-75,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,68094-600-59,NDC,,,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,35402,CDM,J7510,HCPCS,17856-0815-1,NDC,,,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE  5 MG ORAL TAB,35402,CDM,J3490,HCPCS,60687-620-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",35402,CDM,J3490,HCPCS,0409-4887-17,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,68094-231-59,NDC,,,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,68094-231-59,NDC,,,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,35402,CDM,J7510,HCPCS,17856-0815-1,NDC,,,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG ORAL CAP,35402,CDM,J3490,HCPCS,60687-776-11,NDC,,,facility,both,1,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,81033-002-30,NDC,,,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 30 MG ORAL CPDR,35402,CDM,J3490,HCPCS,60687-734-11,NDC,,,facility,both,1,EA,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 150 MG CAP,35402,CDM,J3490,HCPCS,68084-243-11,NDC,,,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) IV SOLN",35402,CDM,J3490,HCPCS,0013-1114-20,NDC,,,facility,both,1,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,68094-231-59,NDC,,,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,81033-002-10,NDC,,,facility,both,1,ML,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR PHOSPHATE 30 MG ORAL CAP,35402,CDM,J3490,HCPCS,72205-042-11,NDC,,,facility,both,1,EA,,139,97.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE IN 0.9% NS (PF) 1 MG/10 ML (100 MCG/ML) IV SYRG(PDS MERGE),35402,CDM,J3490,HCPCS,65302-506-10,NDC,,,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 125 MG ORAL CPSP,35402,CDM,J3490,HCPCS,0074-6114-13,NDC,,,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  75 MG ORAL CAP,35402,CDM,J3490,HCPCS,60687-495-01,NDC,,,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE  7 % INHL NEBU,35402,CDM,J3490,HCPCS,8349020760,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,35402,CDM,J8540,HCPCS,0054-8175-25,NDC,,,facility,both,1,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,35402,CDM,J1100,HCPCS,63323-506-01,NDC,,,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-0430-04,NDC,,,facility,both,1,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0338-0049-48,NDC,,,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,0093-2279-73,NDC,,,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COLCHICINE 0.6 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-7120-04,NDC,,,facility,both,1,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,42806-151-34,NDC,,,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-7912-51,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BALANCED SALT IRRIG SOLN COMB2 INTRAOCULAR,35402,CDM,J3490,HCPCS,0065-0795-15,NDC,,,facility,both,1,ML,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYMETAZOLINE 0.05 % NASL SPRA,35402,CDM,J3490,HCPCS,4110081117,NDC,,,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,35402,CDM,J3490,HCPCS,71399-1025-3,NDC,,,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 50 MG ORAL TAB,35402,CDM,J7512,HCPCS,55289-330-05,NDC,,,facility,both,1,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 5 MG ORAL TAB,35402,CDM,J3490,HCPCS,60687-381-11,NDC,,,facility,both,1,EA,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,35402,CDM,J3490,HCPCS,0904-6930-61,NDC,,,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,68180-441-02,NDC,,,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM BICARB-CITRIC ACID 20 MEQ ORAL TBEF,35402,CDM,J3490,HCPCS,51801-011-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DUPILUMAB 200 MG/1.14 ML SUBQ PNIJ,35402,CDM,J3490,HCPCS,0024-5919-00,NDC,,,facility,both,1,ML,,5511,3857.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J3490,HCPCS,63323-492-31,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 875 MG-125 MG TAB,35402,CDM,J3490,HCPCS,16714-014-02,NDC,,,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 500 MG ORAL CAP,35402,CDM,J3490,HCPCS,60687-787-11,NDC,,,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TROPICAMIDE 1 % OPHT DROP,35402,CDM,J3490,HCPCS,61314-355-01,NDC,,,facility,both,1,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RACEPINEPHRINE 2.25 % INHL NEBU,35402,CDM,J3490,HCPCS,0487-2784-01,NDC,,,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNITS/1 GRAM PACKET (MERGE RECORD),35402,CDM,J3490,HCPCS,45802-060-00,NDC,,,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TETRACAINE 0.5 % EYE DROPS,35402,CDM,J3490,HCPCS,59390-181-13,NDC,,,facility,both,1,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,81033-002-10,NDC,,,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,35402,CDM,J3490,HCPCS,63323-485-41,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,35402,CDM,J7512,HCPCS,0378-0642-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J3490,HCPCS,0409-4279-02,NDC,,,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0338-0049-02,NDC,,,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,J7040,HCPCS,0264-7800-10,NDC,,,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0990-7983-61,NDC,,,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 150 MG CAP,35402,CDM,J3490,HCPCS,0904-5959-61,NDC,,,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,68094-231-59,NDC,,,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,63868-176-26,NDC,,,facility,both,1,ML,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 10 GRAM/15 ML ORAL SOLN,35402,CDM,J3490,HCPCS,66689-038-01,NDC,,,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,35402,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,1,ML,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETIRIZINE 10 MG ORAL TAB,35402,CDM,J3490,HCPCS,51079-597-20,NDC,,,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0990-7983-61,NDC,,,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,0093-2279-73,NDC,,,facility,both,1,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUMAZENIL 0.1 MG/ML IV SOLN,35402,CDM,J3490,HCPCS,36000-148-01,NDC,,,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG ORAL CAP,35402,CDM,J3490,HCPCS,16714-298-01,NDC,,,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,68094-330-59,NDC,,,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,35402,CDM,J2003,HCPCS,70756-643-85,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCUSATE SODIUM 100 MG ORAL CAP,35402,CDM,J3490,HCPCS,0904-7183-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 10 MG ORAL CAP,35402,CDM,J3490,HCPCS,0904-6987-61,NDC,,,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE HCL  2 % MM JELP,35402,CDM,J3490,HCPCS,25021-673-76,NDC,,,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J2003,HCPCS,0409-4713-32,NDC,,,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4% TOP PATCH,35402,CDM,J3490,HCPCS,0536-1202-07,NDC,,,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG ORAL CAP,35402,CDM,J3490,HCPCS,60687-152-11,NDC,,,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 5 MG/ML INHL NEB CONTINUOUS,35402,CDM,J3490,HCPCS,69374-309-20,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,35402,CDM,J2003,HCPCS,63323-485-03,NDC,,,facility,both,1,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,35402,CDM,J3490,HCPCS,0409-4276-16,NDC,,,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE  25 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-6638-61,NDC,,,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,67877-548-88,NDC,,,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COLCHICINE 0.6 MG ORAL TAB,35402,CDM,J3490,HCPCS,60687-727-11,NDC,,,facility,both,1,EA,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NYSTATIN  100000 UNIT/G TOP POWD,35402,CDM,J3490,HCPCS,0574-2008-15,NDC,,,facility,both,1,GM,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL 2 MG/ML ORAL CONCENTRATE,35402,CDM,J3490,HCPCS,0904-7112-41,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,35402,CDM,J2003,HCPCS,63323-201-02,NDC,,,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CUPRIC CHLORIDE 0.4 MG/ML IV SOLN,35402,CDM,J3490,HCPCS,70069-506-01,NDC,,,facility,both,1,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 500 MG (200 MG ELEMENTAL) CHEW TAB,35402,CDM,J3490,HCPCS,66553-004-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,68180-150-01,NDC,,,facility,both,1,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,35402,CDM,J2003,HCPCS,63323-201-02,NDC,,,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,35402,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",35402,CDM,J3490,HCPCS,0409-3178-02,NDC,,,facility,both,1,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,67877-548-88,NDC,,,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,35402,CDM,J3490,HCPCS,55150-255-20,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORATADINE 10 MG ORAL TAB,35402,CDM,J3490,HCPCS,50268-489-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0990-7984-36,NDC,,,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,35402,CDM,J7510,HCPCS,17856-0815-1,NDC,,,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK,35402,CDM,J3490,HCPCS,12870-0001-2,NDC,,,facility,both,1,EA,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,0121-1314-11,NDC,,,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,35402,CDM,J3490,HCPCS,63323-495-07,NDC,,,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE 1 MG/2 ML INHL NBSP,35402,CDM,J3490,HCPCS,69097-321-86,NDC,,,facility,both,1,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",35402,CDM,J3490,HCPCS,63323-482-01,NDC,,,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J2003,HCPCS,63323-492-09,NDC,,,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETIRIZINE 5 MG/5 ML ORAL SOLN,35402,CDM,J3490,HCPCS,68094-004-59,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,68094-600-59,NDC,,,facility,both,2,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0990-7984-37,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0338-0049-02,NDC,,,facility,both,1,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 0.025 % TOP OINT,35402,CDM,J3490,HCPCS,45802-054-35,NDC,,,facility,both,1,GM,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJ SOLN",35402,CDM,J3490,HCPCS,63323-468-37,NDC,,,facility,both,1,ML,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR PHOSPHATE 75 MG ORAL CAP,35402,CDM,J3490,HCPCS,64380-799-01,NDC,,,facility,both,1,EA,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J3490,HCPCS,63323-492-27,NDC,,,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,35402,CDM,J3490,HCPCS,63323-485-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,35402,CDM,J7510,HCPCS,17856-0815-1,NDC,,,facility,both,1,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 1 % NASAL SPRAY AEROSOL,35402,CDM,J3490,HCPCS,0225-0810-47,NDC,,,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 20 MG ORAL CAP,35402,CDM,J3490,HCPCS,0904-7346-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,35402,CDM,J7510,HCPCS,17856-0815-1,NDC,,,facility,both,1,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,67877-548-88,NDC,,,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE  5 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-6370-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM BROMIDE 0.02 % INHL SOLN,35402,CDM,J3490,HCPCS,76204-100-01,NDC,,,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,J7040,HCPCS,0338-0049-04,NDC,,,facility,both,1,ML,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,35402,CDM,FAMNOCHARGE,HCPCS,0054-8175-25,NDC,,,facility,both,1,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 250 MG ORAL TBEC,35402,CDM,J3490,HCPCS,0904-6860-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,81033-002-10,NDC,,,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,35402,CDM,J3490,HCPCS,63323-202-02,NDC,,,facility,both,1,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MOXIFLOXACIN 0.5 % OPHT DROP,35402,CDM,J3490,HCPCS,68180-422-01,NDC,,,facility,both,1,ML,,603,422.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM,35402,CDM,J3490,HCPCS,1254717167,NDC,,,facility,both,1,GM,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 15 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-6519-61,NDC,,,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN  5 MG ORAL TAB,35402,CDM,J3490,HCPCS,62584-994-11,NDC,,,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG ORAL CAP,35402,CDM,J3490,HCPCS,16714-298-01,NDC,,,facility,both,1,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,11822-2399-90,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,J7040,HCPCS,0264-1800-31,NDC,,,facility,both,1,ML,,469,328.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,35402,CDM,J3490,HCPCS,63323-485-57,NDC,,,facility,both,1,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER SULFADIAZINE 1 % TOP CREA,35402,CDM,J3490,HCPCS,61570-131-50,NDC,,,facility,both,1,GM,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) NEB SOLUTION,35402,CDM,J3490,HCPCS,76204-200-01,NDC,,,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J2003,HCPCS,63323-492-04,NDC,,,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,35402,CDM,J3490,HCPCS,68084-354-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J3490,HCPCS,63323-492-27,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,35402,CDM,J3490,HCPCS,68462-157-13,NDC,,,facility,both,1,EA,,227,158.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,1093935033,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",35402,CDM,J3490,HCPCS,63323-185-05,NDC,,,facility,both,1,ML,,138,96.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,35402,CDM,J7512,HCPCS,0904-7127-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,35402,CDM,J3490,HCPCS,50111-787-10,NDC,,,facility,both,1,EA,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,35402,CDM,J7512,HCPCS,60687-145-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,35402,CDM,J1100,HCPCS,63323-165-01,NDC,,,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORDIAZEPOXIDE 25 MG CAP,35402,CDM,J3490,HCPCS,51079-141-01,NDC,,,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-7914-61,NDC,,,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  5 MG ORAL TAB,35402,CDM,J3490,HCPCS,51079-453-01,NDC,,,facility,both,1,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 500 MG ORAL TAB,35402,CDM,J3490,HCPCS,50419-754-01,NDC,,,facility,both,1,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,35402,CDM,J7512,HCPCS,59746-175-09,NDC,,,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,35402,CDM,J3490,HCPCS,62756-240-64,NDC,,,facility,both,1,EA,,218,152.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG ORAL TAB,35402,CDM,J3490,HCPCS,0143-2112-50,NDC,,,facility,both,1,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,35402,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,0093-2279-73,NDC,,,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,0093-2279-73,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,35402,CDM,J7510,HCPCS,17856-0815-1,NDC,,,facility,both,1,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J3490,HCPCS,0143-9595-25,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE  5 MG ORAL TAB,35402,CDM,J3490,HCPCS,51079-886-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,67877-548-88,NDC,,,facility,both,1,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,68180-150-01,NDC,,,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIFEPRISTONE 200 MG ORAL TAB,35402,CDM,S0190,HCPCS,43393-001-01,NDC,,,facility,both,1,EA,,285,199.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),35402,CDM,J3490,HCPCS,73013-2002-2,NDC,,,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 60 MG ORAL CPDR,35402,CDM,J3490,HCPCS,0904-7045-61,NDC,,,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,35402,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,0121-1022-05,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:200,000 INJ SOLN",35402,CDM,J3490,HCPCS,63323-487-31,NDC,,,facility,both,1,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,68180-441-02,NDC,,,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG ORAL TAB,35402,CDM,J3490,HCPCS,60687-113-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,35402,CDM,Q0177,HCPCS,60687-675-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) NEB SOLUTION,35402,CDM,J3490,HCPCS,0378-8270-31,NDC,,,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) NEB SOLUTION,35402,CDM,J3490,HCPCS,47335-703-48,NDC,,,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) NEB SOLUTION,35402,CDM,J3490,HCPCS,0487-9501-01,NDC,,,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,J7040,HCPCS,0264-1800-31,NDC,,,facility,both,1,ML,,397,277.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,35402,CDM,J7512,HCPCS,0904-6923-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,35402,CDM,J3490,HCPCS,16714-200-10,NDC,,,facility,both,1,EA,,221,154.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),35402,CDM,J3490,HCPCS,0409-4888-03,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,35402,CDM,J7510,HCPCS,17856-0815-1,NDC,,,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J3490,HCPCS,63323-492-43,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % MUCOSAL GEL,35402,CDM,J3490,HCPCS,17478-711-10,NDC,,,facility,both,1,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE  5 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-6370-61,NDC,,,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),35402,CDM,J3490,HCPCS,0409-4888-06,NDC,,,facility,both,1,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,68094-494-59,NDC,,,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CONJUGATED ESTROGENS 0.625 MG/G VAGL CREA,35402,CDM,J3490,HCPCS,0046-0872-21,NDC,,,facility,both,1,GM,,1243,870.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZONATATE 100 MG ORAL CAP,35402,CDM,J3490,HCPCS,0904-7153-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,42806-151-34,NDC,,,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 10 GRAM/15 ML ORAL SOLN,35402,CDM,J3490,HCPCS,66689-038-01,NDC,,,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,35402,CDM,J2003,HCPCS,63323-201-02,NDC,,,facility,both,1,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  15 MG ORAL TAB,35402,CDM,J3490,HCPCS,0406-8515-23,NDC,,,facility,both,1,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN NORMAL SALINE IV,35402,CDM,FAMNOCHARGE,HCPCS,0264-7610-00,NDC,,,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J3490,HCPCS,63323-492-41,NDC,,,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 600 MG ORAL TP12,35402,CDM,J3490,HCPCS,0904-6718-39,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),35402,CDM,J3490,HCPCS,63037-136-25,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,35402,CDM,J3490,HCPCS,69339-152-01,NDC,,,facility,both,2,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,35402,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,1,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJ SOLN,35402,CDM,J3490,HCPCS,55150-167-10,NDC,,,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J3490,HCPCS,0409-4713-32,NDC,,,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,35402,CDM,J2003,HCPCS,63323-495-07,NDC,,,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),35402,CDM,J3490,HCPCS,0409-4888-06,NDC,,,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 20 MG/2 ML IV SOLN,35402,CDM,J3490,HCPCS,70860-751-02,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4 % MUCOSAL TOPICAL SOLN,35402,CDM,J3490,HCPCS,0054-3505-47,NDC,,,facility,both,1,ML,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,67877-548-88,NDC,,,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,76297-001-32,NDC,,,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,35402,CDM,J2003,HCPCS,55150-254-10,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AXATILIMAB-CSFR 50 MG/ML IV SOLN,35402,CDM,J3490,HCPCS,50881-034-12,NDC,,,facility,both,1,ML,,22460,15722,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG ORAL CAP,35402,CDM,J3490,HCPCS,60687-152-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK,35402,CDM,J3490,HCPCS,12870-0001-1,NDC,,,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 150 MG/ML INJECTION,35402,CDM,J3490,HCPCS,25021-115-06,NDC,,,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,35402,CDM,Q0162,HCPCS,68094-763-59,NDC,,,facility,both,1,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,35402,CDM,J3490,HCPCS,63323-486-02,NDC,,,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0338-0049-02,NDC,,,facility,both,1,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,35402,CDM,J3490,HCPCS,63323-201-03,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FERRIC SUBSULFATE 0.2 TO 0.22 GRAM/ML MISC SOLA,35402,CDM,J3490,HCPCS,48783-112-08,NDC,,,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR PHOSPHATE 30 MG ORAL CAP,35402,CDM,J3490,HCPCS,47781-468-13,NDC,,,facility,both,1,EA,,139,97.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  5 MG ORAL TAB,35402,CDM,J7512,HCPCS,60687-122-11,NDC,,,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,35402,CDM,J3490,HCPCS,69339-152-01,NDC,,,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,J7040,HCPCS,0338-0049-04,NDC,,,facility,both,1,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,68094-231-59,NDC,,,facility,both,1,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG ORAL TAB,35402,CDM,J3490,HCPCS,63739-499-10,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,68094-231-59,NDC,,,facility,both,1,ML,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,68180-150-01,NDC,,,facility,both,1,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 25 MG CAP,35402,CDM,J3490,HCPCS,1093-9955-30,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COLCHICINE 0.6 MG ORAL TAB,35402,CDM,J3490,HCPCS,65162-710-09,NDC,,,facility,both,1,EA,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4% TOP PATCH,35402,CDM,J3490,HCPCS,46581-830-01,NDC,,,facility,both,1,EA,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 10 MG ORAL TAB,35402,CDM,J3490,HCPCS,60687-179-11,NDC,,,facility,both,1,EA,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COLCHICINE 0.6 MG ORAL TAB,35402,CDM,J3490,HCPCS,65162-710-09,NDC,,,facility,both,1,EA,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",35402,CDM,J3490,HCPCS,0641-6147-01,NDC,,,facility,both,1,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,35402,CDM,Q0162,HCPCS,16714-671-02,NDC,,,facility,both,1,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,1093930833,NDC,,,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) IV SOLN",35402,CDM,J3490,HCPCS,67457-197-00,NDC,,,facility,both,1,ML,,368,257.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,68094-231-59,NDC,,,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,J7040,HCPCS,0264-1800-31,NDC,,,facility,both,1,ML,,577,403.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,67877-545-88,NDC,,,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0264-1800-36,NDC,,,facility,both,1,ML,,185,129.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J2003,HCPCS,0409-4279-16,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM PHOSPHATE DIBASIC 3 MMOLE/ML IV SOLP,35402,CDM,J3490,HCPCS,80830-1691-2,NDC,,,facility,both,1,ML,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,68094-494-59,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,68094-600-59,NDC,,,facility,both,1,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,35402,CDM,J3490,HCPCS,63323-495-27,NDC,,,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETIRIZINE 5 MG/5 ML ORAL SOLN,35402,CDM,J3490,HCPCS,68094-004-59,NDC,,,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,35402,CDM,J3490,HCPCS,63323-495-27,NDC,,,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,0093-2279-73,NDC,,,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,35402,CDM,J3490,HCPCS,68462-157-13,NDC,,,facility,both,1,EA,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYMETAZOLINE 0.05 % NASL SPRA,35402,CDM,J3490,HCPCS,41100-81127,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,35402,CDM,J7510,HCPCS,17856-0759-5,NDC,,,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,J7040,HCPCS,0264-1800-31,NDC,,,facility,both,1,ML,,865,605.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:200,000 INJ SOLN",35402,CDM,J2004,HCPCS,63323-487-01,NDC,,,facility,both,1,ML,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J2003,HCPCS,63323-492-27,NDC,,,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",35402,CDM,J3490,HCPCS,63323-185-07,NDC,,,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,J7040,HCPCS,0338-0049-04,NDC,,,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LET TOPICAL GEL 3 ML,35402,CDM,J3490,HCPCS,70092-1611-44,NDC,,,facility,both,1,ML,,108,75.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  120 MG RECT SUPP,35402,CDM,J3490,HCPCS,51672-2115-0,NDC,,,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,67877-548-88,NDC,,,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0338-0049-48,NDC,,,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  5 MG ORAL TAB,35402,CDM,J7512,HCPCS,60687-122-11,NDC,,,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOBRAMYCIN 0.3 % EYE DROPS,35402,CDM,J3490,HCPCS,62332-518-05,NDC,,,facility,both,1,ML,,167,116.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOMYCIN-BACITRACIN ZN-POLYMYXIN 3.5 MG-400 UN*,35402,CDM,J3490,HCPCS,45802-143-01,NDC,,,facility,both,1,GM,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,68180-150-01,NDC,,,facility,both,1,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJ SOLN,35402,CDM,J3490,HCPCS,63323-464-01,NDC,,,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,35402,CDM,J8540,HCPCS,0054-4184-25,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",35402,CDM,J2004,HCPCS,63323-482-27,NDC,,,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 20 GRAM/30 ML ORAL SOLN,35402,CDM,J3490,HCPCS,0121-1154-30,NDC,,,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG ORAL TAB,35402,CDM,J3490,HCPCS,0527-2395-32,NDC,,,facility,both,1,EA,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUORESCEIN 1 MG OPHT STRP,35402,CDM,J3490,HCPCS,17238-900-99,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TROPICAMIDE 0.5 % OPHT DROP,35402,CDM,J3490,HCPCS,24208-590-64,NDC,,,facility,both,1,ML,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MUPIROCIN 2 % TOP OINT,35402,CDM,J3490,HCPCS,68462-180-22,NDC,,,facility,both,1,GM,,210,147,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),35402,CDM,J3490,HCPCS,73013-2002-2,NDC,,,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,35402,CDM,J2250,HCPCS,0409-2305-16,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,35402,CDM,J7510,HCPCS,17856-0815-1,NDC,,,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETHYL CHLORIDE 100 % TOP SPRA,35402,CDM,J3490,HCPCS,386000104,NDC,,,facility,both,1,ML,,194,135.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J3490,HCPCS,0409-4279-16,NDC,,,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,0143-9889-15,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 100 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-6500-61,NDC,,,facility,both,2,EA,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,35402,CDM,J3490,HCPCS,63323-202-02,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 10 GRAM/15 ML ORAL SOLN,35402,CDM,J3490,HCPCS,66689-038-01,NDC,,,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4% TOP PATCH,35402,CDM,J3490,HCPCS,0536-1202-15,NDC,,,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENAZOPYRIDINE 100 MG ORAL TAB,35402,CDM,J3490,HCPCS,65162-681-10,NDC,,,facility,both,1,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE 21 MG/24 HR TD PT24,35402,CDM,J3490,HCPCS,43598-448-74,NDC,,,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MENING A,C,Y,W TT-N. MEN B(PF) 5-120 MCG/0.5 ML IM KIT (CAM USE ONLY)",35402,CDM,J3490,HCPCS,0069-0600-05,NDC,,,facility,both,1,EA,,637,445.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,35402,CDM,J3490,HCPCS,10135-123-50,NDC,,,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-6773-61,NDC,,,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE 10 MG ORAL TAB,35402,CDM,J3490,HCPCS,51079-888-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),35402,CDM,J3490,HCPCS,23155-166-31,NDC,,,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4% TOP PATCH,35402,CDM,J3490,HCPCS,70512-812-01,NDC,,,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,35402,CDM,J3490,HCPCS,57237-077-10,NDC,,,facility,both,2,EA,,218,152.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,0093-2279-73,NDC,,,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,60687-743-40,NDC,,,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,16714-294-02,NDC,,,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYOSCYAMINE SULFATE 0.125 MG ORAL TAB,35402,CDM,J3490,HCPCS,68220-112-10,NDC,,,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,0121-0657-05,NDC,,,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,35402,CDM,J2003,HCPCS,63323-495-04,NDC,,,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 40 % ORAL GEL,35402,CDM,J3490,HCPCS,574006915,NDC,,,facility,both,1,GM,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 100 MG ORAL TAB,35402,CDM,J3490,HCPCS,68084-728-11,NDC,,,facility,both,2,EA,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",35402,CDM,J3490,HCPCS,0409-4887-25,NDC,,,facility,both,1,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,35402,CDM,J3490,HCPCS,0406-0552-23,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J3490,HCPCS,0143-9595-01,NDC,,,facility,both,1,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML (1ML) INJ SOLN (FOR IRRIGATION ONLY),35402,CDM,J3490,HCPCS,54288-119-25,NDC,,,facility,both,1,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",35402,CDM,J3490,HCPCS,63323-482-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,35402,CDM,J3490,HCPCS,62756-240-60,NDC,,,facility,both,1,EA,,218,152.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACTERIOSTATIC SALINE 0.9 % INJ SOLN,35402,CDM,J3490,HCPCS,0409-1966-05,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,0121-1314-11,NDC,,,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALACYCLOVIR 500 MG ORAL TAB,35402,CDM,J3490,HCPCS,63739-077-10,NDC,,,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 0.4 MG SL SUBL,35402,CDM,J3490,HCPCS,58151-310-94,NDC,,,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,68180-150-01,NDC,,,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,35402,CDM,J3490,HCPCS,60687-742-11,NDC,,,facility,both,1,EA,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  650 MG RECT SUPP,35402,CDM,J3490,HCPCS,45802-730-00,NDC,,,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 1% 10MG/ML (1ML-UD) OR SYRINGE,35402,CDM,J2003,HCPCS,0409-4276-02,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LET TOPICAL GEL 3 ML,35402,CDM,J3490,HCPCS,70092-1611-44,NDC,,,facility,both,1,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNIT/G TOP PACK,35402,CDM,J3490,HCPCS,50090-0845-0,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,35402,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENAZOPYRIDINE 100 MG ORAL TAB,35402,CDM,J3490,HCPCS,69367-611-01,NDC,,,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 20 MG/2 ML IV SOLN,35402,CDM,J3490,HCPCS,67457-433-00,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJ SOLN",35402,CDM,J3490,HCPCS,63323-468-37,NDC,,,facility,both,1,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,35402,CDM,J3490,HCPCS,63323-486-26,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 8 MG ORAL TBDL,35402,CDM,Q0162,HCPCS,68462-158-40,NDC,,,facility,both,1,EA,,189,132.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,35402,CDM,J1885,HCPCS,68462-755-01,NDC,,,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,76297-001-32,NDC,,,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 10 MG ORAL CAP,35402,CDM,J3490,HCPCS,60687-369-11,NDC,,,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,35402,CDM,J2003,HCPCS,63323-202-02,NDC,,,facility,both,1,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,35402,CDM,J3490,HCPCS,0409-4282-01,NDC,,,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 5 MG/5 ML IV,35402,CDM,J3490,HCPCS,36000-033-10,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,70954-316-10,NDC,,,facility,both,1,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,0093-2279-73,NDC,,,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,0121-0914-05,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:200,000 INJ SOLN",35402,CDM,J2004,HCPCS,63323-487-01,NDC,,,facility,both,1,ML,,130,91,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),35402,CDM,J3490,HCPCS,6380710011,NDC,,,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0990-7983-61,NDC,,,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE  25 MG ORAL TAB,35402,CDM,J3490,HCPCS,63739-544-10,NDC,,,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 20 MG ORAL CAP,35402,CDM,J3490,HCPCS,0904-5785-61,NDC,,,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MENING A,C,Y,W TT-N. MEN B(PF) 5-120 MCG/0.5 ML IM KIT (CAM USE ONLY)",35402,CDM,J3490,HCPCS,0069-0332-01,NDC,,,facility,both,1,ML,,817,571.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIVAROXABAN 15 MG ORAL TAB,35402,CDM,J3490,HCPCS,50458-578-01,NDC,,,facility,both,1,EA,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/0.5 ML INHL NEBU,35402,CDM,J3490,HCPCS,0487-9901-30,NDC,,,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,68180-150-01,NDC,,,facility,both,1,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,35402,CDM,J3490,HCPCS,70756-645-86,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,35402,CDM,J3490,HCPCS,63323-202-02,NDC,,,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  5 MG ORAL TAB,35402,CDM,J3490,HCPCS,51079-453-01,NDC,,,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,42806-151-34,NDC,,,facility,both,1,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,68180-441-02,NDC,,,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 875 MG-125 MG TAB,35402,CDM,J3490,HCPCS,16714-297-02,NDC,,,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,35402,CDM,J8540,HCPCS,0904-7266-61,NDC,,,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNIT/G TOP PACK,35402,CDM,J3490,HCPCS,0904-7402-67,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,67877-548-88,NDC,,,facility,both,1,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,68094-494-59,NDC,,,facility,both,4,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J2003,HCPCS,55150-162-05,NDC,,,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG ORAL TAB,35402,CDM,J3490,HCPCS,62584-693-11,NDC,,,facility,both,1,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 0.4 MG SL SUBL,35402,CDM,J3490,HCPCS,59762-3304-3,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,35402,CDM,J2003,HCPCS,63323-485-26,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE HCL  2 % MM JELP,35402,CDM,J3490,HCPCS,76329-3015-5,NDC,,,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYMETAZOLINE 0.05 % NASL SPRA,35402,CDM,J3490,HCPCS,4110081123,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,42806-151-34,NDC,,,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYMETAZOLINE 0.05 % NASAL MERGE,35402,CDM,J3490,HCPCS,70677-1037-1,NDC,,,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE HCL  2 % MM JELP,35402,CDM,J3490,HCPCS,76329-3015-5,NDC,,,facility,both,1,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,16714-294-02,NDC,,,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,35402,CDM,J3490,HCPCS,1191706767,NDC,,,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 10 MG ORAL CAP,35402,CDM,J3490,HCPCS,60687-369-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,68094-231-59,NDC,,,facility,both,1,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,35402,CDM,J3490,HCPCS,0378-7732-93,NDC,,,facility,both,1,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J3490,HCPCS,63323-492-31,NDC,,,facility,both,1,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,35402,CDM,J2003,HCPCS,63323-486-05,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,24385-009-26,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,17271-701-05,NDC,,,facility,both,1,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"HYOSCYAMINE 0.125 MG TAB, RAPID DISSOLVE",35402,CDM,J3490,HCPCS,42192-338-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,35402,CDM,J3490,HCPCS,0378-7732-93,NDC,,,facility,both,1,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.2 MG ORAL TAB,35402,CDM,J3490,HCPCS,60687-124-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES-DOCUSATE SODIUM 8.6 MG-50 MG TAB,35402,CDM,J3490,HCPCS,0904-7440-61,NDC,,,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,35402,CDM,J3490,HCPCS,63323-201-03,NDC,,,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 20 MG/5 ML ORAL SOLN,35402,CDM,J3490,HCPCS,65862-306-12,NDC,,,facility,both,1,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 5 MG ORAL TAB,35402,CDM,J3490,HCPCS,60687-381-11,NDC,,,facility,both,1,EA,,343,240.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  120 MG RECT SUPP,35402,CDM,J3490,HCPCS,45802-732-30,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMETHICONE  80 MG ORAL CHEW,35402,CDM,J3490,HCPCS,77333-812-25,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),35402,CDM,J3490,HCPCS,51754-5001-1,NDC,,,facility,both,1,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:200,000 INJ SOLN",35402,CDM,J3490,HCPCS,63323-487-01,NDC,,,facility,both,1,ML,,130,91,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,68180-723-05,NDC,,,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 500 MG ORAL CAP,35402,CDM,J3490,HCPCS,16714-299-03,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J3490,HCPCS,63323-492-45,NDC,,,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MENING A,C,Y,W TT-N. MEN B(PF) 5-120 MCG/0.5 ML IM KIT",35402,CDM,J3490,HCPCS,0069-0600-01,NDC,,,facility,both,1,EA,,817,571.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  25 MG ORAL TAB,35402,CDM,J3490,HCPCS,50268-504-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,16714-294-02,NDC,,,facility,both,1,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,70954-316-10,NDC,,,facility,both,3,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 1 % NASAL SPRAY AEROSOL,35402,CDM,J3490,HCPCS,0225-0810-47,NDC,,,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,35402,CDM,J2003,HCPCS,72603-505-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,35402,CDM,J7510,HCPCS,17856-0815-1,NDC,,,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,35402,CDM,J3490,HCPCS,55150-164-09,NDC,,,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,35402,CDM,J1100,HCPCS,63323-165-01,NDC,,,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  2 MG ORAL TAB,35402,CDM,J3490,HCPCS,42858-301-01,NDC,,,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,35402,CDM,J3490,HCPCS,55150-164-02,NDC,,,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,35402,CDM,J3490,HCPCS,63739-434-02,NDC,,,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5 % (5 MG/ML) INJ SOLN,35402,CDM,J3490,HCPCS,55150-250-50,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-7350-61,NDC,,,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MECLIZINE 25 MG ORAL TAB,35402,CDM,J3490,HCPCS,60687-730-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,35402,CDM,J2003,HCPCS,63323-201-03,NDC,,,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,35402,CDM,J3490,HCPCS,63323-485-03,NDC,,,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LET TOPICAL GEL 3 ML,35402,CDM,J3490,HCPCS,62295-5013-3,NDC,,,facility,both,1,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 10 GRAM/15 ML ORAL SOLN,35402,CDM,J3490,HCPCS,0116-4005-30,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE  5 MG ORAL TAB,35402,CDM,J3490,HCPCS,0406-5755-23,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,67877-548-88,NDC,,,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SYRG,35402,CDM,J3490,HCPCS,6380710010,NDC,,,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  75 MCG ORAL TAB,35402,CDM,J3490,HCPCS,60687-475-11,NDC,,,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYMETAZOLINE 0.05 % NASL SPRA,35402,CDM,J3490,HCPCS,0904-7427-30,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,68094-231-59,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J3490,HCPCS,63323-492-09,NDC,,,facility,both,1,ML,,157,109.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,35402,CDM,J3490,HCPCS,65862-390-10,NDC,,,facility,both,1,EA,,219,153.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,35402,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0338-0049-41,NDC,,,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LATANOPROST 0.005 % OPHT DROP,35402,CDM,J3490,HCPCS,70069-421-01,NDC,,,facility,both,1,ML,,403,282.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,35402,CDM,J3490,HCPCS,68462-157-40,NDC,,,facility,both,1,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2% 20MG/ML (5ML-UD) OR SYRINGE,35402,CDM,J3490,HCPCS,63323-486-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,35402,CDM,J3490,HCPCS,60687-464-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG ORAL TAB,35402,CDM,J3490,HCPCS,61442-121-10,NDC,,,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),35402,CDM,J3490,HCPCS,70860-400-41,NDC,,,facility,both,1,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-6008-60,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERYTHROMYCIN 5 MG/G OPHT OINT,35402,CDM,J3490,HCPCS,17478-070-35,NDC,,,facility,both,1,GM,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PSEUDOEPHEDRINE 30 MG TAB,35402,CDM,J3490,HCPCS,45802-432-62,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0990-7983-61,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BISACODYL 10 MG RECT SUPP,35402,CDM,J3490,HCPCS,0574-7050-12,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,35402,CDM,J3490,HCPCS,71399-1025-3,NDC,,,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,67877-548-88,NDC,,,facility,both,1,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4 % TOP CREA,35402,CDM,J3490,HCPCS,0496-0882-06,NDC,,,facility,both,1,GM,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,0121-1022-05,NDC,,,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE 0.5 %-1:200,000 INJ SOLN",35402,CDM,J3490,HCPCS,0409-1755-50,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER SULFADIAZINE 1 % TOP CREA,35402,CDM,J3490,HCPCS,67877-124-05,NDC,,,facility,both,1,GM,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,35402,CDM,J7510,HCPCS,17856-0815-1,NDC,,,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),35402,CDM,J3490,HCPCS,55150-188-10,NDC,,,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),35402,CDM,J3490,HCPCS,51754-5001-1,NDC,,,facility,both,1,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",35402,CDM,J3490,HCPCS,63323-482-17,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,68094-330-59,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,76297-001-32,NDC,,,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERYTHROMYCIN 5 MG/G OPHT OINT,35402,CDM,J3490,HCPCS,24208-910-55,NDC,,,facility,both,1,GM,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % MUCOSAL SOLN (VISCOUS),35402,CDM,J3490,HCPCS,17856-0138-1,NDC,,,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG ORAL TAB,35402,CDM,J3490,HCPCS,29300-135-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,35402,CDM,J3490,HCPCS,60687-390-11,NDC,,,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,16714-293-03,NDC,,,facility,both,1,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,35402,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PSEUDOEPHEDRINE 30 MG TAB,35402,CDM,J3490,HCPCS,0904-5053-59,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACTERIOSTATIC SALINE 0.9 % INJ SOLN,35402,CDM,J3490,HCPCS,0409-1966-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,67877-548-88,NDC,,,facility,both,1,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,35402,CDM,J3490,HCPCS,59762-3060-1,NDC,,,facility,both,1,EA,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),35402,CDM,J3490,HCPCS,0409-4888-06,NDC,,,facility,both,1,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN V POTASSIUM 250 MG ORAL TAB,35402,CDM,J3490,HCPCS,16714-234-01,NDC,,,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,35402,CDM,J2250,HCPCS,0409-2305-16,NDC,,,facility,both,1,ML,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIPHTH,PERTUS(ACELL),TETANUS SYRG(BOOSTRIX) 2.5-8-5 LF-MCG-LF/0.5ML IM SYRG",35402,CDM,90715,HCPCS,58160-842-43,NDC,,,facility,both,1,ML,,247,172.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,42806-151-34,NDC,,,facility,both,1,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNITS/1 GRAM PACKET (MERGE RECORD),35402,CDM,J3490,HCPCS,0904-7023-67,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN V POTASSIUM 250 MG ORAL TAB,35402,CDM,J3490,HCPCS,57237-040-01,NDC,,,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4% TOP PATCH,35402,CDM,J3490,HCPCS,46581-830-01,NDC,,,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",35402,CDM,J3490,HCPCS,63323-482-01,NDC,,,facility,both,1,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ROTAVIRUS VACCINE LIVE, PENTA 2 ML ORAL SUSP",35402,CDM,90680,HCPCS,0006-4047-02,NDC,,,facility,both,1,ML,,427,298.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE 15 MG/5 ML ORAL SOLN,35402,CDM,J7510,HCPCS,50383-042-24,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 100 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-6500-61,NDC,,,facility,both,1,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LATANOPROST 0.005 % OPHT DROP,35402,CDM,J3490,HCPCS,59762-0333-2,NDC,,,facility,both,1,ML,,404,282.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0990-7984-23,NDC,,,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,68180-150-01,NDC,,,facility,both,1,ML,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,70954-316-10,NDC,,,facility,both,1,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ROTAVIRUS VACCINE LIVE, PENTA 2 ML ORAL SUSP",35402,CDM,90680,HCPCS,0006-4047-41,NDC,,,facility,both,1,ML,,427,298.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,J7030,HCPCS,0338-0049-04,NDC,,,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,35402,CDM,Q0177,HCPCS,0904-6617-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJ SOLN,35402,CDM,J3490,HCPCS,0409-1559-19,NDC,,,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,35402,CDM,J7512,HCPCS,10135-778-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR PHOSPHATE 75 MG ORAL CAP,35402,CDM,J3490,HCPCS,33342-258-66,NDC,,,facility,both,1,EA,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,35402,CDM,J3490,HCPCS,50580-458-11,NDC,,,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 1%/EPINEPHRINE 1:200K INJECTION (PF),35402,CDM,J3490,HCPCS,63739-468-05,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,68094-330-59,NDC,,,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,35402,CDM,J3490,HCPCS,11822-3615-30,NDC,,,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J2003,HCPCS,63323-492-37,NDC,,,facility,both,1,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE 100 MG ORAL TAB,35402,CDM,J3490,HCPCS,60687-487-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,35402,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,68094-494-59,NDC,,,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,68180-150-01,NDC,,,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,0121-0917-05,NDC,,,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 400 MG ORAL TAB,35402,CDM,J3490,HCPCS,67877-319-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  20 MEQ ORAL TBTQ,35402,CDM,J3490,HCPCS,49999-740-30,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,35402,CDM,J3490,HCPCS,0536-1327-06,NDC,,,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,35402,CDM,J3490,HCPCS,57237-077-10,NDC,,,facility,both,1,EA,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN   81 MG ORAL TBEC,35402,CDM,J3490,HCPCS,57896-981-01,NDC,,,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 25 MG CAP,35402,CDM,J3490,HCPCS,0904-7237-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,35402,CDM,J3490,HCPCS,55289-218-30,NDC,,,facility,both,1,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,68180-441-02,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,35402,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,67877-548-88,NDC,,,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 500 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-7126-61,NDC,,,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE HCL  2 % MM JELP,35402,CDM,J3490,HCPCS,76329-3015-5,NDC,,,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOPERAMIDE 2 MG ORAL CAP,35402,CDM,J3490,HCPCS,60687-229-11,NDC,,,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SYRG,35402,CDM,J3490,HCPCS,6425311130,NDC,,,facility,both,1,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 17 GRAM (100 %) ORAL PWPK,35402,CDM,J3490,HCPCS,1152372688,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.2 MG ORAL TAB,35402,CDM,J3490,HCPCS,62584-339-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SYRG,35402,CDM,J3490,HCPCS,6425311130,NDC,,,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLN,35402,CDM,J3490,HCPCS,0121-1971-00,NDC,,,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE PAMOATE  25 MG ORAL CAP,35402,CDM,Q0177,HCPCS,50268-398-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VERAPAMIL 120 MG ORAL TAB,35402,CDM,J3490,HCPCS,23155-486-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5 % (5 MG/ML) INJ SOLN,35402,CDM,J3490,HCPCS,63323-467-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,16714-294-02,NDC,,,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ROTAVIRUS VAC,LIVE ATT, 89-12 STRAIN G1P(8) 10EXP6 CCID50/ML ORAL SUSP",35402,CDM,90681,HCPCS,58160-851-01,NDC,,,facility,both,1,ML,,953,667.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),35402,CDM,J3490,HCPCS,0409-4888-06,NDC,,,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,35402,CDM,J8540,HCPCS,60687-718-11,NDC,,,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,16714-294-02,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) NEB SOLUTION,35402,CDM,J3490,HCPCS,0487-9501-01,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COLCHICINE 0.6 MG ORAL TAB,35402,CDM,J3490,HCPCS,59651-455-01,NDC,,,facility,both,1,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 10 MG/ML INJECTION,35402,CDM,J1100,HCPCS,0641-0367-21,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,35402,CDM,J7510,HCPCS,17856-0815-1,NDC,,,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"N.MENINGITIDIS B,LIPID FHBP RC 120 MCG/0.5 ML IM SYRG",35402,CDM,J3490,HCPCS,0005-0100-10,NDC,,,facility,both,1,ML,,896,627.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,35402,CDM,J3490,HCPCS,60687-742-11,NDC,,,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INHL NEBU,35402,CDM,J3490,HCPCS,0487-9301-33,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",35402,CDM,J3490,HCPCS,63323-185-07,NDC,,,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMIDE PEROXIDE 6.5 % OTIC DROP,35402,CDM,J3490,HCPCS,0904-6627-35,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  88 MCG ORAL TAB,35402,CDM,J3490,HCPCS,42292-038-20,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,35402,CDM,J7510,HCPCS,17856-0759-5,NDC,,,facility,both,1,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J2003,HCPCS,63323-492-04,NDC,,,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE  50 MCG/ACTUATION NASL SPSN,35402,CDM,J3490,HCPCS,60505-0829-1,NDC,,,facility,both,1,GM,,362,253.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN  325 MG ORAL TBEC,35402,CDM,J3490,HCPCS,57896-921-01,NDC,,,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,81033-002-10,NDC,,,facility,both,1,ML,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ROTAVIRUS VACCINE, LIVE, 89-12 10EXP6 CCID50 /1.5 ML ORAL SUSP",35402,CDM,90681,HCPCS,58160-740-02,NDC,,,facility,both,1,ML,,424,296.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 600 MG ORAL TP12,35402,CDM,J3490,HCPCS,0904-6718-39,NDC,,,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,16714-293-03,NDC,,,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ROTAVIRUS VACCINE LIVE, PENTA 2 ML ORAL SUSP",35402,CDM,90680,HCPCS,0006-4047-41,NDC,,,facility,both,1,ML,,145,101.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,0093-2279-73,NDC,,,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MECLIZINE 25 MG ORAL TAB,35402,CDM,J3490,HCPCS,63629-1266-2,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-6007-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,35402,CDM,J3490,HCPCS,0409-4277-16,NDC,,,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG ORAL TAB,35402,CDM,Q0169,HCPCS,50090-4811-0,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,35402,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,16714-294-02,NDC,,,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,35402,CDM,J3490,HCPCS,60687-742-11,NDC,,,facility,both,1,EA,,165,115.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,35402,CDM,J3490,HCPCS,0409-4276-01,NDC,,,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) IV SOLN",35402,CDM,J3490,HCPCS,43066-008-01,NDC,,,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) NEB SOLUTION,35402,CDM,J3490,HCPCS,0487-9501-03,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,67877-548-88,NDC,,,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL 2 MG/ML ORAL CONCENTRATE,35402,CDM,J3490,HCPCS,0121-0581-05,NDC,,,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,35402,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,1,ML,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,42806-151-34,NDC,,,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,68180-150-01,NDC,,,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"TRANEXAMIC ACID IN NACL,ISO-OS 1,000 MG/100 ML (10 MG/ML) IV PGBK",35402,CDM,J3490,HCPCS,51754-0108-1,NDC,,,facility,both,1,ML,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MECLIZINE 25 MG ORAL TAB,35402,CDM,J3490,HCPCS,50268-523-11,NDC,,,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 25 MG CAP,35402,CDM,J3490,HCPCS,71399-1027-1,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMIDE PEROXIDE 6.5 % OTIC DROP,35402,CDM,J3490,HCPCS,4203710478,NDC,,,facility,both,1,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,35402,CDM,J3490,HCPCS,65862-390-10,NDC,,,facility,both,1,EA,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,35402,CDM,J3490,HCPCS,63323-202-02,NDC,,,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL  3.125 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-7305-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRICHLOROACETIC ACID 80 % TOP SOLN,35402,CDM,J3490,HCPCS,5021700106,NDC,,,facility,both,1,ML,,329,230.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 875 MG-125 MG TAB,35402,CDM,J3490,HCPCS,60687-803-11,NDC,,,facility,both,1,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),35402,CDM,J3490,HCPCS,6380710005,NDC,,,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,42806-151-34,NDC,,,facility,both,1,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,35402,CDM,FAMNOCHARGE,HCPCS,16714-671-02,NDC,,,facility,both,1,ML,,234,163.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,35402,CDM,J8540,HCPCS,0054-8175-25,NDC,,,facility,both,1,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM BROMIDE 0.02 % INHL SOLN,35402,CDM,J3490,HCPCS,76204-100-01,NDC,,,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 1 GRAM ORAL PACK,35402,CDM,J3490,HCPCS,59762-3051-5,NDC,,,facility,both,1,EA,,143,100.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LET TOP SOLN 5ML (COMPOUNDED),35402,CDM,J3490,HCPCS,17478-045-32,NDC,,,facility,both,1,ML,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0990-7984-36,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SYRG,35402,CDM,J3490,HCPCS,8290306499,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROFURANTOIN (25% MACROCRYSTAL FORM) 100 MG CAP,35402,CDM,J3490,HCPCS,16714-439-01,NDC,,,facility,both,1,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG ORAL CAP,35402,CDM,J3490,HCPCS,0781-2020-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 10 MG/ML INJECTION,35402,CDM,J1100,HCPCS,63323-516-10,NDC,,,facility,both,1,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSP,35402,CDM,J3490,HCPCS,0574-0521-76,NDC,,,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4% TOP PATCH,35402,CDM,J3490,HCPCS,4116705840,NDC,,,facility,both,1,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,35402,CDM,Q0162,HCPCS,0904-7073-41,NDC,,,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,0093-2279-73,NDC,,,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  5 MG ORAL TAB,35402,CDM,FAMNOCHARGE,HCPCS,60687-122-11,NDC,,,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CONJUGATED ESTROGENS 0.625 MG/G VAGL CREA,35402,CDM,J3490,HCPCS,0046-0872-21,NDC,,,facility,both,1,GM,,1272,890.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,0121-1314-11,NDC,,,facility,both,1,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,35402,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,35402,CDM,J2003,HCPCS,63323-485-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,35402,CDM,J3490,HCPCS,0173-0682-24,NDC,,,facility,both,1,GM,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM POLYSTYRENE SULF-SORBTL 15-20 GRAM/60 ML ORAL SUSP,35402,CDM,J3490,HCPCS,46287-006-60,NDC,,,facility,both,1,ML,,152,106.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJ SOLN,35402,CDM,J3490,HCPCS,55150-167-10,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,35402,CDM,J7512,HCPCS,60219-1708-1,NDC,,,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,35402,CDM,J3490,HCPCS,0093-3426-01,NDC,,,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,16714-294-02,NDC,,,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,68094-503-59,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE 1 MG/2 ML INHL NBSP,35402,CDM,J3490,HCPCS,69097-321-86,NDC,,,facility,both,1,ML,,113,79.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG ORAL CAP,35402,CDM,J3490,HCPCS,60687-152-11,NDC,,,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 112 MCG ORAL TAB,35402,CDM,J3490,HCPCS,42292-039-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",35402,CDM,J3490,HCPCS,63323-185-05,NDC,,,facility,both,1,ML,,157,109.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJ SOLN,35402,CDM,J3490,HCPCS,0409-1559-10,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,0143-9889-15,NDC,,,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,35402,CDM,J8540,HCPCS,0054-8175-25,NDC,,,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,35402,CDM,J2003,HCPCS,0143-9577-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  5 MG ORAL TAB,35402,CDM,FAMNOCHARGE,HCPCS,60687-122-11,NDC,,,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,68180-441-02,NDC,,,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,35402,CDM,J8540,HCPCS,49999-059-06,NDC,,,facility,both,1,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,35402,CDM,J8540,HCPCS,49999-059-06,NDC,,,facility,both,1,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,35402,CDM,J2003,HCPCS,63323-486-41,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM-ALBUTEROL 0.5 MG-2.5 MG/3 ML NEB SOLUTION,35402,CDM,J3490,HCPCS,47335-756-48,NDC,,,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,68180-150-01,NDC,,,facility,both,1,ML,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",35402,CDM,J3490,HCPCS,0409-4887-10,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J3490,HCPCS,63323-492-57,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MUPIROCIN 2 % TOP OINT,35402,CDM,J3490,HCPCS,0093-1010-42,NDC,,,facility,both,1,GM,,363,254.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,35402,CDM,J7512,HCPCS,0054-0017-20,NDC,,,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,35402,CDM,J3490,HCPCS,70756-644-82,NDC,,,facility,both,1,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,35402,CDM,J3490,HCPCS,64679-961-01,NDC,,,facility,both,1,EA,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,68180-150-01,NDC,,,facility,both,1,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,35402,CDM,J2003,HCPCS,63323-486-17,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE HCL  2 % MM JELP,35402,CDM,J3490,HCPCS,76329-3012-5,NDC,,,facility,both,1,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",35402,CDM,J2004,HCPCS,63323-482-03,NDC,,,facility,both,1,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK,35402,CDM,J3490,HCPCS,12870-0001-1,NDC,,,facility,both,1,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 20 GRAM/30 ML ORAL SOLN,35402,CDM,J3490,HCPCS,0121-1154-30,NDC,,,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,35402,CDM,J3490,HCPCS,60687-742-11,NDC,,,facility,both,1,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER SULFADIAZINE 1 % TOP CREA,35402,CDM,J3490,HCPCS,67877-124-20,NDC,,,facility,both,1,GM,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,68094-494-59,NDC,,,facility,both,2,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,0093-2279-73,NDC,,,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG ORAL CAP,35402,CDM,J3490,HCPCS,0904-7336-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG ORAL TAB,35402,CDM,J3490,HCPCS,50111-788-67,NDC,,,facility,both,1,EA,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,16714-294-02,NDC,,,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,67877-548-88,NDC,,,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,35402,CDM,J3490,HCPCS,63323-485-27,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,35402,CDM,Q0162,HCPCS,51672-4091-3,NDC,,,facility,both,1,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,67877-548-88,NDC,,,facility,both,1,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,81033-002-20,NDC,,,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,35402,CDM,J3490,HCPCS,68084-354-11,NDC,,,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),35402,CDM,J3490,HCPCS,0409-4888-06,NDC,,,facility,both,1,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,68094-231-59,NDC,,,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYMETAZOLINE 0.05 % NASL SPRA,35402,CDM,J3490,HCPCS,1093941033,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCERIN (ADULT) RECTAL SUPPOSITORY,35402,CDM,J3490,HCPCS,57237-325-21,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEMOLIZUMAB-ILTO 30 MG SUBQ PNIJ,35402,CDM,J3490,HCPCS,0299-6220-15,NDC,,,facility,both,1,EA,,9752,6826.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,35402,CDM,J3490,HCPCS,47682-145-99,NDC,,,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,0121-0914-05,NDC,,,facility,both,1,ML,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETIRIZINE 5 MG/5 ML ORAL SOLN,35402,CDM,J3490,HCPCS,68094-004-59,NDC,,,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,35402,CDM,FAMNOCHARGE,HCPCS,0054-8175-25,NDC,,,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",35402,CDM,J3490,HCPCS,0409-4887-24,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0264-1800-31,NDC,,,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 500 MG ORAL CAP,35402,CDM,J3490,HCPCS,16714-299-03,NDC,,,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 400 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-5853-61,NDC,,,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  25 MG ORAL TAB,35402,CDM,J3490,HCPCS,63739-673-10,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,35402,CDM,J3490,HCPCS,0409-4277-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",35402,CDM,J2004,HCPCS,63323-482-03,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:200,000 INJ SOLN",35402,CDM,J2004,HCPCS,63323-487-07,NDC,,,facility,both,1,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  25 MG ORAL TAB,35402,CDM,J3490,HCPCS,50268-504-11,NDC,,,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,16714-294-02,NDC,,,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  88 MCG ORAL TAB,35402,CDM,J3490,HCPCS,42292-038-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-7912-59,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,35402,CDM,J7510,HCPCS,17856-0815-1,NDC,,,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-7193-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-0430-06,NDC,,,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYMETAZOLINE 0.05 % NASAL MERGE,35402,CDM,J3490,HCPCS,0904-6761-30,NDC,,,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 100 MG ORAL TAB,35402,CDM,J3490,HCPCS,50268-337-11,NDC,,,facility,both,1,EA,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG ORAL TAB,35402,CDM,J3490,HCPCS,10135-143-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
2-OCTYL CYANOACRYLATE TOPICAL LIQD,35402,CDM,J3490,HCPCS,8438912178,NDC,,,facility,both,1,EA,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,35402,CDM,J2003,HCPCS,63323-486-57,NDC,,,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK,35402,CDM,J3490,HCPCS,12870-0001-2,NDC,,,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 150 MG CAP,35402,CDM,J3490,HCPCS,0904-5959-61,NDC,,,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,J7040,HCPCS,0338-0049-02,NDC,,,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0990-7983-61,NDC,,,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALUMINUM CHLORIDE 20 % TOP SOLN,35402,CDM,J3490,HCPCS,0096-0707-37,NDC,,,facility,both,1,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,35402,CDM,J3490,HCPCS,68462-157-40,NDC,,,facility,both,1,EA,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,42806-151-34,NDC,,,facility,both,1,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,35402,CDM,J2003,HCPCS,0409-4276-16,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES-DOCUSATE SODIUM 8.6 MG-50 MG TAB,35402,CDM,J3490,HCPCS,63739-432-02,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,35402,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,35402,CDM,J7512,HCPCS,60687-134-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),35402,CDM,J3490,HCPCS,0409-4888-06,NDC,,,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",35402,CDM,J3490,HCPCS,0409-4887-24,NDC,,,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,35402,CDM,J3490,HCPCS,60687-742-11,NDC,,,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG ORAL CAP,35402,CDM,J3490,HCPCS,16714-298-01,NDC,,,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",35402,CDM,J2004,HCPCS,63323-482-03,NDC,,,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOBRAMYCIN 0.3 % EYE OINTMENT,35402,CDM,J3490,HCPCS,0078-0813-01,NDC,,,facility,both,1,GM,,902,631.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",35402,CDM,J3490,HCPCS,63323-185-10,NDC,,,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,0093-2279-73,NDC,,,facility,both,1,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,35402,CDM,J3490,HCPCS,60687-591-11,NDC,,,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,60687-429-45,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,J7040,HCPCS,0264-1800-31,NDC,,,facility,both,1,ML,,595,416.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE HCL  2 % MM JELP,35402,CDM,J3490,HCPCS,76329-3011-5,NDC,,,facility,both,1,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,J3490,HCPCS,0338-0049-48,NDC,,,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J3490,HCPCS,55150-161-02,NDC,,,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,35402,CDM,J3490,HCPCS,63323-201-02,NDC,,,facility,both,1,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,35402,CDM,J3490,HCPCS,0409-4276-16,NDC,,,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",35402,CDM,J2004,HCPCS,63323-482-03,NDC,,,facility,both,1,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,0093-2279-73,NDC,,,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,0093-4155-80,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR PHOSPHATE 30 MG ORAL CAP,35402,CDM,J3490,HCPCS,64380-797-01,NDC,,,facility,both,1,EA,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  2 MG ORAL TAB,35402,CDM,J3490,HCPCS,0406-3243-01,NDC,,,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,35402,CDM,J7510,HCPCS,17856-0759-5,NDC,,,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0338-0049-02,NDC,,,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,35402,CDM,J7512,HCPCS,60687-145-11,NDC,,,facility,both,1,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN   80 MG ORAL CHEW,35402,CDM,J3490,HCPCS,0904-5791-46,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG IV SOLR,35402,CDM,J3490,HCPCS,0008-0923-51,NDC,,,facility,both,1,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,68094-231-59,NDC,,,facility,both,1,ML,,154,107.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,16714-294-02,NDC,,,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SYRG,35402,CDM,J3490,HCPCS,8290306546,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,35402,CDM,J3490,HCPCS,69339-152-01,NDC,,,facility,both,1,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,42806-151-34,NDC,,,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,0121-1314-11,NDC,,,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 500 MG ORAL TAB,35402,CDM,J3490,HCPCS,60687-550-11,NDC,,,facility,both,1,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VERAPAMIL 120 MG ORAL TAB,35402,CDM,J3490,HCPCS,42291-855-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,35402,CDM,J2003,HCPCS,70756-645-86,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,68180-150-01,NDC,,,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 5 MG/ML IV SOLN,35402,CDM,J1921,HCPCS,0143-9622-01,NDC,,,facility,both,1,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",35402,CDM,J3490,HCPCS,63323-482-17,NDC,,,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  25 MG ORAL TAB,35402,CDM,J3490,HCPCS,51079-075-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,42806-151-34,NDC,,,facility,both,1,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER SULFADIAZINE 1 % TOP CREA,35402,CDM,J3490,HCPCS,43598-210-55,NDC,,,facility,both,1,GM,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,0143-9853-16,NDC,,,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG ORAL TAB,35402,CDM,FAMNOCHARGE,HCPCS,0904-7304-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG ORAL TAB,35402,CDM,J3490,HCPCS,69315-904-01,NDC,,,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J2003,HCPCS,63323-492-09,NDC,,,facility,both,1,ML,,157,109.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,70954-316-10,NDC,,,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,70954-316-10,NDC,,,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,0121-1314-11,NDC,,,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-7193-06,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 5 MG ORAL TAB,35402,CDM,J3490,HCPCS,0003-0894-31,NDC,,,facility,both,1,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,42806-151-34,NDC,,,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,68094-330-59,NDC,,,facility,both,1,ML,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,68094-231-59,NDC,,,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,35402,CDM,J2003,HCPCS,0409-4277-02,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BALANCED SALT IRRIG SOLN COMB2 INTRAOCULAR,35402,CDM,J3490,HCPCS,0065-0795-15,NDC,,,facility,both,1,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG ORAL CAP,35402,CDM,J3490,HCPCS,16714-298-01,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,35402,CDM,FAMNOCHARGE,HCPCS,60687-145-11,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0338-0049-41,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4% TOP PATCH,35402,CDM,J3490,HCPCS,0121-0970-01,NDC,,,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,35402,CDM,J3490,HCPCS,63323-495-04,NDC,,,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J2003,HCPCS,63323-492-07,NDC,,,facility,both,1,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,35402,CDM,J2003,HCPCS,63323-201-10,NDC,,,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/0.5 ML INHL NEBU,35402,CDM,J3490,HCPCS,0487-9901-30,NDC,,,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOMYCIN-BACITRACN ZN-POLYMYXIN 3.5 MG-400 U*,35402,CDM,J3490,HCPCS,45802-143-00,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,35402,CDM,Q0162,HCPCS,60687-252-40,NDC,,,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG ORAL CAP,35402,CDM,J3490,HCPCS,0093-3145-01,NDC,,,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG ORAL TAB,35402,CDM,J3490,HCPCS,10135-183-05,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM-ALBUTEROL 0.5 MG-2.5 MG/3 ML NEB SOLUTION,35402,CDM,J3490,HCPCS,0487-0201-03,NDC,,,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,76297-001-32,NDC,,,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0990-7984-23,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,35402,CDM,J1100,HCPCS,63323-165-05,NDC,,,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,35402,CDM,J8540,HCPCS,0054-4184-25,NDC,,,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 500 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-7057-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MENING A,C,Y,W TT-N. MEN B(PF) 5-120 MCG/0.5 ML IM KIT (CAM USE ONLY)",35402,CDM,J3490,HCPCS,0069-0600-05,NDC,,,facility,both,1,EA,,637,445.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,70954-316-10,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4 % TOP CREA,35402,CDM,J3490,HCPCS,61825-701-15,NDC,,,facility,both,1,GM,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,0093-2279-73,NDC,,,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,16714-293-03,NDC,,,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J3490,HCPCS,63323-492-08,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,35402,CDM,J2250,HCPCS,0409-2305-02,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES  8.6 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-6522-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",35402,CDM,J3490,HCPCS,63323-185-07,NDC,,,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,17271-701-05,NDC,,,facility,both,1,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,35402,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,35402,CDM,J7510,HCPCS,17856-0759-5,NDC,,,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,68094-494-59,NDC,,,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0338-0049-48,NDC,,,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,11673-130-26,NDC,,,facility,both,1,ML,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,35402,CDM,J7512,HCPCS,60219-1708-1,NDC,,,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,35402,CDM,Q0162,HCPCS,17856-0691-5,NDC,,,facility,both,1,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,35402,CDM,Q0162,HCPCS,60687-252-40,NDC,,,facility,both,1,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BISACODYL  5 MG ORAL TBEC,35402,CDM,J3490,HCPCS,0904-6407-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 60 MG ORAL CPDR,35402,CDM,J3490,HCPCS,68180-296-06,NDC,,,facility,both,1,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,35402,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERYTHROMYCIN 5 MG/G OPHT OINT,35402,CDM,J3490,HCPCS,48102-057-11,NDC,,,facility,both,1,GM,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0264-1800-36,NDC,,,facility,both,1,ML,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE HCL  2 % MM JELP,35402,CDM,J3490,HCPCS,76329-3011-5,NDC,,,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 800 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-5855-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 100 MG/5 ML ORAL LIQD,35402,CDM,J3490,HCPCS,0121-1488-10,NDC,,,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 500 MG ORAL TAB,35402,CDM,J3490,HCPCS,72162-2425-5,NDC,,,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 10 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-6475-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 15 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-6519-61,NDC,,,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG ORAL TAB,35402,CDM,J3490,HCPCS,9629511419,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALUM-MAG HYDROXIDE-SIMETH 400 MG-400 MG-40 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,0904-7326-62,NDC,,,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG ORAL TBEC,35402,CDM,J3490,HCPCS,63739-564-10,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,0121-1314-11,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,67877-548-88,NDC,,,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  2.5 MG ORAL TAB,35402,CDM,J3490,HCPCS,60505-3110-0,NDC,,,facility,both,1,EA,,220,154,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 20 MG ORAL TAB,35402,CDM,J3490,HCPCS,51079-072-20,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,J7040,HCPCS,0264-1800-31,NDC,,,facility,both,1,ML,,433,303.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJ SOLN,35402,CDM,J3490,HCPCS,63323-464-17,NDC,,,facility,both,1,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4% TOP PATCH,35402,CDM,J3490,HCPCS,46581-830-01,NDC,,,facility,both,1,EA,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM BROMIDE 0.02 % INHL SOLN,35402,CDM,J3490,HCPCS,0378-7970-62,NDC,,,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG ORAL CAP,35402,CDM,J3490,HCPCS,0093-3145-01,NDC,,,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MECLIZINE 12.5 MG ORAL TAB,35402,CDM,J3490,HCPCS,65162-441-10,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,42806-151-34,NDC,,,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK,35402,CDM,J3490,HCPCS,12870-0001-1,NDC,,,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE  7 MG/24 HR TD PT24,35402,CDM,J3490,HCPCS,43598-446-71,NDC,,,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM CITRATE ORAL SOLN,35402,CDM,J3490,HCPCS,1093911233,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,35402,CDM,J3490,HCPCS,0409-4276-16,NDC,,,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,35402,CDM,J2003,HCPCS,0409-4276-17,NDC,,,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALUM-MAG HYDROXIDE-SIMETH 400 MG-400 MG-40 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,0904-7326-62,NDC,,,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",35402,CDM,J3490,HCPCS,63323-185-07,NDC,,,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCERIN (ADULT) RECTAL SUPPOSITORY,35402,CDM,J3490,HCPCS,0132-0079-24,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,0093-2279-73,NDC,,,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 2 %-1:200,000 INJ SOLN",35402,CDM,J3490,HCPCS,63323-489-03,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,16714-294-02,NDC,,,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 10 MG ORAL TAB,35402,CDM,J3490,HCPCS,68084-617-11,NDC,,,facility,both,1,EA,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM BROMIDE 0.02 % INHL SOLN,35402,CDM,J3490,HCPCS,60687-394-79,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PSEUDOEPHEDRINE 30 MG TAB,35402,CDM,J3490,HCPCS,0904-6990-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,35402,CDM,J7512,HCPCS,60687-145-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J2003,HCPCS,63323-492-04,NDC,,,facility,both,1,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE  50 MG ORAL TAB,35402,CDM,j3490,HCPCS,0904-6868-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,35402,CDM,J7512,HCPCS,60760-002-21,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,0121-0914-05,NDC,,,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE HCL  0.5 % NASL SPRY,35402,CDM,J3490,HCPCS,0225-0805-47,NDC,,,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,0121-1314-11,NDC,,,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,68094-600-59,NDC,,,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,0093-2279-73,NDC,,,facility,both,1,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,35402,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G POTASSIUM  5000000 UNIT INJ SOLR,35402,CDM,J2540,HCPCS,0781-6135-94,NDC,,,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,35402,CDM,J3490,HCPCS,63323-486-27,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG ORAL CAP,35402,CDM,J3490,HCPCS,0904-6665-61,NDC,,,facility,both,1,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 100 MG ORAL TAB,35402,CDM,J3490,HCPCS,51079-205-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,68094-494-59,NDC,,,facility,both,1,ML,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,35402,CDM,J8540,HCPCS,60687-718-11,NDC,,,facility,both,1,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPARACAINE 0.5 % OPHT DROP,35402,CDM,J3490,HCPCS,24208-730-06,NDC,,,facility,both,1,ML,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",35402,CDM,J3490,HCPCS,63323-482-01,NDC,,,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 10 MG ORAL TAB,35402,CDM,J3490,HCPCS,68084-617-11,NDC,,,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 25 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-7308-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,35402,CDM,J3490,HCPCS,0121-0865-05,NDC,,,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 300 MG ORAL CAP,35402,CDM,J3490,HCPCS,60687-699-11,NDC,,,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),35402,CDM,J3490,HCPCS,51754-5011-1,NDC,,,facility,both,1,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 20 GRAM/30 ML ORAL SOLN,35402,CDM,J3490,HCPCS,0121-1154-30,NDC,,,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM BROMIDE 0.02 % INHL SOLN,35402,CDM,J3490,HCPCS,0487-9801-01,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYMETAZOLINE 0.05 % NASAL MERGE,35402,CDM,J3490,HCPCS,70677-1037-1,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL  4 MG ORAL TAB,35402,CDM,Q0162,HCPCS,55111-153-30,NDC,,,facility,both,1,EA,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),35402,CDM,J3490,HCPCS,0409-4888-01,NDC,,,facility,both,1,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUORESCEIN 1 MG OPHT STRP,35402,CDM,J3490,HCPCS,17238-900-30,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,35402,CDM,FAMNOCHARGE,HCPCS,60687-145-11,NDC,,,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMIDE PEROXIDE 6.5 % OTIC DROP,35402,CDM,J3490,HCPCS,8770143151,NDC,,,facility,both,1,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 0.75 MG ORAL TAB,35402,CDM,J8540,HCPCS,0054-4180-25,NDC,,,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MONTELUKAST 10 MG ORAL TAB,35402,CDM,J3490,HCPCS,68084-875-11,NDC,,,facility,both,1,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 112 MCG ORAL TAB,35402,CDM,J3490,HCPCS,60687-508-11,NDC,,,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNITS/1 GRAM PACKET (MERGE RECORD),35402,CDM,J3490,HCPCS,45802-060-00,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,35402,CDM,J3490,HCPCS,0409-4277-16,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,68094-503-59,NDC,,,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,35402,CDM,J3490,HCPCS,63323-495-09,NDC,,,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",35402,CDM,J3490,HCPCS,63323-482-03,NDC,,,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,35402,CDM,J7512,HCPCS,59746-173-06,NDC,,,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK,35402,CDM,J3490,HCPCS,12870-0001-1,NDC,,,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,35402,CDM,J7510,HCPCS,17856-0815-1,NDC,,,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COLCHICINE 0.6 MG ORAL TAB,35402,CDM,J3490,HCPCS,60687-727-11,NDC,,,facility,both,1,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR PHOSPHATE 30 MG ORAL CAP,35402,CDM,J3490,HCPCS,72205-042-11,NDC,,,facility,both,1,EA,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 600 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-5854-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 1.25 MG/3 ML INHL NEBU,35402,CDM,J3490,HCPCS,0487-9904-01,NDC,,,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,35402,CDM,J7510,HCPCS,17856-0815-1,NDC,,,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0264-1800-36,NDC,,,facility,both,1,ML,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE  25 MG ORAL TAB,35402,CDM,J3490,HCPCS,63739-544-10,NDC,,,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERYTHROMYCIN 5 MG/G OPHT OINT,35402,CDM,J3490,HCPCS,24208-910-19,NDC,,,facility,both,1,GM,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,35402,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK,35402,CDM,J3490,HCPCS,12870-0001-1,NDC,,,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,35402,CDM,J2003,HCPCS,55150-165-05,NDC,,,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,68094-231-59,NDC,,,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,35402,CDM,J2003,HCPCS,63323-486-02,NDC,,,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EMTRICITABINE-TENOFOVIR 200 MG-300 MG TAB,35402,CDM,J0750,HCPCS,65862-354-30,NDC,,,facility,both,1,EA,,297,207.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,42806-151-34,NDC,,,facility,both,1,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 875 MG-125 MG TAB,35402,CDM,J3490,HCPCS,60687-803-11,NDC,,,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,35402,CDM,J3490,HCPCS,68084-354-11,NDC,,,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,0121-2044-10,NDC,,,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,35402,CDM,J7510,HCPCS,17856-0815-1,NDC,,,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 500 MG-125 MG TAB,35402,CDM,J3490,HCPCS,0781-1831-01,NDC,,,facility,both,1,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J2003,HCPCS,0143-9595-01,NDC,,,facility,both,1,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J2003,HCPCS,0409-4713-32,NDC,,,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV SOLN,35402,CDM,J3490,HCPCS,0409-6625-22,NDC,,,facility,both,1,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MISOPROSTOL 200 MCG ORAL TAB,35402,CDM,S0191,HCPCS,55289-698-02,NDC,,,facility,both,1,EA,,101,70.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENAZOPYRIDINE 100 MG ORAL TAB,35402,CDM,J3490,HCPCS,75826-114-10,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,0121-1022-05,NDC,,,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,35402,CDM,J2003,HCPCS,0409-4277-17,NDC,,,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL  4 MG ORAL TAB,35402,CDM,Q0162,HCPCS,68084-220-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  20 MEQ ORAL PACK,35402,CDM,J3490,HCPCS,43386-194-90,NDC,,,facility,both,1,EA,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0990-7983-02,NDC,,,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML SYRUP,35402,CDM,J3490,HCPCS,69339-150-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,35402,CDM,FAMNOCHARGE,HCPCS,17856-0759-5,NDC,,,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 100 MG ORAL TAB,35402,CDM,J3490,HCPCS,60687-439-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL  6.25 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-7306-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,67877-548-88,NDC,,,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J3490,HCPCS,0143-9595-01,NDC,,,facility,both,1,ML,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,35402,CDM,FAMNOCHARGE,HCPCS,16714-671-02,NDC,,,facility,both,1,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:200,000 INJ SOLN",35402,CDM,J2004,HCPCS,63323-487-01,NDC,,,facility,both,1,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,68180-150-01,NDC,,,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOBENZAPRINE 10 MG ORAL TAB,35402,CDM,J3490,HCPCS,69097-846-07,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG ORAL TBEC,35402,CDM,J3490,HCPCS,0904-6474-61,NDC,,,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 160 MG-800 MG TAB,35402,CDM,J3490,HCPCS,0904-2725-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),35402,CDM,J3490,HCPCS,0409-4888-06,NDC,,,facility,both,1,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 17 GRAM (100 %) ORAL PWPK,35402,CDM,J3490,HCPCS,11523-7234-1,NDC,,,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM-ALBUTEROL 0.5 MG-2.5 MG/3 ML NEB SOLUTION,35402,CDM,J3490,HCPCS,0487-0201-01,NDC,,,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNIT/G TOP PACK,35402,CDM,J3490,HCPCS,72162-2280-2,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,35402,CDM,J2003,HCPCS,63323-202-02,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  5 MG ORAL TBDL,35402,CDM,J3490,HCPCS,55111-262-79,NDC,,,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,0093-2279-73,NDC,,,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,68094-503-59,NDC,,,facility,both,1,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J2003,HCPCS,0409-4279-16,NDC,,,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLN,35402,CDM,J3490,HCPCS,0121-1971-21,NDC,,,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 8 MG ORAL TBDL,35402,CDM,Q0162,HCPCS,68462-158-11,NDC,,,facility,both,1,EA,,189,132.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,68180-150-01,NDC,,,facility,both,1,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,35402,CDM,J1100,HCPCS,25021-053-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 500 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-7243-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0338-0049-31,NDC,,,facility,both,1,ML,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENAZOPYRIDINE 100 MG ORAL TAB,35402,CDM,J3490,HCPCS,75826-114-10,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,35402,CDM,Q0177,HCPCS,0093-5061-01,NDC,,,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,68180-441-02,NDC,,,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"HYOSCYAMINE 0.125 MG TAB, RAPID DISSOLVE",35402,CDM,J3490,HCPCS,63629-1030-1,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,67877-548-88,NDC,,,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AXATILIMAB-CSFR 50 MG/ML IV SOLN,35402,CDM,J3490,HCPCS,50881-034-12,NDC,,,facility,both,1,ML,,25286,17700.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG ORAL CAP,35402,CDM,J3490,HCPCS,16714-298-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,35402,CDM,J7512,HCPCS,60219-1708-1,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJ SOLN,35402,CDM,J3490,HCPCS,0409-1159-19,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 100 MG ORAL TAB,35402,CDM,J3490,HCPCS,60687-253-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES-DOCUSATE SODIUM 8.6 MG-50 MG TAB,35402,CDM,J3490,HCPCS,60687-622-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MISOPROSTOL 800 MCG (4 X 200 MCG TAB) PACKAGE,35402,CDM,S0191,HCPCS,43393-023-04,NDC,,,facility,both,1,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-7912-59,NDC,,,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J2003,HCPCS,63323-492-04,NDC,,,facility,both,1,ML,,126,88.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,35402,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J3490,HCPCS,63323-492-09,NDC,,,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,35402,CDM,J1100,HCPCS,63323-165-05,NDC,,,facility,both,1,ML,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 10 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-6426-61,NDC,,,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0990-7983-61,NDC,,,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE 15 MG ORAL TAB,35402,CDM,J3490,HCPCS,51079-960-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJ SOLN",35402,CDM,J3490,HCPCS,0409-1746-10,NDC,,,facility,both,1,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),35402,CDM,J3490,HCPCS,63037-136-25,NDC,,,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,J7040,HCPCS,0264-1800-36,NDC,,,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,67877-548-88,NDC,,,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDO-EPI WITH 8.4% SOD BICARB 1 %- 1:100,000 (3 ML) INJ SYRG",35402,CDM,J3490,HCPCS,70092-1691-44,NDC,,,facility,both,1,ML,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJ SOLN,35402,CDM,J3490,HCPCS,0409-1159-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,35402,CDM,J2003,HCPCS,63323-485-27,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,0143-9889-15,NDC,,,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) NEB SOLUTION,35402,CDM,J3490,HCPCS,0487-9501-01,NDC,,,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJ SOLN,35402,CDM,J3490,HCPCS,0409-1559-10,NDC,,,facility,both,1,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,42806-151-34,NDC,,,facility,both,1,ML,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J3490,HCPCS,0409-4279-16,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,35402,CDM,J3490,HCPCS,0409-4276-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERYTHROMYCIN 5 MG/G OPHT OINT,35402,CDM,J3490,HCPCS,0574-4024-50,NDC,,,facility,both,1,GM,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,35402,CDM,J8540,HCPCS,0054-8175-25,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,35402,CDM,J3490,HCPCS,63323-201-01,NDC,,,facility,both,1,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,35402,CDM,J3490,HCPCS,42858-001-10,NDC,,,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,67877-548-88,NDC,,,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,35402,CDM,J3490,HCPCS,63323-495-09,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN  325 MG ORAL TAB,35402,CDM,J3490,HCPCS,66553-001-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,70954-316-10,NDC,,,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,35402,CDM,J3490,HCPCS,63323-495-09,NDC,,,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,35402,CDM,J2405,HCPCS,60505-6130-0,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 100 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-6500-61,NDC,,,facility,both,1,EA,,190,133,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK,35402,CDM,J3490,HCPCS,12870-0001-2,NDC,,,facility,both,1,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICLOFENAC 1 % TOPICAL GEL,35402,CDM,J3490,HCPCS,0067-8152-02,NDC,,,facility,both,1,GM,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,35402,CDM,J7512,HCPCS,0904-7127-61,NDC,,,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 10 MG ORAL CAP,35402,CDM,J3490,HCPCS,60687-369-11,NDC,,,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",35402,CDM,J3490,HCPCS,63323-482-57,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,35402,CDM,J7510,HCPCS,17856-0815-1,NDC,,,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE 21 MG/24 HR TD PT24,35402,CDM,J3490,HCPCS,43598-448-71,NDC,,,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,68180-441-02,NDC,,,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,16714-294-02,NDC,,,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,16714-294-02,NDC,,,facility,both,1,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUORESCEIN 1 MG OPHT STRP,35402,CDM,J3490,HCPCS,8385110001,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,35402,CDM,FAMNOCHARGE,HCPCS,0054-8175-25,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,67877-548-88,NDC,,,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR PHOSPHATE 30 MG ORAL CAP,35402,CDM,J3490,HCPCS,0527-4591-13,NDC,,,facility,both,1,EA,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,35402,CDM,J7510,HCPCS,17856-0815-1,NDC,,,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 500 MG ORAL TAB,35402,CDM,J3490,HCPCS,60687-559-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,68180-441-02,NDC,,,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 400 MG ORAL TAB,35402,CDM,J3490,HCPCS,60687-446-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE HCL  2 % MM JELP,35402,CDM,J3490,HCPCS,25021-673-77,NDC,,,facility,both,1,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,35402,CDM,J3490,HCPCS,63323-486-17,NDC,,,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL  50 MCG/HR TD PT72,35402,CDM,J3490,HCPCS,47781-426-11,NDC,,,facility,both,1,EA,,191,133.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,35402,CDM,J2003,HCPCS,0409-2066-05,NDC,,,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,35402,CDM,J3490,HCPCS,60687-742-11,NDC,,,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM  5 MG ORAL TAB,35402,CDM,J3490,HCPCS,51079-285-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),35402,CDM,J3490,HCPCS,23155-166-31,NDC,,,facility,both,1,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,35402,CDM,J1100,HCPCS,67457-423-00,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACTERIOSTATIC SALINE 0.9 % INJ SOLN,35402,CDM,J3490,HCPCS,63323-259-30,NDC,,,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,35402,CDM,J7510,HCPCS,17856-0815-1,NDC,,,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,35402,CDM,J3490,HCPCS,60687-653-11,NDC,,,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 100 MG TAB,35402,CDM,J3490,HCPCS,62584-267-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,35402,CDM,J3490,HCPCS,0409-4276-16,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) NEB SOLUTION,35402,CDM,J3490,HCPCS,0487-9501-01,NDC,,,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,68180-441-02,NDC,,,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,0143-9853-16,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TETRACAINE 0.5 % EYE DROPS,35402,CDM,J3490,HCPCS,49999-268-15,NDC,,,facility,both,1,ML,,159,111.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,35402,CDM,J3490,HCPCS,8770179215,NDC,,,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,16714-294-02,NDC,,,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE  75 MG IMPL PLLT,35402,CDM,J3490,HCPCS,66887-004-01,NDC,,,facility,both,1,EA,,29210,20447,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,35402,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,70954-316-10,NDC,,,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMIDE PEROXIDE 6.5 % OTIC DROP,35402,CDM,J3490,HCPCS,7811273623,NDC,,,facility,both,1,ML,,181,126.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-6052-61,NDC,,,facility,both,1,EA,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,35402,CDM,J3490,HCPCS,63323-201-02,NDC,,,facility,both,1,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RALTEGRAVIR 400 MG ORAL TAB,35402,CDM,J3490,HCPCS,0006-0227-61,NDC,,,facility,both,1,EA,,204,142.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,68180-441-02,NDC,,,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,35402,CDM,J7510,HCPCS,17856-0815-1,NDC,,,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 5 MG ORAL TAB,35402,CDM,J3490,HCPCS,0003-0894-31,NDC,,,facility,both,1,EA,,119,83.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG ORAL CAP,35402,CDM,J3490,HCPCS,60687-580-11,NDC,,,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,35402,CDM,J7510,HCPCS,17856-0815-1,NDC,,,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/0.5 ML INHL NEBU,35402,CDM,J3490,HCPCS,0487-9901-30,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4% TOP PATCH,35402,CDM,J3490,HCPCS,0536-1202-15,NDC,,,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,0093-2279-73,NDC,,,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,J3490,HCPCS,0338-0049-02,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,35402,CDM,J3490,HCPCS,17856-0815-1,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,35402,CDM,Q0162,HCPCS,60687-252-40,NDC,,,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,35402,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALACYCLOVIR 500 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-6565-61,NDC,,,facility,both,1,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE  5 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-6370-61,NDC,,,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,76297-001-32,NDC,,,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,17271-701-05,NDC,,,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 5 MG ORAL TAB,35402,CDM,J3490,HCPCS,60687-381-11,NDC,,,facility,both,1,EA,,583,408.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,35402,CDM,J3490,HCPCS,63323-486-05,NDC,,,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALUMINUM CHLORIDE 20 % TOP SOLN,35402,CDM,J3490,HCPCS,0096-0707-35,NDC,,,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TAB,35402,CDM,J3490,HCPCS,0406-0512-23,NDC,,,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM-ALBUTEROL 0.5 MG-2.5 MG/3 ML NEB SOLUTION,35402,CDM,J3490,HCPCS,0378-9671-93,NDC,,,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 30 MG ORAL CPDR,35402,CDM,J3490,HCPCS,60687-734-11,NDC,,,facility,both,1,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMIDE PEROXIDE 6.5 % OTIC DROP,35402,CDM,J3490,HCPCS,0904-6627-35,NDC,,,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJ SOLN",35402,CDM,J3490,HCPCS,63323-468-01,NDC,,,facility,both,1,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % MUCOSAL SOLN (VISCOUS),35402,CDM,J3490,HCPCS,0121-4950-15,NDC,,,facility,both,1,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,35402,CDM,Q0162,HCPCS,0904-7073-41,NDC,,,facility,both,1,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TETRACAINE 0.5 % EYE DROPS,35402,CDM,J3490,HCPCS,68682-920-05,NDC,,,facility,both,1,ML,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMIDE PEROXIDE 6.5 % OTIC DROP,35402,CDM,J3490,HCPCS,70677-1153-1,NDC,,,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG ORAL TAB,35402,CDM,J3490,HCPCS,55289-673-17,NDC,,,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSP,35402,CDM,J3490,HCPCS,68094-061-59,NDC,,,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,35402,CDM,J7510,HCPCS,17856-0815-1,NDC,,,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,35402,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,1,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,35402,CDM,J3490,HCPCS,0904-6794-30,NDC,,,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG ORAL TAB,35402,CDM,FAMNOCHARGE,HCPCS,68084-155-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 150 MG CAP,35402,CDM,J3490,HCPCS,68084-243-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE  5 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-6370-61,NDC,,,facility,both,1,EA,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,81033-002-10,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,68094-330-59,NDC,,,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,68180-441-02,NDC,,,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG ORAL CAP,35402,CDM,J3490,HCPCS,0093-3145-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEGINTERFERON ALFA-2A 180 MCG/ML SUBQ SOLN,35402,CDM,J3490,HCPCS,0004-0350-09,NDC,,,facility,both,1,ML,,2820,1974,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,35402,CDM,J2003,HCPCS,63323-495-04,NDC,,,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 500 MG ORAL TAB,35402,CDM,J3490,HCPCS,60687-550-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 150 MG CAP,35402,CDM,J3490,HCPCS,0904-5959-61,NDC,,,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,0093-2279-73,NDC,,,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM-ALBUTEROL 0.5 MG-2.5 MG/3 ML NEB SOLUTION,35402,CDM,J3490,HCPCS,47335-756-48,NDC,,,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN   81 MG ORAL TBEC,35402,CDM,J3490,HCPCS,63739-212-02,NDC,,,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,35402,CDM,J3490,HCPCS,68084-354-11,NDC,,,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 150 MG/ML INJECTION,35402,CDM,J3490,HCPCS,25021-115-06,NDC,,,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0264-1800-36,NDC,,,facility,both,1,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE 100 MG TAB,35402,CDM,J3490,HCPCS,60687-344-95,NDC,,,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE HCL  2 % MM JELP,35402,CDM,J3490,HCPCS,25021-673-77,NDC,,,facility,both,1,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0338-0049-02,NDC,,,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  5 MG ORAL TBDL,35402,CDM,J3490,HCPCS,33342-083-07,NDC,,,facility,both,1,EA,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,0121-0657-05,NDC,,,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,42806-151-34,NDC,,,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE MALEATE 10 MG ORAL TAB,35402,CDM,Q0164,HCPCS,50268-685-11,NDC,,,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG ORAL CAP,35402,CDM,J3490,HCPCS,0904-6665-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,J7040,HCPCS,0264-1800-31,NDC,,,facility,both,1,ML,,973,681.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,70954-316-10,NDC,,,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,68180-150-01,NDC,,,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 150 MG CAP,35402,CDM,J3490,HCPCS,0904-5959-61,NDC,,,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG ORAL TAB,35402,CDM,J3490,HCPCS,51672-4005-1,NDC,,,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,35402,CDM,J3490,HCPCS,60687-653-11,NDC,,,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J3490,HCPCS,0143-9595-01,NDC,,,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/0.5 ML INHL NEBU,35402,CDM,J3490,HCPCS,0487-9901-30,NDC,,,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMIDE PEROXIDE 6.5 % OTIC DROP,35402,CDM,J3490,HCPCS,70677-1154-1,NDC,,,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,35402,CDM,J3490,HCPCS,69339-152-01,NDC,,,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J2003,HCPCS,63323-492-04,NDC,,,facility,both,1,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE  5 MG ORAL TAB,35402,CDM,J3490,HCPCS,60687-488-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 150 MG CAP,35402,CDM,J3490,HCPCS,68084-243-11,NDC,,,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZONATATE 100 MG ORAL CAP,35402,CDM,J3490,HCPCS,68084-214-11,NDC,,,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNITS/1 GRAM PACKET (MERGE RECORD),35402,CDM,J3490,HCPCS,45802-060-00,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",35402,CDM,J3490,HCPCS,0409-4887-24,NDC,,,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 100 MG ORAL TAB,35402,CDM,J3490,HCPCS,50268-337-11,NDC,,,facility,both,1,EA,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J2003,HCPCS,0409-4279-02,NDC,,,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,35402,CDM,J7510,HCPCS,17856-0815-1,NDC,,,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 875 MG-125 MG TAB,35402,CDM,J3490,HCPCS,65862-503-01,NDC,,,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG RECT SUPP,35402,CDM,J3490,HCPCS,51672-2116-0,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE 150 MG ORAL CP24,35402,CDM,J3490,HCPCS,68084-713-11,NDC,,,facility,both,1,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAMSULOSIN 0.4 MG ORAL CP24,35402,CDM,J3490,HCPCS,68084-299-11,NDC,,,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  5 MG ORAL TAB,35402,CDM,J7512,HCPCS,60687-122-11,NDC,,,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",35402,CDM,J3490,HCPCS,63323-482-03,NDC,,,facility,both,1,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-0430-06,NDC,,,facility,both,1,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 8 MG ORAL TBDL,35402,CDM,Q0162,HCPCS,65862-391-10,NDC,,,facility,both,1,EA,,182,127.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  25 MG ORAL CAP,35402,CDM,J3490,HCPCS,60687-473-11,NDC,,,facility,both,1,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,68180-441-02,NDC,,,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-7914-61,NDC,,,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG ORAL TAB,35402,CDM,J3490,HCPCS,60687-271-11,NDC,,,facility,both,1,EA,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 300 MG ORAL CAP,35402,CDM,J3490,HCPCS,57237-099-60,NDC,,,facility,both,1,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJ SOLN,35402,CDM,J3490,HCPCS,63323-464-17,NDC,,,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAMADOL  50 MG ORAL TAB,35402,CDM,J3490,HCPCS,60687-795-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0990-7983-02,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEMAZEPAM  7.5 MG ORAL CAP,35402,CDM,J3490,HCPCS,0904-6436-04,NDC,,,facility,both,1,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,0093-2279-73,NDC,,,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,35402,CDM,J3490,HCPCS,68094-024-59,NDC,,,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  75 MCG ORAL TAB,35402,CDM,J3490,HCPCS,0904-6951-61,NDC,,,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,70954-316-10,NDC,,,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMIDE PEROXIDE 6.5 % OTIC DROP,35402,CDM,J3490,HCPCS,1191710788,NDC,,,facility,both,1,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 20 MG ORAL TAB,35402,CDM,J3490,HCPCS,0054-8297-25,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,0143-9889-15,NDC,,,facility,both,7,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK,35402,CDM,J3490,HCPCS,12870-0001-2,NDC,,,facility,both,1,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,35402,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) NEB SOLUTION,35402,CDM,J3490,HCPCS,76204-200-30,NDC,,,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNIT/G TOP PACK,35402,CDM,J3490,HCPCS,45802-060-70,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUORESCEIN 1 MG OPHT STRP,35402,CDM,J3490,HCPCS,83851-100-30,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,35402,CDM,J7512,HCPCS,59746-175-06,NDC,,,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5 % (5 MG/ML) INJ SOLN,35402,CDM,J3490,HCPCS,0143-9329-01,NDC,,,facility,both,1,ML,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,35402,CDM,J3490,HCPCS,0143-9577-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,35402,CDM,J3490,HCPCS,17856-0823-10,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNIT/G TOP PACK,35402,CDM,J3490,HCPCS,72162-2280-4,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPEGINTERFERON ALFA-2B-NJFT 500 MCG/ML SUBQ SYRG,35402,CDM,J9999,HCPCS,73536-500-01,NDC,,,facility,both,1,ML,,23234,16263.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,0121-1314-11,NDC,,,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,35402,CDM,J3490,HCPCS,60687-464-11,NDC,,,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,67877-548-88,NDC,,,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),35402,CDM,J3490,HCPCS,51754-5001-1,NDC,,,facility,both,1,ML,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0338-0049-48,NDC,,,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG ORAL CHEW,35402,CDM,J3490,HCPCS,0573-0179-20,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,35402,CDM,J2003,HCPCS,63323-495-07,NDC,,,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-7350-61,NDC,,,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE 0.5 MG/2 ML INHL NBSP,35402,CDM,J3490,HCPCS,68180-984-05,NDC,,,facility,both,1,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LET TOPICAL GEL 3 ML,35402,CDM,J3490,HCPCS,70092-1611-44,NDC,,,facility,both,1,ML,,161,112.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 5 MG ORAL TAB,35402,CDM,J3490,HCPCS,76282-740-30,NDC,,,facility,both,1,EA,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,35402,CDM,J2003,HCPCS,63323-486-02,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,35402,CDM,J3490,HCPCS,63323-486-05,NDC,,,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,J7030,HCPCS,0338-0049-04,NDC,,,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,0121-1314-11,NDC,,,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAMSULOSIN 0.4 MG ORAL CP24,35402,CDM,J3490,HCPCS,50268-740-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,0093-2279-73,NDC,,,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,35402,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,1,ML,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J3490,HCPCS,63323-492-97,NDC,,,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 50 MG 24 HR TAB,35402,CDM,J3490,HCPCS,0904-6323-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG ORAL CAP,35402,CDM,J3490,HCPCS,60687-580-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJ SOLN,35402,CDM,J3490,HCPCS,0409-1559-19,NDC,,,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0338-0049-48,NDC,,,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,67877-548-88,NDC,,,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"N.MENINGITIDIS B,LIPID FHBP RC 120 MCG/0.5 ML IM SYRG",35402,CDM,J3490,HCPCS,0005-0100-01,NDC,,,facility,both,1,ML,,822,575.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL 2 MG/ML ORAL CONCENTRATE,35402,CDM,J3490,HCPCS,0904-7112-41,NDC,,,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,J7040,HCPCS,0264-1800-31,NDC,,,facility,both,1,ML,,451,315.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 100 MG ORAL TAB,35402,CDM,J3490,HCPCS,50268-337-11,NDC,,,facility,both,1,EA,,140,98,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  75 MCG ORAL TAB,35402,CDM,J3490,HCPCS,0904-6951-61,NDC,,,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,35402,CDM,J2003,HCPCS,63323-201-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),35402,CDM,J3490,HCPCS,0409-4888-06,NDC,,,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCERIN (CHILD) RECTAL SUPPOSITORY,35402,CDM,J3490,HCPCS,57237-326-21,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),35402,CDM,J3490,HCPCS,0409-4888-02,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0990-7983-61,NDC,,,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,35402,CDM,FAMNOCHARGE,HCPCS,68094-763-59,NDC,,,facility,both,1,ML,,150,105,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,35402,CDM,Q0177,HCPCS,63739-486-10,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 500 MG ORAL TAB,35402,CDM,J3490,HCPCS,68084-070-11,NDC,,,facility,both,1,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,35402,CDM,J7512,HCPCS,60687-145-11,NDC,,,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 10 MG ORAL TAB,35402,CDM,J3490,HCPCS,60687-503-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG ORAL CAP,35402,CDM,J3490,HCPCS,60687-152-11,NDC,,,facility,both,3,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACTERIOSTATIC SALINE 0.9 % INJ SOLN,35402,CDM,J3490,HCPCS,0409-1966-06,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RALTEGRAVIR 400 MG ORAL TAB,35402,CDM,J3490,HCPCS,0006-0227-61,NDC,,,facility,both,1,EA,,196,137.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,35402,CDM,J7510,HCPCS,17856-0815-1,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER SULFADIAZINE 1 % TOP CREA,35402,CDM,J3490,HCPCS,67877-124-20,NDC,,,facility,both,1,GM,,142,99.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TETRACAINE 0.5 % EYE DROPS,35402,CDM,J3490,HCPCS,70069-596-01,NDC,,,facility,both,1,ML,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,81033-002-10,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  120 MG RECT SUPP,35402,CDM,J3490,HCPCS,0713-0118-06,NDC,,,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM OXIDE 400 MG ORAL TAB,35402,CDM,J3490,HCPCS,1000670028,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOMYCIN-BACITRACN ZN-POLYMYXIN 3.5 MG-400 U*,35402,CDM,J3490,HCPCS,45802-143-70,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  1 MG ORAL TAB,35402,CDM,J7512,HCPCS,59746-171-06,NDC,,,facility,both,1,EA,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYOSCYAMINE SULFATE 0.125 MG ORAL TAB,35402,CDM,J3490,HCPCS,42192-340-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0338-0049-31,NDC,,,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",35402,CDM,J3490,HCPCS,63323-482-03,NDC,,,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 1 % NASAL SPRAY AEROSOL,35402,CDM,J3490,HCPCS,0024-1352-02,NDC,,,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM-ALBUTEROL 0.5 MG-2.5 MG/3 ML NEB SOLUTION,35402,CDM,J3490,HCPCS,0487-0201-01,NDC,,,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE 10 MG ORAL TAB,35402,CDM,J3490,HCPCS,51079-986-01,NDC,,,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,42806-151-34,NDC,,,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 5 MG/ML IV SOLN,35402,CDM,J1921,HCPCS,36000-322-02,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 25 MG TAB,35402,CDM,J3490,HCPCS,65862-146-36,NDC,,,facility,both,1,EA,,133,93.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,35402,CDM,J8540,HCPCS,60687-718-11,NDC,,,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN  325 MG ORAL TAB,35402,CDM,J3490,HCPCS,1284310120,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,68180-441-02,NDC,,,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCRALFATE 100 MG/ML ORAL SUSP,35402,CDM,J3490,HCPCS,0121-0974-10,NDC,,,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,60687-429-45,NDC,,,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,35402,CDM,J3490,HCPCS,0409-4276-17,NDC,,,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,68180-150-01,NDC,,,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,0143-9889-15,NDC,,,facility,both,10,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETIC ACID (VINEGAR) 5% IRRIGATION 12 ML (REPACK),35402,CDM,J3490,HCPCS,5155200556,NDC,,,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,35402,CDM,J2003,HCPCS,63323-485-41,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0338-0049-48,NDC,,,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,60687-751-42,NDC,,,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL  12 MCG/HR TD PT72,35402,CDM,J3490,HCPCS,0378-9119-16,NDC,,,facility,both,1,EA,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJ SOLN,35402,CDM,J3490,HCPCS,63323-464-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,35402,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNIT/G TOP PACK,35402,CDM,J3490,HCPCS,45802-060-70,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,35402,CDM,J2003,HCPCS,63323-201-10,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,68094-231-59,NDC,,,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTIAN VIOLET 1 % TOP SOLN,35402,CDM,J3490,HCPCS,0395-1003-92,NDC,,,facility,both,1,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2% 20MG/ML (5ML-UD) OR SYRINGE,35402,CDM,J3490,HCPCS,63323-486-01,NDC,,,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INHL NEBU,35402,CDM,J3490,HCPCS,0487-9301-03,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,35402,CDM,J2003,HCPCS,63323-486-20,NDC,,,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSP,35402,CDM,J3490,HCPCS,0574-0521-76,NDC,,,facility,both,1,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,0121-1314-11,NDC,,,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 100 MG/5 ML ORAL LIQD,35402,CDM,J3490,HCPCS,0121-1488-10,NDC,,,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES-DOCUSATE SODIUM 8.6 MG-50 MG TAB,35402,CDM,J3490,HCPCS,0904-7440-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,35402,CDM,Q0177,HCPCS,23155-501-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESKETAMINE 84 MG (28 MG X 3) NASL SPRY,35402,CDM,J3490,HCPCS,50458-028-03,NDC,,,facility,both,1,EA,,5213,3649.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0264-7800-20,NDC,,,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,76297-001-32,NDC,,,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,70954-316-10,NDC,,,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0990-7983-61,NDC,,,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,35402,CDM,J7512,HCPCS,59651-488-01,NDC,,,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE HCL  2 % MM JELP,35402,CDM,J3490,HCPCS,76329-3013-5,NDC,,,facility,both,1,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 10 GRAM/15 ML ORAL SOLN,35402,CDM,J3490,HCPCS,0116-4005-30,NDC,,,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,35402,CDM,J8540,HCPCS,0904-7266-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 150 MG CAP,35402,CDM,J3490,HCPCS,0904-5959-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES  8.6 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-7252-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J3490,HCPCS,55150-162-05,NDC,,,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,68094-600-59,NDC,,,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG ORAL TAB,35402,CDM,J3490,HCPCS,60687-113-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACTERIOSTATIC SALINE 0.9 % INJ SOLN,35402,CDM,J3490,HCPCS,63323-259-30,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,68094-330-59,NDC,,,facility,both,1,ML,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,0093-2279-73,NDC,,,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J3490,HCPCS,0143-9595-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,35402,CDM,J3490,HCPCS,63739-903-10,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0264-7800-20,NDC,,,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-6773-61,NDC,,,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSP,35402,CDM,J3490,HCPCS,68094-061-59,NDC,,,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,35402,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,1,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,0121-0431-30,NDC,,,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES-DOCUSATE SODIUM 8.6 MG-50 MG TAB,35402,CDM,J3490,HCPCS,60687-622-11,NDC,,,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 2 %-1:200,000 INJ SOLN",35402,CDM,J3490,HCPCS,63323-489-27,NDC,,,facility,both,1,ML,,138,96.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 500 MG ORAL TAB,35402,CDM,J3490,HCPCS,60687-559-11,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 400 MG ORAL TAB,35402,CDM,J3490,HCPCS,68084-658-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  25 MG ORAL TAB,35402,CDM,J3490,HCPCS,60687-822-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM-ALBUTEROL 0.5 MG-2.5 MG/3 ML NEB SOLUTION,35402,CDM,J3490,HCPCS,60687-405-79,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,70954-316-10,NDC,,,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJ SOLN",35402,CDM,J3490,HCPCS,0409-1746-10,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,16714-294-02,NDC,,,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 200 MG ORAL TAB,35402,CDM,J3490,HCPCS,0245-0147-89,NDC,,,facility,both,1,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,35402,CDM,J3490,HCPCS,0409-4277-17,NDC,,,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,35402,CDM,J3490,HCPCS,62756-240-64,NDC,,,facility,both,1,EA,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 100 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-6500-61,NDC,,,facility,both,1,EA,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J3490,HCPCS,70756-641-85,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAMSULOSIN 0.4 MG ORAL CP24,35402,CDM,J3490,HCPCS,68084-299-11,NDC,,,facility,both,1,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,0093-2279-73,NDC,,,facility,both,1,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE  1 % TOP CREA,35402,CDM,J3490,HCPCS,0472-0321-26,NDC,,,facility,both,1,GM,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,J3490,HCPCS,0264-1800-31,NDC,,,facility,both,1,ML,,415,290.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,35402,CDM,J2003,HCPCS,63323-486-05,NDC,,,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,J7040,HCPCS,0264-1800-31,NDC,,,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 10 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-6798-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL  5 MG ORAL TAB,35402,CDM,J3490,HCPCS,68180-513-01,NDC,,,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE 10 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-6371-61,NDC,,,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE MALEATE 10 MG ORAL TAB,35402,CDM,Q0164,HCPCS,50268-685-15,NDC,,,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J3490,HCPCS,0143-9595-01,NDC,,,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,35402,CDM,FAMNOCHARGE,HCPCS,0904-6617-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 500 MG ORAL CAP,35402,CDM,J3490,HCPCS,16714-299-03,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,J7040,HCPCS,0338-9806-01,NDC,,,facility,both,1,ML,,200,140,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J3490,HCPCS,63323-492-09,NDC,,,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,68180-150-01,NDC,,,facility,both,1,ML,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  75 MCG ORAL TAB,35402,CDM,J3490,HCPCS,60687-475-11,NDC,,,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,35402,CDM,J1100,HCPCS,63323-165-05,NDC,,,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJ SOLN,35402,CDM,J3490,HCPCS,0409-1559-19,NDC,,,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,0143-9889-15,NDC,,,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,0143-9889-15,NDC,,,facility,both,15,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,67877-548-88,NDC,,,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOMYCIN-BACITRACIN ZN-POLYMYXIN 3.5 MG-400 UN*,35402,CDM,J3490,HCPCS,0904-0734-31,NDC,,,facility,both,1,GM,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LET TOPICAL GEL 3 ML,35402,CDM,J3490,HCPCS,05446-0607-01,NDC,,,facility,both,1,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR PHOSPHATE 30 MG ORAL CAP,35402,CDM,J3490,HCPCS,0527-4591-13,NDC,,,facility,both,1,EA,,139,97.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG ORAL TBEC,35402,CDM,J3490,HCPCS,35573-428-51,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,68094-600-59,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,35402,CDM,FAMNOCHARGE,HCPCS,17856-0759-5,NDC,,,facility,both,2,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 500 MG ORAL CAP,35402,CDM,J3490,HCPCS,60687-787-11,NDC,,,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 17 GRAM (100 %) ORAL PWPK,35402,CDM,J3490,HCPCS,1152372688,NDC,,,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDO-EPI WITH 8.4% SOD BICARB 1 %- 1:100,000 (3 ML) INJ SYRG",35402,CDM,J3490,HCPCS,70092-1691-44,NDC,,,facility,both,1,ML,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 5 MG-325 MG TAB,35402,CDM,J3490,HCPCS,0406-0123-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SYRG,35402,CDM,J3490,HCPCS,8290306546,NDC,,,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,68094-231-59,NDC,,,facility,both,1,ML,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,0121-1314-11,NDC,,,facility,both,1,ML,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % MUCOSAL GEL,35402,CDM,J3490,HCPCS,17478-711-31,NDC,,,facility,both,1,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,35402,CDM,J3490,HCPCS,0409-4277-02,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,81033-002-10,NDC,,,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,35402,CDM,J3010,HCPCS,0409-9094-22,NDC,,,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALUM-MAG HYDROXIDE-SIMETH 200 MG-200 MG-20 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,17856-0630-1,NDC,,,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,0093-2279-73,NDC,,,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 500 MG ORAL CAP,35402,CDM,J3490,HCPCS,16714-299-03,NDC,,,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G POTASSIUM  5000000 UNIT INJ SOLR,35402,CDM,J2540,HCPCS,0781-6135-94,NDC,,,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIOTHYRONINE  5 MCG ORAL TAB,35402,CDM,J3490,HCPCS,16714-166-01,NDC,,,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,0143-9889-15,NDC,,,facility,both,11,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  15 MG ORAL TAB,35402,CDM,J3490,HCPCS,0406-8515-23,NDC,,,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J2003,HCPCS,0143-9595-01,NDC,,,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER SULFADIAZINE 1 % TOP CREA,35402,CDM,J3490,HCPCS,43598-210-50,NDC,,,facility,both,1,GM,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACTERIOSTATIC SALINE 0.9 % INJ SOLN,35402,CDM,J3490,HCPCS,63323-924-10,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,70954-316-10,NDC,,,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0990-7983-02,NDC,,,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,35402,CDM,J3490,HCPCS,0143-9575-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  120 MG RECT SUPP,35402,CDM,J3490,HCPCS,45802-732-00,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SYRG,35402,CDM,J3490,HCPCS,8290306547,NDC,,,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",35402,CDM,J3490,HCPCS,0409-3178-01,NDC,,,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,0121-1022-05,NDC,,,facility,both,1,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MECLIZINE 25 MG ORAL TAB,35402,CDM,J3490,HCPCS,60687-730-11,NDC,,,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),35402,CDM,J3490,HCPCS,63323-186-00,NDC,,,facility,both,1,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,35402,CDM,J3490,HCPCS,55150-164-02,NDC,,,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 7.5 MG-325 MG/15 ML ORAL SOLN (REPACK),35402,CDM,J3490,HCPCS,0121-2316-15,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE 14 MG/24 HR TD PT24,35402,CDM,J3490,HCPCS,43598-447-71,NDC,,,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",35402,CDM,J3490,HCPCS,63323-482-03,NDC,,,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",35402,CDM,J2004,HCPCS,0409-3178-01,NDC,,,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,35402,CDM,J7512,HCPCS,0054-0018-20,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0990-7983-61,NDC,,,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMIDE PEROXIDE 6.5 % OTIC DROP,35402,CDM,J3490,HCPCS,4203710478,NDC,,,facility,both,1,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,35402,CDM,J3490,HCPCS,0904-6930-61,NDC,,,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,1093930833,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,0121-0917-05,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,0121-0917-05,NDC,,,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,35402,CDM,J3490,HCPCS,0093-3426-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 100 MG/5 ML ORAL LIQD,35402,CDM,J3490,HCPCS,0536-1314-85,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MISOPROSTOL 200 MCG ORAL TAB,35402,CDM,S0191,HCPCS,60687-746-01,NDC,,,facility,both,1,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),35402,CDM,J3490,HCPCS,0409-4888-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,35402,CDM,Q0162,HCPCS,16714-671-02,NDC,,,facility,both,1,ML,,234,163.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYMETAZOLINE 0.05 % NASAL MERGE,35402,CDM,J3490,HCPCS,45802-410-59,NDC,,,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,35402,CDM,FAMNOCHARGE,HCPCS,0904-7127-61,NDC,,,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNITS/1 GRAM PACKET (MERGE RECORD),35402,CDM,J3490,HCPCS,45802-060-00,NDC,,,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALACYCLOVIR 500 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-6565-61,NDC,,,facility,both,1,EA,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,35402,CDM,J3490,HCPCS,66553-002-01,NDC,,,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 0.4 MG SL SUBL,35402,CDM,J3490,HCPCS,0071-0418-13,NDC,,,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALUM-MAG HYDROXIDE-SIMETH 400 MG-400 MG-40 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,0904-5725-14,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,35402,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % MUCOSAL SOLN (VISCOUS),35402,CDM,J3490,HCPCS,0054-8500-16,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,35402,CDM,Q0162,HCPCS,16714-671-02,NDC,,,facility,both,1,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG ORAL CAP,35402,CDM,J3490,HCPCS,0904-7336-61,NDC,,,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,35402,CDM,J2003,HCPCS,63323-202-02,NDC,,,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPRAZOLAM 0.5 MG ORAL TAB,35402,CDM,J3490,HCPCS,59762-3720-1,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN NORMAL SALINE IV,35402,CDM,FAMNOCHARGE,HCPCS,0338-0089-04,NDC,,,facility,both,1,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,68094-231-59,NDC,,,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,42806-151-34,NDC,,,facility,both,1,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,70954-316-10,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  5 MG ORAL TAB,35402,CDM,FAMNOCHARGE,HCPCS,60687-122-11,NDC,,,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,0093-2279-73,NDC,,,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % MUCOSAL SOLN (VISCOUS),35402,CDM,J3490,HCPCS,50383-775-17,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 1 MG ORAL TAB,35402,CDM,J3490,HCPCS,59651-723-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,35402,CDM,J3490,HCPCS,50268-671-11,NDC,,,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 10 MG/ML INJECTION,35402,CDM,J1100,HCPCS,70069-025-10,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,35402,CDM,J8540,HCPCS,0054-8175-25,NDC,,,facility,both,1,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0990-7983-61,NDC,,,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),35402,CDM,J3490,HCPCS,0409-4888-06,NDC,,,facility,both,1,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 4 MG/ACTUATION NASL SPRY,35402,CDM,J3490,HCPCS,0093-2165-19,NDC,,,facility,both,1,EA,,303,212.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,35402,CDM,J3490,HCPCS,51079-444-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 10 GRAM/15 ML ORAL SOLN,35402,CDM,J3490,HCPCS,66689-038-01,NDC,,,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG ORAL TBEC,35402,CDM,J3490,HCPCS,60687-736-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,35402,CDM,FAMNOCHARGE,HCPCS,60687-252-40,NDC,,,facility,both,1,ML,,161,112.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,67877-548-88,NDC,,,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN  325 MG ORAL TBEC,35402,CDM,J3490,HCPCS,0536-1232-01,NDC,,,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,1191702059,NDC,,,facility,both,1,ML,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALUMINUM-MAGNESIUM HYDROXIDE 200 MG-200 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,0121-1760-30,NDC,,,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,60687-751-42,NDC,,,facility,both,1,ML,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,35402,CDM,J3490,HCPCS,55150-252-20,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,35402,CDM,J3490,HCPCS,63323-485-03,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,16714-293-03,NDC,,,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,0143-9853-16,NDC,,,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LET TOPICAL GEL 3 ML,35402,CDM,J3490,HCPCS,70092-1611-44,NDC,,,facility,both,1,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE  75 MG IMPL PLLT,35402,CDM,J3490,HCPCS,66887-004-01,NDC,,,facility,both,1,EA,,2337,1635.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAMADOL  50 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-7496-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) IV SOLN",35402,CDM,J3490,HCPCS,43066-008-01,NDC,,,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0990-7983-61,NDC,,,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,42806-151-34,NDC,,,facility,both,1,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SYRG,35402,CDM,J3490,HCPCS,8290306547,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",35402,CDM,J3490,HCPCS,63323-482-01,NDC,,,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,35402,CDM,Q0162,HCPCS,60687-252-40,NDC,,,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG ORAL TAB,35402,CDM,J3490,HCPCS,50268-192-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 25 MG CAP,35402,CDM,J3490,HCPCS,0904-5306-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",35402,CDM,J3490,HCPCS,0409-4887-23,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN V POTASSIUM 250 MG ORAL TAB,35402,CDM,J3490,HCPCS,16714-234-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,J7040,HCPCS,0264-1800-31,NDC,,,facility,both,1,ML,,613,429.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0990-7983-02,NDC,,,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJ SOLN,35402,CDM,J3490,HCPCS,0409-1159-09,NDC,,,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-6773-61,NDC,,,facility,both,3,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNIT/G TOP PACK,35402,CDM,J3490,HCPCS,1678411613,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",35402,CDM,J3490,HCPCS,63323-462-17,NDC,,,facility,both,1,ML,,157,109.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,35402,CDM,J1100,HCPCS,0641-6145-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  5 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-6818-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE 0.5 MG/2 ML INHL NBSP,35402,CDM,J3490,HCPCS,0487-9701-01,NDC,,,facility,both,1,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALUM-MAG HYDROXIDE-SIMETH 200 MG-200 MG-20 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,63739-159-10,NDC,,,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ROTAVIRUS VACCINE, LIVE, 89-12 10EXP6 CCID50 /1.5 ML ORAL SUSP",35402,CDM,90681,HCPCS,58160-740-21,NDC,,,facility,both,1,ML,,400,280,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,68180-150-01,NDC,,,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR  6 MG/ML ORAL SUSR,35402,CDM,J3490,HCPCS,27241-139-09,NDC,,,facility,both,1,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,35402,CDM,J3490,HCPCS,57237-077-10,NDC,,,facility,both,1,EA,,218,152.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  75 MG ORAL CAP,35402,CDM,J3490,HCPCS,60687-495-11,NDC,,,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2% 20MG/ML (5ML-UD) OR SYRINGE,35402,CDM,J3490,HCPCS,63323-486-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE-ALOE VERA 1 % TOP CREA,35402,CDM,J3490,HCPCS,49348-441-72,NDC,,,facility,both,1,GM,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",35402,CDM,J3490,HCPCS,63323-482-01,NDC,,,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM BICARB-CITRIC ACID 20 MEQ ORAL TBEF,35402,CDM,J3490,HCPCS,51801-011-01,NDC,,,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK,35402,CDM,J3490,HCPCS,12165-100-03,NDC,,,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNITS/1 GRAM PACKET (MERGE RECORD),35402,CDM,J3490,HCPCS,57896-111-09,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),35402,CDM,J3490,HCPCS,0409-4888-06,NDC,,,facility,both,1,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  15 MG ORAL TAB,35402,CDM,J3490,HCPCS,0406-8515-23,NDC,,,facility,both,1,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,35402,CDM,J7510,HCPCS,17856-0815-1,NDC,,,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,0121-1022-05,NDC,,,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,42806-151-34,NDC,,,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,35402,CDM,J3490,HCPCS,63323-486-17,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE  75 MG IMPL PLLT,35402,CDM,J3490,HCPCS,66887-004-10,NDC,,,facility,both,1,EA,,1956,1369.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,60687-751-42,NDC,,,facility,both,1,ML,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",35402,CDM,J3490,HCPCS,0409-3178-17,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),35402,CDM,J3490,HCPCS,0409-4888-02,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0990-7984-23,NDC,,,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL  25 MCG/HR TD PT72,35402,CDM,J3490,HCPCS,47781-424-11,NDC,,,facility,both,1,EA,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 20 MG ORAL TAB,35402,CDM,J3490,HCPCS,60687-333-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SYRG,35402,CDM,J3490,HCPCS,8290306553,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,70954-316-10,NDC,,,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,68094-231-59,NDC,,,facility,both,2,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5 % (5 MG/ML) INJ SOLN,35402,CDM,J3490,HCPCS,0409-1163-18,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,J7040,HCPCS,0264-1800-31,NDC,,,facility,both,1,ML,,487,340.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0990-7983-61,NDC,,,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"NEOMYCIN-POLYMYXIN-HC 3.5 MG-10,000 UNIT/ML-1 % EAR DROPS, SUSP",35402,CDM,J3490,HCPCS,61314-645-11,NDC,,,facility,both,1,ML,,378,264.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAMADOL  50 MG ORAL TAB,35402,CDM,J3490,HCPCS,68084-808-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),35402,CDM,J3490,HCPCS,67850-041-00,NDC,,,facility,both,1,ML,,172,120.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),35402,CDM,J3490,HCPCS,0409-4888-03,NDC,,,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,76297-001-32,NDC,,,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0338-0049-31,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COLCHICINE 0.6 MG ORAL TAB,35402,CDM,J3490,HCPCS,50268-187-11,NDC,,,facility,both,2,EA,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG ORAL TAB,35402,CDM,J3490,HCPCS,69315-904-01,NDC,,,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J3490,HCPCS,63323-492-37,NDC,,,facility,both,1,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),35402,CDM,J3490,HCPCS,51754-5001-1,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J3490,HCPCS,63323-492-04,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J2003,HCPCS,0143-9595-01,NDC,,,facility,both,1,ML,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRICHLOROACETIC ACID 80 % TOP SOLN,35402,CDM,J3490,HCPCS,10481-3008-1,NDC,,,facility,both,1,ML,,329,230.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,35402,CDM,J7510,HCPCS,17856-0759-5,NDC,,,facility,both,1,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,35402,CDM,J8540,HCPCS,60687-718-11,NDC,,,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,J7040,HCPCS,0264-1800-31,NDC,,,facility,both,1,ML,,541,378.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,35402,CDM,J3490,HCPCS,68462-157-40,NDC,,,facility,both,1,EA,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J2003,HCPCS,0409-4713-02,NDC,,,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) NEB SOLUTION,35402,CDM,J3490,HCPCS,0487-9501-25,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,17271-701-05,NDC,,,facility,both,1,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,68180-150-01,NDC,,,facility,both,1,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",35402,CDM,J3490,HCPCS,63323-482-03,NDC,,,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,35402,CDM,J7510,HCPCS,17856-0815-1,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE  5 MG ORAL TAB,35402,CDM,J3490,HCPCS,60687-620-11,NDC,,,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,35402,CDM,FAMNOCHARGE,HCPCS,17856-0759-5,NDC,,,facility,both,1,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,16714-293-03,NDC,,,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,35402,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-7350-61,NDC,,,facility,both,1,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COLCHICINE 0.6 MG ORAL TAB,35402,CDM,J3490,HCPCS,65162-710-09,NDC,,,facility,both,1,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,35402,CDM,FAMNOCHARGE,HCPCS,0904-7266-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,35402,CDM,J3490,HCPCS,55150-255-24,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) NEB SOLUTION,35402,CDM,J3490,HCPCS,60687-395-79,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",35402,CDM,J2004,HCPCS,63323-482-01,NDC,,,facility,both,1,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J3490,HCPCS,63323-492-04,NDC,,,facility,both,1,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",35402,CDM,J2004,HCPCS,63323-482-03,NDC,,,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,35402,CDM,J3490,HCPCS,0904-6930-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,0121-0917-05,NDC,,,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,67877-548-88,NDC,,,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,35402,CDM,J2704,HCPCS,63323-269-22,NDC,,,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,35402,CDM,J7512,HCPCS,60687-145-11,NDC,,,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG ORAL CAP,35402,CDM,J3490,HCPCS,60687-776-11,NDC,,,facility,both,1,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,67877-548-88,NDC,,,facility,both,1,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,68094-600-59,NDC,,,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,68094-231-59,NDC,,,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,68094-231-59,NDC,,,facility,both,1,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,35402,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,1,ML,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE  25 MG ORAL TAB,35402,CDM,J3490,HCPCS,51079-103-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J2003,HCPCS,63323-492-09,NDC,,,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,68180-150-01,NDC,,,facility,both,1,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN V POTASSIUM 250 MG ORAL TAB,35402,CDM,J3490,HCPCS,16714-234-01,NDC,,,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J2003,HCPCS,63323-492-27,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,68094-231-59,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,35402,CDM,J3490,HCPCS,60687-591-11,NDC,,,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4% TOP PATCH,35402,CDM,J3490,HCPCS,0536-1202-07,NDC,,,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG ORAL TAB,35402,CDM,J3490,HCPCS,10135-162-13,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",35402,CDM,J3490,HCPCS,0641-6147-01,NDC,,,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMIDE PEROXIDE 6.5 % OTIC DROP,35402,CDM,J3490,HCPCS,59779-486-01,NDC,,,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJ SOLN",35402,CDM,J3490,HCPCS,0409-1746-10,NDC,,,facility,both,1,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,35402,CDM,J7510,HCPCS,17856-0815-1,NDC,,,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,35402,CDM,FAMNOCHARGE,HCPCS,68094-763-59,NDC,,,facility,both,1,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,65862-707-55,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,35402,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYMETAZOLINE 0.05 % NASL SPRA,35402,CDM,J3490,HCPCS,4110081125,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRBESARTAN 150 MG ORAL TAB,35402,CDM,J3490,HCPCS,43547-375-09,NDC,,,facility,both,1,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 4 MG/ACTUATION NASL SPRY,35402,CDM,J3490,HCPCS,69547-353-02,NDC,,,facility,both,1,EA,,270,189,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,68180-441-02,NDC,,,facility,both,1,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG IV SOLR,35402,CDM,J3490,HCPCS,55150-202-00,NDC,,,facility,both,1,EA,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,68180-150-01,NDC,,,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETIRIZINE 5 MG/5 ML ORAL SOLN,35402,CDM,J3490,HCPCS,68094-004-59,NDC,,,facility,both,2,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),35402,CDM,J3490,HCPCS,39822-1000-1,NDC,,,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0338-0049-38,NDC,,,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:200,000 INJ SOLN",35402,CDM,J3490,HCPCS,63323-487-01,NDC,,,facility,both,1,ML,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORDIAZEPOXIDE 25 MG CAP,35402,CDM,J3490,HCPCS,60687-807-11,NDC,,,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALUM-MAG HYDROXIDE-SIMETH 200 MG-200 MG-20 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,11822-3324-70,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,35402,CDM,J7510,HCPCS,17856-0759-5,NDC,,,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNITS/1 GRAM PACKET (MERGE RECORD),35402,CDM,J3490,HCPCS,45802-060-00,NDC,,,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,35402,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,1,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,81033-002-20,NDC,,,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5 % (5 MG/ML) INJ SOLN,35402,CDM,J3490,HCPCS,0143-9329-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TAB,35402,CDM,J3490,HCPCS,71205-909-30,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,42806-151-34,NDC,,,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,42806-151-34,NDC,,,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J3490,HCPCS,55150-162-05,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,70954-316-10,NDC,,,facility,both,1,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LET TOPICAL GEL 3 ML,35402,CDM,J3490,HCPCS,70092-1135-44,NDC,,,facility,both,1,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE  25 MG ORAL TAB,35402,CDM,J3490,HCPCS,63739-544-10,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENAZOPYRIDINE 100 MG ORAL TAB,35402,CDM,J3490,HCPCS,65162-681-10,NDC,,,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,16714-294-02,NDC,,,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-6773-61,NDC,,,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG ORAL TBEC,35402,CDM,J3490,HCPCS,51079-051-01,NDC,,,facility,both,1,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG ORAL TAB,35402,CDM,J3490,HCPCS,0904-6953-61,NDC,,,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORATADINE 10 MG ORAL TAB,35402,CDM,J3490,HCPCS,68084-248-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJ SOLN,35402,CDM,J3490,HCPCS,63323-464-17,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,67877-548-88,NDC,,,facility,both,1,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,0093-2279-73,NDC,,,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,35402,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,1,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J2003,HCPCS,0143-9595-01,NDC,,,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,35402,CDM,J3490,HCPCS,0143-9173-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,35402,CDM,FAMNOCHARGE,HCPCS,16714-082-10,NDC,,,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENAZOPYRIDINE 100 MG ORAL TAB,35402,CDM,J3490,HCPCS,69367-611-01,NDC,,,facility,both,1,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,35402,CDM,J3490,HCPCS,0378-7732-93,NDC,,,facility,both,1,EA,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J3490,HCPCS,63323-492-04,NDC,,,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 20 GRAM/30 ML ORAL SOLN,35402,CDM,J3490,HCPCS,0121-1154-30,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 100 MG ORAL TAB,35402,CDM,J3490,HCPCS,68084-728-11,NDC,,,facility,both,1,EA,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),35402,CDM,J3490,HCPCS,0409-4888-03,NDC,,,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,68094-231-59,NDC,,,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN  325 MG ORAL TAB,35402,CDM,J3490,HCPCS,10135-150-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SYRG,35402,CDM,J3490,HCPCS,8290306553,NDC,,,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE  1 % TOP CREA,35402,CDM,J3490,HCPCS,45802-438-03,NDC,,,facility,both,1,GM,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETIC ACID (VINEGAR) 5% IRRIGATION 12 ML (REPACK),35402,CDM,J3490,HCPCS,5155200556,NDC,,,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,0121-0917-05,NDC,,,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,35402,CDM,J7510,HCPCS,17856-0815-1,NDC,,,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"N.MENINGITIDIS B,LIPID FHBP RC 120 MCG/0.5 ML IM SYRG",35402,CDM,J3490,HCPCS,0005-0100-10,NDC,,,facility,both,1,ML,,822,575.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYMETAZOLINE 0.05 % NASL SPRA,35402,CDM,J3490,HCPCS,4110081125,NDC,,,facility,both,1,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 20 GRAM/30 ML ORAL SOLN,35402,CDM,J3490,HCPCS,0121-1154-30,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,68180-723-05,NDC,,,facility,both,1,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,67877-548-88,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL  4 MG ORAL TAB,35402,CDM,Q0162,HCPCS,65862-187-03,NDC,,,facility,both,1,EA,,119,83.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMIDE PEROXIDE 6.5 % OTIC DROP,35402,CDM,J3490,HCPCS,66267-976-15,NDC,,,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,35402,CDM,J3490,HCPCS,17856-0815-1,NDC,,,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOMYCIN-BACITRACN ZN-POLYMYXIN 3.5 MG-400 U*,35402,CDM,J3490,HCPCS,45802-143-00,NDC,,,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",35402,CDM,J2004,HCPCS,63323-482-41,NDC,,,facility,both,1,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  75 MG ORAL CAP,35402,CDM,J3490,HCPCS,60687-495-11,NDC,,,facility,both,1,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN V POTASSIUM 250 MG ORAL TAB,35402,CDM,J3490,HCPCS,16714-234-01,NDC,,,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,35402,CDM,FAMNOCHARGE,HCPCS,0054-8175-25,NDC,,,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ROTAVIRUS VACCINE LIVE, PENTA 2 ML ORAL SUSP",35402,CDM,90680,HCPCS,0006-4047-02,NDC,,,facility,both,1,ML,,252,176.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,35402,CDM,J3490,HCPCS,63323-485-03,NDC,,,facility,both,1,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,16714-294-02,NDC,,,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJ SOLN,35402,CDM,J3490,HCPCS,0409-1559-19,NDC,,,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,35402,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,35402,CDM,J2003,HCPCS,63323-201-02,NDC,,,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE  6.25 MG/5 ML ORAL SYRP,35402,CDM,Q0169,HCPCS,81033-016-05,NDC,,,facility,both,1,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J3490,HCPCS,63323-492-57,NDC,,,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J2003,HCPCS,63323-492-27,NDC,,,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,35402,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG ORAL TAB,35402,CDM,J3490,HCPCS,50268-279-11,NDC,,,facility,both,1,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5 % (5 MG/ML) INJ SOLN,35402,CDM,J3490,HCPCS,63323-467-01,NDC,,,facility,both,1,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,0121-1314-11,NDC,,,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM BROMIDE 0.02 % INHL SOLN,35402,CDM,J3490,HCPCS,76204-100-01,NDC,,,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",35402,CDM,J3490,HCPCS,0409-3178-16,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE 21 MG/24 HR TD PT24,35402,CDM,J3490,HCPCS,43598-448-71,NDC,,,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0338-0049-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,81033-002-10,NDC,,,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0990-7984-37,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TROPICAMIDE 0.5 % OPHT DROP,35402,CDM,J3490,HCPCS,61314-354-01,NDC,,,facility,both,1,ML,,131,91.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SYRG,35402,CDM,J3490,HCPCS,8290306546,NDC,,,facility,both,1,ML,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE  7 % INHL NEBU,35402,CDM,J3490,HCPCS,8349030760,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 25 MG CAP,35402,CDM,J3490,HCPCS,0904-7237-61,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,35402,CDM,J3490,HCPCS,63323-485-26,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALUM-MAG HYDROXIDE-SIMETH 400 MG-400 MG-40 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,0113-0588-40,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,68094-600-59,NDC,,,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM CITRATE ORAL SOLN,35402,CDM,J3490,HCPCS,71399-0051-1,NDC,,,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJ SOLN",35402,CDM,J3490,HCPCS,0409-9042-11,NDC,,,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0264-1800-36,NDC,,,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J3490,HCPCS,55150-161-02,NDC,,,facility,both,1,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  2 MG ORAL TAB,35402,CDM,J3490,HCPCS,0406-3243-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZONATATE 100 MG ORAL CAP,35402,CDM,J3490,HCPCS,68084-214-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) NEB SOLUTION,35402,CDM,J3490,HCPCS,0487-9501-00,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  2.5 MG ORAL TAB,35402,CDM,J3490,HCPCS,60505-3110-0,NDC,,,facility,both,1,EA,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MENING A,C,Y,W TT-N. MEN B(PF) 5-120 MCG/0.5 ML IM KIT (CAM USE ONLY)",35402,CDM,J3490,HCPCS,0069-0271-01,NDC,,,facility,both,1,EA,,817,571.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J2003,HCPCS,63323-492-89,NDC,,,facility,both,1,ML,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",35402,CDM,J2004,HCPCS,0409-3178-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",35402,CDM,J3490,HCPCS,63323-185-07,NDC,,,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,16714-294-02,NDC,,,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,35402,CDM,J7512,HCPCS,59746-175-06,NDC,,,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,J7040,HCPCS,0338-0049-04,NDC,,,facility,both,1,ML,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,68180-441-02,NDC,,,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",35402,CDM,J3490,HCPCS,63323-482-03,NDC,,,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,68094-330-59,NDC,,,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,68180-150-01,NDC,,,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDO-EPI WITH 8.4% SOD BICARB 1 %- 1:100,000 (3 ML) INJ SYRG",35402,CDM,J3490,HCPCS,70092-1691-44,NDC,,,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION,35402,CDM,J3490,HCPCS,0186-0372-28,NDC,,,facility,both,1,GM,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJ SOLN,35402,CDM,J3490,HCPCS,63323-464-17,NDC,,,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV SOLN,35402,CDM,J3490,HCPCS,0409-6625-22,NDC,,,facility,both,1,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 500 MG ORAL CAP,35402,CDM,J3490,HCPCS,60687-787-11,NDC,,,facility,both,1,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0264-1800-36,NDC,,,facility,both,1,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,0121-1314-11,NDC,,,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J3490,HCPCS,63323-492-07,NDC,,,facility,both,1,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J3490,HCPCS,55150-161-02,NDC,,,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,35402,CDM,J3490,HCPCS,63323-202-02,NDC,,,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,35402,CDM,J2003,HCPCS,0409-4277-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR PHOSPHATE 75 MG ORAL CAP,35402,CDM,J3490,HCPCS,0004-0800-85,NDC,,,facility,both,1,EA,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,35402,CDM,Q0162,HCPCS,17856-0691-5,NDC,,,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0338-0049-48,NDC,,,facility,both,1,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  25 MG ORAL TAB,35402,CDM,J3490,HCPCS,68084-346-11,NDC,,,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMIDE PEROXIDE 6.5 % OTIC DROP,35402,CDM,J3490,HCPCS,63029-322-01,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HONEY 100 % TOP PSTE,35402,CDM,J3490,HCPCS,995803360,NDC,,,facility,both,1,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,35402,CDM,FAMNOCHARGE,HCPCS,0904-7266-61,NDC,,,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MONTELUKAST 10 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-6808-06,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER SULFADIAZINE 1 % TOP CREA,35402,CDM,J3490,HCPCS,67877-124-50,NDC,,,facility,both,1,GM,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 10 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-6426-61,NDC,,,facility,both,1,EA,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,35402,CDM,J3490,HCPCS,50268-074-11,NDC,,,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE 0.5 MG/2 ML INHL NBSP,35402,CDM,J3490,HCPCS,0093-6816-19,NDC,,,facility,both,1,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 500 MG ORAL TAB,35402,CDM,J3490,HCPCS,60687-550-11,NDC,,,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,68094-600-59,NDC,,,facility,both,3,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL 2 MG/ML ORAL CONCENTRATE,35402,CDM,J3490,HCPCS,60687-799-40,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIPASE-PROTEASE-AMYLASE 24,000-76,000- 120,000 UNIT ORAL CAP, DELAY REL",35402,CDM,J3490,HCPCS,0032-2636-01,NDC,,,facility,both,1,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,67877-548-88,NDC,,,facility,both,1,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,35402,CDM,J3490,HCPCS,42858-001-10,NDC,,,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,35402,CDM,FAMNOCHARGE,HCPCS,0904-7127-61,NDC,,,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOMYCIN-BACITRACIN ZN-POLYMYXIN 3.5 MG-400 UN*,35402,CDM,J3490,HCPCS,59390-027-14,NDC,,,facility,both,1,GM,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,16714-294-02,NDC,,,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,35402,CDM,J3490,HCPCS,60687-742-11,NDC,,,facility,both,1,EA,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 1.25 MG/3 ML INHL NEBU,35402,CDM,J3490,HCPCS,76204-011-05,NDC,,,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,35402,CDM,FAMNOCHARGE,HCPCS,0054-8175-25,NDC,,,facility,both,3,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,35402,CDM,J7510,HCPCS,17856-0759-5,NDC,,,facility,both,1,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,0121-1314-11,NDC,,,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJ SOLN,35402,CDM,J3490,HCPCS,63323-464-17,NDC,,,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOBENZAPRINE 10 MG ORAL TAB,35402,CDM,J3490,HCPCS,60687-558-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,35402,CDM,J7510,HCPCS,17856-0815-1,NDC,,,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG ORAL TAB,35402,CDM,J3490,HCPCS,60687-595-11,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-0430-06,NDC,,,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL  6.25 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-6301-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,35402,CDM,J7512,HCPCS,60687-134-11,NDC,,,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG RECT SUPP,35402,CDM,J3490,HCPCS,45802-759-00,NDC,,,facility,both,1,EA,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,35402,CDM,J7512,HCPCS,63629-1579-2,NDC,,,facility,both,1,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,35402,CDM,J7512,HCPCS,0054-0018-20,NDC,,,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM POLYSTYRENE SULF-SORBTL 15-20 GRAM/60 ML ORAL SUSP,35402,CDM,J3490,HCPCS,46287-006-60,NDC,,,facility,both,1,ML,,264,184.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-7914-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 100 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-6500-61,NDC,,,facility,both,1,EA,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),35402,CDM,J3490,HCPCS,0409-4888-06,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-7350-06,NDC,,,facility,both,1,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,0093-2279-73,NDC,,,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  2 MG ORAL TAB,35402,CDM,J3490,HCPCS,42858-301-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,35402,CDM,J3010,HCPCS,0409-9094-22,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR PHOSPHATE 30 MG ORAL CAP,35402,CDM,J3490,HCPCS,47781-468-13,NDC,,,facility,both,1,EA,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,J7040,HCPCS,0264-1800-31,NDC,,,facility,both,1,ML,,505,353.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,35402,CDM,J7510,HCPCS,17856-0759-5,NDC,,,facility,both,1,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,42806-151-34,NDC,,,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,68094-600-59,NDC,,,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % MUCOSAL GEL,35402,CDM,J3490,HCPCS,17478-711-30,NDC,,,facility,both,1,ML,,463,324.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,35402,CDM,J7510,HCPCS,17856-0815-1,NDC,,,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE  25 MG ORAL TAB,35402,CDM,J3490,HCPCS,63629-1064-3,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJ SOLN,35402,CDM,J3490,HCPCS,63323-464-01,NDC,,,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER SULFADIAZINE 1 % TOP CREA,35402,CDM,J3490,HCPCS,49999-185-25,NDC,,,facility,both,1,GM,,129,90.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,68180-441-02,NDC,,,facility,both,1,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE 21 MG/24 HR TD PT24,35402,CDM,J3490,HCPCS,0536-5896-88,NDC,,,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,76297-001-32,NDC,,,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 300 MG ORAL CAP,35402,CDM,J3490,HCPCS,57237-099-60,NDC,,,facility,both,1,EA,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 15 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-6519-61,NDC,,,facility,both,1,EA,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),35402,CDM,J3490,HCPCS,0409-4888-10,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,35402,CDM,J3490,HCPCS,60687-653-11,NDC,,,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,68094-494-59,NDC,,,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4 % TOP CREA,35402,CDM,J3490,HCPCS,0496-0882-05,NDC,,,facility,both,1,GM,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TAB,35402,CDM,J3490,HCPCS,0406-0512-23,NDC,,,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG ORAL TAB,35402,CDM,J3490,HCPCS,0093-3425-01,NDC,,,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMETHICONE  80 MG ORAL CHEW,35402,CDM,J3490,HCPCS,0904-7206-60,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,35402,CDM,J7510,HCPCS,17856-0815-1,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,67877-548-88,NDC,,,facility,both,1,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,35402,CDM,J7510,HCPCS,17856-0815-1,NDC,,,facility,both,1,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,35402,CDM,FAMNOCHARGE,HCPCS,60687-145-11,NDC,,,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,35402,CDM,J2003,HCPCS,0409-4276-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 8 MG ORAL TBDL,35402,CDM,Q0162,HCPCS,62756-356-64,NDC,,,facility,both,1,EA,,180,126,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  120 MG RECT SUPP,35402,CDM,J3490,HCPCS,51672-2115-0,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",35402,CDM,J3490,HCPCS,63323-482-01,NDC,,,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,35402,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J3490,HCPCS,63323-492-09,NDC,,,facility,both,1,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),35402,CDM,J3490,HCPCS,73013-2002-2,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 5 MG ORAL TAB,35402,CDM,J3490,HCPCS,60687-381-11,NDC,,,facility,both,1,EA,,198,138.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,35402,CDM,J7510,HCPCS,17856-0815-1,NDC,,,facility,both,1,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4% TOP PATCH,35402,CDM,J3490,HCPCS,46581-830-01,NDC,,,facility,both,2,EA,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 20 MG ORAL TAB,35402,CDM,J3490,HCPCS,0054-8297-25,NDC,,,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,0121-1314-11,NDC,,,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J3490,HCPCS,63323-492-27,NDC,,,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5 % (5 MG/ML) INJ SOLN,35402,CDM,J3490,HCPCS,0409-1163-18,NDC,,,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 600 MG ORAL TP12,35402,CDM,J3490,HCPCS,0536-1163-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,35402,CDM,Q0162,HCPCS,60687-252-40,NDC,,,facility,both,1,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-6172-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,16714-294-02,NDC,,,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 2 %-1:200,000 INJ SOLN",35402,CDM,J3490,HCPCS,63323-489-21,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,16714-294-02,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYBUTYNIN CHLORIDE  5 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-7027-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 100 MG ORAL TAB,35402,CDM,J3490,HCPCS,68084-728-11,NDC,,,facility,both,1,EA,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZOCAINE 20 % MM SPRY,35402,CDM,J3490,HCPCS,0283-0610-43,NDC,,,facility,both,1,EA,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALUMINUM CHLORIDE 20 % TOP SOLN,35402,CDM,J3490,HCPCS,0096-0707-35,NDC,,,facility,both,1,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) NEB SOLUTION,35402,CDM,J3490,HCPCS,0487-9501-60,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,35402,CDM,J7510,HCPCS,17856-0815-1,NDC,,,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  25 MG ORAL TAB,35402,CDM,J3490,HCPCS,68084-346-11,NDC,,,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0338-0049-48,NDC,,,facility,both,1,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  500 MG ORAL TAB,35402,CDM,J3490,HCPCS,10135-144-01,NDC,,,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALUM-MAG HYDROXIDE-SIMETH 200 MG-200 MG-20 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,63739-159-77,NDC,,,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",35402,CDM,J3490,HCPCS,0409-4887-17,NDC,,,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0264-7800-20,NDC,,,facility,both,1,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  120 MG RECT SUPP,35402,CDM,J3490,HCPCS,51672-2115-2,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),35402,CDM,J3490,HCPCS,0409-4888-06,NDC,,,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG RECT SUPP,35402,CDM,J3490,HCPCS,51672-2116-0,NDC,,,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE 0.5 MG/2 ML INHL NBSP,35402,CDM,J3490,HCPCS,68180-984-30,NDC,,,facility,both,1,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",35402,CDM,J3490,HCPCS,0409-3178-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESKETAMINE 56 MG (28 MG X 2) NASL SPRY,35402,CDM,J3490,HCPCS,50458-028-02,NDC,,,facility,both,1,EA,,1159,811.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOPERAMIDE 2 MG ORAL CAP,35402,CDM,J3490,HCPCS,60687-229-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUORESCEIN 1 MG OPHT STRP,35402,CDM,J3490,HCPCS,17238-900-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",35402,CDM,J3490,HCPCS,63323-482-41,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % MUCOSAL SOLN (VISCOUS),35402,CDM,J3490,HCPCS,0121-0903-15,NDC,,,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,35402,CDM,J3490,HCPCS,60687-390-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.45 % 0.45 % IV SOLP,35402,CDM,J3490,HCPCS,0990-7985-09,NDC,,,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNITS/1 GRAM PACKET (MERGE RECORD),35402,CDM,J3490,HCPCS,45802-060-00,NDC,,,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,J7040,HCPCS,0264-1800-31,NDC,,,facility,both,1,ML,,523,366.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TAB,35402,CDM,J3490,HCPCS,0025-0061-31,NDC,,,facility,both,1,EA,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNIT/G TOP PACK,35402,CDM,J3490,HCPCS,67777-116-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0990-7983-61,NDC,,,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0264-1800-32,NDC,,,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % MUCOSAL GEL,35402,CDM,J3490,HCPCS,17478-711-30,NDC,,,facility,both,1,ML,,1181,826.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE HCL  2 % MM JELP,35402,CDM,J3490,HCPCS,76329-3012-5,NDC,,,facility,both,1,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),35402,CDM,J3490,HCPCS,81284-611-00,NDC,,,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,42806-151-34,NDC,,,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,35402,CDM,J2003,HCPCS,63323-485-03,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,35402,CDM,J3490,HCPCS,0904-6666-61,NDC,,,facility,both,1,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER SULFADIAZINE 1 % TOP CREA,35402,CDM,J3490,HCPCS,67877-124-50,NDC,,,facility,both,1,GM,,203,142.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  120 MG RECT SUPP,35402,CDM,J3490,HCPCS,45802-732-00,NDC,,,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,35402,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"NEOMYCIN-POLYMYXIN-HC 3.5 MG-10,000 UNIT/ML-1 % EAR DROPS, SUSP",35402,CDM,J3490,HCPCS,24208-635-62,NDC,,,facility,both,1,ML,,363,254.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 5 MG/ML INHL NEB CONTINUOUS,35402,CDM,J3490,HCPCS,65302-528-15,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,35402,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,0781-6041-55,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,35402,CDM,J3490,HCPCS,0143-9594-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,35402,CDM,J1100,HCPCS,63323-506-01,NDC,,,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,35402,CDM,FAMNOCHARGE,HCPCS,0054-8175-25,NDC,,,facility,both,1,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,68180-441-02,NDC,,,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,35402,CDM,J2003,HCPCS,0409-2066-10,NDC,,,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG ORAL TAB,35402,CDM,J3490,HCPCS,60687-595-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",35402,CDM,J3490,HCPCS,63323-482-03,NDC,,,facility,both,1,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,35402,CDM,FAMNOCHARGE,HCPCS,60687-145-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,35402,CDM,J3490,HCPCS,66553-002-01,NDC,,,facility,both,4,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALUM-MAG HYDROXIDE-SIMETH 400 MG-400 MG-40 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,0904-7326-62,NDC,,,facility,both,1,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG ORAL CAP,35402,CDM,J3490,HCPCS,60687-580-11,NDC,,,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DORZOLAMIDE-TIMOLOL 2 %-0.5 % EYE DROPS,35402,CDM,J3490,HCPCS,62332-553-10,NDC,,,facility,both,1,ML,,440,308,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),35402,CDM,J3490,HCPCS,0409-4888-06,NDC,,,facility,both,1,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORDIAZEPOXIDE 25 MG CAP,35402,CDM,J3490,HCPCS,51079-141-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,16714-294-02,NDC,,,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,35402,CDM,J2003,HCPCS,63323-201-02,NDC,,,facility,both,1,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,35402,CDM,J3490,HCPCS,68462-157-40,NDC,,,facility,both,1,EA,,227,158.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM-ALBUTEROL 0.5 MG-2.5 MG/3 ML NEB SOLUTION,35402,CDM,J3490,HCPCS,0487-0201-00,NDC,,,facility,both,1,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 500 MG-125 MG TAB,35402,CDM,J3490,HCPCS,42571-161-01,NDC,,,facility,both,1,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG ORAL TAB,35402,CDM,J3490,HCPCS,60687-627-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,35402,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,67877-548-88,NDC,,,facility,both,1,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,0143-9889-15,NDC,,,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,35402,CDM,J3490,HCPCS,68084-354-11,NDC,,,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 25 MG TAB,35402,CDM,J3490,HCPCS,51079-255-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",35402,CDM,J2004,HCPCS,0409-3178-16,NDC,,,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,70954-316-10,NDC,,,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J3490,HCPCS,63323-492-08,NDC,,,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,35402,CDM,FAMNOCHARGE,HCPCS,60687-675-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % MUCOSAL GEL,35402,CDM,J3490,HCPCS,17478-840-05,NDC,,,facility,both,1,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/0.5 ML INHL NEBU,35402,CDM,J3490,HCPCS,62135-829-84,NDC,,,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J3490,HCPCS,0409-4713-12,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,35402,CDM,J3490,HCPCS,0904-6666-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,35402,CDM,J3490,HCPCS,0409-2066-05,NDC,,,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,35402,CDM,J3490,HCPCS,60687-742-11,NDC,,,facility,both,1,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,35402,CDM,Q0162,HCPCS,17856-0555-5,NDC,,,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG ORAL TAB,35402,CDM,J3490,HCPCS,72789-355-30,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MONTELUKAST 10 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-6808-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJ SOLN,35402,CDM,J3490,HCPCS,0409-1559-19,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG ORAL TAB,35402,CDM,J3490,HCPCS,69315-904-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETIRIZINE 5 MG/5 ML ORAL SOLN,35402,CDM,J3490,HCPCS,68094-004-59,NDC,,,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJ SOLN",35402,CDM,J3490,HCPCS,0409-9042-17,NDC,,,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALACYCLOVIR 500 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-6565-61,NDC,,,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,68094-330-59,NDC,,,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE  5 MG ORAL TAB,35402,CDM,J3490,HCPCS,51079-886-01,NDC,,,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,68180-441-02,NDC,,,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ROTAVIRUS VACCINE, LIVE, 89-12 10EXP6 CCID50 /1.5 ML ORAL SUSP",35402,CDM,90681,HCPCS,58160-740-02,NDC,,,facility,both,1,ML,,599,419.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0338-0049-38,NDC,,,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,35402,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J3490,HCPCS,0409-4713-32,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,0121-0914-05,NDC,,,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),35402,CDM,J3490,HCPCS,73013-2002-2,NDC,,,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ROTAVIRUS VACCINE, LIVE, 89-12 10EXP6 CCID50 /1.5 ML ORAL SUSP",35402,CDM,90681,HCPCS,58160-740-02,NDC,,,facility,both,1,ML,,400,280,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,81033-002-20,NDC,,,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,67877-548-88,NDC,,,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMIDE PEROXIDE 6.5 % OTIC DROP,35402,CDM,J3490,HCPCS,4203710479,NDC,,,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,16714-293-03,NDC,,,facility,both,1,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNIT/G TOP PACK,35402,CDM,J3490,HCPCS,67777-116-10,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNIT/G TOP PACK,35402,CDM,J3490,HCPCS,68001-477-45,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  5 MG ORAL TBDL,35402,CDM,J3490,HCPCS,55111-262-79,NDC,,,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BALANCED SALT IRRIG SOLN COMB2 INTRAOCULAR,35402,CDM,J3490,HCPCS,0065-0795-15,NDC,,,facility,both,1,ML,,149,104.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,J7040,HCPCS,0338-0049-03,NDC,,,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",35402,CDM,J3490,HCPCS,0409-3178-03,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,63739-196-01,NDC,,,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,63739-196-01,NDC,,,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MISOPROSTOL 200 MCG ORAL TAB,35402,CDM,S0191,HCPCS,59762-5008-1,NDC,,,facility,both,1,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,35402,CDM,J3490,HCPCS,77333-049-25,NDC,,,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J3490,HCPCS,63323-492-27,NDC,,,facility,both,1,ML,,236,165.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM-ALBUTEROL 0.5 MG-2.5 MG/3 ML NEB SOLUTION,35402,CDM,J3490,HCPCS,76204-600-01,NDC,,,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 0.25 MG ORAL TAB,35402,CDM,J3490,HCPCS,68084-270-11,NDC,,,facility,both,1,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,70954-316-10,NDC,,,facility,both,1,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENAZOPYRIDINE 100 MG ORAL TAB,35402,CDM,J3490,HCPCS,75826-114-10,NDC,,,facility,both,1,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALUMINUM-MAGNESIUM HYDROXIDE 200 MG-200 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,0121-1760-30,NDC,,,facility,both,1,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL 100 MCG/HR TD PT72,35402,CDM,J3490,HCPCS,0378-9124-16,NDC,,,facility,both,1,EA,,227,158.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,35402,CDM,J7510,HCPCS,17856-0815-1,NDC,,,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJ SOLN,35402,CDM,J3490,HCPCS,63323-464-01,NDC,,,facility,both,1,ML,,143,100.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,68180-150-01,NDC,,,facility,both,1,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,J7040,HCPCS,0264-1800-31,NDC,,,facility,both,1,ML,,685,479.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,67877-548-88,NDC,,,facility,both,1,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,68094-600-59,NDC,,,facility,both,1,ML,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MECLIZINE 25 MG ORAL TAB,35402,CDM,J3490,HCPCS,50268-523-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG ORAL TAB,35402,CDM,J3490,HCPCS,0187-0063-01,NDC,,,facility,both,1,EA,,218,152.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"TYPHOID VACCINE 2 BILLION UNIT CAP, DELAYED RELEASE",35402,CDM,90690,HCPCS,69401-000-02,NDC,,,facility,both,1,EA,,157,109.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROFURANTOIN (25% MACROCRYSTAL FORM) 100 MG CAP,35402,CDM,J3490,HCPCS,0904-7137-61,NDC,,,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,35402,CDM,J3490,HCPCS,69315-905-01,NDC,,,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",35402,CDM,J3490,HCPCS,63323-185-10,NDC,,,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZOCAINE 20 % MM SPRY,35402,CDM,J3490,HCPCS,0283-0610-43,NDC,,,facility,both,1,EA,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ROTAVIRUS VACCINE, LIVE, 89-12 10EXP6 CCID50 /1.5 ML ORAL SUSP",35402,CDM,90681,HCPCS,58160-740-21,NDC,,,facility,both,1,ML,,424,296.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETIRIZINE 10 MG ORAL TAB,35402,CDM,J3490,HCPCS,51079-597-01,NDC,,,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ROTAVIRUS VACCINE, LIVE, 89-12 10EXP6 CCID50 /1.5 ML ORAL SUSP",35402,CDM,90681,HCPCS,58160-740-21,NDC,,,facility,both,1,ML,,635,444.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,35402,CDM,J3490,HCPCS,3786407039,NDC,,,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNITS/1 GRAM PACKET (MERGE RECORD),35402,CDM,J3490,HCPCS,0904-7023-67,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,35402,CDM,J3490,HCPCS,16714-200-10,NDC,,,facility,both,1,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,35402,CDM,J3490,HCPCS,16714-200-10,NDC,,,facility,both,1,EA,,111,77.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR PHOSPHATE 30 MG ORAL CAP,35402,CDM,J3490,HCPCS,31722-630-31,NDC,,,facility,both,1,EA,,139,97.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LET TOPICAL GEL 3 ML,35402,CDM,J3490,HCPCS,05446-0607-01,NDC,,,facility,both,1,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,70954-316-10,NDC,,,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",35402,CDM,J2004,HCPCS,63323-482-03,NDC,,,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,68180-150-01,NDC,,,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 20 MG ORAL TAB,35402,CDM,J3490,HCPCS,42291-468-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 875 MG-125 MG TAB,35402,CDM,J3490,HCPCS,60687-803-01,NDC,,,facility,both,1,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIOTHYRONINE  5 MCG ORAL TAB,35402,CDM,J3490,HCPCS,68382-582-01,NDC,,,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,0093-2279-73,NDC,,,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 20 MG/2 ML IV SOLN,35402,CDM,J3490,HCPCS,63323-739-12,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,35402,CDM,J3490,HCPCS,60687-742-11,NDC,,,facility,both,1,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 600 MG ORAL TAB,35402,CDM,J3490,HCPCS,43353-393-60,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4 % TOP CREA,35402,CDM,J3490,HCPCS,0496-0882-05,NDC,,,facility,both,1,GM,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,35402,CDM,J7512,HCPCS,0054-0018-29,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),35402,CDM,J3490,HCPCS,6425311125,NDC,,,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,35402,CDM,J3490,HCPCS,68094-900-30,NDC,,,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 8 MG ORAL TBDL,35402,CDM,Q0162,HCPCS,68462-158-40,NDC,,,facility,both,1,EA,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0338-0049-41,NDC,,,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE CONCENTRATE 10 MG/ 0.5 ML ORAL SYRINGE (0.5ML UD MERGE),35402,CDM,J3490,HCPCS,0406-8003-30,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,35402,CDM,J3490,HCPCS,69315-905-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK,35402,CDM,J3490,HCPCS,12870-0001-1,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,35402,CDM,J3490,HCPCS,63323-201-02,NDC,,,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,35402,CDM,J3490,HCPCS,63323-202-02,NDC,,,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  5 MG ORAL TAB,35402,CDM,J7512,HCPCS,60687-122-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE HCL  2 % MM JELP,35402,CDM,J3490,HCPCS,25021-673-77,NDC,,,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,35402,CDM,J3490,HCPCS,50268-074-11,NDC,,,facility,both,1,EA,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG ORAL CAP,35402,CDM,J3490,HCPCS,60687-580-11,NDC,,,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 100 MG ORAL TAB,35402,CDM,J3490,HCPCS,60687-439-11,NDC,,,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG ORAL CAP,35402,CDM,J3490,HCPCS,60687-776-11,NDC,,,facility,both,1,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G POTASSIUM  5000000 UNIT INJ SOLR,35402,CDM,J2540,HCPCS,0781-6135-94,NDC,,,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,35402,CDM,J3490,HCPCS,60687-653-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,68180-150-01,NDC,,,facility,both,1,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,35402,CDM,J2003,HCPCS,63323-208-05,NDC,,,facility,both,1,ML,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJ SOLN,35402,CDM,J3490,HCPCS,63323-464-17,NDC,,,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 5 MG ORAL TAB,35402,CDM,J3490,HCPCS,0003-0894-31,NDC,,,facility,both,1,EA,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,35402,CDM,J8540,HCPCS,0904-7266-61,NDC,,,facility,both,1,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",35402,CDM,J3490,HCPCS,63323-482-01,NDC,,,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,35402,CDM,J2003,HCPCS,63323-486-02,NDC,,,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,J7040,HCPCS,0264-1800-31,NDC,,,facility,both,1,ML,,739,517.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN V POTASSIUM 250 MG ORAL TAB,35402,CDM,J3490,HCPCS,57237-040-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 2 %-1:200,000 INJ SOLN",35402,CDM,J3490,HCPCS,0409-3183-11,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,0093-2279-73,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,35402,CDM,J3490,HCPCS,60687-591-11,NDC,,,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0990-7984-36,NDC,,,facility,both,1,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG ORAL CAP,35402,CDM,J3490,HCPCS,60687-152-11,NDC,,,facility,both,4,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 600 MG ORAL TP12,35402,CDM,J3490,HCPCS,68084-572-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 112 MCG ORAL TAB,35402,CDM,J3490,HCPCS,60687-508-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,68180-150-01,NDC,,,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL  5 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-6797-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,35402,CDM,J3490,HCPCS,17856-0759-5,NDC,,,facility,both,1,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,35402,CDM,J3490,HCPCS,7733351625,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,35402,CDM,J3490,HCPCS,63323-208-05,NDC,,,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,67877-548-88,NDC,,,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,0121-1314-11,NDC,,,facility,both,1,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,35402,CDM,J3490,HCPCS,60687-742-11,NDC,,,facility,both,2,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-7914-61,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG ORAL TAB,35402,CDM,Q0169,HCPCS,68084-155-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJ SOLN,35402,CDM,J3490,HCPCS,0409-1559-19,NDC,,,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",35402,CDM,J3490,HCPCS,0409-3178-03,NDC,,,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,35402,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,1,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJ SOLN,35402,CDM,J3490,HCPCS,0409-1559-18,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TETRACAINE HCL (PF) 0.5 % OPHT DROP (STANDARD STOCK),35402,CDM,J3490,HCPCS,0065-0741-14,NDC,,,facility,both,1,ML,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,35402,CDM,J7512,HCPCS,59651-488-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,68180-150-01,NDC,,,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 2 %-1:200,000 INJ SOLN",35402,CDM,J3490,HCPCS,63323-489-02,NDC,,,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,68180-150-01,NDC,,,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"N.MENINGITIDIS B,LIPID FHBP RC 120 MCG/0.5 ML IM SYRG",35402,CDM,J3490,HCPCS,0005-0100-01,NDC,,,facility,both,1,ML,,896,627.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUORESCEIN 1 MG OPHT STRP,35402,CDM,J3490,HCPCS,51801-009-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 5 MG ORAL TAB,35402,CDM,J3490,HCPCS,52959-424-10,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,J7040,HCPCS,0264-1800-31,NDC,,,facility,both,1,ML,,415,290.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/0.5 ML INHL NEBU,35402,CDM,J3490,HCPCS,0487-9901-30,NDC,,,facility,both,1,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J3490,HCPCS,0409-4713-32,NDC,,,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,35402,CDM,J1885,HCPCS,68462-755-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0338-0049-38,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,68094-503-61,NDC,,,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 800 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-5855-60,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCRALFATE 100 MG/ML ORAL SUSP,35402,CDM,J3490,HCPCS,0121-0974-10,NDC,,,facility,both,1,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,35402,CDM,Q0162,HCPCS,17856-0555-1,NDC,,,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MENING A,C,Y,W TT-N. MEN B(PF) 5-120 MCG/0.5 ML IM KIT (CAM USE ONLY)",35402,CDM,J3490,HCPCS,0069-0332-01,NDC,,,facility,both,1,ML,,817,571.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,81033-002-10,NDC,,,facility,both,1,ML,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,35402,CDM,J3490,HCPCS,16714-200-10,NDC,,,facility,both,1,EA,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOBENZAPRINE 10 MG ORAL TAB,35402,CDM,J3490,HCPCS,50268-191-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJ SOLN,35402,CDM,J3490,HCPCS,0409-1159-19,NDC,,,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,J7040,HCPCS,0338-0049-18,NDC,,,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0338-0049-31,NDC,,,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",35402,CDM,J3490,HCPCS,63323-482-05,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MENING A,C,Y,W TT-N. MEN B(PF) 5-120 MCG/0.5 ML IM KIT (CAM USE ONLY)",35402,CDM,J3490,HCPCS,0069-0600-05,NDC,,,facility,both,1,EA,,817,571.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,35402,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,0093-2279-73,NDC,,,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),35402,CDM,J3490,HCPCS,0409-4888-50,NDC,,,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0264-1800-36,NDC,,,facility,both,1,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM-ALBUTEROL 0.5 MG-2.5 MG/3 ML NEB SOLUTION,35402,CDM,J3490,HCPCS,0487-0201-60,NDC,,,facility,both,1,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:200,000 INJ SOLN",35402,CDM,J3490,HCPCS,63323-487-07,NDC,,,facility,both,1,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,35402,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",35402,CDM,J3490,HCPCS,63323-482-01,NDC,,,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,35402,CDM,J3490,HCPCS,51079-444-01,NDC,,,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TETRACAINE HCL (PF) 0.5 % OPHT DROP (STANDARD STOCK),35402,CDM,J3490,HCPCS,0065-0741-14,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 20 GRAM/30 ML ORAL SOLN,35402,CDM,J3490,HCPCS,0121-1154-30,NDC,,,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0990-7984-37,NDC,,,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,35402,CDM,J3490,HCPCS,55150-165-05,NDC,,,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SEMAGLUTIDE 1 MG/DOSE (4 MG/3 ML) SUBQ PNIJ,35402,CDM,J3490,HCPCS,0169-4130-01,NDC,,,facility,both,1,ML,,2754,1927.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIPHTH,PERTUS(ACELL),TETANUS SYRG(BOOSTRIX) 2.5-8-5 LF-MCG-LF/0.5ML IM SYRG",35402,CDM,90715,HCPCS,58160-842-52,NDC,,,facility,both,1,ML,,247,172.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMIDE PEROXIDE 6.5 % OTIC DROP,35402,CDM,J3490,HCPCS,11822-3349-10,NDC,,,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,35402,CDM,J1100,HCPCS,63323-165-05,NDC,,,facility,both,1,ML,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,35402,CDM,J3490,HCPCS,0409-2066-10,NDC,,,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,35402,CDM,J3490,HCPCS,0409-4276-16,NDC,,,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 20 GRAM/30 ML ORAL SOLN,35402,CDM,J3490,HCPCS,0121-1154-30,NDC,,,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,0121-0917-05,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG ORAL TAB,35402,CDM,J3490,HCPCS,0228-2127-10,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % MUCOSAL GEL,35402,CDM,J3490,HCPCS,17478-711-30,NDC,,,facility,both,1,ML,,2067,1446.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J3490,HCPCS,63323-492-04,NDC,,,facility,both,1,ML,,236,165.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-0430-04,NDC,,,facility,both,1,EA,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ROTAVIRUS VACCINE, LIVE, 89-12 10EXP6 CCID50 /1.5 ML ORAL SUSP",35402,CDM,90681,HCPCS,58160-740-21,NDC,,,facility,both,1,ML,,599,419.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,35402,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,16714-293-03,NDC,,,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,35402,CDM,FAMNOCHARGE,HCPCS,0904-7127-61,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,35402,CDM,J2003,HCPCS,63323-201-02,NDC,,,facility,both,1,ML,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALUM-MAG HYDROXIDE-SIMETH 200 MG-200 MG-20 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,0121-1761-30,NDC,,,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) NEB SOLUTION,35402,CDM,J3490,HCPCS,47335-703-48,NDC,,,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALUM-MAG HYDROXIDE-SIMETH 400 MG-400 MG-40 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,0121-1762-30,NDC,,,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALUM-MAG HYDROXIDE-SIMETH 400 MG-400 MG-40 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,17856-5725-3,NDC,,,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOMYCIN-BACITRACN ZN-POLYMYXIN 3.5 MG-400 U*,35402,CDM,J3490,HCPCS,45802-143-00,NDC,,,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LET TOPICAL GEL 3 ML,35402,CDM,J3490,HCPCS,69623-801-14,NDC,,,facility,both,1,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,35402,CDM,J3490,HCPCS,60687-464-11,NDC,,,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0338-0049-48,NDC,,,facility,both,3,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOPERAMIDE 2 MG ORAL CAP,35402,CDM,J3490,HCPCS,51079-690-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,35402,CDM,FAMNOCHARGE,HCPCS,60687-145-11,NDC,,,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,35402,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 875 MG-125 MG TAB,35402,CDM,J3490,HCPCS,0781-1852-20,NDC,,,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0338-0049-31,NDC,,,facility,both,1,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,0093-2279-73,NDC,,,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 300 MG ORAL CAP,35402,CDM,J3490,HCPCS,60687-699-11,NDC,,,facility,both,1,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,J7040,HCPCS,0338-0049-04,NDC,,,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,35402,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG ORAL TAB,35402,CDM,J3490,HCPCS,50268-279-11,NDC,,,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM-ALBUTEROL 0.5 MG-2.5 MG/3 ML NEB SOLUTION,35402,CDM,J3490,HCPCS,76204-600-30,NDC,,,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4% TOP PATCH,35402,CDM,J3490,HCPCS,0536-1202-15,NDC,,,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,68180-150-01,NDC,,,facility,both,1,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SOLN,35402,CDM,J3490,HCPCS,0904-7319-41,NDC,,,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",35402,CDM,J3490,HCPCS,63323-185-07,NDC,,,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  75 MCG ORAL TAB,35402,CDM,J3490,HCPCS,0904-6951-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,68094-015-59,NDC,,,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMETHICONE 40 MG/0.6 ML ORAL DRPS,35402,CDM,J3490,HCPCS,70677-1078-1,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,35402,CDM,J3490,HCPCS,63323-202-02,NDC,,,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SYRG,35402,CDM,J3490,HCPCS,8290306546,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,35402,CDM,J3490,HCPCS,63323-202-02,NDC,,,facility,both,1,ML,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J3490,HCPCS,0409-4713-12,NDC,,,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),35402,CDM,J3490,HCPCS,72485-510-01,NDC,,,facility,both,1,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SYRG,35402,CDM,J3490,HCPCS,8290306546,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 600 MG ORAL TAB,35402,CDM,J3490,HCPCS,60687-457-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 500 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-7243-61,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNITS/1 GRAM PACKET (MERGE RECORD),35402,CDM,J3490,HCPCS,57896-145-09,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COLCHICINE 0.6 MG ORAL TAB,35402,CDM,J3490,HCPCS,70010-002-01,NDC,,,facility,both,1,EA,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INHL NEBU,35402,CDM,J3490,HCPCS,7620430003,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"TYPHOID VACCINE 2 BILLION UNIT CAP, DELAYED RELEASE",35402,CDM,90690,HCPCS,50632-016-02,NDC,,,facility,both,1,EA,,173,121.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0338-0049-01,NDC,,,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,35402,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,68094-231-59,NDC,,,facility,both,1,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,35402,CDM,J7510,HCPCS,17856-0815-1,NDC,,,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,35402,CDM,J1100,HCPCS,55150-304-01,NDC,,,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,35402,CDM,FAMNOCHARGE,HCPCS,60687-252-40,NDC,,,facility,both,1,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,35402,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,35402,CDM,J3490,HCPCS,48433-129-01,NDC,,,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0990-7984-36,NDC,,,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 15 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-6519-61,NDC,,,facility,both,1,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,0093-2279-73,NDC,,,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,35402,CDM,J2003,HCPCS,63323-201-02,NDC,,,facility,both,1,ML,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,0121-2044-10,NDC,,,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0338-0049-31,NDC,,,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  120 MG RECT SUPP,35402,CDM,J3490,HCPCS,51672-2115-0,NDC,,,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),35402,CDM,J3490,HCPCS,0409-4888-06,NDC,,,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,68180-441-02,NDC,,,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,35402,CDM,Q0162,HCPCS,60687-252-40,NDC,,,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM CITRATE ORAL SOLN,35402,CDM,J3490,HCPCS,69452-389-98,NDC,,,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,J3490,HCPCS,0264-1800-31,NDC,,,facility,both,1,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,35402,CDM,FAMNOCHARGE,HCPCS,0904-7266-61,NDC,,,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 50 MG CAP,35402,CDM,Q0163,HCPCS,0904-2056-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYMETAZOLINE 0.05 % NASL SPRA,35402,CDM,J3490,HCPCS,0904-7427-30,NDC,,,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG TAB,35402,CDM,J3490,HCPCS,904719106,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,0093-2279-73,NDC,,,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 5 MG-325 MG TAB,35402,CDM,J3490,HCPCS,0406-0123-23,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 2 %-1:200,000 INJ SOLN",35402,CDM,J3490,HCPCS,63323-489-02,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EMTRICITABINE-TENOFOVIR 200 MG-300 MG TAB,35402,CDM,J0750,HCPCS,16714-534-01,NDC,,,facility,both,1,EA,,297,207.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,J3490,HCPCS,0264-1800-31,NDC,,,facility,both,1,ML,,451,315.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 2 %-1:200,000 INJ SOLN",35402,CDM,J3490,HCPCS,63323-489-02,NDC,,,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",35402,CDM,J3490,HCPCS,63323-482-03,NDC,,,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,0121-0657-00,NDC,,,facility,both,1,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0264-7800-20,NDC,,,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 500 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-7083-95,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,68180-723-05,NDC,,,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,67877-548-88,NDC,,,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,35402,CDM,Q0162,HCPCS,71205-109-50,NDC,,,facility,both,1,ML,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNIT/G TOP PACK,35402,CDM,J3490,HCPCS,0904-7402-67,NDC,,,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,42806-151-34,NDC,,,facility,both,1,ML,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,35402,CDM,FAMNOCHARGE,HCPCS,0904-7266-61,NDC,,,facility,both,1,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ROTAVIRUS VACCINE LIVE, PENTA 2 ML ORAL SUSP",35402,CDM,90680,HCPCS,0006-4047-01,NDC,,,facility,both,1,ML,,427,298.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,35402,CDM,J3490,HCPCS,0406-5771-23,NDC,,,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,35402,CDM,J7512,HCPCS,63629-1587-1,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 20 GRAM/30 ML ORAL SOLN,35402,CDM,J3490,HCPCS,0121-1154-30,NDC,,,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 875 MG-125 MG TAB,35402,CDM,J3490,HCPCS,65862-503-20,NDC,,,facility,both,1,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,35402,CDM,FAMNOCHARGE,HCPCS,0904-7266-61,NDC,,,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG ORAL TAB,35402,CDM,Q0169,HCPCS,0904-7304-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVONORGESTREL 1.5 MG ORAL TAB,35402,CDM,J3490,HCPCS,69536-162-88,NDC,,,facility,both,1,EA,,191,133.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,35402,CDM,FAMNOCHARGE,HCPCS,17856-0759-5,NDC,,,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4% TOP PATCH,35402,CDM,J3490,HCPCS,46581-830-01,NDC,,,facility,both,1,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,70954-316-10,NDC,,,facility,both,1,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM CITRATE ORAL SOLN,35402,CDM,J3490,HCPCS,70677-1111-1,NDC,,,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER SULFADIAZINE 1 % TOP CREA,35402,CDM,J3490,HCPCS,67877-124-50,NDC,,,facility,both,1,GM,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,J3490,HCPCS,0264-1800-31,NDC,,,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),35402,CDM,J3490,HCPCS,0409-4888-06,NDC,,,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,16714-294-02,NDC,,,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG ORAL TAB,35402,CDM,J3490,HCPCS,0187-0063-01,NDC,,,facility,both,1,EA,,377,263.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,67877-548-88,NDC,,,facility,both,1,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5 % (5 MG/ML) INJ SOLN,35402,CDM,J3490,HCPCS,0143-9329-10,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,35402,CDM,J8540,HCPCS,0904-7266-61,NDC,,,facility,both,1,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ROTAVIRUS VACCINE, LIVE, 89-12 10EXP6 CCID50 /1.5 ML ORAL SUSP",35402,CDM,90681,HCPCS,58160-740-02,NDC,,,facility,both,1,ML,,635,444.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG ORAL TAB,35402,CDM,J3490,HCPCS,63739-645-10,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,0093-2279-73,NDC,,,facility,both,1,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MUPIROCIN 2 % TOP OINT,35402,CDM,J3490,HCPCS,45802-112-22,NDC,,,facility,both,1,GM,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNIT/G TOP PACK,35402,CDM,J3490,HCPCS,0904-7402-67,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",35402,CDM,J2004,HCPCS,63323-482-27,NDC,,,facility,both,1,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 150 MG CAP,35402,CDM,J3490,HCPCS,0904-5959-61,NDC,,,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J3490,HCPCS,55150-163-30,NDC,,,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 875 MG-125 MG TAB,35402,CDM,J3490,HCPCS,16714-297-01,NDC,,,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),35402,CDM,J3490,HCPCS,0409-4888-50,NDC,,,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,35402,CDM,Q0162,HCPCS,60687-252-40,NDC,,,facility,both,1,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,35402,CDM,J7510,HCPCS,17856-0815-1,NDC,,,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,35402,CDM,J3490,HCPCS,63323-486-41,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",35402,CDM,J3490,HCPCS,63323-482-03,NDC,,,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,68180-723-05,NDC,,,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,67877-548-88,NDC,,,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG ORAL CAP,35402,CDM,J3490,HCPCS,0781-2020-01,NDC,,,facility,both,1,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMIDE PEROXIDE 6.5 % OTIC DROP,35402,CDM,J3490,HCPCS,46122-249-05,NDC,,,facility,both,1,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJ SOLN,35402,CDM,J3490,HCPCS,63323-464-17,NDC,,,facility,both,1,ML,,143,100.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,67877-548-88,NDC,,,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,35402,CDM,J2003,HCPCS,0409-4277-02,NDC,,,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",35402,CDM,J2004,HCPCS,63323-482-01,NDC,,,facility,both,1,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,68180-150-01,NDC,,,facility,both,1,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-6052-61,NDC,,,facility,both,1,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 20 MG/5 ML ORAL SOLN,35402,CDM,J3490,HCPCS,0121-0721-04,NDC,,,facility,both,1,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,70954-316-10,NDC,,,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJ SOLN,35402,CDM,J3490,HCPCS,63323-464-17,NDC,,,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,35402,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROFURANTOIN (25% MACROCRYSTAL FORM) 100 MG CAP,35402,CDM,J3490,HCPCS,60687-633-11,NDC,,,facility,both,1,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,35402,CDM,FAMNOCHARGE,HCPCS,17856-0759-5,NDC,,,facility,both,1,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG ORAL TAB,35402,CDM,J3490,HCPCS,63739-645-10,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,68094-600-59,NDC,,,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,35402,CDM,J3490,HCPCS,57237-077-10,NDC,,,facility,both,1,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,42806-151-34,NDC,,,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,35402,CDM,J3490,HCPCS,63323-496-97,NDC,,,facility,both,1,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 10 MG ORAL CAP,35402,CDM,J3490,HCPCS,60687-369-11,NDC,,,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  5 MG ORAL TAB,35402,CDM,FAMNOCHARGE,HCPCS,60687-122-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RACEPINEPHRINE 2.25 % INHL NEBU,35402,CDM,J3490,HCPCS,0487-5901-99,NDC,,,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,35402,CDM,J3490,HCPCS,0173-0682-24,NDC,,,facility,both,1,GM,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,67877-548-88,NDC,,,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,35402,CDM,J3490,HCPCS,63323-495-07,NDC,,,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE 0.5 MG/2 ML INHL NBSP,35402,CDM,J3490,HCPCS,0093-6816-73,NDC,,,facility,both,1,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-7912-51,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,35402,CDM,J3490,HCPCS,60687-591-11,NDC,,,facility,both,1,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  50 MG ORAL TAB,35402,CDM,J3490,HCPCS,60687-242-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCRALFATE 100 MG/ML ORAL SUSP,35402,CDM,J3490,HCPCS,0121-0974-10,NDC,,,facility,both,1,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 25 MG TAB,35402,CDM,J3490,HCPCS,65862-146-36,NDC,,,facility,both,1,EA,,390,273,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,0093-2279-73,NDC,,,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0264-1800-36,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,67877-548-88,NDC,,,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSP,35402,CDM,J3490,HCPCS,68094-061-59,NDC,,,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,35402,CDM,J2003,HCPCS,63323-201-03,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),35402,CDM,J3490,HCPCS,72603-387-01,NDC,,,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4 % MUCOSAL TOPICAL SOLN,35402,CDM,J3490,HCPCS,70954-518-10,NDC,,,facility,both,1,ML,,275,192.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 8 MG ORAL TBDL,35402,CDM,Q0162,HCPCS,57237-078-30,NDC,,,facility,both,1,EA,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALACYCLOVIR 500 MG ORAL TAB,35402,CDM,J3490,HCPCS,63739-077-10,NDC,,,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,0121-1314-11,NDC,,,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 2 %-1:200,000 INJ SOLN",35402,CDM,J2004,HCPCS,63323-489-02,NDC,,,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,35402,CDM,J2003,HCPCS,63323-201-02,NDC,,,facility,both,1,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 100 MG ORAL TAB,35402,CDM,J3490,HCPCS,68084-728-11,NDC,,,facility,both,1,EA,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5 % (5 MG/ML) INJ SOLN,35402,CDM,J3490,HCPCS,63323-467-57,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TAB,35402,CDM,J3490,HCPCS,0406-0512-23,NDC,,,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",35402,CDM,J3490,HCPCS,0409-4887-23,NDC,,,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,16714-293-03,NDC,,,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCHLOROTHIAZIDE  25 MG ORAL TAB,35402,CDM,J3490,HCPCS,60687-593-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,35402,CDM,Q0162,HCPCS,60687-252-40,NDC,,,facility,both,1,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,67877-548-88,NDC,,,facility,both,1,ML,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,35402,CDM,Q0177,HCPCS,0093-5061-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,0121-0657-05,NDC,,,facility,both,1,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  15 MG ORAL TAB,35402,CDM,J3490,HCPCS,0406-8515-23,NDC,,,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 500 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-7126-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE  7 % INHL NEBU,35402,CDM,J3490,HCPCS,487900730,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,35402,CDM,J3490,HCPCS,60687-464-11,NDC,,,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,68094-494-59,NDC,,,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,35402,CDM,J3490,HCPCS,10135-123-24,NDC,,,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,35402,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ROTAVIRUS VAC,LIVE ATT, 89-12 STRAIN G1P(8) 10EXP6 CCID50/ML ORAL SUSP",35402,CDM,90681,HCPCS,58160-854-52,NDC,,,facility,both,1,ML,,873,611.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J2003,HCPCS,0409-4713-02,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-7124-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN NORMAL SALINE IV,35402,CDM,FAMNOCHARGE,HCPCS,0338-0089-04,NDC,,,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,35402,CDM,J3490,HCPCS,63323-202-02,NDC,,,facility,both,1,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM-ALBUTEROL 0.5 MG-2.5 MG/3 ML NEB SOLUTION,35402,CDM,J3490,HCPCS,47335-756-49,NDC,,,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN V POTASSIUM 250 MG ORAL TAB,35402,CDM,J3490,HCPCS,57237-040-01,NDC,,,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/0.5 ML INHL NEBU,35402,CDM,J3490,HCPCS,0487-9901-02,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,35402,CDM,J3490,HCPCS,0409-4277-02,NDC,,,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE 10 MG ORAL TAB,35402,CDM,J3490,HCPCS,68382-123-16,NDC,,,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,68180-150-01,NDC,,,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,35402,CDM,FAMNOCHARGE,HCPCS,0054-8175-25,NDC,,,facility,both,4,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,35402,CDM,J3490,HCPCS,63323-486-05,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIVAROXABAN 10 MG ORAL TAB,35402,CDM,J3490,HCPCS,50458-580-01,NDC,,,facility,both,1,EA,,234,163.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % MUCOSAL SOLN (VISCOUS),35402,CDM,J3490,HCPCS,0054-0548-44,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,0093-2279-73,NDC,,,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),35402,CDM,J3490,HCPCS,63037-136-25,NDC,,,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,0121-1022-05,NDC,,,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,68180-150-01,NDC,,,facility,both,1,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,0143-9889-15,NDC,,,facility,both,8,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SYRG,35402,CDM,J3490,HCPCS,6380710001,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,68094-231-59,NDC,,,facility,both,3,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,35402,CDM,J3490,HCPCS,68462-157-40,NDC,,,facility,both,1,EA,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,35402,CDM,J8540,HCPCS,0904-7266-61,NDC,,,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,60687-751-42,NDC,,,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,35402,CDM,J3490,HCPCS,10135-123-01,NDC,,,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CUPRIC CHLORIDE 0.4 MG/ML IV SOLN,35402,CDM,J3490,HCPCS,0409-4092-01,NDC,,,facility,both,1,ML,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0990-7983-02,NDC,,,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0338-0049-02,NDC,,,facility,both,1,ML,,175,122.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-7350-61,NDC,,,facility,both,1,EA,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,35402,CDM,J3490,HCPCS,0406-5771-62,NDC,,,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIMOLOL MALEATE 0.5 % OPHT DROP,35402,CDM,J3490,HCPCS,64980-514-05,NDC,,,facility,both,1,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 20 MG/2 ML IV SOLN,35402,CDM,J3490,HCPCS,63323-739-11,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),35402,CDM,J3490,HCPCS,0409-4888-06,NDC,,,facility,both,1,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 0.4 MG SL SUBL,35402,CDM,J3490,HCPCS,43598-436-35,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 1% 10MG/ML (1ML-UD) OR SYRINGE,35402,CDM,J3490,HCPCS,0409-4276-02,NDC,,,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J3490,HCPCS,63323-492-27,NDC,,,facility,both,1,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0990-7983-61,NDC,,,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,60687-751-42,NDC,,,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJ SOLN",35402,CDM,J3490,HCPCS,0409-9042-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE  5 MG ORAL TAB,35402,CDM,J3490,HCPCS,51079-886-01,NDC,,,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCERIN (CHILD) RECTAL SUPPOSITORY,35402,CDM,J3490,HCPCS,58980-409-12,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,35402,CDM,J3490,HCPCS,50268-074-11,NDC,,,facility,both,1,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,16714-294-02,NDC,,,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,35402,CDM,J3490,HCPCS,0378-7732-93,NDC,,,facility,both,1,EA,,219,153.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,68180-441-02,NDC,,,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),35402,CDM,J3490,HCPCS,0409-4888-06,NDC,,,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR  6 MG/ML ORAL SUSR,35402,CDM,J3490,HCPCS,27241-139-09,NDC,,,facility,both,1,ML,,134,93.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSP,35402,CDM,J3490,HCPCS,0121-1781-05,NDC,,,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,0093-2279-73,NDC,,,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,35402,CDM,J3490,HCPCS,0409-4277-01,NDC,,,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN  325 MG ORAL TAB,35402,CDM,J3490,HCPCS,57896-901-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,16714-294-02,NDC,,,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,67877-548-88,NDC,,,facility,both,1,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,67877-548-88,NDC,,,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,35402,CDM,J7510,HCPCS,17856-0815-1,NDC,,,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,1093990033,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 400 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-5853-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,35402,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,67877-548-88,NDC,,,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 5 MG/5 ML IV,35402,CDM,J3490,HCPCS,63323-660-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 100 MG ORAL TAB,35402,CDM,J3490,HCPCS,50268-337-11,NDC,,,facility,both,1,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,60687-751-42,NDC,,,facility,both,1,ML,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMIDE PEROXIDE 6.5 % OTIC DROP,35402,CDM,J3490,HCPCS,8770143152,NDC,,,facility,both,1,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,76297-001-32,NDC,,,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,35402,CDM,J3490,HCPCS,69339-152-01,NDC,,,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,35402,CDM,J3490,HCPCS,0406-5771-23,NDC,,,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR PHOSPHATE 30 MG ORAL CAP,35402,CDM,J3490,HCPCS,31722-630-31,NDC,,,facility,both,1,EA,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZOCAINE 20 % MM SPRY,35402,CDM,J3490,HCPCS,0283-0610-43,NDC,,,facility,both,1,EA,,101,70.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,J3490,HCPCS,0338-0049-31,NDC,,,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  75 MCG ORAL TAB,35402,CDM,J3490,HCPCS,60687-475-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG ORAL CAP,35402,CDM,J3490,HCPCS,60687-152-11,NDC,,,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  20 MEQ ORAL PACK,35402,CDM,J3490,HCPCS,0245-0360-89,NDC,,,facility,both,1,EA,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL  5 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-6797-61,NDC,,,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,0121-0657-05,NDC,,,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0990-7983-61,NDC,,,facility,both,1,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,35402,CDM,J7510,HCPCS,17856-0815-1,NDC,,,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MOXIFLOXACIN 400 MG ORAL TAB,35402,CDM,J3490,HCPCS,65862-603-30,NDC,,,facility,both,1,EA,,134,93.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,35402,CDM,Q0162,HCPCS,60687-252-40,NDC,,,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:200,000 INJ SOLN",35402,CDM,J2004,HCPCS,63323-487-07,NDC,,,facility,both,1,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  5 MG ORAL TAB,35402,CDM,FAMNOCHARGE,HCPCS,60687-122-11,NDC,,,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,67877-548-88,NDC,,,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,67877-548-88,NDC,,,facility,both,1,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 250 MG ORAL TAB,35402,CDM,J3490,HCPCS,43547-688-10,NDC,,,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 1% 10MG/ML (1ML-UD) OR SYRINGE,35402,CDM,J3490,HCPCS,0409-4276-02,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 875 MG-125 MG TAB,35402,CDM,J3490,HCPCS,52959-478-10,NDC,,,facility,both,1,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AXATILIMAB-CSFR 50 MG/ML IV SOLN,35402,CDM,J3490,HCPCS,50881-034-12,NDC,,,facility,both,1,ML,,26082,18257.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,68180-441-02,NDC,,,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAZOSIN 1 MG ORAL CAP,35402,CDM,J3490,HCPCS,0904-7020-61,NDC,,,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4% TOP PATCH,35402,CDM,J3490,HCPCS,46581-830-01,NDC,,,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,35402,CDM,J3490,HCPCS,68084-354-11,NDC,,,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,35402,CDM,J3490,HCPCS,63323-486-02,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOBRAMYCIN 0.3 % EYE OINTMENT,35402,CDM,J3490,HCPCS,0078-0813-01,NDC,,,facility,both,1,GM,,992,694.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,0093-2279-73,NDC,,,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,35402,CDM,FAMNOCHARGE,HCPCS,0904-7127-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR PHOSPHATE 30 MG ORAL CAP,35402,CDM,J3490,HCPCS,64380-797-01,NDC,,,facility,both,1,EA,,139,97.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,35402,CDM,J3490,HCPCS,10135-163-13,NDC,,,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 400 MG ORAL TAB,35402,CDM,J3490,HCPCS,60687-446-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",35402,CDM,J2004,HCPCS,63323-482-17,NDC,,,facility,both,1,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",35402,CDM,J3490,HCPCS,63323-482-03,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROFURANTOIN (25% MACROCRYSTAL FORM) 100 MG CAP,35402,CDM,J3490,HCPCS,59746-762-01,NDC,,,facility,both,1,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 1% 10MG/ML (1ML-UD) OR SYRINGE,35402,CDM,J2003,HCPCS,0409-4276-02,NDC,,,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,35402,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,1,ML,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNITS/1 GRAM PACKET (MERGE RECORD),35402,CDM,J3490,HCPCS,45802-060-00,NDC,,,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0990-7983-61,NDC,,,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE  75 MG IMPL PLLT,35402,CDM,J3490,HCPCS,66887-004-10,NDC,,,facility,both,1,EA,,18330,12831,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MOXIFLOXACIN 400 MG ORAL TAB,35402,CDM,J3490,HCPCS,68084-722-11,NDC,,,facility,both,1,EA,,132,92.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,35402,CDM,J3490,HCPCS,0904-6794-80,NDC,,,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J3490,HCPCS,70756-641-25,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,35402,CDM,J2003,HCPCS,63323-201-02,NDC,,,facility,both,1,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOMYCIN-BACITRACIN ZN-POLYMYXIN 3.5 MG-400 UN*,35402,CDM,J3490,HCPCS,1191705095,NDC,,,facility,both,1,GM,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE MALEATE 10 MG ORAL TAB,35402,CDM,Q0164,HCPCS,60687-825-11,NDC,,,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG ORAL CAP,35402,CDM,J3490,HCPCS,16714-298-02,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,35402,CDM,FAMNOCHARGE,HCPCS,17856-0691-5,NDC,,,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G POTASSIUM  5000000 UNIT INJ SOLR,35402,CDM,J2540,HCPCS,0781-6135-94,NDC,,,facility,both,1,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,35402,CDM,J3490,HCPCS,42858-001-10,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,35402,CDM,J1100,HCPCS,67457-423-12,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  50 MG ORAL CAP,35402,CDM,J3490,HCPCS,0071-1013-41,NDC,,,facility,both,1,EA,,196,137.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J3490,HCPCS,63323-492-09,NDC,,,facility,both,1,ML,,262,183.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJ SOLN",35402,CDM,J3490,HCPCS,0409-9042-16,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 8 MG ORAL TBDL,35402,CDM,Q0162,HCPCS,57237-078-10,NDC,,,facility,both,1,EA,,182,127.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,35402,CDM,J3490,HCPCS,57237-077-10,NDC,,,facility,both,1,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES-DOCUSATE SODIUM 8.6 MG-50 MG TAB,35402,CDM,J3490,HCPCS,10135-669-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 20 GRAM/30 ML ORAL SOLN,35402,CDM,J3490,HCPCS,0121-1154-00,NDC,,,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,35402,CDM,J3490,HCPCS,42023-115-10,NDC,,,facility,both,1,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYMETAZOLINE 0.05 % NASAL MERGE,35402,CDM,J3490,HCPCS,45802-410-59,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIVAROXABAN 15 MG ORAL TAB,35402,CDM,J3490,HCPCS,50458-578-01,NDC,,,facility,both,1,EA,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",35402,CDM,J3490,HCPCS,0409-4887-25,NDC,,,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PILOCARPINE 2 % EYE DROPS,35402,CDM,J3490,HCPCS,61314-204-15,NDC,,,facility,both,1,ML,,363,254.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG ORAL TAB,35402,CDM,J3490,HCPCS,11822-5279-30,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYMETAZOLINE 0.05 % NASL SPRA,35402,CDM,J3490,HCPCS,1093941433,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,16714-294-02,NDC,,,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,35402,CDM,J3490,HCPCS,42806-151-34,NDC,,,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE  25 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-6638-61,NDC,,,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DUPILUMAB 300 MG/2 ML SUBQ PNIJ,35402,CDM,J3490,HCPCS,0024-5915-00,NDC,,,facility,both,1,ML,,5511,3857.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOMYCIN-BACITRACN ZN-POLYMYXIN 3.5 MG-400 U*,35402,CDM,J3490,HCPCS,45802-143-00,NDC,,,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,35402,CDM,J3490,HCPCS,50102-400-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,35402,CDM,J3490,HCPCS,63323-201-10,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),35402,CDM,J3490,HCPCS,0121-1314-11,NDC,,,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERYTHROMYCIN 5 MG/G OPHT OINT,35402,CDM,J3490,HCPCS,72485-670-31,NDC,,,facility,both,1,GM,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,35402,CDM,J3490,HCPCS,55150-254-10,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,35402,CDM,J2003,HCPCS,0409-4277-16,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,J7040,HCPCS,0338-0049-03,NDC,,,facility,both,1,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,17271-701-05,NDC,,,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM-ALBUTEROL 0.5 MG-2.5 MG/3 ML NEB SOLUTION,35402,CDM,J3490,HCPCS,69097-840-87,NDC,,,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MONTELUKAST 10 MG ORAL TAB,35402,CDM,J3490,HCPCS,31722-726-30,NDC,,,facility,both,1,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0990-7983-02,NDC,,,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % MUCOSAL SOLN (VISCOUS),35402,CDM,J3490,HCPCS,0121-4950-15,NDC,,,facility,both,1,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 1.25 MG/3 ML INHL NEBU,35402,CDM,J3490,HCPCS,76204-011-05,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 5 % TOP OINT,35402,CDM,J3490,HCPCS,16714-878-01,NDC,,,facility,both,1,GM,,803,562.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK,35402,CDM,J3490,HCPCS,12870-0001-2,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,35402,CDM,J3490,HCPCS,69339-152-01,NDC,,,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",35402,CDM,J2004,HCPCS,63323-482-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BALANCED SALT SOLN NON-SURG #3 EYE,35402,CDM,J3490,HCPCS,0065-0530-01,NDC,,,facility,both,1,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",35402,CDM,J3490,HCPCS,63323-482-17,NDC,,,facility,both,1,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,35402,CDM,J3490,HCPCS,60687-742-11,NDC,,,facility,both,1,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5 % (5 MG/ML) INJ SOLN,35402,CDM,J3490,HCPCS,0409-1163-01,NDC,,,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J2003,HCPCS,63323-492-31,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZONATATE 100 MG ORAL CAP,35402,CDM,J3490,HCPCS,0904-7153-61,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,68180-150-01,NDC,,,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TETRACAINE HCL (PF) 0.5 % OPHT DROP (STANDARD STOCK),35402,CDM,J3490,HCPCS,0065-0741-14,NDC,,,facility,both,1,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 500 MG ORAL TAB,35402,CDM,J3490,HCPCS,68084-070-01,NDC,,,facility,both,1,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-6008-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,35402,CDM,J3490,HCPCS,63323-486-57,NDC,,,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 20 GRAM/30 ML ORAL SOLN,35402,CDM,J3490,HCPCS,0121-1154-30,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOPERAMIDE 2 MG ORAL CAP,35402,CDM,J3490,HCPCS,51079-690-01,NDC,,,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",35402,CDM,J3490,HCPCS,0409-0007-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE 15 MG ORAL TAB,35402,CDM,J3490,HCPCS,51079-960-01,NDC,,,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE  25 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-6638-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0990-7983-61,NDC,,,facility,both,1,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,68094-494-58,NDC,,,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0990-7983-02,NDC,,,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALUM-MAG HYDROXIDE-SIMETH 200 MG-200 MG-20 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,0904-7325-62,NDC,,,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 8 MG ORAL TBDL,35402,CDM,Q0162,HCPCS,68462-158-11,NDC,,,facility,both,1,EA,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J2003,HCPCS,63323-492-04,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,35402,CDM,J3490,HCPCS,16714-294-02,NDC,,,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LATANOPROST 0.005 % OPHT DROP,35402,CDM,J3490,HCPCS,61314-547-01,NDC,,,facility,both,1,ML,,403,282.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  2 MG ORAL TAB,35402,CDM,J3490,HCPCS,0406-3243-01,NDC,,,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,35402,CDM,FAMNOCHARGE,HCPCS,0264-1800-36,NDC,,,facility,both,1,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,35402,CDM,J3490,HCPCS,63323-495-26,NDC,,,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,35402,CDM,J3490,HCPCS,63323-495-04,NDC,,,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 25 MG TAB,35402,CDM,J3490,HCPCS,65862-146-36,NDC,,,facility,both,1,EA,,230,161,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYMETAZOLINE 0.05 % NASAL MERGE,35402,CDM,J3490,HCPCS,70677-1037-1,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG ORAL TAB,35402,CDM,J3490,HCPCS,50268-299-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDO-EPI WITH 8.4% SOD BICARB 1 %- 1:100,000 (3 ML) INJ SYRG",35402,CDM,J3490,HCPCS,70092-1691-44,NDC,,,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:200,000 INJ SOLN",35402,CDM,J2004,HCPCS,63323-487-01,NDC,,,facility,both,1,ML,,195,136.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",35402,CDM,J3490,HCPCS,0409-4887-25,NDC,,,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,35402,CDM,J3490,HCPCS,60687-464-11,NDC,,,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG ORAL TAB,35402,CDM,J3490,HCPCS,16837-855-25,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,35402,CDM,J3490,HCPCS,69339-152-01,NDC,,,facility,both,1,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG ORAL CAP,35402,CDM,J3490,HCPCS,0093-3145-01,NDC,,,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5 % (5 MG/ML) INJ SOLN,35402,CDM,J3490,HCPCS,0409-1610-50,NDC,,,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COLCHICINE 0.6 MG ORAL TAB,35402,CDM,J3490,HCPCS,42292-054-01,NDC,,,facility,both,1,EA,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,35402,CDM,J3490,HCPCS,57237-077-10,NDC,,,facility,both,1,EA,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,35402,CDM,J3490,HCPCS,50111-787-66,NDC,,,facility,both,1,EA,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,35402,CDM,J3490,HCPCS,42291-082-30,NDC,,,facility,both,1,EA,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,35402,CDM,J3490,HCPCS,63323-492-04,NDC,,,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MECLIZINE 25 MG ORAL TAB,35402,CDM,J3490,HCPCS,0904-7376-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 100 MG/5 ML ORAL LIQD,35402,CDM,J3490,HCPCS,0121-1488-10,NDC,,,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBQ SYRG,35444,CDM,Q5111,HCPCS,70114-101-01,NDC,,,facility,both,12,ML,,11523,8066.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MENINGOCOCCAL B VACC,4-CMP(PF) 50-50-50-25 MCG/0.5 ML IM SYRG",35526,CDM,90620,HCPCS,58160-976-20,NDC,,,facility,both,1,ML,,839,587.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MENINGOCOCCAL B VACC,4-CMP(PF) 50-50-50-25 MCG/0.5 ML IM SYRG",35526,CDM,90620,HCPCS,46028-114-11,NDC,,,facility,both,1,ML,,694,485.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MENINGOCOCCAL B VACC,4-CMP(PF) 50-50-50-25 MCG/0.5 ML IM SYRG",35526,CDM,90620,HCPCS,58160-976-02,NDC,,,facility,both,1,ML,,839,587.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MENINGOCOCCAL B VACC,4-CMP(PF) 50-50-50-25 MCG/0.5 ML IM SYRG",35526,CDM,90620,HCPCS,58160-976-20,NDC,,,facility,both,1,ML,,792,554.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MENINGOCOCCAL B VACC,4-CMP(PF) 50-50-50-25 MCG/0.5 ML IM SYRG",35526,CDM,90620,HCPCS,58160-976-02,NDC,,,facility,both,1,ML,,792,554.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIP,PER(A)TET-HEPB-POL-HIB(PF) 15 UNIT-5 UNIT- 10 MCG/0.5 ML IM INJ MERGE (CAM USE ONLY)",35715,CDM,90697,HCPCS,63361-243-15,NDC,,,facility,both,1,ML,,674,471.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIP,PER(A)TET-HEPB-POL-HIB(PF) 15 UNIT-5 UNIT- 10 MCG/0.5 ML IM INJ MERGE (CAM USE ONLY)",35715,CDM,90697,HCPCS,63361-243-15,NDC,,,facility,both,1,ML,,631,441.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIP,PER(A)TET-HEPB-POL-HIB(PF) 15 UNIT-5 UNIT- 10 MCG/0.5 ML IM INJ MERGE (CAM USE ONLY)",35715,CDM,90697,HCPCS,63361-243-88,NDC,,,facility,both,1,ML,,674,471.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIPH,PERTUS(ACEL),TET,POLIO(PF)(KINRIX) 25 LF-58 MCG-10 LF/0.5 ML IM SYRINGE",35715,CDM,90696,HCPCS,58160-812-43,NDC,,,facility,both,1,ML,,318,222.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIP,PER(A)TET-HEPB-POL-HIB(PF) 15 UNIT-5 UNIT- 10 MCG/0.5 ML IM INJ MERGE (CAM USE ONLY)",35715,CDM,90697,HCPCS,63361-243-88,NDC,,,facility,both,1,ML,,674,471.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIP,PER(A)TET-HEPB-POL-HIB(PF) 15 UNIT-5 UNIT- 10 MCG/0.5 ML IM INJ MERGE (CAM USE ONLY)",35715,CDM,90697,HCPCS,63361-243-15,NDC,,,facility,both,1,ML,,674,471.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIP,PER(A)TET-HEPB-POL-HIB(PF) 15 UNIT-5 UNIT- 10 MCG/0.5 ML IM SYRG",35715,CDM,90697,HCPCS,49281-561-01,NDC,,,facility,both,1,ML,,421,294.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLIOVIRUS VACCINE 40-8-32 UNIT/0.5 ML INJ SUSP,35715,CDM,90713,HCPCS,49281-860-10,NDC,,,facility,both,1,ML,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIP,PER(A)TET-HEPB-POL-HIB(PF) 15 UNIT-5 UNIT- 10 MCG/0.5 ML IM INJ MERGE (CAM USE ONLY)",35715,CDM,90697,HCPCS,63361-243-88,NDC,,,facility,both,1,ML,,631,441.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIP,PER(A)TET-HEPB-POL-HIB(PF) 15 UNIT-5 UNIT- 10 MCG/0.5 ML IM INJ MERGE (CAM USE ONLY)",35715,CDM,90697,HCPCS,63361-243-58,NDC,,,facility,both,1,ML,,674,471.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEGFILGRASTIM 6 MG/0.6 ML SUBQ W/ ON BODY INJECTOR,35727,CDM,J2506,HCPCS,55513-192-01,NDC,,,facility,both,12,ML,,17714,12399.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEGFILGRASTIM (NEULASTA) 6 MG/0.6ML SUBQ SYRG,35727,CDM,J2506,HCPCS,55513-190-01,NDC,,,facility,both,12,ML,,17714,12399.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEGFILGRASTIM (NEULASTA) 6 MG/0.6ML SUBQ SYRG,35727,CDM,J2506,HCPCS,54868-5229-0,NDC,,,facility,both,12,ML,,9784,6848.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FILGRASTIM-SNDZ 300 MCG/0.5 ML INJ SYRG,35776,CDM,Q5101,HCPCS,61314-304-10,NDC,,,facility,both,300,ML,,976,683.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FILGRASTIM-SNDZ 300 MCG/0.5 ML INJ SYRG,35776,CDM,Q5101,HCPCS,61314-318-01,NDC,,,facility,both,300,ML,,972,680.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FILGRASTIM-SNDZ 480 MCG/0.8 ML INJ SYRG,35776,CDM,Q5101,HCPCS,61314-326-01,NDC,,,facility,both,480,ML,,1212,848.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FILGRASTIM-SNDZ 300 MCG/0.5 ML INJ SYRG,35776,CDM,Q5101,HCPCS,61314-318-05,NDC,,,facility,both,300,ML,,972,680.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FILGRASTIM-SNDZ 480 MCG/0.8 ML INJ SYRG,35776,CDM,Q5101,HCPCS,61314-326-05,NDC,,,facility,both,480,ML,,1212,848.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIVANTAMAB-VMJW 50 MG/ML IV SOLN,35787,CDM,J9061,HCPCS,57894-501-00,NDC,,,facility,both,175,ME,,41176,28823.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIVANTAMAB-VMJW 50 MG/ML IV SOLN,35787,CDM,J9061,HCPCS,57894-501-00,NDC,,,facility,both,140,ME,,32941,23058.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIVANTAMAB-VMJW 50 MG/ML IV SOLN,35787,CDM,J9061,HCPCS,57894-501-00,NDC,,,facility,both,105,ME,,24706,17294.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIVANTAMAB-VMJW 50 MG/ML IV SOLN,35787,CDM,J9061,HCPCS,57894-501-00,NDC,,,facility,both,35,ME,,8236,5765.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOHEXOL 240 MG/ML IV SOLN,35799,CDM,Q9966,HCPCS,0407-1412-10,NDC,,,facility,both,10,ML,,256,179.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOHEXOL 240 MG/ML IV SOLN,35799,CDM,Q9966,HCPCS,0407-1412-10,NDC,,,facility,both,4,ML,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOHEXOL 240 MG/ML IV SOLN,35799,CDM,Q9966,HCPCS,0407-1412-29,NDC,,,facility,both,50,ML,,260,182,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOHEXOL 240 MG/ML IV SOLN,35799,CDM,Q9966,HCPCS,0407-1412-10,NDC,,,facility,both,8,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOHEXOL 240 MG/ML IV SOLN,35799,CDM,Q9966,HCPCS,0407-1412-10,NDC,,,facility,both,3,ML,,108,75.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOHEXOL 240 MG/ML IV SOLN,35799,CDM,Q9966,HCPCS,0407-1412-10,NDC,,,facility,both,5,ML,,145,101.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOHEXOL 240 MG/ML IV SOLN,35799,CDM,Q9966,HCPCS,0407-1412-10,NDC,,,facility,both,6,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOHEXOL 240 MG/ML IV SOLN,35799,CDM,Q9966,HCPCS,0407-1412-30,NDC,,,facility,both,40,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOHEXOL 240 MG/ML IV SOLN,35799,CDM,Q9966,HCPCS,0407-1412-10,NDC,,,facility,both,2,ML,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOHEXOL 240 MG/ML IV SOLN,35799,CDM,Q9966,HCPCS,0407-1412-10,NDC,,,facility,both,7,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOHEXOL 240 MG/ML IV SOLN,35799,CDM,Q9966,HCPCS,0407-1412-10,NDC,,,facility,both,8,ML,,232,162.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOHEXOL 240 MG/ML IV SOLN,35799,CDM,Q9966,HCPCS,0407-1412-20,NDC,,,facility,both,20,ML,,271,189.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOHEXOL 240 MG/ML IV SOLN,35799,CDM,Q9966,HCPCS,0407-1412-30,NDC,,,facility,both,10,ML,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLATUZUMAB VEDOTIN-PIIQ 20 MG/ML IV WET SOLR VIAL (RECON 140 MG VIAL),35979,CDM,J9309,HCPCS,50242-103-01,NDC,,,facility,both,46,EA,,21221,14854.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLATUZUMAB VEDOTIN-PIIQ 20 MG/ML IV WET SOLR VIAL (RECON 140 MG VIAL),35979,CDM,J9309,HCPCS,50242-103-01,NDC,,,facility,both,100,EA,,46132,32292.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLATUZUMAB VEDOTIN-PIIQ 20 MG/ML IV WET SOLR VIAL (RECON 140 MG VIAL),35979,CDM,J9309,HCPCS,50242-103-01,NDC,,,facility,both,22,EA,,10149,7104.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLATUZUMAB VEDOTIN-PIIQ 20 MG/ML IV WET SOLR VIAL (RECON 140 MG VIAL),35979,CDM,J9309,HCPCS,50242-103-01,NDC,,,facility,both,90,EA,,41519,29063.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLATUZUMAB VEDOTIN-PIIQ 20 MG/ML IV WET SOLR VIAL (RECON 140 MG VIAL),35979,CDM,J9309,HCPCS,50242-105-01,NDC,,,facility,both,14,ME,,1800,1260,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLATUZUMAB VEDOTIN-PIIQ 20 MG/ML IV WET SOLR VIAL (RECON 140 MG VIAL),35979,CDM,J9309,HCPCS,50242-103-01,NDC,,,facility,both,82,EA,,37828,26479.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLATUZUMAB VEDOTIN-PIIQ 20 MG/ML IV WET SOLR VIAL (RECON 140 MG VIAL),35979,CDM,J9309,HCPCS,50242-103-01,NDC,,,facility,both,120,EA,,55358,38750.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLATUZUMAB VEDOTIN-PIIQ 20 MG/ML IV WET SOLR VIAL (RECON 140 MG VIAL),35979,CDM,J9309,HCPCS,50242-103-01,NDC,,,facility,both,30,EA,,13840,9688,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLATUZUMAB VEDOTIN-PIIQ 20 MG/ML IV WET SOLR VIAL (RECON 140 MG VIAL),35979,CDM,J9309,HCPCS,50242-103-01,NDC,,,facility,both,80,EA,,36906,25834.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLATUZUMAB VEDOTIN-PIIQ 20 MG/ML IV WET SOLR VIAL (RECON 140 MG VIAL),35979,CDM,J9309,HCPCS,50242-103-01,NDC,,,facility,both,8,EA,,1605,1123.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLATUZUMAB VEDOTIN-PIIQ 20 MG/ML IV WET SOLR VIAL (RECON 140 MG VIAL),35979,CDM,J9309,HCPCS,50242-103-01,NDC,,,facility,both,140,EA,,64585,45209.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLATUZUMAB VEDOTIN-PIIQ 20 MG/ML IV WET SOLR VIAL (RECON 140 MG VIAL),35979,CDM,J9309,HCPCS,50242-105-01,NDC,,,facility,both,120,ME,,35486,24840.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLATUZUMAB VEDOTIN-PIIQ 20 MG/ML IV WET SOLR VIAL (RECON 140 MG VIAL),35979,CDM,J9309,HCPCS,50242-105-01,NDC,,,facility,both,140,ME,,41400,28980,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLATUZUMAB VEDOTIN-PIIQ 20 MG/ML IV WET SOLR VIAL (RECON 140 MG VIAL),35979,CDM,J9309,HCPCS,50242-103-01,NDC,,,facility,both,60,EA,,27679,19375.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLATUZUMAB VEDOTIN-PIIQ 20 MG/ML IV WET SOLR VIAL (RECON 140 MG VIAL),35979,CDM,J9309,HCPCS,50242-105-01,NDC,,,facility,both,82,ME,,24249,16974.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLATUZUMAB VEDOTIN-PIIQ 20 MG/ML IV WET SOLR VIAL (RECON 140 MG VIAL),35979,CDM,J9309,HCPCS,50242-105-01,NDC,,,facility,both,58,ME,,7458,5220.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLATUZUMAB VEDOTIN-PIIQ 20 MG/ML IV WET SOLR VIAL (RECON 140 MG VIAL),35979,CDM,J9309,HCPCS,50242-103-01,NDC,,,facility,both,40,EA,,18453,12917.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLATUZUMAB VEDOTIN-PIIQ 20 MG/ML IV WET SOLR VIAL (RECON 140 MG VIAL),35979,CDM,J9309,HCPCS,50242-103-01,NDC,,,facility,both,56,EA,,25834,18083.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLATUZUMAB VEDOTIN-PIIQ 20 MG/ML IV WET SOLR VIAL (RECON 140 MG VIAL),35979,CDM,J9309,HCPCS,50242-103-01,NDC,,,facility,both,4,EA,,803,562.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLATUZUMAB VEDOTIN-PIIQ 20 MG/ML IV WET SOLR VIAL (RECON 140 MG VIAL),35979,CDM,J9309,HCPCS,50242-103-01,NDC,,,facility,both,96,EA,,44286,31000.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLATUZUMAB VEDOTIN-PIIQ 20 MG/ML IV WET SOLR VIAL (RECON 140 MG VIAL),35979,CDM,J9309,HCPCS,50242-103-01,NDC,,,facility,both,14,EA,,2809,1966.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLATUZUMAB VEDOTIN-PIIQ 20 MG/ML IV WET SOLR VIAL (RECON 140 MG VIAL),35979,CDM,J9309,HCPCS,50242-105-01,NDC,,,facility,both,20,ME,,2572,1800.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLATUZUMAB VEDOTIN-PIIQ 20 MG/ML IV WET SOLR VIAL (RECON 140 MG VIAL),35979,CDM,J9309,HCPCS,50242-105-01,NDC,,,facility,both,126,ME,,37260,26082,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC DRESSING CHANGE W/ ANESTHESIA,36000002,CDM,360,RC,15852,HCPCS,,,facility,both,,,,3030,2121,,,,,,,,,,,,,Gross Charge Type: Central
HC BRONCH FB REMOVAL,36000006,CDM,360,RC,31635,HCPCS,,,facility,both,,,,2833,1983.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PERQ TRANSCATH STENT CERV CAROTID,36000009,CDM,360,RC,37215,HCPCS,,,facility,both,,,,7247,5072.9,,,,,,,,,,,,,Gross Charge Type: Central
HC EXC LINGUAL FRENUM,36000010,CDM,360,RC,41115,HCPCS,,,facility,both,,,,801,560.7,,,,,,,,,,,,,Gross Charge Type: Central
HC REP OF OMPHALOCELE,36000013,CDM,360,RC,36000013,HCPCS,,,facility,both,,,,3632,2542.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PDA LIGATION,36000014,CDM,360,RC,36000014,HCPCS,,,facility,both,,,,6576,4603.2,,,,,,,,,,,,,Gross Charge Type: Central
US ENDOBRONCHIAL ADD-ON,36000015,CDM,360,RC,31654,HCPCS,,,facility,both,,,,2496,1747.2,,,,,,,,,,,,,Gross Charge Type: Central
DX BRONCHOSCOPE/BRUSH,36000016,CDM,360,RC,31623,HCPCS,,,facility,both,,,,3258,2280.6,,,,,,,,,,,,,Gross Charge Type: Central
HC DX BRONCHOSCOPE/LAVAGE,36000017,CDM,360,RC,31624,HCPCS,,,facility,both,,,,3748,2623.6,,,,,,,,,,,,,Gross Charge Type: Central
HC BRONCHOSCOPY RIGID/FLEX INCL FLUORO GUIDE W/TRANSBRONCHIAL LUNG BIOPSY(S) SINGLE LOBE,36000018,CDM,360,RC,31628,HCPCS,,,facility,both,,,,2979,2085.3,,,,,,,,,,,,,Gross Charge Type: Central
NAVIGATIONAL BRONCHOSCOPY,36000020,CDM,360,RC,31627,HCPCS,,,facility,both,,,,314,219.8,,,,,,,,,,,,,Gross Charge Type: Central
BRONCH NEEDLE ASP BX EACH,36000021,CDM,360,RC,31629,HCPCS,,,facility,both,,,,3427,2398.9,,,,,,,,,,,,,Gross Charge Type: Central
BRONCH DILATE W/STENT,36000022,CDM,360,RC,31631,HCPCS,,,facility,both,,,,6489,4542.3,,,,,,,,,,,,,Gross Charge Type: Central
BRONCH NEEDLE BX ADDL LOBE,36000023,CDM,360,RC,31633,HCPCS,,,facility,both,,,,753,527.1,,,,,,,,,,,,,Gross Charge Type: Central
HC ABLATION THER 1 OR MORE PULM TUMORS INCL PLEURA/CHEST WALL WHEN INVOL BY TUMOR EXT PERQ  INCL GUIDE WHEN PEF UNILATERAL CRYOABLATION,36000024,CDM,360,RC,32994,HCPCS,,,facility,both,,,,3210,2247,,,,,,,,,,,,,Gross Charge Type: Central
BRONCH W/BALLOON OCCLUSION,36000025,CDM,360,RC,31634,HCPCS,,,facility,both,,,,6489,4542.3,,,,,,,,,,,,,Gross Charge Type: Central
BRONCH W/PLMT BRONC STENT INIT,36000026,CDM,360,RC,31636,HCPCS,,,facility,both,,,,7463,5224.1,,,,,,,,,,,,,Gross Charge Type: Central
BRONCH W/PCMT BRONC STENT ADDI,36000027,CDM,360,RC,31637,HCPCS,,,facility,both,,,,794,555.8,,,,,,,,,,,,,Gross Charge Type: Central
HC BRONCH W/REVI TRAC/BRONC STENT,36000028,CDM,360,RC,36000028,HCPCS,,,facility,both,,,,3878,2714.6,,,,,,,,,,,,,Gross Charge Type: Central
HC BRONCHOSCOPY W/THERAPEUTIC ASPIRATION OF TRACHBRNCL TREE INITIAL,36000029,CDM,360,RC,31645,HCPCS,,,facility,both,,,,4722,3305.4,,,,,,,,,,,,,Gross Charge Type: Central
HC OR ACUITY 1,36000035,CDM,360,RC,36000035,HCPCS,,,facility,both,,,,4455,3118.5,,,,,,,,,,,,,Gross Charge Type: Central
HC OR ACUITY 2,36000036,CDM,360,RC,36000036,HCPCS,,,facility,both,,,,8105,5673.5,,,,,,,,,,,,,Gross Charge Type: Central
HC OR ACUITY 3,36000037,CDM,360,RC,36000037,HCPCS,,,facility,both,,,,12329,8630.3,,,,,,,,,,,,,Gross Charge Type: Central
HC OR ACUITY 4,36000038,CDM,360,RC,36000038,HCPCS,,,facility,both,,,,18147,12702.9,,,,,,,,,,,,,Gross Charge Type: Central
HC OR ACUITY 5,36000039,CDM,360,RC,36000039,HCPCS,,,facility,both,,,,27329,19130.3,,,,,,,,,,,,,Gross Charge Type: Central
HC C-SECTION FIRST HALF HOUR,36000044,CDM,360,RC,36000044,HCPCS,,,facility,both,,,,8018,5612.6,,,,,,,,,,,,,Gross Charge Type: Central
HC ABDOMINAL HYSTERECTOMY FIRST HALF HOUR,36000045,CDM,360,RC,36000045,HCPCS,,,facility,both,,,,9778,6844.6,,,,,,,,,,,,,Gross Charge Type: Central
HC D & C FIRST HALF HOUR,36000046,CDM,360,RC,36000046,HCPCS,,,facility,both,,,,5902,4131.4,,,,,,,,,,,,,Gross Charge Type: Central
HC LAC REPAIR FIRST HALF HOUR,36000047,CDM,360,RC,36000047,HCPCS,,,facility,both,,,,6811,4767.7,,,,,,,,,,,,,Gross Charge Type: Central
HC 4TH DEGREE LAC REP FIRST HALF HOUR,36000048,CDM,360,RC,36000048,HCPCS,,,facility,both,,,,2651,1855.7,,,,,,,,,,,,,Gross Charge Type: Central
HC OR L&D STAFF 2 15 MIN,36000050,CDM,360,RC,36000050,HCPCS,,,facility,both,,,,608,425.6,,,,,,,,,,,,,Gross Charge Type: Central
HC OR L&D STAFF 3 15 MIN,36000051,CDM,360,RC,36000051,HCPCS,,,facility,both,,,,810,567,,,,,,,,,,,,,Gross Charge Type: Central
HC OR L&D STAFF > 3 15 MIN,36000052,CDM,360,RC,36000052,HCPCS,,,facility,both,,,,1013,709.1,,,,,,,,,,,,,Gross Charge Type: Central
HC OR STAFF 1 15 MIN,36000079,CDM,360,RC,36000079,HCPCS,,,facility,both,,,,440,308,,,,,,,,,,,,,Gross Charge Type: Central
HC OR STAFF 2 15 MIN,36000080,CDM,360,RC,36000080,HCPCS,,,facility,both,,,,656,459.2,,,,,,,,,,,,,Gross Charge Type: Central
HC OR STAFF 3 15 MIN,36000081,CDM,360,RC,36000081,HCPCS,,,facility,both,,,,876,613.2,,,,,,,,,,,,,Gross Charge Type: Central
HC OR STAFF > 3 15 MIN,36000082,CDM,360,RC,36000082,HCPCS,,,facility,both,,,,1095,766.5,,,,,,,,,,,,,Gross Charge Type: Central
HC COSMETIC SURGERY 1 HR,36000086,CDM,360,RC,36000086,HCPCS,,,facility,both,,,,1400,980,,,,,,,,,,,,,Gross Charge Type: Central
HC COSMETIC SURGERY 1.5 HRS,36000088,CDM,360,RC,36000088,HCPCS,,,facility,both,,,,2100,1470,,,,,,,,,,,,,Gross Charge Type: Central
HC COSMETIC SURGERY 2 HRS,36000090,CDM,360,RC,36000090,HCPCS,,,facility,both,,,,2800,1960,,,,,,,,,,,,,Gross Charge Type: Central
HC COSMETIC SURGERY 2.5 HRS,36000092,CDM,360,RC,36000092,HCPCS,,,facility,both,,,,3500,2450,,,,,,,,,,,,,Gross Charge Type: Central
HC COSMETIC SURGERY 3 HRS,36000094,CDM,360,RC,36000094,HCPCS,,,facility,both,,,,4200,2940,,,,,,,,,,,,,Gross Charge Type: Central
HC COSMETIC SURGERY 3.5 HRS,36000096,CDM,360,RC,36000096,HCPCS,,,facility,both,,,,4900,3430,,,,,,,,,,,,,Gross Charge Type: Central
HC COSMETIC SURGERY 4 HRS,36000098,CDM,360,RC,36000098,HCPCS,,,facility,both,,,,5600,3920,,,,,,,,,,,,,Gross Charge Type: Central
HC COSMETIC SURGERY 4.5 HRS,36000100,CDM,360,RC,36000100,HCPCS,,,facility,both,,,,6300,4410,,,,,,,,,,,,,Gross Charge Type: Central
HC COSMETIC SURGERY 5 HRS,36000102,CDM,360,RC,36000102,HCPCS,,,facility,both,,,,7000,4900,,,,,,,,,,,,,Gross Charge Type: Central
HC COSMETIC SURGERY 5.5 HRS,36000104,CDM,360,RC,36000104,HCPCS,,,facility,both,,,,7700,5390,,,,,,,,,,,,,Gross Charge Type: Central
HC COSMETIC SURGERY 6 HRS,36000106,CDM,360,RC,36000106,HCPCS,,,facility,both,,,,8400,5880,,,,,,,,,,,,,Gross Charge Type: Central
HC COSMETIC SECONDARY EA ADDTL 15 MIN,36000110,CDM,360,RC,36000110,HCPCS,,,facility,both,,,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Central
HC COSMETIC OVERNIGHT STAY,36000111,CDM,360,RC,36000111,HCPCS,,,facility,both,,,,711,497.7,,,,,,,,,,,,,Gross Charge Type: Central
HC ESOPH ENDOSCOPY ABLA (HALO BARX),36000112,CDM,750,RC,36000112,HCPCS,,,facility,both,,,,14105,9873.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PERIURETHRAL LACERATION REPAIR,36000113,CDM,360,RC,36000113,HCPCS,,,facility,both,,,,5605,3923.5,,,,,,,,,,,,,Gross Charge Type: Central
HC CIRCLAGE CERVIX INSERT/REMOVAL,36000114,CDM,360,RC,36000114,HCPCS,,,facility,both,,,,2516,1761.2,,,,,,,,,,,,,Gross Charge Type: Central
HC UTERINE INVERSION,36000116,CDM,360,RC,36000116,HCPCS,,,facility,both,,,,8714,6099.8,,,,,,,,,,,,,Gross Charge Type: Central
HC REMOVAL CERVICAL CERCLAGE,36000118,CDM,360,RC,36000118,HCPCS,,,facility,both,,,,635,444.5,,,,,,,,,,,,,Gross Charge Type: Central
HC EVACUATION OF HEMATOMA,36000119,CDM,360,RC,36000119,HCPCS,,,facility,both,,,,7355,5148.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PERFUSIONIST,36000122,CDM,360,RC,36000122,HCPCS,,,facility,both,,,,6680,4676,,,,,,,,,,,,,Gross Charge Type: Central
HC EXPLORATORY LAP/CELIOTOMY W/WO BIOPSY,36000123,CDM,360,RC,49000,HCPCS,,,facility,both,,,,10057,7039.9,,,,,,,,,,,,,Gross Charge Type: Central
HC BRONCHIAL VALVE INSERT INIT,36000124,CDM,360,RC,31647,HCPCS,,,facility,both,,,,5523,3866.1,,,,,,,,,,,,,Gross Charge Type: Central
HC BRONCHIAL VALVE INSERT ADDL,36000125,CDM,360,RC,31651,HCPCS,,,facility,both,,,,1073,751.1,,,,,,,,,,,,,Gross Charge Type: Central
HC BRONCHIAL VALVE REMOV INIT,36000126,CDM,360,RC,31648,HCPCS,,,facility,both,,,,4694,3285.8,,,,,,,,,,,,,Gross Charge Type: Central
HC BRONCHIAL VALVE REMOV ADDL,36000127,CDM,360,RC,31649,HCPCS,,,facility,both,,,,1224,856.8,,,,,,,,,,,,,Gross Charge Type: Central
HC BRONCHOSCOPY RIGID/FLEX INCL FLUORO DX W/ CELL WASHING,36000132,CDM,360,RC,31622,HCPCS,,,facility,both,,,,2833,1983.1,,,,,,,,,,,,,Gross Charge Type: Central
HC CLOSURE MEDIAN STERNOTOMY SEPARATION W/WO DEBRIDEMENT,36000137,CDM,360,RC,21750,HCPCS,,,facility,both,,,,2966,2076.2,,,,,,,,,,,,,Gross Charge Type: Central
HC BRONCHOSCOPY RIGID/FLEX INCL FLURO GUIDE W/TRACHEAL/BRONCHIAL DILATION OR CLSD REDUCTION OF FX,36000140,CDM,360,RC,31630,HCPCS,,,facility,both,,,,3942,2759.4,,,,,,,,,,,,,Gross Charge Type: Central
HC BRONCHOSCOPY RIGID/FLEXIBLE INCL FLUORO GUIDE W/EXCISION OF TUMOR,36000147,CDM,360,RC,31640,HCPCS,,,facility,both,,,,13532,9472.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PLEURAL DRAINAGE PERCUTANEOUS W/INSERTION OF INDWELLING CATHETER W/O IMAGING GUIDE,36000149,CDM,360,RC,32556,HCPCS,,,facility,both,,,,2504,1752.8,,,,,,,,,,,,,Gross Charge Type: Central
HC DENTAL VERT BITEWINGS-SEV TO EIGHT,36000157,CDM,360,RC,D0277,HCPCS,,,facility,both,,,,1879,1315.3,,,,,,,,,,,,,Gross Charge Type: Central
HC BRONCH RIGID/FLEX W/ EBUS SAMPLING 1 OR 2 NODE,36000166,CDM,360,RC,31652,HCPCS,,,facility,both,,,,8379,5865.3,,,,,,,,,,,,,Gross Charge Type: Central
HC BRONCH RIGID/FLEX INCL FLUORO W/ EBUS 3 OR MORE NODES STATNS/STRCT,36000167,CDM,360,RC,31653,HCPCS,,,facility,both,,,,9636,6745.2,,,,,,,,,,,,,Gross Charge Type: Central
HC BRONCHOSCOPY RIGID/FLEX INCL FLUORO GUIDE W/BRONCHIAL OR ENDOBRONC BIOPSY(S) SINGLE/MULTI SITES,36000168,CDM,360,RC,31625,HCPCS,,,facility,both,,,,4310,3017,,,,,,,,,,,,,Gross Charge Type: Central
HC THORACOSCOPY SURGICAL W/RESECTION-PLICATION EMPHYSEMA LUNG FOR LUNG VOL REDUCT UNILAT INCL PLEURAL PROCEDURE,36000169,CDM,360,RC,32672,HCPCS,,,facility,both,,,,4380,3066,,,,,,,,,,,,,Gross Charge Type: Central
HC REMOVAL OF LUNG OTH/THN PNEUMONEC W/RESECTION-PLICATION OF EMPHYSEMATOUS LUNG FOR LUNG VOL REDUCT STERNAL SPLIT /TRANSTHORACIC APPROACH,36000170,CDM,360,RC,32491,HCPCS,,,facility,both,,,,3141,2198.7,,,,,,,,,,,,,Gross Charge Type: Central
HC BRONCHOSCOPY W/THERAPEUTIC ASPIRATION OF TRACHBRNCL TREE SUBSEQUENT,36000171,CDM,360,RC,31646,HCPCS,,,facility,both,,,,2543,1780.1,,,,,,,,,,,,,Gross Charge Type: Central
HC BRONCHOSCOPY RIGID/FLEXIBLE INCLUDE FLUOROSCOPIC GUIDE WHEN PERFORMED W/TRANSBRONCHIAL LUNG BIOPSY EA ADDTL LOBE,36000175,CDM,360,RC,31632,HCPCS,,,facility,both,,,,3256,2279.2,,,,,,,,,,,,,Gross Charge Type: Central
I&D SKIN SUBQ ABSCESS SIMPLE,36100002,CDM,361,RC,10060,HCPCS,,,facility,both,,,,287,200.9,,,,,,,,,,,,,Gross Charge Type: Central
HC I&D HEMATOMA SEROMA,36100003,CDM,361,RC,10140,HCPCS,,,facility,both,,,,1369,958.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PUNCTURE ASPIRATION ABSCESS/HEMATOMA/BULLA/CYST,36100004,CDM,361,RC,10160,HCPCS,,,facility,both,,,,336,235.2,,,,,,,,,,,,,Gross Charge Type: Central
HC DEBRID SKIN UP TO 10% BODY SURF,36100005,CDM,361,RC,11000,HCPCS,,,facility,both,,,,424,296.8,,,,,,,,,,,,,Gross Charge Type: Central
HC DEBRID MUSC/FASCIA FIRST 20 SQ CM OR LESS,36100006,CDM,361,RC,11043,HCPCS,,,facility,both,,,,424,296.8,,,,,,,,,,,,,Gross Charge Type: Central
HC DEBRID BONE 1ST 20 SQ CM,36100007,CDM,361,RC,11044,HCPCS,,,facility,both,,,,1233,863.1,,,,,,,,,,,,,Gross Charge Type: Central
HC TRIMMING NONDYSTROPHIC NAILS ANY NUMBER,36100012,CDM,361,RC,11719,HCPCS,,,facility,both,,,,223,156.1,,,,,,,,,,,,,Gross Charge Type: Central
HC SKIN ALLOGRAFT T/A/L 1ST 25 SQ CM,36100013,CDM,361,RC,15271,HCPCS,,,facility,both,,,,2390,1673,,,,,,,,,,,,,Gross Charge Type: Central
HC SKIN ALLOGRAFT T/A/L ADDL 25 SQ CM,36100014,CDM,361,RC,15272,HCPCS,,,facility,both,,,,394,275.8,,,,,,,,,,,,,Gross Charge Type: Central
HC CAUTERY TISSUE CHEMICAL,36100015,CDM,361,RC,17250,HCPCS,,,facility,both,,,,740,518,,,,,,,,,,,,,Gross Charge Type: Central
HC ASP PUNCTURE CYST BREA,36100016,CDM,361,RC,19000,HCPCS,,,facility,both,,,,2620,1834,,,,,,,,,,,,,Gross Charge Type: Central
HC OPEN BX BREAST WO IMAG,36100018,CDM,361,RC,19101,HCPCS,,,facility,both,,,,2692,1884.4,,,,,,,,,,,,,Gross Charge Type: Central
HC BIOPSY MUSCLE PERCUTANEOUS NEEDLE,36100020,CDM,361,RC,20206,HCPCS,,,facility,both,,,,1571,1099.7,,,,,,,,,,,,,Gross Charge Type: Central
HC BONE BX TROCAR/NEEDLE,36100021,CDM,361,RC,20220,HCPCS,,,facility,both,,,,1350,945,,,,,,,,,,,,,Gross Charge Type: Central
HC BONE BX TROCAR/NEEDLE DEEP,36100022,CDM,361,RC,20225,HCPCS,,,facility,both,,,,2109,1476.3,,,,,,,,,,,,,Gross Charge Type: Central
HC BONE BX EXCISIONAL SUPERFICIAL,36100023,CDM,361,RC,20240,HCPCS,,,facility,both,,,,10428,7299.6,,,,,,,,,,,,,Gross Charge Type: Central
HC INJ SINUS TRACT FOR X-RAY,36100024,CDM,361,RC,20501,HCPCS,,,facility,both,,,,272,190.4,,,,,,,,,,,,,Gross Charge Type: Central
HC INJ TENDON SHEATH/LIGAMENT,36100025,CDM,361,RC,20550,HCPCS,,,facility,both,,,,406,284.2,,,,,,,,,,,,,Gross Charge Type: Central
HC INJ TRIGGER POINT 1/2 MUSCL,36100027,CDM,361,RC,20552,HCPCS,,,facility,both,,,,276,193.2,,,,,,,,,,,,,Gross Charge Type: Central
HC INJ TRIGGER POINTS => 3,36100028,CDM,361,RC,20553,HCPCS,,,facility,both,,,,276,193.2,,,,,,,,,,,,,Gross Charge Type: Central
HC ARTHROCENTESIS ASPIRATION/INJ SMALL JOINT/BURSA W/O US GUIDE,36100029,CDM,361,RC,20600,HCPCS,,,facility,both,,,,540,378,,,,,,,,,,,,,Gross Charge Type: Central
HC ARTHROCENTESIS ASPIRATION/INJ INTERMEDIATE JOINT/BURSA W/O US GUIDE,36100030,CDM,361,RC,20605,HCPCS,,,facility,both,,,,620,434,,,,,,,,,,,,,Gross Charge Type: Central
HC ARTHROCENTESIS ASPIRATION/INJ MAJOR JOINT/BURSA W/O US GUIDE,36100031,CDM,361,RC,20610,HCPCS,,,facility,both,,,,714,499.8,,,,,,,,,,,,,Gross Charge Type: Central
HC ABLATE BONE TUMOR(S) PERQ,36100032,CDM,361,RC,20982,HCPCS,,,facility,both,,,,5618,3932.6,,,,,,,,,,,,,Gross Charge Type: Central
HC BX OF NECK/CHEST SFT TISSUE,36100033,CDM,361,RC,21550,HCPCS,,,facility,both,,,,2244,1570.8,,,,,,,,,,,,,Gross Charge Type: Central
HC INJ FOR SHOULDER X-RAY,36100040,CDM,361,RC,23350,HCPCS,,,facility,both,,,,275,192.5,,,,,,,,,,,,,Gross Charge Type: Central
HC INJ FOR WRIST ARTHROGRAPHY,36100041,CDM,361,RC,25246,HCPCS,,,facility,both,,,,369,258.3,,,,,,,,,,,,,Gross Charge Type: Central
HC TREAT FX RAD & ULNA SHAFT,36100042,CDM,361,RC,25560,HCPCS,,,facility,both,,,,440,308,,,,,,,,,,,,,Gross Charge Type: Central
HC INJECTION FOR HIP ARTHROGRAPHY W/O ANESTHESIA,36100044,CDM,361,RC,27093,HCPCS,,,facility,both,,,,753,527.1,,,,,,,,,,,,,Gross Charge Type: Central
HC INJ SACROILIAC ARTHRGRPHY/ANES/STEROID W/IMAGE GUIDE,36100045,CDM,361,RC,27096,HCPCS,,,facility,both,,,,791,553.7,,,,,,,,,,,,,Gross Charge Type: Central
HC APPLY MULTLAY COMPRS LWR LEG,36100047,CDM,361,RC,29581,HCPCS,,,facility,both,,,,552,386.4,,,,,,,,,,,,,Gross Charge Type: Central
NASAL/SINUS ENDOS W/ BX,36100048,CDM,361,RC,31237,HCPCS,,,facility,both,,,,1812,1268.4,,,,,,,,,,,,,Gross Charge Type: Central
HC INSERT EMERGENCY AIRWAY,36100049,CDM,361,RC,31500,HCPCS,,,facility,both,,,,773,541.1,,,,,,,,,,,,,Gross Charge Type: Central
HC LARYNGOSCOPY FLEXIBLE DIAGNOSTIC,36100050,CDM,761,RC,31575,HCPCS,,,facility,both,,,,786,550.2,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH ASP NASOTRACHEAL,36100051,CDM,361,RC,31720,HCPCS,,,facility,both,,,,198,138.6,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH ASP TRACHEOBRONCH W/ FIBERSCOPE BEDSIDE,36100052,CDM,361,RC,31725,HCPCS,,,facility,both,,,,446,312.2,,,,,,,,,,,,,Gross Charge Type: Central
HC INTRO WINDPIPE WIRE/TUBE,36100053,CDM,361,RC,31730,HCPCS,,,facility,both,,,,596,417.2,,,,,,,,,,,,,Gross Charge Type: Central
HC NEEDLE BX CHEST LINING,36100055,CDM,361,RC,32400,HCPCS,,,facility,both,,,,1568,1097.6,,,,,,,,,,,,,Gross Charge Type: Central
INSERT PLEURAL CATH,36100059,CDM,361,RC,32550,HCPCS,,,facility,both,,,,3250,2275,,,,,,,,,,,,,Gross Charge Type: Central
INSERTION CHEST TUBE,36100060,CDM,361,RC,32551,HCPCS,,,facility,both,,,,690,483,,,,,,,,,,,,,Gross Charge Type: Central
HC ABLATE THER REDUCT/ERAD 1+ PULM TUMOR(S) INCL PLEURA/CHEST WALL PERQ INCL IMAGE GUIDE UNILATL RF,36100061,CDM,361,RC,32998,HCPCS,,,facility,both,,,,7144,5000.8,,,,,,,,,,,,,Gross Charge Type: Central
HC INSERT HEART PM VENTRICULAR,36100064,CDM,361,RC,33207,HCPCS,,,facility,both,,,,12422,8695.4,,,,,,,,,,,,,Gross Charge Type: Central
HC INSRT HEART PM ATRIAL & VENT,36100065,CDM,361,RC,33208,HCPCS,,,facility,both,,,,18009,12606.3,,,,,,,,,,,,,Gross Charge Type: Central
HC INSERT ELECTRD/PM CATH SNGL,36100066,CDM,361,RC,33210,HCPCS,,,facility,both,,,,9309,6516.3,,,,,,,,,,,,,Gross Charge Type: Central
HC INSERT PULSE GEN DUAL LEADS,36100068,CDM,361,RC,33213,HCPCS,,,facility,both,,,,13809,9666.3,,,,,,,,,,,,,Gross Charge Type: Central
HC INSERT 1 ELECTRODE PM-DEFIB,36100070,CDM,361,RC,33216,HCPCS,,,facility,both,,,,7522,5265.4,,,,,,,,,,,,,Gross Charge Type: Central
HC INSERT 2 ELECTRODE PM-DEFIB,36100071,CDM,361,RC,33217,HCPCS,,,facility,both,,,,12318,8622.6,,,,,,,,,,,,,Gross Charge Type: Central
HC REPAIR LEAD PACE-DEFIB ONE,36100072,CDM,361,RC,33218,HCPCS,,,facility,both,,,,4851,3395.7,,,,,,,,,,,,,Gross Charge Type: Central
HC REVISE POCKET PACEMAKER,36100073,CDM,361,RC,33222,HCPCS,,,facility,both,,,,2222,1555.4,,,,,,,,,,,,,Gross Charge Type: Central
HC REVISE POCKET FOR DEFIB,36100074,CDM,361,RC,33223,HCPCS,,,facility,both,,,,2532,1772.4,,,,,,,,,,,,,Gross Charge Type: Central
HC REMV/REPLC PM GEN SINGL,36100075,CDM,361,RC,33227,HCPCS,,,facility,both,,,,16794,11755.8,,,,,,,,,,,,,Gross Charge Type: Central
HC REMV/REPLC PM GEN DUAL LEAD,36100076,CDM,361,RC,33228,HCPCS,,,facility,both,,,,18774,13141.8,,,,,,,,,,,,,Gross Charge Type: Central
HC INSRT PULSE GEN W/MULT LEADS,36100077,CDM,361,RC,33231,HCPCS,,,facility,both,,,,43822,30675.4,,,,,,,,,,,,,Gross Charge Type: Central
HC REMV PM GENERATOR,36100078,CDM,361,RC,33233,HCPCS,,,facility,both,,,,9309,6516.3,,,,,,,,,,,,,Gross Charge Type: Central
HC REMV PM SYSTEM,36100079,CDM,361,RC,33234,HCPCS,,,facility,both,,,,16857,11799.9,,,,,,,,,,,,,Gross Charge Type: Central
HC REMV PM ELECTRODE,36100080,CDM,361,RC,33235,HCPCS,,,facility,both,,,,12318,8622.6,,,,,,,,,,,,,Gross Charge Type: Central
HC REMOVAL OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR ONLY,36100082,CDM,361,RC,33241,HCPCS,,,facility,both,,,,4965,3475.5,,,,,,,,,,,,,Gross Charge Type: Central
HC REMV ELTRD TRANSVEN,36100083,CDM,361,RC,33244,HCPCS,,,facility,both,,,,8108,5675.6,,,,,,,,,,,,,Gross Charge Type: Central
HC INSERT PACE-DEFIB W/LEAD,36100084,CDM,361,RC,33249,HCPCS,,,facility,both,,,,44794,31355.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PERQ INSERT AORTA BALLOON DEVICE,36100090,CDM,361,RC,33967,HCPCS,,,facility,both,,,,6137,4295.9,,,,,,,,,,,,,Gross Charge Type: Central
HC CARDIAC SURG PROCEDURE UNLIS,36100091,CDM,361,RC,33999,HCPCS,,,facility,both,,,,558,390.6,,,,,,,,,,,,,Gross Charge Type: Central
HC INJ PSEUDOANEURYSM,36100096,CDM,361,RC,36002,HCPCS,,,facility,both,,,,506,354.2,,,,,,,,,,,,,Gross Charge Type: Central
HC INJ FOR EXT VENOGRAPHY,36100097,CDM,361,RC,36005,HCPCS,,,facility,both,,,,381,266.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PLACE CATH SUP INF VENA CAVA,36100098,CDM,361,RC,36010,HCPCS,,,facility,both,,,,558,390.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PLACE CATH VEIN 1ST ORDER,36100099,CDM,361,RC,36011,HCPCS,,,facility,both,,,,750,525,,,,,,,,,,,,,Gross Charge Type: Central
HC PLACE CATH IN VEIN 2ND>  ORDER,36100100,CDM,361,RC,36012,HCPCS,,,facility,both,,,,1060,742,,,,,,,,,,,,,Gross Charge Type: Central
HC PLACE CATH IN PULM ARTERY,36100101,CDM,361,RC,36015,HCPCS,,,facility,both,,,,1598,1118.6,,,,,,,,,,,,,Gross Charge Type: Central
HC INTRO OF NEEDLE/INTRACATHETER UPPER OR LOWER EXTREMITY ARTERY,36100102,CDM,361,RC,36140,HCPCS,,,facility,both,,,,267,186.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PLACE CATHETER IN AORTA,36100105,CDM,361,RC,36200,HCPCS,,,facility,both,,,,665,465.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PLACE CATH 1ST THOR BRACHIO,36100106,CDM,361,RC,36215,HCPCS,,,facility,both,,,,731,511.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PLACE CATH 2ND THOR BRACHIO,36100107,CDM,361,RC,36216,HCPCS,,,facility,both,,,,2087,1460.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PLACE CATH 3RD> THOR BRACHIO,36100108,CDM,361,RC,36217,HCPCS,,,facility,both,,,,1497,1047.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PLACE CATH ADD 2ND 3RD THOR BRACH,36100109,CDM,361,RC,36218,HCPCS,,,facility,both,,,,749,524.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PLACE CATH 1ST ABD PELVIC LWR EXT,36100110,CDM,361,RC,36245,HCPCS,,,facility,both,,,,1071,749.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PLACE CATH 2ND ABD PELVIC LWR EXT,36100111,CDM,361,RC,36246,HCPCS,,,facility,both,,,,1885,1319.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PLACE CATH 3D> ABD PELVIC LWR EXT,36100112,CDM,361,RC,36247,HCPCS,,,facility,both,,,,2358,1650.6,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH ADD 2D 3D ABD PEL LWR EXT,36100113,CDM,361,RC,36248,HCPCS,,,facility,both,,,,317,221.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PLACE CATH 1ST RENAL UNILAT SI,36100114,CDM,361,RC,36251,HCPCS,,,facility,both,,,,6468,4527.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PLACE CATH 1ST RENAL BILAT SI,36100115,CDM,361,RC,36252,HCPCS,,,facility,both,,,,9703,6792.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PLACE CATH 2D> RENAL UNILAT SI,36100116,CDM,361,RC,36253,HCPCS,,,facility,both,,,,6601,4620.7,,,,,,,,,,,,,Gross Charge Type: Central
HC VENIPUNCTURE YOUNGER THAN AGE 3 YEAR NECESSITATING SKILL OF A PHYSICIAN OTHER VEIN,36100117,CDM,361,RC,36406,HCPCS,,,facility,both,,,,306,214.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PERCUTANEOUS PORTAL VEIN CATH ANY METHOD,36100118,CDM,361,RC,36481,HCPCS,,,facility,both,,,,5333,3733.1,,,,,,,,,,,,,Gross Charge Type: Central
HC INSERTION CATH VEIN,36100119,CDM,361,RC,36500,HCPCS,,,facility,both,,,,1275,892.5,,,,,,,,,,,,,Gross Charge Type: Central
HC INSERTION CATH VEIN,36100120,CDM,761,RC,36510,HCPCS,,,facility,both,,,,386,270.2,,,,,,,,,,,,,Gross Charge Type: Central
INSERT NON-TUNN CV CATH <5 YRS,36100121,CDM,361,RC,36555,HCPCS,,,facility,both,,,,1512,1058.4,,,,,,,,,,,,,Gross Charge Type: Central
HC INSERT NON-TUNN CV CATH >5 YRS,36100122,CDM,361,RC,36556,HCPCS,,,facility,both,,,,1308,915.6,,,,,,,,,,,,,Gross Charge Type: Central
HC INSERT TUNNEL CV CATH >5 YRS,36100123,CDM,361,RC,36558,HCPCS,,,facility,both,,,,3338,2336.6,,,,,,,,,,,,,Gross Charge Type: Central
HC INSERT TUNNEL CV DEVICE >5 YRS,36100124,CDM,361,RC,36561,HCPCS,,,facility,both,,,,7179,5025.3,,,,,,,,,,,,,Gross Charge Type: Central
INSERT PICC CATH <5 YRS,36100125,CDM,361,RC,36568,HCPCS,,,facility,both,,,,1309,916.3,,,,,,,,,,,,,Gross Charge Type: Central
HC INSERT PICC CATH >5 YRS,36100126,CDM,361,RC,36569,HCPCS,,,facility,both,,,,1217,851.9,,,,,,,,,,,,,Gross Charge Type: Central
HC REPAIR CV DEVICE,36100128,CDM,361,RC,36576,HCPCS,,,facility,both,,,,1344,940.8,,,,,,,,,,,,,Gross Charge Type: Central
HC REPLACE NON-TUNN CV CATH,36100129,CDM,361,RC,36580,HCPCS,,,facility,both,,,,1092,764.4,,,,,,,,,,,,,Gross Charge Type: Central
HC REPLACE TUNNEL CV CATH,36100130,CDM,361,RC,36581,HCPCS,,,facility,both,,,,2712,1898.4,,,,,,,,,,,,,Gross Charge Type: Central
HC REPLACE PICC CATH,36100131,CDM,361,RC,36584,HCPCS,,,facility,both,,,,2807,1964.9,,,,,,,,,,,,,Gross Charge Type: Central
HC REPLACE CV DEVICE,36100132,CDM,361,RC,36585,HCPCS,,,facility,both,,,,4353,3047.1,,,,,,,,,,,,,Gross Charge Type: Central
HC REMOV TUNNEL CV CATH,36100133,CDM,361,RC,36589,HCPCS,,,facility,both,,,,920,644,,,,,,,,,,,,,Gross Charge Type: Central
HC REMOV TUNNEL CV DEVICE,36100134,CDM,361,RC,36590,HCPCS,,,facility,both,,,,3020,2114,,,,,,,,,,,,,Gross Charge Type: Central
HC BLOOD COLLECT CV DEVICE,36100135,CDM,361,RC,36591,HCPCS,,,facility,both,,,,294,205.8,,,,,,,,,,,,,Gross Charge Type: Central
DECLOT VASCULAR CATH DEVICE,36100136,CDM,361,RC,36593,HCPCS,,,facility,both,,,,629,440.3,,,,,,,,,,,,,Gross Charge Type: Central
HC REPOSITION VENOUS CATH FLUORO,36100137,CDM,361,RC,36597,HCPCS,,,facility,both,,,,1123,786.1,,,,,,,,,,,,,Gross Charge Type: Central
HC X-RAY CV DEVICE FLUORO,36100138,CDM,361,RC,36598,HCPCS,,,facility,both,,,,262,183.4,,,,,,,,,,,,,Gross Charge Type: Central
HC INSERT CATH ARTERY,36100139,CDM,361,RC,36620,HCPCS,,,facility,both,,,,285,199.5,,,,,,,,,,,,,Gross Charge Type: Central
HC INSERT CATH UMBIL ARTERY,36100140,CDM,361,RC,36660,HCPCS,,,facility,both,,,,568,397.6,,,,,,,,,,,,,Gross Charge Type: Central
HC INSERT NEEDLE BONE CAVITY,36100141,CDM,361,RC,36680,HCPCS,,,facility,both,,,,300,210,,,,,,,,,,,,,Gross Charge Type: Central
HC INSERT HEPATIC SHUNT (TIPS),36100143,CDM,361,RC,37182,HCPCS,,,facility,both,,,,13661,9562.7,,,,,,,,,,,,,Gross Charge Type: Central
HC REVJ TRANSVNS INTRAHEPATIC PORTOSYSTEMIC SHUNT,36100144,CDM,361,RC,37183,HCPCS,,,facility,both,,,,12254,8577.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PRIMARY PERCU TRANSLUM MECH THROMBECTOMY NONCORONARY/NONINTRACRANIAL ARTERIAL/ARTERIAL BYPASS GRAFT INCL FLUORO & INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTION(S) INITIAL VESSEL,36100145,CDM,361,RC,37184,HCPCS,,,facility,both,,,,21596,15117.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PRIMARY PERCU TRANSLUM MECH THROMBECTOMY NONCORONARY/NONINTRACRANIAL ARTERIAL/ARTERIAL BYPASS GRAFT INCL FLUORO & INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTION(S) EACH ADDTL VE*,36100146,CDM,361,RC,37185,HCPCS,,,facility,both,,,,12777,8943.9,,,,,,,,,,,,,Gross Charge Type: Central
HC SECONDARY PERCU TRANSLUM THROMBECTOMY NONCORONARY/NONINTRACRANIAL ARTERIAL/ARTERIAL BYPASS GRAFT INCL FLUORO & INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTION(S),36100147,CDM,361,RC,37186,HCPCS,,,facility,both,,,,12285,8599.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PRIM PERQ MECH VEN THROMB,36100148,CDM,361,RC,37187,HCPCS,,,facility,both,,,,17677,12373.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PRIM PERQ MECH VEN THROMB ADDL,36100149,CDM,361,RC,37188,HCPCS,,,facility,both,,,,15274,10691.8,,,,,,,,,,,,,Gross Charge Type: Central
HC TRANSCATHETER BX,36100150,CDM,361,RC,37200,HCPCS,,,facility,both,,,,4839,3387.3,,,,,,,,,,,,,Gross Charge Type: Central
HC ILIAC ARTERY REVASC,36100157,CDM,361,RC,37220,HCPCS,,,facility,both,,,,5498,3848.6,,,,,,,,,,,,,Gross Charge Type: Central
HC ILIAC ARTERY REVASC STENT,36100158,CDM,361,RC,37221,HCPCS,,,facility,both,,,,12763,8934.1,,,,,,,,,,,,,Gross Charge Type: Central
HC REVASCULARIZATION ENDOVASCULAR OPEN/PERCUTANEOUS ILIAC ARTERY EACH ADDTL IPSILATERAL ILIAC VESSEL W/TRANSLUMINAL ANGIOPLASTY,36100159,CDM,361,RC,37222,HCPCS,,,facility,both,,,,14351,10045.7,,,,,,,,,,,,,Gross Charge Type: Central
HC REVASCULARIZATION ENDOVASCULAR OPEN/PERCUTANEOUS ILIAC ARTERY EACH ADDTL IPSILATERAL ILIAC VESSEL W/TRANSLUMINAL STENT PLACEMENT(S) INCL ANGIOPLASTY WITHIN SAME VESSEL,36100160,CDM,361,RC,37223,HCPCS,,,facility,both,,,,16504,11552.8,,,,,,,,,,,,,Gross Charge Type: Central
HC FEM/POPL ART REVASC W/TLA,36100161,CDM,361,RC,37224,HCPCS,,,facility,both,,,,5498,3848.6,,,,,,,,,,,,,Gross Charge Type: Central
HC FEM/POPL ART REVASC ATHERECT,36100162,CDM,361,RC,37225,HCPCS,,,facility,both,,,,68415,47890.5,,,,,,,,,,,,,Gross Charge Type: Central
HC FEM/POPL ART REVASC STENT,36100163,CDM,361,RC,37226,HCPCS,,,facility,both,,,,42923,30046.1,,,,,,,,,,,,,Gross Charge Type: Central
HC FEM/POPL ART REVASC STENT ARTHR,36100164,CDM,361,RC,37227,HCPCS,,,facility,both,,,,20213,14149.1,,,,,,,,,,,,,Gross Charge Type: Central
HC TIB/PER ART REVASC W/TLA,36100165,CDM,361,RC,37228,HCPCS,,,facility,both,,,,17218,12052.6,,,,,,,,,,,,,Gross Charge Type: Central
HC TIB/PER ART REVASC W/ATHERECT,36100166,CDM,361,RC,37229,HCPCS,,,facility,both,,,,21111,14777.7,,,,,,,,,,,,,Gross Charge Type: Central
HC TIB/PER ART REVASC STENT,36100167,CDM,361,RC,37230,HCPCS,,,facility,both,,,,21111,14777.7,,,,,,,,,,,,,Gross Charge Type: Central
HC TIB/PER ARAT REVASC STENT ATHER,36100168,CDM,361,RC,37231,HCPCS,,,facility,both,,,,64135,44894.5,,,,,,,,,,,,,Gross Charge Type: Central
HC TIB/PER ART REVASC W/TLA ADDL,36100169,CDM,361,RC,37232,HCPCS,,,facility,both,,,,5498,3848.6,,,,,,,,,,,,,Gross Charge Type: Central
NEEDLE BIOPSY LYMPH NODES,36100172,CDM,361,RC,38505,HCPCS,,,facility,both,,,,1571,1099.7,,,,,,,,,,,,,Gross Charge Type: Central
HC RA TRACER ID OF SENTINL NODE,36100173,CDM,361,RC,38792,HCPCS,,,facility,both,,,,1561,1092.7,,,,,,,,,,,,,Gross Charge Type: Central
HC NASO/OROGASTRIC TUBE PLACE FLUORO GUIDE,36100175,CDM,361,RC,43752,HCPCS,,,facility,both,,,,234,163.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PLACEMENT LONG GI TUBE,36100176,CDM,361,RC,44500,HCPCS,,,facility,both,,,,655,458.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PERQ NEEDLE BX LIVER,36100178,CDM,361,RC,47000,HCPCS,,,facility,both,,,,1521,1064.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PERQ RF ABLATION 1> LIVER TUMORS,36100181,CDM,361,RC,47382,HCPCS,,,facility,both,,,,6771,4739.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PERQ CHOLECYSTOSTOMY SI,36100182,CDM,361,RC,47490,HCPCS,,,facility,both,,,,3394,2375.8,,,,,,,,,,,,,Gross Charge Type: Central
HC DILAT BILIARY DUCT ENDO W/ STENT,36100189,CDM,361,RC,47556,HCPCS,,,facility,both,,,,18937,13255.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PERQ NEEDLE BX PANCREAS,36100191,CDM,361,RC,48102,HCPCS,,,facility,both,,,,1699,1189.3,,,,,,,,,,,,,Gross Charge Type: Central
HC ABDOMINAL PARACENTESIS DX/THERAPEUTIC W/IMAGING GUIDANCE,36100196,CDM,361,RC,49083,HCPCS,,,facility,both,,,,2047,1432.9,,,,,,,,,,,,,Gross Charge Type: Central
HC BIOPSY ABDOMINAL/RETROPERITONEAL MASS PERCUTANEOUS NEEDLE,36100197,CDM,361,RC,49180,HCPCS,,,facility,both,,,,1378,964.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PERQ RAD DEVICE ABD PELVIC,36100198,CDM,361,RC,49411,HCPCS,,,facility,both,,,,1331,931.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PERQ INSERT TUNN CATH ABD PELV,36100199,CDM,361,RC,49418,HCPCS,,,facility,both,,,,3262,2283.4,,,,,,,,,,,,,Gross Charge Type: Central
HC REMOVAL TUNN CATH ABD PELV,36100200,CDM,361,RC,49422,HCPCS,,,facility,both,,,,2673,1871.1,,,,,,,,,,,,,Gross Charge Type: Central
HC EXCHANGE DRAINAGE CATH,36100201,CDM,361,RC,49423,HCPCS,,,facility,both,,,,1920,1344,,,,,,,,,,,,,Gross Charge Type: Central
HC INJECT CONTRAST ASSESS CYST,36100202,CDM,361,RC,49424,HCPCS,,,facility,both,,,,474,331.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PERQ PLACE GASTRO TUBE,36100203,CDM,361,RC,49440,HCPCS,,,facility,both,,,,3452,2416.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PERQ PLACE DUOD JEJUN TUBE,36100204,CDM,361,RC,49441,HCPCS,,,facility,both,,,,1358,950.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PERQ CHANGE G-TUBE TO G-J TUBE,36100205,CDM,361,RC,49446,HCPCS,,,facility,both,,,,1358,950.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PERQ REPLACE G/C TUBE,36100206,CDM,750,RC,49450,HCPCS,,,facility,both,,,,2266,1586.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PERQ REPLACE DOUD JEJUN TUBE,36100207,CDM,361,RC,49451,HCPCS,,,facility,both,,,,655,458.5,,,,,,,,,,,,,Gross Charge Type: Central
HC REPLACE GASTROJEJUNOSTOMY TUBE PERQ  UNDER FLUORO GUIDE INCL CONTRAST INJECTION(S) IMAGE DOC & REPORT,36100208,CDM,361,RC,49452,HCPCS,,,facility,both,,,,655,458.5,,,,,,,,,,,,,Gross Charge Type: Central
HC FLUORO EXAM OF G/COLON TUBE,36100209,CDM,761,RC,49465,HCPCS,,,facility,both,,,,220,154,,,,,,,,,,,,,Gross Charge Type: Central
HC REPAIR UMBILICAL LESION,36100210,CDM,361,RC,49605,HCPCS,,,facility,both,,,,11808,8265.6,,,,,,,,,,,,,Gross Charge Type: Central
HC RENAL BIOPSY PERCUTANEOUS BY TROCAR/NEEDLE,36100212,CDM,361,RC,50200,HCPCS,,,facility,both,,,,1697,1187.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PERC URETER STENT CHANGE,36100213,CDM,361,RC,50382,HCPCS,,,facility,both,,,,7217,5051.9,,,,,,,,,,,,,Gross Charge Type: Central
HC REMOVE & REPLACE EXTERNALLY ACCESSIBLE NEPHROURETERAL CATHETER,36100214,CDM,361,RC,50387,HCPCS,,,facility,both,,,,3461,2422.7,,,,,,,,,,,,,Gross Charge Type: Central
HC REM RENAL TUBE W/ FLUORO,36100215,CDM,361,RC,50389,HCPCS,,,facility,both,,,,2759,1931.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PERC NEEDLE ASP/INJ RENAL CYST,36100216,CDM,361,RC,50390,HCPCS,,,facility,both,,,,1571,1099.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PERC ABLAT CRYO REN TUMOR UNILAT,36100223,CDM,361,RC,50593,HCPCS,,,facility,both,,,,5271,3689.7,,,,,,,,,,,,,Gross Charge Type: Central
HC CHANGE OF URETER TUBE/STENT,36100224,CDM,361,RC,50688,HCPCS,,,facility,both,,,,1583,1108.1,,,,,,,,,,,,,Gross Charge Type: Central
HC INJECTION FOR URETER X-RAY,36100225,CDM,361,RC,50690,HCPCS,,,facility,both,,,,136,95.2,,,,,,,,,,,,,Gross Charge Type: Central
DRAIN BL VIA SUPRAPUBIC CATH,36100226,CDM,361,RC,51102,HCPCS,,,facility,both,,,,2844,1990.8,,,,,,,,,,,,,Gross Charge Type: Central
HC INJECTION PX FOR RETROGRADE URETHROCYSTOGRAPHY,36100228,CDM,361,RC,51610,HCPCS,,,facility,both,,,,227,158.9,,,,,,,,,,,,,Gross Charge Type: Central
INSERT NON-INDWELLING BL CATH,36100229,CDM,761,RC,51701,HCPCS,,,facility,both,,,,256,179.2,,,,,,,,,,,,,Gross Charge Type: Central
HC INSERT TEMP INDWELLING BLADDER CATH SIMPLE,36100230,CDM,761,RC,51702,HCPCS,,,facility,both,,,,198,138.6,,,,,,,,,,,,,Gross Charge Type: Central
HC INSERT TEMP INDWELLING BLADDER CATH COMPLICATED,36100231,CDM,361,RC,51703,HCPCS,,,facility,both,,,,379,265.3,,,,,,,,,,,,,Gross Charge Type: Central
HC CHANGE BLADDER CATH SIMPLE,36100232,CDM,361,RC,51705,HCPCS,,,facility,both,,,,440,308,,,,,,,,,,,,,Gross Charge Type: Central
HC CHANGE OF CYSTOSTOMY TUBE COMPLICATED,36100233,CDM,361,RC,51710,HCPCS,,,facility,both,,,,1598,1118.6,,,,,,,,,,,,,Gross Charge Type: Central
HC US URINE CAPACITY MEASURE,36100235,CDM,361,RC,51798,HCPCS,,,facility,both,,,,230,161,,,,,,,,,,,,,Gross Charge Type: Central
HC BIOPSY PROSTATE,36100236,CDM,361,RC,55700,HCPCS,,,facility,both,,,,7739,5417.3,,,,,,,,,,,,,Gross Charge Type: Central
PLACE RAD THER DEVICE PROSTATE,36100237,CDM,361,RC,55876,HCPCS,,,facility,both,,,,1608,1125.6,,,,,,,,,,,,,Gross Charge Type: Central
INSERT VAG BRACHYTX DEVICE,36100239,CDM,333,RC,57156,HCPCS,,,facility,both,,,,825,577.5,,,,,,,,,,,,,Gross Charge Type: Central
HC CATHETERIZE FOR HYSTEROGRAPHY,36100240,CDM,761,RC,58340,HCPCS,,,facility,both,,,,227,158.9,,,,,,,,,,,,,Gross Charge Type: Central
HC AMNIOCENTESIS DIAGNOSTIC,36100243,CDM,361,RC,59000,HCPCS,,,facility,both,,,,2691,1883.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PERQ ASPIR INTERDISCAL DX,36100245,CDM,361,RC,62267,HCPCS,,,facility,both,,,,1510,1057,,,,,,,,,,,,,Gross Charge Type: Central
HC PUNCTURE SPINAL LUMB DX,36100246,CDM,920,RC,62270,HCPCS,,,facility,both,,,,664,464.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PUNCTURE DRAIN CSF,36100247,CDM,361,RC,62272,HCPCS,,,facility,both,,,,974,681.8,,,,,,,,,,,,,Gross Charge Type: Central
HC INJECT EPIDURAL BLOOD PATCH,36100248,CDM,361,RC,62273,HCPCS,,,facility,both,,,,1727,1208.9,,,,,,,,,,,,,Gross Charge Type: Central
HC MYLEGRAM NOT C1-C2,36100249,CDM,361,RC,62284,HCPCS,,,facility,both,,,,637,445.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PUMP REFILL REPROGRAM,36100256,CDM,361,RC,62370,HCPCS,,,facility,both,,,,897,627.9,,,,,,,,,,,,,Gross Charge Type: Central
HC INJ NERVE BLOCK OCCIPITAL,36100257,CDM,361,RC,64405,HCPCS,,,facility,both,,,,1095,766.5,,,,,,,,,,,,,Gross Charge Type: Central
HC INJ NERVE BLOCK SUPRASCAP,36100258,CDM,361,RC,64418,HCPCS,,,facility,both,,,,884,618.8,,,,,,,,,,,,,Gross Charge Type: Central
HC INJ AA(S) / STEROID INTERCOSTAL NERVE SINGLE LEVEL,36100259,CDM,361,RC,64420,HCPCS,,,facility,both,,,,2464,1724.8,,,,,,,,,,,,,Gross Charge Type: Central
HC INJ NERVE BLOCK INTERCOST MULT,36100260,CDM,361,RC,64421,HCPCS,,,facility,both,,,,3259,2281.3,,,,,,,,,,,,,Gross Charge Type: Central
HC INJ NERVE BLOCK ILIOING HYPOGI,36100261,CDM,361,RC,64425,HCPCS,,,facility,both,,,,1423,996.1,,,,,,,,,,,,,Gross Charge Type: Central
HC INJ NERVE BLOCK OTHER PERIPH,36100262,CDM,361,RC,64450,HCPCS,,,facility,both,,,,921,644.7,,,,,,,,,,,,,Gross Charge Type: Central
HC INJ FORA EPIDU CERV THOR SINGL,36100263,CDM,361,RC,64479,HCPCS,,,facility,both,,,,2545,1781.5,,,,,,,,,,,,,Gross Charge Type: Central
HC INJ FORA EPIDU CERV THOR ADDL,36100264,CDM,361,RC,64480,HCPCS,,,facility,both,,,,1159,811.3,,,,,,,,,,,,,Gross Charge Type: Central
HC INJ FORA EPIDU LUMB SACR SINGL,36100265,CDM,361,RC,64483,HCPCS,,,facility,both,,,,1805,1263.5,,,,,,,,,,,,,Gross Charge Type: Central
HC INJ FORA EPIDU LUMB SACR ADDL,36100266,CDM,361,RC,64484,HCPCS,,,facility,both,,,,1214,849.8,,,,,,,,,,,,,Gross Charge Type: Central
HC INJ FACET CERV THOR FLUORO SINGL,36100267,CDM,361,RC,64490,HCPCS,,,facility,both,,,,1699,1189.3,,,,,,,,,,,,,Gross Charge Type: Central
HC INJ FACET CERV THOR FLUORO 2ND,36100268,CDM,361,RC,64491,HCPCS,,,facility,both,,,,860,602,,,,,,,,,,,,,Gross Charge Type: Central
HC INJECTION(S) PARAVERTEBRAL FACET JOINT W/ IMAGE GUIDE CERVICAL/THORACIC THIRD AND ANY ADDITIONAL LEVEL(S),36100269,CDM,361,RC,64492,HCPCS,,,facility,both,,,,881,616.7,,,,,,,,,,,,,Gross Charge Type: Central
HC INJ FACET LUMB SACR FLUORO SINGL,36100270,CDM,361,RC,64493,HCPCS,,,facility,both,,,,1278,894.6,,,,,,,,,,,,,Gross Charge Type: Central
HC INJ FACET LUMB SACR FLUORO 2ND,36100271,CDM,361,RC,64494,HCPCS,,,facility,both,,,,645,451.5,,,,,,,,,,,,,Gross Charge Type: Central
HC INJ FACET LUMB SACR FLUORO 3RD>,36100272,CDM,361,RC,64495,HCPCS,,,facility,both,,,,600,420,,,,,,,,,,,,,Gross Charge Type: Central
HC INJ N BLOCK SPHENOPAL GANG,36100273,CDM,361,RC,64505,HCPCS,,,facility,both,,,,1081,756.7,,,,,,,,,,,,,Gross Charge Type: Central
HC INJ N BLOCK STELLATE GANG,36100274,CDM,361,RC,64510,HCPCS,,,facility,both,,,,1484,1038.8,,,,,,,,,,,,,Gross Charge Type: Central
HC INJ N BLOCK LUMB THOR SYMPH,36100275,CDM,361,RC,64520,HCPCS,,,facility,both,,,,3294,2305.8,,,,,,,,,,,,,Gross Charge Type: Central
HC INJ N BLOCK CELIAC PLEXUS,36100276,CDM,361,RC,64530,HCPCS,,,facility,both,,,,3294,2305.8,,,,,,,,,,,,,Gross Charge Type: Central
HC DESTROY NERVE FACE MUSCLE,36100277,CDM,361,RC,64612,HCPCS,,,facility,both,,,,1112,778.4,,,,,,,,,,,,,Gross Charge Type: Central
HC DESTROY CERV/THOR FACET JNT SINGL,36100280,CDM,361,RC,64633,HCPCS,,,facility,both,,,,2981,2086.7,,,,,,,,,,,,,Gross Charge Type: Central
HC DESTROY CERV/THOR FACET JNT ADDL,36100281,CDM,361,RC,64634,HCPCS,,,facility,both,,,,1498,1048.6,,,,,,,,,,,,,Gross Charge Type: Central
HC DESTROY LUMB/SAC FACET JNT,36100282,CDM,361,RC,64635,HCPCS,,,facility,both,,,,2628,1839.6,,,,,,,,,,,,,Gross Charge Type: Central
HC DESTROY LUMB/SAC FACET JNT ADDL,36100283,CDM,361,RC,64636,HCPCS,,,facility,both,,,,1200,840,,,,,,,,,,,,,Gross Charge Type: Central
HC DESTROY PERIPHER NERVE,36100284,CDM,361,RC,64640,HCPCS,,,facility,both,,,,1121,784.7,,,,,,,,,,,,,Gross Charge Type: Central
HC NERV SYS SURG UNLISTED,36100285,CDM,361,RC,64999,HCPCS,,,facility,both,,,,2020,1414,,,,,,,,,,,,,Gross Charge Type: Central
HC ELECTRONIC ANALYSIS IMPLANTED NERUOSTIMULATOR PULSE GENERATOR/TRANSMITTER SIMPLE SPINAL CORD/PERIPHERAL NERVE PROGRAMMING,36100288,CDM,361,RC,95971,HCPCS,,,facility,both,,,,174,121.8,,,,,,,,,,,,,Gross Charge Type: Central
HC SACROPLASTY INJ BILAT 2> NEEDLES,36100289,CDM,361,RC,0201T,HCPCS,,,facility,both,,,,3260,2282,,,,,,,,,,,,,Gross Charge Type: Central
HC PLACE OCC DEVICE POST PROCED,36100291,CDM,361,RC,G0269,HCPCS,,,facility,both,,,,375,262.5,,,,,,,,,,,,,Gross Charge Type: Central
FNA W/O IMAGE,36100292,CDM,761,RC,10021,HCPCS,,,facility,both,,,,424,296.8,,,,,,,,,,,,,Gross Charge Type: Central
HC COMPLEX DRAINAGE WOUND,36100293,CDM,361,RC,10180,HCPCS,,,facility,both,,,,8925,6247.5,,,,,,,,,,,,,Gross Charge Type: Central
HC DEBRIDE SKIN/MUSCLE FX,36100296,CDM,361,RC,11011,HCPCS,,,facility,both,,,,2563,1794.1,,,,,,,,,,,,,Gross Charge Type: Central
HC REMOVAL OF SKIN TAGS,36100299,CDM,361,RC,11200,HCPCS,,,facility,both,,,,198,138.6,,,,,,,,,,,,,Gross Charge Type: Central
HC SHAVING EPIDERMAL/DERMAL LESION SINGLE LESION TRUNK/ARMS/LEGS 0.6-1.0 CM,36100302,CDM,361,RC,11301,HCPCS,,,facility,both,,,,724,506.8,,,,,,,,,,,,,Gross Charge Type: Central
HC EXC TR-EXT BEN MARG 0.5 <CM,36100313,CDM,361,RC,11400,HCPCS,,,facility,both,,,,4687,3280.9,,,,,,,,,,,,,Gross Charge Type: Central
EXC FACE-MM B9+MARG 0.6-1CM,36100326,CDM,361,RC,11441,HCPCS,,,facility,both,,,,6671,4669.7,,,,,,,,,,,,,Gross Charge Type: Central
EXC FACE-MM B9+MARG 1.1-2 CM,36100327,CDM,361,RC,11442,HCPCS,,,facility,both,,,,7671,5369.7,,,,,,,,,,,,,Gross Charge Type: Central
HC EXCISION OF NAIL FOLD TOE,36100350,CDM,361,RC,11765,HCPCS,,,facility,both,,,,163,114.1,,,,,,,,,,,,,Gross Charge Type: Central
HC INJECTION INTRALESIONAL MORE THAN 7 LESIONS,36100352,CDM,361,RC,11901,HCPCS,,,facility,both,,,,833,583.1,,,,,,,,,,,,,Gross Charge Type: Central
HC REMOVAL CONTRACEPTIVE CAP,36100354,CDM,361,RC,11976,HCPCS,,,facility,both,,,,335,234.5,,,,,,,,,,,,,Gross Charge Type: Central
HC INSERT DRUG IMPLANT DEVICE,36100355,CDM,361,RC,11981,HCPCS,,,facility,both,,,,501,350.7,,,,,,,,,,,,,Gross Charge Type: Central
RPR CMPLX TRNK 2.6-7.5CM,36100358,CDM,361,RC,13101,HCPCS,,,facility,both,,,,656,459.2,,,,,,,,,,,,,Gross Charge Type: Central
HC RPR CMPLX F/C/C/M/N/AX/G/H/F EA AD 5CM OR LESS,36100359,CDM,361,RC,13133,HCPCS,,,facility,both,,,,453,317.1,,,,,,,,,,,,,Gross Charge Type: Central
HC DRESSING/DEBRIDEMENT PARTIAL THICKNESS BURNS INITIAL/SUBSEQUENT MEDIUM,36100360,CDM,361,RC,16025,HCPCS,,,facility,both,,,,525,367.5,,,,,,,,,,,,,Gross Charge Type: Central
HC ASPIRATE/INJ GANGLION CYST(S),36100387,CDM,361,RC,20612,HCPCS,,,facility,both,,,,3485,2439.5,,,,,,,,,,,,,Gross Charge Type: Central
HC RMVL SUPPRT IMPLNT SPRFCL,36100388,CDM,361,RC,20670,HCPCS,,,facility,both,,,,5803,4062.1,,,,,,,,,,,,,Gross Charge Type: Central
HC CLOSED TX NASAL BONE FX W/MANIP W/O STABLIZATION,36100392,CDM,361,RC,21315,HCPCS,,,facility,both,,,,5591,3913.7,,,,,,,,,,,,,Gross Charge Type: Central
HC DRAINAGE OF ARM BURSA,36100395,CDM,361,RC,23931,HCPCS,,,facility,both,,,,5970,4179,,,,,,,,,,,,,Gross Charge Type: Central
HC REMOVAL FOREIGN BODY UPPER ARM/ELBOW AREA SUBCUTANEOUS,36100398,CDM,361,RC,24200,HCPCS,,,facility,both,,,,2004,1402.8,,,,,,,,,,,,,Gross Charge Type: Central
HC REMOVAL FOREIGN BODY UPPER ARM/ELBOW AREA DEEP (SUBFASCIAL/INTRAMUSCULAR),36100399,CDM,361,RC,24201,HCPCS,,,facility,both,,,,6053,4237.1,,,,,,,,,,,,,Gross Charge Type: Central
RX HUMERUS FX,36100400,CDM,361,RC,24530,HCPCS,,,facility,both,,,,852,596.4,,,,,,,,,,,,,Gross Charge Type: Central
HC CLOSED TX HUMERAL EPICONDYLAR FX MEDIAL/LATERAL W/O MANIPULATION,36100401,CDM,361,RC,24560,HCPCS,,,facility,both,,,,852,596.4,,,,,,,,,,,,,Gross Charge Type: Central
HC CLOSED TREATMENT RADIAL SHAFT FX W/O MANIPULATION,36100404,CDM,361,RC,25500,HCPCS,,,facility,both,,,,914,639.8,,,,,,,,,,,,,Gross Charge Type: Central
HC CLSD ULNAR W/O MANIP,36100405,CDM,361,RC,25530,HCPCS,,,facility,both,,,,852,596.4,,,,,,,,,,,,,Gross Charge Type: Central
HC CLOSED TX CARPAL BONE FX W/O MANIPULATION EACH BONE,36100406,CDM,361,RC,25630,HCPCS,,,facility,both,,,,852,596.4,,,,,,,,,,,,,Gross Charge Type: Central
HC CLOSED TX ULNAR STYLOID FX,36100408,CDM,361,RC,25650,HCPCS,,,facility,both,,,,852,596.4,,,,,,,,,,,,,Gross Charge Type: Central
HC CLSD TX DISTAL RADIO DISLOC,36100409,CDM,361,RC,25675,HCPCS,,,facility,both,,,,898,628.6,,,,,,,,,,,,,Gross Charge Type: Central
HC EXC HAND LES SC > 1.5 CM,36100410,CDM,361,RC,26111,HCPCS,,,facility,both,,,,6544,4580.8,,,,,,,,,,,,,Gross Charge Type: Central
HC CLOSED TX METACARPAL FX SINGLE W/O MANIPULATION EACH BONE,36100411,CDM,361,RC,26600,HCPCS,,,facility,both,,,,846,592.2,,,,,,,,,,,,,Gross Charge Type: Central
HC TREAT THUMB DISLOCATION,36100412,CDM,361,RC,26641,HCPCS,,,facility,both,,,,320,224,,,,,,,,,,,,,Gross Charge Type: Central
TREAT THUMB FRACTURE,36100413,CDM,361,RC,26645,HCPCS,,,facility,both,,,,5792,4054.4,,,,,,,,,,,,,Gross Charge Type: Central
HC CLOSED TX METACARPOPHALANGEAL DISLOCATION SINGLE W/ MANIP & ANES,36100414,CDM,361,RC,26705,HCPCS,,,facility,both,,,,6326,4428.2,,,,,,,,,,,,,Gross Charge Type: Central
HC CLSD TX ARTICULAR FX INCL METACARPOPHALANGEAL/INTERPHANLANGEAL JOINT W/MANIP EACH,36100416,CDM,361,RC,26742,HCPCS,,,facility,both,,,,5523,3866.1,,,,,,,,,,,,,Gross Charge Type: Central
HC CLOSED TX FEMORAL SHAFT FRACTURE W/MANIPULATION W/ OR W/O SKIN/SKELETAL TRACTION,36100419,CDM,361,RC,27502,HCPCS,,,facility,both,,,,3078,2154.6,,,,,,,,,,,,,Gross Charge Type: Central
HC CLOSED TX FEMORAL FRACTURE DISTAL END MEDIAL/LATERAL CONDYLE W/O MANIPULATION,36100420,CDM,361,RC,27508,HCPCS,,,facility,both,,,,852,596.4,,,,,,,,,,,,,Gross Charge Type: Central
HC CLOSED RX TIBIA,36100424,CDM,361,RC,27750,HCPCS,,,facility,both,,,,383,268.1,,,,,,,,,,,,,Gross Charge Type: Central
HC CLOSED TX DISTAL FIBULAR FX W/O MANIPULATION,36100426,CDM,361,RC,27786,HCPCS,,,facility,both,,,,716,501.2,,,,,,,,,,,,,Gross Charge Type: Central
HC METATARSAL FX W/O MANIP,36100431,CDM,361,RC,28470,HCPCS,,,facility,both,,,,792,554.4,,,,,,,,,,,,,Gross Charge Type: Central
HC METATARSAL FX W/MANIP,36100432,CDM,361,RC,28475,HCPCS,,,facility,both,,,,880,616,,,,,,,,,,,,,Gross Charge Type: Central
HC CLOSED TX OF FX GREAT TOE PHALANX/PHALANGES W/O MANIPULATION,36100433,CDM,361,RC,28490,HCPCS,,,facility,both,,,,836,585.2,,,,,,,,,,,,,Gross Charge Type: Central
HC CLOSED TX FX GREAT TOE PHALANX/PHALANGES W/MANIPULATION,36100434,CDM,361,RC,28495,HCPCS,,,facility,both,,,,961,672.7,,,,,,,,,,,,,Gross Charge Type: Central
HC CLSD FOOT DISLOC W/O ANEST,36100436,CDM,361,RC,28570,HCPCS,,,facility,both,,,,885,619.5,,,,,,,,,,,,,Gross Charge Type: Central
HC TARSOMETATRSL DIS W/O ANES,36100437,CDM,361,RC,28600,HCPCS,,,facility,both,,,,914,639.8,,,,,,,,,,,,,Gross Charge Type: Central
HC APPLY HAND/WRIST CAST,36100442,CDM,361,RC,29085,HCPCS,,,facility,both,,,,335,234.5,,,,,,,,,,,,,Gross Charge Type: Central
INTRANASAL BIOPSY,36100449,CDM,361,RC,30100,HCPCS,,,facility,both,,,,965,675.5,,,,,,,,,,,,,Gross Charge Type: Central
HC REPEAT CONTROL OF NOSEBLEED,36100452,CDM,361,RC,30906,HCPCS,,,facility,both,,,,195,136.5,,,,,,,,,,,,,Gross Charge Type: Central
FLEX LARYNGOSCOPY BX,36100453,CDM,361,RC,31576,HCPCS,,,facility,both,,,,1668,1167.6,,,,,,,,,,,,,Gross Charge Type: Central
HC NON-ROUTINE BL DRAW > 3 YRS,36100457,CDM,361,RC,36410,HCPCS,,,facility,both,,,,133,93.1,,,,,,,,,,,,,Gross Charge Type: Central
HC INJECT SCLEROSANT SINGLE INCOMPETENT VEIN,36100461,CDM,361,RC,36470,HCPCS,,,facility,both,,,,527,368.9,,,,,,,,,,,,,Gross Charge Type: Central
HC CUTDWN ARTERY CATH SMPLNG,36100463,CDM,361,RC,36625,HCPCS,,,facility,both,,,,2256,1579.2,,,,,,,,,,,,,Gross Charge Type: Central
REMOVAL FOREIGN BODY MOUTH,36100464,CDM,361,RC,40804,HCPCS,,,facility,both,,,,198,138.6,,,,,,,,,,,,,Gross Charge Type: Central
BIOPSY OF MOUTH LESION,36100465,CDM,361,RC,40808,HCPCS,,,facility,both,,,,543,380.1,,,,,,,,,,,,,Gross Charge Type: Central
NDLE BX SALIVARY GLAND,36100470,CDM,361,RC,42400,HCPCS,,,facility,both,,,,729,510.3,,,,,,,,,,,,,Gross Charge Type: Central
HC DRAINAGE OF SALIVARY CYST,36100471,CDM,361,RC,42409,HCPCS,,,facility,both,,,,10709,7496.3,,,,,,,,,,,,,Gross Charge Type: Central
HC DILATION OF ESOPHAGUS SINGLE/MULTIPLE PASSES,36100473,CDM,750,RC,43450,HCPCS,,,facility,both,,,,3628,2539.6,,,,,,,,,,,,,Gross Charge Type: Central
HC DRAINAGE OF RECTAL ABSCESS,36100475,CDM,361,RC,45005,HCPCS,,,facility,both,,,,4388,3071.6,,,,,,,,,,,,,Gross Charge Type: Central
HC DIAGNOSTIC SIGMOIDOSCOPY,36100479,CDM,750,RC,45330,HCPCS,,,facility,both,,,,3020,2114,,,,,,,,,,,,,Gross Charge Type: Central
HC DILT URETHRA STRCTR INIT,36100493,CDM,361,RC,53600,HCPCS,,,facility,both,,,,1133,793.1,,,,,,,,,,,,,Gross Charge Type: Central
HC DILATION URETHRAL STRICTURE BY PASSAGE OF FILLIFORM AND FOLLOWER MALE INITIAL,36100495,CDM,361,RC,53620,HCPCS,,,facility,both,,,,5120,3584,,,,,,,,,,,,,Gross Charge Type: Central
HC FORESKIN MANIPULATION INCL LYSIS PREPUTIAL ADHESIONS AND STRETCHING,36100507,CDM,361,RC,54450,HCPCS,,,facility,both,,,,320,224,,,,,,,,,,,,,Gross Charge Type: Central
I & D OF VULVA/PERINEUM,36100510,CDM,361,RC,56405,HCPCS,,,facility,both,,,,1146,802.2,,,,,,,,,,,,,Gross Charge Type: Central
HC BX VULVA/PERINEUM ONE,36100514,CDM,361,RC,56605,HCPCS,,,facility,both,,,,3290,2303,,,,,,,,,,,,,Gross Charge Type: Central
HC BX VAGINAL MUCOSA SIMPLE,36100518,CDM,361,RC,57100,HCPCS,,,facility,both,,,,922,645.4,,,,,,,,,,,,,Gross Charge Type: Central
REMV VAG FOREIGN BODY,36100524,CDM,361,RC,57415,HCPCS,,,facility,both,,,,12352,8646.4,,,,,,,,,,,,,Gross Charge Type: Central
HC ENDOMETRIAL BIOPSY W/ OR W/O ENDOCERVIX BIOPSY W/O CERVICAL DILATION ANY METHOD,36100534,CDM,361,RC,58100,HCPCS,,,facility,both,,,,590,413,,,,,,,,,,,,,Gross Charge Type: Central
HC DILATION AND CURETTAGE,36100535,CDM,361,RC,58120,HCPCS,,,facility,both,,,,9300,6510,,,,,,,,,,,,,Gross Charge Type: Central
HC INJECTION(S) ANESTHERIC AGENT(S)/STERIOD PLANTAR DIGITAL NERVE(S),36100543,CDM,361,RC,64455,HCPCS,,,facility,both,,,,4649,3254.3,,,,,,,,,,,,,Gross Charge Type: Central
HC CHEMODEN ECCRINE BOTH AXIL,36100544,CDM,361,RC,64650,HCPCS,,,facility,both,,,,2760,1932,,,,,,,,,,,,,Gross Charge Type: Central
HC DRAIN EXTRNL EAR LESN SMPL,36100558,CDM,361,RC,69000,HCPCS,,,facility,both,,,,243,170.1,,,,,,,,,,,,,Gross Charge Type: Central
BIOPSY OF EXTERNAL EAR,36100559,CDM,361,RC,69100,HCPCS,,,facility,both,,,,959,671.3,,,,,,,,,,,,,Gross Charge Type: Central
HC COLO CA SCRNG/SIGMOID,36100565,CDM,750,RC,G0104,HCPCS,,,facility,both,,,,3020,2114,,,,,,,,,,,,,Gross Charge Type: Central
HC CYSTOSCOPY,36100568,CDM,361,RC,52000,HCPCS,,,facility,both,,,,4417,3091.9,,,,,,,,,,,,,Gross Charge Type: Central
HC INSTL CH TUBE/CATH FBRN 1ST DAY,36100573,CDM,361,RC,32561,HCPCS,,,facility,both,,,,460,322,,,,,,,,,,,,,Gross Charge Type: Central
HC INSTL CH TUBE/CATH FBRN SBSQ DAY,36100574,CDM,361,RC,32562,HCPCS,,,facility,both,,,,460,322,,,,,,,,,,,,,Gross Charge Type: Central
HC INSERT NEW/REPL PERM PMKR W/ TRNSVN ELECTRODE(S) ATRIAL,36100576,CDM,361,RC,33206,HCPCS,,,facility,both,,,,11462,8023.4,,,,,,,,,,,,,Gross Charge Type: Central
HC INSRT TUNNELED CENTRALLY INSRTD CV ACCESS DEVICE W/ SUBCU PORT < 5 YRS,36100577,CDM,361,RC,36560,HCPCS,,,facility,both,,,,10198,7138.6,,,,,,,,,,,,,Gross Charge Type: Central
HC INSERT TUN IP CATH PERC,36100579,CDM,361,RC,49418,HCPCS,,,facility,both,,,,3262,2283.4,,,,,,,,,,,,,Gross Charge Type: Central
HC THORACENTESIS NEEDLE/CATH W/O IMAGE GUIDE,36100580,CDM,361,RC,32554,HCPCS,,,facility,both,,,,586,410.2,,,,,,,,,,,,,Gross Charge Type: Central
HC THORACENTESIS NEEDLE/CATH W/ IMAGE GUIDE,36100581,CDM,361,RC,32555,HCPCS,,,facility,both,,,,1681,1176.7,,,,,,,,,,,,,Gross Charge Type: Central
HC REMOVAL INDWELLING TUNNELED PLEURAL CATH W/ CUFF,36100583,CDM,361,RC,32552,HCPCS,,,facility,both,,,,699,489.3,,,,,,,,,,,,,Gross Charge Type: Central
HC INSERT PICVAD CATH,36100584,CDM,361,RC,36571,HCPCS,,,facility,both,,,,4788,3351.6,,,,,,,,,,,,,Gross Charge Type: Central
HC TRANSCATH THERAPY ARTERIAL INFUSION FOR THROMBOLYSIS OTHER THAN CORONARY/INTRACRANIAL ANY METHOD INCL RAD S & I INTIAL TX DAY,36100585,CDM,361,RC,37211,HCPCS,,,facility,both,,,,2631,1841.7,,,,,,,,,,,,,Gross Charge Type: Central
HC THROMBOLYTIC VENOUS THERAPY,36100586,CDM,361,RC,37212,HCPCS,,,facility,both,,,,3770,2639,,,,,,,,,,,,,Gross Charge Type: Central
HC CESSJ THERAPY CATH REMOVAL,36100587,CDM,361,RC,37214,HCPCS,,,facility,both,,,,3090,2163,,,,,,,,,,,,,Gross Charge Type: Central
HC PERC RF ABLATE 1 OR MORE RENAL TUMOR(S),36100588,CDM,361,RC,50592,HCPCS,,,facility,both,,,,5271,3689.7,,,,,,,,,,,,,Gross Charge Type: Central
HC INJECTION FOR URETER X-RAY,36100589,CDM,361,RC,50684,HCPCS,,,facility,both,,,,107,74.9,,,,,,,,,,,,,Gross Charge Type: Central
HC DESTRUCTION BY NEUROLYTIC AGENT CELIAC PLEXUS,36100590,CDM,361,RC,64680,HCPCS,,,facility,both,,,,1112,778.4,,,,,,,,,,,,,Gross Charge Type: Central
HC TRANSCATH STENT CCA W/O EPS,36100591,CDM,361,RC,37216,HCPCS,,,facility,both,,,,40376,28263.2,,,,,,,,,,,,,Gross Charge Type: Central
HC TIBPER REVASC W/ ATHER ADD-ON,36100593,CDM,361,RC,37233,HCPCS,,,facility,both,,,,11673,8171.1,,,,,,,,,,,,,Gross Charge Type: Central
HC REVSC OPN/PRQ TIB/PERO STENT,36100594,CDM,361,RC,37234,HCPCS,,,facility,both,,,,5498,3848.6,,,,,,,,,,,,,Gross Charge Type: Central
HC TIB/PER REVASC STENT & ATHER,36100595,CDM,361,RC,37235,HCPCS,,,facility,both,,,,17231,12061.7,,,,,,,,,,,,,Gross Charge Type: Central
HC IVUS FIRST VESSEL ADD-ON,36100596,CDM,361,RC,37252,HCPCS,,,facility,both,,,,2540,1778,,,,,,,,,,,,,Gross Charge Type: Central
HC IVUS EA ADD VESSEL ADD -ON,36100597,CDM,361,RC,37253,HCPCS,,,facility,both,,,,2117,1481.9,,,,,,,,,,,,,Gross Charge Type: Central
HC INSERT PULSE GEN MULT LEADS,36100598,CDM,361,RC,33221,HCPCS,,,facility,both,,,,23331,16331.7,,,,,,,,,,,,,Gross Charge Type: Central
HC INSERT PULSE GEN W/ DUAL LEADS,36100599,CDM,361,RC,33230,HCPCS,,,facility,both,,,,34916,24441.2,,,,,,,,,,,,,Gross Charge Type: Central
HC REMOVE & REPLACE PERM PM GEN MULTI LEADS,36100600,CDM,361,RC,33229,HCPCS,,,facility,both,,,,18774,13141.8,,,,,,,,,,,,,Gross Charge Type: Central
HC DIAGNOSTIC BONE MARROW BIOPSY(IES),36100601,CDM,761,RC,38221,HCPCS,,,facility,both,,,,2952,2066.4,,,,,,,,,,,,,Gross Charge Type: Central
HC EGD W/BIOPSY SINGLE/MULTIPLE,36100605,CDM,750,RC,43239,HCPCS,,,facility,both,,,,3608,2525.6,,,,,,,,,,,,,Gross Charge Type: Central
HC THORACOSCOPY W/ PLEURODESIS,36100608,CDM,361,RC,32650,HCPCS,,,facility,both,,,,13655,9558.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PLACE CATH RT HEART OR MAIN PULM ARTERY,36100609,CDM,361,RC,36013,HCPCS,,,facility,both,,,,1410,987,,,,,,,,,,,,,Gross Charge Type: Central
HC PLACE CATH LT OR RT PULM ARTERY,36100610,CDM,361,RC,36014,HCPCS,,,facility,both,,,,1357,949.9,,,,,,,,,,,,,Gross Charge Type: Central
HC EGD REMOVE FOREIGN BODY,36100611,CDM,750,RC,43247,HCPCS,,,facility,both,,,,3966,2776.2,,,,,,,,,,,,,Gross Charge Type: Central
HC FETAL FLUID DRAINAGE W/ US GUIDANCE,36100612,CDM,361,RC,59074,HCPCS,,,facility,both,,,,401,280.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PLEURAL DRAIN PERCU W/ INDWELLING CATH W/ IMAGE GUIDE,36100613,CDM,361,RC,32557,HCPCS,,,facility,both,,,,2879,2015.3,,,,,,,,,,,,,Gross Charge Type: Central
HC IRRIGATION CORPORA CAVERNOSA FOR PRIAPRISM,36100617,CDM,361,RC,54220,HCPCS,,,facility,both,,,,320,224,,,,,,,,,,,,,Gross Charge Type: Central
HC EGD PLACE GASTROSTOMY TUBE,36100618,CDM,750,RC,43246,HCPCS,,,facility,both,,,,5474,3831.8,,,,,,,,,,,,,Gross Charge Type: Central
HC DRAIN BLADDER BY TROCAR/CATH,36100619,CDM,361,RC,51101,HCPCS,,,facility,both,,,,3973,2781.1,,,,,,,,,,,,,Gross Charge Type: Central
HC EGD CONTROL BLEEDING ANY METHOD,36100620,CDM,750,RC,43255,HCPCS,,,facility,both,,,,4199,2939.3,,,,,,,,,,,,,Gross Charge Type: Central
HC IMAGE GUIDED FLUID COLLECTION BY CATH PERCU SOFT TISSUE,36100622,CDM,361,RC,10030,HCPCS,,,facility,both,,,,1294,905.8,,,,,,,,,,,,,Gross Charge Type: Central
HC BREAST BX 1ST LES W/ PLACE LOCALIZATION DEVICE,36100623,CDM,361,RC,19083,HCPCS,,,facility,both,,,,4482,3137.4,,,,,,,,,,,,,Gross Charge Type: Central
HC TRNSCATH PLACE INTRAVASC STENT OPEN/PERCU INIT ARTERY,36100635,CDM,361,RC,37236,HCPCS,,,facility,both,,,,13132,9192.4,,,,,,,,,,,,,Gross Charge Type: Central
HC TRNSCATH PLACE INTRAVASC STENT OPEN/PERCU EA ADD ART,36100636,CDM,361,RC,37237,HCPCS,,,facility,both,,,,6351,4445.7,,,,,,,,,,,,,Gross Charge Type: Central
HC TRANSCATH PLACE INTRAVASC OPEN/PERCU INITIAL VEIN,36100637,CDM,361,RC,37238,HCPCS,,,facility,both,,,,13132,9192.4,,,,,,,,,,,,,Gross Charge Type: Central
HC TRNSCATH PLACE INTRAVASC STENT OPEN/PERCU EA ADD VEIN,36100638,CDM,361,RC,37239,HCPCS,,,facility,both,,,,6351,4445.7,,,,,,,,,,,,,Gross Charge Type: Central
HC VASC EMBOLIZE/OCCLUDE VENOUS,36100639,CDM,361,RC,37241,HCPCS,,,facility,both,,,,15212,10648.4,,,,,,,,,,,,,Gross Charge Type: Central
HC VASC EMBOLIZE/OCCLUDE ARTERY,36100640,CDM,361,RC,37242,HCPCS,,,facility,both,,,,15212,10648.4,,,,,,,,,,,,,Gross Charge Type: Central
HC VASC EMBOLIZE/OCCLUDE ORGAN,36100641,CDM,361,RC,37243,HCPCS,,,facility,both,,,,15212,10648.4,,,,,,,,,,,,,Gross Charge Type: Central
HC VASC EMBOLIZE/OCCLUDE ART/VENOUS HEMORRHAGE,36100642,CDM,361,RC,37244,HCPCS,,,facility,both,,,,15212,10648.4,,,,,,,,,,,,,Gross Charge Type: Central
HC IMAGE GUIDED FLUID CATH COLLECT PERCU VISCERAL,36100643,CDM,361,RC,49405,HCPCS,,,facility,both,,,,2104,1472.8,,,,,,,,,,,,,Gross Charge Type: Central
HC IMAGE GUIDED FLUID CATH COLLECT PERI/RETROPERI,36100644,CDM,361,RC,49406,HCPCS,,,facility,both,,,,2104,1472.8,,,,,,,,,,,,,Gross Charge Type: Central
HC IMAGE GUIDED FLUID CATH COLLECT TRNSVAG/TRNSRECT,36100645,CDM,361,RC,49407,HCPCS,,,facility,both,,,,1787,1250.9,,,,,,,,,,,,,Gross Charge Type: Central
HC CHEMODENERV MUSC NECK DYSTONIA,36100646,CDM,361,RC,64616,HCPCS,,,facility,both,,,,1542,1079.4,,,,,,,,,,,,,Gross Charge Type: Central
HC CHEMODENERV 1 EXTREMITY 1-4 MUSC,36100647,CDM,361,RC,64642,HCPCS,,,facility,both,,,,1096,767.2,,,,,,,,,,,,,Gross Charge Type: Central
HC CHEMODENERV 1 EXTREMITY 1-4 EA ADD MUSC,36100648,CDM,361,RC,64643,HCPCS,,,facility,both,,,,801,560.7,,,,,,,,,,,,,Gross Charge Type: Central
HC CHEMODENERV 1 EXTREMITY 5 OR MORE MUSC,36100649,CDM,361,RC,64644,HCPCS,,,facility,both,,,,1261,882.7,,,,,,,,,,,,,Gross Charge Type: Central
HC CHEMODENERV 1 EXTREMITY EA ADD EXTREMITY 5 OR MORE MUSC,36100650,CDM,361,RC,64645,HCPCS,,,facility,both,,,,697,487.9,,,,,,,,,,,,,Gross Charge Type: Central
HC CHEMODENERV TRUNK 1-5 MUSC,36100651,CDM,361,RC,64646,HCPCS,,,facility,both,,,,356,249.2,,,,,,,,,,,,,Gross Charge Type: Central
HC CHEMODENERV TRUNK 6 OR MORE MUSC,36100652,CDM,361,RC,64647,HCPCS,,,facility,both,,,,2702,1891.4,,,,,,,,,,,,,Gross Charge Type: Central
HC TRANSCATHETER RETRIVAL PERCUTANEOUS INTRAVASCULAR FOREIGN BODY,36100663,CDM,361,RC,37197,HCPCS,,,facility,both,,,,3924,2746.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PERCUTANEOUS REMOVAL OF URETERAL STENT VIA SNARE/CAPTURE,36100664,CDM,361,RC,50384,HCPCS,,,facility,both,,,,6917,4841.9,,,,,,,,,,,,,Gross Charge Type: Central
HC TRANSURETHERAL REPLACEMENT OF INTERNAL URETERAL STENT B,36100665,CDM,361,RC,50385,HCPCS,,,facility,both,,,,7360,5152,,,,,,,,,,,,,Gross Charge Type: Central
HC REMOVAL DWELLING URETERAL STENT VIA TRANSURETHERAL W/CYSTOSCOPY,36100666,CDM,361,RC,50386,HCPCS,,,facility,both,,,,8159,5711.3,,,,,,,,,,,,,Gross Charge Type: Central
HC BIOPSY THYROID PERCUTANEOUS CORE NEEDLE,36100667,CDM,361,RC,60100,HCPCS,,,facility,both,,,,932,652.4,,,,,,,,,,,,,Gross Charge Type: Central
HC ASPIRATION AND/OR INJECTION THYRIOD CYST,36100668,CDM,361,RC,60300,HCPCS,,,facility,both,,,,751,525.7,,,,,,,,,,,,,Gross Charge Type: Central
HC NON-SELECT CATHETER PLACE W/ANGIOGRAPHY EXTRACRANIAL CAROTID VERTEBRAL/INTRACRANIAL VESSESLS UNILAT OR BILAT,36100669,CDM,361,RC,36221,HCPCS,,,facility,both,,,,10264,7184.8,,,,,,,,,,,,,Gross Charge Type: Central
HC COMMON CAROTID AND EXTERNAL CAROTID IMAGING W/CATHETER,36100670,CDM,361,RC,36222,HCPCS,,,facility,both,,,,2277,1593.9,,,,,,,,,,,,,Gross Charge Type: Central
HC REMOVAL OF IMPLANT DEEP,36100672,CDM,361,RC,20680,HCPCS,,,facility,both,,,,12185,8529.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PELVIC EXAMINATION UNDER ANESTHESIA,36100675,CDM,361,RC,57410,HCPCS,,,facility,both,,,,2879,2015.3,,,,,,,,,,,,,Gross Charge Type: Central
HC CHEMODENERV MUSC MIGRAINE,36100681,CDM,361,RC,64615,HCPCS,,,facility,both,,,,1112,778.4,,,,,,,,,,,,,Gross Charge Type: Central
HC REM ENDOVAS VENA CAVA FILTER,36100689,CDM,361,RC,37193,HCPCS,,,facility,both,,,,11476,8033.2,,,,,,,,,,,,,Gross Charge Type: Central
HC SKIN SUBSTITUTE APPLICATION TO FOOT FIRST 25 SQ CM,36100694,CDM,361,RC,15275,HCPCS,,,facility,both,,,,7384,5168.8,,,,,,,,,,,,,Gross Charge Type: Central
HC INSERT/PLACE HEART CATH SWAN GANZ,36100697,CDM,361,RC,93503,HCPCS,,,facility,both,,,,2242,1569.4,,,,,,,,,,,,,Gross Charge Type: Central
HC I&D DEEP ABSCESS/HEMATOMA SOFT TISS NECK/THORAX,36100698,CDM,361,RC,21501,HCPCS,,,facility,both,,,,2442,1709.4,,,,,,,,,,,,,Gross Charge Type: Central
HC LARYNGOSCOPY FLEX FIBEROPTIC W/ REM,36100702,CDM,361,RC,31577,HCPCS,,,facility,both,,,,1919,1343.3,,,,,,,,,,,,,Gross Charge Type: Central
HC NASAL/SINUS ENDOSCOPY SURG W/ CONTROL NASAL HEMORRHAGE,36100705,CDM,361,RC,31238,HCPCS,,,facility,both,,,,1461,1022.7,,,,,,,,,,,,,Gross Charge Type: Central
HC TRACHEOBRONCH THROUGH ESTAB TRACH INCISION,36100706,CDM,361,RC,31615,HCPCS,,,facility,both,,,,750,525,,,,,,,,,,,,,Gross Charge Type: Central
HC INCISION LABIAL FRENUM,36100710,CDM,361,RC,40806,HCPCS,,,facility,both,,,,543,380.1,,,,,,,,,,,,,Gross Charge Type: Central
HC INJ INTRALESIONAL UP TO AND INCL 7 LESIONS,36100711,CDM,361,RC,11900,HCPCS,,,facility,both,,,,724,506.8,,,,,,,,,,,,,Gross Charge Type: Central
HC BIOPSY OROPHARYNX,36100716,CDM,361,RC,42800,HCPCS,,,facility,both,,,,965,675.5,,,,,,,,,,,,,Gross Charge Type: Central
HC BIOPSY/EXCISION LYMPH NODE(S) OPEN SUPERFICIAL,36100717,CDM,361,RC,38500,HCPCS,,,facility,both,,,,16303,11412.1,,,,,,,,,,,,,Gross Charge Type: Central
HC REPLACE TUNNELED CV CATH COMPLETE,36100718,CDM,361,RC,36582,HCPCS,,,facility,both,,,,3546,2482.2,,,,,,,,,,,,,Gross Charge Type: Central
HC TRACHEOSTOMY EMERGENCY PROCEDURE CRICOTHYROID MEMBRANE,36100719,CDM,361,RC,31605,HCPCS,,,facility,both,,,,2089,1462.3,,,,,,,,,,,,,Gross Charge Type: Central
HC TREAT PLEUROSESIS W/ AGENT,36100720,CDM,361,RC,32560,HCPCS,,,facility,both,,,,731,511.7,,,,,,,,,,,,,Gross Charge Type: Central
HC BIOPSY BONE OPEN DEEP,36100721,CDM,361,RC,20245,HCPCS,,,facility,both,,,,10428,7299.6,,,,,,,,,,,,,Gross Charge Type: Central
HC INSERT CECOSTOMY/COLONIC TUBE PERCU UNDER FLUORO INCL CONTRAST INJ,36100723,CDM,361,RC,49442,HCPCS,,,facility,both,,,,2147,1502.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PERCU VERTEBROPLASTY 1 VERT BODY UNILAT/BILAT INJ LUMB INCLUDES ALL IMAGING GUIDANCE,36100726,CDM,361,RC,22511,HCPCS,,,facility,both,,,,4420,3094,,,,,,,,,,,,,Gross Charge Type: Central
HC PERCU KYPHOPLASTY 1 VERT BODY UNILAT/BILAT CANN THORACIC INCLUDES ALL IMAGING GUIDANCE,36100727,CDM,361,RC,22513,HCPCS,,,facility,both,,,,10737,7515.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PERCU KYPHOPLASTY 1 VERT BODY UNILAT/BILAT CANN LUMBAR INCLUDES ALL IMAGING GUIDANCE,36100728,CDM,361,RC,22514,HCPCS,,,facility,both,,,,10737,7515.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PERCU KYPHOPLASTY 1 VERT BODY UNILAT/BILAT CANN EA ADD THOR/LUMB VERT BODY,36100729,CDM,361,RC,22515,HCPCS,,,facility,both,,,,10737,7515.9,,,,,,,,,,,,,Gross Charge Type: Central
HC INSERT/REPLACE PERM SUBCU IMPLANTABLE DEFIB SYSTEM INCL PRO/REPROGRAMMING WHEN PERFORMED,36100733,CDM,361,RC,33270,HCPCS,,,facility,both,,,,43805,30663.5,,,,,,,,,,,,,Gross Charge Type: Central
HC INSERT PACING CARDIOVERTER-DEFIBRILLATOR PULSE GEN ONLY W/ EXISTING SINGLE LEAD,36100735,CDM,361,RC,33240,HCPCS,,,facility,both,,,,92369,64658.3,,,,,,,,,,,,,Gross Charge Type: Central
HC REMOVE AND REPLACE PACING CARDIOVERTER-DEFIBRILLATOR PULSE GEN SINGLE LEAD SYSTEM,36100737,CDM,361,RC,33262,HCPCS,,,facility,both,,,,32573,22801.1,,,,,,,,,,,,,Gross Charge Type: Central
HC REMOVE AND REPLACE PACING CARDIOVERTER-DEFIBRILLATOR PULSE GEN DUAL LEAD SYSTEM,36100738,CDM,361,RC,33263,HCPCS,,,facility,both,,,,32573,22801.1,,,,,,,,,,,,,Gross Charge Type: Central
HC REMOVE AND REPLACE PACING CARDIOVERTER-DEFIBRILLATOR PULSE GEN MULTIPLE LEAD SYSTEM,36100739,CDM,361,RC,33264,HCPCS,,,facility,both,,,,128359,89851.3,,,,,,,,,,,,,Gross Charge Type: Central
HC REMOVE SUBCU IMPLANTABLE DEFIBRILLATOR ELECTRODE,36100740,CDM,361,RC,33272,HCPCS,,,facility,both,,,,3336,2335.2,,,,,,,,,,,,,Gross Charge Type: Central
HC REPOSITION PREVIOUSLY IMPLANTED SUBCU IMPLANTABLE DEFIBRILLATOR ELECTRODE,36100741,CDM,361,RC,33273,HCPCS,,,facility,both,,,,10559,7391.3,,,,,,,,,,,,,Gross Charge Type: Central
HC NASAL ENDOSCOPY DX UNILATERAL/BILATERAL,36100742,CDM,361,RC,31231,HCPCS,,,facility,both,,,,176,123.2,,,,,,,,,,,,,Gross Charge Type: Central
HC DBRDMT SUB TIS EACH ADDL 20 SQ CM,36100745,CDM,361,RC,11045,HCPCS,,,facility,both,,,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Central
HC DBRDMT MUSCLE AND/OR FASCIA EA ADDTL 20 SQ CM,36100746,CDM,361,RC,11046,HCPCS,,,facility,both,,,,171,119.7,,,,,,,,,,,,,Gross Charge Type: Central
HC DBRMT BONE EA ADDL 20 SQ CM,36100747,CDM,361,RC,11047,HCPCS,,,facility,both,,,,341,238.7,,,,,,,,,,,,,Gross Charge Type: Central
HC INSRT TUNNELED CENTRALLY INSRTD CV CATH W/O SUBCU PORT/PUMP < 5 YRS,36100748,CDM,361,RC,36557,HCPCS,,,facility,both,,,,3338,2336.6,,,,,,,,,,,,,Gross Charge Type: Central
HC REPLACE CATH ONLY CV DEVICE W/SUBCU PORT/PUMP CENTRAL/PERIPH INSERT SITE,36100749,CDM,361,RC,36578,HCPCS,,,facility,both,,,,12370,8659,,,,,,,,,,,,,Gross Charge Type: Central
HC TRANSCATH PLACE INTRAVASC STENT(S) INTRATHOR COMM CAROTID ART/INNOM ART OPEN/PERCUT ANTEGRADE APPROACH INCLUD ANGIO WHEN PEF RAD S & I,36100751,CDM,361,RC,37218,HCPCS,,,facility,both,,,,2873,2011.1,,,,,,,,,,,,,Gross Charge Type: Central
HC MYELOGRAPHY LUMBAR INJ INCL RADIOLOGICAL SUPRVSON/INTERP LOMBOSACRAL,36100755,CDM,361,RC,62304,HCPCS,,,facility,both,,,,960,672,,,,,,,,,,,,,Gross Charge Type: Central
HC INJECTION OF SINUS TRACT THERAPEUTIC,36100756,CDM,361,RC,20500,HCPCS,,,facility,both,,,,965,675.5,,,,,,,,,,,,,Gross Charge Type: Central
HC LARYNGOSCOPY INDIRECT DIAGNOSTIC (SEPARATE PROCEDURE),36100757,CDM,361,RC,31505,HCPCS,,,facility,both,,,,684,478.8,,,,,,,,,,,,,Gross Charge Type: Central
HC REP TWO TRANSVENOUS ELECTRODES FOR PERM PACEMAKER/IMPLANTABLE DEFIBRILLATOR,36100759,CDM,361,RC,33220,HCPCS,,,facility,both,,,,10559,7391.3,,,,,,,,,,,,,Gross Charge Type: Central
HC CANTHOTOMY,36100762,CDM,361,RC,67715,HCPCS,,,facility,both,,,,14518,10162.6,,,,,,,,,,,,,Gross Charge Type: Central
HC CLOSED TX INTERPHALANGEAL JOINT DISLOC SINGLE W/MANIP REQ ANESTH,36100763,CDM,361,RC,26775,HCPCS,,,facility,both,,,,1253,877.1,,,,,,,,,,,,,Gross Charge Type: Central
HC INCISION OF LINGUAL FRENUM (FRENOTOMY),36100764,CDM,361,RC,41010,HCPCS,,,facility,both,,,,965,675.5,,,,,,,,,,,,,Gross Charge Type: Central
HC REPAIR INTERMED WOUNDS NCK/HNDS/FT/EXTERNAL GENITALIA OVER 30.0,36100765,CDM,361,RC,12047,HCPCS,,,facility,both,,,,5963,4174.1,,,,,,,,,,,,,Gross Charge Type: Central
HC REPAIR COMPLEX TRUNK EACH ADDL 5 CM OR LESS,36100766,CDM,361,RC,13102,HCPCS,,,facility,both,,,,431,301.7,,,,,,,,,,,,,Gross Charge Type: Central
HC CLOSURE OF LACERATION VESTIBULE OF MOUTH OVER 2.5 CM OR COMPLEX,36100767,CDM,361,RC,40831,HCPCS,,,facility,both,,,,2393,1675.1,,,,,,,,,,,,,Gross Charge Type: Central
HC ARTHROCENTESIS ASPIRATION/INJECTION MAJOR JOINT/BURSA W/ ULTRASOUND GUIDANCE,36100768,CDM,361,RC,20611,HCPCS,,,facility,both,,,,1459,1021.3,,,,,,,,,,,,,Gross Charge Type: Central
HC BLEPHAROTOMY DRAINAGE OF ABSCESS EYELID,36100771,CDM,450,RC,67700,HCPCS,,,facility,both,,,,446,312.2,,,,,,,,,,,,,Gross Charge Type: Central
HC REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT,36100772,CDM,361,RC,11982,HCPCS,,,facility,both,,,,198,138.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PLACE URETERAL STENT PERCU INCL DX NEPHROSTOGRAM AND/OR URETEROGRAM IMAGE GUIDE ASSOC RAD S & I PRE-EXISTING NEPHROSTOMY TRACT,36100774,CDM,361,RC,50693,HCPCS,,,facility,both,,,,7874,5511.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PLACE URETERAL STENT PERCU INCL DX NEPHROSTOGRAM AND/OR URETEROGRAM IMAGE GUIDE ASSOC RAD S & I NEW ACCESS W/SEP NEPHROSTOMY CATH,36100776,CDM,361,RC,50695,HCPCS,,,facility,both,,,,13191,9233.7,,,,,,,,,,,,,Gross Charge Type: Central
HC INJECT PX ANTEGRADE NEPHROSTOGRAM AND/OR URETEROGRAM COMPLETE DX PX INCL IMAGE GUIDE ASSOC RAD S & I NEW ACCESS,36100777,CDM,361,RC,50430,HCPCS,,,facility,both,,,,689,482.3,,,,,,,,,,,,,Gross Charge Type: Central
HC INJECT PX ANTEGRADE NEPHROSTOGRAM AND/OR URETEROGRAM COMPLETE DX PX INCL IMAGE GUIDE ASSOC RAD S & I EXISTING ACCESS,36100778,CDM,361,RC,50431,HCPCS,,,facility,both,,,,689,482.3,,,,,,,,,,,,,Gross Charge Type: Central
HC URETERAL EMBOLIZATION/OCCLUSION INCL IMAGE GUIDE ASSOC RAD S & I,36100779,CDM,361,RC,50705,HCPCS,,,facility,both,,,,771,539.7,,,,,,,,,,,,,Gross Charge Type: Central
HC BALLOON DILATION URETERAL STRICTURE INCL IMAGE GUIDE ASSOC RAD S & I,36100780,CDM,361,RC,50706,HCPCS,,,facility,both,,,,1754,1227.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PARAVERTEBRAL BLOCK (PVB) THORACIC SINGLE INJECT SITE,36100781,CDM,361,RC,64461,HCPCS,,,facility,both,,,,2499,1749.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PARAVERTEBRAL BLOCK (PVB) THORACIC SECOND & ADDL INJECT SITE(S),36100782,CDM,361,RC,64462,HCPCS,,,facility,both,,,,184,128.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PARAVERTEBRAL BLOCK (PVB) THORACIC CONTINUOUS INFUSION BY CATHETER,36100783,CDM,361,RC,64463,HCPCS,,,facility,both,,,,2499,1749.3,,,,,,,,,,,,,Gross Charge Type: Central
HC INJ CHOLANGIO PERCU COMPLETE DX PX INCL IMAGE GUIDE ASSOC RAD S & I EXISTING ACCESS,36100784,CDM,361,RC,47531,HCPCS,,,facility,both,,,,652,456.4,,,,,,,,,,,,,Gross Charge Type: Central
HC INJ CHOLANGIO PERCU COMPLETE DX PX INCL IMAGE GUIDE ASSOC RAD S & I NEW ACCESS,36100785,CDM,361,RC,47532,HCPCS,,,facility,both,,,,2109,1476.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PLACEMENT BILIARY DRAIN CATH PERCU INCL DX CHOLANGIO IMAGE GUIDE ASSOC RAD  S & I EXTERNAL,36100786,CDM,361,RC,47533,HCPCS,,,facility,both,,,,8004,5602.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PLACEMENT BILIARY DRAIN CATH PERCU INCL DX CHOLANGIO IMAGE GUIDE ASSOC RAD  S & I INTERNAL/EXTERNAL,36100787,CDM,361,RC,47534,HCPCS,,,facility,both,,,,11276,7893.2,,,,,,,,,,,,,Gross Charge Type: Central
HC CONVERSION EXTERNAL BILIARY DRAIN CATH TO INTERNAL-EXTERNAL BILIARY DRAIN CATH PERCU INCL DX CHOLANGIO IMAGE GUIDE ASSOC RAD S & I,36100788,CDM,361,RC,47535,HCPCS,,,facility,both,,,,10538,7376.6,,,,,,,,,,,,,Gross Charge Type: Central
HC EXCHANGE BILIARY DRAIN CATH PERCU INCL DX CHOLANGIO IMAGE GUIDE ASSOC RAD S & I,36100789,CDM,361,RC,47536,HCPCS,,,facility,both,,,,3620,2534,,,,,,,,,,,,,Gross Charge Type: Central
HC REMOVAL BILIARY DRAIN CATH PERCU FLUORO GUIDE INCL DX CHOLANGIO IMAGE GUIDE ASSOC RAD S & I,36100790,CDM,361,RC,47537,HCPCS,,,facility,both,,,,1120,784,,,,,,,,,,,,,Gross Charge Type: Central
HC PLACE STENT(S) BILE DUCTS PERCU INCL DX CHOLANGIO IMAGE GUIDE BALLOON DILATION CATH EXCHANGE(S) & CATH REMOVAL(S) ASSOC RAD S & I EACH STENT EXISTING ACCESS,36100791,CDM,361,RC,47538,HCPCS,,,facility,both,,,,11304,7912.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PLACE STENT(S) BILE DUCTS PERCU INCL DX CHOLANGIO IMAGE GUIDE BALLOON DILATION CATH EXCHANGE(S)  & CATH REMOVAL(S) ASSOC RAD S & I NEW ACCESS W/O SEP BILIARY DRAIN CATH,36100792,CDM,361,RC,47539,HCPCS,,,facility,both,,,,14164,9914.8,,,,,,,,,,,,,Gross Charge Type: Central
HC REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE UNILATERAL,36100794,CDM,361,RC,69209,HCPCS,,,facility,both,,,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Central
HC BALLOON DILATION BILIARY DUCT(S) OR AMPULLA PERCU INCL IMAGE GUIDE ASSOC RAD S & I EACH DUCT,36100796,CDM,361,RC,47542,HCPCS,,,facility,both,,,,7184,5028.8,,,,,,,,,,,,,Gross Charge Type: Central
HC ENDOLUMINAL BX(S) BILIARY TREE PERCU ANY METHOD(S) INCL IMAGE GUIDE ASSOC RAD S & I SINGLE/MULTI,36100797,CDM,361,RC,47543,HCPCS,,,facility,both,,,,2471,1729.7,,,,,,,,,,,,,Gross Charge Type: Central
HC SCLEROTHERAPY OF FLUID COLLECT PERCU INCL CONTRAST INJECT(S) SCLEROSANT INJECT(S) DX STUDY IMAGE GUIDE RAD S& I,36100799,CDM,361,RC,49185,HCPCS,,,facility,both,,,,1377,963.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PLACE NEPHROSTOMY CATH PERCU INC DX NEPHROSTOGRAM URETOGRAM IMAGE GUIDE  ASSOC  RAD S & I,36100800,CDM,361,RC,50432,HCPCS,,,facility,both,,,,6976,4883.2,,,,,,,,,,,,,Gross Charge Type: Central
HC EXCHANGE NEPHROSTOMY CATH PERCU INCL DX NEPHROSTOGRAM URETEROGRAM IMAGE GUIDE  ASSOC RAD S & I,36100801,CDM,361,RC,50435,HCPCS,,,facility,both,,,,2817,1971.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PLACE NEPHROURETERAL CATH PERCU INCL DX NEPHROSTOGRAM/URETEROGRAM IMAGE GUIDE ASSOC RAD S & I NEW ACCESS,36100802,CDM,361,RC,50433,HCPCS,,,facility,both,,,,9952,6966.4,,,,,,,,,,,,,Gross Charge Type: Central
HC CONVERT NEPHROSTOMY CATH TO NEPHROURETERAL CATH PERCU INCL DX NEPHROSTOGRAM/URETERGRAM IMAGE GUIDE ASSOC RAD S & I VIA PRE-EXISTING NEPHROSTOMY TRACT,36100803,CDM,361,RC,50434,HCPCS,,,facility,both,,,,8578,6004.6,,,,,,,,,,,,,Gross Charge Type: Central
HC ENDOLUMINAL BX URETER/RENAL PELVIS NON-ENDOSCOPIC INCL IMAGE GUIDE ASSOC RAD S & I,36100804,CDM,361,RC,50606,HCPCS,,,facility,both,,,,602,421.4,,,,,,,,,,,,,Gross Charge Type: Central
HC TRANSCATH PULM VALVE IMPLANT PERQ INCL PRE-STENTING VALVE DELIVERY SITE,36100809,CDM,361,RC,33477,HCPCS,,,facility,both,,,,20826,14578.2,,,,,,,,,,,,,Gross Charge Type: Central
HC BONE MARROW ASPIRATION W/BONE MARROW BIOPSY SAME INCISION SAME DOS,36100810,CDM,761,RC,38222,HCPCS,,,facility,both,,,,3259,2281.3,,,,,,,,,,,,,Gross Charge Type: Central
HC TRACHEOSTOMY PLANNED SEPARATE PROCEDURE,36100812,CDM,361,RC,31600,HCPCS,,,facility,both,,,,2689,1882.3,,,,,,,,,,,,,Gross Charge Type: Central
HC TRACHEOSTOMY EMERGENCY PROCEDURE TRANSTRACHEAL,36100813,CDM,361,RC,31603,HCPCS,,,facility,both,,,,1148,803.6,,,,,,,,,,,,,Gross Charge Type: Central
HC DIAGNOSTIC BONE MARROW ASPIRATION(S),36100850,CDM,361,RC,38220,HCPCS,,,facility,both,,,,2867,2006.9,,,,,,,,,,,,,Gross Charge Type: Central
HC EGD FLEXIBLE/TRANSORAL W/BAND LIGATION ESOPHAGEAL/GASTRIC VARICES,36100851,CDM,750,RC,43244,HCPCS,,,facility,both,,,,5104,3572.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PINCH GRAFT SINGLE/MULTIPLE COVER SMALL ULCER/TIP OF DIGIT/MINIMAL OPEN AREA UP TO 2CM DIAMETER,36100852,CDM,361,RC,15050,HCPCS,,,facility,both,,,,595,416.5,,,,,,,,,,,,,Gross Charge Type: Central
HC SPLIT-THICKNESS AUTOGRAFT TRUNK/ARMS/LEGS FIRST 100 SQ CM OR LESS OR 1% OF BODY AREA OF INFANTS/CHILDREN,36100853,CDM,361,RC,15100,HCPCS,,,facility,both,,,,2966,2076.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PERCUT TRANSCATH CLOSURE LEFT ATRIAL APPENDAGE W/ENDOCARDIAL IMPLANT INCL FLUORO  RAD S&I,36100855,CDM,361,RC,33340,HCPCS,,,facility,both,,,,11522,8065.4,,,,,,,,,,,,,Gross Charge Type: Central
HC INTRO CATH DIALYSIS CIRCUIT W/DX ANGIO INCL DIRECT PUNCT/CATH PLACE/INJECT CONTRAST INCL INFERIOR/SUPERIOR VENA CAVA FLUORO GUIDE RAD S&I IMAGE DOC/REPORT,36100856,CDM,361,RC,36901,HCPCS,,,facility,both,,,,1704,1192.8,,,,,,,,,,,,,Gross Charge Type: Central
HC INTRO CATH DIALYSIS CIRCUIT W/TRANSLUMINAL BALLOON ANGIO PERIPHERAL DIALYSIS SEG INCL IMAGE  RAD S&I,36100857,CDM,361,RC,36902,HCPCS,,,facility,both,,,,15822,11075.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PERCUT TRANSLUMINAL MECHANICAL THROMBECTOMY/INFUSION ANY METHOD INCL IMAGE/RAD S&I INTERP,36100859,CDM,361,RC,36904,HCPCS,,,facility,both,,,,19271,13489.7,,,,,,,,,,,,,Gross Charge Type: Central
HC THRMBC/NFS DIALYSIS CIRCUIT W/TRANSLUMINAL BALLOON ANGIO PERIPHERAL DIALYSIS SEG INCL IMAGE RAD S&I INTERP,36100860,CDM,361,RC,36905,HCPCS,,,facility,both,,,,37814,26469.8,,,,,,,,,,,,,Gross Charge Type: Central
HC THRMBC/NFS DIALYSIS CIRCUIT W/TRANSCATH PLACE INTRAVASCULAR STENT PERIPHERAL DIALYSIS SEG INCL IMAGE RAD S&I INTERP,36100861,CDM,361,RC,36906,HCPCS,,,facility,both,,,,21291,14903.7,,,,,,,,,,,,,Gross Charge Type: Central
HC TRANSLUMINAL BALLOON ANGIO CENTRAL DIALYSIS SEG DIALYSIS CIRCUIT INCL IMAGE RAD S&I  (LIST SEP IN ADDITION TO CODE FOR PRIMARY PX),36100862,CDM,361,RC,36907,HCPCS,,,facility,both,,,,15822,11075.4,,,,,,,,,,,,,Gross Charge Type: Central
HC TRANSLUMINAL BALLOON ANGIO OPEN/ PERCUT INCL IMAGE RAD S&I INITIAL ARTERY,36100863,CDM,361,RC,37246,HCPCS,,,facility,both,,,,14865,10405.5,,,,,,,,,,,,,Gross Charge Type: Central
HC TRANSLUMINAL BALLOON ANGIO OPEN/PERCUT INCL IMAGE RAD S&I EACH ADDL ARTERY (LIST SEP IN ADDITION TO CODE FOR PRIMARY PX),36100864,CDM,361,RC,37247,HCPCS,,,facility,both,,,,623,436.1,,,,,,,,,,,,,Gross Charge Type: Central
HC TRANSLUMINAL BALLOON ANGIO (EXCEPT DIALYSIS CIRCUIT) OPEN/PERCUT INCL IMAGE RAD S&I INITIAL VEIN,36100865,CDM,361,RC,37248,HCPCS,,,facility,both,,,,14118,9882.6,,,,,,,,,,,,,Gross Charge Type: Central
HC TRANSLUMINAL BALLOON ANGIO OPEN/PERCUT INCL IMAGE RAD S&I EACH ADDL VEIN (LIST SEP IN ADDITION TO CODE FOR PRIMARY PX),36100866,CDM,361,RC,37249,HCPCS,,,facility,both,,,,4096,2867.2,,,,,,,,,,,,,Gross Charge Type: Central
HC INJECT DX/THERPEUTIC SUBSTANCE INCL NEEDLE/CATH PLACE INTERLAMINAR EPIDURAL/SUBARACHNOID/CERVICAL/THORACIC W/O IMAGE GUIDE,36100867,CDM,361,RC,62320,HCPCS,,,facility,both,,,,2499,1749.3,,,,,,,,,,,,,Gross Charge Type: Central
HC INJECT DX/THERPEUTIC SUBSTANCE INCL NEEDLE/CATH PLACE INTERLAMINAR EPIDURAL/SUBARACHNOID/CERVICAL/THORACIC W/IMAGE GUIDE (IE FLUORO OR CT),36100868,CDM,361,RC,62321,HCPCS,,,facility,both,,,,1727,1208.9,,,,,,,,,,,,,Gross Charge Type: Central
HC INJECT DX/THERAPEUTIC SUBSTANCE INCL NEEDLE/CATH PLACE INTERLAMINAR EPIDURAL/SUBARACHNOID/ LUMBAR/SACRAL (CAUDAL) W/O IMAGE GUIDE,36100869,CDM,361,RC,62322,HCPCS,,,facility,both,,,,2945,2061.5,,,,,,,,,,,,,Gross Charge Type: Central
HC INJECT DX/THERAPEUTIC SUBSTANCE INCL NEEDLE/ CATH PLACE INTERLAMINAR EPIDURAL/SUBARACHNOID/LUMBAR/SACRAL (CAUDAL) W/IMAGE GUIDE (IE FLUORO OR CT),36100870,CDM,361,RC,62323,HCPCS,,,facility,both,,,,1504,1052.8,,,,,,,,,,,,,Gross Charge Type: Central
HC INJECT INCL INDWELLING CATH PLACE CONT INFUSION/INTERMIT BOLUS INTERLAMINAR EPIDURAL/SUBARACHNOID/CERVICAL/THORACIC W/O IMAGE GUIDE,36100871,CDM,361,RC,62324,HCPCS,,,facility,both,,,,3294,2305.8,,,,,,,,,,,,,Gross Charge Type: Central
HC INJECT INCL INDWELLING CATH PLACE CONT INFUSION/INTERMIT BOLUS INTERLAMINAR EPIDURAL/SUBARACHNOID/CERVICAL/THORACIC W/IMAGE GUIDE (IE FLUORO OR CT),36100872,CDM,361,RC,62325,HCPCS,,,facility,both,,,,3788,2651.6,,,,,,,,,,,,,Gross Charge Type: Central
HC INJECT INCL INDWELLING CATH PLACE CONT INFUSION/INTERMIT BOLUS INTERLAMINAR EPIDURAL/SUBARACHNOID/LUMBAR/SACRAL (CAUDAL) W/O IMAGE GUIDE,36100873,CDM,361,RC,62326,HCPCS,,,facility,both,,,,1323,926.1,,,,,,,,,,,,,Gross Charge Type: Central
HC INJECT INCL INDWELLING CATH PLACE CONT INFUSION/INTERMIT BOLUS INTERLAMINAR EPIDURAL/ SUBARACHNOID/LUMBAR/SACRAL (CAUDAL) W/IMAGE GUIDE (IE FLUORO OR CT),36100874,CDM,361,RC,62327,HCPCS,,,facility,both,,,,3294,2305.8,,,,,,,,,,,,,Gross Charge Type: Central
HC DECOMPRESSION FASCIOTOMY FOREARM/WRIST FLEXOR AND EXTENSOR COMPARTMENT W/O DEBRIDEMENT NONVIABLE MUSCLE/NERVE,36100875,CDM,361,RC,25024,HCPCS,,,facility,both,,,,9421,6594.7,,,,,,,,,,,,,Gross Charge Type: Central
HC MYELOGRAPHY VIA LUMBAR INJECT INCL RAD S&I 2 OR MORE REGIONS,36100876,CDM,361,RC,62305,HCPCS,,,facility,both,,,,1738,1216.6,,,,,,,,,,,,,Gross Charge Type: Central
HC MYELOGRAPHY VIA LUMBAR INJECTION INC RAD S&I CERVICAL,36100877,CDM,361,RC,62302,HCPCS,,,facility,both,,,,1738,1216.6,,,,,,,,,,,,,Gross Charge Type: Central
HC CYSTOURETHROSCOPY W/URETERAL CATH W/WO IRRIGATION/INSTILLATION/URETEROPYELOGRAPHY EXCLUSIVE OF RA,36100879,CDM,361,RC,52005,HCPCS,,,facility,both,,,,4726,3308.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PERCU VRTBRPLSTY 1 VERT BODY UNI/BIL INJ INCL IMG GUID CERVICOTHORA,36100894,CDM,361,RC,22510,HCPCS,,,facility,both,,,,11791,8253.7,,,,,,,,,,,,,Gross Charge Type: Central
HC INJECTION ANESTHETIC AGENT SUPERIOR HYPOGASTRIC PLEXUS,36100902,CDM,361,RC,64517,HCPCS,,,facility,both,,,,3294,2305.8,,,,,,,,,,,,,Gross Charge Type: Central
HC TANGENTIAL BIOPSY OF SKIN SINGLE LESION,36100913,CDM,361,RC,11102,HCPCS,,,facility,both,,,,704,492.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PUNCH BIOPSY OF SKIN INCL SIMPLE CLOSURE SINGLE LESION,36100914,CDM,361,RC,11104,HCPCS,,,facility,both,,,,740,518,,,,,,,,,,,,,Gross Charge Type: Central
HC INCISIONAL BIOPSY OF SKIN INCL SIMPLE CLOSURE SINGLE LESION,36100915,CDM,361,RC,11106,HCPCS,,,facility,both,,,,1251,875.7,,,,,,,,,,,,,Gross Charge Type: Central
HC TANGENTIAL BIOPSY OF SKIN EACH SEPARATE/ADDTL LESION,36100916,CDM,361,RC,11103,HCPCS,,,facility,both,,,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PUNCH BIOPSY OF SKIN INCL SIMPLE CLOSURE EACH SEPARATE/ADDTL LESION,36100917,CDM,361,RC,11105,HCPCS,,,facility,both,,,,352,246.4,,,,,,,,,,,,,Gross Charge Type: Central
HC INCISIONAL BIOPSY OF SKIN EACH SEPARATE/ADDT LESION,36100918,CDM,361,RC,11107,HCPCS,,,facility,both,,,,626,438.2,,,,,,,,,,,,,Gross Charge Type: Central
HC INSERTION SUBCUTANEOUS CARDIAC RHYTHM MONITOR INCL PROGRAMMING,36100919,CDM,361,RC,33285,HCPCS,,,facility,both,,,,26892,18824.4,,,,,,,,,,,,,Gross Charge Type: Central
HC REMOVAL SUBCUTANEOUS CARDIAC RHYTHM MONITOR,36100920,CDM,361,RC,33286,HCPCS,,,facility,both,,,,2104,1472.8,,,,,,,,,,,,,Gross Charge Type: Central
HC DILATION OF EXISIT TRAC PERCUTANEOUS FOR ENDOURO PX INCL IMAGE GUID RAD S&I,36100921,CDM,361,RC,50436,HCPCS,,,facility,both,,,,7549,5284.3,,,,,,,,,,,,,Gross Charge Type: Central
HC DILATION OF EXIST TRACT ENDOURO PX INCL IMAGE GUIDE RAD S&I W/POST PX TUBE PLCMT,36100922,CDM,361,RC,50437,HCPCS,,,facility,both,,,,13563,9494.1,,,,,,,,,,,,,Gross Charge Type: Central
HC INJECTION PROCEDURE FOR CONTRAST KNEE ARTHROGRAPY/CONTRAST ENCHANCED CT/MRI KNEE ARTHROGRAPY,36100923,CDM,361,RC,27369,HCPCS,,,facility,both,,,,265,185.5,,,,,,,,,,,,,Gross Charge Type: Central
HC INSERT OF PICC W/O SUB PORT/PUMP INCLUD ALL IMAGE GUIDE IMAGE DOC/ASSOC RADIOLOGICAL < 5 YRS,36100924,CDM,361,RC,36572,HCPCS,,,facility,both,,,,2470,1729,,,,,,,,,,,,,Gross Charge Type: Central
HC INSERT OF PICC W/O SUB PORT/PUMP INCLUD ALL IMAGE GUIDE IMAGE DOC/ASSOC RADIOLOGICAL >5 YRS,36100925,CDM,361,RC,36573,HCPCS,,,facility,both,,,,4356,3049.2,,,,,,,,,,,,,Gross Charge Type: Central
HC EGD INSERT GUIDE WIRE DILATOR PASSAGE ESOPHAGUS,36100927,CDM,750,RC,43248,HCPCS,,,facility,both,,,,3208,2245.6,,,,,,,,,,,,,Gross Charge Type: Central
HC ARTHOCENTISIS ASPIR/INJECT SM JOINT/BURSA W/ULTRA SOUND GUIDE W/PERM RECORDING & REPORTING,36100928,CDM,361,RC,20604,HCPCS,,,facility,both,,,,1103,772.1,,,,,,,,,,,,,Gross Charge Type: Central
HC ENDOVENOUS ABLATION THERAPY INCOMP VEIN EXTREMITY IMAGE GUIDE & MONITORING FIRST VEIN TX,36100930,CDM,361,RC,36473,HCPCS,,,facility,both,,,,11932,8352.4,,,,,,,,,,,,,Gross Charge Type: Central
HC ENDOVENOUS ABLATION THERAPY INCOM VEIN EXTREMITY IMAGE GUIDE & MONITOR SUBQ VEIN(S) TX IN SINGLE EXTREMITY EA SEP ACESS SITES,36100931,CDM,361,RC,36474,HCPCS,,,facility,both,,,,100,70,,,,,,,,,,,,,Gross Charge Type: Central
HC INJECTION PX FOR ANKLE ARTHROGRAPHY,36100932,CDM,361,RC,27648,HCPCS,,,facility,both,,,,958,670.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PERICARDIOCENTESIS INCL IMAGE GUIDE WHEN PERFORMED,36100940,CDM,361,RC,33016,HCPCS,,,facility,both,,,,6288,4401.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PERICARDIAL DRAINAGE W/INSERT INDWELLING CATH PERQ INCL FLURO AND/OR US GUIDE 6 YEARS AND OLDER W/O CONGENTIAL CARDIAC ANOMALY,36100941,CDM,361,RC,33017,HCPCS,,,facility,both,,,,6107,4274.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PERICARDIAL DRAINAGE W/INSERT INDEWLLING CATH PERQ INCL FLURO AND/OR US GUIDE BIRTH THROUGH 5 YEARS OF AGE OR ANY AGE W/CONGENTIAL CARDIAC ANOMALY,36100942,CDM,361,RC,33018,HCPCS,,,facility,both,,,,6107,4274.9,,,,,,,,,,,,,Gross Charge Type: Central
HC INJECTION ANESTHETIC AGENT(S)/STEROID NERVES INNERVATING THE SACROILIAC JOINT W/IMAGE GUIDANCE,36100944,CDM,361,RC,64451,HCPCS,,,facility,both,,,,2566,1796.2,,,,,,,,,,,,,Gross Charge Type: Central
HC DESTRUCTION NEUROLYTIC AGT W/IMG,36100946,CDM,361,RC,64624,HCPCS,,,facility,both,,,,7058,4940.6,,,,,,,,,,,,,Gross Charge Type: Central
HC DIAGNOSTIC LUMBAR SPINAL PUNCTURE W/FLUOR OR CT,36100947,CDM,361,RC,62328,HCPCS,,,facility,both,,,,2802,1961.4,,,,,,,,,,,,,Gross Charge Type: Central
HC EGD ESOPHAGOGASTRC FUNDOPLASTY,36100951,CDM,750,RC,43210,HCPCS,,,facility,both,,,,3208,2245.6,,,,,,,,,,,,,Gross Charge Type: Central
HC CORE NEEDLE BIOPSY LUNG/MED PERQ INCL IMAGE GUIDE,36100952,CDM,361,RC,32408,HCPCS,,,facility,both,,,,3021,2114.7,,,,,,,,,,,,,Gross Charge Type: Central
HC BURR HOLE IMPLANT VENTRICULAR CATH/OTHER DEVICE,36100953,CDM,361,RC,61210,HCPCS,,,facility,both,,,,23290,16303,,,,,,,,,,,,,Gross Charge Type: Central
HC TAS CONGENTIAL CARDIAC ANOMALIES INCL IMAGING GUIDANCE ANY METHOD,36100955,CDM,361,RC,33741,HCPCS,,,facility,both,,,,5764,4034.8,,,,,,,,,,,,,Gross Charge Type: Central
HC INJECTION(S) ANESTHETIC AGENT(S) AND/OR STERIOD GENICULAR NERVE BRANCHES INCL IMAGE GUIDE WHEN PERFORMED,36100956,CDM,361,RC,64454,HCPCS,,,facility,both,,,,2800,1960,,,,,,,,,,,,,Gross Charge Type: Central
HC BIOPSY MUSCLE SUPERFICIAL,36100957,CDM,361,RC,20200,HCPCS,,,facility,both,,,,5815,4070.5,,,,,,,,,,,,,Gross Charge Type: Central
HC BIOPSY MUSCLE DEEP,36100958,CDM,361,RC,20205,HCPCS,,,facility,both,,,,9794,6855.8,,,,,,,,,,,,,Gross Charge Type: Central
HC SPINAL PUNCTURE THERAPEUTIC DRAINAGE OF CSF W/FLUORO OR CT GUIDE,36100959,CDM,361,RC,62329,HCPCS,,,facility,both,,,,2884,2018.8,,,,,,,,,,,,,Gross Charge Type: Central
HC EVASC TTA REPAIR W/O SUBCLAVIAN ARTERY ORIGIN TO LEVEL OF CELIAC ATETERY ORIGIN,36100960,CDM,361,RC,33881,HCPCS,,,facility,both,,,,18516,12961.2,,,,,,,,,,,,,Gross Charge Type: Central
HC AMPUTATION TOE METATARSOPHALANGEAL JOINT,36100961,CDM,361,RC,28820,HCPCS,,,facility,both,,,,12082,8457.4,,,,,,,,,,,,,Gross Charge Type: Central
HC OPEN AXILLARY/SUBCL ARTERY EXPOSE DELIVERY ENDOVASCULAR PROSTHESIS UNILATERAL,36100962,CDM,361,RC,34715,HCPCS,,,facility,both,,,,1201,840.7,,,,,,,,,,,,,Gross Charge Type: Central
HC EXTRAORAL INCISION & DRAINAGE ABSCESS/CYSTS/HEMATOMA OF MOUTH MASTICATOR SPACE,36100963,CDM,361,RC,41018,HCPCS,,,facility,both,,,,5758,4030.6,,,,,,,,,,,,,Gross Charge Type: Central
HC CHEMODENERV PAROTID&SUBMANDIBL SALIVARY GLNDS BILATERAL,36100964,CDM,361,RC,64611,HCPCS,,,facility,both,,,,1211,847.7,,,,,,,,,,,,,Gross Charge Type: Central
HC CHEMODENERV MUSCLE LARYNX UNILAT INCL GUIDE NEEDLE EMG WHEN PERFORMED,36100965,CDM,361,RC,64617,HCPCS,,,facility,both,,,,3675,2572.5,,,,,,,,,,,,,Gross Charge Type: Central
HC DESTRUCTION NEUROLYTIC AGENT INTERCOSTAL NERVE,36100966,CDM,361,RC,64620,HCPCS,,,facility,both,,,,3501,2450.7,,,,,,,,,,,,,Gross Charge Type: Central
HC RADIOFREQUENCY ABLTJ NERVE SI JOINT W/IMG GUIDANCE,36100967,CDM,361,RC,64625,HCPCS,,,facility,both,,,,8165,5715.5,,,,,,,,,,,,,Gross Charge Type: Central
HC DESTRUCTION NEUROLYTIC AGENT PUDENDAL NERVE,36100968,CDM,361,RC,64630,HCPCS,,,facility,both,,,,3501,2450.7,,,,,,,,,,,,,Gross Charge Type: Central
HC DESTRUCTION BY NEUROLYTIC AGENT PLANTAR COMMON DIGITAL NERVE,36100969,CDM,361,RC,64632,HCPCS,,,facility,both,,,,1112,778.4,,,,,,,,,,,,,Gross Charge Type: Central
HC INTRAORAL INCISION/DRAINAGE OF ABSCESS/CYST/HEMATOMA OF TONGUE OR FLOOR OF MOUTH SUBMENTAL SPACE,36100970,CDM,361,RC,41007,HCPCS,,,facility,both,,,,5758,4030.6,,,,,,,,,,,,,Gross Charge Type: Central
HC DRAINAGE ABSCESS/HEMATOMA NASAL SEPTUM,36100971,CDM,361,RC,30020,HCPCS,,,facility,both,,,,1926,1348.2,,,,,,,,,,,,,Gross Charge Type: Central
HC INJECT/INFUSION NEUROLYTIC SUBST W/WO THERAP SUBST EPIDURAL/CERVICAL/THORACIC,36100972,CDM,361,RC,62281,HCPCS,,,facility,both,,,,3558,2490.6,,,,,,,,,,,,,Gross Charge Type: Central
HC INJECT/INFUSION NEUROLYTIC SUBST W/WO THERAP SUBST EPIDURAL/LUMBAR/SACRAL,36100973,CDM,361,RC,62282,HCPCS,,,facility,both,,,,3876,2713.2,,,,,,,,,,,,,Gross Charge Type: Central
HC LARYNGOSCOPY FOREIGN BODY REMVL W/OPERATING MICROSCOPE OR TELESCOPE,36100974,CDM,361,RC,31531,HCPCS,,,facility,both,,,,9952,6966.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PERCUTANEOUS/NEPHROLITHOTOMY/PYELOLITHOTOMY/LITHOTRIPSY STONE EXTRACTION INCL IMAGE GUIDE SIMPLE UP TO 2 CM KIDNEY/RENAL PELVIS,36100975,CDM,361,RC,50080,HCPCS,,,facility,both,,,,38852,27196.4,,,,,,,,,,,,,Gross Charge Type: Central
HC CISTERNAL/LATERAL C1-C2 PUNCTURE W/INJECTION OF MEDICATION/OTH SUBSTANCE DX/TREATMENT,36100976,CDM,361,RC,61055,HCPCS,,,facility,both,,,,2328,1629.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PUNCTURE ASPIRATION HYDROCELE TUNICA VAGIS W/WO INJECTION OF MEDICATION,36100977,CDM,361,RC,55000,HCPCS,,,facility,both,,,,2689,1882.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PLACEMENT OF NEEDLE PELVIC ORGAN RADIOELEMENT APPL,36100978,CDM,361,RC,55920,HCPCS,,,facility,both,,,,17148,12003.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PLACEMENT SOFT TISS LOC DEVICE PLMT W/GUIDANCE 1ST LESION,36100980,CDM,361,RC,10035,HCPCS,,,facility,both,,,,2682,1877.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PLACEMENT SOFT TISS LOC DEVICE PLMT W/GUIDANCE EACH ADDTL LESION,36100981,CDM,361,RC,10036,HCPCS,,,facility,both,,,,175,122.5,,,,,,,,,,,,,Gross Charge Type: Central
HC INJECTION ANESTHETIC AGENT(S)/STEROID AXILLARY NERVE INCL IMAGE GUIDE,36100983,CDM,361,RC,64417,HCPCS,,,facility,both,,,,3086,2160.2,,,,,,,,,,,,,Gross Charge Type: Central
HC UNLISTED PROCEDURE VASCULAR SURGERY,36100984,CDM,361,RC,37799,HCPCS,,,facility,both,,,,3849,2694.3,,,,,,,,,,,,,Gross Charge Type: Central
HC UNLISTED PROCEDURE SKIN MUCOUS MEMBRANE & SUBCUTANEOUS TISSUE,36100985,CDM,361,RC,17999,HCPCS,,,facility,both,,,,674,471.8,,,,,,,,,,,,,Gross Charge Type: Central
HC MECHANICAL RMVL INTRAL OBSTRUCTIVE CENTRAL VENOUS DEVICE LUMEN,36100986,CDM,361,RC,36596,HCPCS,,,facility,both,,,,5272,3690.4,,,,,,,,,,,,,Gross Charge Type: Central
HC EGD INTRALUMINAL TUBE/CATHETER INSERTION,36100987,CDM,750,RC,43241,HCPCS,,,facility,both,,,,3803,2662.1,,,,,,,,,,,,,Gross Charge Type: Central
HC TRANSCATHETER MITRAL VALVE IMPLANTATION/REPLACEMENT W/PROSTHETIC VALVE PERCUTANEOUS APPROACH,36100988,CDM,361,RC,0483T,HCPCS,,,facility,both,,,,4795,3356.5,,,,,,,,,,,,,Gross Charge Type: Central
HC REVASCULAR ENDOVASC OPEN/PERCU LOW EXTREM ARTERY EXCEPT TIBI/PERONE W/INTRAVASC LITHO INCL ANGIO WITHIN SAME VESSEL,36100989,CDM,361,RC,C9764,HCPCS,,,facility,both,,,,35180,24626,,,,,,,,,,,,,Gross Charge Type: Central
HC REVASCULAR ENDOVASC OPEN/PERCU LOW EXTREM ARTERY EXCEPT TIBI/PERONE W/INTRAVASC LITHO-STENT  INCL ANGIO WITHIN SAME VESSEL,36100990,CDM,361,RC,C9765,HCPCS,,,facility,both,,,,56250,39375,,,,,,,,,,,,,Gross Charge Type: Central
HC REVASCULAR ENDOVASC OPEN/PERCU LOW EXTREM ARTERY EXCEPT TIBI/PERONE W/INTRAVASC LITHO/ATHER INCL ANGIO WITHIN SAME VESSEL,36100991,CDM,361,RC,C9766,HCPCS,,,facility,both,,,,56250,39375,,,,,,,,,,,,,Gross Charge Type: Central
HC REVASCULARENDOVASC OPEN/PERCUTAN TIBI/PERONE W/INTRAVASC LITHOTRIPSY INCL ANGIO WITHIN SAME VESSEL,36100992,CDM,361,RC,C9772,HCPCS,,,facility,both,,,,44801,31360.7,,,,,,,,,,,,,Gross Charge Type: Central
HC REVASCULAR ENDOVASC OPEN/PERCU TIBI/PERONE W/INTRAVASC LITHOTR-STENT INCL ANGIO WITHIN SAME VESSEL,36100993,CDM,361,RC,C9773,HCPCS,,,facility,both,,,,71661,50162.7,,,,,,,,,,,,,Gross Charge Type: Central
HC REVASCULAR ENDOVASC OPEN/PERCU TIBI/PERONE W/INTRAVASC LITHO/ATHER INCL ANGIO WITHIN SAME VESSEL,36100994,CDM,361,RC,C9774,HCPCS,,,facility,both,,,,71661,50162.7,,,,,,,,,,,,,Gross Charge Type: Central
HC REVASCULAR ENDOVASC OPEN/PERCU TIBI/PERONE W/INTRAVASC LITH-STENT PLACE/ATHER INCL ANGIO WITHIN SAME VESSELS,36100995,CDM,361,RC,C9775,HCPCS,,,facility,both,,,,71661,50162.7,,,,,,,,,,,,,Gross Charge Type: Central
HC REVASCULAR ENDOVASC OPEN/PERCU LOW EXTREM ARTERY EXCEPT TIBI/PERONE W/INTRAVASC LITHO-STENT-ATHER INCL ANGIO WITHIN SAME VESSEL,36100996,CDM,361,RC,C9767,HCPCS,,,facility,both,,,,71108,49775.6,,,,,,,,,,,,,Gross Charge Type: Central
HC REMOVAL INFLATABLE PENILE PROSTHESIS W/O RPLCMT PROSTHESIS,36100997,CDM,361,RC,54406,HCPCS,,,facility,both,,,,12066,8446.2,,,,,,,,,,,,,Gross Charge Type: Central
HC UNLISTED PROCEDURE ABDOMEN MUSCULOSKELETAL SYSTEM,36100998,CDM,361,RC,22999,HCPCS,,,facility,both,,,,203,142.1,,,,,,,,,,,,,Gross Charge Type: Central
HC SIGMOIDOSCOPY FLEXIBLE W/TRANSENDOSCOPIC BALLOON DILATION,36100999,CDM,750,RC,45340,HCPCS,,,facility,both,,,,3620,2534,,,,,,,,,,,,,Gross Charge Type: Central
HC UNLISTED LAPAROSCOPY PROCEDURE ABDOMEN PERITONEUM & OMENTUM,36101000,CDM,361,RC,49329,HCPCS,,,facility,both,,,,18008,12605.6,,,,,,,,,,,,,Gross Charge Type: Central
HC UNLISTED LAPAROSCOPY PROCEDURE STOMACH,36101001,CDM,361,RC,43659,HCPCS,,,facility,both,,,,31396,21977.2,,,,,,,,,,,,,Gross Charge Type: Central
HC RESEARCH ONLY EVASC VEN ARTLZ TIBL/PRNL VN W/TRANSCATH PLACE INTRAVASC STENT GRAFT/CLOSE INCL PERCUT/OPEN VASC ACCESS US VASC ACCESS CATH/INTRAPROC ROADMAP/IMAGE GUIDE RAD SUPERVISON,36101002,CDM,361,RC,0620T,HCPCS,,,facility,both,,,,54125,37887.5,,,,,,,,,,,,,Gross Charge Type: Central
HC ESOPHAGOSCOPY FLEXIBLE TRANSORAL W/BIOPSY SINGLE/ MULTIPLE,36101003,CDM,750,RC,43202,HCPCS,,,facility,both,,,,3608,2525.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PUNCTURE OF SHUNT TUBING OR RESERVOIR FOR ASPIRATION/INJECTION PROCEDURE,36101004,CDM,361,RC,61070,HCPCS,,,facility,both,,,,2227,1558.9,,,,,,,,,,,,,Gross Charge Type: Central
HC ENDOVENOUS FEMORAL POPLITEAL ARTERIAL REVSC W/TRANSCATH PLMT INTRAVAS STENT GRAFT/CLSR INCL PERCUT/OPEN VASC ACCESS US GUIDE FOR VASC ACCESS CATH/INTRAPROC ROADMAP/IMAGE GUIDE RAD S&I,36101005,CDM,361,RC,0505T,HCPCS,,,facility,both,,,,39081,27356.7,,,,,,,,,,,,,Gross Charge Type: Central
HC REPOSITIONING NASO-OR ORO-GASTRIC FEEDING TUBE THRU DUODENUM FOR ENTERIC NUTRITION,36101006,CDM,361,RC,43761,HCPCS,,,facility,both,,,,2583,1808.1,,,,,,,,,,,,,Gross Charge Type: Central
HC INJECTION ANESTHETIC AGENT/STEROID PUDENDAL NERVE,36101007,CDM,361,RC,64430,HCPCS,,,facility,both,,,,3440,2408,,,,,,,,,,,,,Gross Charge Type: Central
HC TRANSVERSUS ABDOMINIS PLANE BLOCK UNILATERAL BY INJECTION,36101008,CDM,361,RC,64486,HCPCS,,,facility,both,,,,222,155.4,,,,,,,,,,,,,Gross Charge Type: Central
HC TRANSVERSUS ABDOMINIS PLANE BLOCK UNILATERAL BY CONTINUOUS INFUSION,36101009,CDM,361,RC,64487,HCPCS,,,facility,both,,,,256,179.2,,,,,,,,,,,,,Gross Charge Type: Central
HC TRANSVERSUS ABDOMINIS PLANE BLOCK BILATERAL BY INJECTIONS,36101010,CDM,361,RC,64488,HCPCS,,,facility,both,,,,279,195.3,,,,,,,,,,,,,Gross Charge Type: Central
HC TRANSVERSUS ABDOMINIS PLANE BLOCK BY CONTINUOUS INFUSIONS,36101011,CDM,361,RC,64489,HCPCS,,,facility,both,,,,314,219.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY EPIDURAL,36101012,CDM,361,RC,63650,HCPCS,,,facility,both,,,,29045,20331.5,,,,,,,,,,,,,Gross Charge Type: Central
HC AMPUTATION TOE INTERPHALANGEAL JOINT,36101013,CDM,361,RC,28825,HCPCS,,,facility,both,,,,11385,7969.5,,,,,,,,,,,,,Gross Charge Type: Central
HC INJECTION PROCEDURE LYMPHANGIOGRAPHY,36101014,CDM,361,RC,38790,HCPCS,,,facility,both,,,,815,570.5,,,,,,,,,,,,,Gross Charge Type: Central
HC INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID VAGUS NERVE,36101015,CDM,361,RC,64408,HCPCS,,,facility,both,,,,2015,1410.5,,,,,,,,,,,,,Gross Charge Type: Central
HC INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID BRACHIAL PLEXUS INCL IMAGE GUIDE,36101016,CDM,361,RC,64415,HCPCS,,,facility,both,,,,3294,2305.8,,,,,,,,,,,,,Gross Charge Type: Central
HC INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID BRACHIAL PLEXUS CONT INFUSION BY CATHETER INCL IMAGE GUIDE,36101017,CDM,361,RC,64416,HCPCS,,,facility,both,,,,3789,2652.3,,,,,,,,,,,,,Gross Charge Type: Central
HC INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID PARACERVICAL UTERINE NERVE,36101018,CDM,361,RC,64435,HCPCS,,,facility,both,,,,2499,1749.3,,,,,,,,,,,,,Gross Charge Type: Central
HC INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID SCIATIC NERVE CONT INFUSION BY CATHETER INCL IMAGE GUIDE,36101019,CDM,361,RC,64446,HCPCS,,,facility,both,,,,4306,3014.2,,,,,,,,,,,,,Gross Charge Type: Central
HC INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID FEMORAL NERVE CONT INFUSION BY CATHETER INCL IMAGE GUIDE,36101020,CDM,361,RC,64448,HCPCS,,,facility,both,,,,3294,2305.8,,,,,,,,,,,,,Gross Charge Type: Central
HC INJECTION(S) AGENT(S) AND/OR STEROID LUMBAR PLEXUS POSTERIOR APPROACH CONT INFUSION BY CATHETER INCL CATHETER PLACEMENT,36101021,CDM,361,RC,64449,HCPCS,,,facility,both,,,,3789,2652.3,,,,,,,,,,,,,Gross Charge Type: Central
HC UNLISTED PROCEDURE PELVIS OR HIP JOINT,36101022,CDM,361,RC,27299,HCPCS,,,facility,both,,,,1071,749.7,,,,,,,,,,,,,Gross Charge Type: Central
HC INITIATION SELECTIVE HEAD/TOTAL BODY HYPOTHERMIA NEONATE,36101023,CDM,361,RC,99184,HCPCS,,,facility,both,,,,771,539.7,,,,,,,,,,,,,Gross Charge Type: Central
HC REMOVAL OF SUBSTERNAL IMPLANTABLE DEFIBRILLATOR ELECTRODE,36101024,CDM,361,RC,0573T,HCPCS,,,facility,both,,,,14363,10054.1,,,,,,,,,,,,,Gross Charge Type: Central
HC ENDOVASCULAR REPAIR DESCENDING THORACIC AORTA LEFT SUBCLAVIAN ARTERY ORIGIN INITIAL ENDOPROSTHESIS PLUS DESCENDING THORACIC AORTIC EXTENSION(S),36101025,CDM,361,RC,33880,HCPCS,,,facility,both,,,,2207,1544.9,,,,,,,,,,,,,Gross Charge Type: Central
HC INJECTION FOR HIP ARTHROGRAPHY W/ANESTHESIA,36101026,CDM,361,RC,27095,HCPCS,,,facility,both,,,,866,606.2,,,,,,,,,,,,,Gross Charge Type: Central
HC UNLISTED PROCEDURE FEMALE GENITAL SYSTEM,36101036,CDM,361,RC,58999,HCPCS,,,facility,both,,,,3082,2157.4,,,,,,,,,,,,,Gross Charge Type: Central
HC INSERTION OF PERIPHERALLY INSERTED CENTRAL VENOUS ACCESS DEVICE W/SUBQ PORT UNDER 5 YRS,36101037,CDM,361,RC,36570,HCPCS,,,facility,both,,,,12111,8477.7,,,,,,,,,,,,,Gross Charge Type: Central
HC TRANSCATHETER TRICUSPID VALVE REPAIR PERQ APPROACH INITIAL PROSTHESIS,36101038,CDM,361,RC,0569T,HCPCS,,,facility,both,,,,6686,4680.2,,,,,,,,,,,,,Gross Charge Type: Central
HC TRANSCATHETER TRICUSPID VALVE REPAIR PERQ APPROACH EACH ADDTL PROSTHESIS,36101039,CDM,361,RC,0570T,HCPCS,,,facility,both,,,,1577,1103.9,,,,,,,,,,,,,Gross Charge Type: Central
HC TTVI/REPLACEMENT PROSTC VALVE PERQ W/RIGHT HEART CATH & ANGRPH,36101040,CDM,361,RC,0646T,HCPCS,,,facility,both,,,,4649,3254.3,,,,,,,,,,,,,Gross Charge Type: Central
HC MECHANICAL RMVL PRICATH OBSTR  MATRL FROM CENTRAL VENOUS DEVICE VIA SEPARATE VENOUS ACCESS,36101042,CDM,361,RC,36595,HCPCS,,,facility,both,,,,12111,8477.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY PERIPHERAL NERVE,36101043,CDM,361,RC,64555,HCPCS,,,facility,both,,,,26489,18542.3,,,,,,,,,,,,,Gross Charge Type: Central
HC SUTURE PHARYNX FOR WOUND OR INJURY,36101044,CDM,361,RC,42900,HCPCS,,,facility,both,,,,5979,4185.3,,,,,,,,,,,,,Gross Charge Type: Central
HC MANOMETRIC STUDIES THRU NEPHROSTOMY/PYELOSTOMY TUBE/INDWELLING URETERAL CATHETER,36101046,CDM,361,RC,50396,HCPCS,,,facility,both,,,,2695,1886.5,,,,,,,,,,,,,Gross Charge Type: Central
HC THORACIC FASCIAL PLANE BLOCK UNILATERAL BY INJECTION INCL IMAGE GUIDE WHEN PERFORMED,36101048,CDM,361,RC,64466,HCPCS,,,facility,both,,,,2949,2064.3,,,,,,,,,,,,,Gross Charge Type: Central
HC LOWER EXTREMITY FASCIAL PLANE BLOCK UNILATERAL BY INJECTION INCL IMAGE GUIDE WHEN PERFORMED,36101049,CDM,361,RC,64473,HCPCS,,,facility,both,,,,2949,2064.3,,,,,,,,,,,,,Gross Charge Type: Central
HC THORACIC FASCIAL PLANE BLOCK UNILATERAL CONT INFUSION INCL IMAGE GUIDE WHEN PERFORMED,36101050,CDM,361,RC,64467,HCPCS,,,facility,both,,,,2949,2064.3,,,,,,,,,,,,,Gross Charge Type: Central
HC THORACIC FASCIAL PLANE BLOCK BILATERAL INJECTION INCL IMAGE GUIDE WHEN PERFORMED,36101051,CDM,361,RC,64468,HCPCS,,,facility,both,,,,2949,2064.3,,,,,,,,,,,,,Gross Charge Type: Central
HC THORACIC FASCIAL PLANE BLOCK BILATERAL CONT INFUSION INCL IMAGE GUIDE WHEN PERFORMED,36101052,CDM,361,RC,64469,HCPCS,,,facility,both,,,,2949,2064.3,,,,,,,,,,,,,Gross Charge Type: Central
HC LOWER EXTREMITY FASCIAL PLANE BLOCK UNILATERAL CONT INFUSION INCL IMAGE GUIDE WHEN PERFORMED,36101053,CDM,361,RC,64474,HCPCS,,,facility,both,,,,2949,2064.3,,,,,,,,,,,,,Gross Charge Type: Central
HC EXCISION TUMOR SOFT TISSUE FOOT/TOE SUBFASCIAL LESS THAN 1.5CM,36101054,CDM,361,RC,28045,HCPCS,,,facility,both,,,,12185,8529.5,,,,,,,,,,,,,Gross Charge Type: Central
HC REMOVAL SPINAL NEUROSTIMULATOR ELECTRODE PERCUTANEOUS ARRAY(S) INCL FLUORO,36101055,CDM,361,RC,63661,HCPCS,,,facility,both,,,,8314,5819.8,,,,,,,,,,,,,Gross Charge Type: Central
HC REMOVAL SPINAL NEUOSTIMULATOR ELECTRODE PLATE/PADDLE(S) LAMINOTOMY/LAMINECTOMY INCL FLUORO,36101056,CDM,361,RC,63662,HCPCS,,,facility,both,,,,14641,10248.7,,,,,,,,,,,,,Gross Charge Type: Central
HC REVISION INCL REPLACEMENT SPINAL NEUROSTIMULATOR ELECTRODE PERCUTANEOUS ARRAY(S) INCL FLUORO,36101057,CDM,361,RC,63663,HCPCS,,,facility,both,,,,27940,19558,,,,,,,,,,,,,Gross Charge Type: Central
HC REVISION INCL REPLACEMENT SPINAL NEUROSTIMULATOR ELECTRODE PLATE/PADDLE(S) LAMINOTOMY/LAMINECTOMY INCL FLUORO,36101058,CDM,361,RC,63664,HCPCS,,,facility,both,,,,53090,37163,,,,,,,,,,,,,Gross Charge Type: Central
HC REVISION/REMOVAL IMPLANTED SPINAL NEUROSTIMULATOR PULSE GENERATOR/RECEIVER DETACH CONNECTION ELECTORDE ARRAY,36101059,CDM,361,RC,63688,HCPCS,,,facility,both,,,,14641,10248.7,,,,,,,,,,,,,Gross Charge Type: Central
HC UNLISTED LAPAROSCOPY PROCEDURE ESOPHAGUS,36101060,CDM,361,RC,43289,HCPCS,,,facility,both,,,,44324,31026.8,,,,,,,,,,,,,Gross Charge Type: Central
HC ABLATION IRREVERSIBLE ELECTROPORATION 1 OR MORE TUMORS PER ORGAN INCLUDING IMAGING GUIDANCE PERCUATANEOUS,36101061,CDM,361,RC,0600T,HCPCS,,,facility,both,,,,44324,31026.8,,,,,,,,,,,,,Gross Charge Type: Central
HC ABLATION IRREVERSIBLE ELECTROPORATION 1 OR MORE TUMORS PER ORGAN INCLUDING FLUOROSCOPIC AND ULTRASOUND GUIDANCE OPEN,36101062,CDM,361,RC,0601T,HCPCS,,,facility,both,,,,44324,31026.8,,,,,,,,,,,,,Gross Charge Type: Central
IOPAMIDOL 76 % IV SOLN,36221,CDM,Q9967,HCPCS,0270-1316-35,NDC,,,facility,both,100,ML,,299,209.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,36221,CDM,Q9967,HCPCS,0270-1315-25,NDC,,,facility,both,90,ML,,389,272.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,36221,CDM,Q9967,HCPCS,0270-1316-35,NDC,,,facility,both,80,ML,,271,189.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,36221,CDM,Q9967,HCPCS,0270-1315-35,NDC,,,facility,both,100,ML,,269,188.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BCG LIVE 50 MG IVES SUSR,36333,CDM,J9030,HCPCS,0052-0602-02,NDC,,,facility,both,25,EA,,394,275.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BCG LIVE 50 MG IVES SUSR,36333,CDM,J9030,HCPCS,0052-0602-01,NDC,,,facility,both,50,EA,,734,513.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BCG LIVE 50 MG IVES SUSR,36333,CDM,J9030,HCPCS,0052-0602-02,NDC,,,facility,both,50,EA,,734,513.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BCG LIVE 50 MG IVES SUSR,36333,CDM,J9030,HCPCS,0052-0602-01,NDC,,,facility,both,25,EA,,382,267.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BCG LIVE 50 MG IVES SUSR,36333,CDM,J9030,HCPCS,0052-0602-01,NDC,,,facility,both,25,EA,,367,256.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BCG LIVE 50 MG IVES SUSR,36333,CDM,J9030,HCPCS,0052-0602-02,NDC,,,facility,both,25,EA,,367,256.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BCG LIVE 50 MG IVES SUSR,36333,CDM,J9030,HCPCS,0052-0602-02,NDC,,,facility,both,50,EA,,764,534.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE HCL  2 % MM JELP,36333,CDM,J3490,HCPCS,76329-3013-5,NDC,,,facility,both,50,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BCG LIVE 50 MG IVES SUSR,36333,CDM,J9030,HCPCS,0052-0602-01,NDC,,,facility,both,50,EA,,787,550.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BCG LIVE 50 MG IVES SUSR,36333,CDM,J9030,HCPCS,0052-0602-01,NDC,,,facility,both,50,EA,,764,534.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BCG LIVE 50 MG IVES SUSR,36333,CDM,J9030,HCPCS,0052-0602-01,NDC,,,facility,both,25,EA,,394,275.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BCG LIVE 50 MG IVES SUSR,36333,CDM,J9030,HCPCS,0052-0602-02,NDC,,,facility,both,25,EA,,382,267.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"TRASTUZUMAB-HYALURONIDASE-OYSK 600 MG-10,000 UNIT/5 ML SUBQ SOLN",36481,CDM,J9356,HCPCS,50242-077-01,NDC,,,facility,both,60,ML,,12904,9032.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG IV SOLR,36561,CDM,J9358,HCPCS,65597-406-01,NDC,,,facility,both,274,EA,,17364,12154.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG IV SOLR,36561,CDM,J9358,HCPCS,65597-406-01,NDC,,,facility,both,340,EA,,21546,15082.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG IV SOLR,36561,CDM,J9358,HCPCS,65597-406-01,NDC,,,facility,both,32,EA,,882,617.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG IV SOLR,36561,CDM,J9358,HCPCS,65597-406-01,NDC,,,facility,both,20,EA,,552,386.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG IV SOLR,36561,CDM,J9358,HCPCS,65597-406-01,NDC,,,facility,both,324,EA,,20532,14372.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG IV SOLR,36561,CDM,J9358,HCPCS,65597-406-01,NDC,,,facility,both,500,EA,,31685,22179.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG IV SOLR,36561,CDM,J9358,HCPCS,65597-406-01,NDC,,,facility,both,14,EA,,386,270.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG IV SOLR,36561,CDM,J9358,HCPCS,65597-406-01,NDC,,,facility,both,326,EA,,20659,14461.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG IV SOLR,36561,CDM,J9358,HCPCS,65597-406-01,NDC,,,facility,both,74,EA,,2039,1427.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG IV SOLR,36561,CDM,J9358,HCPCS,65597-406-01,NDC,,,facility,both,76,EA,,2094,1465.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG IV SOLR,36561,CDM,J9358,HCPCS,65597-406-01,NDC,,,facility,both,66,EA,,1819,1273.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG IV SOLR,36561,CDM,J9358,HCPCS,65597-406-01,NDC,,,facility,both,362,EA,,22940,16058,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG IV SOLR,36561,CDM,J9358,HCPCS,65597-406-01,NDC,,,facility,both,62,EA,,1709,1196.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG IV SOLR,36561,CDM,J9358,HCPCS,65597-406-01,NDC,,,facility,both,34,EA,,937,655.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG IV SOLR,36561,CDM,J9358,HCPCS,65597-406-01,NDC,,,facility,both,400,EA,,25348,17743.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG IV SOLR,36561,CDM,J9358,HCPCS,65597-406-01,NDC,,,facility,both,276,EA,,17490,12243,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG IV SOLR,36561,CDM,J9358,HCPCS,65597-406-01,NDC,,,facility,both,200,EA,,12674,8871.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG IV SOLR,36561,CDM,J9358,HCPCS,65597-406-01,NDC,,,facility,both,380,EA,,24081,16856.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG IV SOLR,36561,CDM,J9358,HCPCS,65597-406-01,NDC,,,facility,both,26,EA,,717,501.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG IV SOLR,36561,CDM,J9358,HCPCS,65597-406-01,NDC,,,facility,both,300,EA,,19011,13307.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG IV SOLR,36561,CDM,J9358,HCPCS,65597-406-01,NDC,,,facility,both,60,EA,,1654,1157.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG IV SOLR,36561,CDM,J9358,HCPCS,65597-406-01,NDC,,,facility,both,352,EA,,22306,15614.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG IV SOLR,36561,CDM,J9358,HCPCS,65597-406-01,NDC,,,facility,both,354,EA,,22433,15703.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG IV SOLR,36561,CDM,J9358,HCPCS,65597-406-01,NDC,,,facility,both,46,EA,,1268,887.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG IV SOLR,36561,CDM,J9358,HCPCS,65597-406-01,NDC,,,facility,both,38,EA,,1047,732.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG IV SOLR,36561,CDM,J9358,HCPCS,65597-406-01,NDC,,,facility,both,600,EA,,38022,26615.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG IV SOLR,36561,CDM,J9358,HCPCS,65597-406-01,NDC,,,facility,both,466,EA,,29530,20671,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG IV SOLR,36561,CDM,J9358,HCPCS,65597-406-01,NDC,,,facility,both,366,EA,,23193,16235.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG IV SOLR,36561,CDM,J9358,HCPCS,65597-406-01,NDC,,,facility,both,58,EA,,1598,1118.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG IV SOLR,36561,CDM,J9358,HCPCS,65597-406-01,NDC,,,facility,both,370,EA,,23447,16412.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG IV SOLR,36561,CDM,J9358,HCPCS,65597-406-01,NDC,,,facility,both,24,EA,,662,463.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG IV SOLR,36561,CDM,J9358,HCPCS,65597-406-01,NDC,,,facility,both,30,EA,,827,578.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG IV SOLR,36561,CDM,J9358,HCPCS,65597-406-01,NDC,,,facility,both,568,EA,,35994,25195.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG IV SOLR,36561,CDM,J9358,HCPCS,65597-406-01,NDC,,,facility,both,286,EA,,18124,12686.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG IV SOLR,36561,CDM,J9358,HCPCS,65597-406-01,NDC,,,facility,both,238,EA,,15082,10557.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG IV SOLR,36561,CDM,J9358,HCPCS,65597-406-01,NDC,,,facility,both,266,EA,,16857,11799.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG IV SOLR,36561,CDM,J9358,HCPCS,65597-406-01,NDC,,,facility,both,234,EA,,14829,10380.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG IV SOLR,36561,CDM,J9358,HCPCS,65597-406-01,NDC,,,facility,both,426,EA,,26996,18897.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG IV SOLR,36561,CDM,J9358,HCPCS,65597-406-01,NDC,,,facility,both,342,EA,,21673,15171.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG IV SOLR,36561,CDM,J9358,HCPCS,65597-406-01,NDC,,,facility,both,48,EA,,1323,926.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 75 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-775-01,NDC,,,facility,both,22,ME,,909,636.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 25 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-711-01,NDC,,,facility,both,44,ME,,1872,1310.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 25 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-711-01,NDC,,,facility,both,200,ME,,19569,13698.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 25 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-711-01,NDC,,,facility,both,50,ME,,2128,1489.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 25 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-711-01,NDC,,,facility,both,48,ME,,4697,3287.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 25 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-711-01,NDC,,,facility,both,300,ME,,29355,20548.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 25 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-711-01,NDC,,,facility,both,2,ME,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 75 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-775-01,NDC,,,facility,both,42,ME,,1735,1214.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 75 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-775-01,NDC,,,facility,both,176,ME,,7268,5087.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 25 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-711-01,NDC,,,facility,both,32,ME,,1362,953.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 75 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-775-01,NDC,,,facility,both,14,ME,,579,405.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 25 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-711-01,NDC,,,facility,both,400,ME,,39139,27397.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 25 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-711-01,NDC,,,facility,both,54,ME,,5284,3698.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 75 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-775-01,NDC,,,facility,both,38,ME,,1570,1099,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 75 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-775-01,NDC,,,facility,both,286,ME,,27164,19014.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 75 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-775-01,NDC,,,facility,both,20,ME,,826,578.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 75 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-775-01,NDC,,,facility,both,12,ME,,496,347.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 75 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-775-01,NDC,,,facility,both,288,ME,,27354,19147.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 25 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-711-01,NDC,,,facility,both,10,ME,,426,298.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 25 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-711-01,NDC,,,facility,both,126,ME,,12329,8630.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 75 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-775-01,NDC,,,facility,both,24,ME,,992,694.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 25 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-711-01,NDC,,,facility,both,36,ME,,1532,1072.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 75 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-775-01,NDC,,,facility,both,45,ME,,1859,1301.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 25 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-711-01,NDC,,,facility,both,38,ME,,1617,1131.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 25 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-711-01,NDC,,,facility,both,60,ME,,5871,4109.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 75 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-775-01,NDC,,,facility,both,10,ME,,413,289.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 75 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-775-01,NDC,,,facility,both,300,ME,,28494,19945.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 25 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-711-01,NDC,,,facility,both,200,ME,,19570,13699,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 25 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-711-01,NDC,,,facility,both,72,ME,,3064,2144.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 25 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-711-01,NDC,,,facility,both,198,ME,,19374,13561.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 75 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-775-01,NDC,,,facility,both,262,ME,,24884,17418.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 25 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-711-01,NDC,,,facility,both,52,ME,,5089,3562.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 75 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-775-01,NDC,,,facility,both,34,ME,,1405,983.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 25 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-711-01,NDC,,,facility,both,66,ME,,6458,4520.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 25 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-711-01,NDC,,,facility,both,58,ME,,5676,3973.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 25 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-711-01,NDC,,,facility,both,74,ME,,3149,2204.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 25 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-711-01,NDC,,,facility,both,64,ME,,6263,4384.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 25 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-711-01,NDC,,,facility,both,34,ME,,1447,1012.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 75 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-775-01,NDC,,,facility,both,424,ME,,40271,28189.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 25 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-711-01,NDC,,,facility,both,40,ME,,1702,1191.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 75 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-775-01,NDC,,,facility,both,50,ME,,2065,1445.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 25 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-711-01,NDC,,,facility,both,62,ME,,6067,4246.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 75 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-775-01,NDC,,,facility,both,556,ME,,52808,36965.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 25 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-711-01,NDC,,,facility,both,68,ME,,6654,4657.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 25 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-711-01,NDC,,,facility,both,18,ME,,766,536.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 75 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-775-01,NDC,,,facility,both,44,ME,,1817,1271.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 25 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-711-01,NDC,,,facility,both,100,ME,,9785,6849.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 25 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-711-01,NDC,,,facility,both,14,ME,,596,417.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 25 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-711-01,NDC,,,facility,both,52,ME,,2213,1549.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 25 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-711-01,NDC,,,facility,both,50,ME,,4893,3425.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 75 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-775-01,NDC,,,facility,both,258,ME,,24505,17153.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 75 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-775-01,NDC,,,facility,both,280,ME,,26594,18615.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 75 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-775-01,NDC,,,facility,both,76,ME,,3139,2197.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 25 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-711-01,NDC,,,facility,both,56,ME,,5480,3836,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 25 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-711-01,NDC,,,facility,both,48,ME,,2043,1430.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 75 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-775-01,NDC,,,facility,both,278,ME,,26404,18482.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 25 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-711-01,NDC,,,facility,both,350,ME,,34247,23972.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 25 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-711-01,NDC,,,facility,both,124,ME,,12134,8493.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 25 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-711-01,NDC,,,facility,both,46,ME,,1957,1369.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 75 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-775-01,NDC,,,facility,both,40,ME,,1652,1156.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 25 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-711-01,NDC,,,facility,both,86,ME,,8415,5890.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 75 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-775-01,NDC,,,facility,both,266,ME,,25264,17684.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 75 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-775-01,NDC,,,facility,both,290,ME,,27544,19280.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 75 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-775-01,NDC,,,facility,both,260,ME,,24694,17285.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 75 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-775-01,NDC,,,facility,both,360,ME,,34192,23934.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 25 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-711-01,NDC,,,facility,both,82,ME,,8024,5616.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 25 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-711-01,NDC,,,facility,both,24,ME,,1022,715.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 25 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-711-01,NDC,,,facility,both,90,ME,,8807,6164.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 75 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-775-01,NDC,,,facility,both,276,ME,,26214,18349.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 75 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-775-01,NDC,,,facility,both,224,ME,,21275,14892.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 25 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-711-01,NDC,,,facility,both,42,ME,,1787,1250.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 25 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-711-01,NDC,,,facility,both,28,ME,,2740,1918,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 75 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-775-01,NDC,,,facility,both,255,ME,,24220,16954,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 75 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-775-01,NDC,,,facility,both,550,ME,,52238,36566.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 25 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-711-01,NDC,,,facility,both,76,ME,,3234,2263.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 25 MG SUBQ SOLR,36564,CDM,J0896,HCPCS,59572-711-01,NDC,,,facility,both,76,ME,,7437,5205.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENFORTUMAB VEDOTIN-EJFV 30 MG IV SOLR,36569,CDM,J9177,HCPCS,51144-030-01,NDC,,,facility,both,2,EA,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENFORTUMAB VEDOTIN-EJFV 20 MG IV SOLR,36569,CDM,J9177,HCPCS,51144-020-01,NDC,,,facility,both,40,ME,,1266,886.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENFORTUMAB VEDOTIN-EJFV 20 MG IV SOLR,36569,CDM,J9177,HCPCS,51144-020-01,NDC,,,facility,both,177,ME,,12885,9019.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENFORTUMAB VEDOTIN-EJFV 30 MG IV SOLR,36569,CDM,J9177,HCPCS,51144-030-01,NDC,,,facility,both,240,EA,,17471,12229.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENFORTUMAB VEDOTIN-EJFV 20 MG IV SOLR,36569,CDM,J9177,HCPCS,51144-020-01,NDC,,,facility,both,20,ME,,633,443.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENFORTUMAB VEDOTIN-EJFV 20 MG IV SOLR,36569,CDM,J9177,HCPCS,51144-020-01,NDC,,,facility,both,38,ME,,2767,1936.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENFORTUMAB VEDOTIN-EJFV 20 MG IV SOLR,36569,CDM,J9177,HCPCS,51144-020-01,NDC,,,facility,both,67,ME,,4878,3414.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENFORTUMAB VEDOTIN-EJFV 20 MG IV SOLR,36569,CDM,J9177,HCPCS,51144-020-01,NDC,,,facility,both,46,ME,,1456,1019.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENFORTUMAB VEDOTIN-EJFV 30 MG IV SOLR,36569,CDM,J9177,HCPCS,51144-030-01,NDC,,,facility,both,4,EA,,127,88.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENFORTUMAB VEDOTIN-EJFV 30 MG IV SOLR,36569,CDM,J9177,HCPCS,51144-030-01,NDC,,,facility,both,6,EA,,190,133,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENFORTUMAB VEDOTIN-EJFV 30 MG IV SOLR,36569,CDM,J9177,HCPCS,51144-030-01,NDC,,,facility,both,42,EA,,1355,948.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENFORTUMAB VEDOTIN-EJFV 30 MG IV SOLR,36569,CDM,J9177,HCPCS,51144-030-01,NDC,,,facility,both,238,EA,,17297,12107.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENFORTUMAB VEDOTIN-EJFV 20 MG IV SOLR,36569,CDM,J9177,HCPCS,51144-020-01,NDC,,,facility,both,160,ME,,11648,8153.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENFORTUMAB VEDOTIN-EJFV 30 MG IV SOLR,36569,CDM,J9177,HCPCS,51144-030-01,NDC,,,facility,both,480,EA,,34942,24459.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENFORTUMAB VEDOTIN-EJFV 20 MG IV SOLR,36569,CDM,J9177,HCPCS,51144-020-01,NDC,,,facility,both,60,ME,,1899,1329.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENFORTUMAB VEDOTIN-EJFV 20 MG IV SOLR,36569,CDM,J9177,HCPCS,51144-020-01,NDC,,,facility,both,20,ME,,1456,1019.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENFORTUMAB VEDOTIN-EJFV 20 MG IV SOLR,36569,CDM,J9177,HCPCS,51144-020-01,NDC,,,facility,both,40,ME,,2912,2038.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENFORTUMAB VEDOTIN-EJFV 30 MG IV SOLR,36569,CDM,J9177,HCPCS,51144-030-01,NDC,,,facility,both,26,EA,,836,585.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENFORTUMAB VEDOTIN-EJFV 20 MG IV SOLR,36569,CDM,J9177,HCPCS,51144-020-01,NDC,,,facility,both,74,ME,,5387,3770.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENFORTUMAB VEDOTIN-EJFV 20 MG IV SOLR,36569,CDM,J9177,HCPCS,51144-020-01,NDC,,,facility,both,34,ME,,2476,1733.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENFORTUMAB VEDOTIN-EJFV 30 MG IV SOLR,36569,CDM,J9177,HCPCS,51144-030-01,NDC,,,facility,both,2,EA,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENFORTUMAB VEDOTIN-EJFV 30 MG IV SOLR,36569,CDM,J9177,HCPCS,51144-030-01,NDC,,,facility,both,23,EA,,735,514.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENFORTUMAB VEDOTIN-EJFV 30 MG IV SOLR,36569,CDM,J9177,HCPCS,51144-030-01,NDC,,,facility,both,343,EA,,24926,17448.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENFORTUMAB VEDOTIN-EJFV 30 MG IV SOLR,36569,CDM,J9177,HCPCS,51144-030-01,NDC,,,facility,both,360,EA,,26207,18344.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENFORTUMAB VEDOTIN-EJFV 20 MG IV SOLR,36569,CDM,J9177,HCPCS,51144-020-01,NDC,,,facility,both,23,ME,,728,509.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENFORTUMAB VEDOTIN-EJFV 30 MG IV SOLR,36569,CDM,J9177,HCPCS,51144-030-01,NDC,,,facility,both,318,EA,,23091,16163.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENFORTUMAB VEDOTIN-EJFV 30 MG IV SOLR,36569,CDM,J9177,HCPCS,51144-030-01,NDC,,,facility,both,114,EA,,8299,5809.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENFORTUMAB VEDOTIN-EJFV 20 MG IV SOLR,36569,CDM,J9177,HCPCS,51144-020-01,NDC,,,facility,both,63,ME,,1994,1395.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENFORTUMAB VEDOTIN-EJFV 20 MG IV SOLR,36569,CDM,J9177,HCPCS,51144-020-01,NDC,,,facility,both,53,ME,,1678,1174.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENFORTUMAB VEDOTIN-EJFV 20 MG IV SOLR,36569,CDM,J9177,HCPCS,51144-020-01,NDC,,,facility,both,2,ME,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENFORTUMAB VEDOTIN-EJFV 20 MG IV SOLR,36569,CDM,J9177,HCPCS,51144-020-01,NDC,,,facility,both,238,ME,,17326,12128.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENFORTUMAB VEDOTIN-EJFV 30 MG IV SOLR,36569,CDM,J9177,HCPCS,51144-030-01,NDC,,,facility,both,120,EA,,8736,6115.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENFORTUMAB VEDOTIN-EJFV 30 MG IV SOLR,36569,CDM,J9177,HCPCS,51144-030-01,NDC,,,facility,both,100,EA,,3165,2215.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENFORTUMAB VEDOTIN-EJFV 30 MG IV SOLR,36569,CDM,J9177,HCPCS,51144-030-01,NDC,,,facility,both,17,EA,,558,390.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENFORTUMAB VEDOTIN-EJFV 30 MG IV SOLR,36569,CDM,J9177,HCPCS,51144-030-01,NDC,,,facility,both,238,EA,,17267,12086.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENFORTUMAB VEDOTIN-EJFV 30 MG IV SOLR,36569,CDM,J9177,HCPCS,51144-030-01,NDC,,,facility,both,236,EA,,17180,12026,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENFORTUMAB VEDOTIN-EJFV 20 MG IV SOLR,36569,CDM,J9177,HCPCS,51144-020-01,NDC,,,facility,both,140,ME,,10192,7134.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENFORTUMAB VEDOTIN-EJFV 20 MG IV SOLR,36569,CDM,J9177,HCPCS,51144-020-01,NDC,,,facility,both,154,ME,,11211,7847.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENFORTUMAB VEDOTIN-EJFV 20 MG IV SOLR,36569,CDM,J9177,HCPCS,51144-020-01,NDC,,,facility,both,80,ME,,5824,4076.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENFORTUMAB VEDOTIN-EJFV 20 MG IV SOLR,36569,CDM,J9177,HCPCS,51144-020-01,NDC,,,facility,both,13,ME,,412,288.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENFORTUMAB VEDOTIN-EJFV 20 MG IV SOLR,36569,CDM,J9177,HCPCS,51144-020-01,NDC,,,facility,both,27,ME,,1966,1376.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENFORTUMAB VEDOTIN-EJFV 30 MG IV SOLR,36569,CDM,J9177,HCPCS,51144-030-01,NDC,,,facility,both,97,EA,,7047,4932.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENFORTUMAB VEDOTIN-EJFV 30 MG IV SOLR,36569,CDM,J9177,HCPCS,51144-030-01,NDC,,,facility,both,380,EA,,27663,19364.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENFORTUMAB VEDOTIN-EJFV 30 MG IV SOLR,36569,CDM,J9177,HCPCS,51144-030-01,NDC,,,facility,both,454,EA,,33020,23114,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENFORTUMAB VEDOTIN-EJFV 20 MG IV SOLR,36569,CDM,J9177,HCPCS,51144-020-01,NDC,,,facility,both,42,ME,,1330,931,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENFORTUMAB VEDOTIN-EJFV 20 MG IV SOLR,36569,CDM,J9177,HCPCS,51144-020-01,NDC,,,facility,both,6,ME,,190,133,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENFORTUMAB VEDOTIN-EJFV 20 MG IV SOLR,36569,CDM,J9177,HCPCS,51144-020-01,NDC,,,facility,both,57,ME,,4150,2905,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENFORTUMAB VEDOTIN-EJFV 20 MG IV SOLR,36569,CDM,J9177,HCPCS,51144-020-01,NDC,,,facility,both,158,ME,,11502,8051.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,36896,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,1,ML,,350,245,,,,,,,,,,,,,Gross Charge Type: Pharmacy
REGADENOSON 0.4 MG/5 ML IV SYRG,36917,CDM,J2785,HCPCS,0469-6501-89,NDC,,,facility,both,4,ML,,913,639.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
REGADENOSON 0.4 MG/5 ML IV SYRG,36917,CDM,J2785,HCPCS,67457-994-05,NDC,,,facility,both,4,ML,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
REGADENOSON 0.4 MG/5 ML IV SYRG,36917,CDM,J2785,HCPCS,60505-6116-0,NDC,,,facility,both,4,ML,,886,620.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
REGADENOSON 0.4 MG/5 ML IV SYRG,36917,CDM,J2785,HCPCS,71288-201-85,NDC,,,facility,both,4,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
REGADENOSON 0.4 MG/5 ML IV SYRG,36917,CDM,J2785,HCPCS,0641-6253-01,NDC,,,facility,both,4,ML,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC ISOFLURANE INH,37000001,CDM,370,RC,37000001,HCPCS,,,facility,both,,,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Central
HC SEVOFLURANE INH,37000002,CDM,370,RC,37000002,HCPCS,,,facility,both,,,,248,173.6,,,,,,,,,,,,,Gross Charge Type: Central
HC DESFLURANE INH,37000003,CDM,370,RC,37000003,HCPCS,,,facility,both,,,,292,204.4,,,,,,,,,,,,,Gross Charge Type: Central
HC ANESTHESIA PX HEART PERICARDIAL SAC GREAT VESSELS OF CHEST W/O PUMP OXYGENATOR,37000008,CDM,370,RC,560,HCPCS,,,facility,both,,,,358,250.6,,,,,,,,,,,,,Gross Charge Type: Central
HC MOD SEDATION SAME PHYS/QHP ENDOSCOPIC SERVICE INITIAL 15 MIN PATIENT 5 YEARS OR OLDER,37000015,CDM,370,RC,G0500,HCPCS,,,facility,both,,,,445,311.5,,,,,,,,,,,,,Gross Charge Type: Central
HC MOD SEDATION SAME PHYS/QHP INITIAL 15 MIN PATIENT YOUNGER THAN 5 YEARS OF AGE,37100005,CDM,371,RC,99151,HCPCS,,,facility,both,,,,223,156.1,,,,,,,,,,,,,Gross Charge Type: Central
HC MOD SEDATION SAME PHYS/QHP INITIAL 15 MIN PATIENT AGE 5 YEARS OR OLDER,37100006,CDM,371,RC,99152,HCPCS,,,facility,both,,,,423,296.1,,,,,,,,,,,,,Gross Charge Type: Central
HC MOD SEDATION SAME PHYS/QHP EACH ADDTL 15 MIN INTRASERVICE TIME (LIST SEP  IN ADDT TO CODE FOR PRIMARY SERVICE),37100007,CDM,371,RC,99153,HCPCS,,,facility,both,,,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Central
HC MOD SEDATION OTHER PHYS/QHP INITIAL 15 MIN INTRASERVICE TIME PATIENT YOUNGER THAN 5 YEARS OF AGE,37100008,CDM,371,RC,99155,HCPCS,,,facility,both,,,,307,214.9,,,,,,,,,,,,,Gross Charge Type: Central
HC MOD SEDATION OTHER PHYS/QHP INITIAL 15 MIN INTRASERVICE TIME PATIENT AGE 5 YEARS OR OLDER,37100009,CDM,371,RC,99156,HCPCS,,,facility,both,,,,307,214.9,,,,,,,,,,,,,Gross Charge Type: Central
HC MOD SEDATION OTHER PHYS/QHP EACH ADDTL 15 MIN INTRASERVICE TIME (LIST SEP IN ADDT TO CODE FOR PRIMARY SERVICE),37100010,CDM,371,RC,99157,HCPCS,,,facility,both,,,,154,107.8,,,,,,,,,,,,,Gross Charge Type: Central
BCG LIVE 50 MG IVES SUSR,3746,CDM,J9030,HCPCS,0052-0602-01,NDC,,,facility,both,1,EA,,382,267.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,3746,CDM,J7040,HCPCS,0264-1800-31,NDC,,,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVONORGESTREL 14 MCG/24 HOUR (3 YEARS) IU IUD,3755,CDM,J7301,HCPCS,50419-422-01,NDC,,,facility,both,1,EA,,1973,1381.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE (3 MONTH) 22.5 MG IM SYRG,3755,CDM,J9217,HCPCS,0074-3346-03,NDC,,,facility,both,1,EA,,1176,823.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,3755,CDM,J7060,HCPCS,0990-7923-23,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SYRG,3755,CDM,J3490,HCPCS,8290306546,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) BLADDER INSTILLATION,3755,CDM,J9201,HCPCS,0409-0182-01,NDC,,,facility,both,1,ML,,392,274.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COPPER 380 SQUARE MM IU IUD,3755,CDM,J7300,HCPCS,59365-5128-1,NDC,,,facility,both,1,EA,,3142,2199.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETONOGESTREL 68 MG SDRM IMPL,3755,CDM,J7307,HCPCS,78206-145-01,NDC,,,facility,both,1,EA,,2258,1580.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COPPER 380 SQUARE MM IU IUD,3755,CDM,J7300,HCPCS,59365-5128-1,NDC,,,facility,both,1,EA,,858,600.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,3755,CDM,J3420,HCPCS,0517-0031-01,NDC,,,facility,both,1,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,3755,CDM,J7060,HCPCS,0338-0017-02,NDC,,,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 2 %-1:200,000 INJ SOLN",3755,CDM,J2004,HCPCS,63323-489-02,NDC,,,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,3755,CDM,J3420,HCPCS,63323-044-00,NDC,,,facility,both,1,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVONORGESTREL 20 MCG/24 HR IU IUD,3755,CDM,J7298,HCPCS,50419-423-01,NDC,,,facility,both,1,EA,,2369,1658.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE LAUROXIL 882 MG/3.2 ML IM SERS,37581,CDM,J1944,HCPCS,65757-403-03,NDC,,,facility,both,882,ME,,7575,5302.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE LAUROXIL 441 MG/1.6 ML IM SERS,37581,CDM,J1944,HCPCS,65757-401-03,NDC,,,facility,both,441,ME,,3788,2651.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE LAUROXIL 662 MG/2.4 ML IM SERS,37581,CDM,J1944,HCPCS,65757-402-03,NDC,,,facility,both,662,ML,,6592,4614.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMOSOZUMAB-AQQG 105 MG/1.17 ML SUBQ SYRG,37759,CDM,J3111,HCPCS,55513-998-01,NDC,,,facility,both,210,ML,,5349,3744.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEMIPLIMAB-RWLC 50 MG/ML IV SOLN,38133,CDM,J9119,HCPCS,61755-008-01,NDC,,,facility,both,350,ML,,25491,17843.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAFASITAMAB-CXIX 200 MG IV SOLR,38189,CDM,J9349,HCPCS,73535-208-01,NDC,,,facility,both,561,EA,,18581,13006.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAFASITAMAB-CXIX 200 MG IV SOLR,38189,CDM,J9349,HCPCS,50881-013-03,NDC,,,facility,both,461,EA,,17383,12168.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAFASITAMAB-CXIX 200 MG IV SOLR,38189,CDM,J9349,HCPCS,50881-013-03,NDC,,,facility,both,42,EA,,700,490,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAFASITAMAB-CXIX 200 MG IV SOLR,38189,CDM,J9349,HCPCS,50881-013-03,NDC,,,facility,both,477,EA,,17994,12595.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAFASITAMAB-CXIX 200 MG IV SOLR,38189,CDM,J9349,HCPCS,73535-208-01,NDC,,,facility,both,400,EA,,13248,9273.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAFASITAMAB-CXIX 200 MG IV SOLR,38189,CDM,J9349,HCPCS,50881-013-03,NDC,,,facility,both,45,EA,,743,520.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAFASITAMAB-CXIX 200 MG IV SOLR,38189,CDM,J9349,HCPCS,73535-208-01,NDC,,,facility,both,39,EA,,562,393.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAFASITAMAB-CXIX 200 MG IV SOLR,38189,CDM,J9349,HCPCS,73535-208-01,NDC,,,facility,both,497,EA,,16461,11522.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAFASITAMAB-CXIX 200 MG IV SOLR,38189,CDM,J9349,HCPCS,50881-013-03,NDC,,,facility,both,3,EA,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAFASITAMAB-CXIX 200 MG IV SOLR,38189,CDM,J9349,HCPCS,73535-208-01,NDC,,,facility,both,3,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAFASITAMAB-CXIX 200 MG IV SOLR,38189,CDM,J9349,HCPCS,50881-013-03,NDC,,,facility,both,455,EA,,17179,12025.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAFASITAMAB-CXIX 200 MG IV SOLR,38189,CDM,J9349,HCPCS,73535-208-01,NDC,,,facility,both,500,EA,,16560,11592,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAFASITAMAB-CXIX 200 MG IV SOLR,38189,CDM,J9349,HCPCS,50881-013-03,NDC,,,facility,both,39,EA,,654,457.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAFASITAMAB-CXIX 200 MG IV SOLR,38189,CDM,J9349,HCPCS,50881-013-03,NDC,,,facility,both,23,EA,,388,271.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAFASITAMAB-CXIX 200 MG IV SOLR,38189,CDM,J9349,HCPCS,50881-013-03,NDC,,,facility,both,258,EA,,9723,6806.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAFASITAMAB-CXIX 200 MG IV SOLR,38189,CDM,J9349,HCPCS,50881-013-03,NDC,,,facility,both,497,EA,,18742,13119.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB-QYYP 420 MG IV SOLR,38791,CDM,Q5116,HCPCS,0069-0306-01,NDC,,,facility,both,38,ME,,8469,5928.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB-QYYP 420 MG IV SOLR,38791,CDM,Q5116,HCPCS,0069-0306-01,NDC,,,facility,both,10,ME,,2229,1560.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB-QYYP 420 MG IV SOLR,38791,CDM,Q5116,HCPCS,0069-0306-01,NDC,,,facility,both,15,ME,,3343,2340.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB-QYYP 420 MG IV SOLR,38791,CDM,Q5116,HCPCS,0069-0306-01,NDC,,,facility,both,11,ME,,1066,746.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB-QYYP 420 MG IV SOLR,38791,CDM,Q5116,HCPCS,0069-0306-01,NDC,,,facility,both,13,ME,,2898,2028.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB-QYYP 420 MG IV SOLR,38791,CDM,Q5116,HCPCS,0069-0306-01,NDC,,,facility,both,39,ME,,8692,6084.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB-QYYP 420 MG IV SOLR,38791,CDM,Q5116,HCPCS,0069-0306-01,NDC,,,facility,both,26,ME,,5795,4056.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB-QYYP 420 MG IV SOLR,38791,CDM,Q5116,HCPCS,0069-0306-01,NDC,,,facility,both,52,ME,,11589,8112.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB-QYYP 420 MG IV SOLR,38791,CDM,Q5116,HCPCS,0069-0306-01,NDC,,,facility,both,67,ME,,14931,10451.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB-QYYP 420 MG IV SOLR,38791,CDM,Q5116,HCPCS,0069-0306-01,NDC,,,facility,both,53,ME,,11811,8267.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB-QYYP 420 MG IV SOLR,38791,CDM,Q5116,HCPCS,0069-0306-01,NDC,,,facility,both,75,ME,,16714,11699.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB-QYYP 420 MG IV SOLR,38791,CDM,Q5116,HCPCS,0069-0306-01,NDC,,,facility,both,53,ME,,11812,8268.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB-QYYP 420 MG IV SOLR,38791,CDM,Q5116,HCPCS,0069-0306-01,NDC,,,facility,both,37,ME,,8246,5772.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB-QYYP 420 MG IV SOLR,38791,CDM,Q5116,HCPCS,0069-0306-01,NDC,,,facility,both,90,ME,,20057,14039.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB-QYYP 420 MG IV SOLR,38791,CDM,Q5116,HCPCS,0069-0306-01,NDC,,,facility,both,14,ME,,3120,2184,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB-QYYP 420 MG IV SOLR,38791,CDM,Q5116,HCPCS,0069-0306-01,NDC,,,facility,both,30,ME,,6686,4680.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB-QYYP 420 MG IV SOLR,38791,CDM,Q5116,HCPCS,0069-0305-01,NDC,,,facility,both,54,ME,,12034,8423.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB-QYYP 420 MG IV SOLR,38791,CDM,Q5116,HCPCS,0069-0306-01,NDC,,,facility,both,18,ME,,4012,2808.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB-QYYP 420 MG IV SOLR,38791,CDM,Q5116,HCPCS,0069-0306-01,NDC,,,facility,both,105,ME,,23399,16379.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB-QYYP 420 MG IV SOLR,38791,CDM,Q5116,HCPCS,0069-0306-01,NDC,,,facility,both,46,ME,,10251,7175.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB-QYYP 420 MG IV SOLR,38791,CDM,Q5116,HCPCS,0069-0306-01,NDC,,,facility,both,54,ME,,12034,8423.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB-QYYP 420 MG IV SOLR,38791,CDM,Q5116,HCPCS,0069-0306-01,NDC,,,facility,both,12,ME,,2675,1872.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB-QYYP 420 MG IV SOLR,38791,CDM,Q5116,HCPCS,0069-0306-01,NDC,,,facility,both,84,ME,,18720,13104,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB-QYYP 420 MG IV SOLR,38791,CDM,Q5116,HCPCS,0069-0306-01,NDC,,,facility,both,27,ME,,6017,4211.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB-QYYP 420 MG IV SOLR,38791,CDM,Q5116,HCPCS,0069-0306-01,NDC,,,facility,both,60,ME,,13372,9360.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB-QYYP 420 MG IV SOLR,38791,CDM,Q5116,HCPCS,0069-0306-01,NDC,,,facility,both,36,ME,,8023,5616.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB-QYYP 420 MG IV SOLR,38791,CDM,Q5116,HCPCS,0069-0306-01,NDC,,,facility,both,20,ME,,4457,3119.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB-QYYP 420 MG IV SOLR,38791,CDM,Q5116,HCPCS,0069-0306-01,NDC,,,facility,both,45,ME,,10029,7020.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB-QYYP 420 MG IV SOLR,38791,CDM,Q5116,HCPCS,0069-0306-01,NDC,,,facility,both,60,ME,,13371,9359.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB-QYYP 420 MG IV SOLR,38791,CDM,Q5116,HCPCS,0069-0306-01,NDC,,,facility,both,51,ME,,11366,7956.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB-QYYP 420 MG IV SOLR,38791,CDM,Q5116,HCPCS,0069-0306-01,NDC,,,facility,both,23,ME,,5126,3588.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB-QYYP 420 MG IV SOLR,38791,CDM,Q5116,HCPCS,0069-0306-01,NDC,,,facility,both,42,ME,,9360,6552,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB-QYYP 420 MG IV SOLR,38791,CDM,Q5116,HCPCS,0069-0306-01,NDC,,,facility,both,34,ME,,7577,5303.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB-QYYP 420 MG IV SOLR,38791,CDM,Q5116,HCPCS,0069-0306-01,NDC,,,facility,both,21,ME,,4680,3276,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB-QYYP 420 MG IV SOLR,38791,CDM,Q5116,HCPCS,0069-0306-01,NDC,,,facility,both,31,ME,,6909,4836.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB-QYYP 420 MG IV SOLR,38791,CDM,Q5116,HCPCS,0069-0306-01,NDC,,,facility,both,20,ME,,4458,3120.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB-QYYP 420 MG IV SOLR,38791,CDM,Q5116,HCPCS,0069-0306-01,NDC,,,facility,both,11,ME,,2452,1716.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB-QYYP 420 MG IV SOLR,38791,CDM,Q5116,HCPCS,0069-0306-01,NDC,,,facility,both,24,ME,,5349,3744.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB-QYYP 420 MG IV SOLR,38791,CDM,Q5116,HCPCS,0069-0306-01,NDC,,,facility,both,35,ME,,7800,5460,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,38796,CDM,Q5119,HCPCS,0069-0238-01,NDC,,,facility,both,2,ML,,173,121.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,38796,CDM,Q5119,HCPCS,0069-0238-01,NDC,,,facility,both,17,ML,,3364,2354.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,38796,CDM,Q5119,HCPCS,0069-0238-01,NDC,,,facility,both,8,ML,,1583,1108.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,38796,CDM,Q5119,HCPCS,0069-0238-01,NDC,,,facility,both,3,ML,,259,181.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,38796,CDM,Q5119,HCPCS,0069-0249-01,NDC,,,facility,both,13,ML,,1119,783.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,38796,CDM,Q5119,HCPCS,0069-0238-01,NDC,,,facility,both,29,ML,,5738,4016.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,38796,CDM,Q5119,HCPCS,0069-0238-01,NDC,,,facility,both,39,ML,,7716,5401.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,38796,CDM,Q5119,HCPCS,0069-0249-01,NDC,,,facility,both,100,ML,,19784,13848.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,38796,CDM,Q5119,HCPCS,0069-0238-01,NDC,,,facility,both,24,ML,,4749,3324.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,38796,CDM,Q5119,HCPCS,0069-0249-01,NDC,,,facility,both,90,ML,,17806,12464.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,38796,CDM,Q5119,HCPCS,0069-0238-01,NDC,,,facility,both,30,ML,,5936,4155.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,38796,CDM,Q5119,HCPCS,0069-0249-01,NDC,,,facility,both,47,ML,,9299,6509.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,38796,CDM,Q5119,HCPCS,0069-0238-01,NDC,,,facility,both,25,ML,,4946,3462.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,38796,CDM,Q5119,HCPCS,0069-0249-01,NDC,,,facility,both,50,ML,,9892,6924.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,38796,CDM,Q5119,HCPCS,0069-0238-01,NDC,,,facility,both,20,ML,,3957,2769.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,38796,CDM,Q5119,HCPCS,0069-0238-01,NDC,,,facility,both,13,ML,,2572,1800.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,38796,CDM,Q5119,HCPCS,0069-0238-01,NDC,,,facility,both,1,ML,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,38796,CDM,Q5119,HCPCS,0069-0238-01,NDC,,,facility,both,80,ML,,15827,11078.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,38796,CDM,Q5119,HCPCS,0069-0238-01,NDC,,,facility,both,90,ML,,17806,12464.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,38796,CDM,Q5119,HCPCS,0069-0249-01,NDC,,,facility,both,49,ML,,9695,6786.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,38796,CDM,Q5119,HCPCS,0069-0238-01,NDC,,,facility,both,1,ML,,198,138.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,38796,CDM,Q5119,HCPCS,0069-0238-01,NDC,,,facility,both,34,ML,,6727,4708.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,38796,CDM,Q5119,HCPCS,0069-0238-01,NDC,,,facility,both,26,ML,,5144,3600.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,38796,CDM,Q5119,HCPCS,0069-0238-01,NDC,,,facility,both,16,ML,,3166,2216.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,38796,CDM,Q5119,HCPCS,0069-0238-01,NDC,,,facility,both,9,ML,,775,542.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,38796,CDM,Q5119,HCPCS,0069-0238-01,NDC,,,facility,both,10,ML,,1979,1385.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,38796,CDM,Q5119,HCPCS,0069-0238-01,NDC,,,facility,both,5,ML,,431,301.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,38796,CDM,Q5119,HCPCS,0069-0249-01,NDC,,,facility,both,38,ML,,7518,5262.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,38796,CDM,Q5119,HCPCS,0069-0238-01,NDC,,,facility,both,33,ML,,6529,4570.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,38796,CDM,Q5119,HCPCS,0069-0238-01,NDC,,,facility,both,14,ML,,2770,1939,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,38796,CDM,Q5119,HCPCS,0069-0238-01,NDC,,,facility,both,8,ML,,689,482.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,38796,CDM,Q5119,HCPCS,0069-0238-01,NDC,,,facility,both,7,ML,,1385,969.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,38796,CDM,Q5119,HCPCS,0069-0238-01,NDC,,,facility,both,7,ML,,603,422.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,38796,CDM,Q5119,HCPCS,0069-0238-01,NDC,,,facility,both,38,ML,,7518,5262.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,38796,CDM,Q5119,HCPCS,0069-0238-01,NDC,,,facility,both,1,ML,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,38796,CDM,Q5119,HCPCS,0069-0238-01,NDC,,,facility,both,6,ML,,1188,831.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,38796,CDM,Q5119,HCPCS,0069-0249-01,NDC,,,facility,both,6,ML,,517,361.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,38796,CDM,Q5119,HCPCS,0069-0249-01,NDC,,,facility,both,40,ML,,7914,5539.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,38796,CDM,Q5119,HCPCS,0069-0238-01,NDC,,,facility,both,5,ML,,990,693,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,38796,CDM,Q5119,HCPCS,0069-0238-01,NDC,,,facility,both,4,ML,,345,241.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,38796,CDM,Q5119,HCPCS,0069-0238-01,NDC,,,facility,both,69,ML,,13651,9555.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,38796,CDM,Q5119,HCPCS,0069-0249-01,NDC,,,facility,both,3,ML,,259,181.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,38796,CDM,Q5119,HCPCS,0069-0238-01,NDC,,,facility,both,37,ML,,7320,5124,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,38796,CDM,Q5119,HCPCS,0069-0238-01,NDC,,,facility,both,36,ML,,7123,4986.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,38796,CDM,Q5119,HCPCS,0069-0238-01,NDC,,,facility,both,15,ML,,2968,2077.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,38796,CDM,Q5119,HCPCS,0069-0238-01,NDC,,,facility,both,40,ML,,7914,5539.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,38796,CDM,Q5119,HCPCS,0069-0238-01,NDC,,,facility,both,9,ML,,1781,1246.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,38796,CDM,Q5119,HCPCS,0069-0238-01,NDC,,,facility,both,27,ML,,5342,3739.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,38796,CDM,Q5119,HCPCS,0069-0249-01,NDC,,,facility,both,87,ML,,17212,12048.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,38796,CDM,Q5119,HCPCS,0069-0238-01,NDC,,,facility,both,86,ML,,17014,11909.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,38796,CDM,Q5119,HCPCS,0069-0238-01,NDC,,,facility,both,19,ML,,3759,2631.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,38796,CDM,Q5119,HCPCS,0069-0238-01,NDC,,,facility,both,6,ML,,517,361.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,38796,CDM,Q5119,HCPCS,0069-0238-01,NDC,,,facility,both,66,ML,,13058,9140.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,38796,CDM,Q5119,HCPCS,0069-0238-01,NDC,,,facility,both,28,ML,,5540,3878,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,38796,CDM,Q5119,HCPCS,0069-0249-01,NDC,,,facility,both,10,ML,,861,602.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,38796,CDM,Q5119,HCPCS,0069-0238-01,NDC,,,facility,both,12,ML,,2375,1662.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,38796,CDM,Q5119,HCPCS,0069-0249-01,NDC,,,facility,both,12,ML,,1033,723.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,38796,CDM,Q5119,HCPCS,0069-0249-01,NDC,,,facility,both,1,ML,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,38796,CDM,Q5119,HCPCS,0069-0238-01,NDC,,,facility,both,18,ML,,3562,2493.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,38796,CDM,Q5119,HCPCS,0069-0249-01,NDC,,,facility,both,44,ML,,8705,6093.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,38796,CDM,Q5119,HCPCS,0069-0249-01,NDC,,,facility,both,2,ML,,173,121.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,38796,CDM,Q5119,HCPCS,0069-0249-01,NDC,,,facility,both,48,ML,,9497,6647.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"RHO(D) IMMUNE GLOBULIN (RHOPHYLAC) 1,500 UNIT (300 MCG)/2 ML INJ SYRG",38950,CDM,J2791,HCPCS,44206-300-90,NDC,,,facility,both,1,ML,,693,485.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"RHO(D) IMMUNE GLOBULIN (RHOPHYLAC) 1,500 UNIT (300 MCG)/2 ML INJ SYRG",38950,CDM,J2791,HCPCS,44206-300-01,NDC,,,facility,both,1,ML,,693,485.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,38999,CDM,FAMNOCHARGE,HCPCS,0338-0049-02,NDC,,,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC RBC LEUKOC REDUCED EA UNIT,39000001,CDM,390,RC,P9016,HCPCS,,,facility,both,,,,337,235.9,,,,,,,,,,,,,Gross Charge Type: Central
HC RBC WASHED EA UNIT,39000003,CDM,390,RC,P9022,HCPCS,,,facility,both,,,,498,348.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PLATE LEU REDUC PHER IRR EA UNIT,39000004,CDM,390,RC,P9037,HCPCS,,,facility,both,,,,910,637,,,,,,,,,,,,,Gross Charge Type: Central
HC PLASMA CRYOPREC REDUC EA UNIT,39000005,CDM,390,RC,P9044,HCPCS,,,facility,both,,,,295,206.5,,,,,,,,,,,,,Gross Charge Type: Central
HC CRYOPRECIPITATE EA UNIT,39000006,CDM,390,RC,P9012,HCPCS,,,facility,both,,,,157,109.9,,,,,,,,,,,,,Gross Charge Type: Central
HC POOLED CRYOPRECIPITATE EA UNIT,39000007,CDM,390,RC,P9012,HCPCS,,,facility,both,,,,706,494.2,,,,,,,,,,,,,Gross Charge Type: Central
FRESH FROZEN PLASMA 50ML,39000008,CDM,390,RC,P9017,HCPCS,,,facility,both,,,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Central
HC FRESH FROZEN PLASMA 10ML,39000009,CDM,390,RC,P9017,HCPCS,,,facility,both,,,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Central
HC FRESH FROZEN PLASMA 20ML,39000010,CDM,390,RC,P9017,HCPCS,,,facility,both,,,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Central
HC FRESH FROZEN PLASMA 100ML,39000011,CDM,390,RC,P9017,HCPCS,,,facility,both,,,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Central
HC FRESH FROZEN PLASMA SINGLE DONOR,39000012,CDM,390,RC,P9017,HCPCS,,,facility,both,,,,164,114.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PLATELETS PHERESIS LEUKOCYTES REDUCED EACH UNIT,39000017,CDM,390,RC,P9035,HCPCS,,,facility,both,,,,577,403.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PLATELET PHERESIS LEUKOCYTE REDUCED,39000018,CDM,390,RC,P9035,HCPCS,,,facility,both,,,,794,555.8,,,,,,,,,,,,,Gross Charge Type: Central
HC RED BLD CELLS LEUKOREDUCED IRRAD 100ML,39000019,CDM,390,RC,P9040,HCPCS,,,facility,both,,,,170,119,,,,,,,,,,,,,Gross Charge Type: Central
HC RED BLD CELLS LEUKOREDUCED IRRAD 50ML,39000020,CDM,390,RC,P9040,HCPCS,,,facility,both,,,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Central
HC RED BLD CELLS LEUKOREDUCED IRRAD 20ML,39000021,CDM,390,RC,P9040,HCPCS,,,facility,both,,,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Central
HC RED BLD CELLS LEUKOREDUCED IRRAD 10ML,39000022,CDM,390,RC,P9040,HCPCS,,,facility,both,,,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Central
HC RBC LEUKO REDUCED/IRRADIATED EA UNIT,39000023,CDM,390,RC,P9040,HCPCS,,,facility,both,,,,453,317.1,,,,,,,,,,,,,Gross Charge Type: Central
HC RED BLOOD CELLS LEUKOREDUCED 10ML,39000024,CDM,390,RC,P9016,HCPCS,,,facility,both,,,,793,555.1,,,,,,,,,,,,,Gross Charge Type: Central
HC RED BLOOD CELLS LEUKOREDUCED 50ML,39000026,CDM,390,RC,P9016,HCPCS,,,facility,both,,,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Central
HC RED BLOOD CELLS LEUKOREDUCED100ML,39000027,CDM,390,RC,P9016,HCPCS,,,facility,both,,,,169,118.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PLATELET PHERESIS LEUKOCYTE REDUCED 50ML,39000031,CDM,390,RC,P9035,HCPCS,,,facility,both,,,,289,202.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PLATELETS PHERESIS LEUKO REDUC/IRRAD 20M,39000033,CDM,390,RC,P9037,HCPCS,,,facility,both,,,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PLATELETS PHERESIS LEUKO REDUC/IRRAD 50M,39000034,CDM,390,RC,P9037,HCPCS,,,facility,both,,,,228,159.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PLATE PHERESIS LEUKO REDUC/IRRAD 100ML,39000035,CDM,390,RC,P9037,HCPCS,,,facility,both,,,,456,319.2,,,,,,,,,,,,,Gross Charge Type: Central
HC FRESH FRZN PLSMA 8-24HR COLLECT EACH,39000036,CDM,390,RC,P9059,HCPCS,,,facility,both,,,,164,114.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PLSMA 8-24HR COLLECT 20ML,39000038,CDM,390,RC,P9059,HCPCS,,,facility,both,,,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PLSMA 8-24HR COLLECT 50ML,39000039,CDM,390,RC,P9059,HCPCS,,,facility,both,,,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PLSMA 8-24HR COLLECT 100ML,39000040,CDM,390,RC,P9059,HCPCS,,,facility,both,,,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Central
FERUMOXYTOL 510 MG/17 ML (30 MG/ML) IV SOLN,39045,CDM,Q0138,HCPCS,0781-3154-01,NDC,,,facility,both,510,ML,,2499,1749.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FERUMOXYTOL 510 MG/17 ML (30 MG/ML) IV SOLN,39045,CDM,Q0138,HCPCS,59338-775-01,NDC,,,facility,both,510,ML,,3295,2306.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TECHNETIUM TC 99M SESTAMIBI - CARDIOLITE,39046,CDM,A9500,HCPCS,65857-500-20,NDC,,,facility,both,1,EA,,214,149.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC BLOOD ADMINISTRATION,39100001,CDM,391,RC,36430,HCPCS,,,facility,both,,,,1602,1121.4,,,,,,,,,,,,,Gross Charge Type: Central
HC BLOOD TRANSFUSION LEVEL 2 2-4,39100002,CDM,391,RC,36430,HCPCS,,,facility,both,,,,1486,1040.2,,,,,,,,,,,,,Gross Charge Type: Central
HC BLOOD TRANSFUSION LEVEL 3 4-6,39100003,CDM,391,RC,36430,HCPCS,,,facility,both,,,,1691,1183.7,,,,,,,,,,,,,Gross Charge Type: Central
HC BLOOD TRANSFUSION LEVEL 4 6-9,39100004,CDM,391,RC,36430,HCPCS,,,facility,both,,,,1894,1325.8,,,,,,,,,,,,,Gross Charge Type: Central
HC BLOOD TRANSFUSION LEVEL 5 9+ H,39100005,CDM,391,RC,36430,HCPCS,,,facility,both,,,,2099,1469.3,,,,,,,,,,,,,Gross Charge Type: Central
BEVACIZUMAB-BVZR 25 MG/ML IV SOLN,39588,CDM,Q5118,HCPCS,0069-0342-01,NDC,,,facility,both,40,ML,,6772,4740.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BEVACIZUMAB-BVZR 25 MG/ML IV SOLN,39588,CDM,Q5118,HCPCS,0069-0315-01,NDC,,,facility,both,3,ML,,221,154.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BEVACIZUMAB-BVZR 25 MG/ML IV SOLN,39588,CDM,Q5118,HCPCS,0069-0315-01,NDC,,,facility,both,10,ML,,1693,1185.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BEVACIZUMAB-BVZR 25 MG/ML IV SOLN,39588,CDM,Q5118,HCPCS,0069-0315-01,NDC,,,facility,both,80,ML,,13544,9480.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BEVACIZUMAB-BVZR 25 MG/ML IV SOLN,39588,CDM,Q5118,HCPCS,0069-0315-01,NDC,,,facility,both,27,ML,,4572,3200.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BEVACIZUMAB-BVZR 25 MG/ML IV SOLN,39588,CDM,Q5118,HCPCS,0069-0342-01,NDC,,,facility,both,120,ML,,20316,14221.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BEVACIZUMAB-BVZR 25 MG/ML IV SOLN,39588,CDM,Q5118,HCPCS,0069-0342-01,NDC,,,facility,both,4,ML,,295,206.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BEVACIZUMAB-BVZR 25 MG/ML IV SOLN,39588,CDM,Q5118,HCPCS,0069-0342-01,NDC,,,facility,both,36,ML,,6095,4266.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BEVACIZUMAB-BVZR 25 MG/ML IV SOLN,39588,CDM,Q5118,HCPCS,0069-0342-01,NDC,,,facility,both,80,ML,,13544,9480.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BEVACIZUMAB-BVZR 25 MG/ML IV SOLN,39588,CDM,Q5118,HCPCS,0069-0342-01,NDC,,,facility,both,10,ML,,737,515.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BEVACIZUMAB-BVZR 25 MG/ML IV SOLN,39588,CDM,Q5118,HCPCS,0069-0342-01,NDC,,,facility,both,6,ML,,442,309.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BEVACIZUMAB-BVZR 25 MG/ML IV SOLN,39588,CDM,Q5118,HCPCS,0069-0342-01,NDC,,,facility,both,30,ML,,5079,3555.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BEVACIZUMAB-BVZR 25 MG/ML IV SOLN,39588,CDM,Q5118,HCPCS,0069-0315-01,NDC,,,facility,both,2,ML,,148,103.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BEVACIZUMAB-BVZR 25 MG/ML IV SOLN,39588,CDM,Q5118,HCPCS,0069-0315-01,NDC,,,facility,both,60,ML,,10158,7110.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BEVACIZUMAB-BVZR 25 MG/ML IV SOLN,39588,CDM,Q5118,HCPCS,0069-0315-01,NDC,,,facility,both,20,ML,,3386,2370.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BEVACIZUMAB-BVZR 25 MG/ML IV SOLN,39588,CDM,Q5118,HCPCS,0069-0315-01,NDC,,,facility,both,6,ML,,442,309.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BEVACIZUMAB-BVZR 25 MG/ML IV SOLN,39588,CDM,Q5118,HCPCS,0069-0342-01,NDC,,,facility,both,34,ML,,5757,4029.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BEVACIZUMAB-BVZR 25 MG/ML IV SOLN,39588,CDM,Q5118,HCPCS,0069-0315-01,NDC,,,facility,both,50,ML,,8465,5925.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BEVACIZUMAB-BVZR 25 MG/ML IV SOLN,39588,CDM,Q5118,HCPCS,0069-0315-01,NDC,,,facility,both,130,ML,,22009,15406.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BEVACIZUMAB-BVZR 25 MG/ML IV SOLN,39588,CDM,Q5118,HCPCS,0069-0342-01,NDC,,,facility,both,200,ML,,33860,23702,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BEVACIZUMAB-BVZR 25 MG/ML IV SOLN,39588,CDM,Q5118,HCPCS,0069-0315-01,NDC,,,facility,both,100,ML,,16930,11851,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BEVACIZUMAB-BVZR 25 MG/ML IV SOLN,39588,CDM,Q5118,HCPCS,0069-0315-01,NDC,,,facility,both,110,ML,,18623,13036.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BEVACIZUMAB-BVZR 25 MG/ML IV SOLN,39588,CDM,Q5118,HCPCS,0069-0315-01,NDC,,,facility,both,70,ML,,11851,8295.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BEVACIZUMAB-BVZR 25 MG/ML IV SOLN,39588,CDM,Q5118,HCPCS,0069-0315-01,NDC,,,facility,both,4,ML,,295,206.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BEVACIZUMAB-BVZR 25 MG/ML IV SOLN,39588,CDM,Q5118,HCPCS,0069-0315-01,NDC,,,facility,both,24,ML,,4064,2844.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BEVACIZUMAB-BVZR 25 MG/ML IV SOLN,39588,CDM,Q5118,HCPCS,0069-0315-01,NDC,,,facility,both,4,ML,,294,205.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BEVACIZUMAB-BVZR 25 MG/ML IV SOLN,39588,CDM,Q5118,HCPCS,0069-0315-01,NDC,,,facility,both,30,ML,,5079,3555.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BEVACIZUMAB-BVZR 25 MG/ML IV SOLN,39588,CDM,Q5118,HCPCS,0069-0315-01,NDC,,,facility,both,140,ML,,23702,16591.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BEVACIZUMAB-BVZR 25 MG/ML IV SOLN,39588,CDM,Q5118,HCPCS,0069-0315-01,NDC,,,facility,both,40,ML,,6772,4740.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BEVACIZUMAB-BVZR 25 MG/ML IV SOLN,39588,CDM,Q5118,HCPCS,0069-0315-01,NDC,,,facility,both,28,ML,,4741,3318.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BEVACIZUMAB-BVZR 25 MG/ML IV SOLN,39588,CDM,Q5118,HCPCS,0069-0315-01,NDC,,,facility,both,90,ML,,15237,10665.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BEVACIZUMAB-BVZR 25 MG/ML IV SOLN,39588,CDM,Q5118,HCPCS,0069-0315-01,NDC,,,facility,both,26,ML,,4402,3081.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,39714,CDM,J1756,HCPCS,0517-2340-01,NDC,,,facility,both,100,ML,,321,224.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,39714,CDM,J1756,HCPCS,0517-2340-01,NDC,,,facility,both,300,ML,,963,674.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,39714,CDM,J1756,HCPCS,0517-2340-01,NDC,,,facility,both,200,ML,,642,449.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,39714,CDM,J1756,HCPCS,0517-2340-10,NDC,,,facility,both,200,ML,,661,462.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,39714,CDM,J1756,HCPCS,0517-2340-10,NDC,,,facility,both,300,ML,,963,674.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,39714,CDM,J1756,HCPCS,0517-2340-01,NDC,,,facility,both,200,ML,,623,436.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,39714,CDM,J1756,HCPCS,0517-2340-01,NDC,,,facility,both,100,ML,,331,231.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,39714,CDM,J1756,HCPCS,0517-2340-01,NDC,,,facility,both,300,ML,,935,654.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,39714,CDM,J1756,HCPCS,0517-2340-01,NDC,,,facility,both,200,ML,,661,462.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,39714,CDM,J1756,HCPCS,0517-2340-01,NDC,,,facility,both,300,ML,,992,694.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,39714,CDM,J1756,HCPCS,0517-2340-10,NDC,,,facility,both,200,ML,,642,449.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,3985,CDM,J1580,HCPCS,63323-010-01,NDC,,,facility,both,1,ML,,101,70.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,3985,CDM,J1580,HCPCS,63323-010-01,NDC,,,facility,both,1,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,3985,CDM,J1580,HCPCS,63323-010-01,NDC,,,facility,both,1,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACITUZUMAB GOVITECAN-HZIY 180 MG IV SOLR,39886,CDM,J9317,HCPCS,55135-132-01,NDC,,,facility,both,188,EA,,14939,10457.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACITUZUMAB GOVITECAN-HZIY 180 MG IV SOLR,39886,CDM,J9317,HCPCS,55135-132-01,NDC,,,facility,both,175,EA,,13858,9700.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACITUZUMAB GOVITECAN-HZIY 180 MG IV SOLR,39886,CDM,J9317,HCPCS,55135-132-01,NDC,,,facility,both,321,EA,,25491,17843.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACITUZUMAB GOVITECAN-HZIY 180 MG IV SOLR,39886,CDM,J9317,HCPCS,55135-132-01,NDC,,,facility,both,53,EA,,1838,1286.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACITUZUMAB GOVITECAN-HZIY 180 MG IV SOLR,39886,CDM,J9317,HCPCS,55135-132-01,NDC,,,facility,both,317,EA,,25174,17621.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACITUZUMAB GOVITECAN-HZIY 180 MG IV SOLR,39886,CDM,J9317,HCPCS,55135-132-01,NDC,,,facility,both,288,EA,,22885,16019.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACITUZUMAB GOVITECAN-HZIY 180 MG IV SOLR,39886,CDM,J9317,HCPCS,55135-132-01,NDC,,,facility,both,41,EA,,1438,1006.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACITUZUMAB GOVITECAN-HZIY 180 MG IV SOLR,39886,CDM,J9317,HCPCS,55135-132-01,NDC,,,facility,both,34,EA,,1189,832.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACITUZUMAB GOVITECAN-HZIY 180 MG IV SOLR,39886,CDM,J9317,HCPCS,55135-132-01,NDC,,,facility,both,326,EA,,25873,18111.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACITUZUMAB GOVITECAN-HZIY 180 MG IV SOLR,39886,CDM,J9317,HCPCS,55135-132-01,NDC,,,facility,both,43,EA,,1493,1045.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACITUZUMAB GOVITECAN-HZIY 180 MG IV SOLR,39886,CDM,J9317,HCPCS,55135-132-01,NDC,,,facility,both,216,EA,,17164,12014.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACITUZUMAB GOVITECAN-HZIY 180 MG IV SOLR,39886,CDM,J9317,HCPCS,55135-132-01,NDC,,,facility,both,28,EA,,968,677.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACITUZUMAB GOVITECAN-HZIY 180 MG IV SOLR,39886,CDM,J9317,HCPCS,55135-132-01,NDC,,,facility,both,163,EA,,12937,9055.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACITUZUMAB GOVITECAN-HZIY 180 MG IV SOLR,39886,CDM,J9317,HCPCS,55135-132-01,NDC,,,facility,both,39,EA,,1355,948.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,40184,CDM,J3420,HCPCS,0517-0031-01,NDC,,,facility,both,1,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLU VACCINE TS 2025-26 65 YR UP (PF) 180 MCG/0.5 ML IM SYRG,40184,CDM,90662,HCPCS,49281-125-88,NDC,,,facility,both,1,ML,,403,282.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIPHTH,PERTUS(ACELL),TETANUS SYRG(BOOSTRIX) 2.5-8-5 LF-MCG-LF/0.5ML IM SYRG",40184,CDM,90715,HCPCS,58160-842-43,NDC,,,facility,both,1,ML,,247,172.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLU VACCINE TS 2025-26 65 YR UP (PF) 180 MCG/0.5 ML IM SYRG,40184,CDM,90662,HCPCS,49281-125-88,NDC,,,facility,both,1,ML,,372,260.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLU VACCINE TS 2025-26 6 MO UP (PF) 45 MCG (15 MCG X 3)/0.5 ML IM SYRG,40184,CDM,90656,HCPCS,58160-912-41,NDC,,,facility,both,1,ML,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC US BRAIN,40200001,CDM,402,RC,76506,HCPCS,,,facility,both,,,,425,297.5,,,,,,,,,,,,,Gross Charge Type: Central
HC US SOFT TISSUE HEAD NECK,40200002,CDM,402,RC,76536,HCPCS,,,facility,both,,,,425,297.5,,,,,,,,,,,,,Gross Charge Type: Central
HC US CHEST,40200003,CDM,402,RC,76604,HCPCS,,,facility,both,,,,425,297.5,,,,,,,,,,,,,Gross Charge Type: Central
HC US ABDOMEN,40200005,CDM,402,RC,76700,HCPCS,,,facility,both,,,,690,483,,,,,,,,,,,,,Gross Charge Type: Central
HC US ABDOMEN SINGLE ORGAN,40200006,CDM,402,RC,76705,HCPCS,,,facility,both,,,,634,443.8,,,,,,,,,,,,,Gross Charge Type: Central
HC US RETROPERITONEAL,40200007,CDM,402,RC,76770,HCPCS,,,facility,both,,,,450,315,,,,,,,,,,,,,Gross Charge Type: Central
HC US RETROPERITONEAL LIMITED,40200008,CDM,402,RC,76775,HCPCS,,,facility,both,,,,450,315,,,,,,,,,,,,,Gross Charge Type: Central
US TRANSPLANTED KIDNEY,40200009,CDM,402,RC,76776,HCPCS,,,facility,both,,,,581,406.7,,,,,,,,,,,,,Gross Charge Type: Central
HC US SPINAL CANAL,40200010,CDM,402,RC,76800,HCPCS,,,facility,both,,,,233,163.1,,,,,,,,,,,,,Gross Charge Type: Central
HC US OB <14 WKS SINGL/1ST GESTAT,40200011,CDM,402,RC,76801,HCPCS,,,facility,both,,,,487,340.9,,,,,,,,,,,,,Gross Charge Type: Central
HC US OB < 14 WKS ADD'L GESTAT,40200012,CDM,402,RC,76802,HCPCS,,,facility,both,,,,246,172.2,,,,,,,,,,,,,Gross Charge Type: Central
HC US OB >=14 WKS SINGL/1ST GESTAT,40200013,CDM,402,RC,76805,HCPCS,,,facility,both,,,,487,340.9,,,,,,,,,,,,,Gross Charge Type: Central
HC US OB >=14 WKS ADD'L GESTAT,40200014,CDM,402,RC,76810,HCPCS,,,facility,both,,,,573,401.1,,,,,,,,,,,,,Gross Charge Type: Central
HC US OB LIMITED FETUS(S),40200015,CDM,402,RC,76815,HCPCS,,,facility,both,,,,425,297.5,,,,,,,,,,,,,Gross Charge Type: Central
HC OB US FOLLOW-UP PER FETUS,40200016,CDM,402,RC,76816,HCPCS,,,facility,both,,,,428,299.6,,,,,,,,,,,,,Gross Charge Type: Central
HC US OB TRANSVAGINAL,40200017,CDM,402,RC,76817,HCPCS,,,facility,both,,,,425,297.5,,,,,,,,,,,,,Gross Charge Type: Central
HC FETAL BIOPHYS PROFIL W/O NST,40200018,CDM,402,RC,76819,HCPCS,,,facility,both,,,,410,287,,,,,,,,,,,,,Gross Charge Type: Central
HC US NOT OB TRANSVAGINAL,40200019,CDM,402,RC,76830,HCPCS,,,facility,both,,,,537,375.9,,,,,,,,,,,,,Gross Charge Type: Central
SONOHYSTEROGRAPHY,40200020,CDM,402,RC,76831,HCPCS,,,facility,both,,,,424,296.8,,,,,,,,,,,,,Gross Charge Type: Central
HC US NOT OB PELVIC COMPLETE,40200021,CDM,402,RC,76856,HCPCS,,,facility,both,,,,569,398.3,,,,,,,,,,,,,Gross Charge Type: Central
HC US NOT OB PELVIC LIMITED FUP,40200022,CDM,402,RC,76857,HCPCS,,,facility,both,,,,425,297.5,,,,,,,,,,,,,Gross Charge Type: Central
HC US SCROTUM,40200023,CDM,402,RC,76870,HCPCS,,,facility,both,,,,425,297.5,,,,,,,,,,,,,Gross Charge Type: Central
HC US TRANSRECTAL,40200024,CDM,402,RC,76872,HCPCS,,,facility,both,,,,555,388.5,,,,,,,,,,,,,Gross Charge Type: Central
HC US COMPLETE JOINT REAL-TIME W/ IMAGE DOCUMENTATION,40200026,CDM,402,RC,76881,HCPCS,,,facility,both,,,,425,297.5,,,,,,,,,,,,,Gross Charge Type: Central
HC US LIMITED JOINT/FOCAL EVAL NONVASC EXTREMITY STRUCTURE(S) REAL-TIME W/IMAGE DOC,40200027,CDM,402,RC,76882,HCPCS,,,facility,both,,,,425,297.5,,,,,,,,,,,,,Gross Charge Type: Central
US INFANT HIPS DYNAMIC,40200028,CDM,402,RC,76885,HCPCS,,,facility,both,,,,453,317.1,,,,,,,,,,,,,Gross Charge Type: Central
HC US GUIDE VASCULAR ACCESS,40200031,CDM,402,RC,76937,HCPCS,,,facility,both,,,,201,140.7,,,,,,,,,,,,,Gross Charge Type: Central
HC US GUIDE TISSUE ABLATION,40200032,CDM,402,RC,76940,HCPCS,,,facility,both,,,,621,434.7,,,,,,,,,,,,,Gross Charge Type: Central
HC US GUIDE NEEDLE PLACEMENT SI,40200033,CDM,402,RC,76942,HCPCS,,,facility,both,,,,656,459.2,,,,,,,,,,,,,Gross Charge Type: Central
HC US GUIDE FOR AMNIO SI,40200034,CDM,402,RC,76946,HCPCS,,,facility,both,,,,573,401.1,,,,,,,,,,,,,Gross Charge Type: Central
HC US GUIDE PLACE INTERSTITIAL RAD,40200036,CDM,402,RC,76965,HCPCS,,,facility,both,,,,1166,816.2,,,,,,,,,,,,,Gross Charge Type: Central
HC US GUIDE INTRAOP,40200037,CDM,402,RC,76998,HCPCS,,,facility,both,,,,509,356.3,,,,,,,,,,,,,Gross Charge Type: Central
HC US UNLISTED PROC,40200038,CDM,402,RC,76999,HCPCS,,,facility,both,,,,145,101.5,,,,,,,,,,,,,Gross Charge Type: Central
US FOR AAA SCREEN,40200039,CDM,402,RC,76706,HCPCS,,,facility,both,,,,425,297.5,,,,,,,,,,,,,Gross Charge Type: Central
HC FETAL BIOPHYS PROFILE W/NST,40200040,CDM,402,RC,76818,HCPCS,,,facility,both,,,,642,449.4,,,,,,,,,,,,,Gross Charge Type: Central
HC US BREAST UNILAT INCL AXILLA WHEN PERFORMED LIMITED,40200043,CDM,402,RC,76642,HCPCS,,,facility,both,,,,314,219.8,,,,,,,,,,,,,Gross Charge Type: Central
HC DUPLEX SCAN HEMODIALYSIS ACCESS,40200044,CDM,921,RC,93990,HCPCS,,,facility,both,,,,223,156.1,,,,,,,,,,,,,Gross Charge Type: Central
HC DOPPLER VELOCIMETRY FETAL UMBILICAL ARTERY,40200051,CDM,402,RC,76820,HCPCS,,,facility,both,,,,431,301.7,,,,,,,,,,,,,Gross Charge Type: Central
HC ULTRASOUND ELASTOGRAPHY PARENCHYMA,40200054,CDM,402,RC,76981,HCPCS,,,facility,both,,,,507,354.9,,,,,,,,,,,,,Gross Charge Type: Central
HC DOPPLER VELOCIMETRY FETAL MIDDLE CEREBRAL ATERY,40200057,CDM,402,RC,76821,HCPCS,,,facility,both,,,,496,347.2,,,,,,,,,,,,,Gross Charge Type: Central
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-172-21,NDC,,,facility,both,351,ML,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,60505-6132-7,NDC,,,facility,both,61,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,60505-6132-7,NDC,,,facility,both,12,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,123,ML,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,60505-6132-7,NDC,,,facility,both,397,ML,,858,600.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-20,NDC,,,facility,both,200,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,15,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,71,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,67457-469-10,NDC,,,facility,both,21,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,67457-469-10,NDC,,,facility,both,53,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-172-21,NDC,,,facility,both,131,ML,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,58,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,67457-469-10,NDC,,,facility,both,12,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-172-21,NDC,,,facility,both,67,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,67457-469-10,NDC,,,facility,both,50,ML,,216,151.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,67457-469-10,NDC,,,facility,both,11,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,36,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-172-21,NDC,,,facility,both,336,ML,,198,138.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,67457-469-10,NDC,,,facility,both,31,ML,,134,93.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,30,ML,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,60505-6132-7,NDC,,,facility,both,200,ML,,432,302.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,60505-6132-7,NDC,,,facility,both,73,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,60505-6132-7,NDC,,,facility,both,300,ML,,648,453.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,61,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,134,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,46,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,60505-6132-7,NDC,,,facility,both,27,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-172-21,NDC,,,facility,both,191,ML,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,33,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,60505-6132-7,NDC,,,facility,both,344,ML,,744,520.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,67457-469-10,NDC,,,facility,both,71,ML,,307,214.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-172-21,NDC,,,facility,both,320,ML,,188,131.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,70,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,25,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-171-11,NDC,,,facility,both,76,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-172-21,NDC,,,facility,both,51,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,55,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,60505-6132-7,NDC,,,facility,both,400,ML,,864,604.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,60505-6132-7,NDC,,,facility,both,186,ML,,402,281.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,16,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,32,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,60505-6132-7,NDC,,,facility,both,3,ML,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,67,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,25,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,89,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,60505-6132-7,NDC,,,facility,both,64,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-172-21,NDC,,,facility,both,270,ML,,159,111.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-172-21,NDC,,,facility,both,200,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,66,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,60,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,47,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-172-21,NDC,,,facility,both,9,ML,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,60505-6132-7,NDC,,,facility,both,313,ML,,677,473.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,33,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-172-21,NDC,,,facility,both,133,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,67457-469-10,NDC,,,facility,both,30,ML,,130,91,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,74,ML,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-171-11,NDC,,,facility,both,38,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-172-21,NDC,,,facility,both,2,ML,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,51,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,60505-6132-7,NDC,,,facility,both,147,ML,,318,222.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,67457-469-10,NDC,,,facility,both,44,ML,,191,133.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,157,ML,,139,97.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-172-21,NDC,,,facility,both,354,ML,,208,145.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,67457-469-10,NDC,,,facility,both,86,ML,,372,260.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,60505-6132-7,NDC,,,facility,both,100,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,31,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,67457-469-10,NDC,,,facility,both,56,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,68,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,67457-469-10,NDC,,,facility,both,89,ML,,385,269.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,66,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,67457-469-10,NDC,,,facility,both,70,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,67457-469-10,NDC,,,facility,both,7,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,67457-469-10,NDC,,,facility,both,79,ML,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-172-21,NDC,,,facility,both,68,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,26,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,61,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-172-21,NDC,,,facility,both,75,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,67457-469-10,NDC,,,facility,both,93,ML,,402,281.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,67457-469-10,NDC,,,facility,both,69,ML,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,2,ML,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,60505-6132-7,NDC,,,facility,both,342,ML,,739,517.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,60505-6132-7,NDC,,,facility,both,14,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,67457-469-10,NDC,,,facility,both,36,ML,,156,109.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,72,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,93,ML,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,84,ML,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,67457-469-10,NDC,,,facility,both,5,ML,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,0955-1727-20,NDC,,,facility,both,526,ML,,1135,794.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,83,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,60505-6132-7,NDC,,,facility,both,60,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-172-21,NDC,,,facility,both,325,ML,,191,133.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,16714-728-01,NDC,,,facility,both,347,ML,,1288,901.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,59,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,67457-469-10,NDC,,,facility,both,66,ML,,286,200.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,67457-469-10,NDC,,,facility,both,100,ML,,432,302.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-172-21,NDC,,,facility,both,53,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,78,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,37,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,60505-6132-7,NDC,,,facility,both,121,ML,,262,183.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,70,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-172-21,NDC,,,facility,both,191,ML,,113,79.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-172-21,NDC,,,facility,both,69,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-172-21,NDC,,,facility,both,386,ML,,227,158.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,67457-469-10,NDC,,,facility,both,50,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,76,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,139,ML,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,60505-6132-7,NDC,,,facility,both,49,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-172-21,NDC,,,facility,both,198,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-172-21,NDC,,,facility,both,14,ML,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-172-21,NDC,,,facility,both,86,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,15,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,54,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,0955-1727-20,NDC,,,facility,both,400,ML,,863,604.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,41,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,60505-6132-7,NDC,,,facility,both,600,ML,,1296,907.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,86,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,83,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,185,ML,,163,114.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,66,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,60505-6132-7,NDC,,,facility,both,195,ML,,422,295.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,71,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,178,ML,,157,109.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,67457-469-10,NDC,,,facility,both,34,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,67457-469-10,NDC,,,facility,both,64,ML,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-172-21,NDC,,,facility,both,378,ML,,222,155.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,60505-6132-7,NDC,,,facility,both,134,ML,,290,203,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,29,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,60505-6132-7,NDC,,,facility,both,111,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-172-21,NDC,,,facility,both,357,ML,,210,147,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,88,ML,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,95,ML,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,39,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,42,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-171-11,NDC,,,facility,both,86,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-172-21,NDC,,,facility,both,340,ML,,200,140,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,60505-6132-7,NDC,,,facility,both,7,ML,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-20,NDC,,,facility,both,39,ML,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-20,NDC,,,facility,both,361,ML,,212,148.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,42,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,67457-469-10,NDC,,,facility,both,67,ML,,290,203,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-20,NDC,,,facility,both,400,ML,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,60505-6132-7,NDC,,,facility,both,339,ML,,733,513.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,61703-363-22,NDC,,,facility,both,400,ML,,830,581,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,38,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-172-21,NDC,,,facility,both,34,ML,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,37,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-172-21,NDC,,,facility,both,337,ML,,198,138.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,60505-6132-7,NDC,,,facility,both,373,ML,,806,564.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,22,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,67457-469-10,NDC,,,facility,both,47,ML,,204,142.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,60505-6132-7,NDC,,,facility,both,79,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,100,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,30,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,60505-6132-7,NDC,,,facility,both,289,ML,,625,437.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,45,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,67457-469-10,NDC,,,facility,both,29,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,31,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,67457-469-10,NDC,,,facility,both,72,ML,,312,218.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,67457-469-10,NDC,,,facility,both,65,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,16,ML,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-172-21,NDC,,,facility,both,374,ML,,220,154,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,132,ML,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-172-21,NDC,,,facility,both,397,ML,,233,163.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-172-21,NDC,,,facility,both,64,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,67457-469-10,NDC,,,facility,both,28,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-172-21,NDC,,,facility,both,359,ML,,211,147.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,43,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,22,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-172-21,NDC,,,facility,both,149,ML,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,60505-6132-7,NDC,,,facility,both,371,ML,,802,561.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,58,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,81,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,57,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,60505-6132-7,NDC,,,facility,both,19,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,69,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,60505-6132-7,NDC,,,facility,both,327,ML,,707,494.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,137,ML,,121,84.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,60505-6132-7,NDC,,,facility,both,70,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,33,ML,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,60505-6132-7,NDC,,,facility,both,65,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-171-11,NDC,,,facility,both,100,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-172-21,NDC,,,facility,both,314,ML,,185,129.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,60505-6132-7,NDC,,,facility,both,47,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,60505-6132-7,NDC,,,facility,both,330,ML,,713,499.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,60505-6132-7,NDC,,,facility,both,321,ML,,694,485.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,60505-6132-7,NDC,,,facility,both,153,ML,,331,231.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,21,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,88,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,17,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-171-11,NDC,,,facility,both,14,ML,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-171-11,NDC,,,facility,both,45,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,67457-469-10,NDC,,,facility,both,24,ML,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-172-21,NDC,,,facility,both,49,ML,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-20,NDC,,,facility,both,179,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-172-21,NDC,,,facility,both,41,ML,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,61703-363-22,NDC,,,facility,both,200,ML,,415,290.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,60505-6132-7,NDC,,,facility,both,388,ML,,839,587.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,75,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,67457-469-10,NDC,,,facility,both,76,ML,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,60505-6132-7,NDC,,,facility,both,351,ML,,759,531.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,67457-469-10,NDC,,,facility,both,95,ML,,411,287.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,60505-6132-7,NDC,,,facility,both,36,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-20,NDC,,,facility,both,200,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,60505-6132-7,NDC,,,facility,both,53,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-172-21,NDC,,,facility,both,26,ML,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-172-21,NDC,,,facility,both,135,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-172-21,NDC,,,facility,both,80,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,66,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-172-21,NDC,,,facility,both,44,ML,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,72,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-172-21,NDC,,,facility,both,366,ML,,215,150.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,18,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-172-21,NDC,,,facility,both,400,ML,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,67457-469-10,NDC,,,facility,both,88,ML,,381,266.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,89,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-171-11,NDC,,,facility,both,24,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,60505-6132-7,NDC,,,facility,both,136,ML,,294,205.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,28,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,60505-6132-7,NDC,,,facility,both,87,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,91,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,34,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,60505-6132-7,NDC,,,facility,both,393,ML,,849,594.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,60505-6132-7,NDC,,,facility,both,188,ML,,407,284.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,60505-6132-7,NDC,,,facility,both,381,ML,,823,576.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,69,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,87,ML,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,60505-6132-7,NDC,,,facility,both,56,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,60505-6132-7,NDC,,,facility,both,58,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,152,ML,,134,93.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,48,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,12,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,67457-469-10,NDC,,,facility,both,14,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,60505-6132-7,NDC,,,facility,both,391,ML,,845,591.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,11,ML,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-20,NDC,,,facility,both,600,ML,,353,247.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,67457-469-10,NDC,,,facility,both,33,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,67457-469-10,NDC,,,facility,both,200,ML,,864,604.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-172-21,NDC,,,facility,both,156,ML,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,60505-6132-7,NDC,,,facility,both,335,ML,,724,506.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,60505-6132-7,NDC,,,facility,both,364,ML,,787,550.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,60505-6132-7,NDC,,,facility,both,66,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-20,NDC,,,facility,both,21,ML,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,45,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,60505-6132-7,NDC,,,facility,both,5,ML,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,98,ML,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,16714-728-01,NDC,,,facility,both,200,ML,,743,520.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-172-21,NDC,,,facility,both,332,ML,,195,136.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,44,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,34,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-171-11,NDC,,,facility,both,55,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,14,ML,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,60505-6132-7,NDC,,,facility,both,340,ML,,735,514.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,79,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,60505-6132-7,NDC,,,facility,both,9,ML,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,60505-6132-7,NDC,,,facility,both,29,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-172-21,NDC,,,facility,both,347,ML,,204,142.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,16714-728-01,NDC,,,facility,both,400,ML,,1485,1039.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,62,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,67457-469-10,NDC,,,facility,both,35,ML,,152,106.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-101-10,NDC,,,facility,both,147,ML,,130,91,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,40327,CDM,J9263,HCPCS,71288-171-11,NDC,,,facility,both,62,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"HYALURONATE SOD, CROSS-LINKED 30 MG/3 ML IATC SYRG",40342,CDM,J7326,HCPCS,8754130091,NDC,,,facility,both,1,ML,,2827,1978.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"HYALURONATE SOD, CROSS-LINKED 30 MG/3 ML IATC SYRG",40342,CDM,J7326,HCPCS,5001695711,NDC,,,facility,both,1,ML,,3174,2221.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"HYALURONATE SOD, CROSS-LINKED 30 MG/3 ML IATC SYRG",40342,CDM,J7326,HCPCS,8754130091,NDC,,,facility,both,2,ML,,5653,3957.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC PET IMAGE SKULL-THIGH,40400002,CDM,404,RC,78812,HCPCS,,,facility,both,,,,5996,4197.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PET IMAGE FULL BODY,40400003,CDM,404,RC,78813,HCPCS,,,facility,both,,,,6896,4827.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PET IMAGE W/CT SKULL-THIGH,40400004,CDM,404,RC,78815,HCPCS,,,facility,both,,,,5416,3791.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PET IMAGE W/CT FULL BODY,40400005,CDM,404,RC,78816,HCPCS,,,facility,both,,,,5416,3791.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PET W/CT FOR ATTENUATION CORRECTION/ANATOMICAL LOCALIZATION IMAGING LIMITED AREA,40400006,CDM,404,RC,78814,HCPCS,,,facility,both,,,,4513,3159.1,,,,,,,,,,,,,Gross Charge Type: Central
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,40688,CDM,1,RC,A9541,HCPCS,45567-0030-1,NDC,facility,both,1,EA,,483,338.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,40688,CDM,1,RC,A9520,HCPCS,65857-400-01,NDC,facility,both,1,EA,,1080,756,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,40688,CDM,1,RC,A9562,HCPCS,65174-660-30,NDC,facility,both,1,EA,,1046,732.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,40688,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,17,EA,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,40688,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,16,EA,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,40688,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,1,EA,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,40688,CDM,1,RC,A9557,HCPCS,65857-100-30,NDC,facility,both,1,EA,,4113,2879.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TECHNETIUM TC 99M SESTAMIBI - CARDIOLITE,40688,CDM,250,RC,A9500,HCPCS,65857-500-20,NDC,facility,both,1,EA,,214,149.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,40688,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,14,EA,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,40688,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,16,EA,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,40688,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,1,EA,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,40688,CDM,1,RC,A9520,HCPCS,65857-400-01,NDC,facility,both,4,EA,,3540,2478,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,40688,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,1,EA,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,40688,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,30,EA,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,40688,CDM,1,RC,A9560,HCPCS,69945-068-20,NDC,facility,both,2,EA,,886,620.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,40688,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,15,EA,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,40688,CDM,250,RC,A9520,HCPCS,65857-400-01,NDC,facility,both,1,EA,,1080,756,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,40688,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,1,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,40688,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,3,EA,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,40688,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,1,EA,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,40688,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,2,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,40688,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,15,EA,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,40688,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,1,EA,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,40688,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,15,EA,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,40688,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,1,EA,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,40688,CDM,1,RC,A9538,HCPCS,45567-0060-1,NDC,facility,both,1,EA,,255,178.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,40688,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,15,EA,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,40688,CDM,1,RC,A9567,HCPCS,65174-288-30,NDC,facility,both,1,EA,,522,365.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,40688,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,17,EA,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,40688,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,1,EA,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,40688,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,40688,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,1,EA,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,40688,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,1,EA,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,40688,CDM,1,RC,A9520,HCPCS,65857-400-01,NDC,facility,both,1,EA,,1770,1239,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,40688,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,16,EA,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,40688,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,14,EA,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,40688,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,12,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,40688,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,1,EA,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,40688,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,3,EA,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,40688,CDM,1,RC,A9520,HCPCS,65857-400-01,NDC,facility,both,1,EA,,3540,2478,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,40688,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,21,EA,,108,75.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,40688,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,3,EA,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,40688,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,16,EA,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,40688,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,17,EA,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,40688,CDM,1,RC,A9541,HCPCS,45567-0030-1,NDC,facility,both,1,EA,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,40688,CDM,1,RC,A9503,HCPCS,65174-660-30,NDC,facility,both,1,EA,,210,147,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,40688,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,40688,CDM,250,RC,A9541,HCPCS,45567-0030-1,NDC,facility,both,1,EA,,483,338.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,40688,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,1,EA,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,40688,CDM,1,RC,A9541,HCPCS,45567-0030-1,NDC,facility,both,1,EA,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,40688,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,3,EA,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,40688,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,40688,CDM,1,RC,A9569,HCPCS,99999-0407-05,NDC,facility,both,1,EA,,5381,3766.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,40688,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,1,EA,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,40688,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,1,EA,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,40688,CDM,1,RC,A9537,HCPCS,0270-0083-20,NDC,facility,both,1,EA,,237,165.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,40688,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,1,EA,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,40688,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,14,EA,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,40688,CDM,1,RC,A9520,HCPCS,65857-400-01,NDC,facility,both,2,EA,,1770,1239,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,40688,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,15,EA,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,40688,CDM,250,RC,A9537,HCPCS,0270-0083-20,NDC,facility,both,1,EA,,237,165.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TECHNETIUM TC 99M SESTAMIBI - CARDIOLITE,40688,CDM,1,RC,A9500,HCPCS,65857-500-20,NDC,facility,both,1,EA,,214,149.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,40688,CDM,1,RC,A9541,HCPCS,45567-0030-1,NDC,facility,both,1,EA,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,40688,CDM,250,RC,A9503,HCPCS,65174-660-30,NDC,facility,both,1,EA,,210,147,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,40688,CDM,1,RC,A9560,HCPCS,69945-068-20,NDC,facility,both,1,EA,,443,310.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,40688,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,14,EA,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,40688,CDM,1,RC,A9567,HCPCS,99999-0400-16,NDC,facility,both,1,EA,,522,365.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,40688,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,9,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,40688,CDM,1,RC,A9540,HCPCS,65174-270-30,NDC,facility,both,1,EA,,642,449.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,40688,CDM,1,RC,A9541,HCPCS,45567-0030-1,NDC,facility,both,1,EA,,108,75.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PNEUMOC 20-VAL CONJ-DIP CR(PF) 0.5 ML IM SYRG,40805,CDM,90677,HCPCS,0005-2000-02,NDC,,,facility,both,1,ML,,1003,702.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PNEUMOC 20-VAL CONJ-DIP CR(PF) 0.5 ML IM SYRG,40805,CDM,90677,HCPCS,0005-2000-01,NDC,,,facility,both,1,ML,,2005,1403.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PNEUMOC 20-VAL CONJ-DIP CR(PF) 0.5 ML IM SYRG,40805,CDM,90677,HCPCS,0005-2000-01,NDC,,,facility,both,2,ML,,2005,1403.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PNEUMOC 20-VAL CONJ-DIP CR(PF) 0.5 ML IM SYRG,40805,CDM,90677,HCPCS,0005-2000-02,NDC,,,facility,both,1,ML,,955,668.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PNEUMOC 20-VAL CONJ-DIP CR(PF) 0.5 ML IM SYRG,40805,CDM,90677,HCPCS,0005-2000-01,NDC,,,facility,both,1,ML,,1003,702.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PNEUMOC 20-VAL CONJ-DIP CR(PF) 0.5 ML IM SYRG,40805,CDM,90677,HCPCS,0005-2000-10,NDC,,,facility,both,1,ML,,926,648.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PNEUMOC 20-VAL CONJ-DIP CR(PF) 0.5 ML IM SYRG,40805,CDM,90677,HCPCS,0005-2000-10,NDC,,,facility,both,1,ML,,972,680.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PNEUMOC 20-VAL CONJ-DIP CR(PF) 0.5 ML IM SYRG,40805,CDM,90677,HCPCS,0005-2000-01,NDC,,,facility,both,1,ML,,955,668.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIPH,PERTUS(ACEL),TET,POLIO(PF)(KINRIX) 25 LF-58 MCG-10 LF/0.5 ML IM SYRINGE",40955,CDM,90696,HCPCS,58160-812-52,NDC,,,facility,both,1,ML,,318,222.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIPH,PERTUS(ACEL),TET,POLIO(PF)(KINRIX) 25 LF-58 MCG-10 LF/0.5 ML IM SYRINGE",40955,CDM,90696,HCPCS,58160-812-43,NDC,,,facility,both,1,ML,,309,216.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIPH,PERTUS(ACEL),TET,POLIO(PF)(KINRIX) 25 LF-58 MCG-10 LF/0.5 ML IM SYRINGE",40955,CDM,90696,HCPCS,0006-4171-01,NDC,,,facility,both,1,EA,,776,543.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIPH,PERTUS(ACEL),TET,POLIO(PF)(KINRIX) 25 LF-58 MCG-10 LF/0.5 ML IM SYRINGE",40955,CDM,90696,HCPCS,58160-812-43,NDC,,,facility,both,1,ML,,318,222.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIPH,PERTUS(ACEL),TET,POLIO(PF)(KINRIX) 25 LF-58 MCG-10 LF/0.5 ML IM SYRINGE",40955,CDM,90696,HCPCS,58160-812-52,NDC,,,facility,both,1,ML,,309,216.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"HIB CONJ-TET,COMPNT 2 OF 2(PF) 10 MCG/0.5 ML IM SOLR",40956,CDM,90698,HCPCS,49281-548-58,NDC,,,facility,both,1,EA,,456,319.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIP-PERT(A)-TET-POLIO-HIB (PF) 15LF-20MCG-5LF- 62 DU/0.5 ML IM KIT,40956,CDM,90698,HCPCS,49281-511-05,NDC,,,facility,both,1,EA,,493,345.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIP-PERT(A)-TET-POLIO-HIB (PF) 15LF-20MCG-5LF- 62 DU/0.5 ML IM KIT,40956,CDM,90698,HCPCS,49281-511-05,NDC,,,facility,both,1,EA,,516,361.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"HIB CONJ-TET,COMPNT 2 OF 2(PF) 10 MCG/0.5 ML IM SOLR",40956,CDM,90698,HCPCS,49281-545-15,NDC,,,facility,both,1,EA,,456,319.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"HIB CONJ-TET,COMPNT 2 OF 2(PF) 10 MCG/0.5 ML IM SOLR",40956,CDM,90698,HCPCS,49281-544-58,NDC,,,facility,both,1,EA,,493,345.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIP,PER(A)TET-HEPB-POL-HIB(PF) 15 UNIT-5 UNIT- 10 MCG/0.5 ML IM SYRG",40956,CDM,90698,HCPCS,49281-561-01,NDC,,,facility,both,1,ML,,421,294.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"HIB CONJ-TET,COMPNT 2 OF 2(PF) 10 MCG/0.5 ML IM SOLR",40956,CDM,90698,HCPCS,49281-544-58,NDC,,,facility,both,1,EA,,516,361.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"HIB CONJ-TET,COMPNT 2 OF 2(PF) 10 MCG/0.5 ML IM SOLR",40956,CDM,90698,HCPCS,49281-544-58,NDC,,,facility,both,1,EA,,516,361.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIP,PER(A)TET-HEPB-POL-HIB(PF) 15 UNIT-5 UNIT- 10 MCG/0.5 ML IM SYRG",40956,CDM,90698,HCPCS,49281-561-01,NDC,,,facility,both,1,ML,,421,294.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIP-PERT(A)-TET-POLIO-HIB (PF) 15LF-20MCG-5LF- 62 DU/0.5 ML IM KIT,40956,CDM,90698,HCPCS,49281-511-05,NDC,,,facility,both,1,EA,,516,361.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"HIB CONJ-TET,COMPNT 2 OF 2(PF) 10 MCG/0.5 ML IM SOLR",40956,CDM,90698,HCPCS,49281-548-58,NDC,,,facility,both,1,EA,,456,319.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC VENT MGMT INPAT INIT DAY,41000001,CDM,410,RC,94002,HCPCS,,,facility,both,,,,2919,2043.3,,,,,,,,,,,,,Gross Charge Type: Central
HC VENT MGMT INPAT SUBQ DAY,41000002,CDM,410,RC,94003,HCPCS,,,facility,both,,,,2919,2043.3,,,,,,,,,,,,,Gross Charge Type: Central
HC SURFACTANT ADMIN THRU TUBE,41000003,CDM,410,RC,94610,HCPCS,,,facility,both,,,,277,193.9,,,,,,,,,,,,,Gross Charge Type: Central
HC INHALAT THERAPY TREATMENT,41000004,CDM,410,RC,94640,HCPCS,,,facility,both,,,,247,172.9,,,,,,,,,,,,,Gross Charge Type: Central
HC AEROSOL INHALATION TREATMENT,41000005,CDM,410,RC,94642,HCPCS,,,facility,both,,,,247,172.9,,,,,,,,,,,,,Gross Charge Type: Central
HC INHALAT TX CONTINUOUS 1ST HOUR,41000006,CDM,410,RC,94644,HCPCS,,,facility,both,,,,194,135.8,,,,,,,,,,,,,Gross Charge Type: Central
HC INHALAT TX CONTINUOUS EA ADDL HR,41000007,CDM,410,RC,94645,HCPCS,,,facility,both,,,,141,98.7,,,,,,,,,,,,,Gross Charge Type: Central
HC CPAP INITIATION AND MGMT DAILY,41000008,CDM,410,RC,94660,HCPCS,,,facility,both,,,,902,631.4,,,,,,,,,,,,,Gross Charge Type: Central
EVALUATE PT USE OF INHALER,41000009,CDM,410,RC,94664,HCPCS,,,facility,both,,,,247,172.9,,,,,,,,,,,,,Gross Charge Type: Central
HC MANIP CHEST WALL INITIAL,41000010,CDM,410,RC,94667,HCPCS,,,facility,both,,,,247,172.9,,,,,,,,,,,,,Gross Charge Type: Central
HC MANIP CHEST WALL SUBSQ,41000011,CDM,410,RC,94668,HCPCS,,,facility,both,,,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Central
BEHAV CHNG SMOKING > 10 MIN,41000012,CDM,942,RC,99407,HCPCS,,,facility,both,,,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Central
HC NEWBORN RESUSCITATION,41000013,CDM,410,RC,99465,HCPCS,,,facility,both,,,,628,439.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PULM THERAPY 1-1 EA 15 MIN,41000014,CDM,410,RC,G0237,HCPCS,,,facility,both,,,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PULM REHAB GROUP,41000015,CDM,410,RC,G0239,HCPCS,,,facility,both,,,,315,220.5,,,,,,,,,,,,,Gross Charge Type: Central
HC HIGH FREQ VENT INITIAL,41000016,CDM,410,RC,94002,HCPCS,,,facility,both,,,,5564,3894.8,,,,,,,,,,,,,Gross Charge Type: Central
HC HIGH FREQ VENT SUBSEQUENT,41000017,CDM,410,RC,94003,HCPCS,,,facility,both,,,,5564,3894.8,,,,,,,,,,,,,Gross Charge Type: Central
HC MECHANICAL CHEST WALL OSCILLATION,41000021,CDM,410,RC,94669,HCPCS,,,facility,both,,,,855,598.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PHYS/QHP SVS OP PULM RHAB W/O CONT OXIMETRY MONITORING PER SESSION,41000022,CDM,410,RC,94625,HCPCS,,,facility,both,,,,317,221.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PHYS/QHP SVCS OP PULM REHAB W/CONT OXIMTRY MONITORING PER SESSION,41000023,CDM,410,RC,94626,HCPCS,,,facility,both,,,,317,221.9,,,,,,,,,,,,,Gross Charge Type: Central
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,43598-305-62,NDC,,,facility,both,67,EA,,162,113.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,72485-201-01,NDC,,,facility,both,71,EA,,443,310.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,0143-9606-01,NDC,,,facility,both,145,EA,,627,438.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,0143-9606-01,NDC,,,facility,both,83,EA,,101,70.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,72485-201-01,NDC,,,facility,both,155,EA,,2195,1536.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,72485-201-01,NDC,,,facility,both,43,EA,,266,186.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,0143-9606-01,NDC,,,facility,both,117,EA,,503,352.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,72485-201-01,NDC,,,facility,both,3,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,0143-9606-01,NDC,,,facility,both,57,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,72485-201-01,NDC,,,facility,both,118,EA,,1674,1171.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,0143-9606-01,NDC,,,facility,both,71,EA,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,72485-201-01,NDC,,,facility,both,59,EA,,369,258.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,0143-9606-01,NDC,,,facility,both,55,EA,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,0143-9606-01,NDC,,,facility,both,145,EA,,332,232.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,72485-201-01,NDC,,,facility,both,45,EA,,282,197.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,72485-201-01,NDC,,,facility,both,50,EA,,309,216.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,0143-9606-01,NDC,,,facility,both,150,EA,,344,240.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,72485-201-01,NDC,,,facility,both,145,EA,,2057,1439.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,72485-201-01,NDC,,,facility,both,82,EA,,508,355.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,72485-201-01,NDC,,,facility,both,57,EA,,356,249.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,72485-201-01,NDC,,,facility,both,143,EA,,2025,1417.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,72485-201-01,NDC,,,facility,both,67,EA,,416,291.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,0143-9606-01,NDC,,,facility,both,155,EA,,668,467.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,0143-9606-01,NDC,,,facility,both,118,EA,,509,356.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,0143-9606-01,NDC,,,facility,both,141,EA,,323,226.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,0143-9606-01,NDC,,,facility,both,5,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,16729-306-10,NDC,,,facility,both,157,EA,,2231,1561.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,0143-9606-01,NDC,,,facility,both,29,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,0143-9606-01,NDC,,,facility,both,3,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,0143-9606-01,NDC,,,facility,both,113,EA,,259,181.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,72485-201-01,NDC,,,facility,both,97,EA,,1371,959.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,72485-201-01,NDC,,,facility,both,29,EA,,180,126,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,43598-305-62,NDC,,,facility,both,71,EA,,610,427,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,0143-9606-01,NDC,,,facility,both,55,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,0143-9606-01,NDC,,,facility,both,87,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,0143-9606-01,NDC,,,facility,both,118,EA,,510,357,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,16729-306-10,NDC,,,facility,both,141,EA,,1993,1395.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,72485-201-01,NDC,,,facility,both,59,EA,,365,255.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,72485-201-01,NDC,,,facility,both,83,EA,,517,361.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,72485-201-01,NDC,,,facility,both,97,EA,,1376,963.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,43598-305-62,NDC,,,facility,both,141,EA,,1213,849.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,0143-9606-01,NDC,,,facility,both,95,EA,,218,152.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,72485-201-01,NDC,,,facility,both,55,EA,,341,238.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,43598-305-62,NDC,,,facility,both,50,EA,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,0143-9606-01,NDC,,,facility,both,129,EA,,555,388.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,0143-9606-01,NDC,,,facility,both,143,EA,,328,229.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,43598-305-62,NDC,,,facility,both,59,EA,,144,100.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,72485-201-01,NDC,,,facility,both,3,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,0143-9606-01,NDC,,,facility,both,57,EA,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,0143-9606-01,NDC,,,facility,both,97,EA,,223,156.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,43598-305-62,NDC,,,facility,both,150,EA,,1296,907.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,72485-201-01,NDC,,,facility,both,129,EA,,1823,1276.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,72485-201-01,NDC,,,facility,both,150,EA,,2131,1491.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,16729-306-10,NDC,,,facility,both,141,EA,,2003,1402.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,72485-201-01,NDC,,,facility,both,157,EA,,2231,1561.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,16729-306-10,NDC,,,facility,both,59,EA,,369,258.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,16729-306-10,NDC,,,facility,both,59,EA,,365,255.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,72485-201-01,NDC,,,facility,both,117,EA,,1653,1157.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,16729-306-10,NDC,,,facility,both,150,EA,,2131,1491.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,0143-9606-01,NDC,,,facility,both,55,EA,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,0143-9606-01,NDC,,,facility,both,45,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,0143-9606-01,NDC,,,facility,both,59,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,0143-9606-01,NDC,,,facility,both,71,EA,,163,114.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,72485-201-01,NDC,,,facility,both,42,EA,,263,184.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,0143-9606-01,NDC,,,facility,both,145,EA,,626,438.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,72485-201-01,NDC,,,facility,both,141,EA,,2003,1402.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,0143-9606-01,NDC,,,facility,both,143,EA,,618,432.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,0143-9606-01,NDC,,,facility,both,50,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,72485-201-01,NDC,,,facility,both,71,EA,,1009,706.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,43598-305-62,NDC,,,facility,both,133,EA,,1148,803.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,43598-305-62,NDC,,,facility,both,29,EA,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,72485-201-01,NDC,,,facility,both,133,EA,,1887,1320.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,16729-306-10,NDC,,,facility,both,50,EA,,309,216.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,0143-9606-01,NDC,,,facility,both,36,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,0143-9606-01,NDC,,,facility,both,82,EA,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,72485-201-01,NDC,,,facility,both,141,EA,,1993,1395.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,0143-9606-01,NDC,,,facility,both,58,EA,,249,174.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,0143-9606-01,NDC,,,facility,both,164,EA,,376,263.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,72485-201-01,NDC,,,facility,both,158,EA,,2238,1566.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,16729-306-10,NDC,,,facility,both,43,EA,,266,186.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,41086,CDM,J9025,HCPCS,0143-9606-01,NDC,,,facility,both,143,EA,,616,431.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,284,ML,,343,240.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,153,ML,,185,129.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,73,ML,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,114,ML,,138,96.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,287,ML,,348,243.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,350,ML,,424,296.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,98,ML,,119,83.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,358,ML,,433,303.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,343,ML,,415,290.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,384,ML,,465,325.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,506,ML,,612,428.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,77,ML,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,229,ML,,276,193.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,161,ML,,195,136.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,324,ML,,392,274.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,91,ML,,111,77.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,331,ML,,400,280,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,233,ML,,281,196.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,237,ML,,286,200.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,308,ML,,373,261.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,280,ML,,339,237.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,95,ML,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,293,ML,,355,248.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,45963-613-59,NDC,,,facility,both,164,ML,,236,165.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,126,ML,,152,106.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,230,ML,,278,194.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,319,ML,,386,270.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,45963-613-59,NDC,,,facility,both,171,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,258,ML,,312,218.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,0703-4766-01,NDC,,,facility,both,87,ML,,192,134.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,99,ML,,119,83.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,137,ML,,166,116.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,93,ML,,113,79.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,270,ML,,326,228.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,251,ML,,303,212.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,444,ML,,537,375.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,253,ML,,306,214.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,72,ML,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,139,ML,,168,117.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,362,ML,,438,306.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,326,ML,,394,275.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,378,ML,,458,320.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,101,ML,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,160,ML,,194,135.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,382,ML,,462,323.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,45963-613-59,NDC,,,facility,both,361,ML,,520,364,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,288,ML,,348,243.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,142,ML,,171,119.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,300,ML,,363,254.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,380,ML,,460,322,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,249,ML,,301,210.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,272,ML,,329,230.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,340,ML,,411,287.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,0703-4766-01,NDC,,,facility,both,319,ML,,701,490.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,279,ML,,337,235.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,119,ML,,144,100.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,273,ML,,331,231.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,373,ML,,451,315.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,45963-613-59,NDC,,,facility,both,138,ML,,198,138.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,291,ML,,352,246.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,164,ML,,198,138.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,62,ML,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,159,ML,,192,134.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,121,ML,,146,102.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,307,ML,,371,259.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,120,ML,,146,102.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,234,ML,,283,198.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,61,ML,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,177,ML,,214,149.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,335,ML,,405,283.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,107,ML,,129,90.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,317,ML,,383,268.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,168,ML,,203,142.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,0703-4768-01,NDC,,,facility,both,300,ML,,549,384.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,361,ML,,436,305.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,142,ML,,172,120.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,85,ML,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,296,ML,,358,250.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,999,ML,,2017,1411.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,97,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,45963-613-59,NDC,,,facility,both,288,ML,,415,290.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,133,ML,,161,112.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,167,ML,,202,141.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,88,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,288,ML,,349,244.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,129,ML,,156,109.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,265,ML,,320,224,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,137,ML,,165,115.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,200,ML,,242,169.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,222,ML,,268,187.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,154,ML,,186,130.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,81,ML,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,123,ML,,148,103.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,96,ML,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,169,ML,,204,142.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,243,ML,,294,205.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,241,ML,,291,203.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,368,ML,,445,311.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,304,ML,,368,257.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,246,ML,,297,207.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,192,ML,,232,162.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,59,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,254,ML,,307,214.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,191,ML,,231,161.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,189,ML,,228,159.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,101,ML,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,135,ML,,163,114.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,86,ML,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,280,ML,,338,236.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,45963-613-59,NDC,,,facility,both,314,ML,,452,316.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,100,ML,,121,84.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,211,ML,,255,178.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,192,ML,,233,163.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,349,ML,,422,295.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,282,ML,,341,238.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,301,ML,,364,254.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,193,ML,,233,163.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,75,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,146,ML,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,450,ML,,544,380.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,226,ML,,273,191.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,266,ML,,322,225.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,342,ML,,413,289.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,122,ML,,148,103.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,90,ML,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,227,ML,,274,191.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,364,ML,,440,308,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,148,ML,,178,124.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,41,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,170,ML,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,0703-4766-01,NDC,,,facility,both,112,ML,,247,172.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,112,ML,,136,95.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,134,ML,,162,113.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,231,ML,,280,196,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,0703-3217-01,NDC,,,facility,both,123,ML,,275,192.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,189,ML,,229,160.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,250,ML,,303,212.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,230,ML,,279,195.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,184,ML,,222,155.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,180,ML,,218,152.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,45963-613-59,NDC,,,facility,both,282,ML,,406,284.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,333,ML,,403,282.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,45963-613-59,NDC,,,facility,both,384,ML,,552,386.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,289,ML,,350,245,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,144,ML,,175,122.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,269,ML,,325,227.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,329,ML,,398,278.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,287,ML,,347,242.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,321,ML,,388,271.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,141,ML,,171,119.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,122,ML,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,45963-613-59,NDC,,,facility,both,129,ML,,186,130.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,45963-613-59,NDC,,,facility,both,82,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,305,ML,,369,258.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,128,ML,,155,108.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,111,ML,,134,93.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,126,ML,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,127,ML,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,336,ML,,407,284.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,470,ML,,569,398.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,392,ML,,474,331.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,371,ML,,449,314.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,303,ML,,367,256.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,94,ML,,113,79.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,257,ML,,311,217.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,188,ML,,227,158.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,136,ML,,165,115.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,45963-613-59,NDC,,,facility,both,300,ML,,432,302.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,104,ML,,126,88.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,286,ML,,345,241.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,352,ML,,426,298.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,163,ML,,197,137.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,60,ML,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,203,ML,,246,172.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,74,ML,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,107,ML,,130,91,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,314,ML,,379,265.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,228,ML,,275,192.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,87,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,198,ML,,240,168,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,221,ML,,267,186.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,37,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,132,ML,,160,112,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,96,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,223,ML,,270,189,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,45963-613-59,NDC,,,facility,both,87,ML,,126,88.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,174,ML,,210,147,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,207,ML,,250,175,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,208,ML,,252,176.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,45963-613-59,NDC,,,facility,both,85,ML,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,45963-613-59,NDC,,,facility,both,177,ML,,255,178.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,74,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,165,ML,,200,140,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,302,ML,,366,256.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,82,ML,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,219,ML,,265,185.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,79,ML,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,138,ML,,166,116.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,270,ML,,327,228.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,140,ML,,169,118.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,132,ML,,159,111.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,365,ML,,441,308.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,300,ML,,362,253.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,66,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,486,ML,,588,411.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,99,ML,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,89,ML,,107,74.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,89,ML,,108,75.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,0703-4766-01,NDC,,,facility,both,97,ML,,213,149.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,169,ML,,205,143.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,246,ML,,298,208.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,259,ML,,314,219.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-22,NDC,,,facility,both,61,ML,,101,70.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,131,ML,,158,110.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,71,ML,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,182,ML,,220,154,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,41089,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,345,ML,,417,291.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARSENIC TRIOXIDE 10 MG/10 ML IV SOLN,41092,CDM,J9017,HCPCS,69918-720-01,NDC,,,facility,both,5,ML,,134,93.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARSENIC TRIOXIDE 10 MG/10 ML IV SOLN,41092,CDM,J9017,HCPCS,69918-720-01,NDC,,,facility,both,15,ML,,1093,765.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARSENIC TRIOXIDE 10 MG/10 ML IV SOLN,41092,CDM,J9017,HCPCS,69918-720-01,NDC,,,facility,both,16,ML,,1175,822.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARSENIC TRIOXIDE 10 MG/10 ML IV SOLN,41092,CDM,J9017,HCPCS,69918-720-01,NDC,,,facility,both,4,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETUXIMAB 200 MG/100 ML IV SOLN,41094,CDM,J9055,HCPCS,66733-948-23,NDC,,,facility,both,10,ML,,2152,1506.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETUXIMAB 200 MG/100 ML IV SOLN,41094,CDM,J9055,HCPCS,66733-948-23,NDC,,,facility,both,5,ML,,1121,784.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETUXIMAB 200 MG/100 ML IV SOLN,41094,CDM,J9055,HCPCS,66733-948-23,NDC,,,facility,both,1,ML,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETUXIMAB 100 MG/50 ML IV SOLN,41094,CDM,J9055,HCPCS,66733-958-23,NDC,,,facility,both,120,ML,,26632,18642.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETUXIMAB 200 MG/100 ML IV SOLN,41094,CDM,J9055,HCPCS,66733-948-23,NDC,,,facility,both,2,ML,,241,168.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETUXIMAB 200 MG/100 ML IV SOLN,41094,CDM,J9055,HCPCS,66733-948-23,NDC,,,facility,both,5,ML,,488,341.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETUXIMAB 200 MG/100 ML IV SOLN,41094,CDM,J9055,HCPCS,66733-948-23,NDC,,,facility,both,9,ML,,2018,1412.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETUXIMAB 200 MG/100 ML IV SOLN,41094,CDM,J9055,HCPCS,66733-948-23,NDC,,,facility,both,8,ML,,1776,1243.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETUXIMAB 100 MG/50 ML IV SOLN,41094,CDM,J9055,HCPCS,66733-958-23,NDC,,,facility,both,100,ML,,22415,15690.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETUXIMAB 200 MG/100 ML IV SOLN,41094,CDM,J9055,HCPCS,66733-948-23,NDC,,,facility,both,3,ML,,293,205.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETUXIMAB 100 MG/50 ML IV SOLN,41094,CDM,J9055,HCPCS,66733-958-23,NDC,,,facility,both,7,ML,,676,473.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETUXIMAB 200 MG/100 ML IV SOLN,41094,CDM,J9055,HCPCS,66733-948-23,NDC,,,facility,both,5,ML,,488,341.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETUXIMAB 100 MG/50 ML IV SOLN,41094,CDM,J9055,HCPCS,66733-958-23,NDC,,,facility,both,40,ML,,8878,6214.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETUXIMAB 200 MG/100 ML IV SOLN,41094,CDM,J9055,HCPCS,66733-948-23,NDC,,,facility,both,7,ML,,676,473.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETUXIMAB 100 MG/50 ML IV SOLN,41094,CDM,J9055,HCPCS,66733-958-23,NDC,,,facility,both,100,ML,,22193,15535.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETUXIMAB 100 MG/50 ML IV SOLN,41094,CDM,J9055,HCPCS,66733-958-23,NDC,,,facility,both,60,ML,,13853,9697.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETUXIMAB 200 MG/100 ML IV SOLN,41094,CDM,J9055,HCPCS,66733-948-23,NDC,,,facility,both,1,ML,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETUXIMAB 200 MG/100 ML IV SOLN,41094,CDM,J9055,HCPCS,66733-948-23,NDC,,,facility,both,12,ML,,2664,1864.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETUXIMAB 100 MG/50 ML IV SOLN,41094,CDM,J9055,HCPCS,66733-958-23,NDC,,,facility,both,33,ML,,7324,5126.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETUXIMAB 200 MG/100 ML IV SOLN,41094,CDM,J9055,HCPCS,66733-948-23,NDC,,,facility,both,10,ML,,2220,1554,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETUXIMAB 100 MG/50 ML IV SOLN,41094,CDM,J9055,HCPCS,66733-958-23,NDC,,,facility,both,40,ML,,8966,6276.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETUXIMAB 200 MG/100 ML IV SOLN,41094,CDM,J9055,HCPCS,66733-948-23,NDC,,,facility,both,1,ML,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETUXIMAB 200 MG/100 ML IV SOLN,41094,CDM,J9055,HCPCS,66733-948-23,NDC,,,facility,both,2,ML,,234,163.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETUXIMAB 100 MG/50 ML IV SOLN,41094,CDM,J9055,HCPCS,66733-958-23,NDC,,,facility,both,60,ML,,13316,9321.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETUXIMAB 100 MG/50 ML IV SOLN,41094,CDM,J9055,HCPCS,66733-958-23,NDC,,,facility,both,2,ML,,193,135.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETUXIMAB 100 MG/50 ML IV SOLN,41094,CDM,J9055,HCPCS,66733-958-23,NDC,,,facility,both,80,ML,,17755,12428.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETUXIMAB 200 MG/100 ML IV SOLN,41094,CDM,J9055,HCPCS,66733-948-23,NDC,,,facility,both,8,ML,,772,540.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETUXIMAB 200 MG/100 ML IV SOLN,41094,CDM,J9055,HCPCS,66733-948-23,NDC,,,facility,both,8,ML,,1755,1228.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETUXIMAB 100 MG/50 ML IV SOLN,41094,CDM,J9055,HCPCS,66733-958-23,NDC,,,facility,both,60,ML,,13853,9697.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETUXIMAB 200 MG/100 ML IV SOLN,41094,CDM,J9055,HCPCS,66733-948-23,NDC,,,facility,both,7,ML,,1570,1099,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETUXIMAB 100 MG/50 ML IV SOLN,41094,CDM,J9055,HCPCS,66733-958-23,NDC,,,facility,both,80,ML,,17932,12552.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETUXIMAB 200 MG/100 ML IV SOLN,41094,CDM,J9055,HCPCS,66733-948-23,NDC,,,facility,both,2,ML,,193,135.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETUXIMAB 200 MG/100 ML IV SOLN,41094,CDM,J9055,HCPCS,66733-948-23,NDC,,,facility,both,9,ML,,1998,1398.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETUXIMAB 200 MG/100 ML IV SOLN,41094,CDM,J9055,HCPCS,66733-948-23,NDC,,,facility,both,5,ML,,1121,784.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETUXIMAB 200 MG/100 ML IV SOLN,41094,CDM,J9055,HCPCS,66733-948-23,NDC,,,facility,both,8,ML,,1794,1255.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETUXIMAB 200 MG/100 ML IV SOLN,41094,CDM,J9055,HCPCS,66733-948-23,NDC,,,facility,both,10,ML,,2309,1616.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETUXIMAB 200 MG/100 ML IV SOLN,41094,CDM,J9055,HCPCS,66733-948-23,NDC,,,facility,both,2,ML,,195,136.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETUXIMAB 100 MG/50 ML IV SOLN,41094,CDM,J9055,HCPCS,66733-958-23,NDC,,,facility,both,40,ML,,9235,6464.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETUXIMAB 100 MG/50 ML IV SOLN,41094,CDM,J9055,HCPCS,66733-958-23,NDC,,,facility,both,78,ML,,17311,12117.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETUXIMAB 100 MG/50 ML IV SOLN,41094,CDM,J9055,HCPCS,66733-958-23,NDC,,,facility,both,120,ML,,26898,18828.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETUXIMAB 200 MG/100 ML IV SOLN,41094,CDM,J9055,HCPCS,66733-948-23,NDC,,,facility,both,9,ML,,1928,1349.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETUXIMAB 100 MG/50 ML IV SOLN,41094,CDM,J9055,HCPCS,66733-958-23,NDC,,,facility,both,80,ML,,17932,12552.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETUXIMAB 200 MG/100 ML IV SOLN,41094,CDM,J9055,HCPCS,66733-948-23,NDC,,,facility,both,4,ML,,386,270.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETUXIMAB 200 MG/100 ML IV SOLN,41094,CDM,J9055,HCPCS,66733-948-23,NDC,,,facility,both,16,ML,,3551,2485.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETUXIMAB 100 MG/50 ML IV SOLN,41094,CDM,J9055,HCPCS,66733-958-23,NDC,,,facility,both,80,ML,,17755,12428.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETUXIMAB 200 MG/100 ML IV SOLN,41094,CDM,J9055,HCPCS,66733-948-23,NDC,,,facility,both,1,ML,,101,70.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETUXIMAB 200 MG/100 ML IV SOLN,41094,CDM,J9055,HCPCS,66733-948-23,NDC,,,facility,both,8,ML,,1704,1192.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETUXIMAB 100 MG/50 ML IV SOLN,41094,CDM,J9055,HCPCS,66733-958-23,NDC,,,facility,both,40,ML,,8966,6276.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETUXIMAB 100 MG/50 ML IV SOLN,41094,CDM,J9055,HCPCS,66733-958-23,NDC,,,facility,both,80,ML,,18470,12929,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETUXIMAB 200 MG/100 ML IV SOLN,41094,CDM,J9055,HCPCS,66733-948-23,NDC,,,facility,both,4,ML,,402,281.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETUXIMAB 200 MG/100 ML IV SOLN,41094,CDM,J9055,HCPCS,66733-948-23,NDC,,,facility,both,6,ML,,1386,970.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETUXIMAB 200 MG/100 ML IV SOLN,41094,CDM,J9055,HCPCS,66733-948-23,NDC,,,facility,both,10,ML,,2242,1569.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETUXIMAB 200 MG/100 ML IV SOLN,41094,CDM,J9055,HCPCS,66733-948-23,NDC,,,facility,both,9,ML,,2078,1454.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETUXIMAB 200 MG/100 ML IV SOLN,41094,CDM,J9055,HCPCS,66733-948-23,NDC,,,facility,both,3,ML,,666,466.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETUXIMAB 100 MG/50 ML IV SOLN,41094,CDM,J9055,HCPCS,66733-958-23,NDC,,,facility,both,100,ML,,22193,15535.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETUXIMAB 100 MG/50 ML IV SOLN,41094,CDM,J9055,HCPCS,66733-958-23,NDC,,,facility,both,120,ML,,27705,19393.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETUXIMAB 100 MG/50 ML IV SOLN,41094,CDM,J9055,HCPCS,66733-958-23,NDC,,,facility,both,60,ML,,13449,9414.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,0517-4300-01,NDC,,,facility,both,100,EA,,4524,3166.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,0517-4300-01,NDC,,,facility,both,150,EA,,6786,4750.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,0517-4300-01,NDC,,,facility,both,51,EA,,1004,702.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,0517-4300-01,NDC,,,facility,both,143,EA,,6447,4512.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,0517-4300-01,NDC,,,facility,both,189,EA,,8550,5985,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,68817-134-50,NDC,,,facility,both,21,EA,,399,279.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,0517-4300-01,NDC,,,facility,both,23,EA,,453,317.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,68817-134-50,NDC,,,facility,both,81,EA,,1536,1075.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,68817-134-50,NDC,,,facility,both,17,EA,,323,226.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,68817-134-50,NDC,,,facility,both,11,EA,,20857,14599.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,68817-134-50,NDC,,,facility,both,82,EA,,1565,1095.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,68817-134-50,NDC,,,facility,both,300,EA,,13083,9158.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,68817-134-50,NDC,,,facility,both,6,EA,,11377,7963.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,68817-134-50,NDC,,,facility,both,114,EA,,4972,3480.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,68817-134-50,NDC,,,facility,both,183,EA,,7981,5586.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,0517-4300-01,NDC,,,facility,both,237,EA,,10721,7504.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,0517-4300-01,NDC,,,facility,both,36,EA,,709,496.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,68817-134-50,NDC,,,facility,both,189,EA,,8243,5770.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,68817-134-50,NDC,,,facility,both,46,EA,,87220,61054,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,0517-4300-01,NDC,,,facility,both,173,EA,,7826,5478.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,68817-134-50,NDC,,,facility,both,118,EA,,512413,358689.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,0517-4300-01,NDC,,,facility,both,169,EA,,7645,5351.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,0517-4300-01,NDC,,,facility,both,57,EA,,1131,791.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,0517-4300-01,NDC,,,facility,both,188,EA,,8505,5953.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,0517-4300-01,NDC,,,facility,both,165,EA,,7464,5224.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,68817-134-50,NDC,,,facility,both,200,EA,,8722,6105.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,0517-4300-01,NDC,,,facility,both,260,EA,,11762,8233.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,68817-134-50,NDC,,,facility,both,82,EA,,156426,109498.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,0517-4300-01,NDC,,,facility,both,83,EA,,1633,1143.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,68817-134-50,NDC,,,facility,both,119,EA,,5190,3633,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,0480-3290-01,NDC,,,facility,both,200,EA,,8832,6182.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,0517-4300-01,NDC,,,facility,both,174,EA,,7871,5509.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,0517-4300-01,NDC,,,facility,both,39,EA,,768,537.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,68817-134-50,NDC,,,facility,both,127,EA,,5539,3877.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,68817-134-50,NDC,,,facility,both,68,EA,,1290,903,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,60505-6230-4,NDC,,,facility,both,179,EA,,7416,5191.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,68817-134-50,NDC,,,facility,both,189,EA,,824222,576955.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,68817-134-50,NDC,,,facility,both,35,EA,,66363,46454.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,0517-4300-01,NDC,,,facility,both,269,EA,,12169,8518.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,0517-4300-01,NDC,,,facility,both,152,EA,,6876,4813.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,68817-134-50,NDC,,,facility,both,254,EA,,11077,7753.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,0517-4300-01,NDC,,,facility,both,121,EA,,5474,3831.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,68817-134-50,NDC,,,facility,both,235,EA,,1024826,717378.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,0517-4300-01,NDC,,,facility,both,6,EA,,119,83.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,68817-134-50,NDC,,,facility,both,63,EA,,1195,836.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,68817-134-50,NDC,,,facility,both,227,EA,,9900,6930,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,68817-134-50,NDC,,,facility,both,118,EA,,5146,3602.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,68817-134-50,NDC,,,facility,both,137,EA,,5975,4182.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,0517-4300-01,NDC,,,facility,both,234,EA,,10586,7410.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,0517-4300-01,NDC,,,facility,both,63,EA,,1240,868,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,68817-134-50,NDC,,,facility,both,6,EA,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,0517-4300-01,NDC,,,facility,both,217,EA,,9794,6855.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,68817-134-50,NDC,,,facility,both,118,EA,,5125,3587.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,0517-4300-01,NDC,,,facility,both,11,EA,,217,151.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,68817-134-50,NDC,,,facility,both,66,EA,,1252,876.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,68817-134-50,NDC,,,facility,both,165,EA,,719559,503691.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,0517-4300-01,NDC,,,facility,both,79,EA,,1554,1087.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,68817-134-50,NDC,,,facility,both,217,EA,,9464,6624.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,0517-4300-01,NDC,,,facility,both,27,EA,,532,372.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,68817-134-50,NDC,,,facility,both,86,EA,,1631,1141.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,0517-4300-01,NDC,,,facility,both,194,EA,,8776,6143.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,0517-4300-01,NDC,,,facility,both,217,EA,,9817,6871.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,68817-134-50,NDC,,,facility,both,35,EA,,664,464.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,68817-134-50,NDC,,,facility,both,234,EA,,10205,7143.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,68817-134-50,NDC,,,facility,both,65,EA,,1233,863.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,0517-4300-01,NDC,,,facility,both,161,EA,,7283,5098.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,0517-4300-01,NDC,,,facility,both,177,EA,,8007,5604.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,0517-4300-01,NDC,,,facility,both,35,EA,,689,482.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,68817-134-50,NDC,,,facility,both,125,EA,,5452,3816.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,68817-134-50,NDC,,,facility,both,75,EA,,1423,996.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,0517-4300-01,NDC,,,facility,both,26,EA,,512,358.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,68817-134-50,NDC,,,facility,both,100,EA,,436097,305267.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,68817-134-50,NDC,,,facility,both,82,EA,,1555,1088.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,0517-4300-01,NDC,,,facility,both,118,EA,,5338,3736.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,68817-134-50,NDC,,,facility,both,232,EA,,10118,7082.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,68817-134-50,NDC,,,facility,both,235,EA,,10249,7174.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,68817-134-50,NDC,,,facility,both,46,EA,,873,611.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,0517-4300-01,NDC,,,facility,both,50,EA,,984,688.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,68817-134-50,NDC,,,facility,both,179,EA,,7807,5464.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,0517-4300-01,NDC,,,facility,both,164,EA,,7419,5193.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,68817-134-50,NDC,,,facility,both,194,EA,,8461,5922.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,68817-134-50,NDC,,,facility,both,200,EA,,872193,610535.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,0480-3290-01,NDC,,,facility,both,165,EA,,7287,5100.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,68817-134-50,NDC,,,facility,both,157,EA,,6847,4792.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,0517-4300-01,NDC,,,facility,both,81,EA,,3665,2565.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,0517-4300-01,NDC,,,facility,both,235,EA,,10631,7441.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,68817-134-50,NDC,,,facility,both,83,EA,,1574,1101.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,0517-4300-01,NDC,,,facility,both,82,EA,,1613,1129.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,0517-4300-01,NDC,,,facility,both,249,EA,,11264,7884.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,68817-134-50,NDC,,,facility,both,194,EA,,846027,592218.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,0517-4300-01,NDC,,,facility,both,29,EA,,571,399.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,68817-134-50,NDC,,,facility,both,43,EA,,816,571.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,0517-4300-01,NDC,,,facility,both,31,EA,,610,427,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,68817-134-50,NDC,,,facility,both,83,EA,,157374,110161.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,68817-134-50,NDC,,,facility,both,217,EA,,946329,662430.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,68817-134-50,NDC,,,facility,both,100,EA,,4361,3052.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,68817-134-50,NDC,,,facility,both,73,EA,,1385,969.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,0517-4300-01,NDC,,,facility,both,200,EA,,9048,6333.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,0480-3290-01,NDC,,,facility,both,35,EA,,672,470.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,0517-4300-01,NDC,,,facility,both,12,EA,,237,165.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,0517-4300-01,NDC,,,facility,both,19,EA,,374,261.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,68817-134-50,NDC,,,facility,both,65,EA,,123245,86271.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,0517-4300-01,NDC,,,facility,both,40,EA,,787,550.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,68817-134-50,NDC,,,facility,both,11,EA,,209,146.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,0517-4300-01,NDC,,,facility,both,66,EA,,1299,909.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,0517-4300-01,NDC,,,facility,both,48,EA,,945,661.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,68817-134-50,NDC,,,facility,both,400,EA,,17444,12210.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,0517-4300-01,NDC,,,facility,both,65,EA,,1279,895.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,68817-134-50,NDC,,,facility,both,254,EA,,1107685,775379.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,0517-4300-01,NDC,,,facility,both,83,EA,,1643,1150.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,41096,CDM,J9264,HCPCS,68817-134-50,NDC,,,facility,both,165,EA,,7196,5037.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMBROLIZUMAB 100 MG/4 ML (25 MG/ML) IV SOLN,41099,CDM,J9271,HCPCS,0006-3026-01,NDC,,,facility,both,200,ML,,24182,16927.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMBROLIZUMAB 100 MG/4 ML (25 MG/ML) IV SOLN,41099,CDM,J9271,HCPCS,0006-3026-01,NDC,,,facility,both,400,ML,,48364,33854.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMBROLIZUMAB 100 MG/4 ML (25 MG/ML) IV SOLN,41099,CDM,J9271,HCPCS,0006-3026-01,NDC,,,facility,both,100,ML,,12091,8463.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMBROLIZUMAB 100 MG/4 ML (25 MG/ML) IV SOLN,41099,CDM,J9271,HCPCS,0006-3026-01,NDC,,,facility,both,400,ML,,48363,33854.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIVOLUMAB 240 MG/24 ML IV SOLN,41102,CDM,J9299,HCPCS,0003-3756-14,NDC,,,facility,both,120,ML,,9356,6549.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIVOLUMAB 240 MG/24 ML IV SOLN,41102,CDM,J9299,HCPCS,0003-3734-13,NDC,,,facility,both,480,ML,,34738,24316.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIVOLUMAB 40 MG/4 ML IV SOLN,41102,CDM,J9299,HCPCS,0003-3772-11,NDC,,,facility,both,15,ML,,445,311.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIVOLUMAB 240 MG/24 ML IV SOLN,41102,CDM,J9299,HCPCS,0003-3774-12,NDC,,,facility,both,200,ML,,13637,9545.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIVOLUMAB 240 MG/24 ML IV SOLN,41102,CDM,J9299,HCPCS,0003-3774-12,NDC,,,facility,both,200,ML,,13638,9546.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIVOLUMAB 240 MG/24 ML IV SOLN,41102,CDM,J9299,HCPCS,0003-3756-14,NDC,,,facility,both,120,ML,,9356,6549.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIVOLUMAB 40 MG/4 ML IV SOLN,41102,CDM,J9299,HCPCS,0003-3772-11,NDC,,,facility,both,80,ML,,5455,3818.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIVOLUMAB 240 MG/24 ML IV SOLN,41102,CDM,J9299,HCPCS,0003-3774-12,NDC,,,facility,both,300,ML,,20456,14319.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIVOLUMAB 240 MG/24 ML IV SOLN,41102,CDM,J9299,HCPCS,0003-3734-13,NDC,,,facility,both,200,ML,,14474,10131.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIVOLUMAB 240 MG/24 ML IV SOLN,41102,CDM,J9299,HCPCS,0003-3774-12,NDC,,,facility,both,80,ML,,5455,3818.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIVOLUMAB 240 MG/24 ML IV SOLN,41102,CDM,J9299,HCPCS,0003-3734-13,NDC,,,facility,both,120,ML,,3776,2643.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIVOLUMAB 240 MG/24 ML IV SOLN,41102,CDM,J9299,HCPCS,0003-3734-13,NDC,,,facility,both,240,ML,,17369,12158.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIVOLUMAB 40 MG/4 ML IV SOLN,41102,CDM,J9299,HCPCS,0003-3772-11,NDC,,,facility,both,160,ML,,10910,7637,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIVOLUMAB 40 MG/4 ML IV SOLN,41102,CDM,J9299,HCPCS,0003-3772-11,NDC,,,facility,both,63,ML,,4296,3007.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIVOLUMAB 40 MG/4 ML IV SOLN,41102,CDM,J9299,HCPCS,0003-3772-11,NDC,,,facility,both,40,ML,,2728,1909.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIVOLUMAB 240 MG/24 ML IV SOLN,41102,CDM,J9299,HCPCS,0003-3734-13,NDC,,,facility,both,240,ML,,17369,12158.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIVOLUMAB 240 MG/24 ML IV SOLN,41102,CDM,J9299,HCPCS,0003-3774-12,NDC,,,facility,both,100,ML,,6819,4773.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIVOLUMAB 40 MG/4 ML IV SOLN,41102,CDM,J9299,HCPCS,0003-3772-11,NDC,,,facility,both,17,ML,,504,352.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIVOLUMAB 240 MG/24 ML IV SOLN,41102,CDM,J9299,HCPCS,0003-3774-12,NDC,,,facility,both,100,ML,,6819,4773.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIVOLUMAB 240 MG/24 ML IV SOLN,41102,CDM,J9299,HCPCS,0003-3756-14,NDC,,,facility,both,120,ML,,9356,6549.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIVOLUMAB 240 MG/24 ML IV SOLN,41102,CDM,J9299,HCPCS,0003-3774-12,NDC,,,facility,both,300,ML,,20456,14319.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIVOLUMAB 40 MG/4 ML IV SOLN,41102,CDM,J9299,HCPCS,0003-3772-11,NDC,,,facility,both,40,ML,,2728,1909.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIVOLUMAB 240 MG/24 ML IV SOLN,41102,CDM,J9299,HCPCS,0003-3734-13,NDC,,,facility,both,40,ML,,1259,881.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIVOLUMAB 40 MG/4 ML IV SOLN,41102,CDM,J9299,HCPCS,0003-3772-11,NDC,,,facility,both,65,ML,,4433,3103.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIVOLUMAB 240 MG/24 ML IV SOLN,41102,CDM,J9299,HCPCS,0003-3734-13,NDC,,,facility,both,240,ML,,17369,12158.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIVOLUMAB 240 MG/24 ML IV SOLN,41102,CDM,J9299,HCPCS,0003-3774-12,NDC,,,facility,both,35,ML,,1038,726.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIVOLUMAB 240 MG/24 ML IV SOLN,41102,CDM,J9299,HCPCS,0003-3734-13,NDC,,,facility,both,480,ML,,34737,24315.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIVOLUMAB 240 MG/24 ML IV SOLN,41102,CDM,J9299,HCPCS,0003-3756-14,NDC,,,facility,both,120,ML,,4068,2847.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIVOLUMAB 40 MG/4 ML IV SOLN,41102,CDM,J9299,HCPCS,0003-3772-11,NDC,,,facility,both,40,ML,,2727,1908.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIVOLUMAB 240 MG/24 ML IV SOLN,41102,CDM,J9299,HCPCS,0003-3734-13,NDC,,,facility,both,360,ML,,26054,18237.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIVOLUMAB 240 MG/24 ML IV SOLN,41102,CDM,J9299,HCPCS,0003-3774-12,NDC,,,facility,both,200,ML,,13637,9545.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIVOLUMAB 240 MG/24 ML IV SOLN,41102,CDM,J9299,HCPCS,0003-3756-14,NDC,,,facility,both,120,ML,,9356,6549.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIVOLUMAB 240 MG/24 ML IV SOLN,41102,CDM,J9299,HCPCS,0003-3734-13,NDC,,,facility,both,140,ML,,10132,7092.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIVOLUMAB 40 MG/4 ML IV SOLN,41102,CDM,J9299,HCPCS,0003-3772-11,NDC,,,facility,both,80,ML,,5455,3818.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIVOLUMAB 240 MG/24 ML IV SOLN,41102,CDM,J9299,HCPCS,0003-3774-12,NDC,,,facility,both,20,ML,,593,415.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIVOLUMAB 240 MG/24 ML IV SOLN,41102,CDM,J9299,HCPCS,0003-3774-12,NDC,,,facility,both,65,ML,,4433,3103.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIVOLUMAB 240 MG/24 ML IV SOLN,41102,CDM,J9299,HCPCS,0003-3756-14,NDC,,,facility,both,360,ML,,28067,19646.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CABAZITAXEL 10 MG/ML (FINAL) IV SOLN,41109,CDM,J9043,HCPCS,0024-5823-15,NDC,,,facility,both,31,ME,,17291,12103.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CABAZITAXEL 10 MG/ML (FINAL) IV SOLN,41109,CDM,J9043,HCPCS,0024-5823-15,NDC,,,facility,both,21,ME,,5093,3565.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CABAZITAXEL 10 MG/ML (FINAL) IV SOLN,41109,CDM,J9043,HCPCS,0024-5823-15,NDC,,,facility,both,60,ME,,33467,23426.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CABAZITAXEL 10 MG/ML (FINAL) IV SOLN,41109,CDM,J9043,HCPCS,0024-5823-15,NDC,,,facility,both,15,ME,,8367,5856.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CABAZITAXEL 10 MG/ML (FINAL) IV SOLN,41109,CDM,J9043,HCPCS,0024-5823-15,NDC,,,facility,both,18,ME,,4366,3056.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CABAZITAXEL 10 MG/ML (FINAL) IV SOLN,41109,CDM,J9043,HCPCS,0024-5823-15,NDC,,,facility,both,29,ME,,7033,4923.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CABAZITAXEL 10 MG/ML (FINAL) IV SOLN,41109,CDM,J9043,HCPCS,0024-5823-15,NDC,,,facility,both,39,ME,,21754,15227.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CABAZITAXEL 10 MG/ML (FINAL) IV SOLN,41109,CDM,J9043,HCPCS,0024-5823-15,NDC,,,facility,both,16,ME,,3881,2716.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CABAZITAXEL 10 MG/ML (FINAL) IV SOLN,41109,CDM,J9043,HCPCS,0024-5823-15,NDC,,,facility,both,45,ME,,10913,7639.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CABAZITAXEL 10 MG/ML (FINAL) IV SOLN,41109,CDM,J9043,HCPCS,0024-5823-15,NDC,,,facility,both,42,ME,,23427,16398.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CABAZITAXEL 10 MG/ML (FINAL) IV SOLN,41109,CDM,J9043,HCPCS,0024-5823-15,NDC,,,facility,both,44,ME,,24543,17180.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIRZEPATIDE  2.5 MG/0.5 ML SUBQ PNIJ,41413,CDM,C9399,HCPCS,0002-1506-01,NDC,,,facility,both,1,ML,,956,669.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FULVESTRANT 250 MG/5 ML IM SYRG,41482,CDM,J9395,HCPCS,63323-715-05,NDC,,,facility,both,20,ML,,2760,1932,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC CANALITH REPOSITIONING,42000001,CDM,420,RC,95992,HCPCS,,,facility,both,,,,131,91.7,,,,,,,,,,,,,Gross Charge Type: Central
TEAM CONF 1-1 NONPHYS >30 MIN,42000003,CDM,420,RC,99366,HCPCS,,,facility,both,,,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Central
HC TEAM CONF NONPHYS >30 MIN,42000004,CDM,420,RC,99368,HCPCS,,,facility,both,,,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Central
HC BIOFEEDBACK PERI/ANORECTAL/URETHRAL SPHINCTER INCL EMG/MANOMETRY 15 MIN,42000028,CDM,420,RC,90912,HCPCS,,,facility,both,,,,152,106.4,,,,,,,,,,,,,Gross Charge Type: Central
HC BIOFEEDBACK PERI/ANORECTAL/URETHRAL SPHINCTER INCL EMG/MANOMETRY EACH ADDTL 15 MIN,42000029,CDM,420,RC,90913,HCPCS,,,facility,both,,,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Central
HC THER INTERVENT COGNITIVE FUNCTION DIRECT PATIENT CONTACT INITIAL 15 MIN,42000030,CDM,420,RC,97129,HCPCS,,,facility,both,,,,392,274.4,,,,,,,,,,,,,Gross Charge Type: Central
HC THER INTERVENT COGNITIVE FUNCTION DIRECT PATIENT CONTACT EACH ADDITIONAL 15 MINUTES,42000031,CDM,420,RC,97130,HCPCS,,,facility,both,,,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Central
HC MECHANICAL TRACTION THERAPY,42100002,CDM,421,RC,97012,HCPCS,,,facility,both,,,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Central
HC ELECT STIM OTHER THAN WND CARE,42100003,CDM,421,RC,97014,HCPCS,,,facility,both,,,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Central
HC VASOPNEUMATIC DEVICE THERAPY,42100004,CDM,421,RC,97016,HCPCS,,,facility,both,,,,90,63,,,,,,,,,,,,,Gross Charge Type: Central
HC PARAFFIN BATH THERAPY,42100005,CDM,421,RC,97018,HCPCS,,,facility,both,,,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Central
HC DIATHERMY THERAPY,42100006,CDM,421,RC,97024,HCPCS,,,facility,both,,,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Central
HC INFRARED THERAPY,42100007,CDM,421,RC,97026,HCPCS,,,facility,both,,,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Central
HC ELECTRICAL STIMULATION EA 15 MIN,42100008,CDM,421,RC,97032,HCPCS,,,facility,both,,,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Central
IONTOPHORESIS EA 15 MIN,42100009,CDM,421,RC,97033,HCPCS,,,facility,both,,,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Central
HC ULTRASOUND THERAPY EA 15 MIN,42100010,CDM,421,RC,97035,HCPCS,,,facility,both,,,,169,118.3,,,,,,,,,,,,,Gross Charge Type: Central
HC THERAPEUTIC EXERCISES EA 15 MIN,42100012,CDM,421,RC,97110,HCPCS,,,facility,both,,,,139,97.3,,,,,,,,,,,,,Gross Charge Type: Central
HC NEUROMUSC REEDUCAT EA 15 MIN,42100013,CDM,421,RC,97112,HCPCS,,,facility,both,,,,175,122.5,,,,,,,,,,,,,Gross Charge Type: Central
HC AQUA THER/EXERCISES EA 15 MIN,42100014,CDM,421,RC,97113,HCPCS,,,facility,both,,,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Central
HC GAIT TRAINING EA 15 MIN,42100015,CDM,421,RC,97116,HCPCS,,,facility,both,,,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Central
HC MANUAL THERAPY EA 15 MIN,42100018,CDM,421,RC,97140,HCPCS,,,facility,both,,,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Central
HC THER ACTIVITIES 1-1 EA 15 MIN,42100019,CDM,421,RC,97530,HCPCS,,,facility,both,,,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Central
HC SENS INTEGRATION 1-1 EA 15 MIN,42100021,CDM,421,RC,97533,HCPCS,,,facility,both,,,,131,91.7,,,,,,,,,,,,,Gross Charge Type: Central
HC ADL TRAINING 1-1 EA 15 MIN,42100022,CDM,421,RC,97535,HCPCS,,,facility,both,,,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Central
REINTER TRAIN 1-1 EA 15 MIN,42100023,CDM,421,RC,97537,HCPCS,,,facility,both,,,,70,49,,,,,,,,,,,,,Gross Charge Type: Central
HC WHEELCHAIR TRAIN EA 15 MIN,42100024,CDM,421,RC,97542,HCPCS,,,facility,both,,,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Central
HC DEBRIDEMENT OPEN WOUND FIRST 20 SQ CM OR LESS,42100025,CDM,421,RC,97597,HCPCS,,,facility,both,,,,296,207.2,,,,,,,,,,,,,Gross Charge Type: Central
HC RMVL DEVITAL TISSUE ADDL 20 SQ CM,42100026,CDM,421,RC,97598,HCPCS,,,facility,both,,,,347,242.9,,,,,,,,,,,,,Gross Charge Type: Central
HC NEG PRESS WOUND THERAPY DME LESS THAN OR EQUAL TO 50 SQ CM,42100027,CDM,421,RC,97605,HCPCS,,,facility,both,,,,408,285.6,,,,,,,,,,,,,Gross Charge Type: Central
HC NEG PRESS WOUND THERAPY DME GREATER THAN 50 SQ CM,42100028,CDM,421,RC,97606,HCPCS,,,facility,both,,,,520,364,,,,,,,,,,,,,Gross Charge Type: Central
HC ORTHOTIC(S) MGMT AND TRAINING INITIAL ENCOUNTER 15 MIN,42100029,CDM,421,RC,97760,HCPCS,,,facility,both,,,,162,113.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PROSTHETIC(S) TRAINING INITIAL ENCOUNTER 15 MIN,42100030,CDM,421,RC,97761,HCPCS,,,facility,both,,,,172,120.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PHYSICAL PERFORMANCE TEST EA 15 MIN,42100033,CDM,421,RC,97750,HCPCS,,,facility,both,,,,143,100.1,,,,,,,,,,,,,Gross Charge Type: Central
HC NEEDLE INSERTION W/O INJECTION 1 OR 2 MUSCLES,42100040,CDM,421,RC,20560,HCPCS,,,facility,both,,,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Central
HC COLD LASER,42100041,CDM,421,RC,97039,HCPCS,,,facility,both,,,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Central
HC CUPPING,42100042,CDM,421,RC,97039,HCPCS,,,facility,both,,,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Central
HC ORTHOTIC/PROSTHETIC MGMT AND/OR TRAINING SUBSEQUENT ENCOUNTER 15 MIN,42100044,CDM,421,RC,97763,HCPCS,,,facility,both,,,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Central
HC NEEDLE INSERTION W/O INJECTION 3 OR MORE MUSCLES,42100046,CDM,421,RC,20561,HCPCS,,,facility,both,,,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Central
HC CAREGIVER TRAINING STRATEGIES/TECHNIQUES FACILITATE THE PATIENT FUNCTIONAL PERFORMANCE IN HOME/COMMUNITY FACE TO FACE INITIAL 30 MIN,42100048,CDM,421,RC,97550,HCPCS,,,facility,both,,,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Central
HC CAREGIVER TRAINING STRATEGIES/TECHNIQUES TO FACILITATE THE PATIENT FUNCTIONAL PERFORMANCE IN HOME/COMMUNITY FACE TO FACE EA ADDTL 15 MIN,42100049,CDM,421,RC,97551,HCPCS,,,facility,both,,,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Central
HC GROUP CAREGIVER TRAINING STRATEGIES/TECHNIQUES TO FACILITATE THE PATIENT FUNCTIONAL PERFORMANCE IN HOME/COMMUNITY FACE TO FACE W/MULTIPLE SETS OF CAREGIVERS,42100050,CDM,421,RC,97552,HCPCS,,,facility,both,,,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Central
HC GROUP THERAPEUTIC PROCEDURES,42300001,CDM,423,RC,97150,HCPCS,,,facility,both,,,,128,89.6,,,,,,,,,,,,,Gross Charge Type: Central
FERRIC CARBOXYMALTOSE (INJECTAFER) 50 MG IRON/ML IV SOLN,42339,CDM,J1439,HCPCS,0517-0650-01,NDC,,,facility,both,750,ML,,4234,2963.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FERRIC CARBOXYMALTOSE (INJECTAFER) 50 MG IRON/ML IV SOLN,42339,CDM,J1439,HCPCS,0517-0650-01,NDC,,,facility,both,750,ML,,4111,2877.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FERRIC CARBOXYMALTOSE (INJECTAFER) 50 MG IRON/ML IV SOLN,42339,CDM,J1439,HCPCS,0517-0650-01,NDC,,,facility,both,750,ML,,4446,3112.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARFILZOMIB 30 MG IV SOLR,42343,CDM,J9047,HCPCS,76075-102-01,NDC,,,facility,both,30,EA,,2645,1851.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARFILZOMIB 10 MG IV SOLR,42343,CDM,J9047,HCPCS,76075-103-01,NDC,,,facility,both,3,EA,,140,98,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARFILZOMIB 30 MG IV SOLR,42343,CDM,J9047,HCPCS,76075-102-01,NDC,,,facility,both,28,EA,,2451,1715.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARFILZOMIB 10 MG IV SOLR,42343,CDM,J9047,HCPCS,76075-103-01,NDC,,,facility,both,17,EA,,2329,1630.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARFILZOMIB 30 MG IV SOLR,42343,CDM,J9047,HCPCS,76075-102-01,NDC,,,facility,both,60,EA,,5289,3702.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARFILZOMIB 10 MG IV SOLR,42343,CDM,J9047,HCPCS,76075-103-01,NDC,,,facility,both,2,EA,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARFILZOMIB 10 MG IV SOLR,42343,CDM,J9047,HCPCS,76075-103-01,NDC,,,facility,both,8,EA,,372,260.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARFILZOMIB 60 MG IV SOLR,42343,CDM,J9047,HCPCS,76075-101-01,NDC,,,facility,both,10,EA,,407,284.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARFILZOMIB 10 MG IV SOLR,42343,CDM,J9047,HCPCS,76075-103-01,NDC,,,facility,both,14,EA,,1918,1342.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARFILZOMIB 30 MG IV SOLR,42343,CDM,J9047,HCPCS,76075-102-01,NDC,,,facility,both,2,EA,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARFILZOMIB 10 MG IV SOLR,42343,CDM,J9047,HCPCS,76075-103-01,NDC,,,facility,both,8,EA,,1096,767.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARFILZOMIB 30 MG IV SOLR,42343,CDM,J9047,HCPCS,76075-102-01,NDC,,,facility,both,3,EA,,131,91.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARFILZOMIB 60 MG IV SOLR,42343,CDM,J9047,HCPCS,76075-101-01,NDC,,,facility,both,50,EA,,4354,3047.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARFILZOMIB 10 MG IV SOLR,42343,CDM,J9047,HCPCS,76075-103-01,NDC,,,facility,both,7,EA,,959,671.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARFILZOMIB 60 MG IV SOLR,42343,CDM,J9047,HCPCS,76075-101-01,NDC,,,facility,both,58,EA,,5042,3529.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARFILZOMIB 30 MG IV SOLR,42343,CDM,J9047,HCPCS,76075-102-01,NDC,,,facility,both,5,EA,,200,140,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARFILZOMIB 30 MG IV SOLR,42343,CDM,J9047,HCPCS,76075-102-01,NDC,,,facility,both,5,EA,,192,134.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARFILZOMIB 60 MG IV SOLR,42343,CDM,J9047,HCPCS,76075-101-01,NDC,,,facility,both,117,EA,,10242,7169.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARFILZOMIB 10 MG IV SOLR,42343,CDM,J9047,HCPCS,76075-103-01,NDC,,,facility,both,6,EA,,279,195.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARFILZOMIB 30 MG IV SOLR,42343,CDM,J9047,HCPCS,76075-102-01,NDC,,,facility,both,27,EA,,2380,1666,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARFILZOMIB 60 MG IV SOLR,42343,CDM,J9047,HCPCS,76075-101-01,NDC,,,facility,both,2,EA,,108,75.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARFILZOMIB 30 MG IV SOLR,42343,CDM,J9047,HCPCS,76075-102-01,NDC,,,facility,both,27,EA,,2345,1641.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARFILZOMIB 60 MG IV SOLR,42343,CDM,J9047,HCPCS,76075-101-01,NDC,,,facility,both,140,EA,,12339,8637.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARFILZOMIB 60 MG IV SOLR,42343,CDM,J9047,HCPCS,76075-101-01,NDC,,,facility,both,60,EA,,5289,3702.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARFILZOMIB 60 MG IV SOLR,42343,CDM,J9047,HCPCS,76075-101-01,NDC,,,facility,both,120,EA,,10577,7403.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARFILZOMIB 60 MG IV SOLR,42343,CDM,J9047,HCPCS,76075-101-01,NDC,,,facility,both,3,EA,,146,102.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARFILZOMIB 10 MG IV SOLR,42343,CDM,J9047,HCPCS,76075-103-01,NDC,,,facility,both,2,EA,,274,191.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARFILZOMIB 10 MG IV SOLR,42343,CDM,J9047,HCPCS,76075-103-01,NDC,,,facility,both,10,EA,,1370,959,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARFILZOMIB 30 MG IV SOLR,42343,CDM,J9047,HCPCS,76075-102-01,NDC,,,facility,both,9,EA,,353,247.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARFILZOMIB 30 MG IV SOLR,42343,CDM,J9047,HCPCS,76075-102-01,NDC,,,facility,both,25,EA,,2204,1542.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARFILZOMIB 60 MG IV SOLR,42343,CDM,J9047,HCPCS,76075-101-01,NDC,,,facility,both,52,EA,,4531,3171.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARFILZOMIB 30 MG IV SOLR,42343,CDM,J9047,HCPCS,76075-102-01,NDC,,,facility,both,21,EA,,1834,1283.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARFILZOMIB 10 MG IV SOLR,42343,CDM,J9047,HCPCS,76075-103-01,NDC,,,facility,both,20,EA,,2740,1918,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARFILZOMIB 60 MG IV SOLR,42343,CDM,J9047,HCPCS,76075-101-01,NDC,,,facility,both,8,EA,,330,231,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARFILZOMIB 30 MG IV SOLR,42343,CDM,J9047,HCPCS,76075-102-01,NDC,,,facility,both,25,EA,,2186,1530.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARFILZOMIB 10 MG IV SOLR,42343,CDM,J9047,HCPCS,76075-103-01,NDC,,,facility,both,30,EA,,4110,2877,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARFILZOMIB 30 MG IV SOLR,42343,CDM,J9047,HCPCS,76075-102-01,NDC,,,facility,both,3,EA,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARFILZOMIB 60 MG IV SOLR,42343,CDM,J9047,HCPCS,76075-101-01,NDC,,,facility,both,40,EA,,1533,1073.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARFILZOMIB 30 MG IV SOLR,42343,CDM,J9047,HCPCS,76075-102-01,NDC,,,facility,both,60,EA,,5236,3665.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARFILZOMIB 60 MG IV SOLR,42343,CDM,J9047,HCPCS,76075-101-01,NDC,,,facility,both,60,EA,,5236,3665.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RAMUCIRUMAB 10 MG/ML IV SOLN,42347,CDM,J9308,HCPCS,0002-7678-01,NDC,,,facility,both,264,ML,,42005,29403.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RAMUCIRUMAB 10 MG/ML IV SOLN,42347,CDM,J9308,HCPCS,0002-7669-01,NDC,,,facility,both,30,ML,,4438,3106.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RAMUCIRUMAB 10 MG/ML IV SOLN,42347,CDM,J9308,HCPCS,0002-7678-01,NDC,,,facility,both,16,ML,,1029,720.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RAMUCIRUMAB 10 MG/ML IV SOLN,42347,CDM,J9308,HCPCS,0002-7669-01,NDC,,,facility,both,79,ML,,11685,8179.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RAMUCIRUMAB 10 MG/ML IV SOLN,42347,CDM,J9308,HCPCS,0002-7669-01,NDC,,,facility,both,2,ML,,129,90.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RAMUCIRUMAB 10 MG/ML IV SOLN,42347,CDM,J9308,HCPCS,0002-7678-01,NDC,,,facility,both,100,ML,,14790,10353,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RAMUCIRUMAB 10 MG/ML IV SOLN,42347,CDM,J9308,HCPCS,0002-7678-01,NDC,,,facility,both,79,ML,,11685,8179.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RAMUCIRUMAB 10 MG/ML IV SOLN,42347,CDM,J9308,HCPCS,0002-7678-01,NDC,,,facility,both,200,ML,,29581,20706.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RAMUCIRUMAB 10 MG/ML IV SOLN,42347,CDM,J9308,HCPCS,0002-7669-01,NDC,,,facility,both,1,ML,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RAMUCIRUMAB 10 MG/ML IV SOLN,42347,CDM,J9308,HCPCS,0002-7678-01,NDC,,,facility,both,100,ML,,14791,10353.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RAMUCIRUMAB 10 MG/ML IV SOLN,42347,CDM,J9308,HCPCS,0002-7669-01,NDC,,,facility,both,8,ML,,515,360.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RAMUCIRUMAB 10 MG/ML IV SOLN,42347,CDM,J9308,HCPCS,0002-7669-01,NDC,,,facility,both,40,ML,,5917,4141.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RAMUCIRUMAB 10 MG/ML IV SOLN,42347,CDM,J9308,HCPCS,0002-7669-01,NDC,,,facility,both,27,ML,,3994,2795.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RAMUCIRUMAB 10 MG/ML IV SOLN,42347,CDM,J9308,HCPCS,0002-7669-01,NDC,,,facility,both,80,ML,,11833,8283.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RAMUCIRUMAB 10 MG/ML IV SOLN,42347,CDM,J9308,HCPCS,0002-7678-01,NDC,,,facility,both,2,ML,,129,90.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RAMUCIRUMAB 10 MG/ML IV SOLN,42347,CDM,J9308,HCPCS,0002-7678-01,NDC,,,facility,both,21,ML,,1351,945.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RAMUCIRUMAB 10 MG/ML IV SOLN,42347,CDM,J9308,HCPCS,0002-7669-01,NDC,,,facility,both,20,ML,,2958,2070.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RAMUCIRUMAB 10 MG/ML IV SOLN,42347,CDM,J9308,HCPCS,0002-7669-01,NDC,,,facility,both,4,ML,,258,180.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RAMUCIRUMAB 10 MG/ML IV SOLN,42347,CDM,J9308,HCPCS,0002-7669-01,NDC,,,facility,both,10,ML,,644,450.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RAMUCIRUMAB 10 MG/ML IV SOLN,42347,CDM,J9308,HCPCS,0002-7669-01,NDC,,,facility,both,32,ML,,4733,3313.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RAMUCIRUMAB 10 MG/ML IV SOLN,42347,CDM,J9308,HCPCS,0002-7678-01,NDC,,,facility,both,98,ML,,14495,10146.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RAMUCIRUMAB 10 MG/ML IV SOLN,42347,CDM,J9308,HCPCS,0002-7669-01,NDC,,,facility,both,58,ML,,8579,6005.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RAMUCIRUMAB 10 MG/ML IV SOLN,42347,CDM,J9308,HCPCS,0002-7669-01,NDC,,,facility,both,60,ML,,8875,6212.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RAMUCIRUMAB 10 MG/ML IV SOLN,42347,CDM,J9308,HCPCS,0002-7669-01,NDC,,,facility,both,20,ML,,2959,2071.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RAMUCIRUMAB 10 MG/ML IV SOLN,42347,CDM,J9308,HCPCS,0002-7669-01,NDC,,,facility,both,13,ML,,836,585.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RAMUCIRUMAB 10 MG/ML IV SOLN,42347,CDM,J9308,HCPCS,0002-7669-01,NDC,,,facility,both,76,ML,,11241,7868.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLN (MERGE)",42351,CDM,P9047,HCPCS,64208-2512-8,NDC,,,facility,both,2,ML,,238,166.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLP",42351,CDM,P9047,HCPCS,68516-5216-8,NDC,,,facility,both,4,ML,,1614,1129.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLN (MERGE)",42351,CDM,P9047,HCPCS,13533-692-71,NDC,,,facility,both,2,ML,,427,298.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLP",42351,CDM,P9047,HCPCS,68516-5216-8,NDC,,,facility,both,4,ML,,1614,1129.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLN (MERGE)",42351,CDM,P9047,HCPCS,68516-5216-2,NDC,,,facility,both,2,ML,,427,298.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLN (MERGE)",42351,CDM,P9047,HCPCS,68516-5216-4,NDC,,,facility,both,2,ML,,427,298.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLP",42351,CDM,P9047,HCPCS,68516-5216-8,NDC,,,facility,both,2,ML,,807,564.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLN (MERGE)",42351,CDM,P9047,HCPCS,64208-2512-8,NDC,,,facility,both,4,ML,,475,332.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 1 GRAM INJ SOLR,42392,CDM,J0692,HCPCS,60505-6146-0,NDC,,,facility,both,2,EA,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 2 GRAM INJ SOLR,42392,CDM,J0692,HCPCS,60505-6147-0,NDC,,,facility,both,4,EA,,198,138.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DECITABINE 50 MG IV SOLR,42396,CDM,J0894,HCPCS,55111-556-10,NDC,,,facility,both,18,EA,,597,417.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DECITABINE 50 MG IV SOLR,42396,CDM,J0894,HCPCS,0143-9385-01,NDC,,,facility,both,12,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DECITABINE 50 MG IV SOLR,42396,CDM,J0894,HCPCS,0143-9385-01,NDC,,,facility,both,13,EA,,113,79.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DECITABINE 50 MG IV SOLR,42396,CDM,J0894,HCPCS,71288-119-20,NDC,,,facility,both,38,EA,,324,226.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DECITABINE 50 MG IV SOLR,42396,CDM,J0894,HCPCS,55111-556-10,NDC,,,facility,both,13,EA,,431,301.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DECITABINE 50 MG IV SOLR,42396,CDM,J0894,HCPCS,55111-556-10,NDC,,,facility,both,33,EA,,875,612.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DECITABINE 50 MG IV SOLR,42396,CDM,J0894,HCPCS,0143-9385-01,NDC,,,facility,both,37,EA,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DECITABINE 50 MG IV SOLR,42396,CDM,J0894,HCPCS,0143-9385-01,NDC,,,facility,both,13,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DECITABINE 50 MG IV SOLR,42396,CDM,J0894,HCPCS,55111-556-10,NDC,,,facility,both,12,EA,,173,121.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DECITABINE 50 MG IV SOLR,42396,CDM,J0894,HCPCS,0143-9385-01,NDC,,,facility,both,17,EA,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DECITABINE 50 MG IV SOLR,42396,CDM,J0894,HCPCS,55150-376-01,NDC,,,facility,both,18,EA,,465,325.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DECITABINE 50 MG IV SOLR,42396,CDM,J0894,HCPCS,0143-9385-01,NDC,,,facility,both,22,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DECITABINE 50 MG IV SOLR,42396,CDM,J0894,HCPCS,55111-556-10,NDC,,,facility,both,38,EA,,1259,881.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DECITABINE 50 MG IV SOLR,42396,CDM,J0894,HCPCS,0143-9385-01,NDC,,,facility,both,37,EA,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DECITABINE 50 MG IV SOLR,42396,CDM,J0894,HCPCS,55111-556-10,NDC,,,facility,both,41,EA,,1358,950.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DECITABINE 50 MG IV SOLR,42396,CDM,J0894,HCPCS,0143-9385-01,NDC,,,facility,both,14,EA,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DECITABINE 50 MG IV SOLR,42396,CDM,J0894,HCPCS,0143-9385-01,NDC,,,facility,both,36,EA,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DECITABINE 50 MG IV SOLR,42396,CDM,J0894,HCPCS,0143-9385-01,NDC,,,facility,both,33,EA,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DECITABINE 50 MG IV SOLR,42396,CDM,J0894,HCPCS,55111-556-10,NDC,,,facility,both,35,EA,,1160,812,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DECITABINE 50 MG IV SOLR,42396,CDM,J0894,HCPCS,55111-556-10,NDC,,,facility,both,16,EA,,530,371,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DECITABINE 50 MG IV SOLR,42396,CDM,J0894,HCPCS,0143-9385-01,NDC,,,facility,both,18,EA,,152,106.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DECITABINE 50 MG IV SOLR,42396,CDM,J0894,HCPCS,55111-556-10,NDC,,,facility,both,17,EA,,564,394.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DECITABINE 50 MG IV SOLR,42396,CDM,J0894,HCPCS,55111-556-10,NDC,,,facility,both,15,EA,,216,151.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DECITABINE 50 MG IV SOLR,42396,CDM,J0894,HCPCS,55111-556-10,NDC,,,facility,both,8,EA,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DECITABINE 50 MG IV SOLR,42396,CDM,J0894,HCPCS,0143-9385-01,NDC,,,facility,both,38,EA,,329,230.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DECITABINE 50 MG IV SOLR,42396,CDM,J0894,HCPCS,55150-376-01,NDC,,,facility,both,12,EA,,108,75.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DECITABINE 50 MG IV SOLR,42396,CDM,J0894,HCPCS,55150-376-01,NDC,,,facility,both,32,EA,,293,205.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DECITABINE 50 MG IV SOLR,42396,CDM,J0894,HCPCS,55111-556-10,NDC,,,facility,both,33,EA,,476,333.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DECITABINE 50 MG IV SOLR,42396,CDM,J0894,HCPCS,0143-9385-01,NDC,,,facility,both,35,EA,,302,211.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DECITABINE 50 MG IV SOLR,42396,CDM,J0894,HCPCS,16714-928-01,NDC,,,facility,both,41,EA,,2538,1776.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DECITABINE 50 MG IV SOLR,42396,CDM,J0894,HCPCS,55150-376-01,NDC,,,facility,both,33,EA,,302,211.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DECITABINE 50 MG IV SOLR,42396,CDM,J0894,HCPCS,55111-556-10,NDC,,,facility,both,37,EA,,533,373.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DECITABINE 50 MG IV SOLR,42396,CDM,J0894,HCPCS,0143-9385-01,NDC,,,facility,both,15,EA,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DECITABINE 50 MG IV SOLR,42396,CDM,J0894,HCPCS,0143-9385-01,NDC,,,facility,both,38,EA,,324,226.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DECITABINE 50 MG IV SOLR,42396,CDM,J0894,HCPCS,55111-556-10,NDC,,,facility,both,36,EA,,519,363.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DECITABINE 50 MG IV SOLR,42396,CDM,J0894,HCPCS,0143-9385-01,NDC,,,facility,both,37,EA,,320,224,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DECITABINE 50 MG IV SOLR,42396,CDM,J0894,HCPCS,55111-556-10,NDC,,,facility,both,14,EA,,464,324.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DECITABINE 50 MG IV SOLR,42396,CDM,J0894,HCPCS,0143-9385-01,NDC,,,facility,both,9,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DECITABINE 50 MG IV SOLR,42396,CDM,J0894,HCPCS,55111-556-10,NDC,,,facility,both,34,EA,,490,343,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DECITABINE 50 MG IV SOLR,42396,CDM,J0894,HCPCS,62856-600-01,NDC,,,facility,both,42,EA,,3967,2776.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DECITABINE 50 MG IV SOLR,42396,CDM,J0894,HCPCS,0143-9385-01,NDC,,,facility,both,12,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DECITABINE 50 MG IV SOLR,42396,CDM,J0894,HCPCS,55111-556-10,NDC,,,facility,both,13,EA,,188,131.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DECITABINE 50 MG IV SOLR,42396,CDM,J0894,HCPCS,62856-600-01,NDC,,,facility,both,18,EA,,1701,1190.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DECITABINE 50 MG IV SOLR,42396,CDM,J0894,HCPCS,0143-9385-01,NDC,,,facility,both,13,EA,,108,75.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DECITABINE 50 MG IV SOLR,42396,CDM,J0894,HCPCS,71288-119-20,NDC,,,facility,both,12,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DECITABINE 50 MG IV SOLR,42396,CDM,J0894,HCPCS,55111-556-10,NDC,,,facility,both,37,EA,,1226,858.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DECITABINE 50 MG IV SOLR,42396,CDM,J0894,HCPCS,55111-556-10,NDC,,,facility,both,32,EA,,461,322.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DECITABINE 50 MG IV SOLR,42396,CDM,J0894,HCPCS,0143-9385-01,NDC,,,facility,both,32,EA,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DECITABINE 50 MG IV SOLR,42396,CDM,J0894,HCPCS,55111-556-10,NDC,,,facility,both,42,EA,,1392,974.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DECITABINE 50 MG IV SOLR,42396,CDM,J0894,HCPCS,16714-928-01,NDC,,,facility,both,9,EA,,243,170.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DECITABINE 50 MG IV SOLR,42396,CDM,J0894,HCPCS,55150-376-01,NDC,,,facility,both,38,EA,,1009,706.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DECITABINE 50 MG IV SOLR,42396,CDM,J0894,HCPCS,55111-556-10,NDC,,,facility,both,17,EA,,245,171.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DECITABINE 50 MG IV SOLR,42396,CDM,J0894,HCPCS,0143-9385-01,NDC,,,facility,both,41,EA,,355,248.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DECITABINE 50 MG IV SOLR,42396,CDM,J0894,HCPCS,55111-556-10,NDC,,,facility,both,17,EA,,196,137.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DECITABINE 50 MG IV SOLR,42396,CDM,J0894,HCPCS,0143-9385-01,NDC,,,facility,both,28,EA,,242,169.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DECITABINE 50 MG IV SOLR,42396,CDM,J0894,HCPCS,55111-556-10,NDC,,,facility,both,50,EA,,1656,1159.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DECITABINE 50 MG IV SOLR,42396,CDM,J0894,HCPCS,55111-556-10,NDC,,,facility,both,33,EA,,1093,765.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DECITABINE 50 MG IV SOLR,42396,CDM,J0894,HCPCS,55111-556-10,NDC,,,facility,both,9,EA,,130,91,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DECITABINE 50 MG IV SOLR,42396,CDM,J0894,HCPCS,55150-376-01,NDC,,,facility,both,17,EA,,439,307.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC PT EVAL LOW COMPLEXITY 20 MIN,42400005,CDM,424,RC,97161,HCPCS,,,facility,both,,,,291,203.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PT EVAL MODERATE COMPLEXITY 30 MIN,42400006,CDM,424,RC,97162,HCPCS,,,facility,both,,,,335,234.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PT EVAL HIGH COMPLEXITY 45 MIN,42400007,CDM,424,RC,97163,HCPCS,,,facility,both,,,,384,268.8,,,,,,,,,,,,,Gross Charge Type: Central
HC RE-EVAL PT ESTABLISHED POC 20 MIN,42400008,CDM,424,RC,97164,HCPCS,,,facility,both,,,,186,130.2,,,,,,,,,,,,,Gross Charge Type: Central
HYLAN G-F 20 16 MG/2 ML IATC SYRG,42873,CDM,J7325,HCPCS,5846800903,NDC,,,facility,both,48,ML,,3781,2646.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYLAN G-F 20 16 MG/2 ML IATC SYRG,42873,CDM,J7325,HCPCS,5846800902,NDC,,,facility,both,32,ML,,2521,1764.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYLAN G-F 20 48 MG/6 ML IATC SYRG,42873,CDM,J7325,HCPCS,5846800901,NDC,,,facility,both,48,ML,,3781,2646.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYLAN G-F 20 16 MG/2 ML IATC SYRG,42873,CDM,J7325,HCPCS,5846800902,NDC,,,facility,both,16,ML,,1261,882.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYLAN G-F 20 48 MG/6 ML IATC SYRG,42873,CDM,J7325,HCPCS,5846800901,NDC,,,facility,both,16,ML,,1261,882.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYLAN G-F 20 48 MG/6 ML IATC SYRG,42873,CDM,J7325,HCPCS,5846800901,NDC,,,facility,both,32,ML,,2521,1764.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYLAN G-F 20 16 MG/2 ML IATC SYRG,42873,CDM,J7325,HCPCS,5846800903,NDC,,,facility,both,48,ML,,3781,2646.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYLAN G-F 20 16 MG/2 ML IATC SYRG,42873,CDM,J7325,HCPCS,5846800903,NDC,,,facility,both,16,ML,,1261,882.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYLAN G-F 20 16 MG/2 ML IATC SYRG,42873,CDM,J7325,HCPCS,5846800903,NDC,,,facility,both,96,ML,,7561,5292.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYLAN G-F 20 16 MG/2 ML IATC SYRG,42873,CDM,J7325,HCPCS,5846800903,NDC,,,facility,both,32,ML,,1096,767.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYLAN G-F 20 48 MG/6 ML IATC SYRG,42873,CDM,J7325,HCPCS,5846800901,NDC,,,facility,both,16,ML,,1261,882.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 0.1 MG/ML INJ SYRG,42949,CDM,J0461,HCPCS,76329-3340-1,NDC,,,facility,both,80,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 1 MG/ML IV SOLN,42949,CDM,J0461,HCPCS,0517-1001-01,NDC,,,facility,both,25,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 0.1 MG/ML INJ SYRG,42949,CDM,J0461,HCPCS,76329-3340-1,NDC,,,facility,both,25,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 0.1 MG/ML INJ SYRG,42949,CDM,J0461,HCPCS,76329-3340-1,NDC,,,facility,both,100,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 0.1 MG/ML INJ SYRG,42949,CDM,J0461,HCPCS,76329-3340-1,NDC,,,facility,both,75,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 1 MG/ML IV SOLN,42949,CDM,J0461,HCPCS,0517-1001-01,NDC,,,facility,both,50,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 1 MG/ML IV SOLN,42949,CDM,J0461,HCPCS,0517-1001-01,NDC,,,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 1 MG/ML IV SOLN,42949,CDM,J0461,HCPCS,0517-1001-01,NDC,,,facility,both,100,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 1 MG/ML IV SOLN,42949,CDM,J0461,HCPCS,0517-1001-01,NDC,,,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 1 MG/ML IV SOLN,42949,CDM,J0461,HCPCS,0517-1001-01,NDC,,,facility,both,50,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 1 MG/ML IV SOLN,42949,CDM,J0461,HCPCS,0517-1001-01,NDC,,,facility,both,50,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 1 MG/ML IV SOLN,42949,CDM,J0461,HCPCS,0517-1001-25,NDC,,,facility,both,2,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 1 MG/ML IV SOLN,42949,CDM,J0461,HCPCS,0517-1001-01,NDC,,,facility,both,1,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 1 MG/ML IV SOLN,42949,CDM,J0461,HCPCS,0517-1001-01,NDC,,,facility,both,75,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 0.1 MG/ML INJ SYRG,42949,CDM,J0461,HCPCS,76329-3340-1,NDC,,,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 0.1 MG/ML INJ SYRG,42949,CDM,J0461,HCPCS,76329-3340-1,NDC,,,facility,both,50,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 0.1 MG/ML INJ SYRG,42949,CDM,J0461,HCPCS,0409-1630-15,NDC,,,facility,both,25,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 1 MG/ML INJ SOLN,42949,CDM,J0461,HCPCS,0517-1010-25,NDC,,,facility,both,100,ML,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 1 MG/ML IV SOLN,42949,CDM,J0461,HCPCS,0517-1001-01,NDC,,,facility,both,25,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 1 MG/ML IV SOLN,42949,CDM,J0461,HCPCS,0517-1001-25,NDC,,,facility,both,50,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 1 MG/ML IV SOLN,42949,CDM,J0461,HCPCS,0517-1001-01,NDC,,,facility,both,100,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 1 MG/ML IV SOLN,42949,CDM,J0461,HCPCS,0517-1001-25,NDC,,,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 1 MG/ML IV SOLN,42949,CDM,J0461,HCPCS,16729-526-63,NDC,,,facility,both,1,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COSYNTROPIN 0.25 MG INJ SOLR,42950,CDM,J0834,HCPCS,0548-5900-00,NDC,,,facility,both,1,EA,,461,322.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COSYNTROPIN 0.25 MG INJ SOLR,42950,CDM,J0834,HCPCS,0781-3440-71,NDC,,,facility,both,1,EA,,409,286.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC APPLY FOREARM SPLINT STATIC,43100001,CDM,431,RC,29125,HCPCS,,,facility,both,,,,221,154.7,,,,,,,,,,,,,Gross Charge Type: Central
HC APPLY FOREARM SPLINT DYNAMIC,43100002,CDM,431,RC,29126,HCPCS,,,facility,both,,,,294,205.8,,,,,,,,,,,,,Gross Charge Type: Central
HC APPLY FINGER SPLINT,43100003,CDM,431,RC,29130,HCPCS,,,facility,both,,,,169,118.3,,,,,,,,,,,,,Gross Charge Type: Central
HC ULTRAVIOLET THERAPY,43100006,CDM,431,RC,97028,HCPCS,,,facility,both,,,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Central
HC FLUIDOTHERAPY,43100010,CDM,431,RC,97022,HCPCS,,,facility,both,,,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Central
RASBURICASE 1.5 MG IV SOLR,43179,CDM,J2783,HCPCS,0024-5150-11,NDC,,,facility,both,9,EA,,8637,6045.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RASBURICASE 1.5 MG IV SOLR,43179,CDM,J2783,HCPCS,0024-5154-11,NDC,,,facility,both,6,EA,,5758,4030.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RASBURICASE 1.5 MG IV SOLR,43179,CDM,J2783,HCPCS,0024-5150-10,NDC,,,facility,both,12,EA,,11515,8060.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RASBURICASE 1.5 MG IV SOLR,43179,CDM,J2783,HCPCS,0024-5150-10,NDC,,,facility,both,6,EA,,5758,4030.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RASBURICASE 1.5 MG IV SOLR,43179,CDM,J2783,HCPCS,0024-5154-11,NDC,,,facility,both,3,EA,,2879,2015.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VEDOLIZUMAB 300 MG IV SOLR,43182,CDM,J3380,HCPCS,64764-300-20,NDC,,,facility,both,300,EA,,11084,7758.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENDAMUSTINE 25 MG/ML IV SOLN,43208,CDM,J9034,HCPCS,63459-348-04,NDC,,,facility,both,160,ML,,10925,7647.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENDAMUSTINE 25 MG/ML IV SOLN,43208,CDM,J9034,HCPCS,63459-348-04,NDC,,,facility,both,183,ML,,12495,8746.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENDAMUSTINE 25 MG/ML IV SOLN,43208,CDM,J9034,HCPCS,63459-348-04,NDC,,,facility,both,57,ML,,1693,1185.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENDAMUSTINE 25 MG/ML IV SOLN,43208,CDM,J9034,HCPCS,63459-348-04,NDC,,,facility,both,300,ML,,20484,14338.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENDAMUSTINE 25 MG/ML IV SOLN,43208,CDM,J9034,HCPCS,63459-348-04,NDC,,,facility,both,95,ML,,6487,4540.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENDAMUSTINE 25 MG/ML IV SOLN,43208,CDM,J9034,HCPCS,63459-348-04,NDC,,,facility,both,173,ML,,11812,8268.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENDAMUSTINE 25 MG/ML IV SOLN,43208,CDM,J9034,HCPCS,63459-348-04,NDC,,,facility,both,125,ML,,8535,5974.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENDAMUSTINE 25 MG/ML IV SOLN,43208,CDM,J9034,HCPCS,63459-348-04,NDC,,,facility,both,128,ML,,8740,6118,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENDAMUSTINE 25 MG/ML IV SOLN,43208,CDM,J9034,HCPCS,63459-348-04,NDC,,,facility,both,143,ML,,9764,6834.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENDAMUSTINE 25 MG/ML IV SOLN,43208,CDM,J9034,HCPCS,63459-348-04,NDC,,,facility,both,200,ML,,13656,9559.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENDAMUSTINE 25 MG/ML IV SOLN,43208,CDM,J9034,HCPCS,63459-348-04,NDC,,,facility,both,40,ML,,1188,831.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENDAMUSTINE 25 MG/ML IV SOLN,43208,CDM,J9034,HCPCS,63459-348-04,NDC,,,facility,both,100,ML,,6828,4779.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENDAMUSTINE 25 MG/ML IV SOLN,43208,CDM,J9034,HCPCS,63459-348-04,NDC,,,facility,both,72,ML,,2138,1496.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENDAMUSTINE 25 MG/ML IV SOLN,43208,CDM,J9034,HCPCS,63459-348-04,NDC,,,facility,both,188,ML,,12837,8985.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,71288-118-10,NDC,,,facility,both,24,EA,,142,99.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,10019-991-01,NDC,,,facility,both,14,EA,,129,90.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,20,EA,,131,91.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,50742-484-01,NDC,,,facility,both,25,EA,,744,520.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,71288-118-10,NDC,,,facility,both,21,EA,,127,88.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,12,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,10019-991-01,NDC,,,facility,both,24,EA,,216,151.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,71288-118-10,NDC,,,facility,both,6,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,71288-118-10,NDC,,,facility,both,13,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,71288-118-10,NDC,,,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,10019-991-01,NDC,,,facility,both,11,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,10019-991-01,NDC,,,facility,both,12,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,10019-991-01,NDC,,,facility,both,16,EA,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,50742-484-01,NDC,,,facility,both,16,EA,,486,340.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,72603-270-01,NDC,,,facility,both,2,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,71288-118-10,NDC,,,facility,both,8,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,10019-991-01,NDC,,,facility,both,24,EA,,214,149.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,72603-270-01,NDC,,,facility,both,7,EA,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,50742-484-01,NDC,,,facility,both,12,EA,,129,90.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,22,EA,,142,99.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,16,EA,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,11,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,15,EA,,238,166.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,71288-118-10,NDC,,,facility,both,34,EA,,204,142.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,34,EA,,528,369.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,24,EA,,152,106.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,28,EA,,444,310.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,17,EA,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,72603-270-01,NDC,,,facility,both,19,EA,,163,114.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,25021-244-10,NDC,,,facility,both,11,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,71288-118-10,NDC,,,facility,both,12,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,15,EA,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,71288-118-10,NDC,,,facility,both,7,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,23,EA,,361,252.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,10,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,71288-118-10,NDC,,,facility,both,3,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,50742-484-01,NDC,,,facility,both,23,EA,,683,478.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,25021-244-10,NDC,,,facility,both,23,EA,,232,162.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,71288-118-10,NDC,,,facility,both,25,EA,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,25021-244-10,NDC,,,facility,both,13,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,17,EA,,268,187.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,71288-118-10,NDC,,,facility,both,23,EA,,141,98.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,71288-118-10,NDC,,,facility,both,10,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,72603-270-01,NDC,,,facility,both,21,EA,,525,367.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,22,EA,,349,244.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,71288-118-10,NDC,,,facility,both,22,EA,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,50742-484-01,NDC,,,facility,both,10,EA,,108,75.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,71288-118-10,NDC,,,facility,both,20,EA,,121,84.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,10019-991-01,NDC,,,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,72603-270-01,NDC,,,facility,both,26,EA,,652,456.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,13,EA,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,35,EA,,551,385.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,21,EA,,329,230.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,25021-244-10,NDC,,,facility,both,24,EA,,237,165.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,10019-991-01,NDC,,,facility,both,22,EA,,200,140,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,72603-270-01,NDC,,,facility,both,15,EA,,129,90.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,11,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,25021-244-10,NDC,,,facility,both,12,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,71288-118-10,NDC,,,facility,both,22,EA,,132,92.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,19,EA,,297,207.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,9,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,35,EA,,229,160.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,71288-118-10,NDC,,,facility,both,10,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,72603-270-01,NDC,,,facility,both,7,EA,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,4,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,4,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,26,EA,,412,288.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,17,EA,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,17,EA,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,72603-270-01,NDC,,,facility,both,4,EA,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,31,EA,,479,335.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,72603-270-01,NDC,,,facility,both,5,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,72603-270-01,NDC,,,facility,both,33,EA,,835,584.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,28,EA,,182,127.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,50742-484-01,NDC,,,facility,both,23,EA,,691,483.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,18,EA,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,25,EA,,396,277.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,72603-270-01,NDC,,,facility,both,22,EA,,550,385,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,10019-991-01,NDC,,,facility,both,19,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,28,EA,,183,128.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,17,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,22,EA,,341,238.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,19,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,13,EA,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,71288-118-10,NDC,,,facility,both,32,EA,,194,135.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,15,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,10019-991-01,NDC,,,facility,both,12,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,71288-118-10,NDC,,,facility,both,22,EA,,133,93.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,17,EA,,270,189,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,50742-484-01,NDC,,,facility,both,15,EA,,155,108.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,10019-991-01,NDC,,,facility,both,34,EA,,306,214.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,16,EA,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,21,EA,,136,95.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,50742-484-01,NDC,,,facility,both,11,EA,,119,83.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,50742-484-01,NDC,,,facility,both,23,EA,,698,488.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,25021-244-10,NDC,,,facility,both,10,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,25021-244-10,NDC,,,facility,both,6,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,71288-118-10,NDC,,,facility,both,29,EA,,178,124.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,71288-118-10,NDC,,,facility,both,16,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,72603-270-01,NDC,,,facility,both,13,EA,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,71288-118-10,NDC,,,facility,both,15,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,50742-484-01,NDC,,,facility,both,20,EA,,607,424.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,71288-118-10,NDC,,,facility,both,23,EA,,139,97.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,35,EA,,555,388.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,50742-484-01,NDC,,,facility,both,32,EA,,944,660.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,72603-270-01,NDC,,,facility,both,33,EA,,822,575.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,25021-244-10,NDC,,,facility,both,22,EA,,222,155.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,23,EA,,365,255.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,71288-118-10,NDC,,,facility,both,20,EA,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,9,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,31,EA,,198,138.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,10019-991-01,NDC,,,facility,both,13,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,71288-118-10,NDC,,,facility,both,35,EA,,213,149.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,7,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,50742-484-01,NDC,,,facility,both,11,EA,,121,84.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,18,EA,,282,197.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,10,EA,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,16,EA,,254,177.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,71288-118-10,NDC,,,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,50742-484-01,NDC,,,facility,both,30,EA,,903,632.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,20,EA,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,71288-118-10,NDC,,,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,26,EA,,170,119,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,9,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,32,EA,,503,352.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,5,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,71288-118-10,NDC,,,facility,both,24,EA,,144,100.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,18,EA,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,71288-118-10,NDC,,,facility,both,3,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,72603-270-01,NDC,,,facility,both,26,EA,,658,460.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,25,EA,,384,268.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,24,EA,,369,258.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,50742-484-01,NDC,,,facility,both,21,EA,,615,430.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,20,EA,,128,89.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,25021-244-10,NDC,,,facility,both,35,EA,,357,249.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,50742-484-01,NDC,,,facility,both,12,EA,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,71288-118-10,NDC,,,facility,both,16,EA,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,3,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,72603-270-01,NDC,,,facility,both,14,EA,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,50742-484-01,NDC,,,facility,both,16,EA,,168,117.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,25021-244-10,NDC,,,facility,both,19,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,71288-118-10,NDC,,,facility,both,25,EA,,150,105,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,71288-118-10,NDC,,,facility,both,11,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,25021-244-10,NDC,,,facility,both,24,EA,,240,168,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,19,EA,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,26,EA,,400,280,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,26,EA,,404,282.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,14,EA,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,10019-991-01,NDC,,,facility,both,10,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,72603-270-01,NDC,,,facility,both,28,EA,,702,491.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,50742-484-01,NDC,,,facility,both,34,EA,,1011,707.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,50742-484-01,NDC,,,facility,both,29,EA,,877,613.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,50742-484-01,NDC,,,facility,both,3,EA,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,71288-118-10,NDC,,,facility,both,28,EA,,168,117.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,50742-484-01,NDC,,,facility,both,13,EA,,139,97.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,25021-244-10,NDC,,,facility,both,29,EA,,295,206.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,10019-991-01,NDC,,,facility,both,21,EA,,186,130.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,25021-244-10,NDC,,,facility,both,16,EA,,163,114.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,72603-270-01,NDC,,,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,72603-270-01,NDC,,,facility,both,18,EA,,456,319.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,63020-049-01,NDC,,,facility,both,18,ME,,2276,1593.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,72603-270-01,NDC,,,facility,both,27,EA,,664,464.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,10019-991-01,NDC,,,facility,both,13,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,72603-270-01,NDC,,,facility,both,20,EA,,494,345.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,72603-270-01,NDC,,,facility,both,9,EA,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,71288-118-10,NDC,,,facility,both,31,EA,,185,129.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,50742-484-01,NDC,,,facility,both,12,EA,,126,88.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,72603-270-01,NDC,,,facility,both,9,EA,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,50742-484-01,NDC,,,facility,both,24,EA,,706,494.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,71288-118-10,NDC,,,facility,both,19,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,72603-270-01,NDC,,,facility,both,31,EA,,784,548.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,10019-991-01,NDC,,,facility,both,23,EA,,209,146.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,72603-270-01,NDC,,,facility,both,23,EA,,576,403.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,10019-991-01,NDC,,,facility,both,21,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,25021-244-10,NDC,,,facility,both,23,EA,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,63020-049-01,NDC,,,facility,both,35,ME,,4425,3097.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,72603-270-01,NDC,,,facility,both,15,EA,,133,93.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,33,EA,,216,151.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,20,EA,,317,221.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,25021-244-10,NDC,,,facility,both,22,EA,,219,153.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,10019-991-01,NDC,,,facility,both,23,EA,,211,147.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,72603-270-01,NDC,,,facility,both,16,EA,,138,96.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,50742-484-01,NDC,,,facility,both,5,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,7,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,9,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,23,EA,,149,104.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,25021-244-10,NDC,,,facility,both,13,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,71288-118-10,NDC,,,facility,both,33,EA,,200,140,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,10019-991-01,NDC,,,facility,both,11,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,10019-991-01,NDC,,,facility,both,25,EA,,230,161,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,71288-118-10,NDC,,,facility,both,19,EA,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,71288-118-10,NDC,,,facility,both,13,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,50742-484-01,NDC,,,facility,both,6,EA,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,72603-270-01,NDC,,,facility,both,17,EA,,146,102.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,13,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,25021-244-10,NDC,,,facility,both,11,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,18,EA,,285,199.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,50742-484-01,NDC,,,facility,both,10,EA,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,25021-244-10,NDC,,,facility,both,12,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,71288-118-10,NDC,,,facility,both,32,EA,,190,133,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,14,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,71288-118-10,NDC,,,facility,both,14,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,50742-484-01,NDC,,,facility,both,19,EA,,569,398.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,71288-118-10,NDC,,,facility,both,9,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,15,EA,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,30,EA,,195,136.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,26,EA,,408,285.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,72603-270-01,NDC,,,facility,both,28,EA,,708,495.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,72603-270-01,NDC,,,facility,both,16,EA,,405,283.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,10019-991-01,NDC,,,facility,both,22,EA,,198,138.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,25021-244-10,NDC,,,facility,both,25,EA,,255,178.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,18,EA,,278,194.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,71288-118-10,NDC,,,facility,both,26,EA,,156,109.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,20,EA,,309,216.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,50742-484-01,NDC,,,facility,both,19,EA,,196,137.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,13,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,72603-270-01,NDC,,,facility,both,20,EA,,506,354.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,10019-991-01,NDC,,,facility,both,14,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,50742-484-01,NDC,,,facility,both,22,EA,,653,457.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,71288-118-10,NDC,,,facility,both,16,EA,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,72603-270-01,NDC,,,facility,both,8,EA,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,9,EA,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,32,EA,,493,345.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,3,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,72603-270-01,NDC,,,facility,both,30,EA,,753,527.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,9,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,50742-484-01,NDC,,,facility,both,1,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,71288-118-10,NDC,,,facility,both,21,EA,,126,88.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,50742-484-01,NDC,,,facility,both,25,EA,,759,531.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,26,EA,,399,279.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,28,EA,,443,310.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,7,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,72603-270-01,NDC,,,facility,both,12,EA,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,50742-484-01,NDC,,,facility,both,14,EA,,152,106.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,22,EA,,345,241.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,72603-270-01,NDC,,,facility,both,19,EA,,481,336.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,71288-118-10,NDC,,,facility,both,27,EA,,161,112.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,50742-484-01,NDC,,,facility,both,24,EA,,714,499.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,43210,CDM,J9041,HCPCS,70710-1411-1,NDC,,,facility,both,12,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BRENTUXIMAB VEDOTIN 50 MG IV SOLR,43219,CDM,J9042,HCPCS,51144-050-01,NDC,,,facility,both,30,EA,,4557,3189.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BRENTUXIMAB VEDOTIN 50 MG IV SOLR,43219,CDM,J9042,HCPCS,51144-050-01,NDC,,,facility,both,70,EA,,24452,17116.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BRENTUXIMAB VEDOTIN 50 MG IV SOLR,43219,CDM,J9042,HCPCS,51144-050-01,NDC,,,facility,both,40,EA,,6075,4252.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BRENTUXIMAB VEDOTIN 50 MG IV SOLR,43219,CDM,J9042,HCPCS,51144-050-01,NDC,,,facility,both,180,EA,,62876,44013.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BRENTUXIMAB VEDOTIN 50 MG IV SOLR,43219,CDM,J9042,HCPCS,51144-050-01,NDC,,,facility,both,5,EA,,760,532,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BRENTUXIMAB VEDOTIN 50 MG IV SOLR,43219,CDM,J9042,HCPCS,51144-050-01,NDC,,,facility,both,20,EA,,3038,2126.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BRENTUXIMAB VEDOTIN 50 MG IV SOLR,43219,CDM,J9042,HCPCS,51144-050-01,NDC,,,facility,both,140,EA,,48903,34232.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BRENTUXIMAB VEDOTIN 50 MG IV SOLR,43219,CDM,J9042,HCPCS,51144-050-01,NDC,,,facility,both,15,EA,,2279,1595.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BRENTUXIMAB VEDOTIN 50 MG IV SOLR,43219,CDM,J9042,HCPCS,51144-050-01,NDC,,,facility,both,85,EA,,29691,20783.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BRENTUXIMAB VEDOTIN 50 MG IV SOLR,43219,CDM,J9042,HCPCS,51144-050-01,NDC,,,facility,both,10,EA,,1519,1063.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BRENTUXIMAB VEDOTIN 50 MG IV SOLR,43219,CDM,J9042,HCPCS,51144-050-01,NDC,,,facility,both,130,EA,,45410,31787,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BRENTUXIMAB VEDOTIN 50 MG IV SOLR,43219,CDM,J9042,HCPCS,51144-050-01,NDC,,,facility,both,110,EA,,38424,26896.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BRENTUXIMAB VEDOTIN 50 MG IV SOLR,43219,CDM,J9042,HCPCS,51144-050-01,NDC,,,facility,both,145,EA,,50650,35455,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BRENTUXIMAB VEDOTIN 50 MG IV SOLR,43219,CDM,J9042,HCPCS,51144-050-01,NDC,,,facility,both,95,EA,,33185,23229.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERIBULIN 0.5 MG/ML IV SOLN,43231,CDM,J9179,HCPCS,62856-389-01,NDC,,,facility,both,27,ML,,7706,5394.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERIBULIN 0.5 MG/ML IV SOLN,43231,CDM,J9179,HCPCS,62856-389-01,NDC,,,facility,both,1,ML,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERIBULIN 0.5 MG/ML IV SOLN,43231,CDM,J9179,HCPCS,62856-389-01,NDC,,,facility,both,20,ML,,5708,3995.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERIBULIN 0.5 MG/ML IV SOLN,43231,CDM,J9179,HCPCS,10019-080-01,NDC,,,facility,both,20,ML,,4692,3284.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERIBULIN 0.5 MG/ML IV SOLN,43231,CDM,J9179,HCPCS,62856-389-01,NDC,,,facility,both,5,ML,,621,434.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERIBULIN 0.5 MG/ML IV SOLN,43231,CDM,J9179,HCPCS,62856-389-01,NDC,,,facility,both,25,ML,,7135,4994.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERIBULIN 0.5 MG/ML IV SOLN,43231,CDM,J9179,HCPCS,62856-389-01,NDC,,,facility,both,29,ML,,8277,5793.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERIBULIN 0.5 MG/ML IV SOLN,43231,CDM,J9179,HCPCS,62856-389-01,NDC,,,facility,both,3,ML,,373,261.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OBINUTUZUMAB 900 MG IN NS 286 ML (STOCK DOSE),43289,CDM,J9301,HCPCS,50242-070-01,NDC,,,facility,both,90,ML,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OBINUTUZUMAB 900 MG IN NS 286 ML (STOCK DOSE),43289,CDM,J9301,HCPCS,50242-070-01,NDC,,,facility,both,10,ML,,15457,10819.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OBINUTUZUMAB 900 MG IN NS 286 ML (STOCK DOSE),43289,CDM,J9301,HCPCS,50242-070-01,NDC,,,facility,both,90,ML,,13905,9733.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OBINUTUZUMAB 900 MG IN NS 286 ML (STOCK DOSE),43289,CDM,J9301,HCPCS,50242-070-01,NDC,,,facility,both,10,ML,,672,470.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OBINUTUZUMAB 900 MG IN NS 286 ML (STOCK DOSE),43289,CDM,J9301,HCPCS,50242-070-01,NDC,,,facility,both,90,ML,,6046,4232.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OBINUTUZUMAB 900 MG IN NS 286 ML (STOCK DOSE),43289,CDM,J9301,HCPCS,50242-070-01,NDC,,,facility,both,100,ML,,15450,10815,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OBINUTUZUMAB 900 MG IN NS 286 ML (STOCK DOSE),43289,CDM,J9301,HCPCS,50242-070-01,NDC,,,facility,both,10,ML,,1545,1081.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANITUMUMAB 400 MG/20 ML (20 MG/ML) IV SOLN,43293,CDM,J9303,HCPCS,55513-956-01,NDC,,,facility,both,80,ML,,40002,28001.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANITUMUMAB 400 MG/20 ML (20 MG/ML) IV SOLN,43293,CDM,J9303,HCPCS,55513-954-01,NDC,,,facility,both,30,ML,,15001,10500.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANITUMUMAB 400 MG/20 ML (20 MG/ML) IV SOLN,43293,CDM,J9303,HCPCS,55513-954-01,NDC,,,facility,both,30,ML,,14286,10000.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANITUMUMAB 400 MG/20 ML (20 MG/ML) IV SOLN,43293,CDM,J9303,HCPCS,55513-956-01,NDC,,,facility,both,40,ML,,19049,13334.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANITUMUMAB 400 MG/20 ML (20 MG/ML) IV SOLN,43293,CDM,J9303,HCPCS,55513-956-01,NDC,,,facility,both,40,ML,,20001,14000.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANITUMUMAB 400 MG/20 ML (20 MG/ML) IV SOLN,43293,CDM,J9303,HCPCS,55513-954-01,NDC,,,facility,both,20,ML,,10001,7000.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANITUMUMAB 400 MG/20 ML (20 MG/ML) IV SOLN,43293,CDM,J9303,HCPCS,55513-954-01,NDC,,,facility,both,30,ML,,14287,10000.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANITUMUMAB 400 MG/20 ML (20 MG/ML) IV SOLN,43293,CDM,J9303,HCPCS,55513-956-01,NDC,,,facility,both,40,ML,,19048,13333.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANITUMUMAB 400 MG/20 ML (20 MG/ML) IV SOLN,43293,CDM,J9303,HCPCS,55513-956-01,NDC,,,facility,both,37,ML,,18501,12950.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANITUMUMAB 400 MG/20 ML (20 MG/ML) IV SOLN,43293,CDM,J9303,HCPCS,55513-956-01,NDC,,,facility,both,3,ML,,653,457.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMETREXED 100 MG IV SOLR,43295,CDM,J9305,HCPCS,71288-166-10,NDC,,,facility,both,35,EA,,617,431.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMETREXED 100 MG IV SOLR,43295,CDM,J9305,HCPCS,71288-166-10,NDC,,,facility,both,37,EA,,652,456.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMETREXED 100 MG IV SOLR,43295,CDM,J9305,HCPCS,71288-166-10,NDC,,,facility,both,10,EA,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMETREXED 500 MG IV SOLR,43295,CDM,J9305,HCPCS,71288-167-50,NDC,,,facility,both,49,EA,,636,445.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMETREXED 500 MG IV SOLR,43295,CDM,J9305,HCPCS,71288-167-50,NDC,,,facility,both,7,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMETREXED 100 MG IV SOLR,43295,CDM,J9305,HCPCS,71288-166-10,NDC,,,facility,both,4,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMETREXED 500 MG IV SOLR,43295,CDM,J9305,HCPCS,71288-167-50,NDC,,,facility,both,13,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMETREXED 100 MG IV SOLR,43295,CDM,J9305,HCPCS,71288-166-10,NDC,,,facility,both,108,EA,,1893,1325.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMETREXED 500 MG IV SOLR,43295,CDM,J9305,HCPCS,71288-167-50,NDC,,,facility,both,50,EA,,648,453.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMETREXED 100 MG IV SOLR,43295,CDM,J9305,HCPCS,71288-166-10,NDC,,,facility,both,30,EA,,520,364,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMETREXED 500 MG IV SOLR,43295,CDM,J9305,HCPCS,71288-167-50,NDC,,,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMETREXED 500 MG IV SOLR,43295,CDM,J9305,HCPCS,71288-167-50,NDC,,,facility,both,98,EA,,1271,889.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMETREXED 100 MG IV SOLR,43295,CDM,J9305,HCPCS,71288-166-10,NDC,,,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMETREXED 100 MG IV SOLR,43295,CDM,J9305,HCPCS,71288-166-10,NDC,,,facility,both,3,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMETREXED 100 MG IV SOLR,43295,CDM,J9305,HCPCS,71288-166-10,NDC,,,facility,both,8,EA,,133,93.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMETREXED 500 MG IV SOLR,43295,CDM,J9305,HCPCS,71288-167-50,NDC,,,facility,both,5,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMETREXED 100 MG IV SOLR,43295,CDM,J9305,HCPCS,71288-166-10,NDC,,,facility,both,4,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMETREXED 100 MG IV SOLR,43295,CDM,J9305,HCPCS,71288-166-10,NDC,,,facility,both,19,EA,,335,234.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMETREXED 100 MG IV SOLR,43295,CDM,J9305,HCPCS,71288-166-10,NDC,,,facility,both,7,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMETREXED 100 MG IV SOLR,43295,CDM,J9305,HCPCS,71288-166-10,NDC,,,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMETREXED 500 MG IV SOLR,43295,CDM,J9305,HCPCS,71288-167-50,NDC,,,facility,both,43,EA,,558,390.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMETREXED 500 MG IV SOLR,43295,CDM,J9305,HCPCS,71288-167-50,NDC,,,facility,both,99,EA,,1284,898.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMETREXED 500 MG IV SOLR,43295,CDM,J9305,HCPCS,71288-167-50,NDC,,,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMETREXED 500 MG IV SOLR,43295,CDM,J9305,HCPCS,71288-167-50,NDC,,,facility,both,41,EA,,532,372.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMETREXED 100 MG IV SOLR,43295,CDM,J9305,HCPCS,71288-166-10,NDC,,,facility,both,19,EA,,326,228.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMETREXED 500 MG IV SOLR,43295,CDM,J9305,HCPCS,71288-167-50,NDC,,,facility,both,87,EA,,1128,789.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMETREXED 100 MG IV SOLR,43295,CDM,J9305,HCPCS,71288-166-10,NDC,,,facility,both,40,EA,,696,487.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMETREXED 500 MG IV SOLR,43295,CDM,J9305,HCPCS,0002-7623-01,NDC,,,facility,both,50,EA,,11159,7811.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMETREXED 100 MG IV SOLR,43295,CDM,J9305,HCPCS,71288-166-10,NDC,,,facility,both,29,EA,,502,351.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMETREXED 100 MG IV SOLR,43295,CDM,J9305,HCPCS,71288-166-10,NDC,,,facility,both,6,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMETREXED 500 MG IV SOLR,43295,CDM,J9305,HCPCS,71288-167-50,NDC,,,facility,both,93,EA,,1206,844.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMETREXED 100 MG IV SOLR,43295,CDM,J9305,HCPCS,71288-166-10,NDC,,,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMETREXED 100 MG IV SOLR,43295,CDM,J9305,HCPCS,71288-166-10,NDC,,,facility,both,28,EA,,485,339.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMETREXED 100 MG IV SOLR,43295,CDM,J9305,HCPCS,71288-166-10,NDC,,,facility,both,13,EA,,229,160.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMETREXED 100 MG IV SOLR,43295,CDM,J9305,HCPCS,71288-166-10,NDC,,,facility,both,9,EA,,150,105,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMETREXED 500 MG IV SOLR,43295,CDM,J9305,HCPCS,71288-167-50,NDC,,,facility,both,95,EA,,1232,862.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMETREXED 100 MG IV SOLR,43295,CDM,J9305,HCPCS,71288-166-10,NDC,,,facility,both,39,EA,,687,480.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMETREXED 100 MG IV SOLR,43295,CDM,J9305,HCPCS,71288-166-10,NDC,,,facility,both,20,EA,,352,246.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMETREXED 100 MG IV SOLR,43295,CDM,J9305,HCPCS,71288-166-10,NDC,,,facility,both,26,EA,,453,317.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMETREXED 100 MG IV SOLR,43295,CDM,J9305,HCPCS,71288-166-10,NDC,,,facility,both,14,EA,,247,172.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMETREXED 100 MG IV SOLR,43295,CDM,J9305,HCPCS,71288-166-10,NDC,,,facility,both,28,EA,,493,345.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMETREXED 100 MG IV SOLR,43295,CDM,J9305,HCPCS,71288-166-10,NDC,,,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMETREXED 500 MG IV SOLR,43295,CDM,J9305,HCPCS,71288-167-50,NDC,,,facility,both,46,EA,,597,417.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMETREXED 100 MG IV SOLR,43295,CDM,J9305,HCPCS,71288-166-10,NDC,,,facility,both,20,EA,,353,247.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMETREXED 500 MG IV SOLR,43295,CDM,J9305,HCPCS,71288-167-50,NDC,,,facility,both,8,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMETREXED 500 MG IV SOLR,43295,CDM,J9305,HCPCS,71288-167-50,NDC,,,facility,both,100,EA,,1296,907.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMETREXED 100 MG IV SOLR,43295,CDM,J9305,HCPCS,0002-7640-01,NDC,,,facility,both,40,EA,,8927,6248.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMETREXED 500 MG IV SOLR,43295,CDM,J9305,HCPCS,71288-167-50,NDC,,,facility,both,4,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMETREXED 100 MG IV SOLR,43295,CDM,J9305,HCPCS,71288-166-10,NDC,,,facility,both,30,EA,,529,370.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMETREXED 100 MG IV SOLR,43295,CDM,J9305,HCPCS,71288-166-10,NDC,,,facility,both,37,EA,,643,450.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMETREXED 500 MG IV SOLR,43295,CDM,J9305,HCPCS,71288-167-50,NDC,,,facility,both,9,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMETREXED 500 MG IV SOLR,43295,CDM,J9305,HCPCS,71288-167-50,NDC,,,facility,both,42,EA,,545,381.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMETREXED 500 MG IV SOLR,43295,CDM,J9305,HCPCS,71288-167-50,NDC,,,facility,both,94,EA,,1219,853.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMETREXED 100 MG IV SOLR,43295,CDM,J9305,HCPCS,71288-166-10,NDC,,,facility,both,18,EA,,302,211.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMETREXED 100 MG IV SOLR,43295,CDM,J9305,HCPCS,71288-166-10,NDC,,,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMETREXED 100 MG IV SOLR,43295,CDM,J9305,HCPCS,71288-166-10,NDC,,,facility,both,5,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMETREXED 100 MG IV SOLR,43295,CDM,J9305,HCPCS,71288-166-10,NDC,,,facility,both,36,EA,,634,443.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMETREXED 100 MG IV SOLR,43295,CDM,J9305,HCPCS,71288-166-10,NDC,,,facility,both,40,EA,,705,493.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMETREXED 500 MG IV SOLR,43295,CDM,J9305,HCPCS,71288-167-50,NDC,,,facility,both,6,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMETREXED 100 MG IV SOLR,43295,CDM,J9305,HCPCS,71288-166-10,NDC,,,facility,both,3,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMETREXED 100 MG IV SOLR,43295,CDM,J9305,HCPCS,71288-166-10,NDC,,,facility,both,25,EA,,441,308.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB EMTANSINE 100 MG IV SOLR,43302,CDM,J9354,HCPCS,50242-088-01,NDC,,,facility,both,198,EA,,12631,8841.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB EMTANSINE 100 MG IV SOLR,43302,CDM,J9354,HCPCS,50242-088-01,NDC,,,facility,both,212,EA,,13524,9466.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB EMTANSINE 100 MG IV SOLR,43302,CDM,J9354,HCPCS,50242-088-01,NDC,,,facility,both,40,EA,,1110,777,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB EMTANSINE 100 MG IV SOLR,43302,CDM,J9354,HCPCS,50242-088-01,NDC,,,facility,both,84,EA,,2330,1631,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB EMTANSINE 100 MG IV SOLR,43302,CDM,J9354,HCPCS,50242-088-01,NDC,,,facility,both,2,EA,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB EMTANSINE 100 MG IV SOLR,43302,CDM,J9354,HCPCS,50242-088-01,NDC,,,facility,both,38,EA,,1054,737.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB EMTANSINE 100 MG IV SOLR,43302,CDM,J9354,HCPCS,50242-088-01,NDC,,,facility,both,30,EA,,833,583.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB EMTANSINE 100 MG IV SOLR,43302,CDM,J9354,HCPCS,50242-088-01,NDC,,,facility,both,188,EA,,11993,8395.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB EMTANSINE 100 MG IV SOLR,43302,CDM,J9354,HCPCS,50242-088-01,NDC,,,facility,both,316,EA,,20159,14111.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB EMTANSINE 100 MG IV SOLR,43302,CDM,J9354,HCPCS,50242-088-01,NDC,,,facility,both,52,EA,,3318,2322.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB EMTANSINE 160 MG IV SOLR,43302,CDM,J9354,HCPCS,50242-087-01,NDC,,,facility,both,4,EA,,111,77.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB EMTANSINE 100 MG IV SOLR,43302,CDM,J9354,HCPCS,50242-088-01,NDC,,,facility,both,48,EA,,1332,932.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB EMTANSINE 160 MG IV SOLR,43302,CDM,J9354,HCPCS,50242-087-01,NDC,,,facility,both,160,EA,,10207,7144.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB EMTANSINE 100 MG IV SOLR,43302,CDM,J9354,HCPCS,50242-088-01,NDC,,,facility,both,88,EA,,2441,1708.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB EMTANSINE 100 MG IV SOLR,43302,CDM,J9354,HCPCS,50242-088-01,NDC,,,facility,both,60,EA,,3828,2679.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB EMTANSINE 160 MG IV SOLR,43302,CDM,J9354,HCPCS,50242-087-01,NDC,,,facility,both,130,EA,,8293,5805.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB EMTANSINE 100 MG IV SOLR,43302,CDM,J9354,HCPCS,50242-088-01,NDC,,,facility,both,264,EA,,16842,11789.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB EMTANSINE 100 MG IV SOLR,43302,CDM,J9354,HCPCS,50242-088-01,NDC,,,facility,both,70,EA,,4466,3126.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB EMTANSINE 100 MG IV SOLR,43302,CDM,J9354,HCPCS,50242-088-01,NDC,,,facility,both,12,EA,,333,233.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB EMTANSINE 100 MG IV SOLR,43302,CDM,J9354,HCPCS,50242-088-01,NDC,,,facility,both,300,EA,,19138,13396.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB EMTANSINE 160 MG IV SOLR,43302,CDM,J9354,HCPCS,50242-087-01,NDC,,,facility,both,316,EA,,20159,14111.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB EMTANSINE 160 MG IV SOLR,43302,CDM,J9354,HCPCS,50242-087-01,NDC,,,facility,both,320,EA,,20414,14289.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB EMTANSINE 100 MG IV SOLR,43302,CDM,J9354,HCPCS,50242-088-01,NDC,,,facility,both,36,EA,,999,699.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB EMTANSINE 100 MG IV SOLR,43302,CDM,J9354,HCPCS,50242-088-01,NDC,,,facility,both,262,EA,,16714,11699.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB EMTANSINE 160 MG IV SOLR,43302,CDM,J9354,HCPCS,50242-087-01,NDC,,,facility,both,30,EA,,833,583.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB EMTANSINE 100 MG IV SOLR,43302,CDM,J9354,HCPCS,50242-088-01,NDC,,,facility,both,400,EA,,25517,17861.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB EMTANSINE 100 MG IV SOLR,43302,CDM,J9354,HCPCS,50242-088-01,NDC,,,facility,both,100,EA,,6380,4466,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB EMTANSINE 100 MG IV SOLR,43302,CDM,J9354,HCPCS,50242-088-01,NDC,,,facility,both,200,EA,,12759,8931.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC OT EVAL LOW COMPLEXITY 30 MIN,43400004,CDM,434,RC,97165,HCPCS,,,facility,both,,,,291,203.7,,,,,,,,,,,,,Gross Charge Type: Central
HC OT EVAL  MODERATE COMPLEXITY 45 MIN,43400005,CDM,434,RC,97166,HCPCS,,,facility,both,,,,335,234.5,,,,,,,,,,,,,Gross Charge Type: Central
HC OT EVAL HIGH COMPLEXITY 60 MIN,43400006,CDM,434,RC,97167,HCPCS,,,facility,both,,,,384,268.8,,,,,,,,,,,,,Gross Charge Type: Central
HC RE-EVAL OT ESTABLISHED POC 30 MIN,43400007,CDM,434,RC,97168,HCPCS,,,facility,both,,,,186,130.2,,,,,,,,,,,,,Gross Charge Type: Central
CALCIUM GLUCONATE (FOR EMERGENCY) 100 MG/ML (10%) IV SOLN,43444,CDM,J0612,HCPCS,63323-360-01,NDC,,,facility,both,100,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE (FOR EMERGENCY) 100 MG/ML (10%) IV SOLN,43444,CDM,J0612,HCPCS,63323-360-01,NDC,,,facility,both,300,ML,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC SPEECH/HEARING THERAPY,44100001,CDM,441,RC,92507,HCPCS,,,facility,both,,,,186,130.2,,,,,,,,,,,,,Gross Charge Type: Central
HC ORAL/SWALLOW FUNCTION THERAPY,44100002,CDM,441,RC,92526,HCPCS,,,facility,both,,,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Central
HC USE OF SPEECH DEVICE SERVICE,44100004,CDM,441,RC,92609,HCPCS,,,facility,both,,,,157,109.9,,,,,,,,,,,,,Gross Charge Type: Central
HC DEVELOPMENTAL TEST LIMITED,44100007,CDM,441,RC,96110,HCPCS,,,facility,both,,,,50,35,,,,,,,,,,,,,Gross Charge Type: Central
HC ORAL SPEECH DEVICE EVAL,44100008,CDM,444,RC,92597,HCPCS,,,facility,both,,,,447,312.9,,,,,,,,,,,,,Gross Charge Type: Central
HC SPEECH/HEARING THERAPY GROUP,44100009,CDM,441,RC,92508,HCPCS,,,facility,both,,,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Central
HC ASSESSMENT OF APHASIA PER HOUR,44100010,CDM,444,RC,96105,HCPCS,,,facility,both,,,,218,152.6,,,,,,,,,,,,,Gross Charge Type: Central
PERTUZUMAB-TRASTUZUMAB-HY-ZZXF 600 MG-600 MG- 20000 UNIT/10ML SUBQ SOLN,44221,CDM,J9316,HCPCS,50242-260-01,NDC,,,facility,both,120,ML,,23380,16366,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"PERTUZUMAB-TRASTUZUMAB-HY-ZZXF 1,200 MG-600MG- 30000 UNIT/15ML SUBQ SOLN",44221,CDM,J9316,HCPCS,50242-245-01,NDC,,,facility,both,180,ML,,35072,24550.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CABOTEGRAVIR 600 MG/3 ML (200 MG/ML) IM SPER,44276,CDM,J0739,HCPCS,49702-264-23,NDC,,,facility,both,600,ML,,11110,7777,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CABOTEGRAVIR 600 MG/3 ML (200 MG/ML) IM SPER,44276,CDM,J0739,HCPCS,49702-238-03,NDC,,,facility,both,600,ML,,11110,7777,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC EX FOR SPEECH DEVICE TRAIN 1HR,44400002,CDM,444,RC,92607,HCPCS,,,facility,both,,,,236,165.2,,,,,,,,,,,,,Gross Charge Type: Central
HC EVALUATE SWALLOWING FUNCTION,44400003,CDM,444,RC,92610,HCPCS,,,facility,both,,,,491,343.7,,,,,,,,,,,,,Gross Charge Type: Central
HC MOTION FLUOROSCOPY/SWALLOW,44400004,CDM,444,RC,92611,HCPCS,,,facility,both,,,,410,287,,,,,,,,,,,,,Gross Charge Type: Central
HC ENDOSCOPY SWALLOW TST (FEES),44400005,CDM,444,RC,92612,HCPCS,,,facility,both,,,,295,206.5,,,,,,,,,,,,,Gross Charge Type: Central
HC COGN TEST FACE TO FACE PER HOUR,44400006,CDM,444,RC,96125,HCPCS,,,facility,both,,,,361,252.7,,,,,,,,,,,,,Gross Charge Type: Central
HC HB EVALUATION OF SPEECH FLUENCY,44400007,CDM,444,RC,92521,HCPCS,,,facility,both,,,,261,182.7,,,,,,,,,,,,,Gross Charge Type: Central
HC EVALUATE SPEECH PRODUCTION,44400008,CDM,444,RC,92522,HCPCS,,,facility,both,,,,261,182.7,,,,,,,,,,,,,Gross Charge Type: Central
HC SPEECH SOUND LANG COMPREHEN,44400009,CDM,444,RC,92523,HCPCS,,,facility,both,,,,261,182.7,,,,,,,,,,,,,Gross Charge Type: Central
HC BEHAVORIAL AND QUAL ANALYSIS VOICE,44400010,CDM,444,RC,92524,HCPCS,,,facility,both,,,,261,182.7,,,,,,,,,,,,,Gross Charge Type: Central
HC FLEXIBLE ENDOSCOPIC EVAL SWALLOWING/LARYNGEAL SENSORY TESTING BY CINE OR VIDEO RECORDING,44400012,CDM,444,RC,92616,HCPCS,,,facility,both,,,,366,256.2,,,,,,,,,,,,,Gross Charge Type: Central
TRABECTEDIN 1 MG IV SOLR,44455,CDM,J9352,HCPCS,59676-610-01,NDC,,,facility,both,20,EA,,14904,10432.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRABECTEDIN 1 MG IV SOLR,44455,CDM,J9352,HCPCS,59676-610-01,NDC,,,facility,both,12,EA,,8943,6260.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRABECTEDIN 1 MG IV SOLR,44455,CDM,J9352,HCPCS,59676-610-01,NDC,,,facility,both,2,EA,,648,453.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRABECTEDIN 1 MG IV SOLR,44455,CDM,J9352,HCPCS,59676-610-01,NDC,,,facility,both,23,EA,,17140,11998,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRABECTEDIN 1 MG IV SOLR,44455,CDM,J9352,HCPCS,59676-610-01,NDC,,,facility,both,8,EA,,2592,1814.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRABECTEDIN 1 MG IV SOLR,44455,CDM,J9352,HCPCS,59676-610-01,NDC,,,facility,both,9,EA,,6707,4694.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRABECTEDIN 1 MG IV SOLR,44455,CDM,J9352,HCPCS,59676-610-01,NDC,,,facility,both,5,EA,,1620,1134,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRABECTEDIN 1 MG IV SOLR,44455,CDM,J9352,HCPCS,59676-610-01,NDC,,,facility,both,18,EA,,13414,9389.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRABECTEDIN 1 MG IV SOLR,44455,CDM,J9352,HCPCS,59676-610-01,NDC,,,facility,both,1,EA,,324,226.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRABECTEDIN 1 MG IV SOLR,44455,CDM,J9352,HCPCS,59676-610-01,NDC,,,facility,both,24,EA,,17885,12519.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRABECTEDIN 1 MG IV SOLR,44455,CDM,J9352,HCPCS,59676-610-01,NDC,,,facility,both,6,EA,,1944,1360.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRABECTEDIN 1 MG IV SOLR,44455,CDM,J9352,HCPCS,59676-610-01,NDC,,,facility,both,30,EA,,22356,15649.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRABECTEDIN 1 MG IV SOLR,44455,CDM,J9352,HCPCS,59676-610-01,NDC,,,facility,both,7,EA,,2268,1587.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRABECTEDIN 1 MG IV SOLR,44455,CDM,J9352,HCPCS,59676-610-01,NDC,,,facility,both,15,EA,,11178,7824.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIROLIMUS-PROTEIN BOUND 100 MG IV SUSR (WET SUSR VIAL),44919,CDM,J9331,HCPCS,80803-153-50,NDC,,,facility,both,50,EA,,10230,7161,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIROLIMUS-PROTEIN BOUND 100 MG IV SUSR (WET SUSR VIAL),44919,CDM,J9331,HCPCS,80803-153-50,NDC,,,facility,both,190,EA,,38872,27210.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIROLIMUS-PROTEIN BOUND 100 MG IV SUSR (WET SUSR VIAL),44919,CDM,J9331,HCPCS,80803-153-50,NDC,,,facility,both,56,EA,,11457,8019.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIROLIMUS-PROTEIN BOUND 100 MG IV SUSR (WET SUSR VIAL),44919,CDM,J9331,HCPCS,80803-153-50,NDC,,,facility,both,47,EA,,9616,6731.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
I&D SKIN SUBQ ABSCESS COMPLEX,45000001,CDM,361,RC,10061,HCPCS,,,facility,both,,,,287,200.9,,,,,,,,,,,,,Gross Charge Type: Central
I&D PILONIDAL CYST SIMPLE,45000002,CDM,450,RC,10080,HCPCS,,,facility,both,,,,287,200.9,,,,,,,,,,,,,Gross Charge Type: Central
HC I&D PILONIDAL CYST COMPLEX,45000003,CDM,450,RC,10081,HCPCS,,,facility,both,,,,1361,952.7,,,,,,,,,,,,,Gross Charge Type: Central
I&D REM FB SUBQ SIMPLE,45000004,CDM,361,RC,10120,HCPCS,,,facility,both,,,,424,296.8,,,,,,,,,,,,,Gross Charge Type: Central
I&D REM FB SUBQ COMPLICAT,45000005,CDM,450,RC,10121,HCPCS,,,facility,both,,,,1886,1320.2,,,,,,,,,,,,,Gross Charge Type: Central
HC REM NAIL PLATE SINGL,45000006,CDM,450,RC,11730,HCPCS,,,facility,both,,,,218,152.6,,,,,,,,,,,,,Gross Charge Type: Central
HC AVULSION NAIL PLATE COMPLETE/SIMPLE EACH ADDITIONAL NAIL PLATE,45000007,CDM,450,RC,11732,HCPCS,,,facility,both,,,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Central
HC DRAIN BLOOD FROM UNDER NAIL,45000008,CDM,450,RC,11740,HCPCS,,,facility,both,,,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Central
HC EXC NAIL BED,45000009,CDM,450,RC,11750,HCPCS,,,facility,both,,,,578,404.6,,,,,,,,,,,,,Gross Charge Type: Central
HC REPAIR NAIL BED,45000011,CDM,450,RC,11760,HCPCS,,,facility,both,,,,352,246.4,,,,,,,,,,,,,Gross Charge Type: Central
HC SIMPLE REPAIR SUPRFCL WNDS S/N/A/GEN/TNK EXT INCL HANDS & FEET 2.5 CM OR LESS,45000012,CDM,361,RC,12001,HCPCS,,,facility,both,,,,413,289.1,,,,,,,,,,,,,Gross Charge Type: Central
HC SIMPLE REPAIR SUPRFCL WNDS S/N/AX/GEN/TRNK EXT INCL HANDS & FEET 2.6--7.5 CM,45000013,CDM,361,RC,12002,HCPCS,,,facility,both,,,,455,318.5,,,,,,,,,,,,,Gross Charge Type: Central
HC SIMPLE REPAIR SUPRFCL WNDS S/N/AX/GEN/TRK EXT INCL HANDS & FEET 7.6-12.5 CM,45000014,CDM,361,RC,12004,HCPCS,,,facility,both,,,,478,334.6,,,,,,,,,,,,,Gross Charge Type: Central
HC SIMPLE REPAIR SUPRFCL WNDS S/N/A/GEN/TRK EXT INCL HANDS & FEET 12.6-20.0 CM,45000015,CDM,361,RC,12005,HCPCS,,,facility,both,,,,500,350,,,,,,,,,,,,,Gross Charge Type: Central
HC SIMPLE REPAIR SUPRFCL WNDS S/N/A/GEN/TRK EXT INCL HANDS & FEET 20.1-30.0 CM,45000016,CDM,450,RC,12006,HCPCS,,,facility,both,,,,525,367.5,,,,,,,,,,,,,Gross Charge Type: Central
HC SIMPLE REPAIR SUPRFCL WNDS S/N/A/GEN/TRNK EXT INCL HANDS & FEET OVER 30.0 CM,45000017,CDM,450,RC,12007,HCPCS,,,facility,both,,,,553,387.1,,,,,,,,,,,,,Gross Charge Type: Central
HC SIMPLE REPAIR SUPRFCL WNDS F/E/E/N/L/M 2.5 CM LESS,45000018,CDM,450,RC,12011,HCPCS,,,facility,both,,,,413,289.1,,,,,,,,,,,,,Gross Charge Type: Central
HC SIMPLE REPAIR SUPRFCL WNDS F/E/E/N/L/M 2.6-5.0 CM,45000019,CDM,361,RC,12013,HCPCS,,,facility,both,,,,435,304.5,,,,,,,,,,,,,Gross Charge Type: Central
HC SIMPLE REPAIR SUPRFCL WNDS F/E/E/N/L/M 5.1-7.5 CM,45000020,CDM,361,RC,12014,HCPCS,,,facility,both,,,,455,318.5,,,,,,,,,,,,,Gross Charge Type: Central
HC SIMPLE REPAIR SUPRFCL WNDS F/E/E/N/L/M 7.6-12.5 CM,45000021,CDM,450,RC,12015,HCPCS,,,facility,both,,,,478,334.6,,,,,,,,,,,,,Gross Charge Type: Central
HC SIMPLE REPAIR SUPRFCL WNDS F/E/E/N/L/M 12.6-20.0 CM,45000022,CDM,450,RC,12016,HCPCS,,,facility,both,,,,500,350,,,,,,,,,,,,,Gross Charge Type: Central
HC SIMPLE REPAIR SUPRFCL WNDS F/E/E/N/L/M OVER 30.0 CM,45000023,CDM,450,RC,12018,HCPCS,,,facility,both,,,,1483,1038.1,,,,,,,,,,,,,Gross Charge Type: Central
HC REP INT WND S/A/T/EXT <2.5 CM,45000024,CDM,450,RC,12031,HCPCS,,,facility,both,,,,455,318.5,,,,,,,,,,,,,Gross Charge Type: Central
HC REP INT WND S/A/T/EXT 2.6-7.5 CM,45000025,CDM,361,RC,12032,HCPCS,,,facility,both,,,,500,350,,,,,,,,,,,,,Gross Charge Type: Central
HC REP INT WND S/A/T/EXT 7.6-12.5,45000026,CDM,450,RC,12034,HCPCS,,,facility,both,,,,525,367.5,,,,,,,,,,,,,Gross Charge Type: Central
HC REP INT WND S/A/T/EXT 12.6-20.0,45000027,CDM,450,RC,12035,HCPCS,,,facility,both,,,,553,387.1,,,,,,,,,,,,,Gross Charge Type: Central
HC REP INT WND S/A/T/EXT 20.1-30,45000028,CDM,450,RC,12036,HCPCS,,,facility,both,,,,575,402.5,,,,,,,,,,,,,Gross Charge Type: Central
HC REPAIR INTERMED WND S/A/T/EXT (EXCL HANDS & FEET) OVER 30.0 CM,45000029,CDM,450,RC,12037,HCPCS,,,facility,both,,,,601,420.7,,,,,,,,,,,,,Gross Charge Type: Central
HC REP INT WND N/H/F/GNT<2.5 CM,45000030,CDM,361,RC,12041,HCPCS,,,facility,both,,,,455,318.5,,,,,,,,,,,,,Gross Charge Type: Central
HC REP INT WND N/H/F/GNT2.6-7.5,45000031,CDM,450,RC,12042,HCPCS,,,facility,both,,,,500,350,,,,,,,,,,,,,Gross Charge Type: Central
HC REP INT WND N/H/F/GNT7.6-12.5,45000032,CDM,450,RC,12044,HCPCS,,,facility,both,,,,525,367.5,,,,,,,,,,,,,Gross Charge Type: Central
HC REP INT WND N/H/F/GNT 12.6-20.0,45000033,CDM,450,RC,12045,HCPCS,,,facility,both,,,,548,383.6,,,,,,,,,,,,,Gross Charge Type: Central
HC REP INT WND N/H/F/GNT20.1-30,45000034,CDM,450,RC,12046,HCPCS,,,facility,both,,,,575,402.5,,,,,,,,,,,,,Gross Charge Type: Central
HC REPAIR INTERMED WNDS F/E/E/N/L/M 2.5 CM OR LESS,45000035,CDM,450,RC,12051,HCPCS,,,facility,both,,,,455,318.5,,,,,,,,,,,,,Gross Charge Type: Central
HC REPAIR INTERMED WNDS F/E/E/N/L/M 2.6-5.0 CM,45000036,CDM,450,RC,12052,HCPCS,,,facility,both,,,,478,334.6,,,,,,,,,,,,,Gross Charge Type: Central
HC REPAIR INTERMED WNDS F/E/E/N/L/M 5.1-7.5 CM,45000037,CDM,450,RC,12053,HCPCS,,,facility,both,,,,500,350,,,,,,,,,,,,,Gross Charge Type: Central
HC REPAIR INTERMED WNDS F/E/E/N/L/M 7.6-12.5 CM,45000038,CDM,450,RC,12054,HCPCS,,,facility,both,,,,525,367.5,,,,,,,,,,,,,Gross Charge Type: Central
HC REPAIR INTERMED WNDS F/E/E/N/L/M 12.6-20.0 CM,45000039,CDM,450,RC,12055,HCPCS,,,facility,both,,,,553,387.1,,,,,,,,,,,,,Gross Charge Type: Central
HC REPAIR INTERMED WNDS F/E/E/N/L/M OVER 30.0 CM,45000041,CDM,450,RC,12057,HCPCS,,,facility,both,,,,601,420.7,,,,,,,,,,,,,Gross Charge Type: Central
HC REP COM WND S/A/L 1.1-2.5CM,45000042,CDM,450,RC,13120,HCPCS,,,facility,both,,,,598,418.6,,,,,,,,,,,,,Gross Charge Type: Central
HC REP COM WND S/A/L 2.6-7.5CM,45000043,CDM,450,RC,13121,HCPCS,,,facility,both,,,,661,462.7,,,,,,,,,,,,,Gross Charge Type: Central
HC REP COM WND F/H/F/A/G/N1.1-2.5,45000044,CDM,450,RC,13131,HCPCS,,,facility,both,,,,630,441,,,,,,,,,,,,,Gross Charge Type: Central
HC REPAIR COMPLEX FOREHEAD/CHEEKS/CHIN/MOUTH/NECK/AXILLAE/GENITALIA/HANDS/FEET 2.6-7.5 CM,45000045,CDM,450,RC,13132,HCPCS,,,facility,both,,,,661,462.7,,,,,,,,,,,,,Gross Charge Type: Central
HC REP COM WND E/N/E/L 1.0-2.5CM,45000047,CDM,450,RC,13151,HCPCS,,,facility,both,,,,1504,1052.8,,,,,,,,,,,,,Gross Charge Type: Central
HC REP COM WND E/N/E/L2.6-7.5CM,45000048,CDM,450,RC,13152,HCPCS,,,facility,both,,,,1730,1211,,,,,,,,,,,,,Gross Charge Type: Central
HC TREAT 1ST DEG BURN LOCAL INITIAL,45000049,CDM,450,RC,16000,HCPCS,,,facility,both,,,,401,280.7,,,,,,,,,,,,,Gross Charge Type: Central
HC DRESSINGS/DEBRIDEMENT PARTIAL THICKNESS BURNS INITIAL/SUBSEQUENT SM,45000050,CDM,450,RC,16020,HCPCS,,,facility,both,,,,456,319.2,,,,,,,,,,,,,Gross Charge Type: Central
HC DRESSING/DEBRIDEMENT PARTIAL THICKNESS BURNS INITIAL/SUBSEQUENT LARGE,45000051,CDM,450,RC,16030,HCPCS,,,facility,both,,,,604,422.8,,,,,,,,,,,,,Gross Charge Type: Central
HC REMOVAL FB MUSCLE/TENDON SIMPLE,45000052,CDM,450,RC,20520,HCPCS,,,facility,both,,,,1197,837.9,,,,,,,,,,,,,Gross Charge Type: Central
HC RESET DISLOCATED JAW,45000055,CDM,450,RC,21480,HCPCS,,,facility,both,,,,341,238.7,,,,,,,,,,,,,Gross Charge Type: Central
HC CLOSED TX CLAVICULAR FX W/O MANIPULATION,45000056,CDM,450,RC,23500,HCPCS,,,facility,both,,,,275,192.5,,,,,,,,,,,,,Gross Charge Type: Central
HC CLOSED TX ACROMIOCLAVICULAR DISLOCATION W/O MANIPULATION,45000057,CDM,450,RC,23540,HCPCS,,,facility,both,,,,852,596.4,,,,,,,,,,,,,Gross Charge Type: Central
HC CLOSED TX PROXIMAL HUMERAL FX W/MANIPULATION W/WO SKELETAL TRACTION,45000058,CDM,450,RC,23605,HCPCS,,,facility,both,,,,2480,1736,,,,,,,,,,,,,Gross Charge Type: Central
HC TREAT HUM GR TUB FX W/MAN,45000059,CDM,450,RC,23625,HCPCS,,,facility,both,,,,2192,1534.4,,,,,,,,,,,,,Gross Charge Type: Central
HC TREAT SHOULDER DISLOCATION,45000060,CDM,450,RC,23650,HCPCS,,,facility,both,,,,275,192.5,,,,,,,,,,,,,Gross Charge Type: Central
HC DRAIN UPPER ARM ELBOW LESION,45000061,CDM,450,RC,23930,HCPCS,,,facility,both,,,,2442,1709.4,,,,,,,,,,,,,Gross Charge Type: Central
HC TREAT HUM SHAFT FX,45000062,CDM,450,RC,24500,HCPCS,,,facility,both,,,,836,585.2,,,,,,,,,,,,,Gross Charge Type: Central
HC CLOSED TX HUMERAL SHAFT FX W/MANIPULATION W/WO SKELETAL TRACTION,45000063,CDM,450,RC,24505,HCPCS,,,facility,both,,,,1666,1166.2,,,,,,,,,,,,,Gross Charge Type: Central
HC TREAT HUM SUPRAC FX W/ MAN,45000064,CDM,450,RC,24535,HCPCS,,,facility,both,,,,980,686,,,,,,,,,,,,,Gross Charge Type: Central
HC TREAT ELBOW DISL W/O ANESTH,45000065,CDM,450,RC,24600,HCPCS,,,facility,both,,,,693,485.1,,,,,,,,,,,,,Gross Charge Type: Central
HC TREAT RAD HEAD DISL W/MAN,45000066,CDM,450,RC,24640,HCPCS,,,facility,both,,,,361,252.7,,,,,,,,,,,,,Gross Charge Type: Central
HC CLOSED TX RADIAL HEAD NECK FX W/O MANIPULATION,45000067,CDM,450,RC,24650,HCPCS,,,facility,both,,,,361,252.7,,,,,,,,,,,,,Gross Charge Type: Central
HC TREAT RAD HEAD NECK FX W/ MAN,45000068,CDM,450,RC,24655,HCPCS,,,facility,both,,,,600,420,,,,,,,,,,,,,Gross Charge Type: Central
HC CLOSED TX RADIAL SHAFT FX W/ MANIPULATION,45000069,CDM,450,RC,25505,HCPCS,,,facility,both,,,,1066,746.2,,,,,,,,,,,,,Gross Charge Type: Central
HC CLOSED TX ULNAR SHAFT FX W/MANIPULATION,45000070,CDM,450,RC,25535,HCPCS,,,facility,both,,,,898,628.6,,,,,,,,,,,,,Gross Charge Type: Central
HC TREAT FX RAD ULNA SHAFT W/ MAN,45000071,CDM,450,RC,25565,HCPCS,,,facility,both,,,,735,514.5,,,,,,,,,,,,,Gross Charge Type: Central
HC TREAT FX RADIUS/ULNA DISTAL,45000072,CDM,450,RC,25600,HCPCS,,,facility,both,,,,716,501.2,,,,,,,,,,,,,Gross Charge Type: Central
HC TREAT FX RAD/ULNA DISTAL W/ MAN,45000073,CDM,450,RC,25605,HCPCS,,,facility,both,,,,1826,1278.2,,,,,,,,,,,,,Gross Charge Type: Central
HC CLOSED TX METACARPAL FX SINGLE W/MANIPULATION EACH BONE,45000075,CDM,450,RC,26605,HCPCS,,,facility,both,,,,973,681.1,,,,,,,,,,,,,Gross Charge Type: Central
HC TX MP DISLOC W/ MANIP,45000076,CDM,450,RC,26700,HCPCS,,,facility,both,,,,357,249.9,,,,,,,,,,,,,Gross Charge Type: Central
HC CLOSED TX PHALANGEAL SHAFT FX PROXIMAL/MIDDLE PHALANX FINGER/THUMB W/O MANIPULATION EACH,45000077,CDM,450,RC,26720,HCPCS,,,facility,both,,,,357,249.9,,,,,,,,,,,,,Gross Charge Type: Central
HC CLOSED TX PHALANGEAL SHAFT FX PROXIMAL/MIDDLE PHALANX FINGER/THUMB W/MANIPULATE W/WO SKIN/SKELETAL TRACTION EACH,45000078,CDM,450,RC,26725,HCPCS,,,facility,both,,,,357,249.9,,,,,,,,,,,,,Gross Charge Type: Central
TREAT FINGER DISLOCATION,45000079,CDM,450,RC,26770,HCPCS,,,facility,both,,,,716,501.2,,,,,,,,,,,,,Gross Charge Type: Central
HC TREAT HIP DISL W/O ANESTH,45000081,CDM,450,RC,27250,HCPCS,,,facility,both,,,,499,349.3,,,,,,,,,,,,,Gross Charge Type: Central
HC CLOSED TX POST HIP ARTHROPLASTY DISLOCATION W/O ANESTHESIA,45000082,CDM,450,RC,27265,HCPCS,,,facility,both,,,,332,232.4,,,,,,,,,,,,,Gross Charge Type: Central
TREAT KNEECAP DISL W/O ANESTH,45000083,CDM,450,RC,27560,HCPCS,,,facility,both,,,,653,457.1,,,,,,,,,,,,,Gross Charge Type: Central
TREAT KNEECAP DISL W/ ANESTH,45000084,CDM,450,RC,27562,HCPCS,,,facility,both,,,,3899,2729.3,,,,,,,,,,,,,Gross Charge Type: Central
HC CLOSED TX TIBIAL SHAFT FX W/WO FIBULAR FX W/MANIPULATION W/W/O SKELETAL TRACTION,45000085,CDM,450,RC,27752,HCPCS,,,facility,both,,,,2063,1444.1,,,,,,,,,,,,,Gross Charge Type: Central
HC CLOSED TX MEDIAL MALLEOLUS FX W/O MANIPULATION,45000086,CDM,450,RC,27760,HCPCS,,,facility,both,,,,852,596.4,,,,,,,,,,,,,Gross Charge Type: Central
HC CLOSED TX MEDIAL MALLEOLUS FX W/MANIPULATION W/WO SKIN OR SKELETAL TRACTION,45000087,CDM,450,RC,27762,HCPCS,,,facility,both,,,,2063,1444.1,,,,,,,,,,,,,Gross Charge Type: Central
HC CLOSED TX PROXIMAL FIBULA/SHAFT FX W/O MANIPULATION,45000088,CDM,450,RC,27780,HCPCS,,,facility,both,,,,852,596.4,,,,,,,,,,,,,Gross Charge Type: Central
HC TREAT PROX FIBULA FX W/ MANIP,45000089,CDM,450,RC,27781,HCPCS,,,facility,both,,,,4729,3310.3,,,,,,,,,,,,,Gross Charge Type: Central
HC TREAT LAT MALLEOLUS FX W/ MAN,45000090,CDM,450,RC,27788,HCPCS,,,facility,both,,,,825,577.5,,,,,,,,,,,,,Gross Charge Type: Central
HC TREAT BIMALLEOLAR FX W/O MANIP,45000091,CDM,450,RC,27808,HCPCS,,,facility,both,,,,349,244.3,,,,,,,,,,,,,Gross Charge Type: Central
HC TREAT BIMALLEOLAR FX W/ MAN,45000092,CDM,450,RC,27810,HCPCS,,,facility,both,,,,1113,779.1,,,,,,,,,,,,,Gross Charge Type: Central
HC TREAT TRIMALLEOLAR FX W/O MANIP,45000093,CDM,450,RC,27816,HCPCS,,,facility,both,,,,852,596.4,,,,,,,,,,,,,Gross Charge Type: Central
HC TREAT TRIMALLEOLAR FX W/ MAN,45000094,CDM,450,RC,27818,HCPCS,,,facility,both,,,,1113,779.1,,,,,,,,,,,,,Gross Charge Type: Central
HC TX CLOSED ANKLE DISLOCATION W/O ANESTHESIA,45000095,CDM,450,RC,27840,HCPCS,,,facility,both,,,,614,429.8,,,,,,,,,,,,,Gross Charge Type: Central
HC REM OF FOOT FB SUBQ,45000096,CDM,450,RC,28190,HCPCS,,,facility,both,,,,1233,863.1,,,,,,,,,,,,,Gross Charge Type: Central
HC CLOSED TX CALCANEAL FX W/O MANIPULATION,45000097,CDM,450,RC,28400,HCPCS,,,facility,both,,,,852,596.4,,,,,,,,,,,,,Gross Charge Type: Central
HC TREAT TALUS FX,45000099,CDM,450,RC,28435,HCPCS,,,facility,both,,,,1959,1371.3,,,,,,,,,,,,,Gross Charge Type: Central
HC CLOSED TX FX PHALANX/PHALANGES OTHER THAN GREAT TOE W/MANIPULATION EACH,45000100,CDM,450,RC,28515,HCPCS,,,facility,both,,,,961,672.7,,,,,,,,,,,,,Gross Charge Type: Central
HC TREAT MP TOE DISLOC,45000101,CDM,450,RC,28630,HCPCS,,,facility,both,,,,320,224,,,,,,,,,,,,,Gross Charge Type: Central
HC CLSD TRMT INTRPHLNGL JT DL W/O,45000102,CDM,450,RC,28660,HCPCS,,,facility,both,,,,207,144.9,,,,,,,,,,,,,Gross Charge Type: Central
HC APPLY SHORT ARM CAST,45000104,CDM,450,RC,29075,HCPCS,,,facility,both,,,,939,657.3,,,,,,,,,,,,,Gross Charge Type: Central
HC APPLY LONG ARM SPLINT,45000105,CDM,450,RC,29105,HCPCS,,,facility,both,,,,200,140,,,,,,,,,,,,,Gross Charge Type: Central
HC STRAPPING SHOULDER VELPEAU,45000107,CDM,450,RC,29240,HCPCS,,,facility,both,,,,341,238.7,,,,,,,,,,,,,Gross Charge Type: Central
HC STRAPPING HAND OR FINGER,45000108,CDM,450,RC,29280,HCPCS,,,facility,both,,,,119,83.3,,,,,,,,,,,,,Gross Charge Type: Central
HC APPLY SHORT LEG CAST,45000109,CDM,450,RC,29405,HCPCS,,,facility,both,,,,483,338.1,,,,,,,,,,,,,Gross Charge Type: Central
HC APPLY LONG LEG SPLINT,45000110,CDM,450,RC,29505,HCPCS,,,facility,both,,,,854,597.8,,,,,,,,,,,,,Gross Charge Type: Central
HC APPLY LOWER LEG SPLINT,45000111,CDM,450,RC,29515,HCPCS,,,facility,both,,,,431,301.7,,,,,,,,,,,,,Gross Charge Type: Central
HC STRAPPING ANKLE AND/OR FOOT,45000113,CDM,450,RC,29540,HCPCS,,,facility,both,,,,637,445.9,,,,,,,,,,,,,Gross Charge Type: Central
HC STRAPPING TOES,45000114,CDM,450,RC,29550,HCPCS,,,facility,both,,,,169,118.3,,,,,,,,,,,,,Gross Charge Type: Central
HC REMOVAL/BIVALVING GAUNTLET BOOT/BODY CAST,45000115,CDM,450,RC,29700,HCPCS,,,facility,both,,,,970,679,,,,,,,,,,,,,Gross Charge Type: Central
HC REM/REVISE FULL ARM/LEG CAST,45000116,CDM,450,RC,29705,HCPCS,,,facility,both,,,,283,198.1,,,,,,,,,,,,,Gross Charge Type: Central
REMOVE NASAL FB,45000117,CDM,450,RC,30300,HCPCS,,,facility,both,,,,299,209.3,,,,,,,,,,,,,Gross Charge Type: Central
HC CONTROL OF NOSEBLEED SIMPLE,45000118,CDM,450,RC,30901,HCPCS,,,facility,both,,,,247,172.9,,,,,,,,,,,,,Gross Charge Type: Central
HC CONTROL OF NOSEBLEED COMPLEX,45000119,CDM,450,RC,30903,HCPCS,,,facility,both,,,,297,207.9,,,,,,,,,,,,,Gross Charge Type: Central
CONTROL OF NOSEBLEED POSTERIOR INITIAL,45000120,CDM,450,RC,30905,HCPCS,,,facility,both,,,,390,273,,,,,,,,,,,,,Gross Charge Type: Central
HC THROMBOLYSIS CEREBRAL IV,45000121,CDM,450,RC,37195,HCPCS,,,facility,both,,,,236,165.2,,,,,,,,,,,,,Gross Charge Type: Central
HC REP MOUTH LACERATION <2.5CM,45000122,CDM,450,RC,40830,HCPCS,,,facility,both,,,,1036,725.2,,,,,,,,,,,,,Gross Charge Type: Central
HC REP ANT TONG MOUTH FLOOR <2.5CM,45000123,CDM,450,RC,41250,HCPCS,,,facility,both,,,,448,313.6,,,,,,,,,,,,,Gross Charge Type: Central
HC REP TONG MOUTH FLOOR >2.5 CM,45000124,CDM,450,RC,41252,HCPCS,,,facility,both,,,,922,645.4,,,,,,,,,,,,,Gross Charge Type: Central
HC I&D GUM LESION,45000125,CDM,450,RC,41800,HCPCS,,,facility,both,,,,271,189.7,,,,,,,,,,,,,Gross Charge Type: Central
HC DRAINAGE ABSC PALATE UVULA,45000126,CDM,450,RC,42000,HCPCS,,,facility,both,,,,863,604.1,,,,,,,,,,,,,Gross Charge Type: Central
I&D TONSIL ABSCESS,45000127,CDM,450,RC,42700,HCPCS,,,facility,both,,,,574,401.8,,,,,,,,,,,,,Gross Charge Type: Central
REM FB PHARYNX,45000129,CDM,450,RC,42809,HCPCS,,,facility,both,,,,197,137.9,,,,,,,,,,,,,Gross Charge Type: Central
HC INTUBATE GASTRIC WITH ASP,45000130,CDM,450,RC,43753,HCPCS,,,facility,both,,,,173,121.1,,,,,,,,,,,,,Gross Charge Type: Central
HC REM RECTAL OBSTRUCT W/ANESTH,45000132,CDM,450,RC,45915,HCPCS,,,facility,both,,,,3903,2732.1,,,,,,,,,,,,,Gross Charge Type: Central
HC I&D PERIANAL ABSCESS SUPERFICIAL,45000133,CDM,450,RC,46050,HCPCS,,,facility,both,,,,1522,1065.4,,,,,,,,,,,,,Gross Charge Type: Central
HC INCISE EXTERNAL HEMORRHOID,45000134,CDM,450,RC,46083,HCPCS,,,facility,both,,,,325,227.5,,,,,,,,,,,,,Gross Charge Type: Central
HC ANOSCOPY DIAGNOSTIC,45000135,CDM,450,RC,46600,HCPCS,,,facility,both,,,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Central
PARACENTESIS ABD,45000136,CDM,450,RC,49082,HCPCS,,,facility,both,,,,768,537.6,,,,,,,,,,,,,Gross Charge Type: Central
HC INJ CORPORA CAVERNOSA W/PHARM,45000137,CDM,450,RC,54235,HCPCS,,,facility,both,,,,320,224,,,,,,,,,,,,,Gross Charge Type: Central
HC I&D GLAND ABSCESS,45000138,CDM,450,RC,56420,HCPCS,,,facility,both,,,,347,242.9,,,,,,,,,,,,,Gross Charge Type: Central
HC REMOVE IUD,45000139,CDM,450,RC,58301,HCPCS,,,facility,both,,,,301,210.7,,,,,,,,,,,,,Gross Charge Type: Central
HC VAGINAL DELIVERY,45000140,CDM,450,RC,59409,HCPCS,,,facility,both,,,,10132,7092.4,,,,,,,,,,,,,Gross Charge Type: Central
DELIVER PLACENTA,45000141,CDM,450,RC,59414,HCPCS,,,facility,both,,,,11285,7899.5,,,,,,,,,,,,,Gross Charge Type: Central
INJ NERVE BLOCK TRIGEMINAL,45000142,CDM,450,RC,64400,HCPCS,,,facility,both,,,,801,560.7,,,,,,,,,,,,,Gross Charge Type: Central
HC INJECTION ANESTHETIC AGENT(S)/STEROID FEMORAL NERVE INCL IMAGE GUIDE,45000143,CDM,450,RC,64447,HCPCS,,,facility,both,,,,600,420,,,,,,,,,,,,,Gross Charge Type: Central
HC REM FB EYE EXTERNAL,45000144,CDM,450,RC,65205,HCPCS,,,facility,both,,,,313,219.1,,,,,,,,,,,,,Gross Charge Type: Central
HC REM FB EYE EMBEDDED,45000145,CDM,450,RC,65210,HCPCS,,,facility,both,,,,313,219.1,,,,,,,,,,,,,Gross Charge Type: Central
REM FB CORNEA W/O SLIT LAMP,45000146,CDM,450,RC,65220,HCPCS,,,facility,both,,,,313,219.1,,,,,,,,,,,,,Gross Charge Type: Central
REM FB CORNEA W/ SLIT LAMP,45000147,CDM,450,RC,65222,HCPCS,,,facility,both,,,,344,240.8,,,,,,,,,,,,,Gross Charge Type: Central
REM FB EXTERNAL EAR CANAL,45000148,CDM,450,RC,69200,HCPCS,,,facility,both,,,,192,134.4,,,,,,,,,,,,,Gross Charge Type: Central
HC REMOVAL IMPACTED CERUMEN INSTRUMENTATION UNILATERAL,45000149,CDM,450,RC,69210,HCPCS,,,facility,both,,,,151,105.7,,,,,,,,,,,,,Gross Charge Type: Central
HC EMERGENCY DEPT VISIT LEVEL 1,45000150,CDM,450,RC,99281,HCPCS,,,facility,both,,,,183,128.1,,,,,,,,,,,,,Gross Charge Type: Central
HC EMERGENCY DEPT VISIT LEVEL 2,45000151,CDM,450,RC,99282,HCPCS,,,facility,both,,,,247,172.9,,,,,,,,,,,,,Gross Charge Type: Central
HC EMERGENCY DEPT VISIT LEVEL 3,45000152,CDM,450,RC,99283,HCPCS,,,facility,both,,,,535,374.5,,,,,,,,,,,,,Gross Charge Type: Central
HC EMERGENCY DEPT VISIT LEVEL 4,45000153,CDM,450,RC,99284,HCPCS,,,facility,both,,,,1025,717.5,,,,,,,,,,,,,Gross Charge Type: Central
HC EMERGENCY DEPT VISIT LEVEL 5,45000154,CDM,450,RC,99285,HCPCS,,,facility,both,,,,1798,1258.6,,,,,,,,,,,,,Gross Charge Type: Central
HC CRITICAL CARE 1ST 31-74 MIN,45000155,CDM,450,RC,99291,HCPCS,,,facility,both,,,,2320,1624,,,,,,,,,,,,,Gross Charge Type: Central
HC CRITICAL CARE EA ADDL 30 MIN,45000156,CDM,450,RC,99292,HCPCS,,,facility,both,,,,1162,813.4,,,,,,,,,,,,,Gross Charge Type: Central
HC REP COM WND S/A/L ADDL 5CM OR LESS,45000159,CDM,450,RC,13122,HCPCS,,,facility,both,,,,130,91,,,,,,,,,,,,,Gross Charge Type: Central
HC INCISION OF BREAST LESION,45000160,CDM,450,RC,19020,HCPCS,,,facility,both,,,,6448,4513.6,,,,,,,,,,,,,Gross Charge Type: Central
HC CLOSED TX STERNOCLAVICULAR DISL W/ MANIP,45000162,CDM,450,RC,23525,HCPCS,,,facility,both,,,,542,379.4,,,,,,,,,,,,,Gross Charge Type: Central
HC CLOSED TX SHOULDER DISLOC W/ FX,45000163,CDM,450,RC,23665,HCPCS,,,facility,both,,,,1066,746.2,,,,,,,,,,,,,Gross Charge Type: Central
HC CLOSED TX POST HIP ARTHROPL DISLOC REQ ANESTH,45000164,CDM,450,RC,27266,HCPCS,,,facility,both,,,,1735,1214.5,,,,,,,,,,,,,Gross Charge Type: Central
HC IRRIGATION OF BLADDER SIMPLE,45000165,CDM,450,RC,51700,HCPCS,,,facility,both,,,,320,224,,,,,,,,,,,,,Gross Charge Type: Central
HC I&D ISCHIORECTAL/PERIRECTAL ABSCESS,45000167,CDM,361,RC,46040,HCPCS,,,facility,both,,,,7232,5062.4,,,,,,,,,,,,,Gross Charge Type: Central
HC CLOSED TX ULNAR FX PROX END W/ MANIP,45000171,CDM,450,RC,24675,HCPCS,,,facility,both,,,,1404,982.8,,,,,,,,,,,,,Gross Charge Type: Central
HC EXCISION THROMBOSED HEMORRHOID EXTERNAL,45000172,CDM,360,RC,46320,HCPCS,,,facility,both,,,,1921,1344.7,,,,,,,,,,,,,Gross Charge Type: Central
HC CL TX DIST PHALANG FX FINGER/THUMB W/ MANIP,45000184,CDM,450,RC,26755,HCPCS,,,facility,both,,,,773,541.1,,,,,,,,,,,,,Gross Charge Type: Central
HC SHLDR DISLOC MANIP REQ ANESTHESIA,45000187,CDM,450,RC,23655,HCPCS,,,facility,both,,,,1745,1221.5,,,,,,,,,,,,,Gross Charge Type: Central
HC TREAT KNEE DISLOCATION,45000188,CDM,450,RC,27550,HCPCS,,,facility,both,,,,261,182.7,,,,,,,,,,,,,Gross Charge Type: Central
HC DRAIN EXTERNAL EAR ABSCESS/HEMATOMA COMPLICATED,45000190,CDM,450,RC,69005,HCPCS,,,facility,both,,,,1278,894.6,,,,,,,,,,,,,Gross Charge Type: Central
HC REPAIR LIP HALF VERTICAL,45000191,CDM,450,RC,40652,HCPCS,,,facility,both,,,,965,675.5,,,,,,,,,,,,,Gross Charge Type: Central
HC EXPLORE WOUND EXTREMITY,45000192,CDM,450,RC,20103,HCPCS,,,facility,both,,,,1294,905.8,,,,,,,,,,,,,Gross Charge Type: Central
HC DRAIN THIGH/KNEE LESION,45000193,CDM,450,RC,27301,HCPCS,,,facility,both,,,,2373,1661.1,,,,,,,,,,,,,Gross Charge Type: Central
HC TX CLOSED TX ANKLE DISLOCATION W/ANESTHESIA W/ OR W/O PERCUT SKELETAL FIXATION,45000194,CDM,450,RC,27842,HCPCS,,,facility,both,,,,1561,1092.7,,,,,,,,,,,,,Gross Charge Type: Central
HC REPAIR LIP VERMILION ONLY,45000195,CDM,450,RC,40650,HCPCS,,,facility,both,,,,965,675.5,,,,,,,,,,,,,Gross Charge Type: Central
HC DRAINAGE OF SCROTUM ABSCESS,45000196,CDM,450,RC,55100,HCPCS,,,facility,both,,,,1278,894.6,,,,,,,,,,,,,Gross Charge Type: Central
HC REMOVAL OF FOOT FOREIGN BODY,45000197,CDM,450,RC,28192,HCPCS,,,facility,both,,,,1759,1231.3,,,,,,,,,,,,,Gross Charge Type: Central
HC TREAT WRIST DISLOCATION,45000198,CDM,450,RC,25690,HCPCS,,,facility,both,,,,5564,3894.8,,,,,,,,,,,,,Gross Charge Type: Central
HC CLOSURE OF SPLIT WOUND,45000199,CDM,450,RC,12020,HCPCS,,,facility,both,,,,592,414.4,,,,,,,,,,,,,Gross Charge Type: Central
HC AMPUTATION OF FINGER/THUMB,45000200,CDM,450,RC,26951,HCPCS,,,facility,both,,,,12299,8609.3,,,,,,,,,,,,,Gross Charge Type: Central
HC CLSD TX INTERPHALANGEAL JOINT DISLOCATION W/ANESTHESIA,45000201,CDM,450,RC,28665,HCPCS,,,facility,both,,,,335,234.5,,,,,,,,,,,,,Gross Charge Type: Central
HC REPAIR ACHILLES TENDON,45000202,CDM,450,RC,27650,HCPCS,,,facility,both,,,,6228,4359.6,,,,,,,,,,,,,Gross Charge Type: Central
HC ANOSCOPY W/ REM FOREIGN BODY,45000203,CDM,450,RC,46608,HCPCS,,,facility,both,,,,960,672,,,,,,,,,,,,,Gross Charge Type: Central
HC DRAINAGE OF ABSCESS/CYST/HEMATOMA/VESTIBULE OF MOUTH SIMPLE,45000204,CDM,450,RC,40800,HCPCS,,,facility,both,,,,243,170.1,,,,,,,,,,,,,Gross Charge Type: Central
HC CLSD TX CARPOMETACARP DISL W/ MANIP EA JOINT W/O ANESTH,45000205,CDM,450,RC,26670,HCPCS,,,facility,both,,,,253,177.1,,,,,,,,,,,,,Gross Charge Type: Central
HC REPAIR BLOOD VESSEL DIRECT LWR EXTREMITY,45000206,CDM,450,RC,35226,HCPCS,,,facility,both,,,,7377,5163.9,,,,,,,,,,,,,Gross Charge Type: Central
HC CLSD TX FX OF DISTAL TIBIA W/ OR W/O ANESTH W/ TRACTION OR MANIP,45000208,CDM,450,RC,27825,HCPCS,,,facility,both,,,,1977,1383.9,,,,,,,,,,,,,Gross Charge Type: Central
HC CLOSED TX ELBOW DISL REQ ANESTHESIA,45000209,CDM,450,RC,24605,HCPCS,,,facility,both,,,,1745,1221.5,,,,,,,,,,,,,Gross Charge Type: Central
HC REPAIR LIP FULL THICKNESS OVER ONE-HALF VERTICAL HEIGHT OR COMPLEX,45000212,CDM,450,RC,40654,HCPCS,,,facility,both,,,,825,577.5,,,,,,,,,,,,,Gross Charge Type: Central
HC TREAT ELBOW FRACTURE,45000213,CDM,450,RC,24620,HCPCS,,,facility,both,,,,1893,1325.1,,,,,,,,,,,,,Gross Charge Type: Central
HC DX LARYNGOSCOPY EXCL NB,45000214,CDM,450,RC,31525,HCPCS,,,facility,both,,,,1428,999.6,,,,,,,,,,,,,Gross Charge Type: Central
HC CRPRA CVRNSA SAPHNS VEIN SHUNT UNI/BIL,45000215,CDM,450,RC,54420,HCPCS,,,facility,both,,,,4827,3378.9,,,,,,,,,,,,,Gross Charge Type: Central
HC TREAT CLAVICLE FRACTURE W/MANIP,45000217,CDM,450,RC,23505,HCPCS,,,facility,both,,,,1066,746.2,,,,,,,,,,,,,Gross Charge Type: Central
HC DRAINAGE OF MOUTH LESION,45000218,CDM,450,RC,41008,HCPCS,,,facility,both,,,,1842,1289.4,,,,,,,,,,,,,Gross Charge Type: Central
HC TREAT HIP DISLOCATION REQ ANES,45000219,CDM,450,RC,27252,HCPCS,,,facility,both,,,,1161,812.7,,,,,,,,,,,,,Gross Charge Type: Central
HC CORPORA CAVERNOSA-GLANS PENIS FISTULIZATION FOR PRIAPISM,45000221,CDM,450,RC,54435,HCPCS,,,facility,both,,,,3797,2657.9,,,,,,,,,,,,,Gross Charge Type: Central
HC SIMPLE RPR WND 20.1-30.0 CM,45000223,CDM,450,RC,12017,HCPCS,,,facility,both,,,,1289,902.3,,,,,,,,,,,,,Gross Charge Type: Central
HC CLSD TX FEMORAL FX DISTAL END MEDIAL/LATERAL CONDYLE MANIP,45000225,CDM,450,RC,27510,HCPCS,,,facility,both,,,,3078,2154.6,,,,,,,,,,,,,Gross Charge Type: Central
HC CLOSED TX TIBAL FX PROXIMAL PLATEAU W/O MANIPULATION,45000231,CDM,450,RC,27530,HCPCS,,,facility,both,,,,320,224,,,,,,,,,,,,,Gross Charge Type: Central
HC CLSD TX OF INTER/PERI/SUBTROCHANTERIC FEMORAL FX W/MANIPULATION W/W/O SKIN/SKELETAL TRACTION,45000232,CDM,450,RC,27240,HCPCS,,,facility,both,,,,13140,9198,,,,,,,,,,,,,Gross Charge Type: Central
HC DRAINAGE EXTERNAL AUDITORY CANAL ABSCESS,45000233,CDM,450,RC,69020,HCPCS,,,facility,both,,,,2540,1778,,,,,,,,,,,,,Gross Charge Type: Central
HC ESOPHAGOGASTRIC TAMPONADE W/BALLOON,45000236,CDM,450,RC,43460,HCPCS,,,facility,both,,,,4004,2802.8,,,,,,,,,,,,,Gross Charge Type: Central
HC DRAINAGE OF FINGER ABSCESS COMPLICATED,45000237,CDM,450,RC,26011,HCPCS,,,facility,both,,,,1377,963.9,,,,,,,,,,,,,Gross Charge Type: Central
HC CLOSED TX PROXIMAL HUMERAL FX W/O MANIPULATION,45000239,CDM,450,RC,23600,HCPCS,,,facility,both,,,,836,585.2,,,,,,,,,,,,,Gross Charge Type: Central
HC TX TARSAL BONE FX W/O MANIPULATION EACH,45000242,CDM,450,RC,28450,HCPCS,,,facility,both,,,,915,640.5,,,,,,,,,,,,,Gross Charge Type: Central
HC CLOSED TX FX PHALANX/PHALANGES OTHER THAN GREAT TOE W/O MANIPULATION EACH,45000243,CDM,450,RC,28510,HCPCS,,,facility,both,,,,836,585.2,,,,,,,,,,,,,Gross Charge Type: Central
HC CLOSED TX SCAPULAR FX W/O MANIPULATION,45000244,CDM,450,RC,23570,HCPCS,,,facility,both,,,,852,596.4,,,,,,,,,,,,,Gross Charge Type: Central
HC CLOSED TX PATELLAR FX W/O MANIPULATION,45000245,CDM,450,RC,27520,HCPCS,,,facility,both,,,,852,596.4,,,,,,,,,,,,,Gross Charge Type: Central
HC CLOSED TX KNEE DISLOCATION W/ANESTHESIA,45000247,CDM,450,RC,27552,HCPCS,,,facility,both,,,,1872,1310.4,,,,,,,,,,,,,Gross Charge Type: Central
HC REPAIR CMPLX E/N/E/L EACH ADDL 5CM/<,45000248,CDM,450,RC,13153,HCPCS,,,facility,both,,,,447,312.9,,,,,,,,,,,,,Gross Charge Type: Central
HC REPAIR LACERATION 2.5CM/< POSTERIOR ONE-THIRD TONGUE,45000249,CDM,450,RC,41251,HCPCS,,,facility,both,,,,1036,725.2,,,,,,,,,,,,,Gross Charge Type: Central
HC CLSD TX SHOULDER DISLOCATION W/SURGICAL/ANATOMICAL NECK FX W/MANIP,45000250,CDM,450,RC,23675,HCPCS,,,facility,both,,,,320,224,,,,,,,,,,,,,Gross Charge Type: Central
HC THERAPEUTIC PROPHYLACTIC DX INJECTION INTRA-ARTERIAL,45000251,CDM,450,RC,96373,HCPCS,,,facility,both,,,,134,93.8,,,,,,,,,,,,,Gross Charge Type: Central
HC INTRAORAL INCISION & DRAINAGE OF ABSCESS/CYST/HEMATOMA OF TONGUE/FLOOR OF MOUTH LINGUAL,45000253,CDM,450,RC,41000,HCPCS,,,facility,both,,,,965,675.5,,,,,,,,,,,,,Gross Charge Type: Central
HC EXTRACTION ERUPTED TOOTH OR EXPOSED ROOT (EVELATION AND/OR FORCEPS REMOVAL),45000257,CDM,450,RC,D7140,HCPCS,,,facility,both,,,,439,307.3,,,,,,,,,,,,,Gross Charge Type: Central
HC CLSD TX TIBIAL FX PROXIMAL (PLATEAU) W/WO MANIP W/SKELETAL TRACTION,45000258,CDM,450,RC,27532,HCPCS,,,facility,both,,,,1603,1122.1,,,,,,,,,,,,,Gross Charge Type: Central
HC ARTHROCENTESIS ASPIRATION/INJECTION INTERMEDIATE JOINT OR BURSA W/ US GUIDE W/RECORDING & REPORTING,45000300,CDM,450,RC,20606,HCPCS,,,facility,both,,,,1268,887.6,,,,,,,,,,,,,Gross Charge Type: Central
HC CLOSED TREATMENT OF RADIOCARPAL/INTERCARPAL DISLOCATION 1 OR MORE BONES W/ MANIPULATION,45000308,CDM,450,RC,25660,HCPCS,,,facility,both,,,,330,231,,,,,,,,,,,,,Gross Charge Type: Central
HC REDUCTION OF PROCIDENTIA UNDER ANESTHESIA,45000309,CDM,450,RC,45900,HCPCS,,,facility,both,,,,1913,1339.1,,,,,,,,,,,,,Gross Charge Type: Central
HC INCISION & DRAINAGE EPIDIDYMIS/TESTIS/SCROTAL SPACE,45000350,CDM,450,RC,54700,HCPCS,,,facility,both,,,,2091,1463.7,,,,,,,,,,,,,Gross Charge Type: Central
HC REMOVAL FOREIGN BODY INTRANASAL REQUIRING GENERAL ANESTHESIA,45000351,CDM,450,RC,30310,HCPCS,,,facility,both,,,,11486,8040.2,,,,,,,,,,,,,Gross Charge Type: Central
HC REMOVAL EMBEDDED FOREIGN BODY FROM EYELID,45000353,CDM,450,RC,67938,HCPCS,,,facility,both,,,,1023,716.1,,,,,,,,,,,,,Gross Charge Type: Central
HC UNLISTED PROCEDURE ANUS,45000354,CDM,450,RC,46999,HCPCS,,,facility,both,,,,4265,2985.5,,,,,,,,,,,,,Gross Charge Type: Central
HC UNLISTED PROCEDURE RECTUM,45000355,CDM,450,RC,45999,HCPCS,,,facility,both,,,,2812,1968.4,,,,,,,,,,,,,Gross Charge Type: Central
HC MANIPULATION OF TEMPROMANDIBULAR JOINT(S) THERAPEUTIC REQUIRING AN ANESTHESIA SERVICE,45000356,CDM,450,RC,21073,HCPCS,,,facility,both,,,,4373,3061.1,,,,,,,,,,,,,Gross Charge Type: Central
HC UNLISTED PROCEDURE URINARY SYSTEM,45000359,CDM,450,RC,53899,HCPCS,,,facility,both,,,,17700,12390,,,,,,,,,,,,,Gross Charge Type: Central
HC CLOSED TX OF TALOTARSAL JOINT DISLOCATION REQUIRING ANESTHESIA,45000362,CDM,450,RC,28575,HCPCS,,,facility,both,,,,9425,6597.5,,,,,,,,,,,,,Gross Charge Type: Central
HC UNLISTED PROCEDURE COLON,45000368,CDM,750,RC,45399,HCPCS,,,facility,both,,,,3772,2640.4,,,,,,,,,,,,,Gross Charge Type: Central
HC CLOSED TX ACROMIOCLAVICULAR DISLOCATION W/MANIPULATION,45000370,CDM,450,RC,23545,HCPCS,,,facility,both,,,,1375,962.5,,,,,,,,,,,,,Gross Charge Type: Central
HC TREAT HIP DISLOC BY ABDUCTION/SPLINT/TRACT W/ MANIP REQ ANESTH,45000371,CDM,450,RC,27257,HCPCS,,,facility,both,,,,2824,1976.8,,,,,,,,,,,,,Gross Charge Type: Central
HC CLOSED TX POSTERIOR MALLEOLUS FRACTURE W/ MANIP,45000372,CDM,450,RC,27768,HCPCS,,,facility,both,,,,5523,3866.1,,,,,,,,,,,,,Gross Charge Type: Central
HC INJECTION ANESTHETIC AGENT(S)/STEROID SCIATIC NERVE INCL IMAGE GUIDE,45000373,CDM,450,RC,64445,HCPCS,,,facility,both,,,,3744,2620.8,,,,,,,,,,,,,Gross Charge Type: Central
HC REPLACE OF GASTRO TUBE PERCUTANEOUS INCL REMOVE W/O IMAGE OR ENDO GUIDE REQ REVISE GASTRO TRACT,45000375,CDM,450,RC,43763,HCPCS,,,facility,both,,,,922,645.4,,,,,,,,,,,,,Gross Charge Type: Central
HC REPLACE OF GASTRO TUBE PERCUTANEOUS INCL REMOVE W/O IMAGE OR ENDO GUIDE NOT REQ REV GASTRO TRACT,45000376,CDM,450,RC,43762,HCPCS,,,facility,both,,,,922,645.4,,,,,,,,,,,,,Gross Charge Type: Central
HC CLOSED TX RADIAL SHAFT & DISLOCATION DISTAL RADIOULNAR JOINT,45000379,CDM,450,RC,25520,HCPCS,,,facility,both,,,,3078,2154.6,,,,,,,,,,,,,Gross Charge Type: Central
HC CLSD TX UNLAR FRACTURE PROXIMAL END W/O MANIP,45000380,CDM,450,RC,24670,HCPCS,,,facility,both,,,,794,555.8,,,,,,,,,,,,,Gross Charge Type: Central
HC CLOSED TX VERTEBRAL BODY FX(S) W/O MANIP INCL CASTING/BRACING,45000381,CDM,450,RC,22310,HCPCS,,,facility,both,,,,1578,1104.6,,,,,,,,,,,,,Gross Charge Type: Central
HC OPEN TX BIMALLEOLAR ANKLE FX INCL INTERNAL FIX,45000383,CDM,450,RC,27814,HCPCS,,,facility,both,,,,29049,20334.3,,,,,,,,,,,,,Gross Charge Type: Central
HC UNLISTED PROCEDURE PHARYNX ADENOIDS AND TONSILS,45000384,CDM,450,RC,42999,HCPCS,,,facility,both,,,,462,323.4,,,,,,,,,,,,,Gross Charge Type: Central
HC OPEN TX TRIMALLEOLAR ANKLE FX INCL INT FIXATION MEDIAL/ LATERAL MALLEOLUS W/O FIXATION POST LIP,45000385,CDM,450,RC,27822,HCPCS,,,facility,both,,,,25921,18144.7,,,,,,,,,,,,,Gross Charge Type: Central
HC CLOSED TREATMENT OF DISTAL PHLNGL FRACTURE FINGER OR THUMB W/O MANIPULATION EACH,45000386,CDM,450,RC,26750,HCPCS,,,facility,both,,,,672,470.4,,,,,,,,,,,,,Gross Charge Type: Central
HC OPEN TX DISTAL RADIAL EXTRA ARTICULAR FX/EPIPHYSEAL SEP W/INT FIX,45000387,CDM,450,RC,25607,HCPCS,,,facility,both,,,,23479,16435.3,,,,,,,,,,,,,Gross Charge Type: Central
HC IMPLANT BIO IMPLANT SOFT TISSUE REINFORCE ADD-ON,45000388,CDM,450,RC,15777,HCPCS,,,facility,both,,,,6011,4207.7,,,,,,,,,,,,,Gross Charge Type: Central
HC REPAIR ANT ABDOMINAL HERNIA(S) ANY APPROACH RECURRENT INCL IMPLANT MESH/PROSTHESIS LESS THAN 3 CM REDUCIBLE,45000389,CDM,450,RC,49613,HCPCS,,,facility,both,,,,12237,8565.9,,,,,,,,,,,,,Gross Charge Type: Central
HC REPAIR ANT ABDOMINAL HERNIA(S) ANY APPROACH RECURRENT INCL IMPLANT MESH/PROSTHESIS LESS THAN 3 CM INCARCERATED OR STRANGULATED,45000390,CDM,450,RC,49614,HCPCS,,,facility,both,,,,18008,12605.6,,,,,,,,,,,,,Gross Charge Type: Central
HC REPAIR ANT ABDOMINAL HERNIA(S) ANY APPROACH RECURRENT INCL IMPLANT MESH/PROSTHESIS 3-10 CM REDUCIBLE,45000391,CDM,450,RC,49615,HCPCS,,,facility,both,,,,12237,8565.9,,,,,,,,,,,,,Gross Charge Type: Central
HC REPAIR ANT ABDOMINAL HERNIA(S) ANY APPROACH RECURRENT INCL IMPLANT MESH/PROSTHESIS 3-10 CM INCARCERATED OR STRANGULATED,45000392,CDM,450,RC,49616,HCPCS,,,facility,both,,,,19620,13734,,,,,,,,,,,,,Gross Charge Type: Central
HC REPAIR ANT ABDOMINAL HERNIA(S) ANY APPROACH RECURRENT INCL IMPLANT MESH/PROSTHESIS GREATER THAN 10 CM REDUCIBLE,45000393,CDM,450,RC,49617,HCPCS,,,facility,both,,,,13333,9333.1,,,,,,,,,,,,,Gross Charge Type: Central
HC REPAIR ANT ABDOMINAL HERNIA(S) ANY APPROACH RECURRENT INCL IMPLANT MESH/PROSTHESIS GREATER THAN 10 CM INCARCERATED OR STRANGULATED,45000394,CDM,450,RC,49618,HCPCS,,,facility,both,,,,15334,10733.8,,,,,,,,,,,,,Gross Charge Type: Central
HC REMOVAL OF FOREIGN BODY DEEP THIGH REGION OR KNEE AREA,45000395,CDM,450,RC,27372,HCPCS,,,facility,both,,,,8925,6247.5,,,,,,,,,,,,,Gross Charge Type: Central
HC CLOSED TREATMENT  MANDIBULAR/MAXILLARY ALVEOLAR RIDGE FX,45000396,CDM,450,RC,21440,HCPCS,,,facility,both,,,,10709,7496.3,,,,,,,,,,,,,Gross Charge Type: Central
HC REMOVAL FOREIGN BODY MUSCLE/TENDON SHEATH DEEP OR COMPLICATED,45000397,CDM,450,RC,20525,HCPCS,,,facility,both,,,,8925,6247.5,,,,,,,,,,,,,Gross Charge Type: Central
HC TX OF MISSED ABORTION COMPLETED SURGICALLY FIRST TRIMESTER,45000398,CDM,450,RC,59820,HCPCS,,,facility,both,,,,9498,6648.6,,,,,,,,,,,,,Gross Charge Type: Central
HC INDUCED ABORTION 1 OR MORE VAGINAL SUPPOSITORIES W/WO CERVICAL DILATION INCL DELIVERY FETUS/SECUNDINES,45000399,CDM,450,RC,59855,HCPCS,,,facility,both,,,,6065,4245.5,,,,,,,,,,,,,Gross Charge Type: Central
HC INDUCED ABORTION 1 OR MORE VAGINAL SUPPOSITORIES W/WO CERVICAL DILATION & CURETTAGE/EVACUATION,45000400,CDM,450,RC,59856,HCPCS,,,facility,both,,,,6975,4882.5,,,,,,,,,,,,,Gross Charge Type: Central
HC INDUCED ABORTION 1 OR MORE VAGINAL SUPPOSITORIES W/WO CERVICAL DILATION INCL DELIVERY FETUS/SECUNDINES W/HYSTEROTOMY,45000401,CDM,450,RC,59857,HCPCS,,,facility,both,,,,8021,5614.7,,,,,,,,,,,,,Gross Charge Type: Central
HC COLPORRHAPHY SUTURE OF INJURY OF VAGINA NON-OBSTETRICAL,45000402,CDM,450,RC,57200,HCPCS,,,facility,both,,,,12436,8705.2,,,,,,,,,,,,,Gross Charge Type: Central
HC CLOSED TX CARPAL SCAPHOID (NAVICULAR) FX W/O MANIPULATION,45000403,CDM,450,RC,25622,HCPCS,,,facility,both,,,,852,596.4,,,,,,,,,,,,,Gross Charge Type: Central
HC CLOSED TREATMENT OF GREATER HUMERAL TUBEROSITY FRACTURE W/O MANIPULATION,45000404,CDM,450,RC,23620,HCPCS,,,facility,both,,,,852,596.4,,,,,,,,,,,,,Gross Charge Type: Central
HC CLOSED TX HUMERAL CONDYLAR FX MEDIAL/LATERAL W/O MANIPULATION,45000406,CDM,450,RC,24576,HCPCS,,,facility,both,,,,852,596.4,,,,,,,,,,,,,Gross Charge Type: Central
HC REMOVAL FOREIGN BODY IN SCROTUM,45000407,CDM,450,RC,55120,HCPCS,,,facility,both,,,,7352,5146.4,,,,,,,,,,,,,Gross Charge Type: Central
HC ALCOHOL AND/OR DRUG SERVICES BRIEF INTERVENTION PER 15 MINUTES,45000408,CDM,450,RC,H0050,HCPCS,,,facility,both,,,,128,89.6,,,,,,,,,,,,,Gross Charge Type: Central
HC REMOVAL FOREIGN BODY FROM DEEP PENILE TISSUE,45000409,CDM,450,RC,54115,HCPCS,,,facility,both,,,,10257,7179.9,,,,,,,,,,,,,Gross Charge Type: Central
HC ALCOHOL AND/OR DRUG SCREENING,45000412,CDM,450,RC,H0049,HCPCS,,,facility,both,,,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Central
HC HYMENOTOMY SIMPLE INCISION,45000413,CDM,450,RC,56442,HCPCS,,,facility,both,,,,11879,8315.3,,,,,,,,,,,,,Gross Charge Type: Central
HC CLOSED TX TARSAL BONE DISLOCATION OTHER THAN TALOTARSAL REQUIRING ANESTHESIA,45000414,CDM,450,RC,28545,HCPCS,,,facility,both,,,,12299,8609.3,,,,,,,,,,,,,Gross Charge Type: Central
HC CYSTOSCOPY W/REMOVAL FOREIGN BODY CALCULUS/URETERAL STENT FROM URETHRA/BLADDER SIMPLE,45000415,CDM,450,RC,52310,HCPCS,,,facility,both,,,,8772,6140.4,,,,,,,,,,,,,Gross Charge Type: Central
HC REMOVAL FOREIGN BODY SHOULDER SUBCUTANEOUS,45000416,CDM,450,RC,23330,HCPCS,,,facility,both,,,,6898,4828.6,,,,,,,,,,,,,Gross Charge Type: Central
HC DRAINAGE ABSCESS/CYST/HEMATOMA/VESTIBULE OF MOUTH COMPLICATED,45000417,CDM,450,RC,40801,HCPCS,,,facility,both,,,,2393,1675.1,,,,,,,,,,,,,Gross Charge Type: Central
HC E&M SERVICE UNLISTED,45100001,CDM,451,RC,99499,HCPCS,,,facility,both,,,,161,112.7,,,,,,,,,,,,,Gross Charge Type: Central
"HYALURONATE SODIUM, STABILIZED 60 MG/3 ML IATC SYRG",45374,CDM,J7318,HCPCS,8913020201,NDC,,,facility,both,60,ML,,3078,2154.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"HYALURONATE SODIUM, STABILIZED 60 MG/3 ML IATC SYRG",45374,CDM,J7318,HCPCS,1698602080,NDC,,,facility,both,20,ML,,989,692.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"HYALURONATE SODIUM, STABILIZED 60 MG/3 ML IATC SYRG",45374,CDM,J7318,HCPCS,1698602080,NDC,,,facility,both,40,ML,,860,602,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"HYALURONATE SODIUM, STABILIZED 60 MG/3 ML IATC SYRG",45374,CDM,J7318,HCPCS,1698602080,NDC,,,facility,both,60,ML,,2967,2076.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"HYALURONATE SODIUM, STABILIZED 60 MG/3 ML IATC SYRG",45374,CDM,J7318,HCPCS,8913020201,NDC,,,facility,both,60,ML,,2967,2076.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PNEUMOC 13-VAL CONJ-DIP CR(PF) 0.5 ML IM SYRG,45429,CDM,90670,HCPCS,0005-1971-05,NDC,,,facility,both,1,ML,,827,578.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PNEUMOC 13-VAL CONJ-DIP CR(PF) 0.5 ML IM SYRG,45429,CDM,90670,HCPCS,0005-1971-01,NDC,,,facility,both,1,ML,,802,561.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIFEPRISTONE 200 MG ORAL TAB,45535,CDM,S0190,HCPCS,43393-001-01,NDC,,,facility,both,1,EA,,285,199.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETONOGESTREL 68 MG SDRM IMPL,45955,CDM,J7307,HCPCS,78206-145-01,NDC,,,facility,both,1,EA,,2258,1580.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",45955,CDM,J2004,HCPCS,63323-482-03,NDC,,,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETONOGESTREL 68 MG SDRM IMPL,45955,CDM,J7307,HCPCS,0052-4330-01,NDC,,,facility,both,1,EA,,1951,1365.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",45955,CDM,J2004,HCPCS,63323-482-03,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC SPIROMETRY,46000001,CDM,460,RC,94010,HCPCS,,,facility,both,,,,480,336,,,,,,,,,,,,,Gross Charge Type: Central
HC SPIR PRE POST BRONCHODILATOR,46000002,CDM,460,RC,94060,HCPCS,,,facility,both,,,,624,436.8,,,,,,,,,,,,,Gross Charge Type: Central
HC VITAL CAPACITY / WEANING PARAMETERS,46000003,CDM,460,RC,94150,HCPCS,,,facility,both,,,,273,191.1,,,,,,,,,,,,,Gross Charge Type: Central
HC LUNG FUNCTION TEST (MBC/MVV),46000004,CDM,460,RC,94200,HCPCS,,,facility,both,,,,576,403.2,,,,,,,,,,,,,Gross Charge Type: Central
HC EXHALED AIR ANALYSIS O2/CO2,46000006,CDM,460,RC,94681,HCPCS,,,facility,both,,,,262,183.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PULSE OXIMETRY SNGL DETERMIN,46000012,CDM,460,RC,94760,HCPCS,,,facility,both,,,,140,98,,,,,,,,,,,,,Gross Charge Type: Central
HC PULSE OXIMETRY MULT DETERMIN,46000013,CDM,460,RC,94761,HCPCS,,,facility,both,,,,205,143.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PULSE OXIMETRY CONTIN MONITOR,46000014,CDM,460,RC,94762,HCPCS,,,facility,both,,,,245,171.5,,,,,,,,,,,,,Gross Charge Type: Central
HC CAR SEAT/BED TEST 1ST 60 MIN,46000024,CDM,460,RC,94780,HCPCS,,,facility,both,,,,189,132.3,,,,,,,,,,,,,Gross Charge Type: Central
HC CAR SEAT/BED TEST EA ADDL 30 MIN,46000025,CDM,460,RC,94781,HCPCS,,,facility,both,,,,159,111.3,,,,,,,,,,,,,Gross Charge Type: Central
TISOTUMAB VEDOTIN-TFTV 40 MG IV SOLR,46241,CDM,J9273,HCPCS,51144-003-01,NDC,,,facility,both,8,EA,,1468,1027.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TISOTUMAB VEDOTIN-TFTV 40 MG IV SOLR,46241,CDM,J9273,HCPCS,51144-003-01,NDC,,,facility,both,112,EA,,47249,33074.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TISOTUMAB VEDOTIN-TFTV 40 MG IV SOLR,46241,CDM,J9273,HCPCS,51144-003-01,NDC,,,facility,both,160,EA,,67499,47249.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 80 MG/ML SUSP FOR INJECTION,46257,CDM,J1010,HCPCS,70121-1574-1,NDC,,,facility,both,60,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 40 MG/ML SUSP (DEPO-MEDROL) INJECTION,46257,CDM,J1010,HCPCS,70121-1573-1,NDC,,,facility,both,80,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 80 MG/ML SUSP FOR INJECTION,46257,CDM,J1010,HCPCS,70121-1574-1,NDC,,,facility,both,60,ML,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 40 MG/ML SUSP (DEPO-MEDROL) INJECTION,46257,CDM,J1010,HCPCS,60219-1573-1,NDC,,,facility,both,40,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 40 MG/ML SUSP (DEPO-MEDROL) INJECTION,46257,CDM,J1010,HCPCS,70121-1573-5,NDC,,,facility,both,80,ML,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 40 MG/ML SUSP (DEPO-MEDROL) INJECTION,46257,CDM,J1010,HCPCS,0009-0280-52,NDC,,,facility,both,320,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 40 MG/ML SUSP (DEPO-MEDROL) INJECTION,46257,CDM,J1010,HCPCS,0009-3073-03,NDC,,,facility,both,40,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 40 MG/ML SUSP (DEPO-MEDROL) INJECTION,46257,CDM,J1010,HCPCS,0009-3073-03,NDC,,,facility,both,80,ML,,134,93.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 40 MG/ML SUSP (DEPO-MEDROL) INJECTION,46257,CDM,J1010,HCPCS,0009-3073-01,NDC,,,facility,both,20,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 40 MG/ML SUSP (DEPO-MEDROL) INJECTION,46257,CDM,J1010,HCPCS,70121-1573-1,NDC,,,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 80 MG/ML SUSP FOR INJECTION,46257,CDM,J1010,HCPCS,70121-1574-1,NDC,,,facility,both,40,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 40 MG/ML SUSP (DEPO-MEDROL) INJECTION,46257,CDM,J1010,HCPCS,70121-1573-1,NDC,,,facility,both,1,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 40 MG/ML SUSP (DEPO-MEDROL) INJECTION,46257,CDM,J1010,HCPCS,70121-1573-1,NDC,,,facility,both,40,ML,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 40 MG/ML SUSP (DEPO-MEDROL) INJECTION,46257,CDM,J1010,HCPCS,70121-1573-1,NDC,,,facility,both,40,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 80 MG/ML SUSP FOR INJECTION,46257,CDM,J1010,HCPCS,60219-1574-1,NDC,,,facility,both,80,ML,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 40 MG/ML SUSP (DEPO-MEDROL) INJECTION,46257,CDM,J1010,HCPCS,0009-3073-01,NDC,,,facility,both,40,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 40 MG/ML SUSP (DEPO-MEDROL) INJECTION,46257,CDM,J1010,HCPCS,0009-3073-01,NDC,,,facility,both,1,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 40 MG/ML SUSP (DEPO-MEDROL) INJECTION,46257,CDM,J1010,HCPCS,70121-1573-1,NDC,,,facility,both,20,ML,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 80 MG/ML SUSP FOR INJECTION,46257,CDM,J1010,HCPCS,70121-1574-1,NDC,,,facility,both,20,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 40 MG/ML SUSP (DEPO-MEDROL) INJECTION,46257,CDM,J1010,HCPCS,0009-0280-02,NDC,,,facility,both,160,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 40 MG/ML SUSP (DEPO-MEDROL) INJECTION,46257,CDM,J1010,HCPCS,0009-0280-02,NDC,,,facility,both,80,ML,,101,70.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 40 MG/ML SUSP (DEPO-MEDROL) INJECTION,46257,CDM,J1010,HCPCS,0009-3073-01,NDC,,,facility,both,20,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 40 MG/ML SUSP (DEPO-MEDROL) INJECTION,46257,CDM,J1010,HCPCS,0009-3073-22,NDC,,,facility,both,40,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 40 MG/ML SUSP (DEPO-MEDROL) INJECTION,46257,CDM,J1010,HCPCS,0009-0280-02,NDC,,,facility,both,40,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 40 MG/ML SUSP (DEPO-MEDROL) INJECTION,46257,CDM,J1010,HCPCS,0703-0031-01,NDC,,,facility,both,40,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 80 MG/ML SUSP FOR INJECTION,46257,CDM,J1010,HCPCS,0009-3475-03,NDC,,,facility,both,80,ML,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 80 MG/ML SUSP FOR INJECTION,46257,CDM,J1010,HCPCS,70121-1574-1,NDC,,,facility,both,40,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 40 MG/ML SUSP (DEPO-MEDROL) INJECTION,46257,CDM,J1010,HCPCS,0009-0280-52,NDC,,,facility,both,80,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 80 MG/ML SUSP FOR INJECTION,46257,CDM,J1010,HCPCS,76420-081-01,NDC,,,facility,both,80,ML,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 80 MG/ML SUSP FOR INJECTION,46257,CDM,J1010,HCPCS,0009-0306-02,NDC,,,facility,both,80,ML,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 80 MG/ML SUSP FOR INJECTION,46257,CDM,J1010,HCPCS,60219-1574-5,NDC,,,facility,both,80,ML,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 80 MG/ML SUSP FOR INJECTION,46257,CDM,J1010,HCPCS,70121-1574-1,NDC,,,facility,both,20,ML,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 80 MG/ML SUSP FOR INJECTION,46257,CDM,J1010,HCPCS,0009-3475-01,NDC,,,facility,both,40,ML,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 80 MG/ML SUSP FOR INJECTION,46257,CDM,J1010,HCPCS,70121-1574-1,NDC,,,facility,both,80,ML,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 40 MG/ML SUSP (DEPO-MEDROL) INJECTION,46257,CDM,J1010,HCPCS,70121-1573-1,NDC,,,facility,both,20,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 80 MG/ML SUSP FOR INJECTION,46257,CDM,J1010,HCPCS,0009-0306-02,NDC,,,facility,both,320,ML,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 40 MG/ML SUSP (DEPO-MEDROL) INJECTION,46257,CDM,J1010,HCPCS,0009-0280-02,NDC,,,facility,both,120,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 40 MG/ML SUSP (DEPO-MEDROL) INJECTION,46257,CDM,J1010,HCPCS,70121-1573-1,NDC,,,facility,both,2,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 80 MG/ML SUSP FOR INJECTION,46257,CDM,J1010,HCPCS,70121-1574-1,NDC,,,facility,both,2,ML,,192,134.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 40 MG/ML SUSP (DEPO-MEDROL) INJECTION,46257,CDM,J1010,HCPCS,70121-1573-1,NDC,,,facility,both,80,ML,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 40 MG/ML SUSP (DEPO-MEDROL) INJECTION,46257,CDM,J1010,HCPCS,70121-1573-5,NDC,,,facility,both,40,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 40 MG/ML SUSP (DEPO-MEDROL) INJECTION,46257,CDM,J1010,HCPCS,0009-3073-01,NDC,,,facility,both,80,ML,,134,93.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 80 MG/ML SUSP FOR INJECTION,46257,CDM,J1010,HCPCS,0009-3475-01,NDC,,,facility,both,80,ML,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,46259,CDM,J2919,HCPCS,0009-0047-25,NDC,,,facility,both,11,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,46259,CDM,J2919,HCPCS,0009-0039-30,NDC,,,facility,both,3,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,46259,CDM,J2919,HCPCS,0009-0047-25,NDC,,,facility,both,16,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,46259,CDM,J2919,HCPCS,0009-0047-26,NDC,,,facility,both,17,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,46259,CDM,J2919,HCPCS,0009-0039-32,NDC,,,facility,both,25,EA,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 125 MG INJECTION SOLR,46259,CDM,J2919,HCPCS,63323-258-03,NDC,,,facility,both,25,EA,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,46259,CDM,J2919,HCPCS,0009-0047-25,NDC,,,facility,both,16,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,46259,CDM,J2919,HCPCS,0009-0039-32,NDC,,,facility,both,8,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,46259,CDM,J2919,HCPCS,0009-0039-30,NDC,,,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,46259,CDM,J2919,HCPCS,0009-0039-05,NDC,,,facility,both,8,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,46259,CDM,J2919,HCPCS,0009-0047-25,NDC,,,facility,both,9,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,46259,CDM,J2919,HCPCS,0009-0047-25,NDC,,,facility,both,12,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,46259,CDM,J2919,HCPCS,0009-0047-26,NDC,,,facility,both,8,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,46259,CDM,J2919,HCPCS,0009-0039-30,NDC,,,facility,both,5,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,46259,CDM,J2919,HCPCS,0009-0047-25,NDC,,,facility,both,9,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,46259,CDM,J2919,HCPCS,0009-0047-25,NDC,,,facility,both,4,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,46259,CDM,J2919,HCPCS,0009-0047-25,NDC,,,facility,both,17,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,46259,CDM,J2919,HCPCS,0009-0047-25,NDC,,,facility,both,13,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,46259,CDM,J2919,HCPCS,0009-0039-05,NDC,,,facility,both,8,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,46259,CDM,J2919,HCPCS,0009-0047-25,NDC,,,facility,both,8,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,46259,CDM,J2919,HCPCS,0009-0039-30,NDC,,,facility,both,6,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,46259,CDM,J2919,HCPCS,0009-0039-32,NDC,,,facility,both,7,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,46259,CDM,J2919,HCPCS,0009-0047-25,NDC,,,facility,both,19,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,46259,CDM,J2919,HCPCS,0009-0039-30,NDC,,,facility,both,8,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,46259,CDM,J2919,HCPCS,0009-0039-30,NDC,,,facility,both,16,EA,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,46259,CDM,J2919,HCPCS,0009-0039-33,NDC,,,facility,both,8,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,46259,CDM,J2919,HCPCS,0009-0047-25,NDC,,,facility,both,8,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,46259,CDM,J2919,HCPCS,0009-0047-25,NDC,,,facility,both,20,EA,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,46259,CDM,J2919,HCPCS,0009-0039-30,NDC,,,facility,both,10,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,46259,CDM,J2919,HCPCS,0009-0047-25,NDC,,,facility,both,6,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,46259,CDM,J2919,HCPCS,0009-0039-30,NDC,,,facility,both,12,EA,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,46259,CDM,J2919,HCPCS,0009-0047-25,NDC,,,facility,both,6,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 40 MG SOLUTION FOR INJECTION,46259,CDM,J2919,HCPCS,63323-255-03,NDC,,,facility,both,6,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,46259,CDM,J2919,HCPCS,0009-0047-25,NDC,,,facility,both,25,EA,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,46259,CDM,J2919,HCPCS,0009-0039-30,NDC,,,facility,both,4,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,46259,CDM,J2919,HCPCS,0009-0047-25,NDC,,,facility,both,19,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,46259,CDM,J2919,HCPCS,0009-0047-25,NDC,,,facility,both,5,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,46259,CDM,J2919,HCPCS,0009-0047-25,NDC,,,facility,both,21,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,46259,CDM,J2919,HCPCS,0009-0047-26,NDC,,,facility,both,25,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,46259,CDM,J2919,HCPCS,0009-0039-30,NDC,,,facility,both,9,EA,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,0781-3244-94,NDC,,,facility,both,165,EA,,1564,1094.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,70121-1239-1,NDC,,,facility,both,151,EA,,629,440.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,46273,CDM,J9075,HCPCS,0781-3233-94,NDC,,,facility,both,62,EA,,754,527.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,46273,CDM,J9075,HCPCS,0781-3233-94,NDC,,,facility,both,78,EA,,322,225.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,10019-956-16,NDC,,,facility,both,46,EA,,132,92.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,10019-956-16,NDC,,,facility,both,154,EA,,993,695.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,46273,CDM,J9075,HCPCS,0781-3233-94,NDC,,,facility,both,12,EA,,146,102.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,46273,CDM,J9075,HCPCS,0781-3233-94,NDC,,,facility,both,75,EA,,310,217,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,0781-3244-94,NDC,,,facility,both,68,EA,,281,196.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 2 GRAM IV SOLUTION,46273,CDM,J9075,HCPCS,0781-3255-94,NDC,,,facility,both,364,EA,,3442,2409.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,46273,CDM,J9075,HCPCS,0781-3233-94,NDC,,,facility,both,40,EA,,487,340.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,46273,CDM,J9075,HCPCS,0781-3233-94,NDC,,,facility,both,68,EA,,827,578.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 2 GRAM IV SOLUTION,46273,CDM,J9075,HCPCS,0781-3255-94,NDC,,,facility,both,78,EA,,325,227.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 2 GRAM IV SOLUTION,46273,CDM,J9075,HCPCS,0781-3255-94,NDC,,,facility,both,336,EA,,3185,2229.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,46273,CDM,J9075,HCPCS,0781-3233-94,NDC,,,facility,both,62,EA,,256,179.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,46273,CDM,J9075,HCPCS,0781-3233-94,NDC,,,facility,both,45,EA,,547,382.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 2 GRAM IV SOLUTION,46273,CDM,J9075,HCPCS,0781-3255-94,NDC,,,facility,both,68,EA,,282,197.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,46273,CDM,J9075,HCPCS,0781-3233-94,NDC,,,facility,both,33,EA,,402,281.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,46273,CDM,J9075,HCPCS,0781-3233-94,NDC,,,facility,both,24,EA,,292,204.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,46273,CDM,J9075,HCPCS,0781-3233-94,NDC,,,facility,both,25,EA,,304,212.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,46273,CDM,J9075,HCPCS,0781-3233-94,NDC,,,facility,both,49,EA,,202,141.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,46273,CDM,J9075,HCPCS,0781-3233-94,NDC,,,facility,both,68,EA,,281,196.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 2 GRAM IV SOLUTION,46273,CDM,J9075,HCPCS,0781-3255-94,NDC,,,facility,both,318,EA,,3014,2109.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,46273,CDM,J9075,HCPCS,65219-135-20,NDC,,,facility,both,33,EA,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,46273,CDM,J9075,HCPCS,0781-3233-94,NDC,,,facility,both,87,EA,,359,251.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,10019-956-16,NDC,,,facility,both,166,EA,,1073,751.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,46273,CDM,J9075,HCPCS,0781-3233-94,NDC,,,facility,both,33,EA,,136,95.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,46273,CDM,J9075,HCPCS,0781-3233-94,NDC,,,facility,both,37,EA,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,46273,CDM,J9075,HCPCS,0781-3233-94,NDC,,,facility,both,80,EA,,973,681.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,10019-956-16,NDC,,,facility,both,300,EA,,1944,1360.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,0781-3244-94,NDC,,,facility,both,65,EA,,268,187.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 2 GRAM IV SOLUTION,46273,CDM,J9075,HCPCS,10019-957-11,NDC,,,facility,both,323,EA,,3264,2284.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,65219-131-20,NDC,,,facility,both,135,EA,,857,599.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,46273,CDM,J9075,HCPCS,0781-3233-94,NDC,,,facility,both,60,EA,,730,511,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 2 GRAM IV SOLUTION,46273,CDM,J9075,HCPCS,0781-3255-94,NDC,,,facility,both,323,EA,,3060,2142,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,0781-3244-94,NDC,,,facility,both,186,EA,,1763,1234.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,0781-3244-94,NDC,,,facility,both,131,EA,,1242,869.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,0781-3244-94,NDC,,,facility,both,10,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,0781-3244-94,NDC,,,facility,both,149,EA,,1413,989.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,70121-1239-1,NDC,,,facility,both,51,EA,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,46273,CDM,J9075,HCPCS,0781-3233-94,NDC,,,facility,both,32,EA,,132,92.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,46273,CDM,J9075,HCPCS,0781-3233-94,NDC,,,facility,both,100,EA,,1216,851.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,0781-3244-94,NDC,,,facility,both,198,EA,,1877,1313.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,46273,CDM,J9075,HCPCS,0781-3233-94,NDC,,,facility,both,36,EA,,438,306.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,46273,CDM,J9075,HCPCS,65219-135-20,NDC,,,facility,both,67,EA,,517,361.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,46273,CDM,J9075,HCPCS,0781-3233-94,NDC,,,facility,both,55,EA,,227,158.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,0781-3244-94,NDC,,,facility,both,183,EA,,1735,1214.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,46273,CDM,J9075,HCPCS,0781-3233-94,NDC,,,facility,both,66,EA,,803,562.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,46273,CDM,J9075,HCPCS,0781-3233-94,NDC,,,facility,both,40,EA,,165,115.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,46273,CDM,J9075,HCPCS,0781-3233-94,NDC,,,facility,both,36,EA,,149,104.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,65219-131-20,NDC,,,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,0781-3244-94,NDC,,,facility,both,332,EA,,3147,2202.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,10019-956-16,NDC,,,facility,both,10,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,0781-3244-94,NDC,,,facility,both,87,EA,,359,251.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 2 GRAM IV SOLUTION,46273,CDM,J9075,HCPCS,0781-3255-94,NDC,,,facility,both,400,EA,,3791,2653.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,46273,CDM,J9075,HCPCS,0781-3233-94,NDC,,,facility,both,51,EA,,620,434,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,70121-1239-1,NDC,,,facility,both,9,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,0781-3244-94,NDC,,,facility,both,6,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,70121-1239-1,NDC,,,facility,both,49,EA,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,46273,CDM,J9075,HCPCS,0781-3233-94,NDC,,,facility,both,60,EA,,248,173.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,65219-131-20,NDC,,,facility,both,76,EA,,166,116.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,0781-3244-94,NDC,,,facility,both,24,EA,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,46273,CDM,J9075,HCPCS,0781-3233-94,NDC,,,facility,both,72,EA,,876,613.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,65219-131-20,NDC,,,facility,both,200,EA,,1270,889,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,0781-3244-94,NDC,,,facility,both,135,EA,,1280,896,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,46273,CDM,J9075,HCPCS,0781-3233-94,NDC,,,facility,both,96,EA,,1167,816.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,70121-1239-1,NDC,,,facility,both,200,EA,,836,585.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,70121-1239-1,NDC,,,facility,both,135,EA,,562,393.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,10019-956-16,NDC,,,facility,both,5,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,0781-3244-94,NDC,,,facility,both,176,EA,,1668,1167.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,0781-3244-94,NDC,,,facility,both,172,EA,,1630,1141,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,0781-3244-94,NDC,,,facility,both,12,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,10019-956-16,NDC,,,facility,both,156,EA,,1011,707.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,0781-3244-94,NDC,,,facility,both,194,EA,,1839,1287.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,0781-3244-94,NDC,,,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 2 GRAM IV SOLUTION,46273,CDM,J9075,HCPCS,10019-957-11,NDC,,,facility,both,322,EA,,3247,2272.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,65219-131-20,NDC,,,facility,both,200,EA,,1275,892.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,46273,CDM,J9075,HCPCS,0781-3233-94,NDC,,,facility,both,38,EA,,462,323.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,46273,CDM,J9075,HCPCS,0781-3233-94,NDC,,,facility,both,81,EA,,985,689.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,0781-3244-94,NDC,,,facility,both,200,EA,,1896,1327.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,0781-3244-94,NDC,,,facility,both,28,EA,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,0781-3244-94,NDC,,,facility,both,15,EA,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,46273,CDM,J9075,HCPCS,0781-3233-94,NDC,,,facility,both,132,EA,,1605,1123.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,46273,CDM,J9075,HCPCS,0781-3233-94,NDC,,,facility,both,300,EA,,3647,2552.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,46273,CDM,J9075,HCPCS,0781-3233-94,NDC,,,facility,both,80,EA,,330,231,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 2 GRAM IV SOLUTION,46273,CDM,J9075,HCPCS,0781-3255-94,NDC,,,facility,both,322,EA,,3044,2130.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,46273,CDM,J9075,HCPCS,0781-3233-94,NDC,,,facility,both,4,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,70121-1239-1,NDC,,,facility,both,65,EA,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,0781-3244-94,NDC,,,facility,both,35,EA,,145,101.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,70121-1239-1,NDC,,,facility,both,200,EA,,1820,1274,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,46273,CDM,J9075,HCPCS,0781-3233-94,NDC,,,facility,both,28,EA,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,46273,CDM,J9075,HCPCS,65219-135-20,NDC,,,facility,both,81,EA,,626,438.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,0781-3244-94,NDC,,,facility,both,400,EA,,3791,2653.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,46273,CDM,J9075,HCPCS,0781-3233-94,NDC,,,facility,both,42,EA,,511,357.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,46273,CDM,J9075,HCPCS,0781-3233-94,NDC,,,facility,both,122,EA,,1483,1038.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,46273,CDM,J9075,HCPCS,0781-3233-94,NDC,,,facility,both,6,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 2 GRAM IV SOLUTION,46273,CDM,J9075,HCPCS,0781-3255-94,NDC,,,facility,both,396,EA,,3753,2627.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,0781-3244-94,NDC,,,facility,both,112,EA,,1062,743.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,10019-956-16,NDC,,,facility,both,195,EA,,1260,882,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,65219-131-20,NDC,,,facility,both,117,EA,,745,521.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,0781-3244-94,NDC,,,facility,both,67,EA,,277,193.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,46273,CDM,J9075,HCPCS,0781-3233-94,NDC,,,facility,both,63,EA,,766,536.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,0781-3244-94,NDC,,,facility,both,185,EA,,1754,1227.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,46273,CDM,J9075,HCPCS,0781-3233-94,NDC,,,facility,both,67,EA,,815,570.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,10019-956-16,NDC,,,facility,both,190,EA,,1231,861.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,46273,CDM,J9075,HCPCS,0781-3233-94,NDC,,,facility,both,76,EA,,314,219.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,46273,CDM,J9075,HCPCS,0781-3233-94,NDC,,,facility,both,13,EA,,159,111.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,46273,CDM,J9075,HCPCS,0781-3233-94,NDC,,,facility,both,64,EA,,264,184.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,0781-3244-94,NDC,,,facility,both,51,EA,,211,147.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,46273,CDM,J9075,HCPCS,0781-3233-94,NDC,,,facility,both,19,EA,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 2 GRAM IV SOLUTION,46273,CDM,J9075,HCPCS,0781-3255-94,NDC,,,facility,both,353,EA,,3340,2338,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,46273,CDM,J9075,HCPCS,0781-3233-94,NDC,,,facility,both,94,EA,,1143,800.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,0781-3244-94,NDC,,,facility,both,190,EA,,1801,1260.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 2 GRAM IV SOLUTION,46273,CDM,J9075,HCPCS,10019-957-11,NDC,,,facility,both,77,EA,,340,238,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,46273,CDM,J9075,HCPCS,0781-3233-94,NDC,,,facility,both,64,EA,,778,544.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 2 GRAM IV SOLUTION,46273,CDM,J9075,HCPCS,0781-3255-94,NDC,,,facility,both,77,EA,,319,223.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 2 GRAM IV SOLUTION,46273,CDM,J9075,HCPCS,0781-3255-94,NDC,,,facility,both,82,EA,,338,236.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,0781-3244-94,NDC,,,facility,both,17,EA,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,0781-3244-94,NDC,,,facility,both,88,EA,,363,254.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 2 GRAM IV SOLUTION,46273,CDM,J9075,HCPCS,0781-3255-94,NDC,,,facility,both,4,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,65219-131-20,NDC,,,facility,both,83,EA,,180,126,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,0781-3244-94,NDC,,,facility,both,113,EA,,1071,749.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,46273,CDM,J9075,HCPCS,0781-3233-94,NDC,,,facility,both,38,EA,,157,109.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,70121-1239-1,NDC,,,facility,both,149,EA,,622,435.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,46273,CDM,J9075,HCPCS,0781-3233-94,NDC,,,facility,both,20,EA,,244,170.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,0781-3244-94,NDC,,,facility,both,69,EA,,285,199.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,65219-131-20,NDC,,,facility,both,198,EA,,1262,883.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,46273,CDM,J9075,HCPCS,0781-3233-94,NDC,,,facility,both,34,EA,,141,98.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,0781-3244-94,NDC,,,facility,both,83,EA,,342,239.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,46273,CDM,J9075,HCPCS,0781-3233-94,NDC,,,facility,both,88,EA,,363,254.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,65219-131-20,NDC,,,facility,both,194,EA,,1232,862.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,46273,CDM,J9075,HCPCS,65219-135-20,NDC,,,facility,both,100,EA,,778,544.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,0781-3244-94,NDC,,,facility,both,14,EA,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,0781-3244-94,NDC,,,facility,both,188,EA,,1782,1247.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 2 GRAM IV SOLUTION,46273,CDM,J9075,HCPCS,0781-3255-94,NDC,,,facility,both,36,EA,,152,106.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,46273,CDM,J9075,HCPCS,65219-135-20,NDC,,,facility,both,19,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 2 GRAM IV SOLUTION,46273,CDM,J9075,HCPCS,0781-3255-94,NDC,,,facility,both,332,EA,,3143,2200.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 2 GRAM IV SOLUTION,46273,CDM,J9075,HCPCS,10019-957-11,NDC,,,facility,both,364,EA,,3672,2570.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 2 GRAM IV SOLUTION,46273,CDM,J9075,HCPCS,0781-3255-94,NDC,,,facility,both,64,EA,,264,184.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,65219-131-20,NDC,,,facility,both,6,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,70121-1239-1,NDC,,,facility,both,191,EA,,798,558.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,0781-3244-94,NDC,,,facility,both,117,EA,,1109,776.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,65219-131-20,NDC,,,facility,both,124,EA,,786,550.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,46273,CDM,J9075,HCPCS,70121-1238-1,NDC,,,facility,both,45,EA,,230,161,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,46273,CDM,J9075,HCPCS,70121-1238-1,NDC,,,facility,both,55,EA,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,65219-131-20,NDC,,,facility,both,65,EA,,142,99.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,0781-3244-94,NDC,,,facility,both,133,EA,,1261,882.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,46273,CDM,J9075,HCPCS,0781-3233-94,NDC,,,facility,both,20,EA,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,0781-3244-94,NDC,,,facility,both,154,EA,,1460,1022,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,10019-956-16,NDC,,,facility,both,200,EA,,1296,907.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,10019-956-16,NDC,,,facility,both,44,EA,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,46273,CDM,J9075,HCPCS,0781-3233-94,NDC,,,facility,both,58,EA,,239,167.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,46273,CDM,J9075,HCPCS,70121-1238-1,NDC,,,facility,both,100,EA,,510,357,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,46273,CDM,J9075,HCPCS,0781-3233-94,NDC,,,facility,both,67,EA,,277,193.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,46273,CDM,J9075,HCPCS,0781-3244-94,NDC,,,facility,both,46,EA,,190,133,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 2 GRAM IV SOLUTION,46273,CDM,J9075,HCPCS,0781-3255-94,NDC,,,facility,both,47,EA,,197,137.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE 64 MG/0.18 ML SUBQ SLSY,46289,CDM,J0578,HCPCS,58284-264-01,NDC,,,facility,both,1,ML,,4047,2832.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TREMELIMUMAB-ACTL 20 MG/ML IV SOLN,46427,CDM,J9347,HCPCS,0310-4535-30,NDC,,,facility,both,300,ML,,107640,75348,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TREMELIMUMAB-ACTL 20 MG/ML IV SOLN,46427,CDM,J9347,HCPCS,0310-4505-25,NDC,,,facility,both,75,ML,,26910,18837,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC IV INFUSION PEMIVIBART,46555,CDM,771,RC,Q0224,HCPCS,81960-031-03,NDC,facility,both,1,ML,,15939,11157.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC IV INFUSION PEMIVIBART,46561,CDM,Q0224,HCPCS,81960-031-03,NDC,,,facility,both,1,ML,,15939,11157.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOSTARLIMAB-GXLY 50 MG/ML IV SOLN,46784,CDM,J9272,HCPCS,0173-0898-03,NDC,,,facility,both,100,ML,,61350,42945,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOSTARLIMAB-GXLY 50 MG/ML IV SOLN,46784,CDM,J9272,HCPCS,0173-0898-03,NDC,,,facility,both,50,ML,,30675,21472.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,47045,CDM,J0561,HCPCS,60793-701-02,NDC,,,facility,both,6,ML,,594,415.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 2400000 UNIT/4 ML IM SYRG,47045,CDM,J0561,HCPCS,60793-702-04,NDC,,,facility,both,24,ML,,1898,1328.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,47045,CDM,J0561,HCPCS,60793-701-10,NDC,,,facility,both,6,ML,,222,155.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,47045,CDM,J0561,HCPCS,60793-701-10,NDC,,,facility,both,6,ML,,654,457.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 2400000 UNIT/4 ML IM SYRG,47045,CDM,J0561,HCPCS,60793-702-04,NDC,,,facility,both,24,ML,,1725,1207.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,47045,CDM,J0561,HCPCS,60793-701-02,NDC,,,facility,both,24,ML,,2160,1512,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 2400000 UNIT/4 ML IM SYRG,47045,CDM,J0561,HCPCS,60793-702-04,NDC,,,facility,both,24,ML,,1725,1207.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,47045,CDM,J0561,HCPCS,60793-701-02,NDC,,,facility,both,12,ML,,1080,756,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,47045,CDM,J0561,HCPCS,60793-701-02,NDC,,,facility,both,24,ML,,2376,1663.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,47045,CDM,J0561,HCPCS,60793-701-02,NDC,,,facility,both,12,ML,,1188,831.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,47045,CDM,J0561,HCPCS,60793-701-02,NDC,,,facility,both,6,ML,,222,155.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 2400000 UNIT/4 ML IM SYRG,47045,CDM,J0561,HCPCS,60793-702-04,NDC,,,facility,both,24,ML,,2088,1461.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,47045,CDM,J0561,HCPCS,60793-701-02,NDC,,,facility,both,12,ML,,1080,756,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 2400000 UNIT/4 ML IM SYRG,47045,CDM,J0561,HCPCS,60793-702-04,NDC,,,facility,both,24,ML,,2088,1461.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 1200000 UNIT/2 ML IM SYRG,47045,CDM,J0561,HCPCS,60793-700-10,NDC,,,facility,both,12,ML,,1674,1171.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,47045,CDM,J0561,HCPCS,60793-701-02,NDC,,,facility,both,12,ML,,1188,831.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,47045,CDM,J0561,HCPCS,60793-700-01,NDC,,,facility,both,12,ML,,1522,1065.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,47045,CDM,J0561,HCPCS,60793-701-10,NDC,,,facility,both,24,ML,,2376,1663.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 1200000 UNIT/2 ML IM SYRG,47045,CDM,J0561,HCPCS,60793-700-10,NDC,,,facility,both,24,ML,,3043,2130.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,47045,CDM,J0561,HCPCS,60793-700-01,NDC,,,facility,both,6,ML,,755,528.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,47045,CDM,J0561,HCPCS,60793-701-02,NDC,,,facility,both,24,ML,,2613,1829.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,47045,CDM,J0561,HCPCS,60793-701-02,NDC,,,facility,both,12,ML,,1307,914.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,47045,CDM,J0561,HCPCS,60793-701-02,NDC,,,facility,both,12,ML,,1307,914.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 1200000 UNIT/2 ML IM SYRG,47045,CDM,J0561,HCPCS,60793-700-10,NDC,,,facility,both,24,ML,,3348,2343.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,47045,CDM,J0561,HCPCS,60793-701-02,NDC,,,facility,both,6,ML,,202,141.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,47045,CDM,J0561,HCPCS,60793-701-02,NDC,,,facility,both,24,ML,,2613,1829.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,47045,CDM,J0561,HCPCS,60793-701-02,NDC,,,facility,both,99999,ML,,593811400,415667980,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,47045,CDM,J0561,HCPCS,60793-701-02,NDC,,,facility,both,24,ML,,2160,1512,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,47045,CDM,J0561,HCPCS,60793-700-01,NDC,,,facility,both,6,ML,,761,532.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,47045,CDM,J0561,HCPCS,60793-701-10,NDC,,,facility,both,12,ML,,1188,831.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,47045,CDM,J0561,HCPCS,60793-701-02,NDC,,,facility,both,24,ML,,2376,1663.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,47045,CDM,J0561,HCPCS,60793-701-02,NDC,,,facility,both,6,ML,,654,457.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,47045,CDM,J0561,HCPCS,60793-701-10,NDC,,,facility,both,12,ML,,1307,914.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,47045,CDM,J0561,HCPCS,60793-700-01,NDC,,,facility,both,6,ML,,761,532.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,47045,CDM,J0561,HCPCS,60793-701-10,NDC,,,facility,both,12,ML,,1188,831.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,47045,CDM,J0561,HCPCS,60793-700-01,NDC,,,facility,both,24,ML,,3018,2112.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC HEARING SCREEN-JOHN HOPKINS CONTRACT,47100016,CDM,471,RC,47100016,HCPCS,,,facility,both,,,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Central
HC AUDITOR EVOKE POTENT SCEEN AUDITOR POTENT W/BROADBAND  STIMULI AUTO ANALYSIS,47100038,CDM,471,RC,92650,HCPCS,,,facility,both,,,,535,374.5,,,,,,,,,,,,,Gross Charge Type: Central
HC AUDITOR EVOKE POTENT HEARING STATUS DETER BROADBAND STIMULI W/INTERP & REPORT,47100039,CDM,471,RC,92651,HCPCS,,,facility,both,,,,611,427.7,,,,,,,,,,,,,Gross Charge Type: Central
"PENICILLIN G BENZATHINE&PROCAIN 1,200,000 UNIT/2 ML IM SYRINGE",47119,CDM,J0558,HCPCS,60793-600-02,NDC,,,facility,both,12,ML,,861,602.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"PENICILLIN G BENZATHINE&PROCAIN 1,200,000 UNIT/2 ML IM SYRINGE",47119,CDM,J0558,HCPCS,60793-601-02,NDC,,,facility,both,12,ML,,861,602.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML (1ML) INJ SOLN,47126,CDM,J0171,HCPCS,42023-159-01,NDC,,,facility,both,10,ML,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.3 MG/0.3 ML IM PNIJ,47126,CDM,J0171,HCPCS,49502-102-01,NDC,,,facility,both,3,EA,,675,472.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.3 MG/0.3 ML IM PNIJ,47126,CDM,J0171,HCPCS,49502-500-01,NDC,,,facility,both,3,EA,,1078,754.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.15 MG/0.3 ML IM PNIJ,47126,CDM,J0171,HCPCS,49502-101-01,NDC,,,facility,both,2,EA,,675,472.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIVOLUMAB-RELATLIMAB-RMBW 240-80 MG/20 ML IV SOLN,47433,CDM,J9298,HCPCS,0003-7125-11,NDC,,,facility,both,1,EA,,56694,39685.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 120 ML OF NIVOLUMAB-RELATLIMAB-RMBW
NIVOLUMAB-RELATLIMAB-RMBW 240-80 MG/20 ML IV SOLN,47433,CDM,J9298,HCPCS,0003-7125-11,NDC,,,facility,both,1,EA,,75593,52915.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 120 ML OF NIVOLUMAB-RELATLIMAB-RMBW
NIVOLUMAB-RELATLIMAB-RMBW 240-80 MG/20 ML IV SOLN,47433,CDM,J9298,HCPCS,0003-7125-11,NDC,,,facility,both,1,EA,,56695,39686.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 120 ML OF NIVOLUMAB-RELATLIMAB-RMBW
NIVOLUMAB-RELATLIMAB-RMBW 240-80 MG/20 ML IV SOLN,47433,CDM,J9298,HCPCS,0003-7125-11,NDC,,,facility,both,1,EA,,75593,52915.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 160 ML OF NIVOLUMAB-RELATLIMAB-RMBW
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,63323-466-03,NDC,,,facility,both,90,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0143-9328-01,NDC,,,facility,both,75,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,55150-170-30,NDC,,,facility,both,60,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,63323-466-31,NDC,,,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0409-1162-19,NDC,,,facility,both,270,ML,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0409-1162-18,NDC,,,facility,both,200,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0143-9328-01,NDC,,,facility,both,2,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,55150-169-10,NDC,,,facility,both,50,ML,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0409-1162-19,NDC,,,facility,both,200,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,55150-169-10,NDC,,,facility,both,60,ML,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0409-1162-18,NDC,,,facility,both,40,ML,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,63323-465-01,NDC,,,facility,both,150,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0143-9328-01,NDC,,,facility,both,4,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,63323-466-03,NDC,,,facility,both,70,ML,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0409-1160-01,NDC,,,facility,both,13,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0409-1162-01,NDC,,,facility,both,100,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,63323-466-17,NDC,,,facility,both,300,ML,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0409-1560-18,NDC,,,facility,both,80,ML,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0143-9328-01,NDC,,,facility,both,15,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0409-1162-18,NDC,,,facility,both,500,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0409-1162-01,NDC,,,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,55150-169-10,NDC,,,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,55150-169-10,NDC,,,facility,both,200,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0409-1162-18,NDC,,,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0409-1160-18,NDC,,,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,63323-465-01,NDC,,,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,63323-465-01,NDC,,,facility,both,15,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,63323-465-01,NDC,,,facility,both,150,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0409-1162-19,NDC,,,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0409-1162-01,NDC,,,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,55150-170-30,NDC,,,facility,both,280,ML,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,55150-169-10,NDC,,,facility,both,100,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0409-1162-01,NDC,,,facility,both,80,ML,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,63323-466-17,NDC,,,facility,both,100,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0409-1162-18,NDC,,,facility,both,160,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,55150-170-30,NDC,,,facility,both,300,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0409-1162-19,NDC,,,facility,both,250,ML,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0409-1162-18,NDC,,,facility,both,100,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,55150-169-10,NDC,,,facility,both,40,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,70594-117-01,NDC,,,facility,both,300,ML,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0409-1162-19,NDC,,,facility,both,280,ML,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0409-1162-19,NDC,,,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,63323-466-03,NDC,,,facility,both,100,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,55150-169-10,NDC,,,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,55150-249-50,NDC,,,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,55150-170-30,NDC,,,facility,both,60,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0409-1162-02,NDC,,,facility,both,290,ML,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0409-1162-18,NDC,,,facility,both,60,ML,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,70594-117-01,NDC,,,facility,both,100,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0409-1162-01,NDC,,,facility,both,90,ML,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0409-1160-01,NDC,,,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0409-1162-18,NDC,,,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,55150-169-10,NDC,,,facility,both,80,ML,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,63323-466-03,NDC,,,facility,both,50,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,63323-466-31,NDC,,,facility,both,200,ML,,165,115.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,55150-170-30,NDC,,,facility,both,8,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,63323-465-01,NDC,,,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0409-1162-19,NDC,,,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,55150-170-30,NDC,,,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0409-1162-18,NDC,,,facility,both,200,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,55150-249-50,NDC,,,facility,both,150,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,63323-466-03,NDC,,,facility,both,50,ML,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,63323-465-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,55150-170-30,NDC,,,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,63323-466-17,NDC,,,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,55150-170-30,NDC,,,facility,both,240,ML,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,72603-506-01,NDC,,,facility,both,300,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0409-1162-18,NDC,,,facility,both,100,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0409-1160-01,NDC,,,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,63323-466-17,NDC,,,facility,both,100,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0409-1162-19,NDC,,,facility,both,300,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,55150-169-10,NDC,,,facility,both,60,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,63323-466-03,NDC,,,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0409-1162-18,NDC,,,facility,both,300,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,63323-466-03,NDC,,,facility,both,60,ML,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,63323-465-01,NDC,,,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0409-1162-01,NDC,,,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,55150-170-30,NDC,,,facility,both,250,ML,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0409-1162-18,NDC,,,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0409-1162-02,NDC,,,facility,both,260,ML,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0143-9328-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,70594-117-01,NDC,,,facility,both,200,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0409-1162-01,NDC,,,facility,both,25,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0409-1162-02,NDC,,,facility,both,40,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,55150-169-10,NDC,,,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0409-1162-18,NDC,,,facility,both,70,ML,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0409-1162-01,NDC,,,facility,both,200,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0409-1162-02,NDC,,,facility,both,295,ML,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0409-1162-02,NDC,,,facility,both,250,ML,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0409-1162-02,NDC,,,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0143-9328-01,NDC,,,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,55150-170-30,NDC,,,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0143-9328-01,NDC,,,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,55150-170-30,NDC,,,facility,both,6,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,63323-466-03,NDC,,,facility,both,80,ML,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0409-1162-18,NDC,,,facility,both,50,ML,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0409-1162-19,NDC,,,facility,both,100,ML,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,63323-466-31,NDC,,,facility,both,300,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0409-1560-18,NDC,,,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,55150-170-30,NDC,,,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0409-1162-18,NDC,,,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,63323-466-03,NDC,,,facility,both,200,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,63323-466-01,NDC,,,facility,both,300,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,55150-170-30,NDC,,,facility,both,16,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,55150-170-30,NDC,,,facility,both,270,ML,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0409-1162-01,NDC,,,facility,both,200,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0409-1560-18,NDC,,,facility,both,60,ML,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,63323-466-03,NDC,,,facility,both,40,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,63323-466-17,NDC,,,facility,both,300,ML,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,55150-170-30,NDC,,,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,63323-466-03,NDC,,,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0409-1160-18,NDC,,,facility,both,15,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,63323-465-01,NDC,,,facility,both,25,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0409-1162-01,NDC,,,facility,both,200,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0409-1162-18,NDC,,,facility,both,40,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,63323-465-01,NDC,,,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0143-9328-01,NDC,,,facility,both,150,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0409-1162-18,NDC,,,facility,both,300,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,63323-466-17,NDC,,,facility,both,90,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0409-1162-01,NDC,,,facility,both,75,ML,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0409-1162-18,NDC,,,facility,both,80,ML,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0409-1160-01,NDC,,,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,63323-465-57,NDC,,,facility,both,150,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,72603-506-01,NDC,,,facility,both,100,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0409-1162-02,NDC,,,facility,both,300,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0409-1560-18,NDC,,,facility,both,40,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,63323-466-03,NDC,,,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,55150-169-10,NDC,,,facility,both,70,ML,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0409-1162-18,NDC,,,facility,both,300,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0409-1162-01,NDC,,,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,63323-466-03,NDC,,,facility,both,300,ML,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0143-9334-01,NDC,,,facility,both,300,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,63323-466-31,NDC,,,facility,both,280,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,63323-466-03,NDC,,,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,55150-170-30,NDC,,,facility,both,100,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0409-1162-19,NDC,,,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0409-1560-18,NDC,,,facility,both,100,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0409-1162-01,NDC,,,facility,both,50,ML,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0409-1162-02,NDC,,,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0409-1162-18,NDC,,,facility,both,200,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,63323-466-17,NDC,,,facility,both,200,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,55150-170-30,NDC,,,facility,both,200,ML,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0409-1162-01,NDC,,,facility,both,100,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0409-1162-19,NDC,,,facility,both,200,ML,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0409-1160-01,NDC,,,facility,both,150,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,63323-466-03,NDC,,,facility,both,95,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,55150-169-10,NDC,,,facility,both,300,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,0409-1162-02,NDC,,,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,47474,CDM,J0665,HCPCS,55150-170-30,NDC,,,facility,both,9,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEGFILGRASTIM-PBBK 6 MG/0.6 ML SUBQ SYRG,47676,CDM,Q5130,HCPCS,70121-1627-1,NDC,,,facility,both,12,ML,,6900,4830,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,47684,CDM,J1938,HCPCS,23155-473-32,NDC,,,facility,both,80,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,47684,CDM,J1938,HCPCS,36000-283-25,NDC,,,facility,both,40,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,47684,CDM,J1938,HCPCS,23155-473-32,NDC,,,facility,both,40,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,47684,CDM,J1938,HCPCS,63323-280-03,NDC,,,facility,both,40,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,47684,CDM,J1938,HCPCS,0409-6102-19,NDC,,,facility,both,40,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,47684,CDM,J1938,HCPCS,63323-280-03,NDC,,,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,47684,CDM,J1938,HCPCS,0409-6102-19,NDC,,,facility,both,20,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,47684,CDM,J1938,HCPCS,63323-280-04,NDC,,,facility,both,40,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COVID VACCINE 24-25 (6M-4Y)(PFI)-PF 3 MCG/0.3 ML IM SUSP,47937,CDM,91318,HCPCS,59267-4426-1,NDC,,,facility,both,1,ML,,249,174.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COVID VACCINE 24-25 (6M-4Y)(PFI)-PF 3 MCG/0.3 ML IM SUSP,47937,CDM,91318,HCPCS,59267-4426-2,NDC,,,facility,both,1,ML,,249,174.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COVID VACCINE 24-25 (5-11Y)(PFI)-PF 10 MCG/0.3 ML IM SUSP,47941,CDM,91319,HCPCS,59267-4438-1,NDC,,,facility,both,1,ML,,392,274.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COVID VACCINE 24-25 (5-11Y)(PFI)-PF 10 MCG/0.3 ML IM SUSP,47941,CDM,91319,HCPCS,59267-4438-2,NDC,,,facility,both,1,ML,,392,274.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COVID VACCINE 24-25 (12UP)(PFI)(PF) 30 MCG/0.3 ML IM SYRG,47945,CDM,91320,HCPCS,0069-2528-01,NDC,,,facility,both,1,ML,,639,447.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COVID VACCINE 24-25 (12UP)(PFI)(PF) 30 MCG/0.3 ML IM SYRG,47945,CDM,91320,HCPCS,0069-2528-01,NDC,,,facility,both,1,ML,,639,447.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COVID VACCINE 24-25 (12UP)(PFI)(PF) 30 MCG/0.3 ML IM SYRG,47945,CDM,91320,HCPCS,0069-2432-01,NDC,,,facility,both,1,ML,,1182,827.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COVID VACCINE 24-25 (12UP)(PFI)(PF) 30 MCG/0.3 ML IM SYRG,47945,CDM,91320,HCPCS,0069-2432-10,NDC,,,facility,both,2,ML,,1182,827.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COVID VACCINE 24-25 (12UP)(PFI)(PF) 30 MCG/0.3 ML IM SYRG,47945,CDM,91320,HCPCS,0069-2432-01,NDC,,,facility,both,1,ML,,591,413.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COVID VACCINE 24-25 (12UP)(PFI)(PF) 30 MCG/0.3 ML IM SYRG,47945,CDM,91320,HCPCS,0069-2528-01,NDC,,,facility,both,2,ML,,1277,893.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COVID VACCINE 24-25 (12UP)(PFI)(PF) 30 MCG/0.3 ML IM SYRG,47945,CDM,91320,HCPCS,0069-2432-01,NDC,,,facility,both,2,ML,,1182,827.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COVID VACCINE 24-25 (12UP)(PFI)(PF) 30 MCG/0.3 ML IM SYRG,47945,CDM,91320,HCPCS,0069-2432-10,NDC,,,facility,both,1,ML,,591,413.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COVID VAC 25-26(12UP)(PFI)(PF) 30 MCG/0.3 ML IM SYRG,47945,CDM,91320,HCPCS,0069-2528-10,NDC,,,facility,both,1,ML,,639,447.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COVID VACCINE 24-25 (6M-11Y)(MOD)PF 25 MCG/0.25 ML IM SYRG,47949,CDM,91321,HCPCS,80777-291-09,NDC,,,facility,both,2,ML,,1115,780.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COVID VACCINE 24-25 (6M-11Y)(MOD)PF 25 MCG/0.25 ML IM SYRG,47949,CDM,91321,HCPCS,80777-291-81,NDC,,,facility,both,1,ML,,558,390.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COVID VACCINE 24-25 (6M-11Y)(MOD)PF 25 MCG/0.25 ML IM SYRG,47949,CDM,91321,HCPCS,80777-291-80,NDC,,,facility,both,1,ML,,558,390.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COVID VACCINE 24-25 (6M-11Y)(MOD)PF 25 MCG/0.25 ML IM SYRG,47949,CDM,91321,HCPCS,80777-291-09,NDC,,,facility,both,1,ML,,558,390.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COVID VAC 25-26(6M-11Y)(MOD)PF 25 MCG/0.25 ML IM SYRG,47949,CDM,91321,HCPCS,80777-113-09,NDC,,,facility,both,1,ML,,558,390.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COVID VAC 25-26(12UP)(MOD)(PF) 50 MCG/0.5 ML IM SYRG,47953,CDM,91322,HCPCS,80777-112-01,NDC,,,facility,both,1,ML,,613,429.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COVID VACCINE 24-25 (12UP)(MOD)(PF) 50 MCG/0.5 ML IM SYRG,47953,CDM,91322,HCPCS,80777-110-01,NDC,,,facility,both,1,ML,,613,429.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COVID VACCINE 24-25 (12UP)(MOD)(PF) 50 MCG/0.5 ML IM SYRG,47953,CDM,91322,HCPCS,80777-110-93,NDC,,,facility,both,1,ML,,613,429.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"RSV VAC, PREF A AND PREF B(PF) 120 MCG/0.5 ML IM SOLR",47959,CDM,90678,HCPCS,0069-0344-01,NDC,,,facility,both,1,EA,,1087,760.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"RSV VAC, PREF A AND PREF B(PF) 120 MCG/0.5 ML IM SOLR",47959,CDM,90678,HCPCS,0069-0207-01,NDC,,,facility,both,1,EA,,1087,760.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"RSV VAC, PREF A AND PREF B(PF) 120 MCG/0.5 ML IM SOLR",47959,CDM,90678,HCPCS,0069-0344-01,NDC,,,facility,both,1,EA,,1045,731.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"RSV VAC, PREF A AND PREF B(PF) 120 MCG/0.5 ML IM SOLR",47959,CDM,90678,HCPCS,0069-0344-05,NDC,,,facility,both,1,EA,,1045,731.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"RSV VAC, PREF A AND PREF B(PF) 120 MCG/0.5 ML IM SOLR",47959,CDM,90678,HCPCS,0069-2465-01,NDC,,,facility,both,1,EA,,1087,760.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"RSV VAC, PREF A AND PREF B(PF) 120 MCG/0.5 ML IM SOLR",47959,CDM,90678,HCPCS,0069-0207-01,NDC,,,facility,both,1,EA,,1045,731.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC HEART/LUNG RESUSCITATION CPR,48000001,CDM,480,RC,92950,HCPCS,,,facility,both,,,,962,673.4,,,,,,,,,,,,,Gross Charge Type: Central
HC TEMPORARY EXTERNAL PACING,48000002,CDM,480,RC,92953,HCPCS,,,facility,both,,,,937,655.9,,,,,,,,,,,,,Gross Charge Type: Central
CARDIOVERSION ELECTRIC EXT,48000003,CDM,480,RC,92960,HCPCS,,,facility,both,,,,1742,1219.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PERQ CORONARY THROMBECT,48000004,CDM,480,RC,92973,HCPCS,,,facility,both,,,,5916,4141.2,,,,,,,,,,,,,Gross Charge Type: Central
HC THROMBOL CORONARY ANGIO,48000005,CDM,480,RC,92975,HCPCS,,,facility,both,,,,2306,1614.2,,,,,,,,,,,,,Gross Charge Type: Central
HC THROMBOL CORONARY IV INFUSION,48000006,CDM,480,RC,92977,HCPCS,,,facility,both,,,,1118,782.6,,,,,,,,,,,,,Gross Charge Type: Central
HC INTRAVASCULAR HEART ADD-ON INITIAL VESSEL (LIST SEP IN ADDT TO CODE FOR PRIMARY PROCEDURE),48000007,CDM,480,RC,92978,HCPCS,,,facility,both,,,,3055,2138.5,,,,,,,,,,,,,Gross Charge Type: Central
HC INTRAVASCULAR HEART ADD-ON EACH ADDTL VESSEL (LIST SEP IN ADDT TO CODE FOR PRIMARY PROCEDURE),48000008,CDM,480,RC,92979,HCPCS,,,facility,both,,,,1869,1308.3,,,,,,,,,,,,,Gross Charge Type: Central
HC INSERT INTRACORON STENT SINGL,48000009,CDM,480,RC,92928,HCPCS,,,facility,both,,,,13060,9142,,,,,,,,,,,,,Gross Charge Type: Central
HC INSERT INTRACORON STENT ADDL EA,48000010,CDM,480,RC,92929,HCPCS,,,facility,both,,,,8885,6219.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PTA CORONARY SINGL,48000011,CDM,480,RC,92920,HCPCS,,,facility,both,,,,11109,7776.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PTA CORONARY ADDL EA,48000012,CDM,480,RC,92921,HCPCS,,,facility,both,,,,7738,5416.6,,,,,,,,,,,,,Gross Charge Type: Central
HC REVISION OF AORTIC VALVE,48000013,CDM,480,RC,92986,HCPCS,,,facility,both,,,,36231,25361.7,,,,,,,,,,,,,Gross Charge Type: Central
HC REVISION OF PULMONARY VALVE,48000014,CDM,480,RC,92990,HCPCS,,,facility,both,,,,13691,9583.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PTA PULMONARY ARTERY BALLOON ANGIOPLASTY SINGLE VESSEL,48000016,CDM,480,RC,92997,HCPCS,,,facility,both,,,,18545,12981.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PTA PULMONARY ARTERY BALLOON ANGIOPLASTY EA ADDTL VESSEL,48000017,CDM,480,RC,92998,HCPCS,,,facility,both,,,,13653,9557.1,,,,,,,,,,,,,Gross Charge Type: Central
ECHO TRANSESOPH CARD ANOMAL,48000018,CDM,483,RC,93315,HCPCS,,,facility,both,,,,771,539.7,,,,,,,,,,,,,Gross Charge Type: Central
HC ECHO SPECTRAL DOPPLER ADD-ON,48000019,CDM,480,RC,93320,HCPCS,,,facility,both,,,,377,263.9,,,,,,,,,,,,,Gross Charge Type: Central
HC ECHO COLOR FLOW ADD-ON,48000020,CDM,480,RC,93325,HCPCS,,,facility,both,,,TC,121,84.7,,,,,,,,,,,,,"Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier TC: Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities"
HC HEART FLOW RESERVE MEASURE,48000021,CDM,480,RC,93571,HCPCS,,,facility,both,,,,3755,2628.5,,,,,,,,,,,,,Gross Charge Type: Central
HC HEART FLOW RESERVE MEASURE,48000022,CDM,480,RC,93572,HCPCS,,,facility,both,,,,3786,2650.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PERQ TRCATH CLOSURE OF ASD IMPLA,48000023,CDM,480,RC,93580,HCPCS,,,facility,both,,,,20512,14358.4,,,,,,,,,,,,,Gross Charge Type: Central
HC BUNDLE OF HIS RECORDING,48000024,CDM,480,RC,93600,HCPCS,,,facility,both,,,,6592,4614.4,,,,,,,,,,,,,Gross Charge Type: Central
HC MAP TACHYCARDIA ADD-ON,48000025,CDM,480,RC,93609,HCPCS,,,facility,both,,,,144,100.8,,,,,,,,,,,,,Gross Charge Type: Central
HC ELECTROPHYS MAP 3D ADD-ON,48000026,CDM,480,RC,93613,HCPCS,,,facility,both,,,,15496,10847.2,,,,,,,,,,,,,Gross Charge Type: Central
HC COMP ELECTROPH EVAL,48000027,CDM,480,RC,93619,HCPCS,,,facility,both,,,,29138,20396.6,,,,,,,,,,,,,Gross Charge Type: Central
HC COMP ELECTROPH EVAL R HRT,48000028,CDM,480,RC,93620,HCPCS,,,facility,both,,,,10776,7543.2,,,,,,,,,,,,,Gross Charge Type: Central
HC EVAL DEFIB PUL GEN AND LEADS,48000029,CDM,480,RC,93641,HCPCS,,,facility,both,,,,1516,1061.2,,,,,,,,,,,,,Gross Charge Type: Central
HC EVAL DEFIB PUL GEN,48000030,CDM,480,RC,93642,HCPCS,,,facility,both,,,,5715,4000.5,,,,,,,,,,,,,Gross Charge Type: Central
HC TILT TABLE EVALUATION W/WO RX,48000031,CDM,480,RC,93660,HCPCS,,,facility,both,,,,1873,1311.1,,,,,,,,,,,,,Gross Charge Type: Central
HC ECHO TRAN 2D W-INTRP SUP,48000034,CDM,480,RC,93351,HCPCS,,,facility,both,,,,844,590.8,,,,,,,,,,,,,Gross Charge Type: Central
HC ECHOC REAL-T,48000035,CDM,480,RC,C8928,HCPCS,,,facility,both,,,,2372,1660.4,,,,,,,,,,,,,Gross Charge Type: Central
HC INSERT VAD ARTERY ACCESS LEFT HEART,48000038,CDM,480,RC,33990,HCPCS,,,facility,both,,,,6710,4697,,,,,,,,,,,,,Gross Charge Type: Central
HC REMOVE VAD DISTINCT SESSION ARTERIAL OR ARTERIAL & VENOUS CANNULA(S),48000039,CDM,480,RC,33992,HCPCS,,,facility,both,,,,6710,4697,,,,,,,,,,,,,Gross Charge Type: Central
HC REPOSITION VAD DISTINCT SESSION RT OR LT HEART,48000040,CDM,480,RC,33993,HCPCS,,,facility,both,,,,6710,4697,,,,,,,,,,,,,Gross Charge Type: Central
HC REMOVE AORTIC ASSIST DEVICE,48000041,CDM,480,RC,33968,HCPCS,,,facility,both,,,,3522,2465.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PERC DRUG EL COR STENT SING,48000042,CDM,480,RC,C9600,HCPCS,,,facility,both,,,,17552,12286.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PERC D E COR REVASC W AMI S,48000043,CDM,480,RC,C9606,HCPCS,,,facility,both,,,,21111,14777.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PERC DRUG-EL STENT BRAN,48000044,CDM,480,RC,C9601,HCPCS,,,facility,both,,,,11109,7776.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PERC D-E STENT ATHER S,48000045,CDM,480,RC,C9602,HCPCS,,,facility,both,,,,21111,14777.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PERC D-E STENT ATHER BR,48000046,CDM,480,RC,C9603,HCPCS,,,facility,both,,,,11109,7776.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PERC D-E REVASC T CABG S,48000047,CDM,480,RC,C9604,HCPCS,,,facility,both,,,,14693,10285.1,,,,,,,,,,,,,Gross Charge Type: Central
HC D-E COR REVASC T CABG B,48000048,CDM,480,RC,C9605,HCPCS,,,facility,both,,,,11109,7776.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PERC D-E COR REVASC CHRO SIN,48000049,CDM,480,RC,C9607,HCPCS,,,facility,both,,,,21111,14777.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PERC D-E REVASC CHRO ADD,48000050,CDM,480,RC,C9608,HCPCS,,,facility,both,,,,11109,7776.3,,,,,,,,,,,,,Gross Charge Type: Central
HC REVISION OF MITRAL VALVE,48000051,CDM,480,RC,92987,HCPCS,,,facility,both,,,,13501,9450.7,,,,,,,,,,,,,Gross Charge Type: Central
HC ELECTROPHYSIOLOGIC EVAL OF SUBCU IMPLANTABLE DEFIBRILLATOR,48000052,CDM,480,RC,93644,HCPCS,,,facility,both,,,,3065,2145.5,,,,,,,,,,,,,Gross Charge Type: Central
HC SHOCKWAVE CORONARY IVL,48000055,CDM,480,RC,93799,HCPCS,,,facility,both,,,,18988,13291.6,,,,,,,,,,,,,Gross Charge Type: Central
HC TRANSESOPHAGEAL ECHO CONGENITAL CARDIAC ANOMALIES PLACEMENT OF TRANSESOPHAGEAL PROBE ONLY,48000058,CDM,483,RC,93316,HCPCS,,,facility,both,,,,2605,1823.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PERIPHERAL ARTERIAL DISEASE (PAD) REHABILITATION PER SESSION,48000059,CDM,480,RC,93668,HCPCS,,,facility,both,,,,241,168.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PM/ICD REMOTE TECH SERV,48000060,CDM,480,RC,93296,HCPCS,,,facility,both,,,,278,194.6,,,,,,,,,,,,,Gross Charge Type: Central
HC TRANSCATHETER INSERT/REPLACE PERM LEADLESS PACEMAKER RT VENT INCL IMAGE GUIDE/DEVICE EVAL,48000061,CDM,480,RC,33274,HCPCS,,,facility,both,,,,55766,39036.2,,,,,,,,,,,,,Gross Charge Type: Central
HC TRANSCATHETER REMOVAL PERMANENT LEADLESS PACEMAKER RT VENTRICULAR,48000062,CDM,480,RC,33275,HCPCS,,,facility,both,,,,11658,8160.6,,,,,,,,,,,,,Gross Charge Type: Central
HC INTRA-ATRIAL PACING,48000063,CDM,480,RC,93610,HCPCS,,,facility,both,,,,27316,19121.2,,,,,,,,,,,,,Gross Charge Type: Central
HC CARDIOVERSION ELECTRIC INT,48000065,CDM,480,RC,92961,HCPCS,,,facility,both,,,,2069,1448.3,,,,,,,,,,,,,Gross Charge Type: Central
HC MYOCARDIAL STRAIN IMG USING SPECKLE TRACKING-DERIVED ASSESSMENT OF MYOCARDIAL MECHANICS,48000067,CDM,480,RC,93356,HCPCS,,,facility,both,,,,40,28,,,,,,,,,,,,,Gross Charge Type: Central
HC TIS CREATION BY STENT CGEN CAR ANOMAL INCL ALL IMG GUIDE WHEN PERFORM LT/RT HEART DIAGNOS CARDIAC CATH CGEN CAR ANOMAL INITIAL INTRACARDIAC SHUNT,48000068,CDM,480,RC,33745,HCPCS,,,facility,both,,,,3814,2669.8,,,,,,,,,,,,,Gross Charge Type: Central
HC TIS CREATION BY STENT CGEN CAR ANOMALINCL ALL IMG GUIDE WHEN PERFORM LT/RT HEART DIAGNOS CARDIAC CGEN CATH CAR ANOMAL EA ADDL,48000069,CDM,480,RC,33746,HCPCS,,,facility,both,,,,1501,1050.7,,,,,,,,,,,,,Gross Charge Type: Central
HC INSERTION OF VENTRICULAR ASSIST DEVICE PERCUTANEOUS INCL RADIOLOGICAL SUPERVISON & INTERP RT HEART VENOUS ACCESS ONLY,48000070,CDM,480,RC,33995,HCPCS,,,facility,both,,,,1301,910.7,,,,,,,,,,,,,Gross Charge Type: Central
HC REMOVAL OF PERQ RT HEART VENTRICULAR ASSIST DEVICE VENOUS CANNULA AT SEPARATE & DISTINCT SESSION FROM INSERTION,48000071,CDM,480,RC,33997,HCPCS,,,facility,both,,,,580,406,,,,,,,,,,,,,Gross Charge Type: Central
HC PERCUTANEOUS PULM ARTERY REVASCULAR STENT PLACEMENT INITIAL NORMAL NATIVE CONNECT UNILATERAL,48000073,CDM,480,RC,33900,HCPCS,,,facility,both,,,,33448,23413.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PERCUTANEOUS PULM ARTERY REVASCULAR STENT PLACEMENT INITIAL NORMAL NATIVE CONNECT BILATERAL,48000074,CDM,480,RC,33901,HCPCS,,,facility,both,,,,33448,23413.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PERCUTANEOUS PULM ARTERY REVASCULAR STENT PLACEMENT INITIAL ABNORMAL CONNECT UNILATERAL,48000075,CDM,480,RC,33902,HCPCS,,,facility,both,,,,71877,50313.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PERCUTANEOUS PULM ARTERY REVASCULAR STENT PLACEMENT INITIAL ABNORMAL CONNECT BILATERAL,48000076,CDM,480,RC,33903,HCPCS,,,facility,both,,,,82658,57860.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PERCUTANEOUS PULM ARTERY REVASCULAR STENT PLACEMENT EA ADDTL VESSEL/SEPARATE LESION NORMAL/ABNORMAL CONNECTIONS,48000077,CDM,480,RC,33904,HCPCS,,,facility,both,,,,16725,11707.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PERCUTANEOUS TRANSLUMINAL ANGIOPLASTY NATIVE/RECURRENT COARCTATION OF THE AORTA,48000078,CDM,480,RC,33897,HCPCS,,,facility,both,,,,19271,13489.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PERCUTANEOUS TRANSLUMINAL CORONARY LITHOTRIPSY,48000079,CDM,480,RC,92972,HCPCS,,,facility,both,,,,10942,7659.4,,,,,,,,,,,,,Gross Charge Type: Central
HC INSERTION/REPLACEMENT IMPLANT CARDIOVERTER-DEFIBRILLATOR SYSTEM W/SUBSTERNAL ELECTRODE(S) INCL IMAGE GUIDE/ELECTROPHYSIOLOGICAL EVAL,48000085,CDM,480,RC,0571T,HCPCS,,,facility,both,,,,58680,41076,,,,,,,,,,,,,Gross Charge Type: Central
HC INSERT VAD PERQ INCL RS&I LT HEART BOTH ARTERIAL/VENOUS ACCESS W/TRANSSEPTAL PUNCTURE,48000086,CDM,480,RC,33991,HCPCS,,,facility,both,,,,2098,1468.6,,,,,,,,,,,,,Gross Charge Type: Central
HC ENDOVASCULAR STENT REPAIR COARCTATION ASCENDING/TRANSVERSE/DESCENDING THORACIC ABDOMINAL AORTA STENT PLACEMENT ACROSS MAJOR SIDE BRANCHES,48000087,CDM,480,RC,33894,HCPCS,,,facility,both,,,,1114,779.8,,,,,,,,,,,,,Gross Charge Type: Central
HC ENDOVASCULAR STENT REPAIR COARCTATION ASCENDING/TRANSVERSE/DESCENDING THORACIC ABDOMINAL AORTA STENT PLACEMENT NOT CROSSING MAJOR SIDE BRANCHES,48000088,CDM,480,RC,33895,HCPCS,,,facility,both,,,,887,620.9,,,,,,,,,,,,,Gross Charge Type: Central
HC INJECTION CARDIAC CATH INCL IMAGE S I & REPORT SELECTIVE PULM VENOUS ANGIOGRAPHY EACH DISTINCT PULM VEIN,48000089,CDM,480,RC,93574,HCPCS,,,facility,both,,,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Central
HC INJECTION CARDIAC CATH INCL IMAGE S I & REPORT SELECTIVE PULM ANGIOGRAPHY MAJOR AORTOPULM COLLATERAL ARTERIES EACH DISTINCT VESSEL,48000090,CDM,480,RC,93575,HCPCS,,,facility,both,,,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Central
HC VENOGRAPHY CONGENITAL HEART DEFECT(S) INCL CATH PLACEMENT S&I ANOMALOUS PERSISTENT SUPERIOR VENA CAVA SECOND CONTRALATERAL W/NATIVE DRAINAGE TO HEART,48000091,CDM,480,RC,93584,HCPCS,,,facility,both,,,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Central
HC VENOGRAPHY CONGENITAL HEART DEFECT(S) INCL CATH PLACEMENT S&I AZYGOS/HEMIAZYGOS VENOUS SYSTEM,48000092,CDM,480,RC,93585,HCPCS,,,facility,both,,,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Central
HC VENOGRAPHY CONGENITAL HEART DEFECT(S) INCL CATH PLACEMENT S&I CORONARY SINUS,48000093,CDM,480,RC,93586,HCPCS,,,facility,both,,,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Central
HC VENOGRAPHY CONGENITAL HEART DEFECT(S) INCL CATH PLACEMENT S&I VENOVENOUS COLLATERALS AT OR ABOVE THE HEART,48000094,CDM,480,RC,93587,HCPCS,,,facility,both,,,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Central
HC VENOGRAPHY CONGENITAL HEART DEFECT(S) INCL CATH PLACEMENT S&I VENOVENOUS COLLATERALS BELOW THE HEART,48000095,CDM,480,RC,93588,HCPCS,,,facility,both,,,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Central
HC ELECTROPHYSIOLOGIC EVALUATION OF IMPLANTABLE CARDIOVERTER-DEFIBRILLATOR SYSTEM WITH SUBSTERNAL ELECTRODE,48000097,CDM,480,RC,0577T,HCPCS,,,facility,both,,,,5169,3618.3,,,,,,,,,,,,,Gross Charge Type: Central
HC REMOVAL OF SUBSTERNAL IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR ONLY,48000098,CDM,480,RC,0580T,HCPCS,,,facility,both,,,,15494,10845.8,,,,,,,,,,,,,Gross Charge Type: Central
HC REMOVAL AND REPLACEMENT OF SUBSTERNAL IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR,48000099,CDM,480,RC,0614T,HCPCS,,,facility,both,,,,95560,66892,,,,,,,,,,,,,Gross Charge Type: Central
HC REPOSITIONING OF PREVIOUSLY IMPLANTABLE DEFIBRILLATOR-PACING ELECTRODE,48000100,CDM,480,RC,0574T,HCPCS,,,facility,both,,,,15494,10845.8,,,,,,,,,,,,,Gross Charge Type: Central
HC INSERTION OF SUBSTERNAL IMPLANTABLE DEFIBRILLATOR ELECTRODE,48000101,CDM,480,RC,0572T,HCPCS,,,facility,both,,,,35233,24663.1,,,,,,,,,,,,,Gross Charge Type: Central
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML IV SOLN,48081,CDM,J9063,HCPCS,72903-853-01,NDC,,,facility,both,27,ML,,2016,1411.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML IV SOLN,48081,CDM,J9063,HCPCS,72903-853-01,NDC,,,facility,both,6,ML,,448,313.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML IV SOLN,48081,CDM,J9063,HCPCS,72903-853-01,NDC,,,facility,both,213,ML,,36567,25596.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML IV SOLN,48081,CDM,J9063,HCPCS,72903-853-01,NDC,,,facility,both,81,ML,,6046,4232.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML IV SOLN,48081,CDM,J9063,HCPCS,72903-853-01,NDC,,,facility,both,334,ML,,57339,40137.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML IV SOLN,48081,CDM,J9063,HCPCS,72903-853-01,NDC,,,facility,both,30,ML,,2240,1568,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML IV SOLN,48081,CDM,J9063,HCPCS,72903-853-01,NDC,,,facility,both,10,ML,,747,522.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML IV SOLN,48081,CDM,J9063,HCPCS,72903-853-01,NDC,,,facility,both,265,ML,,45494,31845.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML IV SOLN,48081,CDM,J9063,HCPCS,72903-853-01,NDC,,,facility,both,243,ML,,41717,29201.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML IV SOLN,48081,CDM,J9063,HCPCS,72903-853-01,NDC,,,facility,both,74,ML,,5524,3866.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML IV SOLN,48081,CDM,J9063,HCPCS,72903-853-01,NDC,,,facility,both,359,ML,,61631,43141.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML IV SOLN,48081,CDM,J9063,HCPCS,72903-853-01,NDC,,,facility,both,34,ML,,2538,1776.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML IV SOLN,48081,CDM,J9063,HCPCS,72903-853-01,NDC,,,facility,both,390,ML,,66953,46867.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML IV SOLN,48081,CDM,J9063,HCPCS,72903-853-01,NDC,,,facility,both,41,ML,,3061,2142.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML IV SOLN,48081,CDM,J9063,HCPCS,72903-853-01,NDC,,,facility,both,57,ML,,4255,2978.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML IV SOLN,48081,CDM,J9063,HCPCS,72903-853-01,NDC,,,facility,both,15,ML,,1120,784,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML IV SOLN,48081,CDM,J9063,HCPCS,72903-853-01,NDC,,,facility,both,319,ML,,54764,38334.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML IV SOLN,48081,CDM,J9063,HCPCS,72903-853-01,NDC,,,facility,both,230,ML,,39485,27639.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML IV SOLN,48081,CDM,J9063,HCPCS,72903-853-01,NDC,,,facility,both,266,ML,,45665,31965.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML IV SOLN,48081,CDM,J9063,HCPCS,72903-853-01,NDC,,,facility,both,395,ML,,67811,47467.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML IV SOLN,48081,CDM,J9063,HCPCS,72903-853-01,NDC,,,facility,both,36,ML,,2688,1881.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML IV SOLN,48081,CDM,J9063,HCPCS,72903-853-01,NDC,,,facility,both,164,ML,,28155,19708.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML IV SOLN,48081,CDM,J9063,HCPCS,72903-853-01,NDC,,,facility,both,33,ML,,2464,1724.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML IV SOLN,48081,CDM,J9063,HCPCS,72903-853-01,NDC,,,facility,both,323,ML,,55451,38815.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML IV SOLN,48081,CDM,J9063,HCPCS,72903-853-01,NDC,,,facility,both,270,ML,,46352,32446.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML IV SOLN,48081,CDM,J9063,HCPCS,72903-853-01,NDC,,,facility,both,194,ML,,33305,23313.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML IV SOLN,48081,CDM,J9063,HCPCS,72903-853-01,NDC,,,facility,both,77,ML,,5748,4023.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML IV SOLN,48081,CDM,J9063,HCPCS,72903-853-01,NDC,,,facility,both,173,ML,,29700,20790,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML IV SOLN,48081,CDM,J9063,HCPCS,72903-853-01,NDC,,,facility,both,76,ML,,5673,3971.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML IV SOLN,48081,CDM,J9063,HCPCS,72903-853-01,NDC,,,facility,both,35,ML,,2613,1829.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML IV SOLN,48081,CDM,J9063,HCPCS,72903-853-01,NDC,,,facility,both,70,ML,,5225,3657.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML IV SOLN,48081,CDM,J9063,HCPCS,72903-853-01,NDC,,,facility,both,5,ML,,374,261.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML IV SOLN,48081,CDM,J9063,HCPCS,72903-853-01,NDC,,,facility,both,87,ML,,6494,4545.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML IV SOLN,48081,CDM,J9063,HCPCS,72903-853-01,NDC,,,facility,both,324,ML,,55622,38935.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML IV SOLN,48081,CDM,J9063,HCPCS,72903-853-01,NDC,,,facility,both,66,ML,,4927,3448.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML IV SOLN,48081,CDM,J9063,HCPCS,72903-853-01,NDC,,,facility,both,285,ML,,48927,34248.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML IV SOLN,48081,CDM,J9063,HCPCS,72903-853-01,NDC,,,facility,both,267,ML,,45837,32085.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRVETUXIMAB SORAVTANSINE-GYNX 5 MG/ML IV SOLN,48081,CDM,J9063,HCPCS,72903-853-01,NDC,,,facility,both,330,ML,,56652,39656.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC REPOSITION PACING-DEFIB LEAD,48100001,CDM,481,RC,33215,HCPCS,,,facility,both,,,,2452,1716.4,,,,,,,,,,,,,Gross Charge Type: Central
HC INSERT PACING LEAD & CONNECT,48100002,CDM,481,RC,33224,HCPCS,,,facility,both,,,,36248,25373.6,,,,,,,,,,,,,Gross Charge Type: Central
HC L VENTR PACING LEAD ADD-ON,48100003,CDM,481,RC,33225,HCPCS,,,facility,both,,,,36248,25373.6,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH RIGHT HEART,48100005,CDM,481,RC,93451,HCPCS,,,facility,both,,,,6485,4539.5,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH LEFT HEART,48100006,CDM,481,RC,93452,HCPCS,,,facility,both,,,,3967,2776.9,,,,,,,,,,,,,Gross Charge Type: Central
HC CATH RIGHT AND LEFT HEART,48100007,CDM,481,RC,93453,HCPCS,,,facility,both,,,,4289,3002.3,,,,,,,,,,,,,Gross Charge Type: Central
HC CORONARY ARTERY ANGIO SI,48100008,CDM,481,RC,93454,HCPCS,,,facility,both,,,,6485,4539.5,,,,,,,,,,,,,Gross Charge Type: Central
HC CORONARY ART/GRFT ANGIO SI,48100009,CDM,481,RC,93455,HCPCS,,,facility,both,,,,6485,4539.5,,,,,,,,,,,,,Gross Charge Type: Central
HC R HRT CORONARY ARTERY ANGIO SI,48100010,CDM,481,RC,93456,HCPCS,,,facility,both,,,,12714,8899.8,,,,,,,,,,,,,Gross Charge Type: Central
HC R HRT ART/GRFT ANGIO SI,48100011,CDM,481,RC,93457,HCPCS,,,facility,both,,,,3967,2776.9,,,,,,,,,,,,,Gross Charge Type: Central
HC L HRT ARTERY/VENTR ANGIO SI,48100012,CDM,481,RC,93458,HCPCS,,,facility,both,,,,12714,8899.8,,,,,,,,,,,,,Gross Charge Type: Central
HC L HRT ART/GRFT VENTR ANGIO SI,48100013,CDM,481,RC,93459,HCPCS,,,facility,both,,,,3967,2776.9,,,,,,,,,,,,,Gross Charge Type: Central
HC R&L HRT ART/VENTRICLE ANGIO SI,48100014,CDM,481,RC,93460,HCPCS,,,facility,both,,,,12714,8899.8,,,,,,,,,,,,,Gross Charge Type: Central
HC R&L HRT ART/VENTRICLE ANGIO SI,48100015,CDM,481,RC,93461,HCPCS,,,facility,both,,,,3967,2776.9,,,,,,,,,,,,,Gross Charge Type: Central
HC L HRT CATH TRNSPTL PUNCTURE,48100016,CDM,481,RC,93462,HCPCS,,,facility,both,,,,3967,2776.9,,,,,,,,,,,,,Gross Charge Type: Central
HC DRUG ADMIN & HEMODYN MEAS,48100017,CDM,481,RC,93463,HCPCS,,,facility,both,,,,196,137.2,,,,,,,,,,,,,Gross Charge Type: Central
HC EXERCISE W/HEMODYN MEAS,48100018,CDM,481,RC,93464,HCPCS,,,facility,both,,,,589,412.3,,,,,,,,,,,,,Gross Charge Type: Central
HC INJ ANG COR DURIN HRT CATH CONG,48100022,CDM,481,RC,93563,HCPCS,,,facility,both,,,,196,137.2,,,,,,,,,,,,,Gross Charge Type: Central
HC INJ ANG L HRT DURIN HRT CATH CONG,48100023,CDM,481,RC,93565,HCPCS,,,facility,both,,,,196,137.2,,,,,,,,,,,,,Gross Charge Type: Central
HC INJ ANG R HRT DURIN HRT CATH CONG,48100024,CDM,481,RC,93566,HCPCS,,,facility,both,,,,196,137.2,,,,,,,,,,,,,Gross Charge Type: Central
HC INJ ANG AORT DURIN HRT CATH CONG,48100025,CDM,481,RC,93567,HCPCS,,,facility,both,,,,196,137.2,,,,,,,,,,,,,Gross Charge Type: Central
HC INJECTION PX DURING CARDIAC CATH INCL IMAGE SI & REPORT NONSELECT PULM ARTERIAL ANGIOGRAPHY,48100026,CDM,481,RC,93568,HCPCS,,,facility,both,,,,196,137.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PERQ TRCATH CLOSURE OF VSD IMPLA,48100027,CDM,481,RC,93581,HCPCS,,,facility,both,,,,64135,44894.5,,,,,,,,,,,,,Gross Charge Type: Central
HC COMP ELECTROPH EVAL L ATRIUM +,48100028,CDM,481,RC,93621,HCPCS,,,facility,both,,,,12058,8440.6,,,,,,,,,,,,,Gross Charge Type: Central
HC COMP ELECTROPH EVAL L VENT +,48100029,CDM,481,RC,93622,HCPCS,,,facility,both,,,,12058,8440.6,,,,,,,,,,,,,Gross Charge Type: Central
HC STIMULATION PACING HEART,48100030,CDM,481,RC,93623,HCPCS,,,facility,both,,,,5292,3704.4,,,,,,,,,,,,,Gross Charge Type: Central
HC ABLATION AV NODE,48100031,CDM,481,RC,93650,HCPCS,,,facility,both,,,,17214,12049.8,,,,,,,,,,,,,Gross Charge Type: Central
HC COMP ELECTRO EVAL W/INSERT REPOSITION MULTI ELECTRODE CATH INDUCT INCL INTRACARDIAC ELECTRO 3D MAPPING SVT,48100032,CDM,481,RC,93653,HCPCS,,,facility,both,,,,98159,68711.3,,,,,,,,,,,,,Gross Charge Type: Central
HC COMP ELECTRO EVAL W/INSERT REPOSITION MULTI ELECTRODE CATH INDUCT INCL INTRACARDIAC ELECTRO 3D MAPPING VT,48100033,CDM,481,RC,93654,HCPCS,,,facility,both,,,,41479,29035.3,,,,,,,,,,,,,Gross Charge Type: Central
HC ECHO INTRACARD DURING INTERVENT,48100034,CDM,481,RC,93662,HCPCS,,,facility,both,,,,306,214.2,,,,,,,,,,,,,Gross Charge Type: Central
HC INTRAVENTRICULAR PACING,48100037,CDM,481,RC,93612,HCPCS,,,facility,both,,,,27316,19121.2,,,,,,,,,,,,,Gross Charge Type: Central
HC ENDOMYOCARDIAL BIOPSY,48100039,CDM,481,RC,93505,HCPCS,,,facility,both,,,,2242,1569.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PRQ CARD STENT/ATH/ANGIO SNGL MAJ CORON ART/BRANCH,48100040,CDM,481,RC,92933,HCPCS,,,facility,both,,,,21111,14777.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PRQ CARD STENT/ATH/ANGIO EA ADD BRANCH MAJ CORON ART,48100041,CDM,481,RC,92934,HCPCS,,,facility,both,,,,31448,22013.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PRQ REVASC BYP GRAFT SINGLE VESSEL,48100042,CDM,481,RC,92937,HCPCS,,,facility,both,,,,13691,9583.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PRQ CARD REVASC MI SINGLE VESSEL,48100044,CDM,481,RC,92941,HCPCS,,,facility,both,,,,13691,9583.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PRQ CARD REVASC CHRONIC OCCL SINGLE VESSEL,48100045,CDM,481,RC,92943,HCPCS,,,facility,both,,,,13691,9583.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PRQ CARD REVASC CHRONIC OCCL EA ADD,48100046,CDM,481,RC,92944,HCPCS,,,facility,both,,,,9008,6305.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PRQ CARD ANGIO/ATHRECT EA ADD BRANCH,48100047,CDM,481,RC,92925,HCPCS,,,facility,both,,,,11307,7914.9,,,,,,,,,,,,,Gross Charge Type: Central
HC ABLATE ARRHYTHMIA ADD ON,48100048,CDM,481,RC,93655,HCPCS,,,facility,both,,,,12452,8716.4,,,,,,,,,,,,,Gross Charge Type: Central
HC COMP ELECTRO EVAL W/ TRANSSEPTAL CATH INSERT/REPOSITION MULTI ELECTRODE CATH & INTRACARDIAC CATH ABLATION ATRIAL FIB PULM VEIN ISOL INCL ELECT 3D MAPPING W/IMAGING S&I,48100049,CDM,481,RC,93656,HCPCS,,,facility,both,,,,98159,68711.3,,,,,,,,,,,,,Gross Charge Type: Central
HC TX L/R ATRIAL FIB ADDL,48100050,CDM,481,RC,93657,HCPCS,,,facility,both,,,,12452,8716.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PERCU TRANSCATH CLOSURE PDA,48100051,CDM,481,RC,93582,HCPCS,,,facility,both,,,,18493,12945.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PERCU TRANSCATH SEPTAL REDUCTION THERAPY,48100052,CDM,481,RC,93583,HCPCS,,,facility,both,,,,1484,1038.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PRQ CARD ANGIO/ANTHRECT SINGLE MAJOR ART/BRANCH,48100054,CDM,481,RC,92924,HCPCS,,,facility,both,,,,13691,9583.7,,,,,,,,,,,,,Gross Charge Type: Central
HC RT HEART CATH CHD INCL IMAGE GUIDE NORMAL NATIVE CONNECTIONS,48100059,CDM,481,RC,93593,HCPCS,,,facility,both,,,,11427,7998.9,,,,,,,,,,,,,Gross Charge Type: Central
HC RT HEART CATH CHD INCL IMAGE GUIDE ABNORMAL NATIVE CONNECTIONS,48100060,CDM,481,RC,93594,HCPCS,,,facility,both,,,,11427,7998.9,,,,,,,,,,,,,Gross Charge Type: Central
HC RT & LT HEART CATH CHD INCL IMAGE GUIDE NORMAL NATIVE CONNECTIONS,48100061,CDM,481,RC,93596,HCPCS,,,facility,both,,,,11427,7998.9,,,,,,,,,,,,,Gross Charge Type: Central
HC RT & LT HEART CATH CHD INCL IMAGE GUIDE ABNORMAL NATIVE CONNECTIONS,48100062,CDM,481,RC,93597,HCPCS,,,facility,both,,,,11427,7998.9,,,,,,,,,,,,,Gross Charge Type: Central
HC LT HEART CATH CONGENITAL HEART DEFECT(S) NORMAL/ABNORMAL NATIVE CONNECTIONS,48100063,CDM,481,RC,93595,HCPCS,,,facility,both,,,,13794,9655.8,,,,,,,,,,,,,Gross Charge Type: Central
HC TRANSCATHETER RENAL SYMPATHETIC DENERVATION PERQ BILATERAL,48100064,CDM,481,RC,0339T,HCPCS,,,facility,both,,,,24273,16991.1,,,,,,,,,,,,,Gross Charge Type: Central
HC INJECT PROCEDURE CARDIAC CATHETERIZATION INCL IMAGE SI & REPORT PULMONARY ARTERIAL ANGIOGRAPHY BILATERAL,48100065,CDM,481,RC,93573,HCPCS,,,facility,both,,,,457,319.9,,,,,,,,,,,,,Gross Charge Type: Central
HC INJECT PROCEDURE CARDIAC CATHETERIZATION INCL IMAGE SI & REPORT PULMONARY ARTERIAL ANGIOGRAPHY UNILATERAL,48100066,CDM,481,RC,93569,HCPCS,,,facility,both,,,,236,165.2,,,,,,,,,,,,,Gross Charge Type: Central
HC ELECTROPHYSIOLOGIC FOLLOW-UP STUDY W/PACING AND RECORDING INCL INDCUTION/ATTEMPTED INDCUTION OF ARRHYTHMIA,48100067,CDM,481,RC,93624,HCPCS,,,facility,both,,,,30627,21438.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PERQ TRANSCATHER THERAPEUTIC DRUG DELIVERY INTRACORONARY DRUG-DELIVERY BALLOON SINGLE MAJOR CORONARY ARTERY OR BRANCH,48100068,CDM,481,RC,0913T,HCPCS,,,facility,both,,,,24273,16991.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PERQ TRANSCATHER THERAPEUTIC DRUG DELIVERY INTRACORONARY DRUG-DELIVERY BALLOON SEP TARGET LESION SINGLE MAJOR CORONARY ARTERY OR BRANCH,48100069,CDM,481,RC,0914T,HCPCS,,,facility,both,,,,6069,4248.3,,,,,,,,,,,,,Gross Charge Type: Central
HC RIGHT VENTRICULAR RECORDING,48100070,CDM,481,RC,93603,HCPCS,,,facility,both,,,,5169,3618.3,,,,,,,,,,,,,Gross Charge Type: Central
HC TRANSCATHETER RENAL SYMPATHETIC DENERVATION PREQ INCL ARTERIAL PUNCTURE UNILATERAL,48100071,CDM,481,RC,0338T,HCPCS,,,facility,both,,,,24273,16991.1,,,,,,,,,,,,,Gross Charge Type: Central
GLOFITAMAB-GXBM 1 MG/ML IV SOLN (>10 MG DOSE 10 ML MIXTURE COMPONENT),48105,CDM,J9286,HCPCS,50242-127-01,NDC,,,facility,both,12,ML,,84614,59229.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC CV STRESS TEST TRACING ONLY,48200001,CDM,482,RC,93017,HCPCS,,,facility,both,,,,1200,840,,,,,,,,,,,,,Gross Charge Type: Central
ELRANATAMAB-BCMM 40 MG/ML SUBQ SOLN,48264,CDM,J1323,HCPCS,0069-4494-01,NDC,,,facility,both,4,ML,,825,577.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ELRANATAMAB-BCMM 40 MG/ML SUBQ SOLN,48264,CDM,J1323,HCPCS,0069-4494-01,NDC,,,facility,both,76,ML,,36020,25214,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ELRANATAMAB-BCMM 40 MG/ML SUBQ SOLN,48264,CDM,J1323,HCPCS,0069-2522-01,NDC,,,facility,both,12,ML,,2473,1731.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ELRANATAMAB-BCMM 40 MG/ML SUBQ SOLN,48264,CDM,J1323,HCPCS,0069-2522-01,NDC,,,facility,both,32,ML,,15167,10616.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC ECHO TRANSTHOR W/ DOPPLER,48300001,CDM,483,RC,93306,HCPCS,,,facility,both,,,,2559,1791.3,,,,,,,,,,,,,Gross Charge Type: Central
HC ECHO TRANSTHOR W/WO DYE,48300002,CDM,483,RC,93307,HCPCS,,,facility,both,,,,1396,977.2,,,,,,,,,,,,,Gross Charge Type: Central
HC ECHO TRANSTHOR LIMITED FUP,48300003,CDM,483,RC,93308,HCPCS,,,facility,both,,,,916,641.2,,,,,,,,,,,,,Gross Charge Type: Central
ECHO TRANSESOPHAGEAL,48300004,CDM,483,RC,93312,HCPCS,,,facility,both,,,,2569,1798.3,,,,,,,,,,,,,Gross Charge Type: Central
ECHO DOPPLER LIMITED FUP ADD-ON,48300005,CDM,483,RC,93321,HCPCS,,,facility,both,,,TC,133,93.1,,,,,,,,,,,,,"Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier TC: Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities"
HC ECHO TRANSTHOR STRESS TEST,48300006,CDM,483,RC,93350,HCPCS,,,facility,both,,,,1544,1080.8,,,,,,,,,,,,,Gross Charge Type: Central
HC TRNSTH ECHO CONGENITAL CAR ANOM COMPLETE,48300008,CDM,483,RC,93303,HCPCS,,,facility,both,,,,844,590.8,,,,,,,,,,,,,Gross Charge Type: Central
HC TRNSTH ECHO CONGENITAL CAR ANOM FOLLOW-UP/LTD,48300009,CDM,483,RC,93304,HCPCS,,,facility,both,,,,606,424.2,,,,,,,,,,,,,Gross Charge Type: Central
HC TRNSTH ECHO CONGENITAL CAR ANOM INTERP/REPORT ONLY,48300010,CDM,483,RC,93317,HCPCS,,,facility,both,,,,758,530.6,,,,,,,,,,,,,Gross Charge Type: Central
HC ECHO TRANSEOPHAGEAL INTRAOP,48300011,CDM,483,RC,93318,HCPCS,,,facility,both,,,,844,590.8,,,,,,,,,,,,,Gross Charge Type: Central
HC ECHO FETAL CARDIOVASCULAR SYSTEM (2D) W/WITHOUT M-MODE RECORDING,48300012,CDM,483,RC,76825,HCPCS,,,facility,both,,,,2142,1499.4,,,,,,,,,,,,,Gross Charge Type: Central
HC DOPPLER ECHO FETAL PULSED WAVE AND/OR CONT WAVE W/SPECTRAL DISPLAY COMPLETE,48300013,CDM,483,RC,76827,HCPCS,,,facility,both,,,,445,311.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PEDIATRIC ECHO COMPLETE,48300014,CDM,483,RC,48300014,HCPCS,,,facility,both,,,,2252,1576.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PEDIATRIC ECHO LIMITED,48300015,CDM,483,RC,48300015,HCPCS,,,facility,both,,,,1118,782.6,,,,,,,,,,,,,Gross Charge Type: Central
HC TEE FOR GUIDANCE OF TRANSCATH/GREAT VESSEL(S) STRUCTURAL INTERVENT,48300016,CDM,483,RC,93355,HCPCS,,,facility,both,,,,865,605.5,,,,,,,,,,,,,Gross Charge Type: Central
HC TRANSTHORACIC ECHOCARDIO W/CONTRAST OR W/O FOL BY W/CONTRAST REAL-TIME W/IMAGE DOC (2D) INCL M-MO,48300017,CDM,483,RC,C8929,HCPCS,,,facility,both,,,,2299,1609.3,,,,,,,,,,,,,Gross Charge Type: Central
HC ECHO FETAL CARDIOVASC SYS REAL TIME W/IMAGE DOC W/WO M-MODE RECORDING F/U OR REPEAT STUDY,48300018,CDM,483,RC,76826,HCPCS,,,facility,both,,,,1622,1135.4,,,,,,,,,,,,,Gross Charge Type: Central
HC DOPPLER ECHO FETAL PULSED WAVE AND/OR CONT WAVE W/SPECTRAL DISPLAY F/U OR REPEAT STUDY,48300019,CDM,483,RC,76828,HCPCS,,,facility,both,,,,445,311.5,,,,,,,,,,,,,Gross Charge Type: Central
HC TRANSTHOR ECHO W/WO CONTRAST REAL-TIME W/IMAGE DOC (2D) INCL M-MO WHEN PERFORM F/U OR LIMITED STUDY,48300021,CDM,483,RC,C8924,HCPCS,,,facility,both,,,,2036,1425.2,,,,,,,,,,,,,Gross Charge Type: Central
HC TRANSESOPHAGEAL ECHO W/WO CONTRAST REAL-TIME W/IMAGE DOC (2D) INCL PROBE PLACEMENT IMAGE ACQUISITION INTERP/REPORT,48300022,CDM,483,RC,C8925,HCPCS,,,facility,both,,,,2522,1765.4,,,,,,,,,,,,,Gross Charge Type: Central
HC TTE W/CONTRAST OR W/O CONTRAST W/CONTRAST REAL TIME W/IMAGE DOC (2D) INCL PROBE PLACE IMAGE ACUQUISITION INTERP/REPORT,48300023,CDM,483,RC,C8921,HCPCS,,,facility,both,,,,2303,1612.1,,,,,,,,,,,,,Gross Charge Type: Central
HC TTE W/CONTRAST OR W/O CONTRAST W/CONTRAST CONGENITAL CARDIAC ANOMALIES FOLLOW-UP OR LIMITED STUDY,48300024,CDM,483,RC,C8922,HCPCS,,,facility,both,,,,2303,1612.1,,,,,,,,,,,,,Gross Charge Type: Central
HC TTE W/CONTRAST W/O CONTRAST W/CONTRAST INCL PROBE PLACE REAL-TIME 2D IMAGE ACQUISITION/INTERP ONGOING ASSESSMENT,48300027,CDM,483,RC,C8927,HCPCS,,,facility,both,,,,2303,1612.1,,,,,,,,,,,,,Gross Charge Type: Central
HC ECHOCARDIOGRAPHY TRANSESOPHAGEAL REAL-TIME W/IMAGE DOCUMENT 2D PLACEMENT OF TRANSESOPHAGEAL PROBE ONLY,48300028,CDM,483,RC,93313,HCPCS,,,facility,both,,,,2097,1467.9,,,,,,,,,,,,,Gross Charge Type: Central
HC ECHOCARDIOGRAPHY TRANSESOPHAGEAL REAL-TIME W/IMAGE DOCUMENT 2D IMAGE ACQUISITION INTERP/REPORT ONLY,48300029,CDM,483,RC,93314,HCPCS,,,facility,both,,,,758,530.6,,,,,,,,,,,,,Gross Charge Type: Central
HC NONINVASIVE DETECTION HEART FAILURE AUGMENTATIVE ANALYSIS ECHOCARDIOGRAM W/INTERP & REPORT,48300030,CDM,483,RC,0932T,HCPCS,,,facility,both,,,,23780,16646,,,,,,,,,,,,,Gross Charge Type: Central
HC ADMIN RESPIRATORY SYNCYTIAL VIRUS MONOCLONAL ANTIBODY SEASONAL DOSE INTRAMUSCULAR INJECTION,48306,CDM,90380,HCPCS,49281-575-00,NDC,,,facility,both,1,ML,,1435,1004.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC ADMIN RESPIRATORY SYNCYTIAL VIRUS MONOCLONAL ANTIBODY SEASONAL DOSE INTRAMUSCULAR INJECTION,48306,CDM,90380,HCPCS,49281-574-88,NDC,,,facility,both,2,ML,,1535,1074.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIRSEVIMAB-ALIP 50 MG/0.5 ML IM SYRG,48306,CDM,90380,HCPCS,49281-575-15,NDC,,,facility,both,1,ML,,1435,1004.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC ADMIN RESPIRATORY SYNCYTIAL VIRUS MONOCLONAL ANTIBODY SEASONAL DOSE INTRAMUSCULAR INJECTION,48306,CDM,90380,HCPCS,49281-575-00,NDC,,,facility,both,1,ML,,1535,1074.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC ADMIN RESPIRATORY SYNCYTIAL VIRUS MONOCLONAL ANTIBODY SEASONAL DOSE INTRAMUSCULAR INJECTION,48306,CDM,90380,HCPCS,49281-574-88,NDC,,,facility,both,2,ML,,1435,1004.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIRSEVIMAB-ALIP 50 MG/0.5 ML IM SYRG,48306,CDM,90380,HCPCS,49281-575-15,NDC,,,facility,both,1,ML,,1535,1074.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIRSEVIMAB-ALIP 100 MG/ML IM SYRG,48357,CDM,90381,HCPCS,49281-574-15,NDC,,,facility,both,1,ML,,1535,1074.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC ADMIN RESPIRATORY SYNCYTIAL VIRUS MONOCLONAL ANTIBODY SEASONAL DOSE INTRAMUSCULAR INJECTION,48357,CDM,90381,HCPCS,49281-574-88,NDC,,,facility,both,1,ML,,1435,1004.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC ADMIN RESPIRATORY SYNCYTIAL VIRUS MONOCLONAL ANTIBODY SEASONAL DOSE INTRAMUSCULAR INJECTION,48357,CDM,90381,HCPCS,49281-575-00,NDC,,,facility,both,1,ML,,3070,2149,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC ADMIN RESPIRATORY SYNCYTIAL VIRUS MONOCLONAL ANTIBODY SEASONAL DOSE INTRAMUSCULAR INJECTION,48357,CDM,90381,HCPCS,49281-575-00,NDC,,,facility,both,1,ML,,2870,2009,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIRSEVIMAB-ALIP 100 MG/ML IM SYRG,48357,CDM,90381,HCPCS,49281-574-15,NDC,,,facility,both,1,ML,,1435,1004.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC ADMIN RESPIRATORY SYNCYTIAL VIRUS MONOCLONAL ANTIBODY SEASONAL DOSE INTRAMUSCULAR INJECTION,48357,CDM,90381,HCPCS,49281-574-88,NDC,,,facility,both,1,ML,,1535,1074.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC ADMIN RESPIRATORY SYNCYTIAL VIRUS MONOCLONAL ANTIBODY SEASONAL DOSE INTRAMUSCULAR INJECTION,48357,CDM,90381,HCPCS,49281-574-88,NDC,,,facility,both,2,ML,,2870,2009,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIRSEVIMAB-ALIP 50 MG/0.5 ML IM SYRG,48357,CDM,90381,HCPCS,49281-575-15,NDC,,,facility,both,1,ML,,3070,2149,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EMTRICITABINE-TENOFOVIR 200 MG-300 MG TAB,48414,CDM,J0750,HCPCS,65862-354-30,NDC,,,facility,both,1,EA,,297,207.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EMTRICITABINE-TENOFOVIR 200 MG-300 MG TAB,48414,CDM,J0750,HCPCS,61958-0701-1,NDC,,,facility,both,1,EA,,313,219.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPCORITAMAB-BYSP  4 MG/0.8 ML SUBQ SOLN,48675,CDM,J9321,HCPCS,82705-002-01,NDC,,,facility,both,5,ML,,753,527.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPCORITAMAB-BYSP  4 MG/0.8 ML SUBQ SOLN,48675,CDM,J9321,HCPCS,82705-002-01,NDC,,,facility,both,1,ML,,151,105.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPCORITAMAB-BYSP  4 MG/0.8 ML SUBQ SOLN,48675,CDM,J9321,HCPCS,82705-002-01,NDC,,,facility,both,24,ML,,1571,1099.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPCORITAMAB-BYSP  4 MG/0.8 ML SUBQ SOLN,48675,CDM,J9321,HCPCS,82705-002-01,NDC,,,facility,both,6,ML,,393,275.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPCORITAMAB-BYSP  4 MG/0.8 ML SUBQ SOLN,48675,CDM,J9321,HCPCS,82705-002-01,NDC,,,facility,both,19,ML,,2860,2002,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPCORITAMAB-BYSP  4 MG/0.8 ML SUBQ SOLN,48675,CDM,J9321,HCPCS,82705-002-01,NDC,,,facility,both,20,ML,,1309,916.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPCORITAMAB-BYSP 48 MG/0.8 ML SUBQ SOLN,48675,CDM,J9321,HCPCS,82705-010-01,NDC,,,facility,both,300,ML,,44594,31215.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLU VACCINE TS 2024-25 6MOS UP (PF) 45 MCG (15 MCG X 3)/0.5 ML IM SYRG,48705,CDM,90656,HCPCS,70461-654-04,NDC,,,facility,both,1,ML,,190,133,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLU VACCINE 2024-25 65YR UP ADJMF59C (PF) 45 MCG (15 MCG X 3)/0.5 ML IM SYRG,48706,CDM,90653,HCPCS,70461-024-04,NDC,,,facility,both,1,ML,,373,261.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,0409-4276-16,NDC,,,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,48711,CDM,J2003,HCPCS,63323-486-05,NDC,,,facility,both,42,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,48711,CDM,J2003,HCPCS,0409-4279-16,NDC,,,facility,both,40,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,48711,CDM,J2003,HCPCS,55150-163-30,NDC,,,facility,both,300,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,48711,CDM,J2003,HCPCS,55150-162-05,NDC,,,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,0143-9577-01,NDC,,,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,48711,CDM,J2003,HCPCS,73293-0001-1,NDC,,,facility,both,21,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,63323-485-03,NDC,,,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,63323-485-03,NDC,,,facility,both,65,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,48711,CDM,J2003,HCPCS,0143-9595-25,NDC,,,facility,both,40,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,63323-201-03,NDC,,,facility,both,60,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,63323-201-01,NDC,,,facility,both,20,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,0409-4276-16,NDC,,,facility,both,7,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,48711,CDM,J2003,HCPCS,63323-492-09,NDC,,,facility,both,300,ML,,157,109.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,63323-201-02,NDC,,,facility,both,40,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,48711,CDM,J2003,HCPCS,55150-162-05,NDC,,,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,63323-201-01,NDC,,,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,0409-4276-16,NDC,,,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,48711,CDM,J2003,HCPCS,0143-9595-01,NDC,,,facility,both,100,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,0143-9577-01,NDC,,,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,48711,CDM,J2003,HCPCS,63323-486-05,NDC,,,facility,both,60,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,48711,CDM,J2003,HCPCS,63323-486-05,NDC,,,facility,both,80,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 1% 10MG/ML (1ML-UD) OR SYRINGE,48711,CDM,J2003,HCPCS,0409-4276-02,NDC,,,facility,both,30,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,48711,CDM,J2003,HCPCS,63323-495-07,NDC,,,facility,both,200,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,0143-9577-01,NDC,,,facility,both,40,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,63323-201-01,NDC,,,facility,both,21,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,63323-485-03,NDC,,,facility,both,80,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,48711,CDM,J2003,HCPCS,63323-202-02,NDC,,,facility,both,200,ML,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,0409-4276-01,NDC,,,facility,both,200,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,48711,CDM,J2003,HCPCS,0409-4279-16,NDC,,,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,63323-485-03,NDC,,,facility,both,120,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,63323-485-03,NDC,,,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,0409-4276-16,NDC,,,facility,both,130,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,0409-4276-16,NDC,,,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,63323-485-01,NDC,,,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,0409-4276-16,NDC,,,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,48711,CDM,J2003,HCPCS,63323-202-02,NDC,,,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,48711,CDM,J2003,HCPCS,63323-492-27,NDC,,,facility,both,60,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,55150-253-50,NDC,,,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,0409-4276-16,NDC,,,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,0143-9577-01,NDC,,,facility,both,21,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,48711,CDM,J2003,HCPCS,63323-492-04,NDC,,,facility,both,100,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,48711,CDM,J2003,HCPCS,0409-4277-16,NDC,,,facility,both,400,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,0409-4276-16,NDC,,,facility,both,110,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,48711,CDM,J2003,HCPCS,63323-495-09,NDC,,,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,48711,CDM,J2003,HCPCS,63323-495-04,NDC,,,facility,both,100,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,63323-201-03,NDC,,,facility,both,70,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,48711,CDM,J2003,HCPCS,63323-486-02,NDC,,,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,48711,CDM,J2003,HCPCS,63323-492-04,NDC,,,facility,both,120,ML,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,0409-4276-16,NDC,,,facility,both,80,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,48711,CDM,J2003,HCPCS,55150-164-02,NDC,,,facility,both,40,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,63323-201-01,NDC,,,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,48711,CDM,J2003,HCPCS,0409-4279-16,NDC,,,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,48711,CDM,J2003,HCPCS,63323-492-27,NDC,,,facility,both,40,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,48711,CDM,J2003,HCPCS,63323-202-02,NDC,,,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,48711,CDM,J2003,HCPCS,63323-486-17,NDC,,,facility,both,40,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,63323-201-03,NDC,,,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,48711,CDM,J2003,HCPCS,0409-4277-17,NDC,,,facility,both,1000,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,63323-201-10,NDC,,,facility,both,21,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,48711,CDM,J2003,HCPCS,63323-492-04,NDC,,,facility,both,300,ML,,236,165.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,63323-485-01,NDC,,,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,63323-485-03,NDC,,,facility,both,9,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,63323-485-03,NDC,,,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,63323-485-01,NDC,,,facility,both,25,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,63323-485-03,NDC,,,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,0409-4276-16,NDC,,,facility,both,60,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,48711,CDM,J2003,HCPCS,63323-492-04,NDC,,,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,48711,CDM,J2003,HCPCS,0409-4279-16,NDC,,,facility,both,200,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,48711,CDM,J2003,HCPCS,63323-492-09,NDC,,,facility,both,50,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,63323-201-03,NDC,,,facility,both,40,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,0409-4276-16,NDC,,,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,63323-201-02,NDC,,,facility,both,20,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,48711,CDM,J2003,HCPCS,0409-4713-02,NDC,,,facility,both,29,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,63323-201-02,NDC,,,facility,both,20,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,48711,CDM,J2003,HCPCS,0409-4279-16,NDC,,,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,48711,CDM,J2003,HCPCS,63323-202-02,NDC,,,facility,both,100,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,48711,CDM,J2003,HCPCS,0409-4713-02,NDC,,,facility,both,21,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,48711,CDM,J2003,HCPCS,0143-9595-25,NDC,,,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,48711,CDM,J2003,HCPCS,63323-492-04,NDC,,,facility,both,40,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,63323-485-03,NDC,,,facility,both,200,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,63323-485-03,NDC,,,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,63323-201-02,NDC,,,facility,both,40,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,48711,CDM,J2003,HCPCS,0409-2066-05,NDC,,,facility,both,100,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,48711,CDM,J2003,HCPCS,0409-4279-16,NDC,,,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,0409-4276-16,NDC,,,facility,both,150,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,48711,CDM,J2003,HCPCS,63323-492-37,NDC,,,facility,both,300,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,0409-4276-16,NDC,,,facility,both,200,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,48711,CDM,J2003,HCPCS,63323-208-05,NDC,,,facility,both,100,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,63323-485-03,NDC,,,facility,both,21,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,48711,CDM,J2003,HCPCS,63323-486-05,NDC,,,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,63323-485-03,NDC,,,facility,both,60,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,0409-4276-16,NDC,,,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,63323-485-01,NDC,,,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,48711,CDM,J2003,HCPCS,63739-170-13,NDC,,,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,63323-201-02,NDC,,,facility,both,60,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,48711,CDM,J2003,HCPCS,0409-4713-32,NDC,,,facility,both,60,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 1% 10MG/ML (1ML-UD) OR SYRINGE,48711,CDM,J2003,HCPCS,0409-4276-02,NDC,,,facility,both,500,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,0409-4276-17,NDC,,,facility,both,300,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,48711,CDM,J2003,HCPCS,63323-495-04,NDC,,,facility,both,200,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,0409-4276-17,NDC,,,facility,both,500,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,63323-485-03,NDC,,,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,0409-4276-16,NDC,,,facility,both,90,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,48711,CDM,J2003,HCPCS,0409-4713-32,NDC,,,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,48711,CDM,J2003,HCPCS,63323-486-05,NDC,,,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,48711,CDM,J2003,HCPCS,63323-486-05,NDC,,,facility,both,300,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,48711,CDM,J2003,HCPCS,0409-4279-16,NDC,,,facility,both,300,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,63323-201-01,NDC,,,facility,both,20,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,63323-201-03,NDC,,,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,0143-9577-01,NDC,,,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,48711,CDM,J2003,HCPCS,63323-486-26,NDC,,,facility,both,80,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,48711,CDM,J2003,HCPCS,63323-202-02,NDC,,,facility,both,40,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,48711,CDM,J2003,HCPCS,0409-4713-42,NDC,,,facility,both,21,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,63323-201-02,NDC,,,facility,both,100,ML,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,48711,CDM,J2003,HCPCS,63323-486-05,NDC,,,facility,both,200,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,63323-485-03,NDC,,,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,63323-485-03,NDC,,,facility,both,300,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,48711,CDM,J2003,HCPCS,0143-9595-01,NDC,,,facility,both,300,ML,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,48711,CDM,J2003,HCPCS,0409-4282-02,NDC,,,facility,both,400,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,48711,CDM,J2003,HCPCS,63323-495-07,NDC,,,facility,both,100,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,48711,CDM,J2003,HCPCS,63323-486-05,NDC,,,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,63323-201-03,NDC,,,facility,both,100,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,48711,CDM,J2003,HCPCS,63323-492-27,NDC,,,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,48711,CDM,J2003,HCPCS,0409-4279-02,NDC,,,facility,both,3,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,63323-485-01,NDC,,,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,48711,CDM,J2003,HCPCS,63323-492-07,NDC,,,facility,both,300,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,48711,CDM,J2003,HCPCS,63323-486-05,NDC,,,facility,both,1000,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,48711,CDM,J2003,HCPCS,0409-4279-16,NDC,,,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,63323-485-03,NDC,,,facility,both,40,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,63323-485-01,NDC,,,facility,both,13,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2% 20MG/ML (5ML-UD) OR SYRINGE,48711,CDM,J2003,HCPCS,63323-486-01,NDC,,,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,63323-485-27,NDC,,,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,63323-485-01,NDC,,,facility,both,21,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2% 20MG/ML (5ML-UD) OR SYRINGE,48711,CDM,J2003,HCPCS,63323-486-01,NDC,,,facility,both,12,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,0409-4276-16,NDC,,,facility,both,140,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,48711,CDM,J2003,HCPCS,63323-492-04,NDC,,,facility,both,80,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,63323-485-01,NDC,,,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,48711,CDM,J2003,HCPCS,63323-486-05,NDC,,,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,63323-485-27,NDC,,,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,48711,CDM,J2003,HCPCS,0409-4277-01,NDC,,,facility,both,400,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,0409-4276-16,NDC,,,facility,both,120,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,48711,CDM,J2003,HCPCS,55150-162-05,NDC,,,facility,both,50,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,48711,CDM,J2003,HCPCS,0409-4279-02,NDC,,,facility,both,300,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,48711,CDM,J2003,HCPCS,63323-208-05,NDC,,,facility,both,200,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,48711,CDM,J2003,HCPCS,63323-492-09,NDC,,,facility,both,200,ML,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,63323-485-03,NDC,,,facility,both,500,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,48711,CDM,J2003,HCPCS,63323-486-17,NDC,,,facility,both,120,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,0409-4276-16,NDC,,,facility,both,13,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,63323-201-03,NDC,,,facility,both,21,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,63323-201-01,NDC,,,facility,both,30,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,63323-485-41,NDC,,,facility,both,21,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,48711,CDM,J2003,HCPCS,63323-202-02,NDC,,,facility,both,80,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,63323-485-03,NDC,,,facility,both,15,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,48711,CDM,J2003,HCPCS,63323-486-02,NDC,,,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,63323-485-01,NDC,,,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,63323-485-01,NDC,,,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,48711,CDM,J2003,HCPCS,63323-486-05,NDC,,,facility,both,40,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,0143-9577-10,NDC,,,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,0143-9577-01,NDC,,,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,48711,CDM,J2003,HCPCS,63323-486-17,NDC,,,facility,both,80,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,63323-485-41,NDC,,,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,63323-201-10,NDC,,,facility,both,42,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,48711,CDM,J2003,HCPCS,63323-492-09,NDC,,,facility,both,100,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,48711,CDM,J2003,HCPCS,63323-492-41,NDC,,,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,0143-9577-10,NDC,,,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,0409-4276-16,NDC,,,facility,both,21,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,48711,CDM,J2003,HCPCS,63323-492-97,NDC,,,facility,both,100,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,63323-201-01,NDC,,,facility,both,40,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,48711,CDM,J2003,HCPCS,0409-4713-02,NDC,,,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,0409-4276-16,NDC,,,facility,both,170,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,48711,CDM,J2003,HCPCS,0409-4277-02,NDC,,,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,48711,CDM,J2003,HCPCS,63323-492-16,NDC,,,facility,both,60,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,48711,CDM,J2003,HCPCS,63323-202-02,NDC,,,facility,both,60,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,48711,CDM,J2003,HCPCS,63739-170-13,NDC,,,facility,both,21,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,0143-9577-01,NDC,,,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,48711,CDM,J2003,HCPCS,63323-486-20,NDC,,,facility,both,400,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,63323-485-03,NDC,,,facility,both,25,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,48711,CDM,J2003,HCPCS,0143-9595-01,NDC,,,facility,both,50,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,48711,CDM,J2003,HCPCS,63323-492-04,NDC,,,facility,both,60,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,48711,CDM,J2003,HCPCS,0409-4276-16,NDC,,,facility,both,40,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",48722,CDM,J2004,HCPCS,0409-3178-16,NDC,,,facility,both,300,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",48722,CDM,J2004,HCPCS,63323-482-03,NDC,,,facility,both,100,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",48722,CDM,J2004,HCPCS,0409-3178-01,NDC,,,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",48722,CDM,J2004,HCPCS,63323-482-03,NDC,,,facility,both,80,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",48722,CDM,J2004,HCPCS,63323-482-03,NDC,,,facility,both,300,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",48722,CDM,J2004,HCPCS,0409-3178-17,NDC,,,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",48722,CDM,J2004,HCPCS,63323-482-01,NDC,,,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",48722,CDM,J2004,HCPCS,0409-3178-17,NDC,,,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",48722,CDM,J2004,HCPCS,63323-482-01,NDC,,,facility,both,300,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",48722,CDM,J2004,HCPCS,0409-3178-01,NDC,,,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",48722,CDM,J2004,HCPCS,63323-482-27,NDC,,,facility,both,200,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:200,000 INJ SOLN",48722,CDM,J2004,HCPCS,63323-487-01,NDC,,,facility,both,100,ML,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",48722,CDM,J2004,HCPCS,0409-3178-01,NDC,,,facility,both,300,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",48722,CDM,J2004,HCPCS,63323-482-03,NDC,,,facility,both,200,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",48722,CDM,J2004,HCPCS,63323-482-01,NDC,,,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 2 %-1:200,000 INJ SOLN",48722,CDM,J2004,HCPCS,63323-489-01,NDC,,,facility,both,200,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",48722,CDM,J2004,HCPCS,63323-482-03,NDC,,,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",48722,CDM,J2004,HCPCS,63323-482-41,NDC,,,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",48722,CDM,J2004,HCPCS,63323-482-03,NDC,,,facility,both,13,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:200,000 INJ SOLN",48722,CDM,J2004,HCPCS,63323-487-31,NDC,,,facility,both,600,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",48722,CDM,J2004,HCPCS,63323-482-03,NDC,,,facility,both,60,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",48722,CDM,J2004,HCPCS,63323-482-03,NDC,,,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",48722,CDM,J2004,HCPCS,63323-482-03,NDC,,,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",48722,CDM,J2004,HCPCS,63323-482-41,NDC,,,facility,both,300,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",48722,CDM,J2004,HCPCS,63323-482-01,NDC,,,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:200,000 INJ SOLN",48722,CDM,J2004,HCPCS,63323-487-01,NDC,,,facility,both,200,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",48722,CDM,J2004,HCPCS,63323-482-01,NDC,,,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:200,000 INJ SOLN",48722,CDM,J2004,HCPCS,63323-487-03,NDC,,,facility,both,10,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",48722,CDM,J2004,HCPCS,63323-482-03,NDC,,,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",48722,CDM,J2004,HCPCS,63323-482-03,NDC,,,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",48722,CDM,J2004,HCPCS,63323-482-01,NDC,,,facility,both,70,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:200,000 INJ SOLN",48722,CDM,J2004,HCPCS,63323-487-07,NDC,,,facility,both,300,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",48722,CDM,J2004,HCPCS,63323-482-03,NDC,,,facility,both,200,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 2 %-1:200,000 INJ SOLN",48722,CDM,J2004,HCPCS,63323-489-02,NDC,,,facility,both,60,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",48722,CDM,J2004,HCPCS,63323-482-26,NDC,,,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:200,000 INJ SOLN",48722,CDM,J2004,HCPCS,63323-487-01,NDC,,,facility,both,100,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",48722,CDM,J2004,HCPCS,0409-3178-01,NDC,,,facility,both,200,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",48722,CDM,J2004,HCPCS,63323-482-01,NDC,,,facility,both,300,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",48722,CDM,J2004,HCPCS,63323-482-03,NDC,,,facility,both,15,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",48722,CDM,J2004,HCPCS,0409-0007-10,NDC,,,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",48722,CDM,J2004,HCPCS,63323-482-01,NDC,,,facility,both,40,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",48722,CDM,J2004,HCPCS,63323-482-03,NDC,,,facility,both,144,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",48722,CDM,J2004,HCPCS,63323-482-57,NDC,,,facility,both,500,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",48722,CDM,J2004,HCPCS,63323-482-03,NDC,,,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",48722,CDM,J2004,HCPCS,0409-3178-01,NDC,,,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",48722,CDM,J2004,HCPCS,0409-3178-01,NDC,,,facility,both,400,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",48722,CDM,J2004,HCPCS,63323-482-17,NDC,,,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",48722,CDM,J2004,HCPCS,63323-482-05,NDC,,,facility,both,500,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",48722,CDM,J2004,HCPCS,0409-3178-01,NDC,,,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",48722,CDM,J2004,HCPCS,63323-482-05,NDC,,,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:200,000 INJ SOLN",48722,CDM,J2004,HCPCS,63323-487-03,NDC,,,facility,both,100,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",48722,CDM,J2004,HCPCS,63323-482-01,NDC,,,facility,both,100,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:200,000 INJ SOLN",48722,CDM,J2004,HCPCS,63323-487-07,NDC,,,facility,both,600,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",48722,CDM,J2004,HCPCS,63323-482-03,NDC,,,facility,both,45,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 2 %-1:200,000 INJ SOLN",48722,CDM,J2004,HCPCS,63323-489-02,NDC,,,facility,both,60,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",48722,CDM,J2004,HCPCS,63323-482-03,NDC,,,facility,both,7,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",48722,CDM,J2004,HCPCS,63323-482-03,NDC,,,facility,both,40,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",48722,CDM,J2004,HCPCS,0409-3178-17,NDC,,,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",48722,CDM,J2004,HCPCS,63323-482-01,NDC,,,facility,both,13,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",48722,CDM,J2004,HCPCS,63323-482-03,NDC,,,facility,both,100,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",48722,CDM,J2004,HCPCS,63323-482-27,NDC,,,facility,both,400,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",48722,CDM,J2004,HCPCS,63323-482-17,NDC,,,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",48722,CDM,J2004,HCPCS,63323-482-01,NDC,,,facility,both,80,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",48722,CDM,J2004,HCPCS,63323-482-03,NDC,,,facility,both,400,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",48722,CDM,J2004,HCPCS,0409-3178-16,NDC,,,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",48722,CDM,J2004,HCPCS,63323-482-03,NDC,,,facility,both,300,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",48722,CDM,J2004,HCPCS,0409-3178-03,NDC,,,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",48722,CDM,J2004,HCPCS,63323-482-01,NDC,,,facility,both,100,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",48722,CDM,J2004,HCPCS,0409-3178-02,NDC,,,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:200,000 INJ SOLN",48722,CDM,J2004,HCPCS,63323-487-07,NDC,,,facility,both,300,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",48722,CDM,J2004,HCPCS,0409-3178-01,NDC,,,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",48722,CDM,J2004,HCPCS,0409-3178-16,NDC,,,facility,both,400,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",48722,CDM,J2004,HCPCS,0409-3178-03,NDC,,,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",48722,CDM,J2004,HCPCS,63323-482-41,NDC,,,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",48722,CDM,J2004,HCPCS,63323-482-03,NDC,,,facility,both,1,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",48722,CDM,J2004,HCPCS,63323-482-17,NDC,,,facility,both,300,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",48722,CDM,J2004,HCPCS,0409-3178-16,NDC,,,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TARLATAMAB-DLLE 10 MG IV SOLR,48723,CDM,C9170,HCPCS,55513-069-01,NDC,,,facility,both,10,EA,,41381,28966.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TARLATAMAB-DLLE 10 MG IV SOLR,48723,CDM,C9170,HCPCS,55513-069-01,NDC,,,facility,both,10,EA,,41400,28980,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NADOFARAGENE FIRADENOVEC-VNCG 3X10EXP11 VP/ML IVES SUSP,48729,CDM,J9029,HCPCS,55566-1050-0,NDC,,,facility,both,1,ML,,87000,60900,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NADOFARAGENE FIRADENOVEC-VNCG 3X10EXP11 VP/ML IVES SUSP,48729,CDM,J9029,HCPCS,55566-1050-1,NDC,,,facility,both,1,ML,,87000,60900,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLBETUXIMAB-CLZB 300 MG IV SOLR (WET SOLR VIAL),48772,CDM,C9303,HCPCS,0469-4425-30,NDC,,,facility,both,740,EA,,32679,22875.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLBETUXIMAB-CLZB 100 MG IV SOLR (WET SOLR VIAL),48772,CDM,C9303,HCPCS,0469-3425-10,NDC,,,facility,both,140,EA,,6183,4328.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLBETUXIMAB-CLZB 300 MG IV SOLR (WET SOLR VIAL),48772,CDM,C9303,HCPCS,0469-4425-30,NDC,,,facility,both,160,EA,,3072,2150.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLBETUXIMAB-CLZB 100 MG IV SOLR (WET SOLR VIAL),48772,CDM,C9303,HCPCS,0469-3425-10,NDC,,,facility,both,60,EA,,1152,806.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLBETUXIMAB-CLZB 100 MG IV SOLR (WET SOLR VIAL),48772,CDM,C9303,HCPCS,0469-3425-10,NDC,,,facility,both,90,EA,,1728,1209.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLBETUXIMAB-CLZB 100 MG IV SOLR (WET SOLR VIAL),48772,CDM,C9303,HCPCS,0469-3425-10,NDC,,,facility,both,110,EA,,4858,3400.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLBETUXIMAB-CLZB 300 MG IV SOLR (WET SOLR VIAL),48772,CDM,C9303,HCPCS,0469-4425-30,NDC,,,facility,both,600,EA,,26496,18547.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENDAMUSTINE 25 MG/ML IV SOLN,48851,CDM,J9036,HCPCS,63459-348-04,NDC,,,facility,both,160,ML,,10925,7647.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APREPITANT 130 MG/18 ML (7.2 MG/ML) IV EMUL,48994,CDM,J0185,HCPCS,47426-201-01,NDC,,,facility,both,130,ML,,1206,844.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APREPITANT 130 MG/18 ML (7.2 MG/ML) IV EMUL,48994,CDM,J0185,HCPCS,47426-201-01,NDC,,,facility,both,130,ML,,1231,861.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LONCASTUXIMAB TESIRINE-LPYL 10 MG IV SOLR,49107,CDM,J9359,HCPCS,79952-110-01,NDC,,,facility,both,180,EA,,87367,61156.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LONCASTUXIMAB TESIRINE-LPYL 10 MG IV SOLR,49107,CDM,J9359,HCPCS,79952-110-01,NDC,,,facility,both,31,EA,,6754,4727.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LONCASTUXIMAB TESIRINE-LPYL 10 MG IV SOLR,49107,CDM,J9359,HCPCS,79952-110-01,NDC,,,facility,both,90,EA,,43684,30578.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LONCASTUXIMAB TESIRINE-LPYL 10 MG IV SOLR,49107,CDM,J9359,HCPCS,79952-110-01,NDC,,,facility,both,102,EA,,49327,34528.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TARLATAMAB-DLLE 10 MG IV SOLR,49118,CDM,J9026,HCPCS,55513-069-01,NDC,,,facility,both,10,EA,,41381,28966.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TARLATAMAB-DLLE 10 MG IV SOLR,49118,CDM,J9026,HCPCS,55513-069-01,NDC,,,facility,both,10,EA,,41400,28980,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IMETELSTAT 188 MG IV SOLR,49119,CDM,J0870,HCPCS,82959-111-01,NDC,,,facility,both,377,EA,,54674,38271.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IMETELSTAT 188 MG IV SOLR,49119,CDM,J0870,HCPCS,82959-111-01,NDC,,,facility,both,376,EA,,54496,38147.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IMETELSTAT  47 MG IV SOLR,49119,CDM,J0870,HCPCS,82959-112-01,NDC,,,facility,both,37,EA,,5335,3734.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IMETELSTAT  47 MG IV SOLR,49119,CDM,J0870,HCPCS,82959-112-01,NDC,,,facility,both,74,EA,,10711,7497.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IMETELSTAT 188 MG IV SOLR,49119,CDM,J0870,HCPCS,82959-111-01,NDC,,,facility,both,566,EA,,82013,57409.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IMETELSTAT 188 MG IV SOLR,49119,CDM,J0870,HCPCS,82959-111-01,NDC,,,facility,both,334,EA,,48436,33905.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IMETELSTAT  47 MG IV SOLR,49119,CDM,J0870,HCPCS,82959-112-01,NDC,,,facility,both,93,EA,,13490,9443,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IMETELSTAT  47 MG IV SOLR,49119,CDM,J0870,HCPCS,82959-112-01,NDC,,,facility,both,146,EA,,21098,14768.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IMETELSTAT 188 MG IV SOLR,49119,CDM,J0870,HCPCS,82959-111-01,NDC,,,facility,both,564,EA,,81790,57253,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IMETELSTAT 188 MG IV SOLR,49119,CDM,J0870,HCPCS,82959-111-01,NDC,,,facility,both,334,EA,,48441,33908.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IMETELSTAT 188 MG IV SOLR,49119,CDM,J0870,HCPCS,82959-111-01,NDC,,,facility,both,263,EA,,38047,26632.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IMETELSTAT 188 MG IV SOLR,49119,CDM,J0870,HCPCS,82959-111-01,NDC,,,facility,both,189,EA,,27340,19138,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TORIPALIMAB-TPZI 240 MG/6 ML (40 MG/ML) IV SOLN,49225,CDM,J3263,HCPCS,70114-340-01,NDC,,,facility,both,240,ML,,25650,17955,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN D5W 1 GRAM/200 ML IV PGBK,49393,CDM,J3373,HCPCS,0338-3552-48,NDC,,,facility,both,100,ML,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.3 MG/0.3 ML IM PNIJ,49399,CDM,J0169,HCPCS,49502-102-01,NDC,,,facility,both,3,EA,,675,472.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.3 MG/0.3 ML IM PNIJ,49399,CDM,J0169,HCPCS,49502-500-02,NDC,,,facility,both,3,EA,,840,588,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLBETUXIMAB-CLZB 100 MG IV SOLR (WET SOLR VIAL),49404,CDM,J1326,HCPCS,0469-3425-10,NDC,,,facility,both,70,EA,,6183,4328.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLBETUXIMAB-CLZB 300 MG IV SOLR (WET SOLR VIAL),49404,CDM,J1326,HCPCS,0469-4425-30,NDC,,,facility,both,300,EA,,26496,18547.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLBETUXIMAB-CLZB 100 MG IV SOLR (WET SOLR VIAL),49404,CDM,J1326,HCPCS,0469-3425-10,NDC,,,facility,both,50,EA,,4416,3091.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLBETUXIMAB-CLZB 300 MG IV SOLR (WET SOLR VIAL),49404,CDM,J1325,HCPCS,0469-4425-30,NDC,,,facility,both,1,EA,,26496,18547.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLBETUXIMAB-CLZB 100 MG IV SOLR (WET SOLR VIAL),49404,CDM,J1325,HCPCS,0469-3425-10,NDC,,,facility,both,1,EA,,1152,806.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLBETUXIMAB-CLZB 300 MG IV SOLR (WET SOLR VIAL),49404,CDM,C9303,HCPCS,0469-4425-30,NDC,,,facility,both,1,EA,,26496,18547.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLBETUXIMAB-CLZB 100 MG IV SOLR (WET SOLR VIAL),49404,CDM,J1326,HCPCS,0469-3425-10,NDC,,,facility,both,45,EA,,1728,1209.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLBETUXIMAB-CLZB 100 MG IV SOLR (WET SOLR VIAL),49404,CDM,C9303,HCPCS,0469-3425-10,NDC,,,facility,both,1,EA,,1152,806.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLBETUXIMAB-CLZB 100 MG IV SOLR (WET SOLR VIAL),49404,CDM,J1325,HCPCS,0469-3425-10,NDC,,,facility,both,1,EA,,6183,4328.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLBETUXIMAB-CLZB 100 MG IV SOLR (WET SOLR VIAL),49404,CDM,J1326,HCPCS,0469-3425-10,NDC,,,facility,both,30,EA,,1152,806.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLBETUXIMAB-CLZB 100 MG IV SOLR (WET SOLR VIAL),49404,CDM,J1326,HCPCS,0469-3425-10,NDC,,,facility,both,55,EA,,4858,3400.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLBETUXIMAB-CLZB 100 MG IV SOLR (WET SOLR VIAL),49404,CDM,C9303,HCPCS,0469-3425-10,NDC,,,facility,both,1,EA,,6183,4328.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DENOSUMAB-BBDZ 60 MG/ML SUBQ SYRG,49437,CDM,Q5136,HCPCS,61314-240-63,NDC,,,facility,both,60,ML,,4428,3099.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DENOSUMAB-BBDZ 120 MG/1.7 ML (70 MG/ML) SUBQ SOLN,49437,CDM,q5136,HCPCS,61314-228-94,NDC,,,facility,both,120,ML,,8855,6198.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MENING A,C,Y,W TT-N. MEN B(PF) 5-120 MCG/0.5 ML IM KIT (CAM USE ONLY)",49614,CDM,90623,HCPCS,0069-0332-01,NDC,,,facility,both,1,ML,,817,571.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MENING A,C,Y,W TT-N. MEN B(PF) 5-120 MCG/0.5 ML IM KIT (CAM USE ONLY)",49614,CDM,90623,HCPCS,0069-0271-01,NDC,,,facility,both,1,EA,,841,588.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MENING A,C,Y,W TT-N. MEN B(PF) 5-120 MCG/0.5 ML IM KIT (CAM USE ONLY)",49614,CDM,90623,HCPCS,0069-0271-01,NDC,,,facility,both,1,EA,,817,571.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),49675,CDM,J1611,HCPCS,63323-596-11,NDC,,,facility,both,1,EA,,895,626.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.3 MG/0.3 ML IM PNIJ,49689,CDM,J0171,HCPCS,49502-102-01,NDC,,,facility,both,3,EA,,675,472.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DATOPOTAMAB DERUXTECAN-DLNK 100 MG IV SOLR,49698,CDM,C9174,HCPCS,65597-801-01,NDC,,,facility,both,540,EA,,72897,51027.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DATOPOTAMAB DERUXTECAN-DLNK 100 MG IV SOLR,49698,CDM,C9174,HCPCS,65597-801-01,NDC,,,facility,both,60,EA,,3522,2465.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TISLELIZUMAB-JSGR 10 MG/ML IV SOLN,49775,CDM,J9329,HCPCS,72579-121-01,NDC,,,facility,both,50,ML,,3345,2341.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TISLELIZUMAB-JSGR 10 MG/ML IV SOLN,49775,CDM,J9329,HCPCS,72579-121-01,NDC,,,facility,both,150,ML,,23077,16153.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DATOPOTAMAB DERUXTECAN-DLNK 100 MG IV SOLR,49798,CDM,J9011,HCPCS,65597-801-01,NDC,,,facility,both,540,EA,,72897,51027.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DATOPOTAMAB DERUXTECAN-DLNK 100 MG IV SOLR,49798,CDM,J9011,HCPCS,65597-801-01,NDC,,,facility,both,60,EA,,3522,2465.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC IV INFUSION HYDRAT 31-60 MIN,50823,CDM,260,RC,J0248,HCPCS,61958-2901-2,NDC,facility,both,1,EA,XU,2392,1674.4,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
IOFLUPANE I 123 5 MCI/2.5 ML (185 MBQ/2.5ML) IV SOLN,50857,CDM,250,RC,A9584,HCPCS,17156-210-01,NDC,facility,both,1,EA,,2294,1605.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODINE I-123 SODIUM IODINE CAPSULE,50857,CDM,1,RC,A9509,HCPCS,48815-1001-1,NDC,facility,both,1,EA,,423,296.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODINE (I-131) CAPSULE FOR THYROID THERAPY,50857,CDM,1,RC,A9517,HCPCS,65174-880-00,NDC,facility,both,151,EA,,7520,5264,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,6,EA,,10520,7364,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,6,EA,,10540,7378,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOFLUPANE I 123 5 MCI/2.5 ML (185 MBQ/2.5ML) IV SOLN,50857,CDM,1,RC,A9584,HCPCS,17156-210-01,NDC,facility,both,1,EA,,2075,1452.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODINE (I-131) CAPSULE FOR THYROID THERAPY,50857,CDM,1,RC,A9517,HCPCS,65174-880-00,NDC,facility,both,103,EA,,5129,3590.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,6,EA,,10276,7193.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,50857,CDM,1,RC,A9539,HCPCS,65174-288-30,NDC,facility,both,1,EA,,131,91.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODINE (I-131) CAPSULE FOR THYROID THERAPY,50857,CDM,1,RC,A9517,HCPCS,65174-880-00,NDC,facility,both,126,EA,,6275,4392.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,50857,CDM,1,RC,A9520,HCPCS,65857-400-01,NDC,facility,both,2,EA,,1770,1239,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,6,EA,,10845,7591.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,50857,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,14,EA,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,6,EA,,10662,7463.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,6,EA,,11129,7790.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,6,EA,,10459,7321.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,50857,CDM,250,RC,A9537,HCPCS,0270-0083-20,NDC,facility,both,1,EA,,237,165.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOFLUPANE I 123 5 MCI/2.5 ML (185 MBQ/2.5ML) IV SOLN,50857,CDM,1,RC,A9584,HCPCS,17156-210-01,NDC,facility,both,1,EA,,1989,1392.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,50857,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,17,EA,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,6,EA,PI,10581,7406.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PI: Positron emission tomography (pet) or pet/computed tomography (ct) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,50857,CDM,1,RC,A9539,HCPCS,65174-288-30,NDC,facility,both,1,EA,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODINE (I-131) CAPSULE FOR THYROID THERAPY,50857,CDM,1,RC,A9517,HCPCS,65174-880-00,NDC,facility,both,101,EA,,5030,3521,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOFLUPANE I 123 5 MCI/2.5 ML (185 MBQ/2.5ML) IV SOLN,50857,CDM,1,RC,A9584,HCPCS,17156-210-01,NDC,facility,both,1,EA,,2065,1445.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,50857,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,1,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,5,EA,,9931,6951.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,6,EA,,10337,7235.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODINE (I-131) CAPSULE FOR THYROID THERAPY,50857,CDM,1,RC,A9517,HCPCS,65174-880-00,NDC,facility,both,107,EA,,5329,3730.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,50857,CDM,1,RC,A9552,HCPCS,65857-100-30,NDC,facility,both,1,EA,PI,1170,819,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PI: Positron emission tomography (pet) or pet/computed tomography (ct) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,50857,CDM,1,RC,A9567,HCPCS,99999-0400-16,NDC,facility,both,1,EA,,522,365.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,6,EA,,10296,7207.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TECHNETIUM TC 99M SESTAMIBI - CARDIOLITE,50857,CDM,250,RC,A9500,HCPCS,65857-500-20,NDC,facility,both,1,EA,,214,149.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOFLUPANE I 123 5 MCI/2.5 ML (185 MBQ/2.5ML) IV SOLN,50857,CDM,1,RC,A9584,HCPCS,17156-210-01,NDC,facility,both,1,EA,,2192,1534.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,6,EA,,10824,7576.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,6,EA,,10581,7406.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOFLUPANE I 123 5 MCI/2.5 ML (185 MBQ/2.5ML) IV SOLN,50857,CDM,1,RC,A9584,HCPCS,17156-210-01,NDC,facility,both,1,EA,,2091,1463.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODINE (I-131) CAPSULE FOR THYROID THERAPY,50857,CDM,1,RC,A9517,HCPCS,65174-880-00,NDC,facility,both,121,EA,,6026,4218.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODINE (I-131) CAPSULE FOR THYROID THERAPY,50857,CDM,1,RC,A9517,HCPCS,65174-880-00,NDC,facility,both,161,EA,,8018,5612.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,5,EA,,10073,7051.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT FOR PREP OF GA 68-DOTATATE 40 MCG IV SOLR,50857,CDM,1,RC,A9587,HCPCS,69488-001-40,NDC,facility,both,60,EA,,10325,7227.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,50857,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,16,EA,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,5,EA,,9687,6780.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOFLUPANE I 123 5 MCI/2.5 ML (185 MBQ/2.5ML) IV SOLN,50857,CDM,1,RC,A9584,HCPCS,17156-210-01,NDC,facility,both,1,EA,,2345,1641.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,50857,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,20,EA,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,50857,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,17,EA,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,50857,CDM,1,RC,A9541,HCPCS,45567-0030-1,NDC,facility,both,1,EA,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,6,EA,,10743,7520.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,50857,CDM,1,RC,A9539,HCPCS,65174-288-30,NDC,facility,both,1,EA,,127,88.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,50857,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,21,EA,,108,75.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,50857,CDM,250,RC,A9503,HCPCS,65174-660-30,NDC,facility,both,1,EA,,210,147,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,50857,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,50857,CDM,1,RC,A9539,HCPCS,65174-288-30,NDC,facility,both,1,EA,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,50857,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,17,EA,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,6,EA,PI,10540,7378,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PI: Positron emission tomography (pet) or pet/computed tomography (ct) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,6,EA,,10905,7633.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOFLUPANE I 123 5 MCI/2.5 ML (185 MBQ/2.5ML) IV SOLN,50857,CDM,1,RC,A9584,HCPCS,17156-210-01,NDC,facility,both,1,EA,,1938,1356.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,50857,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,25,EA,XU,129,90.3,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,A9596,HCPCS,74725-100-64,NDC,,,facility,both,6,EA,,11048,7733.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODINE I-123 SODIUM IODINE CAPSULE,50857,CDM,1,RC,A9509,HCPCS,48815-1001-1,NDC,facility,both,1,EA,,240,168,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,5,EA,,9910,6937,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,6,EA,PI,10804,7562.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PI: Positron emission tomography (pet) or pet/computed tomography (ct) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,50857,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,16,EA,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GALLIUM-67 CITRATE 74 MBQ/ML (2 MCI/ML) IV SOLN,50857,CDM,1,RC,A9556,HCPCS,69945-180-06,NDC,facility,both,6,EA,,251,175.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODINE (I-131) CAPSULE FOR THYROID THERAPY,50857,CDM,1,RC,A9517,HCPCS,65174-880-00,NDC,facility,both,104,EA,,5179,3625.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,6,EA,,11169,7818.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TECHNETIUM TC 99M SESTAMIBI - CARDIOLITE,50857,CDM,1,RC,A9500,HCPCS,65857-500-20,NDC,facility,both,1,EA,,214,149.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODINE (I-131) CAPSULE FOR THYROID THERAPY,50857,CDM,1,RC,A9517,HCPCS,65174-880-00,NDC,facility,both,21,EA,,1277,893.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,50857,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,14,EA,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODINE (I-131) CAPSULE FOR THYROID THERAPY,50857,CDM,1,RC,A9517,HCPCS,65174-880-00,NDC,facility,both,4,EA,,331,231.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,6,EA,,11088,7761.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODINE (I-131) CAPSULE FOR UPTAKE DIAGNOSTIC,50857,CDM,1,RC,A9531,HCPCS,99999-402-98,NDC,facility,both,1,EA,,191,133.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 100 MICROCURIE.
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,6,EA,,12185,8529.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,50857,CDM,1,RC,A9552,HCPCS,65857-100-30,NDC,facility,both,1,EA,PS,1170,819,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PS: Positron emission tomography (pet) or pet/computed tomography (ct) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary's treating physician determines that the pet study is needed to inform subsequent anti-tumor strategy
KIT FOR PREP OF GA 68-DOTATATE 40 MCG IV SOLR,50857,CDM,1,RC,A9587,HCPCS,69488-001-40,NDC,facility,both,58,EA,,16100,11270,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,50857,CDM,1,RC,A9539,HCPCS,65174-288-30,NDC,facility,both,3,EA,,662,463.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT FOR PREP OF GA 68-DOTATATE 40 MCG IV SOLR,50857,CDM,1,RC,A9587,HCPCS,69488-001-40,NDC,facility,both,112,EA,,16100,11270,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,6,EA,PI,10946,7662.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PI: Positron emission tomography (pet) or pet/computed tomography (ct) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing
GALLIUM-67 CITRATE 74 MBQ/ML (2 MCI/ML) IV SOLN,50857,CDM,1,RC,A9556,HCPCS,69945-180-06,NDC,facility,both,9,EA,,425,297.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,6,EA,,10865,7605.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,50857,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,16,EA,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,50857,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,6,EA,PI,11169,7818.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PI: Positron emission tomography (pet) or pet/computed tomography (ct) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,5,EA,,10053,7037.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,6,EA,PS,11169,7818.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PS: Positron emission tomography (pet) or pet/computed tomography (ct) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary's treating physician determines that the pet study is needed to inform subsequent anti-tumor strategy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,50857,CDM,1,RC,A9503,HCPCS,65174-660-30,NDC,facility,both,1,EA,,210,147,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,6,EA,PI,11048,7733.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PI: Positron emission tomography (pet) or pet/computed tomography (ct) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing
IODINE (I-131) CAPSULE FOR THYROID THERAPY,50857,CDM,1,RC,A9517,HCPCS,65174-880-00,NDC,facility,both,99,EA,,4930,3451,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,50857,CDM,1,RC,A9540,HCPCS,65174-270-30,NDC,facility,both,1,EA,,642,449.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,50857,CDM,1,RC,A9567,HCPCS,65174-288-30,NDC,facility,both,1,EA,,522,365.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,6,EA,,10560,7392,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,6,EA,,10479,7335.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INDIUM IN-111 LABELED AUTOLOGOUS WHITE BLOOD CELLS,50857,CDM,1,RC,A9570,HCPCS,17156-021-01,NDC,facility,both,1,EA,,6136,4295.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,6,EA,,11109,7776.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,50857,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,2,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODINE (I-131) CAPSULE FOR THYROID THERAPY,50857,CDM,1,RC,A9517,HCPCS,65174-880-00,NDC,facility,both,108,EA,,5378,3764.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,6,EA,PS,11129,7790.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PS: Positron emission tomography (pet) or pet/computed tomography (ct) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary's treating physician determines that the pet study is needed to inform subsequent anti-tumor strategy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,50857,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,16,EA,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,50857,CDM,1,RC,A9539,HCPCS,65174-288-30,NDC,facility,both,3,EA,,794,555.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,5,EA,,9707,6794.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,4,EA,,8123,5686.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,6,EA,,11068,7747.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODINE (I-131) CAPSULE FOR THYROID THERAPY,50857,CDM,1,RC,A9517,HCPCS,65174-880-00,NDC,facility,both,105,EA,,5229,3660.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,50857,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,30,EA,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,5,EA,,9728,6809.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,6,EA,,10418,7292.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT FOR PREP OF GA 68-DOTATATE 40 MCG IV SOLR,50857,CDM,1,RC,A9587,HCPCS,69488-001-40,NDC,facility,both,54,EA,,16100,11270,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODINE I-123 CAPSULE FOR WHOLE BODY SCAN,50857,CDM,1,RC,A9509,HCPCS,99999-0407-66,NDC,facility,both,1,EA,,1681,1176.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 3 MILLICURIE
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,6,EA,,10885,7619.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,6,EA,,10357,7249.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,6,EA,,10784,7548.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODINE (I-131) CAPSULE FOR THYROID THERAPY,50857,CDM,1,RC,A9517,HCPCS,65174-880-00,NDC,facility,both,30,EA,,1494,1045.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,50857,CDM,1,RC,A9552,HCPCS,65857-100-30,NDC,facility,both,1,EA,,1170,819,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,50857,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,15,EA,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,50857,CDM,250,RC,A9541,HCPCS,45567-0030-1,NDC,facility,both,1,EA,,483,338.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,6,EA,,10317,7221.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODINE (I-131) CAPSULE FOR THYROID THERAPY,50857,CDM,1,RC,A9517,HCPCS,65174-880-00,NDC,facility,both,102,EA,,5080,3556,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,5,EA,,10114,7079.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,50857,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,16,EA,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,50857,CDM,1,RC,A9539,HCPCS,65174-288-30,NDC,facility,both,1,EA,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,50857,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,18,EA,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT FOR PREP OF GA 68-DOTATATE 40 MCG IV SOLR,50857,CDM,1,RC,A9587,HCPCS,69488-001-40,NDC,facility,both,53,EA,,10325,7227.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODINE (I-131) CAPSULE FOR THYROID THERAPY,50857,CDM,1,RC,A9517,HCPCS,65174-880-00,NDC,facility,both,153,EA,,7619,5333.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,50857,CDM,250,RC,A9520,HCPCS,65857-400-01,NDC,facility,both,1,EA,,1080,756,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,6,EA,,11149,7804.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCICLOVINE F18 10 MCI (370 MBQ) IV SOLN,50857,CDM,A9588,HCPCS,69932-001-01,NDC,,,facility,both,11,EA,,12529,8770.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,50857,CDM,1,RC,A9541,HCPCS,45567-0030-1,NDC,facility,both,1,EA,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP TC-99M-SOD OXIDRONATE 3.15 MG IV SOLR,50857,CDM,1,RC,A9561,HCPCS,69945-091-20,NDC,facility,both,1,EA,,265,185.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOFLUPANE I 123 5 MCI/2.5 ML (185 MBQ/2.5ML) IV SOLN,50857,CDM,1,RC,A9584,HCPCS,17156-210-01,NDC,facility,both,1,EA,,2243,1570.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,5,EA,,9261,6482.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,6,EA,,10763,7534.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,50857,CDM,1,RC,A9560,HCPCS,69945-068-20,NDC,facility,both,2,EA,,886,620.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,50857,CDM,1,RC,A9538,HCPCS,45567-0060-1,NDC,facility,both,1,EA,,255,178.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODINE (I-131) CAPSULE FOR THYROID THERAPY,50857,CDM,1,RC,A9517,HCPCS,65174-880-00,NDC,facility,both,128,EA,,6374,4461.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,6,EA,,10377,7263.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,50857,CDM,250,RC,A9552,HCPCS,65857-100-30,NDC,facility,both,1,EA,,1170,819,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,5,EA,,9992,6994.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,6,EA,PS,11068,7747.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PS: Positron emission tomography (pet) or pet/computed tomography (ct) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary's treating physician determines that the pet study is needed to inform subsequent anti-tumor strategy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,6,EA,,10174,7121.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,6,EA,PS,11149,7804.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PS: Positron emission tomography (pet) or pet/computed tomography (ct) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary's treating physician determines that the pet study is needed to inform subsequent anti-tumor strategy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,50857,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,17,EA,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,50857,CDM,1,RC,A9562,HCPCS,65174-660-30,NDC,facility,both,1,EA,,1046,732.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,6,EA,,10702,7491.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODINE (I-131) CAPSULE FOR THYROID THERAPY,50857,CDM,1,RC,A9517,HCPCS,65174-880-00,NDC,facility,both,122,EA,,6076,4253.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODINE (I-131) CAPSULE FOR THYROID THERAPY,50857,CDM,1,RC,A9517,HCPCS,65174-880-00,NDC,facility,both,109,EA,,5428,3799.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,50857,CDM,1,RC,A9541,HCPCS,45567-0030-1,NDC,facility,both,1,EA,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,50857,CDM,1,RC,A9569,HCPCS,99999-0407-05,NDC,facility,both,1,EA,,5381,3766.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT FOR PREP OF GA 68-DOTATATE 40 MCG IV SOLR,50857,CDM,1,RC,A9587,HCPCS,69488-001-40,NDC,facility,both,56,EA,,10325,7227.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOFLUPANE I 123 5 MCI/2.5 ML (185 MBQ/2.5ML) IV SOLN,50857,CDM,1,RC,A9584,HCPCS,17156-210-01,NDC,facility,both,1,EA,,2141,1498.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODINE (I-131) CAPSULE FOR THYROID THERAPY,50857,CDM,1,RC,A9517,HCPCS,65174-880-00,NDC,facility,both,100,EA,,4980,3486,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,6,EA,,10256,7179.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,6,EA,,11027,7718.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,50857,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,13,EA,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,50857,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,14,EA,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,50857,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,14,EA,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,6,EA,,11007,7704.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,6,EA,,10804,7562.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODINE (I-131) CAPSULE FOR THYROID THERAPY,50857,CDM,1,RC,A9517,HCPCS,65174-880-00,NDC,facility,both,154,EA,,7669,5368.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODINE (I-131) CAPSULE FOR THYROID THERAPY,50857,CDM,1,RC,A9528,HCPCS,65174-880-00,NDC,facility,both,36,EA,,1569,1098.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,50857,CDM,1,RC,A9520,HCPCS,65857-400-01,NDC,facility,both,1,EA,,1770,1239,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,5,EA,,10134,7093.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,6,EA,PS,10905,7633.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PS: Positron emission tomography (pet) or pet/computed tomography (ct) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary's treating physician determines that the pet study is needed to inform subsequent anti-tumor strategy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,6,EA,,10966,7676.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,6,EA,,10438,7306.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,5,EA,PI,10154,7107.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PI: Positron emission tomography (pet) or pet/computed tomography (ct) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing
IODINE (I-131) CAPSULE FOR THYROID THERAPY,50857,CDM,1,RC,A9517,HCPCS,65174-880-00,NDC,facility,both,106,EA,,5279,3695.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,A9596,HCPCS,74725-100-64,NDC,,,facility,both,5,EA,,10154,7107.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,50857,CDM,1,RC,A9541,HCPCS,45567-0030-1,NDC,facility,both,1,EA,,108,75.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,6,EA,,10682,7477.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INDIUM IN-111 PENTETATE,50857,CDM,1,RC,A9548,HCPCS,69945-0050-40,NDC,facility,both,2,EA,,13053,9137.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,6,EA,,10926,7648.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,50857,CDM,1,RC,A9520,HCPCS,65857-400-01,NDC,facility,both,1,EA,,1080,756,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,50857,CDM,1,RC,A9520,HCPCS,65857-400-01,NDC,facility,both,4,EA,,3540,2478,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODINE (I-131) CAPSULE FOR UPTAKE DIAGNOSTIC,50857,CDM,1,RC,A9531,HCPCS,65174-461-05,NDC,facility,both,100,EA,,191,133.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT FOR PREP OF GA 68-DOTATATE 40 MCG IV SOLR,50857,CDM,1,RC,A9587,HCPCS,69488-001-40,NDC,facility,both,54,EA,,10325,7227.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOFLUPANE I 123 5 MCI/2.5 ML (185 MBQ/2.5ML) IV SOLN,50857,CDM,1,RC,A9584,HCPCS,17156-210-01,NDC,facility,both,1,EA,,2045,1431.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,6,EA,PI,10987,7690.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PI: Positron emission tomography (pet) or pet/computed tomography (ct) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,50857,CDM,1,RC,A9539,HCPCS,65174-288-30,NDC,facility,both,1,EA,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOFLUPANE I 123 5 MCI/2.5 ML (185 MBQ/2.5ML) IV SOLN,50857,CDM,1,RC,A9584,HCPCS,17156-210-01,NDC,facility,both,1,EA,,2080,1456,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,6,EA,,10723,7506.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP TC-99M-SOD OXIDRONATE 3.15 MG IV SOLR,50857,CDM,1,RC,A9561,HCPCS,69945-091-20,NDC,facility,both,1,EA,,284,198.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,50857,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,15,EA,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODINE (I-131) CAPSULE FOR THYROID THERAPY,50857,CDM,1,RC,A9517,HCPCS,65174-880-00,NDC,facility,both,119,EA,,5926,4148.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOFLUPANE I 123 5 MCI/2.5 ML (185 MBQ/2.5ML) IV SOLN,50857,CDM,1,RC,A9584,HCPCS,17156-210-01,NDC,facility,both,1,EA,,2040,1428,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODINE (I-131) CAPSULE FOR THYROID THERAPY,50857,CDM,1,RC,A9517,HCPCS,65174-880-00,NDC,facility,both,16,EA,,973,681.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,50857,CDM,1,RC,A9537,HCPCS,0270-0083-20,NDC,facility,both,1,EA,,237,165.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,50857,CDM,1,RC,A9541,HCPCS,45567-0030-1,NDC,facility,both,1,EA,,483,338.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,50857,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODINE (I-131) CAPSULE FOR THYROID THERAPY,50857,CDM,250,RC,A9517,HCPCS,65174-880-00,NDC,facility,both,16,EA,,973,681.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,50857,CDM,1,RC,A9560,HCPCS,69945-068-20,NDC,facility,both,1,EA,,443,310.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,50857,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,12,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TECHNETIUM TC 99M SESTAMIBI - CARDIOLITE,50857,CDM,A9500,HCPCS,65857-500-20,NDC,,,facility,both,1,EA,,214,149.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,6,EA,PI,10966,7676.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PI: Positron emission tomography (pet) or pet/computed tomography (ct) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing
KIT FOR PREP OF GA 68-DOTATATE 40 MCG IV SOLR,50857,CDM,1,RC,A9587,HCPCS,69488-001-40,NDC,facility,both,2,EA,,16100,11270,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,6,EA,,10641,7448.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,6,EA,,10987,7690.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT FOR PREP OF GA 68-DOTATATE 40 MCG IV SOLR,50857,CDM,1,RC,A9587,HCPCS,69488-001-40,NDC,facility,both,5,EA,,16100,11270,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,5,EA,,10154,7107.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,6,EA,,10946,7662.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IOBENGUANE, I-123",50857,CDM,1,RC,A9582,HCPCS,17156-235-01,NDC,facility,both,1,EA,,8818,6172.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,50857,CDM,1,RC,A9557,HCPCS,65857-100-30,NDC,facility,both,1,EA,,4113,2879.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,50857,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,15,EA,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,50857,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,15,EA,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODINE (I-131) CAPSULE FOR THYROID THERAPY,50857,CDM,1,RC,A9528,HCPCS,65174-880-00,NDC,facility,both,6,EA,,356,249.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,50857,CDM,1,RC,A9539,HCPCS,65174-288-30,NDC,facility,both,4,EA,,821,574.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,5,EA,PS,10154,7107.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PS: Positron emission tomography (pet) or pet/computed tomography (ct) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary's treating physician determines that the pet study is needed to inform subsequent anti-tumor strategy
KIT FOR PREP OF GA 68-DOTATATE 40 MCG IV SOLR,50857,CDM,1,RC,A9587,HCPCS,69488-001-40,NDC,facility,both,1,EA,,10325,7227.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,5,EA,,10093,7065.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,6,EA,,10601,7420.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,6,EA,,10621,7434.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KIT PREP OF GA-68-GOZETOTIDE 25 MCG IV SOLR,50857,CDM,1,RC,A9596,HCPCS,74725-100-64,NDC,facility,both,6,EA,,11048,7733.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,50857,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,15,EA,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODINE I-123 SODIUM IODINE CAPSULE,50857,CDM,1,RC,A9509,HCPCS,48815-1001-1,NDC,facility,both,3,EA,,1711,1197.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODINE (I-131) CAPSULE FOR THYROID THERAPY,50857,CDM,1,RC,A9517,HCPCS,65174-880-00,NDC,facility,both,110,EA,,5478,3834.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC TC-99 FROM NON-HIGHLY ENRICHED URANIUM SOURCE FULL COST ADD ON PER STUDY DOSE,50857,CDM,1,RC,A9512,HCPCS,69945-110-12,NDC,facility,both,9,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODINE (I-131) CAPSULE FOR THYROID THERAPY,50857,CDM,1,RC,A9517,HCPCS,65174-880-00,NDC,facility,both,123,EA,,6125,4287.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL (NEO/PEDS),50863,CDM,250,RC,J3490,HCPCS,63323-820-00,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RAMIPRIL  1.25 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,68382-144-06,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,J0665,HCPCS,70594-117-01,NDC,,,facility,both,300,ML,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 10 GRAM/15 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,66689-038-01,NDC,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),50863,CDM,636,RC,J0171,HCPCS,76329-3318-1,NDC,facility,both,20,ML,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6638-61,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGIC MOUTHWASH REPACK (BMX 1:1:1),50863,CDM,250,RC,J3490,HCPCS,99999-500-91,NDC,facility,both,3,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN IN D5W 900 MG/50 ML IV PGBK,50863,CDM,636,RC,J0736,HCPCS,0781-3290-91,NDC,facility,both,2,ML,JZ,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,J3373,HCPCS,0143-9162-01,NDC,,,facility,both,100,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-511-11,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 2.5 %-1/2 NORMAL SALINE IV,50863,CDM,250,RC,J3490,HCPCS,0338-0073-04,NDC,facility,both,1,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAZOLAMIDE 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6663-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,0075-0622-01,NDC,facility,both,8,ML,JZ,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ACIDOPHILUS-PECTIN W CITRUS 25 MILLION-100 CELL MG TAB,50863,CDM,J3490,HCPCS,1785614241,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,636,RC,J1815,HCPCS,49502-393-80,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,640,ML,,919,643.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,J1611,HCPCS,63323-596-11,NDC,,,facility,both,1,EA,,895,626.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,636,RC,J1953,HCPCS,63323-400-01,NDC,facility,both,225,ML,,237,165.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN IN SALINE (ISO-OSMOTIC) 80 MG/100 ML IV PIGGY BACK,50863,CDM,636,RC,J1580,HCPCS,0338-0503-48,NDC,facility,both,3,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,J1644,HCPCS,72603-179-01,NDC,,,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"TRANEXAMIC ACID IN NACL,ISO-OS 1,000 MG/100 ML (10 MG/ML) IV PGBK",50863,CDM,636,RC,J3490,HCPCS,51754-0108-3,NDC,facility,both,3,ML,,370,259,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-075-01,NDC,facility,both,4,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL  1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0832-1520-89,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,43598-931-11,NDC,facility,both,3,ML,JW,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
BUPROPION HCL 150 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,43598-655-30,NDC,facility,both,1,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE 20 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0093-7115-98,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42858-301-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOFLOXACIN 750 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6353-61,NDC,facility,both,1,EA,,121,84.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DACTINOMYCIN 0.5 MG IV SOLR,50863,CDM,250,RC,J9120,HCPCS,71288-129-02,NDC,facility,both,2,EA,,2222,1555.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,250,RC,J0690,HCPCS,61553-012-72,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE  5 MG ORAL CP24,50863,CDM,636,RC,J3490,HCPCS,70010-029-01,NDC,facility,both,5,EA,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 8-2 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,50268-145-11,NDC,facility,both,1,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM ACETATE 2 MEQ/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,69784-230-10,NDC,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7047-61,NDC,facility,both,3,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE-DEXTROSE-WATER(PF) 7.5 MG/ML (0.75 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,71351-022-10,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE HCL 0.3 MG/ML INJ (MERGE),50863,CDM,250,RC,J0592,HCPCS,70069-027-01,NDC,facility,both,6,ML,,179,125.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"RABIES VACCINE, PURIFIED CHICKEN EMBRYO CELL (PF) 2.5 UNIT IM KIT",50863,CDM,636,RC,90675,HCPCS,50632-013-01,NDC,facility,both,1,EA,,1200,840,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANTI-INHIBITOR COAGULANT CMPLX (PHS MERGE),50863,CDM,J7198,HCPCS,64193-426-02,NDC,,,facility,both,7500,UN,,54165,37915.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANTI-THYMOCYTE GLOB (RABBIT) 25 MG IV SOLR,50863,CDM,J7511,HCPCS,58468-0080-1,NDC,,,facility,both,7,EA,,14154,9907.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-0430-06,NDC,facility,both,18,EA,,231,161.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) IV (NEO) EMERGENCY SYRINGE,50863,CDM,250,RC,J3490,HCPCS,0409-5534-34,NDC,facility,both,2,ML,,127,88.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIMODIPINE 30 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,23155-512-11,NDC,facility,both,2,EA,,181,126.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML IV (MERGE) (FOR VENT),50863,CDM,250,RC,J3010,HCPCS,70092-1509-35,NDC,facility,both,25,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6370-61,NDC,facility,both,2,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML ORAL SOLUTION (FOR PEDIATRIC USE),50863,CDM,250,RC,J3480,HCPCS,63323-965-05,NDC,facility,both,18,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,J3490,HCPCS,66794-228-02,NDC,,,facility,both,2,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 10 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6987-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,6,EA,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,636,RC,J7999,HCPCS,70092-1017-46,NDC,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42858-302-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENRALIZUMAB 30 MG/ML SUBQ SYRG,50863,CDM,636,RC,J0517,HCPCS,0310-1730-30,NDC,facility,both,30,ML,JZ,13116,9181.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SERTRALINE 20 MG/ML ORAL CONC,50863,CDM,636,RC,J3490,HCPCS,71093-143-11,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOBUTAMINE IN D5W 500 MG/250 ML (2 MG/ML) INFUSION (PREMIX),50863,CDM,636,RC,J1250,HCPCS,0338-1075-02,NDC,facility,both,2,ML,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,0409-1886-22,NDC,facility,both,380,ML,,197,137.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE DINITRATE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6619-61,NDC,facility,both,3,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J2004,HCPCS,0409-3178-16,NDC,facility,both,80,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J2004,HCPCS,63323-482-27,NDC,facility,both,200,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-9558-05,NDC,facility,both,3,ML,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  5 GRAM IV SOLR,50863,CDM,250,RC,J3373,HCPCS,63323-295-61,NDC,facility,both,200,EA,,162,113.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLEDRONIC ACID IN MANNITOL & WATER 5 MG/100 ML IV SOLN,50863,CDM,636,RC,J3489,HCPCS,0078-0435-61,NDC,facility,both,5,ML,JZ,2992,2094.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DEXTROSE 10% IN WATER (D10) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0990-7930-09,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-50,NDC,facility,both,105,ML,,185,129.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,72603-179-01,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-38,NDC,facility,both,1,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,J1644,HCPCS,0409-2720-31,NDC,,,facility,both,20,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 3000 MCG/ML INJECTION,50863,CDM,250,RC,J0153,HCPCS,67457-855-00,NDC,facility,both,12,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESTRADIOL 0.1 MG/24 HR TD PTWK,50863,CDM,250,RC,J7304,HCPCS,0378-3352-16,NDC,facility,both,1,EA,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN 50 MG ORAL CHEW,50863,CDM,636,RC,J3490,HCPCS,60687-156-95,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESVENLAFAXINE  50 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,0054-0400-13,NDC,facility,both,2,EA,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB 10 MG/ML IV CONC,50863,CDM,J9312,HCPCS,50242-053-06,NDC,,,facility,both,100,ML,,25931,18151.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51672-4035-1,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-3178-16,NDC,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATOMOXETINE  10 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,68462-265-30,NDC,facility,both,6,EA,,363,254.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE HCL  2 % MM JELP,50863,CDM,250,RC,J3490,HCPCS,25021-673-76,NDC,facility,both,9,ML,,273,191.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 400 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,16714-663-01,NDC,facility,both,3,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IV PGBK,50863,CDM,250,RC,J3475,HCPCS,63323-106-02,NDC,facility,both,4,ML,JZ,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DIVALPROEX 500 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,0904-6861-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE (POLACRILEX) 4 MG BUCL GUM,50863,CDM,250,RC,J3490,HCPCS,70677-1167-1,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE IN D5W 1 GRAM/100 ML IV PGBK,50863,CDM,250,RC,J3475,HCPCS,63323-108-00,NDC,facility,both,4,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,636,RC,P9045,HCPCS,64208-2510-2,NDC,facility,both,2,ML,,238,166.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,636,RC,J1100,HCPCS,25021-053-01,NDC,facility,both,8,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
AMOXICILLIN 500 MG ORAL CAP,50863,CDM,J3490,HCPCS,60687-787-11,NDC,,,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 500 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,50268-260-11,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CINACALCET 30 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-525-11,NDC,facility,both,1,EA,,152,106.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-354-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION,50863,CDM,250,RC,J3490,HCPCS,0186-0370-20,NDC,facility,both,1,GM,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-4264-11,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0780,HCPCS,23155-294-31,NDC,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,70860-406-41,NDC,facility,both,4,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM IN NACL (ISO-OS) 500 MG/100 ML IV PGBK,50863,CDM,250,RC,J1953,HCPCS,70860-602-41,NDC,facility,both,50,ML,,200,140,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,72603-251-01,NDC,facility,both,60,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,0409-9094-22,NDC,facility,both,4,ML,JZ,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
OLANZAPINE 10 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,55111-263-79,NDC,facility,both,2,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,250,RC,J3490,HCPCS,63323-486-05,NDC,facility,both,300,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUVOXAMINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0832-1671-11,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7030,HCPCS,0338-0049-04,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,424,ME,JZ,5754,4027.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,250,RC,J3101,HCPCS,50242-037-06,NDC,facility,both,33,EA,JW,6200,4340,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,J2270,HCPCS,0409-1890-03,NDC,,,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 1% 10MG/ML (1ML-UD) OR SYRINGE,50863,CDM,J2003,HCPCS,0409-4276-02,NDC,,,facility,both,150,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZOCAINE-MENTHOL 15-2.6 MG MM LOZG,50863,CDM,J3490,HCPCS,17856-0732-1,NDC,,,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,636,RC,J3490,HCPCS,60687-653-11,NDC,facility,both,3,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,78,ML,,111,77.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,60687-134-11,NDC,facility,both,5,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,63323-104-25,NDC,facility,both,26,ML,,163,114.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,0075-0622-01,NDC,facility,both,6,ML,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTAROLINE FOSAMIL 600 MG IV SOLR,50863,CDM,250,RC,J0712,HCPCS,0456-0600-01,NDC,facility,both,40,EA,JW,197,137.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
TACROLIMUS 0.75 MG (ENVARSUS XR) 24-HOUR EXTENDED-RELEASE TABLET,50863,CDM,636,RC,J7503,HCPCS,68992-3075-3,NDC,facility,both,9,EA,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 0.1 MG/ML IV SYRINGE (NEO/INFANT),50863,CDM,250,RC,J1100,HCPCS,99999-0405-74,NDC,facility,both,1,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-555-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE  5 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,64850-510-01,NDC,facility,both,6,EA,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GOLIMUMAB  12.5 MG/ML IV SOLN,50863,CDM,636,RC,J1602,HCPCS,57894-350-01,NDC,facility,both,230,ML,,25382,17767.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 20 MG/ML INJ SOLN,50863,CDM,250,RC,J0360,HCPCS,0641-6231-01,NDC,facility,both,2,ML,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-453-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEMAZEPAM  7.5 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,68084-549-11,NDC,facility,both,1,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-590-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0555-0873-02,NDC,facility,both,24,EA,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE 100 MG ORAL CAP,50863,CDM,636,RC,J7502,HCPCS,0078-0241-61,NDC,facility,both,1,EA,,108,75.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0555-0873-02,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANTI-INHIBITOR COAGULANT CMPLX (PHS MERGE),50863,CDM,250,RC,J7198,HCPCS,64193-424-02,NDC,facility,both,1300,UN,,7745,5421.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYTOCIN IN 0.9 % SOD CHLORIDE 30 UNIT/500 ML IV SOLN,50863,CDM,250,RC,J2590,HCPCS,70092-1068-07,NDC,facility,both,1,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,636,RC,J3490,HCPCS,55150-188-10,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GOLIMUMAB  12.5 MG/ML IV SOLN,50863,CDM,636,RC,J1602,HCPCS,57894-350-01,NDC,facility,both,100,ML,,11036,7725.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-975-11,NDC,facility,both,2,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,636,RC,Q0162,HCPCS,65162-691-79,NDC,facility,both,2,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALUM-MAG HYDROXIDE-SIMETH 200 MG-200 MG-20 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,63739-159-77,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60505-3110-0,NDC,facility,both,1,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PYRIDOXINE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,7733394025,NDC,facility,both,5,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZINC OXIDE 16 % TOP PSTE,50863,CDM,636,RC,J3490,HCPCS,6210333304,NDC,facility,both,1,GM,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-22,NDC,facility,both,4,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,636,RC,J2795,HCPCS,70069-064-25,NDC,facility,both,40,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROPROCAINE 3 % INJ SOLN,50863,CDM,250,RC,J2401,HCPCS,63323-478-01,NDC,facility,both,301,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,81284-315-05,NDC,facility,both,2,ML,,1770,1239,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,121059530,NDC,facility,both,1,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,636,RC,J3010,HCPCS,0409-9093-32,NDC,facility,both,5,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 150 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,0904-7084-61,NDC,facility,both,2,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,3,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
AZITHROMYCIN 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-074-11,NDC,facility,both,2,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-48,NDC,facility,both,1,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,50863,CDM,250,RC,J9025,HCPCS,72485-201-01,NDC,facility,both,138,EA,,1951,1365.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROGESTERONE MICRONIZED 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,16714-157-01,NDC,facility,both,2,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PYRIDOSTIGMINE BROMIDE 60 MG/5 ML ORAL SYRP,50863,CDM,250,RC,J3490,HCPCS,70954-148-10,NDC,facility,both,1,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 50 % (4 MEQ/ML) INJ SOLN,50863,CDM,250,RC,J3475,HCPCS,63323-064-01,NDC,facility,both,8,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0143-9889-15,NDC,facility,both,6,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"HEPARIN, PORCINE (PF)  100 UNIT/ML IV SYRG",50863,CDM,636,RC,J1642,HCPCS,6380760055,NDC,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,636,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,4,EA,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,27,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR 200 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60505-0042-6,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,62559-440-02,NDC,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE (DIAGNOSTIC) 3 MG/ML IV SOLN,50863,CDM,636,RC,J0153,HCPCS,55150-193-01,NDC,facility,both,180,ML,,1545,1081.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68180-980-01,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MANNITOL 25 % IV SOLN,50863,CDM,250,RC,J2150,HCPCS,63323-024-01,NDC,facility,both,50,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0990-7983-02,NDC,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-25,NDC,facility,both,40,ML,"JZ,JA,JG",5658,3960.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously | Modifier JG: Drug or biological acquired with 340b drug pricing program discount
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,27,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC MCARE ADMIN HEPATITIS B VACC,50863,CDM,250,RC,90746,HCPCS,58160-821-01,NDC,facility,both,1,ML,,353,247.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,72888-060-30,NDC,facility,both,4,EA,,146,102.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM & SODIUM PHOSPHATES 280-160-250 MG ORAL PWPK,50863,CDM,636,RC,J3490,HCPCS,7135101001,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-479-10,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 150 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,0904-7505-61,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J2310,HCPCS,70069-072-10,NDC,facility,both,4,ML,,424,296.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % (1 MEQ/ML) IV 50 ML EMERGENCY SYRINGE,50863,CDM,250,RC,J3490,HCPCS,70092-1015-50,NDC,facility,both,4,ML,,248,173.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 200 MG/100 ML IVPB (MERGE),50863,CDM,250,RC,J1450,HCPCS,69784-002-06,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,636,RC,J3101,HCPCS,50242-037-06,NDC,facility,both,25,EA,,11451,8015.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESALAMINE 1000 MG RECT SUPP,50863,CDM,636,RC,J3490,HCPCS,0472-1915-01,NDC,facility,both,1,EA,,216,151.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELIMUMAB 120 MG IV SOLR,50863,CDM,636,RC,J0490,HCPCS,49401-101-01,NDC,facility,both,48,ME,"JZ,JA",5638,3946.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,1,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,71288-505-02,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0781-1818-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0143-9982-50,NDC,facility,both,19,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIFEDIPINE 30 MG ORAL TO24,50863,CDM,250,RC,J3490,HCPCS,50268-597-11,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNITS/1 GRAM PACKET (MERGE RECORD),50863,CDM,250,RC,J3490,HCPCS,45802-060-00,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM PHOS IN 0.9 % NACL 15 MMOL/250 ML IVPB PREMIX,50863,CDM,250,RC,J3490,HCPCS,65219-658-01,NDC,facility,both,1,ML,,233,163.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN PEDS SYRINGE (20MG/ML) IN DEXTROSE (CDS MIX,50863,CDM,636,RC,J0690,HCPCS,0781-3451-70,NDC,facility,both,1,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,11,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV (BOLUS),50863,CDM,250,RC,J7120,HCPCS,0264-7750-07,NDC,facility,both,2,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL  75 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6635-61,NDC,facility,both,2,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 3000 MCG/ML INJECTION,50863,CDM,636,RC,J0153,HCPCS,25021-318-02,NDC,facility,both,12,ML,JZ,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CLINDAMYCIN 1 % TOPICAL GEL,50863,CDM,636,RC,J3490,HCPCS,45802-900-94,NDC,facility,both,1,GM,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"HEPARIN, PORCINE (PF)   10 UNIT/ML IV SYRG",50863,CDM,636,RC,J1642,HCPCS,6425322233,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR  6 MG/ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0004-0822-05,NDC,facility,both,10,ML,,149,104.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,50863,CDM,250,RC,J9025,HCPCS,72485-201-01,NDC,facility,both,41,EA,JW,254,177.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
AMIODARONE 50 MG/ML IV SOLN,50863,CDM,J0282,HCPCS,70436-232-72,NDC,,,facility,both,5,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 100 MG ORAL TBSR,50863,CDM,636,RC,J3490,HCPCS,0591-3540-60,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,50863,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,3,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUVOXAMINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60505-0165-1,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PSYLLIUM HUSK (WITH SUGAR) 3.4 GRAM ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,37000-023-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-822-11,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,49,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PILOCARPINE 5 MG TAB,50863,CDM,250,RC,J3490,HCPCS,68084-928-95,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0630,HCPCS,42023-205-01,NDC,facility,both,1,ML,,6093,4265.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE 25 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,68180-657-01,NDC,facility,both,1,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM 500 MG IV SOLR,50863,CDM,250,RC,J2185,HCPCS,0409-1390-21,NDC,facility,both,5,EA,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,250,RC,J3360,HCPCS,0641-6244-01,NDC,facility,both,2,ML,JZ,145,101.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SODIUM CHLORIDE 0.9 % INJ SYRG,50863,CDM,636,RC,J3490,HCPCS,8290306504,NDC,facility,both,5,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,16714-016-01,NDC,facility,both,4,ML,JZ,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,636,RC,J2795,HCPCS,43066-023-01,NDC,facility,both,50,ML,JW,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ADVATE: FACTOR VIII CONCENTRATE (MERGE RECORD),50863,CDM,250,RC,J7192,HCPCS,0944-3053-02,NDC,facility,both,1000,UN,,4186,2930.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADVATE: FACTOR VIII CONCENTRATE (MERGE RECORD),50863,CDM,250,RC,J7192,HCPCS,0944-3053-03,NDC,facility,both,2000,UN,,10488,7341.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG TAB,50863,CDM,250,RC,J3490,HCPCS,50268-728-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SYRSPEND SF (COMPOUND VEH.SUSP SUGAR-FREE 3) ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,5155210795,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MANNITOL 20% IV SOLP,50863,CDM,250,RC,J2150,HCPCS,0990-7715-13,NDC,facility,both,1,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER FLUSH,50863,CDM,636,RC,J7060,HCPCS,0338-0062-30,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,63323-466-17,NDC,facility,both,100,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE 25 MG/ML INJ SOLN,50863,CDM,250,RC,J3230,HCPCS,55150-319-01,NDC,facility,both,2,ML,,292,204.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 1 MG ORAL CAP,50863,CDM,250,RC,J7507,HCPCS,54288-135-01,NDC,facility,both,3,EA,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM SR 420 MG CAP,50863,CDM,250,RC,68682-372-90,NDC,,,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6371-61,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 300 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-722-11,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-495-04,NDC,,,facility,both,300,ML,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IMIPENEM-CILASTATIN 500 MG IV SOLR,50863,CDM,250,RC,J0743,HCPCS,44567-705-10,NDC,facility,both,2,EA,,161,112.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CITRATE-VITAMIN D3 200 MG CALCIUM -250 UNIT ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,1650053502,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,71399-1025-3,NDC,facility,both,2,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (NEO) <2 KG,50863,CDM,250,RC,J7060,HCPCS,0338-0017-41,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAVASTATIN 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-458-01,NDC,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN IN SALINE (ISO-OSMOTIC) 100 MG/50 ML IV PIGGY BACK,50863,CDM,250,RC,J1580,HCPCS,0338-0511-41,NDC,facility,both,2,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOPIDOGREL  75 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-6294-61,NDC,,,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN D5W 20000 UNIT/500 ML,50863,CDM,250,RC,J1644,HCPCS,0264-9567-10,NDC,facility,both,4,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 5 MG/ML (0.5 %) INJECTION,50863,CDM,250,RC,J3490,HCPCS,0409-4275-16,NDC,facility,both,45,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-465-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 20% IN WATER (NEO) 500ML,50863,CDM,250,RC,J3490,HCPCS,0409-7935-19,NDC,facility,both,1,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,636,RC,J3490,HCPCS,63323-486-02,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,636,RC,J3490,HCPCS,0409-1323-15,NDC,facility,both,1000,ML,,440,308,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPYLTHIOURACIL 5MG/ML SUSPENSION (REPACK),50863,CDM,250,RC,J3490,HCPCS,0143-1480-01,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0131-2477-60,NDC,facility,both,2,EA,,156,109.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7188-61,NDC,facility,both,2,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1162-18,NDC,facility,both,150,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,0409-4279-16,NDC,,,facility,both,60,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,J1580,HCPCS,63323-010-03,NDC,,,facility,both,4,ML,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML IV,50863,CDM,636,RC,J3490,HCPCS,70860-301-41,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,250,RC,J3101,HCPCS,50242-037-06,NDC,facility,both,24,EA,,10993,7695.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYMETAZOLINE 0.05 % NASL SPRA,50863,CDM,250,RC,J3490,HCPCS,11523-4112-1,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  50 MG ORAL TAB,50863,CDM,J3490,HCPCS,60687-242-11,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEP B-DP(ACELL)T-POLIO VACC-PF 10MCG-25LF-25MCG-10LF-40-8-32 IM SYRING,50863,CDM,250,RC,90723,HCPCS,58160-811-52,NDC,facility,both,1,ML,,445,311.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,250,RC,J0330,HCPCS,0409-6629-02,NDC,facility,both,9,ML,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,17,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,50863,CDM,636,RC,J1885,HCPCS,72266-119-01,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 5 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,0409-1778-15,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EMTRICITABINE-TENOFOVIR 200 MG-300 MG TAB,50863,CDM,636,RC,J0750,HCPCS,61958-0701-1,NDC,facility,both,1,EA,,313,219.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPRAZOLAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-388-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 1 MG ORAL CAP,50863,CDM,636,RC,J7507,HCPCS,68084-450-11,NDC,facility,both,2,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,51754-4250-1,NDC,facility,both,2,ML,,145,101.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLPIDEM  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6082-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,70069-363-01,NDC,facility,both,2,ML,,281,196.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-9558-05,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 5 MG-325 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0406-0123-01,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IR SOLN,50863,CDM,636,RC,J3490,HCPCS,0338-0048-04,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETIRIZINE 10 MG ORAL TAB,50863,CDM,J3490,HCPCS,51079-597-01,NDC,,,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-25,NDC,facility,both,160,ML,,22631,15841.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0781-3156-06,NDC,facility,both,27,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,50863,CDM,250,RC,J0585,HCPCS,0023-1145-01,NDC,facility,both,100,EA,JZ,1599,1119.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),50863,CDM,250,RC,J1815,HCPCS,0024-5926-05,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN LOCK FLUSH 100 UNIT/ML IV SOLN,50863,CDM,636,RC,J1644,HCPCS,63323-545-01,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,250,RC,J0132,HCPCS,70594-111-01,NDC,facility,both,59,ML,,297,207.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 300 MG ORAL TAB,50863,CDM,J3490,HCPCS,60687-722-11,NDC,,,facility,both,2,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,7,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 40 MG-200 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,65862-496-47,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LANTHANUM  500 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,68180-819-42,NDC,facility,both,4,EA,,220,154,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  37.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-844-11,NDC,facility,both,2,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML IV SOLN (MERGE),50863,CDM,636,RC,J3490,HCPCS,70756-611-82,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LITHIUM CARBONATE 150 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0054-8526-25,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG ORAL TB12,50863,CDM,250,RC,J3490,HCPCS,16571-681-01,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-9558-05,NDC,facility,both,3,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALSARTAN  80 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,31722-152-90,NDC,facility,both,4,EA,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 100 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,60687-479-11,NDC,facility,both,3,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2599,HCPCS,63323-930-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68094-005-59,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIVASTIGMINE 1.5 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,33342-089-09,NDC,facility,both,2,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GAMMAGARD LIQUID 10 % IV SOLN,50863,CDM,636,RC,J1569,HCPCS,0944-2700-10,NDC,facility,both,70,ML,"JZ,JA",12620,8834,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
PIOGLITAZONE 30 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,57237-220-90,NDC,facility,both,2,EA,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN NPH & REGULAR HUMAN 100 UNIT/ML (70-30) SUBQ SUSP,50863,CDM,250,RC,J1815,HCPCS,0169-1837-11,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE IN 0.9% NS (PF) 1 MG/10 ML (100 MCG/ML) IV SYRG(PDS MERGE),50863,CDM,636,RC,J3490,HCPCS,71449-001-15,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,62584-984-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADVATE: FACTOR VIII CONCENTRATE (MERGE RECORD),50863,CDM,250,RC,J7192,HCPCS,0944-3051-02,NDC,facility,both,750,UN,,4027,2818.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-04,NDC,facility,both,12,ML,,200,140,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,76329-3352-1,NDC,facility,both,6,ML,,694,485.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0338-1055-48,NDC,facility,both,25,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DENOSUMAB 60 MG/ML SUBQ SYRG,50863,CDM,636,RC,J0897,HCPCS,55513-710-01,NDC,facility,both,60,ML,,4930,3451,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,68180-723-04,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 10 MEQ/100 ML IV PGBK (USE NON-PROTOCOL PANEL),50863,CDM,250,RC,J3480,HCPCS,0338-0709-48,NDC,facility,both,5,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 125 MG ORAL CPSP,50863,CDM,250,RC,J3490,HCPCS,63739-995-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-980-01,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACIDOPHILUS-PECTIN W CITRUS 25 MILLION-100 CELL MG TAB,50863,CDM,250,RC,J3490,HCPCS,1785614241,NDC,facility,both,14,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LANTHANUM  500 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,68180-819-42,NDC,facility,both,3,EA,,191,133.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 800 MG ORAL TAB,50863,CDM,250,RC,J0601,HCPCS,50268-720-11,NDC,facility,both,80,EA,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLECAINIDE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-0011-21,NDC,facility,both,1,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLNALTREXONE 12 MG/0.6 ML SUBQ SOLN,50863,CDM,636,RC,J2212,HCPCS,65649-551-02,NDC,facility,both,1,ML,GZ,735,514.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier GZ: Item or service expected to be denied as not reasonable and necessary
COLLAGENASE 250 UNIT/G TOP OINT,50863,CDM,636,RC,J3490,HCPCS,50484-010-30,NDC,facility,both,1,GM,,1124,786.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 150 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7212-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5-7.5-10 MG RECT KIT,50863,CDM,250,RC,J3490,HCPCS,68682-652-20,NDC,facility,both,1,EA,,1074,751.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOLIC ACID  1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-681-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,50863,CDM,250,RC,J9075,HCPCS,10019-956-16,NDC,facility,both,100,EA,,648,453.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2310,HCPCS,67457-299-00,NDC,facility,both,2,ML,,257,179.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,636,RC,J3490,HCPCS,51754-4250-1,NDC,facility,both,3,ML,,218,152.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 50 % (4 MEQ/ML) INJ SOLN,50863,CDM,636,RC,J3475,HCPCS,63323-064-01,NDC,facility,both,4,ML,,15091,10563.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE 0.5 MG SL (1/4 TAB) SUBL,50863,CDM,250,RC,J3490,HCPCS,99999-0408-26,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 QUARTER TABLET
VANCOMYCIN  500 MG IV SOLR,50863,CDM,250,RC,J3373,HCPCS,0143-9161-01,NDC,facility,both,25,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM 500 MG IV SOLR,50863,CDM,250,RC,J2185,HCPCS,0781-3000-95,NDC,facility,both,10,EA,,179,125.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,7733393825,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,250,RC,J3490,HCPCS,0143-9679-01,NDC,facility,both,1,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DONANEMAB-AZBT 17.5 MG/ML IV SOLN,50863,CDM,636,RC,J0175,HCPCS,0002-9401-01,NDC,facility,both,700,ML,"JZ,Q0",6401,4480.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier Q0: Investigational clinical service provided in a clinical research study that is in an approved clinical research study
SCOPOLAMINE TRANSDERMAL PATCH 1MG OVER 3 DAYS,50863,CDM,636,RC,J3490,HCPCS,45802-580-01,NDC,facility,both,1,EA,,113,79.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  750 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7125-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 50% IN WATER (MERGE RECORD),50863,CDM,250,RC,J7060,HCPCS,70092-1475-50,NDC,facility,both,1,ML,PLAD,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,636,RC,J7060,HCPCS,0338-0017-31,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,50863,CDM,250,RC,J2359,HCPCS,55150-308-01,NDC,facility,both,5,EA,JW,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
HYDROCORTISONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-582-11,NDC,facility,both,2,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0536-1327-10,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-0552-23,NDC,facility,both,3,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMIDE PEROXIDE 6.5 % OTIC DROP,50863,CDM,250,RC,J3490,HCPCS,4203710478,NDC,facility,both,1,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,31722-711-30,NDC,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN  10 GRAM INJ SOLR,50863,CDM,250,RC,J0690,HCPCS,0143-9983-03,NDC,facility,both,16,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 125 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-443-01,NDC,facility,both,3,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOPIDOGREL  75 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65862-357-90,NDC,facility,both,1,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-1749-70,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6966-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6799-61,NDC,facility,both,1,EA,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6950-61,NDC,facility,both,4,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,50863,CDM,250,RC,J0640,HCPCS,0143-9552-01,NDC,facility,both,6,EA,,131,91.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) NEB SOLUTION,50863,CDM,636,RC,J3490,HCPCS,0378-8270-31,NDC,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RASBURICASE 7.5 MG IV SOLR,50863,CDM,250,RC,J2783,HCPCS,0024-5151-74,NDC,facility,both,12,EA,,11746,8222.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7912-51,NDC,facility,both,9,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE MICROSPHERES 25 MG/2 ML IM SYRG,50863,CDM,250,RC,J2794,HCPCS,50458-306-01,NDC,facility,both,50,EA,,1782,1247.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOBRAMYCIN 1.2 G POWDER VIAL,50863,CDM,250,RC,J3260,HCPCS,39822-0412-6,NDC,facility,both,135,EA,,3578,2504.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN PEDS SYRINGE (20MG/ML) IN DEXTROSE (CDS MIX,50863,CDM,636,RC,J7999,HCPCS,0781-3451-70,NDC,facility,both,6,EA,,155,108.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,38,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN   81 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,0536-1234-41,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM 1 GRAM IV SOLR,50863,CDM,250,RC,J2185,HCPCS,63323-508-01,NDC,facility,both,60,EA,,236,165.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2305-16,NDC,facility,both,7,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-591-11,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  500 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,25021-465-01,NDC,facility,both,20,ML,JA,206,144.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
PREGABALIN  25 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6991-04,NDC,facility,both,8,EA,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0093-4177-73,NDC,facility,both,4,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYMETAZOLINE 0.05 % NASAL MERGE,50863,CDM,250,RC,J3490,HCPCS,0573-1191-20,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,250,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7001-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7350-61,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2308-22,NDC,facility,both,6,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LEUCOVORIN CALCIUM 100 MG INJ SOLR,50863,CDM,250,RC,J0640,HCPCS,0143-9554-01,NDC,facility,both,4,EA,,166,116.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPTOMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0878,HCPCS,0409-0122-01,NDC,facility,both,500,EA,,402,281.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLMESARTAN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68462-437-90,NDC,facility,both,2,EA,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN  100 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,8068107100,NDC,facility,both,5,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 250 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,50268-259-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM  4.5 GRAM IV SOLR,50863,CDM,250,RC,J2543,HCPCS,44567-803-10,NDC,facility,both,4,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GAMMAGARD LIQUID 10 % IV SOLN,50863,CDM,636,RC,J1569,HCPCS,0944-2700-13,NDC,facility,both,60,ML,"JG,JZ,JA",10817,7571.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
ACETAMINOPHEN  650 MG RECT SUPP,50863,CDM,250,RC,J3490,HCPCS,45802-730-00,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROIC ACID 250 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,63739-086-10,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER SULFADIAZINE 1 % TOP CREA,50863,CDM,636,RC,J3490,HCPCS,61570-131-20,NDC,facility,both,3,GM,,161,112.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,7,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 100 MG/ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,31722-574-47,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-01,NDC,facility,both,5,ML,,128,89.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69238-1491-1,NDC,facility,both,3,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE SODIUM 2.5 MG ORAL TAB,50863,CDM,250,RC,J8610,HCPCS,0904-7141-10,NDC,facility,both,4,EA,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,16714-298-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,49502-393-80,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,71247-130-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE  5 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,0228-3062-11,NDC,facility,both,2,EA,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 250 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,0904-6363-61,NDC,facility,both,6,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/0.5 ML INHL NEBU,50863,CDM,J3490,HCPCS,0487-9901-30,NDC,,,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,50863,CDM,J1756,HCPCS,0517-2340-01,NDC,,,facility,both,200,ML,,661,462.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICLOFENAC 1 % TOPICAL GEL,50863,CDM,250,RC,J3490,HCPCS,58602-604-07,NDC,facility,both,1,GM,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,43598-053-11,NDC,facility,both,22,ML,,764,534.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GAMMAGARD LIQUID 10 % IV SOLN,50863,CDM,636,RC,J1569,HCPCS,0944-2700-11,NDC,facility,both,20,ML,,3606,2524.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,63323-461-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATED 20 MG/ML IV SOLN,50863,CDM,250,RC,J0706,HCPCS,51754-0500-1,NDC,facility,both,15,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,25021-468-10,NDC,facility,both,1,EA,,307,214.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETIRIZINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-597-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALTREXONE 50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-291-11,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENAZOPYRIDINE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,69367-611-01,NDC,facility,both,2,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,0409-9094-18,NDC,facility,both,5,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,3,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 75 MG/5 ML ORAL SOLUTION,50863,CDM,250,RC,J3490,HCPCS,64980-511-10,NDC,facility,both,7,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,67877-548-88,NDC,facility,both,4,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"RABIES VACCINE,HUMAN DIPLOID (PF) 2.5 UNIT IM",50863,CDM,636,RC,90675,HCPCS,49281-246-58,NDC,facility,both,1,EA,,1365,955.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 10 MG/ML ORAL SOLUTION (REPACK),50863,CDM,250,RC,J3490,HCPCS,0131-5410-71,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MYCOPHENOLATE SODIUM 360 MG ORAL TBEC,50863,CDM,250,RC,J7518,HCPCS,0904-6786-61,NDC,facility,both,6,EA,,172,120.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 400 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6667-61,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DONANEMAB-AZBT 17.5 MG/ML IV SOLN,50863,CDM,636,RC,J0175,HCPCS,0002-9401-01,NDC,facility,both,525,ML,"JZ,Q0",4801,3360.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier Q0: Investigational clinical service provided in a clinical research study that is in an approved clinical research study
PREDNISONE 10 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,60687-134-11,NDC,facility,both,15,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOPIDOGREL  75 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6294-61,NDC,facility,both,4,EA,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,0904-6923-61,NDC,facility,both,5,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,72205-102-01,NDC,facility,both,10,ML,,200,140,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,63323-162-01,NDC,facility,both,4,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE 2 MG SL SUBL,50863,CDM,636,RC,J3490,HCPCS,0904-7154-04,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUBIPROSTONE  8 MCG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0480-3479-06,NDC,facility,both,1,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-613-04,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,250,RC,Q9968,HCPCS,70710-1838-1,NDC,facility,both,111,ML,,1839,1287.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,636,RC,J2405,HCPCS,23155-547-31,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTAGAM 10 % IV SOLN,50863,CDM,636,RC,J1568,HCPCS,68982-850-04,NDC,facility,both,40,ML,,7348,5143.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EZETIMIBE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-298-11,NDC,facility,both,1,EA,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 50 MG/ML IV SOLN,50863,CDM,250,RC,J0282,HCPCS,70436-232-72,NDC,facility,both,10,ML,JZ,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ONDANSETRON 4 MG ORAL TBDL,50863,CDM,636,RC,J3490,HCPCS,65862-390-10,NDC,facility,both,1,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,636,RC,J1815,HCPCS,0088-2220-33,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,60219-1708-1,NDC,facility,both,300,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTAMIDINE 300 MG INJ SOLR,50863,CDM,250,RC,J3490,HCPCS,23155-748-31,NDC,facility,both,1,EA,,132,92.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) BLADDER INSTILLATION,50863,CDM,J9201,HCPCS,0409-0182-01,NDC,,,facility,both,10,ML,,392,274.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM-ALBUTEROL 0.5 MG-2.5 MG/3 ML NEB SOLUTION,50863,CDM,J3490,HCPCS,47335-756-48,NDC,,,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-02,NDC,facility,both,2,ML,JZ,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ZOLEDRONIC ACID IN MANNITOL & WATER 5 MG/100 ML IV SOLN,50863,CDM,J3489,HCPCS,55111-688-52,NDC,,,facility,both,5,ML,,1062,743.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE (PF) 1000 MCG/10 ML EPID SOLN,50863,CDM,J0735,HCPCS,39822-2000-1,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE 20 MG TAB,50863,CDM,250,RC,J3490,HCPCS,68084-045-11,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE 100 MG TAB,50863,CDM,250,RC,J3490,HCPCS,60687-344-95,NDC,facility,both,10,EA,,130,91,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 100 MG PE/2 ML INJ SOLN,50863,CDM,250,RC,Q2009,HCPCS,63323-403-01,NDC,facility,both,2,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,85,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 0.25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-270-11,NDC,facility,both,3,EA,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-1752-50,NDC,facility,both,2,ML,,200,140,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,0517-4620-25,NDC,facility,both,5,ML,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J2004,HCPCS,0409-3178-01,NDC,facility,both,300,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 400 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0143-9887-01,NDC,facility,both,25,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,250,RC,J7060,HCPCS,0338-0017-38,NDC,facility,both,1,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,114,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EMTRICITABINE-TENOFOVIR 200 MG-300 MG TAB,50863,CDM,636,RC,J0750,HCPCS,65862-354-30,NDC,facility,both,1,EA,,297,207.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,636,RC,J1610,HCPCS,63323-582-82,NDC,facility,both,1,EA,,991,693.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMMONIUM LACTATE 12 % TOP LOTN,50863,CDM,636,RC,J3490,HCPCS,904598426,NDC,facility,both,1,GM,,187,130.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,636,RC,J2795,HCPCS,70069-064-25,NDC,facility,both,125,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0832-1211-89,NDC,facility,both,7,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORDIAZEPOXIDE 25 MG CAP,50863,CDM,636,RC,J3490,HCPCS,60687-807-11,NDC,facility,both,20,EA,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,23,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,50863,CDM,250,RC,J0696,HCPCS,60505-6149-0,NDC,facility,both,24,EA,,1162,813.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOMYCIN-BACITRACN ZN-POLYMYXIN 3.5 MG-400 U*,50863,CDM,250,RC,J3490,HCPCS,45802-143-00,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,63739-931-28,NDC,facility,both,7,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 10 MG TAB,50863,CDM,250,RC,Q0177,HCPCS,16714-081-10,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 1 GRAM INJ SOLR,50863,CDM,250,RC,J0692,HCPCS,0409-0219-01,NDC,facility,both,2,EA,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEPROTUMUMAB-TRBW 500 MG IV SOLR,50863,CDM,636,RC,J3241,HCPCS,75987-130-15,NDC,facility,both,160,EA,,113871,79709.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-467-01,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,76045-009-10,NDC,facility,both,14,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,636,RC,J3490,HCPCS,63323-486-05,NDC,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEFIBROTIDE 80 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,68727-800-01,NDC,facility,both,2,ML,,2449,1714.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE  5 MG/ML INJ SOLN,50863,CDM,636,RC,J2765,HCPCS,0409-3414-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLPIDEM  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-0073-01,NDC,facility,both,1,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,23155-833-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NORTRIPTYLINE 25 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,50268-604-11,NDC,facility,both,5,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-3426-05,NDC,facility,both,4,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7124-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MISOPROSTOL 800 MCG (4 X 200 MCG TAB) PACKAGE,50863,CDM,250,RC,S0191,HCPCS,43386-161-06,NDC,facility,both,3,EA,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,70095-026-01,NDC,facility,both,2,ML,JW,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LEVOTHYROXINE 112 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-508-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUORESCEIN 1 MG OPHT STRP,50863,CDM,250,RC,J3490,HCPCS,83851-100-30,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,J3490,HCPCS,0904-6794-80,NDC,,,facility,both,3,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 800 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-5855-60,NDC,facility,both,1,EA,PLAD,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,250,RC,J0330,HCPCS,31722-981-10,NDC,facility,both,5,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,636,RC,J3490,HCPCS,63037-136-25,NDC,facility,both,2,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-50,NDC,facility,both,42,ML,JW,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PHENYLEPHRINE IN 0.9% NS (PF) 1 MG/10 ML (100 MCG/ML) IV SYRG(PDS MERGE),50863,CDM,250,RC,J3490,HCPCS,65302-506-10,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,2,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ABATACEPT 250 MG IV SOLR,50863,CDM,636,RC,J0129,HCPCS,0003-2187-13,NDC,facility,both,100,EA,JA,17112,11978.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
ENOXAPARIN 30 MG/0.3 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,16714-006-01,NDC,facility,both,3,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  25 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6991-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,67877-432-03,NDC,facility,both,1,EA,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CANGRELOR 50 MG IV SOLR,50863,CDM,250,RC,C9460,HCPCS,10122-620-01,NDC,facility,both,100,EA,,5527,3868.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE MODIFIED 100 MG/ML ORAL SOLN,50863,CDM,250,RC,J7502,HCPCS,0172-7313-20,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM BROMIDE 0.02 % INHL SOLN,50863,CDM,250,RC,J3490,HCPCS,76204-100-01,NDC,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXAZOSIN 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-836-95,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,636,RC,J1953,HCPCS,0409-1886-22,NDC,facility,both,50,ML,JZ,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-1749-70,NDC,facility,both,2,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,55150-169-10,NDC,facility,both,200,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 20 MG/ML ORAL SUSPENSION (REPACK),50863,CDM,250,RC,J3490,HCPCS,16714-041-04,NDC,facility,both,9,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML INJECTION,50863,CDM,636,RC,J3411,HCPCS,0641-6228-01,NDC,facility,both,4,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16714-950-01,NDC,facility,both,3,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,7733351625,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUMAZENIL 0.1 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-424-05,NDC,facility,both,2,ML,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 125 MG ORAL CPSP,50863,CDM,636,RC,J3490,HCPCS,68084-313-11,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,6809411059,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESNA 100 MG/ML IV SOLN,50863,CDM,250,RC,J9209,HCPCS,10019-953-62,NDC,facility,both,2,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 5 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,63323-660-01,NDC,facility,both,2,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6501-61,NDC,facility,both,2,EA,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM SR 180 MG 24 HR CAP,50863,CDM,636,RC,J3490,HCPCS,50742-249-90,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE IN 0.9% NS (PF) 1 MG/10 ML (100 MCG/ML) IV SYRG(PDS MERGE),50863,CDM,636,RC,J3490,HCPCS,70092-1046-46,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 30 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0093-0318-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"TRANEXAMIC ACID IN NACL,ISO-OS 1,000 MG/100 ML (10 MG/ML) IV PGBK",50863,CDM,636,RC,J3490,HCPCS,51754-0108-1,NDC,facility,both,1,ML,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J1610,HCPCS,63323-582-82,NDC,facility,both,5,EA,,4953,3467.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE (DIAGNOSTIC) 3 MG/ML IV SOLN,50863,CDM,636,RC,J0153,HCPCS,55150-193-01,NDC,facility,both,100,ML,JZ,858,600.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2598,HCPCS,43598-914-11,NDC,facility,both,20,ML,JZ,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ENALAPRIL MALEATE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,43547-548-10,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZONISAMIDE 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-230-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,50863,CDM,250,RC,J0561,HCPCS,60793-701-02,NDC,facility,both,12,ML,,1188,831.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SYRG,50863,CDM,636,RC,J3490,HCPCS,8290306547,NDC,facility,both,6,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,250,RC,J3490,HCPCS,63323-486-05,NDC,facility,both,80,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 100 MG/5 ML ORAL LIQD,50863,CDM,250,RC,J3490,HCPCS,60687-863-42,NDC,facility,both,2,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,200,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,67457-385-10,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-344-11,NDC,facility,both,3,EA,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM PHOSPHATE 4.4 MEQ/ML ORAL SOLUTION (CDS),50863,CDM,250,RC,J3490,HCPCS,0409-7295-11,NDC,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIVAROXABAN 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50458-579-90,NDC,facility,both,1,EA,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68180-513-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,636,RC,J3370,HCPCS,63323-284-01,NDC,facility,both,2,EA,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE ACETATE 25 MG RECT SUPP,50863,CDM,250,RC,J3490,HCPCS,50268-411-11,NDC,facility,both,1,EA,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BISACODYL 10 MG RECT SUPP,50863,CDM,250,RC,J3490,HCPCS,58980-415-04,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-325-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE (FOR CODE) 10% (100 MG/ML) IV SYRINGE,50863,CDM,636,RC,J3490,HCPCS,64253-900-30,NDC,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOPERAMIDE 2 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-229-11,NDC,facility,both,14,EA,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIZATRIPTAN  5 MG ORAL TBDL,50863,CDM,636,RC,J3490,HCPCS,65862-625-03,NDC,facility,both,2,EA,,282,197.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2599,HCPCS,43598-914-25,NDC,facility,both,5,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J3490,HCPCS,0338-0049-48,NDC,facility,both,2,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 50 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,59651-489-01,NDC,facility,both,50,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,J7510,HCPCS,17856-0815-1,NDC,,,facility,both,3,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICARDIPINE 25 MG/10 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,55150-183-01,NDC,facility,both,5,ML,,623,436.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,10135-778-01,NDC,facility,both,13,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7243-61,NDC,facility,both,18,EA,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML (PEDS CALCLUATOR 0.5),50863,CDM,250,RC,J1815,HCPCS,0024-5924-10,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BISACODYL  5 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,0904-6748-17,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,250,RC,J3490,HCPCS,0409-4277-16,NDC,facility,both,400,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEPLIZUMAB-MZWV 2 MG/20 ML IV SOLN,50863,CDM,636,RC,J9381,HCPCS,73650-316-01,NDC,facility,both,381,ME,JW,11145,7801.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,28,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,11,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 100 MG PE/2 ML INJ SOLN,50863,CDM,250,RC,Q2009,HCPCS,0069-6001-02,NDC,facility,both,2,ML,,238,166.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 1 MG ORAL CAP,50863,CDM,250,RC,J7507,HCPCS,51079-818-01,NDC,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,609,ME,,8265,5785.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,J2371,HCPCS,70594-063-01,NDC,,,facility,both,40,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 60 MG ORAL CPDR,50863,CDM,636,RC,J3490,HCPCS,68180-296-09,NDC,facility,both,1,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"VITAMIN E (DL, ACETATE) 22.5 MG (50 UNIT)/ML ORAL DROP",50863,CDM,250,RC,J3490,HCPCS,7132180230,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-25,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZTROPINE 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-388-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-559-01,NDC,facility,both,20,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-22,NDC,facility,both,80,ML,,160,112,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZIPRASIDONE 20 MG IM,50863,CDM,636,RC,J3486,HCPCS,72205-205-01,NDC,facility,both,2,EA,JZ,192,134.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LANTHANUM  500 MG ORAL CHEW,50863,CDM,636,RC,J3490,HCPCS,68180-819-42,NDC,facility,both,1,EA,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAVASTATIN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-178-11,NDC,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J1610,HCPCS,63323-582-82,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,35,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-38,NDC,facility,both,1,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J1610,HCPCS,63323-582-82,NDC,facility,both,10,EA,JZ,9905,6933.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CHLORTHALIDONE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-317-95,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL  32.4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,13517-626-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPTOMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0878,HCPCS,0409-0122-01,NDC,facility,both,400,EA,,322,225.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,636,RC,J2270,HCPCS,0409-1891-03,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN   81 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,77333-031-25,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 500 MG SOLUTION FOR INJECTION,50863,CDM,636,RC,J2919,HCPCS,0009-0758-01,NDC,facility,both,100,EA,JZ,143,100.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,636,RC,J1610,HCPCS,63323-582-82,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0143-9386-01,NDC,facility,both,45,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0832-1211-89,NDC,facility,both,4,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % MBP,50863,CDM,250,RC,J3490,HCPCS,0338-0553-18,NDC,facility,both,6,ML,,266,186.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL 120 MG ORAL CS24,50863,CDM,250,RC,J3490,HCPCS,0527-4118-37,NDC,facility,both,2,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",50863,CDM,250,RC,J1561,HCPCS,13533-800-25,NDC,facility,both,80,ML,,11316,7921.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-1159-19,NDC,facility,both,9,ML,,146,102.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ESMOLOL IN SALINE (ISO-OSMOTIC) 2,000 MG/100 ML (20 MG/ML) IV",50863,CDM,636,RC,J1805,HCPCS,44567-451-01,NDC,facility,both,1,ML,,419,293.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 800 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65162-058-27,NDC,facility,both,1,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FELODIPINE 10 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,68462-235-01,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6938-06,NDC,facility,both,2,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7126-61,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,67457-433-00,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6550-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 400 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0143-9887-01,NDC,facility,both,18,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZTROPINE 1 MG/ML INJ SOLN,50863,CDM,636,RC,J0515,HCPCS,68382-860-02,NDC,facility,both,2,ML,,250,175,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NORTRIPTYLINE 10 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,75907-069-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,250,RC,J2270,HCPCS,0409-1890-13,NDC,facility,both,1,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MONTELUKAST 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6808-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
D5W WITH POTASSIUM CHLORIDE 20 MEQ/L IV SOLP,50863,CDM,636,RC,J3490,HCPCS,0338-0683-04,NDC,facility,both,1,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROPROCAINE 3 % INJ SOLN,50863,CDM,250,RC,J2401,HCPCS,0143-9210-01,NDC,facility,both,549,ML,JW,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PROPYLTHIOURACIL 50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-964-95,NDC,facility,both,3,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 50 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,59651-489-01,NDC,facility,both,40,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0245-0147-89,NDC,facility,both,2,EA,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB 100 MG IV SOLR,50863,CDM,636,RC,J1745,HCPCS,57894-030-01,NDC,facility,both,28,EA,,9025,6317.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM & SODIUM PHOSPHATES 280-160-250 MG ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,6025800615,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 150 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-445-01,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIHEXYPHENIDYL 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,70954-211-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6371-61,NDC,facility,both,2,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,50863,CDM,250,RC,J0696,HCPCS,44567-702-25,NDC,facility,both,8,EA,JZ,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ROSUVASTATIN 10 MG ORAL TAB,50863,CDM,J3490,HCPCS,60687-245-11,NDC,,,facility,both,1,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MECLIZINE 25 MG ORAL TAB,50863,CDM,J3490,HCPCS,50268-523-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM IN D5W 125 MG/125 ML (1 MG/ML) IV SOLN (PREMIX),50863,CDM,J3490,HCPCS,63037-119-05,NDC,,,facility,both,1,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,J2003,HCPCS,63323-486-27,NDC,,,facility,both,1000,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,609,ME,JZ,8265,5785.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-087-02,NDC,facility,both,15,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE-EPI-CLONID-KETOROL 2.46-0.005- 0.0008-0.3MG/ML PATC SYRG,50863,CDM,636,RC,J3490,HCPCS,70092-1433-50,NDC,facility,both,20,ML,,4245,2971.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HUMAN PROTHROMBIN COMPLEX 500 UNIT IV SOLR,50863,CDM,250,RC,J7168,HCPCS,63833-386-02,NDC,facility,both,500,UN,,2910,2037,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J3490,HCPCS,0338-0049-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERYTHROMYCIN 5 MG/G OPHT OINT,50863,CDM,250,RC,J3490,HCPCS,16590-090-35,NDC,facility,both,1,GM,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 10 MG ORAL CAP,50863,CDM,J3490,HCPCS,60687-369-11,NDC,,,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOVASTATIN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,61442-142-01,NDC,facility,both,4,EA,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  2 MG ORAL TAB,50863,CDM,J3490,HCPCS,0406-3243-01,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,68382-444-05,NDC,facility,both,2,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 500 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,50268-152-15,NDC,facility,both,21,EA,,126,88.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIGOXIN 125 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-5921-61,NDC,facility,both,2,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,250,RC,J2270,HCPCS,0409-1890-13,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLMESARTAN  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0527-2425-46,NDC,facility,both,2,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-22,NDC,facility,both,120,ML,,240,168,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,636,RC,J7510,HCPCS,17856-0815-1,NDC,facility,both,8,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE-SALMETEROL 500 MCG-50 MCG/DOSE DISK DEVICE FOR INHALATION,50863,CDM,250,RC,J3490,HCPCS,0378-9322-32,NDC,facility,both,1,EA,,1359,951.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 300 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,69452-125-50,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE  2 MG/ML INJ SOLN,50863,CDM,J3490,HCPCS,25021-671-82,NDC,,,facility,both,2,ML,,454,317.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL (VITAMIN D3)  1000 UNIT ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,2055503300,NDC,facility,both,6,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLN,50863,CDM,636,RC,J3262,HCPCS,50242-135-01,NDC,facility,both,800,ML,"JZ,JA",14661,10262.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J1940,HCPCS,63323-280-03,NDC,facility,both,2,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN NEO/PEDS IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0456,HCPCS,63323-398-14,NDC,facility,both,1,EA,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 150 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-445-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),50863,CDM,250,RC,J3490,HCPCS,0409-4888-06,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZTREONAM 1 GRAM INJ SOLR,50863,CDM,250,RC,J0457,HCPCS,0409-0829-11,NDC,facility,both,5,EA,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERYTHROMYCIN 5 MG/G OPHT OINT,50863,CDM,636,RC,J3490,HCPCS,0574-4024-11,NDC,facility,both,1,GM,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"HEPARIN, PORCINE (PF)  100 UNIT/ML IV SYRG",50863,CDM,636,RC,J1642,HCPCS,8290306424,NDC,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-4827-05,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSINOPRIL 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,43547-386-09,NDC,facility,both,4,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,97,EA,,13386,9370.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68382-123-16,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 30 MG ORAL CPDR,50863,CDM,636,RC,J3490,HCPCS,68180-295-09,NDC,facility,both,2,EA,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML IV SOLN (MERGE),50863,CDM,250,RC,J3490,HCPCS,70756-611-82,NDC,facility,both,1,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERTAPENEM 1 GRAM INJ SOLR,50863,CDM,250,RC,J1335,HCPCS,42023-221-01,NDC,facility,both,1,EA,JW,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,250,RC,J3360,HCPCS,0641-6244-01,NDC,facility,both,4,ML,,289,202.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYPROHEPTADINE 4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-189-11,NDC,facility,both,3,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,636,RC,J1611,HCPCS,0597-0053-45,NDC,facility,both,1,EA,,371,259.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-3178-01,NDC,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM 1 GRAM IV SOLR,50863,CDM,250,RC,J2185,HCPCS,63323-508-01,NDC,facility,both,100,EA,,393,275.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML IV,50863,CDM,636,RC,J3490,HCPCS,55150-425-01,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 50% IN WATER (MERGE RECORD),50863,CDM,250,RC,J7060,HCPCS,0409-6648-02,NDC,facility,both,2,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-760-11,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-444-01,NDC,facility,both,6,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,1,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FELODIPINE  5 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,68462-234-01,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.25 MG/0.5 ML (0.5 MG/1 ML) ORAL SUSPENSION (REPACK),50863,CDM,250,RC,J3490,HCPCS,0591-0240-01,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6418-61,NDC,facility,both,2,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE  5 MG/ML INJ SOLN,50863,CDM,250,RC,J2765,HCPCS,0409-3413-01,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 0.25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-570-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,250,RC,J0690,HCPCS,44567-707-25,NDC,facility,both,6,EA,JZ,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,63323-162-00,NDC,facility,both,4,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,636,RC,J3490,HCPCS,66553-002-01,NDC,facility,both,2,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE 2 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,60687-481-11,NDC,facility,both,6,EA,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,0904-6794-80,NDC,facility,both,4,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 50 % (4 MEQ/ML) INJ SOLN,50863,CDM,250,RC,J3475,HCPCS,63323-064-01,NDC,facility,both,8,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHOTERICIN B LIPOSOME 50 MG IV SUSR,50863,CDM,250,RC,J0289,HCPCS,23155-594-31,NDC,facility,both,30,EA,,5411,3787.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
D5-0.9%NACL-POTASSIUM CHLORIDE 20 MEQ/L IV SOLP,50863,CDM,636,RC,J3480,HCPCS,0338-0803-04,NDC,facility,both,10,ML,JZ,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",50863,CDM,250,RC,J1561,HCPCS,13533-800-21,NDC,facility,both,10,ML,"JZ,JA",1415,990.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7050,HCPCS,0338-0049-03,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR  6 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,42291-567-60,NDC,facility,both,5,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-05,NDC,facility,both,8,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,636,RC,J3490,HCPCS,63037-136-25,NDC,facility,both,2,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,250,RC,J3490,HCPCS,63037-136-25,NDC,facility,both,4,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0054-8297-25,NDC,facility,both,4,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MICAFUNGIN 100 MG IV SOLR,50863,CDM,250,RC,J2248,HCPCS,42023-230-01,NDC,facility,both,200,EA,,1293,905.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) IV SOLN,50863,CDM,250,RC,J9201,HCPCS,0409-0181-01,NDC,facility,both,10,ML,,461,322.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6869-61,NDC,facility,both,1,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,63323-185-07,NDC,facility,both,8,ML,,266,186.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,J3490,HCPCS,0093-4177-73,NDC,,,facility,both,4,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 0.5 % OPHT DROP,50863,CDM,250,RC,J3490,HCPCS,61314-126-05,NDC,facility,both,1,ML,,380,266,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,42806-150-33,NDC,facility,both,8,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,55,ML,JW,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
SODIUM BICARBONATE IV CONCENTRATED INFUSION (1 MEQ/ML),50863,CDM,250,RC,J3490,HCPCS,0409-6625-02,NDC,facility,both,1,ML,,249,174.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MANNITOL 25 % IV SOLN,50863,CDM,250,RC,J2150,HCPCS,63323-024-01,NDC,facility,both,6,ML,,225,157.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE IN 0.9% NS (PF) 1 MG/10 ML (100 MCG/ML) IV SYRG(PDS MERGE),50863,CDM,250,RC,J3490,HCPCS,71019-263-20,NDC,facility,both,2,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 1 MG ORAL CAP,50863,CDM,636,RC,J7507,HCPCS,51079-818-01,NDC,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML IM SOLN,50863,CDM,90375,HCPCS,13533-318-05,NDC,,,facility,both,10,ML,,8946,6262.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NADOLOL  40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69238-1124-9,NDC,facility,both,2,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,250,RC,J3490,HCPCS,73013-2002-2,NDC,facility,both,2,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,J3490,HCPCS,0781-3220-70,NDC,,,facility,both,2,ML,,370,259,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J3490,HCPCS,0338-0049-01,NDC,facility,both,2,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,636,RC,J3490,HCPCS,63323-485-27,NDC,facility,both,85,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0093-3425-01,NDC,facility,both,4,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) IV SOLN",50863,CDM,250,RC,J3490,HCPCS,0013-1114-01,NDC,facility,both,1,ML,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,250,RC,J0690,HCPCS,60505-6142-0,NDC,facility,both,1,EA,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GRANISETRON 1 MG/ML (1 ML) IV SOLN,50863,CDM,250,RC,J1626,HCPCS,0143-9744-01,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE  5 MG/ML INJ SOLN,50863,CDM,250,RC,J2765,HCPCS,0703-4502-01,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN PEDS INFUSION (CDS MIXTURE),50863,CDM,250,RC,J0290,HCPCS,25021-136-10,NDC,facility,both,2,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6007-61,NDC,facility,both,8,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,636,RC,J2704,HCPCS,16714-528-01,NDC,facility,both,2,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE  0.65 % NASL SPRA,50863,CDM,636,RC,J3490,HCPCS,49348-356-25,NDC,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,636,RC,J1815,HCPCS,0088-2220-33,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM  3.375 GRAM IV SOLR,50863,CDM,250,RC,J2543,HCPCS,0409-3385-11,NDC,facility,both,3,EA,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,50863,CDM,J0696,HCPCS,44567-702-25,NDC,,,facility,both,4,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-098-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/0.5 ML INHL NEBU,50863,CDM,250,RC,J3490,HCPCS,0487-9901-30,NDC,facility,both,6,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE PAMOATE  50 MG ORAL CAP,50863,CDM,250,RC,Q0177,HCPCS,50268-399-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM SR 120 MG 12 HR CAP,50863,CDM,250,RC,J3490,HCPCS,0378-6120-01,NDC,facility,both,2,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACIDOPHILUS-PECTIN W CITRUS 25 MILLION-100 CELL MG TAB,50863,CDM,250,RC,J3490,HCPCS,1785614241,NDC,facility,both,20,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-673-10,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPHENIDATE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,57664-228-88,NDC,facility,both,8,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,51754-5001-1,NDC,facility,both,4,ML,,159,111.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ (REPACK)(MERGE) (FOR PCA),50863,CDM,250,RC,J3010,HCPCS,61553-0118-53,NDC,facility,both,25,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 50% IN WATER (MERGE RECORD),50863,CDM,250,RC,J7060,HCPCS,76329-3302-1,NDC,facility,both,1,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J1165,HCPCS,0641-2555-41,NDC,facility,both,25,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,63323-806-13,NDC,facility,both,6,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPHENIDATE 27 MG ORAL TO24,50863,CDM,250,RC,J3490,HCPCS,31722-953-01,NDC,facility,both,1,EA,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LANTHANUM  500 MG ORAL CHEW,50863,CDM,636,RC,J3490,HCPCS,68180-819-52,NDC,facility,both,3,EA,,191,133.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60505-3113-0,NDC,facility,both,1,EA,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6188-01,NDC,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN (NEO),50863,CDM,250,RC,J1938,HCPCS,71288-203-10,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE HCL IN NS 10 MG/250 ML (0.04 MG/ML) IV SOLN (PDS MERGE),50863,CDM,250,RC,J2371,HCPCS,70004-811-40,NDC,facility,both,1000,ML,,291,203.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  50 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,72205-012-90,NDC,facility,both,5,EA,,207,144.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL IV BOLUS 10MG/ML (ANESTHESIA ONLY),50863,CDM,250,RC,J2704,HCPCS,0409-4699-54,NDC,facility,both,200,ML,,254,177.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,70436-030-82,NDC,facility,both,146,ML,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 0.4 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,59762-3304-3,NDC,facility,both,3,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IRRIGATION SOLN,50863,CDM,636,RC,J7120,HCPCS,0264-7389-60,NDC,facility,both,25,ML,,400,280,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,58657-676-01,NDC,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEPERIDINE (PF) 25 MG/ML IV SOLN (PHS MERGE),50863,CDM,250,RC,J2175,HCPCS,0409-1362-11,NDC,facility,both,1,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 15 MG/ML (1.5 %) INJ SOLN,50863,CDM,250,RC,J2003,HCPCS,0409-4776-10,NDC,facility,both,60,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIFAXIMIN 550 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65649-303-02,NDC,facility,both,1,EA,,294,205.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-590-11,NDC,facility,both,3,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 10 % (100 MG/ML) MISC SOLN,50863,CDM,250,RC,J3490,HCPCS,0517-7504-01,NDC,facility,both,2,ML,,128,89.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0075-0622-01,NDC,facility,both,6,ML,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7914-61,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7914-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACTIVATED CHARCOAL 25 GRAM/120 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0574-0521-74,NDC,facility,both,2,ML,,164,114.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
B COMPLEX-VITAMIN C-FOLIC ACID 100-1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,1054201010,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 500 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,16714-485-01,NDC,facility,both,3,EA,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6638-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 0.125 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68462-330-90,NDC,facility,both,2,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,0121-4799-05,NDC,facility,both,1,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,636,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,16,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-078-33,NDC,facility,both,1,EA,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOL 1.4 % MM SPRA,50863,CDM,250,RC,J3490,HCPCS,0536-2425-58,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM SR 120 MG 12 HR CAP,50863,CDM,250,RC,J3490,HCPCS,0378-6120-01,NDC,facility,both,3,EA,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0074-4552-90,NDC,facility,both,2,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 1 % TOP GEL,50863,CDM,636,RC,J3490,HCPCS,0713-0574-60,NDC,facility,both,1,GM,,818,572.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,250,RC,J0132,HCPCS,63323-963-21,NDC,facility,both,300,ML,,2376,1663.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PALONOSETRON 0.25 MG/5 ML IV INJECTION (MERGE),50863,CDM,250,RC,J2469,HCPCS,60505-6193-1,NDC,facility,both,10,ML,,605,423.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25 MG-100 MG TAB,50863,CDM,250,RC,J3490,HCPCS,60687-661-11,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2%/EPINEPHRINE 1:200K INJECTION (PF),50863,CDM,250,RC,J3490,HCPCS,0409-3183-01,NDC,facility,both,1,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,636,RC,J3490,HCPCS,63037-136-25,NDC,facility,both,10,ML,,222,155.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAPTOPRIL  12.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7105-61,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,250,RC,J0690,HCPCS,70092-1017-46,NDC,facility,both,2,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 15 MG ORAL TAB,50863,CDM,J3490,HCPCS,68084-119-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCRALFATE 100 MG/ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0121-0974-10,NDC,facility,both,1,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GAMMAGARD LIQUID 10 % IV SOLN,50863,CDM,636,RC,J1569,HCPCS,0944-2700-05,NDC,facility,both,20,ML,,3606,2524.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60505-3110-0,NDC,facility,both,1,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 20 MG ORAL CPDR,50863,CDM,636,RC,J3490,HCPCS,68180-294-07,NDC,facility,both,1,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM ACETATE 2 MEQ/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-3299-15,NDC,facility,both,1,ML,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-986-01,NDC,facility,both,3,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN PEDS INFUSION (CDS MIXTURE),50863,CDM,250,RC,J0290,HCPCS,99999-408-63,NDC,facility,both,2,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN PEDS INFUSION (CDS MIXTURE),50863,CDM,250,RC,J0290,HCPCS,25021-136-10,NDC,facility,both,2,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,25021-468-10,NDC,facility,both,1,EA,,397,277.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 75 MG/5 ML ORAL SOLUTION,50863,CDM,250,RC,J3490,HCPCS,16714-483-02,NDC,facility,both,10,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE (FOR EMERGENCY) 100 MG/ML (10%) IV SOLN,50863,CDM,250,RC,J0612,HCPCS,63323-360-03,NDC,facility,both,1000,ML,JZ,317,221.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ADVATE: FACTOR VIII CONCENTRATE (MERGE RECORD),50863,CDM,250,RC,J7192,HCPCS,0944-3051-03,NDC,facility,both,2000,UN,,10738,7516.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 2 MG/ML IV SOLN,50863,CDM,250,RC,J9000,HCPCS,25021-207-51,NDC,facility,both,2,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL  3.125 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7305-61,NDC,facility,both,8,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,55150-221-10,NDC,facility,both,3,ML,,160,112,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,250,RC,J0132,HCPCS,55150-259-30,NDC,facility,both,13,ML,JW,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
MIDAZOLAM 250 MG/50 ML CONCENTRATED DRIP (RSE),50863,CDM,250,RC,J2250,HCPCS,0641-6060-01,NDC,facility,both,200,ML,,162,113.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PALONOSETRON 0.25 MG/5 ML IV INJECTION (MERGE),50863,CDM,250,RC,J2469,HCPCS,55111-694-07,NDC,facility,both,10,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROPROCAINE 3 % INJ SOLN,50863,CDM,250,RC,J2401,HCPCS,63323-478-01,NDC,facility,both,36,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,63323-104-25,NDC,facility,both,17,ML,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,62584-994-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,16714-293-03,NDC,facility,both,7,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LITHIUM CARBONATE 450 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,68462-224-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,54288-137-01,NDC,facility,both,3,ML,,560,392,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,7733393825,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0054-0710-20,NDC,facility,both,16,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN SODIUM EXTENDED 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0071-0369-40,NDC,facility,both,4,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G POTASSIUM  5000000 UNIT INJ SOLR,50863,CDM,250,RC,J2540,HCPCS,0049-0520-84,NDC,facility,both,7,EA,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SOD CHLOR&BICARB-SQUEEZ BOTTLE NASL PKDV,50863,CDM,636,RC,J3490,HCPCS,592800100,NDC,facility,both,50,EA,,1239,867.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,69315-904-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MANNITOL 20% IV SOLP,50863,CDM,250,RC,J2150,HCPCS,0990-7715-13,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,63323-400-01,NDC,facility,both,387,ML,,406,284.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-580-11,NDC,facility,both,14,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 1 GRAM INJ SOLR,50863,CDM,636,RC,J0692,HCPCS,0409-9566-10,NDC,facility,both,2,EA,JZ,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"ALBUMIN, HUMAN 25 % IV SOLN (MERGE)",50863,CDM,250,RC,P9047,HCPCS,76125-792-11,NDC,facility,both,8,ML,,1659,1161.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J2004,HCPCS,0409-3178-16,NDC,facility,both,600,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-5771-23,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 20 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,0904-7043-61,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DROXIDOPA 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,31722-014-90,NDC,facility,both,1,EA,,180,126,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN  500 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,70010-491-01,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAZOLAMIDE SODIUM 500 (100 MG/ML) INJ SOLR,50863,CDM,250,RC,J1120,HCPCS,23155-313-31,NDC,facility,both,1,EA,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-512-11,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7007-61,NDC,facility,both,5,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,636,RC,Q9968,HCPCS,70710-1838-1,NDC,facility,both,45,ML,JW,254,177.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DICLOFENAC 0.1 % EYE DROPS,50863,CDM,636,RC,J3490,HCPCS,61314-014-25,NDC,facility,both,1,ML,,219,153.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,50863,CDM,250,RC,J9075,HCPCS,10019-956-16,NDC,facility,both,88,EA,,569,398.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-406-03,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,636,RC,J0690,HCPCS,60505-6142-0,NDC,facility,both,6,EA,JZ,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CLINDAMYCIN IN D5W 300 MG/50 ML IV PGBK,50863,CDM,250,RC,J0736,HCPCS,0338-3410-50,NDC,facility,both,1,ML,JZ,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LABETALOL 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-450-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COLCHICINE 0.6 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-727-11,NDC,facility,both,1,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IV PGBK,50863,CDM,250,RC,J3475,HCPCS,0264-4204-52,NDC,facility,both,4,ML,JZ,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MIDOSTAURIN 25 MG ORAL CAP,50863,CDM,250,RC,J9999,HCPCS,0078-0698-02,NDC,facility,both,2,EA,,1203,842.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EVEROLIMUS (IMMUNOSUPPRESSIVE) 0.5 MG ORAL TAB,50863,CDM,250,RC,J7527,HCPCS,67877-719-33,NDC,facility,both,2,EA,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VINCRISTINE 2 MG/2 ML IV SOLN,50863,CDM,636,RC,J9370,HCPCS,61703-309-16,NDC,facility,both,2,ML,JZ,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PROMETHAZINE 25 MG RECT SUPP,50863,CDM,636,RC,J3490,HCPCS,45802-759-00,NDC,facility,both,1,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,0143-9577-01,NDC,,,facility,both,40,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,55111-263-79,NDC,facility,both,3,EA,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR PHOSPHATE 75 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,64380-799-01,NDC,facility,both,9,EA,,501,350.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  25 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,69238-1310-9,NDC,facility,both,2,EA,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,0409-6102-18,NDC,facility,both,160,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,14,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-DYYB 100 MG IV SOLR,50863,CDM,636,RC,Q5103,HCPCS,0069-0809-01,NDC,facility,both,32,EA,,8358,5850.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG IV SOLR,50863,CDM,J3490,HCPCS,67457-437-00,NDC,,,facility,both,1,EA,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,43598-053-11,NDC,facility,both,29,ML,,1037,725.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2003,HCPCS,0409-2066-05,NDC,,,facility,both,700,ML,,128,89.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 875 MG-125 MG TAB,50863,CDM,636,RC,J3490,HCPCS,42571-162-42,NDC,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,250,RC,J0132,HCPCS,70594-111-01,NDC,facility,both,118,ML,,601,420.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
D5-0.9%NACL-POTASSIUM CHLORIDE 20 MEQ/L IV SOLP,50863,CDM,250,RC,J3480,HCPCS,0338-0803-04,NDC,facility,both,10,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EFGARTIGIMOD ALFA-FCAB 20 MG/ML IV SOLN,50863,CDM,J9332,HCPCS,73475-3041-5,NDC,,,facility,both,400,ML,,32844,22990.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NELARABINE 250 MG/50 ML IV SOLN (PEDS ONCOLOGY),50863,CDM,250,RC,J9261,HCPCS,0007-4401-01,NDC,facility,both,15,ML,,6089,4262.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,46,ML,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES-DOCUSATE SODIUM 8.6 MG-50 MG TAB,50863,CDM,250,RC,J3490,HCPCS,63739-432-02,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EMTRICITABINE-TENOFOVIR 200 MG-300 MG TAB,50863,CDM,636,RC,J0750,HCPCS,0904-7172-07,NDC,facility,both,2,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68180-113-16,NDC,facility,both,2,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 100 MG/1 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,63323-586-21,NDC,facility,both,10,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID (PORK)  30 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0456-0458-01,NDC,facility,both,2,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR PHOSPHATE 75 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,33342-258-66,NDC,facility,both,1,EA,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCUSATE SODIUM 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-129-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-677-11,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 150 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,16729-443-16,NDC,facility,both,1,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE MONONITRATE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,7733393425,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROTHIAZIDE SODIUM 500 MG IV SOLR,50863,CDM,250,RC,J1205,HCPCS,0517-1820-01,NDC,facility,both,1,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUPHENAZINE DECANOATE 25 MG/ML INJ SOLN,50863,CDM,250,RC,J2680,HCPCS,55150-267-05,NDC,facility,both,2,ML,,195,136.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 875 MG-125 MG TAB,50863,CDM,636,RC,J3490,HCPCS,65862-503-01,NDC,facility,both,20,EA,,420,294,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-319-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-3178-01,NDC,facility,both,45,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC IV INFUSION HYDRAT 31-60 MIN,50863,CDM,636,RC,J0248,HCPCS,61958-2901-2,NDC,facility,both,100,EA,,1196,837.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MECLIZINE 25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-523-11,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCUSATE SODIUM 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7183-61,NDC,facility,both,6,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE IN 0.9 % SOD CHLORIDE 100 MG/10 ML (10 MG/ML) IV SYRG,50863,CDM,J3490,HCPCS,61553-331-65,NDC,,,facility,both,1,ML,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MINOXIDIL  2.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-204-11,NDC,facility,both,3,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0781-3246-02,NDC,facility,both,5,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN IN D5W 900 MG/50 ML IV PGBK,50863,CDM,636,RC,J0736,HCPCS,0781-3290-91,NDC,facility,both,1,ML,JZ,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ACETYLCYSTEINE 20 % (200 MG/ML) MISC SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-694-41,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,50863,CDM,J3490,HCPCS,67877-548-88,NDC,,,facility,both,12,ML,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,150,ML,,136,95.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN NACL (PF) 1000 UNIT/500 ML IV SOLP,50863,CDM,636,RC,J1644,HCPCS,0264-9872-10,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,28,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OMEPRAZOLE-SODIUM BICARBONATE 2-84 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,65628-270-03,NDC,facility,both,5,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,250,RC,Q0162,HCPCS,16714-671-02,NDC,facility,both,2,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,71399-1025-3,NDC,facility,both,24,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,636,RC,J7060,HCPCS,0264-1510-32,NDC,facility,both,1,ML,JZ,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PHENYTOIN SODIUM EXTENDED 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0071-0369-24,NDC,facility,both,2,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,67457-423-00,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 5 % TOP OINT,50863,CDM,250,RC,J3490,HCPCS,51672-3020-9,NDC,facility,both,1,GM,,935,654.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,25021-053-01,NDC,facility,both,6,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
OLANZAPINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6377-61,NDC,facility,both,1,EA,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,68180-723-04,NDC,facility,both,6,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 10 GRAM/100 ML (10%) INJ SOLN",50863,CDM,250,RC,J1561,HCPCS,13533-800-72,NDC,facility,both,20,ML,"JZ,JA",2829,1980.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLN,50863,CDM,636,RC,J3262,HCPCS,50242-135-01,NDC,facility,both,320,ML,JZ,5865,4105.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0904-7127-61,NDC,facility,both,40,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,50863,CDM,250,RC,J2359,HCPCS,0781-3159-72,NDC,facility,both,10,EA,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PSEUDOEPHEDRINE 30 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0904-5053-59,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0121-1781-05,NDC,facility,both,3,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 875 MG-125 MG TAB,50863,CDM,636,RC,J3490,HCPCS,65862-503-01,NDC,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,3,EA,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CEFTRIAXONE   2 GRAM INJ SOLR,50863,CDM,250,RC,J0696,HCPCS,0143-9856-01,NDC,facility,both,8,EA,JZ,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PHENOBARBITAL  97.2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16571-668-01,NDC,facility,both,3,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 2400000 UNIT/4 ML IM SYRG,50863,CDM,250,RC,J0561,HCPCS,60793-702-04,NDC,facility,both,24,ML,,1725,1207.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68180-966-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0093-3426-05,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,50863,CDM,250,RC,J9045,HCPCS,0703-4239-01,NDC,facility,both,15,ML,,419,293.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE  10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,70710-1225-1,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,50863,CDM,250,RC,J1885,HCPCS,63323-162-03,NDC,facility,both,4,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-591-11,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SORBITOL 70 % MISC SOLN,50863,CDM,250,RC,J3490,HCPCS,4628750030,NDC,facility,both,2,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE 100 MG TAB,50863,CDM,636,RC,J3490,HCPCS,23155-135-25,NDC,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,636,RC,J2270,HCPCS,0409-1890-03,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BISACODYL  5 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,0904-6407-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,67457-433-00,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,72603-209-01,NDC,facility,both,2,ML,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXEPIN  25 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,51079-437-01,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0137,HCPCS,55150-307-01,NDC,facility,both,93,ML,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-03,NDC,facility,both,3,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-591-11,NDC,facility,both,6,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIRMATRELVIR-RITONAVIR 300-100 MG ORAL TAB DOSEPACK (FOR ED/IP TAKE HOME PANEL),50863,CDM,250,RC,J3490,HCPCS,0069-5321-03,NDC,facility,both,30,EA,,4010,2807,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-ABDA 100 MG IV SOLR,50863,CDM,636,RC,Q5104,HCPCS,78206-162-99,NDC,facility,both,79,EA,,16427,11498.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE IN SALINE (ISO-OSM) 400 MG/200 ML IV PIGGY BACK,50863,CDM,250,RC,J1450,HCPCS,25021-184-87,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 1 % INJ SOLN,50863,CDM,250,RC,Q9968,HCPCS,17478-504-01,NDC,facility,both,30,ML,,246,172.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 2-0.5 MG SL SUBL,50863,CDM,636,RC,J3490,HCPCS,50268-144-11,NDC,facility,both,4,EA,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SUSP,50863,CDM,90714,HCPCS,49281-215-58,NDC,,,facility,both,1,ML,,214,149.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,J0665,HCPCS,0409-1162-02,NDC,,,facility,both,300,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,16714-026-01,NDC,facility,both,6,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON DEXTRAN 50 MG/ML INJ SOLN,50863,CDM,J1750,HCPCS,0023-6082-01,NDC,,,facility,both,1,ML,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR IRRIGATION, STERILE SOLUTION",50863,CDM,J3490,HCPCS,0338-0004-02,NDC,,,facility,both,2,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,0409-4713-32,NDC,,,facility,both,160,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,P9045,HCPCS,68516-5219-0,NDC,,,facility,both,9,ML,,2288,1601.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 40 % ORAL GEL,50863,CDM,250,RC,J3490,HCPCS,574007030,NDC,facility,both,46,GM,,653,457.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-344-11,NDC,facility,both,2,EA,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-495-09,NDC,,,facility,both,120,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 50% IN WATER (MERGE RECORD),50863,CDM,250,RC,J7060,HCPCS,76329-3302-1,NDC,facility,both,2,ML,,238,166.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES-DOCUSATE SODIUM 8.6 MG-50 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0536-1247-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-645-11,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,25,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 500 MG (200 MG ELEMENTAL) CHEW TAB,50863,CDM,636,RC,J3490,HCPCS,66553-004-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRBESARTAN  75 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,31722-729-30,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 1 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,49884-315-52,NDC,facility,both,2,EA,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,63323-161-00,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,0955-1008-01,NDC,facility,both,5,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51672-4027-1,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,13,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEPLIZUMAB-MZWV 2 MG/20 ML IV SOLN,50863,CDM,636,RC,J9381,HCPCS,73650-316-01,NDC,facility,both,292,ME,,19614,13729.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,250,RC,J2405,HCPCS,60505-6130-0,NDC,facility,both,4,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-492-04,NDC,facility,both,80,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0781-6041-46,NDC,facility,both,5,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0093-4155-73,NDC,facility,both,11,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN PEDS SYRINGE (20MG/ML) IN DEXTROSE (CDS MIX,50863,CDM,250,RC,J0690,HCPCS,0781-3451-70,NDC,facility,both,6,EA,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  75 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,68084-709-11,NDC,facility,both,2,EA,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 100 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,31722-574-47,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 100 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,70954-240-10,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAZOLAMIDE SODIUM 500 (100 MG/ML) INJ SOLR,50863,CDM,250,RC,J1120,HCPCS,67457-853-50,NDC,facility,both,1,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM CITRATE ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,70677-1112-1,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0121-1022-05,NDC,facility,both,1,ML,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-453-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,0409-9094-22,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,250,RC,J3490,HCPCS,73013-2002-2,NDC,facility,both,2,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAPTOPRIL  12.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7105-61,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0121-1781-05,NDC,facility,both,4,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SULFACETAMIDE SODIUM 10 % OPHT DROP,50863,CDM,250,RC,J3490,HCPCS,24208-670-04,NDC,facility,both,1,ML,,259,181.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN  500 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,70010-491-01,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  60 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69292-536-01,NDC,facility,both,2,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRIL MALEATE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,43547-546-10,NDC,facility,both,4,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DALBAVANCIN 500 MG IV SOLN,50863,CDM,636,RC,J0875,HCPCS,57970-100-01,NDC,facility,both,300,EA,,14732,10312.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  75 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,69238-1312-9,NDC,facility,both,1,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J1610,HCPCS,63323-596-03,NDC,facility,both,1,EA,,895,626.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,636,RC,J0330,HCPCS,69374-919-10,NDC,facility,both,6,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM  1.5 GRAM INJ SOLR,50863,CDM,636,RC,J0295,HCPCS,71288-005-21,NDC,facility,both,1,EA,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-3178-01,NDC,facility,both,150,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J3490,HCPCS,0338-0049-48,NDC,facility,both,2,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VERAPAMIL 2.5 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,70710-1643-1,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IV PGBK,50863,CDM,250,RC,J3490,HCPCS,0264-4204-52,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),50863,CDM,636,RC,J0171,HCPCS,76329-3318-1,NDC,facility,both,90,ML,,661,462.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J2250,HCPCS,0409-2305-17,NDC,facility,both,6,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,44,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM  3 GRAM INJ SOLR,50863,CDM,250,RC,J0295,HCPCS,55150-117-20,NDC,facility,both,2,EA,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENAZOPYRIDINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65162-681-10,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-8297-25,NDC,facility,both,6,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-145-11,NDC,facility,both,20,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,250,RC,J3490,HCPCS,63037-136-25,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-520-11,NDC,facility,both,12,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68180-445-01,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALTREXONE MICROSPHERES 380 MG IM SERR,50863,CDM,636,RC,J2315,HCPCS,65757-300-01,NDC,facility,both,380,EA,,4666,3266.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 0.8 GRAM ORAL PWPK,50863,CDM,250,RC,J0602,HCPCS,0115-1365-30,NDC,facility,both,40,EA,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42858-001-10,NDC,facility,both,6,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT 25 MCG/0.42 ML INJ SYRG,50863,CDM,636,RC,J0881,HCPCS,55513-057-04,NDC,facility,both,25,ML,"JZ,EC",836,585.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier EC: Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy
DICYCLOMINE 10 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-369-11,NDC,facility,both,4,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  500 MG IV SOLR,50863,CDM,250,RC,J3370,HCPCS,0143-9161-01,NDC,facility,both,1,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0781-6041-46,NDC,facility,both,9,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,4,EA,JW,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,63323-482-03,NDC,facility,both,200,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 100 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,43547-288-10,NDC,facility,both,2,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,50863,CDM,250,RC,J9025,HCPCS,72485-201-01,NDC,facility,both,32,EA,JW,198,138.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
TRIMETHOPRIM-SULFAMETHOXAZOLE 160 MG-800 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0904-2725-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VORICONAZOLE 200 MG IV SOLN,50863,CDM,250,RC,J3465,HCPCS,0781-3416-94,NDC,facility,both,40,EA,,1099,769.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7178-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-25,NDC,facility,both,80,ML,,11316,7921.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 20 MG/ML INJ SOLN,50863,CDM,J0360,HCPCS,63323-614-00,NDC,,,facility,both,1,ML,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 17 GRAM (100 %) ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,1152372688,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,0409-1207-03,NDC,facility,both,5,ML,,121,84.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0781-3246-02,NDC,facility,both,3,ML,JW,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LORAZEPAM 2 MG/ML INJ SOLN,50863,CDM,250,RC,J2060,HCPCS,0641-6207-01,NDC,facility,both,2,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 10 % (100 MG/ML) MISC SOLN,50863,CDM,J3490,HCPCS,63323-695-04,NDC,,,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,J2371,HCPCS,70594-063-01,NDC,,,facility,both,500,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INEBILIZUMAB-CDON 10 MG/ML IV SOLN,50863,CDM,636,RC,J1823,HCPCS,75987-150-01,NDC,facility,both,300,ML,,387086,270960.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,J1100,HCPCS,63323-165-01,NDC,,,facility,both,4,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZOCAINE 20 % MM SPRY,50863,CDM,636,RC,J3490,HCPCS,0283-0610-43,NDC,facility,both,1,EA,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,8,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J2004,HCPCS,63323-482-27,NDC,facility,both,400,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 600 MG ORAL TP12,50863,CDM,636,RC,J3490,HCPCS,0536-1163-61,NDC,facility,both,6,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,636,RC,J3490,HCPCS,51754-4250-1,NDC,facility,both,2,ML,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 30 MG TAB,50863,CDM,636,RC,J3490,HCPCS,60687-717-11,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 500 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,65862-019-01,NDC,facility,both,2,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  20 MEQ ORAL PACK,50863,CDM,250,RC,J3490,HCPCS,72888-024-06,NDC,facility,both,1,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM SR 120 MG 24 HR CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7217-61,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,3,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-8299-25,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.15 MG/0.3 ML IM PNIJ,50863,CDM,250,RC,J0169,HCPCS,49502-101-01,NDC,facility,both,2,EA,,675,472.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,J2003,HCPCS,63323-486-27,NDC,,,facility,both,40,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0039-28,NDC,facility,both,16,EA,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GOLIMUMAB  12.5 MG/ML IV SOLN,50863,CDM,J1602,HCPCS,57894-350-01,NDC,,,facility,both,150,ML,,16554,11587.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FINAL) IV SOLR,50863,CDM,250,RC,J9330,HCPCS,65219-205-05,NDC,facility,both,30,ML,,9771,6839.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,164,ML,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),50863,CDM,250,RC,J3490,HCPCS,0409-4888-02,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,2,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ (MERGE),50863,CDM,636,RC,J2250,HCPCS,70069-817-01,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLECAINIDE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-0011-20,NDC,facility,both,1,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROTHIAZIDE SODIUM 500 MG IV SOLR,50863,CDM,250,RC,J1205,HCPCS,0517-1820-01,NDC,facility,both,1,EA,,720,504,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,J7512,HCPCS,60687-145-11,NDC,,,facility,both,40,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 400 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,65862-071-01,NDC,facility,both,6,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM SR 120 MG 24 HR CAP,50863,CDM,636,RC,J3490,HCPCS,63739-283-10,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 75 MG/5 ML ORAL SOLUTION,50863,CDM,636,RC,J3490,HCPCS,16714-483-02,NDC,facility,both,30,ML,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ECULIZUMAB 300 MG/30 ML IV SOLN,50863,CDM,250,RC,J1300,HCPCS,25682-001-01,NDC,facility,both,90,ML,,51817,36271.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPOETIN ALFA-EPBX 10000 UNITS/ML INJ SOLN,50863,CDM,636,RC,Q5106,HCPCS,0069-1308-01,NDC,facility,both,4,ML,EC,191,133.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier EC: Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy
BUDESONIDE 3 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,60687-596-33,NDC,facility,both,3,EA,,238,166.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J1938,HCPCS,63323-280-03,NDC,facility,both,80,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 1 % TOPICAL SOLN,50863,CDM,636,RC,J3490,HCPCS,51672-4081-3,NDC,facility,both,1,ML,,200,140,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MILRINONE 1 MG/ML IV SOLN,50863,CDM,250,RC,J2260,HCPCS,72485-501-01,NDC,facility,both,2,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN IN D5W 900 MG/50 ML IV PGBK,50863,CDM,250,RC,J0736,HCPCS,0781-3290-91,NDC,facility,both,3,ML,JZ,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),50863,CDM,250,RC,J2060,HCPCS,0641-6001-01,NDC,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,0641-6145-01,NDC,facility,both,10,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-210-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM  50 MG INJ SOLR,50863,CDM,250,RC,J0640,HCPCS,25021-813-10,NDC,facility,both,1,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0780,HCPCS,0713-0351-02,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN DEXTROSE (ISO-OSMOTIC) 1 GRAM/50 ML IV PIGGY BACK,50863,CDM,250,RC,J0689,HCPCS,0338-3503-41,NDC,facility,both,6,ML,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITRIOL 0.5 MCG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,64380-724-06,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPHENIDATE 18 MG ORAL TO24,50863,CDM,636,RC,J3490,HCPCS,62175-310-37,NDC,facility,both,3,EA,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML ORAL SOLUTION (FOR PEDIATRIC USE),50863,CDM,250,RC,J3480,HCPCS,63323-965-05,NDC,facility,both,5,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE 0.5 MG SL (1/4 TAB) SUBL,50863,CDM,636,RC,J3490,HCPCS,99999-0408-26,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 QUARTER TABLET
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,125,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 50 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,10135-779-01,NDC,facility,both,100,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML IV SOLN (MERGE),50863,CDM,250,RC,J3490,HCPCS,16714-037-01,NDC,facility,both,1,ML,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE HCL  2 % MM JELP,50863,CDM,250,RC,J3490,HCPCS,25021-673-76,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-02,NDC,facility,both,2,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,150,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,636,RC,J2270,HCPCS,0641-6125-01,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 10 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,67457-420-00,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 0.4 MG/HR TD PT24,50863,CDM,250,RC,J3490,HCPCS,0378-9112-16,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,16714-016-01,NDC,facility,both,6,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VERAPAMIL 120 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,23155-486-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACCHAROMYCES BOULARDII 250 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,414200007,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAZOLAMIDE 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-054-11,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATOMOXETINE  40 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,55111-521-30,NDC,facility,both,1,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 100 MG PE/2 ML INJ SOLN,50863,CDM,250,RC,Q2009,HCPCS,0641-6136-01,NDC,facility,both,3,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1940,HCPCS,63323-280-03,NDC,facility,both,4,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,104,ML,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MANNITOL 20% IV SOLP,50863,CDM,250,RC,J2150,HCPCS,0990-7715-13,NDC,facility,both,1,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DABIGATRAN  150 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0597-0360-82,NDC,facility,both,1,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-349-11,NDC,facility,both,2,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-03,NDC,facility,both,3,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0248-01,NDC,facility,both,100,ML,JZ,127,88.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-464-11,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2720-03,NDC,facility,both,30,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,250,RC,J3101,HCPCS,50242-037-06,NDC,facility,both,30,EA,JW,5636,3945.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ACAMPROSATE 333 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,0378-6333-80,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PERPHENAZINE  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68382-591-01,NDC,facility,both,4,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOTRIMAZOLE 1 % VAGL CREA,50863,CDM,250,RC,J3490,HCPCS,51672-2003-6,NDC,facility,both,1,GM,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 500 MG (200 MG ELEMENTAL) CHEW TAB,50863,CDM,636,RC,J3490,HCPCS,66553-004-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,42494-415-01,NDC,facility,both,1,ML,,129,90.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 10 GRAM/100 ML (10%) INJ SOLN",50863,CDM,250,RC,J1561,HCPCS,13533-800-72,NDC,facility,both,20,ML,JA,2829,1980.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
ARSENIC TRIOXIDE 10 MG/10 ML IV SOLN,50863,CDM,250,RC,J9017,HCPCS,69918-720-01,NDC,facility,both,15,ML,,1116,781.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-097-11,NDC,facility,both,8,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LITHIUM CARBONATE 300 MG ORAL TBSR,50863,CDM,636,RC,J3490,HCPCS,68084-640-11,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  15 MG ORAL TBSR,50863,CDM,636,RC,J3490,HCPCS,0406-8315-23,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,42806-150-33,NDC,facility,both,3,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEPROTUMUMAB-TRBW 500 MG IV SOLR,50863,CDM,636,RC,J3241,HCPCS,75987-130-15,NDC,facility,both,200,EA,,142339,99637.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE HCL  2 % MM JELP,50863,CDM,636,RC,J3490,HCPCS,25021-673-76,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 50 MG TAB,50863,CDM,636,RC,J3490,HCPCS,51079-801-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,250,RC,J2720,HCPCS,63323-229-01,NDC,facility,both,12,ML,,218,152.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DACTINOMYCIN 0.5 MG IV SOLR,50863,CDM,636,RC,J9120,HCPCS,71288-129-02,NDC,facility,both,2,EA,,2348,1643.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB 10 MG/ML IV CONC,50863,CDM,636,RC,J9312,HCPCS,50242-053-06,NDC,facility,both,50,ML,JZ,12966,9076.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
FAMOTIDINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-739-11,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2599,HCPCS,65219-039-00,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUBIPROSTONE  8 MCG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0480-3479-06,NDC,facility,both,1,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEPROTUMUMAB-TRBW 500 MG IV SOLR,50863,CDM,636,RC,J3241,HCPCS,75987-130-15,NDC,facility,both,60,EA,,42346,29642.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CRRT-HEPARIN 1000 UNITS/ML IN NS INTERMITTENT BOLUS,50863,CDM,250,RC,J3490,HCPCS,0069-0059-01,NDC,facility,both,1,ML,,208,145.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 40 % ORAL GEL,50863,CDM,636,RC,J3490,HCPCS,574006930,NDC,facility,both,1,GM,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE-PRAMOXINE 1 %-1 % RECTAL FOAM,50863,CDM,636,RC,J3490,HCPCS,0037-6822-10,NDC,facility,both,1,GM,,840,588,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELOXICAM  7.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68382-050-01,NDC,facility,both,1,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN 250 MG SOLUTION FOR INJECTION,50863,CDM,636,RC,J0290,HCPCS,65219-014-01,NDC,facility,both,1,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE IN SALINE (ISO-OSM) 400 MG/200 ML IV PIGGY BACK,50863,CDM,250,RC,J1450,HCPCS,25021-184-87,NDC,facility,both,4,ML,,165,115.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BISACODYL 10 MG RECT SUPP,50863,CDM,250,RC,J3490,HCPCS,8142102103,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,J3490,HCPCS,0409-1159-09,NDC,,,facility,both,2,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 250 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,42192-608-05,NDC,facility,both,3,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-6665-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-31,NDC,facility,both,1,ML,PLAD,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,636,RC,J1815,HCPCS,0088-2220-33,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 3000 MCG/ML INJECTION,50863,CDM,636,RC,J0153,HCPCS,63323-651-00,NDC,facility,both,12,ML,,129,90.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 10 GRAM/15 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0116-4005-30,NDC,facility,both,2,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-495-27,NDC,facility,both,60,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0121-1022-05,NDC,facility,both,5,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 75 MG SUBQ SOLR,50863,CDM,J0896,HCPCS,59572-775-01,NDC,,,facility,both,260,ME,,10737,7515.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-9558-05,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,50863,CDM,250,RC,J0696,HCPCS,0781-3208-85,NDC,facility,both,4,EA,JZ,225,157.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
BUPROPION HCL 150 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,68180-319-09,NDC,facility,both,1,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE IN D5W 1 GRAM/100 ML IV PGBK,50863,CDM,250,RC,J3475,HCPCS,0338-1709-40,NDC,facility,both,2,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,50863,CDM,636,RC,J1885,HCPCS,0409-3796-19,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-682-02,NDC,facility,both,2,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIFAXIMIN 550 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65649-303-02,NDC,facility,both,1,EA,,278,194.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALUM-MAG HYDROXIDE-SIMETH 200 MG-200 MG-20 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0904-7325-62,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,54,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,63323-280-03,NDC,facility,both,160,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 200 MG/20 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,31722-203-20,NDC,facility,both,1,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7193-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-25,NDC,facility,both,70,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOL 1.4 % MM SPRA,50863,CDM,250,RC,J3490,HCPCS,1093945944,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,636,RC,J2795,HCPCS,70069-064-25,NDC,facility,both,125,ML,JW,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-22,NDC,facility,both,60,ML,JZ,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ROMIPLOSTIM 125 MCG SUBQ SOLR,50863,CDM,J2796,HCPCS,55513-223-01,NDC,,,facility,both,50,EA,,10260,7182,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,6,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYALURONIDASE 150 UNIT/ML INJ SOLN,50863,CDM,250,RC,J3473,HCPCS,18657-117-01,NDC,facility,both,300,ML,,568,397.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1940,HCPCS,0409-6102-20,NDC,facility,both,10,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,636,RC,J3360,HCPCS,69339-136-03,NDC,facility,both,1,ML,JZ,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
HYDROMORPHONE (PF) 2 MG/ML IV SOLN (PRMC ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-1312-03,NDC,facility,both,40,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ABATACEPT 250 MG IV SOLR,50863,CDM,J0129,HCPCS,0003-2187-13,NDC,,,facility,both,100,EA,,16146,11302.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPATITIS B IMMUNE GLOBULIN 220 UNIT/ML (5 ML) IM SOLN,50863,CDM,636,RC,90371,HCPCS,13533-636-50,NDC,facility,both,7,ML,,3048,2133.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 40 MG-200 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,65862-496-47,NDC,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,0641-6145-01,NDC,facility,both,12,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,250,RC,J2003,HCPCS,63323-208-01,NDC,facility,both,500,ML,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) IV SOLN",50863,CDM,250,RC,J3490,HCPCS,43066-008-01,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,50863,CDM,250,RC,J2359,HCPCS,55150-308-01,NDC,facility,both,5,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM POLYSTYRENE SULF-SORBTL 15-20 GRAM/60 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,46287-006-60,NDC,facility,both,1,ML,,152,106.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,57237-077-10,NDC,facility,both,1,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,50863,CDM,636,RC,J3490,HCPCS,68462-157-40,NDC,facility,both,1,EA,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,4,EA,,113,79.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 50 MG/5 ML (10 MG/ML) IV SYRG,50863,CDM,250,RC,J3490,HCPCS,63037-155-25,NDC,facility,both,2,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOLUTEGRAVIR 50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,49702-228-13,NDC,facility,both,1,EA,,383,268.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 10 MG-100 MG TAB,50863,CDM,250,RC,J3490,HCPCS,42291-471-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOBAZAM 2.5 MG/ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,99999-0404-03,NDC,facility,both,6,ML,,246,172.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  125 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,62559-390-50,NDC,facility,both,4,EA,,451,315.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN IN D5W 400 MG/200 ML IV PGBK,50863,CDM,J0744,HCPCS,25021-192-87,NDC,,,facility,both,2,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7122-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 10 % (100 MG/ML) MISC SOLN,50863,CDM,J3490,HCPCS,63323-695-22,NDC,,,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,636,RC,J2795,HCPCS,43066-023-01,NDC,facility,both,45,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CHLOROPROCAINE 3 % INJ SOLN,50863,CDM,250,RC,J2401,HCPCS,63323-478-01,NDC,facility,both,240,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  100 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,63323-376-00,NDC,facility,both,8,ML,JA,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
ATROPINE 0.1 MG/ML INJ SYRG,50863,CDM,250,RC,J0461,HCPCS,16729-484-03,NDC,facility,both,100,ML,JZ,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
WARFARIN 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0832-1211-89,NDC,facility,both,4,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,70095-031-01,NDC,facility,both,30,ML,,1231,861.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,50863,CDM,J0696,HCPCS,60505-6149-0,NDC,,,facility,both,4,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J3490,HCPCS,63323-482-03,NDC,,,facility,both,300,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,73,ML,JW,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,250,RC,J2795,HCPCS,63323-286-20,NDC,facility,both,100,ML,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,91,EA,,12558,8790.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,27241-001-06,NDC,facility,both,1,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM NEO IV SYRINGE (PHS FROM PREMIX),50863,CDM,250,RC,J1953,HCPCS,44567-501-01,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE 21 MG/24 HR TD PT24,50863,CDM,J3490,HCPCS,43598-448-71,NDC,,,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESTRADIOL 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42806-088-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES-DOCUSATE SODIUM 8.6 MG-50 MG TAB,50863,CDM,636,RC,J3490,HCPCS,57896-303-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42858-301-01,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IR SOLN,50863,CDM,636,RC,J3490,HCPCS,0338-0047-46,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-339-11,NDC,facility,both,2,EA,,160,112,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,42806-151-34,NDC,facility,both,10,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0406-3243-01,NDC,facility,both,4,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-0905-05,NDC,facility,both,6,ML,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLOPATADINE 0.1 % OPHT DROP,50863,CDM,250,RC,J3490,HCPCS,43598-765-07,NDC,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN 0.9 % SODIUM CHL 1.5 GRAM/500 ML IV SOLN,50863,CDM,250,RC,J3373,HCPCS,71506-016-59,NDC,facility,both,150,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 6 MG/0.5 ML SUB-Q,50863,CDM,636,RC,J3030,HCPCS,0143-9638-01,NDC,facility,both,1,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN NACL (PF) 1000 UNIT/500 ML IV SOLP,50863,CDM,250,RC,J1644,HCPCS,0409-1005-01,NDC,facility,both,6,ML,,250,175,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MYCOPHENOLATE 180 MG TAB, DELAYED RELEASE",50863,CDM,250,RC,J7518,HCPCS,0904-6785-61,NDC,facility,both,1,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-48,NDC,facility,both,2,ML,,128,89.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,70010-754-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,50863,CDM,250,RC,J0696,HCPCS,44567-701-25,NDC,facility,both,3,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 125 MG/5 ML (25MG/ML) ORAL SYRINGE (REPACK),50863,CDM,250,RC,J3373,HCPCS,67457-340-00,NDC,facility,both,25,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,636,RC,J3490,HCPCS,63323-486-05,NDC,facility,both,500,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VORICONAZOLE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-165-01,NDC,facility,both,2,EA,,277,193.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ (MERGE),50863,CDM,636,RC,J2250,HCPCS,0409-2305-17,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MYCOPHENOLATE 500 MG TAB,50863,CDM,636,RC,J7517,HCPCS,60687-438-11,NDC,facility,both,6,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOPIDOGREL 300 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6467-10,NDC,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,16,EA,JZ,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,35,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,636,RC,J1596,HCPCS,0143-9679-01,NDC,facility,both,6,ML,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE DINITRATE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0781-1556-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAY 1 NEO SOLUTION (D5W/AA 2%/HEPARIN 0.5 UNITS/ML),50863,CDM,250,RC,J3490,HCPCS,0264-9341-55,NDC,facility,both,1,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL 20 MG/5 ML ORAL ELIX,50863,CDM,250,RC,J3490,HCPCS,0121-0942-05,NDC,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-18,NDC,facility,both,400,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,71288-414-01,NDC,facility,both,2,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,250,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,12,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 125 MG ORAL CPSP,50863,CDM,636,RC,J3490,HCPCS,68084-313-11,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM 1 GRAM IV SOLR,50863,CDM,636,RC,J2185,HCPCS,55150-208-30,NDC,facility,both,10,EA,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPHENIDATE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-1142-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0093-2279-73,NDC,facility,both,3,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE  2.5 % RECT CREA,50863,CDM,250,RC,J3490,HCPCS,69315-312-28,NDC,facility,both,1,GM,,357,249.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,63323-104-06,NDC,facility,both,14,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NORTRIPTYLINE 25 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,50268-604-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 500 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,16714-299-03,NDC,facility,both,14,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE IN 0.9% NACL 3 GRAM/100 ML IV SOLN,50863,CDM,250,RC,J0612,HCPCS,61553-056-48,NDC,facility,both,340,ML,,145,101.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICLOXACILLIN 500 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,59651-566-01,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM BICARB-CITRIC ACID 20 MEQ ORAL TBEF,50863,CDM,250,RC,J3490,HCPCS,51801-011-30,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J3490,HCPCS,0409-3178-16,NDC,,,facility,both,120,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,132,92.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,0338-0072-25,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTAZIDIME-AVIBACTAM 2.5 GRAM (2 GRAM-0.5 GRAM) IV SOLR,50863,CDM,250,RC,J0714,HCPCS,0456-2700-10,NDC,facility,both,2,EA,,701,490.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,68094-231-59,NDC,facility,both,3,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),50863,CDM,636,RC,J1630,HCPCS,63323-474-00,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 20 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,50111-648-01,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 17 GRAM (100 %) ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,0904-6931-86,NDC,facility,both,7,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25 MG-250 MG TAB,50863,CDM,636,RC,J3490,HCPCS,60687-836-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0641-6059-01,NDC,facility,both,5,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
QUETIAPINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-349-11,NDC,facility,both,2,EA,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE  75 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-040-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7410-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,50863,CDM,250,RC,J0561,HCPCS,60793-701-02,NDC,facility,both,24,ML,,2160,1512,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV,50863,CDM,636,RC,J7120,HCPCS,0338-0117-04,NDC,facility,both,12,ML,,399,279.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,J3490,HCPCS,2055503601,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,0409-3178-01,NDC,,,facility,both,250,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DENOSUMAB 60 MG/ML SUBQ SYRG,50863,CDM,J0897,HCPCS,55513-710-21,NDC,,,facility,both,60,ML,,4930,3451,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML IV,50863,CDM,250,RC,J3490,HCPCS,70860-301-41,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,J3360,HCPCS,0641-6244-01,NDC,,,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUPHENAZINE 2.5 MG TAB,50863,CDM,250,RC,J3490,HCPCS,10135-726-01,NDC,facility,both,4,EA,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL  32.4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6575-61,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IDARUBICIN 1 MG/ML IV SOLN,50863,CDM,250,RC,J9211,HCPCS,63323-194-20,NDC,facility,both,4,ML,,814,569.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 4 MEQ/ML IV SOLP (COMPOUNDED 30ML),50863,CDM,250,RC,J3490,HCPCS,63323-093-01,NDC,facility,both,1,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 25 MG TAB,50863,CDM,250,RC,J3490,HCPCS,62584-265-11,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL TBTQ,50863,CDM,J3490,HCPCS,0245-5317-89,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRBESARTAN 150 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,33342-048-07,NDC,facility,both,2,EA,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ABATACEPT 250 MG IV SOLR,50863,CDM,636,RC,J0129,HCPCS,0003-2187-13,NDC,facility,both,50,EA,"JZ,JA",8556,5989.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
BELIMUMAB 120 MG IV SOLR,50863,CDM,J0490,HCPCS,49401-101-01,NDC,,,facility,both,36,ME,,4228,2959.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 150 MG ORAL CAP,50863,CDM,J3490,HCPCS,0904-7002-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,J2704,HCPCS,63323-269-22,NDC,,,facility,both,7,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCRALFATE 1 GRAM ORAL TAB,50863,CDM,J3490,HCPCS,59762-0401-1,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J3490,HCPCS,0409-4279-16,NDC,,,facility,both,300,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,J7999,HCPCS,70092-1017-46,NDC,,,facility,both,2,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2001,HCPCS,63323-492-09,NDC,,,facility,both,5,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUORESCEIN 1 MG OPHT STRP,50863,CDM,J3490,HCPCS,17238-900-99,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,J3490,HCPCS,0143-9889-15,NDC,,,facility,both,5,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TALQUETAMAB-TGVS 40 MG/ML SUBQ SOLN,50863,CDM,250,RC,J3055,HCPCS,57894-470-01,NDC,facility,both,16,ML,,2745,1921.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GAMMAGARD LIQUID 10 % IV SOLN,50863,CDM,636,RC,J1569,HCPCS,0944-2700-11,NDC,facility,both,10,ML,"JW,JA",784,548.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
BORTEZOMIB 3.5 MG IV SOLR,50863,CDM,J9041,HCPCS,72603-270-01,NDC,,,facility,both,30,EA,,753,527.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB-QYYP 420 MG IV SOLR,50863,CDM,Q5116,HCPCS,0069-0306-01,NDC,,,facility,both,30,ME,,6686,4680.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5% W/EPINEPHRINE 1:200K INJECTION,50863,CDM,J3490,HCPCS,0409-1749-29,NDC,,,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL  6.25 MG ORAL TAB,50863,CDM,J3490,HCPCS,68084-854-11,NDC,,,facility,both,2,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETHYL CHLORIDE 100 % TOP SPRA,50863,CDM,636,RC,J3490,HCPCS,386000103,NDC,facility,both,1,ML,,180,126,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYBUTYNIN CHLORIDE  5 MG ORAL TO24,50863,CDM,250,RC,J3490,HCPCS,68084-480-11,NDC,facility,both,1,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN 0.9% SODIUM CL 1.25 GRAM/250 ML IV SOLN,50863,CDM,250,RC,J3373,HCPCS,70004-923-59,NDC,facility,both,125,ML,,189,132.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MONTELUKAST 10 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-6808-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,18,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,636,RC,J3490,HCPCS,63323-485-27,NDC,facility,both,125,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE  2 MG/ML INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-9300-11,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 60 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,0904-7045-61,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,J3490,HCPCS,66794-228-02,NDC,,,facility,both,2,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITRIOL 0.5 MCG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,23155-663-01,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  25 MG ORAL TAB,50863,CDM,J3490,HCPCS,63739-673-10,NDC,,,facility,both,4,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,Q5121,HCPCS,55513-670-01,NDC,,,facility,both,43,EA,,5934,4153.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 150 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-711-11,NDC,facility,both,2,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE  4 MG ORAL TAB,50863,CDM,250,RC,J7509,HCPCS,0904-6914-61,NDC,facility,both,3,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-3178-16,NDC,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOPIDOGREL  75 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6294-61,NDC,facility,both,3,EA,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,250,RC,J2720,HCPCS,63323-229-05,NDC,facility,both,5,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51672-4027-1,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6869-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J1611,HCPCS,63323-596-11,NDC,facility,both,1,EA,JZ,895,626.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
HALOPERIDOL DECANOATE 100 MG/ML IM SOLN,50863,CDM,250,RC,J1631,HCPCS,70069-383-01,NDC,facility,both,2,ML,,238,166.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOMYCIN-BACITRACN ZN-POLYMYXIN 3.5 MG-400 U*,50863,CDM,250,RC,J3490,HCPCS,0904-8805-67,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 100 MG ORAL TB12,50863,CDM,636,RC,J3490,HCPCS,42806-274-01,NDC,facility,both,2,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DONEPEZIL 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-303-11,NDC,facility,both,1,EA,PLAD,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
NELARABINE 250 MG/50 ML IV SOLN (PEDS ONCOLOGY),50863,CDM,250,RC,J9261,HCPCS,43598-142-11,NDC,facility,both,2,ML,JW,462,323.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DEXMEDETOMIDINE IN 0.9 % NACL 400 MCG/100 ML (4 MCG/ML) IV SOLN,50863,CDM,J3490,HCPCS,0338-9557-12,NDC,,,facility,both,1,ML,,165,115.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE 20 MG TAB,50863,CDM,250,RC,J3490,HCPCS,68084-045-11,NDC,facility,both,3,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,71288-402-10,NDC,facility,both,8,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,92,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,5,EA,,167,116.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-8515-23,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT 300 MCG/0.6 ML INJ SYRG,50863,CDM,250,RC,J0881,HCPCS,55513-111-01,NDC,facility,both,300,ML,,6409,4486.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPAGLIFLOZIN PROPANEDIOL 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0310-6210-30,NDC,facility,both,1,EA,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN (NEW TX NON-NEURO INDICATION)",50863,CDM,250,RC,J1561,HCPCS,13533-800-71,NDC,facility,both,20,ML,,2829,1980.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-0007-01,NDC,facility,both,300,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-760-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J1610,HCPCS,63323-582-82,NDC,facility,both,1,EA,JW,336,235.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PAROXETINE 30 MG TAB,50863,CDM,250,RC,J3490,HCPCS,50268-642-11,NDC,facility,both,2,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 200 MG/10 ML IRON IV SOLN,50863,CDM,J1756,HCPCS,0517-2310-05,NDC,,,facility,both,200,ML,,545,381.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  1 MG/ML ORAL LIQD,50863,CDM,636,RC,J3490,HCPCS,5843800571,NDC,facility,both,1,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ORAL ELECTROLYTES ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,7007411133,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-587-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,636,RC,J3490,HCPCS,63323-486-05,NDC,facility,both,60,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE (FOR CODE) 10% IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0517-6710-01,NDC,facility,both,1,ML,,59316,41521.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN   1.5 G IV SOLR,50863,CDM,636,RC,J3370,HCPCS,0409-3515-11,NDC,facility,both,3,EA,,143,100.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,51754-4250-1,NDC,facility,both,4,ML,,240,168,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0630,HCPCS,42023-205-01,NDC,facility,both,1,ML,,1127,788.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-242-11,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA 25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68682-200-25,NDC,facility,both,2,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,40,EA,JZ,5520,3864,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CLINDAMYCIN 150 MG/ML INJECTION,50863,CDM,250,RC,J3490,HCPCS,25021-115-06,NDC,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETIRIZINE 5 MG/5 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,68094-004-59,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 75 MG/5 ML ORAL SOLUTION,50863,CDM,250,RC,J3490,HCPCS,64980-511-10,NDC,facility,both,23,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0456,HCPCS,70860-100-41,NDC,facility,both,1,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,591,ME,JZ,8020,5614,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,J1100,HCPCS,0641-6145-01,NDC,,,facility,both,10,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-467-01,NDC,facility,both,1,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,250,RC,J0137,HCPCS,0143-9386-01,NDC,facility,both,100,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,304,ML,,215,150.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-8299-25,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 100 MG IV SOLR,50863,CDM,250,RC,J2997,HCPCS,50242-085-25,NDC,facility,both,100,EA,,24289,17002.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,636,RC,J0330,HCPCS,0409-6629-02,NDC,facility,both,25,ML,,285,199.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 100 MG 24 HR TAB,50863,CDM,636,RC,J3490,HCPCS,60687-413-11,NDC,facility,both,2,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,2,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN D5W 20000 UNIT/500 ML,50863,CDM,J1644,HCPCS,0264-9567-10,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60505-0252-2,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0054-0018-20,NDC,facility,both,40,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOVASTATIN 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68180-468-07,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,0641-6025-01,NDC,facility,both,5,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOZAPINE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-922-01,NDC,facility,both,6,EA,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL  1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-734-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,71288-505-02,NDC,facility,both,2,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  100 MCG/ML INJ SOLN,50863,CDM,636,RC,J2354,HCPCS,63323-376-00,NDC,facility,both,6,ML,JB,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JB: Administered subcutaneously
BUSPIRONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,24689-907-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 100 MG TAB,50863,CDM,636,RC,J3490,HCPCS,65862-064-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2599,HCPCS,43598-914-25,NDC,facility,both,8,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-134-11,NDC,facility,both,15,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,22,EA,,3036,2125.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLN,50863,CDM,636,RC,J3262,HCPCS,50242-136-01,NDC,facility,both,160,ML,JA,2933,2053.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-5771-23,NDC,facility,both,17,EA,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COLCHICINE 0.6 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,42292-054-01,NDC,facility,both,2,EA,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZOCAINE-MENTHOL 15-3.6 MG MM LOZG,50863,CDM,636,RC,J3490,HCPCS,7031246129,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,0409-4887-17,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,68462-755-01,NDC,facility,both,2,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NORTRIPTYLINE 10 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,50268-603-11,NDC,facility,both,3,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,3,EA,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
BELATACEPT 250 MG IV SOLR,50863,CDM,636,RC,J0485,HCPCS,0003-0371-13,NDC,facility,both,525,EA,,5417,3791.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE 8 MG SL SUBL,50863,CDM,636,RC,J3490,HCPCS,60687-492-11,NDC,facility,both,2,EA,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE  2 MG/ML INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-285-23,NDC,facility,both,1,ML,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,68180-441-01,NDC,facility,both,6,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLMESARTAN 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0527-2427-46,NDC,facility,both,1,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN SODIUM  2 GRAM INJ SOLR,50863,CDM,250,RC,J0290,HCPCS,25021-137-20,NDC,facility,both,3,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,42494-416-01,NDC,facility,both,1,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK,50863,CDM,250,RC,J3490,HCPCS,12870-0001-2,NDC,facility,both,6,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 125 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-519-11,NDC,facility,both,3,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIFAMPIN 600 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,0068-0597-01,NDC,facility,both,1,EA,,242,169.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMOSOZUMAB-AQQG 210MG/2.34ML ( 105MG/1.17MLX2) SUBQ SYRG,50863,CDM,636,RC,J3111,HCPCS,55513-998-02,NDC,facility,both,105,ML,JZ,2947,2062.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
POTASSIUM CHLORIDE 20 MEQ/100 ML IV PGBK,50863,CDM,250,RC,J3480,HCPCS,0338-0705-48,NDC,facility,both,20,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,636,RC,J3490,HCPCS,0904-6794-89,NDC,facility,both,4,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 20 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,60687-723-11,NDC,facility,both,2,EA,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV (BOLUS),50863,CDM,250,RC,J7120,HCPCS,0264-7750-07,NDC,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-086-01,NDC,facility,both,3,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9% IV (PEDS) BOLUS,50863,CDM,250,RC,J7030,HCPCS,0264-7800-09,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FELBAMATE 600 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65162-735-09,NDC,facility,both,2,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITRIOL 0.5 MCG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,23155-663-01,NDC,facility,both,5,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE (FOR EMERGENCY) 100 MG/ML (10%) IV SOLN,50863,CDM,636,RC,J0612,HCPCS,63323-360-01,NDC,facility,both,300,ML,JZ,177,123.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SODIUM BICARBONATE IV CONCENTRATED INFUSION (1 MEQ/ML),50863,CDM,250,RC,J3490,HCPCS,0409-6625-02,NDC,facility,both,1,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-9543-02,NDC,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6638-61,NDC,facility,both,6,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-191-11,NDC,facility,both,1,EA,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE 1 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,46287-035-15,NDC,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2312,HCPCS,0409-1215-21,NDC,facility,both,20,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELATACEPT 250 MG IV SOLR,50863,CDM,636,RC,J0485,HCPCS,0003-0371-13,NDC,facility,both,212,EA,JW,951,665.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
THROMBIN (RECOMBINANT) 5000 UNIT TOP SOLR,50863,CDM,250,RC,J3490,HCPCS,0338-0324-01,NDC,facility,both,20,EA,,7431,5201.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,5,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE  7 MG/24 HR TD PT24,50863,CDM,250,RC,J3490,HCPCS,0536-5894-88,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  500 MCG/ML INJ SOLN,50863,CDM,636,RC,J2354,HCPCS,25021-465-01,NDC,facility,both,20,ML,"JZ,JA",206,144.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
SENNOSIDES  8.6 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6522-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN-ACETAMINOPHEN-CAFFEINE 250 MG-250 MG-65 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0067-2039-91,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,76045-009-10,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALTREXONE 50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68094-853-62,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEPLIZUMAB-MZWV 2 MG/20 ML IV SOLN,50863,CDM,636,RC,J9381,HCPCS,73650-316-01,NDC,facility,both,20,ME,,1210,847,,,,,,,,,,,,,Gross Charge Type: Pharmacy
D5-1/2 NS AND POTASSIUM CHLORIDE 20 MEQ/L IV (PEDS CHEMO),50863,CDM,250,RC,J3490,HCPCS,0338-0671-04,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 300 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,63739-132-33,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,636,RC,J3490,HCPCS,61553-320-70,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSULFAN BLUE 1 % INJ SOLN,50863,CDM,250,RC,Q9968,HCPCS,67457-220-00,NDC,facility,both,50,ML,,4299,3009.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,636,RC,J3490,HCPCS,70004-600-09,NDC,facility,both,1,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAZOSIN 1 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,51079-630-01,NDC,facility,both,2,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,76045-009-10,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,63323-465-01,NDC,facility,both,15,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPOETIN ALFA  4000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J0885,HCPCS,59676-304-00,NDC,facility,both,40,ML,"JZ,EC",462,323.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier EC: Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy
METHOTREXATE SODIUM 2.5 MG ORAL TAB,50863,CDM,636,RC,J8610,HCPCS,51079-670-01,NDC,facility,both,5,EA,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,50863,CDM,250,RC,J9075,HCPCS,10019-956-16,NDC,facility,both,68,EA,JW,192,134.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ROPIVACAINE  2 MG/ML INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,70069-062-01,NDC,facility,both,2,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,250,RC,J7999,HCPCS,70092-1017-46,NDC,facility,both,2,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % MUCOSAL GEL,50863,CDM,250,RC,J3490,HCPCS,50383-781-05,NDC,facility,both,4,ML,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN PEDS INFUSION (CDS MIXTURE),50863,CDM,250,RC,J0290,HCPCS,25021-136-10,NDC,facility,both,2,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,636,RC,J1953,HCPCS,63323-400-01,NDC,facility,both,100,ML,JZ,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-145-11,NDC,facility,both,35,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 7.5 MG-325 MG/15 ML ORAL SOLN (REPACK),50863,CDM,636,RC,J3490,HCPCS,66689-023-01,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK,50863,CDM,J3490,HCPCS,12870-0001-1,NDC,,,facility,both,10,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROPHILLIC OINTMENT (AQUAPHOR),50863,CDM,250,RC,J3490,HCPCS,7214063608,NDC,facility,both,1,GM,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAZOSIN 1 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7020-61,NDC,facility,both,3,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7050,HCPCS,0264-7800-20,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEMAZEPAM  7.5 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6436-04,NDC,facility,both,2,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 1 % NASAL SPRAY AEROSOL,50863,CDM,636,RC,J3490,HCPCS,0024-1352-02,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 20 MG/ML INJ SOLN,50863,CDM,250,RC,J0360,HCPCS,0641-6231-01,NDC,facility,both,1,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE 2 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,50383-924-93,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE SR 25 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,62175-471-32,NDC,facility,both,1,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIPASE-PROTEASE-AMYLASE 24,000-76,000- 120,000 UNIT ORAL CAP, DELAY REL",50863,CDM,636,RC,J3490,HCPCS,0032-2636-01,NDC,facility,both,3,EA,,150,105,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANAKINRA 100 MG/0.67 ML SUBQ SYRG,50863,CDM,250,RC,J3590,HCPCS,66658-234-01,NDC,facility,both,1,ML,,562,393.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J2003,HCPCS,0409-4279-16,NDC,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,65862-642-30,NDC,facility,both,1,EA,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6374-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,81033-002-20,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0054-0710-20,NDC,facility,both,5,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PATIROMER CALCIUM SORBITEX  8.4 G ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,53436-084-01,NDC,facility,both,3,EA,,461,322.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,68094-147-01,NDC,facility,both,1,ML,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),50863,CDM,250,RC,J3490,HCPCS,8290306544,NDC,facility,both,7,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ABATACEPT 250 MG IV SOLR,50863,CDM,636,RC,J0129,HCPCS,0003-2187-13,NDC,facility,both,100,EA,,16146,11302.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  75 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6951-61,NDC,facility,both,2,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) MISC SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-694-04,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOLUTEGRAVIR 50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,49702-228-13,NDC,facility,both,1,EA,,383,268.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 10 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-369-11,NDC,facility,both,20,EA,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIFEPRISTONE 200 MG ORAL TAB,50863,CDM,250,RC,S0190,HCPCS,43393-001-01,NDC,facility,both,1,EA,,285,199.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM ACETATE 667 MG ORAL CAP,50863,CDM,250,RC,J0615,HCPCS,0904-7119-61,NDC,facility,both,29,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,8,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,42,ML,JW,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IRON SUCROSE 100 MG/5 ML IV SOLN,50863,CDM,636,RC,J1756,HCPCS,0517-2340-10,NDC,facility,both,200,ML,,642,449.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,135,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,636,RC,J2405,HCPCS,23155-547-31,NDC,facility,both,16,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50580-458-11,NDC,facility,both,2,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,60687-571-24,NDC,facility,both,2,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML IV SOLN (MERGE),50863,CDM,250,RC,J3490,HCPCS,70756-611-82,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPRAZOLAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-388-11,NDC,facility,both,4,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE HCL IN 0.9% NACL 1 MG/10 ML (100 MCG/ML) IV SYRG,50863,CDM,250,RC,J3490,HCPCS,73177-108-03,NDC,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MULTIVIT-MIN-FERROUS GLUCONATE 9 MG IRON/ 15 ML (15 ML) ORAL LIQD,50863,CDM,250,RC,J3490,HCPCS,6809412059,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  2.5 MG ORAL TAB,50863,CDM,636,RC,J7510,HCPCS,59651-485-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 0.8 GRAM ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,65862-930-08,NDC,facility,both,1,EA,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-3178-01,NDC,facility,both,120,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,3,EA,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6949-61,NDC,facility,both,6,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN  750 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,50268-551-11,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELIMUMAB 120 MG IV SOLR,50863,CDM,636,RC,J0490,HCPCS,49401-101-01,NDC,facility,both,4,ME,"JW,JA",205,143.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
CALCIUM GLUCONATE 20MG/ML IV SYRINGE (PEDS/NEO),50863,CDM,250,RC,J0612,HCPCS,63323-311-10,NDC,facility,both,56,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0536-1327-10,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,50863,CDM,250,RC,J1756,HCPCS,0517-2340-01,NDC,facility,both,100,ML,JZ,321,224.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
BISACODYL  5 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,0904-6407-61,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 10 MEQ/100 ML IV PGBK,50863,CDM,636,RC,J3480,HCPCS,0990-7074-26,NDC,facility,both,10,ML,JZ,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MEDROXYPROGESTERONE 150 MG/ML IM SYRG,50863,CDM,250,RC,J1050,HCPCS,0548-5701-00,NDC,facility,both,150,ML,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J2250,HCPCS,0409-2305-17,NDC,facility,both,2,ML,PLAD,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0781-3458-75,NDC,facility,both,5000,ML,,269,188.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRP (MERGE/REPACK),50863,CDM,636,RC,J3490,HCPCS,68094-764-59,NDC,facility,both,2,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM 1 GRAM IV SOLR,50863,CDM,636,RC,J2185,HCPCS,63323-508-01,NDC,facility,both,10,EA,JZ,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,35,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-466-03,NDC,facility,both,50,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,636,RC,J3490,HCPCS,0904-6930-61,NDC,facility,both,3,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG ORAL TBEC,50863,CDM,J3490,HCPCS,50268-639-11,NDC,,,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR PHOSPHATE 75 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,68180-677-11,NDC,facility,both,1,EA,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,0904-6923-61,NDC,facility,both,50,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,16714-294-01,NDC,facility,both,8,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPRAZOLAM 0.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0228-2029-10,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60505-0252-3,NDC,facility,both,2,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 400 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0143-9887-01,NDC,facility,both,19,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 50% IN WATER (MERGE RECORD),50863,CDM,636,RC,J7060,HCPCS,0409-4902-64,NDC,facility,both,1,ML,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-ABDA 100 MG IV SOLR,50863,CDM,636,RC,Q5104,HCPCS,78206-162-99,NDC,facility,both,64,EA,,13308,9315.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZTROPINE 1 MG/ML INJ SOLN,50863,CDM,250,RC,J0515,HCPCS,68382-860-02,NDC,facility,both,1,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLNALTREXONE 12 MG/0.6 ML SUBQ SYRG,50863,CDM,250,RC,J2212,HCPCS,65649-552-04,NDC,facility,both,80,ML,,735,514.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  10 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-0904-05,NDC,facility,both,2,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENAZOPYRIDINE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,75826-115-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,50863,CDM,250,RC,J2359,HCPCS,55150-308-01,NDC,facility,both,20,EA,JZ,208,145.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CARBAMAZEPINE 200 MG ORAL TB12,50863,CDM,250,RC,J3490,HCPCS,60687-583-11,NDC,facility,both,2,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 20 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,0904-7458-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DENOSUMAB 120 MG/1.7 ML (70 MG/ML) SUBQ SOLN,50863,CDM,J0897,HCPCS,55513-730-01,NDC,,,facility,both,2,ML,,9522,6665.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 10 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-6987-61,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  75 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16714-658-01,NDC,facility,both,2,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6084-61,NDC,facility,both,3,EA,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COENZYME Q10  30 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,536143607,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EMTRICITABINE-TENOFOVIR 200 MG-300 MG TAB,50863,CDM,250,RC,J0750,HCPCS,65862-354-30,NDC,facility,both,1,EA,,297,207.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DROXIDOPA 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,31722-014-90,NDC,facility,both,2,EA,,312,218.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC IV INFUSION HYDRAT 31-60 MIN,50863,CDM,250,RC,J0248,HCPCS,61958-2901-2,NDC,facility,both,93,EA,JW,485,339.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
HYDRALAZINE  10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50111-398-01,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0338-1055-48,NDC,facility,both,50,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LEVOTHYROXINE 100 MCG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,25021-468-10,NDC,facility,both,2,EA,,817,571.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL  6.25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6301-61,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 10 MG/50 ML (0.2MG/ML) PCA IN NS (MERGE),50863,CDM,250,RC,J1171,HCPCS,61553-830-41,NDC,facility,both,200,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-686-10,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1940,HCPCS,63323-280-03,NDC,facility,both,2,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-285-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 150 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-445-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-134-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE (PF) IN 0.9 % NACL 1 MG/ML VENT INFUSION,50863,CDM,250,RC,J2274,HCPCS,70092-1522-35,NDC,facility,both,5,ML,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,28,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM POLYSTYRENE SULFONATE ORAL POWDER,50863,CDM,250,RC,J3490,HCPCS,11534-166-16,NDC,facility,both,1,GM,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,63323-485-27,NDC,,,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT 200 MCG/0.4 ML INJ SYRG,50863,CDM,636,RC,J0881,HCPCS,55513-028-01,NDC,facility,both,200,ML,"JZ,EC",4273,2991.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier EC: Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,250,RC,J7999,HCPCS,70092-1017-46,NDC,facility,both,12,ML,,238,166.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE  7 % INHL NEBU,50863,CDM,250,RC,J3490,HCPCS,487900730,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,636,RC,Q0162,HCPCS,65162-691-79,NDC,facility,both,4,ML,,111,77.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 10% IN WATER (NEO) 2 - 3.99 KG,50863,CDM,250,RC,J3490,HCPCS,0338-0023-04,NDC,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) IV SOLN",50863,CDM,636,RC,J3490,HCPCS,0013-1114-20,NDC,facility,both,3,ML,,353,247.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,10,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1815,HCPCS,0169-1833-11,NDC,facility,both,7,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTOBARBITAL 75 MG/1.5 ML SYRINGE (REPACK),50863,CDM,636,RC,J2515,HCPCS,25021-676-20,NDC,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML INJ SOLN,50863,CDM,250,RC,J0171,HCPCS,76329-9060-0,NDC,facility,both,8,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID (PORK)  60 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0456-0459-01,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE SODIUM 2.5 MG ORAL TAB,50863,CDM,250,RC,J8610,HCPCS,0904-7141-10,NDC,facility,both,8,EA,,141,98.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,0641-6147-01,NDC,facility,both,2,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATED 20 MG/ML IV SOLN,50863,CDM,250,RC,J0706,HCPCS,51754-0500-1,NDC,facility,both,6,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYMETAZOLINE 0.05 % NASL SPRA,50863,CDM,250,RC,J3490,HCPCS,0904-7427-30,NDC,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIRMATRELVIR-RITONAVIR 300-100 MG ORAL TAB DOSEPACK (FOR ED/IP TAKE HOME PANEL),50863,CDM,250,RC,J3490,HCPCS,0069-5321-03,NDC,facility,both,30,EA,,4130,2891,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-0053-01,NDC,facility,both,3,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0904-7127-61,NDC,facility,both,120,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  25 MG ORAL TAB,50863,CDM,J3490,HCPCS,51079-075-01,NDC,,,facility,both,4,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INDOMETHACIN 25 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,50268-430-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,250,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,71,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,50863,CDM,J1644,HCPCS,0641-0400-37,NDC,,,facility,both,5,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,50863,CDM,250,RC,J1885,HCPCS,0409-3796-19,NDC,facility,both,4,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM POLYSTYRENE SULFONATE ORAL POWDER,50863,CDM,636,RC,J3490,HCPCS,10702-036-15,NDC,facility,both,2,GM,,133,93.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 100 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,0591-3540-60,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELATACEPT 250 MG IV SOLR,50863,CDM,636,RC,J0485,HCPCS,0003-0371-13,NDC,facility,both,520,EA,,5366,3756.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6283-61,NDC,facility,both,1,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 4 MG/ACTUATION NASL SPRY,50863,CDM,636,RC,J3490,HCPCS,0093-2165-68,NDC,facility,both,1,EA,,257,179.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,51754-5001-1,NDC,facility,both,5,ML,,232,162.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J1938,HCPCS,0409-6102-18,NDC,facility,both,2,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,67877-246-01,NDC,facility,both,1,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCERIN-WITCH HAZEL 12.5 %-50 % TOPICAL PADS,50863,CDM,250,RC,J3490,HCPCS,50289-3250-1,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 20 MG/ML ORAL CONC,50863,CDM,250,RC,J3490,HCPCS,71093-143-11,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GALANTAMINE  4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-729-11,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-076-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPRAZOLAM 0.25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-647-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,636,RC,J0132,HCPCS,55150-259-30,NDC,facility,both,240,ML,,1084,758.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN D5W 20000 UNIT/500 ML,50863,CDM,J1644,HCPCS,0264-9567-10,NDC,,,facility,both,8,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,4,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 50% IN WATER (MERGE RECORD),50863,CDM,636,RC,J7060,HCPCS,76329-3302-1,NDC,facility,both,1,ML,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7410-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,67877-545-88,NDC,facility,both,20,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,50863,CDM,636,RC,J9000,HCPCS,63323-883-30,NDC,facility,both,10,ML,,392,274.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J7510,HCPCS,17856-0815-1,NDC,facility,both,12,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN PEDS IV INFUSION 12 MG/ML (CDS MIXTURE FROM PREMIX),50863,CDM,250,RC,J0736,HCPCS,0781-3289-91,NDC,facility,both,2,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2308-22,NDC,facility,both,7,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DRONABINOL  2.5 MG ORAL CAP,50863,CDM,250,RC,Q0167,HCPCS,60687-375-11,NDC,facility,both,2,EA,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  500 MG IV SOLR,50863,CDM,250,RC,J3373,HCPCS,0143-9161-01,NDC,facility,both,40,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-088-11,NDC,facility,both,2,EA,,220,154,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7728-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,J3490,HCPCS,63739-434-02,NDC,,,facility,both,4,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,J3490,HCPCS,60687-390-11,NDC,,,facility,both,2,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J7510,HCPCS,17856-0815-1,NDC,facility,both,6,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,636,RC,J0690,HCPCS,44567-707-25,NDC,facility,both,2,EA,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PERPHENAZINE  4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-602-11,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,J3490,HCPCS,51079-444-01,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MISOPROSTOL 800 MCG (4 X 200 MCG TAB) PACKAGE,50863,CDM,250,RC,S0191,HCPCS,43393-023-04,NDC,facility,both,4,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,12,EA,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOLIC ACID 400 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,5026834611,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMETHICONE 40 MG/0.6 ML ORAL DRPS,50863,CDM,250,RC,J3490,HCPCS,0603-0894-50,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J2004,HCPCS,0409-3178-16,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VECURONIUM 1 MG/ML IV SYRINGE (NEO),50863,CDM,250,RC,J3490,HCPCS,41616-931-44,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLN,50863,CDM,636,RC,J3262,HCPCS,50242-137-01,NDC,facility,both,400,ML,,7331,5131.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-580-11,NDC,facility,both,8,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,62332-600-01,NDC,facility,both,5,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,59762-4910-3,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6949-61,NDC,facility,both,6,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM-ALBUTEROL 20-100 MCG/ACTUATION INHL MIST,50863,CDM,250,RC,J3490,HCPCS,0597-0024-02,NDC,facility,both,1,GM,,1351,945.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 10 GRAM/15 ML ORAL SOLN,50863,CDM,J3490,HCPCS,0116-4005-30,NDC,,,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),50863,CDM,636,RC,J3490,HCPCS,0409-4888-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,122,EA,,16836,11785.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 50 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,59651-489-01,NDC,facility,both,100,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUINIDINE SR 324 MG TAB,50863,CDM,250,RC,J3490,HCPCS,53489-141-01,NDC,facility,both,1,EA,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,50863,CDM,J1885,HCPCS,72266-119-01,NDC,,,facility,both,2,ML,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV (BOLUS),50863,CDM,636,RC,J7120,HCPCS,0264-7750-07,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-739-11,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,8,EA,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIRMATRELVIR-RITONAVIR 300-100 MG ORAL TAB DOSEPACK (FOR ED/IP TAKE HOME PANEL),50863,CDM,J3490,HCPCS,0069-5321-30,NDC,,,facility,both,30,EA,,4010,2807,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,J1171,HCPCS,0409-1283-03,NDC,,,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 1 MG/ML NEEDLELESS SYRG,50863,CDM,J2312,HCPCS,76329-3369-1,NDC,,,facility,both,200,ML,,194,135.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOTRIMAZOLE 1 % TOP CREA,50863,CDM,250,RC,J3490,HCPCS,0536-1272-22,NDC,facility,both,1,GM,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 200 MG INJ SOLR,50863,CDM,250,RC,J0640,HCPCS,0143-9553-01,NDC,facility,both,4,EA,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4% TOP PATCH,50863,CDM,250,RC,J3490,HCPCS,46581-830-01,NDC,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,50863,CDM,250,RC,J9025,HCPCS,0143-9606-01,NDC,facility,both,157,EA,,360,252,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 300 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-722-11,NDC,facility,both,4,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-5771-23,NDC,facility,both,23,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL (VITAMIN D3)  1000 UNIT ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,8068116900,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 20 GRAM/30 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-1154-30,NDC,facility,both,2,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 800 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6707-06,NDC,facility,both,5,EA,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR PHOSPHATE 75 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,64380-799-01,NDC,facility,both,10,EA,,557,389.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16714-681-01,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM SR 60 MG 12 HR CAP,50863,CDM,250,RC,J3490,HCPCS,51079-924-01,NDC,facility,both,2,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN 0.9 % SODIUM CHL 1.5 GRAM/500 ML IV SOLN,50863,CDM,250,RC,J3370,HCPCS,99999-502-02,NDC,facility,both,3,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHIMAZOLE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-669-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,J2704,HCPCS,0069-0209-01,NDC,,,facility,both,20,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,J2704,HCPCS,63323-269-69,NDC,,,facility,both,100,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-229-02,NDC,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 100 MG IV SOLR,50863,CDM,J2997,HCPCS,50242-085-25,NDC,,,facility,both,50,EA,,12145,8501.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 500 MG PE/10 ML INJ SOLN,50863,CDM,636,RC,Q2009,HCPCS,25021-798-10,NDC,facility,both,10,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,J3010,HCPCS,63323-806-13,NDC,,,facility,both,5,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,J3490,HCPCS,72789-057-01,NDC,,,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,636,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,1,ML,GZ,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier GZ: Item or service expected to be denied as not reasonable and necessary
BUSPIRONE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-0053-05,NDC,facility,both,12,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,50863,CDM,636,RC,J3490,HCPCS,68462-157-40,NDC,facility,both,12,EA,,819,573.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML IV,50863,CDM,250,RC,J3490,HCPCS,25021-319-05,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0630,HCPCS,42023-205-01,NDC,facility,both,1,ML,,8642,6049.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE MODIFIED 100 MG ORAL CAP,50863,CDM,250,RC,J7502,HCPCS,0093-9020-19,NDC,facility,both,1,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEPERIDINE (PF) 25 MG/ML IV SOLN (PHS MERGE),50863,CDM,636,RC,J2175,HCPCS,0409-1362-11,NDC,facility,both,1,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM PHOSPHATE 3 MMOL/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-7391-82,NDC,facility,both,1,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-9558-05,NDC,facility,both,2,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,33,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE (PF) 1 MG/ML INJ SOLN,50863,CDM,636,RC,J0169,HCPCS,54288-103-01,NDC,facility,both,60,ML,,514,359.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,14789-251-09,NDC,facility,both,2,ML,,265,185.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",50863,CDM,J1561,HCPCS,13533-800-21,NDC,,,facility,both,20,ML,,2829,1980.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE (PF) 25 MG/ML INJ SOLN (FOR ECTOPIC PREGNANCY),50863,CDM,636,RC,J9260,HCPCS,0143-9519-01,NDC,facility,both,2,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,125,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0074-4341-90,NDC,facility,both,3,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-131-11,NDC,facility,both,14,EA,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ELECTROLYTE-A IV,50863,CDM,250,RC,J3490,HCPCS,0338-0221-04,NDC,facility,both,2,ML,,196,137.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DANTROLENE  25 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7211-04,NDC,facility,both,4,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN PEDS INFUSION (CDS MIXTURE),50863,CDM,250,RC,J0290,HCPCS,25021-136-10,NDC,facility,both,3,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 10 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,0641-0367-25,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 112 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42292-039-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0121-1781-05,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,68516-5214-4,NDC,facility,both,16,ML,,2282,1597.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,110,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,63323-104-25,NDC,facility,both,10,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML IM SOLN,50863,CDM,636,RC,90375,HCPCS,13533-318-05,NDC,facility,both,9,ML,JW,3657,2559.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ALLOPURINOL 20 MG/ML ORAL SUSPENSION (REPACK),50863,CDM,250,RC,J3490,HCPCS,16714-041-04,NDC,facility,both,6,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,85,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 15 MG/ML (1.5 %) INJ SOLN,50863,CDM,J2003,HCPCS,0409-4776-10,NDC,,,facility,both,75,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  125 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,23155-858-78,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLESTYRAMINE 4 G ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,0245-0036-89,NDC,facility,both,1,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 50% IN WATER (MERGE RECORD),50863,CDM,250,RC,J7060,HCPCS,76329-3302-1,NDC,facility,both,7,ML,,832,582.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0039-28,NDC,facility,both,8,EA,JZ,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6322-61,NDC,facility,both,6,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,13107-085-01,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 20 MEQ/100 ML IV PGBK,50863,CDM,636,RC,J3480,HCPCS,0338-0705-48,NDC,facility,both,10,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLN (MERGE)",50863,CDM,250,RC,P9047,HCPCS,64208-2512-8,NDC,facility,both,1,ML,JZ,119,83.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PROMETHAZINE 25 MG ORAL TAB,50863,CDM,636,RC,Q0169,HCPCS,0904-7304-61,NDC,facility,both,12,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % (1 MEQ/ML) IV 50 ML EMERGENCY SYRINGE,50863,CDM,636,RC,J3490,HCPCS,70092-1015-50,NDC,facility,both,1,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN  325 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,66553-001-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0143-9853-16,NDC,facility,both,6,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLIOVIRUS VACCINE 40-8-32 UNIT/0.5 ML INJ SUSP,50863,CDM,90713,HCPCS,49281-860-10,NDC,,,facility,both,1,ML,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCOSAMINE SULFATE  500 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,5026837511,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 50 MG TAB,50863,CDM,250,RC,Q0177,HCPCS,51079-816-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) 1000 UNITS/ML INJ SOL (FOR DIALYSIS ONLY),50863,CDM,250,RC,J1644,HCPCS,25021-400-10,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEMANTINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6505-61,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  5 GRAM IV SOLR,50863,CDM,250,RC,J3370,HCPCS,0409-6509-01,NDC,facility,both,4,EA,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,13533-690-20,NDC,facility,both,1,ML,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZONISAMIDE 10 MG/ML ORAL SYRUP (REPACK),50863,CDM,250,RC,J3490,HCPCS,64679-990-01,NDC,facility,both,1,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,50863,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,14,EA,,306,214.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,16714-294-01,NDC,facility,both,7,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 10 % (100 MG/ML) MISC SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-695-04,NDC,facility,both,2,ML,,129,90.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLP",50863,CDM,250,RC,P9047,HCPCS,0944-0493-04,NDC,facility,both,4,ML,,1001,700.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J3430,HCPCS,69097-708-31,NDC,facility,both,3,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL  20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6671-04,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TETRABENAZINE 12.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,67386-421-01,NDC,facility,both,2,EA,,386,270.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 100 MG/1 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0781-3268-05,NDC,facility,both,17,ML,JZ,233,163.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MESNA 100 MG/ML IV SOLN,50863,CDM,250,RC,J9209,HCPCS,10019-953-62,NDC,facility,both,3,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE-SALMETEROL 250 MCG-50 MCG/DOSE DISK DEVICE FOR INHALATION,50863,CDM,636,RC,J3490,HCPCS,0093-7518-31,NDC,facility,both,1,EA,,1325,927.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-663-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 600 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-457-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 100 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,0904-3854-61,NDC,facility,both,5,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J2004,HCPCS,63323-482-03,NDC,facility,both,24,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-0430-06,NDC,,,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,85,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,42806-151-34,NDC,facility,both,5,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,2055503601,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2599,HCPCS,43598-914-25,NDC,facility,both,9,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,43,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 12.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6302-61,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-3426-01,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COENZYME Q10  30 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,536135807,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-327-10,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,3,EA,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,76045-009-96,NDC,facility,both,5,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN SODIUM EXTENDED 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6187-61,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,636,RC,J3490,HCPCS,0409-4887-23,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN DEGLUDEC 100 UNITS/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,73070-400-11,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RACEPINEPHRINE 2.25 % INHL NEBU,50863,CDM,636,RC,J3490,HCPCS,0487-2784-01,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-742-11,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-345-11,NDC,facility,both,2,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEPERIDINE (PF) 25 MG/ML IV SOLN (PHS MERGE),50863,CDM,636,RC,J2175,HCPCS,0409-1176-03,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML INJ SOLN,50863,CDM,250,RC,J0169,HCPCS,76329-9060-0,NDC,facility,both,12,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0137,HCPCS,0264-4100-90,NDC,facility,both,100,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-406-03,NDC,facility,both,1,ML,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIP,PER(A)TET-HEPB-POL-HIB(PF) 15 UNIT-5 UNIT- 10 MCG/0.5 ML IM INJ MERGE (CAM USE ONLY)",50863,CDM,90697,HCPCS,63361-243-15,NDC,,,facility,both,1,ML,,674,471.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2001,HCPCS,63323-492-04,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,250,RC,J2720,HCPCS,63323-229-01,NDC,facility,both,2,ML,JW,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DICYCLOMINE 20 MG ORAL TAB,50863,CDM,636,RC,J0500,HCPCS,0527-1282-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51672-4027-1,NDC,facility,both,8,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 30 MG TAB,50863,CDM,636,RC,J3490,HCPCS,60687-717-11,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-02,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML IV,50863,CDM,J3490,HCPCS,25021-319-05,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,50863,CDM,250,RC,J8540,HCPCS,0054-8175-25,NDC,facility,both,128,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLU VACCINE TS 2025-26 6 MO UP (PF) 45 MCG (15 MCG X 3)/0.5 ML IM SYRG,50863,CDM,90656,HCPCS,19515-904-41,NDC,,,facility,both,1,ML,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-592-11,NDC,facility,both,3,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMFIBROZIL 600 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-350-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN D5W 25000 UNIT/250 ML (PTT MONITORING),50863,CDM,250,RC,J1644,HCPCS,0264-9587-20,NDC,facility,both,25,ML,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACIDOPHILUS-PECTIN W CITRUS 25 MILLION-100 CELL MG TAB,50863,CDM,250,RC,J3490,HCPCS,8068102600,NDC,facility,both,5,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  15 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,0406-8315-23,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  20 MEQ ORAL PACK,50863,CDM,J3490,HCPCS,72888-024-06,NDC,,,facility,both,1,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-3178-01,NDC,facility,both,15,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROPRUSSIDE 25 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,70436-028-80,NDC,facility,both,2,ML,,245,171.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID (PORK) 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0456-0457-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG TAB,50863,CDM,636,RC,J3490,HCPCS,50268-728-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,42023-164-25,NDC,facility,both,20,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  100 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,0641-6175-01,NDC,facility,both,8,ML,JB,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JB: Administered subcutaneously
POLYETHYLENE GLYCOL 3350 17 GRAM (100 %) ORAL PWPK,50863,CDM,636,RC,J3490,HCPCS,62559-157-17,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,50863,CDM,J2354,HCPCS,25021-463-01,NDC,,,facility,both,2,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 40 MG-200 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0121-0853-20,NDC,facility,both,1,ML,,101,70.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0630,HCPCS,43598-051-11,NDC,facility,both,1,ML,,6281,4396.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANTI-INHIBITOR COAGULANT CMPLX (PHS MERGE),50863,CDM,J7198,HCPCS,64193-426-02,NDC,,,facility,both,390,UN,,2817,1971.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16571-109-01,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIGOXIN 250 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-5922-61,NDC,facility,both,2,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0641-0400-37,NDC,facility,both,3,ML,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 1 GRAM INJ SOLR,50863,CDM,250,RC,J0692,HCPCS,25021-121-20,NDC,facility,both,24,EA,,479,335.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,144,ML,,2072,1450.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,636,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,13,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,636,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,636,RC,J3490,HCPCS,73013-2002-2,NDC,facility,both,3,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  1 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,64380-782-06,NDC,facility,both,3,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TERAZOSIN  1 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,59746-383-06,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESNA 100 MG/ML IV SOLN,50863,CDM,250,RC,J9209,HCPCS,0338-1305-01,NDC,facility,both,5,ML,,194,135.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEMANTINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,47335-321-86,NDC,facility,both,1,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE  4 MG ORAL TAB,50863,CDM,250,RC,J7509,HCPCS,0904-6914-61,NDC,facility,both,8,EA,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"CALCIUM GLUC IN NACL, ISO-OSM 1 G/100 ML IV SOLN",50863,CDM,636,RC,J0612,HCPCS,44567-622-01,NDC,facility,both,50,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,7733351625,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL 2 MG/ML ORAL CONCENTRATE,50863,CDM,250,RC,J3490,HCPCS,0121-0581-05,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE 25 MG/ML INJ SOLN,50863,CDM,250,RC,J3230,HCPCS,70710-1850-1,NDC,facility,both,1,ML,,168,117.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J3490,HCPCS,0409-0007-01,NDC,,,facility,both,300,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,0409-3178-17,NDC,,,facility,both,25,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZONATATE 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7153-61,NDC,facility,both,20,EA,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN 1 MG/ML INJECTION (PEDS ONCOLOGY),50863,CDM,250,RC,J0640,HCPCS,71288-160-10,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0630,HCPCS,63323-865-02,NDC,facility,both,1,ML,,2065,1445.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,71288-402-10,NDC,facility,both,15,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IRRIGATION SOLN,50863,CDM,636,RC,J7120,HCPCS,0264-7389-60,NDC,facility,both,18,ML,,300,210,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,10135-778-01,NDC,facility,both,50,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN PEDS SYRINGE (20MG/ML) IN DEXTROSE (CDS MIX,50863,CDM,250,RC,J0690,HCPCS,0781-3451-70,NDC,facility,both,4,EA,PLAD,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
TEPROTUMUMAB-TRBW 500 MG IV SOLR,50863,CDM,636,RC,J3241,HCPCS,75987-130-15,NDC,facility,both,99,EA,,70458,49320.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR  6 MG/ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,68180-678-01,NDC,facility,both,4,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  15 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,0406-8315-23,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIPASE-PROTEASE-AMYLASE 5,000-17,000- 24,000 UNIT ORAL CPDR",50863,CDM,250,RC,J3490,HCPCS,73562-115-01,NDC,facility,both,2,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,63323-400-01,NDC,facility,both,150,ML,JZ,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CHLORHEXIDINE GLUCONATE  0.12 % MM MWSH,50863,CDM,636,RC,J3490,HCPCS,69339-138-15,NDC,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2599,HCPCS,43598-914-25,NDC,facility,both,13,ML,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCUSATE SODIUM 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-129-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETHYL CHLORIDE 100 % TOP SPRA,50863,CDM,250,RC,J3490,HCPCS,386000103,NDC,facility,both,1,ML,,180,126,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,636,RC,J3490,HCPCS,63323-486-02,NDC,facility,both,300,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-288-07,NDC,facility,both,1,ML,,134,93.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,J2704,HCPCS,63323-269-22,NDC,,,facility,both,20,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,J2371,HCPCS,70594-063-01,NDC,,,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 40 MG-200 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,65862-496-47,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 25 MG TAB,50863,CDM,250,RC,J3490,HCPCS,62584-265-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6818-61,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYMETAZOLINE 0.05 % NASL SPRA,50863,CDM,250,RC,J3490,HCPCS,4110081125,NDC,facility,both,1,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  5 GRAM IV SOLR,50863,CDM,250,RC,J3370,HCPCS,0409-6509-01,NDC,facility,both,3,EA,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,63323-162-00,NDC,facility,both,1,ML,JW,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
TOBRAMYCIN 300 MG/5 ML INHL NEBU (REPACK),50863,CDM,250,RC,J3490,HCPCS,70756-604-56,NDC,facility,both,1,ML,,464,324.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-349-11,NDC,facility,both,3,EA,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 0.5 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,49884-311-52,NDC,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7362-61,NDC,facility,both,1,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL 5 MCG/ML INJECTION,50863,CDM,250,RC,J3010,HCPCS,61553-479-78,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 1 GRAM/10 ML (10 %) INJ SOLN",50863,CDM,J1561,HCPCS,13533-800-12,NDC,,,facility,both,60,ML,,13283,9298.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE 0.25 MG/2 ML INHL NBSP,50863,CDM,250,RC,J3490,HCPCS,47335-631-48,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0074-4552-11,NDC,facility,both,4,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEGFILGRASTIM-PBBK 6 MG/0.6 ML SUBQ SYRG,50863,CDM,Q5130,HCPCS,70121-1627-1,NDC,,,facility,both,12,ML,,6900,4830,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA SR 25 MG-100 MG TAB,50863,CDM,250,RC,J3490,HCPCS,68084-281-11,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL,50863,CDM,636,RC,J1071,HCPCS,0409-6562-01,NDC,facility,both,200,ML,,130,91,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE CONCENTRATE 10 MG/ 0.5 ML ORAL SYRINGE (0.5ML UD MERGE),50863,CDM,250,RC,J3490,HCPCS,68094-045-01,NDC,facility,both,2,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE  2 MG/ML INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-285-23,NDC,facility,both,2,ML,,130,91,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,636,RC,J2003,HCPCS,76329-3390-1,NDC,facility,both,2000,ML,,1084,758.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),50863,CDM,636,RC,J0171,HCPCS,76329-3318-1,NDC,facility,both,20,ML,,162,113.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-487-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISATRACURIUM  2 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0781-3152-70,NDC,facility,both,20,ML,,3094,2165.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,0641-6007-01,NDC,facility,both,7,ML,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE  5 MG ORAL CP24,50863,CDM,636,RC,J3490,HCPCS,31722-185-01,NDC,facility,both,3,EA,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,50863,CDM,636,RC,J0696,HCPCS,0781-3208-85,NDC,facility,both,8,EA,JZ,450,315,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
BUSPIRONE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-0053-05,NDC,facility,both,8,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,J2704,HCPCS,0069-0209-01,NDC,,,facility,both,6,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOZAPINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-922-01,NDC,facility,both,3,EA,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 2.5 GRAM/25 ML (10 %) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-15,NDC,facility,both,5,ML,,908,635.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 40 GRAM/400 ML (10 %) INJ SOLN",50863,CDM,250,RC,J1561,HCPCS,13533-800-40,NDC,facility,both,80,ML,JA,11316,7921.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J1610,HCPCS,0597-0053-45,NDC,facility,both,1,EA,,742,519.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J2310,HCPCS,36000-308-01,NDC,facility,both,1,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORTHALIDONE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-058-01,NDC,facility,both,3,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,70860-405-04,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG/ML INJ SOLN,50863,CDM,636,RC,J2550,HCPCS,0641-6084-01,NDC,facility,both,1,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLN (MERGE)",50863,CDM,250,RC,P9047,HCPCS,64208-2512-8,NDC,facility,both,5,ML,,594,415.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,60687-755-40,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-ABDA 100 MG IV SOLR,50863,CDM,636,RC,Q5104,HCPCS,78206-162-99,NDC,facility,both,56,EA,,11645,8151.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  5 MG ORAL TBDL,50863,CDM,636,RC,J3490,HCPCS,55111-262-79,NDC,facility,both,4,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,636,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,4,EA,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"TRIMETHOPRIM-POLYMYXIN B 0.1 %-10,000 UNIT/ML EYE DROPS",50863,CDM,250,RC,J3490,HCPCS,61314-628-10,NDC,facility,both,1,ML,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLMESARTAN 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68462-437-30,NDC,facility,both,1,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLMESARTAN 40 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0527-2427-46,NDC,facility,both,1,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 25 MG CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7237-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,10135-778-01,NDC,facility,both,80,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION,50863,CDM,250,RC,J3490,HCPCS,0186-0370-28,NDC,facility,both,1,GM,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 50 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,10135-779-01,NDC,facility,both,50,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERYTHROMYCIN 5 MG/G OPHT OINT,50863,CDM,250,RC,J3490,HCPCS,0574-4024-11,NDC,facility,both,1,GM,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE (POLACRILEX) 4 MG MM LOZG,50863,CDM,636,RC,J3490,HCPCS,45802-873-03,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,636,RC,J3490,HCPCS,0409-1323-15,NDC,facility,both,200,ML,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69315-117-01,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOMYCIN-BACITRACN ZN-POLYMYXIN 3.5 MG-400 U*,50863,CDM,250,RC,J3490,HCPCS,45802-143-00,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN 0.9 % SODIUM CHL 2 GRAM/500 ML IV SOLN,50863,CDM,250,RC,J3373,HCPCS,70092-9338-07,NDC,facility,both,200,ML,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TAB,50863,CDM,250,RC,J3490,HCPCS,60687-672-11,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GAMMAGARD LIQUID 10 % IV SOLN,50863,CDM,636,RC,J1569,HCPCS,0944-2700-05,NDC,facility,both,20,ML,"JZ,JA",3606,2524.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
WHITE PETROLATUM-MINERAL OIL 57.3-42.5 % OPHT OINT,50863,CDM,250,RC,J3490,HCPCS,0023-0240-04,NDC,facility,both,1,GM,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0137,HCPCS,0264-4100-90,NDC,facility,both,41,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16729-137-00,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SITAGLIPTIN 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0006-0277-01,NDC,facility,both,1,EA,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALGANCICLOVIR 50 MG/ML ORAL SOLR,50863,CDM,250,RC,J3490,HCPCS,0591-2579-20,NDC,facility,both,1,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-645-11,NDC,facility,both,2,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,65862-707-80,NDC,facility,both,8,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,J3360,HCPCS,0409-1273-03,NDC,,,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) NEB SOLUTION,50863,CDM,250,RC,J3490,HCPCS,0487-9501-00,NDC,facility,both,20,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR NEO/PEDS INFUSION (CDS FROM PREMIX),50863,CDM,250,RC,J0133,HCPCS,63323-325-10,NDC,facility,both,17,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,62584-984-11,NDC,facility,both,3,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,67457-423-00,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMINOCAPROIC ACID 25 % ORAL SYRP,50863,CDM,250,RC,J3490,HCPCS,52817-815-08,NDC,facility,both,1,ML,,795,556.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-467-01,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE 20 MG TAB,50863,CDM,250,RC,J3490,HCPCS,13107-155-30,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-822-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM BICARB-CITRIC ACID 20 MEQ ORAL TBEF,50863,CDM,636,RC,J3490,HCPCS,51801-011-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,70954-059-10,NDC,facility,both,60,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-25,NDC,facility,both,4000,ML,,213,149.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-571-10,NDC,facility,both,1,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 10 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-6290-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE 20 MG TAB,50863,CDM,J3490,HCPCS,0904-5677-61,NDC,,,facility,both,2,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,636,RC,J7510,HCPCS,17856-0815-1,NDC,facility,both,8,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,37,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,50863,CDM,J3490,HCPCS,57237-077-10,NDC,,,facility,both,1,EA,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NYSTATIN 100000 UNIT/ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,63739-160-70,NDC,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-492-27,NDC,,,facility,both,200,ML,,157,109.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,J3490,HCPCS,0093-2279-73,NDC,,,facility,both,7,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25 MG-100 MG TAB,50863,CDM,250,RC,J3490,HCPCS,60687-661-11,NDC,facility,both,3,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 0.4 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,59762-3304-3,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 20 MG/ML INJ SOLN,50863,CDM,636,RC,J0360,HCPCS,0641-6231-01,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-345-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,250,RC,J0132,HCPCS,25021-812-30,NDC,facility,both,143,ML,,1024,716.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 0.5 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J2004,HCPCS,63323-481-01,NDC,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2310,HCPCS,36000-310-01,NDC,facility,both,1,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,J1596,HCPCS,10019-016-39,NDC,,,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7912-59,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EXEMESTANE 25 MG ORAL TAB,50863,CDM,250,RC,J9999,HCPCS,69097-316-02,NDC,facility,both,1,EA,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 20 MG ORAL TAB,50863,CDM,636,RC,J8499,HCPCS,60687-380-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0904-7127-61,NDC,facility,both,180,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM BICARB-CITRIC ACID 20 MEQ ORAL TBEF,50863,CDM,250,RC,J3490,HCPCS,51801-012-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,4,ML,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL,50863,CDM,250,RC,J3490,HCPCS,63323-820-01,NDC,facility,both,2,ML,,176,123.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 400 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-602-11,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DALBAVANCIN 500 MG IV SOLN,50863,CDM,J0875,HCPCS,57970-100-01,NDC,,,facility,both,100,EA,,4911,3437.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,J3490,HCPCS,68094-147-01,NDC,,,facility,both,129,ML,,12648,8853.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUM U-500 CONC 500 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1815,HCPCS,0002-8501-01,NDC,facility,both,1,ML,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,5,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4% TOP PATCH,50863,CDM,J3490,HCPCS,0536-1202-15,NDC,,,facility,both,2,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE HCL IN D5W 4 MG/250 ML (16 MCG/ML) IV SOLN,50863,CDM,636,RC,J0169,HCPCS,72196-7018-1,NDC,facility,both,40,ML,,211,147.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM PEDS IVPB (FROM PREMIX),50863,CDM,250,RC,J1953,HCPCS,43598-635-52,NDC,facility,both,50,ML,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE  25 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-6638-61,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BIVALIRUDIN 250 MG/50 ML (5 MG/ML) IV SOLN,50863,CDM,636,RC,J0583,HCPCS,42023-622-01,NDC,facility,both,250,ML,,242,169.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,250,RC,J3490,HCPCS,0093-3174-31,NDC,facility,both,1,GM,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  25 MG ORAL TAB,50863,CDM,J3490,HCPCS,68084-346-11,NDC,,,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  75 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6951-61,NDC,facility,both,3,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),50863,CDM,636,RC,J1815,HCPCS,0024-5926-05,NDC,facility,both,5,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPTOMYCIN IN 0.9 % SOD CHLOR 500 MG/50 ML IV PGBK,50863,CDM,250,RC,J3490,HCPCS,0338-0714-24,NDC,facility,both,500,ML,,159,111.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENOFIBRATE NANOCRYSTALLIZED 145 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-629-11,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42291-560-90,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYBUTYNIN CHLORIDE  5 MG ORAL TO24,50863,CDM,636,RC,J3490,HCPCS,0904-6570-61,NDC,facility,both,4,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE  25 MG ORAL TAB,50863,CDM,J3490,HCPCS,51079-103-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE-VITAMIN D3 250 MG-125 UNIT TAB,50863,CDM,636,RC,J3490,HCPCS,2055502500,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 250 MG ORAL TBEC,50863,CDM,J3490,HCPCS,68084-776-11,NDC,,,facility,both,2,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  5 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,59746-172-06,NDC,facility,both,10,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOCARNITINE 200 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0143-9852-01,NDC,facility,both,1,ML,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYBUTYNIN CHLORIDE  5 MG ORAL TO24,50863,CDM,250,RC,J3490,HCPCS,0904-6570-61,NDC,facility,both,6,EA,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J2004,HCPCS,0409-3178-01,NDC,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0832-1216-89,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES-DOCUSATE SODIUM 8.6 MG-50 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0536-1247-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTAMIDINE 300 MG INJ SOLR,50863,CDM,636,RC,J3490,HCPCS,63323-113-01,NDC,facility,both,1,EA,,222,155.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG IV SOLR,50863,CDM,636,RC,J0456,HCPCS,70095-025-01,NDC,facility,both,1,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE IN D5W 1 GRAM/100 ML IV PGBK,50863,CDM,250,RC,J3475,HCPCS,63323-108-00,NDC,facility,both,2,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 500 MG ORAL CAP,50863,CDM,J3490,HCPCS,16714-299-03,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALSARTAN 160 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0078-0359-34,NDC,facility,both,1,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,J0665,HCPCS,0409-1160-01,NDC,,,facility,both,150,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,J3490,HCPCS,68180-150-01,NDC,,,facility,both,2,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSAPREPITANT 150 MG IV SOLR,50863,CDM,J1453,HCPCS,71839-104-01,NDC,,,facility,both,150,EA,,1065,745.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,636,RC,J3360,HCPCS,76045-204-00,NDC,facility,both,2,ML,,145,101.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,J1940,HCPCS,72603-251-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-657-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-50,NDC,facility,both,8,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IVPB (PEDIATRICS/ADULT NON-FORM)",50863,CDM,636,RC,J0137,HCPCS,24201-100-01,NDC,facility,both,100,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,250,RC,Q0162,HCPCS,16714-671-02,NDC,facility,both,2,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 125 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0074-7068-11,NDC,facility,both,2,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-491-01,NDC,,,facility,both,15,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,50863,CDM,J1756,HCPCS,0517-2340-10,NDC,,,facility,both,300,ML,,963,674.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXRAZOXANE 250 MG IV SOLR,50863,CDM,250,RC,J1190,HCPCS,55150-432-01,NDC,facility,both,1,EA,,899,629.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-492-41,NDC,facility,both,50,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,J3490,HCPCS,63323-739-41,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BLEOMYCIN 30 UNIT INJ SOLR,50863,CDM,250,RC,J9040,HCPCS,71288-107-20,NDC,facility,both,2,EA,,286,200.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-1638-32,NDC,facility,both,2,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-495-27,NDC,facility,both,16,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,2,EA,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN (PF) NEO IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J1580,HCPCS,63323-513-02,NDC,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,0409-4276-16,NDC,,,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0781-3220-70,NDC,facility,both,1,ML,,185,129.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,63323-485-27,NDC,,,facility,both,40,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 50 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6323-61,NDC,facility,both,4,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE (DIAGNOSTIC) 3 MG/ML IV SOLN,50863,CDM,636,RC,J0153,HCPCS,16714-997-01,NDC,facility,both,90,ML,,735,514.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOXYMETHYLCELLULOSE SODIUM 1 % OPHT DPGE,50863,CDM,250,RC,J3490,HCPCS,0023-4554-30,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 20 MG/ML (1 ML) IV SOLN,50863,CDM,636,RC,J9171,HCPCS,16729-267-65,NDC,facility,both,250,ML,,10499,7349.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-113-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  75 MG ORAL CP24,50863,CDM,636,RC,J3490,HCPCS,50268-874-11,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 1 GRAM INJ SOLR,50863,CDM,250,RC,J0692,HCPCS,0409-0219-11,NDC,facility,both,2,EA,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 30 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,68180-295-09,NDC,facility,both,1,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 1000 MG MISC TBSO,50863,CDM,250,RC,J3490,HCPCS,77333-844-25,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERYTHROMYCIN 5 MG/G OPHT OINT,50863,CDM,250,RC,J3490,HCPCS,0574-4024-50,NDC,facility,both,1,GM,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 500 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,16714-299-02,NDC,facility,both,18,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0536-1327-06,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN  750 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,70010-492-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACCHAROMYCES BOULARDII 250 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,7733380050,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,636,RC,J3490,HCPCS,68180-963-01,NDC,facility,both,1,GM,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ELTROMBOPAG 25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,31722-842-30,NDC,facility,both,2,EA,,1296,907.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,0409-4264-11,NDC,facility,both,10,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEO TPN SODIUM ACETATE 2 MEQ/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-7299-83,NDC,facility,both,2,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,50,EA,JZ,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,636,RC,J7999,HCPCS,70092-1017-46,NDC,facility,both,2,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,26,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRIVIGEN 10 % IV SOLN,50863,CDM,636,RC,J1459,HCPCS,44206-439-93,NDC,facility,both,160,ML,,28704,20092.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VORICONAZOLE 200 MG IV SOLN,50863,CDM,250,RC,J3465,HCPCS,0781-3416-94,NDC,facility,both,33,EA,,883,618.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ACTUATION NASL SPRA,50863,CDM,250,RC,J3490,HCPCS,49884-161-11,NDC,facility,both,1,ML,,427,298.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN,50863,CDM,250,RC,J2916,HCPCS,0143-9570-01,NDC,facility,both,5,ML,,187,130.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-097-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,50863,CDM,636,RC,J0696,HCPCS,44567-701-25,NDC,facility,both,4,EA,JZ,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,10135-778-01,NDC,facility,both,40,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM 1 GRAM IV SOLR,50863,CDM,250,RC,J2185,HCPCS,55150-208-30,NDC,facility,both,10,EA,JZ,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,636,RC,J1610,HCPCS,0597-0053-45,NDC,facility,both,1,EA,,742,519.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN SODIUM EXTENDED 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0071-0369-40,NDC,facility,both,2,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NAPROXEN 250 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-594-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOLVAPTAN 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,49884-768-52,NDC,facility,both,1,EA,,1293,905.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-9558-05,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7350-06,NDC,facility,both,4,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,63323-010-02,NDC,facility,both,5,ML,,140,98,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE 150 MG ORAL CP24,50863,CDM,636,RC,J3490,HCPCS,68084-713-11,NDC,facility,both,2,EA,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE 21 MG/24 HR TD PT24,50863,CDM,250,RC,J3490,HCPCS,43598-448-71,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,75,ML,,107,74.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 50 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,59651-489-01,NDC,facility,both,25,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAVASTATIN 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-458-01,NDC,facility,both,2,EA,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAZOSIN 2 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,51079-631-01,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID (PORK)  90 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,24338-008-90,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 1 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,59746-020-22,NDC,facility,both,3,EA,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5% W/EPINEPHRINE 1:200K INJECTION,50863,CDM,250,RC,J3490,HCPCS,0409-1749-29,NDC,facility,both,2,ML,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIROFIBAN-0.9% SODIUM CHLORIDE 5 MG/100 ML (50 MCG/ML) IV SOLN,50863,CDM,250,RC,J3246,HCPCS,25208-002-03,NDC,facility,both,2,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE DINITRATE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0781-1695-01,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-5755-23,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,67457-423-00,NDC,facility,both,4,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROPROCAINE 3 % INJ SOLN,50863,CDM,250,RC,J2401,HCPCS,0143-9210-01,NDC,facility,both,510,ML,JW,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LACOSAMIDE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-676-11,NDC,facility,both,4,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-6666-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,70,ML,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 125 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6955-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOPIDOGREL 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-184-11,NDC,facility,both,1,EA,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,636,RC,J2270,HCPCS,0409-1890-13,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 4 MG/ACTUATION NASL SPRY,50863,CDM,636,RC,J3490,HCPCS,69547-353-02,NDC,facility,both,1,EA,,270,189,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7244-68,NDC,facility,both,2,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  0.25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-577-11,NDC,facility,both,3,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-466-17,NDC,facility,both,200,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ABATACEPT 250 MG IV SOLR,50863,CDM,636,RC,J0129,HCPCS,0003-2187-13,NDC,facility,both,100,EA,"JZ,JA",16146,11302.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-1749-70,NDC,facility,both,3,ML,,136,95.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM ZIRCONIUM CYCLOSILICATE  5 G ORAL PWPK (USE PANEL),50863,CDM,636,RC,J3490,HCPCS,0310-1105-01,NDC,facility,both,1,EA,,161,112.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN D5W 20000 UNIT/500 ML,50863,CDM,250,RC,J1644,HCPCS,0264-9567-10,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  5 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,55111-262-79,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  5 MG ORAL TBDL,50863,CDM,636,RC,J3490,HCPCS,55111-262-79,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETHAMBUTOL 400 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-280-11,NDC,facility,both,3,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROMETHORPHAN POLY COMPLEX ER 30 MG/5 ML ORAL SU12,50863,CDM,250,RC,J3490,HCPCS,63824-171-63,NDC,facility,both,2,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE MALEATE 10 MG ORAL TAB,50863,CDM,250,RC,Q0164,HCPCS,59746-115-06,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 0.4 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,43598-436-35,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SITAGLIPTIN  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0006-0221-01,NDC,facility,both,2,EA,,130,91,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,636,RC,J1100,HCPCS,63323-506-41,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 5 % TOP OINT,50863,CDM,J3490,HCPCS,68462-418-20,NDC,,,facility,both,1,GM,,935,654.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NAPROXEN 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-491-11,NDC,facility,both,6,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,76045-009-96,NDC,facility,both,4,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0172-3758-70,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE SODIUM 2.5 MG ORAL TAB,50863,CDM,250,RC,J8610,HCPCS,51079-670-01,NDC,facility,both,5,EA,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0955-1008-01,NDC,facility,both,16,ML,,201,140.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CANDESARTAN 16 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,33342-116-07,NDC,facility,both,2,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 650 MG ORAL TAB,50863,CDM,J3490,HCPCS,77333-827-25,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN   81 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,0904-6783-70,NDC,facility,both,4,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1815,HCPCS,0002-8215-01,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 1 MG/0.5 ML INJ SYRG,50863,CDM,J3430,HCPCS,76329-1240-1,NDC,,,facility,both,1,ML,,146,102.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,80,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM CITRATE ORAL SOLN,50863,CDM,J3490,HCPCS,71399-0051-1,NDC,,,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAVASTATIN 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-5891-61,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,636,RC,J3490,HCPCS,60687-390-11,NDC,facility,both,3,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE NA (PRESERV FREE) 25 MG/ML INJ SOLN,50863,CDM,250,RC,J9260,HCPCS,61703-408-41,NDC,facility,both,200,ML,,2156,1509.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BECLOMETHASONE DIPROPIONATE 40 MCG/ACTUATION INHL HFAB,50863,CDM,636,RC,J3490,HCPCS,59310-302-40,NDC,facility,both,1,GM,,757,529.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,16714-293-01,NDC,facility,both,10,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LANSOPRAZOLE 15 MG ORAL TBLD,50863,CDM,636,RC,J3490,HCPCS,64764-543-30,NDC,facility,both,1,EA,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE (PF) 25 MG/ML INJ SOLN (FOR ECTOPIC PREGNANCY),50863,CDM,636,RC,J9260,HCPCS,0143-9519-01,NDC,facility,both,2,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50580-600-02,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,14,ML,,24277,16993.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,250,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,J0665,HCPCS,55150-169-10,NDC,,,facility,both,80,ML,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2599,HCPCS,43598-914-25,NDC,facility,both,11,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLBETUXIMAB-CLZB 300 MG IV SOLR (WET SOLR VIAL),50863,CDM,C9303,HCPCS,0469-4425-30,NDC,,,facility,both,740,EA,,32679,22875.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  1 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,64380-782-06,NDC,facility,both,5,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,43066-007-10,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2305-04,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MANNITOL 20% IV SOLP,50863,CDM,250,RC,J2150,HCPCS,0990-7715-13,NDC,facility,both,1,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INEBILIZUMAB-CDON 10 MG/ML IV SOLN,50863,CDM,J1823,HCPCS,75987-150-01,NDC,,,facility,both,300,ML,,694691,486283.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  5 GRAM IV SOLR,50863,CDM,250,RC,J3370,HCPCS,0143-9163-01,NDC,facility,both,2,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOCARNITINE 200 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,54482-147-01,NDC,facility,both,1,ML,,229,160.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,250,RC,J2270,HCPCS,0641-6125-25,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN PUMP LISPRO (PATIENT OWN PUMP PHS SUPPLIED),50863,CDM,250,RC,J1815,HCPCS,0002-7510-01,NDC,facility,both,2,ML,,338,236.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % MUCOSAL SOLN (VISCOUS),50863,CDM,250,RC,J3490,HCPCS,0121-4950-15,NDC,facility,both,1,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE 25 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,68180-657-01,NDC,facility,both,1,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,5,ML,,8150,5705,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE  5 MG/ML INJ SOLN,50863,CDM,J2765,HCPCS,0409-3414-11,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"RABIES VACCINE,HUMAN DIPLOID (PF) 2.5 UNIT IM",50863,CDM,90675,HCPCS,49281-252-51,NDC,,,facility,both,1,EA,,1198,838.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0143-9509-01,NDC,facility,both,1,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THROMBIN (RECOMBINANT) 5000 UNIT TOP SOLR,50863,CDM,250,RC,J3490,HCPCS,0338-0324-01,NDC,facility,both,6,EA,,2230,1561,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6519-61,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESALAMINE 1000 MG RECT SUPP,50863,CDM,250,RC,J3490,HCPCS,0472-1915-01,NDC,facility,both,1,EA,,216,151.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,0143-9577-01,NDC,,,facility,both,500,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,250,RC,J0690,HCPCS,63323-237-10,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0093-2279-73,NDC,facility,both,10,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,J3490,HCPCS,0904-6322-61,NDC,,,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,113,79.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EZETIMIBE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-373-11,NDC,facility,both,1,EA,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,4,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE  10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69367-388-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN  325 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,0536-1232-01,NDC,facility,both,1,EA,PLAD,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0143-9889-01,NDC,facility,both,10,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IVERMECTIN 3 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,42799-806-01,NDC,facility,both,5,EA,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 7.5 MG-325 MG/15 ML ORAL SOLN (REPACK),50863,CDM,250,RC,J3490,HCPCS,0121-2316-15,NDC,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 1 % OPHT DROP,50863,CDM,250,RC,J3490,HCPCS,17478-215-05,NDC,facility,both,1,ML,,248,173.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ANTI-INHIBITOR COAGULANT CMPLX 1,750-3,250 UNIT IV SOLR",50863,CDM,250,RC,J7198,HCPCS,64193-425-02,NDC,facility,both,521,UN,,3104,2172.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,50863,CDM,636,RC,J0696,HCPCS,25021-106-10,NDC,facility,both,4,EA,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6322-06,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE  7.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,13107-001-30,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 2 GRAM INJ SOLR,50863,CDM,250,RC,J0692,HCPCS,44567-241-10,NDC,facility,both,68,EA,,978,684.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LATANOPROST 0.005 % OPHT DROP,50863,CDM,636,RC,J3490,HCPCS,61314-547-01,NDC,facility,both,1,ML,,403,282.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPHENIDATE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0115-1800-01,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL  97.2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16571-668-01,NDC,facility,both,4,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOBAZAM 2.5 MG/ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,99999-0404-03,NDC,facility,both,3,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ANTI-INHIBITOR COAGULANT CMPLX 1,750-3,250 UNIT IV SOLR",50863,CDM,250,RC,J7198,HCPCS,64193-425-02,NDC,facility,both,2675,UN,JW,6929,4850.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,250,RC,J3490,HCPCS,23155-166-31,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN LOCK FLUSH 100 UNIT/ML IV SOLN,50863,CDM,250,RC,J1644,HCPCS,6425333335,NDC,facility,both,50,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-406-03,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 16 MG ORAL TAB,50863,CDM,250,RC,J7509,HCPCS,59762-0050-1,NDC,facility,both,13,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTASE 3000 UNIT ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,45008002,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 50 % (4 MEQ/ML) INJ SOLN,50863,CDM,636,RC,J3475,HCPCS,63323-064-02,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THROMBIN (RECOMBINANT) 5000 UNIT TOP SOLR,50863,CDM,636,RC,J3490,HCPCS,0338-0324-01,NDC,facility,both,2,EA,,744,520.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,10702-018-01,NDC,facility,both,2,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-492-09,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOLAZONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50742-351-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,0641-6008-10,NDC,facility,both,4,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,23155-001-01,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLN,50863,CDM,636,RC,J3262,HCPCS,50242-135-01,NDC,facility,both,720,ML,,13195,9236.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68094-005-59,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,72162-1330-6,NDC,facility,both,3,ML,,1102,771.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 150 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7212-61,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROMETHORPHAN POLY COMPLEX ER 30 MG/5 ML ORAL SU12,50863,CDM,250,RC,J3490,HCPCS,63824-171-63,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 150 MG/1 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,0548-5607-00,NDC,facility,both,12,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 0.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-544-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,250,RC,J2270,HCPCS,63323-454-00,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INDOCYANINE GREEN 25 MG INJ,50863,CDM,636,RC,J3490,HCPCS,70100-725-01,NDC,facility,both,1,EA,,198,138.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J3430,HCPCS,69097-708-96,NDC,facility,both,5,ML,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),50863,CDM,250,RC,J0171,HCPCS,76329-3318-1,NDC,facility,both,70,ML,,565,395.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,17856-0574-1,NDC,facility,both,2,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0121-0431-30,NDC,facility,both,2,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7130-61,NDC,facility,both,4,EA,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J3430,HCPCS,0409-9158-50,NDC,facility,both,10,ML,,250,175,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6370-61,NDC,facility,both,2,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TORSEMIDE   5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,31722-529-01,NDC,facility,both,8,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRIL MALEATE  2.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16714-442-01,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACCHAROMYCES BOULARDII 250 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,7733380050,NDC,facility,both,6,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT 100 MCG/0.5 ML INJ SYRG,50863,CDM,250,RC,J0881,HCPCS,55513-025-01,NDC,facility,both,100,ML,JZ,2137,1495.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
WARFARIN  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,57237-120-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG IV SOLR,50863,CDM,636,RC,J3490,HCPCS,0008-0923-51,NDC,facility,both,2,EA,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE MALEATE 10 MG ORAL TAB,50863,CDM,250,RC,Q0164,HCPCS,59746-115-06,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROATE SODIUM 100 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,70860-784-41,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE IN SALINE (ISO-OSM) 400 MG/200 ML IV PIGGY BACK,50863,CDM,250,RC,J3490,HCPCS,25021-184-87,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,16714-294-01,NDC,facility,both,12,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV (BOLUS),50863,CDM,636,RC,J7120,HCPCS,0264-7750-10,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-4713-32,NDC,facility,both,300,ML,,129,90.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6426-61,NDC,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 500 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,0832-7124-89,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM ACETATE 667 MG ORAL CAP,50863,CDM,250,RC,J0615,HCPCS,69097-862-83,NDC,facility,both,29,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN D5W 1 GRAM/200 ML IV PGBK,50863,CDM,250,RC,J3370,HCPCS,0338-3552-48,NDC,facility,both,2,ML,JZ,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50580-600-02,NDC,facility,both,3,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25 MG-100 MG TAB,50863,CDM,250,RC,J3490,HCPCS,50228-458-01,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE (PF-DURAMORPH/ASTRAMORPH) 0.5 MG/ML INJ SOLN,50863,CDM,636,RC,J2274,HCPCS,0641-6020-01,NDC,facility,both,1,ML,,340,238,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-1283-17,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRP (MERGE/REPACK),50863,CDM,636,RC,J3490,HCPCS,68094-764-59,NDC,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 20 MG/ML INJ SOLN,50863,CDM,250,RC,J0360,HCPCS,0641-6231-01,NDC,facility,both,1,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELIMUMAB 120 MG IV SOLR,50863,CDM,250,RC,J0490,HCPCS,49401-101-01,NDC,facility,both,24,ME,JA,2819,1973.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0703-1153-01,NDC,facility,both,1,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,4,EA,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GRANISETRON 1 MG/ML (1 ML) IV SOLN,50863,CDM,250,RC,J1626,HCPCS,0143-9744-01,NDC,facility,both,4,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,71399-1025-3,NDC,facility,both,3,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,68462-157-40,NDC,facility,both,2,EA,,227,158.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM  3 GRAM INJ SOLR,50863,CDM,250,RC,J0295,HCPCS,0049-0014-81,NDC,facility,both,2,EA,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 250 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,50268-259-11,NDC,facility,both,3,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 1%/EPINEPHRINE 1:200K INJECTION (PF),50863,CDM,636,RC,J3490,HCPCS,63739-468-05,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,72603-180-01,NDC,facility,both,1,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J1610,HCPCS,0597-0053-45,NDC,facility,both,5,EA,JZ,3707,2594.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J1610,HCPCS,63323-583-13,NDC,facility,both,1,EA,,991,693.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLPIDEM  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-838-11,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 400 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0143-9887-01,NDC,facility,both,14,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,23155-001-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROMETHORPHAN POLY COMPLEX ER 30 MG/5 ML ORAL SU12,50863,CDM,250,RC,J3490,HCPCS,63824-171-63,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
0.45 % NACL-POTASSIUM CHLORIDE 20 MEQ/L IV SOLP (PEDS ONC),50863,CDM,250,RC,J3490,HCPCS,0338-0704-34,NDC,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  30 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,0406-8330-62,NDC,facility,both,1,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 300 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,69452-125-50,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,0409-1886-22,NDC,facility,both,5,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PANTOPRAZOLE 40 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,55150-202-00,NDC,facility,both,2,EA,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,0781-3232-94,NDC,facility,both,1,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2599,HCPCS,65219-039-00,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2599,HCPCS,43598-914-25,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,636,RC,J2405,HCPCS,0409-4755-18,NDC,facility,both,8,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOMYCIN-BACITRACN ZN-POLYMYXIN 3.5 MG-400 U*,50863,CDM,250,RC,J3490,HCPCS,45802-143-00,NDC,facility,both,5,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,0409-4264-11,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  5 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-122-11,NDC,facility,both,100,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 0.1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-721-11,NDC,facility,both,3,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-41,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,70954-316-10,NDC,facility,both,3,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",50863,CDM,250,RC,J1561,HCPCS,13533-800-25,NDC,facility,both,40,ML,JZ,5658,3960.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CLONIDINE 0.2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-124-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4 % TOPICAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-4698-01,NDC,facility,both,2,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),50863,CDM,250,RC,J3490,HCPCS,63323-186-01,NDC,facility,both,1,ML,PLAD,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
PHENYLEPHRINE IN 0.9% NS (PF) 1 MG/10 ML (100 MCG/ML) IV SYRG(PDS MERGE),50863,CDM,250,RC,J3490,HCPCS,70092-1046-46,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,68180-150-01,NDC,facility,both,2,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPSONE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,70954-135-10,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCAINAMIDE 100 MG/ML INJECTION (MERGE),50863,CDM,636,RC,J2690,HCPCS,14789-901-07,NDC,facility,both,1,ML,,1656,1159.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MYCOPHENOLATE 180 MG TAB, DELAYED RELEASE",50863,CDM,636,RC,J7518,HCPCS,0904-6785-61,NDC,facility,both,1,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,636,RC,J1953,HCPCS,0409-1886-22,NDC,facility,both,450,ML,JZ,233,163.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0832-6045-50,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MANNITOL 20% IV SOLP,50863,CDM,250,RC,J2150,HCPCS,0990-7715-13,NDC,facility,both,1,ML,JZ,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
TERAZOSIN  5 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,59746-385-06,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE 3 MG ORAL CP24,50863,CDM,636,RC,J3490,HCPCS,0574-9855-10,NDC,facility,both,3,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUANFACINE 1 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,62332-745-31,NDC,facility,both,2,EA,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 10 MG-100 MG TAB,50863,CDM,636,RC,J3490,HCPCS,42291-471-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-544-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR PHOSPHATE 30 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,62332-413-10,NDC,facility,both,1,EA,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,0088-2220-33,NDC,facility,both,7,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0904-6923-61,NDC,facility,both,50,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE IN D5W 1 GRAM/100 ML IV PGBK,50863,CDM,636,RC,J3475,HCPCS,0264-4400-54,NDC,facility,both,2,ML,JZ,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LEVOTHYROXINE 100 MCG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,25021-468-10,NDC,facility,both,1,EA,,205,143.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  2.5 MG ORAL TAB,50863,CDM,636,RC,J7510,HCPCS,59651-485-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,250,RC,J0690,HCPCS,70092-1017-46,NDC,facility,both,8,ML,,159,111.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUBIPROSTONE  8 MCG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0254-3028-02,NDC,facility,both,2,EA,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,929,ME,JZ,12607,8824.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,0955-1008-01,NDC,facility,both,16,ML,,201,140.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-02,NDC,facility,both,5,ML,,262,183.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,30,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-444-01,NDC,facility,both,2,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0143-9509-01,NDC,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,50863,CDM,250,RC,J0696,HCPCS,60505-6148-0,NDC,facility,both,1,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL  32.4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,13517-626-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEMIPLIMAB-RWLC 50 MG/ML IV SOLN,50863,CDM,J9119,HCPCS,61755-008-01,NDC,,,facility,both,350,ML,,25491,17843.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2001,HCPCS,63323-492-09,NDC,,,facility,both,10,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,50863,CDM,J1650,HCPCS,0075-0622-01,NDC,,,facility,both,16,ML,,234,163.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68180-981-01,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  100 MCG/ML INJ SOLN,50863,CDM,636,RC,J2354,HCPCS,63323-376-00,NDC,facility,both,2,ML,"JW,JA",6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
MEMANTINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-173-11,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7363-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-3178-16,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPRAZOLAM 0.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-388-11,NDC,facility,both,4,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NYSTATIN  100000 UNIT/G TOP POWD,50863,CDM,250,RC,J3490,HCPCS,0574-2008-15,NDC,facility,both,1,GM,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MULTIVITAMIN WITH FOLIC ACID 400 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,904053961,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLP",50863,CDM,636,RC,P9047,HCPCS,0944-0493-04,NDC,facility,both,2,ML,JZ,501,350.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DOXORUBICIN 50 MG/25 ML IV SOLN,50863,CDM,250,RC,J9000,HCPCS,25021-207-25,NDC,facility,both,5,ML,,143,100.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,250,RC,J3490,HCPCS,60687-653-11,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-090-11,NDC,facility,both,1,EA,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0904-6923-61,NDC,facility,both,10,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,636,RC,J0690,HCPCS,0143-9924-90,NDC,facility,both,4,EA,JZ,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MISOPROSTOL 800 MCG (4 X 200 MCG TAB) PACKAGE,50863,CDM,250,RC,S0191,HCPCS,43386-161-06,NDC,facility,both,4,EA,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYBUTYNIN CHLORIDE  5 MG ORAL TO24,50863,CDM,250,RC,J3490,HCPCS,62175-270-37,NDC,facility,both,3,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0074-4341-90,NDC,facility,both,2,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTAZIDIME-AVIBACTAM 2.5 GRAM (2 GRAM-0.5 GRAM) IV SOLR,50863,CDM,250,RC,J0714,HCPCS,0456-2700-10,NDC,facility,both,1,EA,JW,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-229-02,NDC,facility,both,2,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50580-458-11,NDC,facility,both,3,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 10 MEQ/100 ML IV PGBK,50863,CDM,636,RC,J3480,HCPCS,14789-109-16,NDC,facility,both,5,ML,JZ,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,7,ML,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 0.5 % OPHT DROP,50863,CDM,636,RC,J3490,HCPCS,61314-126-05,NDC,facility,both,1,ML,,380,266,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ANTI-INHIBITOR COAGULANT CMPLX 1,750-3,250 UNIT IV SOLR",50863,CDM,J7198,HCPCS,64193-425-02,NDC,,,facility,both,4310,UN,,25675,17972.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ORPHENADRINE CITRATE 30 MG/ML INJ SOLN,50863,CDM,J2360,HCPCS,0641-6182-10,NDC,,,facility,both,1,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,0143-9381-01,NDC,facility,both,2,EA,,248,173.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN PEDS SYRINGE (20MG/ML) IN DEXTROSE (CDS MIX,50863,CDM,636,RC,J0690,HCPCS,0781-3451-70,NDC,facility,both,1,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALUM-MAG HYDROXIDE-SIMETH 200 MG-200 MG-20 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,70677-1063-1,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN  500 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,60687-640-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,636,RC,J3490,HCPCS,73013-2002-2,NDC,facility,both,4,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,23155-687-31,NDC,facility,both,4,ML,JB,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JB: Administered subcutaneously
POTASSIUM CHLORIDE  20 MEQ ORAL PACK,50863,CDM,J3490,HCPCS,72888-024-06,NDC,,,facility,both,2,EA,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORTHALIDONE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-167-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,65145-146-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IV PGBK,50863,CDM,J3475,HCPCS,0338-1708-40,NDC,,,facility,both,4,ML,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7243-61,NDC,facility,both,6,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-492-27,NDC,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7914-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCOSANOL 10 % TOP CREAM,50863,CDM,250,RC,J3490,HCPCS,0135-0300-01,NDC,facility,both,1,GM,,152,106.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 800 MG ORAL TAB,50863,CDM,250,RC,J0601,HCPCS,50268-720-11,NDC,facility,both,40,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM SR 120 MG 12 HR CAP,50863,CDM,636,RC,J3490,HCPCS,0378-6120-01,NDC,facility,both,1,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 10 % (100 MG/ML) MISC SOLN,50863,CDM,250,RC,J3490,HCPCS,0517-7504-01,NDC,facility,both,1,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAZOLAMIDE 500 MG ORAL CPSR,50863,CDM,250,RC,J3490,HCPCS,60687-578-11,NDC,facility,both,1,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,70069-363-01,NDC,facility,both,1,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR 200 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-5789-61,NDC,facility,both,2,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,0409-4264-11,NDC,facility,both,6,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESNA 100 MG/ML IV SOLN,50863,CDM,250,RC,J9209,HCPCS,10019-953-62,NDC,facility,both,4,ML,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-05,NDC,facility,both,16,EA,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 250 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,42192-608-05,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-9558-05,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOPIDOGREL  75 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6294-61,NDC,facility,both,2,EA,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
URSODIOL 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,59651-421-01,NDC,facility,both,2,EA,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,43066-007-10,NDC,facility,both,2,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7247-68,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 10 % (100 MG/ML) MISC SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-695-04,NDC,facility,both,2,ML,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL  50 MCG/HR TD PT72,50863,CDM,250,RC,J3490,HCPCS,47781-426-11,NDC,facility,both,1,EA,,191,133.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISATRACURIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0781-3153-80,NDC,facility,both,3,ML,,3023,2116.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51672-4027-1,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEFIBROTIDE 80 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,68727-800-01,NDC,facility,both,3,ML,,5579,3905.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG ORAL TB12,50863,CDM,250,RC,J3490,HCPCS,60687-583-11,NDC,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN 50 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,60687-156-95,NDC,facility,both,3,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,160,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE  6.25 MG/5 ML ORAL SYRP,50863,CDM,636,RC,Q0169,HCPCS,70752-138-12,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,50,ML,,113,79.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE IN 0.9% NS (PF) 1 MG/10 ML (100 MCG/ML) IV SYRG(PDS MERGE),50863,CDM,636,RC,J3490,HCPCS,70092-1046-46,NDC,facility,both,1,ML,,240,168,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,68,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IR SOLN,50863,CDM,250,RC,J3490,HCPCS,0338-0048-03,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV,50863,CDM,250,RC,J7120,HCPCS,0338-0117-03,NDC,facility,both,3,ML,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE 0.5 MG/2 ML INHL NBSP,50863,CDM,J3490,HCPCS,0487-9701-01,NDC,,,facility,both,1,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,J3490,HCPCS,63323-739-11,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 10 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,0641-0367-21,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  75 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-495-11,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,116,ML,,167,116.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRP (MERGE/REPACK),50863,CDM,250,RC,J3490,HCPCS,60687-576-40,NDC,facility,both,2,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0093-4155-73,NDC,facility,both,8,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PSEUDOEPHEDRINE 30 MG TAB,50863,CDM,636,RC,J3490,HCPCS,45802-432-62,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYTOCIN 10 UNIT/ML INJ SOLN,50863,CDM,250,RC,J2590,HCPCS,42023-116-25,NDC,facility,both,5,ML,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIP-PERT(A)-TET-POLIO-HIB (PF) 15LF-20MCG-5LF- 62 DU/0.5 ML IM KIT,50863,CDM,90698,HCPCS,49281-511-05,NDC,,,facility,both,1,EA,,516,361.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,J2704,HCPCS,63323-269-22,NDC,,,facility,both,2,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 3 MG/ 3ML ORAL SOLUTION (PEDS),50863,CDM,250,RC,J3490,HCPCS,0054-3555-63,NDC,facility,both,3,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SYRG,50863,CDM,J3490,HCPCS,8290306546,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLN,50863,CDM,J3262,HCPCS,50242-135-01,NDC,,,facility,both,240,ML,,4399,3079.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,40,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,9,ML,,278,194.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,J2795,HCPCS,17478-081-30,NDC,,,facility,both,95,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTAMIDINE 300 MG INJ SOLR,50863,CDM,250,RC,J3490,HCPCS,23155-748-31,NDC,facility,both,1,EA,,133,93.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RANOLAZINE  500 MG ORAL TB12,50863,CDM,250,RC,J3490,HCPCS,60687-549-11,NDC,facility,both,2,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,2,EA,,148,103.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J1940,HCPCS,63323-280-03,NDC,facility,both,5,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUANFACINE 2 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,60505-3928-1,NDC,facility,both,2,EA,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM BROMIDE 0.02 % INHL SOLN,50863,CDM,636,RC,J3490,HCPCS,60687-394-79,NDC,facility,both,3,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CELECOXIB 200 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,50268-169-11,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-285-01,NDC,facility,both,14,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-01,NDC,facility,both,2,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51672-4035-1,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6773-61,NDC,facility,both,3,EA,PLAD,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
METHADONE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0406-5771-23,NDC,facility,both,8,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),50863,CDM,250,RC,J1815,HCPCS,0024-5926-05,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-50,NDC,facility,both,133,ML,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENAZOPYRIDINE 100 MG ORAL TAB,50863,CDM,J3490,HCPCS,75826-114-10,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,23155-687-31,NDC,facility,both,8,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNIT/G TOP PACK,50863,CDM,250,RC,J3490,HCPCS,0904-7402-67,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,8,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLIMEPIRIDE 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-788-95,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZIPRASIDONE 20 MG IM,50863,CDM,250,RC,J3486,HCPCS,72205-205-01,NDC,facility,both,2,EA,,192,134.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML INJ SOLN,50863,CDM,J0171,HCPCS,76329-9061-0,NDC,,,facility,both,300,ML,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  88 MCG ORAL TAB,50863,CDM,J3490,HCPCS,42292-038-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 50 MG 24 HR TAB,50863,CDM,636,RC,J3490,HCPCS,60687-402-11,NDC,facility,both,3,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  25 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,69238-1310-9,NDC,facility,both,4,EA,,165,115.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 0.5 MG ORAL TAB,50863,CDM,250,RC,J8540,HCPCS,72603-212-01,NDC,facility,both,6,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-385-01,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0832-1211-89,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7016-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-41,NDC,facility,both,2,ML,,338,236.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-495-27,NDC,facility,both,120,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM 2000 MG IV SOLR,50863,CDM,636,RC,J2185,HCPCS,44567-402-01,NDC,facility,both,20,EA,JZ,194,135.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
HYDROXYCHLOROQUINE 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-269-11,NDC,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-284-01,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 150 MG CAP,50863,CDM,250,RC,J3490,HCPCS,0904-5959-61,NDC,facility,both,14,EA,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,65862-707-55,NDC,facility,both,17,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) IV SOLN,50863,CDM,636,RC,J9201,HCPCS,0409-0181-01,NDC,facility,both,10,ML,,461,322.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-05,NDC,facility,both,6,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 400 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0143-9887-01,NDC,facility,both,13,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MILRINONE IN D5W 20 MG/100 ML (0.2 MG/ML) INFUSION,50863,CDM,250,RC,J2260,HCPCS,0409-2045-01,NDC,facility,both,4,ML,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-580-11,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,63323-400-01,NDC,facility,both,50,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 100 MG/ML FROM 1 GRAM VIAL (PRMC PEDS ONLY),50863,CDM,636,RC,J0696,HCPCS,0409-7332-11,NDC,facility,both,7,EA,,173,121.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIPASE-PROTEASE-AMYLASE 5,000-17,000- 24,000 UNIT ORAL CPDR",50863,CDM,636,RC,J3490,HCPCS,73562-115-01,NDC,facility,both,5,EA,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,127,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MODAFINIL 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-621-11,NDC,facility,both,1,EA,,129,90.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",50863,CDM,250,RC,J1561,HCPCS,13533-800-24,NDC,facility,both,40,ML,,5658,3960.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 1 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,27808-002-01,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-3178-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,0143-9682-25,NDC,facility,both,4,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-210-11,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68180-981-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESNA 100 MG/ML IV SOLN,50863,CDM,250,RC,J9209,HCPCS,10019-953-62,NDC,facility,both,9,ML,,253,177.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0406-5771-23,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 10 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,16714-720-02,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,76045-009-10,NDC,facility,both,20,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,66794-237-02,NDC,facility,both,1,EA,,148,103.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BEVACIZUMAB-BVZR 25 MG/ML IV SOLN,50863,CDM,250,RC,Q5118,HCPCS,0069-0342-01,NDC,facility,both,80,ML,,13544,9480.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-591-11,NDC,facility,both,2,EA,PLAD,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,68094-193-59,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISONIAZID 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-083-01,NDC,facility,both,3,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HETASTARCH 6 % IN NORMAL SALINE IV,50863,CDM,636,RC,J3490,HCPCS,0409-7248-13,NDC,facility,both,1,ML,,167,116.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,0641-0400-12,NDC,facility,both,10,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,250,RC,J3490,HCPCS,0143-9679-01,NDC,facility,both,1,ML,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TERBUTALINE 1 MG/ML SUBQ SOLN,50863,CDM,250,RC,J3105,HCPCS,0143-9746-01,NDC,facility,both,20,ML,,532,372.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CODEINE-GUAIFENESIN 10-100 MG/5 ML ORAL LIQD (REPACK),50863,CDM,636,RC,J3490,HCPCS,0121-1775-05,NDC,facility,both,2,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-01,NDC,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE SODIUM 25 MG/ML INJ SOLN,50863,CDM,636,RC,J9260,HCPCS,61703-350-37,NDC,facility,both,2,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-02,NDC,facility,both,4,ML,,204,142.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOFLOXACIN IN D5W 750 MG/150 ML IV PGBK,50863,CDM,250,RC,J1956,HCPCS,44567-437-24,NDC,facility,both,3,ML,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 100 MG/ML INJ SOLN,50863,CDM,250,RC,J2800,HCPCS,55150-223-10,NDC,facility,both,1,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J2310,HCPCS,70069-072-01,NDC,facility,both,1,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,636,RC,FAMNOCHARGE,HCPCS,60687-145-11,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLIPIZIDE 10 MG ORAL TO24,50863,CDM,636,RC,J3490,HCPCS,64980-281-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0295,HCPCS,63323-368-20,NDC,facility,both,2,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,66689-201-08,NDC,facility,both,1,ML,,199,139.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC MCARE ADMIN HEPATITIS B VACC,50863,CDM,636,RC,90746,HCPCS,58160-821-01,NDC,facility,both,1,ML,,367,256.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETHAMBUTOL 400 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-280-11,NDC,facility,both,2,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE IN SALINE (ISO-OSM) 400 MG/200 ML IV PIGGY BACK,50863,CDM,636,RC,J1450,HCPCS,25021-184-87,NDC,facility,both,2,ML,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,64208-2510-2,NDC,facility,both,2,ML,JZ,238,166.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
THIAMINE MONONITRATE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,5026885111,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIROFIBAN-0.9% SODIUM CHLORIDE 5 MG/100 ML (50 MCG/ML) IV SOLN,50863,CDM,250,RC,J3246,HCPCS,25208-002-03,NDC,facility,both,8,ML,JW,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-406-03,NDC,facility,both,1,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-25,NDC,facility,both,2000,ML,,107,74.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,70000-0409-1,NDC,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,65,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-582-11,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,0121-0657-05,NDC,facility,both,4,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,0409-1283-03,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 200 MG/20 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0131-1810-67,NDC,facility,both,1,ML,,429,300.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM  3 GRAM INJ SOLR,50863,CDM,636,RC,J0295,HCPCS,44567-211-10,NDC,facility,both,2,EA,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE  2 MG/ML INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-285-10,NDC,facility,both,3,ML,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIPHTH,PERTUS(ACELL),TETANUS SYRG (INFANRIX) 25 LF UNIT-58MCG-10 LF/0.5ML IM SYRINGE",50863,CDM,636,RC,90700,HCPCS,58160-810-43,NDC,facility,both,1,ML,,343,240.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,10702-018-01,NDC,facility,both,4,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 2 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J2004,HCPCS,0409-3183-11,NDC,facility,both,200,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,65162-691-79,NDC,facility,both,1,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-11,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  30 MG ORAL TBSR,50863,CDM,636,RC,J3490,HCPCS,0406-8330-23,NDC,facility,both,2,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYMETAZOLINE 0.05 % NASL SPRA,50863,CDM,636,RC,J3490,HCPCS,4110081123,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTAMIDINE 300 MG INJ SOLR,50863,CDM,636,RC,J3490,HCPCS,63323-113-01,NDC,facility,both,1,EA,,130,91,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIOTHYRONINE 25 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-167-01,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 10 % (100 MG/ML) MISC SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-695-04,NDC,facility,both,2,ML,,150,105,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,13668-010-01,NDC,facility,both,2,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELATACEPT 250 MG IV SOLR,50863,CDM,636,RC,J0485,HCPCS,0003-0371-13,NDC,facility,both,488,EA,,5035,3524.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,0409-9094-25,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,250,RC,J2270,HCPCS,0409-1891-01,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZONISAMIDE 10 MG/ML ORAL SYRUP (REPACK),50863,CDM,250,RC,J3490,HCPCS,64679-990-01,NDC,facility,both,1,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,20,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM ACETATE 667 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7119-06,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,50863,CDM,250,RC,J9206,HCPCS,0009-7529-03,NDC,facility,both,10,ML,,485,339.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRILAT 1.25 MG/ML IV INJ,50863,CDM,250,RC,J3490,HCPCS,0409-2122-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 100 % ORAL POWDER 238 GRAMS,50863,CDM,636,RC,J3490,HCPCS,43386-312-08,NDC,facility,both,1,GM,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL 100 MCG/HR TD PT72,50863,CDM,250,RC,J3490,HCPCS,47781-428-11,NDC,facility,both,1,EA,,334,233.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 100 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6342-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,72603-179-01,NDC,facility,both,8,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
D5-1/4 NS & POTASSIUM CHLORIDE 20 MEQ/L IV SOLP,50863,CDM,250,RC,J3490,HCPCS,0338-0663-04,NDC,facility,both,1,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM NEO IV SYRINGE (PHS FROM PREMIX),50863,CDM,250,RC,J1953,HCPCS,44567-501-01,NDC,facility,both,14,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,67877-246-01,NDC,facility,both,1,EA,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6370-61,NDC,facility,both,5,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,0409-4887-24,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,58657-675-01,NDC,facility,both,2,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-01,NDC,facility,both,1,ML,JZ,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
VENLAFAXINE  37.5 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,68084-698-11,NDC,facility,both,6,EA,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0781-3458-75,NDC,facility,both,2500,ML,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 7.5 MG-325 MG/15 ML ORAL SOLN (REPACK),50863,CDM,250,RC,J3490,HCPCS,0121-2316-15,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-075-01,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IR SOLN,50863,CDM,250,RC,J3490,HCPCS,0338-0047-46,NDC,facility,both,6,ML,,305,213.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LINEZOLID 600 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,67877-419-20,NDC,facility,both,1,EA,,662,463.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,250,RC,J0690,HCPCS,44567-707-25,NDC,facility,both,12,EA,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,63323-325-03,NDC,facility,both,114,ML,,126,88.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN SODIUM EXTENDED 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6187-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,49502-393-80,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,63739-903-10,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
D5-1/2 NS AND POTASSIUM CHLORIDE 30 MEQ/L IV,50863,CDM,250,RC,J3490,HCPCS,0338-0673-04,NDC,facility,both,1,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-38,NDC,facility,both,2,ML,,121,84.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE-DEXTROSE-WATER(PF) 7.5 MG/ML (0.75 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,71351-022-10,NDC,facility,both,2,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMBROLIZUMAB 100 MG/4 ML (25 MG/ML) IV SOLN,50863,CDM,J9271,HCPCS,0006-3026-01,NDC,,,facility,both,400,ML,,48364,33854.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZTROPINE 1 MG/ML INJ SOLN,50863,CDM,J0515,HCPCS,0143-9729-01,NDC,,,facility,both,2,ML,,318,222.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,J7040,HCPCS,0338-0049-48,NDC,,,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 10 MG ORAL TAB,50863,CDM,J3490,HCPCS,60687-179-11,NDC,,,facility,both,1,EA,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 10 MG ORAL TAB,50863,CDM,J3490,HCPCS,60687-179-11,NDC,,,facility,both,1,EA,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LITHIUM CARBONATE 300 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,68084-640-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"VITAMIN E (DL, ACETATE) 22.5 MG (50 UNIT)/ML ORAL DROP",50863,CDM,636,RC,J3490,HCPCS,7132180230,NDC,facility,both,1,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,636,RC,J1596,HCPCS,70700-165-22,NDC,facility,both,8,ML,,203,142.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,47,EA,,6486,4540.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,636,RC,J1596,HCPCS,70069-011-01,NDC,facility,both,6,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORDIAZEPOXIDE 25 MG CAP,50863,CDM,636,RC,J3490,HCPCS,60687-807-11,NDC,facility,both,10,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,636,RC,J3490,HCPCS,14789-251-09,NDC,facility,both,1,ML,,221,154.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXRAZOXANE 500 MG IV SOLR,50863,CDM,250,RC,J1190,HCPCS,55150-435-01,NDC,facility,both,2,EA,,1499,1049.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,0517-0020-10,NDC,facility,both,60,ML,,111,77.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIVAROXABAN  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50458-577-01,NDC,facility,both,1,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,65862-859-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,28,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,70069-363-01,NDC,facility,both,1,ML,,155,108.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,90,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  1 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,64380-782-06,NDC,facility,both,1,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   2 G INJ SOLR,50863,CDM,250,RC,J0690,HCPCS,60505-6231-0,NDC,facility,both,4,EA,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTOBACILLUS ACIDOPH-PECTIN 75 MILLION CELL -100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,5789683701,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,16714-294-01,NDC,facility,both,2,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM BROMIDE 0.02 % INHL SOLN,50863,CDM,250,RC,J3490,HCPCS,60687-394-79,NDC,facility,both,2,ML,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0641-6057-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 2 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J2004,HCPCS,0409-3183-11,NDC,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE (POLACRILEX) 2 MG BUCL GUM,50863,CDM,250,RC,J3490,HCPCS,0536-1362-06,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 100 MG TAB,50863,CDM,250,RC,J3490,HCPCS,62584-267-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6925-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-48,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,62,EA,,8556,5989.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,250,RC,J2720,HCPCS,63323-229-01,NDC,facility,both,6,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN 0.9% SODIUM CL 1.25 GRAM/250 ML IV SOLN,50863,CDM,250,RC,J3373,HCPCS,61553-009-02,NDC,facility,both,125,ML,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  15 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,0406-8315-23,NDC,facility,both,6,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,636,RC,P9045,HCPCS,68516-5219-0,NDC,facility,both,11,ML,,2796,1957.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-0710-20,NDC,facility,both,7,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2312,HCPCS,36000-308-01,NDC,facility,both,20,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,16714-046-01,NDC,facility,both,10,ML,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-492-27,NDC,facility,both,200,ML,,157,109.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,636,RC,J2003,HCPCS,63323-495-09,NDC,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
0.45 % NACL-POTASSIUM CHLORIDE 20 MEQ/L IV SOLP (PEDS ONC),50863,CDM,636,RC,J3490,HCPCS,0338-0704-34,NDC,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUANFACINE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,59651-840-01,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,10,ML,JZ,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
FAMOTIDINE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-645-10,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0075-0622-01,NDC,facility,both,1,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,71399-1025-3,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2598,HCPCS,43598-914-11,NDC,facility,both,19,ML,JW,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LINEZOLID 100 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0009-5136-01,NDC,facility,both,1,ML,,390,273,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE HCL  2 % MM JELP,50863,CDM,250,RC,J3490,HCPCS,76329-3013-5,NDC,facility,both,2,ML,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SITAGLIPTIN 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0006-0277-01,NDC,facility,both,1,EA,,113,79.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,55150-370-01,NDC,facility,both,2,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML IV SOLN (MERGE),50863,CDM,J3490,HCPCS,42023-216-01,NDC,,,facility,both,1,ML,,171,119.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,64380-972-06,NDC,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,51754-5001-1,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEFIBROTIDE 80 MG/ML IV SOLN,50863,CDM,J3490,HCPCS,68727-800-01,NDC,,,facility,both,3,ML,,5579,3905.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,65219-570-01,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-179-11,NDC,facility,both,1,EA,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  20 MEQ ORAL PACK,50863,CDM,250,RC,J3490,HCPCS,72888-024-06,NDC,facility,both,2,EA,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-609-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE HCL IN 5% DEXTROSE 100 MCG/10 ML (10 MCG/ML) IV SYRG,50863,CDM,250,RC,J0169,HCPCS,70092-1617-46,NDC,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 600 MG ORAL TP12,50863,CDM,250,RC,J3490,HCPCS,0536-1163-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0143-9594-01,NDC,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-453-11,NDC,facility,both,3,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-208-01,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,250,RC,J0137,HCPCS,0264-4100-90,NDC,facility,both,100,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PYRIDOSTIGMINE BROMIDE  60 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0115-3511-01,NDC,facility,both,2,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPTOMYCIN IN 0.9 % SOD CHLOR 350 MG/50 ML IV PGBK,50863,CDM,636,RC,J0874,HCPCS,0338-0712-24,NDC,facility,both,350,ML,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM PHOSPHATE 0.06 MMOL/ML IVPB (FOR PEDIATRICS),50863,CDM,250,RC,J3490,HCPCS,70121-1722-1,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ICATIBANT 30 MG/3 ML SUBQ SYRG,50863,CDM,636,RC,J1744,HCPCS,0093-3066-34,NDC,facility,both,30,ML,JZ,29229,20460.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,25021-402-01,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM 1 GRAM IV SOLR,50863,CDM,J2185,HCPCS,55150-208-30,NDC,,,facility,both,10,EA,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSCARNET 24 MG/ML IV SOLN,50863,CDM,250,RC,J1455,HCPCS,76310-024-15,NDC,facility,both,6,ML,,1325,927.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6928-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3370,HCPCS,63323-284-26,NDC,facility,both,4,EA,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,42494-415-01,NDC,facility,both,4,ML,,825,577.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"AMIODARONE IN DEXTROSE,ISO-OSM 150 MG/100 ML (PREMIX)",50863,CDM,636,RC,J0282,HCPCS,43066-150-10,NDC,facility,both,5,ML,JZ,204,142.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
TAMSULOSIN 0.4 MG ORAL CP24,50863,CDM,636,RC,J3490,HCPCS,0904-6401-61,NDC,facility,both,7,EA,,145,101.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,636,RC,J7060,HCPCS,0338-0017-03,NDC,facility,both,1,ML,JZ,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
NICOTINE (POLACRILEX) 2 MG BUCL GUM,50863,CDM,636,RC,J3490,HCPCS,0536-1362-06,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,63323-461-01,NDC,facility,both,1,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL 20 MG/5 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,0054-3727-63,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  25 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,59762-1342-1,NDC,facility,both,1,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7156-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR PHOSPHATE 75 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,64380-799-01,NDC,facility,both,7,EA,,390,273,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML IV,50863,CDM,250,RC,J3490,HCPCS,70860-301-41,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0832-1211-89,NDC,facility,both,6,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-18,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML IV,50863,CDM,250,RC,J3490,HCPCS,25021-319-05,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 650 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,66553-008-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6924-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTAMIDINE 300 MG INJ SOLR,50863,CDM,636,RC,J3490,HCPCS,63323-113-01,NDC,facility,both,1,EA,,157,109.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0630,HCPCS,42023-205-01,NDC,facility,both,1,ML,,1557,1089.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,90,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,70095-031-01,NDC,facility,both,18,ML,,704,492.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J2004,HCPCS,63323-482-03,NDC,facility,both,80,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COENZYME Q10  30 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,536135807,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 20 GRAM/30 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,0121-1154-30,NDC,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXAZOSIN 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68382-783-01,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,24,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,72485-106-01,NDC,facility,both,75,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-480-10,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML INJECTION,50863,CDM,250,RC,J3411,HCPCS,72603-139-01,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0630,HCPCS,43598-051-11,NDC,facility,both,1,ML,,6391,4473.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NS WITH POTASSIUM CHLORIDE 20 MEQ/L IV SOLP,50863,CDM,636,RC,J3480,HCPCS,0338-0691-04,NDC,facility,both,10,ML,JZ,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
AMLODIPINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6370-61,NDC,facility,both,3,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETHAMBUTOL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,54879-001-01,NDC,facility,both,3,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN IN D5W 300 MG/50 ML IV PGBK,50863,CDM,250,RC,J0736,HCPCS,0338-3410-50,NDC,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNIT/G TOP PACK,50863,CDM,636,RC,J3490,HCPCS,45802-060-70,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN   81 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,0904-6783-70,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2599,HCPCS,70121-1642-1,NDC,facility,both,20,ML,,455,318.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOSENTAN 62.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,66215-101-03,NDC,facility,both,1,EA,,413,289.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG TAB,50863,CDM,636,RC,J3490,HCPCS,904719106,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,50863,CDM,250,RC,J9263,HCPCS,71288-172-21,NDC,facility,both,317,ML,,186,130.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 1 % TOPICAL SOLN,50863,CDM,250,RC,J3490,HCPCS,45802-562-01,NDC,facility,both,1,ML,,142,99.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,50863,CDM,636,RC,Q5119,HCPCS,0069-0238-01,NDC,facility,both,1,ML,,198,138.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZTROPINE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-388-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) MISC SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-694-41,NDC,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J1611,HCPCS,63323-596-11,NDC,facility,both,2,EA,,1432,1002.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 60 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,68180-296-09,NDC,facility,both,2,EA,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 500 MG INJ SOLR,50863,CDM,636,RC,J0696,HCPCS,0409-7338-11,NDC,facility,both,2,EA,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3373,HCPCS,0143-9162-01,NDC,facility,both,175,EA,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 50 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,68084-666-11,NDC,facility,both,5,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTAMIDINE 300 MG INJ SOLR,50863,CDM,636,RC,J3490,HCPCS,63323-113-01,NDC,facility,both,1,EA,,193,135.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL IV BOLUS 10MG/ML (ANESTHESIA ONLY),50863,CDM,636,RC,J2704,HCPCS,0409-4699-54,NDC,facility,both,110,ML,JZ,140,98,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DULOXETINE 60 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,0904-7045-61,NDC,facility,both,2,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE 8 MG SL SUBL,50863,CDM,636,RC,J3490,HCPCS,42858-502-03,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,250,RC,J2405,HCPCS,0641-6078-01,NDC,facility,both,8,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
TAMSULOSIN 0.4 MG ORAL CP24,50863,CDM,636,RC,J3490,HCPCS,0904-7383-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOMIPRAMINE 25 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,70756-405-11,NDC,facility,both,1,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-580-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,42806-150-33,NDC,facility,both,8,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,72603-179-01,NDC,facility,both,7,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 6 MG/0.5 ML SUB-Q,50863,CDM,636,RC,J3030,HCPCS,0143-9638-01,NDC,facility,both,2,ML,,141,98.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,13,ML,,22543,15780.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,63323-185-10,NDC,facility,both,2,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,0904-7509-30,NDC,facility,both,3,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 0.1 % DENT PSTE,50863,CDM,250,RC,J3490,HCPCS,64980-320-05,NDC,facility,both,1,GM,,342,239.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,636,RC,J3490,HCPCS,0143-9575-01,NDC,facility,both,80,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCERIN (ADULT) RECTAL SUPPOSITORY,50863,CDM,250,RC,J3490,HCPCS,132007924,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NATALIZUMAB 300 MG/15 ML IV SOLN,50863,CDM,636,RC,J2323,HCPCS,64406-008-01,NDC,facility,both,300,ML,JZ,16000,11200,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MESALAMINE  250 MG ORAL CPSR,50863,CDM,636,RC,J3490,HCPCS,54092-189-81,NDC,facility,both,1,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.3 MG/0.3 ML IM PNIJ,50863,CDM,250,RC,J0171,HCPCS,49502-500-01,NDC,facility,both,12,EA,,4309,3016.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,40,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,31722-711-30,NDC,facility,both,1,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN PEDS SYRINGE (20MG/ML) IN DEXTROSE (CDS MIX,50863,CDM,636,RC,J0690,HCPCS,0781-3451-70,NDC,facility,both,2,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PALONOSETRON 0.25 MG/5 ML IV INJECTION (MERGE),50863,CDM,636,RC,J2469,HCPCS,55111-694-07,NDC,facility,both,10,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE (POLACRILEX) 4 MG BUCL GUM,50863,CDM,250,RC,J3490,HCPCS,49348-572-36,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PNEUMOCOCCAL 23-VALPS VACCINE 25 MCG/0.5 ML INJ,50863,CDM,250,RC,90732,HCPCS,0006-4943-01,NDC,facility,both,1,ML,,506,354.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,0641-6145-01,NDC,facility,both,2,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ALBUTEROL SULFATE 5 MG/ML INHL NEB CONTINUOUS,50863,CDM,250,RC,J3490,HCPCS,73177-163-33,NDC,facility,both,2,ML,,424,296.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-01,NDC,facility,both,2,ML,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAUNORUBICIN 5 MG/ML IV INJ,50863,CDM,250,RC,J9150,HCPCS,42658-021-01,NDC,facility,both,3,ML,,609,426.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,72485-106-01,NDC,facility,both,50,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-245-11,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM PHOSPHATE 3 MMOL/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-884-01,NDC,facility,both,2,ML,,228,159.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL (VITAMIN D3) 400 UNIT/ML ORAL DROP,50863,CDM,636,RC,J3490,HCPCS,1785600492,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGIC MOUTHWASH REPACK (BMX 1:1:1),50863,CDM,636,RC,J3490,HCPCS,0603-0823-54,NDC,facility,both,3,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-461-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,3,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOLIC ACID  1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-681-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,62559-440-02,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J2003,HCPCS,63323-492-09,NDC,facility,both,150,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,4,EA,,127,88.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6374-61,NDC,facility,both,3,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J2004,HCPCS,63323-482-27,NDC,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG TAB,50863,CDM,250,RC,J3490,HCPCS,904719106,NDC,facility,both,5,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,90,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,J0780,HCPCS,23155-294-31,NDC,,,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,636,RC,J1953,HCPCS,63323-400-01,NDC,facility,both,100,ML,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,63323-400-01,NDC,facility,both,100,ML,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,71247-130-01,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN IN 0.9 % NS 40 UNIT/100 ML (0.4 UNIT/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0338-9647-12,NDC,facility,both,1,ML,,648,453.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIOTHYRONINE 25 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42794-019-12,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHENAMINE HIPPURATE 1 GRAM ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,30698-477-01,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,16729-114-31,NDC,facility,both,9,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLU VACCINE TS 2024-25 65 YR UP (PF) 180 MCG/0.5 ML IM SYRG,50863,CDM,250,RC,90662,HCPCS,49281-124-88,NDC,facility,both,1,ML,,373,261.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 300 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,65162-649-78,NDC,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,72603-251-01,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,13668-219-30,NDC,facility,both,2,EA,,210,147,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-48,NDC,facility,both,2,ML,,140,98,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  20 MEQ ORAL PACK,50863,CDM,250,RC,J3490,HCPCS,72888-024-06,NDC,facility,both,2,EA,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J0461,HCPCS,0517-0401-25,NDC,facility,both,40,ML,JZ,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ACETAMINOPHEN  650 MG ORAL TBSR,50863,CDM,636,RC,J3490,HCPCS,45029721,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE 110 MCG/ACTUATION INHL AERO,50863,CDM,636,RC,J3490,HCPCS,0173-0719-20,NDC,facility,both,1,GM,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  75 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-475-11,NDC,facility,both,3,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,71399-1025-3,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,12,EA,JW,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ENALAPRIL MALEATE 1 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,69238-2141-7,NDC,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0054-0710-20,NDC,facility,both,11,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-617-11,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,36000-283-25,NDC,facility,both,480,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,24338-136-10,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,3,ML,JW,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
NYSTATIN 100000 UNIT/ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0121-0868-05,NDC,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 10 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,250,RC,J2270,HCPCS,0409-1893-13,NDC,facility,both,1,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL (5 MG/ML) IV SYRG PF,50863,CDM,636,RC,J3490,HCPCS,69374-946-04,NDC,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 80 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-211-01,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIROLIMUS 0.5 MG ORAL TAB,50863,CDM,250,RC,J7520,HCPCS,59762-1001-1,NDC,facility,both,1,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0832-0540-11,NDC,facility,both,2,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE  7 MG/24 HR TD PT24,50863,CDM,636,RC,J3490,HCPCS,60505-7061-0,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % MBP,50863,CDM,636,RC,J3490,HCPCS,0338-9662-35,NDC,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6953-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TROPICAMIDE 0.5 % OPHT DROP,50863,CDM,636,RC,J3490,HCPCS,61314-354-01,NDC,facility,both,1,ML,,131,91.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  75 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6951-61,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OFLOXACIN 0.3 % OTIC DROP,50863,CDM,636,RC,J3490,HCPCS,69238-1615-3,NDC,facility,both,1,ML,,567,396.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,0121-4675-05,NDC,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR  6 MG/ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,27241-139-09,NDC,facility,both,5,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM  4.5 GRAM IV SOLR,50863,CDM,636,RC,J2543,HCPCS,0409-3390-11,NDC,facility,both,4,EA,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0047-03,NDC,facility,both,25,EA,JZ,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ENOXAPARIN 150 MG/1 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,0955-1015-01,NDC,facility,both,14,ML,,170,119,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-25,NDC,facility,both,120,ML,JZ,16973,11881.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ACETAMINOPHEN  325 MG RECT SUPP,50863,CDM,250,RC,J3490,HCPCS,51672-2116-0,NDC,facility,both,3,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADVATE: FACTOR VIII CONCENTRATE (MERGE RECORD),50863,CDM,250,RC,J7192,HCPCS,0944-3051-03,NDC,facility,both,750,UN,,4027,2818.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-1283-17,NDC,facility,both,10,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML IV,50863,CDM,250,RC,J3490,HCPCS,70860-301-41,NDC,facility,both,2,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",50863,CDM,250,RC,J1561,HCPCS,13533-800-41,NDC,facility,both,40,ML,,5658,3960.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IVPB (PEDIATRICS/ADULT NON-FORM)",50863,CDM,636,RC,J0131,HCPCS,24201-100-01,NDC,facility,both,14,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,55,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,50863,CDM,250,RC,J9045,HCPCS,16729-295-12,NDC,facility,both,12,ML,,356,249.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,636,RC,J2003,HCPCS,63323-495-27,NDC,facility,both,50,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7122-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,250,RC,J0690,HCPCS,60505-6142-0,NDC,facility,both,4,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IV PGBK,50863,CDM,250,RC,J3475,HCPCS,63323-106-02,NDC,facility,both,4,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6642-61,NDC,facility,both,1,EA,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN PEDS INFUSION (CDS MIXTURE),50863,CDM,250,RC,J0290,HCPCS,25021-136-10,NDC,facility,both,3,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,50863,CDM,250,RC,J9025,HCPCS,72485-201-01,NDC,facility,both,159,EA,,2259,1581.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACUBITRIL-VALSARTAN 24-26 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0078-0659-20,NDC,facility,both,2,EA,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-253-11,NDC,facility,both,2,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,8,EA,,214,149.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 125 MG/5 ML (25MG/ML) ORAL SYRINGE (REPACK),50863,CDM,250,RC,J3370,HCPCS,67457-340-00,NDC,facility,both,5,EA,,260,182,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,78206-121-01,NDC,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE (PF) 25 MG/ML INJ SOLN (FOR ECTOPIC PREGNANCY),50863,CDM,636,RC,J9260,HCPCS,0143-9519-01,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,76329-3352-1,NDC,facility,both,7,ML,,810,567,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 0.125 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68462-330-90,NDC,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOLIC ACID 400 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,5026834611,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 100 MG PE/2 ML INJ SOLN,50863,CDM,250,RC,Q2009,HCPCS,0641-6136-01,NDC,facility,both,2,ML,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0630,HCPCS,43598-051-11,NDC,facility,both,1,ML,,4665,3265.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHIMAZOLE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-680-11,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-05,NDC,facility,both,4,EA,JW,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GENTIAN VIOLET 1 % TOP SOLN,50863,CDM,250,RC,J3490,HCPCS,0395-1003-92,NDC,facility,both,1,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 150 MG ORAL TB24,50863,CDM,J3490,HCPCS,16729-443-15,NDC,,,facility,both,1,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE (FOR CODE) 10% IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0517-6710-01,NDC,facility,both,1,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYPROHEPTADINE 4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0115-1757-01,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LINEZOLID 100 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,31722-865-25,NDC,facility,both,1,ML,,531,371.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-234-11,NDC,facility,both,1,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EFGARTIGIMOD ALFA-FCAB 20 MG/ML IV SOLN,50863,CDM,636,RC,J9332,HCPCS,73475-3041-5,NDC,facility,both,400,ML,JZ,32844,22990.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
FILGRASTIM-SNDZ 480 MCG/0.8 ML INJ SYRG,50863,CDM,250,RC,Q5101,HCPCS,61314-326-05,NDC,facility,both,480,ML,,1212,848.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  1 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,59651-484-01,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,636,RC,J2003,HCPCS,63323-485-27,NDC,facility,both,130,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 8-2 MG SL SUBL,50863,CDM,636,RC,J3490,HCPCS,0904-7010-06,NDC,facility,both,2,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE PEDS SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J3490,HCPCS,0338-6045-37,NDC,facility,both,1,ML,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG ORAL TB12,50863,CDM,636,RC,J3490,HCPCS,60687-583-11,NDC,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 500 MG SOLUTION FOR INJECTION,50863,CDM,250,RC,J2919,HCPCS,43598-128-11,NDC,facility,both,100,EA,,130,91,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0456,HCPCS,55150-174-10,NDC,facility,both,1,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7178-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),50863,CDM,250,RC,J2060,HCPCS,0641-6044-01,NDC,facility,both,25,ML,,216,151.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,0641-6236-01,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MINERAL OIL ORAL (REPACK),50863,CDM,250,RC,J3490,HCPCS,54162-190-16,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,36,EA,,4968,3477.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6797-61,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 50 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0054-0019-20,NDC,facility,both,100,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,250,RC,J1596,HCPCS,0143-9679-01,NDC,facility,both,10,ML,,228,159.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 10 GRAM/100 ML (10%) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-72,NDC,facility,both,120,ML,,16973,11881.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE 3 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,0574-9855-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,636,RC,J3490,HCPCS,0641-6236-01,NDC,facility,both,1,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-572-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,63323-485-03,NDC,,,facility,both,21,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM 1 GRAM IV SOLR,50863,CDM,J2185,HCPCS,63323-508-01,NDC,,,facility,both,10,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN IN D5W 400 MG/200 ML IV PGBK,50863,CDM,636,RC,J0744,HCPCS,25021-192-87,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,J2003,HCPCS,63323-486-27,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,102,EA,,250,175,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE  1 % TOP OINT,50863,CDM,250,RC,J3490,HCPCS,45802-276-03,NDC,facility,both,2,GM,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOPIDOGREL  75 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6294-61,NDC,facility,both,8,EA,,171,119.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSAPREPITANT 150 MG IV SOLR,50863,CDM,636,RC,J1453,HCPCS,0006-3061-01,NDC,facility,both,150,EA,,1185,829.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML (1ML) INJ SOLN,50863,CDM,250,RC,J0169,HCPCS,42023-159-01,NDC,facility,both,20,ML,,176,123.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,2,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL,50863,CDM,250,RC,J3490,HCPCS,63323-820-01,NDC,facility,both,1,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACIDOPHILUS-PECTIN W CITRUS 25 MILLION-100 CELL MG TAB,50863,CDM,636,RC,J3490,HCPCS,536142401,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  1 MG/ML INJ SYRG,50863,CDM,J1171,HCPCS,0409-1283-10,NDC,,,facility,both,10,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE  10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,70756-201-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,52817-180-10,NDC,facility,both,6,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6924-61,NDC,facility,both,5,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYTOCIN 10 UNIT/ML INJ SOLN,50863,CDM,J2590,HCPCS,63323-012-11,NDC,,,facility,both,3,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN 0.9% SODIUM CL 1.25 GRAM/250 ML IV SOLN,50863,CDM,636,RC,J3373,HCPCS,71266-5083-1,NDC,facility,both,125,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,43825-102-01,NDC,facility,both,47,ML,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN DEXTROSE (ISO-OSMOTIC) 1 GRAM/50 ML IV PIGGY BACK,50863,CDM,J0690,HCPCS,0264-3103-11,NDC,,,facility,both,2,ML,,1811,1267.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-559-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,50863,CDM,250,RC,J9075,HCPCS,10019-956-16,NDC,facility,both,116,EA,,752,526.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63304-773-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 40 MG-200 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,65862-496-47,NDC,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 50 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6323-61,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,2000,ML,,107,74.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 2 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,250,RC,J2270,HCPCS,76045-004-01,NDC,facility,both,1,ML,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,636,RC,J2270,HCPCS,0409-1891-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,416,ME,JZ,5646,3952.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
NAPHAZOLINE-GLYCERIN 0.012-0.25 % OPHT DROP,50863,CDM,636,RC,J3490,HCPCS,7811225419,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,636,RC,J1100,HCPCS,63323-506-00,NDC,facility,both,12,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 10 MEQ/100 ML IV PGBK (USE NON-PROTOCOL PANEL),50863,CDM,250,RC,J3480,HCPCS,0338-0709-48,NDC,facility,both,5,ML,JZ,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DIVALPROEX 500 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,0904-6861-61,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,636,RC,J1100,HCPCS,63323-506-00,NDC,facility,both,4,ML,JW,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,70,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,50863,CDM,636,RC,J2354,HCPCS,0641-6174-01,NDC,facility,both,2,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0904-6923-61,NDC,facility,both,5,EA,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IVPB (PEDIATRICS/ADULT NON-FORM)",50863,CDM,636,RC,J0137,HCPCS,24201-100-01,NDC,facility,both,67,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,3,EA,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
USTEKINUMAB-KFCE 130 MG/26 ML IV SOLN,50863,CDM,636,RC,Q5100,HCPCS,83257-026-11,NDC,facility,both,390,ML,JZ,4248,2973.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,16729-114-08,NDC,facility,both,11,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-631-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BEVACIZUMAB 25 MG/ML IV SOLN,50863,CDM,250,RC,J9035,HCPCS,50242-060-01,NDC,facility,both,1,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 30% IN WATER (NEO),50863,CDM,250,RC,J3490,HCPCS,0409-6648-16,NDC,facility,both,1,ML,,113,79.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0641-6057-01,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,55150-161-02,NDC,facility,both,60,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM OXIDE 400 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,6498033990,NDC,facility,both,9,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-48,NDC,facility,both,1,ML,JZ,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),50863,CDM,250,RC,J0169,HCPCS,76329-3318-1,NDC,facility,both,30,ML,,242,169.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LANTHANUM  500 MG ORAL CHEW,50863,CDM,636,RC,J3490,HCPCS,54092-252-45,NDC,facility,both,1,EA,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,0378-7732-93,NDC,facility,both,2,EA,,219,153.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,44567-600-04,NDC,facility,both,1,ML,,402,281.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6291-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MVI, ADULT INJECTION (PHS)",50863,CDM,J3490,HCPCS,54643-5649-1,NDC,,,facility,both,1,ML,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,14789-128-07,NDC,facility,both,2,ML,,224,156.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,0409-4279-16,NDC,,,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J2310,HCPCS,70069-072-10,NDC,facility,both,1,ML,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR  6 MG/ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,68180-678-01,NDC,facility,both,13,ML,,167,116.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 500 MG INJ SOLR,50863,CDM,636,RC,J0696,HCPCS,60505-6152-4,NDC,facility,both,2,EA,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,0409-9094-12,NDC,facility,both,3,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0143-9386-01,NDC,facility,both,26,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG ORAL TAB,50863,CDM,636,RC,Q0169,HCPCS,0904-7304-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYTOCIN IN 0.9 % SOD CHLORIDE 30 UNIT/500 ML IV SOLN,50863,CDM,250,RC,J2590,HCPCS,70092-1552-07,NDC,facility,both,2,ML,,186,130.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANTI-INHIBITOR COAGULANT CMPLX (PHS MERGE),50863,CDM,250,RC,J7198,HCPCS,64193-325-01,NDC,facility,both,2675,UN,JW,7223,5056.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,414,ME,JZ,5618,3932.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,51754-5001-1,NDC,facility,both,3,ML,,155,108.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPSONE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,70954-135-10,NDC,facility,both,2,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML (1ML) INJ SOLN,50863,CDM,250,RC,J0171,HCPCS,54288-119-01,NDC,facility,both,3,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,1,EA,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,8,EA,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7914-61,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,50863,CDM,250,RC,J2359,HCPCS,72603-181-01,NDC,facility,both,5,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYBUTYNIN CHLORIDE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0832-0038-89,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,72603-209-01,NDC,facility,both,2,ML,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIRMATRELVIR-RITONAVIR 300-100 MG ORAL TAB DOSEPACK (FOR ED/IP TAKE HOME PANEL),50863,CDM,636,RC,J3490,HCPCS,0069-0345-30,NDC,facility,both,30,EA,,3837,2685.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,0409-3795-19,NDC,facility,both,2,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-0710-20,NDC,facility,both,19,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIOTHYRONINE  5 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,59762-1206-1,NDC,facility,both,4,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NABUMETONE 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50228-465-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0904-7127-61,NDC,facility,both,20,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  750 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7125-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOXYL 25 MCG ORAL TAB (FOR NEONATAL PATIENTS),50863,CDM,250,RC,J3490,HCPCS,60793-850-01,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN PEDS INFUSION (CDS MIXTURE),50863,CDM,250,RC,J0290,HCPCS,25021-136-10,NDC,facility,both,3,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,J3490,HCPCS,70004-600-09,NDC,,,facility,both,2,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES-DOCUSATE SODIUM 8.6 MG-50 MG TAB,50863,CDM,636,RC,J3490,HCPCS,63739-432-02,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIFEDIPINE 30 MG ORAL TO24,50863,CDM,636,RC,J3490,HCPCS,0904-7208-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,63323-165-01,NDC,facility,both,20,ML,PLAD,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
CISATRACURIUM  2 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0074-4380-10,NDC,facility,both,4,ML,,565,395.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 50% IN WATER (MERGE RECORD),50863,CDM,636,RC,J7060,HCPCS,0409-6648-02,NDC,facility,both,2,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-327-11,NDC,facility,both,3,EA,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 500 MG/10 ML IV SOLN,50863,CDM,250,RC,J9190,HCPCS,62332-751-50,NDC,facility,both,3,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NELARABINE 250 MG/50 ML IV SOLN (PEDS ONCOLOGY),50863,CDM,250,RC,J9261,HCPCS,70710-1726-1,NDC,facility,both,25,ML,,8918,6242.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRIVIGEN 10 % IV SOLN,50863,CDM,636,RC,J1459,HCPCS,44206-437-91,NDC,facility,both,20,ML,JZ,3588,2511.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IPRATROPIUM BROMIDE 17 MCG/ACTUATION INHL AERO,50863,CDM,636,RC,J3490,HCPCS,0597-0087-17,NDC,facility,both,1,GM,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0780,HCPCS,0641-6135-01,NDC,facility,both,1,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,250,RC,J0690,HCPCS,70092-1017-46,NDC,facility,both,7,ML,,127,88.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BISACODYL  5 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,0904-6407-61,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE (PF-DURAMORPH/ASTRAMORPH) 0.5 MG/ML INJ SOLN,50863,CDM,250,RC,J2274,HCPCS,0409-3814-11,NDC,facility,both,1,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EMOLLIENT COMBINATION NO.10 TOPICAL EMULSION,50863,CDM,636,RC,J3490,HCPCS,1381156545,NDC,facility,both,1,GM,,156,109.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,250,RC,J2795,HCPCS,70069-064-25,NDC,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,63739-903-10,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMCICLOVIR 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42291-416-30,NDC,facility,both,1,EA,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 10 MG/ML (PF) IV SOLN,50863,CDM,250,RC,J2270,HCPCS,0641-6127-01,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.3 MG/0.3 ML IM PNIJ,50863,CDM,J0169,HCPCS,49502-500-01,NDC,,,facility,both,3,EA,,1078,754.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,32,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,10,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,J7999,HCPCS,70092-1017-46,NDC,,,facility,both,52,ML,,2055,1438.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-656-11,NDC,facility,both,1,EA,PLAD,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
TEPLIZUMAB-MZWV 2 MG/20 ML IV SOLN,50863,CDM,636,RC,J9381,HCPCS,73650-316-01,NDC,facility,both,324,ME,,19587,13710.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE  2 MG/ML INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,43066-015-01,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON DEXTRAN 50 MG/ML INJ SOLN,50863,CDM,250,RC,J1750,HCPCS,0023-6082-01,NDC,facility,both,12,ML,,1251,875.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ (MERGE),50863,CDM,J2250,HCPCS,0409-2305-17,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,0641-0477-21,NDC,facility,both,9,ML,,2785,1949.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,24,ML,,162,113.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,51079-169-01,NDC,facility,both,4,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,50863,CDM,636,RC,J1756,HCPCS,0517-2340-01,NDC,facility,both,100,ML,,331,231.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE IV BOLUS (STROKE) 100 MG (2 X 50 MG VIALS),50863,CDM,636,RC,J2997,HCPCS,50242-044-06,NDC,facility,both,50,EA,JZ,12145,8501.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PREDNISONE 20 MG ORAL TAB,50863,CDM,FAMNOCHARGE,HCPCS,0904-7127-61,NDC,,,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,25021-315-01,NDC,facility,both,40,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 30% IN WATER (NEO),50863,CDM,250,RC,J7070,HCPCS,0409-6648-16,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN SODIUM EXTENDED 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0071-0369-24,NDC,facility,both,9,EA,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6008-60,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAMADOL  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-795-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,15,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGIC MOUTHWASH REPACK (BMX 1:1:1),50863,CDM,636,RC,J3490,HCPCS,0603-0823-54,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,56,EA,,7728,5409.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 8-2 MG SL SUBL,50863,CDM,636,RC,J3490,HCPCS,50268-145-11,NDC,facility,both,1,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-229-02,NDC,facility,both,2,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 250 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,42192-608-05,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  1 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,64380-782-06,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN  325 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,69618-015-01,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENOFIBRATE NANOCRYSTALLIZED  48 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-599-01,NDC,facility,both,4,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYCHLOROQUINE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7046-61,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLPIDEM  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0781-5317-01,NDC,facility,both,2,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,0517-4620-25,NDC,facility,both,18,ML,,256,179.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MYCOPHENOLATE 500 MG TAB,50863,CDM,636,RC,J7517,HCPCS,60687-438-11,NDC,facility,both,4,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,55566-2200-0,NDC,facility,both,4,ML,,413,289.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,250,RC,J2001,HCPCS,0409-1323-05,NDC,facility,both,40,ML,,160,112,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM  4.5 GRAM IV SOLR,50863,CDM,250,RC,J2543,HCPCS,55150-121-50,NDC,facility,both,4,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORDIAZEPOXIDE 25 MG CAP,50863,CDM,250,RC,J3490,HCPCS,0555-0159-02,NDC,facility,both,3,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-398-11,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5%/EPINEPHRINE 1:300K INJECTION,50863,CDM,636,RC,J3490,HCPCS,0409-1161-01,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COSYNTROPIN 0.25 MG INJ SOLR,50863,CDM,636,RC,J0834,HCPCS,0781-3440-71,NDC,facility,both,1,EA,,409,286.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,23155-001-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 80 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-8301-25,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML (1ML) INJ SOLN,50863,CDM,636,RC,J0171,HCPCS,54288-119-01,NDC,facility,both,10,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-38,NDC,facility,both,2,ML,,121,84.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-089-50,NDC,facility,both,2,ML,,292,204.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 2 MG/ML IN NS 50ML INFUSION (STOCK DOSE),50863,CDM,250,RC,J3490,HCPCS,0143-9508-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL 20 MG/5 ML ORAL ELIX,50863,CDM,250,RC,J3490,HCPCS,0121-0942-05,NDC,facility,both,2,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 2 MG INJ SOLR,50863,CDM,636,RC,J2997,HCPCS,50242-041-64,NDC,facility,both,4,EA,,1600,1120,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-581-11,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 12.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68382-094-01,NDC,facility,both,3,EA,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  25 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-6991-61,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,0143-9682-01,NDC,facility,both,4,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-638-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEPLIZUMAB-MZWV 2 MG/20 ML IV SOLN,50863,CDM,636,RC,J9381,HCPCS,73650-316-01,NDC,facility,both,286,ME,,17290,12103,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 150 MG/ML INJECTION,50863,CDM,250,RC,J3490,HCPCS,25021-115-06,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,4,EA,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML (PEDS CALCLUATOR 0.5),50863,CDM,250,RC,J1815,HCPCS,0024-5924-10,NDC,facility,both,14,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN-ACETAMINOPHEN-CAFFEINE 250 MG-250 MG-65 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0067-2039-91,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE 150 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,68084-713-11,NDC,facility,both,2,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,50863,CDM,636,RC,J9171,HCPCS,67457-533-16,NDC,facility,both,211,ML,,2002,1401.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROGESTERONE MICRONIZED 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,69452-233-20,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,0641-6145-01,NDC,facility,both,6,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOPERAMIDE 1 MG/7.5 ML ORAL LIQD,50863,CDM,250,RC,J3490,HCPCS,17856-6836-1,NDC,facility,both,3,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",50863,CDM,250,RC,J1561,HCPCS,13533-800-21,NDC,facility,both,80,ML,,11316,7921.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE 2 MG SL SUBL,50863,CDM,636,RC,J3490,HCPCS,60687-481-11,NDC,facility,both,3,EA,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7452-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN SODIUM EXTENDED 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,58151-110-32,NDC,facility,both,3,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % MBP,50863,CDM,250,RC,J3490,HCPCS,0338-0553-18,NDC,facility,both,6,ML,,290,203,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0536-1327-10,NDC,facility,both,3,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNITS/1 GRAM PACKET (MERGE RECORD),50863,CDM,250,RC,J3490,HCPCS,0904-7023-67,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 10 GRAM IV SOLR,50863,CDM,250,RC,J3370,HCPCS,0143-9164-01,NDC,facility,both,4,EA,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-4713-75,NDC,facility,both,1,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLIPIZIDE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-362-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOPAMINE IN D5W 400 MG/250 ML (1.6 MG/ML) IV,50863,CDM,636,RC,J1265,HCPCS,0409-7809-22,NDC,facility,both,10,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,J2270,HCPCS,76045-004-10,NDC,,,facility,both,1,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,J2405,HCPCS,70860-776-41,NDC,,,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL IV BOLUS 10MG/ML (ANESTHESIA ONLY),50863,CDM,636,RC,J2704,HCPCS,0409-4699-54,NDC,facility,both,95,ML,JW,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CIPROFLOXACIN 750 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-653-01,NDC,facility,both,10,EA,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,0409-4713-32,NDC,,,facility,both,40,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 100 MG ORAL TAB,50863,CDM,J3490,HCPCS,68084-319-11,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG TAB,50863,CDM,J3490,HCPCS,904719106,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROTHIAZIDE SODIUM 500 MG IV SOLR,50863,CDM,250,RC,J1205,HCPCS,0517-1820-01,NDC,facility,both,1,EA,,271,189.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2001,HCPCS,0409-2066-05,NDC,,,facility,both,10,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,0143-9381-01,NDC,facility,both,1,EA,PLAD,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,50863,CDM,250,RC,J3490,HCPCS,58657-528-16,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-098-10,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOZAPINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-921-01,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-205-01,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN NEO/PEDS IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0456,HCPCS,63323-398-14,NDC,facility,both,1,EA,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-25,NDC,facility,both,13,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE DINITRATE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-367-10,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-1749-70,NDC,facility,both,2,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,636,RC,J2795,HCPCS,70069-064-25,NDC,facility,both,163,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 400 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0143-9887-01,NDC,facility,both,3,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE 25 MG/ML INJ SOLN,50863,CDM,250,RC,J3230,HCPCS,0641-1398-31,NDC,facility,both,1,ML,,195,136.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-1749-70,NDC,facility,both,4,ML,,182,127.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,1,EA,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MINERAL OIL ORAL (REPACK),50863,CDM,250,RC,J3490,HCPCS,48433-202-30,NDC,facility,both,2,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TERAZOSIN  1 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,50268-764-11,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,636,RC,J7060,HCPCS,0338-0017-04,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOPAMINE INFUSION NEO IV SYRINGE (FROM PREMIX),50863,CDM,250,RC,J1265,HCPCS,0338-1007-02,NDC,facility,both,10,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,544,ME,,7383,5168.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID (PORK)  30 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42192-329-01,NDC,facility,both,4,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROPROCAINE 3 % INJ SOLN,50863,CDM,250,RC,J2401,HCPCS,63323-478-01,NDC,facility,both,450,ML,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,8,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-587-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROATE SODIUM 100 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-494-01,NDC,facility,both,2,ML,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANTI-INHIBITOR COAGULANT CMPLX (PHS MERGE),50863,CDM,250,RC,J7198,HCPCS,64193-325-01,NDC,facility,both,3825,UN,,23754,16627.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 20 GRAM/30 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,0121-1154-30,NDC,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL  6.25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68462-163-01,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-245-11,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE IN D5W 1 GRAM/100 ML IV PGBK,50863,CDM,636,RC,J3475,HCPCS,63323-108-00,NDC,facility,both,2,ML,JZ,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CARVEDILOL  6.25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6301-61,NDC,facility,both,1,EA,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL  6.25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68462-163-01,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 3000 MCG/ML INJECTION,50863,CDM,636,RC,J0153,HCPCS,63323-651-00,NDC,facility,both,6,ML,JZ,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLN,50863,CDM,636,RC,J3262,HCPCS,50242-135-01,NDC,facility,both,240,ML,"JA,JZ",4399,3079.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously | Modifier JZ: Zero drug amount discarded/not administered to any patient
PHENOBARBITAL 20 MG/5 ML ORAL ELIX,50863,CDM,250,RC,J3490,HCPCS,0121-0942-05,NDC,facility,both,2,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0630,HCPCS,24201-400-02,NDC,facility,both,1,ML,,2919,2043.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,946,ME,JZ,12838,8986.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GABAPENTIN 250 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,42192-608-05,NDC,facility,both,3,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1171,HCPCS,0409-2634-01,NDC,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATOMOXETINE  10 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,31722-714-30,NDC,facility,both,2,EA,,140,98,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"RHO(D) IMMUNE GLOBULIN (RHOPHYLAC) 1,500 UNIT (300 MCG)/2 ML INJ SYRG",50863,CDM,250,RC,J2791,HCPCS,44206-300-01,NDC,facility,both,1,ML,,693,485.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,0409-1283-03,NDC,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE SODIUM 2.5 MG ORAL TAB,50863,CDM,250,RC,J8610,HCPCS,0555-0572-02,NDC,facility,both,8,EA,,140,98,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  5 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,59746-172-06,NDC,facility,both,5,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 1 % INJ SOLN,50863,CDM,250,RC,Q9968,HCPCS,17478-504-01,NDC,facility,both,40,ML,,328,229.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,50863,CDM,Q5119,HCPCS,0069-0249-01,NDC,,,facility,both,100,ML,,19784,13848.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-467-01,NDC,facility,both,1,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE 22.5 MG SUBQ SYRG,50863,CDM,J9217,HCPCS,62935-227-10,NDC,,,facility,both,3,EA,,1176,823.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NOREPINEPHRINE BITARTRATE-D5W 16 MG/250 ML (64 MCG/ML) IV SOLN (CENTRAL ONLY),50863,CDM,J3490,HCPCS,0338-0116-20,NDC,,,facility,both,1,ML,,340,238,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7308-61,NDC,facility,both,1,EA,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,43598-053-11,NDC,facility,both,21,ML,,761,532.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LURASIDONE 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7355-04,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,FAMNOCHARGE,HCPCS,0338-0049-38,NDC,,,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0143-9507-01,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRBESARTAN  75 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,31722-729-30,NDC,facility,both,2,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,J0630,HCPCS,67457-675-02,NDC,,,facility,both,1,ML,,2788,1951.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 112 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-508-11,NDC,facility,both,3,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,55150-161-02,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FIDAXOMICIN 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0480-2596-34,NDC,facility,both,1,EA,,876,613.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,23155-832-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZOCAINE-MENTHOL 6-10 MG MM LOZG,50863,CDM,636,RC,J3490,HCPCS,7811201266,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IV PGBK,50863,CDM,636,RC,J3475,HCPCS,47335-992-01,NDC,facility,both,4,ML,JZ,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3370,HCPCS,0143-9162-01,NDC,facility,both,4,EA,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-5771-23,NDC,facility,both,6,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,68180-723-04,NDC,facility,both,4,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,97,ML,JW,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
RIFAXIMIN 550 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,65649-303-02,NDC,facility,both,6,EA,,1226,858.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL  6.25 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-6301-61,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-299-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,42806-150-33,NDC,facility,both,2,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-28,NDC,facility,both,16,EA,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ELTROMBOPAG 25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,31722-842-30,NDC,facility,both,2,EA,,1296,907.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROMETHORPHAN-GUAIFENESIN SR 30 MG-600 MG 12 HR TAB,50863,CDM,250,RC,J3490,HCPCS,0536-1161-37,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,636,RC,J2720,HCPCS,63323-229-01,NDC,facility,both,6,ML,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,71288-402-10,NDC,facility,both,7,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESTRADIOL 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42806-088-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-229-02,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,50863,CDM,636,RC,J0696,HCPCS,0143-9856-01,NDC,facility,both,8,EA,JZ,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MESNA 100 MG/ML IV SOLN,50863,CDM,250,RC,J9209,HCPCS,0338-1305-01,NDC,facility,both,22,ML,,845,591.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  5 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-122-11,NDC,facility,both,3,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 1 % INJ SOLN,50863,CDM,636,RC,Q9968,HCPCS,17478-504-10,NDC,facility,both,100,ML,,725,507.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ELECTROLYTE-A IV,50863,CDM,250,RC,J3490,HCPCS,0338-0221-03,NDC,facility,both,4,ML,,333,233.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZINC OXIDE 20 % TOP OINT (REPACK),50863,CDM,636,RC,J3490,HCPCS,75834-170-01,NDC,facility,both,1,GM,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,2055503601,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTAZIDIME   1 GRAM INJ SOLR,50863,CDM,250,RC,J0713,HCPCS,0409-5082-11,NDC,facility,both,4,EA,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 10 MG TAB,50863,CDM,250,RC,Q0177,HCPCS,60687-664-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM BICARB-CITRIC ACID 20 MEQ ORAL TBEF,50863,CDM,250,RC,J3490,HCPCS,51801-012-01,NDC,facility,both,3,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0406-1236-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,10135-778-01,NDC,facility,both,10,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,71288-402-10,NDC,facility,both,8,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SYRG,50863,CDM,J3490,HCPCS,8290306546,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,J0330,HCPCS,31722-981-10,NDC,,,facility,both,3,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,50863,CDM,250,RC,J9267,HCPCS,61703-342-50,NDC,facility,both,237,ML,,287,200.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,J2270,HCPCS,76045-004-10,NDC,,,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,636,RC,J0132,HCPCS,70594-111-01,NDC,facility,both,5,ML,JW,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DILTIAZEM 5 MG/ML IV,50863,CDM,J3490,HCPCS,0641-6013-01,NDC,,,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATRACURIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-1105-22,NDC,facility,both,1,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7050,HCPCS,0338-0049-03,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-229-02,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,250,RC,J3490,HCPCS,0143-9575-01,NDC,facility,both,60,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEMAZEPAM  7.5 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6436-04,NDC,facility,both,4,EA,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN SODIUM EXTENDED 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0071-0369-24,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NADOLOL  40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69238-1124-9,NDC,facility,both,1,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-48,NDC,facility,both,2,ML,,183,128.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0955-1004-01,NDC,facility,both,12,ML,,151,105.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLPIDEM  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-838-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,54288-136-01,NDC,facility,both,1,ML,,184,128.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NYSTATIN  100000 UNIT/G TOP CREA,50863,CDM,250,RC,J3490,HCPCS,51672-1289-1,NDC,facility,both,3,GM,,224,156.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM BROMIDE 0.02 % INHL SOLN,50863,CDM,250,RC,J3490,HCPCS,76204-100-01,NDC,facility,both,2,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZOCAINE-MENTHOL 20-0.26 % MM GEL,50863,CDM,250,RC,J3490,HCPCS,1031043028,NDC,facility,both,1,GM,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
K PHOS DI & MONO-SOD PHOS MONO 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,486112501,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN NORMAL SALINE IV,50863,CDM,636,RC,J7042,HCPCS,0338-0089-04,NDC,facility,both,2,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAZOSIN 1 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,51079-630-01,NDC,facility,both,2,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,65219-570-01,NDC,facility,both,3,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DONEPEZIL 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6478-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51672-4005-1,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,70700-165-22,NDC,facility,both,6,ML,,152,106.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-1752-50,NDC,facility,both,2,ML,,144,100.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7361-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,0904-6794-80,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 10 MEQ/100 ML IV PGBK,50863,CDM,250,RC,J3480,HCPCS,14789-109-16,NDC,facility,both,5,ML,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,63323-461-01,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,51079-051-20,NDC,facility,both,28,EA,,531,371.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G POTASSIUM  5000000 UNIT INJ SOLR,50863,CDM,250,RC,J2540,HCPCS,72603-210-01,NDC,facility,both,14,EA,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,50863,CDM,250,RC,Q0177,HCPCS,60687-675-11,NDC,facility,both,4,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0245-0144-89,NDC,facility,both,1,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,67877-548-88,NDC,facility,both,6,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG/5 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,0121-4827-05,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES  8.6 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-7252-61,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE 0.25 MG/2 ML INHL NBSP,50863,CDM,250,RC,J3490,HCPCS,0186-1988-04,NDC,facility,both,4,ML,,205,143.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-4279-16,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIPASE-PROTEASE-AMYLASE 24,000-76,000- 120,000 UNIT ORAL CAP, DELAY REL",50863,CDM,250,RC,J3490,HCPCS,0032-2636-01,NDC,facility,both,3,EA,,150,105,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,16714-016-01,NDC,facility,both,3,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 30 MG/0.3 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,25021-410-70,NDC,facility,both,3,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 250 MG INJ SOLR,50863,CDM,636,RC,J0696,HCPCS,0409-7337-11,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,70095-031-01,NDC,facility,both,26,ML,,1062,743.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,636,RC,J7060,HCPCS,0338-0017-38,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SINCALIDE 5 MCG INJ SOLR,50863,CDM,636,RC,J2805,HCPCS,72266-248-05,NDC,facility,both,1,EA,,225,157.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,0904-6474-61,NDC,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE MODIFIED  25 MG ORAL CAP,50863,CDM,636,RC,J7515,HCPCS,0093-9018-19,NDC,facility,both,4,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  88 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-486-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM 2000 MG IV SOLR,50863,CDM,250,RC,J2185,HCPCS,44567-402-01,NDC,facility,both,20,EA,JZ,194,135.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MAGIC MOUTHWASH REPACK (BMX 1:1:1),50863,CDM,250,RC,J3490,HCPCS,0603-0823-54,NDC,facility,both,3,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE 100 MG ORAL CAP,50863,CDM,250,RC,J7502,HCPCS,68084-921-95,NDC,facility,both,1,EA,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT  40 MCG/0.4 ML INJ SYRG,50863,CDM,250,RC,J0881,HCPCS,55513-021-01,NDC,facility,both,40,ML,,1096,767.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPTOMYCIN 500 MG IV SOLR,50863,CDM,636,RC,J0878,HCPCS,67919-012-01,NDC,facility,both,1000,EA,,2460,1722,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOPAMINE INFUSION NEO IV SYRINGE (FROM PREMIX),50863,CDM,250,RC,J1265,HCPCS,0409-7809-11,NDC,facility,both,10,ML,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,70004-600-09,NDC,facility,both,1,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0630,HCPCS,43598-051-11,NDC,facility,both,1,ML,,6868,4807.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NORTRIPTYLINE 25 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,51672-4002-1,NDC,facility,both,2,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,50863,CDM,636,RC,J0561,HCPCS,60793-701-02,NDC,facility,both,12,ML,JZ,1080,756,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6950-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,25021-402-01,NDC,facility,both,5,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE (6 MONTH) 45 MG SUBCUTANOUS KIT,50863,CDM,636,RC,J9217,HCPCS,62935-461-50,NDC,facility,both,6,EA,JZ,1176,823.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
TRAZODONE  50 MG ORAL TAB,50863,CDM,250,RC,j3490,HCPCS,50111-560-01,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SCOPOLAMINE TRANSDERMAL PATCH 1MG OVER 3 DAYS,50863,CDM,636,RC,J3490,HCPCS,50742-505-01,NDC,facility,both,1,EA,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,250,RC,J3360,HCPCS,0641-6244-01,NDC,facility,both,12,ML,,867,606.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0172-3926-60,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 100 MG/1 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0548-5605-00,NDC,facility,both,10,ML,PLAD,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
CALCITRIOL 0.5 MCG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,64380-724-06,NDC,facility,both,2,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES-DOCUSATE SODIUM 8.6 MG-50 MG TAB,50863,CDM,636,RC,J3490,HCPCS,63739-432-02,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 40 MG-200 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0121-0853-20,NDC,facility,both,1,ML,,101,70.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,77,ML,,111,77.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENAZEPRIL 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,43547-336-10,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NYSTATIN 100000 UNIT/ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0904-7276-41,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE 150 MG ORAL CP24,50863,CDM,636,RC,J3490,HCPCS,68084-713-11,NDC,facility,both,2,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  37.5 MG ORAL CP24,50863,CDM,636,RC,J3490,HCPCS,59762-0180-3,NDC,facility,both,2,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,50863,CDM,250,RC,J1756,HCPCS,0517-2340-01,NDC,facility,both,500,ML,JZ,1605,1123.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0780,HCPCS,55390-077-10,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J1938,HCPCS,72603-251-01,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,0641-6145-01,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRIL MALEATE 1 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,69238-1729-7,NDC,facility,both,1,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM SR 120 MG 12 HR CAP,50863,CDM,636,RC,J3490,HCPCS,68462-562-01,NDC,facility,both,1,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 20 GRAM/30 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-1154-30,NDC,facility,both,3,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENEFIX: FIX CONCENTRATE (MERGE RECORD),50863,CDM,J7195,HCPCS,58394-633-03,NDC,,,facility,both,2750,UN,,13305,9313.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,250,RC,J2720,HCPCS,63323-229-01,NDC,facility,both,3,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL (PULM.HYPERTENSION) 10 MG/12.5 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,55150-166-13,NDC,facility,both,1,ML,,791,553.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,250,RC,J0132,HCPCS,25021-812-30,NDC,facility,both,255,ML,,1834,1283.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3370,HCPCS,0143-9162-01,NDC,facility,both,12,EA,,240,168,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IVPB (PEDIATRICS/ADULT NON-FORM)",50863,CDM,636,RC,J0137,HCPCS,24201-100-01,NDC,facility,both,56,ML,JW,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ZOLPIDEM  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0378-5305-01,NDC,facility,both,1,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,636,RC,J1596,HCPCS,0143-9682-01,NDC,facility,both,8,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,55150-169-10,NDC,facility,both,100,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,436,ME,JZ,5917,4141.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,72162-1329-8,NDC,facility,both,3,ML,,1027,718.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NADOLOL  40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69238-1124-9,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,82293-004-10,NDC,facility,both,2,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CELECOXIB 200 MG ORAL CAP,50863,CDM,J3490,HCPCS,60687-447-11,NDC,,,facility,both,2,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE (FOR EMERGENCY) 100 MG/ML (10%) IV SOLN,50863,CDM,J0612,HCPCS,0143-9180-01,NDC,,,facility,both,100,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,250,RC,J3490,HCPCS,0409-1323-05,NDC,facility,both,400,ML,,176,123.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J2310,HCPCS,0409-1219-41,NDC,facility,both,4,ML,,513,359.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG ORAL TAB,50863,CDM,J3490,HCPCS,69315-904-01,NDC,,,facility,both,3,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 17 GRAM (100 %) ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,0904-6931-86,NDC,facility,both,3,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DANTROLENE  25 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0115-4411-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,63323-461-01,NDC,facility,both,1,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,62584-994-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLIPIZIDE 10 MG ORAL TO24,50863,CDM,636,RC,J3490,HCPCS,64980-281-01,NDC,facility,both,4,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB 100 MG IV SOLR,50863,CDM,J1745,HCPCS,57894-160-01,NDC,,,facility,both,8,EA,,456,319.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6500-06,NDC,facility,both,4,EA,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 5 MG/ML (0.5 %) INJECTION,50863,CDM,636,RC,J3490,HCPCS,0409-4275-16,NDC,facility,both,70,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-ABDA 100 MG IV SOLR,50863,CDM,636,RC,Q5104,HCPCS,78206-162-99,NDC,facility,both,51,EA,,10605,7423.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAZOLAMIDE SODIUM 500 (100 MG/ML) INJ SOLR,50863,CDM,636,RC,J1120,HCPCS,67457-853-50,NDC,facility,both,1,EA,JZ,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,83257-011-11,NDC,facility,both,4,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6290-61,NDC,facility,both,8,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE 2 MG SL SUBL,50863,CDM,636,RC,J3490,HCPCS,0904-7154-04,NDC,facility,both,2,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIFEDIPINE 30 MG ORAL TO24,50863,CDM,636,RC,J3490,HCPCS,50268-597-11,NDC,facility,both,3,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM NEO IV SYRINGE (PHS FROM PREMIX),50863,CDM,250,RC,J1953,HCPCS,44567-501-01,NDC,facility,both,29,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE  25 MG ORAL CAP,50863,CDM,250,RC,J7515,HCPCS,0078-0240-61,NDC,facility,both,2,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BISACODYL 10 MG RECT SUPP,50863,CDM,250,RC,J3490,HCPCS,0574-7050-50,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-5771-23,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG IV SOLR,50863,CDM,636,RC,J3490,HCPCS,71288-030-20,NDC,facility,both,1,EA,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,43066-007-10,NDC,facility,both,2,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,63323-185-07,NDC,facility,both,4,ML,,133,93.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-4799-05,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 50 MG/5 ML (10 MG/ML) IV SYRG,50863,CDM,250,RC,J3490,HCPCS,71266-2002-1,NDC,facility,both,2,ML,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-ABDA 100 MG IV SOLR,50863,CDM,636,RC,Q5104,HCPCS,78206-162-99,NDC,facility,both,72,EA,,14972,10480.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM IODIDE 130 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51803-001-01,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IV PGBK,50863,CDM,250,RC,J3475,HCPCS,0338-1708-40,NDC,facility,both,4,ML,JZ,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,63323-185-07,NDC,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM IN NACL (ISO-OS) 500 MG/100 ML IV PGBK,50863,CDM,636,RC,J1953,HCPCS,67457-255-00,NDC,facility,both,300,ML,,493,345.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-0430-06,NDC,facility,both,15,EA,,193,135.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 50 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,59651-489-01,NDC,facility,both,102,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 5 MG-325 MG TAB,50863,CDM,J3490,HCPCS,0406-0123-01,NDC,,,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,0409-3178-17,NDC,,,facility,both,75,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,J1596,HCPCS,0143-9679-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 200 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16729-457-17,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-587-11,NDC,facility,both,6,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DRONABINOL  2.5 MG ORAL CAP,50863,CDM,250,RC,Q0167,HCPCS,0904-6745-61,NDC,facility,both,1,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELATACEPT 250 MG IV SOLR,50863,CDM,636,RC,J0485,HCPCS,0003-0371-13,NDC,facility,both,162,EA,JW,727,508.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
NYSTATIN  100000 UNIT/G TOP OINT,50863,CDM,250,RC,J3490,HCPCS,45802-048-35,NDC,facility,both,1,GM,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,55150-177-05,NDC,facility,both,50,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SYRG,50863,CDM,250,RC,J3490,HCPCS,6425311130,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARISOPRODOL 350 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50742-656-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,25021-410-76,NDC,facility,both,8,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAVASTATIN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,55111-229-90,NDC,facility,both,1,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-826-11,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE  25 MG ORAL CPSP,50863,CDM,250,RC,J3490,HCPCS,68382-005-14,NDC,facility,both,8,EA,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,42806-150-33,NDC,facility,both,8,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"TRANEXAMIC ACID IN NACL,ISO-OS 1,000 MG/100 ML (10 MG/ML) IV PGBK",50863,CDM,250,RC,J3490,HCPCS,51754-0108-3,NDC,facility,both,1,ML,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 250 MG-62.5 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,69097-098-43,NDC,facility,both,10,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-1283-03,NDC,facility,both,10,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,50863,CDM,J1650,HCPCS,0075-0620-01,NDC,,,facility,both,4,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROMETHORPHAN-GUAIFENESIN SR 30 MG-600 MG 12 HR TAB,50863,CDM,250,RC,J3490,HCPCS,17856-1162-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 2 TABLET
CLONIDINE 0.1 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-7442-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ABATACEPT 250 MG IV SOLR,50863,CDM,636,RC,J0129,HCPCS,0003-2187-13,NDC,facility,both,100,EA,JA,16711,11697.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,636,RC,J1953,HCPCS,55150-177-05,NDC,facility,both,150,ML,JZ,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,7,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
AMIKACIN 1000 MG/4 ML INJ SOLN,50863,CDM,636,RC,J0278,HCPCS,23155-290-32,NDC,facility,both,12,ML,,101,70.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATED 20 MG/ML IV SOLN,50863,CDM,250,RC,J0706,HCPCS,51754-0500-1,NDC,facility,both,5,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON DEXTRAN 50 MG/ML INJ SOLN,50863,CDM,636,RC,J1750,HCPCS,0023-6082-01,NDC,facility,both,1,ML,JW,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
POTASSIUM PHOS IN 0.9 % NACL 15 MMOL/250 ML IVPB PREMIX,50863,CDM,636,RC,J3490,HCPCS,72196-6060-1,NDC,facility,both,1,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIFAPENTINE 150 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0088-2102-01,NDC,facility,both,6,EA,,175,122.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNIT/G TOP PACK,50863,CDM,250,RC,J3490,HCPCS,45802-060-70,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN D5W 20000 UNIT/500 ML,50863,CDM,636,RC,J1644,HCPCS,0264-9567-10,NDC,facility,both,8,ML,JW,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,42806-150-33,NDC,facility,both,2,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,636,RC,J3490,HCPCS,70004-600-09,NDC,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,64850-502-01,NDC,facility,both,2,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN 0.9% SODIUM CL 1.25 GRAM/250 ML IV SOLN,50863,CDM,J3373,HCPCS,71266-5083-1,NDC,,,facility,both,125,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FELBAMATE 400 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,62559-730-01,NDC,facility,both,2,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MEASLES,MUMPS,RUBELLA VACC(PF) 10EXP3.4-4.2- 3.3CCID50/0.5ML SUBQ SUSR",50863,CDM,250,RC,90707,HCPCS,58160-831-03,NDC,facility,both,1,EA,,398,278.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),50863,CDM,636,RC,J0171,HCPCS,76329-3318-1,NDC,facility,both,70,ML,,514,359.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACUBITRIL-VALSARTAN 97-103 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0078-0696-20,NDC,facility,both,1,EA,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,8,ML,,13873,9711.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,42806-150-33,NDC,facility,both,6,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0093-2026-31,NDC,facility,both,13,ML,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-453-11,NDC,facility,both,8,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 400 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,69097-815-07,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,5026885511,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-9558-05,NDC,facility,both,4,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,10139-235-10,NDC,facility,both,1,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NS WITH POTASSIUM CHLORIDE 40 MEQ/L IV SOLP,50863,CDM,636,RC,J3490,HCPCS,0338-0695-04,NDC,facility,both,1,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IMIPRAMINE 25 MG TAB,50863,CDM,250,RC,J3490,HCPCS,64380-170-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-545-10,NDC,facility,both,3,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN D5W 20000 UNIT/500 ML,50863,CDM,250,RC,J1644,HCPCS,0264-9567-10,NDC,facility,both,60,ML,,250,175,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG IV SOLR,50863,CDM,636,RC,J3490,HCPCS,55150-202-00,NDC,facility,both,2,EA,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYTOCIN IN 0.9 % SOD CHLORIDE 30 UNIT/500 ML IV SOLN,50863,CDM,250,RC,J2590,HCPCS,70004-085-44,NDC,facility,both,1,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACAMPROSATE 333 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,0378-6333-80,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60505-3111-0,NDC,facility,both,2,EA,,130,91,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,636,RC,Q9968,HCPCS,71288-811-10,NDC,facility,both,3,ML,JZ,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
INSULIN LISPRO PROTAM & LISPRO 100 UNIT/ML (75-25) SUBQ SUSP,50863,CDM,250,RC,J1815,HCPCS,0002-7511-01,NDC,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-1638-32,NDC,facility,both,1,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,250,RC,J2405,HCPCS,23155-549-31,NDC,facility,both,8,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"ALBUMIN, HUMAN 25 % IV SOLP",50863,CDM,250,RC,P9047,HCPCS,44206-251-91,NDC,facility,both,1,ML,,389,272.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG ORAL TB12,50863,CDM,250,RC,J3490,HCPCS,60687-583-11,NDC,facility,both,3,EA,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  80 MG ORAL CS24,50863,CDM,636,RC,J3490,HCPCS,0527-4117-37,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,87,ML,,1239,867.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2308-22,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RACEPINEPHRINE 2.25 % INHL NEBU,50863,CDM,250,RC,J3490,HCPCS,0487-2784-01,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INDOMETHACIN 50 MG RECT SUPP,50863,CDM,250,RC,J3490,HCPCS,69344-102-33,NDC,facility,both,2,EA,,1998,1398.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,0075-0622-01,NDC,facility,both,8,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-0710-20,NDC,facility,both,22,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-089-11,NDC,facility,both,1,EA,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"HYOSCYAMINE 0.125 MG TAB, RAPID DISSOLVE",50863,CDM,250,RC,J3490,HCPCS,42192-338-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,636,RC,J7999,HCPCS,70092-1017-46,NDC,facility,both,3,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 400 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,45963-557-11,NDC,facility,both,3,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BETAMETHASONE, AUGMENTED 0.05 % TOP OINT",50863,CDM,636,RC,J3490,HCPCS,68180-947-01,NDC,facility,both,1,GM,,270,189,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIPHTH,PERTUS(ACELL),TETANUS SYRG(BOOSTRIX) 2.5-8-5 LF-MCG-LF/0.5ML IM SYRG",50863,CDM,250,RC,90715,HCPCS,58160-842-43,NDC,facility,both,1,ML,GZ,247,172.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier GZ: Item or service expected to be denied as not reasonable and necessary
AMBRISENTAN  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,47335-236-83,NDC,facility,both,2,EA,,1567,1096.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-4279-02,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,25021-468-10,NDC,facility,both,1,EA,,152,106.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,118,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB 100 MG IV SOLR,50863,CDM,J1745,HCPCS,57894-030-01,NDC,,,facility,both,50,EA,,16116,11281.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",50863,CDM,J1561,HCPCS,13533-800-41,NDC,,,facility,both,80,ML,,11316,7921.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BISACODYL 10 MG RECT SUPP,50863,CDM,J3490,HCPCS,8142102103,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,250,RC,J3490,HCPCS,0143-9679-01,NDC,facility,both,1,ML,,157,109.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZOCAINE-MENTHOL 20 %-0.5 % TOPICAL AEROSOL,50863,CDM,250,RC,J3490,HCPCS,5140900722,NDC,facility,both,1,GM,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 2-0.5 MG SL SUBL,50863,CDM,636,RC,J3490,HCPCS,0904-7009-06,NDC,facility,both,6,EA,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,J1953,HCPCS,63323-400-01,NDC,,,facility,both,136,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-25,NDC,facility,both,23,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,50863,CDM,J1756,HCPCS,0517-2340-99,NDC,,,facility,both,200,ML,,432,302.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 100 MG IV SOLR,50863,CDM,636,RC,J2997,HCPCS,50242-085-25,NDC,facility,both,50,EA,,12145,8501.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 500 MG/10 ML IV SOLN,50863,CDM,250,RC,J9190,HCPCS,62332-751-50,NDC,facility,both,3,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 5 MG/ML IV SOLN,50863,CDM,250,RC,J1921,HCPCS,17478-420-20,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IR SOLN,50863,CDM,250,RC,J3490,HCPCS,0338-0047-46,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE-SALMETEROL 500 MCG-50 MCG/DOSE DISK DEVICE FOR INHALATION,50863,CDM,250,RC,J3490,HCPCS,0173-0697-04,NDC,facility,both,14,EA,,378,264.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CINACALCET 30 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,64380-883-04,NDC,facility,both,2,EA,,260,182,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOBRAMYCIN SULFATE 40 MG/ML INJ SOLN,50863,CDM,250,RC,J3260,HCPCS,67457-473-22,NDC,facility,both,3,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NELARABINE 250 MG/50 ML IV SOLN (PEDS ONCOLOGY),50863,CDM,250,RC,J9261,HCPCS,71288-165-52,NDC,facility,both,25,ML,,8918,6242.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,0008-0923-60,NDC,facility,both,2,EA,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 20 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,0904-7458-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,636,RC,J3490,HCPCS,73013-2002-2,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMINOCAPROIC ACID 250 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-4346-73,NDC,facility,both,2,ML,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORTHALIDONE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-058-01,NDC,facility,both,2,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,904740361,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM PHOS IN 0.9 % NACL 15 MMOL/250 ML IVPB PREMIX,50863,CDM,636,RC,J3490,HCPCS,70004-841-40,NDC,facility,both,1,ML,,158,110.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 1 MG ORAL TAB,50863,CDM,636,RC,J8540,HCPCS,0054-8174-25,NDC,facility,both,8,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,250,RC,J7060,HCPCS,0338-0017-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0003-0894-31,NDC,facility,both,1,EA,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TERAZOSIN  5 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,50268-766-11,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,76045-009-96,NDC,facility,both,8,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-04,NDC,facility,both,4,ML,JZ,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GENTAMICIN IN SALINE (ISO-OSMOTIC) 100 MG/50 ML IV PIGGY BACK,50863,CDM,250,RC,J1580,HCPCS,0338-0511-41,NDC,facility,both,2,ML,,431,301.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SCOPOLAMINE TRANSDERMAL PATCH 1MG OVER 3 DAYS,50863,CDM,636,RC,J3490,HCPCS,10019-553-90,NDC,facility,both,1,EA,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
URSODIOL 300 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-100-11,NDC,facility,both,3,EA,,113,79.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-492-04,NDC,facility,both,300,ML,,236,165.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,51079-169-01,NDC,facility,both,5,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FERUMOXYTOL 510 MG/17 ML (30 MG/ML) IV SOLN,50863,CDM,636,RC,Q0138,HCPCS,59338-775-01,NDC,facility,both,1020,ML,,6589,4612.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 0.4 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,60429-840-25,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-998-01,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIFEDIPINE 60 MG ORAL TO24,50863,CDM,250,RC,J3490,HCPCS,68084-598-11,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-089-11,NDC,facility,both,2,EA,,183,128.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,0409-1207-03,NDC,facility,both,6,ML,,142,99.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,2,EA,,142,99.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-103-01,NDC,facility,both,5,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATENOLOL  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7187-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-815-11,NDC,facility,both,3,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,7,EA,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  500 MG IV SOLR,50863,CDM,250,RC,J3370,HCPCS,0143-9161-01,NDC,facility,both,1,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 5 % TOP OINT,50863,CDM,250,RC,J3490,HCPCS,68462-418-20,NDC,facility,both,1,GM,,935,654.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-1749-70,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,71399-1025-3,NDC,facility,both,24,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,81033-002-20,NDC,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM  3.375 GRAM IV SOLR,50863,CDM,250,RC,J2543,HCPCS,0781-3113-90,NDC,facility,both,3,EA,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"RABIES VACCINE,HUMAN DIPLOID (PF) 2.5 UNIT IM",50863,CDM,636,RC,90675,HCPCS,49281-252-51,NDC,facility,both,1,EA,,1198,838.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CODEINE-GUAIFENESIN 10-100 MG/5 ML ORAL LIQD (REPACK),50863,CDM,250,RC,J3490,HCPCS,0121-1550-10,NDC,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2312,HCPCS,67457-299-00,NDC,facility,both,40,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 0.2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60505-0258-1,NDC,facility,both,7,EA,,149,104.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,636,RC,J3490,HCPCS,63739-434-02,NDC,facility,both,3,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) IV SOLN",50863,CDM,J3490,HCPCS,0013-1114-20,NDC,,,facility,both,1,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-0710-20,NDC,facility,both,20,EA,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7912-51,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR PHOSPHATE 30 MG ORAL CAP,50863,CDM,J3490,HCPCS,31722-630-31,NDC,,,facility,both,1,EA,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK,50863,CDM,636,RC,J3490,HCPCS,12870-0001-2,NDC,facility,both,5,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,70860-751-02,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,0409-3795-19,NDC,facility,both,1,ML,JW,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ALTEPLASE 1 MG/ML (1ML) SYRINGE (REPACK),50863,CDM,250,RC,J2997,HCPCS,50242-044-13,NDC,facility,both,2,EA,,584,408.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANTI-INHIBITOR COAGULANT CMPLX (PHS MERGE),50863,CDM,250,RC,J7198,HCPCS,64193-426-02,NDC,facility,both,400,UN,,2889,2022.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
REGADENOSON 0.4 MG/5 ML IV SYRG,50863,CDM,250,RC,J2785,HCPCS,0469-6501-89,NDC,facility,both,4,ML,JZ,913,639.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CLINDAMYCIN IN D5W 600 MG/50 ML IV PGBK,50863,CDM,250,RC,J0736,HCPCS,0338-3612-50,NDC,facility,both,2,ML,JZ,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DIAZEPAM  5 MG ORAL TAB,50863,CDM,J3490,HCPCS,51079-285-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 800 MG ORAL TAB,50863,CDM,250,RC,J0601,HCPCS,50268-720-11,NDC,facility,both,160,EA,,175,122.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,636,RC,J3490,HCPCS,55111-466-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,50863,CDM,J9263,HCPCS,67457-469-10,NDC,,,facility,both,2,ML,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 100 MG/ML FROM 1 GRAM VIAL (PRMC PEDS ONLY),50863,CDM,636,RC,J0696,HCPCS,0409-7332-11,NDC,facility,both,8,EA,,183,128.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,10135-778-01,NDC,facility,both,20,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE IN D5W 1 GRAM/100 ML IV PGBK,50863,CDM,636,RC,J3475,HCPCS,0338-1709-40,NDC,facility,both,4,ML,JZ,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
BUDESONIDE 0.5 MG/2 ML INHL NBSP,50863,CDM,250,RC,J3490,HCPCS,0487-9701-01,NDC,facility,both,4,ML,,219,153.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE  50 MG ORAL TAB,50863,CDM,j3490,HCPCS,0904-6868-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 400 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-602-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGIC MOUTHWASH REPACK (BMX 1:1:1),50863,CDM,250,RC,J3490,HCPCS,0603-0823-54,NDC,facility,both,1,ML,,140,98,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEBIVOLOL  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,31722-585-30,NDC,facility,both,2,EA,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,10135-778-01,NDC,facility,both,40,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,636,RC,Q9968,HCPCS,71288-811-10,NDC,facility,both,2,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,50863,CDM,636,RC,J1756,HCPCS,0517-2325-01,NDC,facility,both,100,ML,,371,259.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MODAFINIL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65862-601-30,NDC,facility,both,2,EA,,224,156.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,63323-161-00,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7452-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,63323-161-00,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0054-0710-20,NDC,facility,both,8,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,67,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE PAMOATE  25 MG ORAL CAP,50863,CDM,250,RC,Q0177,HCPCS,60687-696-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,636,RC,J3490,HCPCS,70004-600-09,NDC,facility,both,2,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,70860-406-41,NDC,facility,both,2,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6371-61,NDC,facility,both,2,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML INJ SOLN (PULMONARY USE),50863,CDM,250,RC,J2250,HCPCS,55390-137-02,NDC,facility,both,4,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,69315-904-01,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6007-61,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,2,EA,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,2,ML,,310,217,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,63739-931-14,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 500 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0093-3147-01,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69238-2078-1,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,22,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,50863,CDM,636,RC,J1885,HCPCS,0409-3796-19,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR  6 MG/ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0004-0822-05,NDC,facility,both,4,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOFETILIDE 250 MCG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,72603-131-01,NDC,facility,both,2,EA,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 20 GRAM/30 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,0121-1154-30,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,50863,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,134,ML,,162,113.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-097-11,NDC,facility,both,4,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 0.25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-570-11,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIPHTH,PERTUS(ACELL),TETANUS SYRG (INFANRIX) 25 LF UNIT-58MCG-10 LF/0.5ML IM SYRINGE",50863,CDM,636,RC,90700,HCPCS,58160-810-43,NDC,facility,both,1,ML,VFC,172,120.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier VFC: Modifier description not available
SODIUM PHOSPHATE 3 MMOL/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-7391-82,NDC,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 2 MG/ML IV SOLN,50863,CDM,250,RC,J9000,HCPCS,25021-207-51,NDC,facility,both,10,ML,,279,195.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROTHIAZIDE SODIUM 500 MG IV SOLR,50863,CDM,250,RC,J1205,HCPCS,25021-305-20,NDC,facility,both,1,EA,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,50863,CDM,250,RC,J1756,HCPCS,0517-2340-01,NDC,facility,both,300,ML,,935,654.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-492-27,NDC,facility,both,300,ML,,236,165.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUB-Q SOLN",50863,CDM,250,RC,90716,HCPCS,0006-4827-00,NDC,facility,both,1,EA,,465,325.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-0710-20,NDC,facility,both,16,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOBAZAM 2.5 MG/ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,99999-0404-03,NDC,facility,both,2,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EMTRICITABINE-TENOFOVIR 200 MG-300 MG TAB,50863,CDM,250,RC,J0750,HCPCS,16714-534-01,NDC,facility,both,1,EA,,297,207.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZOCAINE 20 % MM SPRY,50863,CDM,J3490,HCPCS,0283-0610-43,NDC,,,facility,both,2,EA,,101,70.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.3 MG/0.3 ML IM PNIJ,50863,CDM,J0171,HCPCS,0093-5986-19,NDC,,,facility,both,3,EA,,1024,716.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN 0.9 % SODIUM CHL 1.5 GRAM/500 ML IV SOLN,50863,CDM,J3370,HCPCS,70004-924-44,NDC,,,facility,both,3,ML,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML ORAL SOLUTION (FOR PEDIATRIC USE),50863,CDM,250,RC,J3480,HCPCS,63323-965-05,NDC,facility,both,8,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) 1000 UNITS/ML INJ SOL (FOR DIALYSIS ONLY),50863,CDM,250,RC,J1644,HCPCS,25021-400-10,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 10 MEQ/100 ML IV PGBK (USE NON-PROTOCOL PANEL),50863,CDM,636,RC,J3480,HCPCS,0338-0709-48,NDC,facility,both,5,ML,JZ,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
BUSPIRONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,24689-907-01,NDC,facility,both,3,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOFLOXACIN 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6352-61,NDC,facility,both,2,EA,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEMANTINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6505-61,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-9558-05,NDC,facility,both,2,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN PEDS SYRINGE (20MG/ML) IN DEXTROSE (CDS MIX,50863,CDM,250,RC,J0690,HCPCS,0781-3451-70,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 100 MG PE/2 ML INJ SOLN,50863,CDM,250,RC,Q2009,HCPCS,0641-6136-01,NDC,facility,both,2,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 100 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,60687-479-11,NDC,facility,both,4,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0409-4699-24,NDC,facility,both,300,ML,,380,266,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,72888-039-60,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LANREOTIDE 120 MG/0.5 ML SUBQ SYRG,50863,CDM,J1930,HCPCS,69097-870-67,NDC,,,facility,both,120,ML,,24544,17180.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMFIBROZIL 600 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-473-11,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIROFIBAN-0.9% SODIUM CHLORIDE 5 MG/100 ML (50 MCG/ML) IV SOLN,50863,CDM,250,RC,J3246,HCPCS,25208-002-01,NDC,facility,both,20,ML,JZ,398,278.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ADENOSINE 300 MCG/ML BOLUS (NEO),50863,CDM,250,RC,J3490,HCPCS,99999-0403-63,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J3490,HCPCS,0338-0049-01,NDC,facility,both,1,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
TRAMADOL  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0378-4151-01,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,250,RC,Q9968,HCPCS,70710-1838-1,NDC,facility,both,25,ML,JW,141,98.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GABAPENTIN 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-580-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,250,RC,J0132,HCPCS,70594-111-01,NDC,facility,both,132,ML,,671,469.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 100 MG ORAL TB12,50863,CDM,250,RC,J3490,HCPCS,16714-063-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL IV BOLUS 10MG/ML (ANESTHESIA ONLY),50863,CDM,636,RC,J2704,HCPCS,0409-4699-54,NDC,facility,both,161,ML,,204,142.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,71288-402-30,NDC,facility,both,30,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,636,RC,J2270,HCPCS,0409-1890-03,NDC,facility,both,1,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-381-11,NDC,facility,both,2,EA,,583,408.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,636,RC,J1953,HCPCS,63323-400-01,NDC,facility,both,100,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MONTELUKAST 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-875-11,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG/ML INJ SOLN,50863,CDM,250,RC,J2550,HCPCS,0641-6084-25,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,4,EA,,142,99.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESALAMINE 1.2 G ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,0378-7401-78,NDC,facility,both,1,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-3178-16,NDC,facility,both,380,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,8,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,250,RC,J0137,HCPCS,55150-307-01,NDC,facility,both,12,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOPIDOGREL  75 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,65862-357-30,NDC,facility,both,1,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0003-0894-21,NDC,facility,both,4,EA,,238,166.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALSARTAN  80 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,33342-063-10,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 500 MG PE/10 ML INJ SOLN,50863,CDM,250,RC,Q2009,HCPCS,0641-6137-01,NDC,facility,both,30,ML,JZ,726,508.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
OXYTOCIN IN 0.9 % SOD CHLORIDE 30 UNIT/500 ML IV SOLN,50863,CDM,250,RC,J2590,HCPCS,71266-5103-1,NDC,facility,both,4,ML,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,50863,CDM,250,RC,J9060,HCPCS,0703-5748-11,NDC,facility,both,6,ML,,131,91.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 175 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42292-040-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-1971-21,NDC,facility,both,3,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-ABDA 100 MG IV SOLR,50863,CDM,250,RC,Q5104,HCPCS,78206-162-99,NDC,facility,both,70,EA,,14556,10189.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLIPIZIDE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6637-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0121-1781-05,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,63323-185-10,NDC,facility,both,2,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN (NEW TX NON-NEURO INDICATION)",50863,CDM,250,RC,J1561,HCPCS,13533-800-71,NDC,facility,both,20,ML,,2829,1980.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 400 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-5853-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  50 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0071-1013-41,NDC,facility,both,2,EA,,131,91.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,24689-907-01,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICLOXACILLIN 250 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,59651-565-01,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-588-11,NDC,facility,both,3,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM 2000 MG IV SOLR,50863,CDM,250,RC,J2185,HCPCS,44567-402-01,NDC,facility,both,10,EA,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HETASTARCH 6 % IN NORMAL SALINE IV,50863,CDM,636,RC,J3490,HCPCS,0409-7248-13,NDC,facility,both,1,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,64208-2510-1,NDC,facility,both,2,ML,JZ,238,166.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
INSULIN REGULAR HUM U-500 CONC 500 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1815,HCPCS,0002-8501-01,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 10 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-6987-61,NDC,facility,both,3,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-550-11,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUBIPROSTONE  8 MCG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,70710-1641-6,NDC,facility,both,1,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  500 MCG/ML INJ SOLN,50863,CDM,636,RC,J2354,HCPCS,63323-377-00,NDC,facility,both,20,ML,"JZ,JA",253,177.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,636,RC,J2597,HCPCS,65219-293-00,NDC,facility,both,19,ML,,412,288.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,14,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,636,RC,J3490,HCPCS,0641-6236-01,NDC,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,0641-6145-01,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,3,ML,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,J7060,HCPCS,0338-0017-48,NDC,,,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 1 MG ORAL CAP,50863,CDM,250,RC,J7507,HCPCS,51079-818-01,NDC,facility,both,2,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,51754-4250-1,NDC,facility,both,1,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,59762-4910-3,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE  7.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,57237-007-30,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG ORAL CAP,50863,CDM,J3490,HCPCS,0904-6665-61,NDC,,,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,J3490,HCPCS,63323-202-02,NDC,,,facility,both,60,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 60 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,27241-099-03,NDC,facility,both,2,EA,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DENOSUMAB 60 MG/ML SUBQ SYRG,50863,CDM,636,RC,J0897,HCPCS,55513-710-01,NDC,facility,both,60,ML,JZ,4930,3451,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DIPHENHYDRAMINE 50 MG/ML INJECTION,50863,CDM,250,RC,J1200,HCPCS,63323-664-00,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,63323-461-01,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-344-11,NDC,facility,both,1,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,636,RC,J0330,HCPCS,31722-981-10,NDC,facility,both,5,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EMTRICITABINE-TENOFOVIR 200 MG-300 MG TAB,50863,CDM,250,RC,J0750,HCPCS,60687-719-95,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6500-61,NDC,facility,both,4,EA,,190,133,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM 1 GRAM IV SOLR,50863,CDM,250,RC,J2185,HCPCS,0409-1391-22,NDC,facility,both,10,EA,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-344-11,NDC,facility,both,2,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE  7.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,13107-001-30,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZIPRASIDONE 20 MG CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6269-45,NDC,facility,both,5,EA,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,118,EA,,16284,11398.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL (VITAMIN D3)  1000 UNIT ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,2055503300,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  88 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,42292-038-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIFEDIPINE 20 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,23155-195-01,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,J2003,HCPCS,63323-486-05,NDC,,,facility,both,300,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEPLIZUMAB-MZWV 2 MG/20 ML IV SOLN,50863,CDM,636,RC,J9381,HCPCS,73650-316-01,NDC,facility,both,288,ME,,17411,12187.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-351-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,250,RC,J3360,HCPCS,0641-6244-01,NDC,facility,both,1,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,48,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RAMIPRIL 10 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,57237-225-01,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,50863,CDM,J1650,HCPCS,0075-0622-01,NDC,,,facility,both,7,ML,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLECAINIDE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0054-0010-20,NDC,facility,both,2,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 10 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7345-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,50863,CDM,636,RC,J0696,HCPCS,0409-7335-13,NDC,facility,both,8,EA,JZ,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LEVOCARNITINE 200 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0143-9852-01,NDC,facility,both,1,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE IN 0.9% NACL 3 GRAM/100 ML IV SOLN,50863,CDM,636,RC,J0612,HCPCS,61553-056-48,NDC,facility,both,900,ML,,382,267.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTAZIDIME-AVIBACTAM 2.5 GRAM (2 GRAM-0.5 GRAM) IV SOLR,50863,CDM,250,RC,J0714,HCPCS,0456-2700-10,NDC,facility,both,2,EA,JW,312,218.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
VALSARTAN 160 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-634-11,NDC,facility,both,2,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TERAZOSIN  1 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,50268-764-11,NDC,facility,both,4,EA,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCHLOROTHIAZIDE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-593-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 25 MG/5 ML (5 MG/ML) ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,62559-204-12,NDC,facility,both,1,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOVASTATIN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68180-467-01,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-3178-16,NDC,facility,both,210,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 1 GRAM INJ SOLR,50863,CDM,636,RC,J0692,HCPCS,25021-121-20,NDC,facility,both,2,EA,JZ,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,76045-009-96,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,636,RC,J2720,HCPCS,63323-229-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 100 MG PE/2 ML INJ SOLN,50863,CDM,250,RC,Q2009,HCPCS,0641-6136-01,NDC,facility,both,4,ML,,174,121.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICARDIPINE IN NACL (ISO-OS) 20 MG/200 ML IV PGBK,50863,CDM,250,RC,J3490,HCPCS,69097-007-45,NDC,facility,both,1,ML,,227,158.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-327-10,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0406-0512-23,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-208-01,NDC,,,facility,both,4100,ML,,1023,716.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9% IV (PEDS) BOLUS,50863,CDM,J7030,HCPCS,0264-7800-09,NDC,,,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN IN D5W 600 MG/50 ML IV PGBK,50863,CDM,J0736,HCPCS,0338-3616-50,NDC,,,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM SR 120 MG 24 HR CAP,50863,CDM,250,RC,J3490,HCPCS,63739-283-10,NDC,facility,both,2,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEP B-DP(ACELL)T-POLIO VACC-PF 10MCG-25LF-25MCG-10LF-40-8-32 IM SYRING,50863,CDM,250,RC,90723,HCPCS,58160-811-43,NDC,facility,both,1,ML,,421,294.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  500 MCG/ML INJ SOLN,50863,CDM,J2354,HCPCS,0641-6176-01,NDC,,,facility,both,2,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,72603-179-01,NDC,facility,both,6,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 100 MG/5 ML ORAL LIQD,50863,CDM,250,RC,J3490,HCPCS,50383-063-10,NDC,facility,both,30,ML,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLIMEPIRIDE 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-788-95,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MYCOPHENOLATE 500 MG TAB,50863,CDM,636,RC,J7517,HCPCS,0054-0166-25,NDC,facility,both,2,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG/ML INJ SOLN,50863,CDM,250,RC,J2550,HCPCS,0641-0928-21,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV,50863,CDM,250,RC,J7120,HCPCS,0338-0117-03,NDC,facility,both,2,ML,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML IM SOLN,50863,CDM,636,RC,90375,HCPCS,13533-318-05,NDC,facility,both,13,ML,,11093,7765.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,250,RC,J0690,HCPCS,70092-1017-46,NDC,facility,both,12,ML,,238,166.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-22,NDC,facility,both,7,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  100 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,25021-452-01,NDC,facility,both,48,ML,JA,519,363.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
SILDENAFIL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,31722-711-30,NDC,facility,both,1,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-50,NDC,facility,both,135,ML,,238,166.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-25,NDC,facility,both,80,ML,"JZ,JA",11316,7921.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,636,RC,J2003,HCPCS,0409-1323-05,NDC,facility,both,20,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,81,ML,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,250,RC,J2795,HCPCS,70069-064-25,NDC,facility,both,100,ML,JW,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
FOLIC ACID 400 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,5026834611,NDC,facility,both,3,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TORSEMIDE   5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-754-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,25021-601-03,NDC,facility,both,31,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 300 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,69452-125-50,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN DEXTROSE (ISO-OS) 2 GRAM/100 ML IV PGBK,50863,CDM,636,RC,J0689,HCPCS,0338-3508-41,NDC,facility,both,4,ML,JZ,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ASPIRIN   81 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,77333-031-25,NDC,facility,both,4,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MULTIVITAMIN W/IRON ORAL DROP 0.5 ML (PEDS/NEO),50863,CDM,250,RC,J3490,HCPCS,1785600392,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,76045-009-10,NDC,facility,both,10,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE 0.25 MG/2 ML INHL NBSP,50863,CDM,250,RC,J3490,HCPCS,0487-9601-01,NDC,facility,both,4,ML,,186,130.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,55150-307-01,NDC,facility,both,69,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,60,EA,JZ,8280,5796,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
VENLAFAXINE  75 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-314-01,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-333-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN  500 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,70010-491-01,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0456,HCPCS,70436-019-82,NDC,facility,both,1,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,250,RC,J3490,HCPCS,59310-579-20,NDC,facility,both,1,GM,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAVASTATIN 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-886-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE  1 % TOP OINT,50863,CDM,250,RC,J3490,HCPCS,70677-1214-1,NDC,facility,both,1,GM,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,250,RC,J3360,HCPCS,0409-1273-32,NDC,facility,both,2,ML,,198,138.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE 21 MG/24 HR TD PT24,50863,CDM,250,RC,J3490,HCPCS,0536-5896-88,NDC,facility,both,2,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE 0.5 MG/2 ML INHL NBSP,50863,CDM,250,RC,J3490,HCPCS,0487-9701-01,NDC,facility,both,1,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0780,HCPCS,0641-6135-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLMESARTAN 40 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68462-438-30,NDC,facility,both,1,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,50863,CDM,250,RC,J0696,HCPCS,44567-701-25,NDC,facility,both,7,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,76045-009-10,NDC,facility,both,10,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68382-181-01,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7350-61,NDC,facility,both,8,EA,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIMOLOL MALEATE 0.5 % OPHT DROP,50863,CDM,250,RC,J3490,HCPCS,17478-288-10,NDC,facility,both,1,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
23.4% SODIUM CHLORIDE (4 MEQ/ML) INJECTION,50863,CDM,250,RC,J3490,HCPCS,0409-1141-02,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 12.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68382-094-01,NDC,facility,both,6,EA,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETHAMBUTOL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68180-280-01,NDC,facility,both,3,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2310,HCPCS,67457-599-00,NDC,facility,both,1,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,0641-0476-21,NDC,facility,both,3,ML,,470,329,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2308-22,NDC,facility,both,20,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) NEB SOLUTION,50863,CDM,250,RC,J3490,HCPCS,0487-9501-01,NDC,facility,both,2,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,65862-707-55,NDC,facility,both,5,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-4279-16,NDC,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,636,RC,J1836,HCPCS,47335-993-01,NDC,facility,both,150,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM ZIRCONIUM CYCLOSILICATE  5 G ORAL PWPK (USE PANEL),50863,CDM,636,RC,J3490,HCPCS,0310-1105-01,NDC,facility,both,3,EA,,418,292.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16729-216-15,NDC,facility,both,3,EA,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR IRRIGATION, STERILE SOLUTION",50863,CDM,636,RC,J3490,HCPCS,0338-0004-02,NDC,facility,both,4,ML,,139,97.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIPASE-PROTEASE-AMYLASE 12,000-38,000- 60,000 UNIT ORAL CAP, DELAY REL",50863,CDM,636,RC,J3490,HCPCS,0032-1212-01,NDC,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCRALFATE 100 MG/ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0121-0974-10,NDC,facility,both,1,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,131,ML,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORDIAZEPOXIDE 25 MG CAP,50863,CDM,250,RC,J3490,HCPCS,51079-141-01,NDC,facility,both,3,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7126-61,NDC,facility,both,4,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,60687-390-11,NDC,facility,both,5,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,1,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,31722-711-30,NDC,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0641-6206-01,NDC,facility,both,6,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,250,RC,J2405,HCPCS,0641-6078-25,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60505-3113-0,NDC,facility,both,2,EA,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 1 MG/ML PCA (PDS MERGE),50863,CDM,636,RC,J3490,HCPCS,70092-1521-74,NDC,facility,both,1,ML,,154,107.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 1%/EPINEPHRINE 1:200K INJECTION (PF),50863,CDM,636,RC,J3490,HCPCS,63739-468-05,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN PEDS SYRINGE (20MG/ML) IN DEXTROSE (CDS MIX,50863,CDM,250,RC,J7999,HCPCS,0781-3451-70,NDC,facility,both,4,EA,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7188-61,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J2250,HCPCS,0409-2305-17,NDC,facility,both,5,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,10135-778-01,NDC,facility,both,60,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,3700025445,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0904-7127-61,NDC,facility,both,60,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL  12 MCG/HR TD PT72,50863,CDM,636,RC,J3490,HCPCS,0378-9119-16,NDC,facility,both,1,EA,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-406-03,NDC,facility,both,1,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,63323-185-10,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,2,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
SECUKINUMAB  25 MG/ML IV SOLN,50863,CDM,636,RC,J3247,HCPCS,0078-1168-61,NDC,facility,both,190,ML,,8962,6273.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,63323-165-01,NDC,facility,both,6,ML,JZ,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,76045-009-05,NDC,facility,both,4,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-591-11,NDC,facility,both,4,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-25,NDC,facility,both,33,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGIC MOUTHWASH REPACK (BMX 1:1:1),50863,CDM,250,RC,J3490,HCPCS,99999-500-91,NDC,facility,both,2,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,63323-104-25,NDC,facility,both,9,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,636,RC,J3490,HCPCS,61553-320-70,NDC,facility,both,2,ML,,138,96.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZIPRASIDONE 40 MG CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6270-08,NDC,facility,both,1,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT  40 MCG/0.4 ML INJ SYRG,50863,CDM,250,RC,J0881,HCPCS,55513-021-01,NDC,facility,both,80,ML,,2192,1534.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42291-083-30,NDC,facility,both,1,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,63323-468-17,NDC,facility,both,1,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2308-22,NDC,facility,both,7,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CISPLATIN 1 MG/ML IV,50863,CDM,250,RC,J9060,HCPCS,0703-5748-11,NDC,facility,both,13,ML,,296,207.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-506-11,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR  6 MG/ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,42291-567-60,NDC,facility,both,5,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE  75 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,57664-692-88,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,0121-4675-05,NDC,facility,both,2,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 3000 MCG/ML INJECTION,50863,CDM,636,RC,J0153,HCPCS,25021-318-02,NDC,facility,both,6,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 20 GRAM/30 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-1154-30,NDC,facility,both,4,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN   81 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,77333-031-25,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-8297-25,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LANSOPRAZOLE 3 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,65628-080-05,NDC,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM PHOSPHATE 3 MMOL/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-884-01,NDC,facility,both,1,ML,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFUROXIME AXETIL 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,67877-215-60,NDC,facility,both,2,EA,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 875 MG-125 MG TAB,50863,CDM,636,RC,J3490,HCPCS,65862-503-01,NDC,facility,both,14,EA,,294,205.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM HYPOCHLORITE 0.125 % MISC SOLN,50863,CDM,250,RC,J3490,HCPCS,3932806412,NDC,facility,both,1,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,51754-5011-1,NDC,facility,both,5,ML,,270,189,,,,,,,,,,,,,Gross Charge Type: Pharmacy
K PHOS DI & MONO-SOD PHOS MONO 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,6954326810,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FIDAXOMICIN 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,52015-080-01,NDC,facility,both,20,EA,,14366,10056.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN   81 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,63739-212-02,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 2 MG INJ SOLR,50863,CDM,250,RC,J2997,HCPCS,50242-041-64,NDC,facility,both,10,EA,,4000,2800,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOLTERODINE 2 MG ORAL CP24,50863,CDM,636,RC,J3490,HCPCS,43975-322-03,NDC,facility,both,2,EA,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG/5 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,0904-6828-05,NDC,facility,both,2,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,250,RC,J3490,HCPCS,59310-579-22,NDC,facility,both,1,GM,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL (5 MG/ML) IV SYRG (CONTAINS PRESERVATIVE),50863,CDM,250,RC,J3490,HCPCS,65302-503-04,NDC,facility,both,4,ML,,133,93.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,102,EA,,14076,9853.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CINACALCET 30 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,31722-103-30,NDC,facility,both,1,EA,,150,105,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,16714-661-01,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 50 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,59651-489-01,NDC,facility,both,25,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,50863,CDM,250,RC,J0585,HCPCS,0023-1145-01,NDC,facility,both,300,EA,,4795,3356.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE ACETATE 25 MG RECT SUPP,50863,CDM,250,RC,J3490,HCPCS,0713-0503-06,NDC,facility,both,1,EA,,111,77.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,60,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE SODIUM 25 MG/ML INJ SOLN,50863,CDM,636,RC,J9260,HCPCS,61703-350-37,NDC,facility,both,4,ML,,176,123.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATOVAQUONE 750 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0173-0547-00,NDC,facility,both,1,ML,,195,136.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLESTYRAMINE 4 G ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,0245-0036-89,NDC,facility,both,1,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 25 MG CAP,50863,CDM,636,RC,J3490,HCPCS,69618-024-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GOLIMUMAB  12.5 MG/ML IV SOLN,50863,CDM,636,RC,J1602,HCPCS,57894-350-01,NDC,facility,both,25,ML,JW,1200,840,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CEPHALEXIN 250 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7336-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL (5 MG/ML) IV SYRG (CONTAINS PRESERVATIVE),50863,CDM,250,RC,J3490,HCPCS,65302-503-04,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-088-11,NDC,facility,both,2,EA,,254,177.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),50863,CDM,250,RC,J2060,HCPCS,0641-6044-01,NDC,facility,both,3,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM PHOSPHATE 3 MMOL/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-881-01,NDC,facility,both,1,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAZOSIN 1 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7020-61,NDC,facility,both,4,EA,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,250,RC,J0690,HCPCS,70092-1017-46,NDC,facility,both,2,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LITHIUM CARBONATE 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0054-2527-25,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOSTIGMINE METHYLSULFATE 3 MG/3 ML (1 MG/ML) IV SYRG,50863,CDM,250,RC,J2710,HCPCS,69374-932-03,NDC,facility,both,2,ML,,191,133.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN NACL (PF) 1000 UNIT/500 ML IV SOLP,50863,CDM,250,RC,J1644,HCPCS,0409-1005-01,NDC,facility,both,2,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOBRAMYCIN 300 MG/5 ML INHL NEBU (REPACK),50863,CDM,250,RC,J3490,HCPCS,70756-604-56,NDC,facility,both,1,ML,,328,229.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCOSAMINE SULFATE  500 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,5026837511,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION,50863,CDM,250,RC,J3490,HCPCS,0310-7370-20,NDC,facility,both,1,GM,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.3 MG/0.3 ML IM PNIJ,50863,CDM,250,RC,J0171,HCPCS,49502-102-01,NDC,facility,both,3,EA,,675,472.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE (PF) IN 0.9 % NACL 1 MG/ML VENT INFUSION,50863,CDM,250,RC,J2274,HCPCS,70092-1522-35,NDC,facility,both,5,ML,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,43547-351-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIRMATRELVIR-RITONAVIR 150 MG (10)- 100 MG (10) ORAL DSPK,50863,CDM,250,RC,J3490,HCPCS,0069-5317-02,NDC,facility,both,2,EA,,628,439.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,63739-931-14,NDC,facility,both,7,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GAMMAGARD LIQUID 10 % IV SOLN,50863,CDM,636,RC,J1569,HCPCS,0944-2700-12,NDC,facility,both,40,ML,"JZ,JA,JG",7211,5047.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously | Modifier JG: Drug or biological acquired with 340b drug pricing program discount
CEFAZOLIN PEDS SYRINGE (20MG/ML) IN DEXTROSE (CDS MIX,50863,CDM,250,RC,J7999,HCPCS,0781-3451-70,NDC,facility,both,2,EA,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-406-03,NDC,facility,both,1,ML,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE HCL IN NS 10 MG/250 ML (0.04 MG/ML) IV SOLN (PDS MERGE),50863,CDM,636,RC,J2371,HCPCS,72196-6058-1,NDC,facility,both,500,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6303-61,NDC,facility,both,10,EA,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J3430,HCPCS,43598-405-11,NDC,facility,both,7,ME,JW,360,252,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
HYDROMORPHONE  4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42858-302-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 1 MG (ENVARSUS XR) 24-HOUR EXTENDED-RELEASE TABLET,50863,CDM,636,RC,J7508,HCPCS,68992-3010-3,NDC,facility,both,2,EA,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLIPIZIDE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6637-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM  3 GRAM INJ SOLR,50863,CDM,636,RC,J0295,HCPCS,0049-0014-81,NDC,facility,both,2,EA,JZ,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
AZACITIDINE 100 MG INJ SOLR,50863,CDM,250,RC,J9025,HCPCS,72485-201-01,NDC,facility,both,50,EA,JW,309,216.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
FAMOTIDINE 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-966-01,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-4279-16,NDC,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MULTIVITAMIN WITH FOLIC ACID 400 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,904053061,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-25,NDC,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2305-16,NDC,facility,both,10,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATRACURIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,71288-701-06,NDC,facility,both,10,ML,,315,220.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-406-03,NDC,facility,both,1,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEGESTROL 40 MG ORAL TAB,50863,CDM,250,RC,J9999,HCPCS,0555-0607-02,NDC,facility,both,2,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,200,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2308-21,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML IV,50863,CDM,250,RC,J3490,HCPCS,25021-319-05,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0248-01,NDC,facility,both,100,ML,,127,88.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,7733351625,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,70069-363-01,NDC,facility,both,1,ML,,159,111.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  5 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-122-11,NDC,facility,both,2,EA,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIROLIMUS 0.5 MG ORAL TAB,50863,CDM,250,RC,J7520,HCPCS,68382-520-01,NDC,facility,both,1,EA,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATENOLOL 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-685-01,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,0409-9094-22,NDC,facility,both,1,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DULOXETINE 30 MG ORAL CPDR,50863,CDM,636,RC,J3490,HCPCS,60687-734-11,NDC,facility,both,2,EA,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CENOBAMATE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,71699-050-30,NDC,facility,both,1,EA,,238,166.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,42023-164-01,NDC,facility,both,20,ML,,413,289.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,172,ML,,155,108.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,68516-5219-0,NDC,facility,both,10,ML,,2542,1779.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,0944-0495-06,NDC,facility,both,2,ML,,416,291.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELIMUMAB 400 MG IV SOLR,50863,CDM,636,RC,J0490,HCPCS,49401-102-01,NDC,facility,both,40,EA,,4459,3121.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,42858-302-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LET TOPICAL GEL 3 ML,50863,CDM,636,RC,J3490,HCPCS,70092-1611-44,NDC,facility,both,1,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-381-11,NDC,facility,both,1,EA,,343,240.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6426-61,NDC,facility,both,3,EA,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRIL MALEATE 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,43547-548-10,NDC,facility,both,2,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML INJECTION,50863,CDM,250,RC,J3411,HCPCS,72603-139-25,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIPASE-PROTEASE-AMYLASE 12,000-38,000- 60,000 UNIT ORAL CAP, DELAY REL",50863,CDM,636,RC,J3490,HCPCS,0032-0047-70,NDC,facility,both,2,EA,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM PHOSPHATE DIBASIC 3 MMOLE/ML IV SOLP,50863,CDM,250,RC,J3490,HCPCS,0517-2350-25,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6782-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CINACALCET 30 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-525-11,NDC,facility,both,2,EA,,263,184.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZTREONAM 1 GRAM INJ SOLR,50863,CDM,250,RC,J0457,HCPCS,0409-0829-11,NDC,facility,both,10,EA,JZ,194,135.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J2004,HCPCS,63323-482-03,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2599,HCPCS,63323-930-01,NDC,facility,both,9,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2598,HCPCS,43598-914-11,NDC,facility,both,12,ML,JW,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PREDNISONE 20 MG ORAL TAB,50863,CDM,FAMNOCHARGE,HCPCS,60687-145-11,NDC,,,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFUROXIME AXETIL 250 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-272-11,NDC,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-11,NDC,facility,both,19,ML,JW,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ESCITALOPRAM 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,43547-281-10,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 800 MG ORAL TAB,50863,CDM,250,RC,J0601,HCPCS,50268-720-11,NDC,facility,both,120,EA,,131,91.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,71288-505-02,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DORZOLAMIDE-TIMOLOL 2 %-0.5 % EYE DROPS,50863,CDM,250,RC,J3490,HCPCS,62332-553-10,NDC,facility,both,1,ML,,440,308,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE 0.5 MG/2 ML INHL NBSP,50863,CDM,250,RC,J3490,HCPCS,68180-984-05,NDC,facility,both,1,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE  10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,69367-388-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LANSOPRAZOLE 30 MG ORAL TBLD,50863,CDM,636,RC,J3490,HCPCS,68382-772-30,NDC,facility,both,1,EA,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUANFACINE 2 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,62332-746-31,NDC,facility,both,1,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE  10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,70756-201-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2305-16,NDC,facility,both,10,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,23155-902-01,NDC,facility,both,2,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN NORMAL SALINE IV,50863,CDM,636,RC,J7042,HCPCS,0338-0089-03,NDC,facility,both,1,ML,JZ,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PREGABALIN  50 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-484-11,NDC,facility,both,6,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,76045-009-96,NDC,facility,both,15,ML,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3370,HCPCS,63323-284-26,NDC,facility,both,8,EA,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,68180-441-02,NDC,facility,both,6,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 100 MG PE/2 ML INJ SOLN,50863,CDM,250,RC,Q2009,HCPCS,0641-6136-01,NDC,facility,both,4,ML,,157,109.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BISACODYL  5 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,0904-6748-17,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 125 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0074-7068-11,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN NEO IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J3373,HCPCS,0338-3582-01,NDC,facility,both,40,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MINOXIDIL  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-204-11,NDC,facility,both,2,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,636,RC,Q0162,HCPCS,60687-252-40,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,50863,CDM,250,RC,J9075,HCPCS,10019-956-16,NDC,facility,both,53,EA,JW,151,105.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,105,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NADOLOL  20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-302-95,NDC,facility,both,3,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,250,RC,J2795,HCPCS,70069-064-25,NDC,facility,both,25,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
BUPROPION HCL 150 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,0904-7505-61,NDC,facility,both,2,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,68462-469-54,NDC,facility,both,2,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYMETAZOLINE 0.05 % NASAL MERGE,50863,CDM,250,RC,J3490,HCPCS,70677-1037-1,NDC,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE  3 % INHL NEBU,50863,CDM,636,RC,J3490,HCPCS,378699789,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 500 MG/5 ML ORAL SUMC,50863,CDM,250,RC,J3490,HCPCS,50419-773-01,NDC,facility,both,1,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-676-11,NDC,facility,both,3,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE 110 MCG/ACTUATION INHL AERO,50863,CDM,250,RC,J3490,HCPCS,0173-0719-20,NDC,facility,both,1,GM,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOPROTERENOL 0.2 MG/ML INJECTION,50863,CDM,250,RC,J3490,HCPCS,0548-9502-00,NDC,facility,both,4,ML,,3456,2419.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  50 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,72205-012-90,NDC,facility,both,2,EA,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7912-51,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3373,HCPCS,0143-9162-01,NDC,facility,both,500,EA,,200,140,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,636,RC,J7999,HCPCS,70092-1017-46,NDC,facility,both,2,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0003-0893-21,NDC,facility,both,1,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM  50 MG INJ SOLR,50863,CDM,250,RC,J0640,HCPCS,70436-116-82,NDC,facility,both,1,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYPROHEPTADINE 2 MG/5 ML ORAL SYRP,50863,CDM,636,RC,J3490,HCPCS,64980-504-48,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-113-11,NDC,facility,both,4,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,636,RC,J2003,HCPCS,0409-1323-05,NDC,facility,both,400,ML,,176,123.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),50863,CDM,250,RC,J3490,HCPCS,0409-4888-03,NDC,facility,both,2,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NORTRIPTYLINE 50 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-265-33,NDC,facility,both,2,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0131-2477-60,NDC,facility,both,1,EA,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SINCALIDE 5 MCG INJ SOLR,50863,CDM,250,RC,J2805,HCPCS,72266-248-05,NDC,facility,both,1,EA,,154,107.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLERGONOVINE 0.2 MG/ML (1 ML) INJ SOLN,50863,CDM,250,RC,J2210,HCPCS,51991-144-99,NDC,facility,both,2,ML,,232,162.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,64980-562-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0555-0873-02,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-22,NDC,facility,both,120,ML,,240,168,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-6625-22,NDC,facility,both,2,ML,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROMETHORPHAN-GUAIFENESIN SR 30 MG-600 MG 12 HR TAB,50863,CDM,636,RC,J3490,HCPCS,63824-056-34,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML SYRUP,50863,CDM,250,RC,J3490,HCPCS,0904-7134-70,NDC,facility,both,2,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID (PORK)  30 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,62559-741-01,NDC,facility,both,5,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,35,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFUROXIME AXETIL 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65862-700-20,NDC,facility,both,1,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 60 MG TAB,50863,CDM,250,RC,J3490,HCPCS,60687-728-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,406,ME,JZ,5510,3857,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
APREPITANT  40 MG ORAL CAP,50863,CDM,250,RC,J8501,HCPCS,68462-583-40,NDC,facility,both,1,EA,,396,277.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-535-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE IN D5W 1 GRAM/100 ML IV PGBK,50863,CDM,250,RC,J3475,HCPCS,63323-108-00,NDC,facility,both,4,ML,JZ,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ANTI-INHIBITOR COAGULANT CMPLX (PHS MERGE),50863,CDM,250,RC,J7198,HCPCS,64193-326-01,NDC,facility,both,100,UN,,723,506.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0054-0710-20,NDC,facility,both,18,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-3426-05,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) MISC SOLN,50863,CDM,250,RC,J3490,HCPCS,0517-7604-01,NDC,facility,both,1,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORTHALIDONE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-058-01,NDC,facility,both,2,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLP,50863,CDM,250,RC,J3480,HCPCS,0409-6653-18,NDC,facility,both,10,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAMSULOSIN 0.4 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,0904-6401-61,NDC,facility,both,2,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM BROMIDE 17 MCG/ACTUATION INHL AERO,50863,CDM,250,RC,J3490,HCPCS,0597-0087-17,NDC,facility,both,1,GM,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE INFUSION 2MG/ML 100ML (FOR ANESTHESIA USE ONLY),50863,CDM,250,RC,J3490,HCPCS,0409-2051-05,NDC,facility,both,1,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCYTOSINE 500 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,42494-340-01,NDC,facility,both,4,EA,,1462,1023.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,636,RC,J3490,HCPCS,70004-600-09,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,636,RC,J2270,HCPCS,0409-1890-13,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,2055503600,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 875 MG-125 MG TAB,50863,CDM,250,RC,J3490,HCPCS,16714-297-02,NDC,facility,both,6,EA,,145,101.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNIT/G TOP OINT (MERGE),50863,CDM,636,RC,J3490,HCPCS,0536-1263-28,NDC,facility,both,1,GM,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-161-11,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  20 MEQ ORAL PACK,50863,CDM,636,RC,J3490,HCPCS,72888-024-06,NDC,facility,both,3,EA,,150,105,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM 1 GRAM IV SOLR,50863,CDM,250,RC,J2185,HCPCS,63323-508-01,NDC,facility,both,10,EA,JZ,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
KETAMINE 100 MG/ML INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0143-9509-01,NDC,facility,both,1,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-3425-01,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,636,RC,J2560,HCPCS,72162-1330-6,NDC,facility,both,3,ML,,1102,771.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MILRINONE IN D5W 20 MG/100 ML (0.2 MG/ML) INFUSION,50863,CDM,250,RC,J2260,HCPCS,0409-2045-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,100,ML,JZ,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MEROPENEM 2000 MG IV SOLR,50863,CDM,636,RC,J2185,HCPCS,44567-402-01,NDC,facility,both,20,EA,,194,135.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,55150-222-20,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATED 20 MG/ML IV SOLN,50863,CDM,250,RC,J0706,HCPCS,51754-0500-1,NDC,facility,both,17,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAZOSIN 1 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7020-61,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN V POTASSIUM 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,57237-040-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-492-27,NDC,facility,both,60,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,42806-151-34,NDC,facility,both,8,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J2003,HCPCS,55150-161-02,NDC,facility,both,40,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,14,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLN (MERGE)",50863,CDM,636,RC,P9047,HCPCS,68516-5216-2,NDC,facility,both,4,ML,JZ,853,597.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,63323-185-07,NDC,facility,both,14,ML,,466,326.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-444-01,NDC,facility,both,6,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,636,RC,J3010,HCPCS,0409-9094-18,NDC,facility,both,3,ML,JZ,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SODIUM CHLORIDE 0.9 % INJ SYRG,50863,CDM,J3490,HCPCS,8290306504,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM BICARB-CITRIC ACID 20 MEQ ORAL TBEF,50863,CDM,636,RC,J3490,HCPCS,51801-011-01,NDC,facility,both,2,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAZOSIN 2 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7021-61,NDC,facility,both,3,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,J2704,HCPCS,0069-0209-01,NDC,,,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAMSULOSIN 0.4 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,0904-6401-61,NDC,facility,both,30,EA,,455,318.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,50863,CDM,636,RC,J0561,HCPCS,60793-701-10,NDC,facility,both,12,ML,,1188,831.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,50863,CDM,J9206,HCPCS,60505-6128-1,NDC,,,facility,both,10,ML,,353,247.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1815,HCPCS,0169-1833-11,NDC,facility,both,11,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,49502-393-80,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-821-01,NDC,facility,both,3,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOBRAMYCIN 0.3 % EYE DROPS,50863,CDM,250,RC,J3490,HCPCS,70069-131-01,NDC,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 50 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,51079-170-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VERAPAMIL 240 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,75834-159-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0406-1236-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,0641-6236-01,NDC,facility,both,1,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,6,EA,JW,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,636,RC,J2003,HCPCS,63323-485-27,NDC,facility,both,25,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE IN 0.9% NACL 3 GRAM/100 ML IV SOLN,50863,CDM,636,RC,J0612,HCPCS,61553-056-48,NDC,facility,both,600,ML,,255,178.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  10 MG ORAL TR12,50863,CDM,250,RC,J3490,HCPCS,59011-410-20,NDC,facility,both,2,EA,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MICAFUNGIN 100 MG IV SOLR,50863,CDM,250,RC,J2248,HCPCS,0143-9362-01,NDC,facility,both,50,EA,JW,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DEXAMETHASONE 4 MG ORAL TAB,50863,CDM,250,RC,J8540,HCPCS,0904-7266-61,NDC,facility,both,16,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6778-61,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 17 GRAM (100 %) ORAL PWPK,50863,CDM,636,RC,J3490,HCPCS,1152372688,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE  5 MG ORAL CP24,50863,CDM,636,RC,J3490,HCPCS,64850-510-01,NDC,facility,both,2,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE 14 MG/24 HR TD PT24,50863,CDM,250,RC,J3490,HCPCS,0536-5895-88,NDC,facility,both,2,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN  500 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,60687-640-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE 20 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0093-7115-98,NDC,facility,both,2,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,51754-4250-1,NDC,facility,both,2,ML,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",50863,CDM,250,RC,J1561,HCPCS,13533-800-24,NDC,facility,both,40,ML,JZ,5658,3960.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,422,ME,JZ,5727,4008.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,63323-400-01,NDC,facility,both,300,ML,,315,220.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,63323-280-03,NDC,facility,both,40,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORDIAZEPOXIDE 25 MG CAP,50863,CDM,636,RC,J3490,HCPCS,60687-807-11,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 600 MG ORAL TP12,50863,CDM,250,RC,J3490,HCPCS,68084-572-11,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"CIPROFLOXACIN-DEXAMETHASONE 0.3 %-0.1 % EAR DROPS, SUSP",50863,CDM,636,RC,J3490,HCPCS,62756-427-90,NDC,facility,both,1,ML,,827,578.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7001-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 10 % (100 MG/ML) MISC SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-695-04,NDC,facility,both,1,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 250 MCG SUBQ SOLR,50863,CDM,636,RC,J2802,HCPCS,55513-221-01,NDC,facility,both,250,EA,,4390,3073,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,636,RC,J3490,HCPCS,0173-0682-20,NDC,facility,both,1,GM,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 125 MG ORAL CPSP,50863,CDM,636,RC,J3490,HCPCS,68084-313-11,NDC,facility,both,6,EA,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-088-11,NDC,facility,both,1,EA,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM NEO IV SYRINGE (PHS FROM PREMIX),50863,CDM,250,RC,J1953,HCPCS,44567-501-01,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 100 MG IV SOLR,50863,CDM,250,RC,J2997,HCPCS,50242-085-25,NDC,facility,both,100,EA,JZ,24289,17002.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,250,RC,J0330,HCPCS,31722-981-10,NDC,facility,both,8,ML,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 4 MEQ/ML IV SOLP (COMPOUNDED 30ML),50863,CDM,250,RC,J3490,HCPCS,63323-093-01,NDC,facility,both,2,ML,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,40,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DARBEPOETIN ALFA IN POLYSORBAT 100 MCG/0.5 ML INJ SYRG,50863,CDM,636,RC,J0881,HCPCS,55513-025-01,NDC,facility,both,100,ML,EC,2137,1495.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier EC: Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy
INFLIXIMAB 100 MG IV SOLR,50863,CDM,636,RC,J1745,HCPCS,57894-030-01,NDC,facility,both,55,EA,JZ,17728,12409.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ISOSORBIDE DINITRATE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6619-61,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,72603-179-01,NDC,facility,both,8,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFUROXIME AXETIL 250 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-272-11,NDC,facility,both,2,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 125 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,60687-211-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE IN SALINE (ISO-OSM) 400 MG/200 ML IV PIGGY BACK,50863,CDM,250,RC,J1450,HCPCS,25021-184-87,NDC,facility,both,2,ML,JZ,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ONDANSETRON 4 MG ORAL TBDL,50863,CDM,J3490,HCPCS,68462-157-40,NDC,,,facility,both,1,EA,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,50863,CDM,J3490,HCPCS,57237-077-10,NDC,,,facility,both,1,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 15 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-6519-61,NDC,,,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE  5 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-7122-61,NDC,,,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,2,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TERAZOSIN  1 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,50268-764-11,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYBUTYNIN CHLORIDE  5 MG ORAL TO24,50863,CDM,636,RC,J3490,HCPCS,0904-6570-61,NDC,facility,both,3,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIOTROPIUM BROMIDE 18 MCG INHL CPDV,50863,CDM,636,RC,J3490,HCPCS,0597-0075-75,NDC,facility,both,1,EA,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTAMIDINE 300 MG INJ SOLR,50863,CDM,636,RC,J3490,HCPCS,63323-113-01,NDC,facility,both,1,EA,,433,303.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM-DEXTRS 4.5 GRAM/100 ML IV PGBK,50863,CDM,250,RC,J3490,HCPCS,0338-9638-01,NDC,facility,both,1,ML,,111,77.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTAMIDINE 300 MG INJ SOLR,50863,CDM,636,RC,J3490,HCPCS,63323-113-01,NDC,facility,both,1,EA,,332,232.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-229-02,NDC,facility,both,3,ML,,138,96.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,10019-016-39,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARGATROBAN 100 MG/ML IV SOLN,50863,CDM,250,RC,J0883,HCPCS,0409-1140-01,NDC,facility,both,250,ML,,962,673.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM-ALBUTEROL 0.5 MG-2.5 MG/3 ML NEB SOLUTION,50863,CDM,250,RC,J3490,HCPCS,0487-0201-01,NDC,facility,both,28,ML,,263,184.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,250,RC,J0137,HCPCS,0781-3156-06,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM IN D5W 125 MG/125 ML (1 MG/ML) IV SOLN (PREMIX),50863,CDM,250,RC,J3490,HCPCS,70092-1575-36,NDC,facility,both,1,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  15 MG ORAL TBSR,50863,CDM,636,RC,J3490,HCPCS,0406-8315-23,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE 150 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16571-110-01,NDC,facility,both,1,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,10,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,636,RC,J3490,HCPCS,51754-4250-1,NDC,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 25 MG/5 ML (5 MG/ML) ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,52536-600-11,NDC,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,0409-6625-14,NDC,facility,both,11,ML,,635,444.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,59762-0073-1,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 0.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-581-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4% TOP PATCH,50863,CDM,250,RC,J3490,HCPCS,0536-1202-07,NDC,facility,both,3,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,0641-6145-01,NDC,facility,both,4,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOLTERODINE 2 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,13668-189-30,NDC,facility,both,2,EA,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BISMUTH SUBSALICYLATE 262 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,0904-1315-46,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOVASTATIN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-0576-06,NDC,facility,both,2,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2305-04,NDC,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM ACETATE 667 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,68084-479-11,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM IODIDE 1 GRAM/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,75834-280-30,NDC,facility,both,1,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0641-0400-37,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,43,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTOBARBITAL 75 MG/1.5 ML SYRINGE (REPACK),50863,CDM,636,RC,J2515,HCPCS,25021-676-20,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAUNORUBICIN 5 MG/ML IV INJ,50863,CDM,636,RC,J9150,HCPCS,42658-021-01,NDC,facility,both,5,ML,,1370,959,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-173-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,50863,CDM,636,RC,Q5119,HCPCS,0069-0238-01,NDC,facility,both,8,ML,JW,689,482.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,250,RC,Q9968,HCPCS,0517-0381-01,NDC,facility,both,77,ML,,1278,894.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,70860-405-41,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE INFUSION 2MG/ML 100ML (FOR ANESTHESIA USE ONLY),50863,CDM,250,RC,J3490,HCPCS,0409-2051-05,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,250,RC,J3490,HCPCS,0409-1323-15,NDC,facility,both,200,ML,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,250,RC,J3101,HCPCS,50242-037-06,NDC,facility,both,30,EA,JW,5975,4182.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CHLOROPROCAINE 3 % INJ SOLN,50863,CDM,250,RC,J2401,HCPCS,63323-478-01,NDC,facility,both,420,ML,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7362-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRILAT 1.25 MG/ML IV INJ,50863,CDM,636,RC,J3490,HCPCS,0143-9787-01,NDC,facility,both,1,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,17271-701-05,NDC,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-476-11,NDC,facility,both,5,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,50863,CDM,250,RC,J0696,HCPCS,0781-3209-95,NDC,facility,both,8,EA,,388,271.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-19,NDC,facility,both,300,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,636,RC,J1610,HCPCS,0597-0053-45,NDC,facility,both,1,EA,JZ,186,130.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-3178-16,NDC,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LITHIUM CARBONATE 150 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0054-8526-25,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,636,RC,J2405,HCPCS,60505-6130-5,NDC,facility,both,4,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
OCTREOTIDE ACETATE  100 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,25021-452-01,NDC,facility,both,2,ML,"JZ,JA",22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
LANSOPRAZOLE 30 MG ORAL TBLD,50863,CDM,636,RC,J3490,HCPCS,65862-896-10,NDC,facility,both,1,EA,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYBUTYNIN CHLORIDE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,70954-005-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPAGLIFLOZIN PROPANEDIOL  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,66993-456-30,NDC,facility,both,1,EA,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,10,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIPASE-PROTEASE-AMYLASE 12,000-38,000- 60,000 UNIT ORAL CAP, DELAY REL",50863,CDM,250,RC,J3490,HCPCS,0032-1212-01,NDC,facility,both,6,EA,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,63739-903-10,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASCORBIC ACID  250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,2055500100,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MYCOPHENOLATE 200 MG/ML ORAL SUSP,50863,CDM,250,RC,J7517,HCPCS,66689-307-08,NDC,facility,both,1,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CELECOXIB 200 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-447-11,NDC,facility,both,2,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE ENEMA 200G IN SW (1000 ML TOTAL VOLUME),50863,CDM,250,RC,J3490,HCPCS,99999-0405-41,NDC,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,70756-640-82,NDC,,,facility,both,50,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,J2704,HCPCS,63323-269-22,NDC,,,facility,both,5,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/0.5 ML INHL NEBU,50863,CDM,250,RC,J3490,HCPCS,0487-9901-30,NDC,facility,both,8,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 100 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,51672-4047-9,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 100 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,43547-288-10,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6370-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE  50 MG ORAL TAB,50863,CDM,250,RC,j3490,HCPCS,0904-6868-61,NDC,facility,both,6,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,0008-0923-60,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROATE SODIUM 100 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-494-01,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2305-04,NDC,facility,both,7,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAZOLAMIDE 500 MG ORAL CPSR,50863,CDM,636,RC,J3490,HCPCS,23155-787-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-406-03,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2305-16,NDC,facility,both,6,ML,PT,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PT: Colorectal cancer screening test; converted to diagnostic test or other procedure
IMIPRAMINE 10 MG TAB,50863,CDM,250,RC,J3490,HCPCS,69315-133-01,NDC,facility,both,5,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 17 GRAM (100 %) ORAL PWPK,50863,CDM,636,RC,J3490,HCPCS,1152372688,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL  20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-072-33,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE (FOR CODE) 10% (100 MG/ML) IV SYRINGE,50863,CDM,250,RC,J3490,HCPCS,64253-900-30,NDC,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BLEOMYCIN 15 UNITS/5 ML INJ SOLR (WET SOLR VIAL),50863,CDM,636,RC,J9040,HCPCS,16714-886-01,NDC,facility,both,2,EA,,461,322.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRIL MALEATE 1 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,69238-1729-7,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE ACETATE 0.12 % OPHT DRPS,50863,CDM,636,RC,J3490,HCPCS,11980-174-05,NDC,facility,both,1,ML,,660,462,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITRIOL 0.25 MCG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-345-11,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRBESARTAN 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-442-11,NDC,facility,both,1,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,636,RC,J3490,HCPCS,0904-6794-30,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,50863,CDM,636,RC,J3301,HCPCS,70121-1049-2,NDC,facility,both,4,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,636,RC,J2560,HCPCS,0641-0476-21,NDC,facility,both,3,ML,,619,433.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,260,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
THYROID (PORK)  30 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,42192-329-01,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM-ALBUTEROL 0.5 MG-2.5 MG/3 ML NEB SOLUTION,50863,CDM,250,RC,J3490,HCPCS,0487-0201-01,NDC,facility,both,15,ML,,162,113.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-48,NDC,facility,both,1,ML,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,19,ML,JW,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,636,RC,J1611,HCPCS,63323-596-11,NDC,facility,both,2,EA,,1789,1252.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL  32.4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,13517-626-01,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,2,EA,,159,111.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION,50863,CDM,250,RC,J3490,HCPCS,0186-0370-28,NDC,facility,both,1,GM,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EZETIMIBE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69238-1154-3,NDC,facility,both,1,EA,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % MUCOSAL SOLN (VISCOUS),50863,CDM,250,RC,J3490,HCPCS,0603-1393-64,NDC,facility,both,40,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAZOLAMIDE 500 MG ORAL CPSR,50863,CDM,636,RC,J3490,HCPCS,60687-578-11,NDC,facility,both,1,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZINC OXIDE 16 % TOP PSTE,50863,CDM,250,RC,J3490,HCPCS,6210333302,NDC,facility,both,1,GM,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 50 MG TAB,50863,CDM,250,RC,J3490,HCPCS,69452-345-60,NDC,facility,both,1,EA,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42858-001-10,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0990-7983-61,NDC,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2599,HCPCS,55150-370-01,NDC,facility,both,40,ML,,329,230.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML IV,50863,CDM,250,RC,J3490,HCPCS,17478-937-10,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL IV BOLUS 10MG/ML (ANESTHESIA ONLY),50863,CDM,636,RC,J2704,HCPCS,0409-4699-54,NDC,facility,both,16,ML,JW,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CEFTRIAXONE 250 MG INJ SOLR,50863,CDM,636,RC,J0696,HCPCS,0781-3206-85,NDC,facility,both,2,EA,,146,102.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-985-01,NDC,facility,both,3,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,0409-1283-31,NDC,facility,both,10,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALTREXONE 50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7036-04,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,6,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,2055503601,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,250,RC,J2003,HCPCS,0409-1323-15,NDC,facility,both,1200,ML,,480,336,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOCARNITINE 200 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0143-9852-01,NDC,facility,both,6,ML,,1256,879.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,69238-2078-1,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB 100 MG IV SOLR,50863,CDM,636,RC,J1745,HCPCS,57894-030-01,NDC,facility,both,93,EA,,29976,20983.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-339-11,NDC,facility,both,3,EA,,240,168,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,50863,CDM,636,RC,J8540,HCPCS,0054-8175-25,NDC,facility,both,16,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  15 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,0406-8315-23,NDC,facility,both,2,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE MONONITRATE  60 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,0904-6450-61,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ELTROMBOPAG 75 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,31722-844-30,NDC,facility,both,2,EA,,3518,2462.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,250,RC,J2405,HCPCS,60505-6130-0,NDC,facility,both,4,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,20,ML,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ESMOLOL IN SALINE (ISO-OSMOTIC) 2,000 MG/100 ML (20 MG/ML) IV",50863,CDM,250,RC,J1805,HCPCS,25021-309-82,NDC,facility,both,1,ML,,648,453.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN  325 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,66553-001-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLERGONOVINE 0.2 MG/ML (1 ML) INJ SOLN,50863,CDM,636,RC,J2210,HCPCS,0517-0740-01,NDC,facility,both,2,ML,,230,161,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68382-806-01,NDC,facility,both,7,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,636,RC,J2003,HCPCS,63323-485-27,NDC,facility,both,120,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE HCL  2 % MM JELP,50863,CDM,J3490,HCPCS,25021-673-76,NDC,,,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0093-3426-01,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IR SOLN,50863,CDM,250,RC,J3490,HCPCS,0338-0047-46,NDC,facility,both,1,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,15,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,Q0162,HCPCS,16714-671-02,NDC,,,facility,both,8,ML,,234,163.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MILRINONE IN D5W 20 MG/100 ML (0.2 MG/ML) INFUSION,50863,CDM,250,RC,J2260,HCPCS,0409-2045-01,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 20MG/ML IV SYRINGE (PEDS/NEO),50863,CDM,250,RC,J0612,HCPCS,63323-311-10,NDC,facility,both,100,ML,JZ,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL 5 MCG/ML INJECTION,50863,CDM,250,RC,J3010,HCPCS,61553-479-78,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT  60 MCG/0.3 ML INJ SYRG,50863,CDM,250,RC,J0881,HCPCS,55513-023-04,NDC,facility,both,60,ML,,1282,897.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,15,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN PEDS INFUSION (CDS MIXTURE),50863,CDM,250,RC,J0290,HCPCS,99999-408-63,NDC,facility,both,2,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 1000 MG MISC TBSO,50863,CDM,250,RC,J3490,HCPCS,0223-1760-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0143-9889-15,NDC,facility,both,16,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,70,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENOFOVIR DISOPROXIL FUMARATE 300 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,42291-800-30,NDC,facility,both,1,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,50863,CDM,250,RC,J9045,HCPCS,0703-4239-01,NDC,facility,both,11,ML,,303,212.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL  3.125 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7305-61,NDC,facility,both,1,EA,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,50863,CDM,250,RC,J9045,HCPCS,61703-339-22,NDC,facility,both,3,ML,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE  5 MG ORAL CP24,50863,CDM,636,RC,J3490,HCPCS,64850-510-01,NDC,facility,both,4,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 20 MG/ML INJ SOLN,50863,CDM,636,RC,J0360,HCPCS,0517-0901-01,NDC,facility,both,1,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",50863,CDM,J1561,HCPCS,13533-800-25,NDC,,,facility,both,40,ML,,5658,3960.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 60 MG ORAL CPDR,50863,CDM,J3490,HCPCS,27241-099-03,NDC,,,facility,both,1,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROMETHORPHAN POLY COMPLEX ER 30 MG/5 ML ORAL SU12,50863,CDM,636,RC,J3490,HCPCS,45802-433-21,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,5,EA,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLP,50863,CDM,250,RC,J3480,HCPCS,63323-965-03,NDC,facility,both,20,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 20 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,0904-7458-61,NDC,facility,both,1,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,67877-590-01,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NAPROXEN 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68462-190-01,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE  5 MG/ML INJ SOLN,50863,CDM,250,RC,J2765,HCPCS,0409-3414-18,NDC,facility,both,2,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,50863,CDM,250,RC,J9000,HCPCS,0069-1542-20,NDC,facility,both,6,ML,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLP,50863,CDM,636,RC,J3480,HCPCS,0409-6653-18,NDC,facility,both,10,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE (FOR EMERGENCY) 100 MG/ML (10%) IV SOLN,50863,CDM,250,RC,J0612,HCPCS,63323-360-01,NDC,facility,both,50,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC IV INFUSION HYDRAT 31-60 MIN,50863,CDM,250,RC,J0248,HCPCS,61958-2901-2,NDC,facility,both,101,EA,,1208,845.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  250 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7123-61,NDC,facility,both,1,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,42291-809-15,NDC,facility,both,6,EA,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,63739-931-28,NDC,facility,both,9,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,50863,CDM,J0696,HCPCS,44567-702-25,NDC,,,facility,both,8,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,J3490,HCPCS,0409-9558-05,NDC,,,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,50863,CDM,J0696,HCPCS,0781-3209-90,NDC,,,facility,both,4,EA,,194,135.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,J0665,HCPCS,0409-1160-01,NDC,,,facility,both,25,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENFORTUMAB VEDOTIN-EJFV 20 MG IV SOLR,50863,CDM,J9177,HCPCS,51144-020-01,NDC,,,facility,both,20,ME,,633,443.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 400 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,65862-071-01,NDC,facility,both,2,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 250 MG INJ SOLR,50863,CDM,636,RC,J0696,HCPCS,0409-7337-11,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 200 MG INJ SOLR,50863,CDM,250,RC,J0640,HCPCS,63323-710-50,NDC,facility,both,4,EA,,134,93.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTAROLINE FOSAMIL 600 MG IV SOLR,50863,CDM,250,RC,J0712,HCPCS,0456-0600-01,NDC,facility,both,20,EA,JW,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
BUDESONIDE 0.25 MG/2 ML INHL NBSP,50863,CDM,250,RC,J3490,HCPCS,0487-9601-01,NDC,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-349-11,NDC,facility,both,1,EA,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,250,RC,J2003,HCPCS,63323-495-27,NDC,facility,both,240,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 800 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,17856-921-01,NDC,facility,both,2,EA,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,83257-011-11,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIKACIN 1000 MG/4 ML INJ SOLN,50863,CDM,250,RC,J0278,HCPCS,23155-290-31,NDC,facility,both,5,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM IN NACL (ISO-OS) 1500 MG/100 ML IV PGBK,50863,CDM,250,RC,J1953,HCPCS,36000-354-01,NDC,facility,both,150,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR NEO/PEDS INFUSION (CDS FROM PREMIX),50863,CDM,250,RC,J0133,HCPCS,63323-325-10,NDC,facility,both,15,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NORTRIPTYLINE 50 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-265-33,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-440-01,NDC,facility,both,4,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0780,HCPCS,23155-294-31,NDC,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,636,RC,J0690,HCPCS,70092-1017-46,NDC,facility,both,3,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  500 MCG/ML INJ SOLN,50863,CDM,636,RC,J2354,HCPCS,25021-465-01,NDC,facility,both,20,ML,JA,206,144.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
THIAMINE 100 MG TAB,50863,CDM,636,RC,J3490,HCPCS,904719106,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2308-22,NDC,facility,both,6,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
SODIUM PHOSPHATE 3 MMOL/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-170-05,NDC,facility,both,1,ML,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR PHOSPHATE 30 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,64380-797-01,NDC,facility,both,20,EA,,837,585.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNIT/G TOP PACK,50863,CDM,636,RC,J3490,HCPCS,0904-7402-67,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,70954-059-10,NDC,facility,both,10,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ESMOLOL IN SALINE (ISO-OSMOTIC) 2,500 MG/250 ML (10 MG/ML) IV",50863,CDM,250,RC,J1805,HCPCS,25021-308-84,NDC,facility,both,1,ML,,713,499.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL PACK,50863,CDM,250,RC,J3490,HCPCS,67877-422-57,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,4,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,250,RC,Q9968,HCPCS,70710-1838-1,NDC,facility,both,35,ML,JW,197,137.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
NADOLOL  20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-302-95,NDC,facility,both,1,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 10 MG-325 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0406-0125-23,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 2.5 MG RECT KIT,50863,CDM,250,RC,J3490,HCPCS,66490-650-20,NDC,facility,both,1,EA,,1047,732.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE (FOR CODE) 10% (100 MG/ML) IV SYRINGE,50863,CDM,250,RC,J3490,HCPCS,0409-4928-11,NDC,facility,both,4,ML,,402,281.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,60,ML,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BEZLOTOXUMAB 25 MG/ML IV SOLN,50863,CDM,636,RC,J0565,HCPCS,0006-3025-01,NDC,facility,both,70,ML,,7342,5139.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0406-5755-23,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLECAINIDE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-321-11,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-673-10,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MUPIROCIN 2 % TOP OINT,50863,CDM,636,RC,J3490,HCPCS,68462-180-22,NDC,facility,both,3,GM,,462,323.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 0.3 % OPHT DROP,50863,CDM,250,RC,J3490,HCPCS,61314-633-05,NDC,facility,both,2,ML,,213,149.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NAPROXEN 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-594-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-9149-01,NDC,facility,both,2,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 10 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-6987-61,NDC,facility,both,4,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VECURONIUM BROMIDE 10 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,0703-2914-01,NDC,facility,both,2,EA,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM  1.5 GRAM INJ SOLR,50863,CDM,636,RC,J0295,HCPCS,67457-348-15,NDC,facility,both,1,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J2310,HCPCS,0409-1215-01,NDC,facility,both,4,ML,,929,650.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DONEPEZIL  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6477-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-4279-16,NDC,facility,both,90,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,81033-002-05,NDC,facility,both,5,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,63323-104-25,NDC,facility,both,8,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 1000 MG MISC TBSO,50863,CDM,250,RC,J3490,HCPCS,0223-1760-01,NDC,facility,both,5,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,146,102.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,67877-545-68,NDC,facility,both,5,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LURASIDONE 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,67877-638-30,NDC,facility,both,1,EA,,217,151.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 50 MG/ML IV SOLN,50863,CDM,636,RC,J0282,HCPCS,70436-232-72,NDC,facility,both,10,ML,JZ,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
OSELTAMIVIR  6 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0004-0822-05,NDC,facility,both,3,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-272-11,NDC,facility,both,2,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE IN 0.9% NS (PF) 1 MG/10 ML (100 MCG/ML) IV SYRG(PDS MERGE),50863,CDM,250,RC,J3490,HCPCS,65302-506-10,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,42494-415-01,NDC,facility,both,1,ML,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J1940,HCPCS,0409-6102-18,NDC,facility,both,4,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-1283-03,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TARLATAMAB-DLLE  1 MG IV SOLR,50863,CDM,250,RC,J9026,HCPCS,55513-059-01,NDC,facility,both,1,EA,,4140,2898,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT 100 MCG/0.5 ML INJ SYRG,50863,CDM,636,RC,J0881,HCPCS,55513-025-01,NDC,facility,both,100,ML,"JZ,EC",2137,1495.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier EC: Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy
VENLAFAXINE  37.5 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,68084-698-11,NDC,facility,both,3,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-22,NDC,facility,both,20,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0406-0552-23,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6928-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN   81 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,57896-981-12,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,12,ML,JW,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
TEPLIZUMAB-MZWV 2 MG/20 ML IV SOLN,50863,CDM,636,RC,J9381,HCPCS,73650-316-01,NDC,facility,both,80,ME,,4837,3385.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 125 MG ORAL CPSP,50863,CDM,250,RC,J3490,HCPCS,55111-532-01,NDC,facility,both,4,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0003-0894-21,NDC,facility,both,2,EA,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG/5 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,0121-4827-05,NDC,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,13,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE MONONITRATE 120 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,13668-106-01,NDC,facility,both,1,EA,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  75 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-475-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER SULFADIAZINE 1 % TOP CREA,50863,CDM,636,RC,J3490,HCPCS,67877-124-50,NDC,facility,both,1,GM,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-21,NDC,facility,both,10,ML,"JZ,JA",1415,990.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
DILTIAZEM SR 180 MG 24 HR CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7218-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6924-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,55150-222-20,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSULFAN BLUE 1 % INJ SOLN,50863,CDM,250,RC,Q9968,HCPCS,67457-220-05,NDC,facility,both,10,ML,,1050,735,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,636,RC,J0690,HCPCS,70092-1017-46,NDC,facility,both,2,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,0641-6145-01,NDC,facility,both,10,ML,JZ,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ESCITALOPRAM 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-543-01,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 80 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-590-95,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J3430,HCPCS,43598-405-11,NDC,facility,both,5,ME,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-103-01,NDC,facility,both,4,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML INJ SOLN,50863,CDM,250,RC,J0171,HCPCS,76329-9060-0,NDC,facility,both,40,ML,,107,74.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0781-3458-75,NDC,facility,both,500,ML,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,23155-833-01,NDC,facility,both,4,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,636,RC,J2597,HCPCS,43598-931-11,NDC,facility,both,2,ML,JW,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CIPROFLOXACIN 500 MG/5 ML ORAL SUMC,50863,CDM,250,RC,J3490,HCPCS,50419-773-01,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 40 MG/ML (4 %) INJ SOLN (FOR NEBULIZATION),50863,CDM,250,RC,J3490,HCPCS,0409-4283-11,NDC,facility,both,160,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0093-4177-73,NDC,facility,both,4,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 100 MG 24 HR TAB,50863,CDM,636,RC,J3490,HCPCS,51079-171-01,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOZAPINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-415-11,NDC,facility,both,3,EA,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 15% IN WATER,50863,CDM,250,RC,J3490,HCPCS,0338-0023-03,NDC,facility,both,1,ML,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM CITRATE ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,69452-389-98,NDC,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),50863,CDM,250,RC,J3490,HCPCS,8290306545,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42858-302-25,NDC,facility,both,6,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,636,RC,J1953,HCPCS,63323-400-01,NDC,facility,both,136,ML,,143,100.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CANGRELOR 50 MG IV SOLR,50863,CDM,250,RC,C9460,HCPCS,10122-620-01,NDC,facility,both,50,EA,JZ,2764,1934.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CARVEDILOL  6.25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0093-0135-01,NDC,facility,both,2,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,250,RC,J0690,HCPCS,44567-707-25,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CANDESARTAN 16 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,33342-116-07,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,636,RC,J2704,HCPCS,25021-608-20,NDC,facility,both,2,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL,50863,CDM,636,RC,J1071,HCPCS,0143-9659-01,NDC,facility,both,100,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML INJ SOLN,50863,CDM,250,RC,J0169,HCPCS,76329-9060-0,NDC,facility,both,11,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 30 MG/0.3 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0548-5601-00,NDC,facility,both,3,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0781-3220-92,NDC,facility,both,1,ML,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,636,RC,J1596,HCPCS,0143-9679-01,NDC,facility,both,60,ML,,1368,957.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN 50 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,0904-7199-07,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,70069-363-01,NDC,facility,both,2,ML,,258,180.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NADOLOL  40 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,69238-1124-9,NDC,facility,both,1,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  1 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,59651-484-01,NDC,facility,both,3,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,47335-711-86,NDC,facility,both,2,EA,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,636,RC,J1610,HCPCS,63323-596-11,NDC,facility,both,2,EA,,1570,1099,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50228-420-01,NDC,facility,both,4,EA,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-1749-70,NDC,facility,both,2,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,53,EA,,7314,5119.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6950-61,NDC,facility,both,3,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-18,NDC,facility,both,200,ML,JZ,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
BUMETANIDE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-131-11,NDC,facility,both,3,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE  25 MG ORAL CAP,50863,CDM,250,RC,J7515,HCPCS,0078-0240-61,NDC,facility,both,1,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE  25 MG ORAL CAP,50863,CDM,636,RC,J7515,HCPCS,0078-0240-61,NDC,facility,both,3,EA,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 10 GRAM/100 ML (10%) INJ SOLN",50863,CDM,J1561,HCPCS,13533-800-72,NDC,,,facility,both,20,ML,,2829,1980.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARDIOPLEGIC SOLUTION NO.25 29 MMOL/L (POTASSIUM) PERF SOLN,50863,CDM,J3490,HCPCS,69374-984-10,NDC,,,facility,both,1,ML,,504,352.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,55150-177-05,NDC,facility,both,400,ML,JZ,160,112,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CARVEDILOL 12.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68382-094-01,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-7914-61,NDC,,,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  5 MG ORAL TBDL,50863,CDM,J3490,HCPCS,55111-262-79,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,J1815,HCPCS,83257-014-11,NDC,,,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,14,ML,,24277,16993.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0591-5555-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,0703-9514-03,NDC,facility,both,2,ML,,148,103.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,636,RC,J1610,HCPCS,0597-0053-45,NDC,facility,both,1,EA,JZ,742,519.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
METOCLOPRAMIDE HCL 5 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-1576-10,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,636,RC,J3490,HCPCS,59310-579-22,NDC,facility,both,1,GM,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,16714-536-01,NDC,facility,both,8,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,17271-701-02,NDC,facility,both,1,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6665-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROMETHORPHAN-GUAIFENESIN SR 30 MG-600 MG 12 HR TAB,50863,CDM,250,RC,J3490,HCPCS,63824-056-34,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROMETHORPHAN-GUAIFENESIN SR 30 MG-600 MG 12 HR TAB,50863,CDM,250,RC,J3490,HCPCS,6382405620,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,63323-165-01,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,J2003,HCPCS,0409-4903-11,NDC,,,facility,both,100,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,J3490,HCPCS,0409-9558-05,NDC,,,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB 100 MG IV SOLR,50863,CDM,J1745,HCPCS,57894-030-01,NDC,,,facility,both,5,EA,,701,490.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATOMOXETINE  10 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,16714-755-01,NDC,facility,both,2,EA,,140,98,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IVABRADINE 5 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,55513-813-01,NDC,facility,both,1,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENAZEPRIL 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,65862-116-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,80,ML,JW,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CEFAZOLIN IN DEXTROSE (ISO-OSMOTIC) 1 GRAM/50 ML IV PIGGY BACK,50863,CDM,636,RC,J0690,HCPCS,0338-3503-41,NDC,facility,both,2,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CODEINE-GUAIFENESIN 10-100 MG/5 ML ORAL LIQD (REPACK),50863,CDM,636,RC,J3490,HCPCS,0603-1075-58,NDC,facility,both,2,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FONDAPARINUX 2.5 MG/0.5 ML SUBQ SYRG,50863,CDM,636,RC,J1652,HCPCS,67457-582-00,NDC,facility,both,5,ML,,232,162.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYBUTYNIN CHLORIDE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7027-61,NDC,facility,both,3,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2312,HCPCS,67457-299-10,NDC,facility,both,40,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,68462-157-40,NDC,facility,both,1,EA,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 30 MG ORAL CPDR,50863,CDM,636,RC,J3490,HCPCS,27241-098-09,NDC,facility,both,1,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,94,ML,,134,93.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG/ML INJ SOLN,50863,CDM,250,RC,J2550,HCPCS,0641-0928-21,NDC,facility,both,1,ML,PLAD,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,250,RC,J3490,HCPCS,0143-9679-01,NDC,facility,both,1,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0143-9509-01,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,8,ML,,1486,1040.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  2.5 MG ORAL TAB,50863,CDM,250,RC,J7510,HCPCS,59651-485-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42291-809-15,NDC,facility,both,3,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,3,EA,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  500 MG IV SOLR,50863,CDM,636,RC,J3370,HCPCS,0143-9161-01,NDC,facility,both,2,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-8553-24,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MERCAPTOPURINE 50 MG ORAL TAB,50863,CDM,636,RC,J9999,HCPCS,0378-3547-52,NDC,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,63323-461-01,NDC,facility,both,1,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0409-4699-24,NDC,facility,both,200,ML,,254,177.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALASPARGASE PEGOL-MKNL 750 UNITS/ML IV SOLN,50863,CDM,636,RC,J9118,HCPCS,72694-515-01,NDC,facility,both,750,ML,,151101,105770.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,0093-0012-98,NDC,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCRALFATE 100 MG/ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,68094-043-59,NDC,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0131-2477-60,NDC,facility,both,1,EA,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % MUCOSAL SOLN (VISCOUS),50863,CDM,250,RC,J3490,HCPCS,0121-0903-15,NDC,facility,both,4,ML,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 200 MG/20 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,72205-220-01,NDC,facility,both,1,ML,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,0548-5604-00,NDC,facility,both,8,ML,JZ,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,63323-280-03,NDC,facility,both,20,ML,PLAD,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,63323-400-01,NDC,facility,both,200,ML,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,65,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 50 MG/ML IV SOLN,50863,CDM,250,RC,J0282,HCPCS,63323-616-02,NDC,facility,both,15,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE (PF-DURAMORPH/ASTRAMORPH) 0.5 MG/ML INJ SOLN,50863,CDM,636,RC,J2274,HCPCS,0409-3814-11,NDC,facility,both,1,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,61442-121-10,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68180-969-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-319-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENETOCLAX 10 MG ORAL TAB,50863,CDM,250,RC,J9999,HCPCS,0074-0561-11,NDC,facility,both,7,EA,,284,198.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE 14 MG/24 HR TD PT24,50863,CDM,636,RC,J3490,HCPCS,43598-447-71,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-25,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 0.8 GRAM ORAL PWPK,50863,CDM,636,RC,J3490,HCPCS,65862-930-08,NDC,facility,both,1,EA,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRBESARTAN 150 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,31722-730-30,NDC,facility,both,1,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,63323-185-08,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 125 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-519-11,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN D5W 20000 UNIT/500 ML,50863,CDM,636,RC,J1644,HCPCS,0264-9567-10,NDC,facility,both,9,ML,JW,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
AMANTADINE 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7042-06,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-0430-06,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN ENEMA 500MG IN 100ML NS,50863,CDM,250,RC,J3490,HCPCS,67457-339-00,NDC,facility,both,1,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,636,RC,J2405,HCPCS,60505-6130-0,NDC,facility,both,25,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORDIAZEPOXIDE 25 MG CAP,50863,CDM,636,RC,J3490,HCPCS,0555-0159-04,NDC,facility,both,15,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,927,ME,,12580,8806,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-572-10,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTOBARBITAL 75 MG/1.5 ML SYRINGE (REPACK),50863,CDM,636,RC,J3490,HCPCS,25021-676-20,NDC,facility,both,2,ML,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42858-302-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 50 MG TAB,50863,CDM,636,RC,J3490,HCPCS,42043-221-09,NDC,facility,both,1,EA,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-0710-20,NDC,facility,both,15,EA,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NS WITH POTASSIUM CHLORIDE 40 MEQ/L IV SOLP,50863,CDM,250,RC,J3490,HCPCS,0338-0695-04,NDC,facility,both,1,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,50863,CDM,636,RC,J1885,HCPCS,0409-3796-19,NDC,facility,both,4,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0137,HCPCS,0143-9386-01,NDC,facility,both,64,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),50863,CDM,636,RC,J0171,HCPCS,76329-3318-1,NDC,facility,both,40,ML,,323,226.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,16714-294-01,NDC,facility,both,13,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,76045-009-01,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,636,RC,P9045,HCPCS,68516-5218-0,NDC,facility,both,12,ML,,1539,1077.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,68094-750-59,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,62135-579-12,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 500 MG-125 MG TAB,50863,CDM,636,RC,J3490,HCPCS,60687-792-11,NDC,facility,both,1,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA SR 25 MG-100 MG TAB,50863,CDM,636,RC,J3490,HCPCS,68084-281-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,50863,CDM,250,RC,J9075,HCPCS,10019-956-16,NDC,facility,both,2,EA,JW,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0143-9889-15,NDC,facility,both,8,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 125 MG/5 ML (25MG/ML) ORAL SYRINGE (REPACK),50863,CDM,250,RC,J3370,HCPCS,67457-340-00,NDC,facility,both,1,EA,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"HEPARIN, PORCINE (PF)   10 UNIT/ML IV SYRG",50863,CDM,250,RC,J1642,HCPCS,8290306413,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 2 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-3183-11,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,16714-294-01,NDC,facility,both,3,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42291-468-01,NDC,facility,both,4,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,636,RC,J3010,HCPCS,63323-806-13,NDC,facility,both,5,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LANSOPRAZOLE 3 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,65628-080-05,NDC,facility,both,1,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGIC MOUTHWASH REPACK (BMX 1:1:1),50863,CDM,250,RC,J3490,HCPCS,0603-0823-58,NDC,facility,both,20,ML,,134,93.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,63323-280-03,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),50863,CDM,250,RC,J1815,HCPCS,0024-5926-05,NDC,facility,both,6,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL  6.25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6301-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,250,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,14,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7041-61,NDC,facility,both,4,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0536-1327-06,NDC,facility,both,20,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6322-61,NDC,facility,both,8,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  20 MEQ ORAL PACK,50863,CDM,636,RC,J3490,HCPCS,72888-024-06,NDC,facility,both,3,EA,,132,92.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,636,RC,J2560,HCPCS,0641-0477-21,NDC,facility,both,3,ML,,469,328.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 112 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42292-039-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN PEDS INFUSION (CDS MIXTURE),50863,CDM,250,RC,J0290,HCPCS,99999-408-63,NDC,facility,both,2,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),50863,CDM,250,RC,J1815,HCPCS,0024-5926-05,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIMODIPINE 30 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,23155-512-30,NDC,facility,both,1,EA,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,3,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAZOSIN 1 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,51079-630-01,NDC,facility,both,6,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,636,RC,J3490,HCPCS,0904-7509-30,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLN (MERGE)",50863,CDM,250,RC,P9047,HCPCS,64208-2512-8,NDC,facility,both,8,ML,,950,665,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-25,NDC,facility,both,200,ML,"JZ,JA",28288,19801.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM ACETATE 667 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7119-61,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES  8.6 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7252-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE MODIFIED 100 MG ORAL CAP,50863,CDM,250,RC,J7502,HCPCS,51862-460-01,NDC,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-406-03,NDC,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,500,ML,,111,77.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-444-01,NDC,facility,both,7,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUANFACINE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,24979-198-01,NDC,facility,both,3,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT 500 MCG/ML INJ SYRG,50863,CDM,J0881,HCPCS,55513-032-01,NDC,,,facility,both,500,ML,,10682,7477.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-229-02,NDC,facility,both,1,ML,PLAD,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
CALCIUM CARBONATE 500 MG (200 MG ELEMENTAL) CHEW TAB,50863,CDM,250,RC,J3490,HCPCS,66553-004-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,0409-3178-01,NDC,,,facility,both,70,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DATOPOTAMAB DERUXTECAN-DLNK 100 MG IV SOLR,50863,CDM,C9174,HCPCS,65597-801-01,NDC,,,facility,both,540,EA,,72897,51027.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN  750 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,70010-492-01,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIOTHYRONINE  5 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,62756-589-88,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6370-61,NDC,facility,both,8,EA,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J0461,HCPCS,0517-0401-25,NDC,facility,both,20,ML,JW,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,0641-6206-01,NDC,facility,both,2,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,636,RC,J2704,HCPCS,25021-608-20,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,62,ML,JW,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
HYDROMORPHONE 10 MG/50 ML (0.2MG/ML) PCA IN NS (MERGE),50863,CDM,250,RC,J1171,HCPCS,61553-830-41,NDC,facility,both,100,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 800 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-5855-60,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BETAMETHASONE DIPROPIONATE 0.05 % TOP OINT,50863,CDM,250,RC,J3490,HCPCS,72578-093-01,NDC,facility,both,1,GM,,261,182.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BETAMETHASONE ACET & SOD PHOS 6 MG/ML INJ SUSP,50863,CDM,636,RC,J0702,HCPCS,0517-0720-01,NDC,facility,both,5,ML,,281,196.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,66553-002-01,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
URSODIOL 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6221-61,NDC,facility,both,1,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-0710-20,NDC,facility,both,10,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MONTELUKAST  4 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,31722-727-30,NDC,facility,both,1,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5%/EPINEPHRINE 1:300K INJECTION,50863,CDM,636,RC,J3490,HCPCS,0409-1161-01,NDC,facility,both,2,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1162-18,NDC,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAVASTATIN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-5891-61,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FELODIPINE 10 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,13668-134-01,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 10 % (100 MG/ML) MISC SOLN,50863,CDM,636,RC,J3490,HCPCS,0517-7504-01,NDC,facility,both,1,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,636,RC,Q0162,HCPCS,65162-691-79,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,636,RC,J2270,HCPCS,0641-6125-25,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE   4.2 % IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-083-05,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALACYCLOVIR 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6565-61,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CELECOXIB 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6502-61,NDC,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ESMOLOL IN SALINE (ISO-OSMOTIC) 2,000 MG/100 ML (20 MG/ML) IV",50863,CDM,250,RC,J1805,HCPCS,25021-309-82,NDC,facility,both,1,ML,JZ,648,453.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
NIRMATRELVIR-RITONAVIR 300 MG (150 MG X 2)-100 MG ORAL DSPK,50863,CDM,250,RC,J3490,HCPCS,0069-5045-30,NDC,facility,both,30,EA,,3442,2409.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BEVACIZUMAB-BVZR 25 MG/ML IV SOLN,50863,CDM,250,RC,Q5118,HCPCS,0069-0315-01,NDC,facility,both,20,ML,,3386,2370.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0264-1800-36,NDC,facility,both,1,ML,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,5,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-1749-70,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2308-02,NDC,facility,both,5,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,7,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0054-0710-20,NDC,facility,both,15,EA,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXAZOSIN 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68382-783-01,NDC,facility,both,2,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NORETHINDRONE-ETHINYL ESTRADIOL 1 MG-35 MCG TAB,50863,CDM,250,RC,J3490,HCPCS,68462-394-84,NDC,facility,both,2,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-242-11,NDC,facility,both,4,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,636,RC,J3101,HCPCS,50242-037-06,NDC,facility,both,28,EA,JW,5576,3903.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,79,ML,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 20 MG/ML ORAL CONC,50863,CDM,250,RC,J3490,HCPCS,16714-601-02,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BISMUTH SUBSALICYLATE 262 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,0904-7205-46,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRIL MALEATE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51672-4038-1,NDC,facility,both,2,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),50863,CDM,250,RC,J1170,HCPCS,0409-4264-11,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML IM SOLN,50863,CDM,636,RC,90375,HCPCS,13533-318-05,NDC,facility,both,12,ML,,10020,7014,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,636,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,35,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN 0.9% SODIUM CL 1.25 GRAM/250 ML IV SOLN,50863,CDM,636,RC,J3373,HCPCS,72196-6074-1,NDC,facility,both,3,ML,,184,128.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),50863,CDM,250,RC,J1630,HCPCS,63323-474-00,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE PAMOATE  25 MG ORAL CAP,50863,CDM,636,RC,Q0177,HCPCS,68084-847-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,63323-280-04,NDC,facility,both,80,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,2,EA,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0054-0710-20,NDC,facility,both,6,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION,50863,CDM,250,RC,J3490,HCPCS,0186-0372-28,NDC,facility,both,2,GM,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEMANTINE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6506-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,90,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IV PGBK,50863,CDM,250,RC,J3475,HCPCS,0409-6729-41,NDC,facility,both,8,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLIMEPIRIDE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-788-95,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,50863,CDM,250,RC,J3490,HCPCS,69339-152-01,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE IN 0.9 % SOD CHLORIDE 500 MG/100 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,71506-079-56,NDC,facility,both,1,ML,,161,112.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NORETHINDRONE ACETATE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68462-304-50,NDC,facility,both,2,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN   1.5 G IV SOLR,50863,CDM,636,RC,J3373,HCPCS,67457-824-15,NDC,facility,both,3,EA,,142,99.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN  500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-155-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN  200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-5154-60,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,70004-600-09,NDC,facility,both,2,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-3178-16,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,63323-461-01,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-088-11,NDC,facility,both,3,EA,,381,266.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN 1 GRAM SOLUTION FOR INJECTION,50863,CDM,250,RC,J0290,HCPCS,55150-113-10,NDC,facility,both,6,EA,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,71,ML,,101,70.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN 1 GRAM SOLUTION FOR INJECTION,50863,CDM,636,RC,J0290,HCPCS,0781-3404-85,NDC,facility,both,2,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML IV SOLN (MERGE),50863,CDM,250,RC,J3490,HCPCS,70756-611-82,NDC,facility,both,2,ML,,221,154.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 800 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65162-058-27,NDC,facility,both,2,EA,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE (PF) 1 MG/ML INJ SOLN,50863,CDM,636,RC,J0171,HCPCS,54288-103-01,NDC,facility,both,30,ML,,2568,1797.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXEPIN  10 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,51079-436-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,76045-009-10,NDC,facility,both,30,ML,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,J1885,HCPCS,62332-600-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-145-11,NDC,facility,both,40,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE 2 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,0904-7154-04,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 600 MG ORAL TP12,50863,CDM,250,RC,J3490,HCPCS,0536-1163-61,NDC,facility,both,28,EA,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0003-0894-31,NDC,facility,both,12,EA,,514,359.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,1,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-0710-20,NDC,facility,both,18,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL-ROPIVACAINE-NACL (PF) 2-0.2 MCG/ML-% INJ (MERGE ERX),50863,CDM,250,RC,J3490,HCPCS,70092-9259-75,NDC,facility,both,5,ML,,1086,760.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,250,RC,J3101,HCPCS,50242-037-06,NDC,facility,both,28,EA,JW,5576,3903.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,55150-304-01,NDC,facility,both,10,ML,JZ,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PENICILLIN G BENZATHINE 2400000 UNIT/4 ML IM SYRG,50863,CDM,636,RC,J0561,HCPCS,60793-702-04,NDC,facility,both,24,ML,,1725,1207.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-131-11,NDC,facility,both,2,EA,PLAD,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,0409-1207-03,NDC,facility,both,2,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,76045-009-10,NDC,facility,both,30,ML,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,50863,CDM,636,RC,J3490,HCPCS,0378-7732-93,NDC,facility,both,10,EA,,803,562.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE 25 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,68180-657-01,NDC,facility,both,2,ML,,140,98,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,J0665,HCPCS,0409-1160-01,NDC,,,facility,both,70,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,J3490,HCPCS,0409-9558-05,NDC,,,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4 % TOPICAL SOLN,50863,CDM,250,RC,J3490,HCPCS,76329-6300-5,NDC,facility,both,1,ML,,5002,3501.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,J3490,HCPCS,63037-136-25,NDC,,,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IV PGBK,50863,CDM,250,RC,J3490,HCPCS,0264-4204-52,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-888-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN DEXTROSE (ISO-OSMOTIC) 1 GRAM/50 ML IV PIGGY BACK,50863,CDM,636,RC,J0689,HCPCS,0338-3503-41,NDC,facility,both,4,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 400 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-6667-61,NDC,facility,both,3,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"EFGARTIGIMOD-HYALURONIDAS-QVFC 1,008 MG-11,200 UNIT/5.6 ML SUBQ SOLN",50863,CDM,J9334,HCPCS,73475-3102-3,NDC,,,facility,both,504,ML,,43534,30473.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OMALIZUMAB 75 MG/0.5 ML SUBQ SYRG,50863,CDM,636,RC,J2357,HCPCS,50242-214-03,NDC,facility,both,15,ML,JZ,1558,1090.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SENNOSIDES-DOCUSATE SODIUM 8.6 MG-50 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7440-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,70095-026-01,NDC,facility,both,29,ML,,1897,1327.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  120 MG RECT SUPP,50863,CDM,250,RC,J3490,HCPCS,51672-2115-0,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PALIPERIDONE PALMITATE 39 MG/0.25 ML IM SYRG,50863,CDM,250,RC,J2426,HCPCS,50458-560-01,NDC,facility,both,1,ML,,1642,1149.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN 50 MG ORAL CHEW,50863,CDM,636,RC,J3490,HCPCS,51672-4146-1,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 100 MG/1 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,0075-0623-03,NDC,facility,both,10,ML,,146,102.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE 1 MG/0.2 ML SUBQ KIT,50863,CDM,636,RC,J9218,HCPCS,41616-936-40,NDC,facility,both,1,EA,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE (FOR CODE) 10% (100 MG/ML) IV SYRINGE,50863,CDM,250,RC,J3490,HCPCS,64253-900-30,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0075-0620-01,NDC,facility,both,4,ML,JZ,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LISINOPRIL 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6798-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,50863,CDM,250,RC,J8540,HCPCS,0904-7266-61,NDC,facility,both,24,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,50863,CDM,636,RC,J8540,HCPCS,0904-7266-61,NDC,facility,both,24,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,55,EA,,7590,5313,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYOSCYAMINE 0.125 MG SUBLINGUAL TAB,50863,CDM,250,RC,J3490,HCPCS,42192-339-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML INJECTION,50863,CDM,250,RC,J3411,HCPCS,72603-139-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETHACRYNIC ACID 25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69238-1126-1,NDC,facility,both,2,EA,,237,165.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODINE STRONG (LUGOLS) 5 % ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,48433-230-15,NDC,facility,both,1,ML,,190,133,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,636,RC,J2270,HCPCS,0409-1890-13,NDC,facility,both,1,ML,JZ,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CALCIUM GLUCONATE IN 0.9% NACL 3 GRAM/100 ML IV SOLN,50863,CDM,636,RC,J0612,HCPCS,61553-056-48,NDC,facility,both,600,ML,JZ,255,178.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
FOSPHENYTOIN 100 MG PE/2 ML INJ SOLN,50863,CDM,636,RC,Q2009,HCPCS,63323-403-01,NDC,facility,both,4,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TETRACAINE HCL (PF) 0.5 % OPHT DROP (STANDARD STOCK),50863,CDM,636,RC,J3490,HCPCS,0065-0741-14,NDC,facility,both,1,ML,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % MUCOSAL SOLN (VISCOUS),50863,CDM,250,RC,J3490,HCPCS,72888-125-26,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE 0.5 MG SL (1/4 TAB) SUBL,50863,CDM,636,RC,J3490,HCPCS,99999-0408-26,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 2 QUARTER TABLET
ARIPIPRAZOLE 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7369-04,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORDIAZEPOXIDE 25 MG CAP,50863,CDM,250,RC,J3490,HCPCS,0555-0159-04,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ (MERGE),50863,CDM,636,RC,J2250,HCPCS,0409-2305-17,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOFLOXACIN 250 MG/10 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,70954-852-30,NDC,facility,both,1,ML,,156,109.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-25,NDC,facility,both,45,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LET TOPICAL GEL 3 ML,50863,CDM,250,RC,J3490,HCPCS,05446-0607-01,NDC,facility,both,1,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESVENLAFAXINE  50 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,68180-592-06,NDC,facility,both,1,EA,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 100 MG/5 ML ORAL LIQD,50863,CDM,250,RC,J3490,HCPCS,50383-063-10,NDC,facility,both,40,ML,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE (PF-DURAMORPH/ASTRAMORPH) 0.5 MG/ML INJ SOLN,50863,CDM,636,RC,J2274,HCPCS,0641-6020-01,NDC,facility,both,1,ML,,170,119,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,636,RC,J3010,HCPCS,0409-9094-18,NDC,facility,both,3,ML,JZ,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,636,RC,J3490,HCPCS,60687-390-11,NDC,facility,both,2,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MULTIVIT-MIN-FERROUS GLUCONATE 9 MG IRON/ 15 ML (15 ML) ORAL LIQD,50863,CDM,250,RC,J3490,HCPCS,1785600102,NDC,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 10 GRAM IV SOLR,50863,CDM,250,RC,J3370,HCPCS,0143-9164-01,NDC,facility,both,3,EA,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LINEZOLID 600 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6553-04,NDC,facility,both,1,EA,,659,461.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IR SOLN,50863,CDM,J3490,HCPCS,0338-0047-47,NDC,,,facility,both,2,ML,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 500 MG (200 MG ELEMENTAL) CHEW TAB,50863,CDM,636,RC,J3490,HCPCS,66553-004-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,0409-3178-16,NDC,,,facility,both,80,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML INJ SOLN,50863,CDM,J2250,HCPCS,63323-411-15,NDC,,,facility,both,150,ML,,649,454.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 500 MG PE/10 ML INJ SOLN,50863,CDM,636,RC,Q2009,HCPCS,25021-798-10,NDC,facility,both,20,ML,JZ,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,72603-251-01,NDC,facility,both,120,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROATE SODIUM 100 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0143-9785-01,NDC,facility,both,2,ML,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0641-6057-01,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-609-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,250,RC,J3490,HCPCS,73013-2002-2,NDC,facility,both,4,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,4,ML,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,J2560,HCPCS,0641-0477-21,NDC,,,facility,both,3,ML,,697,487.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,50863,CDM,J1885,HCPCS,63323-162-03,NDC,,,facility,both,2,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,50863,CDM,J3490,HCPCS,60687-742-11,NDC,,,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 40 MG-200 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,65862-496-47,NDC,facility,both,1,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"CALCIUM GLUC IN NACL, ISO-OSM 1 G/100 ML IV SOLN",50863,CDM,250,RC,J0613,HCPCS,44567-622-01,NDC,facility,both,200,ML,,149,104.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAMOXIFEN 10 MG ORAL TAB,50863,CDM,636,RC,J9999,HCPCS,59651-299-60,NDC,facility,both,2,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,70700-165-22,NDC,facility,both,4,ML,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,68180-150-01,NDC,facility,both,2,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLESTYRAMINE-SUCROSE 4 GRAM ORAL PACK,50863,CDM,250,RC,J3490,HCPCS,68382-528-60,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-0007-01,NDC,facility,both,40,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 100 MG/5 ML ORAL LIQD,50863,CDM,250,RC,J3490,HCPCS,50383-063-10,NDC,facility,both,20,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,7,ML,,224,156.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLORAZEPATE DIPOTASSIUM  3.75 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,13107-319-01,NDC,facility,both,2,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IR SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-7972-08,NDC,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLPIDEM  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0781-5317-01,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 40 MG-200 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,65862-496-47,NDC,facility,both,1,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,50863,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,5,ML,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 150 MG/1 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,0548-5607-00,NDC,facility,both,3,ML,JW,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
NAFCILLIN 10 GRAM INJ SOLR,50863,CDM,250,RC,J3490,HCPCS,55150-124-99,NDC,facility,both,1,EA,,398,278.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,J0665,HCPCS,0409-1162-02,NDC,,,facility,both,300,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTOBARBITAL 75 MG/1.5 ML SYRINGE (REPACK),50863,CDM,636,RC,J2515,HCPCS,25021-676-20,NDC,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL IV BOLUS 10MG/ML (ANESTHESIA ONLY),50863,CDM,636,RC,J2704,HCPCS,63323-269-29,NDC,facility,both,20,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69238-1491-1,NDC,facility,both,2,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL (5 MG/ML) IV SYRG (CONTAINS PRESERVATIVE),50863,CDM,636,RC,J3490,HCPCS,0409-2339-24,NDC,facility,both,1,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PALONOSETRON 0.25 MG/5 ML IV INJECTION (MERGE),50863,CDM,250,RC,J2469,HCPCS,36000-326-01,NDC,facility,both,10,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN ASP PRT-INSULIN ASPART 100 UNIT/ML (70-30) SUBQ SOLN,50863,CDM,636,RC,J1817,HCPCS,0169-3685-12,NDC,facility,both,2,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FERRIC CARBOXYMALTOSE (INJECTAFER) 50 MG IRON/ML IV SOLN,50863,CDM,636,RC,J1439,HCPCS,0517-0650-01,NDC,facility,both,750,ML,JZ,4111,2877.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
METOPROLOL SUCCINATE SR 100 MG 24 HR TAB,50863,CDM,636,RC,J3490,HCPCS,50268-542-11,NDC,facility,both,3,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,250,RC,J0690,HCPCS,63323-237-10,NDC,facility,both,1,EA,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,250,RC,J2405,HCPCS,60505-6130-0,NDC,facility,both,24,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,3700025445,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68094-005-59,NDC,facility,both,4,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,0409-3795-19,NDC,facility,both,2,ML,JZ,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DOXORUBICIN 50 MG/25 ML IV SOLN,50863,CDM,250,RC,J9000,HCPCS,0069-1542-20,NDC,facility,both,6,ML,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7041-61,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALUM-MAG HYDROXIDE-SIMETH 200 MG-200 MG-20 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,17856-0630-1,NDC,facility,both,3,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAZOSIN 5 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,70954-021-10,NDC,facility,both,2,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,0703-5653-01,NDC,facility,both,8,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,55111-180-15,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,J2919,HCPCS,0009-0039-05,NDC,,,facility,both,16,EA,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J1230,HCPCS,67457-217-20,NDC,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,69918-899-01,NDC,facility,both,20,ML,,1451,1015.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIZATRIPTAN 10 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,0006-3801-01,NDC,facility,both,1,EA,,215,150.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,250,RC,J0132,HCPCS,25021-812-30,NDC,facility,both,120,ML,,864,604.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GALANTAMINE  4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-729-11,NDC,facility,both,2,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,59651-488-01,NDC,facility,both,20,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G POTASSIUM  5000000 UNIT INJ SOLR,50863,CDM,250,RC,J2540,HCPCS,0781-6135-94,NDC,facility,both,5,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-234-02,NDC,facility,both,1,ML,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-0710-20,NDC,facility,both,6,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,25021-468-10,NDC,facility,both,2,EA,,613,429.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0264-7800-20,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE IN D5W 1 GRAM/100 ML IV PGBK,50863,CDM,250,RC,J3475,HCPCS,44567-410-24,NDC,facility,both,4,ML,JZ,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7030,HCPCS,0338-0049-04,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-3178-16,NDC,facility,both,140,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,J0665,HCPCS,70594-118-01,NDC,,,facility,both,100,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID (PORK)  30 MG ORAL TAB,50863,CDM,J3490,HCPCS,42192-329-01,NDC,,,facility,both,3,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROATE SODIUM 100 MG/ML IV SOLN,50863,CDM,J3490,HCPCS,0143-9785-01,NDC,,,facility,both,1,ML,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,76045-009-10,NDC,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACCHAROMYCES BOULARDII 250 MG ORAL CAP,50863,CDM,J3490,HCPCS,7733380025,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-318-11,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,190,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,J7999,HCPCS,70092-1017-46,NDC,,,facility,both,4,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 20 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-7177-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IVERMECTIN 3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42799-806-01,NDC,facility,both,7,EA,,171,119.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIROFIBAN-0.9% SODIUM CHLORIDE 5 MG/100 ML (50 MCG/ML) IV SOLN,50863,CDM,J3246,HCPCS,25208-002-03,NDC,,,facility,both,5,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 10 GRAM IV SOLR,50863,CDM,250,RC,J3370,HCPCS,70436-023-82,NDC,facility,both,4,EA,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2310,HCPCS,36000-308-01,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
REMIFENTANIL 1 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,67457-198-03,NDC,facility,both,1,EA,,312,218.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,J2003,HCPCS,0409-4277-02,NDC,,,facility,both,40,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,J3370,HCPCS,0409-6533-11,NDC,,,facility,both,2,EA,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAMSULOSIN 0.4 MG ORAL CP24,50863,CDM,J3490,HCPCS,68084-299-11,NDC,,,facility,both,2,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,J7040,HCPCS,0338-0049-38,NDC,,,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 3 MG/ML IV SYRG,50863,CDM,636,RC,J0153,HCPCS,25021-301-72,NDC,facility,both,6,ML,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % MUCOSAL SOLN (VISCOUS),50863,CDM,J3490,HCPCS,0121-0903-15,NDC,,,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-492-27,NDC,,,facility,both,500,ML,,393,275.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MULTIVITAMIN WITH FOLIC ACID 400 MCG ORAL TAB,50863,CDM,J3490,HCPCS,904053061,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"HIB CONJ-TET,COMPNT 2 OF 2(PF) 10 MCG/0.5 ML IM SOLR",50863,CDM,90698,HCPCS,49281-544-58,NDC,,,facility,both,1,EA,,493,345.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPATITIS A VIRUS VACCINE (PF) 720 EL UNIT/0.5 ML IM SYRG,50863,CDM,90633,HCPCS,58160-825-52,NDC,,,facility,both,1,ML,,229,160.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM BICARB-CITRIC ACID 20 MEQ ORAL TBEF,50863,CDM,636,RC,J3490,HCPCS,51801-012-01,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,43598-053-11,NDC,facility,both,24,ML,,851,595.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 10 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,16714-720-02,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-559-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),50863,CDM,250,RC,J1630,HCPCS,63323-474-00,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,42806-151-34,NDC,facility,both,7,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-339-11,NDC,facility,both,1,EA,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOFLOXACIN IN D5W 500 MG/100 ML IV PGBK,50863,CDM,250,RC,J1956,HCPCS,25021-132-82,NDC,facility,both,2,ML,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,636,RC,J3010,HCPCS,0409-9094-12,NDC,facility,both,2,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,200,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MEASLES,MUMPS&RUBELLA VACCIN(PF) 1,000-12,500 TCID50/0.5 ML SUB-Q SUSP",50863,CDM,90707,HCPCS,0006-4681-01,NDC,,,facility,both,1,EA,,387,270.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 20 MG/ML INJ SOLN,50863,CDM,J0360,HCPCS,63323-614-00,NDC,,,facility,both,1,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-25,NDC,facility,both,25,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-099-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2308-22,NDC,facility,both,9,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
EPINEPHRINE 1 MG/ML (1ML) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,54288-119-01,NDC,facility,both,1,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-456-01,NDC,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCRALFATE 100 MG/ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0121-0974-10,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEPERIDINE (PF) 25 MG/ML IV SOLN (PHS MERGE),50863,CDM,250,RC,J2175,HCPCS,0409-1176-03,NDC,facility,both,1,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/0.5 ML INHL NEBU,50863,CDM,636,RC,J3490,HCPCS,0487-9901-30,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,50863,CDM,636,RC,J3301,HCPCS,0703-0241-01,NDC,facility,both,4,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,42858-001-10,NDC,facility,both,3,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACUBITRIL-VALSARTAN 24-26 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0078-0659-20,NDC,facility,both,1,EA,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-072-04,NDC,facility,both,1,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-38,NDC,facility,both,1,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"AMIODARONE IN DEXTROSE,ISO-OSM 150 MG/100 ML (PREMIX)",50863,CDM,250,RC,J0282,HCPCS,43066-150-10,NDC,facility,both,10,ML,JZ,407,284.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
OCTREOTIDE ACETATE  100 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,63323-376-00,NDC,facility,both,10,ML,JB,146,102.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JB: Administered subcutaneously
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,535,ME,,7260,5082,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-580-11,NDC,facility,both,9,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),50863,CDM,250,RC,J3490,HCPCS,8290306545,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR IRRIGATION, STERILE SOLUTION",50863,CDM,250,RC,J3490,HCPCS,0338-0004-02,NDC,facility,both,16,ML,,554,387.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0780,HCPCS,23155-294-31,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OMEPRAZOLE 20 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,0904-6917-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOBRAMYCIN 1.2 G POWDER VIAL,50863,CDM,636,RC,J3260,HCPCS,39822-0412-6,NDC,facility,both,15,EA,,398,278.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXAZOSIN 4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-5524-61,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 10 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,65862-192-01,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOMYCIN-BACITRACN ZN-POLYMYXIN 3.5 MG-400 U*,50863,CDM,636,RC,J3490,HCPCS,45802-143-00,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM  2.25 GRAM IV SOLR,50863,CDM,250,RC,J2543,HCPCS,60505-6156-0,NDC,facility,both,2,EA,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  5 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0054-4728-31,NDC,facility,both,5,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-520-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM NEO IV SYRINGE (PHS FROM PREMIX),50863,CDM,250,RC,J1953,HCPCS,44567-501-01,NDC,facility,both,15,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,42806-150-33,NDC,facility,both,3,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-05,NDC,facility,both,8,EA,JZ,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DULOXETINE 60 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,57237-019-90,NDC,facility,both,1,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 7.5 MG-325 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0406-0366-23,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 100 MG PE/2 ML INJ SOLN,50863,CDM,250,RC,Q2009,HCPCS,63323-403-01,NDC,facility,both,2,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML IV SOLN (MERGE),50863,CDM,636,RC,J3490,HCPCS,16714-037-01,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALAMINE-ZINC OXIDE 8 %-8 % TOPICAL SUSP,50863,CDM,250,RC,J3490,HCPCS,1093914833,NDC,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML IM SOLN,50863,CDM,636,RC,90375,HCPCS,13533-318-05,NDC,facility,both,11,ML,,9125,6387.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GANCICLOVIR 500 MG IV SOLUTION,50863,CDM,250,RC,J1570,HCPCS,70436-089-55,NDC,facility,both,1,EA,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,43066-007-10,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,636,RC,J2270,HCPCS,0409-1890-03,NDC,facility,both,1,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,636,RC,J2003,HCPCS,63323-486-05,NDC,facility,both,200,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,51754-4250-1,NDC,facility,both,3,ML,,174,121.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE 25 MG/ML INJ SOLN,50863,CDM,636,RC,J3230,HCPCS,55150-319-01,NDC,facility,both,1,ML,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUDROCORTISONE 0.1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,72603-170-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHOTERICIN B LIPOSOME 50 MG IV SUSR,50863,CDM,250,RC,J0289,HCPCS,55150-365-01,NDC,facility,both,5,EA,,902,631.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EZETIMIBE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6664-04,NDC,facility,both,1,EA,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 10 MG/50 ML (0.2MG/ML) PCA IN NS (MERGE),50863,CDM,636,RC,J1171,HCPCS,70092-1286-74,NDC,facility,both,100,ML,,215,150.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 150 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,0904-7084-04,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROFURANTOIN (25% MACROCRYSTAL FORM) 100 MG CAP,50863,CDM,250,RC,J3490,HCPCS,60687-633-11,NDC,facility,both,1,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PYRIDOSTIGMINE BROMIDE 5 MG/ML INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0781-3040-72,NDC,facility,both,1,ML,,188,131.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-1283-03,NDC,facility,both,10,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-3212-01,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,71247-130-01,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAUNORUBICIN 5 MG/ML IV INJ,50863,CDM,636,RC,J9150,HCPCS,0143-9550-01,NDC,facility,both,3,ML,,535,374.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,60687-429-45,NDC,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,50863,CDM,636,RC,J9000,HCPCS,0069-3032-20,NDC,facility,both,15,ML,,433,303.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  75 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-856-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,64980-562-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0137,HCPCS,0143-9386-01,NDC,facility,both,23,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-811-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML INJECTION,50863,CDM,250,RC,J3411,HCPCS,67457-196-00,NDC,facility,both,2,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,10,ML,,17341,12138.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,43066-007-10,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,43598-053-11,NDC,facility,both,20,ML,,696,487.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6501-06,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE 150 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16571-110-01,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-086-01,NDC,facility,both,2,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE BIT 2 %-1:100,000 INJ CRTG",50863,CDM,636,RC,J3490,HCPCS,0404-6512-05,NDC,facility,both,2,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,34,ML,JZ,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DIVALPROEX 250 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,62756-797-88,NDC,facility,both,3,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TORSEMIDE  20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-756-11,NDC,facility,both,5,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV (BOLUS),50863,CDM,636,RC,J7120,HCPCS,0264-7750-00,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EZETIMIBE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-373-11,NDC,facility,both,1,EA,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VARENICLINE 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68462-893-56,NDC,facility,both,2,EA,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0248-01,NDC,facility,both,30,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 2 GRAM IV SOLUTION,50863,CDM,636,RC,J9075,HCPCS,39822-0260-1,NDC,facility,both,380,EA,,1227,858.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLERGONOVINE 0.2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,69238-1605-2,NDC,facility,both,1,EA,,286,200.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,42,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 7.5 MG-325 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0406-0124-23,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN LOCK FLUSH 100 UNIT/ML IV SOLN,50863,CDM,636,RC,J1642,HCPCS,6425333335,NDC,facility,both,100,ML,,412,288.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM ACETATE 667 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7119-06,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J2312,HCPCS,36000-308-01,NDC,facility,both,40,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J2003,HCPCS,0409-4713-32,NDC,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0406-3244-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2310,HCPCS,0409-1219-41,NDC,facility,both,1,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-645-41,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6641-61,NDC,facility,both,2,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0093-3145-01,NDC,facility,both,3,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML INJ SOLN,50863,CDM,250,RC,J0169,HCPCS,76329-9060-0,NDC,facility,both,300,ML,,797,557.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENAZOPYRIDINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,75826-114-10,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  15 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,0406-8315-23,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEPLIZUMAB-MZWV 2 MG/20 ML IV SOLN,50863,CDM,636,RC,J9381,HCPCS,73650-316-01,NDC,facility,both,114,ME,JW,2997,2097.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DEXAMETHASONE 4 MG ORAL TAB,50863,CDM,250,RC,J8540,HCPCS,0904-7266-61,NDC,facility,both,48,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPLERENONE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-451-11,NDC,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLIMEPIRIDE 2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-326-11,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,63323-506-00,NDC,facility,both,20,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  5 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,55111-262-79,NDC,facility,both,4,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL  75 MCG/HR TD PT72,50863,CDM,250,RC,J3490,HCPCS,0591-3213-54,NDC,facility,both,1,EA,,197,137.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN PEDS IV INFUSION 12 MG/ML (CDS MIXTURE FROM PREMIX),50863,CDM,636,RC,J0736,HCPCS,0338-3612-24,NDC,facility,both,2,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,13668-010-01,NDC,facility,both,2,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL (5 MG/ML) IV SYRG (CONTAINS PRESERVATIVE),50863,CDM,250,RC,J3490,HCPCS,0409-2339-24,NDC,facility,both,3,ML,,160,112,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL  3.125 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6300-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RASBURICASE 1.5 MG IV SOLR,50863,CDM,250,RC,J2783,HCPCS,0024-5150-10,NDC,facility,both,3,EA,,2879,2015.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM  50 MG INJ SOLR,50863,CDM,250,RC,J0640,HCPCS,55390-051-10,NDC,facility,both,1,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,68982-623-02,NDC,facility,both,1,ML,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN ENEMA 500MG IN 100ML NS,50863,CDM,250,RC,J3370,HCPCS,67457-339-00,NDC,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  20 MEQ ORAL PACK,50863,CDM,250,RC,J3490,HCPCS,0245-0360-89,NDC,facility,both,2,EA,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,50863,CDM,636,RC,J1885,HCPCS,72266-119-01,NDC,facility,both,2,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
TIZANIDINE 4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,42291-809-15,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60219-1708-1,NDC,facility,both,120,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-492-04,NDC,facility,both,40,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GOLIMUMAB  12.5 MG/ML IV SOLN,50863,CDM,636,RC,J1602,HCPCS,57894-350-01,NDC,facility,both,100,ML,JZ,11036,7725.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
VALSARTAN  80 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,31722-152-90,NDC,facility,both,1,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE IN D5W 1 GRAM/100 ML IV PGBK,50863,CDM,636,RC,J3475,HCPCS,63323-108-00,NDC,facility,both,2,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN 5 MG/ML AND HEPARIN 5000 UNITS/ML CATHETER LOCK FOR INTERCATHETER DWELL (USE PANEL),50863,CDM,250,RC,J0690,HCPCS,0409-0805-01,NDC,facility,both,1,EA,,156,109.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,3,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML INJECTION,50863,CDM,636,RC,J3411,HCPCS,25021-500-02,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXEPIN  50 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7054-61,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-41,NDC,facility,both,2,ML,,338,236.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-398-11,NDC,facility,both,3,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 50 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0054-0019-20,NDC,facility,both,150,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0137,HCPCS,0143-9386-01,NDC,facility,both,28,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,16714-662-01,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-406-03,NDC,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,18,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51672-4005-1,NDC,facility,both,3,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACUBITRIL-VALSARTAN 24-26 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0078-0659-20,NDC,facility,both,1,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,68180-441-02,NDC,facility,both,10,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % MUCOSAL SOLN (VISCOUS),50863,CDM,636,RC,J3490,HCPCS,0054-3500-49,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLERGONOVINE 0.2 MG/ML (1 ML) INJ SOLN,50863,CDM,250,RC,J2210,HCPCS,0517-0740-01,NDC,facility,both,2,ML,,368,257.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN DETEMIR 100 UNIT/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,0169-3687-12,NDC,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,63323-280-04,NDC,facility,both,40,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIPASE-PROTEASE-AMYLASE 24,000-76,000- 120,000 UNIT ORAL CAP, DELAY REL",50863,CDM,250,RC,J3490,HCPCS,0032-2636-01,NDC,facility,both,1,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,50863,CDM,636,RC,J2359,HCPCS,55150-308-01,NDC,facility,both,20,EA,JZ,208,145.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,60687-390-11,NDC,facility,both,3,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 20 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,0228-2890-06,NDC,facility,both,1,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0093-4177-73,NDC,facility,both,6,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,0088-2220-33,NDC,facility,both,200,ML,,327,228.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0295,HCPCS,63323-368-20,NDC,facility,both,2,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,636,RC,J1610,HCPCS,0597-0053-45,NDC,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 5 MG ORAL CAP,50863,CDM,250,RC,J7507,HCPCS,0904-6624-61,NDC,facility,both,2,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0143-9506-01,NDC,facility,both,2,ML,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 1 MG ORAL CAP,50863,CDM,250,RC,J7507,HCPCS,68084-450-11,NDC,facility,both,2,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),50863,CDM,636,RC,J1630,HCPCS,63323-474-00,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,70095-031-01,NDC,facility,both,25,ML,,1026,718.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIZATRIPTAN  5 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,65862-625-03,NDC,facility,both,2,EA,,282,197.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,70069-363-01,NDC,facility,both,1,ML,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0591-5555-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,57237-004-30,NDC,facility,both,1,EA,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,250,RC,J2405,HCPCS,0641-6078-01,NDC,facility,both,4,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MIDODRINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0245-0212-89,NDC,facility,both,2,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE IN 0.9% NS (PF) 1 MG/10 ML (100 MCG/ML) IV SYRG(PDS MERGE),50863,CDM,250,RC,J3490,HCPCS,65302-506-10,NDC,facility,both,500,ML,,5463,3824.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PERMETHRIN 5 % TOP CREA,50863,CDM,250,RC,J3490,HCPCS,21922-021-07,NDC,facility,both,1,GM,,425,297.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"HIB CONJ-TET,COMPNT 2 OF 2(PF) 10 MCG/0.5 ML IM SOLR",50863,CDM,90698,HCPCS,49281-544-58,NDC,,,facility,both,1,EA,,516,361.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,50863,CDM,J8540,HCPCS,0904-7266-61,NDC,,,facility,both,16,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIRSEVIMAB-ALIP 50 MG/0.5 ML IM SYRG,50863,CDM,90380,HCPCS,49281-575-15,NDC,,,facility,both,1,ML,,1435,1004.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML (1ML) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,54288-119-01,NDC,facility,both,30,ML,,2371,1659.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,P9045,HCPCS,68516-5219-0,NDC,,,facility,both,10,ML,,2542,1779.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2003,HCPCS,0143-9594-01,NDC,,,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0832-1211-89,NDC,facility,both,4,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0781-3246-02,NDC,facility,both,3,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LINEZOLID 100 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,59762-1308-4,NDC,facility,both,1,ML,,221,154.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,250,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GOLIMUMAB  12.5 MG/ML IV SOLN,50863,CDM,636,RC,J1602,HCPCS,57894-350-01,NDC,facility,both,200,ML,,22072,15450.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOMIPRAMINE 50 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,16571-684-03,NDC,facility,both,1,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,25021-463-01,NDC,facility,both,2,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-631-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,J1644,HCPCS,67457-384-31,NDC,,,facility,both,30,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,J2270,HCPCS,76045-004-10,NDC,,,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J3490,HCPCS,63323-482-03,NDC,,,facility,both,100,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOSTIGMINE METHYLSULFATE 1 MG/ML IV SOLN,50863,CDM,J2710,HCPCS,42023-189-01,NDC,,,facility,both,1,ML,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML IV SOLN,50863,CDM,J3490,HCPCS,55150-222-20,NDC,,,facility,both,1,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN 1 MG/ML INJECTION (PEDS ONCOLOGY),50863,CDM,J0640,HCPCS,71288-160-10,NDC,,,facility,both,1,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM  1.5 GRAM INJ SOLR,50863,CDM,250,RC,J0295,HCPCS,0049-0013-81,NDC,facility,both,2,EA,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG ORAL TAB,50863,CDM,J3490,HCPCS,63739-645-10,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,5,EA,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,J3490,HCPCS,67850-041-00,NDC,,,facility,both,1,ML,,172,120.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 20 MG/ML INJ SOLN,50863,CDM,J0360,HCPCS,0641-6231-01,NDC,,,facility,both,1,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-075-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FELODIPINE  5 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,68462-234-01,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
D5-0.9%NACL-POTASSIUM CHLORIDE 20 MEQ/L IV SOLP,50863,CDM,636,RC,J3480,HCPCS,0338-0803-04,NDC,facility,both,10,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,70095-031-01,NDC,facility,both,22,ML,,899,629.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0456,HCPCS,70436-019-82,NDC,facility,both,1,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYBUTYNIN CHLORIDE  5 MG ORAL TO24,50863,CDM,636,RC,J3490,HCPCS,62175-270-37,NDC,facility,both,1,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,250,RC,J3490,HCPCS,59310-579-20,NDC,facility,both,1,GM,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POSACONAZOLE 100 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,70748-258-07,NDC,facility,both,3,EA,,800,560,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 300 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-722-11,NDC,facility,both,2,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,50863,CDM,250,RC,J9263,HCPCS,67457-469-10,NDC,facility,both,200,ML,,864,604.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,76045-009-96,NDC,facility,both,4,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6426-61,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NOREPINEPHRINE BITARTRATE-D5W 4 MG/250 ML (16 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,71285-6056-1,NDC,facility,both,3,ML,,264,184.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 30 MG/0.3 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,16714-006-01,NDC,facility,both,6,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,20,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PRASUGREL 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0002-5123-30,NDC,facility,both,1,EA,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
0.2 MICRON FILTER ATTACHMENT MISC MISC,50863,CDM,250,RC,J3490,HCPCS,99999-0403-06,NDC,facility,both,1,EA,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DICLOFENAC 25 MG TAB, DELAYED RELEASE",50863,CDM,250,RC,J3490,HCPCS,16571-203-10,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL 2.5 MG/ML SUSPENSION,50863,CDM,250,RC,J3490,HCPCS,99999-0404-75,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  100 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,63323-376-00,NDC,facility,both,4,ML,JA,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
NORETHINDRONE ACETATE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50742-267-50,NDC,facility,both,4,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  25 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,59762-1342-1,NDC,facility,both,3,EA,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-3178-01,NDC,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,250,RC,J2270,HCPCS,0409-1890-03,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COLESEVELAM 625 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,27808-190-01,NDC,facility,both,1,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,636,RC,J2720,HCPCS,63323-229-01,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 600 MG ORAL TP12,50863,CDM,250,RC,J3490,HCPCS,63824-008-15,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROATE SODIUM 100 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-494-01,NDC,facility,both,1,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J1940,HCPCS,36000-283-25,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,5,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,63739-931-28,NDC,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-229-41,NDC,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,250,RC,J0330,HCPCS,31722-981-10,NDC,facility,both,7,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 25 MG TAB,50863,CDM,636,RC,J3490,HCPCS,51079-255-01,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,636,RC,J2795,HCPCS,63323-286-20,NDC,facility,both,100,ML,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML (ANESTHESIA INTRAOP ONLY),50863,CDM,250,RC,J3010,HCPCS,0641-6027-01,NDC,facility,both,4,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE 25 MG/ML INJ SOLN,50863,CDM,250,RC,J3230,HCPCS,0641-1397-31,NDC,facility,both,1,ML,,340,238,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-3178-01,NDC,facility,both,1,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEBIVOLOL  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,31722-586-90,NDC,facility,both,1,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE  50 MG ORAL TAB,50863,CDM,250,RC,j3490,HCPCS,60687-443-11,NDC,facility,both,5,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-24,NDC,facility,both,40,ML,"JZ,JA",5658,3960.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
ACETIC ACID (VINEGAR) 5% IRRIGATION 12 ML (REPACK),50863,CDM,636,RC,J3490,HCPCS,5155200556,NDC,facility,both,3,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,18,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE  50 MG ORAL TAB,50863,CDM,250,RC,j3490,HCPCS,60687-443-11,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,14789-127-07,NDC,facility,both,1,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETUXIMAB 200 MG/100 ML IV SOLN,50863,CDM,250,RC,J9055,HCPCS,66733-948-23,NDC,facility,both,13,ML,JW,1267,886.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ZIPRASIDONE 20 MG CAP,50863,CDM,636,RC,J3490,HCPCS,0904-6269-45,NDC,facility,both,2,EA,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,55150-370-01,NDC,facility,both,3,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COCAINE  4 % TOP SOLN (MERGE),50863,CDM,636,RC,C9046,HCPCS,64950-362-04,NDC,facility,both,160,ML,JZ,868,607.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
TRAZODONE  50 MG ORAL TAB,50863,CDM,250,RC,j3490,HCPCS,0904-6868-61,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 400 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-5853-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYLAMINE SUCCINATE 25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,4116700609,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BISACODYL 10 MG RECT SUPP,50863,CDM,250,RC,J3490,HCPCS,0574-7050-50,NDC,facility,both,5,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LATANOPROST 0.005 % OPHT DROP,50863,CDM,J3490,HCPCS,59762-0333-2,NDC,,,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 50 MG 24 HR TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6323-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 2 MG/ML IV SOLN (PRMC ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-1312-03,NDC,facility,both,20,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SITAGLIPTIN  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0006-0221-01,NDC,facility,both,1,EA,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-439-11,NDC,facility,both,4,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL-ROPIVACAINE-NACL (PF) 2-0.2 MCG/ML-% INJ (MERGE ERX),50863,CDM,250,RC,J3490,HCPCS,70092-1259-75,NDC,facility,both,1,ML,,218,152.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM 500 MG IV SOLR,50863,CDM,636,RC,J2185,HCPCS,0781-3000-94,NDC,facility,both,5,EA,JZ,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-24,NDC,facility,both,40,ML,"JA,JZ",5658,3960.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously | Modifier JZ: Zero drug amount discarded/not administered to any patient
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,250,RC,J3360,HCPCS,0409-1273-03,NDC,facility,both,6,ML,,593,415.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 1 GRAM INJ SOLR,50863,CDM,636,RC,J0692,HCPCS,44567-240-10,NDC,facility,both,2,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLN,50863,CDM,636,RC,J3262,HCPCS,50242-135-01,NDC,facility,both,80,ML,"JZ,JA",1467,1026.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
MIDODRINE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-398-11,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,68180-441-02,NDC,facility,both,5,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTAMIDINE 300 MG INJ SOLR,50863,CDM,636,RC,J3490,HCPCS,63323-113-01,NDC,facility,both,1,EA,,447,312.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL  32.4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6575-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,50863,CDM,250,RC,J9263,HCPCS,71288-101-10,NDC,facility,both,97,ML,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DRONABINOL  2.5 MG ORAL CAP,50863,CDM,250,RC,Q0167,HCPCS,60687-375-11,NDC,facility,both,1,EA,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BISOPROLOL FUMARATE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-679-11,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,250,RC,Q9968,HCPCS,70710-1838-1,NDC,facility,both,95,ML,,1570,1099,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,46,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),50863,CDM,250,RC,J1630,HCPCS,63323-474-00,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,66689-053-99,NDC,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN DEXTROSE (ISO-OSMOTIC) 1 GRAM/50 ML IV PIGGY BACK,50863,CDM,250,RC,J0690,HCPCS,0338-3503-41,NDC,facility,both,2,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNIT/G TOP PACK,50863,CDM,J3490,HCPCS,0904-7402-67,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN ENEMA 500MG IN 100ML NS,50863,CDM,250,RC,J3370,HCPCS,67457-339-00,NDC,facility,both,1,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,636,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,3,EA,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,7733393825,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL  6.25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-854-11,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 10 MEQ/100 ML IV PGBK (USE NON-PROTOCOL PANEL),50863,CDM,636,RC,J3480,HCPCS,0338-0709-48,NDC,facility,both,5,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETIRIZINE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16714-799-02,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DASATINIB  50 MG ORAL TAB,50863,CDM,250,RC,J9999,HCPCS,60505-3629-6,NDC,facility,both,2,EA,,1770,1239,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,636,RC,J7510,HCPCS,17856-0815-1,NDC,facility,both,6,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J2310,HCPCS,0641-6132-01,NDC,facility,both,1,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,50863,CDM,636,RC,J3490,HCPCS,0378-7732-93,NDC,facility,both,4,EA,,379,265.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0093-4155-73,NDC,facility,both,4,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,62332-037-31,NDC,facility,both,2,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 400 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-6667-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,0409-3178-16,NDC,,,facility,both,240,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,0409-3178-01,NDC,,,facility,both,160,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,73,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 160 MG-800 MG TAB,50863,CDM,J3490,HCPCS,0904-2725-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,50863,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,117,ML,,142,99.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  125 MG ORAL CAP,50863,CDM,J3490,HCPCS,0121-0867-20,NDC,,,facility,both,1,EA,,154,107.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZONATATE 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,68084-214-11,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 1 MG ORAL TAB,50863,CDM,250,RC,J8540,HCPCS,72578-166-01,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FERRIC SUBSULFATE 0.2 TO 0.22 GRAM/ML MISC SOLA,50863,CDM,636,RC,J3490,HCPCS,48783-112-08,NDC,facility,both,2,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICARDIPINE 25 MG/10 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,64679-631-02,NDC,facility,both,2,ML,,232,162.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,12,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0703-1153-01,NDC,facility,both,1,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETHIODIZED OIL 48 % INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,67684-1901-1,NDC,facility,both,2,ML,,6605,4623.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G POTASSIUM  5000000 UNIT INJ SOLR,50863,CDM,636,RC,J2540,HCPCS,0049-0520-84,NDC,facility,both,9,EA,JZ,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
COLCHICINE 0.6 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,59651-455-01,NDC,facility,both,2,EA,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,3,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB 10 MG/ML IV CONC,50863,CDM,250,RC,J9312,HCPCS,50242-053-06,NDC,facility,both,97,ML,,25153,17607.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,636,RC,J3101,HCPCS,50242-037-06,NDC,facility,both,23,EA,,10535,7374.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,636,RC,J2704,HCPCS,65219-800-01,NDC,facility,both,4,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN 0.9 % SODIUM CHL 2 GRAM/500 ML IV SOLN,50863,CDM,636,RC,J3373,HCPCS,70092-9338-07,NDC,facility,both,4,ML,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MYCOPHENOLATE 250 MG CAP,50863,CDM,636,RC,J7517,HCPCS,0093-7334-01,NDC,facility,both,1,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 500 MG PE/10 ML INJ SOLN,50863,CDM,250,RC,Q2009,HCPCS,68462-621-02,NDC,facility,both,4,ML,,152,106.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,81284-315-00,NDC,facility,both,1,ML,,864,604.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-0552-23,NDC,facility,both,5,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,0641-0477-21,NDC,facility,both,2,ML,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG/ML INJ SOLN,50863,CDM,636,RC,J2550,HCPCS,0641-0928-21,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,50863,CDM,636,RC,J0696,HCPCS,0143-9857-01,NDC,facility,both,4,EA,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PREDNISONE 10 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0904-6923-61,NDC,facility,both,5,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,59651-488-01,NDC,facility,both,20,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,250,RC,J3490,HCPCS,73702-301-15,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR  6 MG/ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0004-0822-05,NDC,facility,both,8,ML,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,0121-1971-21,NDC,facility,both,2,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-504-11,NDC,facility,both,4,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J1610,HCPCS,63323-582-82,NDC,facility,both,2,EA,,1981,1386.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-22,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,5,EA,JW,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ADVATE: FACTOR VIII CONCENTRATE (MERGE RECORD),50863,CDM,250,RC,J7192,HCPCS,0944-3054-02,NDC,facility,both,2250,UN,,9419,6593.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-8297-25,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69238-1056-1,NDC,facility,both,2,EA,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,16714-293-03,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 250 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,68084-776-11,NDC,facility,both,3,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6291-06,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES  8.6 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7252-60,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,45,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7041-61,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,280,ML,,198,138.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-31,NDC,facility,both,1,ML,,111,77.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZATHIOPRINE  50 MG ORAL TAB,50863,CDM,250,RC,J7500,HCPCS,68084-229-11,NDC,facility,both,3,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV (BOLUS),50863,CDM,250,RC,J7120,HCPCS,0338-0117-02,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROATE SODIUM 100 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0143-9785-01,NDC,facility,both,6,ML,,609,426.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,50863,CDM,250,RC,J9263,HCPCS,71288-172-21,NDC,facility,both,83,ML,JW,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
MOXIFLOXACIN 400 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-722-11,NDC,facility,both,1,EA,,132,92.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-0552-23,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL (VITAMIN D3)   400 UNIT ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,7733394825,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,J2704,HCPCS,0069-0209-01,NDC,,,facility,both,29,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOBRAMYCIN 1.2 G POWDER VIAL,50863,CDM,636,RC,J3260,HCPCS,39822-0412-6,NDC,facility,both,45,EA,,1193,835.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THROMBIN (RECOMBINANT) 5000 UNIT TOP SOLR,50863,CDM,250,RC,J3490,HCPCS,0338-0324-01,NDC,facility,both,4,EA,,1487,1040.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOBUTAMINE IN D5W 500 MG/250 ML (2 MG/ML) INFUSION (PREMIX),50863,CDM,636,RC,J1250,HCPCS,0409-2347-31,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G POTASSIUM  5000000 UNIT INJ SOLR,50863,CDM,250,RC,J2540,HCPCS,44567-311-10,NDC,facility,both,1,EA,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DOXORUBICIN 50 MG/25 ML IV SOLN,50863,CDM,250,RC,J9000,HCPCS,0069-1542-20,NDC,facility,both,3,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  750 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,65862-247-08,NDC,facility,both,1,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 0.4 MG SL SUBL,50863,CDM,636,RC,J3490,HCPCS,58151-310-94,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN PEDS INFUSION (CDS MIXTURE),50863,CDM,636,RC,J0290,HCPCS,25021-136-10,NDC,facility,both,3,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENAZEPRIL 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,65862-116-01,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,66689-201-08,NDC,facility,both,1,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOBENZAPRINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-558-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  650 MG RECT SUPP,50863,CDM,636,RC,J3490,HCPCS,45802-730-00,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,250,RC,J2405,HCPCS,60505-6130-0,NDC,facility,both,4,ML,"JZ,PLAD",16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier PLAD: Modifier description not available
ISOSORBIDE MONONITRATE 120 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,50268-453-11,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-360-11,NDC,facility,both,1,EA,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  20 MEQ ORAL PACK,50863,CDM,636,RC,J3490,HCPCS,0245-0360-89,NDC,facility,both,2,EA,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WHITE PETROLATUM-MINERAL OIL TOPICAL CREAM (MERGE),50863,CDM,250,RC,J3490,HCPCS,7214003868,NDC,facility,both,1,GM,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUANFACINE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68094-019-59,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALTREXONE 50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-1170-03,NDC,facility,both,2,EA,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,63323-649-07,NDC,facility,both,5,EA,,2600,1820,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZTROPINE 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7289-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,250,RC,J3490,HCPCS,0054-0742-87,NDC,facility,both,1,GM,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-DYYB 100 MG IV SOLR,50863,CDM,636,RC,Q5103,HCPCS,0069-0809-01,NDC,facility,both,60,EA,JZ,15671,10969.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,250,RC,J2405,HCPCS,23155-547-31,NDC,facility,both,4,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE LIPOSOME (PF) 266 MG/20 ML (13.3 MG/ML) LINF SUSP,50863,CDM,J3490,HCPCS,65250-266-20,NDC,,,facility,both,1,ML,,1116,781.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,14,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML INJ SOLN,50863,CDM,250,RC,J0171,HCPCS,76329-9060-0,NDC,facility,both,320,ML,,850,595,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE (FOR EMERGENCY) 100 MG/ML (10%) IV SOLN,50863,CDM,J0612,HCPCS,63323-360-01,NDC,,,facility,both,100,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,J3010,HCPCS,0641-6027-25,NDC,,,facility,both,2,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,J3490,HCPCS,63037-136-25,NDC,,,facility,both,3,ML,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-822-11,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYBUTYNIN CHLORIDE  5 MG ORAL TO24,50863,CDM,250,RC,J3490,HCPCS,0904-6570-61,NDC,facility,both,2,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DANTROLENE  25 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0115-4411-01,NDC,facility,both,4,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16571-109-01,NDC,facility,both,2,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 500 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,50268-152-11,NDC,facility,both,14,EA,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEMANTINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42292-006-01,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESNA 100 MG/ML IV SOLN,50863,CDM,250,RC,J9209,HCPCS,0338-1305-01,NDC,facility,both,8,ML,,299,209.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE (PF) 1 MG/ML INJ SOLN,50863,CDM,250,RC,J0169,HCPCS,68462-933-01,NDC,facility,both,10,ML,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7057-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 875 MG-125 MG TAB,50863,CDM,636,RC,J3490,HCPCS,16714-297-02,NDC,facility,both,6,EA,,145,101.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,43598-053-11,NDC,facility,both,20,ML,,725,507.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 0.4 MG/HR TD PT24,50863,CDM,636,RC,J3490,HCPCS,0378-9112-16,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,50863,CDM,636,RC,J0561,HCPCS,60793-701-02,NDC,facility,both,12,ML,,1080,756,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BALSALAZIDE 750 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,50268-102-11,NDC,facility,both,3,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
D5-0.9%NACL-POTASSIUM CHLORIDE 20 MEQ/L IV SOLP,50863,CDM,J3480,HCPCS,0338-0803-04,NDC,,,facility,both,10,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,25021-468-10,NDC,facility,both,2,EA,,511,357.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,78206-122-01,NDC,facility,both,2,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAZOLAMIDE 250 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6663-61,NDC,facility,both,2,EA,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MONTELUKAST 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-875-11,NDC,facility,both,1,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 0.5 MG/ML ORAL SUSPENSION (REPACK),50863,CDM,250,RC,J7507,HCPCS,51079-028-01,NDC,facility,both,2,EA,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE 128 MG/0.36 ML SUBQ SLSY,50863,CDM,636,RC,J0578,HCPCS,58284-228-01,NDC,facility,both,1,ML,JZ,4047,2832.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DIGOXIN 125 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-5921-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROPRUSSIDE 25 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-3024-01,NDC,facility,both,1,ML,,243,170.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,63323-280-03,NDC,facility,both,40,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,71288-505-02,NDC,facility,both,1,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOVASTATIN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68180-468-01,NDC,facility,both,2,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
URSODIOL 300 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,59651-421-01,NDC,facility,both,1,EA,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE  3 % INHL NEBU,50863,CDM,250,RC,J3490,HCPCS,487900330,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 2 MG/ML IN NS 50ML INFUSION (STOCK DOSE),50863,CDM,250,RC,J3490,HCPCS,0143-9508-01,NDC,facility,both,1,ML,,183,128.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG/ML INJ SOLN,50863,CDM,250,RC,J2550,HCPCS,0641-6084-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 20 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,0904-7043-04,NDC,facility,both,3,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,68516-5219-0,NDC,facility,both,6,ML,,1525,1067.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6374-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-0430-06,NDC,facility,both,2,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PSEUDOEPHEDRINE 30 MG TAB,50863,CDM,250,RC,J3490,HCPCS,45802-432-62,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PSEUDOEPHEDRINE 30 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6990-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,50863,CDM,250,RC,J9000,HCPCS,0069-1542-20,NDC,facility,both,5,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML SYRUP,50863,CDM,250,RC,J3490,HCPCS,0121-0638-05,NDC,facility,both,2,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MYCOPHENOLATE 250 MG CAP,50863,CDM,636,RC,J7517,HCPCS,51079-721-01,NDC,facility,both,1,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6924-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROPRUSSIDE 25 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0187-4302-02,NDC,facility,both,1,ML,,1062,743.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-02,NDC,facility,both,4,ML,JZ,204,142.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,J1953,HCPCS,63323-400-01,NDC,,,facility,both,80,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"HEPARIN, PORCINE (PF)  100 UNIT/ML IV SYRG",50863,CDM,250,RC,J1642,HCPCS,8290306424,NDC,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,636,RC,J0690,HCPCS,70092-1017-46,NDC,facility,both,2,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DROPERIDOL 2.5 MG/ML INJ SOLN,50863,CDM,J1790,HCPCS,0517-9702-01,NDC,,,facility,both,1,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  500 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,63323-377-00,NDC,facility,both,20,ML,JZ,253,177.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LORAZEPAM 0.5 MG ORAL TAB,50863,CDM,J3490,HCPCS,69315-904-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZIPRASIDONE 20 MG IM,50863,CDM,250,RC,J3486,HCPCS,43598-848-11,NDC,facility,both,1,EA,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,0641-6145-01,NDC,facility,both,9,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 875 MG-125 MG TAB,50863,CDM,250,RC,J3490,HCPCS,65862-503-20,NDC,facility,both,1,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES-DOCUSATE SODIUM 8.6 MG-50 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0536-1247-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,75834-221-01,NDC,facility,both,3,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 40 MG/ML (4 %) INJ SOLN (FOR NEBULIZATION),50863,CDM,636,RC,J3490,HCPCS,0409-4283-11,NDC,facility,both,200,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-11,NDC,facility,both,12,ML,JW,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CEFUROXIME AXETIL 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65862-699-20,NDC,facility,both,12,EA,,224,156.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 40 GRAM/400 ML (10 %) INJ SOLN",50863,CDM,250,RC,J1561,HCPCS,13533-800-40,NDC,facility,both,80,ML,,11316,7921.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,14789-127-07,NDC,facility,both,1,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,0409-6625-14,NDC,facility,both,13,ML,,751,525.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-349-11,NDC,facility,both,1,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 50 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,60687-402-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,50863,CDM,636,RC,Q0177,HCPCS,0904-6617-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,0641-6145-01,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,636,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,6,EA,,198,138.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 20 MG/ML INJ SOLN,50863,CDM,250,RC,J0360,HCPCS,0641-6231-01,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J2003,HCPCS,0409-4279-16,NDC,facility,both,2500,ML,,305,213.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CENOBAMATE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,71699-200-30,NDC,facility,both,1,EA,,238,166.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IVPB (PEDIATRICS/ADULT NON-FORM)",50863,CDM,636,RC,J0137,HCPCS,24201-100-01,NDC,facility,both,40,ML,JW,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-5771-23,NDC,facility,both,10,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 150 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,60687-312-11,NDC,facility,both,1,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,50863,CDM,250,RC,J9263,HCPCS,71288-172-21,NDC,facility,both,24,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,636,RC,J3010,HCPCS,0409-9094-18,NDC,facility,both,3,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANTI-INHIBITOR COAGULANT CMPLX (PHS MERGE),50863,CDM,250,RC,J7198,HCPCS,64193-326-01,NDC,facility,both,575,UN,JW,4153,2907.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PREDNISONE 10 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0904-6923-61,NDC,facility,both,56,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-2051-15,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,0904-6794-80,NDC,facility,both,4,EA,PLAD,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,37,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,0409-3178-17,NDC,,,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN   1.25 G IV SOLR,50863,CDM,J3370,HCPCS,67457-823-12,NDC,,,facility,both,3,EA,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,636,RC,J3490,HCPCS,63037-136-25,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 150 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,50228-175-01,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOPERAMIDE 2 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,51079-690-01,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXAZOSIN 2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-851-95,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,50863,CDM,J1650,HCPCS,0781-3246-02,NDC,,,facility,both,3,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIMOLOL MALEATE 0.25 % OPHT DROP,50863,CDM,636,RC,J3490,HCPCS,61314-226-05,NDC,facility,both,1,ML,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,J2003,HCPCS,0409-4903-11,NDC,,,facility,both,300,ML,,126,88.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,636,RC,J2795,HCPCS,43066-023-01,NDC,facility,both,30,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CHLORTHALIDONE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-058-01,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 10 GRAM/15 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0116-4005-30,NDC,facility,both,1,ML,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9% IV (PEDS) BOLUS,50863,CDM,636,RC,J7030,HCPCS,0264-7800-09,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,63323-161-00,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 500 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,0832-7124-89,NDC,facility,both,3,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 10 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0591-0794-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G POTASSIUM  5000000 UNIT INJ SOLR,50863,CDM,636,RC,J2540,HCPCS,0049-0520-84,NDC,facility,both,9,EA,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,45049660,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-544-10,NDC,facility,both,4,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,51754-5001-1,NDC,facility,both,1,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,50863,CDM,636,RC,J0585,HCPCS,0023-1145-01,NDC,facility,both,75,EA,JW,522,365.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ORPHENADRINE CITRATE 30 MG/ML INJ SOLN,50863,CDM,250,RC,J2360,HCPCS,0641-6182-10,NDC,facility,both,1,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GOLIMUMAB  12.5 MG/ML IV SOLN,50863,CDM,636,RC,J1602,HCPCS,57894-350-01,NDC,facility,both,243,ML,,26817,18771.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-492-27,NDC,facility,both,500,ML,,393,275.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68382-181-01,NDC,facility,both,10,EA,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE SODIUM 2.5 MG ORAL TAB,50863,CDM,250,RC,J8610,HCPCS,0904-7141-10,NDC,facility,both,5,EA,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NOREPINEPHRINE BITARTRATE-D5W 4 MG/250 ML (16 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,71285-6056-1,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB 100 MG IV SOLR,50863,CDM,J1745,HCPCS,57894-160-01,NDC,,,facility,both,28,EA,,3671,2569.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 40 MG/ML (4 %) INJ SOLN (FOR NEBULIZATION),50863,CDM,J2003,HCPCS,0409-4283-11,NDC,,,facility,both,60,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESNA 100 MG/ML IV SOLN,50863,CDM,250,RC,J9209,HCPCS,10019-953-62,NDC,facility,both,7,ML,,197,137.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,70069-363-01,NDC,facility,both,1,ML,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6500-61,NDC,facility,both,2,EA,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,250,RC,J3490,HCPCS,60687-653-11,NDC,facility,both,16,EA,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,636,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,180,ML,,163,114.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,50863,CDM,636,RC,Q0177,HCPCS,60687-675-11,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-0053-05,NDC,facility,both,10,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,76045-009-10,NDC,facility,both,14,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNITS/1 GRAM PACKET (MERGE RECORD),50863,CDM,636,RC,J3490,HCPCS,45802-060-00,NDC,facility,both,6,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),50863,CDM,636,RC,J1815,HCPCS,0024-5926-05,NDC,facility,both,6,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,636,RC,Q9968,HCPCS,70710-1838-1,NDC,facility,both,237,ML,,3924,2746.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  1 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,64380-782-06,NDC,facility,both,14,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,0409-3178-01,NDC,,,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,0409-3178-16,NDC,,,facility,both,75,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,250,RC,J0330,HCPCS,69374-919-10,NDC,facility,both,3,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV,50863,CDM,J7120,HCPCS,0409-7953-09,NDC,,,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,J2003,HCPCS,63323-202-02,NDC,,,facility,both,60,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,J2704,HCPCS,63323-269-69,NDC,,,facility,both,100,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM ZIRCONIUM CYCLOSILICATE  5 G ORAL PWPK (USE PANEL),50863,CDM,J3490,HCPCS,0310-1105-01,NDC,,,facility,both,1,EA,,169,118.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACARBOSE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-0140-25,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,50863,CDM,J2250,HCPCS,0409-2305-04,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,J2371,HCPCS,0641-6142-01,NDC,,,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POVIDONE-IODINE 10 % TOP OINT,50863,CDM,250,RC,J3490,HCPCS,52380-0126-2,NDC,facility,both,29,GM,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIFEDIPINE 20 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,23155-195-01,NDC,facility,both,3,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-48,NDC,facility,both,2,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE PEDS IV INFUSION (CDS MIXTURE),50863,CDM,250,RC,J3490,HCPCS,99999-420-20,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 1 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,49884-315-52,NDC,facility,both,1,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-41,NDC,facility,both,240,ML,,33946,23762.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,300,ML,JZ,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,16714-016-01,NDC,facility,both,8,ML,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0630,HCPCS,42023-205-01,NDC,facility,both,1,ML,,3932,2752.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,636,RC,J0330,HCPCS,31722-981-10,NDC,facility,both,6,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-18,NDC,facility,both,100,ML,JZ,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IVABRADINE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50742-362-60,NDC,facility,both,1,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAMSULOSIN 0.4 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,68084-299-11,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEFLUNOMIDE  20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,62332-062-30,NDC,facility,both,1,EA,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2723-30,NDC,facility,both,2,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ABATACEPT 250 MG IV SOLR,50863,CDM,636,RC,J0129,HCPCS,0003-2187-13,NDC,facility,both,50,EA,"JZ,JA",8356,5849.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-02,NDC,facility,both,1,ML,GA,30,21,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier GA: Waiver of liability statement issued as required by payer policy, individual case"
ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,17856-7014-7,NDC,facility,both,1,ML,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC IV INFUSION HYDRAT 31-60 MIN,50863,CDM,250,RC,J0248,HCPCS,61958-2901-2,NDC,facility,both,99,EA,JW,515,360.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
VENLAFAXINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,23155-248-01,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 10 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,67457-420-00,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  75 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0071-1014-41,NDC,facility,both,1,EA,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-5771-23,NDC,facility,both,7,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLN (MERGE)",50863,CDM,250,RC,P9047,HCPCS,76125-792-10,NDC,facility,both,2,ML,,415,290.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  15 MG ORAL TBSR,50863,CDM,636,RC,J3490,HCPCS,0904-6557-61,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 20 MG ORAL TAB,50863,CDM,J3490,HCPCS,0781-1818-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 500 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,68084-782-11,NDC,facility,both,2,EA,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,66758-016-03,NDC,facility,both,5000,ML,,199,139.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51672-4027-1,NDC,facility,both,3,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON DEXTRAN 50 MG/ML INJ SOLN,50863,CDM,636,RC,J1750,HCPCS,0023-6082-01,NDC,facility,both,1,ML,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2723-30,NDC,facility,both,8,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PSYLLIUM HUSK (WITH SUGAR) 3.4 GRAM ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,37000-023-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 100 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,67877-592-01,NDC,facility,both,3,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 4 MG/ACTUATION NASL SPRY,50863,CDM,636,RC,J3490,HCPCS,69547-627-02,NDC,facility,both,2,EA,,229,160.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0054-8297-25,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,50863,CDM,250,RC,J0640,HCPCS,0143-9554-01,NDC,facility,both,1,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 1250 MG/5 ML SUSPENSION (500 MG/5 ML ELEMENTAL),50863,CDM,636,RC,J3490,HCPCS,0121-4766-05,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MYCOPHENOLATE 250 MG CAP,50863,CDM,250,RC,J7517,HCPCS,0093-7334-01,NDC,facility,both,1,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J7510,HCPCS,17856-0815-1,NDC,facility,both,2,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXEPIN  25 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,51079-437-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-1971-21,NDC,facility,both,2,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,67,ML,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,636,RC,J1953,HCPCS,55150-177-05,NDC,facility,both,300,ML,JZ,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CHOLECALCIFEROL (VITAMIN D3)  1000 UNIT ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,8068116900,NDC,facility,both,4,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,24,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PENTOBARBITAL 75 MG/1.5 ML SYRINGE (REPACK),50863,CDM,636,RC,J2515,HCPCS,25021-676-20,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"VITAMIN E (DL, ACETATE) 22.5 MG (50 UNIT)/ML ORAL DROP",50863,CDM,250,RC,J3490,HCPCS,7132180230,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN NEO/PEDS IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0456,HCPCS,63323-398-14,NDC,facility,both,1,EA,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 5 MG/ML IV SOLN,50863,CDM,250,RC,J1921,HCPCS,0409-2267-54,NDC,facility,both,3,ML,,183,128.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-0007-01,NDC,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IVPB (PEDIATRICS/ADULT NON-FORM)",50863,CDM,636,RC,J0137,HCPCS,24201-100-01,NDC,facility,both,92,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN NPH HUMAN RECOMB 100 UNIT/ML SUBQ SUSP,50863,CDM,636,RC,J1815,HCPCS,0169-1834-11,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-495-27,NDC,facility,both,220,ML,,108,75.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  75 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-495-11,NDC,facility,both,5,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,0143-9577-01,NDC,,,facility,both,200,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,J2919,HCPCS,0009-0039-30,NDC,,,facility,both,9,EA,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  10 MG ORAL TR12,50863,CDM,250,RC,J3490,HCPCS,59011-410-20,NDC,facility,both,5,EA,,171,119.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,J0330,HCPCS,71288-719-10,NDC,,,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"TRANEXAMIC ACID IN NACL,ISO-OS 1,000 MG/100 ML (10 MG/ML) IV PGBK",50863,CDM,J3490,HCPCS,51754-0108-1,NDC,,,facility,both,1,ML,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,68516-5214-1,NDC,facility,both,4,ML,,893,625.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM  4.5 GRAM IV SOLR,50863,CDM,J2543,HCPCS,55150-121-50,NDC,,,facility,both,4,EA,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-461-11,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN 0.9% SODIUM CL 1.25 GRAM/250 ML IV SOLN,50863,CDM,250,RC,J3373,HCPCS,71285-6074-1,NDC,facility,both,125,ML,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM SR 120 MG 24 HR CAP,50863,CDM,250,RC,J3490,HCPCS,60687-195-11,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN 0.9% SODIUM CL 1.25 GRAM/250 ML IV SOLN,50863,CDM,636,RC,J3370,HCPCS,71266-5083-1,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0295,HCPCS,63323-368-20,NDC,facility,both,2,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-18,NDC,facility,both,200,ML,JZ,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MEROPENEM 1 GRAM IV SOLR,50863,CDM,636,RC,J2185,HCPCS,0409-1391-21,NDC,facility,both,10,EA,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAVASTATIN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-5891-61,NDC,facility,both,2,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-821-01,NDC,facility,both,4,EA,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,250,RC,J2704,HCPCS,25021-608-20,NDC,facility,both,2,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,636,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,10,ML,JZ,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
BELATACEPT 250 MG IV SOLR,50863,CDM,636,RC,J0485,HCPCS,0003-0371-13,NDC,facility,both,338,EA,,3488,2441.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGIC MOUTHWASH REPACK (BMX 1:1:1),50863,CDM,250,RC,J3490,HCPCS,0603-0823-54,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,0641-6145-01,NDC,facility,both,4,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,28,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25 MG-250 MG TAB,50863,CDM,636,RC,J3490,HCPCS,60687-836-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-5755-23,NDC,facility,both,3,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIOGLITAZONE 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-391-11,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  50 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,64980-411-09,NDC,facility,both,1,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,13668-010-01,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7030,HCPCS,0338-0049-04,NDC,facility,both,3,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML INJ SOLN,50863,CDM,636,RC,J2060,HCPCS,0641-6207-01,NDC,facility,both,2,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,636,RC,Q0162,HCPCS,65162-691-79,NDC,facility,both,2,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,16714-293-01,NDC,facility,both,3,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SYRG,50863,CDM,250,RC,J3490,HCPCS,8290306547,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-22,NDC,facility,both,20,ML,PLAD,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,65219-572-01,NDC,facility,both,10,ML,,283,198.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUPHENAZINE 5 MG TAB,50863,CDM,250,RC,J3490,HCPCS,60687-749-11,NDC,facility,both,1,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7122-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,67877-545-88,NDC,facility,both,4,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOFLOXACIN 250 MG/10 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0527-1948-66,NDC,facility,both,1,ML,,409,286.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,63323-165-01,NDC,facility,both,2,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,13,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6797-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,76045-009-96,NDC,facility,both,4,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRBESARTAN 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,33342-049-07,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,50863,CDM,250,RC,J1756,HCPCS,0517-2340-01,NDC,facility,both,400,ML,,1246,872.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7369-04,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 1 % INJ SOLN,50863,CDM,636,RC,Q9968,HCPCS,0517-0301-10,NDC,facility,both,10,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN STERILE WATER 2 GRAM/20 ML IV SYRG,50863,CDM,250,RC,J7999,HCPCS,70092-1604-47,NDC,facility,both,2,ML,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25 MG-100 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0378-0085-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,50863,CDM,636,RC,J3420,HCPCS,63323-044-00,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-087-02,NDC,facility,both,30,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1940,HCPCS,36000-283-25,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,16714-293-01,NDC,facility,both,8,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR 200 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,69076-146-01,NDC,facility,both,4,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
D5-1/2 NS AND POTASSIUM CHLORIDE 40 MEQ/L IV,50863,CDM,636,RC,J3490,HCPCS,0338-0675-04,NDC,facility,both,1,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,250,RC,J7999,HCPCS,70092-1017-46,NDC,facility,both,5,ML,,198,138.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-505-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-1283-03,NDC,facility,both,10,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,636,RC,J3490,HCPCS,0409-4887-23,NDC,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,50863,CDM,250,RC,J9025,HCPCS,72485-201-01,NDC,facility,both,73,EA,JW,453,317.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
MIRTAZAPINE 30 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,13107-003-34,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE MONONITRATE  20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,62175-107-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,250,RC,J3490,HCPCS,63037-136-25,NDC,facility,both,2,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OMEPRAZOLE-SODIUM BICARBONATE 2-84 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,65628-270-03,NDC,facility,both,2,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE MONONITRATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,7733393425,NDC,facility,both,3,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % (1 MEQ/ML) IV 50 ML EMERGENCY SYRINGE,50863,CDM,250,RC,J3490,HCPCS,70092-1015-50,NDC,facility,both,3,ML,,186,130.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,250,RC,J3490,HCPCS,72485-510-01,NDC,facility,both,3,ML,,203,142.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUORESCEIN 1 MG OPHT STRP,50863,CDM,J3490,HCPCS,8385110001,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-6773-61,NDC,,,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 10 MG/ML INJ SOLN,50863,CDM,J1171,HCPCS,0703-0018-01,NDC,,,facility,both,2500,ML,,224,156.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,50863,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,237,ML,,286,200.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DORNASE ALFA 1 MG/ML INHL SOLN,50863,CDM,250,RC,J3490,HCPCS,50242-100-39,NDC,facility,both,2,ML,,920,644,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE 20 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0904-5677-61,NDC,facility,both,3,EA,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOLAZONE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,72888-053-01,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,636,RC,J2720,HCPCS,63323-229-01,NDC,facility,both,7,ML,,128,89.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM  2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-284-01,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 500 MG (200 MG ELEMENTAL) CHEW TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6412-92,NDC,facility,both,8,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALSARTAN 160 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,33342-064-10,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5%-1/2 NORMAL SALINE IV,50863,CDM,250,RC,J7042,HCPCS,0264-7612-00,NDC,facility,both,2,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESNA 100 MG/ML IV SOLN,50863,CDM,250,RC,J9209,HCPCS,0338-1305-01,NDC,facility,both,9,ML,,334,233.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESTRADIOL 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42806-088-01,NDC,facility,both,6,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68180-513-01,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON DEXTRAN 50 MG/ML INJ SOLN,50863,CDM,250,RC,J1750,HCPCS,0023-6082-01,NDC,facility,both,1,ML,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BALANCED SALT IRRIG SOLN COMB2 INTRAOCULAR,50863,CDM,636,RC,J3490,HCPCS,0065-0795-15,NDC,facility,both,1,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIOGLITAZONE 30 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,33342-055-07,NDC,facility,both,1,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,819,ME,JZ,11114,7779.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"BICARB DIAL SOLN13-NO CA,K,DEX MG 1.2 MEQ/L HEMO SOLN",50863,CDM,J3490,HCPCS,24571-113-06,NDC,,,facility,both,1,ML,,412,288.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORDIAZEPOXIDE 25 MG CAP,50863,CDM,250,RC,J3490,HCPCS,0555-0159-02,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,50863,CDM,J3301,HCPCS,70121-1049-1,NDC,,,facility,both,12,ML,,150,105,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6928-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,636,RC,J3010,HCPCS,0409-9094-18,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 250 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,0904-6363-45,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM IN NACL (ISO-OS) 1500 MG/100 ML IV PGBK,50863,CDM,250,RC,J1953,HCPCS,55150-248-47,NDC,facility,both,150,ML,,306,214.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J2003,HCPCS,63323-492-09,NDC,facility,both,100,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 150 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7212-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7008-61,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,42494-416-01,NDC,facility,both,3,ML,,577,403.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,50863,CDM,250,RC,J9000,HCPCS,0069-1542-20,NDC,facility,both,2,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOZAPINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-404-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,39,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),50863,CDM,250,RC,J1815,HCPCS,0024-5926-05,NDC,facility,both,5,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,62332-600-01,NDC,facility,both,4,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TECLISTAMAB-CQYV 90 MG/ML SUBQ SOLN,50863,CDM,250,RC,J9380,HCPCS,57894-450-01,NDC,facility,both,306,ML,,24915,17440.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % MBP,50863,CDM,250,RC,J3490,HCPCS,0338-9159-30,NDC,facility,both,1,ML,PLAD,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
HYDRALAZINE 20 MG/ML INJ SOLN,50863,CDM,636,RC,J0360,HCPCS,0641-6231-01,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZOCAINE-MENTHOL 15-3.6 MG MM LOZG,50863,CDM,250,RC,J3490,HCPCS,6382471016,NDC,facility,both,18,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,62584-733-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,J2003,HCPCS,63323-486-17,NDC,,,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,J3490,HCPCS,68180-441-02,NDC,,,facility,both,3,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAPAVERINE 30 MG/ML INJ SOLN,50863,CDM,250,RC,J2440,HCPCS,0517-4010-01,NDC,facility,both,5,ML,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYMETAZOLINE 0.05 % NASL SPRA,50863,CDM,636,RC,J3490,HCPCS,4110081125,NDC,facility,both,1,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB 100 MG IV SOLR,50863,CDM,636,RC,J1745,HCPCS,57894-030-01,NDC,facility,both,37,EA,,11926,8348.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,250,RC,J2795,HCPCS,70069-064-25,NDC,facility,both,90,ML,JW,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
VECURONIUM BROMIDE 10 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,0703-2914-01,NDC,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHIMAZOLE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-669-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-0710-20,NDC,facility,both,23,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,250,RC,J0690,HCPCS,44567-707-25,NDC,facility,both,4,EA,JZ,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PRAMIPEXOLE 0.25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-570-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0904-6923-61,NDC,facility,both,20,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL PHOSPHATE 10 MG ORAL CM24,50863,CDM,250,RC,J3490,HCPCS,16714-227-01,NDC,facility,both,4,EA,,204,142.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 20 GRAM/30 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-1154-30,NDC,facility,both,2,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 20 GRAM/30 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-1154-30,NDC,facility,both,3,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPAGLIFLOZIN PROPANEDIOL 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0310-6210-30,NDC,facility,both,1,EA,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 400 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,45963-557-11,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0054-0017-20,NDC,facility,both,90,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM IN NACL (ISO-OS) 1000 MG/100 ML IV PGBK,50863,CDM,636,RC,J1953,HCPCS,36000-356-01,NDC,facility,both,100,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 250 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,51079-766-01,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  75 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6951-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE  7 MG/24 HR TD PT24,50863,CDM,250,RC,J3490,HCPCS,4898500155,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,42858-001-10,NDC,facility,both,12,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLN (MERGE)",50863,CDM,636,RC,P9047,HCPCS,68516-5216-4,NDC,facility,both,2,ML,,427,298.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE NA (PRESERV FREE) 25 MG/ML INJ SOLN,50863,CDM,250,RC,J9260,HCPCS,16729-277-35,NDC,facility,both,177,ML,,1776,1243.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FELODIPINE  2.5 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,68462-233-01,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TICAGRELOR 90 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0186-0777-39,NDC,facility,both,2,EA,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,636,RC,J2003,HCPCS,0409-1323-05,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 2 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,250,RC,J2270,HCPCS,63323-452-00,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML INJECTION,50863,CDM,250,RC,J3411,HCPCS,43598-050-11,NDC,facility,both,2,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DONEPEZIL  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6477-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 50 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,60687-854-11,NDC,facility,both,50,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORDIAZEPOXIDE 25 MG CAP,50863,CDM,636,RC,J3490,HCPCS,60687-807-11,NDC,facility,both,3,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE  1 % TOP CREA,50863,CDM,250,RC,J3490,HCPCS,45802-438-03,NDC,facility,both,2,GM,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 600 MG ORAL TP12,50863,CDM,250,RC,J3490,HCPCS,0536-1163-61,NDC,facility,both,20,EA,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RACEPINEPHRINE 2.25 % INHL NEBU,50863,CDM,636,RC,J3490,HCPCS,0487-2784-01,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0003-0894-21,NDC,facility,both,1,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,4,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,71288-505-02,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-ABBS 10 MG/ML IV SOLN,50863,CDM,636,RC,Q5115,HCPCS,63459-104-50,NDC,facility,both,100,ML,,23338,16336.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SYRG,50863,CDM,250,RC,J3490,HCPCS,8290306547,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,636,RC,J1953,HCPCS,72485-106-01,NDC,facility,both,150,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RASBURICASE 1.5 MG IV SOLR,50863,CDM,250,RC,J2783,HCPCS,0024-5154-11,NDC,facility,both,2,EA,,1152,806.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VERAPAMIL 180 MG ORAL TBSR,50863,CDM,636,RC,J3490,HCPCS,75834-158-01,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,636,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,9,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1817,HCPCS,0169-1833-11,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML (ANESTHESIA INTRAOP ONLY),50863,CDM,250,RC,J3010,HCPCS,0641-6027-01,NDC,facility,both,1,ML,PLAD,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
POTASSIUM CHLORIDE  20 MEQ ORAL PACK,50863,CDM,636,RC,J3490,HCPCS,0245-0360-89,NDC,facility,both,1,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,16714-294-01,NDC,facility,both,11,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 1200000 UNIT/2 ML IM SYRG,50863,CDM,636,RC,J0561,HCPCS,54569-5877-1,NDC,facility,both,12,ML,,281,196.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,50863,CDM,J1815,HCPCS,0169-1833-11,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,72603-251-01,NDC,facility,both,12,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,12,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9% IV (PEDS) BOLUS,50863,CDM,250,RC,J7030,HCPCS,0264-7800-09,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LINEZOLID NEO IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J2020,HCPCS,0009-5140-01,NDC,facility,both,3,ML,,194,135.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 50 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,60687-854-11,NDC,facility,both,50,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMETHICONE 40 MG/0.6 ML ORAL DRPS,50863,CDM,636,RC,J3490,HCPCS,0536-1303-75,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,563,ME,JZ,7640,5348,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68180-966-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),50863,CDM,636,RC,J0171,HCPCS,0409-4921-34,NDC,facility,both,30,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,16714-294-01,NDC,facility,both,4,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE (FOR EMERGENCY) 100 MG/ML (10%) IV SOLN,50863,CDM,636,RC,J0612,HCPCS,70069-727-01,NDC,facility,both,1000,ML,JZ,343,240.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
BETAMETHASONE ACET & SOD PHOS 6 MG/ML INJ SUSP,50863,CDM,250,RC,J0702,HCPCS,51754-5060-1,NDC,facility,both,2,ML,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNIT/G TOP OINT (MERGE),50863,CDM,636,RC,J3490,HCPCS,51672-2075-2,NDC,facility,both,1,GM,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0406-0552-23,NDC,facility,both,12,EA,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,636,RC,P9045,HCPCS,68516-5218-0,NDC,facility,both,13,ML,,1667,1166.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BIVALIRUDIN 250 MG IV SOLR,50863,CDM,250,RC,J0583,HCPCS,71288-427-10,NDC,facility,both,500,EA,,713,499.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,63323-400-01,NDC,facility,both,40,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERTAPENEM 1 GRAM INJ SOLR,50863,CDM,250,RC,J1335,HCPCS,16714-889-01,NDC,facility,both,4,EA,,1050,735,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-9558-05,NDC,facility,both,4,ML,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,69238-1491-1,NDC,facility,both,2,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA SR 50 MG-200 MG TAB,50863,CDM,636,RC,J3490,HCPCS,68084-282-11,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,0409-6625-14,NDC,facility,both,1,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,59651-488-01,NDC,facility,both,40,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM IN NACL (ISO-OS) 1500 MG/100 ML IV PGBK,50863,CDM,636,RC,J1953,HCPCS,55150-248-47,NDC,facility,both,150,ML,,306,214.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN   81 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,17856-3086-1,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,3,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
REGADENOSON 0.4 MG/5 ML IV SYRG,50863,CDM,J2785,HCPCS,0469-6501-89,NDC,,,facility,both,4,ML,,913,639.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLU VACCINE TS 2024-25 6MOS UP (PF) 45 MCG (15 MCG X 3)/0.5 ML IM SYRG,50863,CDM,250,RC,90656,HCPCS,58160-884-41,NDC,facility,both,1,ML,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHIMAZOLE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,23155-071-01,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,63323-482-03,NDC,facility,both,100,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-0007-01,NDC,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,636,RC,J1610,HCPCS,63323-596-03,NDC,facility,both,2,EA,,1342,939.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRIMIDONE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-202-11,NDC,facility,both,3,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0295,HCPCS,63323-368-20,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,0143-9682-01,NDC,facility,both,4,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  20 MG ORAL TR12,50863,CDM,636,RC,J3490,HCPCS,59011-420-20,NDC,facility,both,3,EA,,180,126,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL  97.2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16571-668-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APREPITANT  40 MG ORAL CAP,50863,CDM,636,RC,J8501,HCPCS,68462-583-40,NDC,facility,both,1,EA,,396,277.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,0143-9682-25,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,16714-016-01,NDC,facility,both,16,ML,,209,146.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FERROUS SULFATE 75 MG/ML (ELEMENTAL IRON 15 MG/ML) 0.1 ML ORAL SYRINGE (REPACK),50863,CDM,250,RC,J3490,HCPCS,3932805750,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2308-21,NDC,facility,both,5,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) NEB SOLUTION,50863,CDM,636,RC,J3490,HCPCS,60687-395-79,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6966-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FERUMOXYTOL 510 MG/17 ML (30 MG/ML) IV SOLN,50863,CDM,636,RC,Q0138,HCPCS,0781-3154-01,NDC,facility,both,510,ML,,2499,1749.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-645-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-145-11,NDC,facility,both,80,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-6625-22,NDC,facility,both,3,ML,,174,121.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,50,EA,JZ,6900,4830,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PRAMIPEXOLE 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-592-11,NDC,facility,both,6,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-48,NDC,facility,both,1,ML,JZ,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CINACALCET 30 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,64380-883-04,NDC,facility,both,4,EA,,442,309.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PYRAZINAMIDE 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-789-11,NDC,facility,both,2,EA,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML INJECTION,50863,CDM,250,RC,J3411,HCPCS,0641-6228-01,NDC,facility,both,3,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,50863,CDM,250,RC,J0640,HCPCS,71288-163-30,NDC,facility,both,5,EA,,107,74.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0527-3281-46,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,636,RC,J1953,HCPCS,55150-177-05,NDC,facility,both,200,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J2004,HCPCS,0409-3178-01,NDC,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,250,RC,J3490,HCPCS,0409-1323-15,NDC,facility,both,100,ML,PLAD,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
TACROLIMUS 1 MG ORAL CAP,50863,CDM,250,RC,J7507,HCPCS,51079-818-01,NDC,facility,both,4,EA,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML INJECTION,50863,CDM,250,RC,J3411,HCPCS,0641-6228-01,NDC,facility,both,4,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADVATE: FACTOR VIII CONCENTRATE (MERGE RECORD),50863,CDM,636,RC,J7192,HCPCS,0944-3052-02,NDC,facility,both,3000,UN,,12558,8790.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6426-61,NDC,facility,both,2,EA,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6188-01,NDC,facility,both,4000,ML,,188,131.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITRIOL 0.25 MCG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,69452-207-20,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOLTERODINE 2 MG ORAL CP24,50863,CDM,636,RC,J3490,HCPCS,60687-319-11,NDC,facility,both,1,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J2004,HCPCS,0409-3178-01,NDC,facility,both,300,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6665-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCOSANOL 10 % TOP CREAM,50863,CDM,636,RC,J3490,HCPCS,61269-981-35,NDC,facility,both,1,GM,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 10 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7345-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,636,RC,J0690,HCPCS,0143-9924-90,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIFEDIPINE 60 MG ORAL TO24,50863,CDM,250,RC,J3490,HCPCS,68084-598-11,NDC,facility,both,2,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN   81 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,69618-066-02,NDC,facility,both,5,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J2003,HCPCS,55150-161-02,NDC,facility,both,60,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-04,NDC,facility,both,4,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-405-11,NDC,facility,both,2,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VERAPAMIL 120 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,68462-292-01,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,J3490,HCPCS,63037-136-25,NDC,,,facility,both,4,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES  8.6 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,69618-064-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM THIOSULFATE 25 % IV SOLN,50863,CDM,250,RC,J3490,HCPCS,60267-705-50,NDC,facility,both,2,ML,,825,577.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYBUTYNIN CHLORIDE  5 MG ORAL TO24,50863,CDM,250,RC,J3490,HCPCS,0904-6570-61,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAMOXIFEN 10 MG ORAL TAB,50863,CDM,636,RC,J9999,HCPCS,0591-2472-60,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,31722-820-30,NDC,facility,both,1,EA,,158,110.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-437-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXAZOSIN 4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-862-95,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,2055503600,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,63323-482-03,NDC,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL  97.2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16571-668-01,NDC,facility,both,6,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMTERENE-HYDROCHLOROTHIAZIDE 37.5 MG-25 MG CAP,50863,CDM,250,RC,J3490,HCPCS,0781-2074-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,636,RC,J0330,HCPCS,31722-981-10,NDC,facility,both,2,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 50 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6323-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML INJ SOLN,50863,CDM,250,RC,J0169,HCPCS,76329-9060-0,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 25 MG TAB,50863,CDM,636,RC,J3490,HCPCS,65862-146-36,NDC,facility,both,2,EA,,230,161,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NAPROXEN 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-491-11,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7728-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,58657-675-01,NDC,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7008-61,NDC,facility,both,4,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6773-61,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 10 MG-325 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0406-0125-23,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"AMIODARONE IN DEXTROSE,ISO-OSM 360 MG/200 ML (1.8 MG/ML) IV SOLN",50863,CDM,250,RC,J0282,HCPCS,43066-360-20,NDC,facility,both,8,ML,,156,109.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL (5 MG/ML) IV SYRG PF,50863,CDM,250,RC,J3490,HCPCS,69374-946-04,NDC,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 200 MG/100 ML IVPB (MERGE),50863,CDM,250,RC,J1450,HCPCS,25021-184-82,NDC,facility,both,4,ML,,212,148.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65162-896-09,NDC,facility,both,3,EA,,340,238,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN (PF) 10 MG/ML INJECTION (NEONATAL IM USE),50863,CDM,636,RC,J1580,HCPCS,63323-173-02,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  20 MEQ ORAL PACK,50863,CDM,636,RC,J3490,HCPCS,72888-024-06,NDC,facility,both,3,EA,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE 150 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,65862-697-90,NDC,facility,both,2,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 10 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,0641-0367-21,NDC,facility,both,10,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IV PGBK,50863,CDM,636,RC,J3475,HCPCS,63323-106-02,NDC,facility,both,4,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 50 MG/ML IV SOLN,50863,CDM,250,RC,J0282,HCPCS,67457-153-00,NDC,facility,both,5,ML,JZ,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,636,RC,Q0162,HCPCS,65162-691-79,NDC,facility,both,3,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM  4.5 GRAM IV SOLR,50863,CDM,250,RC,J2543,HCPCS,60505-6159-0,NDC,facility,both,4,EA,PLAD,107,74.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
PHYTONADIONE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J3430,HCPCS,0409-9158-31,NDC,facility,both,3,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPARACAINE 0.5 % OPHT DROP,50863,CDM,636,RC,J3490,HCPCS,24208-730-06,NDC,facility,both,1,ML,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"RABIES VACCINE,HUMAN DIPLOID (PF) 2.5 UNIT IM",50863,CDM,636,RC,90675,HCPCS,49281-246-58,NDC,facility,both,1,EA,JZ,1365,955.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ASPIRIN 81 MG ORAL CHEW,50863,CDM,636,RC,J3490,HCPCS,0904-6794-80,NDC,facility,both,3,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN IN SALINE (ISO-OSMOTIC) 100 MG/50 ML IV PIGGY BACK,50863,CDM,636,RC,J1580,HCPCS,0338-0511-41,NDC,facility,both,2,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-728-11,NDC,facility,both,2,EA,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,42806-150-33,NDC,facility,both,12,ML,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,67457-385-10,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6500-61,NDC,facility,both,1,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN  850 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-143-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-242-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-453-01,NDC,facility,both,3,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIROLIMUS 1 MG ORAL TAB,50863,CDM,250,RC,J7520,HCPCS,50268-718-11,NDC,facility,both,2,EA,,298,208.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIOGLITAZONE 30 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,65862-513-30,NDC,facility,both,2,EA,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML INJECTION,50863,CDM,250,RC,J3411,HCPCS,25021-500-02,NDC,facility,both,3,ML,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2599,HCPCS,43598-914-25,NDC,facility,both,8,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0143-9386-01,NDC,facility,both,40,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J1938,HCPCS,72603-251-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,23155-600-31,NDC,facility,both,2,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DEXRAZOXANE 250 MG IV SOLR,50863,CDM,250,RC,J1190,HCPCS,55150-432-01,NDC,facility,both,1,EA,,653,457.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5%-1/2 NORMAL SALINE IV,50863,CDM,636,RC,J7042,HCPCS,0990-7926-09,NDC,facility,both,2,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  120 MG RECT SUPP,50863,CDM,250,RC,J3490,HCPCS,51672-2115-0,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,50863,CDM,636,RC,J0561,HCPCS,60793-701-02,NDC,facility,both,12,ML,,1307,914.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-833-11,NDC,facility,both,18,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-2051-15,NDC,facility,both,1,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,0143-9128-01,NDC,facility,both,2,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,J2003,HCPCS,63323-486-05,NDC,,,facility,both,500,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,250,RC,Q0162,HCPCS,60687-252-40,NDC,facility,both,2,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESTRADIOL 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,42806-088-01,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,636,RC,J3490,HCPCS,63323-486-05,NDC,facility,both,400,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MYCOPHENOLATE 500 MG TAB,50863,CDM,636,RC,J7517,HCPCS,60687-438-11,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,21,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,17,ML,JW,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
FINASTERIDE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-428-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FIDAXOMICIN 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,52015-080-01,NDC,facility,both,1,EA,,922,645.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  15 MG ORAL TBSR,50863,CDM,636,RC,J3490,HCPCS,0904-6557-61,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN IN D5W 900 MG/50 ML IV PGBK,50863,CDM,636,RC,J0736,HCPCS,0781-3290-91,NDC,facility,both,2,ML,JZ,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TAB,50863,CDM,636,RC,J3490,HCPCS,68084-396-11,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-950-01,NDC,facility,both,3,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SINCALIDE 5 MCG INJ SOLR,50863,CDM,636,RC,J2805,HCPCS,72266-248-05,NDC,facility,both,1,EA,,248,173.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN SODIUM  2 GRAM INJ SOLR,50863,CDM,250,RC,J0290,HCPCS,63323-399-23,NDC,facility,both,4,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0003-0894-31,NDC,facility,both,1,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,636,RC,Q0162,HCPCS,60687-252-40,NDC,facility,both,4,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 0.1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,23155-489-01,NDC,facility,both,5,EA,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN   81 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,57896-981-12,NDC,facility,both,5,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,FAMNOCHARGE,HCPCS,17856-0759-5,NDC,facility,both,3,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML (1ML) INJ SOLN,50863,CDM,636,RC,J0171,HCPCS,63323-696-02,NDC,facility,both,3,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 5 MG/ML IV SOLN,50863,CDM,636,RC,J1921,HCPCS,17478-420-20,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENOFIBRATE NANOCRYSTALLIZED  48 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-599-01,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUVOXAMINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0832-1671-11,NDC,facility,both,3,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4 % TOP CREA,50863,CDM,250,RC,J3490,HCPCS,43199-040-50,NDC,facility,both,1,GM,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLP",50863,CDM,P9047,HCPCS,0944-0493-04,NDC,,,facility,both,2,ML,,501,350.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,70756-640-82,NDC,,,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,J1885,HCPCS,63323-162-00,NDC,,,facility,both,1,ML,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 10 MG ORAL TAB,50863,CDM,J3490,HCPCS,51079-208-01,NDC,,,facility,both,8,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEBIVOLOL  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7189-04,NDC,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN NPH & REGULAR HUMAN 100 UNIT/ML (70-30) SUBQ SUSP,50863,CDM,250,RC,J1815,HCPCS,0002-8715-01,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50111-561-01,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN NPH & REGULAR HUMAN 100 UNIT/ML (70-30) SUBQ SUSP,50863,CDM,250,RC,J1815,HCPCS,0002-8715-01,NDC,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 17 GRAM (100 %) ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,0904-6931-86,NDC,facility,both,7,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPRAZOLAM 0.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0228-2029-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,19,ML,JW,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DULOXETINE 60 MG ORAL CPDR,50863,CDM,636,RC,J3490,HCPCS,51991-748-90,NDC,facility,both,2,EA,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOFLOXACIN IN D5W 750 MG/150 ML IV PGBK,50863,CDM,250,RC,J1956,HCPCS,25021-132-83,NDC,facility,both,3,ML,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOMYCIN-BACITRACN ZN-POLYMYXIN 3.5 MG-400 U*,50863,CDM,636,RC,J3490,HCPCS,45802-143-00,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6869-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 20 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,70954-600-10,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NOREPINEPHRINE BITARTRATE-D5W 4 MG/250 ML (16 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,71285-6056-1,NDC,facility,both,1,ML,,128,89.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG ORAL CM12,50863,CDM,250,RC,J3490,HCPCS,60505-2806-7,NDC,facility,both,2,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,38,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYPROHEPTADINE 4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0115-1757-01,NDC,facility,both,3,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPRAZOLAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,59762-3720-1,NDC,facility,both,4,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRILAT 1.25 MG/ML IV INJ,50863,CDM,250,RC,J3490,HCPCS,43598-078-11,NDC,facility,both,2,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM 500 MG IV SOLR,50863,CDM,250,RC,J2185,HCPCS,63323-507-01,NDC,facility,both,5,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 20 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7346-61,NDC,facility,both,1,EA,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 50 MG TAB,50863,CDM,636,RC,J3490,HCPCS,16714-797-01,NDC,facility,both,2,EA,,214,149.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 50 MG 24 HR TAB,50863,CDM,J3490,HCPCS,55111-467-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB 100 MG IV SOLR,50863,CDM,J1745,HCPCS,57894-160-01,NDC,,,facility,both,72,EA,,9440,6608,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",50863,CDM,J1561,HCPCS,13533-800-41,NDC,,,facility,both,160,ML,,22631,15841.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 2 % TD OINT,50863,CDM,J3490,HCPCS,0281-0326-08,NDC,,,facility,both,1,GM,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 30 MG ORAL CPDR,50863,CDM,J3490,HCPCS,60687-734-11,NDC,,,facility,both,1,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),50863,CDM,636,RC,J0171,HCPCS,76329-3318-1,NDC,facility,both,50,ML,,367,256.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 400 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-446-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,200,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COLESEVELAM 625 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-385-95,NDC,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-559-01,NDC,facility,both,15,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,00035-0002-80,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2599,HCPCS,42023-164-01,NDC,facility,both,20,ML,,413,289.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  75 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,0904-7077-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,636,RC,J0330,HCPCS,69374-919-10,NDC,facility,both,7,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MANNITOL 20% IV SOLP,50863,CDM,636,RC,J2150,HCPCS,0990-7715-13,NDC,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG/5 ML IV,50863,CDM,636,RC,J3490,HCPCS,0703-9514-01,NDC,facility,both,3,ML,,221,154.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,70095-031-01,NDC,facility,both,18,ML,,724,506.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 25% IN WATER (D25W) IV SYRINGE,50863,CDM,250,RC,J3490,HCPCS,0409-1775-40,NDC,facility,both,1,ML,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1230,HCPCS,67457-217-20,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,50863,CDM,250,RC,J0640,HCPCS,67457-528-10,NDC,facility,both,6,EA,,353,247.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,63323-506-01,NDC,facility,both,10,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHOTERICIN B LIPOSOME 50 MG IV SUSR,50863,CDM,250,RC,J0289,HCPCS,55150-365-01,NDC,facility,both,15,EA,,2706,1894.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-686-10,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MOXIFLOXACIN 400 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6406-06,NDC,facility,both,3,EA,,381,266.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-50,NDC,facility,both,118,ML,,208,145.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,240,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ANTI-INHIBITOR COAGULANT CMPLX 350-650 UNIT IV SOLR,50863,CDM,250,RC,J7198,HCPCS,64193-423-02,NDC,facility,both,39,UN,JW,104,72.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DAPTOMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0878,HCPCS,72603-152-01,NDC,facility,both,2000,EA,,5849,4094.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,13533-690-20,NDC,facility,both,1,ML,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE-PRAMOXINE 2.5 %-1 % RECTAL CREAM,50863,CDM,250,RC,J3490,HCPCS,0496-0799-04,NDC,facility,both,1,GM,,806,564.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE 14 MG/24 HR TD PT24,50863,CDM,250,RC,J3490,HCPCS,43598-447-71,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN SODIUM EXTENDED 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,68084-376-11,NDC,facility,both,3,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-098-10,NDC,facility,both,1,EA,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 2 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J2004,HCPCS,0409-3183-11,NDC,facility,both,400,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZOCAINE-MENTHOL 20-0.26 % MM GEL,50863,CDM,636,RC,J3490,HCPCS,1031043028,NDC,facility,both,1,GM,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZONISAMIDE 10 MG/ML ORAL SYRUP (REPACK),50863,CDM,250,RC,J3490,HCPCS,64679-990-01,NDC,facility,both,1,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,5,ML,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-5771-23,NDC,facility,both,18,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN DEGLUDEC 100 UNITS/ML SUBQ SOLN,50863,CDM,636,RC,J1815,HCPCS,73070-400-11,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NAPROXEN 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,53746-188-01,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,50863,CDM,250,RC,J9267,HCPCS,61703-342-50,NDC,facility,both,274,ML,,332,232.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,63323-161-00,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM OXIDE 400 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,1000670028,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6638-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",50863,CDM,250,RC,J1561,HCPCS,13533-800-21,NDC,facility,both,10,ML,,1415,990.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,63323-104-25,NDC,facility,both,11,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOLIC ACID  1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7224-61,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-444-01,NDC,facility,both,3,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,250,RC,J0690,HCPCS,63323-237-10,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT  10 MCG/0.4 ML INJ SYRG,50863,CDM,636,RC,J0881,HCPCS,55513-098-01,NDC,facility,both,1,ML,EC,3939,2757.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier EC: Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy
ATORVASTATIN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-097-11,NDC,facility,both,3,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,50863,CDM,J9075,HCPCS,70121-1238-1,NDC,,,facility,both,100,EA,,510,357,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 500 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-7057-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB 100 MG IV SOLR,50863,CDM,J1745,HCPCS,57894-160-01,NDC,,,facility,both,47,EA,,6162,4313.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,J1644,HCPCS,0409-2720-31,NDC,,,facility,both,7,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 500 MG ORAL TAB,50863,CDM,J3490,HCPCS,60687-559-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,J1644,HCPCS,0409-2720-31,NDC,,,facility,both,8,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB 100 MG IV SOLR,50863,CDM,J1745,HCPCS,57894-160-01,NDC,,,facility,both,1,EA,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE  25 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-6638-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,4,EA,,146,102.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEGASPARGASE 750 UNIT/ML INJ SOLN,50863,CDM,250,RC,J9266,HCPCS,72694-954-01,NDC,facility,both,2,ML,,85567,59896.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 100 MG/ML FROM 1 GRAM VIAL (PRMC PEDS ONLY),50863,CDM,J0696,HCPCS,0409-7332-11,NDC,,,facility,both,4,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-495-27,NDC,,,facility,both,250,ML,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,130,91,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,1,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC IV INFUSION HYDRAT 31-60 MIN,50863,CDM,250,RC,J0248,HCPCS,61958-2901-2,NDC,facility,both,96,EA,JW,503,352.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LIDOCAINE 5 % TOP OINT,50863,CDM,636,RC,J3490,HCPCS,67877-473-79,NDC,facility,both,1,GM,,890,623,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2599,HCPCS,43598-914-25,NDC,facility,both,7,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NORETHINDRONE ACETATE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50742-267-50,NDC,facility,both,2,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 0.75 % VAGL GEL,50863,CDM,250,RC,J3490,HCPCS,45802-139-70,NDC,facility,both,1,GM,,551,385.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  25 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-6991-04,NDC,facility,both,4,EA,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BEVACIZUMAB-MALY 25 MG/ML IV SOLN,50863,CDM,250,RC,Q5126,HCPCS,70121-1755-1,NDC,facility,both,40,ML,,7934,5553.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) MISC SOLN,50863,CDM,250,RC,J3490,HCPCS,0517-7604-01,NDC,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 20 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,0904-7458-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GAMMAGARD S-D (IGA < 1 MCG/ML) 10 GRAM IV SOLR,50863,CDM,636,RC,J1566,HCPCS,0944-2659-08,NDC,facility,both,20,EA,JZ,4657,3259.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
OLANZAPINE 10 MG IM SOLR,50863,CDM,636,RC,J2359,HCPCS,55150-308-01,NDC,facility,both,10,EA,JZ,104,72.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
NOREPINEPHRINE BITARTRATE-D5W 4 MG/250 ML (16 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,71285-6056-1,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL  32.4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16571-673-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6966-61,NDC,facility,both,12,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR NEO/PEDS INFUSION (CDS FROM PREMIX),50863,CDM,250,RC,J0133,HCPCS,63323-325-10,NDC,facility,both,12,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 50 MG TAB,50863,CDM,636,RC,Q0177,HCPCS,68084-255-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLECAINIDE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-321-11,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7122-61,NDC,facility,both,1,EA,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  1 MG/ML INJ SYRG,50863,CDM,250,RC,J1171,HCPCS,0409-1283-10,NDC,facility,both,10,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 100 MG/ML INJ SOLN,50863,CDM,636,RC,J2800,HCPCS,0641-6103-01,NDC,facility,both,1,ML,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-01,NDC,facility,both,3,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
K PHOS DI & MONO-SOD PHOS MONO 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,486112501,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV (BOLUS),50863,CDM,250,RC,J7120,HCPCS,0264-7750-07,NDC,facility,both,2,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEMAZEPAM  7.5 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6436-04,NDC,facility,both,1,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 40 GRAM/400 ML (10 %) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-40,NDC,facility,both,160,ML,,22631,15841.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,636,RC,J1100,HCPCS,63323-506-01,NDC,facility,both,10,ML,JZ,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,420,ML,,603,422.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-179-11,NDC,facility,both,2,EA,,255,178.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-506-11,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 40 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6292-61,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEO TPN SODIUM CHLORIDE 4 MEQ/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-099-03,NDC,facility,both,1,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,20,EA,,2760,1932,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,0409-6625-14,NDC,facility,both,8,ML,,462,323.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,36,EA,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-0552-23,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,50863,CDM,636,RC,Q5119,HCPCS,0069-0249-01,NDC,facility,both,76,ML,,15036,10525.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM IN NACL (ISO-OS) 1500 MG/100 ML IV PGBK,50863,CDM,250,RC,J1953,HCPCS,44567-503-01,NDC,facility,both,150,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 200 MG/20 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,72205-220-01,NDC,facility,both,1,ML,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
URSODIOL 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-100-11,NDC,facility,both,2,EA,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIVOLUMAB 240 MG/24 ML IV SOLN,50863,CDM,636,RC,J9299,HCPCS,0003-3734-13,NDC,facility,both,240,ML,,17369,12158.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,50863,CDM,636,RC,J1756,HCPCS,0517-2340-10,NDC,facility,both,300,ML,JZ,963,674.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,71288-505-02,NDC,facility,both,2,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV (BOLUS),50863,CDM,250,RC,J7120,HCPCS,0264-7750-00,NDC,facility,both,2,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML INJ SOLN (PULMONARY USE),50863,CDM,250,RC,J2250,HCPCS,55390-137-02,NDC,facility,both,3,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,10135-676-01,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARGATROBAN 100 MG/ML IV SOLN,50863,CDM,636,RC,J0883,HCPCS,0143-9674-01,NDC,facility,both,250,ML,JZ,821,574.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ATROPINE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J0461,HCPCS,0517-1004-01,NDC,facility,both,30,ML,JW,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,636,RC,J1953,HCPCS,63323-400-01,NDC,facility,both,400,ML,,219,153.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,70594-117-01,NDC,facility,both,200,ML,JZ,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,636,RC,J1610,HCPCS,0597-0053-45,NDC,facility,both,1,EA,JZ,371,259.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
BENZOCAINE 20 % MM SPRY,50863,CDM,636,RC,J3490,HCPCS,0283-0610-43,NDC,facility,both,2,EA,,101,70.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 1 MG ORAL CAP,50863,CDM,250,RC,J7507,HCPCS,51079-818-01,NDC,facility,both,2,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,250,RC,J3360,HCPCS,0409-1273-03,NDC,facility,both,1,ML,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,25021-410-76,NDC,facility,both,4,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,20,ML,,34681,24276.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM BICARB-CITRIC ACID 20 MEQ ORAL TBEF,50863,CDM,636,RC,J3490,HCPCS,51801-012-01,NDC,facility,both,3,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  30 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,0904-6558-61,NDC,facility,both,2,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,63,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTAMIDINE 300 MG INJ SOLR,50863,CDM,636,RC,J3490,HCPCS,63323-113-01,NDC,facility,both,1,EA,,205,143.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INEBILIZUMAB-CDON 10 MG/ML IV SOLN,50863,CDM,636,RC,J1823,HCPCS,75987-150-01,NDC,facility,both,300,ML,JZ,387086,270960.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MELATONIN  3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,8068108600,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,68180-150-01,NDC,facility,both,2,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAPSAICIN 0.025 % TOP CREA,50863,CDM,250,RC,J3490,HCPCS,50268-195-60,NDC,facility,both,1,GM,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 0.5 MG/ML ORAL SUSPENSION (REPACK),50863,CDM,250,RC,J7507,HCPCS,51079-028-01,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 10 MEQ/100 ML IV PGBK,50863,CDM,250,RC,J3480,HCPCS,0990-7074-26,NDC,facility,both,10,ML,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-18,NDC,facility,both,200,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 50 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,51079-170-01,NDC,facility,both,2,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-18,NDC,facility,both,300,ML,JZ,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CEFEPIME 1 GRAM INJ SOLR,50863,CDM,250,RC,J0692,HCPCS,0409-9566-01,NDC,facility,both,1,EA,JW,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LEVOTHYROXINE 175 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-541-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,250,RC,J7060,HCPCS,0338-0017-03,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,11,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISRADIPINE  2.5 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,16252-539-01,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-6695-01,NDC,facility,both,20,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM SR 120 MG 24 HR CAP,50863,CDM,250,RC,J3490,HCPCS,63739-283-10,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 50 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,60687-854-11,NDC,facility,both,100,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0143-9386-01,NDC,facility,both,12,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-833-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BISACODYL  5 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,0904-6748-17,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,50863,CDM,250,RC,J0640,HCPCS,25021-814-30,NDC,facility,both,6,EA,,353,247.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-406-03,NDC,facility,both,1,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLP",50863,CDM,250,RC,P9047,HCPCS,44206-251-10,NDC,facility,both,2,ML,,778,544.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,55,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,636,RC,J0690,HCPCS,70092-1017-46,NDC,facility,both,2,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,636,RC,P9045,HCPCS,68516-5219-0,NDC,facility,both,2,ML,,796,557.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,636,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,6,ML,JW,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
METHYLPHENIDATE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-805-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,68516-5214-4,NDC,facility,both,2,ML,,447,312.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALUM-MAG HYDROXIDE-SIMETH 200 MG-200 MG-20 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,63739-159-77,NDC,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GANCICLOVIR 500 MG IV SOLUTION,50863,CDM,250,RC,J1570,HCPCS,70436-089-55,NDC,facility,both,1,EA,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) IV SOLN,50863,CDM,250,RC,J9201,HCPCS,0409-0181-01,NDC,facility,both,5,ML,,231,161.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2599,HCPCS,63323-930-01,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTOBARBITAL 75 MG/1.5 ML SYRINGE (REPACK),50863,CDM,636,RC,J2515,HCPCS,25021-676-20,NDC,facility,both,2,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,76329-3352-1,NDC,facility,both,5,ML,,526,368.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7030,HCPCS,0338-0049-04,NDC,facility,both,1,ML,PLAD,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
HALOPERIDOL  2 MG ORAL TAB,50863,CDM,J3490,HCPCS,51079-735-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,50863,CDM,250,RC,J9060,HCPCS,0703-5748-11,NDC,facility,both,6,ML,,140,98,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN PEDS SYRINGE (20MG/ML) IN DEXTROSE (CDS MIX,50863,CDM,J7999,HCPCS,0781-3451-70,NDC,,,facility,both,2,EA,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,72603-350-01,NDC,,,facility,both,29,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MULTIVIT-MIN-IRON FUM-FOLIC AC 7.5 MG IRON-400 MCG ORAL TAB,50863,CDM,J3490,HCPCS,7985440050,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNIT/G TOP PACK,50863,CDM,J3490,HCPCS,0904-7402-67,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,71288-402-10,NDC,facility,both,7,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 10 MEQ/100 ML IV PGBK,50863,CDM,636,RC,J3480,HCPCS,0990-7074-26,NDC,facility,both,5,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLECAINIDE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-0010-20,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,250,RC,J2795,HCPCS,70069-064-25,NDC,facility,both,150,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZTROPINE 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69315-136-01,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SOTALOL 5 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,24338-530-25,NDC,facility,both,1,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,0641-6236-01,NDC,facility,both,1,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 150 MG/ML INJECTION,50863,CDM,250,RC,J3490,HCPCS,0009-0902-11,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2598,HCPCS,42023-164-25,NDC,facility,both,20,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL  20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6671-04,NDC,facility,both,3,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 2 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,250,RC,J2270,HCPCS,63323-452-00,NDC,facility,both,1,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  1 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,64380-782-06,NDC,facility,both,8,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ (REPACK)(MERGE) (FOR PCA),50863,CDM,250,RC,J3490,HCPCS,70004-211-30,NDC,facility,both,1,ML,,217,151.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML IV SOLN (MERGE),50863,CDM,636,RC,J3490,HCPCS,16714-037-01,NDC,facility,both,1,ML,,127,88.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM SR 120 MG 24 HR CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7217-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  40 MG ORAL TR12,50863,CDM,250,RC,J3490,HCPCS,59011-440-20,NDC,facility,both,3,EA,,267,186.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-454-11,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,13,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE 150 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,0904-7076-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE 2 MG SL SUBL,50863,CDM,636,RC,J3490,HCPCS,60687-481-11,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  250 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7123-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-145-11,NDC,facility,both,40,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,4,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN NORMAL SALINE IV,50863,CDM,250,RC,J7042,HCPCS,0338-0089-04,NDC,facility,both,2,ML,JZ,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ALBUTEROL SULFATE 5 MG/ML INHL NEB CONTINUOUS,50863,CDM,250,RC,J3490,HCPCS,73177-163-33,NDC,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAMPHOR 9% -MENTHOL 1.3% -BORIC ACID OINTMENT (PHS),50863,CDM,250,RC,J3490,HCPCS,10742-0001-1,NDC,facility,both,1,GM,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,636,RC,J2560,HCPCS,54288-137-01,NDC,facility,both,3,ML,,423,296.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 1 MG/ML (1ML) SYRINGE (REPACK),50863,CDM,250,RC,J2997,HCPCS,50242-044-13,NDC,facility,both,6,EA,,1625,1137.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,250,RC,J3101,HCPCS,50242-037-06,NDC,facility,both,35,EA,JW,6576,4603.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,4000,ML,,496,347.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 400 MCG/100 ML (4 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0338-9557-12,NDC,facility,both,1,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-1660-50,NDC,facility,both,1,ML,,165,115.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J3430,HCPCS,68462-758-05,NDC,facility,both,3,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG/ML INJ SOLN,50863,CDM,250,RC,J2550,HCPCS,0641-0928-21,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  75 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6951-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIVOLUMAB 240 MG/24 ML IV SOLN,50863,CDM,250,RC,J9299,HCPCS,0003-3774-12,NDC,facility,both,200,ML,,13638,9546.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN (PF) NEO IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J1580,HCPCS,63323-513-02,NDC,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,636,RC,J1815,HCPCS,83257-011-11,NDC,facility,both,6,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 40 GRAM/400 ML (10 %) INJ SOLN",50863,CDM,250,RC,J1561,HCPCS,13533-800-20,NDC,facility,both,10,ML,,1415,990.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  125 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,62559-390-20,NDC,facility,both,1,EA,,154,107.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE  7 MG/24 HR TD PT24,50863,CDM,250,RC,J3490,HCPCS,4898500155,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,0121-4675-05,NDC,facility,both,4,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0143-9509-01,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,250,RC,J3490,HCPCS,71266-9080-4,NDC,facility,both,3,ML,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,50268-540-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69315-904-01,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,62559-440-02,NDC,facility,both,1,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6322-06,NDC,facility,both,3,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG/ML INJ SOLN,50863,CDM,250,RC,J2550,HCPCS,0641-6084-01,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE (PF-DURAMORPH/ASTRAMORPH) 0.5 MG/ML INJ SOLN,50863,CDM,250,RC,J2274,HCPCS,0409-3814-12,NDC,facility,both,1,ML,,237,165.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,250,RC,J2003,HCPCS,63323-491-01,NDC,facility,both,50,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2720-02,NDC,facility,both,9,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-723-11,NDC,facility,both,1,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-027-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,250,RC,J3490,HCPCS,0904-6930-61,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),50863,CDM,636,RC,J3490,HCPCS,0409-4888-02,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER SULFADIAZINE 1 % TOP CREA,50863,CDM,250,RC,J3490,HCPCS,43598-210-40,NDC,facility,both,2,GM,,458,320.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NS WITH POTASSIUM CHLORIDE 20 MEQ/L IV SOLP,50863,CDM,250,RC,J3480,HCPCS,0338-0691-04,NDC,facility,both,10,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLP",50863,CDM,250,RC,P9047,HCPCS,44206-251-91,NDC,facility,both,1,ML,JW,108,75.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
"MVI, ADULT INJECTION (PHS)",50863,CDM,250,RC,J3490,HCPCS,54643-5649-1,NDC,facility,both,1,ML,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,0409-3795-19,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,J0665,HCPCS,72603-506-01,NDC,,,facility,both,300,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 2 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,250,RC,J2270,HCPCS,76045-004-11,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,J2704,HCPCS,63323-269-65,NDC,,,facility,both,13200,ML,,23238,16266.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  15 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,0904-6557-61,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,70095-026-01,NDC,facility,both,1,ML,JZ,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
BUPROPION HCL 150 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,68084-708-95,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB 100 MG IV SOLR,50863,CDM,636,RC,J1745,HCPCS,57894-030-01,NDC,facility,both,25,EA,,8058,5640.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE  2.5 % RECT CREA,50863,CDM,250,RC,J3490,HCPCS,64980-324-30,NDC,facility,both,1,GM,,371,259.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZONISAMIDE 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-230-11,NDC,facility,both,5,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-752-11,NDC,facility,both,1,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,415,ME,JZ,5632,3942.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
EPOETIN ALFA-EPBX 10000 UNITS/ML INJ SOLN,50863,CDM,636,RC,Q5106,HCPCS,0069-1308-01,NDC,facility,both,6,ML,"JW,EC",80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient | Modifier EC: Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy
PROGESTERONE MICRONIZED 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,65162-807-10,NDC,facility,both,1,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL  25 MCG/HR TD PT72,50863,CDM,250,RC,J3490,HCPCS,60505-7006-0,NDC,facility,both,1,EA,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN SODIUM  2 GRAM INJ SOLR,50863,CDM,250,RC,J0290,HCPCS,72485-422-01,NDC,facility,both,3,EA,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 0.1MG/ML SUSPENSION (REPACK),50863,CDM,250,RC,J3490,HCPCS,51079-882-01,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 60 MG TAB,50863,CDM,250,RC,J3490,HCPCS,60687-728-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,10,ML,,16474,11531.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-21,NDC,facility,both,10,ML,,1415,990.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  75 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,65862-528-90,NDC,facility,both,3,EA,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NOREPINEPHRINE BITARTRATE-D5W 4 MG/250 ML (16 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,72196-6056-1,NDC,facility,both,1,ML,,450,315,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,43598-053-11,NDC,facility,both,20,ML,,700,490,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 400 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0143-9887-75,NDC,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 1 GRAM INJ SOLR,50863,CDM,250,RC,J0692,HCPCS,70594-089-01,NDC,facility,both,2,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,860,ML,,1234,863.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM 500 MG IV SOLR,50863,CDM,250,RC,J2185,HCPCS,70121-1454-1,NDC,facility,both,5,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,0409-3178-01,NDC,,,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-1283-03,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ (MERGE),50863,CDM,J2250,HCPCS,0409-0001-01,NDC,,,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,636,RC,J3490,HCPCS,63037-136-25,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALUM-MAG HYDROXIDE-SIMETH 200 MG-200 MG-20 MG/5 ML ORAL SUSP,50863,CDM,J3490,HCPCS,0904-7325-62,NDC,,,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM  3 GRAM INJ SOLR,50863,CDM,J0295,HCPCS,72485-417-01,NDC,,,facility,both,2,EA,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,50863,CDM,J3420,HCPCS,63323-044-00,NDC,,,facility,both,1,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE IN D5W 1 GRAM/100 ML IV PGBK,50863,CDM,636,RC,J3475,HCPCS,63323-108-00,NDC,facility,both,1,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLN,50863,CDM,J3262,HCPCS,50242-137-01,NDC,,,facility,both,400,ML,,7331,5131.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUVOXAMINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0832-1671-11,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 40 GRAM/400 ML (10 %) INJ SOLN",50863,CDM,J1561,HCPCS,13533-800-20,NDC,,,facility,both,20,ML,,2829,1980.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,63323-010-01,NDC,facility,both,5,ML,,128,89.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2001,HCPCS,0409-4279-02,NDC,,,facility,both,60,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,J3490,HCPCS,0143-9889-15,NDC,,,facility,both,22,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ICATIBANT 30 MG/3 ML SUBQ SYRG,50863,CDM,636,RC,J1744,HCPCS,69097-664-34,NDC,facility,both,30,ML,,29229,20460.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 5 MG-325 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0406-0123-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MOXIFLOXACIN 400 MG/250 ML IVPB PREMIX (MERGE),50863,CDM,250,RC,J2280,HCPCS,67457-323-25,NDC,facility,both,4,ML,,234,163.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISANKIZUMAB-RZAA  60 MG/ML IV SOLN,50863,CDM,636,RC,J2327,HCPCS,0074-5015-01,NDC,facility,both,600,ML,JZ,27931,19551.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0093-2026-94,NDC,facility,both,3,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,16714-536-01,NDC,facility,both,4,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 7.5 MG-325 MG TAB,50863,CDM,J3490,HCPCS,0406-0124-23,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLN,50863,CDM,636,RC,J3262,HCPCS,50242-135-01,NDC,facility,both,440,ML,JA,8064,5644.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
LABETALOL 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-450-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR 200 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,31722-681-47,NDC,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUGAMMADEX 100 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0006-5423-02,NDC,facility,both,4,ML,,2353,1647.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORHEXIDINE GLUCONATE  0.12 % MM MWSH,50863,CDM,250,RC,J3490,HCPCS,0121-0893-15,NDC,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,76329-3352-1,NDC,facility,both,4,ML,,463,324.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,86,EA,,11868,8307.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE 8 MG SL SUBL,50863,CDM,636,RC,J3490,HCPCS,50383-930-93,NDC,facility,both,1,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTAMIDINE 300 MG INJ SOLR,50863,CDM,636,RC,J3490,HCPCS,63323-113-01,NDC,facility,both,1,EA,,149,104.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7030,HCPCS,17271-701-07,NDC,facility,both,1,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYBUTYNIN CHLORIDE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0832-0038-89,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLIPIZIDE  5 MG ORAL TO24,50863,CDM,636,RC,J3490,HCPCS,68084-111-11,NDC,facility,both,4,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-673-10,NDC,facility,both,3,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM PHOSPHATE 3 MMOL/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-7391-82,NDC,facility,both,1,ML,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,50863,CDM,250,RC,J1756,HCPCS,0517-2340-10,NDC,facility,both,100,ML,,321,224.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELATACEPT 250 MG IV SOLR,50863,CDM,636,RC,J0485,HCPCS,0003-0371-13,NDC,facility,both,275,EA,,2838,1986.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZINC OXIDE 20 % TOP OINT (REPACK),50863,CDM,250,RC,J3490,HCPCS,75834-170-01,NDC,facility,both,1,GM,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,250,RC,J3490,HCPCS,73013-2002-2,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  5 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,33342-083-07,NDC,facility,both,1,EA,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),50863,CDM,250,RC,J1815,HCPCS,0024-5926-05,NDC,facility,both,60,ML,,231,161.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PATIROMER CALCIUM SORBITEX  8.4 G ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,53436-084-01,NDC,facility,both,1,EA,,201,140.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NADOLOL  20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-302-95,NDC,facility,both,1,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,50863,CDM,250,RC,J9060,HCPCS,0143-9504-01,NDC,facility,both,3,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MINOXIDIL  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-204-11,NDC,facility,both,4,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-22,NDC,facility,both,140,ML,,280,196,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % MUCOSAL SOLN (VISCOUS),50863,CDM,250,RC,J3490,HCPCS,62135-712-42,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-453-11,NDC,facility,both,6,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,48,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 1 % OPHT DROP,50863,CDM,636,RC,J3490,HCPCS,60219-1748-2,NDC,facility,both,1,ML,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,50863,CDM,250,RC,J9045,HCPCS,16729-295-12,NDC,facility,both,2,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE (PF) 25 MG/ML INJ SOLN (FOR ECTOPIC PREGNANCY),50863,CDM,636,RC,J9260,HCPCS,0143-9519-01,NDC,facility,both,2,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE (FOR CODE) 10% (100 MG/ML) IV SYRINGE,50863,CDM,J3490,HCPCS,0409-4928-11,NDC,,,facility,both,2,ML,,201,140.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COCAINE  4 % TOP SOLN (MERGE),50863,CDM,C9046,HCPCS,81665-301-02,NDC,,,facility,both,160,ML,,1271,889.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,J3101,HCPCS,50242-037-06,NDC,,,facility,both,13,EA,,5955,4168.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,50863,CDM,J3490,HCPCS,60687-591-11,NDC,,,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 5 MG/ML INHL NEB CONTINUOUS,50863,CDM,J3490,HCPCS,73177-146-33,NDC,,,facility,both,2,ML,,424,296.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5% W/EPINEPHRINE 1:200K INJECTION,50863,CDM,636,RC,J3490,HCPCS,0409-1749-29,NDC,facility,both,2,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,70010-754-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BASILIXIMAB 20 MG IV SOLR,50863,CDM,250,RC,J0480,HCPCS,0078-0331-84,NDC,facility,both,1,EA,,12584,8808.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALASPARGASE PEGOL-MKNL 750 UNITS/ML IV SOLN,50863,CDM,636,RC,J9118,HCPCS,72694-515-01,NDC,facility,both,375,ML,,75551,52885.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,2055503601,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUDROCORTISONE 0.1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-330-11,NDC,facility,both,3,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE  10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-037-11,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TICAGRELOR 90 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0186-0777-39,NDC,facility,both,2,EA,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,63739-903-10,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM POLYSTYRENE SULFONATE ORAL POWDER,50863,CDM,250,RC,J3490,HCPCS,11534-166-16,NDC,facility,both,2,GM,,155,108.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYLAMINE SUCCINATE 25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,70677-0068-1,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-1638-32,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0137,HCPCS,0143-9386-01,NDC,facility,both,36,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 875 MG-125 MG TAB,50863,CDM,250,RC,J3490,HCPCS,42571-162-42,NDC,facility,both,8,EA,,198,138.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV,50863,CDM,250,RC,J7120,HCPCS,0990-7953-09,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 400 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-446-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  5 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-122-11,NDC,facility,both,5,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0641-6196-01,NDC,facility,both,100,ML,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,636,RC,J2795,HCPCS,43066-023-01,NDC,facility,both,125,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLN,50863,CDM,636,RC,J3262,HCPCS,50242-135-01,NDC,facility,both,280,ML,"JZ,JA",5132,3592.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
APIXABAN 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0003-0894-31,NDC,facility,both,2,EA,,119,83.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,0409-4264-11,NDC,facility,both,5,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 10 MG/ML INJ SYRG,50863,CDM,636,RC,J2270,HCPCS,0409-1261-30,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE (POLACRILEX) 2 MG MM LOZG,50863,CDM,636,RC,J3490,HCPCS,45802-344-03,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7244-68,NDC,facility,both,4,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML IM SOLN,50863,CDM,636,RC,90375,HCPCS,13533-318-50,NDC,facility,both,10,ML,,8946,6262.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-3178-16,NDC,facility,both,60,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 10 % (100 MG/ML) MISC SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-695-04,NDC,facility,both,1,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,2,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,16714-294-01,NDC,facility,both,16,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-5755-23,NDC,facility,both,15,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,5,ML,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE HCL  2 % MM JELP,50863,CDM,636,RC,J3490,HCPCS,76329-3013-5,NDC,facility,both,2,ML,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,43598-053-11,NDC,facility,both,26,ML,,939,657.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML IV SOLN (MERGE),50863,CDM,250,RC,J3490,HCPCS,70756-611-82,NDC,facility,both,1,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOZAPINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-404-11,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 1% (BUFFERED W/NAHCO3 8.4%) 10 ML SYRINGE (MERGE),50863,CDM,250,RC,J3490,HCPCS,70092-1175-46,NDC,facility,both,1,ML,,233,163.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRIL MALEATE 1 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,52652-4001-1,NDC,facility,both,1,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  5 GRAM IV SOLR,50863,CDM,250,RC,J3373,HCPCS,0143-9163-01,NDC,facility,both,200,EA,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC IV INFUSION HYDRAT 31-60 MIN,50863,CDM,636,RC,J0248,HCPCS,61958-2901-2,NDC,facility,both,200,EA,JZ,2392,1674.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PHYTONADIONE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J3430,HCPCS,43598-405-11,NDC,facility,both,10,ME,,1181,826.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0955-1004-01,NDC,facility,both,1,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ATORVASTATIN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6291-61,NDC,facility,both,2,EA,PLAD,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
LEVETIRACETAM 500 MG/5 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,17856-0574-1,NDC,facility,both,3,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J2312,HCPCS,36000-308-01,NDC,facility,both,2,ML,,167,116.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,636,RC,J0133,HCPCS,63323-325-03,NDC,facility,both,80,ML,JW,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PACLITAXEL 6 MG/ML IV CONC,50863,CDM,250,RC,J9267,HCPCS,61703-342-22,NDC,facility,both,58,ML,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,76045-009-10,NDC,facility,both,20,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,0409-4887-24,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  75 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0071-1014-41,NDC,facility,both,2,EA,,131,91.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6322-61,NDC,facility,both,3,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-132-11,NDC,facility,both,3,EA,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-491-01,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GRANISETRON 1 MG/ML (1 ML) IV SOLN,50863,CDM,250,RC,J1626,HCPCS,0143-9744-01,NDC,facility,both,4,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,636,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,6,EA,,191,133.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 175 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42292-040-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALTREXONE MICROSPHERES 380 MG IM SERR,50863,CDM,636,RC,J2315,HCPCS,65757-302-02,NDC,facility,both,380,EA,,4530,3171,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,17856-0574-1,NDC,facility,both,2,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0904-6923-61,NDC,facility,both,62,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),50863,CDM,250,RC,J3490,HCPCS,0409-4888-20,NDC,facility,both,3,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,43547-354-10,NDC,facility,both,5,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIVASTIGMINE 3 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,33342-090-09,NDC,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J1940,HCPCS,0409-6102-04,NDC,facility,both,4,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEMAZEPAM 15 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,67877-146-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 80 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16714-685-01,NDC,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,63323-010-94,NDC,facility,both,4,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,68462-469-40,NDC,facility,both,10,ML,,152,106.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-4713-32,NDC,facility,both,40,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FERRIC CARBOXYMALTOSE (INJECTAFER) 50 MG IRON/ML IV SOLN,50863,CDM,J1439,HCPCS,0517-0650-01,NDC,,,facility,both,750,ML,,4111,2877.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESALAMINE 4 GRAM/60 ML RECT ENEM,50863,CDM,250,RC,J3490,HCPCS,45802-098-46,NDC,facility,both,1,ML,,119,83.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXAZOSIN 2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-851-95,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,70069-363-01,NDC,facility,both,2,ML,,302,211.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-657-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEMANTINE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6506-06,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISONIAZID 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,81665-108-30,NDC,facility,both,1,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 500 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-163-11,NDC,facility,both,2,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1162-18,NDC,facility,both,70,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,636,RC,J3490,HCPCS,0641-6236-01,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUVOXAMINE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60505-0166-1,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,0641-6236-01,NDC,facility,both,2,ML,,131,91.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE MONONITRATE 120 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,13668-106-01,NDC,facility,both,1,EA,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 100 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,31722-574-47,NDC,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,33,EA,,4554,3187.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,69918-899-01,NDC,facility,both,8,ML,,599,419.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ (REPACK)(MERGE) (FOR PCA),50863,CDM,250,RC,J3490,HCPCS,70092-1664-74,NDC,facility,both,1,ML,,324,226.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADVATE: FACTOR VIII CONCENTRATE (MERGE RECORD),50863,CDM,636,RC,J7209,HCPCS,0944-3053-02,NDC,facility,both,1250,UN,,5233,3663.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 2 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,250,RC,J2270,HCPCS,76045-004-01,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,55150-177-05,NDC,facility,both,50,ML,JZ,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),50863,CDM,250,RC,J3490,HCPCS,0409-4888-01,NDC,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LANTHANUM  500 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,76282-476-45,NDC,facility,both,4,EA,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 400 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65162-464-10,NDC,facility,both,6,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 20 GRAM/30 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-1154-30,NDC,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM SR 180 MG 24 HR CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7218-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6292-61,NDC,facility,both,1,EA,PLAD,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
CLOBAZAM 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-423-11,NDC,facility,both,1,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51672-4027-1,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0264-1800-31,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,63323-400-01,NDC,facility,both,300,ML,,164,114.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"VITAMIN E (DL, ACETATE) 22.5 MG (50 UNIT)/ML ORAL DROP",50863,CDM,250,RC,J3490,HCPCS,5483800530,NDC,facility,both,1,ML,,199,139.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 2 GRAM IV SOLUTION,50863,CDM,636,RC,J9075,HCPCS,0781-3255-94,NDC,facility,both,400,EA,,3791,2653.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0003-0893-31,NDC,facility,both,1,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2312,HCPCS,36000-308-01,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6925-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARISOPRODOL 350 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69584-111-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SCOPOLAMINE TRANSDERMAL PATCH 1MG OVER 3 DAYS,50863,CDM,636,RC,J3490,HCPCS,0591-2258-54,NDC,facility,both,1,EA,,119,83.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,50863,CDM,250,RC,J0640,HCPCS,25021-814-30,NDC,facility,both,1,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE MONONITRATE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,7733393425,NDC,facility,both,5,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE IN SALINE (ISO-OSM) 400 MG/200 ML IV PIGGY BACK,50863,CDM,636,RC,J1450,HCPCS,0409-4321-01,NDC,facility,both,2,ML,JZ,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
POTASSIUM CHLORIDE 2 MEQ/ML ORAL SOLUTION (FOR PEDIATRIC USE),50863,CDM,250,RC,J3480,HCPCS,63323-965-05,NDC,facility,both,5,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE MONONITRATE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,6809411659,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE 100 MG ORAL CAP,50863,CDM,636,RC,J7502,HCPCS,60505-0134-0,NDC,facility,both,1,EA,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 3000 MCG/ML INJECTION,50863,CDM,636,RC,J0153,HCPCS,67457-855-00,NDC,facility,both,18,ML,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZOCAINE-MENTHOL 15-3.6 MG MM LOZG,50863,CDM,250,RC,J3490,HCPCS,63824-713-16,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,78206-122-01,NDC,facility,both,1,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 10 GRAM/15 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,64980-592-95,NDC,facility,both,1,ML,,108,75.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,132,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXAZOSIN 8 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-225-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPENTOLATE 1 % OPHT DROP,50863,CDM,636,RC,J3490,HCPCS,24208-735-01,NDC,facility,both,1,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TETRACYCLINE 500 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,62135-266-60,NDC,facility,both,1,EA,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 150 MG CAP,50863,CDM,250,RC,J3490,HCPCS,0904-5959-61,NDC,facility,both,10,EA,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,65862-707-80,NDC,facility,both,18,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 20 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,0228-2890-06,NDC,facility,both,2,EA,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-739-11,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-1159-19,NDC,facility,both,2,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFUROXIME AXETIL 250 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16714-400-02,NDC,facility,both,2,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 2 MG INJ SOLR,50863,CDM,250,RC,J2997,HCPCS,50242-041-63,NDC,facility,both,2,EA,JZ,662,463.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ADVATE: FACTOR VIII CONCENTRATE (MERGE RECORD),50863,CDM,250,RC,J7192,HCPCS,0944-3047-10,NDC,facility,both,3500,UN,,14651,10255.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-3178-01,NDC,facility,both,175,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VORICONAZOLE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0781-5668-31,NDC,facility,both,1,EA,,230,161,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,14,ML,JW,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,10,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN 0.9% SODIUM CL 1.25 GRAM/250 ML IV SOLN,50863,CDM,250,RC,J3373,HCPCS,71266-5083-1,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,55150-169-10,NDC,facility,both,50,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
SENNOSIDES 15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0067-0696-60,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,636,RC,J2597,HCPCS,43598-053-11,NDC,facility,both,20,ML,JZ,725,507.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DILTIAZEM IN D5W 125 MG/125 ML (1 MG/ML) IV SOLN (PREMIX),50863,CDM,250,RC,J3490,HCPCS,63037-119-05,NDC,facility,both,2,ML,,142,99.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,50863,CDM,250,RC,J8540,HCPCS,0054-8175-25,NDC,facility,both,144,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-4713-32,NDC,facility,both,60,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOSTIGMINE METHYLSULFATE 1 MG/ML IV SOLN,50863,CDM,636,RC,J2710,HCPCS,42023-189-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM IN NACL (ISO-OS) 500 MG/100 ML IV PGBK,50863,CDM,250,RC,J1953,HCPCS,36000-352-01,NDC,facility,both,100,ML,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,16714-294-01,NDC,facility,both,4,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN  325 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,57896-901-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7363-61,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6797-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"NEOMYCIN-POLYMYXIN-HC 3.5 MG-10,000 UNIT/ML-1 % EAR SOLN",50863,CDM,636,RC,J3490,HCPCS,24208-631-10,NDC,facility,both,1,ML,,363,254.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOLIC ACID 1 MG / 0.2 ML SYRINGE (CDS ADS REPACK),50863,CDM,250,RC,J3490,HCPCS,63323-184-10,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-6625-22,NDC,facility,both,4,ML,,231,161.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,64,ML,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-4827-05,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL (5 MG/ML) IV SYRG (CONTAINS PRESERVATIVE),50863,CDM,250,RC,J3490,HCPCS,0409-2339-24,NDC,facility,both,1,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  50 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6992-61,NDC,facility,both,6,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,50863,CDM,636,RC,J3420,HCPCS,70069-005-10,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,50863,CDM,636,RC,J3490,HCPCS,57237-077-10,NDC,facility,both,3,EA,,284,198.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCRALFATE 1 GRAM ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,29033-003-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"CALCIUM GLUC IN NACL, ISO-OSM 1 GRAM/50 ML IV SOLN",50863,CDM,636,RC,J0613,HCPCS,44567-620-01,NDC,facility,both,400,ML,,464,324.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM CITRATE ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,71399-0051-1,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,50863,CDM,250,RC,Q0177,HCPCS,68084-254-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,636,RC,J3490,HCPCS,0409-4887-10,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,250,RC,J0690,HCPCS,63323-237-10,NDC,facility,both,4,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-453-11,NDC,facility,both,6,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,59651-488-01,NDC,facility,both,50,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0093-9149-01,NDC,facility,both,2,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,0409-4887-24,NDC,facility,both,1,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 5 MG/ML IN NS IV SYRINGE,50863,CDM,636,RC,J3490,HCPCS,17478-515-00,NDC,facility,both,3,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-492-09,NDC,facility,both,1000,ML,,5225,3657.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  75 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-475-11,NDC,facility,both,1,EA,PLAD,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
OSELTAMIVIR PHOSPHATE 30 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,64380-797-01,NDC,facility,both,2,EA,,139,97.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR PHOSPHATE 30 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,68180-675-11,NDC,facility,both,1,EA,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-098-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV,50863,CDM,250,RC,J7120,HCPCS,0338-0117-03,NDC,facility,both,3,ML,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN STERILE WATER 2 GRAM/20 ML IV SYRG,50863,CDM,250,RC,J0690,HCPCS,70092-1238-47,NDC,facility,both,4,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0406-5771-23,NDC,facility,both,9,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR  6 MG/ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0004-0822-05,NDC,facility,both,5,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,250,RC,J0690,HCPCS,70092-1017-46,NDC,facility,both,2,ML,,33181,23226.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE  250 MCG/ACTUATION INHL DSDV,50863,CDM,250,RC,J3490,HCPCS,66993-792-97,NDC,facility,both,1,EA,,921,644.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,50863,CDM,250,RC,J9025,HCPCS,72485-201-01,NDC,facility,both,68,EA,JW,420,294,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ASPIRIN 81 MG ORAL CHEW,50863,CDM,636,RC,J3490,HCPCS,63739-434-02,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6322-61,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GAMMAGARD LIQUID 10 % IV SOLN,50863,CDM,636,RC,J1569,HCPCS,0944-2700-13,NDC,facility,both,60,ML,"JZ,JA,JG",10817,7571.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously | Modifier JG: Drug or biological acquired with 340b drug pricing program discount
DESMOPRESSIN 0.1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60505-0257-1,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,65219-445-01,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM NEO IV SYRINGE (PHS FROM PREMIX),50863,CDM,250,RC,J1953,HCPCS,44567-501-01,NDC,facility,both,22,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-739-41,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL (VITAMIN D3)  1000 UNIT ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,2055503300,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,68180-441-02,NDC,facility,both,9,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIOGLITAZONE 15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,65862-512-30,NDC,facility,both,1,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 3000 MCG/ML INJECTION,50863,CDM,636,RC,J0153,HCPCS,67457-855-00,NDC,facility,both,6,ML,JZ,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SACUBITRIL-VALSARTAN 24-26 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0078-0659-20,NDC,facility,both,1,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6925-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOBRAMYCIN 1.2 G POWDER VIAL,50863,CDM,250,RC,J3260,HCPCS,39822-0412-6,NDC,facility,both,6,EA,,159,111.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRILAT 1.25 MG/ML IV INJ,50863,CDM,250,RC,J3490,HCPCS,43598-078-11,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML INJ SOLN,50863,CDM,636,RC,J0171,HCPCS,76329-9061-0,NDC,facility,both,1,ML,,148,103.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 250 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,68084-776-11,NDC,facility,both,2,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK,50863,CDM,250,RC,J3490,HCPCS,12870-0001-2,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN DEXTROSE (ISO-OSMOTIC) 1 GRAM/50 ML IV PIGGY BACK,50863,CDM,636,RC,J0690,HCPCS,0338-3503-41,NDC,facility,both,6,ML,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE IN D5W 1 GRAM/100 ML IV PGBK,50863,CDM,250,RC,J3475,HCPCS,63323-108-00,NDC,facility,both,2,ML,"JZ,PLAD",55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier PLAD: Modifier description not available
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 40 GRAM/400 ML (10 %) INJ SOLN",50863,CDM,250,RC,J1561,HCPCS,13533-800-20,NDC,facility,both,10,ML,JZ,1415,990.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
EPINEPHRINE HCL IN D5W 4 MG/250 ML (16 MCG/ML) IV SOLN,50863,CDM,J0171,HCPCS,72196-7018-1,NDC,,,facility,both,1,ML,,211,147.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSP,50863,CDM,J3490,HCPCS,0574-0521-76,NDC,,,facility,both,1,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,63739-903-10,NDC,facility,both,2,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,50863,CDM,J1885,HCPCS,63323-162-03,NDC,,,facility,both,3,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FERRIC CARBOXYMALTOSE (INJECTAFER) 50 MG IRON/ML IV SOLN,50863,CDM,J1439,HCPCS,0517-0650-01,NDC,,,facility,both,750,ML,,4234,2963.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,63739-931-28,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-9558-05,NDC,facility,both,2,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,63323-487-01,NDC,facility,both,100,ML,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-511-11,NDC,facility,both,2,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASCORBIC ACID  250 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,2055500100,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELIMUMAB 400 MG IV SOLR,50863,CDM,636,RC,J0490,HCPCS,49401-102-01,NDC,facility,both,80,EA,,8917,6241.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMIDE PEROXIDE 6.5 % OTIC DROP,50863,CDM,250,RC,J3490,HCPCS,70677-1154-1,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-349-11,NDC,facility,both,4,EA,,127,88.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,636,RC,J2597,HCPCS,70095-031-01,NDC,facility,both,2,ML,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 50 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,50268-541-11,NDC,facility,both,3,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 0.5 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,59746-010-32,NDC,facility,both,3,EA,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-1638-32,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CANGRELOR 50 MG IV SOLR,50863,CDM,250,RC,C9460,HCPCS,10122-620-01,NDC,facility,both,50,EA,JZ,2635,1844.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ALLOPURINOL 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-205-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-3178-16,NDC,facility,both,12030,ML,,954,667.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAPAVERINE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J2440,HCPCS,0517-4010-01,NDC,facility,both,4,ML,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,70860-700-41,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 16 MG ORAL TAB,50863,CDM,250,RC,J7509,HCPCS,59762-0050-1,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUPHENAZINE 5 MG TAB,50863,CDM,250,RC,J3490,HCPCS,50268-368-11,NDC,facility,both,1,EA,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG IV SOLR,50863,CDM,636,RC,J3490,HCPCS,70436-032-35,NDC,facility,both,5,EA,,739,517.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,636,RC,J2270,HCPCS,0409-1890-13,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,636,RC,J1610,HCPCS,0597-0053-45,NDC,facility,both,50,EA,JZ,37066,25946.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6773-61,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,57237-077-10,NDC,facility,both,9,EA,,722,505.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) IV (NEO) EMERGENCY SYRINGE,50863,CDM,250,RC,J3490,HCPCS,0409-5534-34,NDC,facility,both,20,ML,,1269,888.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL  1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7390-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATOVAQUONE 750 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,60687-534-40,NDC,facility,both,1,ML,,174,121.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) NEB SOLUTION,50863,CDM,250,RC,J3490,HCPCS,0487-9501-25,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,16714-293-03,NDC,facility,both,5,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0228-3003-11,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROPROCAINE 3 % INJ SOLN,50863,CDM,250,RC,J2401,HCPCS,0143-9210-01,NDC,facility,both,570,ML,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,636,RC,P9045,HCPCS,68516-5219-0,NDC,facility,both,15,ML,,3813,2669.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-02,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNIT/G TOP PACK,50863,CDM,250,RC,J3490,HCPCS,45802-060-70,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IVPB (PEDIATRICS/ADULT NON-FORM)",50863,CDM,636,RC,J0137,HCPCS,24201-100-01,NDC,facility,both,9,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 100 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,70954-240-10,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) IV SOLN",50863,CDM,250,RC,J3490,HCPCS,43066-008-01,NDC,facility,both,3,ML,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-02,NDC,facility,both,6,ML,,172,120.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51672-4029-1,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,50863,CDM,250,RC,J3420,HCPCS,70069-005-01,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 10% IN WATER (NEO) 2 - 3.99 KG,50863,CDM,250,RC,J3490,HCPCS,0264-7520-10,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TORSEMIDE   5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,31722-529-01,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,59651-488-01,NDC,facility,both,20,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-134-11,NDC,facility,both,30,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG/5 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,66479-583-05,NDC,facility,both,2,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,636,RC,J7999,HCPCS,70092-1017-46,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR 200 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,50268-060-11,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 50% IN WATER (MERGE RECORD),50863,CDM,636,RC,J7060,HCPCS,0409-7517-66,NDC,facility,both,2,ML,,211,147.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,3,EA,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,250,RC,J7060,HCPCS,0409-7922-02,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,15,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,50863,CDM,250,RC,J9000,HCPCS,0069-1542-20,NDC,facility,both,3,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELIMUMAB 120 MG IV SOLR,50863,CDM,636,RC,J0490,HCPCS,49401-101-01,NDC,facility,both,8,ME,JA,1206,844.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
ASPIRIN-ACETAMINOPHEN-CAFFEINE 250 MG-250 MG-65 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0067-2039-91,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7350-61,NDC,facility,both,2,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  500 MG IV SOLR,50863,CDM,250,RC,J3373,HCPCS,0143-9161-01,NDC,facility,both,175,EA,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIVASTIGMINE 4.6 MG/24 HOUR TD PT24,50863,CDM,250,RC,J3490,HCPCS,0378-9070-16,NDC,facility,both,1,EA,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6949-61,NDC,facility,both,4,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J2312,HCPCS,0409-1215-01,NDC,facility,both,80,ML,,186,130.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-41,NDC,facility,both,80,ML,"JZ,JA",11316,7921.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-495-27,NDC,facility,both,140,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE (PF) 1 MG/ML INJ SOLN,50863,CDM,636,RC,J0169,HCPCS,54288-103-01,NDC,facility,both,90,ML,,771,539.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-815-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16714-989-01,NDC,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,50863,CDM,250,RC,J2359,HCPCS,0781-3159-72,NDC,facility,both,20,EA,JZ,203,142.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
VALACYCLOVIR 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-215-11,NDC,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FERROUS SULFATE 325 MG (65 MG IRON) TAB,50863,CDM,636,RC,J3490,HCPCS,2055502101,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0406-8515-23,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,17856-7014-7,NDC,facility,both,1,ML,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4 % TOPICAL SOLN,50863,CDM,636,RC,J3490,HCPCS,76329-6300-5,NDC,facility,both,7,ML,,749,524.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GAMMAGARD LIQUID 10 % IV SOLN,50863,CDM,636,RC,J1569,HCPCS,0944-2700-04,NDC,facility,both,10,ML,"JZ,JA,JG",1803,1262.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously | Modifier JG: Drug or biological acquired with 340b drug pricing program discount
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,636,RC,Q0162,HCPCS,65162-691-79,NDC,facility,both,2,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0780,HCPCS,25021-790-02,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-ABDA 100 MG IV SOLR,50863,CDM,250,RC,Q5104,HCPCS,78206-162-99,NDC,facility,both,30,EA,,6239,4367.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
K PHOS DI & MONO-SOD PHOS MONO 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,6954326810,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  5 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,13668-086-30,NDC,facility,both,3,EA,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR 200 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,72578-002-01,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-50,NDC,facility,both,6,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,636,RC,Q9968,HCPCS,71288-811-10,NDC,facility,both,50,ML,JZ,830,581,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,636,RC,Q9968,HCPCS,70710-1838-1,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,62559-440-02,NDC,facility,both,1,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-131-11,NDC,facility,both,2,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6418-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 10 GRAM/15 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,50383-779-30,NDC,facility,both,2,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,J2003,HCPCS,0143-9575-01,NDC,,,facility,both,300,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,55150-307-01,NDC,facility,both,57,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,50863,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,7,EA,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZOCAINE-MENTHOL 20 %-0.5 % TOPICAL AEROSOL,50863,CDM,250,RC,J3490,HCPCS,5140900722,NDC,facility,both,2,GM,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RASBURICASE 1.5 MG IV SOLR,50863,CDM,250,RC,J2783,HCPCS,0024-5150-10,NDC,facility,both,6,EA,,5758,4030.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),50863,CDM,250,RC,J3490,HCPCS,63323-186-01,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,90,EA,JZ,12420,8694,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PREGABALIN  25 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-473-11,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-735-11,NDC,facility,both,4,EA,,634,443.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 875 MG-125 MG TAB,50863,CDM,636,RC,J3490,HCPCS,65862-503-01,NDC,facility,both,9,EA,,218,152.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-65,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 600 MG ORAL TP12,50863,CDM,636,RC,J3490,HCPCS,63824-008-15,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2308-22,NDC,facility,both,8,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DIVALPROEX 250 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,0904-6860-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-406-03,NDC,facility,both,1,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM PHOSPHATE 4.4 MEQ/ML ORAL SOLUTION (CDS),50863,CDM,250,RC,J3490,HCPCS,0409-7295-11,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IMIPENEM-CILASTATIN-RELEBACTAM 1.25 G IV SOLR,50863,CDM,250,RC,J0742,HCPCS,0006-3856-02,NDC,facility,both,1,EA,,1120,784,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G POTASSIUM 20000000 UNIT INJ SOLR,50863,CDM,636,RC,J2540,HCPCS,70860-127-51,NDC,facility,both,34,EA,,280,196,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 0.1 MG/ML INJ SYRG,50863,CDM,250,RC,J0461,HCPCS,76329-3340-1,NDC,facility,both,11,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,250,RC,J1596,HCPCS,0143-9679-01,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,14789-127-07,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML IV,50863,CDM,636,RC,J3490,HCPCS,0641-6015-01,NDC,facility,both,1,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 50 MG/ML INJECTION,50863,CDM,250,RC,J1200,HCPCS,0641-0376-21,NDC,facility,both,3,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN D5W 20000 UNIT/500 ML,50863,CDM,636,RC,J1644,HCPCS,0264-9567-10,NDC,facility,both,20,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLERGONOVINE 0.2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,70010-786-12,NDC,facility,both,1,EA,,301,210.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MECLIZINE 25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7376-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0641-6057-01,NDC,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPH-MIN OIL-PETROLATUM 0.25-14-74.9 % RECT OINT,50863,CDM,250,RC,J3490,HCPCS,0573-2871-93,NDC,facility,both,3,GM,,178,124.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,J2250,HCPCS,0409-2308-22,NDC,,,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,70756-640-82,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,J3490,HCPCS,70092-1119-44,NDC,,,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,50863,CDM,636,RC,J3490,HCPCS,57237-077-10,NDC,facility,both,9,EA,,722,505.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE  2.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0555-0872-02,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,50863,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,10,ML,,167,116.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,J1171,HCPCS,0409-1283-03,NDC,,,facility,both,10,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG IV SOLR,50863,CDM,636,RC,J3490,HCPCS,55150-202-00,NDC,facility,both,2,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,50863,CDM,J3490,HCPCS,0143-9509-01,NDC,,,facility,both,1,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FERROUS SULFATE 75 MG/ML (ELEMENTAL IRON 15 MG/ML) 0.2 ML ORAL SYRINGE (REPACK),50863,CDM,250,RC,J3490,HCPCS,17856-7482-02,NDC,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,70095-026-01,NDC,facility,both,4,ML,,268,187.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID (PORK)  30 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42192-329-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,63323-482-03,NDC,facility,both,300,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,68382-444-05,NDC,facility,both,3,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALSARTAN 160 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-634-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IV PGBK,50863,CDM,250,RC,J3475,HCPCS,44567-421-00,NDC,facility,both,8,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,70010-754-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,31722-820-30,NDC,facility,both,1,EA,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,50863,CDM,250,RC,J9171,HCPCS,67457-533-16,NDC,facility,both,224,ML,,2126,1488.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN DEXTROSE (ISO-OSMOTIC) 1 GRAM/50 ML IV PIGGY BACK,50863,CDM,636,RC,J0689,HCPCS,0338-3503-41,NDC,facility,both,4,ML,JZ,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,250,RC,J0690,HCPCS,70092-1017-46,NDC,facility,both,3,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-01,NDC,facility,both,405,ME,JZ,4844,3390.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
AZITHROMYCIN 250 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-742-11,NDC,facility,both,4,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE 14 MG/24 HR TD PT24,50863,CDM,636,RC,J3490,HCPCS,4898500150,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE  10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-162-11,NDC,facility,both,3,EA,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,10702-018-01,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) NEB SOLUTION,50863,CDM,636,RC,J3490,HCPCS,60687-395-79,NDC,facility,both,2,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  60 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69292-536-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,2,EA,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLIPIZIDE  2.5 MG ORAL TO24,50863,CDM,250,RC,J3490,HCPCS,16714-894-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CELECOXIB 400 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,65862-910-60,NDC,facility,both,1,EA,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0143-9509-01,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-492-09,NDC,facility,both,1,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,63323-104-25,NDC,facility,both,15,ML,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEMAZEPAM  7.5 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,68084-549-11,NDC,facility,both,1,EA,PLAD,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
INSULIN NPH HUMAN RECOMB 100 UNIT/ML SUBQ SUSP,50863,CDM,250,RC,J1815,HCPCS,0169-1834-11,NDC,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7243-61,NDC,facility,both,8,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,0904-7127-61,NDC,facility,both,30,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML (ANESTHESIA INTRAOP ONLY),50863,CDM,636,RC,J3010,HCPCS,0641-6027-01,NDC,facility,both,2,ML,JZ,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,43,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 0.4 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,68462-639-25,NDC,facility,both,3,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,75,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-495-27,NDC,facility,both,240,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6666-61,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68180-445-01,NDC,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APREPITANT 125 MG ORAL CAP,50863,CDM,250,RC,J8501,HCPCS,68462-585-40,NDC,facility,both,25,EA,,940,658,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 0.75 % TOP GEL,50863,CDM,250,RC,J3490,HCPCS,51672-4116-6,NDC,facility,both,1,GM,,943,660.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 10 % (100 MG/ML) MISC SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-695-04,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42858-001-10,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0003-0893-31,NDC,facility,both,1,EA,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,250,RC,J3101,HCPCS,50242-037-06,NDC,facility,both,25,EA,,11451,8015.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SCOPOLAMINE TRANSDERMAL PATCH 1MG OVER 3 DAYS,50863,CDM,250,RC,J3490,HCPCS,0591-2258-54,NDC,facility,both,1,EA,,119,83.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-3178-01,NDC,facility,both,270,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIGOXIN 250 MCG/ML INJ SOLN,50863,CDM,636,RC,J1160,HCPCS,0641-1410-31,NDC,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,250,RC,J2720,HCPCS,63323-229-01,NDC,facility,both,4,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN  325 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,0536-1232-01,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE 110 MCG/ACTUATION INHL AERO,50863,CDM,250,RC,J3490,HCPCS,66993-079-96,NDC,facility,both,1,GM,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6773-61,NDC,facility,both,2,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 20 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,0904-7458-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,35,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),50863,CDM,250,RC,J2060,HCPCS,65219-368-01,NDC,facility,both,2,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV (BOLUS),50863,CDM,636,RC,J7120,HCPCS,17271-710-07,NDC,facility,both,1,ML,,411,287.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIFEDIPINE 10 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,23155-194-01,NDC,facility,both,3,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LITHIUM CARBONATE 450 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,68462-224-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML INJ SOLN,50863,CDM,250,RC,J0169,HCPCS,76329-9060-0,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 1 MG/ML IV SOLN,50863,CDM,J0461,HCPCS,0517-1001-01,NDC,,,facility,both,50,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,51754-4250-1,NDC,facility,both,4,ML,,290,203,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",50863,CDM,J1561,HCPCS,13533-800-24,NDC,,,facility,both,120,ML,,16973,11881.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 500 MG PE/10 ML INJ SOLN,50863,CDM,Q2009,HCPCS,0069-6001-10,NDC,,,facility,both,30,ML,,1572,1100.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J3490,HCPCS,0338-0049-48,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,J3490,HCPCS,63323-185-07,NDC,,,facility,both,2,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-426-05,NDC,facility,both,1,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BETHANECHOL CHLORIDE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0832-0511-89,NDC,facility,both,3,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 5 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,63323-660-05,NDC,facility,both,2,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTAMIDINE 300 MG INJ SOLR,50863,CDM,636,RC,J3490,HCPCS,63323-113-01,NDC,facility,both,1,EA,,145,101.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,636,RC,J0330,HCPCS,69374-919-10,NDC,facility,both,3,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 75 MG/5 ML ORAL SOLUTION,50863,CDM,250,RC,J3490,HCPCS,64980-511-10,NDC,facility,both,12,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MANNITOL 20% IV SOLP,50863,CDM,250,RC,J2150,HCPCS,0338-0357-02,NDC,facility,both,1,ML,,128,89.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM ZIRCONIUM CYCLOSILICATE  5 G ORAL PWPK (USE PANEL),50863,CDM,250,RC,J3490,HCPCS,0310-1105-01,NDC,facility,both,2,EA,,279,195.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0641-0400-12,NDC,facility,both,5,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM ZIRCONIUM CYCLOSILICATE  5 G ORAL PWPK (USE PANEL),50863,CDM,250,RC,J3490,HCPCS,0310-1105-01,NDC,facility,both,1,EA,,161,112.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,71288-402-10,NDC,facility,both,7,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE IN 0.9% NS (PF) 1 MG/10 ML (100 MCG/ML) IV SYRG(PDS MERGE),50863,CDM,250,RC,J3490,HCPCS,70092-1046-46,NDC,facility,both,1,ML,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OMALIZUMAB 150 MG SUBQ SOLR,50863,CDM,636,RC,J2357,HCPCS,50242-040-62,NDC,facility,both,15,ME,,1305,913.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN NPH & REGULAR HUMAN 100 UNIT/ML (70-30) SUBQ SUSP,50863,CDM,636,RC,J1815,HCPCS,0169-1837-11,NDC,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,636,RC,J3373,HCPCS,67457-340-01,NDC,facility,both,2,EA,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIGOXIN 250 MCG/ML INJ SOLN,50863,CDM,250,RC,J1160,HCPCS,0781-3059-72,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAMADOL  50 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-7496-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,17271-701-07,NDC,facility,both,2,ML,JZ,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,J2003,HCPCS,0409-4277-02,NDC,,,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,J2704,HCPCS,0069-0209-01,NDC,,,facility,both,16,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEFIBROTIDE 80 MG/ML IV SOLN,50863,CDM,J3490,HCPCS,68727-800-01,NDC,,,facility,both,2,ML,,3530,2471,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RAMUCIRUMAB 10 MG/ML IV SOLN,50863,CDM,J9308,HCPCS,0002-7678-01,NDC,,,facility,both,100,ML,,14791,10353.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RACEPINEPHRINE 2.25 % INHL NEBU,50863,CDM,250,RC,J3490,HCPCS,0487-5901-99,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,J1171,HCPCS,76045-009-96,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-492-07,NDC,,,facility,both,600,ML,,139,97.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOFETILIDE 250 MCG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,42291-412-60,NDC,facility,both,1,EA,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM BICARB-CITRIC ACID 20 MEQ ORAL TBEF,50863,CDM,250,RC,J3490,HCPCS,51801-011-01,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,11,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLORAZEPATE DIPOTASSIUM  3.75 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51672-4042-1,NDC,facility,both,4,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 50 MG/ML IV SOLN,50863,CDM,250,RC,J0282,HCPCS,63323-616-03,NDC,facility,both,15,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 125 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,62756-796-88,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-3426-10,NDC,facility,both,4,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  1 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,64380-782-06,NDC,facility,both,4,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 8-2 MG SL SUBL,50863,CDM,636,RC,J3490,HCPCS,50268-145-11,NDC,facility,both,6,EA,,216,151.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 60 MG ORAL CPDR,50863,CDM,636,RC,J3490,HCPCS,0904-7045-61,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"HEPARIN, PORCINE (PF)   10 UNIT/ML IV SYRG",50863,CDM,250,RC,J1642,HCPCS,6425322233,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 2-0.5 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,50268-144-11,NDC,facility,both,3,EA,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,0409-3178-01,NDC,,,facility,both,300,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,J0665,HCPCS,55150-169-10,NDC,,,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 60 MG ORAL CPDR,50863,CDM,636,RC,J3490,HCPCS,57237-019-30,NDC,facility,both,2,EA,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROBENECID 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0591-5347-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,636,RC,J1953,HCPCS,55150-177-05,NDC,facility,both,75,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYMETAZOLINE 0.05 % NASL SPRA,50863,CDM,250,RC,J3490,HCPCS,11523-4112-1,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 600 MG ORAL TP12,50863,CDM,250,RC,J3490,HCPCS,68084-572-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUDROCORTISONE 0.1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-330-11,NDC,facility,both,3,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6926-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-6625-22,NDC,facility,both,10,ML,,578,404.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-41,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-587-11,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 50 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,59651-489-01,NDC,facility,both,70,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,43066-007-10,NDC,facility,both,2,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 20 MG ORAL TAB,50863,CDM,636,RC,J8499,HCPCS,60687-380-11,NDC,facility,both,6,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,23155-724-01,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2310,HCPCS,67457-299-00,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITRIOL 1 MCG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,64980-447-15,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-069-33,NDC,facility,both,1,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-ABDA 100 MG IV SOLR,50863,CDM,636,RC,Q5104,HCPCS,78206-162-99,NDC,facility,both,50,EA,,10397,7277.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 5 MG/ML IV SOLN,50863,CDM,250,RC,J7525,HCPCS,0469-3016-01,NDC,facility,both,1,ML,,877,613.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPHENIDATE 18 MG ORAL TO24,50863,CDM,250,RC,J3490,HCPCS,50458-585-01,NDC,facility,both,1,EA,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ESMOLOL IN SALINE (ISO-OSMOTIC) 2,500 MG/250 ML (10 MG/ML) IV",50863,CDM,250,RC,J1805,HCPCS,44567-450-01,NDC,facility,both,1,ML,,402,281.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,636,RC,J3490,HCPCS,63037-136-25,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,2000,ML,,221,154.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANTI-INHIBITOR COAGULANT CMPLX (PHS MERGE),50863,CDM,250,RC,J7198,HCPCS,64193-326-01,NDC,facility,both,3825,UN,,27625,19337.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,68094-750-59,NDC,facility,both,2,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DACTINOMYCIN 0.5 MG IV SOLR,50863,CDM,636,RC,J9120,HCPCS,71288-129-02,NDC,facility,both,5,EA,JZ,6900,4830,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,50863,CDM,250,RC,J3490,HCPCS,69339-152-01,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOMYCIN-BACITRACN ZN-POLYMYXIN 3.5 MG-400 U*,50863,CDM,636,RC,J3490,HCPCS,45802-143-00,NDC,facility,both,7,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,16729-114-08,NDC,facility,both,1,ML,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,J2560,HCPCS,72162-1330-6,NDC,,,facility,both,5,ML,,2204,1542.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,J7512,HCPCS,60219-1708-1,NDC,,,facility,both,60,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,J1815,HCPCS,0088-2220-33,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OMALIZUMAB 150 MG SUBQ SOLR,50863,CDM,636,RC,J2357,HCPCS,50242-040-62,NDC,facility,both,60,ME,JZ,5219,3653.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LORAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6008-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLORAZEPATE DIPOTASSIUM  3.75 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51672-4042-1,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-439-11,NDC,facility,both,3,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE (DIAGNOSTIC) 3 MG/ML IV SOLN,50863,CDM,636,RC,J0153,HCPCS,16714-997-01,NDC,facility,both,180,ML,,1470,1029,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,70069-363-01,NDC,facility,both,1,ML,,144,100.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 2 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,636,RC,J2270,HCPCS,76045-004-01,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0228-2127-10,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRIMIDONE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-686-11,NDC,facility,both,3,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 2 % TD OINT,50863,CDM,250,RC,J3490,HCPCS,0281-0326-08,NDC,facility,both,1,GM,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,62332-738-31,NDC,facility,both,1,EA,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,636,RC,J2003,HCPCS,0409-1323-05,NDC,facility,both,300,ML,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"CALCIUM GLUC IN NACL, ISO-OSM 1 G/100 ML IV SOLN",50863,CDM,250,RC,J0612,HCPCS,44567-622-01,NDC,facility,both,300,ML,,223,156.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DANTROLENE  25 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7211-04,NDC,facility,both,2,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE-SALMETEROL 250 MCG-50 MCG/DOSE DISK DEVICE FOR INHALATION,50863,CDM,636,RC,J3490,HCPCS,0054-0327-56,NDC,facility,both,1,EA,,1325,927.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 600 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-5854-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPTOMYCIN IN 0.9 % SOD CHLOR 350 MG/50 ML IV PGBK,50863,CDM,636,RC,J0874,HCPCS,0338-0712-24,NDC,facility,both,350,ML,GY,135,94.5,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier GY: Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit"
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,0409-4887-17,NDC,facility,both,3,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 1% 10MG/ML (1ML-UD) OR SYRINGE,50863,CDM,J2003,HCPCS,0409-4276-02,NDC,,,facility,both,80,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6172-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 1 GRAM INJ SOLR,50863,CDM,636,RC,J0692,HCPCS,60505-6146-0,NDC,facility,both,4,EA,,199,139.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,0641-6236-01,NDC,facility,both,2,ML,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,93,ML,,134,93.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 875 MG-125 MG TAB,50863,CDM,250,RC,J3490,HCPCS,16714-297-02,NDC,facility,both,4,EA,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,9,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,43598-053-11,NDC,facility,both,28,ML,,992,694.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE 20 MG TAB,50863,CDM,250,RC,J3490,HCPCS,63739-963-10,NDC,facility,both,1,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML INJECTION,50863,CDM,250,RC,J3411,HCPCS,0641-6228-01,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE  4 MG ORAL TAB,50863,CDM,636,RC,J7509,HCPCS,0904-6914-61,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 30 MG TAB,50863,CDM,250,RC,J3490,HCPCS,60687-717-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,2,EA,JW,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
SERTRALINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-242-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE IN 0.9% NS (PF) 1 MG/10 ML (100 MCG/ML) IV SYRG(PDS MERGE),50863,CDM,636,RC,J3490,HCPCS,69374-957-10,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 30 MG/0.3 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,0075-0624-01,NDC,facility,both,3,ML,JZ,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"TRANEXAMIC ACID IN NACL,ISO-OS 1,000 MG/100 ML (10 MG/ML) IV PGBK",50863,CDM,636,RC,J3490,HCPCS,51754-0108-3,NDC,facility,both,2,ML,,247,172.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WHITE PETROLATUM-MINERAL OIL OPHT OINT (PDS MERGE),50863,CDM,250,RC,J3490,HCPCS,0023-0312-04,NDC,facility,both,1,GM,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LURASIDONE  60 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7357-61,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN  500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6689-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-407-11,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-48,NDC,facility,both,1,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 30 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,68180-295-09,NDC,facility,both,3,EA,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,25021-402-01,NDC,facility,both,10,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 40 MG/ML (4 %) INJ SOLN (FOR NEBULIZATION),50863,CDM,J2003,HCPCS,0409-4283-11,NDC,,,facility,both,200,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG ORAL CAP,50863,CDM,J3490,HCPCS,60687-580-11,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR IRRIGATION, STERILE SOLUTION",50863,CDM,636,RC,J3490,HCPCS,0338-0004-02,NDC,facility,both,2,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN  325 MG ORAL TAB,50863,CDM,J3490,HCPCS,57896-901-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-65,NDC,facility,both,100,ML,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,250,RC,Q0162,HCPCS,16714-671-02,NDC,facility,both,3,ML,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,J2371,HCPCS,0641-6142-01,NDC,,,facility,both,2000,ML,,107,74.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,636,RC,P9045,HCPCS,64208-2510-5,NDC,facility,both,13,ML,JZ,1074,751.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IVPB (PEDIATRICS/ADULT NON-FORM)",50863,CDM,J0137,HCPCS,24201-100-01,NDC,,,facility,both,100,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 1 MG ORAL TAB,50863,CDM,250,RC,J8540,HCPCS,0054-8174-25,NDC,facility,both,8,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,50863,CDM,J3490,HCPCS,65862-390-10,NDC,,,facility,both,1,EA,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTAMIDINE 300 MG INJ SOLR,50863,CDM,636,RC,J3490,HCPCS,63323-113-01,NDC,facility,both,1,EA,,721,504.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 10% IN WATER (D10) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0990-7930-09,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,250,RC,J2795,HCPCS,70069-064-25,NDC,facility,both,100,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 400 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0143-9887-01,NDC,facility,both,17,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 8-2 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,0904-7010-06,NDC,facility,both,3,EA,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML INJ SOLN,50863,CDM,250,RC,J2060,HCPCS,0409-6778-02,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,636,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,7,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,43598-053-11,NDC,facility,both,51,ML,,1825,1277.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID (PORK) 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0456-0457-01,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,J1885,HCPCS,0338-0072-25,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE (POLACRILEX) 4 MG BUCL GUM,50863,CDM,250,RC,J3490,HCPCS,70677-1167-1,NDC,facility,both,21,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 800 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,17856-921-01,NDC,facility,both,3,EA,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,42806-150-33,NDC,facility,both,12,ML,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE MONONITRATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,6809411659,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,J1100,HCPCS,63323-165-01,NDC,,,facility,both,10,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,J7510,HCPCS,17856-0815-1,NDC,,,facility,both,2,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL (5 MG/ML) IV SYRG (CONTAINS PRESERVATIVE),50863,CDM,J3490,HCPCS,0409-2339-24,NDC,,,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-492-27,NDC,,,facility,both,160,ML,,126,88.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-492-57,NDC,,,facility,both,90,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6007-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PSEUDOEPHEDRINE 30 MG TAB,50863,CDM,J3490,HCPCS,0904-5053-59,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 4 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-6418-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,J7512,HCPCS,0904-7127-61,NDC,,,facility,both,20,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IVABRADINE 7.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,55513-810-60,NDC,facility,both,1,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-9558-05,NDC,facility,both,2,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IVABRADINE 7.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,55513-810-60,NDC,facility,both,2,EA,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 17 GRAM (100 %) ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,0904-6931-86,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  5 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,60687-122-11,NDC,facility,both,10,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,69315-905-01,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,45,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,43598-053-11,NDC,facility,both,20,ML,,718,502.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,7,EA,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,J2704,HCPCS,0069-0209-01,NDC,,,facility,both,12,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,70004-600-09,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,43547-543-01,NDC,facility,both,4,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,4,ML,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7007-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,65862-707-80,NDC,facility,both,12,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 100 MG ORAL TB12,50863,CDM,636,RC,J3490,HCPCS,16714-063-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,636,RC,J3373,HCPCS,63323-284-01,NDC,facility,both,200,EA,,187,130.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAMSULOSIN 0.4 MG ORAL CP24,50863,CDM,636,RC,J3490,HCPCS,65862-598-01,NDC,facility,both,2,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMIDE PEROXIDE 6.5 % OTIC DROP,50863,CDM,250,RC,J3490,HCPCS,0904-6627-35,NDC,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,55111-466-01,NDC,facility,both,3,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NAPROXEN 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68462-190-01,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,0409-9094-22,NDC,facility,both,1,ML,PLAD,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
LINEZOLID 600 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,67877-419-20,NDC,facility,both,1,EA,,390,273,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0121-0914-05,NDC,facility,both,5,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,50863,CDM,250,RC,J9267,HCPCS,61703-342-22,NDC,facility,both,81,ML,,133,93.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 15% IN WATER,50863,CDM,250,RC,J3490,HCPCS,0338-0023-03,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,67877-433-03,NDC,facility,both,2,EA,,272,190.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,16729-114-31,NDC,facility,both,17,ML,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZOXIDE (DIABETIC USE) 50 MG/ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0254-1010-19,NDC,facility,both,1,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 500 MG ORAL CAP,50863,CDM,J3490,HCPCS,60687-787-11,NDC,,,facility,both,2,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,50863,CDM,J0696,HCPCS,0143-9856-01,NDC,,,facility,both,32,EA,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB 100 MG IV SOLR,50863,CDM,J1745,HCPCS,57894-030-01,NDC,,,facility,both,60,EA,,19340,13538,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,250,RC,J1596,HCPCS,0143-9679-01,NDC,facility,both,24,ML,,136,95.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NELARABINE 250 MG/50 ML IV SOLN (PEDS ONCOLOGY),50863,CDM,250,RC,J9261,HCPCS,71288-165-52,NDC,facility,both,15,ML,,5360,3752,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J1611,HCPCS,0597-0053-45,NDC,facility,both,2,EA,,1112,778.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  1 MG/ML IV SOLN,50863,CDM,250,RC,J1800,HCPCS,63323-604-00,NDC,facility,both,1,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  25 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-6991-04,NDC,facility,both,8,EA,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO PROTAM & LISPRO 100 UNIT/ML (75-25) SUBQ SUSP,50863,CDM,636,RC,J1815,HCPCS,0002-7511-01,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-673-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,50863,CDM,636,RC,Q0177,HCPCS,60687-675-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,50863,CDM,636,RC,Q0177,HCPCS,16714-082-10,NDC,facility,both,3,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PNEUMOCOCCAL 23-VAL PS VACCINE 25 MCG/0.5 ML INJ SYRG,50863,CDM,250,RC,90732,HCPCS,0006-4837-01,NDC,facility,both,1,ML,,506,354.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 1 % INJ SOLN,50863,CDM,250,RC,Q9968,HCPCS,0517-0301-10,NDC,facility,both,30,ML,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLN (MERGE)",50863,CDM,250,RC,P9047,HCPCS,64208-2512-8,NDC,facility,both,4,ML,JZ,475,332.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CARBIDOPA-LEVODOPA 25 MG-100 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7257-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25%/EPINEPHRINE 1:100K INJECTION,50863,CDM,636,RC,J3490,HCPCS,0409-1158-01,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 100 MG/ML FROM 1 GRAM VIAL (PRMC PEDS ONLY),50863,CDM,250,RC,J0696,HCPCS,0409-7332-11,NDC,facility,both,8,EA,JZ,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CARVEDILOL  6.25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7306-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 100 MG/ML INJ SOLN,50863,CDM,250,RC,J2800,HCPCS,55150-223-10,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,70710-1833-1,NDC,facility,both,1,EA,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE  2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-087-11,NDC,facility,both,1,EA,,150,105,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-645-11,NDC,facility,both,3,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  75 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6951-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,2,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,50863,CDM,636,RC,J3490,HCPCS,0378-7732-93,NDC,facility,both,12,EA,,790,553,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACIDOPHILUS-PECTIN W CITRUS 25 MILLION-100 CELL MG TAB,50863,CDM,636,RC,J3490,HCPCS,1785614241,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,636,RC,J2405,HCPCS,0409-4755-18,NDC,facility,both,4,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DOXYLAMINE SUCCINATE 25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,4116700607,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69315-904-01,NDC,facility,both,8,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE BIT 2 %-1:100,000 INJ CRTG",50863,CDM,636,RC,J3490,HCPCS,0409-0996-01,NDC,facility,both,2,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-112-02,NDC,facility,both,2,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-31,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6798-61,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN  200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-5154-60,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,636,RC,J7060,HCPCS,0338-0017-01,NDC,facility,both,2,ML,,240,168,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 40 MG/ML (4 %) INJ SOLN (FOR NEBULIZATION),50863,CDM,250,RC,J3490,HCPCS,0409-4283-11,NDC,facility,both,200,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL  32.4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6575-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-25,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 0.1 MG/ML INJ SYRG,50863,CDM,250,RC,J0461,HCPCS,76329-3340-1,NDC,facility,both,18,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-231-11,NDC,facility,both,5,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2308-21,NDC,facility,both,2,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GABAPENTIN 300 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-6666-61,NDC,facility,both,2,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAZOLAMIDE 500 MG ORAL CPSR,50863,CDM,250,RC,J3490,HCPCS,23155-787-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIHYDROERGOTAMINE 1 MG/ML INJ SOLN,50863,CDM,250,RC,J1110,HCPCS,81284-411-05,NDC,facility,both,1,ML,,397,277.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTAMIDINE 300 MG INJ SOLR,50863,CDM,636,RC,J3490,HCPCS,63323-113-01,NDC,facility,both,1,EA,,325,227.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,1,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRBESARTAN 300 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,33342-049-07,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYTOCIN IN 0.9 % SOD CHLORIDE 30 UNIT/500 ML IV SOLN,50863,CDM,250,RC,J2590,HCPCS,71266-5103-1,NDC,facility,both,1,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65862-642-30,NDC,facility,both,1,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN   81 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,57896-981-12,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,636,RC,J7060,HCPCS,0338-0017-31,NDC,facility,both,1,ML,JZ,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
KETAMINE 100 MG/ML INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0143-9509-01,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,68180-723-05,NDC,facility,both,4,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL,50863,CDM,250,RC,J3490,HCPCS,63323-820-01,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOPIDOGREL 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-752-95,NDC,facility,both,1,EA,,131,91.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 150 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7002-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MANNITOL 20% IV SOLP,50863,CDM,636,RC,J2150,HCPCS,0990-7715-13,NDC,facility,both,1,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COSYNTROPIN 0.25 MG INJ SOLR,50863,CDM,250,RC,J0834,HCPCS,0781-3440-71,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,250,RC,J2405,HCPCS,23155-547-31,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 20MG/ML IV SYRINGE (PEDS/NEO),50863,CDM,250,RC,J0612,HCPCS,63323-311-10,NDC,facility,both,29,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7050,HCPCS,17271-701-05,NDC,facility,both,1,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,45,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE 10 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,70954-319-10,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6818-61,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR IRRIGATION, STERILE SOLUTION",50863,CDM,250,RC,J3490,HCPCS,0264-2101-10,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 500 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,68084-415-11,NDC,facility,both,1,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALSARTAN  80 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-623-11,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,50863,CDM,250,RC,J9025,HCPCS,72485-201-01,NDC,facility,both,55,EA,JW,341,238.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,15,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 100 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0078-0508-83,NDC,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,68462-470-40,NDC,facility,both,2,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,50863,CDM,250,RC,Q0177,HCPCS,0093-5061-01,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL  32.4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6575-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACUBITRIL-VALSARTAN 24-26 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,33342-570-09,NDC,facility,both,1,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE 22.5 MG SUBQ SYRG,50863,CDM,636,RC,J9217,HCPCS,62935-223-05,NDC,facility,both,3,EA,JZ,1176,823.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),50863,CDM,636,RC,J0171,HCPCS,0409-4921-34,NDC,facility,both,60,ML,,200,140,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,7733351625,NDC,facility,both,7,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,636,RC,J1953,HCPCS,63323-400-01,NDC,facility,both,135,ML,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYBUTYNIN CHLORIDE  5 MG ORAL TO24,50863,CDM,636,RC,J3490,HCPCS,68084-480-11,NDC,facility,both,2,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 50 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,51079-170-01,NDC,facility,both,3,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,636,RC,J3490,HCPCS,59310-579-20,NDC,facility,both,1,GM,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 2 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,636,RC,J2270,HCPCS,76045-004-01,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-580-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-979-01,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMINOCAPROIC ACID  500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,72205-049-30,NDC,facility,both,2,EA,,220,154,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN PEDS SYRINGE (20MG/ML) IN DEXTROSE (CDS MIX,50863,CDM,636,RC,J0690,HCPCS,0781-3451-70,NDC,facility,both,3,EA,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 2 GRAM INJ SOLR,50863,CDM,250,RC,J0692,HCPCS,25021-122-50,NDC,facility,both,2,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEPIVACAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J0670,HCPCS,63323-260-01,NDC,facility,both,3,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  5 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,60687-122-11,NDC,facility,both,5,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,70095-031-01,NDC,facility,both,24,ML,,970,679,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,13,ML,,22543,15780.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,15,EA,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV (BOLUS),50863,CDM,250,RC,J7120,HCPCS,0264-7750-07,NDC,facility,both,3,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-113-11,NDC,facility,both,5,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE 0.05 % OPHT DPET,50863,CDM,636,RC,J3490,HCPCS,68180-214-30,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VECURONIUM BROMIDE 10 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,47335-931-40,NDC,facility,both,1,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0093-4177-73,NDC,facility,both,6,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN IN D5W 400 MG/200 ML IV PGBK,50863,CDM,250,RC,J0744,HCPCS,25021-114-87,NDC,facility,both,12,ML,,280,196,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7449-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % MUCOSAL SOLN (VISCOUS),50863,CDM,636,RC,J3490,HCPCS,0121-0903-15,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN   81 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,63739-212-02,NDC,facility,both,4,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6291-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPLERENONE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-451-11,NDC,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROPROCAINE 3 % INJ SOLN,50863,CDM,250,RC,J2401,HCPCS,0143-9210-01,NDC,facility,both,546,ML,JW,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PHENAZOPYRIDINE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,75826-114-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
URSODIOL 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-100-11,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,67877-545-88,NDC,facility,both,10,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARIFENACIN  7.5 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,33342-276-07,NDC,facility,both,2,EA,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR IRRIGATION, STERILE SOLUTION",50863,CDM,250,RC,J3490,HCPCS,0338-0004-02,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEBIVOLOL  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-641-11,NDC,facility,both,1,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR IRRIGATION, STERILE SOLUTION",50863,CDM,250,RC,J3490,HCPCS,0338-0004-02,NDC,facility,both,8,ML,,255,178.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EMTRICITABINE-TENOFOVIR ALAFEN 200-25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,61958-2002-2,NDC,facility,both,1,EA,,374,261.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL (NEO/PEDS),50863,CDM,250,RC,J3490,HCPCS,63323-820-00,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 1 MG ORAL TAB,50863,CDM,250,RC,J8540,HCPCS,72578-166-01,NDC,facility,both,22,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,50863,CDM,250,RC,J9075,HCPCS,10019-956-16,NDC,facility,both,200,EA,,1296,907.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,6,EA,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6519-61,NDC,facility,both,2,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE IN 0.9 % NACL 4 MG/250 ML (16 MCG/ML) IV SOLN (MERGE),50863,CDM,250,RC,J3490,HCPCS,70004-613-40,NDC,facility,both,9,ML,,1849,1294.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPOETIN ALFA 2000 UNIT/ML IV SYRINGE (PED/NEO),50863,CDM,250,RC,Q4081,HCPCS,59676-302-00,NDC,facility,both,9,ML,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN  3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0056-0188-70,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,68180-150-01,NDC,facility,both,5,ML,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,30,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,54,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7363-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM 500 MG IV SOLR,50863,CDM,250,RC,J2185,HCPCS,0781-3000-94,NDC,facility,both,5,EA,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-0007-01,NDC,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0228-2127-10,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 1 MG ORAL CAP,50863,CDM,636,RC,J7507,HCPCS,0904-7097-61,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,70069-363-01,NDC,facility,both,1,ML,,172,120.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VERAPAMIL 240 MG ORAL TBSR,50863,CDM,636,RC,J3490,HCPCS,75834-159-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),50863,CDM,250,RC,J1630,HCPCS,63323-474-00,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J3430,HCPCS,69097-708-31,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 8-2 MG SL SUBL,50863,CDM,636,RC,J3490,HCPCS,60687-637-11,NDC,facility,both,4,EA,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,42494-415-01,NDC,facility,both,1,ML,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  100 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,63323-376-00,NDC,facility,both,2,ML,JW,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CARVEDILOL 12.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68382-094-01,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42806-341-01,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LURASIDONE  80 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63402-308-30,NDC,facility,both,1,EA,,241,168.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR PHOSPHATE 75 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,64380-799-01,NDC,facility,both,8,EA,,446,312.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,0781-3232-94,NDC,facility,both,1,EA,PLAD,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
THYROID (PORK) 15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0456-0457-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J2004,HCPCS,63323-482-27,NDC,facility,both,200,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,0409-6625-14,NDC,facility,both,5,ML,,289,202.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOPIDOGREL  75 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6294-61,NDC,facility,both,4,EA,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J3490,HCPCS,63323-492-27,NDC,,,facility,both,60,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCERIN (CHILD) RECTAL SUPPOSITORY,50863,CDM,J3490,HCPCS,58980-409-12,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),50863,CDM,636,RC,J2060,HCPCS,0641-6044-01,NDC,facility,both,2,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2305-16,NDC,facility,both,6,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,636,RC,Q0162,HCPCS,16714-671-02,NDC,facility,both,4,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,50863,CDM,636,RC,Q0177,HCPCS,16714-082-10,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,13,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-25,NDC,facility,both,65,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLP",50863,CDM,636,RC,P9047,HCPCS,0944-0493-04,NDC,facility,both,1,ML,,251,175.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,62332-037-31,NDC,facility,both,14,EA,,247,172.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,636,RC,J7999,HCPCS,70092-1017-46,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE CONCENTRATE 10 MG/ 0.5 ML ORAL SYRINGE (0.5ML UD MERGE),50863,CDM,250,RC,J3490,HCPCS,68094-045-01,NDC,facility,both,2,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 100 MG/ML FROM 1 GRAM VIAL (PRMC PEDS ONLY),50863,CDM,250,RC,J0696,HCPCS,0409-7332-11,NDC,facility,both,4,EA,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
FONDAPARINUX 2.5 MG/0.5 ML SUBQ SYRG,50863,CDM,250,RC,J1652,HCPCS,55150-230-00,NDC,facility,both,5,ML,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,76045-009-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-1660-50,NDC,facility,both,1,ML,,163,114.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VINCRISTINE 2 MG/2 ML IV SOLN,50863,CDM,250,RC,J9370,HCPCS,61703-309-06,NDC,facility,both,1,ML,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,636,RC,J2003,HCPCS,63323-208-01,NDC,facility,both,100,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL IV BOLUS 10MG/ML (ANESTHESIA ONLY),50863,CDM,250,RC,J2704,HCPCS,63323-269-29,NDC,facility,both,20,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYLAMINE SUCCINATE 25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,70677-0068-1,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,14789-128-07,NDC,facility,both,1,ML,,168,117.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE MALEATE 10 MG ORAL TAB,50863,CDM,250,RC,Q0164,HCPCS,59746-115-06,NDC,facility,both,22,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,25,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  20 MEQ ORAL PACK,50863,CDM,250,RC,J3490,HCPCS,69543-451-01,NDC,facility,both,1,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0003-0893-21,NDC,facility,both,2,EA,,119,83.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MVI, ADULT INJECTION (PHS)",50863,CDM,636,RC,J3490,HCPCS,54643-5649-1,NDC,facility,both,1,ML,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2308-21,NDC,facility,both,1,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,40,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIRMATRELVIR-RITONAVIR 150 MG (10)- 100 MG (10) ORAL DSPK,50863,CDM,636,RC,J3490,HCPCS,0069-5317-20,NDC,facility,both,2,EA,,628,439.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 2 MG/ML IV SOLN,50863,CDM,250,RC,J9000,HCPCS,25021-207-51,NDC,facility,both,12,ML,,324,226.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % MUCOSAL SOLN (VISCOUS),50863,CDM,636,RC,J3490,HCPCS,0121-4950-15,NDC,facility,both,1,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,63323-400-01,NDC,facility,both,150,ML,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE 3 MG ORAL CP24,50863,CDM,636,RC,J3490,HCPCS,0574-9855-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,67457-423-00,NDC,facility,both,4,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FINASTERIDE 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,65862-927-30,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,636,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE 21 MG/24 HR TD PT24,50863,CDM,250,RC,J3490,HCPCS,43598-448-71,NDC,facility,both,7,EA,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BARICITINIB 2 MG ORAL TAB (COVID ONLY),50863,CDM,250,RC,J3490,HCPCS,0002-4182-30,NDC,facility,both,2,EA,,790,553,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0591-0407-01,NDC,facility,both,3,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,250,RC,J2704,HCPCS,16714-528-01,NDC,facility,both,3,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6966-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE-PHENYLEPHRINE 4%-0.25% NASAL SPRAY,50863,CDM,636,RC,J3490,HCPCS,0225-0800-47,NDC,facility,both,1,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-497-11,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 200 MG/20 ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,31722-203-20,NDC,facility,both,1,ML,,400,280,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,636,RC,J2560,HCPCS,14789-128-07,NDC,facility,both,2,ML,,224,156.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6966-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,19,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,23155-724-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE HCL 5 MG/5 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,0121-1576-10,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE 25 MG/ML INJ SOLN,50863,CDM,250,RC,J3230,HCPCS,43598-141-11,NDC,facility,both,1,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROGESTERONE MICRONIZED 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,65162-807-10,NDC,facility,both,2,EA,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6780-61,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 30 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,68180-295-09,NDC,facility,both,2,EA,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 0.25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-270-11,NDC,facility,both,2,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-04,NDC,facility,both,4,ML,JZ,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PENICILLIN G BENZATHINE 1200000 UNIT/2 ML IM SYRG,50863,CDM,636,RC,J0561,HCPCS,60793-702-10,NDC,facility,both,24,ML,,2088,1461.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-04,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 10 GRAM/100 ML (10%) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-72,NDC,facility,both,20,ML,"JZ,JA,JG",2829,1980.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously | Modifier JG: Drug or biological acquired with 340b drug pricing program discount
LIDOCAINE 4% TOP PATCH,50863,CDM,250,RC,J3490,HCPCS,70512-812-01,NDC,facility,both,3,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTAMIDINE 300 MG INJ SOLR,50863,CDM,636,RC,J3490,HCPCS,63323-113-01,NDC,facility,both,1,EA,,133,93.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIGOXIN 250 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-5922-61,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,200,ML,,4871,3409.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,636,RC,J0330,HCPCS,31722-981-10,NDC,facility,both,2,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,636,RC,J3490,HCPCS,70004-600-09,NDC,facility,both,3,ML,,138,96.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,636,RC,J1953,HCPCS,63323-400-01,NDC,facility,both,80,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN SODIUM  2 GRAM INJ SOLR,50863,CDM,250,RC,J0290,HCPCS,25021-137-20,NDC,facility,both,4,EA,JZ,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
FUROSEMIDE 10 MG/ML INJ SOLN (NEO),50863,CDM,250,RC,J1938,HCPCS,71288-203-10,NDC,facility,both,150,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,50,ML,,88436,61905.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE (POLACRILEX) 4 MG MM LOZG,50863,CDM,636,RC,J3490,HCPCS,45802-873-03,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",50863,CDM,250,RC,J1561,HCPCS,13533-800-25,NDC,facility,both,40,ML,"JZ,JA",5658,3960.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,16714-046-01,NDC,facility,both,10,ML,JZ,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CIPROFLOXACIN 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7243-61,NDC,facility,both,7,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-360-11,NDC,facility,both,1,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,50863,CDM,J9075,HCPCS,65219-135-20,NDC,,,facility,both,100,EA,,778,544.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,J2003,HCPCS,63323-486-27,NDC,,,facility,both,80,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,636,RC,J2405,HCPCS,23155-547-31,NDC,facility,both,2,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,J3101,HCPCS,50242-037-06,NDC,,,facility,both,34,EA,,6771,4739.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL  32.4 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-6575-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,68094-061-59,NDC,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,J3490,HCPCS,50242-901-09,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,71288-505-02,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6949-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 10 MEQ/100 ML IV PGBK (USE NON-PROTOCOL PANEL),50863,CDM,636,RC,J3480,HCPCS,0338-0709-48,NDC,facility,both,10,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOCARNITINE 200 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0143-9852-01,NDC,facility,both,2,ML,,392,274.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 5 MG/5 ML IV,50863,CDM,636,RC,J3490,HCPCS,63323-660-01,NDC,facility,both,3,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN SODIUM EXTENDED 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,58151-110-32,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,2,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PILOCARPINE 5 MG TAB,50863,CDM,636,RC,J3490,HCPCS,68084-928-95,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAVASTATIN 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-190-11,NDC,facility,both,2,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESNA 100 MG/ML IV SOLN,50863,CDM,636,RC,J9209,HCPCS,10019-953-62,NDC,facility,both,2,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,3,ML,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 150 MG ORAL TBSR,50863,CDM,636,RC,J3490,HCPCS,68084-708-95,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYMETAZOLINE 0.05 % NASAL MERGE,50863,CDM,636,RC,J3490,HCPCS,45802-410-59,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,250,RC,J2270,HCPCS,0409-1891-03,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZTROPINE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-388-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5%-1/2 NORMAL SALINE IV (PEDS ONCOLOGY),50863,CDM,250,RC,J7042,HCPCS,0338-0085-04,NDC,facility,both,2,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,11,EA,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HUMAN PROTHROMBIN COMPLEX 500 UNIT IV SOLR,50863,CDM,250,RC,J7168,HCPCS,63833-396-01,NDC,facility,both,1500,UN,,8729,6110.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE  7.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,57237-007-30,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LURASIDONE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-747-11,NDC,facility,both,2,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,9,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEBIVOLOL  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-641-11,NDC,facility,both,2,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-088-11,NDC,facility,both,5,EA,,539,377.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE IN 0.9% NS (PF) 1 MG/10 ML (100 MCG/ML) IV SYRG(PDS MERGE),50863,CDM,250,RC,J3490,HCPCS,70092-1046-46,NDC,facility,both,1,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,72603-209-01,NDC,facility,both,3,ML,,185,129.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM BROMIDE 0.02 % INHL SOLN,50863,CDM,636,RC,J3490,HCPCS,60687-394-79,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAVASTATIN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-5892-61,NDC,facility,both,3,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML INJ SOLN,50863,CDM,250,RC,J2060,HCPCS,0641-6207-01,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,0088-2220-33,NDC,facility,both,12,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,16714-293-01,NDC,facility,both,7,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML SYRUP,50863,CDM,250,RC,J3490,HCPCS,0121-0638-05,NDC,facility,both,2,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN,50863,CDM,636,RC,J2916,HCPCS,0143-9570-01,NDC,facility,both,10,ML,,374,261.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENAZEPRIL 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-110-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7188-61,NDC,facility,both,3,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6778-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-214-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,J3490,HCPCS,63037-136-25,NDC,,,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,63323-487-37,NDC,facility,both,300,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE (FOR EMERGENCY) 100 MG/ML (10%) IV SOLN,50863,CDM,636,RC,J0612,HCPCS,0143-9180-01,NDC,facility,both,1,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DOBUTAMINE IN D5W 500 MG/250 ML (2 MG/ML) INFUSION (PREMIX),50863,CDM,250,RC,J1250,HCPCS,0409-2347-32,NDC,facility,both,2,ML,,230,161,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,4,EA,,132,92.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,70860-751-02,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 160 MG-800 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0904-2725-61,NDC,facility,both,10,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-119-11,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV,50863,CDM,636,RC,J7120,HCPCS,0990-7953-09,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROTHIAZIDE SODIUM 500 MG IV SOLR,50863,CDM,250,RC,J1205,HCPCS,25021-305-20,NDC,facility,both,1,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,31,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 50% IN WATER (MERGE RECORD),50863,CDM,250,RC,J7060,HCPCS,70092-1475-50,NDC,facility,both,2,ML,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,J1644,HCPCS,63739-931-28,NDC,,,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VECURONIUM BROMIDE 20 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,47335-932-40,NDC,facility,both,1,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,J2003,HCPCS,63323-486-05,NDC,,,facility,both,54,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,50863,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,14,EA,,295,206.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2599,HCPCS,55150-370-01,NDC,facility,both,3,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 500 MG ORAL TAB,50863,CDM,J3490,HCPCS,60687-550-11,NDC,,,facility,both,4,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-161-01,NDC,facility,both,2,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN LYSINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66993-490-36,NDC,facility,both,1,ML,,1235,864.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,J2704,HCPCS,16714-528-01,NDC,,,facility,both,20,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,0409-4279-16,NDC,,,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-132-11,NDC,facility,both,2,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0143-9386-01,NDC,facility,both,46,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VECURONIUM BROMIDE 10 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,0703-2914-01,NDC,facility,both,1,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROPROCAINE 3 % INJ SOLN,50863,CDM,250,RC,J2401,HCPCS,63323-478-01,NDC,facility,both,180,ML,JW,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LEVOTHYROXINE  75 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6951-61,NDC,facility,both,3,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRILAT 1.25 MG/ML IV INJ,50863,CDM,636,RC,J3490,HCPCS,0143-9787-01,NDC,facility,both,2,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 10 MEQ/100 ML IV PGBK (USE NON-PROTOCOL PANEL),50863,CDM,636,RC,J3480,HCPCS,0338-0709-48,NDC,facility,both,20,ML,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 200 MG/20 ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0131-1810-67,NDC,facility,both,1,ML,,429,300.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE 100 MG TAB,50863,CDM,636,RC,J3490,HCPCS,60687-344-95,NDC,facility,both,14,EA,,181,126.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 20 MG ORAL TAB,50863,CDM,250,RC,J8499,HCPCS,60687-380-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAMSULOSIN 0.4 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,0904-7383-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 150 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-711-11,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 30 MG TAB,50863,CDM,250,RC,J3490,HCPCS,60687-717-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,250,RC,J2405,HCPCS,70860-776-41,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CINACALCET 30 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,31722-103-30,NDC,facility,both,3,EA,,390,273,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUPHENAZINE DECANOATE 25 MG/ML INJ SOLN,50863,CDM,250,RC,J2680,HCPCS,42023-129-01,NDC,facility,both,2,ML,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,65219-445-01,NDC,facility,both,2,ML,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-18,NDC,facility,both,100,ML,JZ,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
HYDROXYZINE PAMOATE  25 MG ORAL CAP,50863,CDM,250,RC,Q0177,HCPCS,68084-847-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7367-06,NDC,facility,both,3,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-41,NDC,facility,both,40,ML,,5658,3960.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAMADOL  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,72888-080-01,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,42023-186-20,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5%-LACTATED RINGERS IV,50863,CDM,250,RC,J7120,HCPCS,0264-7751-00,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLN (MERGE)",50863,CDM,250,RC,P9047,HCPCS,64208-2512-8,NDC,facility,both,2,ML,JZ,238,166.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,0409-4264-11,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPRAZOLAM 0.25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-377-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0781-3458-75,NDC,facility,both,500,ML,,404,282.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,10019-506-37,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN  0.4 UNITS/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,42023-219-01,NDC,facility,both,40,ML,,432,302.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,10,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LOSARTAN  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-346-11,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  750 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-882-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6322-06,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN PUMP LISPRO (PATIENT OWN PUMP PHS SUPPLIED),50863,CDM,250,RC,J1815,HCPCS,0002-7510-01,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEMAZEPAM 15 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,50268-779-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),50863,CDM,250,RC,J0171,HCPCS,76329-3318-1,NDC,facility,both,70,ML,,514,359.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,42858-723-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,636,RC,J1100,HCPCS,63323-506-41,NDC,facility,both,10,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-65,NDC,facility,both,6,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CELECOXIB 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6502-61,NDC,facility,both,2,EA,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEPROTUMUMAB-TRBW 500 MG IV SOLR,50863,CDM,636,RC,J3241,HCPCS,75987-130-15,NDC,facility,both,200,EA,,142282,99597.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE IN D5W 1 GRAM/100 ML IV PGBK,50863,CDM,636,RC,J3475,HCPCS,63323-108-00,NDC,facility,both,4,ML,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-495-27,NDC,facility,both,80,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE PEDS IV INFUSION (CDS MIXTURE),50863,CDM,250,RC,61553-149-61,NDC,,,facility,both,0.2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE-DEXTROSE-WATER(PF) 7.5 MG/ML (0.75 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-473-02,NDC,facility,both,2,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 100 MG 24 HR TAB,50863,CDM,636,RC,J3490,HCPCS,50268-542-11,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE IN D5W (PF) 4 MG/ML (0.4 %) IV SOLP,50863,CDM,J3490,HCPCS,0338-0409-03,NDC,,,facility,both,2000,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6292-61,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7188-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 40 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,16714-696-01,NDC,facility,both,1,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1230,HCPCS,67457-217-20,NDC,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68094-005-59,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OFLOXACIN 0.3 % OPHT DROP,50863,CDM,250,RC,J3490,HCPCS,64980-515-05,NDC,facility,both,1,ML,,299,209.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE NA (PRESERV FREE) 25 MG/ML INJ SOLN,50863,CDM,250,RC,J9260,HCPCS,16729-277-35,NDC,facility,both,40,ML,,403,282.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG SUBQ SOLR,50863,CDM,636,RC,J2802,HCPCS,55513-222-01,NDC,facility,both,500,EA,,8780,6146,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE IN D5W 1 GRAM/100 ML IV PGBK,50863,CDM,636,RC,J3475,HCPCS,0338-1709-40,NDC,facility,both,6,ML,,128,89.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,50268-639-11,NDC,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CODEINE-GUAIFENESIN 10-100 MG/5 ML ORAL LIQD (REPACK),50863,CDM,636,RC,J3490,HCPCS,50383-087-10,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
23.4% SODIUM CHLORIDE (4 MEQ/ML) INJECTION,50863,CDM,250,RC,J3490,HCPCS,63323-187-30,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESVENLAFAXINE  50 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,60687-607-11,NDC,facility,both,2,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 10 MEQ/100 ML IV PGBK,50863,CDM,J3480,HCPCS,14789-109-16,NDC,,,facility,both,5,ML,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 875 MG-125 MG TAB,50863,CDM,J3490,HCPCS,81964-221-14,NDC,,,facility,both,1,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,70095-031-01,NDC,facility,both,27,ML,,1070,749,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,327,ME,JZ,4438,3106.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ISOSULFAN BLUE 1 % INJ SOLN,50863,CDM,Q9968,HCPCS,67457-220-00,NDC,,,facility,both,20,ML,,1720,1204,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 20 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-6799-61,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 250 MG INJ SOLR,50863,CDM,J0696,HCPCS,0409-7337-11,NDC,,,facility,both,8,EA,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE   4.2 % IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-083-05,NDC,facility,both,1,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OMEPRAZOLE 10 MG ORAL CPDR,50863,CDM,636,RC,J3490,HCPCS,68462-395-30,NDC,facility,both,2,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRIVIGEN 10 % IV SOLN,50863,CDM,J1459,HCPCS,44206-439-40,NDC,,,facility,both,80,ML,,14352,10046.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,23155-248-01,NDC,facility,both,2,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,0641-6008-01,NDC,facility,both,2,ML,PLAD,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
PHYTONADIONE 10 MG/ML INJ SOLN,50863,CDM,J3430,HCPCS,69097-708-31,NDC,,,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  20 MEQ ORAL PACK,50863,CDM,J3490,HCPCS,72888-024-06,NDC,,,facility,both,1,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0904-6923-61,NDC,facility,both,12,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J3490,HCPCS,63323-208-01,NDC,,,facility,both,100,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORDIAZEPOXIDE 10 MG CAP,50863,CDM,250,RC,J3490,HCPCS,51079-375-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,72603-179-01,NDC,facility,both,9,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM 1 GRAM IV SOLR,50863,CDM,250,RC,J2185,HCPCS,0409-1391-21,NDC,facility,both,10,EA,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLEDRONIC ACID IN MANNITOL & WATER 5 MG/100 ML IV SOLN,50863,CDM,636,RC,J3489,HCPCS,67457-619-10,NDC,facility,both,5,ML,JZ,832,582.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) IV SOLN,50863,CDM,636,RC,J9201,HCPCS,0409-0183-01,NDC,facility,both,1,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,60,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 3000 MCG/ML INJECTION,50863,CDM,250,RC,J0153,HCPCS,67457-855-00,NDC,facility,both,2424,ML,,16787,11750.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 1000 MG MISC TBSO,50863,CDM,250,RC,J3490,HCPCS,904723961,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUPHENAZINE 5 MG TAB,50863,CDM,250,RC,J3490,HCPCS,60687-749-11,NDC,facility,both,2,EA,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,50863,CDM,636,RC,J3420,HCPCS,0517-0031-01,NDC,facility,both,2,ML,JZ,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
METHIMAZOLE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,23155-070-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RALTEGRAVIR 400 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0006-0227-61,NDC,facility,both,2,EA,,339,237.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6638-61,NDC,facility,both,6,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7244-68,NDC,facility,both,5,EA,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,0409-9094-25,NDC,facility,both,3,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,76045-009-10,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,J3490,HCPCS,63037-136-25,NDC,,,facility,both,2,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM  3.375 GRAM IV SOLR,50863,CDM,J2543,HCPCS,65219-436-02,NDC,,,facility,both,3,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0456,HCPCS,70095-025-01,NDC,facility,both,1,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO PROTAM & LISPRO 100 UNIT/ML (75-25) SUBQ SUSP,50863,CDM,250,RC,J1815,HCPCS,0002-7511-01,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,636,RC,Q0162,HCPCS,16714-671-02,NDC,facility,both,2,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-285-01,NDC,facility,both,8,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 500 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,16714-485-01,NDC,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NYSTATIN 100000 UNIT/ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,62135-813-47,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE  5 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,64850-510-01,NDC,facility,both,3,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIPHTH,PERTUS(ACELL),TETANUS SYRG(BOOSTRIX) 2.5-8-5 LF-MCG-LF/0.5ML IM SYRG",50863,CDM,636,RC,90715,HCPCS,58160-842-52,NDC,facility,both,1,ML,,247,172.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/0.5 ML INHL NEBU,50863,CDM,250,RC,J3490,HCPCS,0487-9901-30,NDC,facility,both,24,EA,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,636,RC,J2270,HCPCS,63323-454-00,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 3 MG/ML IV SYRG,50863,CDM,250,RC,J0153,HCPCS,0469-8234-12,NDC,facility,both,6,ML,JZ,212,148.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION,50863,CDM,250,RC,J3490,HCPCS,0186-0370-28,NDC,facility,both,1,GM,,688,481.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LET TOPICAL GEL 3 ML,50863,CDM,250,RC,J3490,HCPCS,70092-1611-44,NDC,facility,both,2,ML,,108,75.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL (VITAMIN D3) 400 UNIT/ML ORAL DROP,50863,CDM,250,RC,J3490,HCPCS,7139974015,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  500 MG IV SOLR,50863,CDM,250,RC,J3370,HCPCS,0409-4332-01,NDC,facility,both,1,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,50863,CDM,J3490,HCPCS,17856-0823-10,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,250,RC,J0330,HCPCS,31722-981-10,NDC,facility,both,4,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,J3101,HCPCS,50242-037-06,NDC,,,facility,both,18,EA,,7778,5444.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJ SOLN",50863,CDM,J3490,HCPCS,0409-1541-10,NDC,,,facility,both,1,ML,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,50863,CDM,636,RC,J9000,HCPCS,25021-207-25,NDC,facility,both,15,ML,JZ,432,302.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
OXYMETAZOLINE 0.05 % NASL SPRA,50863,CDM,250,RC,J3490,HCPCS,4110081125,NDC,facility,both,2,ML,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG/ML INJ SOLN,50863,CDM,250,RC,J2550,HCPCS,0641-6084-25,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOZAPINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-921-01,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MYCOPHENOLATE SODIUM 360 MG ORAL TBEC,50863,CDM,250,RC,J7518,HCPCS,72888-200-12,NDC,facility,both,4,EA,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENTACAPONE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,27241-049-10,NDC,facility,both,1,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLECAINIDE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-0010-20,NDC,facility,both,3,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-559-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,42806-150-33,NDC,facility,both,5,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,0143-9682-01,NDC,facility,both,8,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCRELIZUMAB 30 MG/ML IV SOLN,50863,CDM,636,RC,J2350,HCPCS,50242-150-01,NDC,facility,both,300,ME,JZ,44850,31395,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ATORVASTATIN 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6292-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL (VITAMIN D3)   400 UNIT ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,7733394825,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0555-0873-02,NDC,facility,both,4,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML INJ SOLN,50863,CDM,J0171,HCPCS,76329-9060-0,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25 MG-250 MG TAB,50863,CDM,250,RC,J3490,HCPCS,50228-459-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 0.5 MG/ML ORAL SUSPENSION (REPACK),50863,CDM,250,RC,J7507,HCPCS,51079-028-01,NDC,facility,both,4,EA,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,67877-545-68,NDC,facility,both,10,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN SODIUM  2 GRAM INJ SOLR,50863,CDM,636,RC,J0290,HCPCS,0781-3408-80,NDC,facility,both,4,EA,JZ,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
AMLODIPINE 1 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,46287-035-15,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J0461,HCPCS,0517-0401-25,NDC,facility,both,120,ML,,160,112,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,120,ML,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAZOSIN 5 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-572-33,NDC,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) IN 0.9 % NACL 1 MG/ML IV SOLN,50863,CDM,250,RC,J2250,HCPCS,0143-9379-01,NDC,facility,both,50,ML,,130,91,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR PHOSPHATE 30 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,64380-797-01,NDC,facility,both,9,EA,,460,322,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL,50863,CDM,250,RC,J3490,HCPCS,63323-820-01,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM POLYSTYRENE SULFONATE ORAL POWDER,50863,CDM,250,RC,J3490,HCPCS,10702-036-15,NDC,facility,both,1,GM,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,636,RC,Q9968,HCPCS,70710-1838-1,NDC,facility,both,40,ML,JW,226,158.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,50863,CDM,J0561,HCPCS,60793-701-02,NDC,,,facility,both,12,ML,,1307,914.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 50 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,10135-779-01,NDC,facility,both,50,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LURASIDONE  60 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7357-61,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE DINITRATE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0781-1695-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAZOLAMIDE 500 MG ORAL CPSR,50863,CDM,250,RC,J3490,HCPCS,29033-030-01,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-5755-23,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 0.1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,23155-489-01,NDC,facility,both,1,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN  325 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,0536-1232-01,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6927-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM NEO/PED INFUSION (CDS MIXTURE),50863,CDM,250,RC,J2185,HCPCS,0781-3267-90,NDC,facility,both,2,EA,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MOXIFLOXACIN 400 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-722-11,NDC,facility,both,1,EA,,132,92.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOVASTATIN 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68180-468-07,NDC,facility,both,2,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6376-61,NDC,facility,both,1,EA,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 300 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,65162-649-78,NDC,facility,both,1,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,636,RC,J2704,HCPCS,25021-608-20,NDC,facility,both,10,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE (3 MONTH) 22.5 MG IM SYRG,50863,CDM,636,RC,J9217,HCPCS,0074-3346-03,NDC,facility,both,3,EA,,1176,823.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZTROPINE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7289-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,76329-3352-1,NDC,facility,both,6,ML,,631,441.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2308-21,NDC,facility,both,10,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MORPHINE (PF) IN 0.9 % NACL 1 MG/ML VENT INFUSION,50863,CDM,250,RC,J2274,HCPCS,70092-1522-35,NDC,facility,both,5,ML,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-3178-01,NDC,facility,both,1,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0093-2279-73,NDC,facility,both,5,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,250,RC,J2405,HCPCS,60505-6130-5,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6418-61,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-744-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,50863,CDM,250,RC,J9075,HCPCS,0781-3244-94,NDC,facility,both,400,EA,,3791,2653.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 650 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,66553-008-01,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,636,RC,J7510,HCPCS,17856-0815-1,NDC,facility,both,3,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 500 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,50268-152-11,NDC,facility,both,30,EA,,180,126,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,636,RC,J2560,HCPCS,0641-0476-21,NDC,facility,both,3,ML,,470,329,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM  50 MG INJ SOLR,50863,CDM,250,RC,J0640,HCPCS,25021-813-10,NDC,facility,both,2,EA,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIPASE-PROTEASE-AMYLASE 12,000-38,000- 60,000 UNIT ORAL CAP, DELAY REL",50863,CDM,250,RC,J3490,HCPCS,0032-0047-70,NDC,facility,both,5,EA,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,50863,CDM,636,RC,J3301,HCPCS,70121-1049-2,NDC,facility,both,2,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEG 400-PROPYLENE GLYCOL 0.4-0.3 % OPHT DRPG,50863,CDM,250,RC,J3490,HCPCS,0065-0454-07,NDC,facility,both,1,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,6,ML,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 112 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42292-039-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  60 MG ORAL CS24,50863,CDM,250,RC,J3490,HCPCS,0527-4116-37,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-086-01,NDC,facility,both,3,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),50863,CDM,250,RC,J0171,HCPCS,76329-3318-1,NDC,facility,both,160,ML,,1291,903.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZATHIOPRINE  50 MG ORAL TAB,50863,CDM,636,RC,J7500,HCPCS,68084-229-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-1283-03,NDC,facility,both,20,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE (PF) 1000 MCG/10 ML EPID SOLN,50863,CDM,250,RC,J0735,HCPCS,39822-2000-1,NDC,facility,both,1,ML,PLAD,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
OSELTAMIVIR  6 MG/ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,68180-678-01,NDC,facility,both,3,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 400 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-602-11,NDC,facility,both,3,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROTHIAZIDE SODIUM 500 MG IV SOLR,50863,CDM,250,RC,J1205,HCPCS,25021-305-20,NDC,facility,both,1,EA,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM  1.5 GRAM INJ SOLR,50863,CDM,636,RC,J0295,HCPCS,0641-6116-01,NDC,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL (VITAMIN D3) 400 UNIT/ML ORAL DROP,50863,CDM,250,RC,J3490,HCPCS,7651805050,NDC,facility,both,2,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7111-61,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM IN NACL (ISO-OS) 1000 MG/100 ML IV PGBK,50863,CDM,636,RC,J1953,HCPCS,36000-356-01,NDC,facility,both,200,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,63323-185-07,NDC,facility,both,4,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 150 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,0904-7084-04,NDC,facility,both,3,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPAGLIFLOZIN PROPANEDIOL 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0310-6210-39,NDC,facility,both,1,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,636,RC,J7510,HCPCS,17856-0815-1,NDC,facility,both,4,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMILORIDE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,49884-117-01,NDC,facility,both,2,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J3430,HCPCS,0409-9158-31,NDC,facility,both,2,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PALIPERIDONE PALMITATE 117 MG/0.75 ML IM SYRG,50863,CDM,636,RC,J2426,HCPCS,50458-562-01,NDC,facility,both,234,ML,JZ,9851,6895.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
QUETIAPINE 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,67877-246-01,NDC,facility,both,2,EA,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 0.2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60505-0258-1,NDC,facility,both,2,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,50863,CDM,250,RC,J9045,HCPCS,0703-4239-01,NDC,facility,both,6,ML,,141,98.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,250,RC,J3490,HCPCS,73013-2002-2,NDC,facility,both,4,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,3,ML,,5385,3769.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE IN D5W 1 GRAM/100 ML IV PGBK,50863,CDM,250,RC,J3475,HCPCS,63323-108-00,NDC,facility,both,15,ML,,408,285.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OMALIZUMAB 150 MG SUBQ SOLR,50863,CDM,636,RC,J2357,HCPCS,50242-040-62,NDC,facility,both,45,ME,JZ,3914,2739.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SODIUM CHLORIDE 0.9 % IR SOLN,50863,CDM,J3490,HCPCS,0338-0047-46,NDC,,,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 400 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0143-9887-01,NDC,facility,both,15,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE IN 0.9% NS (PF) 1 MG/10 ML (100 MCG/ML) IV SYRG(PDS MERGE),50863,CDM,250,RC,J3490,HCPCS,71266-9011-1,NDC,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TELMISARTAN 40 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68382-472-30,NDC,facility,both,2,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG/ML INJ SOLN,50863,CDM,250,RC,J2550,HCPCS,0641-6208-01,NDC,facility,both,1,ML,PLAD,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
AZITHROMYCIN 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7351-04,NDC,facility,both,4,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VORICONAZOLE 200 MG IV SOLN,50863,CDM,250,RC,J3465,HCPCS,0781-3416-94,NDC,facility,both,45,EA,,1236,865.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PALONOSETRON 0.25 MG/5 ML IV INJECTION (MERGE),50863,CDM,250,RC,J2469,HCPCS,55111-694-07,NDC,facility,both,10,ML,,255,178.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM ACETATE 667 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,68084-479-11,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 20 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,0904-7043-04,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN (PF) 10 MG/ML INJECTION (NEONATAL IM USE),50863,CDM,250,RC,J1580,HCPCS,63323-173-02,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  20 MEQ ORAL PACK,50863,CDM,250,RC,J3490,HCPCS,0245-0360-89,NDC,facility,both,2,EA,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CELECOXIB 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-436-11,NDC,facility,both,2,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25 MG-100 MG TAB,50863,CDM,636,RC,J3490,HCPCS,59651-457-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMANTADINE 50 MG/5 ML ORAL SYRP,50863,CDM,250,RC,J3490,HCPCS,0121-0646-10,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,50863,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,6,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6475-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 400 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-602-11,NDC,facility,both,3,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-453-11,NDC,facility,both,5,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM  3 GRAM INJ SOLR,50863,CDM,636,RC,J0295,HCPCS,66794-207-02,NDC,facility,both,2,EA,JZ,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MORPHINE  10 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0054-0237-63,NDC,facility,both,3,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,10,ML,PLAD,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
DEXTROSE 50% IN WATER (MERGE RECORD),50863,CDM,250,RC,J7060,HCPCS,0409-6648-02,NDC,facility,both,2,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0143-9595-01,NDC,facility,both,300,ML,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,0075-0622-01,NDC,facility,both,5,ML,JW,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DOCUSATE SODIUM 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,57896-401-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,43547-688-10,NDC,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUANFACINE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,24979-198-01,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATENOLOL  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-759-01,NDC,facility,both,3,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2310,HCPCS,0409-1215-21,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL (VITAMIN D3)  1000 UNIT ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,2055503300,NDC,facility,both,5,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,67877-432-03,NDC,facility,both,2,EA,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,43598-053-11,NDC,facility,both,30,ML,,1087,760.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE (FOR CODE) 10% (100 MG/ML) IV SYRINGE,50863,CDM,250,RC,J3490,HCPCS,64253-900-30,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4% TOP PATCH,50863,CDM,250,RC,J3490,HCPCS,46581-830-06,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,2,EA,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCRALFATE 1 GRAM ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-753-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPTOMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0878,HCPCS,72603-152-01,NDC,facility,both,400,EA,,1170,819,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0780,HCPCS,23155-294-31,NDC,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-620-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERTAPENEM 1 GRAM INJ SOLR,50863,CDM,250,RC,J1335,HCPCS,16714-889-01,NDC,facility,both,8,EA,,2100,1470,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OMEPRAZOLE-SODIUM BICARBONATE 2-84 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,65628-270-03,NDC,facility,both,3,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-406-03,NDC,facility,both,1,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,250,RC,J2270,HCPCS,0641-6125-01,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3370,HCPCS,0143-9162-01,NDC,facility,both,1,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BEZLOTOXUMAB 25 MG/ML IV SOLN,50863,CDM,250,RC,J0565,HCPCS,0006-3025-01,NDC,facility,both,100,ML,,10488,7341.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TERAZOSIN  5 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,59746-385-06,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 250 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,60687-868-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE HCL  2 % MM JELP,50863,CDM,636,RC,J3490,HCPCS,76329-3012-5,NDC,facility,both,1,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/0.5 ML INHL NEBU,50863,CDM,250,RC,J3490,HCPCS,0487-9901-30,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-48,NDC,facility,both,1,ML,JZ,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,636,RC,P9045,HCPCS,68516-5219-0,NDC,facility,both,12,ML,JZ,3050,2135,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,74,EA,,10212,7148.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PYRAZINAMIDE 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,61748-012-06,NDC,facility,both,4,EA,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),50863,CDM,250,RC,J2060,HCPCS,0641-6044-01,NDC,facility,both,2,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE 0.5 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,63323-463-01,NDC,facility,both,1,ML,,107,74.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TORSEMIDE   5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-754-11,NDC,facility,both,4,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,250,RC,J3101,HCPCS,50242-037-06,NDC,facility,both,22,EA,,10077,7053.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2305-16,NDC,facility,both,6,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROPROCAINE 3 % INJ SOLN,50863,CDM,250,RC,J2401,HCPCS,63323-478-01,NDC,facility,both,51,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEMAZEPAM 15 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,67877-146-01,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 150 MG/1 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0955-1015-01,NDC,facility,both,14,ML,,170,119,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,50863,CDM,250,RC,J9075,HCPCS,10019-956-16,NDC,facility,both,149,EA,,965,675.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALSARTAN  80 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-623-11,NDC,facility,both,2,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-41,NDC,facility,both,80,ML,"JZ,JA,JG",11316,7921.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously | Modifier JG: Drug or biological acquired with 340b drug pricing program discount
MIDODRINE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6818-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,0641-6145-01,NDC,facility,both,14,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,60,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,73293-0001-1,NDC,facility,both,50,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-346-11,NDC,facility,both,2,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALUM-MAG HYDROXIDE-SIMETH 200 MG-200 MG-20 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0536-1317-83,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MYCOPHENOLATE SODIUM 360 MG ORAL TBEC,50863,CDM,250,RC,J7518,HCPCS,68084-918-95,NDC,facility,both,2,EA,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,4,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DICLOFENAC 50 MG TAB, DELAYED RELEASE",50863,CDM,250,RC,J3490,HCPCS,16571-202-10,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-683-02,NDC,facility,both,2,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J2312,HCPCS,36000-308-01,NDC,facility,both,200,ML,,167,116.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORATADINE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6852-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICLOXACILLIN 250 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,59651-565-01,NDC,facility,both,12,EA,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE (FOR EMERGENCY) 100 MG/ML (10%) IV SOLN,50863,CDM,250,RC,J0612,HCPCS,63323-360-05,NDC,facility,both,1000,ML,,275,192.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-090-11,NDC,facility,both,1,EA,,150,105,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2310,HCPCS,0409-1215-21,NDC,facility,both,1,ML,,233,163.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-590-11,NDC,facility,both,1,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  75 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-495-11,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-1283-31,NDC,facility,both,10,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 100 MG/ML INJ SOLN,50863,CDM,636,RC,J2800,HCPCS,55150-223-10,NDC,facility,both,1,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIFEDIPINE 60 MG ORAL TO24,50863,CDM,250,RC,J3490,HCPCS,50268-598-11,NDC,facility,both,2,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION,50863,CDM,250,RC,J3490,HCPCS,0310-7372-20,NDC,facility,both,1,GM,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG/24 HR TD PTWK,50863,CDM,636,RC,J3490,HCPCS,0378-0871-16,NDC,facility,both,1,EA,,162,113.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,25021-463-01,NDC,facility,both,3,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL (5 MG/ML) IV SYRG (CONTAINS PRESERVATIVE),50863,CDM,250,RC,J3490,HCPCS,0409-2339-24,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DASATINIB  20 MG ORAL TAB,50863,CDM,250,RC,J9999,HCPCS,60505-3628-6,NDC,facility,both,7,EA,,3097,2167.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE LAUROXIL 662 MG/2.4 ML IM SERS,50863,CDM,250,RC,J1944,HCPCS,65757-402-03,NDC,facility,both,662,ML,,6592,4614.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE 2 MG SL SUBL,50863,CDM,636,RC,J3490,HCPCS,60687-481-11,NDC,facility,both,15,EA,,180,126,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,0904-6794-80,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID (PORK)  60 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,75834-312-01,NDC,facility,both,2,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60505-3113-0,NDC,facility,both,2,EA,,195,136.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7008-61,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0406-0552-23,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IV PGBK,50863,CDM,250,RC,J3490,HCPCS,0338-1708-40,NDC,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,46,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM ACETATE 2 MEQ/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-3299-15,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,83,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50111-398-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,62584-994-11,NDC,facility,both,4,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOXYBENZAMINE 10 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,66993-066-02,NDC,facility,both,3,EA,,1146,802.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE IN D5W 1 GRAM/100 ML IV PGBK,50863,CDM,250,RC,J3475,HCPCS,63323-108-00,NDC,facility,both,4,ML,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,50863,CDM,636,RC,J0561,HCPCS,60793-701-02,NDC,facility,both,24,ML,JZ,2160,1512,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PREDNISONE 20 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,60687-145-11,NDC,facility,both,80,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,50863,CDM,250,RC,J9025,HCPCS,72485-201-01,NDC,facility,both,136,EA,,1930,1351,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J2312,HCPCS,67457-599-00,NDC,facility,both,40,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM  4.5 GRAM IV SOLR,50863,CDM,250,RC,J2543,HCPCS,65219-259-45,NDC,facility,both,4,EA,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE ENEMA 200G IN SW (1000 ML TOTAL VOLUME),50863,CDM,250,RC,J3490,HCPCS,99999-0405-41,NDC,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0075-0622-01,NDC,facility,both,5,ML,JW,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
BELIMUMAB 400 MG IV SOLR,50863,CDM,636,RC,J0490,HCPCS,49401-102-01,NDC,facility,both,4,EA,"JW,JA",194,135.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,50863,CDM,250,RC,J3420,HCPCS,70069-005-10,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GOLIMUMAB  12.5 MG/ML IV SOLN,50863,CDM,636,RC,J1602,HCPCS,57894-350-01,NDC,facility,both,138,ML,,15230,10661,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6084-61,NDC,facility,both,3,EA,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE  1 % TOP OINT,50863,CDM,250,RC,J3490,HCPCS,45802-276-03,NDC,facility,both,1,GM,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  250 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7123-61,NDC,facility,both,18,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-582-11,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GANCICLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J1570,HCPCS,25021-185-10,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PALIPERIDONE PALMITATE 234 MG/1.5 ML IM SYRG,50863,CDM,636,RC,J2426,HCPCS,50458-564-01,NDC,facility,both,234,ML,,9602,6721.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 500 MG PE/10 ML INJ SOLN,50863,CDM,250,RC,Q2009,HCPCS,0409-4857-02,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIOGLITAZONE 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65862-512-30,NDC,facility,both,2,EA,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 500 MG INJ SOLR,50863,CDM,636,RC,J0696,HCPCS,0409-7338-11,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLECAINIDE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-0011-20,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 1 MG/ML (1ML) SYRINGE (REPACK),50863,CDM,250,RC,J2997,HCPCS,50242-044-13,NDC,facility,both,3,EA,,973,681.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROTHIAZIDE SODIUM 500 MG IV SOLR,50863,CDM,250,RC,J1205,HCPCS,0517-1820-01,NDC,facility,both,1,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 20 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,0904-7043-04,NDC,facility,both,2,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,50863,CDM,636,RC,J0585,HCPCS,0023-1145-01,NDC,facility,both,80,EA,JZ,1279,895.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),50863,CDM,250,RC,J0171,HCPCS,76329-3318-1,NDC,facility,both,80,ML,,646,452.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-426-02,NDC,facility,both,3,ML,,113,79.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,250,RC,J2704,HCPCS,25021-608-20,NDC,facility,both,20,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE (POLACRILEX) 2 MG BUCL GUM,50863,CDM,636,RC,J3490,HCPCS,70677-1166-2,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,63323-806-13,NDC,facility,both,10,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,55150-161-02,NDC,facility,both,80,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VERAPAMIL 120 MG ORAL TBSR,50863,CDM,636,RC,J3490,HCPCS,68462-292-01,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  500 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,68462-897-01,NDC,facility,both,20,ML,JZ,214,149.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ROSUVASTATIN 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6781-61,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,50863,CDM,636,RC,J0696,HCPCS,44567-701-25,NDC,facility,both,4,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE HCL  2 % MM JELP,50863,CDM,250,RC,J3490,HCPCS,25021-673-76,NDC,facility,both,4,ML,,140,98,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG RECT SUPP,50863,CDM,250,RC,J3490,HCPCS,0713-0164-06,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,190,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PHENOBARBITAL  97.2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,75826-142-10,NDC,facility,both,2,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GRANISETRON 1 MG/ML (1 ML) IV SOLN,50863,CDM,250,RC,J1626,HCPCS,0143-9744-01,NDC,facility,both,6,ML,JW,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,J0690,HCPCS,60505-6142-0,NDC,,,facility,both,16,EA,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZONATATE 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7153-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 500 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,16714-299-03,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,250,RC,J2003,HCPCS,63323-485-27,NDC,facility,both,220,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COLESEVELAM 625 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-385-95,NDC,facility,both,3,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTAMIDINE 300 MG INJ SOLR,50863,CDM,636,RC,J3490,HCPCS,63323-113-01,NDC,facility,both,1,EA,,192,134.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE MONONITRATE  60 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,0904-6450-61,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 10 GRAM/15 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,66689-038-01,NDC,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6950-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,8,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0780,HCPCS,25021-790-02,NDC,facility,both,1,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUANFACINE 1 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,62332-745-31,NDC,facility,both,1,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN  4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51672-4031-1,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-439-11,NDC,facility,both,6,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 10 GRAM/100 ML (10%) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-72,NDC,facility,both,20,ML,"JG,JZ,JA",2829,1980.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
INSULIN NPH & REGULAR HUMAN 100 UNIT/ML (70-30) SUBQ SUSP,50863,CDM,636,RC,J1815,HCPCS,0002-8715-01,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,636,RC,J0330,HCPCS,69374-919-10,NDC,facility,both,16,ML,,155,108.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM NEO/PEDS (CDS MIXTURE),50863,CDM,636,RC,J0295,HCPCS,63323-368-20,NDC,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J3490,HCPCS,0338-0049-48,NDC,facility,both,4,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE 14 MG/24 HR TD PT24,50863,CDM,250,RC,J3490,HCPCS,1093986244,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 150 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,0904-7505-61,NDC,facility,both,2,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOZAPINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0378-0860-01,NDC,facility,both,2,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 500 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,50268-152-11,NDC,facility,both,12,EA,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"HEPARIN, PORCINE (PF) 1 UNIT/ML IV SYRG NEONATE",50863,CDM,250,RC,J1642,HCPCS,6425344425,NDC,facility,both,2,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM ZIRCONIUM CYCLOSILICATE  5 G ORAL PWPK (USE PANEL),50863,CDM,250,RC,J3490,HCPCS,0310-1105-01,NDC,facility,both,3,EA,,418,292.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,1657187290,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETIRIZINE 5 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,68094-004-59,NDC,facility,both,2,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6665-61,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYTARABINE 100 MG/ML INJ SOLN,50863,CDM,636,RC,J9100,HCPCS,63323-120-20,NDC,facility,both,20,ML,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYUREA  500 MG ORAL CAP,50863,CDM,250,RC,J9999,HCPCS,0904-6939-61,NDC,facility,both,2,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYMETAZOLINE 0.05 % NASAL MERGE,50863,CDM,636,RC,J3490,HCPCS,0573-1191-20,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-349-11,NDC,facility,both,1,EA,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIGOXIN 125 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-5921-61,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXRAZOXANE 500 MG IV SOLR,50863,CDM,250,RC,J1190,HCPCS,0143-9248-01,NDC,facility,both,7,EA,,5208,3645.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROPRUSSIDE 25 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,70436-028-80,NDC,facility,both,1,ML,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,2,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,636,RC,J3490,HCPCS,0641-6236-01,NDC,facility,both,2,ML,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.1 % NASAL SOLN,50863,CDM,636,RC,J3490,HCPCS,42023-103-01,NDC,facility,both,1,ML,,888,621.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,250,RC,J2405,HCPCS,60505-6130-5,NDC,facility,both,4,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
VANCOMYCIN IN 0.9 % SODIUM CHL 2 GRAM/500 ML IV SOLN,50863,CDM,250,RC,J3373,HCPCS,71506-019-59,NDC,facility,both,200,ML,,148,103.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,76045-009-96,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,250,RC,J1596,HCPCS,0143-9679-01,NDC,facility,both,8,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,250,RC,J2270,HCPCS,0409-1890-03,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE (FOR CODE) 10% IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0517-6710-01,NDC,facility,both,1,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,250,RC,J0330,HCPCS,31722-981-10,NDC,facility,both,5,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,23155-832-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTOBARBITAL 75 MG/1.5 ML SYRINGE (REPACK),50863,CDM,636,RC,J3490,HCPCS,25021-676-20,NDC,facility,both,2,ML,,126,88.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 50% IN WATER (MERGE RECORD),50863,CDM,636,RC,J7060,HCPCS,70092-1475-50,NDC,facility,both,1,ML,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM NEO/PEDS INFUSION (CDS MIXTURE),50863,CDM,250,RC,J2543,HCPCS,0206-8852-08,NDC,facility,both,2,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,68462-755-01,NDC,facility,both,1,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LEVOTHYROXINE 100 MCG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,63323-649-07,NDC,facility,both,1,EA,,520,364,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IV PGBK,50863,CDM,250,RC,J3475,HCPCS,44567-420-00,NDC,facility,both,4,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETHYL ALCOHOL  99 % IART SOLN,50863,CDM,250,RC,J3490,HCPCS,54288-105-02,NDC,facility,both,8,ML,,18391,12873.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,J1815,HCPCS,83257-014-11,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7007-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-3426-01,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYPROHEPTADINE 4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0115-1757-01,NDC,facility,both,3,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-559-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 10 MEQ/100 ML IV PGBK (USE NON-PROTOCOL PANEL),50863,CDM,250,RC,J3480,HCPCS,0338-0709-48,NDC,facility,both,5,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50111-561-01,NDC,facility,both,3,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 100 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,31722-574-47,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,13,EA,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 125 MG ORAL CPSP,50863,CDM,250,RC,J3490,HCPCS,68084-313-11,NDC,facility,both,4,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 500 MCG INJ SOLR,50863,CDM,636,RC,J3490,HCPCS,63323-648-10,NDC,facility,both,2,EA,,2915,2040.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-3426-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUORESCEIN 1 MG OPHT STRP,50863,CDM,636,RC,J3490,HCPCS,8385110001,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6519-61,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,72888-037-01,NDC,facility,both,2,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6519-61,NDC,facility,both,3,EA,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,50863,CDM,250,RC,J9060,HCPCS,63323-103-65,NDC,facility,both,12,ML,,281,196.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNITS/1 GRAM PACKET (MERGE RECORD),50863,CDM,250,RC,J3490,HCPCS,57896-145-09,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL  1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-734-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALTREXONE 50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-1170-03,NDC,facility,both,1,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIPHTH,PERTUS(ACELL),TETANUS SYRG(BOOSTRIX) 2.5-8-5 LF-MCG-LF/0.5ML IM SYRG",50863,CDM,636,RC,90715,HCPCS,58160-842-43,NDC,facility,both,1,ML,GZ,240,168,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier GZ: Item or service expected to be denied as not reasonable and necessary
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,250,RC,J3490,HCPCS,0143-9679-01,NDC,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,50863,CDM,250,RC,J2359,HCPCS,0781-3159-72,NDC,facility,both,40,EA,,406,284.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6799-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TERAZOSIN  2 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,59746-384-06,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NORETHINDRONE ACETATE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68462-304-50,NDC,facility,both,3,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYTARABINE 100 MG/ML INJ SOLN,50863,CDM,250,RC,J9100,HCPCS,61703-319-22,NDC,facility,both,80,ML,,477,333.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-02,NDC,facility,both,1,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,51754-5001-1,NDC,facility,both,3,ML,,129,90.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACIDOPHILUS-PECTIN W CITRUS 25 MILLION-100 CELL MG TAB,50863,CDM,636,RC,J3490,HCPCS,17856002601,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 2 TABLET
VALPROIC ACID 250 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,63739-086-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,27,EA,,3726,2608.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICLOFENAC 1 % TOPICAL GEL,50863,CDM,250,RC,J3490,HCPCS,67120176,NDC,facility,both,1,GM,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCUSATE SODIUM 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7280-60,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML (PEDS CALCLUATOR 0.5),50863,CDM,636,RC,J1815,HCPCS,0024-5924-10,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 600 MG ORAL TP12,50863,CDM,250,RC,J3490,HCPCS,0536-1163-61,NDC,facility,both,14,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL,50863,CDM,636,RC,J1071,HCPCS,0143-9659-01,NDC,facility,both,100,ML,JW,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PIOGLITAZONE 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,33342-054-10,NDC,facility,both,1,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-318-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZOCAINE-MENTHOL 20-0.26 % MM GEL,50863,CDM,250,RC,J3490,HCPCS,1031043028,NDC,facility,both,1,GM,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUORESCEIN 500 MG/5 ML (10 %) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0065-0092-65,NDC,facility,both,1,ML,,263,184.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITRIOL 1 MCG/ML IV SOLN,50863,CDM,250,RC,J0636,HCPCS,17478-931-01,NDC,facility,both,10,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,16714-293-03,NDC,facility,both,3,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN IN D5W 400 MG/200 ML IV PGBK,50863,CDM,636,RC,J0744,HCPCS,25021-192-87,NDC,facility,both,2,ML,JZ,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DAPTOMYCIN 500 MG IV SOLR,50863,CDM,636,RC,J0878,HCPCS,0409-0122-01,NDC,facility,both,700,EA,,563,394.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE   4.2 % IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-083-05,NDC,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLIPIZIDE  5 MG ORAL TO24,50863,CDM,636,RC,J3490,HCPCS,68084-111-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLN,50863,CDM,250,RC,J3262,HCPCS,50242-137-01,NDC,facility,both,800,ML,JA,14661,10262.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
IBUPROFEN 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7912-59,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  500 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,0641-6176-01,NDC,facility,both,4,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 50 % (4 MEQ/ML) INJ SOLN,50863,CDM,636,RC,J3475,HCPCS,63323-064-01,NDC,facility,both,4,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FERRIC DERISOMALTOSE 100 MG IRON/ML IV SOLN,50863,CDM,636,RC,J1437,HCPCS,73594-9310-1,NDC,facility,both,100,ML,JZ,8962,6273.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CLOBAZAM 2.5 MG/ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,99999-0404-03,NDC,facility,both,3,ML,,142,99.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BICALUTAMIDE 50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16729-023-10,NDC,facility,both,1,EA,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GRANISETRON 1 MG/ML (1 ML) IV SOLN,50863,CDM,636,RC,J1626,HCPCS,0143-9744-01,NDC,facility,both,6,ML,JW,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
MYCOPHENOLATE SODIUM 360 MG ORAL TBEC,50863,CDM,250,RC,J7518,HCPCS,68084-918-95,NDC,facility,both,6,EA,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J1940,HCPCS,72603-251-01,NDC,facility,both,6,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0003-0894-70,NDC,facility,both,1,EA,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,72603-251-01,NDC,facility,both,2,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SOTALOL  80 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-654-11,NDC,facility,both,2,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZOCAINE-MENTHOL 6-10 MG MM LOZG,50863,CDM,250,RC,J3490,HCPCS,7811201106,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ESMOLOL IN SALINE (ISO-OSMOTIC) 2,500 MG/250 ML (10 MG/ML) IV",50863,CDM,636,RC,J1805,HCPCS,25021-308-84,NDC,facility,both,1,ML,,713,499.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIPASE-PROTEASE-AMYLASE 24,000-76,000- 120,000 UNIT ORAL CAP, DELAY REL",50863,CDM,250,RC,J3490,HCPCS,0032-2636-01,NDC,facility,both,6,EA,,252,176.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-02,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"CALCIUM GLUC IN NACL, ISO-OSM 1 G/100 ML IV SOLN",50863,CDM,J0612,HCPCS,44567-622-01,NDC,,,facility,both,100,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,904518206,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISATRACURIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0781-3153-80,NDC,facility,both,2,ML,,2016,1411.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,0409-3178-16,NDC,,,facility,both,160,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAMADOL  50 MG ORAL TAB,50863,CDM,J3490,HCPCS,60687-795-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,250,RC,J2405,HCPCS,60505-6130-5,NDC,facility,both,2,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
TERAZOSIN  2 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,51079-937-01,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,J2919,HCPCS,0009-0047-03,NDC,,,facility,both,25,EA,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ (MERGE),50863,CDM,J2250,HCPCS,0409-0001-01,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,50863,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,9,ML,,187,130.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2312,HCPCS,67457-299-00,NDC,facility,both,20,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,J7512,HCPCS,60687-145-11,NDC,,,facility,both,20,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN SODIUM EXTENDED 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0071-0369-24,NDC,facility,both,2,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,J1885,HCPCS,72611-722-25,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SULFASALAZINE 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,59762-5000-5,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOCARNITINE 200 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0143-9852-01,NDC,facility,both,1,ML,,210,147,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,57664-507-88,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUM U-500 CONC 500 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1815,HCPCS,0002-8501-01,NDC,facility,both,1,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,63739-903-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 1 % OPHT DROP,50863,CDM,250,RC,J3490,HCPCS,60219-1748-2,NDC,facility,both,1,ML,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 300 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,69452-125-50,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG-10,000 UNIT/G-0.1 % EYE OINTMENT",50863,CDM,250,RC,J3490,HCPCS,61314-631-36,NDC,facility,both,1,GM,,216,151.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,636,RC,J2270,HCPCS,76045-004-10,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-9791-01,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IN NS 500 ML IRRIGATION (REPACK),50863,CDM,250,RC,J3370,HCPCS,99999-0406-16,NDC,facility,both,1,ML,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE  10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69367-388-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60505-3113-0,NDC,facility,both,1,EA,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J3430,HCPCS,43598-405-11,NDC,facility,both,10,ME,,218,152.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE (PF-DURAMORPH/ASTRAMORPH) 0.5 MG/ML INJ SOLN,50863,CDM,636,RC,J2274,HCPCS,0409-3814-12,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOZAPINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0378-0860-01,NDC,facility,both,3,EA,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1940,HCPCS,63323-280-03,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXERCALCIFEROL 4 MCG/2 ML IV SOLN,50863,CDM,250,RC,J1270,HCPCS,71288-802-02,NDC,facility,both,4,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-466-03,NDC,facility,both,50,ML,JW,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7050,HCPCS,0264-1800-32,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,23155-902-01,NDC,facility,both,3,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-5771-23,NDC,facility,both,14,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN 125 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,51672-4069-1,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 400 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-602-11,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 100 % ORAL POWDER 238 GRAMS,50863,CDM,250,RC,J3490,HCPCS,45802-868-02,NDC,facility,both,1,GM,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE 150 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,68084-713-11,NDC,facility,both,2,EA,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN STERILE WATER 2 GRAM/20 ML IV SYRG,50863,CDM,636,RC,J0690,HCPCS,70092-1604-47,NDC,facility,both,4,ML,,30594,21415.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,63323-482-03,NDC,,,facility,both,80,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROATE SODIUM 100 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-494-01,NDC,facility,both,2,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 1 MG ORAL TAB,50863,CDM,250,RC,J8540,HCPCS,72578-166-01,NDC,facility,both,12,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZONATATE 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,42806-714-01,NDC,facility,both,2,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLPIDEM  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-189-11,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 1 GRAM INJ SOLR,50863,CDM,636,RC,J0692,HCPCS,60505-6146-0,NDC,facility,both,2,EA,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J2004,HCPCS,0409-3178-01,NDC,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 100 MG ORAL CHEW,50863,CDM,636,RC,J3490,HCPCS,0904-3854-61,NDC,facility,both,4,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,16714-026-01,NDC,facility,both,6,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON DEXTRAN 50 MG/ML INJ SOLN,50863,CDM,250,RC,J1750,HCPCS,0023-6082-01,NDC,facility,both,2,ML,,209,146.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSAPREPITANT 150 MG IV SOLR,50863,CDM,250,RC,J1453,HCPCS,71839-104-01,NDC,facility,both,150,EA,,1065,745.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
D5-1/2 NS AND POTASSIUM CHLORIDE 40 MEQ/L IV,50863,CDM,250,RC,J3490,HCPCS,0338-0675-04,NDC,facility,both,1,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-979-01,NDC,facility,both,3,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,50863,CDM,250,RC,J8540,HCPCS,0904-7266-61,NDC,facility,both,40,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  1 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,64380-782-06,NDC,facility,both,4,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL LIQD,50863,CDM,636,RC,J3490,HCPCS,0904-7014-16,NDC,facility,both,1,ML,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROGESTERONE MICRONIZED 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,59651-152-01,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETHACRYNIC ACID 25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42799-405-01,NDC,facility,both,1,EA,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAMADOL  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-808-11,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN  500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,65862-008-01,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TAB,50863,CDM,250,RC,J3490,HCPCS,68084-396-11,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J1938,HCPCS,63323-280-03,NDC,facility,both,60,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIOTROPIUM BROMIDE 18 MCG INHL CPDV,50863,CDM,636,RC,J3490,HCPCS,0597-0075-75,NDC,facility,both,1,EA,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIPASE-PROTEASE-AMYLASE 12,000-38,000- 60,000 UNIT ORAL CAP, DELAY REL",50863,CDM,250,RC,J3490,HCPCS,0032-0047-70,NDC,facility,both,6,EA,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 50 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6323-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IV PGBK,50863,CDM,J3475,HCPCS,63323-106-02,NDC,,,facility,both,4,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIVAROXABAN 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50458-579-90,NDC,facility,both,6,EA,,517,361.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESTRADIOL 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,42806-088-01,NDC,facility,both,4,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,50863,CDM,J9263,HCPCS,67457-469-10,NDC,,,facility,both,98,ML,,424,296.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0093-2279-73,NDC,facility,both,5,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZONISAMIDE 10 MG/ML ORAL SYRUP (REPACK),50863,CDM,250,RC,J3490,HCPCS,64679-990-01,NDC,facility,both,8,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE IV BOLUS (STROKE) 100 MG (2 X 50 MG VIALS),50863,CDM,250,RC,J2997,HCPCS,50242-044-06,NDC,facility,both,100,EA,,24290,17003,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  20 MEQ ORAL PACK,50863,CDM,J3490,HCPCS,69543-451-01,NDC,,,facility,both,1,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,50863,CDM,J2359,HCPCS,55150-308-01,NDC,,,facility,both,5,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  1 MG/ML IV SOLN,50863,CDM,636,RC,J1800,HCPCS,63323-604-00,NDC,facility,both,1,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,63323-485-27,NDC,,,facility,both,300,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,0143-9577-01,NDC,,,facility,both,180,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 2 GRAM INJ SOLR,50863,CDM,J0692,HCPCS,0409-9735-01,NDC,,,facility,both,4,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 400 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-5853-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,16714-294-01,NDC,facility,both,7,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 500 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-7126-61,NDC,,,facility,both,4,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,J2312,HCPCS,67457-299-10,NDC,,,facility,both,400,ML,,513,359.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 50% IN WATER (MERGE RECORD),50863,CDM,J7060,HCPCS,0409-7517-66,NDC,,,facility,both,1,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IVERMECTIN 3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42799-806-01,NDC,facility,both,6,EA,,146,102.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,50863,CDM,J2354,HCPCS,23155-687-31,NDC,,,facility,both,2,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 5 MG-325 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0406-0123-23,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR IN 0.9% NACL 100 UNIT/100 ML (1 UNIT/ML) INFUSION FOR OB,50863,CDM,250,RC,J1815,HCPCS,0338-0126-12,NDC,facility,both,1,ML,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN SODIUM  2 GRAM INJ SOLR,50863,CDM,636,RC,J0290,HCPCS,63323-399-23,NDC,facility,both,4,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,J0330,HCPCS,0409-6629-02,NDC,,,facility,both,6,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4 % TOP CREA,50863,CDM,250,RC,J3490,HCPCS,43199-040-05,NDC,facility,both,6,GM,,159,111.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE 20 MG TAB,50863,CDM,636,RC,J3490,HCPCS,13107-155-30,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLN,50863,CDM,636,RC,J3262,HCPCS,50242-137-01,NDC,facility,both,400,ML,"JG,JZ,JA",7331,5131.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
PENTAMIDINE 300 MG INJ SOLR,50863,CDM,636,RC,J3490,HCPCS,63323-113-01,NDC,facility,both,1,EA,,330,231,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2599,HCPCS,43598-914-25,NDC,facility,both,14,ML,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-11,NDC,facility,both,20,ML,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2599,HCPCS,43598-914-25,NDC,facility,both,20,ML,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG/ML ORAL CONC,50863,CDM,250,RC,J3490,HCPCS,0054-3553-44,NDC,facility,both,6,ML,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
D5-1/2 NS AND POTASSIUM CHLORIDE 20 MEQ/L IV (PEDS CHEMO),50863,CDM,250,RC,J3490,HCPCS,0264-7635-00,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
D5-NS WITH POTASSIUM CHLORIDE 40 MEQ/L IV SOLP,50863,CDM,250,RC,J3490,HCPCS,0338-0807-04,NDC,facility,both,1,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,636,RC,J0330,HCPCS,31722-981-10,NDC,facility,both,13,ML,,141,98.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-662-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN DETEMIR 100 UNIT/ML SUBQ SOLN,50863,CDM,636,RC,J1815,HCPCS,0169-3687-12,NDC,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACUBITRIL-VALSARTAN 24-26 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0078-0659-20,NDC,facility,both,1,EA,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J2310,HCPCS,0641-6132-01,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADVATE: FACTOR VIII CONCENTRATE (MERGE RECORD),50863,CDM,636,RC,J7209,HCPCS,0944-3052-04,NDC,facility,both,500,UN,,2093,1465.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,23155-832-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,13,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,7,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE IN 0.9% NS (PF) 1 MG/10 ML (100 MCG/ML) IV SYRG(PDS MERGE),50863,CDM,250,RC,J3490,HCPCS,65302-506-10,NDC,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROGESTERONE MICRONIZED 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,59651-152-01,NDC,facility,both,2,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM ZIRCONIUM CYCLOSILICATE  5 G ORAL PWPK (USE PANEL),50863,CDM,636,RC,J3490,HCPCS,0310-1105-01,NDC,facility,both,2,EA,,293,205.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0591-0407-01,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,250,RC,J3490,HCPCS,0143-9575-01,NDC,facility,both,500,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML INJECTION,50863,CDM,J3411,HCPCS,67457-196-00,NDC,,,facility,both,4,ML,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,250,RC,Q9968,HCPCS,71288-811-10,NDC,facility,both,10,ML,,166,116.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SYRP,50863,CDM,250,RC,J3490,HCPCS,50383-792-16,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 5 MG ORAL TAB,50863,CDM,J3490,HCPCS,0003-0894-31,NDC,,,facility,both,1,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,FAMNOCHARGE,HCPCS,17856-0759-5,NDC,,,facility,both,2,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7050,HCPCS,0264-7800-10,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM IN NACL (ISO-OS) 1000 MG/100 ML IV PGBK,50863,CDM,J1953,HCPCS,44567-502-01,NDC,,,facility,both,100,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,66794-229-02,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM BROMIDE 0.02 % INHL SOLN,50863,CDM,636,RC,J3490,HCPCS,76204-100-01,NDC,facility,both,3,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-821-01,NDC,facility,both,3,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,17,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,12,ML,,20809,14566.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TAB,50863,CDM,250,RC,J3490,HCPCS,71205-909-30,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-467-01,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEBIVOLOL  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,31722-586-90,NDC,facility,both,1,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTOBACILLUS ACIDOPH-PECTIN 75 MILLION CELL -100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,5789683701,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3370,HCPCS,16714-309-01,NDC,facility,both,4,EA,,189,132.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMINOCAPROIC ACID 25 % ORAL SYRP,50863,CDM,250,RC,J3490,HCPCS,52817-815-08,NDC,facility,both,1,ML,,339,237.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J1610,HCPCS,0597-0053-45,NDC,facility,both,2,EA,,1483,1038.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68382-806-01,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 5 MG/ML IV SOLN,50863,CDM,250,RC,J1921,HCPCS,17478-420-20,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-492-27,NDC,,,facility,both,260,ML,,204,142.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,50863,CDM,Q5119,HCPCS,0069-0238-01,NDC,,,facility,both,1,ML,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,J2003,HCPCS,63323-486-05,NDC,,,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-50,NDC,facility,both,44,ML,JW,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,64,ML,JW,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
OLANZAPINE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6376-61,NDC,facility,both,1,EA,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUORESCEIN 1 MG OPHT STRP,50863,CDM,J3490,HCPCS,83851-100-30,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZOCAINE-MENTHOL 15-3.6 MG MM LOZG,50863,CDM,250,RC,J3490,HCPCS,6382471016,NDC,facility,both,10,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID (PORK)  60 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42192-330-01,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-461-11,NDC,facility,both,3,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16714-172-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 400 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0143-9887-01,NDC,facility,both,22,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,6809411059,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,J2405,HCPCS,0409-4755-18,NDC,,,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,43547-352-10,NDC,facility,both,7,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG ORAL CAP,50863,CDM,J3490,HCPCS,0904-7336-61,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,50863,CDM,636,RC,Q0177,HCPCS,0904-6617-61,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  500 MCG/ML INJ SOLN,50863,CDM,J2354,HCPCS,0641-6176-01,NDC,,,facility,both,20,ML,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELIMUMAB 120 MG IV SOLR,50863,CDM,J0490,HCPCS,49401-101-01,NDC,,,facility,both,24,ME,,2819,1973.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,J1171,HCPCS,76045-009-10,NDC,,,facility,both,10,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,636,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,J2003,HCPCS,63323-486-02,NDC,,,facility,both,300,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,72603-179-01,NDC,facility,both,9,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,63323-482-03,NDC,,,facility,both,100,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G POTASSIUM  5000000 UNIT INJ SOLR,50863,CDM,636,RC,J2540,HCPCS,0781-6135-94,NDC,facility,both,7,EA,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRIL MALEATE 1 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,52652-4001-1,NDC,facility,both,1,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENAZOPYRIDINE 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51293-811-01,NDC,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE (FOR EMERGENCY) 100 MG/ML (10%) IV SOLN,50863,CDM,250,RC,J0612,HCPCS,0143-9180-01,NDC,facility,both,400,ML,,236,165.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,0409-1412-04,NDC,facility,both,2,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES  8.6 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7252-61,NDC,facility,both,8,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,0904-6794-89,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALSARTAN  40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-612-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN-ACETAMINOPHEN-CAFFEINE 250 MG-250 MG-65 MG TAB,50863,CDM,250,RC,J3490,HCPCS,70677-1133-1,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE-DEXTROSE-WATER(PF) 7.5 MG/ML (0.75 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,71351-022-10,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-453-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE  5 MG/ML INJ SOLN,50863,CDM,636,RC,J2765,HCPCS,0409-3414-11,NDC,facility,both,2,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,0409-1207-13,NDC,facility,both,2,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 10 MCG/SPRAY NASL SPRA,50863,CDM,636,RC,J3490,HCPCS,60505-0815-0,NDC,facility,both,1,ML,,887,620.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PERPHENAZINE  4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6600-61,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,2,ML,,334,233.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) IV SOLN",50863,CDM,636,RC,J3490,HCPCS,43066-008-01,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,60219-1708-1,NDC,facility,both,40,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0075-0620-01,NDC,facility,both,4,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN DEXTROSE 500 MG/100 ML IV PGBK,50863,CDM,250,RC,J3370,HCPCS,0338-3551-48,NDC,facility,both,1,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 5 MG-325 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0406-0123-23,NDC,facility,both,3,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 17 GRAM (100 %) ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,0904-6931-86,NDC,facility,both,2,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAMOXIFEN 10 MG ORAL TAB,50863,CDM,636,RC,J9999,HCPCS,0591-2472-60,NDC,facility,both,3,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 5 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,36000-033-10,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAMIDRONATE 9 MG/ML IV SOLN,50863,CDM,250,RC,J2430,HCPCS,67457-446-10,NDC,facility,both,3,ML,,405,283.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 50 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,50268-541-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE 150 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16571-110-01,NDC,facility,both,1,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE (POLACRILEX) 4 MG MM LOZG,50863,CDM,250,RC,J3490,HCPCS,45802-873-05,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,16714-298-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICARDIPINE 25 MG/10 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,72485-116-01,NDC,facility,both,4,ML,,548,383.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7411-61,NDC,facility,both,3,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  160 MG ORAL CHEW,50863,CDM,636,RC,J3490,HCPCS,50580-521-24,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB 100 MG IV SOLR,50863,CDM,636,RC,J1745,HCPCS,57894-030-01,NDC,facility,both,35,EA,,11282,7897.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID (PORK) 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42192-327-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,25021-402-01,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,250,RC,J2003,HCPCS,63323-485-27,NDC,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 20MG/ML IV SYRINGE (PEDS/NEO),50863,CDM,250,RC,J0612,HCPCS,63323-311-10,NDC,facility,both,51,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,23,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,636,RC,J1610,HCPCS,0597-0053-45,NDC,facility,both,1,EA,JZ,556,389.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MIDODRINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6818-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0245-0212-89,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML INJECTION,50863,CDM,636,RC,J3411,HCPCS,67457-196-00,NDC,facility,both,2,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7362-61,NDC,facility,both,4,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETIRIZINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16571-401-10,NDC,facility,both,2,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,250,RC,J2270,HCPCS,0409-1890-03,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,2,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ORPHENADRINE CITRATE 30 MG/ML INJ SOLN,50863,CDM,250,RC,J2360,HCPCS,0641-6182-10,NDC,facility,both,1,ML,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NOREPINEPHRINE BITARTRATE-D5W 4 MG/250 ML (16 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66647-6156-33,NDC,facility,both,1,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3373,HCPCS,63323-284-01,NDC,facility,both,200,EA,,187,130.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),50863,CDM,250,RC,J3490,HCPCS,8290306545,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,55,ML,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,250,RC,J2003,HCPCS,0409-4277-01,NDC,facility,both,400,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-453-01,NDC,facility,both,2,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE HCL IN 5% DEXTROSE 100 MCG/10 ML (10 MCG/ML) IV SYRG,50863,CDM,250,RC,J0171,HCPCS,70092-1617-46,NDC,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-480-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON DEXTRAN 50 MG/ML INJ SOLN,50863,CDM,250,RC,J1750,HCPCS,0023-6082-01,NDC,facility,both,20,ML,JZ,2188,1531.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
THYROID (PORK)  60 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42192-330-01,NDC,facility,both,2,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2599,HCPCS,42023-164-25,NDC,facility,both,20,ML,,413,289.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE SOD SUCC (PF) 100 MG/2 ML INJ SOLR,50863,CDM,250,RC,J1720,HCPCS,0009-0011-03,NDC,facility,both,2,EA,,283,198.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LINEZOLID NEO IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J2020,HCPCS,0781-3433-46,NDC,facility,both,3,ML,,331,231.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6797-61,NDC,facility,both,6,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-04,NDC,facility,both,10,ML,,167,116.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE  10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,70756-201-11,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,250,RC,J0132,HCPCS,70594-111-01,NDC,facility,both,31,ML,,157,109.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 20 MG ORAL TAB,50863,CDM,J3490,HCPCS,0054-8297-25,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,50863,CDM,J3490,HCPCS,67877-548-88,NDC,,,facility,both,6,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOBENZAPRINE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-191-11,NDC,facility,both,14,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,250,RC,J2405,HCPCS,23155-547-31,NDC,facility,both,4,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2599,HCPCS,43598-914-25,NDC,facility,both,23,ML,,156,109.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,62584-693-11,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR NEO/PEDS INFUSION (CDS FROM PREMIX),50863,CDM,250,RC,J0133,HCPCS,63323-325-10,NDC,facility,both,14,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,14,ML,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,636,RC,J2704,HCPCS,25021-608-20,NDC,facility,both,15,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYBUTYNIN CHLORIDE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,70954-005-10,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-327-11,NDC,facility,both,1,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7912-51,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML INJ SOLN,50863,CDM,250,RC,J0171,HCPCS,76329-9060-0,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-4264-11,NDC,facility,both,1,ML,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  5 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,13668-086-30,NDC,facility,both,1,EA,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,824,ME,JZ,11182,7827.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LEVOTHYROXINE 125 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-519-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TAB,50863,CDM,636,RC,J3490,HCPCS,10702-253-01,NDC,facility,both,2,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,22,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0121-0917-05,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE   4.2 % IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-083-05,NDC,facility,both,1,ML,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMIDE PEROXIDE 6.5 % OTIC DROP,50863,CDM,636,RC,J3490,HCPCS,4203710478,NDC,facility,both,1,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-01,NDC,facility,both,5,ML,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6322-06,NDC,facility,both,5,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANTI-INHIBITOR COAGULANT CMPLX (PHS MERGE),50863,CDM,250,RC,J7198,HCPCS,64193-426-02,NDC,facility,both,575,UN,,4153,2907.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 400 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-602-11,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,72162-1329-8,NDC,facility,both,1,ML,,149,104.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,636,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,11,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,52817-180-10,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE  10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,69367-388-01,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,70095-026-01,NDC,facility,both,1,ML,JZ,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PHENOBARBITAL 20 MG/5 ML ORAL ELIX,50863,CDM,250,RC,J3490,HCPCS,0121-0942-05,NDC,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MANNITOL 20% IV SOLP,50863,CDM,250,RC,J2150,HCPCS,0990-7715-13,NDC,facility,both,1,ML,,113,79.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LINEZOLID 100 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,59762-1308-4,NDC,facility,both,1,ML,,591,413.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYBUTYNIN CHLORIDE  5 MG ORAL TO24,50863,CDM,636,RC,J3490,HCPCS,68084-480-11,NDC,facility,both,3,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROPRUSSIDE 25 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,70069-261-01,NDC,facility,both,1,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROFURANTOIN MACROCRYSTAL 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-483-01,NDC,facility,both,9,EA,,264,184.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J1610,HCPCS,0597-0053-45,NDC,facility,both,2,EA,,1112,778.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE  7.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-584-11,NDC,facility,both,4,EA,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0990-7984-13,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RASBURICASE 1.5 MG IV SOLR,50863,CDM,250,RC,J2783,HCPCS,0024-5150-10,NDC,facility,both,12,EA,,11515,8060.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VERAPAMIL  80 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,23155-026-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-18,NDC,facility,both,60,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LIDOCAINE 4 % TOP CREA,50863,CDM,636,RC,J3490,HCPCS,43199-040-05,NDC,facility,both,1,GM,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENAZEPRIL  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,43547-335-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF)-0.9 % NACL 0.2 MG/ML IV SOLN BAG (FOR VENT),50863,CDM,250,RC,J1171,HCPCS,70092-1287-35,NDC,facility,both,100,ML,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,15,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSULFAN BLUE 1 % INJ SOLN,50863,CDM,636,RC,Q9968,HCPCS,67457-220-05,NDC,facility,both,20,ML,JW,583,408.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,72485-106-01,NDC,facility,both,25,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,68,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,5500,ML,,606,424.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,10135-778-01,NDC,facility,both,240,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,63323-485-27,NDC,,,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE  7.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-584-11,NDC,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,636,RC,J0330,HCPCS,31722-981-10,NDC,facility,both,9,ML,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0295,HCPCS,63323-368-20,NDC,facility,both,2,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 75 MG/5 ML ORAL SOLUTION,50863,CDM,250,RC,J3490,HCPCS,64980-511-10,NDC,facility,both,15,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXEPIN  50 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,51079-438-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-256-11,NDC,facility,both,2,EA,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-242-11,NDC,facility,both,1,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,0409-6625-14,NDC,facility,both,2,ML,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6572-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 50 MG/10 ML (5 MG/ML) IV SOLN,50863,CDM,636,RC,J2305,HCPCS,0517-4810-01,NDC,facility,both,10,ML,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,2,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL (PULM.HYPERTENSION) 10 MG/12.5 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,55150-166-13,NDC,facility,both,1,ML,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-3178-16,NDC,facility,both,140,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE-ALOE VERA TOPICAL GEL,50863,CDM,636,RC,J3490,HCPCS,225052547,NDC,facility,both,1,GM,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,10135-679-01,NDC,facility,both,2,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  5 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,60687-122-11,NDC,facility,both,8,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML IV SOLN (MERGE),50863,CDM,636,RC,J3490,HCPCS,16714-037-10,NDC,facility,both,1,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN D5W 20000 UNIT/500 ML,50863,CDM,250,RC,J1644,HCPCS,0264-9567-10,NDC,facility,both,40,ML,,167,116.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,250,RC,J3490,HCPCS,53746-542-05,NDC,facility,both,3,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,636,RC,J3490,HCPCS,51754-4250-1,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,50863,CDM,636,RC,J9075,HCPCS,0781-3233-94,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SULFASALAZINE 500 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,59762-0104-1,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IR SOLN,50863,CDM,636,RC,J3490,HCPCS,0338-0047-46,NDC,facility,both,3,ML,,167,116.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 8-2 MG SL SUBL,50863,CDM,J3490,HCPCS,50268-145-11,NDC,,,facility,both,1,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV,50863,CDM,J7120,HCPCS,0338-0117-04,NDC,,,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,50863,CDM,J0561,HCPCS,60793-701-02,NDC,,,facility,both,24,ML,,2376,1663.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSULFAN BLUE 1 % INJ SOLN,50863,CDM,250,RC,Q9968,HCPCS,67457-220-05,NDC,facility,both,40,ML,JW,1166,816.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,J3490,HCPCS,51754-5001-1,NDC,,,facility,both,1,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  750 MG IV SOLR,50863,CDM,J3373,HCPCS,63323-203-01,NDC,,,facility,both,75,EA,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE HCL IN NS 10 MG/250 ML (0.04 MG/ML) IV SOLN (PDS MERGE),50863,CDM,J2371,HCPCS,71506-029-58,NDC,,,facility,both,500,ML,,146,102.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-492-45,NDC,facility,both,300,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-492-27,NDC,,,facility,both,220,ML,,173,121.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,68462-469-40,NDC,facility,both,3,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,50863,CDM,J1756,HCPCS,0517-2340-01,NDC,,,facility,both,300,ML,,992,694.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOLIC ACID  1 MG ORAL TAB,50863,CDM,J3490,HCPCS,60687-681-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIRMATRELVIR-RITONAVIR 300-100 MG ORAL TAB DOSEPACK (FOR ED/IP TAKE HOME PANEL),50863,CDM,J3490,HCPCS,0069-5321-30,NDC,,,facility,both,30,EA,,4010,2807,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,50863,CDM,250,RC,J9171,HCPCS,0409-0201-20,NDC,facility,both,92,ML,,799,559.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ICATIBANT 30 MG/3 ML SUBQ SYRG,50863,CDM,636,RC,J1744,HCPCS,63323-574-86,NDC,facility,both,30,ML,,3588,2511.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-495-04,NDC,,,facility,both,400,ML,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION,50863,CDM,J3490,HCPCS,0186-0372-28,NDC,,,facility,both,2,GM,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ICATIBANT 30 MG/3 ML SUBQ SYRG,50863,CDM,636,RC,J1744,HCPCS,0093-3066-34,NDC,facility,both,30,ML,"JZ,GZ",29229,20460.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier GZ: Item or service expected to be denied as not reasonable and necessary
BUPRENORPHINE-NALOXONE 8-2 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,60687-637-11,NDC,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE 20 MG TAB,50863,CDM,636,RC,J3490,HCPCS,68084-045-11,NDC,facility,both,2,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,J3490,HCPCS,63037-136-25,NDC,,,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,J2250,HCPCS,0409-2308-21,NDC,,,facility,both,1,ML,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-535-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,636,RC,J0132,HCPCS,70594-111-01,NDC,facility,both,11,ML,JW,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 10 GRAM/15 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0116-4005-30,NDC,facility,both,3,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIRMATRELVIR-RITONAVIR 150 MG (10)- 100 MG (10) ORAL DSPK,50863,CDM,250,RC,J3490,HCPCS,0069-5317-20,NDC,facility,both,20,EA,,4130,2891,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,250,RC,J7060,HCPCS,0338-0017-04,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % MBP,50863,CDM,250,RC,J3490,HCPCS,0338-0553-18,NDC,facility,both,4,ML,,193,135.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNITS/1 GRAM PACKET (MERGE RECORD),50863,CDM,636,RC,J3490,HCPCS,57896-145-09,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0137,HCPCS,0264-4100-90,NDC,facility,both,29,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,0409-4887-10,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,16714-036-10,NDC,facility,both,8,ML,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 400 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-602-11,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN SODIUM EXTENDED 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,65862-692-01,NDC,facility,both,5,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,50863,CDM,636,RC,J0561,HCPCS,60793-701-02,NDC,facility,both,12,ML,JZ,1080,756,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CEFEPIME 1 GRAM INJ SOLR,50863,CDM,J0692,HCPCS,25021-121-20,NDC,,,facility,both,4,EA,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML IM SOLN,50863,CDM,90375,HCPCS,13533-318-05,NDC,,,facility,both,10,ML,,8767,6136.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-405-11,NDC,facility,both,2,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE  2 MG/ML INJ SOLN,50863,CDM,J3490,HCPCS,63323-285-23,NDC,,,facility,both,1,ML,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML (PEDS CALCLUATOR 0.5),50863,CDM,J1815,HCPCS,0024-5924-10,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,J3490,HCPCS,0143-9889-15,NDC,,,facility,both,18,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2003,HCPCS,55150-165-05,NDC,,,facility,both,200,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,78206-122-01,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,50863,CDM,J2354,HCPCS,25021-463-01,NDC,,,facility,both,10,ML,,150,105,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 500 MG/10 ML IV SOLN,50863,CDM,250,RC,J9190,HCPCS,63323-117-01,NDC,facility,both,2,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) IV SOLN",50863,CDM,250,RC,J3490,HCPCS,72485-107-01,NDC,facility,both,1,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-1541-10,NDC,facility,both,2,ML,,195,136.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MISOPROSTOL 25 MCG ORAL TAB,50863,CDM,636,RC,S0191,HCPCS,59762-5007-1,NDC,facility,both,4,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,636,RC,J3490,HCPCS,67850-041-00,NDC,facility,both,1,ML,,172,120.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 50% IN WATER (MERGE RECORD),50863,CDM,636,RC,J7060,HCPCS,0409-6648-02,NDC,facility,both,2,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INHL NEBU,50863,CDM,250,RC,J3490,HCPCS,0487-9301-33,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GANCICLOVIR NEO IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J1750,HCPCS,63323-315-10,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-208-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM POLYSTYRENE SULFONATE ORAL POWDER,50863,CDM,250,RC,J3490,HCPCS,11534-166-15,NDC,facility,both,1,GM,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2312,HCPCS,0409-1219-41,NDC,facility,both,800,ML,,1026,718.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE IV",50863,CDM,250,RC,J3490,HCPCS,0338-0013-04,NDC,facility,both,1,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML IM SOLN,50863,CDM,636,RC,90375,HCPCS,13533-318-30,NDC,facility,both,6,ML,,5635,3944.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLP",50863,CDM,250,RC,P9047,HCPCS,0944-0493-04,NDC,facility,both,8,ML,JZ,2001,1400.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CHLORPROMAZINE  10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-162-11,NDC,facility,both,3,EA,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J2312,HCPCS,0409-1215-01,NDC,facility,both,1,ML,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 250 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,58657-675-01,NDC,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0641-6206-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MYCOPHENOLATE 200 MG/ML ORAL SUSP,50863,CDM,250,RC,J7517,HCPCS,0527-5160-82,NDC,facility,both,1,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-03,NDC,facility,both,7,ML,,194,135.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VORICONAZOLE 200 MG IV SOLN,50863,CDM,250,RC,J3465,HCPCS,0781-3416-94,NDC,facility,both,3,EA,JW,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,63323-162-00,NDC,facility,both,2,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE (PF) 1 MG/ML INJ SOLN,50863,CDM,636,RC,J0171,HCPCS,54288-103-01,NDC,facility,both,60,ML,,514,359.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOCARNITINE 200 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,54482-147-01,NDC,facility,both,2,ML,,457,319.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXRAZOXANE 500 MG IV SOLR,50863,CDM,250,RC,J1190,HCPCS,0143-9248-01,NDC,facility,both,6,EA,,4451,3115.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-989-01,NDC,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZTREONAM 2 GRAM INJ SOLR,50863,CDM,250,RC,J0457,HCPCS,63323-402-41,NDC,facility,both,20,EA,,262,183.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6773-61,NDC,facility,both,4,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0781-6041-58,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,65862-707-55,NDC,facility,both,12,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES  8.6 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7252-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 0.8 GRAM ORAL PWPK,50863,CDM,636,RC,J3490,HCPCS,0115-1365-30,NDC,facility,both,3,EA,,245,171.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLIPIZIDE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6637-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),50863,CDM,250,RC,J1815,HCPCS,0024-5926-05,NDC,facility,both,16,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-1721-01,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 100 % ORAL POWDER 238 GRAMS,50863,CDM,250,RC,J3490,HCPCS,70677-1068-1,NDC,facility,both,1,GM,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-02,NDC,facility,both,2,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN PEDS INFUSION (CDS MIXTURE),50863,CDM,636,RC,J0290,HCPCS,25021-136-10,NDC,facility,both,2,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-723-11,NDC,facility,both,2,EA,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE  5 MG/ML INJ SOLN,50863,CDM,636,RC,J2765,HCPCS,23155-240-31,NDC,facility,both,2,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,42806-151-34,NDC,facility,both,3,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),50863,CDM,J3490,HCPCS,63323-186-10,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,40,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,250,RC,J0137,HCPCS,0264-4100-90,NDC,facility,both,17,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 7.5 MG-325 MG/15 ML ORAL SOLN (REPACK),50863,CDM,636,RC,J3490,HCPCS,0121-2316-15,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 300 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,60687-793-11,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,0143-9511-01,NDC,facility,both,9,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MINOXIDIL  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-204-11,NDC,facility,both,3,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IVABRADINE 7.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,55513-810-60,NDC,facility,both,2,EA,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,85,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 100 MG ORAL TB12,50863,CDM,250,RC,J3490,HCPCS,51672-4123-1,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 40 GRAM/400 ML (10 %) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-40,NDC,facility,both,80,ML,JZ,11316,7921.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DIVALPROEX 125 MG ORAL CPSP,50863,CDM,250,RC,J3490,HCPCS,68084-313-11,NDC,facility,both,8,EA,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7448-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE (DIAGNOSTIC) 3 MG/ML IV SOLN,50863,CDM,636,RC,J0153,HCPCS,55150-193-01,NDC,facility,both,90,ML,,773,541.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL 20 MG/5 ML ORAL ELIX,50863,CDM,636,RC,J3490,HCPCS,60687-671-40,NDC,facility,both,2,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 17 GRAM (100 %) ORAL PWPK,50863,CDM,636,RC,J3490,HCPCS,0904-6931-86,NDC,facility,both,4,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,636,RC,J3490,HCPCS,66553-002-01,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,0121-0905-05,NDC,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID (PORK)  30 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42192-329-01,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0228-2129-10,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GAMMAGARD LIQUID 10 % IV SOLN,50863,CDM,636,RC,J1569,HCPCS,0944-2700-06,NDC,facility,both,40,ML,"JZ,JA",7211,5047.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-3178-16,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,51754-5001-1,NDC,facility,both,1,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 4 MG/ACTUATION NASL SPRY,50863,CDM,636,RC,J3490,HCPCS,45802-578-00,NDC,facility,both,1,EA,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PORACTANT ALFA 240 MG/3 ML INTR SUSP,50863,CDM,250,RC,J3490,HCPCS,10122-510-01,NDC,facility,both,5,ML,,7880,5516,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FERROUS SULFATE 325 MG (65 MG IRON) TAB,50863,CDM,636,RC,J3490,HCPCS,904759160,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ORAL ELECTROLYTES ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,7007480336,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLIPIZIDE  2.5 MG ORAL TO24,50863,CDM,250,RC,J3490,HCPCS,60687-480-11,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 20 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,50268-585-11,NDC,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,55390-500-05,NDC,facility,both,2,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL (VITAMIN D3)  1000 UNIT ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,2055503300,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4% TOP PATCH,50863,CDM,636,RC,J3490,HCPCS,0536-1202-07,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1940,HCPCS,72603-251-01,NDC,facility,both,5,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0093-3145-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRIL MALEATE 1 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,69238-1729-7,NDC,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL  32.4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16571-673-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.15 MG/0.3 ML IM PNIJ,50863,CDM,636,RC,J0169,HCPCS,49502-101-01,NDC,facility,both,5,EA,,2250,1575,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EMTRICITABINE-TENOFOVIR 200 MG-300 MG TAB,50863,CDM,636,RC,J0750,HCPCS,65862-354-30,NDC,facility,both,3,EA,,757,529.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-351-11,NDC,facility,both,2,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOBRAMYCIN 1.2 G POWDER VIAL,50863,CDM,250,RC,J3260,HCPCS,39822-0412-6,NDC,facility,both,45,EA,,1193,835.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,63323-165-01,NDC,facility,both,16,ML,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,50863,CDM,250,RC,J0640,HCPCS,67457-528-10,NDC,facility,both,4,EA,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2598,HCPCS,43598-914-11,NDC,facility,both,14,ML,JW,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
METHYLPREDNISOLONE  4 MG ORAL TAB,50863,CDM,250,RC,J7509,HCPCS,0904-6914-61,NDC,facility,both,3,EA,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1940,HCPCS,72603-251-01,NDC,facility,both,3,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE 0.25 MG/2 ML INHL NBSP,50863,CDM,250,RC,J3490,HCPCS,0487-9601-01,NDC,facility,both,2,ML,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25%/EPINEPHRINE 1:100K INJECTION,50863,CDM,250,RC,J3490,HCPCS,0409-1158-01,NDC,facility,both,4,ML,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE MONONITRATE  60 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,13668-105-01,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOBRAMYCIN 1.2 G POWDER VIAL,50863,CDM,250,RC,J3260,HCPCS,39822-0412-6,NDC,facility,both,2,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DICLOFENAC 50 MG TAB, DELAYED RELEASE",50863,CDM,250,RC,J3490,HCPCS,60687-606-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,0641-6146-01,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML INJ SOLN,50863,CDM,636,RC,J1171,HCPCS,63323-852-03,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,96,ML,JW,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
OXYBUTYNIN CHLORIDE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0832-0038-89,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM IN NACL (ISO-OS) 500 MG/100 ML IV PGBK,50863,CDM,250,RC,J1953,HCPCS,67457-255-00,NDC,facility,both,50,ML,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LINEZOLID NEO IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J2020,HCPCS,0009-5140-01,NDC,facility,both,3,ML,,194,135.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2305-04,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,68180-150-01,NDC,facility,both,2,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BISACODYL 10 MG RECT SUPP,50863,CDM,250,RC,J3490,HCPCS,0574-7050-50,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,63323-400-01,NDC,facility,both,450,ML,,473,331.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMANTADINE 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7042-61,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,63739-903-10,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPTOMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0878,HCPCS,72603-152-01,NDC,facility,both,600,EA,,1755,1228.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7188-61,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROPROCAINE 3 % INJ SOLN,50863,CDM,250,RC,J2401,HCPCS,63323-478-01,NDC,facility,both,300,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,636,RC,J0690,HCPCS,70092-1017-46,NDC,facility,both,2,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,88,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,250,RC,J2270,HCPCS,0641-6125-01,NDC,facility,both,1,ML,PLAD,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,250,RC,J3490,HCPCS,62037-560-01,NDC,facility,both,4,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM ACETATE 667 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,68084-479-11,NDC,facility,both,2,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 500 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,0832-7124-89,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIROFIBAN-0.9% SODIUM CHLORIDE 5 MG/100 ML (50 MCG/ML) IV SOLN,50863,CDM,636,RC,J3246,HCPCS,25208-002-03,NDC,facility,both,6,ML,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN IN D5W 400 MG/200 ML IV PGBK,50863,CDM,636,RC,J0744,HCPCS,0409-3300-01,NDC,facility,both,2,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE 0.5 MG/2 ML INHL NBSP,50863,CDM,250,RC,J3490,HCPCS,0093-6816-45,NDC,facility,both,1,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMANTADINE 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0781-2048-01,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6426-61,NDC,facility,both,2,EA,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,45,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,50863,CDM,250,RC,J0640,HCPCS,0143-9554-01,NDC,facility,both,1,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,250,RC,J2405,HCPCS,70860-776-41,NDC,facility,both,16,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,636,RC,J2704,HCPCS,25021-608-20,NDC,facility,both,3,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),50863,CDM,250,RC,J2060,HCPCS,0641-6044-01,NDC,facility,both,4,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAZOLAMIDE 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6663-61,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROPROCAINE 3 % INJ SOLN,50863,CDM,250,RC,J2401,HCPCS,0143-9210-01,NDC,facility,both,150,ML,JW,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
TERAZOSIN  5 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,50268-766-11,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-406-03,NDC,facility,both,1,ML,,872,610.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,72485-106-01,NDC,facility,both,200,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7008-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLEDRONIC ACID 4 MG/5 ML IV SOLN,50863,CDM,250,RC,J3489,HCPCS,55111-685-07,NDC,facility,both,4,ML,,382,267.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J3430,HCPCS,68462-758-05,NDC,facility,both,3,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAZOSIN 1 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,51079-630-01,NDC,facility,both,3,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 500 MG INJ SOLR,50863,CDM,250,RC,J0696,HCPCS,44567-700-25,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6370-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIROFIBAN-0.9% SODIUM CHLORIDE 5 MG/100 ML (50 MCG/ML) IV SOLN,50863,CDM,250,RC,J3246,HCPCS,25208-002-03,NDC,facility,both,12,ML,,239,167.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65862-006-01,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MISOPROSTOL 100 MCG ORAL TAB,50863,CDM,636,RC,S0191,HCPCS,59762-5007-2,NDC,facility,both,4,EA,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHIMAZOLE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-669-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 20 MG/ML ORAL CONC,50863,CDM,250,RC,J3490,HCPCS,71093-143-11,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,1,EA,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6927-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN STERILE WATER 2 GRAM/20 ML IV SYRG,50863,CDM,250,RC,J7999,HCPCS,70092-1238-47,NDC,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,16714-036-01,NDC,facility,both,5,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,43,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NYSTATIN 100000 UNIT/ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,17856-1045-1,NDC,facility,both,1,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CELECOXIB 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-436-11,NDC,facility,both,1,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN STERILE WATER 2 GRAM/20 ML IV SYRG,50863,CDM,250,RC,J7999,HCPCS,70092-1604-47,NDC,facility,both,4,ML,,209,146.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMINOPHYLLINE 500 MG/20 ML IV SOLN,50863,CDM,636,RC,J0280,HCPCS,0409-5922-01,NDC,facility,both,1,ML,JZ,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DESMOPRESSIN 0.2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60505-0258-1,NDC,facility,both,3,EA,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,50863,CDM,636,RC,J1756,HCPCS,0517-2340-01,NDC,facility,both,96,ML,,309,216.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-097-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,66689-056-01,NDC,facility,both,2,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-134-11,NDC,facility,both,10,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,72205-142-90,NDC,facility,both,2,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZTREONAM 2 GRAM INJ SOLR,50863,CDM,636,RC,J0457,HCPCS,63323-402-01,NDC,facility,both,10,EA,JW,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
BUSPIRONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-986-01,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZTROPINE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-388-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,16714-046-01,NDC,facility,both,7,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,62584-984-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-089-11,NDC,facility,both,2,EA,,254,177.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML IV SOLN,50863,CDM,250,RC,J3010,HCPCS,63323-806-50,NDC,facility,both,1,ML,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,20,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,75,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,5,EA,JW,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LACTATED RINGERS IV,50863,CDM,250,RC,J7120,HCPCS,0338-0117-04,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,838,ME,JZ,11372,7960.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-426-02,NDC,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,4,ML,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES-DOCUSATE SODIUM 8.6 MG-50 MG TAB,50863,CDM,250,RC,J3490,HCPCS,10135-669-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB 100 MG IV SOLR,50863,CDM,636,RC,J1745,HCPCS,57894-030-01,NDC,facility,both,8,EA,JW,1122,785.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CARBAMAZEPINE 100 MG ORAL TB12,50863,CDM,250,RC,J3490,HCPCS,51672-4123-1,NDC,facility,both,3,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J2004,HCPCS,0409-3178-16,NDC,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALSARTAN 160 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-634-11,NDC,facility,both,2,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,250,RC,J3490,HCPCS,63323-486-05,NDC,facility,both,400,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,70095-031-01,NDC,facility,both,24,ML,JZ,954,667.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
NEOMYCIN-BACITRACN ZN-POLYMYXIN 3.5 MG-400 U*,50863,CDM,636,RC,J3490,HCPCS,45802-143-00,NDC,facility,both,8,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAZOSIN 2 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,51079-631-01,NDC,facility,both,2,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZIPRASIDONE 20 MG CAP,50863,CDM,636,RC,J3490,HCPCS,0904-6269-45,NDC,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0591-5555-01,NDC,facility,both,6,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6008-61,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOSTIGMINE METHYLSULFATE 1 MG/ML IV SOLN,50863,CDM,250,RC,J2710,HCPCS,42023-189-01,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESTRADIOL 0.05 MG/24 HR TD PTWK,50863,CDM,250,RC,J7304,HCPCS,50419-451-04,NDC,facility,both,1,EA,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,636,RC,J2405,HCPCS,70860-776-41,NDC,facility,both,7,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LECANEMAB-IRMB 100 MG/ML IV SOLN,50863,CDM,636,RC,J0174,HCPCS,62856-215-01,NDC,facility,both,880,ML,Q0,2579,1805.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier Q0: Investigational clinical service provided in a clinical research study that is in an approved clinical research study
AMPICILLIN 250 MG SOLUTION FOR INJECTION,50863,CDM,250,RC,J0290,HCPCS,63323-387-10,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  5 GRAM IV SOLR,50863,CDM,250,RC,J3373,HCPCS,0143-9163-01,NDC,facility,both,175,EA,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6730-61,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-545-10,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLN,50863,CDM,636,RC,J3262,HCPCS,50242-135-01,NDC,facility,both,160,ML,"JZ,JA",2933,2053.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,70069-363-01,NDC,facility,both,1,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  1 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,59651-484-01,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SITAGLIPTIN  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0006-0221-01,NDC,facility,both,1,EA,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-051-10,NDC,facility,both,1,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69315-117-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYPROHEPTADINE 4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0115-1757-01,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN  10 GRAM INJ SOLR,50863,CDM,250,RC,J0690,HCPCS,0143-9983-91,NDC,facility,both,6,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,636,RC,J2405,HCPCS,0641-6078-25,NDC,facility,both,4,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL,50863,CDM,250,RC,J3490,HCPCS,63323-820-01,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL,50863,CDM,250,RC,J3490,HCPCS,63323-820-01,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM,50863,CDM,250,RC,J3490,HCPCS,0168-0258-15,NDC,facility,both,1,GM,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACCHAROMYCES BOULARDII 250 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,904723006,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-DYYB 100 MG IV SOLR,50863,CDM,636,RC,Q5103,HCPCS,0069-0809-01,NDC,facility,both,65,EA,,16977,11883.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZATHIOPRINE  50 MG ORAL TAB,50863,CDM,250,RC,J7500,HCPCS,68084-229-11,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,150,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6926-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 0.5 MG ORAL CAP,50863,CDM,250,RC,J7507,HCPCS,51079-817-01,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 2 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,250,RC,J2270,HCPCS,63323-452-00,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN 0.9 % SODIUM CHL 2 GRAM/500 ML IV SOLN,50863,CDM,250,RC,J3370,HCPCS,70092-9338-07,NDC,facility,both,4,ML,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR PHOSPHATE 75 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,72205-044-11,NDC,facility,both,1,EA,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1940,HCPCS,0409-6102-18,NDC,facility,both,6,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0143-9509-01,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,59762-3130-1,NDC,facility,both,9,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,0955-1004-01,NDC,facility,both,4,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE (FOR CODE) 10% (100 MG/ML) IV SYRINGE,50863,CDM,636,RC,J3490,HCPCS,76329-3304-1,NDC,facility,both,1,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,250,RC,J0330,HCPCS,31722-981-10,NDC,facility,both,15,ML,,169,118.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESTRADIOL 0.025 MG/24 HR TD PTWK,50863,CDM,250,RC,J7304,HCPCS,47781-204-04,NDC,facility,both,2,EA,,217,151.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,63323-461-01,NDC,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON DEXTRAN 50 MG/ML INJ SOLN,50863,CDM,636,RC,J1750,HCPCS,0023-6082-01,NDC,facility,both,30,ML,,3126,2188.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NAFCILLIN 10 GRAM INJ SOLR,50863,CDM,250,RC,J3490,HCPCS,72603-567-01,NDC,facility,both,1,EA,,538,376.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,43547-351-10,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZAFIRLUKAST 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-059-11,NDC,facility,both,1,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0074-4552-11,NDC,facility,both,2,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRIL MALEATE 1 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,69238-1729-7,NDC,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,50863,CDM,250,RC,J9000,HCPCS,0069-1542-20,NDC,facility,both,10,ML,,156,109.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNIT/G TOP OINT (MERGE),50863,CDM,250,RC,J3490,HCPCS,0472-1105-56,NDC,facility,both,1,GM,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,250,RC,J7060,HCPCS,0338-0017-38,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLADRIBINE 1 MG/ML IV SOLN,50863,CDM,250,RC,J9065,HCPCS,0143-9871-01,NDC,facility,both,20,ML,,1770,1239,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-406-03,NDC,facility,both,1,ML,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRBESARTAN 150 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,33342-048-07,NDC,facility,both,2,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,2,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR IRRIGATION, STERILE SOLUTION",50863,CDM,636,RC,J3490,HCPCS,0338-0004-04,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,636,RC,J0132,HCPCS,70594-111-01,NDC,facility,both,212,ML,,1075,752.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUPHENAZINE 5 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0527-1790-01,NDC,facility,both,1,EA,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CANAKINUMAB (PF) 150 MG/ML SUBQ SOLN,50863,CDM,636,RC,J0638,HCPCS,0078-0734-61,NDC,facility,both,150,ML,JZ,36927,25848.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DESIPRAMINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50742-113-01,NDC,facility,both,4,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 800 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-720-11,NDC,facility,both,4,EA,,175,122.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 800 MG ORAL TAB,50863,CDM,250,RC,J0601,HCPCS,60687-328-11,NDC,facility,both,40,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,68180-441-02,NDC,facility,both,9,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN   81 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,57896-981-01,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE 21 MG/24 HR TD PT24,50863,CDM,250,RC,J3490,HCPCS,43598-448-71,NDC,facility,both,5,EA,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACUBITRIL-VALSARTAN 49-51 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0078-0777-67,NDC,facility,both,1,EA,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL DECANOATE 100 MG/ML IM SOLN,50863,CDM,636,RC,J1631,HCPCS,70756-616-10,NDC,facility,both,2,ML,JZ,159,111.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,250,RC,J2270,HCPCS,0409-1890-13,NDC,facility,both,1,ML,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,16714-046-01,NDC,facility,both,20,ML,,229,160.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN  2.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-027-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,24658-141-30,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 0.4 MG SL SUBL,50863,CDM,636,RC,J3490,HCPCS,68462-639-25,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 1 % INJ SOLN,50863,CDM,250,RC,Q9968,HCPCS,0517-0301-10,NDC,facility,both,40,ML,,167,116.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES  8.6 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7252-60,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIROLIMUS 1 MG/ML ORAL SOLN,50863,CDM,250,RC,J7520,HCPCS,60505-6197-2,NDC,facility,both,1,ML,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVONORGESTREL 20 MCG/24 HR IU IUD,50863,CDM,250,RC,J7298,HCPCS,50419-423-01,NDC,facility,both,1,EA,,2369,1658.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G POTASSIUM  5000000 UNIT INJ SOLR,50863,CDM,250,RC,J2540,HCPCS,70860-126-41,NDC,facility,both,9,EA,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-444-01,NDC,facility,both,2,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE 0.5 MG/2 ML INHL NBSP,50863,CDM,636,RC,J3490,HCPCS,0093-6816-45,NDC,facility,both,1,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,114,ML,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM-ALBUTEROL 0.5 MG-2.5 MG/3 ML NEB SOLUTION,50863,CDM,250,RC,J3490,HCPCS,47335-756-48,NDC,facility,both,2,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 125 MG ORAL CPSP,50863,CDM,250,RC,J3490,HCPCS,68084-313-11,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,59762-3741-1,NDC,facility,both,16,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,636,RC,J0690,HCPCS,44567-707-25,NDC,facility,both,8,EA,JZ,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
VANCOMYCIN 125 MG/5 ML (25MG/ML) ORAL SYRINGE (REPACK),50863,CDM,250,RC,J3370,HCPCS,67457-340-00,NDC,facility,both,1,EA,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPSONE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,70954-136-20,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,60687-145-11,NDC,facility,both,20,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL  6.25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-0135-01,NDC,facility,both,4,EA,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 500 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,65862-595-01,NDC,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM IN NACL (ISO-OS) 500 MG/100 ML IV PGBK,50863,CDM,250,RC,J1953,HCPCS,67457-255-00,NDC,facility,both,37,ML,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FERROUS SULFATE 325 MG (65 MG IRON) TAB,50863,CDM,250,RC,J3490,HCPCS,904759060,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 10 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,55150-305-01,NDC,facility,both,80,ML,JW,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PHENYTOIN 50 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,51672-4146-1,NDC,facility,both,6,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,0641-6007-01,NDC,facility,both,4,ML,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,13668-219-30,NDC,facility,both,1,EA,,158,110.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLECAINIDE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-321-11,NDC,facility,both,1,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-078-33,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,16714-036-01,NDC,facility,both,7,ML,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRENATAL VIT NO.130-IRON-FOLIC 27 MG IRON- 800 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,904531360,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7193-06,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,4,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRIMIDONE 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-687-11,NDC,facility,both,1,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARISOPRODOL 350 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50742-656-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,636,RC,J1100,HCPCS,63323-506-41,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,636,RC,J7999,HCPCS,70092-1017-46,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,0008-0923-51,NDC,facility,both,1,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,250,RC,J1596,HCPCS,0143-9679-01,NDC,facility,both,4,ML,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BISACODYL 10 MG RECT SUPP,50863,CDM,250,RC,J3490,HCPCS,57896-444-12,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL  32.4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16571-673-01,NDC,facility,both,3,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 12.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68382-094-01,NDC,facility,both,2,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION,50863,CDM,636,RC,J3490,HCPCS,0186-0370-28,NDC,facility,both,1,GM,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CELECOXIB 200 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-447-11,NDC,facility,both,2,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTAMIDINE 300 MG INHL SOLR,50863,CDM,250,RC,J3490,HCPCS,39822-3030-2,NDC,facility,both,1,EA,,405,283.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,18,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0780,HCPCS,43066-090-01,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,0008-0923-60,NDC,facility,both,1,EA,PLAD,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-440-01,NDC,facility,both,2,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-487-11,NDC,facility,both,3,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,64980-562-01,NDC,facility,both,10,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOLUTEGRAVIR 50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,49702-228-13,NDC,facility,both,1,EA,,395,276.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN GK 2.5 MU IN NS 100ML IVPB (PDS ADS MIXTURE),50863,CDM,636,RC,J2540,HCPCS,99999-0404-10,NDC,facility,both,5,ML,,159,111.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,76282-208-90,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE IV",50863,CDM,250,RC,J3490,HCPCS,0338-0013-04,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,50863,CDM,250,RC,J9000,HCPCS,0069-1542-20,NDC,facility,both,10,ML,,160,112,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,59746-216-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM SR 180 MG 24 HR CAP,50863,CDM,636,RC,J3490,HCPCS,60687-206-11,NDC,facility,both,1,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,68180-723-04,NDC,facility,both,3,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,50863,CDM,250,RC,J9000,HCPCS,0069-1542-20,NDC,facility,both,5,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELIMUMAB 400 MG IV SOLR,50863,CDM,J0490,HCPCS,49401-102-01,NDC,,,facility,both,120,EA,,13375,9362.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 3000 MCG/ML INJECTION,50863,CDM,J0153,HCPCS,67457-855-00,NDC,,,facility,both,6,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 100 MG PE/2 ML INJ SOLN,50863,CDM,250,RC,Q2009,HCPCS,0641-6136-01,NDC,facility,both,6,ML,,261,182.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,63323-485-26,NDC,,,facility,both,150,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,50863,CDM,J0696,HCPCS,0143-9856-01,NDC,,,facility,both,16,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,J0665,HCPCS,55150-169-10,NDC,,,facility,both,50,ML,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,J2704,HCPCS,63323-269-43,NDC,,,facility,both,20,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,J2003,HCPCS,0409-4277-17,NDC,,,facility,both,3000,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN   1.25 G IV SOLR,50863,CDM,J3373,HCPCS,67457-823-12,NDC,,,facility,both,125,EA,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MECLIZINE 25 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-7376-61,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK,50863,CDM,J3490,HCPCS,12870-0001-1,NDC,,,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-491-01,NDC,facility,both,100,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,J1885,HCPCS,0409-3795-19,NDC,,,facility,both,1,ML,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,J7512,HCPCS,0904-7127-61,NDC,,,facility,both,40,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNITS/1 GRAM PACKET (MERGE RECORD),50863,CDM,J3490,HCPCS,45802-060-00,NDC,,,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BLINATUMOMAB 12.5 MCG/ML IV SOLR,50863,CDM,250,RC,J9039,HCPCS,55513-150-01,NDC,facility,both,35,EA,,11056,7739.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,23155-723-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE (3 MONTH) 11.25 MG IM KIT,50863,CDM,636,RC,J1950,HCPCS,0074-3663-03,NDC,facility,both,3,EA,,14204,9942.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 10 MEQ/100 ML IV PGBK,50863,CDM,250,RC,J3480,HCPCS,14789-109-16,NDC,facility,both,20,ML,,939,657.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,10,EA,JW,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IPRATROPIUM-ALBUTEROL 0.5 MG-2.5 MG/3 ML NEB SOLUTION,50863,CDM,J3490,HCPCS,47335-756-48,NDC,,,facility,both,3,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL 20 MG/5 ML ORAL ELIX,50863,CDM,250,RC,J3490,HCPCS,0121-0942-05,NDC,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MENING VAC A,C,Y,W135,TET (PF) 10 MCG/0.5 ML IM SOLN",50863,CDM,90619,HCPCS,49281-590-58,NDC,,,facility,both,1,ML,,743,520.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6924-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM ACETATE 667 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,69097-862-83,NDC,facility,both,3,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN SODIUM EXTENDED  30 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,58151-118-01,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % MUCOSAL GEL,50863,CDM,636,RC,J3490,HCPCS,50383-781-05,NDC,facility,both,2,ML,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0093-4155-73,NDC,facility,both,40,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE 150 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,68084-713-11,NDC,facility,both,1,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-760-11,NDC,facility,both,2,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60505-0252-2,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SOD CHLOR&BICARB-SQUEEZ BOTTLE NASL PKDV,50863,CDM,250,RC,J3490,HCPCS,592800100,NDC,facility,both,50,EA,,1239,867.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLOPATADINE 0.1 % OPHT DROP,50863,CDM,250,RC,J3490,HCPCS,58602-006-40,NDC,facility,both,1,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  75 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16714-314-01,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 20 GRAM/500 ML IV SOLP,50863,CDM,636,RC,J3475,HCPCS,0409-2050-01,NDC,facility,both,40,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",50863,CDM,250,RC,J1561,HCPCS,13533-800-25,NDC,facility,both,40,ML,,5658,3960.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-21,NDC,facility,both,10,ML,,1414,989.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 10 MG/ML ORAL SOLUTION (REPACK),50863,CDM,636,RC,J3490,HCPCS,0131-5410-71,NDC,facility,both,4,ML,,167,116.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 1 % OPHT DROP,50863,CDM,250,RC,J3490,HCPCS,70069-582-01,NDC,facility,both,1,ML,,221,154.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0093-2279-73,NDC,facility,both,5,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIFEDIPINE 60 MG ORAL TO24,50863,CDM,636,RC,J3490,HCPCS,50268-598-11,NDC,facility,both,2,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,7,EA,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-753-11,NDC,facility,both,2,EA,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-9149-01,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,250,RC,J3490,HCPCS,67850-041-00,NDC,facility,both,1,ML,,172,120.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISAVUCONAZONIUM SULFATE 186 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0469-0520-01,NDC,facility,both,2,EA,,820,574,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J2312,HCPCS,36000-308-01,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FEBUXOSTAT 40 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,72578-136-06,NDC,facility,both,1,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 1 MG/ML NEEDLELESS SYRG,50863,CDM,636,RC,J2312,HCPCS,76329-3369-1,NDC,facility,both,2,ML,,194,135.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0641-6022-01,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-686-10,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 500 MG-125 MG TAB,50863,CDM,250,RC,J3490,HCPCS,16714-296-01,NDC,facility,both,6,EA,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 50% IN WATER (MERGE RECORD),50863,CDM,636,RC,J7060,HCPCS,0409-6648-02,NDC,facility,both,4,ML,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"CALCIUM GLUC IN NACL, ISO-OSM 1 G/100 ML IV SOLN",50863,CDM,J0613,HCPCS,44567-622-01,NDC,,,facility,both,200,ML,,149,104.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZTROPINE 1 MG/ML INJ SOLN,50863,CDM,636,RC,J0515,HCPCS,0143-9233-01,NDC,facility,both,1,ML,JW,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,300,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG ORAL TAB,50863,CDM,J3490,HCPCS,60687-113-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,J2003,HCPCS,63323-486-27,NDC,,,facility,both,300,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,J7510,HCPCS,17856-0815-1,NDC,,,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2001,HCPCS,63323-492-27,NDC,,,facility,both,6,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMIDE PEROXIDE 6.5 % OTIC DROP,50863,CDM,J3490,HCPCS,4203710478,NDC,,,facility,both,1,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-426-02,NDC,facility,both,1,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB 100 MG IV SOLR,50863,CDM,636,RC,J1745,HCPCS,57894-030-01,NDC,facility,both,68,EA,JZ,21918,15342.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
EFGARTIGIMOD ALFA-FCAB 20 MG/ML IV SOLN,50863,CDM,636,RC,J9332,HCPCS,73475-3041-5,NDC,facility,both,600,ML,JZ,49266,34486.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LORAZEPAM 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63304-773-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,68180-150-01,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,62584-994-11,NDC,facility,both,1,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G POTASSIUM 20000000 UNIT INJ SOLR,50863,CDM,250,RC,J2540,HCPCS,70860-127-51,NDC,facility,both,32,EA,,266,186.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,636,RC,J0690,HCPCS,70092-1017-46,NDC,facility,both,3,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 40 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-711-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,68180-150-01,NDC,facility,both,5,ML,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,250,RC,J2003,HCPCS,0143-9575-01,NDC,facility,both,200,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,3,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,43598-053-11,NDC,facility,both,19,ML,,674,471.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE 25 MG/ML INJ SOLN,50863,CDM,250,RC,J3230,HCPCS,43598-141-11,NDC,facility,both,2,ML,,252,176.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 0.3 % OPHT OINT,50863,CDM,250,RC,J3490,HCPCS,0078-0841-01,NDC,facility,both,1,GM,,963,674.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,16714-298-02,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6798-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-161-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 12.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68382-094-01,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NAPHAZOLINE-PHENIRAMINE 0.025 %-0.3 % EYE DROPS,50863,CDM,250,RC,J3490,HCPCS,0065-0085-15,NDC,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RANOLAZINE  500 MG ORAL TB12,50863,CDM,250,RC,J3490,HCPCS,50268-722-11,NDC,facility,both,2,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL 400 UNIT/ML ORAL DROP (REPACK),50863,CDM,250,RC,J3490,HCPCS,87086644,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG IV SOLR,50863,CDM,636,RC,J3490,HCPCS,0143-9381-01,NDC,facility,both,1,EA,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 90 MG TAB,50863,CDM,250,RC,J3490,HCPCS,50228-483-01,NDC,facility,both,2,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE IN D5W 1 GRAM/100 ML IV PGBK,50863,CDM,636,RC,J3475,HCPCS,0338-1709-40,NDC,facility,both,4,ML,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  75 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-441-01,NDC,facility,both,3,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-0430-06,NDC,facility,both,5,EA,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,50863,CDM,250,RC,J3420,HCPCS,63323-044-01,NDC,facility,both,1,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,636,RC,J1953,HCPCS,63323-400-01,NDC,facility,both,75,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM-ALBUTEROL 0.5 MG-2.5 MG/3 ML NEB SOLUTION,50863,CDM,636,RC,J3490,HCPCS,0487-0201-01,NDC,facility,both,2,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  10 MG ORAL TR12,50863,CDM,250,RC,J3490,HCPCS,59011-410-20,NDC,facility,both,2,EA,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,24,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 50 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-854-11,NDC,facility,both,50,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN  500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-155-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4% TOP PATCH,50863,CDM,636,RC,J3490,HCPCS,46581-830-01,NDC,facility,both,3,EA,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,300,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 2400000 UNIT/4 ML IM SYRG,50863,CDM,250,RC,J0561,HCPCS,60793-702-04,NDC,facility,both,24,ML,,1725,1207.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,0904-6474-61,NDC,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VARENICLINE 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,49884-155-76,NDC,facility,both,2,EA,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INDOMETHACIN 50 MG RECT SUPP,50863,CDM,636,RC,J3490,HCPCS,69344-102-33,NDC,facility,both,1,EA,,1282,897.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,250,RC,J2270,HCPCS,0641-6125-01,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,636,RC,Q9968,HCPCS,71288-811-10,NDC,facility,both,20,ML,,332,232.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-25,NDC,facility,both,40,ML,,5658,3960.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,18,ML,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX (PF) 10 MCG IM,50863,CDM,90648,HCPCS,49281-545-03,NDC,,,facility,both,1,EA,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  1 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,59651-484-01,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,43598-931-11,NDC,facility,both,17,ML,,910,637,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,2,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,250,RC,J3490,HCPCS,68180-963-01,NDC,facility,both,1,GM,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,70069-011-01,NDC,facility,both,4,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-41,NDC,facility,both,160,ML,,22631,15841.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLARITHROMYCIN 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0527-1931-06,NDC,facility,both,2,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VORICONAZOLE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65862-891-30,NDC,facility,both,6,EA,,320,224,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) BLADDER INSTILLATION,50863,CDM,636,RC,J9201,HCPCS,0409-0182-01,NDC,facility,both,10,ML,,392,274.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,90,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,43598-931-11,NDC,facility,both,16,ML,,892,624.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENAZEPRIL  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,23155-749-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,16714-536-01,NDC,facility,both,2,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 50 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,59651-489-01,NDC,facility,both,50,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLN,50863,CDM,636,RC,J3262,HCPCS,50242-135-01,NDC,facility,both,560,ML,,10263,7184.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NELARABINE 250 MG/50 ML IV SOLN (PEDS ONCOLOGY),50863,CDM,250,RC,J9261,HCPCS,43598-142-11,NDC,facility,both,5,ML,,1621,1134.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.3 MG/0.3 ML IM PNIJ,50863,CDM,J0171,HCPCS,49502-102-01,NDC,,,facility,both,3,EA,,675,472.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYALURONIDASE 150 UNIT INJ SOLR,50863,CDM,J3470,HCPCS,0548-9090-10,NDC,,,facility,both,2,ML,,452,316.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-495-27,NDC,,,facility,both,140,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON DEXTRAN 50 MG/ML INJ SOLN,50863,CDM,636,RC,J1750,HCPCS,0023-6082-01,NDC,facility,both,2,ML,,209,146.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-495-27,NDC,,,facility,both,150,ML,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-3426-01,NDC,facility,both,3,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68180-113-16,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 17 GRAM (100 %) ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,1152372688,NDC,facility,both,4,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  1 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,64380-782-06,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 25 MG/5 ML (5 MG/ML) ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,52652-6001-1,NDC,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16714-355-01,NDC,facility,both,2,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTAMIDINE 300 MG INJ SOLR,50863,CDM,250,RC,J3490,HCPCS,23155-748-31,NDC,facility,both,1,EA,,329,230.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51672-4027-1,NDC,facility,both,4,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,250,RC,J2720,HCPCS,63323-229-01,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,3,ML,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM ACETATE 2 MEQ/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-3299-15,NDC,facility,both,1,ML,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORHEXIDINE GLUCONATE  0.12 % MM MWSH,50863,CDM,250,RC,J3490,HCPCS,69339-138-15,NDC,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOBRAMYCIN 0.3 % EYE DROPS,50863,CDM,636,RC,J3490,HCPCS,61314-643-05,NDC,facility,both,1,ML,,167,116.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-454-11,NDC,facility,both,1,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VECURONIUM BROMIDE 20 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,55150-236-01,NDC,facility,both,1,EA,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-663-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXAZOSIN 2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-851-95,NDC,facility,both,3,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADVATE: FACTOR VIII CONCENTRATE (MERGE RECORD),50863,CDM,250,RC,J7192,HCPCS,0944-3051-02,NDC,facility,both,500,UN,,2685,1879.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML IV SOLN (MERGE),50863,CDM,636,RC,J3490,HCPCS,0781-3269-71,NDC,facility,both,2,ML,,502,351.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GAMMAGARD LIQUID 10 % IV SOLN,50863,CDM,636,RC,J1569,HCPCS,0944-2700-06,NDC,facility,both,80,ML,"JG,JZ,JA",14422,10095.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
LITHIUM CARBONATE 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-8528-25,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TICAGRELOR 90 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,72205-368-91,NDC,facility,both,7,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),50863,CDM,250,RC,J0171,HCPCS,76329-3318-1,NDC,facility,both,60,ML,,441,308.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN  7.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51672-4034-1,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL (VITAMIN D3)   400 UNIT ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,5026886311,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,250,RC,Q9968,HCPCS,70710-1838-1,NDC,facility,both,105,ML,,1735,1214.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 150 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,69238-1314-9,NDC,facility,both,1,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,68382-444-05,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATENOLOL  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-684-01,NDC,facility,both,3,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),50863,CDM,636,RC,J0171,HCPCS,76329-3318-1,NDC,facility,both,60,ML,,484,338.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,636,RC,J3490,HCPCS,0143-9575-01,NDC,facility,both,300,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2305-16,NDC,facility,both,9,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 1 MG ORAL TBDL,50863,CDM,250,RC,0093-9293-19,NDC,,,facility,both,3,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2305-16,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  15 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,0406-8315-01,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 500 MG/100 ML CONCENTRATED DRIP 100 ML (RSE),50863,CDM,250,RC,J2250,HCPCS,0409-2596-15,NDC,facility,both,500,ML,,383,268.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INDOMETHACIN 25 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,31722-542-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,43066-997-01,NDC,facility,both,4,ML,,133,93.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,636,RC,J7060,HCPCS,0338-0017-38,NDC,facility,both,1,ML,JZ,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
WARFARIN  4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51672-4031-1,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 100 MG PE/2 ML INJ SOLN,50863,CDM,636,RC,Q2009,HCPCS,0641-6136-01,NDC,facility,both,2,ML,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J7510,HCPCS,17856-0815-1,NDC,facility,both,7,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOBAZAM 2.5 MG/ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,99999-0404-03,NDC,facility,both,4,ML,,166,116.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BICTEGRAV-EMTRICIT-TENOFOV ALA 50-200-25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,61958-2501-1,NDC,facility,both,1,EA,,574,401.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,636,RC,J0690,HCPCS,70092-1017-46,NDC,facility,both,12,ML,,238,166.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  750 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,65862-247-08,NDC,facility,both,2,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,0904-7127-61,NDC,facility,both,20,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0406-5771-23,NDC,facility,both,10,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN LOCK FLUSH (PORCINE) 10 UNIT/ML IV SOLN (PEDS),50863,CDM,250,RC,J1642,HCPCS,0409-1151-70,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THEOPHYLLINE 300 MG ORAL TB12,50863,CDM,250,RC,J3490,HCPCS,0904-5889-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,25021-701-01,NDC,facility,both,2,ML,JZ,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-04,NDC,facility,both,3,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0143-9889-15,NDC,facility,both,12,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML INJECTION,50863,CDM,250,RC,J3411,HCPCS,0641-6228-01,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZTREONAM 1 GRAM INJ SOLR,50863,CDM,250,RC,J0457,HCPCS,0409-0829-11,NDC,facility,both,10,EA,,200,140,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-453-01,NDC,facility,both,2,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,50863,CDM,250,RC,J1756,HCPCS,0517-2340-01,NDC,facility,both,500,ML,,1605,1123.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE (FOR EMERGENCY) 100 MG/ML (10%) IV SOLN,50863,CDM,636,RC,J0612,HCPCS,0143-9180-01,NDC,facility,both,200,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,636,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,8,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MOXIFLOXACIN 400 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65862-603-30,NDC,facility,both,1,EA,,134,93.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB 10 MG/ML IV CONC,50863,CDM,J9312,HCPCS,50242-053-06,NDC,,,facility,both,50,ML,,12966,9076.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),50863,CDM,J1171,HCPCS,0409-4264-11,NDC,,,facility,both,10,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM   5 MG ORAL TAB,50863,CDM,636,RC,J0640,HCPCS,0054-8496-19,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 3000 MCG/ML INJECTION,50863,CDM,636,RC,J0153,HCPCS,25021-318-02,NDC,facility,both,6,ML,JZ,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,63323-010-02,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2001,HCPCS,55150-162-05,NDC,,,facility,both,10,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-492-04,NDC,,,facility,both,100,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,250,RC,J3490,HCPCS,71266-9080-2,NDC,facility,both,4,ML,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 5 MG-325 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0406-0123-23,NDC,facility,both,2,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES-DOCUSATE SODIUM 8.6 MG-50 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7440-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG ORAL TAB,50863,CDM,250,RC,Q0169,HCPCS,68084-155-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OMALIZUMAB 150 MG SUBQ SOLR,50863,CDM,636,RC,J2357,HCPCS,50242-040-62,NDC,facility,both,45,ME,,3914,2739.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,250,RC,J3490,HCPCS,63323-485-27,NDC,facility,both,200,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),50863,CDM,250,RC,J1630,HCPCS,67457-426-00,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51672-4005-1,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,68180-150-01,NDC,facility,both,2,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML IV SOLN (MERGE),50863,CDM,250,RC,J3490,HCPCS,16714-037-10,NDC,facility,both,1,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),50863,CDM,636,RC,J1630,HCPCS,63323-474-01,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 10 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,0641-0367-25,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J3490,HCPCS,0338-0049-48,NDC,facility,both,10,ML,,200,140,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 10 MG/ML ORAL SOLUTION (REPACK),50863,CDM,250,RC,J3490,HCPCS,0131-5410-71,NDC,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN SODIUM EXTENDED 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0071-0369-40,NDC,facility,both,6,EA,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 5 % TOP OINT,50863,CDM,250,RC,J3490,HCPCS,65162-918-38,NDC,facility,both,1,GM,,885,619.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,4,ML,JW,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
"TRIMETHOPRIM-POLYMYXIN B 0.1 %-10,000 UNIT/ML EYE DROPS",50863,CDM,250,RC,J3490,HCPCS,0023-7824-10,NDC,facility,both,1,ML,,388,271.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COLLAGENASE 250 UNIT/G TOP OINT,50863,CDM,250,RC,J3490,HCPCS,0064-5010-30,NDC,facility,both,1,GM,,885,619.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE PAMOATE  50 MG ORAL CAP,50863,CDM,636,RC,Q0177,HCPCS,50268-399-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIOTHYRONINE  5 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,59762-1206-1,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEO TPN SODIUM ACETATE 2 MEQ/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-7299-83,NDC,facility,both,2,ML,,132,92.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,78206-121-01,NDC,facility,both,1,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE  50 MCG/ACTUATION NASL SPSN,50863,CDM,636,RC,J3490,HCPCS,72888-141-35,NDC,facility,both,1,GM,,396,277.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,63323-482-27,NDC,facility,both,200,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),50863,CDM,250,RC,J2060,HCPCS,76329-8261-0,NDC,facility,both,5,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROPROCAINE 3 % INJ SOLN,50863,CDM,636,RC,J2401,HCPCS,63323-478-01,NDC,facility,both,45,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,50863,CDM,250,RC,J9000,HCPCS,0069-1542-20,NDC,facility,both,2,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,0904-6474-61,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAZOLAMIDE 500 MG ORAL CPSR,50863,CDM,250,RC,J3490,HCPCS,29033-030-01,NDC,facility,both,3,EA,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE (PF-DURAMORPH/ASTRAMORPH) 0.5 MG/ML INJ SOLN,50863,CDM,636,RC,J2274,HCPCS,0409-3814-11,NDC,facility,both,1,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE (PF-DURAMORPH/ASTRAMORPH) 0.5 MG/ML INJ SOLN,50863,CDM,636,RC,J2274,HCPCS,0409-3814-11,NDC,facility,both,1,ML,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,636,RC,P9045,HCPCS,68516-5219-0,NDC,facility,both,10,ML,,2542,1779.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",50863,CDM,250,RC,J1561,HCPCS,13533-800-21,NDC,facility,both,10,ML,JA,1415,990.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,54288-137-01,NDC,facility,both,5,ML,,845,591.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,10,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,0703-9514-03,NDC,facility,both,1,ML,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLNALTREXONE 12 MG/0.6 ML SUBQ SYRG,50863,CDM,250,RC,J2212,HCPCS,65649-552-04,NDC,facility,both,60,ML,,520,364,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL  32.4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16571-673-01,NDC,facility,both,3,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL  4 MG ORAL TAB,50863,CDM,636,RC,Q0162,HCPCS,65862-187-30,NDC,facility,both,24,EA,,523,366.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 1 MG ORAL TAB,50863,CDM,250,RC,J8540,HCPCS,72578-166-01,NDC,facility,both,16,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE MONONITRATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,5026885111,NDC,facility,both,5,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J2250,HCPCS,0409-2305-17,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-543-01,NDC,facility,both,2,EA,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE IN 0.9 % NACL 4 MG/250 ML (16 MCG/ML) IV SOLN (MERGE),50863,CDM,636,RC,J3490,HCPCS,70004-613-40,NDC,facility,both,1,ML,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VERAPAMIL 120 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,23155-486-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-406-03,NDC,facility,both,1,ML,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2308-22,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE   4.2 % IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-5555-12,NDC,facility,both,2,ML,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  75 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6951-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 50 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,59651-489-01,NDC,facility,both,40,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,42,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 10 GRAM/15 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,50383-779-30,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2308-21,NDC,facility,both,3,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DOFETILIDE 125 MCG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,72205-039-60,NDC,facility,both,1,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-50,NDC,facility,both,5,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0143-9386-01,NDC,facility,both,32,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),50863,CDM,250,RC,J2060,HCPCS,0641-6044-01,NDC,facility,both,2,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-6665-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VECURONIUM BROMIDE 10 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,0703-2914-01,NDC,facility,both,2,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-242-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,636,RC,J3360,HCPCS,43598-106-11,NDC,facility,both,1,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J2004,HCPCS,0409-3178-01,NDC,facility,both,70,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NOREPINEPHRINE BITARTRATE-D5W 16 MG/250 ML (64 MCG/ML) IV SOLN (CENTRAL ONLY),50863,CDM,250,RC,J3490,HCPCS,0338-0116-20,NDC,facility,both,1,ML,,340,238,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,636,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,15,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIACIN  250 MG ORAL CPSR,50863,CDM,250,RC,J3490,HCPCS,1000670020,NDC,facility,both,8,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BROMOCRIPTINE 2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0574-0106-03,NDC,facility,both,2,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6925-61,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON DEXTRAN 50 MG/ML INJ SOLN,50863,CDM,250,RC,J1750,HCPCS,0023-6082-01,NDC,facility,both,2,ML,,219,153.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6797-61,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATENOLOL  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-684-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,27241-001-06,NDC,facility,both,1,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0143-9386-01,NDC,facility,both,23,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIVAROXABAN 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50458-580-01,NDC,facility,both,1,EA,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  25 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-6991-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRIL MALEATE 1 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,69238-1729-7,NDC,facility,both,1,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM 1 GRAM IV SOLR,50863,CDM,250,RC,J2185,HCPCS,63323-508-01,NDC,facility,both,150,EA,,589,412.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,636,RC,J2405,HCPCS,23155-549-31,NDC,facility,both,4,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2599,HCPCS,55150-370-01,NDC,facility,both,2,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,179,ML,,256,179.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,17271-701-06,NDC,facility,both,1,ML,JZ,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,0517-4620-25,NDC,facility,both,5,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0641-6059-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,10,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,6,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FERUMOXYTOL 510 MG/17 ML (30 MG/ML) IV SOLN,50863,CDM,636,RC,Q0138,HCPCS,59338-775-01,NDC,facility,both,510,ML,JZ,3295,2306.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
NIFEDIPINE 90 MG ORAL TO24,50863,CDM,636,RC,J3490,HCPCS,50268-599-11,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM  3.375 GRAM IV SOLR,50863,CDM,250,RC,J2543,HCPCS,55150-120-30,NDC,facility,both,3,EA,JZ,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LIDOCAINE-DIPHENHYD-AL-MAG-SIM 200-25-400-40 MG/30 ML MM MWSH,50863,CDM,636,RC,J3490,HCPCS,65628-050-01,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,13533-690-25,NDC,facility,both,10,ML,,1386,970.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,636,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,3,EA,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,1,EA,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-4279-16,NDC,facility,both,300,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLIMEPIRIDE 2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-326-11,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,4,ML,,6070,4249,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6500-61,NDC,facility,both,1,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 200 MG INJ SOLR,50863,CDM,250,RC,J0640,HCPCS,63323-710-50,NDC,facility,both,4,EA,,119,83.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,45,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,636,RC,J0133,HCPCS,63323-325-03,NDC,facility,both,62,ML,JW,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6773-61,NDC,facility,both,3,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,2,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 100 MG PE/2 ML INJ SOLN,50863,CDM,250,RC,Q2009,HCPCS,0641-6136-01,NDC,facility,both,4,ML,,149,104.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,71399-1025-3,NDC,facility,both,12,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2305-04,NDC,facility,both,15,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIVAROXABAN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50458-580-01,NDC,facility,both,2,EA,,223,156.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7366-04,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,636,RC,J2795,HCPCS,43066-023-01,NDC,facility,both,175,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,103,EA,,14214,9949.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,55111-263-81,NDC,facility,both,2,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYBUTYNIN CHLORIDE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,70954-005-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN LYSINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66993-490-36,NDC,facility,both,1,ML,,939,657.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCERIN (ADULT) RECTAL SUPPOSITORY,50863,CDM,636,RC,J3490,HCPCS,57237-325-21,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOPIDOGREL  75 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-052-10,NDC,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 1%/EPINEPHRINE 1:200K INJECTION (PF),50863,CDM,636,RC,J3490,HCPCS,63739-468-05,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN NORMAL SALINE IV,50863,CDM,250,RC,J7042,HCPCS,0338-0089-03,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IV EPINEPHRINE 0.1 MG/ML SYRINGE (NEO-CODE IV),50863,CDM,250,RC,J0169,HCPCS,0409-4901-18,NDC,facility,both,10,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-497-11,NDC,facility,both,1,EA,PLAD,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
PROPRANOLOL  40 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,83980-007-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BETAMETHASONE ACET & SOD PHOS 6 MG/ML INJ SUSP,50863,CDM,250,RC,J0702,HCPCS,78206-118-01,NDC,facility,both,5,ML,,245,171.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,49502-393-80,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"HEPARIN, PORCINE (PF)  100 UNIT/ML IV SYRG",50863,CDM,636,RC,J1642,HCPCS,6380760055,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML (PEDS CALCLUATOR 0.5),50863,CDM,250,RC,J1815,HCPCS,0024-5924-10,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL (VITAMIN D3) 400 UNIT/ML ORAL DROP,50863,CDM,250,RC,J3490,HCPCS,7651805050,NDC,facility,both,10,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,636,RC,Q9968,HCPCS,70710-1838-1,NDC,facility,both,50,ML,JW,282,197.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CYANOCOBALAMIN 1000 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,7733393825,NDC,facility,both,5,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZTREONAM 2 GRAM INJ SOLR,50863,CDM,250,RC,J0457,HCPCS,0409-0830-11,NDC,facility,both,20,EA,,331,231.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELATACEPT 250 MG IV SOLR,50863,CDM,636,RC,J0485,HCPCS,0003-0371-13,NDC,facility,both,125,EA,JW,561,392.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,63323-104-06,NDC,facility,both,16,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PORACTANT ALFA 240 MG/3 ML INTR SUSP,50863,CDM,250,RC,J3490,HCPCS,10122-510-03,NDC,facility,both,3,ML,,9323,6526.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,70004-600-09,NDC,facility,both,2,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7243-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROFURANTOIN (25% MACROCRYSTAL FORM) 100 MG CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7137-61,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VERAPAMIL 2.5 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,70710-1643-1,NDC,facility,both,1,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN PEDS SYRINGE (20MG/ML) IN DEXTROSE (CDS MIX,50863,CDM,636,RC,J0690,HCPCS,0781-3451-70,NDC,facility,both,9,EA,,21640,15148,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAZOLAMIDE SODIUM 500 (100 MG/ML) INJ SOLR,50863,CDM,250,RC,J1120,HCPCS,23155-313-31,NDC,facility,both,1,EA,JZ,233,163.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PREGABALIN  50 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,64980-411-09,NDC,facility,both,2,EA,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,81284-315-05,NDC,facility,both,1,ML,,353,247.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-495-27,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 10 GRAM/15 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,0116-4005-30,NDC,facility,both,4,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-1971-21,NDC,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
STERILE TALC 3 G INPL AERP,50863,CDM,250,RC,J3490,HCPCS,62327-333-03,NDC,facility,both,3,EA,,1107,774.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIRMATRELVIR-RITONAVIR 300 MG (150 MG X 2)-100 MG ORAL DSPK,50863,CDM,250,RC,J3490,HCPCS,0069-5045-30,NDC,facility,both,3,EA,,539,377.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 400 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6667-61,NDC,facility,both,6,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-1749-70,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN LOCK FLUSH 100 UNIT/ML IV SOLN,50863,CDM,J1642,HCPCS,6425333335,NDC,,,facility,both,150,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT  10 MCG/0.4 ML INJ SYRG,50863,CDM,636,RC,J0881,HCPCS,55513-098-01,NDC,facility,both,1,ML,EC,394,275.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier EC: Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy
METHADONE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-5755-23,NDC,facility,both,2,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE  5 MG ORAL TAB,50863,CDM,J3490,HCPCS,51079-886-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,70756-640-82,NDC,,,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,63323-104-25,NDC,facility,both,14,ML,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,63323-161-00,NDC,facility,both,1,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MIRTAZAPINE 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-086-01,NDC,facility,both,2,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 125 MG ORAL CPSP,50863,CDM,250,RC,J3490,HCPCS,0904-6615-61,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NOREPINEPHRINE BITARTRATE-D5W 4 MG/250 ML (16 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,71285-6056-1,NDC,facility,both,3,ML,,279,195.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LANTHANUM  500 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,68180-819-42,NDC,facility,both,2,EA,,127,88.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,0641-6236-01,NDC,facility,both,2,ML,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,68180-150-01,NDC,facility,both,3,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6709-61,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PORACTANT ALFA 240 MG/3 ML INTR SUSP,50863,CDM,250,RC,J3490,HCPCS,10122-510-01,NDC,facility,both,2,ML,,3307,2314.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,636,RC,J3370,HCPCS,0143-9162-01,NDC,facility,both,2,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,50863,CDM,250,RC,J0561,HCPCS,60793-701-02,NDC,facility,both,12,ML,,1307,914.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,60,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZOCAINE-MENTHOL 6-10 MG MM LOZG,50863,CDM,250,RC,J3490,HCPCS,7811201266,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMINOCAPROIC ACID  500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,62559-225-30,NDC,facility,both,2,EA,,220,154,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7367-06,NDC,facility,both,1,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML IV SOLN (MERGE),50863,CDM,250,RC,J3490,HCPCS,70756-611-82,NDC,facility,both,2,ML,,191,133.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G POTASSIUM 20000000 UNIT INJ SOLR,50863,CDM,250,RC,J2540,HCPCS,0781-6136-94,NDC,facility,both,34,EA,JZ,265,185.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-11,NDC,facility,both,14,ML,JW,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PYRIDOSTIGMINE BROMIDE  60 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6622-61,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANIFROLUMAB-FNIA 300 MG/2 ML (150 MG/ML) IV SOLN,50863,CDM,636,RC,J0491,HCPCS,0310-3040-00,NDC,facility,both,300,ME,JZ,12698,8888.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
BUDESONIDE 0.5 MG/2 ML INHL NBSP,50863,CDM,250,RC,J3490,HCPCS,0487-9701-01,NDC,facility,both,2,ML,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 100 MG/1 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0548-5605-00,NDC,facility,both,20,ML,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,68094-600-59,NDC,facility,both,6,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 5 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,63323-660-05,NDC,facility,both,3,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-01,NDC,facility,both,926,ME,JZ,11075,7752.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0990-7983-61,NDC,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADVATE: FACTOR VIII CONCENTRATE (MERGE RECORD),50863,CDM,250,RC,J7192,HCPCS,0944-3052-03,NDC,facility,both,1000,UN,,4186,2930.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 125 MG ORAL CPSP,50863,CDM,250,RC,J3490,HCPCS,0904-6615-61,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,636,RC,J3490,HCPCS,63323-485-27,NDC,facility,both,75,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-124-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,0517-4620-25,NDC,facility,both,10,ML,,144,100.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACIDOPHILUS-PECTIN W CITRUS 25 MILLION-100 CELL MG TAB,50863,CDM,250,RC,J3490,HCPCS,904661161,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,55150-307-01,NDC,facility,both,66,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0143-9386-01,NDC,facility,both,48,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4% TOP PATCH,50863,CDM,636,RC,J3490,HCPCS,46581-830-01,NDC,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,636,RC,J2405,HCPCS,0641-6078-01,NDC,facility,both,8,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
INSULIN NPH & REGULAR HUMAN 100 UNIT/ML (70-30) SUBQ SUSP,50863,CDM,250,RC,J1815,HCPCS,0169-1837-11,NDC,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0093-3426-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-327-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 0.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7361-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,25,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  20 MG ORAL TR12,50863,CDM,250,RC,J3490,HCPCS,59011-420-20,NDC,facility,both,2,EA,,128,89.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 8-2 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,50268-145-11,NDC,facility,both,2,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,250,RC,J0330,HCPCS,0409-6629-02,NDC,facility,both,6,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 500 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-163-11,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VITAMIN A 10000 UNIT ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,904208560,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0406-1236-01,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,5,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIMOLOL MALEATE 0.25 % OPHT DROP,50863,CDM,250,RC,J3490,HCPCS,61314-226-05,NDC,facility,both,1,ML,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,50863,CDM,636,RC,J0696,HCPCS,44567-701-25,NDC,facility,both,3,EA,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIFAMPIN 25MG/ML SUSPENSION (REPACK),50863,CDM,250,RC,J3490,HCPCS,0185-0799-60,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7126-61,NDC,facility,both,5,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLP",50863,CDM,250,RC,P9047,HCPCS,0944-0493-04,NDC,facility,both,7,ML,,1751,1225.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J1940,HCPCS,63323-280-04,NDC,facility,both,4,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOLAZONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,76385-138-01,NDC,facility,both,1,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOSTIGMINE METHYLSULFATE 3 MG/3 ML (1 MG/ML) IV SYRG,50863,CDM,250,RC,J2710,HCPCS,43598-945-11,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLN (MERGE)",50863,CDM,636,RC,P9047,HCPCS,68982-643-02,NDC,facility,both,4,ML,,993,695.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,63323-201-02,NDC,,,facility,both,20,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,636,RC,J1596,HCPCS,0517-4601-25,NDC,facility,both,3,ML,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG IV SOLR,50863,CDM,J0456,HCPCS,55150-174-10,NDC,,,facility,both,1,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,63323-485-27,NDC,,,facility,both,25,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICARDIPINE 25 MG/10 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,55150-183-01,NDC,facility,both,4,ML,,499,349.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIFEDIPINE 10 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,23155-194-01,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROPROCAINE 3 % INJ SOLN,50863,CDM,J2401,HCPCS,63323-478-20,NDC,,,facility,both,60,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,J3490,HCPCS,0093-2279-73,NDC,,,facility,both,2,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,50863,CDM,J3301,HCPCS,70121-1169-1,NDC,,,facility,both,4,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-495-27,NDC,,,facility,both,25,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  60 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,0406-8380-23,NDC,facility,both,1,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL  20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,65162-351-09,NDC,facility,both,1,EA,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-426-02,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM PHOSPHATE 3 MMOL/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-7391-82,NDC,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIROLIMUS 1 MG/ML ORAL SOLN,50863,CDM,250,RC,J7520,HCPCS,72205-099-78,NDC,facility,both,1,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IV PGBK,50863,CDM,636,RC,J3475,HCPCS,0264-4204-52,NDC,facility,both,4,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESALAMINE 400 MG ORAL CAPSULE-WITH DR TABLETS (CDTI),50863,CDM,250,RC,J3490,HCPCS,60687-556-33,NDC,facility,both,2,EA,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
REGADENOSON 0.4 MG/5 ML IV SYRG,50863,CDM,250,RC,J2785,HCPCS,0469-6501-89,NDC,facility,both,4,ML,,913,639.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0409-7983-02,NDC,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,636,RC,J2405,HCPCS,23155-549-31,NDC,facility,both,24,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL 100 MCG/HR TD PT72,50863,CDM,250,RC,J3490,HCPCS,0378-9124-16,NDC,facility,both,2,EA,,385,269.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTOBARBITAL 75 MG/1.5 ML SYRINGE (REPACK),50863,CDM,636,RC,J2515,HCPCS,25021-676-20,NDC,facility,both,1,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 125 MG ORAL CPSP,50863,CDM,636,RC,J3490,HCPCS,63739-995-10,NDC,facility,both,4,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,16714-661-01,NDC,facility,both,5,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-4208-01,NDC,facility,both,1,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  50 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,72205-012-90,NDC,facility,both,2,EA,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6949-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETIRIZINE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-597-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETIRIZINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-799-02,NDC,facility,both,2,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6290-61,NDC,facility,both,8,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROGESTERONE 50 MG/ML IM OIL,50863,CDM,636,RC,J2675,HCPCS,0591-3128-79,NDC,facility,both,10,ML,,190,133,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0121-0914-05,NDC,facility,both,1,ML,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,68094-231-59,NDC,facility,both,4,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,250,RC,J3490,HCPCS,0904-6930-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN ASP PRT-INSULIN ASPART 100 UNIT/ML (70-30) SUBQ SOLN,50863,CDM,250,RC,J1817,HCPCS,0169-3685-12,NDC,facility,both,2,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELATACEPT 250 MG IV SOLR,50863,CDM,636,RC,J0485,HCPCS,0003-0371-13,NDC,facility,both,375,EA,,3870,2709,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN PEDS SYRINGE (20MG/ML) IN DEXTROSE (CDS MIX,50863,CDM,636,RC,J0690,HCPCS,0781-3451-70,NDC,facility,both,6,EA,JZ,125,87.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MONTELUKAST 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6808-61,NDC,facility,both,5,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7449-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-075-01,NDC,facility,both,4,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LANTHANUM  500 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,76282-476-45,NDC,facility,both,1,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRBESARTAN  75 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,31722-729-30,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRIMIDONE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-202-11,NDC,facility,both,4,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPRAZOLAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0781-1077-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,636,RC,J3490,HCPCS,70004-600-09,NDC,facility,both,2,ML,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL IV BOLUS 10MG/ML (ANESTHESIA ONLY),50863,CDM,636,RC,J2704,HCPCS,0409-4699-54,NDC,facility,both,479,ML,,607,424.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ (MERGE),50863,CDM,636,RC,J2250,HCPCS,0409-0001-01,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,15,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BISACODYL  5 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,0904-6407-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LITHIUM CARBONATE 300 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0054-8527-25,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE SODIUM 25 MG/ML INJ SOLN,50863,CDM,636,RC,J9260,HCPCS,61703-350-37,NDC,facility,both,3,ML,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL  4 MG ORAL TAB,50863,CDM,636,RC,Q0162,HCPCS,65862-187-30,NDC,facility,both,36,EA,,785,549.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,0409-1886-22,NDC,facility,both,450,ML,JZ,233,163.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DIPHENHYDRAMINE 25 MG CAP,50863,CDM,636,RC,J3490,HCPCS,71399-1027-1,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J1611,HCPCS,0597-0053-45,NDC,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML INJECTION,50863,CDM,636,RC,J3411,HCPCS,25021-500-02,NDC,facility,both,3,ML,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-1749-71,NDC,facility,both,1,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NAFCILLIN NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J3490,HCPCS,63323-327-10,NDC,facility,both,8,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-279-11,NDC,facility,both,1,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROTHIAZIDE SODIUM 500 MG IV SOLR,50863,CDM,250,RC,J1205,HCPCS,0517-1820-01,NDC,facility,both,1,EA,,444,310.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J2003,HCPCS,63323-492-04,NDC,facility,both,40,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) IV SOLN",50863,CDM,636,RC,J3490,HCPCS,67457-197-00,NDC,facility,both,1,ML,,368,257.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAZOLAMIDE 250 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6663-61,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,60,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 10 % (100 MG/ML) MISC SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-695-22,NDC,facility,both,1,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,16714-294-01,NDC,facility,both,5,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOMYCIN-BACITRACN ZN-POLYMYXIN 3.5 MG-400 U*,50863,CDM,636,RC,J3490,HCPCS,45802-061-70,NDC,facility,both,5,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7188-61,NDC,facility,both,2,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,33,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,250,RC,J3101,HCPCS,50242-037-06,NDC,facility,both,28,EA,JW,5261,3682.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ALBUTEROL SULFATE 2.5 MG/0.5 ML INHL NEBU,50863,CDM,636,RC,J3490,HCPCS,0487-9901-30,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACAMPROSATE 333 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,60687-121-95,NDC,facility,both,2,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 500 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,68084-415-11,NDC,facility,both,2,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0003-0893-31,NDC,facility,both,2,EA,,119,83.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 50 MG TAB,50863,CDM,250,RC,J3490,HCPCS,55111-292-09,NDC,facility,both,2,EA,,214,149.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-609-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-442-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR 200 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,31722-681-47,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,57237-077-10,NDC,facility,both,4,EA,,378,264.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,3,EA,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,51754-5011-1,NDC,facility,both,1,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXAZOSIN 4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-862-95,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 10 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,70954-261-10,NDC,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"HEPARIN, PORCINE (PF)  100 UNIT/ML IV SYRG",50863,CDM,250,RC,J1642,HCPCS,8290306513,NDC,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 25 MG TAB,50863,CDM,636,RC,J3490,HCPCS,16714-796-01,NDC,facility,both,1,EA,,133,93.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-145-11,NDC,facility,both,30,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,250,RC,J3490,HCPCS,63323-563-97,NDC,facility,both,1,ML,,299,209.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6500-61,NDC,facility,both,2,EA,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL IV BOLUS 10MG/ML (ANESTHESIA ONLY),50863,CDM,250,RC,J2704,HCPCS,0409-4699-54,NDC,facility,both,100,ML,JZ,127,88.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3370,HCPCS,0143-9162-01,NDC,facility,both,2,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 2 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,250,RC,J2270,HCPCS,63323-452-00,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,72603-179-01,NDC,facility,both,10,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,250,RC,J7060,HCPCS,0338-0017-31,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,42806-150-33,NDC,facility,both,4,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,66794-229-02,NDC,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 10% IN WATER (NEO) 2 - 3.99 KG,50863,CDM,636,RC,J3490,HCPCS,0338-0023-04,NDC,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML IV SOLN (MERGE),50863,CDM,636,RC,J3490,HCPCS,16714-037-10,NDC,facility,both,2,ML,,354,247.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML IM SOLN,50863,CDM,636,RC,90375,HCPCS,13533-318-05,NDC,facility,both,9,ML,JW,3579,2505.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2599,HCPCS,43598-914-25,NDC,facility,both,10,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-613-04,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ABATACEPT 250 MG IV SOLR,50863,CDM,636,RC,J0129,HCPCS,0003-2187-13,NDC,facility,both,50,EA,JA,8356,5849.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,63739-196-01,NDC,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 250 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,42192-608-05,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISANKIZUMAB-RZAA  60 MG/ML IV SOLN,50863,CDM,636,RC,J2327,HCPCS,0074-5015-01,NDC,facility,both,600,ML,JZ,28629,20040.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MEMANTINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6505-06,NDC,facility,both,4,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE (FOR EMERGENCY) 100 MG/ML (10%) IV SOLN,50863,CDM,250,RC,J0612,HCPCS,63323-360-01,NDC,facility,both,100,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"HEPARIN, PORCINE (PF)   10 UNIT/ML IV SYRG",50863,CDM,250,RC,J1642,HCPCS,8290306413,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,42806-150-33,NDC,facility,both,3,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,4,ML,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LINEZOLID 600 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,67877-419-33,NDC,facility,both,22,EA,,9294,6505.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,76045-009-10,NDC,facility,both,40,ML,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 20MG/ML IV SYRINGE (PEDS/NEO),50863,CDM,250,RC,J0612,HCPCS,63323-311-10,NDC,facility,both,100,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,72266-118-01,NDC,facility,both,1,ML,"JW,PLAD",2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient | Modifier PLAD: Modifier description not available
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,636,RC,J3490,HCPCS,0781-7296-85,NDC,facility,both,1,GM,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE 25 MG/ML INJ SOLN,50863,CDM,250,RC,J3230,HCPCS,70710-1850-1,NDC,facility,both,2,ML,,252,176.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML IM SOLN,50863,CDM,636,RC,90375,HCPCS,13533-318-05,NDC,facility,both,7,ML,,6084,4258.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 15 MG/ML (1.5 %) INJ SOLN,50863,CDM,J2003,HCPCS,0409-4776-10,NDC,,,facility,both,150,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,J2003,HCPCS,63323-486-02,NDC,,,facility,both,24,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE ACETATE 25 MG RECT SUPP,50863,CDM,250,RC,J3490,HCPCS,0713-0503-12,NDC,facility,both,1,EA,,111,77.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPATITIS A VIRUS VACCINE (PF) 25 UNIT/0.5 ML IM MERGE (CAM USE ONLY),50863,CDM,90633,HCPCS,0006-4095-01,NDC,,,facility,both,1,ML,,228,159.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,J7060,HCPCS,0338-0017-02,NDC,,,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,J3490,HCPCS,71266-9080-2,NDC,,,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,9,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MYCOPHENOLATE 500 MG IV SOLUTION,50863,CDM,250,RC,J3490,HCPCS,71288-803-20,NDC,facility,both,2,EA,,554,387.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"OCTREOTIDE,MICROSPHERES 20 MG IM SERR",50863,CDM,J2353,HCPCS,0078-0818-81,NDC,,,facility,both,20,EA,,12741,8918.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,J7512,HCPCS,0054-0017-20,NDC,,,facility,both,30,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,50863,CDM,636,RC,J0696,HCPCS,0781-3209-90,NDC,facility,both,8,EA,JZ,388,271.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
D5-1/2 NS AND POTASSIUM CHLORIDE 20 MEQ/L IV (PEDS CHEMO),50863,CDM,250,RC,J3490,HCPCS,0264-7635-00,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,60687-145-11,NDC,facility,both,30,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7057-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOLTERODINE 2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,33342-098-09,NDC,facility,both,2,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,14789-128-07,NDC,facility,both,7,ML,,1344,940.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,5,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ARIPIPRAZOLE 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-090-11,NDC,facility,both,1,EA,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATED 20 MG/ML IV SOLN,50863,CDM,250,RC,J0706,HCPCS,51754-0500-1,NDC,facility,both,12,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,11,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 1 MG (ENVARSUS XR) 24-HOUR EXTENDED-RELEASE TABLET,50863,CDM,250,RC,J7508,HCPCS,68992-3010-3,NDC,facility,both,8,EA,,225,157.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 40 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,13668-011-01,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7350-06,NDC,facility,both,8,EA,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7008-61,NDC,facility,both,12,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLP",50863,CDM,636,RC,P9047,HCPCS,68516-5216-8,NDC,facility,both,4,ML,JZ,1614,1129.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"ALBUMIN, HUMAN 25 % IV SOLN (MERGE)",50863,CDM,636,RC,P9047,HCPCS,64208-2512-8,NDC,facility,both,1,ML,JW,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CARBIDOPA-LEVODOPA 25 MG-100 MG TAB,50863,CDM,250,RC,J3490,HCPCS,59651-457-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,636,RC,J1939,HCPCS,65219-570-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0703-1153-01,NDC,facility,both,4,ML,,423,296.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE (FOR CODE) 10% (100 MG/ML) IV SYRINGE,50863,CDM,J3490,HCPCS,0409-4928-11,NDC,,,facility,both,1,ML,,101,70.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RASBURICASE 1.5 MG IV SOLR,50863,CDM,J2783,HCPCS,0024-5150-10,NDC,,,facility,both,3,EA,,2879,2015.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCUSATE SODIUM 100 MG ORAL CAP,50863,CDM,J3490,HCPCS,0904-7183-61,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,636,RC,Q9968,HCPCS,70710-1838-1,NDC,facility,both,10,ML,,166,116.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 1 MG ORAL TAB,50863,CDM,J3490,HCPCS,60687-384-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOBENZAPRINE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7401-61,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-411-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 17 GRAM (100 %) ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,0904-6931-86,NDC,facility,both,15,EA,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYBUTYNIN CHLORIDE  5 MG ORAL TO24,50863,CDM,250,RC,J3490,HCPCS,68084-480-11,NDC,facility,both,3,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN ENEMA 500MG IN 100ML NS,50863,CDM,636,RC,J3373,HCPCS,67457-339-00,NDC,facility,both,1,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN PEDS SYRINGE (20MG/ML) IN DEXTROSE (CDS MIX,50863,CDM,636,RC,J7999,HCPCS,0781-3451-70,NDC,facility,both,2,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,0409-9093-32,NDC,facility,both,2,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE IN D5W 1 GRAM/100 ML IV PGBK,50863,CDM,250,RC,J3475,HCPCS,0264-4400-54,NDC,facility,both,8,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 40 % ORAL GEL,50863,CDM,250,RC,J3490,HCPCS,574006930,NDC,facility,both,28,GM,,386,270.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 100 MG ORAL TAB,50863,CDM,J3490,HCPCS,60687-439-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALASPARGASE PEGOL-MKNL 750 UNITS/ML IV SOLN,50863,CDM,J9118,HCPCS,72694-515-01,NDC,,,facility,both,750,ML,,151101,105770.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DATOPOTAMAB DERUXTECAN-DLNK 100 MG IV SOLR,50863,CDM,J9011,HCPCS,65597-801-01,NDC,,,facility,both,60,EA,,3522,2465.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,50863,CDM,J0561,HCPCS,60793-701-02,NDC,,,facility,both,24,ML,,2613,1829.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMINOCAPROIC ACID 250 MG/ML IV SOLN,50863,CDM,J3490,HCPCS,0517-9120-01,NDC,,,facility,both,2,ML,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 2 %-1:200,000 INJ SOLN",50863,CDM,J2004,HCPCS,63323-489-02,NDC,,,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORDIAZEPOXIDE 25 MG CAP,50863,CDM,J3490,HCPCS,0555-0159-02,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN   81 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,57896-981-12,NDC,facility,both,7,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2305-04,NDC,facility,both,9,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL IV BOLUS 10MG/ML (ANESTHESIA ONLY),50863,CDM,J2704,HCPCS,63323-269-29,NDC,,,facility,both,40,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN V POTASSIUM 250 MG ORAL TAB,50863,CDM,J3490,HCPCS,16714-234-01,NDC,,,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,J1171,HCPCS,76045-009-10,NDC,,,facility,both,15,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,10,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-05,NDC,facility,both,4,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,0143-9511-01,NDC,facility,both,21,ML,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,78206-122-01,NDC,facility,both,1,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FILGRASTIM-SNDZ 300 MCG/0.5 ML INJ SYRG,50863,CDM,636,RC,Q5101,HCPCS,61314-318-05,NDC,facility,both,300,ML,,972,680.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,67457-433-00,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  37.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-844-11,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 8-2 MG SL SUBL,50863,CDM,636,RC,J3490,HCPCS,60687-637-11,NDC,facility,both,6,EA,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-229-02,NDC,facility,both,2,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES-DOCUSATE SODIUM 8.6 MG-50 MG TAB,50863,CDM,250,RC,J3490,HCPCS,10135-669-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,636,RC,J3490,HCPCS,63323-486-05,NDC,facility,both,300,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,63323-482-01,NDC,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6303-61,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM IN D5W 125 MG/125 ML (1 MG/ML) IV SOLN (PREMIX),50863,CDM,250,RC,J3490,HCPCS,72196-6054-1,NDC,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6925-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DORAVIRINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0006-3069-01,NDC,facility,both,1,EA,,313,219.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,250,RC,J2720,HCPCS,63323-229-01,NDC,facility,both,10,ML,JZ,182,127.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
AMOXICILLIN-POT CLAVULANATE 250 MG-62.5 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,59651-026-75,NDC,facility,both,7,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  0.25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-577-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPRAZOLAM 0.25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-377-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS",50863,CDM,250,RC,J3490,HCPCS,61314-630-06,NDC,facility,both,1,ML,,216,151.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MANNITOL 25 % IV SOLN,50863,CDM,250,RC,J2150,HCPCS,63323-024-01,NDC,facility,both,150,ML,,121,84.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,63323-104-25,NDC,facility,both,18,ML,,111,77.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0074-4341-90,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 400 MCG/100 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0338-9557-12,NDC,facility,both,2,ML,,233,163.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE NA (PRESERV FREE) 25 MG/ML INJ SOLN,50863,CDM,636,RC,J9260,HCPCS,16729-277-35,NDC,facility,both,20,ML,,202,141.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-1749-70,NDC,facility,both,2,ML,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,16714-016-01,NDC,facility,both,4,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORDIAZEPOXIDE 10 MG CAP,50863,CDM,636,RC,J3490,HCPCS,51079-375-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 20MG/55 ML IVPB IN NS (ONCOLOGY),50863,CDM,250,RC,J1100,HCPCS,63323-165-02,NDC,facility,both,20,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-6773-61,NDC,,,facility,both,3,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,250,RC,J0137,HCPCS,0264-4100-90,NDC,facility,both,36,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES-DOCUSATE SODIUM 8.6 MG-50 MG TAB,50863,CDM,250,RC,J3490,HCPCS,60687-622-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 600 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65162-465-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL  20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-717-11,NDC,facility,both,2,EA,,162,113.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANTIVENIN LATRODECTUS MACTANS INJ CMPK,50863,CDM,636,RC,J3590,HCPCS,0006-5424-02,NDC,facility,both,1,EA,,163,114.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  10 MG ORAL TR12,50863,CDM,250,RC,J3490,HCPCS,59011-410-20,NDC,facility,both,1,EA,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,16714-298-01,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROPRUSSIDE 25 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,43598-587-23,NDC,facility,both,1,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-192-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,68180-150-01,NDC,facility,both,3,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-411-10,NDC,facility,both,18,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL 20 MG/5 ML ORAL ELIX,50863,CDM,636,RC,J3490,HCPCS,0121-0942-05,NDC,facility,both,8,ML,,145,101.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHIMAZOLE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,23155-071-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHIMAZOLE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-680-11,NDC,facility,both,3,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM  2.25 GRAM IV SOLR,50863,CDM,636,RC,J2543,HCPCS,60505-6156-0,NDC,facility,both,3,EA,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 500 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,50268-152-15,NDC,facility,both,28,EA,,168,117.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPRAZOLAM 0.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,59762-3720-1,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,70377-008-12,NDC,facility,both,1,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYL SALICYLATE-MENTHOL 15-1 % TOPICAL CREAM,50863,CDM,636,RC,J3490,HCPCS,0178-0320-03,NDC,facility,both,1,GM,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,0409-1886-22,NDC,facility,both,400,ML,JZ,207,144.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,Q0162,HCPCS,68094-763-59,NDC,,,facility,both,8,ML,,150,105,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL DECANOATE 100 MG/ML IM SOLN,50863,CDM,636,RC,J1631,HCPCS,70069-383-01,NDC,facility,both,2,ML,,238,166.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,25,EA,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 20 MG ORAL CPDR,50863,CDM,636,RC,J3490,HCPCS,51991-746-90,NDC,facility,both,1,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7243-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM  3 GRAM INJ SOLR,50863,CDM,250,RC,J0295,HCPCS,63323-369-20,NDC,facility,both,2,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7121-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FEBUXOSTAT 40 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-538-11,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  60 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,69292-536-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6084-61,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-886-20,NDC,facility,both,15,EA,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE (4-MONTH) 30 MG SUBQ SYRG,50863,CDM,636,RC,J9217,HCPCS,62935-306-40,NDC,facility,both,4,EA,JZ,1176,823.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,636,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,20,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,50863,CDM,250,RC,J9267,HCPCS,61703-342-50,NDC,facility,both,221,ML,,267,186.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  75 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7000-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 5 MG/ML (0.5 %) INJECTION,50863,CDM,636,RC,J3490,HCPCS,0409-4275-16,NDC,facility,both,38,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  20 MG ORAL TAB,50863,CDM,J3490,HCPCS,0378-0183-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,636,RC,J3490,HCPCS,63323-485-27,NDC,facility,both,40,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT 300 MCG/0.6 ML INJ SYRG,50863,CDM,J0881,HCPCS,55513-111-01,NDC,,,facility,both,300,ML,,6409,4486.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIFAMPIN 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-586-11,NDC,facility,both,2,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,50863,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,13,EA,,279,195.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-9791-01,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL,50863,CDM,250,RC,J3490,HCPCS,63323-820-01,NDC,facility,both,1,ML,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLP,50863,CDM,250,RC,J3480,HCPCS,63323-965-02,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,J7510,HCPCS,17856-0759-5,NDC,,,facility,both,3,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 50% IN WATER (MERGE RECORD),50863,CDM,J7060,HCPCS,76329-3302-1,NDC,,,facility,both,1,ML,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6501-61,NDC,facility,both,1,EA,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6501-06,NDC,facility,both,2,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM NEO IV SYRINGE (PHS FROM PREMIX),50863,CDM,250,RC,J1953,HCPCS,44567-501-01,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,16714-046-01,NDC,facility,both,10,ML,JZ,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
HYDROXYZINE 10 MG TAB,50863,CDM,250,RC,Q0177,HCPCS,60687-664-11,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),50863,CDM,636,RC,J0171,HCPCS,0409-4921-34,NDC,facility,both,10,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE-SODIUM BENZOATE 250 MG/ML INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0517-2502-01,NDC,facility,both,1,ML,,215,150.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TERAZOSIN  5 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,59746-385-06,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 250 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,0904-6860-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,636,RC,J2270,HCPCS,0409-1890-03,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,180,EA,,24840,17388,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"TRANEXAMIC ACID IN NACL,ISO-OS 1,000 MG/100 ML (10 MG/ML) IV PGBK",50863,CDM,250,RC,J3490,HCPCS,80830-2329-1,NDC,facility,both,2,ML,,241,168.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J3490,HCPCS,0338-0049-01,NDC,facility,both,2,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,620,ME,JZ,8414,5889.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LITHIUM CARBONATE 300 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0054-8528-25,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENEFIX: FIX CONCENTRATE (MERGE RECORD),50863,CDM,636,RC,J7195,HCPCS,58394-633-03,NDC,facility,both,8000,UN,,38704,27092.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMTERENE-HYDROCHLOROTHIAZIDE 37.5 MG-25 MG CAP,50863,CDM,636,RC,J3490,HCPCS,0781-2074-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNIT/G TOP OINT (MERGE),50863,CDM,250,RC,J3490,HCPCS,1093956433,NDC,facility,both,1,GM,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,J0665,HCPCS,0409-1160-01,NDC,,,facility,both,35,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEBIVOLOL  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,31722-586-90,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-657-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6376-61,NDC,facility,both,3,EA,,194,135.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BIVALIRUDIN 250 MG/50 ML (5 MG/ML) IV SOLN,50863,CDM,250,RC,J0583,HCPCS,42023-622-01,NDC,facility,both,250,ML,,365,255.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,0641-6174-01,NDC,facility,both,3,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DASATINIB 100 MG ORAL TAB,50863,CDM,250,RC,J9999,HCPCS,60505-3631-3,NDC,facility,both,1,EA,,2233,1563.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,81284-315-05,NDC,facility,both,1,ML,,470,329,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,5,EA,,178,124.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,636,RC,J3490,HCPCS,0904-6794-80,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR  6 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0004-0822-05,NDC,facility,both,4,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIFAMPIN 600 MG IV SOLR,50863,CDM,636,RC,J3490,HCPCS,67457-445-60,NDC,facility,both,1,EA,,694,485.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  75 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7000-61,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN 1 MG/ML INJECTION (PEDS ONCOLOGY),50863,CDM,250,RC,J0640,HCPCS,71288-160-10,NDC,facility,both,1,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 100 MG/ML INJ SOLN,50863,CDM,250,RC,J2800,HCPCS,70069-101-01,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J0461,HCPCS,0517-1004-01,NDC,facility,both,10,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE IN D5W 1 GRAM/100 ML IV PGBK,50863,CDM,636,RC,J3475,HCPCS,63323-108-00,NDC,facility,both,4,ML,JZ,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
NICOTINE 14 MG/24 HR TD PT24,50863,CDM,250,RC,J3490,HCPCS,60505-7062-0,NDC,facility,both,2,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MONTELUKAST  5 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,31722-728-30,NDC,facility,both,1,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNITS/1 GRAM PACKET (MERGE RECORD),50863,CDM,250,RC,J3490,HCPCS,0904-7023-67,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,63323-010-02,NDC,facility,both,5,ML,,151,105.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 30 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,13107-003-34,NDC,facility,both,2,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 17 GRAM (100 %) ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,1152372688,NDC,facility,both,1,EA,PLAD,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
LORATADINE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7511-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 200 MG INJ SOLR,50863,CDM,250,RC,J0640,HCPCS,0143-9553-01,NDC,facility,both,4,EA,,141,98.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOPAMINE 200 MG/5 ML (40 MG/ML) IV,50863,CDM,250,RC,J1265,HCPCS,0143-9252-01,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLIPIZIDE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0591-0460-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITRIOL 0.5 MCG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,23155-663-01,NDC,facility,both,2,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,67877-548-88,NDC,facility,both,4,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOPIDOGREL 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6467-10,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,50863,CDM,250,RC,J0640,HCPCS,67457-528-10,NDC,facility,both,1,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO PROTAM & LISPRO 100 UNIT/ML (75-25) SUBQ SUSP,50863,CDM,250,RC,J1815,HCPCS,0002-7511-01,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 80 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-685-02,NDC,facility,both,1,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 125 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6955-61,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,68462-469-40,NDC,facility,both,3,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,68516-5219-0,NDC,facility,both,4,ML,,1304,912.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16714-683-02,NDC,facility,both,1,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,17856-0574-1,NDC,facility,both,4,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,5,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,68516-5214-2,NDC,facility,both,14,ML,,1997,1397.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0245-0144-89,NDC,facility,both,1,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 175 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-541-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MUPIROCIN 2 % TOP OINT,50863,CDM,636,RC,J3490,HCPCS,0093-1010-42,NDC,facility,both,1,GM,,363,254.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ANTI-INHIBITOR COAGULANT CMPLX 1,750-3,250 UNIT IV SOLR",50863,CDM,250,RC,J7198,HCPCS,64193-425-02,NDC,facility,both,4310,UN,,25675,17972.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,636,RC,J2560,HCPCS,14789-128-07,NDC,facility,both,1,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 500 MG/100 ML CONCENTRATED DRIP 100 ML (RSE),50863,CDM,250,RC,J2250,HCPCS,0409-2596-15,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERTAPENEM 1 GRAM INJ SOLR,50863,CDM,636,RC,J1335,HCPCS,60505-6196-0,NDC,facility,both,2,EA,,506,354.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-1283-03,NDC,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE 8 MG SL SUBL,50863,CDM,636,RC,J3490,HCPCS,0054-0177-13,NDC,facility,both,6,EA,,228,159.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,16,EA,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,250,RC,J2720,HCPCS,63323-229-01,NDC,facility,both,3,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,2055503601,NDC,facility,both,14,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML IM SOLN,50863,CDM,250,RC,90375,HCPCS,13533-318-30,NDC,facility,both,12,ML,,11270,7889,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-3178-01,NDC,facility,both,130,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,50863,CDM,636,RC,J0585,HCPCS,0023-1145-01,NDC,facility,both,30,EA,,480,336,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2305-04,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-506-11,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 20 GRAM/30 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,0121-1154-30,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"HEPARIN, PORCINE (PF)  100 UNIT/ML IV SYRG",50863,CDM,250,RC,J1642,HCPCS,8290306424,NDC,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 7.5 MG-325 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0406-0124-23,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,36000-283-25,NDC,facility,both,40,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM 1 GRAM IV SOLR,50863,CDM,250,RC,J2185,HCPCS,55150-208-30,NDC,facility,both,20,EA,JZ,130,91,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
EPHEDRINE 50 MG/ML IV SOLN (MERGE),50863,CDM,250,RC,J3490,HCPCS,16714-037-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,14789-127-07,NDC,facility,both,3,ML,,411,287.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IVPB (PEDIATRICS/ADULT NON-FORM)",50863,CDM,636,RC,J0131,HCPCS,24201-100-01,NDC,facility,both,70,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"NEOMYCIN-POLYMYXIN-HC 3.5 MG-10,000 UNIT/ML-1 % EAR DROPS, SUSP",50863,CDM,250,RC,J3490,HCPCS,61314-645-11,NDC,facility,both,1,ML,,378,264.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1162-18,NDC,facility,both,200,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-6695-02,NDC,facility,both,1,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SINCALIDE 5 MCG INJ SOLR,50863,CDM,636,RC,J2805,HCPCS,72266-248-05,NDC,facility,both,1,EA,,260,182,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,43598-053-11,NDC,facility,both,30,ML,JZ,1084,758.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,636,RC,J0690,HCPCS,60505-6142-0,NDC,facility,both,4,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,25,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 112 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6954-61,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROGESTERONE 50 MG/ML IM OIL,50863,CDM,250,RC,J2675,HCPCS,55150-306-10,NDC,facility,both,10,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,250,RC,Q9968,HCPCS,70710-1838-1,NDC,facility,both,42,ML,JW,240,168,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CHLOROPROCAINE 3 % INJ SOLN,50863,CDM,250,RC,J2401,HCPCS,63323-478-01,NDC,facility,both,551,ML,JW,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LANSOPRAZOLE 3 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,65628-080-05,NDC,facility,both,1,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-130-11,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,50863,CDM,250,RC,J3301,HCPCS,16714-130-01,NDC,facility,both,4,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,50863,CDM,250,RC,J1756,HCPCS,0517-2340-01,NDC,facility,both,200,ML,JZ,642,449.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
OXYCODONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-0552-23,NDC,facility,both,2,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DROPERIDOL 2.5 MG/ML INJ SOLN,50863,CDM,250,RC,J1790,HCPCS,0143-9514-01,NDC,facility,both,1,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0781-3246-02,NDC,facility,both,6,ML,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATENOLOL  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7187-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL  20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-416-11,NDC,facility,both,2,EA,,198,138.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML (ANESTHESIA INTRAOP ONLY),50863,CDM,250,RC,J3010,HCPCS,0641-6027-01,NDC,facility,both,10,ML,,142,99.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J2004,HCPCS,0409-3178-01,NDC,facility,both,170,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),50863,CDM,250,RC,J0171,HCPCS,76329-3318-1,NDC,facility,both,60,ML,,484,338.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN DETEMIR 100 UNIT/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,0169-3687-12,NDC,facility,both,8,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPLERENONE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-451-11,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"HEPARIN (PORCINE) IN 0.9% NACL 2,500 UNIT/250 ML (10 UNIT/ML) IV SOLP",50863,CDM,250,RC,J3490,HCPCS,71285-8000-1,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4% TOP PATCH,50863,CDM,636,RC,J3490,HCPCS,0536-1202-15,NDC,facility,both,4,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML INJ SOLN,50863,CDM,250,RC,J0169,HCPCS,76329-9060-0,NDC,facility,both,160,ML,,425,297.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML IV SOLN (MERGE),50863,CDM,250,RC,J3490,HCPCS,70756-611-82,NDC,facility,both,1,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,140,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,76045-009-96,NDC,facility,both,5,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ESMOLOL IN SALINE (ISO-OSMOTIC) 2,500 MG/250 ML (10 MG/ML) IV",50863,CDM,250,RC,J1805,HCPCS,25021-308-84,NDC,facility,both,1,ML,,143,100.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,636,RC,P9045,HCPCS,64208-2510-5,NDC,facility,both,12,ML,,992,694.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOBUTAMINE IN D5W 500 MG/250 ML (2 MG/ML) INFUSION (PREMIX),50863,CDM,636,RC,J1250,HCPCS,0409-2347-32,NDC,facility,both,2,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,50863,CDM,636,RC,J1756,HCPCS,0517-2340-01,NDC,facility,both,200,ML,,623,436.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,250,RC,J3490,HCPCS,63037-136-25,NDC,facility,both,3,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,636,RC,J1815,HCPCS,0088-2220-33,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTOBARBITAL 75 MG/1.5 ML SYRINGE (REPACK),50863,CDM,636,RC,J3490,HCPCS,25021-676-20,NDC,facility,both,2,ML,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-739-41,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0143-9386-01,NDC,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0143-9889-01,NDC,facility,both,18,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-1749-70,NDC,facility,both,2,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-01,NDC,facility,both,406,ME,JZ,4856,3399.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GUAIFENESIN 600 MG ORAL TP12,50863,CDM,250,RC,J3490,HCPCS,0904-6718-39,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,50863,CDM,636,RC,J0585,HCPCS,0023-1145-01,NDC,facility,both,80,EA,,1279,895.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-089-11,NDC,facility,both,1,EA,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 800 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6707-06,NDC,facility,both,3,EA,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1940,HCPCS,63323-280-03,NDC,facility,both,5,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0780,HCPCS,0641-6135-01,NDC,facility,both,1,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,33,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL,50863,CDM,250,RC,J3490,HCPCS,63323-820-01,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,63323-400-01,NDC,facility,both,50,ML,JZ,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,250,RC,J2795,HCPCS,43066-023-01,NDC,facility,both,150,ML,"JZ,PLAD",54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier PLAD: Modifier description not available
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 10 GRAM/100 ML (10%) INJ SOLN",50863,CDM,250,RC,J1561,HCPCS,13533-800-72,NDC,facility,both,100,ML,JA,14144,9900.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,76045-009-96,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0003-0894-31,NDC,facility,both,1,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,0904-6474-61,NDC,facility,both,2,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 400 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,65862-071-01,NDC,facility,both,9,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,22,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL,50863,CDM,636,RC,J1071,HCPCS,0574-0827-01,NDC,facility,both,200,ML,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0641-6206-01,NDC,facility,both,20,ML,,170,119,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 50 % (4 MEQ/ML) INJ SOLN,50863,CDM,250,RC,J3475,HCPCS,63323-064-02,NDC,facility,both,4,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN LYSINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66993-490-84,NDC,facility,both,1,ML,,794,555.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIOGLITAZONE 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65862-512-90,NDC,facility,both,2,EA,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM IN NACL (ISO-OS) 1500 MG/100 ML IV PGBK,50863,CDM,636,RC,J1953,HCPCS,43598-637-52,NDC,facility,both,150,ML,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INDOMETHACIN 25 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,31722-542-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 250 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,50268-259-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-544-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,50863,CDM,250,RC,J2359,HCPCS,55150-308-01,NDC,facility,both,40,EA,,416,291.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42858-302-25,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VORICONAZOLE 200 MG IV SOLN,50863,CDM,250,RC,J3465,HCPCS,0781-3416-94,NDC,facility,both,29,EA,,774,541.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,636,RC,J3490,HCPCS,72603-387-01,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25 MG-100 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6237-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NADOLOL  20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,76385-133-01,NDC,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,25,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE HCL IN NS 10 MG/250 ML (0.04 MG/ML) IV SOLN (PDS MERGE),50863,CDM,636,RC,J2371,HCPCS,70004-811-40,NDC,facility,both,500,ML,,146,102.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6966-61,NDC,facility,both,5,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPTOMYCIN 500 MG IV SOLR,50863,CDM,636,RC,J0878,HCPCS,0409-0122-01,NDC,facility,both,350,EA,JZ,282,197.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DOXYCYCLINE HYCLATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-0430-06,NDC,facility,both,14,EA,,180,126,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,636,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,138,ML,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NORGESTREL-ETHINYL ESTRADIOL 0.3 MG-30 MCG TAB,50863,CDM,250,RC,J3490,HCPCS,16714-365-04,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE (PF) 1 MG/ML INJ SOLN,50863,CDM,250,RC,J0171,HCPCS,54288-103-01,NDC,facility,both,140,ML,,1199,839.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1940,HCPCS,72603-251-01,NDC,facility,both,8,ML,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE ERX) (STEMI),50863,CDM,636,RC,J3101,HCPCS,50242-120-47,NDC,facility,both,50,EA,,22901,16030.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERTAPENEM 1 GRAM INJ SOLR,50863,CDM,250,RC,J1335,HCPCS,55150-282-20,NDC,facility,both,2,EA,,306,214.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  88 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-486-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7008-61,NDC,facility,both,2,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) IN 0.9 % NACL 1 MG/ML IV SOLN,50863,CDM,250,RC,J2250,HCPCS,65219-650-05,NDC,facility,both,50,ML,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VORICONAZOLE 200 MG IV SOLN,50863,CDM,250,RC,J3465,HCPCS,0781-3416-94,NDC,facility,both,7,EA,JW,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
OLANZAPINE 10 MG IM SOLR,50863,CDM,636,RC,J2359,HCPCS,55150-308-01,NDC,facility,both,5,EA,JZ,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DULOXETINE 20 MG ORAL CPDR,50863,CDM,636,RC,J3490,HCPCS,0904-7043-61,NDC,facility,both,2,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 150 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,0904-7084-61,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIFEDIPINE 30 MG ORAL TO24,50863,CDM,250,RC,J3490,HCPCS,0904-7208-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 50% IN WATER (MERGE RECORD),50863,CDM,250,RC,J7060,HCPCS,0409-7517-66,NDC,facility,both,2,ML,,232,162.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN SODIUM EXTENDED 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,65862-692-01,NDC,facility,both,3,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 0.25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-570-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6290-61,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM  3 GRAM INJ SOLR,50863,CDM,250,RC,J0295,HCPCS,72485-417-01,NDC,facility,both,2,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J2312,HCPCS,67457-299-10,NDC,facility,both,400,ML,,513,359.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAFASITAMAB-CXIX 200 MG IV SOLR,50863,CDM,250,RC,J9349,HCPCS,73535-208-01,NDC,facility,both,500,EA,,16560,11592,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-673-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J1230,HCPCS,17478-380-20,NDC,facility,both,1,ML,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,636,RC,J3490,HCPCS,73013-2002-2,NDC,facility,both,6,ML,,133,93.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE NA (PRESERV FREE) 25 MG/ML INJ SOLN,50863,CDM,250,RC,J9260,HCPCS,61703-408-41,NDC,facility,both,360,ML,,3880,2716,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 160 MG-800 MG TAB,50863,CDM,636,RC,J3490,HCPCS,68084-230-11,NDC,facility,both,14,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 20 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,62332-023-31,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  25 MG ORAL TAB,50863,CDM,J3490,HCPCS,60687-822-11,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLN,50863,CDM,J3262,HCPCS,50242-135-01,NDC,,,facility,both,440,ML,,8064,5644.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 10 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-6798-61,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,35573-428-51,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 0.2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60505-0258-1,NDC,facility,both,2,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MANNITOL 25 % IV SOLN,50863,CDM,J2150,HCPCS,63323-024-01,NDC,,,facility,both,1,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL  6.25 MG ORAL TAB,50863,CDM,J3490,HCPCS,68084-854-11,NDC,,,facility,both,4,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 100 MG/5 ML ORAL LIQD,50863,CDM,250,RC,J3490,HCPCS,0121-1488-10,NDC,facility,both,3,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  1 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,59746-171-06,NDC,facility,both,3,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,636,RC,J0330,HCPCS,0409-6629-02,NDC,facility,both,4,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,30,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 60 MG ORAL CPDR,50863,CDM,636,RC,J3490,HCPCS,57237-019-90,NDC,facility,both,2,EA,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,636,RC,J1596,HCPCS,43547-543-01,NDC,facility,both,2,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM-ALBUTEROL 0.5 MG-2.5 MG/3 ML NEB SOLUTION,50863,CDM,250,RC,J3490,HCPCS,0487-0201-01,NDC,facility,both,24,ML,,225,157.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 20 GRAM/30 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-1154-30,NDC,facility,both,7,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INHL NEBU,50863,CDM,636,RC,J3490,HCPCS,0487-9301-03,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IVPB (PEDIATRICS/ADULT NON-FORM)",50863,CDM,636,RC,J0137,HCPCS,24201-100-01,NDC,facility,both,34,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE NA (PRESERV FREE) 25 MG/ML INJ SOLN,50863,CDM,250,RC,J9260,HCPCS,0703-3678-01,NDC,facility,both,20,ML,,192,134.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,17856-7014-7,NDC,facility,both,1,ML,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,250,RC,J3490,HCPCS,72485-510-01,NDC,facility,both,2,ML,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM IN NACL (ISO-OS) 1000 MG/100 ML IV PGBK,50863,CDM,250,RC,J1953,HCPCS,67457-265-00,NDC,facility,both,100,ML,,127,88.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 25 MG TAB,50863,CDM,250,RC,J3490,HCPCS,51079-255-01,NDC,facility,both,1,EA,PLAD,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
SODIUM BICARBONATE   4.2 % IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-083-05,NDC,facility,both,3,ML,,396,277.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,25021-602-03,NDC,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,636,RC,J3490,HCPCS,70092-1119-44,NDC,facility,both,2,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,2,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,67877-590-01,NDC,facility,both,4,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,50863,CDM,250,RC,J9025,HCPCS,72485-201-01,NDC,facility,both,85,EA,JW,527,368.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PENICILLIN G POTASSIUM  5000000 UNIT INJ SOLR,50863,CDM,250,RC,J2540,HCPCS,44567-311-10,NDC,facility,both,17,EA,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROPROCAINE 3 % INJ SOLN,50863,CDM,250,RC,J2401,HCPCS,0143-9210-01,NDC,facility,both,300,ML,JW,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CODEINE-GUAIFENESIN 10-100 MG/5 ML ORAL LIQD (REPACK),50863,CDM,250,RC,J3490,HCPCS,0603-1075-58,NDC,facility,both,2,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE MALEATE 10 MG ORAL TAB,50863,CDM,250,RC,Q0164,HCPCS,59746-115-06,NDC,facility,both,24,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-0430-06,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 50% IN WATER (MERGE RECORD),50863,CDM,636,RC,J7060,HCPCS,0409-7517-66,NDC,facility,both,2,ML,,192,134.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,51754-5011-1,NDC,facility,both,1,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 10 MG/ML ORAL SOLUTION (REPACK),50863,CDM,250,RC,J3490,HCPCS,0131-5410-71,NDC,facility,both,3,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOPERAMIDE 2 MG ORAL CAP,50863,CDM,J3490,HCPCS,51079-690-01,NDC,,,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J3490,HCPCS,0338-0049-01,NDC,facility,both,4,ML,JZ,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DOXYCYCLINE HYCLATE 100 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,63323-130-02,NDC,facility,both,1,EA,,155,108.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LINACLOTIDE  72 MCG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0456-1203-30,NDC,facility,both,1,EA,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,636,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,92,ML,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J2003,HCPCS,63323-492-27,NDC,facility,both,80,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,50863,CDM,250,RC,J0640,HCPCS,0143-9554-01,NDC,facility,both,1,EA,JW,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CYTARABINE 100 MG/ML INJ SOLN,50863,CDM,250,RC,J9100,HCPCS,63323-120-20,NDC,facility,both,20,ML,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  75 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,68084-709-01,NDC,facility,both,3,EA,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DICLOFENAC 50 MG TAB, DELAYED RELEASE",50863,CDM,636,RC,J3490,HCPCS,16571-202-06,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM,50863,CDM,636,RC,J3490,HCPCS,1093919844,NDC,facility,both,1,GM,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VORICONAZOLE 200 MG IV SOLN,50863,CDM,250,RC,J3465,HCPCS,0781-3416-94,NDC,facility,both,26,EA,,698,488.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOMYCIN-BACITRACN ZN-POLYMYXIN 3.5 MG-400 U*,50863,CDM,J3490,HCPCS,45802-143-00,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB 100 MG IV SOLR,50863,CDM,J1745,HCPCS,57894-160-01,NDC,,,facility,both,10,EA,,1311,917.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"RHO(D) IMMUNE GLOBULIN (RHOPHYLAC) 1,500 UNIT (300 MCG)/2 ML INJ SYRG",50863,CDM,636,RC,J2791,HCPCS,44206-300-90,NDC,facility,both,1,ML,,693,485.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,J0665,HCPCS,70594-118-01,NDC,,,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,49,ML,,702,491.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68462-333-90,NDC,facility,both,2,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,J1953,HCPCS,0409-1886-22,NDC,,,facility,both,450,ML,,233,163.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-1749-70,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-258-11,NDC,facility,both,5,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 2 MG ORAL TAB,50863,CDM,J3490,HCPCS,51079-893-01,NDC,,,facility,both,4,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,5,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-677-11,NDC,facility,both,5,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,J3490,HCPCS,63323-185-10,NDC,,,facility,both,2,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLU VACCINE TS 2024-25 65 YR UP (PF) 180 MCG/0.5 ML IM SYRG,50863,CDM,636,RC,90662,HCPCS,49281-124-65,NDC,facility,both,1,ML,,373,261.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEMAZEPAM  7.5 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,63739-003-33,NDC,facility,both,2,EA,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-495-09,NDC,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOLIC ACID  1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-681-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE MONONITRATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,5026885111,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6953-61,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0143-9386-01,NDC,facility,both,29,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL  32.4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16571-673-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0074-4552-11,NDC,facility,both,3,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
0.45 % NACL-POTASSIUM CHLORIDE 20 MEQ/L IV SOLP (PEDS ONC),50863,CDM,636,RC,J3490,HCPCS,0338-0704-34,NDC,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,0641-6008-01,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZINC OXIDE 20 % TOP OINT (REPACK),50863,CDM,250,RC,J3490,HCPCS,75834-170-01,NDC,facility,both,1,GM,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALUM-MAG HYDROXIDE-SIMETH 200 MG-200 MG-20 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0536-1317-83,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) NEB SOLUTION,50863,CDM,250,RC,J3490,HCPCS,0487-9501-00,NDC,facility,both,30,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,250,RC,J2405,HCPCS,60505-6130-5,NDC,facility,both,24,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML (1ML) INJ SOLN,50863,CDM,250,RC,J0169,HCPCS,63323-696-02,NDC,facility,both,10,ML,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SITAGLIPTIN 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0006-0277-31,NDC,facility,both,1,EA,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2308-01,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,64208-2510-1,NDC,facility,both,1,ML,JZ,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0781-6041-55,NDC,facility,both,9,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-131-11,NDC,facility,both,2,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,50863,CDM,250,RC,J0696,HCPCS,0143-9857-01,NDC,facility,both,4,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IV PGBK,50863,CDM,636,RC,J3475,HCPCS,47335-992-01,NDC,facility,both,4,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-9149-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,6,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-559-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,16,EA,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BLEOMYCIN 30 UNIT INJ SOLR,50863,CDM,636,RC,J9040,HCPCS,71288-107-20,NDC,facility,both,2,EA,,296,207.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIFAMPIN 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-586-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,636,RC,J0330,HCPCS,69374-919-10,NDC,facility,both,2,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 50 MG CAP,50863,CDM,636,RC,Q0163,HCPCS,0904-2056-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),50863,CDM,250,RC,J0169,HCPCS,76329-3318-1,NDC,facility,both,80,ML,,646,452.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VECURONIUM BROMIDE 10 MG IV SOLR,50863,CDM,636,RC,J3490,HCPCS,0703-2914-01,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 1 MG ORAL TAB,50863,CDM,250,RC,J8540,HCPCS,0054-4181-25,NDC,facility,both,12,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-591-11,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,50863,CDM,636,RC,J9000,HCPCS,25021-207-25,NDC,facility,both,5,ML,,144,100.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J7510,HCPCS,17856-0815-1,NDC,facility,both,9,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,35,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,50863,CDM,250,RC,J9060,HCPCS,16729-288-11,NDC,facility,both,14,ML,,291,203.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-50,NDC,facility,both,109,ML,,192,134.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,250,RC,J3101,HCPCS,50242-037-06,NDC,facility,both,31,EA,JW,6174,4321.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LEVETIRACETAM IN NACL (ISO-OS) 500 MG/100 ML IV PGBK,50863,CDM,636,RC,J1953,HCPCS,67457-255-00,NDC,facility,both,100,ML,,165,115.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 500 MG PE/10 ML INJ SOLN,50863,CDM,636,RC,Q2009,HCPCS,0069-6001-10,NDC,facility,both,20,ML,JZ,1048,733.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IRON SUCROSE 200 MG/10 ML IRON IV SOLN,50863,CDM,636,RC,J1756,HCPCS,0517-2310-01,NDC,facility,both,200,ML,,545,381.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK,50863,CDM,636,RC,J3490,HCPCS,12870-0001-1,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EMTRICITABINE-TENOFOVIR ALAFEN 200-25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,61958-2002-1,NDC,facility,both,1,EA,,374,261.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN 0.9 % SODIUM CHL 2 GRAM/500 ML IV SOLN,50863,CDM,636,RC,J3373,HCPCS,71506-019-59,NDC,facility,both,200,ML,,148,103.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE IN 0.9% NS (PF) 1 MG/10 ML (100 MCG/ML) IV SYRG(PDS MERGE),50863,CDM,636,RC,J3490,HCPCS,70092-1046-46,NDC,facility,both,200,ML,,22540,15778,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J1610,HCPCS,0597-0053-45,NDC,facility,both,3,EA,JZ,2224,1556.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LATANOPROST 0.005 % OPHT DROP,50863,CDM,250,RC,J3490,HCPCS,59762-0333-2,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,70095-031-01,NDC,facility,both,32,ML,,1288,901.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,16,EA,JZ,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
VANCOMYCIN IN 0.9% SODIUM CL 1.25 GRAM/250 ML IV SOLN,50863,CDM,636,RC,J3373,HCPCS,70004-923-59,NDC,facility,both,3,ML,,189,132.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES-DOCUSATE SODIUM 8.6 MG-50 MG TAB,50863,CDM,636,RC,J3490,HCPCS,63739-432-02,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,58,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0630,HCPCS,42023-205-01,NDC,facility,both,1,ML,JZ,8426,5898.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
BENZTROPINE 1 MG/ML INJ SOLN,50863,CDM,250,RC,J0515,HCPCS,0143-9233-01,NDC,facility,both,1,ML,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRBESARTAN  75 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,31722-729-30,NDC,facility,both,4,EA,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0832-0540-11,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 75 MG/5 ML ORAL SOLUTION,50863,CDM,250,RC,J3490,HCPCS,64980-511-10,NDC,facility,both,9,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,636,RC,J1953,HCPCS,72485-106-01,NDC,facility,both,50,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J1938,HCPCS,72603-251-01,NDC,facility,both,80,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 10 MG/ML IM SOLN,50863,CDM,250,RC,J0500,HCPCS,72266-127-01,NDC,facility,both,1,ML,,145,101.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,50863,CDM,250,RC,J0696,HCPCS,60505-6149-0,NDC,facility,both,16,EA,,775,542.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,14,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 40 % ORAL GEL (NEONATAL/PEDIATRIC),50863,CDM,250,RC,J3490,HCPCS,574007015,NDC,facility,both,1,GM,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J2250,HCPCS,70069-817-01,NDC,facility,both,2,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,27,EA,,146,102.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NOREPINEPHRINE BITARTRATE-D5W 4 MG/250 ML (16 MCG/ML) IV SOLN,50863,CDM,250,RC,J0171,HCPCS,66647-6156-33,NDC,facility,both,1,ML,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESALAMINE  250 MG ORAL CPSR,50863,CDM,250,RC,J3490,HCPCS,54092-189-81,NDC,facility,both,1,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 30 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,0904-7044-61,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAVASTATIN 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-649-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-464-11,NDC,facility,both,3,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TORSEMIDE  20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-539-11,NDC,facility,both,5,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,793,ML,,1138,796.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE  50 MG ORAL TAB,50863,CDM,636,RC,j3490,HCPCS,60687-443-11,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,622,ME,JZ,8441,5908.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ADVATE: FACTOR VIII CONCENTRATE (MERGE RECORD),50863,CDM,636,RC,J7192,HCPCS,0944-3047-10,NDC,facility,both,3982,UN,JW,7248,5073.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LEVOTHYROXINE 150 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-530-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0641-0400-12,NDC,facility,both,20,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIGECYCLINE 50 MG IV SOLR,50863,CDM,250,RC,J3243,HCPCS,70121-1647-1,NDC,facility,both,50,EA,,420,294,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-04,NDC,facility,both,1,ML,JZ,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DABIGATRAN  75 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0597-0355-56,NDC,facility,both,1,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DICLOFENAC 75 MG TAB, DELAYED RELEASE",50863,CDM,250,RC,J3490,HCPCS,16571-201-06,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 500 MG (200 MG ELEMENTAL) CHEW TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6412-92,NDC,facility,both,8,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,636,RC,J3490,HCPCS,70092-1478-44,NDC,facility,both,3,ML,,316,221.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 100 MG IV SOLR,50863,CDM,250,RC,J2997,HCPCS,50242-085-25,NDC,facility,both,10,EA,JW,1057,739.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GUAIFENESIN 600 MG ORAL TP12,50863,CDM,636,RC,J3490,HCPCS,0536-1163-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERTAPENEM 1 GRAM INJ SOLR,50863,CDM,250,RC,J1335,HCPCS,0143-9398-01,NDC,facility,both,2,EA,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,2,EA,,155,108.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,35,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN PEDS SYRINGE (20MG/ML) IN DEXTROSE (CDS MIX,50863,CDM,250,RC,J0690,HCPCS,0781-3451-70,NDC,facility,both,12,EA,,310,217,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  5 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-122-11,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML (1ML) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,54288-119-01,NDC,facility,both,3,ML,,238,166.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-0007-01,NDC,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAMIDRONATE 9 MG/ML IV SOLN,50863,CDM,250,RC,J2430,HCPCS,61703-326-18,NDC,facility,both,3,ML,,220,154,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-145-11,NDC,facility,both,25,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,J0665,HCPCS,0409-1162-02,NDC,,,facility,both,200,ML,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR IRRIGATION, STERILE SOLUTION",50863,CDM,250,RC,J3490,HCPCS,0338-0004-02,NDC,facility,both,3,ML,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MENING VAC A,C,Y,W135 DIP (PF) 10-5 MCG/0.5 ML IM SOLN",50863,CDM,90734,HCPCS,58160-827-30,NDC,,,facility,both,1,ML,,720,504,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCERIN (ADULT) RECTAL SUPPOSITORY,50863,CDM,J3490,HCPCS,0132-0079-24,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL (5 MG/ML) IV SYRG (CONTAINS PRESERVATIVE),50863,CDM,636,RC,J3490,HCPCS,65302-503-04,NDC,facility,both,2,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6817-61,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN 0.9% SODIUM CL 1.25 GRAM/250 ML IV SOLN,50863,CDM,250,RC,J3373,HCPCS,71266-5083-1,NDC,facility,both,125,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEMANTINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6506-61,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPYLTHIOURACIL 50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-964-95,NDC,facility,both,4,EA,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 40 MG-200 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,65862-496-47,NDC,facility,both,1,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) IV SOLN,50863,CDM,636,RC,J9201,HCPCS,67457-618-10,NDC,facility,both,10,ML,,409,286.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMOSOZUMAB-AQQG 105 MG/1.17 ML SUBQ SYRG,50863,CDM,636,RC,J3111,HCPCS,55513-998-01,NDC,facility,both,210,ML,,5349,3744.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HUMAN PROTHROMBIN COMPLEX 500 UNIT IV SOLR,50863,CDM,250,RC,J7168,HCPCS,63833-396-01,NDC,facility,both,1500,UN,JZ,8729,6110.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LATANOPROST 0.005 % OPHT DROP,50863,CDM,636,RC,J3490,HCPCS,59762-0333-2,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"OMEGA-3 FATTY ACIDS-FISH OIL 360-1,200 MG ORAL CAP (ERX MERGE)",50863,CDM,636,RC,J3490,HCPCS,17856-0055-1,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0641-0400-37,NDC,facility,both,8,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN   1.5 G IV SOLR,50863,CDM,250,RC,J3370,HCPCS,0409-3515-11,NDC,facility,both,3,EA,,143,100.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,0641-0476-21,NDC,facility,both,1,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,0703-9514-03,NDC,facility,both,5,ML,,368,257.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,68094-600-59,NDC,facility,both,4,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROMETHORPHAN POLY COMPLEX ER 30 MG/5 ML ORAL SU12,50863,CDM,250,RC,J3490,HCPCS,45802-433-21,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,0409-9094-22,NDC,facility,both,4,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-9558-05,NDC,facility,both,2,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEBIVOLOL  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7189-04,NDC,facility,both,2,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,68180-150-01,NDC,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,0641-6236-01,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM-ALBUTEROL 0.5 MG-2.5 MG/3 ML NEB SOLUTION,50863,CDM,250,RC,J3490,HCPCS,0487-0201-01,NDC,facility,both,3,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,43598-053-11,NDC,facility,both,22,ML,,768,537.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALSARTAN 160 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,33342-064-10,NDC,facility,both,2,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RAMIPRIL  5 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,68382-146-01,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-9543-02,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,72603-209-01,NDC,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 30 MG ORAL CPDR,50863,CDM,636,RC,J3490,HCPCS,51991-747-90,NDC,facility,both,2,EA,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,8,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,250,RC,J2270,HCPCS,0409-1890-13,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HUMAN PROTHROMBIN COMPLEX 500 UNIT IV SOLR,50863,CDM,250,RC,J7168,HCPCS,63833-386-02,NDC,facility,both,1500,UN,,8729,6110.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE 100 MG TAB,50863,CDM,636,RC,J3490,HCPCS,23155-135-25,NDC,facility,both,8,EA,,193,135.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,636,RC,J1596,HCPCS,0143-9679-01,NDC,facility,both,14,ML,,320,224,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,70700-165-22,NDC,facility,both,2,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FERROUS SULFATE 324 MG (65 MG IRON) ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,574060801,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,636,RC,J1611,HCPCS,0597-0053-45,NDC,facility,both,2,EA,,1112,778.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX (PF) 10 MCG IM,50863,CDM,250,RC,90648,HCPCS,49281-547-58,NDC,facility,both,1,EA,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  2.5 MG ORAL TAB,50863,CDM,250,RC,J7510,HCPCS,59651-485-01,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,636,RC,J2003,HCPCS,63323-495-27,NDC,facility,both,40,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0780,HCPCS,23155-294-31,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM-ALBUTEROL 20-100 MCG/ACTUATION INHL MIST,50863,CDM,636,RC,J3490,HCPCS,0597-0024-02,NDC,facility,both,1,GM,,1351,945.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PYRIDOSTIGMINE BROMIDE  60 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0115-3511-01,NDC,facility,both,2,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,531,ME,,7206,5044.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,919,ME,JZ,12471,8729.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CLOPIDOGREL  75 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-536-11,NDC,facility,both,1,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MOXIFLOXACIN 400 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0093-7387-56,NDC,facility,both,6,EA,,589,412.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60505-3113-0,NDC,facility,both,1,EA,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-4713-32,NDC,facility,both,60,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J2003,HCPCS,0409-4279-16,NDC,facility,both,250,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM  3.375 GRAM IV SOLR,50863,CDM,250,RC,J2543,HCPCS,63323-983-23,NDC,facility,both,3,EA,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 5 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,0143-9660-01,NDC,facility,both,2,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-0905-05,NDC,facility,both,2,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 0.1 MG/ML INJ SYRG,50863,CDM,636,RC,J0461,HCPCS,16729-484-03,NDC,facility,both,25,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CLOZAPINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-404-11,NDC,facility,both,2,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,57237-077-10,NDC,facility,both,1,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTOBARBITAL 75 MG/1.5 ML SYRINGE (REPACK),50863,CDM,636,RC,J3490,HCPCS,25021-676-20,NDC,facility,both,1,ML,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELIMUMAB 120 MG IV SOLR,50863,CDM,636,RC,J0490,HCPCS,49401-101-01,NDC,facility,both,12,ME,,1410,987,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUORESCEIN 1 MG OPHT STRP,50863,CDM,636,RC,J3490,HCPCS,17238-900-99,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOMYCIN-BACITRACIN ZN-POLYMYXIN 3.5 MG-400 UN*,50863,CDM,250,RC,J3490,HCPCS,0713-0268-31,NDC,facility,both,2,GM,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,250,RC,J2405,HCPCS,23155-547-31,NDC,facility,both,16,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM NEO IV SYRINGE (PHS FROM PREMIX),50863,CDM,250,RC,J1953,HCPCS,44567-501-01,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 0.5 MG ORAL CAP,50863,CDM,250,RC,J7507,HCPCS,68084-449-11,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GALANTAMINE  4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65862-458-60,NDC,facility,both,1,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,72266-118-01,NDC,facility,both,2,ML,"JZ,PLAD",16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier PLAD: Modifier description not available
CEFEPIME 1 GRAM INJ SOLR,50863,CDM,636,RC,J0692,HCPCS,25021-121-20,NDC,facility,both,4,EA,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMETHICONE 40MG/0.6ML (0.6ML-UD) SYRINGE (REPACK),50863,CDM,636,RC,J3490,HCPCS,17856-1141-4,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-25,NDC,facility,both,130,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,16714-293-03,NDC,facility,both,6,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,0409-9094-12,NDC,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J3430,HCPCS,0409-9158-31,NDC,facility,both,10,ML,,250,175,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,186,ML,,168,117.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-1283-03,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,76045-009-10,NDC,facility,both,8,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,50863,CDM,250,RC,J9060,HCPCS,0703-5747-11,NDC,facility,both,3,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE 1 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,46287-035-15,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  20 MEQ ORAL PACK,50863,CDM,636,RC,J3490,HCPCS,69543-451-01,NDC,facility,both,1,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUORESCEIN 1 MG OPHT STRP,50863,CDM,636,RC,J3490,HCPCS,83851-100-30,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,250,RC,J3490,HCPCS,0143-9679-01,NDC,facility,both,1,ML,,460,322,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFUROXIME AXETIL 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65862-699-20,NDC,facility,both,8,EA,,173,121.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-4279-02,NDC,facility,both,30,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,42291-083-30,NDC,facility,both,1,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,2,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,250,RC,J3490,HCPCS,0143-9679-01,NDC,facility,both,1,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,250,RC,J0690,HCPCS,70092-1017-46,NDC,facility,both,18,ML,,356,249.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM TETRADECYL SULFATE 3 % IV SOLN,50863,CDM,250,RC,J3490,HCPCS,67457-163-00,NDC,facility,both,1,ML,,398,278.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-347-11,NDC,facility,both,2,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7243-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2599,HCPCS,65219-039-00,NDC,facility,both,6,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 800 MG ORAL TAB,50863,CDM,250,RC,J0601,HCPCS,0904-6707-06,NDC,facility,both,80,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2305-16,NDC,facility,both,5,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN  325 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,57896-921-01,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 500 MG/10 ML IV SOLN,50863,CDM,250,RC,J9190,HCPCS,63323-117-01,NDC,facility,both,6,ML,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIVASTIGMINE 3 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,33342-090-09,NDC,facility,both,2,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,23155-600-31,NDC,facility,both,8,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0093-4177-73,NDC,facility,both,8,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25 MG-250 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0378-1133-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-354-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,50863,CDM,636,RC,Q0177,HCPCS,0093-5061-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,0944-0495-06,NDC,facility,both,1,ML,JZ,245,171.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ISOSORBIDE MONONITRATE  30 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,0904-6449-61,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,4,EA,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR NEO/PEDS INFUSION (CDS FROM PREMIX),50863,CDM,250,RC,J0133,HCPCS,63323-325-10,NDC,facility,both,13,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6519-61,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOPERAMIDE 1 MG/7.5 ML ORAL LIQD,50863,CDM,250,RC,J3490,HCPCS,68094-029-59,NDC,facility,both,4,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0406-8515-23,NDC,facility,both,2,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE HCL  0.5 % NASL SPRY,50863,CDM,250,RC,J3490,HCPCS,0225-0805-47,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69097-125-03,NDC,facility,both,1,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOMYCIN-BACITRACIN ZN-POLYMYXIN 3.5 MG-400 UN*,50863,CDM,250,RC,J3490,HCPCS,45802-143-03,NDC,facility,both,2,GM,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE ACETATE 0.12 % OPHT DRPS,50863,CDM,250,RC,J3490,HCPCS,11980-174-10,NDC,facility,both,1,ML,,1082,757.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IVERMECTIN 3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42799-806-01,NDC,facility,both,5,EA,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 5 MG/ML IV SOLN,50863,CDM,636,RC,J1921,HCPCS,0409-2267-54,NDC,facility,both,3,ML,,183,128.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 60 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,0904-7045-61,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-8299-25,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 1 MG ORAL CAP,50863,CDM,636,RC,J7507,HCPCS,51079-818-01,NDC,facility,both,2,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LURASIDONE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-747-11,NDC,facility,both,3,EA,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,636,RC,J3370,HCPCS,67457-340-01,NDC,facility,both,2,EA,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,25021-402-01,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-580-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB 10 MG/ML IV CONC,50863,CDM,636,RC,J9312,HCPCS,50242-053-06,NDC,facility,both,100,ML,JZ,25931,18151.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
HYDROCODONE-ACETAMINOPHEN 5 MG-325 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0406-0123-23,NDC,facility,both,3,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-327-10,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIFEDIPINE 30 MG ORAL TO24,50863,CDM,250,RC,J3490,HCPCS,0904-7208-61,NDC,facility,both,3,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUANFACINE 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0591-0444-01,NDC,facility,both,3,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J3490,HCPCS,47335-993-01,NDC,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML (PEDS CALCLUATOR 0.5),50863,CDM,250,RC,J1815,HCPCS,0024-5924-10,NDC,facility,both,400,ML,,848,593.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,250,RC,J3490,HCPCS,72485-510-01,NDC,facility,both,6,ML,,405,283.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IMATINIB 100 MG ORAL TAB,50863,CDM,250,RC,J9999,HCPCS,0093-7629-98,NDC,facility,both,4,EA,,1194,835.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,636,RC,J3490,HCPCS,0904-6794-89,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE HCL IN 0.9% NS 100 MCG/10 ML (10 MCG/ML) NON-CARDIAC LOW-DOSE (PEDS/NEO),50863,CDM,250,RC,J0171,HCPCS,69374-544-10,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-598-11,NDC,facility,both,3,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE 150 MG ORAL CP24,50863,CDM,J3490,HCPCS,42291-899-30,NDC,,,facility,both,1,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIP,PER(A)TET-HEPB-POL-HIB(PF) 15 UNIT-5 UNIT- 10 MCG/0.5 ML IM INJ MERGE (CAM USE ONLY)",50863,CDM,90697,HCPCS,63361-243-88,NDC,,,facility,both,1,ML,,631,441.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYTOCIN IN 0.9 % SOD CHLORIDE 30 UNIT/500 ML IV SOLN,50863,CDM,J2590,HCPCS,70092-1552-07,NDC,,,facility,both,1,ML,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-633-11,NDC,facility,both,2,EA,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,J3490,HCPCS,0781-3220-70,NDC,,,facility,both,1,ML,,185,129.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM BICARB-CITRIC ACID 20 MEQ ORAL TBEF,50863,CDM,J3490,HCPCS,51801-012-01,NDC,,,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),50863,CDM,J1630,HCPCS,76045-737-01,NDC,,,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NOREPINEPHRINE BITARTRATE-NACL 4 MG/250 ML (16 MCG/ML) IV SOLN (CENTRAL ONLY),50863,CDM,636,RC,J3490,HCPCS,44567-640-01,NDC,facility,both,1,ML,,218,152.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MYCOPHENOLATE 250 MG CAP,50863,CDM,250,RC,J7517,HCPCS,60687-885-11,NDC,facility,both,4,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
REGADENOSON 0.4 MG/5 ML IV SYRG,50863,CDM,636,RC,J2785,HCPCS,0469-6501-89,NDC,facility,both,4,ML,"JZ,JA",913,639.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
OFLOXACIN 0.3 % OPHT DROP,50863,CDM,636,RC,J3490,HCPCS,24208-434-05,NDC,facility,both,2,ML,,240,168,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR PHOSPHATE 75 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,72205-044-11,NDC,facility,both,1,EA,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHOTERICIN B LIPOSOME 50 MG IV SUSR,50863,CDM,250,RC,J0289,HCPCS,55150-365-01,NDC,facility,both,30,EA,,5411,3787.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE (FOR EMERGENCY) 100 MG/ML (10%) IV SOLN,50863,CDM,250,RC,J0612,HCPCS,63323-311-19,NDC,facility,both,100,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16714-989-01,NDC,facility,both,2,EA,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,1000,ML,,166,116.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,67457-108-00,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADVATE: FACTOR VIII CONCENTRATE (MERGE RECORD),50863,CDM,J7192,HCPCS,0944-3047-10,NDC,,,facility,both,4018,UN,,16820,11774,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,J0330,HCPCS,31722-981-10,NDC,,,facility,both,9,ML,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LURASIDONE  60 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7357-61,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLN,50863,CDM,J3262,HCPCS,50242-135-01,NDC,,,facility,both,160,ML,,2933,2053.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV,50863,CDM,250,RC,J7120,HCPCS,0338-0117-03,NDC,facility,both,44,ML,,2651,1855.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),50863,CDM,636,RC,J1815,HCPCS,0002-7737-01,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,636,RC,J3490,HCPCS,72789-057-01,NDC,facility,both,1,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZTREONAM 1 GRAM INJ SOLR,50863,CDM,636,RC,J0457,HCPCS,0409-0829-11,NDC,facility,both,10,EA,JZ,200,140,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
OSELTAMIVIR PHOSPHATE 75 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,64380-799-01,NDC,facility,both,10,EA,,557,389.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN,50863,CDM,250,RC,J2916,HCPCS,0024-2792-01,NDC,facility,both,20,ML,,747,522.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,23155-248-01,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZTREONAM 2 GRAM INJ SOLR,50863,CDM,250,RC,J0457,HCPCS,63323-402-01,NDC,facility,both,10,EA,JZ,146,102.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
TRASTUZUMAB-QYYP 420 MG IV SOLR,50863,CDM,250,RC,Q5116,HCPCS,0069-0306-01,NDC,facility,both,84,ME,,18720,13104,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7350-06,NDC,facility,both,3,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT  40 MCG/0.4 ML INJ SYRG,50863,CDM,636,RC,J0881,HCPCS,55513-021-01,NDC,facility,both,40,ML,JZ,1096,767.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,636,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,7,EA,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORTHALIDONE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-167-11,NDC,facility,both,6,EA,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLP,50863,CDM,J3480,HCPCS,63323-965-02,NDC,,,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,50863,CDM,J0640,HCPCS,71288-161-20,NDC,,,facility,both,12,EA,,564,394.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,636,RC,P9045,HCPCS,64208-2510-5,NDC,facility,both,10,ML,,826,578.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,67877-433-03,NDC,facility,both,1,EA,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN ASP PRT-INSULIN ASPART 100 UNIT/ML (70-30) SUBQ SOLN,50863,CDM,J1817,HCPCS,0169-3685-12,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE 10 MG ORAL TAB,50863,CDM,J3490,HCPCS,51079-986-01,NDC,,,facility,both,3,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IR SOLN,50863,CDM,250,RC,J3490,HCPCS,0338-0047-46,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLECAINIDE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0054-0010-20,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIHYDROERGOTAMINE 1 MG/ML INJ SOLN,50863,CDM,250,RC,J1110,HCPCS,81284-411-00,NDC,facility,both,1,ML,,397,277.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TERAZOSIN  1 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,50268-764-11,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 250 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,42192-608-05,NDC,facility,both,2,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 125 MG/5 ML (25MG/ML) ORAL SYRINGE (REPACK),50863,CDM,636,RC,J3370,HCPCS,67457-340-00,NDC,facility,both,2,EA,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,16,EA,JZ,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ERYTHROMYCIN 5 MG/G OPHT OINT,50863,CDM,250,RC,J3490,HCPCS,24208-910-55,NDC,facility,both,1,GM,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE (PF) 25 MG/ML INJ SOLN (FOR ECTOPIC PREGNANCY),50863,CDM,250,RC,J9260,HCPCS,0143-9519-01,NDC,facility,both,9,ML,,197,137.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN IN 0.9 % NS 40 UNIT/100 ML (0.4 UNIT/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0338-9647-12,NDC,facility,both,1,ML,,130,91,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 1 % OPHT DROP,50863,CDM,250,RC,J3490,HCPCS,60219-1749-3,NDC,facility,both,1,ML,,248,173.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN NPH HUMAN RECOMB 100 UNIT/ML SUBQ SUSP,50863,CDM,250,RC,J1815,HCPCS,0169-1834-11,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAMIDRONATE 3 MG/ML IV SOLN,50863,CDM,250,RC,J2430,HCPCS,67457-430-10,NDC,facility,both,1,ML,,159,111.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 250 MG-62.5 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,60432-065-75,NDC,facility,both,7,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN NEO/PEDIATRIC SYRINGE < 30 MG,50863,CDM,250,RC,J1650,HCPCS,0548-5608-00,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIRMATRELVIR-RITONAVIR 150 MG (10)- 100 MG (10) ORAL DSPK,50863,CDM,636,RC,J3490,HCPCS,0069-5317-20,NDC,facility,both,20,EA,,4010,2807,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 150 MG CAP,50863,CDM,636,RC,J3490,HCPCS,0904-5959-61,NDC,facility,both,18,EA,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE IN SALINE (ISO-OSM) 400 MG/200 ML IV PIGGY BACK,50863,CDM,250,RC,J1450,HCPCS,0409-4688-16,NDC,facility,both,4,ML,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G POTASSIUM  5000000 UNIT INJ SOLR,50863,CDM,250,RC,J2540,HCPCS,0049-0520-83,NDC,facility,both,9,EA,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0904-6923-61,NDC,facility,both,60,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,0054-0018-20,NDC,facility,both,60,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZTREONAM 2 GRAM INJ SOLR,50863,CDM,636,RC,J0457,HCPCS,0003-2570-16,NDC,facility,both,20,EA,,303,212.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BETAMETHASONE DIPROPIONATE 0.05 % TOP OINT,50863,CDM,636,RC,J3490,HCPCS,72578-093-01,NDC,facility,both,1,GM,,261,182.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN  750 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,51224-107-50,NDC,facility,both,3,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J1230,HCPCS,67457-217-20,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-0430-06,NDC,facility,both,2,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,469,ME,,6365,4455.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6966-61,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANTI-INHIBITOR COAGULANT CMPLX (PHS MERGE),50863,CDM,250,RC,J7198,HCPCS,64193-426-02,NDC,facility,both,478,UN,,3453,2417.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMINOPHYLLINE 500 MG/20 ML IV SOLN,50863,CDM,636,RC,J0280,HCPCS,0409-5922-01,NDC,facility,both,2,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0781-3220-70,NDC,facility,both,3,ML,,554,387.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 17 GRAM (100 %) ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,0904-6931-86,NDC,facility,both,14,EA,,128,89.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZIPRASIDONE 20 MG IM,50863,CDM,250,RC,J3486,HCPCS,43598-848-11,NDC,facility,both,2,EA,,240,168,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 100 MG/1 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0075-0623-03,NDC,facility,both,10,ML,,146,102.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEBIVOLOL  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-641-11,NDC,facility,both,4,EA,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MOXIFLOXACIN 400 MG/250 ML IVPB PREMIX (MERGE),50863,CDM,250,RC,J2280,HCPCS,67457-323-25,NDC,facility,both,16,ML,,933,653.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOLIC ACID 400 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,5026834611,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAY 1 NEO SOLUTION (D12.5W/AA 2%/HEPARIN 0.5 UNITS/ML),50863,CDM,250,RC,J3490,HCPCS,99999-500-93,NDC,facility,both,1,ML,,167,116.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 1 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,27808-002-01,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,0517-4620-25,NDC,facility,both,2,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRIMIDONE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-686-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NADOLOL  40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,76385-134-01,NDC,facility,both,1,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE-SALMETEROL 250 MCG-50 MCG/DOSE DISK DEVICE FOR INHALATION,50863,CDM,636,RC,J3490,HCPCS,0173-0696-04,NDC,facility,both,1,EA,,232,162.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50111-327-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,270,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MANNITOL 20% IV SOLP,50863,CDM,250,RC,J2150,HCPCS,0990-7715-13,NDC,facility,both,1,ML,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRILAT 1.25 MG/ML IV INJ,50863,CDM,250,RC,J3490,HCPCS,43598-078-11,NDC,facility,both,2,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,50863,CDM,636,RC,J8540,HCPCS,0904-7266-61,NDC,facility,both,40,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0143-9386-01,NDC,facility,both,100,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,44567-600-04,NDC,facility,both,3,ML,,1005,703.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  25 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-473-11,NDC,facility,both,6,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CILOSTAZOL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-177-11,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-709-11,NDC,facility,both,7,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN D5W 1 GRAM/200 ML IV PGBK,50863,CDM,J3373,HCPCS,0338-3552-48,NDC,,,facility,both,99999,ML,,134964,94474.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.3 MG/0.3 ML IM PNIJ,50863,CDM,636,RC,J0171,HCPCS,49502-102-01,NDC,facility,both,4,EA,,900,630,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,J7040,HCPCS,17271-701-05,NDC,,,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  1 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,64380-782-06,NDC,facility,both,44,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE (FOR CODE) 10% (100 MG/ML) IV SYRINGE,50863,CDM,250,RC,J3490,HCPCS,0409-1631-40,NDC,facility,both,2,ML,,149,104.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE (FOR CODE) 10% (100 MG/ML) IV SYRINGE,50863,CDM,636,RC,J3490,HCPCS,0409-1631-10,NDC,facility,both,1,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,250,RC,J0330,HCPCS,31722-981-10,NDC,facility,both,4,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"OMEGA-3 FATTY ACIDS-FISH OIL 360-1,200 MG ORAL CAP (ERX MERGE)",50863,CDM,636,RC,J3490,HCPCS,8068105500,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,63323-461-01,NDC,facility,both,1,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZOCAINE 20 % MM SPRY,50863,CDM,250,RC,J3490,HCPCS,0283-0610-43,NDC,facility,both,1,EA,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML INJECTION,50863,CDM,250,RC,J3411,HCPCS,72603-139-01,NDC,facility,both,2,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 25 MG TAB,50863,CDM,636,RC,J3490,HCPCS,62584-265-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE 2 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,0904-7154-04,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON DEXTRAN 50 MG/ML INJ SOLN,50863,CDM,250,RC,J1750,HCPCS,0023-6082-01,NDC,facility,both,1,ML,JZ,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0143-9386-01,NDC,facility,both,33,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 20 GRAM/30 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,0121-1154-30,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,70095-031-01,NDC,facility,both,18,ML,JW,323,226.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ERYTHROMYCIN 5 MG/G OPHT OINT,50863,CDM,J3490,HCPCS,24208-910-19,NDC,,,facility,both,1,GM,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,J2003,HCPCS,63323-486-27,NDC,,,facility,both,120,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,J3490,HCPCS,63323-486-05,NDC,,,facility,both,200,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,55150-307-01,NDC,facility,both,41,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,0641-0476-21,NDC,facility,both,2,ML,,464,324.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN  10 GRAM INJ SOLR,50863,CDM,636,RC,J0690,HCPCS,0143-9983-91,NDC,facility,both,6,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXAZOSIN 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-836-95,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,636,RC,J0690,HCPCS,70092-1017-46,NDC,facility,both,6,ML,,119,83.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRP (MERGE/REPACK),50863,CDM,636,RC,J3490,HCPCS,68094-764-59,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM CITRATE ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,1093911233,NDC,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG RECT SUPP,50863,CDM,250,RC,J3490,HCPCS,51672-2116-0,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR 800 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-062-11,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2310,HCPCS,67457-299-00,NDC,facility,both,4,ML,,513,359.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,41,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,636,RC,J0133,HCPCS,55150-154-10,NDC,facility,both,100,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 1000 MG MISC TBSO,50863,CDM,250,RC,J3490,HCPCS,77333-844-25,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1815,HCPCS,0169-1833-11,NDC,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BISACODYL  5 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,0904-6407-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID (PORK)  60 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,75834-312-01,NDC,facility,both,3,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 20 MG/ML INJ SOLN,50863,CDM,250,RC,J0360,HCPCS,0641-6231-01,NDC,facility,both,2,ML,,111,77.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,50863,CDM,250,RC,J2359,HCPCS,0781-3159-72,NDC,facility,both,15,EA,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,J0665,HCPCS,0409-1160-01,NDC,,,facility,both,550,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 75 MG/5 ML ORAL SOLUTION,50863,CDM,250,RC,J3490,HCPCS,0574-0129-01,NDC,facility,both,2,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J3490,HCPCS,0409-0007-01,NDC,,,facility,both,200,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  100 MCG/ML INJ SOLN,50863,CDM,J2354,HCPCS,23155-688-31,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEPLIZUMAB-MZWV 2 MG/20 ML IV SOLN,50863,CDM,636,RC,J9381,HCPCS,73650-316-01,NDC,facility,both,108,ME,JW,3155,2208.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CEFDINIR 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,67877-548-88,NDC,facility,both,4,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 3000 MCG/ML INJECTION,50863,CDM,250,RC,J0153,HCPCS,25021-301-02,NDC,facility,both,6,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,636,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-591-11,NDC,facility,both,3,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,J7512,HCPCS,0904-7127-61,NDC,,,facility,both,10,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 500 MG PE/10 ML INJ SOLN,50863,CDM,250,RC,Q2009,HCPCS,68462-622-10,NDC,facility,both,10,ML,,242,169.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-0710-20,NDC,facility,both,9,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR 800 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60505-5307-1,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITRIOL 0.25 MCG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-345-11,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DRONABINOL  2.5 MG ORAL CAP,50863,CDM,250,RC,Q0167,HCPCS,60687-375-11,NDC,facility,both,3,EA,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,250,RC,J2795,HCPCS,70069-064-25,NDC,facility,both,110,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,250,RC,J3101,HCPCS,50242-037-06,NDC,facility,both,32,EA,JW,6373,4461.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IPRATROPIUM BROMIDE 0.02 % INHL SOLN,50863,CDM,250,RC,J3490,HCPCS,76204-100-01,NDC,facility,both,3,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN DETEMIR 100 UNIT/ML SUBQ SOLN,50863,CDM,636,RC,J1815,HCPCS,0169-3687-12,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0137,HCPCS,0143-9386-01,NDC,facility,both,62,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SINCALIDE 5 MCG INJ SOLR,50863,CDM,636,RC,J2805,HCPCS,72266-248-05,NDC,facility,both,1,EA,,296,207.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE 100 MG TAB,50863,CDM,636,RC,J3490,HCPCS,23155-135-25,NDC,facility,both,9,EA,,217,151.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB 100 MG IV SOLR,50863,CDM,636,RC,J1745,HCPCS,57894-030-01,NDC,facility,both,86,EA,,27720,19404,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,57237-184-90,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML IV,50863,CDM,250,RC,J3490,HCPCS,70860-301-41,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-098-11,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZIPRASIDONE 40 MG CAP,50863,CDM,250,RC,J3490,HCPCS,68084-104-11,NDC,facility,both,1,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,636,RC,J3490,HCPCS,73013-2002-2,NDC,facility,both,2,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN STERILE WATER 2 GRAM/20 ML IV SYRG,50863,CDM,636,RC,J0690,HCPCS,70092-1238-47,NDC,facility,both,4,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR PHOSPHATE 30 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,33342-256-66,NDC,facility,both,1,EA,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRIMIDONE 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-687-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7188-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-579-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADVATE: FACTOR VIII CONCENTRATE (MERGE RECORD),50863,CDM,250,RC,J7192,HCPCS,0944-3052-04,NDC,facility,both,750,UN,,3140,2198,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 25 MG/5 ML (5 MG/ML) ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,52536-600-11,NDC,facility,both,1,ML,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,50863,CDM,250,RC,J9025,HCPCS,72485-201-01,NDC,facility,both,30,EA,JW,189,132.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CHLOROTHIAZIDE SODIUM 500 MG IV SOLR,50863,CDM,250,RC,J1205,HCPCS,25021-305-20,NDC,facility,both,2,EA,,611,427.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,0409-1207-03,NDC,facility,both,2,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOPROTERENOL 0.2 MG/ML INJECTION,50863,CDM,250,RC,J3490,HCPCS,0548-9502-00,NDC,facility,both,1,ML,,864,604.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-504-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,50863,CDM,636,RC,J3490,HCPCS,68462-157-40,NDC,facility,both,1,EA,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN 125 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,66689-775-08,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,636,RC,J3490,HCPCS,50742-615-01,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE  10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,70710-1225-1,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0093-2279-73,NDC,facility,both,7,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEXILETINE 150 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,50742-239-01,NDC,facility,both,2,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,16714-293-03,NDC,facility,both,6,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-406-03,NDC,facility,both,1,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2308-22,NDC,facility,both,3,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
FILGRASTIM-SNDZ 480 MCG/0.8 ML INJ SYRG,50863,CDM,636,RC,Q5101,HCPCS,61314-326-05,NDC,facility,both,480,ML,,1212,848.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE   4.2 % IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-083-05,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,72603-251-01,NDC,facility,both,15,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 3 MG/ML IV SYRG,50863,CDM,250,RC,J0153,HCPCS,0469-8234-12,NDC,facility,both,6,ML,,212,148.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM CITRATE ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,69452-390-98,NDC,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 50 MG TAB,50863,CDM,250,RC,J3490,HCPCS,55111-292-09,NDC,facility,both,1,EA,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRBESARTAN  75 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,43547-374-03,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMULSION 20 % IV EMUL,50863,CDM,250,RC,j3490,HCPCS,65219-533-01,NDC,facility,both,1,ML,,108,75.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 50 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-854-11,NDC,facility,both,50,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16729-175-01,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3370,HCPCS,63323-284-26,NDC,facility,both,2,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 60 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,57237-019-90,NDC,facility,both,2,EA,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 100 MG ORAL TB12,50863,CDM,250,RC,J3490,HCPCS,51672-4123-1,NDC,facility,both,2,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE  50 MG ORAL TAB,50863,CDM,250,RC,j3490,HCPCS,68382-805-01,NDC,facility,both,3,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-04,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYOSCYAMINE 0.125 MG SUBLINGUAL TAB,50863,CDM,250,RC,J3490,HCPCS,42192-339-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,110,EA,,15180,10626,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE SOD SUCC (PF) 100 MG/2 ML INJ SOLR,50863,CDM,636,RC,J1720,HCPCS,0009-0011-03,NDC,facility,both,2,EA,,283,198.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0093-3425-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAMSULOSIN 0.4 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,0904-6401-61,NDC,facility,both,10,EA,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 10% IN WATER (NEO) 2 - 3.99 KG,50863,CDM,250,RC,J3490,HCPCS,0338-0023-04,NDC,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,250,RC,J2720,HCPCS,63323-229-01,NDC,facility,both,16,ML,,291,203.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,68180-150-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MINERAL OIL,50863,CDM,250,RC,J3490,HCPCS,6332325410,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN 0.9 % SODIUM CHL 2 GRAM/500 ML IV SOLN,50863,CDM,636,RC,J3373,HCPCS,70092-9338-07,NDC,facility,both,200,ML,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-581-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE-SALMETEROL 100 MCG-50 MCG/DOSE DISK DEVICE FOR INHALATION,50863,CDM,250,RC,J3490,HCPCS,0173-0695-04,NDC,facility,both,14,EA,,232,162.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXEPIN  50 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,51079-438-01,NDC,facility,both,4,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ (REPACK)(MERGE) (FOR PCA),50863,CDM,250,RC,J3490,HCPCS,70092-9664-74,NDC,facility,both,1,ML,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  5 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,60687-122-11,NDC,facility,both,20,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 20 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,50111-648-01,NDC,facility,both,2,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 10 GRAM/100 ML (10%) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-72,NDC,facility,both,20,ML,"JZ,JA",2829,1980.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
METHOCARBAMOL 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7057-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,636,RC,J2405,HCPCS,60505-6130-0,NDC,facility,both,2,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-492-27,NDC,facility,both,800,ML,,628,439.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  20 MEQ ORAL PACK,50863,CDM,250,RC,J3490,HCPCS,69543-451-01,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,70954-059-10,NDC,facility,both,10,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0074-4341-90,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1940,HCPCS,72603-251-01,NDC,facility,both,2,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-735-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORDIAZEPOXIDE 25 MG CAP,50863,CDM,J3490,HCPCS,51079-141-01,NDC,,,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,50863,CDM,J9264,HCPCS,0517-4300-01,NDC,,,facility,both,40,EA,,787,550.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CERTOLIZUMAB PEGOL 400 MG/2 ML (200 MG/ML X 2) SUBQ SYKT,50863,CDM,636,RC,J0717,HCPCS,50474-710-79,NDC,facility,both,400,EA,JZ,15785,11049.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,J3490,HCPCS,0093-2279-73,NDC,,,facility,both,7,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATENOLOL  25 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-7187-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE  5 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-6370-61,NDC,,,facility,both,2,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-208-01,NDC,,,facility,both,300,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL DECANOATE  50 MG/ML IM SOLN,50863,CDM,250,RC,J1631,HCPCS,70069-030-03,NDC,facility,both,3,ML,,459,321.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,3,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,636,RC,J2795,HCPCS,70069-064-25,NDC,facility,both,100,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE  7.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-584-11,NDC,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 100 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,60687-479-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LITHIUM CARBONATE 300 MG ORAL TBSR,50863,CDM,636,RC,J3490,HCPCS,68084-640-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 500 MG PE/10 ML INJ SOLN,50863,CDM,250,RC,Q2009,HCPCS,68462-621-02,NDC,facility,both,2,ML,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL  6.25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7306-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-985-01,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPOETIN ALFA 2000 UNIT/ML IV SYRINGE (PED/NEO),50863,CDM,250,RC,Q4081,HCPCS,59676-302-00,NDC,facility,both,20,ML,,267,186.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J3490,HCPCS,0338-0049-01,NDC,facility,both,2,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,394,ME,JZ,5347,3742.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CARBAMAZEPINE 200 MG ORAL TB12,50863,CDM,250,RC,J3490,HCPCS,16571-681-01,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL  97.2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,75826-142-10,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-145-10,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7041-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-0552-23,NDC,facility,both,6,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-4279-16,NDC,facility,both,200,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,39,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,10,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-327-11,NDC,facility,both,2,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7351-04,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,5,ML,,7977,5583.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,0641-6236-01,NDC,facility,both,3,ML,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J3430,HCPCS,65219-635-01,NDC,facility,both,5,ML,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4% (1 MEQ/1 ML) IV 10 ML EMERGENCY SYRINGE,50863,CDM,250,RC,J3490,HCPCS,0409-4900-24,NDC,facility,both,5,ML,,763,534.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 10 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0591-0794-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42858-003-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0555-0873-02,NDC,facility,both,4,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOPERAMIDE 2 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-229-11,NDC,facility,both,3,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 50 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,68084-666-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLU VACCINE TS 2025-26 65 YR UP (PF) 180 MCG/0.5 ML IM SYRG,50863,CDM,636,RC,90662,HCPCS,49281-125-88,NDC,facility,both,1,ML,,403,282.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,6,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
BUDESONIDE 0.5 MG/2 ML INHL NBSP,50863,CDM,250,RC,J3490,HCPCS,0093-6816-45,NDC,facility,both,2,ML,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,115,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,636,RC,J2597,HCPCS,55566-2200-0,NDC,facility,both,20,ML,,2065,1445.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,250,RC,J3101,HCPCS,50242-037-06,NDC,facility,both,20,EA,,9161,6412.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,415,ME,,5632,3942.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 12.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68382-094-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,62584-984-11,NDC,facility,both,3,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6950-61,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 100 MG IV SOLR,50863,CDM,250,RC,J2997,HCPCS,50242-085-27,NDC,facility,both,5,EA,,1215,850.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CELECOXIB 200 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,50268-169-11,NDC,facility,both,2,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-25,NDC,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN PEDS SYRINGE (20MG/ML) IN DEXTROSE (CDS MIX,50863,CDM,636,RC,J7999,HCPCS,0781-3451-70,NDC,facility,both,4,EA,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-132-11,NDC,facility,both,3,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % MUCOSAL SOLN (VISCOUS),50863,CDM,636,RC,J3490,HCPCS,0054-0548-44,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,636,RC,J3490,HCPCS,72603-825-01,NDC,facility,both,200,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0245-0212-89,NDC,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J2250,HCPCS,0409-0001-01,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J3490,HCPCS,0338-0049-41,NDC,facility,both,7,ML,,119,83.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML (1ML) INJ SOLN,50863,CDM,250,RC,J0171,HCPCS,54288-119-01,NDC,facility,both,32,ML,,253,177.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOZAPINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-922-01,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE MONONITRATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,5026885111,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 125 MG INJECTION SOLR,50863,CDM,250,RC,J2919,HCPCS,63323-258-03,NDC,facility,both,25,EA,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL  20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65162-351-09,NDC,facility,both,1,EA,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,636,RC,J3370,HCPCS,63323-284-26,NDC,facility,both,2,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 400 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,65162-464-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-466-17,NDC,facility,both,100,ML,JZ,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IV PGBK,50863,CDM,250,RC,J3475,HCPCS,0409-4121-01,NDC,facility,both,8,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAVASTATIN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-886-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6572-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,76329-3352-1,NDC,facility,both,2,ML,,211,147.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RALTEGRAVIR 400 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0006-0227-61,NDC,facility,both,1,EA,,204,142.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 10 MG/ML IM SOLN,50863,CDM,636,RC,J0500,HCPCS,72266-127-01,NDC,facility,both,1,ML,,145,101.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 800 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-328-11,NDC,facility,both,1,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,63739-931-14,NDC,facility,both,10,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 8-2 MG SL SUBL,50863,CDM,636,RC,J3490,HCPCS,60687-637-11,NDC,facility,both,2,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,34,EA,,4692,3284.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,7,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,1,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,636,RC,J7060,HCPCS,0338-0017-38,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0003-0894-31,NDC,facility,both,2,EA,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0003-0894-31,NDC,facility,both,1,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FELBAMATE 400 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,62559-730-01,NDC,facility,both,1,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL 5 MCG/ML INJECTION,50863,CDM,250,RC,J3010,HCPCS,61553-479-78,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  88 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6952-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE 21 MG/24 HR TD PT24,50863,CDM,636,RC,J3490,HCPCS,43598-448-71,NDC,facility,both,2,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEMAZEPAM  7.5 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,68084-549-11,NDC,facility,both,2,EA,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MILRINONE INFUSION PED/NEO IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J2260,HCPCS,0409-2776-23,NDC,facility,both,4,ML,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0121-1781-05,NDC,facility,both,2,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,5,ML,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J2310,HCPCS,36000-308-01,NDC,facility,both,1,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FERROUS SULFATE 75 MG/ML (ELEMENTAL IRON 15 MG/ML) ORAL DROP,50863,CDM,636,RC,J3490,HCPCS,536134480,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.2 MG/24 HR TD PTWK,50863,CDM,636,RC,J3490,HCPCS,0378-0872-16,NDC,facility,both,1,EA,,237,165.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7193-06,NDC,facility,both,14,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,250,RC,J0132,HCPCS,0574-0805-30,NDC,facility,both,120,ML,,1625,1137.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,636,RC,J7999,HCPCS,70092-1017-46,NDC,facility,both,2,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60219-1708-1,NDC,facility,both,40,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLP (FOR DIALYSIS)",50863,CDM,636,RC,P9047,HCPCS,0944-0493-02,NDC,facility,both,2,ML,JZ,826,578.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
AMOXICILLIN 500 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,16714-299-02,NDC,facility,both,14,EA,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2305-04,NDC,facility,both,5,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,72603-179-01,NDC,facility,both,8,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,427,ML,,612,428.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRASUGREL 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0002-5123-30,NDC,facility,both,6,EA,,397,277.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 100 MG IV SOLR,50863,CDM,J2997,HCPCS,50242-085-25,NDC,,,facility,both,50,EA,,12145,8501.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LITHIUM CARBONATE 300 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0054-8528-25,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0143-9509-01,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIRMATRELVIR-RITONAVIR 300-100 MG ORAL TAB DOSEPACK (FOR ED/IP TAKE HOME PANEL),50863,CDM,250,RC,J3490,HCPCS,0069-5321-30,NDC,facility,both,30,EA,,4130,2891,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK,50863,CDM,636,RC,J3490,HCPCS,12870-0001-2,NDC,facility,both,11,EA,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 40 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,27808-158-01,NDC,facility,both,2,EA,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEBIVOLOL  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,31722-585-30,NDC,facility,both,1,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7050,HCPCS,0338-0049-02,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0121-1781-05,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),50863,CDM,250,RC,J1170,HCPCS,0409-4264-11,NDC,facility,both,1,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J2003,HCPCS,63323-492-09,NDC,facility,both,200,ML,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 40 GRAM/400 ML (10 %) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-20,NDC,facility,both,10,ML,"JZ,JA",1415,990.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0143-9982-50,NDC,facility,both,11,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR 800 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-8947-01,NDC,facility,both,1,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-488-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,11,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 5 MG/ML INHL NEB CONTINUOUS,50863,CDM,250,RC,J3490,HCPCS,73177-146-33,NDC,facility,both,2,ML,,340,238,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,4,EA,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0054-0710-20,NDC,facility,both,7,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLP",50863,CDM,636,RC,P9047,HCPCS,68516-5216-8,NDC,facility,both,4,ML,,1614,1129.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 40 % ORAL GEL,50863,CDM,250,RC,J3490,HCPCS,574007030,NDC,facility,both,1,GM,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,0338-0069-10,NDC,facility,both,1,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
AZITHROMYCIN 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-742-11,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CODEINE-GUAIFENESIN 10-100 MG/5 ML ORAL LIQD (REPACK),50863,CDM,250,RC,J3490,HCPCS,0603-1075-58,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELOXICAM  7.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68382-050-01,NDC,facility,both,3,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOMYCIN-BACITRACIN ZN-POLYMYXIN 3.5 MG-400 UN*,50863,CDM,250,RC,J3490,HCPCS,45802-143-03,NDC,facility,both,3,GM,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,50863,CDM,636,RC,J0696,HCPCS,25021-107-20,NDC,facility,both,8,EA,JZ,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SULFASALAZINE 500 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,59762-0104-5,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,6,EA,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEPROTUMUMAB-TRBW 500 MG IV SOLR,50863,CDM,636,RC,J3241,HCPCS,75987-130-15,NDC,facility,both,49,EA,JW,15447,10812.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GALANTAMINE  4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,57237-049-60,NDC,facility,both,3,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,50863,CDM,636,RC,J0696,HCPCS,44567-701-25,NDC,facility,both,1,EA,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TAB,50863,CDM,J3490,HCPCS,0406-0512-23,NDC,,,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,636,RC,J2003,HCPCS,63323-486-20,NDC,facility,both,400,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"RHO(D) IMMUNE GLOBULIN (RHOPHYLAC) 1,500 UNIT (300 MCG)/2 ML INJ SYRG",50863,CDM,J2791,HCPCS,44206-300-90,NDC,,,facility,both,1,ML,,693,485.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIPH,PERTUS(ACEL),TET,POLIO(PF)(KINRIX) 25 LF-58 MCG-10 LF/0.5 ML IM SYRINGE",50863,CDM,90696,HCPCS,58160-812-43,NDC,,,facility,both,1,ML,,309,216.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML IV,50863,CDM,J3490,HCPCS,17478-937-05,NDC,,,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERTAPENEM 1 GRAM INJ SOLR,50863,CDM,J1335,HCPCS,55150-282-20,NDC,,,facility,both,2,EA,,306,214.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 800 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-5855-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PSEUDOEPHEDRINE 30 MG TAB,50863,CDM,J3490,HCPCS,0904-6990-61,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESMOLOL  100 MG/10 ML IV SOLN,50863,CDM,J3490,HCPCS,55150-194-10,NDC,,,facility,both,1,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,63323-104-25,NDC,facility,both,25,ML,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,J3490,HCPCS,63323-464-02,NDC,,,facility,both,1,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE (POLACRILEX) 2 MG BUCL GUM,50863,CDM,250,RC,J3490,HCPCS,0536-1362-25,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (NEO) <2 KG,50863,CDM,250,RC,J7060,HCPCS,0338-0017-41,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT 100 MCG/0.5 ML INJ SYRG,50863,CDM,250,RC,J0881,HCPCS,55513-025-01,NDC,facility,both,100,ML,EC,2137,1495.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier EC: Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy
"RABIES VACCINE, PURIFIED CHICKEN EMBRYO CELL (PF) 2.5 UNIT IM KIT",50863,CDM,636,RC,90675,HCPCS,50632-010-01,NDC,facility,both,1,EA,,1200,840,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIOGLITAZONE 45 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,64764-451-25,NDC,facility,both,1,EA,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6638-61,NDC,facility,both,5,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL PWPK,50863,CDM,636,RC,J3490,HCPCS,37000-024-44,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR PHOSPHATE 30 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,31722-630-31,NDC,facility,both,9,EA,,460,322,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0093-3426-01,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-65,NDC,facility,both,100,ML,JZ,177,123.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CEFEPIME 1 GRAM INJ SOLR,50863,CDM,250,RC,J0692,HCPCS,25021-121-20,NDC,facility,both,2,EA,JZ,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CARVEDILOL 25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7308-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN 50 MG ORAL CHEW,50863,CDM,636,RC,J3490,HCPCS,60687-156-95,NDC,facility,both,3,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES-DOCUSATE SODIUM 8.6 MG-50 MG TAB,50863,CDM,250,RC,J3490,HCPCS,10135-669-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,5,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 0.1 MG/ML INJ SYRG,50863,CDM,250,RC,J0461,HCPCS,16729-484-03,NDC,facility,both,50,ML,JZ,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,250,RC,J2795,HCPCS,63323-286-20,NDC,facility,both,200,ML,,170,119,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-591-11,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEFIBROTIDE 80 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,68727-800-01,NDC,facility,both,1,ML,,1253,877.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOPERAMIDE 1 MG/7.5 ML ORAL LIQD,50863,CDM,250,RC,J3490,HCPCS,68094-029-59,NDC,facility,both,4,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25 MG-100 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0378-0085-01,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,0904-6794-89,NDC,facility,both,4,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPARACAINE 0.5 % OPHT DROP,50863,CDM,636,RC,J3490,HCPCS,61314-016-01,NDC,facility,both,1,ML,,215,150.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-453-11,NDC,facility,both,6,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FEBUXOSTAT 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,72578-136-06,NDC,facility,both,2,EA,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VERAPAMIL 2.5 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,70710-1643-1,NDC,facility,both,1,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,63323-506-41,NDC,facility,both,4,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ACETAZOLAMIDE SODIUM 500 (100 MG/ML) INJ SOLR,50863,CDM,636,RC,J1120,HCPCS,67457-853-50,NDC,facility,both,1,EA,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OFLOXACIN 0.3 % OPHT DROP,50863,CDM,250,RC,J3490,HCPCS,70756-607-30,NDC,facility,both,1,ML,,299,209.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM NEO/PED INFUSION (CDS MIXTURE),50863,CDM,250,RC,J2185,HCPCS,0781-3267-90,NDC,facility,both,1,EA,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 100 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,31722-574-47,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,636,RC,J3490,HCPCS,0904-6794-80,NDC,facility,both,4,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUGAMMADEX 100 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0006-5423-02,NDC,facility,both,4,ML,,2353,1647.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMETHICONE 40 MG/0.6 ML ORAL DRPS,50863,CDM,636,RC,J3490,HCPCS,5618412041,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,7,EA,JW,420,294,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
SODIUM CHLORIDE 0.9 % IR SOLN,50863,CDM,250,RC,J3490,HCPCS,0338-0047-46,NDC,facility,both,2,ML,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ORAL ELECTROLYTES ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,7007411133,NDC,facility,both,19,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 100 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,31722-574-47,NDC,facility,both,1,ML,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68180-113-16,NDC,facility,both,1,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 300 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,65162-649-78,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 1 MG ORAL CAP,50863,CDM,250,RC,J7507,HCPCS,54288-135-01,NDC,facility,both,4,EA,,136,95.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,636,RC,J3490,HCPCS,63323-485-27,NDC,facility,both,200,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRILAT 1.25 MG/ML IV INJ,50863,CDM,250,RC,J3490,HCPCS,0143-9787-01,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,506,ME,,6867,4806.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0781-3246-02,NDC,facility,both,3,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,28,EA,,3864,2704.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-65,NDC,facility,both,81,ML,,143,100.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,16714-661-01,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN  2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,62584-984-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65162-897-09,NDC,facility,both,2,EA,PLAD,272,190.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
PHENYLEPHRINE IN 0.9% NS (PF) 1 MG/10 ML (100 MCG/ML) IV SYRG(PDS MERGE),50863,CDM,250,RC,J3490,HCPCS,71266-9011-1,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J2004,HCPCS,63323-482-03,NDC,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,636,RC,J2003,HCPCS,0409-1323-15,NDC,facility,both,1000,ML,,440,308,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 125 MG/5 ML (25MG/ML) ORAL SYRINGE (REPACK),50863,CDM,250,RC,J3370,HCPCS,67457-340-00,NDC,facility,both,2,EA,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,70700-165-22,NDC,facility,both,2,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 30 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,0904-7044-61,NDC,facility,both,2,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLP",50863,CDM,636,RC,P9047,HCPCS,68516-5216-8,NDC,facility,both,2,ML,JZ,807,564.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CARVEDILOL PHOSPHATE 10 MG ORAL CM24,50863,CDM,250,RC,J3490,HCPCS,16714-227-01,NDC,facility,both,2,EA,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXRAZOXANE 500 MG IV SOLR,50863,CDM,636,RC,J1190,HCPCS,55150-435-01,NDC,facility,both,1,EA,JW,543,380.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CALCIUM GLUCONATE 20MG/ML IV SYRINGE (PEDS/NEO),50863,CDM,250,RC,J0612,HCPCS,63323-311-10,NDC,facility,both,43,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,J2704,HCPCS,0069-0209-01,NDC,,,facility,both,71,ML,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 2 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,J2270,HCPCS,63323-452-00,NDC,,,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,65649-211-24,NDC,facility,both,2,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,J2405,HCPCS,60505-6130-0,NDC,,,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL,50863,CDM,J1071,HCPCS,0409-6562-01,NDC,,,facility,both,200,ML,,130,91,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,P9045,HCPCS,68516-5214-4,NDC,,,facility,both,16,ML,,2282,1597.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 3000 MCG/ML INJECTION,50863,CDM,250,RC,J0153,HCPCS,72078-033-00,NDC,facility,both,6,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-495-27,NDC,,,facility,both,60,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % MBP,50863,CDM,J3490,HCPCS,0338-0553-18,NDC,,,facility,both,1,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,J3490,HCPCS,63323-185-07,NDC,,,facility,both,2,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,J0690,HCPCS,0143-9924-90,NDC,,,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-208-01,NDC,,,facility,both,400,ML,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN DEXTROSE (ISO-OSMOTIC) 1 GRAM/50 ML IV PIGGY BACK,50863,CDM,J0690,HCPCS,0338-3503-41,NDC,,,facility,both,4,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),50863,CDM,636,RC,J1630,HCPCS,67457-426-00,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MINERAL OIL ORAL (REPACK),50863,CDM,636,RC,J3490,HCPCS,48433-202-30,NDC,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  60 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,42858-803-01,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,282,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-11,NDC,facility,both,16,ML,,108,75.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,580,ML,,833,583.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,65219-570-01,NDC,facility,both,6,ML,,139,97.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR  6 MG/ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,68180-678-01,NDC,facility,both,8,ML,,101,70.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,63739-434-02,NDC,facility,both,3,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATOMOXETINE  40 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-326-95,NDC,facility,both,1,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,636,RC,Q0162,HCPCS,60687-252-40,NDC,facility,both,2,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-22,NDC,facility,both,180,ML,,359,251.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,0409-9094-12,NDC,facility,both,1,ML,PLAD,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
NORGESTREL-ETHINYL ESTRADIOL 0.3 MG-30 MCG TAB,50863,CDM,636,RC,J3490,HCPCS,16714-365-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IMATINIB 100 MG ORAL TAB,50863,CDM,250,RC,J9999,HCPCS,60687-192-11,NDC,facility,both,6,EA,,132,92.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAZOSIN 5 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,70954-021-10,NDC,facility,both,3,EA,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZOCAINE-MENTHOL 15-3.6 MG MM LOZG,50863,CDM,250,RC,J3490,HCPCS,6382471016,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,250,RC,J0690,HCPCS,0143-9924-90,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTOBARBITAL 75 MG/1.5 ML SYRINGE (REPACK),50863,CDM,250,RC,J2515,HCPCS,25021-676-20,NDC,facility,both,2,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM IN NACL (ISO-OS) 500 MG/100 ML IV PGBK,50863,CDM,636,RC,J1953,HCPCS,70860-602-41,NDC,facility,both,50,ML,,200,140,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0780,HCPCS,23155-294-31,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,50863,CDM,250,RC,Q5119,HCPCS,0069-0249-01,NDC,facility,both,100,ML,JZ,19784,13848.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0780,HCPCS,43066-090-01,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 10 MG ORAL TAB,50863,CDM,J3490,HCPCS,60687-503-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,59762-3140-1,NDC,facility,both,13,ML,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM & SODIUM PHOSPHATES 280-160-250 MG ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,7135101099,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALUM-MAG HYDROXIDE-SIMETH 200 MG-200 MG-20 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,17856-0630-1,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DROXIDOPA 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,31722-014-90,NDC,facility,both,3,EA,,398,278.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  25 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6991-61,NDC,facility,both,9,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16571-665-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SALIVA STIMULANT AGENTS COMB.3 MM SPRY (BIOTENE) (REPACK),50863,CDM,250,RC,J3490,HCPCS,4858200155,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-076-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LITHIUM CARBONATE 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0054-8527-25,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1940,HCPCS,63323-280-04,NDC,facility,both,4,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT  60 MCG/0.3 ML INJ SYRG,50863,CDM,250,RC,J0881,HCPCS,55513-023-01,NDC,facility,both,60,ML,EC,1282,897.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier EC: Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy
"ALBUMIN, HUMAN 25 % IV SOLP",50863,CDM,250,RC,P9047,HCPCS,76125-792-26,NDC,facility,both,1,ML,,172,120.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,68180-723-04,NDC,facility,both,2,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 100 MG IV SOLR,50863,CDM,250,RC,J2997,HCPCS,50242-085-25,NDC,facility,both,50,EA,,12145,8501.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,50863,CDM,250,RC,J9060,HCPCS,0703-5748-11,NDC,facility,both,3,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLPIDEM  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6082-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-DYYB 100 MG IV SOLR,50863,CDM,636,RC,Q5103,HCPCS,0069-0809-01,NDC,facility,both,30,EA,JZ,7836,5485.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J1940,HCPCS,63323-280-03,NDC,facility,both,4,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,55111-263-81,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,36,ML,,243,170.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE 0.5%/EPINEPHRINE 1:100K INJECTION,50863,CDM,636,RC,J3490,HCPCS,63323-286-30,NDC,facility,both,1,ML,,128,89.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOVASTATIN 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68180-468-01,NDC,facility,both,2,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MOXIFLOXACIN 400 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7407-04,NDC,facility,both,1,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,0641-6028-01,NDC,facility,both,3,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,77,ML,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESTRADIOL 2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,24658-704-01,NDC,facility,both,2,EA,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,43066-007-10,NDC,facility,both,2,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTAMIDINE 300 MG INJ SOLR,50863,CDM,636,RC,J3490,HCPCS,63323-113-01,NDC,facility,both,1,EA,,225,157.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGIC MOUTHWASH REPACK (BMX 1:1:1),50863,CDM,636,RC,J3490,HCPCS,0603-0823-54,NDC,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,136,ML,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELIMUMAB 400 MG IV SOLR,50863,CDM,636,RC,J0490,HCPCS,49401-102-01,NDC,facility,both,40,EA,"JZ,JA,JG",4459,3121.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously | Modifier JG: Drug or biological acquired with 340b drug pricing program discount
AMPICILLIN-SULBACTAM  3 GRAM INJ SOLR,50863,CDM,636,RC,J0295,HCPCS,66794-207-02,NDC,facility,both,2,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATED 20 MG/ML IV SOLN,50863,CDM,250,RC,J0706,HCPCS,51754-0500-1,NDC,facility,both,13,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM  4.5 GRAM IV SOLR,50863,CDM,636,RC,J2543,HCPCS,64679-012-02,NDC,facility,both,4,EA,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-119-11,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,50863,CDM,250,RC,J3420,HCPCS,63323-044-00,NDC,facility,both,1,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 100 MG ORAL TBSR,50863,CDM,636,RC,J3490,HCPCS,68084-697-11,NDC,facility,both,2,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELATACEPT 250 MG IV SOLR,50863,CDM,636,RC,J0485,HCPCS,0003-0371-13,NDC,facility,both,10,EA,JW,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IRON SUCROSE 100 MG/5 ML IV SOLN,50863,CDM,636,RC,J1756,HCPCS,0517-2340-01,NDC,facility,both,200,ML,JZ,642,449.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
FLUCONAZOLE IN SALINE (ISO-OSM) 400 MG/200 ML IV PIGGY BACK,50863,CDM,250,RC,J1450,HCPCS,0409-4688-02,NDC,facility,both,4,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,50863,CDM,250,RC,J9263,HCPCS,71288-101-10,NDC,facility,both,184,ML,,162,113.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,50863,CDM,250,RC,J0640,HCPCS,0143-9554-01,NDC,facility,both,4,EA,,185,129.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTOBARBITAL 75 MG/1.5 ML SYRINGE (REPACK),50863,CDM,636,RC,J3490,HCPCS,25021-676-20,NDC,facility,both,2,ML,,187,130.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN STERILE WATER 2 GRAM/20 ML IV SYRG,50863,CDM,636,RC,J0690,HCPCS,70092-1604-47,NDC,facility,both,52,ML,,677,473.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,76045-009-01,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNITS/1 GRAM PACKET (MERGE RECORD),50863,CDM,636,RC,J3490,HCPCS,57896-145-09,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,71247-130-01,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0093-4177-73,NDC,facility,both,7,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMIDE PEROXIDE 6.5 % OTIC DROP,50863,CDM,636,RC,J3490,HCPCS,7811273623,NDC,facility,both,1,ML,,181,126.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML IV,50863,CDM,636,RC,J3490,HCPCS,70860-301-41,NDC,facility,both,2,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2310,HCPCS,0641-6132-01,NDC,facility,both,1,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,636,RC,J3490,HCPCS,0904-7509-30,NDC,facility,both,3,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,250,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-161-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1815,HCPCS,0002-8215-17,NDC,facility,both,36,ML,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J2312,HCPCS,0641-6132-01,NDC,facility,both,200,ML,,200,140,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,69618-010-01,NDC,facility,both,3,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 50% IN WATER (MERGE RECORD),50863,CDM,636,RC,J7060,HCPCS,73702-104-65,NDC,facility,both,1,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE IN SALINE (ISO-OSM) 400 MG/200 ML IV PIGGY BACK,50863,CDM,636,RC,J1450,HCPCS,25021-184-87,NDC,facility,both,2,ML,JZ,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DOXYCYCLINE HYCLATE 100 MG IV SOLR,50863,CDM,636,RC,J3490,HCPCS,70436-032-35,NDC,facility,both,1,EA,,148,103.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  75 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7000-61,NDC,facility,both,4,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,63323-162-00,NDC,facility,both,2,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 500 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,0904-7182-61,NDC,facility,both,2,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM IN NACL (ISO-OS) 1500 MG/100 ML IV PGBK,50863,CDM,250,RC,J1953,HCPCS,36000-354-01,NDC,facility,both,300,ML,,127,88.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6374-61,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0456,HCPCS,0069-3150-14,NDC,facility,both,1,EA,,169,118.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN (NEO),50863,CDM,250,RC,J1940,HCPCS,71288-203-10,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6291-61,NDC,facility,both,4,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 500 MG PE/10 ML INJ SOLN,50863,CDM,250,RC,Q2009,HCPCS,68462-622-10,NDC,facility,both,4,ML,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AGALSIDASE BETA 35 MG IV SOLR,50863,CDM,636,RC,J0180,HCPCS,58468-0040-1,NDC,facility,both,70,ME,JZ,32535,22774.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
OCTREOTIDE ACETATE  100 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,0641-6175-01,NDC,facility,both,2,ML,JB,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JB: Administered subcutaneously
LEVOTHYROXINE 100 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-497-11,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0406-5771-23,NDC,facility,both,3,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLIMEPIRIDE 4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,55111-322-01,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 3000 MCG/ML INJECTION,50863,CDM,J0153,HCPCS,63323-651-00,NDC,,,facility,both,18,ML,,193,135.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,J3490,HCPCS,0143-9889-15,NDC,,,facility,both,20,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,J3490,HCPCS,72603-387-01,NDC,,,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-495-27,NDC,,,facility,both,160,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,30,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 875 MG-125 MG TAB,50863,CDM,636,RC,J3490,HCPCS,16714-297-01,NDC,facility,both,14,EA,,300,210,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,636,RC,J3490,HCPCS,63323-485-27,NDC,facility,both,155,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 500 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-163-11,NDC,facility,both,2,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,68180-150-01,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXRAZOXANE 250 MG IV SOLR,50863,CDM,250,RC,J1190,HCPCS,55150-432-01,NDC,facility,both,1,EA,,971,679.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,250,RC,J0330,HCPCS,31722-981-10,NDC,facility,both,7,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,25021-402-01,NDC,facility,both,5,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,0409-2723-30,NDC,facility,both,2,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
NALBUPHINE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J2300,HCPCS,0409-1463-01,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LINEZOLID 100 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,31722-865-25,NDC,facility,both,1,ML,,313,219.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG TAB,50863,CDM,636,RC,J3490,HCPCS,65862-419-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DORZOLAMIDE 2 % OPHT DROP,50863,CDM,636,RC,J3490,HCPCS,42571-141-26,NDC,facility,both,1,ML,,284,198.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-234-11,NDC,facility,both,2,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-229-41,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J2003,HCPCS,63323-492-37,NDC,facility,both,300,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,J3490,HCPCS,68094-494-59,NDC,,,facility,both,7,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,636,RC,J2795,HCPCS,43066-023-01,NDC,facility,both,125,ML,JW,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,J2704,HCPCS,0069-0209-01,NDC,,,facility,both,69,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN  500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7162-61,NDC,facility,both,6,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM IN NACL (ISO-OS) 500 MG/100 ML IV PGBK,50863,CDM,250,RC,J1953,HCPCS,67457-255-00,NDC,facility,both,46,ML,,172,120.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETIRIZINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-597-01,NDC,facility,both,5,EA,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IV PGBK,50863,CDM,250,RC,J3475,HCPCS,44567-420-24,NDC,facility,both,8,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-503-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,636,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,2,ML,GZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier GZ: Item or service expected to be denied as not reasonable and necessary
OXYCODONE  15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6743-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 100 % ORAL POWDER 238 GRAMS,50863,CDM,636,RC,J3490,HCPCS,45802-868-02,NDC,facility,both,1,GM,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,63323-485-27,NDC,,,facility,both,130,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,14,EA,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADVATE: FACTOR VIII CONCENTRATE (MERGE RECORD),50863,CDM,J7192,HCPCS,0944-3051-02,NDC,,,facility,both,260,UN,,1396,977.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4 % TOPICAL SOLN,50863,CDM,J3490,HCPCS,76329-6300-5,NDC,,,facility,both,1,ML,,178,124.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN PEDS SYRINGE (20MG/ML) IN DEXTROSE (CDS MIX,50863,CDM,636,RC,J0690,HCPCS,0781-3451-70,NDC,facility,both,8,EA,JZ,167,116.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-04,NDC,facility,both,20,ML,,333,233.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN IN D5W 300 MG/50 ML IV PGBK,50863,CDM,636,RC,J0736,HCPCS,0781-3288-91,NDC,facility,both,1,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOTRIMAZOLE 1 % TOP CREA,50863,CDM,250,RC,J3490,HCPCS,51672-2002-2,NDC,facility,both,1,GM,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,70436-030-82,NDC,facility,both,109,ML,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0054-8554-24,NDC,facility,both,9,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,50863,CDM,250,RC,J9045,HCPCS,0703-4239-01,NDC,facility,both,11,ML,,295,206.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,43598-053-11,NDC,facility,both,26,ML,,928,649.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,J2003,HCPCS,63323-202-02,NDC,,,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CITRATE  5 MEQ ORAL TBER,50863,CDM,636,RC,J3490,HCPCS,68382-536-01,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6085-61,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRIL MALEATE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51672-4038-1,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J1610,HCPCS,63323-596-11,NDC,facility,both,1,EA,JZ,785,549.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,636,RC,J1611,HCPCS,0597-0053-45,NDC,facility,both,1,EA,,742,519.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-02,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 1 MG ORAL CAP,50863,CDM,636,RC,J7507,HCPCS,51079-818-20,NDC,facility,both,2,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 250 MG INJ SOLR,50863,CDM,636,RC,J0696,HCPCS,0781-3206-85,NDC,facility,both,4,EA,,291,203.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB 100 MG IV SOLR,50863,CDM,636,RC,J1745,HCPCS,57894-030-01,NDC,facility,both,62,EA,,19984,13988.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  1 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,64380-782-06,NDC,facility,both,35,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,19,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN LOCK FLUSH 100 UNIT/ML IV SOLN,50863,CDM,250,RC,J1642,HCPCS,6425333335,NDC,facility,both,200,ML,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-25,NDC,facility,both,13,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,72205-014-90,NDC,facility,both,2,EA,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,25021-321-04,NDC,facility,both,2,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 100 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,51672-4047-9,NDC,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,50863,CDM,250,RC,J9025,HCPCS,72485-201-01,NDC,facility,both,75,EA,JW,467,326.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
TRAZODONE 150 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7212-61,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELATACEPT 250 MG IV SOLR,50863,CDM,636,RC,J0485,HCPCS,0003-0371-13,NDC,facility,both,65,EA,JW,292,204.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
BELATACEPT 250 MG IV SOLR,50863,CDM,250,RC,J0485,HCPCS,0003-0371-13,NDC,facility,both,600,EA,,6191,4333.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 0.4 MG SL SUBL,50863,CDM,636,RC,J3490,HCPCS,0071-0418-13,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIPASE-PROTEASE-AMYLASE 24,000-76,000- 120,000 UNIT ORAL CAP, DELAY REL",50863,CDM,250,RC,J3490,HCPCS,0032-2636-01,NDC,facility,both,2,EA,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROMETHOLONE 0.1 % OPHT DRPS,50863,CDM,636,RC,J3490,HCPCS,60219-1585-3,NDC,facility,both,1,ML,,395,276.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEMAZEPAM 15 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,50268-779-11,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 0.1MG/ML SUSPENSION (REPACK),50863,CDM,250,RC,J3490,HCPCS,51079-882-01,NDC,facility,both,5,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOPIDOGREL 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-184-11,NDC,facility,both,2,EA,,189,132.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6773-61,NDC,facility,both,3,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-3178-16,NDC,facility,both,200,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZOCAINE 20 % MM SPRY,50863,CDM,250,RC,J3490,HCPCS,0283-0610-43,NDC,facility,both,1,EA,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLPIDEM  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-838-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,3,ML,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7448-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69238-2078-1,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"AMIODARONE IN DEXTROSE,ISO-OSM 150 MG/100 ML (PREMIX)",50863,CDM,250,RC,J0282,HCPCS,43066-150-10,NDC,facility,both,5,ML,JZ,204,142.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-18,NDC,facility,both,1,ML,JZ,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LINEZOLID 600 MG/300 ML IV SOLP,50863,CDM,636,RC,J2020,HCPCS,63323-713-03,NDC,facility,both,3,ML,,232,162.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERYTHROMYCIN 5 MG/G OPHT OINT,50863,CDM,636,RC,J3490,HCPCS,0574-4024-50,NDC,facility,both,1,GM,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE  50 MG ORAL TAB,50863,CDM,250,RC,j3490,HCPCS,60687-443-11,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL 20 MG/5 ML ORAL ELIX,50863,CDM,636,RC,J3490,HCPCS,0121-0942-05,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-3178-01,NDC,facility,both,130,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEGESTROL 40 MG ORAL TAB,50863,CDM,250,RC,J9999,HCPCS,0904-7236-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL  50 MCG/HR TD PT72,50863,CDM,250,RC,J3490,HCPCS,47781-426-11,NDC,facility,both,1,EA,,191,133.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-1638-32,NDC,facility,both,2,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANTI-THYMOCYTE GLOB (RABBIT) 25 MG IV SOLR,50863,CDM,250,RC,J7511,HCPCS,58468-0080-1,NDC,facility,both,6,EA,,12132,8492.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-4264-11,NDC,facility,both,20,ML,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MYCOPHENOLATE 250 MG CAP,50863,CDM,250,RC,J7517,HCPCS,51079-721-01,NDC,facility,both,3,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J0461,HCPCS,0517-0401-25,NDC,facility,both,80,ML,,107,74.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MERCAPTOPURINE 50 MG ORAL TAB,50863,CDM,250,RC,J9999,HCPCS,0378-3547-52,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE 0.5 MG/2 ML INHL NBSP,50863,CDM,250,RC,J3490,HCPCS,0093-6816-73,NDC,facility,both,1,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"RABIES VACCINE,HUMAN DIPLOID (PF) 2.5 UNIT IM",50863,CDM,90675,HCPCS,49281-246-58,NDC,,,facility,both,1,EA,,1365,955.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,J0690,HCPCS,44567-707-25,NDC,,,facility,both,4,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIP,PER(A)TET-HEPB-POL-HIB(PF) 15 UNIT-5 UNIT- 10 MCG/0.5 ML IM INJ MERGE (CAM USE ONLY)",50863,CDM,90697,HCPCS,63361-243-15,NDC,,,facility,both,1,ML,,631,441.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,66794-229-02,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,66794-229-02,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,65862-246-08,NDC,facility,both,3,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,50863,CDM,636,RC,J9075,HCPCS,0781-3233-94,NDC,facility,both,100,EA,,1216,851.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,70069-363-01,NDC,facility,both,1,ML,,197,137.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-344-11,NDC,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAMOXIFEN 10 MG ORAL TAB,50863,CDM,250,RC,J9999,HCPCS,0591-2472-60,NDC,facility,both,2,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 20 MG ORAL TAB,50863,CDM,250,RC,J0500,HCPCS,0527-1282-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM-ALBUTEROL 0.5 MG-2.5 MG/3 ML NEB SOLUTION,50863,CDM,250,RC,J3490,HCPCS,0487-0201-01,NDC,facility,both,19,ML,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 20 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7346-61,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,636,RC,J2003,HCPCS,63323-486-05,NDC,facility,both,300,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CUPRIC CHLORIDE 0.4 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,51754-0103-1,NDC,facility,both,1,ML,,154,107.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6665-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN NACL (PF) 1000 UNIT/500 ML IV SOLP,50863,CDM,636,RC,J1644,HCPCS,0409-1005-01,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROMETHORPHAN-GUAIFENESIN SR 30 MG-600 MG 12 HR TAB,50863,CDM,250,RC,J3490,HCPCS,6382405640,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,4,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML IM SYRINGE,50863,CDM,90746,HCPCS,58160-821-43,NDC,,,facility,both,1,ML,,367,256.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,146,102.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2312,HCPCS,0409-1215-01,NDC,facility,both,80,ML,,186,130.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,J2371,HCPCS,0641-6142-25,NDC,,,facility,both,4000,ML,,213,149.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML IM SOLN,50863,CDM,636,RC,90375,HCPCS,13533-318-50,NDC,facility,both,1,ML,JW,389,272.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
"ALBUMIN, HUMAN 25 % IV SOLP",50863,CDM,250,RC,P9047,HCPCS,44206-251-10,NDC,facility,both,1,ML,,389,272.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN PEDS INFUSION (CDS MIXTURE),50863,CDM,250,RC,J0290,HCPCS,99999-408-63,NDC,facility,both,2,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-145-11,NDC,facility,both,120,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,50863,CDM,250,RC,J9075,HCPCS,10019-956-16,NDC,facility,both,171,EA,,1104,772.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,60687-145-11,NDC,facility,both,100,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-3425-01,NDC,facility,both,4,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  2.5 MG ORAL TAB,50863,CDM,250,RC,J7510,HCPCS,59651-485-01,NDC,facility,both,6,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 7.5 MG-325 MG/15 ML ORAL SOLN (REPACK),50863,CDM,636,RC,J3490,HCPCS,0121-2316-15,NDC,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J2004,HCPCS,63323-487-01,NDC,facility,both,100,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0904-7127-61,NDC,facility,both,45,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0295,HCPCS,63323-368-20,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJ SOLN",50863,CDM,J3490,HCPCS,0409-1752-50,NDC,,,facility,both,1,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GRISEOFULVIN MICROSIZE 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,42794-012-08,NDC,facility,both,2,EA,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,J7040,HCPCS,0338-0049-02,NDC,,,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,19,ML,JW,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,636,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,102,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 250 MG/5 ML ORAL SOLN,50863,CDM,J3490,HCPCS,17856-0600-1,NDC,,,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 500 MG PE/10 ML INJ SOLN,50863,CDM,250,RC,Q2009,HCPCS,25021-798-10,NDC,facility,both,20,ML,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLP",50863,CDM,P9047,HCPCS,44206-251-91,NDC,,,facility,both,2,ML,,778,544.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 10 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,67457-420-00,NDC,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  1 MG/ML IV SOLN,50863,CDM,250,RC,J1800,HCPCS,63323-604-00,NDC,facility,both,2,ML,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,636,RC,Q9968,HCPCS,70710-1838-1,NDC,facility,both,25,ML,,415,290.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0121-0917-05,NDC,facility,both,5,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLORAZEPATE DIPOTASSIUM  3.75 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,70954-159-30,NDC,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,14,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,23155-723-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-234-11,NDC,facility,both,1,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,7733351625,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM-ALBUTEROL 0.5 MG-2.5 MG/3 ML NEB SOLUTION,50863,CDM,636,RC,J3490,HCPCS,0487-0201-01,NDC,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML IV SOLN (MERGE),50863,CDM,250,RC,J3490,HCPCS,70756-611-82,NDC,facility,both,1,ML,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,636,RC,J3490,HCPCS,70004-600-09,NDC,facility,both,2,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM PHOSPHATE 4.4 MEQ/ML ORAL SOLUTION (CDS),50863,CDM,250,RC,J3490,HCPCS,0409-7295-11,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID (PORK)  30 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,42192-329-01,NDC,facility,both,3,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN  3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51672-4030-1,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,80,EA,JZ,11040,7728,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SODIUM CHLORIDE 0.9 % INJ SYRG,50863,CDM,636,RC,J3490,HCPCS,8290306546,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,250,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,7,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLESTYRAMINE-SUCROSE 4 GRAM ORAL PACK,50863,CDM,250,RC,J3490,HCPCS,68382-528-60,NDC,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,55150-169-10,NDC,facility,both,200,ML,JZ,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MORPHINE  15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0054-0235-25,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-467-01,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,5789686406,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 875 MG-125 MG TAB,50863,CDM,250,RC,J3490,HCPCS,42571-162-42,NDC,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RAMIPRIL  1.25 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,68382-144-06,NDC,facility,both,2,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,35,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-495-27,NDC,,,facility,both,260,ML,,127,88.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,636,RC,J3370,HCPCS,70436-021-82,NDC,facility,both,2,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,250,RC,J3360,HCPCS,43598-106-11,NDC,facility,both,1,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2599,HCPCS,42023-164-25,NDC,facility,both,20,ML,,413,289.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,54288-136-01,NDC,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-05,NDC,facility,both,16,EA,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 20 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7346-61,NDC,facility,both,1,EA,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CONJUGATED ESTROGENS 0.625 MG/G VAGL CREA,50863,CDM,636,RC,J3490,HCPCS,0046-0872-21,NDC,facility,both,1,GM,,1243,870.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,0088-2220-33,NDC,facility,both,10,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IV PGBK,50863,CDM,636,RC,J3475,HCPCS,25021-612-81,NDC,facility,both,4,ML,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE MONONITRATE  30 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,0904-6449-61,NDC,facility,both,2,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG/24 HR TD PTWK,50863,CDM,250,RC,J3490,HCPCS,0378-0871-99,NDC,facility,both,1,EA,,162,113.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 20MG/ML IV SYRINGE (PEDS/NEO),50863,CDM,250,RC,J0612,HCPCS,63323-311-10,NDC,facility,both,47,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIVOLUMAB 240 MG/24 ML IV SOLN,50863,CDM,J9299,HCPCS,0003-3734-13,NDC,,,facility,both,240,ML,,17369,12158.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,50863,CDM,636,RC,J0696,HCPCS,44567-701-25,NDC,facility,both,4,EA,,154,107.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMETHICONE 40MG/0.6ML (0.6ML-UD) SYRINGE (REPACK),50863,CDM,J3490,HCPCS,17856-1141-4,NDC,,,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6798-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,636,RC,J1100,HCPCS,63323-506-41,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLN (MERGE)",50863,CDM,P9047,HCPCS,64208-2512-8,NDC,,,facility,both,2,ML,,238,166.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYTOCIN IN 0.9 % SOD CHLORIDE 30 UNIT/500 ML IV SOLN,50863,CDM,J2590,HCPCS,71285-6044-1,NDC,,,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE  5 MG ORAL TAB,50863,CDM,J3490,HCPCS,51079-985-01,NDC,,,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,250,RC,J3360,HCPCS,43598-106-11,NDC,facility,both,8,ML,,578,404.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEPLIZUMAB-MZWV 2 MG/20 ML IV SOLN,50863,CDM,636,RC,J9381,HCPCS,73650-316-01,NDC,facility,both,360,ME,JW,9463,6624.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
RIZATRIPTAN  5 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,65862-625-03,NDC,facility,both,1,EA,,163,114.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),50863,CDM,250,RC,J0169,HCPCS,76329-3318-1,NDC,facility,both,50,ML,,404,282.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 800 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6707-06,NDC,facility,both,2,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 300 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,67877-543-60,NDC,facility,both,2,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIACIN  250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,7985420140,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,0409-1207-03,NDC,facility,both,5,ML,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 5 MG/ML IV SOLN,50863,CDM,636,RC,J1921,HCPCS,17478-420-20,NDC,facility,both,1,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 500 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,68084-415-11,NDC,facility,both,3,EA,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,60,ML,JW,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
METHYLPHENIDATE 18 MG ORAL TO24,50863,CDM,250,RC,J3490,HCPCS,62175-310-37,NDC,facility,both,1,EA,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,42494-416-01,NDC,facility,both,1,ML,,145,101.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NYSTATIN  100000 UNIT/G TOP POWD,50863,CDM,636,RC,J3490,HCPCS,0574-2008-15,NDC,facility,both,1,GM,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,636,RC,J0690,HCPCS,70092-1017-46,NDC,facility,both,4,ML,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-01,NDC,facility,both,4,ML,,119,83.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % MUCOSAL GEL,50863,CDM,636,RC,J3490,HCPCS,17478-711-10,NDC,facility,both,1,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN ASP PRT-INSULIN ASPART 100 UNIT/ML (70-30) SUBQ SOLN,50863,CDM,250,RC,J1817,HCPCS,73070-200-11,NDC,facility,both,2,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-742-11,NDC,facility,both,2,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,50863,CDM,636,RC,J0696,HCPCS,60505-6148-0,NDC,facility,both,4,EA,JZ,225,157.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,76045-009-10,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,50863,CDM,250,RC,J0585,HCPCS,0023-1145-01,NDC,facility,both,100,EA,,1599,1119.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,33,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LINEZOLID NEO IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J2020,HCPCS,0781-3433-46,NDC,facility,both,3,ML,JZ,331,231.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MELOXICAM  7.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-525-11,NDC,facility,both,1,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J7510,HCPCS,17856-0815-1,NDC,facility,both,7,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 2 MG/ML IV SOLN (PRMC ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-1312-10,NDC,facility,both,40,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0641-6057-01,NDC,facility,both,2,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,636,RC,J0330,HCPCS,0409-6629-02,NDC,facility,both,2,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LANTHANUM  500 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,54092-252-45,NDC,facility,both,3,EA,,212,148.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE (FOR CODE) 10% (100 MG/ML) IV SYRINGE,50863,CDM,250,RC,J3490,HCPCS,0409-1631-10,NDC,facility,both,3,ML,,223,156.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-1749-70,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE IN 0.9% NS (PF) 1 MG/10 ML (100 MCG/ML) IV SYRG(PDS MERGE),50863,CDM,250,RC,J3490,HCPCS,65302-506-10,NDC,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAUNORUBICIN 5 MG/ML IV INJ,50863,CDM,636,RC,J9150,HCPCS,42658-021-01,NDC,facility,both,3,ML,,841,588.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 2400000 UNIT/4 ML IM SYRG,50863,CDM,250,RC,J0561,HCPCS,60793-702-04,NDC,facility,both,24,ML,,1898,1328.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,250,RC,Q9968,HCPCS,70710-1838-1,NDC,facility,both,2,ML,JW,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
AMPHETAMINE-DEXTROAMPHETAMINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,47781-176-01,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEMAZEPAM 15 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0406-9961-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  88 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42292-038-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN   81 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,69618-066-02,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN SODIUM  2 GRAM INJ SOLR,50863,CDM,636,RC,J0290,HCPCS,72485-422-01,NDC,facility,both,4,EA,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"CIPROFLOXACIN-HYDROCORTISONE 0.2 %-1 % EAR DROPS, SUSP",50863,CDM,636,RC,J3490,HCPCS,66758-087-70,NDC,facility,both,1,ML,,1291,903.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 4 MG/ACTUATION NASL SPRY,50863,CDM,636,RC,J3490,HCPCS,69547-627-02,NDC,facility,both,1,EA,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1940,HCPCS,63323-280-04,NDC,facility,both,6,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,16714-662-01,NDC,facility,both,2,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOPIDOGREL  75 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-052-10,NDC,facility,both,4,EA,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,60687-736-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOSTIGMINE METHYLSULFATE 3 MG/3 ML (1 MG/ML) IV SYRG,50863,CDM,636,RC,J2710,HCPCS,69374-932-03,NDC,facility,both,1,ML,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-467-01,NDC,facility,both,1,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-444-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,76,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6730-61,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CANGRELOR 50 MG IV SOLR,50863,CDM,250,RC,C9460,HCPCS,10122-620-01,NDC,facility,both,100,EA,JZ,5269,3688.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-25,NDC,facility,both,40,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0143-9982-50,NDC,facility,both,2,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FINASTERIDE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65862-927-30,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,46,EA,,6348,4443.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-11,NDC,facility,both,17,ML,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL (VITAMIN D3)  1000 UNIT ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,2055503300,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,23155-600-31,NDC,facility,both,1,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ESCITALOPRAM 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6427-61,NDC,facility,both,1,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-25,NDC,facility,both,15,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,0641-6236-01,NDC,facility,both,2,ML,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 100 MG PE/2 ML INJ SOLN,50863,CDM,250,RC,Q2009,HCPCS,63323-403-01,NDC,facility,both,4,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MANNITOL 20% IV SOLP,50863,CDM,250,RC,J2150,HCPCS,0990-7715-13,NDC,facility,both,1,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE IN 0.9% NS (PF) 1 MG/10 ML (100 MCG/ML) IV SYRG(PDS MERGE),50863,CDM,250,RC,J3490,HCPCS,69374-957-10,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.1 % NASAL SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-103-01,NDC,facility,both,1,ML,,888,621.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM IN NACL (ISO-OS) 500 MG/100 ML IV PGBK,50863,CDM,636,RC,J1953,HCPCS,70860-602-41,NDC,facility,both,150,ML,,599,419.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MYCOPHENOLATE 180 MG TAB, DELAYED RELEASE",50863,CDM,250,RC,J7518,HCPCS,70748-217-16,NDC,facility,both,1,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,16714-026-01,NDC,facility,both,2,ML,JW,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-24,NDC,facility,both,200,ML,"JZ,JA",28288,19801.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
ETOMIDATE 2 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,25021-674-20,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN (NEW TX NON-NEURO INDICATION)",50863,CDM,636,RC,J1561,HCPCS,13533-800-71,NDC,facility,both,20,ML,,2829,1980.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM BROMIDE 17 MCG/ACTUATION INHL AERO,50863,CDM,250,RC,J3490,HCPCS,0597-0087-17,NDC,facility,both,1,GM,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 17 GRAM (100 %) ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,62559-157-17,NDC,facility,both,2,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,10,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,636,RC,J3490,HCPCS,59310-579-22,NDC,facility,both,1,GM,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL 20 MG/5 ML ORAL ELIX,50863,CDM,250,RC,J3490,HCPCS,0121-0942-05,NDC,facility,both,2,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LANREOTIDE 120 MG/0.5 ML SUBQ SYRG,50863,CDM,636,RC,J1930,HCPCS,15054-1120-4,NDC,facility,both,120,ML,,26392,18474.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 20 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7346-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,250,RC,J0330,HCPCS,0409-6629-02,NDC,facility,both,10,ML,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 125 MG/5 ML (25MG/ML) ORAL SYRINGE (REPACK),50863,CDM,250,RC,J3370,HCPCS,67457-340-00,NDC,facility,both,2,EA,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,70069-363-01,NDC,facility,both,1,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZTROPINE 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69315-136-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 100 MG PE/2 ML INJ SOLN,50863,CDM,250,RC,Q2009,HCPCS,0641-6136-01,NDC,facility,both,1,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CARBOXYMETHYLCELLULOSE SODIUM 1 % OPHT DLGL,50863,CDM,250,RC,J3490,HCPCS,0023-9205-15,NDC,facility,both,1,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,636,RC,J3490,HCPCS,66993-019-68,NDC,facility,both,1,GM,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB 100 MG IV SOLR,50863,CDM,636,RC,J1745,HCPCS,57894-030-01,NDC,facility,both,56,EA,,18050,12635,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,63739-931-28,NDC,facility,both,10,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,50863,CDM,250,RC,J8540,HCPCS,0904-7266-61,NDC,facility,both,8,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 30 MG/0.3 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0075-0624-01,NDC,facility,both,3,ML,JZ,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
TRAMADOL  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-795-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORDIAZEPOXIDE 25 MG CAP,50863,CDM,250,RC,J3490,HCPCS,60687-807-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE MONONITRATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,6809411659,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 500 MG PE/10 ML INJ SOLN,50863,CDM,636,RC,Q2009,HCPCS,0641-6137-01,NDC,facility,both,20,ML,,484,338.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-582-11,NDC,facility,both,3,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE NA (PRESERV FREE) 25 MG/ML INJ SOLN,50863,CDM,250,RC,J9260,HCPCS,61703-408-41,NDC,facility,both,320,ML,,3449,2414.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,188,131.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-50,NDC,facility,both,115,ML,,203,142.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2599,HCPCS,63323-930-01,NDC,facility,both,6,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACIDOPHILUS-PECTIN W CITRUS 25 MILLION-100 CELL MG TAB,50863,CDM,250,RC,J3490,HCPCS,1785614241,NDC,facility,both,7,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOL 1.4 % MM SPRA,50863,CDM,250,RC,J3490,HCPCS,0904-6305-21,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 25 MG TAB,50863,CDM,250,RC,J3490,HCPCS,16714-796-01,NDC,facility,both,2,EA,,230,161,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVONORGESTREL 17.5 MCG/24 HR (5 YEARS) IU IUD,50863,CDM,636,RC,J7296,HCPCS,50419-424-01,NDC,facility,both,1,EA,,2509,1756.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 100 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,50268-542-11,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOPIDOGREL  75 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6294-61,NDC,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COENZYME Q10 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,5789687503,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,62332-033-31,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,42494-415-01,NDC,facility,both,2,ML,,385,269.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  37.5 MG ORAL CP24,50863,CDM,636,RC,J3490,HCPCS,65862-527-90,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-405-11,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-1638-32,NDC,facility,both,2,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTAMIDINE 300 MG INHL SOLR,50863,CDM,636,RC,J3490,HCPCS,39822-3030-2,NDC,facility,both,1,EA,,405,283.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-342-11,NDC,facility,both,3,EA,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0075-0622-01,NDC,facility,both,3,ML,JW,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PACLITAXEL 6 MG/ML IV CONC,50863,CDM,250,RC,J9267,HCPCS,61703-342-50,NDC,facility,both,300,ML,,363,254.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-098-10,NDC,facility,both,1,EA,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,250,RC,J3490,HCPCS,62037-560-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 50 % (4 MEQ/ML) INJ SOLN,50863,CDM,250,RC,J3475,HCPCS,63323-064-02,NDC,facility,both,8,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACUBITRIL-VALSARTAN 24-26 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0078-0659-67,NDC,facility,both,1,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG/ML INJ SOLN,50863,CDM,636,RC,J2550,HCPCS,0641-6084-01,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,50863,CDM,250,RC,Q0177,HCPCS,0904-6617-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DICLOFENAC 50 MG TAB, DELAYED RELEASE",50863,CDM,636,RC,J3490,HCPCS,60687-606-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,63323-506-00,NDC,facility,both,10,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPARACAINE 0.5 % OPHT DROP,50863,CDM,250,RC,J3490,HCPCS,24208-730-06,NDC,facility,both,1,ML,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYTOCIN IN 0.9 % SOD CHLORIDE 30 UNIT/500 ML IV SOLN,50863,CDM,250,RC,J2590,HCPCS,61553-735-03,NDC,facility,both,1,ML,,155,108.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 50% IN WATER (MERGE RECORD),50863,CDM,250,RC,J7060,HCPCS,76329-3302-1,NDC,facility,both,1,ML,,119,83.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES-DOCUSATE SODIUM 8.6 MG-50 MG TAB,50863,CDM,250,RC,J3490,HCPCS,60687-622-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-5771-23,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN DEXTROSE (ISO-OSMOTIC) 1 GRAM/50 ML IV PIGGY BACK,50863,CDM,250,RC,J0690,HCPCS,0338-3503-41,NDC,facility,both,2,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-245-11,NDC,facility,both,2,EA,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,23155-600-31,NDC,facility,both,6,ML,JZ,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MORPHINE  10 MG/5 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,68094-001-59,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  50 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-484-11,NDC,facility,both,5,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 16 MG ORAL TAB,50863,CDM,250,RC,J7509,HCPCS,68382-918-18,NDC,facility,both,8,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  500 MG IV SOLR,50863,CDM,250,RC,J3373,HCPCS,0143-9161-01,NDC,facility,both,25,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6475-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-01,NDC,facility,both,4,ML,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 150 MG CAP,50863,CDM,636,RC,J3490,HCPCS,0904-5959-61,NDC,facility,both,3,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-229-02,NDC,facility,both,2,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DROPERIDOL 2.5 MG/ML INJ SOLN,50863,CDM,J1790,HCPCS,0517-9702-01,NDC,,,facility,both,1,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7030,HCPCS,0338-0049-04,NDC,facility,both,2,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2310,HCPCS,36000-308-01,NDC,facility,both,2,ML,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAMIDRONATE 3 MG/ML IV SOLN,50863,CDM,250,RC,J2430,HCPCS,67457-430-10,NDC,facility,both,2,ML,,317,221.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0093-4177-73,NDC,facility,both,10,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COLCHICINE 0.6 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,70010-002-01,NDC,facility,both,1,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % MBP,50863,CDM,636,RC,J3490,HCPCS,0338-9159-30,NDC,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENETOCLAX 100 MG ORAL TAB,50863,CDM,250,RC,J9999,HCPCS,0074-0576-11,NDC,facility,both,2,EA,,689,482.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM  3.375 GRAM IV SOLR,50863,CDM,250,RC,J2543,HCPCS,64679-056-02,NDC,facility,both,3,EA,,107,74.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.45 % 0.45 % IV SOLP,50863,CDM,250,RC,J3490,HCPCS,0338-0043-03,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 20 MG/ML INJ SOLN,50863,CDM,250,RC,J0360,HCPCS,0641-6231-01,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,250,RC,J2003,HCPCS,55150-165-05,NDC,facility,both,500,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 10 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,67457-420-00,NDC,facility,both,40,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,636,RC,J7999,HCPCS,70092-1017-46,NDC,facility,both,2,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE  50 MCG/ACTUATION NASL SPSN,50863,CDM,250,RC,J3490,HCPCS,0054-3270-99,NDC,facility,both,1,GM,,396,277.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J2310,HCPCS,0409-1215-01,NDC,facility,both,1,ML,,186,130.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-4741-19,NDC,facility,both,2,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 500 MG/100 ML CONCENTRATED DRIP 100 ML (RSE),50863,CDM,250,RC,J2250,HCPCS,0409-2596-15,NDC,facility,both,46,ML,JW,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CEPHALEXIN 250 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0093-3145-01,NDC,facility,both,4,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,636,RC,J3490,HCPCS,72789-057-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0904-6923-61,NDC,facility,both,35,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SULFADIAZINE 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0185-0757-01,NDC,facility,both,3,EA,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,0641-6174-01,NDC,facility,both,4,ML,"JZ,JA",60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,16714-293-03,NDC,facility,both,8,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-327-11,NDC,facility,both,2,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 100 MG/ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,31722-574-47,NDC,facility,both,1,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,636,RC,J2795,HCPCS,43066-023-01,NDC,facility,both,105,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-318-11,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTAMIDINE 300 MG INHL SOLR,50863,CDM,636,RC,J3490,HCPCS,39822-3030-1,NDC,facility,both,1,EA,,405,283.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 125 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0074-7068-11,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-25,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  25 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-6991-04,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 1 % TOPICAL SOLN,50863,CDM,250,RC,J3490,HCPCS,51672-4081-3,NDC,facility,both,1,ML,,200,140,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VECURONIUM BROMIDE 10 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,0703-2914-01,NDC,facility,both,1,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-406-03,NDC,facility,both,1,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE HCL 0.3 MG/ML INJ (MERGE),50863,CDM,250,RC,J0592,HCPCS,42023-179-01,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,0641-6145-01,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IMIPRAMINE 50 MG TAB,50863,CDM,250,RC,J3490,HCPCS,69315-135-01,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,67877-548-88,NDC,facility,both,6,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6966-61,NDC,facility,both,4,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,15,ML,JW,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
FILGRASTIM-SNDZ 300 MCG/0.5 ML INJ SYRG,50863,CDM,250,RC,Q5101,HCPCS,61314-318-05,NDC,facility,both,600,ML,,1943,1360.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SELEGILINE 5 MG TAB,50863,CDM,250,RC,J3490,HCPCS,60505-3438-3,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-4713-32,NDC,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NYSTATIN  100000 UNIT/G TOP POWD,50863,CDM,250,RC,J3490,HCPCS,0832-0465-15,NDC,facility,both,1,GM,,184,128.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN PEDS IV INFUSION 12 MG/ML (CDS MIXTURE FROM PREMIX),50863,CDM,636,RC,J0736,HCPCS,0781-3289-91,NDC,facility,both,2,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0074-4341-90,NDC,facility,both,6,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIPASE-PROTEASE-AMYLASE 24,000-76,000- 120,000 UNIT ORAL CAP, DELAY REL",50863,CDM,636,RC,J3490,HCPCS,0032-1224-01,NDC,facility,both,1,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  2.5 MG ORAL TAB,50863,CDM,250,RC,J7510,HCPCS,59651-485-01,NDC,facility,both,36,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 250 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,42192-608-05,NDC,facility,both,2,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 150 MG ORAL TBSR,50863,CDM,636,RC,J3490,HCPCS,0591-3541-60,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATOMOXETINE  10 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,68462-265-30,NDC,facility,both,1,EA,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-444-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,250,RC,J2720,HCPCS,63323-229-01,NDC,facility,both,18,ML,,327,228.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,70069-363-01,NDC,facility,both,1,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB 100 MG IV SOLR,50863,CDM,636,RC,J1745,HCPCS,57894-030-01,NDC,facility,both,82,EA,,26431,18501.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM 1 GRAM IV SOLR,50863,CDM,250,RC,J2185,HCPCS,0310-0321-30,NDC,facility,both,10,EA,,342,239.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,63323-461-01,NDC,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,0409-1886-22,NDC,facility,both,100,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,636,RC,J2560,HCPCS,0641-0476-21,NDC,facility,both,1,ML,,155,108.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAMSULOSIN 0.4 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,72603-115-01,NDC,facility,both,2,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,517,ME,JZ,7016,4911.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
VANCOMYCIN   1.25 G IV SOLR,50863,CDM,250,RC,J3370,HCPCS,67457-823-12,NDC,facility,both,4,EA,,166,116.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE (PEDIATRIC 6 MONTH) 45 MG IM SYKT,50863,CDM,J1950,HCPCS,0074-3575-01,NDC,,,facility,both,12,EA,,71748,50223.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,50863,CDM,J9263,HCPCS,71288-172-21,NDC,,,facility,both,68,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,J3490,HCPCS,63323-739-41,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,50863,CDM,J9263,HCPCS,71288-172-21,NDC,,,facility,both,332,ML,,195,136.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,50863,CDM,J1885,HCPCS,63323-162-03,NDC,,,facility,both,2,ML,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,10019-033-39,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIP,PER(A)TET-HEPB-POL-HIB(PF) 15 UNIT-5 UNIT- 10 MCG/0.5 ML IM INJ MERGE (CAM USE ONLY)",50863,CDM,90697,HCPCS,63361-243-15,NDC,,,facility,both,1,ML,,674,471.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,J3490,HCPCS,60687-653-11,NDC,,,facility,both,4,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,0088-2220-33,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE PEDS SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J1450,HCPCS,0338-6045-37,NDC,facility,both,2,ML,JZ,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LACTATED RINGERS IV (BOLUS),50863,CDM,636,RC,J7120,HCPCS,0264-7750-00,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,55111-466-01,NDC,facility,both,5,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0093-4127-74,NDC,facility,both,5,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DASATINIB 100 MG ORAL TAB,50863,CDM,250,RC,J9999,HCPCS,43598-603-30,NDC,facility,both,1,EA,,1595,1116.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-18,NDC,facility,both,2,ML,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 0.125 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68462-330-90,NDC,facility,both,3,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LANSOPRAZOLE 15 MG ORAL TBLD,50863,CDM,250,RC,J3490,HCPCS,68382-771-30,NDC,facility,both,1,EA,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,J3490,HCPCS,60687-653-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-505-11,NDC,facility,both,3,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60219-1708-1,NDC,facility,both,140,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 100 MG ORAL TAB,50863,CDM,J3490,HCPCS,60687-439-11,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MOXIFLOXACIN 400 MG/250 ML IVPB PREMIX (MERGE),50863,CDM,J2280,HCPCS,67457-323-25,NDC,,,facility,both,4,ML,,234,163.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROMETHORPHAN-GUAIFENESIN SR 30 MG-600 MG 12 HR TAB,50863,CDM,J3490,HCPCS,6382405640,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,J7050,HCPCS,17271-701-05,NDC,,,facility,both,1,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,636,RC,J3010,HCPCS,63323-806-13,NDC,facility,both,5,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-4279-02,NDC,facility,both,2100,ML,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-492-27,NDC,,,facility,both,300,ML,,236,165.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC IV INFUSION HYDRAT 31-60 MIN,50863,CDM,J0248,HCPCS,61958-2901-2,NDC,,,facility,both,100,EA,,1196,837.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0172-5728-80,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTAMIDINE 300 MG INJ SOLR,50863,CDM,636,RC,J3490,HCPCS,63323-113-01,NDC,facility,both,1,EA,,444,310.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB 10 MG/ML IV CONC,50863,CDM,636,RC,J9312,HCPCS,50242-053-06,NDC,facility,both,100,ML,,25931,18151.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACIDOPHILUS-PECTIN W CITRUS 25 MILLION-100 CELL MG TAB,50863,CDM,250,RC,J3490,HCPCS,1785614241,NDC,facility,both,21,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J2004,HCPCS,63323-482-03,NDC,facility,both,40,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 300 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,69452-125-50,NDC,facility,both,1,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM IN NACL (ISO-OS) 500 MG/100 ML IV PGBK,50863,CDM,250,RC,J1953,HCPCS,67457-255-00,NDC,facility,both,100,ML,,165,115.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,72603-251-01,NDC,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOLTERODINE 2 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,0904-6592-04,NDC,facility,both,2,EA,,107,74.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,250,RC,J3490,HCPCS,55150-188-10,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-132-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHIMAZOLE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-669-11,NDC,facility,both,3,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-1165-02,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TICAGRELOR 90 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,72205-368-91,NDC,facility,both,7,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,55390-138-01,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 500 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,50268-152-15,NDC,facility,both,10,EA,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML INJ SOLN (PULMONARY USE),50863,CDM,250,RC,J2250,HCPCS,55390-137-02,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-0430-06,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2312,HCPCS,36000-308-01,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOLIC ACID  1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7224-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPOPROSTENOL (ARGNININE) (VELETRI) CONTINUOUS NEB 1.5 MG IN NS 50 ML,50863,CDM,250,RC,J3490,HCPCS,99999-500-20,NDC,facility,both,1,ML,,243,170.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VORICONAZOLE 200 MG IV SOLN,50863,CDM,250,RC,J3465,HCPCS,0781-3416-94,NDC,facility,both,21,EA,,564,394.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 2 MG/ML IN NS 50ML INFUSION (STOCK DOSE),50863,CDM,250,RC,J3490,HCPCS,0143-9508-01,NDC,facility,both,2,ML,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 1 % INJ SOLN,50863,CDM,636,RC,Q9968,HCPCS,17478-504-01,NDC,facility,both,10,ML,JZ,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CEFEPIME 2 GRAM INJ SOLR,50863,CDM,250,RC,J0692,HCPCS,44567-241-10,NDC,facility,both,4,EA,PLAD,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
AMLODIPINE 1 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,46287-035-15,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 25 MG CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7237-60,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB 10 MG/ML IV CONC,50863,CDM,636,RC,J9312,HCPCS,50242-051-21,NDC,facility,both,30,ML,,6650,4655,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPAGLIFLOZIN PROPANEDIOL 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0310-6210-39,NDC,facility,both,1,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,904740361,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES  8.6 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69618-064-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-04,NDC,facility,both,1,ML,,831,581.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ICATIBANT 30 MG/3 ML SUBQ SYRG,50863,CDM,636,RC,J1744,HCPCS,63323-574-86,NDC,facility,both,30,ML,JZ,3588,2511.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CEFTOLOZANE-TAZOBACTAM 1.5 G IV SOLR,50863,CDM,250,RC,J0695,HCPCS,67919-030-01,NDC,facility,both,40,EA,,1371,959.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,250,RC,J3490,HCPCS,63037-136-25,NDC,facility,both,3,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETHAMBUTOL 400 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68850-012-02,NDC,facility,both,4,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN (NEW TX NON-NEURO INDICATION)",50863,CDM,636,RC,J1561,HCPCS,13533-800-71,NDC,facility,both,20,ML,,2829,1980.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 600 MG ORAL TP12,50863,CDM,J3490,HCPCS,0904-6718-39,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) NEB SOLUTION,50863,CDM,250,RC,J3490,HCPCS,0487-9501-00,NDC,facility,both,24,ML,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-1283-04,NDC,facility,both,15,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRP (MERGE/REPACK),50863,CDM,250,RC,J3490,HCPCS,68094-764-59,NDC,facility,both,1,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,36,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN IN D5W 600 MG/50 ML IV PGBK,50863,CDM,636,RC,J0736,HCPCS,0338-3612-50,NDC,facility,both,3,ML,JZ,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0143-9889-01,NDC,facility,both,33,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,J1596,HCPCS,0143-9679-01,NDC,,,facility,both,4,ML,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,563,ML,,808,565.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4 % TOP CREA,50863,CDM,J3490,HCPCS,0496-0882-05,NDC,,,facility,both,1,GM,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-65,NDC,facility,both,16,ML,JW,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DIPHENHYDRAMINE 25 MG CAP,50863,CDM,250,RC,J3490,HCPCS,1093-9955-30,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-ABDA 100 MG IV SOLR,50863,CDM,636,RC,Q5104,HCPCS,78206-162-99,NDC,facility,both,25,EA,,5199,3639.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-21,NDC,facility,both,10,ML,JZ,1415,990.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,250,RC,J3490,HCPCS,23155-166-31,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,J1885,HCPCS,62332-600-01,NDC,,,facility,both,1,ML,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENTACAPONE 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-188-11,NDC,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLORAZEPATE DIPOTASSIUM  3.75 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51672-4042-1,NDC,facility,both,3,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,88,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0630,HCPCS,42023-205-01,NDC,facility,both,1,ML,,7519,5263.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  80 MG ORAL CS24,50863,CDM,250,RC,J3490,HCPCS,63629-2072-1,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 20MG/ML IV SYRINGE (PEDS/NEO),50863,CDM,250,RC,J0612,HCPCS,63323-311-10,NDC,facility,both,12,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE 20 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0904-5677-61,NDC,facility,both,2,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,68180-150-01,NDC,facility,both,2,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE (CONTRACEPTIVE) 150 MG/ML IM (MERGE),50863,CDM,J1050,HCPCS,55150-330-01,NDC,,,facility,both,150,ML,,357,249.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,0517-4620-25,NDC,facility,both,5,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 500 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,16714-299-03,NDC,facility,both,4,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN 0.9% SODIUM CL 1 GRAM/250 ML IV SOLN,50863,CDM,636,RC,J3373,HCPCS,71266-5082-1,NDC,facility,both,100,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,636,RC,J1610,HCPCS,63323-582-82,NDC,facility,both,1,EA,JZ,991,693.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
RIVASTIGMINE 1.5 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,33342-089-09,NDC,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN  500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,65862-008-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 600 MG ORAL TP12,50863,CDM,250,RC,J3490,HCPCS,68084-572-11,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TAB,50863,CDM,636,RC,J3490,HCPCS,60687-672-11,NDC,facility,both,2,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,250,RC,J7060,HCPCS,0338-0017-03,NDC,facility,both,1,ML,JZ,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ROPINIROLE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,10135-679-01,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MUPIROCIN 2 % TOP OINT,50863,CDM,J3490,HCPCS,45802-112-22,NDC,,,facility,both,1,GM,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE (PF-DURAMORPH/ASTRAMORPH) 0.5 MG/ML INJ SOLN,50863,CDM,J2274,HCPCS,0409-3814-12,NDC,,,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,J1100,HCPCS,0641-6145-01,NDC,,,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE NA (PRESERV FREE) 25 MG/ML INJ SOLN,50863,CDM,250,RC,J9260,HCPCS,61703-408-41,NDC,facility,both,40,ML,,432,302.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 1 MG/ML (1ML) SYRINGE (REPACK),50863,CDM,250,RC,J2997,HCPCS,50242-044-13,NDC,facility,both,3,EA,,677,473.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 1 MG/ML NEEDLELESS SYRG,50863,CDM,636,RC,J2310,HCPCS,76329-3369-1,NDC,facility,both,2,ML,,194,135.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,50863,CDM,250,RC,J0640,HCPCS,25021-814-30,NDC,facility,both,2,EA,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2599,HCPCS,55150-370-01,NDC,facility,both,7,ML,,134,93.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
STERILE TALC 3 G INPL AERP,50863,CDM,250,RC,J3490,HCPCS,62327-333-03,NDC,facility,both,2,EA,,900,630,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  75 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-495-11,NDC,facility,both,4,EA,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUANFACINE 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,24979-198-01,NDC,facility,both,3,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NYSTATIN 100000 UNIT/ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,60687-800-40,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IV PGBK,50863,CDM,250,RC,J3475,HCPCS,44567-420-24,NDC,facility,both,4,ML,JZ,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
AMLODIPINE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6370-61,NDC,facility,both,30,EA,,242,169.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE ENEMA 200G IN SW (1000 ML TOTAL VOLUME),50863,CDM,250,RC,J3490,HCPCS,99999-0405-41,NDC,facility,both,1,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL (5 MG/ML) IV SYRG (CONTAINS PRESERVATIVE),50863,CDM,250,RC,J3490,HCPCS,0409-2339-24,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN NPH HUMAN RECOMB 100 UNIT/ML SUBQ SUSP,50863,CDM,250,RC,J1815,HCPCS,0169-1834-11,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE  10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-162-11,NDC,facility,both,9,EA,,227,158.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNITS/1 GRAM PACKET (MERGE RECORD),50863,CDM,636,RC,J3490,HCPCS,0904-7023-67,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOXYBENZAMINE 10 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0054-0349-25,NDC,facility,both,3,EA,,1195,836.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,0409-3178-16,NDC,,,facility,both,130,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM HYPOCHLORITE 0.125 % MISC SOLN,50863,CDM,J3490,HCPCS,0436-0672-16,NDC,,,facility,both,1,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,J0665,HCPCS,72603-506-01,NDC,,,facility,both,200,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-591-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MILRINONE INFUSION PED/NEO IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J2260,HCPCS,0143-9719-01,NDC,facility,both,4,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM SR 120 MG 12 HR CAP,50863,CDM,250,RC,J3490,HCPCS,0378-6120-01,NDC,facility,both,1,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 500 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,0904-7182-61,NDC,facility,both,3,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,250,RC,J3490,HCPCS,0409-4277-02,NDC,facility,both,400,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCUSATE SODIUM 100 MG ORAL CAP,50863,CDM,J3490,HCPCS,0904-7183-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0630,HCPCS,42023-205-01,NDC,facility,both,1,ML,,2065,1445.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,42023-186-20,NDC,facility,both,1,ML,,219,153.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES  8.6 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,71399-1017-3,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN  750 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,70010-492-01,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 100 MG/ML FROM 1 GRAM VIAL (PRMC PEDS ONLY),50863,CDM,636,RC,J0696,HCPCS,0409-7332-11,NDC,facility,both,4,EA,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
QUETIAPINE 300 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6642-61,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-01,NDC,facility,both,2,ML,JZ,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GABAPENTIN 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6665-61,NDC,facility,both,1,EA,PLAD,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,Q5121,HCPCS,55513-670-01,NDC,,,facility,both,73,EA,,10074,7051.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0054-0017-20,NDC,facility,both,30,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,16714-046-01,NDC,facility,both,3,ML,JW,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6949-61,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POVIDONE-IODINE 10 % TOP OINT,50863,CDM,250,RC,J3490,HCPCS,0603-0599-50,NDC,facility,both,1,GM,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 200 MG/100 ML IVPB (MERGE),50863,CDM,636,RC,J1450,HCPCS,0409-3435-01,NDC,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,50268-540-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,636,RC,J1953,HCPCS,0409-1886-22,NDC,facility,both,200,ML,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68180-998-01,NDC,facility,both,7,EA,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0955-1008-01,NDC,facility,both,3,ML,JW,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ZOLEDRONIC ACID 4 MG/5 ML IV SOLN,50863,CDM,250,RC,J3489,HCPCS,67457-390-54,NDC,facility,both,8,ML,,448,313.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MYCOPHENOLATE 200 MG/ML ORAL SUSP,50863,CDM,250,RC,J7517,HCPCS,66689-307-08,NDC,facility,both,2,ML,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J2310,HCPCS,67457-299-00,NDC,facility,both,1,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML INJECTION,50863,CDM,J3411,HCPCS,0641-6228-01,NDC,,,facility,both,2,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL IV BOLUS 10MG/ML (ANESTHESIA ONLY),50863,CDM,J2704,HCPCS,63323-269-29,NDC,,,facility,both,11,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,63323-161-00,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,78206-122-01,NDC,facility,both,2,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEMAZEPAM  7.5 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-6436-04,NDC,facility,both,1,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 150 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,16729-443-15,NDC,facility,both,3,EA,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE (PF) 25 MG/ML INJ SOLN (FOR ECTOPIC PREGNANCY),50863,CDM,636,RC,J9260,HCPCS,0143-9519-01,NDC,facility,both,2,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,72485-106-01,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-25,NDC,facility,both,75,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-506-11,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-210-01,NDC,facility,both,1,EA,PLAD,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),50863,CDM,J3490,HCPCS,63323-186-10,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE (6 MONTH) 45 MG SUBCUTANOUS KIT,50863,CDM,636,RC,J9217,HCPCS,62935-454-44,NDC,facility,both,6,EA,JZ,1176,823.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
HYDROMORPHONE (PF) 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1171,HCPCS,0409-2634-25,NDC,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 250 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,0904-6363-45,NDC,facility,both,2,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAZOSIN 1 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7020-61,NDC,facility,both,8,EA,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,25021-468-10,NDC,facility,both,1,EA,,298,208.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7243-61,NDC,facility,both,14,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J3490,HCPCS,0409-4276-17,NDC,,,facility,both,500,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,J1610,HCPCS,63323-596-11,NDC,,,facility,both,1,EA,,895,626.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML IV SOLN,50863,CDM,J3490,HCPCS,72266-147-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 25 MG IV SOLR,50863,CDM,250,RC,J3101,HCPCS,50242-009-01,NDC,facility,both,25,EA,JZ,22901,16030.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
VANCOMYCIN  500 MG IV SOLR,50863,CDM,250,RC,J3370,HCPCS,72611-761-01,NDC,facility,both,1,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 1 % INJ SOLN,50863,CDM,636,RC,Q9968,HCPCS,17478-504-01,NDC,facility,both,5,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIOTHYRONINE  5 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,62756-589-88,NDC,facility,both,3,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPILIMUMAB 50 MG/10 ML (5 MG/ML) IV SOLN,50863,CDM,J9228,HCPCS,0003-2327-11,NDC,,,facility,both,89,ML,,33206,23244.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-592-11,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,8,ML,JW,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LISINOPRIL 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6798-61,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 2 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,636,RC,J2270,HCPCS,63323-452-00,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,5,ML,,7457,5219.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIPASE-PROTEASE-AMYLASE 5,000-17,000- 24,000 UNIT ORAL CPDR",50863,CDM,636,RC,J3490,HCPCS,73562-115-01,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE DINITRATE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-448-11,NDC,facility,both,3,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROIC ACID 250 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0591-4012-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FELODIPINE 10 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,13668-134-01,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,5,EA,JW,300,210,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
"LIPASE-PROTEASE-AMYLASE 5,000-17,000- 24,000 UNIT ORAL CPDR",50863,CDM,250,RC,J3490,HCPCS,73562-115-01,NDC,facility,both,5,EA,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0527-3281-46,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CITRATE 4% (3 ML) SYRINGE (FOR DIALYSIS),50863,CDM,250,RC,J3490,HCPCS,61553-481-80,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,9,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
FLUCYTOSINE 500 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,43386-770-01,NDC,facility,both,4,EA,,1462,1023.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON DEXTRAN 50 MG/ML INJ SOLN,50863,CDM,636,RC,J1750,HCPCS,0023-6082-01,NDC,facility,both,2,ML,JZ,219,153.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SODIUM BICARBONATE 650 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,77333-827-25,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOFLOXACIN IN D5W 500 MG/100 ML IV PGBK,50863,CDM,250,RC,J1956,HCPCS,25021-132-82,NDC,facility,both,2,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 112 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-508-11,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,63323-806-13,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IVPB (PEDIATRICS/ADULT NON-FORM)",50863,CDM,636,RC,J0131,HCPCS,24201-100-01,NDC,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MINERAL OIL ENEMA,50863,CDM,250,RC,J3490,HCPCS,132030140,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 40 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0054-8299-25,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,250,RC,J1596,HCPCS,0143-9679-01,NDC,facility,both,5,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,J1644,HCPCS,0409-2720-31,NDC,,,facility,both,9,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-466-03,NDC,facility,both,200,ML,JZ,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,J2003,HCPCS,63323-486-05,NDC,,,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMOSOZUMAB-AQQG 210MG/2.34ML ( 105MG/1.17MLX2) SUBQ SYRG,50863,CDM,J3111,HCPCS,55513-998-02,NDC,,,facility,both,210,ML,,5894,4125.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"HYOSCYAMINE 0.125 MG TAB, RAPID DISSOLVE",50863,CDM,J3490,HCPCS,42192-338-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,72485-106-01,NDC,facility,both,100,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,50863,CDM,J9041,HCPCS,72603-270-01,NDC,,,facility,both,11,EA,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 100 MG/ML FROM 1 GRAM VIAL (PRMC PEDS ONLY),50863,CDM,J0696,HCPCS,0409-7332-11,NDC,,,facility,both,8,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYBUTYNIN CHLORIDE  5 MG ORAL TO24,50863,CDM,636,RC,J3490,HCPCS,0904-6570-61,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,63323-482-27,NDC,,,facility,both,100,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE HCL  2 % MM JELP,50863,CDM,636,RC,J3490,HCPCS,76329-3013-5,NDC,facility,both,3,ML,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IVPB (PEDIATRICS/ADULT NON-FORM)",50863,CDM,J0131,HCPCS,24201-100-01,NDC,,,facility,both,800,ML,,509,356.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE (POLACRILEX) 2 MG BUCL GUM,50863,CDM,636,RC,J3490,HCPCS,1093990433,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 250 MG ORAL TBEC,50863,CDM,J3490,HCPCS,0832-7123-89,NDC,,,facility,both,3,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MYCOPHENOLATE 200 MG/ML ORAL SUSP,50863,CDM,J7517,HCPCS,66689-307-08,NDC,,,facility,both,4,ML,,222,155.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,72603-350-01,NDC,,,facility,both,50,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOMYCIN-BACITRACIN ZN-POLYMYXIN 3.5 MG-400 UN*,50863,CDM,250,RC,J3490,HCPCS,0713-0268-31,NDC,facility,both,1,GM,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG ORAL TB12,50863,CDM,636,RC,J3490,HCPCS,60687-583-11,NDC,facility,both,2,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),50863,CDM,636,RC,J1630,HCPCS,0143-9319-25,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 100 MG/1 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,0781-3268-05,NDC,facility,both,60,ML,,820,574,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7130-61,NDC,facility,both,2,EA,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPOETIN ALFA  4000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J0885,HCPCS,59676-304-00,NDC,facility,both,40,ML,"EC,JB,PLAD",462,323.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier EC: Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy | Modifier JB: Administered subcutaneously | Modifier PLAD: Modifier description not available
HYDROCORTISONE  1 % TOP CREA,50863,CDM,250,RC,J3490,HCPCS,0472-0321-26,NDC,facility,both,1,GM,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,47335-993-01,NDC,facility,both,150,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,636,RC,J1596,HCPCS,0143-9679-01,NDC,facility,both,2,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,150,ML,JG,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount
LEVETIRACETAM NEO IV SYRINGE (PHS FROM PREMIX),50863,CDM,636,RC,J1953,HCPCS,44567-501-01,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BALSALAZIDE 750 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60505-2575-7,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 150 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-711-11,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0143-9507-01,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,80,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE IN 0.9% NS (PF) 1 MG/10 ML (100 MCG/ML) IV SYRG(PDS MERGE),50863,CDM,636,RC,J3490,HCPCS,70092-1046-46,NDC,facility,both,1,ML,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE IN 0.9% NS (PF) 1 MG/10 ML (100 MCG/ML) IV SYRG(PDS MERGE),50863,CDM,636,RC,J3490,HCPCS,70092-1046-46,NDC,facility,both,1,ML,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL 20 MG/5 ML ORAL ELIX,50863,CDM,636,RC,J3490,HCPCS,60687-671-40,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESNA 100 MG/ML IV SOLN,50863,CDM,250,RC,J9209,HCPCS,0338-1305-01,NDC,facility,both,16,ML,,616,431.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PNEUMOCOCCAL 23-VAL PS VACCINE 25 MCG/0.5 ML INJ SYRG,50863,CDM,250,RC,90732,HCPCS,0006-4837-01,NDC,facility,both,1,ML,,506,354.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,636,RC,J2270,HCPCS,0409-1890-03,NDC,facility,both,1,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-699-11,NDC,facility,both,4,EA,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLN,50863,CDM,636,RC,J3262,HCPCS,50242-135-01,NDC,facility,both,160,ML,,2933,2053.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  0.25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6373-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2598,HCPCS,43598-914-11,NDC,facility,both,20,ML,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4% TOP PATCH,50863,CDM,636,RC,J3490,HCPCS,0536-1202-15,NDC,facility,both,3,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM-DEXTROSE (ISO) 3.375 GRAM/50 ML IV PIGGY BACK,50863,CDM,250,RC,J2543,HCPCS,0338-9636-01,NDC,facility,both,3,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6291-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 50 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6323-61,NDC,facility,both,4,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CILOSTAZOL 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-177-11,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,2,ML,,3469,2428.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"CIPROFLOXACIN-HYDROCORTISONE 0.2 %-1 % EAR DROPS, SUSP",50863,CDM,250,RC,J3490,HCPCS,0078-0855-26,NDC,facility,both,1,ML,,1291,903.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 0.5 MG ORAL CAP,50863,CDM,250,RC,J7507,HCPCS,68084-449-11,NDC,facility,both,2,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAZOLAMIDE 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-054-11,NDC,facility,both,2,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-4264-11,NDC,facility,both,4,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,927,ME,JZ,12580,8806,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CIPROFLOXACIN IN D5W 400 MG/200 ML IV PGBK,50863,CDM,250,RC,J0744,HCPCS,0409-3300-01,NDC,facility,both,2,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE MALEATE  5 MG ORAL TAB,50863,CDM,250,RC,Q0164,HCPCS,59746-113-06,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0780,HCPCS,0641-6135-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN   81 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,57896-981-12,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MISOPROSTOL 800 MCG (4 X 200 MCG TAB) PACKAGE,50863,CDM,250,RC,S0191,HCPCS,43393-023-04,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPTOMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0878,HCPCS,0409-0122-01,NDC,facility,both,250,EA,,201,140.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 500 MG/5 ML ORAL SUMC,50863,CDM,250,RC,J3490,HCPCS,50419-773-01,NDC,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,42858-001-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 150 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,69238-1314-9,NDC,facility,both,2,EA,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0047-03,NDC,facility,both,20,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATRACURIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-1109-11,NDC,facility,both,1,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,636,RC,J2560,HCPCS,54288-136-01,NDC,facility,both,1,ML,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 600 MG ORAL TP12,50863,CDM,636,RC,J3490,HCPCS,0536-1163-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLECAINIDE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-321-11,NDC,facility,both,1,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACUBITRIL-VALSARTAN 24-26 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0078-0659-67,NDC,facility,both,1,EA,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE HCL 0.3 MG/ML INJ (MERGE),50863,CDM,250,RC,J0592,HCPCS,42023-179-01,NDC,facility,both,2,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CANGRELOR 50 MG IV SOLR,50863,CDM,250,RC,C9460,HCPCS,10122-620-01,NDC,facility,both,100,EA,,5269,3688.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
K PHOS DI & MONO-SOD PHOS MONO 250 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,6498010401,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE (PF) 1000 MCG/10 ML EPID SOLN,50863,CDM,250,RC,J0735,HCPCS,0143-9724-01,NDC,facility,both,1,ML,,214,149.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MYCOPHENOLATE 250 MG CAP,50863,CDM,250,RC,J7517,HCPCS,51079-721-01,NDC,facility,both,2,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  75 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-856-11,NDC,facility,both,2,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-231-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE DINITRATE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6620-61,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-5755-23,NDC,facility,both,4,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,53,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATENOLOL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-685-01,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESTRADIOL 2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,42806-089-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-1638-32,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFUROXIME AXETIL 250 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,67877-215-60,NDC,facility,both,1,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
23.4% SODIUM CHLORIDE (4 MEQ/ML) INJECTION,50863,CDM,250,RC,J3490,HCPCS,63323-187-30,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 500 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,0904-6861-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,50863,CDM,250,RC,J9025,HCPCS,72485-201-01,NDC,facility,both,125,EA,,1769,1238.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) NEB SOLUTION,50863,CDM,636,RC,J3490,HCPCS,0487-9501-00,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIFAXIMIN 550 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65649-303-03,NDC,facility,both,1,EA,,278,194.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,50863,CDM,636,RC,J1885,HCPCS,72266-119-01,NDC,facility,both,2,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ASPIRIN 81 MG ORAL CHEW,50863,CDM,636,RC,J3490,HCPCS,0904-7509-30,NDC,facility,both,4,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,10,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-0710-20,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE  15 MG ORAL CPSP,50863,CDM,250,RC,J3490,HCPCS,68382-004-14,NDC,facility,both,5,EA,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J1611,HCPCS,63323-596-11,NDC,facility,both,2,EA,,1789,1252.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J3490,HCPCS,0338-0049-48,NDC,facility,both,4,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,58,ML,JW,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ASPIRIN  325 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,69618-015-01,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOFETILIDE 500 MCG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,69452-133-17,NDC,facility,both,1,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE (PF-DURAMORPH/ASTRAMORPH) 0.5 MG/ML INJ SOLN,50863,CDM,250,RC,J2274,HCPCS,0409-3814-12,NDC,facility,both,1,ML,,119,83.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 3000 MCG/ML INJECTION,50863,CDM,250,RC,J0153,HCPCS,63323-651-00,NDC,facility,both,6,ML,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6638-61,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RAVULIZUMAB-CWVZ 100 MG/ML IV SOLN,50863,CDM,636,RC,J1303,HCPCS,25682-028-01,NDC,facility,both,220,ML,,129617,90731.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,70594-117-01,NDC,facility,both,300,ML,JZ,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2599,HCPCS,43598-914-25,NDC,facility,both,17,ML,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,81033-002-05,NDC,facility,both,2,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN  500 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,60687-640-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM CITRATE ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,1093911233,NDC,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,68516-5214-4,NDC,facility,both,8,ML,,1464,1024.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VERAPAMIL 180 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,75834-158-01,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,68516-5214-1,NDC,facility,both,1,ML,,263,184.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-492-09,NDC,facility,both,100,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-4799-05,NDC,facility,both,2,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,42291-468-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN IN D5W 400 MG/200 ML IV PGBK,50863,CDM,250,RC,J0744,HCPCS,25021-114-87,NDC,facility,both,16,ML,,373,261.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROPROCAINE 3 % INJ SOLN,50863,CDM,250,RC,J2401,HCPCS,63323-478-01,NDC,facility,both,540,ML,,119,83.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN  6 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51672-4033-1,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARIFENACIN  7.5 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,33342-276-07,NDC,facility,both,2,EA,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",50863,CDM,250,RC,J1561,HCPCS,13533-800-21,NDC,facility,both,20,ML,,2829,1980.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 1 MG ORAL TAB,50863,CDM,250,RC,J8540,HCPCS,72578-166-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 12.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0093-7295-01,NDC,facility,both,2,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-739-11,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0054-0017-20,NDC,facility,both,150,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG ORAL TAB,50863,CDM,Q0169,HCPCS,68084-155-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0248-01,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LANTHANUM  500 MG ORAL CHEW,50863,CDM,J3490,HCPCS,76282-476-45,NDC,,,facility,both,2,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE IN 0.9% NS (PF) 1 MG/10 ML (100 MCG/ML) IV SYRG(PDS MERGE),50863,CDM,J3490,HCPCS,65302-506-10,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEPERIDINE (PF) 25 MG/ML IV SOLN (PHS MERGE),50863,CDM,250,RC,J2175,HCPCS,0641-6052-01,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2599,HCPCS,43598-914-25,NDC,facility,both,11,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITRIOL 0.5 MCG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,23155-663-01,NDC,facility,both,2,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  75 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-856-11,NDC,facility,both,3,EA,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUPRON 3.75MG IM KIT,50863,CDM,250,RC,J1950,HCPCS,0074-3641-03,NDC,facility,both,1,EA,,4972,3480.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % (1 MEQ/ML) IV 50 ML EMERGENCY SYRINGE,50863,CDM,250,RC,J3490,HCPCS,70092-1015-50,NDC,facility,both,2,ML,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN PEDS SYRINGE (20MG/ML) IN DEXTROSE (CDS MIX,50863,CDM,250,RC,J0690,HCPCS,0781-3451-70,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,50863,CDM,636,RC,J2354,HCPCS,23155-687-31,NDC,facility,both,2,ML,JZ,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-65,NDC,facility,both,99,ML,JW,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ZOLEDRONIC ACID 4 MG/5 ML IV SOLN,50863,CDM,636,RC,J3489,HCPCS,54288-100-01,NDC,facility,both,4,ML,,182,127.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,51079-051-20,NDC,facility,both,5,EA,,129,90.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),50863,CDM,636,RC,J1815,HCPCS,0024-5926-05,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEGFILGRASTIM-JMDB (FULPHILA) 6 MG/0.6 ML SUBQ SYRG,50863,CDM,250,RC,Q5108,HCPCS,83257-005-41,NDC,facility,both,12,ML,JZ,5762,4033.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DICYCLOMINE 10 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0591-0794-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TALQUETAMAB-TGVS 40 MG/ML SUBQ SOLN,50863,CDM,250,RC,J3055,HCPCS,57894-470-01,NDC,facility,both,116,ML,JW,9076,6353.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LEVETIRACETAM  250 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7123-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,121119030,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISATRACURIUM  2 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0074-4380-10,NDC,facility,both,1,ML,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,636,RC,J3490,HCPCS,50742-615-01,NDC,facility,both,4,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN 1 MG/ML INJECTION (PEDS ONCOLOGY),50863,CDM,250,RC,J0640,HCPCS,71288-160-10,NDC,facility,both,4,EA,,207,144.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 125 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6955-61,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERTAPENEM 1 GRAM INJ SOLR,50863,CDM,636,RC,J1335,HCPCS,55150-282-20,NDC,facility,both,2,EA,,306,214.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLPIDEM  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-0073-01,NDC,facility,both,2,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VITAMINS A & D-WHITE PETROLATUM-LANOLIN OINTMENT,50863,CDM,250,RC,J3490,HCPCS,65197-400-10,NDC,facility,both,2,GM,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE MONONITRATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,3160401281,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2312,HCPCS,0641-6132-01,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR NEO/PEDS INFUSION (CDS FROM PREMIX),50863,CDM,250,RC,J0133,HCPCS,63323-325-10,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC IV INFUSION HYDRAT 31-60 MIN,50863,CDM,250,RC,J0248,HCPCS,61958-2901-2,NDC,facility,both,49,EA,JW,258,180.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
"DIPHTH,PERTUS(ACELL),TETANUS SYRG (INFANRIX) 25 LF UNIT-58MCG-10 LF/0.5ML IM SYRINGE",50863,CDM,636,RC,90700,HCPCS,58160-810-43,NDC,facility,both,1,ML,,172,120.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,44567-600-04,NDC,facility,both,2,ML,,415,290.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,50863,CDM,250,RC,J9025,HCPCS,72485-201-01,NDC,facility,both,180,EA,,2557,1789.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,636,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,8,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,0904-7509-30,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID (PORK)  60 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0456-0459-01,NDC,facility,both,3,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,0641-6174-01,NDC,facility,both,2,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE (PF-DURAMORPH/ASTRAMORPH) 0.5 MG/ML INJ SOLN,50863,CDM,250,RC,J2274,HCPCS,0409-3814-12,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NAPROXEN 375 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,70010-138-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7123-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 500 MG-125 MG TAB,50863,CDM,250,RC,J3490,HCPCS,16714-296-01,NDC,facility,both,10,EA,,186,130.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0075-0622-01,NDC,facility,both,3,ML,JZ,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-453-11,NDC,facility,both,3,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZTROPINE 1 MG/ML INJ SOLN,50863,CDM,636,RC,J0515,HCPCS,0143-9233-01,NDC,facility,both,2,ML,,229,160.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM 1 GRAM IV SOLR,50863,CDM,J2185,HCPCS,0409-1391-21,NDC,,,facility,both,10,EA,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,70095-026-01,NDC,facility,both,3,ML,JW,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
BENZTROPINE 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69315-136-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7057-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 20MG/ML IV SYRINGE (PEDS/NEO),50863,CDM,250,RC,J0612,HCPCS,63323-311-10,NDC,facility,both,75,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,70069-363-01,NDC,facility,both,1,ML,,142,99.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,16714-298-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
UREA 15 GRAM PACKET,50863,CDM,250,RC,J3490,HCPCS,99999-0405-84,NDC,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,636,RC,J2795,HCPCS,43066-023-01,NDC,facility,both,75,ML,JW,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ALTEPLASE 100 MG IV SOLR,50863,CDM,250,RC,J2997,HCPCS,50242-085-25,NDC,facility,both,100,EA,,24289,17002.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 100 MG/5 ML ORAL LIQD,50863,CDM,250,RC,J3490,HCPCS,0121-1488-10,NDC,facility,both,2,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPRAZOLAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0228-2029-10,NDC,facility,both,4,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML INJECTION,50863,CDM,636,RC,J3411,HCPCS,0641-6228-01,NDC,facility,both,2,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL  25 MCG/HR TD PT72,50863,CDM,250,RC,J3490,HCPCS,0378-9121-16,NDC,facility,both,1,EA,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,250,RC,J2405,HCPCS,70860-776-41,NDC,facility,both,4,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CYPROHEPTADINE 2 MG/5 ML ORAL SYRP,50863,CDM,250,RC,J3490,HCPCS,64980-504-48,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM IN D5W 125 MG/125 ML (1 MG/ML) IV SOLN (PREMIX),50863,CDM,636,RC,J3490,HCPCS,70092-1007-36,NDC,facility,both,1,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,42023-164-25,NDC,facility,both,20,ML,JZ,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-1749-70,NDC,facility,both,2,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MECLIZINE 25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7376-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0137,HCPCS,0143-9386-01,NDC,facility,both,60,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ELTROMBOPAG 25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0078-0685-15,NDC,facility,both,1,EA,,530,371,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7124-61,NDC,facility,both,1,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUVOXAMINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0832-1671-11,NDC,facility,both,4,EA,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2305-16,NDC,facility,both,6,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IVPB (PEDIATRICS/ADULT NON-FORM)",50863,CDM,J0137,HCPCS,24201-100-01,NDC,,,facility,both,100,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,J7510,HCPCS,17856-0815-1,NDC,,,facility,both,4,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,J7999,HCPCS,70092-1017-46,NDC,,,facility,both,360,ML,,7111,4977.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1815,HCPCS,0002-8215-01,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIRMATRELVIR-RITONAVIR 300-100 MG ORAL TAB DOSEPACK (FOR ED/IP TAKE HOME PANEL),50863,CDM,250,RC,J3490,HCPCS,0069-5321-30,NDC,facility,both,30,EA,,4010,2807,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 500 MG-125 MG TAB,50863,CDM,J3490,HCPCS,42571-161-01,NDC,,,facility,both,1,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SITAGLIPTIN  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0006-0221-01,NDC,facility,both,4,EA,,389,272.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 5 MG-325 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0406-0123-23,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 1 MG ORAL CAP,50863,CDM,250,RC,J7507,HCPCS,68084-450-11,NDC,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADVATE: FACTOR VIII CONCENTRATE (MERGE RECORD),50863,CDM,636,RC,J7192,HCPCS,0944-3051-02,NDC,facility,both,260,UN,,1396,977.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,636,RC,J2270,HCPCS,0409-1890-13,NDC,facility,both,1,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENAZEPRIL  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,43547-335-10,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PILOCARPINE 5 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0527-1313-01,NDC,facility,both,2,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE-VITAMIN D3 250 MG-125 UNIT TAB,50863,CDM,636,RC,J3490,HCPCS,904188260,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-344-11,NDC,facility,both,2,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POSACONAZOLE 100 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,70748-258-07,NDC,facility,both,1,EA,,314,219.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 20 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-6291-61,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DURVALUMAB 50 MG/ML IV SOLN,50863,CDM,J9173,HCPCS,0310-4611-50,NDC,,,facility,both,150,ML,,28805,20163.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  25 MG ORAL TAB,50863,CDM,J3490,HCPCS,63739-673-10,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTAMIDINE 300 MG INJ SOLR,50863,CDM,636,RC,J3490,HCPCS,63323-113-01,NDC,facility,both,1,EA,,601,420.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUVOXAMINE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60505-0165-1,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RANOLAZINE  500 MG ORAL TB12,50863,CDM,636,RC,J3490,HCPCS,60687-549-11,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,250,RC,Q9968,HCPCS,70710-1838-1,NDC,facility,both,20,ML,,332,232.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,67877-548-88,NDC,facility,both,9,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOTRIMAZOLE 1 % TOP CREA,50863,CDM,636,RC,J3490,HCPCS,45802-434-11,NDC,facility,both,1,GM,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,250,RC,J3490,HCPCS,0409-1323-15,NDC,facility,both,400,ML,,176,123.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIGOXIN 250 MCG/ML INJ SOLN,50863,CDM,250,RC,J1160,HCPCS,0781-3059-72,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FERROUS SULFATE 75 MG/ML (ELEMENTAL IRON 15 MG/ML) 0.1 ML ORAL SYRINGE (REPACK),50863,CDM,250,RC,J3490,HCPCS,3932805750,NDC,facility,both,2,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM 1 GRAM IV SOLR,50863,CDM,250,RC,J2185,HCPCS,0409-1391-21,NDC,facility,both,20,EA,,243,170.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0137,HCPCS,0143-9386-01,NDC,facility,both,12,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 50 MG TAB,50863,CDM,250,RC,Q0177,HCPCS,16714-083-10,NDC,facility,both,2,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML INJ SOLN,50863,CDM,250,RC,J0169,HCPCS,76329-9060-0,NDC,facility,both,140,ML,,372,260.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  500 MCG/ML INJ SOLN,50863,CDM,636,RC,J2354,HCPCS,0641-6176-01,NDC,facility,both,20,ML,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,636,RC,J3010,HCPCS,0409-9094-22,NDC,facility,both,4,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0641-6206-01,NDC,facility,both,3,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPHENIDATE 27 MG ORAL TO24,50863,CDM,250,RC,J3490,HCPCS,0406-0127-01,NDC,facility,both,1,EA,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,50863,CDM,250,RC,J9263,HCPCS,71288-172-21,NDC,facility,both,176,ML,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,72205-101-01,NDC,facility,both,3,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM ACETATE 667 MG ORAL CAP,50863,CDM,250,RC,J0615,HCPCS,69097-862-83,NDC,facility,both,116,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,65862-707-55,NDC,facility,both,4,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16729-175-01,NDC,facility,both,2,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXRAZOXANE 250 MG IV SOLR,50863,CDM,250,RC,J1190,HCPCS,55150-432-01,NDC,facility,both,1,EA,,913,639.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68180-966-01,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRBESARTAN 150 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,31722-730-90,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,50863,CDM,250,RC,J9206,HCPCS,0009-0082-02,NDC,facility,both,18,ML,,567,396.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBENDAZOLE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,72205-051-08,NDC,facility,both,2,EA,,1351,945.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0003-0894-31,NDC,facility,both,3,EA,,178,124.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN,50863,CDM,250,RC,J2916,HCPCS,0143-9570-01,NDC,facility,both,10,ML,,374,261.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  0.25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6373-61,NDC,facility,both,3,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,6,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,13,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-822-11,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 15 MG/ML (1.5 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-4776-10,NDC,facility,both,300,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERYTHROMYCIN 5 MG/G OPHT OINT,50863,CDM,250,RC,J3490,HCPCS,48102-057-11,NDC,facility,both,1,GM,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,250,RC,J0330,HCPCS,0409-6629-02,NDC,facility,both,4,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMFIBROZIL 600 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,72603-206-01,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM-ALBUTEROL 0.5 MG-2.5 MG/3 ML NEB SOLUTION,50863,CDM,250,RC,J3490,HCPCS,0487-0201-01,NDC,facility,both,12,ML,,130,91,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLPIDEM  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-621-01,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON DEXTRAN 50 MG/ML INJ SOLN,50863,CDM,636,RC,J1750,HCPCS,0023-6082-01,NDC,facility,both,30,ML,JZ,3282,2297.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,636,RC,J2720,HCPCS,63323-229-01,NDC,facility,both,8,ML,,146,102.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN NEO IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J3370,HCPCS,0338-3582-01,NDC,facility,both,2,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7050,HCPCS,0264-7800-20,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PNEUMOC 20-VAL CONJ-DIP CR(PF) 0.5 ML IM SYRG,50863,CDM,250,RC,90677,HCPCS,0005-2000-01,NDC,facility,both,1,ML,,1003,702.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-1749-70,NDC,facility,both,2,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,636,RC,J3490,HCPCS,63323-486-05,NDC,facility,both,600,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,55150-177-05,NDC,facility,both,100,ML,JZ,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DEXAMETHASONE 4 MG ORAL TAB,50863,CDM,636,RC,J8540,HCPCS,0904-7266-61,NDC,facility,both,8,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-074-10,NDC,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYMETAZOLINE 0.05 % NASAL MERGE,50863,CDM,636,RC,J3490,HCPCS,70677-1037-1,NDC,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DORZOLAMIDE 2 % OPHT DROP,50863,CDM,636,RC,J3490,HCPCS,61314-019-10,NDC,facility,both,1,ML,,284,198.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  50 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-6992-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6426-61,NDC,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE  50 MCG/ACTUATION NASL SPSN,50863,CDM,636,RC,J3490,HCPCS,50383-700-16,NDC,facility,both,1,GM,,358,250.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM OXIDE 400 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,1000670028,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,1,EA,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
INFLIXIMAB 100 MG IV SOLR,50863,CDM,J1745,HCPCS,57894-030-01,NDC,,,facility,both,68,EA,,21918,15342.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN NEO/PEDS IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0456,HCPCS,63323-398-14,NDC,facility,both,1,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,J3490,HCPCS,0093-2279-73,NDC,,,facility,both,4,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 10 MG/50 ML (0.2MG/ML) PCA IN NS (MERGE),50863,CDM,J1171,HCPCS,70092-1286-74,NDC,,,facility,both,300,ML,,643,450.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-495-04,NDC,,,facility,both,1000,ML,,239,167.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE IN D5W 1 GRAM/100 ML IV PGBK,50863,CDM,250,RC,J3475,HCPCS,0409-6727-11,NDC,facility,both,2,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-988-01,NDC,facility,both,1,EA,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0137,HCPCS,55150-307-01,NDC,facility,both,80,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 5 MG-325 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0406-0123-23,NDC,facility,both,1,EA,PLAD,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
BUPROPION HCL 150 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,68084-708-95,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,250,RC,J2270,HCPCS,0409-1890-03,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-337-11,NDC,facility,both,2,EA,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,55150-169-10,NDC,facility,both,300,ML,JZ,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ENALAPRIL MALEATE  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51672-4037-1,NDC,facility,both,2,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7367-06,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 100 MG ORAL TB12,50863,CDM,250,RC,J3490,HCPCS,0078-0510-05,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 0.25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68382-112-14,NDC,facility,both,1,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0264-7800-00,NDC,facility,both,2,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERYTHROMYCIN 5 MG/G OPHT OINT,50863,CDM,636,RC,J3490,HCPCS,72485-670-31,NDC,facility,both,1,GM,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAZOLAMIDE 250 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-054-11,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,50863,CDM,250,RC,J9045,HCPCS,0703-4239-01,NDC,facility,both,9,ML,,230,161,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,250,RC,J3490,HCPCS,0409-1323-15,NDC,facility,both,300,ML,,132,92.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-22,NDC,facility,both,13,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,250,RC,J2270,HCPCS,0641-6125-01,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACTIVATED CHARCOAL 25 GRAM/120 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0574-0521-74,NDC,facility,both,3,ML,,199,139.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN ZINC 500 UNIT/G TOP PACK,50863,CDM,636,RC,J3490,HCPCS,53329-089-87,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 500 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7337-35,NDC,facility,both,8,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOPERAMIDE 1 MG/7.5 ML ORAL LIQD,50863,CDM,250,RC,J3490,HCPCS,68094-029-59,NDC,facility,both,2,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G POTASSIUM  5000000 UNIT INJ SOLR,50863,CDM,250,RC,J2540,HCPCS,0049-0520-84,NDC,facility,both,9,EA,JZ,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CELECOXIB 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,50268-168-11,NDC,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  750 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-882-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,50863,CDM,250,RC,J9045,HCPCS,61703-339-50,NDC,facility,both,18,ML,,480,336,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 20MG/ML (1ML-UD) SYRINGE (REPACK),50863,CDM,250,RC,J3490,HCPCS,66689-025-30,NDC,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANTI-INHIBITOR COAGULANT CMPLX (PHS MERGE),50863,CDM,250,RC,J7198,HCPCS,64193-325-01,NDC,facility,both,5610,UN,,34839,24387.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM  1.5 GRAM INJ SOLR,50863,CDM,250,RC,J0295,HCPCS,0049-0013-81,NDC,facility,both,1,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 400 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,16714-663-01,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,250,RC,J3490,HCPCS,61553-320-70,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 90 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0093-0320-01,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VINCRISTINE 2 MG/2 ML IV SOLN,50863,CDM,636,RC,J9370,HCPCS,61703-309-06,NDC,facility,both,2,ML,JZ,209,146.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ARIPIPRAZOLE  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-157-11,NDC,facility,both,1,EA,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG/24 HR TD PTWK,50863,CDM,250,RC,J3490,HCPCS,0378-0871-16,NDC,facility,both,2,EA,,281,196.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,409,ML,,587,410.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,J1171,HCPCS,76045-009-01,NDC,,,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2723-30,NDC,facility,both,5,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ATORVASTATIN 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-099-11,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0781-2020-01,NDC,facility,both,32,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CODEINE-GUAIFENESIN 10-100 MG/5 ML ORAL LIQD (REPACK),50863,CDM,636,RC,J3490,HCPCS,0121-1550-10,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-087-02,NDC,facility,both,12,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,50863,CDM,250,RC,J9267,HCPCS,61703-342-50,NDC,facility,both,279,ML,,337,235.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE 14 MG/24 HR TD PT24,50863,CDM,250,RC,J3490,HCPCS,4898500150,NDC,facility,both,3,EA,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 50 MG/5 ML (10 MG/ML) IV SYRG,50863,CDM,250,RC,J3490,HCPCS,69374-924-05,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,54288-137-01,NDC,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,636,RC,J2003,HCPCS,0409-4278-01,NDC,facility,both,250,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLECAINIDE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-321-11,NDC,facility,both,3,EA,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,50863,CDM,250,RC,J2359,HCPCS,72603-181-01,NDC,facility,both,10,EA,JZ,104,72.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DOXYCYCLINE HYCLATE 100 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,71288-030-20,NDC,facility,both,1,EA,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,250,RC,J2720,HCPCS,63323-229-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 2 MG INJ SOLR,50863,CDM,250,RC,J2997,HCPCS,50242-041-64,NDC,facility,both,10,EA,JZ,4000,2800,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"ALBUMIN, HUMAN 25 % IV SOLN (MERGE)",50863,CDM,250,RC,P9047,HCPCS,13533-684-17,NDC,facility,both,1,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NOREPINEPHRINE BITARTRATE-NACL 4 MG/250 ML (16 MCG/ML) IV SOLN (CENTRAL ONLY),50863,CDM,250,RC,J3490,HCPCS,44567-640-01,NDC,facility,both,1,ML,,218,152.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,636,RC,J3490,HCPCS,39822-1000-1,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE 2 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,0904-7154-04,NDC,facility,both,2,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL  75 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6635-61,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANTI-INHIBITOR COAGULANT CMPLX (PHS MERGE),50863,CDM,250,RC,J7198,HCPCS,64193-426-02,NDC,facility,both,1300,UN,,9389,6572.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,250,RC,J0690,HCPCS,0143-9924-90,NDC,facility,both,2,EA,JZ,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
TRAZODONE 150 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-432-11,NDC,facility,both,2,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 50 MG/ML IV SOLN,50863,CDM,250,RC,J0282,HCPCS,67457-153-00,NDC,facility,both,5,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROMETHOLONE 0.1 % OPHT DRPS,50863,CDM,250,RC,J3490,HCPCS,60219-1585-3,NDC,facility,both,1,ML,,395,276.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,16714-644-01,NDC,facility,both,1,EA,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 0.5 MG ORAL CAP,50863,CDM,636,RC,J7507,HCPCS,0904-6623-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2305-04,NDC,facility,both,5,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 650 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,66553-008-01,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM SR 180 MG 24 HR CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7218-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV,50863,CDM,250,RC,J7120,HCPCS,0338-0117-03,NDC,facility,both,4,ML,,244,170.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,76045-009-96,NDC,facility,both,14,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER SULFADIAZINE 1 % TOP CREA,50863,CDM,250,RC,J3490,HCPCS,61570-131-20,NDC,facility,both,3,GM,,161,112.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,67457-423-00,NDC,facility,both,4,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
WARFARIN 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51672-4027-1,NDC,facility,both,6,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,636,RC,J3490,HCPCS,63323-563-97,NDC,facility,both,2,ML,,598,418.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),50863,CDM,250,RC,J1815,HCPCS,0024-5926-05,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUANFACINE 1 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,62332-745-31,NDC,facility,both,1,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALUM-MAG HYDROXIDE-SIMETH 200 MG-200 MG-20 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,17856-0630-1,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 10 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,250,RC,J2270,HCPCS,0409-1893-03,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,636,RC,J3490,HCPCS,50268-540-11,NDC,facility,both,2,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 0.125 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68462-330-90,NDC,facility,both,4,EA,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLP,50863,CDM,250,RC,J3480,HCPCS,0409-6653-18,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0121-1781-05,NDC,facility,both,2,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  75 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-475-11,NDC,facility,both,2,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE MONONITRATE  30 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,0904-6449-61,NDC,facility,both,3,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 150 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7002-61,NDC,facility,both,2,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLN (MERGE)",50863,CDM,636,RC,P9047,HCPCS,68982-643-02,NDC,facility,both,4,ML,JZ,993,695.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,42806-150-33,NDC,facility,both,5,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TAB,50863,CDM,J3490,HCPCS,0406-0512-23,NDC,,,facility,both,2,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-229-02,NDC,facility,both,2,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 1 GRAM INJ SOLR,50863,CDM,250,RC,J0692,HCPCS,44567-240-10,NDC,facility,both,2,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,0517-4601-25,NDC,facility,both,2,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,72888-039-60,NDC,facility,both,2,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.45% (1/2 NS) INFUSION (PEDS ONC),50863,CDM,250,RC,J3490,HCPCS,0338-0043-04,NDC,facility,both,1,ML,,192,134.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIPASE-PROTEASE-AMYLASE (PORK) 36,000-114,000- 180,000 UNIT ORAL CPDR",50863,CDM,250,RC,J3490,HCPCS,0032-3016-13,NDC,facility,both,2,EA,,152,106.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-806-50,NDC,facility,both,1,ML,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",50863,CDM,250,RC,J1561,HCPCS,13533-800-41,NDC,facility,both,80,ML,JA,11316,7921.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,63323-461-01,NDC,facility,both,1,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOMYCIN-BACITRACN ZN-POLYMYXIN 3.5 MG-400 U*,50863,CDM,636,RC,J3490,HCPCS,45802-143-00,NDC,facility,both,10,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADVATE: FACTOR VIII CONCENTRATE (MERGE RECORD),50863,CDM,636,RC,J7209,HCPCS,0944-3046-10,NDC,facility,both,3000,UN,,13593,9515.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-41,NDC,facility,both,1,ML,,119,83.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,67877-670-01,NDC,facility,both,4,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0245-0212-11,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4 % TOP CREA,50863,CDM,250,RC,J3490,HCPCS,43199-040-05,NDC,facility,both,1,GM,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE-SALMETEROL 500 MCG-50 MCG/DOSE DISK DEVICE FOR INHALATION,50863,CDM,636,RC,J3490,HCPCS,0054-0328-56,NDC,facility,both,1,EA,,1359,951.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE IN 0.9% NS (PF) 1 MG/10 ML (100 MCG/ML) IV SYRG(PDS MERGE),50863,CDM,636,RC,J3490,HCPCS,65302-506-10,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,55150-177-05,NDC,facility,both,75,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DONEPEZIL  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-292-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-571-10,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-272-11,NDC,facility,both,1,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHIMAZOLE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,23155-071-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MOXIFLOXACIN 400 MG/250 ML IVPB PREMIX (MERGE),50863,CDM,636,RC,J2280,HCPCS,63323-850-74,NDC,facility,both,4,ML,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE 14 MG/24 HR TD PT24,50863,CDM,J3490,HCPCS,60505-7062-0,NDC,,,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,75,ML,JW,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,J2704,HCPCS,0069-0209-01,NDC,,,facility,both,15,ML,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,636,RC,J1836,HCPCS,0338-1055-48,NDC,facility,both,200,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,J1100,HCPCS,63323-165-16,NDC,,,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENAZOPYRIDINE 100 MG ORAL TAB,50863,CDM,J3490,HCPCS,75826-114-10,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,J3490,HCPCS,63323-185-07,NDC,,,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AGALSIDASE BETA  5 MG IV SOLR,50863,CDM,J0180,HCPCS,58468-0041-1,NDC,,,facility,both,5,EA,,2148,1503.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-344-11,NDC,facility,both,1,EA,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PYRIDOXINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,7733394025,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYPROHEPTADINE 4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0115-1757-01,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOPERAMIDE 2 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0378-2100-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 250 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,42192-608-05,NDC,facility,both,3,ML,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"NEOMYCIN-POLYMYXIN-HC 3.5 MG-10,000 UNIT/ML-1 % EAR DROPS, SUSP",50863,CDM,636,RC,J3490,HCPCS,24208-635-62,NDC,facility,both,1,ML,,363,254.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXRAZOXANE 500 MG IV SOLR,50863,CDM,250,RC,J1190,HCPCS,55150-435-01,NDC,facility,both,2,EA,,1514,1059.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE 20 MG TAB,50863,CDM,250,RC,J3490,HCPCS,68084-045-11,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 400 MG/5 ML ORAL SUSR,50863,CDM,J3490,HCPCS,0143-9887-01,NDC,,,facility,both,7,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INDIGOTINDISULFONATE SODIUM 8 MG/ML INJ SOLN,50863,CDM,636,RC,J9920,HCPCS,17478-508-01,NDC,facility,both,40,ML,JZ,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LIDOCAINE 2 % MUCOSAL SOLN (VISCOUS),50863,CDM,250,RC,J3490,HCPCS,50383-775-17,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL (VITAMIN D3)   400 UNIT ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,7733394825,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,500,ML,,1266,886.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FERRIC CARBOXYMALTOSE (INJECTAFER) 50 MG IRON/ML IV SOLN,50863,CDM,J1439,HCPCS,0517-0650-01,NDC,,,facility,both,750,ML,,4446,3112.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 2400000 UNIT/4 ML IM SYRG,50863,CDM,636,RC,J0561,HCPCS,60793-702-04,NDC,facility,both,24,ML,JZ,2088,1461.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2599,HCPCS,43598-914-25,NDC,facility,both,6,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,250,RC,J2405,HCPCS,60505-6130-0,NDC,facility,both,40,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE (POLACRILEX) 2 MG BUCL GUM,50863,CDM,250,RC,J3490,HCPCS,0536-1362-06,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-453-01,NDC,facility,both,3,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FINAL) IV SOLR,50863,CDM,636,RC,J9330,HCPCS,72611-780-01,NDC,facility,both,30,ML,,10681,7476.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  5 GRAM IV SOLR,50863,CDM,250,RC,J3370,HCPCS,0143-9163-01,NDC,facility,both,4,EA,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2598,HCPCS,55150-370-01,NDC,facility,both,2,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 100 MG TAB,50863,CDM,250,RC,J3490,HCPCS,62584-267-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE 0.25 MG/2 ML INHL NBSP,50863,CDM,250,RC,J3490,HCPCS,0093-6815-45,NDC,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50458-593-10,NDC,facility,both,2,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN   81 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,57896-981-12,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,250,RC,J3490,HCPCS,39822-1000-1,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN  500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-155-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE  1 % TOP OINT,50863,CDM,250,RC,J3490,HCPCS,0168-0020-31,NDC,facility,both,1,GM,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,636,RC,J3490,HCPCS,59310-579-22,NDC,facility,both,1,GM,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZONATATE 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,42806-714-01,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,33,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-105-11,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-0235-24,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESNA 100 MG/ML IV SOLN,50863,CDM,250,RC,J9209,HCPCS,25021-201-10,NDC,facility,both,25,ML,,587,410.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESNA 100 MG/ML IV SOLN,50863,CDM,250,RC,J9209,HCPCS,10019-953-62,NDC,facility,both,2,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DISOPYRAMIDE 150 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0093-3129-01,NDC,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0630,HCPCS,42023-205-01,NDC,facility,both,1,ML,,5488,3841.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-04,NDC,facility,both,2,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BALSALAZIDE 750 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60505-2575-7,NDC,facility,both,3,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,63323-400-01,NDC,facility,both,125,ML,,132,92.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE ACETATE 1 % OPHT DROPS,50863,CDM,250,RC,J3490,HCPCS,11980-180-05,NDC,facility,both,1,ML,,693,485.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-590-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 160 MG-800 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0904-2725-61,NDC,facility,both,4,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM BICARB-CITRIC ACID 20 MEQ ORAL TBEF,50863,CDM,J3490,HCPCS,51801-012-01,NDC,,,facility,both,3,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG ORAL CAP,50863,CDM,J3490,HCPCS,60687-580-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,68094-231-59,NDC,facility,both,4,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 500 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-7126-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,50863,CDM,J9264,HCPCS,0517-4300-01,NDC,,,facility,both,260,EA,,11762,8233.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLP,50863,CDM,J3480,HCPCS,0409-6653-18,NDC,,,facility,both,40,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,J1100,HCPCS,63323-165-30,NDC,,,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SCOPOLAMINE TRANSDERMAL PATCH 1MG OVER 3 DAYS,50863,CDM,250,RC,J3490,HCPCS,50742-505-01,NDC,facility,both,1,EA,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ORPHENADRINE CITRATE 30 MG/ML INJ SOLN,50863,CDM,J2360,HCPCS,25021-651-02,NDC,,,facility,both,1,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MISOPROSTOL 800 MCG (4 X 200 MCG TAB) PACKAGE,50863,CDM,250,RC,S0191,HCPCS,43393-023-04,NDC,facility,both,2,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-9558-05,NDC,facility,both,2,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,8,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN PEDS SYRINGE (20MG/ML) IN DEXTROSE (CDS MIX,50863,CDM,250,RC,J0690,HCPCS,0781-3451-70,NDC,facility,both,1,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMFIBROZIL 600 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-224-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,29300-423-01,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLEDRONIC ACID IN MANNITOL & WATER 5 MG/100 ML IV SOLN,50863,CDM,636,RC,J3489,HCPCS,55111-688-52,NDC,facility,both,5,ML,,1062,743.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2305-16,NDC,facility,both,10,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5%-1/2 NORMAL SALINE IV (PEDS ONCOLOGY),50863,CDM,636,RC,J7042,HCPCS,0338-0085-04,NDC,facility,both,2,ML,JZ,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
FLUOXETINE 20 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7346-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACIDOPHILUS-PECTIN W CITRUS 25 MILLION-100 CELL MG TAB,50863,CDM,636,RC,J3490,HCPCS,536142401,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,17,ML,JW,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,3,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLP",50863,CDM,250,RC,P9047,HCPCS,0944-0493-04,NDC,facility,both,4,ML,JZ,1001,700.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,43598-053-11,NDC,facility,both,41,ML,,1473,1031.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,50863,CDM,636,RC,J0696,HCPCS,60505-6149-0,NDC,facility,both,4,EA,,194,135.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-426-02,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J3430,HCPCS,65219-635-01,NDC,facility,both,10,ML,,130,91,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,50863,CDM,250,RC,J2359,HCPCS,72603-181-01,NDC,facility,both,20,EA,,207,144.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNITS/1 GRAM PACKET (MERGE RECORD),50863,CDM,636,RC,J3490,HCPCS,45802-060-00,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,63323-165-01,NDC,facility,both,20,ML,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIOGLITAZONE 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65862-512-30,NDC,facility,both,3,EA,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-119-11,NDC,facility,both,3,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN PEDS SYRINGE (20MG/ML) IN DEXTROSE (CDS MIX,50863,CDM,250,RC,J0690,HCPCS,0781-3451-70,NDC,facility,both,1,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOBENZAPRINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-190-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL  0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-733-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-ABDA 100 MG IV SOLR,50863,CDM,636,RC,Q5104,HCPCS,78206-162-99,NDC,facility,both,69,EA,,14348,10043.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-426-02,NDC,facility,both,2,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,250,RC,J0330,HCPCS,71449-126-15,NDC,facility,both,8,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,34,ML,JW,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
OSELTAMIVIR PHOSPHATE 30 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,64380-797-01,NDC,facility,both,1,EA,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,636,RC,J3490,HCPCS,63323-185-07,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,54288-137-01,NDC,facility,both,5,ML,,1077,753.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-1163-01,NDC,facility,both,2,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 1 MG/1 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,68094-031-59,NDC,facility,both,2,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0536-1327-06,NDC,facility,both,3,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-ABDA 100 MG IV SOLR,50863,CDM,636,RC,Q5104,HCPCS,0006-4305-01,NDC,facility,both,75,EA,,15596,10917.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 2 GRAM IV SOLUTION,50863,CDM,250,RC,J9075,HCPCS,10019-957-11,NDC,facility,both,116,EA,,1173,821.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,6809411059,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 300 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,57237-099-60,NDC,facility,both,1,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,0409-6102-02,NDC,facility,both,120,ML,,167,116.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIACIN  250 MG ORAL CPSR,50863,CDM,636,RC,J3490,HCPCS,1000670020,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,25,EA,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,0781-3246-02,NDC,facility,both,10,ML,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PYRIDOSTIGMINE BROMIDE  60 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6622-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"CALCIUM GLUC IN NACL, ISO-OSM 1 GRAM/50 ML IV SOLN",50863,CDM,636,RC,J0613,HCPCS,44567-620-01,NDC,facility,both,300,ML,,348,243.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANTI-THYMOCYTE GLOB (RABBIT) 25 MG IV SOLR,50863,CDM,250,RC,J7511,HCPCS,58468-0080-1,NDC,facility,both,8,EA,,16175,11322.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"CALCIUM CARBONATE 500 MG (1,250 MG) ORAL TAB",50863,CDM,250,RC,J3490,HCPCS,904188361,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZONISAMIDE 10 MG/ML ORAL SYRUP (REPACK),50863,CDM,250,RC,J3490,HCPCS,64679-990-01,NDC,facility,both,1,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-440-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-65,NDC,facility,both,133,ML,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RASBURICASE 1.5 MG IV SOLR,50863,CDM,250,RC,J2783,HCPCS,0024-5154-11,NDC,facility,both,1,EA,JW,668,467.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0264-1800-36,NDC,facility,both,1,ML,JZ,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-4264-11,NDC,facility,both,30,ML,,127,88.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,58,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J2312,HCPCS,0409-1215-21,NDC,facility,both,40,ML,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYTOCIN 10 UNIT/ML INJ SOLN,50863,CDM,250,RC,J2590,HCPCS,42023-116-25,NDC,facility,both,6,ML,,144,100.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  10 MG/5 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,68094-001-59,NDC,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,0143-9577-01,NDC,,,facility,both,400,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 1 % INJ SOLN,50863,CDM,250,RC,Q9968,HCPCS,17478-504-10,NDC,facility,both,200,ML,,1450,1015,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,50863,CDM,636,RC,J1756,HCPCS,0517-2325-01,NDC,facility,both,40,ML,JW,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,636,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,6,EA,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
STERILE TALC 3 G INPL AERP,50863,CDM,250,RC,J3490,HCPCS,62327-333-03,NDC,facility,both,1,EA,,354,247.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BETAMETHASONE, AUGMENTED 0.05 % TOP OINT",50863,CDM,636,RC,J3490,HCPCS,66993-897-15,NDC,facility,both,1,GM,,270,189,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0406-0552-23,NDC,facility,both,4,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,50863,CDM,636,RC,Q0177,HCPCS,23155-501-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN PEDS INFUSION (CDS MIXTURE),50863,CDM,636,RC,J0290,HCPCS,99999-408-63,NDC,facility,both,2,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-467-01,NDC,facility,both,1,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-407-11,NDC,facility,both,2,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 30 MG/0.3 ML SUBQ SYRG,50863,CDM,J1650,HCPCS,0955-1003-01,NDC,,,facility,both,3,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,250,RC,J7060,HCPCS,0338-0017-03,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN NORMAL SALINE IV,50863,CDM,FAMNOCHARGE,HCPCS,0338-0089-04,NDC,,,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIVOLUMAB 240 MG/24 ML IV SOLN,50863,CDM,636,RC,J9299,HCPCS,0003-3774-12,NDC,facility,both,200,ML,,13638,9546.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-6007-61,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 500 MG-125 MG TAB,50863,CDM,J3490,HCPCS,65862-502-20,NDC,,,facility,both,1,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VINCRISTINE 2 MG/2 ML IV SOLN,50863,CDM,250,RC,J9370,HCPCS,0703-4412-11,NDC,facility,both,2,ML,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,2,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EFGARTIGIMOD ALFA-FCAB 20 MG/ML IV SOLN,50863,CDM,636,RC,J9332,HCPCS,73475-3041-5,NDC,facility,both,400,ML,,32844,22990.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM  2.25 GRAM IV SOLR,50863,CDM,250,RC,J2543,HCPCS,55150-119-30,NDC,facility,both,2,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MANNITOL 20% IV SOLP,50863,CDM,250,RC,J2150,HCPCS,0990-7715-13,NDC,facility,both,1,ML,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-710-11,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,50863,CDM,J3301,HCPCS,70121-1651-5,NDC,,,facility,both,2,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-8297-25,NDC,facility,both,5,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 5 % TOP OINT,50863,CDM,636,RC,J3490,HCPCS,51672-3020-9,NDC,facility,both,1,GM,,935,654.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 500 MG PE/10 ML INJ SOLN,50863,CDM,636,RC,Q2009,HCPCS,25021-798-10,NDC,facility,both,13,ML,,150,105,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 20 MG/ML ORAL CONC,50863,CDM,250,RC,J3490,HCPCS,16714-601-02,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN  325 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0536-1054-29,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZTROPINE 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7288-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,42806-150-33,NDC,facility,both,8,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-0007-01,NDC,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,23155-600-31,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,11,ML,JW,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
MORPHINE 1 MG/ML PCA (PDS MERGE),50863,CDM,250,RC,J3490,HCPCS,70092-1521-74,NDC,facility,both,1,ML,,154,107.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE (POLACRILEX) 2 MG MM LOZG,50863,CDM,636,RC,J3490,HCPCS,45802-344-03,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6426-61,NDC,facility,both,2,EA,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMILORIDE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0574-0292-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,15,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,250,RC,Q9968,HCPCS,70710-1838-1,NDC,facility,both,87,ML,,1431,1001.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROPROCAINE 3 % INJ SOLN,50863,CDM,250,RC,J2401,HCPCS,63323-478-01,NDC,facility,both,450,ML,JW,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
SIMVASTATIN 80 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68180-465-09,NDC,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCAINAMIDE 100 MG/ML INJ SOLN,50863,CDM,250,RC,J2690,HCPCS,0409-1902-11,NDC,facility,both,1,ML,,577,403.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-1749-70,NDC,facility,both,2,ML,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALUM-MAG HYDROXIDE-SIMETH 200 MG-200 MG-20 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0904-7325-62,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELATACEPT 250 MG IV SOLR,50863,CDM,636,RC,J0485,HCPCS,0003-0371-13,NDC,facility,both,150,EA,JW,673,471.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PIPERACILLIN-TAZOBACTAM  4.5 GRAM IV SOLR,50863,CDM,250,RC,J2543,HCPCS,0409-3390-11,NDC,facility,both,4,EA,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 250 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,0904-6363-61,NDC,facility,both,3,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAMSULOSIN 0.4 MG ORAL CP24,50863,CDM,636,RC,J3490,HCPCS,68084-299-11,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,7,ML,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACIDOPHILUS-PECTIN W CITRUS 25 MILLION-100 CELL MG TAB,50863,CDM,636,RC,J3490,HCPCS,1785614241,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-165-11,NDC,facility,both,2,EA,,171,119.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIOTHYRONINE  5 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,59762-1206-1,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CELECOXIB 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-6502-61,NDC,facility,both,2,EA,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,636,RC,J7060,HCPCS,0338-0017-48,NDC,facility,both,1,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 4 MG/ACTUATION NASL SPRY,50863,CDM,250,RC,J3490,HCPCS,69547-627-02,NDC,facility,both,1,EA,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J2003,HCPCS,63323-492-04,NDC,facility,both,100,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,50863,CDM,250,RC,J9060,HCPCS,63323-103-64,NDC,facility,both,12,ML,,248,173.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,636,RC,Q0162,HCPCS,65162-691-79,NDC,facility,both,2,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J2250,HCPCS,0409-2305-17,NDC,facility,both,8,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6084-61,NDC,facility,both,2,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,0409-9094-22,NDC,facility,both,1,ML,"JZ,PLAD",16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier PLAD: Modifier description not available
PROMETHAZINE 25 MG RECT SUPP,50863,CDM,250,RC,J3490,HCPCS,45802-759-00,NDC,facility,both,1,EA,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,50863,CDM,250,RC,J2359,HCPCS,0781-3159-72,NDC,facility,both,3,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISATRACURIUM  2 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0074-4380-79,NDC,facility,both,1,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,63323-104-25,NDC,facility,both,4,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN 100 MG/4 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,60687-275-62,NDC,facility,both,2,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN DEGLUDEC 100 UNITS/ML SUBQ SOLN,50863,CDM,636,RC,J1815,HCPCS,73070-400-11,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL  6.25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68462-163-01,NDC,facility,both,2,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLP",50863,CDM,250,RC,P9047,HCPCS,44206-251-10,NDC,facility,both,1,ML,,389,272.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,59651-488-01,NDC,facility,both,40,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIOGLITAZONE 15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7090-61,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 10 GRAM/15 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,0116-4005-30,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL (5 MG/ML) IV SYRG (CONTAINS PRESERVATIVE),50863,CDM,636,RC,J3490,HCPCS,0409-2339-24,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J2310,HCPCS,0409-1215-21,NDC,facility,both,2,ML,,465,325.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROGESTERONE MICRONIZED  8 % VAGL GEL,50863,CDM,636,RC,j3490,HCPCS,0023-6151-09,NDC,facility,both,2,GM,,238,166.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 1 MG ORAL CAP,50863,CDM,636,RC,J7507,HCPCS,54288-135-01,NDC,facility,both,1,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,72162-1329-8,NDC,facility,both,1,ML,,257,179.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 2 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,250,RC,J2270,HCPCS,0409-1762-30,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 1 MG ORAL CAP,50863,CDM,250,RC,J7507,HCPCS,54288-135-01,NDC,facility,both,2,EA,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6818-61,NDC,facility,both,3,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,50,EA,,6900,4830,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-826-11,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4% TOP PATCH,50863,CDM,636,RC,J3490,HCPCS,70512-812-01,NDC,facility,both,2,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),50863,CDM,250,RC,J1630,HCPCS,67457-426-00,NDC,facility,both,1,ML,PLAD,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
HUMAN PROTHROMBIN COMPLEX 500 UNIT IV SOLR,50863,CDM,250,RC,J7168,HCPCS,63833-386-02,NDC,facility,both,2000,UN,,11638,8146.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  0.25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-741-11,NDC,facility,both,3,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % MUCOSAL SOLN (VISCOUS),50863,CDM,636,RC,J3490,HCPCS,62135-712-42,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,29300-135-01,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 150 MG/1 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,16714-066-01,NDC,facility,both,14,ML,,156,109.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7914-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6376-61,NDC,facility,both,1,EA,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-0552-23,NDC,facility,both,6,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 3000 MCG/ML INJECTION,50863,CDM,636,RC,J0153,HCPCS,72078-033-00,NDC,facility,both,6,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  20 MEQ ORAL PACK,50863,CDM,636,RC,J3490,HCPCS,72888-024-06,NDC,facility,both,2,EA,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,250,RC,J0137,HCPCS,55150-307-01,NDC,facility,both,16,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENAZEPRIL 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-110-11,NDC,facility,both,3,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-242-11,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPHENIDATE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-1142-01,NDC,facility,both,4,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-673-10,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIMOLOL MALEATE 0.5 % OPHT DROP,50863,CDM,250,RC,J3490,HCPCS,68682-813-05,NDC,facility,both,1,ML,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 0.1MG/ML SUSPENSION (REPACK),50863,CDM,250,RC,J3490,HCPCS,51079-882-01,NDC,facility,both,15,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLEDRONIC ACID-MANNITOL-WATER 4 MG/100 ML IV PGBK,50863,CDM,250,RC,J3489,HCPCS,25021-826-82,NDC,facility,both,4,ML,,778,544.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIOTHYRONINE 25 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,59762-1207-1,NDC,facility,both,2,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN   81 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,57896-981-01,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,636,RC,J7510,HCPCS,17856-0815-1,NDC,facility,both,10,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-4799-05,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OFLOXACIN 0.3 % OTIC DROP,50863,CDM,636,RC,J3490,HCPCS,70756-609-15,NDC,facility,both,1,ML,,567,396.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM ACETATE 667 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7119-06,NDC,facility,both,4,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 150 MG/ML INJECTION,50863,CDM,636,RC,J3490,HCPCS,25021-115-06,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,250,RC,J2270,HCPCS,0409-1891-03,NDC,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE NA (PRESERV FREE) 25 MG/ML INJ SOLN,50863,CDM,250,RC,J9260,HCPCS,0703-3678-01,NDC,facility,both,35,ML,,338,236.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,250,RC,J3360,HCPCS,0641-6244-01,NDC,facility,both,10,ML,,723,506.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEXILETINE 200 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,50742-240-01,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6665-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,68180-150-01,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 30 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0093-0318-01,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEPLIZUMAB-MZWV 2 MG/20 ML IV SOLN,50863,CDM,636,RC,J9381,HCPCS,73650-316-01,NDC,facility,both,328,ME,,19829,13880.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,7,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 50 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,60687-402-11,NDC,facility,both,3,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  1 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,64380-782-06,NDC,facility,both,98,EA,,121,84.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 100 MG PE/2 ML INJ SOLN,50863,CDM,250,RC,Q2009,HCPCS,0641-6136-01,NDC,facility,both,3,ML,,131,91.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,92,EA,,12696,8887.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML IV,50863,CDM,250,RC,J3490,HCPCS,55150-425-01,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,50863,CDM,636,RC,J0585,HCPCS,0023-1145-01,NDC,facility,both,130,EA,,2078,1454.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,3,ML,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-579-11,NDC,facility,both,3,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB 100 MG IV SOLR,50863,CDM,636,RC,J1745,HCPCS,57894-030-01,NDC,facility,both,30,EA,JZ,9670,6769,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ALLOPURINOL SODIUM 500 MG IV SOLR,50863,CDM,250,RC,J0206,HCPCS,65219-380-30,NDC,facility,both,1,EA,,4803,3362.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,60,ML,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 5 MG-325 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0406-0123-23,NDC,facility,both,6,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-344-11,NDC,facility,both,2,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,50863,CDM,636,RC,J0561,HCPCS,60793-701-02,NDC,facility,both,12,ML,,1080,756,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 10 MG/5 ML SYRUP,50863,CDM,250,RC,Q0177,HCPCS,54838-502-80,NDC,facility,both,1,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4% TOP PATCH,50863,CDM,250,RC,J3490,HCPCS,46581-830-01,NDC,facility,both,2,EA,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOMYCIN-BACITRACN ZN-POLYMYXIN 3.5 MG-400 U*,50863,CDM,636,RC,J3490,HCPCS,45802-061-70,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE DINITRATE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0781-1556-01,NDC,facility,both,3,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DORZOLAMIDE-TIMOLOL 2 %-0.5 % EYE DROPS,50863,CDM,250,RC,J3490,HCPCS,70069-051-01,NDC,facility,both,1,ML,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG IV SOLR,50863,CDM,636,RC,J3490,HCPCS,25021-751-10,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 600 MG ORAL TP12,50863,CDM,250,RC,J3490,HCPCS,68084-572-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 20 MG/ML ORAL CONC,50863,CDM,250,RC,J3490,HCPCS,16714-601-02,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PERPHENAZINE  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0781-8046-01,NDC,facility,both,2,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASCORBIC ACID  500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,904052361,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 100 MG/ML FROM 1 GRAM VIAL (PRMC PEDS ONLY),50863,CDM,250,RC,J0696,HCPCS,0409-7332-11,NDC,facility,both,4,EA,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,636,RC,J0330,HCPCS,69374-919-10,NDC,facility,both,10,ML,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MYCOPHENOLATE 500 MG TAB,50863,CDM,636,RC,J7517,HCPCS,0054-0166-25,NDC,facility,both,6,EA,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAMSULOSIN 0.4 MG ORAL CP24,50863,CDM,636,RC,J3490,HCPCS,68382-132-01,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,17271-701-05,NDC,facility,both,1,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-6665-61,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-ABDA 100 MG IV SOLR,50863,CDM,636,RC,Q5104,HCPCS,78206-162-99,NDC,facility,both,30,EA,JZ,6239,4367.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PENTAMIDINE 300 MG INJ SOLR,50863,CDM,636,RC,J3490,HCPCS,63323-113-01,NDC,facility,both,1,EA,,202,141.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,44567-600-04,NDC,facility,both,2,ML,,408,285.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,63323-165-01,NDC,facility,both,1,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
HC IV INFUSION HYDRAT 31-60 MIN,50863,CDM,250,RC,J0248,HCPCS,61958-2901-2,NDC,facility,both,25,EA,,299,209.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR IN 0.9% NACL 100 UNIT/100 ML (1 UNIT/ML) INFUSION FOR OB,50863,CDM,250,RC,J1815,HCPCS,0338-0126-12,NDC,facility,both,1,ML,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,50863,CDM,636,RC,J3420,HCPCS,63323-044-00,NDC,facility,both,1,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 12.5 MG ORAL TAB,50863,CDM,250,RC,Q0169,HCPCS,53746-745-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELATACEPT 250 MG IV SOLR,50863,CDM,636,RC,J0485,HCPCS,0003-0371-13,NDC,facility,both,425,EA,,4385,3069.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATED 20 MG/ML IV SOLN,50863,CDM,250,RC,J0706,HCPCS,51754-0500-1,NDC,facility,both,18,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,6,EA,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,60687-134-11,NDC,facility,both,10,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,636,RC,J3490,HCPCS,63323-185-10,NDC,facility,both,2,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 2 MG/ML IV SOLN,50863,CDM,250,RC,J9000,HCPCS,25021-207-51,NDC,facility,both,3,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUBIPROSTONE  8 MCG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,43598-163-60,NDC,facility,both,1,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE SODIUM 25 MG/ML INJ SOLN,50863,CDM,636,RC,J9260,HCPCS,0703-3675-01,NDC,facility,both,4,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 50 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,59651-489-01,NDC,facility,both,55,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0780,HCPCS,43066-090-01,NDC,facility,both,1,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MYCOPHENOLATE 200 MG/ML ORAL SUSP,50863,CDM,250,RC,J7517,HCPCS,66689-307-08,NDC,facility,both,2,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL  6.25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6301-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE  50 MCG/ACTUATION NASL SPSN,50863,CDM,250,RC,J3490,HCPCS,60505-0829-1,NDC,facility,both,1,GM,,362,253.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,3,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  5 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,55111-262-79,NDC,facility,both,2,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACCHAROMYCES BOULARDII 250 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,7733380025,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE IN 0.9% NS (PF) 1 MG/10 ML (100 MCG/ML) IV SYRG(PDS MERGE),50863,CDM,250,RC,J3490,HCPCS,65302-506-10,NDC,facility,both,3,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7126-61,NDC,facility,both,9,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-25,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 30 MG/0.3 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,25021-410-70,NDC,facility,both,3,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 0.75 % VAGL GEL,50863,CDM,636,RC,J3490,HCPCS,45802-139-70,NDC,facility,both,1,GM,,551,385.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE LIPOSOME (PF) 266 MG/20 ML (13.3 MG/ML) LINF SUSP,50863,CDM,636,RC,J3490,HCPCS,65250-266-09,NDC,facility,both,1,ML,,1116,781.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-25,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR 200 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,72578-002-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PALIPERIDONE PALMITATE 117 MG/0.75 ML IM SYRG,50863,CDM,250,RC,J2426,HCPCS,50458-562-01,NDC,facility,both,117,ML,,4926,3448.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-861-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM 1 GRAM IV SOLR,50863,CDM,636,RC,J2185,HCPCS,63323-508-01,NDC,facility,both,20,EA,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 300 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,65162-649-78,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-406-03,NDC,facility,both,1,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAZOLAMIDE 250 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6663-61,NDC,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOLTERODINE 2 MG ORAL CP24,50863,CDM,636,RC,J3490,HCPCS,0904-6592-04,NDC,facility,both,2,EA,,107,74.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0574-0521-76,NDC,facility,both,1,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLP",50863,CDM,636,RC,P9047,HCPCS,44206-251-91,NDC,facility,both,2,ML,JZ,778,544.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,250,RC,Q9968,HCPCS,70710-1838-1,NDC,facility,both,13,ML,JW,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,636,RC,J7999,HCPCS,70092-1017-46,NDC,facility,both,2,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0406-5755-23,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  50 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-7048-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIFEDIPINE 10 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,23155-194-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM-ALBUTEROL 0.5 MG-2.5 MG/3 ML NEB SOLUTION,50863,CDM,636,RC,J3490,HCPCS,47335-756-48,NDC,facility,both,2,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IR SOLN,50863,CDM,250,RC,J3490,HCPCS,0338-0047-47,NDC,facility,both,1,ML,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,63323-280-03,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL  32.4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6575-61,NDC,facility,both,4,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM IN NACL (ISO-OS) 500 MG/100 ML IV PGBK,50863,CDM,636,RC,J1953,HCPCS,36000-352-01,NDC,facility,both,50,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIPHTH,PERTUS(ACELL),TETANUS SYRG (INFANRIX) 25 LF UNIT-58MCG-10 LF/0.5ML IM SYRINGE",50863,CDM,636,RC,90700,HCPCS,58160-810-52,NDC,facility,both,1,ML,,334,233.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 300 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,65162-649-78,NDC,facility,both,1,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,104,EA,,14352,10046.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,636,RC,J3101,HCPCS,50242-037-06,NDC,facility,both,36,EA,JW,7169,5018.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
"ALPHA-1-PROTEINASE INHIBITOR (HUMAN) 1,000 MG IV SUSP (PROLASTIN-C)",50863,CDM,636,RC,J0256,HCPCS,13533-700-01,NDC,facility,both,389,ME,,5509,3856.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,50863,CDM,250,RC,J9060,HCPCS,0143-9504-01,NDC,facility,both,4,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 1 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-9158-01,NDC,facility,both,10,ML,,224,156.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MOXIFLOXACIN 400 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7407-06,NDC,facility,both,1,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,65219-445-01,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALUM-MAG HYDROXIDE-SIMETH 200 MG-200 MG-20 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0904-7325-62,NDC,facility,both,2,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) IV SOLN,50863,CDM,636,RC,J9220,HCPCS,81284-315-05,NDC,facility,both,40,ML,,1728,1209.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,636,RC,J3490,HCPCS,72789-057-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,250,RC,J3490,HCPCS,53746-542-05,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.3 MG/0.3 ML IM PNIJ,50863,CDM,250,RC,J0171,HCPCS,0093-5986-19,NDC,facility,both,3,EA,,1024,716.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6773-61,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 20 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,60687-725-11,NDC,facility,both,1,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES  8.6 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,69618-064-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,146,ML,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,69315-904-01,NDC,facility,both,3,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,250,RC,J3101,HCPCS,50242-037-06,NDC,facility,both,21,EA,,9619,6733.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG/5 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,0121-4827-05,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,J0133,HCPCS,55150-154-10,NDC,,,facility,both,200,ML,,157,109.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID (PORK)  60 MG ORAL TAB,50863,CDM,J3490,HCPCS,42192-330-01,NDC,,,facility,both,2,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-495-27,NDC,,,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,50863,CDM,J3490,HCPCS,50268-074-11,NDC,,,facility,both,2,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOLIC ACID 1 MG / 0.2 ML SYRINGE (CDS ADS REPACK),50863,CDM,250,RC,J3490,HCPCS,63323-184-10,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM-DEXTRS 4.5 GRAM/100 ML IV PGBK,50863,CDM,636,RC,J3490,HCPCS,0338-9638-01,NDC,facility,both,1,ML,,111,77.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6052-61,NDC,facility,both,1,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 2 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,250,RC,J2270,HCPCS,0409-1762-30,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,250,RC,J3490,HCPCS,59310-579-22,NDC,facility,both,1,GM,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 250 MG-62.5 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,43598-004-51,NDC,facility,both,5,ML,,240,168,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,42806-150-33,NDC,facility,both,5,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,14789-251-09,NDC,facility,both,1,ML,,133,93.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,63323-461-01,NDC,facility,both,1,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LINEZOLID 600 MG/300 ML IV SOLP,50863,CDM,250,RC,J2020,HCPCS,63323-713-03,NDC,facility,both,3,ML,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-476-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN D5W 20000 UNIT/500 ML,50863,CDM,636,RC,J1644,HCPCS,0264-9567-10,NDC,facility,both,20,ML,JZ,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
NICARDIPINE 25 MG/10 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,55150-183-01,NDC,facility,both,1,ML,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOSTIGMINE METHYLSULFATE 1 MG/ML IV SOLN,50863,CDM,636,RC,J2710,HCPCS,42023-189-01,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 20 MG/ML IN NS NEONATAL INJECTION (REPACK),50863,CDM,250,RC,J1650,HCPCS,63323-565-86,NDC,facility,both,1,ML,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,76045-009-10,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 1 MG ORAL CAP,50863,CDM,250,RC,J7507,HCPCS,68084-450-11,NDC,facility,both,7,EA,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLN (MERGE)",50863,CDM,250,RC,P9047,HCPCS,68982-643-02,NDC,facility,both,2,ML,,497,347.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-01,NDC,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-681-01,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,636,RC,J2597,HCPCS,69918-899-01,NDC,facility,both,2,ML,,150,105,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 40 MG/ML (4 %) INJ SOLN (FOR NEBULIZATION),50863,CDM,J2003,HCPCS,0409-4283-11,NDC,,,facility,both,56,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,J2003,HCPCS,0409-4903-11,NDC,,,facility,both,200,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 30 MG TAB,50863,CDM,J3490,HCPCS,0093-0318-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,62584-984-11,NDC,facility,both,4,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-492-41,NDC,,,facility,both,60,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-739-41,NDC,facility,both,4,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALACYCLOVIR 500 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-6565-61,NDC,,,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IVPB (PEDIATRICS/ADULT NON-FORM)",50863,CDM,636,RC,J0137,HCPCS,24201-100-01,NDC,facility,both,54,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IR SOLN,50863,CDM,636,RC,J3490,HCPCS,0338-0047-46,NDC,facility,both,3,ML,,139,97.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,2,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 5 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,0409-1778-05,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7124-61,NDC,facility,both,1,EA,PLAD,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
NITROFURANTOIN MACROCRYSTAL  50 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,47781-307-01,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3373,HCPCS,63323-284-01,NDC,facility,both,175,EA,,164,114.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,636,RC,J3360,HCPCS,69339-136-03,NDC,facility,both,4,ML,,289,202.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV,50863,CDM,636,RC,J7120,HCPCS,0338-0117-04,NDC,facility,both,4,ML,,133,93.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,250,RC,J2003,HCPCS,63323-485-27,NDC,facility,both,300,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,43598-931-11,NDC,facility,both,1,ML,JW,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,636,RC,J3490,HCPCS,59310-579-22,NDC,facility,both,1,GM,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 250 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,42192-608-05,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 20MG/55 ML IVPB IN NS (ONCOLOGY),50863,CDM,J1100,HCPCS,63323-165-02,NDC,,,facility,both,20,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,0143-9577-01,NDC,,,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 500 MG-125 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0781-1831-20,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE 2 MG SL SUBL,50863,CDM,636,RC,J3490,HCPCS,0904-7154-04,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE  5 MG/ML INJ SOLN,50863,CDM,250,RC,J2765,HCPCS,0409-3414-21,NDC,facility,both,3,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE  4 MG ORAL TAB,50863,CDM,636,RC,J7509,HCPCS,68084-149-11,NDC,facility,both,11,EA,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J2003,HCPCS,63323-492-09,NDC,facility,both,200,ML,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 4 MG/ACTUATION NASL SPRY,50863,CDM,250,RC,J3490,HCPCS,69547-627-02,NDC,facility,both,2,EA,,229,160.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,16714-294-01,NDC,facility,both,4,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,250,RC,J3490,HCPCS,61553-320-70,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG ORAL TAB,50863,CDM,Q0169,HCPCS,68084-155-11,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"OMEGA-3 FATTY ACIDS-FISH OIL 360-1,200 MG ORAL CAP (ERX MERGE)",50863,CDM,250,RC,J3490,HCPCS,17856-0055-1,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,45,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,50863,CDM,636,RC,J8540,HCPCS,0904-7266-61,NDC,facility,both,48,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
D5W WITH POTASSIUM CHLORIDE 20 MEQ/L IV SOLP,50863,CDM,250,RC,J3490,HCPCS,0338-0683-04,NDC,facility,both,1,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,636,RC,J1815,HCPCS,0088-2220-33,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,80,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0780,HCPCS,23155-294-31,NDC,facility,both,1,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,50863,CDM,250,RC,J9000,HCPCS,0069-1542-20,NDC,facility,both,8,ML,,128,89.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN NEO/PEDS IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0456,HCPCS,63323-398-14,NDC,facility,both,1,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELIMUMAB 400 MG IV SOLR,50863,CDM,636,RC,J0490,HCPCS,49401-102-01,NDC,facility,both,76,EA,JA,8471,5929.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1815,HCPCS,0169-1833-11,NDC,facility,both,12,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 0.1 % TOP CREAM,50863,CDM,636,RC,J3490,HCPCS,45802-064-35,NDC,facility,both,1,GM,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,50863,CDM,250,RC,J9267,HCPCS,61703-342-50,NDC,facility,both,226,ML,,273,191.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,0641-6236-01,NDC,facility,both,3,ML,,160,112,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),50863,CDM,250,RC,J3490,HCPCS,0409-4888-06,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-582-11,NDC,facility,both,2,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OMEPRAZOLE-SODIUM BICARBONATE 2-84 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,65628-270-05,NDC,facility,both,5,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-090-11,NDC,facility,both,2,EA,,260,182,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELATACEPT 250 MG IV SOLR,50863,CDM,636,RC,J0485,HCPCS,0003-0371-13,NDC,facility,both,538,EA,,5551,3885.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIROFIBAN-0.9% SODIUM CHLORIDE 5 MG/100 ML (50 MCG/ML) IV SOLN,50863,CDM,636,RC,J3246,HCPCS,25208-002-03,NDC,facility,both,18,ML,,358,250.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,636,RC,Q9968,HCPCS,71288-811-10,NDC,facility,both,25,ML,,415,290.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DONEPEZIL 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6478-61,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 150 MG CAP,50863,CDM,250,RC,J3490,HCPCS,0904-5959-61,NDC,facility,both,4,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRIVIGEN 10 % IV SOLN,50863,CDM,636,RC,J1459,HCPCS,44206-438-92,NDC,facility,both,80,ML,JZ,14352,10046.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
NORTRIPTYLINE 50 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0093-0812-01,NDC,facility,both,2,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMOSOZUMAB-AQQG 210MG/2.34ML ( 105MG/1.17MLX2) SUBQ SYRG,50863,CDM,636,RC,J3111,HCPCS,55513-880-02,NDC,facility,both,105,ML,JZ,2947,2062.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,636,RC,P9045,HCPCS,64208-2510-1,NDC,facility,both,1,ML,JZ,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2598,HCPCS,55150-370-01,NDC,facility,both,4,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 20 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,60687-723-11,NDC,facility,both,3,EA,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0955-1008-01,NDC,facility,both,5,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CODEINE-GUAIFENESIN 10-100 MG/5 ML ORAL LIQD (REPACK),50863,CDM,250,RC,J3490,HCPCS,0121-1550-10,NDC,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60219-1708-1,NDC,facility,both,60,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON DEXTRAN 50 MG/ML INJ SOLN,50863,CDM,636,RC,J1750,HCPCS,0023-6082-01,NDC,facility,both,38,ML,JZ,3959,2771.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50580-458-11,NDC,facility,both,3,EA,PLAD,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
EPINEPHRINE 1 MG/ML INJ SOLN,50863,CDM,250,RC,J0171,HCPCS,76329-9060-0,NDC,facility,both,64,ML,,170,119,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUM U-500 CONC 500 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1815,HCPCS,0002-8501-01,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-5771-23,NDC,facility,both,15,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALUM-MAG HYDROXIDE-SIMETH 200 MG-200 MG-20 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0121-1761-30,NDC,facility,both,2,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRP (MERGE/REPACK),50863,CDM,636,RC,J3490,HCPCS,68094-764-59,NDC,facility,both,2,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 3000 MCG/ML INJECTION,50863,CDM,250,RC,J0153,HCPCS,67457-855-00,NDC,facility,both,6,ML,JZ,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,76045-009-05,NDC,facility,both,5,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAUNORUBICIN 5 MG/ML IV INJ,50863,CDM,250,RC,J9150,HCPCS,0143-9550-01,NDC,facility,both,2,ML,JW,232,162.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3370,HCPCS,0143-9162-01,NDC,facility,both,3,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2598,HCPCS,43598-914-11,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-075-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  0.25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6373-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,63323-165-01,NDC,facility,both,2,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),50863,CDM,250,RC,J1170,HCPCS,0409-4264-11,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,35,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2308-21,NDC,facility,both,7,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7912-51,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INDOMETHACIN 25 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,50268-430-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) NEB SOLUTION,50863,CDM,250,RC,J3490,HCPCS,0487-9501-01,NDC,facility,both,3,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,25021-315-01,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,75,EA,,184,128.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,636,RC,Q9968,HCPCS,70710-1838-1,NDC,facility,both,35,ML,JW,197,137.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CALCIUM ACETATE 667 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,68084-479-11,NDC,facility,both,2,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IDARUBICIN 1 MG/ML IV SOLN,50863,CDM,250,RC,J9211,HCPCS,63323-194-10,NDC,facility,both,2,ML,,469,328.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1940,HCPCS,63323-280-03,NDC,facility,both,6,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0093-2279-73,NDC,facility,both,7,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0780,HCPCS,23155-294-41,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VERAPAMIL 180 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,75834-158-01,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENAZEPRIL 20 MG ORAL TAB,50863,CDM,J3490,HCPCS,50268-111-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FERRIC SUBSULFATE 0.2 TO 0.22 GRAM/ML MISC SOLA,50863,CDM,J3490,HCPCS,10481-0112-8,NDC,,,facility,both,1,ML,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-2051-15,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,636,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,15,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 125 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-519-11,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV (BOLUS),50863,CDM,250,RC,J7120,HCPCS,0264-7750-07,NDC,facility,both,2,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,76045-009-96,NDC,facility,both,1,ML,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.45% (1/2 NS) INFUSION (PEDS ONC),50863,CDM,250,RC,J3490,HCPCS,0338-0043-04,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,72603-209-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML INJECTION,50863,CDM,250,RC,J3411,HCPCS,43598-050-11,NDC,facility,both,3,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,636,RC,J2405,HCPCS,23155-549-31,NDC,facility,both,16,ML,JZ,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),50863,CDM,636,RC,J0169,HCPCS,76329-3318-1,NDC,facility,both,90,ML,,726,508.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J3490,HCPCS,72485-104-01,NDC,facility,both,5,ML,,255,178.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-406-03,NDC,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,65862-006-01,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,0409-9094-25,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADVATE: FACTOR VIII CONCENTRATE (MERGE RECORD),50863,CDM,250,RC,J7192,HCPCS,0944-3053-02,NDC,facility,both,4000,UN,,16744,11720.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM SR 120 MG 24 HR CAP,50863,CDM,250,RC,J3490,HCPCS,60687-195-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,43547-354-10,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PNEUMOC 20-VAL CONJ-DIP CR(PF) 0.5 ML IM SYRG,50863,CDM,250,RC,90677,HCPCS,0005-2000-10,NDC,facility,both,1,ML,,972,680.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RASBURICASE 1.5 MG IV SOLR,50863,CDM,250,RC,J2783,HCPCS,0024-5154-11,NDC,facility,both,1,EA,JW,501,350.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
WARFARIN  3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51672-4030-1,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 150 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-711-11,NDC,facility,both,3,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2312,HCPCS,55150-328-01,NDC,facility,both,400,ML,,280,196,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENAZEPRIL 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,43547-336-10,NDC,facility,both,4,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7001-61,NDC,facility,both,3,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENAZEPRIL 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,43547-336-10,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE NA (PRESERV FREE) 25 MG/ML INJ SOLN,50863,CDM,250,RC,J9260,HCPCS,16729-277-35,NDC,facility,both,60,ML,,604,422.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASCORBIC ACID 500 MG/ML INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,67157-101-50,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VORICONAZOLE 200 MG IV SOLN,50863,CDM,250,RC,J3465,HCPCS,70436-029-80,NDC,facility,both,43,EA,,1161,812.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,68094-231-59,NDC,facility,both,7,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE 25 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,68180-657-01,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MECLIZINE 12.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6516-61,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 875 MG-125 MG TAB,50863,CDM,636,RC,J3490,HCPCS,42571-162-42,NDC,facility,both,14,EA,,300,210,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,636,RC,J3490,HCPCS,0641-6236-01,NDC,facility,both,2,ML,,145,101.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,63323-482-03,NDC,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MECLIZINE 25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7376-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-979-01,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETHACRYNIC ACID 25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69238-1126-1,NDC,facility,both,1,EA,,119,83.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-550-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-DYYB 100 MG IV SOLR,50863,CDM,636,RC,Q5103,HCPCS,0069-0809-01,NDC,facility,both,40,EA,,10447,7312.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DANTROLENE  25 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0115-4411-01,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYMETAZOLINE 0.05 % NASL SPRA,50863,CDM,636,RC,J3490,HCPCS,11523-4112-1,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,63323-280-03,NDC,facility,both,20,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,15,EA,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0456,HCPCS,70095-025-01,NDC,facility,both,1,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,0409-4264-11,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 50 MG CAP,50863,CDM,250,RC,Q0163,HCPCS,0904-2056-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,72162-1329-8,NDC,facility,both,2,ML,,510,357,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6798-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,14789-127-07,NDC,facility,both,1,ML,,155,108.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOTRIMAZOLE 1 % TOP CREA,50863,CDM,250,RC,J3490,HCPCS,51672-2002-2,NDC,facility,both,1,GM,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  75 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7000-61,NDC,facility,both,3,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUBIPROSTONE  8 MCG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,43598-163-60,NDC,facility,both,1,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-495-27,NDC,facility,both,15,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-461-11,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  5 MG ORAL TBDL,50863,CDM,636,RC,J3490,HCPCS,60505-3275-0,NDC,facility,both,3,EA,,210,147,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0054-0710-20,NDC,facility,both,16,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 20 MG ORAL CPDR,50863,CDM,636,RC,J3490,HCPCS,68180-294-07,NDC,facility,both,3,EA,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,0904-7127-61,NDC,facility,both,30,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INHL NEBU,50863,CDM,250,RC,J3490,HCPCS,0487-9301-03,NDC,facility,both,4,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG IV SOLR,50863,CDM,J3490,HCPCS,63323-130-02,NDC,,,facility,both,1,EA,,155,108.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 10 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-6084-61,NDC,,,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,42806-150-33,NDC,facility,both,13,ML,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6008-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICARDIPINE IN NACL (ISO-OS) 20 MG/200 ML IV PGBK,50863,CDM,250,RC,J3490,HCPCS,69097-007-45,NDC,facility,both,1,ML,,255,178.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"CALCIUM GLUC IN NACL, ISO-OSM 1 G/100 ML IV SOLN",50863,CDM,250,RC,J0612,HCPCS,44567-622-01,NDC,facility,both,200,ML,JZ,149,104.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IPRATROPIUM BROMIDE 17 MCG/ACTUATION INHL AERO,50863,CDM,250,RC,J3490,HCPCS,0597-0087-17,NDC,facility,both,1,GM,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 20 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,50111-648-01,NDC,facility,both,2,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,70069-363-01,NDC,facility,both,1,ML,,164,114.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 100 MG/5 ML ORAL LIQD,50863,CDM,250,RC,J3490,HCPCS,50383-063-10,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,J3490,HCPCS,0409-1159-09,NDC,,,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLP",50863,CDM,250,RC,P9047,HCPCS,44206-251-10,NDC,facility,both,2,ML,,778,544.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) NEB SOLUTION,50863,CDM,250,RC,J3490,HCPCS,0378-8270-93,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,0641-6145-01,NDC,facility,both,16,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),50863,CDM,636,RC,J2060,HCPCS,0641-6001-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOLAZONE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,72888-053-01,NDC,facility,both,3,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EZETIMIBE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51660-200-30,NDC,facility,both,1,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OMEPRAZOLE-SODIUM BICARBONATE 2-84 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,65628-270-05,NDC,facility,both,2,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE (FOR EMERGENCY) 100 MG/ML (10%) IV SOLN,50863,CDM,250,RC,J0612,HCPCS,63323-360-01,NDC,facility,both,200,ML,JZ,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,164,ML,,148,103.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-406-03,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,144,ML,,130,91,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,43598-053-11,NDC,facility,both,25,ML,,881,616.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,250,RC,Q9968,HCPCS,70710-1838-1,NDC,facility,both,79,ML,,1308,915.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIOGLITAZONE 15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-391-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,16714-293-01,NDC,facility,both,3,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0641-6206-01,NDC,facility,both,3,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-078-33,NDC,facility,both,2,EA,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0536-1327-06,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 10 MG-325 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0406-0125-23,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,63323-104-25,NDC,facility,both,4,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,71399-1025-3,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-119-11,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM TETRADECYL SULFATE 3 % IV SOLN,50863,CDM,636,RC,J3490,HCPCS,67457-163-00,NDC,facility,both,2,ML,,796,557.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIVAROXABAN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50458-579-01,NDC,facility,both,1,EA,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/0.5 ML INHL NEBU,50863,CDM,J3490,HCPCS,0487-9901-30,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZOCAINE-MENTHOL 15-2.6 MG MM LOZG,50863,CDM,250,RC,J3490,HCPCS,17856-0732-1,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,250,RC,J3490,HCPCS,59310-579-20,NDC,facility,both,1,GM,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-242-11,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BALSALAZIDE 750 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,50268-102-11,NDC,facility,both,2,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0143-9386-01,NDC,facility,both,34,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-487-11,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OMEPRAZOLE-SODIUM BICARBONATE 2-84 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,65628-270-05,NDC,facility,both,3,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
B COMPLEX-VITAMIN C-FOLIC ACID 100-1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,1054201010,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,636,RC,Q9968,HCPCS,70710-1838-1,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,J1100,HCPCS,63323-165-01,NDC,,,facility,both,14,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM,50863,CDM,J3490,HCPCS,62332-582-04,NDC,,,facility,both,1,GM,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXEPIN  25 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,51079-437-01,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,55150-162-05,NDC,,,facility,both,84,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN DEXTROSE (ISO-OSMOTIC) 1 GRAM/50 ML IV PIGGY BACK,50863,CDM,J0690,HCPCS,0264-3103-11,NDC,,,facility,both,4,ML,,3622,2535.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,42806-150-33,NDC,facility,both,25,ML,,190,133,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,43066-007-10,NDC,facility,both,2,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 125 MG ORAL CPSP,50863,CDM,250,RC,J3490,HCPCS,68084-313-11,NDC,facility,both,4,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 15 MG/ML (1.5 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-4776-10,NDC,facility,both,45,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM IN D5W 125 MG/125 ML (1 MG/ML) IV SOLN (PREMIX),50863,CDM,250,RC,J3490,HCPCS,70092-1007-36,NDC,facility,both,1,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,51754-5001-1,NDC,facility,both,2,ML,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM IN NACL (ISO-OS) 500 MG/100 ML IV PGBK,50863,CDM,250,RC,J1953,HCPCS,67457-255-00,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2003,HCPCS,72603-505-01,NDC,,,facility,both,200,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,50863,CDM,250,RC,J9060,HCPCS,0703-5748-11,NDC,facility,both,2,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6292-06,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCRALFATE 100 MG/ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,17856-0306-1,NDC,facility,both,2,ML,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,636,RC,J0630,HCPCS,24201-400-02,NDC,facility,both,1,ML,,3188,2231.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J2004,HCPCS,0409-3178-01,NDC,facility,both,55,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML IM SOLN,50863,CDM,636,RC,90375,HCPCS,13533-318-50,NDC,facility,both,9,ML,,8052,5636.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6780-61,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-074-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL,50863,CDM,250,RC,J3490,HCPCS,63323-820-01,NDC,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN  500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65862-008-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,55150-177-05,NDC,facility,both,100,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,0641-0400-37,NDC,facility,both,5,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PROPRANOLOL  10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-587-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN DETEMIR 100 UNIT/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,0169-3687-12,NDC,facility,both,8,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV (BOLUS),50863,CDM,250,RC,J7120,HCPCS,0264-7750-10,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,180,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PREDNISONE  5 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-122-11,NDC,facility,both,15,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,176,ML,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,276,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GUAIFENESIN  200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,10135-789-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,25,EA,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,25,EA,JZ,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 2 GRAM INJ SOLR,50863,CDM,250,RC,J0692,HCPCS,44567-241-10,NDC,facility,both,4,EA,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0641-6057-01,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 40 MG ORAL TAB,50863,CDM,J3490,HCPCS,60687-210-11,NDC,,,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,50863,CDM,J9264,HCPCS,0517-4300-01,NDC,,,facility,both,2,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN 1000 MG IN NS 1000 ML IRRIGATION (REPACK),50863,CDM,250,RC,J0690,HCPCS,99999-500-04,NDC,facility,both,2,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,250,RC,J2405,HCPCS,70860-776-41,NDC,facility,both,2,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ANIFROLUMAB-FNIA 300 MG/2 ML (150 MG/ML) IV SOLN,50863,CDM,J0491,HCPCS,0310-3040-00,NDC,,,facility,both,300,ME,,12698,8888.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 10 MG ORAL TAB,50863,CDM,J3490,HCPCS,60687-179-11,NDC,,,facility,both,3,EA,,383,268.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,J3490,HCPCS,0093-2279-73,NDC,,,facility,both,10,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J2312,HCPCS,36000-308-01,NDC,facility,both,100,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 40 % ORAL GEL,50863,CDM,250,RC,J3490,HCPCS,574006930,NDC,facility,both,34,GM,,481,336.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,25021-463-01,NDC,facility,both,2,ML,"JZ,JB",30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JB: Administered subcutaneously
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,83257-011-11,NDC,facility,both,4,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLP",50863,CDM,250,RC,P9047,HCPCS,0944-0493-04,NDC,facility,both,1,ML,JZ,251,175.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7124-61,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0630,HCPCS,24201-400-02,NDC,facility,both,1,ML,,5877,4113.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE 150 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,29300-424-01,NDC,facility,both,1,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 10 MG TAB,50863,CDM,250,RC,Q0177,HCPCS,63739-483-10,NDC,facility,both,1,EA,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,636,RC,J3490,HCPCS,63323-486-05,NDC,facility,both,22,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BISACODYL 10 MG RECT SUPP,50863,CDM,636,RC,J3490,HCPCS,0574-7050-50,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HUMAN PROTHROMBIN COMPLEX 500 UNIT IV SOLR,50863,CDM,250,RC,J7168,HCPCS,63833-386-02,NDC,facility,both,1500,UN,JZ,8729,6110.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IRBESARTAN  75 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,31722-729-30,NDC,facility,both,4,EA,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 150 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,0904-7214-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,0641-0400-37,NDC,facility,both,5,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESNA 100 MG/ML IV SOLN,50863,CDM,636,RC,J9209,HCPCS,10019-953-62,NDC,facility,both,2,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,636,RC,J2795,HCPCS,70069-064-25,NDC,facility,both,75,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  2.5 MG ORAL TAB,50863,CDM,250,RC,J7510,HCPCS,59651-485-01,NDC,facility,both,54,EA,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1940,HCPCS,72603-251-01,NDC,facility,both,14,ML,,126,88.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25 MG-100 MG TAB,50863,CDM,250,RC,J3490,HCPCS,50228-458-01,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN IN D5W 600 MG/50 ML IV PGBK,50863,CDM,636,RC,J0736,HCPCS,0338-3612-50,NDC,facility,both,2,ML,JZ,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LUBIPROSTONE  8 MCG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0480-3479-06,NDC,facility,both,3,EA,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,50863,CDM,636,RC,J8540,HCPCS,60687-718-11,NDC,facility,both,32,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-5771-23,NDC,facility,both,15,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,25021-463-01,NDC,facility,both,2,ML,JA,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
SIMVASTATIN  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16729-156-15,NDC,facility,both,2,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE (PF) 25 MG/ML INJ SOLN (FOR ECTOPIC PREGNANCY),50863,CDM,636,RC,J9260,HCPCS,0143-9519-01,NDC,facility,both,2,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL  20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6671-04,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 2 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J2004,HCPCS,0409-3183-11,NDC,facility,both,360,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERYTHROMYCIN 5 MG/G OPHT OINT,50863,CDM,636,RC,J3490,HCPCS,0574-4024-50,NDC,facility,both,5,GM,,213,149.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE 14 MG/24 HR TD PT24,50863,CDM,636,RC,J3490,HCPCS,1093986244,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUBIPROSTONE  8 MCG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,43598-163-60,NDC,facility,both,3,EA,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-570-10,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,0641-6147-01,NDC,facility,both,3,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7121-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN DEGLUDEC 100 UNITS/ML SUBQ SOLN,50863,CDM,636,RC,J1815,HCPCS,73070-400-11,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,59651-488-01,NDC,facility,both,20,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,62332-600-01,NDC,facility,both,4,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,10135-778-01,NDC,facility,both,180,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-180-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J3490,HCPCS,17271-701-02,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON DEXTRAN 50 MG/ML INJ SOLN,50863,CDM,636,RC,J1750,HCPCS,0023-6082-01,NDC,facility,both,1,ML,JZ,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
INCLISIRAN 284 MG/1.5 ML SUBQ SYRG,50863,CDM,636,RC,J1306,HCPCS,0078-1000-60,NDC,facility,both,284,ML,,8970,6279,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML INJECTION,50863,CDM,636,RC,J3411,HCPCS,72485-507-01,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,636,RC,J2405,HCPCS,0641-6078-01,NDC,facility,both,4,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VORICONAZOLE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,27241-063-03,NDC,facility,both,1,EA,,338,236.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VILAZODONE 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0456-1140-30,NDC,facility,both,1,EA,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,23155-192-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE  4 MG ORAL TAB,50863,CDM,250,RC,J7509,HCPCS,0904-6914-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYMETAZOLINE 0.05 % NASL SPRA,50863,CDM,250,RC,J3490,HCPCS,4110081123,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,250,RC,J1596,HCPCS,0143-9679-01,NDC,facility,both,9,ML,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J1610,HCPCS,63323-596-11,NDC,facility,both,7,EA,,5493,3845.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL DECANOATE 100 MG/ML IM SOLN,50863,CDM,250,RC,J1631,HCPCS,70069-383-01,NDC,facility,both,3,ML,,356,249.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 1 MG/ML IV SOLN,50863,CDM,250,RC,J0461,HCPCS,0517-1001-01,NDC,facility,both,50,ML,JZ,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CEFAZOLIN PEDS SYRINGE (20MG/ML) IN DEXTROSE (CDS MIX,50863,CDM,636,RC,J7999,HCPCS,0781-3451-70,NDC,facility,both,2,EA,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPLERENONE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51991-877-33,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN   81 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,0904-6751-80,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROPROCAINE 3 % INJ SOLN,50863,CDM,250,RC,J2401,HCPCS,63323-478-01,NDC,facility,both,149,ML,JW,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ISOPROTERENOL 0.2 MG/ML INJECTION,50863,CDM,636,RC,J3490,HCPCS,69918-731-01,NDC,facility,both,1,ML,,843,590.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,1,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-076-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 500 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,16714-299-03,NDC,facility,both,20,EA,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3373,HCPCS,0143-9162-01,NDC,facility,both,700,EA,,280,196,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 10 MG/ML IM SOLN,50863,CDM,250,RC,J0500,HCPCS,70436-147-80,NDC,facility,both,1,ML,,229,160.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  75 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,65862-528-90,NDC,facility,both,1,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMETHICONE 40MG/0.6ML (0.6ML-UD) SYRINGE (REPACK),50863,CDM,250,RC,J3490,HCPCS,17856-1141-4,NDC,facility,both,2,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE  4 MG ORAL TAB,50863,CDM,250,RC,J7509,HCPCS,68084-149-11,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"CALCIUM CARBONATE-VITAMIN D3 500 MG(1,250MG) -200 UNIT ORAL TAB",50863,CDM,250,RC,J3490,HCPCS,1000670038,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,23155-473-44,NDC,facility,both,40,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0630,HCPCS,42023-205-01,NDC,facility,both,1,ML,,6136,4295.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42858-301-01,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE 100 MG TAB,50863,CDM,636,RC,J3490,HCPCS,23155-135-25,NDC,facility,both,10,EA,,241,168.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  5 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-122-11,NDC,facility,both,25,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2599,HCPCS,65219-039-00,NDC,facility,both,4,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMETHICONE 40MG/0.6ML (0.6ML-UD) SYRINGE (REPACK),50863,CDM,250,RC,J3490,HCPCS,17856-1141-4,NDC,facility,both,3,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 0.5 % TOP OINT,50863,CDM,636,RC,J3490,HCPCS,45802-049-35,NDC,facility,both,1,GM,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,68180-441-02,NDC,facility,both,10,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB 100 MG IV SOLR,50863,CDM,636,RC,J1745,HCPCS,57894-030-01,NDC,facility,both,46,EA,,14827,10378.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),50863,CDM,250,RC,J0171,HCPCS,76329-3318-1,NDC,facility,both,6,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INDOCYANINE GREEN 25 MG INJ,50863,CDM,250,RC,J3490,HCPCS,70100-725-01,NDC,facility,both,1,EA,,386,270.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,43547-281-10,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE MONONITRATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,7733393425,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,0409-1283-04,NDC,facility,both,10,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICLOFENAC 0.1 % EYE DROPS,50863,CDM,250,RC,J3490,HCPCS,24208-457-05,NDC,facility,both,1,ML,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-444-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FINASTERIDE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-428-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0641-0400-37,NDC,facility,both,5,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ROSUVASTATIN 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-256-11,NDC,facility,both,1,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITRIOL 1 MCG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,64980-447-15,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,636,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,20,ML,JZ,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MAGNESIUM SULFATE 50 % (4 MEQ/ML) INJ SOLN,50863,CDM,250,RC,J3475,HCPCS,63323-064-01,NDC,facility,both,6,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25 MG-100 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7501-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 5 MG ORAL CAP,50863,CDM,250,RC,J7507,HCPCS,0904-6624-61,NDC,facility,both,3,EA,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 500 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,50268-152-15,NDC,facility,both,27,EA,,162,113.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,57,EA,,7866,5506.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CANDESARTAN  8 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,33342-115-07,NDC,facility,both,4,EA,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VORICONAZOLE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65862-891-30,NDC,facility,both,2,EA,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE-EPINEPHR-TETRACAINE 4-0.18-0.5 % TOPICAL GEL,50863,CDM,636,RC,J3490,HCPCS,71266-6290-1,NDC,facility,both,2,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,636,RC,J1953,HCPCS,55150-177-05,NDC,facility,both,40,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
OXYBUTYNIN CHLORIDE 5 MG/5 ML ORAL SYRP,50863,CDM,636,RC,J3490,HCPCS,54838-510-80,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,636,RC,J1953,HCPCS,0409-1886-22,NDC,facility,both,100,ML,JZ,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ENOXAPARIN 300 MG/3 ML SUBQ SOLN,50863,CDM,250,RC,J1650,HCPCS,71288-426-03,NDC,facility,both,3,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 300 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,65162-649-78,NDC,facility,both,1,ML,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-65,NDC,facility,both,300,ML,,529,370.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50111-327-01,NDC,facility,both,4,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 0.5 MG ORAL TBDL,50863,CDM,636,RC,J3490,HCPCS,59746-010-32,NDC,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0047-03,NDC,facility,both,25,EA,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEMAZEPAM 15 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,50268-779-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2308-22,NDC,facility,both,30,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-591-11,NDC,facility,both,2,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 2 GRAM IV SOLUTION,50863,CDM,250,RC,J9075,HCPCS,0781-3255-94,NDC,facility,both,200,EA,,3791,2653.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRIL MALEATE  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51672-4037-1,NDC,facility,both,3,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLP",50863,CDM,250,RC,P9047,HCPCS,0944-0493-04,NDC,facility,both,1,ML,,251,175.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-467-01,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65162-897-09,NDC,facility,both,1,EA,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,76045-009-01,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIFEDIPINE 30 MG ORAL TO24,50863,CDM,250,RC,J3490,HCPCS,68084-597-11,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,63323-165-01,NDC,facility,both,12,ML,JZ,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,64,ML,JW,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,636,RC,J3490,HCPCS,0143-9679-01,NDC,facility,both,1,ML,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,0904-7127-61,NDC,facility,both,20,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-555-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-50,NDC,facility,both,114,ML,,201,140.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,636,RC,J1610,HCPCS,0597-0053-45,NDC,facility,both,2,EA,,1483,1038.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-9558-05,NDC,facility,both,2,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-492-04,NDC,facility,both,80,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-633-11,NDC,facility,both,1,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,50863,CDM,636,RC,J9045,HCPCS,0703-4248-01,NDC,facility,both,18,ML,,662,463.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,J2003,HCPCS,0409-4278-01,NDC,,,facility,both,500,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL (VITAMIN D3) 400 UNIT/ML ORAL DROP,50863,CDM,250,RC,J3490,HCPCS,1785600492,NDC,facility,both,3,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 50% IN WATER (MERGE RECORD),50863,CDM,J7060,HCPCS,76329-3302-1,NDC,,,facility,both,1,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,5,EA,,173,121.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOPAMINE INFUSION NEO IV SYRINGE (FROM PREMIX),50863,CDM,250,RC,J1265,HCPCS,0338-1007-02,NDC,facility,both,10,ML,JZ,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-28,NDC,facility,both,8,EA,JZ,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ALPROSTADIL 500 MCG/ML INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0009-3169-01,NDC,facility,both,1,ML,,664,464.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TERAZOSIN  5 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,59746-385-06,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML INJ SOLN,50863,CDM,250,RC,J0171,HCPCS,76329-9060-0,NDC,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,50863,CDM,250,RC,J1756,HCPCS,0517-2340-10,NDC,facility,both,200,ML,,642,449.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,55150-177-05,NDC,facility,both,150,ML,,221,154.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 20 MG/ML ORAL CONC,50863,CDM,250,RC,J3490,HCPCS,16714-601-02,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RASBURICASE 1.5 MG IV SOLR,50863,CDM,250,RC,J2783,HCPCS,0024-5154-11,NDC,facility,both,2,EA,JW,1002,701.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
COPPER 380 SQUARE MM IU IUD,50863,CDM,636,RC,J7300,HCPCS,59365-5128-1,NDC,facility,both,1,EA,,858,600.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXEPIN 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,51079-651-01,NDC,facility,both,2,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69238-1056-1,NDC,facility,both,1,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EZETIMIBE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7103-04,NDC,facility,both,1,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM THIOSULFATE 25 % IV SOLN,50863,CDM,250,RC,J3490,HCPCS,60267-705-50,NDC,facility,both,1,ML,,413,289.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPTOMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0878,HCPCS,72603-152-01,NDC,facility,both,700,EA,,2047,1432.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHIMAZOLE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-669-11,NDC,facility,both,4,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANIFROLUMAB-FNIA 300 MG/2 ML (150 MG/ML) IV SOLN,50863,CDM,636,RC,J0491,HCPCS,0310-3040-00,NDC,facility,both,300,ME,,12698,8888.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE 110 MCG/ACTUATION INHL AERO,50863,CDM,250,RC,J3490,HCPCS,0173-0719-20,NDC,facility,both,1,GM,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0574-0521-76,NDC,facility,both,1,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-590-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 200 MG/20 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,72205-220-01,NDC,facility,both,1,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MYCOPHENOLATE 250 MG CAP,50863,CDM,250,RC,J7517,HCPCS,0093-7334-01,NDC,facility,both,4,EA,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML SYRUP,50863,CDM,250,RC,J3490,HCPCS,0121-0638-10,NDC,facility,both,15,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOPROTERENOL 0.2 MG/ML INJECTION,50863,CDM,636,RC,J3490,HCPCS,69918-731-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,5,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25%/EPINEPHRINE 1:100K INJECTION,50863,CDM,250,RC,J3490,HCPCS,0409-1158-01,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0641-0400-37,NDC,facility,both,20,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-285-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 100 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,50268-542-11,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 2 MG INJ SOLR,50863,CDM,250,RC,J2997,HCPCS,50242-041-64,NDC,facility,both,2,EA,JZ,800,560,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,250,RC,J2405,HCPCS,0409-4759-01,NDC,facility,both,4,ML,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETIRIZINE 5 MG/5 ML ORAL SOLN,50863,CDM,J3490,HCPCS,68094-004-59,NDC,,,facility,both,2,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,Q5121,HCPCS,55513-670-01,NDC,,,facility,both,60,EA,,8280,5796,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TARLATAMAB-DLLE 10 MG IV SOLR,50863,CDM,J9026,HCPCS,55513-069-01,NDC,,,facility,both,10,EA,,41381,28966.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,50863,CDM,Q0177,HCPCS,60687-675-11,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 50 % (4 MEQ/ML) INJ SOLN,50863,CDM,J3475,HCPCS,63323-064-01,NDC,,,facility,both,4,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,42858-001-10,NDC,facility,both,5,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,24338-136-10,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM IN NACL (ISO-OS) 1000 MG/100 ML IV PGBK,50863,CDM,J1953,HCPCS,44567-502-01,NDC,,,facility,both,500,ML,,326,228.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE  5 MG ORAL TAB,50863,CDM,J3490,HCPCS,0093-0053-01,NDC,,,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,50863,CDM,J3490,HCPCS,60687-742-11,NDC,,,facility,both,8,EA,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXRAZOXANE 500 MG IV SOLR,50863,CDM,250,RC,J1190,HCPCS,55150-435-01,NDC,facility,both,2,EA,,1472,1030.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 5 MG/ML IV SOLN,50863,CDM,636,RC,J1921,HCPCS,17478-420-20,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,35,ML,,60691,42483.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,0781-3246-02,NDC,facility,both,3,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16571-109-01,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 50 MG/10 ML (5 MG/ML) IV SOLN,50863,CDM,250,RC,J2305,HCPCS,0517-4810-01,NDC,facility,both,10,ML,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENOFIBRATE NANOCRYSTALLIZED  48 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-599-01,NDC,facility,both,3,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN 50 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,60687-156-95,NDC,facility,both,6,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,10135-679-01,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASCORBIC ACID  500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,904052361,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 30 MG/0.3 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,16714-006-01,NDC,facility,both,3,ML,JZ,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
METHYLPREDNISOLONE 16 MG ORAL TAB,50863,CDM,250,RC,J7509,HCPCS,68382-918-18,NDC,facility,both,10,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MANNITOL 25 % IV SOLN,50863,CDM,250,RC,J2150,HCPCS,63323-024-01,NDC,facility,both,1,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN 125 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,66689-775-08,NDC,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0456,HCPCS,55150-174-10,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LECANEMAB-IRMB 100 MG/ML IV SOLN,50863,CDM,636,RC,J0174,HCPCS,62856-215-01,NDC,facility,both,120,ML,"JW,Q0",153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient | Modifier Q0: Investigational clinical service provided in a clinical research study that is in an approved clinical research study
BEZLOTOXUMAB 25 MG/ML IV SOLN,50863,CDM,636,RC,J0565,HCPCS,0006-3025-01,NDC,facility,both,30,ML,JW,1368,957.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
RASBURICASE 1.5 MG IV SOLR,50863,CDM,250,RC,J2783,HCPCS,0024-5154-11,NDC,facility,both,2,EA,,1536,1075.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,50863,CDM,636,RC,J0585,HCPCS,0023-1145-01,NDC,facility,both,34,EA,,544,380.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,636,RC,J2405,HCPCS,0409-4755-03,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAUNORUBICIN 5 MG/ML IV INJ,50863,CDM,250,RC,J9150,HCPCS,42658-021-01,NDC,facility,both,1,ML,JW,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DILTIAZEM 5 MG/ML IV,50863,CDM,636,RC,J3490,HCPCS,25021-319-05,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6773-61,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 500 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,68084-782-11,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLERGONOVINE 0.2 MG/ML (1 ML) INJ SOLN,50863,CDM,250,RC,J2210,HCPCS,0517-0740-01,NDC,facility,both,1,ML,,179,125.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
URSODIOL 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,59651-421-01,NDC,facility,both,3,EA,,108,75.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,68094-061-59,NDC,facility,both,3,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,63323-482-01,NDC,facility,both,200,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORDIAZEPOXIDE 25 MG CAP,50863,CDM,636,RC,J3490,HCPCS,0555-0159-02,NDC,facility,both,4,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN NEO/PEDS IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0456,HCPCS,63323-398-14,NDC,facility,both,1,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,636,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,38,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
OXYCODONE 20MG/ML (1ML-UD) SYRINGE (REPACK),50863,CDM,250,RC,J3490,HCPCS,66689-025-30,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM  3.375 GRAM IV SOLR,50863,CDM,636,RC,J2543,HCPCS,60505-6157-0,NDC,facility,both,3,EA,JZ,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
INSULIN REGULAR HUM U-500 CONC 500 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1815,HCPCS,0002-8501-01,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 875 MG-125 MG TAB,50863,CDM,636,RC,J3490,HCPCS,16714-297-02,NDC,facility,both,2,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,50863,CDM,636,RC,J3420,HCPCS,70069-005-01,NDC,facility,both,1,ML,JZ,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  0.25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-741-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,55150-370-01,NDC,facility,both,19,ML,JW,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
BENZONATATE 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7153-61,NDC,facility,both,18,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOPAMINE INFUSION NEO IV SYRINGE (FROM PREMIX),50863,CDM,636,RC,J1265,HCPCS,0338-1007-02,NDC,facility,both,10,ML,JZ,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IPRATROPIUM-ALBUTEROL 0.5 MG-2.5 MG/3 ML NEB SOLUTION,50863,CDM,636,RC,J3490,HCPCS,47335-756-48,NDC,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYCHLOROQUINE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-777-10,NDC,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISANKIZUMAB-RZAA  60 MG/ML IV SOLN,50863,CDM,636,RC,J2327,HCPCS,0074-5015-01,NDC,facility,both,1200,ML,JZ,58689,41082.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,63739-931-14,NDC,facility,both,7,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,636,RC,J2270,HCPCS,76045-004-10,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J2004,HCPCS,63323-482-03,NDC,facility,both,300,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0955-1004-01,NDC,facility,both,4,ML,JZ,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DEXTROSE 20% IN WATER (NEO) 500ML,50863,CDM,250,RC,J3490,HCPCS,0990-7935-19,NDC,facility,both,1,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,68180-150-01,NDC,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLPIDEM  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-189-11,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VORICONAZOLE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-165-01,NDC,facility,both,1,EA,,222,155.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,636,RC,J1953,HCPCS,55150-177-05,NDC,facility,both,50,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM ZIRCONIUM CYCLOSILICATE  5 G ORAL PWPK (USE PANEL),50863,CDM,250,RC,J3490,HCPCS,0310-1105-01,NDC,facility,both,4,EA,,497,347.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 30 MG ORAL CPDR,50863,CDM,636,RC,J3490,HCPCS,68180-295-09,NDC,facility,both,1,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-165-11,NDC,facility,both,2,EA,,128,89.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-6625-22,NDC,facility,both,5,ML,,289,202.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESNA 100 MG/ML IV SOLN,50863,CDM,250,RC,J9209,HCPCS,0338-1305-01,NDC,facility,both,2,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENOFIBRATE NANOCRYSTALLIZED  48 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-599-01,NDC,facility,both,4,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMIVUDINE 150 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,64380-710-03,NDC,facility,both,2,EA,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADVATE: FACTOR VIII CONCENTRATE (MERGE RECORD),50863,CDM,250,RC,J7192,HCPCS,0944-3052-02,NDC,facility,both,1250,UN,,5233,3663.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN  750 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,50268-551-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,4,EA,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN  0.4 UNITS/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,42023-219-01,NDC,facility,both,40,ML,JZ,1173,821.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-21,NDC,facility,both,10,ML,"JZ,JA,JG",1415,990.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously | Modifier JG: Drug or biological acquired with 340b drug pricing program discount
AMPICILLIN PEDS INFUSION (CDS MIXTURE),50863,CDM,250,RC,J0290,HCPCS,99999-408-63,NDC,facility,both,2,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PALONOSETRON 0.25 MG/5 ML IV INJECTION (MERGE),50863,CDM,636,RC,J2469,HCPCS,55111-694-07,NDC,facility,both,10,ML,JZ,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,0338-0069-10,NDC,facility,both,2,ML,JZ,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,63323-104-25,NDC,facility,both,12,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,4,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,63323-104-25,NDC,facility,both,27,ML,,168,117.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATOVAQUONE 750 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,60687-534-40,NDC,facility,both,2,ML,,302,211.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-5770-56,NDC,facility,both,2,EA,,195,136.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,636,RC,J7510,HCPCS,17856-0815-1,NDC,facility,both,8,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"CALCIUM CARBONATE 500 MG (1,250 MG) ORAL TAB",50863,CDM,250,RC,J3490,HCPCS,5164582799,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DATOPOTAMAB DERUXTECAN-DLNK 100 MG IV SOLR,50863,CDM,J9011,HCPCS,65597-801-01,NDC,,,facility,both,540,EA,,72897,51027.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,J2704,HCPCS,0069-0209-01,NDC,,,facility,both,55,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,50863,CDM,J1650,HCPCS,16714-026-01,NDC,,,facility,both,4,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-272-11,NDC,facility,both,3,EA,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DONEPEZIL  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,43547-275-03,NDC,facility,both,2,EA,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETUXIMAB 200 MG/100 ML IV SOLN,50863,CDM,J9055,HCPCS,66733-948-23,NDC,,,facility,both,8,ML,,1755,1228.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,J0256,HCPCS,13533-705-11,NDC,,,facility,both,953,ME,,12933,9053.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,J1940,HCPCS,36000-283-25,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,10,ML,,186,130.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATOMOXETINE  40 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,55111-521-30,NDC,facility,both,1,EA,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NYSTATIN  100000 UNIT/G TOP POWD,50863,CDM,636,RC,J3490,HCPCS,68308-152-15,NDC,facility,both,1,GM,,108,75.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,4,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHOTERICIN B LIPOSOME 50 MG IV SUSR,50863,CDM,250,RC,J0289,HCPCS,0469-3051-30,NDC,facility,both,15,EA,,3283,2298.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN DEGLUDEC 100 UNITS/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,73070-400-11,NDC,facility,both,1,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 20 GRAM/30 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-1154-30,NDC,facility,both,3,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIFEDIPINE 60 MG ORAL TO24,50863,CDM,636,RC,J3490,HCPCS,68084-598-11,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6636-61,NDC,facility,both,2,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,51079-051-01,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERYTHROMYCIN 250 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,13668-586-30,NDC,facility,both,1,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,50863,CDM,250,RC,J1885,HCPCS,72266-119-01,NDC,facility,both,2,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,0409-1207-03,NDC,facility,both,4,ML,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,72603-180-01,NDC,facility,both,1,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 0.1 % TOP CREAM,50863,CDM,250,RC,J3490,HCPCS,0603-7862-74,NDC,facility,both,1,GM,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  2.5 MG ORAL TAB,50863,CDM,250,RC,J7510,HCPCS,59651-485-01,NDC,facility,both,49,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 50 MG 24 HR TAB,50863,CDM,J3490,HCPCS,60687-402-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 15 MG/ML (1.5 %) INJ SOLN,50863,CDM,J2003,HCPCS,0409-4776-10,NDC,,,facility,both,300,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLU VACCINE TS 2025-26 6 MO UP (PF) 45 MCG (15 MCG X 3)/0.5 ML IM SYRG,50863,CDM,90656,HCPCS,49281-425-88,NDC,,,facility,both,1,ML,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 5 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2596-05,NDC,facility,both,50,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 100 MG/ML FROM 1 GRAM VIAL (PRMC PEDS ONLY),50863,CDM,250,RC,J0696,HCPCS,0409-7332-11,NDC,facility,both,4,EA,JZ,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CARBAMAZEPINE 100 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0078-0508-83,NDC,facility,both,1,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IN NS 500 ML IRRIGATION (REPACK),50863,CDM,250,RC,J3373,HCPCS,99999-0406-16,NDC,facility,both,100,ML,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SOTALOL  80 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-654-11,NDC,facility,both,2,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,4,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE (FOR CODE) 10% IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0517-6710-01,NDC,facility,both,2,ML,,59316,41521.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,130,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIACIN  250 MG ORAL CPSR,50863,CDM,250,RC,J3490,HCPCS,1000670020,NDC,facility,both,6,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65862-246-08,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE PEDS IV INFUSION (CDS MIXTURE),50863,CDM,250,RC,99999-420-20,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,70954-059-10,NDC,facility,both,15,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE  5 MG/ML INJ SOLN,50863,CDM,250,RC,J2765,HCPCS,0409-3414-18,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 30% IN WATER (NEO),50863,CDM,250,RC,J7070,HCPCS,0409-6648-16,NDC,facility,both,2,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN DEXTROSE (ISO-OSMOTIC) 1 GRAM/50 ML IV PIGGY BACK,50863,CDM,250,RC,J0690,HCPCS,0338-3503-41,NDC,facility,both,6,ML,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  75 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7000-61,NDC,facility,both,4,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,0409-1283-17,NDC,facility,both,10,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 40 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,16714-696-01,NDC,facility,both,1,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  75 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7000-61,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 150 MG CAP,50863,CDM,636,RC,J3490,HCPCS,0904-5959-61,NDC,facility,both,38,EA,,136,95.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 2 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,636,RC,J2270,HCPCS,76045-004-01,NDC,facility,both,1,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL IV BOLUS 10MG/ML (ANESTHESIA ONLY),50863,CDM,636,RC,J2704,HCPCS,0409-4699-54,NDC,facility,both,39,ML,JW,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LINEZOLID NEO IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J2020,HCPCS,0009-5140-01,NDC,facility,both,2,ML,,408,285.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYALURONIDASE 150 UNIT/ML INJ SOLN,50863,CDM,250,RC,J3473,HCPCS,18657-117-01,NDC,facility,both,450,ML,,852,596.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0143-9982-50,NDC,facility,both,4,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM  3 GRAM INJ SOLR,50863,CDM,250,RC,J0295,HCPCS,55150-117-20,NDC,facility,both,2,EA,PLAD,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,250,RC,J7060,HCPCS,0338-0017-48,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOMYCIN-BACITRACN ZN-POLYMYXIN 3.5 MG-400 U*,50863,CDM,J3490,HCPCS,45802-143-00,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,J3490,HCPCS,0409-9558-05,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJ SOLN",50863,CDM,J3490,HCPCS,63323-461-01,NDC,,,facility,both,1,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MANNITOL 20% IV SOLP,50863,CDM,250,RC,J2150,HCPCS,0990-7715-13,NDC,facility,both,1,ML,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,636,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,7,EA,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERTAPENEM 1 GRAM INJ SOLR,50863,CDM,636,RC,J1335,HCPCS,55150-282-20,NDC,facility,both,2,EA,,305,213.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,250,RC,Q0162,HCPCS,16714-671-02,NDC,facility,both,2,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-467-01,NDC,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPYLTHIOURACIL 5MG/ML SUSPENSION (REPACK),50863,CDM,250,RC,J3490,HCPCS,0143-1480-01,NDC,facility,both,20,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE IV BOLUS (STROKE) 100 MG (2 X 50 MG VIALS),50863,CDM,250,RC,J2997,HCPCS,50242-044-06,NDC,facility,both,10,EA,JZ,2429,1700.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CLINDAMYCIN 150 MG CAP,50863,CDM,636,RC,J3490,HCPCS,0904-5959-61,NDC,facility,both,4,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE NA (PRESERV FREE) 25 MG/ML INJ SOLN,50863,CDM,250,RC,J9260,HCPCS,16729-277-03,NDC,facility,both,185,ML,,2021,1414.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,636,RC,J3490,HCPCS,0143-9575-01,NDC,facility,both,400,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML IV SOLN (MERGE),50863,CDM,250,RC,J3490,HCPCS,16714-037-10,NDC,facility,both,1,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-48,NDC,facility,both,2,ML,,140,98,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSULFAN BLUE 1 % INJ SOLN,50863,CDM,636,RC,Q9968,HCPCS,67457-220-00,NDC,facility,both,25,ML,JW,729,510.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,4,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 10 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,55150-305-01,NDC,facility,both,90,ML,JW,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LEVETIRACETAM  750 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7125-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 20 MG ORAL CPDR,50863,CDM,636,RC,J3490,HCPCS,0904-7043-04,NDC,facility,both,3,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,50863,CDM,250,RC,J2359,HCPCS,0781-3159-72,NDC,facility,both,20,EA,,203,142.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G POTASSIUM  5000000 UNIT INJ SOLR,50863,CDM,250,RC,J2540,HCPCS,72603-210-01,NDC,facility,both,1,EA,JW,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,51754-4250-1,NDC,facility,both,3,ML,,160,112,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,25021-601-03,NDC,facility,both,12,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 112 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6954-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 150 MG CAP,50863,CDM,636,RC,J3490,HCPCS,0904-5959-61,NDC,facility,both,40,EA,,143,100.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZOCAINE-MENTHOL 15-3.6 MG MM LOZG,50863,CDM,636,RC,J3490,HCPCS,63824-713-16,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7121-61,NDC,facility,both,1,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  5 MG ORAL TAB,50863,CDM,J3490,HCPCS,63739-145-10,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROTROPIN ALFA 0.9 MG IM SOLR,50863,CDM,J3240,HCPCS,58468-0030-1,NDC,,,facility,both,1,EA,,8208,5745.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIVAROXABAN  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50458-577-01,NDC,facility,both,3,EA,,168,117.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELOXICAM  7.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-525-15,NDC,facility,both,1,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0143-9889-01,NDC,facility,both,27,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,J1171,HCPCS,0409-1283-03,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETIRIZINE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0378-3635-01,NDC,facility,both,3,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 600 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,59651-361-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IR SOLN,50863,CDM,250,RC,J3490,HCPCS,0338-0048-04,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4 % TOP CREA,50863,CDM,636,RC,J3490,HCPCS,0496-0882-05,NDC,facility,both,1,GM,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-339-11,NDC,facility,both,2,EA,,160,112,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLOPATADINE 0.1 % OPHT DROP,50863,CDM,250,RC,J3490,HCPCS,70069-017-01,NDC,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 60 MG ORAL CPDR,50863,CDM,636,RC,J3490,HCPCS,0904-7045-61,NDC,facility,both,2,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 50% IN WATER (MERGE RECORD),50863,CDM,J7060,HCPCS,0409-7517-66,NDC,,,facility,both,5,ML,,478,334.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60219-1708-1,NDC,facility,both,160,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 50 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6323-61,NDC,facility,both,3,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,117,ML,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,J1171,HCPCS,76045-009-96,NDC,,,facility,both,5,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLP,50863,CDM,J3480,HCPCS,0409-6635-18,NDC,,,facility,both,5,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,636,RC,J3490,HCPCS,73013-2002-2,NDC,facility,both,4,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOMYCIN-BACITRACIN ZN-POLYMYXIN 3.5 MG-400 UN*,50863,CDM,636,RC,J3490,HCPCS,0713-0268-31,NDC,facility,both,1,GM,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,15,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2310,HCPCS,36000-310-02,NDC,facility,both,4,ML,,357,249.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE HCL IN NS 10 MG/250 ML (0.04 MG/ML) IV SOLN (PDS MERGE),50863,CDM,J2371,HCPCS,70004-811-40,NDC,,,facility,both,500,ML,,146,102.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,J3101,HCPCS,50242-037-06,NDC,,,facility,both,30,EA,,12963,9074.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE 0.25 MG/2 ML INHL NBSP,50863,CDM,J3490,HCPCS,0487-9601-01,NDC,,,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUORESCEIN 1 MG OPHT STRP,50863,CDM,636,RC,J3490,HCPCS,83851-100-30,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,50863,CDM,636,RC,J3420,HCPCS,0517-0031-01,NDC,facility,both,1,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM IN NACL (ISO-OS) 1000 MG/100 ML IV PGBK,50863,CDM,250,RC,J1953,HCPCS,36000-356-01,NDC,facility,both,100,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,50863,CDM,250,RC,J9000,HCPCS,0069-1542-20,NDC,facility,both,3,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 20 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,60687-725-11,NDC,facility,both,8,EA,,149,104.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE-DIPHENHYD-AL-MAG-SIM 200-25-400-40 MG/30 ML MM MWSH,50863,CDM,636,RC,J3490,HCPCS,65628-050-01,NDC,facility,both,3,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIFEDIPINE 30 MG ORAL TO24,50863,CDM,250,RC,J3490,HCPCS,50268-597-11,NDC,facility,both,4,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE  6.25 MG/5 ML ORAL SYRP,50863,CDM,250,RC,Q0169,HCPCS,70752-138-12,NDC,facility,both,2,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MODAFINIL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-570-11,NDC,facility,both,1,EA,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE  50 MG ORAL CAP,50863,CDM,250,RC,J8530,HCPCS,62332-619-31,NDC,facility,both,20,EA,,594,415.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,76045-009-96,NDC,facility,both,5,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 100 MG PE/2 ML INJ SOLN,50863,CDM,636,RC,Q2009,HCPCS,0069-6001-02,NDC,facility,both,4,ML,JZ,475,332.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IRON SUCROSE 100 MG/5 ML IV SOLN,50863,CDM,636,RC,J1756,HCPCS,0517-2340-01,NDC,facility,both,5,ML,JW,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
HALOPERIDOL  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6782-61,NDC,facility,both,4,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GOLIMUMAB  12.5 MG/ML IV SOLN,50863,CDM,636,RC,J1602,HCPCS,57894-350-01,NDC,facility,both,238,ML,,26265,18385.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,38,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,50863,CDM,250,RC,J9041,HCPCS,43598-426-60,NDC,facility,both,22,EA,,544,380.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MANNITOL 25 % IV SOLN,50863,CDM,250,RC,J2150,HCPCS,63323-024-01,NDC,facility,both,200,ML,,161,112.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,51754-5001-1,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-333-11,NDC,facility,both,1,EA,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 25 MG CAP,50863,CDM,J3490,HCPCS,0904-7237-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,72205-102-01,NDC,facility,both,3,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2599,HCPCS,43598-914-25,NDC,facility,both,4,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIVAROXABAN 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50458-580-01,NDC,facility,both,1,EA,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0143-9386-01,NDC,facility,both,73,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TORSEMIDE   5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,31722-529-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE MODIFIED  25 MG ORAL CAP,50863,CDM,250,RC,J7515,HCPCS,0093-9018-19,NDC,facility,both,4,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-132-11,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,16714-293-01,NDC,facility,both,5,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,250,RC,Q9968,HCPCS,70710-1838-1,NDC,facility,both,10,ML,,166,116.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,250,RC,Q9968,HCPCS,71288-811-10,NDC,facility,both,5,ML,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BISACODYL  5 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,1093977544,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,636,RC,J3490,HCPCS,53746-542-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,67877-545-88,NDC,facility,both,3,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 500 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,50268-260-11,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE 1 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,46287-035-15,NDC,facility,both,1,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-512-11,NDC,facility,both,2,EA,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-272-11,NDC,facility,both,2,EA,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DORZOLAMIDE-TIMOLOL 2 %-0.5 % EYE DROPS,50863,CDM,250,RC,J3490,HCPCS,24208-486-10,NDC,facility,both,1,ML,,287,200.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 50 MG TAB,50863,CDM,250,RC,J3490,HCPCS,42043-221-09,NDC,facility,both,1,EA,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
STERILE TALC 4 G INPL SUSR,50863,CDM,250,RC,J3490,HCPCS,62327-444-04,NDC,facility,both,1,EA,,172,120.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL (VITAMIN D3) 400 UNIT/ML ORAL DROP,50863,CDM,250,RC,J3490,HCPCS,7651805050,NDC,facility,both,5,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAZOSIN 5 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,51079-632-01,NDC,facility,both,3,EA,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MINOCYCLINE  50 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0591-5694-60,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-4799-05,NDC,facility,both,1,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MANNITOL 25 % IV SOLN,50863,CDM,250,RC,J2150,HCPCS,63323-024-01,NDC,facility,both,100,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,636,RC,J2405,HCPCS,60505-6130-0,NDC,facility,both,104,ML,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,72,ML,JW,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
TACROLIMUS 1 MG ORAL CAP,50863,CDM,636,RC,J7507,HCPCS,51079-818-01,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,63323-400-01,NDC,facility,both,100,ML,JZ,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ECULIZUMAB 300 MG/30 ML IV SOLN,50863,CDM,636,RC,J1299,HCPCS,25682-001-01,NDC,facility,both,300,ML,JZ,34545,24181.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-48,NDC,facility,both,1,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 0.5 MG ORAL CAP,50863,CDM,250,RC,J7507,HCPCS,68462-685-01,NDC,facility,both,2,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,0409-6102-10,NDC,facility,both,200,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETIC ACID (VINEGAR) 5% IRRIGATION 12 ML (REPACK),50863,CDM,250,RC,J3490,HCPCS,5155200556,NDC,facility,both,3,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J1938,HCPCS,23155-473-32,NDC,facility,both,4,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,250,RC,J7999,HCPCS,70092-1017-46,NDC,facility,both,4,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,54,ML,JW,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
SILVER SULFADIAZINE 1 % TOP CREA,50863,CDM,250,RC,J3490,HCPCS,61570-131-50,NDC,facility,both,1,GM,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,636,RC,J2795,HCPCS,70069-064-25,NDC,facility,both,200,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,250,RC,J2405,HCPCS,60505-6130-0,NDC,facility,both,8,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MIDODRINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-145-10,NDC,facility,both,20,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACCHAROMYCES BOULARDII 250 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,1785608695,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXEPIN  50 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7054-61,NDC,facility,both,3,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMINOCAPROIC ACID  500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,62559-225-30,NDC,facility,both,3,EA,,285,199.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV (BOLUS),50863,CDM,636,RC,J7120,HCPCS,0264-7750-07,NDC,facility,both,2,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYMETAZOLINE 0.05 % NASL SPRA,50863,CDM,636,RC,J3490,HCPCS,0904-7427-30,NDC,facility,both,2,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN PEDS SYRINGE (20MG/ML) IN DEXTROSE (CDS MIX,50863,CDM,636,RC,J0690,HCPCS,0781-3451-70,NDC,facility,both,2,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL  12 MCG/HR TD PT72,50863,CDM,250,RC,J3490,HCPCS,0406-9112-76,NDC,facility,both,1,EA,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENETOCLAX 10 MG ORAL TAB,50863,CDM,250,RC,J9999,HCPCS,0074-0561-11,NDC,facility,both,1,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BECLOMETHASONE DIPROPIONATE 80 MCG/ACTUATION INHL HFAB,50863,CDM,636,RC,J3490,HCPCS,59310-304-80,NDC,facility,both,1,GM,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,63323-506-41,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 60 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,68180-296-09,NDC,facility,both,1,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 0.4 MG/HR TD PT24,50863,CDM,636,RC,J3490,HCPCS,0378-9112-16,NDC,facility,both,2,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXRAZOXANE 500 MG IV SOLR,50863,CDM,636,RC,J1190,HCPCS,55150-435-01,NDC,facility,both,1,EA,JW,539,377.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
"NEOMYCIN-POLYMYXIN-HC 3.5 MG-10,000 UNIT/ML-1 % EAR DROPS, SUSP",50863,CDM,250,RC,J3490,HCPCS,24208-635-62,NDC,facility,both,1,ML,,363,254.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTAMIDINE 300 MG INJ SOLR,50863,CDM,636,RC,J3490,HCPCS,63323-113-01,NDC,facility,both,1,EA,,342,239.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLPIDEM  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-621-01,NDC,facility,both,2,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE  7.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,57237-007-30,NDC,facility,both,2,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 1 GRAM INJ SOLR,50863,CDM,250,RC,J0692,HCPCS,0409-9566-01,NDC,facility,both,1,EA,JW,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
FLUCONAZOLE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,57237-004-30,NDC,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOLIC ACID 400 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,5026834611,NDC,facility,both,8,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE  50 MG ORAL TAB,50863,CDM,636,RC,j3490,HCPCS,60505-2653-1,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,636,RC,J2560,HCPCS,42494-415-01,NDC,facility,both,1,ML,,129,90.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MINERAL OIL ENEMA,50863,CDM,250,RC,J3490,HCPCS,0363-0006-11,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-464-11,NDC,facility,both,3,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 0.5 MG ORAL CAP,50863,CDM,250,RC,J7507,HCPCS,68462-685-01,NDC,facility,both,2,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  1 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,59746-171-06,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ELTROMBOPAG 25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0078-0685-15,NDC,facility,both,6,EA,,2028,1419.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 2.5 GRAM/25 ML (10 %) INJ SOLN",50863,CDM,250,RC,J1561,HCPCS,13533-800-15,NDC,facility,both,5,ML,,908,635.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,599,ME,JZ,8129,5690.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PENTOBARBITAL 75 MG/1.5 ML SYRINGE (REPACK),50863,CDM,636,RC,J3490,HCPCS,25021-676-20,NDC,facility,both,2,ML,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"TRANEXAMIC ACID IN NACL,ISO-OS 1,000 MG/100 ML (10 MG/ML) IV PGBK",50863,CDM,250,RC,J3490,HCPCS,80830-2329-1,NDC,facility,both,1,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,70069-363-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,636,RC,J3490,HCPCS,59310-579-20,NDC,facility,both,1,GM,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,2,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 50 MG TAB,50863,CDM,636,RC,Q0177,HCPCS,0904-6618-61,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-087-02,NDC,facility,both,3,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIFEDIPINE 60 MG ORAL TO24,50863,CDM,250,RC,J3490,HCPCS,68084-598-11,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESALAMINE 400 MG ORAL CAPSULE-WITH DR TABLETS (CDTI),50863,CDM,250,RC,J3490,HCPCS,0093-5907-86,NDC,facility,both,2,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 650 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,66553-008-01,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,250,RC,J2003,HCPCS,63323-486-05,NDC,facility,both,640,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOLTERODINE 2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,59762-0800-2,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  20 MEQ ORAL PACK,50863,CDM,250,RC,J3490,HCPCS,72888-024-06,NDC,facility,both,4,EA,,200,140,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,636,RC,J3373,HCPCS,67457-340-01,NDC,facility,both,50,EA,,47062,32943.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HUMAN PROTHROMBIN COMPLEX 500 UNIT IV SOLR,50863,CDM,250,RC,J7168,HCPCS,63833-396-01,NDC,facility,both,1300,UN,,7565,5295.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR IN 0.9% NACL 100 UNIT/100 ML (1 UNIT/ML) INFUSION FOR OB,50863,CDM,J1815,HCPCS,0338-0126-12,NDC,,,facility,both,1,ML,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BRENTUXIMAB VEDOTIN 50 MG IV SOLR,50863,CDM,J9042,HCPCS,51144-050-01,NDC,,,facility,both,20,EA,,3038,2126.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 500 MG PE/10 ML INJ SOLN,50863,CDM,250,RC,Q2009,HCPCS,0069-6001-10,NDC,facility,both,10,ML,,524,366.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN D5W 1 GRAM/200 ML IV PGBK,50863,CDM,250,RC,J3370,HCPCS,0338-3552-48,NDC,facility,both,12,ML,,810,567,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE (FOR EMERGENCY) 100 MG/ML (10%) IV SOLN,50863,CDM,J0612,HCPCS,63323-360-01,NDC,,,facility,both,1000,ML,,588,411.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  25 MG ORAL TAB,50863,CDM,J3490,HCPCS,50268-504-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE (CONTRACEPTIVE) 150 MG/ML IM (MERGE),50863,CDM,J1050,HCPCS,0009-7376-11,NDC,,,facility,both,150,ML,,280,196,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,J7512,HCPCS,10135-778-01,NDC,,,facility,both,40,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-234-11,NDC,facility,both,1,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,71288-402-10,NDC,facility,both,8,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DORNASE ALFA 1 MG/ML INHL SOLN,50863,CDM,250,RC,J3490,HCPCS,50242-100-39,NDC,facility,both,2,ML,,948,663.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,26,EA,,3588,2511.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MICAFUNGIN 100 MG IV SOLR,50863,CDM,250,RC,J2248,HCPCS,0469-3211-10,NDC,facility,both,200,EA,,1616,1131.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER FLUSH,50863,CDM,250,RC,J7060,HCPCS,0264-7510-20,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  15 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,0406-8315-23,NDC,facility,both,2,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML IV,50863,CDM,250,RC,J3490,HCPCS,25021-319-10,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLMESARTAN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65597-103-30,NDC,facility,both,1,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,25021-602-03,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-591-11,NDC,facility,both,21,EA,,142,99.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,0955-1008-01,NDC,facility,both,3,ML,JW,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J2003,HCPCS,0409-4279-16,NDC,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,65862-707-80,NDC,facility,both,15,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZONATATE 100 MG ORAL CAP,50863,CDM,J3490,HCPCS,0904-7153-61,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-4279-02,NDC,facility,both,300,ML,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 1 % OPHT DROP,50863,CDM,250,RC,J3490,HCPCS,0065-0817-01,NDC,facility,both,1,ML,,293,205.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.25 % (LEFT) (PHS CUSTOM PAIN BALL),50863,CDM,636,RC,J3490,HCPCS,0409-1159-02,NDC,facility,both,1,ML,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLU VACCINE TS 2024-25 6MOS UP (PF) 45 MCG (15 MCG X 3)/0.5 ML IM SYRG,50863,CDM,90656,HCPCS,19515-810-41,NDC,,,facility,both,1,ML,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 1% 10MG/ML (1ML-UD) OR SYRINGE,50863,CDM,J2003,HCPCS,0409-4276-02,NDC,,,facility,both,500,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-735-11,NDC,facility,both,1,EA,,216,151.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,J2003,HCPCS,0143-9575-01,NDC,,,facility,both,1000,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACIDOPHILUS-PECTIN W CITRUS 25 MILLION-100 CELL MG TAB,50863,CDM,250,RC,J3490,HCPCS,1785614241,NDC,facility,both,12,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LET TOPICAL GEL 3 ML,50863,CDM,J3490,HCPCS,70092-1611-44,NDC,,,facility,both,2,ML,,108,75.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE  1 % TOP CREA,50863,CDM,J3490,HCPCS,0472-0321-26,NDC,,,facility,both,1,GM,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,J1100,HCPCS,63323-165-01,NDC,,,facility,both,2,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE (FOR EMERGENCY) 100 MG/ML (10%) IV SOLN,50863,CDM,250,RC,J0612,HCPCS,0143-9180-01,NDC,facility,both,300,ML,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE  5 MG/ML INJ SOLN,50863,CDM,250,RC,J2765,HCPCS,23155-240-31,NDC,facility,both,2,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 500 MG INJ SOLR,50863,CDM,J0696,HCPCS,0409-7338-11,NDC,,,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,27808-156-01,NDC,facility,both,2,EA,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 20 MG/ML INJ SOLN,50863,CDM,250,RC,J0360,HCPCS,55150-400-01,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,0409-1283-03,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 0.1 MG/ML IV SYRINGE (NEO/INFANT),50863,CDM,250,RC,J1100,HCPCS,99999-0405-74,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MISOPROSTOL 200 MCG ORAL TAB,50863,CDM,636,RC,S0191,HCPCS,60687-746-11,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYBUTYNIN CHLORIDE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0832-0038-89,NDC,facility,both,10,EA,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6797-61,NDC,facility,both,6,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 500 MG PE/10 ML INJ SOLN,50863,CDM,250,RC,Q2009,HCPCS,68462-622-10,NDC,facility,both,6,ML,JW,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
MIFEPRISTONE 200 MG ORAL TAB,50863,CDM,636,RC,S0190,HCPCS,43393-001-01,NDC,facility,both,1,EA,,285,199.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM PHOSPHATE 3 MMOL/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-881-01,NDC,facility,both,1,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLNALTREXONE 12 MG/0.6 ML SUBQ SOLN,50863,CDM,636,RC,J2212,HCPCS,65649-551-02,NDC,facility,both,1,ML,,693,485.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-986-01,NDC,facility,both,3,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,636,RC,J0133,HCPCS,63323-325-03,NDC,facility,both,300,ML,,331,231.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-630-11,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,50863,CDM,250,RC,J9025,HCPCS,72485-201-01,NDC,facility,both,53,EA,JW,328,229.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
AZITHROMYCIN 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,42291-083-30,NDC,facility,both,1,EA,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROIC ACID 250 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,63739-086-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BETAMETHASONE ACET & SOD PHOS 6 MG/ML INJ SUSP,50863,CDM,250,RC,J0702,HCPCS,78206-118-01,NDC,facility,both,5,ML,,223,156.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
URSODIOL 300 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,50268-797-11,NDC,facility,both,3,EA,,113,79.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EXENATIDE 10 MCG/0.04 ML SUBQ PNIJ,50863,CDM,250,RC,J3490,HCPCS,0310-6524-01,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM SR 120 MG 12 HR CAP,50863,CDM,636,RC,J3490,HCPCS,0378-6120-01,NDC,facility,both,2,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 3 MG/ML IV SYRG,50863,CDM,250,RC,J0153,HCPCS,25021-301-67,NDC,facility,both,18,ML,,282,197.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"CALCIUM CARBONATE 500 MG (1,250 MG) ORAL TAB",50863,CDM,250,RC,J3490,HCPCS,7985450021,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-7912-51,NDC,,,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,636,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,15,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MENING VAC A,C,Y,W135 DIP (PF) 10-5 MCG/0.5 ML IM KIT (CAM USE ONLY)",50863,CDM,90734,HCPCS,58160-959-01,NDC,,,facility,both,1,ML,,680,476,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATENOLOL  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,52427-430-90,NDC,facility,both,1,EA,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,59762-0073-1,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION,50863,CDM,250,RC,J3490,HCPCS,0310-7372-20,NDC,facility,both,28,GM,,349,244.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN-ACETAMINOPHEN-CAFFEINE 250 MG-250 MG-65 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0067-2039-91,NDC,facility,both,6,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,63323-482-03,NDC,,,facility,both,40,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMETHICONE  80 MG ORAL CHEW,50863,CDM,J3490,HCPCS,77333-812-25,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,64850-502-01,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,636,RC,Q0162,HCPCS,16714-671-02,NDC,facility,both,2,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J3490,HCPCS,63323-492-27,NDC,,,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,250,RC,J0137,HCPCS,0264-4100-90,NDC,facility,both,5,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,7,EA,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-495-27,NDC,,,facility,both,340,ML,,166,116.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN 0.9% SODIUM CL 1.25 GRAM/250 ML IV SOLN,50863,CDM,250,RC,J3373,HCPCS,71506-015-58,NDC,facility,both,125,ML,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,0121-4799-05,NDC,facility,both,2,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NORTRIPTYLINE 25 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,50268-604-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ITRACONAZOLE 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,16714-743-02,NDC,facility,both,2,EA,,183,128.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADVATE: FACTOR VIII CONCENTRATE (MERGE RECORD),50863,CDM,250,RC,J7192,HCPCS,0944-3052-02,NDC,facility,both,1000,UN,,4186,2930.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE (FOR CODE) 10% (100 MG/ML) IV SYRINGE,50863,CDM,636,RC,J3490,HCPCS,0409-1631-10,NDC,facility,both,2,ML,,149,104.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM 500 MG IV SOLR,50863,CDM,250,RC,J2185,HCPCS,0781-3000-95,NDC,facility,both,5,EA,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG ORAL TB12,50863,CDM,250,RC,J3490,HCPCS,60687-583-11,NDC,facility,both,4,EA,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,50863,CDM,J9041,HCPCS,72603-270-01,NDC,,,facility,both,28,EA,,702,491.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN  2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,62584-984-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 12.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7307-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEG 3350-ELECTROLYTES 236 G-22.74 G-6.74 G-5.86 G ORAL SOLUTION,50863,CDM,250,RC,J3490,HCPCS,43386-090-19,NDC,facility,both,1,ML,,157,109.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MICAFUNGIN 100 MG IV SOLR,50863,CDM,250,RC,J2248,HCPCS,42023-230-01,NDC,facility,both,100,EA,,647,452.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,43,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,25021-674-20,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  1 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,64380-782-06,NDC,facility,both,133,EA,,165,115.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAMOXIFEN 10 MG ORAL TAB,50863,CDM,636,RC,J9999,HCPCS,0378-0144-91,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,4,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J1610,HCPCS,0597-0053-45,NDC,facility,both,1,EA,,371,259.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE 44 MCG/ACTUATION INHL AERO,50863,CDM,250,RC,J3490,HCPCS,0173-0718-20,NDC,facility,both,2,GM,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM IN D5W 125 MG/125 ML (1 MG/ML) IV SOLN (PREMIX),50863,CDM,250,RC,J3490,HCPCS,70004-540-35,NDC,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,636,RC,J2405,HCPCS,23155-547-31,NDC,facility,both,4,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DULOXETINE 30 MG ORAL CPDR,50863,CDM,636,RC,J3490,HCPCS,51991-747-90,NDC,facility,both,1,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-3178-16,NDC,facility,both,70,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-3178-16,NDC,facility,both,600,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CINACALCET 30 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69097-410-02,NDC,facility,both,2,EA,,260,182,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,250,RC,J0131,HCPCS,55150-307-01,NDC,facility,both,28,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FIDAXOMICIN 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,52015-080-01,NDC,facility,both,4,EA,,2750,1925,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,29300-135-01,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,636,RC,J3490,HCPCS,51754-4250-1,NDC,facility,both,3,ML,,203,142.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,54288-136-01,NDC,facility,both,3,ML,,489,342.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68180-980-01,NDC,facility,both,3,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE (PF) 1000 MCG/10 ML EPID SOLN,50863,CDM,250,RC,J0735,HCPCS,67457-218-10,NDC,facility,both,1,ML,,224,156.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"AMIODARONE IN DEXTROSE,ISO-OSM 150 MG/100 ML (PREMIX)",50863,CDM,250,RC,J0282,HCPCS,43066-150-10,NDC,facility,both,15,ML,,611,427.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACUBITRIL-VALSARTAN 49-51 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0078-0777-67,NDC,facility,both,1,EA,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 4 MEQ/ML IV SOLP (COMPOUNDED 30ML),50863,CDM,250,RC,J3490,HCPCS,63323-093-01,NDC,facility,both,1,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FINASTERIDE 5 MG ORAL TAB,50863,CDM,J3490,HCPCS,60687-428-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN  200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,10135-681-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL (VITAMIN D3)  1000 UNIT ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,2055503300,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  25 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,69238-1310-9,NDC,facility,both,3,EA,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PYRIDOSTIGMINE BROMIDE 60 MG/5 ML ORAL SYRP,50863,CDM,250,RC,J3490,HCPCS,69238-1731-2,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-179-11,NDC,facility,both,1,EA,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2308-22,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ORAL ELECTROLYTES ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,7007480336,NDC,facility,both,5,ML,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,63323-165-01,NDC,facility,both,8,ML,JZ,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
K PHOS DI & MONO-SOD PHOS MONO 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,6498010401,NDC,facility,both,4,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 1 MG ORAL CAP,50863,CDM,636,RC,J7507,HCPCS,51079-818-01,NDC,facility,both,2,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRIL MALEATE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,43547-546-10,NDC,facility,both,4,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,70,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE MONONITRATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,7733393425,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACUBITRIL-VALSARTAN 49-51 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0078-0777-67,NDC,facility,both,1,EA,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-3178-01,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J2004,HCPCS,0409-3178-16,NDC,facility,both,300,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICLOFENAC 1 % TOPICAL GEL,50863,CDM,636,RC,J3490,HCPCS,0067-8152-03,NDC,facility,both,1,GM,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,5,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
HYDROPHILLIC OINTMENT (AQUAPHOR),50863,CDM,636,RC,J3490,HCPCS,7214003147,NDC,facility,both,1,GM,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,68516-5214-2,NDC,facility,both,2,ML,,447,312.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML (1ML) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,54288-119-01,NDC,facility,both,4,ML,,317,221.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MOXIFLOXACIN 400 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7407-04,NDC,facility,both,1,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE  50 MG ORAL TAB,50863,CDM,636,RC,j3490,HCPCS,50111-560-01,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-580-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,2055503600,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"AMIODARONE IN DEXTROSE,ISO-OSM 150 MG/100 ML (PREMIX)",50863,CDM,250,RC,J0282,HCPCS,43066-150-10,NDC,facility,both,10,ML,,407,284.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 500 MG (200 MG ELEMENTAL) CHEW TAB,50863,CDM,250,RC,J3490,HCPCS,66553-004-01,NDC,facility,both,2,EA,PLAD,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
CLONIDINE 0.1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-113-11,NDC,facility,both,4,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,210,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J3490,HCPCS,0409-3178-01,NDC,,,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,J0665,HCPCS,70594-117-01,NDC,,,facility,both,50,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,J3490,HCPCS,63323-462-01,NDC,,,facility,both,1,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-9543-02,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROGESTERONE MICRONIZED 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,59651-152-01,NDC,facility,both,2,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-492-27,NDC,,,facility,both,600,ML,,471,329.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVONORGESTREL 20 MCG/24 HR IU IUD,50863,CDM,636,RC,J7298,HCPCS,50419-423-01,NDC,facility,both,1,EA,GZ,2369,1658.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier GZ: Item or service expected to be denied as not reasonable and necessary
NEBIVOLOL  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-641-11,NDC,facility,both,1,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),50863,CDM,250,RC,J1630,HCPCS,63323-474-00,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,250,RC,J2270,HCPCS,0409-1890-03,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISANKIZUMAB-RZAA  60 MG/ML IV SOLN,50863,CDM,636,RC,J2327,HCPCS,0074-5015-01,NDC,facility,both,1200,ML,,57258,40080.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,68382-444-05,NDC,facility,both,2,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 17 GRAM (100 %) ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,0904-6931-86,NDC,facility,both,7,EA,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENTOLAMINE 5 MG INJ SOLR,50863,CDM,250,RC,J3490,HCPCS,0143-9564-01,NDC,facility,both,2,EA,,2461,1722.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML IV SOLN (MERGE),50863,CDM,636,RC,J3490,HCPCS,16714-037-10,NDC,facility,both,1,ML,,101,70.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 3000 MCG/ML INJECTION,50863,CDM,250,RC,J0153,HCPCS,25021-318-02,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,51079-051-20,NDC,facility,both,1,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,0409-9094-12,NDC,facility,both,3,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN D5W 1 GRAM/200 ML IV PGBK,50863,CDM,250,RC,J3370,HCPCS,0338-3552-48,NDC,facility,both,10,ML,,675,472.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL (5 MG/ML) IV SYRG (CONTAINS PRESERVATIVE),50863,CDM,636,RC,J3490,HCPCS,0409-2339-24,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,50863,CDM,636,RC,Q0177,HCPCS,23155-501-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  5 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,55111-262-79,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1815,HCPCS,0002-8215-01,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 400 MCG/100 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0338-9557-12,NDC,facility,both,1,ML,,165,115.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MONTELUKAST  5 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,50268-574-11,NDC,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,121119030,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 10 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,67457-420-00,NDC,facility,both,12,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN IN D5W 300 MG/50 ML IV PGBK,50863,CDM,636,RC,J0736,HCPCS,0338-3410-50,NDC,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL (5 MG/ML) IV SYRG (CONTAINS PRESERVATIVE),50863,CDM,250,RC,J3490,HCPCS,0409-2339-24,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-776-11,NDC,facility,both,2,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 10 MG-325 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0406-0367-23,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV (BOLUS),50863,CDM,250,RC,J7030,HCPCS,0264-5802-00,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TELMISARTAN 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,43547-284-03,NDC,facility,both,2,EA,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOPAMINE INFUSION PEDS IV SYRINGE (FROM PREMIX),50863,CDM,250,RC,J1265,HCPCS,99999-403-39,NDC,facility,both,2,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,636,RC,J3490,HCPCS,63323-185-08,NDC,facility,both,1,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-495-27,NDC,facility,both,25,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE  2 MG/ML INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,70069-062-01,NDC,facility,both,2,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,42858-001-10,NDC,facility,both,9,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,250,RC,J0690,HCPCS,44567-707-25,NDC,facility,both,2,EA,JZ,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
BUDESONIDE 0.5 MG/2 ML INHL NBSP,50863,CDM,250,RC,J3490,HCPCS,60687-524-79,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE 0.5%/EPINEPHRINE 1:100K INJECTION,50863,CDM,250,RC,J3490,HCPCS,63323-286-30,NDC,facility,both,2,ML,,255,178.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLP",50863,CDM,250,RC,P9047,HCPCS,44206-251-91,NDC,facility,both,2,ML,JZ,778,544.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MIRTAZAPINE  7.5 MG ORAL TAB,50863,CDM,J3490,HCPCS,60687-584-11,NDC,,,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN  500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7162-61,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,636,RC,J1953,HCPCS,63323-400-01,NDC,facility,both,33,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 0.5 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,49884-311-52,NDC,facility,both,2,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOPERAMIDE 1 MG/7.5 ML ORAL LIQD,50863,CDM,250,RC,J3490,HCPCS,68094-029-59,NDC,facility,both,2,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,250,RC,J7060,HCPCS,0338-0017-02,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,6000,ML,,661,462.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOFLOXACIN 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6352-61,NDC,facility,both,1,EA,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,0121-4799-05,NDC,facility,both,4,ML,,183,128.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 80 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16714-685-02,NDC,facility,both,1,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRIMIDONE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-202-11,NDC,facility,both,3,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IV PGBK,50863,CDM,636,RC,J3475,HCPCS,44567-420-24,NDC,facility,both,4,ML,JZ,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6949-61,NDC,facility,both,5,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNITS/1 GRAM PACKET (MERGE RECORD),50863,CDM,636,RC,J3490,HCPCS,57896-145-09,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUDARABINE 50 MG IV SOLR,50863,CDM,250,RC,J9185,HCPCS,45963-609-55,NDC,facility,both,2,EA,,817,571.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 10 MG/50 ML (0.2MG/ML) PCA IN NS (MERGE),50863,CDM,250,RC,J1171,HCPCS,61553-830-41,NDC,facility,both,100,ML,,144,100.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEPROTUMUMAB-TRBW 500 MG IV SOLR,50863,CDM,636,RC,J3241,HCPCS,75987-130-15,NDC,facility,both,100,EA,,71170,49819,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,23155-600-31,NDC,facility,both,6,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,10135-778-01,NDC,facility,both,20,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0054-0710-20,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 5 MG/5 ML IV,50863,CDM,J3490,HCPCS,0143-9660-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,J2704,HCPCS,0069-0209-01,NDC,,,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRIMIDONE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-686-11,NDC,facility,both,4,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,149003908,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,250,RC,J3490,HCPCS,0143-9575-01,NDC,facility,both,400,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"RHO(D) IMMUNE GLOBULIN (RHOPHYLAC) 1,500 UNIT (300 MCG)/2 ML INJ SYRG",50863,CDM,250,RC,J2791,HCPCS,44206-300-90,NDC,facility,both,1,ML,,693,485.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYMETAZOLINE 0.05 % NASL SPRA,50863,CDM,636,RC,J3490,HCPCS,0904-7427-30,NDC,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VORICONAZOLE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-165-01,NDC,facility,both,2,EA,,332,232.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROMETHORPHAN-GUAIFENESIN SR 30 MG-600 MG 12 HR TAB,50863,CDM,250,RC,J3490,HCPCS,63824-056-01,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 50 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,10135-779-01,NDC,facility,both,105,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,409,ME,JZ,5551,3885.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
FENTANYL 100 MCG/HR TD PT72,50863,CDM,636,RC,J3490,HCPCS,0378-9124-16,NDC,facility,both,2,EA,,385,269.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50111-398-01,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 5 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,63323-660-05,NDC,facility,both,2,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0630,HCPCS,24201-400-02,NDC,facility,both,1,ML,,1677,1173.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2599,HCPCS,65219-039-00,NDC,facility,both,6,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 100 MG/ML FROM 1 GRAM VIAL (PRMC PEDS ONLY),50863,CDM,250,RC,J0696,HCPCS,0409-7332-11,NDC,facility,both,3,EA,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYMETAZOLINE 0.05 % NASAL MERGE,50863,CDM,250,RC,J3490,HCPCS,70677-1037-1,NDC,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIPASE-PROTEASE-AMYLASE 12,000-38,000- 60,000 UNIT ORAL CAP, DELAY REL",50863,CDM,250,RC,J3490,HCPCS,0032-0047-70,NDC,facility,both,2,EA,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  37.5 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,68084-698-11,NDC,facility,both,5,EA,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG-10,000 UNIT/G-0.1 % EYE OINTMENT",50863,CDM,250,RC,J3490,HCPCS,24208-795-35,NDC,facility,both,1,GM,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-25,NDC,facility,both,28,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0406-5755-23,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BICARBONATE DIALYSIS SOLN NO.9 K (4 MEQ/L)-CA (2.5)-MG (1.5) HEMO SOLN,50863,CDM,250,RC,J3490,HCPCS,24571-105-06,NDC,facility,both,1,ML,,172,120.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRBESARTAN 150 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,33342-048-07,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J1610,HCPCS,63323-596-11,NDC,facility,both,10,EA,,8945,6261.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,910,ME,JZ,12349,8644.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ISOSORBIDE MONONITRATE  60 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,13668-105-01,NDC,facility,both,3,EA,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,21,ML,JZ,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SENNOSIDES-DOCUSATE SODIUM 8.6 MG-50 MG TAB,50863,CDM,636,RC,J3490,HCPCS,57896-303-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TISLELIZUMAB-JSGR 10 MG/ML IV SOLN,50863,CDM,J9329,HCPCS,72579-121-01,NDC,,,facility,both,150,ML,,23077,16153.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 2 MG/10 ML (200 MCG/ML) IN D5W VIAL-CVL/IR USE (REPACK),50863,CDM,250,RC,J3490,HCPCS,0338-1049-02,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-210-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,50863,CDM,636,RC,Q0177,HCPCS,60687-675-11,NDC,facility,both,4,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,J3490,HCPCS,39822-1000-1,NDC,,,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IR SOLN,50863,CDM,636,RC,J3490,HCPCS,0338-0047-46,NDC,facility,both,2,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,23155-833-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,8,EA,JZ,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MORPHINE  30 MG ORAL TBSR,50863,CDM,636,RC,J3490,HCPCS,0406-8330-23,NDC,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HUMAN PROTHROMBIN COMPLEX 500 UNIT IV SOLR,50863,CDM,250,RC,J7168,HCPCS,63833-396-01,NDC,facility,both,2500,UN,,14548,10183.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZONATATE 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7153-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,2055503600,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,636,RC,J3373,HCPCS,67457-340-01,NDC,facility,both,100,EA,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DORZOLAMIDE 2 % OPHT DROP,50863,CDM,250,RC,J3490,HCPCS,61314-019-10,NDC,facility,both,1,ML,,284,198.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,14789-251-09,NDC,facility,both,1,ML,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,68180-150-01,NDC,facility,both,5,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 1 MG ORAL TBDL,50863,CDM,250,RC,0093-9293-19,NDC,,,facility,both,4,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,2055503601,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASCORBIC ACID  500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,5789684101,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,55150-221-10,NDC,facility,both,1,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAY 1 NEO SOLUTION (D12.5W/AA 2%/HEPARIN 0.5 UNITS/ML),50863,CDM,250,RC,J3490,HCPCS,0264-1933-10,NDC,facility,both,1,ML,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 12.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-7295-01,NDC,facility,both,2,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,63323-165-01,NDC,facility,both,16,ML,JZ,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PREDNISONE 50 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,10135-779-01,NDC,facility,both,121,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 20 MG/ML INJ SOLN,50863,CDM,250,RC,J0360,HCPCS,55150-400-01,NDC,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE IN D5W 1 GRAM/100 ML IV PGBK,50863,CDM,250,RC,J3475,HCPCS,63323-108-00,NDC,facility,both,33,ML,,891,623.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,8,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,2,EA,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-41,NDC,facility,both,1,ML,,119,83.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 0.4 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,43598-436-35,NDC,facility,both,3,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,0409-1207-03,NDC,facility,both,6,ML,,138,96.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIBUCAINE 1 % TOP OINT,50863,CDM,250,RC,J3490,HCPCS,71399-2829-1,NDC,facility,both,2,GM,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,63739-931-28,NDC,facility,both,35,ML,,84386,59070.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-5771-23,NDC,facility,both,5,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML INJECTION,50863,CDM,636,RC,J3411,HCPCS,72603-139-01,NDC,facility,both,4,ML,,111,77.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,J3490,HCPCS,44567-600-04,NDC,,,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,J2270,HCPCS,0409-1891-03,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"POTASSIUM PHOSPHATE, MONOBASIC 500 MG ORAL TBSO",50863,CDM,250,RC,J3490,HCPCS,0486-1111-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APREPITANT  80 MG ORAL CAP,50863,CDM,250,RC,J8501,HCPCS,68462-584-40,NDC,facility,both,16,EA,,734,513.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE  2.5 % RECT CREA,50863,CDM,250,RC,J3490,HCPCS,64980-324-30,NDC,facility,both,1,GM,,371,259.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESNA 100 MG/ML IV SOLN,50863,CDM,250,RC,J9209,HCPCS,10019-953-62,NDC,facility,both,5,ML,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50111-561-01,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES-DOCUSATE SODIUM 8.6 MG-50 MG TAB,50863,CDM,250,RC,J3490,HCPCS,57896-303-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6008-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHACHOLINE CHLORIDE STERILE INHALATION SOLUTION (PF) KIT,50863,CDM,J7674,HCPCS,64281-110-05,NDC,,,facility,both,100,ML,,3494,2445.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,63323-506-01,NDC,facility,both,40,ML,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,250,RC,J3490,HCPCS,50268-671-11,NDC,facility,both,3,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,636,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYTOCIN 10 UNIT/ML INJ SOLN,50863,CDM,250,RC,J2590,HCPCS,63323-012-11,NDC,facility,both,3,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 500 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7337-35,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEZEPELUMAB-EKKO 210 MG/1.91 ML (110 MG/ML) SUBQ SYRG,50863,CDM,636,RC,J2356,HCPCS,55513-112-01,NDC,facility,both,210,ML,JZ,10028,7019.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CEFTRIAXONE 500 MG INJ SOLR,50863,CDM,250,RC,J0696,HCPCS,0409-7338-01,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN  500 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,70010-491-01,NDC,facility,both,4,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69315-904-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 100 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,68084-697-11,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,33,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL  3.125 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7305-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANTI-INHIBITOR COAGULANT CMPLX 350-650 UNIT IV SOLR,50863,CDM,250,RC,J7198,HCPCS,64193-423-02,NDC,facility,both,610,UN,,3634,2543.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J3430,HCPCS,65219-635-01,NDC,facility,both,3,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL  3.125 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68382-092-01,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0536-1327-10,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSULFAN BLUE 1 % INJ SOLN,50863,CDM,636,RC,Q9968,HCPCS,67457-220-00,NDC,facility,both,50,ML,JZ,4299,3009.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ALTEPLASE IV INFUSION (PULMONARY EMBOLISM) 100 MG (2 X 50 MG VIALS),50863,CDM,250,RC,J2997,HCPCS,99999-0402-55,NDC,facility,both,100,ML,,24289,17002.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0245-0144-89,NDC,facility,both,1,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE  50 MG ORAL CAP,50863,CDM,250,RC,J8530,HCPCS,62332-619-31,NDC,facility,both,8,EA,,280,196,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1171,HCPCS,0703-0018-01,NDC,facility,both,50,ML,,224,156.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 7.5 MG-325 MG/15 ML ORAL SOLN (REPACK),50863,CDM,636,RC,J3490,HCPCS,0121-2316-15,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORTHALIDONE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-058-01,NDC,facility,both,4,EA,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,10135-778-01,NDC,facility,both,60,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,6,EA,JW,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0641-6206-01,NDC,facility,both,2,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4% TOP PATCH,50863,CDM,636,RC,J3490,HCPCS,0536-1202-07,NDC,facility,both,2,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE IN SALINE (ISO-OSM) 400 MG/200 ML IV PIGGY BACK,50863,CDM,250,RC,J3490,HCPCS,25021-184-87,NDC,facility,both,1,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,23155-832-01,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 10 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7345-61,NDC,facility,both,2,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLPIDEM  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6082-61,NDC,facility,both,1,EA,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GAMMAGARD LIQUID 10 % IV SOLN,50863,CDM,636,RC,J1569,HCPCS,0944-2700-12,NDC,facility,both,60,ML,JA,10817,7571.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-04,NDC,facility,both,4,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,658,ME,JZ,8930,6251,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DEXTROMETHORPHAN-GUAIFENESIN SR 30 MG-600 MG 12 HR TAB,50863,CDM,250,RC,J3490,HCPCS,6382405640,NDC,facility,both,10,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 600 MG ORAL TP12,50863,CDM,250,RC,J3490,HCPCS,6382400840,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE MODIFIED  25 MG ORAL CAP,50863,CDM,250,RC,J7515,HCPCS,51862-458-01,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 0.5 MG/ML ORAL SUSPENSION (REPACK),50863,CDM,250,RC,J7507,HCPCS,51079-028-01,NDC,facility,both,3,EA,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 250 MG INJ SOLR,50863,CDM,636,RC,J0696,HCPCS,0781-3206-85,NDC,facility,both,8,EA,,581,406.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM SR 60 MG 12 HR CAP,50863,CDM,250,RC,J3490,HCPCS,51079-924-01,NDC,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLOPATADINE 0.1 % OPHT DROP,50863,CDM,250,RC,J3490,HCPCS,0536-1308-40,NDC,facility,both,1,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAUNORUBICIN 5 MG/ML IV INJ,50863,CDM,250,RC,J9150,HCPCS,42658-021-01,NDC,facility,both,3,ML,,841,588.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR IRRIGATION, STERILE SOLUTION",50863,CDM,636,RC,J3490,HCPCS,0338-0004-02,NDC,facility,both,8,ML,,255,178.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN IN D5W 400 MG/200 ML IV PGBK,50863,CDM,250,RC,J0744,HCPCS,25021-114-87,NDC,facility,both,20,ML,,466,326.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL IV BOLUS 10MG/ML (ANESTHESIA ONLY),50863,CDM,636,RC,J2704,HCPCS,0409-4699-54,NDC,facility,both,72,ML,JW,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
SODIUM BICARBONATE 650 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,66553-008-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,636,RC,Q0162,HCPCS,65162-691-79,NDC,facility,both,2,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OMEPRAZOLE-SODIUM BICARBONATE 2-84 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,65628-270-03,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM CITRATE ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,70677-1112-1,NDC,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),50863,CDM,250,RC,J1630,HCPCS,67457-426-00,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZOCAINE-MENTHOL 20 %-0.5 % TOPICAL AEROSOL,50863,CDM,250,RC,J3490,HCPCS,16864-680-03,NDC,facility,both,1,GM,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,8068108600,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,16714-016-01,NDC,facility,both,12,ML,,157,109.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPTOMYCIN 500 MG IV SOLR,50863,CDM,636,RC,J0878,HCPCS,72603-152-01,NDC,facility,both,700,EA,,2047,1432.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEPROTUMUMAB-TRBW 500 MG IV SOLR,50863,CDM,636,RC,J3241,HCPCS,75987-130-15,NDC,facility,both,80,EA,,56936,39855.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,250,RC,J3490,HCPCS,73013-2002-2,NDC,facility,both,3,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 20 MG ORAL CAP,50863,CDM,J3490,HCPCS,0904-7346-61,NDC,,,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,J2003,HCPCS,0143-9575-01,NDC,,,facility,both,200,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COLCHICINE 0.6 MG ORAL TAB,50863,CDM,J3490,HCPCS,59651-455-01,NDC,,,facility,both,2,EA,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 0.4 MG SL SUBL,50863,CDM,J3490,HCPCS,68462-639-25,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0406-0512-23,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML INJECTION,50863,CDM,636,RC,J3411,HCPCS,0641-6228-01,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,18,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,4,ML,,119,83.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCHLOROTHIAZIDE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-593-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,72888-039-60,NDC,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 40 MG-200 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,65862-496-47,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,42806-150-33,NDC,facility,both,5,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J2004,HCPCS,63323-482-03,NDC,facility,both,100,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,72603-506-01,NDC,facility,both,100,ML,JZ,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LEVETIRACETAM NEO IV SYRINGE (PHS FROM PREMIX),50863,CDM,250,RC,J1953,HCPCS,44567-501-01,NDC,facility,both,15,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-3178-16,NDC,facility,both,110,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FELODIPINE  5 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,68462-234-01,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,81284-315-05,NDC,facility,both,1,ML,,1728,1209.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 1 % TOP GEL,50863,CDM,250,RC,J3490,HCPCS,0713-0574-60,NDC,facility,both,1,GM,,818,572.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 300 MG ORAL CM12,50863,CDM,250,RC,J3490,HCPCS,66993-409-32,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,50863,CDM,250,RC,J9060,HCPCS,16729-288-38,NDC,facility,both,8,ML,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,76282-212-60,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL (VITAMIN D3) 400 UNIT/ML ORAL DROP,50863,CDM,250,RC,J3490,HCPCS,17856-0049-01,NDC,facility,both,2,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6370-61,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIOTHYRONINE  5 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,59762-1206-1,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 112 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42292-039-01,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,50863,CDM,636,RC,J3490,HCPCS,68462-157-40,NDC,facility,both,8,EA,,666,466.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0093-3425-10,NDC,facility,both,4,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIVASTIGMINE 9.5 MG/24 HOUR TD PT24,50863,CDM,250,RC,J3490,HCPCS,0378-9071-16,NDC,facility,both,1,EA,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-1749-70,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7728-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,636,RC,J3490,HCPCS,63323-486-05,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J1610,HCPCS,63323-582-82,NDC,facility,both,3,EA,JZ,2972,2080.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,0641-6146-01,NDC,facility,both,35,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0047-03,NDC,facility,both,200,EA,JZ,511,357.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
BUPROPION HCL 100 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,0591-3540-60,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,10135-778-01,NDC,facility,both,40,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,3,EA,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR PHOSPHATE 30 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,64380-797-01,NDC,facility,both,2,EA,,139,97.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIVASTIGMINE 4.6 MG/24 HOUR TD PT24,50863,CDM,250,RC,J3490,HCPCS,51991-897-99,NDC,facility,both,1,EA,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,76045-009-10,NDC,facility,both,10,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0093-4177-73,NDC,facility,both,9,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 3000 MCG/ML INJECTION,50863,CDM,250,RC,J0153,HCPCS,63323-651-00,NDC,facility,both,12,ML,,129,90.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-0430-06,NDC,facility,both,10,EA,,129,90.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,636,RC,J2560,HCPCS,14789-128-07,NDC,facility,both,3,ML,,448,313.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE SODIUM 2.5 MG ORAL TAB,50863,CDM,250,RC,J8610,HCPCS,51079-670-01,NDC,facility,both,6,EA,,183,128.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL  6.25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-854-11,NDC,facility,both,2,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,70436-032-35,NDC,facility,both,1,EA,,148,103.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM & SODIUM PHOSPHATES 280-160-250 MG ORAL PWPK,50863,CDM,636,RC,J3490,HCPCS,6025800615,NDC,facility,both,6,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM IN NACL (ISO-OS) 1500 MG/100 ML IV PGBK,50863,CDM,250,RC,J1953,HCPCS,67457-266-00,NDC,facility,both,150,ML,,168,117.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM  3 GRAM INJ SOLR,50863,CDM,250,RC,J0295,HCPCS,0049-0014-83,NDC,facility,both,24,EA,,1026,718.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7452-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-495-27,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 160 MG-800 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0904-2725-61,NDC,facility,both,12,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG IV SOLR,50863,CDM,636,RC,J3490,HCPCS,0143-9381-01,NDC,facility,both,5,EA,,618,432.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60505-0252-3,NDC,facility,both,2,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML IM SOLN,50863,CDM,636,RC,90375,HCPCS,13533-318-05,NDC,facility,both,18,ML,,15745,11021.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLEDRONIC ACID IN MANNITOL & WATER 5 MG/100 ML IV SOLN,50863,CDM,636,RC,J3489,HCPCS,0409-4228-01,NDC,facility,both,5,ML,,801,560.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,636,RC,J0330,HCPCS,0409-6629-02,NDC,facility,both,8,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-1749-70,NDC,facility,both,2,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG ORAL TBDL,50863,CDM,636,RC,J3490,HCPCS,55111-263-79,NDC,facility,both,2,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),50863,CDM,250,RC,J2060,HCPCS,0641-6044-01,NDC,facility,both,2,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LYMPHOCYTE,ANTI-THYMO IMMUNE GLOBULIN 50 MG/ML IV",50863,CDM,250,RC,J7504,HCPCS,0009-7224-01,NDC,facility,both,13,ML,,172953,121067.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE HCL IN NS 10 MG/250 ML (0.04 MG/ML) IV SOLN (PDS MERGE),50863,CDM,636,RC,J2371,HCPCS,71506-010-58,NDC,facility,both,500,ML,,146,102.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-346-11,NDC,facility,both,2,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,636,RC,J1596,HCPCS,0143-9679-01,NDC,facility,both,2,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL  75 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6635-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,23,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN 0.9% SODIUM CL 1.25 GRAM/250 ML IV SOLN,50863,CDM,250,RC,J3370,HCPCS,71266-5083-1,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 12.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7307-61,NDC,facility,both,1,EA,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYBUTYNIN CHLORIDE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7027-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  750 MG IV SOLR,50863,CDM,636,RC,J3370,HCPCS,63323-203-01,NDC,facility,both,2,EA,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0780,HCPCS,0641-6135-25,NDC,facility,both,1,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPTOMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0878,HCPCS,0409-0122-01,NDC,facility,both,350,EA,,282,197.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOBRAMYCIN SULFATE 40 MG/ML INJ SOLN,50863,CDM,250,RC,J3260,HCPCS,67457-473-00,NDC,facility,both,4,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,5,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLP",50863,CDM,636,RC,P9047,HCPCS,44206-251-10,NDC,facility,both,1,ML,JW,108,75.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GLYCERIN (ADULT) RECTAL SUPPOSITORY,50863,CDM,636,RC,J3490,HCPCS,0132-0079-12,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.3 MG/0.3 ML IM PNIJ,50863,CDM,636,RC,J0171,HCPCS,49502-500-01,NDC,facility,both,12,EA,,4309,3016.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,118,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEPERIDINE (PF) 50 MG/ML IV SOLN (PHS MERGE),50863,CDM,636,RC,J2175,HCPCS,0409-1178-03,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-25,NDC,facility,both,70,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,23,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 150 MG CAP,50863,CDM,250,RC,J3490,HCPCS,0904-5959-61,NDC,facility,both,3,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,50863,CDM,636,RC,J3301,HCPCS,16714-130-01,NDC,facility,both,1,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ABOBOTULINUMTOXINA 500 UNITS IM SOLR,50863,CDM,636,RC,J0586,HCPCS,15054-0500-1,NDC,facility,both,200,EA,,4861,3402.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,48,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,58,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,46,ML,JW,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DILTIAZEM 5 MG/ML IV,50863,CDM,250,RC,J3490,HCPCS,70860-301-41,NDC,facility,both,2,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7041-61,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  5 GRAM IV SOLR,50863,CDM,250,RC,J3370,HCPCS,67457-341-05,NDC,facility,both,4,EA,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-089-11,NDC,facility,both,1,EA,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,50863,CDM,636,RC,J1885,HCPCS,72266-119-01,NDC,facility,both,1,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
INDIGOTINDISULFONATE SODIUM 8 MG/ML INJ SOLN,50863,CDM,J9920,HCPCS,17478-508-01,NDC,,,facility,both,5,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.25 % (LEFT) (PHS CUSTOM PAIN BALL),50863,CDM,636,RC,J3490,HCPCS,0409-1159-02,NDC,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,7,ML,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,636,RC,J3490,HCPCS,0904-6794-89,NDC,facility,both,3,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM IN NACL (ISO-OS) 1000 MG/100 ML IV PGBK,50863,CDM,250,RC,J1953,HCPCS,44567-502-01,NDC,facility,both,300,ML,,196,137.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NYSTATIN  100000 UNIT/G TOP POWD,50863,CDM,J3490,HCPCS,68308-152-15,NDC,,,facility,both,1,GM,,108,75.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE 30 MG TAB,50863,CDM,250,RC,J3490,HCPCS,50268-642-11,NDC,facility,both,2,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MICAFUNGIN 100 MG IV SOLR,50863,CDM,250,RC,J2248,HCPCS,42023-230-01,NDC,facility,both,20,EA,,130,91,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL  32.4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6575-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,2,ML,,3469,2428.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,636,RC,J0330,HCPCS,0409-6629-02,NDC,facility,both,5,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML INJ SOLN,50863,CDM,636,RC,J2060,HCPCS,0641-6207-01,NDC,facility,both,2,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BLEOMYCIN 30 UNIT INJ SOLR,50863,CDM,250,RC,J9040,HCPCS,71288-107-20,NDC,facility,both,2,EA,,272,190.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IVABRADINE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,31722-053-60,NDC,facility,both,1,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-145-10,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLESTYRAMINE-SUCROSE 4 GRAM ORAL PACK,50863,CDM,250,RC,J3490,HCPCS,68382-528-60,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN 250 MG SOLUTION FOR INJECTION,50863,CDM,636,RC,J0290,HCPCS,65219-014-01,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLN,50863,CDM,636,RC,J3262,HCPCS,50242-137-01,NDC,facility,both,80,ML,JW,638,446.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
POTASSIUM ACETATE 2 MEQ/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,51754-2004-4,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEFIBROTIDE 80 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,68727-800-01,NDC,facility,both,1,ML,,1424,996.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NYSTATIN 100000 UNIT/ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,17856-1045-1,NDC,facility,both,1,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLP",50863,CDM,636,RC,P9047,HCPCS,0944-0493-04,NDC,facility,both,6,ML,,1501,1050.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TORSEMIDE   5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,31722-529-01,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,46,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,86,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,50863,CDM,250,RC,J9045,HCPCS,0703-4239-01,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,50863,CDM,636,RC,J9075,HCPCS,0781-3244-94,NDC,facility,both,200,EA,,1896,1327.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-495-27,NDC,facility,both,17,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,0409-3795-19,NDC,facility,both,1,ML,JW,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-50,NDC,facility,both,48,ML,JW,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,Q5121,HCPCS,55513-670-01,NDC,,,facility,both,7,EA,,420,294,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIOTROPIUM BROMIDE 2.5 MCG/ACTUATION INHL MIST,50863,CDM,J3490,HCPCS,0597-0100-51,NDC,,,facility,both,1,GM,,382,267.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRIL MALEATE 1 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,69238-2141-7,NDC,facility,both,1,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,J3490,HCPCS,60687-464-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  500 MCG/ML INJ SOLN,50863,CDM,J2354,HCPCS,25021-465-01,NDC,,,facility,both,20,ML,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-4713-75,NDC,facility,both,200,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,71399-1025-3,NDC,facility,both,20,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,J3490,HCPCS,0536-1327-06,NDC,,,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1230,HCPCS,67457-217-20,NDC,facility,both,1,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,J3490,HCPCS,63323-185-10,NDC,,,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,J1885,HCPCS,72611-722-25,NDC,,,facility,both,1,ML,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-229-02,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"RSV VAC, PREF A AND PREF B(PF) 120 MCG/0.5 ML IM SOLR",50863,CDM,90678,HCPCS,0069-0207-01,NDC,,,facility,both,1,EA,,1087,760.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATOVAQUONE 750 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,66689-062-01,NDC,facility,both,2,ML,,363,254.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNIT/G TOP PACK,50863,CDM,636,RC,J3490,HCPCS,0904-7402-67,NDC,facility,both,8,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIHEXYPHENIDYL 2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0591-5335-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-5755-23,NDC,facility,both,8,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MOXIFLOXACIN 400 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6406-06,NDC,facility,both,5,EA,,539,377.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7350-61,NDC,facility,both,2,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 10 MG/50 ML (0.2MG/ML) PCA IN NS (MERGE),50863,CDM,250,RC,J1171,HCPCS,70092-1286-74,NDC,facility,both,100,ML,,215,150.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLN (MERGE)",50863,CDM,250,RC,P9047,HCPCS,64208-2512-3,NDC,facility,both,2,ML,,274,191.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-0053-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,0409-4887-24,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  75 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7000-61,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7350-06,NDC,facility,both,8,EA,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL  6.25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-854-11,NDC,facility,both,4,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-319-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,636,RC,J3490,HCPCS,66553-002-01,NDC,facility,both,5,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7122-61,NDC,facility,both,1,EA,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,76045-009-10,NDC,facility,both,15,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,636,RC,J3490,HCPCS,76329-3390-1,NDC,facility,both,300,ML,,158,110.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0137,HCPCS,0781-3156-06,NDC,facility,both,58,ML,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 50 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,10135-779-01,NDC,facility,both,40,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM NEO IV SYRINGE (PHS FROM PREMIX),50863,CDM,250,RC,J1953,HCPCS,44567-501-01,NDC,facility,both,37,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,63323-104-25,NDC,facility,both,4,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-975-11,NDC,facility,both,2,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOCARNITINE 200 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0143-9852-01,NDC,facility,both,2,ML,,419,293.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69097-125-03,NDC,facility,both,4,EA,,158,110.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-1749-70,NDC,facility,both,2,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPARACAINE 0.5 % OPHT DROP,50863,CDM,636,RC,J3490,HCPCS,70069-601-01,NDC,facility,both,1,ML,,214,149.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,75,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VERAPAMIL 240 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,75834-159-01,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEBIVOLOL  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7189-04,NDC,facility,both,4,EA,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),50863,CDM,250,RC,J1630,HCPCS,67457-426-00,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 20MG/ML IV SYRINGE (PEDS/NEO),50863,CDM,250,RC,J0612,HCPCS,63323-311-10,NDC,facility,both,20,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FELODIPINE  5 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,68462-234-01,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESNA 100 MG/ML IV SOLN,50863,CDM,250,RC,J9209,HCPCS,10019-953-62,NDC,facility,both,6,ML,,171,119.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7361-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETODOLAC 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,62559-251-01,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VERAPAMIL 2.5 MG/ML IV SOLN,50863,CDM,J3490,HCPCS,0409-1144-02,NDC,,,facility,both,1,ML,,190,133,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,42806-150-33,NDC,facility,both,9,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRIMIDONE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-686-11,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 125 MG/5 ML (25MG/ML) ORAL SYRINGE (REPACK),50863,CDM,250,RC,J3373,HCPCS,67457-340-00,NDC,facility,both,100,EA,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE 44 MCG/ACTUATION INHL AERO,50863,CDM,636,RC,J3490,HCPCS,66993-078-96,NDC,facility,both,2,GM,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,63323-482-03,NDC,facility,both,1,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  1 MG/ML IV SOLN,50863,CDM,250,RC,J1800,HCPCS,63323-604-01,NDC,facility,both,2,ML,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-467-01,NDC,facility,both,1,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 500 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,16714-299-03,NDC,facility,both,19,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-613-04,NDC,facility,both,2,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FINASTERIDE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6830-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NORTRIPTYLINE 10 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0093-0810-01,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 30 MG/0.3 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,16714-006-01,NDC,facility,both,6,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,636,RC,J3490,HCPCS,55111-466-01,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-6966-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65162-896-09,NDC,facility,both,1,EA,,157,109.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"OCRELIZUMAB-HYALURONIDASE-OCSQ 920 MG-23,000 UNIT/23 ML SUBQ SOLN",50863,CDM,636,RC,J2351,HCPCS,50242-554-01,NDC,facility,both,920,ML,JZ,113939,79757.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ACIDOPHILUS-PECTIN W CITRUS 25 MILLION-100 CELL MG TAB,50863,CDM,250,RC,J3490,HCPCS,1785614241,NDC,facility,both,6,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4 % TOPICAL SOLN,50863,CDM,636,RC,J3490,HCPCS,76329-6300-5,NDC,facility,both,1,ML,,13337,9335.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  750 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7125-61,NDC,facility,both,4,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0591-5443-01,NDC,facility,both,40,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MINOXIDIL  2.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-204-11,NDC,facility,both,2,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0904-6923-61,NDC,facility,both,12,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZTROPINE 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-368-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG ORAL TAB,50863,CDM,J3490,HCPCS,51079-442-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,63323-185-08,NDC,facility,both,3,ML,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25 MG-100 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0378-0085-01,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG SUBQ SOLR,50863,CDM,636,RC,J2802,HCPCS,55513-222-01,NDC,facility,both,300,EA,,5268,3687.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"HEPARIN, PORCINE (PF)   10 UNIT/ML IV SYRG",50863,CDM,636,RC,J1642,HCPCS,6425322233,NDC,facility,both,3,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HUMAN PROTHROMBIN COMPLEX 500 UNIT IV SOLR,50863,CDM,250,RC,J7168,HCPCS,63833-396-01,NDC,facility,both,1000,UN,JZ,5819,4073.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
FLUCONAZOLE 100 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-6500-61,NDC,,,facility,both,1,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,57237-184-90,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,J2250,HCPCS,0409-2308-21,NDC,,,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCRALFATE 100 MG/ML ORAL SUSP,50863,CDM,J3490,HCPCS,0121-0974-10,NDC,,,facility,both,1,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAPAVERINE 30 MG/ML INJ SOLN,50863,CDM,J2440,HCPCS,0517-4002-01,NDC,,,facility,both,1,ML,,243,170.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML (PEDS CALCLUATOR 0.5),50863,CDM,250,RC,J1815,HCPCS,0024-5924-10,NDC,facility,both,24,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,63323-482-03,NDC,facility,both,300,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,620,ML,,890,623,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 50 MG/10 ML (5 MG/ML) IV SOLN,50863,CDM,636,RC,J2305,HCPCS,0517-4810-01,NDC,facility,both,9,ML,JW,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) NEB SOLUTION,50863,CDM,636,RC,J3490,HCPCS,0487-9501-01,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  40 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-609-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTOBARBITAL 75 MG/1.5 ML SYRINGE (REPACK),50863,CDM,636,RC,J3490,HCPCS,25021-676-20,NDC,facility,both,1,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,63323-010-02,NDC,facility,both,6,ML,,186,130.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-02,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,636,RC,J3490,HCPCS,0904-6794-30,NDC,facility,both,4,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-131-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR IN 0.9% NACL 100 UNIT/100 ML (1 UNIT/ML) INFUSION FOR OB,50863,CDM,250,RC,J1815,HCPCS,0338-0126-12,NDC,facility,both,1,ML,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRP (MERGE/REPACK),50863,CDM,636,RC,J3490,HCPCS,68094-764-59,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,10702-018-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPHENIDATE 18 MG ORAL TO24,50863,CDM,250,RC,J3490,HCPCS,0591-2715-01,NDC,facility,both,1,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL (5 MG/ML) IV SYRG (CONTAINS PRESERVATIVE),50863,CDM,250,RC,J3490,HCPCS,0409-2339-34,NDC,facility,both,2,ML,,107,74.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,636,RC,J1100,HCPCS,55150-304-01,NDC,facility,both,10,ML,JZ,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ONDANSETRON 4 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,57237-077-10,NDC,facility,both,8,EA,,642,449.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,76045-009-10,NDC,facility,both,10,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL  6.25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7306-61,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  75 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,69238-1312-9,NDC,facility,both,2,EA,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-145-11,NDC,facility,both,60,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CINACALCET 30 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16729-440-10,NDC,facility,both,1,EA,,150,105,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 25 MG CAP,50863,CDM,636,RC,J3490,HCPCS,0904-5306-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6950-61,NDC,facility,both,4,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM SR 180 MG 24 HR CAP,50863,CDM,636,RC,J3490,HCPCS,60687-206-11,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOZAPINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-922-01,NDC,facility,both,3,EA,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,23155-902-01,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NORTRIPTYLINE 25 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0093-0811-01,NDC,facility,both,4,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0781-3246-02,NDC,facility,both,6,ML,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,250,RC,J3360,HCPCS,43598-106-11,NDC,facility,both,14,ML,,1011,707.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTOXIFYLLINE 400 MG ORAL TBSR,50863,CDM,636,RC,J3490,HCPCS,0904-5448-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 500 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,50268-152-15,NDC,facility,both,6,EA,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,1657187290,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 80 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-8301-25,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,16714-661-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,307,ME,JZ,4166,2916.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
VORICONAZOLE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65862-891-30,NDC,facility,both,1,EA,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-447-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.3 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0228-2129-10,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN 0.9 % SODIUM CHL 1.5 GRAM/500 ML IV SOLN,50863,CDM,636,RC,J3370,HCPCS,71506-016-59,NDC,facility,both,3,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INDOMETHACIN 50 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,31722-543-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN NEO IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J3373,HCPCS,0338-3582-01,NDC,facility,both,30,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GAMMAGARD LIQUID 10 % IV SOLN,50863,CDM,636,RC,J1569,HCPCS,0944-2700-06,NDC,facility,both,40,ML,"JG,JZ,JA",7211,5047.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
NEOMYCIN 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0093-1177-01,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 300 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,69452-125-50,NDC,facility,both,1,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAVASTATIN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-5892-61,NDC,facility,both,4,EA,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,50863,CDM,250,RC,J9060,HCPCS,16729-288-11,NDC,facility,both,4,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 500 MG PE/10 ML INJ SOLN,50863,CDM,250,RC,Q2009,HCPCS,25021-798-10,NDC,facility,both,10,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV (BOLUS),50863,CDM,636,RC,J7120,HCPCS,0338-0117-02,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-633-11,NDC,facility,both,2,EA,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,250,RC,J2003,HCPCS,63323-495-27,NDC,facility,both,60,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE 150 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,68084-713-11,NDC,facility,both,3,EA,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,48,ML,JZ,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
NITROPRUSSIDE 25 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,70069-261-01,NDC,facility,both,1,ML,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXRAZOXANE 500 MG IV SOLR,50863,CDM,250,RC,J1190,HCPCS,55150-435-01,NDC,facility,both,4,EA,,3028,2119.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J1611,HCPCS,0597-0053-45,NDC,facility,both,1,EA,,742,519.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3370,HCPCS,0143-9162-01,NDC,facility,both,1,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,636,RC,J0330,HCPCS,0409-6629-02,NDC,facility,both,7,ML,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM SR 120 MG 24 HR CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7217-61,NDC,facility,both,3,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 50 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,10135-779-01,NDC,facility,both,99,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANASTROZOLE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-075-11,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 1 MG ORAL CAP,50863,CDM,250,RC,J7507,HCPCS,51079-818-01,NDC,facility,both,4,EA,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-433-11,NDC,facility,both,4,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-543-01,NDC,facility,both,3,EA,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-231-11,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VERAPAMIL 120 MG ORAL TBSR,50863,CDM,636,RC,J3490,HCPCS,75834-320-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID (PORK)  30 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,42192-329-01,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,17271-701-07,NDC,facility,both,2,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANTI-THYMOCYTE GLOB (RABBIT) 25 MG IV SOLR,50863,CDM,250,RC,J7511,HCPCS,58468-0080-1,NDC,facility,both,4,EA,JZ,8088,5661.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LEVOTHYROXINE  88 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0074-6594-90,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,636,RC,J3490,HCPCS,53746-542-05,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELATACEPT 250 MG IV SOLR,50863,CDM,636,RC,J0485,HCPCS,0003-0371-13,NDC,facility,both,475,EA,,4901,3430.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,50863,CDM,250,RC,J0640,HCPCS,0143-9554-01,NDC,facility,both,6,EA,,282,197.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLESTYRAMINE 4 G ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,0245-0036-89,NDC,facility,both,30,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES-DOCUSATE SODIUM 8.6 MG-50 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0536-1247-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,16,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-5771-23,NDC,facility,both,12,EA,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 400 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6667-61,NDC,facility,both,3,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR 5 % TOP OINT,50863,CDM,250,RC,J3490,HCPCS,68462-746-35,NDC,facility,both,1,GM,,1835,1284.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTOBARBITAL 75 MG/1.5 ML SYRINGE (REPACK),50863,CDM,636,RC,J3490,HCPCS,25021-676-20,NDC,facility,both,2,ML,,119,83.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,49502-393-80,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,55150-370-01,NDC,facility,both,19,ML,JW,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-4713-32,NDC,facility,both,300,ML,,129,90.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,9,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 800 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-5855-61,NDC,facility,both,14,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 100 MG/ML INJ SOLN,50863,CDM,636,RC,J2800,HCPCS,70069-101-01,NDC,facility,both,1,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7050,HCPCS,0264-7800-20,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,72611-722-25,NDC,facility,both,2,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ACETYLCYSTEINE 10 % (100 MG/ML) MISC SOLN,50863,CDM,250,RC,J3490,HCPCS,0517-7504-01,NDC,facility,both,1,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6188-01,NDC,facility,both,500,ML,,1174,821.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELOXICAM  7.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68382-050-01,NDC,facility,both,2,EA,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-0552-01,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"CALCIUM GLUC IN NACL, ISO-OSM 1 G/100 ML IV SOLN",50863,CDM,250,RC,J0612,HCPCS,44567-622-01,NDC,facility,both,400,ML,,298,208.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,J2003,HCPCS,63323-486-05,NDC,,,facility,both,760,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,J3490,HCPCS,0093-2279-73,NDC,,,facility,both,6,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,J2371,HCPCS,0641-6142-01,NDC,,,facility,both,25000,ML,,1330,931,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYBUTYNIN CHLORIDE  5 MG ORAL TO24,50863,CDM,250,RC,J3490,HCPCS,68084-480-11,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0548-5603-00,NDC,facility,both,5,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0137,HCPCS,0143-9386-01,NDC,facility,both,28,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BICALUTAMIDE 50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16729-023-10,NDC,facility,both,1,EA,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM PHOS IN 0.9 % NACL 15 MMOL/250 ML IVPB PREMIX,50863,CDM,250,RC,J3490,HCPCS,70004-841-40,NDC,facility,both,1,ML,,158,110.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN SODIUM  2 GRAM INJ SOLR,50863,CDM,250,RC,J0290,HCPCS,0781-3408-80,NDC,facility,both,4,EA,JZ,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SEVELAMER CARBONATE 800 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-720-11,NDC,facility,both,5,EA,,218,152.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0555-0873-02,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,250,RC,J7999,HCPCS,70092-1017-46,NDC,facility,both,3,ML,,119,83.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANTI-THYMOCYTE GLOB (RABBIT) 25 MG IV SOLR,50863,CDM,250,RC,J7511,HCPCS,58468-0080-1,NDC,facility,both,1,EA,,2022,1415.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOPERAMIDE 1 MG/7.5 ML ORAL LIQD,50863,CDM,250,RC,J3490,HCPCS,68094-029-59,NDC,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) IV (NEO) EMERGENCY SYRINGE,50863,CDM,250,RC,J3490,HCPCS,0409-5534-24,NDC,facility,both,1,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESALAMINE 400 MG ORAL CAPSULE-WITH DR TABLETS (CDTI),50863,CDM,636,RC,J3490,HCPCS,0093-5907-86,NDC,facility,both,3,EA,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  750 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65862-247-08,NDC,facility,both,3,EA,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV (BOLUS),50863,CDM,636,RC,J7120,HCPCS,0264-7750-10,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,25021-601-03,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,636,RC,J3370,HCPCS,0143-9162-01,NDC,facility,both,3,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0832-1211-89,NDC,facility,both,7,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,50863,CDM,250,RC,J9025,HCPCS,72485-201-01,NDC,facility,both,157,EA,,2228,1559.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL PACK,50863,CDM,250,RC,J3490,HCPCS,42806-270-98,NDC,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,63323-104-01,NDC,facility,both,13,ML,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-208-01,NDC,facility,both,4,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,50863,CDM,636,RC,J0696,HCPCS,60505-6148-0,NDC,facility,both,8,EA,JZ,450,315,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ATOVAQUONE 750 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0173-0547-00,NDC,facility,both,2,ML,,338,236.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,50863,CDM,636,RC,J2359,HCPCS,0781-3159-72,NDC,facility,both,10,EA,JW,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
SODIUM CHLORIDE 1000 MG MISC TBSO,50863,CDM,250,RC,J3490,HCPCS,904723961,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42806-359-25,NDC,facility,both,1,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,55111-263-79,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFUROXIME AXETIL 250 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16714-400-01,NDC,facility,both,2,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0781-6041-55,NDC,facility,both,19,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1560-19,NDC,facility,both,300,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORDIAZEPOXIDE 25 MG CAP,50863,CDM,636,RC,J3490,HCPCS,51079-141-01,NDC,facility,both,12,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOPIDOGREL 300 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,55111-671-06,NDC,facility,both,2,EA,,237,165.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,69238-1503-1,NDC,facility,both,1,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,250,RC,J3490,HCPCS,72603-387-01,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEMAZEPAM  7.5 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,68084-549-11,NDC,facility,both,1,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-453-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,250,RC,J0690,HCPCS,44567-707-25,NDC,facility,both,2,EA,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DILTIAZEM SR 90 MG 12 HR CAP,50863,CDM,636,RC,J3490,HCPCS,51079-925-01,NDC,facility,both,2,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE 0.5 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-9046-01,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 160 MG-800 MG TAB,50863,CDM,636,RC,J3490,HCPCS,65862-420-01,NDC,facility,both,2,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60505-0252-2,NDC,facility,both,2,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISATRACURIUM  2 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0074-4380-10,NDC,facility,both,2,ML,,323,226.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,7,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,250,RC,J0137,HCPCS,0781-3156-06,NDC,facility,both,2,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 100 MG/ML INJ SOLN,50863,CDM,636,RC,J2800,HCPCS,0517-1825-01,NDC,facility,both,1,ML,,121,84.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,10135-778-01,NDC,facility,both,20,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,250,RC,J7999,HCPCS,70092-1017-46,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0143-9509-01,NDC,facility,both,1,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADVATE: FACTOR VIII CONCENTRATE (MERGE RECORD),50863,CDM,250,RC,J7192,HCPCS,0944-3052-03,NDC,facility,both,1250,UN,,5233,3663.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 12.5 MG ORAL TAB,50863,CDM,636,RC,Q0169,HCPCS,53746-745-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 2-0.5 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,50268-144-11,NDC,facility,both,5,EA,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GALANTAMINE  4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,57237-049-60,NDC,facility,both,4,EA,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 100 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,50268-542-11,NDC,facility,both,3,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL  32.4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6575-61,NDC,facility,both,2,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 250 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,0832-7123-89,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 17 GRAM (100 %) ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,45802-868-00,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,68382-444-05,NDC,facility,both,2,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE  7.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-584-11,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEMAZEPAM 15 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,50268-779-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN  500 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,70010-491-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,5,ML,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6007-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TAB,50863,CDM,636,RC,J3490,HCPCS,10702-253-01,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25 MG-100 MG TAB,50863,CDM,250,RC,J3490,HCPCS,60687-661-11,NDC,facility,both,3,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,636,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,11,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,110,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DONEPEZIL 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,43547-276-03,NDC,facility,both,1,EA,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOZAPINE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0378-0860-01,NDC,facility,both,2,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML INJ SOLN,50863,CDM,636,RC,J0171,HCPCS,76329-9060-0,NDC,facility,both,30,ML,,797,557.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 0.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-861-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACUBITRIL-VALSARTAN 24-26 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,70710-1272-6,NDC,facility,both,1,EA,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,636,RC,J3010,HCPCS,0409-9094-18,NDC,facility,both,3,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTOBARBITAL 75 MG/1.5 ML SYRINGE (REPACK),50863,CDM,636,RC,J3490,HCPCS,25021-676-20,NDC,facility,both,2,ML,,139,97.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,66553-002-01,NDC,facility,both,3,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4% TOP PATCH,50863,CDM,250,RC,J3490,HCPCS,46581-830-06,NDC,facility,both,8,EA,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 250 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7156-61,NDC,facility,both,42,EA,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE HCL IN 0.9% NACL 1 MG/10 ML (100 MCG/ML) IV SYRG,50863,CDM,250,RC,J3490,HCPCS,73177-108-03,NDC,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 400 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,65162-464-10,NDC,facility,both,10,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-3178-16,NDC,facility,both,170,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN 0.9 % SODIUM CHL 1.5 GRAM/500 ML IV SOLN,50863,CDM,250,RC,J3370,HCPCS,70004-924-44,NDC,facility,both,3,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN  500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-155-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 50 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,59651-489-01,NDC,facility,both,60,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 800 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,17856-921-01,NDC,facility,both,2,EA,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,52,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,53,ML,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,70,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PYRIDOSTIGMINE BROMIDE 180 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,47781-335-30,NDC,facility,both,1,EA,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0003-0894-31,NDC,facility,both,2,EA,,119,83.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN DEXTROSE (ISO-OS) 2 GRAM/100 ML IV PGBK,50863,CDM,636,RC,J0690,HCPCS,0338-3508-41,NDC,facility,both,4,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7007-61,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,67457-423-00,NDC,facility,both,8,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ERTAPENEM 1 GRAM INJ SOLR,50863,CDM,250,RC,J1335,HCPCS,0143-9398-01,NDC,facility,both,1,EA,JW,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CLOPIDOGREL  75 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-052-10,NDC,facility,both,2,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,0641-6145-01,NDC,facility,both,7,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25 MG-250 MG TAB,50863,CDM,250,RC,J3490,HCPCS,68084-094-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WHITE PETROLATUM-MINERAL OIL 80 %-20 % EYE OINTMENT,50863,CDM,636,RC,J3490,HCPCS,1011902239,NDC,facility,both,1,GM,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,72205-014-90,NDC,facility,both,1,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUANFACINE 2 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,62332-746-31,NDC,facility,both,2,EA,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPAGLIFLOZIN PROPANEDIOL  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,66993-456-30,NDC,facility,both,1,EA,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TERAZOSIN  5 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0781-2053-01,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25 MG-100 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0378-0085-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-18,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE IN D7.5W (PF) 50 MG/ML (5 %) IT SOLN,50863,CDM,250,RC,J2003,HCPCS,0409-4712-11,NDC,facility,both,100,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCERIN (ADULT) RECTAL SUPPOSITORY,50863,CDM,636,RC,J3490,HCPCS,132007924,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 8-2 MG SL SUBL,50863,CDM,J3490,HCPCS,50268-145-11,NDC,,,facility,both,3,EA,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,66794-229-02,NDC,facility,both,2,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0641-0400-37,NDC,facility,both,5,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LET TOPICAL GEL 3 ML,50863,CDM,636,RC,J3490,HCPCS,70092-1611-44,NDC,facility,both,2,ML,,108,75.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 10 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,67457-420-00,NDC,facility,both,20,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MITOXANTRONE 2 MG/ML IV CONC,50863,CDM,250,RC,J9293,HCPCS,61703-343-65,NDC,facility,both,3,ML,JW,183,128.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,0121-4675-05,NDC,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIMODIPINE 30 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,23155-512-11,NDC,facility,both,1,EA,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 1000 MG MISC TBSO,50863,CDM,250,RC,J3490,HCPCS,0223-1760-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NYSTATIN 100000 UNIT/ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0904-7276-41,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE MONONITRATE  20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0228-2620-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,106,ML,,151,105.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLN,50863,CDM,636,RC,J3262,HCPCS,50242-135-01,NDC,facility,both,320,ML,,5865,4105.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6007-60,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN  10 GRAM INJ SOLR,50863,CDM,250,RC,J0690,HCPCS,0143-9983-91,NDC,facility,both,8,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATENOLOL  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-759-01,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,63323-162-00,NDC,facility,both,2,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTOBARBITAL 75 MG/1.5 ML SYRINGE (REPACK),50863,CDM,636,RC,J3490,HCPCS,25021-676-20,NDC,facility,both,2,ML,,127,88.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 50 % (4 MEQ/ML) INJ SOLN,50863,CDM,636,RC,J3475,HCPCS,63323-064-01,NDC,facility,both,10,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,636,RC,J2405,HCPCS,0641-6078-25,NDC,facility,both,8,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
METHYLPHENIDATE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-805-11,NDC,facility,both,8,EA,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,50268-540-11,NDC,facility,both,2,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES  8.6 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,71399-1017-3,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM OXIDE 400 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,6498033990,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,121119030,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR NEO/PEDS INFUSION (CDS FROM PREMIX),50863,CDM,250,RC,J0133,HCPCS,63323-325-10,NDC,facility,both,14,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 2.5 %-1/2 NORMAL SALINE IV,50863,CDM,250,RC,J3490,HCPCS,0338-0073-04,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2308-22,NDC,facility,both,50,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J3430,HCPCS,0409-9158-31,NDC,facility,both,7,ML,JW,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PREGABALIN  75 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-495-11,NDC,facility,both,3,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMTERENE-HYDROCHLOROTHIAZIDE 37.5 MG-25 MG TAB,50863,CDM,636,RC,J3490,HCPCS,68084-750-95,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,50863,CDM,636,RC,J1756,HCPCS,0517-2325-01,NDC,facility,both,10,ML,JW,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,636,RC,J1953,HCPCS,63323-400-01,NDC,facility,both,35,ML,JW,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CHLORTHALIDONE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65162-247-09,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOTRIMAZOLE 1 % TOP CREA,50863,CDM,636,RC,J3490,HCPCS,0536-1265-95,NDC,facility,both,1,GM,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-02,NDC,facility,both,3,ML,,146,102.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,0409-4887-10,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 30 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-120-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,0409-1283-17,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) MISC SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-694-04,NDC,facility,both,1,ML,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,2,EA,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ALTEPLASE 1 MG/ML (1ML) SYRINGE (REPACK),50863,CDM,250,RC,J2997,HCPCS,50242-044-13,NDC,facility,both,4,EA,,1083,758.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,636,RC,J1596,HCPCS,70069-013-25,NDC,facility,both,6,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,250,RC,J1596,HCPCS,0143-9679-01,NDC,facility,both,6,ML,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 0.125 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,13668-091-90,NDC,facility,both,6,EA,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,158,ML,,143,100.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6953-61,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J0461,HCPCS,0517-1004-01,NDC,facility,both,50,ML,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5%-LACTATED RINGERS IV,50863,CDM,636,RC,J7120,HCPCS,0264-7751-00,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0955-1004-01,NDC,facility,both,4,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16714-950-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,31722-711-30,NDC,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK,50863,CDM,636,RC,J3490,HCPCS,12870-0001-1,NDC,facility,both,4,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SYRG,50863,CDM,636,RC,J3490,HCPCS,8290306546,NDC,facility,both,5,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESALAMINE 400 MG ORAL CAPSULE-WITH DR TABLETS (CDTI),50863,CDM,636,RC,J3490,HCPCS,60687-556-33,NDC,facility,both,2,EA,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,72162-1329-8,NDC,facility,both,1,ML,,183,128.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,16714-294-01,NDC,facility,both,5,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNIT/G TOP OINT (MERGE),50863,CDM,250,RC,J3490,HCPCS,49348-154-72,NDC,facility,both,1,GM,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-492-09,NDC,facility,both,1,ML,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE 110 MCG/ACTUATION INHL AERO,50863,CDM,250,RC,J3490,HCPCS,66993-079-96,NDC,facility,both,1,GM,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-0430-06,NDC,facility,both,16,EA,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATOMOXETINE  40 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,31722-717-30,NDC,facility,both,2,EA,,152,106.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,50863,CDM,250,RC,J9171,HCPCS,67457-533-16,NDC,facility,both,80,ML,,759,531.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,636,RC,J0133,HCPCS,70436-030-82,NDC,facility,both,250,ML,,196,137.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,10135-778-01,NDC,facility,both,20,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,72603-179-01,NDC,facility,both,9,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,17271-701-05,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MANNITOL 20% IV SOLP,50863,CDM,250,RC,J2150,HCPCS,0990-7715-13,NDC,facility,both,2,ML,,166,116.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FERROUS GLUCONATE 324 MG (38 MG IRON) TAB,50863,CDM,250,RC,J3490,HCPCS,2055501900,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLESTYRAMINE-SUCROSE 4 GRAM ORAL PACK,50863,CDM,636,RC,J3490,HCPCS,68382-528-60,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  75 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,68084-709-11,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,50863,CDM,250,RC,J8540,HCPCS,0054-8175-25,NDC,facility,both,32,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,70095-026-01,NDC,facility,both,3,ML,JW,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
AMIODARONE 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-051-10,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-25,NDC,facility,both,80,ML,"JG,JZ,JA",11316,7921.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
CYCLOPHOSPHAMIDE 500 MG IV SOLR,50863,CDM,250,RC,J9075,HCPCS,0781-3233-94,NDC,facility,both,300,EA,,3647,2552.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCRALFATE 100 MG/ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0121-0974-10,NDC,facility,both,1,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2599,HCPCS,65219-039-00,NDC,facility,both,3,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,492,ME,,6677,4673.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-722-11,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INDIGOTINDISULFONATE SODIUM 8 MG/ML INJ SOLN,50863,CDM,636,RC,J9220,HCPCS,17478-508-01,NDC,facility,both,35,ML,JW,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ANASTROZOLE 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16729-035-10,NDC,facility,both,1,EA,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  37.5 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,59762-0180-3,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENAZEPRIL 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,43547-336-10,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6427-61,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM SR 90 MG 12 HR CAP,50863,CDM,636,RC,J3490,HCPCS,51079-925-01,NDC,facility,both,1,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0990-7983-61,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-985-01,NDC,facility,both,5,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 160 MG-800 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0904-2725-61,NDC,facility,both,20,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1170,HCPCS,76045-009-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,250,RC,J3490,HCPCS,63323-485-27,NDC,facility,both,75,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,29300-135-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 400 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-446-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,2055503600,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,68180-150-01,NDC,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ELTROMBOPAG 25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0078-0685-15,NDC,facility,both,3,EA,,1301,910.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID (PORK)  30 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,42192-329-01,NDC,facility,both,3,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,636,RC,J3490,HCPCS,0143-9575-01,NDC,facility,both,520,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,300,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
NEOMYCIN-BACITRACN ZN-POLYMYXIN 3.5 MG-400 U*,50863,CDM,250,RC,J3490,HCPCS,45802-061-70,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-398-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,68180-150-01,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML IM SOLN,50863,CDM,636,RC,90375,HCPCS,13533-318-05,NDC,facility,both,11,ML,,9662,6763.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DONEPEZIL  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-292-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 200 MG INJ SOLR,50863,CDM,250,RC,J0640,HCPCS,0143-9553-01,NDC,facility,both,2,EA,JW,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
SERTRALINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-613-04,NDC,facility,both,3,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 10 MG TAB,50863,CDM,636,RC,Q0177,HCPCS,60687-664-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 80 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,43547-403-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CANDESARTAN  8 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,33342-115-07,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 10 MEQ/100 ML IV PGBK,50863,CDM,636,RC,J3480,HCPCS,0990-7074-26,NDC,facility,both,15,ML,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,55150-307-01,NDC,facility,both,93,ML,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 25 MG TAB,50863,CDM,250,RC,J3490,HCPCS,51079-255-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,J3490,HCPCS,0143-9889-15,NDC,,,facility,both,28,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25 MG-100 MG TAB,50863,CDM,250,RC,J3490,HCPCS,50228-458-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUM U-500 CONC 500 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1815,HCPCS,0002-8501-01,NDC,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-588-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMINOPHYLLINE 500 MG/20 ML IV SOLN,50863,CDM,250,RC,J0280,HCPCS,0409-5922-16,NDC,facility,both,2,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 250 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,50268-259-11,NDC,facility,both,12,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MINERAL OIL,50863,CDM,636,RC,J3490,HCPCS,6332325410,NDC,facility,both,1,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 0.1 % TOP CREAM,50863,CDM,250,RC,J3490,HCPCS,0168-0004-15,NDC,facility,both,1,GM,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANTI-INHIBITOR COAGULANT CMPLX (PHS MERGE),50863,CDM,250,RC,J7198,HCPCS,64193-424-02,NDC,facility,both,300,UN,JW,777,543.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-453-11,NDC,facility,both,1,EA,PLAD,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
METHYLPHENIDATE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-805-11,NDC,facility,both,4,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,50863,CDM,636,RC,J2359,HCPCS,0002-7597-01,NDC,facility,both,20,EA,,256,179.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DONANEMAB-AZBT 17.5 MG/ML IV SOLN,50863,CDM,636,RC,J0175,HCPCS,0002-9401-01,NDC,facility,both,175,ML,"JZ,Q0",1601,1120.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier Q0: Investigational clinical service provided in a clinical research study that is in an approved clinical research study
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,J2919,HCPCS,0009-0039-30,NDC,,,facility,both,16,EA,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,J2919,HCPCS,0009-0039-05,NDC,,,facility,both,8,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J3490,HCPCS,0409-0007-01,NDC,,,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG ORAL TAB,50863,CDM,J3490,HCPCS,29300-135-01,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,J2795,HCPCS,43066-023-01,NDC,,,facility,both,150,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,J2704,HCPCS,0069-0209-01,NDC,,,facility,both,34,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT 100 MCG/0.5 ML INJ SYRG,50863,CDM,J0881,HCPCS,55513-025-01,NDC,,,facility,both,100,ML,,2137,1495.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,250,RC,J0132,HCPCS,70594-111-01,NDC,facility,both,17,ML,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML IV,50863,CDM,250,RC,J3490,HCPCS,25021-319-10,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,50863,CDM,J3301,HCPCS,16714-130-01,NDC,,,facility,both,6,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CITRATE  5 MEQ ORAL TBER,50863,CDM,250,RC,J3490,HCPCS,31722-129-01,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYTOCIN 10 UNIT/ML INJ SOLN,50863,CDM,250,RC,J2590,HCPCS,63323-012-03,NDC,facility,both,3,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,57237-077-10,NDC,facility,both,3,EA,,284,198.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE  5 MG/ML INJ SOLN,50863,CDM,250,RC,J2765,HCPCS,0409-3414-21,NDC,facility,both,4,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),50863,CDM,636,RC,J3490,HCPCS,8290306545,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,68094-231-59,NDC,facility,both,1,ML,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT  40 MCG/0.4 ML INJ SYRG,50863,CDM,636,RC,J0881,HCPCS,55513-021-01,NDC,facility,both,40,ML,"JZ,EC,PLAD",1096,767.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier EC: Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy | Modifier PLAD: Modifier description not available
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0143-9889-01,NDC,facility,both,9,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MUPIROCIN 2 % TOP OINT,50863,CDM,636,RC,J3490,HCPCS,68462-180-22,NDC,facility,both,1,GM,,210,147,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,57237-077-10,NDC,facility,both,6,EA,,482,337.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25 MG-100 MG TAB,50863,CDM,250,RC,J3490,HCPCS,59651-457-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6953-61,NDC,facility,both,3,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOLIC ACID  1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7224-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALUM-MAG HYDROXIDE-SIMETH 200 MG-200 MG-20 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,17856-0630-1,NDC,facility,both,2,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"OCTREOTIDE,MICROSPHERES 20 MG IM SERR",50863,CDM,636,RC,J2353,HCPCS,0078-0818-81,NDC,facility,both,40,EA,JZ,25482,17837.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
NATALIZUMAB 300 MG/15 ML IV SOLN,50863,CDM,636,RC,J2323,HCPCS,64406-008-01,NDC,facility,both,300,ML,,16000,11200,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,63323-280-03,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7193-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUANFACINE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0591-0444-01,NDC,facility,both,3,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOSTIGMINE 1MG/ML (UD) OR SYRINGE,50863,CDM,250,RC,J2710,HCPCS,63323-383-10,NDC,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUPHENAZINE 1 MG TAB,50863,CDM,250,RC,J3490,HCPCS,70954-273-10,NDC,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,250,RC,J2405,HCPCS,0641-6078-01,NDC,facility,both,16,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN  7.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51672-4034-1,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-381-11,NDC,facility,both,1,EA,,198,138.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-0832-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATENOLOL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,52427-431-90,NDC,facility,both,1,EA,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,250,RC,J7060,HCPCS,0338-0017-11,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,68180-723-04,NDC,facility,both,2,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLU VACCINE TS 2024-25 6MOS UP (PF) 45 MCG (15 MCG X 3)/0.5 ML IM SYRG,50863,CDM,90656,HCPCS,58160-884-41,NDC,,,facility,both,1,ML,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADVATE: FACTOR VIII CONCENTRATE (MERGE RECORD),50863,CDM,J7192,HCPCS,0944-3047-10,NDC,,,facility,both,4000,UN,,16744,11720.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,J2704,HCPCS,16714-690-01,NDC,,,facility,both,20,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG ORAL CAP,50863,CDM,J3490,HCPCS,60687-580-11,NDC,,,facility,both,8,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,250,RC,J3101,HCPCS,50242-037-06,NDC,facility,both,40,EA,JW,7966,5576.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
FLUTICASONE-SALMETEROL 100 MCG-50 MCG/DOSE DISK DEVICE FOR INHALATION,50863,CDM,250,RC,J3490,HCPCS,0054-0326-56,NDC,facility,both,1,EA,,1067,746.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,67,EA,,9246,6472.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-179-11,NDC,facility,both,2,EA,,221,154.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-285-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 50 MG/ML IV SOLN,50863,CDM,250,RC,J0282,HCPCS,63323-616-03,NDC,facility,both,10,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0780,HCPCS,23155-294-31,NDC,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,0641-6206-01,NDC,facility,both,4,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,0641-6145-01,NDC,facility,both,2,ML,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,43547-281-10,NDC,facility,both,2,EA,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMANTADINE 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,62332-246-31,NDC,facility,both,2,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TICAGRELOR 60 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0186-0776-60,NDC,facility,both,1,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,636,RC,J3490,HCPCS,60687-653-11,NDC,facility,both,4,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEPERIDINE (PF) 25 MG/ML IV SOLN (PHS MERGE),50863,CDM,250,RC,J2175,HCPCS,0409-1176-03,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE SODIUM 25 MG/ML INJ SOLN,50863,CDM,636,RC,J9260,HCPCS,16729-277-30,NDC,facility,both,2,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 600 MG ORAL TP12,50863,CDM,636,RC,J3490,HCPCS,0904-6718-39,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN ENEMA 500MG IN 100ML NS,50863,CDM,250,RC,J3490,HCPCS,67457-339-00,NDC,facility,both,1,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BECLOMETHASONE DIPROPIONATE 40 MCG/ACTUATION INHL HFAB,50863,CDM,636,RC,J3490,HCPCS,59310-302-40,NDC,facility,both,1,GM,,776,543.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLNALTREXONE 12 MG/0.6 ML SUBQ SYRG,50863,CDM,250,RC,J2212,HCPCS,65649-551-07,NDC,facility,both,120,ML,,693,485.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,7,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 40 MG-200 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,65862-496-47,NDC,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLESTYRAMINE-SUCROSE 4 GRAM ORAL PACK,50863,CDM,250,RC,J3490,HCPCS,49884-465-64,NDC,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,250,RC,J2270,HCPCS,0409-1890-13,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50228-420-01,NDC,facility,both,2,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  5 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-122-11,NDC,facility,both,126,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 2 MG INJ SOLR,50863,CDM,250,RC,J2997,HCPCS,50242-041-64,NDC,facility,both,6,EA,,2400,1680,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE 220 MCG/ACTUATION INHL AERO,50863,CDM,250,RC,J3490,HCPCS,66993-080-96,NDC,facility,both,1,GM,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML (1ML) INJ SOLN,50863,CDM,636,RC,J0169,HCPCS,63323-696-02,NDC,facility,both,4,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE (PEDIATRIC 3 MONTH) 30 MG IM SYKT,50863,CDM,636,RC,J1950,HCPCS,0074-9694-03,NDC,facility,both,8,EA,,34166,23916.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  120 MG RECT SUPP,50863,CDM,250,RC,J3490,HCPCS,51672-2115-0,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4 % TOPICAL SOLN,50863,CDM,636,RC,J3490,HCPCS,76329-6300-5,NDC,facility,both,2,ML,,308,215.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYMETAZOLINE 0.05 % NASAL MERGE,50863,CDM,636,RC,J3490,HCPCS,5002443100,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,0409-6102-20,NDC,facility,both,100,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0338-1055-48,NDC,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML IV,50863,CDM,636,RC,J3490,HCPCS,55150-425-01,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 2 % TD OINT,50863,CDM,636,RC,J3490,HCPCS,0281-0326-08,NDC,facility,both,2,GM,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),50863,CDM,250,RC,J3490,HCPCS,0409-4888-02,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE DINITRATE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0781-1556-01,NDC,facility,both,2,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 25 MG CAP,50863,CDM,636,RC,J3490,HCPCS,0904-5306-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,63323-482-03,NDC,facility,both,150,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MERCAPTOPURINE 25 MG SPLIT TABLET,50863,CDM,250,RC,J3490,HCPCS,99999-501-19,NDC,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 HALF TABLET
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,25021-608-51,NDC,facility,both,100,ML,,172,120.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,70095-026-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"CALCIUM GLUC IN NACL, ISO-OSM 1 G/100 ML IV SOLN",50863,CDM,636,RC,J0613,HCPCS,44567-622-01,NDC,facility,both,200,ML,JZ,149,104.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,636,RC,J0690,HCPCS,44567-707-25,NDC,facility,both,8,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-04,NDC,facility,both,14,ML,,233,163.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7007-61,NDC,facility,both,12,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MICONAZOLE NITRATE 2 % TOP POWD,50863,CDM,250,RC,J3490,HCPCS,0316-0225-15,NDC,facility,both,1,GM,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THROMBIN (RECOMBINANT) 5000 UNIT TOP SOLR,50863,CDM,250,RC,J3490,HCPCS,0338-0324-01,NDC,facility,both,1,EA,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % MUCOSAL GEL,50863,CDM,250,RC,J3490,HCPCS,17478-711-30,NDC,facility,both,1,ML,,463,324.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-1283-03,NDC,facility,both,7,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,63323-485-03,NDC,,,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,J0665,HCPCS,0409-1160-01,NDC,,,facility,both,40,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DONEPEZIL  5 MG ORAL TAB,50863,CDM,J3490,HCPCS,60687-292-11,NDC,,,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASCORBIC ACID  500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,5789684101,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 20 MG ORAL TAB,50863,CDM,J3490,HCPCS,0054-8297-25,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LONCASTUXIMAB TESIRINE-LPYL 10 MG IV SOLR,50863,CDM,J9359,HCPCS,79952-110-01,NDC,,,facility,both,180,EA,,87367,61156.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,J3490,HCPCS,68094-600-59,NDC,,,facility,both,4,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,J2250,HCPCS,0409-2308-21,NDC,,,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,0409-4713-02,NDC,,,facility,both,21,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,J2560,HCPCS,0641-0477-21,NDC,,,facility,both,3,ML,,469,328.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,J3490,HCPCS,0904-7509-30,NDC,,,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,J3490,HCPCS,42023-186-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,J7040,HCPCS,0338-0049-04,NDC,,,facility,both,4,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CITRATE  5 MEQ ORAL TBER,50863,CDM,250,RC,J3490,HCPCS,42543-406-01,NDC,facility,both,4,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG RECT SUPP,50863,CDM,636,RC,J3490,HCPCS,45802-759-00,NDC,facility,both,2,EA,,174,121.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,63323-161-00,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,107,74.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,636,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,2,EA,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,76045-009-10,NDC,facility,both,16,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,72611-722-25,NDC,facility,both,1,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2305-04,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG SUBQ SOLR,50863,CDM,250,RC,J2802,HCPCS,55513-222-01,NDC,facility,both,500,EA,,8780,6146,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALTREXONE 50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0406-1170-03,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESTRADIOL CYPIONATE 5 MG/ML IM OIL,50863,CDM,250,RC,J1000,HCPCS,0009-0271-01,NDC,facility,both,5,ML,,878,614.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROTHIAZIDE SODIUM 500 MG IV SOLR,50863,CDM,250,RC,J1205,HCPCS,25021-305-20,NDC,facility,both,1,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,636,RC,P9045,HCPCS,68516-5218-0,NDC,facility,both,4,ML,JZ,803,562.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,8,EA,,265,185.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG/6 ML (6 ML) ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,17856-600-02,NDC,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLP (FOR DIALYSIS)",50863,CDM,250,RC,P9047,HCPCS,0944-0493-02,NDC,facility,both,2,ML,JZ,826,578.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LISINOPRIL 20 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-6799-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORDIAZEPOXIDE 25 MG CAP,50863,CDM,J3490,HCPCS,60687-807-11,NDC,,,facility,both,4,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE 0.05 % OPHT DPET,50863,CDM,250,RC,J3490,HCPCS,68180-214-60,NDC,facility,both,1,EA,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOPIDOGREL 300 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6467-10,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  25 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-7047-61,NDC,,,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE IN SALINE (ISO-OSM) 400 MG/200 ML IV PIGGY BACK,50863,CDM,250,RC,J1450,HCPCS,0409-4321-01,NDC,facility,both,2,ML,JZ,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-495-27,NDC,,,facility,both,240,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-426-02,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IV PGBK,50863,CDM,250,RC,J3475,HCPCS,0264-4206-54,NDC,facility,both,8,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLECAINIDE 20MG/ML SUSPENSION (REPACK),50863,CDM,250,RC,J3490,HCPCS,0054-0010-25,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,2,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,50863,CDM,J9075,HCPCS,65219-131-20,NDC,,,facility,both,200,EA,,1275,892.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,50863,CDM,J8540,HCPCS,0054-8175-25,NDC,,,facility,both,160,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-134-11,NDC,facility,both,5,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,43547-688-10,NDC,facility,both,3,EA,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCUSATE SODIUM 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,10135-111-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7122-61,NDC,facility,both,18,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,55150-307-01,NDC,facility,both,11,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-161-11,NDC,facility,both,2,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORDIAZEPOXIDE 25 MG CAP,50863,CDM,636,RC,J3490,HCPCS,60687-807-11,NDC,facility,both,12,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML IV,50863,CDM,250,RC,J3490,HCPCS,70860-301-43,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEMAZEPAM  7.5 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,63739-003-33,NDC,facility,both,4,EA,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEO TPN SODIUM ACETATE 2 MEQ/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-7299-83,NDC,facility,both,2,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MANNITOL 25 % IV SOLN,50863,CDM,250,RC,J2151,HCPCS,0409-4031-16,NDC,facility,both,100,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,40,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1170,HCPCS,76045-009-10,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,50863,CDM,636,RC,J0696,HCPCS,64679-983-01,NDC,facility,both,4,EA,,218,152.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0904-6923-61,NDC,facility,both,8,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MANNITOL 25 % IV SOLN,50863,CDM,250,RC,J2150,HCPCS,0409-4031-16,NDC,facility,both,2,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM BICARB-CITRIC ACID 20 MEQ ORAL TBEF,50863,CDM,636,RC,J3490,HCPCS,51801-011-01,NDC,facility,both,3,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-693-01,NDC,facility,both,2,EA,,141,98.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,0409-3178-16,NDC,,,facility,both,120,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,J0330,HCPCS,31722-981-10,NDC,,,facility,both,4,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE  4 MG ORAL TAB,50863,CDM,636,RC,J7509,HCPCS,68084-149-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,43598-931-11,NDC,facility,both,1,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,636,RC,J3490,HCPCS,0143-9575-01,NDC,facility,both,120,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"POTASSIUM PHOSPHATE, MONOBASIC 500 MG ORAL TBSO",50863,CDM,636,RC,J3490,HCPCS,0486-1111-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 1 MG ORAL CAP,50863,CDM,250,RC,J7507,HCPCS,0904-7097-61,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-1721-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE INFUSION 2MG/ML 100ML (FOR ANESTHESIA USE ONLY),50863,CDM,250,RC,J3490,HCPCS,0409-2051-05,NDC,facility,both,1,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,250,RC,J7060,HCPCS,0338-0017-31,NDC,facility,both,2,ML,JZ,292,204.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"CIPROFLOXACIN-DEXAMETHASONE 0.3 %-0.1 % EAR DROPS, SUSP",50863,CDM,250,RC,J3490,HCPCS,0781-6186-67,NDC,facility,both,1,ML,,827,578.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,16714-293-03,NDC,facility,both,9,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,636,RC,P9045,HCPCS,68516-5219-0,NDC,facility,both,28,ML,,7117,4981.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-245-11,NDC,facility,both,1,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE IN D5W 1 GRAM/100 ML IV PGBK,50863,CDM,250,RC,J3475,HCPCS,0338-1709-40,NDC,facility,both,2,ML,JZ,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
TIZANIDINE 4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-645-11,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NYSTATIN 100000 UNIT/ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,60687-800-40,NDC,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISATRACURIUM  2 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0074-4380-10,NDC,facility,both,2,ML,,218,152.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,0338-0072-25,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GOLIMUMAB  12.5 MG/ML IV SOLN,50863,CDM,636,RC,J1602,HCPCS,57894-350-01,NDC,facility,both,113,ML,,12471,8729.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAUNORUBICIN 5 MG/ML IV INJ,50863,CDM,250,RC,J9150,HCPCS,42658-021-01,NDC,facility,both,1,ML,JW,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
VENLAFAXINE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0093-9149-01,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHOTERICIN B LIPOSOME 50 MG IV SUSR,50863,CDM,250,RC,J0289,HCPCS,55150-365-01,NDC,facility,both,45,EA,,8117,5681.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,50863,CDM,250,RC,J0561,HCPCS,60793-701-02,NDC,facility,both,12,ML,JZ,1080,756,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 2.5 GRAM/25 ML (10 %) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-15,NDC,facility,both,10,ML,"JZ,JA",1815,1270.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,68982-623-02,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NAFCILLIN  1 GRAM INJ SOLR,50863,CDM,250,RC,J3490,HCPCS,44567-221-10,NDC,facility,both,2,EA,,130,91,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 10 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,67457-420-00,NDC,facility,both,11,ML,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,50863,CDM,250,RC,J9025,HCPCS,72485-201-01,NDC,facility,both,141,EA,,1993,1395.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-098-10,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,0904-6794-80,NDC,facility,both,3,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML IV SOLN (MERGE),50863,CDM,250,RC,J3490,HCPCS,16714-037-01,NDC,facility,both,2,ML,,303,212.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALAMINE-ZINC OXIDE 8 %-8 % TOPICAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0904-2533-21,NDC,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,250,RC,J2795,HCPCS,70069-064-25,NDC,facility,both,50,ML,JW,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-24,NDC,facility,both,120,ML,,16973,11881.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN 1 GRAM SOLUTION FOR INJECTION,50863,CDM,636,RC,J0290,HCPCS,0781-3404-85,NDC,facility,both,4,EA,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-580-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM IN D5W 125 MG/125 ML (1 MG/ML) IV SOLN (PREMIX),50863,CDM,250,RC,J3490,HCPCS,63037-119-05,NDC,facility,both,1,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,0409-6625-14,NDC,facility,both,4,ML,,231,161.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,38,EA,,5244,3670.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-1749-70,NDC,facility,both,4,ML,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE SODIUM 25 MG/ML INJ SOLN,50863,CDM,636,RC,J9260,HCPCS,61703-350-37,NDC,facility,both,2,ML,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE 0.05 % OPHT DPET,50863,CDM,250,RC,J3490,HCPCS,68180-214-60,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM ACETATE 667 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7119-06,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,636,RC,J3490,HCPCS,73702-301-15,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 17 GRAM (100 %) ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,1152372688,NDC,facility,both,3,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-467-01,NDC,facility,both,1,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  20 MEQ ORAL PACK,50863,CDM,250,RC,J3490,HCPCS,72888-024-06,NDC,facility,both,1,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNIT/G TOP OINT (MERGE),50863,CDM,250,RC,J3490,HCPCS,0713-0280-31,NDC,facility,both,1,GM,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML (PEDS CALCLUATOR 0.5),50863,CDM,250,RC,J1815,HCPCS,0024-5924-10,NDC,facility,both,8,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"OMEGA-3 FATTY ACIDS-FISH OIL 360-1,200 MG ORAL CAP (ERX MERGE)",50863,CDM,250,RC,J3490,HCPCS,17856-0055-1,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETIRIZINE 5 MG/5 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,68094-004-59,NDC,facility,both,4,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 10 MG/5 ML SYRUP,50863,CDM,636,RC,Q0177,HCPCS,54838-502-80,NDC,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 30 MG/0.3 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,16714-006-01,NDC,facility,both,3,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,72266-118-01,NDC,facility,both,2,ML,PLAD,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,50863,CDM,250,RC,J9075,HCPCS,10019-956-16,NDC,facility,both,132,EA,,856,599.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,64208-2510-1,NDC,facility,both,3,ML,,357,249.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 160 MG-800 MG TAB,50863,CDM,250,RC,J3490,HCPCS,65862-420-01,NDC,facility,both,3,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MANNITOL 25 % IV SOLN,50863,CDM,250,RC,J2150,HCPCS,0409-4031-01,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  25 MG ORAL TAB,50863,CDM,J3490,HCPCS,60687-822-11,NDC,,,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,63323-482-05,NDC,,,facility,both,160,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BISACODYL 10 MG RECT SUPP,50863,CDM,J3490,HCPCS,0574-7050-12,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,125,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  4 MG/ML INJ SYRG,50863,CDM,636,RC,J2270,HCPCS,76045-005-01,NDC,facility,both,1,ML,,169,118.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),50863,CDM,J1171,HCPCS,0409-4264-11,NDC,,,facility,both,4,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 20MG/ML IV SYRINGE (PEDS/NEO),50863,CDM,250,RC,J0612,HCPCS,63323-311-10,NDC,facility,both,50,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM BICARB-CITRIC ACID 20 MEQ ORAL TBEF,50863,CDM,636,RC,J3490,HCPCS,51801-011-01,NDC,facility,both,3,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,63739-931-28,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,486,ML,,698,488.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0630,HCPCS,63323-865-02,NDC,facility,both,2,ML,,2496,1747.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-896-95,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 500 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-787-11,NDC,facility,both,4,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN 0.9% SODIUM CL 1.25 GRAM/250 ML IV SOLN,50863,CDM,636,RC,J3370,HCPCS,71506-015-58,NDC,facility,both,3,ML,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTAMIDINE 300 MG INJ SOLR,50863,CDM,636,RC,J3490,HCPCS,63323-113-01,NDC,facility,both,1,EA,,350,245,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTAMIDINE 300 MG INJ SOLR,50863,CDM,250,RC,J3490,HCPCS,23155-748-31,NDC,facility,both,1,EA,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BISACODYL 10 MG RECT SUPP,50863,CDM,636,RC,J3490,HCPCS,8142102103,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GAMMAGARD S-D (IGA < 1 MCG/ML) 10 GRAM IV SOLR,50863,CDM,636,RC,J1566,HCPCS,0944-2659-08,NDC,facility,both,60,EA,,13969,9778.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLN (MERGE)",50863,CDM,636,RC,P9047,HCPCS,64208-2512-8,NDC,facility,both,5,ML,,594,415.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,7,ML,,198,138.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUGAMMADEX 100 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0006-5423-02,NDC,facility,both,6,ML,,3361,2352.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM SR 60 MG 12 HR CAP,50863,CDM,636,RC,J3490,HCPCS,51079-924-01,NDC,facility,both,3,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VERAPAMIL 120 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,23155-486-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2310,HCPCS,0409-1219-41,NDC,facility,both,2,ML,,257,179.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYALURONIDASE 150 UNIT/ML INJ SOLN,50863,CDM,250,RC,J3473,HCPCS,18657-117-02,NDC,facility,both,150,ML,,284,198.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUPHENAZINE 5 MG TAB,50863,CDM,250,RC,J3490,HCPCS,60687-749-11,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-1749-70,NDC,facility,both,2,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 40 MG/ML SUSP (DEPO-MEDROL) INJECTION,50863,CDM,250,RC,J1010,HCPCS,70121-1573-1,NDC,facility,both,80,ML,JZ,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CIPROFLOXACIN 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,58657-676-01,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0527-3281-46,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE IN D5W 1 GRAM/100 ML IV PGBK,50863,CDM,636,RC,J3475,HCPCS,44567-410-24,NDC,facility,both,2,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0904-7127-61,NDC,facility,both,40,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-686-10,NDC,facility,both,3,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,68462-755-01,NDC,facility,both,1,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLN,50863,CDM,636,RC,J3262,HCPCS,50242-137-01,NDC,facility,both,800,ML,JZ,14661,10262.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"ALBUMIN, HUMAN 25 % IV SOLN (MERGE)",50863,CDM,250,RC,P9047,HCPCS,64208-2512-8,NDC,facility,both,10,ML,,1188,831.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN SODIUM EXTENDED 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,68084-376-11,NDC,facility,both,3,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1230,HCPCS,67457-217-20,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS",50863,CDM,636,RC,J3490,HCPCS,24208-830-60,NDC,facility,both,1,ML,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J2003,HCPCS,0143-9595-01,NDC,facility,both,200,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 50 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,59651-489-01,NDC,facility,both,50,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACIDOPHILUS-PECTIN W CITRUS 25 MILLION-100 CELL MG TAB,50863,CDM,250,RC,J3490,HCPCS,536142401,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FINASTERIDE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,67877-288-90,NDC,facility,both,1,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-0710-20,NDC,facility,both,7,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-5771-23,NDC,facility,both,11,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GANCICLOVIR 500 MG IV SOLUTION,50863,CDM,250,RC,J1570,HCPCS,70436-089-55,NDC,facility,both,1,EA,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE IN 0.9% NS (PF) 1 MG/10 ML (100 MCG/ML) IV SYRG(PDS MERGE),50863,CDM,636,RC,J3490,HCPCS,65302-506-10,NDC,facility,both,2,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE IN 0.9 % NACL 4 MG/250 ML (16 MCG/ML) IV SOLN (MERGE),50863,CDM,250,RC,70004-613-40,NDC,,,facility,both,4,ML,,822,575.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAZOSIN 5 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,70954-021-10,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPAGLIFLOZIN PROPANEDIOL 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0310-6210-39,NDC,facility,both,1,EA,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1230,HCPCS,17478-380-20,NDC,facility,both,2,ML,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,636,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,17,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 125 MCG SUBQ SOLR,50863,CDM,636,RC,J2802,HCPCS,55513-223-01,NDC,facility,both,60,EA,,1232,862.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-503-11,NDC,facility,both,3,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,63323-165-30,NDC,facility,both,180,ML,,355,248.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7124-61,NDC,facility,both,3,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 0.8 GRAM ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,0115-1365-30,NDC,facility,both,2,EA,,189,132.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNIT/G TOP OINT (MERGE),50863,CDM,636,RC,J3490,HCPCS,58980-011-10,NDC,facility,both,2,GM,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,16714-036-01,NDC,facility,both,3,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-1721-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE (POLACRILEX) 2 MG MM LOZG,50863,CDM,636,RC,J3490,HCPCS,45802-344-05,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-492-04,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CANGRELOR 50 MG IV SOLR,50863,CDM,636,RC,C9460,HCPCS,10122-620-01,NDC,facility,both,100,EA,,5527,3868.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN   81 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,69618-066-02,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,636,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIOTHYRONINE  5 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,62756-589-88,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) IN 0.9 % NACL 1 MG/ML IV SOLN,50863,CDM,250,RC,J2250,HCPCS,44567-610-01,NDC,facility,both,50,ML,,130,91,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2599,HCPCS,65219-039-00,NDC,facility,both,20,ML,,136,95.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7362-61,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-592-11,NDC,facility,both,4,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,23155-833-01,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG ORAL TB12,50863,CDM,250,RC,J3490,HCPCS,42806-275-01,NDC,facility,both,2,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,636,RC,J1596,HCPCS,70069-013-25,NDC,facility,both,5,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETIC ACID 0.25 % IR SOLN,50863,CDM,250,RC,J3490,HCPCS,0338-0656-04,NDC,facility,both,1,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,636,RC,J3370,HCPCS,70436-021-82,NDC,facility,both,4,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPRAZOLAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,59762-3720-1,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,23155-832-01,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAMADOL  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-795-11,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN  325 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0536-1054-29,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,12,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEPLIZUMAB-MZWV 2 MG/20 ML IV SOLN,50863,CDM,636,RC,J9381,HCPCS,73650-316-01,NDC,facility,both,330,ME,JW,9638,6746.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
MISOPROSTOL 200 MCG ORAL TAB,50863,CDM,636,RC,S0191,HCPCS,60687-746-11,NDC,facility,both,3,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAUNORUBICIN 5 MG/ML IV INJ,50863,CDM,250,RC,J9150,HCPCS,42658-021-01,NDC,facility,both,12,ML,,3234,2263.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,50863,CDM,250,RC,J9075,HCPCS,10019-956-16,NDC,facility,both,29,EA,JW,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
MOXIFLOXACIN 400 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-576-11,NDC,facility,both,1,EA,,131,91.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-4675-05,NDC,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-821-01,NDC,facility,both,1,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN 1 GRAM SOLUTION FOR INJECTION,50863,CDM,250,RC,J0290,HCPCS,0409-3726-10,NDC,facility,both,4,EA,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIOTHYRONINE  5 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,59762-1206-1,NDC,facility,both,3,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR 5 % TOP OINT,50863,CDM,250,RC,J3490,HCPCS,0187-0993-95,NDC,facility,both,1,GM,,648,453.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25 MG-100 MG TAB,50863,CDM,636,RC,J3490,HCPCS,60687-661-11,NDC,facility,both,3,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAZOSIN 1 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,68084-996-11,NDC,facility,both,2,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7124-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,250,RC,J2270,HCPCS,0409-1890-03,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-18,NDC,facility,both,100,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PREDNISOLONE ACETATE 1 % OPHT DROPS,50863,CDM,250,RC,J3490,HCPCS,61314-637-05,NDC,facility,both,2,ML,,399,279.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-3178-16,NDC,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-03,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,63323-461-01,NDC,facility,both,1,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACIDOPHILUS-PECTIN W CITRUS 25 MILLION-100 CELL MG TAB,50863,CDM,250,RC,J3490,HCPCS,1785614241,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-22,NDC,facility,both,17,ML,JW,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-9558-05,NDC,facility,both,2,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-1749-70,NDC,facility,both,4,ML,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYBUTYNIN CHLORIDE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0832-0038-89,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,1,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,28,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,68180-441-01,NDC,facility,both,6,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 2400000 UNIT/4 ML IM SYRG,50863,CDM,636,RC,J0561,HCPCS,60793-702-04,NDC,facility,both,24,ML,JZ,1898,1328.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J3490,HCPCS,0990-7983-61,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,63323-461-01,NDC,facility,both,1,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0131-2477-35,NDC,facility,both,1,EA,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALSARTAN  80 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-623-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 0.25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68382-112-14,NDC,facility,both,2,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,0409-9094-18,NDC,facility,both,3,ML,JZ,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GRANISETRON 1 MG ORAL TAB,50863,CDM,250,RC,Q0166,HCPCS,51991-735-99,NDC,facility,both,1,EA,,251,175.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0093-2026-31,NDC,facility,both,8,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0143-9889-15,NDC,facility,both,4,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GRANISETRON 1 MG/ML (1 ML) IV SOLN,50863,CDM,636,RC,J1626,HCPCS,66758-035-01,NDC,facility,both,10,ML,,245,171.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,63323-325-03,NDC,facility,both,80,ML,JW,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
AZTREONAM 2 GRAM INJ SOLR,50863,CDM,636,RC,J0457,HCPCS,63323-402-01,NDC,facility,both,10,EA,,187,130.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-131-11,NDC,facility,both,8,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-975-11,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,J1644,HCPCS,72603-179-01,NDC,,,facility,both,6,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DATOPOTAMAB DERUXTECAN-DLNK 100 MG IV SOLR,50863,CDM,C9174,HCPCS,65597-801-01,NDC,,,facility,both,60,EA,,3522,2465.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,J1610,HCPCS,0597-0053-45,NDC,,,facility,both,1,EA,,742,519.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  120 MG RECT SUPP,50863,CDM,J3490,HCPCS,45802-732-00,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 3000 MCG/ML INJECTION,50863,CDM,250,RC,J0153,HCPCS,67457-855-02,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-134-11,NDC,facility,both,5,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IMIPENEM-CILASTATIN 500 MG IV SOLR,50863,CDM,250,RC,J0743,HCPCS,63323-322-01,NDC,facility,both,4,EA,,352,246.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-1283-17,NDC,facility,both,20,ML,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ESMOLOL IN SALINE (ISO-OSMOTIC) 2,500 MG/250 ML (10 MG/ML) IV",50863,CDM,250,RC,J1805,HCPCS,10019-055-61,NDC,facility,both,1,ML,JZ,560,392,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CEFIXIME 100 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,68180-405-01,NDC,facility,both,1,ML,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM POLYSTYRENE SULFONATE ORAL POWDER,50863,CDM,250,RC,J3490,HCPCS,62135-340-62,NDC,facility,both,2,GM,,432,302.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOPIDOGREL  75 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-536-11,NDC,facility,both,2,EA,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANTIVENIN CROTALIDAE (EQUINE) INJ SOLR,50863,CDM,250,RC,J0841,HCPCS,66621-0790-1,NDC,facility,both,6,EA,,21860,15302,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OMALIZUMAB 150 MG SUBQ SOLR,50863,CDM,J2357,HCPCS,50242-040-62,NDC,,,facility,both,15,ME,,1305,913.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,7985420062,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0456,HCPCS,55150-174-10,NDC,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,636,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,1,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
OXYTOCIN IN 0.9 % SOD CHLORIDE 30 UNIT/500 ML IV SOLN,50863,CDM,250,RC,J2590,HCPCS,71266-5102-1,NDC,facility,both,1,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MYCOPHENOLATE 250 MG CAP,50863,CDM,250,RC,J7517,HCPCS,0054-0163-25,NDC,facility,both,1,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT  10 MCG/0.4 ML INJ SYRG,50863,CDM,636,RC,J0881,HCPCS,55513-098-01,NDC,facility,both,1,ML,EC,788,551.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier EC: Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy
ALLOPURINOL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7041-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7047-61,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPHENIDATE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-805-11,NDC,facility,both,3,EA,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  10 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-0904-05,NDC,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 1 MG ORAL TAB,50863,CDM,636,RC,J8540,HCPCS,0054-8174-25,NDC,facility,both,24,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELATACEPT 250 MG IV SOLR,50863,CDM,636,RC,J0485,HCPCS,0003-0371-13,NDC,facility,both,490,EA,,5056,3539.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN SODIUM  2 GRAM INJ SOLR,50863,CDM,250,RC,J0290,HCPCS,72485-422-01,NDC,facility,both,3,EA,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IV PGBK,50863,CDM,250,RC,J3475,HCPCS,47335-992-01,NDC,facility,both,4,ML,JZ,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SINCALIDE 5 MCG INJ SOLR,50863,CDM,636,RC,J2805,HCPCS,72266-248-05,NDC,facility,both,1,EA,,166,116.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TERAZOSIN  5 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0781-2053-01,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE 25 MG/ML INJ SOLN,50863,CDM,250,RC,J3230,HCPCS,43598-140-11,NDC,facility,both,2,ML,,440,308,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYCHLOROQUINE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69238-1544-1,NDC,facility,both,2,EA,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 3000 MCG/ML INJECTION,50863,CDM,250,RC,J0153,HCPCS,25021-318-02,NDC,facility,both,12,ML,JZ,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,54288-137-01,NDC,facility,both,2,ML,,280,196,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN ASP PRT-INSULIN ASPART 100 UNIT/ML (70-30) SUBQ SOLN,50863,CDM,636,RC,J1817,HCPCS,0169-3685-12,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 100 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,68084-697-11,NDC,facility,both,3,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ORPHENADRINE CITRATE 30 MG/ML INJ SOLN,50863,CDM,250,RC,J2360,HCPCS,0641-6182-01,NDC,facility,both,1,ML,PLAD,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
FLUCONAZOLE PEDS SYRINGE (CDS MIXTURE),50863,CDM,636,RC,J1450,HCPCS,0338-6045-37,NDC,facility,both,2,ML,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-406-03,NDC,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOZAPINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-921-01,NDC,facility,both,9,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  88 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0074-6594-90,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,60687-134-11,NDC,facility,both,10,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 1 % INJ SOLN,50863,CDM,636,RC,Q9968,HCPCS,17478-504-10,NDC,facility,both,100,ML,JZ,725,507.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
HYDROCODONE-ACETAMINOPHEN 10 MG-325 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0406-0125-23,NDC,facility,both,2,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  500 MG IV SOLR,50863,CDM,250,RC,J3370,HCPCS,0409-4332-11,NDC,facility,both,2,EA,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 125 MG/5 ML (25MG/ML) ORAL SYRINGE (REPACK),50863,CDM,250,RC,J3370,HCPCS,67457-340-00,NDC,facility,both,3,EA,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,50863,CDM,250,RC,J9060,HCPCS,0703-5748-11,NDC,facility,both,6,ML,,121,84.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,75,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MISOPROSTOL 200 MCG ORAL TAB,50863,CDM,636,RC,S0191,HCPCS,68084-041-01,NDC,facility,both,4,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESTRADIOL 2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,24658-704-01,NDC,facility,both,4,EA,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0172-5728-60,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,55111-466-01,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE  5 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,31722-185-01,NDC,facility,both,6,EA,,180,126,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0074-4341-90,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IV PGBK,50863,CDM,250,RC,J3475,HCPCS,0264-4204-52,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE  50 MG ORAL TAB,50863,CDM,250,RC,j3490,HCPCS,60687-443-11,NDC,facility,both,1,EA,PLAD,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
PEDIATRIC MULTIVITAMIN NO.42 ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,8068104900,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-444-01,NDC,facility,both,5,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LITHIUM CARBONATE 300 MG ORAL TBSR,50863,CDM,636,RC,J3490,HCPCS,68084-640-11,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZONISAMIDE 10 MG/ML ORAL SYRUP (REPACK),50863,CDM,250,RC,J3490,HCPCS,64679-990-01,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-2051-15,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZTREONAM 2 GRAM INJ SOLR,50863,CDM,250,RC,J0457,HCPCS,63323-402-01,NDC,facility,both,10,EA,JW,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
BACITRACIN 500 UNITS/1 GRAM PACKET (MERGE RECORD),50863,CDM,636,RC,J3490,HCPCS,0904-7023-67,NDC,facility,both,5,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYTOCIN 10 UNIT/ML INJ SOLN,50863,CDM,250,RC,J2590,HCPCS,63323-012-03,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 150 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,16729-443-15,NDC,facility,both,1,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 2-0.5 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,60687-626-11,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 400 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,16714-663-01,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,250,RC,J3490,HCPCS,72789-057-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR  6 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0004-0822-05,NDC,facility,both,13,ML,,186,130.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,16714-036-01,NDC,facility,both,8,ML,JZ,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GABAPENTIN 250 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,42192-608-05,NDC,facility,both,2,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISONIAZID 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-553-11,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE  7 MG/24 HR TD PT24,50863,CDM,250,RC,J3490,HCPCS,60505-7061-0,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-0710-20,NDC,facility,both,14,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G POTASSIUM  5000000 UNIT INJ SOLR,50863,CDM,250,RC,J2540,HCPCS,72603-210-01,NDC,facility,both,9,EA,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-5771-23,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,42291-468-01,NDC,facility,both,3,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 0.2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60505-0258-1,NDC,facility,both,3,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,1,EA,25,62,43.4,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the same day of the Procedure or Other Service"
NICOTINE 14 MG/24 HR TD PT24,50863,CDM,636,RC,J3490,HCPCS,60505-7062-0,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG IV SOLR,50863,CDM,636,RC,J3490,HCPCS,63323-130-02,NDC,facility,both,1,EA,,155,108.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE SODIUM 25 MG/ML INJ SOLN,50863,CDM,250,RC,J9260,HCPCS,61703-350-37,NDC,facility,both,35,ML,,1678,1174.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE  25 MG ORAL CAP,50863,CDM,636,RC,J7515,HCPCS,0078-0240-61,NDC,facility,both,1,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6322-61,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIVAROXABAN 15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50458-578-90,NDC,facility,both,1,EA,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE 14 MG/24 HR TD PT24,50863,CDM,250,RC,J3490,HCPCS,4898500150,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AGALSIDASE BETA  5 MG IV SOLR,50863,CDM,636,RC,J0180,HCPCS,58468-0041-1,NDC,facility,both,15,EA,JZ,6442,4509.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
REGADENOSON 0.4 MG/5 ML IV SYRG,50863,CDM,250,RC,J2785,HCPCS,0469-6501-89,NDC,facility,both,4,ML,"JZ,JA",913,639.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-48,NDC,facility,both,2,ML,JZ,160,112,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CYCLOSPORINE 100 MG ORAL CAP,50863,CDM,250,RC,J7502,HCPCS,0078-0241-61,NDC,facility,both,1,EA,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT 200 MCG/0.4 ML INJ SYRG,50863,CDM,636,RC,J0881,HCPCS,55513-028-01,NDC,facility,both,200,ML,EC,4273,2991.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier EC: Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,63323-280-03,NDC,facility,both,80,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,72603-251-01,NDC,facility,both,80,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BETAMETHASONE, AUGMENTED 0.05 % TOP CREA",50863,CDM,250,RC,J3490,HCPCS,51672-1310-1,NDC,facility,both,1,GM,,186,130.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  0.25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-577-11,NDC,facility,both,3,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,636,RC,J2405,HCPCS,23155-549-31,NDC,facility,both,8,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
AMPICILLIN 250 MG SOLUTION FOR INJECTION,50863,CDM,250,RC,J0290,HCPCS,70594-084-01,NDC,facility,both,1,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6188-01,NDC,facility,both,2000,ML,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZIPRASIDONE 20 MG IM,50863,CDM,636,RC,J3486,HCPCS,43598-848-11,NDC,facility,both,2,EA,JZ,240,168,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DEXRAZOXANE 500 MG IV SOLR,50863,CDM,636,RC,J1190,HCPCS,55150-435-01,NDC,facility,both,2,EA,,1311,917.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN D5W 1 GRAM/200 ML IV PGBK,50863,CDM,636,RC,J3373,HCPCS,0338-3552-48,NDC,facility,both,100,ML,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,70095-031-01,NDC,facility,both,23,ML,,934,653.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,308,ME,JZ,4180,2926,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DOXAZOSIN 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-836-95,NDC,facility,both,3,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZTREONAM 1 GRAM INJ SOLR,50863,CDM,250,RC,J0457,HCPCS,63323-401-01,NDC,facility,both,10,EA,JZ,212,148.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0143-9386-01,NDC,facility,both,86,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,250,RC,J0132,HCPCS,70069-788-01,NDC,facility,both,60,ML,,283,198.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICLOFENAC 1 % TOPICAL GEL,50863,CDM,636,RC,J3490,HCPCS,0067-8152-03,NDC,facility,both,1,GM,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 120 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0093-0321-01,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0574-0521-76,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 40 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-210-11,NDC,facility,both,2,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 20MG/ML IV SYRINGE (PEDS/NEO),50863,CDM,250,RC,J0612,HCPCS,63323-311-10,NDC,facility,both,29,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RASBURICASE 1.5 MG IV SOLR,50863,CDM,250,RC,J2783,HCPCS,0024-5154-11,NDC,facility,both,2,EA,,1728,1209.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOSTIGMINE METHYLSULFATE 1 MG/ML IV SOLN,50863,CDM,J2710,HCPCS,42023-189-01,NDC,,,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ABATACEPT 250 MG IV SOLR,50863,CDM,J0129,HCPCS,0003-2187-13,NDC,,,facility,both,75,EA,,12834,8983.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-342-11,NDC,facility,both,2,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 20MG/ML IV SYRINGE (PEDS/NEO),50863,CDM,250,RC,J0612,HCPCS,63323-311-10,NDC,facility,both,54,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CANDESARTAN 16 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,33342-116-07,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,50863,CDM,250,RC,J9267,HCPCS,61703-342-50,NDC,facility,both,181,ML,,219,153.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-208-01,NDC,facility,both,1000,ML,,250,175,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML INJ KIT,50863,CDM,J3490,HCPCS,24357-011-13,NDC,,,facility,both,30,EA,,10685,7479.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 15 MG/ML (1.5 %) INJ SOLN,50863,CDM,J2003,HCPCS,0409-4056-01,NDC,,,facility,both,300,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J3490,HCPCS,63323-482-03,NDC,,,facility,both,200,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 2 GRAM INJ SOLR,50863,CDM,J0692,HCPCS,25021-122-50,NDC,,,facility,both,4,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MERCAPTOPURINE 50 MG ORAL TAB,50863,CDM,250,RC,J9999,HCPCS,0378-3547-52,NDC,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE SOD SUCC (PF) 100 MG/2 ML INJ SOLR,50863,CDM,J1720,HCPCS,0009-0011-03,NDC,,,facility,both,2,EA,,252,176.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPATITIS A VIRUS VACCINE (PF) 25 UNIT/0.5 ML IM MERGE (CAM USE ONLY),50863,CDM,90633,HCPCS,0006-4095-01,NDC,,,facility,both,1,ML,,228,159.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE  25 MG ORAL CPSP,50863,CDM,636,RC,J3490,HCPCS,68382-005-14,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2305-04,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7057-61,NDC,facility,both,12,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  1 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,59651-484-01,NDC,facility,both,121,EA,,150,105,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESNA 100 MG/ML IV SOLN,50863,CDM,250,RC,J9209,HCPCS,10019-953-62,NDC,facility,both,8,ML,,210,147,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESNA 100 MG/ML IV SOLN,50863,CDM,250,RC,J9209,HCPCS,0338-1305-01,NDC,facility,both,32,ML,,1232,862.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPATITIS B IMMUNE GLOBULIN 220 UNIT/ML (5 ML) IM SOLN,50863,CDM,636,RC,90371,HCPCS,13533-636-05,NDC,facility,both,5,ML,,2032,1422.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID (PORK)  30 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42192-329-01,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 100 MG ORAL CAP,50863,CDM,J3490,HCPCS,60687-506-11,NDC,,,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTAMIDINE 300 MG INHL SOLR,50863,CDM,636,RC,J3490,HCPCS,13925-522-01,NDC,facility,both,1,EA,,650,455,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ABOBOTULINUMTOXINA 500 UNITS IM SOLR,50863,CDM,636,RC,J0586,HCPCS,15054-0500-1,NDC,facility,both,100,EA,,2106,1474.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML (1ML) INJ SOLN,50863,CDM,250,RC,J0171,HCPCS,54288-119-01,NDC,facility,both,20,ML,,159,111.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  5 GRAM IV SOLR,50863,CDM,250,RC,J3370,HCPCS,67457-341-05,NDC,facility,both,3,EA,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,J2704,HCPCS,63323-269-22,NDC,,,facility,both,4,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPOETIN ALFA 20000 UNIT/ML INJ SOLN,50863,CDM,J0885,HCPCS,55513-478-01,NDC,,,facility,both,20,ML,,1174,821.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 0.4 MG/ML INJ SOLN,50863,CDM,J0461,HCPCS,0517-1004-01,NDC,,,facility,both,40,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,J3490,HCPCS,71266-9080-4,NDC,,,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % MBP,50863,CDM,J3490,HCPCS,0338-0553-18,NDC,,,facility,both,2,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,50863,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,258,ML,,312,218.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE 20 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0904-5677-61,NDC,facility,both,2,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,43066-007-10,NDC,facility,both,2,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,68094-063-59,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 500 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7337-35,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16729-175-01,NDC,facility,both,2,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7109-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES-DOCUSATE SODIUM 8.6 MG-50 MG TAB,50863,CDM,636,RC,J3490,HCPCS,60687-622-11,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BLEOMYCIN 30 UNIT INJ SOLR,50863,CDM,250,RC,J9040,HCPCS,71288-107-20,NDC,facility,both,2,EA,,286,200.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN NPH & REGULAR HUMAN 100 UNIT/ML (70-30) SUBQ SUSP,50863,CDM,250,RC,J1815,HCPCS,0002-8715-01,NDC,facility,both,9,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,57237-004-30,NDC,facility,both,4,EA,,172,120.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPAFENONE 225 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,59651-257-01,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 300 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,69452-125-50,NDC,facility,both,1,ML,,126,88.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESALAMINE  250 MG ORAL CPSR,50863,CDM,636,RC,J3490,HCPCS,54092-189-81,NDC,facility,both,4,EA,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-1749-70,NDC,facility,both,2,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DENOSUMAB 60 MG/ML SUBQ SYRG,50863,CDM,636,RC,J0897,HCPCS,55513-710-21,NDC,facility,both,60,ML,,5177,3623.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  100 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,68462-896-01,NDC,facility,both,8,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,59762-4910-3,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM  4.5 GRAM IV SOLR,50863,CDM,636,RC,J2543,HCPCS,60505-6159-0,NDC,facility,both,4,EA,,107,74.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,0409-3795-19,NDC,facility,both,4,ML,JZ,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
HYDROMORPHONE  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-3243-01,NDC,facility,both,4,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,59762-3130-1,NDC,facility,both,4,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  1 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,59746-171-06,NDC,facility,both,7,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) 20000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,72603-224-01,NDC,facility,both,1,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IFOSFAMIDE 3 GRAM IV SOLR,50863,CDM,636,RC,J9208,HCPCS,10019-926-16,NDC,facility,both,9,EA,,1394,975.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,51754-4250-1,NDC,facility,both,1,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,636,RC,J3490,HCPCS,0641-6236-01,NDC,facility,both,1,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE  50 MG ORAL TAB,50863,CDM,250,RC,j3490,HCPCS,60505-2653-1,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN IN D5W 300 MG/50 ML IV PGBK,50863,CDM,J0736,HCPCS,0338-3410-50,NDC,,,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ABATACEPT 250 MG IV SOLR,50863,CDM,636,RC,J0129,HCPCS,0003-2187-13,NDC,facility,both,75,EA,"JZ,JA",12110,8477,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
CAPECITABINE 500 MG ORAL TAB,50863,CDM,250,RC,J8522,HCPCS,60687-149-11,NDC,facility,both,10,EA,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NORTRIPTYLINE 50 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0093-0812-01,NDC,facility,both,2,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON DEXTRAN 50 MG/ML INJ SOLN,50863,CDM,250,RC,J1750,HCPCS,0023-6082-01,NDC,facility,both,1,ML,JZ,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ROPINIROLE  0.25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6373-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 800 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-720-11,NDC,facility,both,2,EA,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACCHAROMYCES BOULARDII 250 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,7733380050,NDC,facility,both,14,EA,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITRIOL 1 MCG/ML IV SOLN,50863,CDM,250,RC,J0636,HCPCS,72266-251-01,NDC,facility,both,3,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIACIN  250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,4329255740,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,636,RC,J2405,HCPCS,70860-776-41,NDC,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TORSEMIDE   5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,31722-529-01,NDC,facility,both,4,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,J3490,HCPCS,57896-101-01,NDC,,,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,J3490,HCPCS,71399-1025-3,NDC,,,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALTREXONE MICROSPHERES 380 MG IM SERR,50863,CDM,J2315,HCPCS,65757-302-02,NDC,,,facility,both,380,EA,,4666,3266.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE 100 MG ORAL CAP,50863,CDM,250,RC,J7502,HCPCS,0078-0241-61,NDC,facility,both,3,EA,,268,187.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYOSCYAMINE 0.5 MG/ML INJECTION,50863,CDM,636,RC,J1980,HCPCS,54288-111-01,NDC,facility,both,1,ML,,234,163.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,64850-502-01,NDC,facility,both,3,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLP,50863,CDM,250,RC,J3480,HCPCS,63323-965-02,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,25021-602-03,NDC,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML (ANESTHESIA INTRAOP ONLY),50863,CDM,250,RC,J3010,HCPCS,0641-6027-01,NDC,facility,both,5,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM PHOSPHATE 3 MMOL/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-884-01,NDC,facility,both,3,ML,,304,212.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,J0665,HCPCS,0409-1162-02,NDC,,,facility,both,150,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADVATE: FACTOR VIII CONCENTRATE (MERGE RECORD),50863,CDM,J7192,HCPCS,0944-3052-03,NDC,,,facility,both,500,UN,,2093,1465.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,J2704,HCPCS,0069-0209-01,NDC,,,facility,both,77,ML,,111,77.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,J2704,HCPCS,0069-0209-01,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PNEUMOC 20-VAL CONJ-DIP CR(PF) 0.5 ML IM SYRG,50863,CDM,90677,HCPCS,0005-2000-10,NDC,,,facility,both,1,ML,,972,680.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPOETIN ALFA-EPBX 10000 UNITS/ML INJ SOLN,50863,CDM,Q5106,HCPCS,0069-1308-10,NDC,,,facility,both,10,ML,,477,333.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV,50863,CDM,J7120,HCPCS,0338-0117-04,NDC,,,facility,both,5,ML,,167,116.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,J0780,HCPCS,0713-0351-02,NDC,,,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHOTERICIN B 5 MCG/0.1 ML INTRAVITREAL INJECTION,50863,CDM,J3490,HCPCS,99999-0403-82,NDC,,,facility,both,6000,ML,,111753,78227.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),50863,CDM,636,RC,J1815,HCPCS,0024-5926-05,NDC,facility,both,7,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  100 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,25021-452-01,NDC,facility,both,2,ML,JB,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JB: Administered subcutaneously
DILTIAZEM IN D5W 125 MG/125 ML (1 MG/ML) IV SOLN (PREMIX),50863,CDM,J3490,HCPCS,70004-540-35,NDC,,,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  0.25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-741-11,NDC,facility,both,3,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,J1100,HCPCS,63323-165-05,NDC,,,facility,both,24,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,63323-400-01,NDC,facility,both,400,ML,,420,294,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,636,RC,J3490,HCPCS,14789-251-09,NDC,facility,both,1,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,250,RC,J7060,HCPCS,0338-0017-03,NDC,facility,both,2,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIORIDAZINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-566-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,636,RC,J0330,HCPCS,31722-981-10,NDC,facility,both,5,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"TRANEXAMIC ACID IN NACL,ISO-OS 1,000 MG/100 ML (10 MG/ML) IV PGBK",50863,CDM,636,RC,J3490,HCPCS,80830-2329-1,NDC,facility,both,2,ML,,241,168.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL,50863,CDM,250,RC,J3490,HCPCS,63323-820-01,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,55150-177-05,NDC,facility,both,150,ML,JZ,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ALTEPLASE 100 MG IV SOLR,50863,CDM,250,RC,J2997,HCPCS,50242-085-25,NDC,facility,both,5,EA,,1215,850.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM  50 MG INJ SOLR,50863,CDM,250,RC,J0640,HCPCS,25021-813-10,NDC,facility,both,4,EA,,207,144.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,50863,CDM,250,RC,J0696,HCPCS,0143-9856-01,NDC,facility,both,8,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROMETHORPHAN-GUAIFENESIN SR 30 MG-600 MG 12 HR TAB,50863,CDM,636,RC,J3490,HCPCS,6382405640,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROATE SODIUM 100 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-494-01,NDC,facility,both,2,ML,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOCARNITINE 200 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0143-9852-01,NDC,facility,both,2,ML,,256,179.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL (VITAMIN D3)  1000 UNIT ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,2055503300,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DORZOLAMIDE-TIMOLOL 2 %-0.5 % EYE DROPS,50863,CDM,636,RC,J3490,HCPCS,70069-051-01,NDC,facility,both,1,ML,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN   81 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,0904-6783-70,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE  10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,70756-201-11,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MONTELUKAST  4 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,50268-573-11,NDC,facility,both,2,EA,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOPIDOGREL 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6467-07,NDC,facility,both,2,EA,,189,132.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 250 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,0832-7123-89,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,636,RC,J7510,HCPCS,17856-0815-1,NDC,facility,both,4,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,636,RC,J0690,HCPCS,70092-1017-46,NDC,facility,both,8,ML,,159,111.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2312,HCPCS,36000-308-01,NDC,facility,both,40,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR PHOSPHATE 75 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,42291-664-10,NDC,facility,both,1,EA,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-580-11,NDC,facility,both,9,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6636-61,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,195,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
METHADONE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-5755-23,NDC,facility,both,7,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOPIDOGREL  75 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65862-357-30,NDC,facility,both,1,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0780,HCPCS,25021-790-02,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MISOPROSTOL 200 MCG ORAL TAB,50863,CDM,250,RC,S0191,HCPCS,60687-746-11,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FERROUS SULFATE 75 MG/ML (ELEMENTAL IRON 15 MG/ML) ORAL DROP,50863,CDM,250,RC,J3490,HCPCS,536134480,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,72485-106-01,NDC,facility,both,40,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,16714-293-03,NDC,facility,both,3,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) MISC SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-694-04,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 10 MEQ/100 ML IV PGBK,50863,CDM,J3480,HCPCS,14789-109-16,NDC,,,facility,both,5,ML,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,J2250,HCPCS,0409-2308-22,NDC,,,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 10 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-6426-61,NDC,,,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,J2919,HCPCS,0009-0047-25,NDC,,,facility,both,16,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNITS/1 GRAM PACKET (MERGE RECORD),50863,CDM,J3490,HCPCS,45802-060-00,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NORTRIPTYLINE 25 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0093-0811-01,NDC,facility,both,3,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  5 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-122-11,NDC,facility,both,10,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 1 MG ORAL CAP,50863,CDM,250,RC,J7507,HCPCS,51079-818-01,NDC,facility,both,3,EA,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,636,RC,J3490,HCPCS,51754-4250-1,NDC,facility,both,1,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,0781-3246-02,NDC,facility,both,1,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DIGOXIN 250 MCG/ML INJ SOLN,50863,CDM,250,RC,J1160,HCPCS,0781-3059-72,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THROMBIN (RECOMBINANT) 20000 UNIT TOP SOLR,50863,CDM,250,RC,J3490,HCPCS,0338-0328-01,NDC,facility,both,5,EA,,6089,4262.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM SR 120 MG 24 HR CAP,50863,CDM,636,RC,J3490,HCPCS,60687-195-11,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE MONONITRATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,4843310801,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LINEZOLID 600 MG/300 ML IV SOLP,50863,CDM,250,RC,J2020,HCPCS,57664-683-31,NDC,facility,both,3,ML,JZ,331,231.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
METHOTREXATE NA (PRESERV FREE) 25 MG/ML INJ SOLN,50863,CDM,250,RC,J9260,HCPCS,0703-3678-01,NDC,facility,both,9,ML,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE  7.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,57237-007-30,NDC,facility,both,4,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-103-01,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-354-11,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUVOXAMINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69452-455-20,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML INJ SOLN,50863,CDM,250,RC,J2060,HCPCS,0409-6778-02,NDC,facility,both,2,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CITRATE 4% (3 ML) SYRINGE (FOR DIALYSIS),50863,CDM,250,RC,J3490,HCPCS,0942-9504-10,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE  50 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,50268-277-11,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,89,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCUSATE SODIUM 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7183-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL (VITAMIN D3)  1000 UNIT ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,2055503300,NDC,facility,both,4,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CELECOXIB 200 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-6503-61,NDC,facility,both,1,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 250 MG-125 MG TAB,50863,CDM,250,RC,J3490,HCPCS,16714-476-01,NDC,facility,both,2,EA,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,50863,CDM,250,RC,J1756,HCPCS,0517-2340-01,NDC,facility,both,200,ML,,661,462.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIMOLOL MALEATE 0.5 % OPHT DROP,50863,CDM,250,RC,J3490,HCPCS,64980-514-05,NDC,facility,both,1,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-8515-23,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE MONONITRATE  30 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,0904-6449-61,NDC,facility,both,3,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 30 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-087-01,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,65862-642-30,NDC,facility,both,8,EA,,449,314.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIFEDIPINE 30 MG ORAL TO24,50863,CDM,250,RC,J3490,HCPCS,50268-597-11,NDC,facility,both,2,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,0641-6025-01,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE (FOR EMERGENCY) 100 MG/ML (10%) IV SOLN,50863,CDM,250,RC,J0612,HCPCS,63323-360-01,NDC,facility,both,1000,ML,JZ,588,411.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DOXAZOSIN 8 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-225-11,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,16714-046-01,NDC,facility,both,10,ML,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0780,HCPCS,23155-294-31,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT  60 MCG/0.3 ML INJ SYRG,50863,CDM,636,RC,J0881,HCPCS,55513-023-04,NDC,facility,both,60,ML,"JZ,EC",1282,897.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier EC: Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 40 GRAM/400 ML (10 %) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-40,NDC,facility,both,80,ML,,11316,7921.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DACARBAZINE 200 MG IV SOLR,50863,CDM,250,RC,J9130,HCPCS,63323-128-00,NDC,facility,both,2,EA,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXRAZOXANE 500 MG IV SOLR,50863,CDM,250,RC,J1190,HCPCS,55150-435-01,NDC,facility,both,3,EA,,2260,1582,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,292,ML,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,110,EA,JZ,15180,10626,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,63323-280-03,NDC,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMOSOZUMAB-AQQG 210MG/2.34ML ( 105MG/1.17MLX2) SUBQ SYRG,50863,CDM,636,RC,J3111,HCPCS,55513-998-02,NDC,facility,both,210,ML,JZ,5894,4125.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,653,ME,JZ,8862,6203.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-04,NDC,facility,both,6,ML,JZ,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MORPHINE 100 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,0904-6560-61,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,69,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 800 MG ORAL TAB,50863,CDM,250,RC,J0601,HCPCS,0904-6707-06,NDC,facility,both,40,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  25 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,59762-1342-1,NDC,facility,both,1,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6950-61,NDC,facility,both,3,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG ORAL TAB,50863,CDM,250,RC,Q0169,HCPCS,0904-7304-61,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN 1000 MG IN NS 500 ML IRRIGATION (REPACK),50863,CDM,250,RC,J0690,HCPCS,99999-0406-15,NDC,facility,both,2,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOBRAMYCIN SULFATE 40 MG/ML INJ SOLN,50863,CDM,636,RC,J3260,HCPCS,67457-473-00,NDC,facility,both,5,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 12.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-931-01,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,66689-053-99,NDC,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 0.125 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,13668-091-90,NDC,facility,both,2,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-4827-05,NDC,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,0641-6236-01,NDC,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEXILETINE 200 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,62559-821-01,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 30 MG/0.3 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,25021-410-70,NDC,facility,both,3,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESALAMINE  250 MG ORAL CPSR,50863,CDM,250,RC,J3490,HCPCS,54092-189-81,NDC,facility,both,5,EA,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  25 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6991-04,NDC,facility,both,6,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXAZOSIN 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-5522-61,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 12.5 MG ORAL TAB,50863,CDM,250,RC,Q0169,HCPCS,53746-745-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,31722-828-30,NDC,facility,both,2,EA,,273,191.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 1 MG (ENVARSUS XR) 24-HOUR EXTENDED-RELEASE TABLET,50863,CDM,250,RC,J7508,HCPCS,68992-3010-3,NDC,facility,both,1,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MUPIROCIN 2 % TOP OINT,50863,CDM,250,RC,J3490,HCPCS,45802-112-22,NDC,facility,both,1,GM,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) IV SOLN,50863,CDM,250,RC,J9201,HCPCS,0409-0181-01,NDC,facility,both,15,ML,,692,484.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN D5W 20000 UNIT/500 ML,50863,CDM,250,RC,J1644,HCPCS,0264-9567-10,NDC,facility,both,20,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,14,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ONDANSETRON 4 MG ORAL TBDL,50863,CDM,636,RC,J3490,HCPCS,68462-157-40,NDC,facility,both,2,EA,,227,158.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DONANEMAB-AZBT 17.5 MG/ML IV SOLN,50863,CDM,636,RC,J0175,HCPCS,0002-9401-01,NDC,facility,both,350,ML,,3201,2240.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  20 MEQ ORAL PACK,50863,CDM,636,RC,J3490,HCPCS,0245-0360-89,NDC,facility,both,3,EA,,158,110.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6949-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE NA (PRESERV FREE) 25 MG/ML INJ SOLN,50863,CDM,250,RC,J9260,HCPCS,16729-277-35,NDC,facility,both,240,ML,,2416,1691.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOLTERODINE 2 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,60687-319-11,NDC,facility,both,2,EA,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM NEO IV SYRINGE (PHS FROM PREMIX),50863,CDM,636,RC,J1953,HCPCS,44567-501-01,NDC,facility,both,9,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN 1 MG/ML INJECTION (PEDS ONCOLOGY),50863,CDM,250,RC,71288-160-10,NDC,,,facility,both,3.51,EA,,258,180.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 40 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-099-11,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCAINAMIDE 100 MG/ML INJECTION (MERGE),50863,CDM,250,RC,J2690,HCPCS,14789-901-07,NDC,facility,both,1,ML,,166,116.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOZAPINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-921-01,NDC,facility,both,3,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0047-03,NDC,facility,both,9,EA,JW,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DIVALPROEX 500 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,16714-485-01,NDC,facility,both,2,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OMEPRAZOLE-SODIUM BICARBONATE 2-84 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,62175-114-32,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 50 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,10135-779-01,NDC,facility,both,60,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-433-11,NDC,facility,both,4,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE IN SALINE (ISO-OSM) 400 MG/200 ML IV PIGGY BACK,50863,CDM,250,RC,J3490,HCPCS,25021-184-87,NDC,facility,both,1,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADVATE: FACTOR VIII CONCENTRATE (MERGE RECORD),50863,CDM,250,RC,J7192,HCPCS,0944-3051-04,NDC,facility,both,250,UN,,1343,940.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,250,RC,J0690,HCPCS,70092-1017-46,NDC,facility,both,2,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACUBITRIL-VALSARTAN 49-51 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0078-0777-20,NDC,facility,both,1,EA,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV (BOLUS),50863,CDM,636,RC,J7120,HCPCS,0264-7750-07,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-18,NDC,facility,both,150,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  80 MG ORAL CS24,50863,CDM,250,RC,J3490,HCPCS,0527-4117-37,NDC,facility,both,2,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0781-2020-01,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 20 MG/ML ORAL SUSPENSION (REPACK),50863,CDM,250,RC,J3490,HCPCS,16714-041-04,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIPASE-PROTEASE-AMYLASE 12,000-38,000- 60,000 UNIT ORAL CAP, DELAY REL",50863,CDM,636,RC,J3490,HCPCS,0032-0047-70,NDC,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,250,RC,J7060,HCPCS,0338-0017-01,NDC,facility,both,2,ML,,240,168,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE MODIFIED  25 MG ORAL CAP,50863,CDM,636,RC,J7515,HCPCS,0093-9018-19,NDC,facility,both,8,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2305-16,NDC,facility,both,2,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-25,NDC,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16729-136-00,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE   4.2 % IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-083-05,NDC,facility,both,1,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAZOSIN 2 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7021-61,NDC,facility,both,6,EA,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,50863,CDM,250,RC,J9060,HCPCS,0703-5748-11,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J2004,HCPCS,63323-482-03,NDC,facility,both,70,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-406-03,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM  2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-284-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV (BOLUS),50863,CDM,636,RC,J7120,HCPCS,0264-7750-07,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,J3490,HCPCS,60687-390-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,135,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IVABRADINE 7.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,55513-810-60,NDC,facility,both,1,EA,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOPERAMIDE 2 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,51079-690-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  1 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,59746-171-06,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,66794-229-02,NDC,facility,both,2,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),50863,CDM,250,RC,J2060,HCPCS,0641-6001-01,NDC,facility,both,2,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,60687-755-40,NDC,facility,both,3,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,12,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LEVETIRACETAM IN NACL (ISO-OS) 1000 MG/100 ML IV PGBK,50863,CDM,J1953,HCPCS,44567-502-01,NDC,,,facility,both,200,ML,,131,91.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESALAMINE  250 MG ORAL CPSR,50863,CDM,250,RC,J3490,HCPCS,54092-189-81,NDC,facility,both,3,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOBRAMYCIN SULFATE 40 MG/ML INJ SOLN,50863,CDM,250,RC,J3260,HCPCS,67457-473-22,NDC,facility,both,7,ML,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-9543-02,NDC,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,3,EA,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 1 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-9158-01,NDC,facility,both,3,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICLOFENAC 1 % TOPICAL GEL,50863,CDM,636,RC,J3490,HCPCS,67120176,NDC,facility,both,1,GM,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,12,ML,,19075,13352.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J3490,HCPCS,0338-0049-48,NDC,facility,both,4,ML,JZ,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DAUNORUBICIN 5 MG/ML IV INJ,50863,CDM,250,RC,J9150,HCPCS,42658-021-01,NDC,facility,both,5,ML,,1203,842.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FILGRASTIM-SNDZ 480 MCG/0.8 ML INJ SYRG,50863,CDM,250,RC,Q5101,HCPCS,61314-326-01,NDC,facility,both,480,ML,,1212,848.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,636,RC,J2720,HCPCS,63323-229-01,NDC,facility,both,7,ML,JZ,128,89.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
AMANTADINE 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,62332-246-31,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) IV SOLN",50863,CDM,J3490,HCPCS,0013-1114-20,NDC,,,facility,both,1,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,250,RC,J0131,HCPCS,0781-3156-06,NDC,facility,both,50,ML,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIFEDIPINE 30 MG ORAL TO24,50863,CDM,636,RC,J3490,HCPCS,50268-597-11,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FERRIC CARBOXYMALTOSE (INJECTAFER) 50 MG IRON/ML IV SOLN,50863,CDM,250,RC,J1439,HCPCS,0517-0650-01,NDC,facility,both,1500,ML,,8221,5754.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-742-11,NDC,facility,both,4,EA,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN SODIUM EXTENDED 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,68084-376-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPHENIDATE 18 MG ORAL TO24,50863,CDM,636,RC,J3490,HCPCS,62175-310-37,NDC,facility,both,2,EA,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE (FOR EMERGENCY) 100 MG/ML (10%) IV SOLN,50863,CDM,250,RC,J0612,HCPCS,63323-360-01,NDC,facility,both,1000,ML,,588,411.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZIPRASIDONE 40 MG CAP,50863,CDM,636,RC,J3490,HCPCS,68084-104-09,NDC,facility,both,3,EA,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN 125 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,51672-4069-1,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25 MG-100 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0378-0085-01,NDC,facility,both,3,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 600 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-457-11,NDC,facility,both,6,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,63323-482-05,NDC,,,facility,both,80,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  5 MG ORAL TAB,50863,CDM,J3490,HCPCS,60687-398-11,NDC,,,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,J3490,HCPCS,68180-441-02,NDC,,,facility,both,7,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,68180-441-01,NDC,facility,both,5,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,636,RC,J7999,HCPCS,70092-1017-46,NDC,facility,both,350,ML,,13826,9678.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 0.4 MG SL SUBL,50863,CDM,J3490,HCPCS,58151-310-94,NDC,,,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 20 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,50111-648-01,NDC,facility,both,3,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-070-10,NDC,facility,both,1,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,5026852411,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-22,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,0409-3178-01,NDC,,,facility,both,150,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,16714-293-03,NDC,facility,both,11,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 2 GRAM INJ SOLR,50863,CDM,250,RC,J0692,HCPCS,44567-241-10,NDC,facility,both,20,EA,,288,201.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 250 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,0832-7123-89,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 7.5 MG-325 MG/15 ML ORAL SOLN (REPACK),50863,CDM,250,RC,J3490,HCPCS,0121-2316-15,NDC,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 5 MG-325 MG TAB,50863,CDM,J3490,HCPCS,0406-0123-23,NDC,,,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 40 MG/ML (4 %) INJ SOLN (FOR NEBULIZATION),50863,CDM,J2003,HCPCS,0409-4283-11,NDC,,,facility,both,120,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,63323-482-03,NDC,,,facility,both,200,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,J3370,HCPCS,16714-309-01,NDC,,,facility,both,2,EA,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COVID VACCINE 24-25 (5-11Y)(PFI)-PF 10 MCG/0.3 ML IM SUSP,50863,CDM,91319,HCPCS,59267-4438-1,NDC,,,facility,both,1,ML,,392,274.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN   81 MG ORAL TBEC,50863,CDM,J3490,HCPCS,77333-031-25,NDC,,,facility,both,3,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,J3490,HCPCS,0121-1022-05,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  25 MG ORAL TAB,50863,CDM,J3490,HCPCS,50268-504-11,NDC,,,facility,both,4,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE SODIUM 2.5 MG ORAL TAB,50863,CDM,250,RC,J8610,HCPCS,0555-0572-02,NDC,facility,both,10,EA,,175,122.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VORICONAZOLE 200 MG IV SOLN,50863,CDM,250,RC,J3465,HCPCS,0049-3190-28,NDC,facility,both,20,EA,,307,214.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES-DOCUSATE SODIUM 8.6 MG-50 MG TAB,50863,CDM,636,RC,J3490,HCPCS,60687-622-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOPERAMIDE 2 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,51079-690-01,NDC,facility,both,3,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,42806-150-33,NDC,facility,both,13,ML,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB 100 MG IV SOLR,50863,CDM,636,RC,J1745,HCPCS,57894-030-01,NDC,facility,both,60,EA,JZ,19340,13538,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LOPERAMIDE 2 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0378-2100-01,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-25,NDC,facility,both,120,ML,,16973,11881.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,636,RC,J0330,HCPCS,31722-981-10,NDC,facility,both,8,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,636,RC,J2003,HCPCS,63323-486-05,NDC,facility,both,400,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NORTRIPTYLINE 10 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,50268-603-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROFURANTOIN (25% MACROCRYSTAL FORM) 100 MG CAP,50863,CDM,J3490,HCPCS,0904-7137-61,NDC,,,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"HEPARIN, PORCINE (PF)   10 UNIT/ML IV SYRG",50863,CDM,250,RC,J1642,HCPCS,8290306413,NDC,facility,both,9,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,636,RC,J3490,HCPCS,67850-041-00,NDC,facility,both,1,ML,,172,120.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-130-11,NDC,facility,both,3,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 2.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0003-0893-31,NDC,facility,both,1,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-0552-23,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,23155-902-01,NDC,facility,both,3,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-209-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BISACODYL  5 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,0904-6407-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-980-01,NDC,facility,both,2,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TETRACYCLINE 500 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,62135-266-60,NDC,facility,both,1,EA,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN  325 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,57896-921-01,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MULTIVITAMIN WITH FOLIC ACID 400 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,904053061,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOPAMINE INFUSION NEO IV SYRINGE (FROM PREMIX),50863,CDM,636,RC,J1265,HCPCS,0409-7809-11,NDC,facility,both,9,ML,JW,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,636,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,136,ML,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 10 MG-325 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0406-0125-23,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALSARTAN  80 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,33342-063-10,NDC,facility,both,2,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,71399-1025-3,NDC,facility,both,20,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,65219-570-01,NDC,facility,both,8,ML,,185,129.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CELECOXIB 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,16714-732-01,NDC,facility,both,2,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXEPIN 10 MG/ML ORAL CONC,50863,CDM,250,RC,J3490,HCPCS,54838-512-40,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN PEDS INFUSION (CDS MIXTURE),50863,CDM,250,RC,J0290,HCPCS,99999-408-63,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAMADOL  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7179-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,0904-7509-30,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 500 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,0904-6861-61,NDC,facility,both,2,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
REMIFENTANIL 1 MG IV SOLR,50863,CDM,636,RC,J3490,HCPCS,67457-198-03,NDC,facility,both,2,EA,,624,436.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CANGRELOR 50 MG IV SOLR,50863,CDM,636,RC,C9460,HCPCS,10122-620-01,NDC,facility,both,100,EA,JZ,5527,3868.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IBUPROFEN 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-134-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,16714-293-03,NDC,facility,both,8,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-833-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MYCOPHENOLATE 250 MG CAP,50863,CDM,250,RC,J7517,HCPCS,0054-0163-25,NDC,facility,both,2,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-590-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,23155-902-01,NDC,facility,both,2,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,16714-293-01,NDC,facility,both,3,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,70860-406-41,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6966-61,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,42806-151-34,NDC,facility,both,13,ML,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOSTIGMINE METHYLSULFATE 3 MG/3 ML (1 MG/ML) IV SYRG,50863,CDM,636,RC,J2710,HCPCS,43598-945-11,NDC,facility,both,1,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 500 MG/10 ML IV SOLN,50863,CDM,250,RC,J9190,HCPCS,63323-117-01,NDC,facility,both,8,ML,,182,127.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOZAPINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0378-0860-01,NDC,facility,both,2,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM ACETATE 667 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7119-06,NDC,facility,both,3,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-975-11,NDC,facility,both,2,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,636,RC,J3490,HCPCS,0904-6794-30,NDC,facility,both,3,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-4279-02,NDC,facility,both,900,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0054-0710-20,NDC,facility,both,22,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-DYYB 100 MG IV SOLR,50863,CDM,636,RC,Q5103,HCPCS,0069-0809-01,NDC,facility,both,8,EA,JW,909,636.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
BORTEZOMIB 3.5 MG IV SOLR,50863,CDM,250,RC,J9041,HCPCS,10019-991-01,NDC,facility,both,29,EA,,266,186.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,172,120.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 20 MG/ML INJ SOLN,50863,CDM,250,RC,J0360,HCPCS,55150-400-01,NDC,facility,both,1,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,7,ML,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,14,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ARGATROBAN 100 MG/ML IV SOLN,50863,CDM,250,RC,J0883,HCPCS,0143-9674-01,NDC,facility,both,250,ML,JZ,821,574.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,250,RC,J7060,HCPCS,0264-1510-31,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,50863,CDM,250,RC,Q0177,HCPCS,0093-5061-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZONISAMIDE 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-230-11,NDC,facility,both,6,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESVENLAFAXINE  50 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,60687-607-11,NDC,facility,both,2,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE ACETATE 1 % OPHT DROPS,50863,CDM,250,RC,J3490,HCPCS,60758-119-05,NDC,facility,both,1,ML,,224,156.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE MALEATE  5 MG ORAL TAB,50863,CDM,636,RC,Q0164,HCPCS,50268-684-11,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0630,HCPCS,24201-400-02,NDC,facility,both,1,ML,JZ,3209,2246.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,5,ML,,138,96.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 300 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6572-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML INJECTION,50863,CDM,250,RC,J3411,HCPCS,72603-139-01,NDC,facility,both,3,ML,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 20MG/ML IV SYRINGE (PEDS/NEO),50863,CDM,250,RC,J0612,HCPCS,63323-311-10,NDC,facility,both,66,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NORETHINDRONE-ETHINYL ESTRADIOL 1 MG-35 MCG TAB,50863,CDM,250,RC,J3490,HCPCS,68462-394-84,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN SODIUM  2 GRAM INJ SOLR,50863,CDM,250,RC,J0290,HCPCS,72485-422-01,NDC,facility,both,4,EA,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ESMOLOL IN SALINE (ISO-OSMOTIC) 2,000 MG/100 ML (20 MG/ML) IV",50863,CDM,250,RC,J1805,HCPCS,44567-451-01,NDC,facility,both,1,ML,,419,293.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFPODOXIME 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-395-01,NDC,facility,both,1,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-9543-02,NDC,facility,both,1,ML,JZ,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
BUPRENORPHINE-NALOXONE 8-2 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,50268-145-11,NDC,facility,both,2,EA,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,636,RC,J3490,HCPCS,70004-600-09,NDC,facility,both,2,ML,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,2055503601,NDC,facility,both,3,EA,PLAD,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
SILDENAFIL (PULM.HYPERTENSION) 10 MG/12.5 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,55150-166-13,NDC,facility,both,1,ML,,555,388.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE IN 0.9% NS (PF) 1 MG/10 ML (100 MCG/ML) IV SYRG(PDS MERGE),50863,CDM,250,RC,J3490,HCPCS,65302-506-10,NDC,facility,both,2,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-464-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-975-11,NDC,facility,both,4,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE  7 MG/24 HR TD PT24,50863,CDM,636,RC,J3490,HCPCS,0536-5894-88,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42858-003-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYTOCIN IN 0.9 % SOD CHLORIDE 30 UNIT/500 ML IV SOLN,50863,CDM,J2590,HCPCS,71266-5103-1,NDC,,,facility,both,1,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,50863,CDM,636,RC,J0696,HCPCS,0409-7335-13,NDC,facility,both,8,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,4,EA,,111,77.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIPASE-PROTEASE-AMYLASE 5,000-17,000- 24,000 UNIT ORAL CPDR",50863,CDM,250,RC,J3490,HCPCS,73562-115-01,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE 21 MG/24 HR TD PT24,50863,CDM,250,RC,J3490,HCPCS,43598-448-71,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 125 MG INJECTION SOLR,50863,CDM,636,RC,J2919,HCPCS,63323-258-03,NDC,facility,both,25,EA,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOMYCIN-BACITRACN ZN-POLYMYXIN 3.5 MG-400 U*,50863,CDM,636,RC,J3490,HCPCS,45802-061-70,NDC,facility,both,6,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPRAZOLAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0781-1077-01,NDC,facility,both,5,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 50 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,59651-489-01,NDC,facility,both,10,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BISACODYL  5 MG ORAL TBEC,50863,CDM,J3490,HCPCS,0904-6407-61,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J1940,HCPCS,72603-251-01,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG IV SOLR,50863,CDM,636,RC,J3490,HCPCS,0008-0923-60,NDC,facility,both,2,EA,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NS WITH POTASSIUM CHLORIDE 20 MEQ/L IV SOLP,50863,CDM,636,RC,J3480,HCPCS,0264-7865-00,NDC,facility,both,10,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APREPITANT  40 MG ORAL CAP,50863,CDM,250,RC,J8501,HCPCS,0781-2321-06,NDC,facility,both,2,EA,,792,554.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,57237-004-30,NDC,facility,both,5,EA,,215,150.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,6,ML,,12139,8497.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,70095-031-01,NDC,facility,both,41,ML,,1680,1176,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL  20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6671-04,NDC,facility,both,6,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"CIPROFLOXACIN-DEXAMETHASONE 0.3 %-0.1 % EAR DROPS, SUSP",50863,CDM,636,RC,J3490,HCPCS,43598-326-75,NDC,facility,both,1,ML,,794,555.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,72603-251-01,NDC,facility,both,20,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),50863,CDM,636,RC,J0171,HCPCS,76329-3318-1,NDC,facility,both,30,ML,,221,154.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 5 MG ORAL TAB,50863,CDM,J3490,HCPCS,0003-0894-31,NDC,,,facility,both,2,EA,,119,83.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG ORAL TBDL,50863,CDM,J3490,HCPCS,13668-088-30,NDC,,,facility,both,1,EA,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 2400000 UNIT/4 ML IM SYRG,50863,CDM,J0561,HCPCS,60793-702-04,NDC,,,facility,both,24,ML,,2088,1461.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN PEDS INFUSION (CDS MIXTURE),50863,CDM,250,RC,J0290,HCPCS,25021-136-10,NDC,facility,both,2,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,63323-104-25,NDC,facility,both,19,ML,,119,83.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-184-01,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6418-61,NDC,facility,both,3,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,0409-4887-24,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,125,EA,,306,214.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
URSODIOL 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-100-11,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,63323-010-01,NDC,facility,both,3,ML,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,0409-4887-17,NDC,facility,both,3,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7050,HCPCS,0338-0049-48,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,67877-545-88,NDC,facility,both,2,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 100 MG ORAL TBSR,50863,CDM,636,RC,J3490,HCPCS,43547-288-10,NDC,facility,both,2,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV (BOLUS),50863,CDM,636,RC,J7120,HCPCS,0264-7750-10,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2308-02,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE (PF) 1 MG/ML INJ SOLN,50863,CDM,J0169,HCPCS,54288-103-01,NDC,,,facility,both,120,ML,,1027,718.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-466-03,NDC,facility,both,100,ML,JZ,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
INSULIN REGULAR IN 0.9% NACL 100 UNIT/100 ML (1 UNIT/ML) INFUSION FOR OB,50863,CDM,J1815,HCPCS,0338-0126-12,NDC,,,facility,both,1,ML,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML IM SOLN,50863,CDM,636,RC,90375,HCPCS,13533-318-05,NDC,facility,both,2,ML,JW,856,599.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,Q5121,HCPCS,55513-670-01,NDC,,,facility,both,33,EA,,4554,3187.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COCAINE  4 % TOP SOLN (MERGE),50863,CDM,636,RC,C9046,HCPCS,70839-362-04,NDC,facility,both,160,ML,,1041,728.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,J0132,HCPCS,55150-259-30,NDC,,,facility,both,120,ML,,2066,1446.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 500 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,62756-798-88,NDC,facility,both,2,EA,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,76045-009-96,NDC,facility,both,40,ML,,221,154.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7193-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MOMETASONE 220 MCG (60 DOSES) INHL AEPB,50863,CDM,250,RC,J3490,HCPCS,0085-1341-02,NDC,facility,both,1,EA,,796,557.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ELECTROLYTE-A IV,50863,CDM,250,RC,J3490,HCPCS,0338-0221-03,NDC,facility,both,6,ML,,499,349.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 800 MG ORAL TAB,50863,CDM,250,RC,J0601,HCPCS,65162-058-27,NDC,facility,both,120,EA,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAZOSIN 1 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,51079-630-01,NDC,facility,both,3,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ANTI-INHIBITOR COAGULANT CMPLX 1,750-3,250 UNIT IV SOLR",50863,CDM,250,RC,J7198,HCPCS,64193-425-02,NDC,facility,both,2729,UN,JW,7069,4948.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DOXYCYCLINE HYCLATE 100 MG IV SOLR,50863,CDM,636,RC,J3490,HCPCS,71288-030-20,NDC,facility,both,2,EA,,188,131.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,63323-201-01,NDC,,,facility,both,20,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCHLOROTHIAZIDE  25 MG ORAL TAB,50863,CDM,J3490,HCPCS,60687-593-11,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROTHIAZIDE SODIUM 500 MG IV SOLR,50863,CDM,250,RC,J1205,HCPCS,0517-1820-01,NDC,facility,both,1,EA,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0054-0710-20,NDC,facility,both,10,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,63323-104-01,NDC,facility,both,17,ML,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE MONONITRATE  30 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,0904-6449-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLN (MERGE)",50863,CDM,636,RC,P9047,HCPCS,68516-5216-4,NDC,facility,both,4,ML,,853,597.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 400 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6667-61,NDC,facility,both,3,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,59651-488-01,NDC,facility,both,50,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BEVACIZUMAB 25 MG/ML IV SOLN,50863,CDM,250,RC,J9035,HCPCS,50242-061-01,NDC,facility,both,120,ML,,24030,16821,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-208-01,NDC,facility,both,400,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-174-11,NDC,facility,both,3,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-503-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL  1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-734-01,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,50863,CDM,636,RC,J1885,HCPCS,0409-3796-19,NDC,facility,both,3,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,25021-601-03,NDC,facility,both,5,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV (BOLUS),50863,CDM,250,RC,J7040,HCPCS,65219-472-05,NDC,facility,both,2,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50580-600-02,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,636,RC,J1100,HCPCS,63323-506-41,NDC,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-590-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,636,RC,P9045,HCPCS,68516-5218-0,NDC,facility,both,1,ML,JZ,237,165.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PROPOFOL IV BOLUS 10MG/ML (ANESTHESIA ONLY),50863,CDM,636,RC,J2704,HCPCS,0409-4699-54,NDC,facility,both,173,ML,,220,154,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPRAZOLAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0781-1077-01,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WHITE PETROLATUM-MINERAL OIL OPHT OINT (PDS MERGE),50863,CDM,250,RC,J3490,HCPCS,23066704,NDC,facility,both,1,GM,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,86,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,219,153.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALACYCLOVIR 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6565-61,NDC,facility,both,2,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,9,EA,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,4,EA,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,25021-601-03,NDC,facility,both,300,ML,,587,410.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-0710-20,NDC,facility,both,14,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,4,EA,,134,93.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % MBP,50863,CDM,250,RC,J3490,HCPCS,0338-9159-30,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,50863,CDM,250,RC,J0696,HCPCS,60505-6148-0,NDC,facility,both,4,EA,JZ,225,157.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,37000-024-10,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 2-0.5 MG SL SUBL,50863,CDM,636,RC,J3490,HCPCS,60687-626-11,NDC,facility,both,2,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN DEGLUDEC 100 UNITS/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,73070-400-11,NDC,facility,both,1,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 160 MG-800 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0904-2725-61,NDC,facility,both,20,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,63323-161-00,NDC,facility,both,5,ML,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 12.5 MG ORAL TAB,50863,CDM,636,RC,Q0169,HCPCS,53746-745-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,250,RC,J2405,HCPCS,23155-547-31,NDC,facility,both,4,ML,PLAD,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
LOSARTAN  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,72205-142-90,NDC,facility,both,2,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,0517-3020-01,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,636,RC,J1610,HCPCS,0597-0053-45,NDC,facility,both,2,EA,JZ,1112,778.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
THYROID (PORK)  30 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0456-0458-01,NDC,facility,both,3,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,250,RC,J2720,HCPCS,63323-229-01,NDC,facility,both,2,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE  100 MCG/ACTUATION INHL DSDV,50863,CDM,636,RC,J3490,HCPCS,66993-791-97,NDC,facility,both,1,EA,,840,588,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0093-1712-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 300 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-699-11,NDC,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,50863,CDM,636,RC,J0585,HCPCS,0023-1145-01,NDC,facility,both,100,EA,JZ,1599,1119.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SODIUM CHLORIDE 0.9% IV (PEDS) BOLUS,50863,CDM,636,RC,J7040,HCPCS,0264-7800-09,NDC,facility,both,3,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,55150-307-01,NDC,facility,both,100,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE 25 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0069-0970-65,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 300 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,68180-711-60,NDC,facility,both,1,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-822-11,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE  50 MG ORAL TAB,50863,CDM,250,RC,j3490,HCPCS,60687-443-11,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN 0.9 % SODIUM CHL 2 GRAM/500 ML IV SOLN,50863,CDM,636,RC,J3370,HCPCS,70092-9338-07,NDC,facility,both,4,ML,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OMEPRAZOLE 20 MG ORAL CPDR,50863,CDM,636,RC,J3490,HCPCS,0904-6917-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV (BOLUS),50863,CDM,250,RC,J7120,HCPCS,0264-7750-00,NDC,facility,both,4,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,43,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML INJ SOLN,50863,CDM,250,RC,J1171,HCPCS,63323-852-03,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,3,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE DINITRATE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0781-1556-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,68180-150-01,NDC,facility,both,3,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 100 MG PE/2 ML INJ SOLN,50863,CDM,250,RC,Q2009,HCPCS,0641-6136-01,NDC,facility,both,1,ML,JW,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
AMPICILLIN 1 GRAM SOLUTION FOR INJECTION,50863,CDM,636,RC,J0290,HCPCS,0781-3404-85,NDC,facility,both,2,EA,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
D5-0.9%NACL-POTASSIUM CHLORIDE 20 MEQ/L IV SOLP,50863,CDM,636,RC,J3480,HCPCS,0338-0803-04,NDC,facility,both,10,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LITHIUM CARBONATE 300 MG ORAL TBSR,50863,CDM,636,RC,J3490,HCPCS,68084-640-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,0641-6174-10,NDC,facility,both,4,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,50863,CDM,J0696,HCPCS,25021-107-20,NDC,,,facility,both,8,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,J3490,HCPCS,0093-3426-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIPH,PERTUS(ACEL),TET,POLIO(PF)(KINRIX) 25 LF-58 MCG-10 LF/0.5 ML IM SYRINGE",50863,CDM,90696,HCPCS,58160-812-52,NDC,,,facility,both,1,ML,,318,222.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,636,RC,J1100,HCPCS,63323-506-00,NDC,facility,both,6,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J2312,HCPCS,0641-6132-01,NDC,facility,both,40,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  650 MG RECT SUPP,50863,CDM,J3490,HCPCS,45802-730-30,NDC,,,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,113,79.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THROMBIN (RECOMBINANT) 5000 UNIT TOP SOLR,50863,CDM,J3490,HCPCS,0338-0324-01,NDC,,,facility,both,1,EA,,372,260.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-495-27,NDC,,,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 1 MG/ML NEEDLELESS SYRG,50863,CDM,J2310,HCPCS,76329-3369-1,NDC,,,facility,both,2,ML,,194,135.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 10 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,63323-516-10,NDC,facility,both,10,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DEXTROSE 40 % ORAL GEL,50863,CDM,J3490,HCPCS,574006915,NDC,,,facility,both,1,GM,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GRANISETRON 1 MG ORAL TAB,50863,CDM,250,RC,Q0166,HCPCS,69452-350-60,NDC,facility,both,1,EA,,251,175.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,70069-363-01,NDC,facility,both,1,ML,,127,88.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE 100 MG TAB,50863,CDM,636,RC,J3490,HCPCS,60687-344-95,NDC,facility,both,20,EA,,224,156.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6817-61,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NORTRIPTYLINE 25 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0093-0811-01,NDC,facility,both,5,EA,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE MALEATE  5 MG ORAL TAB,50863,CDM,250,RC,Q0164,HCPCS,50268-684-11,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,0641-6236-01,NDC,facility,both,1,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60505-3113-0,NDC,facility,both,2,EA,,195,136.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16729-216-15,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DABIGATRAN  75 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0597-0355-56,NDC,facility,both,1,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J1610,HCPCS,63323-596-11,NDC,facility,both,10,EA,JZ,7847,5492.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LUBIPROSTONE  8 MCG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,70710-1641-6,NDC,facility,both,3,EA,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6418-61,NDC,facility,both,2,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6519-61,NDC,facility,both,3,EA,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN 0.9% SODIUM CL 1.25 GRAM/250 ML IV SOLN,50863,CDM,250,RC,J3373,HCPCS,71285-6074-1,NDC,facility,both,3,ML,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  10 MG ORAL TR12,50863,CDM,250,RC,J3490,HCPCS,59011-410-20,NDC,facility,both,4,EA,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-22,NDC,facility,both,220,ML,,439,307.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OMEPRAZOLE-SODIUM BICARBONATE 2-84 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,65628-270-05,NDC,facility,both,3,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0548-5604-00,NDC,facility,both,8,ML,JZ,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
INSULIN NPH HUMAN RECOMB 100 UNIT/ML SUBQ SUSP,50863,CDM,636,RC,J1815,HCPCS,0169-1834-11,NDC,facility,both,7,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J2250,HCPCS,0409-2305-17,NDC,facility,both,5,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0143-9889-15,NDC,facility,both,3,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 20 MG/ML INJ SOLN,50863,CDM,250,RC,J0360,HCPCS,55150-400-01,NDC,facility,both,1,ML,PLAD,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
POTASSIUM PHOS IN 0.9 % NACL 15 MMOL/250 ML IVPB PREMIX,50863,CDM,636,RC,J3490,HCPCS,65219-658-01,NDC,facility,both,1,ML,,233,163.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % MBP,50863,CDM,250,RC,J3490,HCPCS,0338-0553-18,NDC,facility,both,10,ML,,482,337.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 300 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-699-11,NDC,facility,both,10,EA,,198,138.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOBUTAMINE IN D5W 500 MG/250 ML (2 MG/ML) INFUSION (PREMIX),50863,CDM,250,RC,J1250,HCPCS,0409-2347-32,NDC,facility,both,2,ML,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 100 MG/ML INJ SOLN,50863,CDM,250,RC,J2800,HCPCS,70069-101-01,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIROFIBAN-0.9% SODIUM CHLORIDE 5 MG/100 ML (50 MCG/ML) IV SOLN,50863,CDM,250,RC,J3246,HCPCS,25208-002-03,NDC,facility,both,80,ML,,1590,1113,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM  3.375 GRAM IV SOLR,50863,CDM,250,RC,J2543,HCPCS,44567-802-10,NDC,facility,both,3,EA,JZ,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) NEB SOLUTION,50863,CDM,250,RC,J3490,HCPCS,0487-9501-00,NDC,facility,both,12,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE  5 MG/ML INJ SOLN,50863,CDM,250,RC,J2765,HCPCS,0409-3414-18,NDC,facility,both,3,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUPHENAZINE 5 MG TAB,50863,CDM,636,RC,J3490,HCPCS,60687-749-11,NDC,facility,both,2,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,63323-104-25,NDC,facility,both,16,ML,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALUM-MAG HYDROXIDE-SIMETH 200 MG-200 MG-20 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0121-1761-30,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 10 % (100 MG/ML) MISC SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-695-04,NDC,facility,both,2,ML,,129,90.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,636,RC,J7510,HCPCS,17856-0815-1,NDC,facility,both,8,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,250,RC,J3490,HCPCS,53746-542-01,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7914-61,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0093-3426-10,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE (PEDIATRIC 3 MONTH) 30 MG IM SYKT,50863,CDM,636,RC,J1950,HCPCS,0074-9694-03,NDC,facility,both,8,EA,JZ,35874,25111.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DEXAMETHASONE 1 MG ORAL TAB,50863,CDM,250,RC,J8540,HCPCS,0054-4181-25,NDC,facility,both,4,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 200 MG/20 ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,72205-220-01,NDC,facility,both,1,ML,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-087-02,NDC,facility,both,6,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN PEDS IVPB (CDS MIXTURE),50863,CDM,250,RC,J3370,HCPCS,0069-2599-99,NDC,facility,both,1,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOLIC ACID  1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-681-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 10 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6987-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACUBITRIL-VALSARTAN 24-26 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0078-0659-20,NDC,facility,both,1,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEPERIDINE (PF) 25 MG/ML IV SOLN (PHS MERGE),50863,CDM,636,RC,J2175,HCPCS,0409-1176-03,NDC,facility,both,1,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE 14 MG/24 HR TD PT24,50863,CDM,250,RC,J3490,HCPCS,0536-5895-88,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  0.25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6373-61,NDC,facility,both,10,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,70436-030-82,NDC,facility,both,44,ML,JW,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
QUETIAPINE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-633-11,NDC,facility,both,2,EA,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-086-01,NDC,facility,both,3,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT  40 MCG/0.4 ML INJ SYRG,50863,CDM,636,RC,J0881,HCPCS,55513-021-01,NDC,facility,both,80,ML,EC,2192,1534.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier EC: Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy
SEVELAMER CARBONATE 800 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-328-11,NDC,facility,both,3,EA,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,67877-548-88,NDC,facility,both,7,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  2.5 MG ORAL TAB,50863,CDM,250,RC,J7510,HCPCS,59651-485-01,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,62756-711-86,NDC,facility,both,2,EA,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOHEXOL   9 MG IODINE/ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,0407-1415-09,NDC,facility,both,1,ML,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,88,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6426-61,NDC,facility,both,2,EA,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,50863,CDM,250,RC,J9206,HCPCS,0009-7529-03,NDC,facility,both,15,ML,,727,508.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-591-11,NDC,facility,both,6,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 150 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7212-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2308-02,NDC,facility,both,30,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0002-4115-30,NDC,facility,both,2,EA,,185,129.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TICAGRELOR 90 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0186-0777-60,NDC,facility,both,2,EA,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM  3 GRAM INJ SOLR,50863,CDM,636,RC,J0295,HCPCS,55150-117-20,NDC,facility,both,2,EA,JZ,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ZONISAMIDE 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-230-11,NDC,facility,both,15,EA,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 400 MCG/100 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0143-9525-01,NDC,facility,both,1,ML,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,31722-828-30,NDC,facility,both,1,EA,,158,110.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-595-11,NDC,facility,both,1,EA,PLAD,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
CLOBAZAM 2.5 MG/ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,99999-0404-03,NDC,facility,both,4,ML,,189,132.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  20 MEQ ORAL PACK,50863,CDM,250,RC,J3490,HCPCS,69543-451-01,NDC,facility,both,1,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 600 MG ORAL TP12,50863,CDM,250,RC,J3490,HCPCS,0536-1163-61,NDC,facility,both,7,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6376-61,NDC,facility,both,2,EA,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INDOMETHACIN 25 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,50268-430-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,158,ML,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 600 MG ORAL TP12,50863,CDM,250,RC,J3490,HCPCS,0904-6718-39,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,70069-363-01,NDC,facility,both,2,ML,,270,189,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,50863,CDM,636,RC,J8540,HCPCS,60687-718-11,NDC,facility,both,24,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 1 % OPHT DROP,50863,CDM,250,RC,J3490,HCPCS,0065-0817-02,NDC,facility,both,1,ML,,213,149.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,70095-026-01,NDC,facility,both,3,ML,JW,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
HUMAN PROTHROMBIN COMPLEX 500 UNIT IV SOLR,50863,CDM,J7168,HCPCS,63833-396-01,NDC,,,facility,both,500,UN,,2910,2037,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 1 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-7362-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  15 MG ORAL TBSR,50863,CDM,J3490,HCPCS,0904-6557-61,NDC,,,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 250 MG INJ SOLR,50863,CDM,J0696,HCPCS,0781-3206-85,NDC,,,facility,both,2,EA,,146,102.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 10 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,16714-695-01,NDC,facility,both,1,ML,,173,121.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,41,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
COVID VACCINE 24-25 (12UP)(PFI)(PF) 30 MCG/0.3 ML IM SYRG,50863,CDM,91320,HCPCS,0069-2432-01,NDC,,,facility,both,1,ML,,591,413.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 40 MG ORAL TAB,50863,CDM,J3490,HCPCS,63739-573-10,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL IV BOLUS 10MG/ML (ANESTHESIA ONLY),50863,CDM,J2704,HCPCS,63323-269-29,NDC,,,facility,both,20,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIRMATRELVIR-RITONAVIR 150 MG (10)- 100 MG (10) ORAL DSPK,50863,CDM,636,RC,J3490,HCPCS,0069-5317-20,NDC,facility,both,20,EA,,4130,2891,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE   4.2 % IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-083-05,NDC,facility,both,2,ML,,149,104.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,J3490,HCPCS,70004-430-09,NDC,,,facility,both,59,ML,,2125,1487.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRIMIDONE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-686-11,NDC,facility,both,3,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,5026852411,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN IN SALINE (ISO-OSMOTIC) 80 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1580,HCPCS,0338-0503-48,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE 8 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,60687-492-11,NDC,facility,both,2,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE  4 MG ORAL TAB,50863,CDM,250,RC,J7509,HCPCS,0904-6914-61,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6798-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-1749-70,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM PHOSPHATE DIBASIC 3 MMOLE/ML IV SOLP,50863,CDM,250,RC,J3490,HCPCS,0517-2315-25,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-975-11,NDC,facility,both,4,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,50863,CDM,250,RC,J9060,HCPCS,16729-288-11,NDC,facility,both,20,ML,,434,303.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,55390-138-01,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LITHIUM CARBONATE 300 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,68462-223-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 2.5 MG RECT KIT,50863,CDM,636,RC,J3490,HCPCS,66490-650-20,NDC,facility,both,4,EA,,3265,2285.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 50 MG/ML IV SOLN,50863,CDM,250,RC,J0282,HCPCS,63323-616-02,NDC,facility,both,12,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 0.2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60505-0258-1,NDC,facility,both,8,EA,,171,119.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,250,RC,J0690,HCPCS,44567-707-25,NDC,facility,both,4,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-4279-16,NDC,facility,both,60,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE (FOR CODE) 10% IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0517-6710-01,NDC,facility,both,1,ML,,23727,16608.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE 44 MCG/ACTUATION INHL AERO,50863,CDM,J3490,HCPCS,66993-078-96,NDC,,,facility,both,2,GM,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,J2704,HCPCS,0069-0209-01,NDC,,,facility,both,63,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ICATIBANT 30 MG/3 ML SUBQ SYRG,50863,CDM,636,RC,J1744,HCPCS,0093-3066-34,NDC,facility,both,30,ML,,29229,20460.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 40 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,70436-227-48,NDC,facility,both,1,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN NPH & REGULAR HUMAN 100 UNIT/ML (70-30) SUBQ SUSP,50863,CDM,250,RC,J1815,HCPCS,0169-1837-11,NDC,facility,both,12,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE IN 0.9% NACL 3 GRAM/100 ML IV SOLN,50863,CDM,250,RC,J0612,HCPCS,61553-056-48,NDC,facility,both,600,ML,,255,178.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J1611,HCPCS,63323-596-11,NDC,facility,both,1,EA,,895,626.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN DEXTROSE (ISO-OSMOTIC) 1 GRAM/50 ML IV PIGGY BACK,50863,CDM,250,RC,J0690,HCPCS,0338-3503-41,NDC,facility,both,2,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTAMIDINE 300 MG INJ SOLR,50863,CDM,636,RC,J3490,HCPCS,63323-113-01,NDC,facility,both,1,EA,,231,161.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-25,NDC,facility,both,40,ML,"JG,JZ,JA",5658,3960.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J2004,HCPCS,0409-3178-16,NDC,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,636,RC,J2795,HCPCS,70069-064-25,NDC,facility,both,50,ML,JW,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,70004-600-09,NDC,facility,both,3,ML,,127,88.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES-DOCUSATE SODIUM 8.6 MG-50 MG TAB,50863,CDM,250,RC,J3490,HCPCS,60687-622-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM IN D5W 125 MG/125 ML (1 MG/ML) IV SOLN (PREMIX),50863,CDM,636,RC,J3490,HCPCS,63037-119-05,NDC,facility,both,1,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE  10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-162-11,NDC,facility,both,5,EA,,126,88.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOFLOXACIN 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6352-61,NDC,facility,both,1,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMANTADINE 50 MG/5 ML ORAL SYRP,50863,CDM,636,RC,J3490,HCPCS,60687-797-42,NDC,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAVASTATIN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-649-10,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TELMISARTAN 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,43547-284-03,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68180-445-01,NDC,facility,both,2,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,67877-548-88,NDC,facility,both,4,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 1000 MG/8 ML IV SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0018-20,NDC,facility,both,400,EA,,702,491.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 30% IN WATER (NEO),50863,CDM,636,RC,J7060,HCPCS,0409-6648-16,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE (POLACRILEX) 4 MG BUCL GUM,50863,CDM,250,RC,J3490,HCPCS,63739-369-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) NEB SOLUTION,50863,CDM,250,RC,J3490,HCPCS,0487-9501-01,NDC,facility,both,4,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0904-6923-61,NDC,facility,both,15,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PERMETHRIN 1 % TOP LIQD (REPACK),50863,CDM,636,RC,J3490,HCPCS,6373612003,NDC,facility,both,1,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,636,RC,J3490,HCPCS,63323-486-05,NDC,facility,both,80,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,250,RC,J0137,HCPCS,0264-4100-90,NDC,facility,both,72,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25 MG-100 MG TAB,50863,CDM,636,RC,J3490,HCPCS,60687-661-11,NDC,facility,both,3,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DONANEMAB-AZBT 17.5 MG/ML IV SOLN,50863,CDM,636,RC,J0175,HCPCS,0002-9401-01,NDC,facility,both,700,ML,"JZ,GA,Q0",6401,4480.7,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier GA: Waiver of liability statement issued as required by payer policy, individual case | Modifier Q0: Investigational clinical service provided in a clinical research study that is in an approved clinical research study"
DESMOPRESSIN 0.2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60505-0258-1,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-245-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-074-11,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 250 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,43547-688-10,NDC,facility,both,2,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DONEPEZIL 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-303-11,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,6,ML,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON DEXTRAN 50 MG/ML INJ SOLN,50863,CDM,636,RC,J1750,HCPCS,0023-6082-01,NDC,facility,both,20,ML,,2188,1531.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MYCOPHENOLATE 180 MG TAB, DELAYED RELEASE",50863,CDM,636,RC,J7518,HCPCS,68084-907-11,NDC,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,70,EA,JZ,9660,6762,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,0143-9682-01,NDC,facility,both,8,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,29300-423-01,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT  25 MCG/ML INJ SOLN,50863,CDM,636,RC,J0881,HCPCS,55513-002-01,NDC,facility,both,25,ML,"JZ,EC",836,585.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier EC: Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy
TOBRAMYCIN 300 MG/5 ML INHL NEBU (REPACK),50863,CDM,250,RC,J3490,HCPCS,70756-604-44,NDC,facility,both,1,ML,,464,324.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL 100 MCG/HR TD PT72,50863,CDM,250,RC,J3490,HCPCS,0378-9124-16,NDC,facility,both,1,EA,,227,158.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MULTIVITAMIN W/IRON ORAL DROP 0.5 ML (PEDS/NEO),50863,CDM,250,RC,J3490,HCPCS,17856-0405-01,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NORETHINDRONE ACETATE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68462-304-50,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 25 MG TAB,50863,CDM,636,RC,J3490,HCPCS,65862-146-36,NDC,facility,both,1,EA,,133,93.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 1 MG ORAL TAB,50863,CDM,250,RC,J8540,HCPCS,72578-166-01,NDC,facility,both,12,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MOXIFLOXACIN 400 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6406-06,NDC,facility,both,2,EA,,254,177.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FERROUS GLUCONATE 324 MG (37.5 MG IRON) ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,7985450032,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,3,EA,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MINERAL OIL ENEMA,50863,CDM,250,RC,J3490,HCPCS,0132-0301-40,NDC,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,250,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,10,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITRIOL 0.25 MCG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-345-11,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXEPIN  25 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,51079-437-01,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,38,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE  1 % TOP OINT,50863,CDM,250,RC,J3490,HCPCS,70677-1214-1,NDC,facility,both,1,GM,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,0641-6145-01,NDC,facility,both,7,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,63323-165-30,NDC,facility,both,50,ML,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 10 MEQ/100 ML IV PGBK,50863,CDM,636,RC,J3480,HCPCS,0990-7074-26,NDC,facility,both,5,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZINC OXIDE 20 % TOP OINT (REPACK),50863,CDM,250,RC,J3490,HCPCS,0168-0062-31,NDC,facility,both,1,GM,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR 200 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,70954-188-10,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-0552-23,NDC,facility,both,4,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE HCL  2 % MM JELP,50863,CDM,250,RC,J3490,HCPCS,76329-3012-5,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FERROUS GLUCONATE 324 MG (38 MG IRON) TAB,50863,CDM,250,RC,J3490,HCPCS,2055501900,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,40,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-476-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLIPIZIDE  5 MG ORAL TO24,50863,CDM,250,RC,J3490,HCPCS,68084-111-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYBUTYNIN CHLORIDE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7027-61,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE-PHENYLEPHRINE 4%-0.25% NASAL SPRAY,50863,CDM,636,RC,J3490,HCPCS,0225-0800-47,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4% TOP PATCH,50863,CDM,636,RC,J3490,HCPCS,46581-830-06,NDC,facility,both,2,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOPIDOGREL 300 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-184-11,NDC,facility,both,1,EA,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN IN D5W 400 MG/200 ML IV PGBK,50863,CDM,250,RC,J0744,HCPCS,0409-3300-01,NDC,facility,both,2,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-285-01,NDC,facility,both,16,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,68180-723-04,NDC,facility,both,2,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAMSULOSIN 0.4 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,0904-6401-61,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG-10,000 UNIT/G-0.1 % EYE OINTMENT",50863,CDM,636,RC,J3490,HCPCS,24208-795-35,NDC,facility,both,1,GM,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 150 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6956-61,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA SR 25 MG-100 MG TAB,50863,CDM,636,RC,J3490,HCPCS,68084-281-11,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,50268-639-11,NDC,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MULTIVIT-MIN-IRON FUM-FOLIC AC 7.5 MG IRON-400 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,7985440050,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-406-03,NDC,facility,both,1,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2308-22,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J2003,HCPCS,63323-492-27,NDC,facility,both,600,ML,,471,329.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,16714-293-01,NDC,facility,both,10,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-3425-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NADOLOL  20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-302-95,NDC,facility,both,4,EA,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,30,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE (DIAGNOSTIC) 3 MG/ML IV SOLN,50863,CDM,250,RC,J0153,HCPCS,16714-997-01,NDC,facility,both,90,ML,,735,514.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZONATATE 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7153-61,NDC,facility,both,9,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0630,HCPCS,24201-400-02,NDC,facility,both,1,ML,,2691,1883.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTAMIDINE 300 MG INJ SOLR,50863,CDM,636,RC,J3490,HCPCS,63323-113-01,NDC,facility,both,1,EA,,154,107.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NELARABINE 250 MG/50 ML IV SOLN (PEDS ONCOLOGY),50863,CDM,636,RC,J9261,HCPCS,71288-165-52,NDC,facility,both,12,ML,,4317,3021.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ELTROMBOPAG 75 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0078-0687-15,NDC,facility,both,2,EA,,1887,1320.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 0.5 MG/ML ORAL SUSPENSION (REPACK),50863,CDM,250,RC,J7507,HCPCS,51079-028-01,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,9,EA,JW,540,378,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,63,EA,,8694,6085.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  5 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,60687-122-11,NDC,facility,both,10,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0093-3426-10,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIFEDIPINE 20 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,23155-195-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 600 MG ORAL TP12,50863,CDM,250,RC,J3490,HCPCS,0904-6718-39,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-349-11,NDC,facility,both,2,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NOREPINEPHRINE BITARTRATE-D5W 4 MG/250 ML (16 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,71285-6056-1,NDC,facility,both,2,ML,,219,153.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,49884-849-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN   81 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,63739-212-02,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-6666-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLMESARTAN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68462-437-90,NDC,facility,both,1,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2598,HCPCS,55150-370-01,NDC,facility,both,18,ML,JW,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IVABRADINE 5 MG ORAL TAB,50863,CDM,250,RC,50742-362-60,NDC,,,facility,both,60,EA,,1517,1061.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML INJ SOLN,50863,CDM,250,RC,J0171,HCPCS,76329-9060-0,NDC,facility,both,30,ML,,797,557.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-0235-24,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PALONOSETRON 0.25 MG/5 ML IV INJECTION (MERGE),50863,CDM,J2469,HCPCS,36000-326-01,NDC,,,facility,both,10,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,636,RC,J3490,HCPCS,14789-251-09,NDC,facility,both,1,ML,,133,93.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-398-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,21,ML,JZ,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DACARBAZINE 200 MG IV SOLR,50863,CDM,636,RC,J9130,HCPCS,0143-9245-01,NDC,facility,both,6,EA,,180,126,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOMIPRAMINE 25 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,70756-405-11,NDC,facility,both,2,EA,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,40,EA,,5520,3864,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 80 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-8301-25,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,250,RC,J2405,HCPCS,60505-6130-5,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,70069-363-01,NDC,facility,both,1,ML,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-579-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,7,ML,,12139,8497.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 0.5 MG ORAL CAP,50863,CDM,250,RC,J7507,HCPCS,0904-6623-61,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,636,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,50,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PREGABALIN  25 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6991-61,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0990-7983-02,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"RABIES VACCINE, PURIFIED CHICKEN EMBRYO CELL (PF) 2.5 UNIT IM KIT",50863,CDM,636,RC,90675,HCPCS,50632-013-01,NDC,facility,both,1,EA,,1466,1026.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 25 MG CAP,50863,CDM,J3490,HCPCS,71399-1027-1,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL,50863,CDM,250,RC,J3490,HCPCS,63323-820-01,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  5 MG ORAL TAB,50863,CDM,J3490,HCPCS,60505-3111-0,NDC,,,facility,both,2,EA,,130,91,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J2004,HCPCS,0409-3178-16,NDC,facility,both,125,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN IN D5W 400 MG/200 ML IV PGBK,50863,CDM,636,RC,J0744,HCPCS,0409-3300-01,NDC,facility,both,2,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,64208-2510-1,NDC,facility,both,2,ML,,238,166.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATENOLOL  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-759-01,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOXYL 25 MCG ORAL TAB (FOR NEONATAL PATIENTS),50863,CDM,636,RC,J3490,HCPCS,60793-850-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNIT/G TOP PACK,50863,CDM,636,RC,J3490,HCPCS,0904-7402-67,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1230,HCPCS,0641-6266-01,NDC,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 5 MG-325 MG TAB,50863,CDM,250,RC,J3490,HCPCS,68084-895-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,636,RC,J1596,HCPCS,0143-9679-01,NDC,facility,both,801,ML,,18255,12778.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALASPARGASE PEGOL-MKNL 750 UNITS/ML IV SOLN,50863,CDM,J9118,HCPCS,72694-515-01,NDC,,,facility,both,375,ML,,75551,52885.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,J0665,HCPCS,55150-249-50,NDC,,,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,J3490,HCPCS,0409-1323-15,NDC,,,facility,both,200,ML,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  100 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,63323-376-00,NDC,facility,both,2,ML,"JW,JA",6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
GENTAMICIN 0.3 % OPHT DROP,50863,CDM,250,RC,J3490,HCPCS,24208-580-60,NDC,facility,both,1,ML,,210,147,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJ SOLN",50863,CDM,J3490,HCPCS,63323-468-37,NDC,,,facility,both,1,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  75 MCG ORAL TAB,50863,CDM,J3490,HCPCS,51079-441-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEGFILGRASTIM-JMDB (FULPHILA) 6 MG/0.6 ML SUBQ SYRG,50863,CDM,Q5108,HCPCS,67457-833-06,NDC,,,facility,both,12,ML,,11523,8066.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PSEUDOEPHEDRINE 30 MG TAB,50863,CDM,J3490,HCPCS,0904-6990-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,0409-9094-12,NDC,facility,both,4,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,15,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,65862-642-30,NDC,facility,both,4,EA,,265,185.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,250,RC,J3490,HCPCS,0143-9679-01,NDC,facility,both,1,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE-DIPHENHYD-AL-MAG-SIM 200-25-400-40 MG/30 ML MM MWSH,50863,CDM,250,RC,J3490,HCPCS,65628-050-01,NDC,facility,both,2,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 150 MG ORAL TBSR,50863,CDM,636,RC,J3490,HCPCS,68084-708-95,NDC,facility,both,3,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,J3490,HCPCS,68180-441-02,NDC,,,facility,both,5,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MODAFINIL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-570-11,NDC,facility,both,3,EA,,312,218.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GOLIMUMAB  12.5 MG/ML IV SOLN,50863,CDM,636,RC,J1602,HCPCS,57894-350-01,NDC,facility,both,20,ML,JW,960,672,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ISOSORBIDE MONONITRATE  20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0228-2620-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL  12 MCG/HR TD PT72,50863,CDM,636,RC,J3490,HCPCS,0406-9112-76,NDC,facility,both,1,EA,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MYCOPHENOLATE 250 MG CAP,50863,CDM,250,RC,J7517,HCPCS,51079-721-01,NDC,facility,both,4,EA,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN  2.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-027-11,NDC,facility,both,3,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN  6 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51672-4033-1,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAZOLAMIDE SODIUM 500 (100 MG/ML) INJ SOLR,50863,CDM,250,RC,J1120,HCPCS,23155-313-31,NDC,facility,both,1,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2308-22,NDC,facility,both,20,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM PHOSPHATES 19 GRAM-7 GRAM ENEMA,50863,CDM,636,RC,J3490,HCPCS,0132-0201-40,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ORAL ELECTROLYTES ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,74024001,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COENZYME Q10 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,5789687503,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,200,ML,,196,137.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYALURONIDASE 150 UNIT/ML INJ SOLN,50863,CDM,250,RC,J3473,HCPCS,18657-117-01,NDC,facility,both,15,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 50 MG TAB,50863,CDM,636,RC,J3490,HCPCS,69452-345-60,NDC,facility,both,1,EA,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,50863,CDM,250,RC,J2359,HCPCS,0781-3159-72,NDC,facility,both,5,EA,JZ,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-28,NDC,facility,both,80,EA,,431,301.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CILOSTAZOL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,70436-157-06,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,2,EA,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ACYCLOVIR 800 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60505-5307-1,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,7,EA,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 10 GRAM/15 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-0873-32,NDC,facility,both,1,ML,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-742-11,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZIPRASIDONE 20 MG IM,50863,CDM,636,RC,J3486,HCPCS,0049-3920-20,NDC,facility,both,2,EA,,328,229.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-50,NDC,facility,both,45,ML,JW,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LURASIDONE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-747-11,NDC,facility,both,1,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,70594-117-01,NDC,facility,both,100,ML,JZ,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,0075-0620-01,NDC,facility,both,4,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML IV SOLN,50863,CDM,J3490,HCPCS,55150-222-20,NDC,,,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,0409-3178-16,NDC,,,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,J0132,HCPCS,55150-259-30,NDC,,,facility,both,120,ML,,542,379.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,50863,CDM,J1650,HCPCS,0548-5604-00,NDC,,,facility,both,16,ML,,141,98.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42291-083-30,NDC,facility,both,4,EA,,265,185.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2001,HCPCS,63323-492-04,NDC,,,facility,both,4,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,250,RC,J3490,HCPCS,0173-0682-20,NDC,facility,both,1,GM,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-735-11,NDC,facility,both,2,EA,,374,261.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,636,RC,J2003,HCPCS,63323-485-27,NDC,facility,both,300,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MICAFUNGIN 100 MG IV SOLR,50863,CDM,250,RC,J2248,HCPCS,42023-230-01,NDC,facility,both,50,EA,,324,226.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,66794-229-02,NDC,facility,both,2,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  125 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,23155-858-78,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-453-11,NDC,facility,both,7,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MODAFINIL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65862-601-30,NDC,facility,both,1,EA,,130,91,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,23155-687-31,NDC,facility,both,2,ML,"JZ,JA",20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
AMPHOTERICIN B LIPOSOME 50 MG IV SUSR,50863,CDM,250,RC,J0289,HCPCS,0469-3051-30,NDC,facility,both,10,EA,,2189,1532.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J3490,HCPCS,0338-0049-01,NDC,facility,both,7,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,417,ME,,5659,3961.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-087-02,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NORTRIPTYLINE 10 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,50268-603-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 125 MG ORAL TBEC,50863,CDM,J3490,HCPCS,62756-796-88,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,0143-9577-01,NDC,,,facility,both,90,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,7,EA,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESNA 100 MG/ML IV SOLN,50863,CDM,250,RC,J9209,HCPCS,10019-953-62,NDC,facility,both,6,ML,,174,121.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-099-11,NDC,facility,both,7,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DASATINIB 100 MG ORAL TAB,50863,CDM,250,RC,J9999,HCPCS,0003-0852-22,NDC,facility,both,1,EA,,1679,1175.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE 14 MG/24 HR TD PT24,50863,CDM,636,RC,J3490,HCPCS,0536-5895-88,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MULTIVIT-MIN-FERROUS GLUCONATE 9 MG IRON/ 15 ML (15 ML) ORAL LIQD,50863,CDM,636,RC,J3490,HCPCS,1785600102,NDC,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 0.1 % TOP OINT,50863,CDM,250,RC,J3490,HCPCS,45802-055-05,NDC,facility,both,1,GM,,203,142.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 0.1 % TOP OINT,50863,CDM,250,RC,J3490,HCPCS,0168-0006-15,NDC,facility,both,2,GM,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,63323-482-01,NDC,facility,both,100,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"TRANEXAMIC ACID IN NACL,ISO-OS 1,000 MG/100 ML (10 MG/ML) IV PGBK",50863,CDM,636,RC,J3490,HCPCS,80830-2329-1,NDC,facility,both,1,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRIL MALEATE 1 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,69238-1729-7,NDC,facility,both,1,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-191-11,NDC,facility,both,2,EA,,202,141.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,50863,CDM,250,RC,J0696,HCPCS,60505-6148-0,NDC,facility,both,20,EA,,1124,786.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,63323-185-09,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7123-61,NDC,facility,both,1,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIACIN  250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,4329255740,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-492-27,NDC,facility,both,160,ML,,126,88.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,24,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FERRIC CARBOXYMALTOSE (INJECTAFER) 50 MG IRON/ML IV SOLN,50863,CDM,636,RC,J1439,HCPCS,0517-0650-01,NDC,facility,both,750,ML,JZ,4446,3112.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,636,RC,J1815,HCPCS,49502-393-80,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J2310,HCPCS,67457-299-00,NDC,facility,both,2,ML,,257,179.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANTI-INHIBITOR COAGULANT CMPLX (PHS MERGE),50863,CDM,250,RC,J7198,HCPCS,64193-324-01,NDC,facility,both,5610,UN,,34839,24387.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE IN D5W 1 GRAM/100 ML IV PGBK,50863,CDM,636,RC,J3475,HCPCS,0409-6727-55,NDC,facility,both,2,ML,JZ,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CISPLATIN 1 MG/ML IV,50863,CDM,250,RC,J9060,HCPCS,63323-103-64,NDC,facility,both,4,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV (BOLUS),50863,CDM,250,RC,J7040,HCPCS,0338-0049-10,NDC,facility,both,1,ML,,130,91,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J3490,HCPCS,63323-201-10,NDC,,,facility,both,21,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 200 MG INJ SOLR,50863,CDM,250,RC,J0640,HCPCS,0143-9553-01,NDC,facility,both,4,EA,,139,97.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG ORAL CAP,50863,CDM,J3490,HCPCS,60687-152-11,NDC,,,facility,both,4,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 20 MG ORAL TAB,50863,CDM,J3490,HCPCS,51079-209-01,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE  50 MCG/ACTUATION NASL SPSN,50863,CDM,J3490,HCPCS,60505-0829-1,NDC,,,facility,both,1,GM,,362,253.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEMAZEPAM  7.5 MG ORAL CAP,50863,CDM,J3490,HCPCS,68084-549-11,NDC,,,facility,both,2,EA,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,50863,CDM,J3490,HCPCS,60687-742-11,NDC,,,facility,both,4,EA,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,63739-931-28,NDC,facility,both,10,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENTACAPONE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-188-11,NDC,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,7,EA,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,J2704,HCPCS,63323-269-69,NDC,,,facility,both,175,ML,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLECAINIDE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-0010-20,NDC,facility,both,2,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2305-16,NDC,facility,both,10,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IR SOLN,50863,CDM,250,RC,J3490,HCPCS,0338-0047-46,NDC,facility,both,2,ML,,111,77.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,43598-053-11,NDC,facility,both,33,ML,,1184,828.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-25,NDC,facility,both,80,ML,,11316,7921.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,70095-026-01,NDC,facility,both,3,ML,JW,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PENTAMIDINE 300 MG INJ SOLR,50863,CDM,250,RC,J3490,HCPCS,23155-748-31,NDC,facility,both,1,EA,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3370,HCPCS,70436-021-82,NDC,facility,both,4,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,70069-013-25,NDC,facility,both,3,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,636,RC,J0330,HCPCS,31722-981-10,NDC,facility,both,15,ML,,169,118.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) 20000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,72603-224-01,NDC,facility,both,1,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 20MG/ML IV SYRINGE (PEDS/NEO),50863,CDM,250,RC,J0612,HCPCS,63323-311-10,NDC,facility,both,15,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,636,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,12,ML,JZ,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-1283-03,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-467-01,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,J3490,HCPCS,63323-486-02,NDC,,,facility,both,200,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,J0665,HCPCS,0409-1162-18,NDC,,,facility,both,300,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,J0665,HCPCS,0409-1162-18,NDC,,,facility,both,200,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,72485-106-01,NDC,facility,both,25,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM BROMIDE 0.02 % INHL SOLN,50863,CDM,J3490,HCPCS,60687-394-79,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),50863,CDM,J0171,HCPCS,76329-3318-1,NDC,,,facility,both,20,ML,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION,50863,CDM,636,RC,J3490,HCPCS,0186-0370-28,NDC,facility,both,1,GM,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,0955-1008-01,NDC,facility,both,8,ML,,101,70.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,50863,CDM,J9025,HCPCS,0143-9606-01,NDC,,,facility,both,55,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TERAZOSIN  1 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,50268-764-11,NDC,facility,both,4,EA,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENOFIBRATE NANOCRYSTALLIZED  48 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-599-01,NDC,facility,both,2,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESNA 100 MG/ML IV SOLN,50863,CDM,250,RC,J9209,HCPCS,10019-953-62,NDC,facility,both,49,ML,,1438,1006.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOMYCIN-BACITRACN ZN-POLYMYXIN 3.5 MG-400 U*,50863,CDM,636,RC,J3490,HCPCS,45802-061-70,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-9558-05,NDC,facility,both,3,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LINEZOLID 100 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0054-0319-50,NDC,facility,both,1,ML,,377,263.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,250,RC,J2270,HCPCS,76045-004-10,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LURASIDONE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7355-04,NDC,facility,both,6,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,68180-150-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,2055503601,NDC,facility,both,5,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J2004,HCPCS,63323-482-03,NDC,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-559-01,NDC,facility,both,5,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL  75 MCG/HR TD PT72,50863,CDM,250,RC,J3490,HCPCS,47781-427-11,NDC,facility,both,1,EA,,252,176.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,250,RC,Q0162,HCPCS,65162-691-79,NDC,facility,both,4,ML,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 650 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,66553-008-01,NDC,facility,both,5,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE  5 MG/ML INJ SOLN,50863,CDM,636,RC,J2765,HCPCS,0409-3414-18,NDC,facility,both,1,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,J3490,HCPCS,70004-600-09,NDC,,,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE IN 0.9% NS (PF) 1 MG/10 ML (100 MCG/ML) IV SYRG(PDS MERGE),50863,CDM,J3490,HCPCS,70092-1046-46,NDC,,,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML IV,50863,CDM,J3490,HCPCS,25021-319-05,NDC,,,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MINERAL OIL,50863,CDM,636,RC,J3490,HCPCS,6332325410,NDC,facility,both,1,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN  100 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,5026885211,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT 200 MCG/0.4 ML INJ SYRG,50863,CDM,J0881,HCPCS,55513-028-01,NDC,,,facility,both,200,ML,,4273,2991.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-492-04,NDC,,,facility,both,300,ML,,236,165.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,J3490,HCPCS,73013-2002-2,NDC,,,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,636,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,6,EA,,208,145.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALACYCLOVIR 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-215-11,NDC,facility,both,4,EA,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MANNITOL 25 % IV SOLN,50863,CDM,J2150,HCPCS,63323-024-01,NDC,,,facility,both,2,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMBRISENTAN  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,47335-236-83,NDC,facility,both,1,EA,,1005,703.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,J7512,HCPCS,0904-7127-61,NDC,,,facility,both,180,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN D5W 20000 UNIT/500 ML,50863,CDM,250,RC,J1644,HCPCS,0264-9567-10,NDC,facility,both,20,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DANTROLENE  25 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7211-04,NDC,facility,both,4,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,63739-931-28,NDC,facility,both,30,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,95,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IR SOLN,50863,CDM,250,RC,J3490,HCPCS,0338-0047-46,NDC,facility,both,3,ML,,139,97.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTAMIDINE 300 MG INJ SOLR,50863,CDM,636,RC,J3490,HCPCS,63323-113-01,NDC,facility,both,1,EA,,194,135.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,50863,CDM,J9041,HCPCS,72603-270-01,NDC,,,facility,both,13,EA,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 17 GRAM (100 %) ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,0904-6931-86,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 300 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-461-11,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELATACEPT 250 MG IV SOLR,50863,CDM,636,RC,J0485,HCPCS,0003-0371-13,NDC,facility,both,485,EA,,5004,3502.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,100,EA,JZ,13800,9660,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
METHYLERGONOVINE 0.2 MG/ML (1 ML) INJ SOLN,50863,CDM,250,RC,J2210,HCPCS,51991-144-99,NDC,facility,both,2,ML,,145,101.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL  6.25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-854-11,NDC,facility,both,3,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LITHIUM CARBONATE 300 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,68084-640-11,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-134-11,NDC,facility,both,10,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,636,RC,P9045,HCPCS,68516-5219-0,NDC,facility,both,8,ML,JZ,2034,1423.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IV PGBK,50863,CDM,250,RC,J3475,HCPCS,44567-420-24,NDC,facility,both,2,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ELECTROLYTE-A IV,50863,CDM,636,RC,J3490,HCPCS,0338-0221-03,NDC,facility,both,2,ML,,167,116.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 300 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,71247-130-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,59651-488-01,NDC,facility,both,40,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM NEO/PEDS INFUSION (CDS MIXTURE),50863,CDM,250,RC,J2543,HCPCS,0206-8852-08,NDC,facility,both,4,EA,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,636,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,9,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 20 MG/ACTUATION NASL SPRY,50863,CDM,636,RC,J3490,HCPCS,0527-1859-43,NDC,facility,both,1,EA,,345,241.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 4 MEQ/ML IV SOLP (COMPOUNDED 30ML),50863,CDM,250,RC,J3490,HCPCS,63323-093-01,NDC,facility,both,2,ML,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 100 % ORAL POWDER 238 GRAMS,50863,CDM,250,RC,J3490,HCPCS,43386-312-08,NDC,facility,both,1,GM,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROATE SODIUM 100 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-494-01,NDC,facility,both,6,ML,,268,187.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN IN D5W 400 MG/200 ML IV PGBK,50863,CDM,250,RC,J0744,HCPCS,25021-114-87,NDC,facility,both,6,ML,,140,98,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,65219-570-01,NDC,facility,both,24,ML,,553,387.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 250 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,50268-259-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,636,RC,J1815,HCPCS,49502-393-80,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  5 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,60687-122-11,NDC,facility,both,3,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 20 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7346-61,NDC,facility,both,2,EA,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCUSATE SODIUM 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,57896-401-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 50 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,59651-489-01,NDC,facility,both,99,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 30 MG TAB,50863,CDM,636,RC,J3490,HCPCS,60687-717-11,NDC,facility,both,12,EA,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 2 GRAM IV SOLUTION,50863,CDM,250,RC,J9075,HCPCS,10019-957-11,NDC,facility,both,362,EA,,3660,2562,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 200 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-552-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 250 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,0904-6363-61,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM & SODIUM PHOSPHATES 280-160-250 MG ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,7135101001,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM  3 GRAM INJ SOLR,50863,CDM,250,RC,J0295,HCPCS,44567-211-10,NDC,facility,both,2,EA,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE MODIFIED 100 MG ORAL CAP,50863,CDM,250,RC,J7502,HCPCS,23155-839-11,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0406-0552-23,NDC,facility,both,3,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEPLIZUMAB-MZWV 2 MG/20 ML IV SOLN,50863,CDM,636,RC,J9381,HCPCS,73650-316-01,NDC,facility,both,380,ME,JW,9988,6991.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GLYCOPYRROLATE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,23155-606-01,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 20 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,60687-723-11,NDC,facility,both,1,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  500 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,0641-6176-01,NDC,facility,both,40,ML,,411,287.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 30 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-087-01,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE CONCENTRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0054-0404-44,NDC,facility,both,3,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAMIDRONATE 3 MG/ML IV SOLN,50863,CDM,250,RC,J2430,HCPCS,61703-324-18,NDC,facility,both,2,ML,,170,119,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,43547-405-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-555-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6290-61,NDC,facility,both,6,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUANFACINE 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,24979-198-01,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIVAROXABAN 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50458-578-01,NDC,facility,both,1,EA,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,14789-127-07,NDC,facility,both,2,ML,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-979-01,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,68094-231-59,NDC,facility,both,3,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM IN NACL (ISO-OS) 500 MG/100 ML IV PGBK,50863,CDM,250,RC,J1953,HCPCS,67457-255-00,NDC,facility,both,19,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"TRANEXAMIC ACID IN NACL,ISO-OS 1,000 MG/100 ML (10 MG/ML) IV PGBK",50863,CDM,250,RC,J3490,HCPCS,65219-534-01,NDC,facility,both,2,ML,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN  10 GRAM INJ SOLR,50863,CDM,636,RC,J0690,HCPCS,0143-9983-03,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0527-3281-46,NDC,facility,both,2,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE  50 MG ORAL TAB,50863,CDM,250,RC,j3490,HCPCS,0904-6868-61,NDC,facility,both,2,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-325-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-433-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 25 MG CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7237-60,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  37.5 MG ORAL CP24,50863,CDM,636,RC,J3490,HCPCS,68084-698-11,NDC,facility,both,2,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,250,RC,J2720,HCPCS,63323-229-01,NDC,facility,both,13,ML,,228,159.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 1 MG ORAL CAP,50863,CDM,250,RC,J7507,HCPCS,51079-818-01,NDC,facility,both,3,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CITRATE  5 MEQ ORAL TBER,50863,CDM,250,RC,J3490,HCPCS,31722-129-01,NDC,facility,both,6,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXAZOSIN 2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-5523-61,NDC,facility,both,3,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCOSAMINE SULFATE  500 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,5026837511,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MERCAPTOPURINE 25 MG SPLIT TABLET,50863,CDM,250,RC,J3490,HCPCS,99999-501-19,NDC,facility,both,1,EA,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 3 HALF TABLET
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,6,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCERIN (ADULT) RECTAL SUPPOSITORY,50863,CDM,636,RC,J3490,HCPCS,0132-0079-24,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  40 MG ORAL TR12,50863,CDM,250,RC,J3490,HCPCS,59011-440-20,NDC,facility,both,2,EA,,205,143.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 2 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,63323-489-27,NDC,facility,both,800,ML,,276,193.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN   81 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,57896-981-01,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-676-11,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,636,RC,J3490,HCPCS,63323-486-02,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4 % MUCOSAL TOPICAL SOLN,50863,CDM,250,RC,J3490,HCPCS,70954-518-10,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,50863,CDM,636,RC,J0561,HCPCS,60793-700-01,NDC,facility,both,12,ML,,1674,1171.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,0143-9511-01,NDC,facility,both,19,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FERUMOXYTOL 510 MG/17 ML (30 MG/ML) IV SOLN,50863,CDM,Q0138,HCPCS,0781-3154-01,NDC,,,facility,both,510,ML,,2499,1749.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,J1885,HCPCS,25021-701-01,NDC,,,facility,both,1,ML,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZONATATE 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7153-61,NDC,facility,both,5,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,9,ML,,14740,10318,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,250,RC,J0330,HCPCS,31722-981-10,NDC,facility,both,10,ML,,113,79.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICARDIPINE 25 MG/10 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,72485-116-01,NDC,facility,both,1,ML,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID (PORK)  30 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0456-0458-01,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML IV SOLN (MERGE),50863,CDM,250,RC,J3490,HCPCS,16714-037-10,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  120 MG RECT SUPP,50863,CDM,250,RC,J3490,HCPCS,0713-0118-06,NDC,facility,both,3,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIVAROXABAN 15 MG ORAL TAB,50863,CDM,J3490,HCPCS,50458-578-01,NDC,,,facility,both,1,EA,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,53,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLN,50863,CDM,636,RC,J3262,HCPCS,50242-135-01,NDC,facility,both,320,ML,"JZ,JA",5865,4105.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
IPRATROPIUM BROMIDE 0.02 % INHL SOLN,50863,CDM,636,RC,J3490,HCPCS,0487-9801-01,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOCARNITINE (WITH SUCROSE) 100 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,52817-830-04,NDC,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VITAMIN A 10000 UNIT ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,904208560,NDC,facility,both,5,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IR SOLN,50863,CDM,250,RC,J3490,HCPCS,0338-0047-46,NDC,facility,both,3,ML,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN NEO/PEDS IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0456,HCPCS,63323-398-14,NDC,facility,both,1,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR 800 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-062-11,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,50863,CDM,250,RC,J9206,HCPCS,0009-0082-02,NDC,facility,both,17,ML,,555,388.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPH-MIN OIL-PETROLATUM 0.25-14-74.9 % RECT OINT,50863,CDM,636,RC,J3490,HCPCS,0536-1288-06,NDC,facility,both,1,GM,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6440-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-5343-01,NDC,facility,both,1,EA,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,636,RC,J3490,HCPCS,0338-1055-48,NDC,facility,both,50,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,J1644,HCPCS,72603-179-01,NDC,,,facility,both,5,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 600 MG ORAL TP12,50863,CDM,636,RC,J3490,HCPCS,63824-008-15,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROPROCAINE 3 % INJ SOLN,50863,CDM,250,RC,J2401,HCPCS,63323-478-01,NDC,facility,both,552,ML,JW,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
SODIUM POLYSTYRENE SULF-SORBTL 15-20 GRAM/60 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,46287-006-60,NDC,facility,both,2,ML,,264,184.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,0338-0069-10,NDC,facility,both,2,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-681-02,NDC,facility,both,2,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6374-61,NDC,facility,both,3,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,60687-145-11,NDC,facility,both,30,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,154,ML,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2305-04,NDC,facility,both,9,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,636,RC,J2003,HCPCS,63323-485-27,NDC,facility,both,90,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COENZYME Q10 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,5789687503,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J3490,HCPCS,0338-0049-48,NDC,facility,both,10,ML,,200,140,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZOCAINE-MENTHOL 20-0.26 % MM GEL,50863,CDM,250,RC,J3490,HCPCS,1031043028,NDC,facility,both,1,GM,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIGOXIN 125 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-5921-61,NDC,facility,both,2,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL (5 MG/ML) IV SYRG PF,50863,CDM,250,RC,J3490,HCPCS,71506-046-45,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,6,EA,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN SODIUM EXTENDED 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,51672-4111-1,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-450-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VERAPAMIL 2.5 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,72485-108-01,NDC,facility,both,1,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,50863,CDM,250,RC,J9075,HCPCS,10019-956-16,NDC,facility,both,114,EA,,739,517.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0574-0521-76,NDC,facility,both,1,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,636,RC,J2003,HCPCS,0409-1323-05,NDC,facility,both,800,ML,,352,246.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"VITAMIN E (DL, ACETATE) 22.5 MG (50 UNIT)/ML ORAL DROP",50863,CDM,250,RC,J3490,HCPCS,7132180230,NDC,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MISOPROSTOL 100 MCG ORAL TAB,50863,CDM,636,RC,S0191,HCPCS,60687-735-11,NDC,facility,both,4,EA,GZ,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier GZ: Item or service expected to be denied as not reasonable and necessary
BETAMETHASONE ACET & SOD PHOS 6 MG/ML INJ SUSP,50863,CDM,636,RC,J0702,HCPCS,78206-118-01,NDC,facility,both,2,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN (NEO),50863,CDM,250,RC,J1940,HCPCS,71288-203-10,NDC,facility,both,8,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 10 % (100 MG/ML) MISC SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-695-04,NDC,facility,both,25,ML,,1289,902.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-543-01,NDC,facility,both,2,EA,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,43547-281-10,NDC,facility,both,2,EA,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENDAMUSTINE 25 MG/ML IV SOLN,50863,CDM,250,RC,J9034,HCPCS,63459-348-04,NDC,facility,both,100,ML,,6828,4779.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE (CONTRACEPTIVE) 150 MG/ML IM SUSP,50863,CDM,250,RC,J1050,HCPCS,55150-329-01,NDC,facility,both,150,ML,,216,151.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 0.1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,23155-489-01,NDC,facility,both,2,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 250 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,0832-7123-89,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-4799-05,NDC,facility,both,3,ML,,101,70.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,72603-179-01,NDC,facility,both,9,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,188,ML,,133,93.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIFAXIMIN 550 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,65649-303-03,NDC,facility,both,1,EA,,278,194.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN ASP PRT-INSULIN ASPART 100 UNIT/ML (70-30) SUBQ SOLN,50863,CDM,636,RC,J1817,HCPCS,73070-200-11,NDC,facility,both,2,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,50863,CDM,250,RC,J9000,HCPCS,0069-1542-20,NDC,facility,both,2,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  20 MEQ ORAL PACK,50863,CDM,250,RC,J3490,HCPCS,43386-194-90,NDC,facility,both,2,EA,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FERROUS SULFATE 220 MG (44 MG IRON)/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,536115516,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-0710-20,NDC,facility,both,17,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0536-1327-06,NDC,facility,both,24,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,636,RC,J2597,HCPCS,65219-293-00,NDC,facility,both,3,ML,JW,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ACETYLCYSTEINE 10 % (100 MG/ML) MISC SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-695-22,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2305-04,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0093-4177-73,NDC,facility,both,7,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RASBURICASE 1.5 MG IV SOLR,50863,CDM,250,RC,J2783,HCPCS,0024-5154-11,NDC,facility,both,1,EA,JW,751,525.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ACYCLOVIR 200 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60505-0042-6,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THEOPHYLLINE 80 MG/15 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-0820-16,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETHAMBUTOL 400 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-280-11,NDC,facility,both,2,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  5 MG ORAL TBDL,50863,CDM,636,RC,J3490,HCPCS,55111-262-79,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,176,ML,,159,111.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM ACETATE 667 MG ORAL CAP,50863,CDM,250,RC,J0615,HCPCS,68084-479-11,NDC,facility,both,87,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 500 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,0832-7124-89,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 100 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,60687-479-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  5 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,60687-122-11,NDC,facility,both,5,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE (PEDIATRIC 3 MONTH) 30 MG IM SYKT,50863,CDM,636,RC,J1950,HCPCS,0074-9694-03,NDC,facility,both,8,EA,,35874,25111.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,50863,CDM,250,RC,J8540,HCPCS,0904-7266-61,NDC,facility,both,32,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-01,NDC,facility,both,1,ML,JZ,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
POTASSIUM CHLORIDE 20 MEQ/100 ML IV PGBK,50863,CDM,250,RC,J3480,HCPCS,0409-7075-26,NDC,facility,both,10,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 100 MG/1 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0075-0623-03,NDC,facility,both,1,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
THROMBIN (RECOMBINANT) 20000 UNIT TOP SOLR,50863,CDM,250,RC,J3490,HCPCS,0338-0326-01,NDC,facility,both,4,EA,,4872,3410.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADVATE: FACTOR VIII CONCENTRATE (MERGE RECORD),50863,CDM,250,RC,J7192,HCPCS,0944-3051-03,NDC,facility,both,500,UN,,2685,1879.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATED 20 MG/ML IV SOLN,50863,CDM,250,RC,J0706,HCPCS,51754-0500-1,NDC,facility,both,7,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,636,RC,J7060,HCPCS,0338-0017-38,NDC,facility,both,1,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,70069-363-01,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,71,EA,,9798,6858.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J0461,HCPCS,0517-1004-01,NDC,facility,both,100,ML,,165,115.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN (NEW TX NON-NEURO INDICATION)",50863,CDM,250,RC,J1561,HCPCS,13533-800-71,NDC,facility,both,20,ML,,2829,1980.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPSONE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,49938-101-30,NDC,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES  8.6 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7252-61,NDC,facility,both,10,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IVPB (PEDIATRICS/ADULT NON-FORM)",50863,CDM,636,RC,J0137,HCPCS,24201-100-01,NDC,facility,both,49,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-709-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE IN D5W 1 GRAM/100 ML IV PGBK,50863,CDM,636,RC,J3475,HCPCS,0409-6727-23,NDC,facility,both,2,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 2-0.5 MG SL SUBL,50863,CDM,636,RC,J3490,HCPCS,0904-7009-06,NDC,facility,both,3,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7243-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPOETIN ALFA-EPBX 10000 UNITS/ML INJ SOLN,50863,CDM,636,RC,Q5106,HCPCS,0069-1308-01,NDC,facility,both,10,ML,EC,477,333.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier EC: Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy
PHYTONADIONE 1 MG/ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-9158-01,NDC,facility,both,3,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-20,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PERPHENAZINE  4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6600-61,NDC,facility,both,3,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 150 MG CAP,50863,CDM,J3490,HCPCS,0904-5959-61,NDC,,,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE SR 37.5 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,42858-707-03,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,50863,CDM,J0696,HCPCS,0143-9856-01,NDC,,,facility,both,24,EA,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,J3490,HCPCS,0409-1891-01,NDC,,,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE  2 MG/ML INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,70069-062-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,J1100,HCPCS,63323-165-16,NDC,,,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIFEDIPINE 10 MG ORAL CAP,50863,CDM,J3490,HCPCS,0904-7229-61,NDC,,,facility,both,3,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,13,EA,JZ,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,14789-128-07,NDC,facility,both,5,ML,,896,627.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  15 MG ORAL TAB,50863,CDM,J3490,HCPCS,0406-8515-23,NDC,,,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLERGONOVINE 0.2 MG/ML (1 ML) INJ SOLN,50863,CDM,J2210,HCPCS,51991-144-99,NDC,,,facility,both,1,ML,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,250,RC,J0690,HCPCS,70092-1017-46,NDC,facility,both,10,ML,,198,138.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML IV,50863,CDM,J3490,HCPCS,70860-301-41,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPTOMYCIN 500 MG IV SOLR,50863,CDM,J0878,HCPCS,70594-034-01,NDC,,,facility,both,700,EA,,428,299.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLECAINIDE  50 MG ORAL TAB,50863,CDM,J3490,HCPCS,0054-0010-21,NDC,,,facility,both,3,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 10 GRAM IV SOLR,50863,CDM,250,RC,J3373,HCPCS,70436-023-82,NDC,facility,both,200,EA,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-208-01,NDC,facility,both,300,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 125 MCG SUBQ SOLR,50863,CDM,636,RC,J2796,HCPCS,55513-223-01,NDC,facility,both,25,EA,,5130,3591,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DROPERIDOL 2.5 MG/ML INJ SOLN,50863,CDM,636,RC,J1790,HCPCS,0143-9514-01,NDC,facility,both,2,ML,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 250 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,50268-259-11,NDC,facility,both,4,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6418-61,NDC,facility,both,2,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,636,RC,J2003,HCPCS,0409-4277-02,NDC,facility,both,200,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,636,RC,J3490,HCPCS,0143-9575-01,NDC,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0121-1022-05,NDC,facility,both,6,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM THIOSULFATE 25 % IV SOLN,50863,CDM,J3490,HCPCS,60267-705-50,NDC,,,facility,both,1,ML,,413,289.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,250,RC,J3490,HCPCS,60687-653-11,NDC,facility,both,4,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL  32.4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6575-61,NDC,facility,both,6,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) IV SOLN",50863,CDM,250,RC,J3490,HCPCS,67457-197-00,NDC,facility,both,1,ML,,368,257.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,3,EA,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),50863,CDM,250,RC,J0169,HCPCS,76329-3318-1,NDC,facility,both,90,ML,,726,508.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE   4.2 % IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-083-05,NDC,facility,both,1,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0143-9595-01,NDC,facility,both,50,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0143-9509-01,NDC,facility,both,1,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IR SOLN,50863,CDM,J3490,HCPCS,0338-0047-47,NDC,,,facility,both,1,ML,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE 2 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,0904-7154-04,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0121-1022-05,NDC,facility,both,5,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 40 MG ORAL TAB,50863,CDM,J3490,HCPCS,51079-210-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-098-11,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IR SOLN,50863,CDM,J3490,HCPCS,0338-0048-03,NDC,,,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
D5-1/2 NS AND POTASSIUM CHLORIDE 20 MEQ/L IV (PEDS CHEMO),50863,CDM,J3490,HCPCS,0338-0671-04,NDC,,,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,63323-482-03,NDC,,,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J3490,HCPCS,0409-3178-16,NDC,,,facility,both,200,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0990-7983-61,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 600 MG ORAL TP12,50863,CDM,J3490,HCPCS,68084-572-11,NDC,,,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TARLATAMAB-DLLE 10 MG IV SOLR,50863,CDM,J9026,HCPCS,55513-069-01,NDC,,,facility,both,10,EA,,17988,12591.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,50863,CDM,J3490,HCPCS,60687-742-11,NDC,,,facility,both,4,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-9303-10,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM BICARB-CITRIC ACID 20 MEQ ORAL TBEF,50863,CDM,J3490,HCPCS,51801-012-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML IM SOLN,50863,CDM,636,RC,90375,HCPCS,13533-318-05,NDC,facility,both,7,ML,,6262,4383.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,76045-009-10,NDC,facility,both,12,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN ASP PRT-INSULIN ASPART 100 UNIT/ML (70-30) SUBQ SOLN,50863,CDM,636,RC,J1817,HCPCS,73070-200-11,NDC,facility,both,2,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 2-0.5 MG SL SUBL,50863,CDM,636,RC,J3490,HCPCS,50268-144-11,NDC,facility,both,3,EA,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN NEO IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J3373,HCPCS,0338-3582-01,NDC,facility,both,33,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SYRG,50863,CDM,J3490,HCPCS,8290306546,NDC,,,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,J3490,HCPCS,0093-2279-73,NDC,,,facility,both,5,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-4278-01,NDC,facility,both,500,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2001,HCPCS,63323-492-57,NDC,,,facility,both,5,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2003,HCPCS,55150-164-02,NDC,,,facility,both,40,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML (1ML) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,54288-119-01,NDC,facility,both,27,ML,,2134,1493.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENOFIBRATE NANOCRYSTALLIZED  48 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0074-6122-90,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,63323-104-01,NDC,facility,both,6,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,68462-469-40,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON DEXTRAN 50 MG/ML INJ SOLN,50863,CDM,250,RC,J1750,HCPCS,0023-6082-01,NDC,facility,both,30,ML,,3126,2188.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,70954-059-10,NDC,facility,both,80,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0047-03,NDC,facility,both,25,EA,JZ,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2310,HCPCS,36000-308-01,NDC,facility,both,4,ML,,333,233.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-097-11,NDC,facility,both,2,EA,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIOTHYRONINE  5 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-166-01,NDC,facility,both,1,EA,PLAD,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
MEDROXYPROGESTERONE  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,59762-3740-1,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 1 % INJ SOLN,50863,CDM,250,RC,Q9968,HCPCS,0517-0301-10,NDC,facility,both,20,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  15 MG ORAL TBSR,50863,CDM,J3490,HCPCS,0904-6557-61,NDC,,,facility,both,4,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ROTAVIRUS VACCINE LIVE, PENTA 2 ML ORAL SUSP",50863,CDM,90680,HCPCS,0006-4047-01,NDC,,,facility,both,1,ML,,444,310.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-492-57,NDC,,,facility,both,50,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-495-27,NDC,facility,both,60,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANTI-INHIBITOR COAGULANT CMPLX 350-650 UNIT IV SOLR,50863,CDM,250,RC,J7198,HCPCS,64193-423-02,NDC,facility,both,16,UN,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-497-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE MONONITRATE  30 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,0904-6449-61,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,636,RC,J0132,HCPCS,55150-259-30,NDC,facility,both,180,ML,,3098,2168.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL (5 MG/ML) IV SYRG (CONTAINS PRESERVATIVE),50863,CDM,250,RC,J3490,HCPCS,65302-503-04,NDC,facility,both,2,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROFURANTOIN (25% MACROCRYSTAL FORM) 100 MG CAP,50863,CDM,250,RC,J3490,HCPCS,60687-633-11,NDC,facility,both,10,EA,,173,121.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE HCL IN NS 10 MG/250 ML (0.04 MG/ML) IV SOLN (PDS MERGE),50863,CDM,636,RC,J2371,HCPCS,71506-029-58,NDC,facility,both,500,ML,,146,102.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-479-10,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELATACEPT 250 MG IV SOLR,50863,CDM,250,RC,J0485,HCPCS,0003-0371-13,NDC,facility,both,150,EA,JW,673,471.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0904-7127-61,NDC,facility,both,160,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0054-0710-20,NDC,facility,both,12,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0143-9889-15,NDC,facility,both,42,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 1 % INJ SOLN,50863,CDM,636,RC,Q9968,HCPCS,0517-0301-10,NDC,facility,both,10,ML,JZ,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MANNITOL 25 % IV SOLN,50863,CDM,250,RC,J2151,HCPCS,63323-024-01,NDC,facility,both,50,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN PEDS INFUSION (CDS MIXTURE),50863,CDM,250,RC,J0290,HCPCS,25021-136-10,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"NEOMYCIN-POLYMYXIN-PRAMOXINE 3.5 MG-10,000 UNIT-10 MG/G TOPICAL CREAM",50863,CDM,250,RC,J3490,HCPCS,70677-1218-1,NDC,facility,both,1,GM,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  750 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7125-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,636,RC,J2795,HCPCS,70069-064-25,NDC,facility,both,175,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,636,RC,J2704,HCPCS,25021-608-20,NDC,facility,both,9,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATRACURIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-1109-11,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE MONONITRATE  30 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,0904-6449-61,NDC,facility,both,5,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-681-02,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 1 MG/ML (1ML) SYRINGE (REPACK),50863,CDM,250,RC,J2997,HCPCS,50242-044-13,NDC,facility,both,5,EA,,1354,947.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE  5 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,0228-3062-11,NDC,facility,both,3,EA,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 150 MG CAP,50863,CDM,636,RC,J3490,HCPCS,68084-243-11,NDC,facility,both,4,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,63323-185-07,NDC,facility,both,3,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMTERENE-HYDROCHLOROTHIAZIDE 75 MG-50 MG TAB,50863,CDM,636,RC,J3490,HCPCS,68382-857-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 5 MG/ML IV SOLN,50863,CDM,250,RC,J1921,HCPCS,17478-420-20,NDC,facility,both,1,ML,JZ,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CARBIDOPA-LEVODOPA SR 50 MG-200 MG TAB,50863,CDM,636,RC,J3490,HCPCS,68084-282-11,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALSARTAN  40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,31722-151-30,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-450-11,NDC,facility,both,4,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,65219-187-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 20 MG/ML ORAL CONC,50863,CDM,250,RC,J3490,HCPCS,59762-4940-1,NDC,facility,both,1,ML,,285,199.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42291-809-15,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-495-09,NDC,,,facility,both,16,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,57237-077-10,NDC,facility,both,15,EA,,987,690.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,J2371,HCPCS,0781-3458-75,NDC,,,facility,both,2000,ML,,108,75.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-354-11,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DALBAVANCIN 500 MG IV SOLN,50863,CDM,250,RC,J0875,HCPCS,57970-100-01,NDC,facility,both,300,EA,,14732,10312.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6475-61,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VERAPAMIL 180 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,75834-158-01,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROTHIAZIDE SODIUM 500 MG IV SOLR,50863,CDM,250,RC,J1205,HCPCS,63323-658-94,NDC,facility,both,1,EA,,229,160.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETHYL ALCOHOL  99 % IART SOLN,50863,CDM,636,RC,J3490,HCPCS,54288-105-02,NDC,facility,both,4,ML,,9196,6437.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7050,HCPCS,0338-0049-02,NDC,facility,both,2,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-174-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) 1000 UNITS/ML INJ SOL (FOR DIALYSIS ONLY),50863,CDM,250,RC,J1644,HCPCS,67457-953-00,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,58657-676-01,NDC,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-245-11,NDC,facility,both,4,EA,,140,98,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7050,HCPCS,0338-0049-04,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-131-11,NDC,facility,both,3,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-145-11,NDC,facility,both,100,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,50863,CDM,250,RC,J9267,HCPCS,61703-342-50,NDC,facility,both,231,ML,,280,196,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),50863,CDM,250,RC,J1815,HCPCS,0024-5926-05,NDC,facility,both,6,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COVID VACCINE 24-25 (12UP)(PFI)(PF) 30 MCG/0.3 ML IM SYRG,50863,CDM,91320,HCPCS,0069-2528-01,NDC,,,facility,both,1,ML,,639,447.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,J2704,HCPCS,63323-269-22,NDC,,,facility,both,20,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSAPREPITANT 150 MG IV SOLR,50863,CDM,J1453,HCPCS,72205-054-01,NDC,,,facility,both,150,EA,,948,663.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,J7510,HCPCS,17856-0759-5,NDC,,,facility,both,6,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,16714-293-03,NDC,facility,both,9,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM-ALBUTEROL 0.5 MG-2.5 MG/3 ML NEB SOLUTION,50863,CDM,250,RC,J3490,HCPCS,0487-0201-00,NDC,facility,both,1,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL  3.125 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7305-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 10 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,67457-420-00,NDC,facility,both,30,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN   1.5 G IV SOLR,50863,CDM,250,RC,J3370,HCPCS,67457-824-99,NDC,facility,both,3,EA,,142,99.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0781-3458-75,NDC,facility,both,500,ML,,269,188.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE   4.2 % IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-083-05,NDC,facility,both,1,ML,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,0409-4264-11,NDC,facility,both,7,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 50 MG/ML IV SOLN,50863,CDM,636,RC,J0282,HCPCS,67457-153-99,NDC,facility,both,5,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 50 MG/ML IV SOLN,50863,CDM,250,RC,J0282,HCPCS,67457-153-03,NDC,facility,both,5,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAZOSIN 1 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,51079-630-01,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTOBARBITAL 75 MG/1.5 ML SYRINGE (REPACK),50863,CDM,636,RC,J3490,HCPCS,25021-676-20,NDC,facility,both,2,ML,,161,112.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  75 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6951-61,NDC,facility,both,3,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,250,RC,J3490,HCPCS,0173-0682-24,NDC,facility,both,30,GM,,1576,1103.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"CALCIUM CARBONATE 500 MG (1,250 MG) ORAL TAB",50863,CDM,250,RC,J3490,HCPCS,904188361,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"NEOMYCIN-POLYMYXIN-HC 3.5 MG-10,000 UNIT/ML-1 % EAR SOLN",50863,CDM,636,RC,J3490,HCPCS,61314-646-10,NDC,facility,both,1,ML,,378,264.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,636,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,25,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NADOLOL  20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-302-95,NDC,facility,both,2,EA,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 1000 MG MISC TBSO,50863,CDM,636,RC,J3490,HCPCS,77333-844-25,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,0904-6794-30,NDC,facility,both,3,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE IN SALINE (ISO-OSM) 400 MG/200 ML IV PIGGY BACK,50863,CDM,250,RC,J1450,HCPCS,0409-4321-01,NDC,facility,both,2,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYLAMINE SUCCINATE 25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,4116700607,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN PEDS INFUSION (CDS MIXTURE),50863,CDM,250,RC,J0290,HCPCS,99999-408-63,NDC,facility,both,2,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,63323-806-13,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,200,ML,,181,126.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3373,HCPCS,0143-9162-01,NDC,facility,both,400,EA,,160,112,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DACARBAZINE 200 MG IV SOLR,50863,CDM,250,RC,J9130,HCPCS,0143-9245-01,NDC,facility,both,6,EA,,180,126,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,636,RC,J1596,HCPCS,70700-165-22,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COENZYME Q10  30 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,536135807,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,83257-011-11,NDC,facility,both,16,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,83257-011-11,NDC,facility,both,6,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 875 MG-125 MG TAB,50863,CDM,J3490,HCPCS,60687-803-11,NDC,,,facility,both,1,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,J2704,HCPCS,0069-0209-01,NDC,,,facility,both,67,ML,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 60 MG ORAL CPDR,50863,CDM,J3490,HCPCS,68180-296-09,NDC,,,facility,both,1,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM BROMIDE 0.02 % INHL SOLN,50863,CDM,J3490,HCPCS,76204-100-01,NDC,,,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANTI-THYMOCYTE GLOB (RABBIT) 25 MG IV SOLR,50863,CDM,J7511,HCPCS,58468-0080-1,NDC,,,facility,both,4,EA,,8088,5661.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,6,ML,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN D5W 25000 UNIT/250 ML (PTT MONITORING),50863,CDM,250,RC,J1644,HCPCS,0409-4520-02,NDC,facility,both,25,ML,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE  50 MG ORAL TAB,50863,CDM,250,RC,j3490,HCPCS,60505-2653-1,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IR SOLN,50863,CDM,636,RC,J3490,HCPCS,0338-0047-46,NDC,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-11,NDC,facility,both,11,ML,JW,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
RISPERIDONE 0.5 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,59746-010-32,NDC,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SINCALIDE 5 MCG INJ SOLR,50863,CDM,636,RC,J2805,HCPCS,72266-248-05,NDC,facility,both,1,EA,,237,165.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 0.5 MG ORAL CAP,50863,CDM,250,RC,J7507,HCPCS,0904-6623-61,NDC,facility,both,3,EA,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER FLUSH,50863,CDM,636,RC,J7060,HCPCS,0264-7510-20,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,36000-283-25,NDC,facility,both,40,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML IV,50863,CDM,636,RC,J3490,HCPCS,17478-937-10,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-22,NDC,facility,both,100,ML,,200,140,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAUNORUBICIN 5 MG/ML IV INJ,50863,CDM,250,RC,J9150,HCPCS,0143-9550-01,NDC,facility,both,13,ML,,2878,2014.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHOTERICIN B LIPOSOME 50 MG IV SUSR,50863,CDM,250,RC,J0289,HCPCS,0469-3051-30,NDC,facility,both,10,EA,,2254,1577.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0904-6923-61,NDC,facility,both,10,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,168,ML,,152,106.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYTOCIN 10 UNIT/ML INJ SOLN,50863,CDM,250,RC,J2590,HCPCS,63323-012-11,NDC,facility,both,6,ML,,138,96.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,260,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENOFIBRATE NANOCRYSTALLIZED 145 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7161-04,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,43598-931-11,NDC,facility,both,24,ML,,1338,936.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69315-905-01,NDC,facility,both,3,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-411-10,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,13,EA,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-0235-25,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB 100 MG IV SOLR,50863,CDM,636,RC,J1745,HCPCS,57894-030-01,NDC,facility,both,90,EA,,29009,20306.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  5 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,0054-8724-25,NDC,facility,both,5,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAZOSIN 2 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,51079-631-01,NDC,facility,both,2,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0630,HCPCS,63323-865-02,NDC,facility,both,1,ML,JZ,2153,1507.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
INSULIN NPH & REGULAR HUMAN 100 UNIT/ML (70-30) SUBQ SUSP,50863,CDM,250,RC,J1815,HCPCS,0002-8715-01,NDC,facility,both,12,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL  97.2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,75826-142-10,NDC,facility,both,1,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 0.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7361-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FERRIC SUBSULFATE 0.2 TO 0.22 GRAM/ML MISC SOLA,50863,CDM,250,RC,J3490,HCPCS,48783-112-08,NDC,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,636,RC,J3490,HCPCS,14789-251-09,NDC,facility,both,1,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J2004,HCPCS,0409-3178-01,NDC,facility,both,40,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAMADOL  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-795-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,636,RC,J2405,HCPCS,70860-776-41,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,2,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 17 GRAM (100 %) ORAL PWPK,50863,CDM,636,RC,J3490,HCPCS,0904-6931-86,NDC,facility,both,2,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0591-0407-01,NDC,facility,both,3,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7247-68,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE (PF-DURAMORPH/ASTRAMORPH) 0.5 MG/ML INJ SOLN,50863,CDM,250,RC,J2274,HCPCS,0409-3814-12,NDC,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  1 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,59746-171-06,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 875 MG-125 MG TAB,50863,CDM,636,RC,J3490,HCPCS,16714-297-02,NDC,facility,both,14,EA,,292,204.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,636,RC,J2795,HCPCS,70069-064-25,NDC,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRIMIDONE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-686-11,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFUROXIME AXETIL 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65862-699-20,NDC,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAMADOL  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7496-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAMSULOSIN 0.4 MG ORAL CP24,50863,CDM,636,RC,J3490,HCPCS,50268-740-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 10 MEQ/100 ML IV PGBK,50863,CDM,250,RC,J3480,HCPCS,0990-7074-26,NDC,facility,both,5,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,72888-037-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-487-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,4,EA,JW,240,168,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
TOPIRAMATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-344-11,NDC,facility,both,2,EA,PLAD,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
HYDRALAZINE 1MG/ML IV SYRINGE (PEDS/NEO),50863,CDM,250,RC,J0360,HCPCS,99999-420-10,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RAVULIZUMAB-CWVZ 100 MG/ML IV SOLN,50863,CDM,636,RC,J1303,HCPCS,25682-025-01,NDC,facility,both,10,ML,JW,2562,1793.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
OXYCODONE 5 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0904-6828-05,NDC,facility,both,3,ML,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,2,EA,,193,135.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MECLIZINE 25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-730-11,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-132-11,NDC,facility,both,2,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,57237-099-60,NDC,facility,both,1,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROIC ACID 250 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,63739-086-10,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN NACL (PF) 1000 UNIT/500 ML IV SOLP,50863,CDM,636,RC,J1644,HCPCS,0409-1005-01,NDC,facility,both,4,ML,,167,116.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,636,RC,J1953,HCPCS,63323-400-01,NDC,facility,both,354,ML,,372,260.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXEPIN  50 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7054-61,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1940,HCPCS,72603-251-01,NDC,facility,both,3,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CITRATE 10 MEQ ORAL TBER,50863,CDM,250,RC,J3490,HCPCS,68084-850-33,NDC,facility,both,3,EA,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"AMIODARONE IN DEXTROSE,ISO-OSM 360 MG/200 ML (1.8 MG/ML) IV SOLN",50863,CDM,250,RC,J0282,HCPCS,43066-360-20,NDC,facility,both,8,ML,,144,100.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6638-61,NDC,facility,both,4,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM IN NACL (ISO-OS) 1000 MG/100 ML IV PGBK,50863,CDM,250,RC,J1953,HCPCS,43598-636-52,NDC,facility,both,100,ML,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 200 MG/100 ML IVPB (MERGE),50863,CDM,250,RC,J1450,HCPCS,0409-3435-01,NDC,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,66553-002-01,NDC,facility,both,5,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,36,ML,JW,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
INSULIN DETEMIR 100 UNIT/ML SUBQ SOLN,50863,CDM,636,RC,J1815,HCPCS,0169-3687-12,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 250 MG/50 ML CONCENTRATED DRIP (RSE),50863,CDM,250,RC,J2250,HCPCS,0641-6060-01,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES  8.6 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,69618-064-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0143-9889-15,NDC,facility,both,36,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  75 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7000-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,50863,CDM,250,RC,J0696,HCPCS,0143-9857-01,NDC,facility,both,8,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LINEZOLID 600 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6553-04,NDC,facility,both,1,EA,,659,461.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,63323-185-09,NDC,facility,both,1,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 12.5 MG ORAL TAB,50863,CDM,636,RC,Q0169,HCPCS,68084-154-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 20 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,0904-7043-61,NDC,facility,both,3,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,6,EA,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIROLIMUS 1 MG/ML ORAL SOLN,50863,CDM,250,RC,J7520,HCPCS,60505-6197-2,NDC,facility,both,1,ML,,139,97.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0054-0017-20,NDC,facility,both,10,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7350-06,NDC,facility,both,4,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUVOXAMINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69452-455-20,NDC,facility,both,3,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,70756-622-85,NDC,facility,both,1500,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,70095-031-01,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TICAGRELOR 90 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0186-0777-60,NDC,facility,both,2,EA,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,3,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE HCL  2 % MM JELP,50863,CDM,636,RC,J3490,HCPCS,76329-3012-5,NDC,facility,both,2,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,16714-294-02,NDC,facility,both,4,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN IN SALINE (ISO-OSMOTIC) 80 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1580,HCPCS,0338-0503-48,NDC,facility,both,6,ML,,160,112,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-328-10,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,63323-165-01,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-3178-16,NDC,facility,both,70,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-03,NDC,facility,both,4,ML,,111,77.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIFAMPIN 600 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,67457-445-60,NDC,facility,both,1,EA,,347,242.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,250,RC,Q0162,HCPCS,17856-0691-5,NDC,facility,both,4,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,63323-165-01,NDC,facility,both,4,ML,JZ,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
BUPRENORPHINE 100 MG/0.5 ML SUBQ SLSY,50863,CDM,636,RC,Q9991,HCPCS,12496-0100-1,NDC,facility,both,1,ML,,4418,3092.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETHAMBUTOL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68180-280-01,NDC,facility,both,7,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,50863,CDM,636,RC,J1756,HCPCS,0517-2340-01,NDC,facility,both,100,ML,JZ,321,224.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
HC IV INFUSION HYDRAT 31-60 MIN,50863,CDM,250,RC,J0248,HCPCS,61958-2901-2,NDC,facility,both,200,EA,JZ,2392,1674.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,68516-5214-1,NDC,facility,both,1,ML,JZ,263,184.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DEXTROSE 5% IN WATER (D5W) IV MBP,50863,CDM,636,RC,J7060,HCPCS,0338-0551-11,NDC,facility,both,1,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,25021-315-01,NDC,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 50 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,59651-489-01,NDC,facility,both,40,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,250,RC,J7060,HCPCS,0338-0017-48,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLORAZEPATE DIPOTASSIUM  3.75 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51672-4042-1,NDC,facility,both,4,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM ACETATE 0.9% WITH HEPARIN IV SYRINGE (NEONATAL),50863,CDM,250,RC,J3490,HCPCS,0409-7984-06,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOPAMINE IN D5W 400 MG/250 ML (1.6 MG/ML) IV,50863,CDM,250,RC,J1265,HCPCS,0409-7809-22,NDC,facility,both,10,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL  20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-717-11,NDC,facility,both,1,EA,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 100 MG/ML FROM 1 GRAM VIAL (PRMC PEDS ONLY),50863,CDM,250,RC,J0696,HCPCS,0409-7332-11,NDC,facility,both,4,EA,PLAD,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
LEVETIRACETAM 100 MG/ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,31722-574-47,NDC,facility,both,1,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TALQUETAMAB-TGVS 40 MG/ML SUBQ SOLN,50863,CDM,250,RC,J3055,HCPCS,57894-470-01,NDC,facility,both,144,ML,JW,11251,7875.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CELECOXIB 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,50268-168-11,NDC,facility,both,2,EA,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 10 GRAM/15 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,50383-779-30,NDC,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 1% 10MG/ML (1ML-UD) OR SYRINGE,50863,CDM,J2003,HCPCS,0409-4276-02,NDC,,,facility,both,300,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 200 MG ORAL TAB,50863,CDM,J3490,HCPCS,60687-437-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 50 MG/ML INJECTION,50863,CDM,J1200,HCPCS,63323-664-01,NDC,,,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLN,50863,CDM,J3262,HCPCS,50242-137-01,NDC,,,facility,both,360,ML,,6598,4618.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL PACK,50863,CDM,636,RC,J3490,HCPCS,42806-270-98,NDC,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE 100 MG CAP,50863,CDM,J3490,HCPCS,50268-281-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-25,NDC,facility,both,85,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-492-27,NDC,,,facility,both,400,ML,,314,219.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 2.5 MG ORAL TAB,50863,CDM,J3490,HCPCS,0003-0893-31,NDC,,,facility,both,2,EA,,119,83.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEMANTINE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-173-11,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENTOLAMINE 5 MG INJ SOLR,50863,CDM,250,RC,J3490,HCPCS,0143-9564-01,NDC,facility,both,1,EA,,1231,861.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,85,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 500 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,65862-019-01,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIFAMPIN 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-586-11,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,11,EA,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEG 3350-ELECTROLYTES 236 G-22.74 G-6.74 G-5.86 G ORAL SOLUTION,50863,CDM,J3490,HCPCS,52268-100-01,NDC,,,facility,both,1,ML,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,3,ML,,5203,3642.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 0.1 % TOP CREA,50863,CDM,250,RC,J3490,HCPCS,45802-056-35,NDC,facility,both,1,GM,,242,169.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 10 MG/50 ML (0.2MG/ML) PCA IN NS (MERGE),50863,CDM,636,RC,J1171,HCPCS,70092-9286-74,NDC,facility,both,100,ML,,131,91.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOLTERODINE 2 MG ORAL CP24,50863,CDM,636,RC,J3490,HCPCS,43975-322-03,NDC,facility,both,1,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM 1 GRAM IV SOLR,50863,CDM,250,RC,J2185,HCPCS,63323-508-01,NDC,facility,both,40,EA,,157,109.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE 110 MCG/ACTUATION INHL AERO,50863,CDM,250,RC,J3490,HCPCS,66993-079-96,NDC,facility,both,1,GM,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-4799-05,NDC,facility,both,2,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 100 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,31722-574-47,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,50863,CDM,250,RC,J9025,HCPCS,72485-201-01,NDC,facility,both,170,EA,,2408,1685.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 200 MG/20 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,72205-220-01,NDC,facility,both,2,ML,,470,329,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CITRATE 10 MEQ ORAL TBER,50863,CDM,250,RC,J3490,HCPCS,68084-850-33,NDC,facility,both,2,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MULTIVITAMIN WITH FOLIC ACID 400 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,904053061,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NAPROXEN 250 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-594-11,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-ABDA 100 MG IV SOLR,50863,CDM,636,RC,Q5104,HCPCS,78206-162-99,NDC,facility,both,33,EA,,6862,4803.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-245-11,NDC,facility,both,2,EA,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0548-5604-00,NDC,facility,both,1,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
AZITHROMYCIN 250 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-074-11,NDC,facility,both,2,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-570-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DACTINOMYCIN 0.5 MG IV SOLR,50863,CDM,250,RC,J9120,HCPCS,42658-008-01,NDC,facility,both,5,EA,,6900,4830,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 10 MG/50 ML (0.2MG/ML) PCA IN NS (MERGE),50863,CDM,250,RC,J1171,HCPCS,73013-1030-1,NDC,facility,both,100,ML,,223,156.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,636,RC,J0690,HCPCS,63323-237-10,NDC,facility,both,1,EA,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,636,RC,J3490,HCPCS,50268-540-11,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE IN D5W 1 GRAM/100 ML IV PGBK,50863,CDM,250,RC,J3475,HCPCS,0338-1709-40,NDC,facility,both,4,ML,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) NEB SOLUTION,50863,CDM,250,RC,J3490,HCPCS,0487-9501-01,NDC,facility,both,8,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51672-4027-1,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTAMIDINE 300 MG INJ SOLR,50863,CDM,636,RC,J3490,HCPCS,63323-113-01,NDC,facility,both,1,EA,,313,219.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,636,RC,J2720,HCPCS,63323-229-01,NDC,facility,both,4,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAZOSIN 2 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,51079-631-01,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 40 MG-200 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,65862-496-47,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) BLADDER INSTILLATION,50863,CDM,636,RC,J9201,HCPCS,0409-0182-01,NDC,facility,both,20,ML,,783,548.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMETHICONE  80 MG ORAL CHEW,50863,CDM,636,RC,J3490,HCPCS,77333-812-25,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 50 MG 24 HR TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6323-61,NDC,facility,both,3,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,68180-150-01,NDC,facility,both,2,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL IV BOLUS 10MG/ML (ANESTHESIA ONLY),50863,CDM,636,RC,J2704,HCPCS,0409-4699-54,NDC,facility,both,228,ML,,289,202.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG ORAL CAP,50863,CDM,J3490,HCPCS,60687-580-11,NDC,,,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 20 GRAM/30 ML ORAL SOLN,50863,CDM,J3490,HCPCS,0121-1154-30,NDC,,,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEMANTINE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6505-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL  32.4 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-6575-61,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,250,RC,J2270,HCPCS,0641-6125-01,NDC,facility,both,1,ML,PLAD,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
MORPHINE CONCENTRATE 10 MG/ 0.5 ML ORAL SYRINGE (0.5ML UD MERGE),50863,CDM,J3490,HCPCS,0406-8003-30,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SECUKINUMAB  25 MG/ML IV SOLN,50863,CDM,J3247,HCPCS,0078-1168-61,NDC,,,facility,both,190,ML,,8962,6273.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,50863,CDM,J3490,HCPCS,60687-591-11,NDC,,,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,16714-293-01,NDC,facility,both,17,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IMIPRAMINE 10 MG TAB,50863,CDM,250,RC,J3490,HCPCS,69315-133-01,NDC,facility,both,4,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-ABDA 100 MG IV SOLR,50863,CDM,Q5104,HCPCS,78206-162-01,NDC,,,facility,both,62,EA,,12893,9025.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE IN SALINE (ISO-OSM) 400 MG/200 ML IV PIGGY BACK,50863,CDM,J1450,HCPCS,25021-184-87,NDC,,,facility,both,2,ML,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE IN D5W 1 GRAM/100 ML IV PGBK,50863,CDM,J3475,HCPCS,0338-1709-40,NDC,,,facility,both,2,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJ SOLN",50863,CDM,J3490,HCPCS,0409-1746-30,NDC,,,facility,both,1,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-327-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-089-50,NDC,facility,both,1,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLN (MERGE)",50863,CDM,250,RC,P9047,HCPCS,13533-684-17,NDC,facility,both,1,ML,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,250,RC,J0330,HCPCS,0409-6629-02,NDC,facility,both,7,ML,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,250,RC,J2270,HCPCS,0409-1890-13,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,68180-150-01,NDC,facility,both,2,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 20 MG ORAL TAB,50863,CDM,636,RC,J0500,HCPCS,60687-380-11,NDC,facility,both,20,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLIMEPIRIDE 2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-326-11,NDC,facility,both,4,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,23155-724-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 400 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,69097-815-07,NDC,facility,both,3,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE  10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-162-11,NDC,facility,both,1,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE HCL IN 0.9 % NACL 4 MG/250 ML (16 MCG/ML) IV SOLN,50863,CDM,250,RC,J0171,HCPCS,70324-227-01,NDC,facility,both,1,ML,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,0904-7127-61,NDC,facility,both,200,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE ACETATE 0.12 % OPHT DRPS,50863,CDM,250,RC,J3490,HCPCS,11980-174-05,NDC,facility,both,1,ML,,660,462,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 1% (BUFFERED W/NAHCO3 8.4%) 10 ML SYRINGE (MERGE),50863,CDM,636,RC,J3490,HCPCS,70092-1175-46,NDC,facility,both,1,ML,,233,163.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0093-4127-73,NDC,facility,both,10,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRP (MERGE/REPACK),50863,CDM,636,RC,J3490,HCPCS,68094-764-59,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,8,EA,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,50863,CDM,J0696,HCPCS,44567-702-25,NDC,,,facility,both,4,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,J2704,HCPCS,0069-0209-01,NDC,,,facility,both,26,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEPLIZUMAB-MZWV 2 MG/20 ML IV SOLN,50863,CDM,J9381,HCPCS,73650-316-01,NDC,,,facility,both,292,ME,,17652,12356.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE SODIUM 25 MG/ML INJ SOLN,50863,CDM,636,RC,J9260,HCPCS,61703-350-37,NDC,facility,both,3,ML,,107,74.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J3490,HCPCS,55150-161-02,NDC,,,facility,both,40,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-344-11,NDC,facility,both,1,EA,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  2.5 MG ORAL TAB,50863,CDM,636,RC,J7510,HCPCS,59651-485-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,636,RC,J3490,HCPCS,51754-4250-1,NDC,facility,both,1,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAUNORUBICIN 5 MG/ML IV INJ,50863,CDM,250,RC,J9150,HCPCS,42658-021-01,NDC,facility,both,6,ML,,1725,1207.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J3490,HCPCS,0338-0049-01,NDC,facility,both,6,ML,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2599,HCPCS,43598-914-25,NDC,facility,both,34,ML,,230,161,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML IV,50863,CDM,250,RC,J3490,HCPCS,55150-425-01,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,66,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 50 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,59651-489-01,NDC,facility,both,50,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SCOPOLAMINE TRANSDERMAL PATCH 1MG OVER 3 DAYS,50863,CDM,636,RC,J3490,HCPCS,50742-505-01,NDC,facility,both,2,EA,,198,138.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.3 MG/0.3 ML IM PNIJ,50863,CDM,250,RC,J0171,HCPCS,49502-500-01,NDC,facility,both,3,EA,,1078,754.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR PHOSPHATE 75 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,64380-799-01,NDC,facility,both,1,EA,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHIMAZOLE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,23155-071-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,0409-1886-22,NDC,facility,both,200,ML,JZ,104,72.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
AMOXICILLIN 400 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,65862-071-01,NDC,facility,both,13,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CELECOXIB 200 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,50268-169-11,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,95,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIROFIBAN-0.9% SODIUM CHLORIDE 5 MG/100 ML (50 MCG/ML) IV SOLN,50863,CDM,636,RC,J3246,HCPCS,55150-429-01,NDC,facility,both,20,ML,,378,264.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN PEDS SYRINGE (20MG/ML) IN DEXTROSE (CDS MIX,50863,CDM,250,RC,J0690,HCPCS,0781-3451-70,NDC,facility,both,6,EA,,155,108.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPTOMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0878,HCPCS,72603-152-01,NDC,facility,both,300,EA,,878,614.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6638-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6797-61,NDC,facility,both,3,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-1541-01,NDC,facility,both,2,ML,,195,136.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BETAMETHASONE ACET & SOD PHOS 6 MG/ML INJ SUSP,50863,CDM,250,RC,J0702,HCPCS,0517-0720-01,NDC,facility,both,5,ML,,281,196.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN   81 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,0536-1234-41,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,50863,CDM,250,RC,Q0177,HCPCS,16714-082-10,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-01,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 50 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,59651-489-01,NDC,facility,both,100,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,50863,CDM,636,RC,J9041,HCPCS,10019-991-01,NDC,facility,both,13,EA,JW,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,63323-104-25,NDC,facility,both,9,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZOCAINE-MENTHOL 15-3.6 MG MM LOZG,50863,CDM,250,RC,J3490,HCPCS,0904-6255-49,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-272-11,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,2,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAZOLAMIDE SODIUM 500 (100 MG/ML) INJ SOLR,50863,CDM,250,RC,J1120,HCPCS,67457-853-50,NDC,facility,both,1,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,62559-440-02,NDC,facility,both,1,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIMENHYDRINATE 50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,70677-1087-1,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,50863,CDM,J0561,HCPCS,60793-701-02,NDC,,,facility,both,12,ML,,1188,831.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE  2.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6369-61,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE IN NACL(PF) 0.15 % EPID SOLN,50863,CDM,250,RC,J2795,HCPCS,61553-227-02,NDC,facility,both,375,ML,,514,359.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-559-11,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,3,ML,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 2 MG/ML IV SOLN (PRMC ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-1312-03,NDC,facility,both,40,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0456,HCPCS,70436-019-82,NDC,facility,both,1,EA,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BISACODYL 10 MG RECT SUPP,50863,CDM,250,RC,J3490,HCPCS,0574-7050-12,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 500 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,65862-019-01,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1162-18,NDC,facility,both,50,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
MANNITOL 20% IV SOLP,50863,CDM,250,RC,J2150,HCPCS,0990-7715-13,NDC,facility,both,1,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BALSALAZIDE 750 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,50268-102-11,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 250 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,42192-608-05,NDC,facility,both,2,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,18,ML,JW,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LOPERAMIDE 1 MG/7.5 ML ORAL LIQD,50863,CDM,636,RC,J3490,HCPCS,68094-029-59,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) IV SOLN",50863,CDM,636,RC,J3490,HCPCS,67457-197-00,NDC,facility,both,1,ML,,368,257.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETIC ACID (VINEGAR) 5% IRRIGATION 12 ML (REPACK),50863,CDM,636,RC,J3490,HCPCS,5155200556,NDC,facility,both,5,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICLOFENAC 1 % TOPICAL GEL,50863,CDM,636,RC,J3490,HCPCS,45802-953-01,NDC,facility,both,1,GM,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,16714-293-01,NDC,facility,both,9,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-327-11,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,0409-4264-11,NDC,facility,both,20,ML,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,250,RC,Q0162,HCPCS,60687-252-40,NDC,facility,both,4,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MOXIFLOXACIN 400 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-7387-56,NDC,facility,both,1,EA,,134,93.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTOBARBITAL 75 MG/1.5 ML SYRINGE (REPACK),50863,CDM,250,RC,J3490,HCPCS,25021-676-20,NDC,facility,both,2,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,250,RC,J3490,HCPCS,53746-542-05,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,101,ML,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0075-0622-01,NDC,facility,both,11,ML,,161,112.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6007-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,636,RC,J2560,HCPCS,54288-137-01,NDC,facility,both,2,ML,,212,148.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0630,HCPCS,24201-400-02,NDC,facility,both,1,ML,,1988,1391.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-097-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIVAROXABAN  2.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50458-577-01,NDC,facility,both,1,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 500 MG PE/10 ML INJ SOLN,50863,CDM,250,RC,Q2009,HCPCS,68462-622-10,NDC,facility,both,6,ML,,146,102.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IVPB (PEDIATRICS/ADULT NON-FORM)",50863,CDM,636,RC,J0131,HCPCS,24201-100-01,NDC,facility,both,65,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,16714-662-01,NDC,facility,both,3,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-318-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-0710-20,NDC,facility,both,6,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 0.125 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68462-330-90,NDC,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAUNORUBICIN 5 MG/ML IV INJ,50863,CDM,636,RC,J9150,HCPCS,42658-021-01,NDC,facility,both,6,ML,,1725,1207.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1940,HCPCS,0409-6102-20,NDC,facility,both,5,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,50863,CDM,636,RC,J1756,HCPCS,0517-2340-01,NDC,facility,both,200,ML,,661,462.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM ACETATE 667 MG ORAL CAP,50863,CDM,250,RC,J0615,HCPCS,69097-862-83,NDC,facility,both,87,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6007-61,NDC,facility,both,6,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTASE 3000 UNIT ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,904522452,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERYTHROMYCIN 5 MG/G OPHT OINT,50863,CDM,250,RC,J3490,HCPCS,72485-670-31,NDC,facility,both,2,GM,,196,137.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE IN D5W 1 GRAM/100 ML IV PGBK,50863,CDM,250,RC,J3475,HCPCS,0409-6727-55,NDC,facility,both,2,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1171,HCPCS,63323-851-03,NDC,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,50863,CDM,636,RC,J0696,HCPCS,60505-6148-0,NDC,facility,both,8,EA,,450,315,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,59762-2198-7,NDC,facility,both,2,EA,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 100 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,0591-3540-60,NDC,facility,both,2,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-384-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLEDRONIC ACID IN MANNITOL & WATER 5 MG/100 ML IV SOLN,50863,CDM,636,RC,J3489,HCPCS,25021-830-82,NDC,facility,both,1,ML,JW,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ZONISAMIDE 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-230-11,NDC,facility,both,4,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GAMMAGARD LIQUID 10 % IV SOLN,50863,CDM,636,RC,J1569,HCPCS,0944-2700-12,NDC,facility,both,40,ML,"JZ,JA",7211,5047.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE IN 0.9% NS (PF) 1 MG/10 ML (100 MCG/ML) IV SYRG(PDS MERGE),50863,CDM,636,RC,J3490,HCPCS,71266-9011-1,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  75 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,0904-7077-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-179-11,NDC,facility,both,1,EA,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NAFCILLIN 10 GRAM INJ SOLR,50863,CDM,250,RC,J3490,HCPCS,63323-330-60,NDC,facility,both,1,EA,,612,428.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,250,RC,J2405,HCPCS,23155-549-31,NDC,facility,both,20,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG/ML ORAL CONC,50863,CDM,250,RC,J3490,HCPCS,0054-3553-44,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6374-61,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL 400 UNIT/ML ORAL DROP (REPACK),50863,CDM,250,RC,J3490,HCPCS,87086644,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,63323-482-27,NDC,facility,both,60,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  20 MEQ ORAL PACK,50863,CDM,636,RC,J3490,HCPCS,43386-194-90,NDC,facility,both,1,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2598,HCPCS,43598-914-11,NDC,facility,both,9,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE PEDS SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J1450,HCPCS,0338-6045-37,NDC,facility,both,4,ML,,245,171.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,0409-4887-17,NDC,facility,both,5,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML INJ SOLN,50863,CDM,250,RC,J0169,HCPCS,76329-9060-0,NDC,facility,both,40,ML,,107,74.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIVAROXABAN  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50458-577-01,NDC,facility,both,6,EA,,290,203,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML (PEDS CALCLUATOR 0.5),50863,CDM,636,RC,J1815,HCPCS,0024-5924-10,NDC,facility,both,11,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIPHTH,PERTUS(ACELL),TETANUS SYRG(BOOSTRIX) 2.5-8-5 LF-MCG-LF/0.5ML IM SYRG",50863,CDM,250,RC,90715,HCPCS,58160-842-43,NDC,facility,both,1,ML,PLAD,247,172.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),50863,CDM,250,RC,J2060,HCPCS,65219-368-01,NDC,facility,both,2,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,69918-901-10,NDC,facility,both,25,ML,,1001,700.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 500 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,50268-152-11,NDC,facility,both,8,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,0409-4276-16,NDC,,,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  750 MG IV SOLR,50863,CDM,J3370,HCPCS,67457-705-00,NDC,,,facility,both,2,EA,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG ORAL TAB,50863,CDM,J3490,HCPCS,0143-2112-50,NDC,,,facility,both,1,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GOLIMUMAB  12.5 MG/ML IV SOLN,50863,CDM,J1602,HCPCS,57894-350-01,NDC,,,facility,both,27,ML,,1296,907.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6869-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,83980-006-01,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENOFIBRATE NANOCRYSTALLIZED 145 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7161-04,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIMODIPINE 30 MG/5 ML ORAL SYRG,50863,CDM,250,RC,J3490,HCPCS,24338-230-15,NDC,facility,both,1,ML,,272,190.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPRAZOLAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-388-11,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 15 MG/ML (1.5 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-4776-10,NDC,facility,both,75,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CANGRELOR 50 MG IV SOLR,50863,CDM,C9460,HCPCS,10122-620-01,NDC,,,facility,both,50,EA,,2764,1934.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 200 MG/10 ML (20 MG/ML) IV SYRG,50863,CDM,250,RC,J3490,HCPCS,71266-2001-2,NDC,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNIT/G TOP OINT (MERGE),50863,CDM,636,RC,J3490,HCPCS,58980-011-10,NDC,facility,both,1,GM,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,55390-500-05,NDC,facility,both,4,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 10 MG-325 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0406-0367-23,NDC,facility,both,2,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,3500,ML,,386,270.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FEBUXOSTAT 40 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,62332-190-30,NDC,facility,both,1,EA,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0143-9889-15,NDC,facility,both,24,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 20 MG/ML ORAL CONC,50863,CDM,250,RC,J3490,HCPCS,16714-601-02,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 100 MG SOLUTION FOR INJECTION,50863,CDM,636,RC,J1720,HCPCS,0009-0825-01,NDC,facility,both,1,EA,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6638-61,NDC,facility,both,1,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 112 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6954-61,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,63323-185-07,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,50863,CDM,250,RC,J0696,HCPCS,44567-701-25,NDC,facility,both,4,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,250,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,3,ML,PLAD,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0536-1327-06,NDC,facility,both,6,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,66794-229-02,NDC,facility,both,2,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J3490,HCPCS,0409-3178-01,NDC,,,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,0409-3178-01,NDC,,,facility,both,80,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN 1 MG/ML INJECTION (PEDS ONCOLOGY),50863,CDM,250,RC,J0640,HCPCS,71288-160-10,NDC,facility,both,2,EA,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,76045-009-10,NDC,facility,both,8,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,636,RC,J1815,HCPCS,49502-393-80,NDC,facility,both,4,ML,GZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier GZ: Item or service expected to be denied as not reasonable and necessary
NAFCILLIN  2 GRAM INJ SOLR,50863,CDM,250,RC,J3490,HCPCS,70860-117-41,NDC,facility,both,6,EA,,765,535.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,63323-161-00,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLN (MERGE)",50863,CDM,250,RC,P9047,HCPCS,64208-2512-8,NDC,facility,both,1,ML,JW,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
"OMEGA-3 FATTY ACIDS-FISH OIL 360-1,200 MG ORAL CAP (ERX MERGE)",50863,CDM,250,RC,J3490,HCPCS,17856-0055-1,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LET TOPICAL GEL 3 ML,50863,CDM,250,RC,J3490,HCPCS,70092-1611-44,NDC,facility,both,1,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML IV SOLN (MERGE),50863,CDM,636,RC,J3490,HCPCS,16714-037-10,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM IN D5W 125 MG/125 ML (1 MG/ML) IV SOLN (PREMIX),50863,CDM,636,RC,J3490,HCPCS,70004-540-35,NDC,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,0409-1886-22,NDC,facility,both,100,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,63323-165-01,NDC,facility,both,20,ML,JZ,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-65,NDC,facility,both,181,ML,,319,223.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,68382-444-05,NDC,facility,both,3,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-1752-50,NDC,facility,both,13,ML,,892,624.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE 0.5 MG/2 ML INHL NBSP,50863,CDM,250,RC,J3490,HCPCS,0093-6816-55,NDC,facility,both,2,ML,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,50863,CDM,636,RC,Q5119,HCPCS,0069-0238-01,NDC,facility,both,9,ML,JW,775,542.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,13533-690-25,NDC,facility,both,1,ML,JZ,256,179.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ACETAMINOPHEN  325 MG RECT SUPP,50863,CDM,636,RC,J3490,HCPCS,51672-2116-0,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7336-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-21,NDC,facility,both,10,ML,"JZ,JA",1415,990.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
RISPERIDONE 0.25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,43547-339-06,NDC,facility,both,2,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,50863,CDM,636,RC,J1756,HCPCS,0517-2340-01,NDC,facility,both,4,ML,JW,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LEVETIRACETAM IN NACL (ISO-OS) 1500 MG/100 ML IV PGBK,50863,CDM,636,RC,J1953,HCPCS,44567-503-01,NDC,facility,both,300,ML,,178,124.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,5,EA,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,0378-7732-93,NDC,facility,both,1,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FERROUS SULFATE 220 MG (44 MG IRON)/5 ML ORAL ELIX,50863,CDM,250,RC,J3490,HCPCS,5483800180,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE SR 25 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,72241-030-22,NDC,facility,both,1,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,42291-809-15,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,0641-6174-01,NDC,facility,both,8,ML,JB,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JB: Administered subcutaneously
LINEZOLID 600 MG/300 ML IV SOLP,50863,CDM,636,RC,J2020,HCPCS,57664-683-31,NDC,facility,both,3,ML,,331,231.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE CONCENTRATE 10 MG/ 0.5 ML ORAL SYRINGE (0.5ML UD MERGE),50863,CDM,250,RC,J3490,HCPCS,68094-045-01,NDC,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 250 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,62756-797-88,NDC,facility,both,3,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,636,RC,J2003,HCPCS,0143-9575-01,NDC,facility,both,300,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE (FOR CODE) 10% (100 MG/ML) IV SYRINGE,50863,CDM,636,RC,J3490,HCPCS,0409-4928-11,NDC,facility,both,2,ML,,201,140.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT 500 MCG/ML INJ SYRG,50863,CDM,250,RC,J0881,HCPCS,55513-032-01,NDC,facility,both,500,ML,,10682,7477.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCOSANOL 10 % TOP CREAM,50863,CDM,250,RC,J3490,HCPCS,61269-881-35,NDC,facility,both,1,GM,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN NPH & REGULAR HUMAN 100 UNIT/ML (70-30) SUBQ SUSP,50863,CDM,636,RC,J1815,HCPCS,0002-8715-01,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0039-05,NDC,facility,both,8,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM 1 GRAM IV SOLR,50863,CDM,250,RC,J2185,HCPCS,63323-508-01,NDC,facility,both,10,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,68180-150-01,NDC,facility,both,3,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL  20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-072-33,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 100 MG/5 ML ORAL LIQD,50863,CDM,636,RC,J3490,HCPCS,0121-1488-10,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,42806-151-34,NDC,facility,both,4,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-728-11,NDC,facility,both,1,EA,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL  97.2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16571-668-01,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,16714-661-01,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,636,RC,J0330,HCPCS,31722-981-10,NDC,facility,both,4,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,149003908,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL,50863,CDM,250,RC,J3490,HCPCS,63323-820-01,NDC,facility,both,1,ML,,131,91.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 250 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,17856-0698-01,NDC,facility,both,2,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,250,RC,J3101,HCPCS,50242-037-06,NDC,facility,both,25,EA,,10803,7562.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 25 MG CAP,50863,CDM,250,RC,J3490,HCPCS,0904-5306-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3370,HCPCS,0143-9162-01,NDC,facility,both,10,EA,,200,140,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 1000 MG MISC TBSO,50863,CDM,250,RC,J3490,HCPCS,904723961,NDC,facility,both,5,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) MISC SOLN,50863,CDM,250,RC,J3490,HCPCS,0517-7604-01,NDC,facility,both,1,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-18,NDC,facility,both,40,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0039-05,NDC,facility,both,11,EA,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,110,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,0069-4547-02,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN  325 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,57896-921-01,NDC,facility,both,3,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
URSODIOL 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-100-11,NDC,facility,both,3,EA,,113,79.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPOPROSTENOL (ARGNININE) (VELETRI) CONTINUOUS NEB 1.5 MG IN NS 50 ML,50863,CDM,250,RC,J3490,HCPCS,67457-588-10,NDC,facility,both,1,EA,,243,170.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANTI-THYMOCYTE GLOB (RABBIT) 25 MG IV SOLR,50863,CDM,250,RC,J7511,HCPCS,58468-0080-1,NDC,facility,both,5,EA,JZ,10110,7077,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
TEPLIZUMAB-MZWV 2 MG/20 ML IV SOLN,50863,CDM,636,RC,J9381,HCPCS,73650-316-01,NDC,facility,both,160,ME,,9673,6771.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J2003,HCPCS,63323-492-27,NDC,facility,both,800,ML,,628,439.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,78206-121-01,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0054-0710-20,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 2-0.5 MG SL SUBL,50863,CDM,636,RC,J3490,HCPCS,0904-7009-06,NDC,facility,both,2,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNITS/1 GRAM PACKET (MERGE RECORD),50863,CDM,636,RC,J3490,HCPCS,57896-145-09,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FONDAPARINUX 2.5 MG/0.5 ML SUBQ SYRG,50863,CDM,250,RC,J1652,HCPCS,67457-582-00,NDC,facility,both,5,ML,,232,162.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FERUMOXYTOL 510 MG/17 ML (30 MG/ML) IV SOLN,50863,CDM,636,RC,Q0138,HCPCS,59338-775-01,NDC,facility,both,510,ML,,3295,2306.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID (PORK)  60 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0456-0459-01,NDC,facility,both,3,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 10 MG/ML ORAL SOLUTION (REPACK),50863,CDM,636,RC,J3490,HCPCS,0131-5410-71,NDC,facility,both,8,ML,,290,203,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RACEPINEPHRINE 2.25 % INHL NEBU,50863,CDM,636,RC,J3490,HCPCS,0487-2784-01,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2598,HCPCS,43598-914-11,NDC,facility,both,15,ML,JW,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
MIRTAZAPINE 30 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-087-01,NDC,facility,both,2,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE 25 MG RECT SUPP,50863,CDM,250,RC,J3490,HCPCS,0574-7226-12,NDC,facility,both,1,EA,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7350-61,NDC,facility,both,8,EA,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 500 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,50268-260-11,NDC,facility,both,2,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COLCHICINE 0.6 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,70010-002-01,NDC,facility,both,1,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 100 MG IV SOLR,50863,CDM,250,RC,J2997,HCPCS,50242-085-25,NDC,facility,both,20,EA,,4858,3400.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 800 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65162-058-27,NDC,facility,both,3,EA,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL  32.4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6575-61,NDC,facility,both,3,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICLOFENAC 1 % TOPICAL GEL,50863,CDM,250,RC,J3490,HCPCS,45802-953-01,NDC,facility,both,1,GM,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,250,RC,J2720,HCPCS,63323-229-30,NDC,facility,both,28,ML,,302,211.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-3178-16,NDC,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE 0.25 MG/2 ML INHL NBSP,50863,CDM,250,RC,J3490,HCPCS,0487-9601-01,NDC,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,0409-4264-11,NDC,facility,both,4,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-5755-23,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0143-9318-01,NDC,facility,both,4,ML,,339,237.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7001-61,NDC,facility,both,3,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,636,RC,J7999,HCPCS,70092-1017-46,NDC,facility,both,2,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BISOPROLOL FUMARATE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,70954-455-20,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
URSODIOL 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7168-61,NDC,facility,both,1,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-25,NDC,facility,both,40,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 200 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-552-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM  4.5 GRAM IV SOLR,50863,CDM,636,RC,J2543,HCPCS,60505-6159-0,NDC,facility,both,4,EA,JZ,107,74.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,5,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,0409-9094-22,NDC,facility,both,3,ML,JZ,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) NEB SOLUTION,50863,CDM,250,RC,J3490,HCPCS,47335-703-52,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 0.125 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68462-330-90,NDC,facility,both,2,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISATRACURIUM  2 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0074-4380-10,NDC,facility,both,2,ML,,210,147,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB 100 MG IV SOLR,50863,CDM,J1745,HCPCS,57894-160-01,NDC,,,facility,both,29,EA,,3802,2661.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,70004-600-09,NDC,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NORTRIPTYLINE 10 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,50268-603-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYMETAZOLINE 0.05 % NASL SPRA,50863,CDM,636,RC,J3490,HCPCS,4110081123,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 50 MG/ML INJECTION,50863,CDM,250,RC,J1200,HCPCS,63323-664-00,NDC,facility,both,2,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IV PGBK,50863,CDM,636,RC,J3475,HCPCS,0264-4206-54,NDC,facility,both,8,ML,JZ,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PENICILLIN G POTASSIUM 20000000 UNIT INJ SOLR,50863,CDM,250,RC,J2540,HCPCS,0781-6136-94,NDC,facility,both,1,EA,JW,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CARVEDILOL 25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7308-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NOREPINEPHRINE BITARTRATE-D5W 4 MG/250 ML (16 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,71285-6056-1,NDC,facility,both,2,ML,,143,100.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,250,RC,J7060,HCPCS,0990-7923-37,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,250,RC,J2270,HCPCS,0409-1891-03,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-234-11,NDC,facility,both,1,EA,PLAD,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
GENTAMICIN 0.1 % TOP OINT,50863,CDM,250,RC,J3490,HCPCS,45802-046-35,NDC,facility,both,1,GM,,242,169.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLN,50863,CDM,250,RC,J3262,HCPCS,50242-135-01,NDC,facility,both,160,ML,JA,2933,2053.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
HYDROPHILLIC OINTMENT (AQUAPHOR),50863,CDM,250,RC,J3490,HCPCS,7214045231,NDC,facility,both,16,GM,,374,261.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,250,RC,Q9968,HCPCS,70710-1838-1,NDC,facility,both,46,ML,JW,262,183.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
MAGNESIUM SULFATE 50 % (4 MEQ/ML) INJ SOLN,50863,CDM,636,RC,J3475,HCPCS,63323-064-01,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACUBITRIL-VALSARTAN 24-26 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0078-0659-67,NDC,facility,both,1,EA,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG TAB,50863,CDM,250,RC,J3490,HCPCS,904719106,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZIPRASIDONE 40 MG CAP,50863,CDM,250,RC,J3490,HCPCS,50268-812-11,NDC,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  75 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-475-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,250,RC,J3490,HCPCS,73013-2002-2,NDC,facility,both,2,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAMSULOSIN 0.4 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,16714-713-01,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,55150-177-05,NDC,facility,both,100,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN NEO/PEDIATRIC SYRINGE < 30 MG,50863,CDM,250,RC,J1650,HCPCS,0548-5608-00,NDC,facility,both,4,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAMSULOSIN 0.4 MG ORAL CP24,50863,CDM,636,RC,J3490,HCPCS,72603-115-01,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 500 MG (200 MG ELEMENTAL) CHEW TAB,50863,CDM,J3490,HCPCS,66553-004-01,NDC,,,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-0007-01,NDC,facility,both,130,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE 1 MG/2 ML INHL NBSP,50863,CDM,J3490,HCPCS,69097-321-32,NDC,,,facility,both,1,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE IN 0.9 % SOD CHLORIDE 100 MG/10 ML (10 MG/ML) IV SYRG,50863,CDM,J3490,HCPCS,61553-331-65,NDC,,,facility,both,2,ML,,191,133.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERTAPENEM 1 GRAM INJ SOLR,50863,CDM,J1335,HCPCS,42023-221-01,NDC,,,facility,both,2,EA,,506,354.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,50863,CDM,J3301,HCPCS,0143-9387-01,NDC,,,facility,both,4,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-7912-51,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"CALCIUM GLUC IN NACL, ISO-OSM 1 G/100 ML IV SOLN",50863,CDM,636,RC,J0613,HCPCS,44567-622-01,NDC,facility,both,100,ML,JZ,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CALCIUM GLUCONATE 20MG/ML IV SYRINGE (PEDS/NEO),50863,CDM,250,RC,J0612,HCPCS,63323-311-10,NDC,facility,both,34,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESNA 100 MG/ML IV SOLN,50863,CDM,250,RC,J9209,HCPCS,10019-953-62,NDC,facility,both,7,ML,,191,133.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,85,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 10 MEQ/100 ML IV PGBK (USE NON-PROTOCOL PANEL),50863,CDM,636,RC,J3480,HCPCS,0338-0709-48,NDC,facility,both,20,ML,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL  20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-072-33,NDC,facility,both,3,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0093-3426-05,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,70095-031-01,NDC,facility,both,16,ML,,617,431.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,636,RC,J2795,HCPCS,70069-064-25,NDC,facility,both,150,ML,JZ,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
VEDOLIZUMAB 300 MG IV SOLR,50863,CDM,636,RC,J3380,HCPCS,64764-300-20,NDC,facility,both,300,EA,JZ,11084,7758.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DULOXETINE 60 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,51991-748-90,NDC,facility,both,1,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 20 MG/ML IN NS NEONATAL INJECTION (REPACK),50863,CDM,250,RC,J1650,HCPCS,63323-565-86,NDC,facility,both,1,ML,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,250,RC,J2270,HCPCS,0409-1890-03,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  15 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,0904-6557-61,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NAFCILLIN NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J3490,HCPCS,63323-327-10,NDC,facility,both,9,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,68180-150-01,NDC,facility,both,3,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-950-01,NDC,facility,both,2,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 25 MG CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7237-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE IN 0.9 % NACL 4 MG/250 ML (16 MCG/ML) IV SOLN (MERGE),50863,CDM,636,RC,J0171,HCPCS,70004-613-40,NDC,facility,both,1,ML,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,636,RC,J3490,HCPCS,63037-136-25,NDC,facility,both,3,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOTRIMAZOLE 1 % TOP CREA,50863,CDM,250,RC,J3490,HCPCS,0536-1265-95,NDC,facility,both,1,GM,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DACTINOMYCIN 0.5 MG IV SOLR,50863,CDM,250,RC,J9120,HCPCS,71288-129-02,NDC,facility,both,2,EA,,2305,1613.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  500 MCG/ML INJ SOLN,50863,CDM,636,RC,J2354,HCPCS,25021-465-01,NDC,facility,both,20,ML,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NAPROXEN 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-403-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  750 MG IV SOLR,50863,CDM,J3370,HCPCS,63323-203-01,NDC,,,facility,both,2,EA,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE  50 MCG/ACTUATION NASL SPSN,50863,CDM,J3490,HCPCS,0054-3270-99,NDC,,,facility,both,1,GM,,396,277.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-344-11,NDC,facility,both,2,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) IV SOLN",50863,CDM,636,RC,J3490,HCPCS,0013-1114-20,NDC,facility,both,1,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42858-301-25,NDC,facility,both,1,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 10 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0781-2823-01,NDC,facility,both,2,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,636,RC,J0330,HCPCS,31722-981-10,NDC,facility,both,6,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 125 MG ORAL CPSP,50863,CDM,250,RC,J3490,HCPCS,0904-6615-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM SR 120 MG 24 HR CAP,50863,CDM,636,RC,J3490,HCPCS,60687-195-11,NDC,facility,both,3,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-3178-01,NDC,facility,both,60,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OMALIZUMAB 150 MG SUBQ SOLR,50863,CDM,636,RC,J2357,HCPCS,50242-040-62,NDC,facility,both,75,ME,,6524,4566.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,17,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,57237-004-30,NDC,facility,both,2,EA,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN NEO/PEDIATRIC SYRINGE < 30 MG,50863,CDM,250,RC,J1650,HCPCS,0548-5608-00,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,6,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 1 MG ORAL CAP,50863,CDM,636,RC,J7507,HCPCS,0904-7097-61,NDC,facility,both,2,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,51079-169-01,NDC,facility,both,6,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6370-61,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTOBARBITAL 75 MG/1.5 ML SYRINGE (REPACK),50863,CDM,636,RC,J2515,HCPCS,25021-676-20,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEMAZEPAM 15 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0406-9961-01,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 650 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7261-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,55390-138-01,NDC,facility,both,5,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
EPLERENONE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42291-454-30,NDC,facility,both,1,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN  500 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,60687-640-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,72603-179-01,NDC,facility,both,6,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,63323-165-01,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OMEPRAZOLE-SODIUM BICARBONATE 2-84 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,62175-114-32,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATOMOXETINE  40 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,64980-376-03,NDC,facility,both,2,EA,,152,106.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATENOLOL  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-759-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6928-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,62756-711-86,NDC,facility,both,1,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE-VITAMIN D3 250 MG-125 UNIT TAB,50863,CDM,250,RC,J3490,HCPCS,904188260,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0093-2279-73,NDC,facility,both,8,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 3 MG/ML IV SYRG,50863,CDM,636,RC,J0153,HCPCS,25021-301-72,NDC,facility,both,6,ML,JZ,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DOXORUBICIN 50 MG/25 ML IV SOLN,50863,CDM,250,RC,J9000,HCPCS,0069-1542-20,NDC,facility,both,9,ML,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,636,RC,J7999,HCPCS,70092-1017-46,NDC,facility,both,6,ML,,238,166.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65862-859-01,NDC,facility,both,2,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,21,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROPROCAINE 3 % INJ SOLN,50863,CDM,250,RC,J2401,HCPCS,0143-9210-01,NDC,facility,both,30,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3370,HCPCS,0143-9162-01,NDC,facility,both,8,EA,,160,112,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,636,RC,J3490,HCPCS,14789-251-09,NDC,facility,both,1,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVONORGESTREL 1.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,69536-162-88,NDC,facility,both,1,EA,,191,133.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,50863,CDM,250,RC,Q0177,HCPCS,10702-011-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM,50863,CDM,250,RC,J3490,HCPCS,45802-358-03,NDC,facility,both,2,GM,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-134-01,NDC,facility,both,6,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LANSOPRAZOLE 3 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,65628-080-05,NDC,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,J3490,HCPCS,67457-433-00,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-631-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,50863,CDM,J0696,HCPCS,60505-6148-0,NDC,,,facility,both,4,EA,,225,157.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 20 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-5785-61,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0406-1236-01,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-545-10,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IR SOLN,50863,CDM,250,RC,J3490,HCPCS,0264-2201-10,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE PAMOATE  25 MG ORAL CAP,50863,CDM,250,RC,Q0177,HCPCS,60687-696-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J2004,HCPCS,0409-3178-16,NDC,facility,both,400,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-466-17,NDC,facility,both,300,ML,JZ,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,13,EA,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVONORGESTREL 1.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0536-1142-63,NDC,facility,both,1,EA,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PYRIDOXINE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,7733394025,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN   1.5 G IV SOLR,50863,CDM,636,RC,J3373,HCPCS,67457-824-15,NDC,facility,both,150,EA,,142,99.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,69623-232-39,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,50863,CDM,250,RC,J8540,HCPCS,0904-7266-61,NDC,facility,both,20,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIACIN  250 MG ORAL CPSR,50863,CDM,250,RC,J3490,HCPCS,1000670020,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 50 MG TAB,50863,CDM,250,RC,J3490,HCPCS,62584-266-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,51754-5001-1,NDC,facility,both,9,ML,,463,324.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7007-61,NDC,facility,both,6,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COCAINE  4 % TOP SOLN (MERGE),50863,CDM,636,RC,C9046,HCPCS,81665-301-02,NDC,facility,both,160,ML,,1271,889.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,70069-011-01,NDC,facility,both,8,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOCONAZOLE 2 % TOP SHAM,50863,CDM,636,RC,J3490,HCPCS,45802-465-64,NDC,facility,both,1,ML,,148,103.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"OMEGA-3 FATTY ACIDS-FISH OIL 360-1,200 MG ORAL CAP (ERX MERGE)",50863,CDM,250,RC,J3490,HCPCS,8068105500,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL IV BOLUS 10MG/ML (ANESTHESIA ONLY),50863,CDM,636,RC,J2704,HCPCS,0409-4699-54,NDC,facility,both,21,ML,JW,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,636,RC,J1953,HCPCS,63323-400-01,NDC,facility,both,50,ML,JZ,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LISINOPRIL  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6797-61,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTAROLINE FOSAMIL 600 MG IV SOLR,50863,CDM,250,RC,J0712,HCPCS,0456-0600-01,NDC,facility,both,40,EA,,608,425.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2598,HCPCS,43598-914-11,NDC,facility,both,18,ML,JW,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ISOSULFAN BLUE 1 % INJ SOLN,50863,CDM,636,RC,Q9968,HCPCS,67457-220-00,NDC,facility,both,35,ML,JW,1020,714,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,636,RC,J7060,HCPCS,0338-0017-03,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE 22.5 MG SUBQ SYRG,50863,CDM,636,RC,J9217,HCPCS,62935-227-10,NDC,facility,both,3,EA,,1176,823.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MICAFUNGIN 100 MG IV SOLR,50863,CDM,250,RC,J2248,HCPCS,42023-230-01,NDC,facility,both,87,EA,,563,394.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAMOXIFEN 10 MG ORAL TAB,50863,CDM,636,RC,J9999,HCPCS,0591-2472-60,NDC,facility,both,2,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DORZOLAMIDE-TIMOLOL 2 %-0.5 % EYE DROPS,50863,CDM,250,RC,J3490,HCPCS,65862-946-01,NDC,facility,both,1,ML,,440,308,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PYRIDOSTIGMINE BROMIDE 60 MG/5 ML ORAL SYRP,50863,CDM,250,RC,J3490,HCPCS,70954-148-10,NDC,facility,both,1,ML,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-11,NDC,facility,both,3,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLMESARTAN 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68462-438-30,NDC,facility,both,1,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,7,ML,,211,147.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7007-61,NDC,facility,both,9,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,62332-037-31,NDC,facility,both,6,EA,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 50 MG TAB,50863,CDM,250,RC,J3490,HCPCS,51079-801-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 500 MG (200 MG ELEMENTAL) CHEW TAB,50863,CDM,250,RC,J3490,HCPCS,68084-988-33,NDC,facility,both,8,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR  6 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,27241-139-09,NDC,facility,both,8,ML,,101,70.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN  6 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51672-4033-1,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN  10 GRAM INJ SOLR,50863,CDM,636,RC,J0690,HCPCS,0143-9983-91,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
REGADENOSON 0.4 MG/5 ML IV SYRG,50863,CDM,250,RC,J2785,HCPCS,0469-6501-89,NDC,facility,both,4,ML,JA,913,639.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
DOXAZOSIN 8 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68382-786-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0172-5728-60,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 1 MG/ML (1ML) SYRINGE (REPACK),50863,CDM,250,RC,J2997,HCPCS,50242-044-13,NDC,facility,both,5,EA,,1946,1362.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J3430,HCPCS,68462-758-05,NDC,facility,both,5,ML,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 250 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,0904-6363-45,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,50863,CDM,250,RC,J9025,HCPCS,72485-201-01,NDC,facility,both,156,EA,,2217,1551.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0245-0144-89,NDC,facility,both,2,EA,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ANTIHEMOPHILIC FACTOR-VWF 1,000-2,400 UNIT IV KIT",50863,CDM,636,RC,J7187,HCPCS,63833-617-02,NDC,facility,both,875,UN,,2818,1972.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,68462-157-40,NDC,facility,both,1,EA,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,167,ML,,239,167.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/G EYE OINTMENT",50863,CDM,250,RC,J3490,HCPCS,0574-4021-35,NDC,facility,both,1,GM,,128,89.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM SR 60 MG 12 HR CAP,50863,CDM,250,RC,J3490,HCPCS,51079-924-01,NDC,facility,both,3,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,62584-984-11,NDC,facility,both,2,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,636,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,5,EA,,179,125.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIFEDIPINE 60 MG ORAL TO24,50863,CDM,250,RC,J3490,HCPCS,50268-598-11,NDC,facility,both,2,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML IM SOLN,50863,CDM,636,RC,90375,HCPCS,13533-318-05,NDC,facility,both,3,ML,JW,1245,871.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,250,RC,J2720,HCPCS,63323-229-01,NDC,facility,both,9,ML,,164,114.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN SODIUM EXTENDED 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0071-0369-40,NDC,facility,both,2,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  20 MEQ ORAL PACK,50863,CDM,250,RC,J3490,HCPCS,43386-194-90,NDC,facility,both,3,EA,,158,110.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TETRABENAZINE 12.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,67386-421-01,NDC,facility,both,1,EA,,223,156.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML IV SOLN (MERGE),50863,CDM,636,RC,J3490,HCPCS,16714-037-01,NDC,facility,both,1,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES-DOCUSATE SODIUM 8.6 MG-50 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0536-1247-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-134-11,NDC,facility,both,60,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,0904-6923-61,NDC,facility,both,20,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,63323-165-30,NDC,facility,both,70,ML,JW,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML SYRUP,50863,CDM,250,RC,J3490,HCPCS,69339-150-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,J3490,HCPCS,51754-4250-1,NDC,,,facility,both,1,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J3490,HCPCS,63323-482-03,NDC,,,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMOSOZUMAB-AQQG 210MG/2.34ML ( 105MG/1.17MLX2) SUBQ SYRG,50863,CDM,J3111,HCPCS,55513-880-02,NDC,,,facility,both,210,ML,,5894,4125.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-7912-59,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,J3490,HCPCS,66553-002-01,NDC,,,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 20 MG ORAL TAB,50863,CDM,636,RC,J0500,HCPCS,60687-380-11,NDC,facility,both,12,EA,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL  3.125 MG ORAL TAB,50863,CDM,J3490,HCPCS,0781-5221-01,NDC,,,facility,both,2,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN DEXTROSE (ISO-OS) 3 GRAM/150 ML IV PGBK,50863,CDM,J0690,HCPCS,0338-0096-06,NDC,,,facility,both,4,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPYLTHIOURACIL 50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,67253-651-10,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISANKIZUMAB-RZAA  60 MG/ML IV SOLN,50863,CDM,636,RC,J2327,HCPCS,0074-5015-01,NDC,facility,both,600,ML,,28629,20040.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,70069-363-01,NDC,facility,both,1,ML,,211,147.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-088-11,NDC,facility,both,2,EA,,254,177.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5%-1/2 NORMAL SALINE IV (PEDS ONCOLOGY),50863,CDM,250,RC,J7042,HCPCS,0338-0085-04,NDC,facility,both,2,ML,JZ,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CALCIUM CARBONATE 500 MG (200 MG ELEMENTAL) CHEW TAB,50863,CDM,250,RC,J3490,HCPCS,66553-004-01,NDC,facility,both,8,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-01,NDC,facility,both,1,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LUBIPROSTONE 24 MCG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0254-3029-02,NDC,facility,both,1,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN LOCK FLUSH (PORCINE) 10 UNIT/ML IV SOLN (PEDS),50863,CDM,636,RC,J1642,HCPCS,0409-1151-70,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-02,NDC,facility,both,2,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BETAMETHASONE DIPROPIONATE 0.05 % TOP LOTN,50863,CDM,250,RC,J3490,HCPCS,0168-0057-60,NDC,facility,both,1,ML,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,78206-121-01,NDC,facility,both,4,EA,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IRRIGATION SOLN,50863,CDM,636,RC,J7120,HCPCS,0264-7389-60,NDC,facility,both,30,ML,,499,349.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,34,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,636,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,1,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
AMLODIPINE 1 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,46287-035-15,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK,50863,CDM,250,RC,J3490,HCPCS,12870-0001-1,NDC,facility,both,4,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-28,NDC,facility,both,12,EA,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BEVACIZUMAB-AWWB 25 MG/ML IV SOLN,50863,CDM,Q5107,HCPCS,55513-206-01,NDC,,,facility,both,30,ML,,5778,4044.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COVID VACCINE 24-25 (12UP)(MOD)(PF) 50 MCG/0.5 ML IM SYRG,50863,CDM,91322,HCPCS,80777-110-93,NDC,,,facility,both,1,ML,,613,429.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 15 MG/ML (1.5 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-493-01,NDC,,,facility,both,60,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE SODIUM 25 MG/ML INJ SOLN,50863,CDM,636,RC,J9260,HCPCS,61703-350-37,NDC,facility,both,3,ML,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADVATE: FACTOR VIII CONCENTRATE (MERGE RECORD),50863,CDM,250,RC,J7192,HCPCS,0944-3053-03,NDC,facility,both,3000,UN,,15732,11012.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL  32.4 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-6575-61,NDC,,,facility,both,8,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IVPB (PEDIATRICS/ADULT NON-FORM)",50863,CDM,J0137,HCPCS,24201-100-01,NDC,,,facility,both,100,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",50863,CDM,J1561,HCPCS,13533-800-25,NDC,,,facility,both,40,ML,,5658,3960.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,636,RC,J1596,HCPCS,0143-9679-01,NDC,facility,both,7,ML,,160,112,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,43598-053-11,NDC,facility,both,21,ML,,751,525.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-1752-50,NDC,facility,both,1,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,636,RC,J3490,HCPCS,0143-9575-01,NDC,facility,both,200,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPTOMYCIN IN 0.9 % SOD CHLOR 350 MG/50 ML IV PGBK,50863,CDM,J0874,HCPCS,0338-0712-24,NDC,,,facility,both,350,ML,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIOTROPIUM BROMIDE 18 MCG INHL CPDV,50863,CDM,250,RC,J3490,HCPCS,0597-0075-75,NDC,facility,both,1,EA,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 50 MG/ML INJECTION,50863,CDM,J1200,HCPCS,0641-0376-25,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,68094-231-59,NDC,facility,both,7,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE NA (PRESERV FREE) 25 MG/ML INJ SOLN,50863,CDM,250,RC,J9260,HCPCS,0703-3678-01,NDC,facility,both,115,ML,,1121,784.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLIMEPIRIDE 4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-327-11,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 2 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,636,RC,J2270,HCPCS,76045-004-01,NDC,facility,both,1,ML,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-2051-15,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,49348-498-07,NDC,facility,both,3,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68382-181-01,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZOXIDE (DIABETIC USE) 50 MG/ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0254-1010-19,NDC,facility,both,1,ML,,182,127.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,25021-468-10,NDC,facility,both,3,EA,,1225,857.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-208-01,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 20 MG/ML INJ SOLN,50863,CDM,250,RC,J0360,HCPCS,55150-400-01,NDC,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,50863,CDM,250,RC,J9267,HCPCS,61703-342-22,NDC,facility,both,96,ML,,159,111.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE 25 MG/ML INJ SOLN,50863,CDM,250,RC,J3230,HCPCS,55150-319-01,NDC,facility,both,1,ML,,148,103.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,0409-6625-14,NDC,facility,both,3,ML,,174,121.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"METHYLPREDNISOLONE 1,000 MG SOLUTION FOR INJECTION",50863,CDM,250,RC,J2919,HCPCS,43598-130-74,NDC,facility,both,150,EA,,144,100.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML INJ SOLN,50863,CDM,J0171,HCPCS,76329-9060-0,NDC,,,facility,both,1800,ML,,4779,3345.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % MUCOSAL SOLN (VISCOUS),50863,CDM,J3490,HCPCS,50383-775-17,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPHENIDATE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0115-1800-01,NDC,facility,both,4,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,636,RC,J3490,HCPCS,60687-390-11,NDC,facility,both,4,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IV PGBK,50863,CDM,636,RC,J3475,HCPCS,44567-420-24,NDC,facility,both,4,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,636,RC,J2003,HCPCS,63323-485-27,NDC,facility,both,75,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,56,ML,JW,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,70004-600-09,NDC,facility,both,4,ML,,170,119,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE IN D5W 1 GRAM/100 ML IV PGBK,50863,CDM,250,RC,J3475,HCPCS,0409-6727-23,NDC,facility,both,4,ML,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,82293-004-10,NDC,facility,both,3,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM IN D5W 125 MG/125 ML (1 MG/ML) IV SOLN (PREMIX),50863,CDM,636,RC,J3490,HCPCS,70092-1575-36,NDC,facility,both,1,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,67877-543-60,NDC,facility,both,1,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-3178-01,NDC,facility,both,25,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,121059530,NDC,facility,both,1,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7048-61,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  75 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,69238-1312-9,NDC,facility,both,2,EA,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 400 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,69097-815-07,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,72603-506-01,NDC,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEPLIZUMAB-MZWV 2 MG/20 ML IV SOLN,50863,CDM,636,RC,J9381,HCPCS,73650-316-01,NDC,facility,both,290,ME,,19480,13636,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,63323-104-06,NDC,facility,both,7,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0137,HCPCS,0264-4100-90,NDC,facility,both,25,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE (PF) 25 MG/ML INJ SOLN (FOR ECTOPIC PREGNANCY),50863,CDM,636,RC,J9260,HCPCS,0143-9519-01,NDC,facility,both,5,ML,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLN (MERGE)",50863,CDM,250,RC,P9047,HCPCS,0053-7680-32,NDC,facility,both,1,ML,,215,150.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LANSOPRAZOLE 15 MG ORAL TBLD,50863,CDM,636,RC,J3490,HCPCS,68382-771-30,NDC,facility,both,1,EA,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN-ACETAMINOPHEN-CAFFEINE 250 MG-250 MG-65 MG TAB,50863,CDM,636,RC,J3490,HCPCS,70677-1133-1,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-1283-17,NDC,facility,both,5,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRIMIDONE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-686-11,NDC,facility,both,4,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,16714-294-01,NDC,facility,both,11,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-087-02,NDC,facility,both,14,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,63323-485-27,NDC,,,facility,both,85,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0075-0621-01,NDC,facility,both,6,ML,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,FAMNOCHARGE,HCPCS,0338-0049-31,NDC,,,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 2 %-1:200,000 INJ SOLN",50863,CDM,J2004,HCPCS,63323-489-02,NDC,,,facility,both,600,ML,,207,144.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN NPH HUMAN RECOMB 100 UNIT/ML SUBQ SUSP,50863,CDM,250,RC,J1815,HCPCS,0169-1834-11,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 0.4 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,43598-436-35,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,636,RC,J2560,HCPCS,72162-1330-6,NDC,facility,both,2,ML,,551,385.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 50% IN WATER (MERGE RECORD),50863,CDM,636,RC,J7060,HCPCS,0409-4902-34,NDC,facility,both,1,ML,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,44567-600-04,NDC,facility,both,2,ML,,410,287,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL,50863,CDM,250,RC,J1071,HCPCS,0143-9659-01,NDC,facility,both,80,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,636,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,146,ML,,132,92.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE MODIFIED 100 MG ORAL CAP,50863,CDM,636,RC,J7502,HCPCS,23155-839-11,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-50,NDC,facility,both,126,ML,,222,155.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,13,ML,JW,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
TRAZODONE  50 MG ORAL TAB,50863,CDM,250,RC,j3490,HCPCS,50111-560-01,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN  325 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0536-1054-29,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 0.5 MG ORAL CAP,50863,CDM,250,RC,J7507,HCPCS,68462-685-01,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADVATE: FACTOR VIII CONCENTRATE (MERGE RECORD),50863,CDM,250,RC,J7192,HCPCS,0944-3053-02,NDC,facility,both,1500,UN,,6279,4395.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42291-748-01,NDC,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN   81 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,57896-981-01,NDC,facility,both,4,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2308-22,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,50863,CDM,250,RC,J9000,HCPCS,0069-1542-20,NDC,facility,both,5,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLP,50863,CDM,250,RC,J3480,HCPCS,0409-6651-19,NDC,facility,both,20,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRIL MALEATE 1 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,69238-1729-7,NDC,facility,both,1,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN   81 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,0904-6751-80,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE 0.5 MG SL (1/4 TAB) SUBL,50863,CDM,250,RC,J3490,HCPCS,99999-0408-26,NDC,facility,both,1,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 5 QUARTER TABLET
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,636,RC,J1953,HCPCS,55150-177-05,NDC,facility,both,130,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,2,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,72162-1330-6,NDC,facility,both,2,ML,,551,385.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN STERILE WATER 2 GRAM/20 ML IV SYRG,50863,CDM,J7999,HCPCS,70092-1604-47,NDC,,,facility,both,2,ML,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,636,RC,J1610,HCPCS,0597-0053-45,NDC,facility,both,2,EA,,1112,778.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 20MG/ML IV SYRINGE (PEDS/NEO),50863,CDM,J0612,HCPCS,63323-311-10,NDC,,,facility,both,100,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN PEDS SYRINGE (20MG/ML) IN DEXTROSE (CDS MIX,50863,CDM,J0690,HCPCS,0781-3451-70,NDC,,,facility,both,4,EA,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,50863,CDM,J2354,HCPCS,0641-6174-01,NDC,,,facility,both,2,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,J7040,HCPCS,0338-0049-02,NDC,,,facility,both,1,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,50863,CDM,J1885,HCPCS,63323-161-00,NDC,,,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  20 MG ORAL TR12,50863,CDM,250,RC,J3490,HCPCS,59011-420-20,NDC,facility,both,3,EA,,191,133.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 10 MG TAB,50863,CDM,250,RC,Q0177,HCPCS,60687-664-11,NDC,facility,both,5,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 100 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,31722-574-47,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  1 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,59651-484-01,NDC,facility,both,2,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  5 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-122-11,NDC,facility,both,105,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-25,NDC,facility,both,120,ML,"JZ,JA",16973,11881.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2001,HCPCS,55150-163-30,NDC,,,facility,both,30,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN 1 GRAM SOLUTION FOR INJECTION,50863,CDM,250,RC,J0290,HCPCS,0781-3404-85,NDC,facility,both,2,EA,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,250,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,11,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 125 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,60687-211-11,NDC,facility,both,3,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 125 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,60687-211-11,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,70,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LURASIDONE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7355-04,NDC,facility,both,4,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 15 MG/ML (1.5 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-4776-10,NDC,facility,both,150,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LANTHANUM  500 MG ORAL CHEW,50863,CDM,636,RC,J3490,HCPCS,68180-819-42,NDC,facility,both,2,EA,,127,88.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LURASIDONE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7355-04,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE BIT 2 %-1:100,000 INJ CRTG",50863,CDM,636,RC,J3490,HCPCS,0404-6512-05,NDC,facility,both,3,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,7,EA,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-1971-00,NDC,facility,both,20,ML,,239,167.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,FAMNOCHARGE,HCPCS,60687-252-40,NDC,,,facility,both,1,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,250,RC,J3490,HCPCS,23155-166-31,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  20 MG ORAL TR12,50863,CDM,250,RC,J3490,HCPCS,59011-420-20,NDC,facility,both,1,EA,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,66794-229-02,NDC,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IR SOLN,50863,CDM,250,RC,J3490,HCPCS,0338-0047-46,NDC,facility,both,3,ML,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0630,HCPCS,63323-865-02,NDC,facility,both,1,ML,,1469,1028.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,250,RC,J3490,HCPCS,59310-579-22,NDC,facility,both,1,GM,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,7733351625,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARDIOPLEGIC SOLUTION NO.25 29 MMOL/L (POTASSIUM) PERF SOLN,50863,CDM,250,RC,J3490,HCPCS,69374-984-10,NDC,facility,both,1,ML,,504,352.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,636,RC,J3490,HCPCS,70004-600-09,NDC,facility,both,3,ML,,127,88.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-0007-01,NDC,facility,both,200,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLMESARTAN  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68462-436-30,NDC,facility,both,2,EA,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE DINITRATE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6619-61,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAZOSIN 5 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,51079-632-01,NDC,facility,both,4,EA,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7177-61,NDC,facility,both,1,EA,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9% IV (PEDS) BOLUS,50863,CDM,636,RC,J7030,HCPCS,0264-7800-09,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE (DIAGNOSTIC) 3 MG/ML IV SOLN,50863,CDM,J0153,HCPCS,55150-193-01,NDC,,,facility,both,180,ML,,1545,1081.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MISOPROSTOL 800 MCG (4 X 200 MCG TAB) PACKAGE,50863,CDM,S0191,HCPCS,43393-023-04,NDC,,,facility,both,4,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  50 MG ORAL TAB,50863,CDM,J3490,HCPCS,60687-242-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7030,HCPCS,0338-0049-04,NDC,facility,both,3,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,50863,CDM,J1644,HCPCS,0409-2723-30,NDC,,,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC ADMIN RESPIRATORY SYNCYTIAL VIRUS MONOCLONAL ANTIBODY SEASONAL DOSE INTRAMUSCULAR INJECTION,50863,CDM,90380,HCPCS,49281-575-00,NDC,,,facility,both,1,ML,,1535,1074.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 0.5 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,59746-010-32,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-38,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 100 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,31722-574-47,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,65649-211-24,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML IV,50863,CDM,250,RC,J3490,HCPCS,55150-425-01,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,65219-570-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,50863,CDM,636,RC,J1756,HCPCS,0517-2325-01,NDC,facility,both,50,ML,,186,130.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,636,RC,J1939,HCPCS,65219-570-01,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FONDAPARINUX 5 MG/0.4 ML SUBQ SYRG,50863,CDM,250,RC,J1652,HCPCS,55111-679-11,NDC,facility,both,10,ML,,489,342.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0003-0894-70,NDC,facility,both,16,EA,,699,489.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,3,EA,,107,74.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,59762-2198-7,NDC,facility,both,1,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION,50863,CDM,250,RC,J3490,HCPCS,0186-0372-28,NDC,facility,both,1,GM,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEDIATRIC MULTIVITAMIN NO.42 ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,8068104900,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 1 % TOPICAL GEL,50863,CDM,250,RC,J3490,HCPCS,16714-161-01,NDC,facility,both,1,GM,,361,252.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J3490,HCPCS,0338-0049-18,NDC,facility,both,2,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"HEPARIN, PORCINE (PF)   10 UNIT/ML IV SYRG",50863,CDM,250,RC,J1642,HCPCS,6425322223,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),50863,CDM,250,RC,J1630,HCPCS,67457-426-00,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 100 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,51672-4047-9,NDC,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COSYNTROPIN 0.25 MG INJ SOLR,50863,CDM,250,RC,J0834,HCPCS,0781-3440-71,NDC,facility,both,1,EA,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),50863,CDM,636,RC,J0169,HCPCS,76329-3318-1,NDC,facility,both,30,ML,,242,169.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE   4.2 % IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-083-05,NDC,facility,both,1,ML,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,29300-245-01,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUM U-500 CONC 500 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1815,HCPCS,0002-8501-01,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,10135-778-01,NDC,facility,both,50,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAZOLAMIDE 250 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,64380-834-06,NDC,facility,both,2,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,5,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HUMAN PROTHROMBIN COMPLEX 500 UNIT IV SOLR,50863,CDM,250,RC,J7168,HCPCS,63833-386-02,NDC,facility,both,1000,UN,,5819,4073.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML INJ SOLN,50863,CDM,J0169,HCPCS,76329-9061-0,NDC,,,facility,both,300,ML,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,J0133,HCPCS,63323-325-14,NDC,,,facility,both,300,ML,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG ORAL TAB,50863,CDM,J3490,HCPCS,69315-904-01,NDC,,,facility,both,4,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-344-11,NDC,facility,both,1,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"CALCIUM GLUC IN NACL, ISO-OSM 1 G/100 ML IV SOLN",50863,CDM,250,RC,J0613,HCPCS,44567-622-01,NDC,facility,both,200,ML,JZ,149,104.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
FLUCONAZOLE PEDS SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J3490,HCPCS,25021-113-82,NDC,facility,both,30,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTOXIFYLLINE 400 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,0904-5448-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7124-61,NDC,facility,both,1,EA,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN NACL (PF) 1000 UNIT/500 ML IV SOLP,50863,CDM,636,RC,J1644,HCPCS,0409-1005-01,NDC,facility,both,2,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MICAFUNGIN 100 MG IV SOLR,50863,CDM,250,RC,J2248,HCPCS,42023-230-01,NDC,facility,both,67,EA,,434,303.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 100 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,0904-3854-61,NDC,facility,both,4,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HUMAN PROTHROMBIN COMPLEX 500 UNIT IV SOLR,50863,CDM,250,RC,J7168,HCPCS,63833-396-01,NDC,facility,both,500,UN,,2910,2037,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,250,RC,J3360,HCPCS,69339-136-03,NDC,facility,both,12,ML,,867,606.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,2055503600,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML IV SOLN (MERGE),50863,CDM,250,RC,J3490,HCPCS,16714-037-10,NDC,facility,both,1,ML,,152,106.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  75 MG ORAL CP24,50863,CDM,636,RC,J3490,HCPCS,0904-7077-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CINACALCET 30 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,31722-103-30,NDC,facility,both,1,EA,,150,105,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE  4 MG ORAL TAB,50863,CDM,636,RC,J7509,HCPCS,0904-6914-61,NDC,facility,both,2,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,0517-4620-25,NDC,facility,both,3,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 500 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7337-35,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 40 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,70377-009-11,NDC,facility,both,1,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN V POTASSIUM 250 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16714-234-01,NDC,facility,both,4,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,636,RC,J2560,HCPCS,54288-137-01,NDC,facility,both,1,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE   4.2 % IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-083-05,NDC,facility,both,2,ML,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 0.3 % OPHT DROP,50863,CDM,636,RC,J3490,HCPCS,24208-580-60,NDC,facility,both,1,ML,,210,147,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 600 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65162-465-10,NDC,facility,both,3,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 5 MG/ML IV SOLN,50863,CDM,636,RC,J1921,HCPCS,25021-317-20,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-426-02,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-03,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEFEROXAMINE 500 MG INJ SOLR,50863,CDM,J0895,HCPCS,60505-6236-6,NDC,,,facility,both,2,EA,,152,106.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIP-PERT(A)-TET-POLIO-HIB (PF) 15LF-20MCG-5LF- 62 DU/0.5 ML IM KIT,50863,CDM,90698,HCPCS,49281-511-05,NDC,,,facility,both,1,EA,,493,345.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,50863,CDM,J1756,HCPCS,0517-2340-01,NDC,,,facility,both,100,ML,,321,224.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,250,RC,J0132,HCPCS,0574-0805-00,NDC,facility,both,180,ML,,2437,1705.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 500 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,50268-260-11,NDC,facility,both,3,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 2 MG INJ SOLR,50863,CDM,J2997,HCPCS,50242-041-64,NDC,,,facility,both,6,EA,,2400,1680,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 2 GRAM IV SOLUTION,50863,CDM,J9075,HCPCS,0781-3255-94,NDC,,,facility,both,400,EA,,3791,2653.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,J2405,HCPCS,0641-6078-25,NDC,,,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 0.5 %-1:200,000 INJ SOLN",50863,CDM,J2004,HCPCS,63323-481-01,NDC,,,facility,both,150,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-ABDA 100 MG IV SOLR,50863,CDM,Q5104,HCPCS,78206-162-01,NDC,,,facility,both,8,EA,,724,506.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM SR 120 MG 24 HR CAP,50863,CDM,250,RC,J3490,HCPCS,60687-195-11,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 10 MG TAB,50863,CDM,250,RC,Q0177,HCPCS,63739-483-10,NDC,facility,both,5,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMFIBROZIL 600 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-473-11,NDC,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 1 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,65162-673-84,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM IN D5W 125 MG/125 ML (1 MG/ML) IV SOLN (PREMIX),50863,CDM,J3490,HCPCS,70092-1575-36,NDC,,,facility,both,1,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,63323-010-02,NDC,facility,both,5,ML,,150,105,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,636,RC,J3490,HCPCS,72603-387-01,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,636,RC,J3490,HCPCS,70860-400-41,NDC,facility,both,1,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,50863,CDM,J0696,HCPCS,25021-107-68,NDC,,,facility,both,8,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLN,50863,CDM,J3262,HCPCS,50242-137-01,NDC,,,facility,both,160,ML,,1275,892.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORDIAZEPOXIDE 25 MG CAP,50863,CDM,J3490,HCPCS,60687-807-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,J2704,HCPCS,16714-528-01,NDC,,,facility,both,8,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,J1171,HCPCS,76045-009-96,NDC,,,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,636,RC,J2795,HCPCS,43066-023-01,NDC,facility,both,120,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3370,HCPCS,0143-9162-01,NDC,facility,both,3,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,63323-165-30,NDC,facility,both,70,ML,,138,96.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-8515-23,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NYSTATIN 100000 UNIT/ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,62135-813-47,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,2,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,250,RC,J3490,HCPCS,0143-9679-01,NDC,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,68382-910-01,NDC,facility,both,1,EA,,148,103.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FELODIPINE  5 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,23155-049-01,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-50,NDC,facility,both,46,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLN (MERGE)",50863,CDM,250,RC,P9047,HCPCS,64208-2512-4,NDC,facility,both,2,ML,,274,191.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INHL NEBU,50863,CDM,250,RC,J3490,HCPCS,0378-6987-89,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,636,RC,J0690,HCPCS,63323-237-10,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 90 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0093-0320-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 7.5 MG-325 MG/15 ML ORAL SOLN (REPACK),50863,CDM,636,RC,J3490,HCPCS,0121-2316-15,NDC,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,13533-690-20,NDC,facility,both,1,ML,,493,345.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OMALIZUMAB 150 MG/ML SUBQ SYRG,50863,CDM,J2357,HCPCS,50242-215-01,NDC,,,facility,both,60,ML,,6230,4361,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 1 GRAM INJ SOLR,50863,CDM,250,RC,J0692,HCPCS,25021-121-20,NDC,facility,both,8,EA,,160,112,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5%-LACTATED RINGERS IV,50863,CDM,250,RC,J7120,HCPCS,0338-0125-03,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 100 MG SOLUTION FOR INJECTION,50863,CDM,250,RC,J1720,HCPCS,0009-0825-01,NDC,facility,both,1,EA,,113,79.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG IV SOLR,50863,CDM,636,RC,J3490,HCPCS,68382-910-01,NDC,facility,both,1,EA,,148,103.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VORICONAZOLE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65862-891-30,NDC,facility,both,5,EA,,267,186.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOPIDOGREL  75 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6294-61,NDC,facility,both,2,EA,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,0641-6145-01,NDC,facility,both,4,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE MODIFIED 100 MG ORAL CAP,50863,CDM,250,RC,J7502,HCPCS,51862-460-01,NDC,facility,both,2,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZONISAMIDE 10 MG/ML ORAL SYRUP (REPACK),50863,CDM,250,RC,J3490,HCPCS,64679-990-01,NDC,facility,both,1,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 1 MG/1 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,68094-031-59,NDC,facility,both,2,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETIRIZINE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16714-799-02,NDC,facility,both,2,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-505-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,16714-046-01,NDC,facility,both,10,ML,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,636,RC,J0690,HCPCS,44567-707-25,NDC,facility,both,3,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 20 GRAM/500 ML IV SOLP,50863,CDM,250,RC,J3475,HCPCS,0409-2050-01,NDC,facility,both,40,ML,JZ,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CEFAZOLIN 1000 MG IN NS 1000 ML IRRIGATION (REPACK),50863,CDM,636,RC,J0690,HCPCS,99999-500-04,NDC,facility,both,2,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE IN D5W 1 GRAM/100 ML IV PGBK,50863,CDM,636,RC,J3475,HCPCS,0409-6727-23,NDC,facility,both,4,ML,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,0409-4887-17,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,72266-118-01,NDC,facility,both,2,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE  7 MG/24 HR TD PT24,50863,CDM,250,RC,J3490,HCPCS,43598-446-71,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,50863,CDM,250,RC,J9267,HCPCS,61703-342-22,NDC,facility,both,129,ML,,213,149.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IV PGBK,50863,CDM,250,RC,J3490,HCPCS,47335-992-01,NDC,facility,both,1,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0172-3926-60,NDC,facility,both,14,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  20 MEQ ORAL PACK,50863,CDM,250,RC,J3490,HCPCS,72888-024-06,NDC,facility,both,5,EA,,228,159.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,126,88.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAZOLAMIDE 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,64380-834-06,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"NEOMYCIN-POLYMYXIN-PRAMOXINE 3.5 MG-10,000 UNIT-10 MG/G TOPICAL CREAM",50863,CDM,636,RC,J3490,HCPCS,81073794,NDC,facility,both,1,GM,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYCHLOROQUINE 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-269-11,NDC,facility,both,3,EA,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,0409-1886-22,NDC,facility,both,400,ML,,207,144.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6782-61,NDC,facility,both,3,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-210-11,NDC,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM PHOSPHATE 4.4 MEQ/ML ORAL SOLUTION (CDS),50863,CDM,250,RC,J3490,HCPCS,0409-7295-11,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 150 MG/1 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0548-5607-00,NDC,facility,both,15,ML,,133,93.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  2.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60505-3110-0,NDC,facility,both,1,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,76045-009-01,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-406-03,NDC,facility,both,1,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL IV BOLUS 10MG/ML (ANESTHESIA ONLY),50863,CDM,636,RC,J2704,HCPCS,0409-4699-54,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,47335-993-01,NDC,facility,both,100,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOBENZAPRINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,52817-332-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM IN NACL (ISO-OS) 1500 MG/100 ML IV PGBK,50863,CDM,250,RC,J1953,HCPCS,43598-637-52,NDC,facility,both,150,ML,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLP",50863,CDM,636,RC,P9047,HCPCS,0944-0493-04,NDC,facility,both,4,ML,,1001,700.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES  8.6 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69618-064-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25 MG-100 MG TAB,50863,CDM,250,RC,J3490,HCPCS,69367-339-05,NDC,facility,both,3,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G POTASSIUM  5000000 UNIT INJ SOLR,50863,CDM,250,RC,J2540,HCPCS,0781-6135-94,NDC,facility,both,7,EA,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLP (FOR DIALYSIS)",50863,CDM,250,RC,P9047,HCPCS,0944-0493-02,NDC,facility,both,2,ML,,826,578.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0003-0893-21,NDC,facility,both,2,EA,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),50863,CDM,250,RC,J2060,HCPCS,0641-6044-01,NDC,facility,both,3,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESALAMINE 4 GRAM/60 ML RECT ENEM,50863,CDM,250,RC,J3490,HCPCS,45802-098-51,NDC,facility,both,1,ML,,119,83.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,65862-219-60,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM  4.5 GRAM IV SOLR,50863,CDM,J2543,HCPCS,81284-153-00,NDC,,,facility,both,4,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  1 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,64380-782-06,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OMALIZUMAB 150 MG SUBQ SOLR,50863,CDM,636,RC,J2357,HCPCS,50242-040-62,NDC,facility,both,30,ME,JZ,2610,1827,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MEMANTINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,47335-321-86,NDC,facility,both,2,EA,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE (FOR CODE) 10% IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0517-6710-01,NDC,facility,both,1,ML,,177948,124563.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  1 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,64380-782-06,NDC,facility,both,8,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,636,RC,J2597,HCPCS,65219-293-00,NDC,facility,both,13,ML,,271,189.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 500 MG (200 MG ELEMENTAL) CHEW TAB,50863,CDM,250,RC,J3490,HCPCS,66553-004-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7367-06,NDC,facility,both,1,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  120 MG RECT SUPP,50863,CDM,636,RC,J3490,HCPCS,51672-2115-0,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG ORAL TAB,50863,CDM,J3490,HCPCS,69315-904-01,NDC,,,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 0.1 MG/ML INJ SYRG,50863,CDM,636,RC,J0461,HCPCS,76329-3340-1,NDC,facility,both,200,ML,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVONORGESTREL 1.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-809-01,NDC,facility,both,1,EA,,165,115.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G POTASSIUM 20000000 UNIT INJ SOLR,50863,CDM,250,RC,J2540,HCPCS,70860-127-51,NDC,facility,both,34,EA,JZ,280,196,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
VALSARTAN 160 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,33342-064-10,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,51754-5001-1,NDC,facility,both,3,ML,,155,108.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,636,RC,J2405,HCPCS,60505-6130-0,NDC,facility,both,8,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
AMPICILLIN-SULBACTAM NEO/PEDS (CDS MIXTURE),50863,CDM,636,RC,J0295,HCPCS,63323-368-20,NDC,facility,both,1,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-344-11,NDC,facility,both,2,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID (PORK)  30 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,62559-741-01,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),50863,CDM,250,RC,J0171,HCPCS,76329-3318-1,NDC,facility,both,150,ML,,1101,770.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
UREA 15 GRAM PACKET,50863,CDM,636,RC,J3490,HCPCS,99999-0405-84,NDC,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J3490,HCPCS,0409-4279-16,NDC,,,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROTHIAZIDE SODIUM 500 MG IV SOLR,50863,CDM,250,RC,J1205,HCPCS,0517-1820-01,NDC,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"CALCIUM GLUC IN NACL, ISO-OSM 1 GRAM/50 ML IV SOLN",50863,CDM,636,RC,J0613,HCPCS,44567-620-01,NDC,facility,both,500,ML,,580,406,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,J1885,HCPCS,0338-0072-25,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 50 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,50268-541-11,NDC,facility,both,2,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-0235-24,NDC,facility,both,3,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DRONEDARONE 400 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0024-4142-60,NDC,facility,both,1,EA,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAMOXIFEN 10 MG ORAL TAB,50863,CDM,250,RC,J9999,HCPCS,75907-058-60,NDC,facility,both,2,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LETROZOLE 2.5 MG ORAL TAB,50863,CDM,636,RC,J9999,HCPCS,50268-476-11,NDC,facility,both,1,EA,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,250,RC,J2720,HCPCS,63323-229-01,NDC,facility,both,4,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,26,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DONANEMAB-AZBT 17.5 MG/ML IV SOLN,50863,CDM,636,RC,J0175,HCPCS,0002-9401-01,NDC,facility,both,525,ML,Q0,4801,3360.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier Q0: Investigational clinical service provided in a clinical research study that is in an approved clinical research study
SILDENAFIL (PULM.HYPERTENSION) 10 MG/12.5 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0069-0338-01,NDC,facility,both,1,ML,,673,471.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-406-03,NDC,facility,both,1,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEO TPN SODIUM ACETATE 2 MEQ/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-7299-73,NDC,facility,both,4,ML,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,203,142.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"AMIODARONE IN DEXTROSE,ISO-OSM 360 MG/200 ML (1.8 MG/ML) IV SOLN",50863,CDM,250,RC,J0282,HCPCS,43066-360-20,NDC,facility,both,37,ML,,716,501.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,63323-162-00,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 10 MG TAB,50863,CDM,636,RC,Q0177,HCPCS,16714-081-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 200 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-6993-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,0409-3178-17,NDC,,,facility,both,125,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIPHTH,PERTUS(ACELL),TETANUS VIAL (BOOSTRIX*) 2.5-8-5 LF-MCG-LF/0.5ML IM SUSP",50863,CDM,250,RC,90715,HCPCS,58160-842-01,NDC,facility,both,1,ML,GZ,240,168,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier GZ: Item or service expected to be denied as not reasonable and necessary
PANTOPRAZOLE 40 MG IV SOLR,50863,CDM,J3490,HCPCS,25021-751-10,NDC,,,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLP",50863,CDM,250,RC,P9047,HCPCS,0944-0493-04,NDC,facility,both,11,ML,,2751,1925.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-22,NDC,facility,both,40,ML,JZ,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,0641-6236-01,NDC,facility,both,1,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-3426-10,NDC,facility,both,3,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 10 MG/5 ML SYRUP,50863,CDM,250,RC,Q0177,HCPCS,54838-502-80,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VORICONAZOLE 200 MG IV SOLN,50863,CDM,250,RC,J3465,HCPCS,0781-3416-94,NDC,facility,both,30,EA,,824,576.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,636,RC,J0690,HCPCS,44567-707-25,NDC,facility,both,2,EA,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
HYDROCHLOROTHIAZIDE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0172-2083-60,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65862-013-01,NDC,facility,both,2,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,96,EA,,13248,9273.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,55150-177-05,NDC,facility,both,75,ML,,111,77.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-979-01,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DABIGATRAN  75 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0597-0355-56,NDC,facility,both,2,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LINEZOLID NEO IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J2020,HCPCS,0009-5140-01,NDC,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DROPERIDOL 2.5 MG/ML INJ SOLN,50863,CDM,250,RC,J1790,HCPCS,0143-9514-01,NDC,facility,both,1,ML,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFUROXIME AXETIL 250 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16714-400-01,NDC,facility,both,1,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN IN D5W 400 MG/200 ML IV PGBK,50863,CDM,636,RC,J0744,HCPCS,25021-192-87,NDC,facility,both,2,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0591-0407-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLIPIZIDE  2.5 MG ORAL TO24,50863,CDM,636,RC,J3490,HCPCS,60687-768-11,NDC,facility,both,2,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACUBITRIL-VALSARTAN 49-51 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0078-0777-20,NDC,facility,both,1,EA,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MONTELUKAST 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6808-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 500 MG (200 MG ELEMENTAL) CHEW TAB,50863,CDM,250,RC,J3490,HCPCS,68084-988-33,NDC,facility,both,4,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB 10 MG/ML IV CONC,50863,CDM,636,RC,J9312,HCPCS,50242-051-21,NDC,facility,both,50,ML,,11083,7758.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,23155-600-31,NDC,facility,both,8,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEGFILGRASTIM (NEULASTA) 6 MG/0.6ML SUBQ SYRG,50863,CDM,250,RC,J2506,HCPCS,55513-190-01,NDC,facility,both,12,ML,,17714,12399.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROATE SODIUM 100 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,70860-784-41,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 50 MG/ML IV SOLN,50863,CDM,250,RC,J0282,HCPCS,0143-9875-25,NDC,facility,both,10,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 300 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,63739-132-33,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 1 MG (ENVARSUS XR) 24-HOUR EXTENDED-RELEASE TABLET,50863,CDM,250,RC,J7508,HCPCS,68992-3010-3,NDC,facility,both,5,EA,,141,98.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE  50 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,50268-277-11,NDC,facility,both,2,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,76045-009-96,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",50863,CDM,250,RC,J1561,HCPCS,13533-800-25,NDC,facility,both,40,ML,JA,5658,3960.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,6,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NAFCILLIN NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J3490,HCPCS,63323-327-10,NDC,facility,both,7,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ (MERGE),50863,CDM,636,RC,J2250,HCPCS,70069-817-01,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RALTEGRAVIR 400 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0006-0227-61,NDC,facility,both,1,EA,,196,137.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6291-06,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYCHLOROQUINE 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-777-10,NDC,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPOETIN ALFA 10000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J0885,HCPCS,55513-144-01,NDC,facility,both,8,ML,"JZ,EC",574,401.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier EC: Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,7,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-50,NDC,facility,both,44,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,636,RC,J7510,HCPCS,17856-0815-1,NDC,facility,both,7,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-406-03,NDC,facility,both,1,ML,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN PEDS SYRINGE (20MG/ML) IN DEXTROSE (CDS MIX,50863,CDM,636,RC,J7999,HCPCS,0781-3451-70,NDC,facility,both,4,EA,,207,144.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL  75 MCG/HR TD PT72,50863,CDM,636,RC,J3490,HCPCS,47781-427-11,NDC,facility,both,1,EA,,252,176.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE IV CONCENTRATED INFUSION (1 MEQ/ML),50863,CDM,250,RC,J3490,HCPCS,0409-6625-02,NDC,facility,both,2,ML,,497,347.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM OXIDE 400 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,1000670028,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 800 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-691-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESALAMINE 1000 MG RECT SUPP,50863,CDM,250,RC,J3490,HCPCS,64980-282-03,NDC,facility,both,1,EA,,187,130.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUMATEPERONE 42 MG ORAL CAP,50863,CDM,250,RC,72060-142-40,NDC,,,facility,both,1,EA,,291,203.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
D5-LR WITH POTASSIUM CHLORIDE 20 MEQ/L IV SOLP,50863,CDM,636,RC,J3490,HCPCS,0338-0811-04,NDC,facility,both,1,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2599,HCPCS,43598-914-25,NDC,facility,both,6,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0003-0894-70,NDC,facility,both,1,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,55390-138-01,NDC,facility,both,3,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,73,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,68094-063-59,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,200,ML,,1884,1318.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROMETHORPHAN-GUAIFENESIN SR 30 MG-600 MG 12 HR TAB,50863,CDM,636,RC,J3490,HCPCS,6382405640,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,55111-150-01,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR PHOSPHATE 75 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,68180-677-11,NDC,facility,both,1,EA,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN IN D5W 900 MG/50 ML IV PGBK,50863,CDM,250,RC,J0736,HCPCS,0338-3814-50,NDC,facility,both,3,ML,JZ,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DOCUSATE SODIUM 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7280-60,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-22,NDC,facility,both,400,ML,,1636,1145.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL  2.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-656-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6640-61,NDC,facility,both,3,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0630,HCPCS,24201-400-02,NDC,facility,both,1,ML,,1248,873.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IV PGBK,50863,CDM,250,RC,J3475,HCPCS,0409-4121-01,NDC,facility,both,69,ML,,453,317.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0832-1211-89,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  100 MCG/ML INJ SOLN,50863,CDM,636,RC,J2354,HCPCS,0641-6175-01,NDC,facility,both,2,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),50863,CDM,250,RC,J3490,HCPCS,0409-4888-03,NDC,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,40,ML,,270,189,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VECURONIUM BROMIDE 10 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,0703-2914-01,NDC,facility,both,1,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,636,RC,J7060,HCPCS,0338-0017-03,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,0409-1283-03,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN NEO/PEDIATRIC SYRINGE < 30 MG,50863,CDM,250,RC,J1650,HCPCS,0548-5608-00,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-01,NDC,facility,both,3,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J3490,HCPCS,0338-0049-41,NDC,facility,both,20,ML,,338,236.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,50,ML,JW,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
MAGIC MOUTHWASH REPACK (BMX 1:1:1),50863,CDM,250,RC,J3490,HCPCS,0603-0823-58,NDC,facility,both,2,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BISACODYL  5 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,57896-441-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR  6 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,68180-678-01,NDC,facility,both,10,ML,,134,93.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,636,RC,P9045,HCPCS,68516-5219-0,NDC,facility,both,8,ML,,2034,1423.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,636,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,8,ML,JW,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
MICAFUNGIN 100 MG IV SOLR,50863,CDM,250,RC,J2248,HCPCS,42023-230-01,NDC,facility,both,23,EA,,146,102.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  1 MG/ML ORAL LIQD,50863,CDM,636,RC,J3490,HCPCS,5843800571,NDC,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,50863,CDM,636,RC,J1756,HCPCS,0517-2340-01,NDC,facility,both,300,ML,,935,654.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,50863,CDM,636,RC,J1756,HCPCS,0517-2325-01,NDC,facility,both,40,ML,,149,104.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,0904-7509-30,NDC,facility,both,4,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0536-1327-10,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NADOLOL  20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,76385-133-01,NDC,facility,both,2,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0406-5771-23,NDC,facility,both,25,EA,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (NEO) <2 KG,50863,CDM,250,RC,J7060,HCPCS,0264-7510-00,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MILRINONE INFUSION PED/NEO IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J2260,HCPCS,0338-6010-48,NDC,facility,both,4,ML,,198,138.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,68462-470-40,NDC,facility,both,3,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,50863,CDM,636,RC,J3490,HCPCS,65862-390-10,NDC,facility,both,2,EA,,219,153.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 2-0.5 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,60687-626-11,NDC,facility,both,2,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,636,RC,J2795,HCPCS,70069-064-25,NDC,facility,both,25,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,30,ML,JZ,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CILOSTAZOL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-177-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DONEPEZIL  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,43547-275-03,NDC,facility,both,1,EA,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM ZIRCONIUM CYCLOSILICATE  5 G ORAL PWPK (USE PANEL),50863,CDM,250,RC,J3490,HCPCS,0310-1105-01,NDC,facility,both,3,EA,,373,261.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-01,NDC,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIVAROXABAN  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50458-577-01,NDC,facility,both,1,EA,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PERPHENAZINE  8 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,52536-168-01,NDC,facility,both,2,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-205-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 50 MG TAB,50863,CDM,250,RC,J3490,HCPCS,69452-345-60,NDC,facility,both,2,EA,,214,149.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELATACEPT 250 MG IV SOLR,50863,CDM,636,RC,J0485,HCPCS,0003-0371-13,NDC,facility,both,370,EA,,3818,2672.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6322-61,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,50863,CDM,250,RC,J2359,HCPCS,55150-308-01,NDC,facility,both,5,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-739-11,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENAZOPYRIDINE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,75826-114-10,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2308-22,NDC,facility,both,8,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-5771-23,NDC,facility,both,8,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6007-60,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6322-61,NDC,facility,both,3,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  500 MG IV SOLR,50863,CDM,636,RC,J3370,HCPCS,0409-4332-11,NDC,facility,both,1,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,636,RC,J2560,HCPCS,54288-136-01,NDC,facility,both,1,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),50863,CDM,250,RC,J3490,HCPCS,0409-4888-02,NDC,facility,both,1,ML,PLAD,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
MULTIVIT-MIN-FERROUS GLUCONATE 9 MG IRON/ 15 ML (15 ML) ORAL LIQD,50863,CDM,250,RC,J3490,HCPCS,8103350115,NDC,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,65649-311-12,NDC,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAZOSIN 1 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7020-61,NDC,facility,both,6,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,636,RC,J3490,HCPCS,0409-4887-17,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,2,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAZOLAMIDE 500 MG ORAL CPSR,50863,CDM,250,RC,J3490,HCPCS,29033-030-01,NDC,facility,both,2,EA,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7193-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN V POTASSIUM 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,57237-040-01,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROPRUSSIDE 25 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,70069-261-01,NDC,facility,both,2,ML,,245,171.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV (BOLUS),50863,CDM,250,RC,J7120,HCPCS,0264-7750-07,NDC,facility,both,2,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6172-61,NDC,facility,both,3,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 50 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,59651-489-01,NDC,facility,both,50,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-01,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,636,RC,J2270,HCPCS,0409-1890-03,NDC,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-65,NDC,facility,both,19,ML,JW,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,636,RC,J2405,HCPCS,0641-6078-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAMADOL  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0378-4151-01,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIOGLITAZONE 30 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,57237-220-90,NDC,facility,both,1,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-440-01,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 1 MG ORAL TAB,50863,CDM,636,RC,J8540,HCPCS,0054-4181-25,NDC,facility,both,24,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  0.25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6373-61,NDC,facility,both,3,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J1938,HCPCS,0409-6102-18,NDC,facility,both,80,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,636,RC,Q0162,HCPCS,16714-671-02,NDC,facility,both,4,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-543-01,NDC,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"CALCIUM GLUC IN NACL, ISO-OSM 1 GRAM/50 ML IV SOLN",50863,CDM,636,RC,J0612,HCPCS,44567-620-01,NDC,facility,both,300,ML,,348,243.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACTIVATED CHARCOAL 25 GRAM/120 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0574-0521-74,NDC,facility,both,2,ML,,164,114.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SOTALOL  80 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-654-11,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAZOSIN 1 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,51079-630-01,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) IV SOLN",50863,CDM,636,RC,J9022,HCPCS,50242-917-01,NDC,facility,both,120,ML,,23792,16654.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-25,NDC,facility,both,18,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,636,RC,P9045,HCPCS,68516-5214-8,NDC,facility,both,12,ML,JZ,3050,2135,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,0409-3178-16,NDC,,,facility,both,70,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,J1100,HCPCS,63323-165-01,NDC,,,facility,both,3,ML,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,636,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,8,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CEFAZOLIN IN DEXTROSE (ISO-OSMOTIC) 1 GRAM/50 ML IV PIGGY BACK,50863,CDM,J0690,HCPCS,0264-3103-11,NDC,,,facility,both,6,ML,,5432,3802.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOMYCIN-BACITRACN ZN-POLYMYXIN 3.5 MG-400 U*,50863,CDM,636,RC,J3490,HCPCS,45802-143-00,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEMANTINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6505-61,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,66794-229-02,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7057-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 1 GRAM INJ SOLR,50863,CDM,250,RC,J0692,HCPCS,0409-9566-01,NDC,facility,both,2,EA,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,636,RC,J0330,HCPCS,0409-6629-02,NDC,facility,both,5,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0456,HCPCS,55150-174-10,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",50863,CDM,250,RC,J1561,HCPCS,13533-800-25,NDC,facility,both,40,ML,JA,5658,3960.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,70004-600-09,NDC,facility,both,2,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,16714-036-01,NDC,facility,both,16,ML,,187,130.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXAZOSIN 4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-862-95,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFUROXIME AXETIL 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-272-11,NDC,facility,both,2,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANAGRELIDE 0.5 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,13668-453-01,NDC,facility,both,2,EA,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,41,EA,,5658,3960.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYUREA  500 MG ORAL CAP,50863,CDM,250,RC,J9999,HCPCS,68084-284-11,NDC,facility,both,5,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,250,RC,J2720,HCPCS,63323-229-01,NDC,facility,both,3,ML,JW,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
SODIUM CHLORIDE 0.9 % INJ SYRG,50863,CDM,636,RC,J3490,HCPCS,8290306553,NDC,facility,both,3,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MINERAL OIL ORAL (REPACK),50863,CDM,250,RC,J3490,HCPCS,48433-202-30,NDC,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACCHAROMYCES BOULARDII 250 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,904723006,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,63323-482-03,NDC,,,facility,both,400,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,60219-1708-1,NDC,facility,both,180,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4 % TOPICAL SOLN,50863,CDM,J3490,HCPCS,76329-6300-5,NDC,,,facility,both,51,ML,,4251,2975.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J3490,HCPCS,0990-7983-61,NDC,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN 0.9 % SODIUM CHL 1.5 GRAM/500 ML IV SOLN,50863,CDM,J3373,HCPCS,71506-016-59,NDC,,,facility,both,150,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-22,NDC,facility,both,9,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,50863,CDM,J9263,HCPCS,71288-171-11,NDC,,,facility,both,55,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,J1836,HCPCS,0338-9541-24,NDC,,,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0143-9509-01,NDC,facility,both,1,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0781-3246-02,NDC,facility,both,4,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THROMBIN (RECOMBINANT) 5000 UNIT TOP SOLR,50863,CDM,250,RC,J3490,HCPCS,0338-0324-01,NDC,facility,both,8,EA,,2973,2081.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-495-27,NDC,,,facility,both,80,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL  12 MCG/HR TD PT72,50863,CDM,250,RC,J3490,HCPCS,47781-423-11,NDC,facility,both,1,EA,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN IN D5W 400 MG/200 ML IV PGBK,50863,CDM,250,RC,J0744,HCPCS,25021-114-87,NDC,facility,both,10,ML,,233,163.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,0944-0495-05,NDC,facility,both,2,ML,,826,578.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN PEDS INFUSION (CDS MIXTURE),50863,CDM,250,RC,J0290,HCPCS,99999-408-63,NDC,facility,both,2,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0143-9889-15,NDC,facility,both,5,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEFLUNOMIDE  10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,23155-043-03,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7350-61,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0093-2279-73,NDC,facility,both,4,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL 10MG/1ML SUSPENSION (REPACK),50863,CDM,250,RC,J3490,HCPCS,57664-167-52,NDC,facility,both,5,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-ABDA 100 MG IV SOLR,50863,CDM,636,RC,Q5104,HCPCS,78206-162-99,NDC,facility,both,40,EA,JZ,8318,5822.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,63323-185-09,NDC,facility,both,20,ML,,993,695.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANTI-INHIBITOR COAGULANT CMPLX (PHS MERGE),50863,CDM,250,RC,J7198,HCPCS,64193-426-02,NDC,facility,both,7500,UN,,54165,37915.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,636,RC,J3490,HCPCS,72789-057-01,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB 100 MG IV SOLR,50863,CDM,636,RC,J1745,HCPCS,57894-030-01,NDC,facility,both,32,EA,,10315,7220.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,50863,CDM,250,RC,J0696,HCPCS,60505-6149-0,NDC,facility,both,32,EA,,1549,1084.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  37.5 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,59762-0180-3,NDC,facility,both,2,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,0143-9680-01,NDC,facility,both,5,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE  7.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,13107-001-30,NDC,facility,both,3,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7363-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,50863,CDM,636,RC,J9000,HCPCS,0069-3032-20,NDC,facility,both,10,ML,,289,202.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,50863,CDM,250,RC,J9000,HCPCS,0069-1542-20,NDC,facility,both,10,ML,,164,114.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE  50 MCG/ACTUATION NASL SPSN,50863,CDM,250,RC,J3490,HCPCS,50383-700-16,NDC,facility,both,1,GM,,358,250.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 30 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,13107-003-34,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,250,RC,J3490,HCPCS,0143-9679-01,NDC,facility,both,1,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 600 MG ORAL TP12,50863,CDM,250,RC,J3490,HCPCS,0536-1163-61,NDC,facility,both,8,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CELECOXIB 400 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,65862-910-60,NDC,facility,both,1,EA,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  500 MG IV SOLR,50863,CDM,250,RC,J3370,HCPCS,0409-4332-11,NDC,facility,both,4,EA,,218,152.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SECUKINUMAB  25 MG/ML IV SOLN,50863,CDM,636,RC,J3247,HCPCS,0078-1168-61,NDC,facility,both,625,ML,"JZ,JA",29479,20635.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
NAFCILLIN  2 GRAM INJ SOLR,50863,CDM,250,RC,J3490,HCPCS,63323-328-21,NDC,facility,both,1,EA,,170,119,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPAGLIFLOZIN PROPANEDIOL 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0310-6210-39,NDC,facility,both,1,EA,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL PACK,50863,CDM,636,RC,J3490,HCPCS,42806-270-98,NDC,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,72266-118-01,NDC,facility,both,2,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
AMINOCAPROIC ACID 250 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-4346-73,NDC,facility,both,1,ML,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUBIPROSTONE  8 MCG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0254-3028-02,NDC,facility,both,3,EA,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZOCAINE-MENTHOL 15-3.6 MG MM LOZG,50863,CDM,250,RC,J3490,HCPCS,7031246129,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,56,ML,JW,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7124-61,NDC,facility,both,12,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NORETHINDRONE ACETATE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68462-304-50,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM NEONATAL INJECTION 0.2 MG/0.5 ML,50863,CDM,250,RC,J2060,HCPCS,0641-6046-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"TRANEXAMIC ACID IN NACL,ISO-OS 1,000 MG/100 ML (10 MG/ML) IV PGBK",50863,CDM,250,RC,J3490,HCPCS,80830-2329-1,NDC,facility,both,1,ML,,121,84.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,16714-661-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,54,EA,,7452,5216.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9% IV (PEDS) BOLUS,50863,CDM,250,RC,J7040,HCPCS,0264-7800-09,NDC,facility,both,2,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,J7060,HCPCS,0338-0017-03,NDC,,,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,31722-711-30,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM  5 MG ORAL TAB,50863,CDM,J3490,HCPCS,51079-285-01,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,3,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-495-27,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,50863,CDM,636,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,100,ML,,269,188.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-075-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  60 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,0406-8380-23,NDC,facility,both,2,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CITRATE  5 MEQ ORAL TBER,50863,CDM,250,RC,J3490,HCPCS,42543-406-01,NDC,facility,both,2,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB 100 MG IV SOLR,50863,CDM,636,RC,J1745,HCPCS,57894-030-01,NDC,facility,both,2,EA,JW,281,196.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,5,ML,,8676,6073.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,0641-6236-01,NDC,facility,both,1,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-407-11,NDC,facility,both,2,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INDOMETHACIN 100 MG RECT SUPP,50863,CDM,250,RC,J3490,HCPCS,73702-140-71,NDC,facility,both,1,EA,,513,359.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE PAMOATE  25 MG ORAL CAP,50863,CDM,636,RC,Q0177,HCPCS,0904-7065-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 0.25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-270-11,NDC,facility,both,1,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-05,NDC,facility,both,12,EA,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIHYDROERGOTAMINE 1 MG/ML INJ SOLN,50863,CDM,250,RC,J1110,HCPCS,0143-9273-01,NDC,facility,both,1,ML,,454,317.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZTREONAM 2 GRAM INJ SOLR,50863,CDM,250,RC,J0457,HCPCS,63323-402-41,NDC,facility,both,20,EA,,278,194.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BICTEGRAV-EMTRICIT-TENOFOV ALA 50-200-25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,61958-2501-3,NDC,facility,both,1,EA,,608,425.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE  5 MG ORAL CP24,50863,CDM,636,RC,J3490,HCPCS,64850-510-01,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60219-1708-1,NDC,facility,both,40,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,636,RC,J3490,HCPCS,63037-136-25,NDC,facility,both,2,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE (PEDIATRIC 6 MONTH) 45 MG SUBQ SYRG,50863,CDM,636,RC,J1951,HCPCS,62935-163-60,NDC,facility,both,180,EA,,75743,53020.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0003-0894-70,NDC,facility,both,6,EA,,309,216.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,636,RC,J0690,HCPCS,0143-9924-90,NDC,facility,both,2,EA,,128,89.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FIDAXOMICIN 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,52015-080-01,NDC,facility,both,6,EA,,4310,3017,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"RSV VAC, PREF A AND PREF B(PF) 120 MCG/0.5 ML IM SOLR",50863,CDM,90678,HCPCS,0069-0344-01,NDC,,,facility,both,1,EA,,1045,731.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,59651-488-01,NDC,facility,both,30,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,50863,CDM,Q0177,HCPCS,60687-675-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,J0133,HCPCS,63323-325-03,NDC,,,facility,both,138,ML,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,J1580,HCPCS,63323-010-03,NDC,,,facility,both,3,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ORPHENADRINE CITRATE 30 MG/ML INJ SOLN,50863,CDM,250,RC,J2360,HCPCS,25021-651-02,NDC,facility,both,1,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 70% IN WATER (D70W) IV,50863,CDM,250,RC,J7070,HCPCS,0338-0719-06,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-657-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL  6.25 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-7306-61,NDC,,,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,25,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-467-01,NDC,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 12 MG/ML ORAL SUSPENSION,50863,CDM,250,RC,J3490,HCPCS,0093-0319-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,0409-4713-75,NDC,,,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 2 MG/10 ML (200 MCG/ML) IN D5W VIAL-CVL/IR USE (REPACK),50863,CDM,250,RC,J2305,HCPCS,0338-1049-02,NDC,facility,both,10,ML,JZ,133,93.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DARBEPOETIN ALFA IN POLYSORBAT  25 MCG/ML INJ SOLN,50863,CDM,636,RC,J0881,HCPCS,55513-002-01,NDC,facility,both,25,ML,JZ,836,585.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PENTAMIDINE 300 MG INJ SOLR,50863,CDM,250,RC,J3490,HCPCS,23155-748-31,NDC,facility,both,1,EA,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-208-01,NDC,facility,both,8,EA,PLAD,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
RISPERIDONE 0.25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-270-11,NDC,facility,both,5,EA,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0574-0521-76,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-22,NDC,facility,both,100,ML,,200,140,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,194,ML,,175,122.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADVATE: FACTOR VIII CONCENTRATE (MERGE RECORD),50863,CDM,250,RC,J7192,HCPCS,0944-3052-04,NDC,facility,both,1000,UN,,4186,2930.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 50% IN WATER (MERGE RECORD),50863,CDM,636,RC,J7060,HCPCS,76329-3302-1,NDC,facility,both,1,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,9,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0003-0894-31,NDC,facility,both,8,EA,,404,282.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIRMATRELVIR-RITONAVIR 150 MG (10)- 100 MG (10) ORAL DSPK,50863,CDM,636,RC,J3490,HCPCS,0069-5317-20,NDC,facility,both,2,EA,,628,439.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,2,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NOREPINEPHRINE BITARTRATE-D5W 4 MG/250 ML (16 MCG/ML) IV SOLN,50863,CDM,J3490,HCPCS,0338-0112-20,NDC,,,facility,both,3,ML,,400,280,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,J3490,HCPCS,59762-3140-1,NDC,,,facility,both,5,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,50863,CDM,J1650,HCPCS,0781-3246-02,NDC,,,facility,both,4,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN IN SALINE (ISO-OSMOTIC) 80 MG/100 ML IV PIGGY BACK,50863,CDM,636,RC,J1580,HCPCS,0338-0503-48,NDC,facility,both,6,ML,,160,112,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPOETIN ALFA 10000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J0885,HCPCS,59676-310-00,NDC,facility,both,8,ML,"JZ,EC",757,529.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier EC: Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,J2704,HCPCS,16714-528-01,NDC,,,facility,both,12,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,50863,CDM,J3490,HCPCS,16714-294-02,NDC,,,facility,both,8,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROGESTERONE MICRONIZED  8 % VAGL GEL,50863,CDM,250,RC,j3490,HCPCS,0023-6151-09,NDC,facility,both,1,GM,,176,123.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,63323-010-02,NDC,facility,both,5,ML,,146,102.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,50863,CDM,Q0177,HCPCS,63739-486-10,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 1 GRAM INJ SOLR,50863,CDM,636,RC,J0692,HCPCS,44567-240-10,NDC,facility,both,2,EA,JZ,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-50,NDC,facility,both,102,ML,,180,126,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-3178-01,NDC,facility,both,70,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 100 MG/1 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,0075-0623-03,NDC,facility,both,9,ML,,132,92.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  125 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,23155-858-78,NDC,facility,both,2,EA,,266,186.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0904-6923-61,NDC,facility,both,15,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  75 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-495-11,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0143-9889-15,NDC,facility,both,10,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FONDAPARINUX 7.5 MG/0.6 ML SUBQ SYRG,50863,CDM,250,RC,J1652,HCPCS,55111-680-11,NDC,facility,both,15,ML,,463,324.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE  5 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,70010-029-01,NDC,facility,both,5,EA,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,7,EA,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0904-7127-61,NDC,facility,both,60,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATED 20 MG/ML IV SOLN,50863,CDM,250,RC,J0706,HCPCS,51754-0500-1,NDC,facility,both,22,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 10 GRAM/15 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0116-4005-30,NDC,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRIVIGEN 10 % IV SOLN,50863,CDM,636,RC,J1459,HCPCS,44206-438-20,NDC,facility,both,80,ML,JZ,14352,10046.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"ALBUMIN, HUMAN 25 % IV SOLN (MERGE)",50863,CDM,250,RC,P9047,HCPCS,64208-2512-7,NDC,facility,both,1,ML,JW,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
EPINEPHRINE (PF) 1 MG/ML INJ SOLN,50863,CDM,J0171,HCPCS,54288-103-01,NDC,,,facility,both,170,ML,,1455,1018.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM 500 MG IV SOLR,50863,CDM,250,RC,J2185,HCPCS,55150-207-20,NDC,facility,both,5,EA,JZ,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ADVATE: FACTOR VIII CONCENTRATE (MERGE RECORD),50863,CDM,250,RC,J7192,HCPCS,0944-3054-02,NDC,facility,both,2000,UN,,8372,5860.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPTOMYCIN 500 MG IV SOLR,50863,CDM,J0878,HCPCS,72603-152-01,NDC,,,facility,both,700,EA,,2047,1432.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,60687-134-11,NDC,facility,both,10,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 500 MG-125 MG TAB,50863,CDM,250,RC,J3490,HCPCS,16714-296-01,NDC,facility,both,9,EA,,167,116.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE 150 MG ORAL CP24,50863,CDM,636,RC,J3490,HCPCS,68084-713-11,NDC,facility,both,2,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 7.5 MG-325 MG/15 ML ORAL SOLN (REPACK),50863,CDM,250,RC,J3490,HCPCS,0121-2316-15,NDC,facility,both,2,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL  6.25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,80725-140-20,NDC,facility,both,1,EA,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 7.5 MG-325 MG/15 ML ORAL SOLN (REPACK),50863,CDM,250,RC,J3490,HCPCS,0121-2316-15,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUMAZENIL 0.1 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0143-9784-01,NDC,facility,both,2,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25 MG-100 MG TAB,50863,CDM,250,RC,J3490,HCPCS,59651-457-01,NDC,facility,both,3,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7126-61,NDC,facility,both,3,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV,50863,CDM,250,RC,J7120,HCPCS,0338-0117-03,NDC,facility,both,21,ML,,1280,896,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,636,RC,J7510,HCPCS,17856-0815-1,NDC,facility,both,6,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,636,RC,J3490,HCPCS,61553-320-70,NDC,facility,both,3,ML,,207,144.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 1000 MG MISC TBSO,50863,CDM,250,RC,J3490,HCPCS,904723961,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-145-11,NDC,facility,both,20,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 17 GRAM (100 %) ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,1152372688,NDC,facility,both,11,EA,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE MALEATE  5 MG ORAL TAB,50863,CDM,636,RC,Q0164,HCPCS,50268-684-11,NDC,facility,both,3,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,48,ML,,324,226.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-5797-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,84,EA,,11592,8114.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-3244-01,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR  6 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,27241-139-09,NDC,facility,both,5,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-0552-23,NDC,facility,both,8,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIMOLOL MALEATE 0.5 % OPHT DROP,50863,CDM,636,RC,J3490,HCPCS,68682-813-05,NDC,facility,both,1,ML,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,72888-060-30,NDC,facility,both,1,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6322-61,NDC,facility,both,3,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE  25 MG ORAL CAP,50863,CDM,250,RC,J7515,HCPCS,0078-0240-61,NDC,facility,both,2,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESTRADIOL 2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42806-089-01,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,50863,CDM,636,RC,J2359,HCPCS,0781-3159-72,NDC,facility,both,10,EA,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,63323-487-07,NDC,facility,both,300,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML IM SOLN,50863,CDM,636,RC,90375,HCPCS,13533-318-05,NDC,facility,both,1,ML,JW,545,381.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,560,ML,,804,562.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,50863,CDM,250,RC,J9000,HCPCS,0069-1542-20,NDC,facility,both,8,ML,,132,92.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNITS/1 GRAM PACKET (MERGE RECORD),50863,CDM,636,RC,J3490,HCPCS,45802-060-00,NDC,facility,both,5,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,2,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 0.2 % 330 ML (RIGHT) (PHS CUSTOM PAIN BALL),50863,CDM,636,RC,J3490,HCPCS,63323-285-64,NDC,facility,both,1,ML,,580,406,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,63323-485-27,NDC,,,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"OCTREOTIDE,MICROSPHERES 10 MG IM SERR",50863,CDM,J2353,HCPCS,0078-0811-81,NDC,,,facility,both,10,EA,,9725,6807.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADVATE: FACTOR VIII CONCENTRATE (MERGE RECORD),50863,CDM,J7209,HCPCS,0944-3053-04,NDC,,,facility,both,1000,UN,,5244,3670.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMULSION 20 % IV BOLUS (FOR OVERDOSE),50863,CDM,250,RC,J3490,HCPCS,0338-0519-02,NDC,facility,both,2,ML,,406,284.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETIRIZINE 5 MG/5 ML ORAL SOLN,50863,CDM,J3490,HCPCS,68094-004-59,NDC,,,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PYRIDOSTIGMINE BROMIDE  60 MG ORAL TAB,50863,CDM,J3490,HCPCS,0115-3511-01,NDC,,,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 100 MG PE/2 ML INJ SOLN,50863,CDM,250,RC,Q2009,HCPCS,63323-403-01,NDC,facility,both,2,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,J2704,HCPCS,63323-269-22,NDC,,,facility,both,40,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN PEDS SYRINGE (20MG/ML) IN DEXTROSE (CDS MIX,50863,CDM,250,RC,J0690,HCPCS,0781-3451-70,NDC,facility,both,10,EA,,258,180.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL (5 MG/ML) IV SYRG (CONTAINS PRESERVATIVE),50863,CDM,J3490,HCPCS,0409-2339-24,NDC,,,facility,both,1,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) NEB SOLUTION,50863,CDM,J3490,HCPCS,0487-9501-00,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE 0.5 MG SL (1/4 TAB) SUBL,50863,CDM,J3490,HCPCS,99999-0408-26,NDC,,,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 2 QUARTER TABLET
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,J3490,HCPCS,0143-9889-15,NDC,,,facility,both,13,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,50863,CDM,250,RC,J9267,HCPCS,61703-342-50,NDC,facility,both,288,ML,,348,243.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYBUTYNIN CHLORIDE  5 MG ORAL TO24,50863,CDM,636,RC,J3490,HCPCS,68084-480-11,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN 0.9% SODIUM CL 1.25 GRAM/250 ML IV SOLN,50863,CDM,250,RC,J3370,HCPCS,72196-6074-1,NDC,facility,both,3,ML,JZ,184,128.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
HEPARIN (PORCINE) 1000 UNITS/ML INJ SOL (FOR DIALYSIS ONLY),50863,CDM,636,RC,J1644,HCPCS,25021-400-10,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML INJ SOLN,50863,CDM,J2250,HCPCS,0641-6057-01,NDC,,,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK,50863,CDM,250,RC,J3490,HCPCS,12870-0001-2,NDC,facility,both,8,EA,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 500 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,50268-152-15,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,0143-9682-01,NDC,facility,both,8,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE  5 MG/ML INJ SOLN,50863,CDM,636,RC,J2765,HCPCS,0409-3414-18,NDC,facility,both,2,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE  10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69367-388-10,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 40 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-573-10,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTAMIDINE 300 MG INHL SOLR,50863,CDM,250,RC,J3490,HCPCS,63323-877-15,NDC,facility,both,1,EA,,721,504.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUVOXAMINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69452-455-20,NDC,facility,both,2,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,50863,CDM,636,RC,J1756,HCPCS,0517-2325-01,NDC,facility,both,1,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,636,RC,J0690,HCPCS,63323-237-10,NDC,facility,both,4,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 17 GRAM (100 %) ORAL PWPK,50863,CDM,J3490,HCPCS,1152372688,NDC,,,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 10 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,50111-647-01,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,65862-246-08,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LATANOPROST 0.005 % OPHT DROP,50863,CDM,J3490,HCPCS,70069-421-01,NDC,,,facility,both,1,ML,,403,282.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,J2704,HCPCS,0069-0209-01,NDC,,,facility,both,13,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,250,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,13,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-492-57,NDC,,,facility,both,200,ML,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,50863,CDM,J3490,HCPCS,68462-157-40,NDC,,,facility,both,1,EA,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEFLUNOMIDE  20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,70748-130-06,NDC,facility,both,1,EA,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLESTYRAMINE 4 G ORAL PWPK,50863,CDM,J3490,HCPCS,49884-466-63,NDC,,,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-05,NDC,facility,both,5,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 60 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,0904-7045-61,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES-DOCUSATE SODIUM 8.6 MG-50 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7440-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 500 MG (200 MG ELEMENTAL) CHEW TAB,50863,CDM,250,RC,J3490,HCPCS,66553-004-01,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 25 MG TAB,50863,CDM,636,RC,J3490,HCPCS,62584-265-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 100 MG/1 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,63323-586-21,NDC,facility,both,10,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,70095-031-01,NDC,facility,both,24,ML,,985,689.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-25,NDC,facility,both,40,ML,JZ,5658,3960.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GENTAMICIN IN SALINE (ISO-OSMOTIC) 80 MG/100 ML IV PIGGY BACK,50863,CDM,636,RC,J1580,HCPCS,0338-0503-48,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),50863,CDM,636,RC,J3490,HCPCS,63323-186-01,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COCAINE  4 % TOP SOLN (MERGE),50863,CDM,250,RC,C9046,HCPCS,70839-362-04,NDC,facility,both,160,ML,,1041,728.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,6,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2599,HCPCS,65219-039-00,NDC,facility,both,7,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 150 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-445-01,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GAMMAGARD LIQUID 10 % IV SOLN,50863,CDM,636,RC,J1569,HCPCS,0944-2700-11,NDC,facility,both,10,ML,JA,1803,1262.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-22,NDC,facility,both,7,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-25,NDC,facility,both,15,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG ORAL TBDL,50863,CDM,636,RC,J3490,HCPCS,55111-263-81,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0780,HCPCS,0641-6135-01,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPTOMYCIN 500 MG IV SOLR,50863,CDM,636,RC,J0878,HCPCS,0409-0122-01,NDC,facility,both,300,EA,JW,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,250,RC,J3490,HCPCS,72789-057-01,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"AMIODARONE IN DEXTROSE,ISO-OSM 360 MG/200 ML (1.8 MG/ML) IV SOLN",50863,CDM,636,RC,J0282,HCPCS,43066-360-20,NDC,facility,both,12,ML,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHIMAZOLE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,23155-070-01,NDC,facility,both,3,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,63323-806-13,NDC,facility,both,3,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 250 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,0904-6363-61,NDC,facility,both,3,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,63323-325-03,NDC,facility,both,120,ML,,133,93.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G POTASSIUM  5000000 UNIT INJ SOLR,50863,CDM,250,RC,J2540,HCPCS,0049-0520-84,NDC,facility,both,9,EA,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,68462-470-40,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 1250 MG/5 ML SUSPENSION (500 MG/5 ML ELEMENTAL),50863,CDM,250,RC,J3490,HCPCS,0121-4766-05,NDC,facility,both,2,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25 MG-100 MG TAB,50863,CDM,636,RC,J3490,HCPCS,60687-661-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCAINAMIDE 100 MG/ML INJ SOLN,50863,CDM,250,RC,J2690,HCPCS,0409-1902-11,NDC,facility,both,1,ML,,398,278.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE HCL  0.5 % NASL SPRY,50863,CDM,250,RC,J3490,HCPCS,0024-1353-01,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.3 MG/0.3 ML IM PNIJ,50863,CDM,636,RC,J0171,HCPCS,0093-5986-19,NDC,facility,both,3,EA,,1024,716.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN IN D5W 400 MG/200 ML IV PGBK,50863,CDM,250,RC,J0744,HCPCS,25021-192-87,NDC,facility,both,2,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,636,RC,J2270,HCPCS,0641-6125-01,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,250,RC,J3490,HCPCS,60687-653-11,NDC,facility,both,4,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,50863,CDM,250,RC,J1756,HCPCS,0517-2340-01,NDC,facility,both,400,ML,,1284,898.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  750 MG IV SOLR,50863,CDM,636,RC,J3370,HCPCS,67457-705-00,NDC,facility,both,2,EA,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2308-22,NDC,facility,both,250,ML,,226,158.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,636,RC,Q0162,HCPCS,60687-252-40,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 0.8 GRAM ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,0115-1365-30,NDC,facility,both,1,EA,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,50863,CDM,636,RC,J8540,HCPCS,0904-7266-61,NDC,facility,both,16,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-590-11,NDC,facility,both,6,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROATE SODIUM 100 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0143-9785-01,NDC,facility,both,4,ML,,406,284.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE (POLACRILEX) 2 MG BUCL GUM,50863,CDM,250,RC,J3490,HCPCS,1093969133,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,50863,CDM,250,RC,J0640,HCPCS,0143-9554-01,NDC,facility,both,2,EA,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 400 MCG/100 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,55150-297-01,NDC,facility,both,1,ML,,268,187.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 20MG/ML IV SYRINGE (PEDS/NEO),50863,CDM,250,RC,J0612,HCPCS,63323-311-10,NDC,facility,both,100,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,63323-806-14,NDC,facility,both,10,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-572-10,NDC,facility,both,1,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THROMBIN (RECOMBINANT) 5000 UNIT TOP SOLR,50863,CDM,636,RC,J3490,HCPCS,0338-0322-01,NDC,facility,both,1,EA,,372,260.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7336-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 112 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-508-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-5771-23,NDC,facility,both,4,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 2 MG/ML IV SOLN,50863,CDM,250,RC,J9000,HCPCS,25021-207-51,NDC,facility,both,2,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7007-61,NDC,facility,both,4,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 40 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-210-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,50863,CDM,636,RC,J1756,HCPCS,0517-2340-01,NDC,facility,both,200,ML,,642,449.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,106,ML,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,50863,CDM,250,RC,J9025,HCPCS,72485-201-01,NDC,facility,both,147,EA,,2089,1462.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL IV BOLUS 10MG/ML (ANESTHESIA ONLY),50863,CDM,636,RC,J2704,HCPCS,63323-269-29,NDC,facility,both,20,ML,JZ,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
HYDROCORTISONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-582-11,NDC,facility,both,3,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,636,RC,J0690,HCPCS,70092-1017-46,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,15,EA,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE (POLACRILEX) 4 MG BUCL GUM,50863,CDM,250,RC,J3490,HCPCS,0536-1372-06,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  75 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-441-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL SODIUM 500 MG IV SOLR,50863,CDM,250,RC,J0206,HCPCS,65219-380-30,NDC,facility,both,1,EA,,1601,1120.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAMSULOSIN 0.4 MG ORAL CP24,50863,CDM,636,RC,J3490,HCPCS,0904-6401-61,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRIMAQUINE 26.3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,76385-102-01,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69238-1056-1,NDC,facility,both,6,EA,,225,157.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,62584-994-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COLCHICINE 0.6 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-187-11,NDC,facility,both,1,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-0710-20,NDC,facility,both,4,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL SODIUM 500 MG IV SOLR,50863,CDM,250,RC,J0206,HCPCS,0143-9533-01,NDC,facility,both,1,EA,,2153,1507.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,636,RC,J3490,HCPCS,60687-653-11,NDC,facility,both,8,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-406-03,NDC,facility,both,1,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL IV BOLUS 10MG/ML (ANESTHESIA ONLY),50863,CDM,636,RC,J2704,HCPCS,0409-4699-54,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLPIDEM  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0781-5317-01,NDC,facility,both,1,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISONIAZID 300 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,81665-108-30,NDC,facility,both,1,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN PEDS SYRINGE (20MG/ML) IN DEXTROSE (CDS MIX,50863,CDM,250,RC,J0690,HCPCS,0781-3451-70,NDC,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE INFUSION 2MG/ML 100ML (FOR ANESTHESIA USE ONLY),50863,CDM,250,RC,J3490,HCPCS,0409-2051-05,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 50 MG/ML IM,50863,CDM,636,RC,J3410,HCPCS,0517-5601-25,NDC,facility,both,1,ML,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-131-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,0409-1283-03,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-570-10,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,16714-026-01,NDC,facility,both,5,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6638-61,NDC,facility,both,7,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"HEPARIN, PORCINE (PF)   10 UNIT/ML IV SYRG",50863,CDM,250,RC,J1642,HCPCS,6425322223,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM SR 300 MG 24 HR CAP,50863,CDM,250,RC,J3490,HCPCS,50742-251-30,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE DINITRATE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-447-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7123-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE  1 % TOP CREA,50863,CDM,250,RC,J3490,HCPCS,45802-438-03,NDC,facility,both,1,GM,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 50 MG/ML INJECTION,50863,CDM,250,RC,J1200,HCPCS,0641-0376-21,NDC,facility,both,1,ML,PLAD,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2598,HCPCS,43598-914-11,NDC,facility,both,8,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,59762-0073-1,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 12.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0093-7295-01,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-152-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCRALFATE 1 GRAM ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,29033-003-01,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CITRATE-VITAMIN D3 200 MG CALCIUM -250 UNIT ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,536322301,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.3 MG/0.3 ML IM PNIJ,50863,CDM,636,RC,J0169,HCPCS,49502-500-01,NDC,facility,both,3,EA,,1078,754.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMINOCAPROIC ACID 25 % ORAL SYRP,50863,CDM,250,RC,J3490,HCPCS,61748-044-16,NDC,facility,both,1,ML,,158,110.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,0143-9682-25,NDC,facility,both,8,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZONISAMIDE 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-230-11,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIROFIBAN-0.9% SODIUM CHLORIDE 5 MG/100 ML (50 MCG/ML) IV SOLN,50863,CDM,250,RC,J3246,HCPCS,25208-002-03,NDC,facility,both,9,ML,,179,125.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,31722-711-30,NDC,facility,both,1,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE  2 MG/ML INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-285-20,NDC,facility,both,5,ML,,285,199.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM ACETATE 667 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7119-61,NDC,facility,both,2,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-2051-15,NDC,facility,both,5,ML,,277,193.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J2003,HCPCS,55150-161-02,NDC,facility,both,40,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,5,ML,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G POTASSIUM  5000000 UNIT INJ SOLR,50863,CDM,250,RC,J2540,HCPCS,0781-6135-94,NDC,facility,both,9,EA,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5%-LACTATED RINGERS IV,50863,CDM,250,RC,J7120,HCPCS,0338-0125-03,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-078-33,NDC,facility,both,2,EA,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-229-02,NDC,facility,both,2,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  650 MG RECT SUPP,50863,CDM,250,RC,J3490,HCPCS,45802-730-00,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE 1 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,46287-035-15,NDC,facility,both,1,ML,,101,70.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,70095-031-01,NDC,facility,both,23,ML,,921,644.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,636,RC,J1836,HCPCS,0338-1055-48,NDC,facility,both,122,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7350-61,NDC,facility,both,4,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FEBUXOSTAT 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,62332-190-30,NDC,facility,both,1,EA,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,63323-185-07,NDC,facility,both,6,ML,,176,123.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE  2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7366-04,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL PACK,50863,CDM,636,RC,J3490,HCPCS,67877-422-57,NDC,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-318-11,NDC,facility,both,6,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM 1 GRAM IV SOLR,50863,CDM,636,RC,J2185,HCPCS,63323-508-01,NDC,facility,both,20,EA,JZ,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,72603-506-01,NDC,facility,both,100,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPTOMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0878,HCPCS,0409-0122-01,NDC,facility,both,700,EA,,563,394.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,51754-4250-1,NDC,facility,both,1,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,40,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3373,HCPCS,0143-9162-01,NDC,facility,both,125,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0630,HCPCS,63323-865-02,NDC,facility,both,1,ML,,1491,1043.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,70095-031-01,NDC,facility,both,38,ML,,1524,1066.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0832-1211-89,NDC,facility,both,2,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SYRG,50863,CDM,250,RC,J3490,HCPCS,8290306504,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IV PGBK,50863,CDM,636,RC,J3475,HCPCS,0264-4206-54,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,63323-400-01,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML (1ML) INJ SOLN,50863,CDM,636,RC,J0171,HCPCS,42023-159-01,NDC,facility,both,30,ML,,264,184.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,63739-196-01,NDC,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG/5 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,0121-4827-05,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J1938,HCPCS,72603-251-01,NDC,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN,50863,CDM,250,RC,J2916,HCPCS,0024-2792-01,NDC,facility,both,10,ML,,374,261.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6427-61,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7007-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0003-0894-21,NDC,facility,both,2,EA,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42806-341-01,NDC,facility,both,3,EA,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-027-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN   81 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,63739-212-02,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6949-61,NDC,facility,both,7,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA SR 50 MG-200 MG TAB,50863,CDM,250,RC,J3490,HCPCS,68084-282-11,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE  5 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,70010-029-01,NDC,facility,both,2,EA,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,72266-147-01,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,3,EA,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,70121-1388-1,NDC,facility,both,4,ML,,911,637.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-7350-06,NDC,,,facility,both,2,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 5 MG-325 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0406-0123-01,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,250,RC,J7060,HCPCS,0338-0017-04,NDC,facility,both,2,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 100 MG/5 ML ORAL LIQD,50863,CDM,636,RC,J3490,HCPCS,0121-1488-10,NDC,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES-DOCUSATE SODIUM 8.6 MG-50 MG TAB,50863,CDM,636,RC,J3490,HCPCS,10135-669-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,63739-931-28,NDC,facility,both,7,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 500 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7337-35,NDC,facility,both,4,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AGALSIDASE BETA 35 MG IV SOLR,50863,CDM,J0180,HCPCS,58468-0040-1,NDC,,,facility,both,70,ME,,32535,22774.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV,50863,CDM,250,RC,J7120,HCPCS,0338-0117-04,NDC,facility,both,1,ML,PLAD,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
OXAZEPAM 15 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,62584-813-11,NDC,facility,both,2,EA,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,43598-053-11,NDC,facility,both,20,ML,,724,506.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0630,HCPCS,42023-205-01,NDC,facility,both,1,ML,,8383,5868.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-229-02,NDC,facility,both,2,ML,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0054-0235-24,NDC,facility,both,8,EA,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE HCL  2 % MM JELP,50863,CDM,636,RC,J3490,HCPCS,76329-3012-5,NDC,facility,both,2,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  15 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,0406-8315-23,NDC,facility,both,3,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4% TOP PATCH,50863,CDM,250,RC,J3490,HCPCS,46581-830-01,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 800 MG ORAL TAB,50863,CDM,250,RC,J0601,HCPCS,17856-921-01,NDC,facility,both,80,EA,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,50863,CDM,250,RC,J0696,HCPCS,60505-6149-0,NDC,facility,both,8,EA,"JZ,PLAD",388,271.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier PLAD: Modifier description not available
VALSARTAN 160 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,33342-064-10,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYBUTYNIN CHLORIDE  5 MG ORAL TO24,50863,CDM,250,RC,J3490,HCPCS,0904-6570-61,NDC,facility,both,2,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 100 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,16714-358-01,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM IN NACL (ISO-OS) 500 MG/100 ML IV PGBK,50863,CDM,250,RC,J1953,HCPCS,0264-5009-90,NDC,facility,both,100,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOTRIMAZOLE 1 % TOP CREA,50863,CDM,636,RC,J3490,HCPCS,0536-1272-22,NDC,facility,both,1,GM,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6640-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLP",50863,CDM,250,RC,P9047,HCPCS,13533-684-71,NDC,facility,both,2,ML,,427,298.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALSARTAN  40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-612-11,NDC,facility,both,4,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR  6 MG/ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,68180-678-01,NDC,facility,both,10,ML,,134,93.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARSENIC TRIOXIDE 10 MG/10 ML IV SOLN,50863,CDM,250,RC,J9017,HCPCS,69918-720-01,NDC,facility,both,5,ML,JW,126,88.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
FLU VACCINE TS 2024-25 6MOS UP (PF) 45 MCG (15 MCG X 3)/0.5 ML IM SYRG,50863,CDM,90656,HCPCS,49281-424-50,NDC,,,facility,both,1,ML,,121,84.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 0.1 MG/ML INJ SYRG,50863,CDM,J0461,HCPCS,76329-3340-1,NDC,,,facility,both,4200,ML,,2822,1975.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-152-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 1 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-9158-01,NDC,facility,both,1,ML,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2312,HCPCS,36000-310-01,NDC,facility,both,40,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,50863,CDM,J3490,HCPCS,0409-2051-15,NDC,,,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-145-11,NDC,facility,both,70,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SULFASALAZINE 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,59762-5000-5,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 250 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,42192-608-05,NDC,facility,both,2,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM BROMIDE 17 MCG/ACTUATION INHL AERO,50863,CDM,636,RC,J3490,HCPCS,0597-0087-17,NDC,facility,both,1,GM,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69315-905-01,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6869-61,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OMALIZUMAB 150 MG SUBQ SOLR,50863,CDM,636,RC,J2357,HCPCS,50242-040-62,NDC,facility,both,75,ME,JZ,6524,4566.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ORAL ELECTROLYTES ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,7007411133,NDC,facility,both,6,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7121-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,250,RC,J3490,HCPCS,59310-579-20,NDC,facility,both,1,GM,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) IV SOLN,50863,CDM,636,RC,J9220,HCPCS,81284-315-05,NDC,facility,both,32,ML,JZ,1383,968.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ACETAMINOPHEN  650 MG RECT SUPP,50863,CDM,250,RC,J3490,HCPCS,45802-730-32,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE 3 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,65162-778-10,NDC,facility,both,3,EA,,317,221.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0143-9982-50,NDC,facility,both,3,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7177-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 650 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,77333-827-25,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM ACETATE 667 MG ORAL CAP,50863,CDM,250,RC,J0615,HCPCS,0904-7119-06,NDC,facility,both,87,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM  4.5 GRAM IV SOLR,50863,CDM,636,RC,J2543,HCPCS,55150-121-50,NDC,facility,both,4,EA,JZ,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LEVOTHYROXINE 100 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6953-61,NDC,facility,both,3,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-512-11,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,63323-506-41,NDC,facility,both,16,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEMAZEPAM 15 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,67877-146-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7912-59,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J1940,HCPCS,0409-6102-18,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 1 MG ORAL TAB,50863,CDM,250,RC,J8540,HCPCS,0054-8174-25,NDC,facility,both,12,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-205-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,50863,CDM,250,RC,J9025,HCPCS,72485-201-01,NDC,facility,both,44,EA,JW,272,190.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-4279-16,NDC,facility,both,200,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0641-6022-01,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR PHOSPHATE 30 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,31722-630-31,NDC,facility,both,1,EA,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 175 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42292-040-01,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0093-3425-01,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2312,HCPCS,67457-299-00,NDC,facility,both,200,ML,,257,179.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,50863,CDM,636,RC,J3420,HCPCS,63323-044-00,NDC,facility,both,1,ML,JZ,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
VENLAFAXINE  75 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,68084-709-01,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXAZOSIN 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-5522-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,2,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TICAGRELOR 90 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0186-0777-39,NDC,facility,both,1,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 20MG/ML IV SYRINGE (PEDS/NEO),50863,CDM,250,RC,J0612,HCPCS,63323-311-10,NDC,facility,both,71,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMETREXED 500 MG IV SOLR,50863,CDM,250,RC,J9305,HCPCS,71288-167-50,NDC,facility,both,50,EA,,648,453.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML IV,50863,CDM,250,RC,J3490,HCPCS,0641-6015-01,NDC,facility,both,125,ML,,215,150.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"METHYLPREDNISOLONE 1,000 MG SOLUTION FOR INJECTION",50863,CDM,636,RC,J2919,HCPCS,63323-265-30,NDC,facility,both,200,EA,,201,140.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML INJ SOLN,50863,CDM,636,RC,J0171,HCPCS,76329-9060-0,NDC,facility,both,300,ML,,797,557.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-342-11,NDC,facility,both,2,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-285-01,NDC,facility,both,4,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 0.1 MG/ML INJ SYRG,50863,CDM,636,RC,J0461,HCPCS,76329-3340-1,NDC,facility,both,60,ML,JW,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
FOSPHENYTOIN 100 MG PE/2 ML INJ SOLN,50863,CDM,250,RC,Q2009,HCPCS,63323-403-01,NDC,facility,both,4,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL  32.4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6575-61,NDC,facility,both,8,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  75 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,0904-7077-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0630,HCPCS,24201-400-02,NDC,facility,both,1,ML,,2526,1768.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-112-02,NDC,facility,both,3,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,88,EA,,12144,8500.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16714-613-04,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-349-11,NDC,facility,both,1,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE 250 MG/5 ML IV SOLN,50863,CDM,250,RC,J7516,HCPCS,0078-0109-61,NDC,facility,both,1,ML,,307,214.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 20 MG/ML ORAL CONC,50863,CDM,250,RC,J3490,HCPCS,16714-601-02,NDC,facility,both,1,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM  4.5 GRAM IV SOLR,50863,CDM,250,RC,J2543,HCPCS,0781-3114-91,NDC,facility,both,4,EA,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NOREPINEPHRINE BITARTRATE-D5W 4 MG/250 ML (16 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,71285-6056-1,NDC,facility,both,1,ML,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-559-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),50863,CDM,250,RC,J1630,HCPCS,25021-806-01,NDC,facility,both,2,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42858-001-10,NDC,facility,both,3,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCERIN 99.5 % TOP SOLN,50863,CDM,636,RC,J3490,HCPCS,0395-1031-96,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,50863,CDM,250,RC,J9060,HCPCS,0143-9504-01,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,636,RC,J0690,HCPCS,70092-1017-46,NDC,facility,both,3,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOVASTATIN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68180-468-07,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7912-59,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 200 MG/20 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,31722-203-20,NDC,facility,both,1,ML,,400,280,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MYCOPHENOLATE 250 MG CAP,50863,CDM,250,RC,J7517,HCPCS,0093-7334-01,NDC,facility,both,3,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENAZEPRIL 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,43547-336-10,NDC,facility,both,3,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-8297-25,NDC,facility,both,2,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROTHIAZIDE SODIUM 500 MG IV SOLR,50863,CDM,250,RC,J1205,HCPCS,0517-1820-01,NDC,facility,both,2,EA,,1440,1008,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM  3 GRAM INJ SOLR,50863,CDM,250,RC,J0295,HCPCS,0049-0014-83,NDC,facility,both,2,EA,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,64208-2510-2,NDC,facility,both,1,ML,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MYCOPHENOLATE SODIUM 360 MG ORAL TBEC,50863,CDM,250,RC,J7518,HCPCS,0904-6786-04,NDC,facility,both,2,EA,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 10 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6987-61,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,70121-1388-1,NDC,facility,both,1,ML,,228,159.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7912-59,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HETASTARCH 6 % IN NORMAL SALINE IV,50863,CDM,636,RC,J3490,HCPCS,0409-7248-13,NDC,facility,both,1,ML,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROFURANTOIN (25% MACROCRYSTAL FORM) 100 MG CAP,50863,CDM,636,RC,J3490,HCPCS,60687-633-11,NDC,facility,both,1,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE 2 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,60687-481-11,NDC,facility,both,2,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 100 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,51672-4047-9,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EZETIMIBE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7103-04,NDC,facility,both,1,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 50 MG/ML IV SOLN,50863,CDM,250,RC,J0282,HCPCS,0143-9875-01,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SOTALOL  80 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-654-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,43598-053-11,NDC,facility,both,13,ML,,455,318.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-325-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,13533-690-25,NDC,facility,both,3,ML,,651,455.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESALAMINE 1000 MG RECT SUPP,50863,CDM,636,RC,J3490,HCPCS,58914-501-01,NDC,facility,both,1,EA,,228,159.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7048-61,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  88 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6952-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM IN NACL (ISO-OS) 1000 MG/100 ML IV PGBK,50863,CDM,636,RC,J1953,HCPCS,43598-636-52,NDC,facility,both,100,ML,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,72162-1329-8,NDC,facility,both,2,ML,,514,359.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,50863,CDM,250,RC,J0561,HCPCS,60793-701-02,NDC,facility,both,24,ML,,2376,1663.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM PEDS IVPB (FROM PREMIX),50863,CDM,250,RC,J1953,HCPCS,43598-635-52,NDC,facility,both,50,ML,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  25 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6991-61,NDC,facility,both,6,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE (PEDIATRIC 6 MONTH) 45 MG IM SYKT,50863,CDM,636,RC,J1950,HCPCS,0074-3575-01,NDC,facility,both,12,EA,,71748,50223.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLADRIBINE 1 MG/ML IV SOLN,50863,CDM,250,RC,J9065,HCPCS,0143-9871-01,NDC,facility,both,20,ML,,2478,1734.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANTI-THYMOCYTE GLOB (RABBIT) 25 MG IV SOLR,50863,CDM,250,RC,J7511,HCPCS,58468-0080-1,NDC,facility,both,4,EA,,8088,5661.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,4,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN IN D5W 400 MG/200 ML IV PGBK,50863,CDM,636,RC,J0744,HCPCS,0409-3300-01,NDC,facility,both,2,ML,JZ,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,250,RC,J2270,HCPCS,0409-1891-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 120 MG/0.8 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,16714-056-01,NDC,facility,both,12,ML,,141,98.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-9543-02,NDC,facility,both,1,ML,JZ,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CYCLOSPORINE MODIFIED  25 MG ORAL CAP,50863,CDM,636,RC,J7515,HCPCS,0093-9018-19,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-5755-23,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-24,NDC,facility,both,80,ML,"JZ,JA",11316,7921.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
PREDNISONE 20 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,0904-7127-61,NDC,facility,both,40,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 50 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0054-0019-20,NDC,facility,both,100,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-145-10,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 150 MG/1 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0955-1015-01,NDC,facility,both,15,ML,,189,132.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-683-02,NDC,facility,both,1,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,250,RC,J3490,HCPCS,72789-057-01,NDC,facility,both,2,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR NEO/PEDS INFUSION (CDS FROM PREMIX),50863,CDM,250,RC,J0133,HCPCS,63323-325-10,NDC,facility,both,24,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5%-1/4 NORMAL SALINE IV,50863,CDM,250,RC,J3490,HCPCS,0264-7616-10,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER SULFADIAZINE 1 % TOP CREA,50863,CDM,636,RC,J3490,HCPCS,67877-124-05,NDC,facility,both,1,GM,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 40 GRAM/400 ML (10 %) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-20,NDC,facility,both,10,ML,,1415,990.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,636,RC,J2560,HCPCS,54288-137-01,NDC,facility,both,2,ML,,280,196,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,63323-104-25,NDC,facility,both,11,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN  6 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51672-4033-1,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLP",50863,CDM,250,RC,P9047,HCPCS,68516-5216-8,NDC,facility,both,2,ML,,807,564.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,50863,CDM,636,RC,J2359,HCPCS,0002-7597-01,NDC,facility,both,20,EA,JZ,256,179.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PHENYTOIN SODIUM EXTENDED 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,58151-110-32,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OMEPRAZOLE-SODIUM BICARBONATE 2-84 MG/ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,62175-114-32,NDC,facility,both,5,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE  7.5 MG SUBQ SYRG,50863,CDM,636,RC,J9217,HCPCS,62935-756-80,NDC,facility,both,1,EA,,1176,823.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-134-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-1283-03,NDC,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 10 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,67457-420-00,NDC,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,0338-0072-25,NDC,facility,both,1,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
METOPROLOL TARTRATE 25 MG TAB,50863,CDM,636,RC,J3490,HCPCS,62584-265-11,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,250,RC,J3490,HCPCS,0143-9679-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-284-01,NDC,facility,both,5,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-205-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,636,RC,J3490,HCPCS,0409-4277-02,NDC,facility,both,200,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMFIBROZIL 600 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-224-11,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ (REPACK)(MERGE) (FOR PCA),50863,CDM,250,RC,J3490,HCPCS,0409-9094-41,NDC,facility,both,1,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-3178-01,NDC,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTAZIDIME-AVIBACTAM 2.5 GRAM (2 GRAM-0.5 GRAM) IV SOLR,50863,CDM,250,RC,J0714,HCPCS,0456-2700-10,NDC,facility,both,1,EA,JW,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
SODIUM CHLORIDE 0.9 % IR SOLN,50863,CDM,636,RC,J3490,HCPCS,0338-0048-02,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN  5 MG/ACTUATION NASL SPRY,50863,CDM,250,RC,J3490,HCPCS,66993-081-69,NDC,facility,both,1,EA,,261,182.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3370,HCPCS,16714-309-01,NDC,facility,both,2,EA,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMIVUDINE-ZIDOVUDINE 150 MG-300 MG TAB,50863,CDM,250,RC,J3490,HCPCS,65862-036-60,NDC,facility,both,1,EA,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID (PORK)  30 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0456-0458-01,NDC,facility,both,3,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 1250 MG/5 ML SUSPENSION (500 MG/5 ML ELEMENTAL),50863,CDM,250,RC,J3490,HCPCS,0121-4766-05,NDC,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACIDOPHILUS-PECTIN W CITRUS 25 MILLION-100 CELL MG TAB,50863,CDM,250,RC,J3490,HCPCS,8068102600,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"TRANEXAMIC ACID IN NACL,ISO-OS 1,000 MG/100 ML (10 MG/ML) IV PGBK",50863,CDM,250,RC,J3490,HCPCS,65219-534-01,NDC,facility,both,2,ML,,193,135.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTAROLINE FOSAMIL 600 MG IV SOLR,50863,CDM,250,RC,J0712,HCPCS,0456-0600-01,NDC,facility,both,30,EA,,456,319.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4% TOP PATCH,50863,CDM,250,RC,J3490,HCPCS,0121-0970-01,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TUBERCULIN PPD 5 UNIT/0.1 ML IDRM SOLN,50863,CDM,636,RC,J3490,HCPCS,49281-752-21,NDC,facility,both,1,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE  75 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,70756-204-11,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-231-11,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE (POLACRILEX) 2 MG MM LOZG,50863,CDM,250,RC,J3490,HCPCS,1093919344,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,1,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 650 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7261-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFUROXIME AXETIL 250 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,65862-699-20,NDC,facility,both,2,EA,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-38,NDC,facility,both,2,ML,,172,120.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOBENZAPRINE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-191-11,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-ABDA 100 MG IV SOLR,50863,CDM,636,RC,Q5104,HCPCS,78206-162-99,NDC,facility,both,77,EA,,16012,11208.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,636,RC,J1815,HCPCS,0088-2220-33,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OMALIZUMAB 150 MG/ML SUBQ SYRG,50863,CDM,J2357,HCPCS,50242-215-01,NDC,,,facility,both,30,ML,,3115,2180.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0093-3426-10,NDC,facility,both,3,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,57237-004-30,NDC,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",50863,CDM,J1561,HCPCS,13533-800-25,NDC,,,facility,both,40,ML,,5658,3960.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,16714-294-01,NDC,facility,both,7,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,J1100,HCPCS,63323-165-01,NDC,,,facility,both,12,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,J2919,HCPCS,0009-0047-25,NDC,,,facility,both,50,EA,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,0409-4279-16,NDC,,,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNITS/1 GRAM PACKET (MERGE RECORD),50863,CDM,636,RC,J3490,HCPCS,0904-7023-67,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,73293-0001-1,NDC,,,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SITAGLIPTIN  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0006-0221-01,NDC,facility,both,1,EA,,113,79.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYBUTYNIN CHLORIDE  5 MG ORAL TO24,50863,CDM,250,RC,J3490,HCPCS,68084-480-11,NDC,facility,both,2,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-444-11,NDC,facility,both,3,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,0143-9682-01,NDC,facility,both,6,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-9558-05,NDC,facility,both,2,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0781-3246-02,NDC,facility,both,12,ML,,164,114.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM BICARB-CITRIC ACID 20 MEQ ORAL TBEF,50863,CDM,250,RC,J3490,HCPCS,51801-012-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  1 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0603-5335-21,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,5789686406,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOPERAMIDE 2 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,51079-690-01,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIRMATRELVIR-RITONAVIR 150 MG (10)- 100 MG (10) ORAL DSPK,50863,CDM,636,RC,J3490,HCPCS,0069-5317-20,NDC,facility,both,20,EA,,4130,2891,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,70069-363-01,NDC,facility,both,1,ML,,180,126,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE  25 MG ORAL CPSP,50863,CDM,250,RC,J3490,HCPCS,68382-005-14,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,133,93.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE   4.2 % IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-083-05,NDC,facility,both,1,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 112 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0378-1811-77,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNIT/G TOP PACK,50863,CDM,636,RC,J3490,HCPCS,0904-7402-67,NDC,facility,both,6,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-544-01,NDC,facility,both,1,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7001-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,50863,CDM,250,RC,J9267,HCPCS,61703-342-22,NDC,facility,both,86,ML,,142,99.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 20 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,51991-746-90,NDC,facility,both,4,EA,,132,92.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE NA (PRESERV FREE) 25 MG/ML INJ SOLN,50863,CDM,250,RC,J9260,HCPCS,0703-3678-01,NDC,facility,both,115,ML,,1114,779.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,J7050,HCPCS,0338-0049-04,NDC,,,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 2 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,J2270,HCPCS,76045-004-01,NDC,,,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  100 MCG/ML INJ SOLN,50863,CDM,J2354,HCPCS,63323-376-00,NDC,,,facility,both,2,ML,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0009-0012-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC ADMIN RESPIRATORY SYNCYTIAL VIRUS MONOCLONAL ANTIBODY SEASONAL DOSE INTRAMUSCULAR INJECTION,50863,CDM,90381,HCPCS,49281-574-88,NDC,,,facility,both,1,ML,,1535,1074.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOPIDOGREL  75 MG ORAL TAB,50863,CDM,J3490,HCPCS,16714-052-10,NDC,,,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,J3490,HCPCS,63037-136-25,NDC,,,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 2.5 MG ORAL TAB,50863,CDM,J3490,HCPCS,0003-0893-31,NDC,,,facility,both,1,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,J3490,HCPCS,0143-9889-15,NDC,,,facility,both,12,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-01,NDC,facility,both,3,ML,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,J3490,HCPCS,0338-0049-18,NDC,,,facility,both,4,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,59762-3130-1,NDC,facility,both,3,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYPROHEPTADINE 2 MG/5 ML ORAL SYRP,50863,CDM,250,RC,J3490,HCPCS,64980-504-48,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 0.3 % OPHT DROP,50863,CDM,250,RC,J3490,HCPCS,60758-188-05,NDC,facility,both,1,ML,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6374-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAZOLAMIDE 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6663-61,NDC,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LET TOPICAL GEL 3 ML,50863,CDM,636,RC,J3490,HCPCS,69623-801-14,NDC,facility,both,1,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) IV SOLN,50863,CDM,636,RC,J9220,HCPCS,81284-315-05,NDC,facility,both,16,ML,JZ,692,484.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DIVALPROEX 500 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,68084-415-11,NDC,facility,both,2,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYL SALICYLATE-MENTHOL 15-1 % TOPICAL CREAM,50863,CDM,636,RC,J3490,HCPCS,0536-1101-45,NDC,facility,both,1,GM,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITRIOL 1 MCG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,64980-447-15,NDC,facility,both,1,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENAZEPRIL 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,65862-116-01,NDC,facility,both,4,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5%-LACTATED RINGERS IV,50863,CDM,250,RC,J7120,HCPCS,0338-0125-04,NDC,facility,both,2,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENAZOPYRIDINE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,75826-114-10,NDC,facility,both,1,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,59762-3130-1,NDC,facility,both,5,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",50863,CDM,250,RC,J1561,HCPCS,13533-800-21,NDC,facility,both,10,ML,,1415,990.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VECURONIUM BROMIDE 10 MG IV SOLR,50863,CDM,636,RC,J3490,HCPCS,0703-2914-01,NDC,facility,both,1,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MYCOPHENOLATE SODIUM 360 MG ORAL TBEC,50863,CDM,250,RC,J7518,HCPCS,0904-6786-04,NDC,facility,both,6,EA,,172,120.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMANTADINE 50 MG/5 ML ORAL SYRP,50863,CDM,250,RC,J3490,HCPCS,0121-0646-16,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 10 GRAM/100 ML (10%) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-72,NDC,facility,both,40,ML,,5658,3960.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 0.1 % TOP OINT,50863,CDM,250,RC,J3490,HCPCS,45802-055-35,NDC,facility,both,1,GM,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  20 MEQ ORAL PACK,50863,CDM,250,RC,J3490,HCPCS,0245-0360-89,NDC,facility,both,3,EA,,158,110.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-245-11,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 20 GRAM/30 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-4577-30,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IR SOLN,50863,CDM,250,RC,J3490,HCPCS,0338-0047-46,NDC,facility,both,2,ML,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MICAFUNGIN 100 MG IV SOLR,50863,CDM,636,RC,J2248,HCPCS,25021-191-10,NDC,facility,both,100,EA,,808,565.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25 MG-100 MG TAB,50863,CDM,636,RC,J3490,HCPCS,69367-339-05,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
URSODIOL 300 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,50268-797-11,NDC,facility,both,2,EA,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,140,ML,,127,88.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,78,EA,,10764,7534.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE (POLACRILEX) 2 MG BUCL GUM,50863,CDM,636,RC,J3490,HCPCS,70677-1166-2,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROIC ACID 250 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,63739-086-10,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-22,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TICAGRELOR 90 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0186-0777-60,NDC,facility,both,1,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,2,EA,,156,109.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1940,HCPCS,63323-280-03,NDC,facility,both,2,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML (1ML) INJ SOLN,50863,CDM,636,RC,J0169,HCPCS,63323-696-02,NDC,facility,both,10,ML,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6799-61,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-4827-05,NDC,facility,both,4,ML,,146,102.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2305-16,NDC,facility,both,2,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORDIAZEPOXIDE 25 MG CAP,50863,CDM,636,RC,J3490,HCPCS,51079-141-01,NDC,facility,both,15,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-9543-02,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
L. ACIDOPHILUS-B. LACTIS-FOS 5 BILLION CELL ORAL PWPK (NEONATAL),50863,CDM,250,RC,J3490,HCPCS,5206100400,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,16,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2308-02,NDC,facility,both,50,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,50863,CDM,250,RC,J0640,HCPCS,67457-528-10,NDC,facility,both,1,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 0.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0093-0832-01,NDC,facility,both,3,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,6,ML,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,636,RC,J2704,HCPCS,65219-800-01,NDC,facility,both,3,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  5 MG ORAL TBDL,50863,CDM,636,RC,J3490,HCPCS,55111-262-79,NDC,facility,both,2,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0137,HCPCS,0143-9386-01,NDC,facility,both,80,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J2003,HCPCS,63323-492-27,NDC,facility,both,300,ML,,236,165.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,63323-649-07,NDC,facility,both,2,EA,,1040,728,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV (BOLUS),50863,CDM,636,RC,J7120,HCPCS,17271-710-07,NDC,facility,both,1,ML,,411,287.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-01,NDC,facility,both,3,ML,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EMTRICITABINE-TENOFOVIR ALAFEN 200-25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,61958-2002-1,NDC,facility,both,1,EA,,374,261.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLIPIZIDE  2.5 MG ORAL TO24,50863,CDM,250,RC,J3490,HCPCS,60687-768-11,NDC,facility,both,2,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RAMIPRIL  1.25 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,65862-474-01,NDC,facility,both,2,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,250,RC,J3490,HCPCS,59310-579-22,NDC,facility,both,1,GM,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RAMIPRIL 10 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,57237-225-01,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZTROPINE 1 MG/ML INJ SOLN,50863,CDM,636,RC,J0515,HCPCS,68382-860-02,NDC,facility,both,1,ML,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0781-2020-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4% TOP PATCH,50863,CDM,250,RC,J3490,HCPCS,46581-830-06,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,636,RC,J1953,HCPCS,63323-400-01,NDC,facility,both,125,ML,,132,92.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,16714-294-01,NDC,facility,both,14,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,250,RC,J0132,HCPCS,25021-812-30,NDC,facility,both,72,ML,,513,359.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,36000-283-25,NDC,facility,both,240,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 25 MG TAB,50863,CDM,250,RC,J3490,HCPCS,65862-146-36,NDC,facility,both,1,EA,,133,93.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,43547-281-10,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE (6 MONTH) 45 MG SUBCUTANOUS KIT,50863,CDM,636,RC,J9217,HCPCS,62935-453-45,NDC,facility,both,6,EA,JZ,1176,823.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,636,RC,Q0162,HCPCS,16714-671-02,NDC,facility,both,2,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,0409-9094-25,NDC,facility,both,5,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J2003,HCPCS,73293-0001-1,NDC,facility,both,29,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-299-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-1638-32,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0245-0212-89,NDC,facility,both,4,EA,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VORICONAZOLE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6596-04,NDC,facility,both,1,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LINEZOLID 600 MG/300 ML IV SOLP,50863,CDM,250,RC,J2020,HCPCS,55150-242-51,NDC,facility,both,3,ML,,397,277.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LINEZOLID NEO IV SYRINGE (CDS MIXTURE),50863,CDM,636,RC,J2020,HCPCS,0781-3433-46,NDC,facility,both,3,ML,JZ,331,231.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,65862-707-80,NDC,facility,both,8,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,5,EA,,170,119,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0143-9595-01,NDC,facility,both,150,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,6,EA,,207,144.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 3000 MCG/ML INJECTION,50863,CDM,250,RC,J0153,HCPCS,17478-542-02,NDC,facility,both,6,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,J3490,HCPCS,0338-0049-41,NDC,,,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCRELIZUMAB 30 MG/ML IV SOLN,50863,CDM,J2350,HCPCS,50242-150-01,NDC,,,facility,both,300,ME,,44850,31395,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCUSATE SODIUM 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6455-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (NEO) <2 KG,50863,CDM,J7060,HCPCS,0338-0017-41,NDC,,,facility,both,2,ML,,307,214.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE  25 MG ORAL TAB,50863,CDM,J3490,HCPCS,68084-318-11,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-22,NDC,facility,both,60,ML,PT,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PT: Colorectal cancer screening test; converted to diagnostic test or other procedure
ALUM-MAG HYDROXIDE-SIMETH 200 MG-200 MG-20 MG/5 ML ORAL SUSP,50863,CDM,J3490,HCPCS,63739-159-77,NDC,,,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,250,RC,J2270,HCPCS,0409-1890-03,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOTRIMAZOLE 1 % VAGL CREA,50863,CDM,636,RC,J3490,HCPCS,61269-220-41,NDC,facility,both,1,GM,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE MALEATE  5 MG ORAL TAB,50863,CDM,250,RC,Q0164,HCPCS,50268-684-11,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,250,RC,J2270,HCPCS,0409-1890-03,NDC,facility,both,1,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE BIT 2 %-1:100,000 INJ CRTG",50863,CDM,250,RC,J3490,HCPCS,0404-6512-05,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6371-61,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,63323-400-01,NDC,facility,both,25,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMETHICONE 40 MG/0.6 ML ORAL DRPS,50863,CDM,250,RC,J3490,HCPCS,0603-0894-50,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SINCALIDE 5 MCG INJ SOLR,50863,CDM,636,RC,J2805,HCPCS,72266-248-05,NDC,facility,both,1,EA,,201,140.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MINERAL OIL ENEMA,50863,CDM,636,RC,J3490,HCPCS,132030140,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROMETHORPHAN-GUAIFENESIN SR 30 MG-600 MG 12 HR TAB,50863,CDM,250,RC,J3490,HCPCS,6382405640,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUMAZENIL 0.1 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-424-05,NDC,facility,both,4,ML,,198,138.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUPHENAZINE 5 MG TAB,50863,CDM,636,RC,J3490,HCPCS,60687-749-11,NDC,facility,both,1,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DONANEMAB-AZBT 17.5 MG/ML IV SOLN,50863,CDM,636,RC,J0175,HCPCS,0002-9401-01,NDC,facility,both,175,ML,JZ,1601,1120.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-48,NDC,facility,both,2,ML,,200,140,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG IV SOLR,50863,CDM,636,RC,J3490,HCPCS,67457-437-00,NDC,facility,both,5,EA,,446,312.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN DETEMIR 100 UNIT/ML SUBQ SOLN,50863,CDM,636,RC,J1815,HCPCS,0169-3687-12,NDC,facility,both,8,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,57237-077-10,NDC,facility,both,10,EA,,803,562.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPOETIN ALFA  4000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J0885,HCPCS,59676-304-00,NDC,facility,both,40,ML,EC,462,323.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier EC: Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy
AMPHETAMINE-DEXTROAMPHETAMINE  5 MG ORAL CP24,50863,CDM,636,RC,J3490,HCPCS,70010-029-01,NDC,facility,both,6,EA,,212,148.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM BICARB-CITRIC ACID 20 MEQ ORAL TBEF,50863,CDM,J3490,HCPCS,51801-011-01,NDC,,,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,50863,CDM,636,RC,J3301,HCPCS,70121-1049-1,NDC,facility,both,6,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEMANTINE  5 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-6505-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG ORAL TAB,50863,CDM,636,RC,Q0169,HCPCS,0904-7304-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,10,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN 0.9% SODIUM CL 1.25 GRAM/250 ML IV SOLN,50863,CDM,250,RC,J3373,HCPCS,72196-6074-1,NDC,facility,both,3,ML,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,43598-053-11,NDC,facility,both,27,ML,,951,665.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,250,RC,J0330,HCPCS,31722-981-10,NDC,facility,both,5,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-3178-01,NDC,facility,both,80,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADVATE: FACTOR VIII CONCENTRATE (MERGE RECORD),50863,CDM,250,RC,J7192,HCPCS,0944-3051-02,NDC,facility,both,2000,UN,,10738,7516.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,636,RC,J2270,HCPCS,0409-1890-03,NDC,facility,both,1,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZONATATE 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7153-61,NDC,facility,both,14,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % MBP,50863,CDM,J3490,HCPCS,0338-0553-18,NDC,,,facility,both,4,ML,,178,124.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 10 GRAM/15 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-0873-16,NDC,facility,both,1,ML,,108,75.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % MBP,50863,CDM,250,RC,J3490,HCPCS,0338-0553-18,NDC,facility,both,17,ML,,754,527.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,636,RC,J1815,HCPCS,49502-393-80,NDC,facility,both,3,ML,GZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier GZ: Item or service expected to be denied as not reasonable and necessary
CEFAZOLIN IN DEXTROSE (ISO-OSMOTIC) 1 GRAM/50 ML IV PIGGY BACK,50863,CDM,250,RC,J0690,HCPCS,0338-3503-41,NDC,facility,both,4,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACCHAROMYCES BOULARDII 250 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,7733380050,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-739-11,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 1 MG/ML PCA (PDS MERGE),50863,CDM,250,RC,J3490,HCPCS,61553-820-41,NDC,facility,both,1,ML,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 0.1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-721-11,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE (PF-DURAMORPH/ASTRAMORPH) 0.5 MG/ML INJ SOLN,50863,CDM,250,RC,J2274,HCPCS,0409-3814-11,NDC,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROTHIAZIDE SODIUM 28 MG/ML IV (PEDS) REPACK,50863,CDM,250,RC,J1205,HCPCS,99999-0404-59,NDC,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,81,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANASTROZOLE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16729-035-10,NDC,facility,both,1,EA,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,45,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN PEDS SYRINGE (20MG/ML) IN DEXTROSE (CDS MIX,50863,CDM,250,RC,J7999,HCPCS,0781-3451-70,NDC,facility,both,1,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMILORIDE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0574-0292-01,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SOTALOL  80 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-654-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE   4.2 % IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-083-05,NDC,facility,both,2,ML,,198,138.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-677-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV (BOLUS),50863,CDM,636,RC,J7120,HCPCS,0264-7750-07,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG ORAL TAB,50863,CDM,636,RC,Q0169,HCPCS,10702-003-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 10 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-369-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 10 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-369-11,NDC,facility,both,12,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNITS/1 GRAM PACKET (MERGE RECORD),50863,CDM,250,RC,J3490,HCPCS,45802-060-00,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6290-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IR SOLN,50863,CDM,250,RC,J3490,HCPCS,0338-0047-46,NDC,facility,both,4,ML,,194,135.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) MISC SOLN,50863,CDM,250,RC,J3490,HCPCS,0517-7604-01,NDC,facility,both,1,ML,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICARDIPINE 25 MG/10 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0143-9689-01,NDC,facility,both,5,ML,,749,524.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-25,NDC,facility,both,160,ML,"JZ,JA",22631,15841.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,12,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,51079-051-20,NDC,facility,both,6,EA,,155,108.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAPAVERINE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J2440,HCPCS,0517-4010-01,NDC,facility,both,5,ML,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  50 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-484-11,NDC,facility,both,3,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-318-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  5 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,33342-083-07,NDC,facility,both,1,EA,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,1093990033,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN  325 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,57896-921-01,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM  4.5 GRAM IV SOLR,50863,CDM,636,RC,J2543,HCPCS,65219-259-05,NDC,facility,both,4,EA,JZ,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,63739-196-01,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-ABDA 100 MG IV SOLR,50863,CDM,636,RC,Q5104,HCPCS,78206-162-99,NDC,facility,both,7,EA,JW,633,443.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,63323-461-01,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,18,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IR SOLN,50863,CDM,250,RC,J3490,HCPCS,0338-0047-46,NDC,facility,both,9,ML,,499,349.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,636,RC,J3490,HCPCS,0409-4277-02,NDC,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,12,ML,,20809,14566.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIROLIMUS 1 MG ORAL TAB,50863,CDM,250,RC,J7520,HCPCS,50268-718-11,NDC,facility,both,1,EA,,172,120.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,3,EA,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16714-990-01,NDC,facility,both,2,EA,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN  500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-155-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,636,RC,J1610,HCPCS,63323-596-11,NDC,facility,both,2,EA,JZ,1789,1252.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,0409-9093-32,NDC,facility,both,2,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OMEPRAZOLE-SODIUM BICARBONATE 2-84 MG/ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,65628-270-05,NDC,facility,both,3,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPOETIN ALFA 2000 UNIT/ML IV SYRINGE (PED/NEO),50863,CDM,250,RC,Q4081,HCPCS,59676-302-00,NDC,facility,both,4,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 0.1 MG/ML INJ SYRG,50863,CDM,250,RC,J0461,HCPCS,16729-484-03,NDC,facility,both,200,ML,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,250,RC,J2795,HCPCS,63323-286-20,NDC,facility,both,100,ML,JZ,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
OCTREOTIDE ACETATE  100 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,68462-896-01,NDC,facility,both,2,ML,JW,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,50863,CDM,636,RC,J0585,HCPCS,0023-1145-01,NDC,facility,both,90,EA,,1439,1007.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 400 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0143-9887-01,NDC,facility,both,15,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZONATATE 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,68084-214-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 100 MG ORAL TB12,50863,CDM,636,RC,J3490,HCPCS,42806-274-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB 100 MG IV SOLR,50863,CDM,636,RC,J1745,HCPCS,57894-030-01,NDC,facility,both,75,EA,,24174,16921.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,43598-931-11,NDC,facility,both,10,ML,,527,368.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPRAZOLAM 0.25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-377-11,NDC,facility,both,4,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25 MG-250 MG TAB,50863,CDM,636,RC,J3490,HCPCS,50228-459-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCRALFATE 100 MG/ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0121-0974-10,NDC,facility,both,1,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-693-01,NDC,facility,both,2,EA,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  20 MG ORAL TR12,50863,CDM,636,RC,J3490,HCPCS,59011-420-10,NDC,facility,both,1,EA,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6501-61,NDC,facility,both,4,EA,,278,194.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,16714-046-01,NDC,facility,both,9,ML,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,71288-402-10,NDC,facility,both,18,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN   81 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,57896-981-01,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 40 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6292-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-1283-03,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE DINITRATE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-083-11,NDC,facility,both,2,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,63,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,72603-209-01,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 400 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-6667-61,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,8,EA,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-21,NDC,facility,both,10,ML,,1415,990.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM HYPOCHLORITE 0.125 % MISC SOLN,50863,CDM,250,RC,J3490,HCPCS,0436-0672-16,NDC,facility,both,16,ML,,791,553.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUMAZENIL 0.1 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,36000-148-01,NDC,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 17 GRAM (100 %) ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,1152372688,NDC,facility,both,7,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRIL MALEATE 1 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,69238-1729-7,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),50863,CDM,636,RC,J0171,HCPCS,76329-3318-1,NDC,facility,both,60,ML,,441,308.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE 0.5 MG/2 ML INHL NBSP,50863,CDM,250,RC,J3490,HCPCS,0487-9701-01,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CELECOXIB 200 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-447-11,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-50,NDC,facility,both,1,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PHENOBARBITAL 20 MG/5 ML ORAL ELIX,50863,CDM,636,RC,J3490,HCPCS,0121-0942-05,NDC,facility,both,5,ML,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,250,RC,J0132,HCPCS,25021-812-30,NDC,facility,both,170,ML,,1222,855.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"AMIODARONE IN DEXTROSE,ISO-OSM 150 MG/100 ML (PREMIX)",50863,CDM,250,RC,J0282,HCPCS,43066-150-10,NDC,facility,both,100,ML,,4069,2848.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,63323-462-17,NDC,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,51754-5001-5,NDC,facility,both,3,ML,,155,108.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOFLOXACIN 750 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6353-61,NDC,facility,both,3,EA,,314,219.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J2003,HCPCS,63323-492-09,NDC,facility,both,100,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0143-9595-01,NDC,facility,both,100,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LET TOPICAL GEL 3 ML,50863,CDM,250,RC,J3490,HCPCS,70092-1611-44,NDC,facility,both,1,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0093-2279-73,NDC,facility,both,10,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,16714-293-01,NDC,facility,both,8,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 0.5 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,63323-481-01,NDC,facility,both,300,ML,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-590-11,NDC,facility,both,3,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 30 MG/0.3 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0955-1003-01,NDC,facility,both,3,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CINACALCET 30 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69097-410-02,NDC,facility,both,1,EA,,150,105,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,68180-441-02,NDC,facility,both,7,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1940,HCPCS,0409-6102-02,NDC,facility,both,10,ML,,278,194.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"RSV VAC, PREF A AND PREF B(PF) 120 MCG/0.5 ML IM SOLR",50863,CDM,250,RC,90678,HCPCS,0069-0207-01,NDC,facility,both,1,EA,,1045,731.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,0641-6145-01,NDC,facility,both,4,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-0430-04,NDC,facility,both,1,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETONOGESTREL 68 MG SDRM IMPL,50863,CDM,J7307,HCPCS,78206-145-01,NDC,,,facility,both,1,EA,,2258,1580.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG ORAL TAB,50863,CDM,636,RC,Q0169,HCPCS,68084-155-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,3,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 500 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-787-11,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,636,RC,J2795,HCPCS,43066-023-01,NDC,facility,both,25,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
OXYBUTYNIN CHLORIDE  5 MG ORAL TO24,50863,CDM,250,RC,J3490,HCPCS,68084-480-11,NDC,facility,both,3,EA,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,11,EA,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 500 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7337-35,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL IV BOLUS 10MG/ML (ANESTHESIA ONLY),50863,CDM,636,RC,J2704,HCPCS,0409-4699-54,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3373,HCPCS,67457-340-01,NDC,facility,both,200,EA,,189,132.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RAVULIZUMAB-CWVZ 100 MG/ML IV SOLN,50863,CDM,636,RC,J1303,HCPCS,25682-028-01,NDC,facility,both,330,ML,,194426,136098.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MECLIZINE 12.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-522-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 100 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,0904-3854-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MANNITOL 20% IV SOLP,50863,CDM,250,RC,J2150,HCPCS,0990-7715-13,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VORICONAZOLE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7024-04,NDC,facility,both,1,EA,,130,91,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,636,RC,J1596,HCPCS,0143-9679-01,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYALURONIDASE 150 UNIT/ML INJ SOLN,50863,CDM,250,RC,J3473,HCPCS,18657-117-02,NDC,facility,both,15,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 10 MG/50 ML (0.2MG/ML) PCA IN NS (MERGE),50863,CDM,250,RC,J1171,HCPCS,70092-1286-74,NDC,facility,both,100,ML,,215,150.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,70860-405-41,NDC,facility,both,2,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7244-68,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 250 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,0904-6860-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7130-61,NDC,facility,both,1,EA,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,75,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,250,RC,J7999,HCPCS,70092-1017-46,NDC,facility,both,8,ML,,159,111.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPTOMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0878,HCPCS,72603-152-01,NDC,facility,both,550,EA,,1609,1126.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-50,NDC,facility,both,32,ML,JW,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LIDOCAINE HCL  2 % MM JELP,50863,CDM,250,RC,J3490,HCPCS,76329-3012-5,NDC,facility,both,2,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 2 MG INJ SOLR,50863,CDM,250,RC,J2997,HCPCS,50242-041-64,NDC,facility,both,2,EA,,800,560,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,250,RC,J0690,HCPCS,70092-1017-46,NDC,facility,both,6,ML,,119,83.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAUNORUBICIN 5 MG/ML IV INJ,50863,CDM,250,RC,J9150,HCPCS,42658-021-01,NDC,facility,both,3,ML,,652,456.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLP,50863,CDM,636,RC,J3480,HCPCS,0409-6653-18,NDC,facility,both,20,ML,JZ,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LACOSAMIDE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0131-2477-60,NDC,facility,both,4,EA,,271,189.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALSARTAN  80 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,31722-152-90,NDC,facility,both,2,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,50863,CDM,250,RC,J0696,HCPCS,0143-9856-01,NDC,facility,both,56,EA,,140,98,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOBRAMYCIN 1.2 G POWDER VIAL,50863,CDM,250,RC,J3260,HCPCS,39822-0412-1,NDC,facility,both,1,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J1938,HCPCS,0409-6102-10,NDC,facility,both,200,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INDOMETHACIN 50 MG RECT SUPP,50863,CDM,250,RC,J3490,HCPCS,69344-102-33,NDC,facility,both,1,EA,,1282,897.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,3,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL IV BOLUS 10MG/ML (ANESTHESIA ONLY),50863,CDM,636,RC,J2704,HCPCS,63323-269-29,NDC,facility,both,80,ML,,160,112,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOPIDOGREL  75 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-536-11,NDC,facility,both,2,EA,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,21,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),50863,CDM,250,RC,J0171,HCPCS,76329-3318-1,NDC,facility,both,40,ML,,323,226.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2599,HCPCS,43598-914-25,NDC,facility,both,7,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,50863,CDM,636,RC,J1756,HCPCS,0517-2340-10,NDC,facility,both,100,ML,,321,224.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,636,RC,J1100,HCPCS,25021-053-01,NDC,facility,both,10,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DAUNORUBICIN 5 MG/ML IV INJ,50863,CDM,250,RC,J9150,HCPCS,42658-021-01,NDC,facility,both,5,ML,,1174,821.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-24,NDC,facility,both,80,ML,,11316,7921.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,68180-150-01,NDC,facility,both,1,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DENOSUMAB 120 MG/1.7 ML (70 MG/ML) SUBQ SOLN,50863,CDM,636,RC,J0897,HCPCS,55513-730-01,NDC,facility,both,120,ML,JZ,9522,6665.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DULOXETINE 60 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,0904-7045-61,NDC,facility,both,2,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN 0.9 % SODIUM CHL 1.5 GRAM/500 ML IV SOLN,50863,CDM,636,RC,J3370,HCPCS,70004-924-44,NDC,facility,both,3,ML,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE DINITRATE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-448-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROMETHORPHAN-GUAIFENESIN SR 30 MG-600 MG 12 HR TAB,50863,CDM,250,RC,J3490,HCPCS,63824-056-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE IN 0.9% NS (PF) 1 MG/10 ML (100 MCG/ML) IV SYRG(PDS MERGE),50863,CDM,250,RC,J3490,HCPCS,65302-506-10,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,63323-280-03,NDC,facility,both,60,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,72603-506-01,NDC,facility,both,300,ML,JZ,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,636,RC,J0330,HCPCS,0409-6629-02,NDC,facility,both,4,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LURASIDONE 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7355-04,NDC,facility,both,6,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TICAGRELOR 90 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0186-0777-60,NDC,facility,both,2,EA,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 2400000 UNIT/4 ML IM SYRG,50863,CDM,250,RC,J0561,HCPCS,60793-702-04,NDC,facility,both,24,ML,JZ,1725,1207.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MESNA 100 MG/ML IV SOLN,50863,CDM,250,RC,J9209,HCPCS,10019-953-62,NDC,facility,both,2,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,250,RC,J1596,HCPCS,0143-9679-01,NDC,facility,both,2,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZONATATE 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7153-61,NDC,facility,both,60,EA,,174,121.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACIDOPHILUS-PECTIN W CITRUS 25 MILLION-100 CELL MG TAB,50863,CDM,250,RC,J3490,HCPCS,1785614241,NDC,facility,both,8,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOMIPRAMINE 75 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,16571-685-03,NDC,facility,both,3,EA,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2305-04,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IDARUBICIN 1 MG/ML IV SOLN,50863,CDM,250,RC,J9211,HCPCS,0013-2586-91,NDC,facility,both,2,ML,,466,326.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR IRRIGATION, STERILE SOLUTION",50863,CDM,250,RC,J3490,HCPCS,0338-0004-02,NDC,facility,both,2,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VINCRISTINE 2 MG/2 ML IV SOLN,50863,CDM,250,RC,J9370,HCPCS,61703-309-16,NDC,facility,both,2,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6953-61,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR 200 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,31722-681-47,NDC,facility,both,1,ML,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,636,RC,J2560,HCPCS,0641-0477-21,NDC,facility,both,2,ML,,349,244.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4 % MUCOSAL TOPICAL SOLN,50863,CDM,250,RC,J3490,HCPCS,70954-518-10,NDC,facility,both,1,ML,,275,192.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE IN D5W (PF) 4 MG/ML (0.4 %) IV SOLP,50863,CDM,636,RC,J3490,HCPCS,0338-0409-03,NDC,facility,both,200,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML (PEDS CALCLUATOR 0.5),50863,CDM,250,RC,J1815,HCPCS,0024-5924-10,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0574-0521-76,NDC,facility,both,1,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANTI-INHIBITOR COAGULANT CMPLX 350-650 UNIT IV SOLR,50863,CDM,250,RC,J7198,HCPCS,64193-423-02,NDC,facility,both,634,UN,JW,1643,1150.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,0641-6027-25,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 1%/EPINEPHRINE 1:200K INJECTION (PF),50863,CDM,636,RC,J3490,HCPCS,63739-468-05,NDC,facility,both,35,ML,,714,499.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOMIPRAMINE 50 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,69238-1109-9,NDC,facility,both,1,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNIT/G TOP PACK,50863,CDM,636,RC,J3490,HCPCS,0904-7402-67,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION,50863,CDM,250,RC,J3490,HCPCS,0310-7372-20,NDC,facility,both,2,GM,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,76045-009-10,NDC,facility,both,8,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 20 MG/ML INJ SOLN,50863,CDM,636,RC,J0360,HCPCS,0641-6231-01,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEPOLIZUMAB 100 MG SUBQ SOLR,50863,CDM,636,RC,J2182,HCPCS,0173-0881-01,NDC,facility,both,300,EA,JZ,21321,14924.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,81033-002-05,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 40 % ORAL GEL,50863,CDM,250,RC,J3490,HCPCS,574006930,NDC,facility,both,39,GM,,552,386.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J0461,HCPCS,16729-512-05,NDC,facility,both,173,ML,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-742-11,NDC,facility,both,2,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,25021-463-01,NDC,facility,both,4,ML,JB,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JB: Administered subcutaneously
METHYLPHENIDATE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,57664-228-88,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,82,ML,JW,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
WARFARIN  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0832-1213-89,NDC,facility,both,3,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROPROCAINE 3 % INJ SOLN,50863,CDM,250,RC,J2401,HCPCS,0143-9210-01,NDC,facility,both,90,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 250 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,68084-776-11,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN  6 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51672-4033-1,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 10 MG-100 MG TAB,50863,CDM,636,RC,J3490,HCPCS,42291-471-01,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIOTHYRONINE  5 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0093-2179-01,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69315-904-01,NDC,facility,both,6,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,50863,CDM,250,RC,J0696,HCPCS,0781-3208-85,NDC,facility,both,4,EA,,225,157.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL  3.125 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7305-61,NDC,facility,both,10,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGIC MOUTHWASH REPACK (BMX 1:1:1),50863,CDM,636,RC,J3490,HCPCS,0603-0823-54,NDC,facility,both,2,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7122-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,0409-1283-03,NDC,facility,both,20,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7048-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANTI-INHIBITOR COAGULANT CMPLX (PHS MERGE),50863,CDM,250,RC,J7198,HCPCS,64193-424-02,NDC,facility,both,725,UN,JW,1878,1314.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DAPAGLIFLOZIN PROPANEDIOL 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0310-6210-30,NDC,facility,both,1,EA,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPTOMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0878,HCPCS,72603-152-01,NDC,facility,both,500,EA,JZ,1463,1024.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,636,RC,J3490,HCPCS,60687-653-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM  4.5 GRAM IV SOLR,50863,CDM,636,RC,J2543,HCPCS,81284-153-00,NDC,facility,both,4,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0406-0552-23,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,636,RC,P9045,HCPCS,68516-5218-0,NDC,facility,both,1,ML,,237,165.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,0641-6174-01,NDC,facility,both,2,ML,JA,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
"ALBUMIN, HUMAN 25 % IV SOLP",50863,CDM,250,RC,P9047,HCPCS,0944-0493-04,NDC,facility,both,1,ML,JW,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,33,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,50863,CDM,636,RC,J1756,HCPCS,0517-2325-01,NDC,facility,both,49,ML,,182,127.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-3178-01,NDC,facility,both,120,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-592-11,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOLAZONE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,72888-053-01,NDC,facility,both,4,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,55150-222-20,NDC,facility,both,1,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,250,RC,J2270,HCPCS,0409-1890-03,NDC,facility,both,1,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 2 GRAM INJ SOLR,50863,CDM,250,RC,J0692,HCPCS,44567-241-10,NDC,facility,both,56,EA,,806,564.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE 150 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16571-110-01,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,62756-711-86,NDC,facility,both,34,EA,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL  25 MCG/HR TD PT72,50863,CDM,250,RC,J3490,HCPCS,0378-9121-16,NDC,facility,both,1,EA,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 2 % TD OINT,50863,CDM,636,RC,J3490,HCPCS,0281-0326-08,NDC,facility,both,1,GM,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-145-10,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN IN D5W 900 MG/50 ML IV PGBK,50863,CDM,636,RC,J0736,HCPCS,0338-3814-50,NDC,facility,both,3,ML,JZ,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GLIPIZIDE  5 MG ORAL TO24,50863,CDM,250,RC,J3490,HCPCS,68084-111-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6640-61,NDC,facility,both,3,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 10 % (100 MG/ML) MISC SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-695-04,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6291-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-210-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE (POLACRILEX) 2 MG BUCL GUM,50863,CDM,250,RC,J3490,HCPCS,70677-1166-1,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,636,RC,J2270,HCPCS,0641-6125-01,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,250,RC,J3101,HCPCS,50242-037-06,NDC,facility,both,38,EA,JW,7139,4997.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
"HYOSCYAMINE 0.125 MG TAB, RAPID DISSOLVE",50863,CDM,636,RC,J3490,HCPCS,63629-1030-1,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 60 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,60687-745-11,NDC,facility,both,1,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0630,HCPCS,24201-400-02,NDC,facility,both,1,ML,,2774,1941.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETHACRYNATE SODIUM 50 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,42023-157-01,NDC,facility,both,1,EA,,10488,7341.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FILGRASTIM-SNDZ 300 MCG/0.5 ML INJ SYRG,50863,CDM,250,RC,Q5101,HCPCS,61314-318-05,NDC,facility,both,300,ML,JZ,972,680.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PREDNISONE  5 MG ORAL TAB,50863,CDM,J7512,HCPCS,60687-122-11,NDC,,,facility,both,5,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,J2003,HCPCS,63323-486-05,NDC,,,facility,both,40,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 25 MG CAP,50863,CDM,J3490,HCPCS,0904-7237-61,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN IN D5W 900 MG/50 ML IV PGBK,50863,CDM,J0736,HCPCS,0338-3814-50,NDC,,,facility,both,3,ML,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,16714-293-03,NDC,facility,both,4,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 10 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-6426-61,NDC,,,facility,both,2,EA,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE MONONITRATE 100 MG ORAL TAB,50863,CDM,J3490,HCPCS,4843310801,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,50863,CDM,J1885,HCPCS,0409-3796-19,NDC,,,facility,both,2,ML,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUVOXAMINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60505-0165-1,NDC,facility,both,2,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,28,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE 20 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0904-5677-61,NDC,facility,both,2,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 125 MG/5 ML (25MG/ML) ORAL SYRINGE (REPACK),50863,CDM,J3370,HCPCS,67457-340-00,NDC,,,facility,both,3,EA,,142,99.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,J1953,HCPCS,63323-400-01,NDC,,,facility,both,75,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),50863,CDM,J3490,HCPCS,63323-186-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,50863,CDM,J3490,HCPCS,68180-723-05,NDC,,,facility,both,3,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,124,ML,JZ,112,78.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
EPOETIN ALFA  4000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J0885,HCPCS,59676-304-00,NDC,facility,both,40,ML,"EC,JB",462,323.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier EC: Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy | Modifier JB: Administered subcutaneously
SENNOSIDES-DOCUSATE SODIUM 8.6 MG-50 MG TAB,50863,CDM,250,RC,J3490,HCPCS,63739-432-02,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,250,RC,J1596,HCPCS,0143-9679-01,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 5 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,0143-9660-01,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEBIVOLOL  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,31722-586-90,NDC,facility,both,4,EA,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOBRAMYCIN 1.2 G POWDER VIAL,50863,CDM,250,RC,J3260,HCPCS,39822-0412-6,NDC,facility,both,105,EA,,2783,1948.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  10 MG/5 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,0121-0904-05,NDC,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE MODIFIED 100 MG ORAL CAP,50863,CDM,250,RC,J7502,HCPCS,23155-839-11,NDC,facility,both,3,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,50863,CDM,250,RC,J9075,HCPCS,10019-956-16,NDC,facility,both,137,EA,,884,618.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 125 MCG SUBQ SOLR,50863,CDM,J2802,HCPCS,55513-223-01,NDC,,,facility,both,105,EA,,2155,1508.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  5 MG ORAL TBDL,50863,CDM,J3490,HCPCS,55111-262-79,NDC,,,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-495-27,NDC,,,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VERAPAMIL 2.5 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,70710-1643-1,NDC,facility,both,2,ML,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FERROUS SULFATE 75 MG/ML (ELEMENTAL IRON 15 MG/ML) 0.1 ML ORAL SYRINGE (REPACK),50863,CDM,250,RC,J3490,HCPCS,3932805750,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63304-773-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,300,ML,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,250,RC,J0330,HCPCS,31722-981-10,NDC,facility,both,6,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,J2270,HCPCS,0409-1891-03,NDC,,,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 500 MG (200 MG ELEMENTAL) CHEW TAB,50863,CDM,250,RC,J3490,HCPCS,68084-988-33,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0630,HCPCS,24201-400-02,NDC,facility,both,1,ML,,1590,1113,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,2,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J1610,HCPCS,63323-582-82,NDC,facility,both,1,EA,,991,693.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,14789-251-09,NDC,facility,both,1,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6360-61,NDC,facility,both,1,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZIPRASIDONE 20 MG IM,50863,CDM,250,RC,J3486,HCPCS,43598-848-11,NDC,facility,both,1,EA,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE HCL IN 0.9% NACL 1 MG/10 ML (100 MCG/ML) IV SYRG,50863,CDM,250,RC,J3490,HCPCS,73177-108-03,NDC,facility,both,3,ML,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,600,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 500 MG (200 MG ELEMENTAL) CHEW TAB,50863,CDM,636,RC,J3490,HCPCS,66553-004-01,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3373,HCPCS,0143-9162-01,NDC,facility,both,100,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,607,ME,JZ,8237,5765.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,J3490,HCPCS,71266-9080-4,NDC,,,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG IV SOLR,50863,CDM,J3490,HCPCS,25021-751-10,NDC,,,facility,both,2,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0630,HCPCS,42023-205-01,NDC,facility,both,1,ML,,5056,3539.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,0641-6145-01,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIOTHYRONINE  5 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,62756-589-88,NDC,facility,both,3,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MEASLES,MUMPS,RUBELLA VACC(PF) 10EXP3.4-4.2- 3.3CCID50/0.5ML SUBQ SUSR",50863,CDM,250,RC,90707,HCPCS,58160-831-03,NDC,facility,both,1,EA,,387,270.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 20 GRAM/500 ML IV SOLP,50863,CDM,636,RC,J3475,HCPCS,63323-106-15,NDC,facility,both,40,ML,JZ,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DILTIAZEM 90 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0093-0320-01,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,636,RC,J2560,HCPCS,0641-0477-25,NDC,facility,both,3,ML,,697,487.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,62332-033-31,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEMAZEPAM 15 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,50268-779-11,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANTI-THYMOCYTE GLOB (RABBIT) 25 MG IV SOLR,50863,CDM,J7511,HCPCS,58468-0080-1,NDC,,,facility,both,5,EA,,10110,7077,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,636,RC,J0690,HCPCS,60505-6142-0,NDC,facility,both,2,EA,JZ,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"DIPHTH,PERTUS(ACELL),TETANUS SYRG(BOOSTRIX) 2.5-8-5 LF-MCG-LF/0.5ML IM SYRG",50863,CDM,250,RC,90715,HCPCS,58160-842-52,NDC,facility,both,1,ML,,247,172.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-544-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,72611-722-25,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,0143-9577-01,NDC,,,facility,both,160,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,63323-482-27,NDC,,,facility,both,200,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE HCL 5 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,62559-190-16,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,J3101,HCPCS,50242-037-06,NDC,,,facility,both,26,EA,,5178,3624.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,50863,CDM,J0561,HCPCS,60793-701-02,NDC,,,facility,both,24,ML,,2160,1512,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYMETAZOLINE 0.05 % NASAL MERGE,50863,CDM,J3490,HCPCS,70677-1037-1,NDC,,,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0904-6923-61,NDC,facility,both,12,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ABATACEPT 250 MG IV SOLR,50863,CDM,636,RC,J0129,HCPCS,0003-2187-13,NDC,facility,both,75,EA,JA,12834,8983.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
SCOPOLAMINE TRANSDERMAL PATCH 1MG OVER 3 DAYS,50863,CDM,250,RC,J3490,HCPCS,0378-6470-16,NDC,facility,both,1,EA,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,250,RC,J2405,HCPCS,0641-6078-25,NDC,facility,both,4,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
HEPARIN (PORCINE) IN NACL (PF) 1000 UNIT/500 ML IV SOLP,50863,CDM,636,RC,J1644,HCPCS,0409-1005-01,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE  50 MG ORAL TAB,50863,CDM,250,RC,j3490,HCPCS,68382-805-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,59762-3130-1,NDC,facility,both,2,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 50 MG TAB,50863,CDM,636,RC,J3490,HCPCS,51079-801-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VECURONIUM BROMIDE 10 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,0703-2914-01,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,0641-6145-01,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPTOMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0878,HCPCS,70594-034-01,NDC,facility,both,500,EA,,306,214.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-676-11,NDC,facility,both,2,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OMEPRAZOLE-SODIUM BICARBONATE 2-84 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,65628-270-05,NDC,facility,both,8,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  75 MG ORAL CP24,50863,CDM,636,RC,J3490,HCPCS,0904-7077-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL,50863,CDM,250,RC,J3490,HCPCS,63323-820-01,NDC,facility,both,1,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  50 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-484-11,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J1938,HCPCS,0409-6102-18,NDC,facility,both,120,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5%-1/4 NORMAL SALINE IV,50863,CDM,250,RC,J3490,HCPCS,0264-7616-10,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,55150-169-10,NDC,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,636,RC,J3490,HCPCS,60687-653-11,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-103-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR  6 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0004-0822-05,NDC,facility,both,8,ML,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOBENZAPRINE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,69097-846-07,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEO TPN SODIUM ACETATE 2 MEQ/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-7299-83,NDC,facility,both,1,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-5755-23,NDC,facility,both,22,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,51754-4250-1,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROATE SODIUM 100 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-494-01,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,636,RC,J1953,HCPCS,63323-400-01,NDC,facility,both,150,ML,,158,110.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFUROXIME AXETIL 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-400-02,NDC,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLN,50863,CDM,636,RC,J3262,HCPCS,50242-137-01,NDC,facility,both,400,ML,JZ,7331,5131.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,29,EA,,4002,2801.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DICLOFENAC 75 MG TAB, DELAYED RELEASE",50863,CDM,250,RC,J3490,HCPCS,60687-658-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0338-1055-48,NDC,facility,both,32,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 20 GRAM/30 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-1154-30,NDC,facility,both,4,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),50863,CDM,636,RC,J0169,HCPCS,76329-3318-1,NDC,facility,both,50,ML,,404,282.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,636,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUPHENAZINE 1 MG TAB,50863,CDM,250,RC,J3490,HCPCS,70954-273-10,NDC,facility,both,2,EA,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42858-301-25,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"POTASSIUM PHOSPHATE, MONOBASIC 500 MG ORAL TBSO",50863,CDM,636,RC,J3490,HCPCS,0486-1111-01,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOPERAMIDE 2 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,51079-690-01,NDC,facility,both,12,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZONISAMIDE 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-230-11,NDC,facility,both,3,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 600 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,59651-361-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 2 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,250,RC,J2270,HCPCS,63323-452-00,NDC,facility,both,1,ML,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,250,RC,J2003,HCPCS,76329-3390-1,NDC,facility,both,100,ML,PLAD,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,60,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,60,EA,,8280,5796,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEXILETINE 200 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,62559-821-01,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMETHICONE 40MG/0.6ML (0.6ML-UD) SYRINGE (REPACK),50863,CDM,636,RC,J3490,HCPCS,17856-1141-4,NDC,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,45,EA,,6210,4347,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM  4.5 GRAM IV SOLR,50863,CDM,636,RC,J2543,HCPCS,0781-3114-91,NDC,facility,both,4,EA,JZ,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LEVOTHYROXINE  75 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6951-61,NDC,facility,both,1,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J2312,HCPCS,0409-1215-01,NDC,facility,both,200,ML,,465,325.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,67457-423-00,NDC,facility,both,2,ML,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,250,RC,Q0162,HCPCS,68094-763-59,NDC,facility,both,4,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,250,RC,Q9968,HCPCS,71288-811-10,NDC,facility,both,45,ML,JW,254,177.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
SENNOSIDES  8.6 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7252-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL (VITAMIN D3)   400 UNIT ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,5026886311,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  10 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-0904-94,NDC,facility,both,2,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NYSTATIN 100000 UNIT/ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0904-7276-41,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-25,NDC,facility,both,40,ML,,5658,3960.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 20 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,0904-7043-61,NDC,facility,both,4,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,60687-390-11,NDC,facility,both,4,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) NEB SOLUTION,50863,CDM,250,RC,J3490,HCPCS,0487-9501-00,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,54,ML,JW,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
APIXABAN 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0003-0894-31,NDC,facility,both,1,EA,PLAD,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
DOXORUBICIN 2 MG/ML IV SOLN,50863,CDM,250,RC,J9000,HCPCS,25021-207-51,NDC,facility,both,2,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 30 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-087-01,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTOBARBITAL 75 MG/1.5 ML SYRINGE (REPACK),50863,CDM,250,RC,J3490,HCPCS,25021-676-20,NDC,facility,both,2,ML,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7123-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0781-6041-55,NDC,facility,both,18,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % MBP,50863,CDM,250,RC,J3490,HCPCS,0338-0553-18,NDC,facility,both,15,ML,,665,465.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,8000,ML,,881,616.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML IV SOLN (MERGE),50863,CDM,250,RC,J3490,HCPCS,16714-037-10,NDC,facility,both,1,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,J7040,HCPCS,0338-0049-02,NDC,,,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEPERIDINE (PF) 25 MG/ML IV SOLN (PHS MERGE),50863,CDM,250,RC,J2175,HCPCS,0409-1362-11,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,250,RC,J3490,HCPCS,0143-9575-01,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,65219-186-01,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,636,RC,J3490,HCPCS,55150-188-10,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-0710-20,NDC,facility,both,12,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 16 MG ORAL TAB,50863,CDM,636,RC,J7509,HCPCS,68382-918-18,NDC,facility,both,4,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  100 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,63323-376-00,NDC,facility,both,2,ML,JA,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
PANTOPRAZOLE 40 MG IV SOLR,50863,CDM,636,RC,J3490,HCPCS,55150-202-00,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7351-04,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL 2.5 MG/ML SUSPENSION,50863,CDM,250,RC,J3490,HCPCS,99999-0404-75,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE IN 0.9% NS (PF) 1 MG/10 ML (100 MCG/ML) IV SYRG(PDS MERGE),50863,CDM,250,RC,J3490,HCPCS,70092-1046-46,NDC,facility,both,1,ML,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,636,RC,J1596,HCPCS,0143-9679-01,NDC,facility,both,2,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CANDESARTAN  8 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,33342-115-07,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXAZOSIN 2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-5523-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,70000-0409-1,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  5 GRAM IV SOLR,50863,CDM,250,RC,J3370,HCPCS,0143-9163-01,NDC,facility,both,3,EA,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESTRADIOL 0.05 MG/24 HR TD PTWK,50863,CDM,250,RC,J7304,HCPCS,50419-451-01,NDC,facility,both,3,EA,,292,204.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  37.5 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,0904-7075-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
K PHOS DI & MONO-SOD PHOS MONO 250 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,6498010401,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-25,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE 0.5 MG/2 ML INHL NBSP,50863,CDM,250,RC,J3490,HCPCS,60687-524-79,NDC,facility,both,1,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOLUTEGRAVIR-RILPIVIRINE 50-25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,49702-242-13,NDC,facility,both,1,EA,,526,368.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROMETHORPHAN-GUAIFENESIN SR 30 MG-600 MG 12 HR TAB,50863,CDM,636,RC,J3490,HCPCS,0536-1161-37,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,636,RC,Q9968,HCPCS,71288-811-10,NDC,facility,both,5,ML,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,J2371,HCPCS,0641-6142-01,NDC,,,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,FAMNOCHARGE,HCPCS,68094-763-59,NDC,,,facility,both,2,ML,,150,105,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPATITIS B IMMUNE GLOBULIN 220 UNIT/ML (5 ML) IM SOLN,50863,CDM,636,RC,90371,HCPCS,13533-636-05,NDC,facility,both,5,ML,,2209,1546.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,250,RC,J2720,HCPCS,63323-229-01,NDC,facility,both,4,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,85,EA,,11730,8211,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0137,HCPCS,0143-9386-01,NDC,facility,both,61,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACCHAROMYCES BOULARDII 250 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,7733380025,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 1 MG ORAL TAB,50863,CDM,250,RC,J8540,HCPCS,0054-8174-25,NDC,facility,both,24,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,50863,CDM,250,RC,J9263,HCPCS,71288-101-10,NDC,facility,both,32,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DORZOLAMIDE-TIMOLOL 2 %-0.5 % EYE DROPS,50863,CDM,636,RC,J3490,HCPCS,42571-147-26,NDC,facility,both,1,ML,,440,308,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69238-1491-1,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOPAMINE INFUSION NEO IV SYRINGE (FROM PREMIX),50863,CDM,636,RC,J1265,HCPCS,0409-7809-11,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROATE SODIUM 100 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0143-9785-01,NDC,facility,both,4,ML,,406,284.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,73,EA,,10074,7051.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,50863,CDM,250,RC,J9075,HCPCS,10019-956-16,NDC,facility,both,63,EA,JW,180,126,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
TETRABENAZINE 25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,67386-422-01,NDC,facility,both,1,EA,,386,270.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,64208-2510-2,NDC,facility,both,1,ML,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALSARTAN  80 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-623-11,NDC,facility,both,4,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIFAXIMIN 550 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65649-303-03,NDC,facility,both,1,EA,,294,205.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENAZEPRIL  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,23155-749-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % MUCOSAL SOLN (VISCOUS),50863,CDM,250,RC,J3490,HCPCS,0054-8500-16,NDC,facility,both,2,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 30 MG/0.3 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0075-0624-01,NDC,facility,both,6,ML,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN PEDS SYRINGE (20MG/ML) IN DEXTROSE (CDS MIX,50863,CDM,250,RC,J0690,HCPCS,0781-3451-70,NDC,facility,both,2,EA,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EMTRICITABINE-TENOFOVIR 200 MG-300 MG TAB,50863,CDM,250,RC,J0750,HCPCS,61958-0701-1,NDC,facility,both,1,EA,,313,219.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE  0.65 % NASL SPRA,50863,CDM,636,RC,J3490,HCPCS,0904-3865-75,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN IN D5W 400 MG/200 ML IV PGBK,50863,CDM,J0744,HCPCS,0409-3300-01,NDC,,,facility,both,2,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE (PF-DURAMORPH/ASTRAMORPH) 0.5 MG/ML INJ SOLN,50863,CDM,J2274,HCPCS,0409-3814-12,NDC,,,facility,both,1,ML,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 1MG/ML SYRINGE (FOR IR USE ONLY),50863,CDM,250,RC,J2997,HCPCS,99999-0403-36,NDC,facility,both,4,ML,,845,591.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-495-09,NDC,,,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,J7512,HCPCS,0904-7127-61,NDC,,,facility,both,60,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-9558-05,NDC,facility,both,2,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 250 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,42192-608-05,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),50863,CDM,636,RC,J1630,HCPCS,63323-474-00,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,9,ML,,15607,10924.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML INJ SOLN,50863,CDM,250,RC,J2060,HCPCS,0641-6207-01,NDC,facility,both,2,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  10 MG ORAL TR12,50863,CDM,250,RC,J3490,HCPCS,59011-410-20,NDC,facility,both,2,EA,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 2 GRAM INJ SOLR,50863,CDM,250,RC,J0692,HCPCS,44567-241-10,NDC,facility,both,24,EA,,346,242.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  1 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,64380-782-06,NDC,facility,both,104,EA,,128,89.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6369-61,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-662-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN 0.9 % SODIUM CHL 1.5 GRAM/500 ML IV SOLN,50863,CDM,636,RC,J3373,HCPCS,71506-016-59,NDC,facility,both,150,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ABATACEPT 250 MG IV SOLR,50863,CDM,636,RC,J0129,HCPCS,0003-2187-13,NDC,facility,both,75,EA,JA,12110,8477,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
RISPERIDONE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,27241-001-06,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML INJECTION,50863,CDM,636,RC,J3411,HCPCS,43598-050-11,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 50 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,60687-854-11,NDC,facility,both,50,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RANOLAZINE  500 MG ORAL TB12,50863,CDM,250,RC,J3490,HCPCS,60687-549-11,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE   4.2 % IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-083-05,NDC,facility,both,1,ML,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,50863,CDM,250,RC,J9263,HCPCS,71288-101-10,NDC,facility,both,89,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,60687-429-45,NDC,facility,both,5,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,636,RC,J3490,HCPCS,50268-540-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-03,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,6,ML,,10405,7283.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0248-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,42806-150-33,NDC,facility,both,4,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SELENIUM SULFIDE 2.5 % TOPICAL LOTN,50863,CDM,250,RC,J3490,HCPCS,45802-040-64,NDC,facility,both,1,ML,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 17 GRAM (100 %) ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,0904-6931-86,NDC,facility,both,11,EA,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NOREPINEPHRINE BITARTRATE-D5W 4 MG/250 ML (16 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,71285-6056-1,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 100 MG/1 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,0781-3268-05,NDC,facility,both,9,ML,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE (PF) 1 MG/ML INJ SOLN,50863,CDM,636,RC,J0171,HCPCS,54288-103-01,NDC,facility,both,40,ML,,343,240.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3373,HCPCS,0143-9162-01,NDC,facility,both,150,EA,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3370,HCPCS,63323-284-26,NDC,facility,both,6,EA,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-9791-01,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,76,EA,,10488,7341.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-48,NDC,facility,both,2,ML,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-03,NDC,facility,both,3,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE (PF) 1000 MCG/10 ML EPID SOLN,50863,CDM,636,RC,J0735,HCPCS,67457-218-10,NDC,facility,both,1,ML,,224,156.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE(PF)-0.9 % SODCHLOR 0.2 % 745 ML LINF ELPH,50863,CDM,636,RC,J3490,HCPCS,71449-079-57,NDC,facility,both,1,ML,,1315,920.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J2004,HCPCS,0409-3178-01,NDC,facility,both,45,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,250,RC,J3490,HCPCS,63323-485-26,NDC,facility,both,150,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE MALEATE 10 MG ORAL TAB,50863,CDM,250,RC,Q0164,HCPCS,50268-685-11,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6798-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-618-11,NDC,facility,both,1,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 2 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,250,RC,J2270,HCPCS,63323-452-00,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ELTROMBOPAG 25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0078-0685-15,NDC,facility,both,2,EA,,868,607.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,50863,CDM,250,RC,J0696,HCPCS,60505-6149-0,NDC,facility,both,40,EA,,1936,1355.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ (REPACK)(MERGE) (FOR PCA),50863,CDM,250,RC,J3490,HCPCS,0641-6030-01,NDC,facility,both,1,ML,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAPSAICIN 0.025 % TOP CREA,50863,CDM,636,RC,J3490,HCPCS,0536-2525-25,NDC,facility,both,1,GM,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML INJECTION,50863,CDM,636,RC,J3411,HCPCS,67457-196-00,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,55111-150-01,NDC,facility,both,5,EA,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLN,50863,CDM,636,RC,J3262,HCPCS,50242-135-01,NDC,facility,both,160,ML,JZ,2933,2053.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,106,EA,,14628,10239.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCUSATE SODIUM 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7183-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM  50 MG INJ SOLR,50863,CDM,250,RC,J0640,HCPCS,25021-813-10,NDC,facility,both,1,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPRAZOLAM 0.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-388-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7126-61,NDC,facility,both,4,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV,50863,CDM,J7120,HCPCS,0338-0117-04,NDC,,,facility,both,3,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DARATUMUMAB-HYALURONIDASE-FIHJ 1,800 MG-30,000 UNIT/15 ML SUBQ SOLN",50863,CDM,J9144,HCPCS,57894-503-01,NDC,,,facility,both,180,ML,,20905,14633.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 3000 MCG/ML INJECTION,50863,CDM,J0153,HCPCS,25021-318-02,NDC,,,facility,both,6,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG/ML INJ SOLN,50863,CDM,J2550,HCPCS,0641-6084-01,NDC,,,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOCILIZUMAB-AAZG 80 MG/4 ML (20 MG/ML) IV SOLN,50863,CDM,636,RC,Q5135,HCPCS,65219-590-04,NDC,facility,both,160,ML,,2774,1941.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,50863,CDM,250,RC,J0696,HCPCS,0143-9856-01,NDC,facility,both,24,EA,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,43598-053-11,NDC,facility,both,38,ML,,1377,963.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,17,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-339-11,NDC,facility,both,1,EA,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,J7040,HCPCS,0264-1800-36,NDC,,,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,28,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BIVALIRUDIN 250 MG/50 ML (5 MG/ML) IV SOLN,50863,CDM,250,RC,J5083,HCPCS,42023-622-01,NDC,facility,both,250,ML,,365,255.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,55,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,25021-601-03,NDC,facility,both,14,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6374-61,NDC,facility,both,4,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-087-02,NDC,facility,both,10,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6781-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATOVAQUONE 750 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0173-0547-00,NDC,facility,both,2,ML,,338,236.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7111-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUBIPROSTONE  8 MCG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0254-3028-02,NDC,facility,both,1,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE (PF) 25 MG/ML INJ SOLN (FOR ECTOPIC PREGNANCY),50863,CDM,636,RC,J9260,HCPCS,0143-9519-01,NDC,facility,both,2,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE  5 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,64850-510-01,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THROMBIN (RECOMBINANT) 5000 UNIT TOP SOLR,50863,CDM,636,RC,J3490,HCPCS,0338-0324-01,NDC,facility,both,1,EA,,372,260.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROPROCAINE 3 % INJ SOLN,50863,CDM,250,RC,J2401,HCPCS,63323-478-01,NDC,facility,both,360,ML,JW,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ONDANSETRON 4 MG ORAL TBDL,50863,CDM,636,RC,J3490,HCPCS,0378-7732-93,NDC,facility,both,6,EA,,482,337.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60505-0252-2,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FILGRASTIM-SNDZ 300 MCG/0.5 ML INJ SYRG,50863,CDM,250,RC,Q5101,HCPCS,61314-318-05,NDC,facility,both,600,ML,,1943,1360.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM NEO/PEDS INFUSION (CDS MIXTURE),50863,CDM,250,RC,J2543,HCPCS,0206-8852-08,NDC,facility,both,2,EA,,209,146.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,50863,CDM,250,RC,J0696,HCPCS,60505-6148-0,NDC,facility,both,8,EA,JZ,450,315,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DILTIAZEM 90 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0378-0135-05,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-346-11,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIFEDIPINE 30 MG ORAL TO24,50863,CDM,636,RC,J3490,HCPCS,68084-597-11,NDC,facility,both,3,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-208-01,NDC,facility,both,4,EA,PLAD,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
AMANTADINE 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7042-61,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 0.4 MG SL SUBL,50863,CDM,636,RC,J3490,HCPCS,59762-3304-3,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 20 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,68180-294-07,NDC,facility,both,1,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2599,HCPCS,43598-914-25,NDC,facility,both,3,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,636,RC,J7060,HCPCS,0338-0017-03,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RASBURICASE 1.5 MG IV SOLR,50863,CDM,250,RC,J2783,HCPCS,0024-5154-11,NDC,facility,both,4,EA,,3455,2418.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,44567-600-04,NDC,facility,both,1,ML,,101,70.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7050,HCPCS,0264-7800-20,NDC,facility,both,1,ML,JZ,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
TOBRAMYCIN 1.2 G POWDER VIAL,50863,CDM,250,RC,J3260,HCPCS,39822-0412-6,NDC,facility,both,120,EA,,3180,2226,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,636,RC,J7060,HCPCS,0338-0017-48,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 0.1 MG/ML INJ SYRG,50863,CDM,636,RC,J0461,HCPCS,16729-484-03,NDC,facility,both,400,ML,JZ,245,171.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,636,RC,J1953,HCPCS,63323-400-01,NDC,facility,both,50,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-406-03,NDC,facility,both,1,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE DINITRATE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-367-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLMESARTAN 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0527-2427-46,NDC,facility,both,1,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENAZOPYRIDINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65162-681-10,NDC,facility,both,2,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  5 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,55111-262-79,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNIT/G TOP OINT (MERGE),50863,CDM,636,RC,J3490,HCPCS,0472-1105-56,NDC,facility,both,1,GM,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE (FOR EMERGENCY) 100 MG/ML (10%) IV SOLN,50863,CDM,636,RC,J0612,HCPCS,75834-171-01,NDC,facility,both,100,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRBESARTAN 300 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-442-11,NDC,facility,both,1,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THEOPHYLLINE 100 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,52244-100-10,NDC,facility,both,1,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 75 MG/5 ML ORAL SOLUTION,50863,CDM,636,RC,J3490,HCPCS,16714-483-02,NDC,facility,both,10,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE   4.2 % IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-5555-12,NDC,facility,both,3,ML,,155,108.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 10 % (100 MG/ML) MISC SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-695-22,NDC,facility,both,1,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPLERENONE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,42291-454-30,NDC,facility,both,2,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 10 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-5784-61,NDC,facility,both,3,EA,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-ABDA 100 MG IV SOLR,50863,CDM,636,RC,Q5104,HCPCS,78206-162-99,NDC,facility,both,37,EA,,7694,5385.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,66794-229-02,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-35,NDC,facility,both,100,ML,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"NEOMYCIN-POLYMYXIN-HC 3.5 MG-10,000 UNIT/ML-1 % EAR SOLN",50863,CDM,250,RC,J3490,HCPCS,24208-631-10,NDC,facility,both,1,ML,,363,254.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOPAMINE INFUSION NEO IV SYRINGE (FROM PREMIX),50863,CDM,250,RC,J1265,HCPCS,0409-7809-11,NDC,facility,both,10,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIFAMPIN 600 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,63323-351-20,NDC,facility,both,1,EA,,331,231.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIROFIBAN-0.9% SODIUM CHLORIDE 5 MG/100 ML (50 MCG/ML) IV SOLN,50863,CDM,250,RC,J3246,HCPCS,55150-429-01,NDC,facility,both,20,ML,JZ,378,264.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,250,RC,J0137,HCPCS,0781-3156-06,NDC,facility,both,100,ML,,218,152.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM SR 300 MG 24 HR CAP,50863,CDM,636,RC,J3490,HCPCS,50742-251-90,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENAZOPYRIDINE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,65162-681-10,NDC,facility,both,2,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN STERILE WATER 2 GRAM/20 ML IV SYRG,50863,CDM,636,RC,J7999,HCPCS,70092-1604-47,NDC,facility,both,4,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOBENZAPRINE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,43547-400-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHIMAZOLE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-669-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 500 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,0904-6861-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 200 MG/20 ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,72205-220-01,NDC,facility,both,1,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,68094-231-59,NDC,facility,both,4,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN   81 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,0904-6783-70,NDC,facility,both,3,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,636,RC,J3490,HCPCS,62037-560-01,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 0.8 GRAM ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,0115-1365-30,NDC,facility,both,4,EA,,327,228.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,42806-150-33,NDC,facility,both,4,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0338-1055-48,NDC,facility,both,69,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAUNORUBICIN 5 MG/ML IV INJ,50863,CDM,636,RC,J9150,HCPCS,42658-021-01,NDC,facility,both,5,ML,,1203,842.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC MCARE ADMIN HEPATITIS B VACC,50863,CDM,636,RC,90746,HCPCS,58160-821-01,NDC,facility,both,1,ML,,353,247.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,70436-030-82,NDC,facility,both,82,ML,JW,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DOXORUBICIN 2 MG/ML IV SOLN,50863,CDM,250,RC,J9000,HCPCS,25021-207-51,NDC,facility,both,6,ML,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,76329-3352-1,NDC,facility,both,1,ML,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-620-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,69315-905-05,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0121-0945-10,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE (FOR CODE) 10% IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0517-6710-01,NDC,facility,both,3,ML,,118632,83042.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-3178-16,NDC,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,636,RC,J3490,HCPCS,0641-6236-01,NDC,facility,both,2,ML,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 75 MG/5 ML ORAL SOLUTION,50863,CDM,250,RC,J3490,HCPCS,64980-511-10,NDC,facility,both,12,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,250,RC,J3360,HCPCS,43598-106-11,NDC,facility,both,4,ML,,289,202.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSULFAN BLUE 1 % INJ SOLN,50863,CDM,636,RC,Q9968,HCPCS,67457-220-00,NDC,facility,both,30,ML,JW,875,612.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PREDNISONE 50 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,59651-489-01,NDC,facility,both,50,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RALTEGRAVIR 400 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0006-0227-61,NDC,facility,both,1,EA,,204,142.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,250,RC,J2405,HCPCS,23155-549-31,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUPHENAZINE DECANOATE 25 MG/ML INJ SOLN,50863,CDM,250,RC,J2680,HCPCS,67457-359-59,NDC,facility,both,2,ML,,201,140.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL IV BOLUS 10MG/ML (ANESTHESIA ONLY),50863,CDM,636,RC,J2704,HCPCS,0409-4699-54,NDC,facility,both,81,ML,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIGOXIN 125 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-5921-61,NDC,facility,both,4,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-179-11,NDC,facility,both,2,EA,,221,154.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,23155-600-31,NDC,facility,both,52,ML,,152,106.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,51079-051-01,NDC,facility,both,1,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMANTADINE 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,62332-246-31,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML INJ SOLN,50863,CDM,636,RC,J0169,HCPCS,76329-9060-0,NDC,facility,both,300,ML,,797,557.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 15% IN WATER,50863,CDM,250,RC,J3490,HCPCS,0338-0023-03,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-464-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-620-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATRACURIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-1105-22,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESALAMINE 400 MG ORAL CAPSULE-WITH DR TABLETS (CDTI),50863,CDM,250,RC,J3490,HCPCS,60687-556-33,NDC,facility,both,1,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 5 MG/5 ML IV,50863,CDM,J3490,HCPCS,36000-033-10,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADVATE: FACTOR VIII CONCENTRATE (MERGE RECORD),50863,CDM,636,RC,J7209,HCPCS,0944-3053-02,NDC,facility,both,3500,UN,,14651,10255.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 1 MG ORAL TBDL,50863,CDM,250,RC,0093-9293-19,NDC,,,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,636,RC,J1953,HCPCS,55150-177-05,NDC,facility,both,300,ML,,441,308.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,J1953,HCPCS,55150-177-05,NDC,,,facility,both,200,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM IN NACL (ISO-OS) 500 MG/100 ML IV PGBK,50863,CDM,J1953,HCPCS,0264-5009-90,NDC,,,facility,both,100,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),50863,CDM,636,RC,J0171,HCPCS,76329-3318-1,NDC,facility,both,140,ML,,1027,718.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 2 %-1:200,000 INJ SOLN",50863,CDM,J2004,HCPCS,0409-3183-11,NDC,,,facility,both,340,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,J3490,HCPCS,63037-136-25,NDC,,,facility,both,2,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLN (MERGE)",50863,CDM,250,RC,P9047,HCPCS,64208-2512-7,NDC,facility,both,1,ML,,119,83.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN IN SALINE (ISO-OSMOTIC) 100 MG/50 ML IV PIGGY BACK,50863,CDM,636,RC,J1580,HCPCS,0338-0511-41,NDC,facility,both,2,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J1230,HCPCS,67457-217-20,NDC,facility,both,1,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,636,RC,J1815,HCPCS,0088-2220-33,NDC,facility,both,1,ML,GZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier GZ: Item or service expected to be denied as not reasonable and necessary
VERAPAMIL 2.5 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,70710-1643-1,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,J3490,HCPCS,0409-4887-20,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,636,RC,J2270,HCPCS,0409-1890-03,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEMANTINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6506-61,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 125 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,60687-211-11,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 10 MEQ/100 ML IV PGBK,50863,CDM,636,RC,J3480,HCPCS,0990-7074-26,NDC,facility,both,10,ML,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BICARB FOR OR,50863,CDM,250,RC,J3490,HCPCS,99999-0402-85,NDC,facility,both,1,ML,,175,122.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % MBP,50863,CDM,J3490,HCPCS,0338-0553-18,NDC,,,facility,both,1,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLP",50863,CDM,250,RC,P9047,HCPCS,0944-0493-04,NDC,facility,both,16,ML,,4001,2800.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,636,RC,J3010,HCPCS,0409-9093-32,NDC,facility,both,2,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IV PGBK,50863,CDM,250,RC,J3490,HCPCS,0409-4121-01,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,63739-434-02,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 1 MG/1 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,68094-031-59,NDC,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  75 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7000-61,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 400 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-602-11,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-208-01,NDC,facility,both,4,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM  3.375 GRAM IV SOLR,50863,CDM,250,RC,J2543,HCPCS,60505-6157-0,NDC,facility,both,3,EA,JZ,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2308-01,NDC,facility,both,125,ML,,193,135.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0143-9509-01,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2310,HCPCS,0409-1215-21,NDC,facility,both,2,ML,,279,195.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,636,RC,J1100,HCPCS,25021-053-01,NDC,facility,both,4,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
TARLATAMAB-DLLE 10 MG IV SOLR,50863,CDM,250,RC,J9026,HCPCS,55513-069-01,NDC,facility,both,10,EA,,41400,28980,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 150 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-432-11,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,636,RC,J3490,HCPCS,0641-6147-01,NDC,facility,both,2,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-134-11,NDC,facility,both,10,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,250,RC,J0132,HCPCS,25021-812-30,NDC,facility,both,160,ML,,1152,806.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYTOCIN IN 0.9 % SOD CHLORIDE 30 UNIT/500 ML IV SOLN,50863,CDM,250,RC,J2590,HCPCS,71266-5100-1,NDC,facility,both,2,ML,,108,75.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0003-0894-21,NDC,facility,both,1,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,83257-011-11,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,63323-185-50,NDC,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,250,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,11,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-4264-11,NDC,facility,both,7,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IV PGBK,50863,CDM,636,RC,J3475,HCPCS,0338-1715-40,NDC,facility,both,8,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAFASITAMAB-CXIX 200 MG IV SOLR,50863,CDM,250,RC,J9349,HCPCS,73535-208-01,NDC,facility,both,400,EA,,13248,9273.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6638-61,NDC,facility,both,4,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 40 MG/4 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,68094-756-59,NDC,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID (PORK)  60 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,42192-330-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25 MG-100 MG TAB,50863,CDM,636,RC,J3490,HCPCS,60687-661-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 0.4 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,58151-310-94,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLMESARTAN 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65597-104-90,NDC,facility,both,1,EA,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,23155-600-31,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 1 GRAM/10 ML (10 %) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-13,NDC,facility,both,6,ML,,1329,930.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATED 20 MG/ML IV SOLN,50863,CDM,250,RC,J0706,HCPCS,51754-0500-1,NDC,facility,both,4,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69238-1490-1,NDC,facility,both,3,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 10 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6987-61,NDC,facility,both,4,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLP",50863,CDM,636,RC,P9047,HCPCS,0944-0493-04,NDC,facility,both,2,ML,,501,350.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 160 MG-800 MG TAB,50863,CDM,636,RC,J3490,HCPCS,68084-230-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,1013565201,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DACTINOMYCIN 0.5 MG IV SOLR,50863,CDM,250,RC,J9120,HCPCS,71288-129-02,NDC,facility,both,2,EA,,2335,1634.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZTREONAM 2 GRAM INJ SOLR,50863,CDM,636,RC,J0457,HCPCS,63323-402-01,NDC,facility,both,10,EA,,146,102.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,7,ML,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,250,RC,J0690,HCPCS,44567-707-25,NDC,facility,both,8,EA,JZ,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-38,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  1 MG ORAL TAB,50863,CDM,J7512,HCPCS,64380-782-06,NDC,,,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SITAGLIPTIN  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0006-0221-01,NDC,facility,both,2,EA,,225,157.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAUNORUBICIN 5 MG/ML IV INJ,50863,CDM,250,RC,J9150,HCPCS,42658-021-01,NDC,facility,both,4,ML,,1159,811.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BETAMETHASONE ACET & SOD PHOS 6 MG/ML INJ SUSP,50863,CDM,636,RC,J0702,HCPCS,78206-118-01,NDC,facility,both,5,ML,,223,156.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 10 % (100 MG/ML) MISC SOLN,50863,CDM,J3490,HCPCS,63323-695-04,NDC,,,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 50 MG/5 ML (10 MG/ML) IV SYRG,50863,CDM,250,RC,J3490,HCPCS,71266-2002-1,NDC,facility,both,2,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,636,RC,J0690,HCPCS,70092-1017-46,NDC,facility,both,2,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LURASIDONE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7355-04,NDC,facility,both,5,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SITAGLIPTIN 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0006-0277-31,NDC,facility,both,1,EA,,113,79.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-02,NDC,facility,both,1,ML,"JZ,GA",30,21,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier GA: Waiver of liability statement issued as required by payer policy, individual case"
THIAMINE 100 MG/ML INJECTION,50863,CDM,636,RC,J3411,HCPCS,72485-507-01,NDC,facility,both,2,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEPLIZUMAB-MZWV 2 MG/20 ML IV SOLN,50863,CDM,636,RC,J9381,HCPCS,73650-316-01,NDC,facility,both,72,ME,JW,1893,1325.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
OXYMETAZOLINE 0.05 % NASAL MERGE,50863,CDM,250,RC,J3490,HCPCS,70677-1037-1,NDC,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM IN NACL (ISO-OS) 500 MG/100 ML IV PGBK,50863,CDM,250,RC,J1953,HCPCS,67457-255-00,NDC,facility,both,200,ML,,329,230.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,71288-505-02,NDC,facility,both,2,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV,50863,CDM,636,RC,J7120,HCPCS,0338-0117-03,NDC,facility,both,1,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE 110 MCG/ACTUATION INHL AERO,50863,CDM,250,RC,J3490,HCPCS,66993-079-96,NDC,facility,both,1,GM,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  100 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,0641-6175-01,NDC,facility,both,2,ML,JA,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
CAPTOPRIL  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7106-61,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BISMUTH SUBSALICYLATE 262 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,0904-7205-46,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 10% IN WATER (NEO) 2 - 3.99 KG,50863,CDM,250,RC,J3490,HCPCS,0338-0023-04,NDC,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE (CONTRACEPTIVE) 150 MG/ML IM SUSP,50863,CDM,250,RC,J1050,HCPCS,70121-1467-2,NDC,facility,both,150,ML,,415,290.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BISOPROLOL FUMARATE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-679-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID (PORK)  30 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42192-329-01,NDC,facility,both,3,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,0641-6008-10,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAZOLAMIDE 125 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,23155-287-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,51754-5011-1,NDC,facility,both,3,ML,,162,113.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VECURONIUM BROMIDE 10 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,0409-1632-21,NDC,facility,both,1,EA,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,50863,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,13,ML,,339,237.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 200 MG/100 ML IVPB (MERGE),50863,CDM,J1450,HCPCS,25021-184-82,NDC,,,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIKACIN 1000 MG/4 ML INJ SOLN,50863,CDM,636,RC,J0278,HCPCS,23155-290-32,NDC,facility,both,10,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADVATE: FACTOR VIII CONCENTRATE (MERGE RECORD),50863,CDM,250,RC,J7192,HCPCS,0944-3045-10,NDC,facility,both,2000,UN,,8372,5860.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 60 MG ORAL CPDR,50863,CDM,636,RC,J3490,HCPCS,27241-099-03,NDC,facility,both,2,EA,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOCARNITINE (WITH SUCROSE) 100 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,64980-503-12,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR IN 0.9% NACL 100 UNIT/100 ML (1 UNIT/ML) INFUSION FOR OB,50863,CDM,636,RC,J1815,HCPCS,0338-0126-12,NDC,facility,both,1,ML,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,250,RC,J3490,HCPCS,81284-611-00,NDC,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-25,NDC,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,23155-723-01,NDC,facility,both,4,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-074-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 300 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7263-61,NDC,facility,both,3,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE IN 0.9% NACL 3 GRAM/100 ML IV SOLN,50863,CDM,250,RC,J0612,HCPCS,61553-056-48,NDC,facility,both,100,ML,JW,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,636,RC,J1953,HCPCS,63323-400-01,NDC,facility,both,150,ML,JZ,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),50863,CDM,250,RC,J1170,HCPCS,0409-4264-11,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-22,NDC,facility,both,10,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J1940,HCPCS,72603-251-01,NDC,facility,both,40,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,64208-2510-1,NDC,facility,both,1,ML,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK,50863,CDM,636,RC,J3490,HCPCS,12870-0001-2,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC IV INFUSION HYDRAT 31-60 MIN,50863,CDM,250,RC,J0248,HCPCS,61958-2901-2,NDC,facility,both,100,EA,,1196,837.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATENOLOL  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-759-20,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0536-1327-10,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  20 MEQ ORAL PACK,50863,CDM,636,RC,J3490,HCPCS,72888-024-06,NDC,facility,both,1,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,636,RC,J7060,HCPCS,0338-0017-31,NDC,facility,both,1,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,70095-031-01,NDC,facility,both,25,ML,,991,693.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 10 MG TAB,50863,CDM,250,RC,Q0177,HCPCS,16714-081-10,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,16714-046-01,NDC,facility,both,10,ML,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,J3490,HCPCS,63323-185-07,NDC,,,facility,both,4,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,50863,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,112,ML,,136,95.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 10 GRAM/15 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,50383-779-30,NDC,facility,both,2,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 17 GRAM (100 %) ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,0904-6931-86,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLU VACCINE TS 2025-26 65 YR UP (PF) 180 MCG/0.5 ML IM SYRG,50863,CDM,250,RC,90662,HCPCS,49281-125-88,NDC,facility,both,1,ML,,403,282.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-41,NDC,facility,both,160,ML,"JZ,JA",22631,15841.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
CEFEPIME 2 GRAM INJ SOLR,50863,CDM,250,RC,J0692,HCPCS,60505-6147-0,NDC,facility,both,4,EA,,198,138.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 200 MCG INJ SOLR,50863,CDM,636,RC,J3490,HCPCS,63323-647-10,NDC,facility,both,1,EA,,746,522.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  1 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,59746-171-06,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PALONOSETRON 0.25 MG/5 ML IV INJECTION (MERGE),50863,CDM,250,RC,J2469,HCPCS,60505-6193-1,NDC,facility,both,10,ML,,605,423.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 3 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7364-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-580-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 30 MG/0.3 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0075-0624-01,NDC,facility,both,3,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZOCAINE-MENTHOL 20 %-0.5 % TOPICAL AEROSOL,50863,CDM,250,RC,J3490,HCPCS,16864-680-03,NDC,facility,both,2,GM,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALVIMOPAN 12 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0591-2312-45,NDC,facility,both,1,EA,,711,497.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALBUPHINE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J2300,HCPCS,0409-1463-71,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 250 MG INJ SOLR,50863,CDM,636,RC,J0696,HCPCS,0781-3206-85,NDC,facility,both,1,EA,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESNA 100 MG/ML IV SOLN,50863,CDM,250,RC,J9209,HCPCS,0338-1305-01,NDC,facility,both,2,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN PEDS SYRINGE (20MG/ML) IN DEXTROSE (CDS MIX,50863,CDM,250,RC,J0690,HCPCS,0781-3451-70,NDC,facility,both,1,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML INJECTION,50863,CDM,250,RC,J3411,HCPCS,67457-196-00,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 20 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7346-61,NDC,facility,both,2,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 1 MG ORAL CAP,50863,CDM,250,RC,J7507,HCPCS,0904-7097-61,NDC,facility,both,3,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,59762-0075-1,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV,50863,CDM,636,RC,J7120,HCPCS,0338-0117-04,NDC,facility,both,9,ML,,300,210,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPRAZOLAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,59762-3720-1,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM HYPOCHLORITE 0.25 % MISC SOLN,50863,CDM,250,RC,J3490,HCPCS,0436-0936-16,NDC,facility,both,3,ML,,202,141.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-191-11,NDC,facility,both,2,EA,,263,184.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-208-01,NDC,facility,both,200,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,0338-0069-10,NDC,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,72266-118-01,NDC,facility,both,1,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LEVETIRACETAM NEO IV SYRINGE (PHS FROM PREMIX),50863,CDM,250,RC,J1953,HCPCS,44567-501-01,NDC,facility,both,15,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"NEOMYCIN-POLYMYXIN-HC 3.5 MG-10,000 UNIT/ML-1 % EAR DROPS, SUSP",50863,CDM,J3490,HCPCS,24208-635-62,NDC,,,facility,both,1,ML,,363,254.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COVID VACCINE 24-25 (6M-11Y)(MOD)PF 25 MCG/0.25 ML IM SYRG,50863,CDM,91321,HCPCS,80777-291-80,NDC,,,facility,both,1,ML,,558,390.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,636,RC,J1596,HCPCS,10019-016-39,NDC,facility,both,10,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,636,RC,J3490,HCPCS,70092-9119-44,NDC,facility,both,3,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOMIPRAMINE 75 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,16714-851-03,NDC,facility,both,2,EA,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NS WITH POTASSIUM CHLORIDE 20 MEQ/L IV SOLP,50863,CDM,J3480,HCPCS,0338-0691-04,NDC,,,facility,both,10,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,J3490,HCPCS,68180-441-02,NDC,,,facility,both,7,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 500 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,68084-415-11,NDC,facility,both,12,EA,,225,157.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,50863,CDM,J1650,HCPCS,16714-036-01,NDC,,,facility,both,7,ML,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,J3490,HCPCS,66553-002-01,NDC,,,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB-QYYP 420 MG IV SOLR,50863,CDM,Q5116,HCPCS,0069-0306-01,NDC,,,facility,both,37,ME,,8246,5772.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM,50863,CDM,250,RC,J3490,HCPCS,45802-358-03,NDC,facility,both,1,GM,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML IV (MERGE) (FOR VENT),50863,CDM,250,RC,J3010,HCPCS,70092-1509-35,NDC,facility,both,25,ML,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON DEXTRAN 50 MG/ML INJ SOLN,50863,CDM,250,RC,J1750,HCPCS,0023-6082-01,NDC,facility,both,10,ML,,1094,765.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GAMMAGARD LIQUID 10 % IV SOLN,50863,CDM,J1569,HCPCS,0944-2700-07,NDC,,,facility,both,60,ML,,10817,7571.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE  5 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,70010-029-01,NDC,facility,both,3,EA,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42291-809-15,NDC,facility,both,2,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-450-11,NDC,facility,both,3,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,14789-128-07,NDC,facility,both,1,ML,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,67877-590-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYLAMINE SUCCINATE 25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,4116700609,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25 MG-100 MG TAB,50863,CDM,250,RC,J3490,HCPCS,69367-339-05,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 300 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6642-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 160 MG-800 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0904-2725-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 160 MG-800 MG TAB,50863,CDM,636,RC,J3490,HCPCS,60687-614-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,70710-1833-1,NDC,facility,both,1,EA,,409,286.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE IN D5W 1 GRAM/100 ML IV PGBK,50863,CDM,636,RC,J3475,HCPCS,0338-1709-40,NDC,facility,both,2,ML,JZ,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DACARBAZINE 200 MG IV SOLR,50863,CDM,250,RC,J9130,HCPCS,0143-9245-01,NDC,facility,both,3,EA,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-11,NDC,facility,both,5,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-723-11,NDC,facility,both,1,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-544-10,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J3430,HCPCS,69097-708-31,NDC,facility,both,9,ML,JW,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
MORPHINE (PF-DURAMORPH/ASTRAMORPH) 0.5 MG/ML INJ SOLN,50863,CDM,250,RC,J2274,HCPCS,0409-3814-11,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAZOSIN 1 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7020-61,NDC,facility,both,16,EA,,127,88.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,68094-231-59,NDC,facility,both,1,ML,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-744-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FERRIC CARBOXYMALTOSE (INJECTAFER) 50 MG IRON/ML IV SOLN,50863,CDM,636,RC,J1439,HCPCS,0517-0650-01,NDC,facility,both,750,ML,,4234,2963.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN DEXTROSE (ISO-OSMOTIC) 1 GRAM/50 ML IV PIGGY BACK,50863,CDM,250,RC,J0689,HCPCS,0338-3503-41,NDC,facility,both,2,ML,JZ,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PREDNISONE 10 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0904-6923-61,NDC,facility,both,57,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2310,HCPCS,55150-328-01,NDC,facility,both,2,ML,,270,189,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,50863,CDM,636,RC,J3301,HCPCS,16714-130-01,NDC,facility,both,3,ML,JW,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J2003,HCPCS,0409-4713-32,NDC,facility,both,100,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROTHIAZIDE SODIUM 500 MG IV SOLR,50863,CDM,250,RC,J1205,HCPCS,25021-305-20,NDC,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT  60 MCG/0.3 ML INJ SYRG,50863,CDM,636,RC,J0881,HCPCS,55513-023-04,NDC,facility,both,60,ML,"JZ,EC,PLAD",1282,897.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier EC: Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy | Modifier PLAD: Modifier description not available
CALCIUM GLUCONATE (FOR EMERGENCY) 100 MG/ML (10%) IV SOLN,50863,CDM,250,RC,J0612,HCPCS,63323-360-19,NDC,facility,both,300,ML,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOPERAMIDE 1 MG/7.5 ML ORAL LIQD,50863,CDM,250,RC,J3490,HCPCS,70677-1107-1,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE NA (PRESERV FREE) 25 MG/ML INJ SOLN,50863,CDM,250,RC,J9260,HCPCS,0703-3678-01,NDC,facility,both,112,ML,,1087,760.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6374-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-3243-01,NDC,facility,both,6,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J3490,HCPCS,63323-482-03,NDC,,,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG ORAL CAP,50863,CDM,J3490,HCPCS,60687-776-11,NDC,,,facility,both,2,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 50 MG/ML INJECTION,50863,CDM,J1200,HCPCS,0641-0376-21,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIBOFLAVIN 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,7431200640,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 10 GRAM/100 ML (10%) INJ SOLN",50863,CDM,J1561,HCPCS,13533-800-72,NDC,,,facility,both,100,ML,,14144,9900.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,J2371,HCPCS,0641-6188-01,NDC,,,facility,both,2000,ML,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,0409-4279-16,NDC,,,facility,both,30,ML,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHOTERICIN B LIPOSOME 50 MG IV SUSR,50863,CDM,250,RC,J0289,HCPCS,0469-3051-30,NDC,facility,both,5,EA,,1095,766.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,J1885,HCPCS,25021-701-01,NDC,,,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-495-27,NDC,,,facility,both,320,ML,,156,109.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 120 MG/0.8 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0955-1012-01,NDC,facility,both,12,ML,,151,105.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,636,RC,J1596,HCPCS,0143-9679-01,NDC,facility,both,10,ML,,228,159.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-657-11,NDC,facility,both,3,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MOXIFLOXACIN 400 MG/250 ML IVPB PREMIX (MERGE),50863,CDM,250,RC,J2280,HCPCS,63323-850-74,NDC,facility,both,4,ML,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARDIOPLEGIC SOLUTION NO.25 29 MMOL/L (POTASSIUM) PERF SOLN,50863,CDM,J3490,HCPCS,69374-984-10,NDC,,,facility,both,2,ML,,1008,705.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 500 MG-125 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0781-1831-01,NDC,facility,both,1,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-0007-01,NDC,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE  2.5 % RECT CREA,50863,CDM,636,RC,J3490,HCPCS,69315-312-28,NDC,facility,both,1,GM,,357,249.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"CARDIOPLEGIC SOLUTION NO.16 26 MEQ/1,052.8 ML (POTASSIUM) PERF SOLN",50863,CDM,250,RC,J3490,HCPCS,71285-0202-1,NDC,facility,both,1,ML,,268,187.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,63323-104-25,NDC,facility,both,19,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPOETIN ALFA  4000 UNIT/ML INJ SOLN,50863,CDM,636,RC,Q4081,HCPCS,59676-304-00,NDC,facility,both,80,ML,"JZ,EC",924,646.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier EC: Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy
HYDRALAZINE 20 MG/ML INJ SOLN,50863,CDM,250,RC,J0360,HCPCS,55150-400-01,NDC,facility,both,2,ML,,127,88.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IMATINIB 100 MG ORAL TAB,50863,CDM,250,RC,J9999,HCPCS,0093-7629-98,NDC,facility,both,3,EA,,895,626.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALTREXONE 50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7036-04,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/0.5 ML INHL NEBU,50863,CDM,250,RC,J3490,HCPCS,0487-9901-02,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % MBP,50863,CDM,250,RC,J3490,HCPCS,0338-0553-18,NDC,facility,both,1,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),50863,CDM,250,RC,J0171,HCPCS,76329-3318-1,NDC,facility,both,21,ML,,1694,1185.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-208-01,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE  5 MG ORAL CP24,50863,CDM,636,RC,J3490,HCPCS,31722-185-01,NDC,facility,both,4,EA,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALTREXONE 50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0406-1170-03,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG ORAL CAP,50863,CDM,J3490,HCPCS,16714-298-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM SR 90 MG 12 HR CAP,50863,CDM,J3490,HCPCS,51079-925-01,NDC,,,facility,both,1,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,50863,CDM,J2250,HCPCS,0409-2305-16,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 40 MG ORAL TAB,50863,CDM,J3490,HCPCS,51079-210-01,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,250,RC,J3490,HCPCS,71449-069-11,NDC,facility,both,3,ML,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  20 MEQ ORAL PACK,50863,CDM,J3490,HCPCS,72888-024-06,NDC,,,facility,both,2,EA,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISATRACURIUM  2 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0074-4380-10,NDC,facility,both,3,ML,,404,282.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,636,RC,J3490,HCPCS,63323-485-27,NDC,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  30 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,0406-8330-62,NDC,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IV PGBK,50863,CDM,250,RC,J3490,HCPCS,0264-4204-52,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR  6 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,68180-678-01,NDC,facility,both,13,ML,,167,116.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,2,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2305-04,NDC,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),50863,CDM,250,RC,J0169,HCPCS,76329-3318-1,NDC,facility,both,100,ML,,807,564.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),50863,CDM,250,RC,J0171,HCPCS,76329-3318-1,NDC,facility,both,90,ML,,661,462.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0054-8297-25,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM  50 MG INJ SOLR,50863,CDM,250,RC,J0640,HCPCS,0143-9555-01,NDC,facility,both,1,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 1 GRAM INJ SOLR,50863,CDM,250,RC,J0692,HCPCS,0409-9566-01,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,0409-1886-22,NDC,facility,both,35,ML,JW,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,50863,CDM,250,RC,J9075,HCPCS,10019-956-16,NDC,facility,both,81,EA,JW,231,161.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DAPTOMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0878,HCPCS,0409-0122-01,NDC,facility,both,800,EA,,644,450.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOZAPINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0378-0860-01,NDC,facility,both,2,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,65162-897-09,NDC,facility,both,1,EA,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLMESARTAN 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,33342-180-10,NDC,facility,both,1,EA,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL  20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-717-11,NDC,facility,both,1,EA,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 50 MG/ML IV SOLN,50863,CDM,250,RC,J0282,HCPCS,63323-616-09,NDC,facility,both,15,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) NEB SOLUTION,50863,CDM,250,RC,J3490,HCPCS,60687-395-79,NDC,facility,both,2,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUVOXAMINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60505-0166-1,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,50863,CDM,636,RC,J1756,HCPCS,0517-2325-01,NDC,facility,both,10,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
URSODIOL 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-100-11,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL (5 MG/ML) IV SYRG (CONTAINS PRESERVATIVE),50863,CDM,250,RC,J3490,HCPCS,70092-1009-44,NDC,facility,both,2,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2305-04,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,42806-341-01,NDC,facility,both,2,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 500 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,65862-595-01,NDC,facility,both,3,EA,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J2250,HCPCS,0409-2305-17,NDC,facility,both,6,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMINOCAPROIC ACID  500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,72205-049-30,NDC,facility,both,7,EA,,565,395.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-590-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,636,RC,J1610,HCPCS,63323-596-11,NDC,facility,both,1,EA,,895,626.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOTRIMAZOLE 1 % VAGL CREA,50863,CDM,636,RC,J3490,HCPCS,61269-220-63,NDC,facility,both,1,GM,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-3178-01,NDC,facility,both,7,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROMETHORPHAN-GUAIFENESIN SR 30 MG-600 MG 12 HR TAB,50863,CDM,250,RC,J3490,HCPCS,17856-0056-1,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,43598-931-11,NDC,facility,both,3,ML,JW,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
AMPICILLIN 1 GRAM SOLUTION FOR INJECTION,50863,CDM,250,RC,J0290,HCPCS,0409-3726-10,NDC,facility,both,2,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  25 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-473-11,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SINCALIDE 5 MCG INJ SOLR,50863,CDM,636,RC,J2805,HCPCS,72266-248-05,NDC,facility,both,1,EA,,178,124.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MISOPROSTOL 800 MCG (4 X 200 MCG TAB) PACKAGE,50863,CDM,636,RC,S0191,HCPCS,43386-161-06,NDC,facility,both,2,EA,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,522,ML,,749,524.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0781-3246-02,NDC,facility,both,10,ML,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG ORAL TB12,50863,CDM,250,RC,J3490,HCPCS,16571-681-01,NDC,facility,both,2,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPRAZOLAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,59762-3720-1,NDC,facility,both,5,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM-ALBUTEROL 0.5 MG-2.5 MG/3 ML NEB SOLUTION,50863,CDM,250,RC,J3490,HCPCS,0487-0201-01,NDC,facility,both,25,ML,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL (VITAMIN D3)   400 UNIT ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,5026886311,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPTOMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0878,HCPCS,72603-152-01,NDC,facility,both,350,EA,,1024,716.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-8297-25,NDC,facility,both,4,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE (POLACRILEX) 2 MG MM LOZG,50863,CDM,250,RC,J3490,HCPCS,45802-344-05,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,636,RC,J7999,HCPCS,70092-1017-46,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,0944-0495-06,NDC,facility,both,4,ML,,832,582.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 30 MG/0.3 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0955-1003-01,NDC,facility,both,6,ML,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,59,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,83980-007-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,636,RC,J3490,HCPCS,0904-7509-30,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 7.5 MG-325 MG/15 ML ORAL SOLN (REPACK),50863,CDM,636,RC,J3490,HCPCS,64950-373-16,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM BICARB-CITRIC ACID 20 MEQ ORAL TBEF,50863,CDM,636,RC,J3490,HCPCS,51801-011-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESVENLAFAXINE  50 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,60687-607-11,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,636,RC,J3490,HCPCS,70004-600-09,NDC,facility,both,1,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",50863,CDM,250,RC,J1561,HCPCS,13533-800-25,NDC,facility,both,80,ML,JA,11316,7921.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1162-18,NDC,facility,both,200,ML,JZ,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,16714-016-01,NDC,facility,both,4,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IR SOLN,50863,CDM,250,RC,J3490,HCPCS,0338-0047-46,NDC,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 125 MG ORAL CPSP,50863,CDM,250,RC,J3490,HCPCS,0904-6615-61,NDC,facility,both,3,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORTHALIDONE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65162-247-09,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,55150-222-20,NDC,facility,both,1,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 500 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7337-35,NDC,facility,both,14,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,210,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-18,NDC,facility,both,60,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,16714-016-01,NDC,facility,both,4,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,55150-370-01,NDC,facility,both,14,ML,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J3490,HCPCS,0264-1800-36,NDC,facility,both,9,ML,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,428,ML,,614,429.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-1749-70,NDC,facility,both,4,ML,,182,127.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-405-11,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BEVACIZUMAB 25 MG/ML IV SOLN,50863,CDM,250,RC,J9035,HCPCS,50242-060-01,NDC,facility,both,1,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-9543-02,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,J3490,HCPCS,0121-4675-05,NDC,,,facility,both,2,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MYCOPHENOLATE 250 MG CAP,50863,CDM,636,RC,J7517,HCPCS,68084-795-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),50863,CDM,250,RC,J3490,HCPCS,63323-186-01,NDC,facility,both,4,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,636,RC,J3490,HCPCS,81284-611-00,NDC,facility,both,3,ML,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRP (MERGE/REPACK),50863,CDM,636,RC,J3490,HCPCS,68094-764-59,NDC,facility,both,2,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,636,RC,J3490,HCPCS,50742-615-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,50863,CDM,250,RC,J0696,HCPCS,44567-701-25,NDC,facility,both,4,EA,JZ,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-1283-17,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,76045-009-10,NDC,facility,both,7,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,3,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  88 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-486-11,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-ABDA 100 MG IV SOLR,50863,CDM,636,RC,Q5104,HCPCS,78206-162-99,NDC,facility,both,58,EA,,12061,8442.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) MISC SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-694-41,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE (FOR EMERGENCY) 100 MG/ML (10%) IV SOLN,50863,CDM,636,RC,J0612,HCPCS,63323-360-19,NDC,facility,both,200,ML,JZ,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,3,EA,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,500,ML,,4512,3158.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETIRIZINE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-597-01,NDC,facility,both,5,EA,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM BICARB-CITRIC ACID 20 MEQ ORAL TBEF,50863,CDM,250,RC,J3490,HCPCS,51801-011-30,NDC,facility,both,6,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),50863,CDM,J1630,HCPCS,67457-426-00,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  25 MG ORAL TAB,50863,CDM,J3490,HCPCS,51079-075-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J2004,HCPCS,0409-3178-01,NDC,facility,both,55,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,55150-222-20,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,J3101,HCPCS,50242-037-06,NDC,,,facility,both,16,EA,,7329,5130.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,170,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IPRATROPIUM BROMIDE 0.02 % INHL SOLN,50863,CDM,250,RC,J3490,HCPCS,0487-9801-01,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-638-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2305-04,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 150 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,0904-7505-61,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,50863,CDM,250,RC,J0696,HCPCS,44567-701-25,NDC,facility,both,8,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 10% IN WATER (NEO) 2 - 3.99 KG,50863,CDM,250,RC,J3490,HCPCS,0264-7520-10,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,70860-405-41,NDC,facility,both,4,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML INJECTION,50863,CDM,636,RC,J3411,HCPCS,43598-050-11,NDC,facility,both,2,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN   1.5 G IV SOLR,50863,CDM,250,RC,J3373,HCPCS,67457-824-15,NDC,facility,both,150,EA,,142,99.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSINOPRIL 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,43547-386-09,NDC,facility,both,4,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ABATACEPT 250 MG IV SOLR,50863,CDM,636,RC,J0129,HCPCS,0003-2187-13,NDC,facility,both,50,EA,JA,8073,5651.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,44567-600-04,NDC,facility,both,1,ML,,402,281.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CODEINE-GUAIFENESIN 10-100 MG/5 ML ORAL LIQD (REPACK),50863,CDM,250,RC,J3490,HCPCS,0121-1775-05,NDC,facility,both,2,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,16714-026-01,NDC,facility,both,4,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,71288-402-10,NDC,facility,both,4,ML,,8421,5894.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL IV BOLUS 10MG/ML (ANESTHESIA ONLY),50863,CDM,636,RC,J2704,HCPCS,0409-4699-54,NDC,facility,both,86,ML,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,250,RC,J3360,HCPCS,69339-136-03,NDC,facility,both,14,ML,,1012,708.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,44567-600-04,NDC,facility,both,5,ML,,2009,1406.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE (POLACRILEX) 2 MG BUCL GUM,50863,CDM,636,RC,J3490,HCPCS,0536-1362-25,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SALIVA SUBSTITUTE COMB NO.11 351 MG MM PWPK,50863,CDM,636,RC,J3490,HCPCS,7027562904,NDC,facility,both,1,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,2,EA,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LURASIDONE  80 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63402-308-30,NDC,facility,both,1,EA,,241,168.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMOSOZUMAB-AQQG 210MG/2.34ML ( 105MG/1.17MLX2) SUBQ SYRG,50863,CDM,636,RC,J3111,HCPCS,55513-998-02,NDC,facility,both,210,ML,,5894,4125.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID (PORK)  30 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,62559-741-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,250,RC,J0690,HCPCS,70092-1017-46,NDC,facility,both,4,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 3 % IV INFUSION,50863,CDM,636,RC,J3490,HCPCS,0338-0054-03,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-487-11,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,38,EA,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.45% (1/2 NS) INFUSION (PEDS ONC),50863,CDM,250,RC,J3490,HCPCS,0264-5804-00,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE (PF) 25 MG/ML INJ SOLN (FOR ECTOPIC PREGNANCY),50863,CDM,636,RC,J9260,HCPCS,0143-9519-01,NDC,facility,both,2,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-02,NDC,facility,both,2,ML,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2599,HCPCS,55150-370-01,NDC,facility,both,4,ML,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BARICITINIB 2 MG ORAL TAB (COVID ONLY),50863,CDM,250,RC,J3490,HCPCS,0002-4182-30,NDC,facility,both,2,EA,,798,558.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MULTIVIT-MIN-IRON FUM-FOLIC AC 7.5 MG IRON-400 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,7985440050,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMIDE PEROXIDE 6.5 % OTIC DROP,50863,CDM,636,RC,J3490,HCPCS,70677-1154-1,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN 0.9 % SODIUM CHL 1.5 GRAM/500 ML IV SOLN,50863,CDM,250,RC,J3373,HCPCS,71506-016-59,NDC,facility,both,3,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL (5 MG/ML) IV SYRG (CONTAINS PRESERVATIVE),50863,CDM,636,RC,J3490,HCPCS,0409-2339-24,NDC,facility,both,2,ML,,107,74.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  50 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,72205-012-90,NDC,facility,both,3,EA,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0143-9509-01,NDC,facility,both,5,ML,,374,261.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68382-079-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACAMPROSATE 333 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,60687-121-95,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATOMOXETINE  40 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,64980-376-03,NDC,facility,both,1,EA,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIPASE-PROTEASE-AMYLASE 24,000-76,000- 120,000 UNIT ORAL CAP, DELAY REL",50863,CDM,250,RC,J3490,HCPCS,0032-2636-01,NDC,facility,both,2,EA,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 100 MG IV SOLR,50863,CDM,250,RC,J2997,HCPCS,50242-085-25,NDC,facility,both,6,EA,,1458,1020.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-2051-15,NDC,facility,both,1,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML (ANESTHESIA INTRAOP ONLY),50863,CDM,250,RC,J3010,HCPCS,0641-6027-01,NDC,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-0430-06,NDC,facility,both,6,EA,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,250,RC,J3101,HCPCS,50242-037-06,NDC,facility,both,27,EA,JW,5073,3551.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PREGABALIN  25 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-473-11,NDC,facility,both,8,EA,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-11,NDC,facility,both,18,ML,JW,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
OSELTAMIVIR PHOSPHATE 75 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,64380-799-01,NDC,facility,both,6,EA,,394,275.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML IV,50863,CDM,250,RC,J3490,HCPCS,55150-425-01,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0131-2477-60,NDC,facility,both,2,EA,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 20 MG ORAL TAB,50863,CDM,J3490,HCPCS,0054-8297-25,NDC,,,facility,both,6,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,J2919,HCPCS,0009-0047-25,NDC,,,facility,both,9,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   1 GRAM IV SOLR,50863,CDM,250,RC,J0696,HCPCS,0409-7333-04,NDC,facility,both,6,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,J0133,HCPCS,65219-622-02,NDC,,,facility,both,138,ML,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,J3490,HCPCS,73013-2002-2,NDC,,,facility,both,2,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COLCHICINE 0.6 MG ORAL TAB,50863,CDM,J3490,HCPCS,60687-727-11,NDC,,,facility,both,1,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MANNITOL 20% IV SOLP,50863,CDM,J2150,HCPCS,0990-7715-13,NDC,,,facility,both,2,ML,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 50% IN WATER (MERGE RECORD),50863,CDM,J7060,HCPCS,0409-7517-66,NDC,,,facility,both,1,ML,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,J3490,HCPCS,51079-444-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,J7512,HCPCS,10135-778-01,NDC,,,facility,both,60,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) BLADDER INSTILLATION,50863,CDM,636,RC,J9201,HCPCS,0409-0182-01,NDC,facility,both,10,ML,,392,274.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-0235-25,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL 20 MG/5 ML ORAL ELIX,50863,CDM,250,RC,J3490,HCPCS,60687-671-40,NDC,facility,both,1,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,70069-363-01,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 60 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,27241-099-03,NDC,facility,both,2,EA,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"OMEGA-3 FATTY ACIDS-FISH OIL 360-1,200 MG ORAL CAP (ERX MERGE)",50863,CDM,250,RC,J3490,HCPCS,8068105500,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,636,RC,J3490,HCPCS,51754-4250-1,NDC,facility,both,3,ML,,174,121.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG IV SOLR,50863,CDM,J3490,HCPCS,16714-644-01,NDC,,,facility,both,1,EA,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL IV BOLUS 10MG/ML (ANESTHESIA ONLY),50863,CDM,J2704,HCPCS,63323-269-29,NDC,,,facility,both,26,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,J0330,HCPCS,31722-981-10,NDC,,,facility,both,6,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  20 MEQ ORAL PACK,50863,CDM,636,RC,J3490,HCPCS,72888-024-06,NDC,facility,both,4,EA,,211,147.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROPROCAINE 2 % INJ SOLN,50863,CDM,636,RC,J2401,HCPCS,63323-476-37,NDC,facility,both,600,ML,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML SYRUP,50863,CDM,250,RC,J3490,HCPCS,0121-0638-05,NDC,facility,both,3,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,50863,CDM,250,RC,J9075,HCPCS,10019-956-16,NDC,facility,both,84,EA,JW,237,165.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
MAGNESIUM SULFATE 50 % (4 MEQ/ML) INJ SOLN,50863,CDM,250,RC,J3475,HCPCS,63323-064-01,NDC,facility,both,4,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,0409-1207-03,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 50 MG/ML IV SOLN,50863,CDM,250,RC,J0282,HCPCS,70436-232-72,NDC,facility,both,5,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLECAINIDE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-321-11,NDC,facility,both,1,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0780,HCPCS,23155-294-31,NDC,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J2003,HCPCS,0409-4279-16,NDC,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,4,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7912-51,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) NEB SOLUTION,50863,CDM,250,RC,J3490,HCPCS,0378-8270-31,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL (NEO/PEDS),50863,CDM,250,RC,J3490,HCPCS,63323-820-00,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,636,RC,J0690,HCPCS,70092-1017-46,NDC,facility,both,3,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCERIN (ADULT) RECTAL SUPPOSITORY,50863,CDM,636,RC,J3490,HCPCS,132007924,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITRIOL 0.25 MCG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-345-11,NDC,facility,both,3,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MISOPROSTOL 200 MCG ORAL TAB,50863,CDM,636,RC,S0191,HCPCS,60687-746-11,NDC,facility,both,2,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-5771-23,NDC,facility,both,2,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ANTI-INHIBITOR COAGULANT CMPLX 1,750-3,250 UNIT IV SOLR",50863,CDM,250,RC,J7198,HCPCS,64193-425-02,NDC,facility,both,2250,UN,JW,5828,4079.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
MIRTAZAPINE 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-086-01,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 100 MG/ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,31722-574-47,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,636,RC,J1836,HCPCS,25021-131-82,NDC,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE INFUSION 2MG/ML 100ML (FOR ANESTHESIA USE ONLY),50863,CDM,250,RC,J3490,HCPCS,0409-2051-05,NDC,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN  10 GRAM INJ SOLR,50863,CDM,250,RC,J0690,HCPCS,0143-9983-91,NDC,facility,both,5,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-6966-61,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-ABDA 100 MG IV SOLR,50863,CDM,Q5104,HCPCS,78206-162-01,NDC,,,facility,both,64,EA,,13308,9315.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0121-1781-05,NDC,facility,both,2,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-134-11,NDC,facility,both,80,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR  6 MG/ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0004-0822-05,NDC,facility,both,5,ML,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLIPIZIDE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-701-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0143-9889-01,NDC,facility,both,20,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,0904-6923-61,NDC,facility,both,15,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-18,NDC,facility,both,350,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,J0780,HCPCS,23155-294-31,NDC,,,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 40 MG/ML (4 %) INJ SOLN (FOR NEBULIZATION),50863,CDM,J2003,HCPCS,0409-4283-11,NDC,,,facility,both,160,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2599,HCPCS,43598-914-11,NDC,facility,both,10,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV SOLN,50863,CDM,J3490,HCPCS,0409-6625-22,NDC,,,facility,both,3,ML,,174,121.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PYRIDOXINE 100 MG/ML INJ SOLN,50863,CDM,J3415,HCPCS,63323-180-00,NDC,,,facility,both,1,ML,,128,89.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANTI-THYMOCYTE GLOB (RABBIT) 25 MG IV SOLR,50863,CDM,J7511,HCPCS,58468-0080-1,NDC,,,facility,both,6,EA,,12132,8492.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,J2270,HCPCS,63323-454-00,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,50863,CDM,J3490,HCPCS,67877-548-88,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,0143-9595-01,NDC,,,facility,both,250,ML,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESMOLOL  100 MG/10 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-652-10,NDC,facility,both,2,ML,,211,147.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 40 GRAM/400 ML (10 %) INJ SOLN",50863,CDM,J1561,HCPCS,13533-800-20,NDC,,,facility,both,10,ML,,1415,990.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DENOSUMAB 120 MG/1.7 ML (70 MG/ML) SUBQ SOLN,50863,CDM,J0897,HCPCS,55513-730-01,NDC,,,facility,both,120,ML,,9522,6665.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,7733393825,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CANAKINUMAB (PF) 150 MG/ML SUBQ SOLN,50863,CDM,J0638,HCPCS,0078-0734-61,NDC,,,facility,both,300,ML,,73854,51697.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NORTRIPTYLINE 50 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0093-0812-01,NDC,facility,both,3,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) IV SOLN",50863,CDM,636,RC,J3490,HCPCS,43066-008-01,NDC,facility,both,2,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE SR 25 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,72241-030-22,NDC,facility,both,2,EA,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  75 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-495-11,NDC,facility,both,4,EA,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,14789-251-09,NDC,facility,both,1,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,250,RC,J3101,HCPCS,50242-037-06,NDC,facility,both,10,EA,,4581,3206.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIOGLITAZONE 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-7271-56,NDC,facility,both,1,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRP (MERGE/REPACK),50863,CDM,636,RC,J3490,HCPCS,68094-764-59,NDC,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMBRISENTAN  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,47335-236-83,NDC,facility,both,2,EA,,1567,1096.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMMONIUM LACTATE 12 % TOP LOTN,50863,CDM,250,RC,J3490,HCPCS,51672-1300-5,NDC,facility,both,1,GM,,210,147,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 2 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J2004,HCPCS,0409-3183-11,NDC,facility,both,200,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0780,HCPCS,67457-640-00,NDC,facility,both,1,ML,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ICATIBANT 30 MG/3 ML SUBQ SYRG,50863,CDM,250,RC,J1744,HCPCS,69097-664-34,NDC,facility,both,30,ML,,29229,20460.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-145-11,NDC,facility,both,10,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) IV (NEO) EMERGENCY SYRINGE,50863,CDM,250,RC,J3490,HCPCS,0409-5534-34,NDC,facility,both,4,ML,,254,177.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 50 MG/5 ML (10 MG/ML) IV SYRG,50863,CDM,636,RC,J3490,HCPCS,63037-155-25,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,63323-162-01,NDC,facility,both,1,ML,JW,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
OBINUTUZUMAB 900 MG IN NS 286 ML (STOCK DOSE),50863,CDM,636,RC,J9301,HCPCS,50242-070-01,NDC,facility,both,100,ML,JZ,15450,10815,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),50863,CDM,J1630,HCPCS,63323-474-00,NDC,,,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 100 MG IV SOLR,50863,CDM,J2997,HCPCS,50242-085-25,NDC,,,facility,both,100,EA,,24289,17002.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 30 MG TAB,50863,CDM,J3490,HCPCS,0093-0318-01,NDC,,,facility,both,3,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,15,EA,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOCILIZUMAB-AAZG 80 MG/4 ML (20 MG/ML) IV SOLN,50863,CDM,636,RC,Q5135,HCPCS,65219-590-04,NDC,facility,both,240,ML,,4160,2912,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 5 MG/5 ML IV,50863,CDM,636,RC,J3490,HCPCS,63323-660-05,NDC,facility,both,2,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-04,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NAPROXEN 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-594-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 30 MG/0.3 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,16714-006-01,NDC,facility,both,9,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,57237-077-10,NDC,facility,both,1,EA,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  500 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,25021-465-01,NDC,facility,both,20,ML,JZ,206,144.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-495-27,NDC,facility,both,50,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,250,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,12,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 400 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-602-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7122-61,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60505-0252-3,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J3490,HCPCS,0990-7983-61,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,50863,CDM,250,RC,J2359,HCPCS,55150-308-01,NDC,facility,both,4,EA,JZ,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
VENLAFAXINE 150 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,68084-713-11,NDC,facility,both,2,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,J2003,HCPCS,63323-486-05,NDC,,,facility,both,600,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MILRINONE INFUSION PED/NEO IV SYRINGE (CDS MIXTURE),50863,CDM,J2260,HCPCS,0143-9719-01,NDC,,,facility,both,4,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,108,ML,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,636,RC,J2003,HCPCS,0143-9575-01,NDC,facility,both,800,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM ZIRCONIUM CYCLOSILICATE  5 G ORAL PWPK (USE PANEL),50863,CDM,J3490,HCPCS,0310-1105-01,NDC,,,facility,both,2,EA,,293,205.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-492-41,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,1,ML,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLP",50863,CDM,250,RC,P9047,HCPCS,0944-0493-04,NDC,facility,both,1,ML,,251,175.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,63323-162-00,NDC,facility,both,2,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,636,RC,J2560,HCPCS,72162-1330-6,NDC,facility,both,1,ML,,276,193.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,50863,CDM,636,RC,J2359,HCPCS,55150-308-01,NDC,facility,both,3,EA,JZ,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
HYDROCODONE-ACETAMINOPHEN 5 MG-325 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0406-0123-23,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 1 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,27808-002-01,NDC,facility,both,1,ML,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-088-11,NDC,facility,both,1,EA,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,636,RC,J2704,HCPCS,25021-608-20,NDC,facility,both,20,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,250,RC,J2795,HCPCS,70069-064-25,NDC,facility,both,75,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,0409-6625-14,NDC,facility,both,3,ML,,174,121.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-411-10,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR IN 0.9% NACL 100 UNIT/100 ML (1 UNIT/ML) INFUSION FOR OB,50863,CDM,636,RC,J1815,HCPCS,0338-0126-12,NDC,facility,both,1,ML,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,250,RC,J2405,HCPCS,0641-6078-01,NDC,facility,both,4,ML,PLAD,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
FLUTICASONE 220 MCG/ACTUATION INHL AERO,50863,CDM,636,RC,J3490,HCPCS,66993-080-96,NDC,facility,both,1,GM,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,72603-209-01,NDC,facility,both,5,ML,,309,216.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2599,HCPCS,65219-039-00,NDC,facility,both,20,ML,,136,95.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIVASTIGMINE 3 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,33342-090-09,NDC,facility,both,2,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL DECANOATE 100 MG/ML IM SOLN,50863,CDM,250,RC,J1631,HCPCS,70756-616-10,NDC,facility,both,3,ML,,238,166.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-950-01,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7007-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0990-7983-61,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 1 GRAM/20 ML IV SOLN,50863,CDM,250,RC,J9190,HCPCS,63323-117-00,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IMIPRAMINE 50 MG TAB,50863,CDM,250,RC,J3490,HCPCS,69315-135-01,NDC,facility,both,2,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G POTASSIUM  5000000 UNIT INJ SOLR,50863,CDM,250,RC,J2540,HCPCS,0781-6135-94,NDC,facility,both,4,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,2,EA,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIFAXIMIN 550 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,65649-303-02,NDC,facility,both,1,EA,,294,205.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOLIC ACID  1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-681-11,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69238-1490-1,NDC,facility,both,2,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25 MG-100 MG TAB,50863,CDM,250,RC,J3490,HCPCS,59651-457-01,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 50 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,59651-489-01,NDC,facility,both,60,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CINACALCET 30 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,64380-883-04,NDC,facility,both,2,EA,,225,157.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 600 MG ORAL TP12,50863,CDM,636,RC,J3490,HCPCS,0904-6718-39,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN  10 GRAM INJ SOLR,50863,CDM,636,RC,J0690,HCPCS,0143-9983-91,NDC,facility,both,4,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE 21 MG/24 HR TD PT24,50863,CDM,250,RC,J3490,HCPCS,43598-448-74,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIVAROXABAN 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50458-579-90,NDC,facility,both,1,EA,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE IV CONCENTRATED INFUSION (1 MEQ/ML),50863,CDM,250,RC,J3490,HCPCS,0409-6625-02,NDC,facility,both,2,ML,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROPHILLIC OINTMENT (AQUAPHOR),50863,CDM,250,RC,J3490,HCPCS,7214045231,NDC,facility,both,1,GM,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION,50863,CDM,250,RC,J3490,HCPCS,0310-7370-20,NDC,facility,both,1,GM,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE  50 MG ORAL TAB,50863,CDM,636,RC,j3490,HCPCS,68382-805-01,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,50863,CDM,636,RC,J9000,HCPCS,0069-3032-20,NDC,facility,both,5,ML,,145,101.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE 1 MG/2 ML INHL NBSP,50863,CDM,250,RC,J3490,HCPCS,0093-6817-19,NDC,facility,both,1,ML,,113,79.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-349-11,NDC,facility,both,3,EA,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 150 MG/1 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,0548-5607-00,NDC,facility,both,14,ML,,119,83.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  50 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6992-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,50863,CDM,250,RC,J9263,HCPCS,71288-172-21,NDC,facility,both,200,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOVASTATIN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68180-468-07,NDC,facility,both,2,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DONEPEZIL 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,43547-276-03,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6376-61,NDC,facility,both,3,EA,,162,113.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-0430-06,NDC,facility,both,8,EA,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  75 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-856-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-9558-05,NDC,facility,both,4,ML,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,636,RC,J3490,HCPCS,0641-6236-01,NDC,facility,both,3,ML,,160,112,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SYRG,50863,CDM,636,RC,J3490,HCPCS,8290033010,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLERGONOVINE 0.2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69238-1605-8,NDC,facility,both,1,EA,,285,199.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IDARUBICIN 1 MG/ML IV SOLN,50863,CDM,250,RC,J9211,HCPCS,0013-2596-20,NDC,facility,both,4,ML,,729,510.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 12.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7307-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,0409-1283-03,NDC,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE (POLACRILEX) 2 MG BUCL GUM,50863,CDM,250,RC,J3490,HCPCS,49348-691-36,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN SODIUM  2 GRAM INJ SOLR,50863,CDM,636,RC,J0290,HCPCS,63323-399-23,NDC,facility,both,4,EA,JZ,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LIDOCAINE 4% TOP PATCH,50863,CDM,636,RC,J3490,HCPCS,70512-812-01,NDC,facility,both,3,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,13,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
INDOMETHACIN 50 MG RECT SUPP,50863,CDM,636,RC,J3490,HCPCS,69344-102-33,NDC,facility,both,2,EA,,1998,1398.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TERAZOSIN  1 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,59746-383-06,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-657-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 100 MG/1 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,63323-586-21,NDC,facility,both,9,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE 44 MCG/ACTUATION INHL AERO,50863,CDM,250,RC,J3490,HCPCS,66993-078-96,NDC,facility,both,1,GM,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16571-109-01,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IR SOLN,50863,CDM,250,RC,J3490,HCPCS,0338-0047-46,NDC,facility,both,6,ML,,333,233.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESVENLAFAXINE  50 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,68180-592-06,NDC,facility,both,1,EA,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,636,RC,J1611,HCPCS,0597-0053-45,NDC,facility,both,1,EA,JZ,371,259.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-3178-01,NDC,facility,both,70,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUVOXAMINE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0832-1671-11,NDC,facility,both,3,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 17 GRAM (100 %) ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,0904-6931-86,NDC,facility,both,6,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE 1 MG/0.2 ML SUBQ KIT,50863,CDM,636,RC,J9218,HCPCS,0781-4003-32,NDC,facility,both,1,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7912-51,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,76045-009-96,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,50863,CDM,636,RC,J3490,HCPCS,0378-7732-93,NDC,facility,both,1,EA,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPHENIDATE 18 MG ORAL TO24,50863,CDM,250,RC,J3490,HCPCS,62175-310-37,NDC,facility,both,2,EA,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 0.25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-570-11,NDC,facility,both,1,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,636,RC,J3490,HCPCS,77333-049-25,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 0.1 % TOP CREAM,50863,CDM,250,RC,J3490,HCPCS,67877-251-15,NDC,facility,both,1,GM,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRABECTEDIN 1 MG IV SOLR,50863,CDM,250,RC,J9352,HCPCS,59676-610-01,NDC,facility,both,30,EA,,22356,15649.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) MISC SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-694-41,NDC,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 50 MG TAB,50863,CDM,636,RC,J3490,HCPCS,42043-221-00,NDC,facility,both,1,EA,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J2310,HCPCS,36000-310-01,NDC,facility,both,4,ML,,357,249.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,50863,CDM,636,RC,J0696,HCPCS,60505-6148-0,NDC,facility,both,2,EA,,113,79.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7126-61,NDC,facility,both,9,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 1%/EPINEPHRINE 1:200K INJECTION (PF),50863,CDM,250,RC,J3490,HCPCS,63739-468-05,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,71288-505-02,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,4000,ML,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,J2919,HCPCS,0009-0039-28,NDC,,,facility,both,8,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,16714-536-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 500 MCG INJ SOLR,50863,CDM,J3490,HCPCS,42023-203-01,NDC,,,facility,both,1,EA,,1458,1020.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,51754-5001-1,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,J2405,HCPCS,60505-6130-0,NDC,,,facility,both,1,ML,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,J3490,HCPCS,51754-5001-1,NDC,,,facility,both,2,ML,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,J3490,HCPCS,68180-441-02,NDC,,,facility,both,9,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,J3490,HCPCS,68180-441-02,NDC,,,facility,both,10,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 40 % ORAL GEL,50863,CDM,250,RC,J3490,HCPCS,574006930,NDC,facility,both,5,GM,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR 200 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,70954-188-10,NDC,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65862-296-30,NDC,facility,both,1,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  750 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-882-11,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL  3.125 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68382-092-01,NDC,facility,both,2,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,250,RC,J3490,HCPCS,72789-057-01,NDC,facility,both,6,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 2 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,636,RC,J2270,HCPCS,0409-1762-30,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCRALFATE 100 MG/ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0121-0974-10,NDC,facility,both,2,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2%/EPINEPHRINE 1:200K INJECTION (PF),50863,CDM,250,RC,J3490,HCPCS,0409-3183-01,NDC,facility,both,1,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM HYPOCHLORITE 0.25 % MISC SOLN,50863,CDM,250,RC,J3490,HCPCS,39328-063-25,NDC,facility,both,1,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRBESARTAN 150 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,31722-730-90,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-4675-05,NDC,facility,both,2,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,25021-321-04,NDC,facility,both,2,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0406-0552-23,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-354-11,NDC,facility,both,6,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,636,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,9,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE-ALOE VERA NASL SPRY,50863,CDM,250,RC,J3490,HCPCS,225052848,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB 10 MG/ML IV CONC,50863,CDM,636,RC,J9312,HCPCS,50242-051-21,NDC,facility,both,50,ML,JZ,11083,7758.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0075-0621-01,NDC,facility,both,6,ML,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-492-27,NDC,facility,both,1000,ML,,785,549.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FILGRASTIM-SNDZ 480 MCG/0.8 ML INJ SYRG,50863,CDM,636,RC,Q5101,HCPCS,61314-326-01,NDC,facility,both,480,ML,JZ,1212,848.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
EPINEPHRINE 1 MG/ML INJ SOLN,50863,CDM,250,RC,J0171,HCPCS,76329-9060-0,NDC,facility,both,14,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,63323-806-13,NDC,facility,both,3,ML,JZ,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,16714-244-01,NDC,facility,both,3,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,13668-219-30,NDC,facility,both,1,EA,,158,110.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MYCOPHENOLATE SODIUM 360 MG ORAL TBEC,50863,CDM,250,RC,J7518,HCPCS,68084-918-95,NDC,facility,both,4,EA,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IVABRADINE 5 MG ORAL TAB,50863,CDM,250,RC,50742-362-60,NDC,,,facility,both,0.5,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN SODIUM  2 GRAM INJ SOLR,50863,CDM,250,RC,J0290,HCPCS,55150-114-20,NDC,facility,both,4,EA,JZ,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1940,HCPCS,72603-251-01,NDC,facility,both,12,ML,,108,75.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,J2003,HCPCS,0409-1323-05,NDC,,,facility,both,100,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VEDOLIZUMAB 300 MG IV SOLR,50863,CDM,J3380,HCPCS,64764-300-20,NDC,,,facility,both,300,EA,,11084,7758.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,11,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0264-5802-10,NDC,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISRADIPINE  2.5 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,16252-539-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,250,RC,J0132,HCPCS,70594-111-01,NDC,facility,both,80,ML,,408,285.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,50863,CDM,J9263,HCPCS,71288-171-11,NDC,,,facility,both,45,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 500 MG PE/10 ML INJ SOLN,50863,CDM,250,RC,Q2009,HCPCS,67457-517-00,NDC,facility,both,29,ML,JZ,709,496.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LACTATED RINGERS IRRIGATION SOLN,50863,CDM,636,RC,J7120,HCPCS,0264-7389-60,NDC,facility,both,15,ML,,250,175,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,70004-600-09,NDC,facility,both,9,ML,,445,311.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALUM-MAG HYDROXIDE-SIMETH 400 MG-400 MG-40 MG/5 ML ORAL SUSP,50863,CDM,J3490,HCPCS,17856-5725-3,NDC,,,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,63323-185-07,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN 0.9% SODIUM CL 1.25 GRAM/250 ML IV SOLN,50863,CDM,636,RC,J3370,HCPCS,70092-9054-05,NDC,facility,both,3,ML,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPTINEZUMAB-JJMR 100 MG/ML IV SOLN,50863,CDM,636,RC,J3032,HCPCS,67386-130-51,NDC,facility,both,100,ML,JZ,4127,2888.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,42806-150-33,NDC,facility,both,5,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 100 MG/5 ML ORAL LIQD,50863,CDM,636,RC,J3490,HCPCS,60687-863-42,NDC,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,636,RC,J0330,HCPCS,0409-6629-02,NDC,facility,both,7,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6303-61,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE  7.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-584-11,NDC,facility,both,2,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 100 MG/60 ML RECT ENEM,50863,CDM,250,RC,J3490,HCPCS,62559-138-07,NDC,facility,both,1,ML,,126,88.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GOLIMUMAB  12.5 MG/ML IV SOLN,50863,CDM,J1602,HCPCS,57894-350-01,NDC,,,facility,both,125,ML,,13795,9656.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4% TOP PATCH,50863,CDM,250,RC,J3490,HCPCS,0536-1202-07,NDC,facility,both,2,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,63323-485-27,NDC,,,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,50863,CDM,250,RC,J9206,HCPCS,0009-7529-03,NDC,facility,both,20,ML,,969,678.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IVPB (PEDIATRICS/ADULT NON-FORM)",50863,CDM,636,RC,J0137,HCPCS,24201-100-01,NDC,facility,both,100,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUDROCORTISONE 0.1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-288-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-24,NDC,facility,both,40,ML,JZ,5658,3960.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PHENYTOIN 50 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,51672-4146-1,NDC,facility,both,4,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML IM SOLN,50863,CDM,636,RC,90375,HCPCS,13533-318-05,NDC,facility,both,10,ML,JZ,8588,6011.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LEVOTHYROXINE 200 MCG INJ SOLR,50863,CDM,636,RC,J3490,HCPCS,63323-647-10,NDC,facility,both,2,EA,,1122,785.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPAGLIFLOZIN PROPANEDIOL 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,66993-457-30,NDC,facility,both,1,EA,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,0143-9381-01,NDC,facility,both,1,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/0.5 ML INHL NEBU,50863,CDM,250,RC,J3490,HCPCS,0487-9901-30,NDC,facility,both,1,EA,PLAD,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
DULOXETINE 20 MG ORAL CPDR,50863,CDM,636,RC,J3490,HCPCS,60687-723-11,NDC,facility,both,21,EA,,618,432.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE 25 MG RECT SUPP,50863,CDM,636,RC,J3490,HCPCS,0574-7226-12,NDC,facility,both,1,EA,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,63323-165-01,NDC,facility,both,10,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7121-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-38,NDC,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,0088-2220-33,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,63323-161-00,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETIRIZINE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6717-61,NDC,facility,both,1,EA,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NAPROXEN 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,53746-188-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,50863,CDM,250,RC,J0696,HCPCS,60505-6148-0,NDC,facility,both,6,EA,,338,236.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % MBP,50863,CDM,250,RC,J3490,HCPCS,0338-0553-11,NDC,facility,both,1,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0781-6041-58,NDC,facility,both,8,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-152-11,NDC,facility,both,3,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 100 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,67877-592-01,NDC,facility,both,2,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-4827-05,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,8,ML,,154,107.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCUSATE SODIUM 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7183-61,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNIT/G TOP PACK,50863,CDM,636,RC,J3490,HCPCS,0904-7402-67,NDC,facility,both,5,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEXILETINE 250 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,62559-822-01,NDC,facility,both,1,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,76045-009-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-ABDA 100 MG IV SOLR,50863,CDM,250,RC,Q5104,HCPCS,78206-162-99,NDC,facility,both,100,EA,,20794,14555.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,636,RC,J3490,HCPCS,61553-320-70,NDC,facility,both,1,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETIRIZINE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16714-799-02,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLESTYRAMINE 4 G ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,0245-0036-89,NDC,facility,both,2,EA,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,636,RC,J0133,HCPCS,63323-325-03,NDC,facility,both,120,ML,,133,93.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYMETAZOLINE 0.05 % NASAL (MERGE)(ENT PRE-PROCEDURE),50863,CDM,636,RC,J3490,HCPCS,0904-7006-35,NDC,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ICATIBANT 30 MG/3 ML SUBQ SYRG,50863,CDM,250,RC,J1744,HCPCS,54092-702-02,NDC,facility,both,30,ML,JZ,30768,21537.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CHOLECALCIFEROL (VITAMIN D3) 400 UNIT/ML ORAL DROP,50863,CDM,250,RC,J3490,HCPCS,1785600492,NDC,facility,both,2,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,0143-9577-01,NDC,,,facility,both,170,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPATITIS B IMMUNE GLOBULIN 220 UNIT/ML (5 ML) IM SOLN,50863,CDM,636,RC,90371,HCPCS,13533-636-50,NDC,facility,both,3,ML,JW,596,417.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
"ANTI-INHIBITOR COAGULANT CMPLX 1,750-3,250 UNIT IV SOLR",50863,CDM,250,RC,J7198,HCPCS,64193-425-02,NDC,facility,both,3825,UN,,22786,15950.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2312,HCPCS,0409-1215-01,NDC,facility,both,120,ML,,279,195.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-2051-15,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,3700025445,NDC,facility,both,4,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC MCARE ADMIN HEPATITIS B VACC,50863,CDM,90744,HCPCS,58160-820-43,NDC,,,facility,both,1,ML,,171,119.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA SR 50 MG-200 MG TAB,50863,CDM,636,RC,J3490,HCPCS,16729-079-01,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,63323-104-25,NDC,facility,both,9,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6322-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PSEUDOEPHEDRINE SR 120 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0081-0670-20,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-253-11,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLN,50863,CDM,250,RC,J3262,HCPCS,50242-137-01,NDC,facility,both,800,ML,,14661,10262.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 25 MG CAP,50863,CDM,250,RC,J3490,HCPCS,0904-5306-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60505-3110-0,NDC,facility,both,2,EA,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-132-11,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BISOPROLOL FUMARATE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,29300-126-01,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,55150-307-01,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ABACAVIR-DOLUTEGRAVIR-LAMIVUD 600-50-300 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,49702-231-13,NDC,facility,both,1,EA,,562,393.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"CALCIUM CARBONATE-VITAMIN D3 500 MG(1,250MG) -200 UNIT ORAL TAB",50863,CDM,250,RC,J3490,HCPCS,1000670038,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-980-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INOTUZUMAB OZOGAMICIN 0.9 MG (0.25 MG/ML INITIAL) IV SOLR,50863,CDM,250,RC,J9229,HCPCS,0008-0100-01,NDC,facility,both,6,EA,,34555,24188.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-1749-70,NDC,facility,both,4,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J1938,HCPCS,72603-251-01,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6377-61,NDC,facility,both,1,EA,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % MUCOSAL SOLN (VISCOUS),50863,CDM,250,RC,J3490,HCPCS,0121-4950-15,NDC,facility,both,4,ML,,151,105.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELATACEPT 250 MG IV SOLR,50863,CDM,636,RC,J0485,HCPCS,0003-0371-13,NDC,facility,both,400,EA,,4127,2888.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-4713-32,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  500 MG IV SOLR,50863,CDM,250,RC,J3373,HCPCS,0143-9161-01,NDC,facility,both,50,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  75 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-475-11,NDC,facility,both,3,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,42858-003-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE SODIUM 2.5 MG ORAL TAB,50863,CDM,636,RC,J8610,HCPCS,0904-7141-10,NDC,facility,both,8,EA,,141,98.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIPASE-PROTEASE-AMYLASE (PORK) 36,000-114,000- 180,000 UNIT ORAL CPDR",50863,CDM,250,RC,J3490,HCPCS,0032-3016-13,NDC,facility,both,3,EA,,221,154.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 15 MG/ML (1.5 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-493-01,NDC,,,facility,both,23,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 25 MG/5 ML (5 MG/ML) ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,52536-600-11,NDC,facility,both,1,ML,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,70069-011-01,NDC,facility,both,2,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 15 MG/ML (1.5 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-493-01,NDC,,,facility,both,45,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPLERENONE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51991-877-33,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,44206-310-91,NDC,facility,both,2,ML,,418,292.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-4799-05,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25 MG-100 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0378-0085-01,NDC,facility,both,3,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25 MG-100 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0378-0085-01,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA SR 50 MG-200 MG TAB,50863,CDM,636,RC,J3490,HCPCS,51079-923-01,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE CONCENTRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0054-0404-44,NDC,facility,both,4,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0781-6041-46,NDC,facility,both,12,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 20MG/ML IV SYRINGE (PEDS/NEO),50863,CDM,250,RC,J0612,HCPCS,63323-311-10,NDC,facility,both,7,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,63323-185-07,NDC,facility,both,10,ML,,333,233.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,50863,CDM,250,RC,J9206,HCPCS,0009-7529-01,NDC,facility,both,2,ML,,208,145.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-0552-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7193-61,NDC,facility,both,2,EA,PLAD,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,0409-1283-03,NDC,facility,both,10,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G POTASSIUM  5000000 UNIT INJ SOLR,50863,CDM,250,RC,J2540,HCPCS,0049-0520-84,NDC,facility,both,20,EA,,180,126,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,636,RC,J3490,HCPCS,0409-4887-23,NDC,facility,both,2,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN-ACETAMINOPHEN-CAFFEINE 250 MG-250 MG-65 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0536-1326-01,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML INJ SOLN (PULMONARY USE),50863,CDM,250,RC,J2250,HCPCS,55390-137-05,NDC,facility,both,2,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLN (MERGE)",50863,CDM,250,RC,P9047,HCPCS,64208-2512-8,NDC,facility,both,12,ML,,1425,997.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,0409-4264-11,NDC,facility,both,8,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6007-61,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIFEDIPINE 60 MG ORAL TO24,50863,CDM,250,RC,J3490,HCPCS,50268-598-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  20 MEQ ORAL PACK,50863,CDM,250,RC,J3490,HCPCS,69543-451-01,NDC,facility,both,4,EA,,211,147.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,10019-506-37,NDC,facility,both,3,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM NEO/PED INFUSION (CDS MIXTURE),50863,CDM,250,RC,J2185,HCPCS,0781-3267-90,NDC,facility,both,2,EA,,127,88.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALSARTAN  80 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,31722-152-90,NDC,facility,both,1,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,20,EA,JW,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DICLOFENAC 0.1 % EYE DROPS,50863,CDM,250,RC,J3490,HCPCS,61314-014-25,NDC,facility,both,1,ML,,219,153.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  75 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6951-61,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,0548-5604-00,NDC,facility,both,16,ML,,141,98.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 10 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-369-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALACYCLOVIR 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-077-10,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,44,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-098-10,NDC,facility,both,2,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL  6.25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-854-11,NDC,facility,both,2,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTAZIDIME NEO IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0713,HCPCS,0781-3177-80,NDC,facility,both,1,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIKACIN 1000 MG/4 ML INJ SOLN,50863,CDM,250,RC,J0278,HCPCS,23155-290-32,NDC,facility,both,10,ML,,144,100.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69097-125-03,NDC,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  125 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,68180-166-11,NDC,facility,both,1,EA,,154,107.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 4 MG/ACTUATION NASL SPRY,50863,CDM,636,RC,J3490,HCPCS,0093-2165-19,NDC,facility,both,1,EA,,303,212.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE DINITRATE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-447-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,10135-778-01,NDC,facility,both,10,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-1159-09,NDC,facility,both,2,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 150 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,68180-319-09,NDC,facility,both,3,EA,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN  500 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,60687-640-11,NDC,facility,both,3,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,0409-4276-16,NDC,,,facility,both,80,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-492-27,NDC,facility,both,140,ML,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % MBP,50863,CDM,250,RC,J3490,HCPCS,0338-0553-18,NDC,facility,both,5,ML,,222,155.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,5,EA,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAPAVERINE 30 MG/ML INJ SOLN,50863,CDM,250,RC,J2440,HCPCS,0517-4002-01,NDC,facility,both,3,ML,,729,510.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMINOCAPROIC ACID 250 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-4346-73,NDC,facility,both,3,ML,,345,241.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-069-33,NDC,facility,both,2,EA,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,80,ML,JW,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
FLUCONAZOLE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-337-11,NDC,facility,both,1,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,J0330,HCPCS,0409-6629-02,NDC,,,facility,both,10,ML,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2310,HCPCS,67457-292-00,NDC,facility,both,1,ML,,233,163.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,76045-009-10,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 5 MG-325 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0406-0123-23,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MOXIFLOXACIN 400 MG/250 ML IVPB PREMIX (MERGE),50863,CDM,636,RC,J2280,HCPCS,67457-323-25,NDC,facility,both,4,ML,,234,163.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE HCL IN 0.9% NACL 1 MG/10 ML (100 MCG/ML) IV SYRG,50863,CDM,250,RC,J3490,HCPCS,73177-108-03,NDC,facility,both,2,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 100 MG/ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,31722-574-47,NDC,facility,both,1,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IR SOLN,50863,CDM,250,RC,J3490,HCPCS,0338-0047-46,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
23.4% SODIUM CHLORIDE (4 MEQ/ML) INJECTION,50863,CDM,250,RC,J3490,HCPCS,63323-187-30,NDC,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 2 GRAM INJ SOLR,50863,CDM,250,RC,J0692,HCPCS,71288-009-21,NDC,facility,both,4,EA,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-1752-50,NDC,facility,both,2,ML,,144,100.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 500 MG (200 MG ELEMENTAL) CHEW TAB,50863,CDM,250,RC,J3490,HCPCS,68084-988-33,NDC,facility,both,3,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0574-0521-76,NDC,facility,both,1,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 200 MG/20 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0131-1810-67,NDC,facility,both,1,ML,,418,292.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 7.5 MG-325 MG/15 ML ORAL SOLN (REPACK),50863,CDM,250,RC,J3490,HCPCS,0121-2316-15,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNITS/1 GRAM PACKET (MERGE RECORD),50863,CDM,250,RC,J3490,HCPCS,57896-145-09,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLU VACCINE TS 2024-25 6MOS UP (PF) 45 MCG (15 MCG X 3)/0.5 ML IM SYRG,50863,CDM,90656,HCPCS,70461-654-04,NDC,,,facility,both,1,ML,,190,133,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN D5W 20000 UNIT/500 ML,50863,CDM,J1644,HCPCS,0264-9567-10,NDC,,,facility,both,20,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,25021-410-76,NDC,facility,both,4,ML,JZ,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MORPHINE 2 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,J2270,HCPCS,0409-1762-30,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIP-PERT(A)-TET-POLIO-HIB (PF) 15LF-20MCG-5LF- 62 DU/0.5 ML IM KIT,50863,CDM,90698,HCPCS,49281-511-05,NDC,,,facility,both,1,EA,,516,361.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,50863,CDM,FAMNOCHARGE,HCPCS,0054-8175-25,NDC,,,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,519,ME,,7043,4930.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J2250,HCPCS,70069-817-01,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPTOMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0878,HCPCS,72603-152-01,NDC,facility,both,750,EA,,2194,1535.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MISOPROSTOL 100 MCG ORAL TAB,50863,CDM,636,RC,S0191,HCPCS,59762-5007-2,NDC,facility,both,3,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROTHIAZIDE SODIUM 500 MG IV SOLR,50863,CDM,250,RC,J1205,HCPCS,25021-305-20,NDC,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 0.4 MG SL SUBL,50863,CDM,J3490,HCPCS,43598-436-35,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEMANTINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6506-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 1 GRAM INJ SOLR,50863,CDM,250,RC,J0692,HCPCS,25021-121-20,NDC,facility,both,12,EA,,240,168,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL  6.25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-854-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN  325 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,57896-921-01,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,70436-030-82,NDC,facility,both,91,ML,JW,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ROSUVASTATIN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-709-11,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-097-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 100 MG/ML INJ SOLN,50863,CDM,250,RC,J2800,HCPCS,70069-101-01,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7363-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 2 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,J2270,HCPCS,63323-452-00,NDC,,,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MENING VAC A,C,Y,W135 DIP (PF) 10-5 MCG/0.5 ML IM SOLN",50863,CDM,90734,HCPCS,58160-827-03,NDC,,,facility,both,1,ML,,720,504,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MEASLES,MUMPS,RUB,VARICEL (PF) 10EXP3-4.3-3-3.99TCID50/0.5ML SUB-Q",50863,CDM,90710,HCPCS,0006-4171-00,NDC,,,facility,both,1,EA,,776,543.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,16714-016-01,NDC,facility,both,4,ML,PLAD,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,250,RC,J2720,HCPCS,63323-229-01,NDC,facility,both,2,ML,JZ,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SPIRONOLACTONE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-476-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0591-0407-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETODOLAC 400 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69238-1342-1,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMINOCAPROIC ACID 250 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0517-9120-01,NDC,facility,both,2,ML,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FELODIPINE 10 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,68462-235-01,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 800 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6707-06,NDC,facility,both,2,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 50 MG CAP,50863,CDM,250,RC,Q0163,HCPCS,0904-2056-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-325-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOBRAMYCIN SULFATE 40 MG/ML INJ SOLN,50863,CDM,636,RC,J3260,HCPCS,63323-306-02,NDC,facility,both,3,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,250,RC,J3490,HCPCS,59310-579-20,NDC,facility,both,1,GM,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2305-04,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),50863,CDM,250,RC,J1630,HCPCS,63323-474-00,NDC,facility,both,2,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7363-61,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-9558-05,NDC,facility,both,3,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE  7.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,57237-007-30,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EMTRICITABINE-TENOFOVIR 200 MG-300 MG TAB,50863,CDM,636,RC,J0750,HCPCS,0093-7704-56,NDC,facility,both,1,EA,GZ,297,207.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier GZ: Item or service expected to be denied as not reasonable and necessary
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,250,RC,J3360,HCPCS,0409-1273-32,NDC,facility,both,2,ML,,198,138.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COCAINE  4 % TOP SOLN (MERGE),50863,CDM,636,RC,C9046,HCPCS,70839-362-04,NDC,facility,both,160,ML,JZ,1041,728.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68180-966-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-398-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,51754-4250-1,NDC,facility,both,3,ML,,218,152.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMETHICONE  80 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,77333-812-25,NDC,facility,both,12,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-28,NDC,facility,both,48,EA,,259,181.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERTAPENEM 1 GRAM INJ SOLR,50863,CDM,J1335,HCPCS,43598-901-11,NDC,,,facility,both,2,EA,,432,302.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,14,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR NEO/PEDS INFUSION (CDS FROM PREMIX),50863,CDM,250,RC,J0133,HCPCS,63323-325-10,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 100 MG/ML INJ SOLN,50863,CDM,J2800,HCPCS,70069-101-01,NDC,,,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63304-773-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,70069-363-01,NDC,facility,both,1,ML,,146,102.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
D5-0.9%NACL-POTASSIUM CHLORIDE 20 MEQ/L IV SOLP,50863,CDM,250,RC,J3480,HCPCS,0338-0803-04,NDC,facility,both,10,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,70069-363-01,NDC,facility,both,1,ML,,151,105.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J2004,HCPCS,0409-3178-16,NDC,facility,both,150,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NOREPINEPHRINE BITARTRATE-D5W 4 MG/250 ML (16 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0338-0112-20,NDC,facility,both,1,ML,,134,93.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-579-11,NDC,facility,both,4,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EMTRICITABINE-TENOFOVIR 200 MG-300 MG TAB,50863,CDM,250,RC,J0750,HCPCS,42385-953-30,NDC,facility,both,1,EA,,297,207.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,70594-117-01,NDC,facility,both,300,ML,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6361-61,NDC,facility,both,1,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,636,RC,J0330,HCPCS,0409-6629-02,NDC,facility,both,7,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50111-398-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM ZIRCONIUM CYCLOSILICATE  5 G ORAL PWPK (USE PANEL),50863,CDM,636,RC,J3490,HCPCS,0310-1105-01,NDC,facility,both,1,EA,,169,118.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 875 MG-125 MG TAB,50863,CDM,636,RC,J3490,HCPCS,16714-297-01,NDC,facility,both,6,EA,,149,104.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0456,HCPCS,70436-019-82,NDC,facility,both,1,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOMYCIN-BACITRACN ZN-POLYMYXIN 3.5 MG-400 U*,50863,CDM,636,RC,J3490,HCPCS,45802-061-70,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 0.25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-270-11,NDC,facility,both,6,EA,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROBENECID 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0591-5347-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN 50 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,60687-156-95,NDC,facility,both,3,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL,50863,CDM,250,RC,J3490,HCPCS,63323-820-01,NDC,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,636,RC,Q0162,HCPCS,68094-763-59,NDC,facility,both,8,ML,,150,105,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-0430-06,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE 1 MG/0.2 ML SUBQ KIT,50863,CDM,636,RC,J9218,HCPCS,0781-4003-32,NDC,facility,both,1,EA,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE   4.2 % IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-083-05,NDC,facility,both,2,ML,,166,116.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE   4.2 % IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-083-05,NDC,facility,both,1,ML,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITRIOL 0.5 MCG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,64380-724-06,NDC,facility,both,2,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0093-2279-73,NDC,facility,both,2,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 100 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,70954-240-10,NDC,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2599,HCPCS,63323-930-01,NDC,facility,both,5,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2310,HCPCS,36000-308-01,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,78206-121-01,NDC,facility,both,2,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-580-11,NDC,facility,both,4,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,49884-849-01,NDC,facility,both,2,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-9543-03,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-349-11,NDC,facility,both,2,EA,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 20MG/ML IV SYRINGE (PEDS/NEO),50863,CDM,250,RC,J0612,HCPCS,63323-311-10,NDC,facility,both,57,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IVABRADINE 5 MG ORAL TAB,50863,CDM,250,RC,31722-053-60,NDC,,,facility,both,1,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  10 MG ORAL TR12,50863,CDM,250,RC,J3490,HCPCS,59011-410-20,NDC,facility,both,1,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,863,ME,JZ,11711,8197.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
TAMSULOSIN 0.4 MG ORAL CP24,50863,CDM,636,RC,J3490,HCPCS,50268-740-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,100,ML,,675,472.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PORACTANT ALFA 240 MG/3 ML INTR SUSP,50863,CDM,250,RC,J3490,HCPCS,10122-510-01,NDC,facility,both,3,ML,,4728,3309.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLP",50863,CDM,250,RC,P9047,HCPCS,0944-0493-04,NDC,facility,both,2,ML,,501,350.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN NEO/PEDIATRIC SYRINGE < 30 MG,50863,CDM,250,RC,J1650,HCPCS,0548-5608-00,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM NEO/PEDS (CDS MIXTURE),50863,CDM,636,RC,J0295,HCPCS,63323-368-20,NDC,facility,both,1,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,170,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-41,NDC,facility,both,80,ML,"JZ,JA",11315,7920.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
ROPIVACAINE 0.5%/EPINEPHRINE 1:100K INJECTION,50863,CDM,250,RC,J2795,HCPCS,63323-286-30,NDC,facility,both,150,ML,,128,89.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,80,EA,,11040,7728,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,43353-298-30,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 1 MG ORAL TAB,50863,CDM,250,RC,J8540,HCPCS,72578-166-01,NDC,facility,both,8,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,50,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PEG 3350-ELECTROLYTES 236 G-22.74 G-6.74 G-5.86 G ORAL SOLUTION,50863,CDM,636,RC,J3490,HCPCS,43386-090-19,NDC,facility,both,1,ML,,157,109.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIPASE-PROTEASE-AMYLASE 12,000-38,000- 60,000 UNIT ORAL CAP, DELAY REL",50863,CDM,636,RC,J3490,HCPCS,0032-0047-70,NDC,facility,both,3,EA,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-440-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 50 MG CAP,50863,CDM,250,RC,Q0163,HCPCS,0603-3340-21,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0003-0894-21,NDC,facility,both,1,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,636,RC,J2405,HCPCS,60505-6130-0,NDC,facility,both,3,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,636,RC,J1953,HCPCS,0409-1886-22,NDC,facility,both,300,ML,,156,109.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FELBAMATE 400 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,62559-730-01,NDC,facility,both,2,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,39,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN  325 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,66553-001-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,68180-441-01,NDC,facility,both,7,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE MONONITRATE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,7733393425,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-9558-05,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,70095-026-01,NDC,facility,both,2,ML,,134,93.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAZOSIN 2 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7021-61,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,J0690,HCPCS,0143-9924-90,NDC,,,facility,both,4,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INDIGOTINDISULFONATE SODIUM 8 MG/ML INJ SOLN,50863,CDM,636,RC,J9220,HCPCS,17478-508-01,NDC,facility,both,40,ML,JZ,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,250,RC,J7060,HCPCS,0338-0017-11,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  7.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,43598-165-30,NDC,facility,both,2,EA,,158,110.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL  25 MCG/HR TD PT72,50863,CDM,250,RC,J3490,HCPCS,0378-9121-98,NDC,facility,both,1,EA,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,13,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RASBURICASE 1.5 MG IV SOLR,50863,CDM,250,RC,J2783,HCPCS,0024-5154-11,NDC,facility,both,1,EA,,1231,861.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4% TOP PATCH,50863,CDM,636,RC,J3490,HCPCS,0121-0970-01,NDC,facility,both,2,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL,50863,CDM,250,RC,J3490,HCPCS,63323-820-01,NDC,facility,both,1,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-595-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,636,RC,J2003,HCPCS,63323-485-27,NDC,facility,both,55,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOPIDOGREL 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6467-10,NDC,facility,both,1,EA,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,13668-010-01,NDC,facility,both,2,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65862-006-01,NDC,facility,both,2,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,636,RC,P9045,HCPCS,68516-5219-0,NDC,facility,both,10,ML,JZ,2542,1779.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CYCLOSPORINE 100 MG ORAL CAP,50863,CDM,250,RC,J7502,HCPCS,0078-0241-61,NDC,facility,both,3,EA,,274,191.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  20 MEQ ORAL PACK,50863,CDM,636,RC,J3490,HCPCS,69543-451-01,NDC,facility,both,2,EA,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYL SALICYLATE-MENTHOL 15-1 % TOPICAL CREAM,50863,CDM,250,RC,J3490,HCPCS,0536-1101-45,NDC,facility,both,1,GM,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CINACALCET 30 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-525-11,NDC,facility,both,24,EA,,447,312.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,250,RC,J2405,HCPCS,23155-549-31,NDC,facility,both,4,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ASPIRIN  325 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0536-1054-29,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,3,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-325-11,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,68382-444-05,NDC,facility,both,3,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZOCAINE 20 % MM SPRY,50863,CDM,250,RC,J3490,HCPCS,0283-0610-43,NDC,facility,both,3,EA,,151,105.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FERRIC DERISOMALTOSE 100 MG IRON/ML IV SOLN,50863,CDM,J1437,HCPCS,73594-9310-1,NDC,,,facility,both,100,ML,,8962,6273.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE HCL IN 5% DEXTROSE 100 MCG/10 ML (10 MCG/ML) IV SYRG,50863,CDM,636,RC,J0169,HCPCS,70092-1688-46,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG/ML INJ SOLN,50863,CDM,J2550,HCPCS,0641-6084-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 160 MG-800 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0904-2725-61,NDC,facility,both,8,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  1 MG/ML INJ SYRG,50863,CDM,250,RC,J1170,HCPCS,0409-1283-10,NDC,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN NPH HUMAN RECOMB 100 UNIT/ML SUBQ SUSP,50863,CDM,636,RC,J1815,HCPCS,0169-1834-11,NDC,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,150,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-344-11,NDC,facility,both,1,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51407-153-90,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-344-11,NDC,facility,both,2,EA,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-9558-05,NDC,facility,both,3,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,250,RC,J0330,HCPCS,31722-981-10,NDC,facility,both,3,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-520-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,69918-899-01,NDC,facility,both,3,ML,JW,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
TAMOXIFEN 10 MG ORAL TAB,50863,CDM,250,RC,J9999,HCPCS,59651-299-60,NDC,facility,both,2,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRIMIDONE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0527-1301-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68180-980-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE SODIUM 25 MG/ML INJ SOLN,50863,CDM,636,RC,J9260,HCPCS,63323-123-10,NDC,facility,both,2,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESALAMINE  250 MG ORAL CPSR,50863,CDM,250,RC,J3490,HCPCS,54092-189-81,NDC,facility,both,2,EA,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 30 MG ORAL CPDR,50863,CDM,636,RC,J3490,HCPCS,27241-098-09,NDC,facility,both,2,EA,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 75 MG/5 ML ORAL SOLUTION,50863,CDM,250,RC,J3490,HCPCS,64980-511-10,NDC,facility,both,14,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 125 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-519-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 2 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,63323-489-02,NDC,facility,both,200,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INEBILIZUMAB-CDON 10 MG/ML IV SOLN,50863,CDM,636,RC,J1823,HCPCS,75987-150-01,NDC,facility,both,300,ML,,694691,486283.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIROFIBAN-0.9% SODIUM CHLORIDE 5 MG/100 ML (50 MCG/ML) IV SOLN,50863,CDM,636,RC,J3246,HCPCS,25208-002-01,NDC,facility,both,20,ML,JZ,398,278.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
VANCOMYCIN  500 MG IV SOLR,50863,CDM,250,RC,J3370,HCPCS,0409-4332-11,NDC,facility,both,1,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,2,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE SODIUM 2.5 MG ORAL TAB,50863,CDM,250,RC,J8610,HCPCS,50268-527-11,NDC,facility,both,1,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0054-0710-20,NDC,facility,both,14,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MANNITOL 25 % IV SOLN,50863,CDM,250,RC,J2150,HCPCS,63323-024-01,NDC,facility,both,10,ML,,402,281.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,111,77.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,81033-002-05,NDC,facility,both,3,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN SODIUM EXTENDED 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,65862-692-01,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,25021-468-10,NDC,facility,both,1,EA,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  75 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-495-11,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,636,RC,J1815,HCPCS,0088-2220-33,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0406-5771-23,NDC,facility,both,20,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,J2405,HCPCS,0641-6078-25,NDC,,,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,50863,CDM,J1644,HCPCS,25021-402-01,NDC,,,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-1749-70,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,J7030,HCPCS,0264-7800-00,NDC,,,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,84,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,50863,CDM,250,RC,J9000,HCPCS,0069-1542-20,NDC,facility,both,10,ML,,152,106.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,J3010,HCPCS,0409-9094-22,NDC,,,facility,both,2,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,J3490,HCPCS,77333-049-25,NDC,,,facility,both,4,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,63323-806-13,NDC,facility,both,7,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  20 MEQ ORAL PACK,50863,CDM,250,RC,J3490,HCPCS,69543-451-01,NDC,facility,both,3,EA,,150,105,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM NEO/PEDS INFUSION (CDS MIXTURE),50863,CDM,250,RC,J2543,HCPCS,0206-8852-08,NDC,facility,both,2,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATED 20 MG/ML IV SOLN,50863,CDM,250,RC,J0706,HCPCS,51754-0500-1,NDC,facility,both,14,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,63323-010-94,NDC,facility,both,6,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
REGADENOSON 0.4 MG/5 ML IV SYRG,50863,CDM,636,RC,J2785,HCPCS,0469-6501-89,NDC,facility,both,4,ML,JA,913,639.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
OLANZAPINE 10 MG IM SOLR,50863,CDM,250,RC,J2359,HCPCS,55150-308-01,NDC,facility,both,5,EA,JZ,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,63323-104-25,NDC,facility,both,9,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT 25 MCG/0.42 ML INJ SYRG,50863,CDM,636,RC,J0881,HCPCS,55513-057-01,NDC,facility,both,25,ML,"JZ,EC",836,585.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier EC: Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,70436-030-82,NDC,facility,both,138,ML,JZ,108,75.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-466-17,NDC,facility,both,100,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,980,ME,JZ,13299,9309.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,0641-6174-01,NDC,facility,both,4,ML,JB,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JB: Administered subcutaneously
LEVOFLOXACIN 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6352-61,NDC,facility,both,1,EA,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 20 MG/ML INJ SOLN,50863,CDM,250,RC,J0360,HCPCS,0641-6231-01,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0121-1781-05,NDC,facility,both,2,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICLOFENAC 1 % TOPICAL GEL,50863,CDM,250,RC,J3490,HCPCS,58602-604-07,NDC,facility,both,1,GM,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9% IV (PEDS) BOLUS,50863,CDM,250,RC,J7040,HCPCS,0264-7800-09,NDC,facility,both,2,ML,PLAD,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,63323-400-01,NDC,facility,both,242,ML,,254,177.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-406-03,NDC,facility,both,1,ML,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAZOSIN 1 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,51079-630-01,NDC,facility,both,5,EA,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 3000 MCG/ML INJECTION,50863,CDM,636,RC,J0153,HCPCS,67457-855-02,NDC,facility,both,12,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,63323-010-02,NDC,facility,both,4,ML,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TERBUTALINE 1 MG/ML SUBQ SOLN,50863,CDM,250,RC,J3105,HCPCS,63323-665-01,NDC,facility,both,50,ML,,5780,4046,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIRMATRELVIR-RITONAVIR 300-100 MG ORAL TAB DOSEPACK (FOR ED/IP TAKE HOME PANEL),50863,CDM,250,RC,J3490,HCPCS,0069-5321-03,NDC,facility,both,30,EA,,4010,2807,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % MUCOSAL SOLN (VISCOUS),50863,CDM,250,RC,J3490,HCPCS,0054-0548-44,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0093-4155-73,NDC,facility,both,6,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,15,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-02,NDC,facility,both,2,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CINACALCET 30 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16729-440-15,NDC,facility,both,1,EA,,150,105,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-087-11,NDC,facility,both,1,EA,,150,105,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN SODIUM EXTENDED 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0071-0369-40,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-495-27,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOBUTAMINE IN D5W 500 MG/250 ML (2 MG/ML) INFUSION (PREMIX),50863,CDM,250,RC,J1250,HCPCS,0338-1075-02,NDC,facility,both,2,ML,JZ,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CYANOCOBALAMIN 1000 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,904740361,NDC,facility,both,5,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,23155-724-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68382-181-01,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7243-61,NDC,facility,both,6,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,50863,CDM,250,RC,J9045,HCPCS,0703-4239-01,NDC,facility,both,10,ML,,267,186.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIBUCAINE 1 % TOP OINT,50863,CDM,250,RC,J3490,HCPCS,71399-2829-1,NDC,facility,both,1,GM,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOLIC ACID  1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-681-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,J1644,HCPCS,0409-2720-31,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,0143-9577-01,NDC,,,facility,both,70,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MANNITOL 20% IV SOLP,50863,CDM,J2150,HCPCS,0990-7715-13,NDC,,,facility,both,1,ML,,113,79.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,J1611,HCPCS,0597-0053-45,NDC,,,facility,both,1,EA,,742,519.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,J3490,HCPCS,68180-150-01,NDC,,,facility,both,2,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,J2704,HCPCS,25021-608-20,NDC,,,facility,both,10,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLP",50863,CDM,P9047,HCPCS,0944-0493-04,NDC,,,facility,both,8,ML,,2001,1400.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-988-01,NDC,facility,both,2,EA,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZTREONAM 2 GRAM INJ SOLR,50863,CDM,636,RC,J0457,HCPCS,63323-402-01,NDC,facility,both,20,EA,,292,204.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SULFASALAZINE 500 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,59762-0104-5,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-8515-23,NDC,facility,both,2,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,42858-001-10,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE-DIPHENHYD-AL-MAG-SIM 200-25-400-40 MG/30 ML MM MWSH,50863,CDM,250,RC,J3490,HCPCS,65628-050-01,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE SODIUM 25 MG/ML INJ SOLN,50863,CDM,250,RC,J9260,HCPCS,61703-350-37,NDC,facility,both,112,ML,,5379,3765.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,250,RC,J0137,HCPCS,55150-307-01,NDC,facility,both,13,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,636,RC,P9045,HCPCS,68516-5218-0,NDC,facility,both,2,ML,JZ,402,281.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-02,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MILRINONE INFUSION PED/NEO IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J2260,HCPCS,99999-0406-25,NDC,facility,both,2,ML,,139,97.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETIRIZINE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-5852-61,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-453-11,NDC,facility,both,4,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPAGLIFLOZIN PROPANEDIOL 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0310-6210-39,NDC,facility,both,1,EA,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 250 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,0904-6363-45,NDC,facility,both,5,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERGOCALCIFEROL (VITAMIN D2) 50000 UNIT ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,69452-151-20,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-2051-15,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE IN D5W 1 GRAM/100 ML IV PGBK,50863,CDM,250,RC,J3475,HCPCS,0338-1709-40,NDC,facility,both,8,ML,,171,119.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,636,RC,J3490,HCPCS,0409-4887-17,NDC,facility,both,1,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PACLITAXEL 6 MG/ML IV CONC,50863,CDM,250,RC,J9267,HCPCS,61703-342-22,NDC,facility,both,49,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN DEXTROSE (ISO-OSMOTIC) 1 GRAM/50 ML IV PIGGY BACK,50863,CDM,636,RC,J0690,HCPCS,0338-3503-41,NDC,facility,both,2,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,16714-016-01,NDC,facility,both,12,ML,,157,109.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,0409-3178-01,NDC,,,facility,both,40,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,63323-578-03,NDC,facility,both,4,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,J7040,HCPCS,0338-0049-41,NDC,,,facility,both,2,ML,,338,236.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,68180-723-05,NDC,facility,both,4,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69315-905-01,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FELODIPINE  5 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,68462-234-01,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,3,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-7124-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,250,RC,J0131,HCPCS,55150-307-01,NDC,facility,both,31,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE 10 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-6371-61,NDC,,,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE  5 MG ORAL TAB,50863,CDM,J3490,HCPCS,60687-620-11,NDC,,,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE-VITAMIN D3 250 MG-125 UNIT TAB,50863,CDM,250,RC,J3490,HCPCS,904188260,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL 20 MG/5 ML ORAL ELIX,50863,CDM,250,RC,J3490,HCPCS,0121-0942-05,NDC,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,12,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,42806-150-33,NDC,facility,both,4,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOMYCIN-BACITRACN ZN-POLYMYXIN 3.5 MG-400 U*,50863,CDM,636,RC,J3490,HCPCS,45802-143-00,NDC,facility,both,5,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOCARNITINE 200 MG/ML IV SOLN,50863,CDM,J3490,HCPCS,54482-147-01,NDC,,,facility,both,2,ML,,446,312.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOCARNITINE 200 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,54482-147-01,NDC,facility,both,6,ML,,1369,958.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 15 MG/ML (1.5 %) INJ SOLN,50863,CDM,250,RC,J2003,HCPCS,0409-4776-10,NDC,facility,both,150,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN PEDS SYRINGE (20MG/ML) IN DEXTROSE (CDS MIX,50863,CDM,636,RC,J0690,HCPCS,0781-3451-70,NDC,facility,both,1,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7124-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 50 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,68084-666-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TAB,50863,CDM,636,RC,J3490,HCPCS,71205-909-30,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL  25 MCG/HR TD PT72,50863,CDM,636,RC,J3490,HCPCS,47781-424-11,NDC,facility,both,1,EA,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SCOPOLAMINE TRANSDERMAL PATCH 1MG OVER 3 DAYS,50863,CDM,250,RC,J3490,HCPCS,50742-505-01,NDC,facility,both,1,EA,,113,79.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-351-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN (NEO),50863,CDM,250,RC,J1940,HCPCS,71288-203-10,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,250,RC,J2270,HCPCS,0409-1890-03,NDC,facility,both,1,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,250,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,636,RC,J3010,HCPCS,0409-9094-12,NDC,facility,both,2,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,5,EA,,159,111.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE (FOR CODE) 10% IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0517-6710-01,NDC,facility,both,1,ML,,119,83.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,5,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,43598-053-11,NDC,facility,both,18,ML,,645,451.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0780,HCPCS,0713-0351-02,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,61442-121-10,NDC,facility,both,2,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25 MG-100 MG TAB,50863,CDM,636,RC,J3490,HCPCS,59651-457-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE  5 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,31722-185-01,NDC,facility,both,2,EA,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE-DEXTROSE-WATER(PF) 7.5 MG/ML (0.75 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,71351-022-10,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-245-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-4279-16,NDC,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) MISC SOLN,50863,CDM,250,RC,J3490,HCPCS,0517-7604-01,NDC,facility,both,1,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0047-03,NDC,facility,both,12,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLP",50863,CDM,636,RC,P9047,HCPCS,0944-0493-04,NDC,facility,both,2,ML,JZ,501,350.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MORPHINE (PF-DURAMORPH/ASTRAMORPH) 0.5 MG/ML INJ SOLN,50863,CDM,636,RC,J2274,HCPCS,0409-3814-11,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOLIC ACID  1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7224-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,76045-009-10,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEFLUNOMIDE  10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-477-11,NDC,facility,both,2,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0093-4177-73,NDC,facility,both,8,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,71288-505-02,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,0904-6923-61,NDC,facility,both,60,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,0409-4887-17,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,636,RC,J0690,HCPCS,44567-707-25,NDC,facility,both,4,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PYRIDOSTIGMINE BROMIDE  60 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6622-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 20 GRAM/500 ML IV SOLP,50863,CDM,636,RC,J3475,HCPCS,63323-106-15,NDC,facility,both,40,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0121-0431-30,NDC,facility,both,2,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,636,RC,J0330,HCPCS,31722-981-10,NDC,facility,both,8,ML,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,49884-849-01,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOBRAMYCIN 0.3 % EYE OINTMENT,50863,CDM,250,RC,J3490,HCPCS,0078-0813-01,NDC,facility,both,1,GM,,992,694.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE MALEATE 10 MG ORAL TAB,50863,CDM,250,RC,Q0164,HCPCS,50268-685-11,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,636,RC,J7060,HCPCS,0338-0017-02,NDC,facility,both,1,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,0517-4605-25,NDC,facility,both,5,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON DEXTRAN 50 MG/ML INJ SOLN,50863,CDM,250,RC,J1750,HCPCS,0023-6082-01,NDC,facility,both,32,ML,,3334,2333.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,55150-202-00,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,636,RC,J1610,HCPCS,63323-596-11,NDC,facility,both,2,EA,JZ,1570,1099,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MELATONIN  3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,2055503600,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-333-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,67877-432-03,NDC,facility,both,1,EA,,157,109.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE (POLACRILEX) 2 MG MM LOZG,50863,CDM,250,RC,J3490,HCPCS,1093919344,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN  2.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-027-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-21,NDC,facility,both,10,ML,"JZ,JA",1415,990.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
ALPRAZOLAM 0.25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-647-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J1940,HCPCS,72603-251-01,NDC,facility,both,3,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 10 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,70954-261-10,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,0517-4620-25,NDC,facility,both,3,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM 500 MG IV SOLR,50863,CDM,250,RC,J2185,HCPCS,70121-1454-7,NDC,facility,both,5,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,129,EA,,17802,12461.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,250,RC,J3101,HCPCS,50242-037-06,NDC,facility,both,31,EA,JW,5824,4076.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,250,RC,J3490,HCPCS,0143-9575-01,NDC,facility,both,1000,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  1 MG/ML IV SOLN,50863,CDM,250,RC,J1800,HCPCS,63323-604-00,NDC,facility,both,5,ML,,337,235.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXRAZOXANE 500 MG IV SOLR,50863,CDM,250,RC,J1190,HCPCS,55150-435-01,NDC,facility,both,2,EA,,1292,904.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 5 MG/ML IV SOLN,50863,CDM,250,RC,J1921,HCPCS,0409-2267-54,NDC,facility,both,1,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0456,HCPCS,55150-174-10,NDC,facility,both,1,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THROMBIN (RECOMBINANT) 20000 UNIT TOP SOLR,50863,CDM,250,RC,J3490,HCPCS,0338-0328-01,NDC,facility,both,1,EA,,1218,852.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADVATE: FACTOR VIII CONCENTRATE (MERGE RECORD),50863,CDM,J7209,HCPCS,0944-3053-02,NDC,,,facility,both,3000,UN,,12558,8790.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE  4 MG ORAL TAB,50863,CDM,J7509,HCPCS,68084-149-11,NDC,,,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 300 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,65162-649-78,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0003-0894-31,NDC,facility,both,6,EA,,309,216.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OBINUTUZUMAB 900 MG IN NS 286 ML (STOCK DOSE),50863,CDM,J9301,HCPCS,50242-070-01,NDC,,,facility,both,100,ML,,15450,10815,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0093-3426-01,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 10 MG TAB,50863,CDM,250,RC,Q0177,HCPCS,63739-483-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTAZIDIME-AVIBACTAM 2.5 GRAM (2 GRAM-0.5 GRAM) IV SOLR,50863,CDM,250,RC,J0714,HCPCS,0456-2700-01,NDC,facility,both,4,EA,,1471,1029.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETIRIZINE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16571-401-10,NDC,facility,both,2,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYBUTYNIN CHLORIDE  5 MG ORAL TO24,50863,CDM,250,RC,J3490,HCPCS,68084-480-11,NDC,facility,both,4,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-113-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DORZOLAMIDE 2 % OPHT DROP,50863,CDM,636,RC,J3490,HCPCS,24208-485-10,NDC,facility,both,1,ML,,225,157.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,250,RC,J0330,HCPCS,31722-981-10,NDC,facility,both,9,ML,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM 500 MG IV SOLR,50863,CDM,250,RC,J2185,HCPCS,55150-207-20,NDC,facility,both,5,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6993-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG ORAL TB12,50863,CDM,250,RC,J3490,HCPCS,60687-583-11,NDC,facility,both,2,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 875 MG-125 MG TAB,50863,CDM,250,RC,J3490,HCPCS,16714-014-02,NDC,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESNA 100 MG/ML IV SOLN,50863,CDM,250,RC,J9209,HCPCS,0338-1305-01,NDC,facility,both,2,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 2 MG/ML SUSPENSION,50863,CDM,250,RC,J3490,HCPCS,0009-0031-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TORSEMIDE  20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-756-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALSARTAN  80 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-623-11,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/0.5 ML INHL NEBU,50863,CDM,636,RC,J3490,HCPCS,0487-9901-30,NDC,facility,both,8,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN  0.4 UNITS/ML IV SOLN,50863,CDM,636,RC,J2598,HCPCS,42023-219-01,NDC,facility,both,40,ML,JZ,1173,821.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
VANCOMYCIN IN 0.9 % SODIUM CHL 2 GRAM/500 ML IV SOLN,50863,CDM,636,RC,J3370,HCPCS,71506-019-59,NDC,facility,both,4,ML,,148,103.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 200 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-552-11,NDC,facility,both,3,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAZOLAMIDE SODIUM 500 (100 MG/ML) INJ SOLR,50863,CDM,636,RC,J1120,HCPCS,23155-313-31,NDC,facility,both,1,EA,,233,163.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATENOLOL  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-759-01,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 25 MG/5 ML (5 MG/ML) ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,52652-6001-1,NDC,facility,both,1,ML,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,636,RC,J3373,HCPCS,0143-9162-01,NDC,facility,both,2,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-ABDA 100 MG IV SOLR,50863,CDM,636,RC,Q5104,HCPCS,78206-162-99,NDC,facility,both,68,EA,,14140,9898,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-9543-03,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELATACEPT 250 MG IV SOLR,50863,CDM,636,RC,J0485,HCPCS,0003-0371-13,NDC,facility,both,500,EA,JZ,5159,3611.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PAMIDRONATE 3 MG/ML IV SOLN,50863,CDM,250,RC,J2430,HCPCS,61703-324-18,NDC,facility,both,3,ML,,255,178.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,250,RC,J3490,HCPCS,72485-510-01,NDC,facility,both,1,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7193-06,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  75 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-475-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) NEB SOLUTION,50863,CDM,636,RC,J3490,HCPCS,47335-703-52,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,5,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),50863,CDM,636,RC,J0169,HCPCS,76329-3318-1,NDC,facility,both,60,ML,,484,338.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,63323-400-01,NDC,facility,both,20,ML,JW,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ENOXAPARIN 30 MG/0.3 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,16714-006-01,NDC,facility,both,6,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELATACEPT 250 MG IV SOLR,50863,CDM,636,RC,J0485,HCPCS,0003-0371-13,NDC,facility,both,50,EA,JW,225,157.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,6,ML,JW,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ISOSULFAN BLUE 1 % INJ SOLN,50863,CDM,636,RC,Q9968,HCPCS,67457-220-00,NDC,facility,both,40,ML,,3439,2407.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPRAZOLAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0228-2029-10,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,16714-294-01,NDC,facility,both,7,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRIL MALEATE 1 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,52652-4001-1,NDC,facility,both,1,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  75 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,68084-709-11,NDC,facility,both,4,EA,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML INJECTION,50863,CDM,250,RC,J3411,HCPCS,25021-500-02,NDC,facility,both,4,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL,50863,CDM,250,RC,J3490,HCPCS,63323-820-01,NDC,facility,both,2,ML,,256,179.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,16714-294-01,NDC,facility,both,4,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 1 MG/ML PCA (PDS MERGE),50863,CDM,250,RC,J3490,HCPCS,61553-820-41,NDC,facility,both,1,ML,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-04,NDC,facility,both,5,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,0409-1886-22,NDC,facility,both,40,ML,JW,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,250,RC,J2405,HCPCS,70860-776-41,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,250,RC,J0137,HCPCS,0264-4100-90,NDC,facility,both,13,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,636,RC,J3490,HCPCS,63323-485-27,NDC,facility,both,60,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 10 MG/5 ML SYRUP,50863,CDM,250,RC,Q0177,HCPCS,54838-502-80,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,25021-674-20,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL DECANOATE 100 MG/ML IM SOLN,50863,CDM,250,RC,J1631,HCPCS,70069-383-10,NDC,facility,both,2,ML,,238,166.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0137,HCPCS,0143-9386-01,NDC,facility,both,23,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,33,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEFIBROTIDE 80 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,68727-800-01,NDC,facility,both,2,ML,,2451,1715.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 250 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,0904-6860-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALACYCLOVIR 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-215-11,NDC,facility,both,2,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB 100 MG IV SOLR,50863,CDM,636,RC,J1745,HCPCS,57894-030-01,NDC,facility,both,4,EA,JW,561,392.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
RAMIPRIL 10 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,65862-477-01,NDC,facility,both,2,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOCARNITINE 200 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,54482-147-01,NDC,facility,both,1,ML,,229,160.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN  4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51672-4031-1,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 0.3 % OPHT DROP,50863,CDM,636,RC,J3490,HCPCS,69315-308-02,NDC,facility,both,1,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN LOCK FLUSH (PORCINE)  10 UNIT/ML IV SOLN,50863,CDM,636,RC,J1642,HCPCS,63323-544-01,NDC,facility,both,45,ML,,502,351.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 250 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,0904-6860-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-342-11,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,63323-165-01,NDC,facility,both,12,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLOPATADINE 0.1 % OPHT DROP,50863,CDM,250,RC,J3490,HCPCS,51407-663-05,NDC,facility,both,1,ML,,187,130.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) NEB SOLUTION,50863,CDM,250,RC,J3490,HCPCS,0378-8270-31,NDC,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN  0.4 UNITS/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,42023-219-01,NDC,facility,both,40,ML,,1173,821.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25 MG-250 MG TAB,50863,CDM,250,RC,J3490,HCPCS,50228-459-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DROPERIDOL 2.5 MG/ML INJ SOLN,50863,CDM,636,RC,J1790,HCPCS,0517-9702-01,NDC,facility,both,2,ML,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 500 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,68084-415-11,NDC,facility,both,2,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  20 MEQ ORAL PACK,50863,CDM,250,RC,J3490,HCPCS,0245-0360-89,NDC,facility,both,1,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE SODIUM 2.5 MG ORAL TAB,50863,CDM,250,RC,J8610,HCPCS,0555-0572-02,NDC,facility,both,1,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES  8.6 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,71399-1017-3,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-492-27,NDC,facility,both,100,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,250,RC,J3490,HCPCS,25021-415-10,NDC,facility,both,2,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,636,RC,J0330,HCPCS,0409-6629-02,NDC,facility,both,7,ML,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPRAZOLAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-388-11,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,132,ML,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 500 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,0904-6861-61,NDC,facility,both,1,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,55150-177-05,NDC,facility,both,125,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE (CONTRACEPTIVE) 150 MG/ML IM SUSP,50863,CDM,250,RC,J1050,HCPCS,0548-5400-00,NDC,facility,both,150,ML,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 60 MG ORAL CPDR,50863,CDM,636,RC,J3490,HCPCS,60687-745-11,NDC,facility,both,2,EA,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  88 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42292-038-01,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,250,RC,J2270,HCPCS,63323-454-00,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,50863,CDM,250,RC,J0640,HCPCS,71288-161-20,NDC,facility,both,3,EA,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6638-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,636,RC,Q9968,HCPCS,70710-1838-1,NDC,facility,both,25,ML,JW,141,98.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,636,RC,Q9968,HCPCS,71288-811-10,NDC,facility,both,25,ML,JW,141,98.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
METHYLPHENIDATE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-805-11,NDC,facility,both,3,EA,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  50 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-484-11,NDC,facility,both,3,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN ASP PRT-INSULIN ASPART 100 UNIT/ML (70-30) SUBQ SOLN,50863,CDM,250,RC,J1817,HCPCS,73070-200-11,NDC,facility,both,2,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 1%/EPINEPHRINE 1:200K INJECTION (PF),50863,CDM,250,RC,J3490,HCPCS,63739-468-05,NDC,facility,both,2,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,63323-506-01,NDC,facility,both,6,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYLAMINE SUCCINATE 25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,4116700607,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 20 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,60687-725-11,NDC,facility,both,2,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,50863,CDM,636,RC,FAMNOCHARGE,HCPCS,0054-8175-25,NDC,facility,both,3,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACCHAROMYCES BOULARDII 250 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,7733380050,NDC,facility,both,4,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADVATE: FACTOR VIII CONCENTRATE (MERGE RECORD),50863,CDM,250,RC,J7192,HCPCS,0944-3052-03,NDC,facility,both,500,UN,,2093,1465.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  75 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-856-11,NDC,facility,both,3,EA,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,250,RC,Q0162,HCPCS,16714-671-02,NDC,facility,both,2,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) MISC SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-694-41,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIFEDIPINE 10 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7229-61,NDC,facility,both,3,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 1000 MG MISC TBSO,50863,CDM,250,RC,J3490,HCPCS,77333-844-25,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0075-0622-01,NDC,facility,both,5,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,250,RC,J3490,HCPCS,81284-611-00,NDC,facility,both,2,ML,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0143-9889-15,NDC,facility,both,20,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM NEO/PEDS INFUSION (CDS MIXTURE),50863,CDM,250,RC,J2543,HCPCS,0206-8852-08,NDC,facility,both,1,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PALONOSETRON 0.25 MG/5 ML IV INJECTION (MERGE),50863,CDM,250,RC,J2469,HCPCS,36000-326-02,NDC,facility,both,10,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,25021-701-01,NDC,facility,both,1,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,0143-9577-01,NDC,,,facility,both,75,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOCILIZUMAB-AAZG 80 MG/4 ML (20 MG/ML) IV SOLN,50863,CDM,636,RC,Q5135,HCPCS,65219-590-04,NDC,facility,both,360,ML,,6240,4368,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,J0665,HCPCS,63323-466-09,NDC,,,facility,both,300,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 1% 10MG/ML (1ML-UD) OR SYRINGE,50863,CDM,J2003,HCPCS,0409-4276-02,NDC,,,facility,both,50,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MILRINONE IN D5W 20 MG/100 ML (0.2 MG/ML) INFUSION,50863,CDM,250,RC,J2260,HCPCS,0409-2045-01,NDC,facility,both,3,ML,JW,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
METHOCARBAMOL 100 MG/ML INJ SOLN,50863,CDM,636,RC,J2800,HCPCS,0641-6103-01,NDC,facility,both,1,ML,,165,115.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,J3490,HCPCS,0409-1638-02,NDC,,,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC IV INFUSION HYDRAT 31-60 MIN,50863,CDM,250,RC,J0248,HCPCS,61958-2901-2,NDC,facility,both,83,EA,JW,434,303.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
"DIP,PER(A)TET-HEPB-POL-HIB(PF) 15 UNIT-5 UNIT- 10 MCG/0.5 ML IM INJ MERGE (CAM USE ONLY)",50863,CDM,90697,HCPCS,63361-243-88,NDC,,,facility,both,1,ML,,674,471.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN 50 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,60687-156-95,NDC,facility,both,2,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7124-61,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 17 GRAM (100 %) ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,0904-6931-86,NDC,facility,both,14,EA,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 40 MG-200 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,65862-496-47,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOCARNITINE 200 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0143-9852-01,NDC,facility,both,3,ML,,618,432.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,38,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN  300 MG RECT SUPP,50863,CDM,636,RC,J3490,HCPCS,0574-7034-12,NDC,facility,both,2,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,63323-165-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GOLIMUMAB  12.5 MG/ML IV SOLN,50863,CDM,636,RC,J1602,HCPCS,57894-350-01,NDC,facility,both,150,ML,JZ,16554,11587.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PREGABALIN  25 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,69238-1310-9,NDC,facility,both,8,EA,,286,200.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,636,RC,J1953,HCPCS,55150-177-05,NDC,facility,both,450,ML,,180,126,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 1 % INJ SOLN,50863,CDM,250,RC,Q9968,HCPCS,0517-0301-10,NDC,facility,both,10,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL  6.25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-0135-01,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 10 GRAM/15 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,50383-779-30,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPAGLIFLOZIN PROPANEDIOL 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,66993-457-30,NDC,facility,both,1,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 2-0.5 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,0904-7009-06,NDC,facility,both,2,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN SODIUM EXTENDED 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0071-0369-40,NDC,facility,both,3,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAMIDRONATE 3 MG/ML IV SOLN,50863,CDM,250,RC,J2430,HCPCS,61703-324-18,NDC,facility,both,2,ML,,165,115.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % MBP,50863,CDM,250,RC,J3490,HCPCS,0338-0553-18,NDC,facility,both,4,ML,,178,124.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMIDE PEROXIDE 6.5 % OTIC DROP,50863,CDM,250,RC,J3490,HCPCS,0904-6627-35,NDC,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML ORAL SOLUTION (FOR PEDIATRIC USE),50863,CDM,250,RC,J3480,HCPCS,63323-965-05,NDC,facility,both,10,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNITS/1 GRAM PACKET (MERGE RECORD),50863,CDM,636,RC,J3490,HCPCS,0904-7023-67,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,250,RC,J3490,HCPCS,73013-2002-2,NDC,facility,both,6,ML,,133,93.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  2.5 MG ORAL TAB,50863,CDM,250,RC,J7510,HCPCS,59651-485-01,NDC,facility,both,42,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NADOLOL  20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-302-95,NDC,facility,both,2,EA,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,636,RC,J3490,HCPCS,50268-540-11,NDC,facility,both,5,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB 100 MG IV SOLR,50863,CDM,636,RC,J1745,HCPCS,57894-030-01,NDC,facility,both,43,EA,,13860,9702,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,63323-485-27,NDC,,,facility,both,135,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VORICONAZOLE 200 MG IV SOLN,50863,CDM,250,RC,J3465,HCPCS,0781-3416-94,NDC,facility,both,14,EA,JW,112,78.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
NIFEDIPINE 30 MG ORAL TO24,50863,CDM,250,RC,J3490,HCPCS,0904-7208-61,NDC,facility,both,2,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIVASTIGMINE 3 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,33342-090-09,NDC,facility,both,2,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THROMBIN (RECOMBINANT) 5000 UNIT TOP SOLR,50863,CDM,250,RC,J3490,HCPCS,0338-0324-01,NDC,facility,both,1,EA,,149,104.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,23155-001-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",50863,CDM,250,RC,J1561,HCPCS,13533-800-24,NDC,facility,both,80,ML,JA,11316,7921.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
CEPHALEXIN 250 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7336-61,NDC,facility,both,4,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-24,NDC,facility,both,40,ML,,5658,3960.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6376-61,NDC,facility,both,2,EA,,130,91,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK,50863,CDM,636,RC,J3490,HCPCS,12870-0001-2,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,50863,CDM,250,RC,J9025,HCPCS,72485-201-01,NDC,facility,both,20,EA,JW,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0536-1327-06,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,72162-1330-6,NDC,facility,both,1,ML,,138,96.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CELECOXIB 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,50268-168-11,NDC,facility,both,2,EA,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,636,RC,J3490,HCPCS,51079-169-01,NDC,facility,both,4,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,63323-400-01,NDC,facility,both,200,ML,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIROFIBAN-0.9% SODIUM CHLORIDE 5 MG/100 ML (50 MCG/ML) IV SOLN,50863,CDM,250,RC,J3246,HCPCS,25208-002-03,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  500 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,0641-6176-01,NDC,facility,both,20,ML,JZ,206,144.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CARBAMAZEPINE 100 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,51672-4047-9,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
URSODIOL 300 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7168-61,NDC,facility,both,1,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J2003,HCPCS,63323-492-41,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  10 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0054-0237-63,NDC,facility,both,2,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOPAMINE 200 MG/5 ML (40 MG/ML) IV,50863,CDM,250,RC,J1265,HCPCS,0143-9252-01,NDC,facility,both,20,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"KETAMINE IN NACL, 10 MG/ML IV SOLN (PHS MERGE RECORD)",50863,CDM,250,RC,J3490,HCPCS,71266-9081-1,NDC,facility,both,1,ML,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 160 MG-800 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0904-2725-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,250,RC,J7060,HCPCS,0338-0017-02,NDC,facility,both,1,ML,JZ,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"ALBUMIN, HUMAN 25 % IV SOLP",50863,CDM,250,RC,P9047,HCPCS,44206-251-10,NDC,facility,both,1,ML,JW,108,75.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
METHYLENE BLUE (ANTIDOTE) 1 % INJ SOLN,50863,CDM,636,RC,Q9968,HCPCS,17478-504-01,NDC,facility,both,20,ML,,164,114.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE 110 MCG/ACTUATION INHL AERO,50863,CDM,636,RC,J3490,HCPCS,0173-0719-20,NDC,facility,both,1,GM,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,70954-059-10,NDC,facility,both,50,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,636,RC,J3490,HCPCS,61553-320-70,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIOTHYRONINE 25 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42794-019-12,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68180-980-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTOBACILLUS ACIDOPHILUS 500 MILLION CELLS ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,7733300415,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVALBUTEROL 1.25 MG/3 ML NEB SOLUTION,50863,CDM,250,RC,J3490,HCPCS,35573-445-25,NDC,facility,both,1,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-22,NDC,facility,both,2,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,250,RC,J0330,HCPCS,0409-6629-02,NDC,facility,both,4,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2599,HCPCS,55150-370-01,NDC,facility,both,3,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FINASTERIDE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,31722-526-30,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,31722-711-30,NDC,facility,both,1,EA,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 650 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7261-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,636,RC,J1100,HCPCS,63323-506-41,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-28,NDC,facility,both,24,EA,,130,91,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT  60 MCG/0.3 ML INJ SYRG,50863,CDM,250,RC,J0881,HCPCS,55513-023-01,NDC,facility,both,60,ML,,1282,897.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOZAPINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-922-01,NDC,facility,both,2,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0093-2279-73,NDC,facility,both,8,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 50 % (4 MEQ/ML) INJ SOLN,50863,CDM,250,RC,J3475,HCPCS,63323-064-01,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7047-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE (FOR EMERGENCY) 100 MG/ML (10%) IV SOLN,50863,CDM,250,RC,J0612,HCPCS,63323-360-01,NDC,facility,both,100,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAUNORUBICIN 5 MG/ML IV INJ,50863,CDM,250,RC,J9150,HCPCS,42658-021-01,NDC,facility,both,5,ML,,1420,994,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIOTHYRONINE 10 MCG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,39822-0151-1,NDC,facility,both,2,ML,,2433,1703.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SECUKINUMAB  25 MG/ML IV SOLN,50863,CDM,636,RC,J3247,HCPCS,0078-1168-61,NDC,facility,both,375,ML,,17688,12381.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM  50 MG INJ SOLR,50863,CDM,250,RC,J0640,HCPCS,25021-813-10,NDC,facility,both,1,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,250,RC,J0690,HCPCS,44567-707-25,NDC,facility,both,10,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0054-0710-20,NDC,facility,both,13,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPTOMYCIN IN 0.9 % SOD CHLOR 350 MG/50 ML IV PGBK,50863,CDM,250,RC,J0874,HCPCS,0338-0712-24,NDC,facility,both,1400,ML,,538,376.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,14,ML,JW,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,5,ML,PLAD,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,87,ML,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROGESTERONE MICRONIZED 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,65162-807-10,NDC,facility,both,1,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFUROXIME AXETIL 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,67877-215-60,NDC,facility,both,1,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,67877-545-88,NDC,facility,both,9,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,68180-441-01,NDC,facility,both,4,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J1610,HCPCS,63323-596-11,NDC,facility,both,5,EA,JZ,3924,2746.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DEXAMETHASONE 4 MG ORAL TAB,50863,CDM,636,RC,J8540,HCPCS,0054-8175-25,NDC,facility,both,80,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE ACETATE 25 MG RECT SUPP,50863,CDM,636,RC,J3490,HCPCS,50268-411-11,NDC,facility,both,1,EA,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J3490,HCPCS,0338-0049-01,NDC,facility,both,3,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,636,RC,J2405,HCPCS,70860-776-41,NDC,facility,both,204,ML,,170,119,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-089-11,NDC,facility,both,2,EA,,220,154,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,1,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN LOCK FLUSH 100 UNIT/ML IV SOLN,50863,CDM,636,RC,J1642,HCPCS,6425333335,NDC,facility,both,100,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOLTERODINE 2 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,0904-6592-04,NDC,facility,both,1,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZINC OXIDE 16 % TOP PSTE,50863,CDM,250,RC,J3490,HCPCS,6210333304,NDC,facility,both,1,GM,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-25,NDC,facility,both,28,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER SULFADIAZINE 1 % TOP CREA,50863,CDM,250,RC,J3490,HCPCS,43598-210-55,NDC,facility,both,1,GM,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IVABRADINE 7.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50742-363-60,NDC,facility,both,1,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSULFAN BLUE 1 % INJ SOLN,50863,CDM,636,RC,Q9968,HCPCS,67457-220-00,NDC,facility,both,20,ML,JG,1720,1204,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,50863,CDM,250,RC,J0561,HCPCS,60793-701-02,NDC,facility,both,12,ML,,1080,756,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAMADOL  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-795-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,405,ME,JZ,5496,3847.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,63323-485-01,NDC,,,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"CALCIUM GLUC IN NACL, ISO-OSM 1 G/100 ML IV SOLN",50863,CDM,J0612,HCPCS,44567-622-01,NDC,,,facility,both,200,ML,,149,104.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PORACTANT ALFA 240 MG/3 ML INTR SUSP,50863,CDM,250,RC,J3490,HCPCS,10122-510-01,NDC,facility,both,3,ML,,4960,3472,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE IV CONCENTRATED INFUSION (1 MEQ/ML),50863,CDM,J3490,HCPCS,0409-6625-02,NDC,,,facility,both,1,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,J1953,HCPCS,72205-120-01,NDC,,,facility,both,350,ML,,140,98,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZTREONAM 2 GRAM INJ SOLR,50863,CDM,J0457,HCPCS,0409-0830-11,NDC,,,facility,both,20,EA,,341,238.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN DEXTROSE (ISO-OSMOTIC) 1 GRAM/50 ML IV PIGGY BACK,50863,CDM,250,RC,J0689,HCPCS,0338-3503-41,NDC,facility,both,4,ML,JZ,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"POTASSIUM PHOSPHATE, MONOBASIC 500 MG ORAL TBSO",50863,CDM,250,RC,J3490,HCPCS,0486-1111-01,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,63739-931-14,NDC,facility,both,8,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 10 MG TAB,50863,CDM,636,RC,Q0177,HCPCS,60687-664-11,NDC,facility,both,5,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,2055503600,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,270,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,14789-251-09,NDC,facility,both,1,ML,,155,108.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,250,RC,J0330,HCPCS,31722-981-10,NDC,facility,both,7,ML,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 30 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,51991-747-90,NDC,facility,both,2,EA,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESNA 100 MG/ML IV SOLN,50863,CDM,250,RC,J9209,HCPCS,10019-953-62,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,50863,CDM,636,RC,J0561,HCPCS,60793-701-02,NDC,facility,both,24,ML,JZ,2613,1829.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,14789-127-07,NDC,facility,both,1,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TERAZOSIN  2 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,50268-765-11,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE 0.25 MG/2 ML INHL NBSP,50863,CDM,636,RC,J3490,HCPCS,0186-1988-04,NDC,facility,both,1,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0137,HCPCS,0143-9386-01,NDC,facility,both,96,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN  10 GRAM INJ SOLR,50863,CDM,636,RC,J0690,HCPCS,0143-9983-91,NDC,facility,both,6,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE IN 0.9% NACL 3 GRAM/100 ML IV SOLN,50863,CDM,636,RC,J0612,HCPCS,61553-056-48,NDC,facility,both,300,ML,JZ,128,89.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ADENOSINE (DIAGNOSTIC) 3 MG/ML IV SOLN,50863,CDM,636,RC,J0153,HCPCS,23155-258-32,NDC,facility,both,90,ML,JZ,719,503.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,12,EA,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES  8.6 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69618-064-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOZAPINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-921-01,NDC,facility,both,2,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
URSODIOL 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6221-61,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DONEPEZIL 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-303-11,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,636,RC,J1596,HCPCS,16714-536-01,NDC,facility,both,4,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,250,RC,J2270,HCPCS,0641-6125-01,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  75 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6951-61,NDC,facility,both,1,EA,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,636,RC,J3490,HCPCS,77333-049-25,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-157-11,NDC,facility,both,3,EA,,328,229.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALSARTAN  80 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,31722-152-90,NDC,facility,both,2,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 500 MG-125 MG TAB,50863,CDM,250,RC,J3490,HCPCS,16714-296-01,NDC,facility,both,1,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50580-458-11,NDC,facility,both,2,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,2,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  2.5 MG ORAL TAB,50863,CDM,636,RC,J7510,HCPCS,59651-485-01,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,636,RC,J7510,HCPCS,17856-0815-1,NDC,facility,both,6,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC IV INFUSION HYDRAT 31-60 MIN,50863,CDM,250,RC,J0248,HCPCS,61958-2901-2,NDC,facility,both,50,EA,JW,260,182,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CLINDAMYCIN PEDS IV INFUSION 12 MG/ML (CDS MIXTURE FROM PREMIX),50863,CDM,636,RC,J0736,HCPCS,0781-3289-91,NDC,facility,both,2,ML,JZ,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,636,RC,J3490,HCPCS,25021-415-10,NDC,facility,both,2,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DOBUTAMINE IN D5W 1,000 MG/250 ML (4,000 MCG/ML) IV SOLP",50863,CDM,250,RC,J1250,HCPCS,0338-1077-02,NDC,facility,both,4,ML,,172,120.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,636,RC,J3490,HCPCS,39822-1000-1,NDC,facility,both,2,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,68516-5214-1,NDC,facility,both,3,ML,,670,469,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN PEDS INFUSION (CDS MIXTURE),50863,CDM,250,RC,J0290,HCPCS,99999-408-63,NDC,facility,both,2,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR NEO/PEDS INFUSION (CDS FROM PREMIX),50863,CDM,250,RC,J0133,HCPCS,63323-325-10,NDC,facility,both,9,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,16714-016-01,NDC,facility,both,1,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IRON SUCROSE 100 MG/5 ML IV SOLN,50863,CDM,636,RC,J1756,HCPCS,0517-2340-01,NDC,facility,both,200,ML,JZ,661,462.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"LIPASE-PROTEASE-AMYLASE 24,000-76,000- 120,000 UNIT ORAL CAP, DELAY REL",50863,CDM,636,RC,J3490,HCPCS,0032-2636-01,NDC,facility,both,2,EA,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6773-61,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN  750 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,51224-107-50,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,65862-707-80,NDC,facility,both,20,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 112 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,42292-039-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-157-11,NDC,facility,both,1,EA,,152,106.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-18,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE IN D5W 1 GRAM/100 ML IV PGBK,50863,CDM,636,RC,J3475,HCPCS,0264-4400-54,NDC,facility,both,4,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NYSTATIN  100000 UNIT/G TOP OINT,50863,CDM,636,RC,J3490,HCPCS,45802-048-35,NDC,facility,both,1,GM,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2599,HCPCS,55150-370-01,NDC,facility,both,12,ML,,229,160.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WHITE PETROLATUM-MINERAL OIL TOPICAL CREAM (MERGE),50863,CDM,250,RC,J3490,HCPCS,7214003868,NDC,facility,both,1,GM,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-744-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN  7.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51672-4034-1,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THEOPHYLLINE 300 MG ORAL TB12,50863,CDM,250,RC,J3490,HCPCS,68462-721-01,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN IN D5W 400 MG/200 ML IV PGBK,50863,CDM,250,RC,J0744,HCPCS,0409-3300-01,NDC,facility,both,2,ML,JZ,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
FILGRASTIM 300 (NEUPOGEN) MCG/ML INJ SOLN,50863,CDM,250,RC,J1442,HCPCS,55513-530-01,NDC,facility,both,300,ML,,1115,780.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE  2 MG/ML INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,70069-062-01,NDC,facility,both,3,ML,,133,93.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 250 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,60687-868-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-18,NDC,facility,both,250,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VECURONIUM BROMIDE 10 MG IV SOLR,50863,CDM,636,RC,J3490,HCPCS,0703-2914-01,NDC,facility,both,2,EA,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 150 MG CAP,50863,CDM,250,RC,J3490,HCPCS,68084-243-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,37000-024-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 2-0.5 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,0904-7009-06,NDC,facility,both,2,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MICAFUNGIN 100 MG IV SOLR,50863,CDM,250,RC,J2248,HCPCS,42023-230-01,NDC,facility,both,29,EA,,184,128.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZONATATE 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7153-61,NDC,facility,both,21,EA,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 10 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7345-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 5 MG ORAL CAP,50863,CDM,250,RC,J7507,HCPCS,0904-6624-61,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOCARNITINE 330 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16571-762-09,NDC,facility,both,3,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,6809411059,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENOFIBRATE NANOCRYSTALLIZED 145 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-629-11,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MISOPROSTOL 50 MCG ORAL SPLIT TAB,50863,CDM,250,RC,S0191,HCPCS,60687-735-01,NDC,facility,both,1,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,22,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOBRAMYCIN 0.3 % EYE DROPS,50863,CDM,636,RC,J3490,HCPCS,70069-131-01,NDC,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,71288-402-10,NDC,facility,both,13,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 125 MG ORAL CPSP,50863,CDM,636,RC,J3490,HCPCS,68084-313-11,NDC,facility,both,4,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,16714-016-01,NDC,facility,both,4,ML,JZ,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MESNA 100 MG/ML IV SOLN,50863,CDM,636,RC,J9209,HCPCS,10019-953-62,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,235,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DORZOLAMIDE 2 % OPHT DROP,50863,CDM,250,RC,J3490,HCPCS,42571-141-26,NDC,facility,both,1,ML,,284,198.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,636,RC,J2003,HCPCS,0409-1323-15,NDC,facility,both,1200,ML,,480,336,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZONATATE 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7153-61,NDC,facility,both,10,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESTRADIOL 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0555-0886-02,NDC,facility,both,6,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,636,RC,J0330,HCPCS,69374-919-10,NDC,facility,both,8,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM 1 GRAM IV SOLR,50863,CDM,250,RC,J2185,HCPCS,55150-208-30,NDC,facility,both,10,EA,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISANKIZUMAB-RZAA  60 MG/ML IV SOLN,50863,CDM,636,RC,J2327,HCPCS,0074-5015-01,NDC,facility,both,600,ML,,27931,19551.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBENDAZOLE 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,72205-051-08,NDC,facility,both,2,EA,,1351,945.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,3,ML,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 10 GRAM/15 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0116-4005-30,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 1 MG (ENVARSUS XR) 24-HOUR EXTENDED-RELEASE TABLET,50863,CDM,250,RC,J7508,HCPCS,68992-3010-3,NDC,facility,both,4,EA,,113,79.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0047-27,NDC,facility,both,25,EA,JZ,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CEFDINIR 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,68180-723-05,NDC,facility,both,4,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIMOLOL MALEATE 0.5 % OPHT DROP,50863,CDM,636,RC,J3490,HCPCS,61314-227-05,NDC,facility,both,2,ML,,167,116.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,59762-0073-1,NDC,facility,both,4,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM  3.375 GRAM IV SOLR,50863,CDM,636,RC,J2543,HCPCS,0409-3385-11,NDC,facility,both,3,EA,JZ,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-01,NDC,facility,both,6,ML,,156,109.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  750 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-882-11,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN PEDS INFUSION (CDS MIXTURE),50863,CDM,250,RC,J0290,HCPCS,99999-408-63,NDC,facility,both,2,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51672-4035-1,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TETRACAINE HCL (PF) 0.5 % OPHT DROP (STANDARD STOCK),50863,CDM,J3490,HCPCS,0065-0741-14,NDC,,,facility,both,1,ML,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 40 GRAM/400 ML (10 %) INJ SOLN",50863,CDM,J1561,HCPCS,13533-800-40,NDC,,,facility,both,80,ML,,11316,7921.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZOCAINE 20 % MM SPRY,50863,CDM,J3490,HCPCS,0283-0610-43,NDC,,,facility,both,1,EA,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,J0665,HCPCS,0409-1162-02,NDC,,,facility,both,40,ML,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 600 MG ORAL TP12,50863,CDM,J3490,HCPCS,0536-1163-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 100 MG IV SOLR,50863,CDM,J2997,HCPCS,50242-085-25,NDC,,,facility,both,50,EA,,5281,3696.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ (MERGE),50863,CDM,J2250,HCPCS,0409-0001-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOBENZAPRINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,52817-332-10,NDC,facility,both,2,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES-DOCUSATE SODIUM 8.6 MG-50 MG TAB,50863,CDM,250,RC,J3490,HCPCS,63739-432-02,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 5 MG-325 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0406-0123-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV MBP,50863,CDM,250,RC,J7060,HCPCS,0338-0551-18,NDC,facility,both,1,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIPASE-PROTEASE-AMYLASE (PORK) 36,000-114,000- 180,000 UNIT ORAL CPDR",50863,CDM,636,RC,J3490,HCPCS,0032-3016-13,NDC,facility,both,2,EA,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATRACURIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-1109-11,NDC,facility,both,1,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-4264-11,NDC,facility,both,35,ML,,148,103.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COLCHICINE 0.6 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,59651-455-01,NDC,facility,both,1,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXEPIN 10 MG/ML ORAL CONC,50863,CDM,250,RC,J3490,HCPCS,54838-512-40,NDC,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 2 MG/ML IV SOLN,50863,CDM,250,RC,J9000,HCPCS,25021-207-51,NDC,facility,both,3,ML,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LINEZOLID 600 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0009-5135-02,NDC,facility,both,1,EA,,662,463.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,0641-0477-21,NDC,facility,both,4,ML,,1045,731.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,66553-002-01,NDC,facility,both,4,EA,PLAD,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
ETHOSUXIMIDE 250 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,64380-878-06,NDC,facility,both,2,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEPROTUMUMAB-TRBW 500 MG IV SOLR,50863,CDM,636,RC,J3241,HCPCS,75987-130-15,NDC,facility,both,30,EA,JW,9574,6701.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IRBESARTAN 150 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,33342-048-07,NDC,facility,both,2,EA,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIMOLOL MALEATE 0.5 % OPHT DROP,50863,CDM,250,RC,J3490,HCPCS,60758-801-05,NDC,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL (VITAMIN D3)   400 UNIT ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,7733394825,NDC,facility,both,125,EA,,139,97.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-208-01,NDC,facility,both,8,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-495-27,NDC,facility,both,260,ML,,127,88.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE  7 MG/24 HR TD PT24,50863,CDM,250,RC,J3490,HCPCS,4898500155,NDC,facility,both,3,EA,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLNALTREXONE 12 MG/0.6 ML SUBQ SYRG,50863,CDM,250,RC,J2212,HCPCS,65649-551-07,NDC,facility,both,12,ML,,735,514.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 30% IN WATER (NEO),50863,CDM,250,RC,J7070,HCPCS,0409-6648-16,NDC,facility,both,4,ML,,139,97.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,636,RC,J3490,HCPCS,0409-4887-24,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,11,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ICATIBANT 30 MG/3 ML SUBQ SYRG,50863,CDM,250,RC,J1744,HCPCS,0093-3066-34,NDC,facility,both,30,ML,,29229,20460.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN D5W 20000 UNIT/500 ML,50863,CDM,636,RC,J1644,HCPCS,0264-9567-10,NDC,facility,both,40,ML,,167,116.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 1 MG/ML PCA (PDS MERGE),50863,CDM,250,RC,J2274,HCPCS,61553-820-41,NDC,facility,both,5,ML,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML INJ SOLN,50863,CDM,J0171,HCPCS,76329-9060-0,NDC,,,facility,both,300,ML,,797,557.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 1 MG (ENVARSUS XR) 24-HOUR EXTENDED-RELEASE TABLET,50863,CDM,250,RC,J7508,HCPCS,68992-3010-3,NDC,facility,both,3,EA,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0536-1327-10,NDC,facility,both,3,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,636,RC,J1836,HCPCS,47335-993-01,NDC,facility,both,50,ML,JZ,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
TOBRAMYCIN 1.2 G POWDER VIAL,50863,CDM,250,RC,J3260,HCPCS,39822-0412-6,NDC,facility,both,240,EA,,6360,4452,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ABOBOTULINUMTOXINA 500 UNITS IM SOLR,50863,CDM,636,RC,J0586,HCPCS,15054-0500-1,NDC,facility,both,200,EA,,4212,2948.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,418,ME,JZ,5673,3971.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML SYRUP,50863,CDM,250,RC,J3490,HCPCS,0121-1276-10,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VECURONIUM BROMIDE 10 MG IV SOLR,50863,CDM,636,RC,J3490,HCPCS,0703-2914-01,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN   81 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,77333-031-25,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EZETIMIBE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-373-11,NDC,facility,both,1,EA,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL (VITAMIN D3)   400 UNIT ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,7733394825,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MONTELUKAST  5 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,50268-574-11,NDC,facility,both,2,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COENZYME Q10 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,5789687503,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-327-11,NDC,facility,both,1,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMETHICONE  80 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,77333-812-25,NDC,facility,both,10,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACCHAROMYCES BOULARDII 250 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,7733380050,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML IV,50863,CDM,250,RC,J3490,HCPCS,0641-6013-01,NDC,facility,both,5,ML,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIACIN  250 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,4329255740,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOBRAMYCIN 300 MG/5 ML INHL NEBU (REPACK),50863,CDM,250,RC,J3490,HCPCS,70756-604-44,NDC,facility,both,1,ML,,328,229.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM SR 300 MG 24 HR CAP,50863,CDM,636,RC,J3490,HCPCS,50742-251-30,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN  100 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,5026885211,NDC,facility,both,5,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  10 MG/5 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,0121-0904-05,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,50863,CDM,250,RC,J9000,HCPCS,0069-1542-20,NDC,facility,both,5,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,J2371,HCPCS,0641-6142-25,NDC,,,facility,both,2000,ML,,107,74.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NA FERRIC GLUC CPLX IN SUCROSE 12.5 MG/ML IV SOLN,50863,CDM,250,RC,J2916,HCPCS,0024-2792-01,NDC,facility,both,5,ML,,187,130.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,50863,CDM,J9025,HCPCS,0143-9606-01,NDC,,,facility,both,58,EA,,249,174.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,54288-136-01,NDC,facility,both,1,ML,,159,111.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4 % TOPICAL SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-4698-01,NDC,facility,both,40,ML,,767,536.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FERROUS GLUCONATE 324 MG (38 MG IRON) TAB,50863,CDM,636,RC,J3490,HCPCS,2055501900,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTAMIDINE 300 MG INJ SOLR,50863,CDM,636,RC,J3490,HCPCS,63323-113-01,NDC,facility,both,1,EA,,214,149.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-3178-01,NDC,facility,both,219,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J3490,HCPCS,0338-0049-01,NDC,facility,both,4,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE 8 MG SL SUBL,50863,CDM,636,RC,J3490,HCPCS,0054-0177-13,NDC,facility,both,1,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 800 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6707-06,NDC,facility,both,1,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICLOFENAC 1 % TOPICAL GEL,50863,CDM,250,RC,J3490,HCPCS,67120176,NDC,facility,both,1,GM,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,80,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  25 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-473-11,NDC,facility,both,6,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR 200 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-5789-61,NDC,facility,both,4,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMETREXED 500 MG IV SOLR,50863,CDM,250,RC,J9305,HCPCS,71288-167-50,NDC,facility,both,150,EA,,1944,1360.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTAMIDINE 300 MG INJ SOLR,50863,CDM,636,RC,J3490,HCPCS,63323-113-01,NDC,facility,both,1,EA,,215,150.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN   81 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,17856-3086-1,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,63323-165-01,NDC,facility,both,32,ML,,154,107.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPTOMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0878,HCPCS,0409-0122-01,NDC,facility,both,650,EA,,523,366.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC IV INFUSION HYDRAT 31-60 MIN,50863,CDM,250,RC,J0248,HCPCS,61958-2901-2,NDC,facility,both,200,EA,,2392,1674.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIVAROXABAN 15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50458-578-01,NDC,facility,both,1,EA,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYBUTYNIN CHLORIDE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7027-61,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOTRIMAZOLE  10 MG MM TROC,50863,CDM,636,RC,J3490,HCPCS,0574-0107-70,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-580-11,NDC,facility,both,5,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0264-1800-36,NDC,facility,both,1,ML,,231,161.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYCHLOROQUINE 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7046-61,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE 110 MCG/ACTUATION INHL AERO,50863,CDM,J3490,HCPCS,0173-0719-20,NDC,,,facility,both,1,GM,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ORPHENADRINE CITRATE 30 MG/ML INJ SOLN,50863,CDM,J2360,HCPCS,0641-6182-10,NDC,,,facility,both,1,ML,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DALBAVANCIN 500 MG IV SOLN,50863,CDM,J0875,HCPCS,57970-100-01,NDC,,,facility,both,300,EA,,14732,10312.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,50863,CDM,250,RC,J0696,HCPCS,0143-9856-01,NDC,facility,both,32,EA,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 50 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6323-61,NDC,facility,both,1,EA,PLAD,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG TAB,50863,CDM,250,RC,J3490,HCPCS,65162-271-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2%/EPINEPHRINE 1:200K INJECTION (PF),50863,CDM,250,RC,J3490,HCPCS,0409-3183-01,NDC,facility,both,2,ML,,3390,2373,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EMTRICITABINE-TENOFOVIR 200 MG-300 MG TAB,50863,CDM,250,RC,J0750,HCPCS,0093-7704-56,NDC,facility,both,1,EA,,297,207.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPRAZOLAM 0.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-388-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51672-4027-1,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 875 MG-125 MG TAB,50863,CDM,636,RC,J3490,HCPCS,16714-297-02,NDC,facility,both,20,EA,,417,291.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE 20 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0904-5677-61,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,300,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,250,RC,J2270,HCPCS,0409-1890-03,NDC,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G POTASSIUM 20000000 UNIT INJ SOLR,50863,CDM,250,RC,J2540,HCPCS,70860-127-51,NDC,facility,both,40,EA,,336,235.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 125 MG ORAL CPSP,50863,CDM,250,RC,J3490,HCPCS,63739-995-10,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-1749-70,NDC,facility,both,1,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIVASTIGMINE 1.5 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7107-61,NDC,facility,both,2,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,66794-229-02,NDC,facility,both,2,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 10 MEQ/100 ML IV PGBK (USE NON-PROTOCOL PANEL),50863,CDM,636,RC,J3480,HCPCS,0338-0709-48,NDC,facility,both,15,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LATANOPROST 0.005 % OPHT DROP,50863,CDM,636,RC,J3490,HCPCS,0013-8303-04,NDC,facility,both,1,ML,,936,655.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,250,RC,Q9968,HCPCS,70710-1838-1,NDC,facility,both,115,ML,,1907,1334.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,636,RC,J3370,HCPCS,0143-9162-01,NDC,facility,both,4,EA,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7308-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXAZOSIN 4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-862-95,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7008-61,NDC,facility,both,3,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,50863,CDM,636,RC,J0696,HCPCS,25021-107-20,NDC,facility,both,8,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NORTRIPTYLINE 25 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0093-0811-01,NDC,facility,both,2,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE 150 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16571-110-01,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 100 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,31722-574-47,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXRAZOXANE 500 MG IV SOLR,50863,CDM,250,RC,J1190,HCPCS,55150-435-01,NDC,facility,both,2,EA,,1321,924.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV (BOLUS),50863,CDM,250,RC,J7120,HCPCS,0264-7750-07,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 1 GRAM INJ SOLR,50863,CDM,250,RC,J0692,HCPCS,60505-6146-0,NDC,facility,both,2,EA,JZ,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0630,HCPCS,43598-051-11,NDC,facility,both,1,ML,,5216,3651.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ (MERGE),50863,CDM,J2250,HCPCS,70069-817-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADVATE: FACTOR VIII CONCENTRATE (MERGE RECORD),50863,CDM,250,RC,J7192,HCPCS,0944-3053-02,NDC,facility,both,2000,UN,,8372,5860.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J1610,HCPCS,0597-0053-45,NDC,facility,both,1,EA,JZ,742,519.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CLINDAMYCIN 75 MG/5 ML ORAL SOLUTION,50863,CDM,250,RC,J3490,HCPCS,64980-511-10,NDC,facility,both,14,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG ORAL TB12,50863,CDM,250,RC,J3490,HCPCS,60687-583-11,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,51754-5001-1,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 10 MG/5 ML SYRUP,50863,CDM,250,RC,Q0177,HCPCS,62135-750-47,NDC,facility,both,1,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,50863,CDM,250,RC,J8540,HCPCS,0904-7266-61,NDC,facility,both,18,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-811-11,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,70095-031-01,NDC,facility,both,20,ML,,781,546.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,250,RC,J2720,HCPCS,63323-229-05,NDC,facility,both,10,ML,,182,127.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLMESARTAN  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68462-436-30,NDC,facility,both,1,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE BOLUS PEDS/NEO IV SYRINGE (1.5MG/ML FROM PREMIX),50863,CDM,250,RC,J0282,HCPCS,99999-0405-70,NDC,facility,both,3,ML,,204,142.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,J7040,HCPCS,0338-0049-31,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,0409-3178-16,NDC,,,facility,both,180,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB 10 MG/ML IV CONC,50863,CDM,636,RC,J9312,HCPCS,50242-051-21,NDC,facility,both,10,ML,JZ,2217,1551.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SEVELAMER CARBONATE 800 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-328-11,NDC,facility,both,2,EA,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 50% IN WATER (MERGE RECORD),50863,CDM,250,RC,J7060,HCPCS,0409-4902-64,NDC,facility,both,1,ML,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,77333-049-25,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL  3.125 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6300-61,NDC,facility,both,2,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,636,RC,J3490,HCPCS,63323-185-10,NDC,facility,both,2,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7041-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL  75 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6635-61,NDC,facility,both,2,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GALANTAMINE  4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-729-11,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSAPREPITANT 150 MG IV SOLR,50863,CDM,J1453,HCPCS,63323-972-10,NDC,,,facility,both,150,EA,,540,378,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-453-11,NDC,facility,both,3,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 10 GRAM/15 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,64980-592-95,NDC,facility,both,1,ML,,108,75.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
0.2 MICRON FILTER ATTACHMENT MISC MISC,50863,CDM,250,RC,J3490,HCPCS,99999-0403-06,NDC,facility,both,2,EA,,130,91,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,250,RC,J3490,HCPCS,63037-136-25,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ELECTROLYTE-A IV,50863,CDM,636,RC,J3490,HCPCS,0338-0221-04,NDC,facility,both,1,ML,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 400 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,16714-505-01,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLN (MERGE)",50863,CDM,636,RC,P9047,HCPCS,64208-2512-7,NDC,facility,both,4,ML,,475,332.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE IN D5W 1 GRAM/100 ML IV PGBK,50863,CDM,636,RC,J3475,HCPCS,0409-6727-55,NDC,facility,both,4,ML,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7243-61,NDC,facility,both,14,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,50863,CDM,J0696,HCPCS,0781-3209-90,NDC,,,facility,both,8,EA,,388,271.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.45% (1/2 NS) INFUSION (PEDS ONC),50863,CDM,250,RC,J3490,HCPCS,0264-5804-00,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ECULIZUMAB 300 MG/30 ML IV SOLN,50863,CDM,636,RC,J1299,HCPCS,25682-001-01,NDC,facility,both,300,ML,,34545,24181.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORDIAZEPOXIDE 25 MG CAP,50863,CDM,636,RC,J3490,HCPCS,51079-141-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCUSATE SODIUM 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7183-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 100 MG/ML INJ SOLN,50863,CDM,250,RC,J2800,HCPCS,63323-778-21,NDC,facility,both,1,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL  6.25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6301-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-1283-03,NDC,facility,both,15,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7050,HCPCS,0338-0049-02,NDC,facility,both,4,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL DECANOATE  50 MG/ML IM SOLN,50863,CDM,250,RC,J1631,HCPCS,70069-030-01,NDC,facility,both,1,ML,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,50863,CDM,250,RC,J1885,HCPCS,72266-119-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ESMOLOL IN SALINE (ISO-OSMOTIC) 2,500 MG/250 ML (10 MG/ML) IV",50863,CDM,250,RC,J1805,HCPCS,67457-657-25,NDC,facility,both,1,ML,,1161,812.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPOPROSTENOL (ARGNININE) (VELETRI) CONTINUOUS NEB 1.5 MG IN NS 50 ML,50863,CDM,250,RC,J3490,HCPCS,67457-588-10,NDC,facility,both,12,EA,,243,170.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE (PF) 25 MG/ML INJ SOLN (FOR ECTOPIC PREGNANCY),50863,CDM,636,RC,J9260,HCPCS,0143-9519-01,NDC,facility,both,3,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 2-0.5 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,0904-7009-06,NDC,facility,both,3,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL PACK,50863,CDM,636,RC,J3490,HCPCS,42806-270-98,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE  50 MG ORAL TAB,50863,CDM,j3490,HCPCS,60687-443-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,J3490,HCPCS,0093-2279-73,NDC,,,facility,both,3,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25 MG-250 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6238-61,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,50863,CDM,J3490,HCPCS,0409-2051-15,NDC,,,facility,both,1,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 0.4 MG SL SUBL,50863,CDM,J3490,HCPCS,59762-3304-3,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-174-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 20 GRAM/30 ML ORAL SOLN,50863,CDM,J3490,HCPCS,0121-1154-30,NDC,,,facility,both,2,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % MBP,50863,CDM,J3490,HCPCS,0338-9159-30,NDC,,,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,15,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,J2003,HCPCS,0143-9575-01,NDC,,,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM BROMIDE 0.03 % NASL SPRA,50863,CDM,636,RC,J3490,HCPCS,60505-0826-1,NDC,facility,both,1,ML,,402,281.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROFURANTOIN (25% MACROCRYSTAL FORM) 100 MG CAP,50863,CDM,636,RC,J3490,HCPCS,59746-762-01,NDC,facility,both,1,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0121-1781-05,NDC,facility,both,2,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-1638-32,NDC,facility,both,2,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 100 MG IV SOLR,50863,CDM,250,RC,J2997,HCPCS,50242-085-25,NDC,facility,both,10,EA,,2429,1700.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM  50 MG INJ SOLR,50863,CDM,250,RC,J0640,HCPCS,25021-813-10,NDC,facility,both,1,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,43547-282-10,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POSACONAZOLE 100 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,70748-258-07,NDC,facility,both,1,EA,,314,219.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,636,RC,J2270,HCPCS,0641-6125-01,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,17856-0574-1,NDC,facility,both,4,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,50863,CDM,250,RC,J9025,HCPCS,72485-201-01,NDC,facility,both,59,EA,JW,369,258.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) NEB SOLUTION,50863,CDM,250,RC,J3490,HCPCS,0487-9501-01,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) NEB SOLUTION,50863,CDM,250,RC,J3490,HCPCS,76204-200-01,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTAZIDIME NEO IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0713,HCPCS,0781-3177-80,NDC,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,636,RC,J1100,HCPCS,63323-506-41,NDC,facility,both,2,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,50863,CDM,636,RC,J1885,HCPCS,63323-162-03,NDC,facility,both,3,ML,JW,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
VANCOMYCIN  125 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,62559-390-20,NDC,facility,both,1,EA,,154,107.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR PHOSPHATE 30 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0527-4591-13,NDC,facility,both,9,EA,,460,322,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,636,RC,J0690,HCPCS,0143-9924-90,NDC,facility,both,4,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 10 GRAM/15 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,0116-4005-30,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML (1ML) INJ SOLN,50863,CDM,636,RC,J0171,HCPCS,54288-119-01,NDC,facility,both,3,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,50863,CDM,636,RC,J1756,HCPCS,0517-2340-01,NDC,facility,both,400,ML,,1284,898.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MOXIFLOXACIN 0.5 % OPHT DROP,50863,CDM,250,RC,J3490,HCPCS,68180-422-01,NDC,facility,both,1,ML,,603,422.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENAZOPYRIDINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,75826-114-10,NDC,facility,both,6,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9% IV (PEDS) BOLUS,50863,CDM,250,RC,J7030,HCPCS,0264-7800-09,NDC,facility,both,1,ML,JZ,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DARBEPOETIN ALFA IN POLYSORBAT 25 MCG/0.42 ML INJ SYRG,50863,CDM,250,RC,J0881,HCPCS,55513-057-01,NDC,facility,both,25,ML,,836,585.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,57237-077-10,NDC,facility,both,1,EA,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE   4.2 % IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-083-05,NDC,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MULTIVIT-IRON-FA-CALCIUM &MINS 9 MG IRON-400 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,7733386125,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3370,HCPCS,0143-9162-01,NDC,facility,both,4,EA,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMTERENE-HYDROCHLOROTHIAZIDE 37.5 MG-25 MG CAP,50863,CDM,250,RC,J3490,HCPCS,0781-2074-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,0143-9682-01,NDC,facility,both,2,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RAVULIZUMAB-CWVZ 100 MG/ML IV SOLN,50863,CDM,636,RC,J1303,HCPCS,25682-025-01,NDC,facility,both,30,ML,JZ,17676,12373.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DILTIAZEM SR 120 MG 24 HR CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7217-61,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TORSEMIDE  20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-756-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG ORAL TB12,50863,CDM,250,RC,J3490,HCPCS,42806-275-01,NDC,facility,both,3,EA,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2723-30,NDC,facility,both,10,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,636,RC,J3490,HCPCS,0173-0682-24,NDC,facility,both,1,GM,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 150 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6956-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  15 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,0904-6557-61,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68462-333-90,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,250,RC,J2405,HCPCS,23155-549-31,NDC,facility,both,16,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,250,RC,J0137,HCPCS,0781-3156-06,NDC,facility,both,49,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,250,RC,J3101,HCPCS,50242-037-06,NDC,facility,both,17,EA,,7346,5142.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV (BOLUS),50863,CDM,250,RC,J7120,HCPCS,17271-710-07,NDC,facility,both,1,ML,,411,287.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  5 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-122-11,NDC,facility,both,60,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LATANOPROST 0.005 % OPHT DROP,50863,CDM,636,RC,J3490,HCPCS,24208-463-25,NDC,facility,both,1,ML,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,170,EA,,23460,16422,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LINEZOLID 600 MG/300 ML IV SOLP,50863,CDM,636,RC,J2020,HCPCS,57664-683-31,NDC,facility,both,3,ML,,331,231.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TERAZOSIN  1 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,50268-764-11,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,250,RC,J1596,HCPCS,0143-9679-01,NDC,facility,both,60,ML,,1368,957.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 600 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,67877-320-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAMSULOSIN 0.4 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,65862-598-01,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-580-11,NDC,facility,both,3,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN   1.25 G IV SOLR,50863,CDM,636,RC,J3373,HCPCS,67457-823-12,NDC,facility,both,125,EA,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROMETHORPHAN-GUAIFENESIN SR 30 MG-600 MG 12 HR TAB,50863,CDM,250,RC,J3490,HCPCS,6382405640,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 17 GRAM (100 %) ORAL PWPK,50863,CDM,636,RC,J3490,HCPCS,0904-6931-86,NDC,facility,both,5,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 0.5 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J8540,HCPCS,0054-3177-63,NDC,facility,both,6,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,51754-5001-1,NDC,facility,both,3,ML,,155,108.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSULFAN BLUE 1 % INJ SOLN,50863,CDM,636,RC,Q9968,HCPCS,67457-220-00,NDC,facility,both,15,ML,,1574,1101.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  0.25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-741-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-089-11,NDC,facility,both,3,EA,,381,266.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,636,RC,J2270,HCPCS,0641-6125-01,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,25,EA,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-342-11,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLMESARTAN  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68462-436-30,NDC,facility,both,4,EA,,111,77.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 10 MG/1 ML SUBCONJUNCTIVAL INJECTION,50863,CDM,250,RC,J3490,HCPCS,99999-0403-91,NDC,facility,both,2,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-1159-19,NDC,facility,both,9,ML,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2305-16,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAUNORUBICIN 5 MG/ML IV INJ,50863,CDM,250,RC,J9150,HCPCS,42658-021-01,NDC,facility,both,1,ML,JW,149,104.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
APIXABAN 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0003-0894-21,NDC,facility,both,8,EA,,412,288.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  8 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-3249-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOPERAMIDE 2 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,51079-690-01,NDC,facility,both,8,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-464-11,NDC,facility,both,1,EA,PLAD,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
LEVETIRACETAM 100 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,31722-574-47,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 12.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6302-61,NDC,facility,both,2,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PYRIDOSTIGMINE BROMIDE  60 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6622-61,NDC,facility,both,3,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-349-11,NDC,facility,both,2,EA,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITRIOL 1 MCG/ML IV SOLN,50863,CDM,250,RC,J0636,HCPCS,72266-251-01,NDC,facility,both,10,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,32,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
SILVER SULFADIAZINE 1 % TOP CREA,50863,CDM,636,RC,J3490,HCPCS,43598-210-55,NDC,facility,both,1,GM,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 10 % (100 MG/ML) MISC SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-695-04,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE  2 MG/ML INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,70069-062-01,NDC,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAUNORUBICIN 5 MG/ML IV INJ,50863,CDM,636,RC,J9150,HCPCS,42658-021-01,NDC,facility,both,1,ML,JW,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
SIMETHICONE 40 MG/0.6 ML ORAL DRPS,50863,CDM,250,RC,J3490,HCPCS,17856-1303-4,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-342-11,NDC,facility,both,4,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 300 MG CAP,50863,CDM,250,RC,J3490,HCPCS,68084-244-11,NDC,facility,both,2,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN D5W 20000 UNIT/500 ML,50863,CDM,250,RC,J1644,HCPCS,0264-9567-10,NDC,facility,both,20,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM POLYSTYRENE SULFONATE ORAL POWDER,50863,CDM,250,RC,J3490,HCPCS,62135-340-62,NDC,facility,both,1,GM,,255,178.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-406-03,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6292-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-249-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  500 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,0641-6176-01,NDC,facility,both,20,ML,JA,206,144.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,118,ML,,107,74.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,50863,CDM,636,RC,Q0177,HCPCS,16714-082-10,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE  2 MG/ML INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,70069-062-01,NDC,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOZAPINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-922-01,NDC,facility,both,3,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-4675-05,NDC,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-DYYB 100 MG IV SOLR,50863,CDM,636,RC,Q5103,HCPCS,0069-0809-01,NDC,facility,both,64,EA,,16716,11701.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE MODIFIED  25 MG ORAL CAP,50863,CDM,250,RC,J7515,HCPCS,0093-9018-19,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 100 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,51079-171-01,NDC,facility,both,2,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 10 MG/ML (PF) IV SOLN,50863,CDM,250,RC,J2270,HCPCS,0641-6127-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,15,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OMEPRAZOLE-SODIUM BICARBONATE 2-84 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,65628-270-03,NDC,facility,both,2,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE (6 MONTH) 45 MG SUBCUTANOUS KIT,50863,CDM,636,RC,J9217,HCPCS,62935-461-50,NDC,facility,both,6,EA,,1176,823.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM  3 GRAM INJ SOLR,50863,CDM,636,RC,J0295,HCPCS,72485-417-01,NDC,facility,both,2,EA,JZ,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,250,RC,J3490,HCPCS,53746-542-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN LYSINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,67386-122-52,NDC,facility,both,2,ML,,1765,1235.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-22,NDC,facility,both,20,ML,JZ,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,636,RC,P9045,HCPCS,64208-2510-5,NDC,facility,both,16,ML,,1322,925.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUGAMMADEX 100 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0006-5423-02,NDC,facility,both,3,ML,,1681,1176.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2599,HCPCS,43598-914-25,NDC,facility,both,3,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR PHOSPHATE 75 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,72205-044-11,NDC,facility,both,1,EA,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 100 MG/5 ML ORAL LIQD,50863,CDM,636,RC,J3490,HCPCS,50383-063-10,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,636,RC,J3490,HCPCS,51754-4250-1,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLPIDEM  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-189-11,NDC,facility,both,2,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16714-050-01,NDC,facility,both,3,EA,,215,150.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESTRADIOL 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0555-0886-02,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,17271-701-05,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  1 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,64380-782-06,NDC,facility,both,100,EA,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6500-61,NDC,facility,both,1,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL  25 MCG/HR TD PT72,50863,CDM,250,RC,J3490,HCPCS,47781-424-47,NDC,facility,both,1,EA,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-1638-32,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,70069-363-01,NDC,facility,both,2,ML,,273,191.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 20MG/ML IV SYRINGE (PEDS/NEO),50863,CDM,250,RC,J0612,HCPCS,63323-311-10,NDC,facility,both,33,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LURASIDONE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7355-04,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LURASIDONE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-747-11,NDC,facility,both,4,EA,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML IV SOLN (MERGE),50863,CDM,250,RC,J3490,HCPCS,16714-037-01,NDC,facility,both,1,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOCONAZOLE 2 % TOP SHAM,50863,CDM,250,RC,J3490,HCPCS,45802-465-64,NDC,facility,both,1,ML,,148,103.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE SOD SUCC (PF) 100 MG/2 ML INJ SOLR,50863,CDM,250,RC,J1720,HCPCS,0009-0011-03,NDC,facility,both,3,EA,,378,264.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,9,ML,JW,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
BACLOFEN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-826-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN SODIUM  2 GRAM INJ SOLR,50863,CDM,250,RC,J0290,HCPCS,0781-3408-80,NDC,facility,both,4,EA,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 12.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7307-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,60505-3276-0,NDC,facility,both,1,EA,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRIL MALEATE 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,23155-773-01,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 10 MG/5 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,70954-261-10,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 2400000 UNIT/4 ML IM SYRG,50863,CDM,250,RC,J0561,HCPCS,60793-702-04,NDC,facility,both,24,ML,,2088,1461.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 150 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-445-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,42023-164-25,NDC,facility,both,20,ML,,413,289.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE  50 MG ORAL TAB,50863,CDM,636,RC,j3490,HCPCS,0904-6868-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHIMAZOLE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-680-11,NDC,facility,both,4,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  25 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-473-11,NDC,facility,both,4,EA,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 12.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68382-094-01,NDC,facility,both,2,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR IRRIGATION, STERILE SOLUTION",50863,CDM,250,RC,J3490,HCPCS,0338-0004-02,NDC,facility,both,4,ML,,128,89.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,636,RC,J3490,HCPCS,51754-4250-1,NDC,facility,both,4,ML,,232,162.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  25 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-6991-61,NDC,facility,both,3,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3370,HCPCS,70436-021-82,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,3,EA,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J2004,HCPCS,0409-3178-01,NDC,facility,both,90,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6007-61,NDC,facility,both,3,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,63323-485-27,NDC,,,facility,both,155,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN NACL (PF) 1000 UNIT/500 ML IV SOLP,50863,CDM,250,RC,J1644,HCPCS,0264-9872-10,NDC,facility,both,5,ML,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.3 MG/0.3 ML IM PNIJ,50863,CDM,J0169,HCPCS,49502-102-01,NDC,,,facility,both,3,EA,,675,472.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 20 MEQ/100 ML IV PGBK,50863,CDM,J3480,HCPCS,0338-0705-48,NDC,,,facility,both,10,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,50863,CDM,636,RC,Q5119,HCPCS,0069-0249-01,NDC,facility,both,28,ML,JW,2409,1686.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,J3490,HCPCS,0093-2279-73,NDC,,,facility,both,4,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,J3490,HCPCS,68084-354-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  25 MG ORAL TAB,50863,CDM,J3490,HCPCS,68084-346-11,NDC,,,facility,both,2,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZOCAINE-MENTHOL 20 %-0.5 % TOPICAL AEROSOL,50863,CDM,250,RC,J3490,HCPCS,16864-680-03,NDC,facility,both,1,GM,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-492-27,NDC,,,facility,both,1000,ML,,785,549.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 500 MG-125 MG TAB,50863,CDM,J3490,HCPCS,0781-1831-01,NDC,,,facility,both,1,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN 50 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,60687-156-95,NDC,facility,both,2,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN D5W 20000 UNIT/500 ML,50863,CDM,250,RC,J1644,HCPCS,0264-9567-10,NDC,facility,both,40,ML,,167,116.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69238-2078-1,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE  7.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,13107-001-30,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3373,HCPCS,0143-9162-01,NDC,facility,both,200,EA,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BACITRACIN ZINC-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM OINTMENT",50863,CDM,250,RC,J3490,HCPCS,58980-012-05,NDC,facility,both,2,GM,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,250,RC,J2795,HCPCS,43066-023-01,NDC,facility,both,150,ML,JZ,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
POTASSIUM CHLORIDE  10 MEQ ORAL TBTQ,50863,CDM,250,RC,J3490,HCPCS,60687-632-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,J3490,HCPCS,72603-387-01,NDC,,,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML IV SOLN (MERGE),50863,CDM,250,RC,J3490,HCPCS,16714-037-01,NDC,facility,both,2,ML,,379,265.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  75 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,65862-528-90,NDC,facility,both,5,EA,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,43547-415-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM  3.375 GRAM IV SOLR,50863,CDM,636,RC,J2543,HCPCS,44567-802-10,NDC,facility,both,3,EA,JZ,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,250,RC,J2270,HCPCS,0409-1891-03,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM BROMIDE 0.02 % INHL SOLN,50863,CDM,636,RC,J3490,HCPCS,0487-9801-01,NDC,facility,both,3,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN LOCK FLUSH 100 UNIT/ML IV SOLN,50863,CDM,250,RC,J1644,HCPCS,63323-545-01,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6782-61,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0093-4177-73,NDC,facility,both,6,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUVOXAMINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60505-0166-1,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESTRADIOL 2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42806-089-01,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DROPERIDOL 2.5 MG/ML INJ SOLN,50863,CDM,250,RC,J1790,HCPCS,0517-9702-25,NDC,facility,both,1,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,250,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,12,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT  40 MCG/0.4 ML INJ SYRG,50863,CDM,250,RC,J0881,HCPCS,55513-021-01,NDC,facility,both,40,ML,EC,1096,767.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier EC: Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,7,ML,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLP",50863,CDM,636,RC,P9047,HCPCS,0944-0493-04,NDC,facility,both,1,ML,,251,175.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRP (MERGE/REPACK),50863,CDM,636,RC,J3490,HCPCS,68094-764-59,NDC,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,636,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,2,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LANSOPRAZOLE 3 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,65628-080-05,NDC,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIMOLOL MALEATE 0.5 % OPHT DROP,50863,CDM,250,RC,J3490,HCPCS,82260-813-05,NDC,facility,both,1,ML,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,68180-723-04,NDC,facility,both,4,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0047-03,NDC,facility,both,16,EA,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THROMBIN (RECOMBINANT) 5000 UNIT TOP SOLR,50863,CDM,250,RC,J3490,HCPCS,0338-0324-01,NDC,facility,both,5,EA,,1858,1300.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SELEGILINE 5 MG TAB,50863,CDM,636,RC,J3490,HCPCS,60505-3438-3,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NYSTATIN  100000 UNIT/G TOP OINT,50863,CDM,250,RC,J3490,HCPCS,33342-481-15,NDC,facility,both,1,GM,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,73,ML,JW,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,50268-540-11,NDC,facility,both,3,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 1200000 UNIT/2 ML IM SYRG,50863,CDM,636,RC,J0561,HCPCS,60793-702-10,NDC,facility,both,24,ML,,1898,1328.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALDESLEUKIN 360,000 UNITS/ ML SOLUTION",50863,CDM,636,RC,J9015,HCPCS,65483-116-07,NDC,facility,both,1,EA,JZ,5121,3584.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SUCRALFATE 100 MG/ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0121-0974-10,NDC,facility,both,1,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0641-6206-01,NDC,facility,both,4,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G POTASSIUM 20000000 UNIT INJ SOLR,50863,CDM,250,RC,J2540,HCPCS,70860-127-51,NDC,facility,both,5,EA,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,504,ML,,724,506.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIOGLITAZONE 30 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,33342-055-07,NDC,facility,both,1,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRIL MALEATE 1 MG/ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,69238-1729-7,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN NEO/PEDS IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0456,HCPCS,63323-398-14,NDC,facility,both,1,EA,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-595-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OMEPRAZOLE-SODIUM BICARBONATE 2-84 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,65628-270-05,NDC,facility,both,3,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 2 MG/ML IV SOLN (PRMC ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-1312-03,NDC,facility,both,40,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 10 MG/ML (PF) IV SOLN,50863,CDM,250,RC,J2270,HCPCS,0641-6127-01,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 500 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,65862-595-01,NDC,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM  4.5 GRAM IV SOLR,50863,CDM,636,RC,J2543,HCPCS,55150-121-50,NDC,facility,both,4,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE (FOR EMERGENCY) 100 MG/ML (10%) IV SOLN,50863,CDM,636,RC,J0612,HCPCS,0143-9180-01,NDC,facility,both,200,ML,JZ,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
OCTREOTIDE ACETATE  100 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,63323-376-00,NDC,facility,both,2,ML,JB,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JB: Administered subcutaneously
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,636,RC,J2003,HCPCS,76329-3390-1,NDC,facility,both,300,ML,,163,114.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,4,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,50863,CDM,636,RC,Q0177,HCPCS,0093-5061-01,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM POLYSTYRENE SULF-SORBTL 15-20 GRAM/60 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,46287-006-60,NDC,facility,both,2,ML,,264,184.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J1230,HCPCS,67457-217-20,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OFLOXACIN 0.3 % OPHT DROP,50863,CDM,250,RC,J3490,HCPCS,24208-434-05,NDC,facility,both,2,ML,,240,168,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PSEUDOEPHEDRINE 30 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0904-5053-59,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 1 % OPHT DROP,50863,CDM,636,RC,J3490,HCPCS,60219-1749-3,NDC,facility,both,1,ML,,248,173.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESTRADIOL 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0555-0886-02,NDC,facility,both,4,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,J3490,HCPCS,0338-0049-38,NDC,,,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:200,000 INJ SOLN",50863,CDM,J3490,HCPCS,63323-487-07,NDC,,,facility,both,300,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,50863,CDM,J1885,HCPCS,72266-119-01,NDC,,,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,50863,CDM,250,RC,J9045,HCPCS,0703-4239-01,NDC,facility,both,12,ML,,333,233.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB-QYYP 420 MG IV SOLR,50863,CDM,636,RC,Q5116,HCPCS,0069-0306-01,NDC,facility,both,38,ME,,8469,5928.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-467-01,NDC,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB 100 MG IV SOLR,50863,CDM,636,RC,J1745,HCPCS,57894-030-01,NDC,facility,both,3,EA,JW,421,294.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LORAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69315-905-01,NDC,facility,both,4,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 160 MG-800 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0904-2725-61,NDC,facility,both,4,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-735-11,NDC,facility,both,1,EA,,216,151.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIVAROXABAN 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50458-579-01,NDC,facility,both,1,EA,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),50863,CDM,636,RC,J2060,HCPCS,0641-6044-01,NDC,facility,both,2,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,63739-931-14,NDC,facility,both,7,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 25 MG TAB,50863,CDM,636,RC,J3490,HCPCS,51079-255-01,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-65,NDC,facility,both,67,ML,JW,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CALCIUM CARBONATE 500 MG (200 MG ELEMENTAL) CHEW TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6412-92,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,250,RC,J2405,HCPCS,23155-549-31,NDC,facility,both,24,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE  50 MG ORAL TAB,50863,CDM,636,RC,j3490,HCPCS,50111-560-01,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 300 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6572-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 20MG/ML IV SYRINGE (PEDS/NEO),50863,CDM,250,RC,J0612,HCPCS,63323-311-10,NDC,facility,both,90,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,55150-202-00,NDC,facility,both,1,EA,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNITS/1 GRAM PACKET (MERGE RECORD),50863,CDM,636,RC,J3490,HCPCS,57896-145-09,NDC,facility,both,12,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE   4.2 % IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-083-05,NDC,facility,both,2,ML,,277,193.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VECURONIUM BROMIDE 10 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,0703-2914-01,NDC,facility,both,1,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMTUZUMAB OZOGAMICIN 4.5 MG (1 MG/ML INITIAL CONC) IV SOLR,50863,CDM,250,RC,J9203,HCPCS,0008-4510-01,NDC,facility,both,204,EA,,32373,22661.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0054-8297-25,NDC,facility,both,14,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,63323-806-13,NDC,facility,both,20,ML,,152,106.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM & SODIUM PHOSPHATES 280-160-250 MG ORAL PWPK,50863,CDM,J3490,HCPCS,6025800615,NDC,,,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHOTERICIN B LIPOSOME 50 MG IV SUSR,50863,CDM,250,RC,J0289,HCPCS,62756-233-01,NDC,facility,both,1,EA,JW,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-495-27,NDC,,,facility,both,12,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-1283-03,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VERAPAMIL 240 MG ORAL TBSR,50863,CDM,636,RC,J3490,HCPCS,75834-159-01,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CERTOLIZUMAB PEGOL 400 MG (200 MG X 2) SUBQ KIT,50863,CDM,636,RC,J0717,HCPCS,50474-700-62,NDC,facility,both,200,EA,,3323,2326.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE  5 MG ORAL CP24,50863,CDM,636,RC,J3490,HCPCS,64850-510-01,NDC,facility,both,3,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRIVIGEN 10 % IV SOLN,50863,CDM,636,RC,J1459,HCPCS,44206-437-10,NDC,facility,both,20,ML,JZ,3588,2511.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,250,RC,J3490,HCPCS,71449-068-11,NDC,facility,both,4,ML,,138,96.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 150 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,0904-7084-04,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHOTERICIN B LIPOSOME 50 MG IV SUSR,50863,CDM,250,RC,J0289,HCPCS,0469-3051-30,NDC,facility,both,5,EA,,1127,788.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,0409-4887-25,NDC,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-760-11,NDC,facility,both,2,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 50 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-854-11,NDC,facility,both,100,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIRMATRELVIR-RITONAVIR 300-100 MG ORAL TAB DOSEPACK (FOR ED/IP TAKE HOME PANEL),50863,CDM,250,RC,J3490,HCPCS,0069-5321-30,NDC,facility,both,30,EA,,4130,2891,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 30% IN WATER (NEO),50863,CDM,636,RC,J7070,HCPCS,0409-6648-16,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0143-9509-01,NDC,facility,both,1,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-25,NDC,facility,both,10,ML,"JW,JA",615,430.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
ARIPIPRAZOLE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,31722-820-30,NDC,facility,both,2,EA,,236,165.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-50,NDC,facility,both,111,ML,,196,137.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,636,RC,J2003,HCPCS,63323-485-27,NDC,facility,both,150,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 5 % TOP OINT,50863,CDM,636,RC,J3490,HCPCS,65162-918-38,NDC,facility,both,1,GM,,885,619.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,636,RC,J1100,HCPCS,55150-304-01,NDC,facility,both,20,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,636,RC,J0133,HCPCS,63323-325-03,NDC,facility,both,138,ML,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65862-642-30,NDC,facility,both,1,EA,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-0710-20,NDC,facility,both,4,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),50863,CDM,250,RC,J1815,HCPCS,0024-5926-05,NDC,facility,both,5,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,63323-104-25,NDC,facility,both,8,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6374-61,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0456,HCPCS,55150-174-10,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,3,EA,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NAFCILLIN NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J3490,HCPCS,63323-327-10,NDC,facility,both,26,EA,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2312,HCPCS,36000-310-01,NDC,facility,both,800,ML,,713,499.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALACYCLOVIR 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-215-11,NDC,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,50863,CDM,636,RC,J0696,HCPCS,25021-106-10,NDC,facility,both,4,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARSENIC TRIOXIDE 10 MG/10 ML IV SOLN,50863,CDM,250,RC,J9017,HCPCS,23155-869-31,NDC,facility,both,5,ML,JW,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
SODIUM CHLORIDE 0.9 % IV SOLN 400ML (PHS REPACK),50863,CDM,250,RC,J7040,HCPCS,99999-408-60,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LANSOPRAZOLE 15 MG ORAL TBLD,50863,CDM,250,RC,J3490,HCPCS,64764-543-30,NDC,facility,both,1,EA,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ELECTROLYTE-A IV,50863,CDM,250,RC,J3490,HCPCS,0338-0221-03,NDC,facility,both,2,ML,,167,116.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 15% IN WATER,50863,CDM,250,RC,J3490,HCPCS,0338-0023-03,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) BLADDER INSTILLATION,50863,CDM,636,RC,J9201,HCPCS,50742-497-53,NDC,facility,both,10,ML,,386,270.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 500 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,0904-7182-61,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,0409-9094-22,NDC,facility,both,2,ML,JZ,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GABAPENTIN 300 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-591-11,NDC,facility,both,9,EA,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,636,RC,J2560,HCPCS,14789-127-07,NDC,facility,both,1,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN IN SALINE (ISO-OSMOTIC) 80 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1580,HCPCS,0338-0503-48,NDC,facility,both,7,ML,,187,130.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN NPH & REGULAR HUMAN 100 UNIT/ML (70-30) SUBQ SUSP,50863,CDM,636,RC,J1815,HCPCS,0169-1837-11,NDC,facility,both,10,ML,GZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier GZ: Item or service expected to be denied as not reasonable and necessary
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-426-02,NDC,facility,both,2,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYL SALICYLATE-MENTHOL 15 %-10 % TOPICAL CREAM,50863,CDM,250,RC,J3490,HCPCS,0536-1349-57,NDC,facility,both,1,GM,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL  2.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-656-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 800 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,17856-921-01,NDC,facility,both,5,EA,,150,105,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 100 MG IV SOLR,50863,CDM,250,RC,J2997,HCPCS,50242-085-25,NDC,facility,both,3,EA,,608,425.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7130-61,NDC,facility,both,3,EA,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCERIN (CHILD) RECTAL SUPPOSITORY,50863,CDM,636,RC,J3490,HCPCS,58980-409-12,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERTAPENEM 1 GRAM INJ SOLR,50863,CDM,636,RC,J1335,HCPCS,0143-9398-01,NDC,facility,both,2,EA,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATRACURIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,71288-701-06,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,636,RC,Q0162,HCPCS,65162-691-79,NDC,facility,both,3,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,636,RC,J3490,HCPCS,63323-486-05,NDC,facility,both,480,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J1610,HCPCS,63323-596-11,NDC,facility,both,2,EA,,1570,1099,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 0.4 MG/HR TD PT24,50863,CDM,250,RC,J3490,HCPCS,0378-9112-16,NDC,facility,both,2,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,1,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZIPRASIDONE 20 MG CAP,50863,CDM,636,RC,J3490,HCPCS,0904-6269-45,NDC,facility,both,3,EA,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LINEZOLID NEO IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J2020,HCPCS,0009-5140-01,NDC,facility,both,3,ML,JZ,194,135.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,0641-6145-01,NDC,facility,both,4,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DIAZEPAM  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-285-01,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ (REPACK)(MERGE) (FOR PCA),50863,CDM,250,RC,J3010,HCPCS,0409-9094-41,NDC,facility,both,50,ML,,256,179.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIFEDIPINE 30 MG ORAL TO24,50863,CDM,250,RC,J3490,HCPCS,68084-597-11,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 160 MG-800 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0904-2725-61,NDC,facility,both,14,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,250,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE CONCENTRATE 10 MG/ 0.5 ML ORAL SYRINGE (0.5ML UD MERGE),50863,CDM,636,RC,J3490,HCPCS,0406-8003-30,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0003-0894-21,NDC,facility,both,1,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 650 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,66553-008-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,26,ML,JW,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ACAMPROSATE 333 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,68462-435-18,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,50863,CDM,250,RC,J9075,HCPCS,10019-956-16,NDC,facility,both,200,EA,,1296,907.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIVAROXABAN  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50458-577-01,NDC,facility,both,2,EA,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0781-3246-02,NDC,facility,both,7,ML,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,24658-141-30,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPHENIDATE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-805-11,NDC,facility,both,4,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,0641-6008-01,NDC,facility,both,5,ML,,101,70.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOLIC ACID  1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-681-11,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,0904-6794-80,NDC,facility,both,4,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NYSTATIN  100000 UNIT/G TOP POWD,50863,CDM,250,RC,J3490,HCPCS,68382-370-01,NDC,facility,both,1,GM,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7184-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE  50 MG ORAL TAB,50863,CDM,636,RC,j3490,HCPCS,68382-805-01,NDC,facility,both,6,EA,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-587-11,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM SR 120 MG 24 HR CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7217-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,42806-151-34,NDC,facility,both,16,ML,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),50863,CDM,250,RC,J1630,HCPCS,76045-737-01,NDC,facility,both,2,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES  8.6 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7252-60,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0121-0945-00,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-25,NDC,facility,both,18,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-8299-25,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BRIMONIDINE 0.2 % OPHT DROP,50863,CDM,250,RC,J3490,HCPCS,70069-231-01,NDC,facility,both,1,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,636,RC,J2795,HCPCS,70069-064-25,NDC,facility,both,100,ML,JW,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DOXAZOSIN 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-836-95,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-6625-22,NDC,facility,both,1,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACCHAROMYCES BOULARDII 250 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,1785600021,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,636,RC,J3373,HCPCS,67457-340-01,NDC,facility,both,200,EA,,189,132.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN 250 MG SOLUTION FOR INJECTION,50863,CDM,250,RC,J0290,HCPCS,0781-3402-78,NDC,facility,both,2,EA,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MINERAL OIL,50863,CDM,636,RC,J3490,HCPCS,6332325410,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  0.25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-577-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 200 MG INJ SOLR,50863,CDM,250,RC,J0640,HCPCS,0143-9553-01,NDC,facility,both,2,EA,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CANGRELOR 50 MG IV SOLR,50863,CDM,636,RC,C9460,HCPCS,10122-620-01,NDC,facility,both,50,EA,JZ,2764,1934.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CALCIUM CHLORIDE (FOR CODE) 10% IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0517-6710-01,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,636,RC,J1953,HCPCS,0409-1886-22,NDC,facility,both,135,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL  12 MCG/HR TD PT72,50863,CDM,636,RC,J3490,HCPCS,47781-423-11,NDC,facility,both,1,EA,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,636,RC,J2270,HCPCS,0409-1891-03,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-1749-70,NDC,facility,both,2,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 250 MG INJ SOLR,50863,CDM,250,RC,J0696,HCPCS,0409-7337-11,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LINEZOLID NEO IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J2020,HCPCS,0009-5140-01,NDC,facility,both,1,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,1,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,63323-461-01,NDC,facility,both,2,ML,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J1940,HCPCS,63323-280-03,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 50 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,10135-779-01,NDC,facility,both,107,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-161-11,NDC,facility,both,2,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL (VITAMIN D3)  1000 UNIT ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,2055503300,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,65219-445-01,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ANTIHEMOPHILIC FACTOR-VWF 1,000-2,400 UNIT IV KIT",50863,CDM,636,RC,J7187,HCPCS,63833-617-02,NDC,facility,both,125,UN,JW,175,122.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
KETAMINE 100 MG/ML INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-2051-15,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 1 % INJ SOLN,50863,CDM,636,RC,Q9968,HCPCS,17478-504-10,NDC,facility,both,50,ML,JW,101,70.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,250,RC,J2003,HCPCS,63323-495-27,NDC,facility,both,25,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOLIC ACID  1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-681-11,NDC,facility,both,1,EA,PLAD,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
IRINOTECAN 100 MG/5 ML IV SOLN,50863,CDM,250,RC,J9206,HCPCS,0143-9702-01,NDC,facility,both,2,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,0944-0495-06,NDC,facility,both,2,ML,JZ,416,291.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LEFLUNOMIDE  10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-477-11,NDC,facility,both,1,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-488-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-94,NDC,facility,both,6,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,0143-9577-01,NDC,,,facility,both,110,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,J2270,HCPCS,76045-004-10,NDC,,,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,50863,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,14,EA,,302,211.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,J3490,HCPCS,63323-739-11,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,636,RC,J7060,HCPCS,0338-0017-01,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,J1100,HCPCS,63323-506-41,NDC,,,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"AMIODARONE IN DEXTROSE,ISO-OSM 360 MG/200 ML (1.8 MG/ML) IV SOLN",50863,CDM,J0282,HCPCS,43066-360-20,NDC,,,facility,both,12,ML,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR  6 MG/ML ORAL SUSR,50863,CDM,J3490,HCPCS,27241-139-09,NDC,,,facility,both,8,ML,,101,70.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),50863,CDM,J1815,HCPCS,0024-5926-05,NDC,,,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % MBP,50863,CDM,250,RC,J3490,HCPCS,0338-0553-18,NDC,facility,both,13,ML,,577,403.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FERROUS SULFATE 325 MG (65 MG IRON) TAB,50863,CDM,250,RC,J3490,HCPCS,904759161,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,636,RC,J3490,HCPCS,50742-615-01,NDC,facility,both,2,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIPASE-PROTEASE-AMYLASE 24,000-76,000- 120,000 UNIT ORAL CAP, DELAY REL",50863,CDM,636,RC,J3490,HCPCS,0032-2636-01,NDC,facility,both,1,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR PHOSPHATE 75 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0004-0800-85,NDC,facility,both,1,EA,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POVIDONE-IODINE 10 % TOP OINT,50863,CDM,250,RC,J3490,HCPCS,0536-1271-80,NDC,facility,both,1,GM,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,618,ME,JZ,8387,5870.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PREDNISONE 50 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,59651-489-01,NDC,facility,both,80,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4 % TOPICAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-4698-01,NDC,facility,both,3,ML,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,0641-6145-01,NDC,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE IV CONCENTRATED INFUSION (1 MEQ/ML),50863,CDM,636,RC,J3490,HCPCS,0409-6625-02,NDC,facility,both,4,ML,,229,160.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIVASTIGMINE 1.5 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,33342-089-09,NDC,facility,both,3,EA,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,50863,CDM,250,RC,J9263,HCPCS,71288-101-10,NDC,facility,both,71,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOBRAMYCIN SULFATE 40 MG/ML INJ SOLN,50863,CDM,250,RC,J3260,HCPCS,0409-3578-01,NDC,facility,both,2,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4 % TOPICAL SOLN,50863,CDM,636,RC,J3490,HCPCS,76329-6300-5,NDC,facility,both,4,ML,,522,365.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITRIOL 0.5 MCG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,69452-208-20,NDC,facility,both,2,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZINC OXIDE 16 % TOP PSTE,50863,CDM,250,RC,J3490,HCPCS,6210333302,NDC,facility,both,1,GM,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,0641-6008-10,NDC,facility,both,3,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR  6 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,68180-678-01,NDC,facility,both,8,ML,,101,70.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,50863,CDM,250,RC,J9025,HCPCS,72485-201-01,NDC,facility,both,150,EA,,2131,1491.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-673-10,NDC,facility,both,4,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,50863,CDM,250,RC,J1756,HCPCS,0517-2340-01,NDC,facility,both,200,ML,,623,436.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,57237-077-10,NDC,facility,both,2,EA,,218,152.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES  8.6 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7252-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,62559-440-02,NDC,facility,both,1,ML,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 0.25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-270-11,NDC,facility,both,2,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,250,RC,J0330,HCPCS,0409-6629-02,NDC,facility,both,11,ML,,126,88.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMETHICONE  80 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,1093979444,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,68180-150-01,NDC,facility,both,3,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,0641-0400-12,NDC,facility,both,8,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,J0690,HCPCS,60505-6142-0,NDC,,,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEMANTINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6505-06,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENOFIBRATE NANOCRYSTALLIZED  48 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-599-01,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 10 MEQ/100 ML IV PGBK (USE NON-PROTOCOL PANEL),50863,CDM,250,RC,J3480,HCPCS,0338-0709-48,NDC,facility,both,10,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENOFIBRATE NANOCRYSTALLIZED  48 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-599-01,NDC,facility,both,4,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6869-61,NDC,facility,both,2,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESVENLAFAXINE  50 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,0054-0400-13,NDC,facility,both,2,EA,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 60 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,57237-019-30,NDC,facility,both,1,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML IM SOLN,50863,CDM,90375,HCPCS,13533-318-05,NDC,,,facility,both,3,ML,,1167,816.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,63323-482-03,NDC,facility,both,200,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID (PORK)  30 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42192-329-01,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MYCOPHENOLATE 500 MG TAB,50863,CDM,250,RC,J7517,HCPCS,0054-0166-25,NDC,facility,both,6,EA,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROMETHORPHAN-GUAIFENESIN SR 30 MG-600 MG 12 HR TAB,50863,CDM,250,RC,J3490,HCPCS,17856-1162-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 TABLET
MIDODRINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,49884-849-01,NDC,facility,both,3,EA,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),50863,CDM,250,RC,J1630,HCPCS,67457-426-12,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.45 % 0.45 % IV SOLP,50863,CDM,250,RC,J3490,HCPCS,0338-0043-03,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,636,RC,J2720,HCPCS,63323-229-01,NDC,facility,both,9,ML,,164,114.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  120 MG RECT SUPP,50863,CDM,636,RC,J3490,HCPCS,0713-0118-06,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3370,HCPCS,0409-6533-11,NDC,facility,both,6,EA,,287,200.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3373,HCPCS,0143-9162-01,NDC,facility,both,100,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-157-11,NDC,facility,both,4,EA,,390,273,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,6,EA,,202,141.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEPROTUMUMAB-TRBW 500 MG IV SOLR,50863,CDM,636,RC,J3241,HCPCS,75987-130-15,NDC,facility,both,198,EA,,140916,98641.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,636,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,6,EA,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL  1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-734-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J2310,HCPCS,0409-1215-01,NDC,facility,both,2,ML,,279,195.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 100 MG/ML INJ SOLN,50863,CDM,250,RC,J2800,HCPCS,0641-6103-01,NDC,facility,both,1,ML,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCHLOROTHIAZIDE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16729-184-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,43,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-145-11,NDC,facility,both,98,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,4,EA,,126,88.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB 100 MG IV SOLR,50863,CDM,J1745,HCPCS,57894-160-01,NDC,,,facility,both,7,EA,,399,279.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOPERAMIDE 2 MG ORAL CAP,50863,CDM,J3490,HCPCS,60687-229-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,0409-3178-16,NDC,,,facility,both,150,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,J3490,HCPCS,63323-486-05,NDC,,,facility,both,22,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,72266-118-01,NDC,facility,both,2,ML,GZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier GZ: Item or service expected to be denied as not reasonable and necessary
CYCLOPHOSPHAMIDE  50 MG ORAL CAP,50863,CDM,250,RC,J8530,HCPCS,62332-619-31,NDC,facility,both,6,EA,,242,169.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 90 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0093-0320-01,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-4713-32,NDC,facility,both,80,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,0904-6794-80,NDC,facility,both,1,EA,PLAD,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
PHYTONADIONE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J3430,HCPCS,43598-405-11,NDC,facility,both,3,ME,,355,248.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PORACTANT ALFA 240 MG/3 ML INTR SUSP,50863,CDM,250,RC,J3490,HCPCS,10122-510-01,NDC,facility,both,3,ML,,4728,3309.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J2310,HCPCS,0641-6132-01,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISATRACURIUM  2 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0074-4380-10,NDC,facility,both,1,ML,,146,102.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,250,RC,J0137,HCPCS,0781-3156-06,NDC,facility,both,7,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0137,HCPCS,0781-3156-06,NDC,facility,both,96,ML,,209,146.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 25 MG CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7237-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE 0.25 MG/2 ML INHL NBSP,50863,CDM,250,RC,J3490,HCPCS,0186-1988-04,NDC,facility,both,1,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-50,NDC,facility,both,4,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-406-03,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0780,HCPCS,0641-6135-25,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,50863,CDM,636,RC,J1756,HCPCS,0517-2340-01,NDC,facility,both,93,ML,,299,209.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GANCICLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J1570,HCPCS,25021-185-10,NDC,facility,both,1,ML,,208,145.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,68180-723-04,NDC,facility,both,3,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE 0.5 MG/2 ML INHL NBSP,50863,CDM,636,RC,J3490,HCPCS,0487-9701-01,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,10,ML,,196,137.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,43,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-50,NDC,facility,both,35,ML,JW,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
AMPICILLIN-SULBACTAM NEO/PEDS (CDS MIXTURE),50863,CDM,636,RC,J0295,HCPCS,63323-368-20,NDC,facility,both,1,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,10135-678-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42858-301-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IR SOLN,50863,CDM,636,RC,J3490,HCPCS,0338-0047-46,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,250,RC,J1596,HCPCS,0143-9679-01,NDC,facility,both,8,ML,,183,128.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL  20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6671-04,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,636,RC,J3490,HCPCS,59310-579-22,NDC,facility,both,1,GM,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 50 MG 24 HR TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6323-61,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 125 MG ORAL CPSP,50863,CDM,250,RC,J3490,HCPCS,68084-313-11,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE ACETATE 1 % OPHT DROPS,50863,CDM,250,RC,J3490,HCPCS,60758-119-05,NDC,facility,both,1,ML,,224,156.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,0409-1207-03,NDC,facility,both,2,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-591-11,NDC,facility,both,4,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,636,RC,J7999,HCPCS,70092-1017-46,NDC,facility,both,2,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOLTERODINE 2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,33342-098-09,NDC,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2599,HCPCS,65219-039-00,NDC,facility,both,4,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPATITIS A VIRUS VACCINE (PF) 720 EL UNIT/0.5 ML IM SYRG,50863,CDM,90633,HCPCS,58160-825-43,NDC,,,facility,both,1,ML,,223,156.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,J1100,HCPCS,63323-506-01,NDC,,,facility,both,10,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6441-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,8,ML,,17957,12569.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 100 MG/5 ML ORAL LIQD,50863,CDM,250,RC,J3490,HCPCS,50383-063-10,NDC,facility,both,14,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,636,RC,J3490,HCPCS,0173-0682-24,NDC,facility,both,1,GM,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG ORAL TB12,50863,CDM,250,RC,J3490,HCPCS,60687-583-11,NDC,facility,both,3,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM-ALBUTEROL 0.5 MG-2.5 MG/3 ML NEB SOLUTION,50863,CDM,250,RC,J3490,HCPCS,60687-405-79,NDC,facility,both,2,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE MALEATE  5 MG ORAL TAB,50863,CDM,250,RC,Q0164,HCPCS,59746-113-06,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1560-19,NDC,facility,both,40,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LIDOCAINE HCL  2 % MM JELP,50863,CDM,250,RC,J3490,HCPCS,0548-3013-00,NDC,facility,both,1,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6500-06,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,69918-901-10,NDC,facility,both,28,ML,JZ,1147,802.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",50863,CDM,250,RC,J1561,HCPCS,13533-800-21,NDC,facility,both,10,ML,,1415,990.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,636,RC,J0330,HCPCS,31722-981-10,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-398-11,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-25,NDC,facility,both,35,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,250,RC,J2270,HCPCS,0641-6125-01,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-25,NDC,facility,both,25,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION,50863,CDM,250,RC,J3490,HCPCS,0186-0370-20,NDC,facility,both,1,GM,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 1 MG ORAL TAB,50863,CDM,250,RC,J8540,HCPCS,72578-166-01,NDC,facility,both,8,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLORAZEPATE DIPOTASSIUM  3.75 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51672-4042-1,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,J2003,HCPCS,76329-3390-1,NDC,,,facility,both,100,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,J0665,HCPCS,0409-1162-18,NDC,,,facility,both,300,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE MODIFIED 100 MG ORAL CAP,50863,CDM,250,RC,J7502,HCPCS,51862-460-01,NDC,facility,both,3,EA,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-4279-16,NDC,facility,both,40,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  50 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,64980-411-09,NDC,facility,both,1,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 3% IV BOLUS (ED ONLY),50863,CDM,250,RC,J3490,HCPCS,0264-7805-10,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR  6 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,27241-139-09,NDC,facility,both,5,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7193-06,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COLCHICINE 0.6 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,59651-455-01,NDC,facility,both,1,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON DEXTRAN 50 MG/ML INJ SOLN,50863,CDM,250,RC,J1750,HCPCS,0023-6082-01,NDC,facility,both,1,ML,JW,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DAPTOMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0878,HCPCS,0409-0122-01,NDC,facility,both,200,EA,,161,112.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,81033-002-20,NDC,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,50863,CDM,636,RC,J2359,HCPCS,0781-3159-72,NDC,facility,both,40,EA,,406,284.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALACYCLOVIR 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6565-61,NDC,facility,both,4,EA,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IVPB (PEDIATRICS/ADULT NON-FORM)",50863,CDM,636,RC,J0137,HCPCS,24201-100-01,NDC,facility,both,60,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLP",50863,CDM,250,RC,P9047,HCPCS,68516-5216-8,NDC,facility,both,4,ML,,1614,1129.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,6,EA,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 10 MG/ML ORAL SOLUTION (REPACK),50863,CDM,250,RC,J3490,HCPCS,0131-5410-71,NDC,facility,both,4,ML,,167,116.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  2.5 MG ORAL TAB,50863,CDM,250,RC,J7510,HCPCS,59651-485-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,25021-321-10,NDC,facility,both,4,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J3430,HCPCS,69097-708-96,NDC,facility,both,3,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAZOLAMIDE SODIUM 500 (100 MG/ML) INJ SOLR,50863,CDM,636,RC,J1120,HCPCS,0143-9503-01,NDC,facility,both,1,EA,,224,156.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES  8.6 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7252-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE (FOR EMERGENCY) 100 MG/ML (10%) IV SOLN,50863,CDM,250,RC,J0612,HCPCS,75834-171-01,NDC,facility,both,100,ML,JZ,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
BELATACEPT 250 MG IV SOLR,50863,CDM,636,RC,J0485,HCPCS,0003-0371-13,NDC,facility,both,450,EA,,4643,3250.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM 2000 MG IV SOLR,50863,CDM,636,RC,J2185,HCPCS,72078-081-00,NDC,facility,both,20,EA,,194,135.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,55111-150-01,NDC,facility,both,3,EA,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,250,RC,J0137,HCPCS,0781-3156-06,NDC,facility,both,70,ML,,151,105.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MINOCYCLINE 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,13668-484-50,NDC,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,636,RC,J7060,HCPCS,0264-7510-10,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL (VITAMIN D3)  1000 UNIT ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,2055503300,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,636,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,150,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50228-420-01,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,0904-6474-61,NDC,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 800 MG ORAL TAB,50863,CDM,250,RC,J0601,HCPCS,0904-6707-06,NDC,facility,both,120,EA,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPHENIDATE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,57664-228-88,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUORESCEIN 500 MG/5 ML (10 %) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0065-0092-65,NDC,facility,both,1,ML,,263,184.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENAZEPRIL 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,43547-336-10,NDC,facility,both,4,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN IN D5W 400 MG/200 ML IV PGBK,50863,CDM,250,RC,J0744,HCPCS,0409-4777-02,NDC,facility,both,6,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  100 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,63323-376-00,NDC,facility,both,8,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-656-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7914-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-354-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,636,RC,J3490,HCPCS,62037-560-01,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  500 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,63323-377-00,NDC,facility,both,20,ML,,253,177.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELIMUMAB 400 MG IV SOLR,50863,CDM,636,RC,J0490,HCPCS,49401-102-01,NDC,facility,both,40,EA,"JG,JZ,JA",4459,3121.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
CAPTOPRIL  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7106-61,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 40 GRAM/400 ML (10 %) INJ SOLN",50863,CDM,250,RC,J1561,HCPCS,13533-800-40,NDC,facility,both,80,ML,,11316,7921.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,50863,CDM,250,RC,J9045,HCPCS,0703-4239-01,NDC,facility,both,3,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,50863,CDM,250,RC,J9000,HCPCS,0069-1542-20,NDC,facility,both,9,ML,,138,96.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL (PULM.HYPERTENSION) 10 MG/12.5 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,55150-166-13,NDC,facility,both,1,ML,,403,282.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL  12 MCG/HR TD PT72,50863,CDM,250,RC,J3490,HCPCS,47781-423-11,NDC,facility,both,1,EA,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0093-3145-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60505-3111-0,NDC,facility,both,2,EA,,130,91,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLP,50863,CDM,250,RC,J3480,HCPCS,63323-965-02,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTAMIDINE 300 MG INHL SOLR,50863,CDM,636,RC,J3490,HCPCS,63323-877-15,NDC,facility,both,1,EA,,721,504.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LINEZOLID 600 MG/300 ML IV SOLP,50863,CDM,250,RC,J2020,HCPCS,0009-7807-01,NDC,facility,both,3,ML,,194,135.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMFIBROZIL 600 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16714-101-02,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 50 MG/ML IV SOLN,50863,CDM,250,RC,J0282,HCPCS,0143-9875-10,NDC,facility,both,10,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0630,HCPCS,42023-205-01,NDC,facility,both,1,ML,,5877,4113.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,76045-009-96,NDC,facility,both,20,ML,,111,77.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK,50863,CDM,636,RC,J3490,HCPCS,12870-0001-1,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,91,ML,JW,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,54288-137-01,NDC,facility,both,2,ML,,212,148.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MYCOPHENOLATE 250 MG CAP,50863,CDM,636,RC,J7517,HCPCS,51079-721-01,NDC,facility,both,2,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 10 MG TAB,50863,CDM,636,RC,Q0177,HCPCS,63739-483-10,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML INJ SOLN,50863,CDM,250,RC,J2060,HCPCS,0409-1985-03,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPTOMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0878,HCPCS,72603-152-01,NDC,facility,both,250,EA,,732,512.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,59651-426-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,4,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA SR 25 MG-100 MG TAB,50863,CDM,250,RC,J3490,HCPCS,62756-461-88,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-105-11,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7308-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3370,HCPCS,70436-021-82,NDC,facility,both,2,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,0904-6923-61,NDC,facility,both,10,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IV PGBK,50863,CDM,250,RC,J3475,HCPCS,63323-106-00,NDC,facility,both,8,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  88 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6952-61,NDC,facility,both,3,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIGOXIN  50 MCG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0054-0057-46,NDC,facility,both,1,ML,,605,423.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE SR 37.5 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,62175-472-32,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTOBARBITAL 75 MG/1.5 ML SYRINGE (REPACK),50863,CDM,636,RC,J3490,HCPCS,25021-676-20,NDC,facility,both,2,ML,,183,128.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,63323-162-01,NDC,facility,both,2,ML,JZ,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,63323-162-00,NDC,facility,both,2,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICARDIPINE IN NACL (ISO-OS) 20 MG/200 ML IV PGBK,50863,CDM,J3490,HCPCS,43066-009-10,NDC,,,facility,both,1,ML,,255,178.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,63323-485-03,NDC,,,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLU VACCINE TS 2025-26 65 YR UP (PF) 180 MCG/0.5 ML IM SYRG,50863,CDM,90662,HCPCS,49281-125-65,NDC,,,facility,both,1,ML,,372,260.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SYRG,50863,CDM,636,RC,J3490,HCPCS,8290306547,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOSTIGMINE 1MG/ML (UD) OR SYRINGE,50863,CDM,J2710,HCPCS,76014-003-33,NDC,,,facility,both,1,ML,,142,99.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,J7040,HCPCS,0338-9543-03,NDC,,,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,50863,CDM,J9263,HCPCS,60505-6132-7,NDC,,,facility,both,136,ML,,294,205.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM IN NACL (ISO-OS) 500 MG/100 ML IV PGBK,50863,CDM,636,RC,J1953,HCPCS,67457-255-00,NDC,facility,both,50,ML,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,8,EA,,297,207.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID (PORK)  60 MG ORAL TAB,50863,CDM,J3490,HCPCS,42192-330-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,50863,CDM,J9041,HCPCS,72603-270-01,NDC,,,facility,both,24,EA,,601,420.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BETHANECHOL CHLORIDE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0832-0511-89,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLEDRONIC ACID IN MANNITOL & WATER 5 MG/100 ML IV SOLN,50863,CDM,636,RC,J3489,HCPCS,25021-830-82,NDC,facility,both,5,ML,,1239,867.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON DEXTRAN 50 MG/ML INJ SOLN,50863,CDM,636,RC,J1750,HCPCS,0023-6082-01,NDC,facility,both,30,ML,JZ,3126,2188.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"LIPASE-PROTEASE-AMYLASE 24,000-76,000- 120,000 UNIT ORAL CAP, DELAY REL",50863,CDM,250,RC,J3490,HCPCS,0032-2636-01,NDC,facility,both,1,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,29300-423-01,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-6102-10,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,50863,CDM,636,RC,J8540,HCPCS,0054-8175-25,NDC,facility,both,32,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 2 MG INJ SOLR,50863,CDM,250,RC,J2997,HCPCS,50242-041-63,NDC,facility,both,2,EA,,662,463.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE-SALMETEROL 500 MCG-50 MCG/DOSE DISK DEVICE FOR INHALATION,50863,CDM,636,RC,J3490,HCPCS,0378-9322-32,NDC,facility,both,1,EA,,1359,951.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SYRG,50863,CDM,250,RC,J3490,HCPCS,8290306553,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0591-0605-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,10135-679-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 20MG/ML IV SYRINGE (PEDS/NEO),50863,CDM,250,RC,J0612,HCPCS,63323-311-10,NDC,facility,both,83,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESTRADIOL 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0555-0886-02,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM SR 120 MG 24 HR CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7217-61,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,250,RC,J0330,HCPCS,31722-981-10,NDC,facility,both,11,ML,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,63323-482-03,NDC,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTAROLINE FOSAMIL 600 MG IV SOLR,50863,CDM,250,RC,J0712,HCPCS,0456-0600-01,NDC,facility,both,20,EA,JW,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
METOPROLOL SUCCINATE SR 100 MG 24 HR TAB,50863,CDM,636,RC,J3490,HCPCS,50268-542-11,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7336-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1940,HCPCS,36000-283-25,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RANOLAZINE  500 MG ORAL TB12,50863,CDM,636,RC,J3490,HCPCS,60687-549-11,NDC,facility,both,2,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-0905-05,NDC,facility,both,5,ML,,113,79.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM-ALBUTEROL 0.5 MG-2.5 MG/3 ML NEB SOLUTION,50863,CDM,250,RC,J3490,HCPCS,0487-0201-01,NDC,facility,both,18,ML,,195,136.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,553,ML,,794,555.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,636,RC,J3360,HCPCS,43598-106-11,NDC,facility,both,2,ML,,145,101.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J2004,HCPCS,0409-3178-01,NDC,facility,both,40,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE 21 MG/24 HR TD PT24,50863,CDM,250,RC,J3490,HCPCS,0536-5896-88,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LANTHANUM  500 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,68180-819-52,NDC,facility,both,1,EA,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,75834-221-01,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J2004,HCPCS,0409-3178-01,NDC,facility,both,90,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMETHICONE 40MG/0.6ML (0.6ML-UD) SYRINGE (REPACK),50863,CDM,250,RC,J3490,HCPCS,17856-1141-4,NDC,facility,both,3,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-327-10,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0630,HCPCS,43598-051-11,NDC,facility,both,1,ML,,5179,3625.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOCILIZUMAB-AAZG 80 MG/4 ML (20 MG/ML) IV SOLN,50863,CDM,636,RC,Q5135,HCPCS,65219-592-10,NDC,facility,both,200,ML,,2703,1892.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0295,HCPCS,63323-368-20,NDC,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAPTOPRIL  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,27241-162-01,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J2004,HCPCS,0409-3178-16,NDC,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 500 MCG INJ SOLR,50863,CDM,636,RC,J3490,HCPCS,25021-470-10,NDC,facility,both,2,EA,,2364,1654.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MICAFUNGIN 100 MG IV SOLR,50863,CDM,250,RC,J2248,HCPCS,42023-230-01,NDC,facility,both,113,EA,,731,511.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,52817-180-10,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,50863,CDM,J0640,HCPCS,25021-814-30,NDC,,,facility,both,2,EA,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNIT/G TOP OINT (MERGE),50863,CDM,250,RC,J3490,HCPCS,0603-0441-50,NDC,facility,both,1,GM,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 1 % NASAL SPRAY AEROSOL,50863,CDM,J3490,HCPCS,0225-0810-47,NDC,,,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 500 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,16714-299-03,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,2,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 10 MEQ/100 ML IV PGBK,50863,CDM,636,RC,J3480,HCPCS,0990-7074-26,NDC,facility,both,5,ML,JZ,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CEFTRIAXONE   2 GRAM INJ SOLR,50863,CDM,250,RC,J0696,HCPCS,0781-3209-90,NDC,facility,both,4,EA,,194,135.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,50863,CDM,636,RC,J0696,HCPCS,44567-702-25,NDC,facility,both,4,EA,JW,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CALCIUM CHLORIDE (FOR CODE) 10% (100 MG/ML) IV SYRINGE,50863,CDM,250,RC,J3490,HCPCS,64253-900-30,NDC,facility,both,3,ML,,150,105,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,Q0162,HCPCS,60687-252-40,NDC,,,facility,both,4,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEG 3350-ELECTROLYTES 236 G-22.74 G-6.74 G-5.86 G ORAL SOLUTION,50863,CDM,250,RC,J3490,HCPCS,43386-090-19,NDC,facility,both,2,ML,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXEPIN  25 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,51079-437-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOZAPINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-922-01,NDC,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-349-11,NDC,facility,both,2,EA,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR 200 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-5789-61,NDC,facility,both,2,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-342-11,NDC,facility,both,2,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-8297-25,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 1250 MG/5 ML SUSPENSION (500 MG/5 ML ELEMENTAL),50863,CDM,250,RC,J3490,HCPCS,0121-4766-05,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2308-22,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLN,50863,CDM,636,RC,J3262,HCPCS,50242-137-01,NDC,facility,both,120,ML,"JW,JA",957,669.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
URSODIOL 300 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,50268-797-11,NDC,facility,both,1,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-406-03,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 8-2 MG SL SUBL,50863,CDM,636,RC,J3490,HCPCS,50268-145-11,NDC,facility,both,3,EA,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  50 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,72205-012-90,NDC,facility,both,1,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOZAPINE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-922-01,NDC,facility,both,6,EA,,101,70.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYOSCYAMINE SULFATE 0.375 MG ORAL TB12,50863,CDM,250,RC,J3490,HCPCS,47781-014-01,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-0430-04,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2310,HCPCS,0409-1219-41,NDC,facility,both,4,ML,,513,359.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIVAROXABAN 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50458-578-01,NDC,facility,both,1,EA,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GAMMAGARD S-D (IGA < 1 MCG/ML) 10 GRAM IV SOLR,50863,CDM,636,RC,J1566,HCPCS,0944-2659-08,NDC,facility,both,60,EA,JZ,13969,9778.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,300,ML,,4494,3145.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,72485-106-01,NDC,facility,both,150,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN  10 GRAM INJ SOLR,50863,CDM,250,RC,J0690,HCPCS,0143-9983-91,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) IV SOLN,50863,CDM,250,RC,J9920,HCPCS,81284-315-00,NDC,facility,both,40,ML,,1728,1209.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0641-6057-01,NDC,facility,both,2,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"DICLOFENAC 75 MG TAB, DELAYED RELEASE",50863,CDM,636,RC,J3490,HCPCS,60687-658-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCRELIZUMAB 30 MG/ML IV SOLN,50863,CDM,636,RC,J2350,HCPCS,50242-150-01,NDC,facility,both,600,ME,JZ,89700,62790,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,636,RC,J0132,HCPCS,66220-207-30,NDC,facility,both,120,ML,,305,213.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEMAZEPAM 15 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0228-2076-10,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LANSOPRAZOLE 3 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,65628-080-05,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-544-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLPIDEM  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-621-01,NDC,facility,both,1,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TORSEMIDE  20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-539-11,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 40 GRAM/400 ML (10 %) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-40,NDC,facility,both,80,ML,"JZ,JA",11316,7921.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
AMITRIPTYLINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-444-11,NDC,facility,both,3,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOXYMETHYLCELLULOSE SODIUM 1 % OPHT DLGL,50863,CDM,636,RC,J3490,HCPCS,0023-9205-15,NDC,facility,both,1,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN  500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7162-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,250,RC,J3490,HCPCS,63323-486-02,NDC,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6797-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",50863,CDM,250,RC,J1561,HCPCS,13533-800-21,NDC,facility,both,20,ML,JA,2829,1980.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
"BETAMETHASONE, AUGMENTED 0.05 % TOP CREA",50863,CDM,250,RC,J3490,HCPCS,45802-376-35,NDC,facility,both,1,GM,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFUROXIME AXETIL 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-400-01,NDC,facility,both,2,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,17271-701-05,NDC,facility,both,1,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROGESTERONE MICRONIZED 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,59651-152-01,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-112-02,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,51754-5001-1,NDC,facility,both,2,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,636,RC,J2720,HCPCS,63323-229-01,NDC,facility,both,3,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN 1 MG/ML INJECTION (PEDS ONCOLOGY),50863,CDM,250,RC,J0640,HCPCS,71288-160-10,NDC,facility,both,1,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,250,RC,J3490,HCPCS,68180-963-01,NDC,facility,both,1,GM,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 10 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-6987-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,636,RC,J3101,HCPCS,50242-037-06,NDC,facility,both,14,EA,,6413,4489.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,636,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,100,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,427,ME,JZ,5795,4056.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
POTASSIUM CHLORIDE  20 MEQ ORAL PACK,50863,CDM,636,RC,J3490,HCPCS,0245-0360-89,NDC,facility,both,2,EA,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRP (MERGE/REPACK),50863,CDM,636,RC,J3490,HCPCS,68094-764-59,NDC,facility,both,2,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL  1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-734-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELIMUMAB 120 MG IV SOLR,50863,CDM,636,RC,J0490,HCPCS,49401-101-01,NDC,facility,both,27,ME,JA,3171,2219.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
MAGNESIUM SULFATE 50 % (4 MEQ/ML) INJ SOLN,50863,CDM,250,RC,J3475,HCPCS,63323-064-01,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0003-0894-70,NDC,facility,both,1,EA,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,7,EA,,253,177.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,15,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN NORMAL SALINE IV,50863,CDM,250,RC,J7042,HCPCS,0338-0089-03,NDC,facility,both,1,ML,JZ,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CALCIUM ACETATE 667 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7119-06,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,13533-690-25,NDC,facility,both,3,ML,JZ,651,455.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CYCLOSPORINE 100 MG ORAL CAP,50863,CDM,250,RC,J7502,HCPCS,60505-0134-0,NDC,facility,both,1,EA,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1940,HCPCS,23155-473-33,NDC,facility,both,8,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-119-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIVAROXABAN 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50458-578-90,NDC,facility,both,1,EA,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,50863,CDM,250,RC,J2359,HCPCS,55150-308-01,NDC,facility,both,15,EA,,156,109.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 175 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42292-040-01,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-989-01,NDC,facility,both,1,EA,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,76045-009-10,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,250,RC,Q9968,HCPCS,70710-1838-1,NDC,facility,both,30,ML,JW,169,118.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PROGESTERONE MICRONIZED 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,16714-157-01,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  50 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0071-1013-41,NDC,facility,both,1,EA,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,636,RC,J3490,HCPCS,63037-136-25,NDC,facility,both,2,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 40 MG/ML SUSP (DEPO-MEDROL) INJECTION,50863,CDM,250,RC,J1010,HCPCS,70121-1573-1,NDC,facility,both,80,ML,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN NACL (PF) 1000 UNIT/500 ML IV SOLP,50863,CDM,250,RC,J1644,HCPCS,0409-1005-01,NDC,facility,both,4,ML,,167,116.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  37.5 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,68084-698-11,NDC,facility,both,2,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESIPRAMINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50742-113-01,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,48,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 2 MG INJ SOLR,50863,CDM,636,RC,J2997,HCPCS,50242-041-64,NDC,facility,both,1,EA,JZ,400,280,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2599,HCPCS,63323-930-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7126-61,NDC,facility,both,1,EA,PLAD,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
MIDAZOLAM 1 MG/ML INJ SOLN (PULMONARY USE),50863,CDM,250,RC,J2250,HCPCS,55390-137-05,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1815,HCPCS,0002-8215-01,NDC,facility,both,320,ML,,364,254.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6924-61,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 10 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,16714-720-02,NDC,facility,both,3,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 2 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,250,RC,J2270,HCPCS,0409-1890-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,250,RC,J0330,HCPCS,69374-919-10,NDC,facility,both,9,ML,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 500 MG/10 ML IV SOLN,50863,CDM,250,RC,J9190,HCPCS,63323-117-01,NDC,facility,both,2,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,5,ML,JW,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LOVASTATIN 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,61442-142-01,NDC,facility,both,4,EA,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),50863,CDM,250,RC,J2060,HCPCS,0641-6001-25,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0003-0894-70,NDC,facility,both,1,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE   4.2 % IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-083-05,NDC,facility,both,1,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-464-11,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN LYSINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66993-490-84,NDC,facility,both,1,ML,,451,315.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,69238-1491-1,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-ABDA 100 MG IV SOLR,50863,CDM,250,RC,Q5104,HCPCS,78206-162-99,NDC,facility,both,80,EA,,16635,11644.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,25021-701-01,NDC,facility,both,2,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,250,RC,J0690,HCPCS,0143-9924-90,NDC,facility,both,4,EA,JZ,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,16714-293-01,NDC,facility,both,8,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELATACEPT 250 MG IV SOLR,50863,CDM,636,RC,J0485,HCPCS,0003-0371-13,NDC,facility,both,15,EA,JW,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
OXYCODONE  15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0406-8515-23,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-6666-61,NDC,facility,both,1,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 1000 MG MISC TBSO,50863,CDM,250,RC,J3490,HCPCS,904723961,NDC,facility,both,7,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOTRIMAZOLE 1 % TOP CREA,50863,CDM,636,RC,J3490,HCPCS,68462-181-35,NDC,facility,both,1,GM,,171,119.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS",50863,CDM,250,RC,J3490,HCPCS,0998-0630-06,NDC,facility,both,1,ML,,489,342.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FERRIC CARBOXYMALTOSE (INJECTAFER) 50 MG IRON/ML IV SOLN,50863,CDM,636,RC,J1439,HCPCS,0517-0650-01,NDC,facility,both,750,ML,JZ,4234,2963.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
TRIAMCINOLONE ACETONIDE 0.1 % TOP OINT,50863,CDM,636,RC,J3490,HCPCS,51672-1284-1,NDC,facility,both,1,GM,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,0904-7127-61,NDC,facility,both,240,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION,50863,CDM,636,RC,J3490,HCPCS,0310-7372-20,NDC,facility,both,120,GM,,1040,728,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GRANISETRON 1 MG/ML (1 ML) IV SOLN,50863,CDM,636,RC,J1626,HCPCS,0143-9744-01,NDC,facility,both,4,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,72611-722-25,NDC,facility,both,1,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CLOTRIMAZOLE 1 % TOP CREA,50863,CDM,250,RC,J3490,HCPCS,0536-1272-22,NDC,facility,both,2,GM,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOBAZAM 2.5 MG/ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,67877-658-61,NDC,facility,both,1,ML,,169,118.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN NPH HUMAN RECOMB 100 UNIT/ML SUBQ SUSP,50863,CDM,636,RC,J1815,HCPCS,0169-1834-11,NDC,facility,both,12,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MITOMYCIN 20 MG IV SOLR,50863,CDM,636,RC,J9280,HCPCS,71288-138-50,NDC,facility,both,2,EA,,621,434.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLU VACCINE TS 2024-25 6MOS UP (PF) 45 MCG (15 MCG X 3)/0.5 ML IM SYRG,50863,CDM,90656,HCPCS,49281-424-88,NDC,,,facility,both,1,ML,,121,84.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,10135-778-01,NDC,facility,both,30,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARTIFICIAL TEAR(DXTRN-HPM-GLY) 0.1-0.3-0.2 % OPHT DROP,50863,CDM,636,RC,J3490,HCPCS,0065-0426-36,NDC,facility,both,1,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BIVALIRUDIN 250 MG IV SOLR,50863,CDM,250,RC,J0583,HCPCS,63323-562-10,NDC,facility,both,500,EA,,1253,877.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0832-1216-89,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J3430,HCPCS,69097-708-31,NDC,facility,both,10,ML,,218,152.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RALOXIFENE 60 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-694-11,NDC,facility,both,1,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,3,EA,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN PEDS SYRINGE (20MG/ML) IN DEXTROSE (CDS MIX,50863,CDM,636,RC,J0690,HCPCS,0781-3451-70,NDC,facility,both,4,EA,JZ,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2310,HCPCS,0409-1215-01,NDC,facility,both,3,ML,,558,390.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,636,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,7,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADVATE: FACTOR VIII CONCENTRATE (MERGE RECORD),50863,CDM,636,RC,J7209,HCPCS,0944-3053-04,NDC,facility,both,3000,UN,,15732,11012.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",50863,CDM,J1561,HCPCS,13533-800-25,NDC,,,facility,both,120,ML,,16973,11881.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,250,RC,J2003,HCPCS,76329-3390-1,NDC,facility,both,800,ML,,434,303.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 1 GRAM INJ SOLR,50863,CDM,J0692,HCPCS,25021-121-20,NDC,,,facility,both,2,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 1 MG ORAL TBDL,50863,CDM,J3490,HCPCS,59746-020-22,NDC,,,facility,both,2,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 10 MEQ/100 ML IV PGBK (USE NON-PROTOCOL PANEL),50863,CDM,J3480,HCPCS,0338-0709-48,NDC,,,facility,both,10,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML INJ SOLN,50863,CDM,J2060,HCPCS,0641-6207-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOPIDOGREL  75 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-6294-61,NDC,,,facility,both,4,EA,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J3490,HCPCS,63323-492-09,NDC,,,facility,both,50,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIVAROXABAN  2.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50458-577-01,NDC,facility,both,1,EA,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,50863,CDM,J0696,HCPCS,0143-9857-01,NDC,,,facility,both,4,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-4741-19,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 1 % INJ SOLN,50863,CDM,636,RC,Q9968,HCPCS,17478-504-01,NDC,facility,both,5,ML,JW,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,65649-311-12,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,70436-030-82,NDC,facility,both,42,ML,JW,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,20,EA,JZ,2760,1932,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PIOGLITAZONE 30 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,65862-513-30,NDC,facility,both,1,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE ACETATE 1 % OPHT DROPS,50863,CDM,636,RC,J3490,HCPCS,61314-637-05,NDC,facility,both,2,ML,,399,279.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 20MG/ML IV SYRINGE (PEDS/NEO),50863,CDM,250,RC,J0612,HCPCS,63323-311-10,NDC,facility,both,46,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",50863,CDM,250,RC,J1561,HCPCS,13533-800-21,NDC,facility,both,20,ML,,2829,1980.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,0641-6147-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,J3490,HCPCS,66794-229-02,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J3490,HCPCS,0409-3178-01,NDC,,,facility,both,300,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",50863,CDM,J1561,HCPCS,13533-800-41,NDC,,,facility,both,80,ML,,11316,7921.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,68180-441-02,NDC,facility,both,5,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,50863,CDM,J9263,HCPCS,67457-469-10,NDC,,,facility,both,100,ML,,432,302.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,10,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 12.5 MG RECT SUPP,50863,CDM,636,RC,J3490,HCPCS,45802-758-00,NDC,facility,both,1,EA,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARSENIC TRIOXIDE 10 MG/10 ML IV SOLN,50863,CDM,250,RC,J9017,HCPCS,69918-720-01,NDC,facility,both,5,ML,,372,260.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,50863,CDM,J0696,HCPCS,25021-106-10,NDC,,,facility,both,4,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYBUTYNIN CHLORIDE  5 MG ORAL TO24,50863,CDM,250,RC,J3490,HCPCS,0904-6570-61,NDC,facility,both,4,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG ORAL TAB,50863,CDM,636,RC,Q0169,HCPCS,68084-155-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,23155-723-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPYLTHIOURACIL 50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-964-95,NDC,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  20 MG ORAL TR12,50863,CDM,636,RC,J3490,HCPCS,59011-420-20,NDC,facility,both,1,EA,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 17 GRAM (100 %) ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,0904-6931-86,NDC,facility,both,14,EA,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 5 MG-325 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0406-0123-23,NDC,facility,both,3,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML IM SOLN,50863,CDM,636,RC,90375,HCPCS,13533-318-05,NDC,facility,both,10,ML,,8946,6262.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE IN D5W 1 GRAM/100 ML IV PGBK,50863,CDM,J3475,HCPCS,0338-1709-40,NDC,,,facility,both,8,ML,,171,119.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J7510,HCPCS,17856-0815-1,NDC,facility,both,10,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FERUMOXYTOL 510 MG/17 ML (30 MG/ML) IV SOLN,50863,CDM,636,RC,Q0138,HCPCS,0781-3154-01,NDC,facility,both,1020,ML,,4998,3498.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYTOCIN IN 0.9 % SOD CHLORIDE 30 UNIT/500 ML IV SOLN,50863,CDM,250,RC,J2590,HCPCS,71266-5103-1,NDC,facility,both,2,ML,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPHENIDATE 27 MG ORAL TO24,50863,CDM,250,RC,J3490,HCPCS,31722-953-01,NDC,facility,both,2,EA,,133,93.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,250,RC,J3490,HCPCS,0143-9679-01,NDC,facility,both,1,ML,,183,128.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,63323-400-01,NDC,facility,both,450,ML,JZ,246,172.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MYCOPHENOLATE SODIUM 360 MG ORAL TBEC,50863,CDM,636,RC,J7518,HCPCS,0904-6786-04,NDC,facility,both,4,EA,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-0710-20,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,13668-009-01,NDC,facility,both,2,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENETOCLAX 100 MG ORAL TAB,50863,CDM,250,RC,J9999,HCPCS,0074-0576-11,NDC,facility,both,1,EA,,406,284.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-0710-20,NDC,facility,both,10,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,63323-161-00,NDC,facility,both,2,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE MALEATE 10 MG ORAL TAB,50863,CDM,636,RC,Q0164,HCPCS,59746-115-06,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,71399-1025-3,NDC,facility,both,40,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN LIPOSOMAL 2 MG/ML IV INJ,50863,CDM,250,RC,Q2050,HCPCS,70710-1531-1,NDC,facility,both,5,ML,,4681,3276.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,10135-778-01,NDC,facility,both,40,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,76045-009-10,NDC,facility,both,37,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IVPB (PEDIATRICS/ADULT NON-FORM)",50863,CDM,636,RC,J0137,HCPCS,24201-100-01,NDC,facility,both,66,ML,JW,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
BUPROPION HCL 150 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,16729-443-15,NDC,facility,both,1,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEPOLIZUMAB 100 MG SUBQ SOLR,50863,CDM,636,RC,J2182,HCPCS,0173-0881-01,NDC,facility,both,100,EA,JZ,7107,4974.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
TELMISARTAN 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68382-472-30,NDC,facility,both,2,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-495-09,NDC,facility,both,16,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 125 MCG SUBQ SOLR,50863,CDM,250,RC,J2796,HCPCS,55513-223-01,NDC,facility,both,13,EA,,2565,1795.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,50863,CDM,250,RC,J9045,HCPCS,16729-295-12,NDC,facility,both,11,ML,,323,226.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,250,RC,J3360,HCPCS,43598-106-11,NDC,facility,both,2,ML,,145,101.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SYRG,50863,CDM,J3490,HCPCS,6425311130,NDC,,,facility,both,3,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 10 MG TAB,50863,CDM,250,RC,Q0177,HCPCS,16714-081-10,NDC,facility,both,5,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,636,RC,J0330,HCPCS,0409-6629-02,NDC,facility,both,15,ML,,171,119.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0295,HCPCS,63323-368-20,NDC,facility,both,2,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL,50863,CDM,250,RC,J3490,HCPCS,63323-820-01,NDC,facility,both,1,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML INJECTION,50863,CDM,636,RC,J3411,HCPCS,25021-500-02,NDC,facility,both,2,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 30 MG ORAL CPDR,50863,CDM,636,RC,J3490,HCPCS,0904-7044-61,NDC,facility,both,3,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACCHAROMYCES BOULARDII 250 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,1785608695,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"METHYLPREDNISOLONE 1,000 MG SOLUTION FOR INJECTION",50863,CDM,250,RC,J2919,HCPCS,63323-265-30,NDC,facility,both,200,EA,,201,140.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 0.5 MG/ML ORAL SUSPENSION (REPACK),50863,CDM,250,RC,J7507,HCPCS,51079-028-01,NDC,facility,both,2,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,67877-545-68,NDC,facility,both,10,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAMSULOSIN 0.4 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,0904-7383-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYCHLOROQUINE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7046-61,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,636,RC,J2405,HCPCS,0641-6078-01,NDC,facility,both,2,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
TACROLIMUS 1 MG ORAL CAP,50863,CDM,250,RC,J7507,HCPCS,0904-7097-61,NDC,facility,both,4,EA,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-18,NDC,facility,both,10,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLN,50863,CDM,636,RC,J3262,HCPCS,50242-135-01,NDC,facility,both,400,ML,"JZ,JA",7331,5131.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
LEVETIRACETAM NEO IV SYRINGE (PHS FROM PREMIX),50863,CDM,250,RC,J1953,HCPCS,44567-501-01,NDC,facility,both,15,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 12.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68382-094-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESIPRAMINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50742-113-01,NDC,facility,both,2,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,16714-294-01,NDC,facility,both,11,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0780,HCPCS,25021-790-02,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,55150-169-10,NDC,facility,both,80,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
VECURONIUM BROMIDE 10 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,0703-2914-01,NDC,facility,both,2,EA,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 50 MG 24 HR TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6323-61,NDC,facility,both,4,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-752-11,NDC,facility,both,2,EA,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXRAZOXANE 500 MG IV SOLR,50863,CDM,636,RC,J1190,HCPCS,55150-435-01,NDC,facility,both,2,EA,,1321,924.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE 25 MG/ML INJ SOLN,50863,CDM,250,RC,J3230,HCPCS,0641-1397-35,NDC,facility,both,1,ML,,170,119,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,636,RC,J3490,HCPCS,59310-579-22,NDC,facility,both,1,GM,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 1 GRAM INJ SOLR,50863,CDM,250,RC,J0692,HCPCS,0409-9566-01,NDC,facility,both,2,EA,JZ,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,J3490,HCPCS,68180-150-01,NDC,,,facility,both,3,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,636,RC,J3490,HCPCS,0641-6236-01,NDC,facility,both,3,ML,,203,142.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,FAMNOCHARGE,HCPCS,0338-0049-02,NDC,,,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 50 MG/ML INJECTION,50863,CDM,J1200,HCPCS,25021-481-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,J1940,HCPCS,0409-6102-02,NDC,,,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,J1100,HCPCS,63323-506-00,NDC,,,facility,both,10,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE IN D5W 1 GRAM/100 ML IV PGBK,50863,CDM,J3475,HCPCS,63323-108-00,NDC,,,facility,both,4,ML,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 10 MEQ/100 ML IV PGBK (USE NON-PROTOCOL PANEL),50863,CDM,636,RC,J3480,HCPCS,0338-0709-48,NDC,facility,both,5,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOPERAMIDE 2 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,51079-690-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0406-3243-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,636,RC,J3490,HCPCS,59310-579-22,NDC,facility,both,1,GM,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MICAFUNGIN 100 MG IV SOLR,50863,CDM,250,RC,J2248,HCPCS,42023-230-01,NDC,facility,both,150,EA,,970,679,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 8-2 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,0904-7010-06,NDC,facility,both,2,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,75,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 125 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,62756-796-88,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-698-11,NDC,facility,both,1,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,636,RC,J0330,HCPCS,0409-6629-02,NDC,facility,both,6,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,49,ML,,690,483,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LURASIDONE 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7355-04,NDC,facility,both,4,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NAPROXEN 500 MG ORAL TAB,50863,CDM,J3490,HCPCS,63739-403-10,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MISOPROSTOL 50 MCG ORAL SPLIT TAB,50863,CDM,250,RC,S0191,HCPCS,60687-735-01,NDC,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOPERAMIDE 2 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-229-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,50863,CDM,636,RC,Q5119,HCPCS,0069-0238-01,NDC,facility,both,50,ML,,9892,6924.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXAZOSIN 8 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16729-415-01,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-406-03,NDC,facility,both,1,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 250 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,0904-6363-45,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,68462-469-40,NDC,facility,both,2,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYOSCYAMINE SULFATE 0.375 MG ORAL TB12,50863,CDM,636,RC,J3490,HCPCS,16477-738-01,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7007-61,NDC,facility,both,8,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,636,RC,J3490,HCPCS,63037-136-25,NDC,facility,both,2,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,55566-2200-0,NDC,facility,both,28,ML,,2890,2023,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 40 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-210-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-1749-70,NDC,facility,both,4,ML,,134,93.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25 MG-100 MG TAB,50863,CDM,250,RC,J3490,HCPCS,69367-339-05,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,50863,CDM,250,RC,J2359,HCPCS,55150-308-01,NDC,facility,both,10,EA,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
REGADENOSON 0.4 MG/5 ML IV SYRG,50863,CDM,636,RC,J2785,HCPCS,0469-6501-89,NDC,facility,both,4,ML,JZ,913,639.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ERYTHROMYCIN 250 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,13668-586-30,NDC,facility,both,1,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,50863,CDM,250,RC,J9060,HCPCS,16729-288-11,NDC,facility,both,12,ML,,262,183.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPTOMYCIN 500 MG IV SOLR,50863,CDM,636,RC,J0878,HCPCS,0409-0122-01,NDC,facility,both,250,EA,JZ,201,140.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,250,RC,J3490,HCPCS,61553-320-70,NDC,facility,both,3,ML,,194,135.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIVASTIGMINE 9.5 MG/24 HOUR TD PT24,50863,CDM,250,RC,J3490,HCPCS,0078-0502-61,NDC,facility,both,1,EA,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 20 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,50268-585-11,NDC,facility,both,2,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLIPIZIDE  2.5 MG ORAL TO24,50863,CDM,250,RC,J3490,HCPCS,60687-480-21,NDC,facility,both,5,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,16729-114-31,NDC,facility,both,4,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,250,RC,Q9968,HCPCS,70710-1838-1,NDC,facility,both,57,ML,,946,662.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  60 MG ORAL CS24,50863,CDM,250,RC,J3490,HCPCS,0527-4116-37,NDC,facility,both,2,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.3 MG/0.3 ML IM PNIJ,50863,CDM,636,RC,J0169,HCPCS,0093-5986-19,NDC,facility,both,3,EA,,1024,716.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 20 GRAM/30 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,0121-1154-30,NDC,facility,both,3,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROATE SODIUM 100 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-494-01,NDC,facility,both,6,ML,,259,181.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,42291-468-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPTOMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0878,HCPCS,71288-016-15,NDC,facility,both,2000,EA,,705,493.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EZETIMIBE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,69238-1154-3,NDC,facility,both,1,EA,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,636,RC,J1596,HCPCS,0143-9679-01,NDC,facility,both,40,ML,,912,638.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUVOXAMINE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60505-0165-1,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 500 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,0832-7124-89,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,636,RC,J2003,HCPCS,0409-1323-15,NDC,facility,both,1600,ML,,640,448,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-ABDA 100 MG IV SOLR,50863,CDM,636,RC,Q5104,HCPCS,0006-4305-01,NDC,facility,both,5,EA,JW,453,317.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,50863,CDM,250,RC,J9075,HCPCS,10019-956-16,NDC,facility,both,123,EA,,794,555.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60505-3110-0,NDC,facility,both,4,EA,,220,154,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEPERIDINE (PF) 25 MG/ML IV SOLN (PHS MERGE),50863,CDM,636,RC,J2175,HCPCS,0409-1176-03,NDC,facility,both,1,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM ACETATE 667 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,69097-862-83,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUVOXAMINE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0832-1671-11,NDC,facility,both,2,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CABERGOLINE 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,23155-823-73,NDC,facility,both,1,EA,,180,126,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J0461,HCPCS,0517-0401-25,NDC,facility,both,120,ML,,160,112,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25 MG-100 MG TAB,50863,CDM,250,RC,J3490,HCPCS,69367-339-05,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FERROUS SULFATE 325 MG (65 MG IRON) TAB,50863,CDM,636,RC,J3490,HCPCS,904759182,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LECANEMAB-IRMB 100 MG/ML IV SOLN,50863,CDM,636,RC,J0174,HCPCS,62856-215-01,NDC,facility,both,150,ML,JW,192,134.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CARBOPLATIN 10 MG/ML IV,50863,CDM,636,RC,J9045,HCPCS,0703-4239-01,NDC,facility,both,5,ML,,132,92.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MODAFINIL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-621-11,NDC,facility,both,1,EA,,129,90.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC IV INFUSION HYDRAT 31-60 MIN,50863,CDM,250,RC,J0248,HCPCS,61958-2901-2,NDC,facility,both,70,EA,,838,586.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROMETHORPHAN-GUAIFENESIN SR 30 MG-600 MG 12 HR TAB,50863,CDM,636,RC,J3490,HCPCS,63824-056-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7126-61,NDC,facility,both,20,EA,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN V POTASSIUM 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,57237-041-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,636,RC,J2270,HCPCS,0409-1890-03,NDC,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,63739-903-10,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL IV BOLUS 10MG/ML (ANESTHESIA ONLY),50863,CDM,250,RC,J2704,HCPCS,63323-269-29,NDC,facility,both,60,ML,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLMESARTAN 40 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68462-438-30,NDC,facility,both,1,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,63323-165-01,NDC,facility,both,6,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,90,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISONIAZID 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0555-0071-02,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLP",50863,CDM,250,RC,P9047,HCPCS,44206-251-91,NDC,facility,both,4,ML,JZ,1556,1089.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ENALAPRIL MALEATE 1 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,69238-2141-7,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE  2 MG/ML INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,70069-062-01,NDC,facility,both,3,ML,,159,111.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,250,RC,Q9968,HCPCS,70710-1838-1,NDC,facility,both,8,ML,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,FAMNOCHARGE,HCPCS,17856-0759-5,NDC,facility,both,1,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THROMBIN (BOVINE)  5000 UNIT TOP SOLR,50863,CDM,250,RC,J3490,HCPCS,60793-315-01,NDC,facility,both,1,EA,,386,270.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROMETHORPHAN-GUAIFENESIN SR 30 MG-600 MG 12 HR TAB,50863,CDM,250,RC,J3490,HCPCS,17856-0056-1,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,128,ML,,184,128.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,72205-014-90,NDC,facility,both,1,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOPIDOGREL  75 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,65862-357-90,NDC,facility,both,1,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 40 MG/ML (4 %) INJ SOLN (FOR NEBULIZATION),50863,CDM,250,RC,J3490,HCPCS,0409-4283-11,NDC,facility,both,80,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN SODIUM  2 GRAM INJ SOLR,50863,CDM,636,RC,J0290,HCPCS,55150-114-20,NDC,facility,both,4,EA,JZ,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,63323-165-01,NDC,facility,both,24,ML,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL  32.4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6575-61,NDC,facility,both,2,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRIL MALEATE  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-442-01,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 150 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,43598-655-30,NDC,facility,both,1,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,25021-701-01,NDC,facility,both,2,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZTREONAM 2 GRAM INJ SOLR,50863,CDM,250,RC,J0457,HCPCS,0409-0830-11,NDC,facility,both,20,EA,JZ,341,238.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
AMPHETAMINE-DEXTROAMPHETAMINE  5 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,64850-510-01,NDC,facility,both,5,EA,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARSENIC TRIOXIDE 10 MG/10 ML IV SOLN,50863,CDM,250,RC,J9017,HCPCS,23155-869-31,NDC,facility,both,2,ML,JW,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PACLITAXEL 6 MG/ML IV CONC,50863,CDM,250,RC,J9267,HCPCS,61703-342-50,NDC,facility,both,258,ML,,312,218.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OMEPRAZOLE 10 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,68462-395-30,NDC,facility,both,1,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DROPERIDOL 2.5 MG/ML INJ SOLN,50863,CDM,250,RC,J1790,HCPCS,0517-9702-01,NDC,facility,both,2,ML,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INDOMETHACIN 25 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,31722-542-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOBRAMYCIN 1.2 G POWDER VIAL,50863,CDM,636,RC,J3260,HCPCS,39822-0412-6,NDC,facility,both,3,EA,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,50742-615-01,NDC,facility,both,5,EA,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,25021-468-10,NDC,facility,both,1,EA,,225,157.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,16714-293-01,NDC,facility,both,11,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE MONONITRATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,7733393425,NDC,facility,both,1,EA,PLAD,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,6,EA,,211,147.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,636,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,11,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,J3490,HCPCS,76329-3352-1,NDC,,,facility,both,3,ML,,316,221.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2599,HCPCS,65219-039-00,NDC,facility,both,7,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 800 MG ORAL TAB,50863,CDM,J0601,HCPCS,17856-921-01,NDC,,,facility,both,160,EA,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2599,HCPCS,55150-370-01,NDC,facility,both,12,ML,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3370,HCPCS,0143-9162-01,NDC,facility,both,22,EA,,439,307.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 25 MG/5 ML (5 MG/ML) ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,52652-6001-1,NDC,facility,both,1,ML,,107,74.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6427-61,NDC,facility,both,1,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACIDOPHILUS-PECTIN W CITRUS 25 MILLION-100 CELL MG TAB,50863,CDM,250,RC,J3490,HCPCS,17856002601,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 2 TABLET
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,35,EA,,4830,3381,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7362-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML INJECTION,50863,CDM,250,RC,J3411,HCPCS,0641-6228-01,NDC,facility,both,3,ML,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PERMETHRIN 5 % TOP CREA,50863,CDM,636,RC,J3490,HCPCS,21922-021-07,NDC,facility,both,1,GM,,425,297.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-11,NDC,facility,both,16,ML,JW,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DILTIAZEM 30 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0093-0318-01,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 0.25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-270-11,NDC,facility,both,1,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CINACALCET 30 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16729-440-15,NDC,facility,both,3,EA,,390,273,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  75 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,68084-709-11,NDC,facility,both,2,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-01,NDC,facility,both,300,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TORSEMIDE  20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-539-11,NDC,facility,both,5,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,0409-6625-14,NDC,facility,both,2,ML,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROMETHORPHAN-GUAIFENESIN SR 30 MG-600 MG 12 HR TAB,50863,CDM,250,RC,J3490,HCPCS,17856-0056-1,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 300 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,65162-649-78,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-592-11,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MICAFUNGIN 100 MG IV SOLR,50863,CDM,250,RC,J2248,HCPCS,0143-9362-01,NDC,facility,both,50,EA,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-088-11,NDC,facility,both,3,EA,,318,222.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID (PORK) 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0456-1045-01,NDC,facility,both,3,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,70377-008-12,NDC,facility,both,2,EA,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL 2.5 MG/ML SUSPENSION,50863,CDM,250,RC,J3490,HCPCS,99999-0404-75,NDC,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-152-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 300 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,69452-125-50,NDC,facility,both,1,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CITRATE  5 MEQ ORAL TBER,50863,CDM,250,RC,J3490,HCPCS,42543-406-01,NDC,facility,both,6,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VORICONAZOLE 200 MG IV SOLN,50863,CDM,250,RC,J3465,HCPCS,0781-3416-94,NDC,facility,both,39,EA,,1047,732.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6290-61,NDC,facility,both,8,EA,PLAD,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
TRIMETHOPRIM-SULFAMETHOXAZOLE 160 MG-800 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0904-2725-61,NDC,facility,both,8,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0630,HCPCS,42023-205-01,NDC,facility,both,1,ML,,1988,1391.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,J2003,HCPCS,0409-1323-15,NDC,,,facility,both,400,ML,,160,112,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,J3490,HCPCS,63323-486-05,NDC,,,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACIDOPHILUS-PECTIN W CITRUS 25 MILLION-100 CELL MG TAB,50863,CDM,J3490,HCPCS,536142401,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-35,NDC,facility,both,100,ML,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLN (MERGE)",50863,CDM,250,RC,P9047,HCPCS,76125-792-11,NDC,facility,both,1,ML,JW,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DEXRAZOXANE 250 MG IV SOLR,50863,CDM,250,RC,J1190,HCPCS,55150-432-01,NDC,facility,both,2,EA,,1399,979.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE  7 MG/24 HR TD PT24,50863,CDM,J3490,HCPCS,43598-446-71,NDC,,,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEMANTINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6505-06,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 8-2 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,60687-637-11,NDC,facility,both,2,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,7733351625,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 60 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,27241-099-03,NDC,facility,both,1,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7442-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,636,RC,J2003,HCPCS,63323-485-27,NDC,facility,both,145,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,69315-905-05,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENOFIBRATE NANOCRYSTALLIZED  48 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0074-6122-90,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EMTRICITABINE-TENOFOVIR 200 MG-300 MG TAB,50863,CDM,636,RC,J0750,HCPCS,60687-719-95,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUM U-500 CONC 500 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1815,HCPCS,0002-8501-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ESMOLOL IN SALINE (ISO-OSMOTIC) 2,000 MG/100 ML (20 MG/ML) IV",50863,CDM,250,RC,J1805,HCPCS,67457-658-10,NDC,facility,both,1,ML,,1251,875.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NS WITH POTASSIUM CHLORIDE 20 MEQ/L IV SOLP,50863,CDM,250,RC,J3480,HCPCS,0338-0691-04,NDC,facility,both,10,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 600 MG ORAL TP12,50863,CDM,250,RC,J3490,HCPCS,0536-1163-61,NDC,facility,both,6,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LINACLOTIDE 145 MCG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0456-1201-30,NDC,facility,both,1,EA,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIOTHYRONINE  5 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-2179-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLIPIZIDE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0591-0460-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-0710-20,NDC,facility,both,8,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,62559-440-02,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLP",50863,CDM,250,RC,P9047,HCPCS,44206-251-91,NDC,facility,both,2,ML,JZ,778,544.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,250,RC,J3490,HCPCS,67457-197-10,NDC,facility,both,1,ML,,368,257.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TERBUTALINE 1 MG/ML SUBQ SOLN,50863,CDM,250,RC,J3105,HCPCS,63323-665-00,NDC,facility,both,1,ML,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETHOSUXIMIDE 250 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,64380-878-06,NDC,facility,both,3,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,50863,CDM,250,RC,J2359,HCPCS,72603-181-01,NDC,facility,both,10,EA,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN DEXTROSE (ISO-OSMOTIC) 1 GRAM/50 ML IV PIGGY BACK,50863,CDM,636,RC,J0690,HCPCS,0338-3503-41,NDC,facility,both,4,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOFLOXACIN 250 MG/10 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0527-1948-66,NDC,facility,both,1,ML,,273,191.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,636,RC,J3490,HCPCS,60687-653-11,NDC,facility,both,6,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-630-11,NDC,facility,both,1,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7363-61,NDC,facility,both,2,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 10 GRAM/100 ML (10%) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-72,NDC,facility,both,20,ML,,2829,1980.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ORAL ELECTROLYTES ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,7007411133,NDC,facility,both,2,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,636,RC,J1596,HCPCS,16714-536-01,NDC,facility,both,2,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16714-613-04,NDC,facility,both,2,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROATE SODIUM 100 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-494-01,NDC,facility,both,1,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FERUMOXYTOL 510 MG/17 ML (30 MG/ML) IV SOLN,50863,CDM,636,RC,Q0138,HCPCS,0781-3154-01,NDC,facility,both,510,ML,JZ,2499,1749.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LORAZEPAM 0.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,69315-904-01,NDC,facility,both,4,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIPASE-PROTEASE-AMYLASE 24,000-76,000- 120,000 UNIT ORAL CAP, DELAY REL",50863,CDM,636,RC,J3490,HCPCS,0032-2636-01,NDC,facility,both,1,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,13668-219-30,NDC,facility,both,1,EA,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOLAZONE  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69292-562-01,NDC,facility,both,3,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PSYLLIUM HUSK (WITH SUGAR) 3.4 GRAM ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,37000-023-10,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DICLOFENAC 75 MG TAB, DELAYED RELEASE",50863,CDM,250,RC,J3490,HCPCS,0228-2551-06,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL  50 MCG/HR TD PT72,50863,CDM,250,RC,J3490,HCPCS,47781-426-11,NDC,facility,both,2,EA,,330,231,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,136,ML,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,636,RC,P9045,HCPCS,68516-5218-0,NDC,facility,both,1,ML,,237,165.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,68180-723-04,NDC,facility,both,3,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML IV SOLN (MERGE),50863,CDM,636,RC,J3490,HCPCS,16714-037-10,NDC,facility,both,1,ML,,127,88.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 100 MG ORAL TB12,50863,CDM,636,RC,J3490,HCPCS,0078-0510-05,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,16714-293-01,NDC,facility,both,10,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,67877-433-03,NDC,facility,both,1,EA,,157,109.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,0641-6007-01,NDC,facility,both,2,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SINCALIDE 5 MCG INJ SOLR,50863,CDM,636,RC,J2805,HCPCS,72266-248-05,NDC,facility,both,1,EA,,272,190.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7369-04,NDC,facility,both,2,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
URSODIOL 300 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-100-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-6666-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN STERILE WATER 2 GRAM/20 ML IV SYRG,50863,CDM,250,RC,J7999,HCPCS,70092-1604-47,NDC,facility,both,3,ML,,157,109.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIBOFLAVIN 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,7431200640,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NAPHAZOLINE-PHENIRAMINE 0.025 %-0.3 % EYE DROPS,50863,CDM,250,RC,J3490,HCPCS,69968-0063-1,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1940,HCPCS,0409-6102-02,NDC,facility,both,5,ML,,139,97.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN PEDS SYRINGE (20MG/ML) IN DEXTROSE (CDS MIX,50863,CDM,636,RC,J0690,HCPCS,0781-3451-70,NDC,facility,both,1,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MULTIVITAMIN W/IRON ORAL DROP 1 ML (PEDS/NEO),50863,CDM,250,RC,J3490,HCPCS,17856-0039-04,NDC,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 40 GRAM/400 ML (10 %) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-20,NDC,facility,both,20,ML,,2829,1980.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,54288-137-01,NDC,facility,both,1,ML,,140,98,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,636,RC,J3010,HCPCS,63323-806-13,NDC,facility,both,3,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 12.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7307-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-22,NDC,facility,both,5,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,636,RC,J7060,HCPCS,0338-0017-03,NDC,facility,both,2,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML IV,50863,CDM,636,RC,J3490,HCPCS,70860-301-41,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 0.1 MG/ML IV SYRINGE (NEO/INFANT),50863,CDM,250,RC,J1100,HCPCS,99999-0405-74,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG RECT SUPP,50863,CDM,250,RC,J3490,HCPCS,51672-2116-2,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7126-61,NDC,facility,both,18,EA,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRIL MALEATE 1 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,52652-4001-1,NDC,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MYCOPHENOLATE 250 MG CAP,50863,CDM,250,RC,J7517,HCPCS,51079-721-01,NDC,facility,both,1,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,636,RC,J1836,HCPCS,0338-1055-48,NDC,facility,both,50,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ACETYLCYSTEINE 10 % (100 MG/ML) MISC SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-695-22,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPSONE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,64980-567-03,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENDAMUSTINE 25 MG/ML IV SOLN,50863,CDM,250,RC,J9034,HCPCS,63459-348-04,NDC,facility,both,200,ML,,13656,9559.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0143-9386-01,NDC,facility,both,23,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-088-11,NDC,facility,both,4,EA,,431,301.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0603-3901-21,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LANTHANUM  500 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,0093-5938-54,NDC,facility,both,2,EA,,134,93.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXAZOSIN 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-5522-61,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZATHIOPRINE  50 MG ORAL TAB,50863,CDM,250,RC,J7500,HCPCS,68084-229-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM IN NACL (ISO-OS) 500 MG/100 ML IV PGBK,50863,CDM,636,RC,J1953,HCPCS,67457-255-00,NDC,facility,both,150,ML,,247,172.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50111-328-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CITRATE-VITAMIN D3 200 MG CALCIUM -250 UNIT ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,536322301,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9% IV (PEDS) BOLUS,50863,CDM,250,RC,J7040,HCPCS,0264-7800-09,NDC,facility,both,4,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,70377-008-12,NDC,facility,both,2,EA,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6817-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7448-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,40,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESNA 100 MG/ML IV SOLN,50863,CDM,636,RC,J9209,HCPCS,0338-1305-01,NDC,facility,both,2,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL 20 MG/5 ML ORAL ELIX,50863,CDM,636,RC,J3490,HCPCS,60687-671-40,NDC,facility,both,2,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-9558-05,NDC,facility,both,2,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MICAFUNGIN 100 MG IV SOLR,50863,CDM,250,RC,J2248,HCPCS,0143-9362-01,NDC,facility,both,100,EA,,647,452.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,42806-150-33,NDC,facility,both,6,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  30 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,0406-8330-62,NDC,facility,both,3,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,250,RC,J2795,HCPCS,70069-064-25,NDC,facility,both,75,ML,JW,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DOXAZOSIN 4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-5524-61,NDC,facility,both,4,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,51754-5001-1,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-613-04,NDC,facility,both,2,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-990-01,NDC,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 30 MG/0.3 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,0548-5601-00,NDC,facility,both,3,ML,JZ,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-41,NDC,facility,both,80,ML,"JG,JZ,JA",11316,7921.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-25,NDC,facility,both,200,ML,"JZ,JA",28288,19801.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
EPINEPHRINE IN 0.9 % SOD CHLOR 4 MG/250 ML (16 MCG/ML) IV SOLN,50863,CDM,636,RC,J0171,HCPCS,42023-315-01,NDC,facility,both,1,ML,,389,272.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-05,NDC,facility,both,12,EA,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN NACL (PF) 1000 UNIT/500 ML IV SOLP,50863,CDM,250,RC,J1644,HCPCS,0264-9872-10,NDC,facility,both,3,ML,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,1657187290,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6640-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,68180-441-02,NDC,facility,both,3,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAUNORUBICIN 5 MG/ML IV INJ,50863,CDM,250,RC,J9150,HCPCS,42658-021-01,NDC,facility,both,1,ML,JW,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-444-01,NDC,facility,both,8,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,60219-1708-1,NDC,facility,both,50,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID (PORK)  60 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,42192-330-01,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENAZEPRIL 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-110-11,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE  50 MG ORAL CAP,50863,CDM,250,RC,J8530,HCPCS,62332-619-31,NDC,facility,both,44,EA,,1071,749.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOLIC ACID  1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-681-11,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALTREXONE 50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-291-11,NDC,facility,both,2,EA,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-464-17,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 500 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,0832-7124-89,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRP (MERGE/REPACK),50863,CDM,636,RC,J3490,HCPCS,68094-764-59,NDC,facility,both,2,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICARDIPINE IN NACL (ISO-OS) 20 MG/200 ML IV PGBK,50863,CDM,J3490,HCPCS,0143-9634-01,NDC,,,facility,both,1,ML,,414,289.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,64,ML,JW,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,0409-6102-02,NDC,facility,both,240,ML,,334,233.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,0409-1283-03,NDC,facility,both,20,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,J0132,HCPCS,55150-259-30,NDC,,,facility,both,78,ML,,353,247.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 200 MG/10 ML IRON IV SOLN,50863,CDM,J1756,HCPCS,0517-2310-01,NDC,,,facility,both,200,ML,,545,381.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIVOLUMAB 240 MG/24 ML IV SOLN,50863,CDM,250,RC,J9299,HCPCS,0003-3734-13,NDC,facility,both,240,ML,,17369,12158.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  5 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,33342-083-07,NDC,facility,both,2,EA,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,50863,CDM,J9025,HCPCS,0143-9606-01,NDC,,,facility,both,145,EA,,332,232.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,J2919,HCPCS,0009-0039-30,NDC,,,facility,both,12,EA,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN PEDS SYRINGE (20MG/ML) IN DEXTROSE (CDS MIX,50863,CDM,250,RC,J0690,HCPCS,0781-3451-70,NDC,facility,both,8,EA,,167,116.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM PHOS IN 0.9 % NACL 15 MMOL/250 ML IVPB PREMIX,50863,CDM,250,RC,J3490,HCPCS,72196-6060-1,NDC,facility,both,1,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5% W/EPINEPHRINE 1:200K INJECTION,50863,CDM,250,RC,J3490,HCPCS,0409-1749-29,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC MCARE ADMIN HEPATITIS B VACC,50863,CDM,250,RC,90746,HCPCS,58160-821-01,NDC,facility,both,1,ML,,367,256.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 0.1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-721-11,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0264-1800-36,NDC,facility,both,1,ML,,131,91.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPRAZOLAM 0.25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0781-1061-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.3 MG/0.3 ML IM PNIJ,50863,CDM,636,RC,J0171,HCPCS,0115-1694-30,NDC,facility,both,3,EA,,890,623,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOLAZONE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-635-01,NDC,facility,both,2,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,70954-316-10,NDC,facility,both,2,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,250,RC,Q0162,HCPCS,65162-691-79,NDC,facility,both,2,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACUBITRIL-VALSARTAN 24-26 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0078-0659-67,NDC,facility,both,1,EA,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,5,EA,,185,129.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LYMPHOCYTE,ANTI-THYMO IMMUNE GLOBULIN 50 MG/ML IV",50863,CDM,250,RC,J7504,HCPCS,0009-7224-01,NDC,facility,both,10,ML,,133041,93128.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML (1ML) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,54288-119-01,NDC,facility,both,3,ML,,238,166.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 500 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,68084-415-11,NDC,facility,both,4,EA,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,250,RC,J3490,HCPCS,0574-0181-01,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25 MG-100 MG TAB,50863,CDM,250,RC,J3490,HCPCS,69367-339-05,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,68982-623-02,NDC,facility,both,2,ML,JZ,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IRON SUCROSE 100 MG/5 ML IV SOLN,50863,CDM,636,RC,J1756,HCPCS,0517-2340-01,NDC,facility,both,100,ML,,312,218.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSINOPRIL 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,43547-386-09,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0904-7127-61,NDC,facility,both,20,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,636,RC,J0690,HCPCS,44567-707-25,NDC,facility,both,4,EA,JZ,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-453-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,J3490,HCPCS,0641-6147-01,NDC,,,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRP (MERGE/REPACK),50863,CDM,636,RC,J3490,HCPCS,68094-764-59,NDC,facility,both,2,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIVOLUMAB 240 MG/24 ML IV SOLN,50863,CDM,J9299,HCPCS,0003-3734-13,NDC,,,facility,both,240,ML,,17369,12158.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INDOCYANINE GREEN 25 MG INJ,50863,CDM,J3490,HCPCS,70100-424-01,NDC,,,facility,both,15,EA,,11270,7889,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHIMAZOLE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,49884-641-01,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3373,HCPCS,0143-9162-01,NDC,facility,both,600,EA,,240,168,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALSARTAN 160 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-634-11,NDC,facility,both,2,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN D5W 25000 UNIT/250 ML (PTT MONITORING),50863,CDM,250,RC,J1644,HCPCS,0264-9587-20,NDC,facility,both,25,ML,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,4,ML,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM PEDS IVPB (FROM PREMIX),50863,CDM,250,RC,J1953,HCPCS,43598-635-52,NDC,facility,both,50,ML,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL  32.4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16571-673-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-580-11,NDC,facility,both,6,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAMSULOSIN 0.4 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,0904-6401-61,NDC,facility,both,2,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,65219-445-01,NDC,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,14789-127-07,NDC,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,25021-601-03,NDC,facility,both,26,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE 0.05 % OPHT DPET,50863,CDM,636,RC,J3490,HCPCS,10702-808-03,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68180-513-01,NDC,facility,both,4,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6636-61,NDC,facility,both,3,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68180-966-01,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,43598-931-11,NDC,facility,both,2,ML,JW,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
MEROPENEM 1 GRAM IV SOLR,50863,CDM,250,RC,J2185,HCPCS,63323-508-01,NDC,facility,both,120,EA,,471,329.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 500 MG PE/10 ML INJ SOLN,50863,CDM,250,RC,Q2009,HCPCS,0069-6001-10,NDC,facility,both,30,ML,,1572,1100.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE (PF-DURAMORPH/ASTRAMORPH) 0.5 MG/ML INJ SOLN,50863,CDM,250,RC,J2274,HCPCS,0409-3814-12,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,2,EA,,101,70.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 100 MG PE/2 ML INJ SOLN,50863,CDM,250,RC,Q2009,HCPCS,63323-403-01,NDC,facility,both,4,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,250,RC,J0330,HCPCS,0409-6629-02,NDC,facility,both,3,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 2 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,250,RC,J2270,HCPCS,63323-452-00,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,5,ML,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0630,HCPCS,24201-400-02,NDC,facility,both,1,ML,JZ,2112,1478.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LEVETIRACETAM NEO IV SYRINGE (PHS FROM PREMIX),50863,CDM,250,RC,J1953,HCPCS,44567-501-01,NDC,facility,both,24,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOBRAMYCIN 150 MG/3.75 ML NEBULIZER SOLN (REPACK),50863,CDM,250,RC,J3490,HCPCS,63323-306-30,NDC,facility,both,2,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,250,RC,J3490,HCPCS,73013-2002-2,NDC,facility,both,3,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 50 % (4 MEQ/ML) INJ SOLN,50863,CDM,250,RC,J3475,HCPCS,63323-642-50,NDC,facility,both,200,ML,,378,264.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 20 GRAM/30 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-1154-30,NDC,facility,both,2,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0093-0053-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6084-61,NDC,facility,both,4,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-3178-16,NDC,facility,both,40,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-742-11,NDC,facility,both,4,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLIPIZIDE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0591-0461-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,13533-690-25,NDC,facility,both,13,ML,,1802,1261.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-ABDA 100 MG IV SOLR,50863,CDM,636,RC,Q5104,HCPCS,78206-162-99,NDC,facility,both,9,EA,JW,814,569.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LEVETIRACETAM IN NACL (ISO-OS) 1000 MG/100 ML IV PGBK,50863,CDM,636,RC,J1953,HCPCS,44567-502-01,NDC,facility,both,200,ML,,131,91.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,250,RC,Q0162,HCPCS,65162-691-79,NDC,facility,both,2,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,10135-678-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TETRACAINE HCL (PF) 0.5 % OPHT DROP (STANDARD STOCK),50863,CDM,636,RC,J3490,HCPCS,0065-0741-14,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES-DOCUSATE SODIUM 8.6 MG-50 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7440-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 2 MG/ML IV SOLN (PRMC ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-1312-03,NDC,facility,both,60,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-04,NDC,facility,both,18,ML,,300,210,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTAMIDINE 300 MG INHL SOLR,50863,CDM,250,RC,J3490,HCPCS,13925-522-01,NDC,facility,both,1,EA,,650,455,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM,50863,CDM,636,RC,J3490,HCPCS,45802-358-03,NDC,facility,both,1,GM,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML INJ SOLN,50863,CDM,250,RC,J0169,HCPCS,76329-9060-0,NDC,facility,both,30,ML,,797,557.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J0461,HCPCS,0517-1004-01,NDC,facility,both,50,ML,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7243-61,NDC,facility,both,10,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML (1ML-UD) OR SYRINGE,50863,CDM,250,RC,J3490,HCPCS,25021-662-05,NDC,facility,both,5,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 2-0.5 MG SL SUBL,50863,CDM,636,RC,J3490,HCPCS,50268-144-11,NDC,facility,both,6,EA,,140,98,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,636,RC,J3490,HCPCS,50268-540-11,NDC,facility,both,6,EA,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELIMUMAB 120 MG IV SOLR,50863,CDM,636,RC,J0490,HCPCS,49401-101-01,NDC,facility,both,120,ME,"JZ,JA",14093,9865.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
PANTOPRAZOLE 40 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,25021-751-10,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 160 MG-800 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0904-2725-61,NDC,facility,both,12,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-18,NDC,facility,both,1,ML,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN NACL (PF) 1000 UNIT/500 ML IV SOLP,50863,CDM,250,RC,J1644,HCPCS,0409-1005-01,NDC,facility,both,2,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-24,NDC,facility,both,40,ML,JA,5658,3960.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
METOPROLOL SUCCINATE SR 50 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6323-61,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69315-905-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,42806-150-33,NDC,facility,both,4,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM IN NACL (ISO-OS) 500 MG/100 ML IV PGBK,50863,CDM,250,RC,J1953,HCPCS,36000-352-01,NDC,facility,both,50,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,72888-037-01,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,636,RC,J1596,HCPCS,0143-9679-01,NDC,facility,both,9,ML,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE IN 0.9% NACL 3 GRAM/100 ML IV SOLN,50863,CDM,250,RC,J0612,HCPCS,61553-056-48,NDC,facility,both,200,ML,JW,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LACTATED RINGERS IV,50863,CDM,J7120,HCPCS,0338-0117-03,NDC,,,facility,both,1,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJ SOLN",50863,CDM,J3490,HCPCS,0409-1746-71,NDC,,,facility,both,1,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,25021-602-03,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % MBP,50863,CDM,636,RC,J3490,HCPCS,0338-0553-18,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,25021-701-01,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZOCAINE-MENTHOL 15-3.6 MG MM LOZG,50863,CDM,636,RC,J3490,HCPCS,6382471016,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOZAPINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-922-01,NDC,facility,both,4,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-723-11,NDC,facility,both,2,EA,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,72888-037-01,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RACEPINEPHRINE 2.25 % INHL NEBU,50863,CDM,250,RC,J3490,HCPCS,0487-2784-01,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-0552-23,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 50 MG TAB,50863,CDM,250,RC,J3490,HCPCS,42043-221-00,NDC,facility,both,1,EA,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 100 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,51672-4047-9,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PERPHENAZINE  8 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0781-8048-01,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VERAPAMIL 180 MG ORAL TBSR,50863,CDM,636,RC,J3490,HCPCS,75834-158-01,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,636,RC,J3490,HCPCS,77333-049-25,NDC,facility,both,4,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,50863,CDM,250,RC,J9025,HCPCS,72485-201-01,NDC,facility,both,127,EA,,1802,1261.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPHENIDATE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0406-1142-01,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELIMUMAB 400 MG IV SOLR,50863,CDM,636,RC,J0490,HCPCS,49401-102-01,NDC,facility,both,40,EA,JZ,4459,3121.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,636,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,9,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  750 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-882-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,43066-997-01,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOLUTEGRAVIR 50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,49702-228-13,NDC,facility,both,1,EA,,395,276.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GRANISETRON 1 MG/ML (1 ML) IV SOLN,50863,CDM,250,RC,J1626,HCPCS,66758-035-01,NDC,facility,both,10,ML,,245,171.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 125 MG/5 ML (25MG/ML) ORAL SYRINGE (REPACK),50863,CDM,250,RC,J3370,HCPCS,67457-340-00,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,50863,CDM,250,RC,J0696,HCPCS,60505-6148-0,NDC,facility,both,16,EA,,899,629.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 90 MG TAB,50863,CDM,250,RC,J3490,HCPCS,50228-483-01,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,0409-4279-16,NDC,,,facility,both,330,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DONANEMAB-AZBT 17.5 MG/ML IV SOLN,50863,CDM,636,RC,J0175,HCPCS,0002-9401-01,NDC,facility,both,175,ML,Q0,1601,1120.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier Q0: Investigational clinical service provided in a clinical research study that is in an approved clinical research study
OSELTAMIVIR PHOSPHATE 30 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,31722-630-31,NDC,facility,both,2,EA,,139,97.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRP (MERGE/REPACK),50863,CDM,250,RC,J3490,HCPCS,63304-205-18,NDC,facility,both,2,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM BROMIDE 0.03 % NASL SPRA,50863,CDM,250,RC,J3490,HCPCS,24208-398-30,NDC,facility,both,1,ML,,224,156.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE IN D5W 1 GRAM/100 ML IV PGBK,50863,CDM,250,RC,J3475,HCPCS,63323-108-00,NDC,facility,both,21,ML,,570,399,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-495-27,NDC,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-071-04,NDC,facility,both,2,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN PEDS INFUSION (CDS MIXTURE),50863,CDM,250,RC,J0290,HCPCS,99999-408-63,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,636,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,8,EA,,277,193.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN 1000 MG IN NS 1000 ML IRRIGATION (REPACK),50863,CDM,250,RC,J0690,HCPCS,99999-500-04,NDC,facility,both,3,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LITHIUM CARBONATE 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0054-8527-25,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) MISC SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-694-04,NDC,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 800 MG ORAL TAB,50863,CDM,250,RC,J0601,HCPCS,0904-6707-06,NDC,facility,both,200,EA,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,0143-9511-01,NDC,facility,both,12,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,J3490,HCPCS,63323-467-01,NDC,,,facility,both,1,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  1 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,64380-782-06,NDC,facility,both,121,EA,,150,105,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  120 MG RECT SUPP,50863,CDM,636,RC,J3490,HCPCS,51672-2115-0,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-1638-32,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0047-03,NDC,facility,both,200,EA,,511,357.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-492-27,NDC,,,facility,both,180,ML,,142,99.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,5,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANTI-INHIBITOR COAGULANT CMPLX (PHS MERGE),50863,CDM,250,RC,J7198,HCPCS,64193-324-01,NDC,facility,both,1,UN,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PALONOSETRON 0.25 MG/5 ML IV INJECTION (MERGE),50863,CDM,J2469,HCPCS,60505-6193-1,NDC,,,facility,both,10,ML,,605,423.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 2.5 % EYE DROPS,50863,CDM,636,RC,J3490,HCPCS,70756-629-25,NDC,facility,both,1,ML,,199,139.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,J3490,HCPCS,0904-6794-80,NDC,,,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMMONIUM LACTATE 12 % TOP LOTN,50863,CDM,250,RC,J3490,HCPCS,45802-419-54,NDC,facility,both,1,GM,,162,113.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML (PEDS CALCLUATOR 0.5),50863,CDM,250,RC,J1815,HCPCS,0024-5924-10,NDC,facility,both,800,ML,,1695,1186.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4 % TOPICAL SOLN,50863,CDM,250,RC,J3490,HCPCS,76329-6300-5,NDC,facility,both,5,ML,,653,457.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV,50863,CDM,636,RC,J7120,HCPCS,0338-0117-04,NDC,facility,both,5,ML,,167,116.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE (FOR CODE) 10% IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0517-2710-25,NDC,facility,both,2,ML,,227,158.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BICARB FOR OR,50863,CDM,250,RC,J3490,HCPCS,99999-0402-85,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
URSODIOL 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7168-06,NDC,facility,both,1,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,121119030,NDC,facility,both,1,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,32,ML,JW,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LOSARTAN  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,78206-121-01,NDC,facility,both,1,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,13,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIOTHYRONINE  5 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,59762-1206-1,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-175-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE INFUSION 2MG/ML 100ML (FOR ANESTHESIA USE ONLY),50863,CDM,250,RC,J3490,HCPCS,0409-2051-05,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DRONABINOL  2.5 MG ORAL CAP,50863,CDM,250,RC,Q0167,HCPCS,0904-6745-61,NDC,facility,both,2,EA,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  100 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,63323-376-00,NDC,facility,both,24,ML,JA,350,245,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,250,RC,J2003,HCPCS,63323-495-09,NDC,facility,both,16,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 40 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,70436-227-48,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-709-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-444-01,NDC,facility,both,4,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN SODIUM EXTENDED 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,65862-692-01,NDC,facility,both,15,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAZOSIN 5 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,51079-632-01,NDC,facility,both,3,EA,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-495-27,NDC,,,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAMOXIFEN 10 MG ORAL TAB,50863,CDM,250,RC,J9999,HCPCS,75907-058-60,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYBUTYNIN CHLORIDE  5 MG ORAL TO24,50863,CDM,250,RC,J3490,HCPCS,62175-270-37,NDC,facility,both,1,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MYCOPHENOLATE 250 MG CAP,50863,CDM,250,RC,J7517,HCPCS,60687-885-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,J2371,HCPCS,0641-6142-01,NDC,,,facility,both,29500,ML,,3246,2272.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  5 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-122-11,NDC,facility,both,13,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,72603-179-01,NDC,facility,both,10,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,5,ML,,160,112,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 5 MG/5 ML IV,50863,CDM,636,RC,J3490,HCPCS,0143-9873-10,NDC,facility,both,2,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,30000,ML,,52021,36414.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 17 GRAM (100 %) ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,0904-6931-86,NDC,facility,both,17,EA,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE (FOR CODE) 10% (100 MG/ML) IV SYRINGE,50863,CDM,250,RC,J3490,HCPCS,64253-900-30,NDC,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1170,HCPCS,76045-009-96,NDC,facility,both,1,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOFLOXACIN IN D5W 750 MG/150 ML IV PGBK,50863,CDM,250,RC,J1956,HCPCS,0143-9720-01,NDC,facility,both,3,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 40 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7178-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 1 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,65162-673-84,NDC,facility,both,1,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,J2003,HCPCS,0143-9575-01,NDC,,,facility,both,660,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,J3490,HCPCS,68180-441-02,NDC,,,facility,both,20,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML INJ SOLN,50863,CDM,J2060,HCPCS,0409-1985-03,NDC,,,facility,both,2,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,FAMNOCHARGE,HCPCS,17856-0691-5,NDC,,,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 0.1MG/ML SUSPENSION (REPACK),50863,CDM,250,RC,J3490,HCPCS,51079-882-01,NDC,facility,both,20,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 250 MG ORAL TB24,50863,CDM,J3490,HCPCS,0904-6363-61,NDC,,,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,50863,CDM,J3301,HCPCS,70121-1169-1,NDC,,,facility,both,2,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-18,NDC,facility,both,100,ML,JG,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount
FELODIPINE  2.5 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,68462-233-01,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5% W/EPINEPHRINE 1:200K INJECTION,50863,CDM,J3490,HCPCS,0409-1749-29,NDC,,,facility,both,1,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERYTHROMYCIN 5 MG/G OPHT OINT,50863,CDM,J3490,HCPCS,17478-070-35,NDC,,,facility,both,1,GM,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J2004,HCPCS,0409-3178-01,NDC,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 25 MG TAB,50863,CDM,250,RC,J3490,HCPCS,51079-255-01,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 100 MG/5 ML ORAL LIQD,50863,CDM,250,RC,J3490,HCPCS,50383-063-10,NDC,facility,both,12,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,636,RC,J2795,HCPCS,43066-023-01,NDC,facility,both,100,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,250,RC,Q9968,HCPCS,70710-1838-1,NDC,facility,both,110,ML,,1826,1278.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPTOMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0878,HCPCS,0409-0122-01,NDC,facility,both,450,EA,,362,253.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,636,RC,Q0162,HCPCS,16714-671-02,NDC,facility,both,2,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-453-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,70710-1833-1,NDC,facility,both,1,EA,,152,106.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0406-8515-23,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,50863,CDM,636,RC,J2354,HCPCS,23155-687-31,NDC,facility,both,2,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 20 GRAM/30 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-1154-30,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,250,RC,J2003,HCPCS,63323-495-27,NDC,facility,both,80,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROFURANTOIN (25% MACROCRYSTAL FORM) 100 MG CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7137-61,NDC,facility,both,9,EA,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 1 % OPHT DROP,50863,CDM,250,RC,J3490,HCPCS,60219-1748-2,NDC,facility,both,1,ML,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,636,RC,J2560,HCPCS,0641-0477-21,NDC,facility,both,5,ML,,1393,975.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML SYRUP,50863,CDM,250,RC,J3490,HCPCS,0121-0638-10,NDC,facility,both,25,ML,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,63323-482-26,NDC,,,facility,both,200,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,J1596,HCPCS,0517-4601-01,NDC,,,facility,both,2,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 500 MG (200 MG ELEMENTAL) CHEW TAB,50863,CDM,J3490,HCPCS,66553-004-01,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM-ALBUTEROL 0.5 MG-2.5 MG/3 ML NEB SOLUTION,50863,CDM,J3490,HCPCS,60687-405-79,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,63323-165-01,NDC,facility,both,20,ML,JZ,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ATORVASTATIN 10 MG ORAL TAB,50863,CDM,J3490,HCPCS,51079-208-01,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOLUTEGRAVIR-RILPIVIRINE 50-25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,49702-242-13,NDC,facility,both,1,EA,,506,354.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-406-03,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,59651-488-01,NDC,facility,both,160,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DASATINIB 100 MG ORAL TAB,50863,CDM,250,RC,J9999,HCPCS,60505-3631-3,NDC,facility,both,1,EA,,1595,1116.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,636,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,7,EA,,244,170.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25 MG-100 MG TAB,50863,CDM,636,RC,J3490,HCPCS,59651-457-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MITOMYCIN 20 MG IV SOLR,50863,CDM,636,RC,J9280,HCPCS,71288-138-50,NDC,facility,both,8,EA,JZ,2484,1738.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0137,HCPCS,0143-9386-01,NDC,facility,both,21,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,0904-7509-30,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOTRIMAZOLE 1 % TOP CREA,50863,CDM,250,RC,J3490,HCPCS,68462-181-35,NDC,facility,both,1,GM,,171,119.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMTERENE-HYDROCHLOROTHIAZIDE 37.5 MG-25 MG TAB,50863,CDM,250,RC,J3490,HCPCS,68084-750-95,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9% IV (PEDS) BOLUS,50863,CDM,636,RC,J7040,HCPCS,0264-7800-09,NDC,facility,both,2,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6666-61,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NAPROXEN 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-491-11,NDC,facility,both,4,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX (PF) 10 MCG IM,50863,CDM,250,RC,90648,HCPCS,49281-545-03,NDC,facility,both,1,EA,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,J0665,HCPCS,70594-117-01,NDC,,,facility,both,200,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2598,HCPCS,43598-914-11,NDC,facility,both,5,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,J3101,HCPCS,50242-037-06,NDC,,,facility,both,28,EA,,5576,3903.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68180-966-01,NDC,facility,both,4,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,636,RC,Q0162,HCPCS,16714-671-02,NDC,facility,both,2,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,50863,CDM,636,RC,J1756,HCPCS,0517-2340-10,NDC,facility,both,200,ML,,623,436.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,17,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,63323-506-01,NDC,facility,both,16,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0781-6041-55,NDC,facility,both,10,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6475-61,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CELECOXIB 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-6502-61,NDC,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 40 MG/ML SUSP (DEPO-MEDROL) INJECTION,50863,CDM,636,RC,J1010,HCPCS,70121-1573-1,NDC,facility,both,80,ML,JZ,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"LIDOCAINE-EPINEPHRINE 2 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J2004,HCPCS,63323-489-02,NDC,facility,both,160,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,636,RC,J3010,HCPCS,0641-6028-01,NDC,facility,both,3,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IMIPRAMINE 10 MG TAB,50863,CDM,250,RC,J3490,HCPCS,69315-133-01,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,0409-9094-25,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"POTASSIUM CITRATE-CITRIC ACID 1,100 MG-334 MG/5 ML ORAL SOLN",50863,CDM,636,RC,J3490,HCPCS,121067616,NDC,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-5755-23,NDC,facility,both,6,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-02,NDC,facility,both,2,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7912-51,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIPHTH,PERTUS(ACELL),TETANUS SYRG(BOOSTRIX) 2.5-8-5 LF-MCG-LF/0.5ML IM SYRG",50863,CDM,636,RC,90715,HCPCS,58160-842-43,NDC,facility,both,1,ML,GZ,247,172.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier GZ: Item or service expected to be denied as not reasonable and necessary
"LIPASE-PROTEASE-AMYLASE 24,000-76,000- 120,000 UNIT ORAL CAP, DELAY REL",50863,CDM,250,RC,J3490,HCPCS,0032-2636-01,NDC,facility,both,3,EA,,145,101.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE (6 MONTH) 45 MG IM SYKT,50863,CDM,636,RC,J9217,HCPCS,0074-3473-03,NDC,facility,both,6,EA,JZ,1176,823.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,50863,CDM,636,RC,J1885,HCPCS,72266-119-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE MICROSPHERES 25 MG/2 ML IM SYRG,50863,CDM,250,RC,J2794,HCPCS,50458-306-11,NDC,facility,both,50,EA,,1782,1247.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (NEO) <2 KG,50863,CDM,250,RC,J7060,HCPCS,0264-7510-00,NDC,facility,both,2,ML,JZ,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
OXYCODONE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6966-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,17,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60505-3111-0,NDC,facility,both,2,EA,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J0461,HCPCS,0517-1004-01,NDC,facility,both,40,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J2312,HCPCS,67457-299-00,NDC,facility,both,200,ML,,257,179.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-739-12,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,250,RC,J0132,HCPCS,25021-812-30,NDC,facility,both,110,ML,,790,553,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 2 %-1:200,000 INJ SOLN",50863,CDM,J2004,HCPCS,63323-489-02,NDC,,,facility,both,160,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  25 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-7047-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-DYYB 100 MG IV SOLR,50863,CDM,636,RC,Q5103,HCPCS,0069-0809-01,NDC,facility,both,5,EA,JW,568,397.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),50863,CDM,250,RC,J0169,HCPCS,76329-3318-1,NDC,facility,both,60,ML,,484,338.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,16714-294-01,NDC,facility,both,3,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-DYYB 100 MG IV SOLR,50863,CDM,636,RC,Q5103,HCPCS,0069-0809-01,NDC,facility,both,66,EA,,17238,12066.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-25,NDC,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCERIN (CHILD) RECTAL SUPPOSITORY,50863,CDM,636,RC,J3490,HCPCS,57237-326-21,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 100 MG TAB,50863,CDM,250,RC,J3490,HCPCS,62584-267-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARIFENACIN  7.5 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,13668-202-30,NDC,facility,both,1,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 875 MG-125 MG TAB,50863,CDM,250,RC,J3490,HCPCS,16714-297-02,NDC,facility,both,10,EA,,241,168.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIPASE-PROTEASE-AMYLASE 12,000-38,000- 60,000 UNIT ORAL CAP, DELAY REL",50863,CDM,636,RC,J3490,HCPCS,0032-0047-70,NDC,facility,both,4,EA,,101,70.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DONEPEZIL  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6477-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,16714-661-01,NDC,facility,both,4,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 50 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0054-0019-20,NDC,facility,both,50,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID (PORK) 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0456-1045-01,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  100 MCG/ML INJ SOLN,50863,CDM,636,RC,J2354,HCPCS,68462-896-01,NDC,facility,both,16,ML,"JZ,JA",181,126.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,14789-251-09,NDC,facility,both,18,ML,,3917,2741.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-407-11,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0641-6057-01,NDC,facility,both,1,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
INFLIXIMAB-DYYB 100 MG IV SOLR,50863,CDM,636,RC,Q5103,HCPCS,0069-0809-01,NDC,facility,both,35,EA,,9142,6399.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7336-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,250,RC,J3101,HCPCS,50242-037-06,NDC,facility,both,25,EA,JW,4979,3485.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML IM SOLN,50863,CDM,636,RC,90375,HCPCS,13533-318-05,NDC,facility,both,9,ML,,7515,5260.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUDARABINE 50 MG/2 ML IV SOLN,50863,CDM,250,RC,J9185,HCPCS,63323-192-02,NDC,facility,both,2,ML,,1925,1347.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN   1.5 G IV SOLR,50863,CDM,636,RC,J3370,HCPCS,67457-824-15,NDC,facility,both,3,EA,,142,99.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,5,ML,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANTI-INHIBITOR COAGULANT CMPLX (PHS MERGE),50863,CDM,250,RC,J7198,HCPCS,64193-424-02,NDC,facility,both,7500,UN,,44678,31274.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,J3490,HCPCS,71399-8014-1,NDC,,,facility,both,3,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG IV SOLR,50863,CDM,250,RC,J0650,HCPCS,70710-1833-1,NDC,facility,both,20,EA,,817,571.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,J1885,HCPCS,63323-162-01,NDC,,,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEMANTINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6505-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATOMOXETINE  10 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,68462-265-30,NDC,facility,both,2,EA,,140,98,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,70095-031-01,NDC,facility,both,21,ML,,832,582.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,250,RC,J3490,HCPCS,59310-579-22,NDC,facility,both,1,GM,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 120 MG/0.8 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,16714-056-10,NDC,facility,both,12,ML,,141,98.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLECAINIDE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0054-0010-20,NDC,facility,both,2,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,250,RC,J2270,HCPCS,0409-1890-03,NDC,facility,both,1,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE IN 0.9% NACL 3 GRAM/100 ML IV SOLN,50863,CDM,636,RC,J0612,HCPCS,61553-056-48,NDC,facility,both,500,ML,JZ,212,148.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,12,EA,JZ,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 2.5 GRAM/25 ML (10 %) INJ SOLN",50863,CDM,250,RC,J1561,HCPCS,13533-800-15,NDC,facility,both,5,ML,,908,635.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,636,RC,J1596,HCPCS,0517-4601-25,NDC,facility,both,2,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 10 MG/5 ML SYRUP,50863,CDM,250,RC,Q0177,HCPCS,54838-502-80,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIPASE-PROTEASE-AMYLASE (PORK) 36,000-114,000- 180,000 UNIT ORAL CPDR",50863,CDM,636,RC,J3490,HCPCS,0032-3016-13,NDC,facility,both,6,EA,,395,276.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-6665-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J2004,HCPCS,63323-482-03,NDC,facility,both,400,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-50,NDC,facility,both,119,ML,,210,147,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ELTROMBOPAG 75 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0078-0687-15,NDC,facility,both,1,EA,,1210,847,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,23155-833-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZONATATE 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,42806-714-01,NDC,facility,both,2,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAMOXIFEN 10 MG ORAL TAB,50863,CDM,636,RC,J9999,HCPCS,0378-0144-91,NDC,facility,both,2,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,94,EA,,12972,9080.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL,50863,CDM,250,RC,J3490,HCPCS,63323-820-01,NDC,facility,both,1,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,25021-131-82,NDC,facility,both,50,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  1 MG/ML ORAL LIQD,50863,CDM,250,RC,J3490,HCPCS,5843800571,NDC,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLP,50863,CDM,250,RC,J3480,HCPCS,0409-6653-18,NDC,facility,both,40,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM SR 60 MG 12 HR CAP,50863,CDM,250,RC,J3490,HCPCS,51079-924-01,NDC,facility,both,4,EA,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHIMAZOLE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-669-11,NDC,facility,both,4,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,63323-466-03,NDC,facility,both,300,ML,JZ,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-41,NDC,facility,both,1,ML,,119,83.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,25021-674-20,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2599,HCPCS,65219-039-00,NDC,facility,both,22,ML,,150,105,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,68180-150-01,NDC,facility,both,3,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),50863,CDM,250,RC,J2060,HCPCS,65219-368-01,NDC,facility,both,2,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 250 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,62756-797-88,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42858-001-10,NDC,facility,both,4,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,50863,CDM,250,RC,J9060,HCPCS,0143-9504-01,NDC,facility,both,4,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE (FOR EMERGENCY) 100 MG/ML (10%) IV SOLN,50863,CDM,636,RC,J0612,HCPCS,63323-360-01,NDC,facility,both,100,ML,JZ,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MORPHINE  30 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,0406-8330-23,NDC,facility,both,3,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE  2 MG/ML INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-285-10,NDC,facility,both,5,ML,,161,112.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50MG/5ML (10MG/ML) ORAL SOLUTION (REPACK),50863,CDM,636,RC,J3490,HCPCS,71286-3022-1,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0780,HCPCS,23155-294-31,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6925-61,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2599,HCPCS,55150-370-01,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFUROXIME AXETIL 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-272-11,NDC,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 500 MG PE/10 ML INJ SOLN,50863,CDM,250,RC,Q2009,HCPCS,68462-622-10,NDC,facility,both,4,ML,JW,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
FAMOTIDINE 20 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-7193-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,50863,CDM,FAMNOCHARGE,HCPCS,0904-6617-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNITS/1 GRAM PACKET (MERGE RECORD),50863,CDM,J3490,HCPCS,57896-145-09,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNITS/1 GRAM PACKET (MERGE RECORD),50863,CDM,250,RC,J3490,HCPCS,57896-111-09,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 150 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,0591-3541-60,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYBUTYNIN CHLORIDE  5 MG ORAL TO24,50863,CDM,250,RC,J3490,HCPCS,68084-480-11,NDC,facility,both,2,EA,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0630,HCPCS,42023-205-01,NDC,facility,both,1,ML,,3500,2450,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUVOXAMINE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0832-1671-11,NDC,facility,both,5,EA,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,42494-415-01,NDC,facility,both,3,ML,,513,359.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,5,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 500 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,50268-152-11,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,71288-402-10,NDC,facility,both,10,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 500 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,50268-152-11,NDC,facility,both,21,EA,,126,88.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,43598-053-11,NDC,facility,both,24,ML,,838,586.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,5,ML,,7804,5462.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,636,RC,J1610,HCPCS,63323-596-11,NDC,facility,both,2,EA,,1789,1252.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,636,RC,J2795,HCPCS,43066-023-01,NDC,facility,both,100,ML,JW,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,157,ML,,225,157.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LINEZOLID 600 MG/300 ML IV SOLP,50863,CDM,250,RC,J2020,HCPCS,0143-9534-01,NDC,facility,both,3,ML,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 500 MG (200 MG ELEMENTAL) CHEW TAB,50863,CDM,250,RC,J3490,HCPCS,66553-004-01,NDC,facility,both,6,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 40 MG/ML (4 %) INJ SOLN (FOR NEBULIZATION),50863,CDM,636,RC,J3490,HCPCS,0409-4283-11,NDC,facility,both,200,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPRAZOLAM 0.25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-647-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELATACEPT 250 MG IV SOLR,50863,CDM,636,RC,J0485,HCPCS,0003-0371-13,NDC,facility,both,225,EA,JW,1010,707,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
MAGNESIUM SULFATE IN D5W 1 GRAM/100 ML IV PGBK,50863,CDM,636,RC,J3475,HCPCS,0264-4400-54,NDC,facility,both,2,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM PHOSPHATE 0.06 MMOL/ML IVPB (FOR PEDIATRICS),50863,CDM,250,RC,J3490,HCPCS,70121-1722-1,NDC,facility,both,1,ML,,264,184.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7122-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % MUCOSAL GEL,50863,CDM,250,RC,J3490,HCPCS,17478-711-30,NDC,facility,both,1,ML,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE  2.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0555-0872-02,NDC,facility,both,8,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 100 % ORAL POWDER 238 GRAMS,50863,CDM,250,RC,J3490,HCPCS,4110082073,NDC,facility,both,1,GM,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-2051-15,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-815-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-31,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50580-458-11,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 600 MG ORAL TP12,50863,CDM,250,RC,J3490,HCPCS,0536-1163-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-555-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 10 MG ORAL TAB,50863,CDM,J3490,HCPCS,0591-0407-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-38,NDC,facility,both,2,ML,,138,96.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,54288-137-01,NDC,facility,both,5,ML,,1120,784,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYTOCIN 10 UNIT/ML INJ SOLN,50863,CDM,636,RC,J2590,HCPCS,42023-116-25,NDC,facility,both,2,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIVAROXABAN  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50458-577-01,NDC,facility,both,6,EA,,305,213.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,250,RC,J0132,HCPCS,0574-0805-30,NDC,facility,both,180,ML,,2437,1705.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE SR 37.5 MG 24 HR TAB,50863,CDM,636,RC,J3490,HCPCS,62175-472-32,NDC,facility,both,1,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM & SODIUM PHOSPHATES 280-160-250 MG ORAL PWPK,50863,CDM,636,RC,J3490,HCPCS,6025800615,NDC,facility,both,12,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRP (MERGE/REPACK),50863,CDM,636,RC,J3490,HCPCS,68094-764-59,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NORGESTREL-ETHINYL ESTRADIOL 0.3 MG-30 MCG TAB,50863,CDM,250,RC,J3490,HCPCS,16714-365-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRP (MERGE/REPACK),50863,CDM,636,RC,J3490,HCPCS,63304-205-18,NDC,facility,both,2,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN (NEO),50863,CDM,250,RC,J1940,HCPCS,0143-9156-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  10 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-0904-05,NDC,facility,both,2,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN IN D5W 400 MG/200 ML IV PGBK,50863,CDM,250,RC,J0744,HCPCS,25021-114-87,NDC,facility,both,2,ML,JZ,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DOXORUBICIN 50 MG/25 ML IV SOLN,50863,CDM,250,RC,J9000,HCPCS,0069-1542-20,NDC,facility,both,5,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,250,RC,J0131,HCPCS,0143-9386-01,NDC,facility,both,100,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2310,HCPCS,36000-310-01,NDC,facility,both,4,ML,,357,249.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  500 MCG/ML INJ SOLN,50863,CDM,636,RC,J2354,HCPCS,63323-377-00,NDC,facility,both,20,ML,,253,177.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  40 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-609-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,70095-031-01,NDC,facility,both,30,ML,,1214,849.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN 0.5 UNITS/ML IN 0.45% SODIUM CHLORIDE (REPACK REC),50863,CDM,250,RC,J3490,HCPCS,99999-0403-50,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTOBARBITAL 75 MG/1.5 ML SYRINGE (REPACK),50863,CDM,636,RC,J3490,HCPCS,25021-676-20,NDC,facility,both,2,ML,,159,111.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,50863,CDM,636,RC,J3490,HCPCS,57237-077-10,NDC,facility,both,1,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  500 MG IV SOLR,50863,CDM,636,RC,J3373,HCPCS,0409-4332-11,NDC,facility,both,50,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-152-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BISMUTH SUBSALICYLATE 262 MG ORAL CHEW,50863,CDM,636,RC,J3490,HCPCS,0904-7205-46,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML IV,50863,CDM,636,RC,J3490,HCPCS,55150-425-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J0461,HCPCS,0517-1004-01,NDC,facility,both,15,ML,JW,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PHENYLEPHRINE 1 % NASAL SPRAY AEROSOL,50863,CDM,636,RC,J3490,HCPCS,0225-0810-47,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,43547-415-10,NDC,facility,both,6,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"METHYLPREDNISOLONE 1,000 MG SOLUTION FOR INJECTION",50863,CDM,250,RC,J2919,HCPCS,0009-0698-01,NDC,facility,both,400,EA,,448,313.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,0069-4547-02,NDC,facility,both,3,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,13533-690-25,NDC,facility,both,9,ML,,1248,873.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,50863,CDM,250,RC,J9060,HCPCS,0703-5748-11,NDC,facility,both,19,ML,,429,300.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,23155-832-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML IV SOLN,50863,CDM,J3490,HCPCS,65219-445-01,NDC,,,facility,both,88,ML,,3185,2229.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,0409-3178-01,NDC,,,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 500 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-163-11,NDC,facility,both,28,EA,,186,130.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,3,EA,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE ACETATE 25 MG RECT SUPP,50863,CDM,636,RC,J3490,HCPCS,42494-341-12,NDC,facility,both,4,EA,,241,168.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN   1.25 G IV SOLR,50863,CDM,250,RC,J3370,HCPCS,67457-823-12,NDC,facility,both,3,EA,JZ,142,99.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
HYDRALAZINE  10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-074-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN IN D5W 900 MG/50 ML IV PGBK,50863,CDM,636,RC,J0736,HCPCS,0338-3814-50,NDC,facility,both,3,ML,"JZ,JG",77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JG: Drug or biological acquired with 340b drug pricing program discount
EPINEPHRINE IN 0.9 % SOD CHLOR 4 MG/250 ML (16 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-315-01,NDC,facility,both,1,ML,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,63323-165-01,NDC,facility,both,5,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML (1ML) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,54288-119-01,NDC,facility,both,1,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,636,RC,J0690,HCPCS,70092-1017-46,NDC,facility,both,3,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,629,ME,JZ,8536,5975.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"ALBUMIN, HUMAN 25 % IV SOLN (MERGE)",50863,CDM,636,RC,P9047,HCPCS,64208-2512-7,NDC,facility,both,2,ML,,238,166.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68462-255-01,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 2-0.5 MG SL SUBL,50863,CDM,636,RC,J3490,HCPCS,50268-144-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN SODIUM EXTENDED 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6187-61,NDC,facility,both,3,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % MBP,50863,CDM,250,RC,J3490,HCPCS,0338-0553-18,NDC,facility,both,7,ML,,338,236.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,0641-6146-01,NDC,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INHL NEBU,50863,CDM,636,RC,J3490,HCPCS,0378-6987-89,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOPIDOGREL  75 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-536-11,NDC,facility,both,3,EA,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,2,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IVPB (PEDIATRICS/ADULT NON-FORM)",50863,CDM,636,RC,J0137,HCPCS,24201-100-01,NDC,facility,both,34,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROATE SODIUM 100 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-494-01,NDC,facility,both,2,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0137,HCPCS,0781-3156-06,NDC,facility,both,11,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETHYL CHLORIDE 100 % TOP SPRA,50863,CDM,636,RC,J3490,HCPCS,386000102,NDC,facility,both,1,ML,,157,109.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,636,RC,J3490,HCPCS,63323-485-27,NDC,facility,both,115,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTAMIDINE 300 MG INJ SOLR,50863,CDM,636,RC,J3490,HCPCS,63323-113-01,NDC,facility,both,1,EA,,140,98,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRBESARTAN  75 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,31722-729-30,NDC,facility,both,2,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPROSTADIL 500 MCG/ML INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0009-3169-01,NDC,facility,both,1,ML,,697,487.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"OMEGA-3 FATTY ACIDS-FISH OIL 360-1,200 MG ORAL CAP (ERX MERGE)",50863,CDM,636,RC,J3490,HCPCS,17856-0055-1,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUDROCORTISONE 0.1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-330-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN NS 20 MCG/5 ML (4 MCG/ML) IV POST OP SHIVERING,50863,CDM,250,RC,J3490,HCPCS,73177-123-02,NDC,facility,both,1,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,70594-117-01,NDC,facility,both,300,ML,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 150 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6956-61,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTAROLINE FOSAMIL 600 MG IV SOLR,50863,CDM,250,RC,J0712,HCPCS,0456-0600-01,NDC,facility,both,60,EA,,912,638.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68180-980-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 250 MG-62.5 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,59651-026-75,NDC,facility,both,5,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,250,RC,J2405,HCPCS,70860-776-41,NDC,facility,both,8,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
RIVAROXABAN 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50458-580-01,NDC,facility,both,2,EA,,223,156.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICLOFENAC 1 % TOPICAL GEL,50863,CDM,636,RC,J3490,HCPCS,58602-604-07,NDC,facility,both,1,GM,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 1 MG ORAL TAB,50863,CDM,250,RC,J8540,HCPCS,0054-4181-25,NDC,facility,both,8,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2599,HCPCS,65219-039-00,NDC,facility,both,8,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0641-6057-01,NDC,facility,both,4,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
HYDRALAZINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,23155-833-01,NDC,facility,both,4,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,636,RC,J2003,HCPCS,63323-485-27,NDC,facility,both,95,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPRAZOLAM 0.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0781-1077-01,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESMOLOL  100 MG/10 ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-652-10,NDC,facility,both,2,ML,,211,147.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,J3490,HCPCS,65862-707-55,NDC,,,facility,both,16,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MENING VAC A,C,Y,W135,TET (PF) 10 MCG/0.5 ML IM SOLN",50863,CDM,90619,HCPCS,49281-590-10,NDC,,,facility,both,1,ML,,743,520.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OMALIZUMAB 150 MG SUBQ SOLR,50863,CDM,J2357,HCPCS,50242-040-62,NDC,,,facility,both,30,ME,,2610,1827,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0093-4177-73,NDC,facility,both,16,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,31722-711-30,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RASBURICASE 7.5 MG IV SOLR,50863,CDM,250,RC,J2783,HCPCS,0024-5151-74,NDC,facility,both,3,EA,JW,1277,893.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,2,EA,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 50 MG TAB,50863,CDM,636,RC,J3490,HCPCS,55111-292-09,NDC,facility,both,1,EA,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,63323-806-13,NDC,facility,both,9,ML,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,60687-145-11,NDC,facility,both,10,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM PHOSPHATE 0.06 MMOL/ML IVPB (FOR PEDIATRICS),50863,CDM,250,RC,J3490,HCPCS,70121-1722-1,NDC,facility,both,2,ML,,528,369.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  2.5 MG ORAL TAB,50863,CDM,250,RC,J7510,HCPCS,59651-485-01,NDC,facility,both,37,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0245-0147-01,NDC,facility,both,1,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-288-07,NDC,facility,both,2,ML,,267,186.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EVEROLIMUS (IMMUNOSUPPRESSIVE) 0.5 MG ORAL TAB,50863,CDM,250,RC,J7527,HCPCS,67877-719-33,NDC,facility,both,6,EA,,256,179.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SOTALOL 240 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0093-1063-01,NDC,facility,both,1,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE  10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-419-11,NDC,facility,both,3,EA,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,10135-778-01,NDC,facility,both,10,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0527-3281-46,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE MONONITRATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,5026885111,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL  6.25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-854-11,NDC,facility,both,6,EA,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,J3490,HCPCS,69315-905-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 120 MG/0.8 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,0075-2912-00,NDC,facility,both,12,ML,,175,122.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % MUCOSAL GEL,50863,CDM,250,RC,J3490,HCPCS,17478-711-30,NDC,facility,both,1,ML,,273,191.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR PHOSPHATE 30 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0527-4591-13,NDC,facility,both,1,EA,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN IN 0.9 % NS 40 UNIT/100 ML (0.4 UNIT/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0338-9647-12,NDC,facility,both,1,ML,,324,226.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,636,RC,J3490,HCPCS,50268-671-11,NDC,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,636,RC,J3490,HCPCS,0143-9575-01,NDC,facility,both,700,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,J3490,HCPCS,2055503601,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,539,ME,,7315,5120.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJ SOLN",50863,CDM,J3490,HCPCS,63323-468-37,NDC,,,facility,both,2,ML,,143,100.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,J3490,HCPCS,0093-2279-73,NDC,,,facility,both,5,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN D5W 20000 UNIT/500 ML,50863,CDM,J1644,HCPCS,0264-9567-10,NDC,,,facility,both,20,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MERCAPTOPURINE 50 MG ORAL TAB,50863,CDM,636,RC,J9999,HCPCS,0378-3547-52,NDC,facility,both,2,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB-QYYP 420 MG IV SOLR,50863,CDM,Q5116,HCPCS,0069-0306-01,NDC,,,facility,both,51,ME,,11366,7956.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,26,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68382-806-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 125 MG ORAL CPSP,50863,CDM,250,RC,J3490,HCPCS,55111-532-01,NDC,facility,both,2,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OPIUM TINCTURE 10 MG/ML ORAL TINC,50863,CDM,636,RC,J3490,HCPCS,42799-217-01,NDC,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 1 MG/ML IV SOLN,50863,CDM,250,RC,J0461,HCPCS,0517-1001-01,NDC,facility,both,1,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYCHLOROQUINE 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7046-61,NDC,facility,both,2,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,636,RC,J1610,HCPCS,63323-596-11,NDC,facility,both,1,EA,JZ,895,626.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
TRIAMCINOLONE ACETONIDE 0.1 % TOP LOTN,50863,CDM,636,RC,J3490,HCPCS,60432-561-60,NDC,facility,both,1,ML,,208,145.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SYRG,50863,CDM,250,RC,J3490,HCPCS,8290306546,NDC,facility,both,5,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,16714-661-01,NDC,facility,both,4,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLN,50863,CDM,636,RC,J3262,HCPCS,50242-136-01,NDC,facility,both,200,ML,"JA,JZ",3666,2566.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously | Modifier JZ: Zero drug amount discarded/not administered to any patient
CELECOXIB 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,16714-732-01,NDC,facility,both,1,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTASE 3000 UNIT ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,904522452,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,7,ML,,12139,8497.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % MUCOSAL GEL,50863,CDM,250,RC,J3490,HCPCS,17478-711-30,NDC,facility,both,1,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,54288-137-01,NDC,facility,both,9,ML,,2239,1567.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM PHOSPHATE 0.06 MMOL/ML IVPB (FOR PEDIATRICS),50863,CDM,J3490,HCPCS,70121-1722-1,NDC,,,facility,both,1,ML,,264,184.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  750 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-882-11,NDC,facility,both,3,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0630,HCPCS,24201-400-02,NDC,facility,both,1,ML,,1469,1028.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,636,RC,J2720,HCPCS,63323-229-01,NDC,facility,both,3,ML,JZ,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DULOXETINE 30 MG ORAL CPDR,50863,CDM,J3490,HCPCS,0904-7044-61,NDC,,,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,J2405,HCPCS,0409-4755-18,NDC,,,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,J2270,HCPCS,0641-6125-01,NDC,,,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLU VACCINE TS 2024-25 65 YR UP (PF) 180 MCG/0.5 ML IM SYRG,50863,CDM,90662,HCPCS,49281-124-65,NDC,,,facility,both,1,ML,,373,261.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68180-113-16,NDC,facility,both,3,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 20 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7346-61,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,50863,CDM,636,RC,Q0177,HCPCS,0904-6617-61,NDC,facility,both,12,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM BICARB-CITRIC ACID 20 MEQ ORAL TBEF,50863,CDM,636,RC,J3490,HCPCS,51801-012-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTAMIDINE 300 MG INJ SOLR,50863,CDM,250,RC,J3490,HCPCS,23155-748-31,NDC,facility,both,1,EA,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,3,EA,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,70095-031-01,NDC,facility,both,21,ML,,855,598.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-728-11,NDC,facility,both,2,EA,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV (BOLUS),50863,CDM,636,RC,J7120,HCPCS,0264-7750-10,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIVAROXABAN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50458-579-90,NDC,facility,both,1,EA,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 25 MG/5 ML (5 MG/ML) ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,62559-204-12,NDC,facility,both,1,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MYCOPHENOLATE 500 MG TAB,50863,CDM,250,RC,J7517,HCPCS,0054-0166-25,NDC,facility,both,2,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 10 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,16714-720-02,NDC,facility,both,4,EA,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),50863,CDM,250,RC,J2060,HCPCS,0641-6044-01,NDC,facility,both,2,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM 500 MG IV SOLR,50863,CDM,636,RC,J2185,HCPCS,70121-1454-1,NDC,facility,both,5,EA,JZ,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
HYDROXYZINE 50 MG/ML IM,50863,CDM,636,RC,J3410,HCPCS,0517-5601-25,NDC,facility,both,2,ML,,182,127.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,250,RC,J0690,HCPCS,25021-101-10,NDC,facility,both,8,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE  50 MG/ML INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,25021-683-10,NDC,facility,both,2,ML,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 150 MG CAP,50863,CDM,636,RC,J3490,HCPCS,0904-5959-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0093-4155-73,NDC,facility,both,10,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CODEINE-GUAIFENESIN 10-100 MG/5 ML ORAL LIQD (REPACK),50863,CDM,250,RC,J3490,HCPCS,0121-1775-05,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),50863,CDM,250,RC,J0169,HCPCS,76329-3318-1,NDC,facility,both,70,ML,,565,395.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPTOMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0878,HCPCS,0409-0122-01,NDC,facility,both,700,EA,JZ,563,394.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DEXTROSE 5% IN NORMAL SALINE IV,50863,CDM,250,RC,J7042,HCPCS,0264-7610-00,NDC,facility,both,2,ML,JZ,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,636,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,10,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRIMIDONE 250 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-687-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MITOMYCIN 20 MG IV SOLR,50863,CDM,636,RC,J9280,HCPCS,71288-138-50,NDC,facility,both,2,EA,JZ,621,434.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
EPOETIN ALFA 10000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0885,HCPCS,59676-310-00,NDC,facility,both,10,ML,,947,662.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMULSION 20 % IV EMUL,50863,CDM,250,RC,j3490,HCPCS,65219-533-01,NDC,facility,both,1,ML,,119,83.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-492-04,NDC,facility,both,300,ML,,236,165.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 30% IN WATER (NEO),50863,CDM,250,RC,J7070,HCPCS,0409-6648-16,NDC,facility,both,4,ML,,127,88.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOPAMINE INFUSION NEO IV SYRINGE (FROM PREMIX),50863,CDM,250,RC,J1265,HCPCS,0338-1007-02,NDC,facility,both,10,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.45% (1/2 NS) INFUSION (PEDS ONC),50863,CDM,250,RC,J3490,HCPCS,0338-0043-04,NDC,facility,both,1,ML,PLAD,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
LEUCOVORIN CALCIUM  50 MG INJ SOLR,50863,CDM,250,RC,J0640,HCPCS,25021-813-10,NDC,facility,both,1,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-2051-15,NDC,facility,both,1,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEPROTUMUMAB-TRBW 500 MG IV SOLR,50863,CDM,636,RC,J3241,HCPCS,75987-130-15,NDC,facility,both,119,EA,,84692,59284.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,6,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,50863,CDM,250,RC,J8540,HCPCS,0054-8175-25,NDC,facility,both,160,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZTREONAM 1 GRAM INJ SOLR,50863,CDM,250,RC,J0457,HCPCS,0409-0829-11,NDC,facility,both,10,EA,,194,135.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN NACL (PF) 1000 UNIT/500 ML IV SOLP,50863,CDM,250,RC,J1644,HCPCS,0264-9872-10,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 1 MG ORAL TBDL,50863,CDM,636,RC,J3490,HCPCS,49884-315-52,NDC,facility,both,2,EA,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,0143-9284-01,NDC,facility,both,1,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-DYYB 100 MG IV SOLR,50863,CDM,636,RC,Q5103,HCPCS,0069-0809-01,NDC,facility,both,50,EA,,13059,9141.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV (BOLUS),50863,CDM,636,RC,J7120,HCPCS,0264-7750-07,NDC,facility,both,2,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  25 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6991-04,NDC,facility,both,3,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL (VITAMIN D3)  1000 UNIT ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,8068116900,NDC,facility,both,5,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,1,EA,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML IV,50863,CDM,636,RC,J3490,HCPCS,70860-301-41,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-25,NDC,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARDIOPLEGIC SOLUTION NO.25 29 MMOL/L (POTASSIUM) PERF SOLN,50863,CDM,250,RC,J3490,HCPCS,69374-984-10,NDC,facility,both,4,ML,,2016,1411.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM ACETATE 667 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,69097-862-83,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J3430,HCPCS,43598-405-11,NDC,facility,both,3,ME,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  60 MG ORAL CS24,50863,CDM,636,RC,J3490,HCPCS,0527-4116-37,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6519-61,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCRALFATE 100 MG/ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,17856-0306-1,NDC,facility,both,2,ML,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7016-61,NDC,facility,both,2,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,63323-280-03,NDC,facility,both,15,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 10% IN WATER (D10) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0338-0023-02,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,0143-9680-01,NDC,facility,both,10,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CINACALCET 30 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,64380-883-04,NDC,facility,both,3,EA,,390,273,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL (VITAMIN D3) 400 UNIT/ML ORAL DROP,50863,CDM,636,RC,J3490,HCPCS,7651805050,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,50863,CDM,636,RC,J0561,HCPCS,60793-701-02,NDC,facility,both,24,ML,,2613,1829.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL-ROPIVACAINE-NACL (PF) 2-0.2 MCG/ML-% INJ (MERGE ERX),50863,CDM,250,RC,J3490,HCPCS,61553-844-48,NDC,facility,both,2,ML,,1176,823.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN DEXTROSE (ISO-OSMOTIC) 1 GRAM/50 ML IV PIGGY BACK,50863,CDM,250,RC,J0690,HCPCS,0338-3503-41,NDC,facility,both,4,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6476-61,NDC,facility,both,2,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0093-3426-01,NDC,facility,both,3,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,700,ML,,1005,703.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J1610,HCPCS,63323-596-11,NDC,facility,both,25,EA,,22363,15654.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,49884-065-01,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES-DOCUSATE SODIUM 8.6 MG-50 MG TAB,50863,CDM,250,RC,J3490,HCPCS,63739-432-02,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 50 MG 24 HR TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6323-61,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTAZIDIME-AVIBACTAM 2.5 GRAM (2 GRAM-0.5 GRAM) IV SOLR,50863,CDM,250,RC,J0714,HCPCS,0456-2700-10,NDC,facility,both,2,EA,,553,387.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,66794-229-02,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN NPH & REGULAR HUMAN 100 UNIT/ML (70-30) SUBQ SUSP,50863,CDM,636,RC,J1815,HCPCS,0002-8715-01,NDC,facility,both,15,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 20 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7346-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IR SOLN,50863,CDM,636,RC,J3490,HCPCS,0338-0047-47,NDC,facility,both,2,ML,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,250,RC,J2270,HCPCS,0409-1890-13,NDC,facility,both,1,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,636,RC,J3370,HCPCS,0143-9162-01,NDC,facility,both,6,EA,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOVASTATIN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68180-467-01,NDC,facility,both,2,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESTRADIOL 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42806-088-01,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,23155-833-01,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-05,NDC,facility,both,3,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,190,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM-ALBUTEROL 0.5 MG-2.5 MG/3 ML NEB SOLUTION,50863,CDM,636,RC,J3490,HCPCS,47335-756-48,NDC,facility,both,3,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,4,EA,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2310,HCPCS,55150-328-01,NDC,facility,both,4,ML,,539,377.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN 1 MG/ML INJECTION (PEDS ONCOLOGY),50863,CDM,250,RC,71288-160-10,NDC,,,facility,both,0.351,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-0430-06,NDC,facility,both,13,EA,,167,116.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERGOCALCIFEROL (VITAMIN D2) 50000 UNIT ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,69452-151-20,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 50 MG/ML IV SOLN,50863,CDM,636,RC,J0282,HCPCS,70436-232-72,NDC,facility,both,10,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,50863,CDM,636,RC,Q5119,HCPCS,0069-0238-01,NDC,facility,both,20,ML,JZ,3957,2769.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
HYDROXYZINE 25 MG TAB,50863,CDM,636,RC,Q0177,HCPCS,0093-5061-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-0430-04,NDC,facility,both,1,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 3000 MCG/ML INJECTION,50863,CDM,250,RC,J0153,HCPCS,67457-855-02,NDC,facility,both,12,ML,JZ,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-48,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0137,HCPCS,0143-9386-01,NDC,facility,both,48,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,636,RC,J2405,HCPCS,0409-4755-18,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2599,HCPCS,43598-914-25,NDC,facility,both,4,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,16714-294-01,NDC,facility,both,17,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIPASE-PROTEASE-AMYLASE 12,000-38,000- 60,000 UNIT ORAL CAP, DELAY REL",50863,CDM,636,RC,J3490,HCPCS,0032-0047-70,NDC,facility,both,1,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-406-03,NDC,facility,both,1,ML,,133,93.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J3430,HCPCS,0409-9158-31,NDC,facility,both,10,ML,JZ,250,175,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CYCLOSPORINE 100 MG ORAL CAP,50863,CDM,250,RC,J7502,HCPCS,0078-0241-61,NDC,facility,both,1,EA,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN 1 GRAM SOLUTION FOR INJECTION,50863,CDM,250,RC,J0290,HCPCS,0781-3404-85,NDC,facility,both,2,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV,50863,CDM,636,RC,J7120,HCPCS,0338-0117-04,NDC,facility,both,18,ML,,599,419.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 5 MG ORAL CAP,50863,CDM,250,RC,J7507,HCPCS,0904-6624-61,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOPROTERENOL 0.2 MG/ML INJECTION,50863,CDM,636,RC,J3490,HCPCS,69918-731-01,NDC,facility,both,1,ML,,540,378,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-630-11,NDC,facility,both,2,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MOXIFLOXACIN 400 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-576-11,NDC,facility,both,1,EA,,131,91.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,50863,CDM,636,RC,Q5119,HCPCS,0069-0249-01,NDC,facility,both,75,ML,JA,14838,10386.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
OXYCODONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,10702-018-50,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,636,RC,J0132,HCPCS,70594-111-01,NDC,facility,both,109,ML,,555,388.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION,50863,CDM,250,RC,J3490,HCPCS,0310-7370-20,NDC,facility,both,1,GM,,1189,832.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,60687-736-11,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-590-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,50863,CDM,250,RC,J9045,HCPCS,0703-4239-01,NDC,facility,both,10,ML,,279,195.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,49502-393-80,NDC,facility,both,7,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,73293-0001-1,NDC,facility,both,50,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,83257-011-11,NDC,facility,both,5,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0143-9250-01,NDC,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV (BOLUS),50863,CDM,636,RC,J7120,HCPCS,0264-7750-00,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,J3370,HCPCS,0143-9162-01,NDC,,,facility,both,2,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),50863,CDM,250,RC,J2060,HCPCS,0641-6001-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR IRRIGATION, STERILE SOLUTION",50863,CDM,636,RC,J3490,HCPCS,0338-0004-02,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE IN 0.9 % SOD CHLORIDE 100 MG/10 ML (10 MG/ML) IV SYRG,50863,CDM,J3490,HCPCS,70004-430-12,NDC,,,facility,both,1,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LITHIUM CARBONATE 450 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,68084-655-11,NDC,facility,both,3,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 3 MG/ML IV SYRG,50863,CDM,J0153,HCPCS,63323-651-21,NDC,,,facility,both,6,ML,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MUPIROCIN 2 % TOP OINT,50863,CDM,J3490,HCPCS,0093-1010-42,NDC,,,facility,both,1,GM,,363,254.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN LOCK FLUSH 100 UNIT/ML IV SOLN,50863,CDM,636,RC,J1644,HCPCS,63323-545-01,NDC,facility,both,20,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,76045-009-96,NDC,facility,both,10,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-285-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BISOPROLOL FUMARATE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,29300-126-01,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,64980-562-01,NDC,facility,both,5,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 600 MG ORAL TP12,50863,CDM,J3490,HCPCS,0904-6718-39,NDC,,,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC IV INFUSION HYDRAT 31-60 MIN,50863,CDM,250,RC,J0248,HCPCS,61958-2901-2,NDC,facility,both,4,EA,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-191-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PATIROMER CALCIUM SORBITEX  8.4 G ORAL PWPK,50863,CDM,636,RC,J3490,HCPCS,53436-084-01,NDC,facility,both,1,EA,,201,140.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 30 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,0904-7044-61,NDC,facility,both,4,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXRAZOXANE 500 MG IV SOLR,50863,CDM,636,RC,J1190,HCPCS,55150-435-01,NDC,facility,both,3,EA,,1781,1246.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,44567-600-04,NDC,facility,both,2,ML,,406,284.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN   81 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,0904-6783-70,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0003-0894-70,NDC,facility,both,1,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPTOMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0878,HCPCS,0409-0122-01,NDC,facility,both,300,EA,,242,169.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-5755-23,NDC,facility,both,6,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOZAPINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-922-01,NDC,facility,both,2,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLP,50863,CDM,250,RC,J3480,HCPCS,63323-965-03,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 2400000 UNIT/4 ML IM SYRG,50863,CDM,636,RC,J0561,HCPCS,60793-702-04,NDC,facility,both,24,ML,,1898,1328.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  500 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,68462-897-01,NDC,facility,both,20,ML,,214,149.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE CONCENTRATE 10 MG/ 0.5 ML ORAL SYRINGE (0.5ML UD MERGE),50863,CDM,250,RC,J3490,HCPCS,68094-045-01,NDC,facility,both,2,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,70,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,50,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAZOLAMIDE SODIUM 500 (100 MG/ML) INJ SOLR,50863,CDM,250,RC,J1120,HCPCS,67457-853-50,NDC,facility,both,1,EA,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3370,HCPCS,70860-105-20,NDC,facility,both,2,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0093-4177-73,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,72603-251-01,NDC,facility,both,100,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACUBITRIL-VALSARTAN 24-26 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,33342-570-09,NDC,facility,both,1,EA,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,636,RC,J3490,HCPCS,66553-002-01,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,0409-1886-22,NDC,facility,both,110,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETIRIZINE 5 MG/5 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,68094-004-59,NDC,facility,both,2,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,3,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROIC ACID 250 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,69452-150-20,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIROFIBAN-0.9% SODIUM CHLORIDE 5 MG/100 ML (50 MCG/ML) IV SOLN,50863,CDM,250,RC,J3246,HCPCS,25208-002-03,NDC,facility,both,60,ML,,1193,835.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-319-11,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL  6.25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-854-11,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANTI-INHIBITOR COAGULANT CMPLX (PHS MERGE),50863,CDM,250,RC,J7198,HCPCS,64193-426-02,NDC,facility,both,387,UN,,2795,1956.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEMAZEPAM  7.5 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0406-9960-01,NDC,facility,both,1,EA,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 6 MG/0.5 ML SUBQ PEN KIT,50863,CDM,250,RC,J3030,HCPCS,72603-141-02,NDC,facility,both,1,ML,,406,284.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-04,NDC,facility,both,10,ML,,167,116.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16729-137-00,NDC,facility,both,4,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM  3.375 GRAM IV SOLR,50863,CDM,250,RC,J2543,HCPCS,65219-436-02,NDC,facility,both,3,EA,JZ,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ACETAZOLAMIDE SODIUM 500 (100 MG/ML) INJ SOLR,50863,CDM,250,RC,J1120,HCPCS,67457-853-50,NDC,facility,both,1,EA,JZ,169,118.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3370,HCPCS,0143-9162-01,NDC,facility,both,6,EA,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIHYDROERGOTAMINE 1 MG/ML INJ SOLN,50863,CDM,636,RC,J1110,HCPCS,0574-0850-05,NDC,facility,both,1,ML,,568,397.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,110,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-3178-16,NDC,facility,both,300,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,70004-600-09,NDC,facility,both,3,ML,,159,111.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2599,HCPCS,65219-039-00,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAMSULOSIN 0.4 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,0904-7383-61,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROMETHORPHAN-GUAIFENESIN SR 30 MG-600 MG 12 HR TAB,50863,CDM,636,RC,J3490,HCPCS,17856-1162-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 TABLET
MIDODRINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-453-01,NDC,facility,both,4,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,30,EA,JZ,4140,2898,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ANASTROZOLE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-112-11,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE HCL  0.5 % NASL SPRY,50863,CDM,636,RC,J3490,HCPCS,0225-0805-47,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 250 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,42192-608-05,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAZOLAMIDE 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,64380-834-06,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE (PF) 1 MG/ML INJ SOLN,50863,CDM,250,RC,J0169,HCPCS,54288-103-10,NDC,facility,both,10,ML,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,7,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NOREPINEPHRINE BITARTRATE-D5W 4 MG/250 ML (16 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,71285-6056-1,NDC,facility,both,10,ML,,1264,884.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 17 GRAM (100 %) ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,0904-6931-86,NDC,facility,both,5,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MECLIZINE 12.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6516-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE (DIAGNOSTIC) 3 MG/ML IV SOLN,50863,CDM,636,RC,J0153,HCPCS,23155-258-32,NDC,facility,both,90,ML,,719,503.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,92,ML,JW,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,54288-136-01,NDC,facility,both,2,ML,,212,148.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,50863,CDM,636,RC,J0585,HCPCS,0023-1145-01,NDC,facility,both,400,EA,,6393,4475.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR 200 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,72578-002-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN  3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51672-4030-1,NDC,facility,both,3,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIFEDIPINE 10 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,23155-194-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7007-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0780,HCPCS,0641-6135-25,NDC,facility,both,1,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROPROCAINE 3 % INJ SOLN,50863,CDM,250,RC,J2401,HCPCS,63323-478-01,NDC,facility,both,549,ML,JW,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
FENTANYL  75 MCG/HR TD PT72,50863,CDM,250,RC,J3490,HCPCS,47781-427-11,NDC,facility,both,1,EA,,252,176.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 3 MG/ML IV SYRG,50863,CDM,250,RC,J0153,HCPCS,0469-8234-12,NDC,facility,both,12,ML,JZ,423,296.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DIVALPROEX 500 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,68084-782-11,NDC,facility,both,1,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) IV SOLN",50863,CDM,250,RC,J3490,HCPCS,67457-197-00,NDC,facility,both,1,ML,,368,257.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-103-01,NDC,facility,both,6,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM  4.5 GRAM IV SOLR,50863,CDM,250,RC,J2543,HCPCS,81284-153-00,NDC,facility,both,4,EA,JZ,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
FENTANYL  12 MCG/HR TD PT72,50863,CDM,250,RC,J3490,HCPCS,0378-9119-16,NDC,facility,both,1,EA,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DROXIDOPA 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,31722-014-90,NDC,facility,both,5,EA,,663,464.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BALANCED SALT IRRIG SOLN COMB2 INTRAOCULAR,50863,CDM,250,RC,J3490,HCPCS,0065-0795-15,NDC,facility,both,1,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6818-61,NDC,facility,both,4,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 150 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,0591-3541-60,NDC,facility,both,2,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEMANTINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6505-06,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7448-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,42806-150-33,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  5 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,60687-122-11,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 875 MG-125 MG TAB,50863,CDM,636,RC,J3490,HCPCS,16714-297-01,NDC,facility,both,20,EA,,364,254.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PALONOSETRON 0.25 MG/5 ML IV INJECTION (MERGE),50863,CDM,250,RC,J2469,HCPCS,55111-694-07,NDC,facility,both,10,ML,,255,178.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB 100 MG IV SOLR,50863,CDM,636,RC,J1745,HCPCS,57894-030-01,NDC,facility,both,68,EA,,21918,15342.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRASUGREL 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0713-0882-30,NDC,facility,both,1,EA,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PERMETHRIN 5 % TOP CREA,50863,CDM,250,RC,J3490,HCPCS,45802-269-37,NDC,facility,both,1,GM,,428,299.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,250,RC,J0330,HCPCS,31722-981-10,NDC,facility,both,4,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,636,RC,J0330,HCPCS,31722-981-10,NDC,facility,both,4,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,636,RC,J3490,HCPCS,0641-6236-01,NDC,facility,both,2,ML,,131,91.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,70069-363-01,NDC,facility,both,1,ML,,169,118.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,636,RC,J3490,HCPCS,63323-485-27,NDC,facility,both,45,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NOREPINEPHRINE BITARTRATE-D5W 4 MG/250 ML (16 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0338-0112-20,NDC,facility,both,7,ML,,933,653.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J1611,HCPCS,63323-596-11,NDC,facility,both,2,EA,JZ,1136,795.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ISOSULFAN BLUE 1 % INJ SOLN,50863,CDM,636,RC,Q9968,HCPCS,67457-220-00,NDC,facility,both,20,ML,,1720,1204,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,50863,CDM,636,RC,J8540,HCPCS,60687-718-11,NDC,facility,both,16,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16714-990-01,NDC,facility,both,1,EA,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXAZOSIN 4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-5524-61,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LANSOPRAZOLE 3 MG/ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,65628-080-05,NDC,facility,both,1,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,64980-562-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,4,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,70004-600-09,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,636,RC,J3490,HCPCS,51754-4250-1,NDC,facility,both,2,ML,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,250,RC,J3490,HCPCS,0409-1323-15,NDC,facility,both,500,ML,,242,169.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN  500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7162-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML (1ML) INJ SOLN,50863,CDM,250,RC,J0171,HCPCS,54288-119-01,NDC,facility,both,10,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TORSEMIDE  20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-539-11,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6476-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PYRIDOSTIGMINE BROMIDE  60 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6622-61,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-433-11,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 60 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,57237-019-30,NDC,facility,both,2,EA,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL 20 MG/5 ML ORAL ELIX,50863,CDM,250,RC,J3490,HCPCS,60687-671-40,NDC,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE (FOR CODE) 10% IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0517-6710-01,NDC,facility,both,1,ML,,35590,24913,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,250,RC,J2405,HCPCS,0409-4759-01,NDC,facility,both,24,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL,50863,CDM,250,RC,J3490,HCPCS,63323-820-01,NDC,facility,both,1,ML,,142,99.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 800 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,65162-058-27,NDC,facility,both,1,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-1283-03,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 20 MG/ML INJ SOLN,50863,CDM,250,RC,J0360,HCPCS,0641-6231-01,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATOVAQUONE 750 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,66689-062-01,NDC,facility,both,1,ML,,214,149.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6949-61,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLN,50863,CDM,636,RC,J3262,HCPCS,50242-137-01,NDC,facility,both,280,ML,JA,5132,3592.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),50863,CDM,636,RC,J1630,HCPCS,63323-474-00,NDC,facility,both,2,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 1 GRAM INJ SOLR,50863,CDM,250,RC,J0692,HCPCS,25021-121-20,NDC,facility,both,20,EA,,399,279.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LATANOPROST 0.005 % OPHT DROP,50863,CDM,250,RC,J3490,HCPCS,24208-463-25,NDC,facility,both,1,ML,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-339-11,NDC,facility,both,2,EA,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLMESARTAN  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,67877-445-30,NDC,facility,both,2,EA,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J2004,HCPCS,0409-3178-01,NDC,facility,both,70,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0137,HCPCS,0143-9386-01,NDC,facility,both,50,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCUSATE SODIUM 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7183-61,NDC,facility,both,6,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,50863,CDM,250,RC,J9075,HCPCS,10019-956-16,NDC,facility,both,5,EA,JW,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CISPLATIN 1 MG/ML IV,50863,CDM,250,RC,J9060,HCPCS,16729-288-38,NDC,facility,both,4,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INDAPAMIDE 2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0228-2571-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE LAUROXIL 882 MG/3.2 ML IM SERS,50863,CDM,250,RC,J1944,HCPCS,65757-403-03,NDC,facility,both,882,ME,,7575,5302.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7351-04,NDC,facility,both,2,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLN (MERGE)",50863,CDM,636,RC,P9047,HCPCS,64208-2512-8,NDC,facility,both,6,ML,JZ,713,499.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
HYDRALAZINE 20 MG/ML INJ SOLN,50863,CDM,250,RC,J0360,HCPCS,63323-614-00,NDC,facility,both,2,ML,,200,140,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,250,RC,Q9968,HCPCS,70710-1838-1,NDC,facility,both,43,ML,JW,242,169.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
INFLIXIMAB-ABDA 100 MG IV SOLR,50863,CDM,636,RC,Q5104,HCPCS,78206-162-99,NDC,facility,both,67,EA,,13932,9752.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE (PF) 25 MG/ML INJ SOLN (FOR ECTOPIC PREGNANCY),50863,CDM,636,RC,J9260,HCPCS,0143-9519-01,NDC,facility,both,1.79,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,6,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PNEUMOC 20-VAL CONJ-DIP CR(PF) 0.5 ML IM SYRG,50863,CDM,90677,HCPCS,0005-2000-01,NDC,,,facility,both,1,ML,,1003,702.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,J2250,HCPCS,0409-2308-21,NDC,,,facility,both,7,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNITS/1 GRAM PACKET (MERGE RECORD),50863,CDM,J3490,HCPCS,45802-060-00,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0630,HCPCS,63323-865-02,NDC,facility,both,1,ML,,1999,1399.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOFETILIDE 250 MCG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,69452-132-17,NDC,facility,both,1,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,63323-482-03,NDC,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE MODIFIED  25 MG ORAL CAP,50863,CDM,250,RC,J7515,HCPCS,0093-9018-19,NDC,facility,both,14,EA,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 0.5 MG ORAL CAP,50863,CDM,250,RC,J7507,HCPCS,0904-6623-61,NDC,facility,both,2,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARIFENACIN  7.5 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,13668-202-30,NDC,facility,both,1,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 1 MG ORAL TAB,50863,CDM,250,RC,J8540,HCPCS,0054-4181-25,NDC,facility,both,8,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,636,RC,J3490,HCPCS,72789-057-01,NDC,facility,both,3,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MOXIFLOXACIN 400 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6406-06,NDC,facility,both,1,EA,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6322-06,NDC,facility,both,6,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,78206-122-01,NDC,facility,both,2,EA,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  125 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,23155-858-78,NDC,facility,both,1,EA,,154,107.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,62332-599-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN 1000 MG IN NS 1000 ML IRRIGATION (REPACK),50863,CDM,636,RC,J0690,HCPCS,99999-500-04,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69097-125-03,NDC,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE  50 MG ORAL CAP,50863,CDM,250,RC,J8530,HCPCS,62332-619-31,NDC,facility,both,4,EA,,162,113.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,0409-1283-03,NDC,facility,both,7,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 100 MG/ML INJ SOLN,50863,CDM,636,RC,J2800,HCPCS,70069-101-01,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,250,RC,J3490,HCPCS,39822-1000-1,NDC,facility,both,3,ML,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,16714-294-01,NDC,facility,both,6,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENTOLAMINE 5 MG INJ SOLR,50863,CDM,250,RC,J3490,HCPCS,0143-9564-01,NDC,facility,both,1,EA,JZ,1231,861.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LOPERAMIDE 2 MG ORAL CAP,50863,CDM,J3490,HCPCS,51079-690-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB 100 MG IV SOLR,50863,CDM,J1745,HCPCS,57894-030-01,NDC,,,facility,both,61,EA,,19662,13763.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-0007-01,NDC,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GAMMAGARD LIQUID 10 % IV SOLN,50863,CDM,J1569,HCPCS,0944-2700-06,NDC,,,facility,both,40,ML,,7211,5047.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL  32.4 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-6575-61,NDC,,,facility,both,4,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  20 MEQ ORAL PACK,50863,CDM,J3490,HCPCS,0245-0360-89,NDC,,,facility,both,1,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 0.1 % TOP CREAM,50863,CDM,250,RC,J3490,HCPCS,45802-064-35,NDC,facility,both,2,GM,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-145-11,NDC,facility,both,85,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEFLUNOMIDE  10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,23155-043-03,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-172-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,66479-583-05,NDC,facility,both,2,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1170,HCPCS,76045-009-96,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM SR 120 MG 12 HR CAP,50863,CDM,636,RC,J3490,HCPCS,0378-6120-01,NDC,facility,both,3,EA,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-580-11,NDC,facility,both,21,EA,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,63323-482-03,NDC,facility,both,150,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7047-61,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,9,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 20 GRAM/500 ML IV SOLP,50863,CDM,250,RC,J3475,HCPCS,0409-2050-01,NDC,facility,both,40,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE IN SALINE (ISO-OSM) 400 MG/200 ML IV PIGGY BACK,50863,CDM,250,RC,J1450,HCPCS,25021-184-87,NDC,facility,both,2,ML,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-131-11,NDC,facility,both,4,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,50863,CDM,636,RC,J1885,HCPCS,72266-119-01,NDC,facility,both,3,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IBUPROFEN 800 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-5855-61,NDC,facility,both,9,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOVASTATIN 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0093-0576-06,NDC,facility,both,2,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0143-9595-01,NDC,facility,both,200,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,7,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-406-03,NDC,facility,both,1,ML,,237,165.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0295,HCPCS,63323-368-20,NDC,facility,both,1,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 50% IN WATER (MERGE RECORD),50863,CDM,250,RC,J7060,HCPCS,0409-7517-66,NDC,facility,both,2,ML,,211,147.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,168,117.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN SODIUM EXTENDED 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,65862-692-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN-ACETAMINOPHEN-CAFFEINE 250 MG-250 MG-65 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0536-1326-01,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG SUBQ SOLR,50863,CDM,J2802,HCPCS,55513-222-01,NDC,,,facility,both,500,EA,,8780,6146,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTOBARBITAL 75 MG/1.5 ML SYRINGE (REPACK),50863,CDM,636,RC,J2515,HCPCS,25021-676-20,NDC,facility,both,2,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 10 MG ORAL TAB,50863,CDM,J3490,HCPCS,60687-245-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZONATATE 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7153-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) MISC SOLN,50863,CDM,J3490,HCPCS,63323-694-04,NDC,,,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  500 MG IV SOLR,50863,CDM,J3373,HCPCS,70436-020-82,NDC,,,facility,both,50000,EA,,19944,13960.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,250,RC,J3490,HCPCS,63323-485-27,NDC,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0630,HCPCS,42023-205-01,NDC,facility,both,1,ML,,6266,4386.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,250,RC,J7060,HCPCS,0338-0017-31,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 5 MG/5 ML IV,50863,CDM,636,RC,J3490,HCPCS,0409-1778-15,NDC,facility,both,2,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 600 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-5854-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,250,RC,J0330,HCPCS,0409-6629-02,NDC,facility,both,4,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 1 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,65162-673-84,NDC,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,50863,CDM,J3301,HCPCS,70121-1049-1,NDC,,,facility,both,4,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,71288-414-01,NDC,facility,both,8,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,250,RC,J3490,HCPCS,0409-4277-02,NDC,facility,both,300,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DONEPEZIL  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-292-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VECURONIUM BROMIDE 20 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,67457-475-00,NDC,facility,both,1,EA,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 17 GRAM (100 %) ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,0904-6931-86,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,250,RC,J3490,HCPCS,0409-1323-15,NDC,facility,both,600,ML,,264,184.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,70069-011-01,NDC,facility,both,2,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLARITHROMYCIN 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0527-1931-06,NDC,facility,both,2,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-9543-02,NDC,facility,both,1,ML,JZ,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,47,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-18,NDC,facility,both,300,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 250 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,0832-7123-89,NDC,facility,both,3,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,636,RC,J7999,HCPCS,70092-1017-46,NDC,facility,both,2,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,636,RC,J3101,HCPCS,50242-037-06,NDC,facility,both,31,EA,JW,6174,4321.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
TIOTROPIUM BROMIDE 18 MCG INHL CPDV,50863,CDM,250,RC,J3490,HCPCS,0597-0075-75,NDC,facility,both,1,EA,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  20 MG ORAL TR12,50863,CDM,250,RC,J3490,HCPCS,59011-420-20,NDC,facility,both,5,EA,,260,182,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE  7.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-584-11,NDC,facility,both,2,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-9558-05,NDC,facility,both,2,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,13,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXAZOSIN 2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-851-95,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-467-01,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,636,RC,J3490,HCPCS,51754-4250-1,NDC,facility,both,1,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,250,RC,J0330,HCPCS,31722-981-10,NDC,facility,both,9,ML,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-105-11,NDC,facility,both,2,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISATRACURIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,70069-151-01,NDC,facility,both,2,ML,,1916,1341.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,280,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,4,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML IM SOLN,50863,CDM,636,RC,90375,HCPCS,13533-318-05,NDC,facility,both,8,ML,,6978,4884.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  100 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,63323-376-00,NDC,facility,both,8,ML,JB,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JB: Administered subcutaneously
TAMSULOSIN 0.4 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,68084-299-11,NDC,facility,both,1,EA,PLAD,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
MORPHINE  15 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,68084-157-11,NDC,facility,both,2,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-581-11,NDC,facility,both,3,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES  8.6 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6522-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOFETILIDE 500 MCG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,69452-133-17,NDC,facility,both,1,EA,PLAD,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
DEXAMETHASONE 10 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,67457-420-00,NDC,facility,both,90,ML,JW,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LEVETIRACETAM 100 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,31722-574-47,NDC,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,63323-010-02,NDC,facility,both,3,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1171,HCPCS,0703-0113-01,NDC,facility,both,1000,ML,,111,77.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DASATINIB  20 MG ORAL TAB,50863,CDM,250,RC,J9999,HCPCS,60505-3628-6,NDC,facility,both,1,EA,,693,485.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC ADMIN RESPIRATORY SYNCYTIAL VIRUS MONOCLONAL ANTIBODY SEASONAL DOSE INTRAMUSCULAR INJECTION,50863,CDM,250,RC,90380,HCPCS,49281-575-00,NDC,facility,both,1,ML,,1435,1004.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR IRRIGATION, STERILE SOLUTION",50863,CDM,250,RC,J3490,HCPCS,0338-0004-02,NDC,facility,both,4,ML,,139,97.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,50863,CDM,250,RC,J0696,HCPCS,44567-702-25,NDC,facility,both,6,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE (FOR CODE) 10% IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0517-6710-01,NDC,facility,both,1,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 2 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,636,RC,J2270,HCPCS,0409-1762-30,NDC,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,250,RC,J2795,HCPCS,70069-064-25,NDC,facility,both,60,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,54288-137-01,NDC,facility,both,1,ML,,159,111.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 40 MG-200 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0121-0853-20,NDC,facility,both,1,ML,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,250,RC,J0132,HCPCS,70594-111-01,NDC,facility,both,77,ML,,391,273.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0641-6022-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,250,RC,J7060,HCPCS,0338-0017-48,NDC,facility,both,1,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-279-11,NDC,facility,both,14,EA,,318,222.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INHL NEBU,50863,CDM,250,RC,J3490,HCPCS,0487-9301-33,NDC,facility,both,2,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE 2 MG SL SUBL,50863,CDM,636,RC,J3490,HCPCS,60687-481-11,NDC,facility,both,4,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIFEDIPINE 60 MG ORAL TO24,50863,CDM,250,RC,J3490,HCPCS,68084-598-01,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETIRIZINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6717-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEGLOTICASE 8 MG/ML IV SOLN,50863,CDM,636,RC,J2507,HCPCS,75987-080-10,NDC,facility,both,8,ML,,51290,35903,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,0904-6794-80,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.45 % 0.45 % IV SOLP,50863,CDM,250,RC,J3490,HCPCS,0264-7802-00,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,63323-104-01,NDC,facility,both,8,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-180-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-3244-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 250 MG INJ SOLR,50863,CDM,250,RC,J0696,HCPCS,0409-7337-11,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRIL MALEATE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,23155-773-01,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,J1836,HCPCS,0338-1055-48,NDC,,,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE IN 0.9 % SOD CHLORIDE 100 MG/10 ML (10 MG/ML) IV SYRG,50863,CDM,J3490,HCPCS,61553-331-65,NDC,,,facility,both,3,ML,,287,200.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  25 MG ORAL CAP,50863,CDM,J3490,HCPCS,60687-473-11,NDC,,,facility,both,8,EA,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE ERX) (STEMI),50863,CDM,J3101,HCPCS,50242-120-47,NDC,,,facility,both,25,EA,,11451,8015.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INDIGOTINDISULFONATE SODIUM 8 MG/ML INJ SOLN,50863,CDM,J9920,HCPCS,17478-508-01,NDC,,,facility,both,40,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,50863,CDM,636,RC,Q5119,HCPCS,0069-0238-01,NDC,facility,both,30,ML,,5936,4155.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  75 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6951-61,NDC,facility,both,4,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 50 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,68084-666-11,NDC,facility,both,3,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE (FOR CODE) 10% IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0517-6710-01,NDC,facility,both,2,ML,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIVASTIGMINE 1.5 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7107-61,NDC,facility,both,1,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUVOXAMINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60505-0165-1,NDC,facility,both,3,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 75 MG/5 ML ORAL SOLUTION,50863,CDM,250,RC,J3490,HCPCS,64980-511-10,NDC,facility,both,11,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 120 MG/0.8 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,16714-056-01,NDC,facility,both,12,ML,JZ,141,98.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CARBOXYMETHYLCELLULOSE SODIUM 1 % OPHT DPGE,50863,CDM,250,RC,J3490,HCPCS,0023-4554-30,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  120 MG RECT SUPP,50863,CDM,250,RC,J3490,HCPCS,51672-2115-0,NDC,facility,both,2,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-3178-01,NDC,facility,both,40,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYCHLOROQUINE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0781-5994-01,NDC,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLARITHROMYCIN 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0527-1931-06,NDC,facility,both,1,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,82,EA,,11316,7921.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXEPIN  50 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,51079-438-01,NDC,facility,both,3,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  5 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-122-11,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZIPRASIDONE 20 MG IM,50863,CDM,636,RC,J3486,HCPCS,72205-205-01,NDC,facility,both,1,EA,JZ,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,0143-9577-01,NDC,,,facility,both,120,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM SR 120 MG 24 HR CAP,50863,CDM,J3490,HCPCS,0904-7217-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,4,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DUTASTERIDE 0.5 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,31722-131-30,NDC,facility,both,1,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMILORIDE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0574-0292-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TORSEMIDE  20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-756-11,NDC,facility,both,5,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN 0.9% SODIUM CL 1 GRAM/250 ML IV SOLN,50863,CDM,636,RC,J3373,HCPCS,71266-5082-1,NDC,facility,both,1,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 100 MG 24 HR TAB,50863,CDM,636,RC,J3490,HCPCS,60687-413-11,NDC,facility,both,3,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORDIAZEPOXIDE 25 MG CAP,50863,CDM,636,RC,J3490,HCPCS,0555-0159-02,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,250,RC,J7999,HCPCS,70092-1017-46,NDC,facility,both,2,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0003-0894-21,NDC,facility,both,1,EA,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6665-61,NDC,facility,both,2,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LITHIUM CARBONATE 300 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0054-8527-25,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IMIPRAMINE 10 MG TAB,50863,CDM,250,RC,J3490,HCPCS,64380-169-01,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
URSODIOL 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-100-11,NDC,facility,both,1,EA,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6085-61,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR  6 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,68180-678-01,NDC,facility,both,4,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOBUTAMINE IN D5W 500 MG/250 ML (2 MG/ML) INFUSION (PREMIX),50863,CDM,250,RC,J1250,HCPCS,0409-2347-31,NDC,facility,both,2,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 50 MG TAB,50863,CDM,636,RC,J3490,HCPCS,69452-345-60,NDC,facility,both,1,EA,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-595-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6519-61,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVONORGESTREL 20 MCG/24 HR IU IUD,50863,CDM,636,RC,J7298,HCPCS,50419-423-01,NDC,facility,both,1,EA,,2369,1658.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
REMIFENTANIL 2 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,63323-724-01,NDC,facility,both,1,EA,,556,389.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIFEDIPINE 10 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,23155-194-01,NDC,facility,both,3,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPTOMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0878,HCPCS,0409-0122-01,NDC,facility,both,1000,EA,,804,562.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,0008-0923-60,NDC,facility,both,1,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE  10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69367-388-01,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,51079-051-20,NDC,facility,both,10,EA,,224,156.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,50863,CDM,Q5119,HCPCS,0069-0238-01,NDC,,,facility,both,40,ML,,7914,5539.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:200,000 INJ SOLN",50863,CDM,J2004,HCPCS,63323-487-07,NDC,,,facility,both,600,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J3490,HCPCS,63323-492-27,NDC,,,facility,both,100,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % MBP,50863,CDM,J3490,HCPCS,0338-9159-30,NDC,,,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GOLIMUMAB  12.5 MG/ML IV SOLN,50863,CDM,J1602,HCPCS,57894-350-01,NDC,,,facility,both,123,ML,,13574,9501.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,50863,CDM,250,RC,J9267,HCPCS,61703-342-50,NDC,facility,both,259,ML,,314,219.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2001,HCPCS,63323-495-04,NDC,,,facility,both,10,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 125 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,62756-796-88,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0630,HCPCS,42023-205-01,NDC,facility,both,1,ML,,6655,4658.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68382-806-01,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6008-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE  25 MG ORAL CPSP,50863,CDM,250,RC,J3490,HCPCS,0093-7336-06,NDC,facility,both,8,EA,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7030,HCPCS,0338-0049-04,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV (BOLUS),50863,CDM,250,RC,J7120,HCPCS,0264-7750-07,NDC,facility,both,2,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,636,RC,J2003,HCPCS,0409-1323-05,NDC,facility,both,400,ML,,160,112,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0143-9386-01,NDC,facility,both,35,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,70069-363-01,NDC,facility,both,1,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVONORGESTREL 1.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0536-1142-63,NDC,facility,both,1,EA,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 0.5 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,49884-311-52,NDC,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSULFAN BLUE 1 % INJ SOLN,50863,CDM,Q9968,HCPCS,67457-220-00,NDC,,,facility,both,50,ML,,4299,3009.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 7.5 MG-325 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0406-0124-23,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL,50863,CDM,250,RC,J3490,HCPCS,63323-820-01,NDC,facility,both,1,ML,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,J2704,HCPCS,0069-0209-01,NDC,,,facility,both,36,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANTI-INHIBITOR COAGULANT CMPLX (PHS MERGE),50863,CDM,250,RC,J7198,HCPCS,64193-426-02,NDC,facility,both,410,UN,,2962,2073.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AGALSIDASE BETA 35 MG IV SOLR,50863,CDM,636,RC,J0180,HCPCS,58468-0040-1,NDC,facility,both,20,ME,JW,4042,2829.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-21,NDC,facility,both,10,ML,"JZ,JA",1415,990.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,500,ML,,771,539.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,63323-482-05,NDC,,,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHACHOLINE CHLORIDE STERILE INHALATION SOLUTION (PF) KIT,50863,CDM,J7674,HCPCS,64281-110-05,NDC,,,facility,both,320,ML,,11178,7824.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69097-833-02,NDC,facility,both,2,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYALURONIDASE 150 UNIT/ML INJ SOLN,50863,CDM,250,RC,J3473,HCPCS,18657-117-02,NDC,facility,both,30,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7124-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,50863,CDM,250,RC,J9267,HCPCS,61703-342-50,NDC,facility,both,298,ML,,360,252,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTAMIDINE 300 MG INJ SOLR,50863,CDM,636,RC,J3490,HCPCS,63323-113-01,NDC,facility,both,1,EA,,159,111.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 100 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,31722-574-47,NDC,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE 1 MG/0.2 ML SUBQ KIT,50863,CDM,636,RC,J9218,HCPCS,0781-4003-32,NDC,facility,both,1,EA,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML IV SOLN (MERGE),50863,CDM,250,RC,J3490,HCPCS,16714-037-01,NDC,facility,both,1,ML,,127,88.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 25 MG/5 ML (5 MG/ML) ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,52536-600-11,NDC,facility,both,1,ML,,107,74.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 25 MG/5 ML (5 MG/ML) ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,52536-600-11,NDC,facility,both,1,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3370,HCPCS,70436-021-82,NDC,facility,both,4,EA,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,16714-298-01,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3370,HCPCS,0143-9162-01,NDC,facility,both,14,EA,,280,196,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN 0.9% SODIUM CL 1.25 GRAM/250 ML IV SOLN,50863,CDM,636,RC,J3373,HCPCS,71285-6074-1,NDC,facility,both,3,ML,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-822-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,636,RC,J3373,HCPCS,0143-9162-01,NDC,facility,both,200,EA,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OFLOXACIN 0.3 % OPHT DROP,50863,CDM,250,RC,J3490,HCPCS,70756-607-30,NDC,facility,both,1,ML,,299,209.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE IV",50863,CDM,250,RC,J3490,HCPCS,0338-0013-04,NDC,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,J7512,HCPCS,60687-145-11,NDC,,,facility,both,50,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DRONEDARONE 400 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0024-4142-60,NDC,facility,both,1,EA,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 10 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,65862-192-01,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM BROMIDE 17 MCG/ACTUATION INHL AERO,50863,CDM,250,RC,J3490,HCPCS,0597-0087-17,NDC,facility,both,1,GM,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65862-246-08,NDC,facility,both,3,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 250 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,42192-608-05,NDC,facility,both,4,ML,,113,79.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAZOSIN 2 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7021-61,NDC,facility,both,2,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 10 MG TAB,50863,CDM,250,RC,Q0177,HCPCS,63739-483-10,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAMOXIFEN 10 MG ORAL TAB,50863,CDM,250,RC,J9999,HCPCS,0591-2472-60,NDC,facility,both,4,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,250,RC,Q9968,HCPCS,70710-1838-1,NDC,facility,both,162,ML,,2689,1882.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,65862-246-08,NDC,facility,both,2,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,42806-150-33,NDC,facility,both,30,ML,,228,159.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARGATROBAN 100 MG/ML IV SOLN,50863,CDM,250,RC,J0883,HCPCS,0143-9674-01,NDC,facility,both,250,ML,,821,574.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-24,NDC,facility,both,120,ML,"JZ,JA",16973,11881.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
DULOXETINE 30 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,27241-098-09,NDC,facility,both,2,EA,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACIDOPHILUS-PECTIN W CITRUS 25 MILLION-100 CELL MG TAB,50863,CDM,250,RC,J3490,HCPCS,1785614241,NDC,facility,both,5,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-41,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6475-61,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,0338-0069-10,NDC,facility,both,2,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-0053-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BISACODYL 10 MG RECT SUPP,50863,CDM,250,RC,J3490,HCPCS,0574-7050-50,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TETRACAINE HCL (PF) 0.5 % OPHT DROP (STANDARD STOCK),50863,CDM,636,RC,J3490,HCPCS,0065-0741-14,NDC,facility,both,2,ML,,156,109.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,636,RC,J1610,HCPCS,63323-593-03,NDC,facility,both,2,EA,,1342,939.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,55150-307-01,NDC,facility,both,100,ML,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,67877-545-68,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0630,HCPCS,63323-865-02,NDC,facility,both,1,ML,JZ,1712,1198.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LABETALOL 5 MG/ML IV SOLN,50863,CDM,250,RC,J1921,HCPCS,17478-420-20,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-1749-70,NDC,facility,both,2,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAVASTATIN 40 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-190-11,NDC,facility,both,1,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6426-61,NDC,facility,both,2,EA,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM SR 300 MG 24 HR CAP,50863,CDM,250,RC,J3490,HCPCS,60687-228-11,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0003-0894-70,NDC,facility,both,4,EA,,233,163.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,508,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INDIGOTINDISULFONATE SODIUM 8 MG/ML INJ SOLN,50863,CDM,250,RC,J9220,HCPCS,0517-0375-01,NDC,facility,both,40,ML,,783,548.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOVASTATIN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68180-468-07,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE DINITRATE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-367-10,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIGOXIN  50 MCG/ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,0054-0057-46,NDC,facility,both,1,ML,,605,423.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELIMUMAB 400 MG IV SOLR,50863,CDM,636,RC,J0490,HCPCS,49401-102-01,NDC,facility,both,80,EA,"JZ,JA",8917,6241.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-1283-03,NDC,facility,both,15,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNIT/G TOP PACK,50863,CDM,636,RC,J3490,HCPCS,0904-7402-67,NDC,facility,both,10,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,69315-905-05,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE  7.5 MG IM SYKT,50863,CDM,J9217,HCPCS,0074-3642-03,NDC,,,facility,both,1,EA,,1176,823.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6869-61,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,J2704,HCPCS,63323-269-69,NDC,,,facility,both,164,ML,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,50863,CDM,250,RC,J9000,HCPCS,0069-1542-20,NDC,facility,both,12,ML,,186,130.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE-EPINEPHR-TETRACAINE 4-0.18-0.5 % TOPICAL GEL,50863,CDM,250,RC,J3490,HCPCS,71266-6290-1,NDC,facility,both,1,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GANCICLOVIR 500 MG IV SOLUTION,50863,CDM,250,RC,J1570,HCPCS,70436-089-55,NDC,facility,both,1,EA,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYMETAZOLINE 0.05 % NASL SPRAY (BLUE DYE FOR OR),50863,CDM,636,RC,j3490,HCPCS,69618-050-51,NDC,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 800 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,17856-921-01,NDC,facility,both,1,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL  32.4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6575-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL (VITAMIN D3)  1000 UNIT ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,8068116900,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE 21 MG/24 HR TD PT24,50863,CDM,636,RC,J3490,HCPCS,43598-448-71,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 10 MG/ML INJ SUSP,50863,CDM,J3301,HCPCS,0003-0494-20,NDC,,,facility,both,5,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM OXIDE 400 MG ORAL TAB,50863,CDM,J3490,HCPCS,6025817101,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",50863,CDM,J1561,HCPCS,13533-800-21,NDC,,,facility,both,10,ML,,1415,990.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PSEUDOEPHEDRINE 30 MG TAB,50863,CDM,J3490,HCPCS,45802-432-62,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  5 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,60687-122-11,NDC,facility,both,5,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 10% IN WATER (D10) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0264-7520-00,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAZOSIN 2 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7021-61,NDC,facility,both,3,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 250 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,42192-608-05,NDC,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  75 MG ORAL CP24,50863,CDM,636,RC,J3490,HCPCS,68084-709-11,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIPASE-PROTEASE-AMYLASE (PORK) 36,000-114,000- 180,000 UNIT ORAL CPDR",50863,CDM,636,RC,J3490,HCPCS,0032-3016-13,NDC,facility,both,1,EA,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL IV BOLUS 10MG/ML (ANESTHESIA ONLY),50863,CDM,636,RC,J2704,HCPCS,0409-4699-54,NDC,facility,both,14,ML,JW,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,636,RC,J1596,HCPCS,0641-6033-01,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0245-0212-11,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68180-981-01,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68462-333-90,NDC,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,305,ME,JZ,4139,2897.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ALLOPURINOL 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-206-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,J0665,HCPCS,0409-1162-18,NDC,,,facility,both,100,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML SYRUP,50863,CDM,636,RC,J3490,HCPCS,69339-150-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTOBARBITAL 75 MG/1.5 ML SYRINGE (REPACK),50863,CDM,636,RC,J3490,HCPCS,25021-676-20,NDC,facility,both,2,ML,,162,113.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,636,RC,P9045,HCPCS,13533-690-25,NDC,facility,both,2,ML,JZ,434,303.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,250,RC,J3360,HCPCS,0409-1273-03,NDC,facility,both,16,ML,,1581,1106.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  100 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,68462-896-10,NDC,facility,both,8,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BRIMONIDINE 0.2 % OPHT DROP,50863,CDM,250,RC,J3490,HCPCS,24208-411-05,NDC,facility,both,1,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,95,EA,,13110,9177,,,,,,,,,,,,,Gross Charge Type: Pharmacy
23.4% SODIUM CHLORIDE (4 MEQ/ML) INJECTION,50863,CDM,250,RC,J3490,HCPCS,63323-187-30,NDC,facility,both,4,ML,,192,134.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 300 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-699-11,NDC,facility,both,2,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BALANCED SALT IRRIG SOLN COMB2 INTRAOCULAR,50863,CDM,636,RC,J3490,HCPCS,0065-0795-15,NDC,facility,both,2,ML,,149,104.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR 800 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-109-11,NDC,facility,both,1,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,50863,CDM,250,RC,J0640,HCPCS,67457-528-10,NDC,facility,both,2,EA,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CANGRELOR 50 MG IV SOLR,50863,CDM,250,RC,C9460,HCPCS,10122-620-01,NDC,facility,both,50,EA,,2764,1934.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIFAMPIN 600 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,63323-351-20,NDC,facility,both,1,EA,,208,145.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCERIN (ADULT) RECTAL SUPPOSITORY,50863,CDM,250,RC,J3490,HCPCS,0132-0079-24,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  50 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-484-11,NDC,facility,both,4,EA,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/0.5 ML INHL NEBU,50863,CDM,250,RC,J3490,HCPCS,0487-9901-30,NDC,facility,both,3,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VERAPAMIL 120 MG ORAL TBSR,50863,CDM,636,RC,J3490,HCPCS,68462-292-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALTREXONE MICROSPHERES 380 MG IM SERR,50863,CDM,636,RC,J2315,HCPCS,65757-302-02,NDC,facility,both,380,EA,JZ,4666,3266.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
URSODIOL 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,50268-797-11,NDC,facility,both,2,EA,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUVOXAMINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60505-0166-1,NDC,facility,both,2,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LANSOPRAZOLE 3 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,65628-080-05,NDC,facility,both,1,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN  100 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,5026885211,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APREPITANT 125 MG ORAL CAP,50863,CDM,636,RC,J8501,HCPCS,68462-585-40,NDC,facility,both,25,EA,,940,658,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,6,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,250,RC,J3490,HCPCS,63037-136-25,NDC,facility,both,2,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE  25 MG ORAL CAP,50863,CDM,250,RC,J7515,HCPCS,0078-0240-61,NDC,facility,both,1,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE  50 MCG/ACTUATION NASL SPSN,50863,CDM,250,RC,J3490,HCPCS,0054-3270-99,NDC,facility,both,1,GM,,396,277.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIVAROXABAN  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50458-577-01,NDC,facility,both,2,EA,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,50863,CDM,636,RC,J1756,HCPCS,0517-2340-01,NDC,facility,both,7,ML,JW,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,68462-470-40,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0075-0622-01,NDC,facility,both,7,ML,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOBENZAPRINE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-558-11,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,5,ML,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POSACONAZOLE 100 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,70748-258-07,NDC,facility,both,2,EA,,533,373.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIROFIBAN-0.9% SODIUM CHLORIDE 5 MG/100 ML (50 MCG/ML) IV SOLN,50863,CDM,250,RC,J3246,HCPCS,25208-002-03,NDC,facility,both,22,ML,,438,306.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG IV SOLR,50863,CDM,636,RC,J3490,HCPCS,67457-437-00,NDC,facility,both,1,EA,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DORZOLAMIDE-TIMOLOL 2 %-0.5 % EYE DROPS,50863,CDM,250,RC,J3490,HCPCS,42571-147-26,NDC,facility,both,1,ML,,440,308,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 100 MG ORAL TBSR,50863,CDM,636,RC,J3490,HCPCS,68084-697-11,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MYCOPHENOLATE SODIUM 360 MG ORAL TBEC,50863,CDM,636,RC,J7518,HCPCS,0904-6786-61,NDC,facility,both,4,EA,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLN (MERGE)",50863,CDM,250,RC,P9047,HCPCS,64208-2512-8,NDC,facility,both,4,ML,,475,332.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,5,EA,,155,108.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-753-11,NDC,facility,both,1,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN ASP PRT-INSULIN ASPART 100 UNIT/ML (70-30) SUBQ SOLN,50863,CDM,250,RC,J1817,HCPCS,73070-200-11,NDC,facility,both,2,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  125 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,23155-858-78,NDC,facility,both,1,EA,,154,107.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,636,RC,J2560,HCPCS,42494-416-01,NDC,facility,both,2,ML,,289,202.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EVEROLIMUS (IMMUNOSUPPRESSIVE) 0.5 MG ORAL TAB,50863,CDM,250,RC,J7527,HCPCS,67877-719-33,NDC,facility,both,4,EA,,197,137.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN NPH & REGULAR HUMAN 100 UNIT/ML (70-30) SUBQ SUSP,50863,CDM,636,RC,J1815,HCPCS,0169-1837-11,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0990-7983-61,NDC,facility,both,1,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,50863,CDM,250,RC,J9025,HCPCS,72485-201-01,NDC,facility,both,66,EA,JW,411,287.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
BENAZEPRIL 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65862-116-01,NDC,facility,both,4,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM & SODIUM PHOSPHATES 280-160-250 MG ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,7135101099,NDC,facility,both,2,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,50863,CDM,250,RC,J9025,HCPCS,72485-201-01,NDC,facility,both,26,EA,JW,165,115.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ACYCLOVIR 200 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,70954-188-10,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  500 MG IV SOLR,50863,CDM,636,RC,J3373,HCPCS,70436-020-82,NDC,facility,both,50,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 150 MG CAP,50863,CDM,636,RC,J3490,HCPCS,68084-243-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELIMUMAB 120 MG IV SOLR,50863,CDM,636,RC,J0490,HCPCS,49401-101-01,NDC,facility,both,72,ME,,8456,5919.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,50863,CDM,250,RC,J9075,HCPCS,10019-956-16,NDC,facility,both,116,EA,,747,522.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML (PEDS CALCLUATOR 0.5),50863,CDM,636,RC,J1815,HCPCS,0024-5924-10,NDC,facility,both,10,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6418-61,NDC,facility,both,2,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE (PF-DURAMORPH/ASTRAMORPH) 0.5 MG/ML INJ SOLN,50863,CDM,636,RC,J2274,HCPCS,0409-3814-12,NDC,facility,both,1,ML,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN NORMAL SALINE IV,50863,CDM,636,RC,J7042,HCPCS,0338-0089-04,NDC,facility,both,4,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J2312,HCPCS,36000-308-01,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1815,HCPCS,0002-8215-01,NDC,facility,both,40,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETIRIZINE 5 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,68094-004-59,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,186,130.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLN (MERGE)",50863,CDM,636,RC,P9047,HCPCS,64208-2512-8,NDC,facility,both,1,ML,JZ,119,83.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,8,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,636,RC,J0690,HCPCS,44567-707-25,NDC,facility,both,4,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  75 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7000-61,NDC,facility,both,4,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 20 MG/ML INJ SOLN,50863,CDM,636,RC,J0360,HCPCS,0641-6231-01,NDC,facility,both,1,ML,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-02,NDC,facility,both,4,ML,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE  4 MG ORAL TAB,50863,CDM,636,RC,J7509,HCPCS,0904-6914-61,NDC,facility,both,6,EA,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE HCL  2 % MM JELP,50863,CDM,250,RC,J3490,HCPCS,76329-3013-5,NDC,facility,both,2,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0264-7800-10,NDC,facility,both,4,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYOSCYAMINE 0.5 MG/ML INJECTION,50863,CDM,250,RC,J1980,HCPCS,54288-111-01,NDC,facility,both,2,ML,,467,326.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 2 MG/ML IN NS 50ML INFUSION (STOCK DOSE),50863,CDM,250,RC,J3490,HCPCS,0143-9508-01,NDC,facility,both,5,ML,,213,149.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,250,RC,J2405,HCPCS,0409-4759-01,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE  50 MG ORAL TAB,50863,CDM,250,RC,j3490,HCPCS,60687-443-11,NDC,facility,both,10,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,250,RC,J3101,HCPCS,50242-037-06,NDC,facility,both,15,EA,,6871,4809.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,50863,CDM,250,RC,J1756,HCPCS,0517-2340-01,NDC,facility,both,300,ML,JZ,963,674.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,65862-707-80,NDC,facility,both,20,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6374-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 1 % INJ SOLN,50863,CDM,636,RC,Q9968,HCPCS,0517-0301-10,NDC,facility,both,20,ML,JZ,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
NICOTINE 14 MG/24 HR TD PT24,50863,CDM,250,RC,J3490,HCPCS,60505-7062-0,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEMAZEPAM  7.5 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0406-9960-01,NDC,facility,both,1,EA,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MEASLES,MUMPS,RUBELLA VACC(PF) 10EXP3.4-4.2- 3.3CCID50/0.5ML SUBQ SUSR",50863,CDM,250,RC,90707,HCPCS,58160-824-15,NDC,facility,both,1,EA,,398,278.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,68180-723-04,NDC,facility,both,6,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 50 MG/ML IV SOLN,50863,CDM,250,RC,J0282,HCPCS,67457-153-00,NDC,facility,both,5,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,250,RC,J3490,HCPCS,73013-2002-2,NDC,facility,both,2,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25 MG-100 MG TAB,50863,CDM,250,RC,J3490,HCPCS,59651-457-01,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIPHTH,PERTUS(ACELL),TETANUS SYRG(BOOSTRIX) 2.5-8-5 LF-MCG-LF/0.5ML IM SYRG",50863,CDM,636,RC,90715,HCPCS,58160-842-43,NDC,facility,both,1,ML,VFC,247,172.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier VFC: Modifier description not available
BUPRENORPHINE 2 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,60687-481-11,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,636,RC,J0132,HCPCS,55150-259-30,NDC,facility,both,60,ML,,271,189.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,0904-7127-61,NDC,facility,both,20,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-544-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE  7.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-584-11,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MENING VAC A,C,Y,W135,TET (PF) 10 MCG/0.5 ML IM SOLN",50863,CDM,250,RC,90619,HCPCS,49281-590-58,NDC,facility,both,1,ML,,743,520.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUFENTANIL CITRATE 50 MCG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-3382-11,NDC,facility,both,5,ML,,334,233.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-245-11,NDC,facility,both,1,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE-PRAMOXINE 1 %-1 % RECTAL FOAM,50863,CDM,250,RC,J3490,HCPCS,0037-6822-10,NDC,facility,both,1,GM,,840,588,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,65862-707-80,NDC,facility,both,30,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEPROTUMUMAB-TRBW 500 MG IV SOLR,50863,CDM,636,RC,J3241,HCPCS,75987-130-15,NDC,facility,both,39,EA,JW,12353,8647.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
TIZANIDINE 4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-760-11,NDC,facility,both,3,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,72266-118-01,NDC,facility,both,4,ML,JZ,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
QUETIAPINE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,67877-246-01,NDC,facility,both,2,EA,,127,88.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORTHALIDONE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-317-95,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CODEINE-GUAIFENESIN 10-100 MG/5 ML ORAL LIQD (REPACK),50863,CDM,250,RC,J3490,HCPCS,50383-087-10,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0121-0917-05,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,10135-778-01,NDC,facility,both,200,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,0143-9577-01,NDC,,,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GOSERELIN  3.6 MG SUBQ IMPL,50863,CDM,J9202,HCPCS,70720-950-36,NDC,,,facility,both,1,EA,,1670,1169,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,63323-485-27,NDC,,,facility,both,80,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML (1ML) INJ SOLN,50863,CDM,J0171,HCPCS,63323-696-02,NDC,,,facility,both,3,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,50863,CDM,250,RC,J9000,HCPCS,0069-1542-20,NDC,facility,both,9,ML,,134,93.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,J2250,HCPCS,55390-138-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG RECT SUPP,50863,CDM,250,RC,J3490,HCPCS,51672-2116-0,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,J3490,HCPCS,63037-136-25,NDC,,,facility,both,2,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-2051-15,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPLERENONE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-451-11,NDC,facility,both,2,EA,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-656-11,NDC,facility,both,4,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML (ANESTHESIA INTRAOP ONLY),50863,CDM,250,RC,J3010,HCPCS,0641-6027-01,NDC,facility,both,2,ML,JZ,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,8,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,250,RC,J3360,HCPCS,0409-1273-32,NDC,facility,both,4,ML,,396,277.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,50863,CDM,636,RC,Q0177,HCPCS,63739-486-10,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 20 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,0904-7043-61,NDC,facility,both,2,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOXYBENZAMINE 10 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,66993-066-02,NDC,facility,both,1,EA,,467,326.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE 22.5 MG SUBQ SYRG,50863,CDM,636,RC,J9217,HCPCS,62935-223-05,NDC,facility,both,3,EA,,1176,823.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,636,RC,J1939,HCPCS,0641-6008-01,NDC,facility,both,2,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,50863,CDM,636,RC,J1885,HCPCS,72266-119-01,NDC,facility,both,4,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
BUPRENORPHINE-NALOXONE 2-0.5 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,50268-144-11,NDC,facility,both,2,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-1283-03,NDC,facility,both,40,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 500 MG/5 ML ORAL SUMC,50863,CDM,250,RC,J3490,HCPCS,50419-773-01,NDC,facility,both,1,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM ACETATE 667 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,69097-862-83,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-512-11,NDC,facility,both,2,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4 % TOP CREA,50863,CDM,250,RC,J3490,HCPCS,0496-0882-05,NDC,facility,both,2,GM,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYALURONIDASE 150 UNIT/ML INJ SOLN,50863,CDM,250,RC,J3473,HCPCS,18657-117-01,NDC,facility,both,150,ML,JZ,284,198.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LEVOFLOXACIN IN D5W 500 MG/100 ML IV PGBK,50863,CDM,250,RC,J1956,HCPCS,44567-436-24,NDC,facility,both,2,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 0.8 GRAM ORAL PWPK,50863,CDM,250,RC,J0602,HCPCS,0115-1365-30,NDC,facility,both,160,EA,,327,228.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NYSTATIN  100000 UNIT/G TOP POWD,50863,CDM,250,RC,J3490,HCPCS,0574-2008-15,NDC,facility,both,1,GM,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,636,RC,J1611,HCPCS,63323-596-11,NDC,facility,both,2,EA,JZ,1789,1252.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CHLOROPROCAINE 3 % INJ SOLN,50863,CDM,250,RC,J2401,HCPCS,0143-9210-01,NDC,facility,both,300,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-027-11,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALACYCLOVIR 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6565-61,NDC,facility,both,42,EA,,442,309.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 400 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,69097-815-07,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 0.5% NASAL DROPS (REPACK),50863,CDM,636,RC,J3490,HCPCS,69536-050-15,NDC,facility,both,14,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUVOXAMINE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60505-0166-1,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACIDOPHILUS-PECTIN W CITRUS 25 MILLION-100 CELL MG TAB,50863,CDM,250,RC,J3490,HCPCS,1785614241,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 20% IN WATER (NEO) 500ML,50863,CDM,250,RC,J3490,HCPCS,0990-7935-19,NDC,facility,both,1,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,54288-136-01,NDC,facility,both,1,ML,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-18,NDC,facility,both,1,ML,JZ,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,47,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,636,RC,J2597,HCPCS,43598-931-11,NDC,facility,both,2,ML,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTAMIDINE 300 MG INJ SOLR,50863,CDM,636,RC,J3490,HCPCS,63323-113-01,NDC,facility,both,1,EA,,347,242.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 25 MG/5 ML (5 MG/ML) ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,52652-6001-1,NDC,facility,both,1,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J2004,HCPCS,0409-3178-01,NDC,facility,both,400,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,250,RC,J3490,HCPCS,0143-9575-01,NDC,facility,both,300,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESVENLAFAXINE  50 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,68180-592-06,NDC,facility,both,3,EA,,169,118.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSULFAN BLUE 1 % INJ SOLN,50863,CDM,636,RC,Q9968,HCPCS,67457-220-05,NDC,facility,both,40,ML,JW,1166,816.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ALLOPURINOL 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6572-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSULFAN BLUE 1 % INJ SOLN,50863,CDM,636,RC,Q9968,HCPCS,67457-220-00,NDC,facility,both,30,ML,"JW,JG",875,612.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient | Modifier JG: Drug or biological acquired with 340b drug pricing program discount
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,250,RC,J7060,HCPCS,0338-0017-03,NDC,facility,both,2,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE  10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-037-11,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   2 G INJ SOLR,50863,CDM,636,RC,J0690,HCPCS,60505-6231-0,NDC,facility,both,6,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 0.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-581-11,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,55150-307-01,NDC,facility,both,31,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN NEO/PEDS IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0456,HCPCS,63323-398-14,NDC,facility,both,1,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THROMBIN (RECOMBINANT) 20000 UNIT TOP SOLR,50863,CDM,636,RC,J3490,HCPCS,0338-0328-01,NDC,facility,both,1,EA,,1218,852.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 75 MG/5 ML ORAL SOLUTION,50863,CDM,250,RC,J3490,HCPCS,64980-511-10,NDC,facility,both,10,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,636,RC,J3490,HCPCS,0143-9575-01,NDC,facility,both,240,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,68382-444-05,NDC,facility,both,3,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-174-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN LYSINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,67386-122-52,NDC,facility,both,2,ML,,2620,1834,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,68180-723-04,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 40 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,70436-227-48,NDC,facility,both,1,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,0409-1207-03,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),50863,CDM,636,RC,J3490,HCPCS,8290306544,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL-ROPIVACAINE-NACL (PF) 2-0.2 MCG/ML-% INJ (MERGE ERX),50863,CDM,J3490,HCPCS,73013-1048-01,NDC,,,facility,both,1,ML,,1463260,1024282,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT  60 MCG/0.3 ML INJ SYRG,50863,CDM,250,RC,J0881,HCPCS,55513-023-01,NDC,facility,both,60,ML,JZ,1282,897.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0780,HCPCS,0641-6135-01,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL (5 MG/ML) IV SYRG PF,50863,CDM,J3490,HCPCS,71506-046-45,NDC,,,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,J1815,HCPCS,0088-2220-33,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MOXIFLOXACIN 400 MG/250 ML IVPB PREMIX (MERGE),50863,CDM,250,RC,J2280,HCPCS,67457-323-25,NDC,facility,both,4,ML,,234,163.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENOFIBRATE NANOCRYSTALLIZED  48 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-599-01,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUVOXAMINE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0832-1671-11,NDC,facility,both,4,EA,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,255,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMETHICONE  80 MG ORAL CHEW,50863,CDM,636,RC,J3490,HCPCS,77333-812-25,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LURASIDONE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,67877-638-30,NDC,facility,both,1,EA,,217,151.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
UBLITUXIMAB-XIIY 25 MG/ML IV SOLN,50863,CDM,636,RC,J2329,HCPCS,73150-150-06,NDC,facility,both,450,ML,,86713,60699.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYBUTYNIN CHLORIDE  5 MG ORAL TO24,50863,CDM,636,RC,J3490,HCPCS,68084-480-11,NDC,facility,both,2,EA,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-467-01,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,250,RC,J0330,HCPCS,0409-6629-02,NDC,facility,both,2,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,636,RC,J7999,HCPCS,70092-1017-46,NDC,facility,both,2,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,16714-294-02,NDC,facility,both,5,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J2310,HCPCS,36000-308-01,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0641-0400-12,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,49502-393-80,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN DEGLUDEC 100 UNITS/ML SUBQ SOLN,50863,CDM,636,RC,J1815,HCPCS,73070-400-11,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT  60 MCG/0.3 ML INJ SYRG,50863,CDM,636,RC,J0881,HCPCS,55513-023-01,NDC,facility,both,60,ML,JZ,1282,897.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LACOSAMIDE 10 MG/ML ORAL SOLUTION (REPACK),50863,CDM,636,RC,J3490,HCPCS,0131-5410-71,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-406-03,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,63323-165-30,NDC,facility,both,55,ML,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,0641-0477-21,NDC,facility,both,8,ML,,2437,1705.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUPHENAZINE 2.5 MG TAB,50863,CDM,636,RC,J3490,HCPCS,70954-274-10,NDC,facility,both,4,EA,,134,93.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN D5W 1 GRAM/200 ML IV PGBK,50863,CDM,636,RC,J3370,HCPCS,0338-3552-48,NDC,facility,both,100,ML,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,76045-009-10,NDC,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  25 MG ORAL TAB,50863,CDM,J3490,HCPCS,50268-504-11,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN 125 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,51672-4069-1,NDC,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 2 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,250,RC,J2270,HCPCS,76045-004-01,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-975-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-145-11,NDC,facility,both,30,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,63323-104-25,NDC,facility,both,16,ML,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-157-11,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J2003,HCPCS,63323-492-27,NDC,facility,both,300,ML,,236,165.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,63323-280-03,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,68516-5219-0,NDC,facility,both,2,ML,JZ,796,557.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
OLANZAPINE  5 MG ORAL TBDL,50863,CDM,J3490,HCPCS,59746-306-12,NDC,,,facility,both,1,EA,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESTRADIOL 2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,70954-566-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OFLOXACIN 0.3 % OPHT DROP,50863,CDM,250,RC,J3490,HCPCS,60505-0560-0,NDC,facility,both,1,ML,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATRACURIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-1105-22,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 400 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0143-9887-01,NDC,facility,both,16,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"OCTREOTIDE,MICROSPHERES 30 MG IM SERR",50863,CDM,636,RC,J2353,HCPCS,0078-0804-61,NDC,facility,both,30,EA,JZ,19079,13355.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CLOMIPRAMINE 25 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,51672-4011-6,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLNALTREXONE 12 MG/0.6 ML SUBQ SYRG,50863,CDM,250,RC,J2212,HCPCS,65649-552-04,NDC,facility,both,80,ML,,693,485.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM,50863,CDM,250,RC,J3490,HCPCS,45802-358-03,NDC,facility,both,1,GM,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,50863,CDM,250,RC,J9025,HCPCS,72485-201-01,NDC,facility,both,135,EA,,1918,1342.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-5771-23,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,10,ML,,196,137.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN NEO/PEDS IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0456,HCPCS,63323-398-14,NDC,facility,both,1,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 40 MG/ML SUSP (DEPO-MEDROL) INJECTION,50863,CDM,636,RC,J1010,HCPCS,70121-1573-1,NDC,facility,both,39,ML,JW,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
INFLIXIMAB 100 MG IV SOLR,50863,CDM,636,RC,J1745,HCPCS,57894-030-01,NDC,facility,both,16,EA,,5158,3610.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOZAPINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-404-11,NDC,facility,both,3,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NS WITH POTASSIUM CHLORIDE 40 MEQ/L IV SOLP,50863,CDM,250,RC,J3490,HCPCS,0338-0695-04,NDC,facility,both,1,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  500 MG IV SOLR,50863,CDM,250,RC,J3370,HCPCS,70436-020-82,NDC,facility,both,1,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-630-11,NDC,facility,both,1,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 100 MG/ML INJ SOLN,50863,CDM,250,RC,J2800,HCPCS,71288-716-11,NDC,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 10%-1/2 NORMAL SALINE IV,50863,CDM,636,RC,J3490,HCPCS,0264-7622-00,NDC,facility,both,1,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN DEXTROSE (ISO-OSMOTIC) 1 GRAM/50 ML IV PIGGY BACK,50863,CDM,250,RC,J0689,HCPCS,0338-3503-41,NDC,facility,both,2,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,0409-1283-03,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J0461,HCPCS,0517-0401-25,NDC,facility,both,20,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,921,ME,JZ,12498,8748.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
BACITRACIN 500 UNITS/1 GRAM PACKET (MERGE RECORD),50863,CDM,636,RC,J3490,HCPCS,0904-7023-67,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLESTYRAMINE 4 G ORAL PWPK,50863,CDM,636,RC,J3490,HCPCS,49884-466-63,NDC,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN LIPOSOMAL 2 MG/ML IV INJ,50863,CDM,250,RC,Q2050,HCPCS,47335-050-40,NDC,facility,both,10,ML,,13373,9361.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  750 MG IV SOLR,50863,CDM,250,RC,J3370,HCPCS,63323-203-01,NDC,facility,both,3,EA,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,72603-350-01,NDC,,,facility,both,20,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 10 MG/ML INJ SOLN,50863,CDM,J3430,HCPCS,43598-405-11,NDC,,,facility,both,3,ME,,355,248.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",50863,CDM,J1561,HCPCS,13533-800-21,NDC,,,facility,both,190,ML,,26874,18811.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN SODIUM EXTENDED 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0071-0369-24,NDC,facility,both,3,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 875 MG-125 MG TAB,50863,CDM,250,RC,J3490,HCPCS,65862-503-01,NDC,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6052-61,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADVATE: FACTOR VIII CONCENTRATE (MERGE RECORD),50863,CDM,250,RC,J7192,HCPCS,0944-3047-10,NDC,facility,both,4000,UN,,16744,11720.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,636,RC,J2720,HCPCS,63323-229-01,NDC,facility,both,5,ML,JZ,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,636,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,91,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DACARBAZINE 200 MG IV SOLR,50863,CDM,250,RC,J9130,HCPCS,0143-9245-01,NDC,facility,both,5,EA,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MYCOPHENOLATE 180 MG TAB, DELAYED RELEASE",50863,CDM,250,RC,J7518,HCPCS,68084-907-11,NDC,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0456,HCPCS,55150-174-10,NDC,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML IV SOLN (MERGE),50863,CDM,250,RC,J3490,HCPCS,16714-037-10,NDC,facility,both,1,ML,,101,70.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATENOLOL  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0093-0752-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE HCL IN NS 10 MG/250 ML (0.04 MG/ML) IV SOLN (PDS MERGE),50863,CDM,250,RC,J2371,HCPCS,70004-811-40,NDC,facility,both,500,ML,,146,102.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM BICARB-CITRIC ACID 20 MEQ ORAL TBEF,50863,CDM,636,RC,J3490,HCPCS,51801-011-01,NDC,facility,both,4,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 500 MG-125 MG TAB,50863,CDM,250,RC,J3490,HCPCS,65862-502-20,NDC,facility,both,1,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 20 MG/ML INJ SOLN,50863,CDM,250,RC,J0360,HCPCS,55150-400-01,NDC,facility,both,1,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BETAMETHASONE ACET & SOD PHOS 6 MG/ML INJ SUSP,50863,CDM,636,RC,J0702,HCPCS,78206-118-01,NDC,facility,both,3,ML,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MICAFUNGIN 100 MG IV SOLR,50863,CDM,636,RC,J2248,HCPCS,42023-230-01,NDC,facility,both,100,EA,,647,452.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLN,50863,CDM,J3262,HCPCS,50242-136-01,NDC,,,facility,both,200,ML,,3666,2566.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-50,NDC,facility,both,47,ML,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"NEOMYCIN-POLYMYXIN-HC 3.5 MG-10,000 UNIT/ML-1 % EAR DROPS, SUSP",50863,CDM,J3490,HCPCS,61314-645-11,NDC,,,facility,both,1,ML,,378,264.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIVAROXABAN 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50458-580-01,NDC,facility,both,1,EA,,223,156.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,34,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BISACODYL  5 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,1093977544,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COLCHICINE 0.6 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42292-054-01,NDC,facility,both,2,EA,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN ENEMA 500MG IN 100ML NS,50863,CDM,250,RC,J3370,HCPCS,67457-339-00,NDC,facility,both,3,EA,,161,112.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLP,50863,CDM,636,RC,J3480,HCPCS,63323-965-02,NDC,facility,both,20,ML,JZ,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LEVETIRACETAM 500 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-4799-05,NDC,facility,both,4,ML,,183,128.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM TETRADECYL SULFATE 3 % IV SOLN,50863,CDM,636,RC,J3490,HCPCS,24201-201-01,NDC,facility,both,1,ML,,392,274.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-495-09,NDC,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEGARELIX 120 MG SUBQ SOLR,50863,CDM,250,RC,J9155,HCPCS,55566-8402-0,NDC,facility,both,240,EA,,4207,2944.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLNALTREXONE 12 MG/0.6 ML SUBQ SYRG,50863,CDM,250,RC,J2212,HCPCS,65649-551-07,NDC,facility,both,80,ML,,490,343,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,79,ML,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,J7040,HCPCS,00035-0002-80,NDC,,,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0143-9386-01,NDC,facility,both,17,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,J3490,HCPCS,0409-6625-14,NDC,,,facility,both,3,ML,,174,121.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE  25 MG ORAL TAB,50863,CDM,J3490,HCPCS,51079-103-01,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM IN NACL (ISO-OS) 1500 MG/100 ML IV PGBK,50863,CDM,J1953,HCPCS,43598-637-52,NDC,,,facility,both,150,ML,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) IV SOLN",50863,CDM,J3490,HCPCS,43066-008-01,NDC,,,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANTI-INHIBITOR COAGULANT CMPLX (PHS MERGE),50863,CDM,250,RC,J7198,HCPCS,64193-426-02,NDC,facility,both,4195,UN,,30297,21207.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,50863,CDM,J9041,HCPCS,72603-270-01,NDC,,,facility,both,7,EA,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PERTUZUMAB 420 MG/14 ML (30 MG/ML) IV SOLN,50863,CDM,J9306,HCPCS,50242-145-01,NDC,,,facility,both,840,ML,,18749,13124.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,636,RC,J1953,HCPCS,63323-400-01,NDC,facility,both,75,ML,JZ,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,63323-010-02,NDC,facility,both,4,ML,,119,83.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-346-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 120 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0093-0321-01,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL  6.25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6301-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,636,RC,J3360,HCPCS,69374-965-02,NDC,facility,both,2,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLIPIZIDE  5 MG ORAL TO24,50863,CDM,636,RC,J3490,HCPCS,16714-895-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,J1940,HCPCS,63323-280-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 0.1 MG/ML IV SYRINGE (NEO/INFANT),50863,CDM,250,RC,J1100,HCPCS,99999-0405-74,NDC,facility,both,1,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,J2919,HCPCS,0009-0047-25,NDC,,,facility,both,25,EA,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENAZOPYRIDINE 100 MG ORAL TAB,50863,CDM,J3490,HCPCS,65162-681-10,NDC,,,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,50863,CDM,J9041,HCPCS,72603-270-01,NDC,,,facility,both,22,EA,,550,385,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,50863,CDM,J0696,HCPCS,60505-6148-4,NDC,,,facility,both,4,EA,,225,157.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANTIVENIN CROTALIDAE (EQUINE) INJ SOLR,50863,CDM,250,RC,J0841,HCPCS,66621-0790-1,NDC,facility,both,4,EA,,14573,10201.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG TAB,50863,CDM,250,RC,J3490,HCPCS,65862-419-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IR SOLN,50863,CDM,636,RC,J3490,HCPCS,0338-0047-46,NDC,facility,both,6,ML,,333,233.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63304-773-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-0905-05,NDC,facility,both,2,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHIMAZOLE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-680-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INDOMETHACIN 50 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,68462-302-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICARDIPINE IN NACL (ISO-OS) 20 MG/200 ML IV PGBK,50863,CDM,250,RC,J3490,HCPCS,10122-313-01,NDC,facility,both,1,ML,,440,308,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,57237-004-30,NDC,facility,both,2,EA,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN 50 MG ORAL CHEW,50863,CDM,636,RC,J3490,HCPCS,60687-156-95,NDC,facility,both,4,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 875 MG-125 MG TAB,50863,CDM,636,RC,J3490,HCPCS,16714-297-01,NDC,facility,both,8,EA,,198,138.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MISOPROSTOL 800 MCG (4 X 200 MCG TAB) PACKAGE,50863,CDM,636,RC,S0191,HCPCS,43386-161-06,NDC,facility,both,4,EA,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,636,RC,J3370,HCPCS,67457-340-01,NDC,facility,both,4,EA,,189,132.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,2,EA,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,55111-466-01,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-1746-71,NDC,facility,both,1,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,40,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,60,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,636,RC,J3010,HCPCS,0409-9094-22,NDC,facility,both,3,ML,JZ,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J2003,HCPCS,63323-492-57,NDC,facility,both,180,ML,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM NEO IV SYRINGE (PHS FROM PREMIX),50863,CDM,250,RC,J1953,HCPCS,44567-501-01,NDC,facility,both,20,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GAMMAGARD LIQUID 10 % IV SOLN,50863,CDM,636,RC,J1569,HCPCS,0944-2700-12,NDC,facility,both,20,ML,"JW,JA",1568,1097.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-22,NDC,facility,both,12,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 50% IN WATER (MERGE RECORD),50863,CDM,636,RC,J7060,HCPCS,0409-6648-02,NDC,facility,both,3,ML,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-349-11,NDC,facility,both,2,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROFURANTOIN (25% MACROCRYSTAL FORM) 100 MG CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7137-61,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BECLOMETHASONE DIPROPIONATE 40 MCG/ACTUATION INHL HFAB,50863,CDM,250,RC,J3490,HCPCS,59310-302-40,NDC,facility,both,1,GM,,757,529.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARSENIC TRIOXIDE 10 MG/10 ML IV SOLN,50863,CDM,250,RC,J9017,HCPCS,23155-869-31,NDC,facility,both,15,ML,,739,517.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-9149-01,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,461,ML,,662,463.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE (FOR EMERGENCY) 100 MG/ML (10%) IV SOLN,50863,CDM,250,RC,J0612,HCPCS,63323-360-01,NDC,facility,both,300,ML,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE  5 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,64850-510-01,NDC,facility,both,4,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 20 GRAM/500 ML IV SOLP,50863,CDM,250,RC,J3475,HCPCS,63323-106-15,NDC,facility,both,40,ML,JZ,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,636,RC,Q0162,HCPCS,16714-671-02,NDC,facility,both,4,ML,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,636,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,14,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-134-11,NDC,facility,both,10,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE MALEATE  5 MG ORAL TAB,50863,CDM,250,RC,Q0164,HCPCS,59746-113-06,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,250,RC,J2270,HCPCS,0409-1890-13,NDC,facility,both,1,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL 2.5 MG/ML SUSPENSION,50863,CDM,250,RC,J3490,HCPCS,99999-0404-75,NDC,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 40 MG-200 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,65862-496-47,NDC,facility,both,1,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-229-41,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,250,RC,J1596,HCPCS,0143-9679-01,NDC,facility,both,80,ML,,1824,1276.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  1 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,64380-782-06,NDC,facility,both,86,EA,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM HYPOCHLORITE 0.125 % MISC SOLN,50863,CDM,250,RC,J3490,HCPCS,3932806412,NDC,facility,both,1,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4 % TOP CREA,50863,CDM,250,RC,J3490,HCPCS,0496-0882-05,NDC,facility,both,1,GM,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7030,HCPCS,0338-0049-04,NDC,facility,both,1,ML,JZ,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
AMINOCAPROIC ACID  500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,62559-225-30,NDC,facility,both,10,EA,,807,564.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),50863,CDM,250,RC,J2060,HCPCS,65219-368-01,NDC,facility,both,2,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID (PORK)  30 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0456-0458-01,NDC,facility,both,3,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 125 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,0074-6212-13,NDC,facility,both,2,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,55150-169-10,NDC,facility,both,300,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1940,HCPCS,72603-251-01,NDC,facility,both,4,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COENZYME Q10  30 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,536143607,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 50 MG/50 ML (1 MG/ML) IN D5W (INFUSION),50863,CDM,250,RC,J2250,HCPCS,99999-500-26,NDC,facility,both,50,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL  2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-735-01,NDC,facility,both,3,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN PEDS SYRINGE (20MG/ML) IN DEXTROSE (CDS MIX,50863,CDM,636,RC,J0690,HCPCS,0781-3451-70,NDC,facility,both,4,EA,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN IN D5W 400 MG/200 ML IV PGBK,50863,CDM,636,RC,J0744,HCPCS,25021-114-87,NDC,facility,both,2,ML,JZ,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
TOBRAMYCIN (FORTIFIED) 15MG/ML OPHTHALMIC DROP (15ML),50863,CDM,250,RC,J3490,HCPCS,99999-407-39,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,636,RC,J2003,HCPCS,63323-485-27,NDC,facility,both,125,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN (NEW TX NON-NEURO INDICATION)",50863,CDM,250,RC,J1561,HCPCS,13533-800-71,NDC,facility,both,20,ML,,2829,1980.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,0641-6236-01,NDC,facility,both,2,ML,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7363-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0781-3246-02,NDC,facility,both,2,ML,JW,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,600,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM-ALBUTEROL 20-100 MCG/ACTUATION INHL MIST,50863,CDM,636,RC,J3490,HCPCS,0597-0024-02,NDC,facility,both,1,GM,,1392,974.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-074-01,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,75834-221-01,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 125 MG/5 ML (25MG/ML) ORAL SYRINGE (REPACK),50863,CDM,636,RC,J3373,HCPCS,67457-340-00,NDC,facility,both,2,EA,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRILAT 1.25 MG/ML IV INJ,50863,CDM,250,RC,J3490,HCPCS,0143-9787-01,NDC,facility,both,2,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRILAT 1.25 MG/ML IV INJ,50863,CDM,250,RC,J3490,HCPCS,0409-2122-02,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  37.5 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,68084-698-11,NDC,facility,both,1,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 5 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,63323-660-01,NDC,facility,both,3,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,230,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,498,ML,,715,500.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIGECYCLINE 50 MG IV SOLR,50863,CDM,250,RC,J3243,HCPCS,55150-228-10,NDC,facility,both,50,EA,,562,393.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLIPIZIDE  2.5 MG ORAL TO24,50863,CDM,250,RC,J3490,HCPCS,16714-894-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,636,RC,J7060,HCPCS,0338-0017-48,NDC,facility,both,1,ML,JZ,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PEG 3350-ELECTROLYTES 236 G-22.74 G-6.74 G-5.86 G ORAL SOLUTION,50863,CDM,250,RC,J3490,HCPCS,52268-100-01,NDC,facility,both,1,ML,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 0.125 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,13668-091-90,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIOGLITAZONE 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65862-512-30,NDC,facility,both,1,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL,50863,CDM,636,RC,J1071,HCPCS,0143-9659-01,NDC,facility,both,200,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 0.5 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,63323-481-01,NDC,facility,both,300,ML,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-38,NDC,facility,both,1,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,85,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BISACODYL  5 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,0904-6407-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN STERILE WATER 2 GRAM/20 ML IV SYRG,50863,CDM,636,RC,J7999,HCPCS,73702-132-23,NDC,facility,both,2,ML,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 7.5 MG-325 MG/15 ML ORAL SOLN (REPACK),50863,CDM,636,RC,J3490,HCPCS,0121-2316-15,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE IN D5W 1 GRAM/100 ML IV PGBK,50863,CDM,250,RC,J3475,HCPCS,63323-108-00,NDC,facility,both,2,ML,JZ,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
OXYCODONE 5 MG ORAL TAB,50863,CDM,J3490,HCPCS,68084-354-11,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN PEDS INFUSION (CDS MIXTURE),50863,CDM,250,RC,J0290,HCPCS,99999-408-63,NDC,facility,both,2,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2310,HCPCS,36000-308-01,NDC,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELATACEPT 250 MG IV SOLR,50863,CDM,636,RC,J0485,HCPCS,0003-0371-13,NDC,facility,both,230,EA,JW,1032,722.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,145,ML,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BIVALIRUDIN 250 MG/50 ML (5 MG/ML) IV SOLN,50863,CDM,250,RC,J5083,HCPCS,42023-622-01,NDC,facility,both,250,ML,,365,255.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"HEPARIN, PORCINE (PF)   10 UNIT/ML IV SYRG",50863,CDM,250,RC,J1642,HCPCS,6425322233,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,636,RC,J0690,HCPCS,44567-707-25,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 500 MG-125 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0781-1831-01,NDC,facility,both,1,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER FLUSH,50863,CDM,J7060,HCPCS,0264-7510-20,NDC,,,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNITS/1 GRAM PACKET (MERGE RECORD),50863,CDM,636,RC,J3490,HCPCS,45802-060-00,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MANNITOL 25 % IV SOLN,50863,CDM,250,RC,J2150,HCPCS,63323-024-01,NDC,facility,both,5,ML,,193,135.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-742-11,NDC,facility,both,5,EA,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,63323-162-00,NDC,facility,both,1,ML,JW,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
MINOXIDIL  2.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-204-11,NDC,facility,both,8,EA,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DONANEMAB-AZBT 17.5 MG/ML IV SOLN,50863,CDM,636,RC,J0175,HCPCS,0002-9401-01,NDC,facility,both,525,ML,JZ,4801,3360.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,636,RC,J1100,HCPCS,63323-506-01,NDC,facility,both,10,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-087-11,NDC,facility,both,1,EA,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0548-5603-00,NDC,facility,both,12,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-495-27,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPHENIDATE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-805-11,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,50863,CDM,250,RC,J0696,HCPCS,44567-701-25,NDC,facility,both,4,EA,PLAD,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,J3490,HCPCS,68180-441-02,NDC,,,facility,both,15,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"CALCIUM GLUC IN NACL, ISO-OSM 1 G/100 ML IV SOLN",50863,CDM,J0613,HCPCS,44567-622-01,NDC,,,facility,both,100,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,6,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
MIRTAZAPINE 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-119-11,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-3178-01,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 25 MG CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7237-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-090-11,NDC,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA SR 50 MG-200 MG TAB,50863,CDM,250,RC,J3490,HCPCS,50228-461-01,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 50 MG TAB,50863,CDM,250,RC,J3490,HCPCS,51079-801-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,16,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MYCOPHENOLATE 200 MG/ML ORAL SUSP,50863,CDM,250,RC,J7517,HCPCS,66689-307-08,NDC,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,J3490,HCPCS,68180-150-01,NDC,,,facility,both,2,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0536-1327-06,NDC,facility,both,16,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,636,RC,J2405,HCPCS,0409-4759-01,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUVOXAMINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69452-455-20,NDC,facility,both,2,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM IN NACL (ISO-OS) 1000 MG/100 ML IV PGBK,50863,CDM,250,RC,J1953,HCPCS,36000-356-01,NDC,facility,both,200,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 500 MG-125 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0781-1831-01,NDC,facility,both,1,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN NPH HUMAN RECOMB 100 UNIT/ML SUBQ SUSP,50863,CDM,636,RC,J1815,HCPCS,0169-1834-11,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7123-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANTI-INHIBITOR COAGULANT CMPLX (PHS MERGE),50863,CDM,250,RC,J7198,HCPCS,64193-424-02,NDC,facility,both,575,UN,,3426,2398.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J2310,HCPCS,36000-310-01,NDC,facility,both,5,ML,,392,274.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,220,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,68462-755-01,NDC,facility,both,2,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZONATATE 100 MG ORAL CAP,50863,CDM,J3490,HCPCS,0904-7153-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML INJ SOLN,50863,CDM,J2060,HCPCS,0641-6207-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE (PF) 1 MG/ML INJ SOLN,50863,CDM,636,RC,J0171,HCPCS,54288-103-01,NDC,facility,both,30,ML,,257,179.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,250,RC,J3490,HCPCS,63323-485-27,NDC,facility,both,150,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROGESTERONE MICRONIZED 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,16714-157-01,NDC,facility,both,2,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,15,ML,JW,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
OXCARBAZEPINE 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-722-11,NDC,facility,both,3,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,145,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,250,RC,J0132,HCPCS,72611-860-01,NDC,facility,both,60,ML,,218,152.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-027-11,NDC,facility,both,3,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,24,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  100 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,0641-6175-01,NDC,facility,both,2,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMANTADINE 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-422-11,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J3490,HCPCS,0338-1055-48,NDC,facility,both,200,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 1 MG/ML IV SOLN,50863,CDM,250,RC,J0461,HCPCS,0517-1001-01,NDC,facility,both,50,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML INJ SOLN,50863,CDM,636,RC,J2060,HCPCS,0409-1985-03,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0003-0894-31,NDC,facility,both,1,EA,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 250 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,0904-6860-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE DINITRATE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6620-61,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CELECOXIB 200 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-6503-61,NDC,facility,both,2,EA,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 60 MG TAB,50863,CDM,636,RC,J3490,HCPCS,60687-573-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,25021-053-01,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-744-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 500 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,50268-152-15,NDC,facility,both,40,EA,,240,168,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 0.1 % TOP LOTN,50863,CDM,636,RC,J3490,HCPCS,0713-0676-53,NDC,facility,both,1,ML,,382,267.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,140,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3373,HCPCS,0409-6533-11,NDC,facility,both,200,EA,,192,134.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCERIN 99.5 % TOP SOLN,50863,CDM,250,RC,J3490,HCPCS,0395-1031-96,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,50863,CDM,J9206,HCPCS,60505-6128-0,NDC,,,facility,both,1,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0093-4127-73,NDC,facility,both,10,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NOREPINEPHRINE BITARTRATE-NACL 4 MG/250 ML (16 MCG/ML) IV SOLN (CENTRAL ONLY),50863,CDM,J3490,HCPCS,44567-640-01,NDC,,,facility,both,1,ML,,218,152.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,72611-722-25,NDC,facility,both,5,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OMALIZUMAB 150 MG SUBQ SOLR,50863,CDM,636,RC,J2357,HCPCS,50242-040-62,NDC,facility,both,30,ME,,2610,1827,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,2,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ICATIBANT 30 MG/3 ML SUBQ SYRG,50863,CDM,J1744,HCPCS,69097-664-68,NDC,,,facility,both,30,ML,,29229,20460.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPTINEZUMAB-JJMR 100 MG/ML IV SOLN,50863,CDM,636,RC,J3032,HCPCS,67386-130-51,NDC,facility,both,300,ML,JZ,12379,8665.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,250,RC,J7060,HCPCS,0338-0017-03,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOPERAMIDE 2 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0378-2100-01,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXRAZOXANE 500 MG IV SOLR,50863,CDM,636,RC,J1190,HCPCS,55150-435-01,NDC,facility,both,2,EA,,1301,910.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV (BOLUS),50863,CDM,250,RC,J7120,HCPCS,0264-7750-00,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-18,NDC,facility,both,20,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
BENZOCAINE 20 % MM SPRY,50863,CDM,636,RC,J3490,HCPCS,0283-0610-43,NDC,facility,both,2,EA,,151,105.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LANTHANUM  500 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,68180-819-42,NDC,facility,both,1,EA,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID (PORK)  30 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,62559-741-01,NDC,facility,both,3,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,101,ML,,145,101.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE IN 0.9% NS (PF) 1 MG/10 ML (100 MCG/ML) IV SYRG(PDS MERGE),50863,CDM,636,RC,J3490,HCPCS,70092-1046-46,NDC,facility,both,1,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE 1 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,46287-035-15,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9% IV (PEDS) BOLUS,50863,CDM,636,RC,J7030,HCPCS,0264-7800-09,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,65862-859-01,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  75 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6951-61,NDC,facility,both,3,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,66689-020-01,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN NPH & REGULAR HUMAN 100 UNIT/ML (70-30) SUBQ SUSP,50863,CDM,636,RC,J1815,HCPCS,0169-1837-11,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM 1 GRAM IV SOLR,50863,CDM,250,RC,J2185,HCPCS,0409-1391-21,NDC,facility,both,10,EA,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 1 GRAM INJ SOLR,50863,CDM,250,RC,J0692,HCPCS,60505-6146-0,NDC,facility,both,2,EA,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,55150-169-10,NDC,facility,both,300,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE 25 MG/ML INJ SOLN,50863,CDM,250,RC,J3230,HCPCS,43598-141-11,NDC,facility,both,2,ML,,336,235.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAVASTATIN 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-178-11,NDC,facility,both,2,EA,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 2 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,63323-489-02,NDC,facility,both,160,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELIMUMAB 400 MG IV SOLR,50863,CDM,636,RC,J0490,HCPCS,49401-102-01,NDC,facility,both,120,EA,"JZ,JA",13375,9362.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,71288-402-10,NDC,facility,both,7,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  20 MEQ ORAL PACK,50863,CDM,250,RC,J3490,HCPCS,72888-024-06,NDC,facility,both,4,EA,,211,147.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,7,EA,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THROMBIN (RECOMBINANT) 5000 UNIT TOP SOLR,50863,CDM,250,RC,J3490,HCPCS,0338-0324-01,NDC,facility,both,10,EA,,3716,2601.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J2004,HCPCS,63323-482-03,NDC,facility,both,90,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE  10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,70756-201-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,0409-9094-18,NDC,facility,both,8,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML IN NS (PREMIX),50863,CDM,250,RC,J2250,HCPCS,70092-1312-75,NDC,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LANSOPRAZOLE 15 MG ORAL TBLD,50863,CDM,250,RC,J3490,HCPCS,68382-771-30,NDC,facility,both,1,EA,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR PHOSPHATE 75 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,31722-632-31,NDC,facility,both,1,EA,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG IV SOLR,50863,CDM,636,RC,J3490,HCPCS,55150-202-00,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,57237-077-10,NDC,facility,both,12,EA,,789,552.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  30 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,0904-6558-61,NDC,facility,both,3,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MISOPROSTOL 800 MCG (4 X 200 MCG TAB) PACKAGE,50863,CDM,250,RC,S0191,HCPCS,43393-023-04,NDC,facility,both,3,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOLAZONE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-024-01,NDC,facility,both,2,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 10 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,0641-0367-21,NDC,facility,both,20,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-888-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,3700025445,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN SODIUM EXTENDED  30 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0071-3740-66,NDC,facility,both,2,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 2.5 % EYE DROPS,50863,CDM,636,RC,J3490,HCPCS,70756-649-35,NDC,facility,both,1,ML,,405,283.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN SODIUM EXTENDED 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,65862-692-01,NDC,facility,both,9,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,250,RC,J7999,HCPCS,70092-1017-46,NDC,facility,both,2,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,250,RC,J7999,HCPCS,70092-1017-46,NDC,facility,both,1,ML,,3951,2765.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL DECANOATE  50 MG/ML IM SOLN,50863,CDM,250,RC,J1631,HCPCS,70069-030-01,NDC,facility,both,3,ML,,459,321.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV (BOLUS),50863,CDM,250,RC,J7120,HCPCS,17271-710-07,NDC,facility,both,1,ML,,411,287.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2310,HCPCS,67457-299-00,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J1610,HCPCS,63323-596-11,NDC,facility,both,10,EA,JZ,8945,6261.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
TICAGRELOR 90 MG ORAL TAB,50863,CDM,J3490,HCPCS,0186-0777-39,NDC,,,facility,both,2,EA,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,50863,CDM,J3490,HCPCS,0904-6666-61,NDC,,,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIROFIBAN-0.9% SODIUM CHLORIDE 5 MG/100 ML (50 MCG/ML) IV SOLN,50863,CDM,J3246,HCPCS,55150-429-01,NDC,,,facility,both,20,ML,,378,264.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIROFIBAN-0.9% SODIUM CHLORIDE 5 MG/100 ML (50 MCG/ML) IV SOLN,50863,CDM,J3246,HCPCS,25208-002-03,NDC,,,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J3490,HCPCS,63323-492-09,NDC,,,facility,both,300,ML,,157,109.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0054-0710-20,NDC,facility,both,6,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,50863,CDM,J1885,HCPCS,0409-3796-19,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,J7030,HCPCS,0338-0049-04,NDC,,,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE 2 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,60687-481-11,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,63323-411-18,NDC,facility,both,5,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,636,RC,J2704,HCPCS,25021-608-20,NDC,facility,both,4,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITRIOL 1 MCG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,64980-447-15,NDC,facility,both,1,ML,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM  3.375 GRAM IV SOLR,50863,CDM,636,RC,J2543,HCPCS,55150-120-30,NDC,facility,both,3,EA,JZ,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,J3490,HCPCS,0121-0917-05,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-21,NDC,facility,both,10,ML,JA,1415,990.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
FERROUS SULFATE 325 MG (65 MG IRON) TAB,50863,CDM,J3490,HCPCS,904759161,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,7,EA,,233,163.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES  8.6 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-7252-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIZATRIPTAN  5 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,69452-156-74,NDC,facility,both,1,EA,,163,114.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,43598-931-11,NDC,facility,both,2,ML,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESVENLAFAXINE  50 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,68180-592-06,NDC,facility,both,2,EA,,113,79.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL  20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-072-33,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,J2919,HCPCS,0009-0047-25,NDC,,,facility,both,8,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN  5 MG/ACTUATION NASL SPRY,50863,CDM,250,RC,J3490,HCPCS,66993-081-69,NDC,facility,both,4,EA,,886,620.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-580-11,NDC,facility,both,3,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2598,HCPCS,43598-914-06,NDC,facility,both,19,ML,JW,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
RIFAMPIN 25MG/ML SUSPENSION (REPACK),50863,CDM,250,RC,J3490,HCPCS,0185-0801-30,NDC,facility,both,8,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1940,HCPCS,0409-6102-20,NDC,facility,both,13,ML,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 40 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6292-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-4264-11,NDC,facility,both,6,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTAMIDINE 300 MG INHL SOLR,50863,CDM,250,RC,J3490,HCPCS,39822-3030-1,NDC,facility,both,1,EA,,405,283.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELOXICAM  7.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-525-11,NDC,facility,both,2,EA,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DANTROLENE  25 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0115-4411-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,50863,CDM,250,RC,J9075,HCPCS,10019-956-16,NDC,facility,both,198,EA,,1283,898.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-5755-23,NDC,facility,both,19,EA,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,38,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIFEDIPINE 30 MG ORAL TO24,50863,CDM,250,RC,J3490,HCPCS,68084-597-11,NDC,facility,both,3,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J3490,HCPCS,0338-0049-48,NDC,facility,both,2,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  75 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,69238-1312-9,NDC,facility,both,4,EA,,165,115.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLESTYRAMINE 4 G ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,49884-466-63,NDC,facility,both,2,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 6 MG/0.5 ML SUBQ PEN KIT,50863,CDM,636,RC,J3030,HCPCS,72603-141-01,NDC,facility,both,1,ML,,406,284.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,14789-127-07,NDC,facility,both,1,ML,PLAD,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
SPIRONOLACTONE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-545-10,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE NA (PRESERV FREE) 25 MG/ML INJ SOLN,50863,CDM,250,RC,J9260,HCPCS,0703-3678-01,NDC,facility,both,320,ML,,3124,2186.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0832-0540-11,NDC,facility,both,2,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 100 MG/ML INJ SOLN,50863,CDM,250,RC,J2800,HCPCS,71288-716-10,NDC,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE IN D5W 1 GRAM/100 ML IV PGBK,50863,CDM,636,RC,J3475,HCPCS,63323-108-00,NDC,facility,both,2,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,5,ML,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIPH,PERTUS(ACEL),TET,POLIO(PF)(KINRIX) 25 LF-58 MCG-10 LF/0.5 ML IM SYRINGE",50863,CDM,90696,HCPCS,58160-812-43,NDC,,,facility,both,1,ML,,318,222.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,J1836,HCPCS,0338-1055-48,NDC,,,facility,both,76,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 12.5 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-7307-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,J2270,HCPCS,0641-6125-01,NDC,,,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0548-5603-00,NDC,facility,both,6,ML,JZ,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PRAZOSIN 5 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-572-33,NDC,facility,both,2,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,50863,CDM,636,RC,J0696,HCPCS,0143-9857-01,NDC,facility,both,8,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 40 MG/ML (4 %) INJ SOLN (FOR NEBULIZATION),50863,CDM,J2003,HCPCS,0409-4283-11,NDC,,,facility,both,240,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SCOPOLAMINE TRANSDERMAL PATCH 1MG OVER 3 DAYS,50863,CDM,J3490,HCPCS,50742-505-01,NDC,,,facility,both,1,EA,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0904-6923-61,NDC,facility,both,10,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DROXIDOPA 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,31722-014-90,NDC,facility,both,4,EA,,530,371,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,39822-4200-1,NDC,facility,both,2,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,0409-1886-22,NDC,facility,both,200,ML,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRP (MERGE/REPACK),50863,CDM,636,RC,J3490,HCPCS,68094-764-59,NDC,facility,both,2,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL  1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0832-1520-89,NDC,facility,both,4,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CODEINE-GUAIFENESIN 10-100 MG/5 ML ORAL LIQD (REPACK),50863,CDM,250,RC,J3490,HCPCS,0121-1550-10,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE 2 MG SL SUBL,50863,CDM,636,RC,J3490,HCPCS,60687-481-11,NDC,facility,both,8,EA,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 2-0.5 MG SL SUBL,50863,CDM,636,RC,J3490,HCPCS,50268-144-11,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE (PF) 25 MG/ML INJ SOLN (FOR ECTOPIC PREGNANCY),50863,CDM,250,RC,J9260,HCPCS,0143-9519-01,NDC,facility,both,2,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,50268-540-11,NDC,facility,both,5,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 10 GRAM IV SOLR,50863,CDM,636,RC,J3370,HCPCS,0143-9164-01,NDC,facility,both,3,EA,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60219-1708-1,NDC,facility,both,80,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6966-61,NDC,facility,both,8,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,0409-9094-12,NDC,facility,both,2,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPAGLIFLOZIN PROPANEDIOL 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0310-6210-39,NDC,facility,both,1,EA,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,250,RC,J2003,HCPCS,63323-495-27,NDC,facility,both,120,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,57,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,636,RC,J2405,HCPCS,0409-4755-18,NDC,facility,both,4,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,6,EA,JW,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
HYDRALAZINE 20 MG/ML INJ SOLN,50863,CDM,636,RC,J0360,HCPCS,0641-6231-01,NDC,facility,both,1,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,70710-1833-1,NDC,facility,both,1,EA,,205,143.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN DEXTROSE (ISO-OSMOTIC) 1 GRAM/50 ML IV PIGGY BACK,50863,CDM,636,RC,J0690,HCPCS,0338-3503-41,NDC,facility,both,8,ML,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,59762-3130-1,NDC,facility,both,6,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTAZIDIME NEO IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0713,HCPCS,0781-3177-80,NDC,facility,both,1,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,J0665,HCPCS,0409-1160-01,NDC,,,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELATACEPT 250 MG IV SOLR,50863,CDM,636,RC,J0485,HCPCS,0003-0371-13,NDC,facility,both,75,EA,JW,337,235.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,0409-3178-16,NDC,,,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,0641-6236-01,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % MUCOSAL GEL,50863,CDM,250,RC,J3490,HCPCS,17478-711-30,NDC,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE  25 MG ORAL CAP,50863,CDM,250,RC,J7515,HCPCS,68084-879-95,NDC,facility,both,3,EA,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 20 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,51991-746-90,NDC,facility,both,2,EA,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-21,NDC,facility,both,10,ML,"JG,JZ,JA",1415,990.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
PREDNISONE 20 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,60687-145-11,NDC,facility,both,50,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,636,RC,J3490,HCPCS,63323-185-07,NDC,facility,both,2,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNITS/1 GRAM PACKET (MERGE RECORD),50863,CDM,250,RC,J3490,HCPCS,45802-060-00,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 150 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,0904-7084-61,NDC,facility,both,3,EA,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA SR 25 MG-100 MG TAB,50863,CDM,636,RC,J3490,HCPCS,51079-978-01,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL (5 MG/ML) IV SYRG (CONTAINS PRESERVATIVE),50863,CDM,250,RC,J3490,HCPCS,0409-2339-24,NDC,facility,both,2,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOBENZAPRINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69097-846-07,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,250,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEMAZEPAM  7.5 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,68084-549-11,NDC,facility,both,4,EA,,164,114.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM IN NACL (ISO-OS) 500 MG/100 ML IV PGBK,50863,CDM,636,RC,J1953,HCPCS,67457-255-00,NDC,facility,both,200,ML,,329,230.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZIPRASIDONE 40 MG CAP,50863,CDM,636,RC,J3490,HCPCS,0904-6270-08,NDC,facility,both,1,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,0409-9094-12,NDC,facility,both,4,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IRRIGATION SOLN,50863,CDM,250,RC,J7120,HCPCS,0264-7389-60,NDC,facility,both,9,ML,,150,105,,,,,,,,,,,,,Gross Charge Type: Pharmacy
D5W WITH POTASSIUM CHLORIDE 20 MEQ/L IV SOLP,50863,CDM,250,RC,J3490,HCPCS,0264-7625-00,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,J2919,HCPCS,0009-0039-30,NDC,,,facility,both,4,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,636,RC,J1939,HCPCS,72205-101-01,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADVATE: FACTOR VIII CONCENTRATE (MERGE RECORD),50863,CDM,J7192,HCPCS,0944-3053-02,NDC,,,facility,both,1000,UN,,4186,2930.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,636,RC,J2405,HCPCS,23155-548-31,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEZEPELUMAB-EKKO 210 MG/1.91 ML (110 MG/ML) SUBQ SYRG,50863,CDM,J2356,HCPCS,55513-112-01,NDC,,,facility,both,210,ML,,10028,7019.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOBRAMYCIN SULFATE 40 MG/ML INJ SOLN,50863,CDM,250,RC,J3260,HCPCS,67457-473-00,NDC,facility,both,5,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,70095-031-01,NDC,facility,both,23,ML,,924,646.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,636,RC,J1953,HCPCS,63323-400-01,NDC,facility,both,200,ML,,210,147,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORDIAZEPOXIDE 25 MG CAP,50863,CDM,636,RC,J3490,HCPCS,60687-807-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEGESTROL 40 MG ORAL TAB,50863,CDM,250,RC,J9999,HCPCS,0555-0607-02,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 7.5 MG-325 MG TAB,50863,CDM,250,RC,J3490,HCPCS,68084-863-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.3 MG/0.3 ML IM PNIJ,50863,CDM,636,RC,J0171,HCPCS,49502-102-01,NDC,facility,both,6,EA,,1350,945,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZOCAINE-MENTHOL 6-10 MG MM LOZG,50863,CDM,636,RC,J3490,HCPCS,7811201106,NDC,facility,both,18,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,0409-6102-20,NDC,facility,both,250,ML,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J3490,HCPCS,0338-0049-41,NDC,facility,both,1,ML,JZ,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GLIPIZIDE  2.5 MG ORAL TO24,50863,CDM,636,RC,J3490,HCPCS,60687-768-11,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BISOPROLOL FUMARATE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-127-11,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-3178-01,NDC,facility,both,15,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMIVUDINE 10 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,65862-055-24,NDC,facility,both,1,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2308-22,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,0641-6145-01,NDC,facility,both,10,ML,JZ,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
EPLERENONE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51991-877-33,NDC,facility,both,2,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0131-2477-35,NDC,facility,both,2,EA,,142,99.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,250,RC,J3490,HCPCS,50268-671-11,NDC,facility,both,2,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATENOLOL  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-759-01,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-980-01,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69315-117-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-113-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7362-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J3490,HCPCS,0409-4713-32,NDC,,,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,J1885,HCPCS,62332-600-01,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,J7512,HCPCS,60687-134-11,NDC,,,facility,both,10,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-075-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEMANTINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42292-006-01,NDC,facility,both,1,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-454-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB 100 MG IV SOLR,50863,CDM,636,RC,J1745,HCPCS,57894-030-01,NDC,facility,both,40,EA,JZ,12893,9025.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DENOSUMAB-BBDZ 120 MG/1.7 ML (70 MG/ML) SUBQ SOLN,50863,CDM,q5136,HCPCS,61314-228-94,NDC,,,facility,both,120,ML,,8855,6198.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,J3490,HCPCS,63037-136-25,NDC,,,facility,both,2,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,50863,CDM,J3420,HCPCS,0143-9621-01,NDC,,,facility,both,1,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VORICONAZOLE 200 MG IV SOLN,50863,CDM,250,RC,J3465,HCPCS,0781-3416-94,NDC,facility,both,23,EA,,611,427.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,636,RC,J0690,HCPCS,44567-707-25,NDC,facility,both,2,EA,,5924,4146.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65862-246-08,NDC,facility,both,2,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE  2.5 % RECT CREA,50863,CDM,636,RC,J3490,HCPCS,64980-324-30,NDC,facility,both,1,GM,,371,259.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 20 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7346-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 1 MG/ML IV SOLN,50863,CDM,250,RC,J0461,HCPCS,0517-1001-01,NDC,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  1 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,59651-484-01,NDC,facility,both,6,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  5 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-122-11,NDC,facility,both,7,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6172-61,NDC,facility,both,3,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7411-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TETRACYCLINE 500 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,23155-767-01,NDC,facility,both,1,EA,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  37.5 MG ORAL CP24,50863,CDM,636,RC,J3490,HCPCS,65862-527-90,NDC,facility,both,2,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROTHIAZIDE SODIUM 500 MG IV SOLR,50863,CDM,250,RC,J1205,HCPCS,17478-419-40,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN LOCK FLUSH 100 UNIT/ML IV SOLN,50863,CDM,636,RC,J1644,HCPCS,63323-545-01,NDC,facility,both,30,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65862-642-30,NDC,facility,both,4,EA,,265,185.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,0409-3795-19,NDC,facility,both,2,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,0904-7127-61,NDC,facility,both,50,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,59746-175-06,NDC,facility,both,20,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PYRIDOSTIGMINE BROMIDE 5 MG/ML INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0781-3040-95,NDC,facility,both,1,ML,,188,131.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,67457-108-00,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,0088-2220-33,NDC,facility,both,13,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0904-6923-61,NDC,facility,both,65,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,63323-104-06,NDC,facility,both,10,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,10019-506-10,NDC,facility,both,10,ML,,107,74.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 500 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,68084-415-11,NDC,facility,both,3,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,J2704,HCPCS,0069-0209-01,NDC,,,facility,both,9,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COCAINE  4 % TOP SOLN (MERGE),50863,CDM,636,RC,C9046,HCPCS,64950-362-04,NDC,facility,both,160,ML,,868,607.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,J0780,HCPCS,23155-294-31,NDC,,,facility,both,1,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 150 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,68180-319-09,NDC,facility,both,2,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),50863,CDM,250,RC,J1815,HCPCS,0024-5926-05,NDC,facility,both,240,ML,,921,644.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM IN NACL (ISO-OS) 1000 MG/100 ML IV PGBK,50863,CDM,250,RC,J1953,HCPCS,55150-247-47,NDC,facility,both,100,ML,,229,160.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,3,EA,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 150 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,0904-7084-61,NDC,facility,both,3,EA,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-384-11,NDC,facility,both,2,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,0409-3178-16,NDC,,,facility,both,170,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6519-61,NDC,facility,both,2,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-345-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNITS/1 GRAM PACKET (MERGE RECORD),50863,CDM,636,RC,J3490,HCPCS,0904-7023-67,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,9,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,636,RC,J1596,HCPCS,0143-9679-01,NDC,facility,both,8,ML,,183,128.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LATANOPROST 0.005 % OPHT DROP,50863,CDM,636,RC,J3490,HCPCS,59762-0333-2,NDC,facility,both,1,ML,,404,282.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,300,ML,JZ,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DORZOLAMIDE 2 % OPHT DROP,50863,CDM,250,RC,J3490,HCPCS,72266-197-01,NDC,facility,both,1,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,636,RC,J1100,HCPCS,63323-506-00,NDC,facility,both,10,ML,JZ,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CALCIUM GLUCONATE (FOR EMERGENCY) 100 MG/ML (10%) IV SOLN,50863,CDM,250,RC,J0612,HCPCS,63323-360-01,NDC,facility,both,200,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,520,ME,,7057,4939.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MOXIFLOXACIN 400 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,65862-603-30,NDC,facility,both,1,EA,,134,93.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 1 % NASAL SPRAY AEROSOL,50863,CDM,250,RC,J3490,HCPCS,0024-1352-02,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,90,ML,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,16,EA,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/0.5 ML INHL NEBU,50863,CDM,250,RC,J3490,HCPCS,0487-9901-02,NDC,facility,both,8,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,50863,CDM,250,RC,J9025,HCPCS,72485-201-01,NDC,facility,both,132,EA,,1876,1313.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COLCHICINE 0.6 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-727-11,NDC,facility,both,1,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,250,RC,J3490,HCPCS,39822-1000-1,NDC,facility,both,2,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,636,RC,Q0162,HCPCS,65162-691-79,NDC,facility,both,3,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-346-11,NDC,facility,both,4,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-8554-24,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  20 MEQ ORAL PACK,50863,CDM,636,RC,J3490,HCPCS,69543-451-01,NDC,facility,both,2,EA,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) 1000 UNITS/ML INJ SOL (FOR DIALYSIS ONLY),50863,CDM,250,RC,J1644,HCPCS,25021-400-10,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM PHOS IN 0.9 % NACL 15 MMOL/250 ML IVPB PREMIX,50863,CDM,250,RC,J3490,HCPCS,70004-841-40,NDC,facility,both,2,ML,,211,147.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 2-0.5 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,0054-0188-13,NDC,facility,both,1,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN PEDS SYRINGE (20MG/ML) IN DEXTROSE (CDS MIX,50863,CDM,250,RC,J0690,HCPCS,0781-3451-70,NDC,facility,both,6,EA,PLAD,125,87.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J2004,HCPCS,0409-3178-16,NDC,facility,both,170,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2599,HCPCS,65219-039-00,NDC,facility,both,5,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0137,HCPCS,0143-9386-01,NDC,facility,both,35,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXRAZOXANE 500 MG IV SOLR,50863,CDM,250,RC,J1190,HCPCS,0143-9248-01,NDC,facility,both,1,EA,JW,369,258.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,250,RC,J3490,HCPCS,63323-485-27,NDC,facility,both,85,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE 25 MG/ML INJ SOLN,50863,CDM,250,RC,J3230,HCPCS,70710-1850-1,NDC,facility,both,1,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 25 MG CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7237-60,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0780,HCPCS,23155-294-31,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RACEPINEPHRINE 2.25 % INHL NEBU,50863,CDM,250,RC,J3490,HCPCS,0487-2784-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-070-10,NDC,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,62332-033-31,NDC,facility,both,2,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,68084-813-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 20 MEQ/100 ML IV PGBK,50863,CDM,250,RC,J3480,HCPCS,0990-7075-26,NDC,facility,both,20,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0047-03,NDC,facility,both,25,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRIL MALEATE 1 MG/ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,69238-1729-7,NDC,facility,both,1,ML,,140,98,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0093-2279-73,NDC,facility,both,5,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM 2000 MG IV SOLR,50863,CDM,250,RC,J2185,HCPCS,44567-402-01,NDC,facility,both,20,EA,,194,135.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATENOLOL  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-759-01,NDC,facility,both,4,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,50863,CDM,636,RC,J2359,HCPCS,0781-3159-72,NDC,facility,both,10,EA,JZ,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DULOXETINE 20 MG ORAL CPDR,50863,CDM,636,RC,J3490,HCPCS,0904-7043-04,NDC,facility,both,2,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  5 GRAM IV SOLR,50863,CDM,250,RC,J3370,HCPCS,0409-6509-01,NDC,facility,both,4,EA,,156,109.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,250,RC,J2270,HCPCS,0409-1890-13,NDC,facility,both,1,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,72603-506-01,NDC,facility,both,70,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
FLUCONAZOLE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-693-01,NDC,facility,both,1,EA,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 400 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-6667-61,NDC,facility,both,1,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 100 MG/ML FROM 1 GRAM VIAL (PRMC PEDS ONLY),50863,CDM,250,RC,J0696,HCPCS,0409-7332-11,NDC,facility,both,4,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-124-11,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,50863,CDM,250,RC,J0696,HCPCS,44567-702-25,NDC,facility,both,5,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7363-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  120 MG RECT SUPP,50863,CDM,J3490,HCPCS,51672-2115-0,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,J2003,HCPCS,63323-486-27,NDC,,,facility,both,400,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,J2003,HCPCS,63323-486-05,NDC,,,facility,both,400,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN D5W 20000 UNIT/500 ML,50863,CDM,J1644,HCPCS,0264-9567-10,NDC,,,facility,both,20,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETUXIMAB 200 MG/100 ML IV SOLN,50863,CDM,J9055,HCPCS,66733-948-23,NDC,,,facility,both,2,ML,,241,168.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LET TOPICAL GEL 3 ML,50863,CDM,J3490,HCPCS,70092-1611-44,NDC,,,facility,both,1,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR PHOSPHATE 75 MG ORAL CAP,50863,CDM,J3490,HCPCS,72205-044-11,NDC,,,facility,both,1,EA,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,67877-548-88,NDC,facility,both,2,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,Q0162,HCPCS,17856-0691-5,NDC,,,facility,both,8,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG ORAL TAB,50863,CDM,J3490,HCPCS,63739-645-10,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  125 MG ORAL CAP,50863,CDM,J3490,HCPCS,62559-390-20,NDC,,,facility,both,1,EA,,154,107.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,50863,CDM,J0696,HCPCS,0781-3208-85,NDC,,,facility,both,4,EA,,225,157.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG SUBQ SOLR,50863,CDM,J2802,HCPCS,55513-222-01,NDC,,,facility,both,1000,EA,,17559,12291.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,50863,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,107,ML,,129,90.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,4,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,31,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IVPB (PEDIATRICS/ADULT NON-FORM)",50863,CDM,250,RC,J0137,HCPCS,24201-100-01,NDC,facility,both,100,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7188-61,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-406-03,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 20 MG/ML (1 ML) IV SOLN,50863,CDM,636,RC,J9171,HCPCS,16729-267-65,NDC,facility,both,213,ML,,8945,6261.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM  4.5 GRAM IV SOLR,50863,CDM,250,RC,J2543,HCPCS,65219-259-05,NDC,facility,both,4,EA,JZ,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2308-02,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-572-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYALURONIDASE 150 UNIT/ML INJ SOLN,50863,CDM,250,RC,J3473,HCPCS,18657-117-04,NDC,facility,both,15,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,50863,CDM,250,RC,J9025,HCPCS,72485-201-01,NDC,facility,both,62,EA,JW,388,271.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CALCIUM ACETATE 667 MG ORAL CAP,50863,CDM,250,RC,J0615,HCPCS,69097-862-83,NDC,facility,both,58,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-384-11,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOBAZAM 2.5 MG/ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,99999-0404-03,NDC,facility,both,3,ML,,119,83.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES 8.8 MG/5 ML ORAL SYRP,50863,CDM,250,RC,J3490,HCPCS,0536-1266-59,NDC,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-676-11,NDC,facility,both,3,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRP (MERGE/REPACK),50863,CDM,636,RC,J3490,HCPCS,68094-764-59,NDC,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE SODIUM 2.5 MG ORAL TAB,50863,CDM,636,RC,J8610,HCPCS,51079-670-01,NDC,facility,both,8,EA,,244,170.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68094-005-59,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,50863,CDM,J0640,HCPCS,25021-814-30,NDC,,,facility,both,2,EA,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,J3490,HCPCS,55150-188-10,NDC,,,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 10 MEQ/100 ML IV PGBK,50863,CDM,250,RC,J3480,HCPCS,0990-7074-26,NDC,facility,both,5,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0121-0945-10,NDC,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,33,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0228-2127-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIPASE-PROTEASE-AMYLASE (PORK) 36,000-114,000- 180,000 UNIT ORAL CPDR",50863,CDM,250,RC,J3490,HCPCS,0032-3016-13,NDC,facility,both,6,EA,,395,276.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0093-3425-10,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,16714-016-01,NDC,facility,both,2,ML,JW,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,50863,CDM,250,RC,J9075,HCPCS,10019-956-16,NDC,facility,both,147,EA,,949,664.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-319-11,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MECLIZINE 25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-730-11,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,17271-701-05,NDC,facility,both,1,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0781-3246-02,NDC,facility,both,1,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
AMOXICILLIN-POT CLAVULANATE 250 MG-62.5 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,60432-065-75,NDC,facility,both,10,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,68180-441-01,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCRELIZUMAB 30 MG/ML IV SOLN,50863,CDM,636,RC,J2350,HCPCS,50242-150-01,NDC,facility,both,300,ME,,44850,31395,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE 0.5%/EPINEPHRINE 1:100K INJECTION,50863,CDM,636,RC,J3490,HCPCS,63323-286-30,NDC,facility,both,1,ML,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 100 MG/1 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0075-0623-03,NDC,facility,both,9,ML,,132,92.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VECURONIUM BROMIDE 20 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,55150-236-01,NDC,facility,both,1,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,636,RC,J2405,HCPCS,0641-6078-01,NDC,facility,both,4,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-1749-70,NDC,facility,both,2,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6799-61,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALGANCICLOVIR 50 MG/ML ORAL SOLR,50863,CDM,250,RC,J3490,HCPCS,70069-810-01,NDC,facility,both,1,ML,,366,256.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN DEXTROSE (ISO-OS) 2 GRAM/100 ML IV PGBK,50863,CDM,250,RC,J0689,HCPCS,0338-3508-41,NDC,facility,both,4,ML,JZ,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SUCRALFATE 100 MG/ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0121-0974-10,NDC,facility,both,1,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6640-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) 1000 UNITS/ML INJ SOL (FOR DIALYSIS ONLY),50863,CDM,250,RC,J1644,HCPCS,25021-400-10,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE MONONITRATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,7733393425,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0121-1781-05,NDC,facility,both,2,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOVASTATIN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68180-468-01,NDC,facility,both,2,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,42858-301-25,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,290,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MYCOPHENOLATE 500 MG TAB,50863,CDM,250,RC,J7517,HCPCS,51079-379-01,NDC,facility,both,6,EA,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL 20 MG/5 ML ORAL ELIX,50863,CDM,636,RC,J3490,HCPCS,0121-0942-05,NDC,facility,both,4,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACUBITRIL-VALSARTAN 49-51 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0078-0777-67,NDC,facility,both,1,EA,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,50863,CDM,250,RC,J9060,HCPCS,0143-9504-01,NDC,facility,both,5,ML,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCRALFATE 100 MG/ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,17856-0306-1,NDC,facility,both,2,ML,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZIPRASIDONE 40 MG CAP,50863,CDM,636,RC,J3490,HCPCS,68084-104-11,NDC,facility,both,1,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC ADMIN RESPIRATORY SYNCYTIAL VIRUS MONOCLONAL ANTIBODY SEASONAL DOSE INTRAMUSCULAR INJECTION,50863,CDM,250,RC,90381,HCPCS,49281-574-88,NDC,facility,both,1,ML,,1435,1004.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 200 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16729-457-17,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),50863,CDM,250,RC,J2060,HCPCS,76329-8261-0,NDC,facility,both,25,ML,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,25021-131-82,NDC,facility,both,50,ML,JZ,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ALTEPLASE 100 MG IV SOLR,50863,CDM,250,RC,J2997,HCPCS,50242-085-25,NDC,facility,both,2,EA,,486,340.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7188-61,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG/5 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,0121-4827-05,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML INJ SOLN,50863,CDM,250,RC,J0171,HCPCS,76329-9060-0,NDC,facility,both,160,ML,,425,297.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE IN 0.9% NS (PF) 1 MG/10 ML (100 MCG/ML) IV SYRG(PDS MERGE),50863,CDM,636,RC,J3490,HCPCS,63037-173-25,NDC,facility,both,1,ML,,9706,6794.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,296,ME,JZ,4017,2811.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,50863,CDM,636,RC,J0585,HCPCS,0023-1145-01,NDC,facility,both,250,EA,,3996,2797.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (NEO) <2 KG,50863,CDM,250,RC,J7060,HCPCS,0338-0017-41,NDC,facility,both,2,ML,JZ,307,214.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
NEOSTIGMINE METHYLSULFATE 1 MG/ML IV SOLN,50863,CDM,250,RC,J2710,HCPCS,42023-189-01,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSULFAN BLUE 1 % INJ SOLN,50863,CDM,636,RC,Q9968,HCPCS,67457-220-05,NDC,facility,both,10,ML,,1050,735,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE IN 0.9% NS (PF) 1 MG/10 ML (100 MCG/ML) IV SYRG(PDS MERGE),50863,CDM,636,RC,J3490,HCPCS,65302-506-10,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE DINITRATE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6619-61,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA SR 25 MG-100 MG TAB,50863,CDM,250,RC,J3490,HCPCS,51079-978-01,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EZETIMIBE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51660-200-30,NDC,facility,both,1,EA,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE DINITRATE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-083-11,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 250 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,0904-6860-61,NDC,facility,both,1,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,278,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
RISPERIDONE 0.25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-270-11,NDC,facility,both,1,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMETHICONE  80 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,69618-033-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIRAGLUTIDE 0.6 MG/0.1 ML (18 MG/3 ML) SUBQ PNIJ,50863,CDM,250,RC,J3590,HCPCS,0169-4060-12,NDC,facility,both,2,ML,,1925,1347.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G POTASSIUM 20000000 UNIT INJ SOLR,50863,CDM,250,RC,J2540,HCPCS,0781-6136-94,NDC,facility,both,34,EA,,265,185.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICARDIPINE INFUSION 100 MCG/ML 50ML (PEDIATRIC),50863,CDM,250,RC,J3490,HCPCS,43066-026-10,NDC,facility,both,1,ML,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUMAZENIL 0.1 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,36000-148-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  37.5 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,65862-527-90,NDC,facility,both,2,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4% TOP PATCH,50863,CDM,636,RC,J3490,HCPCS,46581-830-01,NDC,facility,both,2,EA,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 100 MG TAB,50863,CDM,250,RC,J3490,HCPCS,65862-064-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6782-61,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-739-41,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 12.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68382-094-01,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0264-7800-00,NDC,facility,both,6,ML,,370,259,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 2 MG INJ SOLR,50863,CDM,636,RC,J2997,HCPCS,50242-041-64,NDC,facility,both,2,EA,JZ,762,533.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,636,RC,J1836,HCPCS,0338-1055-48,NDC,facility,both,60,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMOSOZUMAB-AQQG 210MG/2.34ML ( 105MG/1.17MLX2) SUBQ SYRG,50863,CDM,636,RC,J3111,HCPCS,55513-880-02,NDC,facility,both,210,ML,,5894,4125.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 1 MG ORAL TAB,50863,CDM,636,RC,J8540,HCPCS,72578-166-01,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  5 GRAM IV SOLR,50863,CDM,250,RC,J3370,HCPCS,67457-341-05,NDC,facility,both,4,EA,,154,107.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE SODIUM 25 MG/ML INJ SOLN,50863,CDM,636,RC,J9260,HCPCS,61703-350-37,NDC,facility,both,2,ML,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,250,RC,J2405,HCPCS,60505-6130-5,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 1 GRAM INJ SOLR,50863,CDM,250,RC,J0692,HCPCS,60505-6146-0,NDC,facility,both,4,EA,,199,139.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,636,RC,J1610,HCPCS,63323-582-82,NDC,facility,both,1,EA,JW,336,235.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
AZITHROMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0456,HCPCS,55150-174-10,NDC,facility,both,1,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2305-16,NDC,facility,both,2,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,140,EA,JZ,343,240.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DAPTOMYCIN 500 MG IV SOLR,50863,CDM,636,RC,J0878,HCPCS,72603-152-01,NDC,facility,both,300,EA,JZ,878,614.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LIDOCAINE 2 % MUCOSAL SOLN (VISCOUS),50863,CDM,636,RC,J3490,HCPCS,0054-8500-16,NDC,facility,both,2,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J2250,HCPCS,0409-2305-17,NDC,facility,both,8,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 50 MG TAB,50863,CDM,250,RC,J3490,HCPCS,55111-292-09,NDC,facility,both,1,EA,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN IN D5W 400 MG/200 ML IV PGBK,50863,CDM,250,RC,J0744,HCPCS,0409-3300-01,NDC,facility,both,2,ML,JZ,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PYRAZINAMIDE 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,70954-484-10,NDC,facility,both,4,EA,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,63739-564-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NORETHINDRONE ACETATE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50742-267-50,NDC,facility,both,3,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR  6 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0004-0822-05,NDC,facility,both,4,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7016-61,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,50863,CDM,636,RC,J1885,HCPCS,63323-162-03,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FELBAMATE 400 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,62559-730-01,NDC,facility,both,3,EA,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,6,ML,,173,121.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0630,HCPCS,63323-865-02,NDC,facility,both,1,ML,,1712,1198.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 20MG/ML IV SYRINGE (PEDS/NEO),50863,CDM,250,RC,J0612,HCPCS,63323-311-10,NDC,facility,both,58,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,70069-363-01,NDC,facility,both,1,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 875 MG-125 MG TAB,50863,CDM,636,RC,J3490,HCPCS,42571-162-01,NDC,facility,both,4,EA,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,636,RC,J1596,HCPCS,70069-011-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,50863,CDM,250,RC,Q0177,HCPCS,23155-501-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G POTASSIUM 20000000 UNIT INJ SOLR,50863,CDM,250,RC,J2540,HCPCS,0781-6136-94,NDC,facility,both,32,EA,,252,176.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOL 1.4 % MM SPRA,50863,CDM,636,RC,J3490,HCPCS,0904-6305-21,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 600 MG ORAL TP12,50863,CDM,250,RC,J3490,HCPCS,68084-572-11,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOLAZONE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-024-01,NDC,facility,both,1,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 500 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0093-3147-01,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIPASE-PROTEASE-AMYLASE (PORK) 36,000-114,000- 180,000 UNIT ORAL CPDR",50863,CDM,636,RC,J3490,HCPCS,0032-3016-13,NDC,facility,both,2,EA,,152,106.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE 44 MCG/ACTUATION INHL AERO,50863,CDM,250,RC,J3490,HCPCS,0173-0718-20,NDC,facility,both,1,GM,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 500 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,50268-152-11,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAMSULOSIN 0.4 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,72603-115-01,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAMADOL  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7496-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE  50 MG ORAL TAB,50863,CDM,250,RC,j3490,HCPCS,0904-6868-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0093-1712-01,NDC,facility,both,3,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PALIPERIDONE PALMITATE 78 MG/0.5 ML IM SYRG,50863,CDM,250,RC,J2426,HCPCS,50458-561-01,NDC,facility,both,78,ML,,3201,2240.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 100 MG IV SOLR,50863,CDM,636,RC,J2997,HCPCS,50242-085-25,NDC,facility,both,100,EA,,24289,17002.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J1610,HCPCS,63323-596-11,NDC,facility,both,25,EA,JZ,22363,15654.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MECLIZINE 25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-523-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,68094-231-59,NDC,facility,both,7,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,49884-849-01,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 0.5 MG ORAL TAB,50863,CDM,250,RC,J8540,HCPCS,72603-212-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,636,RC,J1953,HCPCS,55150-177-05,NDC,facility,both,160,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2599,HCPCS,63323-930-01,NDC,facility,both,4,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0074-4552-90,NDC,facility,both,2,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMINOCAPROIC ACID 250 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-4346-16,NDC,facility,both,1,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE 0.05 % OPHT DPET,50863,CDM,250,RC,J3490,HCPCS,10702-808-03,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0641-6057-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,636,RC,Q0162,HCPCS,16714-671-02,NDC,facility,both,4,ML,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-464-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL (VITAMIN D3)   400 UNIT ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,5026886311,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.45% (1/2 NS) INFUSION (PEDS ONC),50863,CDM,250,RC,J3490,HCPCS,0338-0043-04,NDC,facility,both,1,ML,,192,134.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6084-61,NDC,facility,both,2,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J2250,HCPCS,0409-2305-17,NDC,facility,both,2,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6782-61,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 0.4 MG/HR TD PT24,50863,CDM,636,RC,J3490,HCPCS,0378-9112-93,NDC,facility,both,2,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRIL MALEATE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,43547-546-10,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,68516-5214-4,NDC,facility,both,12,ML,,1712,1198.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 2-0.5 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,0904-7009-06,NDC,facility,both,6,EA,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6475-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLU VACCINE TS 2024-25 65 YR UP (PF) 180 MCG/0.5 ML IM SYRG,50863,CDM,636,RC,90662,HCPCS,49281-124-88,NDC,facility,both,1,ML,,373,261.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE  25 MG ORAL CAP,50863,CDM,250,RC,J7515,HCPCS,0078-0240-61,NDC,facility,both,10,EA,,229,160.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN (PF) NEO IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J1580,HCPCS,63323-513-02,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE  2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-157-11,NDC,facility,both,3,EA,,328,229.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-492-27,NDC,facility,both,260,ML,,204,142.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISANKIZUMAB-RZAA  60 MG/ML IV SOLN,50863,CDM,636,RC,J2327,HCPCS,0074-5015-01,NDC,facility,both,600,ML,JZ,29345,20541.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,65,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MECLIZINE 12.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-522-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,31722-820-30,NDC,facility,both,2,EA,,273,191.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7364-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,23155-723-01,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MOXIFLOXACIN 0.5 % OPHT DROP,50863,CDM,636,RC,J3490,HCPCS,68180-422-01,NDC,facility,both,1,ML,,603,422.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN PEDS IV INFUSION 12 MG/ML (CDS MIXTURE FROM PREMIX),50863,CDM,250,RC,J0736,HCPCS,0781-3289-91,NDC,facility,both,2,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPAGLIFLOZIN PROPANEDIOL 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0310-6210-39,NDC,facility,both,1,EA,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,63323-185-09,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-744-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OMEPRAZOLE-SODIUM BICARBONATE 2-84 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,65628-270-05,NDC,facility,both,5,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE MONONITRATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,6809411659,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,138,ML,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZIPRASIDONE 40 MG CAP,50863,CDM,250,RC,J3490,HCPCS,50268-812-11,NDC,facility,both,2,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,5,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM  4.5 GRAM IV SOLR,50863,CDM,636,RC,J2543,HCPCS,0781-3114-91,NDC,facility,both,4,EA,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 250 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,0904-6363-45,NDC,facility,both,3,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 500 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7337-35,NDC,facility,both,9,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,68180-150-01,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SYRG,50863,CDM,250,RC,J3490,HCPCS,8290306546,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,250,RC,J2405,HCPCS,70860-776-41,NDC,facility,both,4,ML,PLAD,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
MULTIVITAMIN WITH FOLIC ACID 400 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,904053961,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NYSTATIN 100000 UNIT/ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,17856-1045-1,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,50863,CDM,636,RC,J3490,HCPCS,57237-077-10,NDC,facility,both,1,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE (PF) 25 MG/ML INJ SOLN (FOR ECTOPIC PREGNANCY),50863,CDM,636,RC,J9260,HCPCS,0143-9519-01,NDC,facility,both,3,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,0143-9284-01,NDC,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,62332-033-31,NDC,facility,both,4,EA,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0172-3926-60,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-327-11,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORTHALIDONE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-167-11,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4 % MUCOSAL TOPICAL SOLN,50863,CDM,636,RC,J3490,HCPCS,70954-518-10,NDC,facility,both,1,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IVPB (PEDIATRICS/ADULT NON-FORM)",50863,CDM,636,RC,J0137,HCPCS,24201-100-01,NDC,facility,both,17,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),50863,CDM,636,RC,J2060,HCPCS,0641-6044-01,NDC,facility,both,2,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROPHILLIC OINTMENT (AQUAPHOR),50863,CDM,636,RC,J3490,HCPCS,7214003147,NDC,facility,both,1,GM,,111,77.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J1610,HCPCS,63323-596-11,NDC,facility,both,5,EA,,4473,3131.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOHEXOL   9 MG IODINE/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0407-1415-09,NDC,facility,both,1,ML,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,55390-138-01,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 25 MG TAB,50863,CDM,250,RC,J3490,HCPCS,62584-265-01,NDC,facility,both,10,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOPIDOGREL  75 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-536-11,NDC,facility,both,4,EA,,134,93.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 2.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0003-0893-31,NDC,facility,both,1,EA,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-354-11,NDC,facility,both,4,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM 2000 MG IV SOLR,50863,CDM,250,RC,J2185,HCPCS,72078-081-00,NDC,facility,both,20,EA,,194,135.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENETOCLAX  50 MG ORAL TAB,50863,CDM,250,RC,J9999,HCPCS,0074-0566-11,NDC,facility,both,2,EA,,284,198.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LURASIDONE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7355-04,NDC,facility,both,8,EA,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,53489-156-01,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,0409-9094-18,NDC,facility,both,5,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60505-3113-0,NDC,facility,both,2,EA,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM ACETATE 667 MG ORAL CAP,50863,CDM,250,RC,J0615,HCPCS,0904-7119-06,NDC,facility,both,116,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,66553-002-01,NDC,facility,both,4,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLN (MERGE)",50863,CDM,636,RC,P9047,HCPCS,64208-2512-8,NDC,facility,both,4,ML,JZ,475,332.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CARBIDOPA-LEVODOPA 25 MG-100 MG TAB,50863,CDM,250,RC,J3490,HCPCS,60687-661-11,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,50863,CDM,250,RC,J3420,HCPCS,70069-005-01,NDC,facility,both,1,ML,JZ,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,135,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,636,RC,J2720,HCPCS,63323-229-01,NDC,facility,both,4,ML,JW,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CEFEPIME 1 GRAM INJ SOLR,50863,CDM,250,RC,J0692,HCPCS,0409-9566-01,NDC,facility,both,2,EA,"JZ,PLAD",41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier PLAD: Modifier description not available
TIROFIBAN-0.9% SODIUM CHLORIDE 5 MG/100 ML (50 MCG/ML) IV SOLN,50863,CDM,250,RC,J3246,HCPCS,25208-002-03,NDC,facility,both,13,ML,JW,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
OLANZAPINE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60505-3111-0,NDC,facility,both,1,EA,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION,50863,CDM,636,RC,J3490,HCPCS,0186-0370-20,NDC,facility,both,1,GM,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 0.5 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J8540,HCPCS,0054-3177-63,NDC,facility,both,4,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 250 MCG SUBQ SOLR,50863,CDM,636,RC,J2796,HCPCS,55513-221-01,NDC,facility,both,50,EA,,8780,6146,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,250,RC,J2270,HCPCS,0409-1890-03,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 1 MG ORAL CAP,50863,CDM,250,RC,J7507,HCPCS,54288-135-01,NDC,facility,both,2,EA,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-3178-01,NDC,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,636,RC,J3360,HCPCS,0409-1273-03,NDC,facility,both,2,ML,JZ,198,138.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0630,HCPCS,24201-400-02,NDC,facility,both,1,ML,,1005,703.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 6 MG/0.5 ML SUB-Q,50863,CDM,250,RC,J3030,HCPCS,55150-173-01,NDC,facility,both,1,ML,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-3178-16,NDC,facility,both,150,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-231-11,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZOCAINE-MENTHOL 6-10 MG MM LOZG,50863,CDM,250,RC,J3490,HCPCS,7811201106,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,522,ME,JZ,7084,4958.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,250,RC,J2405,HCPCS,0641-6078-01,NDC,facility,both,4,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 10 MEQ/100 ML IV PGBK,50863,CDM,250,RC,J3480,HCPCS,14789-109-16,NDC,facility,both,15,ML,,705,493.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,96,ML,JW,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,300,ML,JZ,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ROPIVACAINE-EPI-CLONID-KETOROL 2.46-0.005- 0.0008-0.3MG/ML PATC SYRG,50863,CDM,250,RC,J3490,HCPCS,70092-1433-50,NDC,facility,both,4,ML,,849,594.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 10% IN WATER (D10) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0990-7930-09,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-9543-02,NDC,facility,both,1,ML,JZ,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
AMITRIPTYLINE  10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69367-388-01,NDC,facility,both,5,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 30 MG ORAL CPDR,50863,CDM,636,RC,J3490,HCPCS,0904-7044-61,NDC,facility,both,2,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,68,ML,JW,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
METHADONE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0406-5771-23,NDC,facility,both,4,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,63323-506-41,NDC,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPHENIDATE 18 MG ORAL TO24,50863,CDM,250,RC,J3490,HCPCS,0591-2715-01,NDC,facility,both,2,EA,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,50863,CDM,250,RC,J9045,HCPCS,0703-4239-01,NDC,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 1 MG/ML IV SOLN,50863,CDM,J0461,HCPCS,0517-1001-01,NDC,,,facility,both,50,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,50863,CDM,J0696,HCPCS,60505-6149-0,NDC,,,facility,both,16,EA,,775,542.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SYRG,50863,CDM,J3490,HCPCS,8290306547,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 40 MG/ML (4 %) INJ SOLN (FOR NEBULIZATION),50863,CDM,J2003,HCPCS,0409-4283-11,NDC,,,facility,both,40,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,50863,CDM,J0561,HCPCS,60793-701-02,NDC,,,facility,both,12,ML,,1188,831.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE (3 MONTH) 22.5 MG IM SYRG,50863,CDM,J9217,HCPCS,0074-3346-03,NDC,,,facility,both,3,EA,,1176,823.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) NEB SOLUTION,50863,CDM,250,RC,J3490,HCPCS,0487-9501-25,NDC,facility,both,2,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7050,HCPCS,0338-0049-02,NDC,facility,both,2,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN D5W 1 GRAM/200 ML IV PGBK,50863,CDM,J3370,HCPCS,0338-3552-48,NDC,,,facility,both,2,ML,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLECAINIDE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-0010-20,NDC,facility,both,2,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES-DOCUSATE SODIUM 8.6 MG-50 MG TAB,50863,CDM,250,RC,J3490,HCPCS,57896-303-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  1 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,64380-782-06,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,23155-723-01,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPRAZOLAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0781-1077-01,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-8299-25,NDC,facility,both,4,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-444-11,NDC,facility,both,3,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7124-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZONATATE 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7153-61,NDC,facility,both,42,EA,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NORTRIPTYLINE 10 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0093-0810-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE  5 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,70010-029-01,NDC,facility,both,6,EA,,212,148.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,636,RC,J1815,HCPCS,49502-393-80,NDC,facility,both,6,ML,GZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier GZ: Item or service expected to be denied as not reasonable and necessary
METOCLOPRAMIDE  5 MG/ML INJ SOLN,50863,CDM,250,RC,J2765,HCPCS,0409-3414-21,NDC,facility,both,2,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % MUCOSAL GEL,50863,CDM,250,RC,J3490,HCPCS,17478-711-30,NDC,facility,both,1,ML,,210,147,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIFEDIPINE 30 MG ORAL TO24,50863,CDM,636,RC,J3490,HCPCS,68084-597-11,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,636,RC,J3490,HCPCS,63323-185-07,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-495-27,NDC,facility,both,150,ML,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIVAROXABAN  2.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50458-577-01,NDC,facility,both,2,EA,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 10% IN WATER (D10) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0338-0023-02,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE  5 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,31722-185-01,NDC,facility,both,3,EA,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN DEGLUDEC 100 UNITS/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,73070-400-11,NDC,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN IN 0.9 % NS 40 UNIT/100 ML (0.4 UNIT/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,81298-8554-1,NDC,facility,both,1,ML,,562,393.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-456-01,NDC,facility,both,1,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 100 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,70954-240-10,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 20 MG/ML INJ SOLN,50863,CDM,250,RC,J0360,HCPCS,0517-0901-25,NDC,facility,both,1,ML,PLAD,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TAB,50863,CDM,J3490,HCPCS,0406-0512-23,NDC,,,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,J3490,HCPCS,68180-150-01,NDC,,,facility,both,3,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,J2270,HCPCS,0409-1890-03,NDC,,,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 0.4 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,0071-0418-13,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  500 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,0641-6176-01,NDC,facility,both,12,ML,"JW,JA",26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0955-1004-01,NDC,facility,both,3,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,250,RC,J2704,HCPCS,16714-528-01,NDC,facility,both,5,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORDIAZEPOXIDE 25 MG CAP,50863,CDM,636,RC,J3490,HCPCS,60687-807-11,NDC,facility,both,8,EA,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,63323-104-25,NDC,facility,both,16,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INDOCYANINE GREEN 25 MG INJ,50863,CDM,J3490,HCPCS,70100-725-01,NDC,,,facility,both,1,EA,,386,270.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-657-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,J7510,HCPCS,17856-0815-1,NDC,,,facility,both,2,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN LOCK FLUSH 100 UNIT/ML IV SOLN,50863,CDM,J1642,HCPCS,6425333335,NDC,,,facility,both,200,ML,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,76329-3352-1,NDC,facility,both,1,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUBIPROSTONE 24 MCG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,63304-352-60,NDC,facility,both,1,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYMETAZOLINE 0.05 % NASL SPRA,50863,CDM,636,RC,J3490,HCPCS,0904-7427-30,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRIMAQUINE 26.3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,76385-102-01,NDC,facility,both,2,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,636,RC,P9045,HCPCS,64208-2510-2,NDC,facility,both,2,ML,JZ,238,166.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MELOXICAM  7.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-525-11,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL  6.25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6301-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65862-076-01,NDC,facility,both,10,EA,,225,157.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPHENIDATE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-805-11,NDC,facility,both,7,EA,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,62584-733-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0406-3244-01,NDC,facility,both,3,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25%/EPINEPHRINE 1:100K INJECTION,50863,CDM,636,RC,J3490,HCPCS,0409-1158-01,NDC,facility,both,2,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,0143-9577-01,NDC,,,facility,both,60,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5%-1/4 NORMAL SALINE IV,50863,CDM,J3490,HCPCS,0338-0077-04,NDC,,,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,J2003,HCPCS,63323-486-27,NDC,,,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIROLIMUS 1 MG ORAL TAB,50863,CDM,250,RC,J7520,HCPCS,55111-653-01,NDC,facility,both,1,EA,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.3 MG/0.3 ML IM PNIJ,50863,CDM,J0171,HCPCS,49502-500-01,NDC,,,facility,both,3,EA,,1078,754.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,25021-321-10,NDC,facility,both,8,ML,,146,102.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,J7512,HCPCS,60687-145-11,NDC,,,facility,both,20,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 10 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-5784-61,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIFEDIPINE 60 MG ORAL TO24,50863,CDM,250,RC,J3490,HCPCS,68084-598-11,NDC,facility,both,2,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALGANCICLOVIR 450 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-787-11,NDC,facility,both,1,EA,,538,376.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 2 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J2004,HCPCS,63323-489-02,NDC,facility,both,400,ML,,121,84.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML IV,50863,CDM,250,RC,J3490,HCPCS,70860-301-41,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,66794-229-02,NDC,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-9558-05,NDC,facility,both,3,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-426-02,NDC,facility,both,2,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,0143-9682-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN (NEW TX NON-NEURO INDICATION)",50863,CDM,250,RC,J1561,HCPCS,13533-800-71,NDC,facility,both,20,ML,,2829,1980.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,6,EA,JW,360,252,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
EMTRICITABINE-TENOFOVIR 200 MG-300 MG TAB,50863,CDM,636,RC,J0750,HCPCS,60687-719-95,NDC,facility,both,3,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE  4 MG ORAL TAB,50863,CDM,250,RC,J7509,HCPCS,68084-149-11,NDC,facility,both,2,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NORETHINDRONE ACETATE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68462-304-50,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 800 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6707-06,NDC,facility,both,4,EA,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAMADOL  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-808-11,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXAZOSIN 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-5522-61,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFUROXIME AXETIL 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-400-01,NDC,facility,both,1,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-1749-70,NDC,facility,both,4,ML,,168,117.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
D5-NS WITH POTASSIUM CHLORIDE 40 MEQ/L IV SOLP,50863,CDM,250,RC,J3490,HCPCS,0338-0807-04,NDC,facility,both,1,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROPROCAINE 3 % INJ SOLN,50863,CDM,250,RC,J2401,HCPCS,63323-478-01,NDC,facility,both,52,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-0007-01,NDC,facility,both,200,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLU VACCINE TS 2025-26 65 YR UP (PF) 180 MCG/0.5 ML IM SYRG,50863,CDM,250,RC,90662,HCPCS,49281-125-88,NDC,facility,both,1,ML,,372,260.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIROLIMUS 1 MG ORAL TAB,50863,CDM,636,RC,J7520,HCPCS,50268-718-11,NDC,facility,both,1,EA,,172,120.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 100 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,67877-592-01,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN 0.9 % SODIUM CHL 1.5 GRAM/500 ML IV SOLN,50863,CDM,636,RC,J3373,HCPCS,70004-924-44,NDC,facility,both,150,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM  2.25 GRAM IV SOLR,50863,CDM,636,RC,J2543,HCPCS,60505-6156-0,NDC,facility,both,3,EA,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,25021-410-76,NDC,facility,both,4,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMETHICONE  80 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,77333-812-25,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL PACK,50863,CDM,250,RC,J3490,HCPCS,42806-270-98,NDC,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,78206-122-01,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TELMISARTAN 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68382-472-30,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,0409-4887-17,NDC,facility,both,1,ML,PLAD,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
AZITHROMYCIN 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-742-11,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,3,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) MISC SOLN,50863,CDM,250,RC,J3490,HCPCS,0517-7604-01,NDC,facility,both,1,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHOTERICIN B 5 MCG/0.1 ML INTRAVITREAL INJECTION,50863,CDM,250,RC,J3490,HCPCS,99999-0403-82,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,50863,CDM,636,RC,J0696,HCPCS,60505-6148-0,NDC,facility,both,6,EA,,338,236.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML (1ML) INJ SOLN,50863,CDM,636,RC,J0169,HCPCS,63323-696-02,NDC,facility,both,3,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NOREPINEPHRINE BITARTRATE-D5W 4 MG/250 ML (16 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0338-0112-20,NDC,facility,both,3,ML,,400,280,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,J2704,HCPCS,63323-269-22,NDC,,,facility,both,9,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EVINACUMAB-DGNB 150 MG/ML IV SOLN,50863,CDM,J1305,HCPCS,61755-010-01,NDC,,,facility,both,240,ML,,93288,65301.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,J7040,HCPCS,0264-5802-10,NDC,,,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN D5W 20000 UNIT/500 ML,50863,CDM,636,RC,J1644,HCPCS,0264-9567-10,NDC,facility,both,20,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,69315-905-05,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0121-0945-10,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 20 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,50111-648-01,NDC,facility,both,4,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42858-301-25,NDC,facility,both,5,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,50863,CDM,J0561,HCPCS,60793-701-02,NDC,,,facility,both,12,ML,,1080,756,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJ SOLN",50863,CDM,J3490,HCPCS,0409-1752-50,NDC,,,facility,both,2,ML,,200,140,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 400 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6667-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6377-61,NDC,facility,both,2,EA,,130,91,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-319-11,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZONATATE 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7153-61,NDC,facility,both,9,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE  7.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,13107-001-30,NDC,facility,both,4,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 75 MG/5 ML ORAL SOLUTION,50863,CDM,250,RC,J3490,HCPCS,64980-511-10,NDC,facility,both,20,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J2004,HCPCS,0409-3178-01,NDC,facility,both,60,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETIC ACID (VINEGAR) 5% IRRIGATION 12 ML (REPACK),50863,CDM,636,RC,J3490,HCPCS,5155200556,NDC,facility,both,4,ML,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 500 MG (200 MG ELEMENTAL) CHEW TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6412-92,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0248-01,NDC,facility,both,23,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE 25 MG/ML INJ SOLN,50863,CDM,636,RC,J3230,HCPCS,0641-1398-31,NDC,facility,both,1,ML,,195,136.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,49884-849-01,NDC,facility,both,2,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,58,EA,,8004,5602.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE 8 MG SL SUBL,50863,CDM,636,RC,J3490,HCPCS,60687-492-11,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,76329-3352-1,NDC,facility,both,3,ML,,347,242.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0245-0212-11,NDC,facility,both,2,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,636,RC,J1953,HCPCS,55150-177-05,NDC,facility,both,150,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,133,ML,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,0781-3246-02,NDC,facility,both,8,ML,JZ,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
HYDROXYUREA  500 MG ORAL CAP,50863,CDM,636,RC,J9999,HCPCS,68084-284-11,NDC,facility,both,2,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 2.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0003-0893-21,NDC,facility,both,1,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,27808-158-01,NDC,facility,both,1,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6374-61,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 1 % INJ SOLN,50863,CDM,636,RC,Q9968,HCPCS,17478-504-01,NDC,facility,both,10,ML,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORDIAZEPOXIDE 25 MG CAP,50863,CDM,J3490,HCPCS,60687-807-11,NDC,,,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,0955-1004-01,NDC,facility,both,4,ML,JZ,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0630,HCPCS,42023-205-01,NDC,facility,both,2,ML,,10025,7017.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-411-10,NDC,facility,both,6,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 100 MG/ML INJ SOLN,50863,CDM,250,RC,J2800,HCPCS,0517-1825-01,NDC,facility,both,1,ML,,121,84.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 10 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,636,RC,J2270,HCPCS,0641-6070-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,50863,CDM,250,RC,J1885,HCPCS,72266-119-01,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG IV SOLR,50863,CDM,J0456,HCPCS,70095-025-01,NDC,,,facility,both,1,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 250 MCG SUBQ SOLR,50863,CDM,J2802,HCPCS,55513-221-01,NDC,,,facility,both,55,EA,,420,294,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG ORAL TBDL,50863,CDM,636,RC,J3490,HCPCS,55111-263-79,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROIC ACID 250 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,63739-086-10,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4 % TOP CREA,50863,CDM,636,RC,J3490,HCPCS,0496-0882-05,NDC,facility,both,2,GM,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,70,ML,,1005,703.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-01,NDC,facility,both,3,ML,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7367-06,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.3 MG/0.3 ML IM PNIJ,50863,CDM,636,RC,J0171,HCPCS,49502-500-01,NDC,facility,both,3,EA,JZ,1078,754.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,43,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0131-2477-60,NDC,facility,both,4,EA,,271,189.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LURASIDONE  80 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7358-61,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-8297-25,NDC,facility,both,1,EA,PLAD,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,636,RC,J3010,HCPCS,63323-806-13,NDC,facility,both,3,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,10,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
AMIODARONE 50 MG/ML IV SOLN,50863,CDM,636,RC,J0282,HCPCS,63323-616-02,NDC,facility,both,15,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LET TOPICAL GEL 3 ML,50863,CDM,636,RC,J3490,HCPCS,05446-0607-01,NDC,facility,both,1,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-11,NDC,facility,both,4,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,55150-222-20,NDC,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  75 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7000-61,NDC,facility,both,3,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,636,RC,J0690,HCPCS,0143-9924-90,NDC,facility,both,2,EA,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MEDROXYPROGESTERONE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,59762-0058-1,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 100 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,0406-8390-62,NDC,facility,both,1,EA,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,250,RC,Q9968,HCPCS,70710-1838-1,NDC,facility,both,59,ML,,980,686,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHENAMINE HIPPURATE 1 GRAM ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-549-11,NDC,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE (POLACRILEX) 4 MG BUCL GUM,50863,CDM,250,RC,J3490,HCPCS,70677-1171-1,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J2003,HCPCS,0409-4279-16,NDC,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  5 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,60505-3275-0,NDC,facility,both,3,EA,,210,147,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM NEO IV SYRINGE (PHS FROM PREMIX),50863,CDM,250,RC,J1953,HCPCS,44567-501-01,NDC,facility,both,40,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0245-0144-89,NDC,facility,both,4,EA,,146,102.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN SODIUM EXTENDED 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,65862-692-01,NDC,facility,both,3,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6642-61,NDC,facility,both,2,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0003-0894-70,NDC,facility,both,1,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,68094-231-59,NDC,facility,both,6,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE MONONITRATE  30 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,0904-6449-61,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,63323-104-25,NDC,facility,both,18,ML,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETIRIZINE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-597-01,NDC,facility,both,2,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1560-19,NDC,facility,both,300,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITRIOL 0.5 MCG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,69452-208-20,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6376-61,NDC,facility,both,3,EA,,194,135.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRIMIDONE 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-687-11,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 2 MG/10 ML (200 MCG/ML) IN D5W VIAL-CVL/IR USE (REPACK),50863,CDM,250,RC,J3490,HCPCS,0338-1049-02,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J3430,HCPCS,69097-708-96,NDC,facility,both,5,ML,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNIT/G TOP OINT (MERGE),50863,CDM,250,RC,J3490,HCPCS,51672-2075-2,NDC,facility,both,4,GM,,140,98,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 112 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-508-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMFIBROZIL 600 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-350-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-50,NDC,facility,both,15,ML,JW,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
MIRTAZAPINE  7.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,57237-007-30,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 300 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,65162-649-78,NDC,facility,both,1,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE IN 0.9 % SOD CHLORIDE 500 MG/100 ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,71506-079-56,NDC,facility,both,1,ML,,161,112.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE INFUSION 2MG/ML 100ML (FOR ANESTHESIA USE ONLY),50863,CDM,250,RC,J3490,HCPCS,0409-2051-05,NDC,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRASUGREL 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0713-0882-30,NDC,facility,both,1,EA,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-03,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,59,EA,,8142,5699.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ORAL ELECTROLYTES ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,74024001,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-48,NDC,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFUROXIME AXETIL 250 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,67877-215-60,NDC,facility,both,2,EA,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN NPH & REGULAR HUMAN 100 UNIT/ML (70-30) SUBQ SUSP,50863,CDM,250,RC,J1815,HCPCS,0169-1837-11,NDC,facility,both,7,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J1610,HCPCS,0597-0053-45,NDC,facility,both,25,EA,,18533,12973.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2305-04,NDC,facility,both,20,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOPIDOGREL 300 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,55111-671-06,NDC,facility,both,1,EA,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6953-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOMYCIN-BACITRACN ZN-POLYMYXIN 3.5 MG-400 U*,50863,CDM,636,RC,J3490,HCPCS,0904-8805-67,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,71456-001-01,NDC,facility,both,1,ML,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN D5W 25000 UNIT/250 ML (PTT MONITORING),50863,CDM,250,RC,J1644,HCPCS,0264-9587-20,NDC,facility,both,25,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,250,RC,J3101,HCPCS,50242-037-06,NDC,facility,both,23,EA,,9938,6956.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,250,RC,J0330,HCPCS,31722-981-10,NDC,facility,both,2,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EMTRICITABINE-TENOFOVIR 200 MG-300 MG TAB,50863,CDM,636,RC,J0750,HCPCS,0093-7704-56,NDC,facility,both,1,EA,,297,207.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 2 GRAM INJ SOLR,50863,CDM,636,RC,J0692,HCPCS,44567-241-10,NDC,facility,both,4,EA,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,636,RC,J3490,HCPCS,51079-169-01,NDC,facility,both,2,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G POTASSIUM  5000000 UNIT INJ SOLR,50863,CDM,250,RC,J2540,HCPCS,44567-311-10,NDC,facility,both,9,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,50742-615-01,NDC,facility,both,2,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM ACETATE 667 MG ORAL CAP,50863,CDM,250,RC,J0615,HCPCS,0904-7119-61,NDC,facility,both,87,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,636,RC,J3490,HCPCS,62037-560-01,NDC,facility,both,4,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 20 MG ORAL CPDR,50863,CDM,636,RC,J3490,HCPCS,68180-294-07,NDC,facility,both,2,EA,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5%-LACTATED RINGERS IV,50863,CDM,636,RC,J7120,HCPCS,0338-0125-04,NDC,facility,both,2,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,63323-185-07,NDC,facility,both,2,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LURASIDONE  80 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63402-308-30,NDC,facility,both,2,EA,,409,286.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,636,RC,J0132,HCPCS,70594-111-01,NDC,facility,both,55,ML,,280,196,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM IN NACL (ISO-OS) 500 MG/100 ML IV PGBK,50863,CDM,250,RC,J1953,HCPCS,67457-255-00,NDC,facility,both,40,ML,,150,105,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETIRIZINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-597-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0904-7127-61,NDC,facility,both,30,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOTRIMAZOLE 1 % TOP CREA,50863,CDM,636,RC,J3490,HCPCS,51672-2002-2,NDC,facility,both,1,GM,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML IV,50863,CDM,636,RC,J3490,HCPCS,17478-937-05,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,50863,CDM,250,RC,J0585,HCPCS,0023-1145-01,NDC,facility,both,400,EA,,6393,4475.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOMYCIN-BACITRACN ZN-POLYMYXIN 3.5 MG-400 U*,50863,CDM,250,RC,J3490,HCPCS,45802-061-70,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IR SOLN,50863,CDM,636,RC,J3490,HCPCS,0338-0047-46,NDC,facility,both,2,ML,,111,77.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ (REPACK)(MERGE) (FOR PCA),50863,CDM,250,RC,J3490,HCPCS,0409-9094-41,NDC,facility,both,1,ML,,128,89.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 1 MG ORAL CAP,50863,CDM,250,RC,J7507,HCPCS,68084-450-11,NDC,facility,both,4,EA,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 0.3 % OPHT OINT,50863,CDM,636,RC,J3490,HCPCS,0078-0841-01,NDC,facility,both,1,GM,,963,674.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACAMPROSATE 333 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,68462-435-18,NDC,facility,both,2,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,50863,CDM,250,RC,Q0177,HCPCS,60687-675-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6966-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 500 MG PE/10 ML INJ SOLN,50863,CDM,636,RC,Q2009,HCPCS,68462-622-10,NDC,facility,both,4,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,76282-212-60,NDC,facility,both,2,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2312,HCPCS,0641-6132-01,NDC,facility,both,40,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOLAZONE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50742-351-01,NDC,facility,both,1,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE  2 MG/ML INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,70069-062-01,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-179-11,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4 % TOPICAL SOLN,50863,CDM,636,RC,J3490,HCPCS,76329-6300-5,NDC,facility,both,13,ML,,1390,973,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN IN 0.9 % NS 40 UNIT/100 ML (0.4 UNIT/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,81298-8554-1,NDC,facility,both,1,ML,,562,393.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,65862-707-80,NDC,facility,both,13,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOZAPINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-404-11,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,76045-009-96,NDC,facility,both,8,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUPHENAZINE 5 MG TAB,50863,CDM,250,RC,J3490,HCPCS,60687-749-11,NDC,facility,both,3,EA,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COLCHICINE 0.6 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42292-054-01,NDC,facility,both,1,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,65862-707-80,NDC,facility,both,6,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,50863,CDM,250,RC,Q0177,HCPCS,60687-675-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,62559-440-02,NDC,facility,both,3,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % MBP,50863,CDM,250,RC,J3490,HCPCS,0338-9662-35,NDC,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,4,ML,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTAZIDIME-AVIBACTAM 2.5 GRAM (2 GRAM-0.5 GRAM) IV SOLR,50863,CDM,250,RC,J0714,HCPCS,0456-2700-10,NDC,facility,both,2,EA,,736,515.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CITRATE  5 MEQ ORAL TBER,50863,CDM,250,RC,J3490,HCPCS,42543-406-01,NDC,facility,both,3,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,250,RC,J2003,HCPCS,63323-485-27,NDC,facility,both,200,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50580-458-11,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-209-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-506-11,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,31722-711-30,NDC,facility,both,1,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 17 GRAM (100 %) ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,0904-6931-86,NDC,facility,both,4,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ (REPACK)(MERGE) (FOR PCA),50863,CDM,250,RC,J3490,HCPCS,0409-9094-41,NDC,facility,both,1,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,1657187290,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMETHICONE 40MG/0.6ML (0.6ML-UD) SYRINGE (REPACK),50863,CDM,250,RC,J3490,HCPCS,17856-0799-4,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 2 MG INJ SOLR,50863,CDM,250,RC,J2997,HCPCS,50242-041-64,NDC,facility,both,4,EA,JZ,1524,1066.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CEFEPIME 2 GRAM INJ SOLR,50863,CDM,250,RC,J0692,HCPCS,44567-241-10,NDC,facility,both,16,EA,,231,161.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J1610,HCPCS,0597-0053-45,NDC,facility,both,5,EA,,3707,2594.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,16714-046-01,NDC,facility,both,17,ML,,195,136.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 875 MG-125 MG TAB,50863,CDM,636,RC,J3490,HCPCS,65862-503-01,NDC,facility,both,12,EA,,252,176.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6938-06,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,250,RC,J3101,HCPCS,50242-037-06,NDC,facility,both,25,EA,JW,4697,3287.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,3,EA,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYMETAZOLINE 0.05 % NASAL MERGE,50863,CDM,636,RC,J3490,HCPCS,0904-6761-30,NDC,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 20MG/ML IV SYRINGE (PEDS/NEO),50863,CDM,250,RC,J0612,HCPCS,63323-311-10,NDC,facility,both,62,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,41,ML,JZ,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,32,EA,,4416,3091.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SECUKINUMAB  25 MG/ML IV SOLN,50863,CDM,636,RC,J3247,HCPCS,0078-1168-61,NDC,facility,both,250,ML,,11792,8254.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"AMIODARONE IN DEXTROSE,ISO-OSM 360 MG/200 ML (1.8 MG/ML) IV SOLN",50863,CDM,250,RC,J0282,HCPCS,43066-360-20,NDC,facility,both,12,ML,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM ACETATE 667 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7119-06,NDC,facility,both,3,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENAZOPYRIDINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69367-611-01,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,6,ML,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,3,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 10 MEQ/100 ML IV PGBK,50863,CDM,636,RC,J3480,HCPCS,14789-109-16,NDC,facility,both,5,ML,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,70004-600-09,NDC,facility,both,2,ML,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-710-11,NDC,facility,both,2,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESNA 100 MG/ML IV SOLN,50863,CDM,636,RC,J9209,HCPCS,0338-1305-01,NDC,facility,both,2,ML,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,71288-402-10,NDC,facility,both,30,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6291-61,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6927-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM  4.5 GRAM IV SOLR,50863,CDM,250,RC,J2543,HCPCS,0781-3114-91,NDC,facility,both,4,EA,JZ,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,0641-6007-01,NDC,facility,both,10,ML,,218,152.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACAMPROSATE 333 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,60687-121-95,NDC,facility,both,2,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 50 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,59651-489-01,NDC,facility,both,55,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7030,HCPCS,0338-0049-04,NDC,facility,both,4,ML,,133,93.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML ORAL SOLUTION (FOR PEDIATRIC USE),50863,CDM,250,RC,J3480,HCPCS,63323-965-05,NDC,facility,both,15,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORDIAZEPOXIDE 25 MG CAP,50863,CDM,250,RC,J3490,HCPCS,51079-141-01,NDC,facility,both,4,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,250,RC,J3490,HCPCS,53746-542-01,NDC,facility,both,3,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J0461,HCPCS,0517-0401-25,NDC,facility,both,160,ML,,213,149.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 500 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,0904-6861-61,NDC,facility,both,1,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,636,RC,P9045,HCPCS,68516-5219-0,NDC,facility,both,16,ML,,4067,2846.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN IN 0.9 % NS 40 UNIT/100 ML (0.4 UNIT/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,81298-8554-1,NDC,facility,both,2,ML,,1124,786.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-21,NDC,facility,both,20,ML,"JZ,JA",2829,1980.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
TALQUETAMAB-TGVS 40 MG/ML SUBQ SOLN,50863,CDM,250,RC,J3055,HCPCS,57894-470-01,NDC,facility,both,204,ML,,36314,25419.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNIT/G TOP PACK,50863,CDM,636,RC,J3490,HCPCS,45802-060-70,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MYCOPHENOLATE 250 MG CAP,50863,CDM,636,RC,J7517,HCPCS,60687-885-11,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,42806-150-33,NDC,facility,both,5,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0555-0873-02,NDC,facility,both,16,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,4000,ML,,213,149.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,250,RC,Q9968,HCPCS,70710-1838-1,NDC,facility,both,138,ML,,2291,1603.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 30 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,0904-7044-61,NDC,facility,both,2,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GAMMAGARD LIQUID 10 % IV SOLN,50863,CDM,636,RC,J1569,HCPCS,0944-2700-11,NDC,facility,both,20,ML,"JZ,JA",3606,2524.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,17271-701-06,NDC,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID (PORK)  30 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,62559-741-01,NDC,facility,both,4,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 50 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,59651-489-01,NDC,facility,both,60,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACIDOPHILUS-PECTIN W CITRUS 25 MILLION-100 CELL MG TAB,50863,CDM,636,RC,J3490,HCPCS,1785614241,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN NACL (PF) 1000 UNIT/500 ML IV SOLP,50863,CDM,250,RC,J1644,HCPCS,0409-1005-01,NDC,facility,both,2,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,9,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-1749-70,NDC,facility,both,2,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFUROXIME AXETIL 250 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,65862-699-20,NDC,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROMETHORPHAN-GUAIFENESIN SR 30 MG-600 MG 12 HR TAB,50863,CDM,250,RC,J3490,HCPCS,63824-056-34,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),50863,CDM,250,RC,J3490,HCPCS,63323-186-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6640-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6640-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 125 MG ORAL CPSP,50863,CDM,250,RC,J3490,HCPCS,63739-995-10,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL  97.2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,75826-142-10,NDC,facility,both,3,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,60,ML,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 12.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6302-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,13,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6924-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROPROCAINE 3 % INJ SOLN,50863,CDM,636,RC,J2401,HCPCS,63323-478-20,NDC,facility,both,60,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G POTASSIUM 20000000 UNIT INJ SOLR,50863,CDM,250,RC,J2540,HCPCS,70860-127-51,NDC,facility,both,1,EA,JW,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ROMIPLOSTIM 125 MCG SUBQ SOLR,50863,CDM,636,RC,J2802,HCPCS,55513-223-01,NDC,facility,both,70,EA,JW,625,437.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-821-01,NDC,facility,both,1,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLU VACCINE 2024-25 65YR UP ADJMF59C (PF) 45 MCG (15 MCG X 3)/0.5 ML IM SYRG,50863,CDM,90653,HCPCS,70461-024-04,NDC,,,facility,both,1,ML,,373,261.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELATACEPT 250 MG IV SOLR,50863,CDM,636,RC,J0485,HCPCS,0003-0371-13,NDC,facility,both,435,EA,,4489,3142.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAPTOPRIL  12.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7105-61,NDC,facility,both,3,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,59651-426-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-5771-23,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6322-06,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUPHENAZINE 5 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0527-1790-01,NDC,facility,both,2,EA,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOZAPINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-404-11,NDC,facility,both,6,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,69238-1490-1,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,50863,CDM,250,RC,J9206,HCPCS,0009-0082-02,NDC,facility,both,14,ML,,443,310.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,2055503601,NDC,facility,both,10,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 10 MG/ML INJ SOLN,50863,CDM,636,RC,J1171,HCPCS,0703-0018-01,NDC,facility,both,2500,ML,,224,156.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 40 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,76282-208-90,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,55150-177-05,NDC,facility,both,25,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PACLITAXEL 6 MG/ML IV CONC,50863,CDM,250,RC,J9267,HCPCS,61703-342-22,NDC,facility,both,51,ML,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7126-61,NDC,facility,both,28,EA,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 20 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-4721-05,NDC,facility,both,2,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,70069-363-01,NDC,facility,both,2,ML,,252,176.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 100 MG PE/2 ML INJ SOLN,50863,CDM,250,RC,Q2009,HCPCS,0641-6136-01,NDC,facility,both,1,ML,JW,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,62,ML,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6709-61,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 160 MG-800 MG TAB,50863,CDM,636,RC,J3490,HCPCS,68084-230-11,NDC,facility,both,28,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-8299-25,NDC,facility,both,1,EA,PLAD,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
DOXORUBICIN 50 MG/25 ML IV SOLN,50863,CDM,250,RC,J9000,HCPCS,0069-1542-20,NDC,facility,both,4,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN NORMAL SALINE IV,50863,CDM,636,RC,J7042,HCPCS,0338-0089-03,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,75834-221-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SYRG,50863,CDM,636,RC,J3490,HCPCS,8290306553,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7057-61,NDC,facility,both,5,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLU VACCINE TS 2025-26 65 YR UP (PF) 180 MCG/0.5 ML IM SYRG,50863,CDM,636,RC,90662,HCPCS,49281-125-88,NDC,facility,both,1,ML,,372,260.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAZOSIN 2 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,51079-631-01,NDC,facility,both,3,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZOCAINE 20 % MM SPRY,50863,CDM,250,RC,J3490,HCPCS,0283-0610-43,NDC,facility,both,4,EA,,201,140.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,55150-177-05,NDC,facility,both,150,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,636,RC,J3373,HCPCS,67457-340-01,NDC,facility,both,300,EA,,283,198.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 10 MEQ/100 ML IV PGBK (USE NON-PROTOCOL PANEL),50863,CDM,250,RC,J3480,HCPCS,0338-0709-48,NDC,facility,both,10,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-9543-03,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE 8 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,60687-492-11,NDC,facility,both,3,EA,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE (FOR CODE) 10% IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0517-2710-25,NDC,facility,both,4,ML,,454,317.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL IV BOLUS 10MG/ML (ANESTHESIA ONLY),50863,CDM,636,RC,J2704,HCPCS,0409-4699-54,NDC,facility,both,27,ML,JW,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
MORPHINE 1 MG/ML PCA (PDS MERGE),50863,CDM,250,RC,J3490,HCPCS,70092-1521-74,NDC,facility,both,1,ML,,154,107.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,636,RC,J2270,HCPCS,63323-454-00,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,60687-736-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE  2 MG/ML INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-285-23,NDC,facility,both,3,ML,,195,136.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,31722-713-90,NDC,facility,both,1,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROIC ACID 250 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0591-4012-01,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65862-859-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL (VITAMIN D3)  1000 UNIT ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,2055503300,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,72789-062-01,NDC,facility,both,2,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-50,NDC,facility,both,7,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
WARFARIN 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0832-1211-89,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,55150-161-02,NDC,facility,both,60,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GANCICLOVIR 500 MG IV SOLUTION,50863,CDM,250,RC,J1570,HCPCS,70436-089-55,NDC,facility,both,1,EA,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLERGONOVINE 0.2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,70010-786-12,NDC,facility,both,1,EA,,301,210.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-1749-70,NDC,facility,both,2,ML,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOBENZAPRINE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-191-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 1 MG/ML (1ML) SYRINGE (REPACK),50863,CDM,250,RC,J2997,HCPCS,50242-044-13,NDC,facility,both,2,EA,,779,545.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CERTOLIZUMAB PEGOL 400 MG/2 ML (200 MG/ML X 2) SUBQ SYKT,50863,CDM,636,RC,J0717,HCPCS,50474-710-79,NDC,facility,both,200,EA,JZ,7893,5525.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,58,ML,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-65,NDC,facility,both,15,ML,JW,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,47335-993-01,NDC,facility,both,200,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,16714-298-02,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-1752-50,NDC,facility,both,3,ML,,300,210,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 600 MG ORAL TP12,50863,CDM,250,RC,J3490,HCPCS,6382400840,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,16714-294-01,NDC,facility,both,8,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE PAMOATE  50 MG ORAL CAP,50863,CDM,250,RC,Q0177,HCPCS,50268-399-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-50,NDC,facility,both,119,ML,,210,147,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML INJ SOLN,50863,CDM,636,RC,J0171,HCPCS,76329-9060-0,NDC,facility,both,120,ML,,797,557.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-4675-05,NDC,facility,both,4,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 50 MG TAB,50863,CDM,250,RC,J3490,HCPCS,16714-797-01,NDC,facility,both,1,EA,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0409-4699-24,NDC,facility,both,100,ML,,127,88.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE HCL IN NS 10 MG/250 ML (0.04 MG/ML) IV SOLN (PDS MERGE),50863,CDM,250,RC,J2371,HCPCS,70004-811-40,NDC,facility,both,500,ML,,728,509.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),50863,CDM,250,RC,J1630,HCPCS,63323-474-00,NDC,facility,both,2,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,50863,CDM,250,RC,J9075,HCPCS,10019-956-16,NDC,facility,both,84,EA,JW,239,167.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ISONIAZID 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-083-01,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-411-10,NDC,facility,both,9,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-50,NDC,facility,both,41,ML,JW,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GEMFIBROZIL 600 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,72603-206-01,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL IV BOLUS 10MG/ML (ANESTHESIA ONLY),50863,CDM,636,RC,J2704,HCPCS,0409-4699-54,NDC,facility,both,89,ML,,113,79.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAPSAICIN 0.025 % TOP CREA,50863,CDM,250,RC,J3490,HCPCS,0536-2525-25,NDC,facility,both,1,GM,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML INJECTION,50863,CDM,636,RC,J3411,HCPCS,72603-139-01,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  75 MG ORAL CP24,50863,CDM,636,RC,J3490,HCPCS,50268-874-11,NDC,facility,both,2,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 40 MG/ML SUSP (DEPO-MEDROL) INJECTION,50863,CDM,636,RC,J1010,HCPCS,70121-1573-1,NDC,facility,both,40,ML,JZ,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,43,EA,,5934,4153.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 10 MEQ/100 ML IV PGBK,50863,CDM,636,RC,J3480,HCPCS,14789-109-16,NDC,facility,both,5,ML,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 2 MG INJ SOLR,50863,CDM,636,RC,J2997,HCPCS,50242-041-64,NDC,facility,both,2,EA,JZ,800,560,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
HYDRALAZINE  10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,23155-832-01,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE SOD SUCC (PF) 100 MG/2 ML INJ SOLR,50863,CDM,636,RC,J1720,HCPCS,0009-0011-03,NDC,facility,both,2,EA,,252,176.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"TRANEXAMIC ACID IN NACL,ISO-OS 1,000 MG/100 ML (10 MG/ML) IV PGBK",50863,CDM,250,RC,J3490,HCPCS,14789-115-08,NDC,facility,both,1,ML,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TAB,50863,CDM,250,RC,J3490,HCPCS,60687-672-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
D5-1/2 NS AND POTASSIUM CHLORIDE 20 MEQ/L IV (PEDS CHEMO),50863,CDM,636,RC,J3490,HCPCS,0338-0671-04,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 1 MG/ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-9158-01,NDC,facility,both,10,ML,,224,156.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,270,ML,,469,328.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESNA 100 MG/ML IV SOLN,50863,CDM,250,RC,J9209,HCPCS,10019-953-62,NDC,facility,both,3,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,250,RC,J2270,HCPCS,0641-6125-01,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,14789-251-09,NDC,facility,both,1,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPHENIDATE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16729-478-01,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 20MG/ML IV SYRINGE (PEDS/NEO),50863,CDM,250,RC,J0612,HCPCS,63323-311-10,NDC,facility,both,42,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 2-0.5 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,0904-7009-06,NDC,facility,both,4,EA,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"AMIODARONE IN DEXTROSE,ISO-OSM 150 MG/100 ML (PREMIX)",50863,CDM,636,RC,J0282,HCPCS,43066-150-10,NDC,facility,both,5,ML,,204,142.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOBRAMYCIN 1.2 G POWDER VIAL,50863,CDM,250,RC,J3260,HCPCS,39822-0412-6,NDC,facility,both,3,EA,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65862-013-01,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMINOCAPROIC ACID  500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,72205-049-30,NDC,facility,both,10,EA,,807,564.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3373,HCPCS,0143-9162-01,NDC,facility,both,1200,EA,,479,335.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 20 GRAM/30 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-1154-30,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORDIAZEPOXIDE 25 MG CAP,50863,CDM,250,RC,J3490,HCPCS,60687-807-11,NDC,facility,both,3,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-22,NDC,facility,both,80,ML,,160,112,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER SULFADIAZINE 1 % TOP CREA,50863,CDM,636,RC,J3490,HCPCS,67877-124-50,NDC,facility,both,1,GM,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WHITE PETROLATUM-MINERAL OIL 80 %-20 % EYE OINTMENT,50863,CDM,250,RC,J3490,HCPCS,1011902239,NDC,facility,both,1,GM,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-25,NDC,facility,both,125,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROMETHORPHAN POLY COMPLEX ER 30 MG/5 ML ORAL SU12,50863,CDM,250,RC,J3490,HCPCS,63824-173-63,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL (VITAMIN D3) 400 UNIT/ML ORAL DROP,50863,CDM,250,RC,J3490,HCPCS,7139974015,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN  500 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,60687-640-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPATITIS A VIRUS VACCINE (PF) 1440 ELISA UNIT/ML IM SYRG,50863,CDM,250,RC,90632,HCPCS,58160-826-43,NDC,facility,both,1,ML,,421,294.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTAMIDINE 300 MG INJ SOLR,50863,CDM,636,RC,J3490,HCPCS,63323-113-01,NDC,facility,both,1,EA,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML IM SOLN,50863,CDM,636,RC,90375,HCPCS,13533-318-05,NDC,facility,both,8,ML,JW,3268,2287.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
BISOPROLOL FUMARATE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-679-11,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITRIOL 0.5 MCG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,23155-663-01,NDC,facility,both,3,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 200 MG/20 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,72205-220-01,NDC,facility,both,1,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,63323-487-01,NDC,facility,both,200,ML,,130,91,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-205-01,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 0.25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-270-11,NDC,facility,both,2,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN  3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51672-4030-1,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN  2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,62584-984-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,50863,CDM,250,RC,J0696,HCPCS,0409-7335-13,NDC,facility,both,8,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,20,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  1 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,59746-171-06,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
L. ACIDOPHILUS-B. LACTIS-FOS 5 BILLION CELL ORAL PWPK,50863,CDM,636,RC,J3490,HCPCS,52061-00403,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,75,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEMANTINE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,42292-006-01,NDC,facility,both,1,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,5,ML,,141,98.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPYLTHIOURACIL 50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,67253-651-10,NDC,facility,both,4,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TORSEMIDE   5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,31722-529-01,NDC,facility,both,4,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OMALIZUMAB 75 MG/0.5 ML SUBQ SYRG,50863,CDM,636,RC,J2357,HCPCS,50242-214-01,NDC,facility,both,15,ML,JZ,1558,1090.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,636,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIPASE-PROTEASE-AMYLASE (PORK) 36,000-114,000- 180,000 UNIT ORAL CPDR",50863,CDM,250,RC,J3490,HCPCS,0032-3016-13,NDC,facility,both,2,EA,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE 220 MCG/ACTUATION INHL AERO,50863,CDM,250,RC,J3490,HCPCS,66993-080-96,NDC,facility,both,1,GM,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,2,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTAMIDINE 300 MG INJ SOLR,50863,CDM,636,RC,J3490,HCPCS,63323-113-01,NDC,facility,both,1,EA,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE (PF) 1 MG/ML INJ SOLN,50863,CDM,250,RC,J0171,HCPCS,54288-103-01,NDC,facility,both,20,ML,,172,120.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 5 MG/5 ML IV,50863,CDM,636,RC,J3490,HCPCS,0143-9660-01,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,636,RC,J3370,HCPCS,16714-309-01,NDC,facility,both,4,EA,,189,132.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-663-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZINC OXIDE 20 % TOP OINT (REPACK),50863,CDM,636,RC,J3490,HCPCS,0536-1316-28,NDC,facility,both,1,GM,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IMIPRAMINE 10 MG TAB,50863,CDM,250,RC,J3490,HCPCS,69315-133-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,250,RC,J0131,HCPCS,55150-307-01,NDC,facility,both,53,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES  8.6 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,71399-1017-3,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,67457-433-00,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ORPHENADRINE CITRATE 30 MG/ML INJ SOLN,50863,CDM,250,RC,J2360,HCPCS,25021-651-02,NDC,facility,both,1,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOPIDOGREL  75 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6294-61,NDC,facility,both,3,EA,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,636,RC,P9045,HCPCS,68516-5214-1,NDC,facility,both,1,ML,JZ,263,184.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
POTASSIUM IODIDE 1 GRAM/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,71740-112-30,NDC,facility,both,1,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7350-06,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BICTEGRAV-EMTRICIT-TENOFOV ALA 50-200-25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,61958-2501-1,NDC,facility,both,1,EA,,608,425.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GAMMAGARD S-D (IGA < 1 MCG/ML) 10 GRAM IV SOLR,50863,CDM,636,RC,J1566,HCPCS,0944-2659-08,NDC,facility,both,40,EA,JZ,9313,6519.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,63323-104-25,NDC,facility,both,17,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 100 MG PE/2 ML INJ SOLN,50863,CDM,250,RC,Q2009,HCPCS,0069-6001-02,NDC,facility,both,2,ML,,238,166.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J3430,HCPCS,68462-758-01,NDC,facility,both,3,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J2003,HCPCS,0409-4279-16,NDC,facility,both,200,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 150 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,0904-7084-04,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG IV SOLR,50863,CDM,636,RC,J3490,HCPCS,63323-130-02,NDC,facility,both,2,EA,,310,217,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHOTERICIN B LIPOSOME 50 MG IV SUSR,50863,CDM,250,RC,J0289,HCPCS,55150-365-01,NDC,facility,both,50,EA,,9019,6313.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 7.5 MG-325 MG/15 ML ORAL SOLN (REPACK),50863,CDM,636,RC,J3490,HCPCS,0121-2316-15,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AGALSIDASE BETA 35 MG IV SOLR,50863,CDM,636,RC,J0180,HCPCS,58468-0040-1,NDC,facility,both,85,ME,JZ,39507,27654.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
AZTREONAM 2 GRAM INJ SOLR,50863,CDM,636,RC,J0457,HCPCS,0409-0830-11,NDC,facility,both,20,EA,,341,238.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,100,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 500 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,50268-152-11,NDC,facility,both,4,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOBAZAM 2.5 MG/ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,99999-0404-03,NDC,facility,both,2,ML,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN NORMAL SALINE IV,50863,CDM,636,RC,J7042,HCPCS,0338-0089-04,NDC,facility,both,2,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR IRRIGATION, STERILE SOLUTION",50863,CDM,636,RC,J3490,HCPCS,0338-0004-02,NDC,facility,both,12,ML,,383,268.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM IN NACL (ISO-OS) 500 MG/100 ML IV PGBK,50863,CDM,250,RC,J1953,HCPCS,70860-602-41,NDC,facility,both,205,ML,,818,572.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-0552-23,NDC,facility,both,2,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0630,HCPCS,42023-205-01,NDC,facility,both,1,ML,,7735,5414.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IR SOLN,50863,CDM,636,RC,J3490,HCPCS,0338-0047-46,NDC,facility,both,9,ML,,499,349.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,3,EA,,224,156.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0780,HCPCS,25021-790-02,NDC,facility,both,1,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 50 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,10135-779-01,NDC,facility,both,50,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,0517-4620-25,NDC,facility,both,2,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,18,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,67457-423-00,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL  75 MCG/HR TD PT72,50863,CDM,250,RC,J3490,HCPCS,0378-9123-16,NDC,facility,both,1,EA,,197,137.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-406-03,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68180-445-01,NDC,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIROFIBAN-0.9% SODIUM CHLORIDE 5 MG/100 ML (50 MCG/ML) IV SOLN,50863,CDM,636,RC,J3246,HCPCS,25208-002-03,NDC,facility,both,2,ML,JW,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ACETYLCYSTEINE 20 % (200 MG/ML) MISC SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-694-04,NDC,facility,both,1,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,0409-9094-12,NDC,facility,both,5,ML,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MENTHOL-ZINC OXIDE 0.44-20.625 % TOP OINT,50863,CDM,636,RC,J3490,HCPCS,4687600030,NDC,facility,both,1,GM,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE (PF-DURAMORPH/ASTRAMORPH) 0.5 MG/ML INJ SOLN,50863,CDM,636,RC,J2274,HCPCS,0409-3814-11,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE DINITRATE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0143-1772-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE MONONITRATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,7733393425,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THEOPHYLLINE 100 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,52244-100-10,NDC,facility,both,3,EA,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,50863,CDM,636,RC,Q0177,HCPCS,23155-501-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN PEDS IVPB (CDS MIXTURE),50863,CDM,250,RC,J3370,HCPCS,0069-2599-99,NDC,facility,both,1,EA,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZINC OXIDE 20 % TOP OINT (REPACK),50863,CDM,250,RC,J3490,HCPCS,0536-1316-28,NDC,facility,both,1,GM,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,50863,CDM,250,RC,Q0177,HCPCS,23155-501-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,63323-325-14,NDC,facility,both,100,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,8,EA,JZ,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,2,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  75 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7000-61,NDC,facility,both,3,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7048-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7350-61,NDC,facility,both,4,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 20 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,0904-7043-04,NDC,facility,both,4,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0074-4552-11,NDC,facility,both,5,EA,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-5755-23,NDC,facility,both,5,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPTOMYCIN 500 MG IV SOLR,50863,CDM,636,RC,J0878,HCPCS,72603-152-01,NDC,facility,both,350,EA,JZ,1024,716.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ANTI-INHIBITOR COAGULANT CMPLX (PHS MERGE),50863,CDM,250,RC,J7198,HCPCS,64193-325-01,NDC,facility,both,4959,UN,,30796,21557.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,63323-806-13,NDC,facility,both,8,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MUPIROCIN 2 % TOP OINT,50863,CDM,636,RC,J3490,HCPCS,68462-180-22,NDC,facility,both,1,GM,JW,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
TIZANIDINE 4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6418-61,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NOREPINEPHRINE BITARTRATE-D5W 4 MG/250 ML (16 MCG/ML) IV SOLN,50863,CDM,J3490,HCPCS,0338-0112-20,NDC,,,facility,both,2,ML,,267,186.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 17 GRAM (100 %) ORAL PWPK,50863,CDM,J3490,HCPCS,0904-6931-86,NDC,,,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,63323-482-03,NDC,,,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,636,RC,J3490,HCPCS,0338-1055-48,NDC,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 20 GRAM/30 ML ORAL SOLN,50863,CDM,J3490,HCPCS,0121-1154-30,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-145-11,NDC,facility,both,126,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COVID VACCINE 24-25 (6M-4Y)(PFI)-PF 3 MCG/0.3 ML IM SUSP,50863,CDM,91318,HCPCS,59267-4426-1,NDC,,,facility,both,1,ML,,249,174.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES  8.6 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7252-60,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,636,RC,J2560,HCPCS,42494-416-01,NDC,facility,both,3,ML,,577,403.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % MUCOSAL SOLN (VISCOUS),50863,CDM,636,RC,J3490,HCPCS,0603-1393-64,NDC,facility,both,10,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,70,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML (1ML) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,54288-119-01,NDC,facility,both,9,ML,,712,498.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,200,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2308-21,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,636,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,6,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 5 MG-325 MG TAB,50863,CDM,636,RC,J3490,HCPCS,63739-532-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 400 MCG/100 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0143-9525-01,NDC,facility,both,1,ML,,188,131.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE (FOR EMERGENCY) 100 MG/ML (10%) IV SOLN,50863,CDM,636,RC,J0612,HCPCS,0143-9180-01,NDC,facility,both,100,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  20 MEQ ORAL PACK,50863,CDM,250,RC,J3490,HCPCS,72888-024-06,NDC,facility,both,3,EA,,158,110.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,636,RC,J3490,HCPCS,73013-2002-2,NDC,facility,both,2,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,7,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-131-11,NDC,facility,both,2,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE MONONITRATE  30 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,0904-6449-61,NDC,facility,both,2,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  500 MG IV SOLR,50863,CDM,636,RC,J3370,HCPCS,0143-9161-01,NDC,facility,both,1,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL (VITAMIN D3)  1000 UNIT ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,8068116900,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 0.5 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,63323-481-01,NDC,facility,both,150,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC IV INFUSION HYDRAT 31-60 MIN,50863,CDM,250,RC,J0248,HCPCS,61958-2901-2,NDC,facility,both,51,EA,,604,422.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 17 GRAM (100 %) ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,0904-6931-86,NDC,facility,both,1,EA,PLAD,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
NITROGLYCERIN 0.4 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,59762-3304-3,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT  40 MCG/0.4 ML INJ SYRG,50863,CDM,636,RC,J0881,HCPCS,55513-021-01,NDC,facility,both,40,ML,"JZ,EC",1096,767.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier EC: Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy
ONDANSETRON 4 MG ORAL TBDL,50863,CDM,J3490,HCPCS,57237-077-10,NDC,,,facility,both,2,EA,,218,152.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-208-01,NDC,,,facility,both,800,ML,,184,128.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-467-01,NDC,facility,both,1,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  20 MEQ ORAL PACK,50863,CDM,250,RC,J3490,HCPCS,72888-024-06,NDC,facility,both,12,EA,,441,308.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 15% IN WATER,50863,CDM,250,RC,J3490,HCPCS,0338-0023-03,NDC,facility,both,2,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  40 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,83980-007-01,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,70095-026-01,NDC,facility,both,26,ML,,1697,1187.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,42806-150-33,NDC,facility,both,11,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,J1644,HCPCS,71288-402-01,NDC,,,facility,both,4,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,250,RC,J2405,HCPCS,23155-547-31,NDC,facility,both,1,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
"ROTAVIRUS VACCINE, LIVE, 89-12 10EXP6 CCID50 /1.5 ML ORAL SUSP",50863,CDM,90681,HCPCS,58160-740-02,NDC,,,facility,both,1,ML,,424,296.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,50863,CDM,J1885,HCPCS,63323-162-03,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,9,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYTOCIN IN 0.9 % SOD CHLORIDE 30 UNIT/500 ML IV SOLN,50863,CDM,J2590,HCPCS,70004-085-44,NDC,,,facility,both,1,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-327-10,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOLAZONE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,72888-053-01,NDC,facility,both,2,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-344-11,NDC,facility,both,4,EA,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,0143-9577-01,NDC,,,facility,both,140,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG ORAL TAB,50863,CDM,FAMNOCHARGE,HCPCS,68084-155-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 75 MG/5 ML ORAL SOLUTION,50863,CDM,250,RC,J3490,HCPCS,0574-0129-01,NDC,facility,both,14,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PNEUMOCOCCAL 23-VAL PS VACCINE 25 MCG/0.5 ML INJ SYRG,50863,CDM,90732,HCPCS,0006-4837-01,NDC,,,facility,both,1,ML,,506,354.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,25021-315-01,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,0143-9595-01,NDC,,,facility,both,100,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIKACIN 1000 MG/4 ML INJ SOLN,50863,CDM,J0278,HCPCS,23155-290-32,NDC,,,facility,both,12,ML,,101,70.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,72603-161-01,NDC,facility,both,2,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELIMUMAB 120 MG IV SOLR,50863,CDM,636,RC,J0490,HCPCS,49401-101-01,NDC,facility,both,36,ME,JZ,4228,2959.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LIOTHYRONINE  5 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,59762-1206-1,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,100,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,42806-150-33,NDC,facility,both,2,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,250,RC,J3490,HCPCS,0143-9679-01,NDC,facility,both,1,ML,,134,93.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESALAMINE 1000 MG RECT SUPP,50863,CDM,250,RC,J3490,HCPCS,58914-501-01,NDC,facility,both,1,EA,,228,159.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,6000,ML,,661,462.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MOMETASONE 220 MCG (14 DOSES) INHL AEPB,50863,CDM,636,RC,J3490,HCPCS,78206-114-03,NDC,facility,both,1,EA,,228,159.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,636,RC,J3490,HCPCS,63323-185-07,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIFEDIPINE 30 MG ORAL TO24,50863,CDM,250,RC,J3490,HCPCS,50268-597-11,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL PACK,50863,CDM,250,RC,J3490,HCPCS,67877-422-57,NDC,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0143-9889-15,NDC,facility,both,20,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 20 MG/ML INJ SOLN,50863,CDM,636,RC,J0360,HCPCS,55150-400-01,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,636,RC,J1611,HCPCS,63323-596-11,NDC,facility,both,3,EA,JZ,2684,1878.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
RASBURICASE 7.5 MG IV SOLR,50863,CDM,250,RC,J2783,HCPCS,0024-5151-75,NDC,facility,both,30,EA,,29363,20554.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL (VITAMIN D3) 400 UNIT/ML ORAL DROP,50863,CDM,636,RC,J3490,HCPCS,7651805050,NDC,facility,both,2,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL  3.125 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7305-61,NDC,facility,both,1,EA,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOMYCIN-POLYMYXIN-GRAMICIDIN 1.75-10K-0.025 MG-UNIT-MG/ML OPHT DROP,50863,CDM,250,RC,J3490,HCPCS,24208-790-62,NDC,facility,both,1,ML,,260,182,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 6 MG/0.5 ML SUBQ PEN KIT,50863,CDM,636,RC,J3030,HCPCS,72603-141-02,NDC,facility,both,1,ML,,406,284.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-174-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TELMISARTAN 40 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68382-472-30,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,140,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,50863,CDM,250,RC,J9060,HCPCS,0143-9504-01,NDC,facility,both,7,ML,,126,88.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,250,RC,Q9968,HCPCS,70710-1838-1,NDC,facility,both,40,ML,JW,226,158.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
APIXABAN 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0003-0894-31,NDC,facility,both,2,EA,,119,83.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUANFACINE 1 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,62332-745-31,NDC,facility,both,3,EA,,154,107.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEMAZEPAM 15 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0228-2076-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACUBITRIL-VALSARTAN 97-103 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0078-0696-20,NDC,facility,both,1,EA,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLU VACCINE TS 2024-25 6MOS UP (PF) 45 MCG (15 MCG X 3)/0.5 ML IM SYRG,50863,CDM,636,RC,90656,HCPCS,49281-424-88,NDC,facility,both,1,ML,,121,84.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 10 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,65862-192-01,NDC,facility,both,8,EA,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TETRACAINE HCL (PF) 0.5 % OPHT DROP (STANDARD STOCK),50863,CDM,250,RC,J3490,HCPCS,0065-0741-14,NDC,facility,both,1,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0093-3426-05,NDC,facility,both,4,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML INJ SOLN,50863,CDM,636,RC,J2060,HCPCS,0409-6778-02,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZIPRASIDONE 20 MG IM,50863,CDM,636,RC,J3486,HCPCS,72205-205-01,NDC,facility,both,1,EA,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERYTHROMYCIN 5 MG/G OPHT OINT,50863,CDM,250,RC,J3490,HCPCS,24208-910-19,NDC,facility,both,1,GM,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,636,RC,J0330,HCPCS,31722-981-10,NDC,facility,both,7,ML,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,50863,CDM,J1885,HCPCS,72266-234-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LITHIUM CARBONATE 150 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0054-8526-25,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0406-3243-01,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOTRIMAZOLE 1 % VAGL CREA,50863,CDM,250,RC,J3490,HCPCS,61269-220-63,NDC,facility,both,1,GM,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 125 MG ORAL CPSP,50863,CDM,250,RC,J3490,HCPCS,55111-532-01,NDC,facility,both,4,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-1712-01,NDC,facility,both,3,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LANTHANUM  500 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,76282-476-45,NDC,facility,both,2,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1162-18,NDC,facility,both,300,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPRAZOLAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-388-11,NDC,facility,both,3,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAVASTATIN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-169-11,NDC,facility,both,2,EA,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-089-50,NDC,facility,both,3,ML,,438,306.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE-SALMETEROL 250 MCG-50 MCG/DOSE DISK DEVICE FOR INHALATION,50863,CDM,250,RC,J3490,HCPCS,0054-0327-56,NDC,facility,both,1,EA,,1325,927.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-087-02,NDC,facility,both,8,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,J3490,HCPCS,10135-123-70,NDC,,,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,J3490,HCPCS,68094-231-59,NDC,,,facility,both,4,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,636,RC,J2270,HCPCS,0641-6125-01,NDC,facility,both,1,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,9,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"CALCIUM GLUC IN NACL, ISO-OSM 1 G/100 ML IV SOLN",50863,CDM,250,RC,J0613,HCPCS,44567-622-01,NDC,facility,both,300,ML,JZ,223,156.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CALCIUM GLUCONATE (FOR EMERGENCY) 100 MG/ML (10%) IV SOLN,50863,CDM,250,RC,J0612,HCPCS,63323-360-19,NDC,facility,both,200,ML,JZ,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
KETAMINE 100 MG/ML INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-2051-15,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1815,HCPCS,0169-1833-11,NDC,facility,both,14,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 250 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,50268-259-11,NDC,facility,both,6,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VERAPAMIL 2.5 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-1144-02,NDC,facility,both,1,ML,,190,133,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 100 MG/ML INJ SOLN,50863,CDM,636,RC,J2800,HCPCS,0517-1825-01,NDC,facility,both,1,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,50863,CDM,250,RC,J9045,HCPCS,0703-4239-01,NDC,facility,both,11,ML,,307,214.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE ACETATE 25 MG RECT SUPP,50863,CDM,636,RC,J3490,HCPCS,75834-147-12,NDC,facility,both,1,EA,,111,77.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,44567-600-04,NDC,facility,both,2,ML,,452,316.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,50863,CDM,250,RC,J2359,HCPCS,55150-308-01,NDC,facility,both,10,EA,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,65219-572-01,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,63323-325-03,NDC,facility,both,86,ML,JW,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
"LIPASE-PROTEASE-AMYLASE 24,000-76,000- 120,000 UNIT ORAL CAP, DELAY REL",50863,CDM,250,RC,J3490,HCPCS,0032-2636-01,NDC,facility,both,4,EA,,200,140,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,25021-468-10,NDC,facility,both,1,EA,,377,263.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0054-0017-20,NDC,facility,both,30,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",50863,CDM,J1561,HCPCS,13533-800-24,NDC,,,facility,both,40,ML,,5658,3960.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,J3490,HCPCS,7733351625,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,17271-701-02,NDC,facility,both,1,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,J3490,HCPCS,71399-1025-3,NDC,,,facility,both,3,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3373,HCPCS,0143-9162-01,NDC,facility,both,200,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN D5W 25000 UNIT/250 ML (ANTI-XA MONITORING),50863,CDM,250,RC,J1644,HCPCS,63323-523-01,NDC,facility,both,25,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM  1.5 GRAM INJ SOLR,50863,CDM,250,RC,J0295,HCPCS,67457-348-15,NDC,facility,both,1,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,50863,CDM,250,RC,J0561,HCPCS,60793-700-01,NDC,facility,both,24,ML,,3018,2112.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51672-4027-1,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-1752-50,NDC,facility,both,2,ML,,200,140,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV (BOLUS),50863,CDM,636,RC,J7120,HCPCS,0264-7750-00,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,70069-363-01,NDC,facility,both,1,ML,,121,84.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CITRATE  5 MEQ ORAL TBER,50863,CDM,636,RC,J3490,HCPCS,42543-406-01,NDC,facility,both,3,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,72603-179-01,NDC,facility,both,6,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRIMIDONE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,53746-544-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6924-61,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-3178-16,NDC,facility,both,280,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-1749-70,NDC,facility,both,2,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,0641-6236-01,NDC,facility,both,3,ML,,174,121.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT  25 MCG/ML INJ SOLN,50863,CDM,250,RC,J0881,HCPCS,55513-002-01,NDC,facility,both,50,ML,,1672,1170.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0641-0400-37,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADVATE: FACTOR VIII CONCENTRATE (MERGE RECORD),50863,CDM,636,RC,J7209,HCPCS,0944-3047-10,NDC,facility,both,4000,UN,,16744,11720.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,70095-026-01,NDC,facility,both,22,ML,,1454,1017.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-04,NDC,facility,both,22,ML,,366,256.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-591-11,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-328-10,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50111-398-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7130-61,NDC,facility,both,6,EA,,184,128.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,55150-370-01,NDC,facility,both,5,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,51754-5011-1,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAMSULOSIN 0.4 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,0904-6401-61,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-349-11,NDC,facility,both,1,EA,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 10 MG/5 ML SYRUP,50863,CDM,250,RC,Q0177,HCPCS,62135-750-47,NDC,facility,both,1,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEPLIZUMAB-MZWV 2 MG/20 ML IV SOLN,50863,CDM,636,RC,J9381,HCPCS,73650-316-01,NDC,facility,both,292,ME,,17652,12356.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZOCAINE-MENTHOL 6-10 MG MM LOZG,50863,CDM,250,RC,J3490,HCPCS,7811201266,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOMYCIN 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,39822-0310-5,NDC,facility,both,2,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE  7.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-584-11,NDC,facility,both,3,EA,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J2004,HCPCS,0409-3178-01,NDC,facility,both,120,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,55111-150-01,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM BROMIDE 0.02 % INHL SOLN,50863,CDM,636,RC,J3490,HCPCS,76204-100-01,NDC,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE-SODIUM BENZOATE 250 MG/ML INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0517-2502-01,NDC,facility,both,1,ML,,200,140,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 50 MG TAB,50863,CDM,250,RC,J3490,HCPCS,62584-266-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN IN D5W 400 MG/200 ML IV PGBK,50863,CDM,250,RC,J0744,HCPCS,0409-3300-01,NDC,facility,both,2,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ (MERGE),50863,CDM,636,RC,J2250,HCPCS,0409-2305-17,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,49502-393-80,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 100 MG IV SOLR,50863,CDM,250,RC,J2997,HCPCS,50242-085-25,NDC,facility,both,3,EA,,729,510.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE CONCENTRATE 10 MG/ 0.5 ML ORAL SYRINGE (0.5ML UD MERGE),50863,CDM,250,RC,J3490,HCPCS,68094-045-01,NDC,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROPROCAINE 3 % INJ SOLN,50863,CDM,636,RC,J2401,HCPCS,63323-478-20,NDC,facility,both,540,ML,JW,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
MISOPROSTOL 200 MCG ORAL TAB,50863,CDM,636,RC,S0191,HCPCS,60687-746-11,NDC,facility,both,4,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,3,EA,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,250,RC,J2405,HCPCS,60505-6130-0,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-437-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,55150-169-10,NDC,facility,both,100,ML,JZ,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MAGNESIUM SULFATE IN D5W 1 GRAM/100 ML IV PGBK,50863,CDM,636,RC,J3475,HCPCS,0338-1709-40,NDC,facility,both,8,ML,,171,119.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,7,EA,JW,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
MAGIC MOUTHWASH REPACK (BMX 1:1:1),50863,CDM,250,RC,J3490,HCPCS,0603-0823-54,NDC,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-ABDA 100 MG IV SOLR,50863,CDM,636,RC,Q5104,HCPCS,78206-162-99,NDC,facility,both,50,EA,JZ,10397,7277.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SUMATRIPTAN 50 MG TAB,50863,CDM,250,RC,J3490,HCPCS,16714-797-01,NDC,facility,both,2,EA,,214,149.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOFLOXACIN 250 MG/10 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0527-1948-68,NDC,facility,both,1,ML,,273,191.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IRRIGATION SOLN,50863,CDM,636,RC,J7120,HCPCS,0264-7389-60,NDC,facility,both,6,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0548-5603-00,NDC,facility,both,11,ML,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7001-61,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,50863,CDM,250,RC,J9025,HCPCS,72485-201-01,NDC,facility,both,100,EA,,1418,992.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,78206-121-01,NDC,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,4,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,72603-251-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FERROUS SULFATE 75 MG/ML (ELEMENTAL IRON 15 MG/ML) 0.1 ML ORAL SYRINGE (REPACK),50863,CDM,250,RC,J3490,HCPCS,3932805750,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,72162-1330-6,NDC,facility,both,1,ML,,276,193.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN STERILE WATER 2 GRAM/20 ML IV SYRG,50863,CDM,636,RC,J0690,HCPCS,70092-1604-47,NDC,facility,both,12,ML,,157,109.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J2003,HCPCS,0409-4713-32,NDC,facility,both,60,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 20 GRAM/30 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,0121-1154-30,NDC,facility,both,2,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,0143-9682-25,NDC,facility,both,6,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLNALTREXONE 12 MG/0.6 ML SUBQ SYRG,50863,CDM,250,RC,J2212,HCPCS,65649-552-04,NDC,facility,both,80,ML,,735,514.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-492-09,NDC,facility,both,100,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,0075-0622-01,NDC,facility,both,3,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,85,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASCORBIC ACID  250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,5026886011,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERTAPENEM 1 GRAM INJ SOLR,50863,CDM,250,RC,J1335,HCPCS,16714-889-01,NDC,facility,both,2,EA,,525,367.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE CONCENTRATE 10 MG/ 0.5 ML ORAL SYRINGE (0.5ML UD MERGE),50863,CDM,250,RC,J3490,HCPCS,0406-8003-30,NDC,facility,both,2,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MONTELUKAST 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6808-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,16729-114-31,NDC,facility,both,6,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7008-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,524,ME,JZ,7111,4977.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ACYCLOVIR NEO/PEDS INFUSION (CDS FROM PREMIX),50863,CDM,250,RC,J0133,HCPCS,63323-325-10,NDC,facility,both,65,ML,,141,98.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 250 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,62756-797-88,NDC,facility,both,2,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SECUKINUMAB  25 MG/ML IV SOLN,50863,CDM,636,RC,J3247,HCPCS,0078-1168-61,NDC,facility,both,60,ML,JW,1231,861.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68180-966-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7001-61,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,17,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
OLANZAPINE  7.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,43598-165-30,NDC,facility,both,1,EA,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-328-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 1250 MG/5 ML SUSPENSION (500 MG/5 ML ELEMENTAL),50863,CDM,250,RC,J3490,HCPCS,0121-4766-05,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-742-11,NDC,facility,both,4,EA,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETIRIZINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7510-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,50863,CDM,250,RC,J3301,HCPCS,70121-1049-2,NDC,facility,both,8,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,J1940,HCPCS,23155-473-32,NDC,,,facility,both,4,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 300 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6642-61,NDC,facility,both,2,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML IM SOLN,50863,CDM,90375,HCPCS,13533-318-05,NDC,,,facility,both,7,ML,,6262,4383.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IV PGBK,50863,CDM,636,RC,J3475,HCPCS,0264-4206-54,NDC,facility,both,8,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,0378-7732-93,NDC,facility,both,1,EA,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,12,ML,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 20 MG/ML INJ SOLN,50863,CDM,636,RC,J0360,HCPCS,0641-6231-01,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE  5 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,64850-510-01,NDC,facility,both,2,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 50 MG TAB,50863,CDM,250,RC,J3490,HCPCS,42043-221-09,NDC,facility,both,1,EA,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN IN D5W 300 MG/50 ML IV PGBK,50863,CDM,636,RC,J0736,HCPCS,0338-3410-50,NDC,facility,both,1,ML,JZ,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CLOZAPINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-921-01,NDC,facility,both,5,EA,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,3,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 10 GRAM IV SOLR,50863,CDM,250,RC,J3370,HCPCS,0143-9164-01,NDC,facility,both,2,EA,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,59651-488-01,NDC,facility,both,80,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOVASTATIN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68180-468-01,NDC,facility,both,4,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,5,ML,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,6,EA,,223,156.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELIMUMAB 120 MG IV SOLR,50863,CDM,636,RC,J0490,HCPCS,49401-101-01,NDC,facility,both,36,ME,"JZ,JA",4228,2959.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
DEXTROSE 50% IN WATER (MERGE RECORD),50863,CDM,250,RC,J7060,HCPCS,0409-4902-64,NDC,facility,both,1,ML,,108,75.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,250,RC,J7060,HCPCS,0338-0017-31,NDC,facility,both,2,ML,,300,210,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,67877-246-01,NDC,facility,both,1,EA,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0143-9509-01,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-38,NDC,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68462-255-01,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,50863,CDM,J9263,HCPCS,71288-172-21,NDC,,,facility,both,200,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYTOCIN IN 0.9 % SOD CHLORIDE 30 UNIT/500 ML IV SOLN,50863,CDM,250,RC,J2590,HCPCS,71285-6044-1,NDC,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE  5 MG/ML INJ SOLN,50863,CDM,250,RC,J2765,HCPCS,0703-4502-01,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0143-9386-01,NDC,facility,both,41,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,J7040,HCPCS,0338-0049-38,NDC,,,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0137,HCPCS,0143-9386-01,NDC,facility,both,44,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,50863,CDM,636,RC,J3301,HCPCS,0703-0241-01,NDC,facility,both,8,ML,,108,75.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MINOXIDIL  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-204-11,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 30 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-120-11,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,50863,CDM,636,RC,J3420,HCPCS,69680-112-01,NDC,facility,both,1,ML,JZ,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
AZACITIDINE 100 MG INJ SOLR,50863,CDM,250,RC,J9025,HCPCS,72485-201-01,NDC,facility,both,64,EA,JW,397,277.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ACETAZOLAMIDE 125 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,23155-287-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR  6 MG/ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,68180-678-01,NDC,facility,both,5,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,72888-060-30,NDC,facility,both,2,EA,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25 MG-100 MG TAB,50863,CDM,636,RC,J3490,HCPCS,59651-457-01,NDC,facility,both,3,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN D5W 20000 UNIT/500 ML,50863,CDM,636,RC,J1644,HCPCS,0264-9567-10,NDC,facility,both,11,ML,JW,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3373,HCPCS,0409-6533-11,NDC,facility,both,100,EA,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 5 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,36000-033-10,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,47335-993-01,NDC,facility,both,300,ML,,107,74.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2308-22,NDC,facility,both,9,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LEVOTHYROXINE 125 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-443-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INDOMETHACIN 50 MG RECT SUPP,50863,CDM,250,RC,J3490,HCPCS,69344-102-33,NDC,facility,both,4,EA,,3996,2797.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 5 MG/ML INHL NEB CONTINUOUS,50863,CDM,250,RC,J3490,HCPCS,73177-146-33,NDC,facility,both,1,ML,,245,171.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,132,ML,,119,83.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,250,RC,J3490,HCPCS,73013-2002-2,NDC,facility,both,2,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,68516-5214-3,NDC,facility,both,2,ML,,447,312.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-975-11,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 4 MG (ENVARSUS XR) 24-HOUR EXTENDED-RELEASE TABLET,50863,CDM,250,RC,J7508,HCPCS,68992-3040-3,NDC,facility,both,1,EA,,113,79.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-9149-01,NDC,facility,both,3,EA,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-087-02,NDC,facility,both,4,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,50863,CDM,250,RC,J2359,HCPCS,0781-3159-72,NDC,facility,both,10,EA,JZ,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 40 GRAM/400 ML (10 %) INJ SOLN",50863,CDM,250,RC,J1561,HCPCS,13533-800-20,NDC,facility,both,20,ML,,2829,1980.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0548-5603-00,NDC,facility,both,1,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
VANCOMYCIN  500 MG IV SOLR,50863,CDM,250,RC,J3373,HCPCS,0143-9161-10,NDC,facility,both,50,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 50% IN WATER (MERGE RECORD),50863,CDM,636,RC,J7060,HCPCS,0409-6648-02,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0517-0299-25,NDC,facility,both,1000,ML,,499,349.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,J2704,HCPCS,63323-269-65,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0093-4177-73,NDC,facility,both,8,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,50863,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,300,ML,,363,254.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,250,RC,J3490,HCPCS,71266-9080-2,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV (BOLUS),50863,CDM,J7120,HCPCS,0264-7750-00,NDC,,,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LINEZOLID 600 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,67877-419-33,NDC,facility,both,14,EA,,5914,4139.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIFAXIMIN 550 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65649-303-03,NDC,facility,both,1,EA,,278,194.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM-ALBUTEROL 0.5 MG-2.5 MG/3 ML NEB SOLUTION,50863,CDM,250,RC,J3490,HCPCS,0487-0201-01,NDC,facility,both,30,ML,,281,196.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAZOSIN 5 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,51079-632-01,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYMETAZOLINE 0.05 % NASAL MERGE,50863,CDM,J3490,HCPCS,0904-6761-30,NDC,,,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYMETAZOLINE 0.05 % NASL SPRA,50863,CDM,J3490,HCPCS,4110081125,NDC,,,facility,both,1,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J1938,HCPCS,63323-280-03,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG/ML INJ SOLN,50863,CDM,636,RC,J2550,HCPCS,0641-1495-31,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SELEGILINE 5 MG TAB,50863,CDM,636,RC,J3490,HCPCS,60505-3438-3,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,636,RC,J3490,HCPCS,0409-4887-10,NDC,facility,both,1,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLP,50863,CDM,250,RC,J3480,HCPCS,63323-965-02,NDC,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGIC MOUTHWASH REPACK (BMX 1:1:1),50863,CDM,636,RC,J3490,HCPCS,0603-0823-54,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,50863,CDM,J1815,HCPCS,0002-8215-01,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOBUTAMINE IN D5W 500 MG/250 ML (2 MG/ML) INFUSION (PREMIX),50863,CDM,250,RC,J1250,HCPCS,0409-2347-31,NDC,facility,both,2,ML,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN NPH HUMAN RECOMB 100 UNIT/ML SUBQ SUSP,50863,CDM,250,RC,J1815,HCPCS,0169-1834-11,NDC,facility,both,11,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,50863,CDM,250,RC,J9206,HCPCS,0009-7529-03,NDC,facility,both,5,ML,,243,170.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID (PORK)  60 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0456-0459-01,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0121-1781-05,NDC,facility,both,1,ML,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,72162-1330-6,NDC,facility,both,9,ML,,4238,2966.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,636,RC,J1815,HCPCS,0088-2220-33,NDC,facility,both,7,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML INJ SOLN,50863,CDM,J2250,HCPCS,0641-6057-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0093-4155-73,NDC,facility,both,9,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN  325 MG ORAL TAB,50863,CDM,J3490,HCPCS,66553-001-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,250,RC,Q9968,HCPCS,71288-811-10,NDC,facility,both,15,ML,,249,174.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"RABIES VACCINE,HUMAN DIPLOID (PF) 2.5 UNIT IM",50863,CDM,636,RC,90675,HCPCS,49281-252-51,NDC,facility,both,1,EA,JZ,1246,872.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-208-01,NDC,facility,both,100,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,J3010,HCPCS,0409-9094-12,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,636,RC,J3490,HCPCS,63037-136-25,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J2003,HCPCS,63323-492-27,NDC,facility,both,80,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRP (MERGE/REPACK),50863,CDM,636,RC,J3490,HCPCS,68094-764-59,NDC,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THROMBIN (RECOMBINANT) 5000 UNIT TOP SOLR,50863,CDM,250,RC,J3490,HCPCS,0338-0322-01,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 1 % INJ SOLN,50863,CDM,250,RC,Q9968,HCPCS,17478-504-10,NDC,facility,both,100,ML,,725,507.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANTI-INHIBITOR COAGULANT CMPLX (PHS MERGE),50863,CDM,J7198,HCPCS,64193-325-01,NDC,,,facility,both,5610,UN,,34839,24387.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,0088-2220-33,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-495-27,NDC,,,facility,both,120,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 500 MG/10 ML IV SOLN,50863,CDM,J9190,HCPCS,63323-117-61,NDC,,,facility,both,10,ML,,173,121.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  1 MG/ML INJ SYRG,50863,CDM,636,RC,J1171,HCPCS,0409-1283-10,NDC,facility,both,20,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELIMUMAB 400 MG IV SOLR,50863,CDM,250,RC,J0490,HCPCS,49401-102-01,NDC,facility,both,40,EA,JA,4459,3121.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IVPB (PEDIATRICS/ADULT NON-FORM)",50863,CDM,636,RC,J0131,HCPCS,24201-100-01,NDC,facility,both,31,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) NEB SOLUTION,50863,CDM,250,RC,J3490,HCPCS,60687-395-79,NDC,facility,both,4,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LINEZOLID 600 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,67877-419-33,NDC,facility,both,1,EA,,662,463.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,66553-002-01,NDC,facility,both,9,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,63323-162-00,NDC,facility,both,1,ML,JW,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6322-61,NDC,facility,both,8,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-01,NDC,facility,both,2,ML,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,0409-4887-23,NDC,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL  6.25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7306-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,0338-0072-25,NDC,facility,both,2,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
BUPIVACAINE-DEXTROSE-WATER(PF) 7.5 MG/ML (0.75 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-1761-02,NDC,facility,both,2,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-03,NDC,facility,both,1,ML,PLAD,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
ELECTROLYTE-A IV,50863,CDM,636,RC,J3490,HCPCS,0338-0221-03,NDC,facility,both,1,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,42023-201-01,NDC,facility,both,2,EA,,913,639.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 40 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,13668-011-01,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,J7040,HCPCS,0338-0049-02,NDC,,,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 160 MG-800 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0904-2725-61,NDC,facility,both,24,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,0121-0657-05,NDC,facility,both,3,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 112 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6954-61,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,72266-118-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 40 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,16714-696-01,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) IV SOLN",50863,CDM,636,RC,J3490,HCPCS,43066-008-01,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE (PF) 25 MG/ML INJ SOLN (FOR ECTOPIC PREGNANCY),50863,CDM,636,RC,J9260,HCPCS,0143-9519-01,NDC,facility,both,2,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES  8.6 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7252-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6007-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-444-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUBIPROSTONE  8 MCG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,70710-1641-6,NDC,facility,both,1,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0904-7127-61,NDC,facility,both,300,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEPOLIZUMAB 100 MG SUBQ SOLR,50863,CDM,636,RC,J2182,HCPCS,0173-0881-01,NDC,facility,both,100,EA,,7107,4974.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,62332-599-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPHENIDATE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0406-1142-01,NDC,facility,both,4,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLEVIDIPINE 50 MG/100 ML IV EMUL,50863,CDM,250,RC,C9248,HCPCS,10122-611-01,NDC,facility,both,50,ML,,762,533.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0406-5771-23,NDC,facility,both,17,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,72266-118-01,NDC,facility,both,4,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,145,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE IV CONCENTRATED INFUSION (1 MEQ/ML),50863,CDM,J3490,HCPCS,0409-6625-02,NDC,,,facility,both,5,ML,,287,200.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INHL NEBU,50863,CDM,250,RC,J3490,HCPCS,0487-9301-03,NDC,facility,both,2,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE 100 MG TAB,50863,CDM,636,RC,J3490,HCPCS,23155-135-25,NDC,facility,both,12,EA,,251,175.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),50863,CDM,636,RC,J1815,HCPCS,0024-5926-05,NDC,facility,both,3,ML,GZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier GZ: Item or service expected to be denied as not reasonable and necessary
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0781-6041-46,NDC,facility,both,6,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,1000,ML,,826,578.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,25021-601-03,NDC,facility,both,9,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN ASP PRT-INSULIN ASPART 100 UNIT/ML (70-30) SUBQ SOLN,50863,CDM,250,RC,J1817,HCPCS,73070-200-11,NDC,facility,both,2,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-5771-23,NDC,facility,both,5,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VORICONAZOLE 200 MG IV SOLN,50863,CDM,250,RC,J3465,HCPCS,0781-3416-94,NDC,facility,both,34,EA,,922,645.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL-ROPIVACAINE-NACL (PF) 2-0.2 MCG/ML-% INJ (MERGE ERX),50863,CDM,J3490,HCPCS,70092-9259-75,NDC,,,facility,both,1,ML,,218,152.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,J0665,HCPCS,63323-466-17,NDC,,,facility,both,300,ML,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM-ALBUTEROL 0.5 MG-2.5 MG/3 ML NEB SOLUTION,50863,CDM,J3490,HCPCS,0378-9671-31,NDC,,,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLP,50863,CDM,250,RC,J3480,HCPCS,63323-965-02,NDC,facility,both,29,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN IN D5W 600 MG/50 ML IV PGBK,50863,CDM,250,RC,J0736,HCPCS,0338-3612-50,NDC,facility,both,4,ML,,126,88.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BLEOMYCIN 15 UNITS/5 ML INJ SOLR (WET SOLR VIAL),50863,CDM,636,RC,J9040,HCPCS,16714-886-01,NDC,facility,both,2,EA,,461,322.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE MONONITRATE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,5026885111,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 20MG/ML IV SYRINGE (PEDS/NEO),50863,CDM,250,RC,J0612,HCPCS,63323-311-10,NDC,facility,both,51,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 3000 MCG/ML INJECTION,50863,CDM,250,RC,J0153,HCPCS,17478-542-02,NDC,facility,both,12,ML,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/0.5 ML INHL NEBU,50863,CDM,636,RC,J3490,HCPCS,0487-9901-30,NDC,facility,both,9,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,66689-056-01,NDC,facility,both,2,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,63323-104-06,NDC,facility,both,10,ML,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,54288-137-01,NDC,facility,both,1,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0781-6041-46,NDC,facility,both,2,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,43066-007-10,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,2,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-8515-23,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM NEO/PEDS (CDS MIXTURE),50863,CDM,636,RC,J0295,HCPCS,63323-368-20,NDC,facility,both,2,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTAMIDINE 300 MG INJ SOLR,50863,CDM,636,RC,J3490,HCPCS,63323-113-01,NDC,facility,both,1,EA,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NORTRIPTYLINE 25 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,50268-604-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,3,EA,JW,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,J7050,HCPCS,0264-7800-20,NDC,,,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,2,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-05,NDC,facility,both,16,EA,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN 0.9% SODIUM CL 1.25 GRAM/250 ML IV SOLN,50863,CDM,250,RC,J3370,HCPCS,72196-6074-1,NDC,facility,both,3,ML,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,16714-046-01,NDC,facility,both,10,ML,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MISOPROSTOL 100 MCG ORAL TAB,50863,CDM,250,RC,S0191,HCPCS,59762-5007-2,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),50863,CDM,250,RC,J1630,HCPCS,25021-806-01,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 5 MG/5 ML IV,50863,CDM,636,RC,J3490,HCPCS,63323-660-01,NDC,facility,both,2,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,J7512,HCPCS,0904-7127-61,NDC,,,facility,both,20,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7361-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 20MG/ML IV SYRINGE (PEDS/NEO),50863,CDM,250,RC,J0612,HCPCS,63323-311-10,NDC,facility,both,73,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (NEO) <2 KG,50863,CDM,636,RC,J7060,HCPCS,0338-0017-41,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0456,HCPCS,55150-174-10,NDC,facility,both,1,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,J3490,HCPCS,55150-188-10,NDC,,,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE NA (PRESERV FREE) 25 MG/ML INJ SOLN,50863,CDM,250,RC,J9260,HCPCS,61703-408-41,NDC,facility,both,240,ML,,2587,1810.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE 0.5%/EPINEPHRINE 1:100K INJECTION,50863,CDM,636,RC,J3490,HCPCS,63323-286-30,NDC,facility,both,1,ML,,133,93.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,15,ML,,26011,18207.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6993-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,300,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,0409-4887-24,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16729-137-00,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-097-01,NDC,facility,both,8,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALASPARGASE PEGOL-MKNL 750 UNITS/ML IV SOLN,50863,CDM,250,RC,J9118,HCPCS,72694-515-01,NDC,facility,both,750,ML,,151101,105770.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ICATIBANT 30 MG/3 ML SUBQ SYRG,50863,CDM,250,RC,J1744,HCPCS,0093-3066-19,NDC,facility,both,30,ML,JZ,29229,20460.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
HYDROCODONE-ACETAMINOPHEN 7.5 MG-325 MG/15 ML ORAL SOLN (REPACK),50863,CDM,636,RC,J3490,HCPCS,0121-2316-15,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,250,RC,J2270,HCPCS,0409-1890-13,NDC,facility,both,1,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) IV SOLN",50863,CDM,250,RC,J3490,HCPCS,0013-1114-20,NDC,facility,both,1,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,10135-678-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZTROPINE 1 MG/ML INJ SOLN,50863,CDM,636,RC,J0515,HCPCS,0143-9729-01,NDC,facility,both,2,ML,,318,222.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 7.5 MG-325 MG/15 ML ORAL SOLN (REPACK),50863,CDM,636,RC,J3490,HCPCS,0121-2316-15,NDC,facility,both,1,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM NEO/PEDS INFUSION (CDS MIXTURE),50863,CDM,250,RC,J2543,HCPCS,0206-8852-08,NDC,facility,both,2,EA,,234,163.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEDI MV NO.189-FERROUS SULFATE 11 MG IRON/ML ORAL DROP,50863,CDM,250,RC,J3490,HCPCS,87040501,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,J3490,HCPCS,68094-600-59,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,636,RC,J2003,HCPCS,76329-3390-1,NDC,facility,both,100,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,6,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,50863,CDM,636,RC,J2359,HCPCS,72603-181-01,NDC,facility,both,10,EA,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,50863,CDM,J3490,HCPCS,16714-294-02,NDC,,,facility,both,9,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,636,RC,J1939,HCPCS,0641-6008-01,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,62332-037-31,NDC,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,72205-101-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1162-18,NDC,facility,both,400,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML IV SOLN (MERGE),50863,CDM,250,RC,J3490,HCPCS,16714-037-01,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 10 MG/5 ML SYRUP,50863,CDM,250,RC,Q0177,HCPCS,62135-750-47,NDC,facility,both,1,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTOXIFYLLINE 400 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,0904-5448-61,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,76329-3352-1,NDC,facility,both,1,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,00035-0002-80,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN  500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-155-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,7,ML,JW,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
VANCOMYCIN NEO IV SYRINGE (CDS MIXTURE),50863,CDM,636,RC,J3370,HCPCS,0338-3582-01,NDC,facility,both,2,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAZOSIN 1 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,51079-630-01,NDC,facility,both,8,EA,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1815,HCPCS,0169-1833-11,NDC,facility,both,2,ML,GZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier GZ: Item or service expected to be denied as not reasonable and necessary
MEPERIDINE (PF) 25 MG/ML IV SOLN (PHS MERGE),50863,CDM,250,RC,J2175,HCPCS,0641-6052-01,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON DEXTRAN 50 MG/ML INJ SOLN,50863,CDM,636,RC,J1750,HCPCS,0023-6082-01,NDC,facility,both,32,ML,,3334,2333.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,636,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,5,ML,JW,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
FLUDROCORTISONE 0.1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-288-11,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOBRAMYCIN SULFATE 40 MG/ML INJ SOLN,50863,CDM,636,RC,J3260,HCPCS,67457-473-22,NDC,facility,both,3,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,636,RC,J2003,HCPCS,0143-9575-01,NDC,facility,both,460,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETHACRYNIC ACID 25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69238-1126-1,NDC,facility,both,3,EA,,308,215.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,72603-179-01,NDC,facility,both,6,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,76,ML,JW,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
MIRTAZAPINE 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-119-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB-QYYP 420 MG IV SOLR,50863,CDM,Q5116,HCPCS,0069-0306-01,NDC,,,facility,both,13,ME,,2898,2028.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-7350-61,NDC,,,facility,both,2,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,J0690,HCPCS,25021-101-10,NDC,,,facility,both,4,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2003,HCPCS,0409-2066-05,NDC,,,facility,both,300,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-208-01,NDC,,,facility,both,200,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM BICARB-CITRIC ACID 20 MEQ ORAL TBEF,50863,CDM,250,RC,J3490,HCPCS,51801-012-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-0235-24,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALGANCICLOVIR 450 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-787-11,NDC,facility,both,2,EA,,882,617.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAPTOPRIL  12.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7105-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXEPIN  10 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,51079-436-01,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0093-3426-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 125 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,0074-6212-13,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 5 MG/5 ML IV,50863,CDM,636,RC,J3490,HCPCS,0409-1778-15,NDC,facility,both,2,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,0781-3246-02,NDC,facility,both,4,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LATANOPROST 0.005 % OPHT DROP,50863,CDM,250,RC,J3490,HCPCS,59762-0333-2,NDC,facility,both,1,ML,,404,282.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,636,RC,J3490,HCPCS,0641-6236-01,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL 100 MCG/HR TD PT72,50863,CDM,250,RC,J3490,HCPCS,47781-428-11,NDC,facility,both,1,EA,,334,233.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE 100 MG ORAL CAP,50863,CDM,250,RC,J7502,HCPCS,0078-0241-61,NDC,facility,both,2,EA,,211,147.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DONEPEZIL 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6478-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 50 MG/5 ML (10 MG/ML) IV SYRG,50863,CDM,250,RC,J3490,HCPCS,71266-9005-5,NDC,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,18,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,636,RC,Q9968,HCPCS,70710-1838-1,NDC,facility,both,15,ML,,249,174.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TETRACYCLINE 500 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,51991-907-01,NDC,facility,both,1,EA,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,7,ML,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLIMEPIRIDE 2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-359-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 3000 MCG/ML INJECTION,50863,CDM,250,RC,J0153,HCPCS,67457-855-02,NDC,facility,both,6,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR  6 MG/ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,27241-139-09,NDC,facility,both,5,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-131-11,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEPLIZUMAB-MZWV 2 MG/20 ML IV SOLN,50863,CDM,636,RC,J9381,HCPCS,73650-316-01,NDC,facility,both,141,ME,,9471,6629.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 1 GRAM/10 ML (10 %) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-13,NDC,facility,both,2,ML,,443,310.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 100 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,31722-574-47,NDC,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-492-04,NDC,facility,both,60,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE MODIFIED 100 MG ORAL CAP,50863,CDM,250,RC,J7502,HCPCS,51862-460-01,NDC,facility,both,4,EA,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7914-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,16714-294-01,NDC,facility,both,5,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IRRIGATION SOLN,50863,CDM,636,RC,J7120,HCPCS,0264-7389-60,NDC,facility,both,9,ML,,150,105,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),50863,CDM,636,RC,J3490,HCPCS,63323-186-10,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"CALCIUM GLUC IN NACL, ISO-OSM 1 G/100 ML IV SOLN",50863,CDM,J0612,HCPCS,44567-622-01,NDC,,,facility,both,300,ML,,223,156.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J1938,HCPCS,72603-251-01,NDC,facility,both,120,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,76329-3352-1,NDC,facility,both,3,ML,,347,242.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J1940,HCPCS,36000-283-25,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 0.5 MG ORAL CAP,50863,CDM,250,RC,J7507,HCPCS,68084-449-11,NDC,facility,both,4,EA,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,0641-6206-01,NDC,facility,both,5,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 250 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,62756-797-88,NDC,facility,both,2,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEVIMELINE 30 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,63395-201-13,NDC,facility,both,1,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOPIDOGREL 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,55111-671-06,NDC,facility,both,1,EA,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL,50863,CDM,636,RC,J1071,HCPCS,0143-9659-01,NDC,facility,both,200,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5%/EPINEPHRINE 1:300K INJECTION,50863,CDM,250,RC,J3490,HCPCS,0409-1161-01,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,43547-281-10,NDC,facility,both,2,EA,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0093-2279-73,NDC,facility,both,10,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6927-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE 1 MG/2 ML INHL NBSP,50863,CDM,250,RC,J3490,HCPCS,0093-6817-45,NDC,facility,both,1,ML,,113,79.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 10 MG/ML ORAL SOLUTION (REPACK),50863,CDM,250,RC,J3490,HCPCS,0131-5410-71,NDC,facility,both,2,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NOREPINEPHRINE BITARTRATE-D5W 16 MG/250 ML (64 MCG/ML) IV SOLN (CENTRAL ONLY),50863,CDM,250,RC,J3490,HCPCS,99999-444-41,NDC,facility,both,1,ML,,227,158.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 30 MG TAB,50863,CDM,636,RC,J3490,HCPCS,60687-717-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERTAPENEM 1 GRAM INJ SOLR,50863,CDM,250,RC,J1335,HCPCS,16714-889-01,NDC,facility,both,26,EA,,6823,4776.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB 100 MG IV SOLR,50863,CDM,J1745,HCPCS,57894-160-01,NDC,,,facility,both,35,EA,,4589,3212.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-02,NDC,facility,both,2,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,63323-185-07,NDC,facility,both,3,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,51754-5001-5,NDC,facility,both,2,ML,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,30,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-19,NDC,facility,both,300,ML,JZ,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2310,HCPCS,36000-308-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,14789-127-07,NDC,facility,both,1,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-442-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,84,ML,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,636,RC,J2270,HCPCS,0409-1890-13,NDC,facility,both,1,ML,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,60,ML,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCUSATE SODIUM 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,45802-486-78,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM SR 180 MG 24 HR CAP,50863,CDM,250,RC,J3490,HCPCS,60687-206-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.3 MG/0.3 ML IM PNIJ,50863,CDM,636,RC,J0171,HCPCS,49502-102-01,NDC,facility,both,3,EA,,675,472.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"METHYLPREDNISOLONE 1,000 MG SOLUTION FOR INJECTION",50863,CDM,250,RC,J2919,HCPCS,0009-0698-01,NDC,facility,both,200,EA,,224,156.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORDIAZEPOXIDE 25 MG CAP,50863,CDM,636,RC,J3490,HCPCS,0555-0159-02,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE  10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-037-11,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIPASE-PROTEASE-AMYLASE 12,000-38,000- 60,000 UNIT ORAL CAP, DELAY REL",50863,CDM,250,RC,J3490,HCPCS,0032-0047-70,NDC,facility,both,6,EA,,152,106.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,76045-009-96,NDC,facility,both,4,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL IV BOLUS 10MG/ML (ANESTHESIA ONLY),50863,CDM,636,RC,J2704,HCPCS,63323-269-29,NDC,facility,both,400,ML,,1636,1145.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 50 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,59651-489-01,NDC,facility,both,75,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,63323-280-03,NDC,facility,both,100,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  100 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,63323-376-00,NDC,facility,both,12,ML,JA,175,122.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,250,RC,J2001,HCPCS,0409-1323-15,NDC,facility,both,10,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,67877-670-01,NDC,facility,both,3,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,636,RC,J1939,HCPCS,68462-469-40,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,71288-402-10,NDC,facility,both,12,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,16714-298-01,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCHLOROTHIAZIDE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-593-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESNA 100 MG/ML IV SOLN,50863,CDM,250,RC,J9209,HCPCS,0338-1305-01,NDC,facility,both,4,ML,,133,93.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 20 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,60687-725-11,NDC,facility,both,1,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,67877-670-01,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOLAZONE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7139-61,NDC,facility,both,2,EA,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,636,RC,J3490,HCPCS,51754-4250-1,NDC,facility,both,2,ML,,145,101.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3370,HCPCS,0143-9162-01,NDC,facility,both,3,EA,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE (PF) 1 MG/ML INJ SOLN,50863,CDM,250,RC,J0171,HCPCS,54288-103-01,NDC,facility,both,40,ML,,343,240.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) 1000 UNITS/ML INJ SOL (FOR DIALYSIS ONLY),50863,CDM,636,RC,J1644,HCPCS,25021-400-10,NDC,facility,both,10,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0641-6022-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEFIBROTIDE 80 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,68727-800-01,NDC,facility,both,1,ML,,1421,994.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATED 20 MG/ML IV SOLN,50863,CDM,250,RC,J0706,HCPCS,51754-0500-1,NDC,facility,both,14,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL (PULM.HYPERTENSION) 10 MG/12.5 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,55150-166-13,NDC,facility,both,1,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,63323-325-09,NDC,facility,both,200,ML,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NS WITH POTASSIUM CHLORIDE 20 MEQ/L IV SOLP,50863,CDM,250,RC,J3480,HCPCS,0264-7865-00,NDC,facility,both,10,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE MONONITRATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,7733393425,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 200 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-552-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,53489-156-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL (5 MG/ML) IV SYRG (CONTAINS PRESERVATIVE),50863,CDM,636,RC,J3490,HCPCS,0409-2339-24,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J7510,HCPCS,17856-0815-1,NDC,facility,both,8,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2312,HCPCS,36000-308-01,NDC,facility,both,80,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML IV SOLN,50863,CDM,250,RC,J3010,HCPCS,63323-806-50,NDC,facility,both,25,ML,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,0641-0477-21,NDC,facility,both,3,ML,,697,487.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRIMIDONE 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-203-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE 3 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,65162-778-10,NDC,facility,both,1,EA,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2308-01,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,70436-030-82,NDC,facility,both,86,ML,JW,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DOCUSATE SODIUM 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7183-61,NDC,facility,both,1,EA,PLAD,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
K PHOS DI & MONO-SOD PHOS MONO 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,6498010401,NDC,facility,both,2,EA,PLAD,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,63323-201-01,NDC,,,facility,both,20,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,12,EA,JW,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
EPINEPHRINE 1 MG/ML INJ SOLN,50863,CDM,250,RC,J0171,HCPCS,76329-9060-0,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACCHAROMYCES BOULARDII 250 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,7733380025,NDC,facility,both,1,EA,PLAD,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
CEFAZOLIN IN STERILE WATER 2 GRAM/20 ML IV SYRG,50863,CDM,J7999,HCPCS,70092-1604-47,NDC,,,facility,both,50,ML,,2602,1821.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 250 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,0904-6363-45,NDC,facility,both,3,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV,50863,CDM,250,RC,J7120,HCPCS,0338-0117-04,NDC,facility,both,2,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-0430-06,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J2003,HCPCS,63323-492-57,NDC,facility,both,50,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-582-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-342-11,NDC,facility,both,8,EA,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-1749-70,NDC,facility,both,2,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROATE SODIUM 100 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0143-9785-01,NDC,facility,both,6,ML,,609,426.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,72603-251-01,NDC,facility,both,7,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITRIOL 0.25 MCG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-345-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-231-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7362-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-982-01,NDC,facility,both,5,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV (BOLUS),50863,CDM,250,RC,J7120,HCPCS,0264-7750-07,NDC,facility,both,3,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM BICARB-CITRIC ACID 20 MEQ ORAL TBEF,50863,CDM,636,RC,J3490,HCPCS,51801-011-30,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,1,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,250,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,7,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,68180-441-02,NDC,facility,both,11,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J3490,HCPCS,0338-0049-48,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-591-11,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-8297-25,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML (ANESTHESIA INTRAOP ONLY),50863,CDM,636,RC,J3010,HCPCS,0641-6027-01,NDC,facility,both,1,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SODIUM CHLORIDE 3 % IV INFUSION,50863,CDM,J3490,HCPCS,0338-0054-03,NDC,,,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,636,RC,J0330,HCPCS,0409-6629-02,NDC,facility,both,10,ML,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESNA 100 MG/ML IV SOLN,50863,CDM,250,RC,J9209,HCPCS,10019-953-62,NDC,facility,both,3,ML,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BEVACIZUMAB-MALY 25 MG/ML IV SOLN,50863,CDM,250,RC,Q5126,HCPCS,70121-1754-1,NDC,facility,both,20,ML,,3967,2776.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL  6.25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0093-0135-01,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  75 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-495-11,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL,50863,CDM,250,RC,J1071,HCPCS,0143-9659-01,NDC,facility,both,120,ML,JW,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2312,HCPCS,36000-308-01,NDC,facility,both,200,ML,,167,116.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,636,RC,J0690,HCPCS,60505-6142-0,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROPRUSSIDE 25 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,70069-261-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  75 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-475-11,NDC,facility,both,3,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-488-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAZOSIN 5 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-572-33,NDC,facility,both,2,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,59651-488-01,NDC,facility,both,60,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-145-11,NDC,facility,both,10,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,68516-5214-1,NDC,facility,both,16,ML,,2282,1597.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROTHIAZIDE SODIUM 500 MG IV SOLR,50863,CDM,250,RC,J1205,HCPCS,25021-305-20,NDC,facility,both,1,EA,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN PEDS INFUSION (CDS MIXTURE),50863,CDM,250,RC,J0290,HCPCS,25021-136-10,NDC,facility,both,2,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLP",50863,CDM,250,RC,P9047,HCPCS,44206-251-91,NDC,facility,both,2,ML,,778,544.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0904-7127-61,NDC,facility,both,20,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,43066-007-10,NDC,facility,both,2,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,0944-0495-06,NDC,facility,both,1,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,636,RC,J3490,HCPCS,53746-542-01,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0172-3926-60,NDC,facility,both,8,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOFLOXACIN 750 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6353-61,NDC,facility,both,1,EA,,121,84.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,25021-602-03,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,63323-165-01,NDC,facility,both,8,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,J2270,HCPCS,63323-454-00,NDC,,,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,636,RC,J0690,HCPCS,70092-1017-46,NDC,facility,both,1,ML,,18171,12719.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,636,RC,J7510,HCPCS,17856-0815-1,NDC,facility,both,5,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DONEPEZIL 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-303-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-442-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  75 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-475-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX (PF) 10 MCG IM,50863,CDM,250,RC,90648,HCPCS,49281-547-58,NDC,facility,both,1,EA,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 50 MG TAB,50863,CDM,250,RC,Q0177,HCPCS,0904-6618-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,250,RC,J0690,HCPCS,70092-1017-46,NDC,facility,both,3,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOPIDOGREL 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-752-95,NDC,facility,both,2,EA,,226,158.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE MONONITRATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,7733393425,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,11,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7047-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 500 MG PE/10 ML INJ SOLN,50863,CDM,250,RC,Q2009,HCPCS,0641-6137-01,NDC,facility,both,40,ML,,967,676.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 200 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16729-457-15,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-821-01,NDC,facility,both,4,EA,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COLCHICINE 0.6 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,70010-002-01,NDC,facility,both,2,EA,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,50863,CDM,250,RC,Q0177,HCPCS,16714-082-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-48,NDC,facility,both,2,ML,,183,128.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,2,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
OXYBUTYNIN CHLORIDE  5 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-7027-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIFEDIPINE 60 MG ORAL TO24,50863,CDM,636,RC,J3490,HCPCS,50268-598-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,55150-304-01,NDC,facility,both,20,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,J3010,HCPCS,0409-9094-22,NDC,,,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ROTAVIRUS VACCINE, LIVE, 89-12 10EXP6 CCID50 /1.5 ML ORAL SUSP",50863,CDM,90681,HCPCS,58160-740-02,NDC,,,facility,both,1,ML,,599,419.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-02,NDC,facility,both,3,ML,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,50863,CDM,250,RC,J9045,HCPCS,0703-4239-01,NDC,facility,both,12,ML,,310,217,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,10702-018-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-492-27,NDC,facility,both,80,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 400 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6667-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,50863,CDM,250,RC,J0696,HCPCS,25021-107-20,NDC,facility,both,8,EA,JZ,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DIAZEPAM 5 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-0905-05,NDC,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,43598-053-11,NDC,facility,both,19,ML,,663,464.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 20 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7346-61,NDC,facility,both,2,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE 30 MG TAB,50863,CDM,636,RC,J3490,HCPCS,50268-642-11,NDC,facility,both,2,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,250,RC,J0690,HCPCS,0143-9924-90,NDC,facility,both,2,EA,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LEVETIRACETAM  750 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-882-11,NDC,facility,both,3,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE SODIUM 25 MG/ML INJ SOLN,50863,CDM,636,RC,J9260,HCPCS,16729-277-30,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,8,EA,,282,197.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,50268-540-11,NDC,facility,both,6,EA,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE  15 MG ORAL CPSP,50863,CDM,250,RC,J3490,HCPCS,50458-647-65,NDC,facility,both,1,EA,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNITS/1 GRAM PACKET (MERGE RECORD),50863,CDM,636,RC,J3490,HCPCS,45802-060-00,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  75 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-475-11,NDC,facility,both,4,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IV PGBK,50863,CDM,250,RC,J3475,HCPCS,0264-4204-52,NDC,facility,both,6,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 250 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,50268-259-11,NDC,facility,both,6,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTOLOZANE-TAZOBACTAM 1.5 G IV SOLR,50863,CDM,250,RC,J0695,HCPCS,67919-030-01,NDC,facility,both,10,EA,,343,240.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GOLIMUMAB  12.5 MG/ML IV SOLN,50863,CDM,636,RC,J1602,HCPCS,57894-350-01,NDC,facility,both,12,ML,JW,576,403.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
TIZANIDINE 4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-645-11,NDC,facility,both,2,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7728-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,636,RC,J0690,HCPCS,70092-1017-46,NDC,facility,both,4,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUMAZENIL 0.1 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0143-9784-01,NDC,facility,both,4,ML,,181,126.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLN,50863,CDM,636,RC,J3262,HCPCS,50242-135-01,NDC,facility,both,200,ML,,3666,2566.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,76045-009-10,NDC,facility,both,9,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLEVIDIPINE 50 MG/100 ML IV EMUL,50863,CDM,250,RC,C9248,HCPCS,10122-611-01,NDC,facility,both,50,ML,,740,518,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-495-27,NDC,facility,both,80,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-070-10,NDC,facility,both,2,EA,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,J3490,HCPCS,71449-068-11,NDC,,,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 175 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,42292-040-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2312,HCPCS,0409-1215-01,NDC,facility,both,200,ML,,465,325.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN ENEMA 500MG IN 100ML NS,50863,CDM,250,RC,J3373,HCPCS,67457-339-00,NDC,facility,both,50,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MYCOPHENOLATE SODIUM 360 MG ORAL TBEC,50863,CDM,250,RC,J7518,HCPCS,0904-6786-04,NDC,facility,both,3,EA,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM IN NACL (ISO-OS) 1000 MG/100 ML IV PGBK,50863,CDM,636,RC,J1953,HCPCS,67457-265-00,NDC,facility,both,200,ML,,253,177.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 200 MG/20 ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,72205-220-01,NDC,facility,both,1,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,8,EA,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,63323-506-41,NDC,facility,both,6,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1815,HCPCS,0169-1833-11,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTOLOZANE-TAZOBACTAM 1.5 G IV SOLR,50863,CDM,250,RC,J0695,HCPCS,67919-030-01,NDC,facility,both,6,EA,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,63323-185-08,NDC,facility,both,1,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-5771-23,NDC,facility,both,9,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN D5W 1 GRAM/200 ML IV PGBK,50863,CDM,250,RC,J3373,HCPCS,0338-3552-48,NDC,facility,both,100,ML,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0904-7127-61,NDC,facility,both,240,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPTOMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0878,HCPCS,70594-034-01,NDC,facility,both,1000,EA,,611,427.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,65862-707-80,NDC,facility,both,16,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAMSULOSIN 0.4 MG ORAL CP24,50863,CDM,J3490,HCPCS,68084-299-11,NDC,,,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),50863,CDM,J0169,HCPCS,76329-3318-1,NDC,,,facility,both,10,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,50863,CDM,636,RC,J0585,HCPCS,0023-1145-01,NDC,facility,both,300,EA,,4795,3356.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM NEO/PEDS INFUSION (CDS MIXTURE),50863,CDM,250,RC,J2543,HCPCS,0206-8852-08,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE IN D5W 1 GRAM/100 ML IV PGBK,50863,CDM,250,RC,J3475,HCPCS,0338-1709-40,NDC,facility,both,4,ML,JZ,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
VALSARTAN  80 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,31722-152-90,NDC,facility,both,4,EA,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN   81 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,77333-031-25,NDC,facility,both,3,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0121-1022-05,NDC,facility,both,7,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,67877-545-88,NDC,facility,both,6,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,4,EA,,144,100.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VARICELLA-ZOSTER IG-MALTOSE 125 UNIT/1.2 ML IM SOLN,50863,CDM,636,RC,90396,HCPCS,70257-126-11,NDC,facility,both,1,ML,,25935,18154.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-504-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOPROTERENOL 0.2 MG/ML INJECTION,50863,CDM,250,RC,J3490,HCPCS,70121-1605-1,NDC,facility,both,4,ML,,4994,3495.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPENTOLATE 1 % OPHT DROP,50863,CDM,250,RC,J3490,HCPCS,24208-735-01,NDC,facility,both,1,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,54288-137-01,NDC,facility,both,3,ML,,423,296.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NYSTATIN  100000 UNIT/G TOP POWD,50863,CDM,250,RC,J3490,HCPCS,68308-152-15,NDC,facility,both,2,GM,,215,150.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPSONE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,70954-136-10,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACTERIOSTATIC SALINE 0.9 % INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-924-30,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 800 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-468-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM IODIDE 1 GRAM/ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,75834-280-30,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM  3 GRAM INJ SOLR,50863,CDM,250,RC,J0295,HCPCS,66794-207-02,NDC,facility,both,2,EA,JZ,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
URSODIOL 60 MG/ML ORAL SUSPENSION (REPACK),50863,CDM,250,RC,j3490,HCPCS,0527-1326-01,NDC,facility,both,5,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,636,RC,J0690,HCPCS,60505-6142-0,NDC,facility,both,2,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,72266-147-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1940,HCPCS,72603-251-01,NDC,facility,both,10,ML,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  2.5 MG ORAL TAB,50863,CDM,250,RC,J7510,HCPCS,59651-485-01,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIROFIBAN-0.9% SODIUM CHLORIDE 5 MG/100 ML (50 MCG/ML) IV SOLN,50863,CDM,250,RC,J3246,HCPCS,25208-002-03,NDC,facility,both,18,ML,JW,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PSEUDOEPHEDRINE 30 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6990-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ELECTROLYTE-A IV,50863,CDM,636,RC,J3490,HCPCS,0338-0221-03,NDC,facility,both,1,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE HCL 0.3 MG/ML INJ (MERGE),50863,CDM,250,RC,J0592,HCPCS,70069-027-01,NDC,facility,both,3,ML,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 100 MG IV SOLR,50863,CDM,J2997,HCPCS,50242-085-25,NDC,,,facility,both,50,EA,,5281,3696.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCRALFATE 100 MG/ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,17856-0306-1,NDC,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,50863,CDM,636,RC,J1885,HCPCS,63323-162-03,NDC,facility,both,2,ML,JW,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LACTULOSE 10 GRAM/15 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,0116-4005-30,NDC,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0406-5771-23,NDC,facility,both,19,EA,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL  6.25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-854-11,NDC,facility,both,4,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,42494-416-01,NDC,facility,both,1,ML,,217,151.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-0710-20,NDC,facility,both,15,EA,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0093-0053-01,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MANNITOL 25 % IV SOLN,50863,CDM,250,RC,J2150,HCPCS,63323-024-01,NDC,facility,both,8,ML,,322,225.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0406-0552-23,NDC,facility,both,9,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENDAMUSTINE 25 MG/ML IV SOLN,50863,CDM,J9034,HCPCS,63459-348-04,NDC,,,facility,both,125,ML,,8535,5974.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16729-216-15,NDC,facility,both,2,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 200 MG/20 ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,70710-1359-1,NDC,facility,both,1,ML,,334,233.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-495-27,NDC,facility,both,9,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,636,RC,J3490,HCPCS,70092-9119-44,NDC,facility,both,2,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,250,RC,Q9968,HCPCS,71288-811-10,NDC,facility,both,89,ML,,1464,1024.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,63323-185-07,NDC,facility,both,2,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,250,RC,J0690,HCPCS,63323-237-10,NDC,facility,both,6,EA,JZ,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
METRONIDAZOLE 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16571-665-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT  60 MCG/0.3 ML INJ SYRG,50863,CDM,250,RC,J0881,HCPCS,55513-023-01,NDC,facility,both,40,ML,EC,855,598.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier EC: Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy
LOPERAMIDE 1 MG/7.5 ML ORAL LIQD,50863,CDM,250,RC,J3490,HCPCS,17856-6836-1,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,100,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROATE SODIUM 100 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,70860-784-41,NDC,facility,both,2,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML (1ML) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,54288-119-01,NDC,facility,both,12,ML,,949,664.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),50863,CDM,250,RC,J1815,HCPCS,0024-5926-05,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,636,RC,J3490,HCPCS,39822-1000-1,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GAMMAGARD LIQUID 10 % IV SOLN,50863,CDM,636,RC,J1569,HCPCS,0944-2700-04,NDC,facility,both,10,ML,,1803,1262.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 100 MG TAB,50863,CDM,250,RC,J3490,HCPCS,65862-064-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,250,RC,Q9968,HCPCS,70710-1838-1,NDC,facility,both,41,ML,JW,231,161.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J2003,HCPCS,63323-492-04,NDC,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXAZOSIN 8 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68382-786-01,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,67457-385-10,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML (1ML) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,54288-119-01,NDC,facility,both,6,ML,,475,332.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-354-11,NDC,facility,both,2,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,9,EA,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0295,HCPCS,63323-368-20,NDC,facility,both,1,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,63323-485-01,NDC,,,facility,both,13,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRASUGREL 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0713-0882-30,NDC,facility,both,1,EA,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68180-981-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,0517-4620-25,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 15 MG/ML (1.5 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-4776-10,NDC,facility,both,225,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE BIT 2 %-1:100,000 INJ CRTG",50863,CDM,636,RC,J3490,HCPCS,0404-6512-05,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 125 MG ORAL CPSP,50863,CDM,636,RC,J3490,HCPCS,68084-313-11,NDC,facility,both,8,EA,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 150 MG ORAL TBSR,50863,CDM,636,RC,J3490,HCPCS,0904-7214-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 500 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,50268-152-15,NDC,facility,both,12,EA,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYCHLOROQUINE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-269-11,NDC,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SYRG,50863,CDM,636,RC,J3490,HCPCS,8290306547,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ABATACEPT 250 MG IV SOLR,50863,CDM,636,RC,J0129,HCPCS,0003-2187-13,NDC,facility,both,100,EA,"JZ,JA",16711,11697.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-1749-70,NDC,facility,both,1,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN NPH & REGULAR HUMAN 100 UNIT/ML (70-30) SUBQ SUSP,50863,CDM,250,RC,J1815,HCPCS,0002-8715-01,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MECLIZINE 12.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-775-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM ZIRCONIUM CYCLOSILICATE  5 G ORAL PWPK (USE PANEL),50863,CDM,250,RC,J3490,HCPCS,0310-1105-01,NDC,facility,both,2,EA,PLAD,279,195.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2599,HCPCS,65219-039-00,NDC,facility,both,3,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,636,RC,J2003,HCPCS,0409-1323-15,NDC,facility,both,1000,ML,,400,280,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,636,RC,J3490,HCPCS,59310-579-22,NDC,facility,both,1,GM,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV (BOLUS),50863,CDM,636,RC,J7120,HCPCS,0264-7750-00,NDC,facility,both,2,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,250,RC,J2720,HCPCS,63323-229-01,NDC,facility,both,3,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,11,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,J1885,HCPCS,63323-162-00,NDC,,,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-18,NDC,facility,both,80,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-9558-05,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 20MG/ML IV SYRINGE (PEDS/NEO),50863,CDM,250,RC,J0612,HCPCS,63323-311-10,NDC,facility,both,30,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATOMOXETINE  10 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,68462-265-30,NDC,facility,both,2,EA,,140,98,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 20MG/ML IV SYRINGE (PEDS/NEO),50863,CDM,250,RC,J0612,HCPCS,63323-311-10,NDC,facility,both,39,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL 20 MG/5 ML ORAL ELIX,50863,CDM,250,RC,J3490,HCPCS,60687-671-40,NDC,facility,both,3,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOPAMINE IN D5W 400 MG/250 ML (1.6 MG/ML) IV,50863,CDM,250,RC,J1265,HCPCS,0409-7809-22,NDC,facility,both,10,ML,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 25 MG TAB,50863,CDM,250,RC,J3490,HCPCS,51079-255-01,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 20MG/ML IV SYRINGE (PEDS/NEO),50863,CDM,250,RC,J0612,HCPCS,63323-311-10,NDC,facility,both,60,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 100 MG/1 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,0075-0623-03,NDC,facility,both,20,ML,,292,204.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,50863,CDM,636,RC,J0696,HCPCS,60505-6149-0,NDC,facility,both,8,EA,,388,271.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,28,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 20MG/ML IV SYRINGE (PEDS/NEO),50863,CDM,250,RC,J0612,HCPCS,63323-311-10,NDC,facility,both,59,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 60 MG ORAL CPDR,50863,CDM,636,RC,J3490,HCPCS,27241-099-03,NDC,facility,both,1,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 2 MG/ML IV SOLN (PRMC ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-1312-03,NDC,facility,both,20,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE-VITAMIN D3 250 MG-125 UNIT TAB,50863,CDM,250,RC,J3490,HCPCS,2055502500,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB 100 MG IV SOLR,50863,CDM,J1745,HCPCS,57894-030-01,NDC,,,facility,both,9,EA,,1262,883.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-18,NDC,facility,both,75,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0143-9386-01,NDC,facility,both,25,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,J3490,HCPCS,68094-494-59,NDC,,,facility,both,3,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,636,RC,FAMNOCHARGE,HCPCS,68094-763-59,NDC,facility,both,1,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  88 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6952-61,NDC,facility,both,4,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,250,RC,Q0162,HCPCS,65162-691-79,NDC,facility,both,3,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 500 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,68084-415-11,NDC,facility,both,1,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYTOCIN 10 UNIT/ML INJ SOLN,50863,CDM,250,RC,J2590,HCPCS,42023-116-25,NDC,facility,both,3,ML,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0093-4177-73,NDC,facility,both,7,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 1 MG/ML PCA (PDS MERGE),50863,CDM,250,RC,J2274,HCPCS,61553-820-41,NDC,facility,both,5,ML,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUSELKUMAB 200 MG/20 ML (10 MG/ML) IV SOLN,50863,CDM,636,RC,J1628,HCPCS,57894-650-01,NDC,facility,both,200,ML,JZ,38289,26802.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ATORVASTATIN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6291-61,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,6,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J2003,HCPCS,63323-492-27,NDC,facility,both,40,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRBESARTAN 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,33342-049-07,NDC,facility,both,1,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0143-9595-01,NDC,facility,both,50,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,23,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,67877-548-88,NDC,facility,both,5,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,50863,CDM,J1650,HCPCS,16714-046-01,NDC,,,facility,both,10,ML,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  15 MG ORAL TBSR,50863,CDM,636,RC,J3490,HCPCS,0406-8315-01,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEMAZEPAM  7.5 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6436-04,NDC,facility,both,3,EA,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,50863,CDM,250,RC,J9045,HCPCS,0703-4239-01,NDC,facility,both,12,ML,,317,221.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 300 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-722-11,NDC,facility,both,2,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,14,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,0641-6145-01,NDC,facility,both,10,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 5 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,63323-660-05,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPHENIDATE 18 MG ORAL TO24,50863,CDM,J3490,HCPCS,62175-310-37,NDC,,,facility,both,1,EA,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,0641-6174-10,NDC,facility,both,4,ML,JB,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JB: Administered subcutaneously
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),50863,CDM,J1815,HCPCS,0024-5926-05,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J2003,HCPCS,0409-4713-32,NDC,facility,both,80,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE IN 0.9% NS (PF) 1 MG/10 ML (100 MCG/ML) IV SYRG(PDS MERGE),50863,CDM,250,RC,J3490,HCPCS,63037-173-25,NDC,facility,both,2,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
K PHOS DI & MONO-SOD PHOS MONO 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,486112501,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VERAPAMIL 120 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0591-0345-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  100 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,68462-896-01,NDC,facility,both,6,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MINOCYCLINE 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-336-11,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE  6.25 MG/5 ML ORAL SYRP,50863,CDM,250,RC,Q0169,HCPCS,17856-0059-1,NDC,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,P9045,HCPCS,68516-5214-1,NDC,,,facility,both,2,ML,,447,312.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 12 MG/ML ORAL SUSPENSION,50863,CDM,250,RC,J3490,HCPCS,0093-0319-01,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,20,EA,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERTAPENEM 1 GRAM INJ SOLR,50863,CDM,250,RC,J1335,HCPCS,16714-889-01,NDC,facility,both,6,EA,,1575,1102.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,636,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,94,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,40,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLMESARTAN 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68462-437-30,NDC,facility,both,2,EA,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,250,RC,J3490,HCPCS,0409-4277-16,NDC,facility,both,400,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,63323-482-27,NDC,facility,both,100,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,0409-2723-30,NDC,facility,both,8,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NORTRIPTYLINE 25 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,50268-604-11,NDC,facility,both,3,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6869-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CITRATE  5 MEQ ORAL TBER,50863,CDM,250,RC,J3490,HCPCS,68382-536-01,NDC,facility,both,2,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 20MG/ML IV SYRINGE (PEDS/NEO),50863,CDM,250,RC,J0612,HCPCS,63323-311-10,NDC,facility,both,26,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,432,ME,JZ,5863,4104.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LANREOTIDE 90 MG/0.3 ML SUBQ SYRG,50863,CDM,636,RC,J1930,HCPCS,15054-1090-4,NDC,facility,both,90,ML,JZ,22379,15665.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,14,EA,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,58,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3370,HCPCS,70436-021-82,NDC,facility,both,3,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE HCL 5 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-1576-10,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 30 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,27241-098-09,NDC,facility,both,1,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-11,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-657-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50111-327-01,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE  50 MG ORAL TAB,50863,CDM,636,RC,j3490,HCPCS,68382-805-01,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,17271-701-05,NDC,facility,both,1,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORATADINE 5 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,54838-558-40,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-579-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 250 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,42192-608-05,NDC,facility,both,2,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,50863,CDM,250,RC,J3490,HCPCS,17856-0823-10,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-822-11,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB 100 MG IV SOLR,50863,CDM,636,RC,J1745,HCPCS,57894-030-01,NDC,facility,both,30,EA,,9670,6769,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,7,EA,JW,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DEXTROSE 10% IN WATER (NEO) 2 - 3.99 KG,50863,CDM,250,RC,J3490,HCPCS,0264-7520-10,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-426-02,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68382-806-01,NDC,facility,both,5,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE (PF) 1 MG/ML INJ SOLN,50863,CDM,250,RC,J0169,HCPCS,54288-103-01,NDC,facility,both,30,ML,,257,179.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 5 MG/ML IV SOLN,50863,CDM,636,RC,J1921,HCPCS,36000-322-02,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-467-01,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMFIBROZIL 600 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-101-02,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NYSTATIN 500000 UNIT ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-0983-01,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,250,RC,J2003,HCPCS,0409-1323-05,NDC,facility,both,200,ML,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J1611,HCPCS,0597-0053-45,NDC,facility,both,1,EA,,186,130.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODINE STRONG (LUGOLS) 5 % ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,48433-230-15,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 200 MG/100 ML IVPB (MERGE),50863,CDM,636,RC,J1450,HCPCS,0409-4688-22,NDC,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID (PORK) 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0456-0457-01,NDC,facility,both,4,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MYCOPHENOLATE 500 MG TAB,50863,CDM,250,RC,J7517,HCPCS,0054-0166-25,NDC,facility,both,1,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-975-11,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIROFIBAN-0.9% SODIUM CHLORIDE 5 MG/100 ML (50 MCG/ML) IV SOLN,50863,CDM,250,RC,J3246,HCPCS,25208-002-01,NDC,facility,both,20,ML,,398,278.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2308-22,NDC,facility,both,50,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 250 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,60687-868-11,NDC,facility,both,1,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MYCOPHENOLATE 200 MG/ML ORAL SUSP,50863,CDM,250,RC,J7517,HCPCS,66689-307-08,NDC,facility,both,4,ML,,222,155.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE 0.5%/EPINEPHRINE 1:100K INJECTION,50863,CDM,636,RC,J2795,HCPCS,63323-286-30,NDC,facility,both,150,ML,,128,89.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-258-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 50 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,10135-779-01,NDC,facility,both,126,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 875 MG-125 MG TAB,50863,CDM,J3490,HCPCS,60687-803-11,NDC,,,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,61,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-4264-11,NDC,facility,both,15,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,636,RC,J0132,HCPCS,63323-963-21,NDC,facility,both,180,ML,,1426,998.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,636,RC,J1836,HCPCS,0338-1055-48,NDC,facility,both,150,ML,JZ,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DIAZEPAM  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-285-01,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-406-03,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-0552-23,NDC,facility,both,3,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOZAPINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-415-11,NDC,facility,both,2,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,50863,CDM,250,RC,J1756,HCPCS,0517-2340-01,NDC,facility,both,300,ML,,992,694.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,250,RC,J0132,HCPCS,55150-259-30,NDC,facility,both,58,ML,JW,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
MORPHINE  30 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,0904-6558-61,NDC,facility,both,2,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 250 MG/50 ML CONCENTRATED DRIP (RSE),50863,CDM,250,RC,J2250,HCPCS,0641-6060-01,NDC,facility,both,250,ML,,203,142.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1940,HCPCS,72603-251-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  100 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,0641-6175-01,NDC,facility,both,2,ML,JW,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
VENLAFAXINE  75 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,65862-528-90,NDC,facility,both,2,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,16714-026-01,NDC,facility,both,6,ML,JZ,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CARISOPRODOL 350 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50228-109-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,43547-354-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2310,HCPCS,67457-299-10,NDC,facility,both,1,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,0409-9094-22,NDC,facility,both,3,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-18,NDC,facility,both,40,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DEXTROSE 5%-1/4 NORMAL SALINE IV,50863,CDM,250,RC,J3490,HCPCS,0264-7616-10,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL IV BOLUS 10MG/ML (ANESTHESIA ONLY),50863,CDM,636,RC,J2704,HCPCS,0409-4699-54,NDC,facility,both,4,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J3490,HCPCS,0338-0049-41,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-48,NDC,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,47335-993-01,NDC,facility,both,50,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM SR 180 MG 24 HR CAP,50863,CDM,250,RC,J3490,HCPCS,50742-249-90,NDC,facility,both,2,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER FLUSH,50863,CDM,250,RC,J7060,HCPCS,0264-7510-20,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0003-0894-31,NDC,facility,both,1,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0574-0521-76,NDC,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1940,HCPCS,0409-6102-04,NDC,facility,both,4,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SITAGLIPTIN  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0006-0221-01,NDC,facility,both,2,EA,,130,91,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZONATATE 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,68084-214-11,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENRALIZUMAB 30 MG/ML SUBQ ATIN,50863,CDM,J0517,HCPCS,0310-1830-30,NDC,,,facility,both,30,ML,,14769,10338.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  88 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6952-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J2250,HCPCS,0409-2305-17,NDC,facility,both,6,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE 100 MG/0.5 ML SUBQ SLSY,50863,CDM,636,RC,Q9991,HCPCS,12496-0100-5,NDC,facility,both,1,ML,,2319,1623.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0143-9595-01,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MVI, ADULT INJECTION (PHS)",50863,CDM,636,RC,J3490,HCPCS,54643-5650-2,NDC,facility,both,1,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 5 MG/ML INHL NEB CONTINUOUS,50863,CDM,250,RC,J3490,HCPCS,73177-146-33,NDC,facility,both,2,ML,,424,296.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J1940,HCPCS,72603-251-01,NDC,facility,both,5,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN PEDS SYRINGE (20MG/ML) IN DEXTROSE (CDS MIX,50863,CDM,250,RC,J0690,HCPCS,0781-3451-70,NDC,facility,both,8,EA,,207,144.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 20 GRAM/500 ML IV SOLP,50863,CDM,250,RC,J3475,HCPCS,99999-0401-04,NDC,facility,both,40,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOVASTATIN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,61442-142-01,NDC,facility,both,2,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FILGRASTIM 300 (NEUPOGEN) MCG/ML INJ SOLN,50863,CDM,250,RC,55513-530-01,NDC,,,facility,both,0.012,ML,,157,109.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-099-11,NDC,facility,both,10,EA,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,55390-500-05,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0456,HCPCS,70436-019-82,NDC,facility,both,1,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,50863,CDM,J3490,HCPCS,69339-152-01,NDC,,,facility,both,2,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRIL MALEATE 1 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,52652-4001-1,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,25021-315-01,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,23155-473-32,NDC,facility,both,120,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  50 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-6992-61,NDC,facility,both,3,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,1,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN DETEMIR 100 UNIT/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,0169-3687-12,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV,50863,CDM,250,RC,J7120,HCPCS,0338-0117-04,NDC,facility,both,5,ML,,167,116.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE 2 MG SL SUBL,50863,CDM,636,RC,J3490,HCPCS,60687-481-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAVASTATIN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-5892-61,NDC,facility,both,2,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42806-341-01,NDC,facility,both,2,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE (POLACRILEX) 2 MG BUCL GUM,50863,CDM,250,RC,J3490,HCPCS,1093969133,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,636,RC,J3490,HCPCS,70004-600-09,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOBRAMYCIN SULFATE 40 MG/ML INJ SOLN,50863,CDM,250,RC,J3260,HCPCS,67457-473-00,NDC,facility,both,7,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NAFCILLIN 10 GRAM INJ SOLR,50863,CDM,250,RC,J3490,HCPCS,70860-119-99,NDC,facility,both,1,EA,,432,302.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TORSEMIDE   5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,31722-529-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DONEPEZIL  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6477-61,NDC,facility,both,5,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML (1ML) INJ SOLN,50863,CDM,250,RC,J0171,HCPCS,42023-159-01,NDC,facility,both,160,ML,,1405,983.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IV EPINEPHRINE 0.1 MG/ML SYRINGE (NEO-CODE IV),50863,CDM,250,RC,J0171,HCPCS,0409-4901-18,NDC,facility,both,1,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,636,RC,J2720,HCPCS,63323-229-01,NDC,facility,both,3,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAMSULOSIN 0.4 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,65862-598-01,NDC,facility,both,2,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE ACETATE 0.12 % OPHT DRPS,50863,CDM,250,RC,J3490,HCPCS,11980-174-05,NDC,facility,both,1,ML,,660,462,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN 1 GRAM SOLUTION FOR INJECTION,50863,CDM,250,RC,J0290,HCPCS,0781-3404-85,NDC,facility,both,2,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL (NEO/PEDS),50863,CDM,250,RC,J3490,HCPCS,63323-820-00,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 20 MG/ML INJ SOLN,50863,CDM,250,RC,J0360,HCPCS,63323-614-00,NDC,facility,both,1,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-504-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,65219-570-01,NDC,facility,both,4,ML,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-492-27,NDC,facility,both,80,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 100 % ORAL POWDER 238 GRAMS,50863,CDM,250,RC,J3490,HCPCS,45802-868-02,NDC,facility,both,1,GM,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-264-10,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM  3.375 GRAM IV SOLR,50863,CDM,636,RC,J2543,HCPCS,44567-802-10,NDC,facility,both,3,EA,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCERIN (ADULT) RECTAL SUPPOSITORY,50863,CDM,J3490,HCPCS,57237-325-21,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 20 MG/ML INJ SOLN,50863,CDM,250,RC,J0360,HCPCS,0641-6231-01,NDC,facility,both,1,ML,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,59651-488-01,NDC,facility,both,20,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM BROMIDE 0.02 % INHL SOLN,50863,CDM,J3490,HCPCS,76204-100-01,NDC,,,facility,both,3,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE 1 MG/2 ML INHL NBSP,50863,CDM,J3490,HCPCS,69097-321-86,NDC,,,facility,both,1,ML,,113,79.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2%/EPINEPHRINE 1:200K INJECTION (PF),50863,CDM,J2004,HCPCS,0409-3183-01,NDC,,,facility,both,400,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,50863,CDM,636,RC,J3301,HCPCS,16714-130-01,NDC,facility,both,3,ML,JW,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
POTASSIUM CITRATE 10 MEQ ORAL TBER,50863,CDM,250,RC,J3490,HCPCS,68084-850-33,NDC,facility,both,4,EA,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,J1938,HCPCS,36000-283-25,NDC,,,facility,both,40,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 0.25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-570-11,NDC,facility,both,1,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0121-1781-05,NDC,facility,both,2,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,6,ML,,113,79.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,J3490,HCPCS,63037-136-25,NDC,,,facility,both,2,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,250,RC,J3490,HCPCS,0143-9679-01,NDC,facility,both,1,ML,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN PEDS INFUSION (CDS MIXTURE),50863,CDM,250,RC,J0290,HCPCS,25021-136-10,NDC,facility,both,2,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,59651-426-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,3,EA,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,2,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE 110 MCG/ACTUATION INHL AERO,50863,CDM,636,RC,J3490,HCPCS,66993-079-96,NDC,facility,both,1,GM,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,0904-6794-80,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,7,EA,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0121-1781-05,NDC,facility,both,4,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,24338-134-02,NDC,facility,both,1,ML,,111,77.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IRRIGATION SOLN,50863,CDM,636,RC,J7120,HCPCS,0264-7389-60,NDC,facility,both,2,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-620-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GAMMAGARD S-D (IGA < 1 MCG/ML) 10 GRAM IV SOLR,50863,CDM,636,RC,J1566,HCPCS,0944-2658-04,NDC,facility,both,60,EA,,13969,9778.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ORPHENADRINE CITRATE 30 MG/ML INJ SOLN,50863,CDM,250,RC,J2360,HCPCS,0641-6182-01,NDC,facility,both,1,ML,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML IV SOLN (PRMC ERX MERGE),50863,CDM,250,RC,J2060,HCPCS,0409-1985-05,NDC,facility,both,1,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,636,RC,J0690,HCPCS,60505-6142-0,NDC,facility,both,4,EA,JZ,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GABAPENTIN 400 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-602-11,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,636,RC,J0690,HCPCS,70092-1017-46,NDC,facility,both,2,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J2003,HCPCS,63323-492-26,NDC,facility,both,300,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLP",50863,CDM,250,RC,P9047,HCPCS,44206-251-10,NDC,facility,both,4,ML,,1556,1089.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COLCHICINE 0.6 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,65162-710-09,NDC,facility,both,1,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,J2704,HCPCS,63323-269-22,NDC,,,facility,both,120,ML,,240,168,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J2003,HCPCS,0409-4279-02,NDC,facility,both,600,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 20 MG/ML (1 ML) IV SOLN,50863,CDM,636,RC,J9171,HCPCS,0409-0367-01,NDC,facility,both,200,ML,,2471,1729.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE DINITRATE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0143-1772-01,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25 MG-100 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0378-0085-01,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL  3.125 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68382-092-01,NDC,facility,both,2,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,54288-137-01,NDC,facility,both,1,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,50863,CDM,636,RC,J1885,HCPCS,0409-3796-19,NDC,facility,both,2,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
VANCOMYCIN  500 MG IV SOLR,50863,CDM,636,RC,J3370,HCPCS,70436-020-82,NDC,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,63323-506-41,NDC,facility,both,9,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J1610,HCPCS,63323-582-82,NDC,facility,both,1,EA,JZ,991,693.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PROPRANOLOL  60 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,69238-2080-1,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 2 GRAM INJ SOLR,50863,CDM,J0692,HCPCS,71288-009-21,NDC,,,facility,both,4,EA,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,J3490,HCPCS,0409-4277-16,NDC,,,facility,both,400,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COLCHICINE 0.6 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65162-710-09,NDC,facility,both,2,EA,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TERBUTALINE 1 MG/ML SUBQ SOLN,50863,CDM,250,RC,J3105,HCPCS,0143-9746-01,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J2004,HCPCS,63323-482-03,NDC,facility,both,100,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7008-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN PEDS INFUSION (CDS MIXTURE),50863,CDM,250,RC,J0290,HCPCS,25021-136-10,NDC,facility,both,4,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,636,RC,J3490,HCPCS,63037-136-25,NDC,facility,both,2,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOVASTATIN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-0576-06,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,16714-036-01,NDC,facility,both,1,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CEFTRIAXONE 1 GRAM INJ SOLR,50863,CDM,250,RC,J0696,HCPCS,44567-701-25,NDC,facility,both,4,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  20 MG ORAL TR12,50863,CDM,636,RC,J3490,HCPCS,59011-420-10,NDC,facility,both,3,EA,,187,130.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MEASLES,MUMPS,RUBELLA VACC(PF) 10EXP3.4-4.2- 3.3CCID50/0.5ML SUBQ SUSR",50863,CDM,250,RC,90707,HCPCS,58160-831-03,NDC,facility,both,1,EA,,410,287,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.3 MG/0.3 ML IM PNIJ,50863,CDM,250,RC,J0171,HCPCS,49502-102-01,NDC,facility,both,3,EA,JZ,675,472.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LEUCOVORIN CALCIUM 100 MG INJ SOLR,50863,CDM,250,RC,J0640,HCPCS,25021-814-30,NDC,facility,both,4,EA,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL (VITAMIN D3)   400 UNIT ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,7733394825,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRBESARTAN 150 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,33342-048-07,NDC,facility,both,1,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 100 MG PE/2 ML INJ SOLN,50863,CDM,636,RC,Q2009,HCPCS,0641-6136-01,NDC,facility,both,6,ML,JZ,225,157.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CEFTRIAXONE 500 MG INJ SOLR,50863,CDM,636,RC,J0696,HCPCS,44567-700-25,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIFAMPIN 600 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,0068-0597-01,NDC,facility,both,1,EA,,643,450.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0003-0894-21,NDC,facility,both,12,EA,,524,366.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  1 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0603-5335-21,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV (BOLUS),50863,CDM,250,RC,J7120,HCPCS,17271-710-06,NDC,facility,both,1,ML,,1631,1141.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,636,RC,Q0162,HCPCS,17856-0691-5,NDC,facility,both,8,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 0.5 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,63323-481-01,NDC,facility,both,100,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,636,RC,J7510,HCPCS,17856-0815-1,NDC,facility,both,4,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,90,ML,JW,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,68462-470-40,NDC,facility,both,10,ML,,164,114.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,250,RC,J3490,HCPCS,72789-057-01,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 50% IN WATER (MERGE RECORD),50863,CDM,250,RC,J7060,HCPCS,0409-7517-66,NDC,facility,both,1,ML,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN 100 MG/4 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,66689-036-01,NDC,facility,both,2,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,68180-723-04,NDC,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,250,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,27808-156-01,NDC,facility,both,2,EA,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM OXIDE 400 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,6498033990,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,50863,CDM,250,RC,Q5119,HCPCS,0069-0249-01,NDC,facility,both,100,ML,,19784,13848.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1815,HCPCS,0002-8215-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALACYCLOVIR 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6565-61,NDC,facility,both,2,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-677-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IFOSFAMIDE 1 GRAM IV SOLR,50863,CDM,250,RC,J9208,HCPCS,10019-925-82,NDC,facility,both,1,EA,,216,151.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-346-11,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAZOSIN 1 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,51079-630-01,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN  5 MG/ACTUATION NASL SPRY,50863,CDM,250,RC,J3490,HCPCS,66993-081-69,NDC,facility,both,2,EA,,443,310.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,0409-3178-01,NDC,,,facility,both,180,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,J0665,HCPCS,70594-118-01,NDC,,,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,53,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0780,HCPCS,25021-790-02,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,63323-010-01,NDC,facility,both,2,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 5 MG/5 ML IV,50863,CDM,636,RC,J3490,HCPCS,36000-033-10,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MYCOPHENOLATE SODIUM 360 MG ORAL TBEC,50863,CDM,636,RC,J7518,HCPCS,0904-6786-04,NDC,facility,both,2,EA,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G POTASSIUM  5000000 UNIT INJ SOLR,50863,CDM,250,RC,J2540,HCPCS,0049-0520-83,NDC,facility,both,5,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN LYSINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66993-490-36,NDC,facility,both,2,ML,,1877,1313.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BICTEGRAV-EMTRICIT-TENOFOV ALA 50-200-25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,61958-2501-1,NDC,facility,both,1,EA,,574,401.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 100 MG/5 ML ORAL LIQD,50863,CDM,250,RC,J3490,HCPCS,50383-063-10,NDC,facility,both,25,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DROPERIDOL 2.5 MG/ML INJ SOLN,50863,CDM,636,RC,J1790,HCPCS,0517-9702-01,NDC,facility,both,1,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,0409-4887-17,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,636,RC,J2003,HCPCS,0409-1323-05,NDC,facility,both,100,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-145-11,NDC,facility,both,50,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-742-11,NDC,facility,both,8,EA,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALSARTAN  40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,31722-151-30,NDC,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPROSTADIL 500 MCG/ML INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0703-1501-02,NDC,facility,both,1,ML,,469,328.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GALANTAMINE  4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,57237-049-60,NDC,facility,both,1,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 50% IN WATER (MERGE RECORD),50863,CDM,636,RC,J7060,HCPCS,76329-3302-1,NDC,facility,both,1,ML,,119,83.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,636,RC,J2270,HCPCS,0409-1890-03,NDC,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TELMISARTAN 40 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68382-472-30,NDC,facility,both,1,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 50 MG/ML INJECTION,50863,CDM,J1200,HCPCS,63323-664-00,NDC,,,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,636,RC,J3490,HCPCS,0173-0682-24,NDC,facility,both,1,GM,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPATITIS A VIRUS VACCINE (PF) 1440 ELISA UNIT/ML IM SYRG,50863,CDM,250,RC,90632,HCPCS,58160-826-43,NDC,facility,both,1,ML,,372,260.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM 2000 MG IV SOLR,50863,CDM,636,RC,J2185,HCPCS,72078-081-00,NDC,facility,both,20,EA,,184,128.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 5 MG/ML INHL NEB CONTINUOUS,50863,CDM,250,RC,J3490,HCPCS,73177-163-33,NDC,facility,both,1,ML,,245,171.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 50 % (4 MEQ/ML) INJ SOLN,50863,CDM,250,RC,J3475,HCPCS,63323-642-50,NDC,facility,both,4,ML,,3776,2643.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL 400 UNIT/ML ORAL DROP (REPACK),50863,CDM,250,RC,J3490,HCPCS,87086644,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM  2.25 GRAM IV SOLR,50863,CDM,250,RC,J2543,HCPCS,55150-119-30,NDC,facility,both,2,EA,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,70095-031-01,NDC,facility,both,15,ML,,611,427.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 0.3 % OPHT DROP,50863,CDM,636,RC,J3490,HCPCS,61314-656-25,NDC,facility,both,1,ML,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER SULFADIAZINE 1 % TOP CREA,50863,CDM,636,RC,J3490,HCPCS,61570-131-50,NDC,facility,both,1,GM,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEMANTINE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6505-06,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65862-246-08,NDC,facility,both,2,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0456,HCPCS,55150-174-10,NDC,facility,both,1,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAMOXIFEN 10 MG ORAL TAB,50863,CDM,250,RC,J9999,HCPCS,0378-0144-91,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,63323-461-01,NDC,facility,both,1,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-088-11,NDC,facility,both,1,EA,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  37.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-844-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SYRG,50863,CDM,636,RC,J3490,HCPCS,8290306547,NDC,facility,both,5,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,636,RC,J3490,HCPCS,51754-4250-1,NDC,facility,both,2,ML,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,7,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL 20 MG/5 ML ORAL ELIX,50863,CDM,636,RC,J3490,HCPCS,0121-0942-05,NDC,facility,both,2,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 125 MG ORAL CPSP,50863,CDM,250,RC,J3490,HCPCS,63739-995-10,NDC,facility,both,4,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADVATE: FACTOR VIII CONCENTRATE (MERGE RECORD),50863,CDM,636,RC,J7209,HCPCS,0944-3052-02,NDC,facility,both,500,UN,,2093,1465.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3373,HCPCS,0143-9162-01,NDC,facility,both,175,EA,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,636,RC,J3490,HCPCS,0409-1323-05,NDC,facility,both,200,ML,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOFETILIDE 125 MCG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,72205-039-60,NDC,facility,both,2,EA,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-333-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 100 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,31722-574-47,NDC,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2599,HCPCS,43598-914-25,NDC,facility,both,3,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69315-905-05,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-454-11,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 100 MG/1 ML SUBQ SYRG,50863,CDM,J1650,HCPCS,0548-5605-00,NDC,,,facility,both,10,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE IV BOLUS (STROKE) 100 MG (2 X 50 MG VIALS),50863,CDM,J2997,HCPCS,50242-044-06,NDC,,,facility,both,50,EA,,12145,8501.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),50863,CDM,250,RC,J0171,HCPCS,76329-3318-1,NDC,facility,both,100,ML,,807,564.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NYSTATIN 100000 UNIT/ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,17856-1045-1,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATENOLOL  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7187-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,4,EA,,139,97.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,904740361,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,J3490,HCPCS,0143-9889-15,NDC,,,facility,both,7,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
URSODIOL 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,50268-796-11,NDC,facility,both,1,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,0409-9094-12,NDC,facility,both,1,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,636,RC,J3010,HCPCS,0409-9094-22,NDC,facility,both,1,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
URSODIOL 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-100-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE IN D5W 1 GRAM/100 ML IV PGBK,50863,CDM,J3475,HCPCS,63323-108-00,NDC,,,facility,both,2,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0591-0605-01,NDC,facility,both,4,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,69097-125-03,NDC,facility,both,1,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 10 GRAM/15 ML ORAL SOLN,50863,CDM,J3490,HCPCS,66689-038-01,NDC,,,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN 0.9% SODIUM CL 1.25 GRAM/250 ML IV SOLN,50863,CDM,250,RC,J3370,HCPCS,71285-6074-1,NDC,facility,both,3,ML,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,50863,CDM,250,RC,J0696,HCPCS,0143-9856-01,NDC,facility,both,40,EA,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,16714-293-01,NDC,facility,both,10,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,16714-661-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,636,RC,J1953,HCPCS,63323-400-01,NDC,facility,both,20,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
AMPICILLIN SODIUM  2 GRAM INJ SOLR,50863,CDM,250,RC,J0290,HCPCS,55150-114-20,NDC,facility,both,4,EA,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"NEOMYCIN-POLYMYXIN B GU 40 MG-200,000 UNIT/ML IRRIGATION SOLN",50863,CDM,250,RC,J3490,HCPCS,39822-1201-5,NDC,facility,both,1,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL IV BOLUS 10MG/ML (ANESTHESIA ONLY),50863,CDM,250,RC,J2704,HCPCS,63323-269-29,NDC,facility,both,40,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA SR 25 MG-100 MG TAB,50863,CDM,250,RC,J3490,HCPCS,51079-978-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOPIDOGREL 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6467-10,NDC,facility,both,1,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,250,RC,J2405,HCPCS,0641-6078-01,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,42,ML,,603,422.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN  4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51672-4031-1,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN   81 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,0904-6751-80,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIOTHYRONINE 25 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,62756-590-88,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZTREONAM 1 GRAM INJ SOLR,50863,CDM,636,RC,J0457,HCPCS,0409-0829-11,NDC,facility,both,10,EA,,200,140,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 250 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,42192-608-05,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1940,HCPCS,72603-251-01,NDC,facility,both,5,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,43547-281-10,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  75 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,68084-709-11,NDC,facility,both,5,EA,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPROST TROMETHAMINE 250 MCG/ML IM SOLN,50863,CDM,250,RC,J3490,HCPCS,0009-0856-05,NDC,facility,both,1,ML,,605,423.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,18,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"RABIES VACCINE, PURIFIED CHICKEN EMBRYO CELL (PF) 2.5 UNIT IM KIT",50863,CDM,636,RC,90675,HCPCS,50632-010-01,NDC,facility,both,1,EA,,1466,1026.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID (PORK) 15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,42192-327-01,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG IV SOLR,50863,CDM,636,RC,J3490,HCPCS,0008-0923-60,NDC,facility,both,1,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,63323-462-17,NDC,facility,both,2,ML,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE IV CONCENTRATED INFUSION (1 MEQ/ML),50863,CDM,636,RC,J3490,HCPCS,0409-6625-02,NDC,facility,both,1,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 400 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0143-9887-01,NDC,facility,both,18,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,0517-4601-01,NDC,facility,both,4,ML,,159,111.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,697,ML,,1001,700.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 400 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,65862-071-01,NDC,facility,both,13,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN D5W 20000 UNIT/500 ML,50863,CDM,250,RC,J1644,HCPCS,0264-9567-10,NDC,facility,both,20,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 1 GRAM INJ SOLR,50863,CDM,250,RC,J0692,HCPCS,44567-240-10,NDC,facility,both,2,EA,JZ,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,50,ML,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,68382-444-05,NDC,facility,both,2,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 60 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,57237-019-30,NDC,facility,both,1,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 20MG/ML IV SYRINGE (PEDS/NEO),50863,CDM,250,RC,J0612,HCPCS,63323-311-10,NDC,facility,both,22,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIRAGLUTIDE 0.6 MG/0.1 ML (18 MG/3 ML) SUBQ PNIJ,50863,CDM,636,RC,J3590,HCPCS,0480-3667-20,NDC,facility,both,1,ML,,1426,998.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IVPB (PEDIATRICS/ADULT NON-FORM)",50863,CDM,250,RC,J0137,HCPCS,24201-100-01,NDC,facility,both,100,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,55150-222-20,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALGLUCOSIDASE ALFA 50 MG IV SOLR,50863,CDM,636,RC,J0221,HCPCS,58468-0160-1,NDC,facility,both,110,EA,JZ,45783,32048.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
BUPIVACAINE 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-467-01,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,43547-354-10,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE 21 MG/24 HR TD PT24,50863,CDM,250,RC,J3490,HCPCS,0536-5896-88,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 20MG/ML IV SYRINGE (PEDS/NEO),50863,CDM,250,RC,J0612,HCPCS,63323-311-10,NDC,facility,both,65,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,83980-006-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 100 MG/ML FROM 1 GRAM VIAL (PRMC PEDS ONLY),50863,CDM,250,RC,J0696,HCPCS,0409-7332-11,NDC,facility,both,8,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROMETHORPHAN-GUAIFENESIN SR 30 MG-600 MG 12 HR TAB,50863,CDM,250,RC,J3490,HCPCS,6382405620,NDC,facility,both,10,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0143-9386-01,NDC,facility,both,24,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7263-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7126-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0143-9509-01,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 800 MG ORAL TAB,50863,CDM,250,RC,J0601,HCPCS,17856-921-01,NDC,facility,both,40,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE (POLACRILEX) 2 MG BUCL GUM,50863,CDM,250,RC,J3490,HCPCS,0536-1362-25,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),50863,CDM,250,RC,J0171,HCPCS,76329-3318-1,NDC,facility,both,50,ML,,404,282.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 300 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,65162-649-78,NDC,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCUSATE SODIUM 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7183-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,63323-280-03,NDC,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,55111-150-01,NDC,facility,both,2,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,636,RC,J1953,HCPCS,0409-1886-22,NDC,facility,both,450,ML,,233,163.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRIL MALEATE 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,43547-548-10,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-2051-15,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),50863,CDM,636,RC,J3490,HCPCS,0409-4888-10,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 800 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-328-11,NDC,facility,both,1,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,250,RC,J3101,HCPCS,50242-037-06,NDC,facility,both,34,EA,JW,6771,4739.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CHLORDIAZEPOXIDE 25 MG CAP,50863,CDM,636,RC,J3490,HCPCS,0555-0159-04,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 1 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,0093-9293-19,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,636,RC,J7060,HCPCS,0338-0017-04,NDC,facility,both,2,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-229-02,NDC,facility,both,2,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-426-02,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 3000 MCG/ML INJECTION,50863,CDM,250,RC,J0153,HCPCS,67457-855-00,NDC,facility,both,6,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,110,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM-ALBUTEROL 0.5 MG-2.5 MG/3 ML NEB SOLUTION,50863,CDM,250,RC,J3490,HCPCS,0487-0201-01,NDC,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,50863,CDM,250,RC,J1756,HCPCS,0517-2340-01,NDC,facility,both,200,ML,,642,449.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-3178-01,NDC,facility,both,90,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN 1 GRAM SOLUTION FOR INJECTION,50863,CDM,636,RC,J0290,HCPCS,0781-3404-85,NDC,facility,both,2,EA,JZ,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 40 GRAM/400 ML (10 %) INJ SOLN",50863,CDM,250,RC,J1561,HCPCS,13533-800-20,NDC,facility,both,20,ML,,2829,1980.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-02,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL 20 MG/5 ML ORAL ELIX,50863,CDM,250,RC,J3490,HCPCS,60687-671-40,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN NPH & REGULAR HUMAN 100 UNIT/ML (70-30) SUBQ SUSP,50863,CDM,250,RC,J1815,HCPCS,0002-8715-01,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,636,RC,J2003,HCPCS,0409-1323-15,NDC,facility,both,200,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0781-2020-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,250,RC,J0330,HCPCS,31722-981-10,NDC,facility,both,14,ML,,152,106.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATED 20 MG/ML IV SOLN,50863,CDM,250,RC,J0706,HCPCS,51754-0500-1,NDC,facility,both,11,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,636,RC,J3360,HCPCS,43598-106-11,NDC,facility,both,1,ML,JW,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,16714-046-01,NDC,facility,both,1,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
POTASSIUM CHLORIDE 10 MEQ/100 ML IV PGBK,50863,CDM,636,RC,J3480,HCPCS,14789-109-16,NDC,facility,both,20,ML,,939,657.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,13668-009-01,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6501-06,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-453-01,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WHITE PETROLATUM-MINERAL OIL OPHT OINT (PDS MERGE),50863,CDM,250,RC,J3490,HCPCS,23066704,NDC,facility,both,1,GM,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,8068108600,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J2004,HCPCS,0409-3178-01,NDC,facility,both,85,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL IV BOLUS 10MG/ML (ANESTHESIA ONLY),50863,CDM,636,RC,J2704,HCPCS,0409-4699-54,NDC,facility,both,19,ML,JW,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J3490,HCPCS,17271-701-02,NDC,facility,both,1,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),50863,CDM,250,RC,J3490,HCPCS,63323-186-01,NDC,facility,both,3,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 250 MG-62.5 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,59651-026-75,NDC,facility,both,9,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,28,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,13,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,72162-1329-8,NDC,facility,both,1,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2599,HCPCS,63323-930-01,NDC,facility,both,15,ML,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0264-7800-10,NDC,facility,both,1,ML,JZ,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ONDANSETRON HCL  4 MG ORAL TAB,50863,CDM,636,RC,Q0162,HCPCS,65862-187-30,NDC,facility,both,12,EA,,308,215.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,0641-0400-37,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,636,RC,J7060,HCPCS,0338-0017-04,NDC,facility,both,2,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 250 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,42192-608-05,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXAZOSIN 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-836-95,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,50863,CDM,250,RC,J0696,HCPCS,0781-3209-90,NDC,facility,both,8,EA,JZ,388,271.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-50,NDC,facility,both,116,ML,,205,143.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2305-04,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NORTRIPTYLINE 25 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,50268-604-11,NDC,facility,both,4,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,42806-150-33,NDC,facility,both,2,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG IV SOLR,50863,CDM,636,RC,J0456,HCPCS,70095-025-01,NDC,facility,both,1,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB 100 MG IV SOLR,50863,CDM,636,RC,J1745,HCPCS,57894-030-01,NDC,facility,both,6,EA,JW,841,588.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
HYDROCODONE-ACETAMINOPHEN 5 MG-325 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0406-0123-23,NDC,facility,both,4,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,16714-298-01,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,0121-4675-05,NDC,facility,both,4,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,68180-150-01,NDC,facility,both,2,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6500-06,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,636,RC,J0690,HCPCS,70092-1017-46,NDC,facility,both,4,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-821-01,NDC,facility,both,1,EA,PLAD,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
INSULIN NPH & REGULAR HUMAN 100 UNIT/ML (70-30) SUBQ SUSP,50863,CDM,250,RC,J1815,HCPCS,0169-1837-11,NDC,facility,both,14,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LANTHANUM  500 MG ORAL CHEW,50863,CDM,636,RC,J3490,HCPCS,54092-252-45,NDC,facility,both,3,EA,,212,148.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INEBILIZUMAB-CDON 10 MG/ML IV SOLN,50863,CDM,636,RC,J1823,HCPCS,75987-150-01,NDC,facility,both,300,ML,JZ,694691,486283.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PRAVASTATIN 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-5891-61,NDC,facility,both,2,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIGOXIN 250 MCG/ML INJ SOLN,50863,CDM,250,RC,J1160,HCPCS,0781-3059-72,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7308-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLN (MERGE)",50863,CDM,250,RC,P9047,HCPCS,64208-2512-4,NDC,facility,both,1,ML,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOLAZONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50742-351-01,NDC,facility,both,1,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 100 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,31722-574-47,NDC,facility,both,1,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR  6 MG/ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0004-0822-05,NDC,facility,both,4,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,636,RC,J3490,HCPCS,60687-390-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THROMBIN (RECOMBINANT) 5000 UNIT TOP SOLR,50863,CDM,250,RC,J3490,HCPCS,0338-0324-01,NDC,facility,both,9,EA,,3344,2340.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NYSTATIN 100000 UNIT/ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,69315-504-60,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GRANISETRON 1 MG/ML (1 ML) IV SOLN,50863,CDM,250,RC,J1626,HCPCS,0143-9744-01,NDC,facility,both,6,ML,JW,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CELECOXIB 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-436-11,NDC,facility,both,2,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0406-8515-23,NDC,facility,both,2,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,68094-231-59,NDC,facility,both,6,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,250,RC,J3490,HCPCS,61553-320-70,NDC,facility,both,3,ML,,207,144.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,636,RC,J3490,HCPCS,72485-510-01,NDC,facility,both,1,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MYCOPHENOLATE 500 MG IV SOLUTION,50863,CDM,250,RC,J3490,HCPCS,71288-803-20,NDC,facility,both,1,EA,,185,129.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,636,RC,J3490,HCPCS,73702-301-15,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCRALFATE 100 MG/ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0121-0974-10,NDC,facility,both,1,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IV PGBK,50863,CDM,250,RC,J3475,HCPCS,25021-612-81,NDC,facility,both,4,ML,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,636,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,13,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 250 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,0904-6363-45,NDC,facility,both,3,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-1159-19,NDC,facility,both,2,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-492-26,NDC,facility,both,300,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0143-9889-01,NDC,facility,both,20,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0143-9386-01,NDC,facility,both,16,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPHENIDATE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0115-1800-01,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,68462-755-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-512-11,NDC,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,J3490,HCPCS,68094-231-59,NDC,,,facility,both,3,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEPERIDINE (PF) 25 MG/ML IV SOLN (PHS MERGE),50863,CDM,636,RC,J2175,HCPCS,0409-1176-03,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,J3490,HCPCS,68094-231-59,NDC,,,facility,both,3,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,11,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,636,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,116,ML,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 1 MG/ML (1ML) SYRINGE (REPACK),50863,CDM,250,RC,J2997,HCPCS,50242-044-13,NDC,facility,both,4,EA,,1557,1089.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATED 20 MG/ML IV SOLN,50863,CDM,250,RC,J0706,HCPCS,51754-0500-1,NDC,facility,both,16,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INDOCYANINE GREEN 25 MG INJ,50863,CDM,250,RC,J3490,HCPCS,70100-725-01,NDC,facility,both,1,EA,,1287,900.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAZOSIN 1 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0378-1101-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR NEO/PEDS INFUSION (CDS FROM PREMIX),50863,CDM,250,RC,J0133,HCPCS,63323-325-10,NDC,facility,both,10,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,636,RC,Q0162,HCPCS,65162-691-79,NDC,facility,both,2,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-4675-05,NDC,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,64208-2510-2,NDC,facility,both,2,ML,,238,166.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE HCL IN 5% DEXTROSE 100 MCG/10 ML (10 MCG/ML) IV SYRG,50863,CDM,636,RC,J0171,HCPCS,70092-1617-46,NDC,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRENATAL VIT NO.130-IRON-FOLIC 27 MG IRON- 800 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,7733371525,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,14,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN 0.9% SODIUM CL 1.25 GRAM/250 ML IV SOLN,50863,CDM,250,RC,J3370,HCPCS,70092-9054-05,NDC,facility,both,3,ML,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0093-4155-73,NDC,facility,both,18,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7122-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GALANTAMINE  4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,57237-049-60,NDC,facility,both,1,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
0.2 MICRON FILTER ATTACHMENT MISC MISC,50863,CDM,250,RC,99999-0403-06,NDC,,,facility,both,2,EA,,130,91,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ROTAVIRUS VACCINE, LIVE, 89-12 10EXP6 CCID50 /1.5 ML ORAL SUSP",50863,CDM,90681,HCPCS,58160-740-21,NDC,,,facility,both,1,ML,,635,444.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,FAMNOCHARGE,HCPCS,17856-0759-5,NDC,,,facility,both,1,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,0338-0072-25,NDC,facility,both,1,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CLOPIDOGREL 300 MG ORAL TAB,50863,CDM,J3490,HCPCS,68084-752-95,NDC,,,facility,both,1,EA,,131,91.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) NEB SOLUTION,50863,CDM,636,RC,J3490,HCPCS,0487-9501-01,NDC,facility,both,2,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,636,RC,J1100,HCPCS,63323-506-00,NDC,facility,both,5,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,J3490,HCPCS,63037-136-25,NDC,,,facility,both,2,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-ABDA 100 MG IV SOLR,50863,CDM,Q5104,HCPCS,78206-162-99,NDC,,,facility,both,34,EA,,7070,4949,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-492-27,NDC,,,facility,both,40,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 100 MG/ML INJ SOLN,50863,CDM,250,RC,J2800,HCPCS,70069-101-01,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,55,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,5,EA,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6949-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE  1 % TOP OINT,50863,CDM,636,RC,J3490,HCPCS,70677-1214-1,NDC,facility,both,1,GM,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 125 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-519-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE (PF-DURAMORPH/ASTRAMORPH) 0.5 MG/ML INJ SOLN,50863,CDM,636,RC,J2274,HCPCS,0409-3814-12,NDC,facility,both,1,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 20 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,51991-746-90,NDC,facility,both,3,EA,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,16714-293-01,NDC,facility,both,4,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE IN D5W 1 GRAM/100 ML IV PGBK,50863,CDM,636,RC,J3475,HCPCS,0409-6727-55,NDC,facility,both,2,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VORICONAZOLE 200 MG IV SOLN,50863,CDM,250,RC,J3465,HCPCS,0781-3416-94,NDC,facility,both,1,EA,JW,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,72888-060-30,NDC,facility,both,1,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0093-4155-73,NDC,facility,both,8,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZTREONAM 2 GRAM INJ SOLR,50863,CDM,250,RC,J0457,HCPCS,63323-402-01,NDC,facility,both,20,EA,,374,261.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,60219-1708-1,NDC,facility,both,40,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 40 GRAM/400 ML (10 %) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-20,NDC,facility,both,10,ML,JZ,1415,990.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PACLITAXEL 6 MG/ML IV CONC,50863,CDM,250,RC,J9267,HCPCS,61703-342-22,NDC,facility,both,73,ML,,121,84.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 10 MG/ML ORAL SOLUTION (REPACK),50863,CDM,250,RC,J3490,HCPCS,0131-5410-71,NDC,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,59651-488-01,NDC,facility,both,40,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,1,ML,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VERAPAMIL 180 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,75834-158-01,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNIT/G TOP PACK,50863,CDM,250,RC,J3490,HCPCS,45802-060-70,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIOTHYRONINE  5 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,62756-589-88,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,934,ME,JZ,12675,8872.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SODIUM CHLORIDE 0.9% IV (PEDS) BOLUS,50863,CDM,250,RC,J7040,HCPCS,0264-7800-09,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0591-5443-01,NDC,facility,both,20,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FILGRASTIM-SNDZ 300 MCG/0.5 ML INJ SYRG,50863,CDM,250,RC,Q5101,HCPCS,61314-318-10,NDC,facility,both,300,ML,,972,680.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J2004,HCPCS,63323-487-01,NDC,facility,both,200,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYBUTYNIN CHLORIDE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0832-0038-89,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"HEPARIN, PORCINE (PF)  100 UNIT/ML IV SYRG",50863,CDM,250,RC,J1642,HCPCS,6380760055,NDC,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE-DEXTROSE-WATER(PF) 7.5 MG/ML (0.75 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-1761-02,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J3490,HCPCS,0409-4279-02,NDC,,,facility,both,300,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-492-27,NDC,,,facility,both,560,ML,,440,308,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,J3010,HCPCS,0409-9094-22,NDC,,,facility,both,3,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM TETRADECYL SULFATE 3 % IV SOLN,50863,CDM,636,RC,J3490,HCPCS,67457-163-00,NDC,facility,both,6,ML,,2386,1670.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NATALIZUMAB 300 MG/15 ML IV SOLN,50863,CDM,J2323,HCPCS,64406-008-01,NDC,,,facility,both,300,ML,,16000,11200,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2003,HCPCS,72603-505-01,NDC,,,facility,both,100,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MANNITOL 25 % IV SOLN,50863,CDM,250,RC,J2150,HCPCS,63323-024-01,NDC,facility,both,7,ML,,277,193.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INHL NEBU,50863,CDM,250,RC,J3490,HCPCS,7620430003,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7124-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-439-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM-ALBUTEROL 0.5 MG-2.5 MG/3 ML NEB SOLUTION,50863,CDM,250,RC,J3490,HCPCS,0487-0201-01,NDC,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,636,RC,J1596,HCPCS,70069-013-25,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5%-1/4 NORMAL SALINE IV,50863,CDM,250,RC,J3490,HCPCS,0338-0077-04,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMFIBROZIL 600 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-224-11,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,70,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,250,RC,J0330,HCPCS,0409-6629-02,NDC,facility,both,7,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,J3490,HCPCS,68094-231-59,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOLTERODINE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,33342-097-09,NDC,facility,both,2,EA,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG/24 HR TD PTWK,50863,CDM,250,RC,J3490,HCPCS,0555-1009-16,NDC,facility,both,1,EA,,163,114.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,34,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACAMPROSATE 333 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,68462-435-18,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN D5W 1 GRAM/200 ML IV PGBK,50863,CDM,250,RC,J3370,HCPCS,0338-3552-48,NDC,facility,both,2,ML,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGIC MOUTHWASH REPACK (BMX 1:1:1),50863,CDM,250,RC,J3490,HCPCS,0603-0823-54,NDC,facility,both,2,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-492-27,NDC,facility,both,100,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,636,RC,P9045,HCPCS,68516-5219-0,NDC,facility,both,9,ML,,2288,1601.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6773-61,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM POLYSTYRENE SULF-SORBTL 15-20 GRAM/60 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,46287-006-60,NDC,facility,both,1,ML,,152,106.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6773-61,NDC,facility,both,3,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MANNITOL 25 % IV SOLN,50863,CDM,250,RC,J2150,HCPCS,63323-024-01,NDC,facility,both,2,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0054-0710-20,NDC,facility,both,3,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,50863,CDM,250,RC,J9045,HCPCS,0703-4239-01,NDC,facility,both,7,ML,,194,135.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,50863,CDM,636,RC,J1885,HCPCS,0409-3796-19,NDC,facility,both,1,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-145-11,NDC,facility,both,20,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 500 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,0904-7182-61,NDC,facility,both,6,EA,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VINCRISTINE 2 MG/2 ML IV SOLN,50863,CDM,250,RC,J9370,HCPCS,61703-309-16,NDC,facility,both,2,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-01,NDC,facility,both,2,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOBRAMYCIN-DEXAMETHASONE 0.3 %-0.1 % EYE OINTMENT,50863,CDM,636,RC,J3490,HCPCS,0078-0876-01,NDC,facility,both,1,GM,,1056,739.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  1 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,64380-782-06,NDC,facility,both,66,EA,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE PAMOATE  25 MG ORAL CAP,50863,CDM,250,RC,Q0177,HCPCS,0904-7065-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE  4 MG ORAL TAB,50863,CDM,636,RC,J7509,HCPCS,68084-149-11,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-461-11,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2599,HCPCS,65219-039-00,NDC,facility,both,12,ML,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0143-9386-01,NDC,facility,both,21,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 400 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0143-9887-01,NDC,facility,both,17,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMETHICONE  80 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,69618-033-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6475-61,NDC,facility,both,4,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,636,RC,J2405,HCPCS,60505-6130-0,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,250,RC,J0132,HCPCS,70594-111-01,NDC,facility,both,180,ML,,916,641.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,70954-316-10,NDC,facility,both,2,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,68516-5214-4,NDC,facility,both,6,ML,,1098,768.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7363-61,NDC,facility,both,1,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 500 MG (200 MG ELEMENTAL) CHEW TAB,50863,CDM,250,RC,J3490,HCPCS,66553-004-01,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,50863,CDM,636,RC,J1756,HCPCS,0517-2325-01,NDC,facility,both,46,ML,,171,119.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,72266-118-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IV PGBK,50863,CDM,250,RC,J3475,HCPCS,0409-6729-41,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZONATATE 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7153-61,NDC,facility,both,24,EA,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-464-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETIRIZINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0378-3635-01,NDC,facility,both,2,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE  0.65 % NASL SPRA,50863,CDM,250,RC,J3490,HCPCS,45802-357-58,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE DINITRATE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-569-10,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,42806-150-33,NDC,facility,both,10,ML,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB 100 MG IV SOLR,50863,CDM,636,RC,J1745,HCPCS,57894-030-01,NDC,facility,both,80,EA,,25786,18050.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 4 MEQ/ML IV SOLP (COMPOUNDED 30ML),50863,CDM,250,RC,J3490,HCPCS,63323-093-01,NDC,facility,both,2,ML,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,250,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NOREPINEPHRINE BITARTRATE-D5W 4 MG/250 ML (16 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0338-0112-20,NDC,facility,both,2,ML,,267,186.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL IV BOLUS 10MG/ML (ANESTHESIA ONLY),50863,CDM,636,RC,J2704,HCPCS,0409-4699-54,NDC,facility,both,2,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LIDOCAINE 2 % MUCOSAL SOLN (VISCOUS),50863,CDM,J3490,HCPCS,0121-4950-15,NDC,,,facility,both,1,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRILAT 1.25 MG/ML IV INJ,50863,CDM,250,RC,J3490,HCPCS,0143-9787-01,NDC,facility,both,1,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-253-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 0.1 MG/HR TD PT24,50863,CDM,250,RC,J3490,HCPCS,0378-9102-16,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM  2.25 GRAM IV SOLR,50863,CDM,250,RC,J2543,HCPCS,55150-119-30,NDC,facility,both,1,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN IN D5W 600 MG/50 ML IV PGBK,50863,CDM,250,RC,J0736,HCPCS,0338-3616-50,NDC,facility,both,2,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  75 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,50268-874-11,NDC,facility,both,2,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68180-981-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 80 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0054-8301-25,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,0409-6625-14,NDC,facility,both,10,ML,,578,404.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,31,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,55150-177-05,NDC,facility,both,200,ML,JZ,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DEXAMETHASONE 1 MG ORAL TAB,50863,CDM,636,RC,J8540,HCPCS,72578-166-01,NDC,facility,both,8,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-9558-05,NDC,facility,both,2,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,636,RC,J0132,HCPCS,55150-259-30,NDC,facility,both,180,ML,,813,569.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISANKIZUMAB-RZAA  60 MG/ML IV SOLN,50863,CDM,636,RC,J2327,HCPCS,0074-5015-01,NDC,facility,both,1200,ML,,58689,41082.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,70069-013-25,NDC,facility,both,6,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,63323-010-01,NDC,facility,both,3,ML,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,2055503601,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
URSODIOL 300 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-100-11,NDC,facility,both,2,EA,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,250,RC,J3360,HCPCS,69339-136-03,NDC,facility,both,2,ML,,145,101.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0003-0893-31,NDC,facility,both,1,EA,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 25 MG TAB,50863,CDM,250,RC,J3490,HCPCS,62584-265-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,159,ML,,228,159.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0781-3246-02,NDC,facility,both,14,ML,,192,134.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL 2.5 MG/ML SUSPENSION,50863,CDM,250,RC,J3490,HCPCS,99999-0404-75,NDC,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J2004,HCPCS,0409-3178-01,NDC,facility,both,80,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0781-3246-02,NDC,facility,both,4,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J1610,HCPCS,63323-596-11,NDC,facility,both,5,EA,,3924,2746.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,250,RC,J0330,HCPCS,31722-981-10,NDC,facility,both,13,ML,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-28,NDC,facility,both,32,EA,,173,121.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,636,RC,J3490,HCPCS,51754-4250-1,NDC,facility,both,1,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESNA 100 MG/ML IV SOLN,50863,CDM,250,RC,J9209,HCPCS,10019-953-62,NDC,facility,both,8,ML,,219,153.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,70069-363-01,NDC,facility,both,2,ML,,288,201.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCERIN (ADULT) RECTAL SUPPOSITORY,50863,CDM,250,RC,J3490,HCPCS,132007924,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,55150-177-05,NDC,facility,both,350,ML,,140,98,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-132-11,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-285-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,23155-600-31,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOLUTEGRAVIR-RILPIVIRINE 50-25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,49702-242-13,NDC,facility,both,1,EA,,506,354.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL,50863,CDM,250,RC,J3490,HCPCS,63323-820-01,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROMETHORPHAN POLY COMPLEX ER 30 MG/5 ML ORAL SU12,50863,CDM,250,RC,J3490,HCPCS,63824-272-63,NDC,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 250 MG INJ SOLR,50863,CDM,250,RC,J0696,HCPCS,0781-3206-85,NDC,facility,both,1,EA,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAUNORUBICIN 5 MG/ML IV INJ,50863,CDM,636,RC,J9150,HCPCS,0143-9551-01,NDC,facility,both,6,ML,,1739,1217.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,55390-138-01,NDC,facility,both,2,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,636,RC,J3490,HCPCS,70092-1119-44,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,17856-7014-7,NDC,facility,both,2,ML,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0143-9595-01,NDC,facility,both,200,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,8,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PHENOBARBITAL  32.4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6575-61,NDC,facility,both,8,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,55390-138-01,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2599,HCPCS,43598-914-11,NDC,facility,both,11,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,68094-231-59,NDC,facility,both,2,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6519-61,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG RECT SUPP,50863,CDM,636,RC,J3490,HCPCS,51672-2116-0,NDC,facility,both,3,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADVATE: FACTOR VIII CONCENTRATE (MERGE RECORD),50863,CDM,250,RC,J7192,HCPCS,0944-3052-03,NDC,facility,both,2000,UN,,8372,5860.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,0781-3246-02,NDC,facility,both,3,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,23155-902-01,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0093-2279-73,NDC,facility,both,7,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-0552-23,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6953-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 10 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,65862-192-01,NDC,facility,both,3,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J2003,HCPCS,63323-492-26,NDC,facility,both,300,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE (FOR CODE) 10% IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0517-6710-01,NDC,facility,both,2,ML,,238,166.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,42806-150-33,NDC,facility,both,2,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,67457-385-10,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,J1644,HCPCS,0409-2720-31,NDC,,,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL 20 MG/5 ML ORAL ELIX,50863,CDM,636,RC,J3490,HCPCS,60687-671-40,NDC,facility,both,3,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM  50 MG INJ SOLR,50863,CDM,250,RC,J0640,HCPCS,25021-813-10,NDC,facility,both,1,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 1250 MG/5 ML SUSPENSION (500 MG/5 ML ELEMENTAL),50863,CDM,250,RC,J3490,HCPCS,0121-4766-05,NDC,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOFETILIDE 500 MCG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,42291-413-60,NDC,facility,both,1,EA,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,70,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 100 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,51672-4047-9,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 50 MG TAB,50863,CDM,250,RC,Q0177,HCPCS,0904-6618-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,250,RC,J2270,HCPCS,63323-454-00,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-9791-01,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE MONONITRATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,5026885111,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16729-175-01,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DONEPEZIL  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-292-11,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML INJECTION,50863,CDM,250,RC,J3411,HCPCS,72603-139-25,NDC,facility,both,2,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MINERAL OIL ENEMA,50863,CDM,250,RC,J3490,HCPCS,0132-0301-40,NDC,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON DEXTRAN 50 MG/ML INJ SOLN,50863,CDM,636,RC,J1750,HCPCS,0023-6082-01,NDC,facility,both,1,ML,JW,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",50863,CDM,250,RC,J1561,HCPCS,13533-800-24,NDC,facility,both,40,ML,JA,5658,3960.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2599,HCPCS,43598-914-25,NDC,facility,both,12,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,250,RC,J2270,HCPCS,0409-1890-13,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PNEUMOC 20-VAL CONJ-DIP CR(PF) 0.5 ML IM SYRG,50863,CDM,636,RC,90677,HCPCS,0005-2000-01,NDC,facility,both,1,ML,,1003,702.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE  4 MG ORAL TAB,50863,CDM,636,RC,J7509,HCPCS,68084-149-11,NDC,facility,both,2,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,3,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,0409-6102-18,NDC,facility,both,40,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 0.1 % TOP OINT,50863,CDM,250,RC,0093-3429-10,NDC,,,facility,both,1,GM,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,44,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SITAGLIPTIN  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0006-0221-01,NDC,facility,both,4,EA,,224,156.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-31,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,42023-164-01,NDC,facility,both,40,ML,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN DEXTROSE (ISO-OSMOTIC) 1 GRAM/50 ML IV PIGGY BACK,50863,CDM,636,RC,J0690,HCPCS,0338-3503-41,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,636,RC,J2405,HCPCS,70860-776-41,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CINACALCET 30 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-525-11,NDC,facility,both,3,EA,,395,276.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-447-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE IN 0.9% NS (PF) 1 MG/10 ML (100 MCG/ML) IV SYRG(PDS MERGE),50863,CDM,250,RC,J3490,HCPCS,71266-9011-1,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6501-06,NDC,facility,both,2,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,636,RC,J3490,HCPCS,59310-579-20,NDC,facility,both,1,GM,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-1712-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML IV SOLN (MERGE),50863,CDM,250,RC,J3490,HCPCS,70756-611-82,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,150,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,50863,CDM,636,RC,J3490,HCPCS,69339-152-01,NDC,facility,both,2,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV (BOLUS),50863,CDM,636,RC,J7120,HCPCS,0264-7750-10,NDC,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  20 MG ORAL TR12,50863,CDM,636,RC,J3490,HCPCS,59011-420-20,NDC,facility,both,3,EA,,191,133.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICARDIPINE 25 MG/10 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0143-9689-01,NDC,facility,both,1,ML,,150,105,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 0.1 MG/ML INJ SYRG,50863,CDM,636,RC,J0461,HCPCS,76329-3340-1,NDC,facility,both,50,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5%-1/2 NORMAL SALINE IV,50863,CDM,636,RC,J7042,HCPCS,0338-0085-03,NDC,facility,both,1,ML,JZ,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PANTOPRAZOLE 40 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,0008-0923-51,NDC,facility,both,1,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN D5W 20000 UNIT/500 ML,50863,CDM,250,RC,J1644,HCPCS,0264-9567-10,NDC,facility,both,20,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE IV CONCENTRATED INFUSION (1 MEQ/ML),50863,CDM,636,RC,J3490,HCPCS,0409-6625-02,NDC,facility,both,3,ML,,172,120.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARISOPRODOL 350 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,69584-111-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,63739-236-10,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MYCOPHENOLATE 500 MG TAB,50863,CDM,636,RC,J7517,HCPCS,51079-379-01,NDC,facility,both,4,EA,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE 20 MG TAB,50863,CDM,250,RC,J3490,HCPCS,13107-155-30,NDC,facility,both,2,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,70069-013-25,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
REMIFENTANIL 1 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,67457-198-03,NDC,facility,both,2,EA,,624,436.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  160 MG ORAL CHEW,50863,CDM,636,RC,J3490,HCPCS,0904-6645-24,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,7733351625,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,0143-9682-01,NDC,facility,both,6,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 10 MG/5 ML SYRUP,50863,CDM,250,RC,Q0177,HCPCS,62135-750-47,NDC,facility,both,1,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIRMATRELVIR-RITONAVIR 150 MG (10)- 100 MG (10) ORAL DSPK,50863,CDM,J3490,HCPCS,0069-5317-20,NDC,,,facility,both,20,EA,,4010,2807,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,J2371,HCPCS,0781-3458-75,NDC,,,facility,both,2500,ML,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER SULFADIAZINE 1 % TOP CREA,50863,CDM,J3490,HCPCS,61570-131-50,NDC,,,facility,both,1,GM,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN DEXTROSE (ISO-OS) 2 GRAM/100 ML IV PGBK,50863,CDM,636,RC,J0689,HCPCS,0338-3508-41,NDC,facility,both,4,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J2250,HCPCS,0409-2305-17,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,50863,CDM,636,RC,Q5119,HCPCS,0069-0238-01,NDC,facility,both,25,ML,,4946,3462.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,50863,CDM,636,RC,J1756,HCPCS,0517-2340-01,NDC,facility,both,300,ML,GZ,963,674.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier GZ: Item or service expected to be denied as not reasonable and necessary
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,76329-3352-1,NDC,facility,both,1,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,21,EA,JW,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
INSULIN NPH & REGULAR HUMAN 100 UNIT/ML (70-30) SUBQ SUSP,50863,CDM,250,RC,J1815,HCPCS,0169-1837-11,NDC,facility,both,13,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6008-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,250,RC,Q9968,HCPCS,70710-1838-1,NDC,facility,both,21,ML,JW,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,42806-150-33,NDC,facility,both,4,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"HEPARIN, PORCINE (PF) 1 UNIT/ML IV SYRG NEONATE",50863,CDM,250,RC,J1642,HCPCS,6425344425,NDC,facility,both,6,ML,,252,176.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAMADOL  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0093-0058-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 30 MG/0.3 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,0075-0624-01,NDC,facility,both,3,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE  50 MG ORAL TAB,50863,CDM,250,RC,j3490,HCPCS,0904-6868-61,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,2,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLP,50863,CDM,250,RC,J3480,HCPCS,63323-965-03,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORTHALIDONE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-167-11,NDC,facility,both,2,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 15% IN WATER,50863,CDM,250,RC,J3490,HCPCS,0338-0023-03,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",50863,CDM,J1561,HCPCS,13533-800-25,NDC,,,facility,both,40,ML,,5658,3960.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,J1940,HCPCS,23155-473-32,NDC,,,facility,both,2,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),50863,CDM,J0171,HCPCS,76329-3318-1,NDC,,,facility,both,50,ML,,367,256.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,51,ML,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,16714-294-01,NDC,facility,both,9,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,74,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CITRATE 4 % (3 ML) MISC SYRG,50863,CDM,250,RC,J3490,HCPCS,70092-1148-43,NDC,facility,both,1,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,J7510,HCPCS,17856-0815-1,NDC,,,facility,both,5,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 3000 MCG/ML INJECTION,50863,CDM,J0153,HCPCS,63323-651-00,NDC,,,facility,both,6,ML,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6926-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,76329-3352-1,NDC,facility,both,1,ML,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,25021-468-10,NDC,facility,both,1,EA,,360,252,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-208-01,NDC,,,facility,both,300,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROATE SODIUM 100 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0143-9785-01,NDC,facility,both,1,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,69315-905-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,636,RC,J1596,HCPCS,0517-4605-25,NDC,facility,both,2,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,50863,CDM,250,RC,J8540,HCPCS,0904-7266-61,NDC,facility,both,64,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,68094-494-59,NDC,facility,both,7,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOZAPINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-922-01,NDC,facility,both,4,EA,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MANNITOL 20% IV SOLP,50863,CDM,250,RC,J2150,HCPCS,0990-7715-13,NDC,facility,both,1,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOLTERODINE 2 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,43975-322-03,NDC,facility,both,1,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),50863,CDM,250,RC,J3490,HCPCS,0409-4888-02,NDC,facility,both,3,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-662-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 2 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J2004,HCPCS,0409-3183-11,NDC,facility,both,300,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE 3 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,0574-9855-10,NDC,facility,both,3,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE IN 0.9 % SOD CHLORIDE 100 MG/10 ML (10 MG/ML) IV SYRG,50863,CDM,636,RC,J3490,HCPCS,70004-430-12,NDC,facility,both,1,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CANAKINUMAB (PF) 150 MG/ML SUBQ SOLN,50863,CDM,636,RC,J0638,HCPCS,0078-0734-61,NDC,facility,both,150,ML,,36927,25848.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML IV,50863,CDM,636,RC,J3490,HCPCS,0641-6015-01,NDC,facility,both,125,ML,,215,150.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7449-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACCHAROMYCES BOULARDII 250 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,1785600021,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-076-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCERIN (ADULT) RECTAL SUPPOSITORY,50863,CDM,250,RC,J3490,HCPCS,57237-325-21,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE 0.05 % OPHT DPET,50863,CDM,250,RC,J3490,HCPCS,60505-6202-1,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,13,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,J2704,HCPCS,0069-0209-01,NDC,,,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,71288-402-10,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,4,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,J1885,HCPCS,72611-722-25,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,250,RC,J3101,HCPCS,50242-037-06,NDC,facility,both,12,EA,,5186,3630.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,55150-177-05,NDC,facility,both,130,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-04,NDC,facility,both,6,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LECANEMAB-IRMB 100 MG/ML IV SOLN,50863,CDM,636,RC,J0174,HCPCS,62856-215-01,NDC,facility,both,100,ML,"JW,Q0",128,89.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient | Modifier Q0: Investigational clinical service provided in a clinical research study that is in an approved clinical research study
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-464-11,NDC,facility,both,3,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,50863,CDM,250,RC,J9075,HCPCS,10019-956-16,NDC,facility,both,158,EA,,1024,716.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-328-10,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC IV INFUSION HYDRAT 31-60 MIN,50863,CDM,250,RC,J0248,HCPCS,61958-2901-2,NDC,facility,both,100,EA,JZ,1196,837.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,250,RC,J0132,HCPCS,63323-963-21,NDC,facility,both,1,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,20,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 3 MG/ML IV SYRG,50863,CDM,636,RC,J0153,HCPCS,0469-8234-12,NDC,facility,both,18,ML,,635,444.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-497-11,NDC,facility,both,3,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,67457-108-00,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69618-010-01,NDC,facility,both,3,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 10 MG-325 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0406-0125-23,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2310,HCPCS,0409-1215-21,NDC,facility,both,1,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 10 MG-325 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0406-0125-23,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,20,ML,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOPERAMIDE 1 MG/7.5 ML ORAL LIQD,50863,CDM,250,RC,J3490,HCPCS,17856-6836-1,NDC,facility,both,4,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1815,HCPCS,0169-1833-11,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0904-1313-09,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV (BOLUS),50863,CDM,250,RC,J7120,HCPCS,0264-7750-07,NDC,facility,both,4,ML,,111,77.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 150 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-445-01,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7030,HCPCS,0338-0049-04,NDC,facility,both,2,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTAROLINE FOSAMIL 600 MG IV SOLR,50863,CDM,250,RC,J0712,HCPCS,0456-0600-01,NDC,facility,both,40,EA,JW,206,144.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
SODIUM ZIRCONIUM CYCLOSILICATE  5 G ORAL PWPK (USE PANEL),50863,CDM,636,RC,J3490,HCPCS,0310-1105-01,NDC,facility,both,2,EA,,279,195.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,67877-545-88,NDC,facility,both,5,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SINCALIDE 5 MCG INJ SOLR,50863,CDM,636,RC,J2805,HCPCS,72266-248-05,NDC,facility,both,1,EA,,189,132.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  37.5 MG ORAL CP24,50863,CDM,636,RC,J3490,HCPCS,68084-698-11,NDC,facility,both,1,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,54288-136-01,NDC,facility,both,1,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,49884-849-01,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-48,NDC,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROIC ACID 250 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0591-4012-01,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,0409-6625-14,NDC,facility,both,7,ML,,404,282.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOSTIGMINE METHYLSULFATE 1 MG/ML IV SOLN,50863,CDM,250,RC,J2710,HCPCS,42023-189-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,375,ME,JZ,5089,3562.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ISOSORBIDE DINITRATE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6619-61,NDC,facility,both,3,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,70004-600-09,NDC,facility,both,2,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,63,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,31,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTASE 3000 UNIT ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,904522452,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6642-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,50863,CDM,250,RC,J9263,HCPCS,71288-172-21,NDC,facility,both,65,ML,JW,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
SODIUM BICARBONATE 8.4 % IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-6625-22,NDC,facility,both,7,ML,,404,282.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,23155-687-31,NDC,facility,both,2,ML,JZ,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
EPINEPHRINE 1 MG/ML INJ SOLN,50863,CDM,J0169,HCPCS,76329-9061-0,NDC,,,facility,both,40,ML,,148,103.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,50863,CDM,250,RC,J9267,HCPCS,61703-342-50,NDC,facility,both,157,ML,,190,133,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,50863,CDM,636,RC,J0696,HCPCS,60505-6148-0,NDC,facility,both,4,EA,,194,135.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-4675-05,NDC,facility,both,3,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAZOLAMIDE SODIUM 500 (100 MG/ML) INJ SOLR,50863,CDM,250,RC,J1120,HCPCS,0143-9503-01,NDC,facility,both,1,EA,JZ,224,156.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,63323-506-00,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-1721-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,636,RC,J3490,HCPCS,55150-188-10,NDC,facility,both,2,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,250,RC,J3490,HCPCS,50268-671-11,NDC,facility,both,4,EA,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2305-02,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0093-2279-73,NDC,facility,both,11,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,50863,CDM,J3420,HCPCS,63323-044-01,NDC,,,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6641-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM  3.375 GRAM IV SOLR,50863,CDM,J2543,HCPCS,60505-6157-0,NDC,,,facility,both,3,EA,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J2250,HCPCS,70069-817-01,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAZOSIN 5 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-572-33,NDC,facility,both,3,EA,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML INJ SOLN,50863,CDM,636,RC,J0169,HCPCS,76329-9060-0,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7050,HCPCS,0338-0049-03,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN SODIUM EXTENDED  30 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,58151-118-01,NDC,facility,both,2,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 400 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6667-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,72205-142-90,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NYSTATIN  100000 UNIT/G TOP POWD,50863,CDM,250,RC,J3490,HCPCS,75907-060-44,NDC,facility,both,1,GM,,108,75.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,63323-506-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 12 MG/ML ORAL SUSPENSION,50863,CDM,636,RC,J3490,HCPCS,0093-0319-01,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,3,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GOLIMUMAB  12.5 MG/ML IV SOLN,50863,CDM,636,RC,J1602,HCPCS,57894-350-01,NDC,facility,both,200,ML,JZ,22072,15450.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
OXYTOCIN IN 0.9 % SOD CHLORIDE 30 UNIT/500 ML IV SOLN,50863,CDM,250,RC,J2590,HCPCS,70004-085-44,NDC,facility,both,2,ML,,152,106.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLECAINIDE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-0011-20,NDC,facility,both,2,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALACYCLOVIR 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-077-10,NDC,facility,both,12,EA,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,25021-463-01,NDC,facility,both,2,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE IN D5W 1 GRAM/100 ML IV PGBK,50863,CDM,250,RC,J3475,HCPCS,0409-6727-55,NDC,facility,both,4,ML,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMBRISENTAN  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,70710-1179-3,NDC,facility,both,1,EA,,982,687.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,50863,CDM,636,RC,J2354,HCPCS,0641-6174-01,NDC,facility,both,2,ML,JA,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
INFLIXIMAB-ABDA 100 MG IV SOLR,50863,CDM,636,RC,Q5104,HCPCS,78206-162-99,NDC,facility,both,2,EA,JW,181,126.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
METHYLNALTREXONE 12 MG/0.6 ML SUBQ SYRG,50863,CDM,250,RC,J2212,HCPCS,65649-551-03,NDC,facility,both,120,ML,,693,485.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALGLUCOSIDASE ALFA 50 MG IV SOLR,50863,CDM,J0221,HCPCS,58468-0160-1,NDC,,,facility,both,120,EA,,49945,34961.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5%-1/2 NORMAL SALINE IV (PEDS ONCOLOGY),50863,CDM,636,RC,J7042,HCPCS,0338-0085-04,NDC,facility,both,2,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-208-01,NDC,,,facility,both,100,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 5 MG-325 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0406-0123-23,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN SODIUM EXTENDED 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,68084-376-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J1230,HCPCS,67457-217-20,NDC,facility,both,1,ML,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,63323-185-07,NDC,facility,both,8,ML,,234,163.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN DEGLUDEC 100 UNITS/ML SUBQ SOLN,50863,CDM,636,RC,J1815,HCPCS,0169-2662-11,NDC,facility,both,1,ML,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-38,NDC,facility,both,1,ML,JZ,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
HALOPERIDOL  1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0378-0257-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-01,NDC,facility,both,3,ML,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,124,ML,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,41,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,J3101,HCPCS,50242-037-06,NDC,,,facility,both,17,EA,,7787,5450.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),50863,CDM,250,RC,J2060,HCPCS,0641-6001-01,NDC,facility,both,2,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60505-3111-0,NDC,facility,both,1,EA,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN   81 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,57896-981-12,NDC,facility,both,3,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TERAZOSIN  5 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,59746-385-06,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLP,50863,CDM,250,RC,J3480,HCPCS,63323-965-10,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2308-21,NDC,facility,both,5,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
FERROUS SULFATE 75 MG/ML (ELEMENTAL IRON 15 MG/ML) ORAL DROP,50863,CDM,250,RC,J3490,HCPCS,536134480,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,0409-4887-24,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV,50863,CDM,250,RC,J7120,HCPCS,0338-0117-04,NDC,facility,both,4,ML,,133,93.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,36,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,0088-2220-33,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML IV SOLN,50863,CDM,J3490,HCPCS,55150-222-20,NDC,,,facility,both,1,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,0409-3178-17,NDC,,,facility,both,300,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM-ALBUTEROL 0.5 MG-2.5 MG/3 ML NEB SOLUTION,50863,CDM,J3490,HCPCS,0487-0201-01,NDC,,,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J2004,HCPCS,0409-3178-16,NDC,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,J2704,HCPCS,63323-269-65,NDC,,,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 1 GRAM INJ SOLR,50863,CDM,J0692,HCPCS,60505-6146-0,NDC,,,facility,both,2,EA,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 1 % INJ SOLN,50863,CDM,636,RC,Q9968,HCPCS,17478-504-10,NDC,facility,both,50,ML,,363,254.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 3000 MCG/ML INJECTION,50863,CDM,636,RC,J0153,HCPCS,67457-855-00,NDC,facility,both,6,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BIVALIRUDIN 250 MG IV SOLR,50863,CDM,250,RC,J0583,HCPCS,0781-3158-94,NDC,facility,both,250,EA,,2616,1831.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,636,RC,J3010,HCPCS,0409-9094-22,NDC,facility,both,2,ML,JZ,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0093-2279-73,NDC,facility,both,6,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,636,RC,J3490,HCPCS,71449-068-11,NDC,facility,both,2,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16714-988-01,NDC,facility,both,2,EA,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,250,RC,J7060,HCPCS,0264-7510-10,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 20 MG/ML INJ SOLN,50863,CDM,250,RC,J0360,HCPCS,0517-0901-01,NDC,facility,both,1,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  125 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,23155-858-78,NDC,facility,both,4,EA,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 160 MG-800 MG TAB,50863,CDM,250,RC,J3490,HCPCS,65862-420-01,NDC,facility,both,2,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 100 MG/ML INJ SOLN,50863,CDM,636,RC,J2800,HCPCS,55150-223-10,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID (PORK)  30 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0456-0458-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,55390-138-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,636,RC,J2405,HCPCS,0641-6078-25,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-4827-05,NDC,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELOXICAM  7.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-525-15,NDC,facility,both,20,EA,,263,184.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INOTUZUMAB OZOGAMICIN 0.9 MG (0.25 MG/ML INITIAL) IV SOLR,50863,CDM,250,RC,J9229,HCPCS,0008-0100-01,NDC,facility,both,4,EA,,21560,15092,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,50863,CDM,250,RC,J9060,HCPCS,16729-288-11,NDC,facility,both,13,ML,,287,200.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 20 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,50268-585-11,NDC,facility,both,2,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SCOPOLAMINE TRANSDERMAL PATCH 1MG OVER 3 DAYS,50863,CDM,250,RC,J3490,HCPCS,0067-4345-04,NDC,facility,both,1,EA,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,636,RC,J2405,HCPCS,60505-6130-5,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0121-1781-05,NDC,facility,both,2,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-50,NDC,facility,both,36,ML,JW,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LIOTHYRONINE  5 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-2179-01,NDC,facility,both,2,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN  750 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,70010-492-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TERBUTALINE 1 MG/ML SUBQ SOLN,50863,CDM,250,RC,J3105,HCPCS,63323-665-01,NDC,facility,both,1,ML,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSCARNET 24 MG/ML IV SOLN,50863,CDM,250,RC,J1455,HCPCS,63323-875-50,NDC,facility,both,6,ML,,1305,913.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL  6.25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7306-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,72603-506-01,NDC,facility,both,50,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
BUSPIRONE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-985-01,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,FAMNOCHARGE,HCPCS,60687-145-11,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50580-458-11,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,72603-251-01,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-349-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,50863,CDM,250,RC,J3301,HCPCS,0703-0241-01,NDC,facility,both,4,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"HEPARIN (PORCINE) IN 0.9% NACL 2,500 UNIT/250 ML (10 UNIT/ML) IV SOLP",50863,CDM,636,RC,J3490,HCPCS,71285-8000-1,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLEVIDIPINE 50 MG/100 ML IV EMUL,50863,CDM,250,RC,J0759,HCPCS,10122-611-01,NDC,facility,both,50,ML,,762,533.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 0.8 GRAM ORAL PWPK,50863,CDM,636,RC,J3490,HCPCS,0115-1365-30,NDC,facility,both,1,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETHAMBUTOL 400 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-280-11,NDC,facility,both,4,EA,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESVENLAFAXINE  50 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,68180-592-06,NDC,facility,both,2,EA,,113,79.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-4264-11,NDC,facility,both,5,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL  12 MCG/HR TD PT72,50863,CDM,250,RC,J3490,HCPCS,0378-9119-16,NDC,facility,both,1,EA,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BISACODYL  5 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,0904-6407-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORDIAZEPOXIDE 25 MG CAP,50863,CDM,250,RC,J3490,HCPCS,60687-807-11,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN NEO/PEDS IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0456,HCPCS,63323-398-14,NDC,facility,both,1,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6291-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0832-0540-11,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM  4.5 GRAM IV SOLR,50863,CDM,250,RC,J2543,HCPCS,60505-6159-0,NDC,facility,both,4,EA,,107,74.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,50863,CDM,250,RC,J9025,HCPCS,72485-201-01,NDC,facility,both,174,EA,,2472,1730.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0143-9595-01,NDC,facility,both,1,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN V POTASSIUM 250 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,57237-040-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,16714-036-01,NDC,facility,both,1,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-5771-23,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML INJ SOLN,50863,CDM,250,RC,J2060,HCPCS,0641-6044-25,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-9543-02,NDC,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,71399-1025-3,NDC,facility,both,18,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0137,HCPCS,0143-9386-01,NDC,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 50 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-854-11,NDC,facility,both,150,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-50,NDC,facility,both,17,ML,JW,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
BENZOCAINE-MENTHOL 6-10 MG MM LOZG,50863,CDM,636,RC,J3490,HCPCS,7811201106,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROFURANTOIN MACROCRYSTAL 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-483-01,NDC,facility,both,10,EA,,293,205.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL,50863,CDM,250,RC,J3490,HCPCS,63323-820-04,NDC,facility,both,1,ML,,168,117.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-19,NDC,facility,both,300,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MYCOPHENOLATE 500 MG TAB,50863,CDM,250,RC,J7517,HCPCS,60687-438-11,NDC,facility,both,6,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAMADOL  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0378-4151-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-50,NDC,facility,both,2,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0248-01,NDC,facility,both,100,ML,JZ,127,88.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ATROPINE 0.1 MG/ML INJ SYRG,50863,CDM,250,RC,J0461,HCPCS,76329-3340-1,NDC,facility,both,62,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-04,NDC,facility,both,6,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0264-1800-36,NDC,facility,both,1,ML,JZ,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
POTASSIUM CHLORIDE 10 MEQ/100 ML IV PGBK (USE NON-PROTOCOL PANEL),50863,CDM,250,RC,J3480,HCPCS,0338-0709-48,NDC,facility,both,5,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 1 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,0781-5311-06,NDC,facility,both,1,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-444-11,NDC,facility,both,1,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LITHIUM CARBONATE 450 MG ORAL TBSR,50863,CDM,636,RC,J3490,HCPCS,68084-655-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN D5W 20000 UNIT/500 ML,50863,CDM,250,RC,J1644,HCPCS,0264-9567-10,NDC,facility,both,20,ML,PLAD,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
PROPRANOLOL  80 MG ORAL CS24,50863,CDM,250,RC,J3490,HCPCS,63629-2072-1,NDC,facility,both,2,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 2 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,250,RC,J2270,HCPCS,76045-004-01,NDC,facility,both,1,ML,PLAD,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
LOPERAMIDE 2 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,51079-690-01,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NORTRIPTYLINE 10 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0093-0810-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIACIN  250 MG ORAL CPSR,50863,CDM,250,RC,J3490,HCPCS,1000670020,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUDROCORTISONE 0.1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-330-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IV PGBK,50863,CDM,250,RC,J3475,HCPCS,0409-6729-41,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL  32.4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16571-673-01,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,250,RC,J3490,HCPCS,66993-019-68,NDC,facility,both,1,GM,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 1 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,49884-315-52,NDC,facility,both,3,EA,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORDIAZEPOXIDE 10 MG CAP,50863,CDM,250,RC,J3490,HCPCS,51079-375-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 100 MG TAB,50863,CDM,250,RC,J3490,HCPCS,62584-267-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,42806-150-33,NDC,facility,both,3,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES-DOCUSATE SODIUM 8.6 MG-50 MG TAB,50863,CDM,250,RC,J3490,HCPCS,60687-622-11,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6500-06,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE (FOR CODE) 10% (100 MG/ML) IV SYRINGE,50863,CDM,250,RC,J3490,HCPCS,0409-1631-10,NDC,facility,both,2,ML,,149,104.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-1638-02,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN NEO IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J3373,HCPCS,0338-3582-01,NDC,facility,both,35,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  100 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,68462-896-01,NDC,facility,both,4,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIVAROXABAN 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50458-580-01,NDC,facility,both,2,EA,,234,163.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,220,154,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACCHAROMYCES BOULARDII 250 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,7733380025,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7156-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM POLYSTYRENE SULFONATE ORAL POWDER,50863,CDM,636,RC,J3490,HCPCS,10702-036-15,NDC,facility,both,1,GM,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-205-01,NDC,facility,both,4,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 0.8 GRAM ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,0115-1365-30,NDC,facility,both,1,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOBRAMYCIN 1.2 G POWDER VIAL,50863,CDM,636,RC,J3260,HCPCS,39822-0412-6,NDC,facility,both,5,EA,,133,93.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,71288-402-10,NDC,facility,both,10,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCOSANOL 10 % TOP CREAM,50863,CDM,636,RC,J3490,HCPCS,61269-981-35,NDC,facility,both,2,GM,,157,109.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,65,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SCOPOLAMINE TRANSDERMAL PATCH 1MG OVER 3 DAYS,50863,CDM,250,RC,J3490,HCPCS,45802-580-01,NDC,facility,both,1,EA,,113,79.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOPIDOGREL 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6467-10,NDC,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYTOCIN 10 UNIT/ML INJ SOLN,50863,CDM,636,RC,J2590,HCPCS,42023-116-25,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0781-6041-46,NDC,facility,both,3,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 50% IN WATER (MERGE RECORD),50863,CDM,250,RC,J7060,HCPCS,0409-6648-02,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,50863,CDM,250,RC,Q0177,HCPCS,0904-6617-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-1971-21,NDC,facility,both,2,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOBAZAM 2.5 MG/ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,99999-0404-03,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-134-01,NDC,facility,both,25,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM 2000 MG IV SOLR,50863,CDM,636,RC,J2185,HCPCS,72078-081-00,NDC,facility,both,20,EA,JZ,194,135.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"ALBUMIN, HUMAN 25 % IV SOLP",50863,CDM,250,RC,P9047,HCPCS,44206-251-91,NDC,facility,both,2,ML,,778,544.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-161-11,NDC,facility,both,3,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COLLAGENASE 250 UNIT/G TOP OINT,50863,CDM,250,RC,J3490,HCPCS,50484-010-30,NDC,facility,both,1,GM,,1071,749.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,67877-548-88,NDC,facility,both,3,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 20 GRAM/30 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-1154-30,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,44567-600-04,NDC,facility,both,1,ML,,201,140.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-074-10,NDC,facility,both,1,EA,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,76045-009-96,NDC,facility,both,20,ML,,111,77.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2599,HCPCS,43598-914-25,NDC,facility,both,21,ML,,142,99.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT 100 MCG/0.5 ML INJ SYRG,50863,CDM,636,RC,J0881,HCPCS,55513-025-01,NDC,facility,both,100,ML,JZ,2137,1495.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LIOTHYRONINE 10 MCG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,39822-0151-1,NDC,facility,both,1,ML,,1217,851.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 300 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7263-61,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0990-7983-61,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-22,NDC,facility,both,2,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,100,ML,,144,100.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-398-11,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON DEXTRAN 50 MG/ML INJ SOLN,50863,CDM,636,RC,J1750,HCPCS,0023-6082-01,NDC,facility,both,32,ML,,3501,2450.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0054-8297-25,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,50,EA,JZ,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ACETYLCYSTEINE 10 % (100 MG/ML) MISC SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-695-04,NDC,facility,both,1,ML,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 50 MG/ML IV SOLN,50863,CDM,250,RC,J0282,HCPCS,0143-9875-01,NDC,facility,both,10,ML,JZ,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MYCOPHENOLATE 200 MG/ML ORAL SUSP,50863,CDM,250,RC,J7517,HCPCS,0527-5160-82,NDC,facility,both,2,ML,,111,77.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACAMPROSATE 333 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,68462-435-18,NDC,facility,both,2,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,8,EA,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,250,RC,J0690,HCPCS,0143-9924-90,NDC,facility,both,2,EA,,128,89.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMINOCAPROIC ACID 250 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-4346-73,NDC,facility,both,1,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-9543-02,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2599,HCPCS,63323-930-01,NDC,facility,both,5,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,636,RC,J2405,HCPCS,70860-776-41,NDC,facility,both,2,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,50863,CDM,J1644,HCPCS,25021-402-01,NDC,,,facility,both,9,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,117,EA,,16146,11302.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,63323-162-00,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,0409-4887-23,NDC,facility,both,2,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 0.1MG/ML SUSPENSION (REPACK),50863,CDM,250,RC,J3490,HCPCS,51079-882-01,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALTREXONE 50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7036-04,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 12.5 MG RECT SUPP,50863,CDM,250,RC,J3490,HCPCS,45802-758-00,NDC,facility,both,2,EA,,174,121.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4% TOP PATCH,50863,CDM,J3490,HCPCS,46581-830-01,NDC,,,facility,both,2,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2308-21,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,63323-462-17,NDC,facility,both,2,ML,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,636,RC,J3490,HCPCS,39822-1000-1,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,J7510,HCPCS,17856-0815-1,NDC,,,facility,both,3,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MISOPROSTOL 200 MCG ORAL TAB,50863,CDM,S0191,HCPCS,60687-746-11,NDC,,,facility,both,4,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 150 MG/ML INJECTION,50863,CDM,636,RC,J3490,HCPCS,0009-0902-11,NDC,facility,both,2,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:200,000 INJ SOLN",50863,CDM,J2004,HCPCS,63323-487-07,NDC,,,facility,both,300,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,636,RC,J1953,HCPCS,0409-1886-22,NDC,facility,both,200,ML,JZ,104,72.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,29,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  5 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,60687-122-11,NDC,facility,both,30,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML IV SOLN (MERGE),50863,CDM,636,RC,J3490,HCPCS,0781-3269-71,NDC,facility,both,1,ML,,251,175.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEPIVACAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J0670,HCPCS,63323-260-01,NDC,facility,both,3,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 500 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,50268-152-11,NDC,facility,both,40,EA,,240,168,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 300 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,69452-125-50,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-18,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOSTIGMINE 1MG/ML (UD) OR SYRINGE,50863,CDM,250,RC,J2710,HCPCS,76014-003-33,NDC,facility,both,1,ML,,142,99.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN  3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51672-4030-1,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0990-7983-61,NDC,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2598,HCPCS,43598-914-11,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL  32.4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6575-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 50 MG TAB,50863,CDM,250,RC,J3490,HCPCS,51079-801-01,NDC,facility,both,3,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HUMAN PROTHROMBIN COMPLEX 500 UNIT IV SOLR,50863,CDM,636,RC,J7168,HCPCS,63833-396-01,NDC,facility,both,1000,UN,,5819,4073.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC ADMIN RESPIRATORY SYNCYTIAL VIRUS MONOCLONAL ANTIBODY SEASONAL DOSE INTRAMUSCULAR INJECTION,50863,CDM,250,RC,90380,HCPCS,49281-575-00,NDC,facility,both,1,ML,,1535,1074.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN NACL (PF) 1000 UNIT/500 ML IV SOLP,50863,CDM,250,RC,J1644,HCPCS,0409-1005-01,NDC,facility,both,3,ML,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML (1ML) INJ SOLN,50863,CDM,250,RC,J0171,HCPCS,54288-119-01,NDC,facility,both,8,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 2 MG INJ SOLR,50863,CDM,636,RC,J2997,HCPCS,50242-041-64,NDC,facility,both,2,EA,,762,533.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 300 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,69452-125-50,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 1 GRAM INJ SOLR,50863,CDM,250,RC,J0692,HCPCS,25021-121-20,NDC,facility,both,10,EA,,200,140,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAMSULOSIN 0.4 MG ORAL CP24,50863,CDM,636,RC,J3490,HCPCS,0904-7383-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIVAROXABAN 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50458-579-90,NDC,facility,both,3,EA,,305,213.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 50 MG/10 ML (5 MG/ML) IV SOLN,50863,CDM,636,RC,J2305,HCPCS,0517-4810-25,NDC,facility,both,9,ML,JW,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
SILDENAFIL 2.5 MG/ML SUSPENSION,50863,CDM,250,RC,J3490,HCPCS,99999-0404-75,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,250,RC,J3490,HCPCS,63323-485-26,NDC,facility,both,200,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,6809411059,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,0641-6145-01,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE 0.5 MG/2 ML INHL NBSP,50863,CDM,636,RC,J3490,HCPCS,0487-9701-01,NDC,facility,both,1,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NELARABINE 250 MG/50 ML IV SOLN (PEDS ONCOLOGY),50863,CDM,250,RC,J9261,HCPCS,43598-142-11,NDC,facility,both,13,ML,,4412,3088.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FINASTERIDE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-314-11,NDC,facility,both,1,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN NACL (PF) 1000 UNIT/500 ML IV SOLP,50863,CDM,250,RC,J1644,HCPCS,0409-1005-01,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,636,RC,J2405,HCPCS,60505-6130-5,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL  25 MCG/HR TD PT72,50863,CDM,250,RC,J3490,HCPCS,47781-424-11,NDC,facility,both,1,EA,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NORETHINDRONE ACETATE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68462-304-50,NDC,facility,both,2,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6798-61,NDC,facility,both,1,EA,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,250,RC,J3101,HCPCS,50242-037-06,NDC,facility,both,18,EA,,8245,5771.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,50863,CDM,636,RC,Q5119,HCPCS,0069-0249-01,NDC,facility,both,100,ML,JZ,19784,13848.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,636,RC,J1836,HCPCS,0338-1055-48,NDC,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRIMIDONE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-202-11,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIPASE-PROTEASE-AMYLASE (PORK) 36,000-114,000- 180,000 UNIT ORAL CPDR",50863,CDM,636,RC,J3490,HCPCS,0032-3016-13,NDC,facility,both,1,EA,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPTOMYCIN 500 MG IV SOLR,50863,CDM,J0878,HCPCS,72603-152-01,NDC,,,facility,both,1000,EA,,2925,2047.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,250,RC,J2795,HCPCS,43066-023-01,NDC,facility,both,50,ML,JW,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),50863,CDM,636,RC,J1630,HCPCS,25021-806-01,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,70756-640-82,NDC,,,facility,both,40,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LETROZOLE 2.5 MG ORAL TAB,50863,CDM,636,RC,J9999,HCPCS,0093-7620-56,NDC,facility,both,1,EA,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,68516-5214-1,NDC,facility,both,10,ML,,1426,998.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRIL MALEATE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,43547-546-10,NDC,facility,both,2,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,44567-600-04,NDC,facility,both,2,ML,,420,294,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J2003,HCPCS,63323-492-41,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J1940,HCPCS,0409-6102-18,NDC,facility,both,2,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6085-61,NDC,facility,both,2,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,250,RC,J0132,HCPCS,55150-259-30,NDC,facility,both,240,ML,,1084,758.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,62332-037-31,NDC,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0456,HCPCS,70436-019-82,NDC,facility,both,1,EA,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,66794-229-02,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE 20 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0904-5677-61,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,50863,CDM,636,RC,J0696,HCPCS,60505-6149-0,NDC,facility,both,8,EA,JZ,388,271.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PYRIDOXINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,7733394025,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZIPRASIDONE 20 MG IM,50863,CDM,636,RC,J3486,HCPCS,43598-848-11,NDC,facility,both,1,EA,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2305-16,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 1 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,65162-673-84,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMETREXED 100 MG IV SOLR,50863,CDM,250,RC,J9305,HCPCS,71288-166-10,NDC,facility,both,25,EA,,441,308.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 2 GRAM INJ SOLR,50863,CDM,250,RC,J0692,HCPCS,0409-9735-01,NDC,facility,both,2,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIMOLOL MALEATE 0.25 % OPHT DROP,50863,CDM,250,RC,J3490,HCPCS,61314-226-10,NDC,facility,both,1,ML,,136,95.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 1% 10MG/ML (1ML-UD) OR SYRINGE,50863,CDM,J2003,HCPCS,0409-4276-02,NDC,,,facility,both,200,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J2310,HCPCS,36000-308-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-04,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,250,RC,J3490,HCPCS,60687-653-11,NDC,facility,both,10,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM THIOSULFATE 25 % IV SOLN,50863,CDM,250,RC,J3490,HCPCS,60267-705-50,NDC,facility,both,1,ML,,386,270.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6007-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MYCOPHENOLATE SODIUM 360 MG ORAL TBEC,50863,CDM,250,RC,J7518,HCPCS,0904-6786-04,NDC,facility,both,4,EA,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0054-0710-20,NDC,facility,both,4,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,12,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOBRAMYCIN 150 MG/3.75 ML NEBULIZER SOLN (REPACK),50863,CDM,250,RC,J3490,HCPCS,63323-306-30,NDC,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6418-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 200 MG/20 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,31722-203-20,NDC,facility,both,2,ML,,600,420,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,16714-671-02,NDC,facility,both,1,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MENINGOCOCCAL B VACC,4-CMP(PF) 50-50-50-25 MCG/0.5 ML IM SYRG",50863,CDM,90620,HCPCS,58160-976-02,NDC,,,facility,both,1,ML,,839,587.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-11,NDC,facility,both,1,ML,JZ,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),50863,CDM,250,RC,J3490,HCPCS,63323-186-03,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  75 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-495-11,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 100 MG ORAL CHEW,50863,CDM,636,RC,J3490,HCPCS,0904-3854-61,NDC,facility,both,3,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETIRIZINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-799-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZONISAMIDE 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-230-11,NDC,facility,both,5,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN D5W 20000 UNIT/500 ML,50863,CDM,636,RC,J1644,HCPCS,0264-9567-10,NDC,facility,both,6,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE (PF-DURAMORPH/ASTRAMORPH) 0.5 MG/ML INJ SOLN,50863,CDM,250,RC,J2274,HCPCS,0409-3814-12,NDC,facility,both,1,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,23155-600-31,NDC,facility,both,6,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0121-1022-05,NDC,facility,both,4,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0780,HCPCS,23155-294-41,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2308-21,NDC,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN IN SALINE (ISO-OSMOTIC) 100 MG/50 ML IV PIGGY BACK,50863,CDM,250,RC,J1580,HCPCS,0338-0511-41,NDC,facility,both,4,ML,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 50 MG TAB,50863,CDM,250,RC,Q0177,HCPCS,16714-083-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  50 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,72205-012-90,NDC,facility,both,4,EA,,165,115.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE MALEATE 10 MG ORAL TAB,50863,CDM,250,RC,Q0164,HCPCS,50268-685-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-299-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAZOLAMIDE SODIUM 500 (100 MG/ML) INJ SOLR,50863,CDM,250,RC,J1120,HCPCS,67457-853-50,NDC,facility,both,1,EA,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,626,ME,JZ,8495,5946.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IBUPROFEN LYSINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,67386-122-52,NDC,facility,both,1,ML,,1373,961.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 125 MCG SUBQ SOLR,50863,CDM,636,RC,J2802,HCPCS,55513-223-01,NDC,facility,both,250,EA,,5130,3591,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16714-683-02,NDC,facility,both,2,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,70436-030-82,NDC,facility,both,118,ML,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,16714-036-01,NDC,facility,both,5,ML,JW,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
MANNITOL 20% IV SOLP,50863,CDM,250,RC,J2150,HCPCS,0990-7715-13,NDC,facility,both,1,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,636,RC,J2720,HCPCS,63323-229-01,NDC,facility,both,4,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,0338-0072-25,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 20 MG/ML INJ SOLN,50863,CDM,250,RC,J0360,HCPCS,0517-0901-01,NDC,facility,both,2,ML,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 100 MG/ML FROM 1 GRAM VIAL (PRMC PEDS ONLY),50863,CDM,250,RC,J0696,HCPCS,0409-7332-11,NDC,facility,both,6,EA,,142,99.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 10 MG ORAL CAP,50863,CDM,J3490,HCPCS,0904-6987-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIVAROXABAN 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50458-578-01,NDC,facility,both,2,EA,,223,156.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE HCL  2 % MM JELP,50863,CDM,250,RC,J3490,HCPCS,76329-3012-5,NDC,facility,both,2,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6501-61,NDC,facility,both,1,EA,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN NPH & REGULAR HUMAN 100 UNIT/ML (70-30) SUBQ SUSP,50863,CDM,250,RC,J1815,HCPCS,0169-1837-11,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,69315-905-05,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EMTRICITABINE-TENOFOVIR 200 MG-300 MG TAB,50863,CDM,636,RC,J0750,HCPCS,16714-534-01,NDC,facility,both,1,EA,,297,207.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J2004,HCPCS,0409-3178-01,NDC,facility,both,60,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SYRG,50863,CDM,636,RC,J3490,HCPCS,8290306547,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0641-0400-37,NDC,facility,both,5,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0228-2127-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,250,RC,J2001,HCPCS,76329-3390-1,NDC,facility,both,10,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 875 MG-125 MG TAB,50863,CDM,636,RC,J3490,HCPCS,16714-297-01,NDC,facility,both,28,EA,,510,357,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE (PF) 1 MG/ML INJ SOLN,50863,CDM,636,RC,J0171,HCPCS,54288-103-01,NDC,facility,both,10,ML,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,32,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16729-226-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISATRACURIUM  2 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-416-05,NDC,facility,both,1,ML,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GAMMAGARD S/D  5 GRAM IV SOLR,50863,CDM,636,RC,J1566,HCPCS,0944-2657-07,NDC,facility,both,10,EA,JZ,2329,1630.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PACLITAXEL 6 MG/ML IV CONC,50863,CDM,250,RC,J9267,HCPCS,61703-342-22,NDC,facility,both,40,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,J2371,HCPCS,70756-622-85,NDC,,,facility,both,2000,ML,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE SODIUM 2.5 MG ORAL TAB,50863,CDM,636,RC,J8610,HCPCS,0555-0572-02,NDC,facility,both,6,EA,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 750 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-568-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-985-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL  1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7390-61,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-1159-19,NDC,facility,both,2,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM OXIDE 400 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,1000673038,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,636,RC,J3490,HCPCS,66553-002-01,NDC,facility,both,3,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,1000,ML,,1266,886.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML IV,50863,CDM,250,RC,J3490,HCPCS,55150-425-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,51754-5001-1,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0264-7800-10,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,50863,CDM,636,RC,J0696,HCPCS,44567-701-25,NDC,facility,both,3,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-074-10,NDC,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % MBP,50863,CDM,250,RC,J3490,HCPCS,0338-9159-30,NDC,facility,both,3,ML,,143,100.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,63323-185-10,NDC,facility,both,3,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0245-0212-89,NDC,facility,both,3,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,636,RC,J0690,HCPCS,0143-9924-90,NDC,facility,both,6,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN IN D5W 400 MG/200 ML IV PGBK,50863,CDM,J0744,HCPCS,0409-3300-01,NDC,,,facility,both,2,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-145-11,NDC,facility,both,20,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,48,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J2004,HCPCS,0409-3178-01,NDC,facility,both,35,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  120 MG RECT SUPP,50863,CDM,636,RC,J3490,HCPCS,51672-2115-0,NDC,facility,both,2,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 250 MCG SUBQ SOLR,50863,CDM,250,RC,J2796,HCPCS,55513-221-01,NDC,facility,both,50,EA,,8780,6146,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUPHENAZINE 2.5 MG TAB,50863,CDM,636,RC,J3490,HCPCS,10135-726-01,NDC,facility,both,1,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERYTHROMYCIN 5 MG/G OPHT OINT,50863,CDM,250,RC,J3490,HCPCS,24208-910-55,NDC,facility,both,1,GM,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,66794-229-02,NDC,facility,both,2,ML,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42858-301-01,NDC,facility,both,1,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NORTRIPTYLINE 10 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-281-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0121-0945-10,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 75 MG/5 ML ORAL SOLUTION,50863,CDM,250,RC,J3490,HCPCS,16714-483-02,NDC,facility,both,2,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTAMIDINE 300 MG INJ SOLR,50863,CDM,636,RC,J3490,HCPCS,63323-113-01,NDC,facility,both,1,EA,,189,132.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1162-18,NDC,facility,both,40,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0093-2026-94,NDC,facility,both,2,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,43598-053-11,NDC,facility,both,2,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,76,ML,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 500 MCG INJ SOLR,50863,CDM,636,RC,J3490,HCPCS,42023-203-01,NDC,facility,both,1,EA,,1458,1020.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTAROLINE FOSAMIL 600 MG IV SOLR,50863,CDM,250,RC,J0712,HCPCS,0456-0600-01,NDC,facility,both,20,EA,,304,212.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAMADOL  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7496-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL 160 MG ORAL CS24,50863,CDM,250,RC,J3490,HCPCS,0527-4119-37,NDC,facility,both,1,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,75834-221-01,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 500 MG SOLUTION FOR INJECTION,50863,CDM,636,RC,J2919,HCPCS,43598-128-11,NDC,facility,both,100,EA,,130,91,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 50 MG/ML SUSPENSION (10ML REPACK),50863,CDM,250,RC,J3490,HCPCS,99999-0403-03,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,17856-0574-1,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 20MG/ML IV SYRINGE (PEDS/NEO),50863,CDM,250,RC,J0612,HCPCS,63323-311-10,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN PEDS IVPB (CDS MIXTURE),50863,CDM,250,RC,J3370,HCPCS,0069-2599-99,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE (PF) 1 MG/ML INJ SOLN,50863,CDM,636,RC,J0169,HCPCS,54288-103-01,NDC,facility,both,10,ML,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0406-3243-01,NDC,facility,both,5,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 20 GRAM/30 ML ORAL SOLN,50863,CDM,J3490,HCPCS,0121-1154-30,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE (PF) 1 MG/ML INJ SOLN,50863,CDM,250,RC,J0169,HCPCS,54288-103-01,NDC,facility,both,10,ML,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,J7512,HCPCS,0054-0017-20,NDC,,,facility,both,10,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6778-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IR SOLN,50863,CDM,636,RC,J3490,HCPCS,0338-0047-46,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IV PGBK,50863,CDM,250,RC,J3475,HCPCS,63323-106-00,NDC,facility,both,8,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,67877-670-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  2.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,42291-560-90,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 10 MG TAB,50863,CDM,636,RC,Q0177,HCPCS,63739-483-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 100 MG/1 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0781-3268-05,NDC,facility,both,9,ML,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 40 GRAM/400 ML (10 %) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-40,NDC,facility,both,160,ML,"JZ,JA",22631,15841.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
HUMAN PROTHROMBIN COMPLEX 500 UNIT IV SOLR,50863,CDM,250,RC,J7168,HCPCS,63833-396-01,NDC,facility,both,2000,UN,,11638,8146.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE IN 0.9% NS (PF) 1 MG/10 ML (100 MCG/ML) IV SYRG(PDS MERGE),50863,CDM,250,RC,J3490,HCPCS,70092-1046-46,NDC,facility,both,1,ML,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AGALSIDASE BETA 35 MG IV SOLR,50863,CDM,J0180,HCPCS,58468-0040-1,NDC,,,facility,both,97,ME,,45085,31559.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,636,RC,J3370,HCPCS,0143-9162-01,NDC,facility,both,4,EA,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML INJECTION,50863,CDM,250,RC,J3411,HCPCS,0641-6228-01,NDC,facility,both,6,ML,,176,123.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 10 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-5784-61,NDC,facility,both,2,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESNA 100 MG/ML IV SOLN,50863,CDM,250,RC,J9209,HCPCS,10019-953-62,NDC,facility,both,3,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-579-11,NDC,facility,both,3,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC IV INFUSION HYDRAT 31-60 MIN,50863,CDM,250,RC,J0248,HCPCS,61958-2901-2,NDC,facility,both,75,EA,JW,390,273,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-9558-05,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-579-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 120 MG/0.8 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,0075-2912-00,NDC,facility,both,1,ML,JW,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LATANOPROST 0.005 % OPHT DROP,50863,CDM,250,RC,J3490,HCPCS,61314-547-01,NDC,facility,both,1,ML,,403,282.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,68180-150-01,NDC,facility,both,3,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,2055503600,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",50863,CDM,250,RC,J1561,HCPCS,13533-800-25,NDC,facility,both,80,ML,,11316,7921.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-50,NDC,facility,both,44,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) IV,50863,CDM,250,RC,J1250,HCPCS,70436-203-80,NDC,facility,both,2,ML,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,250,RC,J3490,HCPCS,0173-0682-24,NDC,facility,both,2,GM,,134,93.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 500 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7337-35,NDC,facility,both,27,EA,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,68180-150-01,NDC,facility,both,3,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR NEO/PEDS INFUSION (CDS FROM PREMIX),50863,CDM,250,RC,J0133,HCPCS,63323-325-10,NDC,facility,both,70,ML,,152,106.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IV PGBK,50863,CDM,250,RC,J3475,HCPCS,0338-1708-40,NDC,facility,both,8,ML,,148,103.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LET TOPICAL SOLUTION 4ML (REPACK),50863,CDM,250,RC,J3490,HCPCS,51552-1345-1,NDC,facility,both,1,ML,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC ADMIN RESPIRATORY SYNCYTIAL VIRUS MONOCLONAL ANTIBODY SEASONAL DOSE INTRAMUSCULAR INJECTION,50863,CDM,90380,HCPCS,49281-575-00,NDC,,,facility,both,1,ML,,1435,1004.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,636,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,7,EA,,248,173.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML INJECTION,50863,CDM,250,RC,J3411,HCPCS,43598-050-11,NDC,facility,both,3,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 2 GRAM INJ SOLR,50863,CDM,250,RC,J0692,HCPCS,44567-241-10,NDC,facility,both,8,EA,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,0641-0400-12,NDC,facility,both,5,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DOFETILIDE 250 MCG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,42291-412-60,NDC,facility,both,2,EA,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NOREPINEPHRINE BITARTRATE-D5W 4 MG/250 ML (16 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,71285-6056-1,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZTROPINE 1 MG/ML INJ SOLN,50863,CDM,636,RC,J0515,HCPCS,0143-9233-01,NDC,facility,both,1,ML,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 500 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,50268-152-15,NDC,facility,both,8,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUGAMMADEX 100 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0006-5423-02,NDC,facility,both,1,ML,,589,412.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,50863,CDM,636,RC,J0585,HCPCS,0023-1145-01,NDC,facility,both,390,EA,,6233,4363.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THROMBIN (RECOMBINANT) 5000 UNIT TOP SOLR,50863,CDM,250,RC,J3490,HCPCS,0338-0322-01,NDC,facility,both,2,EA,,744,520.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
URSODIOL 300 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-6221-61,NDC,facility,both,1,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLP,50863,CDM,J3480,HCPCS,63323-965-03,NDC,,,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,J0780,HCPCS,23155-294-31,NDC,,,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 60 MG TAB,50863,CDM,250,RC,J3490,HCPCS,60687-728-11,NDC,facility,both,1,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6322-61,NDC,facility,both,5,EA,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,250,RC,J7060,HCPCS,0338-0017-38,NDC,facility,both,1,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,50863,CDM,J1885,HCPCS,63323-162-03,NDC,,,facility,both,4,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 30% IN WATER (NEO),50863,CDM,250,RC,J7070,HCPCS,0409-6648-16,NDC,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,75,ML,,108,75.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,70069-362-01,NDC,facility,both,4,ML,,233,163.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-398-11,NDC,facility,both,3,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,5,ML,JW,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-492-27,NDC,,,facility,both,120,ML,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,J2704,HCPCS,16714-690-01,NDC,,,facility,both,100,ML,,127,88.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-0710-20,NDC,facility,both,8,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,50863,CDM,J3490,HCPCS,0378-7732-93,NDC,,,facility,both,1,EA,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,J2704,HCPCS,0069-0209-01,NDC,,,facility,both,11,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORHEXIDINE GLUCONATE  0.12 % MM MWSH,50863,CDM,250,RC,J3490,HCPCS,0116-2001-16,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEPIVACAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,636,RC,J0670,HCPCS,63323-294-01,NDC,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0143-9334-01,NDC,facility,both,180,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PREDNISONE 20 MG ORAL TAB,50863,CDM,J7512,HCPCS,60219-1708-1,NDC,,,facility,both,40,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,36000-283-25,NDC,facility,both,80,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7362-61,NDC,facility,both,3,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DORNASE ALFA 1 MG/ML INHL SOLN,50863,CDM,250,RC,J3490,HCPCS,50242-100-39,NDC,facility,both,1,ML,,562,393.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,65862-246-08,NDC,facility,both,1,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) BLADDER INSTILLATION,50863,CDM,636,RC,J9201,HCPCS,16714-930-01,NDC,facility,both,10,EA,JZ,508,355.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IV PGBK,50863,CDM,250,RC,J3475,HCPCS,0338-1715-40,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,63323-564-21,NDC,facility,both,4,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAZOSIN 1 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,59762-5310-1,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SYRG,50863,CDM,636,RC,J3490,HCPCS,8290306546,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),50863,CDM,J0171,HCPCS,76329-3318-1,NDC,,,facility,both,10,ML,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 2 %-1:200,000 INJ SOLN",50863,CDM,J2004,HCPCS,0409-3183-11,NDC,,,facility,both,300,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,50863,CDM,250,RC,J0640,HCPCS,67457-530-35,NDC,facility,both,21,EA,,458,320.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COCAINE  4 % TOP SOLN (MERGE),50863,CDM,250,RC,C9046,HCPCS,64950-362-04,NDC,facility,both,160,ML,,868,607.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,250,RC,J0330,HCPCS,0409-6629-02,NDC,facility,both,20,ML,,228,159.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,16,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  120 MG RECT SUPP,50863,CDM,636,RC,J3490,HCPCS,51672-2115-0,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,250,RC,J3101,HCPCS,50242-037-06,NDC,facility,both,14,EA,,6413,4489.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7050,HCPCS,0264-7800-20,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 100 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,51079-171-01,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SINCALIDE 5 MCG INJ SOLR,50863,CDM,250,RC,J2805,HCPCS,72266-248-01,NDC,facility,both,1,EA,,591,413.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-41,NDC,facility,both,1,ML,JZ,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DEXAMETHASONE 1 MG ORAL TAB,50863,CDM,250,RC,J8540,HCPCS,0054-4181-25,NDC,facility,both,4,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 100 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,60687-413-11,NDC,facility,both,2,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DORZOLAMIDE-TIMOLOL 2 %-0.5 % EYE DROPS,50863,CDM,636,RC,J3490,HCPCS,65862-946-01,NDC,facility,both,1,ML,,440,308,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,J2003,HCPCS,63323-486-20,NDC,,,facility,both,400,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIVASTIGMINE 1.5 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,33342-089-09,NDC,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML IV SOLN,50863,CDM,J3490,HCPCS,72266-146-01,NDC,,,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,250,RC,J0132,HCPCS,66220-207-30,NDC,facility,both,60,ML,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML INJ SOLN,50863,CDM,J2060,HCPCS,0409-1985-03,NDC,,,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J3490,HCPCS,63323-492-04,NDC,,,facility,both,40,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,250,RC,J2003,HCPCS,0409-1323-05,NDC,facility,both,100,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,72,ML,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORDIAZEPOXIDE 25 MG CAP,50863,CDM,250,RC,J3490,HCPCS,51079-141-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,80,ML,JZ,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,636,RC,J3490,HCPCS,70004-600-09,NDC,facility,both,2,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 50 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-854-11,NDC,facility,both,50,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,63323-462-01,NDC,facility,both,2,ML,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GAMMAGARD LIQUID 10 % IV SOLN,50863,CDM,636,RC,J1569,HCPCS,0944-2700-12,NDC,facility,both,40,ML,"JG,JZ,JA",7211,5047.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
AMITRIPTYLINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7410-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68180-981-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2599,HCPCS,43598-914-25,NDC,facility,both,10,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLP",50863,CDM,250,RC,P9047,HCPCS,0944-0493-04,NDC,facility,both,6,ML,,1501,1050.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 0.25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-570-11,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM NEO/PEDS INFUSION (CDS MIXTURE),50863,CDM,250,RC,J2543,HCPCS,0206-8852-08,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J3490,HCPCS,0338-0049-31,NDC,facility,both,1,ML,JZ,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"DIPHTH,PERTUS(ACELL),TETANUS VIAL (BOOSTRIX*) 2.5-8-5 LF-MCG-LF/0.5ML IM SUSP",50863,CDM,250,RC,90715,HCPCS,58160-842-01,NDC,facility,both,1,ML,,240,168,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML INJ SOLN,50863,CDM,J2250,HCPCS,23155-600-31,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE (PF-DURAMORPH/ASTRAMORPH) 0.5 MG/ML INJ SOLN,50863,CDM,636,RC,J2274,HCPCS,0409-3814-11,NDC,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER SULFADIAZINE 1 % TOP CREA,50863,CDM,636,RC,J3490,HCPCS,61570-131-20,NDC,facility,both,8,GM,,371,259.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,16714-294-01,NDC,facility,both,8,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 100 MG ORAL TB12,50863,CDM,250,RC,J3490,HCPCS,51672-4123-1,NDC,facility,both,5,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0781-3246-02,NDC,facility,both,4,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLN,50863,CDM,636,RC,J3262,HCPCS,50242-135-01,NDC,facility,both,240,ML,"JZ,JA",4399,3079.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,14789-251-09,NDC,facility,both,1,ML,,221,154.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,82293-004-10,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,93,EA,,12834,8983.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-6695-01,NDC,facility,both,10,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE (DIAGNOSTIC) 3 MG/ML IV SOLN,50863,CDM,250,RC,J0153,HCPCS,55150-193-01,NDC,facility,both,100,ML,,858,600.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML (1ML) INJ SOLN,50863,CDM,250,RC,J0169,HCPCS,42023-159-01,NDC,facility,both,10,ML,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-467-01,NDC,facility,both,1,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1162-18,NDC,facility,both,72,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,42806-151-34,NDC,facility,both,13,ML,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,636,RC,J2795,HCPCS,70069-064-25,NDC,facility,both,137,ML,JW,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
FINASTERIDE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-428-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM 500 MG IV SOLR,50863,CDM,250,RC,J2185,HCPCS,63323-507-01,NDC,facility,both,5,EA,JZ,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SODIUM ZIRCONIUM CYCLOSILICATE 10 G ORAL PWPK (USE PANEL),50863,CDM,250,RC,J3490,HCPCS,0310-1110-01,NDC,facility,both,1,EA,,161,112.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE  50 MG ORAL TAB,50863,CDM,250,RC,j3490,HCPCS,50111-560-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE IV CONCENTRATED INFUSION (1 MEQ/ML),50863,CDM,636,RC,J3490,HCPCS,0409-6625-02,NDC,facility,both,2,ML,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CINACALCET 30 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,64380-883-04,NDC,facility,both,1,EA,,150,105,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAMADOL  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-808-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,250,RC,J2405,HCPCS,0409-4755-18,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LINEZOLID 600 MG/300 ML IV SOLP,50863,CDM,636,RC,J2020,HCPCS,66794-219-63,NDC,facility,both,3,ML,JZ,112,78.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
TEMAZEPAM  7.5 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-6436-04,NDC,facility,both,2,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,J3490,HCPCS,68180-150-01,NDC,,,facility,both,2,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,42806-341-01,NDC,facility,both,3,EA,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,636,RC,J3490,HCPCS,0409-4277-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE  50 MG ORAL TAB,50863,CDM,250,RC,j3490,HCPCS,60687-443-11,NDC,facility,both,6,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYUREA  500 MG ORAL CAP,50863,CDM,250,RC,J9999,HCPCS,49884-724-01,NDC,facility,both,4,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-349-11,NDC,facility,both,2,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,60,ML,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUMAZENIL 0.1 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,36000-148-01,NDC,facility,both,2,ML,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,35,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROPROCAINE 3 % INJ SOLN,50863,CDM,250,RC,J2401,HCPCS,63323-478-01,NDC,facility,both,150,ML,JW,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
HYOSCYAMINE SULFATE 0.375 MG ORAL TB12,50863,CDM,250,RC,J3490,HCPCS,16477-738-01,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INDIGOTINDISULFONATE SODIUM 8 MG/ML INJ SOLN,50863,CDM,636,RC,J9220,HCPCS,17478-508-01,NDC,facility,both,5,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0054-0017-20,NDC,facility,both,120,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE-DEXTROSE-WATER(PF) 7.5 MG/ML (0.75 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-473-02,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HUMAN PROTHROMBIN COMPLEX 500 UNIT IV SOLR,50863,CDM,250,RC,J7168,HCPCS,63833-396-01,NDC,facility,both,1000,UN,,5819,4073.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNITS/1 GRAM PACKET (MERGE RECORD),50863,CDM,636,RC,J3490,HCPCS,0904-7023-67,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEFEROXAMINE 500 MG INJ SOLR,50863,CDM,J0895,HCPCS,60505-6236-0,NDC,,,facility,both,2,EA,,152,106.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J3430,HCPCS,0409-9158-31,NDC,facility,both,10,ML,,250,175,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,511,ME,JZ,6935,4854.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
NIVOLUMAB 40 MG/4 ML IV SOLN,50863,CDM,636,RC,J9299,HCPCS,0003-3772-11,NDC,facility,both,40,ML,,2728,1909.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROMETHORPHAN-GUAIFENESIN SR 30 MG-600 MG 12 HR TAB,50863,CDM,636,RC,J3490,HCPCS,63824-056-01,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE SODIUM 25 MG/ML INJ SOLN,50863,CDM,636,RC,J9260,HCPCS,61703-350-37,NDC,facility,both,2,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,636,RC,J1596,HCPCS,0143-9680-01,NDC,facility,both,10,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,250,RC,J3490,HCPCS,0409-1323-05,NDC,facility,both,100,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  37.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65162-302-09,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOL-PHENOLATE SODIUM AEROSOL,50863,CDM,250,RC,J3490,HCPCS,0904-1771-21,NDC,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTAZIDIME-AVIBACTAM 2.5 GRAM (2 GRAM-0.5 GRAM) IV SOLR,50863,CDM,250,RC,J0714,HCPCS,0456-2700-01,NDC,facility,both,2,EA,,527,368.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAMSULOSIN 0.4 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,50268-740-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 10 GRAM/100 ML (10%) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-72,NDC,facility,both,20,ML,JZ,2829,1980.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LEUCOVORIN CALCIUM 200 MG INJ SOLR,50863,CDM,250,RC,J0640,HCPCS,0143-9553-01,NDC,facility,both,8,EA,,253,177.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.25 MG/0.5 ML (0.5 MG/1 ML) ORAL SUSPENSION (REPACK),50863,CDM,636,RC,J3490,HCPCS,0591-0240-01,NDC,facility,both,10,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  75 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,0904-7077-61,NDC,facility,both,3,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 12.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6302-61,NDC,facility,both,2,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7366-04,NDC,facility,both,3,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 40 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,76282-208-90,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 2400000 UNIT/4 ML IM SYRG,50863,CDM,636,RC,J0561,HCPCS,60793-702-04,NDC,facility,both,24,ML,,2088,1461.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TICAGRELOR 90 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,72205-368-91,NDC,facility,both,7,EA,,179,125.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,513,ME,JZ,6962,4873.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DEXAMETHASONE 4 MG ORAL TAB,50863,CDM,250,RC,J8540,HCPCS,0904-7266-61,NDC,facility,both,80,EA,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),50863,CDM,250,RC,J1815,HCPCS,0024-5926-05,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,636,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-989-01,NDC,facility,both,2,EA,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISRADIPINE  2.5 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,16252-539-01,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0591-0407-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-587-11,NDC,facility,both,6,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RAVULIZUMAB-CWVZ 100 MG/ML IV SOLN,50863,CDM,636,RC,J1303,HCPCS,25682-025-01,NDC,facility,both,50,ML,,29459,20621.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,636,RC,J3373,HCPCS,67457-340-01,NDC,facility,both,50,EA,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 10 MG-100 MG TAB,50863,CDM,250,RC,J3490,HCPCS,42291-471-01,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIPASE-PROTEASE-AMYLASE 24,000-76,000- 120,000 UNIT ORAL CAP, DELAY REL",50863,CDM,250,RC,J3490,HCPCS,0032-1224-01,NDC,facility,both,1,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,2,EA,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML IV SOLN (MERGE),50863,CDM,636,RC,J3490,HCPCS,16714-037-10,NDC,facility,both,1,ML,,152,106.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51672-4005-1,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,43,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J1610,HCPCS,63323-596-11,NDC,facility,both,5,EA,JZ,4473,3131.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ENALAPRIL MALEATE  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-442-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 100 MG ORAL CHEW,50863,CDM,636,RC,J3490,HCPCS,60687-479-11,NDC,facility,both,4,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 2 MG INJ SOLR,50863,CDM,250,RC,J2997,HCPCS,50242-041-10,NDC,facility,both,5,EA,,2000,1400,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,94,ML,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUVOXAMINE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60505-0166-1,NDC,facility,both,2,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-453-01,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENAZOPYRIDINE 100 MG ORAL TAB,50863,CDM,J3490,HCPCS,69367-611-01,NDC,,,facility,both,2,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,81033-002-30,NDC,facility,both,3,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,250,RC,J3490,HCPCS,0093-3174-31,NDC,facility,both,2,GM,,314,219.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,2,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIPHTH,PERTUS(ACELL),TETANUS SYRG(BOOSTRIX) 2.5-8-5 LF-MCG-LF/0.5ML IM SYRG",50863,CDM,250,RC,90715,HCPCS,58160-842-43,NDC,facility,both,1,ML,,247,172.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 125 MG/5 ML (25MG/ML) ORAL SYRINGE (REPACK),50863,CDM,250,RC,J3373,HCPCS,67457-340-00,NDC,facility,both,50,EA,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLECAINIDE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0054-0010-20,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0406-0512-23,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-439-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 5 MG-325 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0406-0123-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PALIPERIDONE PALMITATE 78 MG/0.5 ML IM SYRG,50863,CDM,250,RC,J2426,HCPCS,50458-561-01,NDC,facility,both,78,ML,,3284,2298.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,2055503601,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 500 MG (200 MG ELEMENTAL) CHEW TAB,50863,CDM,636,RC,J3490,HCPCS,66553-004-01,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,0075-0622-01,NDC,facility,both,8,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-01,NDC,facility,both,6,ML,,166,116.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 2 %-1:200,000 INJ SOLN",50863,CDM,J2004,HCPCS,0409-3183-11,NDC,,,facility,both,360,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,9,ML,,14741,10318.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 8-2 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,50268-145-11,NDC,facility,both,3,EA,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SITAGLIPTIN  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0006-0221-54,NDC,facility,both,8,EA,,381,266.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",50863,CDM,250,RC,J1561,HCPCS,13533-800-24,NDC,facility,both,80,ML,,11316,7921.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,36,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANTI-INHIBITOR COAGULANT CMPLX (PHS MERGE),50863,CDM,250,RC,J7198,HCPCS,64193-325-01,NDC,facility,both,2250,UN,JW,6075,4252.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,636,RC,J1596,HCPCS,0517-4601-25,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXOCOBALAMIN 5 GRAM IV SOLR,50863,CDM,250,RC,J3424,HCPCS,50633-310-11,NDC,facility,both,200,EA,,2755,1928.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,J3490,HCPCS,66553-002-01,NDC,,,facility,both,3,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC IV INFUSION HYDRAT 31-60 MIN,50863,CDM,250,RC,J0248,HCPCS,61958-2901-2,NDC,facility,both,66,EA,JW,348,243.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
BORTEZOMIB 3.5 MG IV SOLR,50863,CDM,250,RC,J9041,HCPCS,70710-1411-1,NDC,facility,both,35,EA,,555,388.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 50% IN WATER (MERGE RECORD),50863,CDM,250,RC,J7060,HCPCS,73702-104-65,NDC,facility,both,2,ML,,121,84.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE (PF) 25 MG/ML INJ SOLN (FOR ECTOPIC PREGNANCY),50863,CDM,636,RC,J9260,HCPCS,0143-9519-01,NDC,facility,both,5,ML,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLN (MERGE)",50863,CDM,250,RC,P9047,HCPCS,64208-2512-7,NDC,facility,both,2,ML,JZ,238,166.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
HYDRALAZINE 20 MG/ML INJ SOLN,50863,CDM,636,RC,J0360,HCPCS,63323-614-00,NDC,facility,both,1,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 50% IN WATER (MERGE RECORD),50863,CDM,636,RC,J7060,HCPCS,0409-6648-02,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTASE 3000 UNIT ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,45008002,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,636,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,4,EA,,139,97.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANTI-INHIBITOR COAGULANT CMPLX (PHS MERGE),50863,CDM,250,RC,J7198,HCPCS,64193-426-02,NDC,facility,both,250,UN,JW,785,549.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,636,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,2,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-074-11,NDC,facility,both,4,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN IN SALINE (ISO-OSMOTIC) 100 MG/50 ML IV PIGGY BACK,50863,CDM,250,RC,J1580,HCPCS,0338-0511-41,NDC,facility,both,2,ML,,431,301.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51672-4035-1,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0781-6041-46,NDC,facility,both,9,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,636,RC,J1815,HCPCS,49502-393-80,NDC,facility,both,2,ML,GZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier GZ: Item or service expected to be denied as not reasonable and necessary
LIDOCAINE 4 % TOPICAL SOLN,50863,CDM,636,RC,J3490,HCPCS,76329-6300-5,NDC,facility,both,160,ML,,13337,9335.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,J2003,HCPCS,0409-4278-01,NDC,,,facility,both,250,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0143-9386-01,NDC,facility,both,19,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,636,RC,J0690,HCPCS,70092-1017-46,NDC,facility,both,2,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,63323-506-01,NDC,facility,both,20,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,16714-294-01,NDC,facility,both,12,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7130-61,NDC,facility,both,21,EA,,473,331.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 10 GRAM/15 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0603-1378-58,NDC,facility,both,1,ML,,108,75.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,FAMNOCHARGE,HCPCS,60687-145-11,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,40,ML,JW,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
WARFARIN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0056-0174-01,NDC,facility,both,1,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,0143-9577-01,NDC,,,facility,both,150,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 1 MG/ML (1ML) SYRINGE (REPACK),50863,CDM,250,RC,J2997,HCPCS,50242-044-13,NDC,facility,both,40,EA,JW,4225,2957.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,250,RC,J2720,HCPCS,63323-229-01,NDC,facility,both,25,ML,,455,318.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,80,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TECLISTAMAB-CQYV 10 MG/ML SUBQ SOLN,50863,CDM,250,RC,J9380,HCPCS,57894-449-01,NDC,facility,both,60,ML,,4886,3420.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PALONOSETRON 0.25 MG/5 ML IV INJECTION (MERGE),50863,CDM,250,RC,J2469,HCPCS,63323-673-05,NDC,facility,both,10,ML,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,25021-601-03,NDC,facility,both,10,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,8,EA,,264,184.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,67457-437-00,NDC,facility,both,1,EA,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-739-11,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),50863,CDM,J1815,HCPCS,0024-5926-05,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,250,RC,J3360,HCPCS,69339-136-03,NDC,facility,both,1,ML,JW,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,J7050,HCPCS,0264-7800-20,NDC,,,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,72611-722-25,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN DEGLUDEC 100 UNITS/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,73070-400-11,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE 20 MG TAB,50863,CDM,250,RC,J3490,HCPCS,63739-963-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  5 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-122-11,NDC,facility,both,10,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLU VACCINE TS 2024-25 6MOS UP (PF) 45 MCG (15 MCG X 3)/0.5 ML IM SYRG,50863,CDM,636,RC,90656,HCPCS,58160-884-41,NDC,facility,both,1,ML,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,9,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IR SOLN,50863,CDM,250,RC,J3490,HCPCS,0338-0048-04,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE IN SALINE (ISO-OSM) 400 MG/200 ML IV PIGGY BACK,50863,CDM,250,RC,J1450,HCPCS,25021-184-87,NDC,facility,both,4,ML,,126,88.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYCHLOROQUINE 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-269-11,NDC,facility,both,2,EA,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIHEXYPHENIDYL 2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0591-5335-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIVAROXABAN 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50458-579-01,NDC,facility,both,1,EA,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,71288-414-01,NDC,facility,both,6,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,70700-165-22,NDC,facility,both,8,ML,,203,142.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOSTIGMINE 1MG/ML (UD) OR SYRINGE,50863,CDM,250,RC,J2710,HCPCS,76014-003-33,NDC,facility,both,2,ML,,284,198.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB 100 MG IV SOLR,50863,CDM,636,RC,J1745,HCPCS,57894-030-01,NDC,facility,both,34,EA,,10959,7671.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),50863,CDM,250,RC,J2060,HCPCS,0641-6001-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,70069-363-01,NDC,facility,both,1,ML,,183,128.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,72266-146-01,NDC,facility,both,2,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-495-27,NDC,,,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MISOPROSTOL 25 MCG ORAL TAB,50863,CDM,S0191,HCPCS,59762-5007-1,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-7350-06,NDC,,,facility,both,8,EA,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 20 MG/ML INJ SOLN,50863,CDM,250,RC,J0360,HCPCS,63323-614-00,NDC,facility,both,2,ML,,169,118.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,63323-161-00,NDC,facility,both,2,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,P9045,HCPCS,68516-5219-0,NDC,,,facility,both,8,ML,,2034,1423.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,50863,CDM,250,RC,J0640,HCPCS,0143-9554-01,NDC,facility,both,4,EA,,173,121.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIVAROXABAN 10 MG ORAL TAB,50863,CDM,J3490,HCPCS,50458-580-01,NDC,,,facility,both,2,EA,,223,156.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,62332-600-01,NDC,facility,both,9,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25%/EPINEPHRINE 1:100K INJECTION,50863,CDM,250,RC,J3490,HCPCS,0409-1158-01,NDC,facility,both,2,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-02,NDC,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,50863,CDM,636,RC,J0696,HCPCS,44567-701-25,NDC,facility,both,8,EA,JZ,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PROMETHAZINE 25 MG RECT SUPP,50863,CDM,636,RC,J3490,HCPCS,45802-759-00,NDC,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NAFCILLIN  2 GRAM INJ SOLR,50863,CDM,250,RC,J3490,HCPCS,63323-328-21,NDC,facility,both,2,EA,,340,238,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,636,RC,J7999,HCPCS,70092-1017-46,NDC,facility,both,2,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J3490,HCPCS,63323-492-37,NDC,,,facility,both,300,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7243-61,NDC,facility,both,4,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2001,HCPCS,0409-4279-02,NDC,,,facility,both,30,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,55150-163-30,NDC,,,facility,both,300,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 500 MG INJ SOLR,50863,CDM,250,RC,J0696,HCPCS,0409-7338-11,NDC,facility,both,4,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,63323-162-01,NDC,facility,both,2,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE (CONTRACEPTIVE) 150 MG/ML IM (MERGE),50863,CDM,J1050,HCPCS,66993-370-83,NDC,,,facility,both,150,ML,,415,290.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES-DOCUSATE SODIUM 8.6 MG-50 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7440-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,50863,CDM,250,RC,J8540,HCPCS,0054-8175-25,NDC,facility,both,48,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYUREA  500 MG ORAL CAP,50863,CDM,250,RC,J9999,HCPCS,49884-724-01,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,0517-4601-25,NDC,facility,both,4,ML,,159,111.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,636,RC,J1596,HCPCS,0143-9679-01,NDC,facility,both,4,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2720-02,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  5 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,60687-122-11,NDC,facility,both,40,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,400,ML,,282,197.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  1 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,64380-782-06,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,70700-165-22,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THROMBIN (RECOMBINANT) 20000 UNIT TOP SOLR,50863,CDM,250,RC,J3490,HCPCS,0338-0328-01,NDC,facility,both,8,EA,,9743,6820.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ICATIBANT 30 MG/3 ML SUBQ SYRG,50863,CDM,636,RC,J1744,HCPCS,69097-664-68,NDC,facility,both,30,ML,,29229,20460.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,636,RC,J2270,HCPCS,0409-1890-03,NDC,facility,both,1,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CINACALCET 30 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,64380-883-04,NDC,facility,both,1,EA,,150,105,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-256-11,NDC,facility,both,1,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MECLIZINE 25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7376-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,50863,CDM,250,RC,J8540,HCPCS,0054-8175-25,NDC,facility,both,80,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SYRG,50863,CDM,250,RC,J3490,HCPCS,8290306546,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,70092-1478-44,NDC,facility,both,2,ML,,211,147.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,636,RC,J1596,HCPCS,10019-016-39,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,89,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE PAMOATE  25 MG ORAL CAP,50863,CDM,636,RC,Q0177,HCPCS,68084-847-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-65,NDC,facility,both,82,ML,,145,101.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,3,ML,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,50863,CDM,250,RC,J9045,HCPCS,0703-4239-01,NDC,facility,both,12,ML,,311,217.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 20 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,60687-725-11,NDC,facility,both,6,EA,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 1 MG/ML (1ML) SYRINGE (REPACK),50863,CDM,J2997,HCPCS,50242-044-13,NDC,,,facility,both,10,EA,,2708,1895.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN ASP PRT-INSULIN ASPART 100 UNIT/ML (70-30) SUBQ SOLN,50863,CDM,250,RC,J1817,HCPCS,0169-3685-12,NDC,facility,both,2,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM NEO/PEDS INFUSION (CDS MIXTURE),50863,CDM,250,RC,J2543,HCPCS,0206-8852-08,NDC,facility,both,3,EA,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BECLOMETHASONE DIPROPIONATE 40 MCG/ACTUATION INHL HFAB,50863,CDM,250,RC,J3490,HCPCS,59310-302-40,NDC,facility,both,1,GM,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,636,RC,J0690,HCPCS,63323-237-10,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,250,RC,J0137,HCPCS,0264-4100-90,NDC,facility,both,23,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 8 MG ORAL TBDL,50863,CDM,Q0162,HCPCS,68462-158-40,NDC,,,facility,both,8,EA,,189,132.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG ORAL TAB,50863,CDM,250,RC,Q0169,HCPCS,0904-7304-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OMALIZUMAB 150 MG SUBQ SOLR,50863,CDM,636,RC,J2357,HCPCS,50242-040-62,NDC,facility,both,15,ME,JW,568,397.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
NICARDIPINE IN NACL (ISO-OS) 20 MG/200 ML IV PGBK,50863,CDM,636,RC,J3490,HCPCS,0143-9634-01,NDC,facility,both,1,ML,,414,289.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0093-3426-10,NDC,facility,both,4,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,250,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV (BOLUS),50863,CDM,250,RC,J7120,HCPCS,0264-7750-10,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 1 MG/0.5 ML INJ SYRG,50863,CDM,250,RC,J3430,HCPCS,0548-1240-00,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM BICARB-CITRIC ACID 20 MEQ ORAL TBEF,50863,CDM,636,RC,J3490,HCPCS,51801-012-01,NDC,facility,both,4,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,Q0162,HCPCS,17856-0691-5,NDC,,,facility,both,4,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN D5W 20000 UNIT/500 ML,50863,CDM,636,RC,J1644,HCPCS,0264-9567-10,NDC,facility,both,7,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAMIDRONATE 90 MG IV SOLR,50863,CDM,250,RC,J2430,HCPCS,55390-129-01,NDC,facility,both,3,EA,,519,363.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,636,RC,J2003,HCPCS,0409-1323-15,NDC,facility,both,400,ML,,160,112,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0591-0605-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-3426-01,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 100 MG/ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,16714-358-01,NDC,facility,both,1,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-985-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-145-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MECLIZINE 25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-523-11,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE IN 0.9% NS (PF) 1 MG/10 ML (100 MCG/ML) IV SYRG(PDS MERGE),50863,CDM,250,RC,J3490,HCPCS,71266-9011-1,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-18,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN  500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6689-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  15 MG ORAL TBSR,50863,CDM,636,RC,J3490,HCPCS,0406-8315-23,NDC,facility,both,2,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAMADOL  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-795-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2599,HCPCS,63323-930-01,NDC,facility,both,8,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0172-5728-60,NDC,facility,both,2,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,250,RC,J0137,HCPCS,0781-3156-06,NDC,facility,both,69,ML,,150,105,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 12.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7307-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN   1.5 G IV SOLR,50863,CDM,250,RC,J3370,HCPCS,67457-824-15,NDC,facility,both,3,EA,,142,99.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ORAL ELECTROLYTES ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,7007480336,NDC,facility,both,8,ML,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GAMMAGARD LIQUID 10 % IV SOLN,50863,CDM,636,RC,J1569,HCPCS,0944-2700-07,NDC,facility,both,180,ML,,32450,22715,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  1 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0603-5335-21,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,636,RC,J1596,HCPCS,0143-9679-01,NDC,facility,both,2,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE IN 0.9% NS (PF) 1 MG/10 ML (100 MCG/ML) IV SYRG(PDS MERGE),50863,CDM,250,RC,J3490,HCPCS,71266-9011-1,NDC,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOSTIGMINE METHYLSULFATE 1 MG/ML IV SOLN,50863,CDM,250,RC,J2710,HCPCS,42023-189-01,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,636,RC,J0132,HCPCS,55150-259-30,NDC,facility,both,120,ML,,542,379.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM IN NACL (ISO-OS) 500 MG/100 ML IV PGBK,50863,CDM,250,RC,J1953,HCPCS,67457-255-00,NDC,facility,both,50,ML,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,J3490,HCPCS,68094-231-59,NDC,,,facility,both,5,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,70954-059-10,NDC,facility,both,40,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPATITIS A VIRUS VACCINE (PF) 720 EL UNIT/0.5 ML IM SYRG,50863,CDM,90633,HCPCS,58160-825-43,NDC,,,facility,both,1,ML,,229,160.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 200 MG ORAL TAB,50863,CDM,J3490,HCPCS,60687-450-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,16,EA,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 875 MG-125 MG TAB,50863,CDM,636,RC,J3490,HCPCS,16714-014-02,NDC,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,71288-402-10,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,70069-363-01,NDC,facility,both,2,ML,,229,160.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BICTEGRAV-EMTRICIT-TENOFOV ALA 50-200-25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,61958-2501-1,NDC,facility,both,1,EA,,608,425.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-3426-10,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATOMOXETINE  10 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,68462-265-30,NDC,facility,both,3,EA,,209,146.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INDOMETHACIN 100 MG RECT SUPP,50863,CDM,636,RC,J3490,HCPCS,73702-140-71,NDC,facility,both,1,EA,,841,588.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 100 MG ORAL TB12,50863,CDM,250,RC,J3490,HCPCS,42806-274-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 600 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,59651-361-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,250,RC,J3490,HCPCS,0143-9679-01,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,J2371,HCPCS,0781-3422-92,NDC,,,facility,both,60,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,50863,CDM,636,RC,J2354,HCPCS,25021-463-01,NDC,facility,both,4,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GAMMAGARD LIQUID 10 % IV SOLN,50863,CDM,636,RC,J1569,HCPCS,0944-2700-13,NDC,facility,both,70,ML,JA,12620,8834,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,J2704,HCPCS,63323-269-22,NDC,,,facility,both,10,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITRIOL 0.25 MCG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-345-11,NDC,facility,both,3,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,55150-162-05,NDC,,,facility,both,50,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IR SOLN,50863,CDM,250,RC,J3490,HCPCS,0338-0047-46,NDC,facility,both,2,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 600 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,59651-361-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM BICARB-CITRIC ACID 20 MEQ ORAL TBEF,50863,CDM,250,RC,J3490,HCPCS,51801-011-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE-VITAMIN D3 250 MG-125 UNIT TAB,50863,CDM,250,RC,J3490,HCPCS,904188260,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ITRACONAZOLE 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-299-95,NDC,facility,both,2,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NORTRIPTYLINE 25 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0093-0811-01,NDC,facility,both,3,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 8-2 MG SL SUBL,50863,CDM,636,RC,J3490,HCPCS,60687-637-11,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,636,RC,J2003,HCPCS,0409-4277-16,NDC,facility,both,400,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 10 MG ORAL TAB,50863,CDM,J3490,HCPCS,68084-097-11,NDC,,,facility,both,4,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML ORAL CONC,50863,CDM,250,RC,J3490,HCPCS,0054-3532-44,NDC,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERYTHROMYCIN 5 MG/G OPHT OINT,50863,CDM,636,RC,J3490,HCPCS,24208-910-55,NDC,facility,both,1,GM,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,2,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM  2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-284-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-811-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYALURONIDASE 150 UNIT/ML INJ SOLN,50863,CDM,250,RC,J3473,HCPCS,18657-117-01,NDC,facility,both,600,ML,,1136,795.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACCHAROMYCES BOULARDII 250 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,904723006,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 0.2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60505-0258-1,NDC,facility,both,2,EA,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1940,HCPCS,63323-280-02,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-464-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"CIPROFLOXACIN-DEXAMETHASONE 0.3 %-0.1 % EAR DROPS, SUSP",50863,CDM,250,RC,J3490,HCPCS,62756-427-90,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,16714-294-01,NDC,facility,both,7,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 0.5 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,59746-010-32,NDC,facility,both,2,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANASTROZOLE 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-112-11,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,1,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,42023-115-10,NDC,facility,both,1,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-22,NDC,facility,both,24,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,7,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SALIVA SUBSTITUTE COMB NO.11 351 MG MM PWPK,50863,CDM,250,RC,J3490,HCPCS,7027562901,NDC,facility,both,1,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,0573-0179-20,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,68516-5214-3,NDC,facility,both,4,ML,,893,625.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,25,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIROFIBAN-0.9% SODIUM CHLORIDE 5 MG/100 ML (50 MCG/ML) IV SOLN,50863,CDM,636,RC,J3246,HCPCS,25208-002-03,NDC,facility,both,12,ML,JW,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
INSULIN REGULAR HUM U-500 CONC 500 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1815,HCPCS,0002-8501-01,NDC,facility,both,1,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLPIDEM  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6082-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-9558-05,NDC,facility,both,4,ML,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,636,RC,J2003,HCPCS,0143-9575-01,NDC,facility,both,200,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEGESTROL 40 MG ORAL TAB,50863,CDM,250,RC,J9999,HCPCS,0904-7236-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,0409-4887-10,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM  1.5 GRAM INJ SOLR,50863,CDM,250,RC,J0295,HCPCS,55150-116-20,NDC,facility,both,1,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 10% IN WATER (D10) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0338-0023-02,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-249-11,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 50 MG/ML IV SOLN,50863,CDM,250,RC,J0282,HCPCS,70436-232-72,NDC,facility,both,10,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL 400 UNIT/ML ORAL DROP (REPACK),50863,CDM,250,RC,J3490,HCPCS,5483800650,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENAZOPYRIDINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,75826-114-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-4675-05,NDC,facility,both,4,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65862-859-01,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM BICARB-CITRIC ACID 20 MEQ ORAL TBEF,50863,CDM,J3490,HCPCS,51801-011-01,NDC,,,facility,both,3,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,J1596,HCPCS,0143-9679-01,NDC,,,facility,both,8,ML,,183,128.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NOREPINEPHRINE BITARTRATE-D5W 4 MG/250 ML (16 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0338-0112-20,NDC,facility,both,6,ML,,800,560,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POVIDONE-IODINE 10 % TOP OINT,50863,CDM,636,RC,J3490,HCPCS,0536-1271-80,NDC,facility,both,1,GM,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J3490,HCPCS,0338-0049-01,NDC,facility,both,3,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-464-02,NDC,facility,both,2,ML,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,8,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 100 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,60687-479-11,NDC,facility,both,5,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0264-1800-36,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOFLOXACIN IN D5W 750 MG/150 ML IV PGBK,50863,CDM,250,RC,J1956,HCPCS,36000-048-24,NDC,facility,both,3,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MYCOPHENOLATE 500 MG IV SOLUTION,50863,CDM,250,RC,J3490,HCPCS,54288-141-01,NDC,facility,both,1,EA,,369,258.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,250,RC,J2003,HCPCS,0409-1323-05,NDC,facility,both,200,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXAZOSIN 4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-224-11,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HUMAN PROTHROMBIN COMPLEX 500 UNIT IV SOLR,50863,CDM,250,RC,J7168,HCPCS,63833-396-01,NDC,facility,both,1000,UN,,5819,4073.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML INJECTION,50863,CDM,250,RC,J3411,HCPCS,25021-500-02,NDC,facility,both,2,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J3430,HCPCS,43598-405-11,NDC,facility,both,10,ME,,218,152.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEPERIDINE (PF) 25 MG/ML IV SOLN (PHS MERGE),50863,CDM,J2175,HCPCS,0409-1176-03,NDC,,,facility,both,1,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0641-0400-37,NDC,facility,both,2,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LIDOCAINE 4% TOP PATCH,50863,CDM,636,RC,J3490,HCPCS,46581-830-06,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,66689-053-01,NDC,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0781-2020-01,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,50863,CDM,J1815,HCPCS,0169-1833-11,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,62332-600-01,NDC,facility,both,1,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,85,ML,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEPIVACAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,250,RC,J0670,HCPCS,63323-294-01,NDC,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 40 MG/ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,16714-696-01,NDC,facility,both,1,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-01,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,0409-4887-23,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,67877-590-01,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,636,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,68,ML,JW,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,128,ML,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,68180-723-05,NDC,facility,both,5,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SALIVA SUBSTITUTE COMB NO.11 351 MG MM PWPK,50863,CDM,250,RC,J3490,HCPCS,7027562904,NDC,facility,both,2,EA,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1940,HCPCS,0409-6102-18,NDC,facility,both,2,ML,PLAD,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
POTASSIUM PHOSPHATE DIBASIC 3 MMOLE/ML IV SOLP,50863,CDM,250,RC,J3490,HCPCS,0517-2305-25,NDC,facility,both,2,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7193-06,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,250,RC,J3490,HCPCS,72789-057-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 50 MG/ML IM,50863,CDM,250,RC,J3410,HCPCS,0517-5601-25,NDC,facility,both,2,ML,,190,133,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMIDE PEROXIDE 6.5 % OTIC DROP,50863,CDM,250,RC,J3490,HCPCS,4203710478,NDC,facility,both,1,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE (FOR EMERGENCY) 100 MG/ML (10%) IV SOLN,50863,CDM,250,RC,J0612,HCPCS,63323-360-19,NDC,facility,both,100,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,50863,CDM,636,RC,J3490,HCPCS,65862-390-10,NDC,facility,both,1,EA,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63304-773-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOMEPIZOLE 1 GRAM/ML IV SOLN,50863,CDM,250,RC,J1451,HCPCS,67457-211-02,NDC,facility,both,100,ML,,2834,1983.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CABOTEGRAVIR 600 MG/3 ML (200 MG/ML) IM SPER,50863,CDM,J0739,HCPCS,49702-264-23,NDC,,,facility,both,600,ML,,11110,7777,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,250,RC,J0137,HCPCS,0143-9386-01,NDC,facility,both,100,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7008-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE IN D5W (PF) 4 MG/ML (0.4 %) IV SOLP,50863,CDM,636,RC,J2003,HCPCS,0338-0409-03,NDC,facility,both,2000,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACTIVATED CHARCOAL 25 GRAM/120 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0574-0521-74,NDC,facility,both,1,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2312,HCPCS,0641-6132-01,NDC,facility,both,140,ML,,140,98,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 250 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,68084-776-11,NDC,facility,both,3,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-1638-32,NDC,facility,both,2,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  500 MG IV SOLR,50863,CDM,250,RC,J3370,HCPCS,0143-9161-01,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTAMIDINE 300 MG INJ SOLR,50863,CDM,636,RC,J3490,HCPCS,63323-113-01,NDC,facility,both,1,EA,,319,223.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE  7.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,13107-001-30,NDC,facility,both,2,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 40 MG/ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0049-3450-19,NDC,facility,both,1,ML,,165,115.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-9558-05,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE  50 MG ORAL TAB,50863,CDM,636,RC,j3490,HCPCS,50111-560-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,19,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV,50863,CDM,636,RC,J7120,HCPCS,0338-0117-03,NDC,facility,both,1,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 12 MG/ML ORAL SUSPENSION,50863,CDM,250,RC,J3490,HCPCS,0093-0319-01,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MYCOPHENOLATE 200 MG/ML ORAL SUSP,50863,CDM,250,RC,J7517,HCPCS,66689-307-08,NDC,facility,both,2,ML,,111,77.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7130-61,NDC,facility,both,2,EA,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,16,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7130-61,NDC,facility,both,3,EA,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 100 MG IV SOLR,50863,CDM,250,RC,J2997,HCPCS,50242-085-25,NDC,facility,both,10,EA,JZ,2429,1700.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,67457-423-00,NDC,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,J3490,HCPCS,59310-579-22,NDC,,,facility,both,1,GM,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 17 GRAM (100 %) ORAL PWPK,50863,CDM,J3490,HCPCS,1152372688,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROPROCAINE 3 % INJ SOLN,50863,CDM,250,RC,J2401,HCPCS,63323-478-01,NDC,facility,both,299,ML,JW,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0121-1781-05,NDC,facility,both,2,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G POTASSIUM  5000000 UNIT INJ SOLR,50863,CDM,250,RC,J2540,HCPCS,44567-311-10,NDC,facility,both,7,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 800 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-5855-60,NDC,facility,both,6,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0047-27,NDC,facility,both,25,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN DEXTROSE (ISO-OSMOTIC) 1 GRAM/50 ML IV PIGGY BACK,50863,CDM,636,RC,J0690,HCPCS,0338-3503-41,NDC,facility,both,2,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,4,ML,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE(PF)-0.9 % SODCHLOR 0.2 % 745 ML LINF ELPH,50863,CDM,636,RC,J3490,HCPCS,71449-079-57,NDC,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1170,HCPCS,76045-009-96,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,68516-5214-4,NDC,facility,both,10,ML,,1426,998.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 3000 MCG/ML INJECTION,50863,CDM,636,RC,J0153,HCPCS,67457-855-02,NDC,facility,both,6,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 16 MG ORAL TAB,50863,CDM,250,RC,J7509,HCPCS,59762-0050-1,NDC,facility,both,4,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  5 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-122-11,NDC,facility,both,20,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69618-010-01,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN PEDS INFUSION (CDS MIXTURE),50863,CDM,250,RC,J0290,HCPCS,99999-408-63,NDC,facility,both,3,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV,50863,CDM,250,RC,J7120,HCPCS,0338-0117-04,NDC,facility,both,5,ML,,167,116.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7227-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,636,RC,P9045,HCPCS,13533-690-25,NDC,facility,both,1,ML,JZ,256,179.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LEUPROLIDE (3 MONTH) 11.25 MG IM KIT,50863,CDM,250,RC,J1950,HCPCS,0074-3663-03,NDC,facility,both,3,EA,,14914,10439.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,50863,CDM,250,RC,J2359,HCPCS,0002-7597-01,NDC,facility,both,20,EA,,256,179.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESIPRAMINE  10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50742-112-01,NDC,facility,both,2,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 12.5 MG RECT SUPP,50863,CDM,636,RC,J3490,HCPCS,0713-0536-06,NDC,facility,both,1,EA,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML (PEDS CALCLUATOR 0.5),50863,CDM,636,RC,J1815,HCPCS,0024-5924-10,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,636,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,8,ML,GZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier GZ: Item or service expected to be denied as not reasonable and necessary
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,71288-402-10,NDC,facility,both,4,ML,,10000,7000,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERYTHROMYCIN 250 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,13668-586-30,NDC,facility,both,4,EA,,165,115.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,4,ML,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,636,RC,J3370,HCPCS,67457-340-01,NDC,facility,both,1,EA,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,636,RC,J0690,HCPCS,60505-6142-0,NDC,facility,both,2,EA,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
AZTREONAM 2 GRAM INJ SOLR,50863,CDM,636,RC,J0457,HCPCS,0409-0830-11,NDC,facility,both,10,EA,JW,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
BUPIVACAINE 0.25%/EPINEPHRINE 1:100K INJECTION,50863,CDM,250,RC,J3490,HCPCS,0409-1158-01,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,13107-085-01,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL  5 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-6797-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML IM SOLN,50863,CDM,636,RC,90375,HCPCS,13533-318-05,NDC,facility,both,16,ML,,13598,9518.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,50863,CDM,FAMNOCHARGE,HCPCS,0054-8175-25,NDC,,,facility,both,3,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,636,RC,J2003,HCPCS,0409-1323-15,NDC,facility,both,100,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,50863,CDM,636,RC,J3490,HCPCS,0378-7732-93,NDC,facility,both,2,EA,,219,153.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITRIOL 1 MCG/ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,64980-447-15,NDC,facility,both,1,ML,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 20 GRAM/30 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-1154-30,NDC,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0641-6022-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,50863,CDM,636,RC,J1885,HCPCS,72266-119-01,NDC,facility,both,1,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0121-1781-05,NDC,facility,both,3,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  5 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,60505-3275-3,NDC,facility,both,2,EA,,140,98,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN NEO/PEDS IV SYRINGE (CDS MIXTURE),50863,CDM,636,RC,J0456,HCPCS,63323-398-14,NDC,facility,both,1,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAVASTATIN 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-190-11,NDC,facility,both,1,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARSENIC TRIOXIDE 10 MG/10 ML IV SOLN,50863,CDM,250,RC,J9017,HCPCS,23155-869-31,NDC,facility,both,10,ML,,493,345.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 2 GRAM IV SOLUTION,50863,CDM,250,RC,J9075,HCPCS,0781-3255-94,NDC,facility,both,400,EA,,3791,2653.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAMSULOSIN 0.4 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,68382-132-01,NDC,facility,both,2,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,23155-724-01,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-ABBS 10 MG/ML IV SOLN,50863,CDM,636,RC,Q5115,HCPCS,63459-104-50,NDC,facility,both,50,ML,,11669,8168.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOBRAMYCIN 1.2 G POWDER VIAL,50863,CDM,250,RC,J3260,HCPCS,39822-0412-6,NDC,facility,both,30,EA,,795,556.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SOTALOL  80 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-654-11,NDC,facility,both,2,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,250,RC,J2270,HCPCS,0641-6125-01,NDC,facility,both,2,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN STERILE WATER 2 GRAM/20 ML IV SYRG,50863,CDM,636,RC,J0690,HCPCS,70092-1604-47,NDC,facility,both,8,ML,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-1749-70,NDC,facility,both,2,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 5 MG/ML IV SOLN,50863,CDM,636,RC,J1921,HCPCS,25021-317-20,NDC,facility,both,1,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LEVETIRACETAM 100 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,16714-358-01,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  5 MG ORAL TAB,50863,CDM,J7512,HCPCS,60687-122-11,NDC,,,facility,both,50,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAUNORUBICIN 5 MG/ML IV INJ,50863,CDM,250,RC,J9150,HCPCS,42658-021-01,NDC,facility,both,1,ML,JW,157,109.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ENOXAPARIN 150 MG/1 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,16714-066-01,NDC,facility,both,1,ML,JW,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
AZITHROMYCIN NEO/PEDS IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0456,HCPCS,63323-398-14,NDC,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0780,HCPCS,0641-6135-25,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-9791-01,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEPERIDINE (PF) 50 MG/ML IV SOLN (PHS MERGE),50863,CDM,636,RC,J2175,HCPCS,0409-1178-03,NDC,facility,both,1,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  100 MCG/ML INJ SOLN,50863,CDM,636,RC,J2354,HCPCS,63323-376-00,NDC,facility,both,2,ML,JA,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
VENLAFAXINE 150 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,65862-697-90,NDC,facility,both,1,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE (PF) 25 MG/ML INJ SOLN (FOR ECTOPIC PREGNANCY),50863,CDM,636,RC,J9260,HCPCS,0143-9519-01,NDC,facility,both,4,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,3,EA,,108,75.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANTI-INHIBITOR COAGULANT CMPLX (PHS MERGE),50863,CDM,250,RC,J7198,HCPCS,64193-426-02,NDC,facility,both,20,UN,,145,101.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM TETRADECYL SULFATE 3 % IV SOLN,50863,CDM,250,RC,J3490,HCPCS,67457-163-02,NDC,facility,both,5,ML,,1988,1391.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  1 MG/ML INJ SYRG,50863,CDM,250,RC,J1171,HCPCS,0409-1283-10,NDC,facility,both,10,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PSEUDOEPHEDRINE 30 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6990-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PSEUDOEPHEDRINE SR 120 MG TAB,50863,CDM,250,RC,J3490,HCPCS,51660-204-21,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISRADIPINE  2.5 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,16252-539-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,250,RC,J3101,HCPCS,50242-037-06,NDC,facility,both,19,EA,,8210,5747,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TAB,50863,CDM,636,RC,J3490,HCPCS,60687-672-11,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL  6.25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68462-163-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLIMEPIRIDE 4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-327-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,3,EA,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,13107-083-05,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0406-5771-23,NDC,facility,both,12,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN SODIUM EXTENDED 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0071-0369-24,NDC,facility,both,3,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE  25 MG ORAL CAP,50863,CDM,250,RC,J7515,HCPCS,68084-879-95,NDC,facility,both,1,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,636,RC,J1953,HCPCS,63323-400-01,NDC,facility,both,80,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON DEXTRAN 50 MG/ML INJ SOLN,50863,CDM,J1750,HCPCS,0023-6082-01,NDC,,,facility,both,20,ML,,2188,1531.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ABOBOTULINUMTOXINA 500 UNITS IM SOLR,50863,CDM,636,RC,J0586,HCPCS,15054-0500-1,NDC,facility,both,160,EA,,3370,2359,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DROXIDOPA 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,67386-820-19,NDC,facility,both,4,EA,,423,296.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLEDRONIC ACID-MANNITOL-WATER 4 MG/100 ML IV PGBK,50863,CDM,636,RC,J3489,HCPCS,25021-826-82,NDC,facility,both,4,ML,,778,544.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1162-18,NDC,facility,both,100,ML,JZ,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"BACITRACIN ZINC-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM OINTMENT",50863,CDM,636,RC,J3490,HCPCS,58980-012-05,NDC,facility,both,1,GM,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,250,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-444-01,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % MBP,50863,CDM,250,RC,J3490,HCPCS,0338-0553-18,NDC,facility,both,1,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,0904-6923-61,NDC,facility,both,10,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALSARTAN  40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-612-11,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,2,EA,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
AMOXICILLIN 400 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0143-9887-01,NDC,facility,both,10,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % MBP,50863,CDM,250,RC,J3490,HCPCS,0338-0553-18,NDC,facility,both,5,ML,,241,168.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE  5 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,31722-185-01,NDC,facility,both,4,EA,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DACTINOMYCIN 0.5 MG IV SOLR,50863,CDM,636,RC,J9120,HCPCS,71288-129-02,NDC,facility,both,2,EA,,2335,1634.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE  5 MG/ML INJ SOLN,50863,CDM,250,RC,J2765,HCPCS,23155-240-31,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUGAMMADEX 100 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0006-5423-02,NDC,facility,both,2,ML,,1177,823.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,25021-463-01,NDC,facility,both,2,ML,JA,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
PIPERACILLIN-TAZOBACTAM NEO/PEDS INFUSION (CDS MIXTURE),50863,CDM,250,RC,J2543,HCPCS,0206-8852-08,NDC,facility,both,3,EA,,321,224.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,0143-9577-01,NDC,,,facility,both,130,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE MODIFIED 100 MG ORAL CAP,50863,CDM,250,RC,J7502,HCPCS,23155-839-11,NDC,facility,both,1,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  650 MG RECT SUPP,50863,CDM,250,RC,J3490,HCPCS,45802-730-00,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-497-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOLIC ACID  1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-681-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLECAINIDE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-0011-20,NDC,facility,both,2,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,10019-506-37,NDC,facility,both,4,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR NEO/PEDS INFUSION (CDS FROM PREMIX),50863,CDM,250,RC,J0133,HCPCS,63323-325-10,NDC,facility,both,13,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
23.4% SODIUM CHLORIDE (4 MEQ/ML) INJECTION,50863,CDM,250,RC,J3490,HCPCS,63323-095-02,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ABATACEPT 250 MG IV SOLR,50863,CDM,636,RC,J0129,HCPCS,0003-2187-13,NDC,facility,both,50,EA,"JZ,JA",8073,5651.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,9,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,3,EA,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 20 MEQ/100 ML IV PGBK,50863,CDM,250,RC,J3480,HCPCS,0338-0705-48,NDC,facility,both,10,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,50863,CDM,250,RC,J9025,HCPCS,72485-201-01,NDC,facility,both,168,EA,,2387,1670.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2310,HCPCS,0409-1215-21,NDC,facility,both,1,ML,,186,130.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DICLOFENAC 50 MG TAB, DELAYED RELEASE",50863,CDM,636,RC,J3490,HCPCS,16571-202-10,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25 MG-100 MG TAB,50863,CDM,636,RC,J3490,HCPCS,69367-339-05,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1162-01,NDC,facility,both,300,ML,JZ,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
AMIODARONE 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6993-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,J0665,HCPCS,63323-466-03,NDC,,,facility,both,100,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOBETASOL PROPIONATE 0.05 % TOP CREA,50863,CDM,250,RC,J3490,HCPCS,45802-129-35,NDC,facility,both,2,GM,,336,235.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NORTRIPTYLINE 25 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,51672-4002-1,NDC,facility,both,6,EA,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J3430,HCPCS,68462-758-01,NDC,facility,both,10,ML,,218,152.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  500 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,25021-465-01,NDC,facility,both,20,ML,"JZ,JA",206,144.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,J0665,HCPCS,0409-1162-18,NDC,,,facility,both,100,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,25021-662-10,NDC,facility,both,1,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,23155-833-01,NDC,facility,both,9,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2001,HCPCS,0143-9577-01,NDC,,,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,27808-158-01,NDC,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TAB,50863,CDM,J3490,HCPCS,0406-0512-23,NDC,,,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,15,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR IN 0.9% NACL 100 UNIT/100 ML (1 UNIT/ML) INFUSION FOR OB,50863,CDM,250,RC,J1815,HCPCS,0338-0126-12,NDC,facility,both,1,ML,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,70700-165-22,NDC,facility,both,2,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 20% IN WATER (NEO) 500ML,50863,CDM,250,RC,J3490,HCPCS,0990-7935-19,NDC,facility,both,1,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),50863,CDM,636,RC,J1815,HCPCS,0024-5926-05,NDC,facility,both,2,ML,GZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier GZ: Item or service expected to be denied as not reasonable and necessary
FOLIC ACID  1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7224-61,NDC,facility,both,5,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOTRIMAZOLE 1 % VAGL CREA,50863,CDM,250,RC,J3490,HCPCS,61269-220-41,NDC,facility,both,1,GM,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,250,RC,J3490,HCPCS,63037-136-25,NDC,facility,both,3,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2310,HCPCS,70069-072-01,NDC,facility,both,1,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1815,HCPCS,0002-8215-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7121-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML IV SOLN,50863,CDM,J3490,HCPCS,55150-222-20,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,68094-193-59,NDC,facility,both,3,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PYRIDOXINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,5026885811,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0780,HCPCS,23155-294-31,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTAZIDIME NEO IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0713,HCPCS,0781-3177-80,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATENOLOL  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-759-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENAZOPYRIDINE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,65162-681-10,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM PHOSPHATE 3 MMOL/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-7391-82,NDC,facility,both,1,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORATADINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-248-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE  250 MCG/ACTUATION INHL DSDV,50863,CDM,636,RC,J3490,HCPCS,66993-792-97,NDC,facility,both,1,EA,,921,644.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),50863,CDM,636,RC,J1815,HCPCS,0024-5926-05,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,636,RC,J1610,HCPCS,63323-593-03,NDC,facility,both,1,EA,,895,626.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,636,RC,J3490,HCPCS,0409-4277-01,NDC,facility,both,400,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-645-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM 2000 MG IV SOLR,50863,CDM,250,RC,J2185,HCPCS,72078-081-00,NDC,facility,both,20,EA,JZ,194,135.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PROMETHAZINE 12.5 MG ORAL TAB,50863,CDM,250,RC,Q0169,HCPCS,60687-660-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,250,RC,J0132,HCPCS,55150-259-30,NDC,facility,both,60,ML,,1033,723.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,18,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,50863,CDM,636,RC,Q5119,HCPCS,0069-0238-01,NDC,facility,both,5,ML,JW,431,301.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,130,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,250,RC,J3490,HCPCS,63323-485-26,NDC,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5%-1/2 NORMAL SALINE IV (PEDS ONCOLOGY),50863,CDM,J7042,HCPCS,0338-0085-04,NDC,,,facility,both,2,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,636,RC,J7060,HCPCS,0338-0017-02,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,250,RC,Q9968,HCPCS,0517-0381-01,NDC,facility,both,150,ML,,2490,1743,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),50863,CDM,250,RC,J2060,HCPCS,0641-6044-01,NDC,facility,both,3,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 5 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,0409-1778-15,NDC,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NORTRIPTYLINE 10 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0093-0810-01,NDC,facility,both,3,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-467-01,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 10 MG TAB,50863,CDM,250,RC,Q0177,HCPCS,60687-664-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,250,RC,J3490,HCPCS,0173-0682-20,NDC,facility,both,1,GM,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-579-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETIRIZINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0378-3635-01,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,68180-441-02,NDC,facility,both,13,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,250,RC,J7060,HCPCS,0338-0017-04,NDC,facility,both,2,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-487-11,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE SODIUM 25 MG/ML INJ SOLN,50863,CDM,636,RC,J9260,HCPCS,61703-350-37,NDC,facility,both,2,ML,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2308-22,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,0409-6102-04,NDC,facility,both,80,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAPAVERINE 30 MG/ML INJ SOLN,50863,CDM,250,RC,J2440,HCPCS,54288-142-01,NDC,facility,both,1,ML,,191,133.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,636,RC,J3101,HCPCS,50242-037-06,NDC,facility,both,19,EA,,8703,6092.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 500 MG/10 ML IV SOLN,50863,CDM,250,RC,J9190,HCPCS,63323-117-01,NDC,facility,both,2,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PNEUMOCOCCAL 23-VAL PS VACCINE 25 MCG/0.5 ML INJ SYRG,50863,CDM,250,RC,90732,HCPCS,0006-4837-01,NDC,facility,both,1,ML,,506,354.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG ORAL TAB,50863,CDM,250,RC,Q0169,HCPCS,68084-155-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN (NEO),50863,CDM,250,RC,J1940,HCPCS,71288-203-10,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,J1953,HCPCS,55150-177-05,NDC,,,facility,both,125,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6426-61,NDC,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMETHICONE  80 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,77333-812-25,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  1 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,64380-782-06,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE 25 MG/ML INJ SOLN,50863,CDM,250,RC,J3230,HCPCS,0641-1397-31,NDC,facility,both,2,ML,,509,356.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,67457-433-00,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,50863,CDM,250,RC,J9045,HCPCS,61703-339-50,NDC,facility,both,9,ML,,240,168,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,63323-461-01,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,67457-433-00,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-3178-01,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL  6.25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68462-163-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0093-2026-94,NDC,facility,both,4,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 2.5 GRAM/25 ML (10 %) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-16,NDC,facility,both,5,ML,,908,635.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CELECOXIB 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,59762-1516-1,NDC,facility,both,1,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLMESARTAN  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0527-2425-46,NDC,facility,both,1,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,2,ML,,291,203.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,70004-600-09,NDC,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-411-10,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM NEO/PEDS INFUSION (CDS MIXTURE),50863,CDM,250,RC,J2543,HCPCS,0206-8852-08,NDC,facility,both,1,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE (POLACRILEX) 2 MG MM LOZG,50863,CDM,636,RC,J3490,HCPCS,45802-344-03,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,50863,CDM,250,RC,J3490,HCPCS,69339-152-01,NDC,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,0904-6794-30,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,20,ML,JZ,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-492-37,NDC,facility,both,300,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 500 MG PE/10 ML INJ SOLN,50863,CDM,250,RC,Q2009,HCPCS,67457-517-00,NDC,facility,both,20,ML,,489,342.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 100 MG/1 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0781-3268-05,NDC,facility,both,10,ML,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2308-22,NDC,facility,both,7,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,J3490,HCPCS,42858-001-10,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 10 MG ORAL TAB,50863,CDM,J3490,HCPCS,51079-208-01,NDC,,,facility,both,4,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0904-6923-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,72603-350-01,NDC,,,facility,both,15,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,J3490,HCPCS,60687-751-42,NDC,,,facility,both,2,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,J3490,HCPCS,0143-9889-15,NDC,,,facility,both,14,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-131-11,NDC,facility,both,12,EA,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 100 MG ORAL CHEW,50863,CDM,636,RC,J3490,HCPCS,0904-3854-61,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,63323-461-01,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORHEXIDINE GLUCONATE  0.12 % MM MWSH,50863,CDM,250,RC,J3490,HCPCS,69339-138-15,NDC,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYUREA  500 MG ORAL CAP,50863,CDM,250,RC,J9999,HCPCS,68084-284-11,NDC,facility,both,4,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSULFAN BLUE 1 % INJ SOLN,50863,CDM,636,RC,Q9968,HCPCS,67457-220-00,NDC,facility,both,30,ML,,2579,1805.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5% W/EPINEPHRINE 1:200K INJECTION,50863,CDM,636,RC,J3490,HCPCS,0409-1749-29,NDC,facility,both,1,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOBUTAMINE IN D5W 500 MG/250 ML (2 MG/ML) INFUSION (PREMIX),50863,CDM,J1250,HCPCS,0338-1075-02,NDC,,,facility,both,2,ML,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLMESARTAN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16729-321-10,NDC,facility,both,6,EA,,202,141.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,250,RC,J2003,HCPCS,0409-4903-11,NDC,facility,both,100,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,50863,CDM,J3490,HCPCS,0143-9853-16,NDC,,,facility,both,6,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,63739-931-28,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 200 MG/100 ML IVPB (MERGE),50863,CDM,250,RC,J1450,HCPCS,0409-4688-22,NDC,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7914-61,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 16 MG ORAL TAB,50863,CDM,250,RC,J7509,HCPCS,68382-918-18,NDC,facility,both,5,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-444-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,76045-009-10,NDC,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6949-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,0338-0069-10,NDC,facility,both,1,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CEFTRIAXONE 100 MG/ML FROM 1 GRAM VIAL (PRMC PEDS ONLY),50863,CDM,636,RC,J0696,HCPCS,0409-7332-11,NDC,facility,both,8,EA,JZ,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
FENOFIBRATE NANOCRYSTALLIZED 145 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-629-11,NDC,facility,both,1,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-888-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NAPROXEN 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-594-11,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE 100 MG TAB,50863,CDM,636,RC,J3490,HCPCS,23155-135-25,NDC,facility,both,20,EA,,418,292.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LITHIUM CARBONATE 300 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,68462-223-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,50863,CDM,636,RC,Q0177,HCPCS,0904-6617-61,NDC,facility,both,6,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J3490,HCPCS,0409-0152-01,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  20 MEQ ORAL PACK,50863,CDM,250,RC,J3490,HCPCS,0245-0360-89,NDC,facility,both,2,EA,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE (PF) 25 MG/ML INJ SOLN (FOR ECTOPIC PREGNANCY),50863,CDM,636,RC,J9260,HCPCS,0143-9519-01,NDC,facility,both,2,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,68094-061-59,NDC,facility,both,2,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM HYPOCHLORITE 0.25 % MISC SOLN,50863,CDM,250,RC,J3490,HCPCS,0436-0936-16,NDC,facility,both,1,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2599,HCPCS,42023-164-01,NDC,facility,both,20,ML,,413,289.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MYCOPHENOLATE 500 MG TAB,50863,CDM,250,RC,J7517,HCPCS,51079-379-01,NDC,facility,both,4,EA,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM  50 MG INJ SOLR,50863,CDM,250,RC,J0640,HCPCS,25021-813-10,NDC,facility,both,6,EA,,353,247.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-161-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG IV SOLR,50863,CDM,636,RC,J3490,HCPCS,0008-0923-51,NDC,facility,both,1,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,69623-232-39,NDC,facility,both,3,ML,,264,184.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,2,EA,,136,95.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,0143-9577-01,NDC,,,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN LYSINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,67386-122-52,NDC,facility,both,1,ML,,1312,918.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 40 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-210-11,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50111-328-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-406-03,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,18,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6426-61,NDC,facility,both,2,EA,PLAD,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,4,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
OLANZAPINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6376-61,NDC,facility,both,1,EA,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-492-09,NDC,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-492-27,NDC,facility,both,1,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,0054-3294-50,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0093-4177-73,NDC,facility,both,10,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLN,50863,CDM,636,RC,J3262,HCPCS,50242-135-01,NDC,facility,both,40,ML,JA,734,513.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
ALTEPLASE 2 MG INJ SOLR,50863,CDM,250,RC,J2997,HCPCS,50242-041-64,NDC,facility,both,4,EA,,1524,1066.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-11,NDC,facility,both,1,ML,JZ,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SUGAMMADEX 100 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0006-5423-02,NDC,facility,both,2,ML,,1177,823.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TAB,50863,CDM,250,RC,J3490,HCPCS,60687-672-11,NDC,facility,both,2,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-152-11,NDC,facility,both,4,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,63,ML,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6950-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROIC ACID 250 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,63739-086-10,NDC,facility,both,4,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMINOCAPROIC ACID 250 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0517-9120-01,NDC,facility,both,1,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM SR 180 MG 24 HR CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7218-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 250 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,68084-776-11,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2308-21,NDC,facility,both,4,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLP,50863,CDM,250,RC,J3480,HCPCS,0409-6653-18,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE (PF-DURAMORPH/ASTRAMORPH) 0.5 MG/ML INJ SOLN,50863,CDM,250,RC,J2274,HCPCS,0409-3814-12,NDC,facility,both,1,ML,,249,174.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLN,50863,CDM,636,RC,J3262,HCPCS,50242-137-01,NDC,facility,both,320,ML,,5865,4105.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0143-9386-01,NDC,facility,both,36,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,636,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,15,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
HYDROPHILLIC OINTMENT (AQUAPHOR),50863,CDM,250,RC,J3490,HCPCS,7214003147,NDC,facility,both,1,GM,,111,77.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOSTIGMINE 1MG/ML (UD) OR SYRINGE,50863,CDM,250,RC,J2710,HCPCS,76014-003-33,NDC,facility,both,1,ML,PLAD,142,99.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
EPINEPHRINE 1 MG/ML INJ SOLN,50863,CDM,250,RC,J0171,HCPCS,76329-9061-0,NDC,facility,both,1,ML,,148,103.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  1 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0603-5335-21,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 160 MG-800 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0904-2725-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,636,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,5,EA,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J1938,HCPCS,0409-6102-18,NDC,facility,both,40,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCUSATE SODIUM 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7183-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,63323-468-37,NDC,facility,both,2,ML,,143,100.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPRAZOLAM 0.25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-377-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NS WITH POTASSIUM CHLORIDE 20 MEQ/L IV SOLP,50863,CDM,250,RC,J3480,HCPCS,0338-0691-04,NDC,facility,both,20,ML,,128,89.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0074-4552-11,NDC,facility,both,3,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-50,NDC,facility,both,3,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CLINDAMYCIN IN D5W 900 MG/50 ML IV PGBK,50863,CDM,250,RC,J0736,HCPCS,0338-3814-50,NDC,facility,both,3,ML,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-231-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,43598-549-10,NDC,facility,both,100,ML,,165,115.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
K PHOS DI & MONO-SOD PHOS MONO 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,6498010401,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,250,RC,J3490,HCPCS,72485-510-01,NDC,facility,both,1,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,67877-545-88,NDC,facility,both,9,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZTROPINE 2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-389-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SALIVA STIMULANT AGENTS COMB.3 MM SPRY (BIOTENE) (REPACK),50863,CDM,636,RC,J3490,HCPCS,4858200155,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-02,NDC,facility,both,1,ML,JZ,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LACOSAMIDE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7244-68,NDC,facility,both,2,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,250,RC,J3101,HCPCS,50242-037-06,NDC,facility,both,26,EA,JW,5178,3624.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,250,RC,J2270,HCPCS,0409-1890-03,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,57237-004-30,NDC,facility,both,4,EA,,172,120.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,250,RC,J7060,HCPCS,0338-0017-31,NDC,facility,both,2,ML,,292,204.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0409-4699-53,NDC,facility,both,50,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,70069-013-25,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J2004,HCPCS,0409-3178-01,NDC,facility,both,400,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE 150 MG/ML IM SYRG,50863,CDM,636,RC,J1050,HCPCS,0548-5701-00,NDC,facility,both,150,ML,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-242-11,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML INJECTION,50863,CDM,250,RC,J3411,HCPCS,25021-500-02,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 30 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,0904-7044-61,NDC,facility,both,3,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,439,ME,JZ,5958,4170.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-3178-01,NDC,facility,both,140,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LANREOTIDE 90 MG/0.3 ML SUBQ SYRG,50863,CDM,636,RC,J1930,HCPCS,15054-1090-4,NDC,facility,both,90,ML,,22379,15665.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,50,ML,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2599,HCPCS,43598-914-25,NDC,facility,both,5,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM 500 MG IV SOLR,50863,CDM,636,RC,J2185,HCPCS,70121-1454-1,NDC,facility,both,5,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  100 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,63323-376-00,NDC,facility,both,8,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 2 MG INJ SOLR,50863,CDM,250,RC,J2997,HCPCS,50242-041-10,NDC,facility,both,2,EA,,800,560,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,1,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2599,HCPCS,43598-914-25,NDC,facility,both,20,ML,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-11,NDC,facility,both,7,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,25021-131-82,NDC,facility,both,150,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 125 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-443-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-440-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR PHOSPHATE 75 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,33342-258-66,NDC,facility,both,9,EA,,501,350.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COVID VACCINE 24-25 (6M-11Y)(MOD)PF 25 MCG/0.25 ML IM SYRG,50863,CDM,91321,HCPCS,80777-291-09,NDC,,,facility,both,1,ML,,558,390.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENAZOPYRIDINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65162-681-10,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-821-01,NDC,facility,both,2,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6008-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,250,RC,J3490,HCPCS,63323-485-26,NDC,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,2,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 10 MG TAB,50863,CDM,250,RC,Q0177,HCPCS,60687-664-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RAMIPRIL 10 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,65862-477-01,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
D5-1/2 NS AND POTASSIUM CHLORIDE 20 MEQ/L IV (PEDS CHEMO),50863,CDM,636,RC,J3490,HCPCS,0264-7635-00,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,15,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  1 MG/ML INJ SYRG,50863,CDM,636,RC,J1171,HCPCS,0409-1283-10,NDC,facility,both,10,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-0905-05,NDC,facility,both,4,ML,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0137,HCPCS,0143-9386-01,NDC,facility,both,29,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.15 MG/0.3 ML IM PNIJ,50863,CDM,636,RC,J0169,HCPCS,49502-101-01,NDC,facility,both,2,EA,,675,472.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-11,NDC,facility,both,10,ML,JW,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,44567-600-04,NDC,facility,both,1,ML,,218,152.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTAMIDINE 300 MG INJ SOLR,50863,CDM,636,RC,J3490,HCPCS,23155-748-31,NDC,facility,both,1,EA,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,78206-121-01,NDC,facility,both,2,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE  2 MG/ML INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-285-10,NDC,facility,both,3,ML,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 20 GRAM/30 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,0121-1154-30,NDC,facility,both,2,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEPLIZUMAB-MZWV 2 MG/20 ML IV SOLN,50863,CDM,636,RC,J9381,HCPCS,73650-316-01,NDC,facility,both,110,ME,JW,3213,2249.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-440-01,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),50863,CDM,636,RC,J0171,HCPCS,76329-3318-1,NDC,facility,both,10,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J2250,HCPCS,0409-0001-01,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,38,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 650 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,77333-827-25,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  5 MG ORAL TBDL,50863,CDM,636,RC,J3490,HCPCS,55111-262-79,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,47,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"AMIODARONE IN DEXTROSE,ISO-OSM 360 MG/200 ML (1.8 MG/ML) IV SOLN",50863,CDM,636,RC,J0282,HCPCS,43066-360-20,NDC,facility,both,12,ML,JZ,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MELATONIN  3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,7733351625,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  5 MG ORAL TBDL,50863,CDM,636,RC,J3490,HCPCS,60505-3275-3,NDC,facility,both,1,EA,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,50863,CDM,250,RC,Q0177,HCPCS,10702-011-01,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN  500 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,70010-491-01,NDC,facility,both,3,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,10135-676-01,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BISACODYL  5 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,0904-6407-61,NDC,facility,both,12,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-03,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE HCL 0.3 MG/ML INJ (MERGE),50863,CDM,250,RC,J0592,HCPCS,42023-179-01,NDC,facility,both,3,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-65,NDC,facility,both,86,ML,,152,106.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE SOD SUCC (PF) 100 MG/2 ML INJ SOLR,50863,CDM,250,RC,J1720,HCPCS,0009-0011-03,NDC,facility,both,1,EA,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,1,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN PEDS SYRINGE (20MG/ML) IN DEXTROSE (CDS MIX,50863,CDM,250,RC,J0690,HCPCS,0781-3451-70,NDC,facility,both,4,EA,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,250,RC,J7060,HCPCS,0338-0017-04,NDC,facility,both,2,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0054-0018-25,NDC,facility,both,60,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES  8.6 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6522-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 160 MG-800 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0904-2725-61,NDC,facility,both,10,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN D5W 1 GRAM/200 ML IV PGBK,50863,CDM,250,RC,J3373,HCPCS,0338-3552-48,NDC,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG IV SOLR,50863,CDM,250,RC,J0650,HCPCS,25021-468-10,NDC,facility,both,10,EA,,397,277.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,68180-441-01,NDC,facility,both,3,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM SR 180 MG 24 HR CAP,50863,CDM,636,RC,J3490,HCPCS,60687-206-11,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIROFIBAN-0.9% SODIUM CHLORIDE 5 MG/100 ML (50 MCG/ML) IV SOLN,50863,CDM,J3246,HCPCS,25208-002-03,NDC,,,facility,both,7,ML,,140,98,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML IV,50863,CDM,250,RC,J3490,HCPCS,25021-319-05,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,636,RC,J2704,HCPCS,65219-800-01,NDC,facility,both,2,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
0.2 MICRON FILTER ATTACHMENT MISC MISC,50863,CDM,J3490,HCPCS,99999-0403-06,NDC,,,facility,both,1,EA,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-492-09,NDC,,,facility,both,100,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,72603-350-01,NDC,,,facility,both,58,ML,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLERGONOVINE 0.2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,69238-1605-2,NDC,facility,both,3,EA,,727,508.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,73293-0001-1,NDC,,,facility,both,200,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,636,RC,J1815,HCPCS,49502-393-80,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEPERIDINE (PF) 25 MG/ML IV SOLN (PHS MERGE),50863,CDM,J2175,HCPCS,0409-1176-03,NDC,,,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 20 MG/ML INJ SOLN,50863,CDM,250,RC,J0360,HCPCS,0641-6231-01,NDC,facility,both,1,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL DECANOATE  50 MG/ML IM SOLN,50863,CDM,636,RC,J1631,HCPCS,70069-030-01,NDC,facility,both,1,ML,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPRAZOLAM 0.25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0781-1061-01,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT  60 MCG/0.3 ML INJ SYRG,50863,CDM,250,RC,J0881,HCPCS,55513-023-01,NDC,facility,both,60,ML,"JZ,EC",1282,897.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier EC: Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,0409-1283-03,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BETAMETHASONE ACET & SOD PHOS 6 MG/ML INJ SUSP,50863,CDM,250,RC,J0702,HCPCS,78206-118-01,NDC,facility,both,3,ML,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-319-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-078-33,NDC,facility,both,1,EA,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 150 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7212-61,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 50 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,59651-489-01,NDC,facility,both,90,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,5,EA,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CHERRY SYRUP,50863,CDM,250,RC,J3490,HCPCS,395266216,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,10135-676-01,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRBESARTAN 150 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,33342-048-07,NDC,facility,both,1,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7244-68,NDC,facility,both,3,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  5 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,59746-306-12,NDC,facility,both,2,EA,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MILRINONE IN D5W 20 MG/100 ML (0.2 MG/ML) INFUSION,50863,CDM,250,RC,J2260,HCPCS,0409-2045-01,NDC,facility,both,2,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0143-9889-15,NDC,facility,both,9,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,60687-134-11,NDC,facility,both,5,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-503-11,NDC,facility,both,3,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-822-11,NDC,facility,both,1,EA,PLAD,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
LIDOCAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-491-01,NDC,,,facility,both,50,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,0409-4713-32,NDC,,,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 875 MG-125 MG TAB,50863,CDM,636,RC,J3490,HCPCS,65862-503-01,NDC,facility,both,19,EA,,399,279.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 2 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,250,RC,J2270,HCPCS,0409-1890-01,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODINE STRONG (LUGOLS) 5 % ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,48433-230-15,NDC,facility,both,1,ML,,136,95.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 150 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6956-61,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,43598-931-11,NDC,facility,both,2,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML IV SOLN (MERGE),50863,CDM,636,RC,J3490,HCPCS,70756-611-82,NDC,facility,both,1,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-284-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,70,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 0.1 MG/ML INJ SYRG,50863,CDM,636,RC,J0461,HCPCS,76329-3340-1,NDC,facility,both,50,ML,JW,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML IM SYRG,50863,CDM,250,RC,90371,HCPCS,13533-636-03,NDC,facility,both,1,ML,,383,268.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,J2003,HCPCS,63323-486-05,NDC,,,facility,both,120,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARGATROBAN 100 MG/ML IV SOLN,50863,CDM,250,RC,J0883,HCPCS,67457-212-02,NDC,facility,both,250,ML,,1408,985.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 500 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,50268-152-11,NDC,facility,both,6,EA,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,59762-4910-3,NDC,facility,both,2,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-18,NDC,facility,both,200,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65162-897-09,NDC,facility,both,3,EA,,340,238,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE HCL  2 % MM JELP,50863,CDM,250,RC,J3490,HCPCS,76329-3012-5,NDC,facility,both,1,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,0904-6794-89,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-01,NDC,facility,both,2,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB 100 MG IV SOLR,50863,CDM,636,RC,J1745,HCPCS,57894-030-01,NDC,facility,both,92,EA,,29654,20757.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 1 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,65162-673-84,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  1 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-6374-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE (FOR CODE) 10% (100 MG/ML) IV SYRINGE,50863,CDM,250,RC,J3490,HCPCS,0409-1631-40,NDC,facility,both,1,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL  6.25 MG ORAL TAB,50863,CDM,J3490,HCPCS,68084-854-11,NDC,,,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 500 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,16714-299-03,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,1,EA,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
SENNOSIDES-DOCUSATE SODIUM 8.6 MG-50 MG TAB,50863,CDM,250,RC,J3490,HCPCS,10135-669-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,70069-363-01,NDC,facility,both,1,ML,,161,112.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,250,RC,J3490,HCPCS,0173-0682-24,NDC,facility,both,1,GM,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICARDIPINE IN NACL (ISO-OS) 20 MG/200 ML IV PGBK,50863,CDM,636,RC,J3490,HCPCS,43066-009-10,NDC,facility,both,1,ML,,255,178.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,43598-053-11,NDC,facility,both,31,ML,,1118,782.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 20MG/ML IV SYRINGE (PEDS/NEO),50863,CDM,250,RC,J0612,HCPCS,63323-311-10,NDC,facility,both,18,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,50863,CDM,250,RC,J0696,HCPCS,0781-3209-90,NDC,facility,both,4,EA,JW,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DEXTROSE 5%-1/2 NORMAL SALINE IV (PEDS ONCOLOGY),50863,CDM,250,RC,J7042,HCPCS,0338-0085-04,NDC,facility,both,2,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM  2.25 GRAM IV SOLR,50863,CDM,636,RC,J2543,HCPCS,60505-6156-0,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,J0665,HCPCS,63323-466-17,NDC,,,facility,both,100,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE  100 MCG/ACTUATION INHL DSDV,50863,CDM,250,RC,J3490,HCPCS,66993-791-97,NDC,facility,both,1,EA,,840,588,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM SR 120 MG 24 HR CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7217-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN D5W 20000 UNIT/500 ML,50863,CDM,636,RC,J1644,HCPCS,0264-9567-10,NDC,facility,both,5,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 300 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,69452-125-50,NDC,facility,both,1,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 1 MG ORAL CAP,50863,CDM,636,RC,J7507,HCPCS,68084-450-11,NDC,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 2400000 UNIT/4 ML IM SYRG,50863,CDM,J0561,HCPCS,60793-702-04,NDC,,,facility,both,24,ML,,2088,1461.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,636,RC,J3010,HCPCS,0409-9094-12,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-453-11,NDC,facility,both,5,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM  1.5 GRAM INJ SOLR,50863,CDM,636,RC,J0295,HCPCS,0641-6116-01,NDC,facility,both,2,EA,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INHL NEBU,50863,CDM,250,RC,J3490,HCPCS,0487-9301-03,NDC,facility,both,8,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0781-1818-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,10135-676-01,NDC,facility,both,1,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML INJ SOLN,50863,CDM,250,RC,J0169,HCPCS,76329-9060-0,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,636,RC,J3490,HCPCS,73702-301-15,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE IN D5W (PF) 4 MG/ML (0.4 %) IV SOLP,50863,CDM,250,RC,J2003,HCPCS,0338-0409-03,NDC,facility,both,2000,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,50863,CDM,636,RC,J3301,HCPCS,70121-1049-2,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63629-1061-1,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/0.5 ML INHL NEBU,50863,CDM,250,RC,J3490,HCPCS,0487-9901-30,NDC,facility,both,4,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,51079-169-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1940,HCPCS,23155-473-44,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 150 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7212-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1815,HCPCS,0169-1833-11,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),50863,CDM,250,RC,J0169,HCPCS,76329-3318-1,NDC,facility,both,10,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,0409-1207-03,NDC,facility,both,4,ML,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZTREONAM 2 GRAM INJ SOLR,50863,CDM,250,RC,J0457,HCPCS,63323-402-01,NDC,facility,both,20,EA,JZ,374,261.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ONDANSETRON 4 MG ORAL TBDL,50863,CDM,636,RC,J3490,HCPCS,0378-7732-93,NDC,facility,both,3,EA,,284,198.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),50863,CDM,250,RC,J1815,HCPCS,0024-5926-05,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE  25 MG ORAL CAP,50863,CDM,250,RC,J7515,HCPCS,68084-879-95,NDC,facility,both,2,EA,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIROFIBAN-0.9% SODIUM CHLORIDE 5 MG/100 ML (50 MCG/ML) IV SOLN,50863,CDM,250,RC,J3246,HCPCS,25208-002-03,NDC,facility,both,40,ML,,795,556.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE 0.5 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-1755-50,NDC,facility,both,1,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-099-11,NDC,facility,both,1,EA,PLAD,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
BUPRENORPHINE 2 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,60687-481-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ (MERGE),50863,CDM,636,RC,J2250,HCPCS,0409-2305-17,NDC,facility,both,8,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 60 MG TAB,50863,CDM,250,RC,J3490,HCPCS,60687-573-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN SODIUM EXTENDED 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,65862-692-01,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,636,RC,J1815,HCPCS,49502-393-80,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,63323-161-00,NDC,facility,both,2,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 125 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-519-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 300 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-461-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,25021-602-03,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,16714-294-02,NDC,facility,both,8,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLP (FOR DIALYSIS)",50863,CDM,250,RC,P9047,HCPCS,0944-0493-02,NDC,facility,both,2,ML,,826,578.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,0591-5443-01,NDC,facility,both,20,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IV PGBK,50863,CDM,250,RC,J3475,HCPCS,0409-6729-24,NDC,facility,both,4,ML,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN IN 0.9 % NS 40 UNIT/100 ML (0.4 UNIT/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0338-9647-12,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SULFADIAZINE 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42806-757-60,NDC,facility,both,3,EA,,255,178.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,71399-1025-3,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,62332-600-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZOCAINE-MENTHOL 15-3.6 MG MM LOZG,50863,CDM,636,RC,J3490,HCPCS,0904-6255-49,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,J7040,HCPCS,0990-7984-13,NDC,,,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN   1.5 G IV SOLR,50863,CDM,J3370,HCPCS,67457-824-15,NDC,,,facility,both,3,EA,,142,99.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,Q5121,HCPCS,55513-670-01,NDC,,,facility,both,30,EA,,4140,2898,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0143-9386-01,NDC,facility,both,22,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),50863,CDM,250,RC,J0171,HCPCS,76329-3318-1,NDC,facility,both,10,ML,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PILOCARPINE 1 % EYE DROPS,50863,CDM,250,RC,J3490,HCPCS,61314-203-15,NDC,facility,both,1,ML,,418,292.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0121-1022-05,NDC,facility,both,2,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPROST TROMETHAMINE 250 MCG/ML IM SOLN,50863,CDM,250,RC,J3490,HCPCS,81298-5010-1,NDC,facility,both,1,ML,,306,214.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,71247-130-01,NDC,facility,both,3,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.25 MG/0.5 ML (0.5 MG/1 ML) ORAL SUSPENSION (REPACK),50863,CDM,250,RC,J3490,HCPCS,0591-0240-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,16714-644-01,NDC,facility,both,2,EA,,274,191.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,636,RC,J7999,HCPCS,70092-1017-46,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-744-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,250,RC,J2270,HCPCS,0641-6125-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE (PF) 1000 MCG/10 ML EPID SOLN,50863,CDM,J0735,HCPCS,67457-218-10,NDC,,,facility,both,1,ML,,224,156.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0093-0053-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MOXIFLOXACIN 400 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0093-7387-56,NDC,facility,both,1,EA,,134,93.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 0.75 MG (ENVARSUS XR) 24-HOUR EXTENDED-RELEASE TABLET,50863,CDM,250,RC,J7503,HCPCS,68992-3075-3,NDC,facility,both,6,EA,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAZOLAMIDE SODIUM 500 (100 MG/ML) INJ SOLR,50863,CDM,250,RC,J1120,HCPCS,39822-0190-1,NDC,facility,both,1,EA,,193,135.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE NA (PRESERV FREE) 25 MG/ML INJ SOLN,50863,CDM,250,RC,J9260,HCPCS,61703-408-41,NDC,facility,both,80,ML,,863,604.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THROMBIN (RECOMBINANT) 5000 UNIT TOP SOLR,50863,CDM,250,RC,J3490,HCPCS,0338-0322-01,NDC,facility,both,1,EA,,372,260.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,FAMNOCHARGE,HCPCS,0264-1800-32,NDC,,,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE 150 MG ORAL CP24,50863,CDM,636,RC,J3490,HCPCS,68084-713-11,NDC,facility,both,1,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,J2405,HCPCS,0409-4755-18,NDC,,,facility,both,8,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLN,50863,CDM,J3262,HCPCS,50242-135-01,NDC,,,facility,both,160,ML,,1275,892.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7048-61,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUM U-500 CONC 500 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1815,HCPCS,0002-8501-01,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,63323-104-06,NDC,facility,both,12,ML,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-131-11,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0121-1781-05,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE DINITRATE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-447-11,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,636,RC,J3010,HCPCS,0409-9094-12,NDC,facility,both,1,ML,JZ,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SODIUM CHLORIDE 0.9 % INHL NEBU,50863,CDM,250,RC,J3490,HCPCS,0378-6985-01,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DACTINOMYCIN 0.5 MG IV SOLR,50863,CDM,636,RC,J9120,HCPCS,71288-129-02,NDC,facility,both,5,EA,,6900,4830,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIOTHYRONINE  5 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,59762-1206-1,NDC,facility,both,6,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MOXIFLOXACIN 0.5 % OPHT DROP,50863,CDM,636,RC,J3490,HCPCS,72266-158-01,NDC,facility,both,1,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7126-61,NDC,facility,both,12,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,17856-7014-7,NDC,facility,both,1,ML,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 20MG/ML IV SYRINGE (PEDS/NEO),50863,CDM,636,RC,J0612,HCPCS,63323-311-10,NDC,facility,both,100,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-467-01,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID (PORK)  30 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0456-0458-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 1 MG ORAL TBDL,50863,CDM,250,RC,0093-9293-19,NDC,,,facility,both,0.5,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-1749-70,NDC,facility,both,2,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 20 MG/ML IN NS NEONATAL INJECTION (REPACK),50863,CDM,250,RC,J1650,HCPCS,63323-565-86,NDC,facility,both,1,ML,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,40,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CARBAMAZEPINE 100 MG ORAL TB12,50863,CDM,636,RC,J3490,HCPCS,51672-4123-1,NDC,facility,both,3,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 500 MG PE/10 ML INJ SOLN,50863,CDM,250,RC,Q2009,HCPCS,68462-621-02,NDC,facility,both,4,ML,,174,121.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,50863,CDM,250,RC,FAMNOCHARGE,HCPCS,0054-8175-25,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV (BOLUS),50863,CDM,250,RC,J7120,HCPCS,0264-7750-07,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4 % TOPICAL SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-4698-01,NDC,facility,both,1,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,48,EA,,6624,4636.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-433-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 250 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,42192-608-16,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM SR 90 MG 12 HR CAP,50863,CDM,250,RC,J3490,HCPCS,51079-925-01,NDC,facility,both,2,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 2400000 UNIT/4 ML IM SYRG,50863,CDM,250,RC,J0561,HCPCS,60793-702-04,NDC,facility,both,24,ML,,2088,1461.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG TAB,50863,CDM,636,RC,J3490,HCPCS,50268-728-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLN,50863,CDM,636,RC,J3262,HCPCS,50242-137-01,NDC,facility,both,800,ML,"JZ,JA",14661,10262.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0143-9334-01,NDC,facility,both,300,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 80 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0054-8301-25,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL 2.5 MG/ML SUSPENSION,50863,CDM,250,RC,J3490,HCPCS,99999-0404-75,NDC,facility,both,1,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-113-11,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SYRG,50863,CDM,636,RC,J3490,HCPCS,8290306547,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-48,NDC,facility,both,1,ML,JZ,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,9,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,3,ML,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",50863,CDM,250,RC,J1561,HCPCS,13533-800-41,NDC,facility,both,80,ML,,11316,7921.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"HEPARIN, PORCINE (PF) 1 UNIT/ML IV SYRG NEONATE",50863,CDM,250,RC,J1642,HCPCS,6425344430,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,250,RC,J2270,HCPCS,0409-1890-13,NDC,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZONISAMIDE 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-230-11,NDC,facility,both,3,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,313,ME,JZ,4248,2973.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MORPHINE 2 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,250,RC,J2270,HCPCS,76045-004-01,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2599,HCPCS,43598-914-11,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYPROHEPTADINE 2 MG/5 ML ORAL SYRP,50863,CDM,250,RC,J3490,HCPCS,64980-504-48,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROMETHORPHAN-GUAIFENESIN SR 30 MG-600 MG 12 HR TAB,50863,CDM,250,RC,J3490,HCPCS,0536-1161-37,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,48,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE  50 MG ORAL TAB,50863,CDM,250,RC,j3490,HCPCS,60687-443-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPTOMYCIN IN 0.9 % SOD CHLOR 500 MG/50 ML IV PGBK,50863,CDM,J3490,HCPCS,0338-0714-24,NDC,,,facility,both,1000,ML,,318,222.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,48,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE CONCENTRATE 20 MG/ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,0054-0404-44,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,250,RC,J7999,HCPCS,70092-1017-46,NDC,facility,both,2,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE IN 0.9 % NACL 4 MG/250 ML (16 MCG/ML) IV SOLN (MERGE),50863,CDM,250,RC,70004-613-40,NDC,,,facility,both,1,ML,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ABOBOTULINUMTOXINA 500 UNITS IM SOLR,50863,CDM,636,RC,J0586,HCPCS,15054-0500-1,NDC,facility,both,60,EA,,1459,1021.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,70594-117-01,NDC,facility,both,50,ML,JZ,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
AMPICILLIN-SULBACTAM NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0295,HCPCS,63323-368-20,NDC,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,50863,CDM,250,RC,J0696,HCPCS,44567-702-25,NDC,facility,both,8,EA,PLAD,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IVPB (PEDIATRICS/ADULT NON-FORM)",50863,CDM,636,RC,J0137,HCPCS,24201-100-01,NDC,facility,both,100,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  75 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-441-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,72603-251-01,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 500 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,68084-415-11,NDC,facility,both,2,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-492-27,NDC,facility,both,1000,ML,,785,549.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,250,RC,J3490,HCPCS,63037-136-25,NDC,facility,both,2,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,636,RC,P9045,HCPCS,68516-5214-1,NDC,facility,both,1,ML,,263,184.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM IN NACL (ISO-OS) 1000 MG/100 ML IV PGBK,50863,CDM,250,RC,J1953,HCPCS,44567-502-01,NDC,facility,both,100,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 112 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-508-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  20 MEQ ORAL PACK,50863,CDM,250,RC,J3490,HCPCS,69543-451-01,NDC,facility,both,2,EA,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOBAZAM 2.5 MG/ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,99999-0404-03,NDC,facility,both,2,ML,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,636,RC,J3490,HCPCS,71449-069-11,NDC,facility,both,2,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  50 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6992-61,NDC,facility,both,3,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,14,EA,JW,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IRBESARTAN 150 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,31722-730-30,NDC,facility,both,1,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM IN NACL (ISO-OS) 1500 MG/100 ML IV PGBK,50863,CDM,636,RC,J1953,HCPCS,44567-503-01,NDC,facility,both,150,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,250,RC,J0137,HCPCS,0264-4100-90,NDC,facility,both,100,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAMADOL  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,72888-080-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",50863,CDM,250,RC,J1561,HCPCS,13533-800-24,NDC,facility,both,40,ML,,5658,3960.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEGFILGRASTIM (NEULASTA) 6 MG/0.6ML SUBQ SYRG,50863,CDM,636,RC,J2506,HCPCS,55513-190-01,NDC,facility,both,12,ML,,17714,12399.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0781-3458-75,NDC,facility,both,2000,ML,,108,75.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASCORBIC ACID  250 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,2055500100,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,16714-293-01,NDC,facility,both,8,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-354-11,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,636,RC,J7999,HCPCS,70092-1017-46,NDC,facility,both,2,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN NPH & REGULAR HUMAN 100 UNIT/ML (70-30) SUBQ SUSP,50863,CDM,250,RC,J1815,HCPCS,0169-1837-11,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,636,RC,J3490,HCPCS,0409-4277-17,NDC,facility,both,1000,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 3 MG/ML IV SYRG,50863,CDM,636,RC,J0153,HCPCS,0469-8234-12,NDC,facility,both,6,ML,,212,148.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-50,NDC,facility,both,141,ML,,249,174.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM  4.5 GRAM IV SOLR,50863,CDM,636,RC,J2543,HCPCS,81284-153-00,NDC,facility,both,4,EA,JZ,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,0641-6027-25,NDC,facility,both,7,ML,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 50 MG/10 ML (5 MG/ML) IV SOLN,50863,CDM,250,RC,J2305,HCPCS,0517-4810-25,NDC,facility,both,10,ML,JW,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LACTATED RINGERS IV (BOLUS),50863,CDM,250,RC,J7120,HCPCS,0264-7750-00,NDC,facility,both,3,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-723-11,NDC,facility,both,1,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM  3 GRAM INJ SOLR,50863,CDM,250,RC,J0295,HCPCS,72485-417-01,NDC,facility,both,2,EA,JZ,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PRAMIPEXOLE 0.125 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,13668-091-90,NDC,facility,both,2,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0121-1022-05,NDC,facility,both,4,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPOETIN ALFA 20000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0885,HCPCS,59676-320-00,NDC,facility,both,20,ML,,1476,1033.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 150 MG ORAL TBSR,50863,CDM,636,RC,J3490,HCPCS,0591-3541-60,NDC,facility,both,2,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,250,RC,J2003,HCPCS,63323-485-27,NDC,facility,both,60,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CITRATE  5 MEQ ORAL TBER,50863,CDM,250,RC,J3490,HCPCS,31722-129-01,NDC,facility,both,2,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,225,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,63739-931-28,NDC,facility,both,13,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LATANOPROST 0.005 % OPHT DROP,50863,CDM,250,RC,J3490,HCPCS,0013-8303-04,NDC,facility,both,1,ML,,936,655.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7367-06,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0295,HCPCS,63323-368-20,NDC,facility,both,1,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,10,EA,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,70004-600-09,NDC,facility,both,3,ML,,149,104.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 100 MG/1 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0075-0623-03,NDC,facility,both,10,ML,JZ,146,102.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MORPHINE 2 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,636,RC,J2270,HCPCS,63323-452-00,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,636,RC,J3490,HCPCS,0143-9575-01,NDC,facility,both,180,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,72603-179-01,NDC,facility,both,6,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,71288-402-10,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2599,HCPCS,42023-164-01,NDC,facility,both,40,ML,,825,577.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOVASTATIN 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68180-467-01,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-3178-01,NDC,facility,both,200,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 1 GRAM INJ SOLR,50863,CDM,250,RC,J0692,HCPCS,25021-121-20,NDC,facility,both,6,EA,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 25 MG/5 ML (5 MG/ML) ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,52536-600-11,NDC,facility,both,1,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-41,NDC,facility,both,80,ML,"JZ,JA",11316,7921.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
TAMSULOSIN 0.4 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,0904-6401-61,NDC,facility,both,7,EA,,145,101.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML SYRUP,50863,CDM,250,RC,J3490,HCPCS,69339-150-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE IN 0.9 % SOD CHLOR 4 MG/250 ML (16 MCG/ML) IV SOLN,50863,CDM,250,RC,42023-315-01,NDC,,,facility,both,1,ML,,389,272.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITRIOL 0.5 MCG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,23155-663-01,NDC,facility,both,4,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,18,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPTOMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0878,HCPCS,72603-152-01,NDC,facility,both,1000,EA,,2925,2047.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0245-0212-89,NDC,facility,both,3,EA,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUMAZENIL 0.1 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0143-9784-01,NDC,facility,both,1,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,21,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) IV SOLN",50863,CDM,636,RC,J9022,HCPCS,50242-917-01,NDC,facility,both,120,ML,,23792,16654.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL 20 MG/5 ML ORAL ELIX,50863,CDM,250,RC,J3490,HCPCS,0121-0942-05,NDC,facility,both,7,ML,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL 20 MG/5 ML ORAL ELIX,50863,CDM,250,RC,J3490,HCPCS,0121-0942-05,NDC,facility,both,2,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IR SOLN,50863,CDM,636,RC,J3490,HCPCS,0338-0047-46,NDC,facility,both,2,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 17 GRAM (100 %) ORAL PWPK,50863,CDM,636,RC,J3490,HCPCS,0904-6931-86,NDC,facility,both,14,EA,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-520-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,16714-298-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),50863,CDM,636,RC,J1630,HCPCS,76045-737-01,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NADOLOL  40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,76385-134-01,NDC,facility,both,2,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 300 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6572-61,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J2004,HCPCS,0409-3178-16,NDC,facility,both,140,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MECLIZINE 12.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-775-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,18,ML,JW,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LAMOTRIGINE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-319-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTAMIDINE 300 MG INJ SOLR,50863,CDM,636,RC,J3490,HCPCS,63323-113-01,NDC,facility,both,1,EA,,457,319.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACTIVATED CHARCOAL 25 GRAM/120 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0574-0521-74,NDC,facility,both,3,ML,,210,147,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DICLOFENAC 25 MG TAB, DELAYED RELEASE",50863,CDM,250,RC,J3490,HCPCS,16571-203-10,NDC,facility,both,3,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-776-11,NDC,facility,both,4,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,63323-400-01,NDC,facility,both,150,ML,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,636,RC,J2405,HCPCS,60505-6130-0,NDC,facility,both,16,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ROPINIROLE  0.25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-577-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"HYOSCYAMINE 0.125 MG TAB, RAPID DISSOLVE",50863,CDM,250,RC,J3490,HCPCS,42192-338-01,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3370,HCPCS,0143-9162-01,NDC,facility,both,2,EA,,29916,20941.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 50 MG/ML INJECTION,50863,CDM,250,RC,J1200,HCPCS,0641-0376-21,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,75,ML,,108,75.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML IV SOLN (MERGE),50863,CDM,636,RC,J3490,HCPCS,16714-037-01,NDC,facility,both,1,ML,,101,70.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,50863,CDM,250,RC,J0640,HCPCS,67457-530-35,NDC,facility,both,7,EA,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM NEO/PEDS (CDS MIXTURE),50863,CDM,636,RC,J0295,HCPCS,63323-368-20,NDC,facility,both,1,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-1283-03,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOVASTATIN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68180-468-01,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6369-61,NDC,facility,both,3,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7411-61,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE MALEATE 10 MG ORAL TAB,50863,CDM,250,RC,Q0164,HCPCS,59746-115-06,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,34,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-48,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAMADOL  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,57664-377-08,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-41,NDC,facility,both,80,ML,,11315,7920.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,66,ML,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LITHIUM CARBONATE 450 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,68084-655-11,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,250,RC,J7060,HCPCS,0338-0017-31,NDC,facility,both,2,ML,,327,228.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE 21 MG/24 HR TD PT24,50863,CDM,636,RC,J3490,HCPCS,43598-448-74,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LITHIUM CARBONATE 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-4527-25,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FELODIPINE  2.5 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,68462-233-01,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (NEO) <2 KG,50863,CDM,636,RC,J7060,HCPCS,0264-7510-00,NDC,facility,both,2,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,250,RC,J0132,HCPCS,70594-111-01,NDC,facility,both,240,ML,,1222,855.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROIC ACID 250 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,63739-086-10,NDC,facility,both,6,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,67457-423-00,NDC,facility,both,4,ML,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0456,HCPCS,55150-174-10,NDC,facility,both,1,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  15 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,68084-157-11,NDC,facility,both,3,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  5 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-122-11,NDC,facility,both,8,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,67457-423-00,NDC,facility,both,9,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-22,NDC,facility,both,60,ML,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN D5W 20000 UNIT/500 ML,50863,CDM,250,RC,J1644,HCPCS,0264-9567-10,NDC,facility,both,16,ML,JW,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DIPHENHYDRAMINE 50 MG/ML INJECTION,50863,CDM,636,RC,J1200,HCPCS,0641-0376-21,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUSPATERCEPT-AAMT 75 MG SUBQ SOLR,50863,CDM,J0896,HCPCS,59572-775-01,NDC,,,facility,both,340,ME,,32293,22605.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHOTERICIN B LIPOSOME 50 MG IV SUSR,50863,CDM,J0289,HCPCS,55150-365-01,NDC,,,facility,both,45,EA,,8117,5681.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,32,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NELARABINE 250 MG/50 ML IV SOLN (PEDS ONCOLOGY),50863,CDM,636,RC,J9261,HCPCS,71288-165-52,NDC,facility,both,3,ML,JW,503,352.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
SODIUM CHLORIDE 0.45 % 0.45 % IV SOLP,50863,CDM,636,RC,J3490,HCPCS,0264-7802-00,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 100 MG ORAL TAB,50863,CDM,J3490,HCPCS,50268-337-11,NDC,,,facility,both,2,EA,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 15 MG/ML (1.5 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-493-91,NDC,,,facility,both,300,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,8,ML,,145,101.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,J2270,HCPCS,0409-1890-03,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"HEPARIN, PORCINE (PF)  100 UNIT/ML IV SYRG",50863,CDM,250,RC,J1642,HCPCS,8290306513,NDC,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6818-61,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J3490,HCPCS,17271-701-02,NDC,facility,both,1,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1560-19,NDC,facility,both,300,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 20MG/55 ML IVPB IN NS (ONCOLOGY),50863,CDM,J1100,HCPCS,63323-165-02,NDC,,,facility,both,6,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7243-61,NDC,facility,both,28,EA,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OBINUTUZUMAB 900 MG IN NS 286 ML (STOCK DOSE),50863,CDM,J9301,HCPCS,50242-070-01,NDC,,,facility,both,10,ML,,672,470.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,50863,CDM,250,RC,J0696,HCPCS,64679-983-01,NDC,facility,both,4,EA,,218,152.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,250,RC,J2003,HCPCS,0409-1323-15,NDC,facility,both,100,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % MBP,50863,CDM,J3490,HCPCS,0338-0553-18,NDC,,,facility,both,3,ML,,133,93.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,50863,CDM,J3490,HCPCS,0143-9509-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL (NEO/PEDS),50863,CDM,250,RC,J3490,HCPCS,63323-820-00,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,76045-009-01,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CODEINE-GUAIFENESIN 10-100 MG/5 ML ORAL LIQD (REPACK),50863,CDM,250,RC,J3490,HCPCS,0121-1550-10,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE IN 0.9 % NACL 4 MG/250 ML (16 MCG/ML) IV SOLN (MERGE),50863,CDM,250,RC,J0171,HCPCS,70004-613-40,NDC,facility,both,1,ML,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0904-7127-61,NDC,facility,both,100,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0121-1781-05,NDC,facility,both,2,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELIMUMAB 120 MG IV SOLR,50863,CDM,636,RC,J0490,HCPCS,49401-101-01,NDC,facility,both,120,ME,,14093,9865.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 10 GRAM/15 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-0873-32,NDC,facility,both,1,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 20 MG/ML INJ SOLN,50863,CDM,250,RC,J0360,HCPCS,0641-6231-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HUMAN PROTHROMBIN COMPLEX 500 UNIT IV SOLR,50863,CDM,250,RC,J7168,HCPCS,63833-396-01,NDC,facility,both,1500,UN,,8729,6110.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN 250 MG SOLUTION FOR INJECTION,50863,CDM,250,RC,J0290,HCPCS,70594-084-01,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7050,HCPCS,0338-0049-02,NDC,facility,both,1,ML,JZ,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-444-01,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,55150-177-05,NDC,facility,both,450,ML,JZ,180,126,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-02,NDC,facility,both,4,ML,,204,142.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,55,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,15,EA,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE  5 MG ORAL TAB,50863,CDM,J3490,HCPCS,51079-886-01,NDC,,,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,50863,CDM,250,RC,J9075,HCPCS,10019-956-16,NDC,facility,both,86,EA,JW,243,170.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,480,ML,,689,482.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 7.5 MG-325 MG/15 ML ORAL SOLN (REPACK),50863,CDM,J3490,HCPCS,0121-2316-15,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51407-153-90,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 10 MG TAB,50863,CDM,250,RC,Q0177,HCPCS,63739-483-10,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,0075-2451-01,NDC,facility,both,4,ML,,337,235.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,512,ME,JZ,6948,4863.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
WHITE PETROLATUM-MINERAL OIL OPHT OINT (PDS MERGE),50863,CDM,250,RC,J3490,HCPCS,23066704,NDC,facility,both,1,GM,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4% TOP PATCH,50863,CDM,250,RC,J3490,HCPCS,70512-812-01,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PERMETHRIN 5 % TOP CREA,50863,CDM,636,RC,J3490,HCPCS,45802-269-37,NDC,facility,both,1,GM,,428,299.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXAZOSIN 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-5522-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,49884-849-01,NDC,facility,both,2,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-ABBS 10 MG/ML IV SOLN,50863,CDM,636,RC,Q5115,HCPCS,63459-104-50,NDC,facility,both,100,ML,JZ,23338,16336.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LACTATED RINGERS IV (BOLUS),50863,CDM,250,RC,J7120,HCPCS,0264-7750-07,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM SR 90 MG 12 HR CAP,50863,CDM,250,RC,J3490,HCPCS,51079-925-01,NDC,facility,both,1,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL  32.4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6575-61,NDC,facility,both,3,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1940,HCPCS,23155-473-32,NDC,facility,both,4,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUORESCEIN 500 MG/5 ML (10 %) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,17478-253-10,NDC,facility,both,1,ML,,367,256.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-02,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,59762-0073-1,NDC,facility,both,1,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 15% IN WATER,50863,CDM,250,RC,J3490,HCPCS,0338-0023-03,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,463,ML,,664,464.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 875 MG-125 MG TAB,50863,CDM,250,RC,J3490,HCPCS,65862-503-01,NDC,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-466-17,NDC,facility,both,300,ML,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 100 MG/1 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,63323-586-21,NDC,facility,both,30,ML,,165,115.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69315-905-05,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PSYLLIUM HUSK (WITH SUGAR) 3.4 GRAM ORAL PWPK,50863,CDM,636,RC,J3490,HCPCS,37000-023-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM PEDS IVPB (FROM PREMIX),50863,CDM,250,RC,J1953,HCPCS,43598-635-52,NDC,facility,both,50,ML,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 50 MG 24 HR TAB,50863,CDM,636,RC,J3490,HCPCS,50268-541-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,29300-136-01,NDC,facility,both,3,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TAB,50863,CDM,250,RC,J3490,HCPCS,62559-490-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN NPH & REGULAR HUMAN 100 UNIT/ML (70-30) SUBQ SUSP,50863,CDM,636,RC,J1815,HCPCS,0169-1837-11,NDC,facility,both,7,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VERAPAMIL  80 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,23155-026-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL  97.2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16571-668-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NADOLOL  40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69238-1124-9,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,16714-298-01,NDC,facility,both,8,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SALIVA SUBSTITUTE COMB NO.11 351 MG MM PWPK,50863,CDM,250,RC,J3490,HCPCS,7027562912,NDC,facility,both,1,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-587-11,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,250,RC,J2405,HCPCS,23155-549-31,NDC,facility,both,16,ML,JZ,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,636,RC,J2720,HCPCS,63323-229-01,NDC,facility,both,1,ML,JW,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
AMITRIPTYLINE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7411-61,NDC,facility,both,3,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,250,RC,J2001,HCPCS,0409-1323-05,NDC,facility,both,100,ML,,400,280,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 10 MEQ/100 ML IV PGBK,50863,CDM,636,RC,J3480,HCPCS,0990-7074-26,NDC,facility,both,20,ML,,129,90.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,50863,CDM,636,RC,Q5119,HCPCS,0069-0249-01,NDC,facility,both,50,ML,JZ,9892,6924.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
TICAGRELOR 90 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0186-0777-60,NDC,facility,both,1,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR 800 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-867-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEDIUM CHAIN TRIGLYCERIDES OIL ORAL,50863,CDM,250,RC,J3490,HCPCS,4167936513,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZATHIOPRINE  50 MG ORAL TAB,50863,CDM,636,RC,J7500,HCPCS,68084-229-11,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EZETIMIBE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-298-11,NDC,facility,both,1,EA,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT  60 MCG/0.3 ML INJ SYRG,50863,CDM,636,RC,J0881,HCPCS,55513-023-01,NDC,facility,both,60,ML,EC,1282,897.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier EC: Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-229-02,NDC,facility,both,2,ML,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LANTHANUM  500 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,68180-819-52,NDC,facility,both,3,EA,,191,133.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0245-0212-89,NDC,facility,both,2,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE IN 0.9% NS (PF) 1 MG/10 ML (100 MCG/ML) IV SYRG(PDS MERGE),50863,CDM,636,RC,J3490,HCPCS,65302-506-10,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-242-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,30,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,250,RC,Q9968,HCPCS,70710-1838-1,NDC,facility,both,55,ML,,912,638.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAMADOL  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-0058-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-1749-70,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG IV SOLR,50863,CDM,636,RC,J3490,HCPCS,25021-751-10,NDC,facility,both,2,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,548,ME,,7437,5205.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FERROUS GLUCONATE 324 MG (37.5 MG IRON) ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,7985450032,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GAMMAGARD LIQUID 10 % IV SOLN,50863,CDM,636,RC,J1569,HCPCS,0944-2700-07,NDC,facility,both,60,ML,,10817,7571.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.3 MG/0.3 ML IM PNIJ,50863,CDM,250,RC,J0169,HCPCS,0093-5986-19,NDC,facility,both,3,EA,,1024,716.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,636,RC,J0690,HCPCS,70092-1017-46,NDC,facility,both,2,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,0409-1886-22,NDC,facility,both,250,ML,,130,91,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,17271-701-06,NDC,facility,both,1,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAVASTATIN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-886-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,60,ML,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL IV BOLUS 10MG/ML (ANESTHESIA ONLY),50863,CDM,636,RC,J2704,HCPCS,0409-4699-54,NDC,facility,both,400,ML,,507,354.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,71,ML,,101,70.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE MONONITRATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,3160401281,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-03,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN   1.25 G IV SOLR,50863,CDM,250,RC,J3373,HCPCS,67457-823-12,NDC,facility,both,125,EA,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,50863,CDM,636,RC,J0585,HCPCS,0023-1145-01,NDC,facility,both,200,EA,,3197,2237.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,17271-701-05,NDC,facility,both,1,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-587-11,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE  50 MG ORAL TAB,50863,CDM,250,RC,j3490,HCPCS,50111-560-01,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-38,NDC,facility,both,1,ML,JZ,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,63323-482-03,NDC,facility,both,60,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,5026852411,NDC,facility,both,4,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
23.4% SODIUM CHLORIDE (4 MEQ/ML) INJECTION,50863,CDM,250,RC,J3490,HCPCS,63323-187-30,NDC,facility,both,1,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2599,HCPCS,43598-914-25,NDC,facility,both,7,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICLOFENAC 1 % TOPICAL GEL,50863,CDM,250,RC,J3490,HCPCS,58602-604-07,NDC,facility,both,1,GM,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-3178-01,NDC,facility,both,45,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,72603-506-01,NDC,facility,both,50,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,250,RC,J0131,HCPCS,0143-9386-01,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG/5 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,0904-6828-05,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0093-4177-73,NDC,facility,both,9,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OMEPRAZOLE-SODIUM BICARBONATE 2-84 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,65628-270-05,NDC,facility,both,2,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,50863,CDM,250,RC,J9025,HCPCS,72485-201-01,NDC,facility,both,26,EA,JW,161,112.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IMIPRAMINE 10 MG TAB,50863,CDM,250,RC,J3490,HCPCS,64380-169-01,NDC,facility,both,5,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MYCOPHENOLATE 250 MG CAP,50863,CDM,250,RC,J7517,HCPCS,0054-0163-25,NDC,facility,both,6,EA,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,68516-5214-1,NDC,facility,both,2,ML,,447,312.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,7,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTAZIDIME NEO IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0713,HCPCS,0781-3177-80,NDC,facility,both,1,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORDIAZEPOXIDE 25 MG CAP,50863,CDM,636,RC,J3490,HCPCS,60687-807-11,NDC,facility,both,6,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0172-5728-60,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,636,RC,J3490,HCPCS,73702-301-15,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-354-11,NDC,facility,both,2,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,72603-251-01,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TERBUTALINE 1 MG/ML SUBQ SOLN,50863,CDM,636,RC,J3105,HCPCS,0143-9746-01,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 20 MCG/ML ORAL SYRUP (LOW CONC NEONATAL ONLY),50863,CDM,250,RC,J3490,HCPCS,63739-060-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-5771-23,NDC,facility,both,4,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE-SALMETEROL 100 MCG-50 MCG/DOSE DISK DEVICE FOR INHALATION,50863,CDM,250,RC,J3490,HCPCS,0173-0695-00,NDC,facility,both,1,EA,,674,471.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITRIOL 0.5 MCG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,69452-208-20,NDC,facility,both,2,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,250,RC,J7999,HCPCS,70092-1017-46,NDC,facility,both,8,ML,,317,221.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYMETAZOLINE 0.05 % NASL SPRA,50863,CDM,250,RC,J3490,HCPCS,0904-7427-30,NDC,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7184-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 50 MG TAB,50863,CDM,250,RC,J3490,HCPCS,62584-266-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN D5W 20000 UNIT/500 ML,50863,CDM,636,RC,J1644,HCPCS,0264-9567-10,NDC,facility,both,10,ML,JW,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ENOXAPARIN 150 MG/1 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,16714-066-01,NDC,facility,both,15,ML,,173,121.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE IN 0.9% NS (PF) 1 MG/10 ML (100 MCG/ML) IV SYRG(PDS MERGE),50863,CDM,250,RC,J3490,HCPCS,71019-263-20,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1940,HCPCS,63323-280-03,NDC,facility,both,3,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROATE SODIUM 100 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0143-9637-01,NDC,facility,both,6,ML,,268,187.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE-PHENYLEPHRINE 4%-0.25% NASAL SPRAY,50863,CDM,250,RC,J3490,HCPCS,0225-0800-47,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FELBAMATE 400 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0037-0430-01,NDC,facility,both,2,EA,,182,127.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,50863,CDM,636,RC,Q5119,HCPCS,0069-0238-01,NDC,facility,both,10,ML,,1979,1385.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN   81 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,57896-981-12,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,50863,CDM,250,RC,J9263,HCPCS,71288-101-10,NDC,facility,both,11,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DIVALPROEX 250 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,0832-7123-89,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE CONCENTRATE 10 MG/ 0.5 ML ORAL SYRINGE (0.5ML UD MERGE),50863,CDM,250,RC,J3490,HCPCS,0406-8003-30,NDC,facility,both,2,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE (CONTRACEPTIVE) 150 MG/ML IM SUSP,50863,CDM,636,RC,J1050,HCPCS,0548-5400-00,NDC,facility,both,150,ML,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6292-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-354-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,68516-5219-0,NDC,facility,both,2,ML,,796,557.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,4,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DIVALPROEX 250 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,62756-797-88,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J2004,HCPCS,63323-487-01,NDC,facility,both,400,ML,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,250,RC,J2720,HCPCS,63323-229-01,NDC,facility,both,20,ML,,364,254.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOXSALEN 20 MCG/ML INJ SOLN,50863,CDM,636,RC,J9999,HCPCS,64067-216-01,NDC,facility,both,1,ML,,403,282.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  60 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,69292-536-01,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  10 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,68094-001-59,NDC,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIROLIMUS 0.5 MG ORAL TAB,50863,CDM,636,RC,J7520,HCPCS,68382-520-01,NDC,facility,both,1,EA,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,50863,CDM,636,RC,J3490,HCPCS,57237-077-10,NDC,facility,both,1,EA,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FERROUS SULFATE 325 MG (65 MG IRON) TAB,50863,CDM,250,RC,J3490,HCPCS,904759060,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  750 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7125-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRP (MERGE/REPACK),50863,CDM,636,RC,J3490,HCPCS,68094-764-59,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALSARTAN  80 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,33342-063-10,NDC,facility,both,4,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0832-1213-89,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,636,RC,J3490,HCPCS,63037-136-25,NDC,facility,both,2,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0456,HCPCS,55150-174-10,NDC,facility,both,1,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,250,RC,J1596,HCPCS,0143-9679-01,NDC,facility,both,7,ML,,160,112,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-20,NDC,facility,both,1,ML,,219,153.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,250,RC,J3490,HCPCS,81284-611-00,NDC,facility,both,3,ML,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NYSTATIN 100000 UNIT/ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,63739-160-70,NDC,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,1,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML INJ SOLN,50863,CDM,250,RC,J2060,HCPCS,0409-1985-03,NDC,facility,both,3,ML,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,0121-0657-05,NDC,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV,50863,CDM,250,RC,J7120,HCPCS,0338-0117-04,NDC,facility,both,10,ML,,333,233.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 600 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65162-465-10,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 20 MG ORAL TAB,50863,CDM,250,RC,J0500,HCPCS,0904-6988-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,636,RC,J3490,HCPCS,0143-9575-01,NDC,facility,both,60,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,55,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,250,RC,J3490,HCPCS,0409-1323-15,NDC,facility,both,100,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
URSODIOL 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-100-11,NDC,facility,both,1,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE ENEMA 200G IN SW (1000 ML TOTAL VOLUME),50863,CDM,250,RC,J3490,HCPCS,99999-0405-41,NDC,facility,both,1,ML,,113,79.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TETRACYCLINE 500 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,23155-767-01,NDC,facility,both,1,EA,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,8,ML,,256,179.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CONJUGATED ESTROGENS  0.625 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0046-1102-81,NDC,facility,both,2,EA,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN SODIUM  2 GRAM INJ SOLR,50863,CDM,250,RC,J0290,HCPCS,70860-115-26,NDC,facility,both,4,EA,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EZETIMIBE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-373-11,NDC,facility,both,1,EA,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,636,RC,J0132,HCPCS,70594-111-01,NDC,facility,both,127,ML,,647,452.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 150 MG/1 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0548-5607-00,NDC,facility,both,30,ML,,265,185.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM HYPOCHLORITE 0.5 % MISC SOLN,50863,CDM,250,RC,J3490,HCPCS,39328-062-50,NDC,facility,both,1,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOBRAMYCIN 1.2 G POWDER VIAL,50863,CDM,250,RC,J3260,HCPCS,39822-0412-6,NDC,facility,both,8,EA,,199,139.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN   81 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,69618-066-02,NDC,facility,both,3,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL (5 MG/ML) IV SYRG (CONTAINS PRESERVATIVE),50863,CDM,250,RC,J3490,HCPCS,0409-2339-24,NDC,facility,both,4,ML,,214,149.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM CITRATE ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,69452-389-98,NDC,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 10 MEQ/100 ML IV PGBK,50863,CDM,250,RC,J3480,HCPCS,0990-7074-26,NDC,facility,both,15,ML,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,0641-6147-01,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J3490,HCPCS,63323-482-03,NDC,,,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN D5W 20000 UNIT/500 ML,50863,CDM,636,RC,J1644,HCPCS,0264-9567-10,NDC,facility,both,12,ML,JW,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PYRIDOXINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,7733394025,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6501-61,NDC,facility,both,1,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,66794-229-02,NDC,facility,both,1,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0591-0605-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 20MG/ML IV SYRINGE (PEDS/NEO),50863,CDM,250,RC,J0612,HCPCS,63323-311-10,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0591-0605-01,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TETRACAINE HCL (PF) 0.5 % OPHT DROP (STANDARD STOCK),50863,CDM,250,RC,J3490,HCPCS,0065-0741-14,NDC,facility,both,1,ML,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 100 MG PE/2 ML INJ SOLN,50863,CDM,250,RC,Q2009,HCPCS,0641-6136-01,NDC,facility,both,2,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5% W/EPINEPHRINE 1:200K INJECTION,50863,CDM,J3490,HCPCS,0409-1749-29,NDC,,,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2308-21,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEGESTROL 20 MG ORAL TAB,50863,CDM,250,RC,J9999,HCPCS,64380-158-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PYRIDOXINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,5026885811,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL  97.2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,75826-142-10,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,68180-150-01,NDC,facility,both,3,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) IV,50863,CDM,250,RC,J1250,HCPCS,70436-203-80,NDC,facility,both,4,ML,,173,121.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3370,HCPCS,0409-6533-11,NDC,facility,both,4,EA,,192,134.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE 20 MG TAB,50863,CDM,636,RC,J3490,HCPCS,68084-045-11,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RAVULIZUMAB-CWVZ 100 MG/ML IV SOLN,50863,CDM,636,RC,J1303,HCPCS,25682-028-01,NDC,facility,both,220,ML,JZ,129617,90731.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,250,RC,J7060,HCPCS,0338-0017-02,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN NPH HUMAN RECOMB 100 UNIT/ML SUBQ SUSP,50863,CDM,636,RC,J1815,HCPCS,0169-1834-11,NDC,facility,both,1,ML,GZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier GZ: Item or service expected to be denied as not reasonable and necessary
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,63323-280-02,NDC,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,63323-806-13,NDC,facility,both,5,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1.5 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J2004,HCPCS,63323-488-07,NDC,facility,both,450,ML,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPAGLIFLOZIN PROPANEDIOL 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,66993-457-30,NDC,facility,both,1,EA,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUDROCORTISONE 0.1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-330-11,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,70004-600-09,NDC,facility,both,2,ML,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,23155-687-31,NDC,facility,both,4,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHOTERICIN B LIPOSOME 50 MG IV SUSR,50863,CDM,250,RC,J0289,HCPCS,55150-365-01,NDC,facility,both,25,EA,,4510,3157,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9% IV (PEDS) BOLUS,50863,CDM,250,RC,J7040,HCPCS,0264-7800-09,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,J3490,HCPCS,0093-2279-73,NDC,,,facility,both,8,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,55150-161-02,NDC,,,facility,both,20,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ (REPACK)(MERGE) (FOR PCA),50863,CDM,250,RC,J3010,HCPCS,0409-9094-41,NDC,facility,both,25,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,50863,CDM,FAMNOCHARGE,HCPCS,60687-675-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 20 MEQ/100 ML IV PGBK,50863,CDM,250,RC,J3480,HCPCS,0990-7075-26,NDC,facility,both,10,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 500 MG/10 ML IV SOLN,50863,CDM,J9190,HCPCS,63323-117-61,NDC,,,facility,both,20,ML,,345,241.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,J3490,HCPCS,0409-4887-17,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG TAB,50863,CDM,250,RC,J3490,HCPCS,50268-728-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML INJ SOLN,50863,CDM,250,RC,J0171,HCPCS,42023-168-01,NDC,facility,both,300,ML,,888,621.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,50863,CDM,J3490,HCPCS,67877-548-88,NDC,,,facility,both,5,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2308-22,NDC,facility,both,5,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
HEPARIN (PORCINE) IN D5W 20000 UNIT/500 ML,50863,CDM,636,RC,J1644,HCPCS,0264-9567-10,NDC,facility,both,10,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,36,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,42,EA,,5796,4057.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,7,EA,JW,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CISATRACURIUM IN NS 400 MG/200 ML (2 MG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,99999-444-26,NDC,facility,both,1,ML,,1503,1052.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SYRG,50863,CDM,250,RC,J3490,HCPCS,8290306546,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE HCL  2 % MM JELP,50863,CDM,636,RC,J3490,HCPCS,76329-3013-5,NDC,facility,both,1,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,0641-6145-01,NDC,facility,both,4,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLERGONOVINE 0.2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69238-1605-2,NDC,facility,both,1,EA,,286,200.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPROST TROMETHAMINE 250 MCG/ML IM SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-0064-01,NDC,facility,both,1,ML,,457,319.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,68094-494-59,NDC,facility,both,4,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION,50863,CDM,636,RC,J3490,HCPCS,0186-0370-28,NDC,facility,both,1,GM,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,250,RC,J0132,HCPCS,70594-111-01,NDC,facility,both,173,ML,,878,614.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPTOMYCIN 500 MG IV SOLR,50863,CDM,636,RC,J0878,HCPCS,67919-012-01,NDC,facility,both,500,EA,,1230,861,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-5755-23,NDC,facility,both,4,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,25021-315-01,NDC,facility,both,25,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50458-593-10,NDC,facility,both,1,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 3% IV BOLUS (ED ONLY),50863,CDM,636,RC,J3490,HCPCS,0264-7805-10,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,72888-037-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYUREA  500 MG ORAL CAP,50863,CDM,250,RC,J9999,HCPCS,49884-724-01,NDC,facility,both,3,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE  50 MG ORAL TAB,50863,CDM,636,RC,j3490,HCPCS,60505-2653-1,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J1610,HCPCS,0597-0053-45,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-3426-05,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTAMIDINE 300 MG INJ SOLR,50863,CDM,636,RC,J3490,HCPCS,63323-113-01,NDC,facility,both,1,EA,,329,230.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LITHIUM CARBONATE 150 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0054-8526-25,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-50,NDC,facility,both,3,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GABAPENTIN 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6665-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,17271-701-07,NDC,facility,both,2,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOMIPRAMINE 75 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,16571-685-03,NDC,facility,both,1,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J3490,HCPCS,0990-7983-61,NDC,facility,both,1,ML,JZ,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
EPINEPHRINE 1 MG/ML (1ML) INJ SOLN,50863,CDM,250,RC,J0171,HCPCS,42023-159-01,NDC,facility,both,40,ML,,352,246.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 25 MG CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7237-60,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0121-0431-30,NDC,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 0.1 MG/ML IV SYRINGE (NEO/INFANT),50863,CDM,250,RC,J1100,HCPCS,99999-0405-74,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4% TOP PATCH,50863,CDM,250,RC,J3490,HCPCS,0121-0970-01,NDC,facility,both,2,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PYRIDOXINE 100 MG/ML INJ SOLN,50863,CDM,250,RC,J3415,HCPCS,63323-180-00,NDC,facility,both,1,ML,,128,89.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GAMMAGARD LIQUID 10 % IV SOLN,50863,CDM,636,RC,J1569,HCPCS,0944-2700-12,NDC,facility,both,80,ML,"JZ,JA",14422,10095.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,250,RC,J7060,HCPCS,0338-0017-38,NDC,facility,both,1,ML,JZ,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,636,RC,J1953,HCPCS,0409-1886-22,NDC,facility,both,25,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",50863,CDM,250,RC,J1561,HCPCS,13533-800-21,NDC,facility,both,20,ML,,2829,1980.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOPIDOGREL 300 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6467-07,NDC,facility,both,1,EA,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MICAFUNGIN 100 MG IV SOLR,50863,CDM,250,RC,J2248,HCPCS,42023-230-01,NDC,facility,both,41,EA,,262,183.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,0517-4620-25,NDC,facility,both,7,ML,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3373,HCPCS,67457-340-01,NDC,facility,both,300,EA,,283,198.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 25 MG IV SOLR,50863,CDM,636,RC,J3101,HCPCS,50242-009-01,NDC,facility,both,25,EA,,22901,16030.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE ACETATE 25 MG RECT SUPP,50863,CDM,250,RC,J3490,HCPCS,50268-411-11,NDC,facility,both,1,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PNEUMOC 20-VAL CONJ-DIP CR(PF) 0.5 ML IM SYRG,50863,CDM,636,RC,90677,HCPCS,0005-2000-01,NDC,facility,both,1,ML,,955,668.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG ORAL TBDL,50863,CDM,636,RC,J3490,HCPCS,60505-3276-0,NDC,facility,both,1,EA,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOBRAMYCIN 1.2 G POWDER VIAL,50863,CDM,250,RC,J3260,HCPCS,39822-0412-6,NDC,facility,both,15,EA,,398,278.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,5,EA,,249,174.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN IN D5W 900 MG/50 ML IV PGBK,50863,CDM,636,RC,J0736,HCPCS,0781-3290-91,NDC,facility,both,3,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,80,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,13,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENAZEPRIL 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-110-11,NDC,facility,both,4,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 25 MG CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7237-61,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAMSULOSIN 0.4 MG ORAL CP24,50863,CDM,636,RC,J3490,HCPCS,65862-598-01,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TUBERCULIN PPD 5 UNIT/0.1 ML IDRM SOLN,50863,CDM,250,RC,J3490,HCPCS,49281-752-78,NDC,facility,both,1,ML,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),50863,CDM,250,RC,J0171,HCPCS,76329-3318-1,NDC,facility,both,30,ML,,221,154.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-591-11,NDC,facility,both,4,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-48,NDC,facility,both,2,ML,,160,112,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,250,RC,J0330,HCPCS,0409-6629-02,NDC,facility,both,8,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SOTALOL 5 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,24338-530-25,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-1749-70,NDC,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51672-4005-1,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0121-0431-30,NDC,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42291-560-90,NDC,facility,both,4,EA,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL (VITAMIN D3)  1000 UNIT ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,8068116900,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,636,RC,J3490,HCPCS,0409-1323-15,NDC,facility,both,200,ML,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-3243-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 5 MG ORAL CAP,50863,CDM,250,RC,J7507,HCPCS,0904-6624-61,NDC,facility,both,4,EA,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,0143-9682-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-02,NDC,facility,both,2,ML,JZ,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IV PGBK,50863,CDM,636,RC,J3475,HCPCS,63323-106-00,NDC,facility,both,8,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3370,HCPCS,67457-340-01,NDC,facility,both,4,EA,,189,132.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,18,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIVAROXABAN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50458-579-01,NDC,facility,both,1,EA,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML INJECTION,50863,CDM,250,RC,J3411,HCPCS,0641-6228-01,NDC,facility,both,2,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6818-61,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-1749-70,NDC,facility,both,2,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,72603-251-01,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,0409-1283-03,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOZAPINE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-922-01,NDC,facility,both,2,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0832-1211-89,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML IV (MERGE) (FOR VENT),50863,CDM,250,RC,J3490,HCPCS,70092-1509-35,NDC,facility,both,1,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,50863,CDM,J9263,HCPCS,71288-171-11,NDC,,,facility,both,14,ML,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISATRACURIUM  2 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,70069-161-01,NDC,facility,both,1,ML,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITRIOL 0.25 MCG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-345-11,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,51079-051-01,NDC,facility,both,2,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16729-136-00,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-571-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RACEPINEPHRINE 2.25 % INHL NEBU,50863,CDM,250,RC,J3490,HCPCS,0487-5901-99,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-495-27,NDC,facility,both,340,ML,,166,116.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,J1100,HCPCS,63323-165-01,NDC,,,facility,both,2,ML,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4% TOP PATCH,50863,CDM,636,RC,J3490,HCPCS,46581-830-01,NDC,facility,both,3,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,0409-6102-18,NDC,facility,both,80,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCRALFATE 1 GRAM ORAL TAB,50863,CDM,J3490,HCPCS,51079-753-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2001,HCPCS,63323-492-26,NDC,,,facility,both,30,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/0.5 ML INHL NEBU,50863,CDM,J3490,HCPCS,0487-9901-30,NDC,,,facility,both,3,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL  32.4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,13517-626-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0264-7800-20,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML INJ SOLN,50863,CDM,J2250,HCPCS,0641-6059-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,17271-701-05,NDC,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,50863,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,13,EA,,274,191.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6377-61,NDC,facility,both,1,EA,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,636,RC,J3010,HCPCS,0641-6027-25,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,J7040,HCPCS,0338-0049-04,NDC,,,facility,both,2,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42858-723-01,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,43547-688-10,NDC,facility,both,2,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IV PGBK,50863,CDM,250,RC,J3475,HCPCS,0409-6729-11,NDC,facility,both,4,ML,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16729-137-00,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,27808-156-01,NDC,facility,both,1,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETIRIZINE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7510-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,250,RC,J3490,HCPCS,0143-9679-01,NDC,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0121-1781-05,NDC,facility,both,2,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALACYCLOVIR 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-215-11,NDC,facility,both,2,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,63323-185-07,NDC,facility,both,3,ML,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMANTADINE 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7042-61,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-1159-19,NDC,facility,both,2,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-631-11,NDC,facility,both,1,EA,PLAD,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,J7040,HCPCS,0338-0049-04,NDC,,,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML IV,50863,CDM,250,RC,J3490,HCPCS,0641-6013-01,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,50863,CDM,636,RC,J0561,HCPCS,60793-701-02,NDC,facility,both,24,ML,,2160,1512,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,13,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-433-11,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN (NEO),50863,CDM,250,RC,J1938,HCPCS,71288-203-10,NDC,facility,both,160,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 50 MG/ML INJECTION,50863,CDM,636,RC,J1200,HCPCS,63323-664-00,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,5789686406,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 400 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0143-9887-01,NDC,facility,both,20,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 600 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,67877-320-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE 20 MG TAB,50863,CDM,636,RC,J3490,HCPCS,63739-963-10,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 50 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,60687-402-11,NDC,facility,both,3,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MULTIVIT-IRON-FA-CALCIUM &MINS 9 MG IRON-400 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,7733386125,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0295,HCPCS,63323-368-20,NDC,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,250,RC,J3360,HCPCS,43598-106-11,NDC,facility,both,2,ML,,145,101.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLMESARTAN  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0527-2425-46,NDC,facility,both,1,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 10 GRAM/100 ML (10%) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-72,NDC,facility,both,20,ML,,2829,1980.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),50863,CDM,250,RC,J2060,HCPCS,0641-6044-01,NDC,facility,both,2,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,70095-026-01,NDC,facility,both,2,ML,JW,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
FUROSEMIDE 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7178-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-3178-01,NDC,facility,both,60,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,72485-106-01,NDC,facility,both,125,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYMETAZOLINE 0.05 % NASAL MERGE,50863,CDM,636,RC,J3490,HCPCS,70677-1037-1,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2003,HCPCS,72603-505-01,NDC,,,facility,both,400,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIPASE-PROTEASE-AMYLASE 12,000-38,000- 60,000 UNIT ORAL CAP, DELAY REL",50863,CDM,250,RC,J3490,HCPCS,0032-0047-70,NDC,facility,both,2,EA,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,500,ML,,1706,1194.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,J1815,HCPCS,83257-014-11,NDC,,,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,23155-473-32,NDC,facility,both,80,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN (NEW TX NON-NEURO INDICATION)",50863,CDM,636,RC,J1561,HCPCS,13533-800-71,NDC,facility,both,20,ML,"JA,JZ",2829,1980.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously | Modifier JZ: Zero drug amount discarded/not administered to any patient
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,524,ME,,7111,4977.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,280,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PAROXETINE 20 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0904-5677-61,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG IV SOLR,50863,CDM,636,RC,J0456,HCPCS,55150-174-10,NDC,facility,both,1,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MICAFUNGIN 100 MG IV SOLR,50863,CDM,250,RC,J2248,HCPCS,63323-729-01,NDC,facility,both,100,EA,,245,171.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIZATRIPTAN  5 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,69452-156-74,NDC,facility,both,2,EA,,282,197.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,50863,CDM,250,RC,J0696,HCPCS,60505-6149-0,NDC,facility,both,8,EA,JZ,388,271.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-65,NDC,facility,both,200,ML,,353,247.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESNA 100 MG/ML IV SOLN,50863,CDM,250,RC,J9209,HCPCS,10019-953-62,NDC,facility,both,2,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9% IV (PEDS) BOLUS,50863,CDM,636,RC,J7040,HCPCS,0264-7800-09,NDC,facility,both,2,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,61,ML,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEXILETINE 150 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,50742-239-01,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IV PGBK,50863,CDM,250,RC,J3490,HCPCS,0409-6729-41,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 100 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-6500-61,NDC,,,facility,both,2,EA,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,50863,CDM,636,RC,J3301,HCPCS,16714-130-01,NDC,facility,both,8,ML,JZ,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
HC IV INFUSION HYDRAT 31-60 MIN,50863,CDM,250,RC,J0248,HCPCS,61958-2901-2,NDC,facility,both,17,EA,,198,138.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANTI-THYMOCYTE GLOB (RABBIT) 25 MG IV SOLR,50863,CDM,250,RC,J7511,HCPCS,58468-0080-1,NDC,facility,both,2,EA,,4044,2830.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4% TOP PATCH,50863,CDM,636,RC,J3490,HCPCS,46581-830-06,NDC,facility,both,3,EA,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-089-50,NDC,facility,both,5,ML,,729,510.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLESTYRAMINE 4 G ORAL PWPK,50863,CDM,636,RC,J3490,HCPCS,0245-0036-89,NDC,facility,both,30,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,250,RC,J2405,HCPCS,23155-547-31,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,15,ML,JW,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DOCUSATE SODIUM 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7183-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"METHYLPREDNISOLONE 1,000 MG SOLUTION FOR INJECTION",50863,CDM,250,RC,J2919,HCPCS,43598-130-74,NDC,facility,both,200,EA,,191,133.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE  0.65 % NASL SPRA,50863,CDM,250,RC,J3490,HCPCS,0904-3865-75,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,24,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2599,HCPCS,43598-914-25,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN NACL (PF) 1000 UNIT/500 ML IV SOLP,50863,CDM,250,RC,J1644,HCPCS,0409-1005-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LURASIDONE 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7355-04,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,34,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,3,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CITRATE-VITAMIN D3 200 MG CALCIUM -250 UNIT ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,536322301,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-027-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN PEDS SYRINGE (20MG/ML) IN DEXTROSE (CDS MIX,50863,CDM,250,RC,J7999,HCPCS,0781-3451-70,NDC,facility,both,1,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0003-0894-31,NDC,facility,both,12,EA,,524,366.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J3490,HCPCS,0338-0049-41,NDC,facility,both,1,ML,JZ,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,16714-294-01,NDC,facility,both,3,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 30 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0093-0318-01,NDC,facility,both,3,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE SR 12.5 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,62175-470-32,NDC,facility,both,1,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,51754-4250-1,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0630,HCPCS,42023-205-01,NDC,facility,both,1,ML,,7259,5081.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 17 GRAM (100 %) ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,1152372688,NDC,facility,both,5,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0641-0400-37,NDC,facility,both,3,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RAMIPRIL  5 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,68382-146-01,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 400 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,65162-464-10,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE-EPI-CLONID-KETOROL 2.46-0.005- 0.0008-0.3MG/ML PATC SYRG,50863,CDM,636,RC,J3490,HCPCS,70092-1433-50,NDC,facility,both,1,ML,,213,149.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,636,RC,J2795,HCPCS,43066-023-01,NDC,facility,both,50,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-253-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0630,HCPCS,24201-400-02,NDC,facility,both,1,ML,,1888,1321.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0781-3246-02,NDC,facility,both,8,ML,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYTARABINE 100 MG/ML INJ SOLN,50863,CDM,250,RC,J9100,HCPCS,61703-319-22,NDC,facility,both,60,ML,,358,250.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0641-0400-37,NDC,facility,both,5,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 30 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,51991-747-90,NDC,facility,both,3,EA,,111,77.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 30 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,60687-734-11,NDC,facility,both,2,EA,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE IN 0.9% NS (PF) 1 MG/10 ML (100 MCG/ML) IV SYRG(PDS MERGE),50863,CDM,250,RC,J3490,HCPCS,70092-1046-46,NDC,facility,both,1,ML,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-074-10,NDC,facility,both,2,EA,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IV PGBK,50863,CDM,250,RC,J3475,HCPCS,0409-4121-01,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES-DOCUSATE SODIUM 8.6 MG-50 MG TAB,50863,CDM,250,RC,J3490,HCPCS,63739-432-02,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 25 MG CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7237-60,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLMESARTAN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68462-437-30,NDC,facility,both,2,EA,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 800 MG ORAL TAB,50863,CDM,250,RC,J0601,HCPCS,17856-921-01,NDC,facility,both,160,EA,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML IV,50863,CDM,250,RC,J3490,HCPCS,0641-6015-01,NDC,facility,both,1,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,63323-468-37,NDC,facility,both,2,ML,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4% TOP PATCH,50863,CDM,636,RC,J3490,HCPCS,0121-0970-01,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,63323-485-03,NDC,,,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN   81 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,63739-212-02,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 0.1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,23155-489-01,NDC,facility,both,1,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,72205-014-90,NDC,facility,both,2,EA,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,63323-485-27,NDC,,,facility,both,65,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACUBITRIL-VALSARTAN 49-51 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0078-0777-20,NDC,facility,both,1,EA,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIOGLITAZONE 15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,65862-512-30,NDC,facility,both,2,EA,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,636,RC,J7510,HCPCS,17856-0815-1,NDC,facility,both,2,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"CIPROFLOXACIN-DEXAMETHASONE 0.3 %-0.1 % EAR DROPS, SUSP",50863,CDM,250,RC,J3490,HCPCS,62756-427-90,NDC,facility,both,1,ML,,827,578.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOBRAMYCIN-DEXAMETHASONE 0.3 %-0.1 % EYE OINTMENT,50863,CDM,250,RC,J3490,HCPCS,0078-0876-01,NDC,facility,both,1,GM,,1056,739.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MYCOPHENOLATE 500 MG TAB,50863,CDM,636,RC,J7517,HCPCS,0054-0166-25,NDC,facility,both,4,EA,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,636,RC,J3490,HCPCS,50268-671-11,NDC,facility,both,2,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"HUMAN PAPILLOMAV VAC,9-VAL(PF) 0.5 ML IM SYRG",50863,CDM,90651,HCPCS,0006-4121-01,NDC,,,facility,both,1,ML,,1089,762.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,63323-400-01,NDC,facility,both,100,ML,JZ,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
FOSPHENYTOIN 500 MG PE/10 ML INJ SOLN,50863,CDM,250,RC,Q2009,HCPCS,0641-6137-01,NDC,facility,both,10,ML,,242,169.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAZOSIN 2 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7021-61,NDC,facility,both,3,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-339-11,NDC,facility,both,4,EA,,277,193.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4 % TOPICAL SOLN,50863,CDM,636,RC,J3490,HCPCS,76329-6300-5,NDC,facility,both,3,ML,,392,274.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,0143-9577-01,NDC,,,facility,both,15,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENAZEPRIL 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-110-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,250,RC,J3101,HCPCS,50242-037-06,NDC,facility,both,36,EA,JW,7169,5018.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
"HYOSCYAMINE 0.125 MG TAB, RAPID DISSOLVE",50863,CDM,250,RC,J3490,HCPCS,63629-1030-1,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SYRG,50863,CDM,250,RC,J3490,HCPCS,8290306547,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LINEZOLID 600 MG/300 ML IV SOLP,50863,CDM,250,RC,J2020,HCPCS,57664-683-31,NDC,facility,both,3,ML,,331,231.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3370,HCPCS,67457-340-01,NDC,facility,both,6,EA,,283,198.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,636,RC,J3490,HCPCS,63323-486-02,NDC,facility,both,60,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL-ROPIVACAINE-NACL (PF) 2-0.2 MCG/ML-% INJ (MERGE ERX),50863,CDM,250,RC,J3490,HCPCS,70092-9259-75,NDC,facility,both,3,ML,,652,456.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,65,ML,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRIMIDONE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-202-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXEPIN  50 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7054-61,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2598,HCPCS,43598-914-11,NDC,facility,both,10,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV,50863,CDM,250,RC,J7120,HCPCS,0338-0117-04,NDC,facility,both,6,ML,,200,140,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,6,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68180-998-01,NDC,facility,both,2,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOSTIGMINE METHYLSULFATE 1 MG/ML IV SOLN,50863,CDM,250,RC,J2710,HCPCS,42023-189-01,NDC,facility,both,2,ML,,191,133.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NAFCILLIN NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J3490,HCPCS,63323-327-10,NDC,facility,both,100,EA,,304,212.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-454-11,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SCOPOLAMINE TRANSDERMAL PATCH 1MG OVER 3 DAYS,50863,CDM,636,RC,J3490,HCPCS,50742-505-01,NDC,facility,both,1,EA,,113,79.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML INJ SOLN (PULMONARY USE),50863,CDM,250,RC,J2250,HCPCS,55390-137-05,NDC,facility,both,5,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,636,RC,J2405,HCPCS,60505-6130-0,NDC,facility,both,2,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,16714-294-01,NDC,facility,both,17,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MONTELUKAST 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6808-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  88 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42292-038-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MYCOPHENOLATE 250 MG CAP,50863,CDM,636,RC,J7517,HCPCS,0054-0163-25,NDC,facility,both,1,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 40 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6292-06,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6924-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 12 MG/ML ORAL SUSPENSION,50863,CDM,636,RC,J3490,HCPCS,0093-0319-01,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE CONCENTRATE 10 MG/ 0.5 ML ORAL SYRINGE (0.5ML UD MERGE),50863,CDM,250,RC,J3490,HCPCS,68094-045-01,NDC,facility,both,2,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,68180-723-04,NDC,facility,both,2,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZONATATE 100 MG ORAL CAP,50863,CDM,J3490,HCPCS,68084-214-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  750 MG IV SOLR,50863,CDM,636,RC,J3373,HCPCS,63323-203-01,NDC,facility,both,75,EA,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69238-1491-1,NDC,facility,both,2,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,63323-165-01,NDC,facility,both,7,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-587-11,NDC,facility,both,8,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN SODIUM  2 GRAM INJ SOLR,50863,CDM,250,RC,J0290,HCPCS,72485-422-01,NDC,facility,both,3,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN  325 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,57896-901-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL (VITAMIN D3)  1000 UNIT ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,8068116900,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,250,RC,J3101,HCPCS,50242-037-06,NDC,facility,both,20,EA,,8642,6049.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-48,NDC,facility,both,2,ML,,160,112,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER SULFADIAZINE 1 % TOP CREA,50863,CDM,250,RC,J3490,HCPCS,67877-124-05,NDC,facility,both,1,GM,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR PHOSPHATE 75 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,31722-632-31,NDC,facility,both,1,EA,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,250,RC,J7060,HCPCS,0338-0017-03,NDC,facility,both,2,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),50863,CDM,636,RC,J0171,HCPCS,76329-3318-1,NDC,facility,both,100,ML,,734,513.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,250,RC,FAMNOCHARGE,HCPCS,68094-763-59,NDC,facility,both,1,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  50 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-6992-61,NDC,facility,both,6,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,636,RC,J1953,HCPCS,0409-1886-22,NDC,facility,both,5,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CHOLECALCIFEROL (VITAMIN D3) 400 UNIT/ML ORAL DROP,50863,CDM,250,RC,J3490,HCPCS,1785600492,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0075-0622-01,NDC,facility,both,8,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0143-2112-50,NDC,facility,both,1,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,636,RC,J3490,HCPCS,0409-1323-15,NDC,facility,both,100,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE  50 MCG/ACTUATION NASL SPSN,50863,CDM,250,RC,J3490,HCPCS,72888-141-35,NDC,facility,both,1,GM,,396,277.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  10 MG/5 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,0054-0237-63,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,4,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,63323-325-03,NDC,facility,both,300,ML,,331,231.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPRAZOLAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0228-2029-10,NDC,facility,both,3,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL,50863,CDM,636,RC,J3490,HCPCS,63323-820-04,NDC,facility,both,1,ML,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-48,NDC,facility,both,2,ML,JZ,140,98,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,623,ME,JZ,8455,5918.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SUMATRIPTAN 25 MG TAB,50863,CDM,636,RC,J3490,HCPCS,65862-146-36,NDC,facility,both,4,EA,,390,273,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,16714-293-01,NDC,facility,both,5,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-02,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXRAZOXANE 250 MG IV SOLR,50863,CDM,250,RC,J1190,HCPCS,55150-432-01,NDC,facility,both,1,EA,,301,210.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN PEDS INFUSION (CDS MIXTURE),50863,CDM,250,RC,J0290,HCPCS,25021-136-10,NDC,facility,both,2,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-739-11,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETIRIZINE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16714-799-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0054-3294-46,NDC,facility,both,1,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,636,RC,J0690,HCPCS,70092-1017-46,NDC,facility,both,8,ML,,14221,9954.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60219-1708-1,NDC,facility,both,200,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIPH,PERTUS(ACEL),TET,POLIO(PF)(KINRIX) 25 LF-58 MCG-10 LF/0.5 ML IM SYRINGE",50863,CDM,90710,HCPCS,0006-4171-01,NDC,,,facility,both,1,EA,,776,543.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  2.5 MG ORAL TAB,50863,CDM,J3490,HCPCS,60505-3110-0,NDC,,,facility,both,2,EA,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROATE SODIUM 100 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-494-01,NDC,facility,both,2,ML,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DICLOFENAC 25 MG TAB, DELAYED RELEASE",50863,CDM,636,RC,J3490,HCPCS,16571-203-10,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,J2250,HCPCS,0409-2308-21,NDC,,,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE  50 MG ORAL TAB,50863,CDM,636,RC,j3490,HCPCS,60687-443-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-492-27,NDC,facility,both,800,ML,,628,439.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"TRANEXAMIC ACID IN NACL,ISO-OS 1,000 MG/100 ML (10 MG/ML) IV PGBK",50863,CDM,636,RC,J3490,HCPCS,65219-534-01,NDC,facility,both,2,ML,,193,135.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,6,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
TRAZODONE  50 MG ORAL TAB,50863,CDM,250,RC,j3490,HCPCS,0904-6868-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLP,50863,CDM,636,RC,J3480,HCPCS,63323-965-03,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GAMMAGARD LIQUID 10 % IV SOLN,50863,CDM,636,RC,J1569,HCPCS,0944-2700-06,NDC,facility,both,80,ML,"JZ,JA",14422,10095.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69618-010-01,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE 110 MCG/ACTUATION INHL AERO,50863,CDM,636,RC,J3490,HCPCS,66993-079-96,NDC,facility,both,1,GM,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,12,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 10 MG-100 MG TAB,50863,CDM,250,RC,J3490,HCPCS,59651-456-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  20 MEQ ORAL PACK,50863,CDM,636,RC,J3490,HCPCS,69543-451-01,NDC,facility,both,1,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,636,RC,J3490,HCPCS,51079-169-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,65862-707-55,NDC,facility,both,7,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE (PF) 25 MG/ML INJ SOLN (FOR ECTOPIC PREGNANCY),50863,CDM,636,RC,J9260,HCPCS,0143-9519-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,0409-3178-01,NDC,,,facility,both,200,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,J3490,HCPCS,0143-9575-01,NDC,,,facility,both,200,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 1% (BUFFERED W/NAHCO3 8.4%) 10 ML SYRINGE (MERGE),50863,CDM,636,RC,J3490,HCPCS,70092-1175-46,NDC,facility,both,1,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,63323-482-03,NDC,,,facility,both,60,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POSACONAZOLE 100 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,0527-2133-35,NDC,facility,both,3,EA,,800,560,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,52,ML,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON DEXTRAN 50 MG/ML INJ SOLN,50863,CDM,636,RC,J1750,HCPCS,0023-6082-01,NDC,facility,both,1,ML,JZ,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,636,RC,J1815,HCPCS,0088-2220-33,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,60,ML,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ICATIBANT 30 MG/3 ML SUBQ SYRG,50863,CDM,636,RC,J1744,HCPCS,69097-664-34,NDC,facility,both,30,ML,JZ,29229,20460.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLN,50863,CDM,636,RC,J3262,HCPCS,50242-137-01,NDC,facility,both,400,ML,"JZ,JA",7331,5131.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
DOPAMINE 200 MG/5 ML (40 MG/ML) IV,50863,CDM,250,RC,J1265,HCPCS,0409-5820-01,NDC,facility,both,5,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROPROCAINE 3 % INJ SOLN,50863,CDM,250,RC,J2401,HCPCS,63323-478-01,NDC,facility,both,48,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 16 MG ORAL TAB,50863,CDM,250,RC,J7509,HCPCS,59762-0050-1,NDC,facility,both,3,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,55150-177-05,NDC,facility,both,25,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,J0330,HCPCS,0409-6629-02,NDC,,,facility,both,5,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 40 GRAM/400 ML (10 %) INJ SOLN",50863,CDM,250,RC,J1561,HCPCS,13533-800-20,NDC,facility,both,10,ML,,1415,990.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM-ALBUTEROL 0.5 MG-2.5 MG/3 ML NEB SOLUTION,50863,CDM,J3490,HCPCS,0487-0201-01,NDC,,,facility,both,2,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN PEDS INFUSION (CDS MIXTURE),50863,CDM,250,RC,J0290,HCPCS,25021-136-10,NDC,facility,both,3,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 150 MG CAP,50863,CDM,636,RC,J3490,HCPCS,68084-243-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  20 MEQ ORAL PACK,50863,CDM,250,RC,J3490,HCPCS,72888-024-06,NDC,facility,both,1,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,63323-806-13,NDC,facility,both,16,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE SOD SUCC (PF) 100 MG/2 ML INJ SOLR,50863,CDM,250,RC,J1720,HCPCS,0009-0011-03,NDC,facility,both,1,EA,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 80 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,43547-403-10,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NAPROXEN 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-491-11,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,27808-156-01,NDC,facility,both,1,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 1 % INJ SOLN,50863,CDM,636,RC,Q9968,HCPCS,17478-504-01,NDC,facility,both,40,ML,,328,229.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE SOD SUCC (PF) 100 MG/2 ML INJ SOLR,50863,CDM,250,RC,J1720,HCPCS,0009-0011-03,NDC,facility,both,2,EA,,269,188.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-097-11,NDC,facility,both,4,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPHENIDATE 18 MG ORAL TO24,50863,CDM,636,RC,J3490,HCPCS,62175-310-37,NDC,facility,both,1,EA,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN PEDS INFUSION (CDS MIXTURE),50863,CDM,250,RC,J0290,HCPCS,99999-408-63,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J2004,HCPCS,0409-3178-16,NDC,facility,both,250,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE  5 MG/ML INJ SOLN,50863,CDM,250,RC,J2765,HCPCS,0409-3414-18,NDC,facility,both,4,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,4,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PATIROMER CALCIUM SORBITEX  8.4 G ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,53436-084-01,NDC,facility,both,1,EA,,209,146.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  25 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-473-11,NDC,facility,both,3,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXEPIN  50 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7054-61,NDC,facility,both,2,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DANTROLENE  25 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,68084-300-11,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,J3490,HCPCS,69315-905-05,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,17,ML,JW,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,250,RC,Q0162,HCPCS,65162-691-79,NDC,facility,both,2,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,636,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,48,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
SACCHAROMYCES BOULARDII 250 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,7733380050,NDC,facility,both,5,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 80 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-877-01,NDC,facility,both,1,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,24,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7912-51,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"POTASSIUM CITRATE-CITRIC ACID 1,100 MG-334 MG/5 ML ORAL SOLN",50863,CDM,250,RC,J3490,HCPCS,121067616,NDC,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-346-11,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-465-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN  100 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,536354201,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THROMBIN (RECOMBINANT) 5000 UNIT TOP SOLR,50863,CDM,250,RC,J3490,HCPCS,0338-0324-01,NDC,facility,both,1,EA,,372,260.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6797-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRP (MERGE/REPACK),50863,CDM,636,RC,J3490,HCPCS,68094-764-59,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,25021-674-20,NDC,facility,both,1,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLP",50863,CDM,636,RC,P9047,HCPCS,44206-251-91,NDC,facility,both,4,ML,,1556,1089.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MECLIZINE 25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-730-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN NPH HUMAN RECOMB 100 UNIT/ML SUBQ SUSP,50863,CDM,250,RC,J1815,HCPCS,0169-1834-11,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANTI-INHIBITOR COAGULANT CMPLX (PHS MERGE),50863,CDM,250,RC,J7198,HCPCS,64193-325-01,NDC,facility,both,7500,UN,,46575,32602.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,9,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,28,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-04,NDC,facility,both,12,ML,,200,140,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,67877-545-88,NDC,facility,both,6,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,50863,CDM,250,RC,J0696,HCPCS,68180-644-01,NDC,facility,both,8,EA,,388,271.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,636,RC,J1596,HCPCS,0143-9679-01,NDC,facility,both,4,ML,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,J1938,HCPCS,0409-6102-02,NDC,,,facility,both,120,ML,,167,116.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,J3490,HCPCS,68094-494-59,NDC,,,facility,both,5,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,66,ML,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESNA 100 MG/ML IV SOLN,50863,CDM,250,RC,J9209,HCPCS,10019-953-62,NDC,facility,both,2,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC IV INFUSION HYDRAT 31-60 MIN,50863,CDM,J0248,HCPCS,61958-2901-2,NDC,,,facility,both,200,EA,,2392,1674.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,250,RC,J1596,HCPCS,0143-9679-01,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,16714-036-01,NDC,facility,both,8,ML,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 10 MG ORAL TAB,50863,CDM,J3490,HCPCS,50268-709-11,NDC,,,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 400 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0143-9887-01,NDC,facility,both,8,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 1000 MG MISC TBSO,50863,CDM,250,RC,J3490,HCPCS,0223-1760-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,50863,CDM,J1644,HCPCS,25021-402-01,NDC,,,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG IV SOLR,50863,CDM,250,RC,J0650,HCPCS,42023-201-01,NDC,facility,both,10,EA,,457,319.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-3425-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,63323-162-00,NDC,facility,both,2,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FINASTERIDE 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,31722-526-30,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN SODIUM EXTENDED 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,65862-692-01,NDC,facility,both,12,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE MODIFIED  25 MG ORAL CAP,50863,CDM,250,RC,J7515,HCPCS,0093-9018-19,NDC,facility,both,5,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,25,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7030,HCPCS,0338-0049-04,NDC,facility,both,2,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,J1940,HCPCS,63323-280-04,NDC,,,facility,both,2,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,636,RC,J0690,HCPCS,63323-237-10,NDC,facility,both,6,EA,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,62332-599-01,NDC,facility,both,1,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,250,RC,J0690,HCPCS,25021-101-10,NDC,facility,both,4,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-097-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,250,RC,J0690,HCPCS,0143-9924-90,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VINBLASTINE 1 MG/ML IV SOLN,50863,CDM,250,RC,J9360,HCPCS,63323-278-10,NDC,facility,both,20,ML,,548,383.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIRMATRELVIR-RITONAVIR 300 MG (150 MG X 2)-100 MG ORAL DSPK,50863,CDM,636,RC,J3490,HCPCS,0069-5045-06,NDC,facility,both,3,EA,,647,452.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-0053-01,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-6102-10,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,65,ML,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,75834-221-01,NDC,facility,both,3,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.3 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0228-2129-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN  500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7162-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,636,RC,J2704,HCPCS,25021-608-20,NDC,facility,both,20,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0264-7800-10,NDC,facility,both,2,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-479-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 10 GRAM/15 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,50383-779-30,NDC,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,J2405,HCPCS,23155-547-31,NDC,,,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2723-30,NDC,facility,both,30,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PNEUMOC 20-VAL CONJ-DIP CR(PF) 0.5 ML IM SYRG,50863,CDM,90677,HCPCS,0005-2000-10,NDC,,,facility,both,1,ML,,926,648.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML (1ML) INJ SOLN,50863,CDM,J0171,HCPCS,42023-159-01,NDC,,,facility,both,10,ML,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MANNITOL 20% IV SOLP,50863,CDM,250,RC,J2150,HCPCS,0990-7715-13,NDC,facility,both,1,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE IN 0.9% NS (PF) 1 MG/10 ML (100 MCG/ML) IV SYRG(PDS MERGE),50863,CDM,250,RC,J3490,HCPCS,65302-506-10,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 250 MG-62.5 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,59651-026-75,NDC,facility,both,6,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPOETIN ALFA 10000 UNIT/ML INJ SOLN,50863,CDM,J0885,HCPCS,59676-310-00,NDC,,,facility,both,20,ML,,1893,1325.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,J7040,HCPCS,0338-0049-04,NDC,,,facility,both,4,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,8,EA,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION,50863,CDM,250,RC,J3490,HCPCS,0186-0372-20,NDC,facility,both,2,GM,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCUSATE SODIUM 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,57896-401-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIPHTH,PERTUS(ACELL),TETANUS SYRG (INFANRIX) 25 LF UNIT-58MCG-10 LF/0.5ML IM SYRINGE",50863,CDM,90700,HCPCS,58160-810-43,NDC,,,facility,both,2,ML,,343,240.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,250,RC,J0132,HCPCS,55150-259-30,NDC,facility,both,240,ML,,4131,2891.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIPHTH,PERTUS(ACELL),TETANUS SYRG (INFANRIX) 25 LF UNIT-58MCG-10 LF/0.5ML IM SYRINGE",50863,CDM,90700,HCPCS,58160-810-43,NDC,,,facility,both,1,ML,,172,120.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN D5W 1 GRAM/200 ML IV PGBK,50863,CDM,636,RC,J3373,HCPCS,0338-3552-48,NDC,facility,both,100,ML,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,76045-009-01,NDC,facility,both,40,ML,,111,77.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J2250,HCPCS,0409-0001-01,NDC,facility,both,8,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-4675-05,NDC,facility,both,5,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-492-04,NDC,,,facility,both,500,ML,,393,275.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"VARICELLA-ZOSTER GE VAC,2 OF 2 50 MCG IM SUSR",50863,CDM,90750,HCPCS,58160-828-03,NDC,,,facility,both,1,EA,,763,534.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,0409-4279-02,NDC,,,facility,both,900,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  500 MG IV SOLR,50863,CDM,250,RC,J3373,HCPCS,0069-2587-03,NDC,facility,both,50,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPTOMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0878,HCPCS,72603-152-01,NDC,facility,both,1050,EA,,3071,2149.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (NEO) <2 KG,50863,CDM,250,RC,J7060,HCPCS,0264-7510-00,NDC,facility,both,2,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 7.5 MG-325 MG/15 ML ORAL SOLN (REPACK),50863,CDM,250,RC,J3490,HCPCS,64950-373-16,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  25 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,59762-1342-1,NDC,facility,both,2,EA,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,J7512,HCPCS,0904-7127-61,NDC,,,facility,both,60,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MOXIFLOXACIN 400 MG/250 ML IVPB PREMIX (MERGE),50863,CDM,250,RC,J2280,HCPCS,67457-323-25,NDC,facility,both,12,ML,,700,490,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM BICARB-CITRIC ACID 20 MEQ ORAL TBEF,50863,CDM,636,RC,J3490,HCPCS,51801-011-01,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  5 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-122-11,NDC,facility,both,15,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,6,ML,,9884,6918.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,70095-026-01,NDC,facility,both,1,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 500 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,16714-299-03,NDC,facility,both,4,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL DECANOATE  50 MG/ML IM SOLN,50863,CDM,250,RC,J1631,HCPCS,70069-030-01,NDC,facility,both,3,ML,,367,256.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4 % TOPICAL SOLN,50863,CDM,250,RC,J3490,HCPCS,76329-6300-5,NDC,facility,both,160,ML,,13337,9335.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV (BOLUS),50863,CDM,J7120,HCPCS,0264-7750-07,NDC,,,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BALANCED SALT SOLN NON-SURG #3 EYE,50863,CDM,J3490,HCPCS,0065-0530-01,NDC,,,facility,both,1,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE (PF) 1000 MCG/10 ML EPID SOLN,50863,CDM,250,RC,J0735,HCPCS,39822-2000-1,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J1610,HCPCS,0597-0053-45,NDC,facility,both,1,EA,JZ,371,259.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1162-18,NDC,facility,both,100,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAMSULOSIN 0.4 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,68084-299-11,NDC,facility,both,2,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  75 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,68084-709-11,NDC,facility,both,4,EA,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLN,50863,CDM,636,RC,J3262,HCPCS,50242-136-01,NDC,facility,both,200,ML,"JZ,JA",3666,2566.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
MECLIZINE 25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-730-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-256-11,NDC,facility,both,1,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLERGONOVINE 0.2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-813-11,NDC,facility,both,1,EA,,280,196,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,71288-422-95,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 100 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,60687-413-11,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,636,RC,J2405,HCPCS,70860-776-41,NDC,facility,both,42,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAVASTATIN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-5892-61,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  0.25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6373-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,23155-600-31,NDC,facility,both,1,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CARBAMAZEPINE 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,75834-221-01,NDC,facility,both,12,EA,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOPAMINE INFUSION NEO IV SYRINGE (FROM PREMIX) 3200 MIG/ML,50863,CDM,250,RC,J1265,HCPCS,99999-444-05,NDC,facility,both,4,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SYRG,50863,CDM,250,RC,J3490,HCPCS,8290306504,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VECURONIUM BROMIDE 10 MG IV SOLR,50863,CDM,636,RC,J3490,HCPCS,0703-2914-01,NDC,facility,both,1,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,52817-180-10,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,14,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEFEROXAMINE 500 MG INJ SOLR,50863,CDM,J0895,HCPCS,63323-597-10,NDC,,,facility,both,2,EA,,152,106.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE HCL IN NS 10 MG/250 ML (0.04 MG/ML) IV SOLN (PDS MERGE),50863,CDM,J2371,HCPCS,71285-6058-1,NDC,,,facility,both,500,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 15 MG/ML (1.5 %) INJ SOLN,50863,CDM,J2003,HCPCS,0409-4776-01,NDC,,,facility,both,300,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,J3490,HCPCS,0904-6322-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7361-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE 30 MG TAB,50863,CDM,250,RC,J3490,HCPCS,50268-642-11,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LINEZOLID 100 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0054-0319-50,NDC,facility,both,1,ML,,133,93.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 10 MG TAB,50863,CDM,250,RC,Q0177,HCPCS,63739-483-10,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOBRAMYCIN 0.3 % EYE DROPS,50863,CDM,636,RC,J3490,HCPCS,62332-518-05,NDC,facility,both,1,ML,,167,116.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 20 MEQ/100 ML IV PGBK,50863,CDM,636,RC,J3480,HCPCS,0338-0705-48,NDC,facility,both,10,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM 1 GRAM IV SOLR,50863,CDM,636,RC,J2185,HCPCS,0409-1391-21,NDC,facility,both,10,EA,JZ,122,85.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,0143-9682-01,NDC,facility,both,8,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALAMINE-ZINC OXIDE 8 %-8 % TOPICAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0904-2533-21,NDC,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,5026852411,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69315-905-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 10 MG/ML IM SOLN,50863,CDM,636,RC,J0500,HCPCS,70436-147-80,NDC,facility,both,1,ML,,229,160.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 600 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-5854-61,NDC,facility,both,1,EA,PLAD,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRP (MERGE/REPACK),50863,CDM,636,RC,J3490,HCPCS,68094-764-59,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  20 MG ORAL TR12,50863,CDM,250,RC,J3490,HCPCS,59011-420-20,NDC,facility,both,1,EA,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOCILIZUMAB-AAZG 80 MG/4 ML (20 MG/ML) IV SOLN,50863,CDM,636,RC,Q5135,HCPCS,65219-594-20,NDC,facility,both,360,ML,,4865,3405.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAMIDRONATE 3 MG/ML IV SOLN,50863,CDM,250,RC,J2430,HCPCS,61703-324-18,NDC,facility,both,3,ML,,247,172.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 250 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,60687-868-11,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0143-9889-15,NDC,facility,both,7,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,66553-002-01,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB 10 MG/ML IV CONC,50863,CDM,J9312,HCPCS,50242-051-21,NDC,,,facility,both,20,ML,,4434,3103.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIVAROXABAN 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50458-578-10,NDC,facility,both,1,EA,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,250,RC,J2003,HCPCS,55150-165-05,NDC,facility,both,100,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORHEXIDINE GLUCONATE  4 % TOP LIQD,50863,CDM,250,RC,J3490,HCPCS,0234-0575-04,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-22,NDC,facility,both,3,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMINOCAPROIC ACID 250 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-4346-73,NDC,facility,both,2,ML,,230,161,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,50863,CDM,636,RC,J3301,HCPCS,70121-1049-1,NDC,facility,both,4,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,250,RC,J7060,HCPCS,0338-0017-02,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,636,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,6,EA,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6370-61,NDC,facility,both,7,EA,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 2 %-1:200,000 INJ SOLN",50863,CDM,J2004,HCPCS,63323-489-01,NDC,,,facility,both,200,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE MALEATE 10 MG ORAL TAB,50863,CDM,636,RC,Q0164,HCPCS,50268-685-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DACTINOMYCIN 0.5 MG IV SOLR,50863,CDM,250,RC,J9120,HCPCS,71288-129-02,NDC,facility,both,5,EA,,6900,4830,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSINOPRIL 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,43547-387-09,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM PHOSPHATE 0.06 MMOL/ML IVPB (FOR PEDIATRICS),50863,CDM,250,RC,J3490,HCPCS,70121-1722-1,NDC,facility,both,4,ML,,1056,739.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-453-11,NDC,facility,both,6,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,250,RC,Q0162,HCPCS,65162-691-79,NDC,facility,both,2,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN  750 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,51224-107-50,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-0430-04,NDC,facility,both,1,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOXYL 25 MCG ORAL TAB (FOR NEONATAL PATIENTS),50863,CDM,250,RC,J3490,HCPCS,60793-850-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML (PEDS CALCLUATOR 0.5),50863,CDM,636,RC,J1815,HCPCS,0024-5924-10,NDC,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 250 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,58657-675-01,NDC,facility,both,2,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,76045-009-10,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CERTOLIZUMAB PEGOL 400 MG (200 MG X 2) SUBQ KIT,50863,CDM,636,RC,J0717,HCPCS,50474-700-62,NDC,facility,both,400,EA,JZ,6646,4652.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IBUPROFEN 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7914-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 250 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,0904-6363-61,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6322-06,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESALAMINE 400 MG ORAL CAPSULE-WITH DR TABLETS (CDTI),50863,CDM,250,RC,J3490,HCPCS,60687-556-33,NDC,facility,both,4,EA,,163,114.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOBAZAM 2.5 MG/ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,99999-0404-03,NDC,facility,both,5,ML,,237,165.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,2,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE IN D5W 1 GRAM/100 ML IV PGBK,50863,CDM,250,RC,J3475,HCPCS,44567-410-24,NDC,facility,both,2,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,250,RC,J0690,HCPCS,60505-6142-0,NDC,facility,both,6,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM  3.375 GRAM IV SOLR,50863,CDM,636,RC,J2543,HCPCS,55150-120-30,NDC,facility,both,3,EA,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE  5 MG/ML INJ SOLN,50863,CDM,250,RC,J2765,HCPCS,0409-3414-11,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-630-11,NDC,facility,both,1,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 10 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-369-11,NDC,facility,both,6,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,82293-004-10,NDC,facility,both,2,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,19,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,26,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-3178-01,NDC,facility,both,170,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IR SOLN,50863,CDM,636,RC,J3490,HCPCS,0338-0047-46,NDC,facility,both,5,ML,,250,175,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM 1 GRAM IV SOLR,50863,CDM,250,RC,J2185,HCPCS,63323-508-01,NDC,facility,both,20,EA,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,250,RC,J7060,HCPCS,0338-0017-48,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL IV BOLUS 10MG/ML (ANESTHESIA ONLY),50863,CDM,J2704,HCPCS,0409-4699-54,NDC,,,facility,both,233,ML,,296,207.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 750 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-653-01,NDC,facility,both,14,EA,,329,230.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,250,RC,J3490,HCPCS,70092-9119-44,NDC,facility,both,2,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIRMATRELVIR-RITONAVIR 150 MG (10)- 100 MG (10) ORAL DSPK,50863,CDM,636,RC,J3490,HCPCS,0069-5317-02,NDC,facility,both,2,EA,,628,439.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIOTHYRONINE 25 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42794-019-12,NDC,facility,both,2,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM PHOSPHATE 3 MMOL/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-884-01,NDC,facility,both,1,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,10,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BISACODYL  5 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,1093977544,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPSONE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,70954-136-10,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELIMUMAB 120 MG IV SOLR,50863,CDM,636,RC,J0490,HCPCS,49401-101-01,NDC,facility,both,24,ME,"JZ,JA",2819,1973.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
ASPIRIN 81 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,0904-6794-80,NDC,facility,both,3,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THROMBIN (RECOMBINANT) 5000 UNIT TOP SOLR,50863,CDM,250,RC,J3490,HCPCS,0338-0324-01,NDC,facility,both,3,EA,,1115,780.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-466-17,NDC,facility,both,200,ML,JZ,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SUCRALFATE 100 MG/ML ORAL SUSP,50863,CDM,J3490,HCPCS,0121-0974-10,NDC,,,facility,both,1,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN NPH & REGULAR HUMAN 100 UNIT/ML (70-30) SUBQ SUSP,50863,CDM,250,RC,J1815,HCPCS,0002-8715-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 100 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-0799-16,NDC,facility,both,1,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J3490,HCPCS,63323-492-26,NDC,,,facility,both,300,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-4279-02,NDC,facility,both,1200,ML,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE SODIUM 2.5 MG ORAL TAB,50863,CDM,250,RC,J8610,HCPCS,51079-670-01,NDC,facility,both,8,EA,,244,170.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,J7040,HCPCS,0338-0049-48,NDC,,,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,250,RC,Q9968,HCPCS,71288-811-10,NDC,facility,both,138,ML,,2282,1597.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOZAPINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-922-01,NDC,facility,both,4,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 15% IN WATER,50863,CDM,250,RC,J3490,HCPCS,0338-0023-03,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 10 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,65862-192-01,NDC,facility,both,2,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN 0.9% SODIUM CL 1.25 GRAM/250 ML IV SOLN,50863,CDM,250,RC,J3370,HCPCS,71266-5073-1,NDC,facility,both,3,ML,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYBUTYNIN CHLORIDE  5 MG ORAL TO24,50863,CDM,250,RC,J3490,HCPCS,0904-6570-61,NDC,facility,both,3,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SULFASALAZINE 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,59762-5000-5,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 10 MEQ/100 ML IV PGBK,50863,CDM,250,RC,J3480,HCPCS,14789-109-16,NDC,facility,both,10,ML,,470,329,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-9558-05,NDC,facility,both,2,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,636,RC,J2003,HCPCS,63323-485-27,NDC,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SYRG,50863,CDM,250,RC,J3490,HCPCS,8290306547,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOLIC ACID  5 MG/ML INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,39822-1100-1,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,50863,CDM,636,RC,J3490,HCPCS,68094-024-59,NDC,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LINEZOLID 100 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,60687-754-05,NDC,facility,both,1,ML,,343,240.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"CALCIUM GLUC IN NACL, ISO-OSM 1 G/100 ML IV SOLN",50863,CDM,636,RC,J0613,HCPCS,44567-622-01,NDC,facility,both,100,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIGOXIN  50 MCG/ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,0054-0057-46,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,250,RC,J3490,HCPCS,60687-653-11,NDC,facility,both,3,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0456,HCPCS,70095-025-01,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES-DOCUSATE SODIUM 8.6 MG-50 MG TAB,50863,CDM,250,RC,J3490,HCPCS,60687-622-11,NDC,facility,both,6,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE (PF) 1 MG/ML INJ SOLN,50863,CDM,250,RC,J0171,HCPCS,54288-103-10,NDC,facility,both,10,ML,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-9558-05,NDC,facility,both,2,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,115,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,250,RC,J0330,HCPCS,0409-6629-02,NDC,facility,both,6,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,50863,CDM,J9263,HCPCS,67457-469-10,NDC,,,facility,both,12,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,16729-114-31,NDC,facility,both,13,ML,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN  100 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,8068107100,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYUREA  500 MG ORAL CAP,50863,CDM,250,RC,J9999,HCPCS,68084-284-11,NDC,facility,both,2,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-242-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLN,50863,CDM,250,RC,J3262,HCPCS,50242-136-01,NDC,facility,both,200,ML,"JZ,JA",3666,2566.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
ATROPINE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J0461,HCPCS,0517-0401-25,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-6625-22,NDC,facility,both,2,ML,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFUROXIME AXETIL 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,67877-216-20,NDC,facility,both,1,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOTRIMAZOLE 1 % VAGL CREA,50863,CDM,250,RC,J3490,HCPCS,51672-2003-6,NDC,facility,both,1,GM,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE 25 MG/ML INJ SOLN,50863,CDM,636,RC,J3230,HCPCS,55150-319-01,NDC,facility,both,1,ML,,195,136.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,636,RC,J3490,HCPCS,68180-963-01,NDC,facility,both,1,GM,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NORETHINDRONE ACETATE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68462-304-50,NDC,facility,both,3,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,440,ML,,632,442.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 100 MG/5 ML ORAL LIQD,50863,CDM,636,RC,J3490,HCPCS,60687-863-42,NDC,facility,both,2,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE 30 MG TAB,50863,CDM,250,RC,J3490,HCPCS,68084-046-11,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  2 MG ORAL TAB,50863,CDM,J3490,HCPCS,0406-3243-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,50863,CDM,J3490,HCPCS,69339-152-01,NDC,,,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63304-773-01,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),50863,CDM,J2060,HCPCS,0641-6044-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-8299-25,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 2 % TD OINT,50863,CDM,250,RC,J3490,HCPCS,0281-0326-08,NDC,facility,both,1,GM,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-25,NDC,facility,both,80,ML,"JZ,JA",11316,7921.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
CALCIUM CHLORIDE (FOR CODE) 10% (100 MG/ML) IV SYRINGE,50863,CDM,250,RC,J3490,HCPCS,64253-900-30,NDC,facility,both,2,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL 2 MG/ML ORAL CONCENTRATE,50863,CDM,250,RC,J3490,HCPCS,0904-7112-41,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MENING VAC A,C,Y,W135,TET (PF) 10 MCG/0.5 ML IM SOLN",50863,CDM,90619,HCPCS,49281-590-58,NDC,,,facility,both,1,ML,,721,504.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 25 MG TAB,50863,CDM,636,RC,J3490,HCPCS,51079-255-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,250,RC,J2720,HCPCS,63323-229-01,NDC,facility,both,5,ML,JZ,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
AMOXICILLIN-POT CLAVULANATE 875 MG-125 MG TAB,50863,CDM,J3490,HCPCS,16714-014-02,NDC,,,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE  50 MCG/ACTUATION NASL SPSN,50863,CDM,250,RC,J3490,HCPCS,60432-264-15,NDC,facility,both,1,GM,,362,253.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCOSANOL 10 % TOP CREAM,50863,CDM,636,RC,J3490,HCPCS,0135-0300-01,NDC,facility,both,1,GM,,152,106.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 400 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65162-464-10,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6927-61,NDC,facility,both,1,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7452-61,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,85,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-492-07,NDC,facility,both,300,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 0.75 % VAGL GEL,50863,CDM,636,RC,J3490,HCPCS,0781-7077-87,NDC,facility,both,1,GM,,551,385.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIROFIBAN-0.9% SODIUM CHLORIDE 5 MG/100 ML (50 MCG/ML) IV SOLN,50863,CDM,250,RC,J3246,HCPCS,25208-002-03,NDC,facility,both,7,ML,,140,98,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 5 MG/ML INHL NEB CONTINUOUS,50863,CDM,250,RC,J3490,HCPCS,69374-330-05,NDC,facility,both,1,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,50863,CDM,636,RC,J9041,HCPCS,10019-991-01,NDC,facility,both,22,EA,,198,138.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J2003,HCPCS,63323-492-27,NDC,facility,both,60,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,67877-548-88,NDC,facility,both,2,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VERAPAMIL 120 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,68462-292-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,0409-1412-04,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,67457-423-00,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,50863,CDM,250,RC,J3301,HCPCS,70121-1049-1,NDC,facility,both,4,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,50,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,J2001,HCPCS,0409-4277-17,NDC,,,facility,both,100,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL (5 MG/ML) IV SYRG (CONTAINS PRESERVATIVE),50863,CDM,636,RC,J3490,HCPCS,70092-1009-44,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 20 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,51991-746-90,NDC,facility,both,1,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN PEDS INFUSION (CDS MIXTURE),50863,CDM,250,RC,J0290,HCPCS,99999-408-63,NDC,facility,both,2,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,0409-9093-35,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TALQUETAMAB-TGVS 40 MG/ML SUBQ SOLN,50863,CDM,250,RC,J3055,HCPCS,57894-470-01,NDC,facility,both,57,ML,JW,4476,3133.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,65219-572-01,NDC,facility,both,2,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6638-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 0.4 MG SL SUBL,50863,CDM,636,RC,J3490,HCPCS,43598-436-35,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,42858-001-10,NDC,facility,both,4,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,68180-441-01,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-464-11,NDC,facility,both,3,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROIC ACID 250 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0591-4012-01,NDC,facility,both,4,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  0.25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-577-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV,50863,CDM,250,RC,J7120,HCPCS,0338-0117-03,NDC,facility,both,3,ML,,183,128.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOPIDOGREL  75 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6294-61,NDC,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,250,RC,J2270,HCPCS,0641-6125-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITRIOL 0.25 MCG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-345-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,63323-482-01,NDC,facility,both,80,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  25 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-473-11,NDC,facility,both,7,EA,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIOGLITAZONE 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65862-512-90,NDC,facility,both,1,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLN (MERGE)",50863,CDM,250,RC,P9047,HCPCS,64208-2512-8,NDC,facility,both,2,ML,,238,166.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,250,RC,J0137,HCPCS,55150-307-01,NDC,facility,both,11,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),50863,CDM,636,RC,J2060,HCPCS,0641-6044-01,NDC,facility,both,2,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,16714-294-01,NDC,facility,both,6,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INDOMETHACIN 25 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,50268-430-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 50% IN WATER (MERGE RECORD),50863,CDM,636,RC,J7060,HCPCS,0409-7517-66,NDC,facility,both,1,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-630-11,NDC,facility,both,3,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  25 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6991-04,NDC,facility,both,4,EA,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0781-6041-46,NDC,facility,both,10,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE SR 37.5 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,62175-472-32,NDC,facility,both,1,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,43598-053-11,NDC,facility,both,19,ML,,684,478.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFUROXIME AXETIL 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65862-699-20,NDC,facility,both,2,EA,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-587-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J3490,HCPCS,0338-0049-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,881,ME,JZ,11956,8369.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MIDODRINE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6818-61,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BALSALAZIDE 750 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0054-0079-28,NDC,facility,both,3,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EMTRICITABINE-TENOFOVIR 200 MG-300 MG TAB,50863,CDM,636,RC,J0750,HCPCS,0904-7172-07,NDC,facility,both,3,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TAB,50863,CDM,636,RC,J3490,HCPCS,68084-396-11,NDC,facility,both,2,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J3490,HCPCS,0338-0049-31,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROATE SODIUM 100 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-494-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,0409-1886-22,NDC,facility,both,145,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG IV SOLR,50863,CDM,636,RC,J3490,HCPCS,0143-9284-01,NDC,facility,both,1,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-284-01,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TORSEMIDE   5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-754-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,63323-165-01,NDC,facility,both,4,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 100 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,0904-3854-61,NDC,facility,both,6,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,63739-931-28,NDC,facility,both,10,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 100 MG/1 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,0075-0623-03,NDC,facility,both,1,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,119,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE  2 MG/ML INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-285-10,NDC,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCAINAMIDE 100 MG/ML IV SYRG,50863,CDM,250,RC,J2690,HCPCS,76329-3399-5,NDC,facility,both,1,ML,,368,257.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-861-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MICAFUNGIN 100 MG IV SOLR,50863,CDM,250,RC,J2248,HCPCS,42023-230-01,NDC,facility,both,50,EA,JW,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
MESNA 100 MG/ML IV SOLN,50863,CDM,250,RC,J9209,HCPCS,10019-953-62,NDC,facility,both,6,ML,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,71288-402-10,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTAZIDIME-AVIBACTAM 2.5 GRAM (2 GRAM-0.5 GRAM) IV SOLR,50863,CDM,250,RC,J0714,HCPCS,0456-2700-10,NDC,facility,both,2,EA,JW,238,166.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,69918-899-01,NDC,facility,both,2,ML,JW,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
MANNITOL 20% IV SOLP,50863,CDM,250,RC,J2150,HCPCS,0338-0357-02,NDC,facility,both,1,ML,,255,178.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXAZOSIN 4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-862-95,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4 % TOP CREA,50863,CDM,636,RC,J3490,HCPCS,43199-040-50,NDC,facility,both,1,GM,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID (PORK)  30 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,62559-741-01,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,250,RC,J3360,HCPCS,69339-136-03,NDC,facility,both,2,ML,,145,101.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-145-10,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXRAZOXANE 500 MG IV SOLR,50863,CDM,636,RC,J1190,HCPCS,55150-435-01,NDC,facility,both,2,EA,,1292,904.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,70069-363-01,NDC,facility,both,2,ML,,356,249.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-411-10,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,63323-165-01,NDC,facility,both,12,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,50863,CDM,J9041,HCPCS,72603-270-01,NDC,,,facility,both,20,EA,,494,345.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0641-6022-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,636,RC,J3490,HCPCS,63323-185-10,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WHITE PETROLATUM TOPICAL GEL,50863,CDM,250,RC,J3490,HCPCS,0168-0053-45,NDC,facility,both,1,GM,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 0.5 MG/ML ORAL SUSPENSION (REPACK),50863,CDM,250,RC,J7507,HCPCS,51079-028-01,NDC,facility,both,1,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,250,RC,J2405,HCPCS,60505-6130-5,NDC,facility,both,16,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,72603-251-01,NDC,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 100 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,50268-542-11,NDC,facility,both,2,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1940,HCPCS,0409-6102-10,NDC,facility,both,5,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-736-01,NDC,facility,both,2,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,67877-432-03,NDC,facility,both,1,EA,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROGESTERONE MICRONIZED  8 % VAGL GEL,50863,CDM,250,RC,j3490,HCPCS,0023-6151-09,NDC,facility,both,2,GM,,226,158.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  0.25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-577-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 800 MG ORAL TAB,50863,CDM,250,RC,J0601,HCPCS,65162-058-27,NDC,facility,both,40,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROATE SODIUM 100 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0143-9785-01,NDC,facility,both,2,ML,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % MUCOSAL SOLN (VISCOUS),50863,CDM,636,RC,J3490,HCPCS,50383-775-15,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7126-61,NDC,facility,both,14,EA,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPTOMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0878,HCPCS,0409-0122-01,NDC,facility,both,600,EA,,483,338.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 0.1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60505-0257-1,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,J2003,HCPCS,0409-4277-17,NDC,,,facility,both,1000,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-6625-22,NDC,facility,both,1,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  20 MEQ ORAL PACK,50863,CDM,J3490,HCPCS,0245-0360-89,NDC,,,facility,both,2,EA,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,J2704,HCPCS,0069-0209-01,NDC,,,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BRIVARACETAM 10 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,50474-870-15,NDC,facility,both,15,ML,,204,142.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE 30 MG TAB,50863,CDM,250,RC,J3490,HCPCS,50268-642-11,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,250,RC,J0330,HCPCS,0409-6629-02,NDC,facility,both,5,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,8,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,636,RC,J1610,HCPCS,0597-0053-45,NDC,facility,both,2,EA,JZ,1483,1038.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,65,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0228-2127-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NAFCILLIN NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J3490,HCPCS,63323-327-10,NDC,facility,both,4,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 6 MG/0.5 ML SUB-Q,50863,CDM,636,RC,J3030,HCPCS,55150-173-01,NDC,facility,both,1,ML,GZ,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier GZ: Item or service expected to be denied as not reasonable and necessary
METHOCARBAMOL 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-520-11,NDC,facility,both,8,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 250 MG/5 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,17856-0600-1,NDC,facility,both,2,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,51754-4250-1,NDC,facility,both,2,ML,,131,91.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  37.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-844-11,NDC,facility,both,2,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEPLIZUMAB-MZWV 2 MG/20 ML IV SOLN,50863,CDM,636,RC,J9381,HCPCS,73650-316-01,NDC,facility,both,240,ME,JW,6309,4416.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
OXAZEPAM 10 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0228-2067-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLN,50863,CDM,636,RC,J3262,HCPCS,50242-136-01,NDC,facility,both,40,ML,"JW,JA",319,223.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
AMIODARONE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6993-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,146,ML,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,0409-6625-14,NDC,facility,both,20,ML,,1155,808.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACITUZUMAB GOVITECAN-HZIY 180 MG IV SOLR,50863,CDM,J9317,HCPCS,55135-132-01,NDC,,,facility,both,360,EA,,28606,20024.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,636,RC,J3490,HCPCS,53746-542-05,NDC,facility,both,3,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 5 MG ORAL TAB,50863,CDM,J3490,HCPCS,0003-0894-31,NDC,,,facility,both,2,EA,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  75 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-856-11,NDC,facility,both,2,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM ACETATE 667 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7119-61,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAZOLAMIDE SODIUM 500 (100 MG/ML) INJ SOLR,50863,CDM,250,RC,J1120,HCPCS,0143-9503-01,NDC,facility,both,1,EA,,224,156.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"CARDIOPLEGIC SOLUTION NO.16 26 MEQ/1,052.8 ML (POTASSIUM) PERF SOLN",50863,CDM,250,RC,J3490,HCPCS,71285-0202-1,NDC,facility,both,2,ML,,535,374.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,0409-1207-03,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CONJUGATED ESTROGENS  0.3 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0046-1100-81,NDC,facility,both,1,EA,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,2,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
MANNITOL 25 % IV SOLN,50863,CDM,250,RC,J2150,HCPCS,63323-024-01,NDC,facility,both,4,ML,,161,112.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MEASLES,MUMPS&RUBELLA VACCIN(PF) 1,000-12,500 TCID50/0.5 ML SUB-Q SUSP",50863,CDM,250,RC,90707,HCPCS,0006-4681-01,NDC,facility,both,1,EA,,387,270.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,636,RC,J3010,HCPCS,63323-806-13,NDC,facility,both,3,ML,JZ,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
AMOXICILLIN-POT CLAVULANATE 875 MG-125 MG TAB,50863,CDM,J3490,HCPCS,65862-503-01,NDC,,,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,63323-482-03,NDC,,,facility,both,100,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 50 MG/ML IV SOLN,50863,CDM,250,RC,J0282,HCPCS,0143-9875-01,NDC,facility,both,10,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J2003,HCPCS,63323-492-04,NDC,facility,both,60,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIPASE-PROTEASE-AMYLASE 24,000-76,000- 120,000 UNIT ORAL CAP, DELAY REL",50863,CDM,250,RC,J3490,HCPCS,0032-2636-01,NDC,facility,both,1,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM  3 GRAM INJ SOLR,50863,CDM,250,RC,J0295,HCPCS,71288-006-31,NDC,facility,both,2,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NYSTATIN 100000 UNIT/ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0121-0868-05,NDC,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0630,HCPCS,24201-400-02,NDC,facility,both,1,ML,,3478,2434.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,7,EA,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 60 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,68180-296-09,NDC,facility,both,2,EA,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOXAPINE 25 MG CAP,50863,CDM,250,RC,J3490,HCPCS,0591-0371-01,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,636,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,8,EA,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM BICARB-CITRIC ACID 20 MEQ ORAL TBEF,50863,CDM,250,RC,J3490,HCPCS,51801-011-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-229-02,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOLAZONE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-024-01,NDC,facility,both,1,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,50863,CDM,636,RC,J0696,HCPCS,44567-702-25,NDC,facility,both,8,EA,JZ,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,1,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,175,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0143-9889-15,NDC,facility,both,14,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25 MG-100 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7257-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYL SALICYLATE-MENTHOL 15-1 % TOPICAL CREAM,50863,CDM,250,RC,J3490,HCPCS,0178-0320-03,NDC,facility,both,1,GM,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 875 MG-125 MG TAB,50863,CDM,636,RC,J3490,HCPCS,42571-162-42,NDC,facility,both,10,EA,,215,150.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,250,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN 50 MG ORAL CHEW,50863,CDM,636,RC,J3490,HCPCS,60687-156-95,NDC,facility,both,2,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM-ALBUTEROL 0.5 MG-2.5 MG/3 ML NEB SOLUTION,50863,CDM,250,RC,J3490,HCPCS,60687-405-79,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,31,ML,,980,686,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COLCHICINE 0.6 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,70010-002-01,NDC,facility,both,2,EA,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLIPIZIDE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6637-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LETROZOLE 2.5 MG ORAL TAB,50863,CDM,250,RC,J9999,HCPCS,0093-7620-56,NDC,facility,both,1,EA,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/0.5 ML INHL NEBU,50863,CDM,636,RC,J3490,HCPCS,0487-9901-30,NDC,facility,both,5,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,J2003,HCPCS,63323-486-05,NDC,,,facility,both,1000,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETIRIZINE 5 MG/5 ML ORAL SOLN,50863,CDM,J3490,HCPCS,68094-004-59,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2308-22,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,50863,CDM,636,RC,J9000,HCPCS,25021-207-25,NDC,facility,both,8,ML,,216,151.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL,50863,CDM,250,RC,J3490,HCPCS,63323-820-01,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOBENZAPRINE 10 MG ORAL TAB,50863,CDM,J3490,HCPCS,50268-191-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,76045-009-10,NDC,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,J3490,HCPCS,0143-9889-15,NDC,,,facility,both,15,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCUSATE SODIUM 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-6998-60,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,50863,CDM,636,RC,J0696,HCPCS,60505-6148-0,NDC,facility,both,6,EA,,326,228.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG/ML ORAL CONC,50863,CDM,250,RC,J3490,HCPCS,0054-3553-44,NDC,facility,both,3,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,36000-283-25,NDC,facility,both,40,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,59651-488-01,NDC,facility,both,200,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIOTHYRONINE 25 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,62756-590-88,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLP,50863,CDM,250,RC,J3480,HCPCS,0409-6653-18,NDC,facility,both,20,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,J1938,HCPCS,63323-280-03,NDC,,,facility,both,40,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCERIN (CHILD) RECTAL SUPPOSITORY,50863,CDM,250,RC,J3490,HCPCS,0132-0081-12,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,636,RC,J7510,HCPCS,17856-0815-1,NDC,facility,both,2,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BRIVARACETAM 10 MG/ML ORAL SOLN,50863,CDM,J3490,HCPCS,50474-870-15,NDC,,,facility,both,40,ML,,543,380.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER SULFADIAZINE 1 % TOP CREA,50863,CDM,250,RC,J3490,HCPCS,67877-124-20,NDC,facility,both,1,GM,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON DEXTRAN 50 MG/ML INJ SOLN,50863,CDM,J1750,HCPCS,0023-6082-01,NDC,,,facility,both,20,ML,,2084,1458.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN D5W 20000 UNIT/500 ML,50863,CDM,250,RC,J1644,HCPCS,0264-9567-10,NDC,facility,both,20,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,0409-3178-01,NDC,,,facility,both,170,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  75 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6951-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0406-0552-23,NDC,facility,both,4,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  750 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-882-11,NDC,facility,both,3,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL  1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0832-1520-89,NDC,facility,both,6,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR  6 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,27241-139-09,NDC,facility,both,4,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,250,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,14,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM 2000 MG IV SOLR,50863,CDM,250,RC,J2185,HCPCS,72078-081-00,NDC,facility,both,20,EA,,184,128.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0264-5535-32,NDC,facility,both,50,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLP",50863,CDM,250,RC,P9047,HCPCS,0944-0493-04,NDC,facility,both,8,ML,,2001,1400.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J2250,HCPCS,0409-2305-17,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,76045-009-96,NDC,facility,both,5,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IMIPENEM-CILASTATIN 500 MG IV SOLR,50863,CDM,250,RC,J0743,HCPCS,44567-705-01,NDC,facility,both,4,EA,,321,224.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZTREONAM 2 GRAM INJ SOLR,50863,CDM,636,RC,J0457,HCPCS,63323-402-01,NDC,facility,both,20,EA,JZ,292,204.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LACTULOSE 10 GRAM/15 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,0121-0873-32,NDC,facility,both,1,ML,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSINOPRIL 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,43547-387-09,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-4264-11,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,J7040,HCPCS,0338-0049-41,NDC,,,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,52,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPTOMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0878,HCPCS,72603-152-01,NDC,facility,both,650,EA,,1901,1330.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 15% IN WATER,50863,CDM,250,RC,J3490,HCPCS,0338-0023-03,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERYTHROMYCIN 5 MG/G OPHT OINT,50863,CDM,636,RC,J3490,HCPCS,48102-057-11,NDC,facility,both,1,GM,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,250,RC,J2003,HCPCS,0409-4277-17,NDC,facility,both,1000,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,70069-363-01,NDC,facility,both,2,ML,,227,158.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,63739-931-28,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE (FOR CODE) 10% IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0517-6710-01,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THROMBIN (RECOMBINANT) 20000 UNIT TOP SOLR,50863,CDM,250,RC,J3490,HCPCS,0338-0328-01,NDC,facility,both,2,EA,,2436,1705.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,636,RC,J3360,HCPCS,69339-136-03,NDC,facility,both,1,ML,JW,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
EPHEDRINE 50 MG/ML IV SOLN (MERGE),50863,CDM,250,RC,J3490,HCPCS,16714-037-01,NDC,facility,both,1,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 25 MG/5 ML (5 MG/ML) ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,52536-600-11,NDC,facility,both,1,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,70095-031-01,NDC,facility,both,40,ML,,1641,1148.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69315-905-05,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-467-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 0.4MG/ML ORAL SOLUTION (REPACK),50863,CDM,250,RC,J1100,HCPCS,0069-4547-01,NDC,facility,both,2,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 125 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,62756-796-88,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORDIAZEPOXIDE 10 MG CAP,50863,CDM,636,RC,J3490,HCPCS,51079-375-01,NDC,facility,both,12,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,69,ML,JW,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
MESNA 100 MG/ML IV SOLN,50863,CDM,250,RC,J9209,HCPCS,10019-953-62,NDC,facility,both,4,ML,,101,70.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE (PF) 1 MG/ML INJ SOLN,50863,CDM,J0171,HCPCS,54288-103-01,NDC,,,facility,both,300,ML,,2568,1797.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN PEDS SYRINGE (20MG/ML) IN DEXTROSE (CDS MIX,50863,CDM,250,RC,J0690,HCPCS,0781-3451-70,NDC,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM-ALBUTEROL 0.5 MG-2.5 MG/3 ML NEB SOLUTION,50863,CDM,250,RC,J3490,HCPCS,0487-0201-01,NDC,facility,both,20,ML,,216,151.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J2004,HCPCS,0409-3178-01,NDC,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0641-0400-12,NDC,facility,both,8,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,30,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE  50 MG/ML INJ SOLN,50863,CDM,J3490,HCPCS,42023-114-10,NDC,,,facility,both,1,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,17,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,59,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,50863,CDM,J1885,HCPCS,0338-0069-10,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM BICARB-CITRIC ACID 20 MEQ ORAL TBEF,50863,CDM,636,RC,J3490,HCPCS,51801-012-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,1,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
NORTRIPTYLINE 10 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-281-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 5 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,0409-1778-15,NDC,facility,both,3,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7448-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  60 MG ORAL TBSR,50863,CDM,636,RC,J3490,HCPCS,0406-8380-62,NDC,facility,both,1,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0456,HCPCS,70095-025-01,NDC,facility,both,1,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,27,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OMALIZUMAB 150 MG SUBQ SOLR,50863,CDM,636,RC,J2357,HCPCS,50242-040-62,NDC,facility,both,60,ME,,5219,3653.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6501-61,NDC,facility,both,1,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,63323-461-01,NDC,facility,both,1,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 400 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0143-9887-01,NDC,facility,both,14,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,J3490,HCPCS,68094-231-59,NDC,,,facility,both,5,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,15,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,636,RC,J1611,HCPCS,0597-0053-45,NDC,facility,both,1,EA,JZ,742,519.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2308-21,NDC,facility,both,3,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
NITROGLYCERIN 50 MG/10 ML (5 MG/ML) IV SOLN,50863,CDM,636,RC,J2305,HCPCS,0517-4810-25,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J7510,HCPCS,17856-0815-1,NDC,facility,both,6,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 125 MG/5 ML (25MG/ML) ORAL SYRINGE (REPACK),50863,CDM,250,RC,J3370,HCPCS,67457-340-00,NDC,facility,both,4,EA,,189,132.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,50863,CDM,636,RC,J8540,HCPCS,0054-8175-25,NDC,facility,both,48,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,0409-1886-22,NDC,facility,both,300,ML,JZ,156,109.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PREDNISONE 50 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-854-11,NDC,facility,both,100,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0264-7800-00,NDC,facility,both,2,ML,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,72603-251-01,NDC,facility,both,40,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,84,ML,JW,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,18,ML,JW,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0137,HCPCS,0781-3156-06,NDC,facility,both,3,ML,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROPROCAINE 3 % INJ SOLN,50863,CDM,250,RC,J2401,HCPCS,0143-9210-01,NDC,facility,both,51,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,61,ML,JW,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
SALIVA SUBSTITUTE COMB NO.11 351 MG MM PWPK,50863,CDM,636,RC,J3490,HCPCS,7027562912,NDC,facility,both,1,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J1938,HCPCS,72603-251-01,NDC,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,49,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN DEXTROSE (ISO-OSMOTIC) 1 GRAM/50 ML IV PIGGY BACK,50863,CDM,636,RC,J0689,HCPCS,0338-3503-41,NDC,facility,both,2,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,250,RC,J2003,HCPCS,63323-486-05,NDC,facility,both,400,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IFOSFAMIDE 3 GRAM IV SOLR,50863,CDM,250,RC,J9208,HCPCS,10019-926-16,NDC,facility,both,9,EA,,1394,975.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,70095-031-01,NDC,facility,both,30,ML,,1208,845.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-03,NDC,facility,both,2,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-1749-70,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL,50863,CDM,250,RC,J3490,HCPCS,63323-820-01,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID (PORK)  30 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,42192-329-01,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9% IV (PEDS) BOLUS,50863,CDM,250,RC,J7040,HCPCS,0264-7800-09,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,72485-106-01,NDC,facility,both,450,ML,,150,105,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCRELIZUMAB 30 MG/ML IV SOLN,50863,CDM,636,RC,J2350,HCPCS,50242-150-01,NDC,facility,both,600,ME,,89700,62790,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEPERIDINE (PF) 100 MG/ML IV SOLN (PHS MERGE),50863,CDM,250,RC,J2175,HCPCS,0641-6054-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,67,ML,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 500 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,50268-152-15,NDC,facility,both,20,EA,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,636,RC,J1596,HCPCS,70700-165-22,NDC,facility,both,2,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-18,NDC,facility,both,400,ML,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,70,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 17 GRAM (100 %) ORAL PWPK,50863,CDM,636,RC,J3490,HCPCS,1152372688,NDC,facility,both,7,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"CALCIUM GLUC IN NACL, ISO-OSM 1 G/100 ML IV SOLN",50863,CDM,250,RC,J0613,HCPCS,44567-622-01,NDC,facility,both,50,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN  300 MG RECT SUPP,50863,CDM,636,RC,J3490,HCPCS,0574-7034-12,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 5 MG/ML IV SOLN,50863,CDM,636,RC,J1921,HCPCS,0143-9622-01,NDC,facility,both,1,ML,JZ,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DOBUTAMINE IN D5W 500 MG/250 ML (2 MG/ML) INFUSION (PREMIX),50863,CDM,250,RC,J1250,HCPCS,0338-1075-02,NDC,facility,both,4,ML,,470,329,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-492-04,NDC,,,facility,both,1000,ML,,785,549.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,J2704,HCPCS,63323-269-22,NDC,,,facility,both,60,ML,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,636,RC,J2405,HCPCS,70860-776-41,NDC,facility,both,12,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6572-61,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,636,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,2,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 50 MG/ML INJECTION,50863,CDM,250,RC,J1200,HCPCS,0641-0376-21,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0591-0407-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 400 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0143-9887-01,NDC,facility,both,5,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 100 MG IV SOLR,50863,CDM,250,RC,J2997,HCPCS,50242-085-25,NDC,facility,both,10,EA,JW,1158,810.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,636,RC,J2405,HCPCS,60505-6130-0,NDC,facility,both,1,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
SEVELAMER CARBONATE 800 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,17856-921-01,NDC,facility,both,6,EA,,179,125.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML IV SOLN (MERGE),50863,CDM,636,RC,J3490,HCPCS,16714-037-01,NDC,facility,both,1,ML,,253,177.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LINEZOLID NEO IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J2020,HCPCS,0781-3433-46,NDC,facility,both,3,ML,,331,231.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % MUCOSAL SOLN (VISCOUS),50863,CDM,250,RC,J3490,HCPCS,0121-4950-15,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOZAPINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-922-01,NDC,facility,both,5,EA,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE (PF-DURAMORPH/ASTRAMORPH) 0.5 MG/ML INJ SOLN,50863,CDM,250,RC,J2274,HCPCS,0409-3814-12,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
0.2 MICRON FILTER ATTACHMENT MISC MISC,50863,CDM,250,RC,99999-0403-06,NDC,,,facility,both,1,EA,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE (3 MONTH) 22.5 MG IM SYRG,50863,CDM,636,RC,J9217,HCPCS,0074-3346-03,NDC,facility,both,3,EA,JZ,1176,823.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
OCTREOTIDE ACETATE  500 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,25021-465-01,NDC,facility,both,20,ML,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NORTRIPTYLINE 50 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0093-0812-01,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,95,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,250,RC,J2405,HCPCS,0409-4755-18,NDC,facility,both,12,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-351-11,NDC,facility,both,3,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAZOLAMIDE 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6663-61,NDC,facility,both,4,EA,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,250,RC,J2270,HCPCS,0409-1890-03,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,63323-462-01,NDC,facility,both,2,ML,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DUTASTERIDE 0.5 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,42806-549-09,NDC,facility,both,1,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0780,HCPCS,23155-294-31,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES 8.8 MG/5 ML ORAL SYRP,50863,CDM,250,RC,J3490,HCPCS,0121-4967-05,NDC,facility,both,2,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOPIDOGREL  75 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6294-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 5 MG/ML IV SOLN,50863,CDM,636,RC,J1921,HCPCS,17478-420-20,NDC,facility,both,1,ML,JZ,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SODIUM CHLORIDE 0.9 % INJ SYRG,50863,CDM,636,RC,J3490,HCPCS,8290306547,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,4,ML,,128,89.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NOREPINEPHRINE BITARTRATE-D5W 4 MG/250 ML (16 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0338-0112-20,NDC,facility,both,4,ML,,534,373.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-18,NDC,facility,both,25,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
MIDODRINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-398-11,NDC,facility,both,4,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLN,50863,CDM,636,RC,J3262,HCPCS,50242-135-01,NDC,facility,both,80,ML,,1467,1026.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYBUTYNIN CHLORIDE 5 MG/5 ML ORAL SYRP,50863,CDM,250,RC,J3490,HCPCS,54838-510-80,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-592-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 2 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J2004,HCPCS,63323-489-27,NDC,facility,both,400,ML,,121,84.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-253-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,0641-0476-21,NDC,facility,both,1,ML,,155,108.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,0143-9577-01,NDC,,,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",50863,CDM,250,RC,J1561,HCPCS,13533-800-41,NDC,facility,both,40,ML,JW,2460,1722,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",50863,CDM,J1561,HCPCS,13533-800-41,NDC,,,facility,both,40,ML,,2460,1722,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,50863,CDM,250,RC,J0561,HCPCS,60793-701-02,NDC,facility,both,24,ML,,2613,1829.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETIRIZINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-597-01,NDC,facility,both,3,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  75 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-495-11,NDC,facility,both,3,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7368-06,NDC,facility,both,2,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL  6.25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7306-61,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,76045-009-01,NDC,facility,both,20,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42291-809-15,NDC,facility,both,2,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-22,NDC,facility,both,4,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,J3490,HCPCS,68180-441-02,NDC,,,facility,both,4,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACIDOPHILUS-PECTIN W CITRUS 25 MILLION-100 CELL MG TAB,50863,CDM,250,RC,J3490,HCPCS,1785614241,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN 0.9 % SODIUM CHL 2 GRAM/500 ML IV SOLN,50863,CDM,250,RC,J3370,HCPCS,70092-9338-07,NDC,facility,both,4,ML,,129,90.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,50863,CDM,250,RC,J9267,HCPCS,61703-342-22,NDC,facility,both,63,ML,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-9543-02,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),50863,CDM,636,RC,J3490,HCPCS,63323-186-20,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,J2371,HCPCS,0641-6142-01,NDC,,,facility,both,15,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,250,RC,J2003,HCPCS,0409-4277-02,NDC,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML IM SYRG,50863,CDM,250,RC,90371,HCPCS,13533-636-30,NDC,facility,both,1,ML,,226,158.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,81,ML,JW,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0075-0622-01,NDC,facility,both,7,ML,JZ,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),50863,CDM,250,RC,J2060,HCPCS,0641-6044-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J1940,HCPCS,63323-280-02,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,50863,CDM,250,RC,J9263,HCPCS,67457-469-10,NDC,facility,both,100,ML,,432,302.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  25 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-6991-61,NDC,facility,both,8,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,6,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-497-11,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-504-11,NDC,facility,both,4,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THROMBIN (RECOMBINANT) 5000 UNIT TOP SOLR,50863,CDM,250,RC,J3490,HCPCS,0338-0324-01,NDC,facility,both,2,EA,,744,520.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,636,RC,J3490,HCPCS,63739-434-02,NDC,facility,both,4,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 150 MG CAP,50863,CDM,250,RC,J3490,HCPCS,0904-5959-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,121119030,NDC,facility,both,1,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALACYCLOVIR 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-077-10,NDC,facility,both,2,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CITRATE 10 MEQ ORAL TBER,50863,CDM,636,RC,J3490,HCPCS,31722-130-01,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE MODIFIED 100 MG ORAL CAP,50863,CDM,250,RC,J7502,HCPCS,51862-460-01,NDC,facility,both,4,EA,,108,75.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-1749-70,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,57,ML,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-01,NDC,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRP (MERGE/REPACK),50863,CDM,636,RC,J3490,HCPCS,68094-764-59,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 4 MG ORAL TAB,50863,CDM,J3490,HCPCS,60505-0252-2,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,0409-9094-22,NDC,facility,both,2,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,J3490,HCPCS,0536-1327-10,NDC,,,facility,both,3,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  75 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-856-11,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 100 MG 24 HR TAB,50863,CDM,636,RC,J3490,HCPCS,67877-592-01,NDC,facility,both,2,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,250,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  5 MG ORAL TAB,50863,CDM,J7512,HCPCS,60687-122-11,NDC,,,facility,both,10,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,0409-4276-16,NDC,,,facility,both,200,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,63323-201-03,NDC,,,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,636,RC,J3490,HCPCS,63323-485-27,NDC,facility,both,105,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN   81 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,77333-031-25,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,50863,CDM,250,RC,J9000,HCPCS,0069-1542-20,NDC,facility,both,11,ML,,181,126.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN V POTASSIUM 250 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16714-234-01,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-497-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,144,100.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGIC MOUTHWASH REPACK (BMX 1:1:1),50863,CDM,250,RC,J3490,HCPCS,0603-0823-58,NDC,facility,both,10,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,50863,CDM,250,RC,J9025,HCPCS,72485-201-01,NDC,facility,both,59,EA,JW,365,255.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DEXTROSE 50% IN WATER (MERGE RECORD),50863,CDM,250,RC,J7060,HCPCS,76329-3302-1,NDC,facility,both,1,ML,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 0.2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60505-0258-1,NDC,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAPAVERINE 30 MG/ML INJ SOLN,50863,CDM,250,RC,J2440,HCPCS,14789-121-07,NDC,facility,both,1,ML,,221,154.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE 150 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,0904-7076-61,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,4,EA,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0780,HCPCS,43066-090-01,NDC,facility,both,1,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-1749-71,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACARBOSE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,64380-759-06,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXAZOSIN 4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-224-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,64208-2510-5,NDC,facility,both,2,ML,,238,166.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),50863,CDM,250,RC,J2060,HCPCS,0641-6044-01,NDC,facility,both,3,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,636,RC,J2597,HCPCS,70095-031-01,NDC,facility,both,38,ML,JW,678,474.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,230,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,636,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE-EPI-CLONID-KETOROL 2.46-0.005- 0.0008-0.3MG/ML PATC SYRG,50863,CDM,250,RC,J3490,HCPCS,70092-1433-50,NDC,facility,both,2,ML,,425,297.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NAFCILLIN NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J3490,HCPCS,63323-327-10,NDC,facility,both,5,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,250,RC,J0132,HCPCS,70594-111-01,NDC,facility,both,100,ML,,509,356.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASCORBIC ACID  250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,2055500100,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOLTERODINE 2 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,43975-322-03,NDC,facility,both,2,EA,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN  7.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,57237-126-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,636,RC,J2270,HCPCS,0409-1891-03,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE IN 0.9% NS (PF) 1 MG/10 ML (100 MCG/ML) IV SYRG(PDS MERGE),50863,CDM,636,RC,J3490,HCPCS,65302-506-10,NDC,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,4,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7263-61,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 8-2 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,0904-7010-06,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TERAZOSIN  5 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0781-2053-01,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7193-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) IV (NEO) EMERGENCY SYRINGE,50863,CDM,250,RC,J3490,HCPCS,0409-5534-34,NDC,facility,both,10,ML,,635,444.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25 MG-100 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7257-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-450-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7030,HCPCS,0338-0049-04,NDC,facility,both,2,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,636,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,8,EA,,128,89.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 4 MEQ/ML IV SOLP (COMPOUNDED 30ML),50863,CDM,250,RC,J3490,HCPCS,63323-093-01,NDC,facility,both,1,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,636,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,6,EA,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM NEO/PEDS INFUSION (CDS MIXTURE),50863,CDM,250,RC,J2543,HCPCS,0206-8852-08,NDC,facility,both,5,EA,,150,105,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),50863,CDM,250,RC,J1815,HCPCS,0024-5926-05,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLN (MERGE)",50863,CDM,250,RC,P9047,HCPCS,68982-643-02,NDC,facility,both,4,ML,,993,695.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0406-5771-23,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0143-9889-15,NDC,facility,both,12,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,250,RC,J3490,HCPCS,73702-301-15,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THROMBIN (RECOMBINANT) 5000 UNIT TOP SOLR,50863,CDM,250,RC,J3490,HCPCS,43825-606-41,NDC,facility,both,1,EA,,372,260.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-103-01,NDC,facility,both,4,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IVPB (PEDIATRICS/ADULT NON-FORM)",50863,CDM,250,RC,J0137,HCPCS,24201-100-01,NDC,facility,both,100,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,636,RC,J1100,HCPCS,25021-053-01,NDC,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELATACEPT 250 MG IV SOLR,50863,CDM,636,RC,J0485,HCPCS,0003-0371-13,NDC,facility,both,388,EA,,4004,2802.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 250 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,0904-6363-61,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,636,RC,Q9968,HCPCS,71288-811-10,NDC,facility,both,30,ML,JW,169,118.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
SENNOSIDES  8.6 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7252-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETHAMBUTOL 400 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-280-11,NDC,facility,both,3,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,0548-5603-00,NDC,facility,both,5,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN PEDS INFUSION (CDS MIXTURE),50863,CDM,250,RC,J0290,HCPCS,25021-136-10,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0121-1781-05,NDC,facility,both,3,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,636,RC,J3490,HCPCS,70092-9119-44,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,0088-2220-33,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1815,HCPCS,0002-8215-01,NDC,facility,both,1,ML,,155,108.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,250,RC,J3360,HCPCS,76045-204-00,NDC,facility,both,1,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,J2704,HCPCS,0069-0209-01,NDC,,,facility,both,14,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4 % TOP CREA,50863,CDM,250,RC,J3490,HCPCS,24357-701-05,NDC,facility,both,1,GM,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  250 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7123-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,636,RC,J7510,HCPCS,17856-0815-1,NDC,facility,both,9,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) IV SOLN",50863,CDM,636,RC,J3490,HCPCS,0013-1114-20,NDC,facility,both,2,ML,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,162,ML,,146,102.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,636,RC,P9045,HCPCS,64208-2510-1,NDC,facility,both,2,ML,,238,166.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN PEDS INFUSION (CDS MIXTURE),50863,CDM,250,RC,J0290,HCPCS,25021-136-10,NDC,facility,both,3,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  1 MG/ML INJ SYRG,50863,CDM,250,RC,J1170,HCPCS,0409-1283-10,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,636,RC,J0330,HCPCS,0409-6629-02,NDC,facility,both,3,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,636,RC,J3490,HCPCS,14789-251-09,NDC,facility,both,2,ML,,309,216.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM  3.375 GRAM IV SOLR,50863,CDM,J2543,HCPCS,64679-056-02,NDC,,,facility,both,3,EA,,107,74.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,63323-161-00,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-6007-61,NDC,,,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAUNORUBICIN 5 MG/ML IV INJ,50863,CDM,636,RC,J9150,HCPCS,0143-9550-01,NDC,facility,both,5,ML,,1122,785.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5%-LACTATED RINGERS IV,50863,CDM,J7120,HCPCS,0338-0125-04,NDC,,,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHOTERICIN B LIPOSOME 50 MG IV SUSR,50863,CDM,250,RC,J0289,HCPCS,0469-3051-30,NDC,facility,both,45,EA,,10142,7099.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 500 MG INJ SOLR,50863,CDM,250,RC,J0696,HCPCS,0409-7338-11,NDC,facility,both,6,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,50863,CDM,J3301,HCPCS,70121-1049-1,NDC,,,facility,both,8,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESMOLOL  100 MG/10 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,67457-182-00,NDC,facility,both,1,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,0409-1412-10,NDC,facility,both,4,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ORPHENADRINE CITRATE 30 MG/ML INJ SOLN,50863,CDM,J2360,HCPCS,0641-6182-01,NDC,,,facility,both,1,ML,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,66553-002-01,NDC,facility,both,3,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) IN 0.9 % NACL 1 MG/ML IV SOLN,50863,CDM,250,RC,J2250,HCPCS,70092-1177-35,NDC,facility,both,50,ML,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5%-LACTATED RINGERS IV,50863,CDM,636,RC,J7120,HCPCS,0338-0125-03,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-723-11,NDC,facility,both,12,EA,,471,329.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID (PORK)  60 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0456-0459-01,NDC,facility,both,4,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NAFCILLIN  1 GRAM INJ SOLR,50863,CDM,250,RC,J3490,HCPCS,44567-221-10,NDC,facility,both,1,EA,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-205-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,0904-6794-89,NDC,facility,both,3,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,50863,CDM,636,RC,J8540,HCPCS,60687-718-11,NDC,facility,both,40,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM NEO/PEDS INFUSION (CDS MIXTURE),50863,CDM,250,RC,J2543,HCPCS,0206-8852-08,NDC,facility,both,2,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 2-0.5 MG SL SUBL,50863,CDM,636,RC,J3490,HCPCS,50268-144-11,NDC,facility,both,2,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYBURIDE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-8344-98,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,18,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CELECOXIB 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,16714-732-01,NDC,facility,both,2,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN 0.9% SODIUM CL 1.25 GRAM/250 ML IV SOLN,50863,CDM,250,RC,J3370,HCPCS,71266-5083-1,NDC,facility,both,3,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
HYDRALAZINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-327-10,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE IN SALINE (ISO-OSM) 400 MG/200 ML IV PIGGY BACK,50863,CDM,636,RC,J1450,HCPCS,25021-184-67,NDC,facility,both,2,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OFLOXACIN 0.3 % OPHT DROP,50863,CDM,636,RC,J3490,HCPCS,60505-0560-0,NDC,facility,both,1,ML,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),50863,CDM,250,RC,J1815,HCPCS,0024-5926-05,NDC,facility,both,5,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB 100 MG IV SOLR,50863,CDM,636,RC,J1745,HCPCS,57894-030-01,NDC,facility,both,50,EA,,16116,11281.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE-DEXTROSE-WATER(PF) 7.5 MG/ML (0.75 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,71351-022-10,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,636,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,3,EA,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0093-3426-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 875 MG-125 MG TAB,50863,CDM,250,RC,J3490,HCPCS,42571-162-01,NDC,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN 0.9 % SODIUM CHL 1.5 GRAM/500 ML IV SOLN,50863,CDM,J3370,HCPCS,70004-924-44,NDC,,,facility,both,3,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6008-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 100 MG/5 ML ORAL LIQD,50863,CDM,250,RC,J3490,HCPCS,50383-063-10,NDC,facility,both,18,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 200 MG/100 ML IVPB (MERGE),50863,CDM,636,RC,J1450,HCPCS,25021-184-82,NDC,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTOBARBITAL 75 MG/1.5 ML SYRINGE (REPACK),50863,CDM,636,RC,J3490,HCPCS,25021-676-20,NDC,facility,both,2,ML,,170,119,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 25 MG TAB,50863,CDM,J3490,HCPCS,65862-146-36,NDC,,,facility,both,2,EA,,230,161,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,3,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  10 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,68094-001-59,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM PHOSPHATE 3 MMOL/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-884-01,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J3490,HCPCS,63323-492-27,NDC,,,facility,both,40,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,0409-4279-02,NDC,,,facility,both,1200,ML,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,636,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,18,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHOTERICIN B LIPOSOME 50 MG IV SUSR,50863,CDM,250,RC,J0289,HCPCS,62756-233-01,NDC,facility,both,15,EA,,2706,1894.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-124-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN-ACETAMINOPHEN-CAFFEINE 250 MG-250 MG-65 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0536-1326-01,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOMYCIN-BACITRACN ZN-POLYMYXIN 3.5 MG-400 U*,50863,CDM,250,RC,J3490,HCPCS,0904-8805-67,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIPHTH,PERTUS(ACELL),TETANUS SYRG(BOOSTRIX) 2.5-8-5 LF-MCG-LF/0.5ML IM SYRG",50863,CDM,250,RC,90715,HCPCS,58160-842-43,NDC,facility,both,1,ML,,240,168,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM  3.375 GRAM IV SOLR,50863,CDM,250,RC,J2543,HCPCS,65219-436-02,NDC,facility,both,3,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NORTRIPTYLINE 25 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0093-0811-01,NDC,facility,both,4,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IR SOLN,50863,CDM,636,RC,J3490,HCPCS,0338-0047-47,NDC,facility,both,3,ML,,221,154.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-8299-25,NDC,facility,both,3,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,250,RC,J2270,HCPCS,76045-004-10,NDC,facility,both,1,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 2 %-1:200,000 INJ SOLN",50863,CDM,J2004,HCPCS,0409-3183-11,NDC,,,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COLCHICINE 0.6 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-727-11,NDC,facility,both,3,EA,,164,114.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-157-11,NDC,facility,both,6,EA,,668,467.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VERAPAMIL 2.5 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-1144-02,NDC,facility,both,1,ML,,190,133,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0121-1781-05,NDC,facility,both,3,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEO TPN SODIUM ACETATE 2 MEQ/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-7299-83,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,24689-907-01,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,0641-6174-01,NDC,facility,both,6,ML,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-087-11,NDC,facility,both,3,EA,,325,227.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR 200 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,70954-188-10,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-492-27,NDC,,,facility,both,100,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) IV SOLN",50863,CDM,250,RC,J3490,HCPCS,0013-1114-01,NDC,facility,both,5,ML,,599,419.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUANFACINE 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0591-0444-01,NDC,facility,both,4,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,76045-009-01,NDC,facility,both,30,ML,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-48,NDC,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6638-61,NDC,facility,both,10,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DASATINIB  20 MG ORAL TAB,50863,CDM,250,RC,J9999,HCPCS,0003-0527-11,NDC,facility,both,2,EA,,1195,836.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,J7040,HCPCS,0338-0049-41,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,50863,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL,50863,CDM,J3490,HCPCS,63323-820-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIOGLITAZONE 45 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,33342-056-07,NDC,facility,both,1,EA,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALSARTAN  40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0378-5807-93,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,17271-701-05,NDC,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PALONOSETRON 0.25 MG/5 ML IV INJECTION (MERGE),50863,CDM,636,RC,J2469,HCPCS,60505-6193-1,NDC,facility,both,10,ML,,605,423.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPAFENONE 150 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,59651-256-01,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CELECOXIB 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,16714-732-01,NDC,facility,both,1,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR 200 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,31722-681-47,NDC,facility,both,1,ML,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML (PEDS CALCLUATOR 0.5),50863,CDM,250,RC,J1815,HCPCS,0024-5924-10,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 20 MG/ML INJ SOLN,50863,CDM,636,RC,J0360,HCPCS,55150-400-01,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,50863,CDM,636,RC,J3301,HCPCS,16714-130-01,NDC,facility,both,2,ML,JW,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
AMINOCAPROIC ACID 250 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0517-9120-01,NDC,facility,both,1,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,2,EA,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 250 MG-125 MG TAB,50863,CDM,250,RC,J3490,HCPCS,16714-476-01,NDC,facility,both,1,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEFEROXAMINE 2 GRAM INJ SOLR,50863,CDM,J0895,HCPCS,63323-599-30,NDC,,,facility,both,4,EA,,242,169.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,J0665,HCPCS,63323-466-01,NDC,,,facility,both,15,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,62584-693-11,NDC,facility,both,1,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,J2001,HCPCS,63323-486-17,NDC,,,facility,both,20,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE 44 MCG/ACTUATION INHL AERO,50863,CDM,636,RC,J3490,HCPCS,66993-078-96,NDC,facility,both,1,GM,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1815,HCPCS,0169-1833-11,NDC,facility,both,4,ML,GZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier GZ: Item or service expected to be denied as not reasonable and necessary
KETAMINE 100 MG/ML INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0143-9509-01,NDC,facility,both,1,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYALURONIDASE 150 UNIT/ML INJ SOLN,50863,CDM,250,RC,J3473,HCPCS,18657-117-01,NDC,facility,both,150,ML,,284,198.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,50863,CDM,250,RC,J0640,HCPCS,0143-9554-01,NDC,facility,both,2,EA,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE IN SALINE (ISO-OSM) 400 MG/200 ML IV PIGGY BACK,50863,CDM,636,RC,J1450,HCPCS,0409-4321-01,NDC,facility,both,2,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPROST TROMETHAMINE 250 MCG/ML IM SOLN,50863,CDM,636,RC,J3490,HCPCS,0009-0856-08,NDC,facility,both,1,ML,,605,423.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0781-6041-46,NDC,facility,both,4,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  20 MEQ ORAL PACK,50863,CDM,636,RC,J3490,HCPCS,43386-194-90,NDC,facility,both,2,EA,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,250,RC,J7060,HCPCS,0338-0017-38,NDC,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN   81 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,69618-066-02,NDC,facility,both,4,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7130-61,NDC,facility,both,1,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE  2 MG/ML INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,70069-062-01,NDC,facility,both,2,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-582-11,NDC,facility,both,2,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1815,HCPCS,0169-1833-11,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,55150-161-02,NDC,facility,both,20,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,0409-3178-01,NDC,,,facility,both,400,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,0409-3178-01,NDC,,,facility,both,60,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 40 MG/ML (4 %) INJ SOLN (FOR NEBULIZATION),50863,CDM,J2003,HCPCS,0409-4283-11,NDC,,,facility,both,320,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"AMIODARONE IN DEXTROSE,ISO-OSM 360 MG/200 ML (1.8 MG/ML) IV SOLN",50863,CDM,636,RC,J0282,HCPCS,43066-360-20,NDC,facility,both,9,ML,,165,115.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,636,RC,J3010,HCPCS,0641-6027-25,NDC,facility,both,2,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,6,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1815,HCPCS,0169-1833-11,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIOTHYRONINE  5 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-166-01,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 112 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6954-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-327-11,NDC,facility,both,2,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,3,EA,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYMETAZOLINE 0.05 % NASAL MERGE,50863,CDM,250,RC,J3490,HCPCS,0904-6761-30,NDC,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLNALTREXONE 12 MG/0.6 ML SUBQ SYRG,50863,CDM,636,RC,J2212,HCPCS,65649-552-04,NDC,facility,both,80,ML,,693,485.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-5771-23,NDC,facility,both,6,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 400 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-6667-61,NDC,facility,both,2,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 7.5 MG-325 MG/15 ML ORAL SOLN (REPACK),50863,CDM,250,RC,J3490,HCPCS,0121-2316-15,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,250,RC,J2003,HCPCS,63323-208-01,NDC,facility,both,400,ML,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DASATINIB 100 MG ORAL TAB,50863,CDM,636,RC,J9999,HCPCS,0003-0852-22,NDC,facility,both,1,EA,,1679,1175.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0904-6923-61,NDC,facility,both,14,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),50863,CDM,250,RC,J2060,HCPCS,17478-040-01,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PORACTANT ALFA 240 MG/3 ML INTR SUSP,50863,CDM,250,RC,J3490,HCPCS,10122-510-03,NDC,facility,both,1,ML,,3260,2282,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,53489-143-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,55150-165-05,NDC,facility,both,400,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM CITRATE ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,70677-1111-1,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLP,50863,CDM,J3480,HCPCS,0409-6653-18,NDC,,,facility,both,20,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-492-16,NDC,,,facility,both,40,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,70756-640-82,NDC,,,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42806-312-50,NDC,facility,both,1,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1815,HCPCS,0002-8215-01,NDC,facility,both,3,ML,GZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier GZ: Item or service expected to be denied as not reasonable and necessary
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J3490,HCPCS,55150-161-02,NDC,,,facility,both,20,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK,50863,CDM,J3490,HCPCS,12870-0001-1,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0338-1055-48,NDC,facility,both,150,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-4799-05,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TERBUTALINE 1 MG/ML SUBQ SOLN,50863,CDM,250,RC,J3105,HCPCS,0143-9746-01,NDC,facility,both,50,ML,,1330,931,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INDOCYANINE GREEN 25 MG INJ,50863,CDM,250,RC,J3490,HCPCS,70100-424-01,NDC,facility,both,1,EA,,917,641.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-440-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN SODIUM  2 GRAM INJ SOLR,50863,CDM,636,RC,J0290,HCPCS,0781-3408-80,NDC,facility,both,4,EA,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7001-61,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOLIC ACID  1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7224-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,J7050,HCPCS,0338-0049-02,NDC,,,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLP",50863,CDM,636,RC,P9047,HCPCS,0944-0493-04,NDC,facility,both,3,ML,,751,525.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL  6.25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7306-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-097-11,NDC,facility,both,8,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % MUCOSAL GEL,50863,CDM,636,RC,J3490,HCPCS,17478-711-30,NDC,facility,both,1,ML,,210,147,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,76045-009-10,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-760-11,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMMONIUM LACTATE 12 % TOP LOTN,50863,CDM,250,RC,J3490,HCPCS,45802-419-54,NDC,facility,both,3,GM,,421,294.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIVAROXABAN 15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50458-578-01,NDC,facility,both,6,EA,,517,361.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0121-1781-05,NDC,facility,both,2,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ANTI-INHIBITOR COAGULANT CMPLX 1,750-3,250 UNIT IV SOLR",50863,CDM,250,RC,J7198,HCPCS,64193-425-02,NDC,facility,both,3250,UN,,19361,13552.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN SODIUM EXTENDED 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,58151-110-32,NDC,facility,both,2,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE HCL  2 % MM JELP,50863,CDM,636,RC,J3490,HCPCS,76329-3012-5,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-1638-32,NDC,facility,both,4,ML,,130,91,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,J2270,HCPCS,0409-1890-03,NDC,,,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0143-9889-15,NDC,facility,both,13,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,14789-128-07,NDC,facility,both,3,ML,,448,313.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0121-1022-05,NDC,facility,both,3,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VORICONAZOLE 200 MG IV SOLN,50863,CDM,250,RC,J3465,HCPCS,0781-3416-94,NDC,facility,both,49,EA,,1324,926.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,250,RC,J3490,HCPCS,39822-1000-1,NDC,facility,both,1,ML,PLAD,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,68094-231-59,NDC,facility,both,4,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,250,RC,J3490,HCPCS,71449-068-11,NDC,facility,both,2,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOPROTERENOL 0.2 MG/ML INJECTION,50863,CDM,250,RC,J3490,HCPCS,70121-1605-1,NDC,facility,both,1,ML,,1249,874.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6773-61,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-588-11,NDC,facility,both,3,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,67877-545-68,NDC,facility,both,4,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,0904-7509-30,NDC,facility,both,3,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THROMBIN (RECOMBINANT) 5000 UNIT TOP SOLR,50863,CDM,250,RC,J3490,HCPCS,0338-0324-01,NDC,facility,both,1,EA,,298,208.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 10 MG/ML (PF) IV SOLN,50863,CDM,636,RC,J2270,HCPCS,0641-6127-01,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,0409-4887-17,NDC,facility,both,2,ML,PLAD,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
MODAFINIL 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-570-11,NDC,facility,both,1,EA,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,636,RC,Q0162,HCPCS,60687-252-40,NDC,facility,both,2,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 50 MG/5 ML (10 MG/ML) IV SYRG,50863,CDM,250,RC,J3490,HCPCS,71449-004-11,NDC,facility,both,1,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-099-11,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VORICONAZOLE 200 MG IV SOLN,50863,CDM,250,RC,J3465,HCPCS,70436-029-80,NDC,facility,both,20,EA,,550,385,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PSEUDOEPHEDRINE 30 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6990-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6927-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 1 MG/ML (1ML) SYRINGE (REPACK),50863,CDM,250,RC,J2997,HCPCS,50242-044-13,NDC,facility,both,10,EA,,2708,1895.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 1000 MG MISC TBSO,50863,CDM,250,RC,J3490,HCPCS,904723961,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,250,RC,J3490,HCPCS,61553-320-70,NDC,facility,both,1,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  125 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,62559-390-50,NDC,facility,both,1,EA,,154,107.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J3430,HCPCS,69097-708-96,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,50863,CDM,636,RC,J1885,HCPCS,63323-162-45,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-453-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE  2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7366-04,NDC,facility,both,3,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  75 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7000-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0781-6041-46,NDC,facility,both,10,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,250,RC,J2795,HCPCS,63323-286-20,NDC,facility,both,100,ML,,150,105,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NAPROXEN 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-491-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,0517-0020-10,NDC,facility,both,60,ML,,111,77.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL  1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-734-01,NDC,facility,both,4,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRP (MERGE/REPACK),50863,CDM,636,RC,J3490,HCPCS,68094-764-59,NDC,facility,both,1,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 1 MG/ML (1ML) SYRINGE (REPACK),50863,CDM,250,RC,J2997,HCPCS,50242-044-13,NDC,facility,both,3,EA,,813,569.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,68094-600-59,NDC,facility,both,4,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEGARELIX 120 MG SUBQ SOLR,50863,CDM,250,RC,J9155,HCPCS,55566-8403-1,NDC,facility,both,240,EA,,4207,2944.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,63323-104-25,NDC,facility,both,20,ML,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,636,RC,J7510,HCPCS,17856-0815-1,NDC,facility,both,7,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  75 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-441-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPTOMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0878,HCPCS,72603-152-01,NDC,facility,both,500,EA,,1463,1024.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TERAZOSIN  5 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,50268-766-11,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J7510,HCPCS,17856-0815-1,NDC,facility,both,5,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML IM SOLN,50863,CDM,636,RC,90375,HCPCS,13533-318-05,NDC,facility,both,1,ML,JW,623,436.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J1938,HCPCS,23155-473-32,NDC,facility,both,80,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0093-4177-73,NDC,facility,both,12,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EMOLLIENT COMBINATION NO.10 TOPICAL EMULSION,50863,CDM,250,RC,J3490,HCPCS,1381156545,NDC,facility,both,1,GM,,156,109.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 20 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,65862-306-12,NDC,facility,both,1,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,50863,CDM,250,RC,Q5119,HCPCS,0069-0238-01,NDC,facility,both,10,ML,,1979,1385.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,250,RC,Q9968,HCPCS,70710-1838-1,NDC,facility,both,5,ML,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,63323-412-03,NDC,facility,both,10,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIPASE-PROTEASE-AMYLASE (PORK) 3,000-9,500- 15,000 UNIT ORAL CPDR",50863,CDM,250,RC,J3490,HCPCS,0032-1203-70,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 80 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6293-04,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM  3 GRAM INJ SOLR,50863,CDM,250,RC,J0295,HCPCS,0049-0014-81,NDC,facility,both,2,EA,JZ,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J2003,HCPCS,0409-4713-32,NDC,facility,both,60,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,636,RC,J3010,HCPCS,0409-9094-12,NDC,facility,both,2,ML,JZ,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-492-09,NDC,facility,both,200,ML,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-511-11,NDC,facility,both,2,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5%-LACTATED RINGERS IV,50863,CDM,250,RC,J7120,HCPCS,0264-7751-00,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,16714-294-01,NDC,facility,both,5,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL (VITAMIN D3)  1000 UNIT ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,8068116900,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,65862-006-01,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPENTOLATE-PHENYLEPHRINE 0.2 %-1 % EYE DROPS,50863,CDM,250,RC,J3490,HCPCS,0065-0359-02,NDC,facility,both,1,ML,,218,152.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,J7040,HCPCS,0338-0049-02,NDC,,,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % MBP,50863,CDM,J3490,HCPCS,0338-0553-18,NDC,,,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN DEGLUDEC 100 UNITS/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,0169-2662-11,NDC,facility,both,20,ML,,23998,16798.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-495-04,NDC,,,facility,both,1400,ML,,335,234.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 500 MG/10 ML IV SOLN,50863,CDM,J9190,HCPCS,63323-117-01,NDC,,,facility,both,2,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,J0690,HCPCS,60505-6142-0,NDC,,,facility,both,4,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.15 MG/0.3 ML IM PNIJ,50863,CDM,636,RC,J0171,HCPCS,49502-101-01,NDC,facility,both,2,EA,,675,472.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC IV INFUSION PEMIVIBART,50863,CDM,636,RC,Q0224,HCPCS,81960-031-03,NDC,facility,both,1,ML,,15939,11157.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLARITHROMYCIN 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-179-11,NDC,facility,both,1,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INDOMETHACIN 100 MG RECT SUPP,50863,CDM,250,RC,J3490,HCPCS,73702-140-71,NDC,facility,both,1,EA,,841,588.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LANTHANUM  500 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,68180-819-52,NDC,facility,both,2,EA,,127,88.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  650 MG RECT SUPP,50863,CDM,250,RC,J3490,HCPCS,45802-730-00,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 1% (BUFFERED W/NAHCO3 8.4%) 10 ML SYRINGE (MERGE),50863,CDM,250,RC,J3490,HCPCS,70092-1175-46,NDC,facility,both,1,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,149003916,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1162-19,NDC,facility,both,300,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 1 MG ORAL TAB,50863,CDM,250,RC,J8540,HCPCS,0054-4181-25,NDC,facility,both,24,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE  4 MG ORAL TAB,50863,CDM,636,RC,J7509,HCPCS,0904-6914-61,NDC,facility,both,5,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,1,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL (VITAMIN D3)  1000 UNIT ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,8068116900,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,14,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALSARTAN  40 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-612-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,250,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 20 MG/ML INJ SOLN,50863,CDM,636,RC,J0360,HCPCS,55150-400-01,NDC,facility,both,1,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL  1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7390-61,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE   4.2 % IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-083-05,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IV PGBK,50863,CDM,636,RC,J3475,HCPCS,0264-4204-52,NDC,facility,both,4,ML,JZ,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PHENYLEPHRINE 1 % NASAL SPRAY AEROSOL,50863,CDM,250,RC,J3490,HCPCS,0225-0810-47,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN NEO/PEDS IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0456,HCPCS,63323-398-14,NDC,facility,both,1,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0517-0299-25,NDC,facility,both,500,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,8,EA,,121,84.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,72266-118-01,NDC,facility,both,2,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IPRATROPIUM BROMIDE 0.02 % INHL SOLN,50863,CDM,250,RC,J3490,HCPCS,0487-9801-01,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-739-41,NDC,facility,both,1,ML,PLAD,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
DEXAMETHASONE 0.1 MG/ML IV SYRINGE (NEO/INFANT),50863,CDM,250,RC,J1100,HCPCS,99999-0405-74,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,25021-131-82,NDC,facility,both,100,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0093-4155-73,NDC,facility,both,7,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IVPB (PEDIATRICS/ADULT NON-FORM)",50863,CDM,250,RC,J0137,HCPCS,24201-100-01,NDC,facility,both,100,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,30,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,3,EA,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2312,HCPCS,0409-1219-41,NDC,facility,both,200,ML,,257,179.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2308-21,NDC,facility,both,2,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,73293-0001-1,NDC,facility,both,100,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 2 MG/ML IV SOLN,50863,CDM,250,RC,J9000,HCPCS,25021-207-51,NDC,facility,both,4,ML,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7008-61,NDC,facility,both,5,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  50 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-6992-61,NDC,facility,both,8,EA,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM IN D5W 125 MG/125 ML (1 MG/ML) IV SOLN (PREMIX),50863,CDM,636,RC,J3490,HCPCS,72196-6054-1,NDC,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,50863,CDM,250,RC,J9060,HCPCS,0703-5748-11,NDC,facility,both,17,ML,,389,272.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL  3.125 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6300-61,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE 250 MG/5 ML IV SOLN,50863,CDM,250,RC,J7516,HCPCS,0078-0109-61,NDC,facility,both,1,ML,,356,249.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50111-334-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAZOSIN 5 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,51079-632-01,NDC,facility,both,2,EA,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DICLOFENAC 50 MG TAB, DELAYED RELEASE",50863,CDM,250,RC,J3490,HCPCS,0228-2550-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0121-0914-05,NDC,facility,both,3,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROMETHOLONE 0.1 % OPHT DRPS,50863,CDM,250,RC,J3490,HCPCS,60758-880-05,NDC,facility,both,1,ML,,395,276.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,62559-440-02,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-5771-23,NDC,facility,both,13,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,16714-293-03,NDC,facility,both,5,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-078-33,NDC,facility,both,2,EA,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,2,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),50863,CDM,250,RC,J2060,HCPCS,65219-368-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,76045-009-96,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,250,RC,J0132,HCPCS,63323-963-21,NDC,facility,both,180,ML,,1426,998.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,12,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATOVAQUONE 750 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0121-1016-05,NDC,facility,both,2,ML,,363,254.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,250,RC,J2405,HCPCS,60505-6130-0,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL DECANOATE  50 MG/ML IM SOLN,50863,CDM,250,RC,J1631,HCPCS,70069-030-01,NDC,facility,both,2,ML,,306,214.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.45% (1/2 NS) INFUSION (PEDS ONC),50863,CDM,636,RC,J3490,HCPCS,0338-0043-04,NDC,facility,both,1,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZOCAINE-MENTHOL 15-3.6 MG MM LOZG,50863,CDM,250,RC,J3490,HCPCS,6382471016,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MILRINONE 1 MG/ML IV SOLN,50863,CDM,250,RC,J2260,HCPCS,72485-501-01,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-38,NDC,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"HEPARIN, PORCINE (PF)  100 UNIT/ML IV SYRG",50863,CDM,J1642,HCPCS,6380760055,NDC,,,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAVASTATIN 20 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-5892-61,NDC,,,facility,both,2,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,J7510,HCPCS,17856-0815-1,NDC,,,facility,both,4,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,50863,CDM,J3301,HCPCS,70121-1168-1,NDC,,,facility,both,2,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,0409-4713-32,NDC,,,facility,both,80,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 4 MEQ/ML IV SOLP (COMPOUNDED 30ML),50863,CDM,J3490,HCPCS,63323-093-01,NDC,,,facility,both,1,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6303-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANTI-INHIBITOR COAGULANT CMPLX (PHS MERGE),50863,CDM,250,RC,J7198,HCPCS,64193-426-02,NDC,facility,both,17,UN,JW,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,54,ML,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,37,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE SOD SUCC (PF) 100 MG/2 ML INJ SOLR,50863,CDM,J1720,HCPCS,0009-0011-03,NDC,,,facility,both,1,EA,,142,99.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,0409-3178-01,NDC,,,facility,both,90,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,24689-907-01,NDC,facility,both,3,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 10 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,63323-516-10,NDC,facility,both,100,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE (PF-DURAMORPH/ASTRAMORPH) 0.5 MG/ML INJ SOLN,50863,CDM,250,RC,J2274,HCPCS,0409-3814-11,NDC,facility,both,1,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE HCL  0.5 % NASL SPRY,50863,CDM,636,RC,J3490,HCPCS,0225-0805-47,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0406-5771-23,NDC,facility,both,9,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC IV INFUSION HYDRAT 31-60 MIN,50863,CDM,250,RC,J0248,HCPCS,61958-2901-2,NDC,facility,both,34,EA,,396,277.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EMTRICITABINE-TENOFOVIR 200 MG-300 MG TAB,50863,CDM,J0750,HCPCS,65862-354-30,NDC,,,facility,both,1,EA,,297,207.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1560-18,NDC,facility,both,100,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-444-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN PEDS INFUSION (CDS MIXTURE),50863,CDM,250,RC,J0290,HCPCS,99999-408-63,NDC,facility,both,2,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60219-1708-1,NDC,facility,both,40,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-264-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  0.25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-741-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,250,RC,J2003,HCPCS,63323-495-27,NDC,facility,both,140,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7350-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,636,RC,J2003,HCPCS,76329-3390-1,NDC,facility,both,200,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ICATIBANT 30 MG/3 ML SUBQ SYRG,50863,CDM,636,RC,J1744,HCPCS,69097-664-68,NDC,facility,both,30,ML,JZ,29229,20460.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,23,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VARENICLINE 0.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68462-893-56,NDC,facility,both,1,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN IN D5W 600 MG/50 ML IV PGBK,50863,CDM,250,RC,J0736,HCPCS,0338-3612-50,NDC,facility,both,2,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,65862-246-08,NDC,facility,both,2,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,67877-545-68,NDC,facility,both,7,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6172-61,NDC,facility,both,2,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MYCOPHENOLATE 500 MG TAB,50863,CDM,250,RC,J7517,HCPCS,60687-438-11,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MILRINONE IN D5W 20 MG/100 ML (0.2 MG/ML) INFUSION,50863,CDM,250,RC,J2260,HCPCS,0409-2045-01,NDC,facility,both,5,ML,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR IRRIGATION, STERILE SOLUTION",50863,CDM,636,RC,J3490,HCPCS,0338-0004-02,NDC,facility,both,8,ML,,277,193.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-657-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL 20 MG/5 ML ORAL ELIX,50863,CDM,250,RC,J3490,HCPCS,0121-0942-05,NDC,facility,both,5,ML,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXRAZOXANE 500 MG IV SOLR,50863,CDM,636,RC,J1190,HCPCS,55150-435-01,NDC,facility,both,2,EA,,1350,945,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0121-0945-00,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 8-2 MG SL SUBL,50863,CDM,636,RC,J3490,HCPCS,60687-637-11,NDC,facility,both,3,EA,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J2004,HCPCS,63323-482-03,NDC,facility,both,200,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 500 MG (200 MG ELEMENTAL) CHEW TAB,50863,CDM,636,RC,J3490,HCPCS,68084-988-33,NDC,facility,both,3,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL 2.5 MG/ML SUSPENSION,50863,CDM,250,RC,J3490,HCPCS,99999-0404-75,NDC,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,475,ML,,681,476.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,J3101,HCPCS,50242-037-06,NDC,,,facility,both,31,EA,,6174,4321.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOXYMETHYLCELLULOSE SODIUM 1 % OPHT DPGE,50863,CDM,636,RC,J3490,HCPCS,0023-4554-30,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE  2.5 % RECT CREA,50863,CDM,250,RC,J3490,HCPCS,62559-431-30,NDC,facility,both,1,GM,,353,247.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRBESARTAN  75 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,43547-374-03,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-454-11,NDC,facility,both,1,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-495-27,NDC,,,facility,both,14,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,50863,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,330,EA,,5274,3691.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,62559-440-02,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,63323-162-01,NDC,facility,both,2,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,60687-571-24,NDC,facility,both,2,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM NEO/PEDS INFUSION (CDS MIXTURE),50863,CDM,250,RC,J2543,HCPCS,0206-8852-08,NDC,facility,both,2,EA,,258,180.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIPHTH,PERTUS(ACELL),TETANUS SYRG (INFANRIX) 25 LF UNIT-58MCG-10 LF/0.5ML IM SYRINGE",50863,CDM,90700,HCPCS,58160-810-43,NDC,,,facility,both,2,ML,,334,233.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE ENEMA 200G IN SW (1000 ML TOTAL VOLUME),50863,CDM,636,RC,J3490,HCPCS,99999-0405-41,NDC,facility,both,1,ML,,113,79.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7041-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMINOCAPROIC ACID 250 MG/ML IV SOLN,50863,CDM,J3490,HCPCS,0517-9120-01,NDC,,,facility,both,2,ML,,111,77.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,636,RC,J7999,HCPCS,70092-1017-46,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TETRACYCLINE 500 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,51991-907-01,NDC,facility,both,1,EA,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICARDIPINE IN NACL (ISO-OS) 20 MG/200 ML IV PGBK,50863,CDM,J3490,HCPCS,10122-313-01,NDC,,,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,J3490,HCPCS,0406-0552-23,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTOBARBITAL 75 MG/1.5 ML SYRINGE (REPACK),50863,CDM,250,RC,J3490,HCPCS,25021-676-20,NDC,facility,both,1,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE IV INFUSION (PULMONARY EMBOLISM) 100 MG (2 X 50 MG VIALS),50863,CDM,J2997,HCPCS,99999-0402-55,NDC,,,facility,both,100,ML,,24289,17002.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,636,RC,J2270,HCPCS,63323-454-00,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 100 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,31722-574-47,NDC,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),50863,CDM,636,RC,J0171,HCPCS,76329-3318-1,NDC,facility,both,50,ML,,404,282.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML INJECTION,50863,CDM,636,RC,J3411,HCPCS,72603-139-01,NDC,facility,both,2,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ABATACEPT 250 MG IV SOLR,50863,CDM,636,RC,J0129,HCPCS,0003-2187-13,NDC,facility,both,100,EA,JA,16146,11302.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2305-16,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"METHYLPREDNISOLONE 1,000 MG SOLUTION FOR INJECTION",50863,CDM,636,RC,J2919,HCPCS,0009-0698-01,NDC,facility,both,200,EA,JZ,224,156.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
TOLTERODINE 2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,33342-098-09,NDC,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,50863,CDM,636,RC,J0585,HCPCS,0023-1145-01,NDC,facility,both,76,EA,JW,529,370.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,250,RC,Q0162,HCPCS,16714-671-02,NDC,facility,both,2,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,636,RC,J1836,HCPCS,0338-1055-48,NDC,facility,both,100,ML,JZ,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,24,EA,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV (BOLUS),50863,CDM,250,RC,J7120,HCPCS,0264-7750-10,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYMETAZOLINE 0.05 % NASL SPRA,50863,CDM,636,RC,J3490,HCPCS,0113-0065-10,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,25021-602-03,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6085-61,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  75 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6951-61,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,16714-036-01,NDC,facility,both,7,ML,JZ,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DROPERIDOL 2.5 MG/ML INJ SOLN,50863,CDM,250,RC,J1790,HCPCS,0517-9702-25,NDC,facility,both,1,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 650 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,77333-827-25,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,4,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-677-11,NDC,facility,both,2,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,1,EA,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
SIMETHICONE 40MG/0.6ML (0.6ML-UD) SYRINGE (REPACK),50863,CDM,250,RC,J3490,HCPCS,17856-1141-4,NDC,facility,both,2,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLERGONOVINE 0.2 MG/ML (1 ML) INJ SOLN,50863,CDM,636,RC,J2210,HCPCS,0517-0740-01,NDC,facility,both,1,ML,,184,128.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL,50863,CDM,636,RC,J1071,HCPCS,52536-625-01,NDC,facility,both,200,ML,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,J2405,HCPCS,60505-6130-0,NDC,,,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TERAZOSIN  2 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,59746-384-06,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),50863,CDM,J3490,HCPCS,0409-4888-02,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSULFAN BLUE 1 % INJ SOLN,50863,CDM,Q9968,HCPCS,67457-220-00,NDC,,,facility,both,30,ML,,2579,1805.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,250,RC,J2405,HCPCS,0641-6078-01,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL,50863,CDM,250,RC,J3490,HCPCS,63323-820-01,NDC,facility,both,1,ML,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 300 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68180-976-09,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,J2405,HCPCS,23155-547-42,NDC,,,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYMETAZOLINE 0.05 % NASAL MERGE,50863,CDM,250,RC,J3490,HCPCS,70677-1037-1,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON DEXTRAN 50 MG/ML INJ SOLN,50863,CDM,636,RC,J1750,HCPCS,0023-6082-01,NDC,facility,both,36,ML,JZ,3751,2625.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,51754-5001-5,NDC,facility,both,1,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,55150-177-05,NDC,facility,both,91,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  100 MCG/ML INJ SOLN,50863,CDM,636,RC,J2354,HCPCS,0641-6175-01,NDC,facility,both,4,ML,JB,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JB: Administered subcutaneously
TRANEXAMIC ACID 650 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69918-301-30,NDC,facility,both,2,EA,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOBRAMYCIN 1.2 G POWDER VIAL,50863,CDM,250,RC,J3260,HCPCS,39822-0412-6,NDC,facility,both,60,EA,,1590,1113,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN LOCK FLUSH 100 UNIT/ML IV SOLN,50863,CDM,250,RC,J1642,HCPCS,6425333335,NDC,facility,both,100,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-591-11,NDC,facility,both,3,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,250,RC,J2405,HCPCS,0641-6078-01,NDC,facility,both,4,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MODAFINIL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-621-11,NDC,facility,both,3,EA,,280,196,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,0641-0400-12,NDC,facility,both,5,ML,JZ,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,250,RC,J0690,HCPCS,0143-9924-90,NDC,facility,both,6,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPTOMYCIN 500 MG IV SOLR,50863,CDM,636,RC,J0878,HCPCS,71288-016-15,NDC,facility,both,350,EA,JZ,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
METRONIDAZOLE 250 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7156-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4% TOP PATCH,50863,CDM,J3490,HCPCS,46581-830-01,NDC,,,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE  50 MG ORAL CAP,50863,CDM,250,RC,J8530,HCPCS,62332-619-31,NDC,facility,both,42,EA,,1022,715.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,62332-037-31,NDC,facility,both,3,EA,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,20,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOPIDOGREL  75 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-536-11,NDC,facility,both,4,EA,,134,93.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,J1580,HCPCS,63323-010-03,NDC,,,facility,both,4,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,636,RC,P9045,HCPCS,68516-5219-0,NDC,facility,both,14,ML,,3559,2491.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-03,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-739-11,NDC,facility,both,3,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAPAVERINE 30 MG/ML INJ SOLN,50863,CDM,250,RC,J2440,HCPCS,0517-4002-25,NDC,facility,both,1,ML,,243,170.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE (POLACRILEX) 2 MG MM LOZG,50863,CDM,250,RC,J3490,HCPCS,45802-344-03,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0131-2477-60,NDC,facility,both,2,EA,,156,109.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMILORIDE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0574-0292-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  20 MG ORAL TR12,50863,CDM,250,RC,J3490,HCPCS,59011-420-20,NDC,facility,both,2,EA,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GALANTAMINE  4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,57237-049-60,NDC,facility,both,3,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACUBITRIL-VALSARTAN 49-51 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0078-0777-20,NDC,facility,both,1,EA,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,0088-2220-33,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,0121-0657-05,NDC,facility,both,2,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,50863,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROFURANTOIN (25% MACROCRYSTAL FORM) 100 MG CAP,50863,CDM,250,RC,J3490,HCPCS,0185-0122-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,0409-1886-22,NDC,facility,both,450,ML,,233,163.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,63323-165-01,NDC,facility,both,2,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,68516-5214-6,NDC,facility,both,1,ML,,182,127.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZIPRASIDONE 40 MG CAP,50863,CDM,636,RC,J3490,HCPCS,68084-104-11,NDC,facility,both,2,EA,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J2003,HCPCS,0409-4713-32,NDC,facility,both,160,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,5,ML,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYLAMINE SUCCINATE 25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,4116700609,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZIPRASIDONE 40 MG CAP,50863,CDM,250,RC,J3490,HCPCS,68084-104-11,NDC,facility,both,2,EA,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,636,RC,J2003,HCPCS,63323-486-05,NDC,facility,both,800,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,50863,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,200,EA,,3197,2237.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM OXIDE 400 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,1000670028,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLN,50863,CDM,J3262,HCPCS,50242-137-01,NDC,,,facility,both,240,ML,,4399,3079.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE NA (PRESERV FREE) 25 MG/ML INJ SOLN,50863,CDM,250,RC,J9260,HCPCS,61703-408-41,NDC,facility,both,100,ML,,1078,754.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIKACIN 1000 MG/4 ML INJ SOLN,50863,CDM,250,RC,J0278,HCPCS,23155-290-32,NDC,facility,both,20,ML,,168,117.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN IN D5W 600 MG/50 ML IV PGBK,50863,CDM,636,RC,J0736,HCPCS,0338-3612-50,NDC,facility,both,2,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN  4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51672-4031-1,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE 2 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,50383-924-93,NDC,facility,both,1,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7057-61,NDC,facility,both,9,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOCARNITINE 200 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0143-9852-01,NDC,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,28,ML,JW,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-94,NDC,facility,both,5,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAZOLAMIDE SODIUM 500 (100 MG/ML) INJ SOLR,50863,CDM,250,RC,J1120,HCPCS,67457-853-50,NDC,facility,both,1,EA,JZ,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-0710-20,NDC,facility,both,3,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,70860-751-02,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM OXIDE 400 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,6498033990,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0121-0431-30,NDC,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES  8.6 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,71399-1017-3,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-384-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),50863,CDM,636,RC,J1815,HCPCS,0024-5926-05,NDC,facility,both,4,ML,GZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier GZ: Item or service expected to be denied as not reasonable and necessary
PATIROMER CALCIUM SORBITEX  8.4 G ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,53436-084-01,NDC,facility,both,3,EA,,443,310.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,636,RC,J3010,HCPCS,63323-806-13,NDC,facility,both,3,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,16714-293-03,NDC,facility,both,7,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,J3490,HCPCS,51754-4250-1,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTOXIFYLLINE 400 MG ORAL TBSR,50863,CDM,J3490,HCPCS,0904-5448-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,250,RC,J3101,HCPCS,50242-037-06,NDC,facility,both,22,EA,,9506,6654.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0641-6059-01,NDC,facility,both,5,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL-ROPIVACAINE-NACL (PF) 2-0.2 MCG/ML-% INJ (MERGE ERX),50863,CDM,J3490,HCPCS,61553-844-48,NDC,,,facility,both,1,ML,,385,269.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-3243-01,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUGAMMADEX 100 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0006-5423-02,NDC,facility,both,10,ML,,5882,4117.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),50863,CDM,J1630,HCPCS,63323-474-00,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-571-10,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-439-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,636,RC,J0330,HCPCS,31722-981-10,NDC,facility,both,5,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 10 MG/5 ML SYRUP,50863,CDM,250,RC,Q0177,HCPCS,54838-502-80,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,3,ML,,5203,3642.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,47335-993-01,NDC,facility,both,500,ML,,178,124.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,70095-031-01,NDC,facility,both,25,ML,,1004,702.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 5 MG/ML IV SOLN,50863,CDM,250,RC,J1921,HCPCS,0143-9623-01,NDC,facility,both,1,ML,JZ,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DOXAZOSIN 4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-862-95,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 100 MG ORAL TB12,50863,CDM,636,RC,J3490,HCPCS,51672-4123-1,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  50 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-484-11,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE (FOR EMERGENCY) 100 MG/ML (10%) IV SOLN,50863,CDM,636,RC,J0612,HCPCS,63323-360-01,NDC,facility,both,200,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN  100 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,8068107100,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  75 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6951-61,NDC,facility,both,3,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J0461,HCPCS,0517-0401-25,NDC,facility,both,40,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0955-1008-01,NDC,facility,both,8,ML,,101,70.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LYMPHOCYTE,ANTI-THYMO IMMUNE GLOBULIN 50 MG/ML IV",50863,CDM,250,RC,J7504,HCPCS,0009-7224-01,NDC,facility,both,1,ML,,13305,9313.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  15 MG ORAL TAB,50863,CDM,J3490,HCPCS,0054-4582-25,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION,50863,CDM,J3490,HCPCS,0310-7372-20,NDC,,,facility,both,2,GM,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,50863,CDM,J8540,HCPCS,0054-8175-25,NDC,,,facility,both,80,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-4264-11,NDC,facility,both,14,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL-ROPIVACAINE-NACL (PF) 2-0.2 MCG/ML-% INJ (MERGE ERX),50863,CDM,250,RC,J3490,HCPCS,70092-1259-75,NDC,facility,both,3,ML,,652,456.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARUNAVIR-COBI-EMTRI-TENOF ALA 800-150-200-10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,59676-800-30,NDC,facility,both,1,EA,,680,476,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  15 MG ORAL TBSR,50863,CDM,636,RC,J3490,HCPCS,68084-157-11,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 20MG/ML IV SYRINGE (PEDS/NEO),50863,CDM,250,RC,J0612,HCPCS,63323-311-10,NDC,facility,both,36,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,44,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  25 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6991-04,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-1638-32,NDC,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUBIPROSTONE 24 MCG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0254-3029-02,NDC,facility,both,1,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,1,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOPIDOGREL  75 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-052-10,NDC,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,0641-6145-01,NDC,facility,both,1,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,22,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN NPH & REGULAR HUMAN 100 UNIT/ML (70-30) SUBQ SUSP,50863,CDM,636,RC,J1815,HCPCS,0169-1837-11,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 400 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0143-9887-01,NDC,facility,both,4,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON DEXTRAN 50 MG/ML INJ SOLN,50863,CDM,636,RC,J1750,HCPCS,0023-6082-01,NDC,facility,both,30,ML,,3282,2297.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML IV,50863,CDM,636,RC,J3490,HCPCS,25021-319-25,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,68180-441-01,NDC,facility,both,9,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,636,RC,J3360,HCPCS,0409-1273-32,NDC,facility,both,2,ML,,198,138.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,636,RC,J2720,HCPCS,63323-229-01,NDC,facility,both,10,ML,,182,127.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,636,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,250,RC,J3490,HCPCS,63323-485-26,NDC,facility,both,300,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),50863,CDM,636,RC,J3490,HCPCS,63323-186-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE  5 MG/ML INJ SOLN,50863,CDM,J2765,HCPCS,0703-4502-01,NDC,,,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE 20 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0904-5677-61,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,50863,CDM,636,RC,J0696,HCPCS,44567-702-25,NDC,facility,both,4,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LATANOPROST 0.005 % OPHT DROP,50863,CDM,636,RC,J3490,HCPCS,70069-421-01,NDC,facility,both,1,ML,,403,282.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLPIDEM  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0093-0073-01,NDC,facility,both,2,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,636,RC,J0330,HCPCS,69374-919-10,NDC,facility,both,4,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 500 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7337-35,NDC,facility,both,40,EA,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OMEPRAZOLE-SODIUM BICARBONATE 2-84 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,62175-114-32,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,25,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 120 MG/0.8 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,0955-1012-01,NDC,facility,both,12,ML,JZ,151,105.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
INSULIN NPH & REGULAR HUMAN 100 UNIT/ML (70-30) SUBQ SUSP,50863,CDM,636,RC,J1815,HCPCS,0002-8715-01,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-466-03,NDC,facility,both,300,ML,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,636,RC,J2560,HCPCS,0641-0476-21,NDC,facility,both,2,ML,,310,217,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,250,RC,J3490,HCPCS,59310-579-20,NDC,facility,both,1,GM,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,19,ML,,32947,23062.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN DEXTROSE (ISO-OSMOTIC) 1 GRAM/50 ML IV PIGGY BACK,50863,CDM,636,RC,J0689,HCPCS,0338-3503-41,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 2 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,63323-489-27,NDC,facility,both,400,ML,,138,96.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LURASIDONE 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7355-04,NDC,facility,both,5,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG/ML INJ SOLN,50863,CDM,250,RC,J2550,HCPCS,39822-5525-2,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 5 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,36000-033-10,NDC,facility,both,2,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 2-0.5 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,0904-7009-06,NDC,facility,both,1,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG IV SOLR,50863,CDM,636,RC,J3490,HCPCS,67457-437-00,NDC,facility,both,1,EA,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FELBAMATE 600 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,65162-686-88,NDC,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-145-11,NDC,facility,both,40,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,0641-6174-01,NDC,facility,both,2,ML,"JZ,JA",30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
FILGRASTIM-SNDZ 300 MCG/0.5 ML INJ SYRG,50863,CDM,636,RC,Q5101,HCPCS,61314-318-05,NDC,facility,both,300,ML,JZ,972,680.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LAMOTRIGINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7007-61,NDC,facility,both,3,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,636,RC,J3490,HCPCS,67457-197-10,NDC,facility,both,1,ML,,368,257.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN (PF) NEO IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J1580,HCPCS,63323-513-02,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOXYBENZAMINE 10 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0054-0349-25,NDC,facility,both,1,EA,,486,340.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM ACETATE 2 MEQ/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0517-2096-25,NDC,facility,both,2,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 20 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,0228-2890-06,NDC,facility,both,3,EA,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0536-1327-06,NDC,facility,both,15,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,636,RC,J2560,HCPCS,0641-0477-21,NDC,facility,both,2,ML,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,25021-053-01,NDC,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,65862-707-80,NDC,facility,both,17,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAPAVERINE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J2440,HCPCS,54288-142-01,NDC,facility,both,1,ML,,191,133.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),50863,CDM,250,RC,J2060,HCPCS,0641-6044-01,NDC,facility,both,2,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,60687-390-11,NDC,facility,both,2,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FELBAMATE 400 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,62559-730-01,NDC,facility,both,1,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 10 GRAM/15 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,66689-038-01,NDC,facility,both,2,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCERIN (CHILD) RECTAL SUPPOSITORY,50863,CDM,250,RC,J3490,HCPCS,58980-409-25,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,105,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,16714-293-03,NDC,facility,both,14,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-645-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J2003,HCPCS,63323-492-27,NDC,facility,both,40,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-354-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-677-11,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,6,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7177-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,33,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIROFIBAN-0.9% SODIUM CHLORIDE 5 MG/100 ML (50 MCG/ML) IV SOLN,50863,CDM,636,RC,J3246,HCPCS,25208-002-03,NDC,facility,both,14,ML,JW,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CISPLATIN 1 MG/ML IV,50863,CDM,250,RC,J9060,HCPCS,0703-5748-11,NDC,facility,both,12,ML,,282,197.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,6,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,J0665,HCPCS,0409-1162-02,NDC,,,facility,both,200,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLP",50863,CDM,636,RC,P9047,HCPCS,0944-0493-04,NDC,facility,both,4,ML,JZ,1001,700.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,81033-002-30,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7452-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN IN D5W 600 MG/50 ML IV PGBK,50863,CDM,636,RC,J0736,HCPCS,0338-3612-50,NDC,facility,both,2,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES 8.8 MG/5 ML ORAL SYRP,50863,CDM,250,RC,J3490,HCPCS,71399-8237-8,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE (POLACRILEX) 2 MG BUCL GUM,50863,CDM,250,RC,J3490,HCPCS,70677-1166-1,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6950-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,1,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1940,HCPCS,23155-473-33,NDC,facility,both,13,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,63323-165-01,NDC,facility,both,4,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6426-61,NDC,facility,both,3,EA,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,31,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 100 MG ORAL CHEW,50863,CDM,636,RC,J3490,HCPCS,60687-479-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN SODIUM  2 GRAM INJ SOLR,50863,CDM,250,RC,J0290,HCPCS,55150-114-20,NDC,facility,both,8,EA,,156,109.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-1162-19,NDC,facility,both,2,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-699-11,NDC,facility,both,10,EA,,198,138.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,63323-400-01,NDC,facility,both,150,ML,JZ,158,110.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
BACLOFEN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-480-10,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR IN 0.9% NACL 100 UNIT/100 ML (1 UNIT/ML) INFUSION FOR OB,50863,CDM,250,RC,J1815,HCPCS,0338-0126-12,NDC,facility,both,2,ML,,411,287.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE 100 MG/0.5 ML SUBQ SLSY,50863,CDM,636,RC,Q9991,HCPCS,12496-0100-2,NDC,facility,both,1,ML,,4418,3092.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLP,50863,CDM,250,RC,J3480,HCPCS,63323-965-02,NDC,facility,both,20,ML,JZ,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LIDOCAINE 2 % MUCOSAL SOLN (VISCOUS),50863,CDM,250,RC,J3490,HCPCS,0121-4950-15,NDC,facility,both,1,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-03,NDC,facility,both,2,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROTHIAZIDE SODIUM 500 MG IV SOLR,50863,CDM,250,RC,J1205,HCPCS,25021-305-20,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL 100 MCG/HR TD PT72,50863,CDM,636,RC,J3490,HCPCS,47781-428-11,NDC,facility,both,2,EA,,567,396.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-811-11,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 15 MG/ML (1.5 %) INJ SOLN,50863,CDM,250,RC,J2003,HCPCS,0409-4776-10,NDC,facility,both,300,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERYTHROMYCIN 5 MG/G OPHT OINT,50863,CDM,636,RC,J3490,HCPCS,72485-670-31,NDC,facility,both,3,GM,,255,178.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 2 GRAM INJ SOLR,50863,CDM,636,RC,J0692,HCPCS,25021-122-50,NDC,facility,both,4,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LANTHANUM  500 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,54092-252-90,NDC,facility,both,1,EA,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL IV BOLUS 10MG/ML (ANESTHESIA ONLY),50863,CDM,636,RC,J2704,HCPCS,0409-4699-54,NDC,facility,both,300,ML,,380,266,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL 2 MG/ML ORAL CONCENTRATE,50863,CDM,250,RC,J3490,HCPCS,0904-7112-41,NDC,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BALANCED SALT SOLN NON-SURG #3 EYE,50863,CDM,250,RC,J3490,HCPCS,0065-0530-01,NDC,facility,both,1,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICARDIPINE 30 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,42806-502-09,NDC,facility,both,1,EA,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML IV SOLN,50863,CDM,250,RC,J3010,HCPCS,63323-806-50,NDC,facility,both,25,ML,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 50 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,59651-489-01,NDC,facility,both,25,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-580-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68382-806-01,NDC,facility,both,10,EA,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,636,RC,J2720,HCPCS,63323-229-05,NDC,facility,both,5,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GAMMAGARD LIQUID 10 % IV SOLN,50863,CDM,636,RC,J1569,HCPCS,0944-2700-07,NDC,facility,both,60,ML,JZ,10817,7571.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLN,50863,CDM,636,RC,J3262,HCPCS,50242-136-01,NDC,facility,both,200,ML,JZ,3666,2566.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,70,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VORICONAZOLE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-165-01,NDC,facility,both,2,EA,,388,271.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIPASE-PROTEASE-AMYLASE 12,000-38,000- 60,000 UNIT ORAL CAP, DELAY REL",50863,CDM,250,RC,J3490,HCPCS,0032-0047-70,NDC,facility,both,1,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSULFAN BLUE 1 % INJ SOLN,50863,CDM,636,RC,Q9968,HCPCS,67457-220-00,NDC,facility,both,10,ML,,1050,735,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 750 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-568-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COLCHICINE 0.6 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7120-04,NDC,facility,both,2,EA,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0143-9386-01,NDC,facility,both,26,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0264-1800-31,NDC,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,38,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN NPH & REGULAR HUMAN 100 UNIT/ML (70-30) SUBQ SUSP,50863,CDM,636,RC,J1815,HCPCS,0002-8715-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J2004,HCPCS,0409-3178-16,NDC,facility,both,120,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 50 MG 24 HR TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6323-61,NDC,facility,both,3,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 3 MG/ 3ML ORAL SOLUTION (PEDS),50863,CDM,250,RC,J3490,HCPCS,0054-3555-63,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESNA 100 MG/ML IV SOLN,50863,CDM,250,RC,J9209,HCPCS,10019-953-62,NDC,facility,both,4,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 0.1 MG/ML INJ SYRG,50863,CDM,250,RC,J0461,HCPCS,76329-3340-1,NDC,facility,both,50,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0143-9506-01,NDC,facility,both,2,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,25021-402-01,NDC,facility,both,20,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML IM SOLN,50863,CDM,636,RC,90375,HCPCS,13533-318-05,NDC,facility,both,4,ML,JW,1867,1306.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DEXTROSE 5%-1/4 NORMAL SALINE IV,50863,CDM,250,RC,J3490,HCPCS,0264-7616-10,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXAZOSIN 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-5522-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 150 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6956-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 0.1 % TOP OINT,50863,CDM,250,RC,68462-534-35,NDC,,,facility,both,1,GM,,769,538.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MILRINONE INFUSION PED/NEO IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J2260,HCPCS,0338-6010-48,NDC,facility,both,4,ML,,198,138.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNIT/G TOP OINT (MERGE),50863,CDM,250,RC,J3490,HCPCS,51672-2075-2,NDC,facility,both,1,GM,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0143-9509-01,NDC,facility,both,4,ML,,300,210,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 125 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,60687-211-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 5 MG/5 ML IV,50863,CDM,636,RC,J3490,HCPCS,0409-1778-15,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TERBUTALINE 1 MG/ML SUBQ SOLN,50863,CDM,250,RC,J3105,HCPCS,63323-665-00,NDC,facility,both,50,ML,,5780,4046,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CELECOXIB 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6502-61,NDC,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,12,ML,JW,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
BISACODYL  5 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,0904-6748-17,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,54,ML,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,J1596,HCPCS,0517-4601-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0075-0622-01,NDC,facility,both,2,ML,JW,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LEVETIRACETAM IN NACL (ISO-OS) 1500 MG/100 ML IV PGBK,50863,CDM,636,RC,J1953,HCPCS,36000-354-01,NDC,facility,both,150,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,J3490,HCPCS,68094-231-59,NDC,,,facility,both,6,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0591-0407-01,NDC,facility,both,4,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,50863,CDM,J0696,HCPCS,44567-701-25,NDC,,,facility,both,4,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LINEZOLID NEO IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J2020,HCPCS,0009-5140-01,NDC,facility,both,3,ML,,194,135.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE IN D5W 1 GRAM/100 ML IV PGBK,50863,CDM,J3475,HCPCS,0264-4400-54,NDC,,,facility,both,2,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 875 MG-125 MG TAB,50863,CDM,636,RC,J3490,HCPCS,65862-503-20,NDC,facility,both,1,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MICAFUNGIN 100 MG IV SOLR,50863,CDM,250,RC,J2248,HCPCS,25021-191-10,NDC,facility,both,100,EA,,808,565.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,636,RC,J3490,HCPCS,59310-579-20,NDC,facility,both,1,GM,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 5 MG-325 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0406-0123-23,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0781-3246-02,NDC,facility,both,9,ML,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 300 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,69452-125-50,NDC,facility,both,1,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-04,NDC,facility,both,4,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,45,ML,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE  2 MG/ML INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-285-23,NDC,facility,both,3,ML,,195,136.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OFLOXACIN 0.3 % OTIC DROP,50863,CDM,250,RC,J3490,HCPCS,70756-609-15,NDC,facility,both,1,ML,,567,396.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYTOCIN 10 UNIT/ML INJ SOLN,50863,CDM,250,RC,J2590,HCPCS,63323-012-11,NDC,facility,both,2,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE (PF-DURAMORPH/ASTRAMORPH) 0.5 MG/ML INJ SOLN,50863,CDM,250,RC,J2274,HCPCS,0409-3814-12,NDC,facility,both,1,ML,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,250,RC,Q9968,HCPCS,70710-1838-1,NDC,facility,both,9,ML,JW,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LACOSAMIDE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0131-2477-35,NDC,facility,both,1,EA,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,4,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TELMISARTAN 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68382-472-30,NDC,facility,both,1,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-5771-23,NDC,facility,both,7,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0143-9889-15,NDC,facility,both,8,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AGALSIDASE BETA  5 MG IV SOLR,50863,CDM,636,RC,J0180,HCPCS,58468-0041-1,NDC,facility,both,5,EA,,2148,1503.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIVASTIGMINE 4.6 MG/24 HOUR TD PT24,50863,CDM,250,RC,J3490,HCPCS,0078-0501-61,NDC,facility,both,1,EA,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,25,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ABACAVIR 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-021-11,NDC,facility,both,2,EA,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL (VITAMIN D3)   400 UNIT ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,7733394825,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETUXIMAB 100 MG/50 ML IV SOLN,50863,CDM,J9055,HCPCS,66733-958-23,NDC,,,facility,both,120,ML,,27705,19393.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0137,HCPCS,0264-4100-90,NDC,facility,both,32,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN PEDS SYRINGE (20MG/ML) IN DEXTROSE (CDS MIX,50863,CDM,250,RC,J7999,HCPCS,0781-3451-70,NDC,facility,both,6,EA,,155,108.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,50863,CDM,636,RC,J3420,HCPCS,0143-9621-01,NDC,facility,both,1,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORZOXAZONE 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0591-2520-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SINCALIDE 5 MCG INJ SOLR,50863,CDM,636,RC,J2805,HCPCS,72266-248-05,NDC,facility,both,1,EA,,307,214.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,23155-473-44,NDC,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0003-0894-31,NDC,facility,both,1,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,35573-428-51,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ (MERGE),50863,CDM,636,RC,J2250,HCPCS,0409-2305-17,NDC,facility,both,6,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE (POLACRILEX) 2 MG MM LOZG,50863,CDM,250,RC,J3490,HCPCS,45802-344-05,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0121-0914-05,NDC,facility,both,6,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHIMAZOLE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,23155-070-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LITHIUM CARBONATE 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0054-8527-25,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-544-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-205-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  25 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,69238-1310-9,NDC,facility,both,1,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROATE SODIUM 100 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0143-9785-10,NDC,facility,both,1,ML,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,1,EA,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-25,NDC,facility,both,45,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,636,RC,J3490,HCPCS,81284-611-00,NDC,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 200 MG/10 ML IRON IV SOLN,50863,CDM,636,RC,J1756,HCPCS,0517-2310-01,NDC,facility,both,200,ML,,562,393.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMTERENE  50 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,52817-364-10,NDC,facility,both,2,EA,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER SULFADIAZINE 1 % TOP CREA,50863,CDM,250,RC,J3490,HCPCS,67877-124-50,NDC,facility,both,1,GM,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,250,RC,J3490,HCPCS,63323-486-05,NDC,facility,both,1000,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VINCRISTINE 2 MG/2 ML IV SOLN,50863,CDM,250,RC,J9370,HCPCS,61703-309-06,NDC,facility,both,2,ML,,209,146.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,J1836,HCPCS,0409-0152-01,NDC,,,facility,both,25,ML,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-65,NDC,facility,both,100,ML,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHIMAZOLE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-680-11,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 875 MG-125 MG TAB,50863,CDM,250,RC,J3490,HCPCS,16714-297-02,NDC,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,50863,CDM,636,RC,J3490,HCPCS,69339-152-01,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,250,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,3,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEBIVOLOL  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,31722-586-90,NDC,facility,both,2,EA,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  1 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,64380-782-06,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,37,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 20 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7346-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,636,RC,J0330,HCPCS,69374-919-10,NDC,facility,both,3,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTAMIDINE 300 MG INJ SOLR,50863,CDM,636,RC,J3490,HCPCS,63323-113-01,NDC,facility,both,1,EA,,327,228.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-ABBS 10 MG/ML IV SOLN,50863,CDM,636,RC,Q5115,HCPCS,63459-104-50,NDC,facility,both,50,ML,JZ,11669,8168.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
EPINEPHRINE 0.15 MG/0.3 ML IM PNIJ,50863,CDM,250,RC,J0171,HCPCS,49502-101-01,NDC,facility,both,2,EA,,675,472.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 500 MG (200 MG ELEMENTAL) CHEW TAB,50863,CDM,J3490,HCPCS,66553-004-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL TBTQ,50863,CDM,250,RC,J3490,HCPCS,0245-5317-90,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-423-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0054-0235-24,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM IN NACL (ISO-OS) 500 MG/100 ML IV PGBK,50863,CDM,J1953,HCPCS,67457-255-00,NDC,,,facility,both,50,ML,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7057-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,J1885,HCPCS,63323-162-00,NDC,,,facility,both,2,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2308-21,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2308-21,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  20 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0054-0238-63,NDC,facility,both,2,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.25 % (LEFT) (PHS CUSTOM PAIN BALL),50863,CDM,636,RC,J3490,HCPCS,0409-1159-02,NDC,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG ORAL TBEC,50863,CDM,J3490,HCPCS,60687-736-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 5 % TOP OINT,50863,CDM,250,RC,J3490,HCPCS,67877-473-79,NDC,facility,both,1,GM,,890,623,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 125 MCG SUBQ SOLR,50863,CDM,636,RC,J2802,HCPCS,55513-223-01,NDC,facility,both,10,EA,JW,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
HYDROCORTISONE  1 % TOP OINT,50863,CDM,636,RC,J3490,HCPCS,0168-0020-31,NDC,facility,both,1,GM,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CELECOXIB 200 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6503-61,NDC,facility,both,1,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,0641-6145-01,NDC,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LITHIUM CARBONATE 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0054-8527-25,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE CONCENTRATE 10 MG/ 0.5 ML ORAL SYRINGE (0.5ML UD MERGE),50863,CDM,250,RC,J3490,HCPCS,68094-045-01,NDC,facility,both,3,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,17,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0780,HCPCS,23155-294-31,NDC,facility,both,1,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,0409-6102-10,NDC,facility,both,100,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,81033-002-05,NDC,facility,both,2,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-22,NDC,facility,both,3,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 600 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-5854-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,50863,CDM,636,RC,J3420,HCPCS,63323-044-00,NDC,facility,both,2,ML,JZ,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-3178-16,NDC,facility,both,400,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,613,ME,JZ,8319,5823.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LACTATED RINGERS IV (BOLUS),50863,CDM,J7120,HCPCS,0264-7750-07,NDC,,,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,J3490,HCPCS,63323-486-05,NDC,,,facility,both,400,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DORZOLAMIDE 2 % OPHT DROP,50863,CDM,250,RC,J3490,HCPCS,42571-141-26,NDC,facility,both,1,ML,,284,198.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM 1 GRAM IV SOLR,50863,CDM,250,RC,J2185,HCPCS,0781-3098-94,NDC,facility,both,10,EA,,179,125.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,636,RC,J1610,HCPCS,63323-583-13,NDC,facility,both,1,EA,JZ,991,693.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,0409-4264-11,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC IV INFUSION HYDRAT 31-60 MIN,50863,CDM,250,RC,J0248,HCPCS,61958-2901-2,NDC,facility,both,7,EA,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT  40 MCG/0.4 ML INJ SYRG,50863,CDM,636,RC,J0881,HCPCS,55513-021-01,NDC,facility,both,40,ML,,1096,767.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,3,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,0641-0477-21,NDC,facility,both,3,ML,,469,328.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
REGADENOSON 0.4 MG/5 ML IV SYRG,50863,CDM,636,RC,J2785,HCPCS,0469-6501-89,NDC,facility,both,4,ML,,913,639.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN NPH HUMAN RECOMB 100 UNIT/ML SUBQ SUSP,50863,CDM,636,RC,J1815,HCPCS,0169-1834-11,NDC,facility,both,15,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"RABIES VACCINE,HUMAN DIPLOID (PF) 2.5 UNIT IM",50863,CDM,636,RC,90675,HCPCS,49281-252-51,NDC,facility,both,1,EA,,1246,872.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VORICONAZOLE 200 MG IV SOLN,50863,CDM,250,RC,J3465,HCPCS,0781-3416-94,NDC,facility,both,51,EA,,1383,968.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-479-10,NDC,facility,both,3,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,72266-118-01,NDC,facility,both,1,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
AZTREONAM 2 GRAM INJ SOLR,50863,CDM,250,RC,J0457,HCPCS,63323-402-01,NDC,facility,both,10,EA,,146,102.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2308-21,NDC,facility,both,3,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
MELATONIN  3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,1657187290,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),50863,CDM,250,RC,J1815,HCPCS,0024-5926-05,NDC,facility,both,5,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,55,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 400 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0143-9887-01,NDC,facility,both,2,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0074-4341-90,NDC,facility,both,5,EA,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE-DEXTROSE-WATER(PF) 7.5 MG/ML (0.75 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-1761-18,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,250,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,636,RC,J3360,HCPCS,0641-6244-01,NDC,facility,both,2,ML,,145,101.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-411-10,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INCLISIRAN 284 MG/1.5 ML SUBQ SYRG,50863,CDM,J1306,HCPCS,0078-1000-60,NDC,,,facility,both,284,ML,,8970,6279,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOPERAMIDE 2 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0378-2100-01,NDC,facility,both,4,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,68382-444-05,NDC,facility,both,2,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2720-02,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,38,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MERCAPTOPURINE 50 MG ORAL TAB,50863,CDM,250,RC,J9999,HCPCS,0378-3547-52,NDC,facility,both,2,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOZAPINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0378-0860-01,NDC,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-205-01,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FILGRASTIM 300 (NEUPOGEN) MCG/ML INJ SOLN,50863,CDM,636,RC,J1442,HCPCS,55513-530-01,NDC,facility,both,300,ML,JZ,1115,780.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
METFORMIN  500 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,60687-640-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,636,RC,P9045,HCPCS,68516-5219-0,NDC,facility,both,13,ML,,3304,2312.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RALTEGRAVIR 400 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0006-0227-61,NDC,facility,both,5,EA,,719,503.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIFEDIPINE 30 MG ORAL TO24,50863,CDM,250,RC,J3490,HCPCS,68084-597-11,NDC,facility,both,3,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE NA (PRESERV FREE) 25 MG/ML INJ SOLN,50863,CDM,250,RC,J9260,HCPCS,61703-408-41,NDC,facility,both,400,ML,,4312,3018.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7367-06,NDC,facility,both,2,EA,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  30 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,0904-6558-61,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,12,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  160 MG ORAL CHEW,50863,CDM,636,RC,J3490,HCPCS,0904-6645-24,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  2.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6817-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML SUSPENSION KIT (REPACK),50863,CDM,636,RC,J3490,HCPCS,99999-805-02,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM IN NACL (ISO-OS) 1500 MG/100 ML IV PGBK,50863,CDM,250,RC,J1953,HCPCS,44567-503-01,NDC,facility,both,150,ML,JZ,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LORAZEPAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69315-904-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0630,HCPCS,24201-400-02,NDC,facility,both,1,ML,,1756,1229.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG ORAL CM12,50863,CDM,636,RC,J3490,HCPCS,60505-2806-7,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69315-905-05,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60505-0252-3,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,250,RC,J0690,HCPCS,0143-9924-90,NDC,facility,both,4,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),50863,CDM,636,RC,J2060,HCPCS,65219-368-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,13,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-686-10,NDC,facility,both,4,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE  5 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-7122-61,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 400 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,45963-557-11,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZONATATE 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7153-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE IN D5W 1 GRAM/100 ML IV PGBK,50863,CDM,250,RC,J3475,HCPCS,44567-410-24,NDC,facility,both,2,ML,PLAD,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,150,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEPROTUMUMAB-TRBW 500 MG IV SOLR,50863,CDM,636,RC,J3241,HCPCS,75987-130-15,NDC,facility,both,100,EA,,71143,49800.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE 2 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,0904-7154-04,NDC,facility,both,4,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMTERENE-HYDROCHLOROTHIAZIDE 37.5 MG-25 MG TAB,50863,CDM,250,RC,J3490,HCPCS,68084-750-95,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 40 % ORAL GEL (NEONATAL/PEDIATRIC),50863,CDM,250,RC,J3490,HCPCS,574007015,NDC,facility,both,1,GM,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,23155-833-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-01,NDC,facility,both,2,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-742-11,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,J3490,HCPCS,71288-505-02,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 20 GRAM/30 ML ORAL SOLN,50863,CDM,J3490,HCPCS,0121-1154-30,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,64980-562-01,NDC,facility,both,30,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 5 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,0143-9873-10,NDC,facility,both,2,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2310,HCPCS,0409-1215-01,NDC,facility,both,1,ML,,186,130.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 40 MG-200 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,65862-496-47,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 20 MG/ML (1 ML) IV SOLN,50863,CDM,J9171,HCPCS,0409-0367-01,NDC,,,facility,both,160,ML,,1977,1383.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,75,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,5,EA,JW,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IPRATROPIUM BROMIDE 0.03 % NASL SPRA,50863,CDM,J3490,HCPCS,0054-0045-44,NDC,,,facility,both,1,ML,,402,281.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,FAMNOCHARGE,HCPCS,0904-7127-61,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXEPIN  10 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,51079-436-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-325-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,0409-4887-24,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,16714-536-01,NDC,facility,both,6,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 50 MG TAB,50863,CDM,636,RC,Q0177,HCPCS,0904-6618-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,78206-121-01,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,636,RC,J2560,HCPCS,54288-136-01,NDC,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE HCL IN 0.9% NACL 1 MG/10 ML (100 MCG/ML) IV SYRG,50863,CDM,250,RC,J3490,HCPCS,73177-108-03,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-48,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
23.4% SODIUM CHLORIDE (4 MEQ/ML) INJECTION,50863,CDM,250,RC,J3490,HCPCS,63323-187-30,NDC,facility,both,3,ML,,128,89.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,636,RC,J2405,HCPCS,70860-776-41,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 25 MG CAP,50863,CDM,636,RC,J3490,HCPCS,1093-9955-30,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORDIAZEPOXIDE 25 MG CAP,50863,CDM,636,RC,J3490,HCPCS,51079-141-01,NDC,facility,both,3,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE 0.25 MG/2 ML INHL NBSP,50863,CDM,250,RC,J3490,HCPCS,0093-6815-19,NDC,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,250,RC,J0137,HCPCS,55150-307-01,NDC,facility,both,100,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE 0.5 MG/2 ML INHL NBSP,50863,CDM,250,RC,J3490,HCPCS,0093-6816-73,NDC,facility,both,1,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROMETHORPHAN-GUAIFENESIN SR 30 MG-600 MG 12 HR TAB,50863,CDM,636,RC,J3490,HCPCS,17856-0056-1,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,50863,CDM,J3490,HCPCS,69339-152-01,NDC,,,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-544-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,51079-051-01,NDC,facility,both,1,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,636,RC,Q0162,HCPCS,65162-691-79,NDC,facility,both,2,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOBENZAPRINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7401-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-406-03,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0131-2477-60,NDC,facility,both,4,EA,,264,184.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,636,RC,J1953,HCPCS,0409-1886-22,NDC,facility,both,195,ML,,101,70.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,636,RC,J2560,HCPCS,54288-136-01,NDC,facility,both,1,ML,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,0641-0476-21,NDC,facility,both,2,ML,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CINACALCET 30 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16729-440-10,NDC,facility,both,2,EA,,260,182,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 20 MEQ/100 ML IV PGBK,50863,CDM,250,RC,J3480,HCPCS,0338-0705-48,NDC,facility,both,10,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 100 MG 24 HR TAB,50863,CDM,636,RC,J3490,HCPCS,50268-542-11,NDC,facility,both,2,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0904-7327-62,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAPAVERINE 30 MG/ML INJ SOLN,50863,CDM,250,RC,J2440,HCPCS,0517-4002-01,NDC,facility,both,1,ML,,243,170.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,636,RC,J1953,HCPCS,63323-400-01,NDC,facility,both,450,ML,,246,172.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,2,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),50863,CDM,250,RC,J3490,HCPCS,0409-4888-10,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYTARABINE 100 MG/ML INJ SOLN,50863,CDM,250,RC,J9100,HCPCS,61703-319-22,NDC,facility,both,20,ML,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0527-3281-46,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN IN SALINE (ISO-OSMOTIC) 80 MG/100 ML IV PIGGY BACK,50863,CDM,636,RC,J1580,HCPCS,0338-0503-48,NDC,facility,both,5,ML,,133,93.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,250,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 10 GRAM/15 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,66689-038-01,NDC,facility,both,2,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,72162-1329-8,NDC,facility,both,1,ML,,152,106.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,68094-231-59,NDC,facility,both,4,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BISACODYL  5 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,0904-6748-17,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,72789-325-90,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 1 GRAM INJ SOLR,50863,CDM,636,RC,J0692,HCPCS,25021-121-20,NDC,facility,both,2,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2308-02,NDC,facility,both,250,ML,,226,158.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,156,109.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,J2003,HCPCS,0409-1323-15,NDC,,,facility,both,100,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,58,ML,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID (PORK)  60 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,42192-330-01,NDC,facility,both,2,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0536-1327-10,NDC,facility,both,2,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 10 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,250,RC,J2270,HCPCS,0409-1893-13,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,1500,ML,,4126,2888.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML ORAL SOLUTION (FOR PEDIATRIC USE),50863,CDM,250,RC,J3480,HCPCS,63323-965-05,NDC,facility,both,9,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN (NEW TX NON-NEURO INDICATION)",50863,CDM,636,RC,J1561,HCPCS,13533-800-71,NDC,facility,both,20,ML,,2829,1980.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE 30 MG TAB,50863,CDM,636,RC,J3490,HCPCS,50268-642-11,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 0.1 MG/ML INJ SYRG,50863,CDM,250,RC,J0461,HCPCS,76329-3340-1,NDC,facility,both,40,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DALBAVANCIN 500 MG IV SOLN,50863,CDM,636,RC,J0875,HCPCS,57970-100-01,NDC,facility,both,300,EA,JZ,14732,10312.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LACTATED RINGERS IV,50863,CDM,250,RC,J7120,HCPCS,0338-0117-03,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 1 MG/1 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,68094-031-59,NDC,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNIT/G TOP PACK,50863,CDM,636,RC,J3490,HCPCS,0904-7402-67,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE 25 MG/ML INJ SOLN,50863,CDM,636,RC,J3230,HCPCS,0641-1397-31,NDC,facility,both,1,ML,,170,119,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SYRG,50863,CDM,636,RC,J3490,HCPCS,8290306500,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  20 MEQ ORAL PACK,50863,CDM,636,RC,J3490,HCPCS,72888-024-06,NDC,facility,both,1,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0143-9982-50,NDC,facility,both,8,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEGASPARGASE 750 UNIT/ML INJ SOLN,50863,CDM,250,RC,J9266,HCPCS,72694-954-01,NDC,facility,both,1,ML,,42784,29948.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM ACETATE 667 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,68084-479-11,NDC,facility,both,4,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,250,RC,J3490,HCPCS,60687-653-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNIT/G TOP OINT (MERGE),50863,CDM,250,RC,J3490,HCPCS,51672-2075-2,NDC,facility,both,1,GM,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL (VITAMIN D3)   400 UNIT ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,5026886311,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J7510,HCPCS,17856-0815-1,NDC,facility,both,4,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 500 MG PE/10 ML INJ SOLN,50863,CDM,636,RC,Q2009,HCPCS,0641-6137-01,NDC,facility,both,20,ML,JZ,484,338.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6188-01,NDC,facility,both,1500,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL,50863,CDM,250,RC,J1071,HCPCS,0143-9659-01,NDC,facility,both,200,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7193-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT  60 MCG/0.3 ML INJ SYRG,50863,CDM,636,RC,J0881,HCPCS,55513-023-01,NDC,facility,both,60,ML,,1282,897.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,73,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL-ROPIVACAINE-NACL (PF) 2-0.2 MCG/ML-% INJ (MERGE ERX),50863,CDM,250,RC,J3490,HCPCS,70092-1259-75,NDC,facility,both,2,ML,,435,304.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB 100 MG IV SOLR,50863,CDM,J1745,HCPCS,57894-030-01,NDC,,,facility,both,35,EA,,11282,7897.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0378-0334-01,NDC,facility,both,14,EA,,129,90.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-078-33,NDC,facility,both,2,EA,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,72205-102-01,NDC,facility,both,4,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLIMEPIRIDE 2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-326-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,50863,CDM,636,RC,J2359,HCPCS,55150-308-01,NDC,facility,both,20,EA,,208,145.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  50 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,72205-012-90,NDC,facility,both,6,EA,,215,150.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,63323-485-26,NDC,,,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON DEXTRAN 50 MG/ML INJ SOLN,50863,CDM,250,RC,J1750,HCPCS,0023-6082-01,NDC,facility,both,40,ML,,4376,3063.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,55,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPTINEZUMAB-JJMR 100 MG/ML IV SOLN,50863,CDM,636,RC,J3032,HCPCS,67386-130-51,NDC,facility,both,300,ML,,12379,8665.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 500 MG ORAL TAB,50863,CDM,J3490,HCPCS,60687-550-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,63323-468-37,NDC,facility,both,3,ML,,214,149.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,36000-283-25,NDC,facility,both,200,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERTAPENEM 1 GRAM INJ SOLR,50863,CDM,250,RC,J1335,HCPCS,42023-221-01,NDC,facility,both,1,EA,,253,177.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,15,EA,JW,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PROMETHAZINE 25 MG ORAL TAB,50863,CDM,636,RC,Q0169,HCPCS,0904-7304-61,NDC,facility,both,6,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,40,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESNA 100 MG/ML IV SOLN,50863,CDM,250,RC,J9209,HCPCS,10019-953-62,NDC,facility,both,8,ML,,226,158.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZONATATE 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7153-61,NDC,facility,both,15,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0406-0512-23,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,250,RC,J1596,HCPCS,0143-9679-01,NDC,facility,both,6,ML,PLAD,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
MIDODRINE  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6817-06,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-444-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,70700-165-22,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,250,RC,J3490,HCPCS,0409-1323-15,NDC,facility,both,100,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-411-10,NDC,facility,both,20,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-454-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC MCARE ADMIN HEPATITIS B VACC,50863,CDM,250,RC,90744,HCPCS,58160-820-43,NDC,facility,both,1,ML,,167,116.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,50863,CDM,J8540,HCPCS,0054-8175-25,NDC,,,facility,both,48,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,40,ML,JZ,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,11,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARUNAVIR-COBI-EMTRI-TENOF ALA 800-150-200-10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,59676-800-30,NDC,facility,both,1,EA,,13019,9113.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,56,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1560-18,NDC,facility,both,200,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-04,NDC,facility,both,14,ML,,233,163.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG/ML ORAL CONC,50863,CDM,636,RC,J3490,HCPCS,0054-3553-44,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-464-11,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RASBURICASE 7.5 MG IV SOLR,50863,CDM,250,RC,J2783,HCPCS,0024-5151-75,NDC,facility,both,15,EA,,14682,10277.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM   5 MG ORAL TAB,50863,CDM,250,RC,J0640,HCPCS,50742-181-30,NDC,facility,both,1,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML (1ML) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,54288-119-01,NDC,facility,both,18,ML,,1423,996.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 50 MG/ML IV SOLN,50863,CDM,250,RC,J0282,HCPCS,70436-232-72,NDC,facility,both,5,ML,JZ,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,68094-600-59,NDC,facility,both,1,ML,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXAZOSIN 4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-5524-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,250,RC,J3101,HCPCS,50242-037-06,NDC,facility,both,26,EA,JW,5178,3624.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
"ALBUMIN, HUMAN 25 % IV SOLP",50863,CDM,636,RC,P9047,HCPCS,68516-5216-8,NDC,facility,both,4,ML,,1614,1129.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,67457-423-00,NDC,facility,both,8,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
METOPROLOL TARTRATE 5 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,0409-1778-15,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,636,RC,J1611,HCPCS,63323-596-11,NDC,facility,both,1,EA,JZ,895,626.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,250,RC,J0330,HCPCS,31722-981-10,NDC,facility,both,6,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN 500 MG SOLUTION FOR INJECTION,50863,CDM,250,RC,J0290,HCPCS,0409-3718-01,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADVATE: FACTOR VIII CONCENTRATE (MERGE RECORD),50863,CDM,636,RC,J7209,HCPCS,0944-3053-02,NDC,facility,both,3000,UN,,12558,8790.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0093-1712-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,78,ML,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE 10 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,70954-319-10,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-208-05,NDC,,,facility,both,400,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,68382-444-05,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,J2704,HCPCS,0069-0209-01,NDC,,,facility,both,42,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TORSEMIDE  20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-756-11,NDC,facility,both,3,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 1 GRAM INJ SOLR,50863,CDM,250,RC,J0692,HCPCS,0409-9566-01,NDC,facility,both,1,EA,JW,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,250,RC,J0132,HCPCS,55150-259-30,NDC,facility,both,60,ML,JZ,271,189.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68180-966-01,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 1 MG ORAL TAB,50863,CDM,636,RC,J8540,HCPCS,72578-166-01,NDC,facility,both,4,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIOTHYRONINE 25 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42794-019-12,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 10 % (100 MG/ML) MISC SOLN,50863,CDM,250,RC,J3490,HCPCS,0517-7504-01,NDC,facility,both,1,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,56,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 80 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-8301-25,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE  25 MG ORAL CAP,50863,CDM,J7515,HCPCS,0078-0240-61,NDC,,,facility,both,2,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65162-898-09,NDC,facility,both,1,EA,,157,109.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,0517-4620-25,NDC,facility,both,7,ML,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUBIPROSTONE 24 MCG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,43598-168-60,NDC,facility,both,1,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4% TOP PATCH,50863,CDM,250,RC,J3490,HCPCS,0536-1202-07,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE 100 MG TAB,50863,CDM,636,RC,J3490,HCPCS,60687-344-95,NDC,facility,both,28,EA,,314,219.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LANTHANUM  500 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,54092-252-90,NDC,facility,both,2,EA,,141,98.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,64,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,636,RC,J2003,HCPCS,0409-4277-02,NDC,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOPERAMIDE 2 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-229-11,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,82,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN PEDS SYRINGE (20MG/ML) IN DEXTROSE (CDS MIX,50863,CDM,636,RC,J0690,HCPCS,0781-3451-70,NDC,facility,both,2,EA,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,78,ML,,111,77.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-437-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-05,NDC,facility,both,15,EA,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,42,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,636,RC,J2720,HCPCS,63323-229-01,NDC,facility,both,5,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE (FOR CODE) 10% IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0517-6710-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 400 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-446-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-65,NDC,facility,both,92,ML,,162,113.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 50 MG/ML INJECTION,50863,CDM,250,RC,J1200,HCPCS,0641-0376-21,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0264-1800-36,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,0008-0923-60,NDC,facility,both,1,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,0409-2723-30,NDC,facility,both,10,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,17,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 400 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0143-9887-01,NDC,facility,both,20,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 250 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,65162-698-90,NDC,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 20 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-5785-61,NDC,facility,both,3,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE IN 0.9% NACL 3 GRAM/100 ML IV SOLN,50863,CDM,250,RC,J0612,HCPCS,61553-056-48,NDC,facility,both,450,ML,,191,133.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,60,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FINAL) IV SOLR,50863,CDM,636,RC,J9330,HCPCS,16729-221-30,NDC,facility,both,25,ML,,10988,7691.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 15 MG/ML (1.5 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-493-91,NDC,facility,both,300,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,636,RC,J2795,HCPCS,43066-023-01,NDC,facility,both,150,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLOPATADINE 0.1 % OPHT DROP,50863,CDM,250,RC,J3490,HCPCS,58602-006-40,NDC,facility,both,1,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,250,RC,J3360,HCPCS,69374-965-02,NDC,facility,both,2,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPYLTHIOURACIL 50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-964-95,NDC,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE 20 MG TAB,50863,CDM,250,RC,J3490,HCPCS,63739-963-10,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNIT/G TOP OINT (MERGE),50863,CDM,636,RC,J3490,HCPCS,1093956433,NDC,facility,both,1,GM,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML IM SOLN,50863,CDM,636,RC,90375,HCPCS,13533-318-05,NDC,facility,both,12,ML,,10377,7263.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,636,RC,J3490,HCPCS,70004-600-09,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,70069-363-01,NDC,facility,both,1,ML,,212,148.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 2 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,250,RC,J2270,HCPCS,63323-452-00,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INDOMETHACIN 50 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,50268-431-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,636,RC,J3360,HCPCS,0641-6244-01,NDC,facility,both,1,ML,JW,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,71288-402-10,NDC,facility,both,9,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 25 MG TAB,50863,CDM,250,RC,J3490,HCPCS,51079-255-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,250,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,J7510,HCPCS,17856-0815-1,NDC,,,facility,both,4,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALUM-MAG HYDROXIDE-SIMETH 200 MG-200 MG-20 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,17856-0630-1,NDC,facility,both,2,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM  3.375 GRAM IV SOLR,50863,CDM,636,RC,J2543,HCPCS,65219-436-02,NDC,facility,both,3,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 0.4 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,0071-0418-13,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0781-6041-46,NDC,facility,both,8,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6665-61,NDC,facility,both,8,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,79,ML,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,72789-325-90,NDC,facility,both,1,EA,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,72162-1329-8,NDC,facility,both,1,ML,,129,90.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IV PGBK,50863,CDM,250,RC,J3475,HCPCS,0338-1708-40,NDC,facility,both,4,ML,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM OXIDE 400 MG ORAL TAB,50863,CDM,J3490,HCPCS,1000670028,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROMETHORPHAN-GUAIFENESIN SR 30 MG-600 MG 12 HR TAB,50863,CDM,250,RC,J3490,HCPCS,6382405640,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 10% IN WATER (NEO) 2 - 3.99 KG,50863,CDM,J3490,HCPCS,0264-7520-10,NDC,,,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,8,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
VANCOMYCIN IN 0.9% SODIUM CL 1.25 GRAM/250 ML IV SOLN,50863,CDM,636,RC,J3370,HCPCS,70004-923-59,NDC,facility,both,3,ML,,189,132.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-3243-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IR SOLN,50863,CDM,636,RC,J3490,HCPCS,0338-0047-47,NDC,facility,both,1,ML,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,135,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYMETAZOLINE 0.05 % NASAL MERGE,50863,CDM,250,RC,J3490,HCPCS,0904-5711-35,NDC,facility,both,1,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,70,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,250,RC,J2720,HCPCS,63323-229-30,NDC,facility,both,22,ML,JW,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GABAPENTIN 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-580-11,NDC,facility,both,3,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIPASE-PROTEASE-AMYLASE 5,000-17,000- 24,000 UNIT ORAL CPDR",50863,CDM,250,RC,J3490,HCPCS,73562-115-01,NDC,facility,both,2,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOPAMINE INFUSION NEO IV SYRINGE (FROM PREMIX) 3200 MIG/ML,50863,CDM,250,RC,J1265,HCPCS,99999-444-03,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE 8 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,0228-3153-03,NDC,facility,both,1,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETIC ACID  2 % OTIC SOLN,50863,CDM,636,RC,J3490,HCPCS,52817-816-15,NDC,facility,both,5,ML,,864,604.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN NEO IV SYRINGE (CDS MIXTURE),50863,CDM,636,RC,J3373,HCPCS,0338-3582-01,NDC,facility,both,75,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1940,HCPCS,23155-473-32,NDC,facility,both,2,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG IV SOLR,50863,CDM,636,RC,J3490,HCPCS,0781-3232-94,NDC,facility,both,2,EA,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB 10 MG/ML IV CONC,50863,CDM,636,RC,J9312,HCPCS,50242-053-06,NDC,facility,both,50,ML,,12966,9076.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-407-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,50863,CDM,250,RC,J0640,HCPCS,71288-163-30,NDC,facility,both,4,EA,JW,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,63323-468-37,NDC,facility,both,1,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3370,HCPCS,0409-6533-11,NDC,facility,both,8,EA,,383,268.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATENOLOL  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-684-01,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,J3490,HCPCS,0409-4903-11,NDC,,,facility,both,200,ML,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL IV BOLUS 10MG/ML (ANESTHESIA ONLY),50863,CDM,636,RC,J2704,HCPCS,0409-4699-54,NDC,facility,both,7,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,636,RC,J2720,HCPCS,63323-229-01,NDC,facility,both,2,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 10 GRAM/100 ML (10%) INJ SOLN",50863,CDM,250,RC,J1561,HCPCS,13533-800-72,NDC,facility,both,40,ML,,5658,3960.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM-ALBUTEROL 0.5 MG-2.5 MG/3 ML NEB SOLUTION,50863,CDM,250,RC,J3490,HCPCS,0487-0201-01,NDC,facility,both,9,ML,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,23155-723-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 1 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,23155-317-51,NDC,facility,both,1,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTAMIDINE 300 MG INJ SOLR,50863,CDM,250,RC,J3490,HCPCS,23155-748-31,NDC,facility,both,1,EA,,136,95.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 250 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,17856-0600-1,NDC,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 100 MG/1 ML SUBQ SYRG,50863,CDM,J1650,HCPCS,0955-1010-01,NDC,,,facility,both,9,ML,,113,79.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,18,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MENINGOCOCCAL B VACC,4-CMP(PF) 50-50-50-25 MCG/0.5 ML IM SYRG",50863,CDM,250,RC,90620,HCPCS,58160-976-02,NDC,facility,both,1,ML,,839,587.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0781-3246-02,NDC,facility,both,4,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,68180-150-01,NDC,facility,both,2,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,250,RC,J0330,HCPCS,31722-981-10,NDC,facility,both,8,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7442-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIVAROXABAN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50458-579-90,NDC,facility,both,1,EA,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-444-11,NDC,facility,both,2,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69315-905-01,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-9558-05,NDC,facility,both,3,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MYCOPHENOLATE 500 MG TAB,50863,CDM,250,RC,J7517,HCPCS,51079-379-01,NDC,facility,both,2,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  30 MG ORAL TBSR,50863,CDM,636,RC,J3490,HCPCS,0904-6558-61,NDC,facility,both,2,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 2 GRAM INJ SOLR,50863,CDM,636,RC,J0692,HCPCS,60505-6147-0,NDC,facility,both,4,EA,,198,138.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J1610,HCPCS,63323-596-11,NDC,facility,both,4,EA,,3578,2504.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NAPHAZOLINE-PHENIRAMINE 0.025 %-0.3 % EYE DROPS,50863,CDM,636,RC,J3490,HCPCS,0065-0085-15,NDC,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,250,RC,J2270,HCPCS,63323-454-00,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-231-11,NDC,facility,both,6,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN PEDS IVPB (CDS MIXTURE),50863,CDM,250,RC,J3373,HCPCS,0069-2599-99,NDC,facility,both,3,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,55150-169-10,NDC,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLESTYRAMINE-SUCROSE 4 GRAM ORAL PACK,50863,CDM,250,RC,J3490,HCPCS,68382-528-60,NDC,facility,both,2,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN D5W 20000 UNIT/500 ML,50863,CDM,636,RC,J1644,HCPCS,0264-9567-10,NDC,facility,both,4,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LINEZOLID 600 MG/300 ML IV SOLP,50863,CDM,636,RC,J2020,HCPCS,55150-242-51,NDC,facility,both,3,ML,JZ,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
THIAMINE 100 MG/ML INJECTION,50863,CDM,250,RC,J3411,HCPCS,0641-6228-01,NDC,facility,both,2,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  15 MG ORAL TBSR,50863,CDM,636,RC,J3490,HCPCS,0406-8315-23,NDC,facility,both,2,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-580-11,NDC,facility,both,30,EA,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN DETEMIR 100 UNIT/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,0169-3687-12,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOLIC ACID 400 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,5026834611,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-18,NDC,facility,both,400,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEMANTINE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6505-06,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOLAZONE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-635-01,NDC,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0990-7983-61,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 50 MG 24 HR TAB,50863,CDM,636,RC,J3490,HCPCS,51079-170-01,NDC,facility,both,2,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6500-06,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,636,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-18,NDC,facility,both,90,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT 100 MCG/0.5 ML INJ SYRG,50863,CDM,250,RC,J0881,HCPCS,55513-025-01,NDC,facility,both,100,ML,,2137,1495.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-559-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,43066-007-10,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN  100 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,5026885211,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE HCL IN 5% DEXTROSE 100 MCG/10 ML (10 MCG/ML) IV SYRG,50863,CDM,250,RC,J0171,HCPCS,70092-1688-46,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2305-16,NDC,facility,both,6,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,636,RC,J1596,HCPCS,70069-011-01,NDC,facility,both,4,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7308-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J0461,HCPCS,0517-1004-01,NDC,facility,both,25,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM NEO/PED INFUSION (CDS MIXTURE),50863,CDM,250,RC,J2185,HCPCS,0781-3267-90,NDC,facility,both,2,EA,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-0710-20,NDC,facility,both,6,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,56,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,250,RC,J2720,HCPCS,63323-229-01,NDC,facility,both,5,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6322-61,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 4 MEQ/ML IV SOLP (COMPOUNDED 30ML),50863,CDM,250,RC,J3490,HCPCS,63323-093-01,NDC,facility,both,1,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,250,RC,J0330,HCPCS,31722-981-10,NDC,facility,both,8,ML,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,70069-013-25,NDC,facility,both,4,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,43598-053-11,NDC,facility,both,23,ML,,806,564.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-932-01,NDC,facility,both,2,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ (REPACK)(MERGE) (FOR PCA),50863,CDM,250,RC,J3010,HCPCS,0409-9094-41,NDC,facility,both,25,ML,,128,89.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  10 MG ORAL TR12,50863,CDM,250,RC,J3490,HCPCS,59011-410-20,NDC,facility,both,3,EA,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,68094-231-59,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROATE SODIUM 100 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-494-01,NDC,facility,both,1,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 15 MG/ML (1.5 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-493-01,NDC,,,facility,both,75,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIZATRIPTAN  5 MG ORAL TBDL,50863,CDM,636,RC,J3490,HCPCS,69452-156-74,NDC,facility,both,1,EA,,163,114.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE MONONITRATE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,5026885111,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML INJ SOLN,50863,CDM,250,RC,J0171,HCPCS,76329-9060-0,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,76045-009-96,NDC,facility,both,5,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,636,RC,J7999,HCPCS,70092-1017-46,NDC,facility,both,2,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6427-61,NDC,facility,both,1,EA,PLAD,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2308-22,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-550-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV,50863,CDM,250,RC,J7120,HCPCS,0338-0117-03,NDC,facility,both,1,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOCARNITINE 200 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0143-9852-01,NDC,facility,both,1,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN STERILE WATER 2 GRAM/20 ML IV SYRG,50863,CDM,636,RC,J0690,HCPCS,70092-1604-47,NDC,facility,both,4,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/0.5 ML INHL NEBU,50863,CDM,250,RC,J3490,HCPCS,0487-9901-30,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6085-61,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  30 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,0406-8330-23,NDC,facility,both,2,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,0409-3178-17,NDC,,,facility,both,70,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML IM SOLN,50863,CDM,90375,HCPCS,13533-318-50,NDC,,,facility,both,20,ML,,17892,12524.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 100 MG/ML INJ SOLN,50863,CDM,J2800,HCPCS,0641-6103-25,NDC,,,facility,both,1,ML,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,23155-833-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,250,RC,J2720,HCPCS,63323-229-01,NDC,facility,both,4,ML,JW,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
FINASTERIDE 5 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-6830-06,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MICAFUNGIN 100 MG IV SOLR,50863,CDM,250,RC,J2248,HCPCS,0143-9362-01,NDC,facility,both,100,EA,,245,171.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J2004,HCPCS,63323-482-03,NDC,facility,both,300,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DENOSUMAB 120 MG/1.7 ML (70 MG/ML) SUBQ SOLN,50863,CDM,J0897,HCPCS,55513-730-01,NDC,,,facility,both,120,ML,,9068,6347.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV,50863,CDM,J7120,HCPCS,0338-0117-04,NDC,,,facility,both,2,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-3178-01,NDC,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 1MG/ML IV SYRINGE (PEDS/NEO),50863,CDM,250,RC,J0360,HCPCS,99999-420-10,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 60 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,57237-019-30,NDC,facility,both,2,EA,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2599,HCPCS,43598-914-25,NDC,facility,both,19,ML,,129,90.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 2 GRAM INJ SOLR,50863,CDM,250,RC,J0692,HCPCS,0409-9735-01,NDC,facility,both,4,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 50 MG/ML INJECTION,50863,CDM,250,RC,J1200,HCPCS,25021-481-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,17271-701-05,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM IN D5W 125 MG/125 ML (1 MG/ML) IV SOLN (PREMIX),50863,CDM,250,RC,J3490,HCPCS,70004-540-35,NDC,facility,both,2,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),50863,CDM,636,RC,J3490,HCPCS,63323-186-20,NDC,facility,both,3,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 500 MG (200 MG ELEMENTAL) CHEW TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6412-92,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0781-3156-06,NDC,facility,both,35,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,636,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,3,EA,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5%/EPINEPHRINE 1:300K INJECTION,50863,CDM,636,RC,J3490,HCPCS,0409-1161-01,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-467-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN DEXTROSE (ISO-OS) 2 GRAM/100 ML IV PGBK,50863,CDM,250,RC,J0689,HCPCS,0338-3508-41,NDC,facility,both,4,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % MUCOSAL SOLN (VISCOUS),50863,CDM,636,RC,J3490,HCPCS,0121-4950-15,NDC,facility,both,1,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELIMUMAB 120 MG IV SOLR,50863,CDM,636,RC,J0490,HCPCS,49401-101-01,NDC,facility,both,24,ME,,2819,1973.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,16714-036-01,NDC,facility,both,7,ML,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML INJ SOLN,50863,CDM,636,RC,J2060,HCPCS,0409-1985-03,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,250,RC,J0131,HCPCS,0781-3156-06,NDC,facility,both,93,ML,,201,140.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRIL MALEATE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,43547-548-10,NDC,facility,both,2,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VITAMINS A & D-WHITE PETROLATUM-LANOLIN OINTMENT,50863,CDM,250,RC,J3490,HCPCS,65197-400-10,NDC,facility,both,1,GM,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE IN 0.9% NS (PF) 1 MG/10 ML (100 MCG/ML) IV SYRG(PDS MERGE),50863,CDM,250,RC,J3490,HCPCS,70092-1046-46,NDC,facility,both,100,ML,,11270,7889,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2598,HCPCS,43598-914-11,NDC,facility,both,17,ML,JW,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LACTATED RINGERS IV (BOLUS),50863,CDM,636,RC,J7120,HCPCS,0264-7750-07,NDC,facility,both,3,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,47,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0904-6923-61,NDC,facility,both,9,EA,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.45% (1/2 NS) INFUSION (PEDS ONC),50863,CDM,250,RC,J3490,HCPCS,0338-0043-04,NDC,facility,both,2,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE (FOR CODE) 10% (100 MG/ML) IV SYRINGE,50863,CDM,250,RC,J3490,HCPCS,64253-900-30,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0137,HCPCS,0143-9386-01,NDC,facility,both,50,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,49,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRBESARTAN  75 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0955-1040-90,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,0121-0657-05,NDC,facility,both,2,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,51754-5011-1,NDC,facility,both,2,ML,,108,75.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASCORBIC ACID  500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,904052361,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL  2.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,43547-351-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,51,ML,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4% TOP PATCH,50863,CDM,250,RC,J3490,HCPCS,46581-830-06,NDC,facility,both,2,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,636,RC,J3490,HCPCS,73013-2002-2,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,3,EA,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,63323-161-00,NDC,facility,both,1,ML,PLAD,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-0710-20,NDC,facility,both,5,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-25,NDC,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,71288-505-02,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  20 MEQ ORAL PACK,50863,CDM,250,RC,J3490,HCPCS,72888-024-06,NDC,facility,both,2,EA,PLAD,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
DEXAMETHASONE 4 MG ORAL TAB,50863,CDM,J8540,HCPCS,0054-8175-25,NDC,,,facility,both,64,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,76045-009-10,NDC,facility,both,25,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-492-04,NDC,,,facility,both,40,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,50863,CDM,636,RC,Q5119,HCPCS,0069-0249-01,NDC,facility,both,50,ML,,9892,6924.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J3490,HCPCS,0990-7983-61,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEPROTUMUMAB-TRBW 500 MG IV SOLR,50863,CDM,636,RC,J3241,HCPCS,75987-130-15,NDC,facility,both,1,EA,JW,594,415.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,68094-600-59,NDC,facility,both,2,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 125 MCG SUBQ SOLR,50863,CDM,636,RC,J2802,HCPCS,55513-223-01,NDC,facility,both,115,EA,,2360,1652,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 1 MG/0.5 ML INJ SOLN,50863,CDM,250,RC,J3430,HCPCS,0409-9157-31,NDC,facility,both,3,ML,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,68094-600-59,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM ACETATE 667 MG ORAL CAP,50863,CDM,250,RC,J0615,HCPCS,0904-7119-06,NDC,facility,both,58,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG TAB,50863,CDM,636,RC,J3490,HCPCS,904719106,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR PHOSPHATE 30 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,31722-630-31,NDC,facility,both,1,EA,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIFAMPIN 25MG/ML SUSPENSION (REPACK),50863,CDM,250,RC,J3490,HCPCS,0185-0799-60,NDC,facility,both,1,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IVPB (PEDIATRICS/ADULT NON-FORM)",50863,CDM,636,RC,J0131,HCPCS,24201-100-01,NDC,facility,both,100,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,63323-485-03,NDC,,,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOMYCIN-BACITRACN ZN-POLYMYXIN 3.5 MG-400 U*,50863,CDM,J3490,HCPCS,45802-143-00,NDC,,,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,636,RC,J7060,HCPCS,0338-0017-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,70095-031-01,NDC,facility,both,26,ML,,1032,722.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0093-4177-73,NDC,facility,both,3,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE (FOR CODE) 10% (100 MG/ML) IV SYRINGE,50863,CDM,250,RC,J3490,HCPCS,70121-2308-1,NDC,facility,both,2,ML,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE (PF-DURAMORPH/ASTRAMORPH) 0.5 MG/ML INJ SOLN,50863,CDM,250,RC,J2274,HCPCS,0409-3814-12,NDC,facility,both,1,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J2003,HCPCS,63323-492-27,NDC,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,13533-690-25,NDC,facility,both,1,ML,,256,179.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALUM-MAG HYDROXIDE-SIMETH 200 MG-200 MG-20 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,17856-0630-1,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,25021-662-10,NDC,facility,both,2,ML,,141,98.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7442-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,636,RC,J7060,HCPCS,0990-7923-37,NDC,facility,both,1,ML,JZ,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,250,RC,J0132,HCPCS,63323-963-21,NDC,facility,both,60,ML,,476,333.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT 100 MCG/0.5 ML INJ SYRG,50863,CDM,636,RC,J0881,HCPCS,55513-025-01,NDC,facility,both,100,ML,"JZ,EC,PLAD",2137,1495.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier EC: Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy | Modifier PLAD: Modifier description not available
CAPTOPRIL  12.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7105-61,NDC,facility,both,2,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7050,HCPCS,0338-0049-02,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  5 MG ORAL TAB,50863,CDM,J7512,HCPCS,60687-122-11,NDC,,,facility,both,15,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,69,ML,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 125 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0074-7068-11,NDC,facility,both,2,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-1638-32,NDC,facility,both,5,ML,,200,140,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0054-0017-20,NDC,facility,both,10,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE  50 MG ORAL TAB,50863,CDM,250,RC,j3490,HCPCS,60687-443-11,NDC,facility,both,7,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,51754-5001-1,NDC,facility,both,2,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7130-61,NDC,facility,both,1,EA,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-833-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL  75 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-943-01,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-453-11,NDC,facility,both,3,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,50863,CDM,250,RC,J9045,HCPCS,16729-295-12,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,67457-423-00,NDC,facility,both,2,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CEFDINIR 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,68180-723-05,NDC,facility,both,5,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,250,RC,Q9968,HCPCS,70710-1838-1,NDC,facility,both,35,ML,JW,198,138.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
HYDROCORTISONE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-582-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM PHOSPHATE 3 MMOL/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0517-7305-01,NDC,facility,both,1,ML,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"NEOMYCIN-BACITRACIN-POLYMYXIN 3.5 MG-400 UNIT-10,000 UNIT/G EYE OINT",50863,CDM,250,RC,J3490,HCPCS,24208-780-55,NDC,facility,both,1,GM,,242,169.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE IN 0.9% NS (PF) 1 MG/10 ML (100 MCG/ML) IV SYRG(PDS MERGE),50863,CDM,250,RC,J3490,HCPCS,63037-173-25,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMINOCAPROIC ACID 250 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0517-9120-01,NDC,facility,both,1,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM BICARBONATE-CITRIC ACID 25 MEQ EFFERVESCENT TAB,50863,CDM,636,RC,J3490,HCPCS,0245-5326-89,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),50863,CDM,250,RC,J1815,HCPCS,0024-5926-05,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-04,NDC,facility,both,2,ML,PLAD,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,636,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLN (MERGE)",50863,CDM,250,RC,P9047,HCPCS,64208-2512-7,NDC,facility,both,2,ML,,238,166.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,300,ML,,3733,2613.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0143-9333-01,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 100 MG/ML FROM 1 GRAM VIAL (PRMC PEDS ONLY),50863,CDM,J0696,HCPCS,0409-7332-11,NDC,,,facility,both,4,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,49502-393-80,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOPERAMIDE 2 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-229-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,40,ML,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCOSANOL 10 % TOP CREAM,50863,CDM,250,RC,J3490,HCPCS,61269-981-35,NDC,facility,both,1,GM,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,250,RC,J2720,HCPCS,63323-229-01,NDC,facility,both,13,ML,,233,163.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN 0.9% SODIUM CL 1.25 GRAM/250 ML IV SOLN,50863,CDM,636,RC,J3373,HCPCS,71285-6074-1,NDC,facility,both,125,ML,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,57237-004-30,NDC,facility,both,2,EA,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,17,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE NA (PRESERV FREE) 25 MG/ML INJ SOLN,50863,CDM,250,RC,J9260,HCPCS,61703-408-41,NDC,facility,both,20,ML,,216,151.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,67,ML,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 90 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0093-0320-01,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV (BOLUS),50863,CDM,636,RC,J7040,HCPCS,0338-0049-10,NDC,facility,both,1,ML,,168,117.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE (PF) 25 MG/ML INJ SOLN (FOR ECTOPIC PREGNANCY),50863,CDM,636,RC,J9260,HCPCS,0143-9519-01,NDC,facility,both,2,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,636,RC,J2560,HCPCS,42494-416-01,NDC,facility,both,5,ML,,1330,931,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE HCL  2 % MM JELP,50863,CDM,250,RC,J3490,HCPCS,76329-3013-5,NDC,facility,both,1,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0137,HCPCS,0143-9386-01,NDC,facility,both,27,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORDIAZEPOXIDE 25 MG CAP,50863,CDM,250,RC,J3490,HCPCS,51079-141-01,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-464-11,NDC,facility,both,3,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OBINUTUZUMAB 900 MG IN NS 286 ML (STOCK DOSE),50863,CDM,636,RC,J9301,HCPCS,50242-070-01,NDC,facility,both,100,ML,,15450,10815,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION,50863,CDM,636,RC,J3490,HCPCS,0310-7372-20,NDC,facility,both,2,GM,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,250,RC,J7999,HCPCS,70092-1017-46,NDC,facility,both,6,ML,,238,166.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRIL MALEATE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51672-4038-1,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE 150 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,68084-713-11,NDC,facility,both,1,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIFEDIPINE 10 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,23155-194-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLERGONOVINE 0.2 MG/ML (1 ML) INJ SOLN,50863,CDM,636,RC,J2210,HCPCS,0517-0740-01,NDC,facility,both,1,ML,,179,125.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,250,RC,J2003,HCPCS,63323-495-27,NDC,facility,both,50,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,71288-505-02,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE IN D5W 1 GRAM/100 ML IV PGBK,50863,CDM,250,RC,J3475,HCPCS,63323-108-00,NDC,facility,both,26,ML,,706,494.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0093-0053-01,NDC,facility,both,3,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE  10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-162-11,NDC,facility,both,1,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SECUKINUMAB  25 MG/ML IV SOLN,50863,CDM,J3247,HCPCS,0078-1168-61,NDC,,,facility,both,375,ML,,17688,12381.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE 2 MG SL SUBL,50863,CDM,636,RC,J3490,HCPCS,0904-7154-04,NDC,facility,both,3,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % MBP,50863,CDM,250,RC,J3490,HCPCS,0338-0553-18,NDC,facility,both,1,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4% TOP PATCH,50863,CDM,250,RC,J3490,HCPCS,46581-830-01,NDC,facility,both,3,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR IRRIGATION, STERILE SOLUTION",50863,CDM,250,RC,J3490,HCPCS,0338-0004-04,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROATE SODIUM 100 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-494-01,NDC,facility,both,2,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 160 MG-800 MG TAB,50863,CDM,250,RC,J3490,HCPCS,68084-230-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG SUBQ SOLR,50863,CDM,636,RC,J2802,HCPCS,55513-222-01,NDC,facility,both,200,EA,JW,1527,1068.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
MISOPROSTOL 200 MCG ORAL TAB,50863,CDM,S0191,HCPCS,60687-746-11,NDC,,,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,636,RC,J3370,HCPCS,0409-6533-11,NDC,facility,both,2,EA,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,55150-169-10,NDC,facility,both,100,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MECLIZINE 12.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-522-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM 1 GRAM IV SOLR,50863,CDM,250,RC,J2185,HCPCS,0781-3098-95,NDC,facility,both,10,EA,,179,125.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7124-61,NDC,facility,both,1,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 0.1 MG/ML INJ SYRG,50863,CDM,636,RC,J0461,HCPCS,76329-3340-1,NDC,facility,both,100,ML,JZ,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,25,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,250,RC,J2270,HCPCS,0409-1890-03,NDC,facility,both,1,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GAMMAGARD LIQUID 10 % IV SOLN,50863,CDM,636,RC,J1569,HCPCS,0944-2700-10,NDC,facility,both,10,ML,"JZ,JA",1803,1262.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
BENZOCAINE 20 % MM SPRY,50863,CDM,636,RC,J3490,HCPCS,0283-0610-43,NDC,facility,both,5,EA,,326,228.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 1 MG ORAL CAP,50863,CDM,250,RC,J7507,HCPCS,51079-818-01,NDC,facility,both,5,EA,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE DINITRATE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-569-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-979-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,57,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADVATE: FACTOR VIII CONCENTRATE (MERGE RECORD),50863,CDM,250,RC,J7192,HCPCS,0944-3047-10,NDC,facility,both,500,UN,JW,910,637,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ORAL ELECTROLYTES ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,7007411133,NDC,facility,both,10,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,250,RC,J2720,HCPCS,63323-229-01,NDC,facility,both,5,ML,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,636,RC,J3373,HCPCS,0143-9162-01,NDC,facility,both,100,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,41,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,636,RC,J3490,HCPCS,70004-600-09,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG ORAL TAB,50863,CDM,J3490,HCPCS,50268-279-11,NDC,,,facility,both,1,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYTOMEGALOVIRUS IMMUNE GLOB 50 MG/ML IV SOLN,50863,CDM,250,RC,J0850,HCPCS,49591-532-50,NDC,facility,both,12,ML,,2475,1732.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,72603-350-01,NDC,,,facility,both,40,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACUBITRIL-VALSARTAN 24-26 MG ORAL TAB,50863,CDM,J3490,HCPCS,0078-0659-20,NDC,,,facility,both,1,EA,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIOTROPIUM BROMIDE 2.5 MCG/ACTUATION INHL MIST,50863,CDM,250,RC,J3490,HCPCS,0597-0100-61,NDC,facility,both,1,GM,,1456,1019.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,31,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR PHOSPHATE 30 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,68180-675-11,NDC,facility,both,3,EA,,174,121.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,28,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELATACEPT 250 MG IV SOLR,50863,CDM,636,RC,J0485,HCPCS,0003-0371-13,NDC,facility,both,62,EA,JW,279,195.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
INSULIN LISPRO 100 UNIT/ML (PEDS CALCLUATOR 0.5),50863,CDM,J1815,HCPCS,0024-5924-10,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51672-4005-1,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J1938,HCPCS,72603-251-01,NDC,facility,both,40,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN (NEW TX NON-NEURO INDICATION)",50863,CDM,636,RC,J1561,HCPCS,13533-800-71,NDC,facility,both,20,ML,"JZ,JA",2829,1980.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
PREDNISONE 10 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-134-11,NDC,facility,both,20,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68382-806-01,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTAMIDINE 300 MG INJ SOLR,50863,CDM,636,RC,J3490,HCPCS,63323-113-01,NDC,facility,both,1,EA,,164,114.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL 20 MG/5 ML ORAL ELIX,50863,CDM,250,RC,J3490,HCPCS,0121-0942-05,NDC,facility,both,2,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,70069-363-01,NDC,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,72603-506-01,NDC,facility,both,300,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE-DEXTROSE-WATER(PF) 7.5 MG/ML (0.75 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,71351-022-10,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,636,RC,J0690,HCPCS,44567-707-25,NDC,facility,both,6,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,288,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,636,RC,J3490,HCPCS,63323-485-27,NDC,facility,both,150,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE 20 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0093-7115-98,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,250,RC,J7060,HCPCS,0338-0017-02,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 2 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,250,RC,J2270,HCPCS,76045-004-01,NDC,facility,both,1,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYCHLOROQUINE 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7046-61,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PORACTANT ALFA 240 MG/3 ML INTR SUSP,50863,CDM,250,RC,J3490,HCPCS,10122-510-03,NDC,facility,both,2,ML,,6216,4351.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-50,NDC,facility,both,47,ML,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,67457-385-10,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZONISAMIDE 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-230-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CROMOLYN 4 % OPHT DROP,50863,CDM,250,RC,J3490,HCPCS,61314-237-10,NDC,facility,both,1,ML,,182,127.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,16,ML,JW,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
HYDROXYCHLOROQUINE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7046-61,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3373,HCPCS,67457-340-01,NDC,facility,both,600,EA,,565,395.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 125 MG ORAL CPSP,50863,CDM,636,RC,J3490,HCPCS,0904-6615-61,NDC,facility,both,6,EA,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 400 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0143-9887-01,NDC,facility,both,12,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 25 MG TAB,50863,CDM,J3490,HCPCS,51079-255-01,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOPERAMIDE 2 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0378-2100-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,74,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,50863,CDM,250,RC,J0696,HCPCS,0781-3209-90,NDC,facility,both,8,EA,,388,271.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WHITE PETROLATUM-MINERAL OIL OPHT OINT (PDS MERGE),50863,CDM,250,RC,J3490,HCPCS,23066704,NDC,facility,both,1,GM,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 2.5 MG ORAL TAB,50863,CDM,J3490,HCPCS,0003-0893-31,NDC,,,facility,both,2,EA,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60505-3110-0,NDC,facility,both,3,EA,,165,115.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,50863,CDM,J3301,HCPCS,70121-1168-1,NDC,,,facility,both,4,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  25 MG ORAL TAB,50863,CDM,J3490,HCPCS,63739-673-10,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-03,NDC,facility,both,2,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML (PEDS CALCLUATOR 0.5),50863,CDM,250,RC,J1815,HCPCS,0024-5924-10,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 1 MG/ML NEEDLELESS SYRG,50863,CDM,250,RC,J2312,HCPCS,76329-3369-1,NDC,facility,both,200,ML,,194,135.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-25,NDC,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE CONCENTRATE 10 MG/ 0.5 ML ORAL SYRINGE (0.5ML UD MERGE),50863,CDM,250,RC,J3490,HCPCS,0406-8003-30,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,63323-185-10,NDC,facility,both,3,ML,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,500,ML,,991,693.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE  5 MG ORAL CP24,50863,CDM,636,RC,J3490,HCPCS,31722-185-01,NDC,facility,both,6,EA,,180,126,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6953-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIGOXIN 125 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-5921-61,NDC,facility,both,3,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,57664-596-40,NDC,facility,both,5,ML,,1634,1143.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,63323-468-37,NDC,facility,both,1,ML,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNITS/1 GRAM PACKET (MERGE RECORD),50863,CDM,J3490,HCPCS,45802-060-00,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-234-11,NDC,facility,both,2,EA,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CANDESARTAN 16 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,33342-116-07,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MULTIVIT-IRON-FA-CALCIUM &MINS 9 MG IRON-400 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,904549280,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,63739-931-28,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR PHOSPHATE 75 MG ORAL CAP,50863,CDM,J3490,HCPCS,64380-799-01,NDC,,,facility,both,1,EA,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,J3490,HCPCS,0641-6022-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,J2704,HCPCS,63323-269-22,NDC,,,facility,both,20,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHACHOLINE CHLORIDE STERILE INHALATION SOLUTION (PF) KIT,50863,CDM,J7674,HCPCS,69374-542-06,NDC,,,facility,both,1,EA,,797,557.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 128 KIT
PANTOPRAZOLE 40 MG IV SOLR,50863,CDM,J3490,HCPCS,0781-3232-94,NDC,,,facility,both,2,EA,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  100 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,0641-6175-01,NDC,facility,both,8,ML,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ROTAVIRUS VACCINE LIVE, PENTA 2 ML ORAL SUSP",50863,CDM,90680,HCPCS,0006-4047-41,NDC,,,facility,both,1,ML,,427,298.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE-ALOE VERA NASL SPRY,50863,CDM,250,RC,J3490,HCPCS,225052848,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,50863,CDM,250,RC,J0640,HCPCS,0143-9554-01,NDC,facility,both,2,EA,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN STERILE WATER 2 GRAM/20 ML IV SYRG,50863,CDM,250,RC,J0690,HCPCS,73702-132-23,NDC,facility,both,4,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,50863,CDM,636,RC,J3301,HCPCS,16714-130-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,0944-0495-06,NDC,facility,both,4,ML,JZ,832,582.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL (VITAMIN D3)   400 UNIT ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,7733394825,NDC,facility,both,13,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1815,HCPCS,0002-8215-01,NDC,facility,both,1,ML,GZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier GZ: Item or service expected to be denied as not reasonable and necessary
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,68094-147-20,NDC,facility,both,1,ML,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 150 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,0904-7084-04,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 20 MG/ML ORAL CONC,50863,CDM,250,RC,J3490,HCPCS,71093-143-11,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,63323-462-01,NDC,facility,both,2,ML,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-0710-20,NDC,facility,both,9,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0406-5771-23,NDC,facility,both,4,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PORACTANT ALFA 240 MG/3 ML INTR SUSP,50863,CDM,250,RC,J3490,HCPCS,10122-510-03,NDC,facility,both,1,ML,,3108,2175.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-11,NDC,facility,both,10,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,44,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,81,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE (FOR CODE) 10% IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0517-2710-25,NDC,facility,both,3,ML,,341,238.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,636,RC,J1596,HCPCS,0143-9682-01,NDC,facility,both,4,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1162-18,NDC,facility,both,200,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,50863,CDM,250,RC,J8540,HCPCS,0054-8175-25,NDC,facility,both,16,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN NEO IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J3373,HCPCS,0338-3582-01,NDC,facility,both,75,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE SOD SUCC (PF) 100 MG/2 ML INJ SOLR,50863,CDM,250,RC,J1720,HCPCS,0009-0011-03,NDC,facility,both,1,EA,,142,99.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE-ACETIC ACID 1 %-2 % EAR DROPS,50863,CDM,636,RC,J3490,HCPCS,51672-3007-1,NDC,facility,both,1,ML,,813,569.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-443-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2599,HCPCS,63323-930-01,NDC,facility,both,13,ML,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,42494-416-01,NDC,facility,both,7,ML,,1729,1210.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACUBITRIL-VALSARTAN 24-26 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0078-0659-61,NDC,facility,both,1,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORDIAZEPOXIDE 25 MG CAP,50863,CDM,636,RC,J3490,HCPCS,60687-807-11,NDC,facility,both,4,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-512-11,NDC,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0121-1781-05,NDC,facility,both,3,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLN (MERGE)",50863,CDM,636,RC,P9047,HCPCS,64208-2512-8,NDC,facility,both,4,ML,,475,332.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-9543-02,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM PHOSPHATE 4.4 MEQ/ML ORAL SOLUTION (CDS),50863,CDM,250,RC,J3490,HCPCS,0409-7295-11,NDC,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69315-905-05,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 500 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,16714-299-03,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,J3490,HCPCS,73013-2002-2,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 1 GRAM/20 ML IV SOLN,50863,CDM,250,RC,J9190,HCPCS,63323-117-00,NDC,facility,both,2,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-492-41,NDC,,,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 5 MG/ML INHL NEB CONTINUOUS,50863,CDM,636,RC,J3490,HCPCS,69374-330-05,NDC,facility,both,2,ML,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  1 MG/ML INJ SYRG,50863,CDM,250,RC,J1171,HCPCS,0409-1283-10,NDC,facility,both,20,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0781-6041-46,NDC,facility,both,8,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUB-Q SOLN",50863,CDM,90716,HCPCS,0006-4827-00,NDC,,,facility,both,1,EA,,465,325.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG/ML INJ SOLN,50863,CDM,J2550,HCPCS,0641-0928-21,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,J3490,HCPCS,81284-611-00,NDC,,,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 1 MG/ML (1ML) SYRINGE (REPACK),50863,CDM,250,RC,J2997,HCPCS,50242-044-13,NDC,facility,both,50,EA,,12145,8501.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,63323-185-07,NDC,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-5771-23,NDC,facility,both,18,EA,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNITS/1 GRAM PACKET (MERGE RECORD),50863,CDM,J3490,HCPCS,0904-7023-67,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,J7040,HCPCS,0338-0049-03,NDC,,,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  5 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-122-11,NDC,facility,both,30,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0264-7800-00,NDC,facility,both,2,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,50863,CDM,J2250,HCPCS,0409-2305-04,NDC,,,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3370,HCPCS,0143-9162-01,NDC,facility,both,2,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 500 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,50268-152-15,NDC,facility,both,13,EA,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 1 GRAM INJ SOLR,50863,CDM,636,RC,J0692,HCPCS,60505-6146-0,NDC,facility,both,2,EA,JZ,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
VANCOMYCIN IN 0.9% SODIUM CL 1 GRAM/250 ML IV SOLN,50863,CDM,250,RC,J3373,HCPCS,71266-5082-1,NDC,facility,both,1,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,250,RC,J3490,HCPCS,59310-579-20,NDC,facility,both,1,GM,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-464-17,NDC,facility,both,2,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE PAMOATE  25 MG ORAL CAP,50863,CDM,636,RC,Q0177,HCPCS,60687-696-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PORACTANT ALFA 240 MG/3 ML INTR SUSP,50863,CDM,250,RC,J3490,HCPCS,10122-510-03,NDC,facility,both,3,ML,,9780,6846,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-709-11,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 0.4 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,43598-436-35,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3370,HCPCS,0069-2589-03,NDC,facility,both,2,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IV PGBK,50863,CDM,636,RC,J3475,HCPCS,0409-6729-11,NDC,facility,both,4,ML,JZ,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,0409-3795-19,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 2-0.5 MG SL SUBL,50863,CDM,636,RC,J3490,HCPCS,50268-144-11,NDC,facility,both,1,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-444-01,NDC,facility,both,3,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,636,RC,J0330,HCPCS,31722-981-10,NDC,facility,both,3,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN DEGLUDEC 100 UNITS/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,73070-400-11,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,50863,CDM,250,RC,J3420,HCPCS,0143-9621-01,NDC,facility,both,1,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,636,RC,J3490,HCPCS,0173-0682-24,NDC,facility,both,1,GM,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHIMAZOLE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-680-11,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEMANTINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6505-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 5 MG/5 ML IV,50863,CDM,636,RC,J3490,HCPCS,63323-660-05,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-145-11,NDC,facility,both,60,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZOCAINE-MENTHOL 15-3.6 MG MM LOZG,50863,CDM,250,RC,J3490,HCPCS,0904-6255-49,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN DEXTROSE (ISO-OSMOTIC) 1 GRAM/50 ML IV PIGGY BACK,50863,CDM,636,RC,J0689,HCPCS,0338-3503-41,NDC,facility,both,2,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML (1ML) INJ SOLN,50863,CDM,636,RC,J0171,HCPCS,54288-119-01,NDC,facility,both,3,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,29,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,J2704,HCPCS,16714-690-01,NDC,,,facility,both,7,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),50863,CDM,J2060,HCPCS,0641-6044-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIROFIBAN-0.9% SODIUM CHLORIDE 5 MG/100 ML (50 MCG/ML) IV SOLN,50863,CDM,250,RC,J3246,HCPCS,25208-002-03,NDC,facility,both,19,ML,JW,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,19,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,250,RC,J3490,HCPCS,73013-2002-2,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-662-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-588-11,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPHENIDATE 18 MG ORAL TO24,50863,CDM,250,RC,J3490,HCPCS,62175-310-37,NDC,facility,both,3,EA,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-134-11,NDC,facility,both,30,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BECLOMETHASONE DIPROPIONATE 40 MCG/ACTUATION INHL HFAB,50863,CDM,250,RC,J3490,HCPCS,59310-302-40,NDC,facility,both,1,GM,,776,543.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,0088-2220-33,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SYRG,50863,CDM,636,RC,J3490,HCPCS,8290306547,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE 8 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,60687-492-11,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ITRACONAZOLE 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-299-95,NDC,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 30 MG TAB,50863,CDM,636,RC,J3490,HCPCS,60687-717-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,33,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-229-02,NDC,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 2 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,250,RC,J2270,HCPCS,76045-004-01,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SYRG,50863,CDM,636,RC,J3490,HCPCS,8290306553,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,250,RC,J0330,HCPCS,0409-6629-02,NDC,facility,both,3,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,2,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,69,ML,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOPAMINE INFUSION NEO IV SYRINGE (FROM PREMIX),50863,CDM,250,RC,J1265,HCPCS,0409-7809-11,NDC,facility,both,10,ML,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOPERAMIDE 2 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,51079-690-01,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 15% IN WATER,50863,CDM,250,RC,J3490,HCPCS,0338-0023-03,NDC,facility,both,1,ML,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM BICARB-CITRIC ACID 20 MEQ ORAL TBEF,50863,CDM,250,RC,J3490,HCPCS,51801-012-01,NDC,facility,both,4,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE-VITAMIN D3 250 MG-125 UNIT TAB,50863,CDM,636,RC,J3490,HCPCS,904188260,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,105,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 17 GRAM (100 %) ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,1152372688,NDC,facility,both,8,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE IN 0.9% NACL 3 GRAM/100 ML IV SOLN,50863,CDM,636,RC,J0612,HCPCS,61553-056-48,NDC,facility,both,400,ML,,170,119,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DANTROLENE  25 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0115-4411-01,NDC,facility,both,4,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN DETEMIR 100 UNIT/ML SUBQ SOLN,50863,CDM,636,RC,J1815,HCPCS,0169-3687-12,NDC,facility,both,17,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),50863,CDM,250,RC,J2060,HCPCS,0641-6044-01,NDC,facility,both,2,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACIDOPHILUS-PECTIN W CITRUS 25 MILLION-100 CELL MG TAB,50863,CDM,250,RC,J3490,HCPCS,1785614241,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,61,EA,,8418,5892.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,42806-150-33,NDC,facility,both,7,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,250,RC,J3490,HCPCS,63323-486-05,NDC,facility,both,45,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ABATACEPT 250 MG IV SOLR,50863,CDM,J0129,HCPCS,0003-2187-13,NDC,,,facility,both,75,EA,,12110,8477,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,50863,CDM,250,RC,J9075,HCPCS,10019-956-16,NDC,facility,both,181,EA,JW,513,359.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0143-9982-50,NDC,facility,both,10,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM PHOSPHATE 4.4 MEQ/ML ORAL SOLUTION (CDS),50863,CDM,250,RC,J3490,HCPCS,0409-7295-11,NDC,facility,both,1,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,68094-600-59,NDC,facility,both,3,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2308-22,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,636,RC,J3490,HCPCS,63323-486-02,NDC,facility,both,200,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-492-04,NDC,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICARDIPINE IN NACL (ISO-OS) 20 MG/200 ML IV PGBK,50863,CDM,636,RC,J3490,HCPCS,10122-313-01,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE  3 % INHL NEBU,50863,CDM,250,RC,J3490,HCPCS,378699789,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELATACEPT 250 MG IV SOLR,50863,CDM,636,RC,J0485,HCPCS,0003-0371-13,NDC,facility,both,100,EA,JW,449,314.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,68516-5219-0,NDC,facility,both,18,ML,,4575,3202.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,250,RC,J3490,HCPCS,61553-320-70,NDC,facility,both,2,ML,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-21,NDC,facility,both,10,ML,,1415,990.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0143-9509-01,NDC,facility,both,2,ML,,150,105,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0548-5604-00,NDC,facility,both,16,ML,,141,98.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-406-03,NDC,facility,both,1,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE ENEMA 200G IN SW (1000 ML TOTAL VOLUME),50863,CDM,250,RC,J3490,HCPCS,99999-0405-41,NDC,facility,both,1,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,250,RC,J0690,HCPCS,70092-1017-46,NDC,facility,both,44,ML,,870,609,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML INJ SOLN,50863,CDM,250,RC,J2060,HCPCS,0641-6207-01,NDC,facility,both,2,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAMADOL  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7179-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,636,RC,J1953,HCPCS,63323-400-01,NDC,facility,both,25,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PROGESTERONE MICRONIZED 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,69452-233-20,NDC,facility,both,2,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,250,RC,J7060,HCPCS,0338-0017-03,NDC,facility,both,2,ML,JZ,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
FOLIC ACID 400 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,8068109900,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6926-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NYSTATIN  100000 UNIT/G TOP CREA,50863,CDM,250,RC,J3490,HCPCS,0603-7818-74,NDC,facility,both,1,GM,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN   1.25 G IV SOLR,50863,CDM,250,RC,J3370,HCPCS,67457-823-12,NDC,facility,both,1,EA,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1560-18,NDC,facility,both,100,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN NEO IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J3373,HCPCS,0338-3582-01,NDC,facility,both,2,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,50863,CDM,636,RC,J8540,HCPCS,0904-7266-61,NDC,facility,both,192,EA,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-070-10,NDC,facility,both,1,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 4 MEQ/ML IV SOLP (COMPOUNDED 30ML),50863,CDM,250,RC,J3490,HCPCS,63323-093-01,NDC,facility,both,2,ML,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMOSOZUMAB-AQQG 210MG/2.34ML ( 105MG/1.17MLX2) SUBQ SYRG,50863,CDM,636,RC,J3111,HCPCS,55513-880-02,NDC,facility,both,210,ML,JZ,5894,4125.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PREGABALIN  25 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,69238-1310-9,NDC,facility,both,1,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 50 MG TAB,50863,CDM,250,RC,J3490,HCPCS,51079-801-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J1940,HCPCS,23155-473-32,NDC,facility,both,4,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,55390-138-01,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOPAMINE INFUSION NEO IV SYRINGE (FROM PREMIX),50863,CDM,250,RC,J1265,HCPCS,0338-1007-02,NDC,facility,both,10,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),50863,CDM,636,RC,J1815,HCPCS,0024-5926-05,NDC,facility,both,1,ML,GZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier GZ: Item or service expected to be denied as not reasonable and necessary
LACTATED RINGERS IV (BOLUS),50863,CDM,250,RC,J7120,HCPCS,0264-7750-07,NDC,facility,both,2,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,J2250,HCPCS,0409-2308-21,NDC,,,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,0409-4276-16,NDC,,,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 112 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0074-9296-19,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE (FOR CODE) 10% (100 MG/ML) IV SYRINGE,50863,CDM,250,RC,J3490,HCPCS,76329-3304-1,NDC,facility,both,2,ML,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,600,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISONIAZID 50 MG/5 ML ORAL SYRP,50863,CDM,250,RC,J3490,HCPCS,46287-009-01,NDC,facility,both,1,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,50863,CDM,Q0177,HCPCS,0904-6617-61,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,250,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,50863,CDM,J1756,HCPCS,0517-2340-01,NDC,,,facility,both,200,ML,,642,449.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 5 MG/5 ML IV,50863,CDM,636,RC,J3490,HCPCS,63323-660-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR 200 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,31722-681-47,NDC,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,68382-444-05,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  20 MEQ ORAL PACK,50863,CDM,J3490,HCPCS,72888-024-06,NDC,,,facility,both,1,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE HCL 5 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,68094-676-59,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN PEDS SYRINGE (20MG/ML) IN DEXTROSE (CDS MIX,50863,CDM,250,RC,J0690,HCPCS,0781-3451-70,NDC,facility,both,12,EA,,250,175,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE (CONTRACEPTIVE) 150 MG/ML IM (MERGE),50863,CDM,J1050,HCPCS,67457-887-00,NDC,,,facility,both,150,ML,,202,141.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 875 MG-125 MG TAB,50863,CDM,636,RC,J3490,HCPCS,16714-297-02,NDC,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,250,RC,J2003,HCPCS,63323-495-09,NDC,facility,both,40,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM 500 MG IV SOLR,50863,CDM,636,RC,J2185,HCPCS,63323-507-01,NDC,facility,both,5,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,55150-165-05,NDC,facility,both,100,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,4,EA,,149,104.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RACEPINEPHRINE 2.25 % INHL NEBU,50863,CDM,J3490,HCPCS,0487-2784-01,NDC,,,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML (ANESTHESIA INTRAOP ONLY),50863,CDM,636,RC,J3010,HCPCS,0641-6027-01,NDC,facility,both,2,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAZOLAMIDE SODIUM 500 (100 MG/ML) INJ SOLR,50863,CDM,636,RC,J1120,HCPCS,0143-9503-01,NDC,facility,both,1,EA,JZ,224,156.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,21,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACUBITRIL-VALSARTAN 24-26 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0078-0659-67,NDC,facility,both,2,EA,,138,96.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC IV INFUSION HYDRAT 31-60 MIN,50863,CDM,250,RC,J0248,HCPCS,61958-2901-2,NDC,facility,both,30,EA,JW,156,109.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
AZITHROMYCIN 500 MG IV SOLR,50863,CDM,636,RC,J0456,HCPCS,63323-398-01,NDC,facility,both,1,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 10%-1/2 NORMAL SALINE IV,50863,CDM,250,RC,J3490,HCPCS,0264-7622-00,NDC,facility,both,1,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FERROUS SULFATE 75 MG/ML (ELEMENTAL IRON 15 MG/ML) ORAL DROP,50863,CDM,250,RC,J3490,HCPCS,5483801150,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG/ML INJ SOLN,50863,CDM,250,RC,J2550,HCPCS,0641-6208-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENTOLAMINE 5 MG INJ SOLR,50863,CDM,636,RC,J3490,HCPCS,0143-9564-01,NDC,facility,both,1,EA,JZ,739,517.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ATORVASTATIN 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6290-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,72266-118-01,NDC,facility,both,1,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,76045-009-01,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,70710-1833-1,NDC,facility,both,1,EA,,307,214.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MYCOPHENOLATE 500 MG TAB,50863,CDM,250,RC,J7517,HCPCS,0054-0166-25,NDC,facility,both,4,EA,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,5026885511,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,50863,CDM,J3490,HCPCS,17856-0823-10,NDC,,,facility,both,2,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN STERILE WATER 2 GRAM/20 ML IV SYRG,50863,CDM,J7999,HCPCS,73702-132-23,NDC,,,facility,both,1,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,250,RC,J3101,HCPCS,50242-037-06,NDC,facility,both,36,EA,JW,6764,4734.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,636,RC,J1836,HCPCS,25021-131-82,NDC,facility,both,50,ML,JZ,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,51754-4250-1,NDC,facility,both,2,ML,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,50863,CDM,250,RC,J0561,HCPCS,60793-700-01,NDC,facility,both,6,ML,,837,585.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 20 MG ORAL TAB,50863,CDM,636,RC,J0500,HCPCS,0904-6988-61,NDC,facility,both,1,EA,JZ,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,70069-363-01,NDC,facility,both,1,ML,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HUMAN PROTHROMBIN COMPLEX 500 UNIT IV SOLR,50863,CDM,636,RC,J7168,HCPCS,63833-396-01,NDC,facility,both,2000,UN,JZ,11638,8146.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CALASPARGASE PEGOL-MKNL 750 UNITS/ML IV SOLN,50863,CDM,250,RC,J9118,HCPCS,72694-515-01,NDC,facility,both,375,ML,,75551,52885.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,63323-485-26,NDC,,,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-208-01,NDC,,,facility,both,200,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0781-3220-70,NDC,facility,both,2,ML,,370,259,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE (FOR CODE) 10% IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0517-6710-01,NDC,facility,both,600,ML,,71179,49825.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOSTIGMINE METHYLSULFATE 1 MG/ML IV SOLN,50863,CDM,636,RC,J2710,HCPCS,70069-806-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,48,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRBESARTAN  75 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,31722-729-30,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-242-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-592-11,NDC,facility,both,2,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 800 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,17856-921-01,NDC,facility,both,4,EA,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0228-2127-10,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,250,RC,J2003,HCPCS,63323-485-27,NDC,facility,both,150,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXAZOSIN 4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-224-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,0591-5443-01,NDC,facility,both,40,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,250,RC,J3490,HCPCS,72485-510-01,NDC,facility,both,1,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OBINUTUZUMAB 900 MG IN NS 286 ML (STOCK DOSE),50863,CDM,250,RC,J9301,HCPCS,50242-070-01,NDC,facility,both,100,ML,,15450,10815,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLN (MERGE)",50863,CDM,250,RC,P9047,HCPCS,64208-2512-7,NDC,facility,both,4,ML,,475,332.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16729-137-00,NDC,facility,both,3,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,250,RC,J3490,HCPCS,71449-069-11,NDC,facility,both,2,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,0121-4675-05,NDC,facility,both,2,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2308-21,NDC,facility,both,4,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,J1885,HCPCS,68462-756-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,J3490,HCPCS,0409-1638-32,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIHYDROERGOTAMINE 1 MG/ML INJ SOLN,50863,CDM,250,RC,J1110,HCPCS,0143-9273-01,NDC,facility,both,1,ML,,646,452.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 125 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,62756-796-88,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,4,ML,,128,89.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN NPH & REGULAR HUMAN 100 UNIT/ML (70-30) SUBQ SUSP,50863,CDM,250,RC,J1815,HCPCS,0002-8715-01,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 5 MG/ML IV SOLN,50863,CDM,250,RC,J1921,HCPCS,36000-322-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-25,NDC,facility,both,40,ML,"JZ,JA",5658,3960.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
SILDENAFIL 2.5 MG/ML SUSPENSION,50863,CDM,250,RC,J3490,HCPCS,99999-0404-75,NDC,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-50,NDC,facility,both,6,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
RIVASTIGMINE 3 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,33342-090-09,NDC,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHOTERICIN B LIPOSOME 50 MG IV SUSR,50863,CDM,250,RC,J0289,HCPCS,0469-3051-30,NDC,facility,both,15,EA,,3381,2366.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENEFIX: FIX CONCENTRATE (MERGE RECORD),50863,CDM,250,RC,J7195,HCPCS,58394-633-03,NDC,facility,both,2750,UN,,13305,9313.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4% TOP PATCH,50863,CDM,250,RC,J3490,HCPCS,46581-830-01,NDC,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 500 MG-125 MG TAB,50863,CDM,636,RC,J3490,HCPCS,42571-161-01,NDC,facility,both,1,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN SODIUM EXTENDED 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-841-11,NDC,facility,both,4,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,25021-701-01,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN D5W 1 GRAM/200 ML IV PGBK,50863,CDM,250,RC,J3373,HCPCS,0338-3552-48,NDC,facility,both,2,ML,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,3,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,636,RC,J3490,HCPCS,66553-002-01,NDC,facility,both,4,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEMAZEPAM  7.5 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,68084-549-11,NDC,facility,both,4,EA,,164,114.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-753-11,NDC,facility,both,2,EA,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 30% IN WATER (NEO),50863,CDM,250,RC,J7070,HCPCS,0409-6648-16,NDC,facility,both,4,ML,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ICATIBANT 30 MG/3 ML SUBQ SYRG,50863,CDM,636,RC,J1744,HCPCS,54092-702-02,NDC,facility,both,30,ML,,30768,21537.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-ABDA 100 MG IV SOLR,50863,CDM,Q5104,HCPCS,78206-162-99,NDC,,,facility,both,6,EA,,543,380.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LINEZOLID 600 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,67877-419-20,NDC,facility,both,1,EA,,662,463.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,72611-722-25,NDC,facility,both,4,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MESALAMINE 1000 MG RECT SUPP,50863,CDM,250,RC,J3490,HCPCS,58914-501-56,NDC,facility,both,1,EA,,228,159.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J2312,HCPCS,0409-1215-01,NDC,facility,both,40,ML,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0169-1833-11,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE IV INFUSION (PULMONARY EMBOLISM) 100 MG (2 X 50 MG VIALS),50863,CDM,250,RC,J2997,HCPCS,99999-0402-55,NDC,facility,both,200,ML,,48578,34004.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-18,NDC,facility,both,1,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,J3490,HCPCS,0093-4155-73,NDC,,,facility,both,12,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,3,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM & SODIUM PHOSPHATES 280-160-250 MG ORAL PWPK,50863,CDM,636,RC,J3490,HCPCS,6025800615,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,4,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-633-11,NDC,facility,both,1,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,71399-1025-3,NDC,facility,both,3,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0002-4115-30,NDC,facility,both,2,EA,,185,129.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,94,ML,JW,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,71399-1025-3,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,636,RC,J3490,HCPCS,71266-9080-2,NDC,facility,both,2,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOXYBENZAMINE 10 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,66993-066-02,NDC,facility,both,2,EA,,764,534.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,250,RC,J3490,HCPCS,63037-136-25,NDC,facility,both,2,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,J2704,HCPCS,16714-528-01,NDC,,,facility,both,3,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,J0132,HCPCS,70594-111-01,NDC,,,facility,both,109,ML,,555,388.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 10 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,63323-516-10,NDC,facility,both,100,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOVASTATIN 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68180-468-01,NDC,facility,both,4,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 10 MG/ML (PF) IV SOLN,50863,CDM,250,RC,J2270,HCPCS,0641-6127-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALUM-MAG HYDROXIDE-SIMETH 200 MG-200 MG-20 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0121-1761-30,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,62584-994-11,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL  1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-734-01,NDC,facility,both,6,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN NPH HUMAN RECOMB 100 UNIT/ML SUBQ SUSP,50863,CDM,250,RC,J1815,HCPCS,0169-1834-11,NDC,facility,both,7,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLP",50863,CDM,250,RC,P9047,HCPCS,0944-0493-04,NDC,facility,both,2,ML,,501,350.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,50863,CDM,250,RC,J9041,HCPCS,10019-991-01,NDC,facility,both,8,EA,JW,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
SODIUM CHLORIDE 0.9 % MBP,50863,CDM,250,RC,J3490,HCPCS,0338-0553-18,NDC,facility,both,2,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN DEGLUDEC 100 UNITS/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,73070-400-11,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  25 MG ORAL TAB,50863,CDM,J3490,HCPCS,68084-180-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0406-5771-23,NDC,facility,both,11,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,0641-6147-01,NDC,facility,both,1,ML,PLAD,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-11,NDC,facility,both,1,ML,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-495-27,NDC,facility,both,320,ML,,156,109.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ELECTROLYTE-A IV,50863,CDM,250,RC,J3490,HCPCS,0338-0221-03,NDC,facility,both,1,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 20 MG/ML INJ SOLN,50863,CDM,636,RC,J0360,HCPCS,0641-6231-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-2051-15,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLN (MERGE)",50863,CDM,P9047,HCPCS,64208-2512-7,NDC,,,facility,both,1,ML,,119,83.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNIT/G TOP PACK,50863,CDM,636,RC,J3490,HCPCS,0904-7402-67,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM  3.375 GRAM IV SOLR,50863,CDM,J2543,HCPCS,55150-120-30,NDC,,,facility,both,3,EA,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,24689-907-01,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE SODIUM 25 MG/ML INJ SOLN,50863,CDM,636,RC,J9260,HCPCS,61703-350-37,NDC,facility,both,1,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,636,RC,J1596,HCPCS,0143-9679-01,NDC,facility,both,3,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE IN 0.9% NS (PF) 1 MG/10 ML (100 MCG/ML) IV SYRG(PDS MERGE),50863,CDM,250,RC,J3490,HCPCS,71449-001-15,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),50863,CDM,636,RC,J1815,HCPCS,0024-5926-05,NDC,facility,both,5,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN LIPOSOMAL 2 MG/ML IV INJ,50863,CDM,250,RC,Q2050,HCPCS,70710-1531-1,NDC,facility,both,10,ML,,9361,6552.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG/ML INJ SOLN,50863,CDM,250,RC,J2550,HCPCS,0641-0928-21,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE IN D5W 1 GRAM/100 ML IV PGBK,50863,CDM,636,RC,J3475,HCPCS,44567-410-24,NDC,facility,both,4,ML,JZ,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"DICLOFENAC 50 MG TAB, DELAYED RELEASE",50863,CDM,250,RC,J3490,HCPCS,16571-202-10,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,68180-723-05,NDC,facility,both,9,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT 200 MCG/0.4 ML INJ SYRG,50863,CDM,250,RC,J0881,HCPCS,55513-028-01,NDC,facility,both,200,ML,,4273,2991.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG ORAL TAB,50863,CDM,J3490,HCPCS,60687-595-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ROTAVIRUS VACCINE, LIVE, 89-12 10EXP6 CCID50 /1.5 ML ORAL SUSP",50863,CDM,90681,HCPCS,58160-740-02,NDC,,,facility,both,1,ML,,635,444.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG ORAL CAP,50863,CDM,J3490,HCPCS,0093-3145-01,NDC,,,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,62584-994-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-03,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7351-04,NDC,facility,both,2,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,0143-9511-01,NDC,facility,both,15,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,636,RC,J2270,HCPCS,0409-1891-03,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,60687-145-11,NDC,facility,both,60,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIPHTH,PERTUS(ACELL),TETANUS SYRG(BOOSTRIX) 2.5-8-5 LF-MCG-LF/0.5ML IM SYRG",50863,CDM,636,RC,90715,HCPCS,58160-842-43,NDC,facility,both,1,ML,,247,172.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,636,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7350-06,NDC,facility,both,2,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,250,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,7,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 400 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,69097-815-07,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN SODIUM EXTENDED 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,65862-692-01,NDC,facility,both,4,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,J3490,HCPCS,0536-1327-06,NDC,,,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,4,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,636,RC,J0330,HCPCS,31722-981-10,NDC,facility,both,7,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 10 GRAM IV SOLR,50863,CDM,250,RC,J3370,HCPCS,70436-023-82,NDC,facility,both,4,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,250,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-464-02,NDC,facility,both,1,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE  50 MG ORAL CAP,50863,CDM,250,RC,J8530,HCPCS,62332-619-31,NDC,facility,both,18,EA,,535,374.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-208-01,NDC,facility,both,500,ML,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-815-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE IN D5W 1 GRAM/100 ML IV PGBK,50863,CDM,250,RC,J3475,HCPCS,0264-4400-54,NDC,facility,both,2,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE IN D5W 1 GRAM/100 ML IV PGBK,50863,CDM,250,RC,J3475,HCPCS,0409-6727-55,NDC,facility,both,2,ML,JZ,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
HYDRALAZINE 20 MG/ML INJ SOLN,50863,CDM,636,RC,J0360,HCPCS,55150-400-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,63323-161-00,NDC,facility,both,2,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-03,NDC,facility,both,2,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE INFUSION 2MG/ML 100ML (FOR ANESTHESIA USE ONLY),50863,CDM,250,RC,J3490,HCPCS,0409-2051-05,NDC,facility,both,1,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 800 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-5855-60,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-492-27,NDC,,,facility,both,280,ML,,220,154,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,2,EA,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,60219-1708-1,NDC,facility,both,60,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,70095-026-01,NDC,facility,both,1,ML,JW,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,63323-161-00,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE-DEXTROSE-WATER(PF) 7.5 MG/ML (0.75 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,71351-022-10,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BACITRACIN ZINC-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM OINTMENT",50863,CDM,250,RC,J3490,HCPCS,58980-012-05,NDC,facility,both,1,GM,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-453-11,NDC,facility,both,6,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,636,RC,J1596,HCPCS,70069-013-25,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-65,NDC,facility,both,200,ML,,353,247.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PORACTANT ALFA 240 MG/3 ML INTR SUSP,50863,CDM,250,RC,J3490,HCPCS,10122-510-01,NDC,facility,both,1,ML,,1654,1157.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-088-11,NDC,facility,both,1,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,636,RC,J1610,HCPCS,0597-0053-45,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-18,NDC,facility,both,200,ML,JZ,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LABETALOL 5 MG/ML IV SOLN,50863,CDM,250,RC,J1921,HCPCS,0409-2267-20,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-0905-05,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,51079-169-01,NDC,facility,both,1,EA,PLAD,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,50863,CDM,250,RC,J3301,HCPCS,70121-1168-1,NDC,facility,both,40,ML,,442,309.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,500,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,25,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,1,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CEPHALEXIN 500 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,50268-152-15,NDC,facility,both,9,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-450-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 10 GRAM/15 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,50383-779-30,NDC,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6641-61,NDC,facility,both,2,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-02,NDC,facility,both,2,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,0409-4713-32,NDC,,,facility,both,60,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,63323-185-09,NDC,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"OCTREOTIDE,MICROSPHERES 20 MG IM SERR",50863,CDM,636,RC,J2353,HCPCS,0078-0818-81,NDC,facility,both,20,EA,JZ,12741,8918.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-22,NDC,facility,both,520,ML,,1038,726.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,0548-5604-00,NDC,facility,both,3,ML,JW,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
NOREPINEPHRINE BITARTRATE-NACL 4 MG/250 ML (16 MCG/ML) IV SOLN (CENTRAL ONLY),50863,CDM,250,RC,J3490,HCPCS,44567-640-01,NDC,facility,both,1,ML,,218,152.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,6,ML,,101,70.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,54288-137-01,NDC,facility,both,4,ML,,840,588,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,636,RC,J1939,HCPCS,65219-570-01,NDC,facility,both,2,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,636,RC,J3010,HCPCS,0409-9094-22,NDC,facility,both,4,ML,JZ,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
FLUCONAZOLE 200 MG/100 ML IVPB (MERGE),50863,CDM,250,RC,J1450,HCPCS,0409-3435-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN ASP PRT-INSULIN ASPART 100 UNIT/ML (70-30) SUBQ SOLN,50863,CDM,250,RC,J1817,HCPCS,73070-200-11,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,4,EA,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,250,RC,J0690,HCPCS,60505-6142-0,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,50863,CDM,636,RC,J0696,HCPCS,0781-3208-85,NDC,facility,both,4,EA,JZ,225,157.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,636,RC,J3010,HCPCS,0409-9093-32,NDC,facility,both,1,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LUBIPROSTONE  8 MCG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0254-3028-02,NDC,facility,both,3,EA,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE SODIUM 2.5 MG ORAL TAB,50863,CDM,250,RC,J8610,HCPCS,51079-670-01,NDC,facility,both,4,EA,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,250,RC,J2003,HCPCS,63323-491-01,NDC,facility,both,100,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,4,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM NEO/PED INFUSION (CDS MIXTURE),50863,CDM,250,RC,J2185,HCPCS,0781-3267-90,NDC,facility,both,20,EA,,1493,1045.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 20 MG ORAL CPDR,50863,CDM,636,RC,J3490,HCPCS,0904-7043-04,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6636-61,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPSONE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,64980-567-03,NDC,facility,both,2,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL IV BOLUS 10MG/ML (ANESTHESIA ONLY),50863,CDM,636,RC,J2704,HCPCS,0409-4699-54,NDC,facility,both,97,ML,JW,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
VANCOMYCIN  500 MG IV SOLR,50863,CDM,250,RC,J3370,HCPCS,0143-9161-01,NDC,facility,both,2,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-1638-32,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FERROUS SULFATE 75 MG/ML (ELEMENTAL IRON 15 MG/ML) ORAL DROP,50863,CDM,636,RC,J3490,HCPCS,6961807059,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE  1 % TOP OINT,50863,CDM,250,RC,J3490,HCPCS,49348-522-72,NDC,facility,both,1,GM,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,68094-600-59,NDC,facility,both,5,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,55150-165-05,NDC,facility,both,100,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0093-2279-73,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1815,HCPCS,0002-8215-01,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 2-0.5 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,0054-0188-13,NDC,facility,both,2,EA,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAZOSIN 1 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7020-61,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6638-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,636,RC,J3010,HCPCS,0409-9094-22,NDC,facility,both,3,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,68094-494-59,NDC,facility,both,1,ML,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,7,ML,JW,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6322-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,60687-429-45,NDC,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETHAMBUTOL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68180-280-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ESMOLOL IN SALINE (ISO-OSMOTIC) 2,500 MG/250 ML (10 MG/ML) IV",50863,CDM,636,RC,J1805,HCPCS,67457-657-25,NDC,facility,both,1,ML,,1161,812.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,0409-3795-19,NDC,facility,both,1,ML,JW,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
BIVALIRUDIN 250 MG IV SOLR,50863,CDM,250,RC,J0583,HCPCS,63323-562-10,NDC,facility,both,250,EA,,627,438.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,J7030,HCPCS,0338-0049-04,NDC,,,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLECAINIDE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-0010-20,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2305-04,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INDOMETHACIN 50 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,50268-431-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,35,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN NPH & REGULAR HUMAN 100 UNIT/ML (70-30) SUBQ SUSP,50863,CDM,250,RC,J1815,HCPCS,0002-8715-01,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2310,HCPCS,36000-308-01,NDC,facility,both,1,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,250,RC,J3490,HCPCS,71449-069-11,NDC,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNIT/G TOP PACK,50863,CDM,250,RC,J3490,HCPCS,45802-060-70,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,76045-009-01,NDC,facility,both,10,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J2003,HCPCS,63323-492-02,NDC,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0121-1781-05,NDC,facility,both,3,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE-DEXTROSE-WATER(PF) 7.5 MG/ML (0.75 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-1761-18,NDC,facility,both,1,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),50863,CDM,636,RC,J1815,HCPCS,0024-5926-05,NDC,facility,both,5,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,50863,CDM,250,RC,J9000,HCPCS,0069-1542-20,NDC,facility,both,2,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-1283-03,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-02,NDC,facility,both,4,ML,,204,142.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,50863,CDM,636,RC,J3420,HCPCS,69680-112-01,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 300 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,68084-252-11,NDC,facility,both,1,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT 25 MCG/0.42 ML INJ SYRG,50863,CDM,250,RC,J0881,HCPCS,55513-057-01,NDC,facility,both,25,ML,EC,836,585.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier EC: Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy
ADENOSINE 3000 MCG/ML INJECTION,50863,CDM,636,RC,J0153,HCPCS,67457-855-00,NDC,facility,both,12,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM OXIDE 400 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,6498033990,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM PHOSPHATE 3 MMOL/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-7391-82,NDC,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLP",50863,CDM,636,RC,P9047,HCPCS,44206-251-10,NDC,facility,both,1,ML,,389,272.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  5 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,59746-306-12,NDC,facility,both,2,EA,,140,98,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0228-3004-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 7.5 MG-325 MG/15 ML ORAL SOLN (REPACK),50863,CDM,250,RC,J3490,HCPCS,0121-2316-15,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERGOCALCIFEROL (VITAMIN D2) 50000 UNIT ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,64380-737-06,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7030,HCPCS,0338-0049-04,NDC,facility,both,3,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 40 % ORAL GEL,50863,CDM,250,RC,J3490,HCPCS,574006915,NDC,facility,both,1,GM,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLP,50863,CDM,250,RC,J3480,HCPCS,63323-965-03,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   2 G INJ SOLR,50863,CDM,636,RC,J0690,HCPCS,0143-9139-01,NDC,facility,both,4,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,250,RC,J3490,HCPCS,71266-9080-2,NDC,facility,both,2,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,J0133,HCPCS,65219-622-02,NDC,,,facility,both,180,ML,,163,114.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 16 MG ORAL TAB,50863,CDM,250,RC,J7509,HCPCS,59762-0050-1,NDC,facility,both,12,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL 10MG/1ML SUSPENSION (REPACK),50863,CDM,250,RC,J3490,HCPCS,57664-167-52,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,250,RC,J2795,HCPCS,70069-064-25,NDC,facility,both,120,ML,JW,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PHENYLEPHRINE IN 0.9% NS (PF) 1 MG/10 ML (100 MCG/ML) IV SYRG(PDS MERGE),50863,CDM,250,RC,J3490,HCPCS,71449-001-15,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,26,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SYRG,50863,CDM,636,RC,J3490,HCPCS,8290306553,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,68094-147-01,NDC,facility,both,2,ML,,12746,8922.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  500 MG IV SOLR,50863,CDM,250,RC,J3370,HCPCS,67457-339-50,NDC,facility,both,1,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LINACLOTIDE  72 MCG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0456-1203-30,NDC,facility,both,2,EA,,223,156.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,J3010,HCPCS,0409-9094-22,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,50863,CDM,Q0177,HCPCS,23155-501-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,636,RC,J1815,HCPCS,0088-2220-33,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0121-1781-05,NDC,facility,both,2,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,636,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,6,ML,GZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier GZ: Item or service expected to be denied as not reasonable and necessary
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",50863,CDM,J1561,HCPCS,13533-800-41,NDC,,,facility,both,80,ML,,11316,7921.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,636,RC,J0690,HCPCS,25021-101-10,NDC,facility,both,4,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,65219-186-01,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN   81 MG ORAL TBEC,50863,CDM,J3490,HCPCS,63739-212-02,NDC,,,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-444-01,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,250,RC,J0690,HCPCS,63323-237-10,NDC,facility,both,6,EA,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  2.5 MG ORAL TAB,50863,CDM,250,RC,J7510,HCPCS,59651-485-01,NDC,facility,both,40,EA,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,636,RC,J2795,HCPCS,70069-064-25,NDC,facility,both,75,ML,JW,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
BUSPIRONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7121-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE (FOR CODE) 10% IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0517-2710-25,NDC,facility,both,2,ML,,68040,47628,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) IV SOLN,50863,CDM,J9201,HCPCS,0409-0183-01,NDC,,,facility,both,3,ML,,165,115.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM IN NACL (ISO-OS) 1000 MG/100 ML IV PGBK,50863,CDM,250,RC,J1953,HCPCS,67457-265-00,NDC,facility,both,200,ML,,253,177.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,0409-3795-19,NDC,facility,both,2,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,49502-393-80,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-327-10,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,2,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 20 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7346-61,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,30,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,30,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,125,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APREPITANT  80 MG ORAL CAP,50863,CDM,636,RC,J8501,HCPCS,68462-584-40,NDC,facility,both,16,EA,,734,513.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,21,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,250,RC,J2003,HCPCS,63323-485-26,NDC,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,70069-011-01,NDC,facility,both,4,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
UBLITUXIMAB-XIIY 25 MG/ML IV SOLN,50863,CDM,636,RC,J2329,HCPCS,73150-150-06,NDC,facility,both,150,ML,,28905,20233.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0039-05,NDC,facility,both,14,EA,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 400 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0143-9887-01,NDC,facility,both,8,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"HUMAN PAPILLOMAV VAC,9-VAL(PF) 0.5 ML IM SYRG",50863,CDM,90651,HCPCS,0006-4121-01,NDC,,,facility,both,1,ML,,1089,762.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 1 MG ORAL CAP,50863,CDM,636,RC,J7507,HCPCS,54288-135-01,NDC,facility,both,2,EA,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MISOPROSTOL 25 MCG ORAL TAB,50863,CDM,250,RC,S0191,HCPCS,59762-5007-1,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZONATATE 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,68084-214-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 100 MG/5 ML ORAL LIQD,50863,CDM,250,RC,J3490,HCPCS,0121-1488-10,NDC,facility,both,3,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,250,RC,J2795,HCPCS,43066-023-01,NDC,facility,both,150,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,10135-679-01,NDC,facility,both,1,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),50863,CDM,250,RC,J1630,HCPCS,67457-426-00,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,100,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
"HUMAN PAPILLOMAV VAC,9-VAL(PF) 0.5 ML IM INJ MERGE (CAM USE ONLY)",50863,CDM,90651,HCPCS,0006-4121-02,NDC,,,facility,both,1,ML,,1089,762.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOMYCIN-BACITRACN ZN-POLYMYXIN 3.5 MG-400 U*,50863,CDM,636,RC,J3490,HCPCS,0904-8805-67,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,540,ML,,775,542.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1162-18,NDC,facility,both,28,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION,50863,CDM,250,RC,J3490,HCPCS,0310-7372-20,NDC,facility,both,2,GM,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-333-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 100 MG/ML INJ SOLN,50863,CDM,250,RC,J2800,HCPCS,70069-101-01,NDC,facility,both,1,ML,,101,70.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2599,HCPCS,55150-370-01,NDC,facility,both,20,ML,,382,267.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,30,EA,,4140,2898,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZTREONAM 1 GRAM INJ SOLR,50863,CDM,250,RC,J0457,HCPCS,63323-401-01,NDC,facility,both,10,EA,,212,148.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUORESCEIN 1 MG OPHT STRP,50863,CDM,250,RC,J3490,HCPCS,17238-900-99,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J3490,HCPCS,0338-0049-38,NDC,facility,both,1,ML,JZ,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),50863,CDM,250,RC,J3490,HCPCS,0409-4888-02,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J2004,HCPCS,0409-3178-16,NDC,facility,both,200,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-439-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV,50863,CDM,636,RC,J7120,HCPCS,0338-0117-03,NDC,facility,both,2,ML,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV (BOLUS),50863,CDM,250,RC,J7120,HCPCS,0264-7750-10,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,19,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB 100 MG IV SOLR,50863,CDM,636,RC,J1745,HCPCS,57894-030-01,NDC,facility,both,48,EA,,15472,10830.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE 20 MG TAB,50863,CDM,636,RC,J3490,HCPCS,63739-963-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL  20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-717-11,NDC,facility,both,2,EA,,162,113.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESNA 100 MG/ML IV SOLN,50863,CDM,250,RC,J9209,HCPCS,0338-1305-01,NDC,facility,both,8,ML,,293,205.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTAZIDIME-AVIBACTAM 2.5 GRAM (2 GRAM-0.5 GRAM) IV SOLR,50863,CDM,250,RC,J0714,HCPCS,0456-2700-10,NDC,facility,both,2,EA,JW,250,175,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
METOPROLOL TARTRATE 25 MG TAB,50863,CDM,250,RC,J3490,HCPCS,51079-255-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LANTHANUM  500 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,54092-252-90,NDC,facility,both,3,EA,,212,148.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69315-117-01,NDC,facility,both,1,EA,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",50863,CDM,250,RC,J1561,HCPCS,13533-800-25,NDC,facility,both,40,ML,,5658,3960.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,25,ML,JZ,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
BACLOFEN 25 MG/5 ML (5 MG/ML) ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,62559-204-12,NDC,facility,both,1,ML,,143,100.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  10 MG ORAL TR12,50863,CDM,636,RC,J3490,HCPCS,59011-410-20,NDC,facility,both,2,EA,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,250,RC,J3490,HCPCS,59310-579-20,NDC,facility,both,1,GM,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOCARNITINE 200 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0143-9852-01,NDC,facility,both,2,ML,,245,171.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,250,RC,J3490,HCPCS,25021-415-10,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 20MG/ML IV SYRINGE (PEDS/NEO),50863,CDM,250,RC,J0612,HCPCS,63323-311-10,NDC,facility,both,24,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOPAMINE INFUSION NEO IV SYRINGE (FROM PREMIX),50863,CDM,250,RC,J1265,HCPCS,0409-7809-11,NDC,facility,both,10,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0121-0914-05,NDC,facility,both,6,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR PHOSPHATE 30 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0004-0802-85,NDC,facility,both,1,EA,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 20 GRAM/500 ML IV SOLP,50863,CDM,250,RC,J3475,HCPCS,63323-106-15,NDC,facility,both,40,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOLAZONE  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0185-5050-01,NDC,facility,both,2,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J3490,HCPCS,0338-0049-01,NDC,facility,both,4,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 20 GRAM/30 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-1154-30,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,150,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,250,RC,J0137,HCPCS,0264-4100-90,NDC,facility,both,6,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL  32.4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6575-61,NDC,facility,both,5,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRETINOIN (CHEMOTHERAPY) 10 MG ORAL CAP,50863,CDM,250,RC,J9999,HCPCS,68084-075-11,NDC,facility,both,5,EA,,546,382.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE DINITRATE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6620-61,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAVASTATIN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-458-01,NDC,facility,both,2,EA,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAUNORUBICIN 5 MG/ML IV INJ,50863,CDM,250,RC,J9150,HCPCS,42658-021-01,NDC,facility,both,6,ML,,1551,1085.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,50863,CDM,250,RC,Q0177,HCPCS,63739-486-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN DETEMIR 100 UNIT/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,0169-3687-12,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MYCOPHENOLATE 250 MG CAP,50863,CDM,250,RC,J7517,HCPCS,0904-7074-61,NDC,facility,both,4,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOPIDOGREL 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-184-11,NDC,facility,both,1,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR IRRIGATION, STERILE SOLUTION",50863,CDM,636,RC,J3490,HCPCS,0338-0004-04,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 10 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-6798-61,NDC,,,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 500 MG/10 ML IV SOLN,50863,CDM,J9190,HCPCS,63323-117-61,NDC,,,facility,both,10,ML,,173,121.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN 0.9 % SODIUM CHL 1.5 GRAM/500 ML IV SOLN,50863,CDM,250,RC,J3370,HCPCS,72196-6176-1,NDC,facility,both,3,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROPROCAINE 3 % INJ SOLN,50863,CDM,250,RC,J2401,HCPCS,63323-478-01,NDC,facility,both,49,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0245-0212-89,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUGAMMADEX 100 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0006-5423-02,NDC,facility,both,3,ML,,1765,1235.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPOTECAN 4 MG/4 ML (1 MG/ML) IV SOLN,50863,CDM,636,RC,J9351,HCPCS,0409-0302-01,NDC,facility,both,40,ML,,353,247.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOVASTATIN 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68180-468-07,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,89,EA,,12282,8597.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2599,HCPCS,43598-914-25,NDC,facility,both,5,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,0075-0622-01,NDC,facility,both,1,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
AMPICILLIN SODIUM  2 GRAM INJ SOLR,50863,CDM,636,RC,J0290,HCPCS,55150-114-20,NDC,facility,both,4,EA,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BRIMONIDINE 0.2 % OPHT DROP,50863,CDM,250,RC,J3490,HCPCS,61314-143-05,NDC,facility,both,1,ML,,160,112,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4% TOP PATCH,50863,CDM,250,RC,J3490,HCPCS,46581-830-01,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,74,ML,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2599,HCPCS,43598-914-25,NDC,facility,both,4,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML IV,50863,CDM,250,RC,J3490,HCPCS,0641-6013-01,NDC,facility,both,2,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,250,RC,J2003,HCPCS,0409-1323-15,NDC,facility,both,200,ML,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0406-0552-23,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,0781-3246-02,NDC,facility,both,2,ML,JW,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
NICARDIPINE 25 MG/10 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,72485-116-01,NDC,facility,both,1,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,63323-482-27,NDC,,,facility,both,200,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-1712-01,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,121119030,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RAMUCIRUMAB 10 MG/ML IV SOLN,50863,CDM,J9308,HCPCS,0002-7669-01,NDC,,,facility,both,76,ML,,11241,7868.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 200 MG INJ SOLR,50863,CDM,250,RC,J0640,HCPCS,63323-710-50,NDC,facility,both,4,EA,,136,95.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPLERENONE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51991-877-33,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITRIOL 0.5 MCG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,69452-208-20,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 3 % IV INFUSION,50863,CDM,250,RC,J3490,HCPCS,0338-0054-03,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCRALFATE 100 MG/ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0121-0974-10,NDC,facility,both,2,ML,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),50863,CDM,636,RC,J0171,HCPCS,76329-3318-1,NDC,facility,both,40,ML,,294,205.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INDIGOTINDISULFONATE SODIUM 8 MG/ML INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,17478-508-01,NDC,facility,both,1,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 875 MG-125 MG TAB,50863,CDM,636,RC,J3490,HCPCS,65862-503-01,NDC,facility,both,10,EA,,243,170.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 875 MG-125 MG TAB,50863,CDM,J3490,HCPCS,16714-297-01,NDC,,,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,68180-723-04,NDC,facility,both,3,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-0430-06,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,64,ML,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,127,ML,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,250,RC,Q9968,HCPCS,70710-1838-1,NDC,facility,both,15,ML,,249,174.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MOXIFLOXACIN 400 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7407-06,NDC,facility,both,1,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J3430,HCPCS,69097-708-31,NDC,facility,both,10,ML,,218,152.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 10 MG/ML ORAL SOLUTION (REPACK),50863,CDM,250,RC,J3490,HCPCS,0131-5410-71,NDC,facility,both,3,ML,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  750 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65862-247-08,NDC,facility,both,2,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  88 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6952-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTAROLINE FOSAMIL 400 MG IV SOLR,50863,CDM,250,RC,J0712,HCPCS,0456-0400-01,NDC,facility,both,40,EA,,912,638.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-573-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,0641-0400-12,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,250,RC,J3101,HCPCS,50242-037-06,NDC,facility,both,24,EA,,10993,7695.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,68094-231-59,NDC,facility,both,5,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,72603-179-01,NDC,facility,both,5,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACIDOPHILUS-PECTIN W CITRUS 25 MILLION-100 CELL MG TAB,50863,CDM,250,RC,J3490,HCPCS,536142401,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,18,ML,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE IN 0.9% NS (PF) 1 MG/10 ML (100 MCG/ML) IV SYRG(PDS MERGE),50863,CDM,636,RC,J3490,HCPCS,71019-263-20,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-31,NDC,facility,both,1,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CYCLOSPORINE MODIFIED  25 MG ORAL CAP,50863,CDM,250,RC,J7515,HCPCS,0093-9018-19,NDC,facility,both,3,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,J2003,HCPCS,55150-255-20,NDC,,,facility,both,300,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM NEO/PEDS (CDS MIXTURE),50863,CDM,J0295,HCPCS,63323-368-20,NDC,,,facility,both,2,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,J2003,HCPCS,63323-486-02,NDC,,,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPRAZOLAM 0.5 MG ORAL TAB,50863,CDM,J3490,HCPCS,60687-388-11,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-50,NDC,facility,both,5,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,67,ML,JW,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
METHYLERGONOVINE 0.2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,69238-1605-8,NDC,facility,both,1,EA,,285,199.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  75 MG ORAL CP24,50863,CDM,636,RC,J3490,HCPCS,0904-7077-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,13668-088-30,NDC,facility,both,1,EA,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PYRIDOSTIGMINE BROMIDE  60 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0115-3511-01,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69315-904-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,411,ME,JZ,5578,3904.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SPIRONOLACTONE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-545-10,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,9,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,3,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,7,ML,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IVPB (PEDIATRICS/ADULT NON-FORM)",50863,CDM,J0137,HCPCS,63323-434-41,NDC,,,facility,both,100,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  60 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69292-536-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOBETASOL PROPIONATE 0.05 % TOP CREA,50863,CDM,636,RC,J3490,HCPCS,45802-129-35,NDC,facility,both,4,GM,,571,399.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,J2704,HCPCS,25021-608-20,NDC,,,facility,both,20,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,J7510,HCPCS,17856-0815-1,NDC,,,facility,both,6,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,J3490,HCPCS,0093-2279-73,NDC,,,facility,both,5,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,J1171,HCPCS,76045-009-96,NDC,,,facility,both,4,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-48,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUPHENAZINE 5 MG TAB,50863,CDM,250,RC,J3490,HCPCS,50268-368-11,NDC,facility,both,2,EA,,126,88.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML (PEDS CALCLUATOR 0.5),50863,CDM,250,RC,J1815,HCPCS,0024-5924-10,NDC,facility,both,10,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0143-9889-01,NDC,facility,both,14,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,636,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,2,EA,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  75 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-495-11,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,70860-700-41,NDC,facility,both,1,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,25021-602-03,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL  1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-734-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,636,RC,P9045,HCPCS,68516-5219-0,NDC,facility,both,2,ML,JZ,796,557.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,636,RC,J3490,HCPCS,0904-6930-61,NDC,facility,both,4,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,63739-903-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-4264-11,NDC,facility,both,10,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60505-3110-0,NDC,facility,both,1,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16729-156-15,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0780,HCPCS,0713-0351-02,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 10 MG/ML IM SOLN,50863,CDM,250,RC,J0500,HCPCS,58914-080-52,NDC,facility,both,1,ML,,364,254.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-161-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POSACONAZOLE 100 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,0527-2133-35,NDC,facility,both,2,EA,,533,373.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NYSTATIN  100000 UNIT/G TOP CREA,50863,CDM,250,RC,J3490,HCPCS,51672-1289-1,NDC,facility,both,1,GM,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,63323-468-37,NDC,facility,both,1,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,3,ML,,492,344.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPLERENONE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-451-11,NDC,facility,both,2,EA,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-01,NDC,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-406-03,NDC,facility,both,1,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  75 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6951-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,3,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG/ML INJ SOLN,50863,CDM,636,RC,J2550,HCPCS,0641-0928-21,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2310,HCPCS,36000-308-01,NDC,facility,both,2,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6926-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-1283-03,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM NEO/PEDS INFUSION (CDS MIXTURE),50863,CDM,250,RC,J2543,HCPCS,0206-8852-08,NDC,facility,both,2,EA,,262,183.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-893-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV (BOLUS),50863,CDM,250,RC,J7120,HCPCS,0264-7750-00,NDC,facility,both,2,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML IV SOLN (MERGE),50863,CDM,636,RC,J3490,HCPCS,70756-611-82,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN-CODEINE 300 MG-15 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0093-0050-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,636,RC,J2597,HCPCS,65219-293-00,NDC,facility,both,1,ML,JW,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),50863,CDM,636,RC,J2060,HCPCS,0641-6044-01,NDC,facility,both,3,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,36000-283-25,NDC,facility,both,40,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,0143-9577-01,NDC,,,facility,both,65,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,14,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-467-01,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  7.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,43598-165-30,NDC,facility,both,3,EA,,236,165.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 50 MG/5 ML (10 MG/ML) IV SYRG,50863,CDM,250,RC,J3490,HCPCS,71449-004-11,NDC,facility,both,2,ML,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-0430-06,NDC,facility,both,4,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 10 MEQ/100 ML IV PGBK (USE NON-PROTOCOL PANEL),50863,CDM,250,RC,J3480,HCPCS,0338-0709-48,NDC,facility,both,15,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-25,NDC,facility,both,55,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE (FOR EMERGENCY) 100 MG/ML (10%) IV SOLN,50863,CDM,250,RC,J0612,HCPCS,0143-9180-01,NDC,facility,both,200,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  5 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-122-11,NDC,facility,both,5,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  88 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42292-038-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEMAZEPAM  7.5 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,68084-549-11,NDC,facility,both,3,EA,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,63323-806-12,NDC,facility,both,2,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42858-301-25,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,71399-1025-3,NDC,facility,both,3,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYMETAZOLINE 0.05 % NASL SPRA,50863,CDM,636,RC,J3490,HCPCS,4110081123,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,7,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,2,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRP (MERGE/REPACK),50863,CDM,636,RC,J3490,HCPCS,68094-764-59,NDC,facility,both,1,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J1611,HCPCS,0597-0053-45,NDC,facility,both,1,EA,,371,259.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-3178-16,NDC,facility,both,200,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID (PORK) 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0456-0457-01,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MECLIZINE 12.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-775-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,125,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,5,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL 20 MG/5 ML ORAL ELIX,50863,CDM,250,RC,J3490,HCPCS,0121-0942-05,NDC,facility,both,3,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,4,ML,,6416,4491.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,120,ML,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,250,RC,J1596,HCPCS,0143-9679-01,NDC,facility,both,6,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3373,HCPCS,67457-340-01,NDC,facility,both,150,EA,,142,99.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,0703-9514-01,NDC,facility,both,2,ML,,148,103.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-337-11,NDC,facility,both,2,EA,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 12.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-7295-01,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 12.5 MG ORAL TAB,50863,CDM,636,RC,Q0169,HCPCS,60687-660-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-411-10,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRP (MERGE/REPACK),50863,CDM,636,RC,J3490,HCPCS,60687-576-40,NDC,facility,both,2,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COLCHICINE 0.6 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,59651-455-01,NDC,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 150 MG CAP,50863,CDM,636,RC,J3490,HCPCS,68084-243-11,NDC,facility,both,3,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-ABDA 100 MG IV SOLR,50863,CDM,636,RC,Q5104,HCPCS,0006-4305-01,NDC,facility,both,3,EA,JW,272,190.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0781-6041-46,NDC,facility,both,7,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0143-9595-01,NDC,facility,both,100,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TALQUETAMAB-TGVS 40 MG/ML SUBQ SOLN,50863,CDM,250,RC,J3055,HCPCS,57894-470-01,NDC,facility,both,103,ML,,18300,12810,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,636,RC,J3490,HCPCS,71449-069-11,NDC,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J2003,HCPCS,63323-492-41,NDC,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 112 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-508-11,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4% TOP PATCH,50863,CDM,J3490,HCPCS,46581-830-01,NDC,,,facility,both,2,EA,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,50863,CDM,Q5119,HCPCS,0069-0238-01,NDC,,,facility,both,20,ML,,3957,2769.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,50863,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,135,ML,,163,114.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 500 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,68084-415-11,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIFAXIMIN 550 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65649-303-03,NDC,facility,both,1,EA,,294,205.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL DECANOATE  50 MG/ML IM SOLN,50863,CDM,250,RC,J1631,HCPCS,10147-0921-3,NDC,facility,both,3,ML,,380,266,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6949-61,NDC,facility,both,4,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG/ML INJ SOLN,50863,CDM,636,RC,J2550,HCPCS,0641-6084-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),50863,CDM,636,RC,J1815,HCPCS,0024-5926-05,NDC,facility,both,60,ML,,231,161.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,636,RC,P9045,HCPCS,68516-5219-0,NDC,facility,both,1,ML,JW,111,77.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
FAMOTIDINE 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-645-10,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,636,RC,J3010,HCPCS,0409-9094-22,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM NEO/PED INFUSION (CDS MIXTURE),50863,CDM,250,RC,J2185,HCPCS,0781-3267-90,NDC,facility,both,1,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 5 MG/ML IV SOLN,50863,CDM,250,RC,J1921,HCPCS,17478-420-20,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  20 MEQ ORAL PACK,50863,CDM,250,RC,J3490,HCPCS,72888-024-06,NDC,facility,both,3,EA,,150,105,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,50863,CDM,636,RC,J1756,HCPCS,0517-2325-01,NDC,facility,both,38,ML,,141,98.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,62584-994-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE (FOR EMERGENCY) 100 MG/ML (10%) IV SOLN,50863,CDM,636,RC,J0612,HCPCS,63323-360-01,NDC,facility,both,100,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,16714-026-01,NDC,facility,both,1,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,0641-6008-01,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J7510,HCPCS,17856-0815-1,NDC,facility,both,6,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CABERGOLINE 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50742-118-08,NDC,facility,both,1,EA,,180,126,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLIMEPIRIDE 2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-326-11,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-4279-16,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROPROCAINE 3 % INJ SOLN,50863,CDM,250,RC,J2401,HCPCS,63323-478-01,NDC,facility,both,564,ML,JW,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,63323-325-20,NDC,facility,both,200,ML,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  5 GRAM IV SOLR,50863,CDM,250,RC,J3373,HCPCS,63323-295-61,NDC,facility,both,100,EA,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42291-468-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 50 MG TAB,50863,CDM,250,RC,Q0177,HCPCS,68084-255-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-492-26,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,636,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51672-4035-1,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-8299-25,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,57237-077-10,NDC,facility,both,1,EA,PLAD,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
ROPINIROLE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,10135-679-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6500-06,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 500 MG (200 MG ELEMENTAL) CHEW TAB,50863,CDM,636,RC,J3490,HCPCS,68084-988-33,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,250,RC,J2270,HCPCS,0409-1890-03,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,60687-755-40,NDC,facility,both,4,ML,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPYLTHIOURACIL 50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,67253-651-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-050-01,NDC,facility,both,1,EA,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLEDRONIC ACID IN MANNITOL & WATER 5 MG/100 ML IV SOLN,50863,CDM,636,RC,J3489,HCPCS,25021-830-82,NDC,facility,both,5,ML,JZ,1239,867.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
BENZONATATE 100 MG ORAL CAP,50863,CDM,J3490,HCPCS,68084-214-11,NDC,,,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,J3490,HCPCS,0409-9558-05,NDC,,,facility,both,2,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUGAMMADEX 100 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0006-5423-02,NDC,facility,both,1,ML,,56014,39209.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7912-51,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,250,RC,J3490,HCPCS,71449-068-11,NDC,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL 400 UNIT/ML ORAL DROP (REPACK),50863,CDM,636,RC,J3490,HCPCS,87086644,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR PHOSPHATE 30 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,72205-042-11,NDC,facility,both,1,EA,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 20MG/ML IV SYRINGE (PEDS/NEO),50863,CDM,250,RC,J0612,HCPCS,63323-311-10,NDC,facility,both,65,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7350-06,NDC,facility,both,12,EA,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,636,RC,J3490,HCPCS,0173-0682-20,NDC,facility,both,1,GM,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  20 MG ORAL TR12,50863,CDM,250,RC,J3490,HCPCS,59011-420-20,NDC,facility,both,3,EA,,180,126,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,636,RC,J0690,HCPCS,44567-707-25,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,636,RC,J3490,HCPCS,0409-4887-17,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0904-7127-61,NDC,facility,both,200,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IV PGBK,50863,CDM,250,RC,J3475,HCPCS,0264-4204-52,NDC,facility,both,14,ML,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 40 MG ORAL TAB,50863,CDM,J3490,HCPCS,60687-210-11,NDC,,,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,11,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,250,RC,J3490,HCPCS,71266-9080-4,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,P9045,HCPCS,68516-5219-0,NDC,,,facility,both,12,ML,,3050,2135,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-ABDA 100 MG IV SOLR,50863,CDM,636,RC,Q5104,HCPCS,78206-162-99,NDC,facility,both,20,EA,JZ,4159,2911.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ABOBOTULINUMTOXINA 300 UNITS IM SOLR,50863,CDM,636,RC,J3490,HCPCS,15054-0530-6,NDC,facility,both,3,EA,,3793,2655.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIKACIN 1000 MG/4 ML INJ SOLN,50863,CDM,250,RC,J0278,HCPCS,23155-290-32,NDC,facility,both,10,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARSENIC TRIOXIDE 10 MG/10 ML IV SOLN,50863,CDM,J9017,HCPCS,69918-720-01,NDC,,,facility,both,16,ML,,1175,822.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,J3490,HCPCS,0143-9889-15,NDC,,,facility,both,19,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 50% IN WATER (MERGE RECORD),50863,CDM,250,RC,J7060,HCPCS,0409-6648-02,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0264-7800-10,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7030,HCPCS,0338-0049-04,NDC,facility,both,33,ML,,1097,767.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,66794-229-02,NDC,facility,both,2,ML,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 150 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,0904-7214-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,636,RC,J1596,HCPCS,10019-016-39,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BIFIDO ANIM-B.INF-S.THERMOPHL 1 BILLION CELL ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,7007467398,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,24,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOLIC ACID 1 MG / 0.2 ML SYRINGE (CDS ADS REPACK),50863,CDM,636,RC,J3490,HCPCS,63323-184-10,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G POTASSIUM 20000000 UNIT INJ SOLR,50863,CDM,250,RC,J2540,HCPCS,70860-127-51,NDC,facility,both,30,EA,,252,176.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,63323-806-13,NDC,facility,both,13,ML,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0406-8515-23,NDC,facility,both,4,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-613-04,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML INJECTION,50863,CDM,636,RC,J3411,HCPCS,63323-013-01,NDC,facility,both,2,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE  50 MG ORAL TAB,50863,CDM,636,RC,j3490,HCPCS,0904-6868-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GAMMAGARD LIQUID 10 % IV SOLN,50863,CDM,636,RC,J1569,HCPCS,0944-2700-07,NDC,facility,both,60,ML,"JZ,JA",10817,7571.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,44,EA,,6072,4250.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68180-513-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,51,ML,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAPSAICIN 0.025 % TOP CREA,50863,CDM,636,RC,J3490,HCPCS,50268-195-60,NDC,facility,both,1,GM,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,636,RC,J2405,HCPCS,70860-776-41,NDC,facility,both,1,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DEXAMETHASONE 4 MG ORAL TAB,50863,CDM,250,RC,J8540,HCPCS,0904-7266-61,NDC,facility,both,12,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J3490,HCPCS,0338-0049-41,NDC,facility,both,7,ML,,119,83.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-074-01,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE NA (PRESERV FREE) 25 MG/ML INJ SOLN,50863,CDM,250,RC,J9260,HCPCS,61703-408-41,NDC,facility,both,20,ML,,216,151.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7350-61,NDC,facility,both,2,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL (VITAMIN D3)  1000 UNIT ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,2055503300,NDC,facility,both,5,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,250,RC,J2003,HCPCS,63323-495-09,NDC,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G POTASSIUM 20000000 UNIT INJ SOLR,50863,CDM,250,RC,J2540,HCPCS,70860-127-51,NDC,facility,both,20,EA,,168,117.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-346-11,NDC,facility,both,3,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,68516-5214-2,NDC,facility,both,10,ML,,1426,998.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,160,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
KETAMINE 100 MG/ML INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0143-9509-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,0548-5604-00,NDC,facility,both,8,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,636,RC,J1100,HCPCS,63323-506-00,NDC,facility,both,5,ML,JW,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
VALACYCLOVIR 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6565-61,NDC,facility,both,4,EA,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  120 MG RECT SUPP,50863,CDM,636,RC,J3490,HCPCS,45802-732-00,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 10 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,65862-192-01,NDC,facility,both,2,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VERAPAMIL 120 MG ORAL TBSR,50863,CDM,636,RC,J3490,HCPCS,75834-320-01,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 175 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,42292-040-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  37.5 MG ORAL CP24,50863,CDM,J3490,HCPCS,68084-698-11,NDC,,,facility,both,2,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0143-9595-01,NDC,facility,both,200,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1815,HCPCS,0169-1833-11,NDC,facility,both,3,ML,GZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier GZ: Item or service expected to be denied as not reasonable and necessary
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,60687-571-24,NDC,facility,both,1,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6322-61,NDC,facility,both,4,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,17856-0574-1,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THROMBIN (RECOMBINANT) 20000 UNIT TOP SOLR,50863,CDM,250,RC,J3490,HCPCS,0338-0328-01,NDC,facility,both,4,EA,,4872,3410.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,56,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON DEXTRAN 50 MG/ML INJ SOLN,50863,CDM,250,RC,J1750,HCPCS,0023-6082-01,NDC,facility,both,1,ML,JW,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,44,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,1,EA,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAUNORUBICIN 5 MG/ML IV INJ,50863,CDM,636,RC,J9150,HCPCS,42658-021-01,NDC,facility,both,1,ML,JW,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
NOREPINEPHRINE BITARTRATE-D5W 4 MG/250 ML (16 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,71285-6056-1,NDC,facility,both,1,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"HEPARIN, PORCINE (PF)  100 UNIT/ML IV SYRG",50863,CDM,250,RC,J1642,HCPCS,6380760055,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 250 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,0832-7123-89,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,50863,CDM,636,RC,Q5119,HCPCS,0069-0249-01,NDC,facility,both,72,ML,,14245,9971.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCERIN-WITCH HAZEL 12.5 %-50 % TOPICAL PADS,50863,CDM,636,RC,J3490,HCPCS,50289-3250-1,NDC,facility,both,40,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEPIVACAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J0670,HCPCS,63323-294-01,NDC,,,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,J3101,HCPCS,50242-037-06,NDC,,,facility,both,33,EA,,6572,4600.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLECAINIDE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-0010-20,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,0409-1886-22,NDC,facility,both,50,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TERAZOSIN  5 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,50268-766-11,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE  10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-037-11,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERTAPENEM 1 GRAM INJ SOLR,50863,CDM,636,RC,J1335,HCPCS,16714-889-01,NDC,facility,both,2,EA,,525,367.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"CALCIUM CARBONATE 500 MG (1,250 MG) ORAL TAB",50863,CDM,250,RC,J3490,HCPCS,904188361,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE MODIFIED 100 MG ORAL CAP,50863,CDM,250,RC,J7502,HCPCS,51862-460-01,NDC,facility,both,1,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SINCALIDE 5 MCG INJ SOLR,50863,CDM,636,RC,J2805,HCPCS,72266-248-05,NDC,facility,both,1,EA,,130,91,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0143-9386-01,NDC,facility,both,83,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOLAZONE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-635-11,NDC,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,250,RC,J3490,HCPCS,0173-0682-20,NDC,facility,both,1,GM,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,0409-3178-17,NDC,,,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE-ALOE VERA TOPICAL GEL,50863,CDM,250,RC,J3490,HCPCS,225052547,NDC,facility,both,1,GM,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAVASTATIN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-5891-61,NDC,facility,both,2,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J2004,HCPCS,0409-3178-01,NDC,facility,both,200,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN D5W 20000 UNIT/500 ML,50863,CDM,636,RC,J1644,HCPCS,0264-9567-10,NDC,facility,both,15,ML,JW,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
QUETIAPINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-349-11,NDC,facility,both,5,EA,,159,111.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4 % MUCOSAL TOPICAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0054-3505-47,NDC,facility,both,1,ML,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,68,ML,JW,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J3490,HCPCS,17271-701-02,NDC,facility,both,1,ML,JZ,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MELATONIN  3 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,7733351625,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZAFIRLUKAST 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,55111-626-60,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-1638-32,NDC,facility,both,1,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42858-723-01,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),50863,CDM,636,RC,J2060,HCPCS,0641-6001-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-132-11,NDC,facility,both,3,EA,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION,50863,CDM,250,RC,J3490,HCPCS,0310-7370-20,NDC,facility,both,1,GM,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),50863,CDM,250,RC,J2060,HCPCS,0641-6044-01,NDC,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 200 MG/20 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0131-1810-67,NDC,facility,both,2,ML,,836,585.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,636,RC,J0690,HCPCS,70092-1017-46,NDC,facility,both,14,ML,,26071,18249.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,636,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6949-61,NDC,facility,both,3,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,636,RC,J3490,HCPCS,0409-4887-17,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,13,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-174-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,J2371,HCPCS,0641-6142-25,NDC,,,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,2,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN IN D5W 600 MG/50 ML IV PGBK,50863,CDM,250,RC,J0736,HCPCS,0009-3375-01,NDC,facility,both,2,ML,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,12,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOCONAZOLE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,35573-433-30,NDC,facility,both,2,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOL 1.4 % MM SPRA,50863,CDM,636,RC,J3490,HCPCS,7811201103,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE-DEXTROSE-WATER(PF) 7.5 MG/ML (0.75 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-1761-18,NDC,facility,both,1,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-31,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ABOBOTULINUMTOXINA 300 UNITS IM SOLR,50863,CDM,636,RC,J3490,HCPCS,15054-0530-6,NDC,facility,both,4,EA,,5057,3539.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOTRIMAZOLE 1 % TOP CREA,50863,CDM,250,RC,J3490,HCPCS,45802-434-11,NDC,facility,both,1,GM,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,J3490,HCPCS,0143-9889-15,NDC,,,facility,both,10,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,22,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNITS/1 GRAM PACKET (MERGE RECORD),50863,CDM,636,RC,J3490,HCPCS,45802-060-00,NDC,facility,both,8,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 500 MG-125 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0781-1831-20,NDC,facility,both,1,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-461-11,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-11,NDC,facility,both,17,ML,JW,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ARIPIPRAZOLE 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,31722-828-30,NDC,facility,both,1,EA,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICLOFENAC 1 % TOPICAL GEL,50863,CDM,J3490,HCPCS,0067-8152-02,NDC,,,facility,both,1,GM,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 50 MG TAB,50863,CDM,J3490,HCPCS,0378-0032-01,NDC,,,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2305-16,NDC,facility,both,8,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE   4.2 % IV SOLN,50863,CDM,250,RC,J3490,HCPCS,51754-5012-1,NDC,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,76045-009-96,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0406-5755-23,NDC,facility,both,7,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPH-MIN OIL-PETROLATUM 0.25-14-74.9 % RECT OINT,50863,CDM,250,RC,J3490,HCPCS,0536-1288-06,NDC,facility,both,1,GM,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACCHAROMYCES BOULARDII 250 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,7733380050,NDC,facility,both,10,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,636,RC,J3010,HCPCS,0409-9094-22,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,50863,CDM,636,RC,J1756,HCPCS,0517-2325-01,NDC,facility,both,50,ML,,191,133.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-5771-23,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATOMOXETINE  40 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,64980-376-03,NDC,facility,both,1,EA,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-1541-10,NDC,facility,both,2,ML,,195,136.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 20 MG/ML INJ SOLN,50863,CDM,636,RC,J0360,HCPCS,63323-614-00,NDC,facility,both,1,ML,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-742-11,NDC,facility,both,2,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BETAMETHASONE, AUGMENTED 0.05 % TOP OINT",50863,CDM,250,RC,J3490,HCPCS,68180-947-01,NDC,facility,both,1,GM,,270,189,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIFEDIPINE 30 MG ORAL TO24,50863,CDM,250,RC,J3490,HCPCS,50268-597-11,NDC,facility,both,3,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42291-809-15,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 100 % ORAL POWDER 238 GRAMS,50863,CDM,250,RC,J3490,HCPCS,57896-489-14,NDC,facility,both,1,GM,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEFLUNOMIDE  20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,62332-062-30,NDC,facility,both,1,EA,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 17 GRAM (100 %) ORAL PWPK,50863,CDM,636,RC,J3490,HCPCS,0904-6931-86,NDC,facility,both,14,EA,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,6,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MINERAL OIL ENEMA,50863,CDM,636,RC,J3490,HCPCS,0132-0301-40,NDC,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 100 MG/5 ML ORAL LIQD,50863,CDM,250,RC,J3490,HCPCS,0121-1744-05,NDC,facility,both,2,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIPASE-PROTEASE-AMYLASE (PORK) 36,000-114,000- 180,000 UNIT ORAL CPDR",50863,CDM,250,RC,J3490,HCPCS,0032-3016-13,NDC,facility,both,1,EA,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BALANCED SALT SOLN NON-SURG #3 EYE,50863,CDM,636,RC,J3490,HCPCS,0065-0530-01,NDC,facility,both,1,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-165-11,NDC,facility,both,1,EA,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ELTROMBOPAG 25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0078-0685-15,NDC,facility,both,5,EA,,1690,1183,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 75 MG/5 ML ORAL SOLUTION,50863,CDM,250,RC,J3490,HCPCS,64980-511-10,NDC,facility,both,13,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE (FOR CODE) 10% IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0517-6710-01,NDC,facility,both,1,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL  20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-717-11,NDC,facility,both,1,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,50863,CDM,636,RC,J3490,HCPCS,69339-152-01,NDC,facility,both,2,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,985,ML,,1414,989.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2723-30,NDC,facility,both,5,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN NPH & REGULAR HUMAN 100 UNIT/ML (70-30) SUBQ SUSP,50863,CDM,636,RC,J1815,HCPCS,0002-8715-01,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE IN 0.9% NACL 3 GRAM/100 ML IV SOLN,50863,CDM,250,RC,J0612,HCPCS,61553-056-48,NDC,facility,both,300,ML,,128,89.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,J7512,HCPCS,60687-145-11,NDC,,,facility,both,30,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXEPIN 10 MG/ML ORAL CONC,50863,CDM,250,RC,J3490,HCPCS,54838-512-40,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7350-06,NDC,facility,both,6,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-495-27,NDC,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOTRIMAZOLE 1 % TOP CREA,50863,CDM,250,RC,J3490,HCPCS,45802-434-11,NDC,facility,both,1,GM,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,636,RC,J3490,HCPCS,63037-136-25,NDC,facility,both,2,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 1 MG (ENVARSUS XR) 24-HOUR EXTENDED-RELEASE TABLET,50863,CDM,250,RC,J7508,HCPCS,68992-3010-3,NDC,facility,both,7,EA,,197,137.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE-DEXTROSE-WATER(PF) 7.5 MG/ML (0.75 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-1761-18,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ELECTROLYTE-A IV,50863,CDM,250,RC,J3490,HCPCS,0338-0221-03,NDC,facility,both,3,ML,,250,175,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARSENIC TRIOXIDE 10 MG/10 ML IV SOLN,50863,CDM,250,RC,J9017,HCPCS,23155-869-31,NDC,facility,both,18,ML,,857,599.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6084-61,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,636,RC,J2003,HCPCS,0409-4277-01,NDC,facility,both,400,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,J2919,HCPCS,0009-0047-25,NDC,,,facility,both,20,EA,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,83257-011-11,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 100 MG/ML INJ SOLN,50863,CDM,250,RC,J2800,HCPCS,0517-1825-01,NDC,facility,both,1,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE  5 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,70010-029-01,NDC,facility,both,1,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % MBP,50863,CDM,250,RC,J3490,HCPCS,0338-0553-11,NDC,facility,both,2,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-492-26,NDC,,,facility,both,300,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE HCL  0.5 % NASL SPRY,50863,CDM,J3490,HCPCS,0225-0805-47,NDC,,,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,63323-482-05,NDC,,,facility,both,400,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 40 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0049-3450-19,NDC,facility,both,1,ML,,165,115.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,0409-3178-16,NDC,,,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,6,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIVOLUMAB 240 MG/24 ML IV SOLN,50863,CDM,636,RC,J9299,HCPCS,0003-3774-12,NDC,facility,both,100,ML,,6819,4773.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7914-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL (NEO/PEDS),50863,CDM,250,RC,J3490,HCPCS,63323-820-00,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,70095-031-01,NDC,facility,both,38,ML,,1559,1091.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,50863,CDM,636,RC,J9075,HCPCS,0781-3233-94,NDC,facility,both,200,EA,,2431,1701.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 5 MG ORAL CAP,50863,CDM,250,RC,J7507,HCPCS,0904-6624-61,NDC,facility,both,6,EA,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 17 GRAM (100 %) ORAL PWPK,50863,CDM,J3490,HCPCS,62559-157-17,NDC,,,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 17 GRAM (100 %) ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,0904-6931-86,NDC,facility,both,11,EA,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE (CONTRACEPTIVE) 150 MG/ML IM SUSP,50863,CDM,250,RC,J1050,HCPCS,55150-329-01,NDC,facility,both,150,ML,,215,150.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL,50863,CDM,250,RC,J3490,HCPCS,63323-820-04,NDC,facility,both,1,ML,,168,117.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  7.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,43598-165-30,NDC,facility,both,2,EA,,158,110.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,42806-150-33,NDC,facility,both,7,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,37,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE-EPI-CLONID-KETOROL 2.46-0.005- 0.0008-0.3MG/ML PATC SYRG,50863,CDM,250,RC,J3490,HCPCS,70092-1433-50,NDC,facility,both,1,ML,,213,149.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HUMAN PROTHROMBIN COMPLEX 500 UNIT IV SOLR,50863,CDM,250,RC,J7168,HCPCS,63833-396-01,NDC,facility,both,200,UN,JW,506,354.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,80,ML,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-1749-70,NDC,facility,both,2,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAMADOL  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0378-4151-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARDIOPLEGIC SOLUTION NO.25 29 MMOL/L (POTASSIUM) PERF SOLN,50863,CDM,250,RC,J3490,HCPCS,69374-984-10,NDC,facility,both,3,ML,,1512,1058.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRIL MALEATE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51672-4038-1,NDC,facility,both,2,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 10 MEQ/100 ML IV PGBK,50863,CDM,250,RC,J3480,HCPCS,14789-109-16,NDC,facility,both,5,ML,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,636,RC,J2795,HCPCS,43066-023-01,NDC,facility,both,145,ML,JW,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
METOPROLOL TARTRATE 5 MG/5 ML IV,50863,CDM,636,RC,J3490,HCPCS,63323-660-01,NDC,facility,both,4,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,63739-931-28,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IVABRADINE 7.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50742-363-60,NDC,facility,both,2,EA,,108,75.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOCARNITINE 200 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,54482-147-01,NDC,facility,both,3,ML,,685,479.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL 20 MG/5 ML ORAL ELIX,50863,CDM,250,RC,J3490,HCPCS,60687-671-40,NDC,facility,both,2,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  120 MG RECT SUPP,50863,CDM,250,RC,J3490,HCPCS,0713-0118-06,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
D5-0.9%NACL-POTASSIUM CHLORIDE 20 MEQ/L IV SOLP (PED ONC),50863,CDM,250,RC,J3480,HCPCS,0264-7652-00,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,636,RC,J3490,HCPCS,51754-4250-1,NDC,facility,both,3,ML,,189,132.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM BICARB-CITRIC ACID 20 MEQ ORAL TBEF,50863,CDM,250,RC,J3490,HCPCS,51801-011-01,NDC,facility,both,3,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0121-0917-05,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLORAZEPATE DIPOTASSIUM  3.75 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,70954-159-30,NDC,facility,both,2,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,71288-402-10,NDC,facility,both,8,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML IV SOLN (MERGE),50863,CDM,250,RC,J3490,HCPCS,70756-611-82,NDC,facility,both,1,ML,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BROMOCRIPTINE 2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0574-0106-03,NDC,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMBROLIZUMAB 100 MG/4 ML (25 MG/ML) IV SOLN,50863,CDM,250,RC,J9271,HCPCS,0006-3026-01,NDC,facility,both,200,ML,,24182,16927.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NYSTATIN  100000 UNIT/G TOP CREA,50863,CDM,636,RC,J3490,HCPCS,0713-0678-15,NDC,facility,both,1,GM,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),50863,CDM,250,RC,J0171,HCPCS,76329-3318-1,NDC,facility,both,10,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),50863,CDM,250,RC,J1630,HCPCS,63323-474-00,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,0075-0620-01,NDC,facility,both,4,ML,JZ,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,636,RC,J3373,HCPCS,0143-9162-01,NDC,facility,both,100,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7030,HCPCS,0338-0049-04,NDC,facility,both,2,ML,JZ,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
HYDROCORTISONE SOD SUCC (PF) 100 MG/2 ML INJ SOLR,50863,CDM,250,RC,J1720,HCPCS,0009-0011-03,NDC,facility,both,2,EA,,252,176.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROMETHORPHAN POLY COMPLEX ER 30 MG/5 ML ORAL SU12,50863,CDM,636,RC,J3490,HCPCS,63824-171-63,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-1638-32,NDC,facility,both,2,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML IV,50863,CDM,250,RC,J3490,HCPCS,25021-319-05,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE DINITRATE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6620-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2305-16,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITRIOL 0.5 MCG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,64380-724-06,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SOTALOL  80 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-654-11,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-1283-03,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,25021-602-03,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,3,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HISTRELIN 50 MG (65 MCG/DAY) IMPL KIT,50863,CDM,636,RC,J9226,HCPCS,67979-002-01,NDC,facility,both,1,EA,,74263,51984.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RALTEGRAVIR 400 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0006-0227-61,NDC,facility,both,5,EA,,750,525,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J7510,HCPCS,17856-0815-1,NDC,facility,both,3,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,50863,CDM,250,RC,Q0177,HCPCS,0904-6617-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DONEPEZIL 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6478-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,6,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,636,RC,J1100,HCPCS,63323-506-00,NDC,facility,both,10,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYL SALICYLATE-MENTHOL 15 %-10 % TOPICAL CREAM,50863,CDM,636,RC,J3490,HCPCS,57896-116-03,NDC,facility,both,1,GM,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 250 MG-62.5 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,59651-026-75,NDC,facility,both,4,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.3 MG/0.3 ML IM PNIJ,50863,CDM,636,RC,J0171,HCPCS,49502-500-01,NDC,facility,both,9,EA,,3232,2262.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),50863,CDM,636,RC,J3490,HCPCS,63323-186-20,NDC,facility,both,2,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON DEXTRAN 50 MG/ML INJ SOLN,50863,CDM,636,RC,J1750,HCPCS,0023-6082-01,NDC,facility,both,10,ML,,1094,765.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYTARABINE 100 MG/ML INJ SOLN,50863,CDM,250,RC,J9100,HCPCS,61703-319-22,NDC,facility,both,40,ML,,239,167.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE 10 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,70954-319-10,NDC,facility,both,1,ML,,155,108.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RAMIPRIL  1.25 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,68382-144-06,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-145-10,NDC,facility,both,3,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 10 % INHL NEBU,50863,CDM,250,RC,J3490,HCPCS,0378-6998-89,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SYRG,50863,CDM,636,RC,J3490,HCPCS,8290306546,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-25,NDC,facility,both,75,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  50 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-484-11,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,16714-294-01,NDC,facility,both,6,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,67457-423-00,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACUBITRIL-VALSARTAN 49-51 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0078-0777-20,NDC,facility,both,2,EA,,138,96.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE   4.2 % IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-5555-12,NDC,facility,both,1,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 150 MG/1 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,0955-1015-01,NDC,facility,both,15,ML,,189,132.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYTOCIN 10 UNIT/ML INJ SOLN,50863,CDM,250,RC,J2590,HCPCS,42023-116-25,NDC,facility,both,2,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN D5W 20000 UNIT/500 ML,50863,CDM,636,RC,J1644,HCPCS,0264-9567-10,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRIL MALEATE 1 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,69238-2141-7,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),50863,CDM,636,RC,J0171,HCPCS,76329-3318-1,NDC,facility,both,70,ML,,565,395.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,59,ML,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,250,RC,J2720,HCPCS,63323-229-01,NDC,facility,both,2,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  80 MG ORAL CS24,50863,CDM,636,RC,J3490,HCPCS,63629-2072-1,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PILOCARPINE 5 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0527-1313-01,NDC,facility,both,2,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE IN 0.9% NS (PF) 1 MG/10 ML (100 MCG/ML) IV SYRG(PDS MERGE),50863,CDM,250,RC,J3490,HCPCS,71449-001-15,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,45,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 5 MG/ML IV SOLN,50863,CDM,250,RC,J1921,HCPCS,0143-9622-01,NDC,facility,both,1,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,72603-179-01,NDC,facility,both,8,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 500 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,50268-152-11,NDC,facility,both,10,EA,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MILTEFOSINE 50 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,69051-300-01,NDC,facility,both,1,EA,,1368,957.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 400 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-5853-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,51754-4250-1,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 125 MG ORAL CPSP,50863,CDM,250,RC,J3490,HCPCS,68084-313-11,NDC,facility,both,6,EA,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXAZOSIN 4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-5524-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEP B-DP(ACELL)T-POLIO VACC-PF 10MCG-25LF-25MCG-10LF-40-8-32 IM SYRING,50863,CDM,250,RC,90723,HCPCS,58160-811-43,NDC,facility,both,1,ML,,445,311.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,250,RC,J3360,HCPCS,69339-136-03,NDC,facility,both,4,ML,,289,202.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,0703-9514-01,NDC,facility,both,1,ML,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SYRG,50863,CDM,636,RC,J3490,HCPCS,8290306546,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,250,RC,J2003,HCPCS,0409-1323-15,NDC,facility,both,800,ML,,320,224,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0630,HCPCS,63323-865-02,NDC,facility,both,1,ML,,1734,1213.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) 1000 UNITS/ML INJ SOL (FOR DIALYSIS ONLY),50863,CDM,636,RC,J1644,HCPCS,25021-400-10,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUPHENAZINE DECANOATE 25 MG/ML INJ SOLN,50863,CDM,250,RC,J2680,HCPCS,63323-272-05,NDC,facility,both,5,ML,,670,469,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69315-905-05,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,50863,CDM,636,RC,J0696,HCPCS,0143-9856-01,NDC,facility,both,8,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2720-02,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLPIDEM  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-0073-01,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE (PF) 1 MG/ML INJ SOLN,50863,CDM,636,RC,J0169,HCPCS,54288-103-01,NDC,facility,both,20,ML,,172,120.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J1610,HCPCS,63323-582-82,NDC,facility,both,2,EA,JZ,1981,1386.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MISOPROSTOL 50 MCG ORAL SPLIT TAB,50863,CDM,250,RC,S0191,HCPCS,60687-735-01,NDC,facility,both,3,EA,,253,177.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,50863,CDM,250,RC,J9075,HCPCS,10019-955-50,NDC,facility,both,100,EA,,1297,907.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,260,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 17 GRAM (100 %) ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,0904-6931-86,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),50863,CDM,250,RC,J1630,HCPCS,0143-9319-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,0703-9526-01,NDC,facility,both,1,ML,,221,154.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV (BOLUS),50863,CDM,636,RC,J7120,HCPCS,0264-7750-07,NDC,facility,both,2,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE BIT 2 %-1:100,000 INJ CRTG",50863,CDM,636,RC,J3490,HCPCS,0409-0996-01,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,63323-461-01,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE (FOR CODE) 10% (100 MG/ML) IV SYRINGE,50863,CDM,250,RC,J3490,HCPCS,64253-900-30,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE 14 MG/24 HR TD PT24,50863,CDM,J3490,HCPCS,43598-447-71,NDC,,,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM BICARB-CITRIC ACID 20 MEQ ORAL TBEF,50863,CDM,250,RC,J3490,HCPCS,51801-012-01,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
D5-1/2 NS AND POTASSIUM CHLORIDE 20 MEQ/L IV (PEDS CHEMO),50863,CDM,636,RC,J3490,HCPCS,0338-0671-04,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,7733351625,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 30 MG/0.3 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,16714-006-01,NDC,facility,both,9,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,636,RC,J2003,HCPCS,0409-4277-17,NDC,facility,both,1000,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,51,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-950-01,NDC,facility,both,2,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,636,RC,J2405,HCPCS,70860-776-41,NDC,facility,both,3,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
RIFAMPIN 300 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-586-11,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,636,RC,J3490,HCPCS,70004-600-09,NDC,facility,both,3,ML,,159,111.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 40 GRAM/400 ML (10 %) INJ SOLN",50863,CDM,250,RC,J1561,HCPCS,13533-800-20,NDC,facility,both,20,ML,JA,2829,1980.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJ SOLN",50863,CDM,J3490,HCPCS,0409-1752-50,NDC,,,facility,both,1,ML,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7124-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,63323-482-27,NDC,,,facility,both,400,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML IM SOLN,50863,CDM,636,RC,90375,HCPCS,13533-318-05,NDC,facility,both,9,ML,,7873,5511.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-48,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MINERAL OIL,50863,CDM,636,RC,J3490,HCPCS,6332325402,NDC,facility,both,1,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
K PHOS DI & MONO-SOD PHOS MONO 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,6498010401,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-886-01,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,0409-4264-11,NDC,facility,both,10,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,29300-136-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 10 GRAM/15 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,50383-779-30,NDC,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4% TOP PATCH,50863,CDM,636,RC,J3490,HCPCS,46581-830-01,NDC,facility,both,2,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADVATE: FACTOR VIII CONCENTRATE (MERGE RECORD),50863,CDM,250,RC,J7192,HCPCS,0944-3053-04,NDC,facility,both,4000,UN,,20976,14683.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0641-6057-01,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51672-4005-1,NDC,facility,both,3,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-18,NDC,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),50863,CDM,250,RC,J2060,HCPCS,0641-6044-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 500 MG ORAL CAP,50863,CDM,J3490,HCPCS,16714-299-03,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,50863,CDM,250,RC,J0561,HCPCS,60793-701-02,NDC,facility,both,12,ML,,1188,831.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 2 GRAM INJ SOLR,50863,CDM,636,RC,J0692,HCPCS,0409-9735-01,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE SR 12.5 MG 24 HR TAB,50863,CDM,636,RC,J3490,HCPCS,62175-470-32,NDC,facility,both,1,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,27,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9% IV (PEDS) BOLUS,50863,CDM,636,RC,J7040,HCPCS,0264-7800-09,NDC,facility,both,2,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FINASTERIDE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6830-06,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 30 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,27241-098-09,NDC,facility,both,3,EA,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSAPREPITANT 150 MG IV SOLR,50863,CDM,250,RC,J1453,HCPCS,0143-9384-01,NDC,facility,both,150,EA,,331,231.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  15 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,0406-8315-23,NDC,facility,both,3,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,21,EA,,2898,2028.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-656-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 20 GRAM/30 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-1154-30,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POSACONAZOLE 100 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,70748-258-07,NDC,facility,both,3,EA,,800,560,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-520-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,13,ML,JW,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
FLUOXETINE 20 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7346-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 500 MG (200 MG ELEMENTAL) CHEW TAB,50863,CDM,250,RC,J3490,HCPCS,68084-988-33,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IFOSFAMIDE 3 GRAM IV SOLR,50863,CDM,250,RC,J9208,HCPCS,10019-926-16,NDC,facility,both,3,EA,,465,325.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,636,RC,J3490,HCPCS,0904-6794-80,NDC,facility,both,2,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,4,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,65862-707-55,NDC,facility,both,9,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,636,RC,J3490,HCPCS,67877-590-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,636,RC,J3490,HCPCS,0904-6794-89,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-21,NDC,facility,both,10,ML,"JZ,JA",1414,989.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
ASPIRIN 81 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,66553-002-01,NDC,facility,both,8,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 16 MG ORAL TAB,50863,CDM,636,RC,J7509,HCPCS,59762-0050-1,NDC,facility,both,8,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE  5 MG/ML INJ SOLN,50863,CDM,250,RC,J2765,HCPCS,0409-3414-18,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN PEDS SYRINGE (20MG/ML) IN DEXTROSE (CDS MIX,50863,CDM,250,RC,J0690,HCPCS,0781-3451-70,NDC,facility,both,4,EA,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J3490,HCPCS,0338-0049-48,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCRELIZUMAB 30 MG/ML IV SOLN,50863,CDM,J2350,HCPCS,50242-150-01,NDC,,,facility,both,600,ME,,89700,62790,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,0409-6625-14,NDC,facility,both,1,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 50% IN WATER (MERGE RECORD),50863,CDM,636,RC,J7060,HCPCS,0409-6648-02,NDC,facility,both,2,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COSYNTROPIN 0.25 MG INJ SOLR,50863,CDM,250,RC,J0834,HCPCS,67457-227-00,NDC,facility,both,1,EA,,381,266.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-02,NDC,facility,both,2,ML,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML (PEDS CALCLUATOR 0.5),50863,CDM,636,RC,J1815,HCPCS,0024-5924-10,NDC,facility,both,7,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,250,RC,J3490,HCPCS,0143-9679-01,NDC,facility,both,1,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-253-11,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN 250 MG SOLUTION FOR INJECTION,50863,CDM,250,RC,J0290,HCPCS,65219-014-01,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCRALFATE 1 GRAM ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-753-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,40,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,0143-9577-01,NDC,,,facility,both,135,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 400 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,65862-071-01,NDC,facility,both,7,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SOMATROPIN  5.8 MG SUBQ SOLR,50863,CDM,636,RC,J3490,HCPCS,0781-4004-36,NDC,facility,both,1,EA,,1207,844.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-65,NDC,facility,both,300,ML,,529,370.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,63323-400-01,NDC,facility,both,75,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZOCAINE-MENTHOL 20 %-0.5 % TOPICAL AEROSOL,50863,CDM,250,RC,J3490,HCPCS,16864-680-03,NDC,facility,both,2,GM,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,636,RC,J2405,HCPCS,23155-547-31,NDC,facility,both,8,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
BALSALAZIDE 750 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,50268-102-11,NDC,facility,both,3,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,63323-400-01,NDC,facility,both,100,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL,50863,CDM,250,RC,J3490,HCPCS,63323-820-01,NDC,facility,both,1,ML,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-11,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WHITE PETROLATUM-MINERAL OIL 57.3-42.5 % OPHT OINT,50863,CDM,636,RC,J3490,HCPCS,0023-0240-04,NDC,facility,both,1,GM,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOBRAMYCIN 0.3 % EYE OINTMENT,50863,CDM,636,RC,J3490,HCPCS,0078-0813-01,NDC,facility,both,1,GM,,992,694.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN D5W 20000 UNIT/500 ML,50863,CDM,636,RC,J1644,HCPCS,0264-9567-10,NDC,facility,both,17,ML,JW,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL,50863,CDM,250,RC,J3490,HCPCS,63323-820-01,NDC,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IRRIGATION SOLN,50863,CDM,636,RC,J7120,HCPCS,0264-7389-60,NDC,facility,both,3,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN NORMAL SALINE IV,50863,CDM,250,RC,J7042,HCPCS,0338-9799-01,NDC,facility,both,2,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,13,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESMOLOL  100 MG/10 ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,67457-182-00,NDC,facility,both,1,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIHEXYPHENIDYL 2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,70954-212-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL 20 MG/5 ML ORAL ELIX,50863,CDM,250,RC,J3490,HCPCS,0121-0942-05,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-467-01,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,5,EA,JW,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
AMIODARONE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-051-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 17 GRAM (100 %) ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,0904-6931-86,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,65,ML,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 100 MG/5 ML ORAL LIQD,50863,CDM,250,RC,J3490,HCPCS,0121-1488-10,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51407-153-90,NDC,facility,both,1,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,636,RC,J2003,HCPCS,0409-1323-05,NDC,facility,both,200,ML,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 20MG/ML IV SYRINGE (PEDS/NEO),50863,CDM,250,RC,J0612,HCPCS,63323-311-10,NDC,facility,both,17,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRIMIDONE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-202-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-65,NDC,facility,both,8,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,250,RC,J2270,HCPCS,0409-1890-13,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,0641-6236-01,NDC,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,71,ML,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,42806-150-33,NDC,facility,both,3,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,250,RC,J2720,HCPCS,63323-229-01,NDC,facility,both,3,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 600 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-457-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-258-11,NDC,facility,both,7,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN 50 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,51672-4146-1,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 5 MG/ML IV SOLN,50863,CDM,636,RC,J1921,HCPCS,0143-9622-01,NDC,facility,both,1,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORDIAZEPOXIDE 25 MG CAP,50863,CDM,250,RC,J3490,HCPCS,0555-0159-02,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIVASTIGMINE 4.6 MG/24 HOUR TD PT24,50863,CDM,250,RC,J3490,HCPCS,70710-1196-1,NDC,facility,both,1,EA,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-1721-01,NDC,facility,both,3,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2310,HCPCS,36000-308-01,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-074-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,63323-462-01,NDC,facility,both,1,ML,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,636,RC,J3010,HCPCS,0409-9094-22,NDC,facility,both,4,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE DINITRATE 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,64455-192-01,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,0409-2723-30,NDC,facility,both,5,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SODIUM POLYSTYRENE SULF-SORBTL 15-20 GRAM/60 ML ORAL SUSP,50863,CDM,J3490,HCPCS,46287-006-60,NDC,,,facility,both,2,ML,,264,184.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRABECTEDIN 1 MG IV SOLR,50863,CDM,J9352,HCPCS,59676-610-01,NDC,,,facility,both,20,EA,,14904,10432.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-710-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-333-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN   1.25 G IV SOLR,50863,CDM,250,RC,J3370,HCPCS,67457-823-12,NDC,facility,both,3,EA,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,J1885,HCPCS,72266-118-01,NDC,,,facility,both,1,ML,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETIRIZINE 10 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-7510-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  1 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,59746-171-06,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE 10 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,70954-319-10,NDC,facility,both,1,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 160 MG-800 MG TAB,50863,CDM,636,RC,J3490,HCPCS,65862-420-01,NDC,facility,both,14,EA,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-253-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J2003,HCPCS,0409-4279-16,NDC,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHOTERICIN B LIPOSOME 50 MG IV SUSR,50863,CDM,250,RC,J0289,HCPCS,0469-3051-30,NDC,facility,both,40,EA,,9015,6310.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUANFACINE 2 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,62332-746-31,NDC,facility,both,1,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-ABDA 100 MG IV SOLR,50863,CDM,636,RC,Q5104,HCPCS,78206-162-99,NDC,facility,both,130,EA,,27032,18922.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,250,RC,J7060,HCPCS,0338-0017-48,NDC,facility,both,1,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,68094-231-59,NDC,facility,both,3,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR 200 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,50268-060-11,NDC,facility,both,2,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2308-21,NDC,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,31722-711-30,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL (VITAMIN D3)  1000 UNIT ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,8068116900,NDC,facility,both,5,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROPROCAINE 3 % INJ SOLN,50863,CDM,250,RC,J2401,HCPCS,0143-9210-01,NDC,facility,both,600,ML,,132,92.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4 % MUCOSAL TOPICAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0054-3505-47,NDC,facility,both,1,ML,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,2,EA,,187,130.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 50 MG TAB,50863,CDM,250,RC,J3490,HCPCS,69452-345-60,NDC,facility,both,1,EA,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J3490,HCPCS,0990-7983-61,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 40 MG/ML SUSP (DEPO-MEDROL) INJECTION,50863,CDM,J1010,HCPCS,0009-3073-01,NDC,,,facility,both,40,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,636,RC,J1953,HCPCS,63323-400-01,NDC,facility,both,150,ML,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIOTHYRONINE  5 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,59762-1206-1,NDC,facility,both,3,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-1638-32,NDC,facility,both,2,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,636,RC,J3490,HCPCS,71266-9080-2,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLN (MERGE)",50863,CDM,636,RC,P9047,HCPCS,64208-2512-8,NDC,facility,both,2,ML,,238,166.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6519-61,NDC,facility,both,3,EA,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN (PF) 10 MG/ML INJECTION (NEONATAL IM USE),50863,CDM,250,RC,J1580,HCPCS,63323-173-01,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-4279-02,NDC,facility,both,600,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,2,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DROPERIDOL 2.5 MG/ML INJ SOLN,50863,CDM,636,RC,J1790,HCPCS,0143-9514-01,NDC,facility,both,1,ML,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,13533-690-20,NDC,facility,both,1,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHOTERICIN B LIPOSOME 50 MG IV SUSR,50863,CDM,250,RC,J0289,HCPCS,55150-365-01,NDC,facility,both,40,EA,,7215,5050.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAZOLAMIDE SODIUM 500 (100 MG/ML) INJ SOLR,50863,CDM,636,RC,J1120,HCPCS,39822-0190-1,NDC,facility,both,1,EA,,193,135.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MOMETASONE 220 MCG (14 DOSES) INHL AEPB,50863,CDM,250,RC,J3490,HCPCS,78206-114-03,NDC,facility,both,1,EA,,228,159.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-4713-32,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DROPERIDOL 2.5 MG/ML INJ SOLN,50863,CDM,636,RC,J1790,HCPCS,0517-9702-25,NDC,facility,both,1,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,J2704,HCPCS,63323-269-22,NDC,,,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 25 MG CAP,50863,CDM,J3490,HCPCS,71399-1027-1,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9% IV (PEDS) BOLUS,50863,CDM,250,RC,J7030,HCPCS,0264-7800-09,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-41,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZTROPINE 1 MG ORAL TAB,50863,CDM,J3490,HCPCS,68084-388-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML (ANESTHESIA INTRAOP ONLY),50863,CDM,J3010,HCPCS,0641-6027-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) NEB SOLUTION,50863,CDM,J3490,HCPCS,0487-9501-01,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-65,NDC,facility,both,84,ML,,148,103.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,68180-441-01,NDC,facility,both,3,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,174,ML,,157,109.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERGOCALCIFEROL (VITAMIN D2) 50000 UNIT ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,64380-737-06,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,636,RC,J7999,HCPCS,70092-1017-46,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 10% IN WATER (D10) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0990-7930-09,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE IN D5W 1 GRAM/100 ML IV PGBK,50863,CDM,250,RC,J3475,HCPCS,0264-4400-54,NDC,facility,both,4,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-505-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PATIROMER CALCIUM SORBITEX  8.4 G ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,53436-084-01,NDC,facility,both,2,EA,,362,253.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THROMBIN (RECOMBINANT) 5000 UNIT TOP SOLR,50863,CDM,250,RC,J3490,HCPCS,28400-105-01,NDC,facility,both,1,EA,,372,260.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAZOSIN 5 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-572-33,NDC,facility,both,2,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 10 MG/ML INJ SYRG,50863,CDM,250,RC,J2270,HCPCS,0409-1261-30,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-488-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLN (MERGE)",50863,CDM,250,RC,P9047,HCPCS,76125-792-11,NDC,facility,both,1,ML,,208,145.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,500,ML,,1431,1001.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTASE 3000 UNIT ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,904522452,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IV PGBK,50863,CDM,636,RC,J3475,HCPCS,63323-106-02,NDC,facility,both,4,ML,JZ,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ESMOLOL  100 MG/10 ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-652-10,NDC,facility,both,1,ML,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM IN NACL (ISO-OS) 1500 MG/100 ML IV PGBK,50863,CDM,250,RC,J1953,HCPCS,44567-503-01,NDC,facility,both,300,ML,,178,124.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE-DEXTROSE-WATER(PF) 7.5 MG/ML (0.75 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-1761-02,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,50863,CDM,250,RC,J9075,HCPCS,0781-3244-94,NDC,facility,both,200,EA,,1896,1327.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE (FOR EMERGENCY) 100 MG/ML (10%) IV SOLN,50863,CDM,250,RC,J0612,HCPCS,0143-9180-01,NDC,facility,both,100,ML,JZ,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
METHYLPHENIDATE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,57664-228-88,NDC,facility,both,4,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN IN SALINE (ISO-OSMOTIC) 100 MG/50 ML IV PIGGY BACK,50863,CDM,250,RC,J1580,HCPCS,0338-0511-41,NDC,facility,both,2,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN  100 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,5026885211,NDC,facility,both,5,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1817,HCPCS,0002-8215-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATENOLOL  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7187-61,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,7,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,0409-9094-25,NDC,facility,both,7,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,4,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,0409-9094-22,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,250,RC,J3490,HCPCS,0143-9679-01,NDC,facility,both,1,ML,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  10 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0054-0237-63,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0143-9509-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J2003,HCPCS,63323-492-27,NDC,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6370-61,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,50863,CDM,250,RC,J9000,HCPCS,0069-1542-20,NDC,facility,both,2,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-442-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,12,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,636,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,54,ML,JW,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
THYROID (PORK)  60 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42192-330-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALPHA-1-PROTEINASE INHIBITOR (HUMAN) 1,000 MG IV SUSP (PROLASTIN-C)",50863,CDM,636,RC,J0256,HCPCS,13533-700-01,NDC,facility,both,406,ME,,5749,4024.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J2003,HCPCS,63323-492-04,NDC,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,67457-433-00,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 500 MG INJ SOLR,50863,CDM,250,RC,J0696,HCPCS,0409-7338-11,NDC,facility,both,3,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTOBACILLUS ACIDOPHILUS 500 MILLION CELLS ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,904726006,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INDIGOTINDISULFONATE SODIUM 8 MG/ML INJ SOLN,50863,CDM,636,RC,J9220,HCPCS,17478-508-01,NDC,facility,both,40,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE HCL IN D5W 4 MG/250 ML (16 MCG/ML) IV SOLN,50863,CDM,250,RC,J0169,HCPCS,72196-7018-1,NDC,facility,both,40,ML,,211,147.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIGOXIN 125 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-5921-61,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEGESTROL 40 MG ORAL TAB,50863,CDM,250,RC,J9999,HCPCS,0555-0607-02,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIFAMPIN 600 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,0068-0597-01,NDC,facility,both,1,EA,,386,270.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,636,RC,J7510,HCPCS,17856-0759-5,NDC,facility,both,3,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-587-11,NDC,facility,both,8,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,50863,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,14,EA,,293,205.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE  50 MG ORAL TAB,50863,CDM,j3490,HCPCS,0904-6868-61,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,12,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J7510,HCPCS,17856-0815-1,NDC,facility,both,9,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2305-04,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,636,RC,J7999,HCPCS,70092-1017-46,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6085-61,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-319-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,0409-9094-22,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0121-0917-05,NDC,facility,both,4,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MERCAPTOPURINE 50 MG ORAL TAB,50863,CDM,250,RC,J9999,HCPCS,0054-4581-11,NDC,facility,both,3,EA,,121,84.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-48,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BISOPROLOL FUMARATE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,70954-455-20,NDC,facility,both,2,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV,50863,CDM,250,RC,J7120,HCPCS,0338-0117-04,NDC,facility,both,2,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON DEXTRAN 50 MG/ML INJ SOLN,50863,CDM,250,RC,J1750,HCPCS,0023-6082-01,NDC,facility,both,14,ML,,1532,1072.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 25 MG CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7237-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4% TOP PATCH,50863,CDM,250,RC,J3490,HCPCS,46581-830-01,NDC,facility,both,1,EA,PLAD,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,250,RC,J7060,HCPCS,0338-0017-02,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,25021-751-10,NDC,facility,both,2,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,68180-150-01,NDC,facility,both,3,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-833-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML IV SOLN (MERGE),50863,CDM,J3490,HCPCS,0781-3269-71,NDC,,,facility,both,1,ML,,251,175.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-18,NDC,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J3490,HCPCS,0338-0049-41,NDC,facility,both,7,ML,JZ,119,83.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
OXALIPLATIN 100 MG/20 ML IV SOLN,50863,CDM,250,RC,J9263,HCPCS,71288-101-20,NDC,facility,both,400,ML,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0904-1313-09,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-231-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2308-22,NDC,facility,both,5,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,17,EA,JW,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,0409-4264-11,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZATHIOPRINE  50 MG ORAL TAB,50863,CDM,636,RC,J7500,HCPCS,68084-229-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE PAMOATE  50 MG ORAL CAP,50863,CDM,636,RC,Q0177,HCPCS,0185-0676-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  500 MCG/ML INJ SOLN,50863,CDM,636,RC,J2354,HCPCS,0641-6176-01,NDC,facility,both,20,ML,"JZ,JA",206,144.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
ASPIRIN 81 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,0904-6794-30,NDC,facility,both,4,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,16,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,250,RC,J3490,HCPCS,53746-542-05,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,636,RC,J1953,HCPCS,0409-1886-22,NDC,facility,both,100,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,44567-600-04,NDC,facility,both,3,ML,,1206,844.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7030,HCPCS,0338-0049-04,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1170,HCPCS,76045-009-96,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0121-0917-05,NDC,facility,both,2,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0245-0212-89,NDC,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0093-4177-73,NDC,facility,both,5,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,J2405,HCPCS,60505-6130-0,NDC,,,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),50863,CDM,250,RC,J0171,HCPCS,76329-3318-1,NDC,facility,both,150,ML,,1210,847,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0003-0894-21,NDC,facility,both,12,EA,,514,359.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J2003,HCPCS,0409-4713-32,NDC,facility,both,40,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,33,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLIPIZIDE  5 MG ORAL TO24,50863,CDM,250,RC,J3490,HCPCS,59762-0541-1,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,42494-415-01,NDC,facility,both,1,ML,,193,135.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0075-0622-01,NDC,facility,both,16,ML,,234,163.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,250,RC,J0137,HCPCS,0264-4100-90,NDC,facility,both,65,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE (POLACRILEX) 4 MG BUCL GUM,50863,CDM,636,RC,J3490,HCPCS,63739-369-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 250 MG-62.5 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,59651-026-75,NDC,facility,both,10,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCRALFATE 1 GRAM ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-695-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,250,RC,J3490,HCPCS,60687-653-11,NDC,facility,both,8,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) IV SOLN,50863,CDM,636,RC,J9220,HCPCS,81284-315-05,NDC,facility,both,40,ML,JZ,1728,1209.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MELOXICAM  7.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-525-15,NDC,facility,both,2,EA,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE  25 MG ORAL CAP,50863,CDM,250,RC,J7515,HCPCS,0078-0240-61,NDC,facility,both,3,EA,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL (VITAMIN D3)  1000 UNIT ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,2055503300,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIROFIBAN-0.9% SODIUM CHLORIDE 5 MG/100 ML (50 MCG/ML) IV SOLN,50863,CDM,250,RC,J3246,HCPCS,25208-002-03,NDC,facility,both,5,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J3490,HCPCS,0338-1055-48,NDC,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,17856-7014-7,NDC,facility,both,2,ML,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,68094-147-01,NDC,facility,both,1,ML,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BICARB DIAL SOLN13-NO CA,K,DEX MG 1.2 MEQ/L HEMO SOLN",50863,CDM,250,RC,J3490,HCPCS,24571-113-06,NDC,facility,both,1,ML,,412,288.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,32,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOBRAMYCIN 1.2 G POWDER VIAL,50863,CDM,250,RC,J3260,HCPCS,39822-0412-6,NDC,facility,both,5,EA,,133,93.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYMETAZOLINE 0.05 % NASL SPRA,50863,CDM,250,RC,J3490,HCPCS,0904-7427-30,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,250,RC,J7060,HCPCS,0338-0017-03,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE  2 MG/ML INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-285-20,NDC,facility,both,2,ML,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,59762-0074-1,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) IV SOLN",50863,CDM,250,RC,J3490,HCPCS,0013-1114-20,NDC,facility,both,1,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML INJ SOLN,50863,CDM,636,RC,J0171,HCPCS,76329-9061-0,NDC,facility,both,30,ML,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MYCOPHENOLATE 250 MG CAP,50863,CDM,250,RC,J7517,HCPCS,0093-7334-01,NDC,facility,both,2,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,55150-165-05,NDC,facility,both,300,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 10 MEQ/100 ML IV PGBK (USE NON-PROTOCOL PANEL),50863,CDM,J3480,HCPCS,0338-0709-48,NDC,,,facility,both,5,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,49502-393-80,NDC,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NOREPINEPHRINE BITARTRATE-NACL 4 MG/250 ML (16 MCG/ML) IV SOLN (CENTRAL ONLY),50863,CDM,250,RC,J3490,HCPCS,44567-640-01,NDC,facility,both,2,ML,,436,305.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BECLOMETHASONE DIPROPIONATE 40 MCG/ACTUATION INHL HFAB,50863,CDM,250,RC,J3490,HCPCS,59310-302-40,NDC,facility,both,1,GM,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GAMMAGARD S-D (IGA < 1 MCG/ML) 10 GRAM IV SOLR,50863,CDM,636,RC,J1566,HCPCS,0944-2658-04,NDC,facility,both,20,EA,JZ,4657,3259.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
HALOPERIDOL  1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0832-1520-89,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN  200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,10135-789-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML (PEDS CALCLUATOR 0.5),50863,CDM,250,RC,J1815,HCPCS,0024-5924-10,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CITRATE 4 % (3 ML) MISC SYRG,50863,CDM,250,RC,J3490,HCPCS,70004-900-25,NDC,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,250,RC,J3490,HCPCS,81284-611-00,NDC,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9% IV (PEDS) BOLUS,50863,CDM,250,RC,J7030,HCPCS,0264-7800-09,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  2.5 MG ORAL TAB,50863,CDM,250,RC,J7510,HCPCS,59651-485-01,NDC,facility,both,35,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML (1ML) INJ SOLN,50863,CDM,636,RC,J0169,HCPCS,42023-159-01,NDC,facility,both,10,ML,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 20 MG ORAL CPDR,50863,CDM,636,RC,J3490,HCPCS,0228-2890-06,NDC,facility,both,3,EA,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FERROUS SULFATE 75 MG/ML (ELEMENTAL IRON 15 MG/ML) ORAL DROP,50863,CDM,250,RC,J3490,HCPCS,87074002,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ANTIHEMOPHILIC FACTOR-VWF 1,000-2,400 UNIT IV KIT",50863,CDM,636,RC,J7187,HCPCS,63833-617-02,NDC,facility,both,1000,UN,,3220,2254,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 500 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,50268-152-11,NDC,facility,both,19,EA,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-1159-09,NDC,facility,both,2,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,50863,CDM,J1885,HCPCS,68462-755-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,9,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0121-1781-05,NDC,facility,both,2,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-ABDA 100 MG IV SOLR,50863,CDM,636,RC,Q5104,HCPCS,78206-162-99,NDC,facility,both,32,EA,,6654,4657.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,0409-9094-22,NDC,facility,both,2,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,3,EA,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0137,HCPCS,0143-9386-01,NDC,facility,both,63,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 0.6 MG/HR TD PT24,50863,CDM,250,RC,J3490,HCPCS,0378-9116-16,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,68516-5219-0,NDC,facility,both,14,ML,,3559,2491.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN (PF) NEO IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J1580,HCPCS,63323-513-02,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-8515-23,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0143-9386-01,NDC,facility,both,55,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 2 %-1:200,000 INJ SOLN",50863,CDM,J2004,HCPCS,63323-489-02,NDC,,,facility,both,200,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 30 MG/0.3 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,16714-006-01,NDC,facility,both,6,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 4 MG/ACTUATION NASL SPRY,50863,CDM,J3490,HCPCS,0093-2165-19,NDC,,,facility,both,1,EA,,303,212.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,16714-293-01,NDC,facility,both,2,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,636,RC,Q0162,HCPCS,60687-252-40,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,636,RC,J2003,HCPCS,63323-486-05,NDC,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,J3360,HCPCS,69339-136-03,NDC,,,facility,both,1,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,250,RC,J3490,HCPCS,0409-1323-15,NDC,facility,both,200,ML,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETIC ACID (VINEGAR) 5% IRRIGATION 12 ML (REPACK),50863,CDM,636,RC,J3490,HCPCS,5155200556,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELATACEPT 250 MG IV SOLR,50863,CDM,636,RC,J0485,HCPCS,0003-0371-13,NDC,facility,both,130,EA,JW,584,408.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
POLYETHYLENE GLYCOL 3350 17 GRAM (100 %) ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,0904-6931-86,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PILOCARPINE 5 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0527-1313-01,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLN (MERGE)",50863,CDM,250,RC,P9047,HCPCS,64208-2512-7,NDC,facility,both,8,ML,,950,665,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES  8.6 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6522-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-1982-61,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPTOMYCIN 500 MG IV SOLR,50863,CDM,J0878,HCPCS,70594-034-01,NDC,,,facility,both,300,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-03,NDC,facility,both,1,ML,JZ,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CLINDAMYCIN IN D5W 600 MG/50 ML IV PGBK,50863,CDM,J0736,HCPCS,0338-3612-50,NDC,,,facility,both,2,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-492-04,NDC,,,facility,both,60,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-7914-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-11,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-1749-70,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-04,NDC,facility,both,2,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,4,EA,,101,70.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"RABIES VACCINE,HUMAN DIPLOID (PF) 2.5 UNIT IM",50863,CDM,90675,HCPCS,49281-252-51,NDC,,,facility,both,1,EA,,1246,872.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  100 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,0641-6175-01,NDC,facility,both,4,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPATITIS A VIRUS VACCINE (PF) 720 EL UNIT/0.5 ML IM SYRG,50863,CDM,90633,HCPCS,58160-825-52,NDC,,,facility,both,1,ML,,223,156.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,J1885,HCPCS,68462-756-01,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE IN D5W 1 GRAM/100 ML IV PGBK,50863,CDM,636,RC,J3475,HCPCS,0409-6727-23,NDC,facility,both,2,ML,JZ,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SACUBITRIL-VALSARTAN 97-103 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0078-0696-20,NDC,facility,both,1,EA,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIOTHYRONINE  5 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,59762-1206-1,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL DECANOATE  50 MG/ML IM SOLN,50863,CDM,250,RC,J1631,HCPCS,70710-1461-1,NDC,facility,both,1,ML,,131,91.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHIMAZOLE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-680-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,72603-179-01,NDC,facility,both,8,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,250,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCHLOROTHIAZIDE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0172-2083-60,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J2004,HCPCS,63323-482-01,NDC,facility,both,300,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 25 MG/5 ML (5 MG/ML) ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,52536-600-11,NDC,facility,both,1,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAMADOL  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,29300-355-01,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 125 MG ORAL CPSP,50863,CDM,250,RC,J3490,HCPCS,68084-313-11,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,250,RC,J2270,HCPCS,0409-1890-03,NDC,facility,both,1,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0456,HCPCS,70436-019-82,NDC,facility,both,1,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESNA 100 MG/ML IV SOLN,50863,CDM,636,RC,J9209,HCPCS,10019-953-62,NDC,facility,both,3,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6501-61,NDC,facility,both,3,EA,,240,168,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN NPH HUMAN RECOMB 100 UNIT/ML SUBQ SUSP,50863,CDM,250,RC,J1815,HCPCS,0169-1834-11,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0093-4155-73,NDC,facility,both,13,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,138,96.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG/ML INJ SOLN,50863,CDM,636,RC,J2550,HCPCS,0641-6208-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HUMAN PROTHROMBIN COMPLEX 500 UNIT IV SOLR,50863,CDM,250,RC,J7168,HCPCS,63833-396-01,NDC,facility,both,2000,UN,,11638,8146.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,636,RC,J7510,HCPCS,17856-0759-5,NDC,facility,both,12,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,5,ML,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPH-MIN OIL-PETROLATUM 0.25-14-74.9 % RECT OINT,50863,CDM,250,RC,J3490,HCPCS,45802-188-16,NDC,facility,both,1,GM,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 0.1MG/ML SUSPENSION (REPACK),50863,CDM,636,RC,J3490,HCPCS,51079-882-01,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AXATILIMAB-CSFR 50 MG/ML IV SOLN,50863,CDM,J3490,HCPCS,50881-034-12,NDC,,,facility,both,1,ML,,25286,17700.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,250,RC,J7060,HCPCS,0338-0017-03,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,J1100,HCPCS,63323-506-01,NDC,,,facility,both,10,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFIXIME 100 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,16714-766-01,NDC,facility,both,1,ML,,378,264.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,42291-083-30,NDC,facility,both,2,EA,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,63323-104-25,NDC,facility,both,19,ML,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 40 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,16714-696-01,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAZOSIN 5 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,51079-632-01,NDC,facility,both,2,EA,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,0641-6145-01,NDC,facility,both,6,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
COLCHICINE 0.6 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7120-04,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,68180-441-02,NDC,facility,both,4,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,3,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,50863,CDM,250,RC,J9267,HCPCS,61703-342-22,NDC,facility,both,38,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,50863,CDM,250,RC,J9267,HCPCS,61703-342-22,NDC,facility,both,45,ML,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2003,HCPCS,55150-165-05,NDC,,,facility,both,500,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,50863,CDM,250,RC,J9264,HCPCS,68817-134-50,NDC,facility,both,200,EA,,8722,6105.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,63323-161-00,NDC,facility,both,1,ML,JZ,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SODIUM ACETATE 0.9% WITH HEPARIN IV SYRINGE (NEONATAL),50863,CDM,250,RC,J3490,HCPCS,0409-7984-06,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,250,RC,J0690,HCPCS,44567-707-25,NDC,facility,both,1,EA,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LACOSAMIDE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-676-11,NDC,facility,both,2,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,J3490,HCPCS,68094-231-59,NDC,,,facility,both,2,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6291-06,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,J3490,HCPCS,68094-231-59,NDC,,,facility,both,1,ML,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-22,NDC,facility,both,260,ML,,519,363.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BEVACIZUMAB-BVZR 25 MG/ML IV SOLN,50863,CDM,Q5118,HCPCS,0069-0342-01,NDC,,,facility,both,4,ML,,295,206.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN 100 MG ORAL TAB,50863,CDM,J3490,HCPCS,50268-506-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 40 MG/4 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,68094-756-59,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTOBARBITAL 75 MG/1.5 ML SYRINGE (REPACK),50863,CDM,636,RC,J3490,HCPCS,25021-676-20,NDC,facility,both,2,ML,,144,100.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,3,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOBENZAPRINE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-191-11,NDC,facility,both,9,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,68094-231-59,NDC,facility,both,5,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 400 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-6667-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN-ACETAMINOPHEN-CAFFEINE 250 MG-250 MG-65 MG TAB,50863,CDM,250,RC,J3490,HCPCS,70677-1133-1,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML (PEDS CALCLUATOR 0.5),50863,CDM,250,RC,J1815,HCPCS,0024-5924-10,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN NPH HUMAN RECOMB 100 UNIT/ML SUBQ SUSP,50863,CDM,250,RC,J1815,HCPCS,0169-1834-11,NDC,facility,both,9,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ICATIBANT 30 MG/3 ML SUBQ SYRG,50863,CDM,250,RC,J1744,HCPCS,0093-3066-34,NDC,facility,both,30,ML,JZ,29229,20460.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LEVOTHYROXINE 112 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6954-61,NDC,facility,both,1,EA,PLAD,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
"WATER FOR IRRIGATION, STERILE SOLUTION",50863,CDM,636,RC,J3490,HCPCS,0338-0004-03,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"CALCIUM GLUC IN NACL, ISO-OSM 1 G/100 ML IV SOLN",50863,CDM,250,RC,J0613,HCPCS,44567-622-01,NDC,facility,both,100,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 500 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,16714-299-02,NDC,facility,both,9,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-25,NDC,facility,both,55,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL IV BOLUS 10MG/ML (ANESTHESIA ONLY),50863,CDM,250,RC,J2704,HCPCS,63323-269-29,NDC,facility,both,80,ML,,160,112,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-8297-25,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 400 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0143-9887-01,NDC,facility,both,13,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,63323-461-01,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 400 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0143-9887-01,NDC,facility,both,5,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  50 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,64980-411-09,NDC,facility,both,2,EA,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2312,HCPCS,0409-1219-41,NDC,facility,both,400,ML,,513,359.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 150 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7002-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6007-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 20% IN WATER (NEO) 500ML,50863,CDM,250,RC,J3490,HCPCS,0990-7935-19,NDC,facility,both,1,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6642-61,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LITHIUM CARBONATE 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-8528-25,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE IV BOLUS (STROKE) 100 MG (2 X 50 MG VIALS),50863,CDM,250,RC,J2997,HCPCS,50242-044-06,NDC,facility,both,50,EA,,12145,8501.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAZOSIN 5 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,70954-021-10,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,63323-468-37,NDC,facility,both,2,ML,,143,100.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIPHTH,PERTUS(ACELL),TETANUS SYRG (INFANRIX) 25 LF UNIT-58MCG-10 LF/0.5ML IM SYRINGE",50863,CDM,250,RC,90700,HCPCS,58160-810-43,NDC,facility,both,2,ML,,343,240.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-426-02,NDC,facility,both,2,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,636,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,39,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,66,ML,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-04,NDC,facility,both,2,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,71288-402-10,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYBUTYNIN CHLORIDE  5 MG ORAL TO24,50863,CDM,636,RC,J3490,HCPCS,68084-480-11,NDC,facility,both,1,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-9558-05,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,70069-363-01,NDC,facility,both,1,ML,,223,156.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-124-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,6,EA,JW,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ENOXAPARIN 100 MG/1 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,0548-5605-00,NDC,facility,both,10,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APREPITANT  40 MG ORAL CAP,50863,CDM,250,RC,J8501,HCPCS,0781-2321-06,NDC,facility,both,1,EA,,396,277.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,63,ML,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 125 MG ORAL CPSP,50863,CDM,636,RC,J3490,HCPCS,0904-6615-61,NDC,facility,both,4,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE 25 MG/ML INJ SOLN,50863,CDM,250,RC,J3230,HCPCS,0641-1398-31,NDC,facility,both,2,ML,,389,272.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-466-03,NDC,facility,both,100,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,73,ML,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 5 MG-325 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0406-0123-23,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB 100 MG IV SOLR,50863,CDM,636,RC,J1745,HCPCS,57894-030-01,NDC,facility,both,80,EA,JZ,25786,18050.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,70594-117-01,NDC,facility,both,100,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRIMIDONE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-202-11,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"RSV VAC, PREF A AND PREF B(PF) 120 MCG/0.5 ML IM SOLR",50863,CDM,250,RC,90678,HCPCS,0069-0207-01,NDC,facility,both,1,EA,,1087,760.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR 800 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-062-11,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 0.1MG/ML SUSPENSION (REPACK),50863,CDM,250,RC,J3490,HCPCS,51079-882-01,NDC,facility,both,10,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYMETAZOLINE 0.05 % NASL SPRA,50863,CDM,250,RC,J3490,HCPCS,0904-7427-30,NDC,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE  0.65 % NASL SPRA,50863,CDM,636,RC,J3490,HCPCS,45802-357-58,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG ORAL TB12,50863,CDM,636,RC,J3490,HCPCS,42806-275-01,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  0.25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6373-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,16714-294-01,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE  1 % TOP CREA,50863,CDM,636,RC,J3490,HCPCS,0472-0321-26,NDC,facility,both,1,GM,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 10 % (100 MG/ML) MISC SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-695-22,NDC,facility,both,2,ML,,129,90.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXAZEPAM 15 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,62584-813-11,NDC,facility,both,2,EA,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-559-01,NDC,facility,both,20,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6928-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FILGRASTIM-SNDZ 300 MCG/0.5 ML INJ SYRG,50863,CDM,250,RC,Q5101,HCPCS,61314-318-05,NDC,facility,both,300,ML,,972,680.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,250,RC,FAMNOCHARGE,HCPCS,17856-0691-5,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLP,50863,CDM,250,RC,J3480,HCPCS,63323-965-02,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,0409-1886-22,NDC,facility,both,50,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 150 MG/1 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,0548-5607-00,NDC,facility,both,15,ML,,133,93.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 10 % (100 MG/ML) MISC SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-695-22,NDC,facility,both,1,ML,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0002-4115-30,NDC,facility,both,3,EA,,241,168.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 7.5 MG-325 MG TAB,50863,CDM,636,RC,J3490,HCPCS,68084-863-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE IN 0.9 % SOD CHLOR 4 MG/250 ML (16 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-315-01,NDC,facility,both,3,ML,,705,493.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TICAGRELOR 90 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0186-0777-39,NDC,facility,both,1,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,0409-3178-01,NDC,,,facility,both,135,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,16,ML,JW,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,51754-5001-1,NDC,facility,both,2,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NORETHINDRONE ACETATE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68462-304-50,NDC,facility,both,4,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,315,ME,JZ,4275,2992.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
POTASSIUM CHLORIDE 20 MEQ/100 ML IV PGBK,50863,CDM,250,RC,J3480,HCPCS,0990-7075-26,NDC,facility,both,10,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 300 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,65162-649-78,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-31,NDC,facility,both,1,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,49,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,953,ME,JZ,12933,9053.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ARIPIPRAZOLE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65162-898-09,NDC,facility,both,1,EA,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,250,RC,J2405,HCPCS,63323-373-02,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,250,RC,J0330,HCPCS,71449-126-15,NDC,facility,both,6,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,0409-3178-16,NDC,,,facility,both,370,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,J2003,HCPCS,0409-4277-02,NDC,,,facility,both,200,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZONATATE 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7153-61,NDC,facility,both,50,EA,,145,101.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 15 MG/ML (1.5 %) INJ SOLN,50863,CDM,J2001,HCPCS,63323-493-91,NDC,,,facility,both,30,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FINASTERIDE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-314-11,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),50863,CDM,250,RC,J3490,HCPCS,0409-4888-02,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,150,ML,PLAD,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
FUROSEMIDE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7177-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.45 % 0.45 % IV SOLP,50863,CDM,636,RC,J3490,HCPCS,0264-7802-00,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WHITE PETROLATUM TOP OIPK,50863,CDM,636,RC,J3490,HCPCS,8452100686,NDC,facility,both,1,GM,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK,50863,CDM,250,RC,J3490,HCPCS,12870-0001-1,NDC,facility,both,5,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,0143-9577-01,NDC,,,facility,both,300,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELATACEPT 250 MG IV SOLR,50863,CDM,636,RC,J0485,HCPCS,0003-0371-13,NDC,facility,both,87,EA,JW,391,273.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,68516-5219-0,NDC,facility,both,12,ML,,3050,2135,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 17 GRAM (100 %) ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,1152372688,NDC,facility,both,6,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IMIPRAMINE 10 MG TAB,50863,CDM,250,RC,J3490,HCPCS,69315-133-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,300,ML,,294,205.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR  6 MG/ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,68180-678-01,NDC,facility,both,5,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
URSODIOL 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,50268-797-11,NDC,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 250 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,50268-259-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,636,RC,Q0162,HCPCS,16714-671-02,NDC,facility,both,2,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLNALTREXONE 12 MG/0.6 ML SUBQ SYRG,50863,CDM,250,RC,J2212,HCPCS,65649-552-04,NDC,facility,both,40,ML,,368,257.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PORACTANT ALFA 240 MG/3 ML INTR SUSP,50863,CDM,250,RC,J3490,HCPCS,10122-510-03,NDC,facility,both,1,ML,,3108,2175.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,42806-150-33,NDC,facility,both,2,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 25 MG/5 ML (5 MG/ML) ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,62559-204-12,NDC,facility,both,1,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,25021-053-01,NDC,facility,both,6,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,44567-600-04,NDC,facility,both,2,ML,,440,308,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,50863,CDM,250,RC,Q0177,HCPCS,0904-6617-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,250,RC,J3490,HCPCS,39822-1000-1,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-744-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 50 MG/ML INJECTION,50863,CDM,J1200,HCPCS,72485-101-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69315-905-05,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MINOCYCLINE 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,13668-484-50,NDC,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE 0.25 MG/2 ML INHL NBSP,50863,CDM,250,RC,J3490,HCPCS,0487-9601-01,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-406-03,NDC,facility,both,1,ML,,202,141.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 50 MG/ML IV SOLN,50863,CDM,636,RC,J0282,HCPCS,63323-616-03,NDC,facility,both,15,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN  325 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,57896-921-01,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  50 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6992-61,NDC,facility,both,4,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,13533-690-25,NDC,facility,both,2,ML,,434,303.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-492-27,NDC,facility,both,60,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN NORMAL SALINE IV,50863,CDM,250,RC,J7042,HCPCS,0264-7610-00,NDC,facility,both,2,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRBESARTAN 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,31722-731-30,NDC,facility,both,1,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 400 MCG/100 ML (4 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0338-9557-12,NDC,facility,both,1,ML,,165,115.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML IV (MERGE) (FOR VENT),50863,CDM,250,RC,J3010,HCPCS,70092-1509-35,NDC,facility,both,25,ML,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 17 GRAM (100 %) ORAL PWPK,50863,CDM,636,RC,J3490,HCPCS,0904-6931-86,NDC,facility,both,3,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM IN NACL (ISO-OS) 1000 MG/100 ML IV PGBK,50863,CDM,250,RC,J1953,HCPCS,36000-356-01,NDC,facility,both,100,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 0.1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-220-11,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,62756-711-86,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,55150-370-01,NDC,facility,both,17,ML,JW,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
POTASSIUM IODIDE 130 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51803-001-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,2,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUANFACINE 1 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,62332-745-31,NDC,facility,both,4,EA,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,0641-6145-01,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE (PF-DURAMORPH/ASTRAMORPH) 0.5 MG/ML INJ SOLN,50863,CDM,250,RC,J2274,HCPCS,0409-3814-11,NDC,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % MUCOSAL SOLN (VISCOUS),50863,CDM,636,RC,J3490,HCPCS,50383-775-17,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,5,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE-SALMETEROL 500 MCG-50 MCG/DOSE DISK DEVICE FOR INHALATION,50863,CDM,636,RC,J3490,HCPCS,66993-586-97,NDC,facility,both,1,EA,,1345,941.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1940,HCPCS,23155-473-33,NDC,facility,both,25,ML,,133,93.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,71456-001-01,NDC,facility,both,8,ML,,1409,986.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-1749-70,NDC,facility,both,2,ML,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,35,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,J2704,HCPCS,63323-269-65,NDC,,,facility,both,100,ML,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 15 MG/ML (1.5 %) INJ SOLN,50863,CDM,J2003,HCPCS,0409-4776-10,NDC,,,facility,both,225,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,70,ML,,101,70.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,46,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,0409-3178-16,NDC,,,facility,both,90,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-580-11,NDC,facility,both,8,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOLTERODINE 2 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,60687-319-11,NDC,facility,both,1,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETIRIZINE 5 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,68094-004-59,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCERIN (ADULT) RECTAL SUPPOSITORY,50863,CDM,250,RC,J3490,HCPCS,0132-0079-24,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,63323-165-01,NDC,facility,both,8,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT  25 MCG/ML INJ SOLN,50863,CDM,250,RC,J0881,HCPCS,55513-002-01,NDC,facility,both,25,ML,EC,836,585.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier EC: Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,250,RC,J3490,HCPCS,0409-4277-01,NDC,facility,both,400,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 400 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0143-9887-01,NDC,facility,both,3,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),50863,CDM,636,RC,J3490,HCPCS,0409-4888-02,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCHLOROTHIAZIDE  25 MG ORAL TAB,50863,CDM,J3490,HCPCS,60687-593-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FERRIC SUBSULFATE 0.2 TO 0.22 GRAM/ML MISC SOLA,50863,CDM,636,RC,J3490,HCPCS,10481-0112-8,NDC,facility,both,1,ML,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4 % TOPICAL SOLN,50863,CDM,636,RC,J3490,HCPCS,76329-6300-5,NDC,facility,both,1,ML,,11670,8169,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAMSULOSIN 0.4 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,0904-6401-61,NDC,facility,both,8,EA,,165,115.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VORICONAZOLE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7024-04,NDC,facility,both,2,EA,,225,157.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-04,NDC,facility,both,2,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 20 MG ORAL TAB,50863,CDM,636,RC,J0500,HCPCS,60687-380-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SYRG,50863,CDM,250,RC,J3490,HCPCS,8290306547,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"CIPROFLOXACIN-HYDROCORTISONE 0.2 %-1 % EAR DROPS, SUSP",50863,CDM,250,RC,J3490,HCPCS,0065-8531-10,NDC,facility,both,1,ML,,1119,783.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,250,RC,J0132,HCPCS,55150-259-30,NDC,facility,both,60,ML,,271,189.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL  50 MCG/HR TD PT72,50863,CDM,636,RC,J3490,HCPCS,0378-9122-16,NDC,facility,both,1,EA,,129,90.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-22,NDC,facility,both,20,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,30,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHIMAZOLE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-669-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 10 MG/50 ML (0.2MG/ML) PCA IN NS (MERGE),50863,CDM,250,RC,J1171,HCPCS,61553-830-41,NDC,facility,both,50,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,549,ME,,7450,5215,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,50863,CDM,250,RC,J0561,HCPCS,60793-701-02,NDC,facility,both,12,ML,,1307,914.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TERBUTALINE 1 MG/ML SUBQ SOLN,50863,CDM,250,RC,J3105,HCPCS,0143-9746-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 3000 MCG/ML INJECTION,50863,CDM,636,RC,J0153,HCPCS,67457-855-00,NDC,facility,both,12,ML,JZ,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ESMOLOL  100 MG/10 ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,55150-194-10,NDC,facility,both,1,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID (PORK)  60 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42192-330-01,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-ABDA 100 MG IV SOLR,50863,CDM,636,RC,Q5104,HCPCS,78206-162-99,NDC,facility,both,38,EA,,7902,5531.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANTI-THYMOCYTE GLOB (RABBIT) 25 MG IV SOLR,50863,CDM,J7511,HCPCS,58468-0080-1,NDC,,,facility,both,3,EA,,6066,4246.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6572-61,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 2 %-1:200,000 INJ SOLN",50863,CDM,J2004,HCPCS,63323-489-27,NDC,,,facility,both,400,ML,,138,96.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BEVACIZUMAB-BVZR 25 MG/ML IV SOLN,50863,CDM,Q5118,HCPCS,0069-0315-01,NDC,,,facility,both,30,ML,,5079,3555.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"TRANEXAMIC ACID IN NACL,ISO-OS 1,000 MG/100 ML (10 MG/ML) IV PGBK",50863,CDM,636,RC,J3490,HCPCS,51754-0108-3,NDC,facility,both,1,ML,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE  2 MG/ML INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-285-23,NDC,facility,both,2,ML,,130,91,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORATADINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-246-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN D5W 1 GRAM/200 ML IV PGBK,50863,CDM,250,RC,J3373,HCPCS,0338-3552-48,NDC,facility,both,2,ML,PLAD,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,50863,CDM,250,RC,J3420,HCPCS,63323-044-00,NDC,facility,both,1,ML,JZ,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CARBIDOPA-LEVODOPA SR 50 MG-200 MG TAB,50863,CDM,250,RC,J3490,HCPCS,16729-079-01,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NYSTATIN 100000 UNIT/ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0904-7276-41,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,250,RC,J0690,HCPCS,44567-707-25,NDC,facility,both,4,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  20 MEQ ORAL PACK,50863,CDM,636,RC,J3490,HCPCS,72888-024-06,NDC,facility,both,2,EA,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN SODIUM  2 GRAM INJ SOLR,50863,CDM,250,RC,J0290,HCPCS,25021-137-20,NDC,facility,both,4,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NYSTATIN 100000 UNIT/ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,60687-800-40,NDC,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-572-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GAMMAGARD LIQUID 10 % IV SOLN,50863,CDM,636,RC,J1569,HCPCS,0944-2700-12,NDC,facility,both,80,ML,,14422,10095.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 250 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,42192-608-05,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6666-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-833-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7001-61,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-5755-23,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 500 MG (200 MG ELEMENTAL) CHEW TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6412-92,NDC,facility,both,16,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-31,NDC,facility,both,1,ML,JZ,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-406-03,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TARLATAMAB-DLLE 10 MG IV SOLR,50863,CDM,250,RC,C9170,HCPCS,55513-069-01,NDC,facility,both,10,EA,,41381,28966.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 125 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-519-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"RSV VAC, PREF A AND PREF B(PF) 120 MCG/0.5 ML IM SOLR",50863,CDM,250,RC,90678,HCPCS,0069-0344-01,NDC,facility,both,1,EA,,1045,731.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 1 MG/ML PCA (PDS MERGE),50863,CDM,636,RC,J3490,HCPCS,61553-820-41,NDC,facility,both,1,ML,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXAZOSIN 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-5522-61,NDC,facility,both,3,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,J3490,HCPCS,63323-462-01,NDC,,,facility,both,1,ML,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-826-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,0409-9094-18,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-4279-02,NDC,facility,both,300,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLN,50863,CDM,636,RC,J3262,HCPCS,50242-136-01,NDC,facility,both,200,ML,,3666,2566.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65862-642-30,NDC,facility,both,2,EA,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  500 MG IV SOLR,50863,CDM,250,RC,J3373,HCPCS,0409-4332-11,NDC,facility,both,50,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,72266-118-01,NDC,facility,both,1,ML,PLAD,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-492-09,NDC,facility,both,50,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOBENZAPRINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-191-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) IV SOLN",50863,CDM,250,RC,J3490,HCPCS,43066-008-01,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,50863,CDM,636,RC,J9000,HCPCS,25021-207-25,NDC,facility,both,15,ML,,432,302.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,42806-312-50,NDC,facility,both,1,EA,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,250,RC,J2003,HCPCS,63323-208-01,NDC,facility,both,300,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM IN NACL (ISO-OS) 1000 MG/100 ML IV PGBK,50863,CDM,250,RC,J1953,HCPCS,55150-247-47,NDC,facility,both,100,ML,,229,160.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,24689-907-01,NDC,facility,both,2,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,6,ML,,101,70.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROMETHORPHAN POLY COMPLEX ER 30 MG/5 ML ORAL SU12,50863,CDM,J3490,HCPCS,63824-171-63,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE (PF-DURAMORPH/ASTRAMORPH) 0.5 MG/ML INJ SOLN,50863,CDM,250,RC,J2274,HCPCS,0641-6020-01,NDC,facility,both,1,ML,,170,119,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4% TOP PATCH,50863,CDM,636,RC,J3490,HCPCS,46581-830-01,NDC,facility,both,4,EA,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,50863,CDM,J3301,HCPCS,70121-1049-1,NDC,,,facility,both,2,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE NA (PRESERV FREE) 25 MG/ML INJ SOLN,50863,CDM,250,RC,J9260,HCPCS,0703-3671-01,NDC,facility,both,81,ML,,4920,3444,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-1159-19,NDC,facility,both,2,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,62332-600-01,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 12.5 MG RECT SUPP,50863,CDM,250,RC,J3490,HCPCS,45802-758-00,NDC,facility,both,1,EA,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 150 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7002-61,NDC,facility,both,2,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FEBUXOSTAT 40 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-538-11,NDC,facility,both,2,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NAPROXEN 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-491-11,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J7510,HCPCS,17856-0815-1,NDC,facility,both,4,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,50863,CDM,636,RC,J1756,HCPCS,0517-2340-01,NDC,facility,both,300,ML,,963,674.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
URSODIOL 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,59651-421-01,NDC,facility,both,1,EA,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN STERILE WATER 2 GRAM/20 ML IV SYRG,50863,CDM,250,RC,J0690,HCPCS,73702-132-23,NDC,facility,both,8,ML,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-ABDA 100 MG IV SOLR,50863,CDM,636,RC,Q5104,HCPCS,78206-162-99,NDC,facility,both,57,EA,,11853,8297.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZIPRASIDONE 40 MG CAP,50863,CDM,250,RC,J3490,HCPCS,68084-104-11,NDC,facility,both,2,EA,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL 10MG/1ML SUSPENSION (REPACK),50863,CDM,250,RC,J3490,HCPCS,57664-167-52,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,63323-806-13,NDC,facility,both,7,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 50% IN WATER (MERGE RECORD),50863,CDM,250,RC,J7060,HCPCS,0409-4902-34,NDC,facility,both,1,ML,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,250,RC,J0132,HCPCS,70594-111-01,NDC,facility,both,60,ML,,306,214.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACCHAROMYCES BOULARDII 250 MG ORAL CAP,50863,CDM,J3490,HCPCS,904723006,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-ABDA 100 MG IV SOLR,50863,CDM,636,RC,Q5104,HCPCS,0006-4305-01,NDC,facility,both,57,EA,,11853,8297.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLECAINIDE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-321-11,NDC,facility,both,2,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-406-03,NDC,facility,both,1,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-279-11,NDC,facility,both,28,EA,,539,377.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,66689-056-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAPTOPRIL 1 MG/ML SOLUTION (REPACK),50863,CDM,250,RC,J3490,HCPCS,0143-1171-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0264-7800-10,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM 2000 MG IV SOLR,50863,CDM,250,RC,J2185,HCPCS,72078-081-00,NDC,facility,both,20,EA,JZ,184,128.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ASPIRIN 81 MG ORAL CHEW,50863,CDM,636,RC,J3490,HCPCS,0904-6794-30,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 100 MG/ML FROM 1 GRAM VIAL (PRMC PEDS ONLY),50863,CDM,636,RC,J0696,HCPCS,0409-7332-11,NDC,facility,both,4,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6773-61,NDC,facility,both,2,EA,PLAD,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,63323-010-02,NDC,facility,both,2,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-492-07,NDC,facility,both,300,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,0409-6102-18,NDC,facility,both,40,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE SODIUM 2.5 MG ORAL TAB,50863,CDM,250,RC,J8610,HCPCS,51079-670-01,NDC,facility,both,3,EA,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OFLOXACIN 0.3 % OPHT DROP,50863,CDM,636,RC,J3490,HCPCS,72485-613-10,NDC,facility,both,1,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0121-1781-05,NDC,facility,both,4,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE  2 MG/ML INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,70069-062-01,NDC,facility,both,2,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2308-02,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,68094-231-59,NDC,facility,both,4,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 112 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,42292-039-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AGALSIDASE BETA  5 MG IV SOLR,50863,CDM,636,RC,J0180,HCPCS,58468-0041-1,NDC,facility,both,5,EA,JZ,2148,1503.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,23155-687-31,NDC,facility,both,2,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE-DEXTROSE-WATER(PF) 7.5 MG/ML (0.75 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-1761-18,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE NA (PRESERV FREE) 25 MG/ML INJ SOLN,50863,CDM,250,RC,J9260,HCPCS,61703-408-41,NDC,facility,both,180,ML,,1940,1358,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6641-61,NDC,facility,both,3,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA SR 50 MG-200 MG TAB,50863,CDM,250,RC,J3490,HCPCS,51079-923-01,NDC,facility,both,2,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOVASTATIN 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,61442-142-01,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MODAFINIL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65862-601-30,NDC,facility,both,3,EA,,336,235.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,16714-036-01,NDC,facility,both,8,ML,JZ,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DEXTROSE 10% IN WATER (NEO) 2 - 3.99 KG,50863,CDM,250,RC,J3490,HCPCS,0264-7520-10,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,50863,CDM,250,RC,J9075,HCPCS,10019-956-16,NDC,facility,both,113,EA,,727,508.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 800 MG ORAL TAB,50863,CDM,250,RC,J0601,HCPCS,65162-058-27,NDC,facility,both,80,EA,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALACYCLOVIR 500 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-6565-61,NDC,,,facility,both,2,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,J3490,HCPCS,67457-433-00,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"CIPROFLOXACIN-HYDROCORTISONE 0.2 %-1 % EAR DROPS, SUSP",50863,CDM,636,RC,J3490,HCPCS,0078-0855-26,NDC,facility,both,1,ML,,1291,903.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GOSERELIN 10.8 MG SUBQ IMPL,50863,CDM,J9202,HCPCS,70720-951-30,NDC,,,facility,both,3,EA,,5010,3507,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,13,EA,JW,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,J3490,HCPCS,63323-185-10,NDC,,,facility,both,2,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,125,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,72603-179-01,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM NEONATAL INJECTION 0.2 MG/0.5 ML,50863,CDM,250,RC,J2060,HCPCS,0641-6046-01,NDC,facility,both,20,ML,,138,96.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOLIC ACID 1 MG / 0.2 ML SYRINGE (CDS ADS REPACK),50863,CDM,250,RC,J3490,HCPCS,63323-184-10,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,J3490,HCPCS,0093-2279-73,NDC,,,facility,both,3,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
0.2 MICRON FILTER ATTACHMENT MISC MISC,50863,CDM,99999-0403-06,NDC,,,,,facility,both,1,EA,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 50 MG/ML IV SOLN,50863,CDM,250,RC,J0282,HCPCS,63323-616-03,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-098-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL,50863,CDM,250,RC,J3490,HCPCS,63323-820-01,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BISOPROLOL FUMARATE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,29300-126-01,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,5,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 500 MG INJ SOLR,50863,CDM,636,RC,J0696,HCPCS,0409-7338-11,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIFEDIPINE 10 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7229-61,NDC,facility,both,2,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FERROUS SULFATE 75 MG/ML (ELEMENTAL IRON 15 MG/ML) ORAL DROP,50863,CDM,250,RC,J3490,HCPCS,6961807059,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 10 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0591-0794-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-5771-23,NDC,facility,both,14,EA,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL (VITAMIN D3)  1000 UNIT ORAL TAB,50863,CDM,J3490,HCPCS,2055503300,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,636,RC,J2270,HCPCS,0641-6125-01,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 50 MG/ML IM,50863,CDM,636,RC,J3410,HCPCS,0517-5601-25,NDC,facility,both,1,ML,JW,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CAFFEINE CITRATED 20 MG/ML IV SOLN,50863,CDM,250,RC,J0706,HCPCS,51754-0500-1,NDC,facility,both,9,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 10 MEQ/100 ML IV PGBK (USE NON-PROTOCOL PANEL),50863,CDM,636,RC,J3480,HCPCS,0338-0709-48,NDC,facility,both,10,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PATIROMER CALCIUM SORBITEX  8.4 G ORAL PWPK,50863,CDM,636,RC,J3490,HCPCS,53436-084-01,NDC,facility,both,2,EA,,362,253.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7912-51,NDC,facility,both,24,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  500 MG IV SOLR,50863,CDM,636,RC,J3370,HCPCS,70436-020-82,NDC,facility,both,2,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7050,HCPCS,0338-0049-02,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,70436-030-82,NDC,facility,both,122,ML,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-497-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAZOSIN 1 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0378-1101-01,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL  0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-733-01,NDC,facility,both,1,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,3,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FERROUS SULFATE 325 MG (65 MG IRON) TAB,50863,CDM,250,RC,J3490,HCPCS,904759182,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-131-11,NDC,facility,both,6,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0781-6041-46,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,63323-806-14,NDC,facility,both,20,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
23.4% SODIUM CHLORIDE (4 MEQ/ML) INJECTION,50863,CDM,250,RC,J3490,HCPCS,63323-093-30,NDC,facility,both,1,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 0.1 % TOP CREAM,50863,CDM,250,RC,J3490,HCPCS,45802-064-35,NDC,facility,both,1,GM,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7243-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYMETAZOLINE 0.05 % NASAL MERGE,50863,CDM,250,RC,J3490,HCPCS,45802-410-59,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MICAFUNGIN 100 MG IV SOLR,50863,CDM,250,RC,J2248,HCPCS,42023-230-01,NDC,facility,both,13,EA,JW,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LACOSAMIDE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0131-2477-35,NDC,facility,both,3,EA,,208,145.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,74,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 500 MG PE/10 ML INJ SOLN,50863,CDM,250,RC,Q2009,HCPCS,25021-798-10,NDC,facility,both,25,ML,,292,204.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,100,EA,,245,171.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISATRACURIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0781-3153-80,NDC,facility,both,1,ML,,1008,705.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 20 MG/ML ORAL CONC,50863,CDM,636,RC,J3490,HCPCS,16714-601-02,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,25021-601-03,NDC,facility,both,15,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE  1 % TOP OINT,50863,CDM,250,RC,J3490,HCPCS,45802-276-03,NDC,facility,both,1,GM,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-25,NDC,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE  7.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,57237-007-30,NDC,facility,both,2,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPTOMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0878,HCPCS,72603-152-01,NDC,facility,both,650,EA,JZ,1901,1330.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,4,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2310,HCPCS,0641-6132-01,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,250,RC,J3490,HCPCS,72789-057-01,NDC,facility,both,3,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,50863,CDM,250,RC,J1756,HCPCS,0517-2340-01,NDC,facility,both,300,ML,,963,674.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,50863,CDM,J9263,HCPCS,67457-469-10,NDC,,,facility,both,37,ML,,160,112,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,J1171,HCPCS,76045-009-10,NDC,,,facility,both,25,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 160 MG-800 MG TAB,50863,CDM,J3490,HCPCS,0904-2725-61,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENFORTUMAB VEDOTIN-EJFV 30 MG IV SOLR,50863,CDM,J9177,HCPCS,51144-030-01,NDC,,,facility,both,360,EA,,26207,18344.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,2,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE IN D5W 1 GRAM/100 ML IV PGBK,50863,CDM,250,RC,J3475,HCPCS,0409-6727-23,NDC,facility,both,2,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 10 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7345-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,200,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL  20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-717-11,NDC,facility,both,3,EA,,242,169.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE (CONTRACEPTIVE) 150 MG/ML IM SUSP,50863,CDM,250,RC,J1050,HCPCS,0009-0746-30,NDC,facility,both,150,ML,,268,187.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THEOPHYLLINE 300 MG ORAL TB12,50863,CDM,636,RC,J3490,HCPCS,68462-721-01,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  75 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6951-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-4279-02,NDC,facility,both,300,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR NEO/PEDS INFUSION (CDS FROM PREMIX),50863,CDM,250,RC,J0133,HCPCS,63323-325-10,NDC,facility,both,16,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,10019-506-37,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,68516-5214-1,NDC,facility,both,2,ML,JZ,447,312.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J2310,HCPCS,0409-1215-01,NDC,facility,both,2,ML,,465,325.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 250 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,51079-766-01,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES  8.6 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7252-61,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MINOCYCLINE  50 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0591-5694-60,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NYSTATIN 100000 UNIT/ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,69315-504-60,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,636,RC,J3490,HCPCS,70860-400-41,NDC,facility,both,1,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-1971-21,NDC,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEG 3350-ELECTROLYTES 236 G-22.74 G-6.74 G-5.86 G ORAL SOLUTION,50863,CDM,J3490,HCPCS,43386-090-19,NDC,,,facility,both,1,ML,,157,109.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,250,RC,Q0162,HCPCS,65162-691-79,NDC,facility,both,2,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J2004,HCPCS,63323-487-01,NDC,facility,both,200,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE SODIUM 2.5 MG ORAL TAB,50863,CDM,250,RC,J8610,HCPCS,51079-670-01,NDC,facility,both,7,EA,,214,149.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUANFACINE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0591-0444-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 10 GRAM/15 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0116-4005-30,NDC,facility,both,3,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIPASE-PROTEASE-AMYLASE (PORK) 3,000-9,500- 15,000 UNIT ORAL CPDR",50863,CDM,250,RC,J3490,HCPCS,0032-0045-70,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,636,RC,P9045,HCPCS,0944-0495-06,NDC,facility,both,1,ML,JZ,245,171.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,636,RC,J3490,HCPCS,0409-4887-10,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0904-6923-61,NDC,facility,both,85,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,13668-010-01,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-02,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,636,RC,J2560,HCPCS,72162-1330-6,NDC,facility,both,1,ML,,159,111.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,J3490,HCPCS,63037-136-25,NDC,,,facility,both,2,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 150 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-432-11,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",50863,CDM,250,RC,J1561,HCPCS,13533-800-21,NDC,facility,both,10,ML,,1415,990.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELIMUMAB 120 MG IV SOLR,50863,CDM,636,RC,J0490,HCPCS,49401-101-01,NDC,facility,both,24,ME,JZ,2819,1973.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
AMPHETAMINE-DEXTROAMPHETAMINE  5 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,31722-185-01,NDC,facility,both,1,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 400 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0143-9887-01,NDC,facility,both,9,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN LOCK FLUSH 100 UNIT/ML IV SOLN,50863,CDM,250,RC,J1642,HCPCS,6425333335,NDC,facility,both,50,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-9791-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25%/EPINEPHRINE 1:100K INJECTION,50863,CDM,636,RC,J3490,HCPCS,0409-1158-01,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENAZOPYRIDINE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65162-682-10,NDC,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J2003,HCPCS,0409-4279-16,NDC,facility,both,300,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR PHOSPHATE 75 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,42291-664-10,NDC,facility,both,1,EA,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-31,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,50863,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,19,EA,,410,287,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,250,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0121-1022-05,NDC,facility,both,6,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,75,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAZOLAMIDE SODIUM 500 (100 MG/ML) INJ SOLR,50863,CDM,250,RC,J1120,HCPCS,23155-313-31,NDC,facility,both,1,EA,,233,163.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) MISC SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-694-22,NDC,facility,both,1,ML,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT 200 MCG/0.4 ML INJ SYRG,50863,CDM,250,RC,J0881,HCPCS,55513-028-01,NDC,facility,both,200,ML,EC,4273,2991.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier EC: Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,13,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES  8.6 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7252-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,78206-121-01,NDC,facility,both,2,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6641-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-381-11,NDC,facility,both,1,EA,,198,138.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,65862-006-01,NDC,facility,both,2,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE 3 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,65162-778-10,NDC,facility,both,2,EA,,244,170.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 650 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7261-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,1,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN NEO/PEDS IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0456,HCPCS,63323-398-14,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN NACL (PF) 1000 UNIT/500 ML IV SOLP,50863,CDM,J1644,HCPCS,0409-1005-01,NDC,,,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,J2795,HCPCS,17478-081-30,NDC,,,facility,both,100,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,16714-294-01,NDC,facility,both,3,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 25 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-7308-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4 % TOPICAL SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-4698-01,NDC,facility,both,3,ML,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,8,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,63323-468-37,NDC,facility,both,1,ML,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,250,RC,J3360,HCPCS,76045-204-00,NDC,facility,both,1,ML,JW,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
BENDAMUSTINE 25 MG/ML IV SOLN,50863,CDM,250,RC,J9034,HCPCS,63459-348-04,NDC,facility,both,300,ML,,20484,14338.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,67457-433-00,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-464-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-406-03,NDC,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,250,RC,Q9968,HCPCS,0517-0381-01,NDC,facility,both,23,ML,JW,130,91,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LIDOCAINE 2 % MUCOSAL SOLN (VISCOUS),50863,CDM,250,RC,J3490,HCPCS,62135-712-42,NDC,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) MISC SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-694-04,NDC,facility,both,1,ML,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0093-4177-73,NDC,facility,both,13,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 250 MG-62.5 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,59651-026-75,NDC,facility,both,6,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,46,ML,JW,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,121119030,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-735-01,NDC,facility,both,3,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 120 MG/0.8 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,16714-056-10,NDC,facility,both,11,ML,JZ,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,70095-031-01,NDC,facility,both,27,ML,,1108,775.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3373,HCPCS,0143-9162-01,NDC,facility,both,50,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4 % TOPICAL SOLN,50863,CDM,636,RC,J3490,HCPCS,76329-6300-5,NDC,facility,both,1,ML,,5002,3501.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 5 MG/ML IV SOLN,50863,CDM,250,RC,J1921,HCPCS,0409-2267-20,NDC,facility,both,1,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,55150-177-05,NDC,facility,both,100,ML,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,50863,CDM,250,RC,J8540,HCPCS,0054-8175-25,NDC,facility,both,32,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-9543-02,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0264-7800-20,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-1749-70,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,0641-0476-21,NDC,facility,both,2,ML,,310,217,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 150 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-711-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 125 MG ORAL CPSP,50863,CDM,250,RC,J3490,HCPCS,55111-532-01,NDC,facility,both,8,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J2004,HCPCS,63323-482-03,NDC,facility,both,400,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,50863,CDM,636,RC,J0585,HCPCS,0023-1145-01,NDC,facility,both,66,EA,JW,459,321.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
AMOXICILLIN 250 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,16714-298-02,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV (BOLUS),50863,CDM,636,RC,J7120,HCPCS,0264-7750-00,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENAZOPYRIDINE 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,65162-682-10,NDC,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXAZOSIN 2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-851-95,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTAMIDINE 300 MG INJ SOLR,50863,CDM,636,RC,J3490,HCPCS,63323-113-01,NDC,facility,both,1,EA,,328,229.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68180-998-01,NDC,facility,both,4,EA,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) 1000 UNITS/ML INJ SOL (FOR DIALYSIS ONLY),50863,CDM,636,RC,J1644,HCPCS,25021-400-10,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,38,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,67457-423-00,NDC,facility,both,2,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,636,RC,J3490,HCPCS,0641-6236-01,NDC,facility,both,2,ML,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN PEDS SYRINGE (20MG/ML) IN DEXTROSE (CDS MIX,50863,CDM,250,RC,J0690,HCPCS,0781-3451-70,NDC,facility,both,2,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2305-04,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,71288-505-02,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROATE SODIUM 100 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0143-9785-01,NDC,facility,both,2,ML,,203,142.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,J3490,HCPCS,63323-486-05,NDC,,,facility,both,300,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTAMIDINE 300 MG INJ SOLR,50863,CDM,636,RC,J3490,HCPCS,63323-113-01,NDC,facility,both,1,EA,,241,168.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,50863,CDM,636,RC,J0696,HCPCS,0781-3209-90,NDC,facility,both,4,EA,,194,135.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,J0665,HCPCS,0409-1162-02,NDC,,,facility,both,260,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,72,ML,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,J0665,HCPCS,70594-118-01,NDC,,,facility,both,160,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LITHIUM CARBONATE 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-4527-25,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL  20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65162-351-09,NDC,facility,both,2,EA,,196,137.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IV PGBK,50863,CDM,250,RC,J3475,HCPCS,0338-1715-40,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,40,ML,JZ,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LISINOPRIL  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,43547-352-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR IRRIGATION, STERILE SOLUTION",50863,CDM,250,RC,J3490,HCPCS,0338-0004-04,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 125 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,60687-211-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,68094-193-59,NDC,facility,both,4,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,250,RC,J0330,HCPCS,0409-6629-02,NDC,facility,both,5,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,636,RC,J2795,HCPCS,43066-023-01,NDC,facility,both,300,ML,,107,74.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ACTUATION NASL SPRA,50863,CDM,250,RC,J3490,HCPCS,60505-0823-6,NDC,facility,both,1,ML,,427,298.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,5026852411,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM,50863,CDM,636,RC,J3490,HCPCS,16714-496-01,NDC,facility,both,1,GM,,184,128.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 0.1 % TOP OINT,50863,CDM,250,RC,J3490,HCPCS,51672-1284-1,NDC,facility,both,1,GM,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 30 MG/0.3 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,16714-006-01,NDC,facility,both,3,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,76329-3352-1,NDC,facility,both,5,ML,,579,405.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TORSEMIDE   5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-754-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FIDAXOMICIN 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,52015-080-01,NDC,facility,both,1,EA,,882,617.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZTREONAM 1 GRAM INJ SOLR,50863,CDM,250,RC,J0457,HCPCS,0409-0829-11,NDC,facility,both,5,EA,JW,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ISRADIPINE  2.5 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,16252-539-01,NDC,facility,both,4,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,636,RC,J1100,HCPCS,25021-053-01,NDC,facility,both,12,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZOCAINE-MENTHOL 15-2.6 MG MM LOZG,50863,CDM,250,RC,J3490,HCPCS,17856-0732-1,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN-DILUENT COMBO NO.1 1.25 GRAM/250 ML IV PGBK,50863,CDM,250,RC,J3370,HCPCS,70594-057-01,NDC,facility,both,3,ML,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1MG/ML ORAL SOLUTION (HIGH CONC FOR PEDS),50863,CDM,J3490,HCPCS,99999-407-47,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,41,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 400 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0143-9887-01,NDC,facility,both,12,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,636,RC,J2270,HCPCS,76045-004-10,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLP",50863,CDM,250,RC,P9047,HCPCS,0944-0493-04,NDC,facility,both,1,ML,JW,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
"TOBRAMYCIN-DEXAMETHASONE 0.3 %-0.1 % EYE DROPS, SUSP",50863,CDM,250,RC,J3490,HCPCS,24208-295-25,NDC,facility,both,1,ML,,258,180.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,37000-024-44,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6938-06,NDC,facility,both,2,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 0.125 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,13668-091-90,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,FAMNOCHARGE,HCPCS,0904-7127-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES-DOCUSATE SODIUM 8.6 MG-50 MG TAB,50863,CDM,250,RC,J3490,HCPCS,57896-303-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENTACAPONE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6822-07,NDC,facility,both,1,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,22,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NORTRIPTYLINE 10 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,75907-069-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5%-1/2 NORMAL SALINE IV (PEDS ONCOLOGY),50863,CDM,250,RC,J7042,HCPCS,0338-0085-04,NDC,facility,both,2,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMANTADINE 50 MG/5 ML ORAL SYRP,50863,CDM,250,RC,J3490,HCPCS,0121-0646-10,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,100,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
OLMESARTAN  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68462-436-30,NDC,facility,both,2,EA,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 0.1 % DENT PSTE,50863,CDM,250,RC,J3490,HCPCS,51672-1267-5,NDC,facility,both,1,GM,,342,239.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51672-4027-1,NDC,facility,both,4,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL 2.5 MG/ML SUSPENSION,50863,CDM,250,RC,J3490,HCPCS,99999-0404-75,NDC,facility,both,1,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0832-1211-89,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPROST TROMETHAMINE 250 MCG/ML IM SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-0064-01,NDC,facility,both,1,ML,,457,319.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,0409-3178-01,NDC,,,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 400 MCG/100 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0143-9525-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ABATACEPT 250 MG IV SOLR,50863,CDM,J0129,HCPCS,0003-2187-13,NDC,,,facility,both,75,EA,,12534,8773.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV,50863,CDM,636,RC,J7120,HCPCS,0338-0117-04,NDC,facility,both,2,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 300 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,69452-125-50,NDC,facility,both,1,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  75 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,50268-874-11,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 80 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-8301-25,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE  50 MG ORAL TAB,50863,CDM,636,RC,j3490,HCPCS,60687-443-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.2 MG/24 HR TD PTWK,50863,CDM,250,RC,J3490,HCPCS,0378-0872-16,NDC,facility,both,1,EA,,237,165.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAVASTATIN 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-5892-61,NDC,facility,both,2,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG IV SOLR,50863,CDM,636,RC,J3490,HCPCS,55150-202-00,NDC,facility,both,1,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASCORBIC ACID  500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,904052361,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 50 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,59651-489-01,NDC,facility,both,65,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 80 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-590-95,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,87,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RASBURICASE 1.5 MG IV SOLR,50863,CDM,250,RC,J2783,HCPCS,0024-5154-11,NDC,facility,both,2,EA,JW,835,584.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CYCLOBENZAPRINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-558-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6868-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,250,RC,Q0162,HCPCS,65162-691-79,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,250,RC,J3490,HCPCS,70092-1119-44,NDC,facility,both,2,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0780,HCPCS,23155-294-41,NDC,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VARENICLINE 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68462-893-56,NDC,facility,both,1,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,67877-246-01,NDC,facility,both,1,EA,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,71456-001-01,NDC,facility,both,1,ML,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,51754-5001-1,NDC,facility,both,1,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE SOD SUCC (PF) 100 MG/2 ML INJ SOLR,50863,CDM,636,RC,J1720,HCPCS,0009-0011-03,NDC,facility,both,1,EA,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,0641-6145-01,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENAZEPRIL 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-110-11,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,250,RC,J7999,HCPCS,70092-1017-46,NDC,facility,both,4,ML,,159,111.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,250,RC,J7999,HCPCS,70092-1017-46,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCRALFATE 1 GRAM ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,59762-0401-1,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J3430,HCPCS,69097-708-96,NDC,facility,both,10,ML,,218,152.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRIL MALEATE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51672-4245-1,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-443-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-9543-03,NDC,facility,both,1,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,20,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
METOPROLOL SUCCINATE SR 100 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,50268-542-11,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,50863,CDM,250,RC,J9000,HCPCS,0069-1542-20,NDC,facility,both,11,ML,,170,119,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VECURONIUM BROMIDE 10 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,0703-2914-01,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLIMEPIRIDE 2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-359-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE (FOR CODE) 10% (100 MG/ML) IV SYRINGE,50863,CDM,250,RC,J3490,HCPCS,64253-900-30,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL  32.4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6575-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV (BOLUS),50863,CDM,636,RC,J7120,HCPCS,17271-710-06,NDC,facility,both,1,ML,,1631,1141.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,10135-676-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0121-1781-05,NDC,facility,both,4,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 25% IN WATER (D25W) IV SYRINGE,50863,CDM,250,RC,J3490,HCPCS,0409-1775-10,NDC,facility,both,2,ML,,200,140,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,50863,CDM,636,RC,Q5119,HCPCS,0069-0249-01,NDC,facility,both,100,ML,,19784,13848.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIVOLUMAB 240 MG/24 ML IV SOLN,50863,CDM,250,RC,J9299,HCPCS,0003-3774-12,NDC,facility,both,100,ML,,6819,4773.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML (PEDS CALCLUATOR 0.5),50863,CDM,250,RC,J1815,HCPCS,0024-5924-10,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 50 MG/ML INJECTION,50863,CDM,636,RC,J1200,HCPCS,63323-664-01,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,250,RC,J0132,HCPCS,0574-0805-30,NDC,facility,both,240,ML,,3249,2274.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,Q0162,HCPCS,68094-763-59,NDC,,,facility,both,4,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLP",50863,CDM,250,RC,P9047,HCPCS,0944-0493-04,NDC,facility,both,4,ML,JZ,1001,700.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CEFDINIR 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,67877-548-88,NDC,facility,both,2,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,250,RC,Q9968,HCPCS,71288-811-10,NDC,facility,both,35,ML,JW,197,137.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GUANFACINE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,59651-840-01,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CANDESARTAN 16 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,33342-116-07,NDC,facility,both,2,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN IN D5W 400 MG/200 ML IV PGBK,50863,CDM,250,RC,J0744,HCPCS,36000-009-24,NDC,facility,both,2,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,68094-600-59,NDC,facility,both,3,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN IN D5W 600 MG/50 ML IV PGBK,50863,CDM,636,RC,J0736,HCPCS,0338-3612-50,NDC,facility,both,4,ML,,126,88.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-103-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IVPB (PEDIATRICS/ADULT NON-FORM)",50863,CDM,250,RC,J0131,HCPCS,24201-100-01,NDC,facility,both,100,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0780,HCPCS,23155-294-41,NDC,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARGININE HCL (L-ARGININE) 10 % IV SOLP,50863,CDM,636,RC,J3490,HCPCS,0009-0436-01,NDC,facility,both,1,ML,,214,149.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,50863,CDM,250,RC,J9263,HCPCS,60505-6132-7,NDC,facility,both,400,ML,,864,604.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE ERX) (STEMI),50863,CDM,250,RC,J3101,HCPCS,50242-120-47,NDC,facility,both,25,EA,,11451,8015.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,11,EA,JW,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,72205-101-01,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VERAPAMIL 120 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,75834-320-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J2003,HCPCS,63323-492-04,NDC,facility,both,40,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,10702-018-01,NDC,facility,both,18,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE PAMOATE  50 MG ORAL CAP,50863,CDM,250,RC,Q0177,HCPCS,50268-399-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J2003,HCPCS,0409-4279-02,NDC,facility,both,300,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  5 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,59746-306-12,NDC,facility,both,1,EA,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE MODIFIED 100 MG ORAL CAP,50863,CDM,636,RC,J7502,HCPCS,51862-460-01,NDC,facility,both,1,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-4279-16,NDC,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7914-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL  32.4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,13517-626-01,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),50863,CDM,250,RC,J1815,HCPCS,0024-5926-05,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 0.1 % TOP OINT,50863,CDM,250,RC,J3490,HCPCS,0168-0006-15,NDC,facility,both,1,GM,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J2250,HCPCS,0409-0001-01,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,50863,CDM,636,RC,Q0177,HCPCS,0904-6617-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV (BOLUS),50863,CDM,250,RC,J7120,HCPCS,0264-7750-07,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,0573-0179-20,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MODAFINIL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-621-11,NDC,facility,both,1,EA,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTAMIDINE 300 MG INJ SOLR,50863,CDM,636,RC,J3490,HCPCS,63323-113-01,NDC,facility,both,1,EA,,349,244.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAMSULOSIN 0.4 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,0904-6401-61,NDC,facility,both,20,EA,,357,249.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZTROPINE 1 MG/ML INJ SOLN,50863,CDM,250,RC,J0515,HCPCS,0143-9233-01,NDC,facility,both,2,ML,,229,160.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE-ALOE VERA TOPICAL GEL,50863,CDM,250,RC,J3490,HCPCS,225052547,NDC,facility,both,1,GM,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MICAFUNGIN 100 MG IV SOLR,50863,CDM,250,RC,J2248,HCPCS,25021-191-10,NDC,facility,both,200,EA,,1616,1131.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 5 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,0143-9873-01,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTAZIDIME   1 GRAM INJ SOLR,50863,CDM,250,RC,J0713,HCPCS,0409-5082-11,NDC,facility,both,2,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0456,HCPCS,55150-174-10,NDC,facility,both,1,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 125 MG ORAL CPSP,50863,CDM,250,RC,J3490,HCPCS,55111-532-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J3490,HCPCS,0338-0049-41,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 300 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68180-976-09,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-580-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LURASIDONE  60 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7357-61,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYUREA  500 MG ORAL CAP,50863,CDM,250,RC,J9999,HCPCS,0904-6939-61,NDC,facility,both,4,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4% TOP PATCH,50863,CDM,250,RC,J3490,HCPCS,70512-812-01,NDC,facility,both,2,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0093-4177-73,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,65,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  1 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,64380-782-06,NDC,facility,both,3,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,25021-468-10,NDC,facility,both,1,EA,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUVOXAMINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0832-1671-11,NDC,facility,both,3,EA,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN V POTASSIUM 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,57237-041-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 17 GRAM (100 %) ORAL PWPK,50863,CDM,636,RC,J3490,HCPCS,0904-6931-86,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCRALFATE 100 MG/ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0121-0974-10,NDC,facility,both,2,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4% TOP PATCH,50863,CDM,250,RC,J3490,HCPCS,0536-1202-15,NDC,facility,both,1,EA,PLAD,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,2,EA,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
AMOXICILLIN-POT CLAVULANATE 875 MG-125 MG TAB,50863,CDM,250,RC,J3490,HCPCS,42571-162-42,NDC,facility,both,14,EA,,300,210,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0456,HCPCS,63323-398-01,NDC,facility,both,1,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7126-61,NDC,facility,both,10,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE IN 0.9% NACL 3 GRAM/100 ML IV SOLN,50863,CDM,636,RC,J0612,HCPCS,61553-056-48,NDC,facility,both,300,ML,,128,89.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IFOSFAMIDE 3 GRAM IV SOLR,50863,CDM,250,RC,J9208,HCPCS,10019-926-16,NDC,facility,both,6,EA,,930,651,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIVAROXABAN  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50458-577-01,NDC,facility,both,1,EA,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-822-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LATANOPROST 0.005 % OPHT DROP,50863,CDM,250,RC,J3490,HCPCS,70069-421-01,NDC,facility,both,1,ML,,403,282.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 400 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-5853-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 0.1 % TOP LOTN,50863,CDM,250,RC,J3490,HCPCS,0713-0676-53,NDC,facility,both,1,ML,,382,267.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LURASIDONE 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7355-04,NDC,facility,both,3,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G POTASSIUM 20000000 UNIT INJ SOLR,50863,CDM,250,RC,J2540,HCPCS,70860-127-51,NDC,facility,both,14,EA,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,59762-0075-1,NDC,facility,both,5,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,59762-0075-1,NDC,facility,both,3,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J1940,HCPCS,23155-473-32,NDC,facility,both,2,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-833-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5%-1/4 NORMAL SALINE IV,50863,CDM,250,RC,J3490,HCPCS,0338-0077-03,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RAMUCIRUMAB 10 MG/ML IV SOLN,50863,CDM,J9308,HCPCS,0002-7669-01,NDC,,,facility,both,4,ML,,258,180.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR PHOSPHATE 75 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,47781-470-13,NDC,facility,both,1,EA,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"HYOSCYAMINE 0.125 MG TAB, RAPID DISSOLVE",50863,CDM,636,RC,J3490,HCPCS,42192-338-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  75 MG ORAL CP24,50863,CDM,636,RC,J3490,HCPCS,50268-874-11,NDC,facility,both,3,EA,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOSTIGMINE METHYLSULFATE 3 MG/3 ML (1 MG/ML) IV SYRG,50863,CDM,250,RC,J2710,HCPCS,69374-932-03,NDC,facility,both,1,ML,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-DYYB 100 MG IV SOLR,50863,CDM,636,RC,Q5103,HCPCS,0069-0809-01,NDC,facility,both,60,EA,,15671,10969.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,636,RC,J1953,HCPCS,0409-1886-22,NDC,facility,both,150,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL (VITAMIN D3)   400 UNIT ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,7733394825,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 125 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-519-11,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROPROCAINE 3 % INJ SOLN,50863,CDM,636,RC,J2401,HCPCS,63323-478-01,NDC,facility,both,555,ML,JW,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0548-5603-00,NDC,facility,both,6,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYTOCIN 10 UNIT/ML INJ SOLN,50863,CDM,250,RC,J2590,HCPCS,42023-116-25,NDC,facility,both,4,ML,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM-ALBUTEROL 20-100 MCG/ACTUATION INHL MIST,50863,CDM,250,RC,J3490,HCPCS,0597-0024-02,NDC,facility,both,1,GM,,1392,974.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,124,ML,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK,50863,CDM,636,RC,J3490,HCPCS,12870-0001-1,NDC,facility,both,3,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,81284-315-05,NDC,facility,both,1,ML,,441,308.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK,50863,CDM,636,RC,J3490,HCPCS,12870-0001-2,NDC,facility,both,3,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAZOLAMIDE 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6663-61,NDC,facility,both,3,EA,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,41,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,3,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON DEXTRAN 50 MG/ML INJ SOLN,50863,CDM,250,RC,J1750,HCPCS,0023-6082-01,NDC,facility,both,10,ML,,1042,729.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLN,50863,CDM,636,RC,J3262,HCPCS,50242-136-01,NDC,facility,both,600,ML,,10996,7697.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE  10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,70756-201-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 125 MG/5 ML (25MG/ML) ORAL SYRINGE (REPACK),50863,CDM,J3370,HCPCS,67457-340-00,NDC,,,facility,both,2,EA,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 50 MG/ML INJECTION,50863,CDM,250,RC,J1200,HCPCS,63323-664-00,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL  50 MCG/HR TD PT72,50863,CDM,250,RC,J3490,HCPCS,0378-9122-16,NDC,facility,both,1,EA,,129,90.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-48,NDC,facility,both,1,ML,JZ,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-38,NDC,facility,both,1,ML,JZ,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ENOXAPARIN 30 MG/0.3 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,16714-006-10,NDC,facility,both,3,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PYRAZINAMIDE 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,70954-484-10,NDC,facility,both,2,EA,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL IV BOLUS 10MG/ML (ANESTHESIA ONLY),50863,CDM,250,RC,J2704,HCPCS,0409-4699-54,NDC,facility,both,300,ML,,380,266,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  37.5 MG ORAL CP24,50863,CDM,636,RC,J3490,HCPCS,59762-0180-3,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL  32.4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16571-673-01,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV,50863,CDM,636,RC,J7120,HCPCS,0338-0117-04,NDC,facility,both,2,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,16714-294-01,NDC,facility,both,17,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROATE SODIUM 100 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0143-9785-01,NDC,facility,both,1,ML,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCRALFATE 1 GRAM ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-753-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 600 MG ORAL TP12,50863,CDM,250,RC,J3490,HCPCS,63824-008-15,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,1,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 200 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16729-457-15,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6927-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7030,HCPCS,0338-0049-04,NDC,facility,both,1,ML,JZ,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
QUETIAPINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6640-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV (BOLUS),50863,CDM,250,RC,J7120,HCPCS,0264-7750-00,NDC,facility,both,2,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  750 MG IV SOLR,50863,CDM,250,RC,J3373,HCPCS,63323-203-01,NDC,facility,both,75,EA,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2308-21,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM  1.5 GRAM INJ SOLR,50863,CDM,250,RC,J0295,HCPCS,0049-0013-81,NDC,facility,both,1,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,68,ML,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6291-06,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  88 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6952-61,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMANTADINE 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7042-06,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN   81 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,57896-981-12,NDC,facility,both,4,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 3 MG/ML IV SYRG,50863,CDM,636,RC,J0153,HCPCS,0469-8234-12,NDC,facility,both,6,ML,JZ,212,148.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DULOXETINE 60 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,60687-745-11,NDC,facility,both,2,EA,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,250,RC,J0132,HCPCS,70594-111-01,NDC,facility,both,88,ML,,447,312.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,250,RC,J7060,HCPCS,0338-0017-02,NDC,facility,both,2,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4% TOP PATCH,50863,CDM,250,RC,J3490,HCPCS,46581-830-06,NDC,facility,both,4,EA,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7188-61,NDC,facility,both,3,EA,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML IV,50863,CDM,636,RC,J3490,HCPCS,55150-425-01,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN   1.25 G IV SOLR,50863,CDM,250,RC,J3370,HCPCS,67457-823-99,NDC,facility,both,3,EA,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE  50 MG/ML INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,42023-114-10,NDC,facility,both,1,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE ACETATE 25 MG RECT SUPP,50863,CDM,250,RC,J3490,HCPCS,42494-341-12,NDC,facility,both,1,EA,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NYSTATIN  100000 UNIT/G TOP CREA,50863,CDM,250,RC,J3490,HCPCS,0713-0678-15,NDC,facility,both,1,GM,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-492-57,NDC,facility,both,90,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-4278-01,NDC,facility,both,250,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-384-11,NDC,facility,both,2,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL  3.125 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7305-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,20,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML (ANESTHESIA INTRAOP ONLY),50863,CDM,250,RC,J3010,HCPCS,0641-6027-01,NDC,facility,both,3,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOBRAMYCIN SULFATE 40 MG/ML INJ SOLN,50863,CDM,250,RC,J3260,HCPCS,67457-473-22,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,0143-9682-01,NDC,facility,both,2,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0536-1286-36,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,51754-5001-1,NDC,facility,both,3,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-02,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-48,NDC,facility,both,1,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,29,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J3490,HCPCS,0990-7983-61,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,636,RC,J2405,HCPCS,0641-6078-01,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE  10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-037-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,871,ME,JZ,11820,8274,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,J7050,HCPCS,0338-0049-03,NDC,,,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-145-11,NDC,facility,both,30,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN NPH HUMAN RECOMB 100 UNIT/ML SUBQ SUSP,50863,CDM,250,RC,J1815,HCPCS,0169-1834-11,NDC,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-31,NDC,facility,both,1,ML,,121,84.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,63323-806-13,NDC,facility,both,8,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,636,RC,J2270,HCPCS,0409-1890-13,NDC,facility,both,1,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,10,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-50,NDC,facility,both,46,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM-ALBUTEROL 0.5 MG-2.5 MG/3 ML NEB SOLUTION,50863,CDM,250,RC,J3490,HCPCS,0487-0201-01,NDC,facility,both,8,ML,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,250,RC,J3360,HCPCS,0409-1273-03,NDC,facility,both,12,ML,,1186,830.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB 100 MG IV SOLR,50863,CDM,250,RC,J1745,HCPCS,57894-030-01,NDC,facility,both,40,EA,,12893,9025.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,42806-150-33,NDC,facility,both,6,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADVATE: FACTOR VIII CONCENTRATE (MERGE RECORD),50863,CDM,636,RC,J7192,HCPCS,0944-3051-02,NDC,facility,both,240,UN,JW,437,305.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DEXMEDETOMIDINE IN 0.9 % NACL 400 MCG/100 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0338-9557-12,NDC,facility,both,1,ML,,165,115.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J2004,HCPCS,0409-3178-01,NDC,facility,both,150,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLMESARTAN  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68462-436-30,NDC,facility,both,1,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GAMMAGARD LIQUID 10 % IV SOLN,50863,CDM,636,RC,J1569,HCPCS,0944-2700-04,NDC,facility,both,10,ML,"JZ,JA",1803,1262.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
LEVONORGESTREL 1.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16714-809-01,NDC,facility,both,1,EA,,165,115.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,66,EA,,9108,6375.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0832-1211-89,NDC,facility,both,3,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PORACTANT ALFA 240 MG/3 ML INTR SUSP,50863,CDM,250,RC,J3490,HCPCS,10122-510-03,NDC,facility,both,4,ML,,13040,9128,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE 25 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,68180-657-01,NDC,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,70069-363-01,NDC,facility,both,1,ML,,203,142.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MILRINONE IN D5W 20 MG/100 ML (0.2 MG/ML) INFUSION,50863,CDM,250,RC,J2260,HCPCS,55150-287-01,NDC,facility,both,4,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,636,RC,J3490,HCPCS,67457-197-10,NDC,facility,both,1,ML,,368,257.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-7914-61,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,50863,CDM,J3490,HCPCS,0409-2051-15,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,636,RC,J3490,HCPCS,55150-188-10,NDC,facility,both,2,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,17856-7014-7,NDC,facility,both,2,ML,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYPROHEPTADINE 4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-189-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMOSOZUMAB-AQQG 105 MG/1.17 ML SUBQ SYRG,50863,CDM,636,RC,J3111,HCPCS,55513-998-01,NDC,facility,both,210,ML,JZ,5349,3744.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MORPHINE  30 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,0406-8330-23,NDC,facility,both,1,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE (DIAGNOSTIC) 3 MG/ML IV SOLN,50863,CDM,250,RC,J0153,HCPCS,16714-997-01,NDC,facility,both,180,ML,,1470,1029,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIMODIPINE 30 MG/5 ML ORAL SYRG,50863,CDM,250,RC,J3490,HCPCS,24338-230-15,NDC,facility,both,2,ML,,462,323.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESNA 100 MG/ML IV SOLN,50863,CDM,250,RC,J9209,HCPCS,10019-953-62,NDC,facility,both,3,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESNA 100 MG/ML IV SOLN,50863,CDM,250,RC,J9209,HCPCS,25021-201-10,NDC,facility,both,10,ML,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J2004,HCPCS,63323-482-03,NDC,facility,both,200,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SYRG,50863,CDM,636,RC,J3490,HCPCS,8290306546,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,250,RC,J3360,HCPCS,0409-1273-03,NDC,facility,both,2,ML,,198,138.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOLIC ACID  1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65162-361-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 500 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,0904-7182-61,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-6625-22,NDC,facility,both,1,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-206-01,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 0.25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-570-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLN (MERGE)",50863,CDM,636,RC,P9047,HCPCS,68516-5216-2,NDC,facility,both,2,ML,,427,298.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42858-001-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,112,ML,,101,70.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0003-0893-31,NDC,facility,both,2,EA,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-354-11,NDC,facility,both,4,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  2.5 MG ORAL TAB,50863,CDM,250,RC,J7510,HCPCS,59651-485-01,NDC,facility,both,2,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,50863,CDM,J3490,HCPCS,60687-742-11,NDC,,,facility,both,2,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,67457-423-00,NDC,facility,both,1,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,150,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,60,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,67,ML,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 0.1 MG/ML INJ SYRG,50863,CDM,636,RC,J0461,HCPCS,76329-3340-1,NDC,facility,both,100,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROPROCAINE 3 % INJ SOLN,50863,CDM,250,RC,J2401,HCPCS,0143-9210-01,NDC,facility,both,54,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,636,RC,J2003,HCPCS,63323-485-27,NDC,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTAMIDINE 300 MG INJ SOLR,50863,CDM,636,RC,J3490,HCPCS,63323-113-01,NDC,facility,both,1,EA,,362,253.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,636,RC,J1596,HCPCS,0143-9679-01,NDC,facility,both,22,ML,,502,351.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,70069-363-01,NDC,facility,both,1,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,72789-062-01,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  25 MG ORAL TAB,50863,CDM,J3490,HCPCS,78206-121-01,NDC,,,facility,both,1,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 80 MG/ML SUSP FOR INJECTION,50863,CDM,J1010,HCPCS,0009-3475-01,NDC,,,facility,both,80,ML,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-492-27,NDC,,,facility,both,80,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % MUCOSAL SOLN (VISCOUS),50863,CDM,J3490,HCPCS,0121-4950-15,NDC,,,facility,both,1,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-319-11,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE  7 MG/24 HR TD PT24,50863,CDM,250,RC,J3490,HCPCS,43598-446-71,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,J7040,HCPCS,0338-0049-18,NDC,,,facility,both,1,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GRANISETRON 1 MG/ML (1 ML) IV SOLN,50863,CDM,250,RC,J1626,HCPCS,0143-9744-01,NDC,facility,both,10,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,FAMNOCHARGE,HCPCS,0338-0049-48,NDC,,,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANTI-THYMOCYTE GLOB (RABBIT) 25 MG IV SOLR,50863,CDM,250,RC,J7511,HCPCS,58468-0080-1,NDC,facility,both,7,EA,,14154,9907.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,65862-707-80,NDC,facility,both,5,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % MBP,50863,CDM,250,RC,J3490,HCPCS,0338-0553-18,NDC,facility,both,1,ML,PLAD,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
CHLORPROMAZINE  10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-419-11,NDC,facility,both,1,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG ORAL CAP,50863,CDM,J3490,HCPCS,60687-152-11,NDC,,,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4% TOP PATCH,50863,CDM,J3490,HCPCS,0536-1202-15,NDC,,,facility,both,3,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,50863,CDM,J9263,HCPCS,71288-101-20,NDC,,,facility,both,400,ML,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERGOCALCIFEROL (VITAMIN D2) 50000 UNIT ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,50268-297-11,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOPROTERENOL 0.2 MG/ML INJECTION,50863,CDM,250,RC,J3490,HCPCS,0548-9501-00,NDC,facility,both,1,ML,,800,560,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,636,RC,J3490,HCPCS,0904-6930-61,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML INJ SOLN,50863,CDM,J0169,HCPCS,76329-9060-0,NDC,,,facility,both,300,ML,,797,557.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6966-61,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOBENZAPRINE 10 MG ORAL TAB,50863,CDM,J3490,HCPCS,60687-558-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,636,RC,P9045,HCPCS,68516-5219-0,NDC,facility,both,12,ML,,3050,2135,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % MUCOSAL SOLN (VISCOUS),50863,CDM,J3490,HCPCS,0054-8500-16,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,50863,CDM,J9075,HCPCS,70121-1239-1,NDC,,,facility,both,195,EA,,813,569.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANTI-INHIBITOR COAGULANT CMPLX (PHS MERGE),50863,CDM,J7198,HCPCS,64193-426-02,NDC,,,facility,both,410,UN,,2962,2073.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN 0.9% SODIUM CL 1.25 GRAM/250 ML IV SOLN,50863,CDM,636,RC,J3373,HCPCS,70004-923-59,NDC,facility,both,125,ML,,189,132.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 10 GRAM/15 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,45963-439-65,NDC,facility,both,1,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 20MG/ML IV SYRINGE (PEDS/NEO),50863,CDM,250,RC,J0612,HCPCS,63323-311-10,NDC,facility,both,44,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7057-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 40 MG-200 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,65862-496-47,NDC,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIHYDROERGOTAMINE 1 MG/ML INJ SOLN,50863,CDM,250,RC,J1110,HCPCS,0574-0850-05,NDC,facility,both,1,ML,,568,397.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,3,ML,,4336,3035.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,636,RC,J3490,HCPCS,70004-600-09,NDC,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TORSEMIDE  20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-539-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALSARTAN 160 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-634-11,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,50863,CDM,250,RC,J0696,HCPCS,60505-6149-0,NDC,facility,both,8,EA,,388,271.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 1 MG ORAL CAP,50863,CDM,250,RC,J7507,HCPCS,0904-7097-61,NDC,facility,both,2,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,12,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J2004,HCPCS,63323-482-03,NDC,facility,both,300,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,250,RC,J3490,HCPCS,0409-4277-01,NDC,facility,both,400,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 100 MG/5 ML ORAL LIQD,50863,CDM,636,RC,J3490,HCPCS,0121-1488-10,NDC,facility,both,2,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 100 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,31722-574-47,NDC,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPTOMYCIN IN 0.9 % SOD CHLOR 500 MG/50 ML IV PGBK,50863,CDM,636,RC,J3490,HCPCS,0338-0714-24,NDC,facility,both,500,ML,,159,111.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,50863,CDM,J3490,HCPCS,67877-548-88,NDC,,,facility,both,3,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 80 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6293-04,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SYRG,50863,CDM,J3490,HCPCS,6425311130,NDC,,,facility,both,2,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOXSALEN 20 MCG/ML INJ SOLN,50863,CDM,J9999,HCPCS,64067-216-01,NDC,,,facility,both,1,ML,,403,282.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % MUCOSAL GEL,50863,CDM,250,RC,J3490,HCPCS,50383-781-05,NDC,facility,both,2,ML,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,3,EA,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0264-7800-20,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0904-6923-61,NDC,facility,both,5,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,68462-755-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 150 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,16729-443-15,NDC,facility,both,2,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,25021-468-10,NDC,facility,both,2,EA,,458,320.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,50863,CDM,636,RC,J9045,HCPCS,0703-4248-01,NDC,facility,both,9,ML,,331,231.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-182-01,NDC,facility,both,1,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,7,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,636,RC,J1596,HCPCS,0517-4601-25,NDC,facility,both,4,ML,,159,111.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORDIAZEPOXIDE 10 MG CAP,50863,CDM,250,RC,J3490,HCPCS,0555-0033-02,NDC,facility,both,21,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,J2270,HCPCS,0641-6125-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 400 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6667-61,NDC,facility,both,4,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATENOLOL  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-759-20,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-4264-11,NDC,facility,both,12,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN 0.9% SODIUM CL 1.25 GRAM/250 ML IV SOLN,50863,CDM,250,RC,J3373,HCPCS,70092-9054-05,NDC,facility,both,125,ML,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  100 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,63323-376-00,NDC,facility,both,4,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 500 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,50268-152-15,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZONISAMIDE 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-230-11,NDC,facility,both,4,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE  25 MG ORAL CAP,50863,CDM,250,RC,J7515,HCPCS,0078-0240-61,NDC,facility,both,3,EA,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60505-0252-3,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 4 MEQ/ML IV SOLP (COMPOUNDED 30ML),50863,CDM,250,RC,J3490,HCPCS,63323-093-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR  6 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,42291-567-60,NDC,facility,both,3,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOBRAMYCIN 0.3 % EYE OINTMENT,50863,CDM,J3490,HCPCS,0078-0813-01,NDC,,,facility,both,1,GM,,902,631.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN   1.5 G IV SOLR,50863,CDM,636,RC,J3373,HCPCS,67457-824-15,NDC,facility,both,3,EA,JZ,142,99.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CARBIDOPA-LEVODOPA 25 MG-100 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0378-0085-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,50863,CDM,636,RC,J2359,HCPCS,55150-308-01,NDC,facility,both,8,EA,JZ,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-21,NDC,facility,both,10,ML,,1415,990.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0264-1800-32,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,14,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,63323-130-02,NDC,facility,both,5,EA,,773,541.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2308-22,NDC,facility,both,3,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
TEPROTUMUMAB-TRBW 500 MG IV SOLR,50863,CDM,636,RC,J3241,HCPCS,75987-130-15,NDC,facility,both,119,EA,JZ,84692,59284.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,10,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,66,ML,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN 250 MG SOLUTION FOR INJECTION,50863,CDM,250,RC,J0290,HCPCS,0781-3402-78,NDC,facility,both,1,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATED 20 MG/ML IV SOLN,50863,CDM,250,RC,J0706,HCPCS,51754-0500-1,NDC,facility,both,28,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE  50 MG ORAL TAB,50863,CDM,636,RC,j3490,HCPCS,0904-6868-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 40 MG-200 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,65862-496-47,NDC,facility,both,1,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,55,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,250,RC,J1596,HCPCS,0143-9679-01,NDC,facility,both,14,ML,,320,224,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL (PULM.HYPERTENSION) 10 MG/12.5 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,55150-166-13,NDC,facility,both,1,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SYRG,50863,CDM,636,RC,J3490,HCPCS,8290306504,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 125 MG/5 ML (25MG/ML) ORAL SYRINGE (REPACK),50863,CDM,250,RC,J3373,HCPCS,67457-340-00,NDC,facility,both,175,EA,,165,115.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-467-01,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CONJUGATED ESTROGENS 0.625 MG/G VAGL CREA,50863,CDM,250,RC,J3490,HCPCS,0046-0872-93,NDC,facility,both,1,GM,,574,401.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-337-11,NDC,facility,both,2,EA,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SYRG,50863,CDM,250,RC,J3490,HCPCS,8290306547,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE INFUSION 2MG/ML 100ML (FOR ANESTHESIA USE ONLY),50863,CDM,250,RC,J3490,HCPCS,0409-2051-05,NDC,facility,both,1,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSULFAN BLUE 1 % INJ SOLN,50863,CDM,636,RC,Q9968,HCPCS,67457-220-00,NDC,facility,both,20,ML,JW,583,408.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
HYDROCORTISONE SOD SUCC (PF) 100 MG/2 ML INJ SOLR,50863,CDM,636,RC,J1720,HCPCS,0009-0011-03,NDC,facility,both,2,EA,,269,188.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,63323-400-01,NDC,facility,both,250,ML,,263,184.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,250,RC,J3360,HCPCS,0641-6244-01,NDC,facility,both,2,ML,,145,101.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,5,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,1,EA,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0143-9506-01,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLP,50863,CDM,250,RC,J3480,HCPCS,63323-965-03,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NOREPINEPHRINE BITARTRATE-D5W 4 MG/250 ML (16 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0338-0112-20,NDC,facility,both,3,ML,,400,280,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THROMBIN (RECOMBINANT) 5000 UNIT TOP SOLR,50863,CDM,250,RC,J3490,HCPCS,0338-0322-01,NDC,facility,both,1,EA,,149,104.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,2055503601,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  1 MG/ML INJ SYRG,50863,CDM,J1171,HCPCS,0409-1283-10,NDC,,,facility,both,10,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DENOSUMAB 120 MG/1.7 ML (70 MG/ML) SUBQ SOLN,50863,CDM,250,RC,J0897,HCPCS,55513-730-01,NDC,facility,both,120,ML,,9068,6347.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-344-11,NDC,facility,both,2,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IR SOLN,50863,CDM,250,RC,J3490,HCPCS,0338-0047-46,NDC,facility,both,3,ML,,167,116.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 20 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7346-61,NDC,facility,both,5,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 50 MG/10 ML (5 MG/ML) IV SOLN,50863,CDM,636,RC,J2305,HCPCS,0517-4810-01,NDC,facility,both,1,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0955-1004-01,NDC,facility,both,4,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 500 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,50268-152-11,NDC,facility,both,20,EA,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,636,RC,J2405,HCPCS,0641-6078-01,NDC,facility,both,12,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,250,RC,J2003,HCPCS,0409-1323-15,NDC,facility,both,1000,ML,,400,280,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 60 MG ORAL CPDR,50863,CDM,636,RC,J3490,HCPCS,57237-019-90,NDC,facility,both,1,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,4,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0630,HCPCS,42023-205-01,NDC,facility,both,1,ML,,4321,3024.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,10019-016-39,NDC,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSULFAN BLUE 1 % INJ SOLN,50863,CDM,636,RC,Q9968,HCPCS,67457-220-00,NDC,facility,both,50,ML,,4299,3009.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,636,RC,J1596,HCPCS,0143-9680-01,NDC,facility,both,10,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,50863,CDM,J3490,HCPCS,0143-9509-01,NDC,,,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-01,NDC,facility,both,3,ML,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,61,ML,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN D5W 20000 UNIT/500 ML,50863,CDM,636,RC,J1644,HCPCS,0264-9567-10,NDC,facility,both,9,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,76329-3352-1,NDC,facility,both,2,ML,,232,162.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,636,RC,J2405,HCPCS,60505-6130-0,NDC,facility,both,4,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN SODIUM  2 GRAM INJ SOLR,50863,CDM,250,RC,J0290,HCPCS,65219-020-03,NDC,facility,both,4,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68180-966-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,15,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE  0.65 % NASL SPRA,50863,CDM,250,RC,J3490,HCPCS,49348-356-25,NDC,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % MBP,50863,CDM,250,RC,J3490,HCPCS,0338-0553-18,NDC,facility,both,3,ML,,145,101.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL DECANOATE  50 MG/ML IM SOLN,50863,CDM,250,RC,J1631,HCPCS,70756-615-10,NDC,facility,both,3,ML,,419,293.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANTIVENIN CROTALIDAE (EQUINE) INJ SOLR,50863,CDM,636,RC,J0841,HCPCS,66621-0790-2,NDC,facility,both,10,EA,,36432,25502.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,50863,CDM,250,RC,J9045,HCPCS,0703-4246-01,NDC,facility,both,3,ML,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,250,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,12,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VECURONIUM BROMIDE 10 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,0409-1632-21,NDC,facility,both,2,EA,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG/ML ORAL CONC,50863,CDM,636,RC,J3490,HCPCS,0054-3553-44,NDC,facility,both,3,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,50863,CDM,J3490,HCPCS,16714-294-02,NDC,,,facility,both,11,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,636,RC,J3490,HCPCS,72789-057-01,NDC,facility,both,6,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN STERILE WATER 2 GRAM/20 ML IV SYRG,50863,CDM,J0690,HCPCS,70092-1604-47,NDC,,,facility,both,8,ML,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,50863,CDM,636,RC,J0561,HCPCS,60793-701-02,NDC,facility,both,12,ML,,1188,831.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALGANCICLOVIR 450 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-965-95,NDC,facility,both,2,EA,,188,131.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J1610,HCPCS,63323-596-11,NDC,facility,both,10,EA,,7847,5492.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLP,50863,CDM,636,RC,J3480,HCPCS,63323-965-02,NDC,facility,both,20,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,55390-138-01,NDC,facility,both,4,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,18,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,43,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,J2003,HCPCS,63323-486-05,NDC,,,facility,both,200,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV MBP,50863,CDM,636,RC,J7060,HCPCS,0338-0551-18,NDC,facility,both,2,ML,,266,186.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFUROXIME AXETIL 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,65862-700-20,NDC,facility,both,1,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALASPARGASE PEGOL-MKNL 750 UNITS/ML IV SOLN,50863,CDM,250,RC,J9118,HCPCS,72694-515-01,NDC,facility,both,13,ML,,2519,1763.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,50863,CDM,250,RC,J3420,HCPCS,63323-044-00,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR PHOSPHATE 30 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,68180-675-11,NDC,facility,both,1,EA,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,2,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN NEO IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J3370,HCPCS,0338-3582-01,NDC,facility,both,2,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,4,EA,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 30 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-120-11,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,636,RC,J3490,HCPCS,0143-9575-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 0.2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60505-0258-1,NDC,facility,both,3,EA,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,42023-186-20,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE-SALMETEROL 100 MCG-50 MCG/DOSE DISK DEVICE FOR INHALATION,50863,CDM,636,RC,J3490,HCPCS,0054-0326-56,NDC,facility,both,1,EA,,1067,746.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOPAMINE INFUSION NEO IV SYRINGE (FROM PREMIX),50863,CDM,250,RC,J1265,HCPCS,0409-7809-11,NDC,facility,both,10,ML,JZ,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7050,HCPCS,0338-0049-02,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-587-11,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63304-773-01,NDC,facility,both,1,EA,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G POTASSIUM 20000000 UNIT INJ SOLR,50863,CDM,250,RC,J2540,HCPCS,0049-0530-28,NDC,facility,both,34,EA,,259,181.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,250,RC,J2405,HCPCS,23155-549-31,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MECLIZINE 25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-730-11,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6797-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIPASE-PROTEASE-AMYLASE 5,000-17,000- 24,000 UNIT ORAL CPDR",50863,CDM,636,RC,J3490,HCPCS,73562-115-01,NDC,facility,both,2,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,J2003,HCPCS,0143-9575-01,NDC,,,facility,both,40,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 800 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-720-11,NDC,facility,both,1,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NS WITH POTASSIUM CHLORIDE 20 MEQ/L IV SOLP,50863,CDM,250,RC,J3480,HCPCS,0264-7865-00,NDC,facility,both,10,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LINEZOLID 600 MG/300 ML IV SOLP,50863,CDM,250,RC,J2020,HCPCS,57664-683-31,NDC,facility,both,3,ML,,331,231.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMINOCAPROIC ACID 250 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0517-9120-01,NDC,facility,both,1,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-11,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,636,RC,J2405,HCPCS,60505-6130-0,NDC,facility,both,12,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,635,ME,JZ,8617,6031.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PHENYLEPHRINE IN 0.9% NS (PF) 1 MG/10 ML (100 MCG/ML) IV SYRG(PDS MERGE),50863,CDM,250,RC,J3490,HCPCS,65302-506-10,NDC,facility,both,2,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 300 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,65162-649-78,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,23,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,11,ML,JW,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
VENLAFAXINE 150 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,68084-713-11,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-253-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 40 MG-200 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,65862-496-47,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZAFIRLUKAST 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-059-11,NDC,facility,both,1,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,23,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,20,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,29,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT 300 MCG/0.6 ML INJ SYRG,50863,CDM,636,RC,J0881,HCPCS,55513-111-01,NDC,facility,both,300,ML,EC,6409,4486.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier EC: Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy
AMPICILLIN-SULBACTAM NEO/PEDS (CDS MIXTURE),50863,CDM,636,RC,J0295,HCPCS,63323-368-20,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,69,ML,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,8068108600,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INDOCYANINE GREEN 25 MG INJ,50863,CDM,636,RC,J3490,HCPCS,70100-424-01,NDC,facility,both,1,EA,,917,641.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASCORBIC ACID  500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,5789684101,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FINASTERIDE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6830-06,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE (CONTRACEPTIVE) 150 MG/ML IM (MERGE),50863,CDM,636,RC,J1050,HCPCS,0009-7376-11,NDC,facility,both,150,ML,,280,196,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,250,RC,J0137,HCPCS,0264-4100-90,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,250,RC,J2270,HCPCS,0409-1891-03,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VARICELLA-ZOSTER IG-MALTOSE 125 UNIT/1.2 ML IM SOLN,50863,CDM,636,RC,90396,HCPCS,70257-126-51,NDC,facility,both,1,ML,,4980,3486,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN  2.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-027-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,47335-993-01,NDC,facility,both,50,ML,JZ,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ACYCLOVIR 200 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,69076-146-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,77,ML,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL DECANOATE 100 MG/ML IM SOLN,50863,CDM,250,RC,J1631,HCPCS,70069-383-10,NDC,facility,both,3,ML,,356,249.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,J3101,HCPCS,50242-037-06,NDC,,,facility,both,19,EA,,8703,6092.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 10% IN WATER (NEO) 2 - 3.99 KG,50863,CDM,636,RC,J3490,HCPCS,0264-7520-10,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 250 MG-62.5 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,60432-065-75,NDC,facility,both,2,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6926-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACIDOPHILUS-PECTIN W CITRUS 25 MILLION-100 CELL MG TAB,50863,CDM,250,RC,J3490,HCPCS,1785614241,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN PEDS SYRINGE (20MG/ML) IN DEXTROSE (CDS MIX,50863,CDM,636,RC,J0690,HCPCS,0781-3451-70,NDC,facility,both,4,EA,,158,110.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACIDOPHILUS-PECTIN W CITRUS 25 MILLION-100 CELL MG TAB,50863,CDM,250,RC,J3490,HCPCS,1785614241,NDC,facility,both,15,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,250,RC,J2405,HCPCS,23155-547-31,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,90,EA,,12420,8694,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 3000 MCG/ML INJECTION,50863,CDM,636,RC,J0153,HCPCS,17478-542-02,NDC,facility,both,6,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,63323-280-03,NDC,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-089-11,NDC,facility,both,2,EA,,220,154,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0093-3145-01,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN NEO/PEDS IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0456,HCPCS,63323-398-14,NDC,facility,both,1,EA,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),50863,CDM,250,RC,J3490,HCPCS,0409-4888-02,NDC,facility,both,5,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL,50863,CDM,250,RC,J3490,HCPCS,63323-820-01,NDC,facility,both,1,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,636,RC,J2405,HCPCS,0409-4759-01,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUGAMMADEX 100 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0006-5423-02,NDC,facility,both,1,ML,,561,392.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 10 MG/ML INJ (REPACK),50863,CDM,250,RC,J2919,HCPCS,99999-0405-85,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE IN 0.9 % NACL 4 MG/250 ML (16 MCG/ML) IV SOLN (MERGE),50863,CDM,250,RC,J3490,HCPCS,70004-613-40,NDC,facility,both,1,ML,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,50863,CDM,636,RC,J0696,HCPCS,44567-701-25,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML SYRUP,50863,CDM,636,RC,J3490,HCPCS,0121-1276-10,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % MUCOSAL SOLN (VISCOUS),50863,CDM,250,RC,J3490,HCPCS,50383-775-15,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAZOSIN 2 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7021-61,NDC,facility,both,2,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENTACAPONE 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6822-07,NDC,facility,both,1,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE IN 0.9% NACL 3 GRAM/100 ML IV SOLN,50863,CDM,250,RC,J0612,HCPCS,61553-056-48,NDC,facility,both,400,ML,,170,119,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETIRIZINE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16571-401-10,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE(PF)0.2 % ELASTOMERIC PUMP (ONQ) 545ML (PREFILLED),50863,CDM,250,RC,J3490,HCPCS,71449-079-51,NDC,facility,both,3,ML,,3512,2458.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 20MG/ML IV SYRINGE (PEDS/NEO),50863,CDM,250,RC,J0612,HCPCS,63323-311-10,NDC,facility,both,35,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTAMIDINE 300 MG INJ SOLR,50863,CDM,636,RC,J3490,HCPCS,63323-113-01,NDC,facility,both,1,EA,,472,330.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,68180-150-01,NDC,facility,both,2,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 40 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0054-8299-25,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-65,NDC,facility,both,100,ML,JZ,177,123.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,63323-482-01,NDC,facility,both,300,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  60 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,63304-758-01,NDC,facility,both,1,EA,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,636,RC,J3360,HCPCS,69339-136-03,NDC,facility,both,2,ML,,145,101.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,63323-165-01,NDC,facility,both,10,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,636,RC,J3490,HCPCS,0409-4277-16,NDC,facility,both,400,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65862-246-08,NDC,facility,both,1,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL PACK,50863,CDM,250,RC,J3490,HCPCS,67877-422-57,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,J1815,HCPCS,83257-014-11,NDC,,,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,J3490,HCPCS,0143-9889-15,NDC,,,facility,both,11,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-617-11,NDC,facility,both,2,EA,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM CITRATE ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,70677-1111-1,NDC,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GRANISETRON (PF) 1 MG/ML (1 ML) IV SOLN,50863,CDM,636,RC,J1626,HCPCS,63323-318-01,NDC,facility,both,10,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUORESCEIN 500 MG/5 ML (10 %) IV SOLN,50863,CDM,J3490,HCPCS,17478-253-10,NDC,,,facility,both,2,ML,,733,513.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,J1836,HCPCS,0409-0152-01,NDC,,,facility,both,125,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,50863,CDM,J9263,HCPCS,60505-6132-7,NDC,,,facility,both,64,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-1283-31,NDC,facility,both,20,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ROTAVIRUS VACCINE LIVE, PENTA 2 ML ORAL SUSP",50863,CDM,90680,HCPCS,0006-4047-01,NDC,,,facility,both,1,ML,,427,298.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 20MG/55 ML IVPB IN NS (ONCOLOGY),50863,CDM,J1100,HCPCS,63323-165-02,NDC,,,facility,both,12,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:200,000 INJ SOLN",50863,CDM,J2004,HCPCS,63323-487-07,NDC,,,facility,both,300,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM  4.5 GRAM IV SOLR,50863,CDM,J2543,HCPCS,60505-6159-0,NDC,,,facility,both,4,EA,,107,74.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL,50863,CDM,250,RC,J3490,HCPCS,63323-820-01,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,0904-6474-61,NDC,facility,both,2,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE  75 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,70756-204-11,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-492-26,NDC,,,facility,both,1200,ML,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG/ML ORAL CONC,50863,CDM,636,RC,J3490,HCPCS,0054-3553-44,NDC,facility,both,2,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 50 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,59651-489-01,NDC,facility,both,150,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % MUCOSAL SOLN (VISCOUS),50863,CDM,250,RC,J3490,HCPCS,0121-4950-15,NDC,facility,both,1,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROFURANTOIN (25% MACROCRYSTAL FORM) 100 MG CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7137-61,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 10 GRAM/15 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0116-4005-30,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-739-12,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-6666-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FERRIC SUBSULFATE 0.2 TO 0.22 GRAM/ML SOLN BULK,50863,CDM,636,RC,J3490,HCPCS,62991-2796-01,NDC,facility,both,1,ML,,227,158.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZATHIOPRINE  50 MG ORAL TAB,50863,CDM,250,RC,J7500,HCPCS,67877-493-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,250,RC,J0132,HCPCS,72611-860-01,NDC,facility,both,120,ML,,435,304.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,50863,CDM,250,RC,J9000,HCPCS,0069-1542-20,NDC,facility,both,11,ML,,173,121.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZIPRASIDONE 40 MG CAP,50863,CDM,250,RC,J3490,HCPCS,68084-104-11,NDC,facility,both,3,EA,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL (5 MG/ML) IV SYRG (CONTAINS PRESERVATIVE),50863,CDM,250,RC,J3490,HCPCS,0409-2339-24,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG/ML INJ SOLN,50863,CDM,636,RC,J2550,HCPCS,39822-5525-2,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25 MG-100 MG TAB,50863,CDM,636,RC,J3490,HCPCS,60687-661-11,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VORICONAZOLE 200 MG IV SOLN,50863,CDM,250,RC,J3465,HCPCS,0781-3416-94,NDC,facility,both,20,EA,,550,385,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLN (MERGE)",50863,CDM,250,RC,P9047,HCPCS,64208-2512-8,NDC,facility,both,10,ML,JZ,1188,831.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,2,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANTI-THYMOCYTE GLOB (RABBIT) 25 MG IV SOLR,50863,CDM,250,RC,J7511,HCPCS,58468-0080-1,NDC,facility,both,3,EA,,6066,4246.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE (PF-DURAMORPH/ASTRAMORPH) 0.5 MG/ML INJ SOLN,50863,CDM,250,RC,J2274,HCPCS,0409-3814-11,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM PEDS IVPB (FROM PREMIX),50863,CDM,636,RC,J1953,HCPCS,43598-635-52,NDC,facility,both,50,ML,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG RECT SUPP,50863,CDM,636,RC,J3490,HCPCS,51672-2116-0,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VERAPAMIL 120 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,23155-486-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INDOMETHACIN 25 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,31722-542-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,67877-548-88,NDC,facility,both,3,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR 200 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,50268-060-11,NDC,facility,both,2,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,2000,ML,,221,154.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEPIVACAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,250,RC,J0670,HCPCS,63323-294-01,NDC,facility,both,1,ML,JW,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
OSELTAMIVIR PHOSPHATE 30 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,64380-797-01,NDC,facility,both,8,EA,,409,286.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,50863,CDM,250,RC,J8540,HCPCS,0904-7266-61,NDC,facility,both,160,EA,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-545-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,50863,CDM,250,RC,J0640,HCPCS,67457-530-35,NDC,facility,both,14,EA,,306,214.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LYMPHOCYTE,ANTI-THYMO IMMUNE GLOBULIN 50 MG/ML IV",50863,CDM,250,RC,J7504,HCPCS,0009-7224-01,NDC,facility,both,9,ML,,119737,83815.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  0.25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6373-61,NDC,facility,both,10,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML IV,50863,CDM,250,RC,J3490,HCPCS,55150-425-01,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-328-10,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  88 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42292-038-01,NDC,facility,both,3,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERTAPENEM 1 GRAM INJ SOLR,50863,CDM,250,RC,J1335,HCPCS,60505-6196-0,NDC,facility,both,2,EA,,506,354.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,72603-209-01,NDC,facility,both,2,ML,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOFLOXACIN 250 MG/10 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,70954-852-30,NDC,facility,both,1,ML,,270,189,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-1283-04,NDC,facility,both,5,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 0.1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,23155-489-01,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,636,RC,J2405,HCPCS,70860-776-41,NDC,facility,both,4,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLP,50863,CDM,250,RC,J3480,HCPCS,63323-965-02,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MEASLES,MUMPS&RUBELLA VACCIN(PF) 1,000-12,500 TCID50/0.5 ML SUB-Q SUSP",50863,CDM,250,RC,90707,HCPCS,0006-4681-01,NDC,facility,both,2,EA,,774,541.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 3000 MCG/ML INJECTION,50863,CDM,250,RC,J0153,HCPCS,63323-651-00,NDC,facility,both,6,ML,JZ,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-492-41,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-986-01,NDC,facility,both,5,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MILRINONE 1 MG/ML IV SOLN,50863,CDM,250,RC,J2260,HCPCS,72485-501-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC IV INFUSION HYDRAT 31-60 MIN,50863,CDM,636,RC,J0248,HCPCS,61958-2901-2,NDC,facility,both,200,EA,,2392,1674.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,250,RC,J3490,HCPCS,72485-510-01,NDC,facility,both,8,ML,,540,378,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE SODIUM 25 MG/ML INJ SOLN,50863,CDM,636,RC,J9260,HCPCS,16729-277-30,NDC,facility,both,3,ML,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,0409-6102-04,NDC,facility,both,40,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 1 MG ORAL TAB,50863,CDM,250,RC,J8540,HCPCS,72578-166-01,NDC,facility,both,4,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPLERENONE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,59762-1710-2,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 125 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-519-11,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,120,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 5 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,0143-9873-10,NDC,facility,both,1,ML,PLAD,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
PROPRANOLOL  20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-598-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZOCAINE 20 % MM SPRY,50863,CDM,250,RC,J3490,HCPCS,0283-0610-43,NDC,facility,both,2,EA,,151,105.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IR SOLN,50863,CDM,250,RC,J3490,HCPCS,0338-0047-47,NDC,facility,both,2,ML,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM BICARB-CITRIC ACID 20 MEQ ORAL TBEF,50863,CDM,250,RC,J3490,HCPCS,51801-011-01,NDC,facility,both,2,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 400 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0143-9887-01,NDC,facility,both,10,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,70092-1478-44,NDC,facility,both,1,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 150 MG/1 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0548-5607-00,NDC,facility,both,12,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-492-27,NDC,facility,both,400,ML,,314,219.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NAFCILLIN NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J3490,HCPCS,63323-327-10,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 100 MG/ML FROM 1 GRAM VIAL (PRMC PEDS ONLY),50863,CDM,250,RC,J0696,HCPCS,0409-7332-11,NDC,facility,both,4,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER FLUSH,50863,CDM,250,RC,J7060,HCPCS,0264-7510-20,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,70377-009-11,NDC,facility,both,1,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6641-61,NDC,facility,both,4,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0054-0710-20,NDC,facility,both,7,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-504-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HUMAN PROTHROMBIN COMPLEX 500 UNIT IV SOLR,50863,CDM,J7168,HCPCS,63833-386-02,NDC,,,facility,both,2000,UN,,11638,8146.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,50863,CDM,J1650,HCPCS,71288-433-82,NDC,,,facility,both,3,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM  50 MG INJ SOLR,50863,CDM,250,RC,J0640,HCPCS,70436-116-82,NDC,facility,both,1,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6966-61,NDC,facility,both,4,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL PACK,50863,CDM,250,RC,J3490,HCPCS,67877-422-57,NDC,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 20 MG/ML INJ SOLN,50863,CDM,250,RC,J0360,HCPCS,0641-6231-01,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,636,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,16,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,0641-6174-01,NDC,facility,both,4,ML,JA,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,50863,CDM,250,RC,J9075,HCPCS,0781-3244-94,NDC,facility,both,200,EA,,1896,1327.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN NPH HUMAN RECOMB 100 UNIT/ML SUBQ SUSP,50863,CDM,250,RC,J1815,HCPCS,0169-1834-11,NDC,facility,both,20,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA SR 25 MG-100 MG TAB,50863,CDM,250,RC,J3490,HCPCS,68084-281-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J7510,HCPCS,17856-0815-1,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE-DEXTROSE-WATER(PF) 7.5 MG/ML (0.75 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,71351-022-10,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 10 % (100 MG/ML) MISC SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-695-22,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,23155-600-31,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML INJ SOLN,50863,CDM,250,RC,J0169,HCPCS,76329-9061-0,NDC,facility,both,40,ML,,148,103.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL (NEO/PEDS),50863,CDM,250,RC,J3490,HCPCS,63323-820-00,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,50863,CDM,636,RC,J0561,HCPCS,60793-701-02,NDC,facility,both,12,ML,JZ,1307,914.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
THYROID (PORK) 15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0456-0457-01,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2599,HCPCS,65219-039-00,NDC,facility,both,5,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2599,HCPCS,43598-914-11,NDC,facility,both,4,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZATHIOPRINE  50 MG ORAL TAB,50863,CDM,250,RC,J7500,HCPCS,68084-229-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0264-1800-36,NDC,facility,both,1,ML,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1940,HCPCS,0409-6102-18,NDC,facility,both,4,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-50,NDC,facility,both,4,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ATROPINE 0.1 MG/ML INJ SYRG,50863,CDM,636,RC,J0461,HCPCS,64253-400-30,NDC,facility,both,100,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-41,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CITRATE 4% (3 ML) SYRINGE (FOR DIALYSIS),50863,CDM,250,RC,J3490,HCPCS,61553-481-80,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,250,RC,J2720,HCPCS,63323-229-01,NDC,facility,both,15,ML,JZ,273,191.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,46,ML,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,19,EA,,2622,1835.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE (POLACRILEX) 2 MG BUCL GUM,50863,CDM,250,RC,J3490,HCPCS,70677-1166-2,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16714-950-01,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYPROHEPTADINE 2 MG/5 ML ORAL SYRP,50863,CDM,636,RC,J3490,HCPCS,64980-504-48,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM  1.5 GRAM INJ SOLR,50863,CDM,250,RC,J0295,HCPCS,0641-6116-01,NDC,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,636,RC,J1611,HCPCS,63323-593-03,NDC,facility,both,1,EA,,895,626.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,25021-463-01,NDC,facility,both,4,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,62584-994-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,6,EA,,193,135.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J0461,HCPCS,0517-1004-01,NDC,facility,both,20,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-0710-20,NDC,facility,both,16,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0003-0894-70,NDC,facility,both,8,EA,,412,288.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J3430,HCPCS,43598-405-11,NDC,facility,both,10,ME,JZ,218,152.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LEVOTHYROXINE 20 MCG/ML IV SYRINGE (PEDIATRIC),50863,CDM,250,RC,J3490,HCPCS,63323-649-94,NDC,facility,both,1,EA,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,50863,CDM,J1650,HCPCS,0781-3246-02,NDC,,,facility,both,1,ML,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHIMAZOLE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-669-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAZOLAMIDE 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6663-61,NDC,facility,both,2,EA,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIPASE-PROTEASE-AMYLASE 24,000-76,000- 120,000 UNIT ORAL CAP, DELAY REL",50863,CDM,636,RC,J3490,HCPCS,0032-1224-01,NDC,facility,both,3,EA,,145,101.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-686-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,636,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 100 MG/ML FROM 1 GRAM VIAL (PRMC PEDS ONLY),50863,CDM,636,RC,J0696,HCPCS,0409-7332-11,NDC,facility,both,8,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,250,RC,J7060,HCPCS,0338-0017-04,NDC,facility,both,4,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IMATINIB 100 MG ORAL TAB,50863,CDM,250,RC,J9999,HCPCS,42292-043-01,NDC,facility,both,4,EA,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,1,EA,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,1500,ML,,166,116.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL  75 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6635-61,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,44567-600-04,NDC,facility,both,2,ML,,435,304.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPOETIN ALFA-EPBX 10000 UNITS/ML INJ SOLN,50863,CDM,636,RC,Q5106,HCPCS,0069-1308-01,NDC,facility,both,40,ML,EA,1906,1334.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier EA: Erythropoetic stimulating agent (esa) administered to treat anemia due to anti-cancer chemotherapy
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),50863,CDM,250,RC,J0169,HCPCS,76329-3318-1,NDC,facility,both,20,ML,,162,113.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROPRUSSIDE 25 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-3024-01,NDC,facility,both,1,ML,,849,594.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MONTELUKAST  4 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,50268-573-11,NDC,facility,both,1,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  75 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-475-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK,50863,CDM,250,RC,J3490,HCPCS,12870-0001-1,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-ABDA 100 MG IV SOLR,50863,CDM,250,RC,Q5104,HCPCS,78206-162-99,NDC,facility,both,50,EA,,10397,7277.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,636,RC,J3490,HCPCS,25021-415-10,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,46,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  50 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,64980-411-09,NDC,facility,both,3,EA,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-50,NDC,facility,both,42,ML,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,68516-5214-6,NDC,facility,both,1,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENETOCLAX 10 MG ORAL TAB,50863,CDM,250,RC,J9999,HCPCS,0074-0561-11,NDC,facility,both,2,EA,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN IN SALINE (ISO-OSMOTIC) 80 MG/100 ML IV PIGGY BACK,50863,CDM,636,RC,J1580,HCPCS,0338-0503-48,NDC,facility,both,4,ML,,107,74.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2310,HCPCS,70069-072-01,NDC,facility,both,8,ML,,848,593.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6007-60,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 0.1MG/ML SUSPENSION (REPACK),50863,CDM,250,RC,J3490,HCPCS,51079-882-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE-SALMETEROL 500 MCG-50 MCG/DOSE DISK DEVICE FOR INHALATION,50863,CDM,636,RC,J3490,HCPCS,0173-0697-04,NDC,facility,both,14,EA,,378,264.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUORESCEIN 500 MG/5 ML (10 %) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,17478-253-10,NDC,facility,both,1,ML,,367,256.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTOBACILLUS ACIDOPHILUS 500 MILLION CELLS ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,904726006,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,636,RC,J7999,HCPCS,70092-1017-46,NDC,facility,both,2,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL IV BOLUS 10MG/ML (ANESTHESIA ONLY),50863,CDM,250,RC,J2704,HCPCS,0409-4699-54,NDC,facility,both,200,ML,,254,177.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN   81 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,63739-212-02,NDC,facility,both,4,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7188-61,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,25,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 0.5 MG/ML ORAL SUSPENSION (REPACK),50863,CDM,250,RC,J7507,HCPCS,51079-028-01,NDC,facility,both,3,EA,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENAZEPRIL 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-110-11,NDC,facility,both,4,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOBRAMYCIN SULFATE 40 MG/ML INJ SOLN,50863,CDM,250,RC,J3260,HCPCS,67457-473-22,NDC,facility,both,2,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,11,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-464-11,NDC,facility,both,3,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-18,NDC,facility,both,300,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,J2003,HCPCS,0409-1323-15,NDC,,,facility,both,200,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,31722-711-30,NDC,facility,both,1,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J1938,HCPCS,0409-6102-10,NDC,facility,both,5,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID 1000 MG/10 ML FOR NEBULIZATION,50863,CDM,250,RC,J3490,HCPCS,83634-401-41,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 875 MG-125 MG TAB,50863,CDM,636,RC,J3490,HCPCS,65862-503-01,NDC,facility,both,2,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,J3490,HCPCS,66794-229-02,NDC,,,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 0.5 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J2004,HCPCS,63323-481-01,NDC,facility,both,45,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),50863,CDM,250,RC,J0171,HCPCS,0409-4921-34,NDC,facility,both,10,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,250,RC,J0690,HCPCS,70092-1017-46,NDC,facility,both,8,ML,,15050,10535,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-41,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,50,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GAMMAGARD LIQUID 10 % IV SOLN,50863,CDM,636,RC,J1569,HCPCS,0944-2700-13,NDC,facility,both,60,ML,"JZ,JA",10817,7571.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRP (MERGE/REPACK),50863,CDM,636,RC,J3490,HCPCS,68094-764-59,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,250,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETIRIZINE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6717-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,250,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FEBUXOSTAT 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-538-11,NDC,facility,both,2,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,00035-0002-80,NDC,facility,both,1,ML,JZ,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LISINOPRIL 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6799-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-21,NDC,facility,both,20,ML,,2829,1980.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GRANISETRON 1 MG/ML (1 ML) IV SOLN,50863,CDM,250,RC,J1626,HCPCS,0143-9744-01,NDC,facility,both,7,ML,JW,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-1159-19,NDC,facility,both,2,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAMADOL  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7496-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-499-10,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COLCHICINE 0.6 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,70010-002-01,NDC,facility,both,3,EA,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IMATINIB 100 MG ORAL TAB,50863,CDM,250,RC,J9999,HCPCS,42292-043-01,NDC,facility,both,3,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,2,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DACTINOMYCIN 0.5 MG IV SOLR,50863,CDM,250,RC,J9120,HCPCS,55150-431-01,NDC,facility,both,2,EA,,8217,5751.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,72789-325-90,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMINOPHYLLINE 500 MG/20 ML IV SOLN,50863,CDM,636,RC,J0280,HCPCS,0409-5922-01,NDC,facility,both,2,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,0338-0069-10,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25 MG-100 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7257-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,50863,CDM,250,RC,J2359,HCPCS,55150-308-01,NDC,facility,both,3,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50MG/5ML (10MG/ML) ORAL SOLUTION (REPACK),50863,CDM,250,RC,J3490,HCPCS,71286-3022-1,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMIDE PEROXIDE 6.5 % OTIC DROP,50863,CDM,636,RC,J3490,HCPCS,4203710478,NDC,facility,both,1,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) MISC SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-694-41,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYTOCIN IN 0.9 % SOD CHLORIDE 30 UNIT/500 ML IV SOLN,50863,CDM,250,RC,J2590,HCPCS,71266-5100-1,NDC,facility,both,1,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYTOCIN IN 0.9 % SOD CHLORIDE 30 UNIT/500 ML IV SOLN,50863,CDM,250,RC,J2590,HCPCS,70092-1552-07,NDC,facility,both,1,ML,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0338-1055-48,NDC,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-098-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORATADINE 5 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,51672-2131-8,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),50863,CDM,250,RC,J3490,HCPCS,0409-4888-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2308-21,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7041-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,63323-165-01,NDC,facility,both,12,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OMEPRAZOLE-SODIUM BICARBONATE 2-84 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,65628-270-03,NDC,facility,both,4,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXEPIN  25 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,51079-437-01,NDC,facility,both,6,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUSELKUMAB 200 MG/20 ML (10 MG/ML) IV SOLN,50863,CDM,636,RC,J1628,HCPCS,57894-650-01,NDC,facility,both,200,ML,"JZ,JA",38289,26802.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
LIDOCAINE 4 % TOPICAL SOLN,50863,CDM,250,RC,J3490,HCPCS,76329-6300-5,NDC,facility,both,1,ML,,178,124.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIROFIBAN-0.9% SODIUM CHLORIDE 5 MG/100 ML (50 MCG/ML) IV SOLN,50863,CDM,636,RC,J3246,HCPCS,25208-002-03,NDC,facility,both,2,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUORESCEIN 1 MG OPHT STRP,50863,CDM,250,RC,J3490,HCPCS,17238-900-99,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELIMUMAB 400 MG IV SOLR,50863,CDM,636,RC,J0490,HCPCS,49401-102-01,NDC,facility,both,120,EA,,13375,9362.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAMSULOSIN 0.4 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,0904-7383-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,72485-106-01,NDC,facility,both,350,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SALIVA STIMULANT AGENTS COMB.3 MM SPRY (BIOTENE) (REPACK),50863,CDM,250,RC,J3490,HCPCS,4858200155,NDC,facility,both,2,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,68094-494-59,NDC,facility,both,5,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,63323-165-01,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN D5W 20000 UNIT/500 ML,50863,CDM,636,RC,J1644,HCPCS,0264-9567-10,NDC,facility,both,13,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,14789-127-07,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,0641-6145-01,NDC,facility,both,8,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SILDENAFIL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,31722-711-30,NDC,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,636,RC,J2270,HCPCS,0641-6125-01,NDC,facility,both,1,ML,JZ,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ASPIRIN   81 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,0135-0117-88,NDC,facility,both,4,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LANSOPRAZOLE 3 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,65628-080-05,NDC,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN D5W 1 GRAM/200 ML IV PGBK,50863,CDM,636,RC,J3373,HCPCS,0338-3552-48,NDC,facility,both,2,ML,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,7,EA,JW,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,250,RC,J3490,HCPCS,61553-320-70,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIPASE-PROTEASE-AMYLASE 24,000-76,000- 120,000 UNIT ORAL CAP, DELAY REL",50863,CDM,250,RC,J3490,HCPCS,0032-2636-01,NDC,facility,both,5,EA,,242,169.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 10 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-369-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,80,ML,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0781-6041-46,NDC,facility,both,11,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J7510,HCPCS,17856-0815-1,NDC,facility,both,3,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,636,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,5,ML,GZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier GZ: Item or service expected to be denied as not reasonable and necessary
CEFAZOLIN  10 GRAM INJ SOLR,50863,CDM,636,RC,J0690,HCPCS,0143-9983-91,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IVPB (PEDIATRICS/ADULT NON-FORM)",50863,CDM,636,RC,J0131,HCPCS,24201-100-01,NDC,facility,both,15,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE 25 MG/ML INJ SOLN,50863,CDM,250,RC,J3230,HCPCS,43598-140-11,NDC,facility,both,2,ML,,586,410.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,128,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,600,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 300 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6572-61,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 250 MG-62.5 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,59651-026-75,NDC,facility,both,3,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRIL MALEATE 1 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,69238-1729-7,NDC,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM SR 180 MG 24 HR CAP,50863,CDM,636,RC,J3490,HCPCS,60687-206-11,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR 200 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-5789-61,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 2 GRAM IV SOLUTION,50863,CDM,250,RC,J9075,HCPCS,10019-957-11,NDC,facility,both,387,EA,,3906,2734.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 15 MG/ML (1.5 %) INJ SOLN,50863,CDM,250,RC,J2003,HCPCS,63323-493-91,NDC,facility,both,300,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,71456-001-01,NDC,facility,both,4,ML,,705,493.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCHLOROTHIAZIDE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16729-184-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEDIUM CHAIN TRIGLYCERIDES OIL ORAL,50863,CDM,250,RC,J3490,HCPCS,4167936503,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLP,50863,CDM,250,RC,J3480,HCPCS,63323-965-03,NDC,facility,both,10,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,35573-428-51,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TARLATAMAB-DLLE 10 MG IV SOLR,50863,CDM,250,RC,C9170,HCPCS,55513-069-01,NDC,facility,both,10,EA,,41400,28980,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 125 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,62756-796-88,NDC,facility,both,3,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WHITE PETROLATUM-MINERAL OIL OPHT OINT (PDS MERGE),50863,CDM,250,RC,J3490,HCPCS,23066704,NDC,facility,both,1,GM,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6798-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 3000 MCG/ML INJECTION,50863,CDM,250,RC,J0153,HCPCS,67457-855-02,NDC,facility,both,12,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,0409-9093-32,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE  1 % TOP CREA,50863,CDM,636,RC,J3490,HCPCS,45802-438-03,NDC,facility,both,1,GM,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPRAZOLAM 0.25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0781-1061-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,250,RC,J3101,HCPCS,50242-037-06,NDC,facility,both,33,EA,JW,6572,4600.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PHYTONADIONE 1 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-9158-01,NDC,facility,both,5,ML,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,65,ML,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,21,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
MELATONIN  1 MG/ML ORAL LIQD,50863,CDM,250,RC,J3490,HCPCS,5843800571,NDC,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,23155-473-32,NDC,facility,both,40,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,55150-202-00,NDC,facility,both,2,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DORZOLAMIDE-TIMOLOL 2 %-0.5 % EYE DROPS,50863,CDM,250,RC,J3490,HCPCS,71921-226-10,NDC,facility,both,1,ML,,442,309.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 300 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-722-11,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,76329-3352-1,NDC,facility,both,13,ML,,1504,1052.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 250 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,42192-608-16,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 650 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7261-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,636,RC,Q0162,HCPCS,16714-671-02,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROPROCAINE 3 % INJ SOLN,50863,CDM,250,RC,J2401,HCPCS,0143-9210-01,NDC,facility,both,450,ML,JW,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0264-1800-31,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,0409-1886-22,NDC,facility,both,20,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,57664-596-40,NDC,facility,both,1,ML,,327,228.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,68,ML,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 400 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0143-9887-01,NDC,facility,both,9,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-253-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICARDIPINE IN NACL (ISO-OS) 20 MG/200 ML IV PGBK,50863,CDM,250,RC,J3490,HCPCS,0143-9634-01,NDC,facility,both,2,ML,,828,579.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,10,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-511-11,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3373,HCPCS,0143-9162-01,NDC,facility,both,300,EA,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM  1.5 GRAM INJ SOLR,50863,CDM,250,RC,J0295,HCPCS,44567-210-10,NDC,facility,both,1,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,250,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6550-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,63323-462-17,NDC,facility,both,1,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-04,NDC,facility,both,1,ML,JZ,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,75,EA,,10350,7245,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTAROLINE FOSAMIL 600 MG IV SOLR,50863,CDM,250,RC,J0712,HCPCS,0456-0600-01,NDC,facility,both,20,EA,,290,203,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,0409-1886-22,NDC,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,14789-127-07,NDC,facility,both,1,ML,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J3490,HCPCS,0338-0049-48,NDC,facility,both,1,ML,JZ,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,49,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZOCAINE-MENTHOL 15-2.6 MG MM LOZG,50863,CDM,636,RC,J3490,HCPCS,63824-732-16,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-242-11,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  50 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-6992-61,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG/ML ORAL CONC,50863,CDM,636,RC,J3490,HCPCS,0054-3553-44,NDC,facility,both,4,ML,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 10 MG/ML IM SOLN,50863,CDM,636,RC,J0500,HCPCS,0641-6173-01,NDC,facility,both,1,ML,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J1610,HCPCS,0597-0053-45,NDC,facility,both,1,EA,JW,206,144.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ATROPINE 0.1 MG/ML INJ SYRG,50863,CDM,250,RC,J0461,HCPCS,64253-400-30,NDC,facility,both,100,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN D5W 20000 UNIT/500 ML,50863,CDM,636,RC,J1644,HCPCS,0264-9567-10,NDC,facility,both,19,ML,JW,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),50863,CDM,250,RC,J3490,HCPCS,0409-4888-02,NDC,facility,both,2,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  5 GRAM IV SOLR,50863,CDM,250,RC,J3370,HCPCS,63323-295-61,NDC,facility,both,4,EA,,162,113.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,50863,CDM,250,RC,J3490,HCPCS,69339-152-01,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NOREPINEPHRINE BITARTRATE-D5W 4 MG/250 ML (16 MCG/ML) IV SOLN,50863,CDM,J3490,HCPCS,0338-0112-20,NDC,,,facility,both,1,ML,,134,93.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  5 MG ORAL TAB,50863,CDM,J7512,HCPCS,60687-122-11,NDC,,,facility,both,15,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  75 MG ORAL CP24,50863,CDM,636,RC,J3490,HCPCS,68084-709-11,NDC,facility,both,4,EA,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 150 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-445-01,NDC,facility,both,1,EA,PLAD,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
"MYCOPHENOLATE 180 MG TAB, DELAYED RELEASE",50863,CDM,250,RC,J7518,HCPCS,68084-907-11,NDC,facility,both,3,EA,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE  7 % INHL NEBU,50863,CDM,250,RC,J3490,HCPCS,4422930760,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOCARNITINE (WITH SUCROSE) 100 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,52817-830-04,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,67877-545-88,NDC,facility,both,5,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,250,RC,J2704,HCPCS,25021-608-20,NDC,facility,both,20,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV,50863,CDM,250,RC,J7120,HCPCS,0338-0117-03,NDC,facility,both,5,ML,,305,213.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENAZEPRIL 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,43547-336-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIFEDIPINE 10 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7229-61,NDC,facility,both,3,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,49502-393-80,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG/ML ORAL CONC,50863,CDM,250,RC,J3490,HCPCS,0054-3553-44,NDC,facility,both,5,ML,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-076-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,16714-294-02,NDC,facility,both,6,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL (VITAMIN D3)   400 UNIT ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,5026886311,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,636,RC,J7999,HCPCS,70092-1017-46,NDC,facility,both,4,ML,,159,111.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELOXICAM  7.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-525-11,NDC,facility,both,2,EA,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0780,HCPCS,0713-0351-02,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J2003,HCPCS,0409-4279-16,NDC,facility,both,200,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENAZOPYRIDINE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,69367-611-01,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROTHIAZIDE SODIUM 500 MG IV SOLR,50863,CDM,250,RC,J1205,HCPCS,0517-1820-01,NDC,facility,both,1,EA,,360,252,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 50% IN WATER (MERGE RECORD),50863,CDM,250,RC,J7070,HCPCS,0409-7517-66,NDC,facility,both,4,ML,,421,294.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,250,RC,J7060,HCPCS,0338-0017-31,NDC,facility,both,2,ML,,269,188.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPHENIDATE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-1142-01,NDC,facility,both,8,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 50% IN WATER (MERGE RECORD),50863,CDM,250,RC,J7060,HCPCS,76329-3302-1,NDC,facility,both,1,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR PHOSPHATE 30 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,64380-797-01,NDC,facility,both,1,EA,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ (MERGE),50863,CDM,636,RC,J2250,HCPCS,0409-0001-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAVASTATIN 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-5892-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J1938,HCPCS,36000-283-25,NDC,facility,both,40,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,17271-701-05,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL IV BOLUS 10MG/ML (ANESTHESIA ONLY),50863,CDM,636,RC,J2704,HCPCS,63323-269-29,NDC,facility,both,5,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE  5 MG/ML INJ SOLN,50863,CDM,636,RC,J2765,HCPCS,0409-3414-21,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 300 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,60687-793-11,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LET TOPICAL GEL 3 ML,50863,CDM,636,RC,J3490,HCPCS,70092-1611-44,NDC,facility,both,1,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,68462-470-40,NDC,facility,both,6,ML,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 50 % (4 MEQ/ML) INJ SOLN,50863,CDM,250,RC,J3475,HCPCS,63323-064-02,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25 MG-100 MG TAB,50863,CDM,250,RC,J3490,HCPCS,60687-661-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE ENEMA 200G IN SW (1000 ML TOTAL VOLUME),50863,CDM,250,RC,J3490,HCPCS,99999-0405-41,NDC,facility,both,1,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERTAPENEM 1 GRAM INJ SOLR,50863,CDM,250,RC,J1335,HCPCS,16714-889-01,NDC,facility,both,12,EA,,3150,2205,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPHENIDATE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-805-11,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 1 MG (ENVARSUS XR) 24-HOUR EXTENDED-RELEASE TABLET,50863,CDM,636,RC,J7508,HCPCS,68992-3010-3,NDC,facility,both,3,EA,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2308-02,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,250,RC,Q0162,HCPCS,68094-763-59,NDC,facility,both,4,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INDAPAMIDE 2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,62559-511-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EXEMESTANE 25 MG ORAL TAB,50863,CDM,250,RC,J9999,HCPCS,59651-516-30,NDC,facility,both,1,EA,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7123-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-512-11,NDC,facility,both,2,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,636,RC,J1100,HCPCS,63323-506-01,NDC,facility,both,10,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,25021-468-10,NDC,facility,both,1,EA,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELIMUMAB 120 MG IV SOLR,50863,CDM,636,RC,J0490,HCPCS,49401-101-01,NDC,facility,both,24,ME,"JG,JZ,JA",2819,1973.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
OLANZAPINE 10 MG IM SOLR,50863,CDM,250,RC,J2359,HCPCS,55150-308-01,NDC,facility,both,15,EA,JW,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,636,RC,J1100,HCPCS,70121-1399-1,NDC,facility,both,10,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN PEDS INFUSION (CDS MIXTURE),50863,CDM,250,RC,J0290,HCPCS,25021-136-10,NDC,facility,both,2,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RAVULIZUMAB-CWVZ 100 MG/ML IV SOLN,50863,CDM,J1303,HCPCS,25682-028-01,NDC,,,facility,both,330,ML,,194426,136098.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-354-11,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOPIDOGREL  75 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6294-61,NDC,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML INJ SOLN,50863,CDM,250,RC,J0171,HCPCS,76329-9060-0,NDC,facility,both,10,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7193-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BETAMETHASONE ACET & SOD PHOS 6 MG/ML INJ SUSP,50863,CDM,250,RC,J0702,HCPCS,78206-118-01,NDC,facility,both,2,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,250,RC,J3490,HCPCS,50268-671-11,NDC,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPHENIDATE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16729-478-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROTHIAZIDE SODIUM 500 MG IV SOLR,50863,CDM,250,RC,J1205,HCPCS,17478-419-40,NDC,facility,both,1,EA,,225,157.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) MISC SOLN,50863,CDM,250,RC,J3490,HCPCS,0517-7604-01,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2310,HCPCS,0409-1219-01,NDC,facility,both,4,ML,,513,359.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN STERILE WATER 2 GRAM/20 ML IV SYRG,50863,CDM,250,RC,J0690,HCPCS,70092-1604-47,NDC,facility,both,12,ML,,157,109.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPHENIDATE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16729-478-01,NDC,facility,both,3,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 500 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,0904-6861-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,636,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,50742-615-01,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 10 MEQ/100 ML IV PGBK,50863,CDM,250,RC,J3480,HCPCS,0990-7074-26,NDC,facility,both,5,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 3000 MCG/ML INJECTION,50863,CDM,636,RC,J0153,HCPCS,72078-033-00,NDC,facility,both,12,ML,JZ,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CAFFEINE CITRATED 20 MG/ML IV SOLN,50863,CDM,250,RC,J0706,HCPCS,51754-0500-1,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIVOLUMAB 240 MG/24 ML IV SOLN,50863,CDM,J9299,HCPCS,0003-3734-13,NDC,,,facility,both,480,ML,,34738,24316.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLMESARTAN 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68462-437-90,NDC,facility,both,2,EA,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,50863,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,21,EA,,445,311.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,250,RC,J0132,HCPCS,25021-812-30,NDC,facility,both,64,ML,,456,319.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICLOXACILLIN 250 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0093-3123-01,NDC,facility,both,2,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,1,EA,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 150 MG CAP,50863,CDM,250,RC,J3490,HCPCS,0904-5959-61,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),50863,CDM,250,RC,J2060,HCPCS,0641-6001-01,NDC,facility,both,3,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-406-03,NDC,facility,both,1,ML,,136,95.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-4713-32,NDC,facility,both,40,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J2003,HCPCS,0409-4713-32,NDC,facility,both,100,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,16729-114-31,NDC,facility,both,10,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,16714-036-01,NDC,facility,both,8,ML,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIOTHYRONINE  5 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,62756-589-88,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,60687-390-11,NDC,facility,both,8,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE HCL  0.5 % NASL SPRY,50863,CDM,250,RC,J3490,HCPCS,0225-0805-47,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-442-20,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN 0.9 % SODIUM CHL 2 GRAM/500 ML IV SOLN,50863,CDM,250,RC,J3370,HCPCS,70092-9338-07,NDC,facility,both,2,ML,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,27,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-22,NDC,facility,both,20,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,J2003,HCPCS,0409-4277-02,NDC,,,facility,both,300,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 10%-1/2 NORMAL SALINE IV,50863,CDM,250,RC,J3490,HCPCS,0264-7622-00,NDC,facility,both,1,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,507,ME,,6880,4816,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 70% IN WATER (D70W) IV,50863,CDM,J7070,HCPCS,0338-0719-06,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE CONCENTRATE 10 MG/ 0.5 ML ORAL SYRINGE (0.5ML UD MERGE),50863,CDM,250,RC,J3490,HCPCS,68094-045-01,NDC,facility,both,4,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 250 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,43547-688-10,NDC,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 2 MG INJ SOLR,50863,CDM,J2997,HCPCS,50242-041-64,NDC,,,facility,both,6,EA,,2286,1600.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL,50863,CDM,250,RC,J3490,HCPCS,63323-820-01,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,72205-014-90,NDC,facility,both,3,EA,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAZOLAMIDE 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-054-11,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,250,RC,Q0162,HCPCS,16714-671-02,NDC,facility,both,4,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  750 MG IV SOLR,50863,CDM,250,RC,J3373,HCPCS,67457-705-00,NDC,facility,both,75,EA,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL 100 MCG/HR TD PT72,50863,CDM,250,RC,J3490,HCPCS,0378-9124-16,NDC,facility,both,1,EA,,227,158.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,59746-218-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,31722-711-30,NDC,facility,both,1,EA,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,0944-0495-06,NDC,facility,both,1,ML,,245,171.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,636,RC,J7060,HCPCS,0338-0017-02,NDC,facility,both,1,ML,JZ,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,24,EA,JW,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-1638-32,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J7510,HCPCS,17856-0815-1,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,44567-600-04,NDC,facility,both,2,ML,,409,286.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,78206-121-01,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,250,RC,Q9968,HCPCS,70710-1838-1,NDC,facility,both,5,ML,JW,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,0143-9577-01,NDC,,,facility,both,21,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 10 MG TAB,50863,CDM,Q0177,HCPCS,60687-664-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-319-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE (FOR EMERGENCY) 100 MG/ML (10%) IV SOLN,50863,CDM,636,RC,J0612,HCPCS,63323-360-19,NDC,facility,both,100,ML,JZ,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,6,ML,,108,75.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE MONONITRATE  20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,81665-103-10,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-0710-20,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NYSTATIN 100000 UNIT/ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0121-0868-02,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID (PORK)  60 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0456-0459-01,NDC,facility,both,2,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLN (MERGE)",50863,CDM,636,RC,P9047,HCPCS,68516-5216-3,NDC,facility,both,2,ML,,502,351.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,250,RC,J3490,HCPCS,63037-136-25,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 0.5% NASAL DROPS (REPACK),50863,CDM,250,RC,J3490,HCPCS,69536-050-15,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
URSODIOL 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7168-61,NDC,facility,both,2,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,62559-440-02,NDC,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,1,ML,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIRMATRELVIR-RITONAVIR 300-100 MG ORAL TAB DOSEPACK (FOR ED/IP TAKE HOME PANEL),50863,CDM,636,RC,J3490,HCPCS,0069-5321-30,NDC,facility,both,30,EA,,4130,2891,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUORESCEIN 1 MG OPHT STRP,50863,CDM,250,RC,J3490,HCPCS,83851-100-30,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,636,RC,P9045,HCPCS,0944-0495-06,NDC,facility,both,13,ML,,1727,1208.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-090-11,NDC,facility,both,2,EA,,260,182,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,636,RC,J3010,HCPCS,0409-9094-22,NDC,facility,both,2,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-01,NDC,facility,both,5,ML,,139,97.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,16714-293-01,NDC,facility,both,6,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-205-01,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-7124-61,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYPROHEPTADINE 4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0115-1757-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE  5 MG/ML INJ SOLN,50863,CDM,J2765,HCPCS,23155-240-31,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-496-97,NDC,,,facility,both,200,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,65,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,636,RC,J7999,HCPCS,70092-1017-46,NDC,facility,both,6,ML,,119,83.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,50863,CDM,250,RC,J0640,HCPCS,0143-9554-01,NDC,facility,both,4,EA,,188,131.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAZOSIN 1 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,51079-630-01,NDC,facility,both,5,EA,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,636,RC,J3490,HCPCS,53746-542-05,NDC,facility,both,4,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  75 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6951-61,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 50 MG/ML IV SOLN,50863,CDM,636,RC,J0282,HCPCS,70436-232-72,NDC,facility,both,5,ML,JZ,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,250,RC,J7060,HCPCS,0338-0017-38,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,636,RC,J7510,HCPCS,17856-0815-1,NDC,facility,both,6,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN  100 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,5026885211,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEPOLIZUMAB 100 MG SUBQ SOLR,50863,CDM,J2182,HCPCS,0173-0881-01,NDC,,,facility,both,100,EA,,7107,4974.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,J3490,HCPCS,63323-739-11,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,636,RC,J1100,HCPCS,25021-053-01,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  5 MG ORAL TBDL,50863,CDM,636,RC,J3490,HCPCS,33342-083-07,NDC,facility,both,1,EA,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE PEDS SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J3490,HCPCS,25021-113-82,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6638-61,NDC,facility,both,10,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM IV SOLR,50863,CDM,250,RC,J0696,HCPCS,0409-7336-04,NDC,facility,both,8,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORTHALIDONE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-167-11,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS",50863,CDM,250,RC,J3490,HCPCS,24208-830-60,NDC,facility,both,1,ML,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,9,EA,JW,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ROPINIROLE  2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,10135-676-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2308-22,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 500 MG PE/10 ML INJ SOLN,50863,CDM,636,RC,Q2009,HCPCS,0069-6001-10,NDC,facility,both,20,ML,,1048,733.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OMEPRAZOLE-SODIUM BICARBONATE 2-84 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,65628-270-03,NDC,facility,both,2,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,29,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),50863,CDM,250,RC,J2060,HCPCS,0641-6044-01,NDC,facility,both,2,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,250,RC,Q9968,HCPCS,70710-1838-1,NDC,facility,both,45,ML,JW,254,177.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LIDOCAINE 4 % MUCOSAL TOPICAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0527-6004-80,NDC,facility,both,1,ML,,275,192.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0121-1022-05,NDC,facility,both,3,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE  2 MG/ML INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-285-20,NDC,facility,both,1,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0137,HCPCS,0143-9386-01,NDC,facility,both,22,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAZOLAMIDE 25MG/ML SUSPENSION (REPACK),50863,CDM,250,RC,J3490,HCPCS,51672-4023-1,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROGESTERONE MICRONIZED  8 % VAGL GEL,50863,CDM,250,RC,j3490,HCPCS,0023-6151-09,NDC,facility,both,2,GM,,238,166.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,250,RC,J3490,HCPCS,59310-579-22,NDC,facility,both,1,GM,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 100 MG SOLUTION FOR INJECTION,50863,CDM,250,RC,J1720,HCPCS,0009-0825-01,NDC,facility,both,1,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM PHOSPHATE 3 MMOL/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-884-01,NDC,facility,both,1,ML,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  5 MG ORAL TBDL,50863,CDM,636,RC,J3490,HCPCS,59746-306-12,NDC,facility,both,1,EA,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 10 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,67457-420-00,NDC,facility,both,18,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,J3490,HCPCS,0409-4277-17,NDC,,,facility,both,1000,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 2.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0003-0893-31,NDC,facility,both,12,EA,,524,366.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMIDE PEROXIDE 6.5 % OTIC DROP,50863,CDM,636,RC,J3490,HCPCS,0904-6627-35,NDC,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATOMOXETINE  40 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60505-2833-3,NDC,facility,both,2,EA,,152,106.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) NEB SOLUTION,50863,CDM,250,RC,J3490,HCPCS,0487-9501-00,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 30 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-120-11,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES 8.8 MG/5 ML ORAL SYRP,50863,CDM,636,RC,J3490,HCPCS,0536-1266-59,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,636,RC,J3490,HCPCS,63037-136-25,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG IV SOLR,50863,CDM,636,RC,J3490,HCPCS,0143-9381-01,NDC,facility,both,2,EA,,248,173.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,63323-162-00,NDC,facility,both,2,ML,JZ,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
BACLOFEN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-815-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN DEGLUDEC 100 UNITS/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,73070-400-11,NDC,facility,both,1,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,98,ML,JW,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
METHADONE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1230,HCPCS,17478-380-20,NDC,facility,both,1,ML,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOLIC ACID  1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-681-11,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,42494-416-01,NDC,facility,both,4,ML,,821,574.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOLIC ACID  1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-681-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0904-7127-61,NDC,facility,both,98,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-344-11,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCRALFATE 100 MG/ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,68094-043-59,NDC,facility,both,2,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-444-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-130-11,NDC,facility,both,2,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 250 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,0904-6363-61,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,250,RC,J3490,HCPCS,71266-9080-4,NDC,facility,both,2,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 50 MG/5 ML (10 MG/ML) IV SYRG,50863,CDM,250,RC,J3490,HCPCS,71266-2002-1,NDC,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,53489-143-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,25021-321-04,NDC,facility,both,3,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,250,RC,J3490,HCPCS,53746-542-05,NDC,facility,both,8,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MUPIROCIN 2 % TOP OINT,50863,CDM,250,RC,J3490,HCPCS,68462-180-22,NDC,facility,both,1,GM,,210,147,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN GK 2.5 MU IN NS 100ML IVPB (PDS ADS MIXTURE),50863,CDM,250,RC,J2540,HCPCS,99999-0404-10,NDC,facility,both,5,ML,,159,111.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69315-904-01,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 1 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,0781-5311-06,NDC,facility,both,3,EA,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,J0665,HCPCS,0409-1162-02,NDC,,,facility,both,300,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,50863,CDM,250,RC,J9263,HCPCS,60505-6132-7,NDC,facility,both,200,ML,,432,302.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIROFIBAN-0.9% SODIUM CHLORIDE 5 MG/100 ML (50 MCG/ML) IV SOLN,50863,CDM,250,RC,J3246,HCPCS,25208-002-03,NDC,facility,both,4,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  88 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-486-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-1638-32,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,63323-806-12,NDC,facility,both,3,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,636,RC,Q0162,HCPCS,16714-671-02,NDC,facility,both,2,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIMODIPINE 60 MG/10 ML ORAL SYRG,50863,CDM,636,RC,J3490,HCPCS,24338-260-10,NDC,facility,both,1,ML,,416,291.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 500 MG PE/10 ML INJ SOLN,50863,CDM,250,RC,Q2009,HCPCS,0641-6137-01,NDC,facility,both,22,ML,,532,372.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,0121-0657-05,NDC,facility,both,2,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-673-10,NDC,facility,both,4,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  500 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,63323-377-01,NDC,facility,both,20,ML,,253,177.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-318-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J2312,HCPCS,70069-072-10,NDC,facility,both,200,ML,,212,148.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM PHOSPHATES 19 GRAM-7 GRAM ENEMA,50863,CDM,250,RC,J3490,HCPCS,0132-0201-40,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,250,RC,J0132,HCPCS,25021-812-30,NDC,facility,both,50,ML,,358,250.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CERTOLIZUMAB PEGOL 400 MG (200 MG X 2) SUBQ KIT,50863,CDM,636,RC,J0717,HCPCS,50474-700-62,NDC,facility,both,200,EA,JZ,3323,2326.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0093-2279-73,NDC,facility,both,11,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J2310,HCPCS,67457-299-10,NDC,facility,both,4,ML,,513,359.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION,50863,CDM,250,RC,J0840,HCPCS,50633-111-11,NDC,facility,both,4,EA,,35306,24714.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1815,HCPCS,0169-1833-11,NDC,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLP",50863,CDM,250,RC,P9047,HCPCS,44206-251-10,NDC,facility,both,1,ML,JW,108,75.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,636,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,6,EA,,139,97.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,64980-562-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 150 MG/ML INJECTION,50863,CDM,250,RC,J3490,HCPCS,0009-0775-26,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,522,ME,,7084,4958.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN  10 GRAM INJ SOLR,50863,CDM,250,RC,J0690,HCPCS,0143-9983-91,NDC,facility,both,6,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0131-2477-60,NDC,facility,both,3,EA,,229,160.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2312,HCPCS,0409-1215-01,NDC,facility,both,40,ML,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,636,RC,J7999,HCPCS,61553-012-72,NDC,facility,both,2,ML,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLN (MERGE)",50863,CDM,250,RC,P9047,HCPCS,64208-2512-8,NDC,facility,both,6,ML,,713,499.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,J0132,HCPCS,55150-259-30,NDC,,,facility,both,240,ML,,1084,758.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN SODIUM EXTENDED 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6187-61,NDC,facility,both,4,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IVPB (PEDIATRICS/ADULT NON-FORM)",50863,CDM,636,RC,J0131,HCPCS,24201-100-01,NDC,facility,both,49,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL-ROPIVACAINE-NACL (PF) 2-0.2 MCG/ML-% INJ (MERGE ERX),50863,CDM,250,RC,J3490,HCPCS,61553-844-48,NDC,facility,both,2,ML,,713,499.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE IN 0.9% NS (PF) 1 MG/10 ML (100 MCG/ML) IV SYRG(PDS MERGE),50863,CDM,250,RC,J3490,HCPCS,65302-506-10,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-333-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICLOFENAC 1 % TOPICAL GEL,50863,CDM,250,RC,J3490,HCPCS,43598-977-10,NDC,facility,both,1,GM,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 0.5 MG ORAL TBDL,50863,CDM,636,RC,J3490,HCPCS,49884-311-52,NDC,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1940,HCPCS,63323-280-03,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,38,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  25 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6991-04,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),50863,CDM,250,RC,J2060,HCPCS,0641-6044-01,NDC,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-1283-03,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 50 MG/ML INJECTION,50863,CDM,636,RC,J1200,HCPCS,0641-0376-25,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOLAZONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50742-351-01,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEMAZEPAM 15 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0228-2076-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FINASTERIDE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-428-11,NDC,facility,both,5,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL  2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-735-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLIPIZIDE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0591-0460-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 100 MG/ML INJ SOLN,50863,CDM,250,RC,J2800,HCPCS,70069-101-01,NDC,facility,both,1,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6708-61,NDC,facility,both,2,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,0904-6794-30,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-588-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-134-11,NDC,facility,both,10,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL  6.25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7306-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML INJ SOLN,50863,CDM,250,RC,J2060,HCPCS,0409-1985-03,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  75 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-495-11,NDC,facility,both,3,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL (VITAMIN D3)  1000 UNIT ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,8068116900,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  2.5 MG ORAL TAB,50863,CDM,250,RC,J7510,HCPCS,59651-485-01,NDC,facility,both,1,EA,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0781-6041-46,NDC,facility,both,7,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-18,NDC,facility,both,89,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
AMOXICILLIN 250 MG ORAL CAP,50863,CDM,J3490,HCPCS,16714-298-01,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MECLIZINE 25 MG ORAL TAB,50863,CDM,J3490,HCPCS,60687-730-11,NDC,,,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 4 MEQ/ML IV SOLP (COMPOUNDED 30ML),50863,CDM,250,RC,J3490,HCPCS,63323-093-01,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,50863,CDM,250,RC,J2359,HCPCS,0781-3159-72,NDC,facility,both,15,EA,JW,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
METOCLOPRAMIDE  5 MG/ML INJ SOLN,50863,CDM,636,RC,J2765,HCPCS,0409-3414-21,NDC,facility,both,6,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,50863,CDM,636,RC,J3490,HCPCS,68462-157-40,NDC,facility,both,9,EA,,749,524.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,0904-6923-61,NDC,facility,both,40,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 1000 MG MISC TBSO,50863,CDM,250,RC,J3490,HCPCS,0223-1760-01,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 15 MG/ML (1.5 %) INJ SOLN,50863,CDM,J2003,HCPCS,0409-4776-10,NDC,,,facility,both,45,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT  60 MCG/0.3 ML INJ SYRG,50863,CDM,636,RC,J0881,HCPCS,55513-023-04,NDC,facility,both,120,ML,EC,2564,1794.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier EC: Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy
MEPERIDINE (PF) 25 MG/ML IV SOLN (PHS MERGE),50863,CDM,636,RC,J2175,HCPCS,0641-6052-01,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-406-03,NDC,facility,both,1,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,68094-231-59,NDC,facility,both,2,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,250,RC,J2405,HCPCS,60505-6130-0,NDC,facility,both,16,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 2 MG/10 ML (200 MCG/ML) IN D5W VIAL-CVL/IR USE (REPACK),50863,CDM,636,RC,J3490,HCPCS,0338-1049-02,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,50863,CDM,J1644,HCPCS,25021-402-01,NDC,,,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,37000-024-44,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRP (MERGE/REPACK),50863,CDM,636,RC,J3490,HCPCS,63304-205-18,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,2,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE 0.5 MG/2 ML INHL NBSP,50863,CDM,250,RC,J3490,HCPCS,60687-524-79,NDC,facility,both,2,ML,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-161-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  25 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-473-11,NDC,facility,both,4,EA,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 1 MG (ENVARSUS XR) 24-HOUR EXTENDED-RELEASE TABLET,50863,CDM,250,RC,J7508,HCPCS,68992-3010-3,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,636,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,125,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 5 MG/5 ML IV,50863,CDM,636,RC,J3490,HCPCS,0143-9873-10,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,70756-622-85,NDC,facility,both,2000,ML,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 5 MG/5 ML IV,50863,CDM,636,RC,J3490,HCPCS,36000-033-10,NDC,facility,both,2,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,63323-165-30,NDC,facility,both,55,ML,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0781-2020-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 10 GRAM/15 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,0116-4005-30,NDC,facility,both,1,ML,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,63323-649-07,NDC,facility,both,2,EA,,913,639.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN STERILE WATER 2 GRAM/20 ML IV SYRG,50863,CDM,250,RC,J7999,HCPCS,70092-1604-47,NDC,facility,both,1,ML,PLAD,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,9,ML,,167,116.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE CONCENTRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0054-0404-44,NDC,facility,both,2,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRP (MERGE/REPACK),50863,CDM,636,RC,J3490,HCPCS,68094-764-59,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,4,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MISOPROSTOL 100 MCG ORAL TAB,50863,CDM,250,RC,S0191,HCPCS,60687-735-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE (CONTRACEPTIVE) 150 MG/ML IM SUSP,50863,CDM,636,RC,J1050,HCPCS,55150-329-01,NDC,facility,both,150,ML,,215,150.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,42806-312-50,NDC,facility,both,2,EA,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 20 GRAM/30 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-1154-30,NDC,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6290-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,63323-162-00,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,76045-009-10,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,0409-4887-24,NDC,facility,both,1,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) 1000 UNITS/ML INJ SOL (FOR DIALYSIS ONLY),50863,CDM,250,RC,J1644,HCPCS,25021-400-10,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 10 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,70954-261-10,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML INJ SOLN,50863,CDM,250,RC,J0169,HCPCS,76329-9060-0,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IV PGBK,50863,CDM,636,RC,J3475,HCPCS,0338-1708-40,NDC,facility,both,4,ML,JZ,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
HYDROMORPHONE  4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-3244-01,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,636,RC,J0330,HCPCS,0409-6629-02,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-253-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,0409-1283-04,NDC,facility,both,5,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,250,RC,J2003,HCPCS,0409-4277-16,NDC,facility,both,400,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,250,RC,J0132,HCPCS,72611-860-01,NDC,facility,both,180,ML,,652,456.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 0.75 % VAGL GEL,50863,CDM,250,RC,J3490,HCPCS,0245-0860-70,NDC,facility,both,1,GM,,587,410.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,250,RC,J7060,HCPCS,0338-0017-04,NDC,facility,both,2,ML,JZ,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
AMPHETAMINE-DEXTROAMPHETAMINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42858-723-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LITHIUM CARBONATE 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0054-8527-25,NDC,facility,both,4,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,72485-106-01,NDC,facility,both,367,ML,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNITS/1 GRAM PACKET (MERGE RECORD),50863,CDM,636,RC,J3490,HCPCS,57896-111-09,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITAZOXANIDE 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,64980-526-60,NDC,facility,both,1,EA,,595,416.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0780,HCPCS,25021-790-02,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LITHIUM CARBONATE 300 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0054-8528-25,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLECAINIDE 20MG/ML SUSPENSION (REPACK),50863,CDM,250,RC,J3490,HCPCS,0054-0010-25,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE HCL IN D5W 4 MG/250 ML (16 MCG/ML) IV SOLN,50863,CDM,636,RC,J0171,HCPCS,72196-7018-1,NDC,facility,both,1,ML,,211,147.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,62,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0780,HCPCS,23155-294-31,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J2003,HCPCS,63323-492-09,NDC,facility,both,50,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,67457-423-00,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML IV SOLN (MERGE),50863,CDM,250,RC,J3490,HCPCS,70756-611-82,NDC,facility,both,1,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIFABUTIN 150 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,10135-738-01,NDC,facility,both,2,EA,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SINCALIDE 5 MCG INJ SOLR,50863,CDM,636,RC,J2805,HCPCS,72266-248-05,NDC,facility,both,1,EA,,154,107.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENAZEPRIL 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,43547-336-10,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE HCL  2 % MM JELP,50863,CDM,250,RC,J3490,HCPCS,25021-673-76,NDC,facility,both,2,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  75 MG ORAL CP24,50863,CDM,636,RC,J3490,HCPCS,68084-709-11,NDC,facility,both,3,EA,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 875 MG-125 MG TAB,50863,CDM,636,RC,J3490,HCPCS,42571-162-42,NDC,facility,both,20,EA,,364,254.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM,50863,CDM,250,RC,J3490,HCPCS,16714-496-01,NDC,facility,both,1,GM,,184,128.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,72162-1329-8,NDC,facility,both,1,ML,,139,97.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,50863,CDM,636,RC,J0585,HCPCS,0023-1145-01,NDC,facility,both,100,EA,"JZ,GZ",1599,1119.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier GZ: Item or service expected to be denied as not reasonable and necessary
ETOMIDATE 2 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,25021-674-20,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0641-6059-01,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,26,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL-ROPIVACAINE-NACL (PF) 2-0.2 MCG/ML-% INJ (MERGE ERX),50863,CDM,250,RC,J3490,HCPCS,73013-1048-01,NDC,facility,both,2,ML,,540,378,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADVATE: FACTOR VIII CONCENTRATE (MERGE RECORD),50863,CDM,250,RC,J7209,HCPCS,0944-3053-03,NDC,facility,both,3000,UN,,15732,11012.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON DEXTRAN 50 MG/ML INJ SOLN,50863,CDM,250,RC,J1750,HCPCS,0023-6082-01,NDC,facility,both,30,ML,,3282,2297.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,12,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,1,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV (BOLUS),50863,CDM,250,RC,J7120,HCPCS,0264-7750-07,NDC,facility,both,2,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CANGRELOR 50 MG IV SOLR,50863,CDM,636,RC,C9460,HCPCS,10122-620-01,NDC,facility,both,50,EA,,2764,1934.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2308-22,NDC,facility,both,6,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ISOSORBIDE MONONITRATE  30 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,0904-6449-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG ORAL TAB,50863,CDM,Q0169,HCPCS,0904-7304-61,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,636,RC,J3490,HCPCS,53746-542-01,NDC,facility,both,4,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 2 GRAM INJ SOLR,50863,CDM,250,RC,J0692,HCPCS,0409-9735-10,NDC,facility,both,4,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 30 MG ORAL CPDR,50863,CDM,636,RC,J3490,HCPCS,60687-734-11,NDC,facility,both,1,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,50863,CDM,250,RC,J9045,HCPCS,0703-4239-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 150 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,0904-7084-61,NDC,facility,both,3,EA,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BISOPROLOL FUMARATE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,70954-455-20,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE   4.2 % IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-083-05,NDC,facility,both,3,ML,,303,212.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,0409-9094-22,NDC,facility,both,2,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-069-33,NDC,facility,both,1,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 50 MG/ML IV SOLN,50863,CDM,636,RC,J0282,HCPCS,67457-153-03,NDC,facility,both,5,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,25021-602-03,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,0641-6206-01,NDC,facility,both,10,ML,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"TOBRAMYCIN-DEXAMETHASONE 0.3 %-0.1 % EYE DROPS, SUSP",50863,CDM,636,RC,J3490,HCPCS,61314-647-25,NDC,facility,both,1,ML,,308,215.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAUNORUBICIN 5 MG/ML IV INJ,50863,CDM,250,RC,J9150,HCPCS,42658-021-01,NDC,facility,both,6,ML,,1565,1095.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-444-01,NDC,facility,both,3,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,21,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DRONABINOL  2.5 MG ORAL CAP,50863,CDM,Q0167,HCPCS,60687-375-11,NDC,,,facility,both,1,EA,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN LYSINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66993-490-36,NDC,facility,both,1,ML,,454,317.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,12,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 10 MG/5 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,0054-0622-63,NDC,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG RECT SUPP,50863,CDM,636,RC,J3490,HCPCS,51672-2116-0,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENDAMUSTINE 25 MG/ML IV SOLN,50863,CDM,250,RC,J9036,HCPCS,63459-348-04,NDC,facility,both,200,ML,,13656,9559.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FERRIC SUBSULFATE 0.2 TO 0.22 GRAM/ML MISC SOLA,50863,CDM,250,RC,J3490,HCPCS,10481-0112-8,NDC,facility,both,1,ML,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 400 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0143-9887-01,NDC,facility,both,6,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CINACALCET 30 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16729-440-15,NDC,facility,both,1,EA,,150,105,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIOTROPIUM BROMIDE 2.5 MCG/ACTUATION INHL MIST,50863,CDM,636,RC,J3490,HCPCS,0597-0100-51,NDC,facility,both,1,GM,,382,267.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IR SOLN,50863,CDM,250,RC,J3490,HCPCS,0338-0047-46,NDC,facility,both,5,ML,,277,193.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-580-11,NDC,facility,both,4,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-3178-16,NDC,facility,both,120,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,636,RC,J0330,HCPCS,69374-919-10,NDC,facility,both,9,ML,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J2004,HCPCS,0409-3178-01,NDC,facility,both,15,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MILRINONE INFUSION PED/NEO IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J2260,HCPCS,0143-9719-01,NDC,facility,both,8,ML,,178,124.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-9543-02,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,250,RC,J0330,HCPCS,31722-981-10,NDC,facility,both,12,ML,,130,91,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 0.5 MG ORAL CAP,50863,CDM,250,RC,J7507,HCPCS,0904-6623-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2598,HCPCS,42023-164-25,NDC,facility,both,20,ML,JZ,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LISINOPRIL  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6797-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PYRIDOSTIGMINE BROMIDE  60 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0115-3511-01,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML INJ SOLN,50863,CDM,250,RC,J2060,HCPCS,0641-6207-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % MUCOSAL SOLN (VISCOUS),50863,CDM,250,RC,J3490,HCPCS,72888-125-26,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 400 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0143-9887-01,NDC,facility,both,13,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7050,HCPCS,0338-0049-03,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,J0133,HCPCS,65219-622-02,NDC,,,facility,both,124,ML,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,636,RC,J3490,HCPCS,63323-485-27,NDC,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICARDIPINE IN NACL (ISO-OS) 20 MG/200 ML IV PGBK,50863,CDM,250,RC,J3490,HCPCS,43066-009-10,NDC,facility,both,2,ML,,509,356.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 1 MG ORAL CAP,50863,CDM,250,RC,J7507,HCPCS,54288-135-01,NDC,facility,both,1,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-229-02,NDC,facility,both,2,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,12,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,72603-506-01,NDC,facility,both,200,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68180-966-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 7.5 MG-325 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0406-0124-23,NDC,facility,both,3,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELLADONNA ALKALOIDS-OPIUM 16.2 MG-30 MG RECTAL SUPPOSITORY,50863,CDM,250,RC,J3490,HCPCS,0574-7045-01,NDC,facility,both,1,EA,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,6809411059,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,636,RC,J2270,HCPCS,0409-1890-13,NDC,facility,both,1,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0641-0400-12,NDC,facility,both,1,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
FLUMAZENIL 0.1 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,36000-148-01,NDC,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0832-1211-89,NDC,facility,both,3,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 100 MG PE/2 ML INJ SOLN,50863,CDM,250,RC,Q2009,HCPCS,63323-403-01,NDC,facility,both,4,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0832-1211-89,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,51754-5001-1,NDC,facility,both,1,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTAMIDINE 300 MG INJ SOLR,50863,CDM,636,RC,J3490,HCPCS,23155-748-31,NDC,facility,both,1,EA,,233,163.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,73293-0001-1,NDC,,,facility,both,100,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MICAFUNGIN 100 MG IV SOLR,50863,CDM,250,RC,J2248,HCPCS,42023-230-01,NDC,facility,both,39,EA,,250,175,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1162-18,NDC,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),50863,CDM,636,RC,J0171,HCPCS,76329-3318-1,NDC,facility,both,10,ML,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,0641-6145-01,NDC,facility,both,3,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CARBIDOPA-LEVODOPA 25 MG-100 MG TAB,50863,CDM,J3490,HCPCS,60687-661-11,NDC,,,facility,both,3,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"VARICELLA-ZOSTER GE VAC,2 OF 2 50 MCG IM SUSR",50863,CDM,90750,HCPCS,58160-828-03,NDC,,,facility,both,1,EA,,763,534.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2305-16,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,636,RC,J7510,HCPCS,17856-0815-1,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 875 MG-125 MG TAB,50863,CDM,636,RC,J3490,HCPCS,42571-162-01,NDC,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),50863,CDM,250,RC,J1630,HCPCS,67457-426-00,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,23155-833-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50111-327-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZTROPINE 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69315-136-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5%-1/2 NORMAL SALINE IV,50863,CDM,250,RC,J7042,HCPCS,0338-0085-03,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM CITRATE ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,70677-1111-1,NDC,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 20 MG ORAL TAB,50863,CDM,250,RC,J8499,HCPCS,0904-6988-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,66794-229-02,NDC,facility,both,2,ML,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,45,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAZOSIN 2 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7021-61,NDC,facility,both,4,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  75 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,68084-709-11,NDC,facility,both,3,EA,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IR SOLN,50863,CDM,636,RC,J3490,HCPCS,0264-2201-00,NDC,facility,both,3,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0630,HCPCS,42023-205-01,NDC,facility,both,1,ML,,1392,974.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,636,RC,J7510,HCPCS,17856-0759-5,NDC,facility,both,9,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,J2250,HCPCS,0409-2308-22,NDC,,,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE HCL  2 % MM JELP,50863,CDM,250,RC,J3490,HCPCS,76329-3012-5,NDC,facility,both,2,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML (ANESTHESIA INTRAOP ONLY),50863,CDM,636,RC,J3010,HCPCS,0641-6027-01,NDC,facility,both,2,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0143-9509-01,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6953-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,63323-506-01,NDC,facility,both,40,ML,,200,140,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/0.5 ML INHL NEBU,50863,CDM,J3490,HCPCS,0487-9901-30,NDC,,,facility,both,6,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANTI-INHIBITOR COAGULANT CMPLX (PHS MERGE),50863,CDM,J7198,HCPCS,64193-426-02,NDC,,,facility,both,1300,UN,,9389,6572.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 500 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,50268-152-15,NDC,facility,both,6,EA,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,49502-393-80,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE IN D5W 1 GRAM/100 ML IV PGBK,50863,CDM,J3475,HCPCS,44567-410-24,NDC,,,facility,both,2,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 100 MG/ML FROM 1 GRAM VIAL (PRMC PEDS ONLY),50863,CDM,J0696,HCPCS,0409-7332-11,NDC,,,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,2,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68180-113-16,NDC,facility,both,1,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,636,RC,J0330,HCPCS,31722-981-10,NDC,facility,both,14,ML,,158,110.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZONATATE 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7153-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ (MERGE),50863,CDM,636,RC,J2250,HCPCS,0409-2305-17,NDC,facility,both,2,ML,AY,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier AY: Item or service furnished to an esrd patient that is not for the treatment of esrd
NEBIVOLOL  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7189-04,NDC,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,50863,CDM,250,RC,J9267,HCPCS,61703-342-22,NDC,facility,both,84,ML,,139,97.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-04,NDC,facility,both,2,ML,JZ,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-444-01,NDC,facility,both,5,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J2003,HCPCS,63323-492-27,NDC,facility,both,100,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-02,NDC,facility,both,1,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 50 MG TAB,50863,CDM,636,RC,J3490,HCPCS,42043-221-09,NDC,facility,both,2,EA,,214,149.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,0075-0622-01,NDC,facility,both,14,ML,,205,143.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,4,EA,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-503-11,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60505-0252-3,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5% W/EPINEPHRINE 1:200K INJECTION,50863,CDM,636,RC,J3490,HCPCS,0409-1749-29,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 7.5 MG-325 MG/15 ML ORAL SOLN (REPACK),50863,CDM,636,RC,J3490,HCPCS,0121-2316-15,NDC,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 30 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0093-0318-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-48,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 40 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,57237-150-35,NDC,facility,both,1,ML,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GALANTAMINE  4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-729-11,NDC,facility,both,1,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COSYNTROPIN 0.25 MG INJ SOLR,50863,CDM,250,RC,J0834,HCPCS,0548-5900-00,NDC,facility,both,1,EA,,461,322.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATENOLOL  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-684-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-01,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,636,RC,J2597,HCPCS,65219-293-00,NDC,facility,both,36,ML,,793,555.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 50 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,60687-402-11,NDC,facility,both,2,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-520-11,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,J1171,HCPCS,0409-1283-03,NDC,,,facility,both,10,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VECURONIUM 1 MG/ML IV SYRINGE (NEO),50863,CDM,250,RC,J3490,HCPCS,41616-931-44,NDC,facility,both,10,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,250,RC,J3490,HCPCS,0173-0682-24,NDC,facility,both,1,GM,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 10 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-5784-61,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0781-3246-02,NDC,facility,both,1,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,71288-402-10,NDC,facility,both,9,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,72603-179-01,NDC,facility,both,5,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,50863,CDM,636,RC,J0561,HCPCS,60793-700-01,NDC,facility,both,12,ML,,1509,1056.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN 50 MG ORAL CHEW,50863,CDM,636,RC,J3490,HCPCS,51672-4146-1,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,59762-0075-1,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TORSEMIDE  20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-539-11,NDC,facility,both,3,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,30,ML,,52021,36414.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,250,RC,J3490,HCPCS,59310-579-20,NDC,facility,both,1,GM,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,7733351625,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIGOXIN 250 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-551-11,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0832-1211-89,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,13,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-05,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2003,HCPCS,0409-2066-05,NDC,,,facility,both,400,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-411-10,NDC,facility,both,10,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 100 MG/ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,31722-574-47,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TAB,50863,CDM,250,RC,J3490,HCPCS,60687-569-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,59762-3140-1,NDC,facility,both,13,ML,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE IN 0.9% NS (PF) 1 MG/10 ML (100 MCG/ML) IV SYRG(PDS MERGE),50863,CDM,250,RC,J3490,HCPCS,63037-173-25,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HUMAN PROTHROMBIN COMPLEX 500 UNIT IV SOLR,50863,CDM,250,RC,J7168,HCPCS,63833-386-02,NDC,facility,both,2000,UN,JZ,11638,8146.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
METOPROLOL TARTRATE 25 MG TAB,50863,CDM,250,RC,J3490,HCPCS,51079-255-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMETHICONE  80 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,77333-812-25,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB 100 MG IV SOLR,50863,CDM,636,RC,J1745,HCPCS,57894-030-01,NDC,facility,both,50,EA,JZ,16116,11281.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,636,RC,J3490,HCPCS,0409-1323-05,NDC,facility,both,100,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-31,NDC,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE-DEXTROSE-WATER(PF) 7.5 MG/ML (0.75 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-473-02,NDC,facility,both,2,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,636,RC,J7510,HCPCS,17856-0815-1,NDC,facility,both,5,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 150 MG/1 ML SUBQ SYRG,50863,CDM,J1650,HCPCS,16714-066-01,NDC,,,facility,both,14,ML,,156,109.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  10 MG ORAL TR12,50863,CDM,636,RC,J3490,HCPCS,59011-410-20,NDC,facility,both,1,EA,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL (5 MG/ML) IV SYRG (CONTAINS PRESERVATIVE),50863,CDM,J3490,HCPCS,0409-2339-24,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,50863,CDM,636,RC,J3490,HCPCS,69339-152-01,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,J0696,HCPCS,0143-9857-25,NDC,,,facility,both,7,EA,,244,170.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2001,HCPCS,63323-208-01,NDC,,,facility,both,10,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZTROPINE 2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6789-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,10019-016-39,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,99,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLMESARTAN 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68462-438-30,NDC,facility,both,1,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,36000-283-25,NDC,facility,both,200,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,23155-600-31,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-573-10,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLP,50863,CDM,250,RC,J3480,HCPCS,0409-6651-19,NDC,facility,both,10,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,40,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 10% IN WATER (NEO) 2 - 3.99 KG,50863,CDM,250,RC,J3490,HCPCS,0338-0023-04,NDC,facility,both,2,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-405-11,NDC,facility,both,2,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLMESARTAN 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68462-437-90,NDC,facility,both,1,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACUBITRIL-VALSARTAN 24-26 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0078-0659-20,NDC,facility,both,1,EA,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN D5W 1 GRAM/200 ML IV PGBK,50863,CDM,250,RC,J3370,HCPCS,0338-3552-48,NDC,facility,both,2,ML,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,65219-570-01,NDC,facility,both,10,ML,,231,161.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J0461,HCPCS,0517-1004-01,NDC,facility,both,40,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 120 MG/0.8 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,0955-1012-01,NDC,facility,both,12,ML,,151,105.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63629-1061-1,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,71288-402-10,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL  0.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-733-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON DEXTRAN 50 MG/ML INJ SOLN,50863,CDM,636,RC,J1750,HCPCS,0023-6082-01,NDC,facility,both,40,ML,,4376,3063.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 500 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,62756-798-88,NDC,facility,both,1,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ (REPACK)(MERGE) (FOR PCA),50863,CDM,250,RC,J3010,HCPCS,0409-9094-41,NDC,facility,both,25,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEGESTROL 40 MG ORAL TAB,50863,CDM,636,RC,J9999,HCPCS,0904-7236-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRP (MERGE/REPACK),50863,CDM,636,RC,J3490,HCPCS,68094-764-59,NDC,facility,both,1,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-645-11,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0630,HCPCS,43598-051-11,NDC,facility,both,1,ML,JZ,4665,3265.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,250,RC,J2270,HCPCS,0409-1890-03,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-385-01,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALSARTAN 160 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-634-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN 0.9 % SODIUM CHL 1.5 GRAM/500 ML IV SOLN,50863,CDM,250,RC,J3373,HCPCS,72196-6176-1,NDC,facility,both,150,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6709-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),50863,CDM,250,RC,J3490,HCPCS,0409-4888-03,NDC,facility,both,2,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IV PGBK,50863,CDM,250,RC,J3475,HCPCS,0264-4206-54,NDC,facility,both,30,ML,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,24,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL IV BOLUS 10MG/ML (ANESTHESIA ONLY),50863,CDM,636,RC,J2704,HCPCS,0409-4699-54,NDC,facility,both,13,ML,JW,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-1749-70,NDC,facility,both,2,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIPASE-PROTEASE-AMYLASE 12,000-38,000- 60,000 UNIT ORAL CAP, DELAY REL",50863,CDM,250,RC,J3490,HCPCS,0032-0047-70,NDC,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMULSION 20 % IV EMUL,50863,CDM,250,RC,j3490,HCPCS,65219-533-01,NDC,facility,both,1,ML,,224,156.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 300 MG CAP,50863,CDM,636,RC,J3490,HCPCS,68084-244-11,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-1283-03,NDC,facility,both,7,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-511-11,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % MBP,50863,CDM,636,RC,J3490,HCPCS,0338-9616-30,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOPROTERENOL 0.2 MG/ML INJECTION,50863,CDM,250,RC,J3490,HCPCS,0548-9502-00,NDC,facility,both,2,ML,,1728,1209.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-492-57,NDC,facility,both,100,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 10 GRAM/15 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,0116-4005-30,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DACARBAZINE 200 MG IV SOLR,50863,CDM,636,RC,J9130,HCPCS,0143-9245-01,NDC,facility,both,6,EA,,184,128.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 250 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,17856-0698-01,NDC,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0093-4155-73,NDC,facility,both,5,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL  6.25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7306-61,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL 20 MG/5 ML ORAL ELIX,50863,CDM,250,RC,J3490,HCPCS,60687-671-40,NDC,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-555-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,250,RC,J7060,HCPCS,0264-7510-10,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),50863,CDM,250,RC,J3490,HCPCS,8290306544,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,45,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM IN D5W 125 MG/125 ML (1 MG/ML) IV SOLN (PREMIX),50863,CDM,J3490,HCPCS,70092-1007-36,NDC,,,facility,both,1,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE (PF) 1 MG/ML INJ SOLN,50863,CDM,250,RC,J0171,HCPCS,54288-103-01,NDC,facility,both,10,ML,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6666-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-723-11,NDC,facility,both,1,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J7510,HCPCS,17856-0815-1,NDC,facility,both,3,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) IV SOLN",50863,CDM,250,RC,J3490,HCPCS,0013-1114-20,NDC,facility,both,1,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL (VITAMIN D3) 400 UNIT/ML ORAL DROP,50863,CDM,250,RC,J3490,HCPCS,7139974015,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,23155-248-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PSEUDOEPHEDRINE SR 120 MG TAB,50863,CDM,636,RC,J3490,HCPCS,51660-204-69,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL (PULM.HYPERTENSION) 10 MG/12.5 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,55150-166-13,NDC,facility,both,1,ML,,792,554.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 60 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,60687-745-11,NDC,facility,both,1,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-50,NDC,facility,both,42,ML,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,140,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-492-04,NDC,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,J2704,HCPCS,0069-0209-01,NDC,,,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 2 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,J2270,HCPCS,76045-004-01,NDC,,,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,50863,CDM,250,RC,Q5119,HCPCS,0069-0238-01,NDC,facility,both,30,ML,,5936,4155.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DORZOLAMIDE 2 % OPHT DROP,50863,CDM,636,RC,J3490,HCPCS,72266-197-01,NDC,facility,both,1,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,50863,CDM,636,RC,J3490,HCPCS,57237-077-10,NDC,facility,both,4,EA,,378,264.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 4 MG (ENVARSUS XR) 24-HOUR EXTENDED-RELEASE TABLET,50863,CDM,250,RC,J7508,HCPCS,68992-3040-3,NDC,facility,both,2,EA,,141,98.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPRAZOLAM 0.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-388-11,NDC,facility,both,3,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,60687-145-11,NDC,facility,both,40,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML (PEDS CALCLUATOR 0.5),50863,CDM,636,RC,J1815,HCPCS,0024-5924-10,NDC,facility,both,14,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,62584-994-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),50863,CDM,250,RC,J1815,HCPCS,0024-5926-05,NDC,facility,both,7,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML IV SOLN (MERGE),50863,CDM,250,RC,J3490,HCPCS,70756-611-82,NDC,facility,both,1,ML,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,636,RC,J3490,HCPCS,63323-486-05,NDC,facility,both,200,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOPERAMIDE 2 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-229-11,NDC,facility,both,4,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,7985420062,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2305-16,NDC,facility,both,8,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 125 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6955-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLP,50863,CDM,250,RC,J3480,HCPCS,63323-965-03,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-406-03,NDC,facility,both,1,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,81,EA,,11178,7824.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,50863,CDM,636,RC,Q5119,HCPCS,0069-0238-01,NDC,facility,both,20,ML,,3957,2769.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,67457-423-00,NDC,facility,both,3,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DOXORUBICIN 50 MG/25 ML IV SOLN,50863,CDM,636,RC,J9000,HCPCS,63323-883-30,NDC,facility,both,5,ML,,196,137.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J7999,HCPCS,0517-0299-25,NDC,facility,both,500,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROPROCAINE 3 % INJ SOLN,50863,CDM,250,RC,J2401,HCPCS,63323-478-01,NDC,facility,both,601,ML,,132,92.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-544-11,NDC,facility,both,4,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL,50863,CDM,250,RC,J3490,HCPCS,63323-820-01,NDC,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,636,RC,J7510,HCPCS,17856-0815-1,NDC,facility,both,3,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML INJ SOLN,50863,CDM,636,RC,J0171,HCPCS,76329-9060-0,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICARDIPINE IN NACL (ISO-OS) 20 MG/200 ML IV PGBK,50863,CDM,J3490,HCPCS,10122-313-01,NDC,,,facility,both,1,ML,,440,308,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 100 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,60687-413-11,NDC,facility,both,3,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,50863,CDM,250,RC,J9060,HCPCS,16729-288-38,NDC,facility,both,7,ML,,149,104.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0781-3458-75,NDC,facility,both,2500,ML,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-591-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARIFENACIN  7.5 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,33342-276-07,NDC,facility,both,1,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 1% 10MG/ML (1ML-UD) OR SYRINGE,50863,CDM,636,RC,J3490,HCPCS,0409-4276-02,NDC,facility,both,200,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-089-50,NDC,facility,both,2,ML,,292,204.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,260,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE 0.25 MG/2 ML INHL NBSP,50863,CDM,636,RC,J3490,HCPCS,0487-9601-01,NDC,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,72162-1329-8,NDC,facility,both,1,ML,,421,294.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,498,ML,,714,499.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,22,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,250,RC,J3490,HCPCS,76329-3390-1,NDC,facility,both,100,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-1749-70,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,67,ML,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL  2.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,43547-351-10,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,71288-505-02,NDC,facility,both,2,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,250,RC,J2405,HCPCS,23155-547-31,NDC,facility,both,24,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML ORAL CONC,50863,CDM,636,RC,J3490,HCPCS,0054-3532-44,NDC,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,J0665,HCPCS,0409-1162-02,NDC,,,facility,both,600,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-1749-70,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL-ROPIVACAINE-NACL (PF) 2-0.2 MCG/ML-% INJ (MERGE ERX),50863,CDM,J3490,HCPCS,61553-844-48,NDC,,,facility,both,1,ML,,588,411.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1940,HCPCS,63323-280-04,NDC,facility,both,2,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE IN 0.9 % SOD CHLORIDE 100 MG/10 ML (10 MG/ML) IV SYRG,50863,CDM,250,RC,J3490,HCPCS,70004-430-12,NDC,facility,both,1,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLIPIZIDE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6637-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRBESARTAN 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-442-11,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J2003,HCPCS,0409-4279-02,NDC,facility,both,60,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATENOLOL  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-0752-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-242-11,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-0710-20,NDC,facility,both,8,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,51754-5001-1,NDC,facility,both,5,ML,,257,179.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,50863,CDM,J0696,HCPCS,60505-6149-0,NDC,,,facility,both,8,EA,,388,271.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOBUTAMINE IN D5W 500 MG/250 ML (2 MG/ML) INFUSION (PREMIX),50863,CDM,250,RC,J1250,HCPCS,0409-2347-31,NDC,facility,both,2,ML,,230,161,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,2,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,43,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,J3490,HCPCS,66794-228-02,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETIRIZINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-597-01,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG IV SOLR,50863,CDM,636,RC,J3490,HCPCS,16714-644-01,NDC,facility,both,1,EA,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-495-27,NDC,facility,both,50,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOPERAMIDE 2 MG ORAL CAP,50863,CDM,J3490,HCPCS,60687-229-11,NDC,,,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOMYCIN-BACITRACN ZN-POLYMYXIN 3.5 MG-400 U*,50863,CDM,J3490,HCPCS,45802-143-00,NDC,,,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 600 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-457-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 10 MEQ/50 ML IV PGBK,50863,CDM,636,RC,J3480,HCPCS,0990-7075-14,NDC,facility,both,10,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,18,ML,,31213,21849.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0406-5771-23,NDC,facility,both,13,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,50863,CDM,250,RC,J9025,HCPCS,72485-201-01,NDC,facility,both,65,EA,JW,402,281.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
"AMIODARONE IN DEXTROSE,ISO-OSM 150 MG/100 ML (PREMIX)",50863,CDM,250,RC,J0282,HCPCS,43066-150-10,NDC,facility,both,5,ML,,204,142.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE  10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69367-388-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0536-1327-06,NDC,facility,both,3,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-492-27,NDC,facility,both,40,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-753-11,NDC,facility,both,1,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6322-06,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6641-61,NDC,facility,both,3,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,55111-466-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 500 MG INJ SOLR,50863,CDM,636,RC,J0696,HCPCS,44567-700-25,NDC,facility,both,2,EA,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
VERAPAMIL 120 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,60687-493-11,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-31,NDC,facility,both,1,ML,JZ,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-492-09,NDC,facility,both,50,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,0904-6794-89,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 300 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6642-61,NDC,facility,both,4,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,50863,CDM,250,RC,J1885,HCPCS,72266-119-01,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NYSTATIN  100000 UNIT/G TOP OINT,50863,CDM,250,RC,J3490,HCPCS,0472-0166-15,NDC,facility,both,1,GM,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 20 GRAM/30 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-1154-30,NDC,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML IV SOLN,50863,CDM,J3490,HCPCS,0143-9507-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,J2003,HCPCS,0143-9575-01,NDC,,,facility,both,700,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL (5 MG/ML) IV SYRG (CONTAINS PRESERVATIVE),50863,CDM,636,RC,J3490,HCPCS,0409-2339-24,NDC,facility,both,1,ML,XU,27,18.9,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
MISOPROSTOL 200 MCG ORAL TAB,50863,CDM,250,RC,S0191,HCPCS,60687-746-11,NDC,facility,both,4,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM,50863,CDM,250,RC,J3490,HCPCS,1093919844,NDC,facility,both,1,GM,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 1 GRAM/20 ML IV SOLN,50863,CDM,250,RC,J9190,HCPCS,63323-117-00,NDC,facility,both,2,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALPHA-1-PROTEINASE INHIBITOR (HUMAN) 1,000 MG IV SUSP (PROLASTIN-C)",50863,CDM,636,RC,J0256,HCPCS,13533-700-01,NDC,facility,both,615,ME,,8709,6096.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML (PEDS CALCLUATOR 0.5),50863,CDM,636,RC,J1815,HCPCS,0024-5924-10,NDC,facility,both,2,ML,GZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier GZ: Item or service expected to be denied as not reasonable and necessary
CETIRIZINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6717-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNIT/G TOP PACK,50863,CDM,250,RC,J3490,HCPCS,0904-7402-67,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIRMATRELVIR-RITONAVIR 300-100 MG ORAL TAB DOSEPACK (FOR ED/IP TAKE HOME PANEL),50863,CDM,636,RC,J3490,HCPCS,0069-5321-03,NDC,facility,both,30,EA,,4010,2807,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,636,RC,J3490,HCPCS,77333-049-25,NDC,facility,both,3,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,250,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BISMUTH SUBSALICYLATE 262 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,0904-7205-46,NDC,facility,both,262,EA,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-075-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 500 MG (200 MG ELEMENTAL) CHEW TAB,50863,CDM,250,RC,J3490,HCPCS,68084-988-33,NDC,facility,both,6,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN 0.9% SODIUM CL 1.25 GRAM/250 ML IV SOLN,50863,CDM,250,RC,J3370,HCPCS,70092-9054-05,NDC,facility,both,3,ML,JZ,122,85.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,200,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0093-2026-94,NDC,facility,both,3,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,636,RC,J3490,HCPCS,14789-251-09,NDC,facility,both,1,ML,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 125 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,0074-6212-13,NDC,facility,both,2,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOTRIMAZOLE 1 % VAGL CREA,50863,CDM,636,RC,J3490,HCPCS,51672-2003-6,NDC,facility,both,1,GM,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-3426-05,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 250 MG/5 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,17856-0600-1,NDC,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) BLADDER INSTILLATION,50863,CDM,250,RC,J9201,HCPCS,0409-0182-01,NDC,facility,both,10,ML,,392,274.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0093-4155-80,NDC,facility,both,18,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FERROUS SULFATE 325 MG (65 MG IRON) TAB,50863,CDM,250,RC,J3490,HCPCS,904759161,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 0.4 MG SL SUBL,50863,CDM,636,RC,J3490,HCPCS,59762-3304-3,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50580-458-11,NDC,facility,both,3,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,60687-390-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),50863,CDM,250,RC,J1815,HCPCS,0024-5926-05,NDC,facility,both,5,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 0.2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60505-0258-1,NDC,facility,both,2,EA,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2312,HCPCS,67457-299-00,NDC,facility,both,100,ML,,129,90.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,13668-219-30,NDC,facility,both,2,EA,,273,191.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,250,RC,J3490,HCPCS,70092-9119-44,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,636,RC,J3490,HCPCS,81284-611-00,NDC,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELIMUMAB 120 MG IV SOLR,50863,CDM,636,RC,J0490,HCPCS,49401-101-01,NDC,facility,both,9,ME,"JW,JA",460,322,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
CLONAZEPAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0228-3003-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,50863,CDM,636,RC,J3490,HCPCS,17856-0823-10,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,6,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PORACTANT ALFA 240 MG/3 ML INTR SUSP,50863,CDM,250,RC,J3490,HCPCS,10122-510-01,NDC,facility,both,1,ML,,1576,1103.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESTRADIOL 2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42806-089-01,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2312,HCPCS,55150-328-01,NDC,facility,both,200,ML,,140,98,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,250,RC,J3360,HCPCS,76045-204-00,NDC,facility,both,2,ML,,145,101.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 1 MG ORAL TBDL,50863,CDM,250,RC,0093-9293-19,NDC,,,facility,both,3.5,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML (ANESTHESIA INTRAOP ONLY),50863,CDM,636,RC,J3010,HCPCS,0641-6027-01,NDC,facility,both,3,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2305-04,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GANCICLOVIR 500 MG IV SOLUTION,50863,CDM,250,RC,J1570,HCPCS,70436-089-55,NDC,facility,both,1,EA,,242,169.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,61,ML,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,636,RC,J0330,HCPCS,0409-6629-02,NDC,facility,both,4,ML,AS,46,32.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier AS: Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery"
SUGAMMADEX 100 MG/ML IV SOLN,50863,CDM,J3490,HCPCS,0006-5423-02,NDC,,,facility,both,1,ML,,561,392.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25 MG-100 MG TAB,50863,CDM,J3490,HCPCS,60687-661-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0137,HCPCS,0143-9386-01,NDC,facility,both,25,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,636,RC,J2405,HCPCS,60505-6130-0,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,14789-127-07,NDC,facility,both,1,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,70860-700-41,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  1 MG/ML ORAL LIQD,50863,CDM,636,RC,J3490,HCPCS,5843800571,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2305-16,NDC,facility,both,6,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-645-11,NDC,facility,both,2,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 40 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-210-11,NDC,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  2.5 MG ORAL TAB,50863,CDM,250,RC,J7510,HCPCS,59651-485-01,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-406-03,NDC,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,35,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL,50863,CDM,250,RC,J3490,HCPCS,63323-820-01,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DECITABINE 50 MG IV SOLR,50863,CDM,250,RC,J0894,HCPCS,55111-556-10,NDC,facility,both,50,EA,,1656,1159.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM ACETATE 2 MEQ/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0641-6262-01,NDC,facility,both,1,ML,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,636,RC,J1953,HCPCS,63323-400-01,NDC,facility,both,75,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  25 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-6991-04,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),50863,CDM,250,RC,J1630,HCPCS,67457-426-00,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-467-01,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 8-2 MG SL SUBL,50863,CDM,636,RC,J3490,HCPCS,50268-145-11,NDC,facility,both,2,EA,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-467-01,NDC,facility,both,1,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM 1 GRAM IV SOLR,50863,CDM,250,RC,J2185,HCPCS,0409-1391-21,NDC,facility,both,10,EA,JZ,122,85.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,8,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LORAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63304-773-01,NDC,facility,both,3,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NOREPINEPHRINE BITARTRATE-D5W 4 MG/250 ML (16 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,71285-6056-1,NDC,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,68180-150-01,NDC,facility,both,4,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,63323-485-27,NDC,,,facility,both,200,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2001,HCPCS,0143-9577-01,NDC,,,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-01,NDC,facility,both,300,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,135,ML,,193,135.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARTIFICIAL TEARS(HYPROMELLOSE) 0.3 % OPHT GEL,50863,CDM,250,RC,J3490,HCPCS,0065-8064-01,NDC,facility,both,1,GM,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIPHTH,PERTUS(ACELL),TETANUS VIAL (BOOSTRIX*) 2.5-8-5 LF-MCG-LF/0.5ML IM SUSP",50863,CDM,636,RC,90715,HCPCS,58160-842-01,NDC,facility,both,1,ML,,240,168,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE ACETATE 25 MG RECT SUPP,50863,CDM,250,RC,J3490,HCPCS,75834-147-06,NDC,facility,both,1,EA,,111,77.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN D5W 20000 UNIT/500 ML,50863,CDM,636,RC,J1644,HCPCS,0264-9567-10,NDC,facility,both,8,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,250,RC,J2720,HCPCS,63323-229-30,NDC,facility,both,50,ML,,539,377.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"TRIMETHOPRIM-POLYMYXIN B 0.1 %-10,000 UNIT/ML EYE DROPS",50863,CDM,250,RC,J3490,HCPCS,24208-315-10,NDC,facility,both,1,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"CALCIUM CARBONATE 500 MG (1,250 MG) ORAL TAB",50863,CDM,250,RC,J3490,HCPCS,5164582799,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 200 MG/20 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,31722-203-20,NDC,facility,both,1,ML,,200,140,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE (PF-DURAMORPH/ASTRAMORPH) 0.5 MG/ML INJ SOLN,50863,CDM,250,RC,J2274,HCPCS,0409-3814-11,NDC,facility,both,1,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIFAMPIN 600 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,0069-0112-01,NDC,facility,both,1,EA,,331,231.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-618-11,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASCORBIC ACID  250 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,5026886011,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,10,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,16714-293-01,NDC,facility,both,6,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,636,RC,J3490,HCPCS,0409-1323-15,NDC,facility,both,100,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 50 MG TAB,50863,CDM,636,RC,J3490,HCPCS,69452-345-60,NDC,facility,both,2,EA,,214,149.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM PHOSPHATE 3 MMOL/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-7391-82,NDC,facility,both,1,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,12,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-303-11,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2310,HCPCS,0409-1215-01,NDC,facility,both,1,ML,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTOBARBITAL 75 MG/1.5 ML SYRINGE (REPACK),50863,CDM,636,RC,J3490,HCPCS,25021-676-20,NDC,facility,both,2,ML,,196,137.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 20 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,68180-294-07,NDC,facility,both,2,EA,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,1657187290,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,16714-026-01,NDC,facility,both,6,ML,JZ,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,636,RC,J3490,HCPCS,25021-415-10,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PATIROMER CALCIUM SORBITEX  8.4 G ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,53436-084-01,NDC,facility,both,2,EA,,348,243.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 100 MG PE/2 ML INJ SOLN,50863,CDM,250,RC,Q2009,HCPCS,63323-403-01,NDC,facility,both,2,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL IV BOLUS 10MG/ML (ANESTHESIA ONLY),50863,CDM,250,RC,J2704,HCPCS,63323-269-29,NDC,facility,both,40,ML,PLAD,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
ALTEPLASE 2 MG INJ SOLR,50863,CDM,250,RC,J2997,HCPCS,50242-041-64,NDC,facility,both,10,EA,,3810,2667,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN   1.5 G IV SOLR,50863,CDM,250,RC,J3370,HCPCS,67457-824-15,NDC,facility,both,3,EA,JZ,142,99.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PROPRANOLOL  10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6550-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM 1 GRAM IV SOLR,50863,CDM,250,RC,J2185,HCPCS,63323-508-01,NDC,facility,both,70,EA,,275,192.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0137,HCPCS,0143-9386-01,NDC,facility,both,17,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,37,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,76045-009-96,NDC,facility,both,3,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-22,NDC,facility,both,10,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J7510,HCPCS,17856-0815-1,NDC,facility,both,4,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCRALFATE 1 GRAM ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,29033-003-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE   4.2 % IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-083-05,NDC,facility,both,2,ML,,183,128.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,23155-902-01,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DENOSUMAB 60 MG/ML SUBQ SYRG,50863,CDM,J0897,HCPCS,55513-710-01,NDC,,,facility,both,60,ML,,4930,3451,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC IV INFUSION HYDRAT 31-60 MIN,50863,CDM,250,RC,J0248,HCPCS,61958-2901-2,NDC,facility,both,50,EA,,598,418.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,J7040,HCPCS,0338-0049-48,NDC,,,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,Q5121,HCPCS,55513-670-01,NDC,,,facility,both,37,EA,,5106,3574.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  25 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,69238-1310-9,NDC,facility,both,2,EA,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-48,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,31722-711-30,NDC,facility,both,1,EA,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLP",50863,CDM,250,RC,P9047,HCPCS,0944-0493-04,NDC,facility,both,2,ML,JZ,501,350.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
METHOTREXATE (PF) 25 MG/ML INJ SOLN (FOR ECTOPIC PREGNANCY),50863,CDM,250,RC,J9260,HCPCS,0143-9519-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BEVACIZUMAB-MALY 25 MG/ML IV SOLN,50863,CDM,250,RC,Q5126,HCPCS,70121-1755-1,NDC,facility,both,80,ML,,15867,11106.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,250,RC,J0137,HCPCS,0264-4100-90,NDC,facility,both,2,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE 0.25 MG/2 ML INHL NBSP,50863,CDM,250,RC,J3490,HCPCS,0186-1988-04,NDC,facility,both,2,ML,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIROFIBAN-0.9% SODIUM CHLORIDE 5 MG/100 ML (50 MCG/ML) IV SOLN,50863,CDM,250,RC,J3246,HCPCS,25208-002-03,NDC,facility,both,14,ML,JW,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
BEVACIZUMAB-MALY 25 MG/ML IV SOLN,50863,CDM,250,RC,Q5126,HCPCS,70121-1754-1,NDC,facility,both,30,ML,,5951,4165.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,65862-219-60,NDC,facility,both,4,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM CITRATE ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,70677-1112-1,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN DETEMIR 100 UNIT/ML SUBQ SOLN,50863,CDM,636,RC,J1815,HCPCS,0169-3687-12,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,57664-596-40,NDC,facility,both,3,ML,,981,686.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,50863,CDM,250,RC,J9000,HCPCS,0069-1542-20,NDC,facility,both,12,ML,,198,138.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE PAMOATE  50 MG ORAL CAP,50863,CDM,636,RC,Q0177,HCPCS,50268-399-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE  1 % TOP OINT,50863,CDM,636,RC,J3490,HCPCS,1093957233,NDC,facility,both,1,GM,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0143-9595-01,NDC,facility,both,200,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,50863,CDM,636,RC,Q0177,HCPCS,63739-486-10,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
D5-LR WITH POTASSIUM CHLORIDE 20 MEQ/L IV SOLP,50863,CDM,250,RC,J3490,HCPCS,0338-0811-04,NDC,facility,both,1,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-354-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,636,RC,P9045,HCPCS,68516-5219-0,NDC,facility,both,16,ML,JZ,4067,2846.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DOXYCYCLINE 100 MG TAB,50863,CDM,636,RC,J3490,HCPCS,23155-135-25,NDC,facility,both,4,EA,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,250,RC,J3490,HCPCS,72603-387-01,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,62332-033-31,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CILOSTAZOL 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-177-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 40 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,27808-158-01,NDC,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,250,RC,J3490,HCPCS,0143-9679-01,NDC,facility,both,1,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-3178-01,NDC,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 400 MCG/100 ML (4 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0143-9525-01,NDC,facility,both,1,ML,,188,131.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4% TOP PATCH,50863,CDM,J3490,HCPCS,46581-830-01,NDC,,,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL 20 MG/5 ML ORAL ELIX,50863,CDM,250,RC,J3490,HCPCS,0121-0942-05,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1815,HCPCS,0002-8215-01,NDC,facility,both,2,ML,PLAD,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
HYDROXYZINE 25 MG TAB,50863,CDM,636,RC,Q0177,HCPCS,16714-082-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,14,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,40,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,24,ML,JZ,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6538-06,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,0409-3178-01,NDC,,,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,4,EA,,347,242.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 0.5 MG ORAL CAP,50863,CDM,250,RC,J7507,HCPCS,68462-685-01,NDC,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-285-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL (VITAMIN D3)   400 UNIT ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,7733394825,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 2 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J2004,HCPCS,63323-489-02,NDC,facility,both,140,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,42858-723-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROATE SODIUM 100 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0143-9785-01,NDC,facility,both,1,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J7510,HCPCS,17856-0759-5,NDC,facility,both,12,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLN (MERGE)",50863,CDM,250,RC,P9047,HCPCS,64208-2512-3,NDC,facility,both,3,ML,,411,287.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROPROCAINE 3 % INJ SOLN,50863,CDM,250,RC,J2401,HCPCS,63323-478-01,NDC,facility,both,300,ML,JW,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0781-3246-02,NDC,facility,both,8,ML,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ (MERGE),50863,CDM,636,RC,J2250,HCPCS,0409-0001-01,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1940,HCPCS,36000-283-25,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1940,HCPCS,36000-283-25,NDC,facility,both,2,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6283-61,NDC,facility,both,2,EA,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL IV BOLUS 10MG/ML (ANESTHESIA ONLY),50863,CDM,250,RC,J2704,HCPCS,0409-4699-54,NDC,facility,both,100,ML,,127,88.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,0409-6102-02,NDC,facility,both,100,ML,,139,97.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE IV CONCENTRATED INFUSION (1 MEQ/ML),50863,CDM,250,RC,J3490,HCPCS,0409-6625-02,NDC,facility,both,2,ML,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,13533-690-25,NDC,facility,both,4,ML,,868,607.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,636,RC,J3490,HCPCS,70092-1119-44,NDC,facility,both,3,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HAEMOPH B POLYSAC CONJ-MENING (PF) 7.5 MCG/0.5 ML IM,50863,CDM,90647,HCPCS,0006-4897-01,NDC,,,facility,both,1,ML,,179,125.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  5 MG ORAL TAB,50863,CDM,J3490,HCPCS,63739-145-10,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-580-11,NDC,facility,both,27,EA,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOZAPINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0378-0860-01,NDC,facility,both,4,EA,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0047-27,NDC,facility,both,25,EA,JZ,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
TOPIRAMATE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-342-11,NDC,facility,both,6,EA,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,3,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,72603-251-01,NDC,facility,both,11,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LURASIDONE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,67877-638-30,NDC,facility,both,3,EA,,552,386.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 600 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50111-789-10,NDC,facility,both,2,EA,,183,128.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,53,ML,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 10 GRAM IV SOLR,50863,CDM,250,RC,J3373,HCPCS,70436-023-82,NDC,facility,both,125,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,250,RC,J0132,HCPCS,55150-259-30,NDC,facility,both,35,ML,JW,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GUANFACINE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,24979-198-01,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEPERIDINE (PF) 50 MG/ML IV SOLN (PHS MERGE),50863,CDM,250,RC,J2175,HCPCS,0641-6053-01,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORDIAZEPOXIDE 25 MG CAP,50863,CDM,250,RC,J3490,HCPCS,60687-807-11,NDC,facility,both,4,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-1638-32,NDC,facility,both,2,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,0904-7127-61,NDC,facility,both,60,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-405-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-886-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0780,HCPCS,0713-0351-02,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,16714-293-01,NDC,facility,both,7,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0295,HCPCS,63323-368-20,NDC,facility,both,2,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0093-4155-73,NDC,facility,both,20,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,76045-009-96,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN DETEMIR 100 UNIT/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,0169-3687-12,NDC,facility,both,7,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-04,NDC,facility,both,8,ML,,133,93.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACCHAROMYCES BOULARDII 250 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,7733380050,NDC,facility,both,7,EA,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0780,HCPCS,23155-294-41,NDC,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-0430-04,NDC,facility,both,2,EA,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 10 MG/ML ORAL SOLUTION (REPACK),50863,CDM,250,RC,J3490,HCPCS,0131-5410-71,NDC,facility,both,3,ML,,126,88.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,16,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAZOLAMIDE 500 MG ORAL CPSR,50863,CDM,250,RC,J3490,HCPCS,60687-578-11,NDC,facility,both,2,EA,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-492-09,NDC,facility,both,150,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLEVIDIPINE 50 MG/100 ML IV EMUL,50863,CDM,250,RC,C9248,HCPCS,10122-611-01,NDC,facility,both,100,ML,,1523,1066.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0548-5604-00,NDC,facility,both,8,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,63323-806-13,NDC,facility,both,16,ML,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1815,HCPCS,0169-1833-11,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5% W/EPINEPHRINE 1:200K INJECTION,50863,CDM,636,RC,J3490,HCPCS,0409-1749-29,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN PEDS SYRINGE (20MG/ML) IN DEXTROSE (CDS MIX,50863,CDM,636,RC,J0690,HCPCS,0781-3451-70,NDC,facility,both,4,EA,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE-DEXTROSE-WATER(PF) 7.5 MG/ML (0.75 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-473-02,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-985-01,NDC,facility,both,3,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,60687-145-11,NDC,facility,both,20,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 400 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,16714-505-01,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN NPH HUMAN RECOMB 100 UNIT/ML SUBQ SUSP,50863,CDM,250,RC,J1815,HCPCS,0169-1834-11,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYTOCIN IN 0.9 % SOD CHLORIDE 30 UNIT/500 ML IV SOLN,50863,CDM,250,RC,J2590,HCPCS,71266-5102-1,NDC,facility,both,2,ML,,111,77.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 500 MG/5 ML ORAL SUMC,50863,CDM,250,RC,J3490,HCPCS,50419-773-01,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM ACETATE 667 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,68084-479-11,NDC,facility,both,3,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOBENZAPRINE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-191-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,2000,ML,,1596,1117.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,250,RC,Q9968,HCPCS,70710-1838-1,NDC,facility,both,38,ML,JW,214,149.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,636,RC,J0690,HCPCS,70092-1017-46,NDC,facility,both,2,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IVPB (PEDIATRICS/ADULT NON-FORM)",50863,CDM,636,RC,J0131,HCPCS,24201-100-01,NDC,facility,both,100,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,250,RC,J3490,HCPCS,53746-542-05,NDC,facility,both,4,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL (VITAMIN D3) 400 UNIT/ML ORAL DROP,50863,CDM,250,RC,J3490,HCPCS,7651805050,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETHOSUXIMIDE 250 MG/5 ML ORAL SYRP,50863,CDM,250,RC,J3490,HCPCS,0121-0670-16,NDC,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,76329-3352-1,NDC,facility,both,1,ML,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 500 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,16714-485-01,NDC,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM ACETATE 667 MG ORAL CAP,50863,CDM,250,RC,J0615,HCPCS,68084-479-11,NDC,facility,both,58,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,9,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-319-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-4799-05,NDC,facility,both,3,ML,,138,96.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  5 MG ORAL TBDL,50863,CDM,636,RC,J3490,HCPCS,59746-306-12,NDC,facility,both,1,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,6,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-711-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,250,RC,J3490,HCPCS,62037-560-01,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLN (MERGE)",50863,CDM,636,RC,P9047,HCPCS,68516-5216-4,NDC,facility,both,4,ML,JZ,853,597.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,43825-102-01,NDC,facility,both,38,ML,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,J2003,HCPCS,63323-486-05,NDC,,,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IMIPRAMINE PAMOATE 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,68180-315-06,NDC,facility,both,1,EA,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 20 MG/ML INJ SOLN,50863,CDM,250,RC,J0360,HCPCS,55150-400-01,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 1250 MG/5 ML SUSPENSION (500 MG/5 ML ELEMENTAL),50863,CDM,636,RC,J3490,HCPCS,0121-4766-05,NDC,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE DINITRATE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-367-10,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42291-468-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % MUCOSAL SOLN (VISCOUS),50863,CDM,636,RC,J3490,HCPCS,0054-8500-16,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,80,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,40,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM PHOSPHATE DIBASIC 3 MMOLE/ML IV SOLP,50863,CDM,250,RC,J3490,HCPCS,70069-747-01,NDC,facility,both,1,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,72266-118-01,NDC,facility,both,1,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,3,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-0710-20,NDC,facility,both,22,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,7,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
VANCOMYCIN IN D5W 1 GRAM/200 ML IV PGBK,50863,CDM,250,RC,J3370,HCPCS,0338-3552-48,NDC,facility,both,4,ML,,270,189,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,16714-293-01,NDC,facility,both,6,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DROPERIDOL 2.5 MG/ML INJ SOLN,50863,CDM,636,RC,J1790,HCPCS,0517-9702-01,NDC,facility,both,1,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-676-11,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 10 % (100 MG/ML) MISC SOLN,50863,CDM,250,RC,J3490,HCPCS,0517-7504-01,NDC,facility,both,2,ML,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 10 MG/ML IM SOLN,50863,CDM,636,RC,J0500,HCPCS,58914-080-52,NDC,facility,both,1,ML,,364,254.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE (CONTRACEPTIVE) 150 MG/ML IM SUSP,50863,CDM,636,RC,J1050,HCPCS,55150-329-01,NDC,facility,both,150,ML,,216,151.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-722-11,NDC,facility,both,2,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPOETIN ALFA-EPBX 10000 UNITS/ML INJ SOLN,50863,CDM,636,RC,Q5106,HCPCS,0069-1308-01,NDC,facility,both,10,ML,,477,333.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2305-16,NDC,facility,both,22,ML,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,250,RC,J7999,HCPCS,70092-1017-46,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML (ANESTHESIA INTRAOP ONLY),50863,CDM,250,RC,J3010,HCPCS,0641-6027-01,NDC,facility,both,1,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,2,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE (PF) 1000 MCG/10 ML EPID SOLN,50863,CDM,250,RC,J0735,HCPCS,0517-0730-01,NDC,facility,both,1,ML,,223,156.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,2,EA,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,636,RC,J2560,HCPCS,72162-1329-8,NDC,facility,both,1,ML,,257,179.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,636,RC,J2720,HCPCS,63323-229-01,NDC,facility,both,3,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,50863,CDM,250,RC,J0640,HCPCS,0143-9552-01,NDC,facility,both,4,EA,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCUSATE SODIUM 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-129-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0641-6059-01,NDC,facility,both,5,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SYRG,50863,CDM,J3490,HCPCS,6425311130,NDC,,,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID (PORK)  60 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,75834-312-01,NDC,facility,both,2,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,50863,CDM,J9206,HCPCS,60505-6128-1,NDC,,,facility,both,5,ML,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 2 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,J2270,HCPCS,76045-004-01,NDC,,,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,J3490,HCPCS,70954-316-10,NDC,,,facility,both,2,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML INJ SOLN,50863,CDM,250,RC,J0169,HCPCS,76329-9061-0,NDC,facility,both,10,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,636,RC,J1815,HCPCS,49502-393-80,NDC,facility,both,1,ML,GZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier GZ: Item or service expected to be denied as not reasonable and necessary
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,63323-482-03,NDC,,,facility,both,200,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL,50863,CDM,250,RC,J3490,HCPCS,63323-820-01,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TETANUS IMMUNE GLOBULIN (PF) 250 UNIT IM SYRG,50863,CDM,250,RC,J1670,HCPCS,13533-634-02,NDC,facility,both,1,ML,,1262,883.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,250,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,16,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,59651-488-01,NDC,facility,both,30,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE  5 MG/ML INJ SOLN,50863,CDM,636,RC,J2765,HCPCS,0409-3414-11,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALTREXONE 50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0406-1170-03,NDC,facility,both,1,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN STERILE WATER 2 GRAM/20 ML IV SYRG,50863,CDM,636,RC,J3490,HCPCS,70092-1604-47,NDC,facility,both,4,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,636,RC,J0133,HCPCS,55150-154-10,NDC,facility,both,200,ML,,157,109.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE (PF) 25 MG/ML INJ SOLN (FOR ECTOPIC PREGNANCY),50863,CDM,636,RC,J9260,HCPCS,0143-9519-01,NDC,facility,both,2,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,636,RC,J3490,HCPCS,67877-590-01,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,0121-0657-05,NDC,facility,both,5,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE HCL  2 % MM JELP,50863,CDM,636,RC,J3490,HCPCS,0548-3013-00,NDC,facility,both,1,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LURASIDONE  60 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7357-61,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7050,HCPCS,0338-0049-02,NDC,facility,both,1,ML,JZ,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,4,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSAPREPITANT 150 MG IV SOLR,50863,CDM,636,RC,J1453,HCPCS,71839-104-01,NDC,facility,both,150,EA,,1065,745.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,812,ME,JZ,11019,7713.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7030,HCPCS,0338-0049-04,NDC,facility,both,1,ML,JZ,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DOPAMINE INFUSION NEO IV SYRINGE (FROM PREMIX),50863,CDM,250,RC,J1265,HCPCS,0338-1007-02,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  1 MG/ML INJ SYRG,50863,CDM,636,RC,J1171,HCPCS,0409-1283-10,NDC,facility,both,10,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 20 GRAM/30 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-1154-30,NDC,facility,both,2,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6475-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-1283-03,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 10 MG/ML ORAL SOLUTION (REPACK),50863,CDM,250,RC,J3490,HCPCS,0131-5410-71,NDC,facility,both,3,ML,,126,88.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCOSE (TOLERANCE TEST) 100 GRAM/180 ML ORAL LIQD,50863,CDM,636,RC,j3490,HCPCS,574195906,NDC,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN  325 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0536-1054-29,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  5 GRAM IV SOLR,50863,CDM,250,RC,J3370,HCPCS,0143-9163-01,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6966-61,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42806-312-50,NDC,facility,both,1,EA,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 50 MG TAB,50863,CDM,636,RC,Q0177,HCPCS,16714-083-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,0409-9094-25,NDC,facility,both,13,ML,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-ABDA 100 MG IV SOLR,50863,CDM,636,RC,Q5104,HCPCS,78206-162-99,NDC,facility,both,35,EA,,7278,5094.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,636,RC,J3490,HCPCS,73013-2002-2,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 10 MG/ML (PF) IV SOLN,50863,CDM,636,RC,J2270,HCPCS,0641-6127-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL (5 MG/ML) IV SYRG (CONTAINS PRESERVATIVE),50863,CDM,636,RC,J3490,HCPCS,0409-2339-34,NDC,facility,both,1,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-ABDA 100 MG IV SOLR,50863,CDM,636,RC,Q5104,HCPCS,78206-162-99,NDC,facility,both,34,EA,,7070,4949,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 30 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,13107-003-34,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR 200 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,70954-188-10,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE IN D5W 1 GRAM/100 ML IV PGBK,50863,CDM,250,RC,J3475,HCPCS,63323-108-00,NDC,facility,both,2,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEPROTUMUMAB-TRBW 500 MG IV SOLR,50863,CDM,636,RC,J3241,HCPCS,75987-130-15,NDC,facility,both,150,EA,,106710,74697,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE IN D5W 1 GRAM/100 ML IV PGBK,50863,CDM,250,RC,J3475,HCPCS,0264-4400-54,NDC,facility,both,2,ML,JZ,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SODIUM CHLORIDE 0.9 % INJ SYRG,50863,CDM,J3490,HCPCS,8290306546,NDC,,,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL,50863,CDM,250,RC,J3490,HCPCS,63323-820-01,NDC,facility,both,1,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) IV SOLN",50863,CDM,636,RC,J3490,HCPCS,0013-1114-20,NDC,facility,both,1,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  5 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-122-11,NDC,facility,both,5,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,72888-039-60,NDC,facility,both,2,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,9,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,2,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUPHENAZINE DECANOATE 25 MG/ML INJ SOLN,50863,CDM,250,RC,J2680,HCPCS,67457-359-59,NDC,facility,both,1,ML,,134,93.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,3,EA,JW,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CALCIUM CARBONATE 500 MG (200 MG ELEMENTAL) CHEW TAB,50863,CDM,250,RC,J3490,HCPCS,66553-004-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-088-11,NDC,facility,both,1,EA,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NOREPINEPHRINE BITARTRATE-D5W 4 MG/250 ML (16 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,71285-6056-1,NDC,facility,both,1,ML,,128,89.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXAZOSIN 2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-851-95,NDC,facility,both,3,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NOREPINEPHRINE BITARTRATE-D5W 4 MG/250 ML (16 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66647-6156-33,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,70095-031-01,NDC,facility,both,26,ML,,1064,744.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 500 MCG INJ SOLR,50863,CDM,636,RC,J3490,HCPCS,63323-648-10,NDC,facility,both,1,EA,,1458,1020.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-728-11,NDC,facility,both,1,EA,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NOREPINEPHRINE BITARTRATE-D5W 4 MG/250 ML (16 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,71285-6056-1,NDC,facility,both,1,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,99,ML,JW,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,250,RC,J3490,HCPCS,0409-4277-01,NDC,facility,both,800,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) 1000 UNITS/ML INJ SOL (FOR DIALYSIS ONLY),50863,CDM,250,RC,J1644,HCPCS,25021-400-10,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESNA 100 MG/ML IV SOLN,50863,CDM,250,RC,J9209,HCPCS,10019-953-62,NDC,facility,both,28,ML,,811,567.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOSTIGMINE METHYLSULFATE 1 MG/ML IV SOLN,50863,CDM,636,RC,J2710,HCPCS,42023-189-01,NDC,facility,both,1,ML,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM SR 120 MG 24 HR CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7217-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,27808-156-01,NDC,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 150 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,0591-3541-60,NDC,facility,both,4,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 1 MG/ML PCA (PDS MERGE),50863,CDM,J3490,HCPCS,61553-820-41,NDC,,,facility,both,1,ML,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEGFILGRASTIM (NEULASTA) 6 MG/0.6ML SUBQ SYRG,50863,CDM,J2506,HCPCS,55513-190-01,NDC,,,facility,both,12,ML,,17714,12399.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 10 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-6426-61,NDC,,,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZOXIDE (DIABETIC USE) 50 MG/ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0254-1010-19,NDC,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE HCL IN 5% DEXTROSE 100 MCG/10 ML (10 MCG/ML) IV SYRG,50863,CDM,250,RC,J0171,HCPCS,70092-1617-46,NDC,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEMAZEPAM  7.5 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0406-9960-01,NDC,facility,both,2,EA,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADVATE: FACTOR VIII CONCENTRATE (MERGE RECORD),50863,CDM,250,RC,J7192,HCPCS,0944-3051-02,NDC,facility,both,1500,UN,,8054,5637.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE  50 MG ORAL CAP,50863,CDM,250,RC,J8530,HCPCS,62332-619-31,NDC,facility,both,12,EA,,420,294,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL IV BOLUS 10MG/ML (ANESTHESIA ONLY),50863,CDM,636,RC,J2704,HCPCS,0409-4699-54,NDC,facility,both,18,ML,JW,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,63323-162-00,NDC,facility,both,1,ML,JW,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PEGFILGRASTIM-JMDB (FULPHILA) 6 MG/0.6 ML SUBQ SYRG,50863,CDM,Q5108,HCPCS,83257-005-41,NDC,,,facility,both,12,ML,,5762,4033.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2312,HCPCS,36000-308-01,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,11,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,70095-031-01,NDC,facility,both,26,ML,,1055,738.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,J0696,HCPCS,0143-9857-25,NDC,,,facility,both,4,EA,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZTROPINE 1 MG/ML INJ SOLN,50863,CDM,250,RC,J0515,HCPCS,68382-860-02,NDC,facility,both,1,ML,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,53,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,63323-201-02,NDC,,,facility,both,60,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,636,RC,J3490,HCPCS,63323-485-27,NDC,facility,both,90,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLN,50863,CDM,250,RC,J3262,HCPCS,50242-137-01,NDC,facility,both,800,ML,,14661,10262.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 15% IN WATER,50863,CDM,250,RC,J3490,HCPCS,0338-0023-03,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,59762-4910-3,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 300 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7263-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0137,HCPCS,0143-9386-01,NDC,facility,both,40,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 100 MG/ML FROM 1 GRAM VIAL (PRMC PEDS ONLY),50863,CDM,250,RC,J0696,HCPCS,0409-7332-11,NDC,facility,both,4,EA,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-1638-32,NDC,facility,both,2,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SINCALIDE 5 MCG INJ SOLR,50863,CDM,636,RC,J2805,HCPCS,72266-248-05,NDC,facility,both,1,EA,,142,99.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG/ML ORAL CONC,50863,CDM,636,RC,J3490,HCPCS,0054-3553-44,NDC,facility,both,5,ML,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0527-3281-46,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,20,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,70004-600-09,NDC,facility,both,1,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0781-3246-02,NDC,facility,both,10,ML,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7449-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,31722-711-30,NDC,facility,both,1,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,68180-441-01,NDC,facility,both,4,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,10,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
HEPARIN (PORCINE) IN D5W 20000 UNIT/500 ML,50863,CDM,636,RC,J1644,HCPCS,0264-9567-10,NDC,facility,both,18,ML,JW,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
METHOCARBAMOL 500 MG ORAL TAB,50863,CDM,J3490,HCPCS,60687-559-11,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,70,ML,,101,70.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL,50863,CDM,250,RC,J3490,HCPCS,63323-820-04,NDC,facility,both,1,ML,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,250,RC,J1596,HCPCS,0143-9679-01,NDC,facility,both,7,ML,,149,104.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,50863,CDM,636,RC,J8540,HCPCS,0904-7266-61,NDC,facility,both,32,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN   1.5 G IV SOLR,50863,CDM,250,RC,J3373,HCPCS,0409-3515-11,NDC,facility,both,150,EA,,143,100.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYTARABINE 100 MG/ML INJ SOLN,50863,CDM,636,RC,J9100,HCPCS,61703-319-22,NDC,facility,both,20,ML,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 50 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,59651-489-01,NDC,facility,both,105,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,7733351625,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MICAFUNGIN 100 MG IV SOLR,50863,CDM,250,RC,J2248,HCPCS,42023-230-01,NDC,facility,both,67,EA,JW,122,85.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-229-02,NDC,facility,both,61,ML,,2982,2087.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-333-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,72603-209-01,NDC,facility,both,1,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORDIAZEPOXIDE 25 MG CAP,50863,CDM,636,RC,J3490,HCPCS,0555-0159-02,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4% TOP PATCH,50863,CDM,250,RC,J3490,HCPCS,46581-830-01,NDC,facility,both,2,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MANNITOL 20% IV SOLP,50863,CDM,250,RC,J2150,HCPCS,0990-7715-13,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,55150-307-01,NDC,facility,both,41,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1940,HCPCS,72603-251-01,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,60505-3276-0,NDC,facility,both,2,EA,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,50863,CDM,636,RC,J0561,HCPCS,60793-700-01,NDC,facility,both,24,ML,,3348,2343.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  120 MG RECT SUPP,50863,CDM,250,RC,J3490,HCPCS,45802-732-00,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,0088-2220-33,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0406-5771-23,NDC,facility,both,12,EA,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,32,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,14,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-559-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0054-0235-25,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,8,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0054-0235-24,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,7,EA,JW,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
BUDESONIDE 180 MCG/INHALATION INHL AEPB,50863,CDM,636,RC,J3490,HCPCS,61269-518-12,NDC,facility,both,1,EA,,937,655.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-50,NDC,facility,both,9,ML,JW,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,0641-6236-01,NDC,facility,both,2,ML,,145,101.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7442-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,44,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE HCL IN 0.9% NS 100 MCG/10 ML (10 MCG/ML) NON-CARDIAC LOW-DOSE (PEDS/NEO),50863,CDM,250,RC,J0169,HCPCS,69374-544-10,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL  20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65162-351-09,NDC,facility,both,1,EA,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-050-01,NDC,facility,both,2,EA,,144,100.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESALAMINE 4 GRAM/60 ML RECT ENEM,50863,CDM,636,RC,J3490,HCPCS,45802-098-46,NDC,facility,both,1,ML,,119,83.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,0409-9094-12,NDC,facility,both,1,ML,JZ,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"DIPHTH,PERTUS(ACELL),TETANUS SYRG(BOOSTRIX) 2.5-8-5 LF-MCG-LF/0.5ML IM SYRG",50863,CDM,90715,HCPCS,58160-842-52,NDC,,,facility,both,1,ML,,247,172.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 750 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-568-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.45% (1/2 NS) INFUSION (PEDS ONC),50863,CDM,J3490,HCPCS,0338-0043-04,NDC,,,facility,both,1,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HUMAN PROTHROMBIN COMPLEX 500 UNIT IV SOLR,50863,CDM,250,RC,J7168,HCPCS,63833-396-01,NDC,facility,both,500,UN,,2910,2037,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 20 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,60687-725-11,NDC,facility,both,1,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J2003,HCPCS,0409-4713-32,NDC,facility,both,40,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,J0780,HCPCS,23155-294-31,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) 1000 UNITS/ML INJ SOL (FOR DIALYSIS ONLY),50863,CDM,250,RC,J1644,HCPCS,67457-953-00,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,0143-9511-01,NDC,facility,both,15,ML,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6086-61,NDC,facility,both,1,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LET TOPICAL GEL 3 ML,50863,CDM,J3490,HCPCS,05446-0607-01,NDC,,,facility,both,1,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,J3490,HCPCS,66553-002-01,NDC,,,facility,both,4,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOZAPINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-921-01,NDC,facility,both,2,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,J3490,HCPCS,68094-231-59,NDC,,,facility,both,4,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-4279-02,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE IN D5W 1 GRAM/100 ML IV PGBK,50863,CDM,636,RC,J3475,HCPCS,63323-108-00,NDC,facility,both,6,ML,,163,114.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,0409-1207-03,NDC,facility,both,4,ML,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,J2560,HCPCS,0641-0477-21,NDC,,,facility,both,2,ML,,349,244.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-ABDA 100 MG IV SOLR,50863,CDM,636,RC,Q5104,HCPCS,78206-162-99,NDC,facility,both,60,EA,,12477,8733.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  5 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,60505-3275-3,NDC,facility,both,1,EA,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,5,ML,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-18,NDC,facility,both,1,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,36,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 500 MG SOLUTION FOR INJECTION,50863,CDM,636,RC,J2919,HCPCS,0009-0758-01,NDC,facility,both,200,EA,,285,199.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0456,HCPCS,55150-174-10,NDC,facility,both,1,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,39,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOZAPINE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-922-01,NDC,facility,both,3,EA,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ (MERGE),50863,CDM,636,RC,J2250,HCPCS,0409-2305-17,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 1 MG ORAL TAB,50863,CDM,636,RC,J8540,HCPCS,72578-166-01,NDC,facility,both,12,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR PHOSPHATE 75 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,33342-258-66,NDC,facility,both,8,EA,,446,312.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANTI-INHIBITOR COAGULANT CMPLX (PHS MERGE),50863,CDM,250,RC,J7198,HCPCS,64193-426-02,NDC,facility,both,636,UN,JW,1999,1399.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
"CARDIOPLEGIC SOLUTION NO.16 26 MEQ/1,052.8 ML (POTASSIUM) PERF SOLN",50863,CDM,250,RC,J3490,HCPCS,71285-0202-1,NDC,facility,both,3,ML,,588,411.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIOTHYRONINE  5 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-166-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE  25 MG ORAL CAP,50863,CDM,250,RC,J7515,HCPCS,0078-0240-15,NDC,facility,both,3,EA,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,24,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,3,EA,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GOLIMUMAB  12.5 MG/ML IV SOLN,50863,CDM,636,RC,J1602,HCPCS,57894-350-01,NDC,facility,both,225,ML,,24830,17381,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN PEDS IV INFUSION 12 MG/ML (CDS MIXTURE FROM PREMIX),50863,CDM,250,RC,J0736,HCPCS,0781-3289-91,NDC,facility,both,2,ML,JZ,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LINEZOLID 600 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,67877-419-33,NDC,facility,both,1,EA,,390,273,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,636,RC,J1815,HCPCS,49502-393-80,NDC,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,63323-161-00,NDC,facility,both,2,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,J2405,HCPCS,23155-547-31,NDC,,,facility,both,4,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-4675-05,NDC,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,636,RC,J3490,HCPCS,0143-9575-01,NDC,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLP,50863,CDM,636,RC,J3480,HCPCS,63323-965-02,NDC,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 0.5% NASAL DROPS (REPACK),50863,CDM,636,RC,J3490,HCPCS,69536-050-15,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 0.1 MG/ML INJ SYRG,50863,CDM,250,RC,J0461,HCPCS,76329-3340-1,NDC,facility,both,7,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",50863,CDM,250,RC,J1561,HCPCS,13533-800-41,NDC,facility,both,80,ML,"JZ,JA",11316,7921.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
METOPROLOL TARTRATE 5 MG/5 ML IV,50863,CDM,J3490,HCPCS,63323-660-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J2003,HCPCS,63323-492-07,NDC,facility,both,300,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,72603-179-01,NDC,facility,both,6,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE IN 0.9% NS (PF) 1 MG/10 ML (100 MCG/ML) IV SYRG(PDS MERGE),50863,CDM,250,RC,J3490,HCPCS,70092-1046-46,NDC,facility,both,1,ML,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,0409-1886-22,NDC,facility,both,200,ML,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,00035-0002-80,NDC,facility,both,1,ML,JZ,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CHLOROTHIAZIDE SODIUM 500 MG IV SOLR,50863,CDM,250,RC,J1205,HCPCS,25021-305-20,NDC,facility,both,1,EA,,306,214.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COCAINE  4 % TOP SOLN (MERGE),50863,CDM,636,RC,C9046,HCPCS,81665-301-02,NDC,facility,both,160,ML,JZ,1271,889.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CARBIDOPA-LEVODOPA SR 50 MG-200 MG TAB,50863,CDM,250,RC,J3490,HCPCS,68084-282-11,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1815,HCPCS,0169-1833-11,NDC,facility,both,16,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOSTIGMINE METHYLSULFATE 3 MG/3 ML (1 MG/ML) IV SYRG,50863,CDM,636,RC,J2710,HCPCS,69374-932-03,NDC,facility,both,2,ML,,191,133.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 1MG/ML SUSPENSION (REPACK),50863,CDM,250,RC,J3490,HCPCS,16714-372-02,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,63323-162-00,NDC,facility,both,2,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,14789-128-07,NDC,facility,both,1,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIFEDIPINE 30 MG ORAL TO24,50863,CDM,636,RC,J3490,HCPCS,50268-597-11,NDC,facility,both,2,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,160,ML,,145,101.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,18,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CEFDINIR 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,67877-548-88,NDC,facility,both,3,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DORZOLAMIDE-TIMOLOL 2 %-0.5 % EYE DROPS,50863,CDM,636,RC,J3490,HCPCS,71921-226-10,NDC,facility,both,1,ML,,442,309.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VARICELLA-ZOSTER IG-MALTOSE 125 UNIT/1.2 ML IM SOLN,50863,CDM,636,RC,90396,HCPCS,49591-126-51,NDC,facility,both,5,ML,,31475,22032.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 125 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-443-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLP",50863,CDM,636,RC,P9047,HCPCS,0944-0493-04,NDC,facility,both,4,ML,,1001,700.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MISOPROSTOL 100 MCG ORAL TAB,50863,CDM,636,RC,S0191,HCPCS,60687-735-11,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCRALFATE 100 MG/ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,17856-0306-1,NDC,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV,50863,CDM,636,RC,J7120,HCPCS,0338-0117-04,NDC,facility,both,3,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,2,EA,,160,112,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,63323-165-30,NDC,facility,both,60,ML,,119,83.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6188-01,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 3 % IV INFUSION,50863,CDM,250,RC,J3490,HCPCS,0338-0054-03,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 25 MG TAB,50863,CDM,636,RC,J3490,HCPCS,16714-796-01,NDC,facility,both,2,EA,,230,161,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LET TOPICAL GEL 3 ML,50863,CDM,636,RC,J3490,HCPCS,70092-1611-44,NDC,facility,both,3,ML,,161,112.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,8,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),50863,CDM,636,RC,J2060,HCPCS,0641-6044-01,NDC,facility,both,3,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-134-11,NDC,facility,both,5,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 160 MG-800 MG TAB,50863,CDM,250,RC,J3490,HCPCS,60687-614-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE LIPOSOME (PF) 266 MG/20 ML (13.3 MG/ML) LINF SUSP,50863,CDM,636,RC,J3490,HCPCS,65250-266-20,NDC,facility,both,1,ML,,1116,781.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,50863,CDM,250,RC,J9075,HCPCS,10019-956-16,NDC,facility,both,119,EA,,766,536.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOBAZAM 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-423-11,NDC,facility,both,2,EA,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPTOMYCIN 500 MG IV SOLR,50863,CDM,636,RC,J0878,HCPCS,0409-0122-01,NDC,facility,both,300,EA,JZ,242,169.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DOXAZOSIN 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-836-95,NDC,facility,both,3,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,250,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL,50863,CDM,250,RC,J3490,HCPCS,63323-820-04,NDC,facility,both,1,ML,,168,117.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML (1ML) INJ SOLN,50863,CDM,250,RC,J0169,HCPCS,54288-119-01,NDC,facility,both,10,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,0143-9682-01,NDC,facility,both,6,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,250,RC,J3490,HCPCS,72603-825-01,NDC,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,65649-311-12,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN DEXTROSE (ISO-OSMOTIC) 1 GRAM/50 ML IV PIGGY BACK,50863,CDM,250,RC,J0690,HCPCS,0338-3503-41,NDC,facility,both,4,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML IV SOLN,50863,CDM,J3490,HCPCS,55150-222-20,NDC,,,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-38,NDC,facility,both,2,ML,,121,84.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,J2003,HCPCS,0143-9575-01,NDC,,,facility,both,440,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL IV BOLUS 10MG/ML (ANESTHESIA ONLY),50863,CDM,636,RC,J2704,HCPCS,0409-4699-54,NDC,facility,both,88,ML,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-9542-01,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,250,RC,J0330,HCPCS,69374-919-10,NDC,facility,both,7,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J1940,HCPCS,0409-6102-10,NDC,facility,both,5,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,23155-600-31,NDC,facility,both,4,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GLYCERIN-WITCH HAZEL 12.5 %-50 % TOPICAL PADS,50863,CDM,250,RC,J3490,HCPCS,50289-3250-1,NDC,facility,both,40,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0780,HCPCS,23155-294-31,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3370,HCPCS,0069-2589-03,NDC,facility,both,4,EA,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  50 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-6992-61,NDC,facility,both,4,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7123-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 150 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,68180-319-09,NDC,facility,both,1,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,636,RC,J3490,HCPCS,72603-387-01,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,636,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0630,HCPCS,42023-205-01,NDC,facility,both,1,ML,JZ,5056,3539.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,59762-3140-1,NDC,facility,both,10,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID (PORK)  30 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,62559-741-01,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IV PGBK,50863,CDM,250,RC,J3475,HCPCS,63323-106-00,NDC,facility,both,8,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,636,RC,J1610,HCPCS,0597-0053-45,NDC,facility,both,1,EA,JW,206,144.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ENALAPRIL MALEATE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,23155-773-01,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORHEXIDINE GLUCONATE  0.12 % MM MWSH,50863,CDM,250,RC,J3490,HCPCS,0121-0893-15,NDC,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,13,ML,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"TRANEXAMIC ACID IN NACL,ISO-OS 1,000 MG/100 ML (10 MG/ML) IV PGBK",50863,CDM,636,RC,J3490,HCPCS,80830-2329-1,NDC,facility,both,1,ML,,121,84.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETIRIZINE 5 MG/5 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,68094-004-59,NDC,facility,both,2,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,636,RC,J2405,HCPCS,70860-776-41,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0641-0400-37,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NORETHINDRONE ACETATE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50742-267-50,NDC,facility,both,2,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,25,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATOMOXETINE  40 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,64980-376-03,NDC,facility,both,2,EA,,152,106.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE (FOR EMERGENCY) 100 MG/ML (10%) IV SOLN,50863,CDM,250,RC,J0612,HCPCS,63323-360-01,NDC,facility,both,100,ML,JZ,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2312,HCPCS,36000-308-01,NDC,facility,both,100,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOMYCIN-BACITRACIN ZN-POLYMYXIN 3.5 MG-400 UN*,50863,CDM,250,RC,J3490,HCPCS,0713-0268-31,NDC,facility,both,1,GM,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-1283-04,NDC,facility,both,20,ML,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,636,RC,J0132,HCPCS,63323-963-21,NDC,facility,both,120,ML,,951,665.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,250,RC,J3490,HCPCS,0904-6930-61,NDC,facility,both,4,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,0641-6174-01,NDC,facility,both,2,ML,JZ,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,17,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,636,RC,J0133,HCPCS,63323-325-03,NDC,facility,both,200,ML,,221,154.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7351-04,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML (PEDS CALCLUATOR 0.5),50863,CDM,636,RC,J1815,HCPCS,0024-5924-10,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 40 GRAM/400 ML (10 %) INJ SOLN",50863,CDM,250,RC,J1561,HCPCS,13533-800-20,NDC,facility,both,10,ML,,1415,990.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,76045-009-10,NDC,facility,both,7,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 0.4 MG SL SUBL,50863,CDM,636,RC,J3490,HCPCS,43598-436-35,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,50863,CDM,250,RC,Q0177,HCPCS,0904-6617-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN  0.4 UNITS/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,42023-219-01,NDC,facility,both,40,ML,JZ,432,302.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,60687-390-11,NDC,facility,both,6,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-645-11,NDC,facility,both,3,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATED 20 MG/ML IV SOLN,50863,CDM,250,RC,J0706,HCPCS,51754-0500-1,NDC,facility,both,7,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM ACETATE 0.45% IV INFUSION (PEDIATRIC),50863,CDM,250,RC,J3490,HCPCS,69784-231-20,NDC,facility,both,1,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DROPERIDOL 2.5 MG/ML INJ SOLN,50863,CDM,636,RC,J1790,HCPCS,0143-9514-01,NDC,facility,both,1,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 20 GRAM/30 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-1154-30,NDC,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,636,RC,J3490,HCPCS,0409-4277-16,NDC,facility,both,400,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HETASTARCH 6 % IN NORMAL SALINE IV,50863,CDM,636,RC,J3490,HCPCS,0409-7248-13,NDC,facility,both,1,ML,,217,151.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  15 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,68084-157-11,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0641-0400-37,NDC,facility,both,5,ML,JZ,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
NIFEDIPINE 20 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,23155-195-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN 1 GRAM SOLUTION FOR INJECTION,50863,CDM,250,RC,J0290,HCPCS,0781-3404-85,NDC,facility,both,3,EA,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-02,NDC,facility,both,2,ML,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 100 MG/5 ML ORAL LIQD,50863,CDM,250,RC,J3490,HCPCS,60687-863-42,NDC,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML INJ SOLN,50863,CDM,250,RC,J2060,HCPCS,0409-1985-03,NDC,facility,both,2,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE (PF) 1000 MCG/10 ML EPID SOLN,50863,CDM,636,RC,J0735,HCPCS,39822-2000-1,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE  10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,70756-201-11,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,J3360,HCPCS,0409-1273-03,NDC,,,facility,both,2,ML,,198,138.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-229-02,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,J3490,HCPCS,0409-1323-15,NDC,,,facility,both,100,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM 1 GRAM IV SOLR,50863,CDM,J2185,HCPCS,0781-3098-94,NDC,,,facility,both,10,EA,,179,125.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,69918-899-01,NDC,facility,both,1,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J3490,HCPCS,0338-1055-48,NDC,facility,both,300,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,7,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6360-61,NDC,facility,both,2,EA,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,39,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-559-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 2 MG INJ SOLR,50863,CDM,250,RC,J2997,HCPCS,50242-041-64,NDC,facility,both,2,EA,,762,533.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTOBARBITAL 75 MG/1.5 ML SYRINGE (REPACK),50863,CDM,636,RC,J2515,HCPCS,25021-676-20,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,50863,CDM,250,RC,J9075,HCPCS,10019-956-16,NDC,facility,both,51,EA,JW,145,101.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PERMETHRIN 1 % TOP LIQD (REPACK),50863,CDM,636,RC,J3490,HCPCS,6373612002,NDC,facility,both,1,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 50 MG/ML IM,50863,CDM,250,RC,J3410,HCPCS,0517-5601-25,NDC,facility,both,2,ML,,174,121.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,636,RC,P9045,HCPCS,68516-5219-0,NDC,facility,both,14,ML,JZ,3559,2491.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,70095-026-01,NDC,facility,both,3,ML,,201,140.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ORA-SWEET SF (COMPOUNDING VEHICLE SF NO.9 ORAL LIQD),50863,CDM,250,RC,J3490,HCPCS,574030216,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML (PEDS CALCLUATOR 0.5),50863,CDM,250,RC,J1815,HCPCS,0024-5924-10,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAZOSIN 5 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-572-33,NDC,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE  50 MG/ML INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-114-10,NDC,facility,both,1,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LINACLOTIDE 145 MCG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0456-1201-30,NDC,facility,both,2,EA,,223,156.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,65862-642-30,NDC,facility,both,2,EA,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50580-458-11,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOPERAMIDE 2 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,51079-690-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % MUCOSAL GEL,50863,CDM,636,RC,J3490,HCPCS,17478-711-30,NDC,facility,both,2,ML,,758,530.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LET TOPICAL GEL 3 ML,50863,CDM,250,RC,J3490,HCPCS,69623-801-14,NDC,facility,both,1,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,70069-363-01,NDC,facility,both,1,ML,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETIC ACID (VINEGAR) 5% IRRIGATION 12 ML (REPACK),50863,CDM,636,RC,J3490,HCPCS,5155200556,NDC,facility,both,2,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 10 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-369-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADVATE: FACTOR VIII CONCENTRATE (MERGE RECORD),50863,CDM,250,RC,J7192,HCPCS,0944-3053-04,NDC,facility,both,1250,UN,,6555,4588.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHOTERICIN B LIPOSOME 50 MG IV SUSR,50863,CDM,J0289,HCPCS,55150-365-01,NDC,,,facility,both,30,EA,,5411,3787.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML (ANESTHESIA INTRAOP ONLY),50863,CDM,250,RC,J3010,HCPCS,0641-6027-01,NDC,facility,both,2,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,J3490,HCPCS,0338-0049-48,NDC,,,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0990-7984-13,NDC,facility,both,1,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PREDNISONE 10 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,70954-059-10,NDC,facility,both,60,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETIRIZINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-597-01,NDC,facility,both,2,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEPLIZUMAB-MZWV 2 MG/20 ML IV SOLN,50863,CDM,636,RC,J9381,HCPCS,73650-316-01,NDC,facility,both,364,ME,JW,10654,7457.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
EPINEPHRINE 1 MG/ML (1ML) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,54288-119-01,NDC,facility,both,15,ML,,1186,830.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 125 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-443-01,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,636,RC,Q0162,HCPCS,65162-691-79,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,50863,CDM,636,RC,Q5119,HCPCS,0069-0238-01,NDC,facility,both,100,ML,,19784,13848.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE  50 MCG/ACTUATION NASL SPSN,50863,CDM,250,RC,J3490,HCPCS,60505-0829-1,NDC,facility,both,1,GM,,362,253.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,63323-506-01,NDC,facility,both,10,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,0409-1207-03,NDC,facility,both,3,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM OXIDE 400 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,1000670028,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,250,RC,J3490,HCPCS,0904-6930-61,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-492-27,NDC,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2310,HCPCS,70069-072-01,NDC,facility,both,4,ML,,424,296.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,50863,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,51,EA,,7038,4926.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAMSULOSIN 0.4 MG ORAL CP24,50863,CDM,J3490,HCPCS,50268-740-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-6773-61,NDC,,,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV (BOLUS),50863,CDM,250,RC,J7120,HCPCS,0264-7750-00,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),50863,CDM,636,RC,J2060,HCPCS,65219-368-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 10 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0054-0622-63,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7126-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLMESARTAN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68462-437-30,NDC,facility,both,1,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOFETILIDE 500 MCG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,42291-413-60,NDC,facility,both,1,EA,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,59746-218-01,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,636,RC,J2003,HCPCS,0409-1323-15,NDC,facility,both,10,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2599,HCPCS,43598-914-11,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,50863,CDM,250,RC,J0640,HCPCS,0143-9554-01,NDC,facility,both,4,EA,,165,115.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZTROPINE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0603-2438-21,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,66689-201-08,NDC,facility,both,1,ML,,199,139.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CELECOXIB 200 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-447-11,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG/ML ORAL CONC,50863,CDM,250,RC,J3490,HCPCS,0054-3553-44,NDC,facility,both,2,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOPIDOGREL  75 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6294-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7030,HCPCS,0338-0049-04,NDC,facility,both,2,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOBRAMYCIN 0.3 % EYE OINTMENT,50863,CDM,J3490,HCPCS,0078-0813-01,NDC,,,facility,both,1,GM,,992,694.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-48,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  750 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7125-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),50863,CDM,250,RC,J1815,HCPCS,0024-5926-05,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0093-7381-01,NDC,facility,both,2,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN 125 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,51672-4069-1,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUANFACINE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0591-0444-01,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE 2 MG SL SUBL,50863,CDM,636,RC,J3490,HCPCS,0904-7154-04,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-22,NDC,facility,both,6,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2308-21,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,63323-185-10,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,J2919,HCPCS,0009-0047-25,NDC,,,facility,both,17,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ELECTROLYTE-A IV,50863,CDM,250,RC,J3490,HCPCS,0338-0221-04,NDC,facility,both,1,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,J3490,HCPCS,0121-1022-05,NDC,,,facility,both,4,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML INJ SOLN,50863,CDM,J0171,HCPCS,76329-9060-0,NDC,,,facility,both,61,ML,,162,113.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,636,RC,J3010,HCPCS,0409-9094-22,NDC,facility,both,1,ML,JZ,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-492-09,NDC,,,facility,both,150,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-38,NDC,facility,both,2,ML,,132,92.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN STERILE WATER 2 GRAM/20 ML IV SYRG,50863,CDM,636,RC,J7999,HCPCS,70092-1604-47,NDC,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-245-11,NDC,facility,both,1,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FERUMOXYTOL 510 MG/17 ML (30 MG/ML) IV SOLN,50863,CDM,250,RC,Q0138,HCPCS,59338-775-01,NDC,facility,both,510,ML,JZ,3295,2306.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,2,EA,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 30 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,13107-003-34,NDC,facility,both,2,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,0409-9094-12,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-492-09,NDC,facility,both,150,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 0.1 MG/ML IV SYRINGE (NEO/INFANT),50863,CDM,250,RC,J1100,HCPCS,99999-0405-74,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,91,ML,,130,91,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0536-1286-36,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR PHOSPHATE 75 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0004-0800-85,NDC,facility,both,1,EA,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANASTROZOLE 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-075-11,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE  10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-037-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLIPIZIDE  2.5 MG ORAL TO24,50863,CDM,636,RC,J3490,HCPCS,16714-894-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE IN SALINE (ISO-OSM) 400 MG/200 ML IV PIGGY BACK,50863,CDM,250,RC,J3490,HCPCS,25021-184-87,NDC,facility,both,1,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN ENEMA 500MG IN 100ML NS,50863,CDM,636,RC,J3370,HCPCS,67457-339-00,NDC,facility,both,1,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-686-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,67457-437-00,NDC,facility,both,1,EA,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLIPIZIDE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-701-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 100 MG/ML INJ SOLN,50863,CDM,636,RC,J2800,HCPCS,70069-101-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLP,50863,CDM,250,RC,J3480,HCPCS,0409-6653-18,NDC,facility,both,20,ML,JZ,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
FOSPHENYTOIN 500 MG PE/10 ML INJ SOLN,50863,CDM,250,RC,Q2009,HCPCS,25021-798-10,NDC,facility,both,25,ML,,293,205.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6291-61,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,50863,CDM,J0640,HCPCS,71288-161-20,NDC,,,facility,both,2,EA,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,63323-280-03,NDC,facility,both,120,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  88 MCG ORAL TAB,50863,CDM,J3490,HCPCS,60687-486-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2599,HCPCS,43598-914-25,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  25 MG ORAL TAB,50863,CDM,J3490,HCPCS,78206-121-01,NDC,,,facility,both,2,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,2,EA,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68180-445-01,NDC,facility,both,3,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYCHLOROQUINE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0781-5994-01,NDC,facility,both,2,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,31,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMFIBROZIL 600 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-101-02,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-02,NDC,facility,both,1,ML,JZ,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-48,NDC,facility,both,1,ML,JZ,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MELATONIN  3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,1657187290,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,43547-354-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETIRIZINE 5 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,68094-004-59,NDC,facility,both,2,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML INJECTION,50863,CDM,250,RC,J3411,HCPCS,43598-050-11,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4 % TOPICAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-4698-01,NDC,facility,both,1,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 60 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,27241-099-03,NDC,facility,both,2,EA,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1940,HCPCS,0409-6102-02,NDC,facility,both,3,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SELEGILINE 5 MG TAB,50863,CDM,250,RC,J3490,HCPCS,60505-3438-3,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML IV,50863,CDM,636,RC,J3490,HCPCS,70860-301-41,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"RABIES VACCINE, PURIFIED CHICKEN EMBRYO CELL (PF) 2.5 UNIT IM KIT",50863,CDM,636,RC,90675,HCPCS,50632-010-01,NDC,facility,both,1,EA,JZ,1200,840,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SODIUM BICARBONATE 650 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,66553-008-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-444-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-0430-04,NDC,,,facility,both,1,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE ACETATE 1 % OPHT DROPS,50863,CDM,636,RC,J3490,HCPCS,60758-119-05,NDC,facility,both,1,ML,,224,156.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-9558-05,NDC,facility,both,4,ML,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VINBLASTINE 1 MG/ML IV SOLN,50863,CDM,636,RC,J9360,HCPCS,63323-278-10,NDC,facility,both,10,ML,,274,191.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,50863,CDM,J1885,HCPCS,0409-3796-19,NDC,,,facility,both,4,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MINOXIDIL  2.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-204-11,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,2,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANTI-INHIBITOR COAGULANT CMPLX (PHS MERGE),50863,CDM,250,RC,J7198,HCPCS,64193-426-02,NDC,facility,both,14,UN,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,J2560,HCPCS,14789-128-07,NDC,,,facility,both,2,ML,,224,156.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,0409-1207-03,NDC,facility,both,5,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 0.1 % TOP OINT,50863,CDM,250,RC,J3490,HCPCS,0168-0006-16,NDC,facility,both,1,GM,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INHL NEBU,50863,CDM,J3490,HCPCS,0487-9301-33,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  30 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,0406-8330-23,NDC,facility,both,3,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0630,HCPCS,63323-865-02,NDC,facility,both,1,ML,,1767,1236.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,11,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN 50 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,0904-7199-07,NDC,facility,both,3,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE (FOR CODE) 10% (100 MG/ML) IV SYRINGE,50863,CDM,250,RC,J3490,HCPCS,0409-4928-11,NDC,facility,both,2,ML,,201,140.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-192-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  1 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,64380-782-06,NDC,facility,both,2,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0781-3220-70,NDC,facility,both,1,ML,,185,129.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,55150-221-10,NDC,facility,both,1,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,250,RC,J2270,HCPCS,0409-1891-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUGAMMADEX 100 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0006-5423-02,NDC,facility,both,4,ML,,2241,1568.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1940,HCPCS,36000-283-25,NDC,facility,both,6,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,55150-154-10,NDC,facility,both,100,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6374-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,636,RC,J1100,HCPCS,63323-506-00,NDC,facility,both,12,ML,JZ,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,0641-6008-01,NDC,facility,both,3,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,250,RC,J2003,HCPCS,55150-165-05,NDC,facility,both,300,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-579-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 20 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,65862-306-12,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RAMIPRIL 10 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,65862-477-01,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN 50 MG ORAL CHEW,50863,CDM,636,RC,J3490,HCPCS,51672-4146-1,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,20,ML,,34681,24276.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,250,RC,J3490,HCPCS,59310-579-22,NDC,facility,both,1,GM,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  5 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,60687-122-11,NDC,facility,both,13,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,59651-488-01,NDC,facility,both,20,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 7.5 MG-325 MG/15 ML ORAL SOLN (REPACK),50863,CDM,250,RC,J3490,HCPCS,0121-2316-15,NDC,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN STERILE WATER 2 GRAM/20 ML IV SYRG,50863,CDM,250,RC,J7999,HCPCS,70092-1604-47,NDC,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-ABDA 100 MG IV SOLR,50863,CDM,636,RC,Q5104,HCPCS,78206-162-99,NDC,facility,both,6,EA,JW,543,380.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LOSARTAN  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,43547-361-09,NDC,facility,both,2,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IVPB (PEDIATRICS/ADULT NON-FORM)",50863,CDM,636,RC,J0137,HCPCS,24201-100-01,NDC,facility,both,44,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,1,ML,,1156,809.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 100 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-7041-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  2.5 MG ORAL TAB,50863,CDM,250,RC,J7510,HCPCS,59651-485-01,NDC,facility,both,25,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,62756-348-44,NDC,facility,both,2,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) IV SOLN",50863,CDM,250,RC,J3490,HCPCS,67457-197-00,NDC,facility,both,1,ML,,368,257.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,6,EA,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN PEDS INFUSION (CDS MIXTURE),50863,CDM,250,RC,J0290,HCPCS,25021-136-10,NDC,facility,both,2,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIVAROXABAN 15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50458-578-90,NDC,facility,both,1,EA,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % MBP,50863,CDM,250,RC,J3490,HCPCS,0338-0553-18,NDC,facility,both,12,ML,,532,372.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 10 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,67457-420-00,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % MBP,50863,CDM,250,RC,J3490,HCPCS,0338-0553-18,NDC,facility,both,3,ML,,133,93.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIFEDIPINE 60 MG ORAL TO24,50863,CDM,250,RC,J3490,HCPCS,50268-598-11,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6084-61,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,68094-147-01,NDC,facility,both,2,ML,,197,137.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"HEPARIN, PORCINE (PF)   10 UNIT/ML IV SYRG",50863,CDM,250,RC,J1642,HCPCS,6425322233,NDC,facility,both,3,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 2.5 MG RECT KIT,50863,CDM,250,RC,J3490,HCPCS,68682-650-20,NDC,facility,both,1,EA,,553,387.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,16714-293-01,NDC,facility,both,11,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,50,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG IV SOLR,50863,CDM,250,RC,J0650,HCPCS,63323-649-07,NDC,facility,both,20,EA,,1040,728,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),50863,CDM,636,RC,J0171,HCPCS,0409-4921-34,NDC,facility,both,23,ML,,764,534.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,73293-0001-1,NDC,,,facility,both,50,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4 % TOPICAL SOLN,50863,CDM,250,RC,J3490,HCPCS,76329-6300-5,NDC,facility,both,3,ML,,392,274.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEPERIDINE (PF) 25 MG/ML IV SOLN (PHS MERGE),50863,CDM,250,RC,J2175,HCPCS,0409-1176-30,NDC,facility,both,1,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE  5 MG/ML INJ SOLN,50863,CDM,250,RC,J2765,HCPCS,0409-3414-21,NDC,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 500 MG (200 MG ELEMENTAL) CHEW TAB,50863,CDM,250,RC,J3490,HCPCS,68084-988-33,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,636,RC,J2003,HCPCS,63323-485-27,NDC,facility,both,200,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VERAPAMIL  80 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,23155-026-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",50863,CDM,J1561,HCPCS,13533-800-21,NDC,,,facility,both,20,ML,,2829,1980.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,71288-402-10,NDC,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 300 MG ORAL CAP,50863,CDM,J3490,HCPCS,60687-699-11,NDC,,,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEPLIZUMAB-MZWV 2 MG/20 ML IV SOLN,50863,CDM,636,RC,J9381,HCPCS,73650-316-01,NDC,facility,both,19,ME,,1236,865.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 20MG/ML IV SYRINGE (PEDS/NEO),50863,CDM,250,RC,J0612,HCPCS,63323-311-10,NDC,facility,both,40,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,0008-0923-51,NDC,facility,both,1,EA,PLAD,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
ROPIVACAINE-EPI-CLONID-KETOROL 2.46-0.005- 0.0008-0.3MG/ML PATC SYRG,50863,CDM,636,RC,J3490,HCPCS,70092-1433-50,NDC,facility,both,2,ML,,425,297.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAMSULOSIN 0.4 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,68084-299-11,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1940,HCPCS,36000-283-25,NDC,facility,both,10,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 10 MG/5 ML SYRUP,50863,CDM,250,RC,Q0177,HCPCS,54838-502-80,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0245-0212-11,NDC,facility,both,3,EA,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J2004,HCPCS,0409-3178-01,NDC,facility,both,210,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,250,RC,J0137,HCPCS,0264-4100-90,NDC,facility,both,3,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-145-10,NDC,facility,both,2,EA,PLAD,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
SILDENAFIL 2.5 MG/ML SUSPENSION,50863,CDM,250,RC,J3490,HCPCS,99999-0404-75,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7110-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 3% IV BOLUS (ED ONLY),50863,CDM,250,RC,J3490,HCPCS,0264-7805-10,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 0.5 MG ORAL CAP,50863,CDM,250,RC,J7507,HCPCS,0469-0607-73,NDC,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2312,HCPCS,0409-1215-21,NDC,facility,both,40,ML,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG ORAL TAB,50863,CDM,J3490,HCPCS,51079-442-01,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOBENZAPRINE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,52817-332-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,636,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,5,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PERMETHRIN 1 % TOP LIQD (REPACK),50863,CDM,250,RC,J3490,HCPCS,6373612002,NDC,facility,both,1,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-0552-23,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,42023-201-01,NDC,facility,both,1,EA,,457,319.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DONEPEZIL 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6478-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 125 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-519-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,50863,CDM,J3490,HCPCS,68462-157-40,NDC,,,facility,both,2,EA,,227,158.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,250,RC,Q9968,HCPCS,0517-0374-01,NDC,facility,both,100,ML,,1660,1162,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,250,RC,J0132,HCPCS,55150-259-30,NDC,facility,both,120,ML,,2066,1446.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 1 MG/ML (1ML) SYRINGE (REPACK),50863,CDM,J2997,HCPCS,50242-044-13,NDC,,,facility,both,50,EA,,12145,8501.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE NA (PRESERV FREE) 25 MG/ML INJ SOLN,50863,CDM,636,RC,J9260,HCPCS,61703-408-41,NDC,facility,both,20,ML,,216,151.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAVASTATIN 40 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-5893-61,NDC,facility,both,2,EA,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ABOBOTULINUMTOXINA 500 UNITS IM SOLR,50863,CDM,636,RC,J0586,HCPCS,15054-0500-1,NDC,facility,both,160,EA,JZ,3889,2722.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-02,NDC,facility,both,1,ML,REMOVED,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier REMOVED: Modifier description not available
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,250,RC,J0690,HCPCS,60505-6142-0,NDC,facility,both,2,EA,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
BENZTROPINE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7289-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,50,EA,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 50 MG TAB,50863,CDM,636,RC,Q0177,HCPCS,68084-255-11,NDC,facility,both,3,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-4279-02,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-103-01,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,4,ML,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J2310,HCPCS,0409-1215-21,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IRRIGATION SOLN,50863,CDM,636,RC,J7120,HCPCS,0264-7389-60,NDC,facility,both,12,ML,,200,140,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,636,RC,Q0162,HCPCS,16714-671-02,NDC,facility,both,2,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,68094-600-59,NDC,facility,both,4,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN DEXTROSE (ISO-OS) 2 GRAM/100 ML IV PGBK,50863,CDM,250,RC,J0690,HCPCS,0338-3508-41,NDC,facility,both,4,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETHAMBUTOL 400 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-280-11,NDC,facility,both,3,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,64,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,70069-011-01,NDC,facility,both,8,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,68180-441-01,NDC,facility,both,2,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML IV SOLN,50863,CDM,J3490,HCPCS,25021-674-20,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1162-18,NDC,facility,both,60,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,68094-193-59,NDC,facility,both,2,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIOTHYRONINE  5 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0093-2179-01,NDC,facility,both,2,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 10% IN WATER (NEO) 2 - 3.99 KG,50863,CDM,250,RC,J3490,HCPCS,0264-7520-10,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,63323-161-00,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
STERILE TALC 4 G INPL SUSR,50863,CDM,250,RC,J3490,HCPCS,62327-444-04,NDC,facility,both,1,EA,,297,207.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELATACEPT 250 MG IV SOLR,50863,CDM,636,RC,J0485,HCPCS,0003-0371-13,NDC,facility,both,300,EA,,3096,2167.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIBOFLAVIN 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,761003220,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,250,RC,J3101,HCPCS,50242-037-06,NDC,facility,both,35,EA,JW,6970,4879,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
"AMIODARONE IN DEXTROSE,ISO-OSM 150 MG/100 ML (PREMIX)",50863,CDM,636,RC,J0282,HCPCS,43066-150-10,NDC,facility,both,10,ML,,407,284.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),50863,CDM,636,RC,J0171,HCPCS,76329-3318-1,NDC,facility,both,30,ML,,242,169.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV (BOLUS),50863,CDM,250,RC,J7120,HCPCS,0264-7750-10,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 80 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-685-01,NDC,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR  6 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0004-0822-05,NDC,facility,both,5,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7007-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,0641-6145-01,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 30 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0093-0318-01,NDC,facility,both,3,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  0.25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6373-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,70,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7914-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,250,RC,J3490,HCPCS,53746-542-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 500 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,68084-415-11,NDC,facility,both,4,EA,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,636,RC,J3010,HCPCS,0409-9094-22,NDC,facility,both,3,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR  6 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,68180-678-01,NDC,facility,both,5,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOBETASOL PROPIONATE 0.05 % TOP CREA,50863,CDM,250,RC,J3490,HCPCS,45802-129-35,NDC,facility,both,1,GM,,194,135.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,59762-0058-1,NDC,facility,both,4,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 500 MG PE/10 ML INJ SOLN,50863,CDM,636,RC,Q2009,HCPCS,0641-6137-01,NDC,facility,both,30,ML,,726,508.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALTREXONE 50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-291-11,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE (FOR EMERGENCY) 100 MG/ML (10%) IV SOLN,50863,CDM,250,RC,J0612,HCPCS,0143-9180-01,NDC,facility,both,100,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EZETIMIBE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68382-773-06,NDC,facility,both,1,EA,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,43598-053-11,NDC,facility,both,28,ML,,995,696.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOLAZONE 1MG/ML SUSPENSION (REPACK),50863,CDM,250,RC,J3490,HCPCS,99999-0404-65,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-591-11,NDC,facility,both,3,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML ORAL SYRP,50863,CDM,250,RC,J3490,HCPCS,0603-1841-58,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-406-03,NDC,facility,both,1,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,1,ML,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENAZEPRIL 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,43547-336-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-22,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60505-3111-0,NDC,facility,both,1,EA,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAZOSIN 1 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7020-61,NDC,facility,both,3,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM SR 300 MG 24 HR CAP,50863,CDM,250,RC,J3490,HCPCS,63304-721-90,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2308-21,NDC,facility,both,7,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-682-02,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA SR 25 MG-100 MG TAB,50863,CDM,250,RC,J3490,HCPCS,68084-281-11,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 1%/EPINEPHRINE 1:200K INJECTION (PF),50863,CDM,250,RC,J3490,HCPCS,63739-468-05,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN NORMAL SALINE IV,50863,CDM,250,RC,J7042,HCPCS,0338-0089-04,NDC,facility,both,2,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPTOMYCIN IN 0.9 % SOD CHLOR 350 MG/50 ML IV PGBK,50863,CDM,250,RC,J0874,HCPCS,0338-0712-24,NDC,facility,both,350,ML,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE   4.2 % IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-083-05,NDC,facility,both,1,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML ORAL SOLUTION (FOR PEDIATRIC USE),50863,CDM,250,RC,J3480,HCPCS,63323-965-05,NDC,facility,both,5,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-487-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-476-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE MODIFIED  25 MG ORAL CAP,50863,CDM,636,RC,J7515,HCPCS,0093-9018-19,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 25 MG TAB,50863,CDM,250,RC,J3490,HCPCS,62584-265-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,55150-177-05,NDC,facility,both,180,ML,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MECLIZINE 25 MG ORAL TAB,50863,CDM,J3490,HCPCS,50268-523-11,NDC,,,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,250,RC,J0137,HCPCS,55150-307-01,NDC,facility,both,2,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML INJECTION,50863,CDM,250,RC,J3411,HCPCS,0641-6228-01,NDC,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,60,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL  50 MCG/HR TD PT72,50863,CDM,250,RC,J3490,HCPCS,0406-9050-76,NDC,facility,both,1,EA,,129,90.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INDIGOTINDISULFONATE SODIUM 8 MG/ML INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,17478-508-01,NDC,facility,both,1,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-074-10,NDC,facility,both,2,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAY 1 NEO SOLUTION (D5W/AA 2%/HEPARIN 0.5 UNITS/ML),50863,CDM,250,RC,J3490,HCPCS,0264-9341-55,NDC,facility,both,1,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0172-3926-60,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE MONONITRATE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,7733393425,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2308-21,NDC,facility,both,9,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MISOPROSTOL 100 MCG ORAL TAB,50863,CDM,636,RC,S0191,HCPCS,60687-735-11,NDC,facility,both,4,EA,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,76045-009-96,NDC,facility,both,3,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,36000-283-25,NDC,facility,both,120,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML IV,50863,CDM,250,RC,J3490,HCPCS,0641-6014-01,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROTHIAZIDE SODIUM 500 MG IV SOLR,50863,CDM,250,RC,J1205,HCPCS,0517-1820-01,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES 8.8 MG/5 ML ORAL SYRP,50863,CDM,250,RC,J3490,HCPCS,54162-007-08,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,72888-019-01,NDC,facility,both,4,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 800 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-5855-60,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J2310,HCPCS,0409-1215-21,NDC,facility,both,1,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUPHENAZINE 5 MG TAB,50863,CDM,250,RC,J3490,HCPCS,60687-749-11,NDC,facility,both,2,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,54288-137-01,NDC,facility,both,1,ML,,210,147,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-3425-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,50863,CDM,636,RC,J3490,HCPCS,68462-157-40,NDC,facility,both,1,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 800 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-468-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,55150-161-02,NDC,facility,both,20,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,3,EA,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THROMBIN (RECOMBINANT) 5000 UNIT TOP SOLR,50863,CDM,636,RC,J3490,HCPCS,0338-0322-01,NDC,facility,both,1,EA,,149,104.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 3000 MCG/ML INJECTION,50863,CDM,250,RC,J0153,HCPCS,67457-855-00,NDC,facility,both,18,ML,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2312,HCPCS,70069-072-10,NDC,facility,both,200,ML,,212,148.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 12.5 MG ORAL TAB,50863,CDM,250,RC,Q0169,HCPCS,60687-660-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,8,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) MISC SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-694-04,NDC,facility,both,1,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUGAMMADEX 100 MG/ML IV SOLN,50863,CDM,J3490,HCPCS,0006-5423-02,NDC,,,facility,both,1,ML,,589,412.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68180-969-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0003-0894-70,NDC,facility,both,2,EA,,119,83.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50111-328-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 500 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,0832-7124-89,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J2003,HCPCS,0409-4279-02,NDC,facility,both,300,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 100 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,50268-542-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV,50863,CDM,636,RC,J7120,HCPCS,0338-0117-03,NDC,facility,both,3,ML,,183,128.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL,50863,CDM,250,RC,J3490,HCPCS,63323-820-01,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-406-03,NDC,facility,both,1,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 50 MG/ML IV SOLN,50863,CDM,250,RC,J0282,HCPCS,67457-153-09,NDC,facility,both,15,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,636,RC,Q9968,HCPCS,71288-811-10,NDC,facility,both,48,ML,JW,273,191.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0143-9982-50,NDC,facility,both,6,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,J3490,HCPCS,43066-007-10,NDC,,,facility,both,88,ML,,2027,1418.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES-DOCUSATE SODIUM 8.6 MG-50 MG TAB,50863,CDM,J3490,HCPCS,60687-622-11,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OMALIZUMAB 150 MG SUBQ SOLR,50863,CDM,J2357,HCPCS,50242-040-62,NDC,,,facility,both,90,ME,,7828,5479.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,5,ML,,8724,6106.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,636,RC,J3490,HCPCS,0409-1323-05,NDC,facility,both,100,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,16714-293-01,NDC,facility,both,11,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,250,RC,J7060,HCPCS,0338-0017-31,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,66758-016-03,NDC,facility,both,500,ML,,199,139.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TAB,50863,CDM,636,RC,J3490,HCPCS,51862-540-01,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNIT/G TOP OINT (MERGE),50863,CDM,250,RC,J3490,HCPCS,0168-0011-04,NDC,facility,both,2,GM,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,636,RC,J2795,HCPCS,43066-023-01,NDC,facility,both,15,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
VANCOMYCIN 125 MG/5 ML (25MG/ML) ORAL SYRINGE (REPACK),50863,CDM,636,RC,J3370,HCPCS,67457-340-00,NDC,facility,both,4,EA,,165,115.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,43,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 500 MCG INJ SOLR,50863,CDM,636,RC,J0650,HCPCS,63323-648-10,NDC,facility,both,50,EA,,1458,1020.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,30,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-41,NDC,facility,both,80,ML,"JZ,JA",11316,7921.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0641-0400-12,NDC,facility,both,2,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
SERTRALINE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16729-216-15,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6007-61,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,15,ML,JW,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,250,RC,J0330,HCPCS,0409-6629-02,NDC,facility,both,12,ML,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM SR 120 MG 12 HR CAP,50863,CDM,250,RC,J3490,HCPCS,51079-926-01,NDC,facility,both,1,EA,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,7,EA,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-089-11,NDC,facility,both,3,EA,,381,266.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VECURONIUM BROMIDE 10 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,67457-438-00,NDC,facility,both,1,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 125 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-443-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-48,NDC,facility,both,2,ML,,133,93.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  100 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,23155-688-31,NDC,facility,both,8,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0143-9509-01,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0245-0212-89,NDC,facility,both,2,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM SR 120 MG 24 HR CAP,50863,CDM,250,RC,J3490,HCPCS,60687-195-11,NDC,facility,both,3,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J0461,HCPCS,0517-1004-01,NDC,facility,both,70,ML,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELATACEPT 250 MG IV SOLR,50863,CDM,636,RC,J0485,HCPCS,0003-0371-13,NDC,facility,both,112,EA,JW,503,352.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
METHADONE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0054-0710-20,NDC,facility,both,13,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,0904-7127-61,NDC,facility,both,40,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  2.5 MG ORAL TAB,50863,CDM,250,RC,J7510,HCPCS,59651-485-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 40 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-711-11,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,16,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE  5 MG/ML INJ SOLN,50863,CDM,250,RC,J2765,HCPCS,0409-3414-21,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM TETRADECYL SULFATE 3 % IV SOLN,50863,CDM,250,RC,J3490,HCPCS,67457-163-02,NDC,facility,both,1,ML,,398,278.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0093-3425-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG IV SOLR,50863,CDM,636,RC,J3490,HCPCS,16714-644-01,NDC,facility,both,2,EA,,274,191.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  750 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7125-61,NDC,facility,both,5,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MANNITOL 25 % IV SOLN,50863,CDM,250,RC,J2150,HCPCS,63323-024-01,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,14,ML,JW,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
HYDROXYUREA  500 MG ORAL CAP,50863,CDM,250,RC,J9999,HCPCS,68084-284-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-02,NDC,facility,both,2,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,100,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
NORETHINDRONE ACETATE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50742-267-50,NDC,facility,both,3,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,636,RC,J7060,HCPCS,0409-7922-02,NDC,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,0409-3795-19,NDC,facility,both,2,ML,JZ,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
BUSPIRONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-986-01,NDC,facility,both,2,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,250,RC,J3360,HCPCS,0409-1273-03,NDC,facility,both,2,ML,,198,138.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SYRG,50863,CDM,250,RC,J3490,HCPCS,8290306546,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTAMIDINE 300 MG INJ SOLR,50863,CDM,636,RC,J3490,HCPCS,63323-113-01,NDC,facility,both,1,EA,,337,235.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MISOPROSTOL 25 MCG ORAL TAB,50863,CDM,250,RC,S0191,HCPCS,59762-5007-1,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID (PORK)  30 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42192-329-01,NDC,facility,both,3,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-22,NDC,facility,both,20,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN PEDS SYRINGE (20MG/ML) IN DEXTROSE (CDS MIX,50863,CDM,250,RC,J0690,HCPCS,0781-3451-70,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN 0.9% SODIUM CL 1.25 GRAM/250 ML IV SOLN,50863,CDM,250,RC,J3373,HCPCS,72196-6074-1,NDC,facility,both,125,ML,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 20MG/ML IV SYRINGE (PEDS/NEO),50863,CDM,250,RC,J0612,HCPCS,63323-311-10,NDC,facility,both,70,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYPROHEPTADINE 4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-189-11,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG ORAL TAB,50863,CDM,636,RC,Q0169,HCPCS,68084-155-11,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML IV SOLN (MERGE),50863,CDM,250,RC,J3490,HCPCS,16714-037-01,NDC,facility,both,1,ML,,152,106.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J2004,HCPCS,0409-3178-16,NDC,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACARBOSE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,64380-759-06,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,636,RC,J0330,HCPCS,0409-6629-02,NDC,facility,both,3,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOTRIMAZOLE 1 % TOP CREA,50863,CDM,636,RC,J3490,HCPCS,0536-1265-95,NDC,facility,both,2,GM,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,62756-711-86,NDC,facility,both,1,EA,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  1 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,64380-782-06,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 20 GRAM/30 ML ORAL SOLN,50863,CDM,J3490,HCPCS,0121-1154-30,NDC,,,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB 100 MG IV SOLR,50863,CDM,636,RC,J1745,HCPCS,57894-030-01,NDC,facility,both,18,EA,,5802,4061.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 150 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,68084-708-95,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-0007-01,NDC,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,4,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN 50 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,51672-4146-1,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,76045-009-01,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,636,RC,J3490,HCPCS,0409-4887-17,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-0053-05,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,63323-162-00,NDC,facility,both,1,ML,JZ,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,63739-931-28,NDC,facility,both,7,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICARDIPINE 25 MG/10 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0143-9689-01,NDC,facility,both,2,ML,,300,210,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,68180-150-01,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VERAPAMIL 2.5 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,70710-1643-1,NDC,facility,both,2,ML,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-492-27,NDC,,,facility,both,800,ML,,628,439.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  75 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0071-1014-41,NDC,facility,both,2,EA,,131,91.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,J3490,HCPCS,0338-0049-48,NDC,,,facility,both,2,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 40 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0054-8299-25,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 150 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,68084-708-95,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE 20 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0904-5677-61,NDC,facility,both,3,EA,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE IN D5W 1 GRAM/100 ML IV PGBK,50863,CDM,250,RC,J3475,HCPCS,44567-410-24,NDC,facility,both,2,ML,JZ,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
FENTANYL  75 MCG/HR TD PT72,50863,CDM,250,RC,J3490,HCPCS,47781-427-11,NDC,facility,both,3,EA,,641,448.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,4,EA,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,636,RC,J0690,HCPCS,0143-9924-90,NDC,facility,both,6,EA,JZ,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-1159-09,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,636,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN (PF) NEO IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J1580,HCPCS,63323-513-02,NDC,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-479-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,67877-246-01,NDC,facility,both,4,EA,,220,154,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,50863,CDM,250,RC,J9267,HCPCS,61703-342-22,NDC,facility,both,54,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,62559-440-02,NDC,facility,both,4,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,J2371,HCPCS,0641-6142-01,NDC,,,facility,both,500,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0904-6923-61,NDC,facility,both,86,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 12.5 MG ORAL TAB,50863,CDM,250,RC,Q0169,HCPCS,68084-154-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 50% IN WATER (MERGE RECORD),50863,CDM,J7060,HCPCS,0409-7517-66,NDC,,,facility,both,1,ML,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR  6 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,42291-567-60,NDC,facility,both,4,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  2.5 MG ORAL TAB,50863,CDM,250,RC,J7510,HCPCS,0054-4742-25,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOPIDOGREL 300 MG ORAL TAB,50863,CDM,J3490,HCPCS,68084-752-95,NDC,,,facility,both,1,EA,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7452-61,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-7350-61,NDC,,,facility,both,4,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,63323-104-25,NDC,facility,both,12,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN STERILE WATER 2 GRAM/20 ML IV SYRG,50863,CDM,636,RC,J7999,HCPCS,70092-1604-47,NDC,facility,both,8,ML,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,25021-463-01,NDC,facility,both,4,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-5771-23,NDC,facility,both,16,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1815,HCPCS,0169-1833-11,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-1159-19,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-495-27,NDC,,,facility,both,16,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE IN D5W 1 GRAM/100 ML IV PGBK,50863,CDM,636,RC,J3475,HCPCS,44567-410-24,NDC,facility,both,4,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-495-27,NDC,,,facility,both,40,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DASATINIB  20 MG ORAL TAB,50863,CDM,636,RC,J9999,HCPCS,60505-3628-6,NDC,facility,both,2,EA,,1135,794.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 7.5 MG-325 MG/15 ML ORAL SOLN (REPACK),50863,CDM,636,RC,J3490,HCPCS,66689-023-01,NDC,facility,both,1,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ICATIBANT 30 MG/3 ML SUBQ SYRG,50863,CDM,250,RC,J1744,HCPCS,69097-664-68,NDC,facility,both,30,ML,JZ,29229,20460.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IVPB (PEDIATRICS/ADULT NON-FORM)",50863,CDM,636,RC,J0137,HCPCS,24201-100-01,NDC,facility,both,23,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,55150-165-05,NDC,facility,both,200,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN PEDS INFUSION (CDS MIXTURE),50863,CDM,250,RC,J0290,HCPCS,25021-136-10,NDC,facility,both,3,EA,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE  25 MG ORAL CAP,50863,CDM,250,RC,J7515,HCPCS,0078-0240-61,NDC,facility,both,2,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 50% IN WATER (MERGE RECORD),50863,CDM,636,RC,J7060,HCPCS,0409-6648-02,NDC,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,70954-059-10,NDC,facility,both,20,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 10 GRAM/100 ML (10%) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-72,NDC,facility,both,20,ML,"JZ,JA",2829,1980.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
AMPICILLIN-SULBACTAM  1.5 GRAM INJ SOLR,50863,CDM,636,RC,J0295,HCPCS,0049-0013-81,NDC,facility,both,1,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DENOSUMAB-BBDZ 60 MG/ML SUBQ SYRG,50863,CDM,636,RC,Q5136,HCPCS,61314-240-63,NDC,facility,both,1,ML,,4428,3099.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2003,HCPCS,72603-505-01,NDC,,,facility,both,300,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 10 MEQ/100 ML IV PGBK (USE NON-PROTOCOL PANEL),50863,CDM,250,RC,J3480,HCPCS,0338-0709-48,NDC,facility,both,20,ML,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,28,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 5 MG/ML IV SOLN,50863,CDM,636,RC,J1921,HCPCS,0409-2267-20,NDC,facility,both,1,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-229-41,NDC,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 500 MG (200 MG ELEMENTAL) CHEW TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6412-92,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPROSTADIL 500 MCG/ML INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0009-3169-01,NDC,facility,both,1,ML,,732,512.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-351-11,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAMADOL  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-795-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4 % MUCOSAL TOPICAL SOLN,50863,CDM,250,RC,J3490,HCPCS,70954-518-10,NDC,facility,both,1,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LINEZOLID 600 MG/300 ML IV SOLP,50863,CDM,250,RC,J2020,HCPCS,66794-219-63,NDC,facility,both,3,ML,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0641-0400-37,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SINCALIDE 5 MCG INJ SOLR,50863,CDM,250,RC,J2805,HCPCS,0270-0556-15,NDC,facility,both,1,EA,,564,394.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,7,EA,JW,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PROPRANOLOL  20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,83980-006-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J2004,HCPCS,0409-3178-16,NDC,facility,both,400,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL,50863,CDM,636,RC,J3490,HCPCS,63323-820-04,NDC,facility,both,1,ML,,168,117.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,250,RC,J2795,HCPCS,70069-064-25,NDC,facility,both,125,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE IN SALINE (ISO-OSM) 400 MG/200 ML IV PIGGY BACK,50863,CDM,250,RC,J3490,HCPCS,25021-184-87,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6799-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESNA 100 MG/ML IV SOLN,50863,CDM,250,RC,J9209,HCPCS,10019-953-62,NDC,facility,both,4,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,636,RC,J1596,HCPCS,0143-9682-25,NDC,facility,both,4,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-3243-01,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IR SOLN,50863,CDM,636,RC,J3490,HCPCS,0338-0047-46,NDC,facility,both,1,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-453-11,NDC,facility,both,9,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOMEPIZOLE 1 GRAM/ML IV SOLN,50863,CDM,250,RC,J1451,HCPCS,70710-1478-1,NDC,facility,both,100,ML,,4140,2898,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,63323-161-00,NDC,facility,both,1,ML,JZ,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0093-4177-73,NDC,facility,both,2,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV,50863,CDM,636,RC,J7120,HCPCS,0338-0117-03,NDC,facility,both,2,ML,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-492-27,NDC,,,facility,both,60,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,0409-4279-16,NDC,,,facility,both,300,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7016-61,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-22,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,J3490,HCPCS,0536-1327-06,NDC,,,facility,both,3,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-25,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2308-21,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6008-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 100 MG/5 ML ORAL LIQD,50863,CDM,250,RC,J3490,HCPCS,0121-1488-10,NDC,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-454-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOMYCIN-BACITRACN ZN-POLYMYXIN 3.5 MG-400 U*,50863,CDM,636,RC,J3490,HCPCS,45802-061-70,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2305-04,NDC,facility,both,2,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,50863,CDM,636,RC,J3490,HCPCS,58657-528-16,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,79,ML,,113,79.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL IV BOLUS 10MG/ML (ANESTHESIA ONLY),50863,CDM,636,RC,J2704,HCPCS,0409-4699-54,NDC,facility,both,11,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DULOXETINE 30 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,0904-7044-61,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE 3 MG ORAL CP24,50863,CDM,636,RC,J3490,HCPCS,0574-9855-10,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-ABDA 100 MG IV SOLR,50863,CDM,250,RC,Q5104,HCPCS,78206-162-99,NDC,facility,both,40,EA,,8318,5822.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 20 MG ORAL CPDR,50863,CDM,636,RC,J3490,HCPCS,0904-7043-61,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,50863,CDM,636,RC,J1885,HCPCS,72266-119-01,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,16714-294-02,NDC,facility,both,5,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ITRACONAZOLE 10 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,31722-006-31,NDC,facility,both,1,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INDAPAMIDE 2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,62559-511-01,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,0409-4887-17,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-505-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RALOXIFENE 60 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-266-11,NDC,facility,both,1,EA,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 150 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,68180-319-09,NDC,facility,both,2,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMMONIUM LACTATE 12 % TOP LOTN,50863,CDM,250,RC,J3490,HCPCS,904598426,NDC,facility,both,1,GM,,187,130.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,63323-185-07,NDC,facility,both,5,ML,,146,102.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE IN D5W 1 GRAM/100 ML IV PGBK,50863,CDM,636,RC,J3475,HCPCS,44567-410-24,NDC,facility,both,2,ML,JZ,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LITHIUM CARBONATE 300 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,68084-640-11,NDC,facility,both,4,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 150 MG ORAL TBSR,50863,CDM,636,RC,J3490,HCPCS,0904-7214-61,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MODAFINIL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-570-11,NDC,facility,both,2,EA,,240,168,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,3,EA,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 400 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,65862-071-01,NDC,facility,both,7,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELATACEPT 250 MG IV SOLR,50863,CDM,636,RC,J0485,HCPCS,0003-0371-13,NDC,facility,both,500,EA,,5159,3611.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL  75 MCG/HR TD PT72,50863,CDM,636,RC,J3490,HCPCS,47781-427-11,NDC,facility,both,2,EA,,428,299.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 30 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,60687-734-11,NDC,facility,both,2,EA,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM-ALBUTEROL 0.5 MG-2.5 MG/3 ML NEB SOLUTION,50863,CDM,250,RC,J3490,HCPCS,0487-0201-03,NDC,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TORSEMIDE   5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-754-11,NDC,facility,both,8,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-41,NDC,facility,both,1,ML,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTOBACILLUS ACIDOPHILUS 500 MILLION CELLS ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,7733300415,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOL 1.4 % MM SPRA,50863,CDM,250,RC,J3490,HCPCS,7811201103,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 800 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-720-11,NDC,facility,both,3,EA,,131,91.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR IRRIGATION, STERILE SOLUTION",50863,CDM,636,RC,J3490,HCPCS,0338-0004-02,NDC,facility,both,4,ML,,128,89.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,12,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,52,ML,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0264-5802-10,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMETHICONE 40MG/0.6ML (0.6ML-UD) SYRINGE (REPACK),50863,CDM,250,RC,J3490,HCPCS,17856-1141-4,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FIDAXOMICIN 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,52015-080-01,NDC,facility,both,10,EA,,6874,4811.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),50863,CDM,636,RC,J3490,HCPCS,63323-186-03,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GAMMAGARD S-D (IGA < 1 MCG/ML) 10 GRAM IV SOLR,50863,CDM,636,RC,J1566,HCPCS,0944-2659-08,NDC,facility,both,80,EA,JZ,18625,13037.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-1283-05,NDC,facility,both,5,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML (ANESTHESIA INTRAOP ONLY),50863,CDM,250,RC,J3010,HCPCS,0641-6027-01,NDC,facility,both,4,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  50 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-6992-61,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0904-7127-61,NDC,facility,both,50,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  60 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,0904-6559-61,NDC,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE-SALMETEROL 250 MCG-50 MCG/DOSE DISK DEVICE FOR INHALATION,50863,CDM,250,RC,J3490,HCPCS,0378-9321-32,NDC,facility,both,1,EA,,1325,927.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLPIDEM  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6082-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN 0.9% SODIUM CL 1 GRAM/250 ML IV SOLN,50863,CDM,250,RC,J3373,HCPCS,71266-5082-1,NDC,facility,both,100,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL IV BOLUS 10MG/ML (ANESTHESIA ONLY),50863,CDM,636,RC,J2704,HCPCS,0409-4699-54,NDC,facility,both,98,ML,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5%-1/2 NORMAL SALINE IV (PEDS ONCOLOGY),50863,CDM,636,RC,J7042,HCPCS,0338-0085-04,NDC,facility,both,2,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0295,HCPCS,63323-368-20,NDC,facility,both,1,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0630,HCPCS,42023-205-01,NDC,facility,both,1,ML,,5618,3932.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 250 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,42192-608-05,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,636,RC,J1815,HCPCS,49502-393-80,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-467-01,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,5,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,116,ML,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB 100 MG IV SOLR,50863,CDM,636,RC,J1745,HCPCS,57894-030-01,NDC,facility,both,89,EA,,28687,20080.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL-ROPIVACAINE-NACL (PF) 2-0.2 MCG/ML-% INJ (MERGE ERX),50863,CDM,250,RC,J3490,HCPCS,70092-9259-75,NDC,facility,both,4,ML,,869,608.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,35,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTAROLINE FOSAMIL 600 MG IV SOLR,50863,CDM,250,RC,J0712,HCPCS,0456-0600-01,NDC,facility,both,60,EA,,869,608.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-48,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 30 MG/0.3 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0548-5601-00,NDC,facility,both,3,ML,JZ,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PREDNISONE  1 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,64380-782-06,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-950-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MICAFUNGIN 100 MG IV SOLR,50863,CDM,250,RC,J2248,HCPCS,42023-230-01,NDC,facility,both,33,EA,,210,147,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG IV SOLR,50863,CDM,636,RC,J0456,HCPCS,70436-019-82,NDC,facility,both,1,EA,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,65862-707-80,NDC,facility,both,7,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-074-11,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  75 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7000-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,J2371,HCPCS,0517-0299-25,NDC,,,facility,both,500,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAMIDRONATE 3 MG/ML IV SOLN,50863,CDM,250,RC,J2430,HCPCS,61703-324-18,NDC,facility,both,1,ML,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML (PEDS CALCLUATOR 0.5),50863,CDM,636,RC,J1815,HCPCS,0024-5924-10,NDC,facility,both,8,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J3490,HCPCS,63323-492-07,NDC,,,facility,both,300,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM  3.375 GRAM IV SOLR,50863,CDM,250,RC,J2543,HCPCS,55150-120-30,NDC,facility,both,3,EA,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,3,EA,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G POTASSIUM  5000000 UNIT INJ SOLR,50863,CDM,636,RC,J2540,HCPCS,44567-311-10,NDC,facility,both,7,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,63739-434-02,NDC,facility,both,4,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,16729-114-31,NDC,facility,both,12,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,50863,CDM,J3490,HCPCS,60687-742-11,NDC,,,facility,both,2,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,78206-122-01,NDC,facility,both,3,EA,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0406-0512-23,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE-VITAMIN D3 250 MG-125 UNIT TAB,50863,CDM,250,RC,J3490,HCPCS,2055502500,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,250,RC,J3490,HCPCS,59310-579-22,NDC,facility,both,1,GM,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,65862-707-80,NDC,facility,both,9,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROPRUSSIDE 25 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,43598-587-23,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J1938,HCPCS,23155-473-32,NDC,facility,both,2,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 1000 MG MISC TBSO,50863,CDM,250,RC,J3490,HCPCS,77333-844-25,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOBAZAM 2.5 MG/ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,99999-0404-03,NDC,facility,both,1,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG IV SOLR,50863,CDM,636,RC,J0456,HCPCS,63323-398-01,NDC,facility,both,1,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 200 MG/20 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,70710-1359-1,NDC,facility,both,1,ML,,334,233.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-986-01,NDC,facility,both,2,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7008-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IV PGBK,50863,CDM,636,RC,J3490,HCPCS,0338-1715-40,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,250,RC,J3490,HCPCS,73013-2002-2,NDC,facility,both,3,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 0.2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60505-0258-1,NDC,facility,both,8,EA,,171,119.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-492-04,NDC,facility,both,40,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOXAPINE 50 MG CAP,50863,CDM,636,RC,J3490,HCPCS,10135-588-01,NDC,facility,both,2,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 2 MG/ML IV SOLN,50863,CDM,250,RC,J9000,HCPCS,25021-207-51,NDC,facility,both,2,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GOLIMUMAB  12.5 MG/ML IV SOLN,50863,CDM,636,RC,J1602,HCPCS,57894-350-01,NDC,facility,both,7,ML,JW,336,235.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
INSULIN ASP PRT-INSULIN ASPART 100 UNIT/ML (70-30) SUBQ SOLN,50863,CDM,250,RC,J1817,HCPCS,73070-200-11,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 300 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,68084-252-11,NDC,facility,both,1,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATED 20 MG/ML IV SOLN,50863,CDM,250,RC,J0706,HCPCS,51754-0500-1,NDC,facility,both,8,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 400 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6667-61,NDC,facility,both,1,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0075-0622-01,NDC,facility,both,8,ML,JZ,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DOPAMINE INFUSION NEO IV SYRINGE (FROM PREMIX),50863,CDM,250,RC,J1265,HCPCS,0338-1007-02,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATOVAQUONE 750 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0121-1016-05,NDC,facility,both,2,ML,,351,245.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FERROUS SULFATE 325 MG (65 MG IRON) TAB,50863,CDM,636,RC,J3490,HCPCS,904759161,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL,50863,CDM,250,RC,J3490,HCPCS,63323-820-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),50863,CDM,636,RC,J0169,HCPCS,76329-3318-1,NDC,facility,both,10,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,47,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SOMATROPIN  5.8 MG SUBQ SOLR,50863,CDM,250,RC,J3490,HCPCS,0781-4004-36,NDC,facility,both,1,EA,,1207,844.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEPLIZUMAB-MZWV 2 MG/20 ML IV SOLN,50863,CDM,636,RC,J9381,HCPCS,73650-316-01,NDC,facility,both,108,ME,JW,2839,1987.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LORAZEPAM 2 MG/ML INJ SOLN,50863,CDM,250,RC,J2060,HCPCS,0409-1985-03,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLP,50863,CDM,250,RC,J3480,HCPCS,63323-965-02,NDC,facility,both,20,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-210-11,NDC,facility,both,2,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOBENZAPRINE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-558-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7047-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) MISC SOLN,50863,CDM,636,RC,J3490,HCPCS,0517-7604-01,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,10702-018-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MERCAPTOPURINE 50 MG ORAL TAB,50863,CDM,250,RC,J9999,HCPCS,0054-4581-11,NDC,facility,both,1,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-492-07,NDC,facility,both,1,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL  3.125 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7305-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 2 MG/ML IN NS 50ML INFUSION (STOCK DOSE),50863,CDM,250,RC,J3490,HCPCS,0143-9508-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 150 MG CAP,50863,CDM,636,RC,J3490,HCPCS,0904-5959-61,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-087-02,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-822-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  2.5 MG ORAL TAB,50863,CDM,250,RC,J7510,HCPCS,59651-485-01,NDC,facility,both,50,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % MUCOSAL GEL,50863,CDM,250,RC,J3490,HCPCS,50383-781-05,NDC,facility,both,1,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2598,HCPCS,43598-914-11,NDC,facility,both,3,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 400 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-602-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MULTIVIT-MIN-FERROUS GLUCONATE 9 MG IRON/ 15 ML (15 ML) ORAL LIQD,50863,CDM,636,RC,J3490,HCPCS,8103350115,NDC,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 160 MG-800 MG TAB,50863,CDM,250,RC,J3490,HCPCS,65862-420-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 2-0.5 MG SL SUBL,50863,CDM,636,RC,J3490,HCPCS,0904-7009-06,NDC,facility,both,1,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 10 MEQ/100 ML IV PGBK (USE NON-PROTOCOL PANEL),50863,CDM,636,RC,J3480,HCPCS,0338-0709-48,NDC,facility,both,20,ML,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL (5 MG/ML) IV SYRG (CONTAINS PRESERVATIVE),50863,CDM,636,RC,J3490,HCPCS,65302-503-04,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6322-06,NDC,facility,both,4,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VORICONAZOLE 200 MG IV SOLN,50863,CDM,250,RC,J3465,HCPCS,70436-029-80,NDC,facility,both,30,EA,,824,576.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID (PORK)  60 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0456-0459-01,NDC,facility,both,3,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7030,HCPCS,0338-0049-04,NDC,facility,both,3,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANTI-INHIBITOR COAGULANT CMPLX (PHS MERGE),50863,CDM,250,RC,J7198,HCPCS,64193-326-01,NDC,facility,both,75,UN,JW,236,165.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,636,RC,J3010,HCPCS,0409-9094-18,NDC,facility,both,3,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) NEB SOLUTION,50863,CDM,J3490,HCPCS,0487-9501-01,NDC,,,facility,both,2,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  500 MG IV SOLR,50863,CDM,636,RC,J3370,HCPCS,0069-2587-03,NDC,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-145-11,NDC,facility,both,20,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM  4.5 GRAM IV SOLR,50863,CDM,J2543,HCPCS,55150-121-50,NDC,,,facility,both,4,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 1 MG ORAL TAB,50863,CDM,636,RC,J8540,HCPCS,72578-166-01,NDC,facility,both,8,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,78206-122-01,NDC,facility,both,1,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-710-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-476-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,50863,CDM,250,RC,J9045,HCPCS,0703-4248-01,NDC,facility,both,9,ML,,331,231.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESNA 100 MG/ML IV SOLN,50863,CDM,250,RC,J9209,HCPCS,10019-953-62,NDC,facility,both,4,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G POTASSIUM 20000000 UNIT INJ SOLR,50863,CDM,250,RC,J2540,HCPCS,70860-127-51,NDC,facility,both,34,EA,,280,196,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IV PGBK,50863,CDM,250,RC,J3475,HCPCS,63323-106-00,NDC,facility,both,8,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,68180-150-01,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5%-LACTATED RINGERS IV,50863,CDM,250,RC,J7120,HCPCS,0338-0125-03,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
D5-0.9%NACL-POTASSIUM CHLORIDE 20 MEQ/L IV SOLP,50863,CDM,250,RC,J3480,HCPCS,0338-0803-04,NDC,facility,both,10,ML,JZ,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,49502-393-80,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 875 MG-125 MG TAB,50863,CDM,636,RC,J3490,HCPCS,65862-503-01,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-3178-01,NDC,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYCHLOROQUINE 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0781-5994-01,NDC,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,72603-179-01,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 17 GRAM (100 %) ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,0904-6931-86,NDC,facility,both,11,EA,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FELODIPINE  5 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,13668-133-01,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-3178-16,NDC,facility,both,300,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COSYNTROPIN 0.25 MG INJ SOLR,50863,CDM,250,RC,J0834,HCPCS,0781-3440-71,NDC,facility,both,1,EA,,409,286.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 30 MG/0.3 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,16714-006-01,NDC,facility,both,6,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FONDAPARINUX 7.5 MG/0.6 ML SUBQ SYRG,50863,CDM,250,RC,J1652,HCPCS,55111-680-11,NDC,facility,both,15,ML,,489,342.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,2,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 10 MG/ML INJECTION,50863,CDM,J1100,HCPCS,63323-516-10,NDC,,,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID (PORK) 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0456-1045-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,250,RC,J2720,HCPCS,63323-229-01,NDC,facility,both,13,ML,,237,165.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,636,RC,J3360,HCPCS,0409-1273-03,NDC,facility,both,1,ML,JW,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,250,RC,J2003,HCPCS,0409-1323-05,NDC,facility,both,100,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,50863,CDM,250,RC,J0561,HCPCS,60793-701-02,NDC,facility,both,12,ML,,1080,756,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,55150-154-10,NDC,facility,both,182,ML,,143,100.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 100 MG/1 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,0548-5605-00,NDC,facility,both,20,ML,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,636,RC,J2795,HCPCS,43066-023-01,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL-ROPIVACAINE-NACL (PF) 2-0.2 MCG/ML-% INJ (MERGE ERX),50863,CDM,250,RC,J3490,HCPCS,73013-1048-01,NDC,facility,both,1,ML,,270,189,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 7.5 MG-325 MG/15 ML ORAL SOLN (REPACK),50863,CDM,636,RC,J3490,HCPCS,0121-2316-15,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE 100 MG TAB,50863,CDM,636,RC,J3490,HCPCS,60687-344-95,NDC,facility,both,4,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,89,ML,JW,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LISINOPRIL  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6797-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  15 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,0406-8315-23,NDC,facility,both,2,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAMADOL  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7496-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MANNITOL 20% IV SOLP,50863,CDM,250,RC,J2150,HCPCS,0338-0357-03,NDC,facility,both,2,ML,,641,448.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPSONE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,70954-135-10,NDC,facility,both,4,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,250,RC,J3360,HCPCS,43598-106-11,NDC,facility,both,1,ML,JW,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
BUPIVACAINE-DEXTROSE-WATER(PF) 7.5 MG/ML (0.75 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,71351-022-10,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,70069-011-01,NDC,facility,both,6,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRP (MERGE/REPACK),50863,CDM,250,RC,J3490,HCPCS,63304-205-18,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2003,HCPCS,0409-4282-12,NDC,,,facility,both,1220,ML,,173,121.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN INFUSION PEDS IV SYRINGE (FROM PREMIX),50863,CDM,250,RC,J3490,HCPCS,99999-999-99,NDC,facility,both,1,ML,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,11,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE 20 MG TAB,50863,CDM,250,RC,J3490,HCPCS,63739-963-10,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOMYCIN-BACITRACN ZN-POLYMYXIN 3.5 MG-400 U*,50863,CDM,250,RC,J3490,HCPCS,45802-143-00,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXAZOSIN 2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-851-95,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7124-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL 20 MG/5 ML ORAL ELIX,50863,CDM,250,RC,J3490,HCPCS,0121-0942-05,NDC,facility,both,2,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB 100 MG IV SOLR,50863,CDM,636,RC,J1745,HCPCS,57894-030-01,NDC,facility,both,56,EA,JZ,18050,12635,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SITAGLIPTIN  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0006-0221-01,NDC,facility,both,4,EA,,224,156.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BLINATUMOMAB 12.5 MCG/ML IV SOLR,50863,CDM,250,RC,J9039,HCPCS,55513-150-01,NDC,facility,both,35,EA,,11056,7739.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,636,RC,J1596,HCPCS,0143-9679-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,88,ML,JW,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ADENOSINE (DIAGNOSTIC) 3 MG/ML IV SOLN,50863,CDM,250,RC,J0153,HCPCS,55150-193-01,NDC,facility,both,201,ML,,1717,1201.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 600 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-457-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN 50 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,0904-7199-07,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,250,RC,J0690,HCPCS,0143-9924-90,NDC,facility,both,4,EA,,255,178.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,71288-402-10,NDC,facility,both,11,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 2 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J2004,HCPCS,0409-3183-11,NDC,facility,both,160,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-208-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,72266-146-01,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-1752-50,NDC,facility,both,1,ML,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN 0.9% SODIUM CL 1.25 GRAM/250 ML IV SOLN,50863,CDM,250,RC,J3373,HCPCS,71266-5073-1,NDC,facility,both,125,ML,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,10,ML,,17341,12138.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  1 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,64380-782-06,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IVPB (PEDIATRICS/ADULT NON-FORM)",50863,CDM,250,RC,J0137,HCPCS,24201-100-01,NDC,facility,both,100,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-444-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0406-0512-23,NDC,facility,both,2,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-18,NDC,facility,both,1,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICARDIPINE 25 MG/10 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,55150-183-01,NDC,facility,both,2,ML,,250,175,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 100 MG/ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,31722-574-47,NDC,facility,both,1,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,250,RC,J2405,HCPCS,70860-776-41,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,25021-402-01,NDC,facility,both,2,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,68094-231-59,NDC,facility,both,4,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLN,50863,CDM,636,RC,J3262,HCPCS,50242-135-01,NDC,facility,both,240,ML,JZ,4399,3079.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,250,RC,J2720,HCPCS,63323-229-01,NDC,facility,both,4,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL 2 MG/ML ORAL CONCENTRATE,50863,CDM,250,RC,J3490,HCPCS,0121-0581-04,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5%-1/2 NORMAL SALINE IV (PEDS ONCOLOGY),50863,CDM,636,RC,J7042,HCPCS,0338-0085-04,NDC,facility,both,2,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-48,NDC,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IR SOLN,50863,CDM,250,RC,J3490,HCPCS,0264-2201-00,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIACIN  250 MG ORAL CPSR,50863,CDM,636,RC,J3490,HCPCS,1000670020,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,J3010,HCPCS,0409-9094-22,NDC,,,facility,both,2,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,250,RC,J2003,HCPCS,63323-495-27,NDC,facility,both,250,ML,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISATRACURIUM  2 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0074-4380-79,NDC,facility,both,1,ML,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,J3490,HCPCS,63037-136-25,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,23155-687-31,NDC,facility,both,6,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,50863,CDM,J0696,HCPCS,44567-702-25,NDC,,,facility,both,4,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE IN D5W (PF) 4 MG/ML (0.4 %) IV SOLP,50863,CDM,J2003,HCPCS,0338-0409-03,NDC,,,facility,both,2000,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 100 MG/ML INJ SOLN,50863,CDM,636,RC,J2800,HCPCS,71288-716-11,NDC,facility,both,1,ML,JZ,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,6,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-02,NDC,facility,both,1,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  1 MG/ML INJ SYRG,50863,CDM,250,RC,J1171,HCPCS,0409-1283-10,NDC,facility,both,40,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-495-04,NDC,,,facility,both,600,ML,,144,100.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM BICARB-CITRIC ACID 20 MEQ ORAL TBEF,50863,CDM,250,RC,J3490,HCPCS,51801-011-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  5 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-122-11,NDC,facility,both,98,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 17 GRAM (100 %) ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,62559-157-17,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 250 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,17856-0600-1,NDC,facility,both,3,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 20 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7346-61,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,0517-4620-25,NDC,facility,both,2,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,55150-307-01,NDC,facility,both,40,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,50863,CDM,250,RC,J8540,HCPCS,0054-8175-25,NDC,facility,both,64,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-48,NDC,facility,both,1,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,300,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 0.1 MG/ML INJ SYRG,50863,CDM,J0461,HCPCS,76329-3340-1,NDC,,,facility,both,2121,ML,,1426,998.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 200 MG ORAL TAB,50863,CDM,J3490,HCPCS,0245-0147-89,NDC,,,facility,both,2,EA,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE IN 0.9% NS (PF) 1 MG/10 ML (100 MCG/ML) IV SYRG(PDS MERGE),50863,CDM,250,RC,J3490,HCPCS,70092-1046-46,NDC,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML (ANESTHESIA INTRAOP ONLY),50863,CDM,636,RC,J3010,HCPCS,0641-6027-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 1 MG/0.5 ML INJ SOLN,50863,CDM,250,RC,J3430,HCPCS,0409-9157-31,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAMSULOSIN 0.4 MG ORAL CP24,50863,CDM,J3490,HCPCS,0904-7383-61,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-02,NDC,facility,both,5,ML,,262,183.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,50863,CDM,250,RC,J9263,HCPCS,71288-101-20,NDC,facility,both,200,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,J1940,HCPCS,63323-280-03,NDC,,,facility,both,2,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,50863,CDM,J9206,HCPCS,0009-0082-02,NDC,,,facility,both,15,ML,,472,330.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 0.3 % OPHT DROP,50863,CDM,636,RC,J3490,HCPCS,61314-656-05,NDC,facility,both,1,ML,,232,162.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,53489-156-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7050,HCPCS,0338-0049-02,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 200 MG/100 ML IVPB (MERGE),50863,CDM,250,RC,J1450,HCPCS,25021-184-82,NDC,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-48,NDC,facility,both,1,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN DEXTROSE (ISO-OSMOTIC) 1 GRAM/50 ML IV PIGGY BACK,50863,CDM,250,RC,J0690,HCPCS,0338-3503-41,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADVATE: FACTOR VIII CONCENTRATE (MERGE RECORD),50863,CDM,250,RC,J7192,HCPCS,0944-3053-04,NDC,facility,both,3500,UN,,18354,12847.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VORICONAZOLE 200 MG IV SOLN,50863,CDM,250,RC,J3465,HCPCS,0781-3416-94,NDC,facility,both,28,EA,,748,523.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,636,RC,J0690,HCPCS,44567-707-25,NDC,facility,both,1,EA,,8227,5758.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-5755-23,NDC,facility,both,5,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"HYOSCYAMINE 0.125 MG TAB, RAPID DISSOLVE",50863,CDM,250,RC,J3490,HCPCS,42192-338-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLU VACCINE TS 2025-26 6 MO UP (PF) 45 MCG (15 MCG X 3)/0.5 ML IM SYRG,50863,CDM,250,RC,90656,HCPCS,58160-912-41,NDC,facility,both,1,ML,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0143-9334-01,NDC,facility,both,120,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL DECANOATE 100 MG/ML IM SOLN,50863,CDM,250,RC,J1631,HCPCS,70069-383-01,NDC,facility,both,3,ML,,297,207.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,500,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN IN 0.9 % NS 40 UNIT/100 ML (0.4 UNIT/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0338-9647-12,NDC,facility,both,2,ML,,1296,907.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NADOLOL  20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,76385-133-01,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-DYYB 100 MG IV SOLR,50863,CDM,636,RC,Q5103,HCPCS,0069-0809-01,NDC,facility,both,4,EA,JW,455,318.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LEVOTHYROXINE 112 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,42292-039-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 800 MG ORAL TAB,50863,CDM,250,RC,J0601,HCPCS,17856-921-01,NDC,facility,both,200,EA,,150,105,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,43547-282-10,NDC,facility,both,1,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60505-3111-0,NDC,facility,both,1,EA,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7007-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM SR 300 MG 24 HR CAP,50863,CDM,250,RC,J3490,HCPCS,50742-251-90,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASCORBIC ACID  250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,5026886011,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE  10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-037-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NYSTATIN  100000 UNIT/G TOP CREA,50863,CDM,636,RC,J3490,HCPCS,45802-059-35,NDC,facility,both,1,GM,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RACEPINEPHRINE 2.25 % INHL NEBU,50863,CDM,636,RC,J3490,HCPCS,0487-5901-99,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,636,RC,J3490,HCPCS,63323-185-08,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0093-4155-73,NDC,facility,both,36,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,0409-4887-17,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 150 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,0904-7084-61,NDC,facility,both,2,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0093-2279-73,NDC,facility,both,8,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0143-9509-01,NDC,facility,both,1,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,4,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,500,ML,,1816,1271.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"CALCIUM GLUC IN NACL, ISO-OSM 1 G/100 ML IV SOLN",50863,CDM,250,RC,J0613,HCPCS,44567-622-01,NDC,facility,both,300,ML,,223,156.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOBENZAPRINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-531-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUVOXAMINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60505-0165-1,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-279-11,NDC,facility,both,13,EA,,295,206.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR PHOSPHATE 30 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,47781-468-13,NDC,facility,both,2,EA,,139,97.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,72162-1329-8,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLN,50863,CDM,636,RC,J3262,HCPCS,50242-136-01,NDC,facility,both,400,ML,JZ,7331,5131.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
OXYMETAZOLINE 0.05 % NASAL MERGE,50863,CDM,250,RC,J3490,HCPCS,70677-1037-1,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE  10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69367-388-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,16714-294-01,NDC,facility,both,5,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MINERAL OIL,50863,CDM,250,RC,J3490,HCPCS,6332325410,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCERIN (ADULT) RECTAL SUPPOSITORY,50863,CDM,250,RC,J3490,HCPCS,0132-0079-12,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIROFIBAN-0.9% SODIUM CHLORIDE 5 MG/100 ML (50 MCG/ML) IV SOLN,50863,CDM,636,RC,J3246,HCPCS,25208-002-03,NDC,facility,both,20,ML,,398,278.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INDOMETHACIN 50 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,50268-431-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 7.5 MG-325 MG/15 ML ORAL SOLN (REPACK),50863,CDM,250,RC,J3490,HCPCS,0121-2316-15,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,250,RC,J0690,HCPCS,44567-707-25,NDC,facility,both,8,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,50863,CDM,250,RC,J9025,HCPCS,72485-201-01,NDC,facility,both,145,EA,,2057,1439.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0093-2279-73,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-492-04,NDC,facility,both,40,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MULTIVIT-MIN-IRON FUM-FOLIC AC 7.5 MG IRON-400 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,7985440050,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  10 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,68094-001-59,NDC,facility,both,2,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WHITE PETROLATUM TOPICAL GEL,50863,CDM,250,RC,J3490,HCPCS,0168-0053-45,NDC,facility,both,1,GM,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,250,RC,J3490,HCPCS,39822-1000-1,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-975-11,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR PHOSPHATE 75 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,64380-799-01,NDC,facility,both,2,EA,,152,106.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  500 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,68462-897-01,NDC,facility,both,20,ML,JA,214,149.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,70436-030-82,NDC,facility,both,64,ML,JW,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DEXTROSE 10% IN WATER (NEO) 2 - 3.99 KG,50863,CDM,250,RC,J3490,HCPCS,0264-7520-10,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,250,RC,J0137,HCPCS,55150-307-01,NDC,facility,both,100,ML,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,6,EA,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,636,RC,Q0162,HCPCS,68094-763-59,NDC,facility,both,4,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7048-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 10 MG/ML ORAL SOLUTION (REPACK),50863,CDM,250,RC,J3490,HCPCS,0131-5410-71,NDC,facility,both,2,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 0.1MG/ML SUSPENSION (REPACK),50863,CDM,636,RC,J3490,HCPCS,51079-882-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 160 MG-800 MG TAB,50863,CDM,636,RC,J3490,HCPCS,65862-420-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,10135-676-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,23,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR NEO/PEDS INFUSION (CDS FROM PREMIX),50863,CDM,636,RC,J0133,HCPCS,63323-325-10,NDC,facility,both,18,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MYCOPHENOLATE SODIUM 360 MG ORAL TBEC,50863,CDM,250,RC,J7518,HCPCS,0904-6786-61,NDC,facility,both,4,EA,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,50863,CDM,636,RC,J1885,HCPCS,63323-162-03,NDC,facility,both,2,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  20 MEQ ORAL PACK,50863,CDM,250,RC,J3490,HCPCS,69543-451-01,NDC,facility,both,3,EA,,158,110.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 2 MG/ML IN NS 50ML INFUSION (STOCK DOSE),50863,CDM,636,RC,J3490,HCPCS,0143-9508-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 2 MG/ML IN NS 50ML INFUSION (STOCK DOSE),50863,CDM,250,RC,J3490,HCPCS,0143-9508-01,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IVPB (PEDIATRICS/ADULT NON-FORM)",50863,CDM,636,RC,J0137,HCPCS,24201-100-01,NDC,facility,both,100,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 20 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,60687-725-11,NDC,facility,both,8,EA,,149,104.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IV PGBK,50863,CDM,250,RC,J3490,HCPCS,0338-1715-40,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOZAPINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-921-01,NDC,facility,both,4,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50580-501-30,NDC,facility,both,3,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,17,EA,JW,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0121-1781-05,NDC,facility,both,1,ML,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J2312,HCPCS,0641-6132-01,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-41,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,62332-600-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,76045-009-96,NDC,facility,both,10,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,67877-432-03,NDC,facility,both,2,EA,,272,190.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,0641-0400-37,NDC,facility,both,8,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACTIVATED CHARCOAL 25 GRAM/120 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0574-0521-74,NDC,facility,both,2,ML,,160,112,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLIMEPIRIDE 2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-359-11,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-1638-32,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0143-9386-01,NDC,facility,both,33,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG ORAL TAB,50863,CDM,250,RC,Q0169,HCPCS,0904-7304-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIFEDIPINE 10 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7229-61,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-6665-61,NDC,facility,both,2,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 100 MG 24 HR TAB,50863,CDM,636,RC,J3490,HCPCS,51079-171-01,NDC,facility,both,2,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-723-11,NDC,facility,both,1,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-48,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J7510,HCPCS,0121-0759-08,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,250,RC,J7999,HCPCS,70092-1017-46,NDC,facility,both,1,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,72205-101-01,NDC,facility,both,2,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"TRIMETHOPRIM-POLYMYXIN B 0.1 %-10,000 UNIT/ML EYE DROPS",50863,CDM,636,RC,J3490,HCPCS,61314-628-10,NDC,facility,both,1,ML,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,10019-033-39,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 650 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7261-61,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-208-01,NDC,,,facility,both,500,ML,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN LYSINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66993-490-84,NDC,facility,both,1,ML,,902,631.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,0121-4675-05,NDC,facility,both,2,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J7510,HCPCS,17856-0759-5,NDC,facility,both,3,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENOFIBRATE NANOCRYSTALLIZED 145 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-629-11,NDC,facility,both,1,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MISOPROSTOL 800 MCG (4 X 200 MCG TAB) PACKAGE,50863,CDM,636,RC,S0191,HCPCS,43393-023-04,NDC,facility,both,4,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-074-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,17271-701-05,NDC,facility,both,1,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMETHICONE 40 MG/0.6 ML ORAL DRPS,50863,CDM,250,RC,J3490,HCPCS,17856-1303-4,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SCOPOLAMINE TRANSDERMAL PATCH 1MG OVER 3 DAYS,50863,CDM,250,RC,J3490,HCPCS,50742-505-01,NDC,facility,both,1,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,42494-415-01,NDC,facility,both,2,ML,,257,179.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN 0.9 % SODIUM CHL 1.5 GRAM/500 ML IV SOLN,50863,CDM,636,RC,J3373,HCPCS,71506-016-59,NDC,facility,both,3,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6797-61,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"AMIODARONE IN DEXTROSE,ISO-OSM 360 MG/200 ML (1.8 MG/ML) IV SOLN",50863,CDM,250,RC,J0282,HCPCS,43066-360-20,NDC,facility,both,36,ML,,705,493.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROMETHORPHAN-GUAIFENESIN SR 30 MG-600 MG 12 HR TAB,50863,CDM,636,RC,J3490,HCPCS,17856-0056-1,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NAFCILLIN 10 GRAM INJ SOLR,50863,CDM,250,RC,J3490,HCPCS,55150-124-99,NDC,facility,both,1,EA,,497,347.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL,50863,CDM,250,RC,J3490,HCPCS,63323-820-01,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,250,RC,Q9968,HCPCS,70710-1838-1,NDC,facility,both,104,ML,,1718,1202.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COPPER 380 SQUARE MM IU IUD,50863,CDM,250,RC,J7300,HCPCS,59365-5128-1,NDC,facility,both,1,EA,,858,600.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIROLIMUS 1 MG ORAL TAB,50863,CDM,250,RC,J7520,HCPCS,50268-718-11,NDC,facility,both,2,EA,,224,156.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2598,HCPCS,43598-914-11,NDC,facility,both,16,ML,JW,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
MIDAZOLAM 1 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,23155-600-31,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 25 MG CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7237-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML INJECTION,50863,CDM,636,RC,J3411,HCPCS,0641-6228-01,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1815,HCPCS,0002-8215-01,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRIMIDONE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-686-11,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,50863,CDM,636,RC,J0696,HCPCS,0781-3208-85,NDC,facility,both,4,EA,,225,157.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,63323-185-07,NDC,facility,both,6,ML,,200,140,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE 10 MG ORAL TAB,50863,CDM,J3490,HCPCS,51079-986-01,NDC,,,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"HEPARIN, PORCINE (PF)   10 UNIT/ML IV SYRG",50863,CDM,J1642,HCPCS,6425322233,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,J1171,HCPCS,76045-009-01,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLNALTREXONE 12 MG/0.6 ML SUBQ SYRG,50863,CDM,J2212,HCPCS,65649-551-07,NDC,,,facility,both,120,ML,,735,514.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAZOSIN 2 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7021-61,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6869-61,NDC,facility,both,1,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-638-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,59762-0075-1,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,70095-031-01,NDC,facility,both,13,ML,,509,356.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,63739-931-28,NDC,facility,both,1,ML,,2482,1737.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTOBACILLUS ACIDOPH-PECTIN 75 MILLION CELL -100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,5789683701,NDC,facility,both,5,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN 125 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,51672-4069-1,NDC,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,31722-820-30,NDC,facility,both,3,EA,,409,286.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NS WITH POTASSIUM CHLORIDE 40 MEQ/L IV SOLP,50863,CDM,636,RC,J3490,HCPCS,0338-0695-04,NDC,facility,both,1,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLPIDEM  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6082-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 10 GRAM/15 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,50383-779-30,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NYSTATIN  100000 UNIT/G TOP CREA,50863,CDM,250,RC,J3490,HCPCS,51672-1289-1,NDC,facility,both,2,GM,,172,120.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,636,RC,J3490,HCPCS,71449-068-11,NDC,facility,both,4,ML,,138,96.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IV PGBK,50863,CDM,250,RC,J3490,HCPCS,0338-1715-40,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OFLOXACIN 0.3 % OPHT DROP,50863,CDM,636,RC,J3490,HCPCS,70756-607-30,NDC,facility,both,1,ML,,299,209.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,3,EA,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6172-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0406-0512-23,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  60 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,42858-803-01,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHIMAZOLE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-680-11,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXRAZOXANE 500 MG IV SOLR,50863,CDM,250,RC,J1190,HCPCS,55150-435-01,NDC,facility,both,2,EA,,1301,910.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,66794-229-02,NDC,facility,both,2,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DORZOLAMIDE 2 % OPHT DROP,50863,CDM,250,RC,J3490,HCPCS,24208-485-10,NDC,facility,both,1,ML,,225,157.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM 1 GRAM IV SOLR,50863,CDM,636,RC,J2185,HCPCS,63323-508-01,NDC,facility,both,10,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7057-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0456,HCPCS,70095-025-01,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOVASTATIN 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68180-468-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5%-1/2 NORMAL SALINE IV,50863,CDM,250,RC,J7042,HCPCS,0338-0085-03,NDC,facility,both,2,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,0904-6794-30,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,25021-321-10,NDC,facility,both,10,ML,,183,128.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXRAZOXANE 500 MG IV SOLR,50863,CDM,250,RC,J1190,HCPCS,55150-435-01,NDC,facility,both,4,EA,,2983,2088.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE  7.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-584-11,NDC,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTAZIDIME NEO IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0713,HCPCS,0781-3177-80,NDC,facility,both,1,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 50 MG 24 HR TAB,50863,CDM,636,RC,J3490,HCPCS,50268-541-11,NDC,facility,both,6,EA,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEMANTINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6506-06,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,24658-141-30,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,64980-562-01,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,150,EA,,367,256.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL,50863,CDM,250,RC,J3490,HCPCS,63323-820-01,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1817,HCPCS,0169-1833-11,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60505-3111-0,NDC,facility,both,1,EA,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROPHILLIC OINTMENT (AQUAPHOR),50863,CDM,250,RC,J3490,HCPCS,7214003147,NDC,facility,both,1,GM,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN STERILE WATER 2 GRAM/20 ML IV SYRG,50863,CDM,636,RC,J7999,HCPCS,70092-1238-47,NDC,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCUSATE SODIUM 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7183-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN IN D5W 400 MG/200 ML IV PGBK,50863,CDM,636,RC,J0744,HCPCS,25021-192-87,NDC,facility,both,4,ML,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,0121-0657-05,NDC,facility,both,4,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIMOLOL MALEATE 0.5 % OPHT DROP,50863,CDM,J3490,HCPCS,64980-514-05,NDC,,,facility,both,1,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOBUTAMINE IN D5W 500 MG/250 ML (2 MG/ML) INFUSION (PREMIX),50863,CDM,250,RC,J1250,HCPCS,0409-2347-31,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,50863,CDM,250,RC,J9025,HCPCS,72485-201-01,NDC,facility,both,43,EA,JW,267,186.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GABAPENTIN 300 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,63739-903-10,NDC,facility,both,9,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,J7030,HCPCS,0338-0049-04,NDC,,,facility,both,2,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETIRIZINE 10 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-6717-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) IV SOLN,50863,CDM,636,RC,J9201,HCPCS,0409-0181-01,NDC,facility,both,5,ML,JZ,231,161.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LEVETIRACETAM IN NACL (ISO-OS) 1500 MG/100 ML IV PGBK,50863,CDM,J1953,HCPCS,44567-503-01,NDC,,,facility,both,300,ML,,178,124.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYMETAZOLINE 0.05 % NASAL MERGE,50863,CDM,J3490,HCPCS,45802-410-59,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYTOCIN IN 0.9 % SOD CHLORIDE 30 UNIT/500 ML IV SOLN,50863,CDM,250,RC,J2590,HCPCS,70092-1552-07,NDC,facility,both,9,ML,,837,585.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-464-11,NDC,facility,both,4,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN SODIUM EXTENDED 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,65862-692-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RASBURICASE 1.5 MG IV SOLR,50863,CDM,250,RC,J2783,HCPCS,0024-5154-11,NDC,facility,both,6,EA,JZ,5758,4030.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DOCUSATE SODIUM 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,57896-401-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7263-61,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,25021-131-82,NDC,facility,both,50,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
BUDESONIDE 0.5 MG/2 ML INHL NBSP,50863,CDM,250,RC,J3490,HCPCS,0487-9701-01,NDC,facility,both,1,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMETHICONE 40MG/0.6ML (0.6ML-UD) SYRINGE (REPACK),50863,CDM,250,RC,J3490,HCPCS,17856-0799-4,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0295,HCPCS,63323-368-20,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORHEXIDINE GLUCONATE  0.12 % MM MWSH,50863,CDM,250,RC,J3490,HCPCS,0121-0893-15,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NELARABINE 250 MG/50 ML IV SOLN (PEDS ONCOLOGY),50863,CDM,250,RC,J9261,HCPCS,71288-165-52,NDC,facility,both,20,ML,,7298,5108.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-444-11,NDC,facility,both,3,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,636,RC,J2405,HCPCS,63323-373-02,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-9543-02,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 12.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7307-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-4827-05,NDC,facility,both,3,ML,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,72603-251-01,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTAROLINE FOSAMIL 600 MG IV SOLR,50863,CDM,250,RC,J0712,HCPCS,0456-0600-01,NDC,facility,both,30,EA,JW,155,108.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,199,ML,,141,98.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-3178-01,NDC,facility,both,85,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 500 MG/10 ML IV SOLN,50863,CDM,250,RC,J9190,HCPCS,63323-117-01,NDC,facility,both,4,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,63323-185-07,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  1 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,64380-782-06,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,43598-053-11,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-05,NDC,facility,both,4,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,5789686406,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXAZOSIN 4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-224-11,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 125 MG/5 ML (25MG/ML) ORAL SYRINGE (REPACK),50863,CDM,636,RC,J3373,HCPCS,67457-340-00,NDC,facility,both,100,EA,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 2 % TD OINT,50863,CDM,250,RC,J3490,HCPCS,0281-0326-08,NDC,facility,both,2,GM,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0264-7800-00,NDC,facility,both,2,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID 1000 MG/10 ML FOR NEBULIZATION,50863,CDM,250,RC,J3490,HCPCS,83634-401-41,NDC,facility,both,5,ML,,193,135.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOLIC ACID 400 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,5026834611,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCROFERRIC OXYHYDROXIDE 500 MG ORAL CHEW,50863,CDM,250,RC,J0605,HCPCS,49230-645-51,NDC,facility,both,100,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  15 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,0406-8315-23,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON DEXTRAN 50 MG/ML INJ SOLN,50863,CDM,636,RC,J1750,HCPCS,0023-6082-01,NDC,facility,both,15,ML,,1641,1148.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM IN NACL (ISO-OS) 1000 MG/100 ML IV PGBK,50863,CDM,250,RC,J1953,HCPCS,44567-502-01,NDC,facility,both,200,ML,,131,91.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WHITE PETROLATUM-MINERAL OIL 57.3-42.5 % OPHT OINT,50863,CDM,250,RC,J3490,HCPCS,0023-0240-04,NDC,facility,both,1,GM,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,410,ME,JZ,5564,3894.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,68094-231-59,NDC,facility,both,3,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TERAZOSIN  1 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,50268-764-11,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXEPIN  50 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,51079-438-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL (NEO/PEDS),50863,CDM,250,RC,J3490,HCPCS,63323-820-00,NDC,facility,both,1,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALTREXONE MICROSPHERES 380 MG IM SERR,50863,CDM,636,RC,J2315,HCPCS,65757-300-01,NDC,facility,both,380,EA,JZ,4666,3266.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
HYDROXYZINE 50 MG/ML IM,50863,CDM,250,RC,J3410,HCPCS,0517-5601-25,NDC,facility,both,2,ML,,182,127.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-497-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68180-966-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEMAZEPAM  7.5 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0406-9960-01,NDC,facility,both,2,EA,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VERAPAMIL 120 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,75834-320-01,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM IN NACL (ISO-OS) 1500 MG/100 ML IV PGBK,50863,CDM,636,RC,J1953,HCPCS,43598-637-52,NDC,facility,both,300,ML,,470,329,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J0461,HCPCS,0517-0401-25,NDC,facility,both,30,ML,JW,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
OLANZAPINE 10 MG IM SOLR,50863,CDM,250,RC,J2359,HCPCS,0781-3159-72,NDC,facility,both,5,EA,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,63323-161-00,NDC,facility,both,1,ML,JZ,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
INSULIN DEGLUDEC 100 UNITS/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,0169-2662-11,NDC,facility,both,1,ML,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,636,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-985-01,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,60687-145-11,NDC,facility,both,20,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALSARTAN  80 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,33342-063-10,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,636,RC,J3490,HCPCS,0904-6794-30,NDC,facility,both,5,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE (POLACRILEX) 4 MG BUCL GUM,50863,CDM,636,RC,J3490,HCPCS,0536-1372-06,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,0641-6145-01,NDC,facility,both,3,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2599,HCPCS,65219-039-00,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRIL MALEATE 1 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,69238-1729-7,NDC,facility,both,1,ML,,140,98,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,250,RC,J0690,HCPCS,70092-1017-46,NDC,facility,both,20,ML,,396,277.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL  32.4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6575-61,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,2,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,57237-184-90,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,250,RC,J2405,HCPCS,23155-549-31,NDC,facility,both,12,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEMAZEPAM 15 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,50268-779-11,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLP,50863,CDM,250,RC,J3480,HCPCS,63323-965-03,NDC,facility,both,20,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAPAVERINE 30 MG/ML INJ SOLN,50863,CDM,250,RC,J2440,HCPCS,0517-4010-01,NDC,facility,both,10,ML,,294,205.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEXILETINE 150 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-778-11,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN IN D5W 600 MG/50 ML IV PGBK,50863,CDM,636,RC,J0736,HCPCS,0338-3612-50,NDC,facility,both,4,ML,,126,88.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,13,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 50 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,59651-489-01,NDC,facility,both,49,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LITHIUM CARBONATE 300 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0054-8527-25,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-1159-09,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BISMUTH SUBSALICYLATE 262 MG ORAL CHEW,50863,CDM,636,RC,J3490,HCPCS,0904-7205-46,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-103-01,NDC,facility,both,3,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,2,EA,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DILTIAZEM SR 60 MG 12 HR CAP,50863,CDM,250,RC,J3490,HCPCS,0378-6060-01,NDC,facility,both,1,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,50863,CDM,250,RC,J0640,HCPCS,0143-9554-01,NDC,facility,both,2,EA,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,636,RC,J2003,HCPCS,0409-1323-05,NDC,facility,both,200,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLEDRONIC ACID 4 MG/5 ML IV SOLN,50863,CDM,250,RC,J3489,HCPCS,67457-390-54,NDC,facility,both,4,ML,,224,156.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN D5W 1 GRAM/200 ML IV PGBK,50863,CDM,250,RC,J3373,HCPCS,0338-3552-48,NDC,facility,both,100,ML,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 500 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,50268-152-11,NDC,facility,both,28,EA,,168,117.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,636,RC,J2003,HCPCS,76329-3390-1,NDC,facility,both,10,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MOXIFLOXACIN 400 MG/250 ML IVPB PREMIX (MERGE),50863,CDM,250,RC,J2280,HCPCS,67457-323-25,NDC,facility,both,8,ML,,467,326.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRP (MERGE/REPACK),50863,CDM,250,RC,J3490,HCPCS,60687-576-40,NDC,facility,both,1,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZONATATE 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7153-61,NDC,facility,both,6,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68382-806-01,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) IV SOLN,50863,CDM,636,RC,J9201,HCPCS,0409-0181-01,NDC,facility,both,5,ML,,231,161.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J2004,HCPCS,63323-482-03,NDC,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODINE STRONG (LUGOLS) 5 % ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,48433-230-15,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE (FOR CODE) 10% (100 MG/ML) IV SYRINGE,50863,CDM,250,RC,J3490,HCPCS,0409-1631-40,NDC,facility,both,3,ML,,223,156.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-105-11,NDC,facility,both,2,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,65862-707-80,NDC,facility,both,22,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,105,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  88 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-486-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,636,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,11,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IPRATROPIUM BROMIDE 0.02 % INHL SOLN,50863,CDM,250,RC,J3490,HCPCS,60687-394-79,NDC,facility,both,3,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,5,ML,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 1 MG/ML (1ML) SYRINGE (REPACK),50863,CDM,250,RC,J2997,HCPCS,50242-044-13,NDC,facility,both,10,EA,,2429,1700.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6500-06,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,71288-414-01,NDC,facility,both,4,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE  5 MG/ML INJ SOLN,50863,CDM,J2765,HCPCS,0409-3414-18,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-492-09,NDC,,,facility,both,200,ML,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,68094-231-59,NDC,facility,both,1,ML,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,J3490,HCPCS,0904-6794-30,NDC,,,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9% IV (PEDS) BOLUS,50863,CDM,636,RC,J7040,HCPCS,0264-7800-09,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,0409-4279-02,NDC,,,facility,both,300,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FILGRASTIM-SNDZ 300 MCG/0.5 ML INJ SYRG,50863,CDM,Q5101,HCPCS,61314-318-01,NDC,,,facility,both,300,ML,,972,680.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,J1885,HCPCS,0409-3795-01,NDC,,,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-598-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,4,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYBUTYNIN CHLORIDE  5 MG ORAL TO24,50863,CDM,636,RC,J3490,HCPCS,0904-6570-61,NDC,facility,both,2,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEMANTINE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6505-61,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-1159-19,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLECAINIDE 20MG/ML SUSPENSION (REPACK),50863,CDM,250,RC,J3490,HCPCS,0054-0011-25,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE  25 MG ORAL CAP,50863,CDM,250,RC,J8530,HCPCS,62332-618-31,NDC,facility,both,1,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOCARNITINE 200 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0143-9852-01,NDC,facility,both,3,ML,,628,439.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 20MG/ML IV SYRINGE (PEDS/NEO),50863,CDM,250,RC,J0612,HCPCS,63323-311-10,NDC,facility,both,25,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % MUCOSAL SOLN (VISCOUS),50863,CDM,250,RC,J3490,HCPCS,50383-363-15,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6292-06,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-173-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN  4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51672-4031-1,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J3430,HCPCS,69097-708-31,NDC,facility,both,5,ML,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7030,HCPCS,0338-0049-04,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  75 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-475-11,NDC,facility,both,2,EA,PLAD,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-0710-20,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,16714-026-10,NDC,facility,both,6,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-590-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 150 MG CAP,50863,CDM,250,RC,J3490,HCPCS,68084-243-11,NDC,facility,both,40,EA,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1815,HCPCS,0169-1833-11,NDC,facility,both,320,ML,,393,275.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2599,HCPCS,55150-370-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0121-0914-05,NDC,facility,both,8,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,50863,CDM,636,RC,J1756,HCPCS,0517-2340-10,NDC,facility,both,200,ML,JZ,642,449.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DOXYCYCLINE HYCLATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-0430-06,NDC,facility,both,12,EA,,154,107.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J2003,HCPCS,0409-4713-32,NDC,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROTHIAZIDE SODIUM 500 MG IV SOLR,50863,CDM,250,RC,J1205,HCPCS,0517-1820-01,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,10702-018-01,NDC,facility,both,8,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 10 MG-325 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0406-0125-23,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0121-1781-05,NDC,facility,both,4,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,250,RC,J3490,HCPCS,73013-2002-2,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RALTEGRAVIR 400 MG ORAL TAB,50863,CDM,J3490,HCPCS,0006-0227-61,NDC,,,facility,both,1,EA,,196,137.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,25021-321-04,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7050,HCPCS,0338-0049-02,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESMOLOL  100 MG/10 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,55150-194-10,NDC,facility,both,1,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,9,EA,JW,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,636,RC,J7510,HCPCS,17856-0815-1,NDC,facility,both,7,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DENOSUMAB 60 MG/ML SUBQ SYRG,50863,CDM,250,RC,J0897,HCPCS,55513-710-01,NDC,facility,both,60,ML,JZ,4930,3451,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
METHYL SALICYLATE-MENTHOL 15 %-10 % TOPICAL CREAM,50863,CDM,636,RC,J3490,HCPCS,0536-1349-57,NDC,facility,both,1,GM,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,2,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,250,RC,J0137,HCPCS,0264-4100-90,NDC,facility,both,7,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL IV BOLUS 10MG/ML (ANESTHESIA ONLY),50863,CDM,636,RC,J2704,HCPCS,63323-269-29,NDC,facility,both,20,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOMIPRAMINE 50 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,16571-684-03,NDC,facility,both,1,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLN,50863,CDM,250,RC,J3262,HCPCS,50242-137-01,NDC,facility,both,800,ML,JA,14661,10262.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
LEVETIRACETAM IN NACL (ISO-OS) 1500 MG/100 ML IV PGBK,50863,CDM,J1953,HCPCS,44567-503-01,NDC,,,facility,both,150,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7030,HCPCS,0338-0049-04,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROATE SODIUM 100 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0143-9785-01,NDC,facility,both,2,ML,,203,142.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) NEB SOLUTION,50863,CDM,250,RC,J3490,HCPCS,60687-395-79,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-103-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7030,HCPCS,0338-0049-04,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIFEDIPINE 10 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,23155-194-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  75 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-441-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-638-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SOTALOL  80 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,76385-114-01,NDC,facility,both,2,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,67457-385-10,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAROMOMYCIN 250 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,80725-250-01,NDC,facility,both,2,EA,,761,532.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-4799-05,NDC,facility,both,4,ML,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE (FOR EMERGENCY) 100 MG/ML (10%) IV SOLN,50863,CDM,250,RC,J0612,HCPCS,63323-360-19,NDC,facility,both,100,ML,JZ,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ROPINIROLE  1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-588-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLIPIZIDE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0591-0460-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 40 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,27808-158-01,NDC,facility,both,1,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE  2.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0555-0872-02,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN PEDS INFUSION (CDS MIXTURE),50863,CDM,250,RC,J0290,HCPCS,25021-136-10,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0093-4127-73,NDC,facility,both,5,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML (PEDS CALCLUATOR 0.5),50863,CDM,250,RC,J1815,HCPCS,0024-5924-10,NDC,facility,both,9,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,200,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
NITROPRUSSIDE 25 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,70069-261-01,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION,50863,CDM,636,RC,J3490,HCPCS,0186-0372-28,NDC,facility,both,2,GM,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CITRATE 10 MEQ ORAL TBER,50863,CDM,636,RC,J3490,HCPCS,68084-850-33,NDC,facility,both,2,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,0409-9094-22,NDC,facility,both,2,ML,JZ,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CHOLECALCIFEROL 400 UNIT/ML ORAL DROP (REPACK),50863,CDM,250,RC,J3490,HCPCS,87086644,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-442-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,48,ML,JW,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-0710-20,NDC,facility,both,12,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BETAMETHASONE ACET & SOD PHOS 6 MG/ML INJ SUSP,50863,CDM,636,RC,J0702,HCPCS,78206-118-01,NDC,facility,both,2,ML,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE 25 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,62135-417-46,NDC,facility,both,1,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 2 MG/10 ML (200 MCG/ML) IN D5W VIAL-CVL/IR USE (REPACK),50863,CDM,250,RC,J3490,HCPCS,0338-1049-02,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 250 MG INJ SOLR,50863,CDM,J0696,HCPCS,0409-7337-11,NDC,,,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  100 MCG/ML INJ SOLN,50863,CDM,J2354,HCPCS,63323-376-00,NDC,,,facility,both,2,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE  5 % OPHT DROP,50863,CDM,636,RC,J3490,HCPCS,0536-1254-94,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMINOCAPROIC ACID 250 MG/ML IV SOLN,50863,CDM,J3490,HCPCS,0517-9120-01,NDC,,,facility,both,1,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J7510,HCPCS,17856-0759-5,NDC,facility,both,6,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,250,RC,J2270,HCPCS,0641-6125-01,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML IV,50863,CDM,636,RC,J3490,HCPCS,55150-425-01,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMOSOZUMAB-AQQG 210MG/2.34ML ( 105MG/1.17MLX2) SUBQ SYRG,50863,CDM,636,RC,J3111,HCPCS,55513-998-02,NDC,facility,both,210,ML,JZ,5893,4125.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,636,RC,J3490,HCPCS,59310-579-20,NDC,facility,both,1,GM,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML IM SOLN,50863,CDM,636,RC,90375,HCPCS,13533-318-05,NDC,facility,both,10,ML,,8231,5761.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LET TOPICAL GEL 3 ML,50863,CDM,636,RC,J3490,HCPCS,70092-1611-44,NDC,facility,both,2,ML,,108,75.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPLERENONE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,59762-1710-2,NDC,facility,both,2,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 50 MG/ML IV SOLN,50863,CDM,250,RC,J0282,HCPCS,0143-9875-25,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,636,RC,J7999,HCPCS,70092-1017-46,NDC,facility,both,4,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,15,EA,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 0.5 MG ORAL CAP,50863,CDM,636,RC,J7507,HCPCS,0904-6623-61,NDC,facility,both,2,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN PEDS SYRINGE (20MG/ML) IN DEXTROSE (CDS MIX,50863,CDM,636,RC,J0690,HCPCS,0781-3451-70,NDC,facility,both,6,EA,,155,108.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,500,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6370-61,NDC,facility,both,4,EA,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J1611,HCPCS,0597-0053-45,NDC,facility,both,1,EA,JZ,742,519.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3370,HCPCS,63323-284-01,NDC,facility,both,2,EA,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ANTI-INHIBITOR COAGULANT CMPLX 1,750-3,250 UNIT IV SOLR",50863,CDM,250,RC,J7198,HCPCS,64193-425-02,NDC,facility,both,725,UN,JW,1878,1314.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
THYROID (PORK)  30 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,62559-741-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESMOLOL  100 MG/10 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-652-10,NDC,facility,both,2,ML,,185,129.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNIT/G TOP PACK,50863,CDM,636,RC,J3490,HCPCS,45802-060-70,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,636,RC,J0330,HCPCS,31722-981-10,NDC,facility,both,3,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HUMAN PROTHROMBIN COMPLEX 500 UNIT IV SOLR,50863,CDM,J7168,HCPCS,63833-396-01,NDC,,,facility,both,1500,UN,,8729,6110.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"RHO(D) IMMUNE GLOBULIN (RHOPHYLAC) 1,500 UNIT (300 MCG)/2 ML INJ SYRG",50863,CDM,J2791,HCPCS,44206-300-01,NDC,,,facility,both,1,ML,,693,485.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 100 MG PE/2 ML INJ SOLN,50863,CDM,250,RC,Q2009,HCPCS,0641-6136-01,NDC,facility,both,3,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SYRG,50863,CDM,J3490,HCPCS,8290306553,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 250 MG/50 ML CONCENTRATED DRIP (RSE),50863,CDM,250,RC,J2250,HCPCS,0641-6060-01,NDC,facility,both,500,ML,,352,246.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 500 MG SOLUTION FOR INJECTION,50863,CDM,250,RC,J2919,HCPCS,0009-0758-01,NDC,facility,both,100,EA,,143,100.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,J3490,HCPCS,0338-0049-31,NDC,,,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,43598-931-11,NDC,facility,both,2,ML,JW,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IPRATROPIUM BROMIDE 17 MCG/ACTUATION INHL AERO,50863,CDM,250,RC,J3490,HCPCS,0597-0087-17,NDC,facility,both,1,GM,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),50863,CDM,250,RC,J1630,HCPCS,76045-737-01,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,J1836,HCPCS,0409-0152-01,NDC,,,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0143-9889-15,NDC,facility,both,19,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"HEPARIN, PORCINE (PF)   10 UNIT/ML IV SYRG",50863,CDM,250,RC,J1642,HCPCS,6425322223,NDC,facility,both,3,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,250,RC,J2720,HCPCS,63323-229-01,NDC,facility,both,15,ML,,273,191.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6869-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 10 GRAM IV SOLR,50863,CDM,250,RC,J3373,HCPCS,70436-023-82,NDC,facility,both,175,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16714-172-01,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,70010-754-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,636,RC,J2003,HCPCS,0409-1323-15,NDC,facility,both,100,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 20 GRAM/30 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-1154-30,NDC,facility,both,2,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CODEINE-GUAIFENESIN 10-100 MG/5 ML ORAL LIQD (REPACK),50863,CDM,636,RC,J3490,HCPCS,0603-1075-58,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,0088-2220-33,NDC,facility,both,16,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV (BOLUS),50863,CDM,250,RC,J7040,HCPCS,0338-6304-02,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NOREPINEPHRINE BITARTRATE-D5W 4 MG/250 ML (16 MCG/ML) IV SOLN,50863,CDM,J3490,HCPCS,72196-6056-1,NDC,,,facility,both,1,ML,,129,90.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,636,RC,J2560,HCPCS,72162-1330-6,NDC,facility,both,1,ML,,138,96.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-48,NDC,facility,both,1,ML,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,63323-806-13,NDC,facility,both,3,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOLIC ACID  1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7224-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CONJUGATED ESTROGENS 0.625 MG/G VAGL CREA,50863,CDM,250,RC,J3490,HCPCS,0046-0872-21,NDC,facility,both,1,GM,,1243,870.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,63323-165-01,NDC,facility,both,5,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 80 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6293-04,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IR SOLN,50863,CDM,636,RC,J3490,HCPCS,0338-0047-46,NDC,facility,both,8,ML,,416,291.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/0.5 ML INHL NEBU,50863,CDM,636,RC,J3490,HCPCS,0487-9901-30,NDC,facility,both,4,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN IN SALINE (ISO-OSMOTIC) 100 MG/50 ML IV PIGGY BACK,50863,CDM,250,RC,J1580,HCPCS,0338-0511-41,NDC,facility,both,2,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 10 GRAM IV SOLR,50863,CDM,250,RC,J3373,HCPCS,70436-023-82,NDC,facility,both,150,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,29300-135-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-18,NDC,facility,both,300,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLOPATADINE 0.1 % OPHT DROP,50863,CDM,636,RC,J3490,HCPCS,58602-006-40,NDC,facility,both,1,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25%/EPINEPHRINE 1:100K INJECTION,50863,CDM,250,RC,J3490,HCPCS,0409-1158-01,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,63739-931-14,NDC,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2310,HCPCS,0409-1219-41,NDC,facility,both,8,ML,,1026,718.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,250,RC,J3490,HCPCS,0173-0682-20,NDC,facility,both,1,GM,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM 1 GRAM IV SOLR,50863,CDM,250,RC,J2185,HCPCS,63323-508-01,NDC,facility,both,20,EA,JZ,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) IV SOLN,50863,CDM,636,RC,J9201,HCPCS,67457-617-30,NDC,facility,both,10,ML,,471,329.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOMIPRAMINE 25 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,51672-4011-6,NDC,facility,both,3,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 150 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6956-61,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,23,EA,,3174,2221.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-11,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE DINITRATE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6619-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-ABDA 100 MG IV SOLR,50863,CDM,636,RC,Q5104,HCPCS,78206-162-99,NDC,facility,both,8,EA,JW,724,506.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,17271-701-05,NDC,facility,both,1,ML,JZ,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CARVEDILOL 25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-932-01,NDC,facility,both,2,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,250,RC,J0330,HCPCS,0409-6629-02,NDC,facility,both,8,ML,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,70069-363-01,NDC,facility,both,1,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML INJ SOLN,50863,CDM,J2250,HCPCS,0641-6057-01,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR 200 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,72578-002-01,NDC,facility,both,1,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 125 MCG SUBQ SOLR,50863,CDM,J2802,HCPCS,55513-223-01,NDC,,,facility,both,125,EA,,2565,1795.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMANTADINE 100 MG ORAL CAP,50863,CDM,J3490,HCPCS,0832-1015-00,NDC,,,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4% TOP PATCH,50863,CDM,J3490,HCPCS,46581-830-06,NDC,,,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,J3490,HCPCS,0143-9889-15,NDC,,,facility,both,150,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE IV",50863,CDM,J3490,HCPCS,0338-0013-04,NDC,,,facility,both,1,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,150,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE (FOR CODE) 10% IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0517-6710-01,NDC,facility,both,3,ML,,356,249.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-454-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES-DOCUSATE SODIUM 8.6 MG-50 MG TAB,50863,CDM,250,RC,J3490,HCPCS,60687-622-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESNA 100 MG/ML IV SOLN,50863,CDM,636,RC,J9209,HCPCS,10019-953-62,NDC,facility,both,3,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE (PF) 1 MG/ML INJ SOLN,50863,CDM,636,RC,J0171,HCPCS,54288-103-01,NDC,facility,both,90,ML,,771,539.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) IV SOLN,50863,CDM,636,RC,J9201,HCPCS,0409-0181-01,NDC,facility,both,10,ML,JZ,462,323.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-3178-01,NDC,facility,both,300,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LURASIDONE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,67877-638-30,NDC,facility,both,6,EA,,904,632.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEFIBROTIDE 80 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,68727-800-01,NDC,facility,both,2,ML,,3530,2471,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TORSEMIDE  20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-539-11,NDC,facility,both,4,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  15 MG ORAL TBSR,50863,CDM,636,RC,J3490,HCPCS,68084-157-11,NDC,facility,both,2,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEDIATRIC MULTIVITAMIN NO.192 250 MCG-50 MG- 10 MCG/ML ORAL DROP,50863,CDM,250,RC,J3490,HCPCS,87040203,NDC,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 7.5 MG-325 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0406-0124-23,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 0.5 MG/ML ORAL SUSPENSION (REPACK),50863,CDM,250,RC,J7507,HCPCS,51079-028-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,636,RC,J3010,HCPCS,0409-9094-12,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXAZOSIN 8 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68382-786-01,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOBRAMYCIN 1.2 G POWDER VIAL,50863,CDM,250,RC,J3260,HCPCS,39822-0412-6,NDC,facility,both,2,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1817,HCPCS,0169-1833-11,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-1638-32,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-098-11,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALPHA-1-PROTEINASE INHIBITOR (HUMAN) 1,000 MG IV SUSP (PROLASTIN-C)",50863,CDM,636,RC,J0256,HCPCS,13533-700-01,NDC,facility,both,415,ME,,5877,4113.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2305-04,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,636,RC,J3010,HCPCS,0409-9094-12,NDC,facility,both,1,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CALCIUM CITRATE-VITAMIN D3 200 MG CALCIUM -250 UNIT ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,536322301,NDC,facility,both,5,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOPIDOGREL  75 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-052-03,NDC,facility,both,1,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,16714-036-01,NDC,facility,both,8,ML,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60505-3113-0,NDC,facility,both,1,EA,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 800 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-5855-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,10702-018-01,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPHENIDATE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16729-478-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN IN 0.9 % NS 40 UNIT/100 ML (0.4 UNIT/ML) IV SOLN,50863,CDM,250,RC,J2601,HCPCS,0338-9647-12,NDC,facility,both,20,ML,,382,267.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,110,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INDIGOTINDISULFONATE SODIUM 8 MG/ML INJ SOLN,50863,CDM,J9920,HCPCS,17478-508-01,NDC,,,facility,both,80,ML,,131,91.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25%/EPINEPHRINE 1:100K INJECTION,50863,CDM,636,RC,J3490,HCPCS,0409-1158-01,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NAFCILLIN NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J3490,HCPCS,63323-327-10,NDC,facility,both,8,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GANCICLOVIR 500 MG IV SOLUTION,50863,CDM,250,RC,J1570,HCPCS,70436-089-55,NDC,facility,both,1,EA,,121,84.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GANCICLOVIR 500 MG IV SOLUTION,50863,CDM,250,RC,J1570,HCPCS,70436-089-55,NDC,facility,both,1,EA,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TUBERCULIN PPD 5 UNIT/0.1 ML IDRM SOLN,50863,CDM,250,RC,J3490,HCPCS,49281-752-21,NDC,facility,both,1,ML,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML IV,50863,CDM,636,RC,J3490,HCPCS,25021-319-05,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2598,HCPCS,43598-914-06,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6926-61,NDC,facility,both,3,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6665-61,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COSYNTROPIN 0.25 MG INJ SOLR,50863,CDM,250,RC,J0834,HCPCS,0781-3440-71,NDC,facility,both,1,EA,,205,143.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,51079-169-01,NDC,facility,both,3,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,42806-150-33,NDC,facility,both,4,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-9791-01,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,250,RC,J3360,HCPCS,76045-204-00,NDC,facility,both,4,ML,,289,202.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,250,RC,J2795,HCPCS,43066-023-01,NDC,facility,both,300,ML,,107,74.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,50863,CDM,636,RC,J3420,HCPCS,69680-112-01,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COLCHICINE 0.6 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7120-04,NDC,facility,both,1,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTAZIDIME NEO IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0713,HCPCS,0781-3177-80,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE  50 MG ORAL TAB,50863,CDM,636,RC,j3490,HCPCS,50111-560-01,NDC,facility,both,3,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,1,EA,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 500 MG/10 ML IV SOLN,50863,CDM,250,RC,J9190,HCPCS,63323-117-01,NDC,facility,both,4,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J2003,HCPCS,0409-4279-02,NDC,facility,both,30,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,50863,CDM,250,RC,J1756,HCPCS,0517-2340-01,NDC,facility,both,100,ML,,321,224.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 1 GRAM INJ SOLR,50863,CDM,250,RC,J0692,HCPCS,0409-0219-01,NDC,facility,both,4,EA,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ESMOLOL IN SALINE (ISO-OSMOTIC) 2,000 MG/100 ML (20 MG/ML) IV",50863,CDM,636,RC,J1805,HCPCS,25021-309-82,NDC,facility,both,1,ML,,648,453.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL (5 MG/ML) IV SYRG (CONTAINS PRESERVATIVE),50863,CDM,250,RC,J3490,HCPCS,65302-503-04,NDC,facility,both,2,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 25% IN WATER (NEO),50863,CDM,250,RC,J3490,HCPCS,99999-0402-06,NDC,facility,both,1,ML,,150,105,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,50863,CDM,636,RC,Q0177,HCPCS,10702-011-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  500 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,63323-377-00,NDC,facility,both,20,ML,JA,253,177.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
SEVELAMER CARBONATE 0.8 GRAM ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,65862-930-08,NDC,facility,both,2,EA,,179,125.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,636,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,12,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WHITE PETROLATUM TOP OIPK,50863,CDM,250,RC,J3490,HCPCS,8452100686,NDC,facility,both,1,GM,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 3000 MCG/ML INJECTION,50863,CDM,636,RC,J0153,HCPCS,63323-651-00,NDC,facility,both,6,ML,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,50863,CDM,250,RC,J9025,HCPCS,72485-201-01,NDC,facility,both,35,EA,JW,221,154.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
"ALBUMIN, HUMAN 25 % IV SOLN (MERGE)",50863,CDM,636,RC,P9047,HCPCS,64208-2512-8,NDC,facility,both,2,ML,JZ,238,166.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
RALOXIFENE 60 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-694-11,NDC,facility,both,1,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 5 % TOP OINT,50863,CDM,250,RC,J3490,HCPCS,16714-878-01,NDC,facility,both,1,GM,,803,562.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,636,RC,J3490,HCPCS,63037-136-25,NDC,facility,both,2,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BETAMETHASONE ACET & SOD PHOS 6 MG/ML INJ SUSP,50863,CDM,250,RC,J0702,HCPCS,78206-118-01,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,0338-0069-10,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN   81 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,0536-1234-41,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC IV INFUSION HYDRAT 31-60 MIN,50863,CDM,250,RC,J0248,HCPCS,61958-2901-2,NDC,facility,both,48,EA,JW,254,177.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2308-22,NDC,facility,both,4,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
OXALIPLATIN 100 MG/20 ML IV SOLN,50863,CDM,J9263,HCPCS,71288-171-11,NDC,,,facility,both,100,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIOTHYRONINE  5 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-2179-01,NDC,facility,both,3,EA,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,63323-165-01,NDC,facility,both,1,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,16714-293-01,NDC,facility,both,2,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 50% IN WATER (MERGE RECORD),50863,CDM,250,RC,J7060,HCPCS,76329-3302-1,NDC,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 20 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,68180-294-07,NDC,facility,both,4,EA,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-098-10,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,250,RC,J3490,HCPCS,59310-579-22,NDC,facility,both,1,GM,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB 100 MG IV SOLR,50863,CDM,J1745,HCPCS,57894-160-01,NDC,,,facility,both,33,EA,,4327,3028.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPILIMUMAB 50 MG/10 ML (5 MG/ML) IV SOLN,50863,CDM,J9228,HCPCS,0003-2327-11,NDC,,,facility,both,150,ML,,55965,39175.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,0088-2220-33,NDC,facility,both,9,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,0088-2220-33,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IV PGBK,50863,CDM,636,RC,J3475,HCPCS,0264-4204-52,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,63323-485-41,NDC,,,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,J3360,HCPCS,69339-136-03,NDC,,,facility,both,2,ML,,145,101.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-495-27,NDC,facility,both,230,ML,,113,79.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPOETIN ALFA-EPBX 10000 UNITS/ML INJ SOLN,50863,CDM,Q5106,HCPCS,0069-1308-01,NDC,,,facility,both,10,ML,,477,333.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE 22.5 MG SUBQ SYRG,50863,CDM,636,RC,J9217,HCPCS,62935-221-04,NDC,facility,both,3,EA,JZ,1176,823.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CEFAZOLIN PEDS SYRINGE (20MG/ML) IN DEXTROSE (CDS MIX,50863,CDM,636,RC,J7999,HCPCS,0781-3451-70,NDC,facility,both,3,EA,,155,108.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0904-6923-61,NDC,facility,both,40,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0143-9982-50,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLIPIZIDE 10 MG ORAL TO24,50863,CDM,250,RC,J3490,HCPCS,64980-281-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNITS/1 GRAM PACKET (MERGE RECORD),50863,CDM,636,RC,J3490,HCPCS,57896-145-09,NDC,facility,both,10,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-663-11,NDC,facility,both,1,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 20 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,50111-648-01,NDC,facility,both,3,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOLIC ACID  5 MG/ML INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,39822-1100-1,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN SODIUM EXTENDED 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,58151-110-32,NDC,facility,both,4,EA,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG ORAL CAP,50863,CDM,J3490,HCPCS,16714-298-01,NDC,,,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HUMAN PROTHROMBIN COMPLEX 500 UNIT IV SOLR,50863,CDM,636,RC,J7168,HCPCS,63833-386-02,NDC,facility,both,500,UN,,2910,2037,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0591-5443-01,NDC,facility,both,20,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,68094-231-59,NDC,facility,both,2,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 150 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6956-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TERAZOSIN  2 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,50268-765-11,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLU VACCINE TS 2025-26 6 MO UP (PF) 45 MCG (15 MCG X 3)/0.5 ML IM SYRG,50863,CDM,250,RC,90656,HCPCS,58160-912-52,NDC,facility,both,1,ML,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,J3490,HCPCS,67457-433-00,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML INJ SOLN,50863,CDM,J2250,HCPCS,0641-6057-01,NDC,,,facility,both,1,ML,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 3000 MCG/ML INJECTION,50863,CDM,636,RC,J0153,HCPCS,63323-651-00,NDC,facility,both,24,ML,,258,180.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN NORMAL SALINE IV,50863,CDM,J7042,HCPCS,0338-0089-04,NDC,,,facility,both,2,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1817,HCPCS,0002-8215-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIOTHYRONINE  5 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16714-166-01,NDC,facility,both,3,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM  3.375 GRAM IV SOLR,50863,CDM,250,RC,J2543,HCPCS,60505-6157-0,NDC,facility,both,3,EA,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-739-11,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 400 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-6667-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE  5 MG/ML INJ SOLN,50863,CDM,250,RC,J2765,HCPCS,0409-3414-11,NDC,facility,both,2,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INHL NEBU,50863,CDM,636,RC,J3490,HCPCS,0487-9301-02,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETIRIZINE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6717-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IMIPENEM-CILASTATIN 500 MG IV SOLR,50863,CDM,250,RC,J0743,HCPCS,63323-322-01,NDC,facility,both,2,EA,,176,123.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0781-3246-02,NDC,facility,both,1,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,50742-615-01,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE-PRAMOXINE 1 %-1 % TOPICAL FOAM,50863,CDM,250,RC,J3490,HCPCS,0037-6824-10,NDC,facility,both,1,GM,,412,288.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,250,RC,J3490,HCPCS,60687-653-11,NDC,facility,both,5,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,76329-3352-1,NDC,facility,both,1,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,50863,CDM,636,RC,J1885,HCPCS,0409-3796-19,NDC,facility,both,3,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,59651-488-01,NDC,facility,both,80,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-495-27,NDC,facility,both,40,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FILGRASTIM-SNDZ 300 MCG/0.5 ML INJ SYRG,50863,CDM,250,RC,Q5101,HCPCS,61314-304-01,NDC,facility,both,300,ML,,976,683.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETIRIZINE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16714-799-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,63323-161-00,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 125 MG/5 ML (25MG/ML) ORAL SYRINGE (REPACK),50863,CDM,250,RC,J3370,HCPCS,67457-340-00,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLP",50863,CDM,250,RC,P9047,HCPCS,0944-0493-04,NDC,facility,both,2,ML,,501,350.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,50863,CDM,250,RC,J9267,HCPCS,61703-342-50,NDC,facility,both,129,ML,,156,109.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,290,ML,JW,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,76329-3352-1,NDC,facility,both,7,ML,,736,515.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  5 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,59746-306-12,NDC,facility,both,1,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOZAPINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,57664-347-88,NDC,facility,both,2,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,50863,CDM,250,RC,Q0177,HCPCS,60687-675-11,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 1 MG/ML (1ML) SYRINGE (REPACK),50863,CDM,250,RC,J2997,HCPCS,50242-044-13,NDC,facility,both,2,EA,,542,379.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOPERAMIDE 1 MG/7.5 ML ORAL LIQD,50863,CDM,636,RC,J3490,HCPCS,68094-029-59,NDC,facility,both,4,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,50863,CDM,636,RC,J0696,HCPCS,0143-9857-01,NDC,facility,both,4,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FERRIC CARBOXYMALTOSE (INJECTAFER) 50 MG IRON/ML IV SOLN,50863,CDM,636,RC,J1439,HCPCS,0517-0650-01,NDC,facility,both,750,ML,,4111,2877.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ICATIBANT 30 MG/3 ML SUBQ SYRG,50863,CDM,250,RC,J1744,HCPCS,63323-574-86,NDC,facility,both,30,ML,JZ,3588,2511.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LAMOTRIGINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7007-61,NDC,facility,both,5,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,0641-6145-01,NDC,facility,both,18,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) IV SOLN",50863,CDM,636,RC,J3490,HCPCS,67457-197-00,NDC,facility,both,2,ML,,736,515.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE  2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,65162-896-09,NDC,facility,both,3,EA,,340,238,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIFEDIPINE 10 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7229-61,NDC,facility,both,5,EA,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0143-9889-15,NDC,facility,both,7,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  750 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7125-61,NDC,facility,both,6,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  60 MG ORAL CS24,50863,CDM,636,RC,J3490,HCPCS,0527-4116-37,NDC,facility,both,2,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOLIC ACID  1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7224-61,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-1283-17,NDC,facility,both,15,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
USTEKINUMAB 130 MG/26 ML IV SOLN,50863,CDM,636,RC,J3358,HCPCS,57894-054-27,NDC,facility,both,520,ML,,14720,10304,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAZOSIN 1 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7020-61,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LINACLOTIDE 145 MCG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0456-1201-30,NDC,facility,both,1,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
0.45 % NACL-POTASSIUM CHLORIDE 20 MEQ/L IV SOLP (PEDS ONC),50863,CDM,J3490,HCPCS,0338-0704-34,NDC,,,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,50863,CDM,250,RC,J0696,HCPCS,25021-107-20,NDC,facility,both,8,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-5755-23,NDC,facility,both,43,EA,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0406-0552-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-191-11,NDC,facility,both,2,EA,,263,184.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MERCAPTOPURINE 50 MG ORAL TAB,50863,CDM,250,RC,J9999,HCPCS,0054-4581-11,NDC,facility,both,2,EA,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELOXICAM  7.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-525-11,NDC,facility,both,1,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 10 MG/ML (PF) IV SOLN,50863,CDM,250,RC,J2270,HCPCS,0641-6127-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOPERAMIDE 1 MG/7.5 ML ORAL LIQD,50863,CDM,250,RC,J3490,HCPCS,17856-6836-1,NDC,facility,both,2,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42858-302-25,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,50863,CDM,636,RC,J1756,HCPCS,0517-2340-01,NDC,facility,both,300,ML,JZ,963,674.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CARVEDILOL  3.125 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6300-61,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 50 MG/ML INJECTION,50863,CDM,250,RC,J1200,HCPCS,72485-101-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PYRIDOSTIGMINE BROMIDE 180 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,0187-3013-30,NDC,facility,both,1,EA,,241,168.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR NEO/PEDS INFUSION (CDS FROM PREMIX),50863,CDM,250,RC,J0133,HCPCS,63323-325-10,NDC,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 2.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0003-0893-31,NDC,facility,both,2,EA,,119,83.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,152,ML,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,16729-114-31,NDC,facility,both,13,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 40 % ORAL GEL,50863,CDM,636,RC,J3490,HCPCS,574007030,NDC,facility,both,1,GM,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE 0.5 MG/2 ML INHL NBSP,50863,CDM,636,RC,J3490,HCPCS,60687-524-79,NDC,facility,both,1,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,250,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,13,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAUNORUBICIN 5 MG/ML IV INJ,50863,CDM,636,RC,J9150,HCPCS,0143-9550-01,NDC,facility,both,2,ML,JW,222,155.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
METHYLERGONOVINE 0.2 MG/ML (1 ML) INJ SOLN,50863,CDM,250,RC,J2210,HCPCS,0517-0740-01,NDC,facility,both,10,ML,,1836,1285.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,J3490,HCPCS,0143-9889-15,NDC,,,facility,both,23,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IVPB (PEDIATRICS/ADULT NON-FORM)",50863,CDM,636,RC,J0131,HCPCS,24201-100-01,NDC,facility,both,45,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,J2405,HCPCS,23155-547-31,NDC,,,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLERGONOVINE 0.2 MG/ML (1 ML) INJ SOLN,50863,CDM,J2210,HCPCS,0517-0740-01,NDC,,,facility,both,1,ML,,179,125.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,J3490,HCPCS,68094-600-59,NDC,,,facility,both,2,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,J2250,HCPCS,55390-138-01,NDC,,,facility,both,4,ML,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 3000 MCG/ML INJECTION,50863,CDM,250,RC,J0153,HCPCS,25021-318-02,NDC,facility,both,12,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,68094-494-59,NDC,facility,both,2,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG ORAL TAB,50863,CDM,J3490,HCPCS,50268-299-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MINERAL OIL,50863,CDM,250,RC,J3490,HCPCS,6332325402,NDC,facility,both,1,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  500 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,0641-6176-01,NDC,facility,both,4,ML,JA,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
INSULIN REGULAR IN 0.9% NACL 100 UNIT/100 ML (1 UNIT/ML) INFUSION FOR OB,50863,CDM,J1815,HCPCS,0338-0126-12,NDC,,,facility,both,1,ML,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN LOCK FLUSH 100 UNIT/ML IV SOLN,50863,CDM,636,RC,J1642,HCPCS,6425333335,NDC,facility,both,50,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,68094-494-59,NDC,facility,both,5,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-495-27,NDC,,,facility,both,110,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL,50863,CDM,250,RC,J3490,HCPCS,63323-820-01,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 600 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,65162-465-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE  5 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-6370-61,NDC,,,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENAZOPYRIDINE 100 MG ORAL TAB,50863,CDM,J3490,HCPCS,65162-681-10,NDC,,,facility,both,2,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,20,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,50863,CDM,250,RC,J0696,HCPCS,25021-106-10,NDC,facility,both,8,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,9,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,50863,CDM,J1650,HCPCS,0955-1004-01,NDC,,,facility,both,4,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,84,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G POTASSIUM 20000000 UNIT INJ SOLR,50863,CDM,250,RC,J2540,HCPCS,70860-127-51,NDC,facility,both,27,EA,,224,156.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,68094-600-59,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,250,RC,Q0162,HCPCS,65162-691-79,NDC,facility,both,2,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,250,RC,Q9968,HCPCS,70710-1838-1,NDC,facility,both,39,ML,JW,221,154.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,J3101,HCPCS,50242-037-06,NDC,,,facility,both,32,EA,,6012,4208.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,51754-5001-1,NDC,facility,both,8,ML,,411,287.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 100 MG IV SOLR,50863,CDM,J2997,HCPCS,50242-085-25,NDC,,,facility,both,10,EA,,2429,1700.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 10 % INHL NEBU,50863,CDM,J3490,HCPCS,0378-6998-89,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 0.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16729-136-00,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,68094-494-59,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,J3490,HCPCS,0121-0917-05,NDC,,,facility,both,6,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,68180-723-04,NDC,facility,both,6,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAZOSIN 1 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,59762-5310-1,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETHIODIZED OIL 48 % INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,67684-1901-1,NDC,facility,both,1,ML,,3303,2312.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN NPH & REGULAR HUMAN 100 UNIT/ML (70-30) SUBQ SUSP,50863,CDM,250,RC,J1815,HCPCS,0002-8715-01,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2001,HCPCS,63323-492-27,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE 25 MG/ML INJ SOLN,50863,CDM,250,RC,J3230,HCPCS,70710-1850-1,NDC,facility,both,2,ML,,336,235.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN  500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65862-008-01,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE IV CONCENTRATED INFUSION (1 MEQ/ML),50863,CDM,250,RC,J3490,HCPCS,0409-6625-02,NDC,facility,both,5,ML,,287,200.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYUREA  500 MG ORAL CAP,50863,CDM,250,RC,J9999,HCPCS,68084-284-11,NDC,facility,both,6,EA,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,75,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,50863,CDM,636,RC,J0561,HCPCS,60793-701-02,NDC,facility,both,24,ML,,2160,1512,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML INJECTION,50863,CDM,250,RC,J3411,HCPCS,0641-6228-01,NDC,facility,both,5,ML,,146,102.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRIL MALEATE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,23155-773-01,NDC,facility,both,2,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-11,NDC,facility,both,8,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIVAROXABAN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50458-580-01,NDC,facility,both,1,EA,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,23155-600-31,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,250,RC,J3490,HCPCS,59310-579-20,NDC,facility,both,1,GM,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,76,ML,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-3178-01,NDC,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOSTIGMINE METHYLSULFATE 1 MG/ML IV SOLN,50863,CDM,250,RC,J2710,HCPCS,42023-189-01,NDC,facility,both,1,ML,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-3178-01,NDC,facility,both,150,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETIC ACID 0.25 % IR SOLN,50863,CDM,250,RC,J3490,HCPCS,0338-0656-04,NDC,facility,both,1,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0121-0945-10,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADVATE: FACTOR VIII CONCENTRATE (MERGE RECORD),50863,CDM,636,RC,J7192,HCPCS,0944-3046-10,NDC,facility,both,2876,UN,,13032,9122.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65162-897-09,NDC,facility,both,1,EA,,157,109.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-41,NDC,facility,both,240,ML,JZ,33946,23762.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
INSULIN NPH & REGULAR HUMAN 100 UNIT/ML (70-30) SUBQ SUSP,50863,CDM,250,RC,J1815,HCPCS,0169-1837-11,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,J0665,HCPCS,0409-1162-02,NDC,,,facility,both,140,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESNA 100 MG/ML IV SOLN,50863,CDM,250,RC,J9209,HCPCS,10019-953-62,NDC,facility,both,8,ML,,222,155.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 250 MG INJ SOLR,50863,CDM,J0696,HCPCS,60505-6151-4,NDC,,,facility,both,8,EA,,624,436.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COCAINE  4 % TOP SOLN (MERGE),50863,CDM,C9046,HCPCS,70839-362-04,NDC,,,facility,both,160,ML,,1041,728.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPRAZOLAM 0.25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-377-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,250,RC,J0690,HCPCS,25021-101-10,NDC,facility,both,16,EA,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENOFIBRATE NANOCRYSTALLIZED 145 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7480-04,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CANGRELOR 50 MG IV SOLR,50863,CDM,C9460,HCPCS,10122-620-01,NDC,,,facility,both,100,EA,,5527,3868.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BEVACIZUMAB-BVZR 25 MG/ML IV SOLN,50863,CDM,Q5118,HCPCS,0069-0342-01,NDC,,,facility,both,36,ML,,6095,4266.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),50863,CDM,J0171,HCPCS,65302-507-10,NDC,,,facility,both,105,ML,,335,234.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,24,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,0264-9376-88,NDC,,,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,50863,CDM,250,RC,J9045,HCPCS,0703-4239-01,NDC,facility,both,3,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) 1000 UNITS/ML INJ SOL (FOR DIALYSIS ONLY),50863,CDM,250,RC,J1644,HCPCS,0069-0058-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRASTUZUMAB-QYYP 420 MG IV SOLR,50863,CDM,Q5116,HCPCS,0069-0306-01,NDC,,,facility,both,20,ME,,4457,3119.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,636,RC,J1596,HCPCS,0143-9679-01,NDC,facility,both,501,ML,,11418,7992.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 20 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-5785-61,NDC,facility,both,2,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0003-0894-21,NDC,facility,both,1,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAVASTATIN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-169-11,NDC,facility,both,1,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-18,NDC,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,50863,CDM,250,RC,J0696,HCPCS,0781-3208-85,NDC,facility,both,8,EA,,450,315,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,0121-0657-05,NDC,facility,both,3,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIVAROXABAN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50458-579-01,NDC,facility,both,1,EA,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM ACETATE 2 MEQ/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-3299-15,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAVASTATIN 40 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-5893-61,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL PACK,50863,CDM,636,RC,J3490,HCPCS,67877-422-57,NDC,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,0143-9577-01,NDC,,,facility,both,80,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE IN D5W 1 GRAM/100 ML IV PGBK,50863,CDM,250,RC,J3475,HCPCS,63323-108-00,NDC,facility,both,1,ML,JW,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LORAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-3426-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,70710-1833-1,NDC,facility,both,3,EA,,1225,857.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,0338-0069-10,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,636,RC,J3490,HCPCS,0904-6794-30,NDC,facility,both,2,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,J0665,HCPCS,0409-1162-02,NDC,,,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA 25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,47781-332-01,NDC,facility,both,2,EA,,214,149.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"OCTREOTIDE,MICROSPHERES 30 MG IM SERR",50863,CDM,J2353,HCPCS,0078-0825-81,NDC,,,facility,both,30,EA,,19079,13355.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,J2250,HCPCS,0409-2308-21,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,50863,CDM,636,RC,J9267,HCPCS,0703-3217-01,NDC,facility,both,167,ML,,374,261.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLPIDEM  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6082-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 100 MG/5 ML ORAL LIQD,50863,CDM,250,RC,J3490,HCPCS,50383-063-10,NDC,facility,both,24,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTOLOZANE-TAZOBACTAM 1.5 G IV SOLR,50863,CDM,250,RC,J0695,HCPCS,67919-030-01,NDC,facility,both,20,EA,,754,527.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J1938,HCPCS,63323-280-03,NDC,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPH-MIN OIL-PETROLATUM 0.25-14-74.9 % RECT OINT,50863,CDM,250,RC,J3490,HCPCS,70677-1108-1,NDC,facility,both,1,GM,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-406-03,NDC,facility,both,1,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-4675-05,NDC,facility,both,3,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN (NEO),50863,CDM,250,RC,J1938,HCPCS,71288-203-10,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,50863,CDM,250,RC,J9025,HCPCS,72485-201-01,NDC,facility,both,134,EA,,1897,1327.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,47781-176-01,NDC,facility,both,2,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7188-61,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNIT/G TOP OINT (MERGE),50863,CDM,636,RC,J3490,HCPCS,49348-154-72,NDC,facility,both,1,GM,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML IV SOLN (MERGE),50863,CDM,636,RC,J3490,HCPCS,70756-611-82,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLECAINIDE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-0011-20,NDC,facility,both,3,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J2310,HCPCS,0409-1215-21,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-0710-20,NDC,facility,both,13,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) IV SOLN",50863,CDM,250,RC,J3490,HCPCS,0013-1114-20,NDC,facility,both,2,ML,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,50268-540-11,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,72603-251-01,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 500 MG (200 MG ELEMENTAL) CHEW TAB,50863,CDM,636,RC,J3490,HCPCS,68084-988-33,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LINEZOLID 600 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,67877-419-33,NDC,facility,both,4,EA,,1690,1183,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN-ACETAMINOPHEN-CAFFEINE 250 MG-250 MG-65 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0067-2039-91,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  60 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,42858-803-01,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NS WITH POTASSIUM CHLORIDE 20 MEQ/L IV SOLP,50863,CDM,250,RC,J3480,HCPCS,0338-0691-04,NDC,facility,both,10,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITRIOL 1 MCG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0054-3120-41,NDC,facility,both,1,ML,,645,451.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-0710-20,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 10 MG/50 ML (0.2MG/ML) PCA IN NS (MERGE),50863,CDM,250,RC,J1171,HCPCS,61553-830-41,NDC,facility,both,100,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-444-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,50863,CDM,636,RC,J0696,HCPCS,60505-6148-0,NDC,facility,both,1,EA,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN  6 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51672-4033-1,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,50863,CDM,636,RC,J1885,HCPCS,0409-3796-19,NDC,facility,both,4,ML,JZ,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LINACLOTIDE 145 MCG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0456-1201-30,NDC,facility,both,1,EA,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,0641-6027-25,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE SOD SUCC (PF) 100 MG/2 ML INJ SOLR,50863,CDM,250,RC,J1720,HCPCS,0009-0011-03,NDC,facility,both,1,EA,,126,88.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,50863,CDM,636,RC,J2354,HCPCS,25021-463-01,NDC,facility,both,10,ML,JB,150,105,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JB: Administered subcutaneously
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60219-1708-1,NDC,facility,both,20,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  100 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,0641-6175-01,NDC,facility,both,4,ML,JB,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JB: Administered subcutaneously
INSULIN NPH HUMAN RECOMB 100 UNIT/ML SUBQ SUSP,50863,CDM,250,RC,J1815,HCPCS,0169-1834-11,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOTRIMAZOLE 1 % TOP CREA,50863,CDM,636,RC,J3490,HCPCS,0536-1272-22,NDC,facility,both,2,GM,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACCHAROMYCES BOULARDII 250 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,1785608695,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENETOCLAX 100 MG ORAL TAB,50863,CDM,250,RC,J9999,HCPCS,0074-0576-11,NDC,facility,both,4,EA,,1128,789.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESTRADIOL 2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,42806-089-01,NDC,facility,both,3,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,50863,CDM,250,RC,J1756,HCPCS,0517-2340-01,NDC,facility,both,100,ML,,312,218.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GAMMAGARD LIQUID 10 % IV SOLN,50863,CDM,636,RC,J1569,HCPCS,0944-2700-12,NDC,facility,both,40,ML,"JA,JZ",7211,5047.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously | Modifier JZ: Zero drug amount discarded/not administered to any patient
PACLITAXEL 6 MG/ML IV CONC,50863,CDM,250,RC,J9267,HCPCS,61703-342-50,NDC,facility,both,458,ML,,554,387.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE  5 MG/ML INJ SOLN,50863,CDM,250,RC,J2765,HCPCS,0409-3414-21,NDC,facility,both,8,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM ACETATE 2 MEQ/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-3299-15,NDC,facility,both,1,ML,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR NEO/PEDS INFUSION (CDS FROM PREMIX),50863,CDM,250,RC,J0133,HCPCS,63323-325-10,NDC,facility,both,39,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR  6 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,27241-139-09,NDC,facility,both,10,ML,,134,93.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,250,RC,J3490,HCPCS,73702-301-15,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) MISC SOLN,50863,CDM,250,RC,J3490,HCPCS,0517-7604-01,NDC,facility,both,1,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2599,HCPCS,43598-914-11,NDC,facility,both,12,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0143-9386-01,NDC,facility,both,52,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,51754-5011-1,NDC,facility,both,3,ML,,162,113.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J7510,HCPCS,17856-0815-1,NDC,facility,both,5,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J3430,HCPCS,68462-758-01,NDC,facility,both,5,ML,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"POTASSIUM CITRATE-CITRIC ACID 1,100 MG-334 MG/5 ML ORAL SOLN",50863,CDM,250,RC,J3490,HCPCS,121067616,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0406-0552-23,NDC,facility,both,5,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2310,HCPCS,0409-1215-01,NDC,facility,both,4,ML,,929,650.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,16,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 50 MG/ML INJECTION,50863,CDM,250,RC,J1200,HCPCS,0641-0376-21,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,636,RC,J1596,HCPCS,0143-9679-01,NDC,facility,both,30,ML,,684,478.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-398-11,NDC,facility,both,3,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG RECT SUPP,50863,CDM,250,RC,J3490,HCPCS,45802-759-00,NDC,facility,both,1,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,39,EA,,5382,3767.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL IV BOLUS 10MG/ML (ANESTHESIA ONLY),50863,CDM,636,RC,J2704,HCPCS,0409-4699-54,NDC,facility,both,87,ML,,111,77.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN NPH & REGULAR HUMAN 100 UNIT/ML (70-30) SUBQ SUSP,50863,CDM,250,RC,J1815,HCPCS,0169-1837-11,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 875 MG-125 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0781-1852-20,NDC,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-520-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTAZIDIME   1 GRAM INJ SOLR,50863,CDM,250,RC,J0713,HCPCS,0409-5082-16,NDC,facility,both,2,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,42806-150-33,NDC,facility,both,4,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BLINATUMOMAB 35 MCG IV KIT,50863,CDM,250,RC,J9039,HCPCS,55513-160-01,NDC,facility,both,35,EA,,9203,6442.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,68,ML,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LANTHANUM  500 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,54092-252-45,NDC,facility,both,1,EA,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,59762-0075-1,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,636,RC,J3490,HCPCS,0173-0682-24,NDC,facility,both,2,GM,,134,93.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,0143-9577-01,NDC,,,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,J3490,HCPCS,0173-0682-24,NDC,,,facility,both,1,GM,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORDIAZEPOXIDE 10 MG CAP,50863,CDM,636,RC,J3490,HCPCS,51079-375-01,NDC,facility,both,5,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 10 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,65862-192-01,NDC,facility,both,5,EA,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 150 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-711-11,NDC,facility,both,2,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 2 MG INJ SOLR,50863,CDM,250,RC,J2997,HCPCS,50242-041-64,NDC,facility,both,2,EA,,800,560,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7050,HCPCS,0338-0049-02,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,636,RC,J2597,HCPCS,65219-293-00,NDC,facility,both,16,ML,JZ,341,238.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,0143-9595-01,NDC,,,facility,both,50,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-48,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,25021-468-10,NDC,facility,both,5,EA,,2042,1429.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,250,RC,J0690,HCPCS,44567-707-25,NDC,facility,both,16,EA,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,63323-185-09,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,82293-004-10,NDC,facility,both,1,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 50 MG 24 HR TAB,50863,CDM,J3490,HCPCS,51079-170-01,NDC,,,facility,both,2,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,J3490,HCPCS,0409-1323-15,NDC,,,facility,both,100,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADVATE: FACTOR VIII CONCENTRATE (MERGE RECORD),50863,CDM,J7192,HCPCS,0944-3052-02,NDC,,,facility,both,1000,UN,,4186,2930.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6798-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL,50863,CDM,250,RC,J3490,HCPCS,63323-820-01,NDC,facility,both,1,ML,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ABATACEPT 250 MG IV SOLR,50863,CDM,J0129,HCPCS,0003-2187-13,NDC,,,facility,both,100,EA,,16711,11697.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,J3490,HCPCS,68180-441-02,NDC,,,facility,both,10,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-50,NDC,facility,both,43,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,76,ML,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC ADMIN RESPIRATORY SYNCYTIAL VIRUS MONOCLONAL ANTIBODY SEASONAL DOSE INTRAMUSCULAR INJECTION,50863,CDM,90381,HCPCS,49281-574-88,NDC,,,facility,both,1,ML,,1435,1004.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 400 MCG/100 ML (4 MCG/ML) IV SOLN,50863,CDM,J3490,HCPCS,0338-9557-12,NDC,,,facility,both,1,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,0409-1207-13,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN PEDS SYRINGE (20MG/ML) IN DEXTROSE (CDS MIX,50863,CDM,636,RC,J0690,HCPCS,0781-3451-70,NDC,facility,both,3,EA,,56093,39265.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 100 MG PE/2 ML INJ SOLN,50863,CDM,250,RC,Q2009,HCPCS,0641-6136-01,NDC,facility,both,2,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN PEDS INFUSION (CDS MIXTURE),50863,CDM,250,RC,J0290,HCPCS,99999-408-63,NDC,facility,both,2,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,2,EA,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAVASTATIN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,55111-229-90,NDC,facility,both,2,EA,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZONATATE 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7153-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 0.1 MG/ML INJ SYRG,50863,CDM,250,RC,J0461,HCPCS,76329-3340-1,NDC,facility,both,16,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,72485-106-01,NDC,facility,both,50,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J3490,HCPCS,0990-7984-13,NDC,facility,both,1,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J3490,HCPCS,0338-0049-01,NDC,facility,both,3,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEPIVACAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,636,RC,J0670,HCPCS,63323-294-01,NDC,facility,both,2,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-089-50,NDC,facility,both,1,ML,,146,102.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,43066-007-10,NDC,facility,both,2,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-18,NDC,facility,both,100,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,250,RC,J2405,HCPCS,60505-6130-0,NDC,facility,both,4,ML,PLAD,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
AMPHETAMINE-DEXTROAMPHETAMINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42858-723-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE 0.5 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,63323-463-01,NDC,facility,both,1,ML,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0641-6059-01,NDC,facility,both,4,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,67877-545-88,NDC,facility,both,2,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0143-9507-10,NDC,facility,both,1,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADVATE: FACTOR VIII CONCENTRATE (MERGE RECORD),50863,CDM,250,RC,J7192,HCPCS,0944-3053-04,NDC,facility,both,2000,UN,,10488,7341.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,6,ML,,179,125.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-581-11,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-710-11,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,51754-5001-1,NDC,facility,both,4,ML,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPYRIDAMOLE-ASPIRIN SR 200 MG-25 MG MULTIPHASE 12 HR CAP,50863,CDM,636,RC,J3490,HCPCS,65162-596-06,NDC,facility,both,1,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,16714-046-01,NDC,facility,both,3,ML,JW,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
SPIRONOLACTONE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-545-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 100 MG/1 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0075-0623-03,NDC,facility,both,20,ML,,292,204.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOPIDOGREL  75 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-536-11,NDC,facility,both,1,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0003-0894-31,NDC,facility,both,2,EA,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 20 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-5785-61,NDC,facility,both,2,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACCHAROMYCES BOULARDII 250 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,7733380050,NDC,facility,both,8,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAMOXIFEN 10 MG ORAL TAB,50863,CDM,250,RC,J9999,HCPCS,75907-058-60,NDC,facility,both,4,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUDROCORTISONE 0.1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-330-11,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,82,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 125 MG ORAL CPSP,50863,CDM,250,RC,J3490,HCPCS,68084-313-11,NDC,facility,both,3,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4 % TOP CREA,50863,CDM,250,RC,J3490,HCPCS,0496-0882-06,NDC,facility,both,1,GM,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1940,HCPCS,23155-473-44,NDC,facility,both,5,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J1610,HCPCS,63323-596-11,NDC,facility,both,1,EA,,895,626.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIRAGLUTIDE 0.6 MG/0.1 ML (18 MG/3 ML) SUBQ PNIJ,50863,CDM,250,RC,J3590,HCPCS,0480-3667-19,NDC,facility,both,1,ML,,1426,998.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-587-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DENOSUMAB 60 MG/ML SUBQ SYRG,50863,CDM,636,RC,J0897,HCPCS,55513-710-21,NDC,facility,both,60,ML,JZ,4930,3451,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,250,RC,J3490,HCPCS,0093-3174-31,NDC,facility,both,1,GM,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIFEDIPINE 10 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7229-61,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.1 % NASAL SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-103-01,NDC,facility,both,1,ML,,20748,14523.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,10,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,0409-9093-35,NDC,facility,both,5,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXAZOSIN 8 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-225-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM IN NACL (ISO-OS) 1000 MG/100 ML IV PGBK,50863,CDM,636,RC,J1953,HCPCS,36000-356-01,NDC,facility,both,100,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,4,EA,,119,83.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 250 MG/50 ML CONCENTRATED DRIP (RSE),50863,CDM,250,RC,J2250,HCPCS,0641-6060-01,NDC,facility,both,50,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 2.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0003-0893-21,NDC,facility,both,1,EA,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3373,HCPCS,63323-284-01,NDC,facility,both,25,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,4,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 20 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,60687-585-11,NDC,facility,both,1,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J3490,HCPCS,63323-482-03,NDC,,,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,184,128.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM  3.375 GRAM IV SOLR,50863,CDM,636,RC,J2543,HCPCS,64679-056-02,NDC,facility,both,3,EA,,107,74.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN SODIUM EXTENDED 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0071-0369-40,NDC,facility,both,4,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-986-01,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL IV BOLUS 10MG/ML (ANESTHESIA ONLY),50863,CDM,J2704,HCPCS,63323-269-29,NDC,,,facility,both,34,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRIL MALEATE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51672-4038-1,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 50 MG/ML INJECTION,50863,CDM,250,RC,J1200,HCPCS,63323-664-01,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16729-216-15,NDC,facility,both,2,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J2310,HCPCS,67457-299-00,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,42,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SALMETEROL 50 MCG/DOSE INHL DSDV,50863,CDM,636,RC,J3490,HCPCS,0173-0521-00,NDC,facility,both,1,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  37.5 MG ORAL CP24,50863,CDM,636,RC,J3490,HCPCS,68084-698-11,NDC,facility,both,6,EA,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 0.1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-721-11,NDC,facility,both,4,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-11,NDC,facility,both,15,ML,JW,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-406-03,NDC,facility,both,1,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCERIN (CHILD) RECTAL SUPPOSITORY,50863,CDM,250,RC,J3490,HCPCS,57237-326-21,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPTOMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0878,HCPCS,72603-152-01,NDC,facility,both,4000,EA,,11697,8187.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 25% IN WATER (D25W) IV SYRINGE,50863,CDM,250,RC,J3490,HCPCS,0409-1775-40,NDC,facility,both,1,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-134-01,NDC,facility,both,9,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-0552-23,NDC,facility,both,4,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 80 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-211-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2599,HCPCS,43598-914-11,NDC,facility,both,6,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN   1.5 G IV SOLR,50863,CDM,250,RC,J3370,HCPCS,0409-3515-11,NDC,facility,both,3,EA,JZ,143,100.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-65,NDC,facility,both,100,ML,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 250 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,0904-6860-61,NDC,facility,both,2,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0295,HCPCS,63323-368-20,NDC,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 1 MG/ML (1ML) SYRINGE (REPACK),50863,CDM,250,RC,J2997,HCPCS,50242-044-13,NDC,facility,both,3,EA,,1168,817.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 75 MG/5 ML ORAL SOLUTION,50863,CDM,250,RC,J3490,HCPCS,64980-511-10,NDC,facility,both,2,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLORAZEPATE DIPOTASSIUM  3.75 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51672-4042-1,NDC,facility,both,8,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,250,RC,J0690,HCPCS,44567-707-25,NDC,facility,both,18,EA,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,71288-402-10,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-103-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE 180 MCG/INHALATION INHL AEPB,50863,CDM,250,RC,J3490,HCPCS,61269-518-12,NDC,facility,both,1,EA,,937,655.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-231-11,NDC,facility,both,4,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25 MG-100 MG TAB,50863,CDM,636,RC,J3490,HCPCS,60687-661-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,J3490,HCPCS,0143-9889-15,NDC,,,facility,both,27,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACUBITRIL-VALSARTAN 49-51 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0078-0777-20,NDC,facility,both,1,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE CONCENTRATE 10 MG/ 0.5 ML ORAL SYRINGE (0.5ML UD MERGE),50863,CDM,250,RC,J3490,HCPCS,0406-8003-30,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BARICITINIB 2 MG ORAL TAB (COVID ONLY),50863,CDM,250,RC,J3490,HCPCS,0002-4182-30,NDC,facility,both,1,EA,,395,276.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE-SALMETEROL 250 MCG-50 MCG/DOSE DISK DEVICE FOR INHALATION,50863,CDM,250,RC,J3490,HCPCS,0173-0696-04,NDC,facility,both,1,EA,,232,162.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES-DOCUSATE SODIUM 8.6 MG-50 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7440-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,250,RC,J3490,HCPCS,0173-0682-24,NDC,facility,both,1,GM,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6924-61,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  60 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,42858-803-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 50 MG 24 HR TAB,50863,CDM,636,RC,J3490,HCPCS,60687-402-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 1250 MG/5 ML SUSPENSION (500 MG/5 ML ELEMENTAL),50863,CDM,250,RC,J3490,HCPCS,0121-0766-16,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-406-03,NDC,facility,both,1,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL (VITAMIN D3)  1000 UNIT ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,2055503300,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-591-11,NDC,facility,both,15,EA,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MONTELUKAST 10 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-6808-06,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INHL NEBU,50863,CDM,250,RC,J3490,HCPCS,487930201,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  25 MG ORAL TAB,50863,CDM,J3490,HCPCS,23155-833-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,0409-3178-01,NDC,,,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,17271-701-06,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0121-1781-05,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSAPREPITANT 150 MG IV SOLR,50863,CDM,J1453,HCPCS,0143-9384-01,NDC,,,facility,both,150,EA,,214,149.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,63323-161-00,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON DEXTRAN 50 MG/ML INJ SOLN,50863,CDM,J1750,HCPCS,0023-6082-01,NDC,,,facility,both,2,ML,,209,146.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 1 % INJ SOLN,50863,CDM,636,RC,Q9968,HCPCS,17478-504-01,NDC,facility,both,25,ML,,205,143.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,J1644,HCPCS,0409-2720-31,NDC,,,facility,both,10,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,J1610,HCPCS,63323-596-11,NDC,,,facility,both,25,EA,,22363,15654.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN (NEW TX NON-NEURO INDICATION)",50863,CDM,J1561,HCPCS,13533-800-71,NDC,,,facility,both,20,ML,,2829,1980.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 0.1 MG/ML INJ SYRG,50863,CDM,J0461,HCPCS,0409-1630-15,NDC,,,facility,both,200,ML,,121,84.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,J0665,HCPCS,0409-1560-29,NDC,,,facility,both,120,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,18,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
FOSPHENYTOIN 500 MG PE/10 ML INJ SOLN,50863,CDM,250,RC,Q2009,HCPCS,0641-6137-01,NDC,facility,both,8,ML,JW,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
POTASSIUM CHLORIDE 10 MEQ/100 ML IV PGBK,50863,CDM,250,RC,J3480,HCPCS,14789-109-16,NDC,facility,both,5,ML,JZ,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,16,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 4 MEQ/ML ORAL SOLUTION (CDS),50863,CDM,250,RC,J3490,HCPCS,0409-7391-72,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 875 MG-125 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0781-1852-20,NDC,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 1 MG ORAL CAP,50863,CDM,636,RC,J7507,HCPCS,68084-450-11,NDC,facility,both,3,EA,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 2 MG INJ SOLR,50863,CDM,250,RC,J2997,HCPCS,50242-041-64,NDC,facility,both,2,EA,JZ,762,533.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
NORTRIPTYLINE 25 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,51672-4002-1,NDC,facility,both,2,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 6 MG/0.5 ML SUB-Q,50863,CDM,636,RC,J3030,HCPCS,55150-173-01,NDC,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 2 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,250,RC,J2270,HCPCS,0409-1762-30,NDC,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,103,ML,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,60,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,0121-0657-05,NDC,facility,both,4,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-38,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOBRAMYCIN SULFATE 40 MG/ML INJ SOLN,50863,CDM,250,RC,J3260,HCPCS,67457-473-22,NDC,facility,both,6,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J1940,HCPCS,72603-251-01,NDC,facility,both,2,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE  1 % TOP CREA,50863,CDM,636,RC,J3490,HCPCS,45802-438-03,NDC,facility,both,2,GM,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE MODIFIED  25 MG ORAL CAP,50863,CDM,250,RC,J7515,HCPCS,51862-458-01,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOCARNITINE 200 MG/ML IV SOLN,50863,CDM,J3490,HCPCS,54482-147-01,NDC,,,facility,both,1,ML,,223,156.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J3490,HCPCS,0409-3178-01,NDC,,,facility,both,200,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9% IV (PEDS) BOLUS,50863,CDM,250,RC,J7030,HCPCS,0264-7800-09,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORDIAZEPOXIDE 25 MG CAP,50863,CDM,636,RC,J3490,HCPCS,60687-807-11,NDC,facility,both,15,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J2004,HCPCS,63323-482-01,NDC,facility,both,100,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NADOLOL  20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7070-61,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 1 MG/ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,27808-002-01,NDC,facility,both,1,ML,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51672-4027-1,NDC,facility,both,3,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE IN 0.9% NACL 3 GRAM/100 ML IV SOLN,50863,CDM,250,RC,J0612,HCPCS,61553-056-48,NDC,facility,both,500,ML,,212,148.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 40 MG-200 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,65862-496-47,NDC,facility,both,1,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 500 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,50268-152-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0630,HCPCS,63323-865-02,NDC,facility,both,1,ML,,1248,873.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUDROCORTISONE 0.1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-330-11,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOPIDOGREL  75 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-536-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 250 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,68084-776-11,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 25 MG TAB,50863,CDM,250,RC,J3490,HCPCS,51079-255-01,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0121-0914-05,NDC,facility,both,3,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL (PULM.HYPERTENSION) 10 MG/12.5 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,55150-166-13,NDC,facility,both,1,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 0.1 MG/ML INJ SYRG,50863,CDM,250,RC,J0461,HCPCS,76329-3340-1,NDC,facility,both,95,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,31722-711-30,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,29300-423-01,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42291-468-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0781-3246-02,NDC,facility,both,2,ML,JW,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DICYCLOMINE 20 MG ORAL TAB,50863,CDM,250,RC,J0500,HCPCS,60687-380-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0295,HCPCS,63323-368-20,NDC,facility,both,2,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASCORBIC ACID  500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,904052361,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NABUMETONE 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-630-11,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,50863,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,4,EA,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,81033-002-05,NDC,facility,both,1,ML,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 100 MG IV SOLR,50863,CDM,250,RC,J2997,HCPCS,50242-085-25,NDC,facility,both,50,EA,,12145,8501.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPTOMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0878,HCPCS,67919-012-02,NDC,facility,both,400,EA,,984,688.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,0904-6474-61,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,0641-6145-01,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 0.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-581-11,NDC,facility,both,3,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,16714-026-01,NDC,facility,both,6,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 500 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,68084-415-11,NDC,facility,both,3,EA,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIROFIBAN-0.9% SODIUM CHLORIDE 5 MG/100 ML (50 MCG/ML) IV SOLN,50863,CDM,636,RC,J3246,HCPCS,25208-002-03,NDC,facility,both,18,ML,JW,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CHLORDIAZEPOXIDE 25 MG CAP,50863,CDM,636,RC,J3490,HCPCS,51079-141-01,NDC,facility,both,6,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,90,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-173-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0093-2279-73,NDC,facility,both,2,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0264-1800-36,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,59762-4900-3,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPH-MIN OIL-PETROLATUM 0.25-14-74.9 % RECT OINT,50863,CDM,636,RC,J3490,HCPCS,45802-188-16,NDC,facility,both,1,GM,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYMETAZOLINE 0.05 % NASAL MERGE,50863,CDM,636,RC,J3490,HCPCS,11523-1159-1,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE 3 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,0574-9855-10,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MINERAL OIL,50863,CDM,636,RC,J3490,HCPCS,6332325410,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCRALFATE 1 GRAM ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-695-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J7510,HCPCS,17856-0815-1,NDC,facility,both,8,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,636,RC,J2704,HCPCS,16714-528-01,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-9791-01,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,0409-1886-22,NDC,facility,both,50,ML,JZ,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PROPOFOL IV BOLUS 10MG/ML (ANESTHESIA ONLY),50863,CDM,636,RC,J2704,HCPCS,0409-4699-54,NDC,facility,both,96,ML,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 250 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,0904-6363-45,NDC,facility,both,2,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE-ACETIC ACID 1 %-2 % EAR DROPS,50863,CDM,250,RC,J3490,HCPCS,51672-3007-1,NDC,facility,both,1,ML,,813,569.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ABATACEPT 250 MG IV SOLR,50863,CDM,636,RC,J0129,HCPCS,0003-2187-13,NDC,facility,both,75,EA,,12534,8773.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  15 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,0406-8315-23,NDC,facility,both,3,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BETAMETHASONE, AUGMENTED 0.05 % TOP CREA",50863,CDM,636,RC,J3490,HCPCS,45802-376-35,NDC,facility,both,1,GM,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,250,RC,J7060,HCPCS,0409-7922-02,NDC,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL (5 MG/ML) IV SYRG (CONTAINS PRESERVATIVE),50863,CDM,250,RC,J3490,HCPCS,0409-2339-34,NDC,facility,both,1,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-31,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM,50863,CDM,636,RC,J3490,HCPCS,0168-0258-15,NDC,facility,both,1,GM,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-9543-02,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TICAGRELOR 90 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0186-0777-60,NDC,facility,both,1,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM  4.5 GRAM IV SOLR,50863,CDM,250,RC,J2543,HCPCS,64679-012-02,NDC,facility,both,4,EA,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB 10 MG/ML IV CONC,50863,CDM,250,RC,J9312,HCPCS,50242-053-06,NDC,facility,both,3,ML,JW,339,237.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
HEPARIN (PORCINE) IN D5W 25000 UNIT/250 ML (PTT MONITORING),50863,CDM,250,RC,J1644,HCPCS,0264-9587-20,NDC,facility,both,50,ML,,184,128.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0002-4115-30,NDC,facility,both,1,EA,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG IV SOLR,50863,CDM,J3490,HCPCS,55150-202-00,NDC,,,facility,both,1,EA,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,67457-423-00,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,50863,CDM,636,RC,J0585,HCPCS,0023-1145-01,NDC,facility,both,20,EA,JW,139,97.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
VANCOMYCIN  500 MG IV SOLR,50863,CDM,636,RC,J3370,HCPCS,70436-020-82,NDC,facility,both,1,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIVAROXABAN 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50458-578-90,NDC,facility,both,1,EA,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 12.5 MG ORAL TAB,50863,CDM,636,RC,Q0169,HCPCS,60687-660-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM  3 GRAM INJ SOLR,50863,CDM,636,RC,J0295,HCPCS,0049-0014-83,NDC,facility,both,2,EA,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYTOCIN 10 UNIT/ML INJ SOLN,50863,CDM,250,RC,J2590,HCPCS,63323-012-11,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,50863,CDM,250,RC,Q0177,HCPCS,0904-6617-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-01,NDC,facility,both,2,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETIRIZINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-799-02,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6007-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % MBP,50863,CDM,250,RC,J3490,HCPCS,0338-0553-18,NDC,facility,both,10,ML,,444,310.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
STERILE TALC 3 G INPL AERP,50863,CDM,250,RC,J3490,HCPCS,62327-333-03,NDC,facility,both,1,EA,,450,315,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE IN D5W (PF) 4 MG/ML (0.4 %) IV SOLP,50863,CDM,636,RC,J3490,HCPCS,0338-0409-03,NDC,facility,both,2000,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  125 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,62559-390-20,NDC,facility,both,4,EA,,451,315.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7126-61,NDC,facility,both,6,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE IN D5W 1 GRAM/100 ML IV PGBK,50863,CDM,250,RC,J3475,HCPCS,0409-6727-23,NDC,facility,both,2,ML,JZ,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CAFFEINE CITRATED 20 MG/ML IV SOLN,50863,CDM,250,RC,J0706,HCPCS,51754-0500-1,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES  8.6 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7252-61,NDC,facility,both,5,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,636,RC,J3490,HCPCS,0904-6794-80,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 50 MG/ML IV SOLN,50863,CDM,250,RC,J0282,HCPCS,67457-153-00,NDC,facility,both,10,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50580-458-11,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7008-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRIL MALEATE 1 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,69238-1729-7,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,0409-6102-20,NDC,facility,both,150,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-1283-03,NDC,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,16714-293-01,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 12.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7307-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEPLIZUMAB-MZWV 2 MG/20 ML IV SOLN,50863,CDM,636,RC,J9381,HCPCS,73650-316-01,NDC,facility,both,259,ME,JW,7564,5294.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,69,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,250,RC,Q9968,HCPCS,71288-811-10,NDC,facility,both,40,ML,JW,226,158.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0093-2279-73,NDC,facility,both,7,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,250,RC,J3490,HCPCS,60687-653-11,NDC,facility,both,12,EA,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
D5-LR WITH POTASSIUM CHLORIDE 20 MEQ/L IV SOLP,50863,CDM,250,RC,J3490,HCPCS,0990-7111-09,NDC,facility,both,1,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOVASTATIN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68180-468-07,NDC,facility,both,4,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,636,RC,J7510,HCPCS,17856-0815-1,NDC,facility,both,9,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,12,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLN,50863,CDM,636,RC,J3262,HCPCS,50242-135-01,NDC,facility,both,360,ML,"JZ,JA",6598,4618.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
HYDROXYZINE 25 MG TAB,50863,CDM,250,RC,Q0177,HCPCS,60687-675-11,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPTOMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0878,HCPCS,72603-152-01,NDC,facility,both,350,EA,JZ,1024,716.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2310,HCPCS,0409-1215-21,NDC,facility,both,1,ML,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,50863,CDM,Q5119,HCPCS,0069-0238-01,NDC,,,facility,both,29,ML,,5738,4016.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0143-9889-15,NDC,facility,both,30,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
0.2 MICRON FILTER ATTACHMENT MISC MISC,50863,CDM,250,RC,J3490,HCPCS,99999-0403-06,NDC,facility,both,1,EA,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAMADOL  50 MG ORAL TAB,50863,CDM,J3490,HCPCS,0093-3301-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,63323-462-01,NDC,facility,both,1,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML INJECTION,50863,CDM,250,RC,J3411,HCPCS,43598-050-11,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMANTADINE 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7042-06,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERTAPENEM 1 GRAM INJ SOLR,50863,CDM,636,RC,J1335,HCPCS,60505-6196-0,NDC,facility,both,2,EA,JZ,506,354.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
FENTANYL  75 MCG/HR TD PT72,50863,CDM,636,RC,J3490,HCPCS,0378-9123-16,NDC,facility,both,1,EA,,197,137.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,250,RC,J7060,HCPCS,0338-0017-11,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,70954-316-10,NDC,facility,both,5,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,250,RC,J0132,HCPCS,55150-259-30,NDC,facility,both,227,ML,,1026,718.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZINC OXIDE 16 % TOP PSTE,50863,CDM,636,RC,J3490,HCPCS,6210333302,NDC,facility,both,1,GM,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,636,RC,P9045,HCPCS,68516-5218-0,NDC,facility,both,1,ML,JZ,237,165.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1162-18,NDC,facility,both,100,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,136,ML,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,14,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,25021-602-03,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 80 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-211-01,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6966-61,NDC,facility,both,4,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOBRAMYCIN SULFATE 40 MG/ML INJ SOLN,50863,CDM,250,RC,J3260,HCPCS,67457-473-22,NDC,facility,both,10,ML,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,68180-150-01,NDC,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COSYNTROPIN 0.25 MG INJ SOLR,50863,CDM,250,RC,J0834,HCPCS,0548-5900-00,NDC,facility,both,4,EA,,1842,1289.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCERIN 99.5 % TOP SOLN,50863,CDM,250,RC,J3490,HCPCS,0395-1031-96,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,60219-1708-1,NDC,facility,both,20,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 300 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6642-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLN (MERGE)",50863,CDM,636,RC,P9047,HCPCS,68516-5216-2,NDC,facility,both,4,ML,,853,597.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIPASE-PROTEASE-AMYLASE 24,000-76,000- 120,000 UNIT ORAL CAP, DELAY REL",50863,CDM,250,RC,J3490,HCPCS,0032-1224-01,NDC,facility,both,1,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LINEZOLID 600 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,67877-419-33,NDC,facility,both,6,EA,,2535,1774.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-2051-15,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 50 MG/5 ML (10 MG/ML) IV SYRG,50863,CDM,250,RC,J3490,HCPCS,71266-2002-1,NDC,facility,both,2,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 50 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-854-11,NDC,facility,both,100,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,636,RC,J0690,HCPCS,44567-707-25,NDC,facility,both,2,EA,JZ,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0264-5802-10,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG IV SOLR,50863,CDM,J0456,HCPCS,63323-398-01,NDC,,,facility,both,1,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 10 MG/50 ML (0.2MG/ML) PCA IN NS (MERGE),50863,CDM,250,RC,J1171,HCPCS,61553-830-41,NDC,facility,both,100,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,50863,CDM,636,RC,J0696,HCPCS,44567-701-25,NDC,facility,both,2,EA,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,50863,CDM,636,RC,J2354,HCPCS,0641-6174-01,NDC,facility,both,2,ML,JB,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JB: Administered subcutaneously
HALOPERIDOL DECANOATE 100 MG/ML IM SOLN,50863,CDM,250,RC,J1631,HCPCS,70756-616-81,NDC,facility,both,3,ML,,238,166.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NORETHINDRONE ACETATE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50742-267-50,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,14,EA,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANTIVENIN CROTALIDAE (EQUINE) INJ SOLR,50863,CDM,250,RC,J0841,HCPCS,66621-0790-1,NDC,facility,both,10,EA,,36432,25502.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,636,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,5,EA,,182,127.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  650 MG RECT SUPP,50863,CDM,250,RC,J3490,HCPCS,45802-730-32,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPRAZOLAM 0.25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-647-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,71399-1025-3,NDC,facility,both,9,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV (BOLUS),50863,CDM,636,RC,J7040,HCPCS,0338-0049-10,NDC,facility,both,1,ML,,130,91,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GALANTAMINE  4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,57237-049-60,NDC,facility,both,2,EA,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIBUCAINE 1 % TOP OINT,50863,CDM,250,RC,J3490,HCPCS,0536-1211-95,NDC,facility,both,1,GM,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUGAMMADEX 100 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0006-5423-02,NDC,facility,both,3,ML,,1765,1235.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,55150-165-05,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 40 MG/ML (4 %) INJ SOLN (FOR NEBULIZATION),50863,CDM,J2003,HCPCS,0409-4283-11,NDC,,,facility,both,80,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,J0665,HCPCS,0409-1162-18,NDC,,,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE IN 0.9% NS (PF) 1 MG/10 ML (100 MCG/ML) IV SYRG(PDS MERGE),50863,CDM,636,RC,J3490,HCPCS,70092-1046-46,NDC,facility,both,300,ML,,33810,23667,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,21,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,636,RC,J3360,HCPCS,0641-6244-01,NDC,facility,both,1,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 20 GRAM/30 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-1154-30,NDC,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,26,EA,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-492-04,NDC,,,facility,both,80,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROTHIAZIDE SODIUM 500 MG IV SOLR,50863,CDM,250,RC,J1205,HCPCS,25021-305-20,NDC,facility,both,1,EA,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  75 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7000-61,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT 25 MCG/0.42 ML INJ SYRG,50863,CDM,636,RC,J0881,HCPCS,55513-057-01,NDC,facility,both,25,ML,,836,585.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL 20 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0054-3727-63,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0406-0552-23,NDC,facility,both,6,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 20MG/ML IV SYRINGE (PEDS/NEO),50863,CDM,250,RC,J0612,HCPCS,63323-311-10,NDC,facility,both,37,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  50 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,64980-411-09,NDC,facility,both,4,EA,,165,115.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,0088-2220-33,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,17,ML,JW,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CHOLECALCIFEROL (VITAMIN D3)  1000 UNIT ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,8068116900,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2308-21,NDC,facility,both,4,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
INFLIXIMAB 100 MG IV SOLR,50863,CDM,636,RC,J1745,HCPCS,57894-030-01,NDC,facility,both,100,EA,,32232,22562.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESTRADIOL 2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42806-089-01,NDC,facility,both,4,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,70069-363-01,NDC,facility,both,2,ML,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,4,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0406-8515-23,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL SODIUM 500 MG IV SOLR,50863,CDM,J0206,HCPCS,67457-187-50,NDC,,,facility,both,1,EA,,11005,7703.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0641-6022-01,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,63323-485-03,NDC,,,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-5755-23,NDC,facility,both,9,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MERCAPTOPURINE 50 MG ORAL TAB,50863,CDM,250,RC,J9999,HCPCS,0378-3547-52,NDC,facility,both,2,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-671-50,NDC,facility,both,1,ML,,219,153.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,250,RC,J7999,HCPCS,70092-1017-46,NDC,facility,both,48,ML,,949,664.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,636,RC,J3370,HCPCS,0409-6533-11,NDC,facility,both,4,EA,,192,134.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16714-989-01,NDC,facility,both,1,EA,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 40 GRAM/400 ML (10 %) INJ SOLN",50863,CDM,J1561,HCPCS,13533-800-40,NDC,,,facility,both,160,ML,,22631,15841.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 100 MG/ML INJ SOLN,50863,CDM,250,RC,J2800,HCPCS,70069-101-01,NDC,facility,both,1,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEMAZEPAM  7.5 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,68084-549-11,NDC,facility,both,2,EA,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE SOD SUCC (PF) 100 MG/2 ML INJ SOLR,50863,CDM,250,RC,J1720,HCPCS,0009-0011-03,NDC,facility,both,3,EA,,404,282.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,636,RC,J2560,HCPCS,0641-0476-21,NDC,facility,both,1,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,63323-400-01,NDC,facility,both,450,ML,,246,172.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6925-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 50 MG/ML INJECTION,50863,CDM,250,RC,J1200,HCPCS,63323-664-00,NDC,facility,both,5,ML,,101,70.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,636,RC,J1836,HCPCS,0338-1055-48,NDC,facility,both,150,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SALIVA SUBSTITUTE COMB NO.11 351 MG MM PWPK,50863,CDM,250,RC,J3490,HCPCS,7027562904,NDC,facility,both,1,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 10 MG/ML IM SOLN,50863,CDM,250,RC,J0500,HCPCS,0641-6173-01,NDC,facility,both,1,ML,,143,100.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-38,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE 21 MG/24 HR TD PT24,50863,CDM,250,RC,J3490,HCPCS,43598-448-71,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0641-0400-12,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 0.1 MG/ML IV SYRINGE (NEO/INFANT),50863,CDM,250,RC,J1100,HCPCS,99999-0405-74,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAUNORUBICIN 5 MG/ML IV INJ,50863,CDM,250,RC,J9150,HCPCS,42658-021-01,NDC,facility,both,5,ML,,1370,959,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FONDAPARINUX 10 MG/0.8 ML SUBQ SYRG,50863,CDM,250,RC,J1652,HCPCS,55150-233-00,NDC,facility,both,20,ML,,370,259,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,16714-294-01,NDC,facility,both,9,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,250,RC,J7060,HCPCS,0338-0070-10,NDC,facility,both,2,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,636,RC,J7060,HCPCS,0338-0017-02,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZTREONAM 1 GRAM INJ SOLR,50863,CDM,636,RC,J0457,HCPCS,63323-401-01,NDC,facility,both,10,EA,,212,148.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN IN D5W 400 MG/200 ML IV PGBK,50863,CDM,636,RC,J0744,HCPCS,0409-3300-01,NDC,facility,both,2,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7442-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RAMIPRIL  5 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,68382-146-01,NDC,facility,both,2,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,J1885,HCPCS,0409-3795-19,NDC,,,facility,both,2,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J7510,HCPCS,17856-0759-5,NDC,facility,both,9,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,67457-385-10,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZTROPINE 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7288-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,4,ML,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 125 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,0074-6212-13,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMFIBROZIL 600 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-350-15,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 8-2 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,0904-7010-06,NDC,facility,both,2,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,43598-053-11,NDC,facility,both,22,ML,,776,543.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR 200 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-5789-61,NDC,facility,both,4,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 300 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,67877-543-60,NDC,facility,both,1,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-01,NDC,facility,both,1,ML,JZ,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MESNA 100 MG/ML IV SOLN,50863,CDM,250,RC,J9209,HCPCS,0338-1305-01,NDC,facility,both,2,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOBENZAPRINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-190-11,NDC,facility,both,6,EA,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 50 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,59651-489-01,NDC,facility,both,100,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOBRAMYCIN SULFATE 40 MG/ML INJ SOLN,50863,CDM,250,RC,J3260,HCPCS,0409-3578-01,NDC,facility,both,3,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 300 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-206-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 10 MG/5 ML SYRUP,50863,CDM,636,RC,Q0177,HCPCS,62135-750-47,NDC,facility,both,1,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 100 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,51079-171-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,28,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1815,HCPCS,0169-1833-11,NDC,facility,both,1,ML,GZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier GZ: Item or service expected to be denied as not reasonable and necessary
ONDANSETRON 4 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,57237-077-10,NDC,facility,both,2,EA,,218,152.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,16,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 250 MG-125 MG TAB,50863,CDM,636,RC,J3490,HCPCS,16714-476-01,NDC,facility,both,1,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLEDRONIC ACID 4 MG/5 ML IV SOLN,50863,CDM,250,RC,J3489,HCPCS,67457-390-54,NDC,facility,both,4,ML,JZ,1629,1140.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DIVALPROEX 250 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,0904-6860-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,636,RC,Q9968,HCPCS,71288-811-10,NDC,facility,both,45,ML,JW,254,177.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ALUM-MAG HYDROXIDE-SIMETH 200 MG-200 MG-20 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0904-7325-62,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,50863,CDM,250,RC,J9000,HCPCS,0069-1542-20,NDC,facility,both,9,ML,,146,102.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RALTEGRAVIR 400 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0006-0227-61,NDC,facility,both,6,EA,,900,630,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,68094-231-59,NDC,facility,both,7,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 0.1 % TOP OINT,50863,CDM,636,RC,J3490,HCPCS,0168-0006-15,NDC,facility,both,1,GM,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-0710-20,NDC,facility,both,18,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EXEMESTANE 25 MG ORAL TAB,50863,CDM,636,RC,J9999,HCPCS,59651-516-30,NDC,facility,both,1,EA,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 100 MG/ML INJ SOLN,50863,CDM,250,RC,J2800,HCPCS,0641-6103-25,NDC,facility,both,1,ML,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,250,RC,J0690,HCPCS,60505-6142-0,NDC,facility,both,4,EA,JZ,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SODIUM ACETATE 2 MEQ/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,69784-230-10,NDC,facility,both,1,ML,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEDIATRIC MULTIVITAMIN NO.192 250 MCG-50 MG- 10 MCG/ML ORAL DROP,50863,CDM,250,RC,J3490,HCPCS,87040203,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-25,NDC,facility,both,60,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-DYYB 100 MG IV SOLR,50863,CDM,636,RC,Q5103,HCPCS,0069-0809-01,NDC,facility,both,6,EA,JW,682,477.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,636,RC,J7060,HCPCS,0338-0017-31,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 0.1 MG/ML INJ SYRG,50863,CDM,J0461,HCPCS,76329-3340-1,NDC,,,facility,both,200,ML,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,14789-251-09,NDC,facility,both,2,ML,,353,247.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CANGRELOR 50 MG IV SOLR,50863,CDM,250,RC,C9460,HCPCS,10122-620-01,NDC,facility,both,50,EA,,2635,1844.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMULSION 20 % IV EMUL,50863,CDM,250,RC,j3490,HCPCS,65219-533-01,NDC,facility,both,1,ML,,129,90.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,250,RC,J3490,HCPCS,72603-387-01,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,63323-482-03,NDC,,,facility,both,300,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPTOMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0878,HCPCS,71288-016-15,NDC,facility,both,500,EA,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-1638-32,NDC,facility,both,2,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,67877-548-88,NDC,facility,both,4,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOZAPINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-415-11,NDC,facility,both,1,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,636,RC,J3490,HCPCS,63037-136-25,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLMESARTAN 40 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0527-2427-46,NDC,facility,both,1,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,44,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL,50863,CDM,250,RC,J3490,HCPCS,63323-820-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEPERIDINE (PF) 25 MG/ML IV SOLN (PHS MERGE),50863,CDM,636,RC,J2175,HCPCS,0409-1362-11,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7030,HCPCS,0338-0049-04,NDC,facility,both,1,ML,JZ,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
AMIODARONE 50 MG/ML IV SOLN,50863,CDM,636,RC,J0282,HCPCS,70436-232-72,NDC,facility,both,5,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAMADOL  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7496-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  75 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-495-11,NDC,facility,both,6,EA,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,30,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 2400000 UNIT/4 ML IM SYRG,50863,CDM,636,RC,J0561,HCPCS,60793-702-04,NDC,facility,both,24,ML,,2088,1461.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4 % TOPICAL SOLN,50863,CDM,250,RC,J3490,HCPCS,76329-6300-5,NDC,facility,both,2,ML,,308,215.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYBUTYNIN CHLORIDE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0832-0038-89,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL  50 MCG/HR TD PT72,50863,CDM,636,RC,J3490,HCPCS,47781-426-11,NDC,facility,both,1,EA,,191,133.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7126-61,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML (1ML) INJ SOLN,50863,CDM,250,RC,J0171,HCPCS,63323-696-02,NDC,facility,both,10,ML,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL,50863,CDM,250,RC,J1071,HCPCS,0143-9659-01,NDC,facility,both,200,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLERGONOVINE 0.2 MG/ML (1 ML) INJ SOLN,50863,CDM,250,RC,J2210,HCPCS,51991-144-99,NDC,facility,both,1,ML,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL 2.5 MG/ML SUSPENSION,50863,CDM,250,RC,J3490,HCPCS,99999-0404-75,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,250,RC,J0132,HCPCS,25021-812-30,NDC,facility,both,127,ML,,909,636.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OMEPRAZOLE-SODIUM BICARBONATE 2-84 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,65628-270-03,NDC,facility,both,2,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,75,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  88 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,42292-038-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  50 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-484-11,NDC,facility,both,3,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60505-3113-0,NDC,facility,both,3,EA,,254,177.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),50863,CDM,636,RC,J2060,HCPCS,17478-040-01,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-466-03,NDC,facility,both,300,ML,JZ,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0904-7127-61,NDC,facility,both,10,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-03,NDC,facility,both,3,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 150 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,16729-443-15,NDC,facility,both,2,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0121-1781-05,NDC,facility,both,2,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,0088-2220-33,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN SODIUM EXTENDED 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-6187-61,NDC,facility,both,5,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROFURANTOIN (25% MACROCRYSTAL FORM) 100 MG CAP,50863,CDM,636,RC,J3490,HCPCS,0185-0122-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-1159-19,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,1000,ML,,111,77.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,68180-723-05,NDC,facility,both,6,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLEDRONIC ACID-MANNITOL-WATER 4 MG/100 ML IV PGBK,50863,CDM,J3489,HCPCS,25021-826-82,NDC,,,facility,both,4,ML,,778,544.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-975-11,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,50863,CDM,250,RC,J9045,HCPCS,0703-4239-01,NDC,facility,both,6,ML,,143,100.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-3425-10,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES  8.6 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7252-60,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE  50 MG/ML INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,25021-683-10,NDC,facility,both,5,ML,,279,195.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,50863,CDM,636,RC,Q0177,HCPCS,16714-082-10,NDC,facility,both,4,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,4,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLESTYRAMINE 4 G ORAL PWPK,50863,CDM,636,RC,J3490,HCPCS,0245-0036-89,NDC,facility,both,1,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALUM-MAG HYDROXIDE-SIMETH 200 MG-200 MG-20 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,17856-0630-1,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-346-11,NDC,facility,both,3,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,68180-723-04,NDC,facility,both,3,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 300 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,50383-312-84,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOMEPIZOLE 1 GRAM/ML IV SOLN,50863,CDM,250,RC,J1451,HCPCS,70710-1478-1,NDC,facility,both,200,ML,,8280,5796,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,62332-600-01,NDC,facility,both,2,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LACTULOSE 20 GRAM/30 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-1154-30,NDC,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ELECTROLYTE-A IV,50863,CDM,250,RC,J3490,HCPCS,0338-0221-04,NDC,facility,both,1,ML,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,636,RC,J0690,HCPCS,44567-707-25,NDC,facility,both,6,EA,JZ,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,0088-2220-33,NDC,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IV PGBK,50863,CDM,250,RC,J3475,HCPCS,0264-4204-52,NDC,facility,both,2,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
OXYCODONE  15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-975-11,NDC,facility,both,3,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  50 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,72205-012-90,NDC,facility,both,2,EA,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,636,RC,J3490,HCPCS,23155-166-31,NDC,facility,both,1,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN  6 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51672-4033-1,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRP (MERGE/REPACK),50863,CDM,636,RC,J3490,HCPCS,68094-764-59,NDC,facility,both,2,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,250,RC,J2003,HCPCS,63323-495-27,NDC,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,50863,CDM,636,RC,J2354,HCPCS,0641-6174-01,NDC,facility,both,2,ML,"JZ,JA",30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
SODIUM CHLORIDE 0.9 % MBP,50863,CDM,636,RC,J3490,HCPCS,0338-0553-18,NDC,facility,both,1,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,4,EA,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,72611-722-25,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,636,RC,J1939,HCPCS,25021-321-04,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IV PGBK,50863,CDM,250,RC,J3475,HCPCS,47335-992-01,NDC,facility,both,8,ML,,155,108.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-94,NDC,facility,both,4,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-279-11,NDC,facility,both,20,EA,,385,269.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-487-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 150 MG/1 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,16714-066-01,NDC,facility,both,14,ML,,156,109.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLECAINIDE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-321-11,NDC,facility,both,2,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6949-61,NDC,facility,both,7,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,636,RC,J7999,HCPCS,70092-1017-46,NDC,facility,both,2,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  500 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,0641-6176-01,NDC,facility,both,12,ML,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 112 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6954-61,NDC,facility,both,3,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,70954-059-10,NDC,facility,both,10,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NYSTATIN  100000 UNIT/G TOP POWD,50863,CDM,636,RC,J3490,HCPCS,75907-060-44,NDC,facility,both,1,GM,,108,75.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,2,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML (PEDS CALCLUATOR 0.5),50863,CDM,250,RC,J1815,HCPCS,0024-5924-10,NDC,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,50863,CDM,250,RC,J0696,HCPCS,60505-6148-0,NDC,facility,both,4,EA,,225,157.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML (PEDS CALCLUATOR 0.5),50863,CDM,636,RC,J1815,HCPCS,0024-5924-10,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,50863,CDM,636,RC,J0696,HCPCS,60505-6148-0,NDC,facility,both,4,EA,,225,157.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,25021-321-04,NDC,facility,both,5,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZIPRASIDONE 40 MG CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6270-08,NDC,facility,both,2,EA,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CABAZITAXEL 10 MG/ML (FINAL) IV SOLN,50863,CDM,250,RC,J9043,HCPCS,0024-5823-15,NDC,facility,both,60,ME,,33467,23426.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OFLOXACIN 0.3 % OPHT DROP,50863,CDM,250,RC,J3490,HCPCS,72485-613-10,NDC,facility,both,1,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASCORBIC ACID 500 MG/ML INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,67157-101-50,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 0.5 MG ORAL CAP,50863,CDM,250,RC,J7507,HCPCS,68084-449-11,NDC,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-826-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,50863,CDM,636,RC,J3490,HCPCS,0904-6741-72,NDC,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,636,RC,J2795,HCPCS,43066-023-01,NDC,facility,both,75,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 40 GRAM/400 ML (10 %) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-40,NDC,facility,both,240,ML,"JZ,JA",33946,23762.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-495-04,NDC,,,facility,both,100,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-6695-01,NDC,facility,both,10,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6371-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J3490,HCPCS,0338-0049-01,NDC,facility,both,2,ML,JZ,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-9543-03,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2598,HCPCS,42023-164-25,NDC,facility,both,20,ML,,413,289.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXRAZOXANE 250 MG IV SOLR,50863,CDM,250,RC,J1190,HCPCS,55150-432-01,NDC,facility,both,1,EA,,957,669.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,51754-5001-1,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-48,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON DEXTRAN 50 MG/ML INJ SOLN,50863,CDM,636,RC,J1750,HCPCS,0023-6082-01,NDC,facility,both,10,ML,JZ,1094,765.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GLYCERIN (LAXATIVE) 2.8 GRAM/2.7 ML RECT SOLN,50863,CDM,250,RC,J3490,HCPCS,0132-0190-12,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB 10 MG/ML IV CONC,50863,CDM,636,RC,J9312,HCPCS,50242-053-06,NDC,facility,both,100,ML,"JZ,JA",25931,18151.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,51754-5001-1,NDC,facility,both,10,ML,,514,359.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PILOCARPINE 2 % EYE DROPS,50863,CDM,636,RC,J3490,HCPCS,61314-204-15,NDC,facility,both,1,ML,,363,254.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIPHTH,PERTUS(ACELL),TETANUS VIAL (BOOSTRIX*) 2.5-8-5 LF-MCG-LF/0.5ML IM SUSP",50863,CDM,636,RC,90715,HCPCS,58160-842-01,NDC,facility,both,1,ML,GZ,240,168,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier GZ: Item or service expected to be denied as not reasonable and necessary
LISINOPRIL 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6799-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68382-806-01,NDC,facility,both,3,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 5 MG-325 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0406-0123-01,NDC,facility,both,4,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,57237-004-30,NDC,facility,both,2,EA,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLPIDEM  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-189-11,NDC,facility,both,2,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,70095-031-01,NDC,facility,both,30,ML,,1229,860.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 5 MG ORAL CAP,50863,CDM,250,RC,J7507,HCPCS,0904-6624-61,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN NEO/PEDIATRIC SYRINGE < 30 MG,50863,CDM,636,RC,J1650,HCPCS,0548-5608-00,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,250,RC,J1596,HCPCS,0143-9679-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6950-61,NDC,facility,both,6,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRIMIDONE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-686-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,50863,CDM,636,RC,J0696,HCPCS,44567-702-25,NDC,facility,both,8,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,180,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PYRIDOXINE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,7733394025,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-18,NDC,facility,both,200,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IV PGBK,50863,CDM,J3475,HCPCS,0409-6729-11,NDC,,,facility,both,4,ML,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,68180-150-01,NDC,facility,both,2,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 2 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,250,RC,J2270,HCPCS,76045-004-01,NDC,facility,both,1,ML,PLAD,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
DULOXETINE 30 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,51991-747-90,NDC,facility,both,1,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IVPB (PEDIATRICS/ADULT NON-FORM)",50863,CDM,636,RC,J0137,HCPCS,24201-100-01,NDC,facility,both,24,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,25021-751-10,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"TOBRAMYCIN-DEXAMETHASONE 0.3 %-0.1 % EYE DROPS, SUSP",50863,CDM,250,RC,J3490,HCPCS,61314-647-25,NDC,facility,both,1,ML,,308,215.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM  4.5 GRAM IV SOLR,50863,CDM,J2543,HCPCS,65219-259-05,NDC,,,facility,both,4,EA,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATED 20 MG/ML IV SOLN,50863,CDM,250,RC,J0706,HCPCS,51754-0500-1,NDC,facility,both,15,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-191-11,NDC,facility,both,1,EA,,152,106.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-02,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,50863,CDM,636,RC,J3301,HCPCS,16714-130-01,NDC,facility,both,4,ML,JZ,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MAGNESIUM OXIDE 400 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,1000673038,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-299-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETHAMBUTOL 400 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-280-11,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6966-61,NDC,facility,both,6,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ELECTROLYTE-A IV,50863,CDM,250,RC,J3490,HCPCS,0338-0221-04,NDC,facility,both,1,ML,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIVAROXABAN 15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50458-578-01,NDC,facility,both,1,EA,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,0121-1971-21,NDC,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,50863,CDM,636,RC,J2359,HCPCS,0781-3159-72,NDC,facility,both,20,EA,,203,142.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,7,EA,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,0955-1008-01,NDC,facility,both,8,ML,JZ,101,70.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
NICOTINE (POLACRILEX) 4 MG BUCL GUM,50863,CDM,636,RC,J3490,HCPCS,70677-1171-1,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG TAB,50863,CDM,250,RC,J3490,HCPCS,904719106,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE  50 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,50268-277-11,NDC,facility,both,2,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENETOCLAX  50 MG ORAL TAB,50863,CDM,250,RC,J9999,HCPCS,0074-0566-11,NDC,facility,both,1,EA,,234,163.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",50863,CDM,250,RC,J1561,HCPCS,13533-800-25,NDC,facility,both,40,ML,,5658,3960.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,636,RC,J0330,HCPCS,31722-981-10,NDC,facility,both,8,ML,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FINASTERIDE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6830-06,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOBRAMYCIN 150 MG/3.75 ML NEBULIZER SOLN (REPACK),50863,CDM,250,RC,J3490,HCPCS,63323-306-30,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOZAPINE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-922-01,NDC,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0780,HCPCS,23155-294-31,NDC,facility,both,1,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,76045-009-96,NDC,facility,both,6,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM CITRATE ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,69452-390-98,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 300 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-206-01,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSINOPRIL 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,43547-386-09,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),50863,CDM,250,RC,J0169,HCPCS,76329-3318-1,NDC,facility,both,40,ML,,323,226.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0295,HCPCS,63323-368-20,NDC,facility,both,1,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,6,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,0641-6146-01,NDC,facility,both,12,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-595-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE  50 MCG/ACTUATION NASL SPSN,50863,CDM,636,RC,J3490,HCPCS,60505-0829-1,NDC,facility,both,1,GM,,362,253.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VITAMINS A & D-WHITE PETROLATUM-LANOLIN OINTMENT,50863,CDM,250,RC,J3490,HCPCS,4110081163,NDC,facility,both,1,GM,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"CALCIUM CARBONATE-VITAMIN D3 500 MG(1,250MG) -200 UNIT ORAL TAB",50863,CDM,636,RC,J3490,HCPCS,1000670038,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60505-3110-0,NDC,facility,both,8,EA,,380,266,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 500 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,16714-299-02,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,66553-002-01,NDC,facility,both,2,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML INJECTION,50863,CDM,636,RC,J3411,HCPCS,72603-139-01,NDC,facility,both,6,ML,,166,116.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM & SODIUM PHOSPHATES 280-160-250 MG ORAL PWPK,50863,CDM,636,RC,J3490,HCPCS,6025800615,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 10 MG/ML IM SOLN,50863,CDM,636,RC,J0500,HCPCS,17478-015-02,NDC,facility,both,1,ML,,385,269.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PALIPERIDONE PALMITATE 117 MG/0.75 ML IM SYRG,50863,CDM,250,RC,J2426,HCPCS,50458-562-01,NDC,facility,both,117,ML,,4801,3360.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG/ML ORAL CONC,50863,CDM,250,RC,J3490,HCPCS,0054-3553-44,NDC,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE  50 MCG/ACTUATION NASL SPSN,50863,CDM,636,RC,J3490,HCPCS,0054-3270-99,NDC,facility,both,1,GM,,396,277.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,19,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAPTOPRIL  12.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7105-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,50863,CDM,250,RC,J9025,HCPCS,72485-201-01,NDC,facility,both,141,EA,,2003,1402.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 112 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-508-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,250,RC,J7060,HCPCS,0338-0017-31,NDC,facility,both,1,ML,JZ,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PERMETHRIN 1 % TOP LIQD (REPACK),50863,CDM,250,RC,J3490,HCPCS,6373612003,NDC,facility,both,1,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC MCARE ADMIN HEPATITIS B VACC,50863,CDM,636,RC,90746,HCPCS,58160-821-01,NDC,facility,both,1,ML,,367,256.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0121-0917-05,NDC,facility,both,2,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,636,RC,J2704,HCPCS,65219-800-01,NDC,facility,both,7,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 50 MG TAB,50863,CDM,636,RC,Q0177,HCPCS,0904-6618-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-119-11,NDC,facility,both,3,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-25,NDC,facility,both,70,ML,JA,9901,6930.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
CYANOCOBALAMIN  100 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,8068107100,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-0552-23,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-686-10,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,62559-440-02,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXEPIN  25 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,51079-437-01,NDC,facility,both,3,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,636,RC,J7999,HCPCS,70092-1017-46,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,636,RC,J0690,HCPCS,70092-1017-46,NDC,facility,both,4,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-04,NDC,facility,both,6,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALTREXONE MICROSPHERES 380 MG IM SERR,50863,CDM,636,RC,J2315,HCPCS,65757-300-01,NDC,facility,both,380,EA,,4529,3170.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  750 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7125-61,NDC,facility,both,3,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,3,EA,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INHL NEBU,50863,CDM,636,RC,J3490,HCPCS,0487-9301-33,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-134-01,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,2,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISATRACURIUM  2 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0074-4380-10,NDC,facility,both,1,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-464-02,NDC,facility,both,1,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,72603-251-01,NDC,facility,both,9,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,FAMNOCHARGE,HCPCS,17856-0759-5,NDC,facility,both,2,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,68462-469-40,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG IV SOLR,50863,CDM,636,RC,J3490,HCPCS,0008-0923-60,NDC,facility,both,1,EA,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELATACEPT 250 MG IV SOLR,50863,CDM,636,RC,J0485,HCPCS,0003-0371-13,NDC,facility,both,413,EA,,4262,2983.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG/5 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,0121-4827-05,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL 5 MCG/ML INJECTION,50863,CDM,250,RC,J3010,HCPCS,61553-479-78,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,636,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,6,EA,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,70710-1833-1,NDC,facility,both,2,EA,,817,571.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCERIN (CHILD) RECTAL SUPPOSITORY,50863,CDM,636,RC,J3490,HCPCS,58980-409-25,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORATADINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6852-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 10 GRAM/15 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,66689-038-01,NDC,facility,both,2,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,72789-325-90,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) IV SOLN,50863,CDM,636,RC,J9201,HCPCS,0409-0181-01,NDC,facility,both,15,ML,,692,484.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,17,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,16729-114-08,NDC,facility,both,18,ML,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 250 MG-62.5 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,59651-026-75,NDC,facility,both,3,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 2 %-1:200,000 INJ SOLN",50863,CDM,J2004,HCPCS,63323-489-01,NDC,,,facility,both,400,ML,,138,96.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYMETAZOLINE 0.05 % NASAL MERGE,50863,CDM,J3490,HCPCS,45802-410-59,NDC,,,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 150 MG/1 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,16714-066-01,NDC,facility,both,1,ML,JW,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DILTIAZEM 5 MG/ML IV,50863,CDM,J3490,HCPCS,0641-6015-01,NDC,,,facility,both,125,ML,,215,150.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,16,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 30 MG/0.3 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,16714-006-01,NDC,facility,both,6,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,36,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN D5W 1 GRAM/200 ML IV PGBK,50863,CDM,250,RC,J3373,HCPCS,0338-3552-48,NDC,facility,both,100,ML,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"CALCIUM CARBONATE 500 MG (1,250 MG) ORAL TAB",50863,CDM,636,RC,J3490,HCPCS,904188361,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
URSODIOL 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,50268-797-11,NDC,facility,both,1,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0904-6923-61,NDC,facility,both,30,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,636,RC,J3101,HCPCS,50242-037-06,NDC,facility,both,36,EA,JW,7169,5018.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,44567-600-04,NDC,facility,both,1,ML,,213,149.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROPROCAINE 3 % INJ SOLN,50863,CDM,250,RC,J2401,HCPCS,63323-478-01,NDC,facility,both,1200,ML,,263,184.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MITOXANTRONE 2 MG/ML IV CONC,50863,CDM,250,RC,J9293,HCPCS,61703-343-65,NDC,facility,both,2,ML,,227,158.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE (FOR EMERGENCY) 100 MG/ML (10%) IV SOLN,50863,CDM,636,RC,J0612,HCPCS,75834-171-01,NDC,facility,both,200,ML,JZ,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
INSULIN ASP PRT-INSULIN ASPART 100 UNIT/ML (70-30) SUBQ SOLN,50863,CDM,250,RC,J1817,HCPCS,73070-200-11,NDC,facility,both,2,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,2,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2308-22,NDC,facility,both,8,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IRINOTECAN 100 MG/5 ML IV SOLN,50863,CDM,250,RC,J9206,HCPCS,0009-0082-02,NDC,facility,both,15,ML,,492,344.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NYSTATIN  100000 UNIT/G TOP POWD,50863,CDM,636,RC,J3490,HCPCS,0832-0465-15,NDC,facility,both,1,GM,,184,128.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIRMATRELVIR-RITONAVIR 300-100 MG ORAL TAB DOSEPACK (FOR ED/IP TAKE HOME PANEL),50863,CDM,636,RC,J3490,HCPCS,0069-5321-30,NDC,facility,both,30,EA,,4010,2807,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE-EPINEPHR-TETRACAINE 4-0.18-0.5 % TOPICAL GEL,50863,CDM,J3490,HCPCS,71266-6290-1,NDC,,,facility,both,1,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETIRIZINE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-597-01,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LINEZOLID 600 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,67877-419-33,NDC,facility,both,1,EA,,662,463.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 20 GRAM/30 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,0121-1154-30,NDC,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,0641-6174-01,NDC,facility,both,8,ML,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG ORAL CAP,50863,CDM,J3490,HCPCS,0904-6665-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IV PGBK,50863,CDM,250,RC,J3475,HCPCS,63323-106-02,NDC,facility,both,8,ML,,151,105.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1815,HCPCS,0169-1833-11,NDC,facility,both,280,ML,,344,240.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 400 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,45963-557-11,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,0409-9094-22,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),50863,CDM,250,RC,J1630,HCPCS,63323-474-00,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTAZIDIME-AVIBACTAM 2.5 GRAM (2 GRAM-0.5 GRAM) IV SOLR,50863,CDM,250,RC,J0714,HCPCS,0456-2700-10,NDC,facility,both,2,EA,JW,297,207.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
FLUCONAZOLE 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6501-61,NDC,facility,both,2,EA,,160,112,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 100 MG/5 ML ORAL LIQD,50863,CDM,250,RC,J3490,HCPCS,50383-063-10,NDC,facility,both,2,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE IN 0.9% NS (PF) 1 MG/10 ML (100 MCG/ML) IV SYRG(PDS MERGE),50863,CDM,250,RC,J3490,HCPCS,70092-1046-46,NDC,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLEDRONIC ACID IN MANNITOL & WATER 5 MG/100 ML IV SOLN,50863,CDM,636,RC,J3489,HCPCS,67457-619-10,NDC,facility,both,5,ML,JZ,2311,1617.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MELATONIN  3 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,2055503601,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6993-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,636,RC,J1596,HCPCS,0143-9679-01,NDC,facility,both,12,ML,,274,191.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 20 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-4721-05,NDC,facility,both,1,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 0.1 MG/ML INJ SYRG,50863,CDM,636,RC,J0461,HCPCS,16729-484-03,NDC,facility,both,50,ML,JZ,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,72603-179-01,NDC,facility,both,7,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,250,RC,J3360,HCPCS,0409-1273-03,NDC,facility,both,14,ML,,1383,968.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-3178-01,NDC,facility,both,300,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7367-06,NDC,facility,both,3,EA,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J2004,HCPCS,63323-482-27,NDC,facility,both,200,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE 8 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,50383-930-93,NDC,facility,both,1,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50111-561-01,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,5026852411,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 875 MG-125 MG TAB,50863,CDM,636,RC,J3490,HCPCS,60687-803-11,NDC,facility,both,1,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-4713-32,NDC,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN IN 0.9 % NS 40 UNIT/100 ML (0.4 UNIT/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0338-9647-12,NDC,facility,both,1,ML,,648,453.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,J0330,HCPCS,0409-6629-02,NDC,,,facility,both,4,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML (ANESTHESIA INTRAOP ONLY),50863,CDM,J3010,HCPCS,0641-6027-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,J2704,HCPCS,63323-269-50,NDC,,,facility,both,47,ML,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J3490,HCPCS,0409-0007-01,NDC,,,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,63739-434-02,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,250,RC,J0132,HCPCS,63323-963-21,NDC,facility,both,240,ML,,1901,1330.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOBRAMYCIN 1.2 G POWDER VIAL,50863,CDM,250,RC,J3260,HCPCS,63323-303-51,NDC,facility,both,15,EA,,361,252.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,50863,CDM,J9263,HCPCS,60505-6132-7,NDC,,,facility,both,200,ML,,432,302.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NYSTATIN  100000 UNIT/G TOP CREA,50863,CDM,636,RC,J3490,HCPCS,51672-1289-1,NDC,facility,both,1,GM,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,50863,CDM,250,RC,J9060,HCPCS,0703-5748-11,NDC,facility,both,19,ML,,445,311.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IV PGBK,50863,CDM,250,RC,J3490,HCPCS,0338-1708-40,NDC,facility,both,1,ML,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-739-11,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,J3490,HCPCS,0904-6794-80,NDC,,,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,67877-246-01,NDC,facility,both,2,EA,,127,88.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHOTERICIN B LIPOSOME 50 MG IV SUSR,50863,CDM,250,RC,J0289,HCPCS,55150-365-01,NDC,facility,both,20,EA,,3608,2525.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IFOSFAMIDE 1 GRAM IV SOLR,50863,CDM,250,RC,J9208,HCPCS,10019-925-82,NDC,facility,both,2,EA,,432,302.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,16714-293-03,NDC,facility,both,7,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,63323-201-02,NDC,,,facility,both,20,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  25 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6991-61,NDC,facility,both,3,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6950-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,112,ML,JZ,101,70.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SODIUM CHLORIDE 3 % IV INFUSION,50863,CDM,250,RC,J3490,HCPCS,0338-0054-03,NDC,facility,both,2,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ELECTROLYTE-A IV,50863,CDM,250,RC,J3490,HCPCS,0338-0221-03,NDC,facility,both,1,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYLAMINE SUCCINATE 25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,4116700609,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-711-11,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NYSTATIN 100000 UNIT/ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,17856-1045-1,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BICALUTAMIDE 50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,47335-485-83,NDC,facility,both,1,EA,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 112 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-508-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN IN SALINE (ISO-OSMOTIC) 100 MG/50 ML IV PIGGY BACK,50863,CDM,250,RC,J1580,HCPCS,0338-0511-41,NDC,facility,both,5,ML,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-4713-32,NDC,facility,both,160,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0536-1327-10,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM NEO/PED INFUSION (CDS MIXTURE),50863,CDM,250,RC,J2185,HCPCS,0781-3267-90,NDC,facility,both,4,EA,,216,151.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  75 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6951-61,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7452-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATOVAQUONE 750 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,81033-104-05,NDC,facility,both,2,ML,,223,156.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,50863,CDM,636,RC,J2354,HCPCS,25021-463-01,NDC,facility,both,2,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,636,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,40,ML,,140,98,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INDIGOTINDISULFONATE SODIUM 8 MG/ML INJ SOLN,50863,CDM,636,RC,J9920,HCPCS,17478-508-01,NDC,facility,both,40,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,68094-600-59,NDC,facility,both,2,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM PHOSPHATE 4.4 MEQ/ML ORAL SOLUTION (CDS),50863,CDM,250,RC,J3490,HCPCS,0409-7295-11,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-722-11,NDC,facility,both,2,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,0409-1283-03,NDC,facility,both,10,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-179-11,NDC,facility,both,2,EA,,255,178.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60505-3111-0,NDC,facility,both,2,EA,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRIL MALEATE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51672-4245-1,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION,50863,CDM,250,RC,J3490,HCPCS,0186-0370-28,NDC,facility,both,1,GM,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-342-11,NDC,facility,both,6,EA,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,250,RC,J0132,HCPCS,0574-0805-30,NDC,facility,both,60,ML,,813,569.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL (NEO/PEDS),50863,CDM,250,RC,J3490,HCPCS,63323-820-00,NDC,facility,both,1,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SOTALOL  80 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-724-11,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 1 MG/1 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,68094-031-59,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,2,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOBENZAPRINE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7401-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
URSODIOL 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-100-11,NDC,facility,both,3,EA,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 0.8 GRAM ORAL PWPK,50863,CDM,636,RC,J3490,HCPCS,0115-1365-30,NDC,facility,both,2,EA,,189,132.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,636,RC,J3010,HCPCS,0409-9094-22,NDC,facility,both,2,ML,JZ,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
NEOSTIGMINE 1MG/ML (UD) OR SYRINGE,50863,CDM,636,RC,J2710,HCPCS,63323-415-10,NDC,facility,both,3,ML,,493,345.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,50863,CDM,636,RC,J3490,HCPCS,0378-7732-93,NDC,facility,both,1,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,55150-161-02,NDC,,,facility,both,40,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLECAINIDE 20MG/ML SUSPENSION (REPACK),50863,CDM,250,RC,J3490,HCPCS,0054-0010-25,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 20 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-5785-61,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE  5 MG/ML INJ SOLN,50863,CDM,636,RC,J2765,HCPCS,0409-3414-21,NDC,facility,both,4,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-492-09,NDC,,,facility,both,50,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,1,ML,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 6 MG/0.5 ML SUBQ PEN KIT,50863,CDM,636,RC,J3030,HCPCS,16714-040-01,NDC,facility,both,1,ML,,406,284.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOCARNITINE 200 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,54482-147-01,NDC,facility,both,1,ML,,223,156.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 10 MG TAB,50863,CDM,636,RC,Q0177,HCPCS,60687-664-11,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"CALCIUM GLUC IN NACL, ISO-OSM 1 G/100 ML IV SOLN",50863,CDM,250,RC,J0613,HCPCS,44567-622-01,NDC,facility,both,100,ML,JZ,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,J3490,HCPCS,0121-0917-05,NDC,,,facility,both,2,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 250 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,17856-0698-01,NDC,facility,both,3,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,90,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 5 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,36000-033-10,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 100 MG/1 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,0781-3268-05,NDC,facility,both,10,ML,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 1 GRAM INJ SOLR,50863,CDM,250,RC,J0692,HCPCS,25021-121-20,NDC,facility,both,4,EA,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 0.1 MG/ML INJ SYRG,50863,CDM,250,RC,J0461,HCPCS,76329-3340-1,NDC,facility,both,150,ML,,101,70.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-444-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOLAZONE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-635-01,NDC,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-327-11,NDC,facility,both,3,EA,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,636,RC,J3490,HCPCS,71266-9080-2,NDC,facility,both,3,ML,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  10 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,60687-760-40,NDC,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1940,HCPCS,63323-280-02,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 200 MG/20 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0131-1810-67,NDC,facility,both,1,ML,,418,292.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,50863,CDM,250,RC,J9045,HCPCS,16729-295-12,NDC,facility,both,10,ML,,298,208.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,43598-053-11,NDC,facility,both,18,ML,,624,436.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 250 MCG SUBQ SOLR,50863,CDM,J2802,HCPCS,55513-221-01,NDC,,,facility,both,195,EA,,3424,2396.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 150 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,60687-312-11,NDC,facility,both,1,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEMANTINE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6506-61,NDC,facility,both,3,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRASUGREL 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0713-0882-30,NDC,facility,both,6,EA,,527,368.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,90,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,1000,ML,,111,77.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-093-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-03,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16729-278-01,NDC,facility,both,1,EA,,157,109.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,J3101,HCPCS,50242-037-06,NDC,,,facility,both,18,EA,,8245,5771.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAMADOL  50 MG ORAL TAB,50863,CDM,J3490,HCPCS,60687-795-11,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 5 MG ORAL TAB,50863,CDM,J3490,HCPCS,0003-0894-31,NDC,,,facility,both,1,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0406-5771-23,NDC,facility,both,6,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,230,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPRAZOLAM 0.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0781-1077-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLIPIZIDE 10 MG ORAL TO24,50863,CDM,250,RC,J3490,HCPCS,59651-782-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-256-11,NDC,facility,both,1,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLN (MERGE)",50863,CDM,P9047,HCPCS,64208-2512-8,NDC,,,facility,both,6,ML,,713,499.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,7,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,68094-231-59,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,250,RC,J0690,HCPCS,25021-101-10,NDC,facility,both,20,EA,,107,74.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE-SALMETEROL 250 MCG-50 MCG/DOSE DISK DEVICE FOR INHALATION,50863,CDM,250,RC,J3490,HCPCS,0093-7518-31,NDC,facility,both,1,EA,,1325,927.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 875 MG-125 MG TAB,50863,CDM,636,RC,J3490,HCPCS,16714-297-01,NDC,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0591-0605-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,63739-931-28,NDC,facility,both,10,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLPIDEM  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6082-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-932-01,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPRAZOLAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0228-2029-10,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,636,RC,J2795,HCPCS,70069-064-01,NDC,facility,both,75,ML,JZ,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DAY 1 NEO SOLUTION (D12.5W/AA 2%/HEPARIN 0.5 UNITS/ML),50863,CDM,250,RC,J3490,HCPCS,0264-1933-10,NDC,facility,both,2,ML,,230,161,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 20MG/ML IV SYRINGE (PEDS/NEO),50863,CDM,250,RC,J0612,HCPCS,63323-311-10,NDC,facility,both,64,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NAPHAZOLINE-GLYCERIN 0.012-0.25 % OPHT DROP,50863,CDM,250,RC,J3490,HCPCS,7811225419,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 100 MG PE/2 ML INJ SOLN,50863,CDM,250,RC,Q2009,HCPCS,63323-403-01,NDC,facility,both,2,ML,JZ,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
TIROFIBAN-0.9% SODIUM CHLORIDE 5 MG/100 ML (50 MCG/ML) IV SOLN,50863,CDM,250,RC,J3246,HCPCS,25208-002-03,NDC,facility,both,20,ML,JZ,398,278.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
HYDROXYZINE 25 MG TAB,50863,CDM,250,RC,Q0177,HCPCS,0904-6617-61,NDC,facility,both,6,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-555-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 3000 MCG/ML INJECTION,50863,CDM,J0153,HCPCS,63323-651-00,NDC,,,facility,both,24,ML,,258,180.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRP (MERGE/REPACK),50863,CDM,636,RC,J3490,HCPCS,60687-576-40,NDC,facility,both,1,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LINEZOLID NEO IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J2020,HCPCS,0781-3433-46,NDC,facility,both,3,ML,,331,231.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,0641-0400-37,NDC,facility,both,5,ML,JZ,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2598,HCPCS,43598-914-11,NDC,facility,both,4,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  88 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6952-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,72485-106-01,NDC,facility,both,100,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN (FORTIFIED) 50MG/ML OPHTHALMIC DROP (15ML),50863,CDM,250,RC,J3490,HCPCS,99999-407-40,NDC,facility,both,1,ML,,326,228.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,63323-400-01,NDC,facility,both,50,ML,JZ,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,412,ME,JZ,5591,3913.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
METHYLPHENIDATE 20 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,0406-1473-01,NDC,facility,both,1,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-50,NDC,facility,both,50,ML,JZ,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MELATONIN  3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,2055503601,NDC,facility,both,1,EA,PLAD,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
SIMVASTATIN  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-570-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG IV SOLR,50863,CDM,J3490,HCPCS,0008-0923-51,NDC,,,facility,both,1,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,J3490,HCPCS,44567-600-04,NDC,,,facility,both,1,ML,,402,281.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,J2919,HCPCS,0009-0047-25,NDC,,,facility,both,12,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,10,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOPROTERENOL 0.2 MG/ML INJECTION,50863,CDM,J3490,HCPCS,0548-9502-00,NDC,,,facility,both,4,ML,,3456,2419.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,72611-722-25,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 10 MG/50 ML (0.2MG/ML) PCA IN NS (MERGE),50863,CDM,636,RC,J1171,HCPCS,61553-830-41,NDC,facility,both,100,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DONANEMAB-AZBT 17.5 MG/ML IV SOLN,50863,CDM,636,RC,J0175,HCPCS,0002-9401-01,NDC,facility,both,350,ML,"JZ,Q0",3201,2240.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier Q0: Investigational clinical service provided in a clinical research study that is in an approved clinical research study
ASPIRIN   81 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,77333-031-25,NDC,facility,both,4,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 20 MG/ML ORAL SUSPENSION (REPACK),50863,CDM,250,RC,J3490,HCPCS,16714-041-04,NDC,facility,both,5,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,50863,CDM,636,RC,J0561,HCPCS,60793-701-02,NDC,facility,both,12,ML,JZ,1188,831.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PYRAZINAMIDE 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-789-11,NDC,facility,both,3,EA,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,57664-596-40,NDC,facility,both,1,ML,,327,228.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2723-30,NDC,facility,both,20,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7126-61,NDC,facility,both,3,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANTI-THYMOCYTE GLOB (RABBIT) 25 MG IV SOLR,50863,CDM,250,RC,J7511,HCPCS,58468-0080-1,NDC,facility,both,5,EA,,10110,7077,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-1749-70,NDC,facility,both,2,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-38,NDC,facility,both,1,ML,JZ,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
TOLTERODINE 2 MG ORAL CP24,50863,CDM,636,RC,J3490,HCPCS,0904-6592-04,NDC,facility,both,1,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-8297-25,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  75 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-856-11,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,25021-674-20,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 400 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0143-9887-75,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MANNITOL 20% IV SOLP,50863,CDM,250,RC,J2150,HCPCS,0990-7715-13,NDC,facility,both,1,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 200 MG/20 ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,31722-203-20,NDC,facility,both,1,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,250,RC,J7060,HCPCS,0338-0017-31,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-512-11,NDC,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZOCAINE-MENTHOL 20 %-0.5 % TOPICAL AEROSOL,50863,CDM,250,RC,J3490,HCPCS,7513785045,NDC,facility,both,1,GM,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,87,EA,,12006,8404.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID (PORK) 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0456-0457-01,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 40 MG/ML SUSP (DEPO-MEDROL) INJECTION,50863,CDM,636,RC,J1010,HCPCS,70121-1573-1,NDC,facility,both,40,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68180-980-01,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0781-3246-64,NDC,facility,both,4,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ABATACEPT 250 MG IV SOLR,50863,CDM,636,RC,J0129,HCPCS,0003-2187-13,NDC,facility,both,50,EA,JA,8556,5989.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,0409-1886-22,NDC,facility,both,150,ML,JZ,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SODIUM CHLORIDE 0.9 % IV (BOLUS),50863,CDM,250,RC,J7040,HCPCS,65219-472-05,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
URSODIOL 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,50268-797-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,250,RC,J3490,HCPCS,73013-2002-2,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  120 MG RECT SUPP,50863,CDM,250,RC,J3490,HCPCS,45802-732-00,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J0461,HCPCS,0517-1004-01,NDC,facility,both,20,ML,JW,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DROPERIDOL 2.5 MG/ML INJ SOLN,50863,CDM,250,RC,J1790,HCPCS,0517-9702-01,NDC,facility,both,1,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML (ANESTHESIA INTRAOP ONLY),50863,CDM,250,RC,J3010,HCPCS,0641-6027-01,NDC,facility,both,2,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CINACALCET 30 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,64380-883-04,NDC,facility,both,3,EA,,390,273,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-990-01,NDC,facility,both,1,EA,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,636,RC,J2405,HCPCS,70860-776-41,NDC,facility,both,8,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,0409-9093-32,NDC,facility,both,1,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
FENTANYL CITRATE (PF) 50 MCG/ML (ANESTHESIA INTRAOP ONLY),50863,CDM,636,RC,J3010,HCPCS,0641-6027-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0093-2279-73,NDC,facility,both,7,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,50863,CDM,636,RC,J8540,HCPCS,0054-8175-25,NDC,facility,both,160,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES-DOCUSATE SODIUM 8.6 MG-50 MG TAB,50863,CDM,250,RC,J3490,HCPCS,60687-622-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG ORAL CM12,50863,CDM,250,RC,J3490,HCPCS,60505-2806-7,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68180-966-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,67877-545-88,NDC,facility,both,8,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIRMATRELVIR-RITONAVIR 150 MG (10)- 100 MG (10) ORAL DSPK,50863,CDM,636,RC,J3490,HCPCS,0069-5317-20,NDC,facility,both,1,EA,,381,266.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
D5-LR WITH POTASSIUM CHLORIDE 20 MEQ/L IV SOLP,50863,CDM,636,RC,J3490,HCPCS,0990-7111-09,NDC,facility,both,1,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-467-01,NDC,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VINCRISTINE 2 MG/2 ML IV SOLN,50863,CDM,J9370,HCPCS,61703-309-16,NDC,,,facility,both,2,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-677-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,40,ML,,140,98,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BECLOMETHASONE DIPROPIONATE 40 MCG/ACTUATION INHL HFAB,50863,CDM,250,RC,J3490,HCPCS,59310-302-40,NDC,facility,both,1,GM,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-0710-20,NDC,facility,both,11,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  750 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-882-11,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G POTASSIUM  5000000 UNIT INJ SOLR,50863,CDM,250,RC,J2540,HCPCS,72603-210-01,NDC,facility,both,7,EA,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 4 MG (ENVARSUS XR) 24-HOUR EXTENDED-RELEASE TABLET,50863,CDM,250,RC,J7508,HCPCS,68992-3040-3,NDC,facility,both,2,EA,,225,157.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-119-11,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 100 MG ORAL TBSR,50863,CDM,J3490,HCPCS,0591-3540-60,NDC,,,facility,both,2,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-1638-32,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,13,EA,JW,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,636,RC,J2560,HCPCS,72162-1329-8,NDC,facility,both,1,ML,,386,270.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIPHTH,PERTUS(ACELL),TETANUS SYRG (INFANRIX) 25 LF UNIT-58MCG-10 LF/0.5ML IM SYRINGE",50863,CDM,636,RC,90700,HCPCS,58160-810-43,NDC,facility,both,1,ML,,334,233.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,81284-315-05,NDC,facility,both,1,ML,,470,329,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-590-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 250 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,42192-608-05,NDC,facility,both,4,ML,,127,88.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM  3 GRAM INJ SOLR,50863,CDM,250,RC,J0295,HCPCS,66794-207-02,NDC,facility,both,2,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION,50863,CDM,250,RC,J0840,HCPCS,50633-111-11,NDC,facility,both,2,EA,,17653,12357.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,70756-622-85,NDC,facility,both,4000,ML,,207,144.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-739-11,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 20 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7346-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),50863,CDM,250,RC,J2060,HCPCS,0641-6044-01,NDC,facility,both,3,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAUNORUBICIN 5 MG/ML IV INJ,50863,CDM,250,RC,J9150,HCPCS,0143-9550-01,NDC,facility,both,12,ML,,2721,1904.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIOTHYRONINE 25 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,59762-1207-1,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE (POLACRILEX) 2 MG MM LOZG,50863,CDM,636,RC,J3490,HCPCS,45802-344-05,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTAZIDIME NEO IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0713,HCPCS,0781-3177-80,NDC,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 200 MG/20 ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,31722-203-20,NDC,facility,both,1,ML,,200,140,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOMYCIN-BACITRACN ZN-POLYMYXIN 3.5 MG-400 U*,50863,CDM,250,RC,J3490,HCPCS,45802-143-00,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GAMMAGARD LIQUID 10 % IV SOLN,50863,CDM,636,RC,J1569,HCPCS,0944-2700-13,NDC,facility,both,50,ML,"JW,JA",3919,2743.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
MORPHINE  15 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,0904-6557-61,NDC,facility,both,5,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J1938,HCPCS,23155-473-32,NDC,facility,both,40,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RAMIPRIL  5 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,68382-146-01,NDC,facility,both,2,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,69918-899-01,NDC,facility,both,4,ML,,223,156.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 20 MG ORAL CPDR,50863,CDM,636,RC,J3490,HCPCS,68180-294-07,NDC,facility,both,3,EA,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 500 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,16714-485-01,NDC,facility,both,2,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IV PGBK,50863,CDM,250,RC,J3490,HCPCS,63323-106-00,NDC,facility,both,1,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,105,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZONATATE 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,68084-214-11,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LINEZOLID 100 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0054-0319-50,NDC,facility,both,1,ML,,689,482.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,50863,CDM,250,RC,Q0177,HCPCS,60687-675-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIROFIBAN-0.9% SODIUM CHLORIDE 5 MG/100 ML (50 MCG/ML) IV SOLN,50863,CDM,250,RC,J3246,HCPCS,25208-002-03,NDC,facility,both,16,ML,JW,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
FLUCONAZOLE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6501-06,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 100 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,31722-574-47,NDC,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEPIVACAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J0670,HCPCS,63323-260-01,NDC,facility,both,3,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT  60 MCG/0.3 ML INJ SYRG,50863,CDM,250,RC,J0881,HCPCS,55513-023-01,NDC,facility,both,20,ML,"JW,EC",186,130.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient | Modifier EC: Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy
THYROID (PORK)  30 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,62559-741-01,NDC,facility,both,3,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,55150-154-10,NDC,facility,both,200,ML,,157,109.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0832-1211-89,NDC,facility,both,5,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,20,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESNA 100 MG/ML IV SOLN,50863,CDM,250,RC,J9209,HCPCS,10019-953-62,NDC,facility,both,47,ML,,1372,960.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-02,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 5 MG/ML IV SOLN,50863,CDM,250,RC,J1921,HCPCS,25021-317-20,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYPROHEPTADINE 4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0115-1757-01,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,636,RC,J0690,HCPCS,70092-1017-46,NDC,facility,both,2,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 500 MG INJ SOLR,50863,CDM,250,RC,J0696,HCPCS,0409-7338-11,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROPROCAINE 3 % INJ SOLN,50863,CDM,250,RC,J2401,HCPCS,63323-478-01,NDC,facility,both,138,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,104,ML,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRIMIDONE 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-687-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG RECT SUPP,50863,CDM,J3490,HCPCS,51672-2116-0,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE  25 MG ORAL TAB,50863,CDM,J3490,HCPCS,68084-342-11,NDC,,,facility,both,2,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2310,HCPCS,0641-6132-01,NDC,facility,both,2,ML,,200,140,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE  7 MG/24 HR TD PT24,50863,CDM,636,RC,J3490,HCPCS,43598-446-71,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,0143-9595-01,NDC,,,facility,both,200,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,50863,CDM,J9045,HCPCS,61703-339-56,NDC,,,facility,both,12,ML,,301,210.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IVPB (PEDIATRICS/ADULT NON-FORM)",50863,CDM,250,RC,J0131,HCPCS,24201-100-01,NDC,facility,both,100,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUB-Q SOLN",50863,CDM,90716,HCPCS,0006-4827-01,NDC,,,facility,both,1,EA,,465,325.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,0409-3795-19,NDC,facility,both,4,ML,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,76045-009-10,NDC,facility,both,13,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB 100 MG IV SOLR,50863,CDM,636,RC,J1745,HCPCS,57894-030-01,NDC,facility,both,60,EA,,19340,13538,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,69315-905-05,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-070-10,NDC,facility,both,3,EA,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN  500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7162-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYUREA  500 MG ORAL CAP,50863,CDM,250,RC,J9999,HCPCS,68084-284-11,NDC,facility,both,3,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOMIPRAMINE 75 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,16714-851-03,NDC,facility,both,1,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,50863,CDM,250,RC,J0696,HCPCS,60505-6148-0,NDC,facility,both,3,EA,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLNALTREXONE 12 MG/0.6 ML SUBQ SYRG,50863,CDM,250,RC,J2212,HCPCS,65649-551-07,NDC,facility,both,40,ML,,272,190.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,636,RC,J3490,HCPCS,71449-068-11,NDC,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0143-2112-50,NDC,facility,both,1,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML IV SOLN (MERGE),50863,CDM,636,RC,J3490,HCPCS,16714-037-10,NDC,facility,both,1,ML,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J7510,HCPCS,17856-0815-1,NDC,facility,both,2,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,J3360,HCPCS,0641-6244-01,NDC,,,facility,both,2,ML,,145,101.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE IN 0.9% NS (PF) 1 MG/10 ML (100 MCG/ML) IV SYRG(PDS MERGE),50863,CDM,636,RC,J3490,HCPCS,65302-506-10,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,16714-293-01,NDC,facility,both,10,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZOCAINE-MENTHOL 20 %-0.5 % TOPICAL AEROSOL,50863,CDM,636,RC,J3490,HCPCS,5140900722,NDC,facility,both,2,GM,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0137,HCPCS,0143-9386-01,NDC,facility,both,15,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-9543-02,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BRENTUXIMAB VEDOTIN 50 MG IV SOLR,50863,CDM,J9042,HCPCS,51144-050-01,NDC,,,facility,both,180,EA,,62876,44013.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 500 MG INJ SOLR,50863,CDM,J0696,HCPCS,44567-700-25,NDC,,,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM  3 GRAM INJ SOLR,50863,CDM,J0295,HCPCS,0049-0014-81,NDC,,,facility,both,2,EA,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZINC SULFATE 220 MG (50 MG) CAP,50863,CDM,636,RC,J3490,HCPCS,7733398325,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOMYCIN-BACITRACN ZN-POLYMYXIN 3.5 MG-400 U*,50863,CDM,636,RC,J3490,HCPCS,0904-8805-67,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,636,RC,J3490,HCPCS,72789-057-01,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,J1171,HCPCS,0409-1283-03,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,70710-1833-1,NDC,facility,both,2,EA,,458,320.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VERAPAMIL 2.5 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,72485-108-01,NDC,facility,both,1,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,4,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),50863,CDM,250,RC,J3490,HCPCS,63323-186-01,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MISOPROSTOL 50 MCG ORAL SPLIT TAB,50863,CDM,250,RC,S0191,HCPCS,60687-735-01,NDC,facility,both,4,EA,,337,235.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 0.4 MG/HR TD PT24,50863,CDM,250,RC,J3490,HCPCS,43598-894-11,NDC,facility,both,2,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J2003,HCPCS,73293-0001-1,NDC,facility,both,200,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEDI MULTIVIT NO.128-VITAMIN K 500 MCG/ML ORAL LIQD,50863,CDM,250,RC,J3490,HCPCS,6817600010,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE  50 MG ORAL TAB,50863,CDM,250,RC,j3490,HCPCS,60687-443-11,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCARPIDASE 1000 UNIT IV SOLR,50863,CDM,250,RC,C9293,HCPCS,50633-210-11,NDC,facility,both,100,EA,,75478,52834.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOPROTERENOL 0.2 MG/ML INJECTION,50863,CDM,250,RC,J3490,HCPCS,69918-731-01,NDC,facility,both,1,ML,,843,590.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAMSULOSIN 0.4 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,50268-740-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NYSTATIN  100000 UNIT/G TOP CREA,50863,CDM,250,RC,J3490,HCPCS,45802-059-35,NDC,facility,both,1,GM,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-464-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AGALSIDASE BETA 35 MG IV SOLR,50863,CDM,636,RC,J0180,HCPCS,58468-0040-1,NDC,facility,both,70,ME,,32535,22774.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV,50863,CDM,636,RC,J7120,HCPCS,0338-0117-03,NDC,facility,both,2,ML,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-4675-05,NDC,facility,both,4,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,42,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML INJ SOLN,50863,CDM,250,RC,J0171,HCPCS,76329-9060-0,NDC,facility,both,71,ML,,189,132.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 0.5% NASAL DROPS (REPACK),50863,CDM,636,RC,J3490,HCPCS,69536-050-15,NDC,facility,both,4,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DROPERIDOL 2.5 MG/ML INJ SOLN,50863,CDM,250,RC,J1790,HCPCS,0517-9702-01,NDC,facility,both,1,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACCHAROMYCES BOULARDII 250 MG ORAL CAP,50863,CDM,J3490,HCPCS,1785608695,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,J1938,HCPCS,0409-6102-18,NDC,,,facility,both,120,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6640-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 50 MG TAB,50863,CDM,636,RC,J3490,HCPCS,62584-266-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 0.5 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,49884-311-52,NDC,facility,both,2,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAUNORUBICIN 5 MG/ML IV INJ,50863,CDM,250,RC,J9150,HCPCS,42658-021-01,NDC,facility,both,1,ML,JW,141,98.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
"DIPHTH,PERTUS(ACELL),TETANUS SYRG (INFANRIX) 25 LF UNIT-58MCG-10 LF/0.5ML IM SYRINGE",50863,CDM,636,RC,90700,HCPCS,58160-810-52,NDC,facility,both,1,ML,,172,120.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,636,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,25,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
SILVER SULFADIAZINE 1 % TOP CREA,50863,CDM,250,RC,J3490,HCPCS,67877-124-50,NDC,facility,both,1,GM,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VARENICLINE 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,49884-155-76,NDC,facility,both,1,EA,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,250,RC,J2270,HCPCS,0409-1891-03,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EZETIMIBE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0781-5690-92,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 50 MG/ML IV SOLN,50863,CDM,636,RC,J0282,HCPCS,0143-9875-10,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 0.3 % OPHT DROP,50863,CDM,250,RC,J3490,HCPCS,61314-656-25,NDC,facility,both,1,ML,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL 100 MCG/HR TD PT72,50863,CDM,250,RC,J3490,HCPCS,60505-7009-0,NDC,facility,both,1,EA,,334,233.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-210-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM POLYSTYRENE SULFONATE ORAL POWDER,50863,CDM,250,RC,J3490,HCPCS,10702-036-15,NDC,facility,both,1,GM,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE PAMOATE  50 MG ORAL CAP,50863,CDM,250,RC,Q0177,HCPCS,0185-0676-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INDOMETHACIN 25 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,31722-542-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,17271-701-05,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6291-06,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 50 MG/ML IV SOLN,50863,CDM,250,RC,J0282,HCPCS,63323-616-09,NDC,facility,both,15,ML,JZ,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
TOLTERODINE 2 MG ORAL CP24,50863,CDM,636,RC,J3490,HCPCS,60687-319-11,NDC,facility,both,2,EA,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-192-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,70095-031-01,NDC,facility,both,24,ML,JZ,968,677.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
VANCOMYCIN IN 0.9 % SODIUM CHL 1.5 GRAM/500 ML IV SOLN,50863,CDM,636,RC,J3370,HCPCS,70004-924-44,NDC,facility,both,3,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,50863,CDM,636,RC,J0585,HCPCS,0023-1145-01,NDC,facility,both,140,EA,,2238,1566.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR IN 0.9% NACL 100 UNIT/100 ML (1 UNIT/ML) INFUSION FOR OB,50863,CDM,250,RC,J1815,HCPCS,0338-0126-12,NDC,facility,both,1,ML,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 250 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,42192-608-05,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-04,NDC,facility,both,2,ML,"JZ,PLAD",34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier PLAD: Modifier description not available
TRAMADOL  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,72888-080-01,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPAGLIFLOZIN PROPANEDIOL  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,66993-456-30,NDC,facility,both,2,EA,,217,151.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID (PORK)  30 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0456-0458-01,NDC,facility,both,4,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATENOLOL  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-684-01,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-1971-21,NDC,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSULFAN BLUE 1 % INJ SOLN,50863,CDM,636,RC,Q9968,HCPCS,67457-220-05,NDC,facility,both,30,ML,,2579,1805.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROMETHORPHAN-GUAIFENESIN SR 30 MG-600 MG 12 HR TAB,50863,CDM,250,RC,J3490,HCPCS,17856-1162-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 TABLET
ENALAPRIL MALEATE 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,23155-773-01,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,21,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0780,HCPCS,23155-294-31,NDC,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,55390-138-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EXENATIDE 5 MCG/0.02 ML SUBQ PNIJ,50863,CDM,250,RC,J3490,HCPCS,0310-6512-01,NDC,facility,both,1,ML,,2346,1642.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,0641-6145-01,NDC,facility,both,6,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,3,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,68516-5219-0,NDC,facility,both,8,ML,,2034,1423.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIRMATRELVIR-RITONAVIR 300-100 MG ORAL TAB DOSEPACK (FOR ED/IP TAKE HOME PANEL),50863,CDM,636,RC,J3490,HCPCS,0069-5321-03,NDC,facility,both,30,EA,,4010,2807,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,250,RC,J3490,HCPCS,0641-6104-01,NDC,facility,both,3,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN ASP PRT-INSULIN ASPART 100 UNIT/ML (70-30) SUBQ SOLN,50863,CDM,250,RC,J1817,HCPCS,73070-200-11,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,1,ML,,1735,1214.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  500 MG IV SOLR,50863,CDM,250,RC,J3370,HCPCS,0069-2587-03,NDC,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 25 MG/5 ML (5 MG/ML) ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,62559-204-12,NDC,facility,both,1,ML,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 60 MG ORAL CPDR,50863,CDM,J3490,HCPCS,57237-019-30,NDC,,,facility,both,2,EA,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIMOLOL MALEATE 0.5 % OPHT DROP,50863,CDM,636,RC,J3490,HCPCS,17478-288-10,NDC,facility,both,1,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,0409-9094-22,NDC,facility,both,3,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,J0665,HCPCS,63323-466-17,NDC,,,facility,both,200,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 40 MG/ML SUSP (DEPO-MEDROL) INJECTION,50863,CDM,J1010,HCPCS,70121-1573-1,NDC,,,facility,both,40,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM 500 MG IV SOLR,50863,CDM,J2185,HCPCS,63323-507-01,NDC,,,facility,both,5,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHIMAZOLE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,23155-070-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,J2560,HCPCS,0641-0476-21,NDC,,,facility,both,1,ML,,155,108.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE CONCENTRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0054-0404-44,NDC,facility,both,5,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  100 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,63323-376-01,NDC,facility,both,4,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNIT/G TOP PACK,50863,CDM,250,RC,J3490,HCPCS,0904-7402-67,NDC,facility,both,8,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-1283-03,NDC,facility,both,20,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN SODIUM EXTENDED 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-841-11,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLIPIZIDE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-362-11,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOLIC ACID  1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-681-11,NDC,facility,both,5,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,62584-994-11,NDC,facility,both,3,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-499-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 10 MG/ML (PF) IV SOLN,50863,CDM,636,RC,J2270,HCPCS,0641-6127-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 3000 MCG/ML INJECTION,50863,CDM,636,RC,J0153,HCPCS,67457-855-00,NDC,facility,both,24,ML,,167,116.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,50863,CDM,636,RC,J3420,HCPCS,63323-044-00,NDC,facility,both,2,ML,JZ,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LEUPROLIDE  7.5 MG SUBQ SYRG,50863,CDM,636,RC,J9217,HCPCS,62935-756-80,NDC,facility,both,1,EA,JZ,1176,823.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ISOPROTERENOL 0.2 MG/ML INJECTION,50863,CDM,636,RC,J3490,HCPCS,70121-1605-1,NDC,facility,both,1,ML,,1249,874.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PSEUDOEPHEDRINE 30 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0904-5053-59,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 2-0.5 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,50268-144-11,NDC,facility,both,2,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25 MG-100 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0378-0085-01,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,50863,CDM,636,RC,J3490,HCPCS,0378-7732-93,NDC,facility,both,1,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,250,RC,J2003,HCPCS,63323-495-27,NDC,facility,both,40,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,0088-2220-33,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.45 % 0.45 % IV SOLP,50863,CDM,250,RC,J3490,HCPCS,0264-7802-00,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLIPIZIDE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0591-0461-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,0409-4887-17,NDC,facility,both,3,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 3000 MCG/ML INJECTION,50863,CDM,250,RC,J0153,HCPCS,67457-855-02,NDC,facility,both,6,ML,JZ,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,71288-402-10,NDC,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,50863,CDM,J3420,HCPCS,63323-044-00,NDC,,,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAUNORUBICIN 5 MG/ML IV INJ,50863,CDM,250,RC,J9150,HCPCS,0143-9550-01,NDC,facility,both,3,ML,JW,285,199.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
TOPIRAMATE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-342-11,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0641-6206-01,NDC,facility,both,5,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25 MG-250 MG TAB,50863,CDM,250,RC,J3490,HCPCS,60687-836-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,50863,CDM,250,RC,J0640,HCPCS,25021-814-30,NDC,facility,both,4,EA,,207,144.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,31722-711-30,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 300 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,69452-125-50,NDC,facility,both,1,ML,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  25 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,69238-1310-9,NDC,facility,both,9,EA,,322,225.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE 220 MCG/ACTUATION INHL AERO,50863,CDM,250,RC,J3490,HCPCS,0173-0720-20,NDC,facility,both,1,GM,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,636,RC,J7060,HCPCS,0338-0017-48,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CELECOXIB 200 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6503-61,NDC,facility,both,2,EA,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM BROMIDE 0.02 % INHL SOLN,50863,CDM,250,RC,J3490,HCPCS,60687-394-79,NDC,facility,both,2,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLNALTREXONE 12 MG/0.6 ML SUBQ SOLN,50863,CDM,250,RC,J2212,HCPCS,65649-551-02,NDC,facility,both,1,ML,,693,485.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DICLOFENAC 50 MG TAB, DELAYED RELEASE",50863,CDM,250,RC,J3490,HCPCS,16571-202-06,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM ACETATE 2 MEQ/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-3299-15,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DONEPEZIL 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6478-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2599,HCPCS,63323-930-01,NDC,facility,both,10,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,67877-545-68,NDC,facility,both,2,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J7510,HCPCS,17856-0815-1,NDC,facility,both,6,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE CONCENTRATE 10 MG/ 0.5 ML ORAL SYRINGE (0.5ML UD MERGE),50863,CDM,636,RC,J3490,HCPCS,68094-045-01,NDC,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,1,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR PHOSPHATE 75 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,64380-799-01,NDC,facility,both,1,EA,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-089-11,NDC,facility,both,2,EA,,254,177.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,28,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 40 MG/ML SUSP (DEPO-MEDROL) INJECTION,50863,CDM,636,RC,J1010,HCPCS,0009-3073-01,NDC,facility,both,120,ML,,200,140,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,81033-002-05,NDC,facility,both,2,ML,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,636,RC,J3360,HCPCS,0409-1273-03,NDC,facility,both,4,ML,,396,277.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,184,ML,,130,91,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0137,HCPCS,0781-3156-06,NDC,facility,both,35,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,987,ME,JZ,13394,9375.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
BUPROPION HCL 100 MG ORAL TBSR,50863,CDM,636,RC,J3490,HCPCS,0591-3540-60,NDC,facility,both,2,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 20 MG/ML INJ SOLN,50863,CDM,636,RC,J0360,HCPCS,0641-6231-01,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-074-01,NDC,facility,both,5,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0245-0212-11,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNITS/1 GRAM PACKET (MERGE RECORD),50863,CDM,250,RC,J3490,HCPCS,45802-060-00,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,63323-400-01,NDC,facility,both,350,ML,,368,257.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-22,NDC,facility,both,40,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,72611-722-25,NDC,facility,both,1,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
BENZOYL PEROXIDE  5 % TOP GEL,50863,CDM,250,RC,J3490,HCPCS,0536-1055-56,NDC,facility,both,1,GM,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"CALCIUM CARBONATE 500 MG (1,250 MG) ORAL TAB",50863,CDM,636,RC,J3490,HCPCS,7985450021,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,50863,CDM,250,RC,J9025,HCPCS,72485-201-01,NDC,facility,both,115,EA,,1631,1141.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN DEGLUDEC 100 UNITS/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,73070-400-11,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN 125 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,51672-4069-2,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFIXIME 100 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,68180-405-01,NDC,facility,both,1,ML,,378,264.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-04,NDC,facility,both,2,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,Q9968,HCPCS,0517-0374-01,NDC,,,facility,both,200,ML,,3319,2323.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-1159-19,NDC,facility,both,4,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7030,HCPCS,0338-0049-04,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR 200 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,70954-188-10,NDC,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,J3490,HCPCS,66794-228-02,NDC,,,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-02,NDC,facility,both,1,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE (FOR CODE) 10% IV SOLN,50863,CDM,J3490,HCPCS,0517-6710-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,50863,CDM,250,RC,J9267,HCPCS,61703-342-22,NDC,facility,both,167,ML,,276,193.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 3 MG/ 3ML ORAL SOLUTION (PEDS),50863,CDM,250,RC,J3490,HCPCS,0054-3555-63,NDC,facility,both,4,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 250 MCG SUBQ SOLR,50863,CDM,250,RC,J2802,HCPCS,55513-221-01,NDC,facility,both,250,EA,,4390,3073,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMPLE SYRUP,50863,CDM,636,RC,J3490,HCPCS,395266116,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUM U-500 CONC 500 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1815,HCPCS,0002-8501-01,NDC,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"TRANEXAMIC ACID IN NACL,ISO-OS 1,000 MG/100 ML (10 MG/ML) IV PGBK",50863,CDM,250,RC,J3490,HCPCS,65219-534-01,NDC,facility,both,1,ML,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6949-61,NDC,facility,both,4,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-503-11,NDC,facility,both,3,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25 MG-100 MG TAB,50863,CDM,250,RC,J3490,HCPCS,60687-661-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUORESCEIN 1 MG OPHT STRP,50863,CDM,636,RC,J3490,HCPCS,17238-900-99,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,250,RC,J3490,HCPCS,55150-188-10,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0121-0917-05,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,14,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR  6 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0004-0822-05,NDC,facility,both,3,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  75 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-441-01,NDC,facility,both,3,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
URSODIOL 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,50268-797-11,NDC,facility,both,3,EA,,113,79.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,636,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,6,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAZOSIN 1 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,68084-996-11,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,62559-440-02,NDC,facility,both,1,ML,,227,158.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7193-06,NDC,facility,both,20,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-492-37,NDC,facility,both,1,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7050,HCPCS,0264-7800-20,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0143-9889-15,NDC,facility,both,15,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE 14 MG/24 HR TD PT24,50863,CDM,250,RC,J3490,HCPCS,43598-447-71,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,2,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0781-6041-58,NDC,facility,both,10,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,50863,CDM,250,RC,J8540,HCPCS,0054-8175-25,NDC,facility,both,16,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DENOSUMAB 60 MG/ML SUBQ SYRG,50863,CDM,636,RC,J0897,HCPCS,55513-710-21,NDC,facility,both,60,ML,JZ,5177,3623.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
VANCOMYCIN IN D5W 1 GRAM/200 ML IV PGBK,50863,CDM,250,RC,J3370,HCPCS,0338-3552-48,NDC,facility,both,2,ML,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42291-560-90,NDC,facility,both,2,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  10 MG ORAL TR12,50863,CDM,636,RC,J3490,HCPCS,59011-410-20,NDC,facility,both,1,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 50 MG 24 HR TAB,50863,CDM,636,RC,J3490,HCPCS,50268-541-11,NDC,facility,both,2,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG IV SOLR,50863,CDM,636,RC,J0456,HCPCS,70095-025-01,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,63,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  5 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0054-8724-25,NDC,facility,both,5,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TERBINAFINE 250 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16714-795-01,NDC,facility,both,14,EA,,611,427.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1162-18,NDC,facility,both,200,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-192-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLPIDEM  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0093-0073-01,NDC,facility,both,1,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,4,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICLOXACILLIN 500 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,59651-566-01,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LANOLIN OINTMENT (MODIFIED),50863,CDM,250,RC,J3490,HCPCS,4467710202,NDC,facility,both,1,GM,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IVABRADINE 5 MG ORAL TAB,50863,CDM,250,RC,50742-362-60,NDC,,,facility,both,1,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,63323-400-01,NDC,facility,both,200,ML,,210,147,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-253-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0990-7983-61,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 875 MG-125 MG TAB,50863,CDM,250,RC,J3490,HCPCS,16714-297-02,NDC,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLESTYRAMINE-SUCROSE 4 GRAM ORAL PACK,50863,CDM,250,RC,J3490,HCPCS,42806-266-98,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,12,EA,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,250,RC,J1596,HCPCS,0143-9679-01,NDC,facility,both,5,ML,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/0.5 ML INHL NEBU,50863,CDM,636,RC,J3490,HCPCS,0487-9901-30,NDC,facility,both,6,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACAMPROSATE 333 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,0378-6333-80,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 1 MG ORAL TAB,50863,CDM,250,RC,J8540,HCPCS,0054-4181-25,NDC,facility,both,72,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SYRG,50863,CDM,J3490,HCPCS,8290306500,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,50863,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,12,EA,,262,183.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,22,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIPASE-PROTEASE-AMYLASE 12,000-38,000- 60,000 UNIT ORAL CAP, DELAY REL",50863,CDM,250,RC,J3490,HCPCS,0032-1212-01,NDC,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM SR 180 MG 24 HR CAP,50863,CDM,J3490,HCPCS,60687-206-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J2250,HCPCS,0409-0001-01,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DENOSUMAB-BBDZ 60 MG/ML SUBQ SYRG,50863,CDM,Q5136,HCPCS,61314-240-63,NDC,,,facility,both,60,ML,,4428,3099.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM-DEXTRS 4.5 GRAM/100 ML IV PGBK,50863,CDM,250,RC,J3490,HCPCS,0338-9638-01,NDC,facility,both,1,ML,,111,77.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NOREPINEPHRINE BITARTRATE-D5W 4 MG/250 ML (16 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0338-0112-20,NDC,facility,both,1,ML,,134,93.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,50863,CDM,250,RC,J9045,HCPCS,0703-4239-01,NDC,facility,both,13,ML,,344,240.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG IV SOLR,50863,CDM,J3490,HCPCS,0143-9381-01,NDC,,,facility,both,1,EA,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 17 GRAM (100 %) ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,0904-6931-86,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,4,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM BROMIDE 17 MCG/ACTUATION INHL AERO,50863,CDM,250,RC,J3490,HCPCS,0597-0087-17,NDC,facility,both,1,GM,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  5 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,60687-122-11,NDC,facility,both,50,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL  5 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-6797-61,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZOCAINE-MENTHOL 6-10 MG MM LOZG,50863,CDM,250,RC,J3490,HCPCS,0363-0700-08,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,636,RC,J2795,HCPCS,70069-064-25,NDC,facility,both,50,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VECURONIUM BROMIDE 20 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,47335-932-40,NDC,facility,both,1,EA,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  10 MG ORAL TR12,50863,CDM,250,RC,J3490,HCPCS,59011-410-20,NDC,facility,both,1,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6008-60,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,63323-461-01,NDC,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 20 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,50111-648-01,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 8-2 MG SL SUBL,50863,CDM,636,RC,J3490,HCPCS,60687-637-11,NDC,facility,both,2,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,250,RC,J2003,HCPCS,63323-485-27,NDC,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0630,HCPCS,42023-205-01,NDC,facility,both,1,ML,,5099,3569.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,636,RC,J2795,HCPCS,63323-286-20,NDC,facility,both,100,ML,JZ,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,53,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  1 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,59651-484-01,NDC,facility,both,1,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,2,ML,,2081,1456.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML INJ SOLN,50863,CDM,250,RC,J2060,HCPCS,0641-6207-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2003,HCPCS,0409-2066-05,NDC,,,facility,both,200,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,25021-410-76,NDC,facility,both,3,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,250,RC,J2720,HCPCS,63323-229-01,NDC,facility,both,2,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 0.4MG/ML ORAL SOLUTION (REPACK),50863,CDM,250,RC,J1100,HCPCS,0069-4547-01,NDC,facility,both,4,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,67457-385-10,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,72789-062-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7057-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  160 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,0904-6645-24,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FERRIC SUBSULFATE 0.2 TO 0.22 GRAM/ML MISC SOLA,50863,CDM,636,RC,J3490,HCPCS,48783-112-08,NDC,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 40 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7178-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J1938,HCPCS,63323-280-03,NDC,facility,both,40,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J1940,HCPCS,72603-251-01,NDC,facility,both,4,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,67457-433-00,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTOBACILLUS ACIDOPHILUS 500 MILLION CELLS ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,7733300415,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV,50863,CDM,250,RC,J7120,HCPCS,0338-0117-04,NDC,facility,both,1,ML,PLAD,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0074-4552-11,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,J2704,HCPCS,0069-0209-01,NDC,,,facility,both,20,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,76045-009-10,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PNEUMOC 20-VAL CONJ-DIP CR(PF) 0.5 ML IM SYRG,50863,CDM,90677,HCPCS,0005-2000-01,NDC,,,facility,both,1,ML,,955,668.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,J1953,HCPCS,55150-177-05,NDC,,,facility,both,300,ML,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 1 MG ORAL TAB,50863,CDM,636,RC,J8540,HCPCS,0054-8174-25,NDC,facility,both,12,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2001,HCPCS,63323-495-09,NDC,,,facility,both,4,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE 20 MG TAB,50863,CDM,250,RC,J3490,HCPCS,68084-045-11,NDC,facility,both,2,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,23155-724-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN NPH & REGULAR HUMAN 100 UNIT/ML (70-30) SUBQ SUSP,50863,CDM,250,RC,J1815,HCPCS,0169-1837-11,NDC,facility,both,15,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 15% IN WATER,50863,CDM,250,RC,J3490,HCPCS,0338-0023-03,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG IV SOLR,50863,CDM,636,RC,J3490,HCPCS,63323-649-07,NDC,facility,both,1,EA,,457,319.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,290,ML,JW,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LEVETIRACETAM NEO IV SYRINGE (PHS FROM PREMIX),50863,CDM,250,RC,J1953,HCPCS,44567-501-01,NDC,facility,both,50,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) IV SOLN",50863,CDM,250,RC,J3490,HCPCS,43066-008-01,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 25 MG CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7237-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
URSODIOL 60 MG/ML ORAL SUSPENSION (REPACK),50863,CDM,250,RC,j3490,HCPCS,0527-1326-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE 21 MG/24 HR TD PT24,50863,CDM,636,RC,J3490,HCPCS,43598-448-71,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DONEPEZIL 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-303-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LANSOPRAZOLE 30 MG ORAL TBLD,50863,CDM,250,RC,J3490,HCPCS,64764-544-30,NDC,facility,both,1,EA,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACIDOPHILUS-PECTIN W CITRUS 25 MILLION-100 CELL MG TAB,50863,CDM,250,RC,J3490,HCPCS,1785614241,NDC,facility,both,10,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL,50863,CDM,250,RC,J3490,HCPCS,63323-820-01,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0264-1800-32,NDC,facility,both,1,ML,JZ,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,68094-494-59,NDC,facility,both,4,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J1940,HCPCS,63323-280-04,NDC,facility,both,2,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL DECANOATE 100 MG/ML IM SOLN,50863,CDM,250,RC,J1631,HCPCS,70069-383-01,NDC,facility,both,4,ML,,475,332.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML INJ SOLN,50863,CDM,636,RC,J2060,HCPCS,0641-6207-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN DETEMIR 100 UNIT/ML SUBQ SOLN,50863,CDM,636,RC,J1815,HCPCS,0169-3687-12,NDC,facility,both,7,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 600 MG ORAL TP12,50863,CDM,250,RC,J3490,HCPCS,63824-008-15,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,2,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,120,EA,,16560,11592,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 0.4 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,68462-639-25,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 1 MG (ENVARSUS XR) 24-HOUR EXTENDED-RELEASE TABLET,50863,CDM,250,RC,J7508,HCPCS,68992-3010-3,NDC,facility,both,2,EA,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,42806-150-33,NDC,facility,both,3,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 10 GRAM/100 ML (10%) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-72,NDC,facility,both,40,ML,"JZ,JA",5658,3960.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
AMPICILLIN-SULBACTAM NEO/PEDS (CDS MIXTURE),50863,CDM,636,RC,J0295,HCPCS,63323-368-20,NDC,facility,both,2,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,636,RC,J3370,HCPCS,16714-309-01,NDC,facility,both,2,EA,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,15,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAMADOL  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-795-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-48,NDC,facility,both,1,ML,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIPASE-PROTEASE-AMYLASE 5,000-17,000- 24,000 UNIT ORAL CPDR",50863,CDM,250,RC,J3490,HCPCS,73562-115-01,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  1 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,64380-782-06,NDC,facility,both,5,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTAMIDINE 300 MG INJ SOLR,50863,CDM,636,RC,J3490,HCPCS,63323-113-01,NDC,facility,both,1,EA,,236,165.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NOREPINEPHRINE BITARTRATE-D5W 4 MG/250 ML (16 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,71285-6056-1,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50111-398-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,59762-4900-3,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7368-06,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML (PEDS CALCLUATOR 0.5),50863,CDM,636,RC,J1815,HCPCS,0024-5924-10,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0536-1286-36,NDC,facility,both,30,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLP",50863,CDM,636,RC,P9047,HCPCS,0944-0493-04,NDC,facility,both,1,ML,JW,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LEVOCARNITINE (WITH SUCROSE) 100 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,52817-830-04,NDC,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0780,HCPCS,25021-790-02,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN PEDS IV INFUSION 12 MG/ML (CDS MIXTURE FROM PREMIX),50863,CDM,250,RC,J0736,HCPCS,0781-3289-91,NDC,facility,both,1,ML,JW,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
NICOTINE (POLACRILEX) 2 MG MM LOZG,50863,CDM,250,RC,J3490,HCPCS,45802-344-05,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,50863,CDM,636,RC,J9075,HCPCS,0781-3244-94,NDC,facility,both,200,EA,,1896,1327.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLECAINIDE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0054-0011-20,NDC,facility,both,1,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM SR 300 MG 24 HR CAP,50863,CDM,250,RC,J3490,HCPCS,60687-228-11,NDC,facility,both,2,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 1 MG (ENVARSUS XR) 24-HOUR EXTENDED-RELEASE TABLET,50863,CDM,636,RC,J7508,HCPCS,68992-3010-3,NDC,facility,both,1,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,57237-077-10,NDC,facility,both,5,EA,,402,281.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,636,RC,J3490,HCPCS,0409-4887-17,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 500 MG-125 MG TAB,50863,CDM,636,RC,J3490,HCPCS,16714-296-01,NDC,facility,both,1,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,636,RC,J1815,HCPCS,49502-393-80,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NAPROXEN 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-403-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LINEZOLID 600 MG/300 ML IV SOLP,50863,CDM,250,RC,J2020,HCPCS,66794-219-63,NDC,facility,both,2,ML,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN 0.9 % SODIUM CHL 2 GRAM/500 ML IV SOLN,50863,CDM,250,RC,J3370,HCPCS,71506-019-59,NDC,facility,both,4,ML,JZ,148,103.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PRAVASTATIN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-649-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6290-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  500 MG IV SOLR,50863,CDM,250,RC,J3373,HCPCS,0143-9161-01,NDC,facility,both,1,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 40 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6781-61,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,68094-494-59,NDC,facility,both,3,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAUNORUBICIN 5 MG/ML IV INJ,50863,CDM,636,RC,J9150,HCPCS,42658-021-01,NDC,facility,both,1,ML,JW,149,104.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0047-03,NDC,facility,both,25,EA,JZ,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
BENZOCAINE 20 % MM SPRY,50863,CDM,636,RC,J3490,HCPCS,0283-0610-43,NDC,facility,both,1,EA,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,636,RC,P9045,HCPCS,68516-5214-1,NDC,facility,both,2,ML,,447,312.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-492-27,NDC,facility,both,40,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOPIDOGREL 300 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-184-11,NDC,facility,both,2,EA,,189,132.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0003-0894-31,NDC,facility,both,1,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,16714-293-01,NDC,facility,both,10,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,16714-294-01,NDC,facility,both,9,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIVAROXABAN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50458-580-01,NDC,facility,both,2,EA,,234,163.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2599,HCPCS,43598-914-25,NDC,facility,both,3,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,1,EA,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MONTELUKAST 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6808-61,NDC,facility,both,7,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE   4.2 % IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-026-05,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TERAZOSIN  5 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,50268-766-11,NDC,facility,both,4,EA,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6928-61,NDC,facility,both,1,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-609-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM  4.5 GRAM IV SOLR,50863,CDM,250,RC,J2543,HCPCS,81284-153-00,NDC,facility,both,4,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0641-0400-12,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68180-445-01,NDC,facility,both,6,EA,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  50 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-484-11,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM  3 GRAM INJ SOLR,50863,CDM,250,RC,J0295,HCPCS,0641-6117-01,NDC,facility,both,2,EA,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,0121-4799-05,NDC,facility,both,3,ML,,101,70.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM-ALBUTEROL 0.5 MG-2.5 MG/3 ML NEB SOLUTION,50863,CDM,636,RC,J3490,HCPCS,60687-405-79,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLECAINIDE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-0011-20,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-3426-05,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,63323-185-07,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PALONOSETRON 0.25 MG/5 ML IV INJECTION (MERGE),50863,CDM,J2469,HCPCS,0703-4094-01,NDC,,,facility,both,10,ML,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,250,RC,J2003,HCPCS,63323-495-09,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-208-01,NDC,,,facility,both,400,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,11,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-559-11,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN NPH & REGULAR HUMAN 100 UNIT/ML (70-30) SUBQ SUSP,50863,CDM,250,RC,J1815,HCPCS,0169-1837-11,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-467-01,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NORTRIPTYLINE 25 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,50268-604-11,NDC,facility,both,6,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,50863,CDM,250,RC,J9075,HCPCS,0781-3233-94,NDC,facility,both,200,EA,,2431,1701.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,70095-031-01,NDC,facility,both,5,ML,,186,130.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,1,ML,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,6,ML,,166,116.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,43598-931-11,NDC,facility,both,3,ML,,134,93.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,250,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,9,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUGAMMADEX 100 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0006-5423-02,NDC,facility,both,2,ML,,1121,784.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 3 MG/ 3ML ORAL SOLUTION (PEDS),50863,CDM,250,RC,J3490,HCPCS,0054-3555-63,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,250,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERYTHROMYCIN 5 MG/G OPHT OINT,50863,CDM,636,RC,J3490,HCPCS,72485-670-31,NDC,facility,both,2,GM,,196,137.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 400 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6667-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETHIODIZED OIL 48 % INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,67684-1901-1,NDC,facility,both,2,ML,,6605,4623.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,18,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GALANTAMINE  4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,57237-049-60,NDC,facility,both,2,EA,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7243-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,250,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,10,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-495-27,NDC,facility,both,13,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 30 MG ORAL CPDR,50863,CDM,636,RC,J3490,HCPCS,51991-747-90,NDC,facility,both,3,EA,,111,77.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 20 MG/ML INJ SOLN,50863,CDM,250,RC,J0360,HCPCS,0641-6231-01,NDC,facility,both,1,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARDIOPLEGIC SOLUTION NO.25 29 MMOL/L (POTASSIUM) PERF SOLN,50863,CDM,J3490,HCPCS,69374-984-10,NDC,,,facility,both,3,ML,,1512,1058.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,J1953,HCPCS,0143-9673-10,NDC,,,facility,both,300,ML,,160,112,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2599,HCPCS,65219-039-00,NDC,facility,both,10,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),50863,CDM,J0171,HCPCS,76329-3318-1,NDC,,,facility,both,300,ML,,2201,1540.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL  2 MG ORAL TAB,50863,CDM,J3490,HCPCS,51079-735-01,NDC,,,facility,both,3,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG ORAL TBEC,50863,CDM,J3490,HCPCS,51079-051-01,NDC,,,facility,both,1,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,72611-722-25,NDC,facility,both,1,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,J3490,HCPCS,0093-2279-73,NDC,,,facility,both,10,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALTREXONE 50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68094-853-62,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,J0133,HCPCS,63323-325-03,NDC,,,facility,both,200,ML,,221,154.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-742-11,NDC,facility,both,2,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 875 MG-125 MG TAB,50863,CDM,J3490,HCPCS,16714-297-02,NDC,,,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-437-11,NDC,facility,both,4,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % MUCOSAL SOLN (VISCOUS),50863,CDM,250,RC,J3490,HCPCS,0603-1393-64,NDC,facility,both,10,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,63323-325-03,NDC,facility,both,200,ML,,221,154.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN D5W 20000 UNIT/500 ML,50863,CDM,636,RC,J1644,HCPCS,0264-9567-10,NDC,facility,both,20,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE  5 MG/ML INJ SOLN,50863,CDM,J2765,HCPCS,0409-3414-21,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NORTRIPTYLINE 25 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0093-0811-01,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16714-988-01,NDC,facility,both,1,EA,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE (DIAGNOSTIC) 3 MG/ML IV SOLN,50863,CDM,636,RC,J0153,HCPCS,16714-997-01,NDC,facility,both,90,ML,JZ,735,514.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0121-0945-10,NDC,facility,both,1,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-467-01,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM HYPOCHLORITE 0.5 % MISC SOLN,50863,CDM,250,RC,J3490,HCPCS,0436-0946-16,NDC,facility,both,1,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NOREPINEPHRINE BITARTRATE-D5W 4 MG/250 ML (16 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,71285-6056-1,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0781-3220-75,NDC,facility,both,1,ML,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOPERAMIDE 2 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-229-11,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICARDIPINE IN NACL (ISO-OS) 20 MG/200 ML IV PGBK,50863,CDM,250,RC,J3490,HCPCS,69097-007-45,NDC,facility,both,2,ML,,509,356.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 125 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,60687-211-11,NDC,facility,both,3,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4 % TOP CREA,50863,CDM,250,RC,J3490,HCPCS,0496-0882-05,NDC,facility,both,1,GM,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,63739-931-28,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,636,RC,J2720,HCPCS,63323-229-01,NDC,facility,both,8,ML,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID (PORK)  60 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,75834-312-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-01,NDC,facility,both,2,ML,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOPERAMIDE 1 MG/7.5 ML ORAL LIQD,50863,CDM,250,RC,J3490,HCPCS,0904-6836-20,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,J1836,HCPCS,0409-0152-01,NDC,,,facility,both,25,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,5026852411,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,636,RC,J2270,HCPCS,0409-1890-03,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IR SOLN,50863,CDM,250,RC,J3490,HCPCS,0338-0047-46,NDC,facility,both,5,ML,,264,184.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE HCL  2 % MM JELP,50863,CDM,636,RC,J3490,HCPCS,76329-3013-5,NDC,facility,both,1,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,517,ME,,7016,4911.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE LIPOSOME (PF) 266 MG/20 ML (13.3 MG/ML) LINF SUSP,50863,CDM,250,RC,J3490,HCPCS,65250-266-09,NDC,facility,both,1,ML,,1116,781.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,55150-370-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  100 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,63323-376-00,NDC,facility,both,4,ML,JB,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JB: Administered subcutaneously
FENTANYL  25 MCG/HR TD PT72,50863,CDM,250,RC,J3490,HCPCS,60505-7081-0,NDC,facility,both,1,EA,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,25021-402-01,NDC,facility,both,15,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-50,NDC,facility,both,108,ML,,191,133.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN PEDS INFUSION (CDS MIXTURE),50863,CDM,250,RC,J0290,HCPCS,25021-136-10,NDC,facility,both,3,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN NPH HUMAN RECOMB 100 UNIT/ML SUBQ SUSP,50863,CDM,250,RC,J1815,HCPCS,0169-1834-11,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,55390-110-10,NDC,facility,both,1,EA,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPATITIS A & B VIRUS VACCINE (PF) 720 ELISA UNIT-20 MCG/ML IM SYRINGE,50863,CDM,90636,HCPCS,58160-815-43,NDC,,,facility,both,1,ML,,572,400.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE  5 MG ORAL TAB,50863,CDM,J3490,HCPCS,50268-088-11,NDC,,,facility,both,1,EA,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV,50863,CDM,J7120,HCPCS,0338-0117-04,NDC,,,facility,both,2,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TICAGRELOR 90 MG ORAL TAB,50863,CDM,J3490,HCPCS,72205-368-91,NDC,,,facility,both,7,EA,,179,125.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,60687-145-11,NDC,facility,both,40,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUBIPROSTONE  8 MCG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0254-3028-02,NDC,facility,both,1,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,2,ML,,227,158.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-318-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 125 MCG SUBQ SOLR,50863,CDM,636,RC,J2802,HCPCS,55513-223-01,NDC,facility,both,55,EA,,1129,790.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-074-11,NDC,facility,both,8,EA,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 10 MG/5 ML SYRUP,50863,CDM,250,RC,Q0177,HCPCS,60432-150-04,NDC,facility,both,1,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,14789-251-09,NDC,facility,both,3,ML,,573,401.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPRAZOLAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-388-11,NDC,facility,both,5,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,68094-231-59,NDC,facility,both,5,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE HCL 0.3 MG/ML INJ (MERGE),50863,CDM,250,RC,J0592,HCPCS,42023-179-01,NDC,facility,both,6,ML,,160,112,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,10702-018-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,72,ML,JW,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
SUMATRIPTAN 50 MG TAB,50863,CDM,636,RC,J3490,HCPCS,55111-292-09,NDC,facility,both,2,EA,,214,149.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,J3490,HCPCS,63037-136-25,NDC,,,facility,both,2,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE (FOR EMERGENCY) 100 MG/ML (10%) IV SOLN,50863,CDM,250,RC,J0612,HCPCS,0143-9180-01,NDC,facility,both,200,ML,JZ,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,60,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,72266-118-01,NDC,facility,both,1,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,250,RC,J3490,HCPCS,63037-136-25,NDC,facility,both,2,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2003,HCPCS,55150-165-05,NDC,,,facility,both,100,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0641-6057-01,NDC,facility,both,1,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
BUPIVACAINE 0.25%/EPINEPHRINE 1:100K INJECTION,50863,CDM,250,RC,J3490,HCPCS,0409-1158-01,NDC,facility,both,2,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,6,EA,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PSEUDOEPHEDRINE 30 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6337-24,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,250,RC,J0690,HCPCS,60505-6142-0,NDC,facility,both,2,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEFLUNOMIDE  20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,62332-062-30,NDC,facility,both,1,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,67877-670-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 250 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,42192-608-05,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,636,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,49502-393-80,NDC,facility,both,1,ML,,321,224.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,70860-700-41,NDC,facility,both,1,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CYCLOPENTOLATE 1 % OPHT DROP,50863,CDM,250,RC,J3490,HCPCS,61314-396-01,NDC,facility,both,1,ML,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,7985420062,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 4 MG (ENVARSUS XR) 24-HOUR EXTENDED-RELEASE TABLET,50863,CDM,250,RC,J7508,HCPCS,68992-3040-3,NDC,facility,both,3,EA,,220,154,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GALANTAMINE  4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-729-11,NDC,facility,both,3,EA,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,636,RC,J1953,HCPCS,55150-177-05,NDC,facility,both,300,ML,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSULFAN BLUE 1 % INJ SOLN,50863,CDM,636,RC,Q9968,HCPCS,67457-220-05,NDC,facility,both,20,ML,,1720,1204,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,76329-3352-1,NDC,facility,both,3,ML,,316,221.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,50863,CDM,250,RC,J0640,HCPCS,0143-9554-01,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 10% IN WATER (D10) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0338-0023-02,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BISOPROLOL FUMARATE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-127-11,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM PHOSPHATE 4.4 MEQ/ML ORAL SOLUTION (CDS),50863,CDM,250,RC,J3490,HCPCS,0409-7295-11,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN PEDS INFUSION (CDS MIXTURE),50863,CDM,636,RC,J0290,HCPCS,25021-136-10,NDC,facility,both,2,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   2 G IV SOLR,50863,CDM,250,RC,J0688,HCPCS,0143-9139-25,NDC,facility,both,4,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELIMUMAB 120 MG IV SOLR,50863,CDM,636,RC,J0490,HCPCS,49401-101-01,NDC,facility,both,24,ME,"JZ,JA,JG",2819,1973.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously | Modifier JG: Drug or biological acquired with 340b drug pricing program discount
PENICILLIN V POTASSIUM 250 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,57237-040-01,NDC,facility,both,28,EA,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE-DIPHENHYD-AL-MAG-SIM 200-25-400-40 MG/30 ML MM MWSH,50863,CDM,250,RC,J3490,HCPCS,65628-050-01,NDC,facility,both,3,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FILGRASTIM-SNDZ 480 MCG/0.8 ML INJ SYRG,50863,CDM,250,RC,Q5101,HCPCS,61314-326-05,NDC,facility,both,480,ML,,1212,848.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,63323-649-07,NDC,facility,both,1,EA,,457,319.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,250,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,25021-602-03,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM IN NACL (ISO-OS) 1000 MG/100 ML IV PGBK,50863,CDM,250,RC,J1953,HCPCS,67457-265-00,NDC,facility,both,100,ML,,127,88.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 7.5 MG-325 MG/15 ML ORAL SOLN (REPACK),50863,CDM,250,RC,J3490,HCPCS,0121-2316-15,NDC,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NAPROXEN 250 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-594-15,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUANFACINE 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0591-0444-01,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,J3490,HCPCS,63323-467-01,NDC,,,facility,both,1,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-01,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.25 MG/0.5 ML (0.5 MG/1 ML) ORAL SUSPENSION (REPACK),50863,CDM,250,RC,J3490,HCPCS,0591-0240-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB 100 MG IV SOLR,50863,CDM,J1745,HCPCS,57894-160-01,NDC,,,facility,both,73,EA,,9571,6699.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE  50 MCG/ACTUATION NASL SPSN,50863,CDM,250,RC,J3490,HCPCS,60429-195-15,NDC,facility,both,1,GM,,413,289.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM  3 GRAM INJ SOLR,50863,CDM,636,RC,J0295,HCPCS,71288-006-31,NDC,facility,both,2,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM BROMIDE 0.03 % NASL SPRA,50863,CDM,250,RC,J3490,HCPCS,0054-0045-44,NDC,facility,both,1,ML,,402,281.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE 2 MG SL SUBL,50863,CDM,636,RC,J3490,HCPCS,0904-7154-04,NDC,facility,both,2,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  50 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-484-11,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6953-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,250,RC,J7060,HCPCS,0990-7923-37,NDC,facility,both,1,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DILTIAZEM SR 60 MG 12 HR CAP,50863,CDM,636,RC,J3490,HCPCS,51079-924-01,NDC,facility,both,2,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ (REPACK)(MERGE) (FOR PCA),50863,CDM,250,RC,J3010,HCPCS,70004-211-30,NDC,facility,both,1,ML,,217,151.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN   81 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,57896-981-12,NDC,facility,both,3,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM NEO/PED INFUSION (CDS MIXTURE),50863,CDM,250,RC,J2185,HCPCS,0781-3267-90,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML IV,50863,CDM,250,RC,J3490,HCPCS,17478-937-05,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-ABDA 100 MG IV SOLR,50863,CDM,636,RC,Q5104,HCPCS,78206-162-99,NDC,facility,both,120,EA,,24953,17467.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5%-LACTATED RINGERS IV,50863,CDM,636,RC,J7120,HCPCS,0338-0125-03,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERYTHROMYCIN 250 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,13668-586-30,NDC,facility,both,2,EA,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRIMIDONE 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-687-11,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-347-11,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,76282-208-90,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID (PORK)  60 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0456-0459-01,NDC,facility,both,2,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 100 MG/ML INJ SOLN,50863,CDM,636,RC,J2800,HCPCS,71288-716-11,NDC,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,636,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,3,ML,GZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier GZ: Item or service expected to be denied as not reasonable and necessary
PHENYTOIN SODIUM EXTENDED 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0071-0369-40,NDC,facility,both,3,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,636,RC,J3490,HCPCS,61553-320-70,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 20 MG/ACTUATION NASL SPRY,50863,CDM,250,RC,J3490,HCPCS,0527-1859-43,NDC,facility,both,1,EA,,345,241.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,636,RC,J3490,HCPCS,73013-2002-2,NDC,facility,both,2,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 0.1 MG/ML INJ SYRG,50863,CDM,250,RC,J0461,HCPCS,16729-484-03,NDC,facility,both,300,ML,,184,128.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,250,RC,J0330,HCPCS,0781-3411-70,NDC,facility,both,5,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,531,ML,,761,532.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DONEPEZIL  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6477-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,250,RC,J3101,HCPCS,50242-037-06,NDC,facility,both,15,EA,,6482,4537.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE (FOR CODE) 10% (100 MG/ML) IV SYRINGE,50863,CDM,250,RC,J3490,HCPCS,64253-900-30,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,25021-402-01,NDC,facility,both,5,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ALLOPURINOL 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-206-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID (PORK)  30 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,62559-741-01,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIOGLITAZONE 30 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65862-513-30,NDC,facility,both,1,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 1 MG ORAL CAP,50863,CDM,250,RC,J7507,HCPCS,51079-818-01,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,636,RC,J3360,HCPCS,76045-204-00,NDC,facility,both,1,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MANNITOL 20% IV SOLP,50863,CDM,250,RC,J2150,HCPCS,0990-7715-13,NDC,facility,both,1,ML,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRIMIDONE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-686-11,NDC,facility,both,4,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,75,ML,,107,74.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,636,RC,J1953,HCPCS,55150-177-05,NDC,facility,both,100,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-48,NDC,facility,both,2,ML,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 25 MG TAB,50863,CDM,250,RC,J3490,HCPCS,51079-255-01,NDC,facility,both,6,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTOBACILLUS ACIDOPHILUS 500 MILLION CELLS ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,904726006,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 60 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,57237-019-90,NDC,facility,both,2,EA,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV (BOLUS),50863,CDM,636,RC,J7120,HCPCS,0264-7750-07,NDC,facility,both,2,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN IN D5W 200 MG/100 ML IV PGBK,50863,CDM,250,RC,J0744,HCPCS,0409-2300-01,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML (PEDS CALCLUATOR 0.5),50863,CDM,250,RC,J1815,HCPCS,0024-5924-10,NDC,facility,both,7,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-208-05,NDC,,,facility,both,100,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,J3490,HCPCS,0409-4887-17,NDC,,,facility,both,2,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,0904-7127-61,NDC,facility,both,100,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,71288-402-10,NDC,facility,both,10,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-988-01,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,46,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,4,ML,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IR SOLN,50863,CDM,636,RC,J3490,HCPCS,0264-2201-00,NDC,facility,both,2,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0630,HCPCS,24201-400-02,NDC,facility,both,1,ML,,1634,1143.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-9558-05,NDC,facility,both,4,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPRAZOLAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-388-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HUMAN PROTHROMBIN COMPLEX 500 UNIT IV SOLR,50863,CDM,250,RC,J7168,HCPCS,63833-396-01,NDC,facility,both,2000,UN,JZ,11638,8146.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PROPOFOL IV BOLUS 10MG/ML (ANESTHESIA ONLY),50863,CDM,636,RC,J2704,HCPCS,0409-4699-54,NDC,facility,both,100,ML,JZ,127,88.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
HALOPERIDOL 2 MG/ML ORAL CONCENTRATE,50863,CDM,250,RC,J3490,HCPCS,0121-0581-05,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,636,RC,J3490,HCPCS,0143-9575-01,NDC,facility,both,500,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,250,RC,J2720,HCPCS,63323-229-30,NDC,facility,both,25,ML,,270,189,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL IV BOLUS 10MG/ML (ANESTHESIA ONLY),50863,CDM,250,RC,J2704,HCPCS,0409-4699-54,NDC,facility,both,400,ML,,507,354.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-405-11,NDC,facility,both,3,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROIC ACID 250 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0591-4012-01,NDC,facility,both,3,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML INJ SOLN,50863,CDM,250,RC,J0171,HCPCS,76329-9060-0,NDC,facility,both,27,ML,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-381-11,NDC,facility,both,2,EA,,583,408.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OMEPRAZOLE-SODIUM BICARBONATE 2-84 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,65628-270-05,NDC,facility,both,10,ML,,107,74.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2720-03,NDC,facility,both,30,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 200 MG/20 ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,72205-220-01,NDC,facility,both,1,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  60 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69292-536-01,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
REPAGLINIDE 2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65862-672-01,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,1500,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7008-61,NDC,facility,both,6,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IV PGBK,50863,CDM,250,RC,J3490,HCPCS,63323-106-02,NDC,facility,both,1,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN  100 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,8068107100,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,50863,CDM,250,RC,J3420,HCPCS,0517-0031-01,NDC,facility,both,1,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-086-01,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,63323-104-25,NDC,facility,both,13,ML,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,15,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 175 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-541-11,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MYCOPHENOLATE 250 MG CAP,50863,CDM,250,RC,J7517,HCPCS,68084-795-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,250,RC,J3101,HCPCS,50242-037-06,NDC,facility,both,14,EA,,6050,4235,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN (NEO),50863,CDM,250,RC,J1938,HCPCS,71288-203-10,NDC,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,63323-506-00,NDC,facility,both,10,ML,JZ,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ALLOPURINOL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-205-01,NDC,facility,both,4,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESIPRAMINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50742-113-01,NDC,facility,both,3,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,2,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC MCARE ADMIN HEPATITIS B VACC,50863,CDM,250,RC,90744,HCPCS,58160-820-43,NDC,facility,both,1,ML,,171,119.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 400 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0143-9887-01,NDC,facility,both,11,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 100 MG/ML FROM 1 GRAM VIAL (PRMC PEDS ONLY),50863,CDM,636,RC,J0696,HCPCS,0409-7332-11,NDC,facility,both,3,EA,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6476-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML IV,50863,CDM,636,RC,J3490,HCPCS,70860-301-41,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRBESARTAN 150 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,33342-048-07,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2308-22,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 60 MG TAB,50863,CDM,250,RC,J3490,HCPCS,50228-482-01,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIFEDIPINE 10 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7229-61,NDC,facility,both,2,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-582-11,NDC,facility,both,5,EA,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-346-11,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,72603-179-01,NDC,facility,both,10,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,25021-321-04,NDC,facility,both,4,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLIMEPIRIDE 2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-326-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOVASTATIN 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,61442-142-01,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZONISAMIDE 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,69097-861-07,NDC,facility,both,3,EA,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,J0665,HCPCS,55150-169-10,NDC,,,facility,both,100,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 15 MG/ML (1.5 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-493-01,NDC,,,facility,both,90,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB 100 MG IV SOLR,50863,CDM,636,RC,J1745,HCPCS,57894-030-01,NDC,facility,both,120,EA,,38679,27075.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0406-0512-23,NDC,facility,both,3,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  75 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-475-01,NDC,facility,both,7,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 500 MCG INJ SOLR,50863,CDM,636,RC,J3490,HCPCS,63323-648-10,NDC,facility,both,1,EA,,1457,1019.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 150 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-432-11,NDC,facility,both,3,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,52,EA,,7176,5023.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  25 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-473-11,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OMEPRAZOLE 20 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,0904-6917-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  500 MCG/ML INJ SOLN,50863,CDM,636,RC,J2354,HCPCS,0641-6176-01,NDC,facility,both,20,ML,JA,206,144.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,636,RC,Q0162,HCPCS,65162-691-79,NDC,facility,both,4,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0137,HCPCS,0143-9386-01,NDC,facility,both,24,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,15,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SINCALIDE 5 MCG INJ SOLR,50863,CDM,636,RC,J2805,HCPCS,72266-248-05,NDC,facility,both,1,EA,,213,149.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,50863,CDM,636,RC,J2359,HCPCS,55150-308-01,NDC,facility,both,10,EA,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 150 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-711-11,NDC,facility,both,4,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J3430,HCPCS,0409-9158-50,NDC,facility,both,5,ML,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FINASTERIDE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,67877-288-90,NDC,facility,both,1,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA 25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68682-200-25,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COENZYME Q10  30 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,536135807,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6799-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BIMATOPROST 0.01 % OPHT DROP,50863,CDM,636,RC,J3490,HCPCS,0023-3205-03,NDC,facility,both,1,ML,,935,654.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 100 MG IV SOLR,50863,CDM,636,RC,J2997,HCPCS,50242-085-25,NDC,facility,both,50,EA,JW,5281,3696.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,250,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  15 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,0406-8315-01,NDC,facility,both,2,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,67877-246-01,NDC,facility,both,2,EA,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,68516-5214-4,NDC,facility,both,4,ML,,893,625.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,37,EA,,5106,3574.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6799-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,80,ML,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN D5W 20000 UNIT/500 ML,50863,CDM,636,RC,J1644,HCPCS,0264-9567-10,NDC,facility,both,11,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,636,RC,J1953,HCPCS,0409-1886-22,NDC,facility,both,400,ML,,207,144.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GAMMAGARD LIQUID 10 % IV SOLN,50863,CDM,636,RC,J1569,HCPCS,0944-2700-13,NDC,facility,both,60,ML,JZ,10817,7571.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CEPHALEXIN 250 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-152-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,4,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON DEXTRAN 50 MG/ML INJ SOLN,50863,CDM,250,RC,J1750,HCPCS,0023-6082-01,NDC,facility,both,20,ML,,2084,1458.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN  850 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-143-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) IV SOLN,50863,CDM,636,RC,J9220,HCPCS,81284-315-05,NDC,facility,both,5,ML,JZ,294,205.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,250,RC,J2270,HCPCS,76045-004-10,NDC,facility,both,1,ML,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0295,HCPCS,63323-368-20,NDC,facility,both,2,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,0517-4620-25,NDC,facility,both,3,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE (FOR EMERGENCY) 100 MG/ML (10%) IV SOLN,50863,CDM,250,RC,J0612,HCPCS,63323-360-01,NDC,facility,both,50,ML,JW,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
METHADONE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-5755-23,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,64208-2510-1,NDC,facility,both,1,ML,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIROFIBAN-0.9% SODIUM CHLORIDE 5 MG/100 ML (50 MCG/ML) IV SOLN,50863,CDM,250,RC,J3246,HCPCS,25208-002-03,NDC,facility,both,6,ML,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAZOSIN 1 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7020-61,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,636,RC,J3490,HCPCS,61553-320-70,NDC,facility,both,4,ML,,276,193.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,636,RC,J3490,HCPCS,60687-653-11,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1815,HCPCS,0002-8215-01,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOBENZAPRINE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-558-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIVAROXABAN  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50458-577-01,NDC,facility,both,8,EA,,387,270.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6966-61,NDC,facility,both,5,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 200 MG/20 ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,72205-220-01,NDC,facility,both,1,ML,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-ABDA 100 MG IV SOLR,50863,CDM,636,RC,Q5104,HCPCS,78206-162-99,NDC,facility,both,1,EA,JW,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,636,RC,J1100,HCPCS,55150-304-01,NDC,facility,both,10,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),50863,CDM,636,RC,J1815,HCPCS,0024-5926-05,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 10 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-6987-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMPLE SYRUP,50863,CDM,250,RC,J3490,HCPCS,395266116,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIPASE-PROTEASE-AMYLASE 24,000-76,000- 120,000 UNIT ORAL CAP, DELAY REL",50863,CDM,250,RC,J3490,HCPCS,0032-2636-01,NDC,facility,both,1,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  20 MEQ ORAL PACK,50863,CDM,250,RC,J3490,HCPCS,72888-024-06,NDC,facility,both,1,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2310,HCPCS,67457-299-00,NDC,facility,both,1,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 250 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0071-2012-23,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2308-22,NDC,facility,both,10,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
RIFAMPIN 150 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-575-11,NDC,facility,both,3,EA,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 250 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,0904-6860-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J2310,HCPCS,36000-308-01,NDC,facility,both,2,ML,,167,116.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MILRINONE IN D5W 20 MG/100 ML (0.2 MG/ML) INFUSION,50863,CDM,250,RC,J2260,HCPCS,0409-2045-01,NDC,facility,both,5,ML,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 500 MCG INJ SOLR,50863,CDM,250,RC,J3490,HCPCS,25021-470-10,NDC,facility,both,1,EA,,1313,919.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,39,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,50863,CDM,636,RC,J0696,HCPCS,25021-106-10,NDC,facility,both,7,EA,,256,179.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EMOLLIENT COMBINATION NO.10 TOPICAL EMULSION,50863,CDM,250,RC,J3490,HCPCS,5898096012,NDC,facility,both,1,GM,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE   4.2 % IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-083-05,NDC,facility,both,1,ML,,108,75.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0780,HCPCS,0713-0351-02,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J2003,HCPCS,0409-4279-16,NDC,facility,both,300,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-0552-23,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOBENZAPRINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69097-846-07,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,636,RC,J7060,HCPCS,0338-0017-04,NDC,facility,both,2,ML,JZ,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
OXALIPLATIN 100 MG/20 ML IV SOLN,50863,CDM,250,RC,J9263,HCPCS,71288-172-21,NDC,facility,both,9,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,250,RC,J3490,HCPCS,70092-1119-44,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 25 MG CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7237-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,636,RC,J0690,HCPCS,70092-1017-46,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,125,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXRAZOXANE 500 MG IV SOLR,50863,CDM,250,RC,J1190,HCPCS,55150-435-01,NDC,facility,both,1,EA,JW,335,234.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-588-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 500 MG (200 MG ELEMENTAL) CHEW TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6412-92,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE SODIUM 25 MG/ML INJ SOLN,50863,CDM,636,RC,J9260,HCPCS,16729-277-30,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,31722-820-30,NDC,facility,both,1,EA,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,2,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,42806-150-33,NDC,facility,both,3,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,636,RC,J0330,HCPCS,31722-981-10,NDC,facility,both,10,ML,,113,79.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,23,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICARDIPINE 20 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,42806-501-09,NDC,facility,both,1,EA,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,636,RC,J7060,HCPCS,0338-0017-31,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68094-005-59,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 500 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,50268-152-11,NDC,facility,both,16,EA,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML INJ SOLN,50863,CDM,250,RC,J0171,HCPCS,76329-9060-0,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,63323-165-01,NDC,facility,both,8,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM NEO IV SYRINGE (PHS FROM PREMIX),50863,CDM,250,RC,J1953,HCPCS,44567-501-01,NDC,facility,both,20,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,0121-1971-21,NDC,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID (PORK)  30 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42192-329-01,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 500 MG (200 MG ELEMENTAL) CHEW TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6412-92,NDC,facility,both,6,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,636,RC,J1596,HCPCS,70069-011-01,NDC,facility,both,2,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DONEPEZIL  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-292-11,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VERAPAMIL 2.5 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,70710-1643-1,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,120,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAMSULOSIN 0.4 MG ORAL CP24,50863,CDM,J3490,HCPCS,0904-7383-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VINCRISTINE 2 MG/2 ML IV SOLN,50863,CDM,636,RC,J9370,HCPCS,61703-309-06,NDC,facility,both,2,ML,,209,146.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-41,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG ORAL CAP,50863,CDM,J3490,HCPCS,0093-3145-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,50863,CDM,J3490,HCPCS,0904-6666-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0003-0894-21,NDC,facility,both,4,EA,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 5 % TOP OINT,50863,CDM,636,RC,J3490,HCPCS,16714-878-01,NDC,facility,both,1,GM,,803,562.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 100 MG ORAL TAB,50863,CDM,J3490,HCPCS,51079-205-01,NDC,,,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 50 MG/ML IM,50863,CDM,J3410,HCPCS,0517-5601-25,NDC,,,facility,both,1,ML,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALUM-MAG HYDROXIDE-SIMETH 200 MG-200 MG-20 MG/5 ML ORAL SUSP,50863,CDM,J3490,HCPCS,0121-1761-30,NDC,,,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  500 MCG/ML INJ SOLN,50863,CDM,J2354,HCPCS,0641-6176-01,NDC,,,facility,both,18,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,12,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,63323-104-01,NDC,facility,both,4,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-25,NDC,facility,both,40,ML,"JZ,JA",5658,3960.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
"WATER FOR INJECTION, STERILE IV",50863,CDM,250,RC,J3490,HCPCS,0338-0013-04,NDC,facility,both,1,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-097-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESNA 100 MG/ML IV SOLN,50863,CDM,250,RC,J9209,HCPCS,10019-953-62,NDC,facility,both,6,ML,,165,115.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,10,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML IV SOLN (MERGE),50863,CDM,636,RC,J3490,HCPCS,70756-611-82,NDC,facility,both,1,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6780-61,NDC,facility,both,2,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ELTROMBOPAG 25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,31722-842-30,NDC,facility,both,1,EA,,832,582.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,0409-4279-16,NDC,,,facility,both,200,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,J3010,HCPCS,0641-6027-25,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VINCRISTINE 2 MG/2 ML IV SOLN,50863,CDM,250,RC,J9370,HCPCS,61703-309-06,NDC,facility,both,1,ML,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL (5 MG/ML) IV SYRG (CONTAINS PRESERVATIVE),50863,CDM,J3490,HCPCS,0409-2339-24,NDC,,,facility,both,1,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATENOLOL  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7187-61,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ICATIBANT 30 MG/3 ML SUBQ SYRG,50863,CDM,J1744,HCPCS,0093-3066-34,NDC,,,facility,both,30,ML,,29229,20460.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,50863,CDM,J0696,HCPCS,63323-346-01,NDC,,,facility,both,4,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6008-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,42806-150-33,NDC,facility,both,7,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYPROHEPTADINE 4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50742-190-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NOREPINEPHRINE BITARTRATE-D5W 4 MG/250 ML (16 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,71285-6056-1,NDC,facility,both,1,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,55,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LURASIDONE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7355-04,NDC,facility,both,3,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6008-61,NDC,facility,both,1,EA,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DRONEDARONE 400 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0024-4142-60,NDC,facility,both,1,EA,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB 100 MG IV SOLR,50863,CDM,636,RC,J1745,HCPCS,57894-030-01,NDC,facility,both,40,EA,,12893,9025.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 40 MG-200 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,65862-496-47,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  5 MG ORAL TBDL,50863,CDM,636,RC,J3490,HCPCS,60505-3275-0,NDC,facility,both,2,EA,,140,98,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 40 MG/ML SUSP (DEPO-MEDROL) INJECTION,50863,CDM,250,RC,J1010,HCPCS,70121-1573-1,NDC,facility,both,40,ML,JZ,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
EPINEPHRINE 1 MG/ML INJ SOLN,50863,CDM,J0171,HCPCS,0548-9061-00,NDC,,,facility,both,300,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,72162-1330-6,NDC,facility,both,5,ML,,2374,1661.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-990-01,NDC,facility,both,2,EA,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 2 MG INJ SOLR,50863,CDM,250,RC,J2997,HCPCS,50242-041-63,NDC,facility,both,6,EA,,1984,1388.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,13,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,10,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,58,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J2004,HCPCS,63323-482-03,NDC,facility,both,60,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIVAROXABAN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50458-580-01,NDC,facility,both,2,EA,,234,163.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORTHALIDONE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-317-95,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOBAZAM 2.5 MG/ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,99999-0404-03,NDC,facility,both,1,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHOTERICIN B LIPOSOME 50 MG IV SUSR,50863,CDM,250,RC,J0289,HCPCS,62756-233-01,NDC,facility,both,69,EA,,12373,8661.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOMYCIN-BACITRACIN ZN-POLYMYXIN 3.5 MG-400 UN*,50863,CDM,250,RC,J3490,HCPCS,45802-143-03,NDC,facility,both,1,GM,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADVATE: FACTOR VIII CONCENTRATE (MERGE RECORD),50863,CDM,J7209,HCPCS,0944-3052-04,NDC,,,facility,both,500,UN,,2093,1465.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"HEPARIN (PORCINE) IN 0.9% NACL 2,500 UNIT/250 ML (10 UNIT/ML) IV SOLP",50863,CDM,250,RC,j3690,HCPCS,71285-8000-1,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT  40 MCG/0.4 ML INJ SYRG,50863,CDM,636,RC,J0881,HCPCS,55513-021-01,NDC,facility,both,40,ML,EC,1096,767.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier EC: Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy
CHLOROPROCAINE 3 % INJ SOLN,50863,CDM,636,RC,J2401,HCPCS,63323-478-01,NDC,facility,both,300,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-086-01,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLIPIZIDE  2.5 MG ORAL TO24,50863,CDM,636,RC,J3490,HCPCS,60687-480-11,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESTRADIOL 2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,70954-566-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUVOXAMINE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0832-1671-11,NDC,facility,both,6,EA,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 875 MG-125 MG TAB,50863,CDM,636,RC,J3490,HCPCS,16714-297-02,NDC,facility,both,10,EA,,241,168.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,62,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIOTHYRONINE 25 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,62756-590-88,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 10 MEQ/100 ML IV PGBK,50863,CDM,J3480,HCPCS,0990-7074-26,NDC,,,facility,both,5,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) IV SOLN",50863,CDM,J9022,HCPCS,50242-917-01,NDC,,,facility,both,120,ML,,23792,16654.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN LOCK FLUSH 100 UNIT/ML IV SOLN,50863,CDM,J1642,HCPCS,6425333335,NDC,,,facility,both,50,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MISOPROSTOL 200 MCG ORAL TAB,50863,CDM,S0191,HCPCS,60687-746-11,NDC,,,facility,both,2,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 40 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-099-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,31722-711-30,NDC,facility,both,1,EA,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,0143-9577-01,NDC,,,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0517-0299-25,NDC,facility,both,500,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN   81 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,63739-212-02,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,50863,CDM,250,RC,J9041,HCPCS,10019-991-01,NDC,facility,both,27,EA,,241,168.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ICATIBANT 30 MG/3 ML SUBQ SYRG,50863,CDM,250,RC,J1744,HCPCS,63323-574-86,NDC,facility,both,30,ML,,3588,2511.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-822-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TERAZOSIN  1 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,59746-383-06,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 10 MEQ/100 ML IV PGBK,50863,CDM,250,RC,J3480,HCPCS,0990-7074-26,NDC,facility,both,5,ML,JZ,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0630,HCPCS,24201-400-02,NDC,facility,both,1,ML,,1127,788.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL  3.125 MG ORAL TAB,50863,CDM,J3490,HCPCS,0781-5221-01,NDC,,,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL,50863,CDM,250,RC,J3490,HCPCS,63323-820-04,NDC,facility,both,1,ML,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7050,HCPCS,0338-0049-48,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0121-0914-05,NDC,facility,both,2,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,J2560,HCPCS,14789-127-07,NDC,,,facility,both,1,ML,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE  5 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,70010-029-01,NDC,facility,both,4,EA,,141,98.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,50863,CDM,J8540,HCPCS,0054-8175-25,NDC,,,facility,both,32,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,68094-494-59,NDC,facility,both,2,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV,50863,CDM,250,RC,J7120,HCPCS,0338-0117-04,NDC,facility,both,3,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,68094-600-59,NDC,facility,both,2,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0121-0914-05,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 0.3 % OPHT DROP,50863,CDM,250,RC,J3490,HCPCS,69315-308-02,NDC,facility,both,1,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,636,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,62,ML,JW,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
KETAMINE IN 0.9 % SOD CHLORIDE 100 MG/10 ML (10 MG/ML) IV SYRG,50863,CDM,636,RC,J3490,HCPCS,61553-331-65,NDC,facility,both,1,ML,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIOTHYRONINE  5 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16714-166-01,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNITS/1 GRAM PACKET (MERGE RECORD),50863,CDM,636,RC,J3490,HCPCS,57896-145-09,NDC,facility,both,6,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0121-0914-05,NDC,facility,both,2,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOMIPRAMINE 50 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,16571-684-03,NDC,facility,both,2,EA,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOFLOXACIN 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6352-61,NDC,facility,both,2,EA,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 200 MG/10 ML IRON IV SOLN,50863,CDM,636,RC,J1756,HCPCS,0517-2310-01,NDC,facility,both,200,ML,JZ,545,381.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,0088-2220-33,NDC,facility,both,12,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 60 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,0904-7045-61,NDC,facility,both,2,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 1 MG ORAL TAB,50863,CDM,250,RC,J8540,HCPCS,72578-166-01,NDC,facility,both,4,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMTERENE-HYDROCHLOROTHIAZIDE 37.5 MG-25 MG CAP,50863,CDM,636,RC,J3490,HCPCS,0781-2074-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,75834-221-01,NDC,facility,both,3,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J2004,HCPCS,0409-3178-01,NDC,facility,both,200,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-1610-50,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZONATATE 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7153-61,NDC,facility,both,6,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-41,NDC,facility,both,80,ML,JZ,11316,7921.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,250,RC,J3360,HCPCS,0641-6244-01,NDC,facility,both,8,ML,,578,404.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSULFAN BLUE 1 % INJ SOLN,50863,CDM,636,RC,Q9968,HCPCS,67457-220-05,NDC,facility,both,50,ML,JZ,4299,3009.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PROPRANOLOL  10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-587-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ABATACEPT 250 MG IV SOLR,50863,CDM,636,RC,J0129,HCPCS,0003-2187-13,NDC,facility,both,75,EA,"JZ,JA",12534,8773.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
"MENING VAC A,C,Y,W135,TET (PF) 10 MCG/0.5 ML IM SOLN",50863,CDM,250,RC,90619,HCPCS,49281-590-58,NDC,facility,both,1,ML,,721,504.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,636,RC,J0330,HCPCS,0409-6629-02,NDC,facility,both,9,ML,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,636,RC,J1596,HCPCS,70069-013-25,NDC,facility,both,4,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-192-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 500 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,65862-019-01,NDC,facility,both,2,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,57237-004-30,NDC,facility,both,3,EA,,129,90.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,55150-370-01,NDC,facility,both,15,ML,JW,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
HYDRALAZINE  10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-074-01,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE  50 MG ORAL TAB,50863,CDM,250,RC,j3490,HCPCS,60505-2653-1,NDC,facility,both,3,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTAMIDINE 300 MG INJ SOLR,50863,CDM,636,RC,J3490,HCPCS,63323-113-01,NDC,facility,both,1,EA,,152,106.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,J3490,HCPCS,0409-6625-14,NDC,,,facility,both,4,ML,,231,161.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCOSANOL 10 % TOP CREAM,50863,CDM,250,RC,J3490,HCPCS,0536-1427-04,NDC,facility,both,1,GM,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MYCOPHENOLATE 500 MG TAB,50863,CDM,250,RC,J7517,HCPCS,60687-438-11,NDC,facility,both,4,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J1610,HCPCS,63323-596-11,NDC,facility,both,1,EA,,785,549.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,250,RC,J2720,HCPCS,63323-229-01,NDC,facility,both,8,ML,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE (3 MONTH) 11.25 MG IM KIT,50863,CDM,636,RC,J1950,HCPCS,0074-3663-03,NDC,facility,both,3,EA,JZ,14914,10439.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,72603-179-01,NDC,facility,both,7,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"OMEGA-3 FATTY ACIDS-FISH OIL 360-1,200 MG ORAL CAP (ERX MERGE)",50863,CDM,250,RC,J3490,HCPCS,8068105500,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,70004-600-09,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,66689-056-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL PACK,50863,CDM,J3490,HCPCS,42806-270-98,NDC,,,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 10 MG/50 ML (0.2MG/ML) PCA IN NS (MERGE),50863,CDM,J1171,HCPCS,61553-830-41,NDC,,,facility,both,100,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,100,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORDIAZEPOXIDE 10 MG CAP,50863,CDM,250,RC,J3490,HCPCS,0555-0033-02,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DANTROLENE  25 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,68084-300-11,NDC,facility,both,2,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 5 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,0409-1778-15,NDC,facility,both,2,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXAZOSIN 2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-851-95,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,5,ML,,8671,6069.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,10,EA,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 500 MG (200 MG ELEMENTAL) CHEW TAB,50863,CDM,250,RC,J3490,HCPCS,66553-004-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLPIDEM  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16714-621-01,NDC,facility,both,2,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),50863,CDM,J3490,HCPCS,0409-4888-06,NDC,,,facility,both,2,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,J1953,HCPCS,55150-177-05,NDC,,,facility,both,150,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 5 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,0143-9873-10,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA SR 25 MG-100 MG TAB,50863,CDM,636,RC,J3490,HCPCS,51079-978-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,48,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"RABIES VACCINE, PURIFIED CHICKEN EMBRYO CELL (PF) 2.5 UNIT IM KIT",50863,CDM,636,RC,90675,HCPCS,50632-010-01,NDC,facility,both,1,EA,JZ,1466,1026.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,636,RC,J1953,HCPCS,63323-400-01,NDC,facility,both,300,ML,,315,220.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J3490,HCPCS,0338-0049-48,NDC,facility,both,7,ML,,140,98,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,55150-222-20,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0137,HCPCS,0143-9386-01,NDC,facility,both,32,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PERPHENAZINE  8 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0603-5062-21,NDC,facility,both,2,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,636,RC,J1100,HCPCS,63323-506-41,NDC,facility,both,5,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
OXYCODONE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6966-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6638-61,NDC,facility,both,1,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 80 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-590-95,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAZOSIN 5 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,51079-632-01,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL  3.125 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68382-092-01,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,636,RC,J3490,HCPCS,0904-7509-30,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENEFIX: FIX CONCENTRATE (MERGE RECORD),50863,CDM,250,RC,J7195,HCPCS,58394-637-03,NDC,facility,both,5000,EA,,45428,31799.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,933,ME,JZ,12661,8862.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
FENTANYL 100 MCG/HR TD PT72,50863,CDM,636,RC,J3490,HCPCS,47781-428-11,NDC,facility,both,1,EA,,334,233.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,16714-294-02,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NORTRIPTYLINE 10 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-281-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,636,RC,J1836,HCPCS,47335-993-01,NDC,facility,both,91,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,16714-036-01,NDC,facility,both,8,ML,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J2004,HCPCS,63323-482-03,NDC,facility,both,300,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM SR 120 MG 24 HR CAP,50863,CDM,250,RC,J3490,HCPCS,60687-195-11,NDC,facility,both,3,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  5 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,60687-122-11,NDC,facility,both,10,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES-DOCUSATE SODIUM 8.6 MG-50 MG TAB,50863,CDM,250,RC,J3490,HCPCS,51645-850-99,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0630,HCPCS,63323-865-02,NDC,facility,both,1,ML,,1314,919.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MICAFUNGIN 100 MG IV SOLR,50863,CDM,250,RC,J2248,HCPCS,63323-729-01,NDC,facility,both,150,EA,,367,256.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,40,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMETHICONE 40MG/0.6ML (0.6ML-UD) SYRINGE (REPACK),50863,CDM,250,RC,J3490,HCPCS,17856-1141-4,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 150 MG/ML INJECTION,50863,CDM,636,RC,J3490,HCPCS,0009-0902-11,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE  50 MG ORAL TAB,50863,CDM,250,RC,j3490,HCPCS,0904-6868-61,NDC,facility,both,1,EA,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADVATE: FACTOR VIII CONCENTRATE (MERGE RECORD),50863,CDM,636,RC,J7192,HCPCS,0944-3047-10,NDC,facility,both,4018,UN,,16820,11774,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  5 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-122-11,NDC,facility,both,5,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 30 MG/0.3 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,16714-006-01,NDC,facility,both,3,ML,JZ,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CEPHALEXIN 250 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-152-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TICAGRELOR 90 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0186-0777-39,NDC,facility,both,1,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0074-4552-11,NDC,facility,both,2,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LITHIUM CARBONATE 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-8528-25,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 200 MG INJ SOLR,50863,CDM,250,RC,J0640,HCPCS,63323-710-50,NDC,facility,both,3,EA,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,23155-600-31,NDC,facility,both,4,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2310,HCPCS,0641-6132-01,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,63323-010-01,NDC,facility,both,2,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7193-06,NDC,facility,both,5,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MANNITOL 25 % IV SOLN,50863,CDM,250,RC,J2150,HCPCS,63323-024-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7351-04,NDC,facility,both,5,EA,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GOLIMUMAB  12.5 MG/ML IV SOLN,50863,CDM,636,RC,J1602,HCPCS,57894-350-01,NDC,facility,both,150,ML,,16554,11587.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  500 MG IV SOLR,50863,CDM,636,RC,J3373,HCPCS,70436-020-82,NDC,facility,both,1,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0121-1781-05,NDC,facility,both,1,ML,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL-ROPIVACAINE-NACL (PF) 2-0.2 MCG/ML-% INJ (MERGE ERX),50863,CDM,250,RC,J3490,HCPCS,61553-844-48,NDC,facility,both,1,ML,,357,249.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUBIPROSTONE  8 MCG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,43598-163-60,NDC,facility,both,3,EA,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,50863,CDM,636,RC,J2354,HCPCS,0641-6174-01,NDC,facility,both,10,ML,JB,150,105,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JB: Administered subcutaneously
METOPROLOL TARTRATE 5 MG/5 ML IV,50863,CDM,636,RC,J3490,HCPCS,63323-660-05,NDC,facility,both,2,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXAZOSIN 2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-5523-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-6172-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,J2704,HCPCS,0069-0209-01,NDC,,,facility,both,48,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,J0665,HCPCS,70594-117-01,NDC,,,facility,both,100,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 60 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,68180-296-09,NDC,facility,both,2,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 100 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,31722-574-47,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,636,RC,J2270,HCPCS,0409-1890-03,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,636,RC,J1953,HCPCS,63323-400-01,NDC,facility,both,50,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL (5 MG/ML) IV SYRG (CONTAINS PRESERVATIVE),50863,CDM,250,RC,J3490,HCPCS,65302-503-04,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3373,HCPCS,63323-284-01,NDC,facility,both,100,EA,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE MODIFIED 100 MG ORAL CAP,50863,CDM,250,RC,J7502,HCPCS,0093-9020-19,NDC,facility,both,3,EA,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,158,110.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-8515-23,NDC,facility,both,2,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68094-799-30,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLEDRONIC ACID IN MANNITOL & WATER 5 MG/100 ML IV SOLN,50863,CDM,636,RC,J3489,HCPCS,0078-0435-61,NDC,facility,both,5,ML,,2992,2094.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE (FOR EMERGENCY) 100 MG/ML (10%) IV SOLN,50863,CDM,250,RC,J0612,HCPCS,63323-360-05,NDC,facility,both,1000,ML,JZ,275,192.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
OXCARBAZEPINE 300 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,72888-074-14,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 40 MG/ML SUSP (DEPO-MEDROL) INJECTION,50863,CDM,636,RC,J1010,HCPCS,70121-1573-1,NDC,facility,both,80,ML,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TICAGRELOR 90 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0186-0777-39,NDC,facility,both,3,EA,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR 5 % TOP OINT,50863,CDM,250,RC,J3490,HCPCS,64455-993-95,NDC,facility,both,1,GM,,1363,954.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  500 MG IV SOLR,50863,CDM,636,RC,J3373,HCPCS,70436-020-82,NDC,facility,both,100,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 60 MG ORAL CPDR,50863,CDM,636,RC,J3490,HCPCS,51991-748-90,NDC,facility,both,1,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,75834-221-01,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J2312,HCPCS,0409-1215-21,NDC,facility,both,20,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7914-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MYCOPHENOLATE SODIUM 360 MG ORAL TBEC,50863,CDM,636,RC,J7518,HCPCS,68084-918-95,NDC,facility,both,2,EA,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIOTHYRONINE 25 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,42794-019-12,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,130,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-113-11,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 1 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,50458-305-03,NDC,facility,both,1,ML,,710,497,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TICAGRELOR 90 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0186-0777-39,NDC,facility,both,1,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,29,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,219,153.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIPHTH,PERTUS(ACELL),TETANUS SYRG(BOOSTRIX) 2.5-8-5 LF-MCG-LF/0.5ML IM SYRG",50863,CDM,636,RC,90715,HCPCS,58160-842-43,NDC,facility,both,1,ML,,240,168,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LATANOPROST 0.005 % OPHT DROP,50863,CDM,250,RC,J3490,HCPCS,61314-547-01,NDC,facility,both,1,ML,,403,282.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-555-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 10 MG/ML ORAL SOLUTION (REPACK),50863,CDM,250,RC,J3490,HCPCS,0131-5410-71,NDC,facility,both,2,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MUPIROCIN 2 % TOP OINT,50863,CDM,250,RC,J3490,HCPCS,68462-180-22,NDC,facility,both,1,GM,,210,147,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,76045-009-96,NDC,facility,both,4,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MODAFINIL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-621-11,NDC,facility,both,2,EA,,224,156.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0074-4552-11,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,50863,CDM,636,RC,J0696,HCPCS,25021-106-10,NDC,facility,both,8,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4% TOP PATCH,50863,CDM,250,RC,J3490,HCPCS,46581-830-01,NDC,facility,both,2,EA,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN SODIUM EXTENDED 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-6187-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2308-21,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,55390-138-01,NDC,facility,both,1,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
BUPRENORPHINE-NALOXONE 2-0.5 MG SL SUBL,50863,CDM,636,RC,J3490,HCPCS,60687-626-11,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL-ROPIVACAINE-NACL (PF) 2-0.2 MCG/ML-% INJ (MERGE ERX),50863,CDM,250,RC,J3490,HCPCS,70092-9259-75,NDC,facility,both,2,ML,,435,304.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 200 MG/100 ML IVPB (MERGE),50863,CDM,250,RC,J1450,HCPCS,0409-3435-01,NDC,facility,both,3,ML,,150,105,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,50863,CDM,250,RC,J9075,HCPCS,10019-956-16,NDC,facility,both,195,EA,,1260,882,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2310,HCPCS,36000-308-01,NDC,facility,both,2,ML,,167,116.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,65282-1605-1,NDC,facility,both,100,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-41,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,44,ML,JW,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ZOLPIDEM  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0781-5317-01,NDC,facility,both,2,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-346-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"TRIMETHOPRIM-POLYMYXIN B 0.1 %-10,000 UNIT/ML EYE DROPS",50863,CDM,250,RC,J3490,HCPCS,61314-628-10,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,27,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,0409-9094-22,NDC,facility,both,3,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZIPRASIDONE 40 MG CAP,50863,CDM,250,RC,J3490,HCPCS,68084-104-11,NDC,facility,both,3,EA,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  20 MEQ ORAL PACK,50863,CDM,250,RC,J3490,HCPCS,72888-024-06,NDC,facility,both,1,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42291-083-30,NDC,facility,both,1,EA,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G POTASSIUM  5000000 UNIT INJ SOLR,50863,CDM,250,RC,J2540,HCPCS,70860-126-41,NDC,facility,both,9,EA,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,25021-315-01,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2%/EPINEPHRINE 1:200K INJECTION (PF),50863,CDM,250,RC,J3490,HCPCS,0409-3183-01,NDC,facility,both,2,ML,,133,93.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIOTHYRONINE 25 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,42794-019-12,NDC,facility,both,2,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,250,RC,J3490,HCPCS,53746-542-01,NDC,facility,both,6,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,16714-293-03,NDC,facility,both,4,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0143-9318-01,NDC,facility,both,4,ML,,133,93.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,50863,CDM,636,RC,J0585,HCPCS,0023-1145-01,NDC,facility,both,330,EA,,5274,3691.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 2-0.5 MG SL SUBL,50863,CDM,636,RC,J3490,HCPCS,0904-7009-06,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM-DEXTROSE (ISO) 3.375 GRAM/50 ML IV PIGGY BACK,50863,CDM,J2543,HCPCS,0338-9636-01,NDC,,,facility,both,3,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENAZOPYRIDINE 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,75826-115-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE CONCENTRATE 10 MG/ 0.5 ML ORAL SYRINGE (0.5ML UD MERGE),50863,CDM,250,RC,J3490,HCPCS,68094-045-01,NDC,facility,both,2,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCRALFATE 1 GRAM ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-753-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,5,EA,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LAMOTRIGINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7007-61,NDC,facility,both,6,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 400 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0143-9887-75,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"HEPARIN, PORCINE (PF) 1 UNIT/ML IV SYRG NEONATE",50863,CDM,250,RC,J1642,HCPCS,6425344430,NDC,facility,both,3,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,847,ME,JZ,11494,8045.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,250,RC,J3490,HCPCS,68180-963-01,NDC,facility,both,1,GM,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),50863,CDM,250,RC,J3490,HCPCS,63323-186-20,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORDIAZEPOXIDE 25 MG CAP,50863,CDM,636,RC,J3490,HCPCS,51079-141-01,NDC,facility,both,4,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CINACALCET 30 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,69097-410-02,NDC,facility,both,3,EA,,390,273,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PYRIDOSTIGMINE BROMIDE  60 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6622-61,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELIMUMAB 400 MG IV SOLR,50863,CDM,636,RC,J0490,HCPCS,49401-102-01,NDC,facility,both,40,EA,"JZ,JA",4459,3121.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
LOVASTATIN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68180-468-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J0461,HCPCS,0517-0401-25,NDC,facility,both,40,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4 % MUCOSAL TOPICAL SOLN,50863,CDM,J3490,HCPCS,0054-3505-47,NDC,,,facility,both,1,ML,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,50863,CDM,250,RC,J0561,HCPCS,60793-701-10,NDC,facility,both,24,ML,,2376,1663.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE 0.5 %-1:200,000 INJ SOLN",50863,CDM,J3490,HCPCS,63323-463-01,NDC,,,facility,both,1,ML,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACCHAROMYCES BOULARDII 250 MG ORAL CAP,50863,CDM,J3490,HCPCS,1785600021,NDC,,,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,636,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,20,ML,JW,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LORAZEPAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69315-904-01,NDC,facility,both,3,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG/ML INJ SOLN,50863,CDM,636,RC,J2550,HCPCS,0641-6084-25,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-342-11,NDC,facility,both,5,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.45 % 0.45 % IV SOLP,50863,CDM,250,RC,J3490,HCPCS,0338-0043-03,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE  50 MG ORAL TAB,50863,CDM,250,RC,j3490,HCPCS,60505-2653-1,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE  5 MG/ML INJ SOLN,50863,CDM,636,RC,J2765,HCPCS,0409-3414-21,NDC,facility,both,8,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIVAROXABAN 15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50458-578-01,NDC,facility,both,2,EA,,223,156.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLN,50863,CDM,636,RC,J3262,HCPCS,50242-135-01,NDC,facility,both,40,ML,"JW,JA",319,223.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
FERROUS SULFATE 220 MG (44 MG IRON)/5 ML ORAL ELIX,50863,CDM,250,RC,J3490,HCPCS,5483800180,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,42806-150-33,NDC,facility,both,6,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 200 MG INJ SOLR,50863,CDM,250,RC,J0640,HCPCS,0143-9553-01,NDC,facility,both,6,EA,,212,148.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-325-11,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,71288-402-10,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,J0665,HCPCS,63323-465-57,NDC,,,facility,both,4025,ML,,1095,766.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  15 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,0406-8315-23,NDC,facility,both,2,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACIDOPHILUS-PECTIN W CITRUS 25 MILLION-100 CELL MG TAB,50863,CDM,250,RC,J3490,HCPCS,1785614241,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,35,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4 % TOPICAL SOLN,50863,CDM,636,RC,J3490,HCPCS,76329-6300-5,NDC,facility,both,1,ML,,178,124.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,16,ML,JW,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1940,HCPCS,36000-283-25,NDC,facility,both,12,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) MISC SOLN,50863,CDM,250,RC,J3490,HCPCS,0517-7604-01,NDC,facility,both,1,ML,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,200,ML,,141,98.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIOTHYRONINE  5 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-166-01,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-50,NDC,facility,both,50,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 7.5 MG-325 MG/15 ML ORAL SOLN (REPACK),50863,CDM,636,RC,J3490,HCPCS,0121-2316-15,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-3243-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN 0.9% SODIUM CL 1.25 GRAM/250 ML IV SOLN,50863,CDM,250,RC,J3370,HCPCS,70004-923-59,NDC,facility,both,3,ML,,189,132.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IR SOLN,50863,CDM,636,RC,J3490,HCPCS,0264-2201-00,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 17 GRAM (100 %) ORAL PWPK,50863,CDM,636,RC,J3490,HCPCS,0904-6931-86,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 600 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,67877-320-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-411-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,69315-905-01,NDC,facility,both,3,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,70004-600-09,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLPIDEM  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-189-11,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 5 MG ORAL CAP,50863,CDM,250,RC,J7507,HCPCS,0904-6624-61,NDC,facility,both,3,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-165-11,NDC,facility,both,2,EA,,171,119.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEP B-DP(ACELL)T-POLIO VACC-PF 10MCG-25LF-25MCG-10LF-40-8-32 IM SYRING,50863,CDM,90723,HCPCS,58160-811-43,NDC,,,facility,both,1,ML,,445,311.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,6,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM 1 GRAM IV SOLR,50863,CDM,636,RC,J2185,HCPCS,55150-208-30,NDC,facility,both,10,EA,JZ,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LEVOTHYROXINE 100 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68180-969-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 0.1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,23155-489-01,NDC,facility,both,3,EA,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1940,HCPCS,0409-6102-02,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,250,RC,J2704,HCPCS,16714-528-01,NDC,facility,both,6,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,15,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
TEMAZEPAM 15 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0406-9961-01,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMTUZUMAB OZOGAMICIN 4.5 MG (1 MG/ML INITIAL CONC) IV SOLR,50863,CDM,250,RC,J9203,HCPCS,0008-4510-01,NDC,facility,both,45,EA,,7142,4999.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRIL MALEATE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51672-4245-1,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 2 GRAM IV SOLUTION,50863,CDM,250,RC,J9075,HCPCS,10019-957-11,NDC,facility,both,340,EA,,3437,2405.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),50863,CDM,250,RC,J2060,HCPCS,65219-368-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE SOD SUCC (PF) 100 MG/2 ML INJ SOLR,50863,CDM,636,RC,J1720,HCPCS,0009-0011-03,NDC,facility,both,1,EA,,126,88.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,1657187290,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,34,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SITAGLIPTIN 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0006-0277-01,NDC,facility,both,1,EA,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,304,ME,JZ,4126,2888.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CETUXIMAB 100 MG/50 ML IV SOLN,50863,CDM,250,RC,J9055,HCPCS,66733-958-23,NDC,facility,both,60,ML,,13449,9414.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-22,NDC,facility,both,160,ML,,320,224,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,20,EA,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2308-22,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITRIOL 0.25 MCG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-345-11,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,250,RC,J3101,HCPCS,50242-037-06,NDC,facility,both,23,EA,,10535,7374.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 60 MG ORAL CPDR,50863,CDM,636,RC,J3490,HCPCS,0904-7045-61,NDC,facility,both,2,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-9543-03,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-41,NDC,facility,both,40,ML,JW,2460,1722,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IPRATROPIUM-ALBUTEROL 0.5 MG-2.5 MG/3 ML NEB SOLUTION,50863,CDM,250,RC,J3490,HCPCS,0487-0201-01,NDC,facility,both,1,ML,PLAD,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
FLUDROCORTISONE 0.1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-288-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,50863,CDM,636,RC,J0585,HCPCS,0023-1145-01,NDC,facility,both,200,EA,JZ,3197,2237.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0990-7983-61,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,79,ML,,113,79.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE MONONITRATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,7733393425,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML SYRUP,50863,CDM,250,RC,J3490,HCPCS,0121-1276-10,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN 0.5 UNITS/ML IN DEXTROSE 10% FOR TRANSPORT (REPACK REC),50863,CDM,250,RC,J3490,HCPCS,99999-0403-51,NDC,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-406-03,NDC,facility,both,1,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,636,RC,Q0162,HCPCS,65162-691-79,NDC,facility,both,4,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML (1ML) INJ SOLN,50863,CDM,250,RC,J0171,HCPCS,42023-159-01,NDC,facility,both,16,ML,,1405,983.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 150 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-711-11,NDC,facility,both,3,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,636,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,9,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1940,HCPCS,23155-473-32,NDC,facility,both,6,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,14789-127-07,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,52817-180-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADVATE: FACTOR VIII CONCENTRATE (MERGE RECORD),50863,CDM,250,RC,J7192,HCPCS,0944-3051-02,NDC,facility,both,250,UN,JW,455,318.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,39,ML,JZ,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LITHIUM CARBONATE 450 MG ORAL TBSR,50863,CDM,636,RC,J3490,HCPCS,68084-655-11,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IR SOLN,50863,CDM,250,RC,J3490,HCPCS,0338-0048-04,NDC,facility,both,3,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCAINAMIDE 100 MG/ML INJ SOLN,50863,CDM,250,RC,J2690,HCPCS,0409-1902-11,NDC,facility,both,1,ML,,1451,1015.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,7,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,636,RC,J3490,HCPCS,51754-4250-1,NDC,facility,both,1,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-41,NDC,facility,both,1,ML,PLAD,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
BUPROPION HCL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-351-11,NDC,facility,both,2,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML INJECTION,50863,CDM,250,RC,J3411,HCPCS,25021-500-02,NDC,facility,both,3,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-253-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PYRIDOXINE 100 MG/ML INJ SOLN,50863,CDM,636,RC,J3415,HCPCS,63323-180-00,NDC,facility,both,1,ML,,128,89.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRILAT 1.25 MG/ML IV INJ,50863,CDM,636,RC,J3490,HCPCS,43598-078-11,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),50863,CDM,250,RC,J3490,HCPCS,0409-4888-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7030,HCPCS,0338-0049-04,NDC,facility,both,3,ML,JZ,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LIDOCAINE 4% TOP PATCH,50863,CDM,636,RC,J3490,HCPCS,70512-812-01,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  5 GRAM IV SOLR,50863,CDM,250,RC,J3370,HCPCS,0409-6509-01,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0904-6828-05,NDC,facility,both,4,ML,,136,95.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYL SALICYLATE-MENTHOL 15 %-10 % TOPICAL CREAM,50863,CDM,250,RC,J3490,HCPCS,57896-116-03,NDC,facility,both,1,GM,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,0088-2220-33,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0641-6059-01,NDC,facility,both,10,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,20,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIFAMPIN 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-586-11,NDC,facility,both,2,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,31722-820-30,NDC,facility,both,1,EA,,158,110.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),50863,CDM,J1171,HCPCS,0409-4264-11,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-2051-15,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 10 MEQ/100 ML IV PGBK (USE NON-PROTOCOL PANEL),50863,CDM,250,RC,J3480,HCPCS,0338-0709-48,NDC,facility,both,20,ML,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 50 MG/5 ML (10 MG/ML) IV SYRG,50863,CDM,636,RC,J3490,HCPCS,71449-004-11,NDC,facility,both,1,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM SR 300 MG 24 HR CAP,50863,CDM,636,RC,J3490,HCPCS,60687-228-11,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANTI-INHIBITOR COAGULANT CMPLX (PHS MERGE),50863,CDM,250,RC,J7198,HCPCS,64193-325-01,NDC,facility,both,3250,UN,,20183,14128.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LECANEMAB-IRMB 100 MG/ML IV SOLN,50863,CDM,636,RC,J0174,HCPCS,62856-215-01,NDC,facility,both,850,ML,,2491,1743.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG IV SOLR,50863,CDM,J3490,HCPCS,0781-3232-94,NDC,,,facility,both,1,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 20 MG/ML ORAL CONC,50863,CDM,636,RC,J3490,HCPCS,71093-143-11,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,59762-0073-1,NDC,facility,both,5,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J1940,HCPCS,63323-280-03,NDC,facility,both,3,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROPROCAINE 3 % INJ SOLN,50863,CDM,250,RC,J2401,HCPCS,0143-9210-01,NDC,facility,both,450,ML,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,250,RC,J0137,HCPCS,0143-9386-01,NDC,facility,both,100,ML,JZ,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DIVALPROEX 500 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,0904-6861-61,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZIPRASIDONE 40 MG CAP,50863,CDM,250,RC,J3490,HCPCS,65862-703-60,NDC,facility,both,1,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0143-9318-01,NDC,facility,both,8,ML,,677,473.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,44567-600-04,NDC,facility,both,2,ML,,414,289.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV (BOLUS),50863,CDM,636,RC,J7120,HCPCS,0264-7750-07,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSAPREPITANT 150 MG IV SOLR,50863,CDM,J1453,HCPCS,43598-948-11,NDC,,,facility,both,150,EA,,419,293.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COMPOUNDING VEHICLE SYRUP NO23 ORAL SYRP,50863,CDM,250,RC,J3490,HCPCS,574030416,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 80 MG/ML SUSP FOR INJECTION,50863,CDM,636,RC,J1010,HCPCS,70121-1574-1,NDC,facility,both,80,ML,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,50863,CDM,636,RC,J3490,HCPCS,68462-157-40,NDC,facility,both,3,EA,,294,205.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,68094-494-59,NDC,facility,both,3,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEPOLIZUMAB 100 MG SUBQ SOLR,50863,CDM,636,RC,J2182,HCPCS,0173-0881-01,NDC,facility,both,300,EA,,21321,14924.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6949-61,NDC,facility,both,8,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-231-11,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE  2 MG/ML INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-285-10,NDC,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN ASP PRT-INSULIN ASPART 100 UNIT/ML (70-30) SUBQ SOLN,50863,CDM,250,RC,J1817,HCPCS,73070-200-11,NDC,facility,both,2,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE  1 % TOP OINT,50863,CDM,250,RC,J3490,HCPCS,0168-0020-31,NDC,facility,both,2,GM,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG RECT SUPP,50863,CDM,250,RC,J3490,HCPCS,45802-759-00,NDC,facility,both,2,EA,,174,121.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN IN D5W 900 MG/50 ML IV PGBK,50863,CDM,250,RC,J0736,HCPCS,0009-3382-01,NDC,facility,both,3,ML,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),50863,CDM,250,RC,J2060,HCPCS,0641-6044-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0264-7800-20,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 125 MG ORAL CPSP,50863,CDM,636,RC,J3490,HCPCS,0904-6615-61,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLEDRONIC ACID IN MANNITOL & WATER 5 MG/100 ML IV SOLN,50863,CDM,J3489,HCPCS,25021-830-82,NDC,,,facility,both,5,ML,,1239,867.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACCHAROMYCES BOULARDII 250 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,1785600021,NDC,facility,both,10,EA,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J3490,HCPCS,63323-482-27,NDC,,,facility,both,200,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 30% IN WATER (NEO),50863,CDM,250,RC,J7060,HCPCS,0409-6648-16,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,636,RC,J2270,HCPCS,0409-1891-03,NDC,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0555-0873-02,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,6,EA,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,636,RC,Q0162,HCPCS,60687-252-40,NDC,facility,both,2,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,76045-009-01,NDC,facility,both,10,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-50,NDC,facility,both,48,ML,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 4 MG (ENVARSUS XR) 24-HOUR EXTENDED-RELEASE TABLET,50863,CDM,250,RC,J7508,HCPCS,68992-3040-3,NDC,facility,both,1,EA,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLU VACCINE TS 2025-26 65 YR UP (PF) 180 MCG/0.5 ML IM SYRG,50863,CDM,90662,HCPCS,49281-125-88,NDC,,,facility,both,1,ML,,372,260.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 5 MG/ML IV SOLN,50863,CDM,250,RC,J1921,HCPCS,72266-103-01,NDC,facility,both,5,ML,,200,140,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 30 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0093-0318-01,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,12,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLN,50863,CDM,J3262,HCPCS,50242-135-01,NDC,,,facility,both,80,ML,,1467,1026.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2599,HCPCS,63323-930-01,NDC,facility,both,3,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,17271-701-06,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,11,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIFEDIPINE 10 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,23155-194-01,NDC,facility,both,6,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML SYRUP,50863,CDM,250,RC,J3490,HCPCS,0121-0638-10,NDC,facility,both,20,ML,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION,50863,CDM,J3490,HCPCS,0186-0370-28,NDC,,,facility,both,1,GM,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,50863,CDM,J9075,HCPCS,10019-956-16,NDC,,,facility,both,200,EA,,1296,907.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLP,50863,CDM,250,RC,J3480,HCPCS,63323-965-03,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-50,NDC,facility,both,49,ML,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 12.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7307-61,NDC,facility,both,1,EA,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,4000,ML,,1706,1194.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,50863,CDM,636,RC,J3490,HCPCS,68462-157-40,NDC,facility,both,10,EA,,833,583.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,50863,CDM,250,RC,Q5119,HCPCS,0069-0249-01,NDC,facility,both,50,ML,,9892,6924.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,18,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 10 GRAM/15 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,66689-038-01,NDC,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1940,HCPCS,23155-473-33,NDC,facility,both,3,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV,50863,CDM,250,RC,J7120,HCPCS,0338-0117-04,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUANFACINE 2 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,60505-3928-1,NDC,facility,both,1,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 500 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,68084-415-11,NDC,facility,both,5,EA,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  5 MG ORAL TBDL,50863,CDM,636,RC,J3490,HCPCS,55111-262-79,NDC,facility,both,3,EA,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,59651-488-01,NDC,facility,both,60,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEFLUNOMIDE  20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,70748-130-06,NDC,facility,both,1,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,50863,CDM,636,RC,J0696,HCPCS,44567-701-25,NDC,facility,both,8,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 10 MG/ML ORAL SOLUTION (REPACK),50863,CDM,250,RC,J3490,HCPCS,0131-5410-71,NDC,facility,both,3,ML,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-087-02,NDC,facility,both,45,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,23155-687-31,NDC,facility,both,2,ML,JB,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JB: Administered subcutaneously
PHENYLEPH-MIN OIL-PETROLATUM 0.25-14-74.9 % RECT OINT,50863,CDM,636,RC,J3490,HCPCS,0573-2871-93,NDC,facility,both,1,GM,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,50863,CDM,636,RC,J1756,HCPCS,0517-2325-01,NDC,facility,both,300,ML,,1111,777.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES  8.6 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7252-61,NDC,facility,both,7,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,250,RC,J2405,HCPCS,0641-6078-01,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANTI-INHIBITOR COAGULANT CMPLX (PHS MERGE),50863,CDM,250,RC,J7198,HCPCS,64193-325-01,NDC,facility,both,7480,UN,,46451,32515.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,0409-9094-12,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL (5 MG/ML) IV SYRG (CONTAINS PRESERVATIVE),50863,CDM,250,RC,J3490,HCPCS,0409-2339-24,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,636,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,4,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,60687-571-24,NDC,facility,both,2,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,636,RC,J3010,HCPCS,0409-9094-22,NDC,facility,both,3,ML,JZ,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,250,RC,J2003,HCPCS,0409-1323-15,NDC,facility,both,100,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTOBACILLUS ACIDOPH-PECTIN 75 MILLION CELL -100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,5789683701,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  0.25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-741-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE PEDS SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J3490,HCPCS,25021-113-82,NDC,facility,both,62,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0093-4177-73,NDC,facility,both,11,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOBENZAPRINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-753-95,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DACARBAZINE 200 MG IV SOLR,50863,CDM,636,RC,J9130,HCPCS,0143-9245-01,NDC,facility,both,5,EA,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,156,ML,,141,98.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 200 MG/20 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0131-1810-67,NDC,facility,both,1,ML,,429,300.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 200 MG/20 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,70710-1359-1,NDC,facility,both,2,ML,,667,466.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-492-27,NDC,facility,both,200,ML,,157,109.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  750 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7125-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,50863,CDM,636,RC,J3490,HCPCS,57237-077-10,NDC,facility,both,12,EA,,789,552.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,50742-615-01,NDC,facility,both,3,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,50863,CDM,250,RC,J9075,HCPCS,0781-3233-94,NDC,facility,both,100,EA,,1216,851.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,20,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,250,RC,J3490,HCPCS,62037-560-01,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-149-01,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,107,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOMIPRAMINE 75 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,16571-685-03,NDC,facility,both,1,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,32,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-1163-01,NDC,facility,both,7,ML,,138,96.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,42806-150-33,NDC,facility,both,11,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),50863,CDM,636,RC,J3490,HCPCS,63323-186-20,NDC,facility,both,2,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYMETAZOLINE 0.05 % NASAL MERGE,50863,CDM,636,RC,J3490,HCPCS,70677-1037-1,NDC,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML IV,50863,CDM,636,RC,J3490,HCPCS,25021-319-05,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,24,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTOBACILLUS ACIDOPHILUS 500 MILLION CELLS ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,904726006,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-487-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-1283-04,NDC,facility,both,10,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IR SOLN,50863,CDM,250,RC,J3490,HCPCS,0338-0047-46,NDC,facility,both,4,ML,,181,126.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VERAPAMIL 120 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,23155-486-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE 3 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,0574-9855-10,NDC,facility,both,5,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESNA 100 MG/ML IV SOLN,50863,CDM,250,RC,J9209,HCPCS,10019-953-62,NDC,facility,both,2,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OMEPRAZOLE-SODIUM BICARBONATE 2-84 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,65628-270-03,NDC,facility,both,4,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,63323-806-13,NDC,facility,both,12,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALSARTAN  80 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-623-11,NDC,facility,both,3,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,23155-687-31,NDC,facility,both,2,ML,JA,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
MYCOPHENOLATE 250 MG CAP,50863,CDM,250,RC,J7517,HCPCS,60687-885-11,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-426-02,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ORPHENADRINE CITRATE 100 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,43386-480-24,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE IN D5W 1 GRAM/100 ML IV PGBK,50863,CDM,636,RC,J3475,HCPCS,0338-1709-40,NDC,facility,both,2,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 100 MG/ML INJ SOLN,50863,CDM,636,RC,J2800,HCPCS,70069-101-01,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-0905-05,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIACIN  250 MG ORAL CPSR,50863,CDM,250,RC,J3490,HCPCS,1000670020,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR 200 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,72578-002-01,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 400 MCG/100 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,55150-297-01,NDC,facility,both,1,ML,,2208,1545.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 17 GRAM (100 %) ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,1152372688,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,636,RC,Q0162,HCPCS,65162-691-79,NDC,facility,both,3,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 10 GRAM/15 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,66689-038-01,NDC,facility,both,2,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIROLIMUS 0.5 MG ORAL TAB,50863,CDM,636,RC,J7520,HCPCS,59762-1001-1,NDC,facility,both,1,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GALANTAMINE  4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-729-11,NDC,facility,both,3,EA,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 6 MG/0.5 ML SUBQ PEN KIT,50863,CDM,636,RC,J3030,HCPCS,72603-141-01,NDC,facility,both,1,ML,GZ,406,284.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier GZ: Item or service expected to be denied as not reasonable and necessary
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,636,RC,J3490,HCPCS,63037-136-25,NDC,facility,both,3,ML,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,70436-030-82,NDC,facility,both,156,ML,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,121119030,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FILGRASTIM-SNDZ 300 MCG/0.5 ML INJ SYRG,50863,CDM,250,RC,Q5101,HCPCS,61314-318-05,NDC,facility,both,300,ML,,972,680.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR IN 0.9% NACL 100 UNIT/100 ML (1 UNIT/ML) INFUSION FOR OB,50863,CDM,250,RC,J1815,HCPCS,0338-0126-12,NDC,facility,both,1,ML,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-598-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,0641-0477-21,NDC,facility,both,2,ML,,349,244.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",50863,CDM,250,RC,J1561,HCPCS,13533-800-24,NDC,facility,both,40,ML,,5658,3960.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROMETHORPHAN-GUAIFENESIN SR 30 MG-600 MG 12 HR TAB,50863,CDM,250,RC,J3490,HCPCS,63824-056-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTAZIDIME NEO IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0713,HCPCS,0781-3177-80,NDC,facility,both,1,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,250,RC,J3490,HCPCS,61553-320-70,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,250,RC,J7999,HCPCS,70092-1017-46,NDC,facility,both,22,ML,,870,609,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 0.8 GRAM ORAL PWPK,50863,CDM,636,RC,J3490,HCPCS,0115-1365-30,NDC,facility,both,1,EA,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELOXICAM  7.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68382-050-01,NDC,facility,both,6,EA,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN  500 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,70010-491-01,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,636,RC,J3490,HCPCS,51754-4250-1,NDC,facility,both,2,ML,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-3178-01,NDC,facility,both,200,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 2 MG/ML IN NS 50ML INFUSION (STOCK DOSE),50863,CDM,250,RC,J3490,HCPCS,0143-9508-01,NDC,facility,both,1,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 2 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,636,RC,J2270,HCPCS,76045-004-01,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-113-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 16 MG ORAL TAB,50863,CDM,250,RC,J7509,HCPCS,59762-0050-1,NDC,facility,both,8,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FERROUS SULFATE 325 MG (65 MG IRON) TAB,50863,CDM,250,RC,J3490,HCPCS,904759160,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,57237-077-10,NDC,facility,both,1,EA,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,5,EA,,184,128.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,6,EA,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 100 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,0904-3854-61,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE (FOR CODE) 10% (100 MG/ML) IV SYRINGE,50863,CDM,250,RC,J3490,HCPCS,64253-900-30,NDC,facility,both,5,ML,,250,175,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,40,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 300 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,68180-320-06,NDC,facility,both,1,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSINOPRIL 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,43547-387-09,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUGAMMADEX 100 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0006-5423-02,NDC,facility,both,1,ML,,561,392.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIPASE-PROTEASE-AMYLASE 24,000-76,000- 120,000 UNIT ORAL CAP, DELAY REL",50863,CDM,250,RC,J3490,HCPCS,0032-1224-01,NDC,facility,both,6,EA,,252,176.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL,50863,CDM,250,RC,J3490,HCPCS,63323-820-01,NDC,facility,both,1,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLP",50863,CDM,250,RC,P9047,HCPCS,0944-0493-04,NDC,facility,both,4,ML,,1001,700.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-087-02,NDC,facility,both,24,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0781-3246-02,NDC,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 30% IN WATER (NEO),50863,CDM,250,RC,J7060,HCPCS,0409-6648-16,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 10 MG/50 ML (0.2MG/ML) PCA IN NS (MERGE),50863,CDM,250,RC,J1171,HCPCS,70092-1286-74,NDC,facility,both,200,ML,,429,300.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,0904-6923-61,NDC,facility,both,20,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) 1000 UNITS/ML INJ SOL (FOR DIALYSIS ONLY),50863,CDM,636,RC,J1644,HCPCS,25021-400-10,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEPROTUMUMAB-TRBW 500 MG IV SOLR,50863,CDM,636,RC,J3241,HCPCS,75987-130-15,NDC,facility,both,40,EA,JW,12521,8764.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CEPHALEXIN 500 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,50268-152-15,NDC,facility,both,14,EA,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLIPIZIDE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0591-0461-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0093-9149-01,NDC,facility,both,3,EA,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,50863,CDM,250,RC,J9045,HCPCS,0703-4239-01,NDC,facility,both,10,ML,,262,183.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON DEXTRAN 50 MG/ML INJ SOLN,50863,CDM,250,RC,J1750,HCPCS,0023-6082-01,NDC,facility,both,20,ML,,2188,1531.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE  50 MG ORAL TAB,50863,CDM,250,RC,j3490,HCPCS,50111-560-01,NDC,facility,both,3,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ORAL PLUS ORAL VEHICLES ORAL LIQUID,50863,CDM,250,RC,J3490,HCPCS,574030316,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2723-30,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,636,RC,J2405,HCPCS,60505-6130-0,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-1749-70,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTOBACILLUS ACIDOPH-PECTIN 75 MILLION CELL -100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,5789683701,NDC,facility,both,7,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,636,RC,J1596,HCPCS,70069-013-25,NDC,facility,both,12,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 500 MG (200 MG ELEMENTAL) CHEW TAB,50863,CDM,250,RC,J3490,HCPCS,66553-004-01,NDC,facility,both,16,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,250,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 50 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,10135-779-01,NDC,facility,both,50,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZATHIOPRINE  50 MG ORAL TAB,50863,CDM,250,RC,J7500,HCPCS,67877-493-01,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-354-11,NDC,facility,both,1,EA,PLAD,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,76045-009-96,NDC,facility,both,6,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,68180-723-04,NDC,facility,both,8,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,63323-165-01,NDC,facility,both,14,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,636,RC,J2560,HCPCS,54288-137-01,NDC,facility,both,3,ML,,560,392,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 112 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6954-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-0710-20,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUM U-500 CONC 500 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1815,HCPCS,0002-8501-01,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 1000 MG MISC TBSO,50863,CDM,250,RC,J3490,HCPCS,904723961,NDC,facility,both,4,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,72603-179-01,NDC,facility,both,8,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,25021-463-01,NDC,facility,both,2,ML,JZ,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
APREPITANT  80 MG ORAL CAP,50863,CDM,636,RC,J8501,HCPCS,68462-584-40,NDC,facility,both,8,EA,,367,256.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,J2371,HCPCS,0641-6142-25,NDC,,,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIROFIBAN-0.9% SODIUM CHLORIDE 5 MG/100 ML (50 MCG/ML) IV SOLN,50863,CDM,J3246,HCPCS,25208-002-03,NDC,,,facility,both,20,ML,,398,278.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 17 GRAM (100 %) ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,1152372688,NDC,facility,both,15,EA,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,16714-046-01,NDC,facility,both,20,ML,,229,160.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,0409-4713-75,NDC,,,facility,both,200,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 2.5 MG ORAL TAB,50863,CDM,J3490,HCPCS,0003-0893-31,NDC,,,facility,both,1,EA,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,P9045,HCPCS,68516-5219-0,NDC,,,facility,both,14,ML,,3559,2491.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,55150-222-20,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,14,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIKACIN 1000 MG/4 ML INJ SOLN,50863,CDM,636,RC,J0278,HCPCS,23155-290-32,NDC,facility,both,8,ML,JW,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DICYCLOMINE 10 MG ORAL CAP,50863,CDM,J3490,HCPCS,0904-6987-61,NDC,,,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,250,RC,J2720,HCPCS,63323-229-30,NDC,facility,both,75,ML,,808,565.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 8-2 MG SL SUBL,50863,CDM,636,RC,J3490,HCPCS,60687-637-11,NDC,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0093-3426-10,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 250 MG/5 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,17856-0600-1,NDC,facility,both,3,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID (PORK)  30 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,42192-329-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 17 GRAM (100 %) ORAL PWPK,50863,CDM,636,RC,J3490,HCPCS,0904-6931-86,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0264-7800-10,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,636,RC,J2270,HCPCS,0409-1890-03,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETIRIZINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16571-401-10,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,0143-9577-01,NDC,,,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISANKIZUMAB-RZAA  60 MG/ML IV SOLN,50863,CDM,J2327,HCPCS,0074-5015-01,NDC,,,facility,both,1200,ML,,58689,41082.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHIMAZOLE 10 MG ORAL TAB,50863,CDM,J3490,HCPCS,49884-641-01,NDC,,,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,42806-150-33,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,83,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,200,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,50863,CDM,J9264,HCPCS,68817-134-50,NDC,,,facility,both,162,EA,,706476,494533.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE  1 % TOP CREA,50863,CDM,J3490,HCPCS,45802-438-03,NDC,,,facility,both,1,GM,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCRALFATE 100 MG/ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0121-0974-10,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM CITRATE ORAL SOLN,50863,CDM,J3490,HCPCS,70677-1111-1,NDC,,,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 0.3 % OPHT DROP,50863,CDM,250,RC,J3490,HCPCS,69315-308-02,NDC,facility,both,1,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MISOPROSTOL 800 MCG (4 X 200 MCG TAB) PACKAGE,50863,CDM,636,RC,S0191,HCPCS,43393-023-04,NDC,facility,both,4,EA,GZ,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier GZ: Item or service expected to be denied as not reasonable and necessary
CARVEDILOL  3.125 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7305-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,J1644,HCPCS,0409-2720-31,NDC,,,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE (FOR CODE) 10% IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0517-2710-25,NDC,facility,both,2,ML,,227,158.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE (FOR CODE) 10% (100 MG/ML) IV SYRINGE,50863,CDM,250,RC,J3490,HCPCS,64253-900-30,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,50863,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,59,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,60687-755-40,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IVPB (PEDIATRICS/ADULT NON-FORM)",50863,CDM,636,RC,J0131,HCPCS,24201-100-01,NDC,facility,both,100,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4% TOP PATCH,50863,CDM,250,RC,J3490,HCPCS,0536-1202-15,NDC,facility,both,2,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUMAZENIL 0.1 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0143-9784-01,NDC,facility,both,1,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,100,EA,,13800,9660,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 300 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,69452-125-50,NDC,facility,both,1,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4 % TOPICAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-4698-01,NDC,facility,both,80,ML,,1195,836.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN 1 MG/ML INJECTION (PEDS ONCOLOGY),50863,CDM,250,RC,J0640,HCPCS,71288-160-10,NDC,facility,both,1,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,68180-150-01,NDC,facility,both,4,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 25 MG/5 ML (5 MG/ML) ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,52652-6001-1,NDC,facility,both,1,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 0.5 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J8540,HCPCS,0054-3177-63,NDC,facility,both,40,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-50,NDC,facility,both,145,ML,,256,179.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,250,RC,J2003,HCPCS,0409-1323-15,NDC,facility,both,1600,ML,,640,448,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLU VACCINE TS 2025-26 6 MO UP (PF) 45 MCG (15 MCG X 3)/0.5 ML IM SYRG,50863,CDM,636,RC,90656,HCPCS,58160-912-41,NDC,facility,both,1,ML,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL 100 MCG/HR TD PT72,50863,CDM,636,RC,J3490,HCPCS,0378-9124-16,NDC,facility,both,1,EA,,227,158.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,636,RC,J1836,HCPCS,47335-993-01,NDC,facility,both,50,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-231-11,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BISOPROLOL FUMARATE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,70954-455-20,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION,50863,CDM,250,RC,J3490,HCPCS,0310-7370-20,NDC,facility,both,1,GM,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VARENICLINE 0.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,49884-155-76,NDC,facility,both,2,EA,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,67457-423-00,NDC,facility,both,2,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,55150-177-05,NDC,facility,both,200,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE 0.05 % OPHT DPET,50863,CDM,636,RC,J3490,HCPCS,68180-214-60,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MECLIZINE 12.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-522-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG IV SOLR,50863,CDM,636,RC,J0456,HCPCS,70860-100-41,NDC,facility,both,1,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 300 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,65162-649-78,NDC,facility,both,1,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 125 MG/5 ML (25MG/ML) ORAL SYRINGE (REPACK),50863,CDM,J3373,HCPCS,67457-340-00,NDC,,,facility,both,100,EA,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,111,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2598,HCPCS,65219-039-00,NDC,facility,both,20,ML,,136,95.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MECLIZINE 25 MG ORAL TAB,50863,CDM,J3490,HCPCS,60687-730-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,98,EA,,13524,9466.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOBRAMYCIN 1.2 G POWDER VIAL,50863,CDM,250,RC,J3260,HCPCS,39822-0412-6,NDC,facility,both,1,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),50863,CDM,250,RC,J3490,HCPCS,0409-4888-12,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN IN D5W 400 MG/200 ML IV PGBK,50863,CDM,J0744,HCPCS,25021-114-87,NDC,,,facility,both,2,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 10 MG/ML (PF) IV SOLN,50863,CDM,J2270,HCPCS,0641-6127-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYUREA  500 MG ORAL CAP,50863,CDM,636,RC,J9999,HCPCS,49884-724-01,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,J2003,HCPCS,0409-4277-16,NDC,,,facility,both,800,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,J2003,HCPCS,0409-4277-01,NDC,,,facility,both,400,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,0409-3178-16,NDC,,,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,J3490,HCPCS,0409-4887-17,NDC,,,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,J2003,HCPCS,0409-1323-15,NDC,,,facility,both,100,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALGANCICLOVIR 450 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-965-95,NDC,facility,both,1,EA,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,68180-150-01,NDC,facility,both,1,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-50,NDC,facility,both,39,ML,JW,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DEXAMETHASONE 0.1 MG/ML IV SYRINGE (NEO/INFANT),50863,CDM,250,RC,J1100,HCPCS,99999-0405-74,NDC,facility,both,2,ML,,101,70.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 800 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,17856-921-01,NDC,facility,both,4,EA,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0295,HCPCS,63323-368-20,NDC,facility,both,2,EA,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZONISAMIDE 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-230-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0781-3246-02,NDC,facility,both,4,ML,JZ,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-464-11,NDC,facility,both,4,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADVATE: FACTOR VIII CONCENTRATE (MERGE RECORD),50863,CDM,636,RC,J7192,HCPCS,0944-3053-03,NDC,facility,both,3045,UN,,15968,11177.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6778-61,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-1541-10,NDC,facility,both,1,ML,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAVASTATIN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-5892-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,250,RC,J3490,HCPCS,63323-485-27,NDC,facility,both,300,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESNA 100 MG/ML IV SOLN,50863,CDM,250,RC,J9209,HCPCS,10019-953-62,NDC,facility,both,7,ML,,184,128.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-112-02,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,18,ML,JW,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
HEPARIN (PORCINE) IN NACL (PF) 1000 UNIT/500 ML IV SOLP,50863,CDM,636,RC,J1644,HCPCS,0409-1005-01,NDC,facility,both,3,ML,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN 250 MG SOLUTION FOR INJECTION,50863,CDM,250,RC,J0290,HCPCS,65219-014-01,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-02,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE  50 MG ORAL TAB,50863,CDM,636,RC,j3490,HCPCS,0904-6868-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,250,RC,J2405,HCPCS,0409-4755-18,NDC,facility,both,4,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,16,EA,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYMETAZOLINE 0.05 % NASL SPRA,50863,CDM,636,RC,J3490,HCPCS,0904-7427-30,NDC,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTAZIDIME-AVIBACTAM 2.5 GRAM (2 GRAM-0.5 GRAM) IV SOLR,50863,CDM,250,RC,J0714,HCPCS,0456-2700-10,NDC,facility,both,2,EA,,527,368.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESNA 100 MG/ML IV SOLN,50863,CDM,250,RC,J9209,HCPCS,0338-1305-01,NDC,facility,both,8,ML,,289,202.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLP",50863,CDM,250,RC,P9047,HCPCS,0944-0493-04,NDC,facility,both,12,ML,,3001,2100.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-633-11,NDC,facility,both,1,EA,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,59651-488-01,NDC,facility,both,30,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-208-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,J3370,HCPCS,0143-9162-01,NDC,,,facility,both,4,EA,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,7,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-1638-32,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,250,RC,J7060,HCPCS,0338-0017-11,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 50 MG/ML IV SOLN,50863,CDM,J0282,HCPCS,67457-153-00,NDC,,,facility,both,5,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE  6.25 MG/5 ML ORAL SYRP,50863,CDM,250,RC,Q0169,HCPCS,70752-138-12,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN STERILE WATER 2 GRAM/20 ML IV SYRG,50863,CDM,J7999,HCPCS,70092-1604-47,NDC,,,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  1 MG/ML ORAL LIQD,50863,CDM,250,RC,J3490,HCPCS,5843800571,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIPHTH,PERTUS(ACELL),TETANUS SYRG(BOOSTRIX) 2.5-8-5 LF-MCG-LF/0.5ML IM SYRG",50863,CDM,90715,HCPCS,58160-842-43,NDC,,,facility,both,1,ML,,240,168,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2003,HCPCS,0409-2066-05,NDC,,,facility,both,500,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IVPB (PEDIATRICS/ADULT NON-FORM)",50863,CDM,250,RC,J0131,HCPCS,24201-100-01,NDC,facility,both,100,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES-DOCUSATE SODIUM 8.6 MG-50 MG TAB,50863,CDM,250,RC,J3490,HCPCS,60687-622-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,69918-899-01,NDC,facility,both,2,ML,,150,105,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,250,RC,J1596,HCPCS,0143-9679-01,NDC,facility,both,3,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-130-11,NDC,facility,both,2,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  40 MG ORAL TR12,50863,CDM,250,RC,J3490,HCPCS,59011-440-20,NDC,facility,both,1,EA,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 10 MCG/SPRAY NASL SPRA,50863,CDM,250,RC,J3490,HCPCS,60505-0815-0,NDC,facility,both,1,ML,,887,620.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,636,RC,J3490,HCPCS,51754-4250-1,NDC,facility,both,2,ML,,131,91.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0295,HCPCS,63323-368-20,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,5,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL TBSR,50863,CDM,J3490,HCPCS,0245-5316-89,NDC,,,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0093-2279-73,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NOREPINEPHRINE BITARTRATE-D5W 4 MG/250 ML (16 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0338-0112-20,NDC,facility,both,1,ML,,134,93.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,636,RC,J2003,HCPCS,76329-3390-1,NDC,facility,both,100,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 2.5 GRAM/25 ML (10 %) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-16,NDC,facility,both,10,ML,,1815,1270.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAFASITAMAB-CXIX 200 MG IV SOLR,50863,CDM,J9349,HCPCS,50881-013-03,NDC,,,facility,both,23,EA,,388,271.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE 25 MG/ML INJ SOLN,50863,CDM,250,RC,J3230,HCPCS,55150-319-01,NDC,facility,both,1,ML,,195,136.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,J3490,HCPCS,0143-9889-15,NDC,,,facility,both,8,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUGAMMADEX 100 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0006-5423-02,NDC,facility,both,2,ML,,1121,784.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 400 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-5853-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML IV SOLN (MERGE),50863,CDM,250,RC,J3490,HCPCS,0781-3269-71,NDC,facility,both,1,ML,,251,175.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,J1885,HCPCS,72266-118-01,NDC,,,facility,both,4,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,4,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG ORAL TAB,50863,CDM,J3490,HCPCS,60687-497-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESTRADIOL 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,42806-088-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM 500 MG IV SOLR,50863,CDM,250,RC,J2185,HCPCS,70121-1454-1,NDC,facility,both,5,EA,JZ,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CEFAZOLIN IN DEXTROSE (ISO-OSMOTIC) 1 GRAM/50 ML IV PIGGY BACK,50863,CDM,250,RC,J0689,HCPCS,0338-3503-41,NDC,facility,both,2,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,34,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,37,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM  3 GRAM INJ SOLR,50863,CDM,636,RC,J0295,HCPCS,72485-417-01,NDC,facility,both,2,EA,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  50 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6992-61,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-9543-02,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-1283-04,NDC,facility,both,5,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACIDOPHILUS-PECTIN W CITRUS 25 MILLION-100 CELL MG TAB,50863,CDM,250,RC,J3490,HCPCS,1785614241,NDC,facility,both,4,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   2 G INJ SOLR,50863,CDM,636,RC,J0690,HCPCS,60505-6231-0,NDC,facility,both,4,EA,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-01,NDC,facility,both,300,ML,JZ,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PHENYLEPHRINE IN 0.9% NS (PF) 1 MG/10 ML (100 MCG/ML) IV SYRG(PDS MERGE),50863,CDM,250,RC,J3490,HCPCS,65302-506-10,NDC,facility,both,200,ML,,2185,1529.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 50 % (4 MEQ/ML) INJ SOLN,50863,CDM,636,RC,J3475,HCPCS,63323-064-02,NDC,facility,both,4,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7041-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOLTERODINE 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,33342-097-09,NDC,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J2003,HCPCS,63323-492-09,NDC,facility,both,50,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7008-61,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESIPRAMINE  10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50742-112-01,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE (FOR CODE) 10% (100 MG/ML) IV SYRINGE,50863,CDM,250,RC,J3490,HCPCS,0409-4928-11,NDC,facility,both,1,ML,,101,70.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ORPHENADRINE CITRATE 100 MG ORAL TBSR,50863,CDM,636,RC,J3490,HCPCS,43386-480-24,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLARITHROMYCIN 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65862-226-60,NDC,facility,both,1,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-229-02,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESNA 100 MG/ML IV SOLN,50863,CDM,250,RC,J9209,HCPCS,10019-953-62,NDC,facility,both,2,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYUREA  500 MG ORAL CAP,50863,CDM,636,RC,J9999,HCPCS,68084-284-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  25 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-473-11,NDC,facility,both,3,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65162-897-09,NDC,facility,both,2,EA,,272,190.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE MALEATE  5 MG ORAL TAB,50863,CDM,636,RC,Q0164,HCPCS,50268-684-11,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-1749-70,NDC,facility,both,2,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0990-7983-61,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3370,HCPCS,0143-9162-01,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J2004,HCPCS,0409-3178-01,NDC,facility,both,80,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,50863,CDM,250,RC,J0696,HCPCS,0409-7335-13,NDC,facility,both,8,EA,JZ,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
RISPERIDONE 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7362-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,7,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,500,ML,,1266,886.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETIRIZINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-597-01,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-208-01,NDC,facility,both,8,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 500 MG-125 MG TAB,50863,CDM,250,RC,J3490,HCPCS,42571-161-01,NDC,facility,both,1,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,66794-229-02,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOFLOXACIN 250 MG/10 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0527-1948-68,NDC,facility,both,1,ML,,409,286.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALGANCICLOVIR 450 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0004-0038-22,NDC,facility,both,1,EA,,382,267.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  75 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6951-61,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML INJECTION,50863,CDM,250,RC,J3411,HCPCS,0641-6228-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,43547-354-10,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,11,EA,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIPASE-PROTEASE-AMYLASE (PORK) 36,000-114,000- 180,000 UNIT ORAL CPDR",50863,CDM,250,RC,J3490,HCPCS,0032-3016-13,NDC,facility,both,1,EA,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM SR 120 MG 24 HR CAP,50863,CDM,636,RC,J3490,HCPCS,60687-195-11,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 100 MG/1 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0781-3268-05,NDC,facility,both,1,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PREDNISONE  5 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-122-11,NDC,facility,both,40,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,636,RC,J1596,HCPCS,0143-9679-01,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 5 MG/ML IV SOLN,50863,CDM,636,RC,J1921,HCPCS,17478-420-20,NDC,facility,both,1,ML,JZ,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CEFTRIAXONE   2 GRAM INJ SOLR,50863,CDM,636,RC,J0696,HCPCS,0781-3209-90,NDC,facility,both,8,EA,,388,271.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV,50863,CDM,250,RC,J7120,HCPCS,0338-0117-03,NDC,facility,both,1,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 17 GRAM (100 %) ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,0904-6931-86,NDC,facility,both,4,EA,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEMANTINE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6505-06,NDC,facility,both,6,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LATANOPROST 0.005 % OPHT DROP,50863,CDM,250,RC,J3490,HCPCS,70069-421-01,NDC,facility,both,1,ML,,403,282.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6925-61,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NORTRIPTYLINE 25 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-293-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARDIOPLEGIC SOLUTION NO.25 29 MMOL/L (POTASSIUM) PERF SOLN,50863,CDM,250,RC,J3490,HCPCS,69374-984-10,NDC,facility,both,2,ML,,1008,705.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 0.5 % TOP OINT,50863,CDM,250,RC,J3490,HCPCS,45802-049-35,NDC,facility,both,1,GM,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,10,ML,JW,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,250,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,100,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J3490,HCPCS,47335-993-01,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,16,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
QUETIAPINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6638-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,636,RC,J1100,HCPCS,63323-506-01,NDC,facility,both,20,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML (1ML) INJ SOLN,50863,CDM,636,RC,J0171,HCPCS,42023-159-01,NDC,facility,both,10,ML,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COSYNTROPIN 0.25 MG INJ SOLR,50863,CDM,636,RC,J0834,HCPCS,0548-5900-00,NDC,facility,both,1,EA,,461,322.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,6,EA,,188,131.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATOVAQUONE 750 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0121-1016-05,NDC,facility,both,2,ML,,351,245.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-03,NDC,facility,both,1,ML,JZ,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,50863,CDM,J1650,HCPCS,16714-016-01,NDC,,,facility,both,4,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML IV SOLN (MERGE),50863,CDM,J3490,HCPCS,42023-216-01,NDC,,,facility,both,2,ML,,341,238.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN 250 MG SOLUTION FOR INJECTION,50863,CDM,250,RC,J0290,HCPCS,65219-014-01,NDC,facility,both,1,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HUMAN PROTHROMBIN COMPLEX 500 UNIT IV SOLR,50863,CDM,J7168,HCPCS,63833-386-02,NDC,,,facility,both,1000,UN,,5819,4073.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 2 GRAM INJ SOLR,50863,CDM,J0692,HCPCS,44567-241-10,NDC,,,facility,both,4,EA,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL IV BOLUS 10MG/ML (ANESTHESIA ONLY),50863,CDM,636,RC,J2704,HCPCS,0409-4699-54,NDC,facility,both,96,ML,JW,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
SODIUM BICARBONATE IV CONCENTRATED INFUSION (1 MEQ/ML),50863,CDM,250,RC,J3490,HCPCS,0409-6625-02,NDC,facility,both,9,ML,,515,360.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,38,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,250,RC,J2405,HCPCS,60505-6130-0,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 40 MG/ML SUSP (DEPO-MEDROL) INJECTION,50863,CDM,J1010,HCPCS,70121-1573-1,NDC,,,facility,both,20,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 175 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-541-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TROSPIUM 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0023-3513-60,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  750 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7125-61,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIKACIN 1000 MG/4 ML INJ SOLN,50863,CDM,250,RC,J0278,HCPCS,23155-290-32,NDC,facility,both,10,ML,JZ,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
BUMETANIDE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-131-11,NDC,facility,both,2,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL,50863,CDM,250,RC,J3490,HCPCS,63323-820-01,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GRANISETRON 1 MG/ML (1 ML) IV SOLN,50863,CDM,636,RC,J1626,HCPCS,0143-9744-01,NDC,facility,both,10,ML,JZ,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
BORTEZOMIB 3.5 MG IV SOLR,50863,CDM,250,RC,J9041,HCPCS,10019-991-01,NDC,facility,both,6,EA,JW,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0093-4127-73,NDC,facility,both,5,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-645-11,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-245-11,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,13668-011-01,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML INJ SOLN,50863,CDM,636,RC,J0171,HCPCS,76329-9060-0,NDC,facility,both,9,ML,,797,557.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN DEXTROSE (ISO-OSMOTIC) 1 GRAM/50 ML IV PIGGY BACK,50863,CDM,250,RC,J0689,HCPCS,0338-3503-41,NDC,facility,both,4,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 80 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-211-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALTREXONE 50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7036-04,NDC,facility,both,2,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0264-7800-10,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NYSTATIN 100000 UNIT/ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,63739-160-70,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  75 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,69238-1312-9,NDC,facility,both,1,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,63323-161-00,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,636,RC,J3490,HCPCS,0904-7509-30,NDC,facility,both,2,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DOBUTAMINE IN D5W 1,000 MG/250 ML (4,000 MCG/ML) IV SOLP",50863,CDM,250,RC,0409-3724-11,NDC,,,facility,both,1,ML,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,81033-002-30,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,63739-931-28,NDC,facility,both,9,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL-ROPIVACAINE-NACL (PF) 2-0.2 MCG/ML-% INJ (MERGE ERX),50863,CDM,250,RC,J3490,HCPCS,70092-9259-75,NDC,facility,both,1,ML,,218,152.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CONJUGATED ESTROGENS 25 MG INJ SOLR,50863,CDM,636,RC,J1410,HCPCS,0046-0749-05,NDC,facility,both,1,EA,,1335,934.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML IM SOLN,50863,CDM,636,RC,90375,HCPCS,13533-318-50,NDC,facility,both,11,ML,,9841,6888.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 30 MG/0.3 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0955-1003-01,NDC,facility,both,3,ML,JZ,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MESNA 100 MG/ML IV SOLN,50863,CDM,250,RC,J9209,HCPCS,10019-953-62,NDC,facility,both,10,ML,,294,205.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,9,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV,50863,CDM,636,RC,J7120,HCPCS,0338-0117-03,NDC,facility,both,4,ML,,214,149.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLN 400ML (PHS REPACK),50863,CDM,250,RC,J7040,HCPCS,99999-408-60,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL  97.2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16571-668-01,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML IM SOLN,50863,CDM,636,RC,90375,HCPCS,13533-318-50,NDC,facility,both,9,ML,JW,3501,2450.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
EZETIMIBE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7103-04,NDC,facility,both,1,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CITRATE-VITAMIN D3 200 MG CALCIUM -250 UNIT ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,536322301,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,55,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL IV BOLUS 10MG/ML (ANESTHESIA ONLY),50863,CDM,250,RC,J2704,HCPCS,0409-4699-54,NDC,facility,both,100,ML,,127,88.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0003-0894-21,NDC,facility,both,1,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIOGLITAZONE 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7090-61,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IR SOLN,50863,CDM,636,RC,J3490,HCPCS,0338-0047-46,NDC,facility,both,2,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,3,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,4,ML,,119,83.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOBUTAMINE IN D5W 500 MG/250 ML (2 MG/ML) INFUSION (PREMIX),50863,CDM,250,RC,J1250,HCPCS,0338-1075-02,NDC,facility,both,1,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,8,ML,,13873,9711.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RASBURICASE 1.5 MG IV SOLR,50863,CDM,250,RC,J2783,HCPCS,0024-5154-11,NDC,facility,both,3,EA,,2879,2015.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,J3490,HCPCS,0904-6794-80,NDC,,,facility,both,4,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  1 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,64380-782-06,NDC,facility,both,7,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 2 MG/10 ML (200 MCG/ML) IN D5W VIAL-CVL/IR USE (REPACK),50863,CDM,J2305,HCPCS,0338-1049-02,NDC,,,facility,both,10,ML,,133,93.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) 20000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,72603-224-01,NDC,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 8-2 MG SL SUBL,50863,CDM,636,RC,J3490,HCPCS,0904-7010-06,NDC,facility,both,1,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DORNASE ALFA 1 MG/ML INHL SOLN,50863,CDM,250,RC,J3490,HCPCS,50242-100-39,NDC,facility,both,1,ML,,578,404.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0039-05,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 250 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,42192-608-05,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,6809411059,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,63323-485-27,NDC,,,facility,both,120,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMETHICONE  80 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,77333-812-25,NDC,facility,both,6,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 15 MG/ML (1.5 %) INJ SOLN,50863,CDM,250,RC,J2003,HCPCS,0409-4776-10,NDC,facility,both,75,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,68180-150-01,NDC,facility,both,3,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORHEXIDINE GLUCONATE  0.12 % MM MWSH,50863,CDM,250,RC,J3490,HCPCS,53462-003-15,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETIRIZINE 5 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,68094-004-59,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  75 MG ORAL CP24,50863,CDM,636,RC,J3490,HCPCS,68084-709-11,NDC,facility,both,2,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,63323-400-01,NDC,facility,both,50,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6926-61,NDC,facility,both,3,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES  8.6 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7252-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  750 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-882-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J2003,HCPCS,0409-4713-32,NDC,facility,both,80,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELIMUMAB 120 MG IV SOLR,50863,CDM,636,RC,J0490,HCPCS,49401-101-01,NDC,facility,both,72,ME,"JZ,JA",8456,5919.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
NIFEDIPINE 30 MG ORAL TO24,50863,CDM,636,RC,J3490,HCPCS,68084-597-11,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GOLIMUMAB  12.5 MG/ML IV SOLN,50863,CDM,636,RC,J1602,HCPCS,57894-350-01,NDC,facility,both,13,ML,JW,624,436.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
INFLIXIMAB-ABDA 100 MG IV SOLR,50863,CDM,636,RC,Q5104,HCPCS,78206-162-99,NDC,facility,both,70,EA,,14556,10189.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 1000 MG MISC TBSO,50863,CDM,636,RC,J3490,HCPCS,77333-844-25,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SYRG,50863,CDM,636,RC,J3490,HCPCS,8290033010,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN   81 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,77333-031-25,NDC,facility,both,5,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,636,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IVERMECTIN 3 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,42799-806-01,NDC,facility,both,4,EA,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM IN NACL (ISO-OS) 1000 MG/100 ML IV PGBK,50863,CDM,636,RC,J1953,HCPCS,36000-356-01,NDC,facility,both,200,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 5 MG-325 MG TAB,50863,CDM,J3490,HCPCS,0406-0123-23,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,J1644,HCPCS,0409-2720-31,NDC,,,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,50863,CDM,J0696,HCPCS,60505-6149-0,NDC,,,facility,both,4,EA,,194,135.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,J1644,HCPCS,71288-402-10,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML INJ SOLN,50863,CDM,250,RC,J0171,HCPCS,76329-9060-0,NDC,facility,both,21,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOVASTATIN 20 MG ORAL TAB,50863,CDM,J3490,HCPCS,68180-468-07,NDC,,,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,500,ML,,716,501.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL DECANOATE  50 MG/ML IM SOLN,50863,CDM,250,RC,J1631,HCPCS,10147-0921-3,NDC,facility,both,1,ML,,152,106.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,62332-600-01,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,50863,CDM,250,RC,J3420,HCPCS,0517-0031-01,NDC,facility,both,1,ML,JZ,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SODIUM CHLORIDE 1000 MG MISC TBSO,50863,CDM,250,RC,J3490,HCPCS,904723961,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 0.4 MG SL SUBL,50863,CDM,636,RC,J3490,HCPCS,68462-639-25,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,49502-393-80,NDC,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-173-11,NDC,facility,both,4,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,2,EA,,199,139.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTASE 3000 UNIT ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,904522452,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0904-7127-61,NDC,facility,both,10,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,0088-2220-33,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARTIFICIAL TEAR(DXTRN-HPM-GLY) 0.1-0.3-0.2 % OPHT DROP,50863,CDM,250,RC,J3490,HCPCS,0065-0426-36,NDC,facility,both,1,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,17,EA,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,25021-602-03,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,636,RC,J3490,HCPCS,73702-301-15,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN PEDS INFUSION (CDS MIXTURE),50863,CDM,250,RC,J0290,HCPCS,25021-136-10,NDC,facility,both,2,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-02,NDC,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE SOD SUCC (PF) 100 MG/2 ML INJ SOLR,50863,CDM,636,RC,J1720,HCPCS,0009-0011-03,NDC,facility,both,1,EA,,142,99.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERTAPENEM 1 GRAM INJ SOLR,50863,CDM,636,RC,J1335,HCPCS,42023-221-01,NDC,facility,both,2,EA,JZ,506,354.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,25021-602-03,NDC,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNIT/G TOP OINT (MERGE),50863,CDM,J3490,HCPCS,0472-1105-56,NDC,,,facility,both,1,GM,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,55150-154-10,NDC,facility,both,18,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,76329-3352-1,NDC,facility,both,2,ML,,211,147.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,187,130.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,25021-402-01,NDC,facility,both,10,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,636,RC,J2560,HCPCS,54288-136-01,NDC,facility,both,1,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,60687-429-45,NDC,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPRAZOLAM 0.25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0781-1061-01,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMINOCAPROIC ACID 250 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0517-9120-01,NDC,facility,both,2,ML,,111,77.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 600 MG ORAL TP12,50863,CDM,250,RC,J3490,HCPCS,0536-1163-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,250,RC,J2270,HCPCS,0409-1891-03,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOTRIMAZOLE  10 MG MM TROC,50863,CDM,250,RC,J3490,HCPCS,0574-0107-70,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRIMIDONE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0527-1301-01,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,50863,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,10,ML,,271,189.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 20 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7346-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-579-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-05,NDC,facility,both,4,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN NPH & REGULAR HUMAN 100 UNIT/ML (70-30) SUBQ SUSP,50863,CDM,636,RC,J1815,HCPCS,0169-1837-11,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 10 MEQ/100 ML IV PGBK (USE NON-PROTOCOL PANEL),50863,CDM,250,RC,J3480,HCPCS,0338-0709-48,NDC,facility,both,5,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,636,RC,J3490,HCPCS,63323-485-27,NDC,facility,both,65,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 125 MG/5 ML (25MG/ML) ORAL SYRINGE (REPACK),50863,CDM,250,RC,J3370,HCPCS,67457-340-00,NDC,facility,both,4,EA,,165,115.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 10 MG/5 ML SYRUP,50863,CDM,250,RC,Q0177,HCPCS,62135-750-47,NDC,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,60687-390-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SULFASALAZINE 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,59762-5000-5,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAMSULOSIN 0.4 MG ORAL CP24,50863,CDM,636,RC,J3490,HCPCS,68084-299-11,NDC,facility,both,2,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG ORAL TAB,50863,CDM,J3490,HCPCS,63304-774-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-467-01,NDC,facility,both,1,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 10 MG TAB,50863,CDM,250,RC,Q0177,HCPCS,63739-483-10,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  1 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,59651-484-01,NDC,facility,both,3,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAMOXIFEN 10 MG ORAL TAB,50863,CDM,250,RC,J9999,HCPCS,59651-299-60,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,8,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"CALCIUM GLUC IN NACL, ISO-OSM 1 G/100 ML IV SOLN",50863,CDM,636,RC,J0612,HCPCS,44567-622-01,NDC,facility,both,100,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,65,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL 20 MG/5 ML ORAL ELIX,50863,CDM,636,RC,J3490,HCPCS,0121-0942-05,NDC,facility,both,3,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES-DOCUSATE SODIUM 8.6 MG-50 MG TAB,50863,CDM,636,RC,J3490,HCPCS,10135-669-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCHLOROTHIAZIDE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-593-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,150,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VEDOLIZUMAB 300 MG IV SOLR,50863,CDM,636,RC,J3380,HCPCS,64764-300-20,NDC,facility,both,300,EA,,11084,7758.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMETHICONE  80 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,77333-812-25,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J2004,HCPCS,63323-482-03,NDC,facility,both,100,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-165-11,NDC,facility,both,3,EA,,222,155.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CINACALCET 30 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16729-440-15,NDC,facility,both,2,EA,,260,182,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  50 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6992-61,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLIMEPIRIDE 2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-326-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CITRATE 10 MEQ ORAL TBER,50863,CDM,636,RC,J3490,HCPCS,68084-850-33,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
D5-1/2 NS AND POTASSIUM CHLORIDE 20 MEQ/L IV (PEDS CHEMO),50863,CDM,250,RC,J3490,HCPCS,0338-0671-04,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TETRACAINE HCL (PF) 0.5 % OPHT DROP (STANDARD STOCK),50863,CDM,636,RC,J3490,HCPCS,0065-0741-14,NDC,facility,both,1,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-3243-01,NDC,facility,both,3,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,100,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE (DIAGNOSTIC) 3 MG/ML IV SOLN,50863,CDM,636,RC,J0153,HCPCS,55150-193-01,NDC,facility,both,100,ML,,858,600.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 8-2 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,60687-637-11,NDC,facility,both,2,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-579-11,NDC,facility,both,4,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 1 MG/0.5 ML INJ SYRG,50863,CDM,250,RC,J3430,HCPCS,76329-1240-1,NDC,facility,both,1,ML,,146,102.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,636,RC,J0330,HCPCS,0409-6629-02,NDC,facility,both,2,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,59762-0075-1,NDC,facility,both,2,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 75 MG/5 ML ORAL SOLUTION,50863,CDM,636,RC,J3490,HCPCS,64980-511-10,NDC,facility,both,16,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAVASTATIN 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-190-11,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOLAZONE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-635-11,NDC,facility,both,2,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0630,HCPCS,42023-205-01,NDC,facility,both,1,ML,,4969,3478.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,111,ML,,159,111.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,68180-150-01,NDC,facility,both,4,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESNA 100 MG/ML IV SOLN,50863,CDM,250,RC,J9209,HCPCS,10019-953-62,NDC,facility,both,3,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,250,RC,J0330,HCPCS,71449-126-15,NDC,facility,both,4,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SITAGLIPTIN  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0006-0221-01,NDC,facility,both,2,EA,,225,157.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZIPRASIDONE 20 MG IM,50863,CDM,250,RC,J3486,HCPCS,72205-205-01,NDC,facility,both,1,EA,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESALAMINE 400 MG ORAL CAPSULE-WITH DR TABLETS (CDTI),50863,CDM,250,RC,J3490,HCPCS,60687-556-33,NDC,facility,both,6,EA,,245,171.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,57237-077-10,NDC,facility,both,20,EA,,1315,920.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
L. ACIDOPHILUS-B. LACTIS-FOS 5 BILLION CELL ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,52061-00403,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,16729-114-08,NDC,facility,both,15,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE  1 % TOP OINT,50863,CDM,636,RC,J3490,HCPCS,0168-0020-31,NDC,facility,both,2,GM,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BECLOMETHASONE DIPROPIONATE 40 MCG/ACTUATION INHL HFAB,50863,CDM,636,RC,J3490,HCPCS,59310-302-40,NDC,facility,both,1,GM,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,J3490,HCPCS,0173-0682-20,NDC,,,facility,both,1,GM,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESTRADIOL 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42806-088-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJ SOLN",50863,CDM,J3490,HCPCS,63323-461-01,NDC,,,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,J2003,HCPCS,63323-486-27,NDC,,,facility,both,200,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,J2795,HCPCS,70069-064-25,NDC,,,facility,both,150,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE IN 0.9% NS (PF) 1 MG/10 ML (100 MCG/ML) IV SYRG(PDS MERGE),50863,CDM,250,RC,J3490,HCPCS,65302-506-10,NDC,facility,both,2,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYMETAZOLINE 0.05 % NASL SPRA,50863,CDM,J3490,HCPCS,0904-7427-30,NDC,,,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAFASITAMAB-CXIX 200 MG IV SOLR,50863,CDM,J9349,HCPCS,50881-013-03,NDC,,,facility,both,477,EA,,17994,12595.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-453-11,NDC,facility,both,7,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEPROTUMUMAB-TRBW 500 MG IV SOLR,50863,CDM,J3241,HCPCS,75987-130-15,NDC,,,facility,both,100,EA,,70828,49579.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 10 GRAM/15 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,66689-038-01,NDC,facility,both,3,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,70095-031-01,NDC,facility,both,18,ML,,722,505.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,50863,CDM,250,RC,J9060,HCPCS,16729-288-38,NDC,facility,both,17,ML,,346,242.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZONATATE 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7153-61,NDC,facility,both,30,EA,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-18,NDC,facility,both,300,ML,JZ,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DOCUSATE SODIUM 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7183-61,NDC,facility,both,10,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-134-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,0409-9094-22,NDC,facility,both,4,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM PHOSPHATE 3 MMOL/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-884-01,NDC,facility,both,2,ML,,152,106.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-4675-05,NDC,facility,both,3,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,50863,CDM,636,RC,J1756,HCPCS,0517-2340-01,NDC,facility,both,400,ML,JZ,1284,898.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
D5-1/2 NS AND POTASSIUM CHLORIDE 10 MEQ/L IV,50863,CDM,250,RC,J3490,HCPCS,0338-0669-04,NDC,facility,both,1,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 10 MG-100 MG TAB,50863,CDM,250,RC,J3490,HCPCS,51862-855-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OFLOXACIN 0.3 % OPHT DROP,50863,CDM,636,RC,J3490,HCPCS,64980-515-05,NDC,facility,both,1,ML,,299,209.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERGOCALCIFEROL (VITAMIN D2) 50000 UNIT ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,50268-297-11,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4 % TOPICAL SOLN,50863,CDM,250,RC,J3490,HCPCS,76329-6300-5,NDC,facility,both,4,ML,,522,365.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PALIPERIDONE PALMITATE 234 MG/1.5 ML IM SYRG,50863,CDM,636,RC,J2426,HCPCS,50458-564-01,NDC,facility,both,234,ML,,9851,6895.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,63323-280-03,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-103-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM ACETATE 667 MG ORAL CAP,50863,CDM,250,RC,J0615,HCPCS,0904-7119-06,NDC,facility,both,29,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6966-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR  6 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,27241-139-09,NDC,facility,both,13,ML,,168,117.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TAB,50863,CDM,250,RC,J3490,HCPCS,10702-253-01,NDC,facility,both,2,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,63323-461-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 0.5 % TOP OINT,50863,CDM,250,RC,J3490,HCPCS,68462-798-17,NDC,facility,both,1,GM,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6550-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL 2.5 MG/ML SUSPENSION,50863,CDM,636,RC,J3490,HCPCS,99999-0404-75,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORHEXIDINE GLUCONATE  0.12 % MM MWSH,50863,CDM,636,RC,J3490,HCPCS,0121-0893-15,NDC,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6665-61,NDC,facility,both,1,EA,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0641-0400-12,NDC,facility,both,5,ML,JZ,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ETODOLAC 400 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,69238-1342-1,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-592-11,NDC,facility,both,3,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOPAMINE INFUSION NEO IV SYRINGE (FROM PREMIX) 3200 MIG/ML,50863,CDM,250,RC,J1265,HCPCS,99999-444-01,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLN,50863,CDM,636,RC,J3262,HCPCS,50242-135-01,NDC,facility,both,240,ML,,4399,3079.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML (1ML) INJ SOLN,50863,CDM,250,RC,J0169,HCPCS,63323-696-02,NDC,facility,both,5,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,250,RC,J3101,HCPCS,50242-037-06,NDC,facility,both,19,EA,,8703,6092.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 800 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6707-06,NDC,facility,both,1,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIPASE-PROTEASE-AMYLASE 12,000-38,000- 60,000 UNIT ORAL CAP, DELAY REL",50863,CDM,250,RC,J3490,HCPCS,0032-0047-70,NDC,facility,both,3,EA,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),50863,CDM,250,RC,J0171,HCPCS,76329-3318-1,NDC,facility,both,40,ML,,294,205.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EZETIMIBE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51660-200-30,NDC,facility,both,1,EA,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-076-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML INJ SOLN,50863,CDM,250,RC,J0171,HCPCS,76329-9060-0,NDC,facility,both,300,ML,,797,557.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 0.5 MG ORAL CAP,50863,CDM,250,RC,J7507,HCPCS,0904-6623-61,NDC,facility,both,4,EA,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,49,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,68462-469-40,NDC,facility,both,2,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6665-61,NDC,facility,both,5,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,48,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,250,RC,J0690,HCPCS,44567-707-25,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 10 MG/ML ORAL SOLUTION (REPACK),50863,CDM,636,RC,J3490,HCPCS,0131-5410-71,NDC,facility,both,2,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CODEINE-GUAIFENESIN 10-100 MG/5 ML ORAL LIQD (REPACK),50863,CDM,636,RC,J3490,HCPCS,0121-1775-05,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,63323-185-07,NDC,facility,both,5,ML,,167,116.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE (POLACRILEX) 2 MG BUCL GUM,50863,CDM,636,RC,J3490,HCPCS,0536-1362-25,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE (6 MONTH) 45 MG IM SYKT,50863,CDM,636,RC,J9217,HCPCS,0074-3473-03,NDC,facility,both,6,EA,,1176,823.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,101,70.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 2 MG/10 ML (200 MCG/ML) IN D5W VIAL-CVL/IR USE (REPACK),50863,CDM,250,RC,J3490,HCPCS,0338-1049-02,NDC,facility,both,10,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML (ANESTHESIA INTRAOP ONLY),50863,CDM,250,RC,J3010,HCPCS,0641-6027-01,NDC,facility,both,25,ML,,353,247.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 40 % ORAL GEL,50863,CDM,636,RC,J3490,HCPCS,574006915,NDC,facility,both,2,GM,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,54,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE-DEXTROSE-WATER(PF) 7.5 MG/ML (0.75 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,71351-022-10,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE 150 MG ORAL CP24,50863,CDM,636,RC,J3490,HCPCS,65862-697-90,NDC,facility,both,1,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7350-61,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 30% IN WATER (NEO),50863,CDM,250,RC,J7070,HCPCS,0409-6648-16,NDC,facility,both,5,ML,,158,110.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE 14 MG/24 HR TD PT24,50863,CDM,250,RC,J3490,HCPCS,4898500150,NDC,facility,both,5,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,50863,CDM,250,RC,J9045,HCPCS,0703-4239-01,NDC,facility,both,12,ML,,321,224.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),50863,CDM,250,RC,J1630,HCPCS,63323-474-00,NDC,facility,both,2,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNIT/G TOP OINT (MERGE),50863,CDM,250,RC,J3490,HCPCS,58980-011-10,NDC,facility,both,2,GM,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML SYRUP,50863,CDM,250,RC,J3490,HCPCS,0121-0638-10,NDC,facility,both,12,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,63323-506-01,NDC,facility,both,4,ML,JW,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,636,RC,J3010,HCPCS,0409-9094-22,NDC,facility,both,2,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,50863,CDM,250,RC,J9000,HCPCS,0069-1542-20,NDC,facility,both,11,ML,,180,126,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,200,ML,,141,98.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,636,RC,Q9968,HCPCS,70710-1838-1,NDC,facility,both,5,ML,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATRACURIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-1105-22,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 500 MG (200 MG ELEMENTAL) CHEW TAB,50863,CDM,250,RC,J3490,HCPCS,66553-004-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MANNITOL 20% IV SOLP,50863,CDM,250,RC,J2150,HCPCS,0338-0357-03,NDC,facility,both,1,ML,,321,224.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACUBITRIL-VALSARTAN 24-26 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0078-0659-61,NDC,facility,both,1,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,636,RC,J2795,HCPCS,63323-286-20,NDC,facility,both,150,ML,JZ,128,89.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
AMPHETAMINE-DEXTROAMPHETAMINE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,64850-502-01,NDC,facility,both,2,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,636,RC,P9045,HCPCS,68516-5214-4,NDC,facility,both,12,ML,JZ,1712,1198.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,12,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 60 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,51991-748-90,NDC,facility,both,2,EA,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 0.1 MG/ML INJ SYRG,50863,CDM,250,RC,J0461,HCPCS,76329-3340-1,NDC,facility,both,50,ML,JW,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,500,ML,,1330,931,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OMEPRAZOLE-SODIUM BICARBONATE 2-84 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,65628-270-03,NDC,facility,both,3,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,16714-036-01,NDC,facility,both,16,ML,,187,130.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-1541-01,NDC,facility,both,1,ML,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,133,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-444-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,55390-138-01,NDC,facility,both,3,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,2,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),50863,CDM,J1171,HCPCS,0409-4264-11,NDC,,,facility,both,5,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,26,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LECANEMAB-IRMB 100 MG/ML IV SOLN,50863,CDM,636,RC,J0174,HCPCS,62856-215-01,NDC,facility,both,860,ML,Q0,2520,1764,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier Q0: Investigational clinical service provided in a clinical research study that is in an approved clinical research study
APIXABAN 5 MG ORAL TAB,50863,CDM,J3490,HCPCS,0003-0894-31,NDC,,,facility,both,1,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,68094-600-59,NDC,facility,both,2,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 250 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,17856-0600-1,NDC,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,636,RC,J1836,HCPCS,47335-993-01,NDC,facility,both,100,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,33,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL,50863,CDM,250,RC,J3490,HCPCS,63323-820-01,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % MBP,50863,CDM,J3490,HCPCS,0338-9662-35,NDC,,,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  50 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-7048-61,NDC,,,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA SR 25 MG-100 MG TAB,50863,CDM,250,RC,J3490,HCPCS,68084-281-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 5 MG-325 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0406-0123-23,NDC,facility,both,2,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM BICARB-CITRIC ACID 20 MEQ ORAL TBEF,50863,CDM,250,RC,J3490,HCPCS,51801-011-30,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 10 GRAM/15 ML ORAL SOLN,50863,CDM,J3490,HCPCS,66689-038-01,NDC,,,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  75 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-475-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 12.5 MG ORAL TAB,50863,CDM,J3490,HCPCS,68462-164-01,NDC,,,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN   81 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,0536-1234-41,NDC,facility,both,4,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOLTERODINE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,33342-097-09,NDC,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUPHENAZINE DECANOATE 25 MG/ML INJ SOLN,50863,CDM,250,RC,J2680,HCPCS,55150-267-05,NDC,facility,both,2,ML,,260,182,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,50863,CDM,250,RC,J9045,HCPCS,0703-4239-01,NDC,facility,both,10,ML,,270,189,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE (FOR CODE) 10% IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0517-6710-01,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADVATE: FACTOR VIII CONCENTRATE (MERGE RECORD),50863,CDM,250,RC,J7192,HCPCS,0944-3053-03,NDC,facility,both,1000,UN,,5244,3670.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SULFASALAZINE 500 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,59762-0104-5,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51407-153-90,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RALTEGRAVIR 400 MG ORAL TAB,50863,CDM,J3490,HCPCS,0006-0227-61,NDC,,,facility,both,1,EA,,204,142.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 5 MG ORAL TAB,50863,CDM,J3490,HCPCS,0003-0894-31,NDC,,,facility,both,1,EA,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,250,RC,J3490,HCPCS,0409-1891-01,NDC,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-ABDA 100 MG IV SOLR,50863,CDM,Q5104,HCPCS,78206-162-01,NDC,,,facility,both,6,EA,,543,380.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6869-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DONEPEZIL  5 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-6477-61,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,2,EA,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,68094-494-59,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,24,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 5 MG-325 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0406-0123-23,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 500 MG PE/10 ML INJ SOLN,50863,CDM,636,RC,Q2009,HCPCS,68462-622-10,NDC,facility,both,6,ML,JW,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
HEPARIN (PORCINE) IN D5W 20000 UNIT/500 ML,50863,CDM,636,RC,J1644,HCPCS,0264-9567-10,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J2310,HCPCS,67457-292-00,NDC,facility,both,1,ML,,233,163.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR  6 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,68180-678-01,NDC,facility,both,4,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,17856-0574-1,NDC,facility,both,3,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRIMIDONE 250 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-687-11,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,70860-700-41,NDC,facility,both,2,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL  6.25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7306-61,NDC,facility,both,1,EA,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,5,EA,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"CALCIUM CARBONATE 500 MG (1,250 MG) ORAL TAB",50863,CDM,250,RC,J3490,HCPCS,7985450021,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,636,RC,J3373,HCPCS,0143-9162-01,NDC,facility,both,125,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ELECTROLYTE-A IV,50863,CDM,250,RC,J3490,HCPCS,0338-0221-04,NDC,facility,both,4,ML,,392,274.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,15,ML,JW,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
OXYBUTYNIN CHLORIDE  5 MG ORAL TO24,50863,CDM,250,RC,J3490,HCPCS,62175-270-37,NDC,facility,both,2,EA,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,70069-363-01,NDC,facility,both,1,ML,,152,106.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACUBITRIL-VALSARTAN 97-103 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0078-0696-20,NDC,facility,both,1,EA,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MISOPROSTOL 800 MCG (4 X 200 MCG TAB) PACKAGE,50863,CDM,250,RC,S0191,HCPCS,43386-161-06,NDC,facility,both,2,EA,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,65162-897-09,NDC,facility,both,1,EA,,157,109.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 60 MG ORAL CPDR,50863,CDM,636,RC,J3490,HCPCS,57237-019-30,NDC,facility,both,1,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM HYPOCHLORITE 0.25 % MISC SOLN,50863,CDM,250,RC,J3490,HCPCS,39328-063-25,NDC,facility,both,1,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN 1 GRAM SOLUTION FOR INJECTION,50863,CDM,636,RC,J0290,HCPCS,55150-113-10,NDC,facility,both,2,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,67877-548-88,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EFGARTIGIMOD ALFA-FCAB 20 MG/ML IV SOLN,50863,CDM,636,RC,J9332,HCPCS,73475-3041-5,NDC,facility,both,350,ML,,28739,20117.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL  3.125 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7305-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRILAT 1.25 MG/ML IV INJ,50863,CDM,250,RC,J3490,HCPCS,0143-9786-01,NDC,facility,both,1,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NORTRIPTYLINE 50 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0093-0812-01,NDC,facility,both,3,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,50863,CDM,636,RC,FAMNOCHARGE,HCPCS,0904-6617-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM NEO/PED INFUSION (CDS MIXTURE),50863,CDM,250,RC,J2185,HCPCS,0781-3267-90,NDC,facility,both,5,EA,,267,186.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,68516-5214-3,NDC,facility,both,1,ML,,263,184.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 500 MG PE/10 ML INJ SOLN,50863,CDM,250,RC,Q2009,HCPCS,68462-621-02,NDC,facility,both,3,ML,,131,91.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,42,ML,JW,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CYCLOBENZAPRINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-190-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"CALCIUM GLUC IN NACL, ISO-OSM 1 GRAM/50 ML IV SOLN",50863,CDM,636,RC,J0613,HCPCS,44567-620-01,NDC,facility,both,200,ML,,232,162.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,276,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
HALOPERIDOL 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-249-11,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 50% IN WATER (MERGE RECORD),50863,CDM,250,RC,J7060,HCPCS,0409-7517-66,NDC,facility,both,2,ML,,192,134.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DORZOLAMIDE 2 % OPHT DROP,50863,CDM,250,RC,J3490,HCPCS,70377-081-11,NDC,facility,both,1,ML,,284,198.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 100 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,16714-358-01,NDC,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-466-03,NDC,facility,both,300,ML,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NAPROXEN 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-491-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG IV SOLR,50863,CDM,250,RC,J0650,HCPCS,63323-649-07,NDC,facility,both,10,EA,,520,364,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0832-0590-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,25021-410-76,NDC,facility,both,4,ML,JZ,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CALCIUM CHLORIDE (FOR CODE) 10% (100 MG/ML) IV SYRINGE,50863,CDM,250,RC,J3490,HCPCS,70121-2308-1,NDC,facility,both,3,ML,,185,129.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,250,RC,J2270,HCPCS,0409-1890-13,NDC,facility,both,1,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,23155-600-31,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,142,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-464-11,NDC,facility,both,5,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLOPATADINE 0.1 % OPHT DROP,50863,CDM,636,RC,J3490,HCPCS,70069-017-01,NDC,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE 220 MCG/ACTUATION INHL AERO,50863,CDM,250,RC,J3490,HCPCS,66993-080-96,NDC,facility,both,1,GM,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-1283-03,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,250,RC,J0137,HCPCS,0264-4100-90,NDC,facility,both,26,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7047-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL (VITAMIN D3) 400 UNIT/ML ORAL DROP,50863,CDM,250,RC,J3490,HCPCS,7651805050,NDC,facility,both,3,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 200 MG/20 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,31722-203-20,NDC,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,636,RC,J3490,HCPCS,61553-320-70,NDC,facility,both,1,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML INJ SOLN,50863,CDM,636,RC,J2060,HCPCS,0641-6207-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE  2.5 % RECT CREA,50863,CDM,636,RC,J3490,HCPCS,62559-431-30,NDC,facility,both,1,GM,,353,247.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 50% IN WATER (MERGE RECORD),50863,CDM,250,RC,J7060,HCPCS,0409-7517-66,NDC,facility,both,1,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,17271-701-05,NDC,facility,both,1,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,54288-136-01,NDC,facility,both,1,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,636,RC,J3490,HCPCS,0143-9575-01,NDC,facility,both,480,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 500 MG (200 MG ELEMENTAL) CHEW TAB,50863,CDM,250,RC,J3490,HCPCS,66553-004-01,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % MUCOSAL SOLN (VISCOUS),50863,CDM,636,RC,J3490,HCPCS,50383-363-15,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROIC ACID 250 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0591-4012-01,NDC,facility,both,3,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0121-0945-10,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,15,ML,,26011,18207.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,68180-150-01,NDC,facility,both,2,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,50863,CDM,636,RC,J0561,HCPCS,60793-701-02,NDC,facility,both,24,ML,JZ,2376,1663.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DEXTROMETHORPHAN-GUAIFENESIN SR 30 MG-600 MG 12 HR TAB,50863,CDM,636,RC,J3490,HCPCS,0536-1161-37,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FINASTERIDE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6830-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-1163-01,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICARDIPINE IN NACL (ISO-OS) 20 MG/200 ML IV PGBK,50863,CDM,250,RC,J3490,HCPCS,43066-009-10,NDC,facility,both,1,ML,,255,178.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 0.1 % EYE DROPS,50863,CDM,250,RC,J3490,HCPCS,24208-720-02,NDC,facility,both,1,ML,,275,192.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADVATE: FACTOR VIII CONCENTRATE (MERGE RECORD),50863,CDM,636,RC,J7192,HCPCS,0944-3053-02,NDC,facility,both,3045,UN,,12747,8922.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,50863,CDM,636,RC,J1756,HCPCS,0517-2325-01,NDC,facility,both,4,ML,JW,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
EPHEDRINE 50 MG/ML IV SOLN (MERGE),50863,CDM,250,RC,J3490,HCPCS,16714-037-10,NDC,facility,both,1,ML,,127,88.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOPERAMIDE 2 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,51079-690-01,NDC,facility,both,10,EA,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,0409-1283-03,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OMEPRAZOLE 20 MG ORAL CPDR,50863,CDM,636,RC,J3490,HCPCS,0904-6917-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,250,RC,J2270,HCPCS,63323-454-00,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,636,RC,J3490,HCPCS,68180-963-01,NDC,facility,both,1,GM,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MISOPROSTOL 100 MCG ORAL TAB,50863,CDM,636,RC,S0191,HCPCS,60687-735-11,NDC,facility,both,2,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE (3 MONTH) 11.25 MG IM KIT,50863,CDM,636,RC,J1950,HCPCS,0074-3663-03,NDC,facility,both,3,EA,,14914,10439.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,250,RC,J2270,HCPCS,0409-1890-03,NDC,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-407-11,NDC,facility,both,2,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,250,RC,J7999,HCPCS,70092-1017-46,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN IN D5W 600 MG/50 ML IV PGBK,50863,CDM,636,RC,J0736,HCPCS,0338-3616-50,NDC,facility,both,2,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML INJ SOLN,50863,CDM,250,RC,J0169,HCPCS,76329-9060-0,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,11,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,19,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,12,ML,JW,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,20,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-ABDA 100 MG IV SOLR,50863,CDM,636,RC,Q5104,HCPCS,78206-162-99,NDC,facility,both,5,EA,JW,453,317.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,13,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML ORAL CONC,50863,CDM,250,RC,J3490,HCPCS,0054-3532-44,NDC,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,59651-488-01,NDC,facility,both,10,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 40 % ORAL GEL,50863,CDM,636,RC,J3490,HCPCS,574006915,NDC,facility,both,1,GM,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION,50863,CDM,636,RC,J3490,HCPCS,0186-0372-20,NDC,facility,both,2,GM,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,50863,CDM,636,RC,Q0177,HCPCS,60687-675-11,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 30% IN WATER (NEO),50863,CDM,250,RC,J3490,HCPCS,0409-6648-16,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-50,NDC,facility,both,50,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,8,EA,,278,194.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,250,RC,J2003,HCPCS,0409-1323-15,NDC,facility,both,800,ML,,352,246.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,100,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,50863,CDM,250,RC,J9206,HCPCS,0009-0082-02,NDC,facility,both,1,ML,JW,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
MEPIVACAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,636,RC,J0670,HCPCS,63323-294-01,NDC,facility,both,1,ML,JW,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
OMEPRAZOLE 10 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,68462-395-30,NDC,facility,both,2,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN SODIUM  2 GRAM INJ SOLR,50863,CDM,636,RC,J0290,HCPCS,25021-137-20,NDC,facility,both,4,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CODEINE-GUAIFENESIN 10-100 MG/5 ML ORAL LIQD (REPACK),50863,CDM,636,RC,J3490,HCPCS,0121-1550-10,NDC,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 600 MG ORAL TP12,50863,CDM,250,RC,J3490,HCPCS,6382400840,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPRAZOLAM 0.25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0781-1061-01,NDC,facility,both,4,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IVPB (PEDIATRICS/ADULT NON-FORM)",50863,CDM,636,RC,J0137,HCPCS,24201-100-01,NDC,facility,both,100,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 300 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,68180-320-06,NDC,facility,both,1,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,636,RC,J2795,HCPCS,63323-286-20,NDC,facility,both,100,ML,,150,105,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 160 MG-800 MG TAB,50863,CDM,250,RC,J3490,HCPCS,68084-230-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALACYCLOVIR 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6565-61,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 20MG/55 ML IVPB IN NS (ONCOLOGY),50863,CDM,250,RC,J1100,HCPCS,63323-165-02,NDC,facility,both,8,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE 0.5 MG/2 ML INHL NBSP,50863,CDM,636,RC,J3490,HCPCS,0487-9701-01,NDC,facility,both,2,ML,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,62584-734-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25 MG-250 MG TAB,50863,CDM,250,RC,J3490,HCPCS,60687-836-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERTAPENEM 1 GRAM INJ SOLR,50863,CDM,250,RC,J1335,HCPCS,16714-889-01,NDC,facility,both,10,EA,,2625,1837.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLMESARTAN 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16729-322-15,NDC,facility,both,1,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,12,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,636,RC,J3490,HCPCS,48433-129-01,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ANTI-INHIBITOR COAGULANT CMPLX 1,750-3,250 UNIT IV SOLR",50863,CDM,250,RC,J7198,HCPCS,64193-425-02,NDC,facility,both,2525,UN,,15042,10529.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-442-01,NDC,facility,both,4,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADVATE: FACTOR VIII CONCENTRATE (MERGE RECORD),50863,CDM,J7192,HCPCS,0944-3053-04,NDC,,,facility,both,2000,UN,,10488,7341.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VORICONAZOLE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6596-04,NDC,facility,both,5,EA,,238,166.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INDIGOTINDISULFONATE SODIUM 8 MG/ML INJ SOLN,50863,CDM,J3490,HCPCS,17478-508-01,NDC,,,facility,both,1,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,13,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),50863,CDM,636,RC,J3490,HCPCS,0409-4888-02,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCERIN (CHILD) RECTAL SUPPOSITORY,50863,CDM,636,RC,J3490,HCPCS,57237-326-52,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-31,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) NEB SOLUTION,50863,CDM,636,RC,J3490,HCPCS,0487-9501-01,NDC,facility,both,4,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,25,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-074-10,NDC,facility,both,2,EA,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0054-8297-25,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMETHICONE 40 MG/0.6 ML ORAL DRPS,50863,CDM,250,RC,J3490,HCPCS,0536-1303-75,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),50863,CDM,250,RC,J3490,HCPCS,0409-4888-02,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,636,RC,J2405,HCPCS,70860-776-41,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SCOPOLAMINE TRANSDERMAL PATCH 1MG OVER 3 DAYS,50863,CDM,250,RC,J3490,HCPCS,0591-2258-54,NDC,facility,both,1,EA,,119,83.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-231-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ (MERGE),50863,CDM,636,RC,J2250,HCPCS,0409-0001-01,NDC,facility,both,6,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,63323-165-01,NDC,facility,both,3,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,63323-462-01,NDC,facility,both,1,ML,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IV PGBK,50863,CDM,636,RC,J3490,HCPCS,63323-106-00,NDC,facility,both,1,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 2 MG INJ SOLR,50863,CDM,J2997,HCPCS,50242-041-64,NDC,,,facility,both,2,EA,,800,560,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 2.5 GRAM/25 ML (10 %) INJ SOLN",50863,CDM,250,RC,J1561,HCPCS,13533-800-16,NDC,facility,both,5,ML,,908,635.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 400 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0143-9887-01,NDC,facility,both,6,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,J2003,HCPCS,0409-4277-02,NDC,,,facility,both,400,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN ASP PRT-INSULIN ASPART 100 UNIT/ML (70-30) SUBQ SOLN,50863,CDM,636,RC,J1817,HCPCS,0169-3685-12,NDC,facility,both,1,ML,GZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier GZ: Item or service expected to be denied as not reasonable and necessary
SUGAMMADEX 100 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0006-5423-02,NDC,facility,both,3,ML,,1681,1176.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,10,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,5,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL,50863,CDM,250,RC,J3490,HCPCS,63323-820-04,NDC,facility,both,1,ML,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLP",50863,CDM,250,RC,P9047,HCPCS,0944-0493-04,NDC,facility,both,9,ML,,2251,1575.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J3490,HCPCS,0338-0049-38,NDC,facility,both,1,ML,JZ,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
OXCARBAZEPINE 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7263-61,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN D5W 20000 UNIT/500 ML,50863,CDM,636,RC,J1644,HCPCS,0264-9567-10,NDC,facility,both,20,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MILRINONE 1 MG/ML IV SOLN,50863,CDM,250,RC,J2260,HCPCS,63323-617-10,NDC,facility,both,2,ML,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,63323-485-26,NDC,,,facility,both,200,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 100 % ORAL POWD,50863,CDM,250,RC,J3490,HCPCS,1093978844,NDC,facility,both,1,GM,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,38,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN 250 MG SOLUTION FOR INJECTION,50863,CDM,250,RC,J0290,HCPCS,0781-3402-78,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZTROPINE 1 MG/ML INJ SOLN,50863,CDM,636,RC,J0515,HCPCS,0143-9729-01,NDC,facility,both,4,ML,,636,445.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN NEO IV SYRINGE (CDS MIXTURE),50863,CDM,J3370,HCPCS,0338-3582-01,NDC,,,facility,both,2,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0527-3281-46,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0641-6022-01,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,159,111.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE 0.05 % OPHT DPET,50863,CDM,636,RC,J3490,HCPCS,0023-9163-30,NDC,facility,both,1,EA,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-25,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-161-11,NDC,facility,both,4,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERTAPENEM 1 GRAM INJ SOLR,50863,CDM,250,RC,J1335,HCPCS,42023-221-01,NDC,facility,both,2,EA,,506,354.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MISOPROSTOL 200 MCG ORAL TAB,50863,CDM,250,RC,S0191,HCPCS,60687-746-11,NDC,facility,both,3,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-4264-11,NDC,facility,both,8,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 60 MG TAB,50863,CDM,636,RC,J3490,HCPCS,60687-728-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,250,RC,J3490,HCPCS,60687-653-11,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-205-01,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE (PF) 1 MG/ML INJ SOLN,50863,CDM,250,RC,J0171,HCPCS,54288-103-01,NDC,facility,both,300,ML,,2568,1797.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN 0.9 % SODIUM CHL 2 GRAM/500 ML IV SOLN,50863,CDM,250,RC,J3370,HCPCS,71506-019-59,NDC,facility,both,4,ML,,148,103.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,16714-294-02,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,50863,CDM,250,RC,J8540,HCPCS,0054-8175-25,NDC,facility,both,48,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0591-0407-01,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,636,RC,J7060,HCPCS,0338-0017-38,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-161-11,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-349-11,NDC,facility,both,3,EA,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV,50863,CDM,636,RC,J7120,HCPCS,0338-0117-04,NDC,facility,both,3,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65162-898-09,NDC,facility,both,2,EA,,272,190.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL  97.2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,75826-142-10,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,636,RC,J1953,HCPCS,63323-400-01,NDC,facility,both,400,ML,,420,294,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML IM SOLN,50863,CDM,636,RC,90375,HCPCS,13533-318-05,NDC,facility,both,11,ML,,9483,6638.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  5 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-122-11,NDC,facility,both,35,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTAMIDINE 300 MG INJ SOLR,50863,CDM,636,RC,J3490,HCPCS,23155-748-31,NDC,facility,both,1,EA,,423,296.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 500 MG (200 MG ELEMENTAL) CHEW TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6412-92,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6780-61,NDC,facility,both,2,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE-EPINEPHR-TETRACAINE 4-0.18-0.5 % TOPICAL GEL,50863,CDM,636,RC,J3490,HCPCS,71266-6290-1,NDC,facility,both,1,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAMADOL  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,29300-355-01,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LINEZOLID 600 MG/300 ML IV SOLP,50863,CDM,250,RC,J2020,HCPCS,63323-713-03,NDC,facility,both,3,ML,,232,162.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 0.5 MG ORAL TAB,50863,CDM,250,RC,J8540,HCPCS,0054-8179-25,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,55150-177-05,NDC,facility,both,25,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0990-7983-61,NDC,facility,both,1,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-089-50,NDC,facility,both,10,ML,,1458,1020.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.3 MG/0.3 ML IM PNIJ,50863,CDM,250,RC,J0169,HCPCS,49502-102-01,NDC,facility,both,3,EA,,675,472.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 12.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68382-094-01,NDC,facility,both,3,EA,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL  97.2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,75826-142-10,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VARENICLINE 0.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,49884-155-76,NDC,facility,both,1,EA,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IV PGBK,50863,CDM,250,RC,J3475,HCPCS,0338-1715-40,NDC,facility,both,8,ML,JZ,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CLOTRIMAZOLE 1 % VAGL CREA,50863,CDM,636,RC,J3490,HCPCS,70677-1228-1,NDC,facility,both,1,GM,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,636,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,7,EA,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6782-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIFAMPIN 150 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-575-11,NDC,facility,both,1,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SALMETEROL 50 MCG/DOSE INHL DSDV,50863,CDM,250,RC,J3490,HCPCS,0173-0521-00,NDC,facility,both,1,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J3430,HCPCS,65219-635-00,NDC,facility,both,10,ML,,130,91,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,70436-030-82,NDC,facility,both,158,ML,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6370-61,NDC,facility,both,10,EA,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-098-10,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 40 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,65862-296-30,NDC,facility,both,1,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,67877-590-01,NDC,facility,both,3,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,63323-185-07,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 250 MG/50 ML CONCENTRATED DRIP (RSE),50863,CDM,250,RC,J2250,HCPCS,0641-6060-01,NDC,facility,both,25,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60505-3111-0,NDC,facility,both,3,EA,,194,135.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIFAMPIN 600 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,0068-0597-01,NDC,facility,both,1,EA,,772,540.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7193-06,NDC,facility,both,10,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL PWPK,50863,CDM,636,RC,J3490,HCPCS,37000-024-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETIRIZINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-799-02,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 1MG/ML SYRINGE (FOR IR USE ONLY),50863,CDM,250,RC,J2997,HCPCS,99999-0403-36,NDC,facility,both,5,ML,,1056,739.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-279-11,NDC,facility,both,6,EA,,157,109.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,250,RC,J3490,HCPCS,0904-6930-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-406-03,NDC,facility,both,1,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J1938,HCPCS,36000-283-25,NDC,facility,both,80,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-318-11,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,636,RC,J1953,HCPCS,63323-400-01,NDC,facility,both,15,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
SERTRALINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6924-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,72603-506-01,NDC,facility,both,150,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2305-16,NDC,facility,both,6,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZINC SULFATE 220 MG (50 MG) CAP,50863,CDM,250,RC,J3490,HCPCS,2055504000,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-3178-16,NDC,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TETANUS IMMUNE GLOBULIN (PF) 250 UNIT IM SYRG,50863,CDM,636,RC,J1670,HCPCS,13533-634-02,NDC,facility,both,1,ML,,1262,883.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50111-328-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN IN D5W 400 MG/200 ML IV PGBK,50863,CDM,636,RC,J0744,HCPCS,0409-3300-01,NDC,facility,both,2,ML,JZ,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PHYTONADIONE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J3430,HCPCS,43598-405-11,NDC,facility,both,5,ME,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM  4.5 GRAM IV SOLR,50863,CDM,636,RC,J2543,HCPCS,55150-121-50,NDC,facility,both,4,EA,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM  4.5 GRAM IV SOLR,50863,CDM,250,RC,J2543,HCPCS,60505-6159-0,NDC,facility,both,4,EA,JZ,107,74.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PROPAFENONE 150 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-709-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
REMDESIVIR 100 MG IV SOLR,50863,CDM,250,RC,J0248,HCPCS,61958-2901-1,NDC,facility,both,100,EA,,1196,837.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16714-990-01,NDC,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORDIAZEPOXIDE 25 MG CAP,50863,CDM,636,RC,J3490,HCPCS,0555-0159-04,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IVPB (PEDIATRICS/ADULT NON-FORM)",50863,CDM,250,RC,J0137,HCPCS,24201-100-01,NDC,facility,both,100,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,77,EA,,10626,7438.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE 0.5 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,63323-463-01,NDC,facility,both,1,ML,,107,74.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,250,RC,J2704,HCPCS,25021-608-20,NDC,facility,both,3,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROATE SODIUM 100 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-494-01,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 10 GRAM/15 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,50383-779-30,NDC,facility,both,2,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 12.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7307-61,NDC,facility,both,2,EA,PLAD,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
PHENOBARBITAL  32.4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6575-61,NDC,facility,both,5,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 800 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,17856-921-01,NDC,facility,both,1,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN NORMAL SALINE IV,50863,CDM,636,RC,J7042,HCPCS,0264-7610-00,NDC,facility,both,2,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,25021-053-01,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-1660-55,NDC,facility,both,1,ML,,165,115.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 112 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42292-039-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE IN 0.9% NS (PF) 1 MG/10 ML (100 MCG/ML) IV SYRG(PDS MERGE),50863,CDM,250,RC,J3490,HCPCS,71019-263-20,NDC,facility,both,3,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROGESTERONE MICRONIZED 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,65162-807-10,NDC,facility,both,2,EA,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 125 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6955-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % MUCOSAL SOLN (VISCOUS),50863,CDM,250,RC,J3490,HCPCS,0054-8500-16,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML INJECTION,50863,CDM,250,RC,J3411,HCPCS,63323-013-01,NDC,facility,both,4,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RASBURICASE 1.5 MG IV SOLR,50863,CDM,250,RC,J2783,HCPCS,0024-5154-11,NDC,facility,both,6,EA,,5758,4030.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLP",50863,CDM,636,RC,P9047,HCPCS,0944-0493-04,NDC,facility,both,1,ML,JW,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
APIXABAN 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0003-0894-70,NDC,facility,both,14,EA,,612,428.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,50863,CDM,250,RC,J1756,HCPCS,0517-2340-01,NDC,facility,both,400,ML,,1322,925.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPAGLIFLOZIN PROPANEDIOL 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0310-6210-39,NDC,facility,both,1,EA,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXAZOSIN 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-836-95,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0780,HCPCS,23155-294-31,NDC,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WHITE PETROLATUM-MINERAL OIL TOPICAL CREAM (MERGE),50863,CDM,636,RC,J3490,HCPCS,7214003868,NDC,facility,both,1,GM,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,25,EA,,3450,2415,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FELBAMATE 400 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,62559-730-01,NDC,facility,both,2,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,63739-903-10,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML IV SOLN (MERGE),50863,CDM,250,RC,J3490,HCPCS,16714-037-01,NDC,facility,both,1,ML,,253,177.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICARDIPINE 25 MG/10 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,55150-183-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,26,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,652,ML,,935,654.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-9558-05,NDC,facility,both,3,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2305-04,NDC,facility,both,5,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-591-11,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HUMAN PROTHROMBIN COMPLEX 500 UNIT IV SOLR,50863,CDM,250,RC,J7168,HCPCS,63833-386-02,NDC,facility,both,500,UN,JZ,2910,2037,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-21,NDC,facility,both,20,ML,,2829,1980.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,250,RC,J3490,HCPCS,0409-1323-05,NDC,facility,both,200,ML,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-405-11,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER SULFADIAZINE 1 % TOP CREA,50863,CDM,250,RC,J3490,HCPCS,43598-210-40,NDC,facility,both,1,GM,,270,189,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAZOLAMIDE 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-054-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,10702-018-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-50,NDC,facility,both,150,ML,,265,185.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,50863,CDM,250,RC,J0640,HCPCS,71288-161-20,NDC,facility,both,4,EA,,165,115.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,250,RC,Q0162,HCPCS,65162-691-79,NDC,facility,both,4,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCRALFATE 1 GRAM ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,59762-0401-1,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,50863,CDM,636,RC,J3420,HCPCS,63323-044-00,NDC,facility,both,1,ML,JZ,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
POTASSIUM CHLORIDE 10 MEQ/100 ML IV PGBK (USE NON-PROTOCOL PANEL),50863,CDM,J3480,HCPCS,0338-0709-48,NDC,,,facility,both,5,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE PEDS SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J3490,HCPCS,0338-6045-37,NDC,facility,both,1,ML,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 5 MG/5 ML IV,50863,CDM,J3490,HCPCS,0409-1778-15,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 150 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-432-11,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TETRACAINE HCL (PF) 0.5 % OPHT DROP (STANDARD STOCK),50863,CDM,J3490,HCPCS,0065-0741-14,NDC,,,facility,both,1,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,11,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1815,HCPCS,0002-8215-01,NDC,facility,both,2,ML,GZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier GZ: Item or service expected to be denied as not reasonable and necessary
MIRTAZAPINE 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6519-61,NDC,facility,both,2,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 10 GRAM/100 ML (10%) INJ SOLN",50863,CDM,250,RC,J1561,HCPCS,13533-800-72,NDC,facility,both,20,ML,,2829,1980.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J3430,HCPCS,0409-9158-31,NDC,facility,both,8,ML,JW,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DOXYCYCLINE HYCLATE 100 MG IV SOLR,50863,CDM,636,RC,J3490,HCPCS,70436-032-35,NDC,facility,both,2,EA,,296,207.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,50863,CDM,250,RC,J0696,HCPCS,44567-701-25,NDC,facility,both,4,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,121,84.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 20 GRAM/30 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-1154-30,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,11,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,63,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,2,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7050,HCPCS,0338-9543-02,NDC,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE HCL IN 0.9% NACL 1 MG/10 ML (100 MCG/ML) IV SYRG,50863,CDM,J3490,HCPCS,73177-108-03,NDC,,,facility,both,2,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,42858-302-01,NDC,facility,both,12,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML INJ SOLN,50863,CDM,250,RC,J0171,HCPCS,76329-9061-0,NDC,facility,both,300,ML,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,50863,CDM,250,RC,Q0177,HCPCS,63739-486-10,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE MONONITRATE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,7733393425,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LITHIUM CARBONATE 300 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,68084-640-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-709-11,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 400 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-6667-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,63323-162-00,NDC,facility,both,2,ML,JZ,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
METHADONE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1230,HCPCS,67457-217-20,NDC,facility,both,1,ML,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-41,NDC,facility,both,2,ML,,338,236.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM PHOSPHATE 0.06 MMOL/ML IVPB (FOR PEDIATRICS),50863,CDM,636,RC,J3490,HCPCS,70121-1722-1,NDC,facility,both,1,ML,,264,184.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,76045-009-10,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALSARTAN  40 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-612-11,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-760-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,12,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLEDRONIC ACID 4 MG/5 ML IV SOLN,50863,CDM,636,RC,J3489,HCPCS,67457-390-54,NDC,facility,both,4,ML,,224,156.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0630,HCPCS,42023-205-01,NDC,facility,both,1,ML,,1921,1344.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,13668-010-01,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN DEXTROSE (ISO-OSMOTIC) 1 GRAM/50 ML IV PIGGY BACK,50863,CDM,250,RC,J0689,HCPCS,0338-3503-41,NDC,facility,both,4,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,636,RC,J1953,HCPCS,63323-400-01,NDC,facility,both,300,ML,,164,114.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J3490,HCPCS,0264-1800-36,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,636,RC,J1596,HCPCS,70069-013-25,NDC,facility,both,3,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML IV (MERGE) (FOR VENT),50863,CDM,250,RC,J3490,HCPCS,70092-1509-35,NDC,facility,both,1,ML,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 50 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-854-11,NDC,facility,both,50,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0990-7983-61,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,636,RC,J2405,HCPCS,23155-547-31,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J2004,HCPCS,63323-482-01,NDC,facility,both,200,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 50 MG 24 HR TAB,50863,CDM,636,RC,J3490,HCPCS,60687-402-11,NDC,facility,both,2,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOLAZONE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7139-61,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 10 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0781-2823-01,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB 100 MG IV SOLR,50863,CDM,636,RC,J1745,HCPCS,57894-030-01,NDC,facility,both,49,EA,,15794,11055.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OMALIZUMAB 75 MG/0.5 ML SUBQ SYRG,50863,CDM,636,RC,J2357,HCPCS,50242-214-03,NDC,facility,both,15,ML,,1558,1090.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TERAZOSIN  2 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,59746-384-06,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETIRIZINE 5 MG/5 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,68094-004-59,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NORETHINDRONE ACETATE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68462-304-50,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,2,EA,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ABATACEPT 250 MG IV SOLR,50863,CDM,636,RC,J0129,HCPCS,0003-2187-13,NDC,facility,both,75,EA,JA,12534,8773.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
TRAZODONE  50 MG ORAL TAB,50863,CDM,250,RC,j3490,HCPCS,60687-443-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 0.2 MG/HR TD PT24,50863,CDM,250,RC,J3490,HCPCS,0378-9104-16,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TERBINAFINE 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-795-01,NDC,facility,both,14,EA,,611,427.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN IN D5W 900 MG/50 ML IV PGBK,50863,CDM,250,RC,J0736,HCPCS,0781-3290-91,NDC,facility,both,3,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 25 MG/5 ML (5 MG/ML) ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,52536-600-11,NDC,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,250,RC,J7060,HCPCS,0338-0017-48,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,J1100,HCPCS,63323-506-01,NDC,,,facility,both,6,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,J1100,HCPCS,63323-506-01,NDC,,,facility,both,12,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 10 MG ORAL CAP,50863,CDM,J3490,HCPCS,60687-369-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,J3490,HCPCS,50580-458-11,NDC,,,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1940,HCPCS,0409-6102-02,NDC,facility,both,2,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE IN 0.9 % SOD CHLORIDE 100 MG/10 ML (10 MG/ML) IV SYRG,50863,CDM,250,RC,J3490,HCPCS,61553-331-65,NDC,facility,both,1,ML,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR PHOSPHATE 30 MG ORAL CAP,50863,CDM,J3490,HCPCS,64380-797-01,NDC,,,facility,both,1,EA,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,51754-5011-1,NDC,facility,both,1,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 400 MG ORAL CAP,50863,CDM,J3490,HCPCS,16714-663-01,NDC,,,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,70069-363-01,NDC,facility,both,1,ML,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPATITIS B IMMUNE GLOBULIN >312 UNIT/ML IM SOLN,50863,CDM,250,RC,90371,HCPCS,69800-4202-1,NDC,facility,both,1,ML,,721,504.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 20MG/ML IV SYRINGE (PEDS/NEO),50863,CDM,250,RC,J0612,HCPCS,63323-311-10,NDC,facility,both,52,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN NPH & REGULAR HUMAN 100 UNIT/ML (70-30) SUBQ SUSP,50863,CDM,250,RC,J1815,HCPCS,0169-1837-11,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,24,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,51754-4250-1,NDC,facility,both,2,ML,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLPIDEM  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-838-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 2 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,636,RC,J2270,HCPCS,76045-004-01,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 125 MG/5 ML (25MG/ML) ORAL SYRINGE (REPACK),50863,CDM,250,RC,J3370,HCPCS,67457-340-00,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4% TOP PATCH,50863,CDM,636,RC,J3490,HCPCS,46581-830-01,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 12.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68382-094-01,NDC,facility,both,2,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,15,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,636,RC,J0330,HCPCS,31722-981-10,NDC,facility,both,4,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOPAMINE INFUSION NEO IV SYRINGE (FROM PREMIX),50863,CDM,636,RC,J1265,HCPCS,0409-7809-11,NDC,facility,both,10,ML,JZ,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PREDNISONE  5 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-122-11,NDC,facility,both,50,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE 25 MG/ML INJ SOLN,50863,CDM,250,RC,J3230,HCPCS,0641-1398-31,NDC,facility,both,1,ML,,195,136.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RAVULIZUMAB-CWVZ 100 MG/ML IV SOLN,50863,CDM,636,RC,J1303,HCPCS,25682-028-01,NDC,facility,both,330,ML,JZ,194426,136098.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SODIUM BICARBONATE IV CONCENTRATED INFUSION (1 MEQ/ML),50863,CDM,250,RC,J3490,HCPCS,0409-6625-02,NDC,facility,both,3,ML,,172,120.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9% IV (PEDS) BOLUS,50863,CDM,250,RC,J7040,HCPCS,0264-7800-09,NDC,facility,both,2,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,250,RC,J7060,HCPCS,0990-7923-37,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 30 MG TAB,50863,CDM,250,RC,J3490,HCPCS,60687-717-11,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 150 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-530-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYBUTYNIN CHLORIDE  5 MG ORAL TO24,50863,CDM,250,RC,J3490,HCPCS,62175-270-37,NDC,facility,both,4,EA,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,50863,CDM,636,RC,J0561,HCPCS,60793-700-01,NDC,facility,both,24,ML,JZ,3018,2112.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 875 MG-125 MG TAB,50863,CDM,636,RC,J3490,HCPCS,60687-803-11,NDC,facility,both,2,EA,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,250,RC,J3360,HCPCS,0641-6244-01,NDC,facility,both,2,ML,,145,101.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 10% IN WATER (NEO) 2 - 3.99 KG,50863,CDM,250,RC,J3490,HCPCS,0338-0023-04,NDC,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0264-7800-00,NDC,facility,both,2,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 300 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-722-11,NDC,facility,both,3,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEMANTINE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6505-06,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,83980-006-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOTRIMAZOLE 1 % VAGL CREA,50863,CDM,250,RC,J3490,HCPCS,70677-1228-1,NDC,facility,both,1,GM,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID (PORK) 15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0456-1045-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,250,RC,J3490,HCPCS,76329-3390-1,NDC,facility,both,200,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 500 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7337-35,NDC,facility,both,28,EA,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0069-0006-01,NDC,facility,both,10,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,14,ML,JW,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,63323-466-17,NDC,facility,both,200,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6371-61,NDC,facility,both,3,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM BROMIDE 0.02 % INHL SOLN,50863,CDM,250,RC,J3490,HCPCS,0487-9801-01,NDC,facility,both,2,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESIPRAMINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50742-113-01,NDC,facility,both,12,EA,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,16714-294-01,NDC,facility,both,10,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,76045-009-96,NDC,facility,both,6,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-582-11,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7007-61,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,J2003,HCPCS,55150-255-20,NDC,,,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,J0665,HCPCS,55150-169-10,NDC,,,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,J2003,HCPCS,63323-486-05,NDC,,,facility,both,60,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROATE SODIUM 100 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0143-9785-01,NDC,facility,both,1,ML,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML INJ SOLN,50863,CDM,636,RC,J0169,HCPCS,76329-9060-0,NDC,facility,both,30,ML,,797,557.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MILRINONE INFUSION PED/NEO IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J2260,HCPCS,99999-0406-26,NDC,facility,both,4,ML,,462,323.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,23,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACUBITRIL-VALSARTAN 97-103 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0078-0696-67,NDC,facility,both,1,EA,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,68,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  37.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-844-11,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,29300-423-01,NDC,facility,both,2,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-18,NDC,facility,both,70,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
POLYETHYLENE GLYCOL 3350 17 GRAM (100 %) ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,0904-6931-86,NDC,facility,both,8,EA,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,18,ML,JW,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
METRONIDAZOLE 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-550-11,NDC,facility,both,4,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"NEOMYCIN-POLYMYXIN-HC 3.5 MG-10,000 UNIT-10 MG/ML EYE DROPS, SUSP",50863,CDM,636,RC,J3490,HCPCS,61314-641-75,NDC,facility,both,1,ML,,674,471.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  5 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-122-11,NDC,facility,both,5,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 150 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,68084-708-95,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,62584-984-11,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4 % MUCOSAL TOPICAL SOLN,50863,CDM,636,RC,J3490,HCPCS,0054-3505-47,NDC,facility,both,1,ML,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 2 MG/10 ML (200 MCG/ML) IN D5W VIAL-CVL/IR USE (REPACK),50863,CDM,636,RC,J2305,HCPCS,0338-1049-02,NDC,facility,both,10,ML,,133,93.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN DEXTROSE (ISO-OSMOTIC) 1 GRAM/50 ML IV PIGGY BACK,50863,CDM,250,RC,J0690,HCPCS,0338-3503-41,NDC,facility,both,4,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE  2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-157-11,NDC,facility,both,1,EA,,152,106.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),50863,CDM,636,RC,J1630,HCPCS,67457-426-00,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  25 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6991-61,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DONEPEZIL  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6477-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN (NEW TX NON-NEURO INDICATION)",50863,CDM,250,RC,J1561,HCPCS,13533-800-71,NDC,facility,both,20,ML,JA,2829,1980.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
FAMOTIDINE 20 MG ORAL TAB,50863,CDM,J3490,HCPCS,50268-299-11,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEPROTUMUMAB-TRBW 500 MG IV SOLR,50863,CDM,636,RC,J3241,HCPCS,75987-130-15,NDC,facility,both,19,EA,JW,6177,4323.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-28,NDC,facility,both,8,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,6,ML,,192,134.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,70095-031-01,NDC,facility,both,33,ML,,1318,922.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
D5-0.9%NACL-POTASSIUM CHLORIDE 20 MEQ/L IV SOLP (PED ONC),50863,CDM,636,RC,J3480,HCPCS,0264-7652-00,NDC,facility,both,10,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,16,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,636,RC,J2720,HCPCS,63323-229-01,NDC,facility,both,2,ML,JW,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,65,ML,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6500-61,NDC,facility,both,4,EA,,190,133,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"RHO(D) IMMUNE GLOBULIN (RHOPHYLAC) 1,500 UNIT (300 MCG)/2 ML INJ SYRG",50863,CDM,636,RC,J2791,HCPCS,44206-300-01,NDC,facility,both,1,ML,,693,485.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,65649-211-24,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-0905-05,NDC,facility,both,3,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,636,RC,J3490,HCPCS,63323-486-02,NDC,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DENOSUMAB 120 MG/1.7 ML (70 MG/ML) SUBQ SOLN,50863,CDM,250,RC,J0897,HCPCS,55513-730-01,NDC,facility,both,120,ML,,9522,6665.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MECLIZINE 25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7376-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,0641-0476-21,NDC,facility,both,3,ML,,619,433.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN  200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,10135-681-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0121-0914-05,NDC,facility,both,4,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE  5 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,70010-029-01,NDC,facility,both,7,EA,,214,149.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,25021-053-01,NDC,facility,both,4,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2308-22,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON DEXTRAN 50 MG/ML INJ SOLN,50863,CDM,636,RC,J1750,HCPCS,0023-6082-01,NDC,facility,both,14,ML,,1532,1072.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 10 MG ORAL TAB,50863,CDM,J3490,HCPCS,50268-089-11,NDC,,,facility,both,1,EA,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIACIN  250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,4329255740,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN SODIUM  2 GRAM INJ SOLR,50863,CDM,J0290,HCPCS,25021-137-20,NDC,,,facility,both,4,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE DINITRATE 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6620-61,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,J2371,HCPCS,0641-6188-01,NDC,,,facility,both,4000,ML,,188,131.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,J2704,HCPCS,63323-269-22,NDC,,,facility,both,40,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN DEXTROSE (ISO-OS) 2 GRAM/100 ML IV PGBK,50863,CDM,J0689,HCPCS,0338-3508-41,NDC,,,facility,both,4,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,63323-165-01,NDC,facility,both,10,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0093-2279-73,NDC,facility,both,6,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0338-1055-48,NDC,facility,both,50,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,P9045,HCPCS,68516-5219-0,NDC,,,facility,both,2,ML,,796,557.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,250,RC,J0132,HCPCS,63323-963-21,NDC,facility,both,120,ML,,951,665.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,J3490,HCPCS,23155-166-31,NDC,,,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),50863,CDM,250,RC,J0171,HCPCS,76329-3318-1,NDC,facility,both,30,ML,,242,169.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL,50863,CDM,250,RC,J3490,HCPCS,63323-820-01,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-492-27,NDC,,,facility,both,240,ML,,189,132.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,J3490,HCPCS,66794-228-02,NDC,,,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),50863,CDM,636,RC,J1630,HCPCS,0143-9319-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,636,RC,J2405,HCPCS,60505-6130-0,NDC,facility,both,64,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,51,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,72162-1330-6,NDC,facility,both,1,ML,,414,289.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACTIVATED CHARCOAL 25 GRAM/120 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0574-0521-74,NDC,facility,both,1,ML,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,0904-6923-61,NDC,facility,both,10,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.45% (1/2 NS) INFUSION (PEDS ONC),50863,CDM,250,RC,J3490,HCPCS,0338-0043-04,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,50863,CDM,250,RC,J9000,HCPCS,63323-883-30,NDC,facility,both,5,ML,,196,137.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0904-7127-61,NDC,facility,both,80,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-354-11,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-25,NDC,facility,both,36,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,43547-281-10,NDC,facility,both,3,EA,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 500 MG PE/10 ML INJ SOLN,50863,CDM,250,RC,Q2009,HCPCS,67457-517-00,NDC,facility,both,10,ML,,245,171.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-503-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NADOLOL  40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,76385-134-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,65862-642-30,NDC,facility,both,3,EA,,229,160.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/G EYE OINTMENT",50863,CDM,250,RC,J3490,HCPCS,24208-555-55,NDC,facility,both,1,GM,,141,98.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATED 20 MG/ML IV SOLN,50863,CDM,250,RC,J0706,HCPCS,51754-0500-1,NDC,facility,both,200,ML,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 250 MCG SUBQ SOLR,50863,CDM,J2802,HCPCS,55513-221-01,NDC,,,facility,both,250,EA,,4390,3073,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-7912-59,NDC,,,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,50863,CDM,J1650,HCPCS,16714-026-01,NDC,,,facility,both,5,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0003-0894-70,NDC,facility,both,28,EA,,982,687.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6290-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,636,RC,J3490,HCPCS,0409-4277-01,NDC,facility,both,400,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 80 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-590-95,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE 0.5%/EPINEPHRINE 1:100K INJECTION,50863,CDM,250,RC,J3490,HCPCS,63323-286-30,NDC,facility,both,2,ML,,255,178.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROPROCAINE 3 % INJ SOLN,50863,CDM,636,RC,J2401,HCPCS,63323-478-20,NDC,facility,both,600,ML,,132,92.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,42858-302-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATENOLOL  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-759-01,NDC,facility,both,4,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7122-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 100 MG/ML INJ SOLN,50863,CDM,636,RC,J2800,HCPCS,70069-101-01,NDC,facility,both,1,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 500 MG (200 MG ELEMENTAL) CHEW TAB,50863,CDM,636,RC,J3490,HCPCS,68084-988-33,NDC,facility,both,8,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,636,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,7,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPAGLIFLOZIN PROPANEDIOL 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,66993-457-30,NDC,facility,both,1,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE-DEXTROSE-WATER(PF) 7.5 MG/ML (0.75 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,71351-022-10,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J2004,HCPCS,0409-3178-16,NDC,facility,both,200,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,250,RC,J3490,HCPCS,67457-197-10,NDC,facility,both,2,ML,,736,515.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-503-11,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"HEPARIN, PORCINE (PF)   10 UNIT/ML IV SYRG",50863,CDM,636,RC,J1642,HCPCS,6425322235,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6418-61,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,72603-350-01,NDC,facility,both,20,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,636,RC,J3490,HCPCS,63739-434-02,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,23,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCHLOROTHIAZIDE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0172-2083-60,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NAPROXEN 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68462-190-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 600 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,59651-361-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IVPB (PEDIATRICS/ADULT NON-FORM)",50863,CDM,636,RC,J0137,HCPCS,24201-100-01,NDC,facility,both,69,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,22,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 20 MG ORAL TBEC,50863,CDM,J3490,HCPCS,50268-585-11,NDC,,,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-1712-01,NDC,facility,both,4,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,250,RC,J7999,HCPCS,70092-1017-46,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR 800 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-867-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOFLOXACIN IN D5W 750 MG/150 ML IV PGBK,50863,CDM,250,RC,J1956,HCPCS,36000-048-24,NDC,facility,both,9,ML,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"NEOMYCIN-BACITRACIN-POLYMYXIN 3.5 MG-400 UNIT-10,000 UNIT/G EYE OINT",50863,CDM,636,RC,J3490,HCPCS,24208-780-55,NDC,facility,both,1,GM,,242,169.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITONAVIR 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,65862-687-30,NDC,facility,both,1,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,68462-157-40,NDC,facility,both,1,EA,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 10 MG TAB,50863,CDM,250,RC,Q0177,HCPCS,16714-081-10,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-131-11,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,18,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRIMIDONE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-202-11,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CELECOXIB 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-436-11,NDC,facility,both,1,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,9,ML,,269,188.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-491-01,NDC,facility,both,100,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-492-57,NDC,facility,both,180,ML,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7047-61,NDC,facility,both,5,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DACARBAZINE 200 MG IV SOLR,50863,CDM,250,RC,J9130,HCPCS,0143-9245-01,NDC,facility,both,1,EA,JW,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,62332-600-01,NDC,facility,both,4,ML,JZ,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LOSARTAN  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-686-10,NDC,facility,both,1,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"CALCIUM GLUC IN NACL, ISO-OSM 1 G/100 ML IV SOLN",50863,CDM,636,RC,J0613,HCPCS,44567-622-01,NDC,facility,both,300,ML,,223,156.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM SR 120 MG 24 HR CAP,50863,CDM,250,RC,J3490,HCPCS,60687-195-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  15 MG ORAL TAB,50863,CDM,J3490,HCPCS,0054-0235-24,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-3178-16,NDC,facility,both,90,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESVENLAFAXINE  50 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,0054-0400-13,NDC,facility,both,1,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 1 MG ORAL CAP,50863,CDM,J7507,HCPCS,68084-450-11,NDC,,,facility,both,2,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69315-905-05,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"AMIODARONE IN DEXTROSE,ISO-OSM 150 MG/100 ML (PREMIX)",50863,CDM,J0282,HCPCS,43066-150-10,NDC,,,facility,both,5,ML,,204,142.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL  20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-416-11,NDC,facility,both,1,EA,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,60687-429-45,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,50863,CDM,J9264,HCPCS,68817-134-50,NDC,,,facility,both,38,EA,,72051,50435.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE HCL IN D5W 4 MG/250 ML (16 MCG/ML) IV SOLN,50863,CDM,J0169,HCPCS,72196-7018-1,NDC,,,facility,both,2360,ML,,12406,8684.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,J2371,HCPCS,0781-3422-92,NDC,,,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,636,RC,J1815,HCPCS,49502-393-80,NDC,facility,both,10,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-1163-01,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,70069-363-01,NDC,facility,both,1,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0121-0945-10,NDC,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAMOXIFEN 10 MG ORAL TAB,50863,CDM,636,RC,J9999,HCPCS,0591-2472-60,NDC,facility,both,4,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 3000 MCG/ML INJECTION,50863,CDM,250,RC,J0153,HCPCS,25021-318-02,NDC,facility,both,6,ML,JZ,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,70436-030-82,NDC,facility,both,164,ML,,129,90.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,0641-0477-21,NDC,facility,both,5,ML,,937,655.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-0710-20,NDC,facility,both,21,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  75 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,69238-1312-9,NDC,facility,both,3,EA,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,3,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0054-0710-20,NDC,facility,both,8,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,181,126.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,250,RC,J3490,HCPCS,0143-9679-01,NDC,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,2,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,38,ML,JW,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,J0665,HCPCS,55150-169-10,NDC,,,facility,both,300,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LATANOPROST 0.005 % OPHT DROP,50863,CDM,J3490,HCPCS,59762-0333-2,NDC,,,facility,both,1,ML,,404,282.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-344-11,NDC,facility,both,3,EA,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69292-208-50,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,50863,CDM,250,RC,J9263,HCPCS,71288-172-21,NDC,facility,both,135,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,50863,CDM,J9206,HCPCS,60505-6128-0,NDC,,,facility,both,3,ML,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 600 MG ORAL TP12,50863,CDM,250,RC,J3490,HCPCS,0536-1163-61,NDC,facility,both,5,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN SODIUM  2 GRAM INJ SOLR,50863,CDM,J0290,HCPCS,55150-114-20,NDC,,,facility,both,4,EA,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE MODIFIED  25 MG ORAL CAP,50863,CDM,250,RC,J7515,HCPCS,0093-9018-19,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SITAGLIPTIN 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0006-0277-01,NDC,facility,both,1,EA,,113,79.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-04,NDC,facility,both,18,ML,,300,210,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,50863,CDM,636,RC,J0585,HCPCS,0023-1145-01,NDC,facility,both,100,EA,,1599,1119.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,16,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,16714-671-02,NDC,facility,both,1,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EMTRICITABINE-TENOFOVIR 200 MG-300 MG TAB,50863,CDM,636,RC,J0750,HCPCS,0904-7172-07,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-354-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,60687-429-45,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J2312,HCPCS,36000-308-01,NDC,facility,both,20,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,69315-904-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CELECOXIB 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,50268-168-11,NDC,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG ORAL TBDL,50863,CDM,636,RC,J3490,HCPCS,60505-3276-0,NDC,facility,both,2,EA,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-582-11,NDC,facility,both,4,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK,50863,CDM,250,RC,J3490,HCPCS,12870-0001-1,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 40 MG-200 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,66993-727-57,NDC,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM-ALBUTEROL 0.5 MG-2.5 MG/3 ML NEB SOLUTION,50863,CDM,250,RC,J3490,HCPCS,47335-756-48,NDC,facility,both,3,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2310,HCPCS,70069-072-10,NDC,facility,both,2,ML,,212,148.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLIPIZIDE  5 MG ORAL TO24,50863,CDM,636,RC,J3490,HCPCS,68084-111-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 50 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,10135-779-01,NDC,facility,both,80,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IV PGBK,50863,CDM,636,RC,J3475,HCPCS,63323-106-00,NDC,facility,both,8,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,50863,CDM,250,RC,J9000,HCPCS,25021-207-25,NDC,facility,both,15,ML,,432,302.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE (PF-DURAMORPH/ASTRAMORPH) 0.5 MG/ML INJ SOLN,50863,CDM,250,RC,J2274,HCPCS,0409-3814-11,NDC,facility,both,1,ML,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0093-2279-73,NDC,facility,both,11,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
URSODIOL 300 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-100-11,NDC,facility,both,1,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,42806-150-33,NDC,facility,both,11,ML,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INDOMETHACIN 25 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,50268-430-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,0409-6637-24,NDC,facility,both,1,ML,,113,79.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB 100 MG IV SOLR,50863,CDM,636,RC,J1745,HCPCS,57894-030-01,NDC,facility,both,70,EA,JZ,22563,15794.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
VECURONIUM BROMIDE 10 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,0703-2914-01,NDC,facility,both,3,EA,,126,88.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-229-02,NDC,facility,both,3,ML,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 10 % (100 MG/ML) MISC SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-695-04,NDC,facility,both,1,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,636,RC,J3490,HCPCS,70092-1478-44,NDC,facility,both,1,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BISOPROLOL FUMARATE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-127-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0780,HCPCS,43066-090-01,NDC,facility,both,1,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,636,RC,Q0162,HCPCS,16714-671-02,NDC,facility,both,2,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROMETHOLONE 0.1 % OPHT DRPS,50863,CDM,636,RC,J3490,HCPCS,60758-880-05,NDC,facility,both,1,ML,,395,276.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,34,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,55390-138-01,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZTREONAM 2 GRAM INJ SOLR,50863,CDM,250,RC,J0457,HCPCS,0003-2570-16,NDC,facility,both,20,EA,,303,212.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,4,ML,,6937,4855.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,68094-600-59,NDC,facility,both,6,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0406-0552-23,NDC,facility,both,2,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,37000-024-10,NDC,facility,both,1,EA,PLAD,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
LOSARTAN  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,31722-701-90,NDC,facility,both,2,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  5 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,60687-122-11,NDC,facility,both,15,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,50863,CDM,250,RC,J0696,HCPCS,0143-9856-01,NDC,facility,both,16,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 150 MG ORAL TBSR,50863,CDM,636,RC,J3490,HCPCS,68084-708-95,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 500 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-163-11,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-0007-01,NDC,facility,both,300,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,63,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLPIDEM  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16714-621-01,NDC,facility,both,1,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 25 MG TAB,50863,CDM,250,RC,J3490,HCPCS,62584-265-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 5 MG ORAL CAP,50863,CDM,250,RC,J7507,HCPCS,0904-6624-61,NDC,facility,both,5,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2305-04,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,29,ML,,50287,35200.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,63739-931-28,NDC,facility,both,8,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BISOPROLOL FUMARATE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,70954-455-20,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,250,RC,J2270,HCPCS,0641-6125-01,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN 1 MG/ML INJECTION (PEDS ONCOLOGY),50863,CDM,250,RC,J0640,HCPCS,71288-160-10,NDC,facility,both,1,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MITOXANTRONE 2 MG/ML IV CONC,50863,CDM,250,RC,J9293,HCPCS,61703-343-65,NDC,facility,both,2,ML,JW,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,636,RC,P9045,HCPCS,68516-5219-0,NDC,facility,both,15,ML,JZ,3813,2669.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,0641-6027-25,NDC,facility,both,2,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT  40 MCG/0.4 ML INJ SYRG,50863,CDM,250,RC,J0881,HCPCS,55513-021-01,NDC,facility,both,40,ML,JZ,1096,767.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,16729-114-08,NDC,facility,both,20,ML,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,42806-150-33,NDC,facility,both,2,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 20 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,60687-723-11,NDC,facility,both,10,EA,,347,242.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL PHOSPHATE 10 MG ORAL CM24,50863,CDM,636,RC,J3490,HCPCS,16714-227-01,NDC,facility,both,1,EA,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 200 MG/10 ML (20 MG/ML) IV SYRG,50863,CDM,636,RC,J3490,HCPCS,71266-2001-2,NDC,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-131-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,0409-9094-12,NDC,facility,both,500,ML,,9330,6531,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOPERAMIDE 1 MG/7.5 ML ORAL LIQD,50863,CDM,250,RC,J3490,HCPCS,68094-029-59,NDC,facility,both,3,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,50863,CDM,250,RC,J9041,HCPCS,70710-1411-1,NDC,facility,both,35,EA,,229,160.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZTREONAM 2 GRAM INJ SOLR,50863,CDM,250,RC,J0457,HCPCS,0409-0830-11,NDC,facility,both,20,EA,JZ,331,231.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LEVOTHYROXINE 100 MCG IV SOLR,50863,CDM,250,RC,J0650,HCPCS,42023-201-01,NDC,facility,both,20,EA,,913,639.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,59651-488-01,NDC,facility,both,120,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESNA 100 MG/ML IV SOLN,50863,CDM,636,RC,J9209,HCPCS,0338-1305-01,NDC,facility,both,8,ML,,291,203.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  5 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,13668-086-30,NDC,facility,both,2,EA,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOBRAMYCIN 150 MG/3.75 ML NEBULIZER SOLN (REPACK),50863,CDM,250,RC,J3490,HCPCS,63323-306-30,NDC,facility,both,2,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SYRG,50863,CDM,250,RC,J3490,HCPCS,8290306546,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 60 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,51991-748-90,NDC,facility,both,2,EA,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZONISAMIDE 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-230-11,NDC,facility,both,9,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR PHOSPHATE 75 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,33342-258-66,NDC,facility,both,10,EA,,557,389.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,50863,CDM,250,RC,J9000,HCPCS,0069-1542-20,NDC,facility,both,10,ML,,167,116.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 40 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-099-11,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,16714-293-01,NDC,facility,both,11,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM NEO/PEDS (CDS MIXTURE),50863,CDM,636,RC,J0295,HCPCS,63323-368-20,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G POTASSIUM 20000000 UNIT INJ SOLR,50863,CDM,250,RC,J2540,HCPCS,70860-127-51,NDC,facility,both,25,EA,,210,147,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DACARBAZINE 200 MG IV SOLR,50863,CDM,636,RC,J9130,HCPCS,0143-9245-01,NDC,facility,both,1,EA,JW,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3370,HCPCS,0143-9162-01,NDC,facility,both,16,EA,,320,224,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-613-04,NDC,facility,both,2,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL  25 MCG/HR TD PT72,50863,CDM,250,RC,J3490,HCPCS,47781-424-11,NDC,facility,both,1,EA,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-6665-61,NDC,facility,both,1,EA,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,51754-5001-1,NDC,facility,both,2,ML,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV,50863,CDM,636,RC,J7120,HCPCS,0338-0117-03,NDC,facility,both,3,ML,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLN,50863,CDM,250,RC,J3262,HCPCS,50242-137-01,NDC,facility,both,400,ML,JA,7331,5131.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
IRON DEXTRAN 50 MG/ML INJ SOLN,50863,CDM,250,RC,J1750,HCPCS,0023-6082-01,NDC,facility,both,20,ML,JZ,2084,1458.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-1749-70,NDC,facility,both,2,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,250,RC,J0132,HCPCS,70594-111-01,NDC,facility,both,160,ML,,814,569.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE  10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,70710-1225-1,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16729-136-00,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALGANCICLOVIR 50 MG/ML ORAL SOLR,50863,CDM,250,RC,J3490,HCPCS,0591-2579-20,NDC,facility,both,1,ML,,369,258.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYBUTYNIN CHLORIDE  5 MG ORAL TO24,50863,CDM,636,RC,J3490,HCPCS,68084-480-11,NDC,facility,both,3,EA,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  1 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,59746-171-06,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OPIUM TINCTURE 10 MG/ML ORAL TINC,50863,CDM,250,RC,J3490,HCPCS,42799-217-01,NDC,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,636,RC,J2003,HCPCS,63323-485-27,NDC,facility,both,250,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 600 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65162-465-10,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,5,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63304-773-01,NDC,facility,both,2,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0295,HCPCS,63323-368-20,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE 25 MG/ML INJ SOLN,50863,CDM,250,RC,J3230,HCPCS,0641-1397-31,NDC,facility,both,1,ML,,170,119,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,636,RC,J3370,HCPCS,0143-9162-01,NDC,facility,both,1,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOFLOXACIN IN D5W 750 MG/150 ML IV PGBK,50863,CDM,250,RC,J1956,HCPCS,36000-048-24,NDC,facility,both,21,ML,,232,162.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIOTROPIUM BROMIDE 1.25 MCG/ACTUATION INHL MIST,50863,CDM,250,RC,J3490,HCPCS,0597-0160-61,NDC,facility,both,1,GM,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,75834-221-01,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NELARABINE 250 MG/50 ML IV SOLN (PEDS ONCOLOGY),50863,CDM,636,RC,J9261,HCPCS,0007-4401-01,NDC,facility,both,15,ML,,6089,4262.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"CALCIUM GLUC IN NACL, ISO-OSM 1 G/100 ML IV SOLN",50863,CDM,636,RC,J0612,HCPCS,44567-622-01,NDC,facility,both,200,ML,,149,104.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0990-7983-61,NDC,facility,both,1,ML,JZ,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CARVEDILOL 12.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6302-61,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 17 GRAM (100 %) ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,1152372688,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARIFENACIN  7.5 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,33342-276-07,NDC,facility,both,1,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,250,RC,J0330,HCPCS,31722-981-10,NDC,facility,both,10,ML,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6666-61,NDC,facility,both,1,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2310,HCPCS,0409-1215-01,NDC,facility,both,2,ML,,465,325.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXAZOSIN 2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-5523-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 5 MG/ML IV SOLN,50863,CDM,636,RC,J1921,HCPCS,0409-2267-54,NDC,facility,both,3,ML,JZ,183,128.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
HYDROCHLOROTHIAZIDE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-593-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALSARTAN 160 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,33342-064-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 10 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,0641-0367-25,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL,50863,CDM,250,RC,J3490,HCPCS,63323-820-01,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,55150-177-05,NDC,facility,both,200,ML,,294,205.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE 8 MG SL SUBL,50863,CDM,636,RC,J3490,HCPCS,60687-492-11,NDC,facility,both,2,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  100 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,63323-376-00,NDC,facility,both,12,ML,,175,122.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 600 MG ORAL TP12,50863,CDM,636,RC,J3490,HCPCS,68084-572-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-433-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0093-4177-73,NDC,facility,both,7,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,63323-280-03,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 1 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,27808-002-01,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSULFAN BLUE 1 % INJ SOLN,50863,CDM,636,RC,Q9968,HCPCS,67457-220-00,NDC,facility,both,25,ML,,2150,1505,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSULFAN BLUE 1 % INJ SOLN,50863,CDM,636,RC,Q9968,HCPCS,67457-220-05,NDC,facility,both,50,ML,,4299,3009.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,250,RC,J3490,HCPCS,0409-1323-05,NDC,facility,both,200,ML,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIFEDIPINE 20 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,23155-195-01,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,636,RC,J3010,HCPCS,0409-9094-22,NDC,facility,both,4,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6172-61,NDC,facility,both,2,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERYTHROMYCIN 5 MG/G OPHT OINT,50863,CDM,250,RC,J3490,HCPCS,72485-670-31,NDC,facility,both,1,GM,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,0075-0622-01,NDC,facility,both,7,ML,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE 1 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,46287-035-15,NDC,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AGALSIDASE BETA 35 MG IV SOLR,50863,CDM,636,RC,J0180,HCPCS,58468-0040-1,NDC,facility,both,75,ME,JZ,34859,24401.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,36000-283-25,NDC,facility,both,160,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-1283-03,NDC,facility,both,15,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-074-10,NDC,facility,both,2,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES  8.6 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7252-61,NDC,facility,both,20,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,28,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,250,RC,J3490,HCPCS,0409-4277-17,NDC,facility,both,1000,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,J2560,HCPCS,0641-0477-21,NDC,,,facility,both,2,ML,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL PWPK,50863,CDM,J3490,HCPCS,37000-024-10,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"CALCIUM GLUC IN NACL, ISO-OSM 1 G/100 ML IV SOLN",50863,CDM,250,RC,J0612,HCPCS,44567-622-01,NDC,facility,both,100,ML,JZ,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GUAIFENESIN 100 MG/5 ML ORAL LIQD,50863,CDM,250,RC,J3490,HCPCS,0121-1488-10,NDC,facility,both,2,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-3426-01,NDC,facility,both,4,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  1 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,64380-782-06,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TORSEMIDE  20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-539-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"TRANEXAMIC ACID IN NACL,ISO-OS 1,000 MG/100 ML (10 MG/ML) IV PGBK",50863,CDM,250,RC,J3490,HCPCS,51754-0108-1,NDC,facility,both,1,ML,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,300,ML,JZ,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
TRAZODONE  50 MG ORAL TAB,50863,CDM,250,RC,j3490,HCPCS,0904-6868-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,10135-676-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 1 MG/0.5 ML INJ SOLN,50863,CDM,636,RC,J3430,HCPCS,0409-9157-31,NDC,facility,both,3,ML,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  88 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42292-038-01,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIBOFLAVIN 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,7431200640,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,23,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZTROPINE 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-388-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE (PF-DURAMORPH/ASTRAMORPH) 0.5 MG/ML INJ SOLN,50863,CDM,636,RC,J2274,HCPCS,0409-3814-11,NDC,facility,both,1,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESTRADIOL 2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,24658-704-01,NDC,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"AMIODARONE IN DEXTROSE,ISO-OSM 360 MG/200 ML (1.8 MG/ML) IV SOLN",50863,CDM,250,RC,J0282,HCPCS,43066-360-20,NDC,facility,both,12,ML,JZ,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK,50863,CDM,636,RC,J3490,HCPCS,12870-0001-1,NDC,facility,both,10,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0641-6059-01,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,636,RC,J2270,HCPCS,63323-454-00,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUGAMMADEX 100 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0006-5423-02,NDC,facility,both,5,ML,,2801,1960.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,250,RC,J3490,HCPCS,73013-2002-2,NDC,facility,both,2,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ (REPACK)(MERGE) (FOR PCA),50863,CDM,250,RC,J3010,HCPCS,0641-6030-01,NDC,facility,both,25,ML,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 40 GRAM/400 ML (10 %) INJ SOLN",50863,CDM,250,RC,J1561,HCPCS,13533-800-20,NDC,facility,both,10,ML,JA,1415,990.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
"WATER FOR IRRIGATION, STERILE SOLUTION",50863,CDM,250,RC,J3490,HCPCS,0338-0004-03,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-544-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,250,RC,J0132,HCPCS,55150-259-30,NDC,facility,both,205,ML,,926,648.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,250,RC,Q9968,HCPCS,70710-1838-1,NDC,facility,both,25,ML,,415,290.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROPROCAINE 3 % INJ SOLN,50863,CDM,636,RC,J2401,HCPCS,63323-478-01,NDC,facility,both,300,ML,JZ,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,3,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),50863,CDM,636,RC,J0169,HCPCS,76329-3318-1,NDC,facility,both,40,ML,,323,226.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 875 MG-125 MG TAB,50863,CDM,250,RC,J3490,HCPCS,16714-297-02,NDC,facility,both,8,EA,,193,135.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,250,RC,J1596,HCPCS,0143-9679-01,NDC,facility,both,2,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,62756-711-86,NDC,facility,both,2,EA,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,68094-600-59,NDC,facility,both,3,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 100 MG PE/2 ML INJ SOLN,50863,CDM,250,RC,Q2009,HCPCS,0069-6001-02,NDC,facility,both,4,ML,JZ,475,332.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
OXALIPLATIN 100 MG/20 ML IV SOLN,50863,CDM,250,RC,J9263,HCPCS,71288-101-10,NDC,facility,both,38,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-433-11,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNIT/G TOP OINT (MERGE),50863,CDM,636,RC,J3490,HCPCS,0713-0280-31,NDC,facility,both,1,GM,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0121-0914-05,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J2310,HCPCS,0409-1215-21,NDC,facility,both,1,ML,,186,130.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2312,HCPCS,67457-299-00,NDC,facility,both,400,ML,,513,359.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  5 GRAM IV SOLR,50863,CDM,250,RC,J3370,HCPCS,63323-295-61,NDC,facility,both,4,EA,,142,99.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  5 GRAM IV SOLR,50863,CDM,636,RC,J3373,HCPCS,0143-9163-01,NDC,facility,both,200,EA,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIFEDIPINE 10 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,23155-194-01,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 10 % (100 MG/ML) MISC SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-695-04,NDC,facility,both,1,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,68180-441-02,NDC,facility,both,10,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COENZYME Q10 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,5789687503,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,250,RC,Q9968,HCPCS,70710-1838-1,NDC,facility,both,91,ML,,1506,1054.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0137,HCPCS,0264-4100-90,NDC,facility,both,21,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,636,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,16,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIROFIBAN-0.9% SODIUM CHLORIDE 5 MG/100 ML (50 MCG/ML) IV SOLN,50863,CDM,250,RC,J3246,HCPCS,25208-002-03,NDC,facility,both,20,ML,,398,278.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,76045-009-96,NDC,facility,both,5,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,0409-4887-23,NDC,facility,both,3,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0780,HCPCS,23155-294-31,NDC,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOPIDOGREL  75 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16714-052-10,NDC,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEPERIDINE (PF) 50 MG/ML IV SOLN (PHS MERGE),50863,CDM,636,RC,J2175,HCPCS,0641-6053-01,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,J3490,HCPCS,63304-773-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL IV BOLUS 10MG/ML (ANESTHESIA ONLY),50863,CDM,636,RC,J2704,HCPCS,0409-4699-54,NDC,facility,both,82,ML,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7121-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATOVAQUONE 750 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0121-1016-05,NDC,facility,both,1,ML,,214,149.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,76,ML,,108,75.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-591-11,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J1938,HCPCS,0409-6102-10,NDC,facility,both,100,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1940,HCPCS,72603-251-01,NDC,facility,both,3,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,J2003,HCPCS,0143-9575-01,NDC,,,facility,both,80,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,250,RC,Q9968,HCPCS,70710-1838-1,NDC,facility,both,45,ML,JW,256,179.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DEXTROSE 5% IN WATER (NEO) <2 KG,50863,CDM,J7060,HCPCS,0338-0017-41,NDC,,,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 500 MG/10 ML IV SOLN,50863,CDM,250,RC,J9190,HCPCS,63323-117-01,NDC,facility,both,6,ML,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-5771-23,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,0075-0622-01,NDC,facility,both,5,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE NA (PRESERV FREE) 25 MG/ML INJ SOLN,50863,CDM,250,RC,J9260,HCPCS,61703-408-41,NDC,facility,both,60,ML,,647,452.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,99999-407-59,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0555-0872-02,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 7.5 MG-325 MG/15 ML ORAL SOLN (REPACK),50863,CDM,250,RC,J3490,HCPCS,0121-2316-15,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7728-61,NDC,facility,both,3,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0121-1022-05,NDC,facility,both,2,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROPHILLIC OINTMENT (AQUAPHOR),50863,CDM,636,RC,J3490,HCPCS,7214045231,NDC,facility,both,1,GM,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-406-03,NDC,facility,both,1,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,636,RC,FAMNOCHARGE,HCPCS,60687-145-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 3 MG/ML IV SYRG,50863,CDM,636,RC,J0153,HCPCS,25021-301-72,NDC,facility,both,12,ML,,188,131.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIVAROXABAN 15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50458-578-01,NDC,facility,both,4,EA,,406,284.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPAGLIFLOZIN PROPANEDIOL 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0310-6210-30,NDC,facility,both,1,EA,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFPODOXIME 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-395-01,NDC,facility,both,2,EA,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  125 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,68180-166-11,NDC,facility,both,1,EA,,154,107.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTOLOZANE-TAZOBACTAM 1.5 G IV SOLR,50863,CDM,250,RC,J0695,HCPCS,67919-030-01,NDC,facility,both,30,EA,,1029,720.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYBUTYNIN CHLORIDE  5 MG ORAL TO24,50863,CDM,250,RC,J3490,HCPCS,0904-6570-06,NDC,facility,both,2,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0003-0894-70,NDC,facility,both,28,EA,,1002,701.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM POLYSTYRENE SULFONATE ORAL POWDER,50863,CDM,250,RC,J3490,HCPCS,10702-036-15,NDC,facility,both,2,GM,,133,93.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"TRIMETHOPRIM-POLYMYXIN B 0.1 %-10,000 UNIT/ML EYE DROPS",50863,CDM,250,RC,J3490,HCPCS,61314-628-10,NDC,facility,both,1,ML,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 20 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,60687-725-11,NDC,facility,both,2,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG RECT SUPP,50863,CDM,636,RC,J3490,HCPCS,0713-0164-06,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RALTEGRAVIR 400 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0006-0227-61,NDC,facility,both,6,EA,,863,604.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 25 MG CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7237-61,NDC,facility,both,9,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,25021-315-01,NDC,facility,both,15,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-617-11,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOZAPINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-922-01,NDC,facility,both,2,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 1 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,50458-596-01,NDC,facility,both,1,ML,,527,368.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN PEDS SYRINGE (20MG/ML) IN DEXTROSE (CDS MIX,50863,CDM,636,RC,J7999,HCPCS,0781-3451-70,NDC,facility,both,2,EA,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM SR 60 MG 12 HR CAP,50863,CDM,636,RC,J3490,HCPCS,51079-924-01,NDC,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7007-61,NDC,facility,both,3,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM SR 300 MG 24 HR CAP,50863,CDM,250,RC,J3490,HCPCS,50742-251-90,NDC,facility,both,2,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,60687-390-11,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORTHALIDONE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-058-01,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,J3490,HCPCS,60687-453-11,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,63323-506-41,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,68180-150-01,NDC,facility,both,2,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-0430-06,NDC,facility,both,9,EA,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0074-4552-90,NDC,facility,both,1,EA,PLAD,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,0409-1886-22,NDC,facility,both,150,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SCOPOLAMINE TRANSDERMAL PATCH 1MG OVER 3 DAYS,50863,CDM,250,RC,J3490,HCPCS,50742-505-01,NDC,facility,both,1,EA,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN D5W 20000 UNIT/500 ML,50863,CDM,636,RC,J1644,HCPCS,0264-9567-10,NDC,facility,both,7,ML,JW,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LISINOPRIL  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,43547-352-10,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,16714-016-01,NDC,facility,both,4,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,636,RC,J1610,HCPCS,63323-596-11,NDC,facility,both,1,EA,,785,549.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,55150-170-30,NDC,facility,both,300,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0143-9506-01,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1162-18,NDC,facility,both,400,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,63323-482-03,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 30 MG TAB,50863,CDM,250,RC,J3490,HCPCS,60687-717-11,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM NEO/PEDS (CDS MIXTURE),50863,CDM,636,RC,J0295,HCPCS,63323-368-20,NDC,facility,both,2,EA,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7126-61,NDC,facility,both,14,EA,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J2250,HCPCS,0409-0001-01,NDC,facility,both,2,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2308-21,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VERAPAMIL 120 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-2924-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRIL MALEATE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51672-4038-1,NDC,facility,both,4,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),50863,CDM,250,RC,J0171,HCPCS,76329-3318-1,NDC,facility,both,20,ML,,162,113.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MENTHOL-ZINC OXIDE 0.44-20.625 % TOP OINT,50863,CDM,250,RC,J3490,HCPCS,4687600030,NDC,facility,both,1,GM,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SULFASALAZINE 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,59762-5000-5,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 5 MG-325 MG TAB,50863,CDM,250,RC,J3490,HCPCS,63739-532-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 50 MG 24 HR TAB,50863,CDM,636,RC,J3490,HCPCS,55111-467-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 10 MEQ/100 ML IV PGBK,50863,CDM,636,RC,J3480,HCPCS,0990-7074-26,NDC,facility,both,5,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,47781-176-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MANNITOL 20% IV SOLP,50863,CDM,250,RC,J2150,HCPCS,0990-7715-13,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,49,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-18,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,250,RC,J3101,HCPCS,50242-037-06,NDC,facility,both,16,EA,,7329,5130.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  5 MG ORAL TAB,50863,CDM,J3490,HCPCS,60687-398-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,7733351625,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,67,ML,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE (FOR CODE) 10% (100 MG/ML) IV SYRINGE,50863,CDM,250,RC,J3490,HCPCS,64253-900-30,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GAMMAGARD LIQUID 10 % IV SOLN,50863,CDM,636,RC,J1569,HCPCS,0944-2700-07,NDC,facility,both,60,ML,"JA,JZ",10817,7571.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously | Modifier JZ: Zero drug amount discarded/not administered to any patient
PHENOBARBITAL  32.4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6575-61,NDC,facility,both,4,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7410-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV (BOLUS),50863,CDM,636,RC,J7120,HCPCS,0264-7750-00,NDC,facility,both,2,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-152-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LYMPHOCYTE,ANTI-THYMO IMMUNE GLOBULIN 50 MG/ML IV",50863,CDM,250,RC,J7504,HCPCS,0009-7224-01,NDC,facility,both,11,ML,,146345,102441.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-229-02,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7124-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COSYNTROPIN 0.25 MG INJ SOLR,50863,CDM,636,RC,J0834,HCPCS,0781-3440-71,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-1752-50,NDC,facility,both,22,ML,,2099,1469.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESNA 100 MG/ML IV SOLN,50863,CDM,250,RC,J9209,HCPCS,0338-1305-01,NDC,facility,both,4,ML,,131,91.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 100 MG/5 ML ORAL LIQD,50863,CDM,250,RC,J3490,HCPCS,50383-063-10,NDC,facility,both,10,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM BICARB-CITRIC ACID 20 MEQ ORAL TBEF,50863,CDM,250,RC,J3490,HCPCS,51801-011-30,NDC,facility,both,4,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,3,ML,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 2 GRAM INJ SOLR,50863,CDM,250,RC,J0692,HCPCS,25021-122-50,NDC,facility,both,4,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,636,RC,J0330,HCPCS,69374-919-10,NDC,facility,both,5,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,636,RC,J3490,HCPCS,63323-485-27,NDC,facility,both,190,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB 100 MG IV SOLR,50863,CDM,636,RC,J1745,HCPCS,57894-030-01,NDC,facility,both,20,EA,JZ,6447,4512.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
WARFARIN 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-1712-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VERAPAMIL 240 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,75834-159-01,NDC,facility,both,2,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE 100 MG TAB,50863,CDM,636,RC,J3490,HCPCS,23155-135-25,NDC,facility,both,13,EA,,272,190.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,42806-151-34,NDC,facility,both,4,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUVOXAMINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0832-1671-11,NDC,facility,both,2,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-3178-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,3,ML,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 400 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65162-464-10,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLPIDEM  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-838-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LINEZOLID 600 MG/300 ML IV SOLP,50863,CDM,250,RC,J2020,HCPCS,55150-242-51,NDC,facility,both,3,ML,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-444-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42858-301-25,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 50 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,60687-402-11,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-975-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ORPHENADRINE CITRATE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J2360,HCPCS,25021-651-02,NDC,facility,both,1,ML,JZ,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
RISPERIDONE 0.25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50458-590-10,NDC,facility,both,2,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 0.5 MG ORAL CAP,50863,CDM,636,RC,J7507,HCPCS,0904-6623-61,NDC,facility,both,2,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV,50863,CDM,250,RC,J7120,HCPCS,0338-0117-04,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,J2003,HCPCS,0409-4277-16,NDC,,,facility,both,400,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOBRAMYCIN 1.2 G POWDER VIAL,50863,CDM,250,RC,J3260,HCPCS,39822-0412-6,NDC,facility,both,90,EA,,2385,1669.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7193-06,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,23,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
AMITRIPTYLINE  10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,70756-201-11,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACIDOPHILUS-PECTIN W CITRUS 25 MILLION-100 CELL MG TAB,50863,CDM,250,RC,J3490,HCPCS,904661161,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-1541-10,NDC,facility,both,1,ML,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CONJUGATED ESTROGENS  0.3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0046-1100-81,NDC,facility,both,2,EA,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-347-11,NDC,facility,both,2,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 10 MG/ML IM SOLN,50863,CDM,636,RC,J0500,HCPCS,0641-6173-01,NDC,facility,both,1,ML,,143,100.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL PWPK,50863,CDM,636,RC,J3490,HCPCS,3700025445,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,0641-6145-01,NDC,facility,both,2,ML,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOLIC ACID  1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7224-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  5 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,60505-3275-0,NDC,facility,both,1,EA,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN NORMAL SALINE IV,50863,CDM,250,RC,J7042,HCPCS,0338-0089-04,NDC,facility,both,2,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE IN 0.9% NS (PF) 1 MG/10 ML (100 MCG/ML) IV SYRG(PDS MERGE),50863,CDM,636,RC,J3490,HCPCS,63037-173-25,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,63323-280-03,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6666-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 1250 MG/5 ML SUSPENSION (500 MG/5 ML ELEMENTAL),50863,CDM,250,RC,J3490,HCPCS,0121-4766-05,NDC,facility,both,3,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0003-0894-21,NDC,facility,both,1,EA,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,28,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 650 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,66553-008-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-886-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 2.5 %-1/2 NORMAL SALINE IV,50863,CDM,636,RC,J3490,HCPCS,0338-0073-04,NDC,facility,both,1,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL,50863,CDM,636,RC,J1071,HCPCS,0009-0417-01,NDC,facility,both,200,ML,,140,98,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,70095-026-01,NDC,facility,both,1,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NS WITH POTASSIUM CHLORIDE 20 MEQ/L IV SOLP,50863,CDM,636,RC,J3480,HCPCS,0264-7865-00,NDC,facility,both,10,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN  325 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0536-1054-29,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,76,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  88 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,42292-038-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  75 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-475-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,16,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,70377-008-12,NDC,facility,both,1,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,70710-1833-1,NDC,facility,both,2,EA,,511,357.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,250,RC,J2405,HCPCS,23155-547-31,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN PEDS SYRINGE (20MG/ML) IN DEXTROSE (CDS MIX,50863,CDM,250,RC,J0690,HCPCS,0781-3451-70,NDC,facility,both,2,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 250 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,42192-608-05,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,6,ML,,10405,7283.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-657-11,NDC,facility,both,3,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,59,ML,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-821-01,NDC,facility,both,1,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NELARABINE 250 MG/50 ML IV SOLN (PEDS ONCOLOGY),50863,CDM,250,RC,J9261,HCPCS,70710-1726-1,NDC,facility,both,15,ML,,5266,3686.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXAZOSIN 4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-862-95,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,59,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE IV CONCENTRATED INFUSION (1 MEQ/ML),50863,CDM,250,RC,J3490,HCPCS,0409-6625-02,NDC,facility,both,1,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM IN NACL (ISO-OS) 500 MG/100 ML IV PGBK,50863,CDM,250,RC,J1953,HCPCS,36000-352-01,NDC,facility,both,50,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM HYPOCHLORITE 0.125 % MISC SOLN,50863,CDM,250,RC,J3490,HCPCS,0436-0672-16,NDC,facility,both,1,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 10 GRAM/100 ML (10%) INJ SOLN",50863,CDM,250,RC,J1561,HCPCS,13533-800-72,NDC,facility,both,80,ML,,11316,7921.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAMADOL  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,29300-355-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN  10 GRAM INJ SOLR,50863,CDM,250,RC,J0690,HCPCS,0143-9983-91,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIVAROXABAN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50458-580-01,NDC,facility,both,1,EA,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,71288-402-10,NDC,facility,both,9,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,636,RC,J1611,HCPCS,0597-0053-45,NDC,facility,both,2,EA,JZ,1483,1038.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.3 MG/0.3 ML IM PNIJ,50863,CDM,636,RC,J0171,HCPCS,49502-500-01,NDC,facility,both,3,EA,,1078,754.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,43547-543-01,NDC,facility,both,2,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-579-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 10 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,67457-420-00,NDC,facility,both,16,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,33,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-31,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN  4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51672-4031-1,NDC,facility,both,3,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN IN D5W 400 MG/200 ML IV PGBK,50863,CDM,250,RC,J0744,HCPCS,25021-114-87,NDC,facility,both,8,ML,,187,130.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-406-03,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,42858-001-10,NDC,facility,both,6,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATED 20 MG/ML IV SOLN,50863,CDM,250,RC,J0706,HCPCS,51754-0500-1,NDC,facility,both,7,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYLAMINE SUCCINATE 25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,4116700607,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-04,NDC,facility,both,12,ML,,200,140,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE HCL IN D5W 4 MG/250 ML (16 MCG/ML) IV SOLN,50863,CDM,250,RC,J0169,HCPCS,72196-7018-1,NDC,facility,both,80,ML,,421,294.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,0904-6794-30,NDC,facility,both,2,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0054-0710-20,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXEPIN  10 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,51079-436-01,NDC,facility,both,3,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 6 MG/0.5 ML SUB-Q,50863,CDM,636,RC,J3030,HCPCS,55150-173-01,NDC,facility,both,1,ML,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,250,RC,J3490,HCPCS,0173-0682-20,NDC,facility,both,1,GM,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  5 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-122-11,NDC,facility,both,45,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NORTRIPTYLINE 10 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,75907-069-01,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4% TOP PATCH,50863,CDM,250,RC,J3490,HCPCS,46581-830-06,NDC,facility,both,3,EA,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RANOLAZINE  500 MG ORAL TB12,50863,CDM,250,RC,J3490,HCPCS,50268-722-11,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,636,RC,J7060,HCPCS,0338-0017-31,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 100 MG TAB,50863,CDM,636,RC,J3490,HCPCS,62584-267-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,1,EA,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLIPIZIDE  5 MG ORAL TO24,50863,CDM,636,RC,J3490,HCPCS,16714-895-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,68094-231-59,NDC,facility,both,2,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,63323-468-17,NDC,facility,both,1,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,17271-701-06,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IVPB (PEDIATRICS/ADULT NON-FORM)",50863,CDM,636,RC,J0131,HCPCS,24201-100-01,NDC,facility,both,17,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV,50863,CDM,636,RC,J7120,HCPCS,0338-0117-04,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0641-6057-01,NDC,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 200 MG INJ SOLR,50863,CDM,250,RC,J0640,HCPCS,63323-710-50,NDC,facility,both,6,EA,,203,142.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,47335-993-01,NDC,facility,both,50,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BEVACIZUMAB-MALY 25 MG/ML IV SOLN,50863,CDM,250,RC,Q5126,HCPCS,70121-1754-1,NDC,facility,both,10,ML,,1984,1388.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATENOLOL 2MG/ML SUSP (REPACK),50863,CDM,250,RC,J3490,HCPCS,0781-1078-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,4,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,53489-143-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,70860-405-04,NDC,facility,both,2,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0641-6206-01,NDC,facility,both,10,ML,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6371-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,50863,CDM,636,RC,J1885,HCPCS,63323-162-03,NDC,facility,both,4,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 500 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,68084-782-11,NDC,facility,both,2,EA,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2308-22,NDC,facility,both,5,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CALCITRIOL 0.5 MCG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,23155-663-01,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPTOMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0878,HCPCS,71288-016-15,NDC,facility,both,350,EA,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPYLTHIOURACIL 50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,67253-651-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOPIDOGREL 300 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6467-10,NDC,facility,both,1,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 250 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,68084-776-11,NDC,facility,both,2,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOPIDOGREL 300 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-752-95,NDC,facility,both,1,EA,,131,91.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,50863,CDM,250,RC,J9060,HCPCS,0703-5747-11,NDC,facility,both,5,ML,,119,83.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  50 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6992-61,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOPROTERENOL 0.2 MG/ML INJECTION,50863,CDM,250,RC,J3490,HCPCS,69918-731-01,NDC,facility,both,1,ML,,540,378,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,109,ML,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  60 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50111-470-01,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DONEPEZIL 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-303-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"CALCIUM CARBONATE-VITAMIN D3 500 MG(1,250MG) -200 UNIT ORAL TAB",50863,CDM,636,RC,J3490,HCPCS,1000670038,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-426-02,NDC,facility,both,2,ML,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAVASTATIN 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-5893-61,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 20MG/ML IV SYRINGE (PEDS/NEO),50863,CDM,250,RC,J0612,HCPCS,63323-311-10,NDC,facility,both,13,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR 800 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-109-11,NDC,facility,both,1,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIROFIBAN-0.9% SODIUM CHLORIDE 5 MG/100 ML (50 MCG/ML) IV SOLN,50863,CDM,250,RC,J3246,HCPCS,55150-429-01,NDC,facility,both,20,ML,,378,264.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESONIDE 0.05 % TOP OINT,50863,CDM,250,RC,J3490,HCPCS,21922-004-04,NDC,facility,both,1,GM,,341,238.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE IN SALINE (ISO-OSM) 400 MG/200 ML IV PIGGY BACK,50863,CDM,250,RC,J1450,HCPCS,25021-184-67,NDC,facility,both,2,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  20 MEQ ORAL PACK,50863,CDM,250,RC,J3490,HCPCS,69543-451-01,NDC,facility,both,2,EA,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR PHOSPHATE 30 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0004-0802-85,NDC,facility,both,1,EA,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM NEO/PEDS INFUSION (CDS MIXTURE),50863,CDM,250,RC,J2543,HCPCS,0206-8852-08,NDC,facility,both,2,EA,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-495-27,NDC,facility,both,160,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0093-4177-73,NDC,facility,both,5,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALACYCLOVIR 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0173-0933-56,NDC,facility,both,1,EA,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL,50863,CDM,250,RC,J3490,HCPCS,63323-820-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 650 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,77333-827-25,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR 200 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-5789-61,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-1559-19,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2305-16,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN IN D5W 400 MG/200 ML IV PGBK,50863,CDM,250,RC,J0744,HCPCS,25021-114-87,NDC,facility,both,2,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,70710-1833-1,NDC,facility,both,1,EA,,360,252,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMETHICONE 40 MG/0.6 ML ORAL DRPS,50863,CDM,636,RC,J3490,HCPCS,0536-1303-75,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,63323-468-37,NDC,facility,both,2,ML,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESALAMINE  250 MG ORAL CPSR,50863,CDM,250,RC,J3490,HCPCS,54092-189-81,NDC,facility,both,6,EA,,107,74.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID (PORK)  30 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0456-0458-01,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,0409-9093-32,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 1 MG/ML NEEDLELESS SYRG,50863,CDM,250,RC,J2310,HCPCS,76329-3369-1,NDC,facility,both,2,ML,,194,135.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 1 MG/ML NEEDLELESS SYRG,50863,CDM,636,RC,J2312,HCPCS,76329-3369-1,NDC,facility,both,200,ML,,194,135.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNITS IN 100 ML NS,50863,CDM,250,RC,J3490,HCPCS,42023-117-25,NDC,facility,both,100,ML,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"CALCIUM GLUC IN NACL, ISO-OSM 1 GRAM/50 ML IV SOLN",50863,CDM,636,RC,J0613,HCPCS,44567-620-01,NDC,facility,both,600,ML,,696,487.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROPROCAINE 3 % INJ SOLN,50863,CDM,250,RC,J2401,HCPCS,63323-478-01,NDC,facility,both,60,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LOSARTAN  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-504-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL,50863,CDM,250,RC,J3490,HCPCS,63323-820-01,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7048-61,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIROFIBAN-0.9% SODIUM CHLORIDE 5 MG/100 ML (50 MCG/ML) IV SOLN,50863,CDM,636,RC,J3246,HCPCS,55150-429-01,NDC,facility,both,20,ML,JZ,378,264.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),50863,CDM,250,RC,J0171,HCPCS,76329-3318-1,NDC,facility,both,20,ML,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENOFOVIR DISOPROXIL FUMARATE 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42291-800-30,NDC,facility,both,1,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN NPH HUMAN RECOMB 100 UNIT/ML SUBQ SUSP,50863,CDM,636,RC,J1815,HCPCS,0169-1834-11,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-464-11,NDC,facility,both,5,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,50863,CDM,250,RC,J0696,HCPCS,25021-106-10,NDC,facility,both,4,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM  3.375 GRAM IV SOLR,50863,CDM,636,RC,J2543,HCPCS,0781-3113-90,NDC,facility,both,3,EA,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-5755-23,NDC,facility,both,19,EA,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,636,RC,P9045,HCPCS,64208-2510-5,NDC,facility,both,4,ML,JZ,404,282.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LEVETIRACETAM  750 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65862-247-08,NDC,facility,both,1,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-3244-01,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-739-41,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0143-9889-15,NDC,facility,both,10,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,250,RC,J2270,HCPCS,0641-6125-01,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL IV BOLUS 10MG/ML (ANESTHESIA ONLY),50863,CDM,636,RC,J2704,HCPCS,0409-4699-54,NDC,facility,both,12,ML,JW,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IPRATROPIUM-ALBUTEROL 0.5 MG-2.5 MG/3 ML NEB SOLUTION,50863,CDM,250,RC,J3490,HCPCS,0487-0201-01,NDC,facility,both,16,ML,,173,121.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE  5 MG ORAL TAB,50863,CDM,J3490,HCPCS,0093-0053-01,NDC,,,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZTROPINE 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7288-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 125 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,60687-211-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"VITAMIN E (DL, ACETATE) 22.5 MG (50 UNIT)/ML ORAL DROP",50863,CDM,250,RC,J3490,HCPCS,7132180230,NDC,facility,both,1,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOPERAMIDE 2 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-229-11,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 100 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,16714-358-01,NDC,facility,both,1,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-18,NDC,facility,both,50,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
AMOXICILLIN 400 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0143-9887-01,NDC,facility,both,2,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUDROCORTISONE 0.1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,72603-170-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,250,RC,J0330,HCPCS,31722-981-10,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0295,HCPCS,63323-368-20,NDC,facility,both,1,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,2055503601,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) 20000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,72603-224-01,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 8-2 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,60687-637-11,NDC,facility,both,2,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,63739-931-14,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6369-61,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3373,HCPCS,67457-340-01,NDC,facility,both,400,EA,,377,263.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN 1 GRAM SOLUTION FOR INJECTION,50863,CDM,250,RC,J0290,HCPCS,0409-3726-10,NDC,facility,both,12,EA,,142,99.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) NEB SOLUTION,50863,CDM,J3490,HCPCS,60687-395-79,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,50863,CDM,J2250,HCPCS,0409-2305-16,NDC,,,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN D5W 20000 UNIT/500 ML,50863,CDM,J1644,HCPCS,0264-9567-10,NDC,,,facility,both,18,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-433-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 2 %-1:200,000 INJ SOLN",50863,CDM,J2004,HCPCS,0409-3183-11,NDC,,,facility,both,60,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 500 MG ORAL TAB,50863,CDM,J3490,HCPCS,60687-559-11,NDC,,,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,J3490,HCPCS,0409-1163-18,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,42806-150-33,NDC,facility,both,8,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-18,NDC,facility,both,11,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 200 MG ORAL TAB,50863,CDM,J3490,HCPCS,0245-0147-89,NDC,,,facility,both,1,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,24,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,39,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,J3101,HCPCS,50242-037-06,NDC,,,facility,both,24,EA,,10993,7695.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN 0.9% SODIUM CL 1.25 GRAM/250 ML IV SOLN,50863,CDM,636,RC,J3370,HCPCS,72196-6074-1,NDC,facility,both,3,ML,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0295,HCPCS,63323-368-20,NDC,facility,both,1,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRBESARTAN  75 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,31722-729-30,NDC,facility,both,2,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN D5W 1 GRAM/200 ML IV PGBK,50863,CDM,250,RC,J3370,HCPCS,0338-3552-48,NDC,facility,both,2,ML,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE HCL IN D5W 4 MG/250 ML (16 MCG/ML) IV SOLN,50863,CDM,J0169,HCPCS,72196-7018-1,NDC,,,facility,both,40,ML,,211,147.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,J3490,HCPCS,0121-1022-05,NDC,,,facility,both,3,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN 0.9 % SODIUM CHL 1.5 GRAM/500 ML IV SOLN,50863,CDM,250,RC,J3373,HCPCS,70004-924-44,NDC,facility,both,150,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,400,ML,,7002,4901.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-9543-02,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"TRANEXAMIC ACID IN NACL,ISO-OS 1,000 MG/100 ML (10 MG/ML) IV PGBK",50863,CDM,636,RC,J3490,HCPCS,65219-534-01,NDC,facility,both,1,ML,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE  6.25 MG/5 ML ORAL SYRP,50863,CDM,250,RC,Q0169,HCPCS,27808-051-02,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 100 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,67877-592-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,0409-6102-02,NDC,facility,both,80,ML,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLIPIZIDE  2.5 MG ORAL TO24,50863,CDM,250,RC,J3490,HCPCS,60687-768-11,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,68382-444-05,NDC,facility,both,2,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRINOTECAN 100 MG/5 ML IV SOLN,50863,CDM,250,RC,J9206,HCPCS,0009-7529-01,NDC,facility,both,3,ML,JW,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML SYRUP,50863,CDM,636,RC,J3490,HCPCS,0121-0638-05,NDC,facility,both,2,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,50863,CDM,250,RC,J9060,HCPCS,16729-288-11,NDC,facility,both,4,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-3178-16,NDC,facility,both,15,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,290,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
TORSEMIDE  20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-539-11,NDC,facility,both,3,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPRAZOLAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-388-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,54288-136-01,NDC,facility,both,1,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,57237-004-30,NDC,facility,both,1,EA,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-9791-01,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,419,ME,JZ,5686,3980.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,636,RC,J1953,HCPCS,0409-1886-22,NDC,facility,both,50,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 17 GRAM (100 %) ORAL PWPK,50863,CDM,636,RC,J3490,HCPCS,1152372688,NDC,facility,both,3,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML INJ SOLN,50863,CDM,250,RC,J0171,HCPCS,76329-9061-0,NDC,facility,both,2,ML,,296,207.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM PHOSPHATE 0.06 MMOL/ML IVPB (FOR PEDIATRICS),50863,CDM,250,RC,J3490,HCPCS,71285-6060-1,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-6695-01,NDC,facility,both,20,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIPASE-PROTEASE-AMYLASE 5,000-17,000- 24,000 UNIT ORAL CPDR",50863,CDM,636,RC,J3490,HCPCS,73562-115-01,NDC,facility,both,2,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN D5W 20000 UNIT/500 ML,50863,CDM,250,RC,J1644,HCPCS,0264-9567-10,NDC,facility,both,40,ML,,167,116.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16729-216-15,NDC,facility,both,2,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROMETHORPHAN-GUAIFENESIN SR 30 MG-600 MG 12 HR TAB,50863,CDM,250,RC,J3490,HCPCS,6382405620,NDC,facility,both,20,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL,50863,CDM,250,RC,J3490,HCPCS,63323-820-01,NDC,facility,both,1,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0295,HCPCS,63323-368-20,NDC,facility,both,2,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL IV BOLUS 10MG/ML (ANESTHESIA ONLY),50863,CDM,636,RC,J2704,HCPCS,0409-4699-54,NDC,facility,both,200,ML,,254,177.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,55150-307-01,NDC,facility,both,60,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,250,RC,J2270,HCPCS,0409-1890-03,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,42858-301-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1940,HCPCS,0409-6102-18,NDC,facility,both,2,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROIC ACID 250 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,69452-150-20,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TICAGRELOR 90 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0186-0777-39,NDC,facility,both,2,EA,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 100 MG/5 ML ORAL LIQD,50863,CDM,250,RC,J3490,HCPCS,50383-063-10,NDC,facility,both,28,ML,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3370,HCPCS,67457-340-01,NDC,facility,both,3,EA,,142,99.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SYRG,50863,CDM,250,RC,J3490,HCPCS,8290306500,NDC,facility,both,100,ML,,372,260.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-598-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  37.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-844-11,NDC,facility,both,3,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,250,RC,J2003,HCPCS,76329-3390-1,NDC,facility,both,200,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZOCAINE 20 % MM SPRY,50863,CDM,J3490,HCPCS,0283-0610-43,NDC,,,facility,both,2,EA,,151,105.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,J0665,HCPCS,0409-1160-01,NDC,,,facility,both,80,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7351-04,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML IV (MERGE) (FOR VENT),50863,CDM,250,RC,J3010,HCPCS,70092-1509-35,NDC,facility,both,1,ML,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN 1000 MG IN NS 500 ML IRRIGATION (REPACK),50863,CDM,250,RC,J0690,HCPCS,99999-0406-15,NDC,facility,both,4,ML,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR IRRIGATION, STERILE SOLUTION",50863,CDM,250,RC,J3490,HCPCS,0338-0004-02,NDC,facility,both,8,ML,,277,193.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,63323-165-01,NDC,facility,both,7,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM SR 180 MG 24 HR CAP,50863,CDM,250,RC,J3490,HCPCS,60687-206-11,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-535-11,NDC,facility,both,13,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 800 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-720-11,NDC,facility,both,2,EA,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 0.125 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68462-330-90,NDC,facility,both,6,EA,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LINEZOLID 600 MG/300 ML IV SOLP,50863,CDM,250,RC,J2020,HCPCS,55150-242-51,NDC,facility,both,3,ML,,397,277.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,636,RC,J1953,HCPCS,0409-1886-22,NDC,facility,both,15,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,62,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7050,HCPCS,0338-0049-02,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,3,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,636,RC,J7060,HCPCS,0338-0017-02,NDC,facility,both,2,ML,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MOXIFLOXACIN 0.5 % OPHT DROP,50863,CDM,636,RC,J3490,HCPCS,0832-1410-03,NDC,facility,both,1,ML,,603,422.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COLCHICINE 0.6 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,59651-455-01,NDC,facility,both,2,EA,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-48,NDC,facility,both,2,ML,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRBESARTAN 300 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,31722-731-30,NDC,facility,both,1,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,250,RC,J3490,HCPCS,60687-653-11,NDC,facility,both,6,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM ZIRCONIUM CYCLOSILICATE  5 G ORAL PWPK (USE PANEL),50863,CDM,636,RC,J3490,HCPCS,0310-1105-01,NDC,facility,both,3,EA,,373,261.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN 0.9 % SODIUM CHL 2 GRAM/500 ML IV SOLN,50863,CDM,636,RC,J3373,HCPCS,71506-019-59,NDC,facility,both,4,ML,,148,103.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-342-11,NDC,facility,both,3,EA,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,0641-6145-01,NDC,facility,both,8,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LACOSAMIDE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0131-2477-60,NDC,facility,both,2,EA,,156,109.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,16,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
INFLIXIMAB 100 MG IV SOLR,50863,CDM,636,RC,J1745,HCPCS,57894-030-01,NDC,facility,both,66,EA,,21273,14891.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYPROHEPTADINE 4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-189-11,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 75 MG/5 ML ORAL SOLUTION,50863,CDM,636,RC,J3490,HCPCS,64980-511-10,NDC,facility,both,11,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,54,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,50863,CDM,250,RC,J0640,HCPCS,0143-9554-01,NDC,facility,both,1,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 50 MG/ML IV SOLN,50863,CDM,250,RC,J0282,HCPCS,0143-9875-10,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,12,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CITALOPRAM 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,13668-010-01,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,636,RC,P9045,HCPCS,0944-0495-06,NDC,facility,both,1,ML,,245,171.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,42,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),50863,CDM,636,RC,J3490,HCPCS,63323-186-01,NDC,facility,both,30,ML,,203,142.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALTREXONE MICROSPHERES 380 MG IM SERR,50863,CDM,636,RC,J2315,HCPCS,65757-300-01,NDC,facility,both,380,EA,,4530,3171,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,5,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN NORMAL SALINE IV,50863,CDM,250,RC,J7042,HCPCS,0338-0089-04,NDC,facility,both,4,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-1749-70,NDC,facility,both,4,ML,,134,93.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 250 MG/50 ML CONCENTRATED DRIP (RSE),50863,CDM,250,RC,J2250,HCPCS,99999-555-57,NDC,facility,both,250,ML,,203,142.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 112 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6954-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ORPHENADRINE CITRATE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J2360,HCPCS,0641-6182-01,NDC,facility,both,1,ML,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,14789-128-07,NDC,facility,both,4,ML,,672,470.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN (PF) 10 MG/ML INJECTION (NEONATAL IM USE),50863,CDM,636,RC,J1580,HCPCS,63323-173-01,NDC,facility,both,6,ML,,985,689.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN V POTASSIUM 250 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,57237-040-01,NDC,facility,both,12,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUBIPROSTONE  8 MCG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0480-3479-06,NDC,facility,both,2,EA,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE  4 MG ORAL TAB,50863,CDM,250,RC,J7509,HCPCS,0904-6914-61,NDC,facility,both,2,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2305-04,NDC,facility,both,7,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,13,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-ABDA 100 MG IV SOLR,50863,CDM,636,RC,Q5104,HCPCS,78206-162-99,NDC,facility,both,76,EA,,15804,11062.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ESMOLOL IN SALINE (ISO-OSMOTIC) 2,500 MG/250 ML (10 MG/ML) IV",50863,CDM,250,RC,J1805,HCPCS,70121-1716-1,NDC,facility,both,1,ML,,648,453.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-347-11,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MANNITOL 25 % IV SOLN,50863,CDM,250,RC,J2151,HCPCS,63323-024-01,NDC,facility,both,900,ML,,723,506.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-710-11,NDC,facility,both,2,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,20,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 125 MG/5 ML (25MG/ML) ORAL SYRINGE (REPACK),50863,CDM,636,RC,J3373,HCPCS,67457-340-00,NDC,facility,both,13,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J3490,HCPCS,0338-0049-38,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-3178-16,NDC,facility,both,60,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOBRAMYCIN SULFATE 40 MG/ML INJ SOLN,50863,CDM,250,RC,J3260,HCPCS,0409-3578-01,NDC,facility,both,4,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAZOSIN 1 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7020-61,NDC,facility,both,4,EA,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-04,NDC,facility,both,2,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,17,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE 0.5 MG SL (1/4 TAB) SUBL,50863,CDM,250,RC,J3490,HCPCS,99999-0408-26,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 2 QUARTER TABLET
LIDOCAINE 4 % TOPICAL SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-4698-01,NDC,facility,both,2,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,636,RC,Q0162,HCPCS,16714-671-02,NDC,facility,both,8,ML,,234,163.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % MBP,50863,CDM,250,RC,J3490,HCPCS,0338-9616-30,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE 2 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,60687-481-11,NDC,facility,both,3,EA,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE 2 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,60687-481-11,NDC,facility,both,2,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,100,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J3490,HCPCS,0338-0049-48,NDC,facility,both,1,ML,JZ,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,76045-009-01,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0641-0400-37,NDC,facility,both,2,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-453-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,16714-293-03,NDC,facility,both,3,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACTIVATED CHARCOAL 25 GRAM/120 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0574-0521-74,NDC,facility,both,1,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLECAINIDE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-0011-21,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOVASTATIN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68180-468-01,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOLIC ACID  1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,65162-361-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-11,NDC,facility,both,9,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,50863,CDM,636,RC,J0585,HCPCS,0023-1145-01,NDC,facility,both,24,EA,,384,268.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IV PGBK,50863,CDM,250,RC,J3475,HCPCS,63323-106-00,NDC,facility,both,8,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYMETAZOLINE 0.05 % NASAL MERGE,50863,CDM,636,RC,J3490,HCPCS,70677-1037-1,NDC,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAVASTATIN 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-5892-61,NDC,facility,both,4,EA,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-1541-10,NDC,facility,both,3,ML,,292,204.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOPIDOGREL 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6467-10,NDC,facility,both,2,EA,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE DINITRATE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-083-11,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,43547-281-10,NDC,facility,both,2,EA,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69238-1056-1,NDC,facility,both,2,EA,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOCARNITINE (WITH SUCROSE) 100 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,52817-830-04,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0121-0914-05,NDC,facility,both,1,ML,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),50863,CDM,250,RC,J3490,HCPCS,0409-4888-01,NDC,facility,both,2,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAZOSIN 1 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,51079-630-01,NDC,facility,both,4,EA,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 80 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16714-877-01,NDC,facility,both,1,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,63323-010-02,NDC,facility,both,3,ML,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LITHIUM CARBONATE 450 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,68084-655-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG IV SOLR,50863,CDM,636,RC,J3490,HCPCS,0781-3232-94,NDC,facility,both,1,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-242-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7041-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J2004,HCPCS,63323-482-03,NDC,facility,both,100,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,250,RC,J2270,HCPCS,76045-004-10,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6500-06,NDC,facility,both,3,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,8,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOCARNITINE 200 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,54482-147-01,NDC,facility,both,2,ML,,446,312.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUGAMMADEX 100 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0006-5423-02,NDC,facility,both,1,ML,,589,412.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 1 GRAM INJ SOLR,50863,CDM,250,RC,J0692,HCPCS,0409-9566-10,NDC,facility,both,2,EA,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3373,HCPCS,67457-340-01,NDC,facility,both,100,EA,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 1 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,59746-020-22,NDC,facility,both,2,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-3178-01,NDC,facility,both,90,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0295,HCPCS,63323-368-20,NDC,facility,both,1,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 17 GRAM (100 %) ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,0904-6931-86,NDC,facility,both,3,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL  97.2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,75826-142-10,NDC,facility,both,2,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV,50863,CDM,636,RC,J7120,HCPCS,0338-0117-04,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-38,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-979-01,NDC,facility,both,3,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,400,ML,,282,197.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,71456-001-01,NDC,facility,both,2,ML,,353,247.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAMADOL  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,72888-080-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 100 MG/ML FROM 1 GRAM VIAL (PRMC PEDS ONLY),50863,CDM,636,RC,J0696,HCPCS,0409-7332-11,NDC,facility,both,4,EA,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J3490,HCPCS,0338-0049-48,NDC,facility,both,2,ML,JZ,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
OFLOXACIN 0.3 % OTIC DROP,50863,CDM,636,RC,J3490,HCPCS,60505-0363-2,NDC,facility,both,1,ML,,911,637.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5%-LACTATED RINGERS IV,50863,CDM,636,RC,J7120,HCPCS,0338-0125-04,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE  25 MG ORAL CAP,50863,CDM,250,RC,J7515,HCPCS,0078-0240-61,NDC,facility,both,3,EA,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORHEXIDINE GLUCONATE  0.12 % MM MWSH,50863,CDM,636,RC,J3490,HCPCS,17856-2002-3,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0172-3926-60,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,1500,ML,,7372,5160.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRILAT 1.25 MG/ML IV INJ,50863,CDM,250,RC,J3490,HCPCS,43598-078-11,NDC,facility,both,1,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
0.45 % NACL-POTASSIUM CHLORIDE 20 MEQ/L IV SOLP (PEDS ONC),50863,CDM,250,RC,J3490,HCPCS,0338-0704-34,NDC,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,636,RC,J3490,HCPCS,63323-185-10,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN   1.5 G IV SOLR,50863,CDM,636,RC,J3373,HCPCS,0409-3515-11,NDC,facility,both,150,EA,,143,100.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSINOPRIL 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,43547-387-09,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,636,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,4,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,55111-180-15,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORTHALIDONE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-167-11,NDC,facility,both,2,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL  6.25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6301-61,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMTERENE-HYDROCHLOROTHIAZIDE 75 MG-50 MG TAB,50863,CDM,250,RC,J3490,HCPCS,68382-857-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,0641-6145-01,NDC,facility,both,4,ML,JZ,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CISPLATIN 1 MG/ML IV,50863,CDM,250,RC,J9060,HCPCS,16729-288-11,NDC,facility,both,13,ML,,282,197.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,636,RC,J3490,HCPCS,63037-136-25,NDC,facility,both,2,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,50863,CDM,636,RC,J1756,HCPCS,0517-2340-01,NDC,facility,both,95,ML,,305,213.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VECURONIUM BROMIDE 10 MG IV SOLR,50863,CDM,636,RC,J3490,HCPCS,0703-2914-01,NDC,facility,both,1,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-229-02,NDC,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-9791-01,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE (PF-DURAMORPH/ASTRAMORPH) 0.5 MG/ML INJ SOLN,50863,CDM,250,RC,J2274,HCPCS,0409-3814-11,NDC,facility,both,1,ML,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETHACRYNIC ACID 25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,69238-1126-1,NDC,facility,both,2,EA,,237,165.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-499-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RACEPINEPHRINE 2.25 % INHL NEBU,50863,CDM,636,RC,J3490,HCPCS,0487-2784-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,63323-462-01,NDC,facility,both,1,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE HCL IN NS 10 MG/250 ML (0.04 MG/ML) IV SOLN (PDS MERGE),50863,CDM,250,RC,J2371,HCPCS,71285-6058-1,NDC,facility,both,500,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MOXIFLOXACIN 400 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65862-603-30,NDC,facility,both,1,EA,,134,93.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BETAMETHASONE ACET & SOD PHOS 6 MG/ML INJ SUSP,50863,CDM,250,RC,J0702,HCPCS,78206-118-01,NDC,facility,both,2,ML,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,51754-5001-1,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,250,RC,J2405,HCPCS,60505-6130-0,NDC,facility,both,1,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-492-09,NDC,facility,both,200,ML,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,50863,CDM,636,RC,Q0177,HCPCS,0904-6617-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7912-59,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),50863,CDM,250,RC,J1815,HCPCS,0024-5926-05,NDC,facility,both,6,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN NACL (PF) 1000 UNIT/500 ML IV SOLP,50863,CDM,636,RC,J1644,HCPCS,0409-1005-01,NDC,facility,both,16,ML,,665,465.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-571-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7188-61,NDC,facility,both,2,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,0409-1886-22,NDC,facility,both,415,ML,,215,150.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 20 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,70954-600-10,NDC,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 125 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,62756-796-88,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6869-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),50863,CDM,250,RC,J3490,HCPCS,0409-4888-10,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J1940,HCPCS,36000-283-25,NDC,facility,both,40,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),50863,CDM,636,RC,J0169,HCPCS,76329-3318-1,NDC,facility,both,80,ML,,646,452.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,250,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-405-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 1 GRAM/20 ML IV SOLN,50863,CDM,250,RC,J9190,HCPCS,63323-117-00,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,54,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLEDRONIC ACID-MANNITOL-WATER 4 MG/100 ML IV PGBK,50863,CDM,636,RC,J3489,HCPCS,25021-826-82,NDC,facility,both,4,ML,JZ,778,544.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,636,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,64,ML,JW,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
RITUXIMAB-PVVR 10 MG/ML IV SOLN,50863,CDM,636,RC,Q5119,HCPCS,0069-0249-01,NDC,facility,both,24,ML,JW,2065,1445.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
BUPIVACAINE (PF) 0.25 % (LEFT) (PHS CUSTOM PAIN BALL),50863,CDM,636,RC,J3490,HCPCS,0409-1159-02,NDC,facility,both,1,ML,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5% W/EPINEPHRINE 1:200K INJECTION,50863,CDM,636,RC,J3490,HCPCS,0409-1749-29,NDC,facility,both,2,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-50,NDC,facility,both,150,ML,,265,185.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J3430,HCPCS,65219-635-01,NDC,facility,both,5,ML,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,9,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
"LIPASE-PROTEASE-AMYLASE 24,000-76,000- 120,000 UNIT ORAL CAP, DELAY REL",50863,CDM,636,RC,J3490,HCPCS,0032-2636-01,NDC,facility,both,3,EA,,145,101.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PATIROMER CALCIUM SORBITEX  8.4 G ORAL PWPK,50863,CDM,636,RC,J3490,HCPCS,53436-084-01,NDC,facility,both,1,EA,,209,146.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-19,NDC,facility,both,300,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-3425-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML INJ SOLN,50863,CDM,250,RC,J0171,HCPCS,76329-9060-0,NDC,facility,both,120,ML,,319,223.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-25,NDC,facility,both,48,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL 120 MG ORAL CS24,50863,CDM,250,RC,J3490,HCPCS,0527-4118-37,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,63323-482-03,NDC,facility,both,100,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,250,RC,J0330,HCPCS,31722-981-10,NDC,facility,both,2,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 500 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0093-3147-01,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 2 GRAM INJ SOLR,50863,CDM,636,RC,J0692,HCPCS,71288-009-21,NDC,facility,both,4,EA,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,250,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,14,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERYTHROMYCIN 5 MG/G OPHT OINT,50863,CDM,250,RC,J3490,HCPCS,72485-670-31,NDC,facility,both,4,GM,,340,238,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MECLIZINE 25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-523-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMETHICONE 40MG/0.6ML (0.6ML-UD) SYRINGE (REPACK),50863,CDM,250,RC,J3490,HCPCS,17856-1141-4,NDC,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,0409-1886-22,NDC,facility,both,100,ML,JZ,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
FLUTICASONE 220 MCG/ACTUATION INHL AERO,50863,CDM,250,RC,J3490,HCPCS,66993-080-96,NDC,facility,both,1,GM,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2599,HCPCS,70121-1642-1,NDC,facility,both,20,ML,,455,318.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
URSODIOL 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-100-11,NDC,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,16729-114-31,NDC,facility,both,8,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0121-1781-05,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,3,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
SERTRALINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-231-11,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE HCL IN NS 10 MG/250 ML (0.04 MG/ML) IV SOLN (PDS MERGE),50863,CDM,250,RC,J2371,HCPCS,70004-811-40,NDC,facility,both,500,ML,,2183,1528.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,65862-707-55,NDC,facility,both,15,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-6625-22,NDC,facility,both,4,ML,,231,161.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-245-11,NDC,facility,both,1,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SYRG,50863,CDM,J3490,HCPCS,8290306546,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN DEXTROSE (ISO-OS) 2 GRAM/50 ML IV PGBK,50863,CDM,J0690,HCPCS,0264-3105-11,NDC,,,facility,both,4,EA,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL-ROPIVACAINE-NACL (PF) 2-0.2 MCG/ML-% INJ (MERGE ERX),50863,CDM,250,RC,J3490,HCPCS,70092-9259-75,NDC,facility,both,10,ML,,2172,1520.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE  7.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-584-11,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CINACALCET 30 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69097-410-02,NDC,facility,both,3,EA,,390,273,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM ZIRCONIUM CYCLOSILICATE  5 G ORAL PWPK (USE PANEL),50863,CDM,250,RC,J3490,HCPCS,0310-1105-01,NDC,facility,both,2,EA,,293,205.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,50863,CDM,J1644,HCPCS,71288-403-01,NDC,,,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,J3101,HCPCS,50242-037-06,NDC,,,facility,both,10,EA,,4581,3206.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0137,HCPCS,0143-9386-01,NDC,facility,both,41,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 50 MG/ML INJECTION,50863,CDM,636,RC,J1200,HCPCS,25021-481-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-464-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,J2704,HCPCS,63323-269-22,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 40 MG/ML SUSP (DEPO-MEDROL) INJECTION,50863,CDM,636,RC,J1010,HCPCS,70121-1573-1,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,21,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG ORAL TBEC,50863,CDM,J3490,HCPCS,0904-6474-61,NDC,,,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN NEO IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J3370,HCPCS,0338-3582-01,NDC,facility,both,2,ML,PLAD,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-495-27,NDC,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN  10 GRAM INJ SOLR,50863,CDM,636,RC,J0690,HCPCS,0143-9983-91,NDC,facility,both,4,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,50863,CDM,250,RC,J9045,HCPCS,0703-4239-01,NDC,facility,both,8,ML,,215,150.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % MUCOSAL GEL,50863,CDM,636,RC,J3490,HCPCS,17478-711-30,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN  10 GRAM INJ SOLR,50863,CDM,250,RC,J0690,HCPCS,0143-9983-03,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM BROMIDE 0.03 % NASL SPRA,50863,CDM,636,RC,J3490,HCPCS,24208-398-30,NDC,facility,both,1,ML,,224,156.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,250,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,9,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPTOMYCIN IN 0.9 % SOD CHLOR 350 MG/50 ML IV PGBK,50863,CDM,250,RC,J0874,HCPCS,0338-0712-24,NDC,facility,both,700,ML,,269,188.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6475-61,NDC,facility,both,4,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,100,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-50,NDC,facility,both,8,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
OSELTAMIVIR  6 MG/ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0004-0822-05,NDC,facility,both,13,ML,,186,130.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,3,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,300,ML,,212,148.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,31,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 150 MG/ML INJECTION,50863,CDM,636,RC,J3490,HCPCS,0009-0775-20,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-25,NDC,facility,both,20,ML,,2829,1980.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68180-969-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 30 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-087-01,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) IV SOLN",50863,CDM,250,RC,J3490,HCPCS,43066-008-01,NDC,facility,both,2,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,71288-505-02,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60505-0252-2,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,20,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-349-11,NDC,facility,both,1,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN PEDS IV INFUSION 12 MG/ML (CDS MIXTURE FROM PREMIX),50863,CDM,250,RC,J0736,HCPCS,0781-3289-91,NDC,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,25,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4% TOP PATCH,50863,CDM,250,RC,J3490,HCPCS,0536-1202-15,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-886-01,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 2 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,250,RC,J2270,HCPCS,63323-452-00,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,27241-001-06,NDC,facility,both,3,EA,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,50863,CDM,636,RC,J0585,HCPCS,0023-1145-01,NDC,facility,both,120,EA,,1918,1342.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 20MG/ML IV SYRINGE (PEDS/NEO),50863,CDM,250,RC,J0612,HCPCS,63323-311-10,NDC,facility,both,49,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,636,RC,J2560,HCPCS,42494-415-01,NDC,facility,both,1,ML,,193,135.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,636,RC,J2405,HCPCS,23155-548-31,NDC,facility,both,4,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CAFFEINE-SODIUM BENZOATE 250 MG/ML INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0517-2502-01,NDC,facility,both,1,ML,,215,150.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0780,HCPCS,25021-790-02,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE 100 MG ORAL CAP,50863,CDM,250,RC,J7502,HCPCS,0078-0241-61,NDC,facility,both,2,EA,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE (FOR EMERGENCY) 100 MG/ML (10%) IV SOLN,50863,CDM,636,RC,J0612,HCPCS,63323-360-01,NDC,facility,both,200,ML,JZ,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,166,ML,,150,105,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,0409-1207-03,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ORPHENADRINE CITRATE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J2360,HCPCS,25021-651-02,NDC,facility,both,1,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,250,RC,J7060,HCPCS,0338-0070-10,NDC,facility,both,2,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRIL MALEATE  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51672-4037-1,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6924-61,NDC,facility,both,6,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,250,RC,J3101,HCPCS,50242-037-06,NDC,facility,both,32,EA,JW,6012,4208.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
MELATONIN  3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,7733351625,NDC,facility,both,5,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0143-9334-10,NDC,facility,both,300,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CONJUGATED ESTROGENS 0.625 MG/G VAGL CREA,50863,CDM,636,RC,J3490,HCPCS,0046-0872-21,NDC,facility,both,2,GM,,2544,1780.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 200 MG/10 ML (20 MG/ML) IV SYRG,50863,CDM,250,RC,J0330,HCPCS,71266-2001-2,NDC,facility,both,10,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 125 MG ORAL CPSP,50863,CDM,636,RC,J3490,HCPCS,0904-6615-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  100 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,63323-376-00,NDC,facility,both,2,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FIDAXOMICIN 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0480-2596-34,NDC,facility,both,1,EA,,876,613.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MEASLES,MUMPS,RUBELLA VACC(PF) 10EXP3.4-4.2- 3.3CCID50/0.5ML SUBQ SUSR",50863,CDM,250,RC,90707,HCPCS,58160-831-03,NDC,facility,both,1,EA,,410,287,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE SODIUM 25 MG/ML INJ SOLN,50863,CDM,636,RC,J9260,HCPCS,61703-350-37,NDC,facility,both,2,ML,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAMSULOSIN 0.4 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,0904-6401-61,NDC,facility,both,5,EA,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,55111-150-01,NDC,facility,both,4,EA,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,135,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER FLUSH,50863,CDM,636,RC,J7060,HCPCS,0264-7510-20,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,636,RC,J1611,HCPCS,63323-596-11,NDC,facility,both,1,EA,,895,626.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-467-01,NDC,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,109,ML,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 125 MG ORAL CPSP,50863,CDM,250,RC,J3490,HCPCS,68084-313-11,NDC,facility,both,5,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MANNITOL 20% IV SOLP,50863,CDM,250,RC,J2150,HCPCS,0990-7715-13,NDC,facility,both,1,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,4,ML,JW,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,38,ML,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,50863,CDM,250,RC,J9060,HCPCS,16729-288-11,NDC,facility,both,12,ML,,258,180.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,63323-482-03,NDC,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,250,RC,J2720,HCPCS,63323-229-01,NDC,facility,both,7,ML,,128,89.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN 1 GRAM SOLUTION FOR INJECTION,50863,CDM,636,RC,J0290,HCPCS,55150-113-10,NDC,facility,both,2,EA,JZ,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,250,RC,J2405,HCPCS,23155-547-31,NDC,facility,both,8,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,0703-9514-01,NDC,facility,both,4,ML,,295,206.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,636,RC,J3490,HCPCS,59310-579-22,NDC,facility,both,1,GM,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOBRAMYCIN 0.3 % EYE DROPS,50863,CDM,250,RC,J3490,HCPCS,61314-643-05,NDC,facility,both,1,ML,,167,116.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 20MG/ML IV SYRINGE (PEDS/NEO),50863,CDM,250,RC,J0612,HCPCS,63323-311-10,NDC,facility,both,14,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,68180-150-01,NDC,facility,both,2,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,72603-179-01,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INDOMETHACIN 50 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,50268-431-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,55150-177-05,NDC,facility,both,50,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE(PF)-0.9 % SODCHLOR 0.2 % 745 ML LINF ELPH,50863,CDM,636,RC,J3490,HCPCS,73177-109-14,NDC,facility,both,1,ML,,2415,1690.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NS WITH POTASSIUM CHLORIDE 20 MEQ/L IV SOLP,50863,CDM,250,RC,J3480,HCPCS,0338-0691-04,NDC,facility,both,10,ML,JZ,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-65,NDC,facility,both,85,ML,,150,105,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,51754-5001-1,NDC,facility,both,1,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-439-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0137,HCPCS,0143-9386-01,NDC,facility,both,100,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL 2.5 MG/ML SUSPENSION,50863,CDM,250,RC,J3490,HCPCS,99999-0404-75,NDC,facility,both,1,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,Q0162,HCPCS,16714-671-02,NDC,,,facility,both,4,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 500 MG (200 MG ELEMENTAL) CHEW TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6412-92,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  80 MG ORAL CS24,50863,CDM,250,RC,J3490,HCPCS,0527-4117-37,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV,50863,CDM,250,RC,J7120,HCPCS,0338-0117-04,NDC,facility,both,3,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,40,ML,,140,98,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIPASE-PROTEASE-AMYLASE (PORK) 36,000-114,000- 180,000 UNIT ORAL CPDR",50863,CDM,250,RC,J3490,HCPCS,0032-3016-13,NDC,facility,both,3,EA,,228,159.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0555-0779-02,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE PAMOATE  25 MG ORAL CAP,50863,CDM,250,RC,Q0177,HCPCS,60687-696-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-495-27,NDC,,,facility,both,15,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEPROTUMUMAB-TRBW 500 MG IV SOLR,50863,CDM,636,RC,J3241,HCPCS,75987-130-15,NDC,facility,both,150,EA,,106755,74728.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZONATATE 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,68084-214-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-663-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,636,RC,J3490,HCPCS,0173-0682-20,NDC,facility,both,1,GM,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM BICARB-CITRIC ACID 20 MEQ ORAL TBEF,50863,CDM,250,RC,J3490,HCPCS,51801-012-01,NDC,facility,both,3,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 125 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,62756-796-88,NDC,facility,both,5,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DISOPYRAMIDE 150 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0093-3129-01,NDC,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZONATATE 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7153-61,NDC,facility,both,12,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIZATRIPTAN  5 MG ORAL TBDL,50863,CDM,636,RC,J3490,HCPCS,69452-156-74,NDC,facility,both,2,EA,,282,197.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEBIVOLOL  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,31722-586-90,NDC,facility,both,2,EA,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,50863,CDM,250,RC,J3490,HCPCS,69339-152-01,NDC,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE (FOR CODE) 10% IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0517-6710-01,NDC,facility,both,10,ML,,1187,830.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL 20 MG/5 ML ORAL ELIX,50863,CDM,250,RC,J3490,HCPCS,0121-0942-05,NDC,facility,both,3,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LURASIDONE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7355-04,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,100,ML,JZ,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
FENTANYL CITRATE (PF) 50 MCG/ML IV (MERGE) (FOR VENT),50863,CDM,250,RC,J3010,HCPCS,70092-1509-35,NDC,facility,both,50,ML,,208,145.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,636,RC,J3490,HCPCS,50268-540-11,NDC,facility,both,3,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0143-9509-01,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 10 MG-325 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0406-0367-23,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN SODIUM EXTENDED 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0071-0369-24,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  1 MG/ML INJ SYRG,50863,CDM,636,RC,J1171,HCPCS,0409-1283-10,NDC,facility,both,30,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL,50863,CDM,636,RC,J1071,HCPCS,0409-6562-01,NDC,facility,both,200,ML,,129,90.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,250,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,18,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6949-61,NDC,facility,both,6,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-145-11,NDC,facility,both,25,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-1159-19,NDC,facility,both,9,ML,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLN (MERGE)",50863,CDM,250,RC,P9047,HCPCS,0944-0493-03,NDC,facility,both,1,ML,,504,352.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEGARELIX 120 MG SUBQ SOLR,50863,CDM,636,RC,J9155,HCPCS,55566-8402-0,NDC,facility,both,240,EA,,4207,2944.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESNA 100 MG/ML IV SOLN,50863,CDM,250,RC,J9209,HCPCS,0338-1305-01,NDC,facility,both,2,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  25 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-7448-61,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 5 MG-325 MG TAB,50863,CDM,J3490,HCPCS,0406-0123-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,5,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
EPINEPHRINE 0.15 MG/0.3 ML IM PNIJ,50863,CDM,J0171,HCPCS,49502-101-01,NDC,,,facility,both,2,EA,,675,472.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLP,50863,CDM,250,RC,J3480,HCPCS,0409-6653-18,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 40 % ORAL GEL,50863,CDM,250,RC,J3490,HCPCS,574006915,NDC,facility,both,1,GM,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,42023-186-20,NDC,facility,both,5,ML,,1094,765.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5% W/EPINEPHRINE 1:200K INJECTION,50863,CDM,250,RC,J3490,HCPCS,0409-1749-29,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,23155-724-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J2312,HCPCS,0409-1215-01,NDC,facility,both,1,ML,,186,130.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,250,RC,J0690,HCPCS,44567-707-25,NDC,facility,both,30,EA,,165,115.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 20 MG/ML INJ SOLN,50863,CDM,636,RC,J0360,HCPCS,0641-6231-01,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV (BOLUS),50863,CDM,250,RC,J7040,HCPCS,0338-0049-10,NDC,facility,both,1,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIPHTH,PERTUS(ACELL),TETANUS SYRG(BOOSTRIX) 2.5-8-5 LF-MCG-LF/0.5ML IM SYRG",50863,CDM,636,RC,90715,HCPCS,58160-842-52,NDC,facility,both,1,ML,,240,168,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN SODIUM EXTENDED 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,65862-692-01,NDC,facility,both,6,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUBIPROSTONE  8 MCG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0480-3479-06,NDC,facility,both,3,EA,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLP",50863,CDM,250,RC,P9047,HCPCS,0944-0493-04,NDC,facility,both,2,ML,JZ,501,350.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ATENOLOL  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-759-20,NDC,facility,both,5,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,93,ML,JW,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,7,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,0409-1207-03,NDC,facility,both,5,ML,,121,84.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,45,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,636,RC,J2597,HCPCS,70095-031-01,NDC,facility,both,33,ML,JZ,1329,930.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0781-3156-06,NDC,facility,both,27,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,60687-755-40,NDC,facility,both,2,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXEPIN  50 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,51079-438-01,NDC,facility,both,2,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,J1836,HCPCS,25021-131-82,NDC,,,facility,both,50,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML IV SOLN (MERGE),50863,CDM,636,RC,J3490,HCPCS,16714-037-10,NDC,facility,both,1,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LURASIDONE 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7355-04,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 250 MCG SUBQ SOLR,50863,CDM,636,RC,J2802,HCPCS,55513-221-01,NDC,facility,both,500,EA,,8780,6146,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 5 MG-325 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0406-0123-01,NDC,facility,both,3,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 10 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-6475-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,35,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,J1885,HCPCS,72266-118-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL IV BOLUS 10MG/ML (ANESTHESIA ONLY),50863,CDM,636,RC,J2704,HCPCS,0409-4699-54,NDC,facility,both,100,ML,,127,88.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 10 GRAM/15 ML ORAL SOLN,50863,CDM,J3490,HCPCS,0116-4005-30,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,73,ML,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTAZIDIME-AVIBACTAM 2.5 GRAM (2 GRAM-0.5 GRAM) IV SOLR,50863,CDM,250,RC,J0714,HCPCS,0456-2700-01,NDC,facility,both,4,EA,,1401,980.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PILOCARPINE 5 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0527-1313-01,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,4,EA,JW,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,13,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAMOXIFEN 10 MG ORAL TAB,50863,CDM,250,RC,J9999,HCPCS,0378-0144-91,NDC,facility,both,2,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NORTRIPTYLINE 25 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0093-0811-01,NDC,facility,both,2,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 10 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,65862-192-01,NDC,facility,both,4,EA,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MYCOPHENOLATE 500 MG TAB,50863,CDM,636,RC,J7517,HCPCS,51079-379-01,NDC,facility,both,2,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,44567-600-04,NDC,facility,both,2,ML,,442,309.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL 2.5 MG/ML SUSPENSION,50863,CDM,250,RC,J3490,HCPCS,99999-0404-75,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOPAMINE IN D5W 400 MG/250 ML (1.6 MG/ML) IV,50863,CDM,250,RC,J1265,HCPCS,0409-7809-22,NDC,facility,both,40,ML,,372,260.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 20MG/ML IV SYRINGE (PEDS/NEO),50863,CDM,250,RC,J0612,HCPCS,63323-311-10,NDC,facility,both,75,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,J3490,HCPCS,0093-2279-73,NDC,,,facility,both,4,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN STERILE WATER 2 GRAM/20 ML IV SYRG,50863,CDM,J0690,HCPCS,70092-1604-47,NDC,,,facility,both,4,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,50863,CDM,J1650,HCPCS,16714-036-01,NDC,,,facility,both,8,ML,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE (FOR CODE) 10% IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0517-2710-25,NDC,facility,both,1,ML,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,J3490,HCPCS,63323-185-10,NDC,,,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 400 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0143-9887-01,NDC,facility,both,4,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0406-0512-23,NDC,facility,both,2,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM NEONATAL INJECTION 0.2 MG/0.5 ML,50863,CDM,250,RC,J2060,HCPCS,0641-6046-01,NDC,facility,both,10,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IR SOLN,50863,CDM,636,RC,J3490,HCPCS,0338-0047-46,NDC,facility,both,2,ML,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,636,RC,J3490,HCPCS,76329-3390-1,NDC,facility,both,100,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-663-11,NDC,facility,both,3,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-3426-05,NDC,facility,both,3,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,19,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-467-01,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7124-61,NDC,facility,both,2,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,72,ML,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLPIDEM  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0781-5317-01,NDC,facility,both,1,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7308-61,NDC,facility,both,6,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6797-61,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,50863,CDM,250,RC,J2359,HCPCS,55150-308-01,NDC,facility,both,20,EA,,208,145.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,14,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-242-11,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT  25 MCG/ML INJ SOLN,50863,CDM,250,RC,J0881,HCPCS,55513-002-01,NDC,facility,both,25,ML,,836,585.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FINASTERIDE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-428-11,NDC,facility,both,1,EA,PLAD,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
HYDROCODONE-ACETAMINOPHEN 7.5 MG-325 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0406-0124-23,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE HCL  2 % MM JELP,50863,CDM,250,RC,J3490,HCPCS,25021-673-76,NDC,facility,both,10,ML,,303,212.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL SODIUM 500 MG IV SOLR,50863,CDM,250,RC,J0206,HCPCS,65219-380-30,NDC,facility,both,1,EA,,801,560.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 20 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,70954-600-10,NDC,facility,both,1,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 5 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,63323-660-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0143-9386-01,NDC,facility,both,13,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE  50 MG ORAL TAB,50863,CDM,250,RC,j3490,HCPCS,68382-805-01,NDC,facility,both,4,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLERGONOVINE 0.2 MG/ML (1 ML) INJ SOLN,50863,CDM,636,RC,J2210,HCPCS,51991-144-99,NDC,facility,both,1,ML,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN DETEMIR 100 UNIT/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,0169-3687-12,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 1 MG ORAL TAB,50863,CDM,636,RC,J8540,HCPCS,0054-8174-25,NDC,facility,both,8,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,636,RC,J7999,HCPCS,70092-1017-46,NDC,facility,both,3,ML,,119,83.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE DINITRATE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-083-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,63323-400-01,NDC,facility,both,130,ML,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-437-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLEDRONIC ACID IN MANNITOL & WATER 5 MG/100 ML IV SOLN,50863,CDM,636,RC,J3489,HCPCS,25021-830-82,NDC,facility,both,5,ML,JZ,540,378,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"LIPASE-PROTEASE-AMYLASE 5,000-17,000- 24,000 UNIT ORAL CPDR",50863,CDM,636,RC,J3490,HCPCS,73562-115-01,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 0.1 MG/ML INJ SYRG,50863,CDM,250,RC,J0461,HCPCS,76329-3340-1,NDC,facility,both,100,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,636,RC,J3360,HCPCS,76045-204-00,NDC,facility,both,1,ML,JW,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
MESNA 100 MG/ML IV SOLN,50863,CDM,636,RC,J9209,HCPCS,10019-953-62,NDC,facility,both,8,ML,,221,154.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0832-1211-89,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,70594-117-01,NDC,facility,both,100,ML,JZ,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DEXTROSE 5%-1/4 NORMAL SALINE IV,50863,CDM,636,RC,J3490,HCPCS,0338-0077-04,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,5,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
SITAGLIPTIN  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0006-0221-54,NDC,facility,both,4,EA,,224,156.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 600 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-5854-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML IV SOLN (MERGE),50863,CDM,250,RC,J3490,HCPCS,0781-3269-71,NDC,facility,both,2,ML,,502,351.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPRAZOLAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0781-1077-01,NDC,facility,both,4,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,250,RC,J0330,HCPCS,0409-6629-02,NDC,facility,both,15,ML,,171,119.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZIPRASIDONE 20 MG CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6269-45,NDC,facility,both,3,EA,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6925-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,3,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,34,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,636,RC,J2795,HCPCS,70069-064-01,NDC,facility,both,150,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIGOXIN 250 MCG/ML INJ SOLN,50863,CDM,250,RC,J1160,HCPCS,0641-1410-31,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM,50863,CDM,250,RC,J3490,HCPCS,68462-298-17,NDC,facility,both,1,GM,,239,167.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-467-01,NDC,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.3 MG/0.3 ML IM PNIJ,50863,CDM,250,RC,J0169,HCPCS,49502-500-01,NDC,facility,both,3,EA,,1078,754.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  5 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-122-11,NDC,facility,both,4,EA,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE (FOR CODE) 10% IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0517-2710-25,NDC,facility,both,5,ML,,567,396.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,29,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  1 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0603-5335-21,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,250,RC,J3490,HCPCS,81284-611-00,NDC,facility,both,6,ML,,220,154,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 2 MG/ML IN NS 50ML INFUSION (STOCK DOSE),50863,CDM,J3490,HCPCS,0143-9508-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,70700-165-22,NDC,facility,both,3,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-728-11,NDC,facility,both,2,EA,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CINACALCET 30 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16729-440-10,NDC,facility,both,3,EA,,390,273,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,250,RC,J2795,HCPCS,70069-064-25,NDC,facility,both,200,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J1611,HCPCS,63323-596-11,NDC,facility,both,5,EA,,4473,3131.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0039-05,NDC,facility,both,2,EA,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,50863,CDM,J3420,HCPCS,0517-0031-01,NDC,,,facility,both,1,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EMTRICITABINE-TENOFOVIR 200 MG-300 MG TAB,50863,CDM,636,RC,J0750,HCPCS,0093-7704-56,NDC,facility,both,1,EA,JG,297,207.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount
MANNITOL 20% IV SOLP,50863,CDM,250,RC,J2150,HCPCS,0338-0357-03,NDC,facility,both,1,ML,JZ,161,112.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SERTRALINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-253-11,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,J2312,HCPCS,36000-308-01,NDC,,,facility,both,80,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 5 MG-325 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0406-0123-23,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-3178-01,NDC,facility,both,80,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,18,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELATACEPT 250 MG IV SOLR,50863,CDM,636,RC,J0485,HCPCS,0003-0371-13,NDC,facility,both,12,EA,JW,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,250,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 125 MG/5 ML (25MG/ML) ORAL SYRINGE (REPACK),50863,CDM,250,RC,J3373,HCPCS,67457-340-00,NDC,facility,both,125,EA,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,636,RC,J7060,HCPCS,0338-0017-04,NDC,facility,both,2,ML,,181,126.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPTOMYCIN 500 MG IV SOLR,50863,CDM,636,RC,J0878,HCPCS,72603-152-01,NDC,facility,both,500,EA,,1463,1024.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN   81 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,0904-6783-70,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MISOPROSTOL 100 MCG ORAL TAB,50863,CDM,250,RC,S0191,HCPCS,59762-5007-2,NDC,facility,both,4,EA,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROPROCAINE 3 % INJ SOLN,50863,CDM,250,RC,J2401,HCPCS,63323-478-01,NDC,facility,both,150,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN STERILE WATER 2 GRAM/20 ML IV SYRG,50863,CDM,250,RC,J0690,HCPCS,70092-1604-47,NDC,facility,both,8,ML,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM  4.5 GRAM IV SOLR,50863,CDM,250,RC,J2543,HCPCS,55150-121-50,NDC,facility,both,4,EA,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),50863,CDM,250,RC,J2060,HCPCS,0641-6044-01,NDC,facility,both,25,ML,,237,165.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,250,RC,J0137,HCPCS,0264-4100-90,NDC,facility,both,24,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7050,HCPCS,0338-0049-48,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16714-988-01,NDC,facility,both,2,EA,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 5 MG/ML IV SOLN,50863,CDM,636,RC,J1921,HCPCS,36000-322-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  50 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,72205-012-90,NDC,facility,both,1,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN NORMAL SALINE IV,50863,CDM,636,RC,J7042,HCPCS,0338-0089-04,NDC,facility,both,2,ML,JZ,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DIVALPROEX 500 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,65862-595-01,NDC,facility,both,2,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL  20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-072-33,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE (FOR CODE) 10% (100 MG/ML) IV SYRINGE,50863,CDM,250,RC,J3490,HCPCS,0409-1631-10,NDC,facility,both,1,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,43066-007-10,NDC,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN 0.9% SODIUM CL 1.25 GRAM/250 ML IV SOLN,50863,CDM,250,RC,J3373,HCPCS,70004-923-59,NDC,facility,both,3,ML,,189,132.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FERUMOXYTOL 510 MG/17 ML (30 MG/ML) IV SOLN,50863,CDM,636,RC,Q0138,HCPCS,59338-775-01,NDC,facility,both,510,ML,,3294,2305.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,8,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-590-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0047-03,NDC,facility,both,25,EA,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHOTERICIN B LIPOSOME 50 MG IV SUSR,50863,CDM,250,RC,J0289,HCPCS,55150-365-01,NDC,facility,both,35,EA,,6313,4419.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MERCAPTOPURINE 25 MG SPLIT TABLET,50863,CDM,250,RC,J3490,HCPCS,99999-501-19,NDC,facility,both,1,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 2 HALF TABLET
ROSUVASTATIN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-245-11,NDC,facility,both,3,EA,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,J2919,HCPCS,0009-0039-30,NDC,,,facility,both,8,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,63323-485-27,NDC,,,facility,both,70,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 1 GRAM INJ SOLR,50863,CDM,250,RC,J0692,HCPCS,0409-9566-01,NDC,facility,both,4,EA,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,63323-482-03,NDC,,,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NAFCILLIN NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J3490,HCPCS,63323-327-10,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,78,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,636,RC,J7510,HCPCS,17856-0759-5,NDC,facility,both,6,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (NEO) <2 KG,50863,CDM,250,RC,J7060,HCPCS,0338-0017-41,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHACHOLINE CHLORIDE STERILE INHALATION SOLUTION (PF) KIT,50863,CDM,J7674,HCPCS,64281-110-05,NDC,,,facility,both,64,ML,,2236,1565.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,10702-018-01,NDC,facility,both,4,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,J3490,HCPCS,68180-441-02,NDC,,,facility,both,8,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IV PGBK,50863,CDM,636,RC,J3475,HCPCS,0409-6729-24,NDC,facility,both,4,ML,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPHENIDATE 18 MG ORAL TO24,50863,CDM,250,RC,J3490,HCPCS,50458-585-01,NDC,facility,both,2,EA,,152,106.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ANTI-INHIBITOR COAGULANT CMPLX 1,750-3,250 UNIT IV SOLR",50863,CDM,250,RC,J7198,HCPCS,64193-425-02,NDC,facility,both,7500,UN,,44678,31274.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,7,EA,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FERROUS SULFATE 75 MG/ML (ELEMENTAL IRON 15 MG/ML) ORAL DROP,50863,CDM,250,RC,J3490,HCPCS,536134480,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-1283-03,NDC,facility,both,20,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,50863,CDM,250,RC,Q0177,HCPCS,16714-082-10,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6376-61,NDC,facility,both,2,EA,,130,91,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IMIPRAMINE 10 MG TAB,50863,CDM,636,RC,J3490,HCPCS,64380-169-01,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML (PEDS CALCLUATOR 0.5),50863,CDM,636,RC,J1815,HCPCS,0024-5924-10,NDC,facility,both,3,ML,GZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier GZ: Item or service expected to be denied as not reasonable and necessary
LINACLOTIDE 145 MCG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0456-1201-30,NDC,facility,both,1,EA,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLN (MERGE)",50863,CDM,250,RC,P9047,HCPCS,64208-2512-8,NDC,facility,both,6,ML,JZ,713,499.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-492-26,NDC,facility,both,300,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,68094-494-59,NDC,facility,both,6,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-ABDA 100 MG IV SOLR,50863,CDM,636,RC,Q5104,HCPCS,78206-162-99,NDC,facility,both,44,EA,,9150,6405,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J2312,HCPCS,0409-1219-41,NDC,facility,both,400,ML,,513,359.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GOLIMUMAB  12.5 MG/ML IV SOLN,50863,CDM,636,RC,J1602,HCPCS,57894-350-01,NDC,facility,both,125,ML,,13795,9656.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 100 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,70954-240-10,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,13,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-0552-23,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J2003,HCPCS,0143-9595-01,NDC,facility,both,50,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,50863,CDM,Q5119,HCPCS,0069-0249-01,NDC,,,facility,both,50,ML,,9892,6924.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML IM SOLN,50863,CDM,636,RC,90375,HCPCS,13533-318-05,NDC,facility,both,9,ML,,7694,5385.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,43598-931-11,NDC,facility,both,4,ML,,223,156.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,0409-4276-17,NDC,,,facility,both,500,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 17 GRAM (100 %) ORAL PWPK,50863,CDM,636,RC,J3490,HCPCS,0904-6931-86,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM NEO IV SYRINGE (PHS FROM PREMIX),50863,CDM,250,RC,J1953,HCPCS,44567-501-01,NDC,facility,both,13,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-337-11,NDC,facility,both,1,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-50,NDC,facility,both,45,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,43598-549-52,NDC,facility,both,100,ML,,165,115.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,8068108600,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J1610,HCPCS,0597-0053-45,NDC,facility,both,1,EA,,186,130.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,60,ML,JZ,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-65,NDC,facility,both,94,ML,,166,116.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOSTIGMINE METHYLSULFATE 1 MG/ML IV SOLN,50863,CDM,636,RC,J2710,HCPCS,70069-806-01,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL  20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-717-11,NDC,facility,both,6,EA,,420,294,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES-DOCUSATE SODIUM 8.6 MG-50 MG TAB,50863,CDM,636,RC,J3490,HCPCS,63739-432-02,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51407-153-90,NDC,facility,both,1,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,32,ML,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZONISAMIDE 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-230-11,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,50863,CDM,J3490,HCPCS,67877-548-88,NDC,,,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 400 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-5853-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,50863,CDM,J3490,HCPCS,69339-152-01,NDC,,,facility,both,2,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 2 MG/ML IV SOLN (PRMC ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-1312-03,NDC,facility,both,20,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,5,ML,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN STERILE WATER 2 GRAM/20 ML IV SYRG,50863,CDM,J0690,HCPCS,70092-1604-47,NDC,,,facility,both,2000,ML,,26015,18210.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-491-01,NDC,,,facility,both,250,ML,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 2 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,636,RC,J2270,HCPCS,63323-452-00,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0456,HCPCS,70436-019-82,NDC,facility,both,1,EA,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,52,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,J7512,HCPCS,60687-145-11,NDC,,,facility,both,60,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,10,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-3426-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DANTROLENE  25 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7211-04,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,63739-931-28,NDC,facility,both,7,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,95,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 50 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,51079-170-01,NDC,facility,both,4,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,71288-402-10,NDC,facility,both,10,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,50863,CDM,250,RC,J0696,HCPCS,44567-702-25,NDC,facility,both,8,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLPIDEM  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-0073-01,NDC,facility,both,2,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,72603-179-01,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 4 MEQ/ML ORAL SOLUTION (CDS),50863,CDM,250,RC,J3490,HCPCS,0409-7391-72,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,17,ML,JW,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GABAPENTIN 400 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6667-61,NDC,facility,both,2,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 100 MG/1 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0548-5605-00,NDC,facility,both,10,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 1 MG ORAL CAP,50863,CDM,250,RC,J7507,HCPCS,68084-450-11,NDC,facility,both,3,EA,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,250,RC,J1596,HCPCS,0143-9679-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIPHTH,PERTUS(ACELL),TETANUS SYRG(BOOSTRIX) 2.5-8-5 LF-MCG-LF/0.5ML IM SYRG",50863,CDM,90715,HCPCS,58160-842-43,NDC,,,facility,both,1,ML,,247,172.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,J1885,HCPCS,72266-118-01,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,636,RC,J1596,HCPCS,0143-9682-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-02,NDC,facility,both,2,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB 100 MG IV SOLR,50863,CDM,636,RC,J1745,HCPCS,57894-030-01,NDC,facility,both,90,EA,JZ,29009,20306.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
FENTANYL CITRATE (PF) 50 MCG/ML (ANESTHESIA INTRAOP ONLY),50863,CDM,250,RC,J3010,HCPCS,0641-6027-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0093-3426-01,NDC,facility,both,3,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE-SALMETEROL 250 MCG-50 MCG/DOSE DISK DEVICE FOR INHALATION,50863,CDM,636,RC,J3490,HCPCS,0378-9321-32,NDC,facility,both,1,EA,,1325,927.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIOTHYRONINE  5 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,42794-018-12,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 50 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6323-61,NDC,facility,both,3,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,250,RC,J2720,HCPCS,63323-229-01,NDC,facility,both,2,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,60219-1708-1,NDC,facility,both,20,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,50863,CDM,J1817,HCPCS,0169-1833-11,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,70069-363-01,NDC,facility,both,1,ML,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,63739-931-28,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-559-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 10 MG TAB,50863,CDM,636,RC,Q0177,HCPCS,60687-664-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IVPB (PEDIATRICS/ADULT NON-FORM)",50863,CDM,J0131,HCPCS,24201-100-01,NDC,,,facility,both,100,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,50863,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,13,EA,,273,191.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,J2405,HCPCS,60505-6130-0,NDC,,,facility,both,4,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ELECTROLYTE-A IV,50863,CDM,250,RC,J3490,HCPCS,0338-0221-03,NDC,facility,both,5,ML,,416,291.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORDIAZEPOXIDE 25 MG CAP,50863,CDM,250,RC,J3490,HCPCS,51079-141-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLU VACCINE TS 2025-26 6 MO UP (PF) 45 MCG (15 MCG X 3)/0.5 ML IM SYRG,50863,CDM,90656,HCPCS,58160-912-41,NDC,,,facility,both,1,ML,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-442-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 10 MG/50 ML (0.2MG/ML) PCA IN NS (MERGE),50863,CDM,250,RC,J1171,HCPCS,61553-830-41,NDC,facility,both,100,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 500 MG INJ SOLR,50863,CDM,636,RC,J0696,HCPCS,0409-7338-11,NDC,facility,both,3,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML INJ SOLN,50863,CDM,250,RC,J0169,HCPCS,76329-9060-0,NDC,facility,both,48,ML,,128,89.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVONORGESTREL 17.5 MCG/24 HR (5 YEARS) IU IUD,50863,CDM,636,RC,J7296,HCPCS,50419-424-08,NDC,facility,both,1,EA,,2509,1756.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLP",50863,CDM,250,RC,P9047,HCPCS,0944-0493-04,NDC,facility,both,3,ML,,751,525.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 600 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-5854-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLU VACCINE TS 2024-25 65 YR UP (PF) 180 MCG/0.5 ML IM SYRG,50863,CDM,90662,HCPCS,49281-124-88,NDC,,,facility,both,1,ML,,373,261.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL  6.25 MG ORAL TAB,50863,CDM,J3490,HCPCS,68084-854-11,NDC,,,facility,both,3,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0456,HCPCS,55150-174-10,NDC,facility,both,1,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NORTRIPTYLINE 10 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0093-0810-01,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 100 MG ORAL TAB,50863,CDM,J3490,HCPCS,60687-677-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 50 % (4 MEQ/ML) INJ SOLN,50863,CDM,J3475,HCPCS,63323-064-01,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 875 MG-125 MG TAB,50863,CDM,636,RC,J3490,HCPCS,42571-162-01,NDC,facility,both,20,EA,,364,254.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,70069-011-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE 150 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,0904-7076-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE MONONITRATE  60 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,0904-6450-61,NDC,facility,both,2,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,50863,CDM,636,RC,J0561,HCPCS,60793-701-02,NDC,facility,both,24,ML,,2376,1663.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN IN SALINE (ISO-OSMOTIC) 80 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1580,HCPCS,0338-0503-48,NDC,facility,both,5,ML,,133,93.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0990-7983-61,NDC,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 75 MG/5 ML ORAL SOLUTION,50863,CDM,250,RC,J3490,HCPCS,0574-0129-01,NDC,facility,both,13,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOSTIGMINE METHYLSULFATE 1 MG/ML IV SOLN,50863,CDM,636,RC,J2710,HCPCS,42023-189-01,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,55150-177-05,NDC,facility,both,300,ML,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETIC ACID 0.25 % IR SOLN,50863,CDM,250,RC,J3490,HCPCS,0264-2304-00,NDC,facility,both,1,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-464-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,0409-6102-18,NDC,facility,both,120,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM SR 180 MG 24 HR CAP,50863,CDM,250,RC,J3490,HCPCS,60687-206-11,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIMODIPINE 60 MG/10 ML ORAL SYRG,50863,CDM,250,RC,J3490,HCPCS,24338-260-10,NDC,facility,both,1,ML,,416,291.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,50863,CDM,250,RC,J9000,HCPCS,0069-1542-20,NDC,facility,both,10,ML,,162,113.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,0641-6145-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 500 MG PE/10 ML INJ SOLN,50863,CDM,250,RC,Q2009,HCPCS,0069-6001-10,NDC,facility,both,21,ML,JZ,1101,770.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GENTAMICIN IN SALINE (ISO-OSMOTIC) 100 MG/50 ML IV PIGGY BACK,50863,CDM,250,RC,J1580,HCPCS,0338-0511-41,NDC,facility,both,2,ML,,431,301.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,63323-482-05,NDC,,,facility,both,150,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 40 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0054-8299-25,NDC,facility,both,3,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN DEGLUDEC 100 UNITS/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,73070-400-11,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,50,ML,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 4 MEQ/ML ORAL SOLUTION (CDS),50863,CDM,250,RC,J3490,HCPCS,99999-0406-81,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 20MG/ML IV SYRINGE (PEDS/NEO),50863,CDM,250,RC,J0612,HCPCS,63323-311-10,NDC,facility,both,21,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,636,RC,J0690,HCPCS,44567-707-25,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 400 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-5853-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICARDIPINE 25 MG/10 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0143-9689-01,NDC,facility,both,4,ML,,599,419.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,69543-386-30,NDC,facility,both,2,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,636,RC,J3490,HCPCS,70004-600-09,NDC,facility,both,1,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J2004,HCPCS,0409-3178-01,NDC,facility,both,120,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,130,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CONJUGATED ESTROGENS 0.625 MG/G VAGL CREA,50863,CDM,250,RC,J3490,HCPCS,0046-0872-21,NDC,facility,both,3,GM,,3816,2671.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7411-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 500 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,16714-299-02,NDC,facility,both,20,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16714-050-01,NDC,facility,both,1,EA,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE INFUSION 2MG/ML 100ML (FOR ANESTHESIA USE ONLY),50863,CDM,250,RC,J3490,HCPCS,0409-2051-05,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BETHANECHOL CHLORIDE 25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0832-0512-89,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCOSE (TOLERANCE TEST) 100 GRAM/180 ML ORAL LIQD,50863,CDM,636,RC,j3490,HCPCS,574195906,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  120 MG RECT SUPP,50863,CDM,J3490,HCPCS,45802-732-00,NDC,,,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,63323-482-03,NDC,,,facility,both,300,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,250,RC,J0690,HCPCS,60505-6142-0,NDC,facility,both,2,EA,JZ,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
METOCLOPRAMIDE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-886-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5% W/EPINEPHRINE 1:200K INJECTION,50863,CDM,250,RC,J3490,HCPCS,0409-1749-29,NDC,facility,both,2,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-0430-06,NDC,,,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,17,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,68094-600-59,NDC,facility,both,6,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,10135-676-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,0641-6145-01,NDC,facility,both,1,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ROPIVACAINE  2 MG/ML INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-285-23,NDC,facility,both,1,ML,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML INJ SOLN,50863,CDM,636,RC,J0171,HCPCS,76329-9060-0,NDC,facility,both,180,ML,,478,334.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 0.125 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68462-330-90,NDC,facility,both,4,EA,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-492-27,NDC,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-492-07,NDC,,,facility,both,300,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 15% IN WATER,50863,CDM,250,RC,J3490,HCPCS,0338-0023-03,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGIC MOUTHWASH REPACK (BMX 1:1:1),50863,CDM,250,RC,J3490,HCPCS,0603-0823-54,NDC,facility,both,2,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  50 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-484-11,NDC,facility,both,4,EA,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  5 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,60505-3275-0,NDC,facility,both,1,EA,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  40 MG ORAL TR12,50863,CDM,250,RC,J3490,HCPCS,59011-440-20,NDC,facility,both,2,EA,,218,152.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J2250,HCPCS,0409-0001-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-677-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPAGLIFLOZIN PROPANEDIOL  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,66993-456-30,NDC,facility,both,2,EA,,217,151.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NABUMETONE 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50228-465-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DONEPEZIL  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,43547-275-03,NDC,facility,both,2,EA,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,250,RC,J3490,HCPCS,0409-4277-02,NDC,facility,both,200,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HUMAN PROTHROMBIN COMPLEX 500 UNIT IV SOLR,50863,CDM,250,RC,J7168,HCPCS,63833-386-02,NDC,facility,both,500,UN,,2910,2037,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL IV BOLUS 10MG/ML (ANESTHESIA ONLY),50863,CDM,636,RC,J2704,HCPCS,0409-4699-54,NDC,facility,both,84,ML,,107,74.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-02,NDC,facility,both,4,ML,,204,142.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VORICONAZOLE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6596-04,NDC,facility,both,2,EA,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROMETHORPHAN-GUAIFENESIN SR 30 MG-600 MG 12 HR TAB,50863,CDM,250,RC,J3490,HCPCS,6382405620,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-444-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,250,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,636,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,4,EA,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRIL MALEATE  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51672-4037-1,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE IN 0.9% NS (PF) 1 MG/10 ML (100 MCG/ML) IV SYRG(PDS MERGE),50863,CDM,250,RC,J3490,HCPCS,71266-9011-1,NDC,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRIL MALEATE 1 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,69238-1729-7,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-31,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCERIN 99.5 % TOP SOLN,50863,CDM,250,RC,J3490,HCPCS,0395-1031-96,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,15,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV,50863,CDM,250,RC,J7120,HCPCS,0338-0117-04,NDC,facility,both,6,ML,,200,140,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,J3490,HCPCS,73013-2002-2,NDC,,,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7030,HCPCS,0338-0049-04,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATED 20 MG/ML IV SOLN,50863,CDM,250,RC,J0706,HCPCS,51754-0500-1,NDC,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-464-11,NDC,facility,both,1,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIVAROXABAN 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50458-578-10,NDC,facility,both,1,EA,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 2 MG/10 ML (200 MCG/ML) IN D5W VIAL-CVL/IR USE (REPACK),50863,CDM,636,RC,J2305,HCPCS,0338-1049-02,NDC,facility,both,10,ML,JZ,133,93.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ACYCLOVIR NEO/PEDS INFUSION (CDS FROM PREMIX),50863,CDM,250,RC,J0133,HCPCS,63323-325-10,NDC,facility,both,10,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESMOLOL  100 MG/10 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-652-10,NDC,facility,both,1,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-464-02,NDC,facility,both,1,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM  4.5 GRAM IV SOLR,50863,CDM,250,RC,J2543,HCPCS,0781-3114-91,NDC,facility,both,4,EA,PLAD,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
POTASSIUM PHOS IN 0.9 % NACL 15 MMOL/250 ML IVPB PREMIX,50863,CDM,250,RC,J3490,HCPCS,70004-841-40,NDC,facility,both,2,ML,,316,221.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,636,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,4,ML,GZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier GZ: Item or service expected to be denied as not reasonable and necessary
BUPROPION HCL 150 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,0904-7084-61,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DROPERIDOL 2.5 MG/ML INJ SOLN,50863,CDM,636,RC,J1790,HCPCS,0517-9702-25,NDC,facility,both,1,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,62332-599-01,NDC,facility,both,1,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GABAPENTIN 400 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,16714-663-01,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-087-02,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6743-61,NDC,facility,both,2,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,25021-674-20,NDC,facility,both,2,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE IN D5W 1 GRAM/100 ML IV PGBK,50863,CDM,250,RC,J3475,HCPCS,63323-108-00,NDC,facility,both,2,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARTIFICIAL TEAR(DXTRN-HPM-GLY) 0.1-0.3-0.2 % OPHT DROP,50863,CDM,250,RC,J3490,HCPCS,0065-0426-36,NDC,facility,both,1,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2310,HCPCS,36000-308-01,NDC,facility,both,1,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-04,NDC,facility,both,2,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-1283-03,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN   81 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,0904-6783-70,NDC,facility,both,4,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE IV CONCENTRATED INFUSION (1 MEQ/ML),50863,CDM,250,RC,J3490,HCPCS,0409-6625-02,NDC,facility,both,6,ML,,344,240.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-1638-32,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-497-11,NDC,facility,both,3,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,1,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN NEO/PEDS IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0456,HCPCS,63323-398-14,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,250,RC,J0132,HCPCS,55150-259-30,NDC,facility,both,180,ML,,3098,2168.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BETAMETHASONE ACET & SOD PHOS 6 MG/ML INJ SUSP,50863,CDM,250,RC,J0702,HCPCS,78206-118-01,NDC,facility,both,3,ML,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 50% IN WATER (MERGE RECORD),50863,CDM,250,RC,J7060,HCPCS,73702-104-65,NDC,facility,both,1,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 2 MG/ML IV SOLN,50863,CDM,250,RC,J9000,HCPCS,25021-207-51,NDC,facility,both,3,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE  25 MG ORAL CAP,50863,CDM,636,RC,J7515,HCPCS,0078-0240-61,NDC,facility,both,2,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMCICLOVIR 250 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,42291-415-30,NDC,facility,both,2,EA,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE  5 MG/ML INJ SOLN,50863,CDM,636,RC,J2765,HCPCS,0703-4502-01,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 100 MG/ML INJ SOLN,50863,CDM,250,RC,J2800,HCPCS,55150-223-10,NDC,facility,both,1,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,250,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIFEDIPINE 30 MG ORAL TO24,50863,CDM,250,RC,J3490,HCPCS,50268-597-11,NDC,facility,both,1,EA,PLAD,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
ROSUVASTATIN 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-709-11,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6949-61,NDC,facility,both,3,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-115-10,NDC,facility,both,1,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INCLISIRAN 284 MG/1.5 ML SUBQ SYRG,50863,CDM,636,RC,J1306,HCPCS,0078-1000-60,NDC,facility,both,284,ML,JZ,8970,6279,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0990-7984-13,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,1000,ML,,166,116.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,156,109.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MUPIROCIN 2 % TOP OINT,50863,CDM,636,RC,J3490,HCPCS,45802-112-22,NDC,facility,both,1,GM,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,2,EA,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-4799-05,NDC,facility,both,2,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE  5 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,31722-185-01,NDC,facility,both,5,EA,,150,105,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIFEDIPINE 90 MG ORAL TO24,50863,CDM,250,RC,J3490,HCPCS,50268-599-11,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPHENIDATE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-805-11,NDC,facility,both,2,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLESTYRAMINE-ASPARTAME 4 GRAM ORAL PACK,50863,CDM,250,RC,J3490,HCPCS,42806-270-98,NDC,facility,both,2,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7728-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,22,EA,JW,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
SOTALOL 150 MG/10 ML (15 MG/ML) IV SOLN,50863,CDM,250,RC,C9482,HCPCS,69724-112-10,NDC,facility,both,150,ML,,3900,2730,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,636,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE SODIUM 25 MG/ML INJ SOLN,50863,CDM,636,RC,J9260,HCPCS,61703-350-37,NDC,facility,both,1,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,43066-997-01,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE 1 MG/ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,46287-035-15,NDC,facility,both,1,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETIRIZINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-597-20,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR PHOSPHATE 30 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,47781-468-13,NDC,facility,both,1,EA,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 2 MG/ML IV SOLN,50863,CDM,250,RC,J9000,HCPCS,25021-207-51,NDC,facility,both,2,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 12.5 MG ORAL TAB,50863,CDM,250,RC,Q0169,HCPCS,60687-660-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  500 MCG/ML INJ SOLN,50863,CDM,636,RC,J2354,HCPCS,68462-897-01,NDC,facility,both,20,ML,"JZ,JA",214,149.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
SEVELAMER CARBONATE 800 MG ORAL TAB,50863,CDM,250,RC,J0601,HCPCS,50268-720-11,NDC,facility,both,200,EA,,218,152.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,16714-293-03,NDC,facility,both,11,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 10 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0054-0622-63,NDC,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-1283-03,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,25021-315-01,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL (5 MG/ML) IV SYRG (CONTAINS PRESERVATIVE),50863,CDM,250,RC,J3490,HCPCS,70092-1009-44,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYTOCIN 10 UNIT/ML INJ SOLN,50863,CDM,250,RC,J2590,HCPCS,42023-116-25,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,50863,CDM,250,RC,J9000,HCPCS,0069-1542-20,NDC,facility,both,2,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J2310,HCPCS,36000-308-01,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  500 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,0641-6176-01,NDC,facility,both,20,ML,"JZ,JA",206,144.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
OLANZAPINE  5 MG ORAL TBDL,50863,CDM,636,RC,J3490,HCPCS,60505-3275-0,NDC,facility,both,1,EA,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0548-5604-00,NDC,facility,both,7,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,250,RC,J3490,HCPCS,0143-9679-01,NDC,facility,both,1,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC IV INFUSION HYDRAT 31-60 MIN,50863,CDM,250,RC,J0248,HCPCS,61958-2901-2,NDC,facility,both,52,EA,,613,429.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELATACEPT 250 MG IV SOLR,50863,CDM,636,RC,J0485,HCPCS,0003-0371-13,NDC,facility,both,25,EA,JW,113,79.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,8,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETHAMBUTOL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68180-280-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) MISC SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-694-41,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN  325 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,0536-1232-01,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,0641-6008-01,NDC,facility,both,2,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/0.5 ML INHL NEBU,50863,CDM,J3490,HCPCS,0487-9901-30,NDC,,,facility,both,4,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,55150-162-05,NDC,,,facility,both,100,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,8,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN V POTASSIUM 250 MG ORAL TAB,50863,CDM,J3490,HCPCS,57237-040-01,NDC,,,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1MG/ML ORAL SOLUTION (HIGH CONC FOR PEDS),50863,CDM,250,RC,J3490,HCPCS,16714-342-03,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENTACAPONE 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,27241-049-10,NDC,facility,both,1,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-6007-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-6102-10,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0245-0147-89,NDC,facility,both,2,EA,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SYRG,50863,CDM,636,RC,J3490,HCPCS,8290306504,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM BICARB-CITRIC ACID 20 MEQ ORAL TBEF,50863,CDM,250,RC,J3490,HCPCS,51801-011-01,NDC,facility,both,3,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-9558-05,NDC,facility,both,2,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,23155-248-01,NDC,facility,both,2,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID (PORK) 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0456-0457-01,NDC,facility,both,3,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 5 MG ORAL CAP,50863,CDM,250,RC,J7507,HCPCS,0904-6624-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0248-01,NDC,facility,both,100,ML,,127,88.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-347-11,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATOMOXETINE  10 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,68462-265-30,NDC,facility,both,4,EA,,242,169.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE  10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,69367-388-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 2 MG/10 ML (200 MCG/ML) IN D5W VIAL-CVL/IR USE (REPACK),50863,CDM,J3490,HCPCS,0338-1049-02,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7364-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,1500,ML,,166,116.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIRMATRELVIR-RITONAVIR 300-100 MG ORAL TAB DOSEPACK (FOR ED/IP TAKE HOME PANEL),50863,CDM,636,RC,J3490,HCPCS,0069-5321-30,NDC,facility,both,30,EA,,4130,2891,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,J1596,HCPCS,0143-9679-01,NDC,,,facility,both,2,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0143-9889-15,NDC,facility,both,22,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68094-005-59,NDC,facility,both,3,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,25021-463-01,NDC,facility,both,2,ML,JB,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JB: Administered subcutaneously
AZTREONAM 2 GRAM INJ SOLR,50863,CDM,250,RC,J0457,HCPCS,63323-402-01,NDC,facility,both,20,EA,JZ,292,204.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
AMOXICILLIN 400 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0143-9887-01,NDC,facility,both,7,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,38,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,0338-0069-10,NDC,facility,both,2,ML,JZ,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
BACITRACIN 500 UNITS/1 GRAM PACKET (MERGE RECORD),50863,CDM,636,RC,J3490,HCPCS,57896-145-09,NDC,facility,both,5,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-645-11,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 5 MG/ML IV SOLN,50863,CDM,250,RC,J1921,HCPCS,17478-420-20,NDC,facility,both,1,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 200 MG ORAL TAB,50863,CDM,J3490,HCPCS,63739-051-10,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HUMAN PROTHROMBIN COMPLEX 500 UNIT IV SOLR,50863,CDM,J7168,HCPCS,63833-396-01,NDC,,,facility,both,2000,UN,,11638,8146.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0137,HCPCS,0264-4100-90,NDC,facility,both,23,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,15,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,250,RC,J0132,HCPCS,66220-207-30,NDC,facility,both,180,ML,,457,319.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LECANEMAB-IRMB 100 MG/ML IV SOLN,50863,CDM,636,RC,J0174,HCPCS,62856-215-01,NDC,facility,both,140,ML,"JW,Q0",179,125.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient | Modifier Q0: Investigational clinical service provided in a clinical research study that is in an approved clinical research study
OMEPRAZOLE-SODIUM BICARBONATE 2-84 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,65628-270-03,NDC,facility,both,10,ML,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,200,EA,,490,343,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-433-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPHENIDATE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-805-11,NDC,facility,both,6,EA,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN   81 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,63739-212-02,NDC,facility,both,5,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,16714-293-01,NDC,facility,both,5,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IV PGBK,50863,CDM,250,RC,J3490,HCPCS,63323-106-00,NDC,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ROTAVIRUS VACCINE LIVE, PENTA 2 ML ORAL SUSP",50863,CDM,90680,HCPCS,0006-4047-02,NDC,,,facility,both,1,ML,,427,298.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 2 %-1:200,000 INJ SOLN",50863,CDM,J2004,HCPCS,63323-489-27,NDC,,,facility,both,400,ML,,121,84.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORDIAZEPOXIDE 25 MG CAP,50863,CDM,J3490,HCPCS,51079-141-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MULTIVITAMIN W/IRON ORAL DROP 1 ML (PEDS/NEO),50863,CDM,J3490,HCPCS,17856-0039-04,NDC,,,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL,50863,CDM,J3490,HCPCS,63323-820-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,50863,CDM,J3490,HCPCS,60687-591-11,NDC,,,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN IN D5W 900 MG/50 ML IV PGBK,50863,CDM,J0736,HCPCS,0781-3290-91,NDC,,,facility,both,3,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,J1938,HCPCS,23155-473-32,NDC,,,facility,both,40,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VARICELLA-ZOSTER GE-AS01B (PF) 50 MCG/0.5 ML IM SUSR,50863,CDM,90750,HCPCS,58160-819-12,NDC,,,facility,both,1,EA,,655,458.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,50863,CDM,250,RC,J9045,HCPCS,61703-339-56,NDC,facility,both,12,ML,,301,210.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,50863,CDM,J1885,HCPCS,72266-119-01,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLNALTREXONE 12 MG/0.6 ML SUBQ SOLN,50863,CDM,636,RC,J2212,HCPCS,65649-551-02,NDC,facility,both,1,ML,,735,514.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MINERAL OIL,50863,CDM,250,RC,J3490,HCPCS,6332325402,NDC,facility,both,2,ML,,155,108.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX (PF) 10 MCG IM,50863,CDM,90648,HCPCS,49281-547-58,NDC,,,facility,both,1,EA,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 10 GRAM/15 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,0116-4005-30,NDC,facility,both,2,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,J2704,HCPCS,0069-0209-01,NDC,,,facility,both,41,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,45049660,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAPTOPRIL 1 MG/ML SOLUTION (REPACK),50863,CDM,250,RC,J3490,HCPCS,0143-1171-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 175 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42292-040-01,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7244-68,NDC,facility,both,6,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE  10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-419-11,NDC,facility,both,1,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,50863,CDM,636,RC,J2359,HCPCS,55150-308-01,NDC,facility,both,15,EA,JW,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GENTAMICIN (PF) NEO IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J1580,HCPCS,63323-513-02,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG IV SOLR,50863,CDM,J0456,HCPCS,70860-100-41,NDC,,,facility,both,1,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6475-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM NEO/PEDS INFUSION (CDS MIXTURE),50863,CDM,250,RC,J2543,HCPCS,0206-8852-08,NDC,facility,both,2,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,59651-488-01,NDC,facility,both,40,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  750 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7125-61,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,4,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,J2003,HCPCS,0409-1323-15,NDC,,,facility,both,300,ML,,132,92.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,J3490,HCPCS,68180-150-01,NDC,,,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,7,EA,,244,170.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATED 20 MG/ML IV SOLN,50863,CDM,250,RC,J0706,HCPCS,51754-0500-1,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-03,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,63739-931-28,NDC,facility,both,8,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6638-61,NDC,facility,both,4,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,23155-600-31,NDC,facility,both,2,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0121-0914-05,NDC,facility,both,5,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE INFUSION 2MG/ML 100ML (FOR ANESTHESIA USE ONLY),50863,CDM,636,RC,J3490,HCPCS,0409-2051-05,NDC,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TALQUETAMAB-TGVS  2 MG/ML SUBQ SOLN,50863,CDM,250,RC,J3055,HCPCS,57894-469-01,NDC,facility,both,12,ML,,2145,1501.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0121-1781-05,NDC,facility,both,2,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"CIPROFLOXACIN-HYDROCORTISONE 0.2 %-1 % EAR DROPS, SUSP",50863,CDM,250,RC,J3490,HCPCS,66758-087-70,NDC,facility,both,1,ML,,1291,903.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-48,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE (POLACRILEX) 2 MG BUCL GUM,50863,CDM,636,RC,J3490,HCPCS,1093969133,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,51754-5001-1,NDC,facility,both,8,ML,,411,287.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYMETAZOLINE 0.05 % NASAL MERGE,50863,CDM,250,RC,J3490,HCPCS,4110081121,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,63323-280-03,NDC,facility,both,60,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL (VITAMIN D3)   400 UNIT ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,5026886311,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACIDOPHILUS-PECTIN W CITRUS 25 MILLION-100 CELL MG TAB,50863,CDM,250,RC,J3490,HCPCS,8068102600,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
23.4% SODIUM CHLORIDE (4 MEQ/ML) INJECTION,50863,CDM,250,RC,J3490,HCPCS,63323-095-02,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IVPB (PEDIATRICS/ADULT NON-FORM)",50863,CDM,636,RC,J0131,HCPCS,24201-100-01,NDC,facility,both,98,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,600,ML,JZ,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CEFTAROLINE FOSAMIL 400 MG IV SOLR,50863,CDM,250,RC,J0712,HCPCS,0456-0400-01,NDC,facility,both,40,EA,,869,608.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,50863,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,94,ML,,113,79.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RASBURICASE 1.5 MG IV SOLR,50863,CDM,250,RC,J2783,HCPCS,0024-5154-11,NDC,facility,both,2,EA,,1344,940.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"TRANEXAMIC ACID IN NACL,ISO-OS 1,000 MG/100 ML (10 MG/ML) IV PGBK",50863,CDM,636,RC,J3490,HCPCS,14789-115-08,NDC,facility,both,1,ML,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE-VITAMIN D3 250 MG-125 UNIT TAB,50863,CDM,636,RC,J3490,HCPCS,2055502500,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-454-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,150,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOSTIGMINE 1MG/ML (UD) OR SYRINGE,50863,CDM,636,RC,J2710,HCPCS,63323-383-10,NDC,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,14789-251-09,NDC,facility,both,2,ML,,441,308.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISANKIZUMAB-RZAA  60 MG/ML IV SOLN,50863,CDM,636,RC,J2327,HCPCS,0074-5015-01,NDC,facility,both,600,ML,,29345,20541.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,42858-301-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES-DOCUSATE SODIUM 8.6 MG-50 MG TAB,50863,CDM,636,RC,J3490,HCPCS,60687-622-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),50863,CDM,250,RC,J2060,HCPCS,0641-6044-01,NDC,facility,both,2,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 50 MG/10 ML (5 MG/ML) IV SOLN,50863,CDM,250,RC,J2305,HCPCS,0517-4810-25,NDC,facility,both,10,ML,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-1162-02,NDC,facility,both,1,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,636,RC,J2003,HCPCS,0409-4277-02,NDC,facility,both,400,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-145-10,NDC,facility,both,4,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXAZOSIN 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-5522-61,NDC,facility,both,3,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,55150-177-05,NDC,facility,both,20,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
MICAFUNGIN 100 MG IV SOLR,50863,CDM,250,RC,J2248,HCPCS,42023-230-01,NDC,facility,both,13,EA,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM ZIRCONIUM CYCLOSILICATE  5 G ORAL PWPK (USE PANEL),50863,CDM,250,RC,J3490,HCPCS,0310-1105-01,NDC,facility,both,1,EA,,169,118.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,50863,CDM,250,RC,J0561,HCPCS,60793-701-02,NDC,facility,both,24,ML,JZ,2613,1829.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,68462-469-40,NDC,facility,both,5,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 4 MEQ/ML IV SOLP (COMPOUNDED 30ML),50863,CDM,250,RC,J3490,HCPCS,63323-093-01,NDC,facility,both,2,ML,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,250,RC,J7060,HCPCS,0338-0017-03,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7030,HCPCS,0338-0049-04,NDC,facility,both,1,ML,PLAD,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
PROMETHAZINE 25 MG ORAL TAB,50863,CDM,636,RC,Q0169,HCPCS,0904-7304-61,NDC,facility,both,8,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE MONONITRATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,5026885111,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ELECTROLYTE-A IV,50863,CDM,636,RC,J3490,HCPCS,0338-0221-04,NDC,facility,both,1,ML,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 125 MG/5 ML (25MG/ML) ORAL SYRINGE (REPACK),50863,CDM,636,RC,J3370,HCPCS,67457-340-00,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 5 MG/ML IV SOLN,50863,CDM,636,RC,J7525,HCPCS,0469-3016-01,NDC,facility,both,1,ML,,903,632.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7243-61,NDC,facility,both,22,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOMYCIN-BACITRACIN ZN-POLYMYXIN 3.5 MG-400 UN*,50863,CDM,636,RC,J3490,HCPCS,51672-2016-2,NDC,facility,both,1,GM,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 10 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,55150-305-01,NDC,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE SODIUM 25 MG/ML INJ SOLN,50863,CDM,636,RC,J9260,HCPCS,16729-277-30,NDC,facility,both,2,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB 100 MG IV SOLR,50863,CDM,J1745,HCPCS,57894-160-01,NDC,,,facility,both,66,EA,,8653,6057.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0143-9506-01,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,636,RC,J2003,HCPCS,0409-1323-15,NDC,facility,both,300,ML,,132,92.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZOCAINE 20 % MM SPRY,50863,CDM,J3490,HCPCS,0283-0610-43,NDC,,,facility,both,1,EA,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,64,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE SODIUM 2.5 MG ORAL TAB,50863,CDM,636,RC,J8610,HCPCS,50268-527-11,NDC,facility,both,8,EA,,140,98,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLN (MERGE)",50863,CDM,636,RC,P9047,HCPCS,64208-2512-7,NDC,facility,both,2,ML,JZ,238,166.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,J3101,HCPCS,50242-037-06,NDC,,,facility,both,40,EA,,7966,5576.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,50863,CDM,J9263,HCPCS,60505-6132-7,NDC,,,facility,both,400,ML,,864,604.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 50 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,59651-489-01,NDC,facility,both,100,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,250,RC,J7060,HCPCS,0338-0017-02,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 1000 MG MISC TBSO,50863,CDM,250,RC,J3490,HCPCS,1013578301,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN ASP PRT-INSULIN ASPART 100 UNIT/ML (70-30) SUBQ SOLN,50863,CDM,636,RC,J1817,HCPCS,73070-200-11,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0054-0017-20,NDC,facility,both,250,EA,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 160 MG-800 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0904-2725-61,NDC,facility,both,13,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PSEUDOEPHEDRINE 30 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6337-24,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MANNITOL 25 % IV SOLN,50863,CDM,250,RC,J2150,HCPCS,63323-024-01,NDC,facility,both,3,ML,,121,84.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 16 MG ORAL TAB,50863,CDM,636,RC,J7509,HCPCS,68382-918-18,NDC,facility,both,10,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLIPIZIDE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-362-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,250,RC,J2003,HCPCS,63323-208-01,NDC,facility,both,200,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEPROTUMUMAB-TRBW 500 MG IV SOLR,50863,CDM,636,RC,J3241,HCPCS,75987-130-15,NDC,facility,both,26,EA,JW,8343,5840.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
SODIUM CHLORIDE 0.9% IV (PEDS) BOLUS,50863,CDM,636,RC,J7040,HCPCS,0264-7800-09,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-1660-50,NDC,facility,both,1,ML,,163,114.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LINEZOLID 600 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,67877-419-33,NDC,facility,both,6,EA,,2535,1774.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7728-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-50,NDC,facility,both,41,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,636,RC,J3490,HCPCS,61553-320-70,NDC,facility,both,6,ML,,400,280,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN DEXTROSE (ISO-OSMOTIC) 1 GRAM/50 ML IV PIGGY BACK,50863,CDM,250,RC,J0689,HCPCS,0338-3503-41,NDC,facility,both,2,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 250 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,0904-6860-61,NDC,facility,both,1,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE 0.25 MG/2 ML INHL NBSP,50863,CDM,250,RC,J3490,HCPCS,0093-6815-45,NDC,facility,both,10,ML,,400,280,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,50863,CDM,J3490,HCPCS,60687-591-11,NDC,,,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0630,HCPCS,63323-865-02,NDC,facility,both,2,ML,,3809,2666.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN NPH & REGULAR HUMAN 100 UNIT/ML (70-30) SUBQ SUSP,50863,CDM,250,RC,J1815,HCPCS,0169-1837-11,NDC,facility,both,9,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-492-27,NDC,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXRAZOXANE 500 MG IV SOLR,50863,CDM,636,RC,J1190,HCPCS,55150-435-01,NDC,facility,both,3,EA,,1790,1253,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,4,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 25 MG TAB,50863,CDM,250,RC,J3490,HCPCS,62584-265-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-1752-50,NDC,facility,both,1,ML,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALUM-MAG HYDROXIDE-SIMETH 200 MG-200 MG-20 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,63739-159-77,NDC,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7411-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,63323-578-03,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CONJUGATED ESTROGENS 0.625 MG/G VAGL CREA,50863,CDM,250,RC,J3490,HCPCS,0046-0872-21,NDC,facility,both,1,GM,,1272,890.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  500 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,0641-6176-01,NDC,facility,both,40,ML,JA,411,287.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1815,HCPCS,0002-8215-01,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 3000 MCG/ML INJECTION,50863,CDM,250,RC,J0153,HCPCS,25021-318-02,NDC,facility,both,6,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,68180-150-01,NDC,facility,both,3,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6500-61,NDC,facility,both,2,EA,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  20 MEQ ORAL PACK,50863,CDM,250,RC,J3490,HCPCS,72888-024-06,NDC,facility,both,6,EA,,274,191.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,250,RC,J7999,HCPCS,70092-1017-46,NDC,facility,both,2,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 10 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-369-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FERROUS SULFATE 75 MG/ML (ELEMENTAL IRON 15 MG/ML) ORAL DROP,50863,CDM,250,RC,J3490,HCPCS,536134480,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  5 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-122-11,NDC,facility,both,121,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN  100 MCG ORAL TAB,50863,CDM,J3490,HCPCS,5026885211,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,155,108.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,50863,CDM,J3490,HCPCS,0378-7732-93,NDC,,,facility,both,1,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0143-9889-15,NDC,facility,both,16,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2003,HCPCS,0409-2066-05,NDC,,,facility,both,100,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NAFCILLIN  2 GRAM INJ SOLR,50863,CDM,250,RC,J3490,HCPCS,55150-123-15,NDC,facility,both,1,EA,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE CONCENTRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0054-0404-44,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 125 MG/5 ML (25MG/ML) ORAL SYRINGE (REPACK),50863,CDM,250,RC,J3373,HCPCS,67457-340-00,NDC,facility,both,13,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,68094-231-59,NDC,facility,both,3,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN IN D5W 600 MG/50 ML IV PGBK,50863,CDM,J0736,HCPCS,0338-3612-50,NDC,,,facility,both,2,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,636,RC,J1815,HCPCS,0088-2220-33,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-234-11,NDC,facility,both,2,EA,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IR SOLN,50863,CDM,250,RC,J3490,HCPCS,0338-0048-03,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZTREONAM 20 MG/ML IV SYRINGE (FOR NEO/PEDS),50863,CDM,250,RC,J3490,HCPCS,63323-401-20,NDC,facility,both,5,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMOSOZUMAB-AQQG 105 MG/1.17 ML SUBQ SYRG,50863,CDM,636,RC,J3111,HCPCS,55513-998-01,NDC,facility,both,105,ML,JZ,2675,1872.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IBUPROFEN 600 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,59651-361-01,NDC,facility,both,12,EA,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IVPB (PEDIATRICS/ADULT NON-FORM)",50863,CDM,636,RC,J0137,HCPCS,24201-100-01,NDC,facility,both,100,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYBUTYNIN CHLORIDE  5 MG ORAL TO24,50863,CDM,250,RC,J3490,HCPCS,68084-480-11,NDC,facility,both,4,EA,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0131-2477-60,NDC,facility,both,1,EA,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZTREONAM 2 GRAM INJ SOLR,50863,CDM,250,RC,J0457,HCPCS,63323-402-01,NDC,facility,both,20,EA,,292,204.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-097-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"HIB CONJ-TET,COMPNT 2 OF 2(PF) 10 MCG/0.5 ML IM SOLR",50863,CDM,90698,HCPCS,49281-544-58,NDC,,,facility,both,1,EA,,516,361.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 10 MG/50 ML (0.2MG/ML) PCA IN NS (MERGE),50863,CDM,250,RC,J1171,HCPCS,61553-830-41,NDC,facility,both,100,ML,,138,96.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2310,HCPCS,36000-308-01,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,2,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  20 MEQ ORAL PACK,50863,CDM,250,RC,J3490,HCPCS,72888-024-06,NDC,facility,both,2,EA,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-074-11,NDC,facility,both,6,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,2,EA,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELIMUMAB 120 MG IV SOLR,50863,CDM,636,RC,J0490,HCPCS,49401-101-01,NDC,facility,both,60,ME,JZ,7047,4932.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
NITROFURANTOIN (25% MACROCRYSTAL FORM) 100 MG CAP,50863,CDM,J3490,HCPCS,60687-633-11,NDC,,,facility,both,1,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25 MG-100 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7257-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IV PGBK,50863,CDM,250,RC,J3475,HCPCS,63323-106-02,NDC,facility,both,4,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,154,107.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IVABRADINE 7.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50742-363-60,NDC,facility,both,1,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN PEDS SYRINGE (20MG/ML) IN DEXTROSE (CDS MIX,50863,CDM,636,RC,J0690,HCPCS,0781-3451-70,NDC,facility,both,2,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63304-773-01,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  20 MG ORAL TR12,50863,CDM,636,RC,J3490,HCPCS,59011-420-20,NDC,facility,both,8,EA,,375,262.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOLIC ACID 1 MG / 0.2 ML SYRINGE (CDS ADS REPACK),50863,CDM,250,RC,J3490,HCPCS,63323-184-10,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,J3490,HCPCS,0121-1022-05,NDC,,,facility,both,2,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,250,RC,J0330,HCPCS,0409-6629-02,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 2 %-1:200,000 INJ SOLN",50863,CDM,J2004,HCPCS,63323-489-01,NDC,,,facility,both,200,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,62332-600-01,NDC,facility,both,1,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IV PGBK,50863,CDM,250,RC,J3475,HCPCS,47335-992-01,NDC,facility,both,4,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,50863,CDM,636,RC,J3490,HCPCS,57237-077-10,NDC,facility,both,6,EA,,482,337.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOBAZAM 2.5 MG/ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,99999-0404-03,NDC,facility,both,4,ML,,189,132.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-4713-75,NDC,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,45,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,50863,CDM,250,RC,J1885,HCPCS,72266-119-01,NDC,facility,both,2,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
VANCOMYCIN  125 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,62559-390-50,NDC,facility,both,2,EA,,266,186.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,50863,CDM,636,RC,J3490,HCPCS,68462-157-40,NDC,facility,both,1,EA,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 2.5 GRAM/25 ML (10 %) INJ SOLN",50863,CDM,250,RC,J1561,HCPCS,13533-800-16,NDC,facility,both,10,ML,,1815,1270.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0093-3426-01,NDC,facility,both,4,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,50863,CDM,J0696,HCPCS,0143-9856-01,NDC,,,facility,both,8,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0630,HCPCS,42023-205-01,NDC,facility,both,1,ML,JZ,5488,3841.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,J1644,HCPCS,72603-179-01,NDC,,,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,J3490,HCPCS,68180-150-01,NDC,,,facility,both,3,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPYLTHIOURACIL 50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-964-95,NDC,facility,both,2,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,J2704,HCPCS,0069-0209-01,NDC,,,facility,both,19,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IR SOLN,50863,CDM,250,RC,J3490,HCPCS,0338-0047-46,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLN,50863,CDM,636,RC,J3262,HCPCS,50242-135-01,NDC,facility,both,800,ML,,14661,10262.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,250,RC,J3360,HCPCS,0641-6244-01,NDC,facility,both,14,ML,,1011,707.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,100,ML,JG,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount
DEXTROSE 5% IN WATER (D5W) IV MBP,50863,CDM,250,RC,J7060,HCPCS,0338-0551-11,NDC,facility,both,1,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL (VITAMIN D3)  1000 UNIT ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,2055503300,NDC,facility,both,8,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN PEDS SYRINGE (20MG/ML) IN DEXTROSE (CDS MIX,50863,CDM,636,RC,J7999,HCPCS,0781-3451-70,NDC,facility,both,1,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/0.5 ML INHL NEBU,50863,CDM,636,RC,J3490,HCPCS,0487-9901-02,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE CONCENTRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0054-0404-44,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25 MG-100 MG TAB,50863,CDM,636,RC,J3490,HCPCS,69367-339-05,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,50863,CDM,250,RC,J9000,HCPCS,0069-1542-20,NDC,facility,both,3,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,50863,CDM,636,RC,J9075,HCPCS,10019-956-16,NDC,facility,both,200,EA,,1296,907.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTOBARBITAL 75 MG/1.5 ML SYRINGE (REPACK),50863,CDM,636,RC,J3490,HCPCS,25021-676-20,NDC,facility,both,1,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,6,EA,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN 100 MG/4 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,66689-036-01,NDC,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE 1 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,46287-035-15,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE 1 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,46287-035-15,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-1159-19,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLESTYRAMINE 4 G ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,49884-466-63,NDC,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-04,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM  3.375 GRAM IV SOLR,50863,CDM,636,RC,J2543,HCPCS,65219-436-02,NDC,facility,both,3,EA,JZ,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SOTALOL  80 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,76385-114-01,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7109-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML IV,50863,CDM,250,RC,J3490,HCPCS,70860-301-41,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACCHAROMYCES BOULARDII 250 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,7733380050,NDC,facility,both,3,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE (DIAGNOSTIC) 3 MG/ML IV SOLN,50863,CDM,250,RC,J0153,HCPCS,16714-997-01,NDC,facility,both,90,ML,JZ,735,514.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,63739-931-28,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 100 MG PE/2 ML INJ SOLN,50863,CDM,250,RC,Q2009,HCPCS,63323-403-01,NDC,facility,both,7,ML,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MECLIZINE 25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-491-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),50863,CDM,250,RC,J0171,HCPCS,76329-3318-1,NDC,facility,both,50,ML,,367,256.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5% W/EPINEPHRINE 1:200K INJECTION,50863,CDM,250,RC,J3490,HCPCS,0409-1749-29,NDC,facility,both,1,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,45963-555-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE (POLACRILEX) 2 MG BUCL GUM,50863,CDM,250,RC,J3490,HCPCS,70677-1166-2,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROATE SODIUM 100 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0143-9785-01,NDC,facility,both,3,ML,,305,213.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEXILETINE 150 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,50742-239-01,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0003-0894-31,NDC,facility,both,1,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACUBITRIL-VALSARTAN 49-51 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0078-0777-61,NDC,facility,both,1,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,50863,CDM,250,RC,J0640,HCPCS,25021-814-30,NDC,facility,both,1,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 500 MG/5 ML ORAL SUMC,50863,CDM,250,RC,J3490,HCPCS,50419-773-01,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6426-61,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOBENZAPRINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-558-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1940,HCPCS,0409-6102-02,NDC,facility,both,18,ML,,501,350.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VECURONIUM BROMIDE 10 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,55150-235-01,NDC,facility,both,1,EA,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELATACEPT 250 MG IV SOLR,50863,CDM,636,RC,J0485,HCPCS,0003-0371-13,NDC,facility,both,350,EA,,3612,2528.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE 180 MCG/INHALATION INHL AEPB,50863,CDM,250,RC,J3490,HCPCS,61269-518-12,NDC,facility,both,1,EA,,937,655.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,636,RC,J3490,HCPCS,0338-1055-48,NDC,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"AMIODARONE IN DEXTROSE,ISO-OSM 360 MG/200 ML (1.8 MG/ML) IV SOLN",50863,CDM,250,RC,J0282,HCPCS,43066-360-20,NDC,facility,both,11,ML,,197,137.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LINACLOTIDE 145 MCG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0456-1201-30,NDC,facility,both,2,EA,,212,148.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZIPRASIDONE 20 MG IM,50863,CDM,250,RC,J3486,HCPCS,72205-205-01,NDC,facility,both,2,EA,JZ,192,134.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
BUSPIRONE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-985-01,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZOXIDE (DIABETIC USE) 50 MG/ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0254-1010-19,NDC,facility,both,1,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG/24 HR TD PTWK,50863,CDM,250,RC,J3490,HCPCS,0378-0871-16,NDC,facility,both,1,EA,,162,113.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,63323-161-00,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATED 20 MG/ML IV SOLN,50863,CDM,250,RC,J0706,HCPCS,51754-0500-1,NDC,facility,both,12,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7366-04,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OMEPRAZOLE 10 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,68462-395-30,NDC,facility,both,4,EA,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IV PGBK,50863,CDM,250,RC,J3475,HCPCS,0338-1715-40,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN DEGLUDEC 100 UNITS/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,73070-400-11,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN LOCK FLUSH (PORCINE)  10 UNIT/ML IV SOLN,50863,CDM,250,RC,J1642,HCPCS,63323-544-01,NDC,facility,both,2,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,44206-310-50,NDC,facility,both,2,ML,,418,292.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE (PF) 1 MG/ML INJ SOLN,50863,CDM,636,RC,J0169,HCPCS,54288-103-01,NDC,facility,both,40,ML,,343,240.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MANNITOL 25 % IV SOLN,50863,CDM,250,RC,J2151,HCPCS,63323-024-01,NDC,facility,both,200,ML,,161,112.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,19,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEPERIDINE (PF) 25 MG/ML IV SOLN (PHS MERGE),50863,CDM,250,RC,J2175,HCPCS,0409-1176-03,NDC,facility,both,1,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,43598-053-11,NDC,facility,both,28,ML,,1008,705.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),50863,CDM,250,RC,J1815,HCPCS,0024-5926-05,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),50863,CDM,250,RC,J0171,HCPCS,76329-3318-1,NDC,facility,both,80,ML,,587,410.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,250,RC,J1596,HCPCS,0143-9679-01,NDC,facility,both,4,ML,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VECURONIUM BROMIDE 10 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,0703-2914-01,NDC,facility,both,1,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 0.1MG/ML SUSPENSION (REPACK),50863,CDM,250,RC,J3490,HCPCS,51079-882-01,NDC,facility,both,30,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),50863,CDM,250,RC,J2060,HCPCS,0409-6780-02,NDC,facility,both,30,ML,,150,105,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 1 MG/ML PCA (PDS MERGE),50863,CDM,250,RC,J3490,HCPCS,70092-1521-74,NDC,facility,both,1,ML,,154,107.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7007-61,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 125 MG/5 ML (25MG/ML) ORAL SYRINGE (REPACK),50863,CDM,250,RC,J3370,HCPCS,67457-340-00,NDC,facility,both,2,EA,JZ,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,17,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,67877-545-68,NDC,facility,both,7,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0338-1055-48,NDC,facility,both,31,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CEFAZOLIN PEDS SYRINGE (20MG/ML) IN DEXTROSE (CDS MIX,50863,CDM,250,RC,J7999,HCPCS,0781-3451-70,NDC,facility,both,8,EA,,207,144.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,53,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0137,HCPCS,0264-4100-90,NDC,facility,both,100,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUVOXAMINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60505-0166-1,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,50863,CDM,250,RC,Q0177,HCPCS,63739-486-10,NDC,facility,both,4,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR  6 MG/ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0004-0822-05,NDC,facility,both,5,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NABUMETONE 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50228-465-01,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 1 GRAM/10 ML (10 %) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-12,NDC,facility,both,2,ML,,443,310.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-087-02,NDC,facility,both,10,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML IN NS (PREMIX),50863,CDM,250,RC,J2250,HCPCS,61553-290-53,NDC,facility,both,50,ML,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,J0133,HCPCS,55150-154-10,NDC,,,facility,both,106,ML,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK,50863,CDM,636,RC,J3490,HCPCS,12870-0001-1,NDC,facility,both,6,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,55150-161-02,NDC,,,facility,both,60,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0143-9889-15,NDC,facility,both,19,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-ABBS 10 MG/ML IV SOLN,50863,CDM,636,RC,Q5115,HCPCS,63459-103-10,NDC,facility,both,100,ML,JZ,23338,16336.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IV PGBK,50863,CDM,J3475,HCPCS,25021-612-81,NDC,,,facility,both,4,ML,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-495-27,NDC,,,facility,both,220,ML,,108,75.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"CALCIUM GLUC IN NACL, ISO-OSM 1 G/100 ML IV SOLN",50863,CDM,250,RC,J0612,HCPCS,44567-622-01,NDC,facility,both,200,ML,,149,104.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,636,RC,J1596,HCPCS,0143-9679-01,NDC,facility,both,5,ML,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42858-301-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,4,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,66479-583-05,NDC,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 7.5 MG-325 MG/15 ML ORAL SOLN (REPACK),50863,CDM,636,RC,J3490,HCPCS,0121-2316-15,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THROMBIN (RECOMBINANT) 5000 UNIT TOP SOLR,50863,CDM,250,RC,J3490,HCPCS,0338-0324-01,NDC,facility,both,2,EA,,3715200,2600640,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7177-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,83,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DENOSUMAB 60 MG/ML SUBQ SYRG,50863,CDM,J0897,HCPCS,55513-710-21,NDC,,,facility,both,60,ML,,5177,3623.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN V POTASSIUM 250 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,57237-040-01,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,636,RC,Q0162,HCPCS,16714-671-02,NDC,facility,both,3,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE SOD SUCC (PF) 100 MG/2 ML INJ SOLR,50863,CDM,J1720,HCPCS,0009-0011-03,NDC,,,facility,both,3,EA,,378,264.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,300,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-21,NDC,facility,both,40,ML,,5658,3960.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOXYBENZAMINE 10 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,66993-066-02,NDC,facility,both,4,EA,,1191,833.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 100 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,0904-3854-61,NDC,facility,both,3,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEMANTINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6505-06,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-18,NDC,facility,both,1,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE SR 37.5 MG 24 HR TAB,50863,CDM,636,RC,J3490,HCPCS,42858-707-03,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,76045-009-10,NDC,facility,both,12,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLPIDEM  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-189-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETIC ACID (VINEGAR) 5% IRRIGATION 12 ML (REPACK),50863,CDM,250,RC,J3490,HCPCS,5155200556,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,636,RC,J3490,HCPCS,0409-4887-17,NDC,facility,both,5,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,636,RC,J3490,HCPCS,59310-579-20,NDC,facility,both,1,GM,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,63739-931-28,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 10 MG/50 ML (0.2MG/ML) PCA IN NS (MERGE),50863,CDM,636,RC,J1171,HCPCS,61553-830-41,NDC,facility,both,200,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  75 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-441-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEPROTUMUMAB-TRBW 500 MG IV SOLR,50863,CDM,636,RC,J3241,HCPCS,75987-130-15,NDC,facility,both,73,EA,,51954,36367.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMETHICONE  80 MG ORAL CHEW,50863,CDM,636,RC,J3490,HCPCS,1093979444,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN   1.5 G IV SOLR,50863,CDM,J3370,HCPCS,0409-3515-11,NDC,,,facility,both,3,EA,,143,100.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,13,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE  6.25 MG/5 ML ORAL SYRP,50863,CDM,250,RC,Q0169,HCPCS,17856-0059-1,NDC,facility,both,2,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,36000-283-25,NDC,facility,both,120,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN SODIUM EXTENDED 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,58151-110-32,NDC,facility,both,2,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-48,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-633-11,NDC,facility,both,2,EA,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IMATINIB 100 MG ORAL TAB,50863,CDM,636,RC,J9999,HCPCS,42292-043-01,NDC,facility,both,2,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-229-02,NDC,facility,both,2,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-7124-61,NDC,,,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,16,ML,,108,75.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,J2003,HCPCS,63323-486-17,NDC,,,facility,both,200,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,25,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-03,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE  5 MG/ML INJ SOLN,50863,CDM,636,RC,J2765,HCPCS,23155-240-31,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,16,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,J3101,HCPCS,50242-037-06,NDC,,,facility,both,32,EA,,6373,4461.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1940,HCPCS,0409-6102-02,NDC,facility,both,9,ML,,251,175.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ (MERGE),50863,CDM,636,RC,J2250,HCPCS,0409-0001-01,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM SR 180 MG 24 HR CAP,50863,CDM,636,RC,J3490,HCPCS,60687-206-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,67457-423-00,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9% IV (PEDS) BOLUS,50863,CDM,250,RC,J7040,HCPCS,0264-7800-09,NDC,facility,both,4,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,50863,CDM,J3301,HCPCS,0003-0293-05,NDC,,,facility,both,4,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 400 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0143-9887-01,NDC,facility,both,11,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,25021-315-01,NDC,facility,both,18,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM  3 GRAM INJ SOLR,50863,CDM,636,RC,J0295,HCPCS,55150-117-20,NDC,facility,both,2,EA,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,6,ML,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,50863,CDM,250,RC,J9045,HCPCS,0703-4239-01,NDC,facility,both,12,ML,,337,235.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-492-27,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,50863,CDM,250,RC,J9075,HCPCS,10019-956-16,NDC,facility,both,19,EA,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTOBARBITAL 75 MG/1.5 ML SYRINGE (REPACK),50863,CDM,636,RC,J3490,HCPCS,25021-676-20,NDC,facility,both,2,ML,,157,109.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  50 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,72205-012-90,NDC,facility,both,4,EA,,165,115.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,63323-104-25,NDC,facility,both,13,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0054-3294-50,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,63323-482-05,NDC,,,facility,both,90,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,20,ML,JZ,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
BUPRENORPHINE-NALOXONE 2-0.5 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,50268-144-11,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 2 GRAM IV SOLUTION,50863,CDM,636,RC,J9075,HCPCS,0781-3255-94,NDC,facility,both,400,EA,JZ,3791,2653.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2599,HCPCS,43598-914-11,NDC,facility,both,20,ML,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 800 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,17856-921-01,NDC,facility,both,5,EA,,150,105,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN IN 0.9 % NS 40 UNIT/100 ML (0.4 UNIT/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0338-9647-12,NDC,facility,both,1,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GOLIMUMAB  12.5 MG/ML IV SOLN,50863,CDM,636,RC,J1602,HCPCS,57894-350-01,NDC,facility,both,37,ML,JW,1776,1243.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
SENNOSIDES 8.8 MG/5 ML ORAL SYRP,50863,CDM,250,RC,J3490,HCPCS,0536-1266-59,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,16714-662-01,NDC,facility,both,2,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,250,RC,J7060,HCPCS,0338-0017-38,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-492-16,NDC,,,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACIDOPHILUS-PECTIN W CITRUS 25 MILLION-100 CELL MG TAB,50863,CDM,250,RC,J3490,HCPCS,536142401,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 10 GRAM/100 ML (10%) INJ SOLN",50863,CDM,250,RC,J1561,HCPCS,13533-800-72,NDC,facility,both,20,ML,,2829,1980.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-587-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,78,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 600 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,62332-253-30,NDC,facility,both,2,EA,,183,128.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,250,RC,J3101,HCPCS,50242-037-06,NDC,facility,both,27,EA,JW,5377,3763.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,250,RC,J3101,HCPCS,50242-037-06,NDC,facility,both,18,EA,,7778,5444.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J3490,HCPCS,63323-623-61,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,81952-111-01,NDC,facility,both,5,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE (POLACRILEX) 2 MG MM LOZG,50863,CDM,250,RC,J3490,HCPCS,45802-344-03,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,58,ML,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ (REPACK)(MERGE) (FOR PCA),50863,CDM,250,RC,J3490,HCPCS,61553-0118-53,NDC,facility,both,1,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NORTRIPTYLINE 50 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,50268-605-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,77,ML,,111,77.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,300,ML,"JZ,PLAD",17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier PLAD: Modifier description not available
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,636,RC,J3490,HCPCS,63323-485-27,NDC,facility,both,80,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOMIPRAMINE 75 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,16571-685-03,NDC,facility,both,2,EA,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6797-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE IN 0.9% NS (PF) 1 MG/10 ML (100 MCG/ML) IV SYRG(PDS MERGE),50863,CDM,250,RC,J3490,HCPCS,70092-1046-46,NDC,facility,both,1,ML,,240,168,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,68180-150-01,NDC,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,23,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  500 MG IV SOLR,50863,CDM,250,RC,J3370,HCPCS,0143-9161-01,NDC,facility,both,3,EA,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,50863,CDM,J1885,HCPCS,72266-119-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIRMATRELVIR-RITONAVIR 300-100 MG ORAL TAB DOSEPACK (FOR ED/IP TAKE HOME PANEL),50863,CDM,636,RC,J3490,HCPCS,0069-5321-03,NDC,facility,both,30,EA,,4130,2891,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-04,NDC,facility,both,1,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,63323-400-01,NDC,facility,both,300,ML,JZ,164,114.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,4,EA,,140,98,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,0409-4887-17,NDC,facility,both,2,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2003,HCPCS,55150-165-05,NDC,,,facility,both,400,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON DEXTRAN 50 MG/ML INJ SOLN,50863,CDM,636,RC,J1750,HCPCS,0023-6082-01,NDC,facility,both,1,ML,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 250 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,17856-0600-1,NDC,facility,both,2,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J2004,HCPCS,63323-482-03,NDC,facility,both,200,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LANREOTIDE 120 MG/0.5 ML SUBQ SYRG,50863,CDM,636,RC,J1930,HCPCS,69097-870-67,NDC,facility,both,120,ML,,24544,17180.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2599,HCPCS,43598-914-25,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB 100 MG IV SOLR,50863,CDM,636,RC,J1745,HCPCS,57894-030-01,NDC,facility,both,47,EA,,15149,10604.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOBUTAMINE IN D5W 500 MG/250 ML (2 MG/ML) INFUSION (PREMIX),50863,CDM,250,RC,J1250,HCPCS,0338-1075-02,NDC,facility,both,1,ML,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESNA 100 MG/ML IV SOLN,50863,CDM,250,RC,J9209,HCPCS,10019-953-62,NDC,facility,both,6,ML,,166,116.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,220,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,42806-150-33,NDC,facility,both,5,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,65,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,68180-441-02,NDC,facility,both,8,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GOLIMUMAB  12.5 MG/ML IV SOLN,50863,CDM,636,RC,J1602,HCPCS,57894-350-01,NDC,facility,both,237,ML,,26155,18308.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,0409-3795-19,NDC,facility,both,1,ML,JW,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LABETALOL 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,71247-130-01,NDC,facility,both,3,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7366-04,NDC,facility,both,1,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-65,NDC,facility,both,14,ML,JW,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ELECTROLYTE-A IV,50863,CDM,250,RC,J3490,HCPCS,0338-0221-04,NDC,facility,both,3,ML,,294,205.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,250,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,63323-482-03,NDC,,,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERYTHROMYCIN 5 MG/G OPHT OINT,50863,CDM,J3490,HCPCS,72485-670-31,NDC,,,facility,both,1,GM,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFUROXIME AXETIL 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-400-02,NDC,facility,both,2,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,J3490,HCPCS,70004-600-09,NDC,,,facility,both,1,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSAPREPITANT 150 MG IV SOLR,50863,CDM,J1453,HCPCS,0006-3061-01,NDC,,,facility,both,150,EA,,1185,829.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,J3490,HCPCS,67457-433-00,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,J3490,HCPCS,44567-600-04,NDC,,,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MYCOPHENOLATE 180 MG TAB, DELAYED RELEASE",50863,CDM,250,RC,J7518,HCPCS,0904-6785-61,NDC,facility,both,2,EA,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,J3490,HCPCS,68180-441-02,NDC,,,facility,both,6,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,0641-6145-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,935,ME,JZ,12688,8881.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MELATONIN  3 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,5789686406,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE 10 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,70954-319-10,NDC,facility,both,1,ML,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,16714-661-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-398-11,NDC,facility,both,6,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,51079-169-01,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE 2 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,0904-7154-04,NDC,facility,both,3,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,72789-325-90,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE IV",50863,CDM,250,RC,J3490,HCPCS,0338-0013-04,NDC,facility,both,1,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV,50863,CDM,636,RC,J7120,HCPCS,0338-0117-03,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,636,RC,J2405,HCPCS,60505-6130-0,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % MUCOSAL GEL,50863,CDM,636,RC,J3490,HCPCS,17478-711-30,NDC,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE IN 0.9 % NACL 4 MG/250 ML (16 MCG/ML) IV SOLN (MERGE),50863,CDM,250,RC,J0171,HCPCS,70004-613-40,NDC,facility,both,2,ML,,411,287.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-31,NDC,facility,both,1,ML,,111,77.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6938-06,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0137,HCPCS,0143-9386-01,NDC,facility,both,44,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYBUTYNIN CHLORIDE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7027-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE  25 MG ORAL CAP,50863,CDM,636,RC,J7515,HCPCS,68084-879-95,NDC,facility,both,2,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMCICLOVIR 125 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,33342-024-07,NDC,facility,both,1,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  15 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,0406-8315-23,NDC,facility,both,6,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,6,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,J0665,HCPCS,0409-1162-18,NDC,,,facility,both,200,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROGESTERONE MICRONIZED 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,69452-233-20,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-4279-16,NDC,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL,50863,CDM,250,RC,J3490,HCPCS,63323-820-01,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-3243-01,NDC,facility,both,3,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOSTIGMINE 1MG/ML (UD) OR SYRINGE,50863,CDM,636,RC,J2710,HCPCS,76014-003-33,NDC,facility,both,1,ML,,142,99.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 1 MG ORAL CAP,50863,CDM,636,RC,J7507,HCPCS,51079-818-01,NDC,facility,both,3,EA,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DENOSUMAB 60 MG/ML SUBQ SYRG,50863,CDM,636,RC,J0897,HCPCS,55513-710-21,NDC,facility,both,60,ML,,4930,3451,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESNA 100 MG/ML IV SOLN,50863,CDM,250,RC,J9209,HCPCS,0338-1305-01,NDC,facility,both,3,ML,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLESTYRAMINE-SUCROSE 4 GRAM ORAL PACK,50863,CDM,250,RC,J3490,HCPCS,49884-465-64,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 120 MG/0.8 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0955-1012-01,NDC,facility,both,12,ML,JZ,151,105.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0137,HCPCS,0781-3156-06,NDC,facility,both,13,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7411-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMINOCAPROIC ACID  500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-739-95,NDC,facility,both,10,EA,,847,592.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPAFENONE 225 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,59651-257-01,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICARDIPINE 25 MG/10 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,72485-116-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMINOCAPROIC ACID 250 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0517-9120-01,NDC,facility,both,2,ML,,121,84.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML INJ SOLN,50863,CDM,636,RC,J2060,HCPCS,0409-1985-03,NDC,facility,both,2,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMINOPHYLLINE 500 MG/20 ML IV SOLN,50863,CDM,250,RC,J0280,HCPCS,0409-5922-01,NDC,facility,both,2,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,50863,CDM,250,RC,J0640,HCPCS,71288-161-20,NDC,facility,both,2,EA,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-279-11,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID (PORK)  60 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,42192-330-01,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-351-11,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6869-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLPIDEM  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-189-11,NDC,facility,both,3,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,250,RC,J2270,HCPCS,0409-1890-13,NDC,facility,both,1,ML,,126,88.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INDOMETHACIN 50 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,68462-302-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,80,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON DEXTRAN 50 MG/ML INJ SOLN,50863,CDM,636,RC,J1750,HCPCS,0023-6082-01,NDC,facility,both,20,ML,JZ,2188,1531.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6798-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BRIMONIDINE 0.2 % OPHT DROP,50863,CDM,636,RC,J3490,HCPCS,70069-231-01,NDC,facility,both,1,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,70069-363-01,NDC,facility,both,1,ML,,173,121.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,70069-363-01,NDC,facility,both,1,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,8,ML,,13006,9104.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTAMIDINE 300 MG INJ SOLR,50863,CDM,250,RC,J3490,HCPCS,23155-748-31,NDC,facility,both,1,EA,,293,205.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB 100 MG IV SOLR,50863,CDM,636,RC,J1745,HCPCS,57894-030-01,NDC,facility,both,1,EA,JW,141,98.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CEFAZOLIN IN DEXTROSE (ISO-OSMOTIC) 1 GRAM/50 ML IV PIGGY BACK,50863,CDM,250,RC,J0690,HCPCS,0338-3503-41,NDC,facility,both,2,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APREPITANT  40 MG ORAL CAP,50863,CDM,636,RC,J8501,HCPCS,0781-2321-06,NDC,facility,both,1,EA,,396,277.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZTROPINE 1 MG/ML INJ SOLN,50863,CDM,250,RC,J0515,HCPCS,68382-860-02,NDC,facility,both,2,ML,,250,175,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE (POLACRILEX) 4 MG MM LOZG,50863,CDM,250,RC,J3490,HCPCS,45802-873-03,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,50863,CDM,636,RC,J0585,HCPCS,0023-1145-01,NDC,facility,both,73,EA,JW,508,355.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
FLUCONAZOLE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6500-61,NDC,facility,both,1,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,636,RC,J1596,HCPCS,70700-165-22,NDC,facility,both,4,ML,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J0461,HCPCS,0517-0401-25,NDC,facility,both,80,ML,,107,74.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOBENZAPRINE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0591-5658-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  1 MG/ML INJ SYRG,50863,CDM,250,RC,J1171,HCPCS,0409-1283-10,NDC,facility,both,10,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOPIDOGREL  75 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6294-61,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 10 MG TAB,50863,CDM,250,RC,Q0177,HCPCS,60687-664-11,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,10,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML IV SOLN (MERGE),50863,CDM,636,RC,J3490,HCPCS,16714-037-10,NDC,facility,both,1,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3370,HCPCS,0143-9162-01,NDC,facility,both,20,EA,,399,279.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,0781-3246-02,NDC,facility,both,4,ML,JZ,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MAGNESIUM SULFATE 4 GRAM/100 ML (4 %) IV PGBK,50863,CDM,250,RC,J3475,HCPCS,0338-1715-40,NDC,facility,both,8,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,636,RC,J1610,HCPCS,63323-596-11,NDC,facility,both,1,EA,JZ,785,549.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,51754-5011-1,NDC,facility,both,1,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 100 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-0799-16,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIMENHYDRINATE 50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-2051-59,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,78,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 50 MG/10 ML (5 MG/ML) IV SOLN,50863,CDM,636,RC,J2305,HCPCS,0517-4810-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM 1 GRAM IV SOLR,50863,CDM,250,RC,J2185,HCPCS,63323-508-01,NDC,facility,both,80,EA,,314,219.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,70095-026-01,NDC,facility,both,1,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN 0.9% SODIUM CL 1.25 GRAM/250 ML IV SOLN,50863,CDM,636,RC,J3370,HCPCS,71266-5073-1,NDC,facility,both,3,ML,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENTECAVIR 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-5786-56,NDC,facility,both,1,EA,,218,152.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN D5W 20000 UNIT/500 ML,50863,CDM,636,RC,J1644,HCPCS,0264-9567-10,NDC,facility,both,16,ML,JW,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,17271-701-05,NDC,facility,both,1,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-1749-70,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25 MG-250 MG TAB,50863,CDM,250,RC,J3490,HCPCS,50228-459-01,NDC,facility,both,2,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG/ML ORAL CONC,50863,CDM,250,RC,J3490,HCPCS,0054-3553-44,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,25021-468-10,NDC,facility,both,1,EA,,143,100.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0093-0053-01,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OMALIZUMAB 150 MG SUBQ SOLR,50863,CDM,J2357,HCPCS,50242-040-62,NDC,,,facility,both,60,ME,,5219,3653.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 160 MG-800 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0904-2725-61,NDC,facility,both,9,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEGFILGRASTIM 6 MG/0.6 ML SUBQ W/ ON BODY INJECTOR,50863,CDM,J2506,HCPCS,55513-192-01,NDC,,,facility,both,12,ML,,17714,12399.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL IV BOLUS 10MG/ML (ANESTHESIA ONLY),50863,CDM,636,RC,J2704,HCPCS,63323-269-29,NDC,facility,both,60,ML,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NORETHINDRONE ACETATE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65162-475-05,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 150 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,0115-6811-10,NDC,facility,both,2,EA,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,10,EA,JW,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IVPB (PEDIATRICS/ADULT NON-FORM)",50863,CDM,J0134,HCPCS,63323-434-41,NDC,,,facility,both,100,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR 200 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,69076-146-01,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,636,RC,J3010,HCPCS,0409-9094-22,NDC,facility,both,3,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-209-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-7912-51,NDC,,,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0093-4155-73,NDC,facility,both,26,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM NEO IV SYRINGE (PHS FROM PREMIX),50863,CDM,636,RC,J1953,HCPCS,44567-501-01,NDC,facility,both,50,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMETHICONE 40MG/0.6ML (0.6ML-UD) SYRINGE (REPACK),50863,CDM,250,RC,J3490,HCPCS,17856-5894-02,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN NACL (PF) 1000 UNIT/500 ML IV SOLP,50863,CDM,636,RC,J1644,HCPCS,0409-1005-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,67877-545-88,NDC,facility,both,9,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,72888-060-30,NDC,facility,both,1,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6322-06,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,636,RC,J3490,HCPCS,0904-6794-30,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6773-61,NDC,facility,both,2,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATED 20 MG/ML IV SOLN,50863,CDM,250,RC,J0706,HCPCS,51754-0500-1,NDC,facility,both,6,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR NEO/PEDS INFUSION (CDS FROM PREMIX),50863,CDM,250,RC,J0133,HCPCS,63323-325-10,NDC,facility,both,15,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE 100 MG ORAL CAP,50863,CDM,250,RC,J7502,HCPCS,60505-0134-0,NDC,facility,both,1,EA,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0406-5771-23,NDC,facility,both,7,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT  60 MCG/0.3 ML INJ SYRG,50863,CDM,636,RC,J0881,HCPCS,55513-023-01,NDC,facility,both,50,ML,"JZ,EC",1069,748.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier EC: Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy
DIVALPROEX 250 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,0904-6363-61,NDC,facility,both,4,EA,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALSARTAN  80 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-623-11,NDC,facility,both,2,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATENOLOL  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7187-61,NDC,facility,both,2,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BLEOMYCIN 30 UNITS/10 ML INJ SOLR (WET SOLR VIAL),50863,CDM,J9040,HCPCS,63323-137-20,NDC,,,facility,both,2,EA,,389,272.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 25 MG TAB,50863,CDM,J3490,HCPCS,51079-255-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DASATINIB  20 MG ORAL TAB,50863,CDM,636,RC,J9999,HCPCS,0003-0527-11,NDC,facility,both,1,EA,,729,510.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM BROMIDE 0.03 % NASL SPRA,50863,CDM,636,RC,J3490,HCPCS,0054-0045-44,NDC,facility,both,1,ML,,402,281.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-288-11,NDC,facility,both,1,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NYSTATIN  100000 UNIT/G TOP POWD,50863,CDM,250,RC,J3490,HCPCS,68308-152-15,NDC,facility,both,1,GM,,108,75.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6868-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM ACETATE 667 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7119-06,NDC,facility,both,4,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-4713-32,NDC,facility,both,80,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,50863,CDM,636,RC,Q5119,HCPCS,0069-0249-01,NDC,facility,both,100,ML,"JZ,JA",19784,13848.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,250,RC,Q9968,HCPCS,70710-1838-1,NDC,facility,both,98,ML,,1619,1133.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  88 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6952-61,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,29,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,86,ML,JW,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,250,RC,J0690,HCPCS,70092-1017-46,NDC,facility,both,2,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,636,RC,J7999,HCPCS,70092-1017-46,NDC,facility,both,2,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EMOLLIENT COMBINATION NO.10 TOPICAL EMULSION,50863,CDM,636,RC,J3490,HCPCS,5898096012,NDC,facility,both,1,GM,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,7,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BISOPROLOL FUMARATE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,29300-126-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7008-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,4,ML,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,68462-470-40,NDC,facility,both,4,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (NEO) <2 KG,50863,CDM,636,RC,J7060,HCPCS,0338-0017-41,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM 500 MG IV SOLR,50863,CDM,250,RC,J2185,HCPCS,63323-507-20,NDC,facility,both,5,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE 110 MCG/ACTUATION INHL AERO,50863,CDM,250,RC,J3490,HCPCS,66993-079-96,NDC,facility,both,1,GM,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,83,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRBESARTAN 300 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,33342-049-07,NDC,facility,both,1,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,0409-4887-17,NDC,facility,both,2,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,636,RC,Q0162,HCPCS,65162-691-79,NDC,facility,both,2,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,12,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-1752-50,NDC,facility,both,1,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXAZOSIN 4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-5524-61,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7411-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXAZOSIN 4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-862-95,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALSARTAN 160 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,33342-064-10,NDC,facility,both,2,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,250,RC,J3360,HCPCS,0409-1273-03,NDC,facility,both,2,ML,JZ,198,138.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
RISPERIDONE 1 MG ORAL TBDL,50863,CDM,636,RC,J3490,HCPCS,49884-315-52,NDC,facility,both,1,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESNA 100 MG/ML IV SOLN,50863,CDM,250,RC,J9209,HCPCS,0338-1305-01,NDC,facility,both,10,ML,,388,271.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,65219-445-01,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL  97.2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,75826-142-10,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,636,RC,J0330,HCPCS,0409-6629-02,NDC,facility,both,8,ML,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PERPHENAZINE  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68382-591-01,NDC,facility,both,6,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0121-1022-05,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 50 MG/ML INJECTION,50863,CDM,636,RC,J1200,HCPCS,72485-101-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6925-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,J1940,HCPCS,23155-473-32,NDC,,,facility,both,6,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VITAMIN A 10000 UNIT ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,904208560,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,636,RC,J3490,HCPCS,63037-136-25,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 600 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,67877-320-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,636,RC,J2003,HCPCS,63323-485-27,NDC,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,10,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16729-137-00,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,J3490,HCPCS,50580-458-11,NDC,,,facility,both,3,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,68094-231-59,NDC,facility,both,1,ML,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0121-1781-05,NDC,facility,both,1,ML,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-2051-15,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2003,HCPCS,55150-165-05,NDC,,,facility,both,300,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"NEOMYCIN-POLYMYXIN-PRAMOXINE 3.5 MG-10,000 UNIT-10 MG/G TOPICAL CREAM",50863,CDM,250,RC,J3490,HCPCS,81073794,NDC,facility,both,1,GM,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNITS/1 GRAM PACKET (MERGE RECORD),50863,CDM,636,RC,J3490,HCPCS,0904-7023-67,NDC,facility,both,6,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1815,HCPCS,0169-1833-11,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,44206-310-25,NDC,facility,both,3,ML,JZ,627,438.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-467-01,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69238-2078-1,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,35,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,1,EA,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,22,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,51754-5011-1,NDC,facility,both,8,ML,,432,302.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE 8 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,0054-0177-13,NDC,facility,both,2,EA,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSULFAN BLUE 1 % INJ SOLN,50863,CDM,636,RC,Q9968,HCPCS,67457-220-00,NDC,facility,both,100,ML,,8597,6017.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRBESARTAN  75 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,31722-729-30,NDC,facility,both,4,EA,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM PHOSPHATE 4.4 MEQ/ML ORAL SOLUTION (CDS),50863,CDM,250,RC,J3490,HCPCS,0409-7295-01,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 150 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-530-11,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-6625-22,NDC,facility,both,3,ML,,174,121.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADVATE: FACTOR VIII CONCENTRATE (MERGE RECORD),50863,CDM,250,RC,J7192,HCPCS,0944-3053-02,NDC,facility,both,500,UN,JW,910,637,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CARBIDOPA-LEVODOPA 25 MG-100 MG TAB,50863,CDM,636,RC,J3490,HCPCS,59651-457-01,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN  3 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51672-4030-1,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE HCL IN 0.9% NACL 1 MG/10 ML (100 MCG/ML) IV SYRG,50863,CDM,250,RC,J3490,HCPCS,73177-108-03,NDC,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE  10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69367-388-01,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR NEO/PEDS INFUSION (CDS FROM PREMIX),50863,CDM,250,RC,J0133,HCPCS,63323-325-10,NDC,facility,both,11,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),50863,CDM,250,RC,J3490,HCPCS,8290306545,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,250,RC,J0132,HCPCS,70594-111-01,NDC,facility,both,120,ML,,611,427.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,46,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PRAZOSIN 1 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7020-61,NDC,facility,both,8,EA,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6426-61,NDC,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,51079-051-01,NDC,facility,both,1,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-25,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE  2 MG/ML INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-285-20,NDC,facility,both,3,ML,,171,119.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-7914-61,NDC,,,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 0.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16729-136-00,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUFENTANIL CITRATE 50 MCG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,17478-050-05,NDC,facility,both,1,ML,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 500 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,0904-6861-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 30 MG/0.3 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,0955-1003-01,NDC,facility,both,3,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50228-420-01,NDC,facility,both,2,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIROLIMUS 1 MG ORAL TAB,50863,CDM,250,RC,J7520,HCPCS,50268-718-11,NDC,facility,both,5,EA,,632,442.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE  50 MG ORAL TAB,50863,CDM,636,RC,j3490,HCPCS,60505-2653-1,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML IV,50863,CDM,250,RC,J3490,HCPCS,70860-301-43,NDC,facility,both,1,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,4,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN IN D5W 900 MG/50 ML IV PGBK,50863,CDM,636,RC,J0736,HCPCS,0781-3290-91,NDC,facility,both,3,ML,JZ,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"CALCIUM GLUC IN NACL, ISO-OSM 1 G/100 ML IV SOLN",50863,CDM,636,RC,J0612,HCPCS,44567-622-01,NDC,facility,both,50,ML,JW,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-04,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-22,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VECURONIUM BROMIDE 10 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,47335-931-40,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROATE SODIUM 100 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0143-9785-01,NDC,facility,both,5,ML,,508,355.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7244-68,NDC,facility,both,4,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,63323-165-01,NDC,facility,both,8,ML,JZ,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CLOPIDOGREL 300 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6467-10,NDC,facility,both,2,EA,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0641-6059-01,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OMEPRAZOLE-SODIUM BICARBONATE 2-84 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,65628-270-03,NDC,facility,both,2,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-645-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUANFACINE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,59651-840-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0093-2279-73,NDC,facility,both,3,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 50 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,59651-489-01,NDC,facility,both,20,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,636,RC,J1953,HCPCS,55150-177-05,NDC,facility,both,100,ML,JZ,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LANSOPRAZOLE 30 MG ORAL TBLD,50863,CDM,250,RC,J3490,HCPCS,68382-772-30,NDC,facility,both,1,EA,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6642-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SYRG,50863,CDM,250,RC,J3490,HCPCS,8290306546,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,636,RC,J3490,HCPCS,81284-611-00,NDC,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,250,RC,J3360,HCPCS,0409-1273-03,NDC,facility,both,4,ML,,396,277.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADVATE: FACTOR VIII CONCENTRATE (MERGE RECORD),50863,CDM,250,RC,J7192,HCPCS,0944-3053-04,NDC,facility,both,500,UN,JW,1140,798,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,72603-209-01,NDC,facility,both,4,ML,,247,172.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 600 MG ORAL TP12,50863,CDM,636,RC,J3490,HCPCS,68084-572-11,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LINEZOLID 600 MG/300 ML IV SOLP,50863,CDM,250,RC,J2020,HCPCS,57664-683-31,NDC,facility,both,3,ML,,331,231.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-405-11,NDC,facility,both,5,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,72603-251-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"METHYLPREDNISOLONE 1,000 MG SOLUTION FOR INJECTION",50863,CDM,250,RC,J2919,HCPCS,63323-265-30,NDC,facility,both,400,EA,,402,281.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 650 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7261-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 0.1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-721-11,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 50 MG/ML IV SOLN,50863,CDM,636,RC,J0282,HCPCS,0143-9875-25,NDC,facility,both,10,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 112 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42292-039-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML SYRUP,50863,CDM,250,RC,J3490,HCPCS,0121-0638-10,NDC,facility,both,10,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 2 MG INJ SOLR,50863,CDM,636,RC,J2997,HCPCS,50242-041-64,NDC,facility,both,2,EA,,800,560,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMINOCAPROIC ACID 250 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0517-9120-01,NDC,facility,both,1,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-4279-02,NDC,facility,both,600,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN STERILE WATER 2 GRAM/20 ML IV SYRG,50863,CDM,636,RC,J7999,HCPCS,70092-1604-47,NDC,facility,both,2,ML,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR  6 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0004-0822-05,NDC,facility,both,3,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,68094-147-01,NDC,facility,both,2,ML,,197,137.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL (VITAMIN D3)   400 UNIT ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,7733394825,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,55150-161-02,NDC,facility,both,40,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE   4.2 % IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-083-05,NDC,facility,both,1,ML,,139,97.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN PEDS IV INFUSION 12 MG/ML (CDS MIXTURE FROM PREMIX),50863,CDM,636,RC,J0736,HCPCS,0781-3289-91,NDC,facility,both,3,ML,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,68094-231-59,NDC,facility,both,3,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-134-01,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,636,RC,J3490,HCPCS,76329-3390-1,NDC,facility,both,100,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-48,NDC,facility,both,2,ML,,140,98,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSAPREPITANT 150 MG IV SOLR,50863,CDM,250,RC,J1453,HCPCS,72205-054-01,NDC,facility,both,150,EA,,948,663.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16729-216-15,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL,50863,CDM,250,RC,J3490,HCPCS,63323-820-01,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 80 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-5798-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG IV SOLR,50863,CDM,636,RC,J3490,HCPCS,55150-202-00,NDC,facility,both,1,EA,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM SR 180 MG 24 HR CAP,50863,CDM,250,RC,J3490,HCPCS,60687-206-11,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM  1.5 GRAM INJ SOLR,50863,CDM,636,RC,J0295,HCPCS,55150-116-20,NDC,facility,both,1,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4% TOP PATCH,50863,CDM,636,RC,J3490,HCPCS,70512-812-01,NDC,facility,both,4,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE HCL IN NS 10 MG/250 ML (0.04 MG/ML) IV SOLN (PDS MERGE),50863,CDM,250,RC,J2371,HCPCS,70004-811-40,NDC,facility,both,2500,ML,,728,509.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALUM-MAG HYDROXIDE-SIMETH 200 MG-200 MG-20 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,17856-0630-1,NDC,facility,both,1,ML,PLAD,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,250,RC,Q0162,HCPCS,65162-691-79,NDC,facility,both,3,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,68180-723-04,NDC,facility,both,3,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J0461,HCPCS,0517-1004-01,NDC,facility,both,40,ML,JZ,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LOVASTATIN 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0093-0576-06,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRIVIGEN 10 % IV SOLN,50863,CDM,636,RC,J1459,HCPCS,44206-438-92,NDC,facility,both,80,ML,,14352,10046.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ACTUATION NASL SPRA,50863,CDM,636,RC,J3490,HCPCS,60505-0823-6,NDC,facility,both,1,ML,,427,298.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  750 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65862-247-08,NDC,facility,both,3,EA,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 16 MG ORAL TAB,50863,CDM,250,RC,J7509,HCPCS,59762-0050-1,NDC,facility,both,10,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE 2 MG SL SUBL,50863,CDM,636,RC,J3490,HCPCS,60687-481-11,NDC,facility,both,2,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,78206-122-01,NDC,facility,both,2,EA,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,68094-231-59,NDC,facility,both,3,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 500 MG-125 MG TAB,50863,CDM,636,RC,J3490,HCPCS,65862-502-20,NDC,facility,both,1,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE-DEXTROSE-WATER(PF) 7.5 MG/ML (0.75 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-1761-18,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 100 MG/ML INJ SOLN,50863,CDM,636,RC,J2800,HCPCS,70069-101-01,NDC,facility,both,1,ML,,101,70.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-450-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,J3490,HCPCS,0121-0917-05,NDC,,,facility,both,5,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,16714-293-01,NDC,facility,both,3,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALGANCICLOVIR 50 MG/ML ORAL SOLR,50863,CDM,250,RC,J3490,HCPCS,0591-2579-20,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML IV,50863,CDM,250,RC,J3490,HCPCS,55150-425-01,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42291-083-30,NDC,facility,both,2,EA,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLP",50863,CDM,250,RC,P9047,HCPCS,0944-0493-04,NDC,facility,both,1,ML,,251,175.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0780,HCPCS,23155-294-41,NDC,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,2,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,43,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  75 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-475-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,636,RC,J1953,HCPCS,55150-177-05,NDC,facility,both,200,ML,JZ,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PRAMIPEXOLE 0.125 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0597-0183-90,NDC,facility,both,3,EA,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,16714-293-01,NDC,facility,both,6,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-492-57,NDC,facility,both,50,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOVASTATIN 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68180-468-01,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN STERILE WATER 2 GRAM/20 ML IV SYRG,50863,CDM,250,RC,J7999,HCPCS,73702-132-23,NDC,facility,both,1,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM OXIDE 400 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,1000673038,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,250,RC,J2003,HCPCS,0409-4278-01,NDC,facility,both,250,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 150 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7212-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML (PEDS CALCLUATOR 0.5),50863,CDM,250,RC,J1815,HCPCS,0024-5924-10,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM NEO/PED INFUSION (CDS MIXTURE),50863,CDM,250,RC,J2185,HCPCS,0781-3267-90,NDC,facility,both,1,EA,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-24,NDC,facility,both,40,ML,,5658,3960.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEPLIZUMAB-MZWV 2 MG/20 ML IV SOLN,50863,CDM,636,RC,J9381,HCPCS,73650-316-01,NDC,facility,both,36,ME,,2365,1655.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,49,EA,,6762,4733.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 2 GRAM IV SOLUTION,50863,CDM,250,RC,J9075,HCPCS,0781-3255-94,NDC,facility,both,800,EA,,7582,5307.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,53,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 150 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,0904-7505-61,NDC,facility,both,3,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-208-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,42023-201-01,NDC,facility,both,4,EA,,1825,1277.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETHAMBUTOL 400 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-280-11,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,250,RC,J3490,HCPCS,67457-197-10,NDC,facility,both,1,ML,,368,257.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,64208-2510-2,NDC,facility,both,1,ML,JZ,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SENNOSIDES  8.6 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7252-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-22,NDC,facility,both,20,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 100 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,68084-697-11,NDC,facility,both,2,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,42494-416-01,NDC,facility,both,2,ML,,289,202.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML SYRUP,50863,CDM,250,RC,J3490,HCPCS,0121-0638-05,NDC,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7193-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-346-11,NDC,facility,both,4,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SINCALIDE 5 MCG INJ SOLR,50863,CDM,636,RC,J2805,HCPCS,0270-0556-15,NDC,facility,both,1,EA,,564,394.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,50863,CDM,636,RC,J1756,HCPCS,0517-2340-01,NDC,facility,both,300,ML,JZ,992,694.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),50863,CDM,250,RC,J0171,HCPCS,0409-4921-34,NDC,facility,both,20,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM IN NACL (ISO-OS) 1500 MG/100 ML IV PGBK,50863,CDM,636,RC,J1953,HCPCS,44567-503-01,NDC,facility,both,450,ML,,267,186.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 160 MG-800 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0904-2725-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,68094-193-59,NDC,facility,both,3,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,250,RC,J0690,HCPCS,44567-707-25,NDC,facility,both,6,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,68094-600-59,NDC,facility,both,5,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL  4 MG ORAL TAB,50863,CDM,636,RC,Q0162,HCPCS,65862-187-30,NDC,facility,both,48,EA,,857,599.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV (BOLUS),50863,CDM,636,RC,J7120,HCPCS,0264-7750-10,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MISOPROSTOL 100 MCG ORAL TAB,50863,CDM,636,RC,S0191,HCPCS,60687-735-11,NDC,facility,both,3,EA,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,250,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 0.1MG/ML SUSPENSION (REPACK),50863,CDM,250,RC,J3490,HCPCS,51079-882-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE HCL IN D5W 4 MG/250 ML (16 MCG/ML) IV SOLN,50863,CDM,250,RC,J0171,HCPCS,72196-7018-1,NDC,facility,both,4,ML,,842,589.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,0088-2220-33,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELIMUMAB 120 MG IV SOLR,50863,CDM,636,RC,J0490,HCPCS,49401-101-01,NDC,facility,both,12,ME,"JZ,JA",1410,987,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
MIRTAZAPINE 30 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-120-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID (PORK)  60 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,75834-312-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE SODIUM 25 MG/ML INJ SOLN,50863,CDM,250,RC,J9260,HCPCS,16729-277-30,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-736-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 50 MG TAB,50863,CDM,636,RC,J3490,HCPCS,51079-801-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML INJECTION,50863,CDM,J3411,HCPCS,0641-6228-01,NDC,,,facility,both,2,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-555-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  25 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-473-11,NDC,facility,both,12,EA,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN-ACETAMINOPHEN-CAFFEINE 250 MG-250 MG-65 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0536-1326-01,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 10 GRAM/15 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,66689-038-01,NDC,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J3490,HCPCS,0409-0152-01,NDC,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML (PEDS CALCLUATOR 0.5),50863,CDM,636,RC,J1815,HCPCS,0024-5924-10,NDC,facility,both,1,ML,GZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier GZ: Item or service expected to be denied as not reasonable and necessary
TRANEXAMIC ACID 1000 MG/10 ML FOR NEBULIZATION,50863,CDM,250,RC,J3490,HCPCS,83634-401-41,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PERTUZUMAB 420 MG/14 ML (30 MG/ML) IV SOLN,50863,CDM,J9306,HCPCS,50242-145-01,NDC,,,facility,both,420,ML,,9375,6562.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-5755-23,NDC,facility,both,11,EA,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,63323-165-01,NDC,facility,both,4,ML,JZ,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
BUPIVACAINE 0.25%/EPINEPHRINE 1:100K INJECTION,50863,CDM,250,RC,J3490,HCPCS,0409-1158-01,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6666-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,J2003,HCPCS,63323-486-17,NDC,,,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCOSAMINE SULFATE  500 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,5026837511,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,50863,CDM,J9263,HCPCS,67457-469-10,NDC,,,facility,both,88,ML,,381,266.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,67877-432-03,NDC,facility,both,2,EA,,272,190.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LECANEMAB-IRMB 100 MG/ML IV SOLN,50863,CDM,636,RC,J0174,HCPCS,62856-215-01,NDC,facility,both,900,ML,Q0,2638,1846.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier Q0: Investigational clinical service provided in a clinical research study that is in an approved clinical research study
ROMIPLOSTIM 125 MCG SUBQ SOLR,50863,CDM,636,RC,J2802,HCPCS,55513-223-01,NDC,facility,both,65,EA,JW,580,406,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
HEPARIN (PORCINE) IN D5W 20000 UNIT/500 ML,50863,CDM,636,RC,J1644,HCPCS,0264-9567-10,NDC,facility,both,14,ML,JW,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,50863,CDM,J3301,HCPCS,70121-1168-1,NDC,,,facility,both,16,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOSTIGMINE 1MG/ML (UD) OR SYRINGE,50863,CDM,636,RC,J2710,HCPCS,76014-003-33,NDC,facility,both,2,ML,,284,198.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-506-01,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.3 MG/24 HR TD PTWK,50863,CDM,250,RC,J3490,HCPCS,0378-0873-16,NDC,facility,both,1,EA,,329,230.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELIMUMAB 120 MG IV SOLR,50863,CDM,636,RC,J0490,HCPCS,49401-101-01,NDC,facility,both,8,ME,"JW,JA",409,286.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,63323-165-01,NDC,facility,both,16,ML,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,69618-010-01,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,50863,CDM,250,RC,Q5119,HCPCS,0069-0238-01,NDC,facility,both,40,ML,,7914,5539.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE 150 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,65862-697-90,NDC,facility,both,2,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,636,RC,J3010,HCPCS,0409-9094-22,NDC,facility,both,2,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM  3.375 GRAM IV SOLR,50863,CDM,250,RC,J2543,HCPCS,44567-802-10,NDC,facility,both,3,EA,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN  500 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,70010-491-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-174-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN SODIUM EXTENDED 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,65862-692-01,NDC,facility,both,4,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 20 MG/ML INJ SOLN,50863,CDM,250,RC,J0360,HCPCS,55150-400-01,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6638-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE (PF-DURAMORPH/ASTRAMORPH) 0.5 MG/ML INJ SOLN,50863,CDM,250,RC,J2274,HCPCS,0409-3814-12,NDC,facility,both,1,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,250,RC,J2270,HCPCS,0409-1891-03,NDC,facility,both,1,ML,PLAD,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J2310,HCPCS,67457-299-00,NDC,facility,both,4,ML,,513,359.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,8,EA,,113,79.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MULTIVITAMIN WITH FOLIC ACID 400 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,1191714663,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,0641-0477-21,NDC,facility,both,6,ML,,1741,1218.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0591-5443-01,NDC,facility,both,60,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IMATINIB 100 MG ORAL TAB,50863,CDM,250,RC,J9999,HCPCS,0093-7629-98,NDC,facility,both,6,EA,,1396,977.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-02,NDC,facility,both,2,ML,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMBRISENTAN  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,47335-236-83,NDC,facility,both,1,EA,,1005,703.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE IN 0.9% NACL 3 GRAM/100 ML IV SOLN,50863,CDM,636,RC,J0612,HCPCS,61553-056-48,NDC,facility,both,1600,ML,,679,475.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TICAGRELOR 90 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0186-0777-60,NDC,facility,both,2,EA,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALTREXONE MICROSPHERES 380 MG IM SERR,50863,CDM,636,RC,J2315,HCPCS,65757-302-02,NDC,facility,both,380,EA,,4666,3266.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6085-61,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,63323-104-05,NDC,facility,both,20,ML,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,1,EA,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 6 MG/0.5 ML SUBQ PEN KIT,50863,CDM,250,RC,J3030,HCPCS,72603-141-01,NDC,facility,both,1,ML,,239,167.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6085-61,NDC,facility,both,2,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7350-06,NDC,facility,both,2,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,71399-1025-3,NDC,facility,both,6,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-4675-05,NDC,facility,both,2,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,63323-104-25,NDC,facility,both,10,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-1283-03,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,78206-122-01,NDC,facility,both,1,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J2003,HCPCS,0409-4279-02,NDC,facility,both,600,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,27808-156-01,NDC,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63629-1061-1,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0780,HCPCS,23155-294-31,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHOTERICIN B LIPOSOME 50 MG IV SUSR,50863,CDM,250,RC,J0289,HCPCS,62756-233-01,NDC,facility,both,10,EA,,1804,1262.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
L. ACIDOPHILUS-B. LACTIS-FOS 5 BILLION CELL ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,52061-00403,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN NPH HUMAN RECOMB 100 UNIT/ML SUBQ SUSP,50863,CDM,636,RC,J1815,HCPCS,0169-1834-11,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0143-9889-15,NDC,facility,both,4,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 100 MG PE/2 ML INJ SOLN,50863,CDM,250,RC,Q2009,HCPCS,63323-403-01,NDC,facility,both,4,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,16714-293-03,NDC,facility,both,8,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATENOLOL  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68382-022-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0990-7983-61,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,50863,CDM,636,RC,J1756,HCPCS,0517-2340-01,NDC,facility,both,100,ML,,321,224.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25 MG-250 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0378-1133-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 150 MG/1 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,0548-5607-00,NDC,facility,both,1,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
POTASSIUM & SODIUM PHOSPHATES 280-160-250 MG ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,6025800615,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM  3 GRAM INJ SOLR,50863,CDM,250,RC,J0295,HCPCS,55150-117-20,NDC,facility,both,2,EA,JZ,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ATENOLOL  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7187-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,636,RC,J3490,HCPCS,50268-671-11,NDC,facility,both,4,EA,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM ACETATE 2 MEQ/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-8183-11,NDC,facility,both,1,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-03,NDC,facility,both,4,ML,,111,77.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-497-11,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) MISC SOLN,50863,CDM,250,RC,J3490,HCPCS,0517-7604-01,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CITRATE 10 MEQ ORAL TBER,50863,CDM,250,RC,J3490,HCPCS,68382-537-01,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J3430,HCPCS,68462-758-05,NDC,facility,both,10,ML,,218,152.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN  750 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,50268-551-11,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANTI-INHIBITOR COAGULANT CMPLX (PHS MERGE),50863,CDM,250,RC,J7198,HCPCS,64193-326-01,NDC,facility,both,650,UN,,4695,3286.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN  2.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-027-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,2,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,53489-143-01,NDC,facility,both,3,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,68180-441-02,NDC,facility,both,8,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CONJUGATED ESTROGENS 25 MG INJ SOLR,50863,CDM,636,RC,J1410,HCPCS,0046-0749-05,NDC,facility,both,1,EA,,1303,912.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION,50863,CDM,636,RC,J3490,HCPCS,0310-7370-20,NDC,facility,both,1,GM,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,0409-6102-04,NDC,facility,both,120,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-285-01,NDC,facility,both,4,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69238-1491-1,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN PEDS SYRINGE (20MG/ML) IN DEXTROSE (CDS MIX,50863,CDM,636,RC,J0690,HCPCS,0781-3451-70,NDC,facility,both,8,EA,,207,144.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-580-11,NDC,facility,both,10,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUBIPROSTONE 24 MCG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,63304-352-60,NDC,facility,both,1,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR 200 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,69076-146-01,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 80 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6293-04,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-25,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 125 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6955-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 0.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-173-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPTOMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0878,HCPCS,71288-016-15,NDC,facility,both,500,EA,JZ,177,123.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IRON SUCROSE 200 MG/10 ML IRON IV SOLN,50863,CDM,636,RC,J1756,HCPCS,0517-2310-01,NDC,facility,both,200,ML,,529,370.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,50863,CDM,636,RC,Q0177,HCPCS,10702-011-01,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPHENIDATE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-1142-01,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 50 MG TAB,50863,CDM,636,RC,J3490,HCPCS,55111-292-09,NDC,facility,both,1,EA,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-285-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,72603-179-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PORACTANT ALFA 240 MG/3 ML INTR SUSP,50863,CDM,250,RC,J3490,HCPCS,10122-510-01,NDC,facility,both,1,ML,,1654,1157.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TAB,50863,CDM,250,RC,J3490,HCPCS,51862-540-01,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,636,RC,J7060,HCPCS,0338-0017-02,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN  500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7162-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CERTOLIZUMAB PEGOL 400 MG (200 MG X 2) SUBQ KIT,50863,CDM,636,RC,J0717,HCPCS,50474-700-62,NDC,facility,both,400,EA,JZ,6646,4652.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ISOSULFAN BLUE 1 % INJ SOLN,50863,CDM,250,RC,Q9968,HCPCS,67457-220-00,NDC,facility,both,20,ML,,1720,1204,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-3178-16,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-04,NDC,facility,both,2,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,50863,CDM,J8540,HCPCS,0054-8175-25,NDC,,,facility,both,16,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADVATE: FACTOR VIII CONCENTRATE (MERGE RECORD),50863,CDM,250,RC,J7192,HCPCS,0944-3051-02,NDC,facility,both,1000,UN,,5369,3758.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-3178-16,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-325-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,0409-1886-22,NDC,facility,both,300,ML,,156,109.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-25,NDC,facility,both,20,ML,JW,1230,861,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LISINOPRIL 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6798-61,NDC,facility,both,1,EA,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ORAL PLUS ORAL VEHICLES ORAL LIQUID,50863,CDM,636,RC,J3490,HCPCS,574030316,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLARITHROMYCIN 250 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0527-1931-06,NDC,facility,both,2,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 3% IV BOLUS (ED ONLY),50863,CDM,250,RC,J3490,HCPCS,0264-7805-10,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEG 3350-ELECTROLYTES 236 G-22.74 G-6.74 G-5.86 G ORAL SOLUTION,50863,CDM,636,RC,J3490,HCPCS,52268-100-01,NDC,facility,both,1,ML,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL IV BOLUS 10MG/ML (ANESTHESIA ONLY),50863,CDM,250,RC,J2704,HCPCS,63323-269-29,NDC,facility,both,20,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG RECT SUPP,50863,CDM,636,RC,J3490,HCPCS,45802-759-00,NDC,facility,both,1,EA,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,50863,CDM,250,RC,J0696,HCPCS,60505-6148-0,NDC,facility,both,12,EA,,675,472.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES  8.6 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7252-61,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUVOXAMINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60505-0166-1,NDC,facility,both,3,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,50863,CDM,250,RC,J9025,HCPCS,72485-201-01,NDC,facility,both,165,EA,,2334,1633.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,50742-615-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 10 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-369-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6519-61,NDC,facility,both,2,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,250,RC,J3490,HCPCS,55150-188-10,NDC,facility,both,2,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,636,RC,J3490,HCPCS,61553-320-70,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,0641-6008-10,NDC,facility,both,2,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE HCL IN 5% DEXTROSE 100 MCG/10 ML (10 MCG/ML) IV SYRG,50863,CDM,250,RC,J0171,HCPCS,70092-1617-46,NDC,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IFOSFAMIDE 1 GRAM IV SOLR,50863,CDM,250,RC,J9208,HCPCS,10019-925-82,NDC,facility,both,3,EA,,647,452.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,50863,CDM,636,RC,J1756,HCPCS,0517-2340-01,NDC,facility,both,500,ML,JZ,1605,1123.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,J0665,HCPCS,55150-169-10,NDC,,,facility,both,200,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,0409-3178-16,NDC,,,facility,both,200,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-65,NDC,facility,both,119,ML,,210,147,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,J3490,HCPCS,0409-4277-16,NDC,,,facility,both,400,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN  500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-155-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0780,HCPCS,23155-294-31,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMIDE PEROXIDE 6.5 % OTIC DROP,50863,CDM,250,RC,J3490,HCPCS,70677-1154-1,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 10 MG/ML ORAL SOLUTION (REPACK),50863,CDM,250,RC,J3490,HCPCS,0131-5410-71,NDC,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IMIPRAMINE 10 MG TAB,50863,CDM,250,RC,J3490,HCPCS,64380-169-01,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 20 GRAM/30 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-1154-30,NDC,facility,both,2,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,636,RC,J0132,HCPCS,72611-860-01,NDC,facility,both,60,ML,,218,152.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 500 MG PE/10 ML INJ SOLN,50863,CDM,250,RC,Q2009,HCPCS,0069-6001-10,NDC,facility,both,20,ML,,1048,733.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,25,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0536-1327-06,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 50 MG/ML IV SOLN,50863,CDM,250,RC,J0282,HCPCS,67457-153-03,NDC,facility,both,10,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,50863,CDM,250,RC,J9171,HCPCS,0409-0201-20,NDC,facility,both,160,ML,,1390,973,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,50863,CDM,250,RC,J9060,HCPCS,63323-103-65,NDC,facility,both,4,ML,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"METHYLPREDNISOLONE 1,000 MG SOLUTION FOR INJECTION",50863,CDM,636,RC,J2919,HCPCS,43598-130-74,NDC,facility,both,200,EA,,191,133.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,23155-600-31,NDC,facility,both,7,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),50863,CDM,250,RC,J1630,HCPCS,67457-426-00,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0172-3926-60,NDC,facility,both,1,EA,PLAD,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
RALTEGRAVIR 400 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0006-0227-61,NDC,facility,both,3,EA,,432,302.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,90,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,50863,CDM,250,RC,Q0177,HCPCS,63739-486-10,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  75 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-475-11,NDC,facility,both,3,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 800 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-5855-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM ACETATE 2 MEQ/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,69784-230-10,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,636,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,84,ML,JW,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,636,RC,J1939,HCPCS,55390-500-05,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % (1 MEQ/ML) IV 50 ML EMERGENCY SYRINGE,50863,CDM,636,RC,J3490,HCPCS,70092-1015-50,NDC,facility,both,2,ML,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 20 GRAM/500 ML IV SOLP,50863,CDM,636,RC,J3475,HCPCS,0409-2050-01,NDC,facility,both,40,ML,JZ,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-087-02,NDC,facility,both,20,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 50% IN WATER (MERGE RECORD),50863,CDM,636,RC,J7060,HCPCS,0409-7517-66,NDC,facility,both,1,ML,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 10 GRAM/15 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,66689-038-01,NDC,facility,both,2,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIFEDIPINE 90 MG ORAL TO24,50863,CDM,250,RC,J3490,HCPCS,68084-603-11,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6475-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6370-61,NDC,facility,both,2,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 7.5 MG-325 MG/15 ML ORAL SOLN (REPACK),50863,CDM,636,RC,J3490,HCPCS,0121-2316-15,NDC,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,63323-185-09,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,72611-722-25,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,636,RC,J2560,HCPCS,54288-137-01,NDC,facility,both,1,ML,,140,98,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COLCHICINE 0.6 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-727-11,NDC,facility,both,2,EA,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 100 MG/ML FROM 1 GRAM VIAL (PRMC PEDS ONLY),50863,CDM,636,RC,J0696,HCPCS,0409-7332-11,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-450-11,NDC,facility,both,3,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 10 GRAM/15 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,50383-779-30,NDC,facility,both,2,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,50863,CDM,636,RC,J3490,HCPCS,68462-157-40,NDC,facility,both,4,EA,,392,274.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHOTERICIN B LIPOSOME 50 MG IV SUSR,50863,CDM,250,RC,J0289,HCPCS,0469-3051-30,NDC,facility,both,30,EA,,6761,4732.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,3,EA,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2599,HCPCS,43598-914-11,NDC,facility,both,9,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NYSTATIN 100000 UNIT/ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,63739-160-70,NDC,facility,both,12,ML,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,0904-7127-61,NDC,facility,both,10,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0548-5604-00,NDC,facility,both,5,ML,JW,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2308-01,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 0.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-861-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESTRADIOL 2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,24658-704-01,NDC,facility,both,2,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"OCTREOTIDE,MICROSPHERES 20 MG IM SERR",50863,CDM,636,RC,J2353,HCPCS,0078-0818-81,NDC,facility,both,20,EA,,12741,8918.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,50863,CDM,250,RC,J2359,HCPCS,0002-7597-01,NDC,facility,both,20,EA,JZ,256,179.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CARVEDILOL  3.125 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68382-092-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,636,RC,J3490,HCPCS,72485-510-01,NDC,facility,both,1,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,63323-162-00,NDC,facility,both,1,ML,JW,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
BUPRENORPHINE 2 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,0904-7154-04,NDC,facility,both,2,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALACYCLOVIR 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-077-10,NDC,facility,both,2,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL-PROTEIN BOUND 100 MG IV SOLR,50863,CDM,J9264,HCPCS,0517-4300-01,NDC,,,facility,both,198,EA,,8957,6269.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (NEO) <2 KG,50863,CDM,J7060,HCPCS,0264-7510-00,NDC,,,facility,both,2,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4% TOP PATCH,50863,CDM,J3490,HCPCS,0536-1202-15,NDC,,,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6949-61,NDC,facility,both,5,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,76045-009-10,NDC,facility,both,15,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,76045-009-10,NDC,facility,both,8,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,63323-161-00,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,72162-1329-8,NDC,facility,both,1,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,636,RC,J0690,HCPCS,60505-6142-0,NDC,facility,both,6,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 50 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,59651-489-01,NDC,facility,both,25,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV (BOLUS),50863,CDM,J7040,HCPCS,0338-6304-02,NDC,,,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 40 % ORAL GEL,50863,CDM,250,RC,J3490,HCPCS,574006915,NDC,facility,both,5,GM,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,49502-393-80,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  75 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-495-11,NDC,facility,both,3,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-3426-01,NDC,facility,both,3,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,68462-755-01,NDC,facility,both,4,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7030,HCPCS,0338-0049-04,NDC,facility,both,2,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-4713-75,NDC,facility,both,200,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,636,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,8,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 3000 MCG/ML INJECTION,50863,CDM,636,RC,J0153,HCPCS,67457-855-02,NDC,facility,both,1,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MIDAZOLAM (PF) 1 MG/ML INJ (MERGE),50863,CDM,J2250,HCPCS,0409-2305-17,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYTOCIN IN 0.9 % SOD CHLORIDE 30 UNIT/500 ML IV SOLN,50863,CDM,J2590,HCPCS,70092-1068-07,NDC,,,facility,both,1,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-145-11,NDC,facility,both,15,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,J1815,HCPCS,83257-014-11,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOPERAMIDE 2 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-229-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-05,NDC,facility,both,8,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE (FOR CODE) 10% IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0517-6710-01,NDC,facility,both,1,ML,,119,83.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,0409-4887-17,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES-DOCUSATE SODIUM 8.6 MG-50 MG TAB,50863,CDM,250,RC,J3490,HCPCS,60687-622-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-492-27,NDC,,,facility,both,1500,ML,,1177,823.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,50863,CDM,250,RC,J1756,HCPCS,0517-2340-01,NDC,facility,both,100,ML,,331,231.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-20,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL  3.125 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6300-61,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,68462-157-40,NDC,facility,both,2,EA,,227,158.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 30% IN WATER (NEO),50863,CDM,250,RC,J7060,HCPCS,0409-6648-16,NDC,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,17,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25 MG-100 MG TAB,50863,CDM,250,RC,J3490,HCPCS,60687-661-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-48,NDC,facility,both,2,ML,,183,128.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-04,NDC,facility,both,4,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,636,RC,J3490,HCPCS,60687-653-11,NDC,facility,both,5,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FERUMOXYTOL 510 MG/17 ML (30 MG/ML) IV SOLN,50863,CDM,Q0138,HCPCS,59338-775-01,NDC,,,facility,both,510,ML,,3295,2306.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,J3490,HCPCS,0409-4887-17,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,76045-009-10,NDC,facility,both,25,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) 1000 UNITS/ML INJ SOL (FOR DIALYSIS ONLY),50863,CDM,250,RC,J1644,HCPCS,67457-953-00,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 112 MCG ORAL TAB,50863,CDM,J3490,HCPCS,60687-508-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5%-LACTATED RINGERS IV,50863,CDM,250,RC,J7120,HCPCS,0338-0125-04,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTOBARBITAL 75 MG/1.5 ML SYRINGE (REPACK),50863,CDM,636,RC,J3490,HCPCS,25021-676-20,NDC,facility,both,1,ML,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,J3490,HCPCS,60687-653-11,NDC,,,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,J9181,HCPCS,16729-114-08,NDC,,,facility,both,25,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRIMIDONE 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-203-11,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-3243-01,NDC,facility,both,4,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IR SOLN,50863,CDM,250,RC,J3490,HCPCS,0338-0047-46,NDC,facility,both,5,ML,,250,175,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLN (MERGE)",50863,CDM,250,RC,P9047,HCPCS,64208-2512-3,NDC,facility,both,1,ML,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN D5W 25000 UNIT/250 ML (PTT MONITORING),50863,CDM,250,RC,J1644,HCPCS,0409-4520-02,NDC,facility,both,25,ML,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,64,EA,,8832,6182.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL,50863,CDM,250,RC,J3490,HCPCS,63323-820-01,NDC,facility,both,2,ML,,138,96.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 10 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-369-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE (FOR CODE) 10% IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0517-2710-25,NDC,facility,both,1,ML,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,250,RC,J3490,HCPCS,0409-1323-05,NDC,facility,both,100,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,636,RC,J2270,HCPCS,0409-1890-03,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 20 MG/ML INJ SOLN,50863,CDM,250,RC,J0360,HCPCS,63323-614-00,NDC,facility,both,1,ML,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEPLIZUMAB-MZWV 2 MG/20 ML IV SOLN,50863,CDM,636,RC,J9381,HCPCS,73650-316-01,NDC,facility,both,320,ME,JW,8411,5887.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
AMPICILLIN SODIUM  2 GRAM INJ SOLR,50863,CDM,636,RC,J0290,HCPCS,65219-020-03,NDC,facility,both,4,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4% TOP PATCH,50863,CDM,250,RC,J3490,HCPCS,46581-830-01,NDC,facility,both,3,EA,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN DEXTROSE (ISO-OSMOTIC) 1 GRAM/50 ML IV PIGGY BACK,50863,CDM,636,RC,J0689,HCPCS,0338-3503-41,NDC,facility,both,2,ML,JZ,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,68180-441-02,NDC,facility,both,12,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 6 MG/0.5 ML SUBQ PEN KIT,50863,CDM,250,RC,J3030,HCPCS,72603-141-01,NDC,facility,both,1,ML,,406,284.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE 0.05 % OPHT DPET,50863,CDM,250,RC,J3490,HCPCS,68180-214-30,NDC,facility,both,1,EA,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,63,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NORTRIPTYLINE 50 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0093-0812-01,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 500 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-787-11,NDC,facility,both,2,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 400 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0143-9887-01,NDC,facility,both,7,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MOXIFLOXACIN 400 MG/250 ML IVPB PREMIX (MERGE),50863,CDM,250,RC,J2280,HCPCS,67457-323-25,NDC,facility,both,20,ML,,1166,816.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE 44 MCG/ACTUATION INHL AERO,50863,CDM,250,RC,J3490,HCPCS,66993-078-96,NDC,facility,both,2,GM,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLMESARTAN  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,67877-445-30,NDC,facility,both,1,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,636,RC,J3360,HCPCS,69339-136-03,NDC,facility,both,2,ML,JZ,145,101.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ACETIC ACID  2 % OTIC SOLN,50863,CDM,250,RC,J3490,HCPCS,52817-816-15,NDC,facility,both,5,ML,,864,604.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,636,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,1,ML,GZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier GZ: Item or service expected to be denied as not reasonable and necessary
MELATONIN  3 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,5026852411,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 125 MG ORAL CPSP,50863,CDM,636,RC,J3490,HCPCS,0904-6615-61,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE 25 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,68180-657-01,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,4,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,75,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  1 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,64380-782-06,NDC,facility,both,25,EA,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,72266-118-01,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,636,RC,J1610,HCPCS,0597-0053-45,NDC,facility,both,1,EA,,371,259.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,10019-016-39,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-467-01,NDC,facility,both,1,ML,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENOFIBRATE NANOCRYSTALLIZED  48 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-599-01,NDC,facility,both,5,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-0905-05,NDC,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-3178-16,NDC,facility,both,180,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 0.5% NASAL DROPS (REPACK),50863,CDM,250,RC,J3490,HCPCS,69536-050-15,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG IV SOLR,50863,CDM,636,RC,J3490,HCPCS,66794-237-02,NDC,facility,both,1,EA,,148,103.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE  10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-419-11,NDC,facility,both,3,EA,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % (1 MEQ/ML) IV 50 ML EMERGENCY SYRINGE,50863,CDM,250,RC,J3490,HCPCS,70092-1015-50,NDC,facility,both,1,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-088-11,NDC,facility,both,1,EA,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK,50863,CDM,636,RC,J3490,HCPCS,12870-0001-2,NDC,facility,both,4,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-3178-01,NDC,facility,both,40,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER SULFADIAZINE 1 % TOP CREA,50863,CDM,636,RC,J3490,HCPCS,67877-124-05,NDC,facility,both,1,GM,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,636,RC,J2003,HCPCS,0409-4277-01,NDC,facility,both,800,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-3178-16,NDC,facility,both,80,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,J2001,HCPCS,0409-4277-16,NDC,,,facility,both,40,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML IV SOLN,50863,CDM,J3490,HCPCS,72266-147-01,NDC,,,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 0.1 MG/ML INJ SYRG,50863,CDM,J0461,HCPCS,16729-484-03,NDC,,,facility,both,100,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOLIC ACID 1 MG / 0.2 ML SYRINGE (CDS ADS REPACK),50863,CDM,J3490,HCPCS,63323-184-10,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"HEPARIN, PORCINE (PF) 1 UNIT/ML IV SYRG NEONATE",50863,CDM,636,RC,J1642,HCPCS,6425344425,NDC,facility,both,2,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0264-5802-10,NDC,facility,both,1,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-94,NDC,facility,both,5,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,55390-500-05,NDC,facility,both,3,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESALAMINE 400 MG ORAL CAPSULE-WITH DR TABLETS (CDTI),50863,CDM,250,RC,J3490,HCPCS,60687-556-33,NDC,facility,both,3,EA,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ORPHENADRINE CITRATE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J2360,HCPCS,0641-6182-10,NDC,facility,both,1,ML,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELATACEPT 250 MG IV SOLR,50863,CDM,636,RC,J0485,HCPCS,0003-0371-13,NDC,facility,both,200,EA,JW,898,628.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DESMOPRESSIN 0.2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60505-0258-1,NDC,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,15,ML,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN PEDS INFUSION (CDS MIXTURE),50863,CDM,250,RC,J0290,HCPCS,99999-408-63,NDC,facility,both,2,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-31,NDC,facility,both,1,ML,JZ,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
NEOSTIGMINE METHYLSULFATE 1 MG/ML IV SOLN,50863,CDM,250,RC,J2710,HCPCS,70069-806-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INDOCYANINE GREEN 25 MG INJ,50863,CDM,250,RC,J3490,HCPCS,70100-725-01,NDC,facility,both,1,EA,,515,360.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 250 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,60687-868-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,68094-231-59,NDC,facility,both,4,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPTOMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0878,HCPCS,72603-152-01,NDC,facility,both,170,EA,,495,346.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,636,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,10,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-279-11,NDC,facility,both,1,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 1 MG/ML ORAL SOLN,50863,CDM,250,RC,J3430,HCPCS,0409-9158-01,NDC,facility,both,10,ML,,250,175,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,16714-293-01,NDC,facility,both,7,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM PHOSPHATE DIBASIC 3 MMOLE/ML IV SOLP,50863,CDM,250,RC,J3490,HCPCS,63323-086-05,NDC,facility,both,1,ML,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7008-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM ACETATE 667 MG ORAL CAP,50863,CDM,250,RC,J0615,HCPCS,68084-479-11,NDC,facility,both,29,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV,50863,CDM,636,RC,J7120,HCPCS,0338-0117-03,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,53,ML,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,636,RC,P9045,HCPCS,64208-2510-5,NDC,facility,both,12,ML,JZ,992,694.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SENNOSIDES  8.6 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7252-60,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,50863,CDM,636,RC,J0585,HCPCS,0023-1145-01,NDC,facility,both,25,EA,,400,280,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL (VITAMIN D3)  1000 UNIT ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,2055503300,NDC,facility,both,10,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYTOCIN IN 0.9 % SOD CHLORIDE 30 UNIT/500 ML IV SOLN,50863,CDM,250,RC,J2590,HCPCS,72196-6044-1,NDC,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,636,RC,Q0162,HCPCS,17856-0691-5,NDC,facility,both,4,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,50863,CDM,250,RC,J9267,HCPCS,61703-342-22,NDC,facility,both,64,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV (BOLUS),50863,CDM,250,RC,J7040,HCPCS,0338-0049-10,NDC,facility,both,1,ML,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,0338-0069-10,NDC,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANTI-INHIBITOR COAGULANT CMPLX (PHS MERGE),50863,CDM,250,RC,J7198,HCPCS,64193-426-02,NDC,facility,both,75,UN,JW,236,165.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
HYDROCODONE-ACETAMINOPHEN 7.5 MG-325 MG/15 ML ORAL SOLN (REPACK),50863,CDM,250,RC,J3490,HCPCS,0121-2316-15,NDC,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,72611-722-25,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,59651-488-01,NDC,facility,both,25,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESMOLOL  100 MG/10 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-652-10,NDC,facility,both,1,ML,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN DEXTROSE (ISO-OSMOTIC) 1 GRAM/50 ML IV PIGGY BACK,50863,CDM,250,RC,J0690,HCPCS,0338-3503-41,NDC,facility,both,8,ML,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISATRACURIUM  2 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0074-4380-10,NDC,facility,both,1,ML,,162,113.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,31722-711-30,NDC,facility,both,1,EA,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,J1171,HCPCS,76045-009-96,NDC,,,facility,both,10,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,50863,CDM,J2250,HCPCS,0409-2305-04,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML INJ SOLN,50863,CDM,J0171,HCPCS,76329-9060-0,NDC,,,facility,both,60,ML,,160,112,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"AMIODARONE IN DEXTROSE,ISO-OSM 360 MG/200 ML (1.8 MG/ML) IV SOLN",50863,CDM,250,RC,J0282,HCPCS,43066-360-20,NDC,facility,both,8,ML,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELIMUMAB 400 MG IV SOLR,50863,CDM,J0490,HCPCS,49401-102-01,NDC,,,facility,both,40,EA,,4459,3121.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,50863,CDM,J3301,HCPCS,16714-140-01,NDC,,,facility,both,4,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,70954-059-10,NDC,facility,both,10,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML (PEDS CALCLUATOR 0.5),50863,CDM,636,RC,J1815,HCPCS,0024-5924-10,NDC,facility,both,4,ML,GZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier GZ: Item or service expected to be denied as not reasonable and necessary
LEVOTHYROXINE  75 MCG ORAL TAB,50863,CDM,J3490,HCPCS,60687-475-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BETAMETHASONE DIPROPIONATE 0.05 % TOP OINT,50863,CDM,250,RC,J3490,HCPCS,0168-0056-15,NDC,facility,both,1,GM,,261,182.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,16714-293-01,NDC,facility,both,5,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0264-7800-10,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 1 % INJ SOLN,50863,CDM,636,RC,Q9968,HCPCS,0517-0301-10,NDC,facility,both,30,ML,JZ,125,87.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
AMIODARONE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6993-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,2,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG ORAL TB12,50863,CDM,636,RC,J3490,HCPCS,60687-583-11,NDC,facility,both,3,EA,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PERPHENAZINE  4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6600-61,NDC,facility,both,2,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0904-7127-61,NDC,facility,both,30,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BISACODYL 10 MG RECT SUPP,50863,CDM,636,RC,J3490,HCPCS,0574-7050-12,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,0143-9682-01,NDC,facility,both,4,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,3,EA,,111,77.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOSTIGMINE 1MG/ML (UD) OR SYRINGE,50863,CDM,J2710,HCPCS,76014-003-33,NDC,,,facility,both,2,ML,,284,198.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN 0.9% SODIUM CL 1.25 GRAM/250 ML IV SOLN,50863,CDM,250,RC,J3370,HCPCS,71506-015-58,NDC,facility,both,3,ML,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),50863,CDM,250,RC,J1630,HCPCS,63323-474-01,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-0235-25,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-739-41,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 5 MG/ML IV SOLN,50863,CDM,250,RC,J7525,HCPCS,0469-3016-01,NDC,facility,both,1,ML,,903,632.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,0409-4279-02,NDC,,,facility,both,600,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0121-1781-05,NDC,facility,both,4,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,7733351625,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J2250,HCPCS,0409-2305-17,NDC,facility,both,10,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,50863,CDM,250,RC,Q0177,HCPCS,63739-486-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-1283-03,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,63323-162-01,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNITS IN 100 ML NS,50863,CDM,636,RC,J3490,HCPCS,42023-117-25,NDC,facility,both,100,ML,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0121-1022-05,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LINACLOTIDE 145 MCG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0456-1201-30,NDC,facility,both,2,EA,,223,156.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,63323-161-00,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE NA (PRESERV FREE) 25 MG/ML INJ SOLN,50863,CDM,250,RC,J9260,HCPCS,16729-277-35,NDC,facility,both,20,ML,,202,141.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,J2704,HCPCS,0069-0209-01,NDC,,,facility,both,3,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-7193-61,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,53489-156-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1815,HCPCS,0169-1833-11,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,J3490,HCPCS,0143-9889-15,NDC,,,facility,both,16,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOBUTAMINE IN D5W 500 MG/250 ML (2 MG/ML) INFUSION (PREMIX),50863,CDM,250,RC,J1250,HCPCS,0338-1075-02,NDC,facility,both,2,ML,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-38,NDC,facility,both,1,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PACLITAXEL 6 MG/ML IV CONC,50863,CDM,J9267,HCPCS,61703-342-50,NDC,,,facility,both,257,ML,,311,217.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK,50863,CDM,250,RC,J3490,HCPCS,12870-0001-2,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOLIC ACID  5 MG/ML INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,39822-1100-1,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,39,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NYSTATIN 100000 UNIT/ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0904-7276-41,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-633-11,NDC,facility,both,1,EA,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,2,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,J3490,HCPCS,0093-2279-73,NDC,,,facility,both,11,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-48,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN D5W 1 GRAM/200 ML IV PGBK,50863,CDM,250,RC,J3370,HCPCS,0338-3552-48,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLECAINIDE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0054-0011-20,NDC,facility,both,2,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPHENIDATE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0115-1800-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 50 MG/ML IV SOLN,50863,CDM,636,RC,J0282,HCPCS,63323-616-03,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0143-9509-01,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,J3010,HCPCS,0409-9093-32,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,9,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE PEDS SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J1450,HCPCS,0338-6045-37,NDC,facility,both,2,ML,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-492-27,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 200 MG/20 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,31722-203-20,NDC,facility,both,2,ML,,800,560,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 800 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-5855-61,NDC,facility,both,10,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 400 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,16714-663-01,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA SR 50 MG-200 MG TAB,50863,CDM,250,RC,J3490,HCPCS,51079-923-01,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK,50863,CDM,250,RC,J3490,HCPCS,12870-0001-1,NDC,facility,both,3,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-9543-02,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE(PF)0.2 % ELASTOMERIC PUMP (ONQ) 545ML (PREFILLED),50863,CDM,636,RC,J3490,HCPCS,71449-079-51,NDC,facility,both,1,ML,,1171,819.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),50863,CDM,250,RC,J1630,HCPCS,63323-474-00,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPENTOLATE-PHENYLEPHRINE 0.2 %-1 % EYE DROPS,50863,CDM,250,RC,J3490,HCPCS,0065-0359-02,NDC,facility,both,1,ML,,207,144.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZINC SULFATE 220 MG (50 MG) CAP,50863,CDM,250,RC,J3490,HCPCS,7733398325,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2308-22,NDC,facility,both,7,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
HYDROXYZINE 25 MG TAB,50863,CDM,636,RC,Q0177,HCPCS,63739-486-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 500 MG PE/10 ML INJ SOLN,50863,CDM,250,RC,Q2009,HCPCS,0641-6137-01,NDC,facility,both,30,ML,,726,508.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-893-01,NDC,facility,both,3,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFIDEROCOL 1 G IV SOLR,50863,CDM,250,RC,J0699,HCPCS,59630-266-01,NDC,facility,both,200,EA,,1649,1154.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM CITRATE ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,70677-1112-1,NDC,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,23,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2308-22,NDC,facility,both,2,ML,,217,151.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZTROPINE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-368-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,5,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN D5W 20000 UNIT/500 ML,50863,CDM,636,RC,J1644,HCPCS,0264-9567-10,NDC,facility,both,12,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,64850-502-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,636,RC,J7060,HCPCS,0338-0017-04,NDC,facility,both,1,ML,JW,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
AMIODARONE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0245-0147-89,NDC,facility,both,4,EA,,156,109.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RASBURICASE 1.5 MG IV SOLR,50863,CDM,250,RC,J2783,HCPCS,0024-5154-11,NDC,facility,both,3,EA,,2687,1880.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,15,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
RISANKIZUMAB-RZAA  60 MG/ML IV SOLN,50863,CDM,636,RC,J2327,HCPCS,0074-5015-01,NDC,facility,both,1200,ML,,55861,39102.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,23,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,0143-9682-25,NDC,facility,both,4,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-426-02,NDC,facility,both,2,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 2 GRAM INJ SOLR,50863,CDM,636,RC,J0692,HCPCS,0409-9735-01,NDC,facility,both,4,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV,50863,CDM,250,RC,J7120,HCPCS,0338-0117-04,NDC,facility,both,4,ML,,133,93.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRIMIDONE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,53746-544-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM-ALBUTEROL 0.5 MG-2.5 MG/3 ML NEB SOLUTION,50863,CDM,636,RC,J3490,HCPCS,0487-0201-01,NDC,facility,both,3,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRIMIDONE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-686-11,NDC,facility,both,3,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESTRADIOL 0.025 MG/24 HR TD PTSW,50863,CDM,250,RC,J7304,HCPCS,0378-4644-16,NDC,facility,both,1,EA,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,50863,CDM,250,RC,J9075,HCPCS,10019-955-50,NDC,facility,both,300,EA,,3890,2723,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2310,HCPCS,36000-308-01,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,72603-506-01,NDC,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,250,RC,J3360,HCPCS,0409-1273-03,NDC,facility,both,4,ML,JZ,396,277.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J2004,HCPCS,0409-3178-01,NDC,facility,both,35,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN  300 MG RECT SUPP,50863,CDM,250,RC,J3490,HCPCS,0574-7034-12,NDC,facility,both,2,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 40 % ORAL GEL,50863,CDM,250,RC,J3490,HCPCS,574007030,NDC,facility,both,1,GM,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-284-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV,50863,CDM,636,RC,J7120,HCPCS,0338-0117-04,NDC,facility,both,15,ML,,499,349.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SULFADIAZINE 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,62135-842-60,NDC,facility,both,3,EA,,255,178.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,120,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,J3490,HCPCS,0143-9889-15,NDC,,,facility,both,24,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,6,EA,,187,130.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MYCOPHENOLATE 500 MG IV SOLUTION,50863,CDM,250,RC,J3490,HCPCS,54288-141-01,NDC,facility,both,2,EA,,738,516.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTAMIDINE 300 MG INJ SOLR,50863,CDM,636,RC,J3490,HCPCS,63323-113-01,NDC,facility,both,1,EA,,183,128.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,13,EA,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,9,ML,,4264,2984.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0630,HCPCS,42023-205-01,NDC,facility,both,1,ML,,4408,3085.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAZOSIN 2 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7021-61,NDC,facility,both,3,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 400 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0143-9887-01,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BLINATUMOMAB 35 MCG IV KIT,50863,CDM,250,RC,J9039,HCPCS,55513-160-01,NDC,facility,both,35,EA,,9203,6442.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 100 MG/ML INJ SOLN,50863,CDM,250,RC,J2800,HCPCS,70069-101-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLPIDEM  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-621-01,NDC,facility,both,3,EA,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GAMMAGARD LIQUID 10 % IV SOLN,50863,CDM,636,RC,J1569,HCPCS,0944-2700-07,NDC,facility,both,60,ML,"JG,JZ,JA",10817,7571.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JG: Drug or biological acquired with 340b drug pricing program discount | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
CARBAMAZEPINE 100 MG ORAL CHEW,50863,CDM,636,RC,J3490,HCPCS,0904-3854-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 400 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0143-9887-01,NDC,facility,both,16,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMETHICONE 40MG/0.6ML (0.6ML-UD) SYRINGE (REPACK),50863,CDM,250,RC,J3490,HCPCS,17856-1141-4,NDC,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,J7030,HCPCS,0338-0049-04,NDC,,,facility,both,3,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE MALEATE 10 MG ORAL TAB,50863,CDM,636,RC,Q0164,HCPCS,50268-685-11,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,250,RC,J3101,HCPCS,50242-037-06,NDC,facility,both,29,EA,JW,5775,4042.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,636,RC,J3490,HCPCS,68180-963-01,NDC,facility,both,1,GM,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,250,RC,J2405,HCPCS,0409-4755-18,NDC,facility,both,8,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACIDOPHILUS-PECTIN W CITRUS 25 MILLION-100 CELL MG TAB,50863,CDM,636,RC,J3490,HCPCS,536142401,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,250,RC,J3360,HCPCS,69339-136-03,NDC,facility,both,1,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,55150-307-01,NDC,facility,both,64,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALBUPHINE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J2300,HCPCS,0409-1464-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J2004,HCPCS,63323-482-01,NDC,facility,both,40,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML IM SOLN,50863,CDM,636,RC,90375,HCPCS,13533-318-50,NDC,facility,both,20,ML,,17892,12524.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,8,ML,JW,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
HYDROCORTISONE ACETATE 25 MG RECT SUPP,50863,CDM,636,RC,J3490,HCPCS,50268-411-24,NDC,facility,both,1,EA,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 500 MG (200 MG ELEMENTAL) CHEW TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6412-92,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-545-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL (NEO/PEDS),50863,CDM,250,RC,J3490,HCPCS,63323-820-00,NDC,facility,both,1,ML,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SYRG,50863,CDM,250,RC,J3490,HCPCS,8290306500,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 600 MG ORAL TP12,50863,CDM,250,RC,J3490,HCPCS,0536-1163-61,NDC,facility,both,10,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SINCALIDE 5 MCG INJ SOLR,50863,CDM,636,RC,J2805,HCPCS,72266-248-01,NDC,facility,both,1,EA,,591,413.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,39,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CLINDAMYCIN 300 MG CAP,50863,CDM,250,RC,J3490,HCPCS,68084-244-11,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,250,RC,J2003,HCPCS,76329-3390-1,NDC,facility,both,100,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE DINITRATE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6619-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIP,PER(A)TET-HEPB-POL-HIB(PF) 15 UNIT-5 UNIT- 10 MCG/0.5 ML IM INJ MERGE (CAM USE ONLY)",50863,CDM,90697,HCPCS,63361-243-88,NDC,,,facility,both,1,ML,,674,471.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J3490,HCPCS,0338-0049-48,NDC,facility,both,8,ML,JZ,160,112,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,0641-6174-01,NDC,facility,both,4,ML,JZ,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DIFLUPREDNATE 0.05 % OPHT DROP,50863,CDM,636,RC,J3490,HCPCS,0078-0862-25,NDC,facility,both,1,ML,,788,551.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0003-0893-31,NDC,facility,both,1,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 50 MG TAB,50863,CDM,636,RC,Q0177,HCPCS,16714-083-10,NDC,facility,both,2,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0143-9509-01,NDC,facility,both,1,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,250,RC,J3490,HCPCS,53746-542-05,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6773-61,NDC,facility,both,4,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM IN NACL (ISO-OS) 1000 MG/100 ML IV PGBK,50863,CDM,636,RC,J1953,HCPCS,55150-247-47,NDC,facility,both,100,ML,,229,160.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 1000 MG MISC TBSO,50863,CDM,250,RC,J3490,HCPCS,77333-844-25,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2308-21,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLMESARTAN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68462-437-30,NDC,facility,both,1,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0003-0894-31,NDC,facility,both,1,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,70436-030-82,NDC,facility,both,114,ML,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASCORBIC ACID  500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,904052361,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,85,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,50863,CDM,250,RC,J9060,HCPCS,0703-5748-11,NDC,facility,both,7,ML,,166,116.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG ORAL TAB,50863,CDM,J3490,HCPCS,60687-113-11,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM SR 120 MG 24 HR CAP,50863,CDM,J3490,HCPCS,60687-195-11,NDC,,,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0093-2279-73,NDC,facility,both,4,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,202,ML,,182,127.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,70069-363-01,NDC,facility,both,1,ML,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,0409-9094-12,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROPROCAINE 3 % INJ SOLN,50863,CDM,250,RC,J2401,HCPCS,0143-9210-01,NDC,facility,both,150,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-440-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,50863,CDM,250,RC,J9045,HCPCS,0703-4239-01,NDC,facility,both,10,ML,,280,196,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN  325 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,66553-001-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,18500,ML,,2036,1425.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMULSION 20 % IV EMUL,50863,CDM,250,RC,j3490,HCPCS,65219-533-01,NDC,facility,both,1,ML,,246,172.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),50863,CDM,636,RC,J3490,HCPCS,0409-4888-06,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,23155-600-31,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1940,HCPCS,36000-283-25,NDC,facility,both,20,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCERIN (ADULT) RECTAL SUPPOSITORY,50863,CDM,250,RC,J3490,HCPCS,132007924,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-209-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL DECANOATE  50 MG/ML IM SOLN,50863,CDM,250,RC,J1631,HCPCS,70069-030-03,NDC,facility,both,3,ML,,383,268.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE 20 MG/ML ORAL CONC,50863,CDM,636,RC,J3490,HCPCS,16714-601-02,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MOXIFLOXACIN 0.5 % OPHT DROP,50863,CDM,250,RC,J3490,HCPCS,72266-158-01,NDC,facility,both,1,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-48,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,14,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACIDOPHILUS-PECTIN W CITRUS 25 MILLION-100 CELL MG TAB,50863,CDM,250,RC,J3490,HCPCS,8068102600,NDC,facility,both,15,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6427-61,NDC,facility,both,2,EA,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,50863,CDM,250,RC,J0640,HCPCS,0143-9554-01,NDC,facility,both,2,EA,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 2 GRAM INJ SOLR,50863,CDM,250,RC,J0692,HCPCS,44567-241-10,NDC,facility,both,40,EA,,576,403.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LETROZOLE 2.5 MG ORAL TAB,50863,CDM,250,RC,J9999,HCPCS,50268-476-11,NDC,facility,both,2,EA,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,42806-150-33,NDC,facility,both,6,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 1 % TOPICAL GEL,50863,CDM,250,RC,J3490,HCPCS,45802-900-94,NDC,facility,both,1,GM,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68094-005-59,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  40 MG ORAL TR12,50863,CDM,250,RC,J3490,HCPCS,59011-440-20,NDC,facility,both,1,EA,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 5 MG/ML IV SOLN,50863,CDM,636,RC,J1921,HCPCS,25021-317-20,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,636,RC,J2795,HCPCS,43066-023-01,NDC,facility,both,20,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,63323-104-25,NDC,facility,both,10,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,636,RC,J3490,HCPCS,67877-590-01,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 20 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-0721-04,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,250,RC,J2003,HCPCS,0409-1323-05,NDC,facility,both,800,ML,,352,246.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,250,RC,J3490,HCPCS,0409-1891-01,NDC,facility,both,2,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,0409-3178-17,NDC,,,facility,both,200,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,636,RC,J1611,HCPCS,63323-596-11,NDC,facility,both,5,EA,JZ,4473,3131.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
TACROLIMUS 1 MG (ENVARSUS XR) 24-HOUR EXTENDED-RELEASE TABLET,50863,CDM,250,RC,J7508,HCPCS,68992-3010-3,NDC,facility,both,6,EA,,169,118.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,2,ML,,400,280,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPOETIN ALFA  4000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J0885,HCPCS,59676-304-00,NDC,facility,both,40,ML,"JZ,EC,PLAD",462,323.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier EC: Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy | Modifier PLAD: Modifier description not available
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0904-7127-61,NDC,facility,both,20,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL  1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0832-1520-89,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  88 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0074-6594-90,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN 1000 MG IN NS 1000 ML IRRIGATION (REPACK),50863,CDM,250,RC,J0690,HCPCS,99999-500-04,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MISOPROSTOL 50 MCG ORAL SPLIT TAB,50863,CDM,250,RC,S0191,HCPCS,60687-735-01,NDC,facility,both,1,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 0.2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60505-0258-1,NDC,facility,both,7,EA,,149,104.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITRIOL 0.5 MCG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,23155-663-01,NDC,facility,both,4,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM NEO IV SYRINGE (PHS FROM PREMIX),50863,CDM,250,RC,J1953,HCPCS,44567-501-01,NDC,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  50 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-484-11,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,30,ML,JW,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
POTASSIUM CITRATE 10 MEQ ORAL TBER,50863,CDM,250,RC,J3490,HCPCS,68084-850-33,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM BICARB-CITRIC ACID 20 MEQ ORAL TBEF,50863,CDM,250,RC,J3490,HCPCS,51801-011-01,NDC,facility,both,4,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,50863,CDM,636,RC,J1756,HCPCS,0517-2340-10,NDC,facility,both,300,ML,,963,674.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM ACETATE 667 MG ORAL CAP,50863,CDM,250,RC,J0615,HCPCS,68084-479-11,NDC,facility,both,116,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6007-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,636,RC,J2003,HCPCS,76329-3390-1,NDC,facility,both,200,ML,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),50863,CDM,636,RC,J1815,HCPCS,0024-5926-05,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COLCHICINE 0.6 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,70010-002-01,NDC,facility,both,1,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FERROUS SULFATE 325 MG (65 MG IRON) TAB,50863,CDM,636,RC,J3490,HCPCS,904759161,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,5026885511,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 20 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,68180-294-07,NDC,facility,both,3,EA,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PORACTANT ALFA 240 MG/3 ML INTR SUSP,50863,CDM,250,RC,J3490,HCPCS,10122-510-03,NDC,facility,both,2,ML,,6520,4564,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,63323-104-06,NDC,facility,both,13,ML,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  1 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,59746-171-06,NDC,facility,both,4,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE   4.2 % IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-083-05,NDC,facility,both,1,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 500 MG-125 MG TAB,50863,CDM,250,RC,J3490,HCPCS,65862-502-20,NDC,facility,both,1,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,72205-142-90,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE IV",50863,CDM,J3490,HCPCS,0338-0013-04,NDC,,,facility,both,1,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,J7040,HCPCS,0338-0049-04,NDC,,,facility,both,2,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63304-773-01,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MISOPROSTOL 800 MCG (4 X 200 MCG TAB) PACKAGE,50863,CDM,636,RC,S0191,HCPCS,43393-023-04,NDC,facility,both,3,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,10139-235-10,NDC,facility,both,1,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLEDRONIC ACID IN MANNITOL & WATER 5 MG/100 ML IV SOLN,50863,CDM,636,RC,J3489,HCPCS,67457-619-10,NDC,facility,both,5,ML,,832,582.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 8-2 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,60687-637-11,NDC,facility,both,3,EA,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0131-2480-35,NDC,facility,both,1,EA,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,250,RC,J0330,HCPCS,31722-981-10,NDC,facility,both,3,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0409-4699-24,NDC,facility,both,100,ML,,127,88.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,636,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 100 MG PE/2 ML INJ SOLN,50863,CDM,250,RC,Q2009,HCPCS,63323-403-01,NDC,facility,both,2,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE (DIAGNOSTIC) 3 MG/ML IV SOLN,50863,CDM,250,RC,J0153,HCPCS,55150-193-01,NDC,facility,both,180,ML,,1545,1081.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE IN 0.9% NACL 3 GRAM/100 ML IV SOLN,50863,CDM,250,RC,J0612,HCPCS,61553-056-48,NDC,facility,both,150,ML,JW,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CARBAMAZEPINE 100 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,60687-479-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50228-420-01,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESNA 100 MG/ML IV SOLN,50863,CDM,250,RC,J9209,HCPCS,25021-201-10,NDC,facility,both,5,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,636,RC,J3490,HCPCS,63323-563-97,NDC,facility,both,1,ML,,299,209.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION,50863,CDM,636,RC,J3490,HCPCS,0186-0372-28,NDC,facility,both,1,GM,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) 1000 UNITS/ML INJ SOL (FOR DIALYSIS ONLY),50863,CDM,250,RC,J1644,HCPCS,25021-400-10,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 1000 MG MISC TBSO,50863,CDM,J3490,HCPCS,904723961,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML IV SOLN (MERGE),50863,CDM,250,RC,J3490,HCPCS,70756-611-82,NDC,facility,both,1,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,250,RC,J2405,HCPCS,0409-4759-01,NDC,facility,both,16,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 10 MG TAB,50863,CDM,250,RC,Q0177,HCPCS,16714-081-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 100 % ORAL POWDER 238 GRAMS,50863,CDM,250,RC,J3490,HCPCS,43386-312-08,NDC,facility,both,1,GM,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-742-11,NDC,facility,both,8,EA,,165,115.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,50863,CDM,636,RC,J0696,HCPCS,0781-3209-90,NDC,facility,both,4,EA,JW,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,636,RC,J1596,HCPCS,10019-016-39,NDC,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN PEDS SYRINGE (20MG/ML) IN DEXTROSE (CDS MIX,50863,CDM,636,RC,J0690,HCPCS,0781-3451-70,NDC,facility,both,2,EA,JZ,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,636,RC,J3360,HCPCS,0409-1273-03,NDC,facility,both,2,ML,,198,138.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VECURONIUM BROMIDE 10 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,0703-2914-01,NDC,facility,both,10,EA,,419,293.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXALIPLATIN 100 MG/20 ML IV SOLN,50863,CDM,J9263,HCPCS,71288-171-11,NDC,,,facility,both,86,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE  5 MG/ML INJ SOLN,50863,CDM,636,RC,J2765,HCPCS,0409-3414-21,NDC,facility,both,2,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESVENLAFAXINE  50 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,60687-607-11,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,59651-488-01,NDC,facility,both,10,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  25 MG ORAL TAB,50863,CDM,J3490,HCPCS,68084-346-11,NDC,,,facility,both,4,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG ORAL TAB,50863,CDM,J3490,HCPCS,51079-442-01,NDC,,,facility,both,3,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 1000 MG MISC TBSO,50863,CDM,250,RC,J3490,HCPCS,0223-1760-01,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN IN 0.9 % NS 40 UNIT/100 ML (0.4 UNIT/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0338-9647-12,NDC,facility,both,1,ML,,149,104.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,70436-030-82,NDC,facility,both,36,ML,JW,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,250,RC,J2003,HCPCS,63323-208-01,NDC,facility,both,100,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUORESCEIN 1 MG OPHT STRP,50863,CDM,636,RC,J3490,HCPCS,8385110001,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE 14 MG/24 HR TD PT24,50863,CDM,250,RC,J3490,HCPCS,4898500150,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 50% IN WATER (MERGE RECORD),50863,CDM,636,RC,J7060,HCPCS,0409-7517-66,NDC,facility,both,1,ML,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) IV SOLN,50863,CDM,636,RC,J9220,HCPCS,81284-315-05,NDC,facility,both,4,ML,JZ,266,186.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CEFTRIAXONE 500 MG INJ SOLR,50863,CDM,250,RC,J0696,HCPCS,0409-7338-11,NDC,facility,both,8,EA,JZ,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
BELIMUMAB 120 MG IV SOLR,50863,CDM,636,RC,J0490,HCPCS,49401-101-01,NDC,facility,both,48,ME,,5638,3946.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN 125 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,51672-4069-2,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  125 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,62559-390-20,NDC,facility,both,4,EA,,451,315.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 150 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,16729-443-15,NDC,facility,both,3,EA,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-444-01,NDC,facility,both,7,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-631-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN PEDS INFUSION (CDS MIXTURE),50863,CDM,250,RC,J0290,HCPCS,25021-136-10,NDC,facility,both,3,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IV PGBK,50863,CDM,636,RC,J3475,HCPCS,0409-6729-11,NDC,facility,both,4,ML,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  125 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,62559-390-20,NDC,facility,both,17,EA,,1225,857.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),50863,CDM,J3490,HCPCS,0409-4888-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 0.75 MG (ENVARSUS XR) 24-HOUR EXTENDED-RELEASE TABLET,50863,CDM,250,RC,J7503,HCPCS,68992-3075-3,NDC,facility,both,3,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INHL NEBU,50863,CDM,250,RC,J3490,HCPCS,0487-9301-03,NDC,facility,both,5,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 50 MG/5 ML (10 MG/ML) IV SYRG,50863,CDM,250,RC,J3490,HCPCS,69374-924-05,NDC,facility,both,2,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,50863,CDM,250,RC,J0696,HCPCS,0143-9857-01,NDC,facility,both,4,EA,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,81033-002-30,NDC,facility,both,10,ML,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHOLECALCIFEROL (VITAMIN D3) 400 UNIT/ML ORAL DROP,50863,CDM,250,RC,J3490,HCPCS,7651805050,NDC,facility,both,2,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65862-076-01,NDC,facility,both,42,EA,,693,485.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BIVALIRUDIN 250 MG IV SOLR,50863,CDM,250,RC,J0583,HCPCS,71288-427-10,NDC,facility,both,250,EA,,357,249.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 150 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,0904-7505-61,NDC,facility,both,3,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIVAROXABAN 15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50458-578-01,NDC,facility,both,6,EA,,493,345.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,0378-7732-93,NDC,facility,both,1,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ORPHENADRINE CITRATE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J2360,HCPCS,25021-651-02,NDC,facility,both,1,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,68094-231-59,NDC,facility,both,5,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,25021-701-01,NDC,facility,both,1,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-5771-23,NDC,facility,both,3,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-985-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25 MG-100 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7501-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,636,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,7,EA,,107,74.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-442-01,NDC,facility,both,3,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,J3360,HCPCS,0641-6244-01,NDC,,,facility,both,1,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM BROMIDE 0.03 % NASL SPRA,50863,CDM,250,RC,J3490,HCPCS,60505-0826-1,NDC,facility,both,1,ML,,402,281.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,J2704,HCPCS,0069-0209-01,NDC,,,facility,both,65,ML,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,J3490,HCPCS,76329-3390-1,NDC,,,facility,both,100,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 1 MG/ML PCA (PDS MERGE),50863,CDM,250,RC,J3490,HCPCS,70092-1521-74,NDC,facility,both,1,ML,,154,107.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRASUGREL 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60505-4642-3,NDC,facility,both,1,EA,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7123-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSP,50863,CDM,J3490,HCPCS,60687-429-45,NDC,,,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR PHOSPHATE 30 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0527-4591-13,NDC,facility,both,1,EA,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-8515-23,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6642-61,NDC,facility,both,3,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,636,RC,J3490,HCPCS,23155-166-31,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-815-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 16 MG ORAL TAB,50863,CDM,636,RC,J7509,HCPCS,59762-0050-1,NDC,facility,both,6,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LANSOPRAZOLE 15 MG ORAL TBLD,50863,CDM,250,RC,J3490,HCPCS,68382-771-30,NDC,facility,both,1,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,72,ML,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LANSOPRAZOLE 15 MG ORAL TBLD,50863,CDM,250,RC,J3490,HCPCS,68382-771-30,NDC,facility,both,2,EA,,155,108.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  500 MG IV SOLR,50863,CDM,250,RC,J3370,HCPCS,0143-9161-01,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,50863,CDM,636,RC,J2359,HCPCS,55150-308-01,NDC,facility,both,5,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"HEPARIN, PORCINE (PF)   10 UNIT/ML IV SYRG",50863,CDM,250,RC,J1642,HCPCS,8290306413,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 100 MG/ML FROM 1 GRAM VIAL (PRMC PEDS ONLY),50863,CDM,636,RC,J0696,HCPCS,0409-7332-11,NDC,facility,both,2,EA,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
NYSTATIN 100000 UNIT/ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,63739-160-70,NDC,facility,both,40,ML,,281,196.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J2003,HCPCS,63323-492-57,NDC,facility,both,100,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 10 GRAM IV SOLR,50863,CDM,250,RC,J3370,HCPCS,0143-9164-01,NDC,facility,both,4,EA,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 3000 MCG/ML INJECTION,50863,CDM,250,RC,J0153,HCPCS,67457-855-00,NDC,facility,both,12,ML,JZ,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0093-2279-73,NDC,facility,both,4,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN IN D5W 600 MG/50 ML IV PGBK,50863,CDM,250,RC,J0736,HCPCS,0338-3612-50,NDC,facility,both,2,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-980-01,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALSARTAN  80 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-623-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,55150-161-02,NDC,facility,both,40,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE 14 MG/24 HR TD PT24,50863,CDM,636,RC,J3490,HCPCS,1093986244,NDC,facility,both,3,EA,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPTOMYCIN 500 MG IV SOLR,50863,CDM,J0878,HCPCS,0409-0122-01,NDC,,,facility,both,700,EA,,563,394.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROPROCAINE 3 % INJ SOLN,50863,CDM,250,RC,J2401,HCPCS,63323-478-01,NDC,facility,both,462,ML,JW,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PHENYLEPHRINE HCL IN NS 10 MG/250 ML (0.04 MG/ML) IV SOLN (PDS MERGE),50863,CDM,250,RC,J2371,HCPCS,71506-029-58,NDC,facility,both,500,ML,,146,102.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL (NEO/PEDS),50863,CDM,250,RC,J3490,HCPCS,63323-820-00,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE NA (PRESERV FREE) 25 MG/ML INJ SOLN,50863,CDM,250,RC,J9260,HCPCS,61703-408-41,NDC,facility,both,120,ML,,1294,905.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZIPRASIDONE 40 MG CAP,50863,CDM,636,RC,J3490,HCPCS,50268-812-11,NDC,facility,both,2,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALUM-MAG HYDROXIDE-SIMETH 200 MG-200 MG-20 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,70677-1063-1,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTAZIDIME-AVIBACTAM 2.5 GRAM (2 GRAM-0.5 GRAM) IV SOLR,50863,CDM,250,RC,J0714,HCPCS,0456-2700-01,NDC,facility,both,5,EA,,1160,812,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,63323-010-02,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DROPERIDOL 2.5 MG/ML INJ SOLN,50863,CDM,250,RC,J1790,HCPCS,0517-9702-01,NDC,facility,both,1,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-ABDA 100 MG IV SOLR,50863,CDM,636,RC,Q5104,HCPCS,78206-162-99,NDC,facility,both,60,EA,JZ,12477,8733.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LEVOTHYROXINE  88 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-486-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0003-0894-31,NDC,facility,both,1,EA,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 50% IN WATER (MERGE RECORD),50863,CDM,250,RC,J7060,HCPCS,0409-6648-02,NDC,facility,both,2,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,250,RC,J3490,HCPCS,55150-188-10,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 25 MG TAB,50863,CDM,J3490,HCPCS,51079-255-01,NDC,,,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN   1.5 G IV SOLR,50863,CDM,J3373,HCPCS,67457-824-15,NDC,,,facility,both,150,EA,,142,99.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN STERILE WATER 2 GRAM/20 ML IV SYRG,50863,CDM,636,RC,J7999,HCPCS,70092-1604-47,NDC,facility,both,5,ML,,261,182.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CANGRELOR 50 MG IV SOLR,50863,CDM,636,RC,C9460,HCPCS,10122-620-01,NDC,facility,both,50,EA,,2635,1844.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,250,RC,J2003,HCPCS,76329-3390-1,NDC,facility,both,200,ML,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 1 GRAM INJ SOLR,50863,CDM,250,RC,J0692,HCPCS,0409-9566-01,NDC,facility,both,6,EA,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXAZOSIN 8 MG ORAL TAB,50863,CDM,J3490,HCPCS,50268-225-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEMECLOCYCLINE 150 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,53746-554-01,NDC,facility,both,2,EA,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,19,ML,JW,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ACIDOPHILUS-PECTIN W CITRUS 25 MILLION-100 CELL MG TAB,50863,CDM,250,RC,J3490,HCPCS,8068102600,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACIDOPHILUS-PECTIN W CITRUS 25 MILLION-100 CELL MG TAB,50863,CDM,250,RC,J3490,HCPCS,17856002601,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1 TABLET
FLUOXETINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50228-420-01,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,636,RC,J3490,HCPCS,0409-1323-15,NDC,facility,both,100,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 30 MG/0.3 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,25021-410-70,NDC,facility,both,3,ML,JZ,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-492-57,NDC,,,facility,both,100,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,13,ML,JW,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,37,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE (FOR EMERGENCY) 100 MG/ML (10%) IV SOLN,50863,CDM,J0612,HCPCS,63323-360-01,NDC,,,facility,both,200,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE IN 0.9 % SOD CHLOR 4 MG/250 ML (16 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-315-01,NDC,facility,both,1,ML,,389,272.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE (POLACRILEX) 2 MG MM LOZG,50863,CDM,250,RC,J3490,HCPCS,45802-344-03,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  100 MCG/ML INJ SOLN,50863,CDM,636,RC,J2354,HCPCS,63323-376-00,NDC,facility,both,2,ML,JW,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,50863,CDM,636,RC,J9171,HCPCS,67457-533-16,NDC,facility,both,212,ML,,2012,1408.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,17271-701-05,NDC,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0054-0710-20,NDC,facility,both,14,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GAMMAGARD LIQUID 10 % IV SOLN,50863,CDM,636,RC,J1569,HCPCS,0944-2700-10,NDC,facility,both,10,ML,JZ,1803,1262.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,3,EA,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-3212-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,59651-488-01,NDC,facility,both,120,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,4,ML,,6937,4855.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,250,RC,J2720,HCPCS,63323-229-01,NDC,facility,both,3,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM NEO IV SYRINGE (PHS FROM PREMIX),50863,CDM,250,RC,J1953,HCPCS,44567-501-01,NDC,facility,both,9,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 20 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7346-61,NDC,facility,both,4,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,72603-179-01,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 500 MG IV SOLR,50863,CDM,636,RC,J9075,HCPCS,0781-3233-94,NDC,facility,both,99,EA,JW,408,285.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,42806-150-33,NDC,facility,both,3,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE (FOR CODE) 10% IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0517-6710-01,NDC,facility,both,1,ML,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PYRIDOXINE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,5026885811,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPRAZOLAM 0.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0228-2029-10,NDC,facility,both,4,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,70069-013-25,NDC,facility,both,5,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,63323-482-27,NDC,facility,both,200,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FIDAXOMICIN 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,52015-080-01,NDC,facility,both,1,EA,,882,617.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,1,EA,JW,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PREDNISONE 50 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,59651-489-01,NDC,facility,both,95,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60505-3113-0,NDC,facility,both,3,EA,,254,177.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9% IV (PEDS) BOLUS,50863,CDM,250,RC,J7040,HCPCS,0264-7800-09,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,71288-505-02,NDC,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR NEO/PEDS INFUSION (CDS FROM PREMIX),50863,CDM,250,RC,J0133,HCPCS,63323-325-10,NDC,facility,both,19,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM IODIDE 1 GRAM/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,71740-112-30,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE (PF-DURAMORPH/ASTRAMORPH) 0.5 MG/ML INJ SOLN,50863,CDM,250,RC,J2274,HCPCS,0409-3814-12,NDC,facility,both,1,ML,,142,99.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 2-0.5 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,50268-144-11,NDC,facility,both,6,EA,,140,98,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE (3 MONTH) 22.5 MG IM SYRG,50863,CDM,250,RC,J9217,HCPCS,0074-3346-03,NDC,facility,both,3,EA,,1176,823.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOVASTATIN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,61442-142-01,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,72266-118-01,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-3244-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-464-02,NDC,facility,both,1,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7914-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 25% IN WATER (D25W) IV SYRINGE,50863,CDM,636,RC,J3490,HCPCS,0409-1775-40,NDC,facility,both,1,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6475-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 100 MG PE/2 ML INJ SOLN,50863,CDM,250,RC,Q2009,HCPCS,63323-403-01,NDC,facility,both,6,ML,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-6008-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENFORTUMAB VEDOTIN-EJFV 20 MG IV SOLR,50863,CDM,J9177,HCPCS,51144-020-01,NDC,,,facility,both,140,ME,,10192,7134.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,636,RC,J0132,HCPCS,72611-860-01,NDC,facility,both,120,ML,,435,304.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIROFIBAN-0.9% SODIUM CHLORIDE 5 MG/100 ML (50 MCG/ML) IV SOLN,50863,CDM,250,RC,J3246,HCPCS,25208-002-03,NDC,facility,both,11,ML,JW,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
FILGRASTIM-SNDZ 480 MCG/0.8 ML INJ SYRG,50863,CDM,636,RC,Q5101,HCPCS,61314-326-05,NDC,facility,both,480,ML,JZ,1212,848.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
METHADONE 10 MG/ML ORAL CONC,50863,CDM,636,RC,J3490,HCPCS,0054-3553-44,NDC,facility,both,6,ML,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,63739-903-10,NDC,facility,both,1,EA,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,78206-121-01,NDC,facility,both,2,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-492-37,NDC,,,facility,both,300,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALUM-MAG HYDROXIDE-SIMETH 200 MG-200 MG-20 MG/5 ML ORAL SUSP,50863,CDM,J3490,HCPCS,17856-0630-1,NDC,,,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML INJECTION,50863,CDM,636,RC,J3411,HCPCS,72603-139-25,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN  200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,10135-681-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 0.5 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,63323-481-01,NDC,facility,both,150,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMULSION 20 % IV EMUL,50863,CDM,250,RC,j3490,HCPCS,0338-0519-09,NDC,facility,both,1,ML,,240,168,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,250,RC,J0132,HCPCS,72611-860-01,NDC,facility,both,240,ML,,869,608.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-5755-23,NDC,facility,both,23,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM CITRATE ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,70677-1111-1,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,23,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6292-61,NDC,facility,both,2,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHIMAZOLE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-669-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLP",50863,CDM,636,RC,P9047,HCPCS,0944-0493-04,NDC,facility,both,2,ML,,501,350.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,250,RC,J3490,HCPCS,72789-057-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOVASTATIN 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,61442-142-01,NDC,facility,both,2,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,65219-572-01,NDC,facility,both,4,ML,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,96,ML,JW,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
TRIMETHOPRIM-SULFAMETHOXAZOLE 160 MG-800 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0904-2725-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,65862-707-80,NDC,facility,both,10,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,50863,CDM,J3420,HCPCS,70069-005-01,NDC,,,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,15,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MYCOPHENOLATE 500 MG TAB,50863,CDM,250,RC,J7517,HCPCS,0054-0166-25,NDC,facility,both,5,EA,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 750 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,59651-873-50,NDC,facility,both,1,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LANTHANUM  500 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,54092-252-45,NDC,facility,both,2,EA,,141,98.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0245-0147-89,NDC,facility,both,1,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  20 MEQ ORAL PACK,50863,CDM,636,RC,J3490,HCPCS,72888-024-06,NDC,facility,both,1,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2305-16,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,63739-931-14,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,636,RC,J3490,HCPCS,51754-4250-1,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,52817-180-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,2055503601,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-739-41,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69315-904-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL  4 MG ORAL TAB,50863,CDM,636,RC,Q0162,HCPCS,65862-187-30,NDC,facility,both,8,EA,,237,165.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,636,RC,J2003,HCPCS,0409-1323-05,NDC,facility,both,1100,ML,,440,308,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMINOCAPROIC ACID 25 % ORAL SYRP,50863,CDM,250,RC,J3490,HCPCS,52817-815-08,NDC,facility,both,1,ML,,389,272.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FERRIC SUBSULFATE 0.2 TO 0.22 GRAM/ML MISC SOLA,50863,CDM,636,RC,J3490,HCPCS,48783-112-08,NDC,facility,both,4,ML,,211,147.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7363-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESNA 100 MG/ML IV SOLN,50863,CDM,250,RC,J9209,HCPCS,10019-953-62,NDC,facility,both,19,ML,,534,373.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 875 MG-125 MG TAB,50863,CDM,636,RC,J3490,HCPCS,60687-803-11,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,6,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 5 MG/ML INHL NEB CONTINUOUS,50863,CDM,636,RC,J3490,HCPCS,69374-330-05,NDC,facility,both,8,ML,,340,238,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68180-969-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,250,RC,J3490,HCPCS,63037-136-25,NDC,facility,both,2,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7369-04,NDC,facility,both,2,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0781-6041-46,NDC,facility,both,14,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MUPIROCIN 2 % TOP OINT,50863,CDM,250,RC,J3490,HCPCS,0093-1010-42,NDC,facility,both,1,GM,,363,254.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6374-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMANTADINE 50 MG/5 ML ORAL SYRP,50863,CDM,250,RC,J3490,HCPCS,0121-0646-16,NDC,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE 100 MG ORAL CAP,50863,CDM,636,RC,J7502,HCPCS,0078-0241-61,NDC,facility,both,1,EA,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,10,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  30 MG ORAL TBSR,50863,CDM,636,RC,J3490,HCPCS,0904-6558-61,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0121-0945-10,NDC,facility,both,2,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"CALCIUM GLUC IN NACL, ISO-OSM 1 G/100 ML IV SOLN",50863,CDM,636,RC,J0612,HCPCS,44567-622-01,NDC,facility,both,100,ML,JZ,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
23.4% SODIUM CHLORIDE (4 MEQ/ML) INJECTION,50863,CDM,250,RC,J3490,HCPCS,63323-187-30,NDC,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,71288-402-10,NDC,facility,both,7,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,50863,CDM,636,RC,J0561,HCPCS,60793-700-01,NDC,facility,both,24,ML,,3018,2112.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0591-0605-01,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,63323-461-01,NDC,facility,both,1,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,16714-036-01,NDC,facility,both,3,ML,JW,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,227,ML,,160,112,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROPRUSSIDE 25 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,43598-587-23,NDC,facility,both,2,ML,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0093-4177-73,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 50 MG TAB,50863,CDM,250,RC,J3490,HCPCS,51079-801-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0093-4177-73,NDC,facility,both,2,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-722-11,NDC,facility,both,4,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 25 MG TAB,50863,CDM,250,RC,J3490,HCPCS,16714-796-01,NDC,facility,both,1,EA,,133,93.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"METHYLPREDNISOLONE 1,000 MG SOLUTION FOR INJECTION",50863,CDM,636,RC,J2919,HCPCS,0009-0698-01,NDC,facility,both,200,EA,,224,156.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 100 MG SOLUTION FOR INJECTION,50863,CDM,250,RC,J1720,HCPCS,0009-0825-01,NDC,facility,both,1,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),50863,CDM,636,RC,J2060,HCPCS,0641-6001-01,NDC,facility,both,2,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFPODOXIME 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16714-395-01,NDC,facility,both,1,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN,50863,CDM,636,RC,Q9968,HCPCS,70710-1838-1,NDC,facility,both,49,ML,JW,276,193.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LEUCOVORIN 1 MG/ML INJECTION (PEDS ONCOLOGY),50863,CDM,250,RC,J0640,HCPCS,71288-160-10,NDC,facility,both,1,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE 250 MG/5 ML IV SOLN,50863,CDM,250,RC,J7516,HCPCS,0078-0109-61,NDC,facility,both,1,ML,,363,254.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,71288-402-10,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,42,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,260,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-50,NDC,facility,both,34,ML,JW,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CLOTRIMAZOLE  10 MG MM TROC,50863,CDM,250,RC,J3490,HCPCS,0054-8146-22,NDC,facility,both,1,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,51754-5001-1,NDC,facility,both,1,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-2051-15,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIOGLITAZONE 30 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,33342-055-07,NDC,facility,both,1,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE IN 0.9% NS (PF) 1 MG/10 ML (100 MCG/ML) IV SYRG(PDS MERGE),50863,CDM,250,RC,J3490,HCPCS,65302-506-10,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOMYCIN 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-1177-01,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE  50 MG ORAL TAB,50863,CDM,250,RC,j3490,HCPCS,68382-805-01,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,10,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,636,RC,J1953,HCPCS,0409-1886-22,NDC,facility,both,150,ML,JZ,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLN,50863,CDM,636,RC,J3262,HCPCS,50242-137-01,NDC,facility,both,800,ML,,14661,10262.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-299-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROMETHORPHAN-GUAIFENESIN SR 30 MG-600 MG 12 HR TAB,50863,CDM,250,RC,J3490,HCPCS,6382405620,NDC,facility,both,6,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTOBACILLUS ACIDOPHILUS 500 MILLION CELLS ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,7733300415,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,636,RC,J3490,HCPCS,71266-9080-4,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM BROMIDE 0.02 % INHL SOLN,50863,CDM,250,RC,J3490,HCPCS,60687-394-79,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 100 MG/1 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,16714-046-10,NDC,facility,both,10,ML,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-103-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN PEDS SYRINGE (20MG/ML) IN DEXTROSE (CDS MIX,50863,CDM,250,RC,J0690,HCPCS,0781-3451-70,NDC,facility,both,4,EA,,158,110.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRBESARTAN  75 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,43547-374-03,NDC,facility,both,4,EA,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,14789-251-09,NDC,facility,both,6,ML,,1321,924.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 80 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0054-8301-25,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IV PGBK,50863,CDM,250,RC,J3490,HCPCS,0264-4204-52,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE-EPINEPHR-TETRACAINE 4-0.18-0.5 % TOPICAL GEL,50863,CDM,636,RC,J3490,HCPCS,71266-6290-1,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LET TOPICAL GEL 3 ML,50863,CDM,J3490,HCPCS,70092-1611-44,NDC,,,facility,both,1,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYMETAZOLINE 0.05 % NASAL MERGE,50863,CDM,J3490,HCPCS,70677-1037-1,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 600 MG ORAL TP12,50863,CDM,J3490,HCPCS,68084-572-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,636,RC,J2405,HCPCS,70860-776-41,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE(PF)-0.9 % SODCHLOR 0.2 % 745 ML LINF ELPH,50863,CDM,250,RC,J3490,HCPCS,71449-079-57,NDC,facility,both,1,ML,,1315,920.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NAFCILLIN NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J3490,HCPCS,63323-327-10,NDC,facility,both,3,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J2250,HCPCS,0409-0001-01,NDC,facility,both,2,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J2003,HCPCS,0409-4279-02,NDC,facility,both,300,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 100 MG IV SOLR,50863,CDM,250,RC,J2997,HCPCS,50242-085-25,NDC,facility,both,1,EA,,243,170.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT 100 MCG/0.5 ML INJ SYRG,50863,CDM,636,RC,J0881,HCPCS,55513-025-01,NDC,facility,both,100,ML,,2137,1495.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 0.5 MG ORAL CAP,50863,CDM,636,RC,J7507,HCPCS,68462-685-01,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MINOXIDIL  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-204-11,NDC,facility,both,8,EA,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,636,RC,J7060,HCPCS,0338-0017-04,NDC,facility,both,2,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN   81 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,69618-066-02,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-027-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0131-2477-60,NDC,facility,both,2,EA,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,59762-0074-1,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,44567-600-04,NDC,facility,both,2,ML,,440,308,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,7,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2308-22,NDC,facility,both,10,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
WARFARIN  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,57237-120-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM  3 GRAM INJ SOLR,50863,CDM,250,RC,J0295,HCPCS,72485-417-01,NDC,facility,both,2,EA,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,73,ML,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0781-2020-01,NDC,facility,both,42,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-01,NDC,facility,both,2,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,70,EA,,9660,6762,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE 22.5 MG SUBQ SYRG,50863,CDM,636,RC,J9217,HCPCS,62935-227-10,NDC,facility,both,3,EA,JZ,1176,823.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-464-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,636,RC,J1836,HCPCS,25021-131-82,NDC,facility,both,50,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TICAGRELOR 90 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,72205-368-91,NDC,facility,both,7,EA,,179,125.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,40,ML,,282,197.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOCONAZOLE 2 % TOP CREA,50863,CDM,636,RC,J3490,HCPCS,51672-1298-1,NDC,facility,both,1,GM,,473,331.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,50863,CDM,636,RC,J0585,HCPCS,0023-1145-01,NDC,facility,both,230,EA,,3676,2573.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,72611-722-25,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 20 MG/ML INJ SOLN,50863,CDM,250,RC,J0360,HCPCS,0517-0901-25,NDC,facility,both,1,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE 2 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,60687-481-11,NDC,facility,both,4,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSULFAN BLUE 1 % INJ SOLN,50863,CDM,636,RC,Q9968,HCPCS,67457-220-00,NDC,facility,both,40,ML,JW,1166,816.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
LIDOCAINE HCL  2 % MM JELP,50863,CDM,250,RC,J3490,HCPCS,76329-3012-5,NDC,facility,both,2,ML,PLAD,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-1749-71,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J1938,HCPCS,63323-280-04,NDC,facility,both,40,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7728-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,0904-6794-80,NDC,facility,both,2,EA,PLAD,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,25,EA,JZ,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
OXYCODONE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,42858-001-10,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,10135-676-01,NDC,facility,both,1,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,636,RC,J1100,HCPCS,63323-506-00,NDC,facility,both,20,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 112 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-508-11,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % MBP,50863,CDM,250,RC,J3490,HCPCS,0338-9159-30,NDC,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 20 MG/ML INJ SOLN,50863,CDM,636,RC,J0360,HCPCS,0641-6231-01,NDC,facility,both,1,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  125 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,62559-390-20,NDC,facility,both,2,EA,,266,186.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INHL NEBU,50863,CDM,250,RC,J3490,HCPCS,0487-9301-03,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFIXIME 100 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,68180-405-01,NDC,facility,both,1,ML,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 500 MG/10 ML IV SOLN,50863,CDM,J9190,HCPCS,63323-117-01,NDC,,,facility,both,3,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM NEO/PED INFUSION (CDS MIXTURE),50863,CDM,250,RC,J2185,HCPCS,0781-3267-90,NDC,facility,both,3,EA,,178,124.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,63323-162-00,NDC,facility,both,4,ML,JZ,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
POTASSIUM CHLORIDE 10 MEQ/100 ML IV PGBK (USE NON-PROTOCOL PANEL),50863,CDM,250,RC,J3480,HCPCS,0338-0709-48,NDC,facility,both,5,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0143-9889-15,NDC,facility,both,11,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN IN D5W 300 MG/50 ML IV PGBK,50863,CDM,250,RC,J0736,HCPCS,0338-3410-50,NDC,facility,both,2,ML,JZ,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
BUPROPION HCL 150 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,43598-655-30,NDC,facility,both,2,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,636,RC,J3490,HCPCS,0409-4887-23,NDC,facility,both,2,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2305-16,NDC,facility,both,8,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,FAMNOCHARGE,HCPCS,17856-0759-5,NDC,,,facility,both,3,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 0.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-544-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1560-18,NDC,facility,both,200,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,50863,CDM,636,RC,Q0177,HCPCS,60687-675-11,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZINC OXIDE 20 % TOP OINT (REPACK),50863,CDM,636,RC,J3490,HCPCS,0536-1316-28,NDC,facility,both,1,GM,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICLOFENAC 1 % TOPICAL GEL,50863,CDM,636,RC,J3490,HCPCS,43598-977-10,NDC,facility,both,1,GM,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1940,HCPCS,0409-6102-18,NDC,facility,both,20,ML,,196,137.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ELECTROLYTE-A IV,50863,CDM,250,RC,J3490,HCPCS,0338-0221-03,NDC,facility,both,2,ML,,167,116.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES 8.8 MG/5 ML ORAL SYRP,50863,CDM,250,RC,J3490,HCPCS,71399-0027-8,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 50 MG/5 ML (10 MG/ML) IV SYRG,50863,CDM,250,RC,J3490,HCPCS,71266-9005-5,NDC,facility,both,2,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J2003,HCPCS,63323-492-07,NDC,facility,both,300,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J2003,HCPCS,55150-161-02,NDC,facility,both,20,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0143-9889-15,NDC,facility,both,14,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-ABDA 100 MG IV SOLR,50863,CDM,636,RC,Q5104,HCPCS,78206-162-99,NDC,facility,both,4,EA,JW,362,253.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,62559-440-02,NDC,facility,both,1,ML,,182,127.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,51079-169-01,NDC,facility,both,2,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,50863,CDM,250,RC,J2359,HCPCS,55150-308-01,NDC,facility,both,10,EA,JZ,104,72.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,6,EA,,205,143.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIVAROXABAN  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50458-577-01,NDC,facility,both,8,EA,,406,284.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LINACLOTIDE 145 MCG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0456-1201-30,NDC,facility,both,2,EA,,212,148.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 1 MG ORAL TAB,50863,CDM,250,RC,J8540,HCPCS,0054-8174-25,NDC,facility,both,4,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,43547-282-10,NDC,facility,both,2,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,0641-6028-01,NDC,facility,both,5,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 300 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68180-976-09,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN DETEMIR 100 UNIT/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,0169-3687-12,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1940,HCPCS,23155-473-33,NDC,facility,both,5,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,63323-806-13,NDC,facility,both,5,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESMOLOL  100 MG/10 ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-652-10,NDC,facility,both,1,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MOXIFLOXACIN 400 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0093-7387-56,NDC,facility,both,4,EA,,393,275.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN V POTASSIUM 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-234-01,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0143-9509-01,NDC,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-5771-23,NDC,facility,both,8,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0143-9595-01,NDC,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7007-61,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-739-11,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,636,RC,Q0162,HCPCS,65162-691-79,NDC,facility,both,2,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,J3490,HCPCS,68094-231-59,NDC,,,facility,both,2,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BIVALIRUDIN 250 MG IV SOLR,50863,CDM,250,RC,J0583,HCPCS,55150-210-10,NDC,facility,both,250,EA,,432,302.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 200 MG/100 ML IVPB (MERGE),50863,CDM,250,RC,J1450,HCPCS,0409-3435-01,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,72888-060-30,NDC,facility,both,1,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,J1580,HCPCS,63323-010-03,NDC,,,facility,both,3,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0904-6923-61,NDC,facility,both,80,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 10 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,0641-0367-21,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR 200 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,31722-681-47,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-492-04,NDC,,,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM  1.5 GRAM INJ SOLR,50863,CDM,636,RC,J0295,HCPCS,44567-210-10,NDC,facility,both,1,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLN (MERGE)",50863,CDM,636,RC,P9047,HCPCS,64208-2512-8,NDC,facility,both,6,ML,,713,499.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,35,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,60505-3276-0,NDC,facility,both,4,EA,,356,249.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0641-6059-01,NDC,facility,both,15,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 150 MG/1 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0548-5607-00,NDC,facility,both,1,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DARBEPOETIN ALFA IN POLYSORBAT  60 MCG/0.3 ML INJ SYRG,50863,CDM,636,RC,J0881,HCPCS,55513-023-01,NDC,facility,both,60,ML,"JZ,EC,PLAD",1282,897.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier EC: Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy | Modifier PLAD: Modifier description not available
EPINEPHRINE HCL IN 5% DEXTROSE 100 MCG/10 ML (10 MCG/ML) IV SYRG,50863,CDM,250,RC,J0169,HCPCS,70092-1688-46,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,67877-433-03,NDC,facility,both,2,EA,,272,190.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,68516-5214-4,NDC,facility,both,14,ML,,1997,1397.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-354-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-090-11,NDC,facility,both,1,EA,,150,105,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,63323-806-13,NDC,facility,both,6,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,3,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM & SODIUM PHOSPHATES 280-160-250 MG ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,7135101001,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,42858-001-10,NDC,facility,both,8,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC ADMIN RESPIRATORY SYNCYTIAL VIRUS MONOCLONAL ANTIBODY SEASONAL DOSE INTRAMUSCULAR INJECTION,50863,CDM,250,RC,90381,HCPCS,49281-574-88,NDC,facility,both,1,ML,,1535,1074.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  25 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,69238-1310-9,NDC,facility,both,6,EA,,215,150.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 0.1 % TOP CREAM,50863,CDM,250,RC,J3490,HCPCS,0168-0004-15,NDC,facility,both,1,GM,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,250,RC,J7999,HCPCS,70092-1017-46,NDC,facility,both,6,ML,,119,83.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCAINAMIDE 100 MG/ML INJ SOLN,50863,CDM,250,RC,J2690,HCPCS,0409-1902-11,NDC,facility,both,1,ML,,577,403.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,0338-0072-25,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 500 MG-125 MG TAB,50863,CDM,250,RC,J3490,HCPCS,16714-296-01,NDC,facility,both,4,EA,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-8515-23,NDC,facility,both,2,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  500 MG IV SOLR,50863,CDM,250,RC,J3373,HCPCS,63323-221-01,NDC,facility,both,50,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GRANISETRON 1 MG/ML (1 ML) IV SOLN,50863,CDM,636,RC,J1626,HCPCS,0143-9744-01,NDC,facility,both,10,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE NA (PRESERV FREE) 25 MG/ML INJ SOLN,50863,CDM,250,RC,J9260,HCPCS,61703-408-41,NDC,facility,both,140,ML,,1509,1056.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLP",50863,CDM,250,RC,P9047,HCPCS,0944-0493-04,NDC,facility,both,1,ML,JW,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
METHOCARBAMOL 100 MG/ML INJ SOLN,50863,CDM,636,RC,J2800,HCPCS,63323-778-21,NDC,facility,both,1,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,0409-3795-19,NDC,facility,both,2,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL  6.25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-854-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-6666-61,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,70860-406-41,NDC,facility,both,3,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,50863,CDM,250,RC,Q0177,HCPCS,63739-486-10,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,636,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,7,ML,JW,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,636,RC,P9045,HCPCS,13533-690-25,NDC,facility,both,2,ML,,434,303.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,636,RC,J1939,HCPCS,25021-321-04,NDC,facility,both,2,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DENOSUMAB-BBDZ 60 MG/ML SUBQ SYRG,50863,CDM,636,RC,Q5136,HCPCS,61314-240-63,NDC,facility,both,1,ML,JZ,4428,3099.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MEDROXYPROGESTERONE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0555-0873-02,NDC,facility,both,6,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALACYCLOVIR 500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-215-11,NDC,facility,both,8,EA,,156,109.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 10 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,55150-305-01,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"NEOMYCIN-POLYMYXIN-PRAMOXINE 3.5 MG-10,000 UNIT-10 MG/G TOPICAL CREAM",50863,CDM,250,RC,J3490,HCPCS,81073794,NDC,facility,both,2,GM,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHOTERICIN B LIPOSOME 50 MG IV SUSR,50863,CDM,250,RC,J0289,HCPCS,55150-365-01,NDC,facility,both,10,EA,,1804,1262.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE 2 MG SL SUBL,50863,CDM,636,RC,J3490,HCPCS,60687-481-11,NDC,facility,both,6,EA,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-492-27,NDC,,,facility,both,40,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J3490,HCPCS,0338-1055-48,NDC,facility,both,50,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MODAFINIL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-570-11,NDC,facility,both,3,EA,,260,182,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,J3490,HCPCS,0406-0552-23,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,72205-142-90,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7366-04,NDC,facility,both,2,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % MBP,50863,CDM,250,RC,J3490,HCPCS,0338-0553-18,NDC,facility,both,8,ML,,355,248.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J2003,HCPCS,55150-161-02,NDC,facility,both,20,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RACEPINEPHRINE 2.25 % INHL NEBU,50863,CDM,J3490,HCPCS,0487-5901-99,NDC,,,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCRALFATE 100 MG/ML ORAL SUSP,50863,CDM,J3490,HCPCS,0121-0974-10,NDC,,,facility,both,2,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MILRINONE INFUSION PED/NEO IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J2260,HCPCS,99999-0406-26,NDC,facility,both,2,ML,,231,161.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOPIDOGREL 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6467-10,NDC,facility,both,1,EA,PLAD,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
ROMIPLOSTIM 125 MCG SUBQ SOLR,50863,CDM,636,RC,J2796,HCPCS,55513-223-01,NDC,facility,both,50,EA,,10260,7182,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN PEDS INFUSION (CDS MIXTURE),50863,CDM,250,RC,J0290,HCPCS,25021-136-10,NDC,facility,both,4,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,J3490,HCPCS,10702-018-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J2003,HCPCS,73293-0001-1,NDC,facility,both,200,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),50863,CDM,250,RC,J1815,HCPCS,0024-5926-05,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,43547-351-10,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,250,RC,J3360,HCPCS,0409-1273-03,NDC,facility,both,3,ML,,297,207.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (NEO) <2 KG,50863,CDM,636,RC,J7060,HCPCS,0264-7510-00,NDC,facility,both,2,ML,JZ,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,68516-5219-0,NDC,facility,both,16,ML,,4067,2846.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE-SALMETEROL 250 MCG-50 MCG/DOSE DISK DEVICE FOR INHALATION,50863,CDM,250,RC,J3490,HCPCS,66993-585-97,NDC,facility,both,1,EA,,1311,917.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOFLOXACIN IN D5W 500 MG/100 ML IV PGBK,50863,CDM,250,RC,J1956,HCPCS,0143-9721-01,NDC,facility,both,2,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,50863,CDM,636,RC,J1885,HCPCS,72266-119-01,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIFAXIMIN 550 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,65649-303-03,NDC,facility,both,1,EA,,294,205.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0406-8515-23,NDC,facility,both,2,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML INJ SOLN,50863,CDM,250,RC,J2060,HCPCS,0409-1985-03,NDC,facility,both,2,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,7,EA,,232,162.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INDOMETHACIN 50 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,50268-431-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-0710-20,NDC,facility,both,17,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,31722-711-30,NDC,facility,both,1,EA,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  500 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,0641-6176-01,NDC,facility,both,48,ML,JA,493,345.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
INSULIN NPH & REGULAR HUMAN 100 UNIT/ML (70-30) SUBQ SUSP,50863,CDM,250,RC,J1815,HCPCS,0002-8715-01,NDC,facility,both,7,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,63323-010-02,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 500 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,16714-299-02,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7912-51,NDC,facility,both,20,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE CONCENTRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0054-0404-44,NDC,facility,both,2,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 500 MG PE/10 ML INJ SOLN,50863,CDM,636,RC,Q2009,HCPCS,0641-6137-01,NDC,facility,both,40,ML,,967,676.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,4,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL (5 MG/ML) IV SYRG (CONTAINS PRESERVATIVE),50863,CDM,250,RC,J3490,HCPCS,0409-2339-24,NDC,facility,both,2,ML,,107,74.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROTHIAZIDE SODIUM 500 MG IV SOLR,50863,CDM,250,RC,J1205,HCPCS,17478-419-40,NDC,facility,both,1,EA,,450,315,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,16714-294-01,NDC,facility,both,6,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE (POLACRILEX) 2 MG BUCL GUM,50863,CDM,636,RC,J3490,HCPCS,49348-691-36,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ (MERGE),50863,CDM,636,RC,J2250,HCPCS,70069-817-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),50863,CDM,250,RC,J3490,HCPCS,0409-4888-03,NDC,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MINERAL OIL ENEMA,50863,CDM,636,RC,J3490,HCPCS,0363-0006-11,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICLOFENAC 1 % TOPICAL GEL,50863,CDM,250,RC,J3490,HCPCS,76282-663-39,NDC,facility,both,1,GM,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1MG/ML ORAL SOLUTION (HIGH CONC FOR PEDS),50863,CDM,250,RC,J3490,HCPCS,99999-407-47,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,300,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL,50863,CDM,250,RC,J3490,HCPCS,63323-820-01,NDC,facility,both,1,ML,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
UREA 15 GRAM PACKET,50863,CDM,250,RC,J3490,HCPCS,99999-0405-84,NDC,facility,both,2,EA,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,67877-545-68,NDC,facility,both,9,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE (PF-DURAMORPH/ASTRAMORPH) 0.5 MG/ML INJ SOLN,50863,CDM,250,RC,J2274,HCPCS,0409-3814-12,NDC,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,50863,CDM,250,RC,J9060,HCPCS,16729-288-38,NDC,facility,both,4,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LINACLOTIDE  72 MCG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0456-1203-30,NDC,facility,both,1,EA,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,63323-506-01,NDC,facility,both,10,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"CALCIUM CARBONATE 500 MG (1,250 MG) ORAL TAB",50863,CDM,636,RC,J3490,HCPCS,904188361,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM SR 120 MG 24 HR CAP,50863,CDM,636,RC,J3490,HCPCS,60687-195-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 50 MG TAB,50863,CDM,250,RC,J3490,HCPCS,16714-797-01,NDC,facility,both,1,EA,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-50,NDC,facility,both,31,ML,JW,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
METOCLOPRAMIDE  5 MG/ML INJ SOLN,50863,CDM,636,RC,J2765,HCPCS,0409-3414-18,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE 0.5 MG SL (1/4 TAB) SUBL,50863,CDM,250,RC,J3490,HCPCS,99999-0408-26,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 3 QUARTER TABLET
ETODOLAC 400 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69238-1342-1,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-208-01,NDC,facility,both,100,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 2 GRAM IV SOLUTION,50863,CDM,250,RC,J9075,HCPCS,39822-0260-1,NDC,facility,both,400,EA,,1291,903.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML INJECTION,50863,CDM,636,RC,J3411,HCPCS,67457-196-00,NDC,facility,both,4,ML,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7362-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAMADOL  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0093-0058-01,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM  3.375 GRAM IV SOLR,50863,CDM,250,RC,J2543,HCPCS,55150-120-30,NDC,facility,both,6,EA,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV,50863,CDM,250,RC,J7120,HCPCS,0338-0117-03,NDC,facility,both,2,ML,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE  75 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-040-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,51754-5001-1,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-1749-70,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,250,RC,J7060,HCPCS,0338-0017-48,NDC,facility,both,1,ML,JZ,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PROPOFOL IV BOLUS 10MG/ML (ANESTHESIA ONLY),50863,CDM,636,RC,J2704,HCPCS,63323-269-29,NDC,facility,both,40,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE HCL IN D5W 4 MG/250 ML (16 MCG/ML) IV SOLN,50863,CDM,250,RC,J0171,HCPCS,72196-7018-1,NDC,facility,both,3,ML,,631,441.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN ENEMA 500MG IN 100ML NS,50863,CDM,250,RC,J3490,HCPCS,67457-339-00,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN PEDS SYRINGE (20MG/ML) IN DEXTROSE (CDS MIX,50863,CDM,250,RC,J7999,HCPCS,0781-3451-70,NDC,facility,both,3,EA,,155,108.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 40 GRAM/400 ML (10 %) INJ SOLN",50863,CDM,250,RC,J1561,HCPCS,13533-800-40,NDC,facility,both,80,ML,,11316,7921.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 0.5 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J8540,HCPCS,0054-3177-63,NDC,facility,both,8,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,636,RC,J3490,HCPCS,0409-4887-17,NDC,facility,both,2,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,19,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADVATE: FACTOR VIII CONCENTRATE (MERGE RECORD),50863,CDM,636,RC,J7192,HCPCS,0944-3051-02,NDC,facility,both,3000,UN,,16107,11274.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE NA (PRESERV FREE) 25 MG/ML INJ SOLN,50863,CDM,250,RC,J9260,HCPCS,16729-277-35,NDC,facility,both,400,ML,,4026,2818.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 40 % ORAL GEL,50863,CDM,250,RC,J3490,HCPCS,574006930,NDC,facility,both,1,GM,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 1 GRAM INJ SOLR,50863,CDM,250,RC,J0692,HCPCS,44567-240-10,NDC,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,250,RC,J3360,HCPCS,0641-6244-01,NDC,facility,both,16,ML,,1156,809.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MINERAL OIL ORAL (REPACK),50863,CDM,250,RC,J3490,HCPCS,48433-202-30,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROBENECID 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0378-0156-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIBAVIRIN 200 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,65862-290-84,NDC,facility,both,1,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-1749-70,NDC,facility,both,2,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE-SALMETEROL 500 MCG-50 MCG/DOSE DISK DEVICE FOR INHALATION,50863,CDM,250,RC,J3490,HCPCS,66993-586-97,NDC,facility,both,1,EA,,1345,941.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE HCL  2 % MM JELP,50863,CDM,250,RC,J3490,HCPCS,76329-3012-5,NDC,facility,both,1,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML INJECTION,50863,CDM,636,RC,J3411,HCPCS,63323-013-01,NDC,facility,both,4,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LANTHANUM  500 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,76282-476-45,NDC,facility,both,3,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 500 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,50268-152-11,NDC,facility,both,15,EA,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE 220 MCG/ACTUATION INHL AERO,50863,CDM,636,RC,J3490,HCPCS,66993-080-96,NDC,facility,both,1,GM,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,14,ML,JW,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ROSUVASTATIN  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51407-153-90,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0143-9386-01,NDC,facility,both,15,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,13,ML,JW,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DOXORUBICIN 50 MG/25 ML IV SOLN,50863,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,10,ML,,161,112.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCUSATE SODIUM 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7183-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,68,EA,,9384,6568.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM-ALBUTEROL 0.5 MG-2.5 MG/3 ML NEB SOLUTION,50863,CDM,250,RC,J3490,HCPCS,47335-756-48,NDC,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,636,RC,J2270,HCPCS,0409-1890-03,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-41,NDC,facility,both,80,ML,,11316,7921.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,42806-150-33,NDC,facility,both,7,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 10% IN WATER (D10) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0264-7520-00,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 500 MG (200 MG ELEMENTAL) CHEW TAB,50863,CDM,250,RC,J3490,HCPCS,66553-004-01,NDC,facility,both,5,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,41,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,5,ML,,8671,6069.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,42806-150-33,NDC,facility,both,5,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,636,RC,J2795,HCPCS,70069-064-25,NDC,facility,both,20,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-48,NDC,facility,both,2,ML,,128,89.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WHITE PETROLATUM-MINERAL OIL 80 %-20 % EYE OINTMENT,50863,CDM,250,RC,J3490,HCPCS,1011902239,NDC,facility,both,1,GM,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE-SALMETEROL 500 MCG-50 MCG/DOSE DISK DEVICE FOR INHALATION,50863,CDM,250,RC,J3490,HCPCS,0054-0328-56,NDC,facility,both,1,EA,,1359,951.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MANNITOL 25 % IV SOLN,50863,CDM,250,RC,J2151,HCPCS,63323-024-01,NDC,facility,both,100,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-811-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DANTROLENE  25 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,68084-300-11,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SOTALOL 5 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,24338-530-25,NDC,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 20 GRAM/30 ML ORAL SOLN,50863,CDM,J3490,HCPCS,0121-1154-30,NDC,,,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 1000 MG MISC TBSO,50863,CDM,636,RC,J3490,HCPCS,904723961,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1940,HCPCS,0409-6102-04,NDC,facility,both,2,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXAZOSIN 2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-5523-61,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IR SOLN,50863,CDM,250,RC,J3490,HCPCS,0338-0047-46,NDC,facility,both,2,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,63739-931-14,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,62584-994-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,679,ML,,974,681.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID (PORK)  30 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0456-0458-01,NDC,facility,both,3,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,71288-402-10,NDC,facility,both,8,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IR SOLN,50863,CDM,636,RC,J3490,HCPCS,0338-0047-46,NDC,facility,both,15,ML,,831,581.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3373,HCPCS,0143-9162-01,NDC,facility,both,800,EA,,320,224,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MISOPROSTOL 200 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-746-11,NDC,facility,both,4,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2308-21,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",50863,CDM,250,RC,J1561,HCPCS,13533-800-24,NDC,facility,both,40,ML,"JZ,JA",5658,3960.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
CLOZAPINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-922-01,NDC,facility,both,5,EA,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CONJUGATED ESTROGENS 0.625 MG/G VAGL CREA,50863,CDM,636,RC,J3490,HCPCS,0046-0872-21,NDC,facility,both,1,GM,,1272,890.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROTHIAZIDE SODIUM 500 MG IV SOLR,50863,CDM,250,RC,J1205,HCPCS,63323-658-20,NDC,facility,both,1,EA,,1054,737.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0781-3458-75,NDC,facility,both,1500,ML,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,636,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,6,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CLONIDINE 0.1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-192-11,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,66689-053-01,NDC,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  37.5 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,65862-527-90,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-581-11,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,50863,CDM,636,RC,Q5119,HCPCS,0069-0238-01,NDC,facility,both,2,ML,,396,277.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,63323-010-02,NDC,facility,both,3,ML,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,250,RC,J3490,HCPCS,61553-320-70,NDC,facility,both,2,ML,,138,96.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) NEB SOLUTION,50863,CDM,636,RC,J3490,HCPCS,0487-9501-25,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE 110 MCG/ACTUATION INHL AERO,50863,CDM,250,RC,J3490,HCPCS,66993-079-96,NDC,facility,both,1,GM,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-0552-23,NDC,facility,both,4,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/0.5 ML INHL NEBU,50863,CDM,636,RC,J3490,HCPCS,0487-9901-30,NDC,facility,both,3,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-4675-05,NDC,facility,both,2,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),50863,CDM,250,RC,J1815,HCPCS,0024-5926-05,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COLCHICINE 0.6 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-727-11,NDC,facility,both,2,EA,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 112 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6954-61,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,25,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-051-10,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG ORAL TAB,50863,CDM,636,RC,Q0169,HCPCS,0904-7304-61,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEGESTROL 20 MG ORAL TAB,50863,CDM,250,RC,J9999,HCPCS,0555-0606-02,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAVASTATIN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-5891-61,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL IV BOLUS 10MG/ML (ANESTHESIA ONLY),50863,CDM,636,RC,J2704,HCPCS,0409-4699-54,NDC,facility,both,93,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 125 MCG SUBQ SOLR,50863,CDM,636,RC,J2802,HCPCS,55513-223-01,NDC,facility,both,500,EA,,10260,7182,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE (FOR CODE) 10% IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0517-6710-01,NDC,facility,both,1,ML,,3559,2491.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-4675-05,NDC,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,62584-734-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAVASTATIN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-458-01,NDC,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-328-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROPROCAINE 3 % INJ SOLN,50863,CDM,250,RC,J2401,HCPCS,63323-478-01,NDC,facility,both,600,ML,,132,92.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-342-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) IV SOLN,50863,CDM,636,RC,J9920,HCPCS,81284-315-05,NDC,facility,both,32,ML,JZ,1383,968.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2308-22,NDC,facility,both,5,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0121-0914-05,NDC,facility,both,8,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN   81 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,0904-6783-70,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN   81 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,69618-066-02,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,23,EA,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SECUKINUMAB  25 MG/ML IV SOLN,50863,CDM,636,RC,J3247,HCPCS,0078-1168-61,NDC,facility,both,125,ML,,5896,4127.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6374-61,NDC,facility,both,3,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML IV,50863,CDM,250,RC,J3490,HCPCS,70860-301-41,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42806-341-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-1638-32,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,70860-751-02,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GANCICLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J1570,HCPCS,25021-185-10,NDC,facility,both,1,ML,,184,128.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,42806-150-33,NDC,facility,both,5,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN NPH & REGULAR HUMAN 100 UNIT/ML (70-30) SUBQ SUSP,50863,CDM,250,RC,J1815,HCPCS,0002-8715-01,NDC,facility,both,11,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,6,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,636,RC,J3490,HCPCS,0641-6236-01,NDC,facility,both,1,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-1749-70,NDC,facility,both,2,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALGANCICLOVIR 450 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-787-11,NDC,facility,both,1,EA,,538,376.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6008-61,NDC,facility,both,1,EA,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0093-2026-94,NDC,facility,both,3,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 500 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7337-35,NDC,facility,both,12,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE 25 MG/ML INJ SOLN,50863,CDM,636,RC,J3230,HCPCS,43598-141-11,NDC,facility,both,1,ML,,168,117.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE 5MG/ML SUSPENSION (REPACK),50863,CDM,250,RC,J3490,HCPCS,65162-511-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  75 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-441-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,10702-018-50,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE (FOR EMERGENCY) 100 MG/ML (10%) IV SOLN,50863,CDM,250,RC,J0612,HCPCS,63323-360-03,NDC,facility,both,1000,ML,,317,221.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN 125 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,66689-775-08,NDC,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,250,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,636,RC,J0690,HCPCS,70092-1017-46,NDC,facility,both,3,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J2250,HCPCS,0409-0001-01,NDC,facility,both,6,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,25021-053-01,NDC,facility,both,10,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ROPINIROLE  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,10135-676-01,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,250,RC,J2003,HCPCS,76329-3390-1,NDC,facility,both,100,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VUTRISIRAN 25 MG/0.5 ML SUBQ SYRG,50863,CDM,636,RC,J0225,HCPCS,71336-1003-1,NDC,facility,both,25,ML,JZ,329409,230586.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
VANCOMYCIN IN 0.9 % SODIUM CHL 1.5 GRAM/500 ML IV SOLN,50863,CDM,250,RC,J3370,HCPCS,71506-016-59,NDC,facility,both,3,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,250,RC,J3360,HCPCS,69374-965-02,NDC,facility,both,2,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 10 MG TAB,50863,CDM,250,RC,Q0177,HCPCS,16714-081-10,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,250,RC,J3490,HCPCS,63323-485-27,NDC,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),50863,CDM,636,RC,J2060,HCPCS,0641-6044-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM BICARB-CITRIC ACID 20 MEQ ORAL TBEF,50863,CDM,636,RC,J3490,HCPCS,51801-012-01,NDC,facility,both,3,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0039-05,NDC,facility,both,8,EA,JZ,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,43066-007-10,NDC,facility,both,2,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NOREPINEPHRINE BITARTRATE-D5W 4 MG/250 ML (16 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,71285-6056-1,NDC,facility,both,1,ML,,128,89.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLECAINIDE 20MG/ML SUSPENSION (REPACK),50863,CDM,636,RC,J3490,HCPCS,0054-0010-25,NDC,facility,both,3,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZIPRASIDONE 20 MG IM,50863,CDM,250,RC,J3486,HCPCS,72205-205-01,NDC,facility,both,1,EA,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 20MG/ML IV SYRINGE (PEDS/NEO),50863,CDM,250,RC,J0612,HCPCS,63323-311-10,NDC,facility,both,23,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM BICARB-CITRIC ACID 20 MEQ ORAL TBEF,50863,CDM,250,RC,J3490,HCPCS,51801-012-01,NDC,facility,both,2,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MISOPROSTOL 800 MCG (4 X 200 MCG TAB) PACKAGE,50863,CDM,636,RC,S0191,HCPCS,43393-023-04,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,636,RC,J1596,HCPCS,0143-9682-01,NDC,facility,both,2,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0054-0710-20,NDC,facility,both,18,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,68180-150-01,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,0641-0477-21,NDC,facility,both,7,ML,,2089,1462.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"HEPARIN, PORCINE (PF)   10 UNIT/ML IV SYRG",50863,CDM,636,RC,J1642,HCPCS,6425322223,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,3,EA,JW,180,126,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-50,NDC,facility,both,106,ML,,187,130.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-492-04,NDC,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE HCL  2 % MM JELP,50863,CDM,J3490,HCPCS,76329-3013-5,NDC,,,facility,both,1,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEPLIZUMAB-MZWV 2 MG/20 ML IV SOLN,50863,CDM,636,RC,J9381,HCPCS,73650-316-01,NDC,facility,both,70,ME,,4702,3291.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUANFACINE 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0591-0444-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 10 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,55150-305-01,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-48,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,J1100,HCPCS,63323-165-01,NDC,,,facility,both,8,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,J3010,HCPCS,0409-9094-12,NDC,,,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,J1939,HCPCS,70748-323-01,NDC,,,facility,both,3,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,50863,CDM,J1756,HCPCS,0517-2340-01,NDC,,,facility,both,300,ML,,963,674.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,50863,CDM,J3490,HCPCS,0409-2051-15,NDC,,,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-444-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-208-01,NDC,facility,both,200,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,J0690,HCPCS,63323-237-10,NDC,,,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN SODIUM EXTENDED 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,65862-692-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DASATINIB  20 MG ORAL TAB,50863,CDM,250,RC,J9999,HCPCS,60505-3628-6,NDC,facility,both,2,EA,,1135,794.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,0703-9526-01,NDC,facility,both,2,ML,,442,309.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 875 MG-125 MG TAB,50863,CDM,250,RC,J3490,HCPCS,60687-803-11,NDC,facility,both,1,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 875 MG-125 MG TAB,50863,CDM,250,RC,J3490,HCPCS,16714-297-01,NDC,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-172-01,NDC,facility,both,2,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIVAROXABAN 15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50458-578-90,NDC,facility,both,6,EA,,517,361.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,J1953,HCPCS,55150-177-05,NDC,,,facility,both,320,ML,,128,89.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,63323-165-01,NDC,facility,both,4,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELIMUMAB 120 MG IV SOLR,50863,CDM,636,RC,J0490,HCPCS,49401-101-01,NDC,facility,both,40,ME,JA,4698,3288.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),50863,CDM,636,RC,J1815,HCPCS,0024-5926-05,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERYTHROMYCIN 250 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,13668-586-30,NDC,facility,both,2,EA,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,0409-3795-19,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN 1000 MG IN NS 1000 ML IRRIGATION (REPACK),50863,CDM,636,RC,J0690,HCPCS,99999-500-04,NDC,facility,both,3,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,636,RC,J3490,HCPCS,66553-002-01,NDC,facility,both,3,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,250,RC,J2003,HCPCS,55150-165-05,NDC,facility,both,200,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 160 MG-800 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0904-2725-61,NDC,facility,both,6,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  125 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,62559-390-50,NDC,facility,both,4,EA,,451,315.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 10 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,67457-420-00,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,66553-002-01,NDC,facility,both,1,EA,PLAD,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
PRAZOSIN 1 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,51079-630-01,NDC,facility,both,4,EA,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,70954-059-10,NDC,facility,both,5,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,63323-010-02,NDC,facility,both,2,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1815,HCPCS,0169-1833-11,NDC,facility,both,9,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COLCHICINE 0.6 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,65162-710-09,NDC,facility,both,3,EA,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  20 MEQ ORAL PACK,50863,CDM,250,RC,J3490,HCPCS,43386-194-90,NDC,facility,both,1,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,0338-0069-10,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL 2 MG/ML ORAL CONCENTRATE,50863,CDM,636,RC,J3490,HCPCS,0121-0581-05,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 20MG/ML IV SYRINGE (PEDS/NEO),50863,CDM,250,RC,J0612,HCPCS,63323-311-10,NDC,facility,both,63,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,636,RC,J2003,HCPCS,63323-486-05,NDC,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-051-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-288-03,NDC,facility,both,1,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-02,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,0703-5653-01,NDC,facility,both,9,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPATITIS A VIRUS VACCINE (PF) 25 UNIT/0.5 ML IM MERGE (CAM USE ONLY),50863,CDM,90633,HCPCS,0006-4095-01,NDC,,,facility,both,1,ML,,234,163.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 100 % ORAL POWD,50863,CDM,J3490,HCPCS,1093978844,NDC,,,facility,both,1,GM,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 50 MG 24 HR TAB,50863,CDM,636,RC,J3490,HCPCS,51079-170-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 17 GRAM (100 %) ORAL PWPK,50863,CDM,636,RC,J3490,HCPCS,1152372688,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,636,RC,J3490,HCPCS,0641-6236-01,NDC,facility,both,1,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NORTRIPTYLINE 10 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,75907-069-01,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,62332-600-01,NDC,facility,both,1,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,50863,CDM,636,RC,J3490,HCPCS,17856-0823-10,NDC,facility,both,2,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % MBP,50863,CDM,250,RC,J3490,HCPCS,0338-0553-18,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUPHENAZINE 2.5 MG TAB,50863,CDM,250,RC,J3490,HCPCS,10135-726-01,NDC,facility,both,2,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPRAZOLAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0228-2029-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCRALFATE 100 MG/ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,17856-0306-1,NDC,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 40 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-6292-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE  7.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,13107-001-30,NDC,facility,both,2,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,J3490,HCPCS,68094-494-59,NDC,,,facility,both,2,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 25 MG TAB,50863,CDM,636,RC,J3490,HCPCS,51079-255-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENOFIBRATE NANOCRYSTALLIZED 145 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7480-04,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSP,50863,CDM,J3490,HCPCS,0121-0431-30,NDC,,,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HUMAN PROTHROMBIN COMPLEX 500 UNIT IV SOLR,50863,CDM,250,RC,J7168,HCPCS,63833-386-02,NDC,facility,both,2000,UN,,11638,8146.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 10 MEQ/100 ML IV PGBK (USE NON-PROTOCOL PANEL),50863,CDM,250,RC,J3480,HCPCS,0338-0709-48,NDC,facility,both,10,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE (6 MONTH) 45 MG IM SYKT,50863,CDM,J9217,HCPCS,0074-3473-03,NDC,,,facility,both,6,EA,,1176,823.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 150 MG CAP,50863,CDM,J3490,HCPCS,68084-243-11,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,50863,CDM,J3490,HCPCS,57237-077-10,NDC,,,facility,both,1,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-492-27,NDC,,,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 7.5 MG-325 MG/15 ML ORAL SOLN (REPACK),50863,CDM,636,RC,J3490,HCPCS,0121-2316-15,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-503-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 40 % ORAL GEL,50863,CDM,250,RC,J3490,HCPCS,574006930,NDC,facility,both,43,GM,,609,426.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE-VITAMIN D3 250 MG-125 UNIT TAB,50863,CDM,250,RC,J3490,HCPCS,2055502500,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 5 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,0409-1778-15,NDC,facility,both,2,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (NEO) <2 KG,50863,CDM,250,RC,J7060,HCPCS,0338-0017-41,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7124-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE 100 MG TAB,50863,CDM,636,RC,J3490,HCPCS,23155-135-25,NDC,facility,both,14,EA,,293,205.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,49884-122-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,63739-931-14,NDC,facility,both,9,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,70095-031-01,NDC,facility,both,20,ML,,808,565.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,50863,CDM,FAMNOCHARGE,HCPCS,0054-8175-25,NDC,,,facility,both,4,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,636,RC,J3490,HCPCS,0409-4277-16,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1560-18,NDC,facility,both,100,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-8297-25,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BISACODYL  5 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,0904-6407-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,0641-6145-01,NDC,facility,both,3,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PREGABALIN 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,72205-014-90,NDC,facility,both,3,EA,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE (PF-DURAMORPH/ASTRAMORPH) 0.5 MG/ML INJ SOLN,50863,CDM,250,RC,J2274,HCPCS,0409-3814-11,NDC,facility,both,1,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7244-68,NDC,facility,both,3,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,62332-037-31,NDC,facility,both,2,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,68180-723-05,NDC,facility,both,2,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE  50 MG ORAL TAB,50863,CDM,636,RC,j3490,HCPCS,68382-805-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIOGLITAZONE 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-391-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATENOLOL  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7187-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ABATACEPT 250 MG IV SOLR,50863,CDM,636,RC,J0129,HCPCS,0003-2187-13,NDC,facility,both,75,EA,"JZ,JA",12834,8983.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
TOBRAMYCIN SULFATE 40 MG/ML INJ SOLN,50863,CDM,250,RC,J3260,HCPCS,67457-473-00,NDC,facility,both,10,ML,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0641-0400-12,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 30 MG ORAL CPDR,50863,CDM,250,RC,J3490,HCPCS,60687-734-11,NDC,facility,both,1,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,5,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRILAT 1.25 MG/ML IV INJ,50863,CDM,250,RC,J3490,HCPCS,43598-078-11,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-22,NDC,facility,both,5,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,636,RC,J3370,HCPCS,63323-284-26,NDC,facility,both,4,EA,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYBUTYNIN CHLORIDE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7027-61,NDC,facility,both,3,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,3,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),50863,CDM,250,RC,J3490,HCPCS,8290306544,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML IV SOLN (MERGE),50863,CDM,250,RC,J3490,HCPCS,16714-037-01,NDC,facility,both,1,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,65649-311-12,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZTREONAM 2 GRAM INJ SOLR,50863,CDM,250,RC,J0457,HCPCS,0003-2570-16,NDC,facility,both,20,EA,JZ,303,212.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,66794-229-02,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,50863,CDM,250,RC,J0696,HCPCS,60505-6148-0,NDC,facility,both,8,EA,,450,315,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 100 MG IV SOLR,50863,CDM,250,RC,J2997,HCPCS,50242-085-25,NDC,facility,both,90,EA,,21626,15138.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE  50 MG ORAL TAB,50863,CDM,250,RC,j3490,HCPCS,0904-6868-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FERROUS SULFATE 75 MG/ML (ELEMENTAL IRON 15 MG/ML) 0.1 ML ORAL SYRINGE (REPACK),50863,CDM,250,RC,J3490,HCPCS,3932805750,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-242-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,50863,CDM,636,RC,J2359,HCPCS,55150-308-01,NDC,facility,both,10,EA,JW,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,24,EA,,3312,2318.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 0.1 MG/ML INJ SYRG,50863,CDM,250,RC,J0461,HCPCS,76329-3340-1,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7411-61,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0990-7984-13,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,250,RC,J2270,HCPCS,0409-1890-13,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN DEGLUDEC 100 UNITS/ML SUBQ SOLN,50863,CDM,636,RC,J1815,HCPCS,73070-400-11,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-464-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FINASTERIDE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6830-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATOVAQUONE 750 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0904-7064-41,NDC,facility,both,2,ML,,323,226.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,J3490,HCPCS,68094-231-59,NDC,,,facility,both,4,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LATANOPROST 0.005 % OPHT DROP,50863,CDM,250,RC,J3490,HCPCS,61314-547-03,NDC,facility,both,1,ML,,403,282.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,72603-251-01,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL  32.4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6575-61,NDC,facility,both,9,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (NEO) <2 KG,50863,CDM,250,RC,J7060,HCPCS,0338-0017-41,NDC,facility,both,2,ML,,307,214.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,10135-676-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,636,RC,J3490,HCPCS,0409-4277-17,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-9791-01,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 500 MG PE/10 ML INJ SOLN,50863,CDM,636,RC,Q2009,HCPCS,25021-798-10,NDC,facility,both,23,ML,,264,184.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,65219-570-01,NDC,facility,both,2,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL (5 MG/ML) IV SYRG (CONTAINS PRESERVATIVE),50863,CDM,636,RC,J3490,HCPCS,65302-503-04,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 500 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,68084-782-11,NDC,facility,both,1,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYTOCIN 10 UNIT/ML INJ SOLN,50863,CDM,250,RC,J2590,HCPCS,63323-012-11,NDC,facility,both,4,ML,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,4,EA,JW,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J2310,HCPCS,67457-299-10,NDC,facility,both,2,ML,,257,179.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN  200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-5154-60,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J1938,HCPCS,36000-283-25,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % MUCOSAL SOLN (VISCOUS),50863,CDM,250,RC,J3490,HCPCS,0121-0903-15,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE (POLACRILEX) 2 MG MM LOZG,50863,CDM,636,RC,J3490,HCPCS,45802-344-03,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICARDIPINE IN NACL (ISO-OS) 20 MG/200 ML IV PGBK,50863,CDM,250,RC,J3490,HCPCS,10122-313-01,NDC,facility,both,2,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-467-01,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,636,RC,J7999,HCPCS,70092-1017-46,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,82,ML,JW,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CHLORHEXIDINE GLUCONATE  0.12 % MM MWSH,50863,CDM,250,RC,J3490,HCPCS,17856-2002-3,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,13,EA,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEBIVOLOL  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-641-11,NDC,facility,both,3,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9% IV (PEDS) BOLUS,50863,CDM,636,RC,J7040,HCPCS,0264-7800-09,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,55150-222-20,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IVABRADINE 7.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,55513-810-60,NDC,facility,both,2,EA,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 0.5 MG ORAL TAB,50863,CDM,250,RC,J8540,HCPCS,72603-212-01,NDC,facility,both,2,EA,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),50863,CDM,636,RC,J1630,HCPCS,63323-474-00,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"HEPARIN, PORCINE (PF) 1 UNIT/ML IV SYRG NEONATE",50863,CDM,250,RC,J1642,HCPCS,6425344425,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,636,RC,J2560,HCPCS,54288-136-01,NDC,facility,both,1,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM BROMIDE 17 MCG/ACTUATION INHL AERO,50863,CDM,636,RC,J3490,HCPCS,0597-0087-17,NDC,facility,both,1,GM,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9% IV (PEDS) BOLUS,50863,CDM,636,RC,J7040,HCPCS,0264-7800-09,NDC,facility,both,2,ML,JZ,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CLINDAMYCIN IN D5W 900 MG/50 ML IV PGBK,50863,CDM,636,RC,J0736,HCPCS,0338-3814-50,NDC,facility,both,3,ML,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  30 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,0406-8330-23,NDC,facility,both,2,EA,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,41,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-4264-11,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCRALFATE 100 MG/ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,68094-043-59,NDC,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIP,PER(A)TET-HEPB-POL-HIB(PF) 15 UNIT-5 UNIT- 10 MCG/0.5 ML IM SYRG",50863,CDM,90698,HCPCS,49281-561-01,NDC,,,facility,both,1,ML,,421,294.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2308-21,NDC,facility,both,10,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-492-09,NDC,facility,both,6000,ML,,31346,21942.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,0641-6174-01,NDC,facility,both,4,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 2 MG/10 ML (200 MCG/ML) IN D5W VIAL-CVL/IR USE (REPACK),50863,CDM,250,RC,J2305,HCPCS,0338-1049-02,NDC,facility,both,10,ML,,133,93.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,0641-6174-01,NDC,facility,both,6,ML,JB,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JB: Administered subcutaneously
CALCIUM ACETATE 667 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7119-61,NDC,facility,both,3,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2308-02,NDC,facility,both,5,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
TRIHEXYPHENIDYL 2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0591-5335-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-208-01,NDC,,,facility,both,100,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROFURANTOIN (25% MACROCRYSTAL FORM) 100 MG CAP,50863,CDM,250,RC,J3490,HCPCS,60687-633-11,NDC,facility,both,1,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7030,HCPCS,0338-0049-04,NDC,facility,both,4,ML,,133,93.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,636,RC,J3490,HCPCS,0904-6794-80,NDC,facility,both,3,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE 150 MG ORAL CP24,50863,CDM,636,RC,J3490,HCPCS,68084-713-11,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"HEPARIN, PORCINE (PF)   10 UNIT/ML IV SYRG",50863,CDM,250,RC,J1642,HCPCS,6425322235,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.45 % 0.45 % IV SOLP,50863,CDM,250,RC,J3490,HCPCS,0409-7985-25,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM PHOSPHATE 0.06 MMOL/ML IVPB (FOR PEDIATRICS),50863,CDM,250,RC,J3490,HCPCS,71285-6060-1,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 16 MG ORAL TAB,50863,CDM,250,RC,J7509,HCPCS,59762-0050-1,NDC,facility,both,6,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL IV BOLUS 10MG/ML (ANESTHESIA ONLY),50863,CDM,J2704,HCPCS,0409-4699-54,NDC,,,facility,both,100,ML,,127,88.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,J0330,HCPCS,0409-6629-02,NDC,,,facility,both,7,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  125 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,62559-390-50,NDC,facility,both,1,EA,,154,107.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,0409-9094-22,NDC,facility,both,4,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,68094-061-59,NDC,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN  750 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,50268-551-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,0944-0495-06,NDC,facility,both,1,ML,,189,132.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,16714-026-01,NDC,facility,both,6,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM IN NACL (ISO-OS) 1000 MG/100 ML IV PGBK,50863,CDM,636,RC,J1953,HCPCS,44567-502-01,NDC,facility,both,100,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,50863,CDM,250,RC,J9025,HCPCS,72485-201-01,NDC,facility,both,174,EA,,2462,1723.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LECANEMAB-IRMB 100 MG/ML IV SOLN,50863,CDM,636,RC,J0174,HCPCS,62856-212-01,NDC,facility,both,600,ML,"JZ,Q0",2747,1922.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier Q0: Investigational clinical service provided in a clinical research study that is in an approved clinical research study
ACETAMINOPHEN  650 MG RECT SUPP,50863,CDM,636,RC,J3490,HCPCS,45802-730-00,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DOBUTAMINE IN D5W 1,000 MG/250 ML (4,000 MCG/ML) IV SOLP",50863,CDM,250,RC,0338-1077-02,NDC,,,facility,both,1,ML,,172,120.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 10 % INHL NEBU,50863,CDM,636,RC,J3490,HCPCS,0378-6998-89,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM PHOSPHATE 3 MMOL/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-7391-82,NDC,facility,both,1,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,63323-010-01,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-492-04,NDC,facility,both,60,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 100 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,70954-240-10,NDC,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6370-61,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,72485-106-01,NDC,facility,both,335,ML,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-464-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 112 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42292-039-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 0.1 % TOP CREAM,50863,CDM,636,RC,J3490,HCPCS,0168-0004-15,NDC,facility,both,1,GM,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,50863,CDM,250,RC,J9000,HCPCS,0069-1542-20,NDC,facility,both,2,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-495-09,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 2 MG INJ SOLR,50863,CDM,250,RC,J2997,HCPCS,50242-041-63,NDC,facility,both,4,EA,,1323,926.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 50 MG/10 ML (5 MG/ML) IV SOLN,50863,CDM,250,RC,J2305,HCPCS,0517-4810-25,NDC,facility,both,9,ML,JW,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
SPIRONOLACTONE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-979-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  5 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-122-11,NDC,facility,both,75,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 5 MG/5 ML IV,50863,CDM,636,RC,J3490,HCPCS,63323-660-01,NDC,facility,both,2,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LETROZOLE 2.5 MG ORAL TAB,50863,CDM,250,RC,J9999,HCPCS,50268-476-11,NDC,facility,both,1,EA,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  10 MG ORAL TR12,50863,CDM,250,RC,J3490,HCPCS,59011-410-20,NDC,facility,both,3,EA,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 10 GRAM/100 ML (10%) INJ SOLN",50863,CDM,250,RC,J1561,HCPCS,13533-800-72,NDC,facility,both,40,ML,JA,5658,3960.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
BENZOCAINE-MENTHOL 15-2.6 MG MM LOZG,50863,CDM,636,RC,J3490,HCPCS,17856-0732-1,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,8,EA,JW,480,336,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,250,RC,J2720,HCPCS,63323-229-01,NDC,facility,both,6,ML,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,63323-564-21,NDC,facility,both,4,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,45,ML,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICARDIPINE IN NACL (ISO-OS) 20 MG/200 ML IV PGBK,50863,CDM,636,RC,J3490,HCPCS,10122-313-01,NDC,facility,both,1,ML,,440,308,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 75 MG/5 ML ORAL SOLUTION,50863,CDM,250,RC,J3490,HCPCS,64980-511-10,NDC,facility,both,9,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,4,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ATROPINE 0.1 MG/ML INJ SYRG,50863,CDM,636,RC,J0461,HCPCS,16729-484-03,NDC,facility,both,100,ML,JZ,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
EFGARTIGIMOD ALFA-FCAB 20 MG/ML IV SOLN,50863,CDM,636,RC,J9332,HCPCS,73475-3041-5,NDC,facility,both,50,ML,JW,1785,1249.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,0143-9682-25,NDC,facility,both,2,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 50 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,10135-779-01,NDC,facility,both,50,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68180-513-01,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,12,EA,JZ,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CARBAMIDE PEROXIDE 6.5 % OTIC DROP,50863,CDM,J3490,HCPCS,70677-1154-1,NDC,,,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J2004,HCPCS,0409-3178-01,NDC,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42858-301-01,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,8,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,200,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE 100 MG TAB,50863,CDM,636,RC,J3490,HCPCS,60687-344-95,NDC,facility,both,10,EA,,130,91,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,636,RC,J2795,HCPCS,70069-064-25,NDC,facility,both,150,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MILRINONE INFUSION PED/NEO IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J2260,HCPCS,0143-9719-01,NDC,facility,both,4,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,636,RC,J7060,HCPCS,0338-0017-31,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,636,RC,J3490,HCPCS,0173-0682-20,NDC,facility,both,1,GM,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CITRATE  5 MEQ ORAL TBER,50863,CDM,636,RC,J3490,HCPCS,31722-129-01,NDC,facility,both,3,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,250,RC,J2720,HCPCS,63323-229-01,NDC,facility,both,8,ML,,146,102.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 40 MG/ML IV SYRINGE,50863,CDM,250,RC,J3475,HCPCS,0409-6729-23,NDC,facility,both,8,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROPRUSSIDE 25 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,43598-587-23,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,250,RC,J3490,HCPCS,0143-9575-01,NDC,facility,both,200,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,636,RC,J2405,HCPCS,60505-6130-0,NDC,facility,both,4,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ENALAPRILAT 1.25 MG/ML IV INJ,50863,CDM,250,RC,J3490,HCPCS,43598-078-11,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6008-61,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN 1 GRAM SOLUTION FOR INJECTION,50863,CDM,250,RC,J0290,HCPCS,55150-113-10,NDC,facility,both,2,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,10135-678-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICARDIPINE 25 MG/10 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,55150-183-01,NDC,facility,both,3,ML,,374,261.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,64980-562-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-4264-11,NDC,facility,both,40,ML,,170,119,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,5,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0780,HCPCS,0713-0351-02,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYALURONIDASE 150 UNIT/ML INJ SOLN,50863,CDM,250,RC,J3473,HCPCS,18657-117-02,NDC,facility,both,300,ML,,568,397.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7193-06,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6322-06,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML INJECTION,50863,CDM,J3411,HCPCS,0641-6228-01,NDC,,,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-384-11,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL  32.4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,13517-626-01,NDC,facility,both,4,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6638-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 250 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,0904-6363-61,NDC,facility,both,4,EA,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCUSATE SODIUM 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7183-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  650 MG RECT SUPP,50863,CDM,636,RC,J3490,HCPCS,45802-730-00,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEGESTROL 40 MG ORAL TAB,50863,CDM,636,RC,J9999,HCPCS,0555-0607-02,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,904740361,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATENOLOL  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-684-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,250,RC,J3490,HCPCS,63037-136-25,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6188-01,NDC,facility,both,2500,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,67457-423-00,NDC,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FIDAXOMICIN 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,52015-080-01,NDC,facility,both,1,EA,,922,645.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"TRANEXAMIC ACID IN NACL,ISO-OS 1,000 MG/100 ML (10 MG/ML) IV PGBK",50863,CDM,250,RC,J3490,HCPCS,51754-0108-3,NDC,facility,both,2,ML,,247,172.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,55150-177-05,NDC,facility,both,5,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPH-MIN OIL-PETROLATUM 0.25-14-74.9 % RECT OINT,50863,CDM,250,RC,J3490,HCPCS,0573-2871-93,NDC,facility,both,1,GM,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MINERAL OIL,50863,CDM,636,RC,J3490,HCPCS,6332325410,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TICAGRELOR 90 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0186-0777-60,NDC,facility,both,1,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 50 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,10135-779-01,NDC,facility,both,120,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLECAINIDE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0054-0010-20,NDC,facility,both,3,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE CONCENTRATE 10 MG/ 0.5 ML ORAL SYRINGE (0.5ML UD MERGE),50863,CDM,250,RC,J3490,HCPCS,68094-045-01,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DUTASTERIDE 0.5 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,42806-549-09,NDC,facility,both,1,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CELECOXIB 200 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,50268-169-11,NDC,facility,both,2,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLP,50863,CDM,250,RC,J3480,HCPCS,63323-965-02,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN IN D5W 400 MG/200 ML IV PGBK,50863,CDM,250,RC,J0744,HCPCS,25021-192-87,NDC,facility,both,2,ML,JZ,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ASCORBIC ACID  500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,904052361,NDC,facility,both,6,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE (FOR CODE) 10% (100 MG/ML) IV SYRINGE,50863,CDM,636,RC,J3490,HCPCS,0409-4928-11,NDC,facility,both,3,ML,,302,211.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5% W/EPINEPHRINE 1:200K INJECTION,50863,CDM,636,RC,J3490,HCPCS,0409-1749-29,NDC,facility,both,2,ML,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DICLOFENAC 75 MG TAB, DELAYED RELEASE",50863,CDM,636,RC,J3490,HCPCS,16571-201-06,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML IM SOLN,50863,CDM,636,RC,90375,HCPCS,13533-318-05,NDC,facility,both,10,ML,,8588,6011.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION,50863,CDM,J3490,HCPCS,0310-7370-20,NDC,,,facility,both,1,GM,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,36,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7362-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ESMOLOL IN SALINE (ISO-OSMOTIC) 2,500 MG/250 ML (10 MG/ML) IV",50863,CDM,250,RC,J1805,HCPCS,10019-055-61,NDC,facility,both,1,ML,,560,392,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0904-6923-61,NDC,facility,both,20,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-572-10,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,49502-393-80,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 40 MG/ML (4 %) INJ SOLN (FOR NEBULIZATION),50863,CDM,J2001,HCPCS,0409-4283-11,NDC,,,facility,both,12,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMETREXED 500 MG IV SOLR,50863,CDM,J9305,HCPCS,71288-167-50,NDC,,,facility,both,87,EA,,1128,789.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 1000 MG MISC TBSO,50863,CDM,250,RC,J3490,HCPCS,904723961,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,63323-104-06,NDC,facility,both,17,ML,,121,84.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7110-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0137,HCPCS,0264-4100-90,NDC,facility,both,85,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-998-01,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNITS/1 GRAM PACKET (MERGE RECORD),50863,CDM,250,RC,J3490,HCPCS,45802-060-00,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 1 MG ORAL TAB,50863,CDM,250,RC,J8540,HCPCS,72578-166-01,NDC,facility,both,24,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG IV SOLR,50863,CDM,J3490,HCPCS,55150-202-00,NDC,,,facility,both,1,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML INJ SOLN,50863,CDM,J2250,HCPCS,23155-600-31,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,J2250,HCPCS,0409-2308-21,NDC,,,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,24689-907-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 250 MG INJ SOLR,50863,CDM,636,RC,J0696,HCPCS,60505-6151-4,NDC,facility,both,2,EA,,156,109.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J3490,HCPCS,0338-1055-48,NDC,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 2-0.5 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,0904-7009-06,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,636,RC,J1100,HCPCS,63323-506-00,NDC,facility,both,8,ML,JW,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CARBIDOPA-LEVODOPA 25 MG-100 MG TAB,50863,CDM,250,RC,J3490,HCPCS,59651-457-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 20 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,50268-585-11,NDC,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6322-06,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,50863,CDM,636,RC,J2359,HCPCS,0781-3159-72,NDC,facility,both,20,EA,JZ,203,142.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
NEO TPN SODIUM CHLORIDE 4 MEQ/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-099-03,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,636,RC,J3490,HCPCS,23155-166-31,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,636,RC,J1610,HCPCS,63323-596-03,NDC,facility,both,1,EA,,895,626.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN (PF) NEO IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J1580,HCPCS,63323-513-02,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0406-5771-23,NDC,facility,both,16,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL IV BOLUS 10MG/ML (ANESTHESIA ONLY),50863,CDM,250,RC,J2704,HCPCS,63323-269-29,NDC,facility,both,120,ML,,240,168,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALTREXONE 50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7036-04,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZTREONAM 2 GRAM INJ SOLR,50863,CDM,250,RC,J0457,HCPCS,0409-0830-11,NDC,facility,both,20,EA,,341,238.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN SODIUM EXTENDED 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0071-0369-40,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-21,NDC,facility,both,80,ML,"JZ,JA",11316,7921.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-145-11,NDC,facility,both,40,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AGALSIDASE BETA 35 MG IV SOLR,50863,CDM,636,RC,J0180,HCPCS,58468-0040-1,NDC,facility,both,85,ME,,39507,27654.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),50863,CDM,250,RC,J2060,HCPCS,0641-6001-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYMETAZOLINE 0.05 % NASL SPRA,50863,CDM,636,RC,J3490,HCPCS,11523-4112-1,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,33,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROMETHORPHAN-GUAIFENESIN SR 30 MG-600 MG 12 HR TAB,50863,CDM,250,RC,J3490,HCPCS,6382405620,NDC,facility,both,8,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6500-06,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-41,NDC,facility,both,1,ML,JZ,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,250,RC,J3490,HCPCS,71266-9080-2,NDC,facility,both,3,ML,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IV PGBK,50863,CDM,250,RC,J3475,HCPCS,44567-420-24,NDC,facility,both,4,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,62332-600-01,NDC,facility,both,2,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,4,EA,,133,93.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,55150-165-05,NDC,facility,both,300,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARTIFICIAL TEAR(DXTRN-HPM-GLY) 0.1-0.3-0.2 % OPHT DROP,50863,CDM,250,RC,J3490,HCPCS,50268-043-15,NDC,facility,both,1,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0093-3425-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 7.5 MG-325 MG/15 ML ORAL SOLN (REPACK),50863,CDM,636,RC,J3490,HCPCS,66689-023-01,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,72266-146-01,NDC,facility,both,2,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"OCTREOTIDE,MICROSPHERES 20 MG IM SERR",50863,CDM,250,RC,J2353,HCPCS,0078-0818-81,NDC,facility,both,20,EA,,12741,8918.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,636,RC,J2405,HCPCS,70860-776-41,NDC,facility,both,16,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE HCL  2 % MM JELP,50863,CDM,636,RC,J3490,HCPCS,25021-673-76,NDC,facility,both,2,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMBROLIZUMAB 100 MG/4 ML (25 MG/ML) IV SOLN,50863,CDM,J9271,HCPCS,0006-3026-01,NDC,,,facility,both,200,ML,,24182,16927.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,63323-482-03,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN IN 0.9 % NS 40 UNIT/100 ML (0.4 UNIT/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0338-9647-12,NDC,facility,both,1,ML,,343,240.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,250,RC,J3360,HCPCS,69339-136-03,NDC,facility,both,16,ML,,1156,809.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 20 MG ORAL TAB,50863,CDM,636,RC,J8499,HCPCS,0904-6988-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-41,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,FAMNOCHARGE,HCPCS,60687-145-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.45% (1/2 NS) INFUSION (PEDS ONC),50863,CDM,250,RC,J3490,HCPCS,0338-0043-04,NDC,facility,both,1,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-0235-24,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB 100 MG IV SOLR,50863,CDM,636,RC,J1745,HCPCS,57894-030-01,NDC,facility,both,5,EA,JW,701,490.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
BUPROPION HCL 150 MG ORAL TBSR,50863,CDM,636,RC,J3490,HCPCS,50228-175-01,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,9,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,636,RC,J2003,HCPCS,63323-485-27,NDC,facility,both,70,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,40,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLPIDEM  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6082-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MICAFUNGIN 100 MG IV SOLR,50863,CDM,250,RC,J2248,HCPCS,42023-230-01,NDC,facility,both,36,EA,,233,163.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB 100 MG IV SOLR,50863,CDM,636,RC,J1745,HCPCS,57894-030-01,NDC,facility,both,45,EA,,14505,10153.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE  4 MG ORAL TAB,50863,CDM,250,RC,J7509,HCPCS,0904-6914-61,NDC,facility,both,6,EA,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE (FOR CODE) 10% (100 MG/ML) IV SYRINGE,50863,CDM,250,RC,J3490,HCPCS,76329-3304-1,NDC,facility,both,1,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAVASTATIN 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-5892-61,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESNA 100 MG/ML IV SOLN,50863,CDM,250,RC,J9209,HCPCS,25021-201-10,NDC,facility,both,35,ML,,822,575.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,636,RC,J3490,HCPCS,0093-3174-31,NDC,facility,both,1,GM,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 1 GRAM INJ SOLR,50863,CDM,636,RC,J0692,HCPCS,0409-9566-01,NDC,facility,both,2,EA,JZ,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,63323-506-01,NDC,facility,both,10,ML,JZ,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,68094-231-59,NDC,facility,both,7,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MINOXIDIL  2.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-204-11,NDC,facility,both,4,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-617-11,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPTOMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0878,HCPCS,72603-152-01,NDC,facility,both,450,EA,,1316,921.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,63323-165-01,NDC,facility,both,3,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ASPIRIN   81 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,57896-981-12,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,76045-009-96,NDC,facility,both,6,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,32,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM CITRATE ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,71399-0051-1,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV,50863,CDM,250,RC,J7120,HCPCS,0338-0117-03,NDC,facility,both,8,ML,,488,341.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,63739-903-10,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  25 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,59762-1342-1,NDC,facility,both,6,EA,,215,150.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL  2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-735-01,NDC,facility,both,5,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SINCALIDE 5 MCG INJ SOLR,50863,CDM,250,RC,J2805,HCPCS,72266-248-05,NDC,facility,both,1,EA,,272,190.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2305-04,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 1 MG/ML (1ML) SYRINGE (REPACK),50863,CDM,250,RC,J2997,HCPCS,50242-044-13,NDC,facility,both,1,EA,,390,273,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  75 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-475-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COLLAGENASE 250 UNIT/G TOP OINT,50863,CDM,250,RC,J3490,HCPCS,50484-010-30,NDC,facility,both,1,GM,,1124,786.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN D5W 1 GRAM/200 ML IV PGBK,50863,CDM,636,RC,J3370,HCPCS,0338-3552-48,NDC,facility,both,2,ML,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  25 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-473-11,NDC,facility,both,8,EA,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0143-9386-01,NDC,facility,both,28,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,5026852411,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM  2.25 GRAM IV SOLR,50863,CDM,636,RC,J2543,HCPCS,60505-6156-0,NDC,facility,both,4,EA,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3370,HCPCS,0143-9162-01,NDC,facility,both,1,EA,,4029,2820.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOLIC ACID  5 MG/ML INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,39822-1100-1,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 40 MG-200 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,65862-496-47,NDC,facility,both,1,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMETREXED 500 MG IV SOLR,50863,CDM,250,RC,J9305,HCPCS,71288-167-50,NDC,facility,both,100,EA,,1296,907.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE MONONITRATE  60 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,0904-6450-61,NDC,facility,both,2,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,250,RC,J2405,HCPCS,60505-6130-5,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-03,NDC,facility,both,5,ML,JZ,139,97.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LEVOTHYROXINE 150 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-445-01,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),50863,CDM,250,RC,J3490,HCPCS,63323-186-10,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 150 MG/ML INJECTION,50863,CDM,250,RC,J3490,HCPCS,0009-0902-11,NDC,facility,both,2,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOBRAMYCIN SULFATE 40 MG/ML INJ SOLN,50863,CDM,250,RC,J3260,HCPCS,63323-306-02,NDC,facility,both,3,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.3 MG/0.3 ML IM PNIJ,50863,CDM,636,RC,J0169,HCPCS,49502-102-01,NDC,facility,both,3,EA,,675,472.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),50863,CDM,250,RC,J3490,HCPCS,63323-186-10,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1940,HCPCS,72603-251-01,NDC,facility,both,6,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,7733351625,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  25 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-6991-61,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE MODIFIED  25 MG ORAL CAP,50863,CDM,250,RC,J7515,HCPCS,0093-9018-19,NDC,facility,both,6,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE 150 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,29300-424-01,NDC,facility,both,1,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,636,RC,J2704,HCPCS,16714-528-01,NDC,facility,both,8,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,25021-315-01,NDC,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,76045-009-01,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7243-61,NDC,facility,both,1,EA,PLAD,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
SPIRONOLACTONE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-476-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J3490,HCPCS,0338-0049-48,NDC,facility,both,2,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN  10 GRAM INJ SOLR,50863,CDM,250,RC,J0690,HCPCS,0143-9983-91,NDC,facility,both,4,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG IV SOLR,50863,CDM,250,RC,J0650,HCPCS,70710-1833-1,NDC,facility,both,10,EA,,409,286.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-591-11,NDC,facility,both,30,EA,,203,142.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 50 MG/ML INJECTION,50863,CDM,636,RC,J1200,HCPCS,0641-0376-21,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE  5 MG ORAL CP24,50863,CDM,636,RC,J3490,HCPCS,64850-510-01,NDC,facility,both,6,EA,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTAMIDINE 300 MG INJ SOLR,50863,CDM,636,RC,J3490,HCPCS,63323-113-01,NDC,facility,both,1,EA,,226,158.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,0548-5604-00,NDC,facility,both,5,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PNEUMOC 20-VAL CONJ-DIP CR(PF) 0.5 ML IM SYRG,50863,CDM,250,RC,90677,HCPCS,0005-2000-01,NDC,facility,both,1,ML,,955,668.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB 100 MG IV SOLR,50863,CDM,636,RC,J1745,HCPCS,57894-030-01,NDC,facility,both,7,EA,JW,981,686.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J3490,HCPCS,0338-0049-38,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV,50863,CDM,250,RC,J7120,HCPCS,0338-0117-03,NDC,facility,both,2,ML,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INHL NEBU,50863,CDM,636,RC,J3490,HCPCS,0487-9301-02,NDC,facility,both,2,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,50863,CDM,250,RC,J9045,HCPCS,0703-4248-01,NDC,facility,both,18,ML,,662,463.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
23.4% SODIUM CHLORIDE (4 MEQ/ML) INJECTION,50863,CDM,250,RC,J3490,HCPCS,0409-1141-02,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE SODIUM 2.5 MG ORAL TAB,50863,CDM,250,RC,J8610,HCPCS,51079-670-01,NDC,facility,both,10,EA,,265,185.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,636,RC,J7999,HCPCS,70092-1017-46,NDC,facility,both,8,ML,,159,111.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-130-11,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUVOXAMINE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60505-0166-1,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE HCL  2 % MM JELP,50863,CDM,250,RC,J3490,HCPCS,76329-3013-5,NDC,facility,both,1,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,7733393825,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,250,RC,J3490,HCPCS,81284-611-00,NDC,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-131-11,NDC,facility,both,2,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML INJ SOLN,50863,CDM,250,RC,J0171,HCPCS,76329-9060-0,NDC,facility,both,18,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,636,RC,J3490,HCPCS,53746-542-01,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IVPB (PEDIATRICS/ADULT NON-FORM)",50863,CDM,250,RC,J0137,HCPCS,24201-100-01,NDC,facility,both,101,ML,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML ORAL SOLUTION (FOR PEDIATRIC USE),50863,CDM,250,RC,J3480,HCPCS,63323-965-05,NDC,facility,both,2,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE SODIUM 2.5 MG ORAL TAB,50863,CDM,636,RC,J8610,HCPCS,51079-670-01,NDC,facility,both,6,EA,,183,128.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRIL MALEATE  2.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51672-4037-1,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,3,EA,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 40 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6781-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ABATACEPT 250 MG IV SOLR,50863,CDM,250,RC,J0129,HCPCS,0003-2187-13,NDC,facility,both,75,EA,JA,12110,8477,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
MEPIVACAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,636,RC,J0670,HCPCS,63323-294-01,NDC,facility,both,2,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN PEDS SYRINGE (20MG/ML) IN DEXTROSE (CDS MIX,50863,CDM,636,RC,J0690,HCPCS,0781-3451-70,NDC,facility,both,10,EA,,258,180.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,39822-4200-1,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCOSANOL 10 % TOP CREAM,50863,CDM,250,RC,J3490,HCPCS,0766-0801-00,NDC,facility,both,1,GM,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,250,RC,J3360,HCPCS,43598-106-11,NDC,facility,both,16,ML,,1156,809.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,50863,CDM,J9041,HCPCS,72603-270-01,NDC,,,facility,both,5,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 160 MG-800 MG TAB,50863,CDM,636,RC,J3490,HCPCS,65862-420-01,NDC,facility,both,4,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DASATINIB  50 MG ORAL TAB,50863,CDM,250,RC,J9999,HCPCS,0003-0528-11,NDC,facility,both,2,EA,,1863,1304.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,8,EA,JZ,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MENTHOLATUM CAMPHOR 9% -MENTHOL 1.3% OINTMENT,50863,CDM,250,RC,J3490,HCPCS,10742-0001-2,NDC,facility,both,1,GM,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 875 MG-125 MG TAB,50863,CDM,636,RC,J3490,HCPCS,16714-297-01,NDC,facility,both,12,EA,,258,180.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPRAZOLAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,59762-3720-1,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,J3490,HCPCS,0904-6322-06,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2720-02,NDC,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,12,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6500-06,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-444-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOVASTATIN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68180-467-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRASUGREL 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0002-5123-30,NDC,facility,both,1,EA,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,250,RC,J2720,HCPCS,63323-229-30,NDC,facility,both,25,ML,JZ,270,189,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
TRAZODONE  50 MG ORAL TAB,50863,CDM,250,RC,j3490,HCPCS,68382-805-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,250,RC,J2720,HCPCS,63323-229-01,NDC,facility,both,11,ML,,200,140,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV,50863,CDM,250,RC,J7120,HCPCS,0338-0117-03,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELATACEPT 250 MG IV SOLR,50863,CDM,636,RC,J0485,HCPCS,0003-0371-13,NDC,facility,both,438,EA,,4519,3163.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J3490,HCPCS,63323-492-04,NDC,,,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,50863,CDM,250,RC,J0640,HCPCS,25021-814-30,NDC,facility,both,4,EA,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,0409-1207-03,NDC,facility,both,5,ML,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLIMEPIRIDE 4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-327-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,50242-901-09,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 0.1 % TOP CREAM,50863,CDM,250,RC,J3490,HCPCS,45802-064-35,NDC,facility,both,4,GM,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0143-9889-15,NDC,facility,both,18,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,25021-315-01,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 10% IN WATER (NEO) 2 - 3.99 KG,50863,CDM,250,RC,J3490,HCPCS,0264-7520-10,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7124-61,NDC,facility,both,5,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,50863,CDM,J1650,HCPCS,25021-410-76,NDC,,,facility,both,4,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0781-3458-75,NDC,facility,both,4000,ML,,216,151.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEP B-DP(ACELL)T-POLIO VACC-PF 10MCG-25LF-25MCG-10LF-40-8-32 IM SYRING,50863,CDM,90723,HCPCS,58160-811-52,NDC,,,facility,both,1,ML,,445,311.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERTAPENEM 1 GRAM INJ SOLR,50863,CDM,250,RC,J1335,HCPCS,0143-9398-01,NDC,facility,both,1,EA,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOPIDOGREL 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6467-07,NDC,facility,both,1,EA,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,0641-6206-01,NDC,facility,both,3,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),50863,CDM,J2060,HCPCS,0641-6001-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  500 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,0641-6176-01,NDC,facility,both,20,ML,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,31722-711-30,NDC,facility,both,1,EA,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 250 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,62756-797-88,NDC,facility,both,2,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 10 % (100 MG/ML) MISC SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-695-22,NDC,facility,both,25,ML,,1289,902.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % MBP,50863,CDM,250,RC,J3490,HCPCS,0338-0553-18,NDC,facility,both,14,ML,,621,434.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOZAPINE 100 MG ORAL TAB,50863,CDM,J3490,HCPCS,65862-846-01,NDC,,,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,50863,CDM,250,RC,Q5119,HCPCS,0069-0238-01,NDC,facility,both,60,ML,,11871,8309.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,J1100,HCPCS,63323-506-41,NDC,,,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J3490,HCPCS,63323-492-04,NDC,,,facility,both,60,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE  3 % INHL NEBU,50863,CDM,J3490,HCPCS,378699789,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 1 MG ORAL TAB,50863,CDM,250,RC,J8540,HCPCS,0054-8174-25,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-48,NDC,facility,both,1,ML,JZ,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN IN SALINE (ISO-OSMOTIC) 80 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1580,HCPCS,0338-0503-48,NDC,facility,both,4,ML,,107,74.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,14,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IR SOLN,50863,CDM,636,RC,J3490,HCPCS,0338-0048-03,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 250 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,17856-0600-1,NDC,facility,both,4,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE INFUSION 2MG/ML 100ML (FOR ANESTHESIA USE ONLY),50863,CDM,250,RC,J3490,HCPCS,0409-2051-05,NDC,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,2055503601,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLERGONOVINE 0.2 MG/ML (1 ML) INJ SOLN,50863,CDM,250,RC,J2210,HCPCS,0517-0740-01,NDC,facility,both,1,ML,,184,128.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-1749-71,NDC,facility,both,1,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,6,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN   81 MG ORAL TBEC,50863,CDM,J3490,HCPCS,69618-066-02,NDC,,,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOPIDOGREL  75 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-536-11,NDC,facility,both,3,EA,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,636,RC,J1953,HCPCS,0409-1886-22,NDC,facility,both,75,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,71288-505-02,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) 1000 UNITS/ML INJ SOL (FOR DIALYSIS ONLY),50863,CDM,250,RC,J1644,HCPCS,25021-400-10,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-38,NDC,facility,both,1,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,63323-485-27,NDC,,,facility,both,75,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-41,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0780,HCPCS,23155-294-31,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"HIB CONJ-TET,COMPNT 2 OF 2(PF) 10 MCG/0.5 ML IM SOLR",50863,CDM,250,RC,90698,HCPCS,49281-544-58,NDC,facility,both,1,EA,,493,345.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEFLUNOMIDE  10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,23155-043-03,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,76045-009-96,NDC,facility,both,10,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MANNITOL 20% IV SOLP,50863,CDM,250,RC,J2150,HCPCS,0990-7715-13,NDC,facility,both,1,ML,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN INFUSION PEDS IV SYRINGE IN D5W (FROM PREMIX),50863,CDM,250,RC,J2598,HCPCS,99999-408-72,NDC,facility,both,20,ML,,752,526.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-22,NDC,facility,both,60,ML,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0641-6059-01,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ESMOLOL IN SALINE (ISO-OSMOTIC) 2,000 MG/100 ML (20 MG/ML) IV",50863,CDM,250,RC,J1805,HCPCS,10019-075-87,NDC,facility,both,1,ML,,1391,973.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,J3370,HCPCS,0143-9162-01,NDC,,,facility,both,4,EA,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  100 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,0641-6175-01,NDC,facility,both,2,ML,"JW,JB",4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient | Modifier JB: Administered subcutaneously
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,0409-3795-19,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-DYYB 100 MG IV SOLR,50863,CDM,636,RC,Q5103,HCPCS,0069-0809-01,NDC,facility,both,20,EA,JZ,5224,3656.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,FAMNOCHARGE,HCPCS,0338-0049-41,NDC,,,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-381-11,NDC,facility,both,1,EA,,343,240.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VERAPAMIL 120 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42291-855-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-406-03,NDC,facility,both,1,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOBENZAPRINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,43547-400-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0003-0893-21,NDC,facility,both,1,EA,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-319-11,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM ACETATE 667 MG ORAL CAP,50863,CDM,250,RC,J0615,HCPCS,0904-7119-61,NDC,facility,both,58,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),50863,CDM,250,RC,J2060,HCPCS,0641-6044-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-0710-20,NDC,facility,both,5,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,7733393825,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LANSOPRAZOLE 3 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,65628-080-05,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN  750 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,67877-414-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR PHOSPHATE 30 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,72205-042-11,NDC,facility,both,1,EA,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLN,50863,CDM,636,RC,J3262,HCPCS,50242-136-01,NDC,facility,both,200,ML,,3666,2566.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-349-11,NDC,facility,both,1,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,2,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,0641-6145-01,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 10 MG/ML ORAL SOLUTION (REPACK),50863,CDM,250,RC,J3490,HCPCS,0131-5410-71,NDC,facility,both,1,ML,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-492-04,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,71399-1025-3,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,51079-051-20,NDC,facility,both,14,EA,,313,219.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),50863,CDM,250,RC,J1815,HCPCS,0024-5926-05,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0780,HCPCS,23155-294-31,NDC,facility,both,1,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2599,HCPCS,63323-930-01,NDC,facility,both,3,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,82,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB 100 MG IV SOLR,50863,CDM,636,RC,J1745,HCPCS,57894-030-01,NDC,facility,both,70,EA,,22563,15794.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7007-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6426-61,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-231-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAUNORUBICIN 5 MG/ML IV INJ,50863,CDM,250,RC,J9150,HCPCS,0143-9550-01,NDC,facility,both,10,ML,,2375,1662.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,636,RC,Q0162,HCPCS,60687-252-40,NDC,facility,both,2,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,61,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,57,ML,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIMOLOL MALEATE 0.25 % OPHT DROP,50863,CDM,250,RC,J3490,HCPCS,61314-226-05,NDC,facility,both,1,ML,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE (FOR CODE) 10% (100 MG/ML) IV SYRINGE,50863,CDM,636,RC,J3490,HCPCS,0409-4928-11,NDC,facility,both,1,ML,,101,70.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  37.5 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,65862-527-90,NDC,facility,both,3,EA,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TARLATAMAB-DLLE  1 MG IV SOLR,50863,CDM,250,RC,C9170,HCPCS,55513-059-01,NDC,facility,both,1,EA,,4140,2898,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 200 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-552-11,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMINOPHYLLINE 500 MG/20 ML IV SOLN,50863,CDM,250,RC,J0280,HCPCS,0409-5922-01,NDC,facility,both,2,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,16729-114-08,NDC,facility,both,10,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2310,HCPCS,0409-1215-01,NDC,facility,both,2,ML,,279,195.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 40 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,70436-227-48,NDC,facility,both,1,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,71456-001-01,NDC,facility,both,16,ML,,2817,1971.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE (FOR CODE) 10% (100 MG/ML) IV SYRINGE,50863,CDM,250,RC,J3490,HCPCS,76329-3304-1,NDC,facility,both,3,ML,,185,129.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3370,HCPCS,16714-309-01,NDC,facility,both,4,EA,,165,115.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0069-0006-04,NDC,facility,both,1,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),50863,CDM,636,RC,J3490,HCPCS,71266-9080-4,NDC,facility,both,2,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML INJ SOLN,50863,CDM,J0171,HCPCS,76329-9060-0,NDC,,,facility,both,160,ML,,425,297.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 20 MG ORAL CPDR,50863,CDM,636,RC,J3490,HCPCS,60687-723-11,NDC,facility,both,1,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOSTIGMINE METHYLSULFATE 1 MG/ML IV SOLN,50863,CDM,636,RC,J2710,HCPCS,42023-189-01,NDC,facility,both,2,ML,,191,133.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J3490,HCPCS,0143-9595-01,NDC,,,facility,both,50,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,65862-707-80,NDC,facility,both,4,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0143-9889-01,NDC,facility,both,30,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,50863,CDM,250,RC,Q0177,HCPCS,60687-675-11,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,50863,CDM,J9041,HCPCS,72603-270-01,NDC,,,facility,both,15,EA,,133,93.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,8,ML,JW,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
HYALURONIDASE 150 UNIT/ML INJ SOLN,50863,CDM,250,RC,J3473,HCPCS,18657-117-02,NDC,facility,both,135,ML,,256,179.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,0121-1971-21,NDC,facility,both,2,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 3000 MCG/ML INJECTION,50863,CDM,J0153,HCPCS,63323-651-00,NDC,,,facility,both,12,ML,,129,90.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE NA (PRESERV FREE) 25 MG/ML INJ SOLN,50863,CDM,250,RC,J9260,HCPCS,16729-277-35,NDC,facility,both,200,ML,,2013,1409.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  20 MEQ ORAL PACK,50863,CDM,250,RC,J3490,HCPCS,69543-451-01,NDC,facility,both,1,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 300 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,63739-132-33,NDC,facility,both,2,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BISACODYL 10 MG RECT SUPP,50863,CDM,250,RC,J3490,HCPCS,0574-7050-12,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-986-01,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN PEDS SYRINGE (20MG/ML) IN DEXTROSE (CDS MIX,50863,CDM,636,RC,J0690,HCPCS,0781-3451-70,NDC,facility,both,6,EA,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE IN D5W 1 GRAM/100 ML IV PGBK,50863,CDM,250,RC,J3475,HCPCS,44567-410-24,NDC,facility,both,4,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 1 GRAM INJ SOLR,50863,CDM,250,RC,J0692,HCPCS,0409-9566-01,NDC,facility,both,1,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-134-11,NDC,facility,both,20,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7111-61,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,40,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 100 MG IV SOLR,50863,CDM,636,RC,J2997,HCPCS,50242-085-25,NDC,facility,both,100,EA,JZ,24289,17002.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LITHIUM CARBONATE 300 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,68084-640-11,NDC,facility,both,3,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-0552-23,NDC,facility,both,1,EA,PLAD,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
HYDROMORPHONE 10 MG/50 ML (0.2MG/ML) PCA IN NS (MERGE),50863,CDM,250,RC,J1171,HCPCS,61553-830-41,NDC,facility,both,100,ML,,144,100.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYBUTYNIN CHLORIDE  5 MG ORAL TO24,50863,CDM,250,RC,J3490,HCPCS,0904-6570-06,NDC,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25 MG-100 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7501-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,636,RC,J2003,HCPCS,55150-165-05,NDC,facility,both,100,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,250,RC,J0690,HCPCS,44567-707-25,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID,50863,CDM,636,RC,J3490,HCPCS,69339-152-01,NDC,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-492-04,NDC,facility,both,1,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 250 MG/50 ML CONCENTRATED DRIP (RSE),50863,CDM,250,RC,J2250,HCPCS,0641-6060-01,NDC,facility,both,250,ML,,230,161,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN  300 MG RECT SUPP,50863,CDM,250,RC,J3490,HCPCS,0574-7034-12,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,68,ML,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 2 MG INJ SOLR,50863,CDM,250,RC,J2997,HCPCS,50242-041-64,NDC,facility,both,6,EA,,2286,1600.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,18,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,J3490,HCPCS,57896-102-01,NDC,,,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIOTROPIUM BROMIDE 2.5 MCG/ACTUATION INHL MIST,50863,CDM,250,RC,J3490,HCPCS,0597-0100-51,NDC,facility,both,1,GM,,382,267.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,J7512,HCPCS,60687-145-11,NDC,,,facility,both,40,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),50863,CDM,250,RC,J3490,HCPCS,63323-186-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-495-27,NDC,,,facility,both,280,ML,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN  325 MG ORAL TBEC,50863,CDM,J3490,HCPCS,0536-1232-01,NDC,,,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OBINUTUZUMAB 900 MG IN NS 286 ML (STOCK DOSE),50863,CDM,J9301,HCPCS,50242-070-01,NDC,,,facility,both,90,ML,,13905,9733.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPTINEZUMAB-JJMR 100 MG/ML IV SOLN,50863,CDM,636,RC,J3032,HCPCS,67386-130-51,NDC,facility,both,100,ML,,4127,2888.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68382-806-01,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYPROHEPTADINE 4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0115-1757-01,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,47,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,18,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,71288-402-10,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 120 MG/0.8 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0548-5606-00,NDC,facility,both,12,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE 100 MG TAB,50863,CDM,636,RC,J3490,HCPCS,23155-135-25,NDC,facility,both,28,EA,,496,347.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  50 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,64980-411-09,NDC,facility,both,3,EA,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE NA (PRESERV FREE) 25 MG/ML INJ SOLN,50863,CDM,250,RC,J9260,HCPCS,61703-408-41,NDC,facility,both,40,ML,,432,302.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,J3490,HCPCS,68094-494-59,NDC,,,facility,both,6,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 50 MG/ML INJECTION,50863,CDM,250,RC,J1200,HCPCS,63323-664-00,NDC,facility,both,2,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRIL MALEATE  2.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16714-442-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,50863,CDM,636,RC,J8540,HCPCS,0054-8175-25,NDC,facility,both,64,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NOREPINEPHRINE BITARTRATE-D5W 4 MG/250 ML (16 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0338-0112-20,NDC,facility,both,1,ML,,134,93.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLN,50863,CDM,636,RC,J3262,HCPCS,50242-135-01,NDC,facility,both,80,ML,JZ,1467,1026.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ERYTHROMYCIN 5 MG/G OPHT OINT,50863,CDM,636,RC,J3490,HCPCS,48102-057-11,NDC,facility,both,2,GM,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0904-6828-05,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN NACL (PF) 1000 UNIT/500 ML IV SOLP,50863,CDM,636,RC,J1644,HCPCS,0264-9872-10,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6369-61,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-229-02,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,65,EA,,8970,6279,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOPAMINE INFUSION NEO IV SYRINGE (FROM PREMIX),50863,CDM,636,RC,J1265,HCPCS,0409-7809-11,NDC,facility,both,10,ML,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLU VACCINE TS 2025-26 65 YR UP (PF) 180 MCG/0.5 ML IM SYRG,50863,CDM,90662,HCPCS,49281-125-88,NDC,,,facility,both,1,ML,,403,282.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,2,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN D5W 20000 UNIT/500 ML,50863,CDM,636,RC,J1644,HCPCS,0264-9567-10,NDC,facility,both,13,ML,JW,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DULOXETINE 30 MG ORAL CPDR,50863,CDM,636,RC,J3490,HCPCS,0904-7044-61,NDC,facility,both,4,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,J2003,HCPCS,76329-3390-1,NDC,,,facility,both,100,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYCHLOROQUINE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7046-61,NDC,facility,both,2,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID (PORK) 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0456-1045-01,NDC,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,68180-150-01,NDC,facility,both,3,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7030,HCPCS,0338-0049-04,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,68094-494-59,NDC,facility,both,8,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML INJ SOLN,50863,CDM,250,RC,J0171,HCPCS,76329-9061-0,NDC,facility,both,30,ML,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-572-10,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-191-11,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,72205-101-01,NDC,facility,both,4,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,250,RC,J3490,HCPCS,72789-057-01,NDC,facility,both,1,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-38,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,50863,CDM,250,RC,J9000,HCPCS,63323-883-30,NDC,facility,both,10,ML,,392,274.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-6695-02,NDC,facility,both,1,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2308-22,NDC,facility,both,9,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
NYSTATIN 100000 UNIT/ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,63739-160-70,NDC,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-087-02,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6773-61,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FERROUS SULFATE 325 MG (65 MG IRON) TAB,50863,CDM,636,RC,J3490,HCPCS,904759060,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOPAMINE 200 MG/5 ML (40 MG/ML) IV,50863,CDM,250,RC,J1265,HCPCS,0143-9252-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % MBP,50863,CDM,636,RC,J3490,HCPCS,0338-0553-18,NDC,facility,both,1,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,250,RC,J2270,HCPCS,0409-1890-13,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-1283-03,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 10 MG ORAL TAB,50863,CDM,J3490,HCPCS,68084-097-11,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,68180-441-02,NDC,facility,both,2,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON DEXTRAN 50 MG/ML INJ SOLN,50863,CDM,250,RC,J1750,HCPCS,0023-6082-01,NDC,facility,both,1,ML,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,51754-5001-1,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 0.1 MG/ML INJ SYRG,50863,CDM,636,RC,J0461,HCPCS,76329-3340-1,NDC,facility,both,40,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUTILIDE FUMARATE 0.1 MG/ML IV SOLN,50863,CDM,250,RC,J1742,HCPCS,67457-366-10,NDC,facility,both,1,ML,,1100,770,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,65219-445-01,NDC,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 50 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,59651-489-01,NDC,facility,both,100,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LANSOPRAZOLE 30 MG ORAL TBLD,50863,CDM,250,RC,J3490,HCPCS,65862-896-10,NDC,facility,both,1,EA,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOPAMINE IN D5W 400 MG/250 ML (1.6 MG/ML) IV,50863,CDM,250,RC,J1265,HCPCS,0409-7809-22,NDC,facility,both,10,ML,JZ,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,21,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEPLIZUMAB-MZWV 2 MG/20 ML IV SOLN,50863,CDM,636,RC,J9381,HCPCS,73650-316-01,NDC,facility,both,76,ME,JW,1998,1398.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PROMETHAZINE  6.25 MG/5 ML ORAL SYRP,50863,CDM,250,RC,Q0169,HCPCS,62135-774-41,NDC,facility,both,1,ML,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LITHIUM CARBONATE 450 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,68084-655-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  25 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6991-61,NDC,facility,both,4,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OMEPRAZOLE-SODIUM BICARBONATE 2-84 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,65628-270-03,NDC,facility,both,2,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7244-68,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,71288-402-10,NDC,facility,both,13,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-25,NDC,facility,both,60,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PEMETREXED 100 MG IV SOLR,50863,CDM,250,RC,J9305,HCPCS,71288-166-10,NDC,facility,both,5,EA,JW,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-1638-32,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 10 MG/50 ML (0.2MG/ML) PCA IN NS (MERGE),50863,CDM,250,RC,J1171,HCPCS,70092-9286-74,NDC,facility,both,100,ML,,131,91.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 17 GRAM (100 %) ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,1152372688,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-229-02,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-506-11,NDC,facility,both,3,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE (PF-DURAMORPH/ASTRAMORPH) 0.5 MG/ML INJ SOLN,50863,CDM,250,RC,J2274,HCPCS,0409-3814-12,NDC,facility,both,1,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELIMUMAB 120 MG IV SOLR,50863,CDM,636,RC,J0490,HCPCS,49401-101-01,NDC,facility,both,36,ME,,4228,2959.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG IV SOLR,50863,CDM,636,RC,J3490,HCPCS,63323-130-02,NDC,facility,both,5,EA,,773,541.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6950-61,NDC,facility,both,3,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNIT/G TOP PACK,50863,CDM,250,RC,J3490,HCPCS,45802-060-70,NDC,facility,both,6,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,50863,CDM,250,RC,J9171,HCPCS,67457-533-16,NDC,facility,both,160,ML,,1518,1062.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MILRINONE 1 MG/ML IV SOLN,50863,CDM,250,RC,J2260,HCPCS,0143-9710-01,NDC,facility,both,2,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM BICARB-CITRIC ACID 20 MEQ ORAL TBEF,50863,CDM,J3490,HCPCS,51801-011-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,J3490,HCPCS,66794-228-02,NDC,,,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID (PORK) 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0456-0457-01,NDC,facility,both,3,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE CONCENTRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0054-0404-44,NDC,facility,both,2,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-145-11,NDC,facility,both,134,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 500 MG PE/10 ML INJ SOLN,50863,CDM,250,RC,Q2009,HCPCS,0641-6137-01,NDC,facility,both,42,ML,,1016,711.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,J2003,HCPCS,0409-1323-15,NDC,,,facility,both,200,ML,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2305-04,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESCITALOPRAM 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,43547-282-10,NDC,facility,both,1,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,250,RC,J0690,HCPCS,70092-1017-46,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-723-11,NDC,facility,both,1,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROATE SODIUM 100 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0143-9785-01,NDC,facility,both,3,ML,,305,213.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,250,RC,J0132,HCPCS,55150-259-30,NDC,facility,both,120,ML,,542,379.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,636,RC,J7999,HCPCS,70092-1017-46,NDC,facility,both,180,ML,,7111,4977.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,50383-584-05,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLEVIDIPINE 50 MG/100 ML IV EMUL,50863,CDM,250,RC,C9248,HCPCS,10122-611-01,NDC,facility,both,100,ML,,1479,1035.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 100 MG PE/2 ML INJ SOLN,50863,CDM,250,RC,Q2009,HCPCS,0641-6136-01,NDC,facility,both,4,ML,,174,121.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM  3 GRAM INJ SOLR,50863,CDM,250,RC,J0295,HCPCS,25021-143-30,NDC,facility,both,2,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J2312,HCPCS,36000-308-01,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,76045-009-05,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACTERIOSTATIC SALINE 0.9 % INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-924-30,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,250,RC,J3490,HCPCS,0641-6104-01,NDC,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 2-0.5 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,50268-144-11,NDC,facility,both,1,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATOVAQUONE 750 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,60687-534-40,NDC,facility,both,2,ML,,302,211.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL  6.25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-0135-01,NDC,facility,both,2,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,250,RC,J7999,HCPCS,70092-1017-46,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),50863,CDM,636,RC,J2060,HCPCS,0641-6044-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  75 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7000-61,NDC,facility,both,3,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR IRRIGATION, STERILE SOLUTION",50863,CDM,250,RC,J3490,HCPCS,0338-0004-02,NDC,facility,both,2,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-4264-11,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,636,RC,J2270,HCPCS,0641-6125-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,63739-903-10,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J1610,HCPCS,63323-596-11,NDC,facility,both,2,EA,,1789,1252.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0137,HCPCS,0143-9386-01,NDC,facility,both,26,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  75 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,68084-709-11,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORDIAZEPOXIDE 25 MG CAP,50863,CDM,636,RC,J3490,HCPCS,0555-0159-02,NDC,facility,both,3,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0781-3156-06,NDC,facility,both,83,ML,,180,126,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0121-1781-05,NDC,facility,both,4,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 250 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,0832-7123-89,NDC,facility,both,3,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE HCL IN NS 10 MG/250 ML (0.04 MG/ML) IV SOLN (PDS MERGE),50863,CDM,250,RC,J2371,HCPCS,71506-010-58,NDC,facility,both,500,ML,,146,102.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0780,HCPCS,0641-6135-01,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,0641-6145-01,NDC,facility,both,2,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  75 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-658-01,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,0409-9094-22,NDC,facility,both,1,ML,JZ,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
BENRALIZUMAB 30 MG/ML SUBQ SYRG,50863,CDM,636,RC,J0517,HCPCS,0310-1730-30,NDC,facility,both,30,ML,,13116,9181.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,50863,CDM,636,RC,J3301,HCPCS,70121-1049-2,NDC,facility,both,8,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  50 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,72205-012-90,NDC,facility,both,3,EA,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,65219-570-01,NDC,facility,both,12,ML,,277,193.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELATACEPT 250 MG IV SOLR,50863,CDM,636,RC,J0485,HCPCS,0003-0371-13,NDC,facility,both,550,EA,,5675,3972.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPROST TROMETHAMINE 250 MCG/ML IM SOLN,50863,CDM,250,RC,J3490,HCPCS,0009-0856-08,NDC,facility,both,1,ML,,605,423.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE (POLACRILEX) 2 MG MM LOZG,50863,CDM,636,RC,J3490,HCPCS,45802-344-05,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,50863,CDM,250,RC,J2359,HCPCS,55150-308-01,NDC,facility,both,10,EA,JW,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,0641-6145-01,NDC,facility,both,2,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PHYTONADIONE 1 MG/ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-9158-01,NDC,facility,both,5,ML,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-65,NDC,facility,both,18,ML,JW,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DOXAZOSIN 4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-224-11,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1162-18,NDC,facility,both,150,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VERAPAMIL  80 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,23155-026-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN IN D5W 400 MG/200 ML IV PGBK,50863,CDM,636,RC,J0744,HCPCS,25021-114-87,NDC,facility,both,2,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J3490,HCPCS,0338-0049-41,NDC,facility,both,2,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,28,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG/ML ORAL CONC,50863,CDM,250,RC,J3490,HCPCS,0054-3553-44,NDC,facility,both,4,ML,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-04,NDC,facility,both,2,ML,JZ,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,636,RC,J2405,HCPCS,23155-549-31,NDC,facility,both,16,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSULFAN BLUE 1 % INJ SOLN,50863,CDM,636,RC,Q9968,HCPCS,67457-220-05,NDC,facility,both,30,ML,JW,875,612.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
SEVELAMER CARBONATE 800 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,17856-921-01,NDC,facility,both,3,EA,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7263-61,NDC,facility,both,4,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL  32.4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,13517-626-01,NDC,facility,both,3,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS",50863,CDM,636,RC,J3490,HCPCS,61314-630-06,NDC,facility,both,1,ML,,216,151.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-41,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  5 GRAM IV SOLR,50863,CDM,250,RC,J3370,HCPCS,0143-9163-01,NDC,facility,both,4,EA,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),50863,CDM,250,RC,J3490,HCPCS,0409-4888-03,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 100 MG IV SOLR,50863,CDM,J2997,HCPCS,50242-085-25,NDC,,,facility,both,100,EA,,24289,17002.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-588-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COLCHICINE 0.6 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,65162-710-09,NDC,facility,both,2,EA,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16729-216-15,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,0409-6625-14,NDC,facility,both,6,ML,,347,242.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42291-560-90,NDC,facility,both,3,EA,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 5 MG/ML IV SOLN,50863,CDM,636,RC,J1921,HCPCS,17478-420-20,NDC,facility,both,1,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SODIUM CHLORIDE 0.9 % IR SOLN,50863,CDM,250,RC,J3490,HCPCS,0338-0047-46,NDC,facility,both,2,ML,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0456,HCPCS,70436-019-82,NDC,facility,both,1,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE (FOR EMERGENCY) 100 MG/ML (10%) IV SOLN,50863,CDM,250,RC,J0612,HCPCS,0143-9184-01,NDC,facility,both,1000,ML,,286,200.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J2003,HCPCS,63323-492-27,NDC,facility,both,60,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,200,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
AMLODIPINE  2.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6369-61,NDC,facility,both,2,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  100 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,23155-688-31,NDC,facility,both,4,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE 200 MG/20 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,31722-203-20,NDC,facility,both,1,ML,,300,210,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,50863,CDM,636,RC,J0585,HCPCS,0023-1145-01,NDC,facility,both,27,EA,,432,302.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,51754-5001-1,NDC,facility,both,2,ML,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4% TOP PATCH,50863,CDM,636,RC,J3490,HCPCS,0536-1202-15,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65862-006-01,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LANSOPRAZOLE 3 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,65628-080-05,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMETHICONE 40MG/0.6ML (0.6ML-UD) SYRINGE (REPACK),50863,CDM,250,RC,J3490,HCPCS,17856-0799-4,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,25021-674-20,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J1610,HCPCS,63323-596-11,NDC,facility,both,1,EA,JZ,895,626.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
FLUOXETINE 10 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7345-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,100,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-426-02,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 50% IN WATER (MERGE RECORD),50863,CDM,250,RC,J7060,HCPCS,0409-7517-66,NDC,facility,both,1,ML,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-9558-05,NDC,facility,both,3,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,636,RC,J2560,HCPCS,0641-0477-21,NDC,facility,both,3,ML,,697,487.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 50 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6323-61,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,5,ML,,160,112,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERYTHROMYCIN 5 MG/G OPHT OINT,50863,CDM,636,RC,J3490,HCPCS,24208-910-19,NDC,facility,both,1,GM,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 1 GRAM INJ SOLR,50863,CDM,250,RC,J0692,HCPCS,25021-121-20,NDC,facility,both,2,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,300,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
COLCHICINE 0.6 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7120-04,NDC,facility,both,1,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,16714-298-01,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,70004-600-09,NDC,facility,both,2,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,72603-179-01,NDC,facility,both,10,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL 20 MG/5 ML ORAL ELIX,50863,CDM,636,RC,J3490,HCPCS,60687-671-40,NDC,facility,both,6,ML,,158,110.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5%-1/2 NORMAL SALINE IV,50863,CDM,250,RC,J7042,HCPCS,0990-7926-09,NDC,facility,both,2,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 1 MG ORAL TAB,50863,CDM,250,RC,J8540,HCPCS,0054-8174-25,NDC,facility,both,8,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 500 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,50268-152-11,NDC,facility,both,9,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1817,HCPCS,0169-1833-11,NDC,facility,both,1,ML,GZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier GZ: Item or service expected to be denied as not reasonable and necessary
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,76329-3352-1,NDC,facility,both,9,ML,,1041,728.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZOCAINE-MENTHOL 20-0.26 % MM GEL,50863,CDM,636,RC,J3490,HCPCS,1031043028,NDC,facility,both,1,GM,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANTI-THYMOCYTE GLOB (RABBIT) 25 MG IV SOLR,50863,CDM,636,RC,J7511,HCPCS,58468-0080-1,NDC,facility,both,3,EA,JZ,6066,4246.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
APIXABAN 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0003-0894-21,NDC,facility,both,10,EA,,437,305.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,250,RC,J3490,HCPCS,60687-653-11,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV,50863,CDM,J7120,HCPCS,0338-0117-04,NDC,,,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-4799-05,NDC,facility,both,2,ML,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACUBITRIL-VALSARTAN 24-26 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0078-0659-67,NDC,facility,both,1,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,0641-6007-01,NDC,facility,both,3,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,0409-9094-12,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,250,RC,J3490,HCPCS,53746-542-01,NDC,facility,both,4,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR  6 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0004-0822-05,NDC,facility,both,3,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYTOCIN 10 UNIT/ML INJ SOLN,50863,CDM,250,RC,J2590,HCPCS,63323-012-11,NDC,facility,both,5,ML,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 50% IN WATER (MERGE RECORD),50863,CDM,250,RC,J7060,HCPCS,70092-1475-50,NDC,facility,both,1,ML,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR 800 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-109-11,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON 4 MG ORAL TBDL,50863,CDM,636,RC,J3490,HCPCS,57237-077-10,NDC,facility,both,2,EA,,218,152.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML ORAL SOLUTION (FOR PEDIATRIC USE),50863,CDM,250,RC,J3480,HCPCS,63323-965-05,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68180-969-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,50863,CDM,636,RC,J1885,HCPCS,63323-162-03,NDC,facility,both,4,ML,JZ,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PANTOPRAZOLE 40 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,51079-051-20,NDC,facility,both,1,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  500 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,0641-6176-01,NDC,facility,both,20,ML,JA,206,144.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,636,RC,Q0162,HCPCS,16714-671-02,NDC,facility,both,2,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG ORAL TBDL,50863,CDM,636,RC,J3490,HCPCS,13668-088-30,NDC,facility,both,1,EA,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-4827-05,NDC,facility,both,2,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4 % MUCOSAL TOPICAL SOLN,50863,CDM,250,RC,J3490,HCPCS,70954-518-10,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,72603-251-01,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-02,NDC,facility,both,5,ML,,262,183.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,43066-007-10,NDC,facility,both,3,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESIPRAMINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50742-113-01,NDC,facility,both,8,EA,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,636,RC,Q0162,HCPCS,65162-691-79,NDC,facility,both,2,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0143-9386-01,NDC,facility,both,44,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GAMMAGARD LIQUID 10 % IV SOLN,50863,CDM,636,RC,J1569,HCPCS,0944-2700-06,NDC,facility,both,40,ML,JZ,7211,5047.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
TEPLIZUMAB-MZWV 2 MG/20 ML IV SOLN,50863,CDM,636,RC,J9381,HCPCS,73650-316-01,NDC,facility,both,40,ME,,2419,1693.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-242-11,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,0409-1283-03,NDC,facility,both,15,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE MONONITRATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,5026885111,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0003-0894-70,NDC,facility,both,20,EA,,856,599.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 10 % (100 MG/ML) MISC SOLN,50863,CDM,250,RC,J3490,HCPCS,0517-7504-01,NDC,facility,both,1,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIROFIBAN-0.9% SODIUM CHLORIDE 5 MG/100 ML (50 MCG/ML) IV SOLN,50863,CDM,636,RC,J3246,HCPCS,25208-002-03,NDC,facility,both,68,ML,,1352,946.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 2 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,250,RC,J2270,HCPCS,76045-004-01,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,J7510,HCPCS,17856-0759-5,NDC,,,facility,both,3,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,FAMNOCHARGE,HCPCS,16714-671-02,NDC,,,facility,both,1,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60505-3111-0,NDC,facility,both,3,EA,,194,135.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESALAMINE  250 MG ORAL CPSR,50863,CDM,636,RC,J3490,HCPCS,54092-189-81,NDC,facility,both,2,EA,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MISOPROSTOL 200 MCG ORAL TAB,50863,CDM,250,RC,S0191,HCPCS,60687-746-11,NDC,facility,both,2,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0121-0914-05,NDC,facility,both,4,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML IV,50863,CDM,250,RC,J3490,HCPCS,70860-301-41,NDC,facility,both,2,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPAGLIFLOZIN PROPANEDIOL  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,66993-456-30,NDC,facility,both,1,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,63739-564-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-591-11,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOZAPINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0378-0860-01,NDC,facility,both,2,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PYRIDOSTIGMINE BROMIDE 180 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,64980-220-03,NDC,facility,both,1,EA,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-723-11,NDC,facility,both,2,EA,,107,74.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-406-03,NDC,facility,both,1,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-595-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM NEO/PED INFUSION (CDS MIXTURE),50863,CDM,250,RC,J2185,HCPCS,0781-3267-90,NDC,facility,both,8,EA,,469,328.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 1 % TOPICAL GEL,50863,CDM,250,RC,J3490,HCPCS,0168-0202-30,NDC,facility,both,1,GM,,374,261.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CONJUGATED ESTROGENS  0.3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0046-1100-81,NDC,facility,both,1,EA,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM SR 90 MG 12 HR CAP,50863,CDM,250,RC,J3490,HCPCS,51079-925-01,NDC,facility,both,3,EA,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE  2 MG/ML INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-285-20,NDC,facility,both,1,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,6,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TAB,50863,CDM,250,RC,J3490,HCPCS,10702-253-01,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,250,RC,J3490,HCPCS,68180-963-01,NDC,facility,both,1,GM,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADVATE: FACTOR VIII CONCENTRATE (MERGE RECORD),50863,CDM,250,RC,J7192,HCPCS,0944-3054-02,NDC,facility,both,1500,UN,,6279,4395.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN  5 MG/ACTUATION NASL SPRY,50863,CDM,636,RC,J3490,HCPCS,66993-081-69,NDC,facility,both,1,EA,,261,182.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE  7.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-584-11,NDC,facility,both,6,EA,,101,70.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DABIGATRAN  150 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0597-0360-82,NDC,facility,both,1,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAMADOL  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-808-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,0781-3232-94,NDC,facility,both,2,EA,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML INJECTION,50863,CDM,636,RC,J3411,HCPCS,0641-6228-01,NDC,facility,both,2,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,250,RC,J3101,HCPCS,50242-037-06,NDC,facility,both,17,EA,,7787,5450.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 20 MEQ/100 ML IV PGBK,50863,CDM,250,RC,J3480,HCPCS,0338-0705-48,NDC,facility,both,10,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,16714-026-01,NDC,facility,both,6,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-492-41,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,636,RC,J1953,HCPCS,0409-1886-22,NDC,facility,both,300,ML,JZ,156,109.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ENALAPRILAT 1.25 MG/ML IV INJ,50863,CDM,636,RC,J3490,HCPCS,43598-078-11,NDC,facility,both,1,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  75 MG ORAL CP24,50863,CDM,636,RC,J3490,HCPCS,65862-528-90,NDC,facility,both,1,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 2 MG INJ SOLR,50863,CDM,250,RC,J2997,HCPCS,50242-041-64,NDC,facility,both,5,EA,JZ,1905,1333.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
TOPIRAMATE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,62756-711-86,NDC,facility,both,1,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIROFIBAN-0.9% SODIUM CHLORIDE 5 MG/100 ML (50 MCG/ML) IV SOLN,50863,CDM,250,RC,J3246,HCPCS,25208-002-03,NDC,facility,both,15,ML,JW,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-3178-16,NDC,facility,both,35,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 50 MG TAB,50863,CDM,636,RC,J3490,HCPCS,16714-797-01,NDC,facility,both,1,EA,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPTOMYCIN 500 MG IV SOLR,50863,CDM,636,RC,J0878,HCPCS,72603-152-01,NDC,facility,both,650,EA,,1901,1330.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-520-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,250,RC,J3490,HCPCS,0173-0682-24,NDC,facility,both,1,GM,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL  3.125 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6300-61,NDC,facility,both,2,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G POTASSIUM  5000000 UNIT INJ SOLR,50863,CDM,250,RC,J2540,HCPCS,72603-210-01,NDC,facility,both,9,EA,JZ,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PROPARACAINE 0.5 % OPHT DROP,50863,CDM,250,RC,J3490,HCPCS,61314-016-01,NDC,facility,both,1,ML,,215,150.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7030,HCPCS,0338-0049-04,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 120 MG/0.8 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,16714-056-01,NDC,facility,both,12,ML,,141,98.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 100 MG ORAL TBSR,50863,CDM,636,RC,J3490,HCPCS,43547-288-10,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,636,RC,J3490,HCPCS,0641-6147-01,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,636,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,12,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-172-01,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 40 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,16714-696-01,NDC,facility,both,1,ML,,181,126.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 500 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-7243-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-1283-03,NDC,facility,both,30,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL  6.25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7306-61,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,3,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,J1171,HCPCS,76045-009-10,NDC,,,facility,both,20,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 5 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0641-6061-01,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,0143-9511-01,NDC,facility,both,12,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,63323-806-13,NDC,facility,both,5,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCERIN (CHILD) RECTAL SUPPOSITORY,50863,CDM,250,RC,J3490,HCPCS,57237-326-52,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0047-03,NDC,facility,both,25,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-442-01,NDC,facility,both,3,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML INJ SOLN,50863,CDM,250,RC,J2060,HCPCS,0641-6207-01,NDC,facility,both,2,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-1638-32,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES  8.6 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7252-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),50863,CDM,250,RC,J1815,HCPCS,0024-5926-05,NDC,facility,both,7,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,5026885511,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELIMUMAB 120 MG IV SOLR,50863,CDM,636,RC,J0490,HCPCS,49401-101-01,NDC,facility,both,60,ME,,7047,4932.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BIVALIRUDIN 250 MG IV SOLR,50863,CDM,250,RC,J0583,HCPCS,55150-210-10,NDC,facility,both,500,EA,,864,604.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NORTRIPTYLINE 25 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0093-0811-01,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-124-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,636,RC,Q0162,HCPCS,60687-252-40,NDC,facility,both,2,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
23.4% SODIUM CHLORIDE (4 MEQ/ML) INJECTION,50863,CDM,250,RC,J3490,HCPCS,63323-187-30,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENAZEPRIL 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65862-116-01,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,0409-9094-22,NDC,facility,both,2,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,2,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MERCAPTOPURINE 50 MG ORAL TAB,50863,CDM,250,RC,J9999,HCPCS,0378-3547-52,NDC,facility,both,3,EA,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN  500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7162-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESALAMINE  250 MG ORAL CPSR,50863,CDM,250,RC,J3490,HCPCS,54092-189-81,NDC,facility,both,4,EA,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,70004-600-09,NDC,facility,both,3,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,23,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25 MG-100 MG TAB,50863,CDM,250,RC,J3490,HCPCS,69367-339-05,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE IN SALINE (ISO-OSM) 400 MG/200 ML IV PIGGY BACK,50863,CDM,250,RC,J1450,HCPCS,25021-184-87,NDC,facility,both,2,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,0641-6174-01,NDC,facility,both,2,ML,JB,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JB: Administered subcutaneously
HYDROXYZINE 50 MG TAB,50863,CDM,250,RC,Q0177,HCPCS,68084-255-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0904-6923-61,NDC,facility,both,30,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 400 MCG/100 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0338-9557-12,NDC,facility,both,1,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 1 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0641-6059-01,NDC,facility,both,5,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,17271-701-05,NDC,facility,both,1,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,0409-1283-03,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IMATINIB 100 MG ORAL TAB,50863,CDM,250,RC,J9999,HCPCS,60687-192-11,NDC,facility,both,4,EA,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 100 MG/ML FROM 1 GRAM VIAL (PRMC PEDS ONLY),50863,CDM,636,RC,J0696,HCPCS,0409-7332-11,NDC,facility,both,4,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZTREONAM 2 GRAM INJ SOLR,50863,CDM,636,RC,J0457,HCPCS,0409-0830-11,NDC,facility,both,10,EA,,171,119.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,16714-293-03,NDC,facility,both,10,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML IV (MERGE) (FOR VENT),50863,CDM,250,RC,J3010,HCPCS,70092-1509-35,NDC,facility,both,25,ML,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,63323-185-07,NDC,facility,both,10,ML,,292,204.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR NEO/PEDS INFUSION (CDS FROM PREMIX),50863,CDM,250,RC,J0133,HCPCS,63323-325-10,NDC,facility,both,87,ML,,188,131.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN LOCK FLUSH 100 UNIT/ML IV SOLN,50863,CDM,636,RC,J1644,HCPCS,63323-545-05,NDC,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  50 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0071-1013-41,NDC,facility,both,1,EA,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZINC OXIDE 20 % TOP OINT (REPACK),50863,CDM,250,RC,J3490,HCPCS,0536-1316-28,NDC,facility,both,1,GM,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,636,RC,J1939,HCPCS,68462-469-40,NDC,facility,both,2,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J2310,HCPCS,0409-1215-21,NDC,facility,both,1,ML,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6085-61,NDC,facility,both,2,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,24,ML,JW,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ROCURONIUM 50 MG/5 ML (10 MG/ML) IV SYRG,50863,CDM,250,RC,J3490,HCPCS,63037-155-25,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML ORAL SOLUTION (CDS),50863,CDM,250,RC,J3490,HCPCS,0641-6104-01,NDC,facility,both,4,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  75 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-475-11,NDC,facility,both,3,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRENATAL VIT NO.130-IRON-FOLIC 27 MG IRON- 800 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,7733371525,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE MONONITRATE  30 MG ORAL TB24,50863,CDM,250,RC,J3490,HCPCS,0904-6449-61,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR IN 0.9% NACL 100 UNIT/100 ML (1 UNIT/ML) INFUSION FOR OB,50863,CDM,250,RC,J1815,HCPCS,0338-0126-12,NDC,facility,both,2,ML,,411,287.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLIPIZIDE  2.5 MG ORAL TO24,50863,CDM,250,RC,J3490,HCPCS,60687-480-21,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 500 MG/100 ML CONCENTRATED DRIP 100 ML (RSE),50863,CDM,250,RC,J2250,HCPCS,0409-2596-15,NDC,facility,both,50,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68382-079-01,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,50863,CDM,636,RC,J3420,HCPCS,70069-005-01,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 250 MG-125 MG TAB,50863,CDM,250,RC,J3490,HCPCS,60687-781-11,NDC,facility,both,1,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2310,HCPCS,36000-310-01,NDC,facility,both,2,ML,,179,125.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J2003,HCPCS,0143-9595-01,NDC,facility,both,200,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PILOCARPINE 1 % EYE DROPS,50863,CDM,636,RC,J3490,HCPCS,61314-203-15,NDC,facility,both,1,ML,,418,292.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-709-11,NDC,facility,both,4,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,63323-485-27,NDC,,,facility,both,150,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE (PF) 25 MG/ML INJ SOLN (FOR ECTOPIC PREGNANCY),50863,CDM,636,RC,J9260,HCPCS,0143-9519-01,NDC,facility,both,2,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEPROTUMUMAB-TRBW 500 MG IV SOLR,50863,CDM,J3241,HCPCS,75987-130-15,NDC,,,facility,both,160,EA,,113871,79709.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,12,EA,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,16714-036-01,NDC,facility,both,16,ML,,187,130.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOMYCIN-BACITRACN ZN-POLYMYXIN 3.5 MG-400 U*,50863,CDM,636,RC,J3490,HCPCS,45802-143-00,NDC,facility,both,6,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0093-3426-05,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0406-3243-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SITAGLIPTIN  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0006-0221-01,NDC,facility,both,4,EA,,389,272.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE 100 MG TAB,50863,CDM,636,RC,J3490,HCPCS,60687-344-95,NDC,facility,both,6,EA,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,63323-325-03,NDC,facility,both,100,ML,,111,77.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LANTHANUM  500 MG ORAL CHEW,50863,CDM,636,RC,J3490,HCPCS,76282-476-45,NDC,facility,both,1,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMFIBROZIL 600 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-224-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VINBLASTINE 1 MG/ML IV SOLN,50863,CDM,250,RC,J9360,HCPCS,63323-278-10,NDC,facility,both,10,ML,,274,191.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,636,RC,J3010,HCPCS,0409-9094-22,NDC,facility,both,2,ML,JZ,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
VERAPAMIL 120 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,68462-292-01,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,9,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
AMOXICILLIN 400 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0143-9887-01,NDC,facility,both,25,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUB-Q SOLN",50863,CDM,250,RC,90716,HCPCS,0006-4827-01,NDC,facility,both,1,EA,,465,325.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE IV BOLUS (STROKE) 100 MG (2 X 50 MG VIALS),50863,CDM,250,RC,J2997,HCPCS,50242-044-06,NDC,facility,both,50,EA,,12145,8501.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-975-11,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,0143-9511-01,NDC,facility,both,20,ML,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 600 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-5854-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,J1610,HCPCS,63323-596-11,NDC,,,facility,both,1,EA,,785,549.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 1 MG ORAL CAP,50863,CDM,J7507,HCPCS,51079-818-01,NDC,,,facility,both,2,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,63323-482-27,NDC,,,facility,both,300,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 50% IN WATER (MERGE RECORD),50863,CDM,250,RC,J7060,HCPCS,0409-6648-02,NDC,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,J7030,HCPCS,0338-0049-04,NDC,,,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,68094-231-59,NDC,facility,both,2,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6966-61,NDC,facility,both,6,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 20 MEQ/100 ML IV PGBK,50863,CDM,250,RC,J3480,HCPCS,0990-7075-26,NDC,facility,both,10,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,Q0162,HCPCS,51672-4091-3,NDC,,,facility,both,2,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,63323-806-12,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 10 GRAM/100 ML (10%) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-72,NDC,facility,both,20,ML,"JZ,JA",2829,1980.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
MORPHINE CONCENTRATE 20 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0054-0404-44,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,71399-1025-3,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NYSTATIN 100000 UNIT/ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0121-1045-16,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML (PEDS CALCLUATOR 0.5),50863,CDM,250,RC,J1815,HCPCS,0024-5924-10,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIMOLOL MALEATE 0.5 % OPHT DROP,50863,CDM,636,RC,J3490,HCPCS,60758-801-05,NDC,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIRTAZAPINE 15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-119-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-41,NDC,facility,both,1,ML,,169,118.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 0.5% NASAL DROPS (REPACK),50863,CDM,636,RC,J3490,HCPCS,69536-050-15,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,250,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,2,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 10 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,65862-192-01,NDC,facility,both,3,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,636,RC,J2795,HCPCS,43066-023-01,NDC,facility,both,150,ML,JZ,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CALCIUM CHLORIDE (FOR CODE) 10% IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0517-6710-01,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL 120 MG ORAL CS24,50863,CDM,636,RC,J3490,HCPCS,0527-4118-37,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-444-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML IM SOLN,50863,CDM,636,RC,90375,HCPCS,13533-318-05,NDC,facility,both,8,ML,JW,3423,2396.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,8,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,2055503601,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,500,ML,,1101,770.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,J0132,HCPCS,72611-860-01,NDC,,,facility,both,120,ML,,435,304.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR PHOSPHATE 75 MG ORAL CAP,50863,CDM,J3490,HCPCS,33342-258-66,NDC,,,facility,both,1,EA,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 100 MG IV SOLR,50863,CDM,250,RC,J2997,HCPCS,50242-085-25,NDC,facility,both,50,EA,JW,5281,3696.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CARVEDILOL 25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7308-61,NDC,facility,both,1,EA,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,72266-118-01,NDC,facility,both,4,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,636,RC,J3490,HCPCS,68180-963-01,NDC,facility,both,1,GM,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,63323-461-01,NDC,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6778-61,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 17 GRAM (100 %) ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,1152372688,NDC,facility,both,14,EA,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR IN 0.9% NACL 100 UNIT/100 ML (1 UNIT/ML) INFUSION FOR OB,50863,CDM,J1815,HCPCS,0338-0126-12,NDC,,,facility,both,1,ML,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,0409-4887-24,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VINCRISTINE 2 MG/2 ML IV SOLN,50863,CDM,636,RC,J9370,HCPCS,61703-309-16,NDC,facility,both,2,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,2,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,53,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG SUBQ SOLR,50863,CDM,636,RC,J2796,HCPCS,55513-222-01,NDC,facility,both,50,EA,,8780,6146,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,J2003,HCPCS,63323-486-02,NDC,,,facility,both,200,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,J0330,HCPCS,31722-981-10,NDC,,,facility,both,5,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",50863,CDM,J1561,HCPCS,13533-800-41,NDC,,,facility,both,200,ML,,28288,19801.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,23155-192-01,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,68094-231-59,NDC,facility,both,4,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE (NORVASC) 1MG/ML SUSPENSION (REPACK),50863,CDM,250,RC,J3490,HCPCS,68084-259-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-492-27,NDC,,,facility,both,140,ML,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,50863,CDM,250,RC,J0696,HCPCS,60505-6148-0,NDC,facility,both,4,EA,PLAD,225,157.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),50863,CDM,J1815,HCPCS,0024-5926-05,NDC,,,facility,both,5,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COLCHICINE 0.6 MG ORAL TAB,50863,CDM,J3490,HCPCS,60687-727-11,NDC,,,facility,both,2,EA,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-8515-23,NDC,facility,both,4,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TORSEMIDE  20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-756-11,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,0409-1283-03,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,0409-2723-30,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAMADOL  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,29300-355-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69238-1490-1,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2003,HCPCS,55150-165-05,NDC,,,facility,both,1700,ML,,340,238,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,55150-304-01,NDC,facility,both,10,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69315-904-01,NDC,facility,both,4,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,8,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,67457-385-10,NDC,facility,both,10,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUTICASONE-SALMETEROL 250 MCG-50 MCG/DOSE DISK DEVICE FOR INHALATION,50863,CDM,636,RC,J3490,HCPCS,66993-585-97,NDC,facility,both,1,EA,,1311,917.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIVOLUMAB 40 MG/4 ML IV SOLN,50863,CDM,250,RC,J9299,HCPCS,0003-3772-11,NDC,facility,both,40,ML,,2728,1909.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,70095-031-01,NDC,facility,both,36,ML,JZ,1475,1032.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,36,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL  20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6671-04,NDC,facility,both,3,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0406-3244-01,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,636,RC,J3490,HCPCS,39822-1000-1,NDC,facility,both,2,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7367-06,NDC,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,72603-179-01,NDC,facility,both,9,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,50863,CDM,250,RC,J0561,HCPCS,60793-700-01,NDC,facility,both,6,ML,,761,532.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 20 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7346-61,NDC,facility,both,6,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML (ANESTHESIA INTRAOP ONLY),50863,CDM,250,RC,J3010,HCPCS,0641-6027-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTASE 3000 UNIT ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,7733343025,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 150 MG CAP,50863,CDM,J3490,HCPCS,0904-5959-61,NDC,,,facility,both,3,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % MUCOSAL GEL,50863,CDM,636,RC,J3490,HCPCS,50383-781-05,NDC,facility,both,1,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-03,NDC,facility,both,2,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-089-50,NDC,facility,both,1,ML,,146,102.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON DEXTRAN 50 MG/ML INJ SOLN,50863,CDM,636,RC,J1750,HCPCS,0023-6082-01,NDC,facility,both,20,ML,JZ,2084,1458.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLN,50863,CDM,250,RC,J3262,HCPCS,50242-136-01,NDC,facility,both,200,ML,JA,3666,2566.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JA: Administered intravenously
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,350,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE IN 0.9% NS (PF) 1 MG/10 ML (100 MCG/ML) IV SYRG(PDS MERGE),50863,CDM,J3490,HCPCS,71449-001-15,NDC,,,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,J2704,HCPCS,0069-0209-01,NDC,,,facility,both,38,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML IM SOLN,50863,CDM,90375,HCPCS,13533-318-50,NDC,,,facility,both,10,ML,,8946,6262.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,0409-1283-03,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOBRAMYCIN SULFATE 40 MG/ML INJ SOLN,50863,CDM,250,RC,J3260,HCPCS,67457-473-00,NDC,facility,both,6,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL  5 MG ORAL TAB,50863,CDM,J3490,HCPCS,68180-513-01,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJ SOLN",50863,CDM,J3490,HCPCS,63323-468-37,NDC,,,facility,both,1,ML,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0781-6041-58,NDC,facility,both,7,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOPERAMIDE 1 MG/7.5 ML ORAL LIQD,50863,CDM,250,RC,J3490,HCPCS,68094-029-59,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,0409-4279-16,NDC,,,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELOXICAM  7.5 MG ORAL TAB,50863,CDM,J3490,HCPCS,68382-050-01,NDC,,,facility,both,2,EA,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-5771-23,NDC,facility,both,13,EA,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,61442-121-10,NDC,facility,both,2,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,50863,CDM,636,RC,Q0177,HCPCS,60687-675-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 10 GRAM/15 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0116-4005-30,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELIMUMAB 120 MG IV SOLR,50863,CDM,636,RC,J0490,HCPCS,49401-101-01,NDC,facility,both,84,ME,,9865,6905.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM-DEXTROSE (ISO) 3.375 GRAM/50 ML IV PIGGY BACK,50863,CDM,636,RC,J2543,HCPCS,0338-9636-01,NDC,facility,both,3,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN NEO/PEDS IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0456,HCPCS,63323-398-14,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,72611-722-25,NDC,facility,both,2,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
AZTREONAM 1 GRAM INJ SOLR,50863,CDM,250,RC,J0457,HCPCS,63323-401-01,NDC,facility,both,5,EA,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-495-27,NDC,facility,both,40,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2599,HCPCS,65219-039-00,NDC,facility,both,16,ML,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT  60 MCG/0.3 ML INJ SYRG,50863,CDM,636,RC,J0881,HCPCS,55513-023-01,NDC,facility,both,60,ML,"JZ,EC",1282,897.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier EC: Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,50,EA,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-25,NDC,facility,both,23,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,250,RC,J3490,HCPCS,25021-415-10,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML (PEDS CALCLUATOR 0.5),50863,CDM,250,RC,J1815,HCPCS,0024-5924-10,NDC,facility,both,2,ML,,424,296.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,4,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,250,RC,J3490,HCPCS,53746-542-01,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALLOPURINOL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-677-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 0.8 GRAM ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,0115-1365-30,NDC,facility,both,3,EA,,245,171.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-04,NDC,facility,both,4,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BISOPROLOL FUMARATE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,70954-455-20,NDC,facility,both,2,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VECURONIUM BROMIDE 10 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,47335-931-40,NDC,facility,both,2,EA,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-03,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 100 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,0186-1092-05,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG/24 HR TD PTWK,50863,CDM,636,RC,J3490,HCPCS,0378-0871-16,NDC,facility,both,2,EA,,281,196.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCETAXEL 160 MG/16 ML (10 MG/ML) IV SOLN,50863,CDM,250,RC,J9171,HCPCS,67457-533-16,NDC,facility,both,60,ML,,570,399,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE IN DEXTROSE (ISO-OSMOTIC) 1 GRAM/50 ML IV PIGGY BACK,50863,CDM,J0696,HCPCS,0264-3153-11,NDC,,,facility,both,4,EA,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) IV SOLN,50863,CDM,J9201,HCPCS,0409-0181-01,NDC,,,facility,both,5,ML,,231,161.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,62,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,91,ML,JW,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
"OCTREOTIDE,MICROSPHERES 30 MG IM SERR",50863,CDM,636,RC,J2353,HCPCS,0078-0825-81,NDC,facility,both,30,EA,JZ,19079,13355.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,68094-231-59,NDC,facility,both,4,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,250,RC,J2795,HCPCS,70069-064-01,NDC,facility,both,150,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,0088-2220-33,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,12,ML,JW,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
OXCARBAZEPINE 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-722-11,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN  200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,10135-681-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIPASE-PROTEASE-AMYLASE 12,000-38,000- 60,000 UNIT ORAL CAP, DELAY REL",50863,CDM,250,RC,J3490,HCPCS,0032-0047-70,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE  50 MG ORAL TAB,50863,CDM,250,RC,j3490,HCPCS,68382-805-01,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIVAROXABAN 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50458-578-01,NDC,facility,both,1,EA,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50580-458-11,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-6625-22,NDC,facility,both,3,ML,,174,121.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,636,RC,J3101,HCPCS,50242-037-06,NDC,facility,both,14,EA,,6413,4489.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-3425-01,NDC,facility,both,3,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN NPH HUMAN RECOMB 100 UNIT/ML SUBQ SUSP,50863,CDM,636,RC,J1815,HCPCS,0169-1834-11,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 800 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-5855-61,NDC,facility,both,6,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-4279-16,NDC,facility,both,300,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,13668-009-01,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 300 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6642-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-174-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IMIPENEM-CILASTATIN 500 MG IV SOLR,50863,CDM,250,RC,J0743,HCPCS,44567-705-01,NDC,facility,both,2,EA,,161,112.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,J3490,HCPCS,68094-494-59,NDC,,,facility,both,4,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 2 % MUCOSAL GEL,50863,CDM,636,RC,J3490,HCPCS,17478-711-30,NDC,facility,both,1,ML,,463,324.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-0053-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 20 MG/ML INJ SOLN,50863,CDM,636,RC,J0360,HCPCS,0641-6231-01,NDC,facility,both,1,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,3,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0121-1781-05,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-744-11,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,636,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,4,EA,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50580-458-11,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN ASP PRT-INSULIN ASPART 100 UNIT/ML (70-30) SUBQ SOLN,50863,CDM,250,RC,J1817,HCPCS,0169-3685-12,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,63323-400-01,NDC,facility,both,18,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 1 MG/ML (1ML) SYRINGE (REPACK),50863,CDM,250,RC,J2997,HCPCS,50242-044-13,NDC,facility,both,1,EA,,271,189.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-5771-23,NDC,facility,both,17,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILVER SULFADIAZINE 1 % TOP CREA,50863,CDM,250,RC,J3490,HCPCS,67877-124-05,NDC,facility,both,1,GM,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,50863,CDM,636,RC,J3301,HCPCS,16714-130-01,NDC,facility,both,4,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,4,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,50863,CDM,J3301,HCPCS,81298-5781-1,NDC,,,facility,both,4,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0137,HCPCS,0143-9386-01,NDC,facility,both,100,ML,JZ,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,J3490,HCPCS,68094-494-59,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COMPOUNDING VEHICLE SYRUP NO23 ORAL SYRP,50863,CDM,636,RC,J3490,HCPCS,574030416,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J2003,HCPCS,63323-492-04,NDC,facility,both,80,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-739-41,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,77333-049-25,NDC,facility,both,4,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,77333-049-25,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,63323-104-25,NDC,facility,both,8,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT  60 MCG/0.3 ML INJ SYRG,50863,CDM,J0881,HCPCS,55513-023-01,NDC,,,facility,both,40,ML,,855,598.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,636,RC,J1171,HCPCS,0409-1283-03,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE (PF) 25 MG/ML INJ SOLN (FOR ECTOPIC PREGNANCY),50863,CDM,636,RC,J9260,HCPCS,0143-9519-01,NDC,facility,both,2,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,70860-406-41,NDC,facility,both,10,ML,,221,154.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIMOLOL MALEATE 0.5 % OPHT DROP,50863,CDM,250,RC,J3490,HCPCS,61314-227-05,NDC,facility,both,2,ML,,167,116.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANAKINRA 100 MG/0.67 ML SUBQ SYRG,50863,CDM,250,RC,J3590,HCPCS,66658-234-07,NDC,facility,both,1,ML,,562,393.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAROXETINE SR 37.5 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,62175-472-32,NDC,facility,both,2,EA,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM  4.5 GRAM IV SOLR,50863,CDM,250,RC,J2543,HCPCS,55150-121-50,NDC,facility,both,4,EA,JZ,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
OXALIPLATIN 100 MG/20 ML IV SOLN,50863,CDM,250,RC,J9263,HCPCS,71288-172-21,NDC,facility,both,391,ML,,230,161,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,518,ME,,7030,4921,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"AMIODARONE IN DEXTROSE,ISO-OSM 150 MG/100 ML (PREMIX)",50863,CDM,250,RC,J0282,HCPCS,43066-150-10,NDC,facility,both,20,ML,,814,569.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0641-0400-37,NDC,facility,both,25,ML,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-41,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-598-11,NDC,facility,both,1,EA,PLAD,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-41,NDC,facility,both,160,ML,JZ,22631,15841.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SIMETHICONE  80 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,0904-7206-60,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,250,RC,J2405,HCPCS,23155-547-31,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-3178-01,NDC,facility,both,190,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,55150-221-10,NDC,facility,both,2,ML,,107,74.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,5,ML,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-405-11,NDC,facility,both,2,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-231-11,NDC,facility,both,4,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ERTAPENEM 1 GRAM INJ SOLR,50863,CDM,636,RC,J1335,HCPCS,55150-282-20,NDC,facility,both,2,EA,JZ,306,214.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
RIFABUTIN 150 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,10135-738-01,NDC,facility,both,1,EA,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML IV SOLN (MERGE),50863,CDM,250,RC,J3490,HCPCS,16714-037-10,NDC,facility,both,1,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,250,RC,J3360,HCPCS,69339-136-03,NDC,facility,both,2,ML,JZ,145,101.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-9791-01,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM PHOSPHATE 4.4 MEQ/ML ORAL SOLUTION (CDS),50863,CDM,250,RC,J3490,HCPCS,80830-1693-1,NDC,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 0.1 MG/ML INJ SYRG,50863,CDM,250,RC,J0461,HCPCS,76329-3340-1,NDC,facility,both,100,ML,JZ,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,250,RC,J2795,HCPCS,43066-023-01,NDC,facility,both,100,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,100,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
TRAZODONE  50 MG ORAL TAB,50863,CDM,250,RC,j3490,HCPCS,68382-805-01,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TORSEMIDE   5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-754-11,NDC,facility,both,4,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DULOXETINE 30 MG ORAL CPDR,50863,CDM,636,RC,J3490,HCPCS,0904-7044-61,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE IN 0.9% NS (PF) 1 MG/10 ML (100 MCG/ML) IV SYRG(PDS MERGE),50863,CDM,250,RC,J3490,HCPCS,70092-1046-46,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,72603-179-01,NDC,facility,both,7,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAVASTATIN 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-5893-61,NDC,facility,both,2,EA,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,636,RC,J2597,HCPCS,43598-053-11,NDC,facility,both,17,ML,JZ,589,412.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
VANCOMYCIN IN D5W 1 GRAM/200 ML IV PGBK,50863,CDM,250,RC,J3373,HCPCS,0338-3552-48,NDC,facility,both,100,ML,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,636,RC,J3490,HCPCS,76329-3390-1,NDC,facility,both,200,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,69,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,6,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,250,RC,J2405,HCPCS,0641-6078-25,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,203,ML,,143,100.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,16,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,43,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-18,NDC,facility,both,150,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2599,HCPCS,55150-370-01,NDC,facility,both,3,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRIL MALEATE 1 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,69238-2141-7,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  5 GRAM IV SOLR,50863,CDM,250,RC,J3370,HCPCS,0143-9163-01,NDC,facility,both,3,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J3430,HCPCS,43598-405-11,NDC,facility,both,1,ME,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,42806-150-33,NDC,facility,both,10,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IR SOLN,50863,CDM,250,RC,J3490,HCPCS,0264-2201-00,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,2,EA,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CEFAZOLIN IN STERILE WATER 2 GRAM/20 ML IV SYRG,50863,CDM,250,RC,J0690,HCPCS,73702-132-23,NDC,facility,both,24,ML,,276,193.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COLCHICINE 0.6 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-727-11,NDC,facility,both,1,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN 500 MG SOLUTION FOR INJECTION,50863,CDM,250,RC,J0290,HCPCS,0781-3407-78,NDC,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COLCHICINE 0.6 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7120-04,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COLCHICINE 0.6 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65162-710-09,NDC,facility,both,1,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,69,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,636,RC,J3101,HCPCS,50242-037-06,NDC,facility,both,22,EA,,10077,7053.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-01,NDC,facility,both,100,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PYRIDOSTIGMINE BROMIDE  60 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6622-61,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM-ALBUTEROL 0.5 MG-2.5 MG/3 ML NEB SOLUTION,50863,CDM,250,RC,J3490,HCPCS,0487-0201-01,NDC,facility,both,2,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
D5-0.9%NACL-POTASSIUM CHLORIDE 20 MEQ/L IV SOLP (PED ONC),50863,CDM,250,RC,J3480,HCPCS,0264-7652-00,NDC,facility,both,10,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MYCOPHENOLATE SODIUM 360 MG ORAL TBEC,50863,CDM,636,RC,J7518,HCPCS,68084-918-95,NDC,facility,both,4,EA,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-739-41,NDC,facility,both,5,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  5 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,60505-3275-0,NDC,facility,both,2,EA,,140,98,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPTOMYCIN 500 MG IV SOLR,50863,CDM,636,RC,J0878,HCPCS,72603-152-01,NDC,facility,both,350,EA,JW,347,242.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ALPRAZOLAM 0.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,59762-3720-1,NDC,facility,both,4,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL 2.5 MG/ML SUSPENSION,50863,CDM,250,RC,J3490,HCPCS,99999-0404-75,NDC,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL  75 MCG/HR TD PT72,50863,CDM,250,RC,J3490,HCPCS,47781-427-11,NDC,facility,both,2,EA,,428,299.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,70594-063-01,NDC,facility,both,23,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  2.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60505-3110-0,NDC,facility,both,2,EA,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC IV INFUSION HYDRAT 31-60 MIN,50863,CDM,636,RC,J0248,HCPCS,61958-2901-2,NDC,facility,both,100,EA,JZ,1196,837.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LABETALOL 5 MG/ML IV SOLN,50863,CDM,636,RC,J1921,HCPCS,17478-420-20,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0990-7983-61,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG ORAL TAB,50863,CDM,636,RC,FAMNOCHARGE,HCPCS,0054-8175-25,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-645-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,65862-859-01,NDC,facility,both,2,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM IN NACL (ISO-OS) 1000 MG/100 ML IV PGBK,50863,CDM,636,RC,J1953,HCPCS,67457-265-00,NDC,facility,both,100,ML,,127,88.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMINOPHYLLINE 500 MG/20 ML IV SOLN,50863,CDM,250,RC,J0280,HCPCS,0409-5922-16,NDC,facility,both,2,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-579-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-19,NDC,facility,both,300,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,44,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6500-61,NDC,facility,both,2,EA,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INDIGOTINDISULFONATE SODIUM 8 MG/ML INJ SOLN,50863,CDM,250,RC,J9920,HCPCS,17478-508-01,NDC,facility,both,40,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN DEXTROSE (ISO-OSMOTIC) 1 GRAM/50 ML IV PIGGY BACK,50863,CDM,636,RC,J0690,HCPCS,0338-3503-41,NDC,facility,both,2,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3370,HCPCS,0409-6533-11,NDC,facility,both,2,EA,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 500 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,50268-152-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE IN 0.9 % SOD CHLOR 4 MG/250 ML (16 MCG/ML) IV SOLN,50863,CDM,250,RC,J0171,HCPCS,42023-315-01,NDC,facility,both,1,ML,,389,272.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,63323-482-03,NDC,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLN,50863,CDM,636,RC,J3262,HCPCS,50242-137-01,NDC,facility,both,400,ML,"JZ,JA",7331,5131.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
ARIPIPRAZOLE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65162-897-09,NDC,facility,both,3,EA,,408,285.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE IV CONCENTRATED INFUSION (1 MEQ/ML),50863,CDM,250,RC,J3490,HCPCS,0409-6625-02,NDC,facility,both,4,ML,,229,160.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CINACALCET 30 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,64380-883-04,NDC,facility,both,2,EA,,260,182,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-242-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 400 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65162-464-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9% IV (PEDS) BOLUS,50863,CDM,636,RC,J7040,HCPCS,0264-7800-09,NDC,facility,both,4,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,250,RC,J2003,HCPCS,0409-1323-15,NDC,facility,both,200,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,61,ML,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV (BOLUS),50863,CDM,250,RC,J7120,HCPCS,0338-0117-02,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLN 400ML (PHS REPACK),50863,CDM,636,RC,J7040,HCPCS,99999-408-60,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,636,RC,J0330,HCPCS,31722-981-10,NDC,facility,both,12,ML,,136,95.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,16714-661-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J2004,HCPCS,0409-3178-01,NDC,facility,both,25,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 600 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-457-11,NDC,facility,both,12,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,59762-3130-1,NDC,facility,both,3,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,43,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBAMAZEPINE 200 MG ORAL TB12,50863,CDM,250,RC,J3490,HCPCS,42806-275-01,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG ORAL TAB,50863,CDM,J3490,HCPCS,60687-595-11,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,2,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARSENIC TRIOXIDE 10 MG/10 ML IV SOLN,50863,CDM,J9017,HCPCS,69918-720-01,NDC,,,facility,both,4,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,130,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
HYDROMORPHONE  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42858-301-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7124-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,62756-711-86,NDC,facility,both,1,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES-DOCUSATE SODIUM 8.6 MG-50 MG TAB,50863,CDM,636,RC,J3490,HCPCS,60687-622-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,63739-931-28,NDC,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,70069-363-01,NDC,facility,both,1,ML,,186,130.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NORTRIPTYLINE 25 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,50268-604-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,72603-179-01,NDC,facility,both,6,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB 100 MG IV SOLR,50863,CDM,636,RC,J1745,HCPCS,57894-030-01,NDC,facility,both,17,EA,JZ,5480,3836,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-411-10,NDC,facility,both,12,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN 0.9% SODIUM CL 1.25 GRAM/250 ML IV SOLN,50863,CDM,636,RC,J3370,HCPCS,71285-6074-1,NDC,facility,both,3,ML,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,636,RC,J2597,HCPCS,69918-899-01,NDC,facility,both,2,ML,JW,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,636,RC,J3490,HCPCS,0641-6236-01,NDC,facility,both,1,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAMSULOSIN 0.4 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,68382-132-01,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIPHTH,PERTUS(ACELL),TETANUS VIAL (BOOSTRIX*) 2.5-8-5 LF-MCG-LF/0.5ML IM SUSP",50863,CDM,636,RC,90715,HCPCS,58160-842-11,NDC,facility,both,1,ML,,240,168,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  100 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,63323-376-00,NDC,facility,both,4,ML,JZ,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-22,NDC,facility,both,20,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,636,RC,P9045,HCPCS,68516-5214-2,NDC,facility,both,2,ML,JZ,447,312.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
POLIOVIRUS VACCINE 40-8-32 UNIT/0.5 ML INJ SUSP,50863,CDM,90713,HCPCS,49281-860-78,NDC,,,facility,both,1,ML,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 0.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-3425-01,NDC,facility,both,6,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,23,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,J3490,HCPCS,60687-751-42,NDC,,,facility,both,1,ML,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,2000,ML,,936,655.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-454-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  30 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,0406-8330-23,NDC,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-9558-05,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  5 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-122-11,NDC,facility,both,8,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  1 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,64380-782-06,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,250,RC,J2270,HCPCS,76045-004-10,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J1610,HCPCS,63323-596-11,NDC,facility,both,2,EA,JZ,1570,1099,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ZOLPIDEM  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0781-5317-01,NDC,facility,both,3,EA,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6709-61,NDC,facility,both,2,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,68094-750-59,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOPIDOGREL  75 MG ORAL TAB,50863,CDM,J3490,HCPCS,68084-536-11,NDC,,,facility,both,1,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16729-175-01,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1560-18,NDC,facility,both,100,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-18,NDC,facility,both,400,ML,JZ,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
BALANCED SALT IRRIG SOLN COMB2 INTRAOCULAR,50863,CDM,250,RC,J3490,HCPCS,0065-0795-15,NDC,facility,both,1,ML,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VENLAFAXINE  75 MG ORAL TR24,50863,CDM,636,RC,J3490,HCPCS,0131-3266-46,NDC,facility,both,5,EA,,113,79.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,636,RC,J1596,HCPCS,71288-414-01,NDC,facility,both,4,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,68094-231-59,NDC,facility,both,2,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML INJECTION,50863,CDM,636,RC,J3411,HCPCS,72485-507-01,NDC,facility,both,4,ML,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J7510,HCPCS,17856-0815-1,NDC,facility,both,4,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLIMEPIRIDE 4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,55111-322-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB 100 MG IV SOLR,50863,CDM,J1745,HCPCS,57894-160-01,NDC,,,facility,both,4,EA,,228,159.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNITS/1 GRAM PACKET (MERGE RECORD),50863,CDM,636,RC,J3490,HCPCS,45802-060-00,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-134-11,NDC,facility,both,20,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0121-1781-05,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,16,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,60687-145-11,NDC,facility,both,35,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,50863,CDM,J2250,HCPCS,0409-2305-16,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM NEO/PEDS INFUSION (CDS MIXTURE),50863,CDM,250,RC,J2543,HCPCS,0206-8852-08,NDC,facility,both,2,EA,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,J2405,HCPCS,0641-6078-01,NDC,,,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 0.1 MG/ML INJ SYRG,50863,CDM,250,RC,J0461,HCPCS,16729-484-03,NDC,facility,both,100,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOPERAMIDE 2 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-229-11,NDC,facility,both,10,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,2,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,16714-046-01,NDC,facility,both,10,ML,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MINOCYCLINE 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-336-11,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,62584-984-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE (POLACRILEX) 2 MG BUCL GUM,50863,CDM,636,RC,J3490,HCPCS,70677-1166-1,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-179-11,NDC,facility,both,1,EA,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,59762-2198-7,NDC,facility,both,2,EA,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"CIPROFLOXACIN-DEXAMETHASONE 0.3 %-0.1 % EAR DROPS, SUSP",50863,CDM,250,RC,J3490,HCPCS,43598-326-75,NDC,facility,both,1,ML,,794,555.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0780,HCPCS,0641-6135-01,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR 200 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,72578-002-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXCARBAZEPINE 300 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,69452-125-50,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,428,ME,JZ,5808,4065.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
FUROSEMIDE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,64980-562-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXEPIN  25 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,51079-437-01,NDC,facility,both,3,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPLERENONE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,42291-454-30,NDC,facility,both,1,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,636,RC,Q0162,HCPCS,65162-691-79,NDC,facility,both,2,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TARLATAMAB-DLLE 10 MG IV SOLR,50863,CDM,250,RC,J9026,HCPCS,55513-069-01,NDC,facility,both,10,EA,,41381,28966.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-132-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SILDENAFIL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,31722-711-30,NDC,facility,both,1,EA,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,0904-7327-62,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 50 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,59651-489-01,NDC,facility,both,70,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,250,RC,J3490,HCPCS,63323-486-05,NDC,facility,both,600,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,520,ML,,747,522.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOCARNITINE 330 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,70954-492-10,NDC,facility,both,3,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALSARTAN 160 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-634-11,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,62,ML,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,636,RC,J3360,HCPCS,69339-136-03,NDC,facility,both,1,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLEDRONIC ACID IN MANNITOL & WATER 5 MG/100 ML IV SOLN,50863,CDM,636,RC,J3489,HCPCS,25021-830-82,NDC,facility,both,5,ML,,540,378,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 25 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0378-0018-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE(PF)0.2 % ELASTOMERIC PUMP (ONQ) 545ML (PREFILLED),50863,CDM,250,RC,J3490,HCPCS,71449-079-51,NDC,facility,both,1,ML,,1171,819.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,14,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,0088-2220-33,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROGESTERONE MICRONIZED 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,16714-157-01,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,17271-701-06,NDC,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  100 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,68462-896-01,NDC,facility,both,2,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,64850-502-01,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORDIAZEPOXIDE 25 MG CAP,50863,CDM,250,RC,J3490,HCPCS,60687-807-11,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTAGAM 10 % IV SOLN,50863,CDM,636,RC,J1568,HCPCS,68982-850-04,NDC,facility,both,80,ML,JZ,14695,10286.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,74,ML,,107,74.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,44,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,0641-6145-01,NDC,facility,both,20,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MISOPROSTOL 50 MCG ORAL SPLIT TAB,50863,CDM,250,RC,S0191,HCPCS,60687-735-01,NDC,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE (POLACRILEX) 2 MG BUCL GUM,50863,CDM,636,RC,J3490,HCPCS,1093969133,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,68094-494-59,NDC,facility,both,1,ML,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7350-06,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN NEO/PEDIATRIC SYRINGE < 30 MG,50863,CDM,250,RC,J1650,HCPCS,0548-5608-00,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,68094-061-59,NDC,facility,both,4,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,636,RC,J2310,HCPCS,0409-1215-01,NDC,facility,both,1,ML,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,46,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZOCAINE-MENTHOL 6-10 MG MM LOZG,50863,CDM,636,RC,J3490,HCPCS,0363-0700-08,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 100 MG 24 HR TAB,50863,CDM,636,RC,J3490,HCPCS,67877-592-01,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
D5-1/2 NS AND POTASSIUM CHLORIDE 20 MEQ/L IV (PEDS CHEMO),50863,CDM,636,RC,J3490,HCPCS,0264-7635-00,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0093-4177-73,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM IN NACL (ISO-OS) 500 MG/100 ML IV PGBK,50863,CDM,250,RC,J1953,HCPCS,36000-352-01,NDC,facility,both,50,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION,50863,CDM,636,RC,J3490,HCPCS,0310-7370-20,NDC,facility,both,1,GM,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0093-4177-73,NDC,facility,both,7,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML INJ SOLN,50863,CDM,250,RC,J0169,HCPCS,76329-9061-0,NDC,facility,both,30,ML,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/0.5 ML INHL NEBU,50863,CDM,250,RC,J3490,HCPCS,0487-9901-30,NDC,facility,both,4,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAPSAICIN 0.025 % TOP CREA,50863,CDM,250,RC,J3490,HCPCS,50268-195-60,NDC,facility,both,1,GM,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORDIAZEPOXIDE 25 MG CAP,50863,CDM,636,RC,J3490,HCPCS,0555-0159-04,NDC,facility,both,14,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,636,RC,J1836,HCPCS,0338-1055-48,NDC,facility,both,100,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL  1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7390-61,NDC,facility,both,3,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 5 MG-325 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0406-0123-23,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN NPH HUMAN RECOMB 100 UNIT/ML SUBQ SUSP,50863,CDM,250,RC,J1815,HCPCS,0169-1834-11,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,636,RC,J3010,HCPCS,0409-9093-32,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCERIN (CHILD) RECTAL SUPPOSITORY,50863,CDM,J3490,HCPCS,57237-326-21,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM,50863,CDM,636,RC,J3490,HCPCS,45802-358-03,NDC,facility,both,2,GM,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE (FOR CODE) 10% IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0517-6710-01,NDC,facility,both,1,ML,,127,88.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 750 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-568-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN  500 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,60687-640-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-22,NDC,facility,both,40,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 500 MG PE/10 ML INJ SOLN,50863,CDM,250,RC,Q2009,HCPCS,0641-6137-01,NDC,facility,both,20,ML,,484,338.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL (5 MG/ML) IV SYRG (CONTAINS PRESERVATIVE),50863,CDM,250,RC,J3490,HCPCS,0409-2339-24,NDC,facility,both,1,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,636,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,90,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DROPERIDOL 2.5 MG/ML INJ SOLN,50863,CDM,636,RC,J1790,HCPCS,0517-9702-01,NDC,facility,both,1,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,31722-828-30,NDC,facility,both,2,EA,,273,191.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,63323-280-03,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIMOLOL MALEATE 0.5 % OPHT DROP,50863,CDM,636,RC,J3490,HCPCS,64980-514-05,NDC,facility,both,1,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTASE 3000 UNIT ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,904522452,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,50863,CDM,250,RC,J2359,HCPCS,0781-3159-72,NDC,facility,both,10,EA,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,63323-010-02,NDC,facility,both,4,ML,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-01,NDC,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,63323-649-07,NDC,facility,both,3,EA,,1369,958.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,50863,CDM,636,RC,Q5119,HCPCS,0069-0238-01,NDC,facility,both,22,ML,,4353,3047.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAMOXIFEN 10 MG ORAL TAB,50863,CDM,250,RC,J9999,HCPCS,0591-2472-60,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  5 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-122-11,NDC,facility,both,10,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,636,RC,J0133,HCPCS,63323-325-03,NDC,facility,both,100,ML,,111,77.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 10 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,636,RC,J2270,HCPCS,0409-1893-03,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,16714-016-01,NDC,facility,both,8,ML,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-739-11,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELIMUMAB 120 MG IV SOLR,50863,CDM,636,RC,J0490,HCPCS,49401-101-01,NDC,facility,both,60,ME,"JZ,JA",7047,4932.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,68094-231-59,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUANFACINE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,24979-198-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6370-61,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-0430-06,NDC,facility,both,7,EA,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-456-01,NDC,facility,both,1,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-492-27,NDC,facility,both,300,ML,,236,165.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,50863,CDM,636,RC,J3301,HCPCS,16714-130-01,NDC,facility,both,2,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42858-003-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,13668-011-01,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,70860-751-02,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN SODIUM EXTENDED 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,65862-692-01,NDC,facility,both,5,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,0409-9093-32,NDC,facility,both,1,ML,PLAD,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
LEVOTHYROXINE 100 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68180-969-01,NDC,facility,both,3,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLECAINIDE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0054-0011-20,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,50863,CDM,J3490,HCPCS,43066-997-01,NDC,,,facility,both,248,ML,,8244,5770.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM SR 120 MG 12 HR CAP,50863,CDM,636,RC,J3490,HCPCS,51079-926-01,NDC,facility,both,1,EA,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMTERENE  50 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,70377-138-12,NDC,facility,both,1,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J2004,HCPCS,0409-3178-16,NDC,facility,both,300,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 1 MG ORAL TAB,50863,CDM,250,RC,J8540,HCPCS,0054-4181-25,NDC,facility,both,32,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CANAKINUMAB (PF) 150 MG/ML SUBQ SOLN,50863,CDM,636,RC,J0638,HCPCS,0078-0734-61,NDC,facility,both,300,ML,,73854,51697.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MONTELUKAST 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-875-11,NDC,facility,both,1,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,55390-138-01,NDC,facility,both,4,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
FENTANYL CITRATE (PF) 50 MCG/ML (ANESTHESIA INTRAOP ONLY),50863,CDM,250,RC,J3010,HCPCS,0409-9094-17,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN DEGLUDEC 100 UNITS/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,73070-400-11,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL (NEO/PEDS),50863,CDM,250,RC,J3490,HCPCS,63323-820-00,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60505-3111-0,NDC,facility,both,4,EA,,225,157.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-22,NDC,facility,both,160,ML,,320,224,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60505-3113-0,NDC,facility,both,3,EA,,244,170.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,0409-9094-18,NDC,facility,both,3,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,142,ML,,128,89.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,0409-9094-12,NDC,facility,both,2,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR PHOSPHATE 30 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,31722-630-31,NDC,facility,both,1,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN PEDS INFUSION (CDS MIXTURE),50863,CDM,250,RC,J0290,HCPCS,25021-136-10,NDC,facility,both,4,EA,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNITS/1 GRAM PACKET (MERGE RECORD),50863,CDM,250,RC,J3490,HCPCS,0904-7023-67,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-495-27,NDC,facility,both,207,ML,,101,70.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL  1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0832-1520-89,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,72611-722-25,NDC,facility,both,1,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,0409-3178-01,NDC,,,facility,both,280,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,J2704,HCPCS,0069-0209-01,NDC,,,facility,both,59,ML,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM PHOSPHATE 0.06 MMOL/ML IVPB (FOR PEDIATRICS),50863,CDM,250,RC,J3490,HCPCS,70121-1722-1,NDC,facility,both,2,ML,,352,246.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16729-137-00,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-288-07,NDC,facility,both,1,ML,,134,93.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN   1.5 G IV SOLR,50863,CDM,J3373,HCPCS,0409-3515-11,NDC,,,facility,both,150,EA,,143,100.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,J0132,HCPCS,70594-111-01,NDC,,,facility,both,180,ML,,916,641.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPIRAMATE  25 MG ORAL TAB,50863,CDM,J3490,HCPCS,68084-342-11,NDC,,,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,J0780,HCPCS,23155-294-31,NDC,,,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLIMEPIRIDE 2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,68084-326-11,NDC,facility,both,3,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,J3490,HCPCS,57896-102-01,NDC,,,facility,both,3,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN,50863,CDM,J3490,HCPCS,0703-1153-01,NDC,,,facility,both,1,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0904-6923-61,NDC,facility,both,55,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,636,RC,J1815,HCPCS,0088-2220-33,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-495-27,NDC,,,facility,both,50,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,68094-231-59,NDC,facility,both,2,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN 0.9% SODIUM CL 1.25 GRAM/250 ML IV SOLN,50863,CDM,636,RC,J3373,HCPCS,72196-6074-1,NDC,facility,both,125,ML,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-134-11,NDC,facility,both,50,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOMYCIN-BACITRACIN ZN-POLYMYXIN 3.5 MG-400 UN*,50863,CDM,250,RC,J3490,HCPCS,45802-143-03,NDC,facility,both,1,GM,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM  3.375 GRAM IV SOLR,50863,CDM,636,RC,J2543,HCPCS,60505-6157-0,NDC,facility,both,3,EA,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FEBUXOSTAT 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-538-11,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,1,ML,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 250 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7350-06,NDC,facility,both,5,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,0409-9094-12,NDC,facility,both,2,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,50863,CDM,250,RC,J9181,HCPCS,63323-104-06,NDC,facility,both,17,ML,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE  25 MG ORAL CAP,50863,CDM,250,RC,J7515,HCPCS,68084-879-95,NDC,facility,both,2,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM  3 GRAM INJ SOLR,50863,CDM,J0295,HCPCS,55150-117-20,NDC,,,facility,both,2,EA,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOFLOXACIN IN D5W 500 MG/100 ML IV PGBK,50863,CDM,250,RC,J1956,HCPCS,44567-436-24,NDC,facility,both,2,ML,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLECAINIDE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0054-0011-20,NDC,facility,both,2,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPTOMYCIN 500 MG IV SOLR,50863,CDM,636,RC,J0878,HCPCS,71288-016-15,NDC,facility,both,200,EA,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,250,RC,Q0162,HCPCS,65162-691-79,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN NORMAL SALINE IV,50863,CDM,636,RC,J7042,HCPCS,0264-7610-00,NDC,facility,both,2,ML,JZ,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CHLORTHALIDONE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-167-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,50863,CDM,Q5119,HCPCS,0069-0238-01,NDC,,,facility,both,30,ML,,5936,4155.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIRMATRELVIR-RITONAVIR 300-100 MG ORAL TAB DOSEPACK (FOR ED/IP TAKE HOME PANEL),50863,CDM,636,RC,J3490,HCPCS,0069-5321-30,NDC,facility,both,30,EA,,4010,2807,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN LIPOSOMAL 2 MG/ML IV INJ,50863,CDM,250,RC,Q2050,HCPCS,72603-103-01,NDC,facility,both,2,ML,,2675,1872.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 400 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,16714-505-01,NDC,facility,both,3,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 150 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6956-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR PHOSPHATE 30 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,33342-256-66,NDC,facility,both,1,EA,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-631-11,NDC,facility,both,3,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEBIVOLOL  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,31722-585-30,NDC,facility,both,4,EA,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-595-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,13,ML,JW,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CERTOLIZUMAB PEGOL 400 MG (200 MG X 2) SUBQ KIT,50863,CDM,636,RC,J0717,HCPCS,50474-700-62,NDC,facility,both,200,EA,JW,1445,1011.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CHLORTHALIDONE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-167-11,NDC,facility,both,5,EA,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,4,EA,JW,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,144,ML,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICARDIPINE 25 MG/10 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,72485-116-01,NDC,facility,both,2,ML,,274,191.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,636,RC,J3490,HCPCS,81284-611-00,NDC,facility,both,2,ML,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NORETHINDRONE ACETATE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50742-267-50,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-02,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV (BOLUS),50863,CDM,636,RC,J7120,HCPCS,0264-7750-07,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAT EMUL-SOY-MCT-OLIV-FISH OIL 20 % IV EMUL (NEO/PEDS),50863,CDM,250,RC,J3490,HCPCS,63323-820-00,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN D5W 20000 UNIT/500 ML,50863,CDM,636,RC,J1644,HCPCS,0264-9567-10,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,J1953,HCPCS,55150-177-05,NDC,,,facility,both,100,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,63323-482-03,NDC,facility,both,40,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,72266-146-01,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONAZEPAM 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0228-3004-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7243-61,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,250,RC,J0690,HCPCS,60505-6142-0,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-8515-23,NDC,facility,both,3,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLMESARTAN 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16729-322-15,NDC,facility,both,1,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,65219-186-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,13533-690-25,NDC,facility,both,2,ML,JZ,434,303.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,9,ML,,162,113.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOBAZAM 2.5 MG/ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,99999-0404-03,NDC,facility,both,4,ML,,166,116.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LITHIUM CARBONATE 300 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,68084-640-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,0409-3795-19,NDC,facility,both,2,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,636,RC,J2270,HCPCS,76045-004-10,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 80 MG-400 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,0703-9514-01,NDC,facility,both,3,ML,,221,154.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,0904-6923-61,NDC,facility,both,5,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE (FOR CODE) 10% (100 MG/ML) IV SYRINGE,50863,CDM,250,RC,J3490,HCPCS,64253-900-30,NDC,facility,both,1,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 1 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,27808-002-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-681-01,NDC,facility,both,2,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,636,RC,J3490,HCPCS,63323-185-07,NDC,facility,both,2,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE IV",50863,CDM,250,RC,J3490,HCPCS,0338-0013-04,NDC,facility,both,1,ML,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON DEXTRAN 50 MG/ML INJ SOLN,50863,CDM,636,RC,J1750,HCPCS,0023-6082-01,NDC,facility,both,2,ML,,219,153.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  20 MEQ ORAL PACK,50863,CDM,250,RC,J3490,HCPCS,72888-024-06,NDC,facility,both,2,EA,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML (1ML) INJ SOLN,50863,CDM,250,RC,J0171,HCPCS,42023-159-01,NDC,facility,both,10,ML,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 1% (BUFFERED W/NAHCO3 8.4%) 10 ML SYRINGE (MERGE),50863,CDM,250,RC,J3490,HCPCS,70092-1175-46,NDC,facility,both,2,ML,,466,326.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,36,ML,JW,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
NIRMATRELVIR-RITONAVIR 150 MG (10)- 100 MG (10) ORAL DSPK,50863,CDM,250,RC,J3490,HCPCS,0069-5317-02,NDC,facility,both,2,EA,,647,452.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,250,RC,J3101,HCPCS,50242-037-06,NDC,facility,both,13,EA,,5955,4168.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYBUTYNIN CHLORIDE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0832-0038-89,NDC,facility,both,7,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ (MERGE),50863,CDM,636,RC,J2250,HCPCS,0409-2305-17,NDC,facility,both,5,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42858-001-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,636,RC,P9045,HCPCS,13533-690-25,NDC,facility,both,1,ML,,256,179.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 3000 MCG/ML INJECTION,50863,CDM,250,RC,J0153,HCPCS,25021-318-02,NDC,facility,both,5,ML,JW,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DENOSUMAB-BBDZ 60 MG/ML SUBQ SYRG,50863,CDM,636,RC,Q5136,HCPCS,61314-240-63,NDC,facility,both,60,ML,,4428,3099.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-975-11,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6291-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES  8.6 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7252-60,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUPHENAZINE 5 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0527-1790-01,NDC,facility,both,3,EA,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATED 20 MG/ML IV SOLN,50863,CDM,250,RC,J0706,HCPCS,51754-0500-1,NDC,facility,both,3,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  88 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-486-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIZANIDINE 4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-645-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,66553-002-01,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALUM-MAG HYDROXIDE-SIMETH 200 MG-200 MG-20 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,17856-0630-1,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,63739-903-10,NDC,facility,both,1,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J1940,HCPCS,72603-251-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOL 1.4 % MM SPRA,50863,CDM,250,RC,J3490,HCPCS,0536-1228-58,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-089-11,NDC,facility,both,1,EA,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACUBITRIL-VALSARTAN 49-51 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0078-0777-20,NDC,facility,both,10,EA,,508,355.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUBIPROSTONE 24 MCG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,43598-168-60,NDC,facility,both,1,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFPODOXIME 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-395-01,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4 % MUCOSAL TOPICAL SOLN,50863,CDM,636,RC,J3490,HCPCS,70954-518-10,NDC,facility,both,1,ML,,275,192.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0406-5755-23,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-5755-23,NDC,facility,both,3,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM PHOSPHATE 4.4 MEQ/ML ORAL SOLUTION (CDS),50863,CDM,250,RC,J3490,HCPCS,0409-7295-01,NDC,facility,both,1,ML,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-591-11,NDC,facility,both,4,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0780,HCPCS,23155-294-31,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PORACTANT ALFA 240 MG/3 ML INTR SUSP,50863,CDM,250,RC,J3490,HCPCS,10122-510-01,NDC,facility,both,1,ML,,1576,1103.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 80 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-685-02,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML IV,50863,CDM,636,RC,J3490,HCPCS,25021-319-05,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  1 MG/ML INJ SYRG,50863,CDM,250,RC,J1171,HCPCS,0409-1283-10,NDC,facility,both,20,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J2250,HCPCS,0409-0001-01,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG/5 ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,0121-4827-05,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZOCAINE 20 % MM SPRY,50863,CDM,250,RC,J3490,HCPCS,0283-0610-43,NDC,facility,both,2,EA,,101,70.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 10 % INHL NEBU,50863,CDM,250,RC,J3490,HCPCS,0378-6998-89,NDC,facility,both,20,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,10019-033-39,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 100 MG PE/2 ML INJ SOLN,50863,CDM,250,RC,Q2009,HCPCS,0069-6001-02,NDC,facility,both,4,ML,JZ,475,332.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IBUPROFEN 400 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-446-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID (PORK)  30 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0456-0458-01,NDC,facility,both,2,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,636,RC,J0330,HCPCS,31722-981-10,NDC,facility,both,11,ML,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,250,RC,J2004,HCPCS,0409-3178-01,NDC,facility,both,150,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE (POLACRILEX) 4 MG MM LOZG,50863,CDM,250,RC,J3490,HCPCS,1093919444,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,19,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1MG/ML ORAL SOLUTION (HIGH CONC FOR PEDS),50863,CDM,636,RC,J3490,HCPCS,99999-407-47,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CITRATE  5 MEQ ORAL TBER,50863,CDM,250,RC,J3490,HCPCS,31722-129-01,NDC,facility,both,3,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,636,RC,J3490,HCPCS,0641-6236-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE 10 MG/ML ORAL SUSPENSION,50863,CDM,250,RC,J3490,HCPCS,16714-454-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,51,ML,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 0.1 MG/ML INJ SYRG,50863,CDM,250,RC,J0461,HCPCS,76329-3340-1,NDC,facility,both,50,ML,JZ,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SERTRALINE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16714-613-04,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BALSALAZIDE 750 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,50268-102-11,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN  500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7162-61,NDC,facility,both,8,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,9,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,27,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZTROPINE 0.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7288-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,250,RC,J2270,HCPCS,0409-1890-03,NDC,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEBIVOLOL  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-641-11,NDC,facility,both,2,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 3000 MCG/ML INJECTION,50863,CDM,250,RC,J0153,HCPCS,63323-651-00,NDC,facility,both,12,ML,JZ,129,90.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-492-41,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOPAMINE 200 MG/5 ML (40 MG/ML) IV,50863,CDM,250,RC,J1265,HCPCS,0143-9252-01,NDC,facility,both,5,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,J3490,HCPCS,0143-9889-15,NDC,,,facility,both,9,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  20 MEQ ORAL PACK,50863,CDM,J3490,HCPCS,72888-024-06,NDC,,,facility,both,3,EA,,158,110.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-480-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,250,RC,J3490,HCPCS,68180-963-01,NDC,facility,both,1,GM,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 400 MG ORAL CAP,50863,CDM,J3490,HCPCS,0904-6667-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,50863,CDM,J0561,HCPCS,60793-701-02,NDC,,,facility,both,12,ML,,1080,756,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-444-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,63323-485-03,NDC,,,facility,both,500,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,50863,CDM,250,RC,J0696,HCPCS,44567-702-25,NDC,facility,both,8,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69315-905-05,NDC,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.15 MG/0.3 ML IM PNIJ,50863,CDM,J0171,HCPCS,0093-5985-19,NDC,,,facility,both,2,EA,,1024,716.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NITROGLYCERIN 50 MG/10 ML (5 MG/ML) IV SOLN,50863,CDM,250,RC,J2305,HCPCS,0517-4810-25,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,139,ML,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,10,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,636,RC,J3490,HCPCS,66993-019-68,NDC,facility,both,1,GM,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,14,ML,,447,312.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BLEOMYCIN 30 UNIT INJ SOLR,50863,CDM,250,RC,J9040,HCPCS,71288-107-20,NDC,facility,both,2,EA,,282,197.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,24,ML,JW,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
NITROPRUSSIDE 25 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,43598-587-23,NDC,facility,both,1,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,250,RC,J0132,HCPCS,25021-812-30,NDC,facility,both,80,ML,,576,403.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"CIPROFLOXACIN-HYDROCORTISONE 0.2 %-1 % EAR DROPS, SUSP",50863,CDM,250,RC,J3490,HCPCS,66758-087-70,NDC,facility,both,1,ML,,214,149.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,636,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,150,ML,JZ,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ISOSULFAN BLUE 1 % INJ SOLN,50863,CDM,250,RC,Q9968,HCPCS,67457-220-00,NDC,facility,both,30,ML,JW,875,612.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-11,NDC,facility,both,4,ML,JW,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0093-4177-73,NDC,facility,both,3,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAUNORUBICIN 5 MG/ML IV INJ,50863,CDM,636,RC,J9150,HCPCS,0143-9551-01,NDC,facility,both,4,ML,,1159,811.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-25,NDC,facility,both,35,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE CONCENTRATE 10 MG/ 0.5 ML ORAL SYRINGE (0.5ML UD MERGE),50863,CDM,250,RC,J3490,HCPCS,68094-045-01,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 80 MG/ML SUSP FOR INJECTION,50863,CDM,250,RC,J1010,HCPCS,70121-1574-1,NDC,facility,both,80,ML,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM  4.5 GRAM IV SOLR,50863,CDM,636,RC,J2543,HCPCS,65219-259-05,NDC,facility,both,4,EA,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,16714-661-01,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,0093-4177-73,NDC,facility,both,9,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 3 MG/ML IV SYRG,50863,CDM,250,RC,J0153,HCPCS,0469-8234-12,NDC,facility,both,12,ML,,423,296.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN PEDS SYRINGE (20MG/ML) IN DEXTROSE (CDS MIX,50863,CDM,250,RC,J7999,HCPCS,0781-3451-70,NDC,facility,both,4,EA,,207,144.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,12,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLPIDEM  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-621-01,NDC,facility,both,2,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FILGRASTIM 300 (NEUPOGEN) MCG/ML INJ SOLN,50863,CDM,636,RC,J1442,HCPCS,55513-530-01,NDC,facility,both,300,ML,,1115,780.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,90,ML,,129,90.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POSACONAZOLE 100 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,0527-2133-35,NDC,facility,both,1,EA,,314,219.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAMADOL  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,72888-080-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-074-10,NDC,facility,both,1,EA,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0137,HCPCS,0143-9386-01,NDC,facility,both,16,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACIDOPHILUS-PECTIN W CITRUS 25 MILLION-100 CELL MG TAB,50863,CDM,636,RC,J3490,HCPCS,904661161,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE SODIUM 25 MG/ML INJ SOLN,50863,CDM,636,RC,J9260,HCPCS,61703-350-37,NDC,facility,both,2,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LANSOPRAZOLE 30 MG ORAL TBLD,50863,CDM,636,RC,J3490,HCPCS,64764-544-30,NDC,facility,both,1,EA,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LITHIUM CARBONATE 300 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-4527-25,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,42806-150-33,NDC,facility,both,9,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARTIFICIAL TEARS(HYPROMELLOSE) 0.3 % OPHT GEL,50863,CDM,250,RC,J3490,HCPCS,0065-0474-01,NDC,facility,both,1,GM,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCUSATE SODIUM 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7280-60,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1940,HCPCS,0409-6102-20,NDC,facility,both,8,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML ORAL SOLUTION (FOR PEDIATRIC USE),50863,CDM,250,RC,J3480,HCPCS,63323-965-05,NDC,facility,both,15,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,50863,CDM,250,RC,J9075,HCPCS,10019-956-16,NDC,facility,both,42,EA,JW,119,83.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
APIXABAN 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0003-0894-21,NDC,facility,both,2,EA,,119,83.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR PHOSPHATE 75 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,33342-258-66,NDC,facility,both,1,EA,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 100 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,67877-592-01,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  25 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-473-11,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  1 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,64380-782-06,NDC,facility,both,126,EA,,156,109.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,72205-003-90,NDC,facility,both,1,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2308-21,NDC,facility,both,1,ML,JW,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
RITUXIMAB-PVVR 10 MG/ML IV SOLN,50863,CDM,250,RC,Q5119,HCPCS,0069-0238-01,NDC,facility,both,20,ML,,3957,2769.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,50863,CDM,250,RC,J1756,HCPCS,0517-2340-01,NDC,facility,both,400,ML,JZ,1284,898.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,463,ML,,665,465.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORTHALIDONE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,65162-247-09,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SULFASALAZINE 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,59762-5000-5,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,67457-228-00,NDC,facility,both,2,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 17 GRAM (100 %) ORAL PWPK,50863,CDM,636,RC,J3490,HCPCS,0904-6931-86,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,10,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,0409-4279-16,NDC,,,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,0409-4276-16,NDC,,,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,14,EA,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIVALPROEX 125 MG ORAL CPSP,50863,CDM,250,RC,J3490,HCPCS,0904-6615-61,NDC,facility,both,4,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,29,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,43598-053-11,NDC,facility,both,18,ML,,634,443.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE (DIAGNOSTIC) 3 MG/ML IV SOLN,50863,CDM,250,RC,J0153,HCPCS,23155-258-32,NDC,facility,both,90,ML,,719,503.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-18,NDC,facility,both,100,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6500-61,NDC,facility,both,1,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,50863,CDM,J0561,HCPCS,60793-701-02,NDC,,,facility,both,24,ML,,2160,1512,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE  4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-3244-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,46,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON DEXTRAN 50 MG/ML INJ SOLN,50863,CDM,636,RC,J1750,HCPCS,0023-6082-01,NDC,facility,both,20,ML,,2084,1458.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,2500,ML,,276,193.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 50 MG 24 HR TAB,50863,CDM,J3490,HCPCS,60687-402-11,NDC,,,facility,both,4,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,50863,CDM,636,RC,J0696,HCPCS,60505-6149-0,NDC,facility,both,4,EA,JW,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,50,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISRADIPINE  2.5 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,16252-539-01,NDC,facility,both,2,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIFAMPIN 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,68180-659-06,NDC,facility,both,1,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE  50 MG ORAL TAB,50863,CDM,250,RC,j3490,HCPCS,50111-560-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEPIVACAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,250,RC,J0670,HCPCS,63323-294-01,NDC,facility,both,2,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE IN 0.9% NS (PF) 1 MG/10 ML (100 MCG/ML) IV SYRG(PDS MERGE),50863,CDM,250,RC,J3490,HCPCS,63037-173-25,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,J2003,HCPCS,0143-9575-01,NDC,,,facility,both,860,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SYRG,50863,CDM,J3490,HCPCS,6425311130,NDC,,,facility,both,4,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLNALTREXONE 12 MG/0.6 ML SUBQ SYRG,50863,CDM,636,RC,J2212,HCPCS,65649-551-07,NDC,facility,both,80,ML,GZ,490,343,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier GZ: Item or service expected to be denied as not reasonable and necessary
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,55150-370-01,NDC,facility,both,18,ML,JW,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,16,ML,JW,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
THIAMINE 100 MG/ML INJECTION,50863,CDM,250,RC,J3411,HCPCS,63323-013-01,NDC,facility,both,2,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),50863,CDM,J2060,HCPCS,0641-6044-01,NDC,,,facility,both,2,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYMETAZOLINE 0.05 % NASAL MERGE,50863,CDM,636,RC,J3490,HCPCS,45802-410-59,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,250,RC,J3360,HCPCS,0409-1273-03,NDC,facility,both,1,ML,JW,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CEFEPIME 1 GRAM INJ SOLR,50863,CDM,636,RC,J0692,HCPCS,0409-9566-01,NDC,facility,both,2,EA,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,67457-384-31,NDC,facility,both,57,ML,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOXYMETHYLCELLULOSE SODIUM 1 % OPHT DPGE,50863,CDM,636,RC,J3490,HCPCS,0023-4554-30,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,636,RC,J3490,HCPCS,63323-485-27,NDC,facility,both,70,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE 20MG/ML IV SYRINGE (PEDS/NEO),50863,CDM,250,RC,J0612,HCPCS,63323-311-10,NDC,facility,both,79,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE  1 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,59651-484-01,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-0007-01,NDC,facility,both,150,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,636,RC,J2003,HCPCS,0409-1323-15,NDC,facility,both,200,ML,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,71,ML,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-932-01,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,250,RC,J2270,HCPCS,0409-1890-13,NDC,facility,both,1,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,0641-0400-12,NDC,facility,both,5,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 10 MEQ/100 ML IV PGBK (USE NON-PROTOCOL PANEL),50863,CDM,636,RC,J3480,HCPCS,0338-0709-48,NDC,facility,both,5,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-826-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATROPINE 0.1 MG/ML INJ SYRG,50863,CDM,636,RC,J0461,HCPCS,16729-484-03,NDC,facility,both,100,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,350,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE HCL 5 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,66689-031-01,NDC,facility,both,1,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,72162-1329-8,NDC,facility,both,1,ML,,386,270.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 40 MG/ML SUSP (DEPO-MEDROL) INJECTION,50863,CDM,250,RC,J1010,HCPCS,70121-1573-1,NDC,facility,both,40,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PORACTANT ALFA 240 MG/3 ML INTR SUSP,50863,CDM,250,RC,J3490,HCPCS,10122-510-03,NDC,facility,both,1,ML,,3260,2282,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4 % TOPICAL SOLN,50863,CDM,250,RC,J3490,HCPCS,76329-6300-5,NDC,facility,both,1,ML,,13337,9335.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  30 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,0406-8330-62,NDC,facility,both,2,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,70095-031-01,NDC,facility,both,17,ML,,688,481.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,250,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,10,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-598-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCOSANOL 10 % TOP CREAM,50863,CDM,250,RC,J3490,HCPCS,0766-0801-35,NDC,facility,both,1,GM,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESNA 100 MG/ML IV SOLN,50863,CDM,250,RC,J9209,HCPCS,0338-1305-01,NDC,facility,both,6,ML,,210,147,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,250,RC,J2720,HCPCS,63323-229-01,NDC,facility,both,10,ML,,182,127.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,68180-150-01,NDC,facility,both,2,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-24,NDC,facility,both,40,ML,,5658,3960.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 25 MG TAB,50863,CDM,250,RC,J3490,HCPCS,62584-265-11,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IPRATROPIUM-ALBUTEROL 0.5 MG-2.5 MG/3 ML NEB SOLUTION,50863,CDM,250,RC,J3490,HCPCS,0487-0201-01,NDC,facility,both,10,ML,,108,75.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLPIDEM  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-838-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL 20 MG/5 ML ORAL ELIX,50863,CDM,250,RC,J3490,HCPCS,60687-671-40,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELLADONNA ALKALOIDS-OPIUM 16.2 MG-30 MG RECTAL SUPPOSITORY,50863,CDM,636,RC,J3490,HCPCS,0574-7045-01,NDC,facility,both,1,EA,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,83,ML,JW,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PROTAMINE 10 MG/ML IV SOLN,50863,CDM,636,RC,J2720,HCPCS,63323-229-01,NDC,facility,both,3,ML,JW,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
RISANKIZUMAB-RZAA  60 MG/ML IV SOLN,50863,CDM,636,RC,J2327,HCPCS,0074-5015-01,NDC,facility,both,1200,ML,JZ,57258,40080.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,21,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 15% IN WATER,50863,CDM,636,RC,J3490,HCPCS,0338-0023-03,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0630,HCPCS,42023-205-01,NDC,facility,both,1,ML,,5272,3690.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-1749-70,NDC,facility,both,2,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,114,EA,,15732,11012.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 20 MG/ML INJ SOLN,50863,CDM,636,RC,J0360,HCPCS,0517-0901-25,NDC,facility,both,1,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,26,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEFLUNOMIDE  20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,70748-130-06,NDC,facility,both,1,EA,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPINIROLE  1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6374-61,NDC,facility,both,5,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 0.1 % TOP CREAM,50863,CDM,636,RC,J3490,HCPCS,67877-251-15,NDC,facility,both,1,GM,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,4,EA,,130,91,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM 10 MG/5 ML (2 MG/ML) ORAL SYRP (MERGE/REPACK),50863,CDM,636,RC,J3490,HCPCS,68094-764-59,NDC,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-505-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 6 MG/0.5 ML SUBQ PEN KIT,50863,CDM,636,RC,J3030,HCPCS,72603-141-01,NDC,facility,both,1,ML,,239,167.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,636,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,9,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6475-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-134-11,NDC,facility,both,62,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOZAPINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-921-01,NDC,facility,both,6,EA,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68180-998-01,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J2004,HCPCS,0409-3178-16,NDC,,,facility,both,60,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,250,RC,J1815,HCPCS,0088-2220-33,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,3,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IV PGBK,50863,CDM,250,RC,J3475,HCPCS,0264-4204-52,NDC,facility,both,4,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IV PGBK,50863,CDM,250,RC,J3475,HCPCS,47335-992-01,NDC,facility,both,4,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 16 MG ORAL TAB,50863,CDM,250,RC,J7509,HCPCS,68382-918-18,NDC,facility,both,4,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,63323-487-01,NDC,facility,both,100,ML,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 50% IN WATER (MERGE RECORD),50863,CDM,636,RC,J7060,HCPCS,76329-3302-1,NDC,facility,both,1,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE IN SALINE (ISO-OSM) 400 MG/200 ML IV PIGGY BACK,50863,CDM,250,RC,J1450,HCPCS,25021-184-87,NDC,facility,both,2,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-01,NDC,facility,both,58,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,68462-469-40,NDC,facility,both,4,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,76045-009-96,NDC,facility,both,7,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE  10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,69367-388-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOVASTATIN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,61442-142-01,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENAZOPYRIDINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,69367-611-01,NDC,facility,both,2,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZIPRASIDONE 40 MG CAP,50863,CDM,250,RC,J3490,HCPCS,65862-703-60,NDC,facility,both,2,EA,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN  325 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-087-02,NDC,facility,both,3,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR NEO/PEDS INFUSION (CDS FROM PREMIX),50863,CDM,250,RC,J0133,HCPCS,63323-325-10,NDC,facility,both,12,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATED 20 MG/ML IV SOLN,50863,CDM,250,RC,J0706,HCPCS,51754-0500-1,NDC,facility,both,9,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEO TPN SODIUM ACETATE 2 MEQ/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-7299-73,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM ACETATE 667 MG ORAL CAP,50863,CDM,636,RC,J0615,HCPCS,0904-7119-06,NDC,facility,both,58,EA,GZ,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier GZ: Item or service expected to be denied as not reasonable and necessary
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,636,RC,J3010,HCPCS,0409-9094-12,NDC,facility,both,2,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0131-2477-35,NDC,facility,both,1,EA,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  100 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,25021-452-01,NDC,facility,both,24,ML,,260,182,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TENECTEPLASE 50 MG IV (MERGE) (STROKE),50863,CDM,J3101,HCPCS,50242-037-06,NDC,,,facility,both,22,EA,,10077,7053.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  25 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-473-11,NDC,facility,both,5,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 2 %-1:200,000 INJ SOLN",50863,CDM,J2004,HCPCS,63323-489-01,NDC,,,facility,both,600,ML,,207,144.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 175 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,42292-040-01,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,67457-433-00,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,50863,CDM,636,RC,Q0177,HCPCS,63739-486-10,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-739-41,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRIVIGEN 10 % IV SOLN,50863,CDM,636,RC,J1459,HCPCS,44206-437-91,NDC,facility,both,20,ML,,3588,2511.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIRMATRELVIR-RITONAVIR 150 MG (10)- 100 MG (10) ORAL DSPK,50863,CDM,636,RC,J3490,HCPCS,0069-5317-02,NDC,facility,both,2,EA,,628,439.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,25021-131-82,NDC,facility,both,50,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 3 % IV INFUSION,50863,CDM,250,RC,J3490,HCPCS,0338-0054-03,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-ABDA 100 MG IV SOLR,50863,CDM,636,RC,Q5104,HCPCS,78206-162-99,NDC,facility,both,75,EA,,15596,10917.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN STERILE WATER 2 GRAM/20 ML IV SYRG,50863,CDM,636,RC,J7999,HCPCS,73702-132-23,NDC,facility,both,250,ML,,11496,8047.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN 125 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,51672-4069-2,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,68462-755-01,NDC,facility,both,2,ML,JZ,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
TEPLIZUMAB-MZWV 2 MG/20 ML IV SOLN,50863,CDM,636,RC,J9381,HCPCS,73650-316-01,NDC,facility,both,112,ME,JW,2944,2060.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
HYDROCODONE-ACETAMINOPHEN 7.5 MG-325 MG/15 ML ORAL SOLN (REPACK),50863,CDM,250,RC,J3490,HCPCS,0121-2316-15,NDC,facility,both,1,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,70004-600-09,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,6,EA,,219,153.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,636,RC,J7512,HCPCS,60687-134-11,NDC,facility,both,50,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE INFUSION 2MG/ML 100ML (FOR ANESTHESIA USE ONLY),50863,CDM,636,RC,J3490,HCPCS,0409-2051-05,NDC,facility,both,1,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % MBP,50863,CDM,250,RC,J3490,HCPCS,0338-0553-18,NDC,facility,both,2,ML,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,4,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ABATACEPT 250 MG IV SOLR,50863,CDM,636,RC,J0129,HCPCS,0003-2187-13,NDC,facility,both,100,EA,"JZ,JA",17112,11978.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
ZIPRASIDONE 40 MG CAP,50863,CDM,250,RC,J3490,HCPCS,68084-104-09,NDC,facility,both,1,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,50863,CDM,J1650,HCPCS,0075-0622-01,NDC,,,facility,both,8,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,300,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN 1 GRAM SOLUTION FOR INJECTION,50863,CDM,250,RC,J0290,HCPCS,0781-3404-95,NDC,facility,both,2,EA,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CANDESARTAN  8 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,33342-115-07,NDC,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,300,ML,,212,148.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,63323-162-00,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-38,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-495-07,NDC,,,facility,both,100,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IVABRADINE 7.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,55513-810-60,NDC,facility,both,2,EA,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LINEZOLID 600 MG/300 ML IV SOLP,50863,CDM,636,RC,J2020,HCPCS,57664-683-31,NDC,facility,both,3,ML,JZ,331,231.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
VANCOMYCIN IN 0.9% SODIUM CL 1.25 GRAM/250 ML IV SOLN,50863,CDM,250,RC,J3373,HCPCS,70092-9054-05,NDC,facility,both,3,ML,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-50,NDC,facility,both,24,ML,JW,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0904-7127-61,NDC,facility,both,40,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL TBTQ,50863,CDM,636,RC,J3490,HCPCS,0245-5317-01,NDC,facility,both,4,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEPIVACAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,250,RC,J0670,HCPCS,63323-294-01,NDC,facility,both,2,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOZAPINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-404-11,NDC,facility,both,18,EA,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAZOSIN 5 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,70954-021-10,NDC,facility,both,2,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TORIPALIMAB-TPZI 240 MG/6 ML (40 MG/ML) IV SOLN,50863,CDM,J3263,HCPCS,70114-340-01,NDC,,,facility,both,240,ML,,25650,17955,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHADONE 10 MG/ML ORAL CONC,50863,CDM,J3490,HCPCS,0054-3553-44,NDC,,,facility,both,2,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DONEPEZIL  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6477-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-9791-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4% TOP PATCH,50863,CDM,250,RC,J3490,HCPCS,46581-830-06,NDC,facility,both,5,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),50863,CDM,250,RC,J1171,HCPCS,76045-009-96,NDC,facility,both,30,ML,,166,116.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TERAZOSIN  5 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,59746-385-06,NDC,facility,both,4,EA,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE 40 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,68180-150-01,NDC,facility,both,2,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 150 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6956-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM 5 MG/ML IV,50863,CDM,636,RC,J3490,HCPCS,0641-6013-01,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68180-445-01,NDC,facility,both,2,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 2 MG INJ SOLR,50863,CDM,250,RC,J2997,HCPCS,50242-041-64,NDC,facility,both,4,EA,,1600,1120,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,67877-545-88,NDC,facility,both,10,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALPROATE SODIUM 100 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0143-9785-10,NDC,facility,both,3,ML,,305,213.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 0.25 % NASAL SPRAY,50863,CDM,250,RC,J3490,HCPCS,0024-1348-03,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-464-11,NDC,facility,both,4,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,67457-423-00,NDC,facility,both,4,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DILTIAZEM SR 120 MG 24 HR CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7217-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENTAMIDINE 300 MG INJ SOLR,50863,CDM,636,RC,J3490,HCPCS,63323-113-01,NDC,facility,both,1,EA,,455,318.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  500 MCG/ML INJ SOLN,50863,CDM,250,RC,J2354,HCPCS,0641-6176-01,NDC,facility,both,20,ML,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OMEPRAZOLE-SODIUM BICARBONATE 2-84 MG/ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,65628-270-05,NDC,facility,both,2,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7177-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREGABALIN  25 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-473-11,NDC,facility,both,9,EA,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL  97.2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16571-668-01,NDC,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0143-9507-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0054-8299-25,NDC,facility,both,5,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLNALTREXONE 12 MG/0.6 ML SUBQ SOLN,50863,CDM,250,RC,J2212,HCPCS,65649-551-02,NDC,facility,both,1,ML,,735,514.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0074-4552-90,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,0008-0923-51,NDC,facility,both,2,EA,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 100 MG 24 HR TAB,50863,CDM,636,RC,J3490,HCPCS,60687-413-11,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,17,ML,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORDIAZEPOXIDE 25 MG CAP,50863,CDM,636,RC,J3490,HCPCS,51079-141-01,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTAZIDIME NEO IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0713,HCPCS,0781-3177-80,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-1638-32,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) NEB SOLUTION,50863,CDM,250,RC,J3490,HCPCS,0487-9501-01,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML (ANESTHESIA INTRAOP ONLY),50863,CDM,250,RC,J3010,HCPCS,0641-6027-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL  2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-735-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0093-3145-01,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE  0.65 % NASL SPRA,50863,CDM,250,RC,J3490,HCPCS,0904-3865-75,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-591-11,NDC,facility,both,3,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,636,RC,J2405,HCPCS,0641-6078-01,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) IV (NEO) EMERGENCY SYRINGE,50863,CDM,250,RC,J3490,HCPCS,0409-5534-34,NDC,facility,both,1,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 10 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,16714-720-02,NDC,facility,both,2,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0075-0620-01,NDC,facility,both,4,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE 0.05 % OPHT DPET,50863,CDM,250,RC,J3490,HCPCS,68180-214-30,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE 0.05 % OPHT DPET,50863,CDM,250,RC,J3490,HCPCS,0023-9163-30,NDC,facility,both,1,EA,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOSPORINE 0.05 % OPHT DPET,50863,CDM,250,RC,J3490,HCPCS,60505-6202-1,NDC,facility,both,1,EA,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN,50863,CDM,636,RC,J0256,HCPCS,13533-705-11,NDC,facility,both,614,ME,,8332,5832.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE  10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-037-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,250,RC,J0132,HCPCS,55150-259-30,NDC,facility,both,180,ML,,813,569.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  750 MG IV SOLR,50863,CDM,250,RC,J3370,HCPCS,67457-705-00,NDC,facility,both,2,EA,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN NEO/PEDS IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0456,HCPCS,63323-398-14,NDC,facility,both,1,EA,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0075-0622-01,NDC,facility,both,3,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRON SUCROSE 100 MG/5 ML IV SOLN,50863,CDM,636,RC,J1756,HCPCS,0517-2340-01,NDC,facility,both,500,ML,,1605,1123.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7008-61,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,250,RC,J7060,HCPCS,0338-0017-04,NDC,facility,both,2,ML,,181,126.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,50863,CDM,250,RC,J9075,HCPCS,10019-956-16,NDC,facility,both,77,EA,JW,219,153.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GLIPIZIDE  2.5 MG ORAL TO24,50863,CDM,250,RC,J3490,HCPCS,16714-894-01,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,63739-903-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,250,RC,J7999,HCPCS,70092-1017-46,NDC,facility,both,2,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DICLOFENAC 50 MG TAB, DELAYED RELEASE",50863,CDM,250,RC,J3490,HCPCS,60687-606-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RASBURICASE 1.5 MG IV SOLR,50863,CDM,250,RC,J2783,HCPCS,0024-5154-11,NDC,facility,both,1,EA,JW,585,409.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML IM SOLN,50863,CDM,636,RC,90375,HCPCS,13533-318-30,NDC,facility,both,12,ML,,11270,7889,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,50863,CDM,636,RC,J0561,HCPCS,60793-700-01,NDC,facility,both,24,ML,,3348,2343.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,17271-701-05,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7363-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,636,RC,J0330,HCPCS,31722-981-10,NDC,facility,both,9,ML,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,636,RC,J0330,HCPCS,0409-6629-02,NDC,facility,both,8,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,J7040,HCPCS,0338-0049-03,NDC,,,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 120 MG/0.8 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,0075-2912-00,NDC,facility,both,11,ML,,154,107.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 600 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-457-11,NDC,facility,both,15,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,55150-222-20,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLEDRONIC ACID IN MANNITOL & WATER 5 MG/100 ML IV SOLN,50863,CDM,636,RC,J3489,HCPCS,67457-619-10,NDC,facility,both,5,ML,,2311,1617.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE  50 MG ORAL TAB,50863,CDM,250,RC,j3490,HCPCS,60687-443-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN 0.9 % SODIUM CHL 1.5 GRAM/500 ML IV SOLN,50863,CDM,250,RC,J3370,HCPCS,70004-924-44,NDC,facility,both,3,ML,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-6665-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUPHENAZINE DECANOATE 25 MG/ML INJ SOLN,50863,CDM,250,RC,J2680,HCPCS,67457-359-59,NDC,facility,both,1,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,10,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,636,RC,J1596,HCPCS,70069-013-25,NDC,facility,both,8,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,27,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MELATONIN  3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,2055503601,NDC,facility,both,7,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6666-61,NDC,facility,both,2,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,636,RC,J1953,HCPCS,63323-400-01,NDC,facility,both,200,ML,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  5 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,55111-262-79,NDC,facility,both,3,EA,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,4,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,636,RC,J2405,HCPCS,23155-547-31,NDC,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 5 MG/5 ML IV,50863,CDM,250,RC,J3490,HCPCS,63323-660-01,NDC,facility,both,2,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN  325 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,1284355565,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN DEXTROSE (ISO-OSMOTIC) 1 GRAM/50 ML IV PIGGY BACK,50863,CDM,250,RC,J0690,HCPCS,0338-3503-41,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,51,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,J1100,HCPCS,63323-506-01,NDC,,,facility,both,4,ML,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,0409-4279-16,NDC,,,facility,both,150,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,26,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 250 MG/5 ML ORAL SUSR,50863,CDM,J3490,HCPCS,67877-548-88,NDC,,,facility,both,6,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,636,RC,J3360,HCPCS,0409-1273-03,NDC,facility,both,1,ML,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LANREOTIDE 120 MG/0.5 ML SUBQ SYRG,50863,CDM,636,RC,J1930,HCPCS,15054-1120-4,NDC,facility,both,120,ML,JZ,26392,18474.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,J0690,HCPCS,44567-707-25,NDC,,,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,J1885,HCPCS,0409-3795-19,NDC,,,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-229-02,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN 1 UNIT/ML IN NS 20 ML SYRINGE (CDS ADS MIXTURE),50863,CDM,250,RC,J3490,HCPCS,70092-1217-47,NDC,facility,both,1,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL 20 MG/5 ML ORAL ELIX,50863,CDM,250,RC,J3490,HCPCS,0121-0942-05,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IVABRADINE 7.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50742-363-60,NDC,facility,both,2,EA,,108,75.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARVEDILOL 25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7308-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,J1100,HCPCS,63323-165-01,NDC,,,facility,both,5,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYLEPHRINE 10 MG/ML INJECTION,50863,CDM,250,RC,J2371,HCPCS,0641-6142-25,NDC,facility,both,500,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GAMMAGARD LIQUID 10 % IV SOLN,50863,CDM,J1569,HCPCS,0944-2700-13,NDC,,,facility,both,70,ML,,12620,8834,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 200 MG/100 ML IVPB (MERGE),50863,CDM,250,RC,J1450,HCPCS,25021-184-82,NDC,facility,both,2,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-208-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,25021-468-10,NDC,facility,both,1,EA,,409,286.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIMETHOPRIM-SULFAMETHOXAZOLE 40 MG-200 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,65862-496-47,NDC,facility,both,1,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 50% IN WATER (MERGE RECORD),50863,CDM,636,RC,J7060,HCPCS,0409-4902-64,NDC,facility,both,1,ML,,108,75.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) IV,50863,CDM,250,RC,J1250,HCPCS,70436-203-80,NDC,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7124-61,NDC,facility,both,2,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IVERMECTIN 3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42799-806-01,NDC,facility,both,4,EA,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,636,RC,J3490,HCPCS,66993-019-68,NDC,facility,both,1,GM,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESNA 100 MG/ML IV SOLN,50863,CDM,250,RC,J9209,HCPCS,10019-953-62,NDC,facility,both,46,ML,,1350,945,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,5,ML,,131,91.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-071-04,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLENE BLUE (ANTIDOTE) 1 % INJ SOLN,50863,CDM,636,RC,Q9968,HCPCS,17478-504-01,NDC,facility,both,30,ML,,246,172.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RIFAMPIN 300 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-586-11,NDC,facility,both,2,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,J3490,HCPCS,63323-482-03,NDC,,,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIPASE-PROTEASE-AMYLASE (PORK) 36,000-114,000- 180,000 UNIT ORAL CPDR",50863,CDM,250,RC,J3490,HCPCS,0032-3016-13,NDC,facility,both,1,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) IN D5W 20000 UNIT/500 ML,50863,CDM,J1644,HCPCS,0264-9567-10,NDC,,,facility,both,20,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2305-04,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,42806-150-33,NDC,facility,both,2,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50111-327-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FINAL) IV SOLR,50863,CDM,636,RC,J9330,HCPCS,65219-205-05,NDC,facility,both,30,ML,,9771,6839.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 1 MG ORAL TBDL,50863,CDM,250,RC,J3490,HCPCS,59746-020-22,NDC,facility,both,1,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,250,RC,J3360,HCPCS,0641-6244-01,NDC,facility,both,1,ML,JW,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,42806-150-33,NDC,facility,both,4,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYCHLOROQUINE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-269-11,NDC,facility,both,2,EA,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,29300-135-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,250,RC,J1596,HCPCS,0143-9682-01,NDC,facility,both,4,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6441-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE (3 MONTH) 11.25 MG IM KIT,50863,CDM,250,RC,J1950,HCPCS,0074-3663-03,NDC,facility,both,3,EA,,14204,9942.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0143-9507-01,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,250,RC,J0330,HCPCS,31722-981-10,NDC,facility,both,12,ML,,136,95.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,120,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-476-11,NDC,facility,both,4,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN   1.25 G IV SOLR,50863,CDM,636,RC,J3370,HCPCS,67457-823-12,NDC,facility,both,3,EA,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68462-333-90,NDC,facility,both,3,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLADRIBINE 1 MG/ML IV SOLN,50863,CDM,250,RC,J9065,HCPCS,0143-9871-01,NDC,facility,both,10,ML,,885,619.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACAMPROSATE 333 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,0378-6333-80,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-50,NDC,facility,both,31,ML,JW,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,50863,CDM,636,RC,J0561,HCPCS,60793-700-01,NDC,facility,both,6,ML,,761,532.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-48,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,23155-833-01,NDC,facility,both,20,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYPROHEPTADINE 4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-189-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,25021-662-10,NDC,facility,both,1,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),50863,CDM,636,RC,J0330,HCPCS,69374-919-10,NDC,facility,both,4,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J2004,HCPCS,63323-482-03,NDC,facility,both,200,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51672-4027-1,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,250,RC,J2795,HCPCS,70069-064-25,NDC,facility,both,150,ML,JZ,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-466-17,NDC,facility,both,100,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LURASIDONE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-747-11,NDC,facility,both,6,EA,,150,105,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-592-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",50863,CDM,636,RC,J1561,HCPCS,13533-800-41,NDC,facility,both,240,ML,"JZ,JA",33946,23762.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
ALPRAZOLAM 0.5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,59762-3720-1,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MANNITOL 20% IV SOLP,50863,CDM,250,RC,J2150,HCPCS,0338-0357-02,NDC,facility,both,1,ML,,278,194.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.45% (1/2 NS) INFUSION (PEDS ONC),50863,CDM,250,RC,J3490,HCPCS,0338-0043-04,NDC,facility,both,1,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM SR 120 MG 24 HR CAP,50863,CDM,636,RC,J3490,HCPCS,0904-7217-61,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 200 MG INJ SOLR,50863,CDM,250,RC,J0640,HCPCS,63323-710-50,NDC,facility,both,4,EA,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,71456-001-01,NDC,facility,both,3,ML,,529,370.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,4,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-465-57,NDC,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,3,ML,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 3 % IV INFUSION,50863,CDM,250,RC,J3490,HCPCS,0338-0054-03,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,0143-9509-01,NDC,facility,both,1,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOBRAMYCIN 0.3 % EYE OINTMENT,50863,CDM,636,RC,J3490,HCPCS,0078-0813-01,NDC,facility,both,1,GM,,902,631.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN PEDS SYRINGE (20MG/ML) IN DEXTROSE (CDS MIX,50863,CDM,250,RC,J0690,HCPCS,0781-3451-70,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,19,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ZIPRASIDONE 20 MG IM,50863,CDM,250,RC,J3486,HCPCS,43598-848-11,NDC,facility,both,1,EA,JZ,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
MIDODRINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-145-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROSUVASTATIN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-256-11,NDC,facility,both,2,EA,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PYRIDOSTIGMINE BROMIDE 60 MG/5 ML ORAL SYRP,50863,CDM,250,RC,J3490,HCPCS,70954-148-10,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IDARUBICIN 1 MG/ML IV SOLN,50863,CDM,250,RC,J9211,HCPCS,0013-2596-91,NDC,facility,both,4,ML,,895,626.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 1% 10MG/ML (1ML-UD) OR SYRINGE,50863,CDM,J2003,HCPCS,0409-4276-02,NDC,,,facility,both,100,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAMSULOSIN 0.4 MG ORAL CP24,50863,CDM,250,RC,J3490,HCPCS,68084-299-11,NDC,facility,both,2,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MOMETASONE 110 MCG (30 DOSES) INHL AEPB,50863,CDM,250,RC,J3490,HCPCS,78206-115-01,NDC,facility,both,1,EA,,402,281.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 800 MG ORAL TAB,50863,CDM,250,RC,J0601,HCPCS,17856-921-01,NDC,facility,both,120,EA,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,72,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6950-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,1,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALDESLEUKIN 360,000 UNITS/ ML SOLUTION",50863,CDM,636,RC,J9015,HCPCS,65483-116-07,NDC,facility,both,1,EA,,5121,3584.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPLERENONE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51991-877-33,NDC,facility,both,2,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,16714-661-01,NDC,facility,both,2,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALUM-MAG HYDROXIDE-SIMETH 200 MG-200 MG-20 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0121-1761-30,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,62584-693-11,NDC,facility,both,1,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAVASTATIN 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-5892-61,NDC,facility,both,2,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-11,NDC,facility,both,6,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,636,RC,J1953,HCPCS,63323-400-01,NDC,facility,both,165,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV (BOLUS),50863,CDM,250,RC,J7120,HCPCS,0264-7750-00,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTULOSE 20 GRAM/30 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-1154-30,NDC,facility,both,5,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLU VACCINE TS 2025-26 6 MO UP (PF) 45 MCG (15 MCG X 3)/0.5 ML IM SYRG,50863,CDM,636,RC,90656,HCPCS,49281-425-88,NDC,facility,both,1,ML,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM SR 120 MG 12 HR CAP,50863,CDM,250,RC,J3490,HCPCS,51079-926-01,NDC,facility,both,2,EA,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J1938,HCPCS,72603-251-01,NDC,facility,both,60,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN 250 MG SOLUTION FOR INJECTION,50863,CDM,636,RC,J0290,HCPCS,70594-084-01,NDC,facility,both,1,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE (PF) 25 MG/ML INJ SOLN (FOR ECTOPIC PREGNANCY),50863,CDM,636,RC,J9260,HCPCS,0143-9519-01,NDC,facility,both,2,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,636,RC,J1836,HCPCS,0409-0152-01,NDC,facility,both,62,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,63323-466-01,NDC,facility,both,300,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOCUSATE SODIUM 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,0904-7183-61,NDC,facility,both,5,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LAMOTRIGINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-318-11,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2308-22,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 150 MG/1 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0548-5607-00,NDC,facility,both,14,ML,,119,83.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J3490,HCPCS,0338-0049-31,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,250,RC,J7060,HCPCS,0338-0017-02,NDC,facility,both,1,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,78,ML,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J1938,HCPCS,72603-251-01,NDC,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMILORIDE 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0574-0292-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"NEOMYCIN-POLYMYXIN-HC 3.5 MG-10,000 UNIT/ML-1 % EAR SOLN",50863,CDM,250,RC,J3490,HCPCS,24208-631-10,NDC,facility,both,1,ML,,363,254.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLARITHROMYCIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0781-6023-46,NDC,facility,both,1,ML,,107,74.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUSPIRONE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-0053-01,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 5 MG/ML (0.5 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-4278-01,NDC,facility,both,250,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 7.5 MG-325 MG/15 ML ORAL SOLN (REPACK),50863,CDM,250,RC,J3490,HCPCS,66689-023-01,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROPROCAINE 3 % INJ SOLN,50863,CDM,250,RC,J2401,HCPCS,63323-478-01,NDC,facility,both,750,ML,,165,115.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,50863,CDM,250,RC,J9000,HCPCS,0069-1542-20,NDC,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,70121-1388-1,NDC,facility,both,1,ML,,228,159.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  750 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7125-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CERTOLIZUMAB PEGOL 400 MG (200 MG X 2) SUBQ KIT,50863,CDM,636,RC,J0717,HCPCS,50474-700-62,NDC,facility,both,200,EA,JZ,3323,2326.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,0409-3795-19,NDC,facility,both,2,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPIVACAINE (PF) 0.2 % 330 ML (RIGHT) (PHS CUSTOM PAIN BALL),50863,CDM,636,RC,J3490,HCPCS,63323-285-64,NDC,facility,both,1,ML,,580,406,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,J1953,HCPCS,72205-120-01,NDC,,,facility,both,150,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUMAZENIL 0.1 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,36000-148-01,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7362-61,NDC,facility,both,3,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4% TOP PATCH,50863,CDM,J3490,HCPCS,70512-812-01,NDC,,,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE  50 MG ORAL TAB,50863,CDM,250,RC,j3490,HCPCS,60687-443-11,NDC,facility,both,1,EA,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 500 MG/5 ML IV SOLN,50863,CDM,250,RC,J1953,HCPCS,63323-400-01,NDC,facility,both,150,ML,,158,110.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLNALTREXONE 12 MG/0.6 ML SUBQ SYRG,50863,CDM,250,RC,J2212,HCPCS,65649-551-03,NDC,facility,both,80,ML,,462,323.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,72,ML,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN 1000 MG IN NS 1000 ML IRRIGATION (REPACK),50863,CDM,636,RC,J0690,HCPCS,99999-500-04,NDC,facility,both,4,ML,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-450-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITUXIMAB-PVVR 10 MG/ML IV SOLN,50863,CDM,636,RC,Q5119,HCPCS,0069-0249-01,NDC,facility,both,25,ML,"JW,JA",2151,1505.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously
ROCURONIUM 50 MG/5 ML (10 MG/ML) IV SYRG,50863,CDM,636,RC,J3490,HCPCS,69374-924-05,NDC,facility,both,2,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,60687-580-11,NDC,facility,both,5,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,0641-6236-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,0093-4177-73,NDC,facility,both,8,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 1 MG ORAL TAB,50863,CDM,636,RC,J8540,HCPCS,0054-4181-25,NDC,facility,both,8,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0121-0914-05,NDC,facility,both,7,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 20 MG/2 ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,67457-433-00,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LYMPHOCYTE,ANTI-THYMO IMMUNE GLOBULIN 50 MG/ML IV",50863,CDM,250,RC,J7504,HCPCS,0009-7224-02,NDC,facility,both,1,ML,,13305,9313.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TIMOLOL MALEATE 0.5 % OPHT DROP,50863,CDM,250,RC,J3490,HCPCS,17478-288-10,NDC,facility,both,1,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 100 MG SOLUTION FOR INJECTION,50863,CDM,636,RC,J1720,HCPCS,0009-0825-01,NDC,facility,both,1,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0548-5604-00,NDC,facility,both,3,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,53489-143-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR 200 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,70954-188-10,NDC,facility,both,1,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6949-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE IV",50863,CDM,250,RC,J3490,HCPCS,0338-0013-04,NDC,facility,both,1,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,57,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUMETANIDE 0.25 MG/ML INJ SOLN,50863,CDM,250,RC,J1939,HCPCS,72205-102-01,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DACARBAZINE 200 MG IV SOLR,50863,CDM,250,RC,J9130,HCPCS,0143-9245-01,NDC,facility,both,8,EA,,282,197.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MECLIZINE 25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-523-11,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 15% IN WATER,50863,CDM,250,RC,J3490,HCPCS,0338-0023-03,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,0409-6102-02,NDC,facility,both,20,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMETHICONE 40 MG/0.6 ML ORAL DRPS,50863,CDM,250,RC,J3490,HCPCS,0536-1303-75,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE (PF) 25 MG/ML INJ SOLN (FOR ECTOPIC PREGNANCY),50863,CDM,636,RC,J9260,HCPCS,0143-9519-01,NDC,facility,both,2,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60219-1708-1,NDC,facility,both,280,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,0641-0477-21,NDC,facility,both,2,ML,,349,244.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,830,ML,,1191,833.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMINOCAPROIC ACID 250 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-4346-16,NDC,facility,both,1,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 6 MG/0.5 ML SUB-Q,50863,CDM,J3030,HCPCS,55150-173-01,NDC,,,facility,both,1,ML,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6949-61,NDC,facility,both,3,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DAPTOMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0878,HCPCS,0409-0122-01,NDC,facility,both,550,EA,,443,310.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),50863,CDM,J1610,HCPCS,63323-596-11,NDC,,,facility,both,5,EA,,4473,3131.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,0904-7278-41,NDC,facility,both,2,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J7510,HCPCS,17856-0815-1,NDC,facility,both,3,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,J3490,HCPCS,0409-4277-01,NDC,,,facility,both,400,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,16714-294-01,NDC,facility,both,4,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,63323-201-10,NDC,,,facility,both,21,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-2051-15,NDC,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,250,RC,J3490,HCPCS,81033-002-20,NDC,facility,both,2,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,50863,CDM,636,RC,J3301,HCPCS,16714-130-01,NDC,facility,both,8,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 50 MG/ML INJECTION,50863,CDM,250,RC,J1200,HCPCS,63323-664-00,NDC,facility,both,3,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,4,EA,,326,228.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM IODIDE 1 GRAM/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,75834-280-30,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COLCHICINE 0.6 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7120-04,NDC,facility,both,2,EA,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,50863,CDM,636,RC,J7060,HCPCS,0338-0017-02,NDC,facility,both,1,ML,JZ,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DIVALPROEX 500 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,0904-6861-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,6,EA,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIFEDIPINE 60 MG ORAL TO24,50863,CDM,636,RC,J3490,HCPCS,50268-598-11,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 500 MG-125 MG TAB,50863,CDM,250,RC,J3490,HCPCS,16714-296-01,NDC,facility,both,8,EA,,149,104.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTOLOZANE-TAZOBACTAM 1.5 G IV SOLR,50863,CDM,250,RC,J0695,HCPCS,67919-030-01,NDC,facility,both,40,EA,,1507,1054.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6950-61,NDC,facility,both,3,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,50863,CDM,250,RC,J3010,HCPCS,63323-806-02,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GANCICLOVIR NEO IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J1750,HCPCS,63323-315-10,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGIC MOUTHWASH REPACK (BMX 1:1:1),50863,CDM,250,RC,J3490,HCPCS,99999-500-91,NDC,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICARDIPINE IN NACL (ISO-OS) 20 MG/200 ML IV PGBK,50863,CDM,250,RC,J3490,HCPCS,10122-313-01,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM  1.5 GRAM INJ SOLR,50863,CDM,250,RC,J0295,HCPCS,25021-142-20,NDC,facility,both,1,EA,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,50863,CDM,636,RC,Q0162,HCPCS,65162-691-79,NDC,facility,both,2,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR 800 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-109-11,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM IN NACL (ISO-OS) 500 MG/100 ML IV PGBK,50863,CDM,250,RC,J1953,HCPCS,70860-602-41,NDC,facility,both,100,ML,,400,280,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLBETUXIMAB-CLZB 300 MG IV SOLR (WET SOLR VIAL),50863,CDM,C9303,HCPCS,0469-4425-30,NDC,,,facility,both,160,EA,,3072,2150.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) MISC SOLN,50863,CDM,J3490,HCPCS,63323-694-41,NDC,,,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 25 MG/5 ML (5 MG/ML) ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,62559-204-12,NDC,facility,both,1,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICARDIPINE 25 MG/10 ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,72485-116-01,NDC,facility,both,5,ML,,685,479.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE 8 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,60687-492-11,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-41,NDC,facility,both,1,ML,JZ,119,83.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DEXAMETHASONE 1 MG ORAL TAB,50863,CDM,250,RC,J8540,HCPCS,0054-8174-25,NDC,facility,both,4,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5%-1/2 NORMAL SALINE IV,50863,CDM,636,RC,J7042,HCPCS,0264-7612-00,NDC,facility,both,2,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DONEPEZIL  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6477-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN 250 MG SOLUTION FOR INJECTION,50863,CDM,250,RC,J0290,HCPCS,44567-100-10,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-407-11,NDC,facility,both,3,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,50863,CDM,636,RC,J2003,HCPCS,0143-9575-01,NDC,facility,both,100,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-11,NDC,facility,both,5,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE LIPOSOME (PF) 266 MG/20 ML (13.3 MG/ML) LINF SUSP,50863,CDM,250,RC,J3490,HCPCS,65250-266-20,NDC,facility,both,1,ML,,1116,781.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLOROTHIAZIDE SODIUM 28 MG/ML IV (PEDS) REPACK,50863,CDM,250,RC,J1205,HCPCS,99999-0404-59,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE 8 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,0054-0177-13,NDC,facility,both,1,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 50 MG/ML INJECTION,50863,CDM,250,RC,J1200,HCPCS,0409-2290-31,NDC,facility,both,3,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLN,50863,CDM,636,RC,J3262,HCPCS,50242-137-01,NDC,facility,both,400,ML,,7331,5131.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROID (PORK)  30 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,62559-741-01,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM SR 180 MG 24 HR CAP,50863,CDM,250,RC,J3490,HCPCS,50742-249-90,NDC,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WARFARIN 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-1712-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LURASIDONE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65162-879-03,NDC,facility,both,1,EA,,229,160.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,J3490,HCPCS,65862-707-01,NDC,,,facility,both,4,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE  1 % TOP CREA,50863,CDM,250,RC,J3490,HCPCS,45802-438-03,NDC,facility,both,1,GM,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML IV SOLN (MERGE),50863,CDM,250,RC,J3490,HCPCS,16714-037-01,NDC,facility,both,1,ML,,101,70.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-495-04,NDC,,,facility,both,200,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,5,ML,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,31722-820-30,NDC,facility,both,2,EA,,273,191.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 100 MG/5 ML ORAL LIQD,50863,CDM,250,RC,J3490,HCPCS,0121-1488-10,NDC,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5%-1/2 NORMAL SALINE IV,50863,CDM,636,RC,J7042,HCPCS,0338-0085-03,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 10 MEQ/100 ML IV PGBK,50863,CDM,636,RC,J3480,HCPCS,0409-7074-26,NDC,facility,both,5,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0781-3220-75,NDC,facility,both,2,ML,,193,135.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,21,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,63323-467-01,NDC,facility,both,1,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0456,HCPCS,70436-019-82,NDC,facility,both,1,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,25,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACLOFEN 25 MG/5 ML (5 MG/ML) ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,52536-600-11,NDC,facility,both,1,ML,,143,100.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 1000 MG IV SOLR,50863,CDM,250,RC,J3370,HCPCS,67457-340-01,NDC,facility,both,2,EA,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-050-01,NDC,facility,both,2,EA,,108,75.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,51754-4250-1,NDC,facility,both,3,ML,,203,142.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  15 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,0406-8315-23,NDC,facility,both,4,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 100 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-439-11,NDC,facility,both,3,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,41,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML IV SOLN,50863,CDM,J3490,HCPCS,0143-9506-01,NDC,,,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN SODIUM EXTENDED 100 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0904-6187-61,NDC,facility,both,3,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 20 MG/ML INJ SOLN,50863,CDM,250,RC,J0360,HCPCS,55150-400-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-04,NDC,facility,both,3,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RITONAVIR 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65862-687-30,NDC,facility,both,1,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,84,ML,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,636,RC,J1815,HCPCS,0088-2220-33,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BELATACEPT 250 MG IV SOLR,50863,CDM,636,RC,J0485,HCPCS,0003-0371-13,NDC,facility,both,300,EA,JZ,3096,2167.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ACETAMINOPHEN 160 MG/5 ML ORAL (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,68094-231-59,NDC,facility,both,3,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % MBP,50863,CDM,250,RC,J3490,HCPCS,0338-0553-18,NDC,facility,both,1,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,65862-707-55,NDC,facility,both,8,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0121-1781-05,NDC,facility,both,4,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 40 GRAM/400 ML (10 %) INJ SOLN",50863,CDM,250,RC,J1561,HCPCS,13533-800-20,NDC,facility,both,50,ML,,7072,4950.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 10 MG-325 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0406-0125-23,NDC,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,60687-145-11,NDC,facility,both,133,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 2-0.5 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,50268-144-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  20 MEQ ORAL PACK,50863,CDM,250,RC,J3490,HCPCS,0245-0360-89,NDC,facility,both,1,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALTEPLASE 1 MG/ML (1ML) SYRINGE (REPACK),50863,CDM,250,RC,J2997,HCPCS,50242-044-13,NDC,facility,both,5,EA,JZ,1215,850.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,3,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,50863,CDM,250,RC,J9000,HCPCS,0069-1542-20,NDC,facility,both,2,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,636,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,13,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 250 MG-125 MG TAB,50863,CDM,250,RC,J3490,HCPCS,42571-160-30,NDC,facility,both,1,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0295,HCPCS,63323-368-20,NDC,facility,both,2,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOL 1.4 % MM SPRA,50863,CDM,636,RC,J3490,HCPCS,0536-1228-58,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,250,RC,J2270,HCPCS,0409-1890-03,NDC,facility,both,1,ML,PLAD,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
HYDROCORTISONE ACETATE 25 MG RECT SUPP,50863,CDM,250,RC,J3490,HCPCS,75834-147-12,NDC,facility,both,1,EA,,111,77.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZIPRASIDONE 20 MG CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6269-45,NDC,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,68094-600-59,NDC,facility,both,1,ML,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68180-966-01,NDC,facility,both,1,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 100 MG/ML INJ SOLN,50863,CDM,636,RC,J2800,HCPCS,71288-716-10,NDC,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,50863,CDM,250,RC,J1644,HCPCS,0409-2720-31,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 25 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-444-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,17271-701-05,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN STERILE WATER 2 GRAM/20 ML IV SYRG,50863,CDM,636,RC,J7999,HCPCS,73702-132-23,NDC,facility,both,1,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,80,ML,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE  50 MG ORAL TAB,50863,CDM,250,RC,j3490,HCPCS,60687-443-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SYRG,50863,CDM,250,RC,J3490,HCPCS,8290306546,NDC,facility,both,1,ML,PLAD,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
IPRATROPIUM BROMIDE 0.02 % INHL SOLN,50863,CDM,250,RC,J3490,HCPCS,0487-9801-01,NDC,facility,both,3,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL CPSR,50863,CDM,636,RC,J3490,HCPCS,0904-6930-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-492-27,NDC,,,facility,both,80,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG ORAL TAB,50863,CDM,J3490,HCPCS,42858-001-10,NDC,,,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BETAMETHASONE ACET & SOD PHOS 6 MG/ML INJ SUSP,50863,CDM,J0702,HCPCS,0517-0720-01,NDC,,,facility,both,2,ML,,113,79.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,50863,CDM,250,RC,J2310,HCPCS,67457-292-00,NDC,facility,both,1,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,J2704,HCPCS,63323-269-22,NDC,,,facility,both,80,ML,,160,112,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOPIDOGREL 300 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-6467-10,NDC,,,facility,both,2,EA,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,FAMNOCHARGE,HCPCS,17856-0759-5,NDC,,,facility,both,4,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL  32.4 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6575-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:200,000 INJ SOLN",50863,CDM,J2004,HCPCS,63323-487-01,NDC,,,facility,both,200,ML,,130,91,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,50863,CDM,250,RC,J1885,HCPCS,63323-161-00,NDC,facility,both,2,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,50,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),50863,CDM,J3490,HCPCS,0409-4888-06,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0338-0049-38,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN NEO/PEDS IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0456,HCPCS,63323-398-14,NDC,facility,both,1,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ABATACEPT 250 MG IV SOLR,50863,CDM,636,RC,J0129,HCPCS,0003-2187-13,NDC,facility,both,100,EA,,16711,11697.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,J7040,HCPCS,17271-701-05,NDC,,,facility,both,1,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARGATROBAN 100 MG/ML IV SOLN,50863,CDM,J0883,HCPCS,0143-9674-01,NDC,,,facility,both,250,ML,,821,574.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADVATE: FACTOR VIII CONCENTRATE (MERGE RECORD),50863,CDM,J7192,HCPCS,0944-3051-02,NDC,,,facility,both,500,UN,,2685,1879.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 2 MG/ML IV SOLN (PHS/CDS MERGE),50863,CDM,J2270,HCPCS,63323-452-00,NDC,,,facility,both,10,ML,,861,602.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE 0.5 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,63323-463-01,NDC,facility,both,1,ML,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 500 MG SOLUTION FOR INJECTION,50863,CDM,250,RC,J2919,HCPCS,0009-0758-01,NDC,facility,both,200,EA,,285,199.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 500 MG SOLUTION FOR INJECTION,50863,CDM,636,RC,J2919,HCPCS,0009-0758-01,NDC,facility,both,100,EA,,143,100.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 1 MG/ML ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,27808-002-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CHLORIDE (FOR CODE) 10% (100 MG/ML) IV SYRINGE,50863,CDM,250,RC,J3490,HCPCS,0409-4928-11,NDC,facility,both,3,ML,,302,211.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 600 MG ORAL TAB,50863,CDM,J3490,HCPCS,60687-457-11,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),50863,CDM,636,RC,J3490,HCPCS,63323-186-10,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLIMEPIRIDE 4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,55111-322-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  10 MEQ ORAL TBTQ,50863,CDM,J3490,HCPCS,0904-7292-61,NDC,,,facility,both,4,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,44567-600-04,NDC,facility,both,2,ML,,603,422.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4% TOP PATCH,50863,CDM,250,RC,J3490,HCPCS,0536-1202-15,NDC,facility,both,3,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,65162-898-09,NDC,facility,both,1,EA,,157,109.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACUBITRIL-VALSARTAN 49-51 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0078-0777-20,NDC,facility,both,2,EA,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLOPIDOGREL  75 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-536-11,NDC,facility,both,1,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 2 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6360-61,NDC,facility,both,1,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN (NEO),50863,CDM,250,RC,J1938,HCPCS,71288-203-10,NDC,facility,both,500,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DILTIAZEM SR 120 MG 12 HR CAP,50863,CDM,250,RC,J3490,HCPCS,51079-926-01,NDC,facility,both,3,EA,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,250,RC,J0131,HCPCS,55150-307-01,NDC,facility,both,40,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1940,HCPCS,72603-251-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COCAINE  4 % TOP SOLN (MERGE),50863,CDM,250,RC,C9046,HCPCS,64950-362-04,NDC,facility,both,160,ML,JZ,868,607.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
HC IV INFUSION HYDRAT 31-60 MIN,50863,CDM,250,RC,J0248,HCPCS,61958-2901-2,NDC,facility,both,100,EA,,1196,837.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,250,RC,J3490,HCPCS,0409-1749-70,NDC,facility,both,2,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,600,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,46,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METRONIDAZOLE IN SODIUM CHLORIDE (ISO-OSM) 500 MG/100 ML IV PIGGY BACK,50863,CDM,250,RC,J1836,HCPCS,0338-1055-48,NDC,facility,both,100,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDODRINE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-145-10,NDC,facility,both,2,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 1 MG ORAL TAB,50863,CDM,250,RC,J8540,HCPCS,72578-166-01,NDC,facility,both,18,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,88,ML,,126,88.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAMIPEXOLE 1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-592-11,NDC,facility,both,3,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-03,NDC,facility,both,2,ML,JZ,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0264-1800-32,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-22,NDC,facility,both,40,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIGOXIN 250 MCG/ML INJ SOLN,50863,CDM,250,RC,J1160,HCPCS,0641-1410-31,NDC,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEFIBROTIDE 80 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,68727-800-01,NDC,facility,both,3,ML,,5584,3908.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-4827-05,NDC,facility,both,2,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-440-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,636,RC,J1938,HCPCS,72603-251-01,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEPHALEXIN 250 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,67877-545-88,NDC,facility,both,10,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SERTRALINE  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6925-61,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORHEXIDINE GLUCONATE  0.12 % MM MWSH,50863,CDM,250,RC,J3490,HCPCS,0374-5080-01,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPRANOLOL  10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6550-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 50 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,59651-489-01,NDC,facility,both,20,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,69,EA,,9522,6665.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6638-61,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATORVASTATIN 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-208-01,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,50863,CDM,636,RC,J0690,HCPCS,0143-9924-90,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,5,ML,,144,100.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXYCYCLINE HYCLATE 100 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,0143-9381-01,NDC,facility,both,1,EA,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LURASIDONE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,67877-638-30,NDC,facility,both,2,EA,,368,257.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 0.8 GRAM ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,65862-930-08,NDC,facility,both,3,EA,,233,163.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,636,RC,J2003,HCPCS,0409-1323-05,NDC,facility,both,100,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,250,RC,J3490,HCPCS,25021-415-10,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN 81 MG ORAL CHEW,50863,CDM,636,RC,J3490,HCPCS,66553-002-01,NDC,facility,both,1,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBIDOPA-LEVODOPA 25 MG-100 MG TAB,50863,CDM,250,RC,J3490,HCPCS,69367-339-05,NDC,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2599,HCPCS,43598-914-25,NDC,facility,both,6,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYOSCYAMINE 0.5 MG/ML INJECTION,50863,CDM,250,RC,J1980,HCPCS,54288-111-01,NDC,facility,both,1,ML,,234,163.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68084-975-11,NDC,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 0.1 MG/ML IV SYRINGE (NEO/INFANT),50863,CDM,250,RC,J1100,HCPCS,99999-0405-74,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM GLUCONATE (FOR EMERGENCY) 100 MG/ML (10%) IV SOLN,50863,CDM,636,RC,J0612,HCPCS,0143-9180-01,NDC,facility,both,100,ML,JZ,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,43598-914-25,NDC,facility,both,4,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN V POTASSIUM 250 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,57237-040-01,NDC,facility,both,4,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESTRADIOL 2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42806-089-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,250,RC,J2405,HCPCS,63323-373-02,NDC,facility,both,8,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUORESCEIN 500 MG/5 ML (10 %) IV SOLN,50863,CDM,250,RC,J3490,HCPCS,17478-253-10,NDC,facility,both,2,ML,,733,513.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,79,EA,,10902,7631.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FIDAXOMICIN 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,52015-080-01,NDC,facility,both,2,EA,,1437,1005.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYCLOPHOSPHAMIDE 20 MG/ML IN NS,50863,CDM,250,RC,J9075,HCPCS,10019-956-16,NDC,facility,both,87,EA,JW,248,173.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,39,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENALAPRIL MALEATE  5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,43547-546-10,NDC,facility,both,2,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,636,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,3,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,636,RC,J2560,HCPCS,14789-127-07,NDC,facility,both,1,ML,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,78206-121-01,NDC,facility,both,4,EA,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,50863,CDM,250,RC,J1580,HCPCS,63323-010-03,NDC,facility,both,6,ML,,108,75.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZIPRASIDONE 20 MG CAP,50863,CDM,250,RC,J3490,HCPCS,0904-6269-45,NDC,facility,both,2,EA,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,50863,CDM,250,RC,J1100,HCPCS,63323-506-41,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUMAZENIL 0.1 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-424-05,NDC,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J3490,HCPCS,0338-0049-48,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,636,RC,J2598,HCPCS,43598-914-11,NDC,facility,both,6,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACUBITRIL-VALSARTAN 97-103 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0078-0696-67,NDC,facility,both,1,EA,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J7510,HCPCS,17856-0815-1,NDC,facility,both,4,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  100 MCG/ML INJ SOLN,50863,CDM,636,RC,J2354,HCPCS,63323-376-00,NDC,facility,both,2,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FOSPHENYTOIN 500 MG PE/10 ML INJ SOLN,50863,CDM,250,RC,Q2009,HCPCS,0641-6137-01,NDC,facility,both,40,ML,JZ,967,676.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
CLONIDINE 0.3 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0228-2129-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,19,ML,JW,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0781-3246-02,NDC,facility,both,11,ML,,151,105.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7362-61,NDC,facility,both,3,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FINASTERIDE 5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-314-11,NDC,facility,both,1,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TACROLIMUS 1 MG ORAL CAP,50863,CDM,250,RC,J7507,HCPCS,0904-7097-61,NDC,facility,both,3,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),50863,CDM,636,RC,J3490,HCPCS,0409-4888-03,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 600 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-457-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE PEDS SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J3490,HCPCS,25021-113-82,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,36000-283-25,NDC,facility,both,80,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-113-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,636,RC,J2405,HCPCS,23155-547-31,NDC,facility,both,4,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESTRADIOL 1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0555-0886-02,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 5 MG/ML IV SOLN,50863,CDM,636,RC,J1921,HCPCS,0409-2267-20,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0456,HCPCS,55150-174-10,NDC,facility,both,1,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-426-02,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPYRIDAMOLE-ASPIRIN SR 200 MG-25 MG MULTIPHASE 12 HR CAP,50863,CDM,250,RC,J3490,HCPCS,65162-596-06,NDC,facility,both,1,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.25 % (2.5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1160-01,NDC,facility,both,150,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LABETALOL 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-439-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM BICARB-CITRIC ACID 20 MEQ ORAL TBEF,50863,CDM,636,RC,J3490,HCPCS,51801-011-30,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,2,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-7410-61,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
QUETIAPINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6638-61,NDC,facility,both,8,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,55150-222-20,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,42023-186-01,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2003,HCPCS,63323-492-26,NDC,,,facility,both,600,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,J2001,HCPCS,63323-492-27,NDC,,,facility,both,30,ML,,236,165.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0245-0147-89,NDC,facility,both,1,EA,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,300,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,636,RC,J2560,HCPCS,72162-1329-8,NDC,facility,both,1,ML,,129,90.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,5,ML,,154,107.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM ZIRCONIUM CYCLOSILICATE  5 G ORAL PWPK (USE PANEL),50863,CDM,J3490,HCPCS,0310-1105-01,NDC,,,facility,both,3,EA,,418,292.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML INJECTION,50863,CDM,250,RC,J3411,HCPCS,72603-139-01,NDC,facility,both,6,ML,,166,116.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 20 MG ORAL TAB,50863,CDM,636,RC,J0500,HCPCS,0904-6988-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LINEZOLID NEO IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J2020,HCPCS,0009-5140-01,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE 21 MG/24 HR TD PT24,50863,CDM,250,RC,J3490,HCPCS,43598-448-71,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NS WITH POTASSIUM CHLORIDE 20 MEQ/L IV SOLP,50863,CDM,636,RC,J3480,HCPCS,0338-0691-04,NDC,facility,both,10,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SEVELAMER CARBONATE 800 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-720-11,NDC,facility,both,1,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL  5 MG ORAL TAB,50863,CDM,J3490,HCPCS,0904-6797-61,NDC,,,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-9791-01,NDC,facility,both,1,ML,JZ,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,63323-462-01,NDC,facility,both,2,ML,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOXETINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,16714-112-02,NDC,facility,both,4,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,4,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METFORMIN  500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-155-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 40 MG/ML IV SYRINGE (CDS MIXTURE),50863,CDM,250,RC,J0692,HCPCS,60505-0834-0,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,68180-113-16,NDC,facility,both,2,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRAZODONE  50 MG ORAL TAB,50863,CDM,250,RC,j3490,HCPCS,0904-6868-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  88 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-486-11,NDC,facility,both,3,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LISINOPRIL  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-656-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0378-4543-01,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE 25 MG/ML INJ SOLN,50863,CDM,250,RC,J3230,HCPCS,55150-319-01,NDC,facility,both,1,ML,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-089-11,NDC,facility,both,1,EA,PLAD,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
CEFTRIAXONE   2 GRAM INJ SOLR,50863,CDM,636,RC,J0696,HCPCS,44567-702-25,NDC,facility,both,8,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J2004,HCPCS,0409-3178-01,NDC,facility,both,30,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADVATE: FACTOR VIII CONCENTRATE (MERGE RECORD),50863,CDM,250,RC,J7192,HCPCS,0944-3052-02,NDC,facility,both,500,UN,,2093,1465.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
USTEKINUMAB 130 MG/26 ML IV SOLN,50863,CDM,636,RC,J3358,HCPCS,57894-054-27,NDC,facility,both,260,ML,,7360,5152,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  25 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-7448-61,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 650 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,77333-827-25,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 150 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,0591-3541-60,NDC,facility,both,3,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN-SULBACTAM  3 GRAM INJ SOLR,50863,CDM,636,RC,J0295,HCPCS,0049-0014-81,NDC,facility,both,2,EA,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,50863,CDM,250,RC,J2597,HCPCS,43598-053-11,NDC,facility,both,26,ML,,912,638.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,50863,CDM,636,RC,J1650,HCPCS,16714-016-01,NDC,facility,both,8,ML,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,250,RC,J7999,HCPCS,70092-1017-46,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,50863,CDM,J3301,HCPCS,16714-130-01,NDC,,,facility,both,4,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 25 MG TAB,50863,CDM,Q0177,HCPCS,0904-6617-61,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJ SOLN",50863,CDM,636,RC,J3490,HCPCS,0409-3178-01,NDC,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IRBESARTAN  75 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,43547-374-03,NDC,facility,both,2,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCERIN-WITCH HAZEL 12.5 %-50 % TOPICAL PADS,50863,CDM,250,RC,J3490,HCPCS,50289-3250-1,NDC,facility,both,40,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0904-6828-05,NDC,facility,both,2,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-AXXQ 100 MG IV SOLR,50863,CDM,636,RC,Q5121,HCPCS,55513-670-01,NDC,facility,both,125,EA,,17250,12075,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYUREA  500 MG ORAL CAP,50863,CDM,250,RC,J9999,HCPCS,68084-284-11,NDC,facility,both,8,EA,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSULFAN BLUE 1 % INJ SOLN,50863,CDM,636,RC,Q9968,HCPCS,67457-220-00,NDC,facility,both,10,ML,JW,292,204.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
FLUCONAZOLE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6500-06,NDC,facility,both,3,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,70004-600-09,NDC,facility,both,3,ML,,138,96.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOLAZONE  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-023-01,NDC,facility,both,2,EA,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ASPIRIN  325 MG ORAL TBEC,50863,CDM,636,RC,J3490,HCPCS,0536-1232-01,NDC,facility,both,2,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOLAZONE  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,51079-023-01,NDC,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYOSCYAMINE 0.125 MG SUBLINGUAL TAB,50863,CDM,636,RC,J3490,HCPCS,42192-339-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE MALEATE  5 MG ORAL TAB,50863,CDM,636,RC,Q0164,HCPCS,59746-113-06,NDC,facility,both,8,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM OXIDE 400 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,1000670028,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 25 MG TAB,50863,CDM,636,RC,J3490,HCPCS,51079-255-01,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFDINIR 300 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-699-11,NDC,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0990-7983-61,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GABAPENTIN 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-580-11,NDC,facility,both,4,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J3490,HCPCS,0338-0049-48,NDC,facility,both,4,ML,JZ,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,50863,CDM,250,RC,J2560,HCPCS,14789-127-07,NDC,facility,both,1,ML,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,12,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,636,RC,J3490,HCPCS,0409-1323-05,NDC,facility,both,200,ML,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) IV SYRG,50863,CDM,250,RC,J2003,HCPCS,0409-1323-05,NDC,facility,both,300,ML,,132,92.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SENNOSIDES 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0067-0696-60,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML INJECTION,50863,CDM,636,RC,J3411,HCPCS,0641-6228-01,NDC,facility,both,3,ML,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONABOTULINUMTOXINA 200 UNIT INJ SOLR,50863,CDM,636,RC,J0585,HCPCS,0023-3921-02,NDC,facility,both,200,EA,,3197,2237.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 17 GRAM (100 %) ORAL PWPK,50863,CDM,636,RC,J3490,HCPCS,0904-6931-86,NDC,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENYTOIN 50 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,60687-156-95,NDC,facility,both,4,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG IV SOLR,50863,CDM,250,RC,J0456,HCPCS,70436-019-82,NDC,facility,both,1,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML (ANESTHESIA INTRAOP ONLY),50863,CDM,250,RC,J3010,HCPCS,0641-6027-01,NDC,facility,both,3,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACIDOPHILUS-PECTIN W CITRUS 25 MILLION-100 CELL MG TAB,50863,CDM,250,RC,J3490,HCPCS,8068102600,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,42806-341-01,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE 5 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-4827-05,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,J2250,HCPCS,0409-2308-22,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLEDRONIC ACID IN MANNITOL & WATER 5 MG/100 ML IV SOLN,50863,CDM,636,RC,J3489,HCPCS,25021-830-82,NDC,facility,both,4,ML,,432,302.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACETYLCYSTEINE 20 % (200 MG/ML) IV SOLN,50863,CDM,250,RC,J0132,HCPCS,55150-259-30,NDC,facility,both,122,ML,,551,385.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,250,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,511,ML,,733,513.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TAMSULOSIN 0.4 MG ORAL CP24,50863,CDM,J3490,HCPCS,57237-014-01,NDC,,,facility,both,2,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML IV SOLN,50863,CDM,636,RC,J3490,HCPCS,0143-9507-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MENINGOCOCCAL B VACC,4-CMP(PF) 50-50-50-25 MCG/0.5 ML IM SYRG",50863,CDM,90620,HCPCS,58160-976-20,NDC,,,facility,both,1,ML,,839,587.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML IV SOLN,50863,CDM,J3490,HCPCS,25021-674-20,NDC,,,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,636,RC,J0665,HCPCS,0409-1162-02,NDC,facility,both,300,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BACITRACIN 500 UNIT/G TOP OINT (MERGE),50863,CDM,250,RC,J3490,HCPCS,0536-1263-28,NDC,facility,both,1,GM,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,J2270,HCPCS,0409-1890-13,NDC,,,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYBUTYNIN CHLORIDE  5 MG ORAL TO24,50863,CDM,636,RC,J3490,HCPCS,68084-480-11,NDC,facility,both,4,EA,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIPERACILLIN-TAZOBACTAM  4.5 GRAM IV SOLR,50863,CDM,250,RC,J2543,HCPCS,65219-259-05,NDC,facility,both,4,EA,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,60,ML,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE NA (PRESERV FREE) 25 MG/ML INJ SOLN,50863,CDM,250,RC,J9260,HCPCS,0703-3678-01,NDC,facility,both,12,ML,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PIOGLITAZONE 15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,65862-512-30,NDC,facility,both,3,EA,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN D5W 1 GRAM/200 ML IV PGBK,50863,CDM,250,RC,J3373,HCPCS,0338-3552-48,NDC,facility,both,200,ML,,270,189,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"RABIES VACCINE, PURIFIED CHICKEN EMBRYO CELL (PF) 2.5 UNIT IM KIT",50863,CDM,250,RC,90675,HCPCS,50632-010-01,NDC,facility,both,1,EA,,1466,1026.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG ORAL TBDL,50863,CDM,636,RC,J3490,HCPCS,13668-088-30,NDC,facility,both,2,EA,,203,142.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE MONONITRATE 100 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,7733393425,NDC,facility,both,5,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2305-04,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  15 MG ORAL TBSR,50863,CDM,250,RC,J3490,HCPCS,0406-8315-01,NDC,facility,both,3,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN (NEW TX NON-NEURO INDICATION)",50863,CDM,636,RC,J1561,HCPCS,13533-800-71,NDC,facility,both,20,ML,"JZ,JA,JG",2829,1980.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier JA: Administered intravenously | Modifier JG: Drug or biological acquired with 340b drug pricing program discount
ROSUVASTATIN 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6780-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEFLUNOMIDE  10 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,23155-043-03,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-ABDA 100 MG IV SOLR,50863,CDM,250,RC,Q5104,HCPCS,78206-162-99,NDC,facility,both,60,EA,,12477,8733.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZTREONAM 2 GRAM INJ SOLR,50863,CDM,636,RC,J0457,HCPCS,63323-402-01,NDC,facility,both,10,EA,JW,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,26,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 20 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,59651-488-01,NDC,facility,both,140,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,63323-165-01,NDC,facility,both,20,ML,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),50863,CDM,250,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RACEPINEPHRINE 2.25 % INHL NEBU,50863,CDM,636,RC,J3490,HCPCS,0487-5901-99,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOLTERODINE 2 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,33342-098-09,NDC,facility,both,2,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J3490,HCPCS,0338-0049-31,NDC,facility,both,1,ML,JZ,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GABAPENTIN 250 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,636,RC,J3490,HCPCS,17856-0698-01,NDC,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J3490,HCPCS,0338-0049-31,NDC,facility,both,3,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV (BOLUS),50863,CDM,250,RC,J7120,HCPCS,0338-6307-03,NDC,facility,both,1,ML,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE (PF-DURAMORPH/ASTRAMORPH) 0.5 MG/ML INJ SOLN,50863,CDM,250,RC,J2274,HCPCS,0409-3814-12,NDC,facility,both,1,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,50863,CDM,636,RC,J3490,HCPCS,0409-4279-02,NDC,facility,both,1200,ML,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATRACURIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,0409-1109-11,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN 10 GRAM IV SOLR,50863,CDM,250,RC,J3373,HCPCS,70436-023-82,NDC,facility,both,25,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,250,RC,J2250,HCPCS,0409-2308-22,NDC,facility,both,25,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"LIPASE-PROTEASE-AMYLASE (PORK) 36,000-114,000- 180,000 UNIT ORAL CPDR",50863,CDM,636,RC,J3490,HCPCS,0032-3016-13,NDC,facility,both,3,EA,,221,154.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXAZOSIN 4 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-224-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TERBUTALINE 1 MG/ML SUBQ SOLN,50863,CDM,636,RC,J3105,HCPCS,0143-9746-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLONIDINE 0.1 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,29300-135-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,50863,CDM,636,RC,J2405,HCPCS,0641-6078-01,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,50863,CDM,250,RC,J2270,HCPCS,76045-004-10,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB 100 MG IV SOLR,50863,CDM,636,RC,J1745,HCPCS,57894-030-01,NDC,facility,both,65,EA,,20951,14665.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACUBITRIL-VALSARTAN 24-26 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0078-0659-20,NDC,facility,both,1,EA,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL TARTRATE 50 MG TAB,50863,CDM,250,RC,J3490,HCPCS,62584-266-11,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,72603-251-01,NDC,facility,both,19,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 8-2 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,50268-145-11,NDC,facility,both,2,EA,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-229-02,NDC,facility,both,1,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,16714-293-01,NDC,facility,both,4,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BISACODYL  5 MG ORAL TBEC,50863,CDM,250,RC,J3490,HCPCS,0904-6407-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,636,RC,J7040,HCPCS,0338-0049-48,NDC,facility,both,1,ML,JZ,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ASPIRIN 81 MG ORAL CHEW,50863,CDM,250,RC,J3490,HCPCS,77333-049-25,NDC,facility,both,3,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BISOPROLOL FUMARATE  5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,29300-126-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE HCL IN 0.9% NS 100 MCG/10 ML (10 MCG/ML) NON-CARDIAC LOW-DOSE (PEDS/NEO),50863,CDM,250,RC,J0171,HCPCS,69374-544-10,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,50863,CDM,636,RC,J3420,HCPCS,0517-0031-01,NDC,facility,both,1,ML,JZ,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
EPINEPHRINE HCL IN D5W 4 MG/250 ML (16 MCG/ML) IV SOLN,50863,CDM,250,RC,J0171,HCPCS,72196-7018-1,NDC,facility,both,1,ML,,211,147.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPIVACAINE 0.5 % (5 MG/ML) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,63323-467-01,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50MG/5ML (10MG/ML) ORAL SOLUTION (REPACK),50863,CDM,250,RC,J3490,HCPCS,71286-3022-1,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCIUM CARBONATE 1250 MG/5 ML SUSPENSION (500 MG/5 ML ELEMENTAL),50863,CDM,250,RC,J3490,HCPCS,0121-4766-05,NDC,facility,both,2,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE 15 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,31722-828-30,NDC,facility,both,1,EA,,158,110.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CETIRIZINE 5 MG/5 ML ORAL SOLN,50863,CDM,J3490,HCPCS,68094-004-59,NDC,,,facility,both,2,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,50863,CDM,250,RC,J9060,HCPCS,0703-5747-11,NDC,facility,both,3,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2598,HCPCS,55150-370-01,NDC,facility,both,40,ML,,329,230.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT 25 MCG/0.42 ML INJ SYRG,50863,CDM,636,RC,J0881,HCPCS,55513-057-01,NDC,facility,both,25,ML,EC,836,585.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier EC: Erythropoetic stimulating agent (esa) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy
GLYCERIN (CHILD) RECTAL SUPPOSITORY,50863,CDM,250,RC,J3490,HCPCS,58980-409-12,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR SODIUM 50 MG/ML IV SOLN,50863,CDM,250,RC,J0133,HCPCS,65219-622-02,NDC,facility,both,182,ML,,164,114.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE IN D5W (PF) 4 MG/ML (0.4 %) IV SOLP,50863,CDM,250,RC,J3490,HCPCS,0338-0409-03,NDC,facility,both,2000,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LINEZOLID 600 MG/300 ML IV SOLP,50863,CDM,250,RC,J2020,HCPCS,66794-219-63,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,50863,CDM,250,RC,J9045,HCPCS,0703-4239-01,NDC,facility,both,2,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FEBUXOSTAT 40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,62332-190-30,NDC,facility,both,2,EA,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-65,NDC,facility,both,81,ML,JW,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
BUSPIRONE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-986-01,NDC,facility,both,2,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPROPION HCL 150 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,43598-655-30,NDC,facility,both,2,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOPERAMIDE 2 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,51079-690-01,NDC,facility,both,6,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV (BOLUS),50863,CDM,636,RC,J7120,HCPCS,0264-7750-07,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 10 MG/ML (1 %) INJECTION,50863,CDM,J2003,HCPCS,63323-485-03,NDC,,,facility,both,40,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
STERILE TALC 3 G INPL AERP,50863,CDM,250,RC,J3490,HCPCS,62327-333-03,NDC,facility,both,1,EA,,204,142.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 10 MG TAB,50863,CDM,250,RC,Q0177,HCPCS,60687-664-11,NDC,facility,both,3,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACOSAMIDE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0131-2477-35,NDC,facility,both,3,EA,,213,149.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,50863,CDM,250,RC,J7040,HCPCS,0990-7983-61,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOSARTAN  50 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,50268-505-11,NDC,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,50863,CDM,636,RC,J1815,HCPCS,49502-393-80,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-822-11,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBANDRONATE 3 MG/3 ML IV SYKT,50863,CDM,636,RC,J1740,HCPCS,60505-6097-0,NDC,facility,both,3,ML,JZ,1162,813.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,636,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,6,EA,JW,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DOXORUBICIN 2 MG/ML IV SOLN,50863,CDM,250,RC,J9000,HCPCS,25021-207-51,NDC,facility,both,3,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYCODONE  15 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0406-8515-23,NDC,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,7,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLN,50863,CDM,250,RC,J3490,HCPCS,55150-165-05,NDC,facility,both,200,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACYCLOVIR 200 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,70954-188-10,NDC,facility,both,1,ML,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),50863,CDM,250,RC,J3490,HCPCS,51754-4250-1,NDC,facility,both,3,ML,,189,132.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN IN STERILE WATER 2 GRAM/20 ML IV SYRG,50863,CDM,250,RC,J0690,HCPCS,70092-1604-47,NDC,facility,both,4,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",50863,CDM,250,RC,J3490,HCPCS,63323-185-07,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,50863,CDM,636,RC,J1885,HCPCS,62332-600-01,NDC,facility,both,6,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML (PEDS CALCLUATOR 0.5),50863,CDM,250,RC,J1815,HCPCS,0024-5924-10,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EXENATIDE 10 MCG/0.04 ML SUBQ PNIJ,50863,CDM,250,RC,J3490,HCPCS,66780-212-01,NDC,facility,both,1,ML,,1179,825.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9% IV (PEDS) BOLUS,50863,CDM,250,RC,J7040,HCPCS,0264-7800-09,NDC,facility,both,2,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE-NALOXONE 8-2 MG SL SUBL,50863,CDM,250,RC,J3490,HCPCS,0904-7010-06,NDC,facility,both,1,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROCURONIUM 10 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,10,ML,,294,205.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CITALOPRAM 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6085-61,NDC,facility,both,2,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICARDIPINE IN NACL (ISO-OS) 20 MG/200 ML IV PGBK,50863,CDM,250,RC,J3490,HCPCS,0143-9634-01,NDC,facility,both,1,ML,,414,289.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIROLIMUS 1 MG/ML ORAL SOLN,50863,CDM,636,RC,J7520,HCPCS,60505-6197-2,NDC,facility,both,1,ML,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN 250 MG/5 ML ORAL SUSR,50863,CDM,636,RC,J3490,HCPCS,65862-707-80,NDC,facility,both,33,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOCARBAMOL 100 MG/ML INJ SOLN,50863,CDM,636,RC,J2800,HCPCS,70069-101-01,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 25 % IV SOLP",50863,CDM,250,RC,P9047,HCPCS,0944-0493-04,NDC,facility,both,1,ML,,253,177.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOPROLOL SUCCINATE SR 25 MG 24 HR TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6322-61,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE 1 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,46287-035-15,NDC,facility,both,1,ML,,202,141.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),50863,CDM,250,RC,J3490,HCPCS,0409-4888-20,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPHENIDATE 27 MG ORAL TO24,50863,CDM,250,RC,J3490,HCPCS,0406-0127-01,NDC,facility,both,2,EA,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,50863,CDM,J3360,HCPCS,0409-1273-03,NDC,,,facility,both,1,ML,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NIMODIPINE 30 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,69452-209-07,NDC,facility,both,2,EA,,189,132.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  10 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-0904-05,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INFLIXIMAB-ABDA 100 MG IV SOLR,50863,CDM,636,RC,Q5104,HCPCS,78206-162-99,NDC,facility,both,3,EA,JW,272,190.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
AMOXICILLIN-POT CLAVULANATE 600 MG-42.9 MG/5 ML ORAL SUSP,50863,CDM,250,RC,J3490,HCPCS,16714-294-01,NDC,facility,both,3,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FERUMOXYTOL 510 MG/17 ML (30 MG/ML) IV SOLN,50863,CDM,Q0138,HCPCS,59338-775-01,NDC,,,facility,both,1020,ML,,6589,4612.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MYCOPHENOLATE SODIUM 360 MG ORAL TBEC,50863,CDM,250,RC,J7518,HCPCS,0904-6786-61,NDC,facility,both,2,EA,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
WHITE PETROLATUM-MINERAL OIL TOPICAL CREAM (MERGE),50863,CDM,250,RC,J3490,HCPCS,7214003868,NDC,facility,both,2,GM,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,72603-251-01,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IBUPROFEN 100 MG/5 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,68094-494-59,NDC,facility,both,6,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEMAZEPAM 15 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,0406-9961-01,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMITRIPTYLINE  75 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-040-11,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2308-22,NDC,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,50863,CDM,J1885,HCPCS,72266-119-01,NDC,,,facility,both,3,ML,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRANEXAMIC ACID (FOR TOPICAL USE),50863,CDM,636,RC,J3490,HCPCS,55150-188-10,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE HCL IN D5W 4 MG/250 ML (16 MCG/ML) IV SOLN,50863,CDM,250,RC,J0171,HCPCS,72196-7018-1,NDC,facility,both,2,ML,,421,294.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOMIDATE 2 MG/ML IV SOLN,50863,CDM,250,RC,J3490,HCPCS,72266-146-01,NDC,facility,both,3,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ISOSORBIDE MONONITRATE  30 MG ORAL TB24,50863,CDM,636,RC,J3490,HCPCS,0904-6449-61,NDC,facility,both,2,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE (PF-DURAMORPH/ASTRAMORPH) 0.5 MG/ML INJ SOLN,50863,CDM,250,RC,J2274,HCPCS,0409-3814-11,NDC,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  20 MEQ ORAL PACK,50863,CDM,636,RC,J3490,HCPCS,72888-024-06,NDC,facility,both,3,EA,,158,110.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN  100 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,5026885211,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  10 MG/5 ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,0121-0904-05,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 16 MG ORAL TAB,50863,CDM,636,RC,J7509,HCPCS,59762-0050-1,NDC,facility,both,4,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),50863,CDM,636,RC,J3490,HCPCS,76329-3352-1,NDC,facility,both,2,ML,,232,162.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALBUMIN, HUMAN 5 % IV SOLP MERGE",50863,CDM,250,RC,P9045,HCPCS,44206-310-25,NDC,facility,both,1,ML,,246,172.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN,50863,CDM,636,RC,J3490,HCPCS,42023-186-20,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PSEUDOEPHEDRINE 30 MG TAB,50863,CDM,636,RC,J3490,HCPCS,0904-5053-59,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COCAINE  4 % TOP SOLN (MERGE),50863,CDM,C9046,HCPCS,64950-362-04,NDC,,,facility,both,160,ML,,868,607.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TISLELIZUMAB-JSGR 10 MG/ML IV SOLN,50863,CDM,J9329,HCPCS,72579-121-01,NDC,,,facility,both,50,ML,,3345,2341.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2308-22,NDC,facility,both,5,ML,JZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
LINACLOTIDE  72 MCG ORAL CAP,50863,CDM,250,RC,0456-1203-30,NDC,,,facility,both,1,EA,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,636,RC,J1100,HCPCS,63323-165-01,NDC,facility,both,6,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN  750 MG IV SOLR,50863,CDM,250,RC,J3370,HCPCS,63323-203-01,NDC,facility,both,2,EA,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN PUMP LISPRO (PATIENT OWN PUMP PHS SUPPLIED),50863,CDM,250,RC,J1815,HCPCS,0002-7510-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 120 MG/0.8 ML SUBQ SYRG,50863,CDM,250,RC,J1650,HCPCS,0075-2912-00,NDC,facility,both,12,ML,,175,122.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ATOMOXETINE  40 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,55111-521-30,NDC,facility,both,2,EA,,152,106.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 20 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,59762-0075-1,NDC,facility,both,3,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLYETHYLENE GLYCOL 3350 17 GRAM (100 %) ORAL PWPK,50863,CDM,250,RC,J3490,HCPCS,1152372688,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SACUBITRIL-VALSARTAN 97-103 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0078-0696-67,NDC,facility,both,1,EA,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCODONE-ACETAMINOPHEN 5 MG-325 MG TAB,50863,CDM,250,RC,J3490,HCPCS,0406-0123-23,NDC,facility,both,3,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,50863,CDM,636,RC,J1817,HCPCS,0002-8215-01,NDC,facility,both,1,ML,GZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier GZ: Item or service expected to be denied as not reasonable and necessary
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLN,50863,CDM,636,RC,J3262,HCPCS,50242-136-01,NDC,facility,both,400,ML,,7331,5131.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN FOR PERI-OPERATIVE",50863,CDM,636,RC,J0131,HCPCS,0264-4100-90,NDC,facility,both,22,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALTREXONE 50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0406-1170-03,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GUAIFENESIN 100 MG/5 ML ORAL LIQD,50863,CDM,250,RC,J3490,HCPCS,0121-1488-10,NDC,facility,both,6,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOMYCIN-BACITRACN ZN-POLYMYXIN 3.5 MG-400 U*,50863,CDM,636,RC,J3490,HCPCS,45802-143-00,NDC,facility,both,4,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,50268-339-11,NDC,facility,both,1,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMLODIPINE  2.5 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42806-055-09,NDC,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,63323-269-69,NDC,facility,both,100,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN SODIUM-STERILE WATER 1 GRAM/10 ML IV SYRG,50863,CDM,636,RC,J7999,HCPCS,70092-1017-46,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,50863,CDM,250,RC,J9060,HCPCS,63323-103-64,NDC,facility,both,20,ML,,417,291.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUCONAZOLE 200 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0904-6501-61,NDC,facility,both,2,EA,,160,112,,,,,,,,,,,,,Gross Charge Type: Pharmacy
L. ACIDOPHILUS-B. LACTIS-FOS 5 BILLION CELL ORAL PWPK,50863,CDM,636,RC,J3490,HCPCS,52061-00403,NDC,facility,both,2,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM  500 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,51079-821-01,NDC,facility,both,2,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXRAZOXANE 500 MG IV SOLR,50863,CDM,250,RC,J1190,HCPCS,55150-435-01,NDC,facility,both,2,EA,,987,690.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0630,HCPCS,24201-400-02,NDC,facility,both,1,ML,,1259,881.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE  5 MG ORAL TBDL,50863,CDM,636,RC,J3490,HCPCS,60505-3275-3,NDC,facility,both,2,EA,,140,98,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SOTALOL 240 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-1063-01,NDC,facility,both,1,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE  50 MCG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0904-6950-61,NDC,facility,both,4,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VALSARTAN  40 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,65862-570-30,NDC,facility,both,5,EA,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV (BOLUS),50863,CDM,250,RC,J7120,HCPCS,0264-7750-07,NDC,facility,both,1,ML,PLAD,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
GABAPENTIN 300 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,16714-662-01,NDC,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIOTHYRONINE  5 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0093-2179-01,NDC,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISONE 10 MG ORAL TAB,50863,CDM,250,RC,J7512,HCPCS,0904-6923-61,NDC,facility,both,10,EA,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
APIXABAN 5 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,0003-0894-31,NDC,facility,both,1,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LINEZOLID 600 MG/300 ML IV SOLP,50863,CDM,250,RC,J2020,HCPCS,57664-683-31,NDC,facility,both,3,ML,,331,231.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PANTOPRAZOLE 40 MG IV SOLR,50863,CDM,250,RC,J3490,HCPCS,55150-202-00,NDC,facility,both,1,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCARPIDASE 1000 UNIT IV SOLR,50863,CDM,250,RC,C9293,HCPCS,50633-210-11,NDC,facility,both,200,EA,,150956,105669.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,50863,CDM,250,RC,J0630,HCPCS,24201-400-02,NDC,facility,both,1,ML,,1513,1059.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,50863,CDM,636,RC,J1596,HCPCS,10019-016-39,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE  20 MEQ ORAL PACK,50863,CDM,250,RC,J3490,HCPCS,69543-451-01,NDC,facility,both,1,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 4% TOP PATCH,50863,CDM,636,RC,J3490,HCPCS,0536-1202-15,NDC,facility,both,2,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVETIRACETAM 100 MG/ML ORAL SOLN,50863,CDM,250,RC,J3490,HCPCS,31722-574-47,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ALBUTEROL SULFATE 90 MCG/ACTUATION INHL HFAA,50863,CDM,636,RC,J3490,HCPCS,59310-579-22,NDC,facility,both,1,GM,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMIODARONE 200 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,60687-437-11,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN NPH HUMAN RECOMB 100 UNIT/ML SUBQ SUSP,50863,CDM,636,RC,J1815,HCPCS,0169-1834-11,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 50 MG/ML IM,50863,CDM,636,RC,J3410,HCPCS,0517-5601-01,NDC,facility,both,2,ML,JZ,190,133,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GUAIFENESIN 600 MG ORAL TP12,50863,CDM,636,RC,J3490,HCPCS,0904-6718-39,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 200 MG/5 ML ORAL SUSR,50863,CDM,250,RC,J3490,HCPCS,42806-151-34,NDC,facility,both,9,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZOCAINE-MENTHOL 15-2.6 MG MM LOZG,50863,CDM,250,RC,J3490,HCPCS,63824-732-16,NDC,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,40,EA,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,50863,CDM,250,RC,J7510,HCPCS,17856-0815-1,NDC,facility,both,7,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LOPERAMIDE 2 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,60687-229-11,NDC,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OSELTAMIVIR PHOSPHATE 30 MG ORAL CAP,50863,CDM,636,RC,J3490,HCPCS,47781-468-13,NDC,facility,both,1,EA,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CIPROFLOXACIN IN D5W 400 MG/200 ML IV PGBK,50863,CDM,636,RC,J0744,HCPCS,36000-009-24,NDC,facility,both,2,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1940,HCPCS,23155-473-44,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL  75 MCG/HR TD PT72,50863,CDM,250,RC,J3490,HCPCS,0406-9175-76,NDC,facility,both,1,EA,,197,137.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,67457-423-00,NDC,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,50863,CDM,250,RC,J1100,HCPCS,0641-6145-01,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,636,RC,J2704,HCPCS,0069-0209-01,NDC,facility,both,19,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 100ML INFUSION IV EMUL,50863,CDM,J2704,HCPCS,63323-269-69,NDC,,,facility,both,107,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,50863,CDM,636,RC,J2250,HCPCS,0409-2305-16,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZONATATE 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,42806-714-01,NDC,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROPOFOL 10 MG/ML 20ML BOLUS IV EMUL,50863,CDM,250,RC,J2704,HCPCS,63323-269-22,NDC,facility,both,6,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ (MERGE),50863,CDM,250,RC,J2250,HCPCS,0409-0001-01,NDC,facility,both,10,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMOXICILLIN-POT CLAVULANATE 400 MG-57 MG/5 ML ORAL SUSP,50863,CDM,J3490,HCPCS,0093-2279-73,NDC,,,facility,both,7,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NADOLOL  80 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,0378-1132-01,NDC,facility,both,1,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),50863,CDM,250,RC,J0696,HCPCS,0143-9857-25,NDC,facility,both,2,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ADENOSINE 3000 MCG/ML INJECTION,50863,CDM,250,RC,J0153,HCPCS,63323-651-00,NDC,facility,both,18,ML,,193,135.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 50 MG/ML IM,50863,CDM,636,RC,J3410,HCPCS,0517-5601-25,NDC,facility,both,2,ML,,190,133,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPHETAMINE-DEXTROAMPHETAMINE 10 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,16714-950-01,NDC,facility,both,2,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,50863,CDM,250,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,6,EA,JW,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
CAFFEINE CITRATE PEDS/NEO IV SYR (CDS MIX) LD,50863,CDM,250,RC,J0706,HCPCS,72485-104-01,NDC,facility,both,22,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZITHROMYCIN 500 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,60687-753-11,NDC,facility,both,1,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COENZYME Q10 100 MG ORAL CAP,50863,CDM,250,RC,J3490,HCPCS,5789687503,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % MBP,50863,CDM,636,RC,J3490,HCPCS,0338-9159-30,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGIC MOUTHWASH REPACK (BMX 1:1:1),50863,CDM,636,RC,J3490,HCPCS,99999-500-91,NDC,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CINACALCET 30 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,64380-883-04,NDC,facility,both,1,EA,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SPIRONOLACTONE  50 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,63739-545-10,NDC,facility,both,2,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIOTHYRONINE  5 MCG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,62756-589-88,NDC,facility,both,1,EA,PLAD,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
VASOPRESSIN 20 UNIT/ML IV SOLN,50863,CDM,250,RC,J2599,HCPCS,63323-930-01,NDC,facility,both,10,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BISMUTH SUBSALICYLATE 262 MG ORAL CHEW,50863,CDM,636,RC,J3490,HCPCS,0904-7205-46,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 20 MG/ML INJ SOLN,50863,CDM,636,RC,J0360,HCPCS,0641-6231-01,NDC,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NICOTINE 21 MG/24 HR TD PT24,50863,CDM,636,RC,J3490,HCPCS,0536-5896-88,NDC,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,50863,CDM,250,RC,J1938,HCPCS,63323-280-05,NDC,facility,both,100,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SIMVASTATIN 40 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-573-10,NDC,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSP,50863,CDM,636,RC,J3490,HCPCS,0574-0521-76,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PRAVASTATIN 20 MG ORAL TAB,50863,CDM,636,RC,J3490,HCPCS,63739-649-10,NDC,facility,both,4,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"CALCIUM GLUC IN NACL, ISO-OSM 1 G/100 ML IV SOLN",50863,CDM,250,RC,J0612,HCPCS,44567-622-01,NDC,facility,both,100,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPLERENONE  25 MG ORAL TAB,50863,CDM,250,RC,J3490,HCPCS,42291-454-30,NDC,facility,both,2,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML IM SOLN,50863,CDM,636,RC,90375,HCPCS,13533-318-05,NDC,facility,both,9,ML,JW,3812,2668.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
HC DEBRIDE SUBQ TISSUE FIRST 20 SQ CM OR LESS,51000001,CDM,361,RC,11042,HCPCS,,,facility,both,,,,789,552.3,,,,,,,,,,,,,Gross Charge Type: Central
HC APPLY TOTAL CONTACT LEG CAST,51000002,CDM,361,RC,29445,HCPCS,,,facility,both,,,,689,482.3,,,,,,,,,,,,,Gross Charge Type: Central
BLOOD COLLECT PICC,51000004,CDM,361,RC,36592,HCPCS,,,facility,both,,,,294,205.8,,,,,,,,,,,,,Gross Charge Type: Central
HC TELEHEALTH FACILITY FEE,51000007,CDM,780,RC,Q3014,HCPCS,,,facility,both,,,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Central
HC NASOPHARYNGOSCOPY,51000013,CDM,361,RC,92511,HCPCS,,,facility,both,,,,493,345.1,,,,,,,,,,,,,Gross Charge Type: Central
HC NEG PRESS WOUND NON-DME LESS THAN OR EQUAL TO 50 SQ CM,51000024,CDM,361,RC,97607,HCPCS,,,facility,both,,,,416,291.2,,,,,,,,,,,,,Gross Charge Type: Central
HC NEG PRESS WOUND NON-DME GREATER THAN 50 SQ CM,51000025,CDM,361,RC,97608,HCPCS,,,facility,both,,,,330,231,,,,,,,,,,,,,Gross Charge Type: Central
HC APPLICATION MULTI-LAYER COMPRESSION SYSTEM UPPER ARM/FOREARM/HAND/FINGERS,51000027,CDM,361,RC,29584,HCPCS,,,facility,both,,,,672,470.4,,,,,,,,,,,,,Gross Charge Type: Central
HC IV INFUSION HYDRAT 31-60 MIN,51012,CDM,260,RC,J0248,HCPCS,61958-2901-2,NDC,facility,both,8,EA,XU,1196,837.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
HC IV INFUSION HYDRAT 31-60 MIN,51014,CDM,260,RC,J0248,HCPCS,61958-2901-2,NDC,facility,both,1,EA,,434,303.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
REMDESIVIR 100 MG IV SOLR,51014,CDM,260,RC,J0248,HCPCS,61958-2901-1,NDC,facility,both,1,EA,,1196,837.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC IV INFUSION HYDRAT 31-60 MIN,51014,CDM,260,RC,J0248,HCPCS,61958-2901-2,NDC,facility,both,1,EA,,604,422.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC IV INFUSION HYDRAT 31-60 MIN,51014,CDM,260,RC,J0248,HCPCS,61958-2901-2,NDC,facility,both,1,EA,,1196,837.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC IV INFUSION HYDRAT 31-60 MIN,51014,CDM,260,RC,J0248,HCPCS,61958-2901-2,NDC,facility,both,1,EA,,254,177.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC IV INFUSION HYDRAT 31-60 MIN,51014,CDM,260,RC,J0248,HCPCS,61958-2901-2,NDC,facility,both,1,EA,,260,182,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC IV INFUSION HYDRAT 31-60 MIN,51014,CDM,450,RC,J0248,HCPCS,61958-2901-2,NDC,facility,both,1,EA,XU,2392,1674.4,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
HC IV INFUSION HYDRAT 31-60 MIN,51014,CDM,260,RC,J0248,HCPCS,61958-2901-2,NDC,facility,both,1,EA,,598,418.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC IV INFUSION HYDRAT 31-60 MIN,51014,CDM,260,RC,J0248,HCPCS,61958-2901-2,NDC,facility,both,1,EA,,348,243.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC IV INFUSION HYDRAT 31-60 MIN,51014,CDM,260,RC,J0248,HCPCS,61958-2901-2,NDC,facility,both,1,EA,,613,429.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC IV INFUSION HYDRAT 31-60 MIN,51014,CDM,260,RC,J0248,HCPCS,61958-2901-2,NDC,facility,both,1,EA,,515,360.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC IV INFUSION HYDRAT 31-60 MIN,51014,CDM,450,RC,J0248,HCPCS,61958-2901-2,NDC,facility,both,1,EA,,2392,1674.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC IV INFUSION HYDRAT 31-60 MIN,51014,CDM,260,RC,J0248,HCPCS,61958-2901-2,NDC,facility,both,1,EA,,396,277.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC IV INFUSION HYDRAT 31-60 MIN,51014,CDM,260,RC,J0248,HCPCS,61958-2901-2,NDC,facility,both,1,EA,,156,109.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC IV INFUSION HYDRAT 31-60 MIN,51014,CDM,260,RC,J0248,HCPCS,61958-2901-2,NDC,facility,both,1,EA,XU,2392,1674.4,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
HC IV INFUSION HYDRAT 31-60 MIN,51014,CDM,260,RC,J0248,HCPCS,61958-2901-2,NDC,facility,both,1,EA,,485,339.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC IV INFUSION HYDRAT 31-60 MIN,51014,CDM,260,RC,J0248,HCPCS,61958-2901-2,NDC,facility,both,1,EA,,258,180.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC IV INFUSION HYDRAT 31-60 MIN,51014,CDM,260,RC,J0248,HCPCS,61958-2901-2,NDC,facility,both,1,EA,,1208,845.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC IV INFUSION HYDRAT 31-60 MIN,51014,CDM,260,RC,J0248,HCPCS,61958-2901-2,NDC,facility,both,1,EA,,838,586.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC IV INFUSION HYDRAT 31-60 MIN,51014,CDM,450,RC,J0248,HCPCS,61958-2901-2,NDC,facility,both,1,EA,XU,1196,837.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
HC IV INFUSION HYDRAT 31-60 MIN,51014,CDM,450,RC,J0248,HCPCS,61958-2901-2,NDC,facility,both,1,EA,,1196,837.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC IV INFUSION HYDRAT 31-60 MIN,51014,CDM,260,RC,J0248,HCPCS,61958-2901-2,NDC,facility,both,1,EA,,503,352.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC IV INFUSION HYDRAT 31-60 MIN,51014,CDM,260,RC,J0248,HCPCS,61958-2901-2,NDC,facility,both,1,EA,,299,209.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC IV INFUSION HYDRAT 31-60 MIN,51014,CDM,260,RC,J0248,HCPCS,61958-2901-2,NDC,facility,both,1,EA,,2392,1674.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC IV INFUSION HYDRAT 31-60 MIN,51014,CDM,260,RC,J0248,HCPCS,61958-2901-2,NDC,facility,both,1,EA,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC IV INFUSION HYDRAT 31-60 MIN,51014,CDM,260,RC,J0248,HCPCS,61958-2901-2,NDC,facility,both,1,EA,,390,273,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC IV INFUSION HYDRAT 31-60 MIN,51014,CDM,260,RC,J0248,HCPCS,61958-2901-2,NDC,facility,both,1,EA,,198,138.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC IV INFUSION HYDRAT 31-60 MIN,51014,CDM,260,RC,J0248,HCPCS,61958-2901-2,NDC,facility,both,1,EA,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC IV INFUSION HYDRAT 31-60 MIN,51014,CDM,260,RC,J0248,HCPCS,61958-2901-2,NDC,facility,both,1,EA,XU,1196,837.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
HC IV INFUSION HYDRAT 31-60 MIN,51016,CDM,260,RC,J0248,HCPCS,61958-2901-2,NDC,facility,both,1,EA,,2392,1674.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC IV INFUSION HYDRAT 31-60 MIN,51018,CDM,260,RC,J0248,HCPCS,61958-2901-2,NDC,facility,both,1,EA,,1196,837.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 30 MG/0.3 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,16714-006-01,NDC,facility,both,1,ML,XS,39,27.3,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
TERBUTALINE 1 MG/ML SUBQ SOLN,51022,CDM,260,RC,J3105,HCPCS,0143-9746-01,NDC,facility,both,1,ML,XS,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
GENTAMICIN 40 MG/ML INJ SOLN,51022,CDM,450,RC,J1580,HCPCS,63323-010-01,NDC,facility,both,1,ML,XS,93,65.1,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,51022,CDM,260,RC,J1815,HCPCS,0088-2220-33,NDC,facility,both,1,ML,,327,228.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.3 MG/0.3 ML IM PNIJ,51022,CDM,450,RC,J0169,HCPCS,49502-102-01,NDC,facility,both,1,EA,XS,675,472.5,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
"WATER FOR INJECTION, STERILE INJECTION",51022,CDM,260,RC,J3490,HCPCS,63323-185-10,NDC,facility,both,1,ML,XU,34,23.8,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
PROMETHAZINE 25 MG/ML INJ SOLN,51022,CDM,450,RC,J2550,HCPCS,0641-6084-01,NDC,facility,both,1,ML,XS,23,16.1,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,0781-3246-02,NDC,facility,both,1,ML,XS,55,38.5,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
BETAMETHASONE ACET & SOD PHOS 6 MG/ML INJ SUSP,51022,CDM,260,RC,J0702,HCPCS,78206-118-01,NDC,facility,both,1,ML,,223,156.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),51022,CDM,450,RC,J1630,HCPCS,25021-806-01,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),51022,CDM,260,RC,J3490,HCPCS,0409-4888-03,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML INJ SOLN,51022,CDM,260,RC,J0171,HCPCS,76329-9060-0,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),51022,CDM,260,RC,J2270,HCPCS,0641-6125-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,51022,CDM,260,RC,J0630,HCPCS,42023-205-01,NDC,facility,both,1,ML,,1557,1089.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,16714-016-01,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,51022,CDM,450,RC,J1100,HCPCS,63323-506-01,NDC,facility,both,1,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,16714-036-01,NDC,facility,both,1,ML,XU,82,57.4,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
INSULIN LISPRO 100 UNIT/ML (PEDS CALCLUATOR 0.5),51022,CDM,260,RC,J1815,HCPCS,0024-5924-10,NDC,facility,both,1,ML,,848,593.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,51022,CDM,450,RC,J3360,HCPCS,69374-965-02,NDC,facility,both,1,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,51022,CDM,450,RC,J3490,HCPCS,0143-9509-01,NDC,facility,both,1,ML,XS,17,11.9,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
EPHEDRINE 50 MG/ML IV SOLN (MERGE),51022,CDM,260,RC,J3490,HCPCS,16714-037-01,NDC,facility,both,1,ML,,379,265.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CERTOLIZUMAB PEGOL 400 MG/2 ML (200 MG/ML X 2) SUBQ SYKT,51022,CDM,260,RC,J0717,HCPCS,50474-710-79,NDC,facility,both,2,EA,,15785,11049.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL DECANOATE 100 MG/ML IM SOLN,51022,CDM,450,RC,J1631,HCPCS,70069-383-01,NDC,facility,both,1,ML,,238,166.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),51022,CDM,260,RC,J1630,HCPCS,63323-474-00,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,51022,CDM,260,RC,J2597,HCPCS,70095-026-01,NDC,facility,both,1,ML,,201,140.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 50 MG/ML INJECTION,51022,CDM,260,RC,J1200,HCPCS,25021-481-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VARICELLA-ZOSTER IG-MALTOSE 125 UNIT/1.2 ML IM SOLN,51022,CDM,260,RC,90396,HCPCS,70257-126-11,NDC,facility,both,2,ML,,25935,18154.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),51022,CDM,450,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 6 MG/0.5 ML SUBQ PEN KIT,51022,CDM,450,RC,J3030,HCPCS,16714-040-01,NDC,facility,both,1,ML,XS,406,284.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
OLANZAPINE 10 MG IM SOLR,51022,CDM,450,RC,J2359,HCPCS,55150-308-01,NDC,facility,both,1,EA,,416,291.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE (PF) 25 MG/ML INJ SOLN (FOR ECTOPIC PREGNANCY),51022,CDM,450,RC,J9260,HCPCS,0143-9519-01,NDC,facility,both,1,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,51022,CDM,450,RC,J2354,HCPCS,0641-6174-01,NDC,facility,both,1,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,51022,CDM,260,RC,J3420,HCPCS,0143-9621-01,NDC,facility,both,1,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE (PF) 25 MG/ML INJ SOLN (FOR ECTOPIC PREGNANCY),51022,CDM,260,RC,J9260,HCPCS,0143-9519-01,NDC,facility,both,1,ML,XS,73,51.1,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
"WATER FOR INJECTION, STERILE INJECTION",51022,CDM,260,RC,J3490,HCPCS,0409-4887-23,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE MICROSPHERES 25 MG/2 ML IM SYRG,51022,CDM,260,RC,J2794,HCPCS,50458-306-11,NDC,facility,both,1,EA,,1782,1247.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ABOBOTULINUMTOXINA 500 UNITS IM SOLR,51022,CDM,260,RC,J0586,HCPCS,15054-0500-1,NDC,facility,both,1,EA,XS,2106,1474.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
EPINEPHRINE 1 MG/ML (1ML) INJ SOLN,51022,CDM,450,RC,J0169,HCPCS,42023-159-01,NDC,facility,both,1,ML,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,51022,CDM,450,RC,J3490,HCPCS,67457-108-00,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT  60 MCG/0.3 ML INJ SYRG,51022,CDM,450,RC,J0881,HCPCS,55513-023-01,NDC,facility,both,1,ML,,1282,897.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 100 MG/1 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,0075-0623-03,NDC,facility,both,1,ML,,146,102.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ICATIBANT 30 MG/3 ML SUBQ SYRG,51022,CDM,450,RC,J1744,HCPCS,63323-574-86,NDC,facility,both,1,ML,,3588,2511.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,51022,CDM,260,RC,J2354,HCPCS,25021-463-01,NDC,facility,both,1,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,51022,CDM,260,RC,J1100,HCPCS,63323-165-01,NDC,facility,both,1,ML,XS,39,27.3,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,51022,CDM,260,RC,J1596,HCPCS,70700-165-22,NDC,facility,both,1,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,51022,CDM,260,RC,J0630,HCPCS,42023-205-01,NDC,facility,both,1,ML,,2065,1445.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPOETIN ALFA-EPBX 10000 UNITS/ML INJ SOLN,51022,CDM,260,RC,Q5106,HCPCS,0069-1308-01,NDC,facility,both,2,ML,,1906,1334.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,51022,CDM,450,RC,J1885,HCPCS,70860-700-41,NDC,facility,both,1,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,0781-3246-02,NDC,facility,both,1,ML,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,51022,CDM,260,RC,J0630,HCPCS,24201-400-02,NDC,facility,both,1,ML,,1259,881.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),51022,CDM,450,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",51022,CDM,260,RC,J3490,HCPCS,0409-4887-24,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,51022,CDM,450,RC,J0690,HCPCS,44567-707-25,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML (PEDS CALCLUATOR 0.5),51022,CDM,260,RC,J1815,HCPCS,0024-5924-10,NDC,facility,both,1,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 120 MG/0.8 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,0075-2912-00,NDC,facility,both,1,ML,XU,175,122.5,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
GENTAMICIN 40 MG/ML INJ SOLN,51022,CDM,450,RC,J1580,HCPCS,63323-010-01,NDC,facility,both,1,ML,XU,93,65.1,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
MORPHINE 2 MG/ML IV SOLN (PHS/CDS MERGE),51022,CDM,450,RC,J2270,HCPCS,76045-004-01,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.15 MG/0.3 ML IM PNIJ,51022,CDM,450,RC,J0169,HCPCS,49502-101-01,NDC,facility,both,1,EA,XS,675,472.5,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
EPINEPHRINE 1 MG/ML INJ SOLN,51022,CDM,260,RC,J0171,HCPCS,76329-9060-0,NDC,facility,both,1,ML,,797,557.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,16714-016-01,NDC,facility,both,1,ML,"XU,XS",53,37.1,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
ROMIPLOSTIM 500 MCG SUBQ SOLR,51022,CDM,260,RC,J2802,HCPCS,55513-222-01,NDC,facility,both,1,EA,,5268,3687.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE (CONTRACEPTIVE) 150 MG/ML IM SUSP,51022,CDM,260,RC,J1050,HCPCS,55150-329-01,NDC,facility,both,1,ML,,216,151.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUPHENAZINE DECANOATE 25 MG/ML INJ SOLN,51022,CDM,260,RC,J2680,HCPCS,55150-267-05,NDC,facility,both,1,ML,,260,182,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 100 MG/1 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,0781-3268-05,NDC,facility,both,1,ML,XU,137,95.9,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
OLANZAPINE 10 MG IM SOLR,51022,CDM,450,RC,J2359,HCPCS,0781-3159-72,NDC,facility,both,1,EA,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,51022,CDM,450,RC,J0630,HCPCS,42023-205-01,NDC,facility,both,1,ML,,7519,5263.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,51022,CDM,260,RC,J1815,HCPCS,0088-2220-33,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML INJ SOLN,51022,CDM,260,RC,J0169,HCPCS,76329-9060-0,NDC,facility,both,1,ML,,128,89.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 100 MG/1 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,63323-586-21,NDC,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 10 MG/ML IM SOLN,51022,CDM,450,RC,J0500,HCPCS,0641-6173-01,NDC,facility,both,1,ML,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  100 MCG/ML INJ SOLN,51022,CDM,260,RC,J2354,HCPCS,68462-896-01,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE SODIUM 25 MG/ML INJ SOLN,51022,CDM,450,RC,J9260,HCPCS,16729-277-30,NDC,facility,both,1,ML,XS,28,19.6,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
MEDROXYPROGESTERONE (CONTRACEPTIVE) 150 MG/ML IM SUSP,51022,CDM,450,RC,J1050,HCPCS,0548-5400-00,NDC,facility,both,1,ML,XS,147,102.9,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
GLUCAGON 1 MG/ML INJ (MERGE),51022,CDM,450,RC,J1611,HCPCS,63323-596-11,NDC,facility,both,1,EA,XS,895,626.5,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
OLANZAPINE 10 MG IM SOLR,51022,CDM,260,RC,J2359,HCPCS,55150-308-01,NDC,facility,both,1,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,0548-5603-00,NDC,facility,both,1,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),51022,CDM,260,RC,J3490,HCPCS,70004-600-09,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 100 MG/1 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,0075-0623-03,NDC,facility,both,1,ML,,146,102.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOSTIGMINE 1MG/ML (UD) OR SYRINGE,51022,CDM,260,RC,J2710,HCPCS,76014-003-33,NDC,facility,both,1,ML,,142,99.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,51022,CDM,450,RC,J1815,HCPCS,0088-2220-33,NDC,facility,both,1,ML,XS,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
METHOTREXATE (PF) 25 MG/ML INJ SOLN (FOR ECTOPIC PREGNANCY),51022,CDM,260,RC,J9260,HCPCS,0143-9519-01,NDC,facility,both,1,ML,XS,110,77,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,51022,CDM,450,RC,J1644,HCPCS,25021-402-01,NDC,facility,both,1,ML,XS,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
CHLORPROMAZINE 25 MG/ML INJ SOLN,51022,CDM,260,RC,J3230,HCPCS,43598-140-11,NDC,facility,both,1,ML,,586,410.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,51022,CDM,260,RC,J3301,HCPCS,0703-0241-01,NDC,facility,both,1,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BETAMETHASONE ACET & SOD PHOS 6 MG/ML INJ SUSP,51022,CDM,260,RC,J0702,HCPCS,78206-118-01,NDC,facility,both,1,ML,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 30 MG/0.3 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,16714-006-01,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN 1 GRAM SOLUTION FOR INJECTION,51022,CDM,260,RC,J0290,HCPCS,0781-3404-85,NDC,facility,both,1,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,0075-0620-01,NDC,facility,both,1,ML,XS,59,41.3,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,51022,CDM,450,RC,J3420,HCPCS,70069-005-01,NDC,facility,both,1,ML,XS,25,17.5,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
ORPHENADRINE CITRATE 30 MG/ML INJ SOLN,51022,CDM,450,RC,J2360,HCPCS,25021-651-02,NDC,facility,both,1,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),51022,CDM,450,RC,J1815,HCPCS,0024-5926-05,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN NPH & REGULAR HUMAN 100 UNIT/ML (70-30) SUBQ SUSP,51022,CDM,260,RC,J1815,HCPCS,0002-8715-01,NDC,facility,both,1,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
SUMATRIPTAN 6 MG/0.5 ML SUBQ PEN KIT,51022,CDM,450,RC,J3030,HCPCS,72603-141-02,NDC,facility,both,1,ML,XU,406,284.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,51022,CDM,450,RC,J1885,HCPCS,62332-599-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG/ML INJ SOLN,51022,CDM,450,RC,J2550,HCPCS,0641-6084-01,NDC,facility,both,1,ML,XS,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,51022,CDM,260,RC,J1644,HCPCS,0409-2723-30,NDC,facility,both,1,ML,XU,22,15.4,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),51022,CDM,260,RC,J1630,HCPCS,67457-426-00,NDC,facility,both,1,ML,XS,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,51022,CDM,450,RC,J1100,HCPCS,63323-506-01,NDC,facility,both,1,ML,XU,50,35,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
"WATER FOR INJECTION, STERILE INJECTION",51022,CDM,260,RC,J3490,HCPCS,63323-185-07,NDC,facility,both,1,ML,XU,34,23.8,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,51022,CDM,450,RC,J0561,HCPCS,60793-700-01,NDC,facility,both,1,ML,,3348,2343.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPOETIN ALFA-EPBX 10000 UNITS/ML INJ SOLN,51022,CDM,260,RC,Q5106,HCPCS,0069-1308-01,NDC,facility,both,1,ML,XS,477,333.9,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
HALOPERIDOL DECANOATE 100 MG/ML IM SOLN,51022,CDM,260,RC,J1631,HCPCS,70756-616-81,NDC,facility,both,1,ML,,238,166.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,51022,CDM,260,RC,J0630,HCPCS,63323-865-02,NDC,facility,both,1,ML,,1491,1043.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL DECANOATE  50 MG/ML IM SOLN,51022,CDM,260,RC,J1631,HCPCS,70710-1461-1,NDC,facility,both,1,ML,,131,91.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,51022,CDM,450,RC,J1885,HCPCS,0409-3796-19,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOSTIGMINE METHYLSULFATE 1 MG/ML IV SOLN,51022,CDM,260,RC,J2710,HCPCS,42023-189-01,NDC,facility,both,1,ML,XS,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,51022,CDM,450,RC,J0780,HCPCS,23155-294-31,NDC,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN NPH & REGULAR HUMAN 100 UNIT/ML (70-30) SUBQ SUSP,51022,CDM,450,RC,J1815,HCPCS,0169-1837-11,NDC,facility,both,1,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
TETANUS IMMUNE GLOBULIN (PF) 250 UNIT IM SYRG,51022,CDM,260,RC,J1670,HCPCS,13533-634-02,NDC,facility,both,1,ML,,1262,883.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TALQUETAMAB-TGVS 40 MG/ML SUBQ SOLN,51022,CDM,260,RC,J3055,HCPCS,57894-470-01,NDC,facility,both,1,ML,,18300,12810,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DENOSUMAB 120 MG/1.7 ML (70 MG/ML) SUBQ SOLN,51022,CDM,260,RC,J0897,HCPCS,55513-730-01,NDC,facility,both,1,ML,,9068,6347.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),51022,CDM,260,RC,J0169,HCPCS,76329-3318-1,NDC,facility,both,1,ML,XU,81,56.7,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
GLUCAGON 1 MG/ML INJ (MERGE),51022,CDM,450,RC,J1611,HCPCS,63323-596-11,NDC,facility,both,1,EA,,895,626.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML IV SOLN (MERGE),51022,CDM,260,RC,J3490,HCPCS,16714-037-01,NDC,facility,both,1,ML,,127,88.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 250 MCG SUBQ SOLR,51022,CDM,260,RC,J2796,HCPCS,55513-221-01,NDC,facility,both,1,EA,,8780,6146,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,51022,CDM,260,RC,J2250,HCPCS,0409-2305-04,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,51022,CDM,450,RC,J3490,HCPCS,0409-2051-15,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CANAKINUMAB (PF) 150 MG/ML SUBQ SOLN,51022,CDM,260,RC,J0638,HCPCS,0078-0734-61,NDC,facility,both,1,ML,,36927,25848.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJ SOLN",51022,CDM,450,RC,J3490,HCPCS,0409-1749-71,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OMALIZUMAB 150 MG SUBQ SOLR,51022,CDM,260,RC,J2357,HCPCS,50242-040-62,NDC,facility,both,1,ME,XS,5219,3653.3,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
OCTREOTIDE ACETATE  100 MCG/ML INJ SOLN,51022,CDM,260,RC,J2354,HCPCS,63323-376-00,NDC,facility,both,1,ML,,146,102.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 150 MG/1 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,0548-5607-00,NDC,facility,both,1,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,51022,CDM,260,RC,J0630,HCPCS,42023-205-01,NDC,facility,both,1,ML,,1988,1391.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML (1ML) INJ SOLN,51022,CDM,260,RC,J0171,HCPCS,54288-119-01,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,51022,CDM,450,RC,J1815,HCPCS,0002-8215-01,NDC,facility,both,1,ML,XS,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,0955-1004-01,NDC,facility,both,1,ML,,151,105.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 500 MG INJ SOLR,51022,CDM,260,RC,J0696,HCPCS,44567-700-25,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,51022,CDM,260,RC,J7040,HCPCS,0338-0049-31,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,0075-0620-01,NDC,facility,both,1,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",51022,CDM,450,RC,J3490,HCPCS,63323-185-10,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,51022,CDM,260,RC,J2310,HCPCS,67457-292-00,NDC,facility,both,1,ML,,233,163.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 30 MG/0.3 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,16714-006-01,NDC,facility,both,1,ML,PLAD,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
"RHO(D) IMMUNE GLOBULIN (RHOPHYLAC) 1,500 UNIT (300 MCG)/2 ML INJ SYRG",51022,CDM,260,RC,J2791,HCPCS,44206-300-01,NDC,facility,both,1,ML,,693,485.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,51022,CDM,260,RC,J0630,HCPCS,43598-051-11,NDC,facility,both,1,ML,,5216,3651.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 1 MG/0.5 ML INJ SYRG,51022,CDM,260,RC,J3430,HCPCS,0548-1240-00,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,51022,CDM,260,RC,J0585,HCPCS,0023-1145-01,NDC,facility,both,1,EA,XU,1599,1119.3,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,16714-016-01,NDC,facility,both,1,ML,XU,53,37.1,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
KETAMINE 100 MG/ML INJ SOLN,51022,CDM,450,RC,J3490,HCPCS,0409-2051-15,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPOETIN ALFA  4000 UNIT/ML INJ SOLN,51022,CDM,260,RC,Q4081,HCPCS,59676-304-00,NDC,facility,both,1,ML,,924,646.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,51022,CDM,260,RC,J0585,HCPCS,0023-1145-01,NDC,facility,both,1,EA,XU,2238,1566.6,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
ANAKINRA 100 MG/0.67 ML SUBQ SYRG,51022,CDM,260,RC,J3590,HCPCS,66658-234-07,NDC,facility,both,1,ML,,562,393.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 125 MCG SUBQ SOLR,51022,CDM,260,RC,J2796,HCPCS,55513-223-01,NDC,facility,both,1,EA,,5130,3591,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMOSOZUMAB-AQQG 105 MG/1.17 ML SUBQ SYRG,51022,CDM,260,RC,J3111,HCPCS,55513-998-01,NDC,facility,both,2,ML,,5349,3744.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,51022,CDM,450,RC,J1817,HCPCS,0169-1833-11,NDC,facility,both,1,ML,XS,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),51022,CDM,260,RC,J3490,HCPCS,63323-186-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN 250 MG SOLUTION FOR INJECTION,51022,CDM,260,RC,J0290,HCPCS,65219-014-01,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 30 MG/0.3 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,0075-0624-01,NDC,facility,both,1,ML,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML IM SOLN,51022,CDM,450,RC,90375,HCPCS,13533-318-05,NDC,facility,both,1,ML,,8946,6262.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE NA (PRESERV FREE) 25 MG/ML INJ SOLN,51022,CDM,260,RC,J9260,HCPCS,0703-3671-01,NDC,facility,both,1,ML,,4920,3444,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,51022,CDM,260,RC,J0585,HCPCS,0023-1145-01,NDC,facility,both,1,EA,XU,1918,1342.6,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
EPINEPHRINE 1 MG/ML INJ SOLN,51022,CDM,260,RC,J0171,HCPCS,76329-9060-0,NDC,facility,both,1,ML,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN DETEMIR 100 UNIT/ML SUBQ SOLN,51022,CDM,260,RC,J1815,HCPCS,0169-3687-12,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 100 MCG IV SOLR,51022,CDM,260,RC,J3490,HCPCS,25021-468-10,NDC,facility,both,1,EA,,2042,1429.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 50 MG/ML IM,51022,CDM,450,RC,J3410,HCPCS,0517-5601-25,NDC,facility,both,1,ML,XU,190,133,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,51022,CDM,450,RC,J2250,HCPCS,0409-2305-16,NDC,facility,both,1,ML,XS,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
CEFTRIAXONE 1 GRAM INJ SOLR,51022,CDM,450,RC,J0696,HCPCS,25021-106-10,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,51022,CDM,260,RC,J0630,HCPCS,43598-051-11,NDC,facility,both,1,ML,,6868,4807.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,51022,CDM,260,RC,J3360,HCPCS,69339-136-03,NDC,facility,both,1,ML,,289,202.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL DECANOATE 100 MG/ML IM SOLN,51022,CDM,260,RC,J1631,HCPCS,70069-383-01,NDC,facility,both,1,ML,,297,207.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,51022,CDM,260,RC,J0561,HCPCS,60793-700-01,NDC,facility,both,1,ML,,837,585.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TETANUS IMMUNE GLOBULIN (PF) 250 UNIT IM SYRG,51022,CDM,450,RC,J1670,HCPCS,13533-634-02,NDC,facility,both,1,ML,XU,1262,883.4,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
EPINEPHRINE 0.3 MG/0.3 ML IM PNIJ,51022,CDM,260,RC,J0171,HCPCS,0093-5986-19,NDC,facility,both,1,EA,,1024,716.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 500 MCG INJ SOLR,51022,CDM,260,RC,J3490,HCPCS,63323-648-10,NDC,facility,both,1,EA,XE,1458,1020.6,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XE: Separate encounter, a service that is distinct because it occurred during a separate encounter"
ENOXAPARIN 100 MG/1 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,0075-0623-03,NDC,facility,both,1,ML,,292,204.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLNALTREXONE 12 MG/0.6 ML SUBQ SOLN,51022,CDM,260,RC,J2212,HCPCS,65649-551-02,NDC,facility,both,1,ML,,735,514.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT  60 MCG/0.3 ML INJ SYRG,51022,CDM,260,RC,J0881,HCPCS,55513-023-01,NDC,facility,both,1,ML,XU,855,598.5,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
AMPICILLIN 1 GRAM SOLUTION FOR INJECTION,51022,CDM,260,RC,J0290,HCPCS,0781-3404-85,NDC,facility,both,1,EA,XU,48,33.6,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
INSULIN NPH HUMAN RECOMB 100 UNIT/ML SUBQ SUSP,51022,CDM,450,RC,J1815,HCPCS,0169-1834-11,NDC,facility,both,1,ML,XS,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,51022,CDM,260,RC,J0585,HCPCS,0023-1145-01,NDC,facility,both,1,EA,XS,3197,2237.9,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
INSULIN NPH HUMAN RECOMB 100 UNIT/ML SUBQ SUSP,51022,CDM,260,RC,J1815,HCPCS,0169-1834-11,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,51022,CDM,260,RC,J0630,HCPCS,24201-400-02,NDC,facility,both,1,ML,,1005,703.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENTOLAMINE 5 MG INJ SOLR,51022,CDM,260,RC,J3490,HCPCS,0143-9564-01,NDC,facility,both,1,EA,XU,1231,861.7,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
INSULIN DEGLUDEC 100 UNITS/ML SUBQ SOLN,51022,CDM,450,RC,J1815,HCPCS,0169-2662-11,NDC,facility,both,1,ML,XU,120,84,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,51022,CDM,260,RC,J1817,HCPCS,0169-1833-11,NDC,facility,both,1,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
EPOETIN ALFA-EPBX 10000 UNITS/ML INJ SOLN,51022,CDM,260,RC,Q5106,HCPCS,0069-1308-01,NDC,facility,both,1,ML,,477,333.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ICATIBANT 30 MG/3 ML SUBQ SYRG,51022,CDM,450,RC,J1744,HCPCS,0093-3066-34,NDC,facility,both,1,ML,XU,29229,20460.3,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),51022,CDM,260,RC,J1815,HCPCS,0024-5926-05,NDC,facility,both,1,ML,,231,161.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",51022,CDM,260,RC,J3490,HCPCS,63323-185-07,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,51022,CDM,260,RC,J0630,HCPCS,42023-205-01,NDC,facility,both,1,ML,,7259,5081.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,51022,CDM,260,RC,J1644,HCPCS,0641-0400-37,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),51022,CDM,450,RC,J1815,HCPCS,0024-5926-05,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,51022,CDM,450,RC,J1885,HCPCS,70860-700-41,NDC,facility,both,1,ML,XS,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
TERBUTALINE 1 MG/ML SUBQ SOLN,51022,CDM,260,RC,J3105,HCPCS,0143-9746-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,51022,CDM,450,RC,J1885,HCPCS,0338-0072-25,NDC,facility,both,1,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
CEFTRIAXONE 250 MG INJ SOLR,51022,CDM,450,RC,J0696,HCPCS,0781-3206-85,NDC,facility,both,1,EA,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,51022,CDM,450,RC,J3010,HCPCS,0409-9094-12,NDC,facility,both,1,ML,XS,19,13.3,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
PROMETHAZINE 25 MG/ML INJ SOLN,51022,CDM,260,RC,J2550,HCPCS,0641-6084-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN ASP PRT-INSULIN ASPART 100 UNIT/ML (70-30) SUBQ SOLN,51022,CDM,450,RC,J1817,HCPCS,73070-200-11,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE NA (PRESERV FREE) 25 MG/ML INJ SOLN,51022,CDM,260,RC,J9260,HCPCS,61703-408-41,NDC,facility,both,1,ML,,863,604.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ABOBOTULINUMTOXINA 300 UNITS IM SOLR,51022,CDM,260,RC,J3490,HCPCS,15054-0530-6,NDC,facility,both,1,EA,XU,3793,2655.1,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,51022,CDM,260,RC,J1644,HCPCS,0641-0400-37,NDC,facility,both,1,ML,XU,26,18.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
EPINEPHRINE 0.3 MG/0.3 ML IM PNIJ,51022,CDM,450,RC,J0171,HCPCS,49502-500-01,NDC,facility,both,1,EA,,1078,754.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",51022,CDM,450,RC,J3490,HCPCS,0409-4887-17,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,16714-036-01,NDC,facility,both,1,ML,XS,82,57.4,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
FENTANYL CITRATE (PF) 50 MCG/ML (ANESTHESIA INTRAOP ONLY),51022,CDM,260,RC,J3010,HCPCS,0641-6027-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,51022,CDM,260,RC,J1815,HCPCS,0002-8215-17,NDC,facility,both,1,ML,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE INFUSION 2MG/ML 100ML (FOR ANESTHESIA USE ONLY),51022,CDM,450,RC,J3490,HCPCS,0409-2051-05,NDC,facility,both,1,ML,XS,56,39.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,51022,CDM,260,RC,J0585,HCPCS,0023-1145-01,NDC,facility,both,1,EA,XS,1599,1119.3,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
OCTREOTIDE ACETATE  100 MCG/ML INJ SOLN,51022,CDM,260,RC,J2354,HCPCS,68462-896-10,NDC,facility,both,1,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,51022,CDM,450,RC,J2250,HCPCS,0409-2308-02,NDC,facility,both,1,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,51022,CDM,260,RC,J2597,HCPCS,69918-899-01,NDC,facility,both,1,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 500 MCG INJ SOLR,51022,CDM,260,RC,J3490,HCPCS,63323-648-10,NDC,facility,both,2,EA,,2915,2040.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMOSOZUMAB-AQQG 105 MG/1.17 ML SUBQ SYRG,51022,CDM,260,RC,J3111,HCPCS,55513-998-01,NDC,facility,both,1,ML,,2675,1872.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),51022,CDM,260,RC,J1815,HCPCS,0024-5926-05,NDC,facility,both,1,ML,XS,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),51022,CDM,450,RC,J1630,HCPCS,67457-426-00,NDC,facility,both,2,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,51022,CDM,260,RC,J1815,HCPCS,0169-1833-11,NDC,facility,both,1,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,0781-3246-02,NDC,facility,both,1,ML,XS,55,38.5,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
GLUCAGON 1 MG/ML INJ (MERGE),51022,CDM,450,RC,J1610,HCPCS,63323-596-11,NDC,facility,both,1,EA,XU,1570,1099,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
MEPOLIZUMAB 100 MG SUBQ SOLR,51022,CDM,260,RC,J2182,HCPCS,0173-0881-01,NDC,facility,both,1,EA,,7107,4974.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"OCTREOTIDE,MICROSPHERES 30 MG IM SERR",51022,CDM,260,RC,J2353,HCPCS,0078-0804-61,NDC,facility,both,1,EA,,19079,13355.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),51022,CDM,260,RC,J1630,HCPCS,25021-806-01,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 30 MG/0.3 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,16714-006-01,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BETAMETHASONE ACET & SOD PHOS 6 MG/ML INJ SUSP,51022,CDM,260,RC,J0702,HCPCS,0517-0720-01,NDC,facility,both,1,ML,XU,281,196.7,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,0781-3246-02,NDC,facility,both,1,ML,XU,41,28.7,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
DEXAMETHASONE 4 MG/ML INJECTION,51022,CDM,450,RC,J1100,HCPCS,63323-165-01,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FILGRASTIM 300 (NEUPOGEN) MCG/ML INJ SOLN,51022,CDM,260,RC,J1442,HCPCS,55513-530-01,NDC,facility,both,1,ML,,1115,780.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML (PEDS CALCLUATOR 0.5),51022,CDM,260,RC,J1815,HCPCS,0024-5924-10,NDC,facility,both,1,ML,"XS,XU",16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
DICYCLOMINE 10 MG/ML IM SOLN,51022,CDM,450,RC,J0500,HCPCS,58914-080-52,NDC,facility,both,1,ML,XU,364,254.8,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,51022,CDM,260,RC,J3420,HCPCS,63323-044-00,NDC,facility,both,1,ML,XS,46,32.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
INSULIN NPH & REGULAR HUMAN 100 UNIT/ML (70-30) SUBQ SUSP,51022,CDM,260,RC,J1815,HCPCS,0169-1837-11,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,51022,CDM,450,RC,J3360,HCPCS,0409-1273-03,NDC,facility,both,1,ML,XU,99,69.3,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
INSULIN ASP PRT-INSULIN ASPART 100 UNIT/ML (70-30) SUBQ SOLN,51022,CDM,260,RC,J1817,HCPCS,73070-200-11,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),51022,CDM,450,RC,J1630,HCPCS,63323-474-00,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,51022,CDM,260,RC,J2597,HCPCS,43598-931-11,NDC,facility,both,1,ML,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZTROPINE 1 MG/ML INJ SOLN,51022,CDM,450,RC,J0515,HCPCS,68382-860-02,NDC,facility,both,1,ML,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,16714-026-01,NDC,facility,both,1,ML,XU,70,49,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
EPINEPHRINE 0.3 MG/0.3 ML IM PNIJ,51022,CDM,450,RC,J0169,HCPCS,0093-5986-19,NDC,facility,both,1,EA,,1024,716.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  100 MCG/ML INJ SOLN,51022,CDM,450,RC,J2354,HCPCS,63323-376-00,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TERBUTALINE 1 MG/ML SUBQ SOLN,51022,CDM,450,RC,J3105,HCPCS,0143-9746-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FONDAPARINUX 10 MG/0.8 ML SUBQ SYRG,51022,CDM,260,RC,J1652,HCPCS,55150-233-00,NDC,facility,both,1,ML,,370,259,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,51022,CDM,260,RC,J3010,HCPCS,0409-9094-12,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 2 MG/ML IN NS 50ML INFUSION (STOCK DOSE),51022,CDM,260,RC,J3490,HCPCS,0143-9508-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML (ANESTHESIA INTRAOP ONLY),51022,CDM,450,RC,J3010,HCPCS,0641-6027-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,51022,CDM,450,RC,J2250,HCPCS,0409-2308-21,NDC,facility,both,1,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
EPINEPHRINE 1 MG/ML INJ SOLN,51022,CDM,260,RC,J0169,HCPCS,76329-9060-0,NDC,facility,both,1,ML,XU,797,557.9,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,51022,CDM,450,RC,J1100,HCPCS,63323-506-41,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUM U-500 CONC 500 UNIT/ML INJ SOLN,51022,CDM,450,RC,J1815,HCPCS,0002-8501-01,NDC,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN DETEMIR 100 UNIT/ML SUBQ SOLN,51022,CDM,450,RC,J1815,HCPCS,0169-3687-12,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,51022,CDM,450,RC,J1815,HCPCS,0088-2220-33,NDC,facility,both,1,ML,PLAD,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
BENZTROPINE 1 MG/ML INJ SOLN,51022,CDM,260,RC,J0515,HCPCS,0143-9233-01,NDC,facility,both,1,ML,,229,160.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,51022,CDM,450,RC,J1885,HCPCS,63323-162-00,NDC,facility,both,1,ML,XU,38,26.6,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),51022,CDM,260,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 10 MG/ML IM SOLN,51022,CDM,450,RC,J0500,HCPCS,70436-147-80,NDC,facility,both,1,ML,XS,229,160.3,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
METOCLOPRAMIDE  5 MG/ML INJ SOLN,51022,CDM,450,RC,J2765,HCPCS,0703-4502-01,NDC,facility,both,1,ML,XS,23,16.1,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
INSULIN LISPRO 100 UNIT/ML (PEDS CALCLUATOR 0.5),51022,CDM,260,RC,J1815,HCPCS,0024-5924-10,NDC,facility,both,2,ML,XS,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
EPINEPHRINE 0.3 MG/0.3 ML IM PNIJ,51022,CDM,450,RC,J0171,HCPCS,49502-102-01,NDC,facility,both,1,EA,,675,472.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 125 MCG SUBQ SOLR,51022,CDM,260,RC,J2796,HCPCS,55513-223-01,NDC,facility,both,1,EA,,2565,1795.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML INJ SOLN,51022,CDM,260,RC,J0169,HCPCS,76329-9060-0,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,51022,CDM,450,RC,J1815,HCPCS,0088-2220-33,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,0955-1008-01,NDC,facility,both,1,ML,,101,70.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 30 MG/0.3 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,0075-0624-01,NDC,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLERGONOVINE 0.2 MG/ML (1 ML) INJ SOLN,51022,CDM,260,RC,J2210,HCPCS,0517-0740-01,NDC,facility,both,1,ML,,368,257.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",51022,CDM,450,RC,J3490,HCPCS,63323-185-07,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,0955-1004-01,NDC,facility,both,1,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE NA (PRESERV FREE) 25 MG/ML INJ SOLN,51022,CDM,260,RC,J9260,HCPCS,16729-277-35,NDC,facility,both,1,ML,,4026,2818.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ABOBOTULINUMTOXINA 500 UNITS IM SOLR,51022,CDM,260,RC,J0586,HCPCS,15054-0500-1,NDC,facility,both,1,EA,XU,4212,2948.4,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
HALOPERIDOL DECANOATE  50 MG/ML IM SOLN,51022,CDM,260,RC,J1631,HCPCS,70069-030-01,NDC,facility,both,1,ML,,306,214.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TALQUETAMAB-TGVS 40 MG/ML SUBQ SOLN,51022,CDM,260,RC,J3055,HCPCS,57894-470-01,NDC,facility,both,1,ML,,2745,1921.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),51022,CDM,260,RC,J1630,HCPCS,76045-737-01,NDC,facility,both,1,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),51022,CDM,260,RC,J1171,HCPCS,0409-4264-11,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TERBUTALINE 1 MG/ML SUBQ SOLN,51022,CDM,260,RC,J3105,HCPCS,0143-9746-01,NDC,facility,both,1,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
OLANZAPINE 10 MG IM SOLR,51022,CDM,260,RC,J2359,HCPCS,55150-308-01,NDC,facility,both,1,EA,XS,52,36.4,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
CHLORPROMAZINE 25 MG/ML INJ SOLN,51022,CDM,450,RC,J3230,HCPCS,0641-1398-31,NDC,facility,both,1,ML,XS,195,136.5,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,51022,CDM,450,RC,J1815,HCPCS,0088-2220-33,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTAZIDIME   1 GRAM INJ SOLR,51022,CDM,260,RC,J0713,HCPCS,0409-5082-16,NDC,facility,both,1,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),51022,CDM,260,RC,J1815,HCPCS,0024-5926-05,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENTOLAMINE 5 MG INJ SOLR,51022,CDM,450,RC,J3490,HCPCS,0143-9564-01,NDC,facility,both,1,EA,,2461,1722.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZIPRASIDONE 20 MG IM,51022,CDM,260,RC,J3486,HCPCS,43598-848-11,NDC,facility,both,1,EA,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  100 MCG/ML INJ SOLN,51022,CDM,450,RC,J2354,HCPCS,63323-376-00,NDC,facility,both,1,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),51022,CDM,260,RC,J1610,HCPCS,63323-596-11,NDC,facility,both,1,EA,,785,549.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROGESTERONE 50 MG/ML IM OIL,51022,CDM,260,RC,J2675,HCPCS,0591-3128-79,NDC,facility,both,1,ML,,190,133,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),51022,CDM,450,RC,J2270,HCPCS,0641-6125-01,NDC,facility,both,1,ML,XS,17,11.9,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,51022,CDM,450,RC,J1644,HCPCS,0409-2723-30,NDC,facility,both,1,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
ZIPRASIDONE 20 MG IM,51022,CDM,260,RC,J3486,HCPCS,72205-205-01,NDC,facility,both,1,EA,,192,134.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,51022,CDM,450,RC,J1644,HCPCS,0409-2723-30,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 100 MG/1 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,63323-586-21,NDC,facility,both,1,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,51022,CDM,260,RC,J1815,HCPCS,83257-011-11,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TERBUTALINE 1 MG/ML SUBQ SOLN,51022,CDM,450,RC,J3105,HCPCS,63323-665-01,NDC,facility,both,1,ML,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,51022,CDM,260,RC,J1644,HCPCS,25021-402-01,NDC,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"RHO(D) IMMUNE GLOBULIN (RHOPHYLAC) 1,500 UNIT (300 MCG)/2 ML INJ SYRG",51022,CDM,260,RC,J2791,HCPCS,44206-300-90,NDC,facility,both,1,ML,,693,485.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,16714-036-01,NDC,facility,both,2,ML,XU,94,65.8,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
"WATER FOR INJECTION, STERILE INJECTION",51022,CDM,260,RC,J3490,HCPCS,63323-185-10,NDC,facility,both,1,ML,XS,30,21,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
ENOXAPARIN 150 MG/1 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,0548-5607-00,NDC,facility,both,1,ML,,119,83.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZIPRASIDONE 20 MG IM,51022,CDM,260,RC,J3486,HCPCS,43598-848-11,NDC,facility,both,1,EA,XS,240,168,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,51022,CDM,260,RC,J0630,HCPCS,42023-205-01,NDC,facility,both,1,ML,,3500,2450,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALDESLEUKIN 360,000 UNITS/ ML SOLUTION",51022,CDM,260,RC,J9015,HCPCS,65483-116-07,NDC,facility,both,1,EA,,5121,3584.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML IM SOLN,51022,CDM,450,RC,90375,HCPCS,13533-318-30,NDC,facility,both,1,ML,,11270,7889,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN DEGLUDEC 100 UNITS/ML SUBQ SOLN,51022,CDM,260,RC,J1815,HCPCS,73070-400-11,NDC,facility,both,1,ML,XS,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
METHOTREXATE NA (PRESERV FREE) 25 MG/ML INJ SOLN,51022,CDM,260,RC,J9260,HCPCS,16729-277-35,NDC,facility,both,1,ML,,1776,1243.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,51022,CDM,260,RC,J1644,HCPCS,25021-402-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,51022,CDM,450,RC,J1815,HCPCS,49502-393-80,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 30 MG/0.3 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,16714-006-10,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FILGRASTIM-SNDZ 300 MCG/0.5 ML INJ SYRG,51022,CDM,260,RC,Q5101,HCPCS,61314-318-05,NDC,facility,both,1,ML,,972,680.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  100 MCG/ML INJ SOLN,51022,CDM,260,RC,J2354,HCPCS,63323-376-00,NDC,facility,both,1,ML,XS,88,61.6,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,51022,CDM,260,RC,J1644,HCPCS,0641-0400-37,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),51022,CDM,260,RC,J0171,HCPCS,76329-3318-1,NDC,facility,both,1,ML,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TECLISTAMAB-CQYV 90 MG/ML SUBQ SOLN,51022,CDM,260,RC,J9380,HCPCS,57894-450-01,NDC,facility,both,1,ML,,24915,17440.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 200 MCG INJ SOLR,51022,CDM,260,RC,J3490,HCPCS,63323-647-10,NDC,facility,both,1,EA,,1122,785.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLERGONOVINE 0.2 MG/ML (1 ML) INJ SOLN,51022,CDM,260,RC,J2210,HCPCS,0517-0740-01,NDC,facility,both,1,ML,XU,179,125.3,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
ENOXAPARIN 30 MG/0.3 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,16714-006-01,NDC,facility,both,1,ML,XU,39,27.3,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
EPINEPHRINE 0.3 MG/0.3 ML IM PNIJ,51022,CDM,450,RC,J0171,HCPCS,49502-102-01,NDC,facility,both,1,EA,XS,675,472.5,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
EPHEDRINE 50 MG/ML IV SOLN (MERGE),51022,CDM,260,RC,J3490,HCPCS,70756-611-82,NDC,facility,both,1,ML,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),51022,CDM,450,RC,J2060,HCPCS,0641-6044-01,NDC,facility,both,1,ML,XS,29,20.3,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
EPINEPHRINE 1 MG/ML (1ML) INJ SOLN,51022,CDM,450,RC,J0171,HCPCS,42023-159-01,NDC,facility,both,1,ML,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,51022,CDM,260,RC,J1815,HCPCS,0002-8215-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN DEGLUDEC 100 UNITS/ML SUBQ SOLN,51022,CDM,260,RC,J1815,HCPCS,73070-400-11,NDC,facility,both,1,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,51022,CDM,260,RC,J0630,HCPCS,63323-865-02,NDC,facility,both,1,ML,,2153,1507.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE 25 MG/ML INJ SOLN,51022,CDM,260,RC,J3230,HCPCS,70710-1850-1,NDC,facility,both,1,ML,,168,117.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),51022,CDM,450,RC,J1171,HCPCS,76045-009-96,NDC,facility,both,1,ML,XS,56,39.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,51022,CDM,260,RC,J0630,HCPCS,42023-205-01,NDC,facility,both,1,ML,,7519,5263.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMOSOZUMAB-AQQG 105 MG/1.17 ML SUBQ SYRG,51022,CDM,260,RC,J3111,HCPCS,55513-998-01,NDC,facility,both,1,ML,,5349,3744.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZTROPINE 1 MG/ML INJ SOLN,51022,CDM,450,RC,J0515,HCPCS,0143-9729-01,NDC,facility,both,1,ML,,636,445.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,51022,CDM,450,RC,J2560,HCPCS,0641-0477-21,NDC,facility,both,1,ML,,349,244.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 150 MG/1 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,0548-5607-00,NDC,facility,both,1,ML,XU,119,83.3,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),51022,CDM,260,RC,J3490,HCPCS,51754-4250-1,NDC,facility,both,1,ML,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN ASP PRT-INSULIN ASPART 100 UNIT/ML (70-30) SUBQ SOLN,51022,CDM,260,RC,J1817,HCPCS,73070-200-11,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN (PF) 10 MG/ML INJECTION (NEONATAL IM USE),51022,CDM,260,RC,J1580,HCPCS,63323-173-01,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALTREXONE MICROSPHERES 380 MG IM SERR,51022,CDM,450,RC,J2315,HCPCS,65757-300-01,NDC,facility,both,1,EA,,4666,3266.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN ASP PRT-INSULIN ASPART 100 UNIT/ML (70-30) SUBQ SOLN,51022,CDM,260,RC,J1817,HCPCS,73070-200-11,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,51022,CDM,450,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,51022,CDM,260,RC,J3420,HCPCS,0517-0031-01,NDC,facility,both,1,ML,XS,97,67.9,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
METHYLNALTREXONE 12 MG/0.6 ML SUBQ SOLN,51022,CDM,450,RC,J2212,HCPCS,65649-551-02,NDC,facility,both,1,ML,,693,485.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,51022,CDM,260,RC,J0630,HCPCS,24201-400-02,NDC,facility,both,1,ML,,1248,873.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML INJ SOLR,51022,CDM,260,RC,J2919,HCPCS,0009-0039-30,NDC,facility,both,1,EA,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,51022,CDM,450,RC,J3490,HCPCS,0143-9509-01,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),51022,CDM,260,RC,J2060,HCPCS,0641-6001-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,51022,CDM,260,RC,J1885,HCPCS,62332-600-01,NDC,facility,both,1,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
FLUPHENAZINE DECANOATE 25 MG/ML INJ SOLN,51022,CDM,260,RC,J2680,HCPCS,67457-359-59,NDC,facility,both,1,ML,,201,140.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE (3 MONTH) 11.25 MG IM KIT,51022,CDM,260,RC,J1950,HCPCS,0074-3663-03,NDC,facility,both,1,EA,,14204,9942.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 500 MG INJ SOLR,51022,CDM,450,RC,J0696,HCPCS,60505-6152-4,NDC,facility,both,1,EA,XU,137,95.9,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),51022,CDM,450,RC,J2270,HCPCS,0641-6125-01,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 10 MG/ML (PF) IV SOLN,51022,CDM,450,RC,J2270,HCPCS,0641-6127-01,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FILGRASTIM-SNDZ 300 MCG/0.5 ML INJ SYRG,51022,CDM,260,RC,Q5101,HCPCS,61314-318-10,NDC,facility,both,1,ML,,972,680.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,51022,CDM,260,RC,J3420,HCPCS,69680-112-01,NDC,facility,both,1,ML,XS,22,15.4,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
ENOXAPARIN 120 MG/0.8 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,0075-2912-00,NDC,facility,both,1,ML,,175,122.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENTOLAMINE 5 MG INJ SOLR,51022,CDM,260,RC,J3490,HCPCS,0143-9564-01,NDC,facility,both,1,EA,,1231,861.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,51022,CDM,260,RC,J2359,HCPCS,55150-308-01,NDC,facility,both,1,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG/ML INJ SOLN,51022,CDM,260,RC,J2550,HCPCS,0641-0928-21,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ICATIBANT 30 MG/3 ML SUBQ SYRG,51022,CDM,260,RC,J1744,HCPCS,0093-3066-34,NDC,facility,both,1,ML,,29229,20460.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,51022,CDM,260,RC,J0630,HCPCS,42023-205-01,NDC,facility,both,1,ML,,1392,974.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT  10 MCG/0.4 ML INJ SYRG,51022,CDM,260,RC,J0881,HCPCS,55513-098-01,NDC,facility,both,1,ML,,788,551.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,51022,CDM,260,RC,J2597,HCPCS,43598-931-11,NDC,facility,both,1,ML,,223,156.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,51022,CDM,450,RC,J0696,HCPCS,60505-6148-0,NDC,facility,both,1,EA,XU,225,157.5,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,51022,CDM,450,RC,J1644,HCPCS,0641-0400-37,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 2400000 UNIT/4 ML IM SYRG,51022,CDM,450,RC,J0561,HCPCS,60793-702-04,NDC,facility,both,1,ML,,1898,1328.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CLINDAMYCIN 150 MG/ML INJECTION,51022,CDM,260,RC,J3490,HCPCS,0009-0775-26,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT  10 MCG/0.4 ML INJ SYRG,51022,CDM,260,RC,J0881,HCPCS,55513-098-01,NDC,facility,both,1,ML,,394,275.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),51022,CDM,260,RC,J1815,HCPCS,0024-5926-05,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),51022,CDM,450,RC,J2270,HCPCS,0641-6125-01,NDC,facility,both,1,ML,XU,17,11.9,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
CHLORPROMAZINE 25 MG/ML INJ SOLN,51022,CDM,450,RC,J3230,HCPCS,0641-1398-31,NDC,facility,both,1,ML,,195,136.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,51022,CDM,450,RC,J1100,HCPCS,63323-506-01,NDC,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN DEGLUDEC 100 UNITS/ML SUBQ SOLN,51022,CDM,260,RC,J1815,HCPCS,0169-2662-11,NDC,facility,both,1,ML,,23998,16798.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",51022,CDM,450,RC,J3490,HCPCS,0409-4887-17,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 30 MG/0.3 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,25021-410-70,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TEZEPELUMAB-EKKO 210 MG/1.91 ML (110 MG/ML) SUBQ SYRG,51022,CDM,260,RC,J2356,HCPCS,55513-112-01,NDC,facility,both,1,ML,XS,10028,7019.6,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
FILGRASTIM-SNDZ 480 MCG/0.8 ML INJ SYRG,51022,CDM,450,RC,Q5101,HCPCS,61314-326-05,NDC,facility,both,1,ML,,1212,848.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTAZIDIME   1 GRAM INJ SOLR,51022,CDM,260,RC,J0713,HCPCS,0409-5082-11,NDC,facility,both,1,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,51022,CDM,260,RC,J0690,HCPCS,44567-707-25,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,16714-036-10,NDC,facility,both,1,ML,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,51022,CDM,260,RC,J0585,HCPCS,0023-1145-01,NDC,facility,both,1,EA,XU,4795,3356.5,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,51022,CDM,450,RC,J1817,HCPCS,0002-8215-01,NDC,facility,both,1,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
INSULIN DEGLUDEC 100 UNITS/ML SUBQ SOLN,51022,CDM,260,RC,J1815,HCPCS,0169-2662-11,NDC,facility,both,1,ML,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,51022,CDM,260,RC,J3301,HCPCS,70121-1049-1,NDC,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,0075-0622-01,NDC,facility,both,1,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN ASP PRT-INSULIN ASPART 100 UNIT/ML (70-30) SUBQ SOLN,51022,CDM,450,RC,J1817,HCPCS,0169-3685-12,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,51022,CDM,260,RC,J1644,HCPCS,0641-0400-37,NDC,facility,both,1,ML,"XU,PLAD",18,12.6,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service | Modifier PLAD: Modifier description not available"
PROMETHAZINE 25 MG/ML INJ SOLN,51022,CDM,450,RC,J2550,HCPCS,0641-6084-01,NDC,facility,both,1,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,51022,CDM,260,RC,J0630,HCPCS,42023-205-01,NDC,facility,both,1,ML,,6655,4658.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,51022,CDM,260,RC,J2270,HCPCS,0409-1890-03,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,0075-0622-01,NDC,facility,both,1,ML,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),51022,CDM,260,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT  60 MCG/0.3 ML INJ SYRG,51022,CDM,260,RC,J0881,HCPCS,55513-023-04,NDC,facility,both,1,ML,PLAD,1282,897.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
HYDROXYZINE 50 MG/ML IM,51022,CDM,260,RC,J3410,HCPCS,0517-5601-25,NDC,facility,both,1,ML,,182,127.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ORPHENADRINE CITRATE 30 MG/ML INJ SOLN,51022,CDM,450,RC,J2360,HCPCS,25021-651-02,NDC,facility,both,1,ML,XS,71,49.7,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
METHOTREXATE NA (PRESERV FREE) 25 MG/ML INJ SOLN,51022,CDM,450,RC,J9260,HCPCS,61703-408-41,NDC,facility,both,1,ML,,216,151.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),51022,CDM,450,RC,J2060,HCPCS,0641-6044-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 100 MG SOLUTION FOR INJECTION,51022,CDM,260,RC,J1720,HCPCS,0009-0825-01,NDC,facility,both,1,EA,XS,94,65.8,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
LORAZEPAM 2 MG/ML INJ SOLN,51022,CDM,450,RC,J2060,HCPCS,0409-1985-03,NDC,facility,both,1,ML,XS,24,16.8,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
FILGRASTIM-SNDZ 480 MCG/0.8 ML INJ SYRG,51022,CDM,260,RC,Q5101,HCPCS,61314-326-05,NDC,facility,both,1,ML,,1212,848.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),51022,CDM,450,RC,J2060,HCPCS,0641-6044-01,NDC,facility,both,1,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,51022,CDM,260,RC,J3420,HCPCS,63323-044-00,NDC,facility,both,1,ML,XU,23,16.1,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
NALTREXONE MICROSPHERES 380 MG IM SERR,51022,CDM,260,RC,J2315,HCPCS,65757-302-02,NDC,facility,both,1,EA,,4530,3171,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE (PEDIATRIC 3 MONTH) 30 MG IM SYKT,51022,CDM,260,RC,J1950,HCPCS,0074-9694-03,NDC,facility,both,1,EA,,35874,25111.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUPHENAZINE DECANOATE 25 MG/ML INJ SOLN,51022,CDM,260,RC,J2680,HCPCS,67457-359-59,NDC,facility,both,1,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",51022,CDM,260,RC,J3490,HCPCS,0409-4887-17,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),51022,CDM,260,RC,J3490,HCPCS,0409-4888-02,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,51022,CDM,260,RC,J0630,HCPCS,63323-865-02,NDC,facility,both,1,ML,,1314,919.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,16714-016-01,NDC,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,51022,CDM,260,RC,J0696,HCPCS,60505-6148-0,NDC,facility,both,1,EA,,225,157.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  100 MCG/ML INJ SOLN,51022,CDM,450,RC,J2354,HCPCS,25021-452-01,NDC,facility,both,1,ML,XS,22,15.4,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,51022,CDM,450,RC,J1885,HCPCS,62332-600-01,NDC,facility,both,1,ML,XS,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
METHOTREXATE (PF) 25 MG/ML INJ SOLN (FOR ECTOPIC PREGNANCY),51022,CDM,260,RC,J9260,HCPCS,0143-9519-01,NDC,facility,both,1,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
TEZEPELUMAB-EKKO 210 MG/1.91 ML (110 MG/ML) SUBQ SYRG,51022,CDM,260,RC,J2356,HCPCS,55513-112-01,NDC,facility,both,1,ML,,10028,7019.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE (CONTRACEPTIVE) 150 MG/ML IM SUSP,51022,CDM,260,RC,J1050,HCPCS,70121-1467-2,NDC,facility,both,1,ML,,415,290.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),51022,CDM,260,RC,J1610,HCPCS,63323-582-82,NDC,facility,both,1,EA,,991,693.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,16714-016-01,NDC,facility,both,1,ML,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,51022,CDM,260,RC,J2354,HCPCS,0641-6174-01,NDC,facility,both,1,ML,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL DECANOATE 100 MG/ML IM SOLN,51022,CDM,260,RC,J1631,HCPCS,70756-616-10,NDC,facility,both,1,ML,,238,166.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPROST TROMETHAMINE 250 MCG/ML IM SOLN,51022,CDM,260,RC,J3490,HCPCS,0009-0856-05,NDC,facility,both,1,ML,,605,423.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),51022,CDM,260,RC,J2270,HCPCS,0641-6125-01,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ABOBOTULINUMTOXINA 300 UNITS IM SOLR,51022,CDM,260,RC,J3490,HCPCS,15054-0530-6,NDC,facility,both,1,EA,XU,5057,3539.9,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
BETAMETHASONE ACET & SOD PHOS 6 MG/ML INJ SUSP,51022,CDM,260,RC,J0702,HCPCS,78206-118-01,NDC,facility,both,1,ML,XU,98,68.6,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
"WATER FOR INJECTION, STERILE INJECTION",51022,CDM,450,RC,J3490,HCPCS,0409-4887-17,NDC,facility,both,1,ML,XU,23,16.1,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
ORPHENADRINE CITRATE 30 MG/ML INJ SOLN,51022,CDM,450,RC,J2360,HCPCS,0641-6182-01,NDC,facility,both,1,ML,XS,92,64.4,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,51022,CDM,450,RC,J1100,HCPCS,63323-506-01,NDC,facility,both,1,ML,XS,50,35,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
NEOSTIGMINE METHYLSULFATE 1 MG/ML IV SOLN,51022,CDM,260,RC,J2710,HCPCS,42023-189-01,NDC,facility,both,1,ML,59,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier 59: Distinct Procedural Service
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,51022,CDM,260,RC,J2597,HCPCS,70095-026-01,NDC,facility,both,1,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,63323-564-21,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT  25 MCG/ML INJ SOLN,51022,CDM,450,RC,J0881,HCPCS,55513-002-01,NDC,facility,both,1,ML,XU,836,585.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
HYALURONIDASE 150 UNIT/ML INJ SOLN,51022,CDM,260,RC,J3473,HCPCS,18657-117-02,NDC,facility,both,1,ML,,568,397.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENZTROPINE 1 MG/ML INJ SOLN,51022,CDM,260,RC,J0515,HCPCS,0143-9233-01,NDC,facility,both,1,ML,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE NA (PRESERV FREE) 25 MG/ML INJ SOLN,51022,CDM,260,RC,J9260,HCPCS,61703-408-41,NDC,facility,both,1,ML,,3449,2414.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,51022,CDM,260,RC,J0561,HCPCS,60793-700-01,NDC,facility,both,1,ML,,3018,2112.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,51022,CDM,450,RC,J1100,HCPCS,0641-6145-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,0075-0622-01,NDC,facility,both,1,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,51022,CDM,260,RC,J1100,HCPCS,63323-165-01,NDC,facility,both,1,ML,XU,96,67.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,51022,CDM,260,RC,J1815,HCPCS,0088-2220-33,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 50 MG/ML INJECTION,51022,CDM,450,RC,J1200,HCPCS,25021-481-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),51022,CDM,450,RC,J1630,HCPCS,67457-426-00,NDC,facility,both,1,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,51022,CDM,450,RC,J3420,HCPCS,0517-0031-01,NDC,facility,both,1,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DENOSUMAB 60 MG/ML SUBQ SYRG,51022,CDM,260,RC,J0897,HCPCS,55513-710-21,NDC,facility,both,1,ML,XS,4930,3451,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,51022,CDM,450,RC,J0561,HCPCS,60793-701-02,NDC,facility,both,1,ML,XS,2376,1663.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
INSULIN DETEMIR 100 UNIT/ML SUBQ SOLN,51022,CDM,260,RC,J1815,HCPCS,0169-3687-12,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,51022,CDM,260,RC,J3301,HCPCS,16714-130-01,NDC,facility,both,1,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
AMPICILLIN 250 MG SOLUTION FOR INJECTION,51022,CDM,260,RC,J0290,HCPCS,0781-3402-78,NDC,facility,both,1,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLNALTREXONE 12 MG/0.6 ML SUBQ SYRG,51022,CDM,260,RC,J2212,HCPCS,65649-552-04,NDC,facility,both,1,ML,,520,364,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,16714-036-01,NDC,facility,both,1,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,51022,CDM,450,RC,J2405,HCPCS,23155-547-31,NDC,facility,both,1,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
HALOPERIDOL DECANOATE 100 MG/ML IM SOLN,51022,CDM,260,RC,J1631,HCPCS,70069-383-01,NDC,facility,both,1,ML,,238,166.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML (PEDS CALCLUATOR 0.5),51022,CDM,450,RC,J1815,HCPCS,0024-5924-10,NDC,facility,both,1,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
EPHEDRINE 50 MG/ML IV SOLN (MERGE),51022,CDM,260,RC,J3490,HCPCS,70756-611-82,NDC,facility,both,1,ML,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,51022,CDM,260,RC,J3420,HCPCS,63323-044-00,NDC,facility,both,1,ML,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML IM SOLN,51022,CDM,260,RC,90375,HCPCS,13533-318-30,NDC,facility,both,1,ML,,11270,7889,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML (PEDS CALCLUATOR 0.5),51022,CDM,260,RC,J1815,HCPCS,0024-5924-10,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,51022,CDM,260,RC,J3420,HCPCS,63323-044-01,NDC,facility,both,1,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,51022,CDM,450,RC,J1817,HCPCS,0169-1833-11,NDC,facility,both,1,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
DENOSUMAB 60 MG/ML SUBQ SYRG,51022,CDM,260,RC,J0897,HCPCS,55513-710-21,NDC,facility,both,1,ML,,5177,3623.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  100 MCG/ML INJ SOLN,51022,CDM,450,RC,J2354,HCPCS,63323-376-00,NDC,facility,both,1,ML,XS,30,21,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
PALIPERIDONE PALMITATE 117 MG/0.75 ML IM SYRG,51022,CDM,450,RC,J2426,HCPCS,50458-562-01,NDC,facility,both,1,ML,,9851,6895.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,51022,CDM,260,RC,J3360,HCPCS,0409-1273-03,NDC,facility,both,1,ML,,396,277.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG/ML INJ SOLN,51022,CDM,450,RC,J2550,HCPCS,0641-0928-21,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE NA (PRESERV FREE) 25 MG/ML INJ SOLN,51022,CDM,260,RC,J9260,HCPCS,61703-408-41,NDC,facility,both,1,ML,,3880,2716,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),51022,CDM,450,RC,J1815,HCPCS,0024-5926-05,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,51022,CDM,260,RC,J2597,HCPCS,70095-026-01,NDC,facility,both,1,ML,,268,187.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",51022,CDM,260,RC,J3490,HCPCS,0409-4887-17,NDC,facility,both,1,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),51022,CDM,260,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,1,ML,XS,17,11.9,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
OLANZAPINE 10 MG IM SOLR,51022,CDM,260,RC,J2359,HCPCS,55150-308-01,NDC,facility,both,1,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,51022,CDM,450,RC,J1815,HCPCS,0169-1833-11,NDC,facility,both,1,ML,XS,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
EPHEDRINE 50 MG/ML IV SOLN (MERGE),51022,CDM,260,RC,J3490,HCPCS,16714-037-01,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML (PEDS CALCLUATOR 0.5),51022,CDM,450,RC,J1815,HCPCS,0024-5924-10,NDC,facility,both,1,ML,XS,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
EPINEPHRINE 0.3 MG/0.3 ML IM PNIJ,51022,CDM,450,RC,J0169,HCPCS,49502-102-01,NDC,facility,both,1,EA,XU,675,472.5,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,51022,CDM,260,RC,J0561,HCPCS,60793-701-02,NDC,facility,both,1,ML,,1307,914.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALTREXONE MICROSPHERES 380 MG IM SERR,51022,CDM,260,RC,J2315,HCPCS,65757-300-01,NDC,facility,both,1,EA,,4530,3171,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",51022,CDM,260,RC,J3490,HCPCS,0409-4887-17,NDC,facility,both,1,ML,XS,23,16.1,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
CHLORPROMAZINE 25 MG/ML INJ SOLN,51022,CDM,260,RC,J3230,HCPCS,70710-1850-1,NDC,facility,both,1,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE SODIUM 25 MG/ML INJ SOLN,51022,CDM,260,RC,J9260,HCPCS,16729-277-30,NDC,facility,both,1,ML,XU,28,19.6,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,51022,CDM,450,RC,J1644,HCPCS,0409-2723-30,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BETAMETHASONE ACET & SOD PHOS 6 MG/ML INJ SUSP,51022,CDM,260,RC,J0702,HCPCS,78206-118-01,NDC,facility,both,1,ML,,245,171.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BETAMETHASONE ACET & SOD PHOS 6 MG/ML INJ SUSP,51022,CDM,260,RC,J0702,HCPCS,51754-5060-1,NDC,facility,both,1,ML,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,51022,CDM,450,RC,J2359,HCPCS,0002-7597-01,NDC,facility,both,1,EA,XS,256,179.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
OLANZAPINE 10 MG IM SOLR,51022,CDM,260,RC,J2359,HCPCS,55150-308-01,NDC,facility,both,1,EA,XU,104,72.8,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
GLUCAGON 1 MG/ML INJ (MERGE),51022,CDM,450,RC,J1610,HCPCS,63323-596-11,NDC,facility,both,1,EA,,1570,1099,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),51022,CDM,450,RC,J3490,HCPCS,0409-4888-02,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),51022,CDM,260,RC,J1171,HCPCS,0409-4264-11,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG/ML INJ SOLN,51022,CDM,450,RC,J2550,HCPCS,0641-6084-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,51022,CDM,450,RC,J0561,HCPCS,60793-701-02,NDC,facility,both,1,ML,XU,1188,831.6,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,16714-016-01,NDC,facility,both,1,ML,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PALIPERIDONE PALMITATE 78 MG/0.5 ML IM SYRG,51022,CDM,260,RC,J2426,HCPCS,50458-561-01,NDC,facility,both,1,ML,,3284,2298.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN ASP PRT-INSULIN ASPART 100 UNIT/ML (70-30) SUBQ SOLN,51022,CDM,260,RC,J1817,HCPCS,0169-3685-12,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 20 MG/ML IN NS NEONATAL INJECTION (REPACK),51022,CDM,260,RC,J1650,HCPCS,63323-565-86,NDC,facility,both,1,ML,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE NA (PRESERV FREE) 25 MG/ML INJ SOLN,51022,CDM,260,RC,J9260,HCPCS,61703-408-41,NDC,facility,both,1,ML,,216,151.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",51022,CDM,450,RC,J3490,HCPCS,63323-185-10,NDC,facility,both,1,ML,XU,34,23.8,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,16714-036-01,NDC,facility,both,1,ML,,187,130.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,51022,CDM,450,RC,J1644,HCPCS,0641-0400-12,NDC,facility,both,1,ML,XU,18,12.6,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
DIAZEPAM 5 MG/ML INJ SYRG,51022,CDM,450,RC,J3360,HCPCS,0409-1273-32,NDC,facility,both,1,ML,XU,198,138.6,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
DICYCLOMINE 10 MG/ML IM SOLN,51022,CDM,450,RC,J0500,HCPCS,58914-080-52,NDC,facility,both,1,ML,,364,254.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,51022,CDM,260,RC,J1644,HCPCS,0641-0400-37,NDC,facility,both,1,ML,XU,18,12.6,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,16714-026-01,NDC,facility,both,1,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 2 MG/ML IV SOLN (PHS/CDS MERGE),51022,CDM,260,RC,J2270,HCPCS,76045-004-01,NDC,facility,both,1,ML,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT 200 MCG/0.4 ML INJ SYRG,51022,CDM,450,RC,J0881,HCPCS,55513-028-01,NDC,facility,both,1,ML,,4273,2991.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,51022,CDM,260,RC,J0630,HCPCS,42023-205-01,NDC,facility,both,1,ML,,8383,5868.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE (PF) 25 MG/ML INJ SOLN (FOR ECTOPIC PREGNANCY),51022,CDM,260,RC,J9260,HCPCS,0143-9519-01,NDC,facility,both,1,ML,XU,61,42.7,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
INSULIN DETEMIR 100 UNIT/ML SUBQ SOLN,51022,CDM,450,RC,J1815,HCPCS,0169-3687-12,NDC,facility,both,1,ML,XS,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
KETAMINE 100 MG/ML INJ SOLN,51022,CDM,450,RC,J3490,HCPCS,0409-2051-15,NDC,facility,both,1,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPOETIN ALFA 20000 UNIT/ML INJ SOLN,51022,CDM,450,RC,J0885,HCPCS,59676-320-00,NDC,facility,both,1,ML,,1476,1033.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,51022,CDM,260,RC,J1885,HCPCS,62332-600-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPOETIN ALFA 10000 UNIT/ML INJ SOLN,51022,CDM,260,RC,J0885,HCPCS,55513-144-01,NDC,facility,both,1,ML,,574,401.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,51022,CDM,450,RC,J2250,HCPCS,0409-2305-16,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MENING VAC A,C,Y,W135,TET (PF) 10 MCG/0.5 ML IM SOLN",51022,CDM,260,RC,90619,HCPCS,49281-590-58,NDC,facility,both,1,ML,,721,504.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,51022,CDM,450,RC,J2359,HCPCS,0781-3159-72,NDC,facility,both,1,EA,XU,203,142.1,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
HYDROXYZINE 50 MG/ML IM,51022,CDM,260,RC,J3410,HCPCS,0517-5601-25,NDC,facility,both,1,ML,XU,190,133,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,51022,CDM,450,RC,J2354,HCPCS,0641-6174-01,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,51022,CDM,450,RC,J0561,HCPCS,60793-701-02,NDC,facility,both,1,ML,,2160,1512,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),51022,CDM,450,RC,J2270,HCPCS,0641-6125-01,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYALURONIDASE 150 UNIT/ML INJ SOLN,51022,CDM,260,RC,J3473,HCPCS,18657-117-02,NDC,facility,both,1,ML,,284,198.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 50 MG/ML INJECTION,51022,CDM,450,RC,J1200,HCPCS,63323-664-00,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 500 MG INJ SOLR,51022,CDM,450,RC,J0696,HCPCS,44567-700-25,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,51022,CDM,450,RC,J1885,HCPCS,72266-119-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,51022,CDM,260,RC,J1100,HCPCS,63323-165-01,NDC,facility,both,1,ML,XU,24,16.8,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
"WATER FOR INJECTION, STERILE INJECTION",51022,CDM,260,RC,J3490,HCPCS,0409-4887-17,NDC,facility,both,1,ML,XS,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,51022,CDM,260,RC,J0630,HCPCS,24201-400-02,NDC,facility,both,1,ML,,1590,1113,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML (ANESTHESIA INTRAOP ONLY),51022,CDM,450,RC,J3010,HCPCS,0641-6027-01,NDC,facility,both,1,ML,XS,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,51022,CDM,260,RC,J1644,HCPCS,71288-422-95,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT  40 MCG/0.4 ML INJ SYRG,51022,CDM,260,RC,J0881,HCPCS,55513-021-01,NDC,facility,both,2,ML,,2192,1534.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 500 MCG INJ SOLR,51022,CDM,260,RC,J3490,HCPCS,25021-470-10,NDC,facility,both,2,EA,,2364,1654.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 6 MG/0.5 ML SUBQ PEN KIT,51022,CDM,450,RC,J3030,HCPCS,72603-141-02,NDC,facility,both,1,ML,,406,284.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,51022,CDM,260,RC,J1885,HCPCS,0338-0069-10,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.3 MG/0.3 ML IM PNIJ,51022,CDM,260,RC,J0171,HCPCS,49502-102-01,NDC,facility,both,1,EA,,675,472.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ORPHENADRINE CITRATE 30 MG/ML INJ SOLN,51022,CDM,450,RC,J2360,HCPCS,0641-6182-10,NDC,facility,both,1,ML,XS,92,64.4,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
PROMETHAZINE 25 MG/ML INJ SOLN,51022,CDM,450,RC,J2550,HCPCS,0641-0928-21,NDC,facility,both,1,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),51022,CDM,450,RC,J2270,HCPCS,63323-454-00,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,51022,CDM,450,RC,J1815,HCPCS,0088-2220-33,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,51022,CDM,450,RC,J3010,HCPCS,0409-9094-12,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,51022,CDM,450,RC,J0630,HCPCS,42023-205-01,NDC,facility,both,1,ML,,5488,3841.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",51022,CDM,450,RC,J3490,HCPCS,63323-185-07,NDC,facility,both,1,ML,XU,30,21,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL,51022,CDM,260,RC,J1071,HCPCS,52536-625-01,NDC,facility,both,1,ML,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,51022,CDM,450,RC,J2250,HCPCS,0409-2308-22,NDC,facility,both,1,ML,XS,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,51022,CDM,260,RC,J2354,HCPCS,0641-6174-01,NDC,facility,both,1,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ICATIBANT 30 MG/3 ML SUBQ SYRG,51022,CDM,450,RC,J1744,HCPCS,69097-664-68,NDC,facility,both,1,ML,XU,29229,20460.3,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
KETAMINE 100 MG/ML INJ SOLN,51022,CDM,450,RC,J3490,HCPCS,0143-9509-01,NDC,facility,both,1,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
METHOTREXATE (PF) 25 MG/ML INJ SOLN (FOR ECTOPIC PREGNANCY),51022,CDM,260,RC,J9260,HCPCS,0143-9519-01,NDC,facility,both,1,ML,XS,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,51022,CDM,260,RC,J2354,HCPCS,23155-687-31,NDC,facility,both,1,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,51022,CDM,260,RC,J2250,HCPCS,0409-2308-21,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,51022,CDM,450,RC,J1815,HCPCS,49502-393-80,NDC,facility,both,1,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
FONDAPARINUX 5 MG/0.4 ML SUBQ SYRG,51022,CDM,260,RC,J1652,HCPCS,55111-679-11,NDC,facility,both,1,ML,,489,342.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN ASP PRT-INSULIN ASPART 100 UNIT/ML (70-30) SUBQ SOLN,51022,CDM,260,RC,J1817,HCPCS,73070-200-11,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,51022,CDM,450,RC,J3490,HCPCS,0409-2051-15,NDC,facility,both,1,ML,XS,24,16.8,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,16714-016-01,NDC,facility,both,1,ML,,209,146.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,51022,CDM,260,RC,J1100,HCPCS,63323-165-01,NDC,facility,both,1,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPOETIN ALFA 10000 UNIT/ML INJ SOLN,51022,CDM,260,RC,J0885,HCPCS,59676-310-00,NDC,facility,both,1,ML,,757,529.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ (MERGE),51022,CDM,450,RC,J2250,HCPCS,0409-0001-01,NDC,facility,both,1,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
INSULIN NPH & REGULAR HUMAN 100 UNIT/ML (70-30) SUBQ SUSP,51022,CDM,450,RC,J1815,HCPCS,0002-8715-01,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL DECANOATE 100 MG/ML IM SOLN,51022,CDM,260,RC,J1631,HCPCS,70069-383-10,NDC,facility,both,1,ML,,238,166.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,51022,CDM,450,RC,J3490,HCPCS,65219-186-01,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE (PF) 25 MG/ML INJ SOLN (FOR ECTOPIC PREGNANCY),51022,CDM,450,RC,J9260,HCPCS,0143-9519-01,NDC,facility,both,1,ML,XS,23,16.1,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML IM SOLN,51022,CDM,450,RC,90375,HCPCS,13533-318-05,NDC,facility,both,1,ML,,6262,4383.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE NA (PRESERV FREE) 25 MG/ML INJ SOLN,51022,CDM,260,RC,J9260,HCPCS,16729-277-35,NDC,facility,both,1,ML,,2013,1409.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,51022,CDM,450,RC,J3490,HCPCS,0409-2051-15,NDC,facility,both,1,ML,XS,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,51022,CDM,260,RC,J0630,HCPCS,43598-051-11,NDC,facility,both,1,ML,,5179,3625.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,51022,CDM,260,RC,J1644,HCPCS,0641-0400-37,NDC,facility,both,1,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",51022,CDM,260,RC,J3490,HCPCS,63323-185-07,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEPOLIZUMAB 100 MG SUBQ SOLR,51022,CDM,260,RC,J2182,HCPCS,0173-0881-01,NDC,facility,both,1,EA,,21321,14924.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,16714-046-01,NDC,facility,both,1,ML,,229,160.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN NPH HUMAN RECOMB 100 UNIT/ML SUBQ SUSP,51022,CDM,450,RC,J1815,HCPCS,0169-1834-11,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,51022,CDM,450,RC,J3490,HCPCS,0143-9509-01,NDC,facility,both,1,ML,XU,30,21,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,51022,CDM,260,RC,J3420,HCPCS,70069-005-10,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 150 MG/1 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,0955-1015-01,NDC,facility,both,1,ML,,170,119,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,51022,CDM,450,RC,J3490,HCPCS,0143-9509-01,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),51022,CDM,450,RC,J2270,HCPCS,63323-454-00,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,51022,CDM,260,RC,J1815,HCPCS,0088-2220-33,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG/ML INJ SOLN,51022,CDM,450,RC,J2550,HCPCS,0641-0928-21,NDC,facility,both,1,ML,XS,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
EPINEPHRINE 1 MG/ML INJ SOLN,51022,CDM,260,RC,J0171,HCPCS,76329-9060-0,NDC,facility,both,1,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),51022,CDM,260,RC,J1171,HCPCS,76045-009-96,NDC,facility,both,1,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL DECANOATE 100 MG/ML IM SOLN,51022,CDM,450,RC,J1631,HCPCS,70756-616-10,NDC,facility,both,1,ML,,159,111.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 6 MG/0.5 ML SUBQ PEN KIT,51022,CDM,450,RC,J3030,HCPCS,72603-141-01,NDC,facility,both,1,ML,XS,406,284.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
DARBEPOETIN ALFA IN POLYSORBAT  40 MCG/0.4 ML INJ SYRG,51022,CDM,260,RC,J0881,HCPCS,55513-021-01,NDC,facility,both,1,ML,PLAD,1096,767.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
INSULIN DEGLUDEC 100 UNITS/ML SUBQ SOLN,51022,CDM,260,RC,J1815,HCPCS,73070-400-11,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 100 MG/1 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,0781-3268-05,NDC,facility,both,1,ML,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,51022,CDM,260,RC,J3490,HCPCS,42023-115-10,NDC,facility,both,1,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE (CONTRACEPTIVE) 150 MG/ML IM SUSP,51022,CDM,450,RC,J1050,HCPCS,55150-329-01,NDC,facility,both,1,ML,,215,150.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.3 MG/0.3 ML IM PNIJ,51022,CDM,450,RC,J0169,HCPCS,49502-102-01,NDC,facility,both,1,EA,,675,472.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL,51022,CDM,260,RC,J1071,HCPCS,0409-6562-01,NDC,facility,both,1,ML,,130,91,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,0955-1004-01,NDC,facility,both,1,ML,XS,51,35.7,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
LEVOTHYROXINE 500 MCG INJ SOLR,51022,CDM,260,RC,J3490,HCPCS,63323-648-10,NDC,facility,both,1,EA,,1458,1020.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE NA (PRESERV FREE) 25 MG/ML INJ SOLN,51022,CDM,260,RC,J9260,HCPCS,61703-408-41,NDC,facility,both,1,ML,,1078,754.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,51022,CDM,450,RC,J3360,HCPCS,0409-1273-03,NDC,facility,both,1,ML,,198,138.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FILGRASTIM-SNDZ 480 MCG/0.8 ML INJ SYRG,51022,CDM,260,RC,Q5101,HCPCS,61314-326-01,NDC,facility,both,1,ML,,1212,848.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",51022,CDM,450,RC,J3490,HCPCS,0409-4887-17,NDC,facility,both,1,ML,XS,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,51022,CDM,450,RC,J3010,HCPCS,0409-9094-12,NDC,facility,both,1,ML,XS,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),51022,CDM,260,RC,J2060,HCPCS,0641-6044-01,NDC,facility,both,1,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
METHOTREXATE NA (PRESERV FREE) 25 MG/ML INJ SOLN,51022,CDM,260,RC,J9260,HCPCS,16729-277-35,NDC,facility,both,1,ML,,604,422.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN ASP PRT-INSULIN ASPART 100 UNIT/ML (70-30) SUBQ SOLN,51022,CDM,260,RC,J1817,HCPCS,0169-3685-12,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,51022,CDM,260,RC,J3490,HCPCS,0169-1833-11,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 50 MG/ML INJECTION,51022,CDM,450,RC,J1200,HCPCS,0641-0376-21,NDC,facility,both,1,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,51022,CDM,260,RC,J0630,HCPCS,24201-400-02,NDC,facility,both,1,ML,,2774,1941.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,16714-026-10,NDC,facility,both,1,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,51022,CDM,260,RC,J0585,HCPCS,0023-1145-01,NDC,facility,both,1,EA,XS,1439,1007.3,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
KETAMINE 100 MG/ML INJ SOLN,51022,CDM,450,RC,J3490,HCPCS,0409-2051-15,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,51022,CDM,450,RC,J2405,HCPCS,23155-547-31,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  100 MCG/ML INJ SOLN,51022,CDM,260,RC,J2354,HCPCS,0641-6175-01,NDC,facility,both,1,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 30 MG/0.3 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,0548-5601-00,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,0548-5603-00,NDC,facility,both,1,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,51022,CDM,260,RC,J0780,HCPCS,25021-790-02,NDC,facility,both,1,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ORPHENADRINE CITRATE 30 MG/ML INJ SOLN,51022,CDM,450,RC,J2360,HCPCS,25021-651-02,NDC,facility,both,1,ML,XU,71,49.7,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,51022,CDM,260,RC,J0630,HCPCS,63323-865-02,NDC,facility,both,1,ML,,1767,1236.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,0075-0622-01,NDC,facility,both,1,ML,,234,163.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),51022,CDM,450,RC,J1171,HCPCS,0409-1283-03,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",51022,CDM,450,RC,J3490,HCPCS,63323-185-08,NDC,facility,both,1,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,51022,CDM,450,RC,J3360,HCPCS,0641-6244-01,NDC,facility,both,1,ML,XS,73,51.1,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,51022,CDM,260,RC,J1815,HCPCS,0088-2220-33,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,16714-026-01,NDC,facility,both,1,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LANREOTIDE 120 MG/0.5 ML SUBQ SYRG,51022,CDM,260,RC,J1930,HCPCS,15054-1120-4,NDC,facility,both,1,ML,,26392,18474.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,51022,CDM,450,RC,J2310,HCPCS,0409-1215-21,NDC,facility,both,1,ML,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ORPHENADRINE CITRATE 30 MG/ML INJ SOLN,51022,CDM,450,RC,J2360,HCPCS,0641-6182-10,NDC,facility,both,1,ML,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),51022,CDM,260,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,51022,CDM,450,RC,J1885,HCPCS,63323-161-00,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPROST TROMETHAMINE 250 MCG/ML IM SOLN,51022,CDM,260,RC,J3490,HCPCS,0409-0064-01,NDC,facility,both,1,ML,XU,457,319.9,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
CEFTRIAXONE 1 GRAM INJ SOLR,51022,CDM,450,RC,J0696,HCPCS,60505-6148-0,NDC,facility,both,1,EA,,225,157.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN (PF) 10 MG/ML INJECTION (NEONATAL IM USE),51022,CDM,260,RC,J1580,HCPCS,63323-173-02,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZIPRASIDONE 20 MG IM,51022,CDM,450,RC,J3486,HCPCS,43598-848-11,NDC,facility,both,1,EA,XS,120,84,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
BETAMETHASONE ACET & SOD PHOS 6 MG/ML INJ SUSP,51022,CDM,260,RC,J0702,HCPCS,78206-118-01,NDC,facility,both,1,ML,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,51022,CDM,450,RC,J2310,HCPCS,0409-1215-21,NDC,facility,both,1,ML,XS,93,65.1,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
NALOXONE 0.4 MG/ML INJ SOLN,51022,CDM,450,RC,J2310,HCPCS,36000-308-01,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE NA (PRESERV FREE) 25 MG/ML INJ SOLN,51022,CDM,260,RC,J9260,HCPCS,0703-3678-01,NDC,facility,both,1,ML,,3124,2186.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DROPERIDOL 2.5 MG/ML INJ SOLN,51022,CDM,450,RC,J1790,HCPCS,0517-9702-01,NDC,facility,both,1,ML,XS,55,38.5,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
DROPERIDOL 2.5 MG/ML INJ SOLN,51022,CDM,450,RC,J1790,HCPCS,0517-9702-01,NDC,facility,both,1,ML,XU,57,39.9,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
DENOSUMAB-BBDZ 60 MG/ML SUBQ SYRG,51022,CDM,260,RC,61314-240-63,NDC,,,facility,both,1,ML,,4428,3099.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN DEGLUDEC 100 UNITS/ML SUBQ SOLN,51022,CDM,260,RC,J1815,HCPCS,73070-400-11,NDC,facility,both,1,ML,XU,21,14.7,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
CEFAZOLIN   1 GRAM INJ SOLR,51022,CDM,450,RC,J0690,HCPCS,44567-707-25,NDC,facility,both,1,EA,XU,22,15.4,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
DENOSUMAB 60 MG/ML SUBQ SYRG,51022,CDM,260,RC,J0897,HCPCS,55513-710-01,NDC,facility,both,1,ML,XS,4930,3451,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
NALOXONE 0.4 MG/ML INJ SOLN,51022,CDM,450,RC,J2312,HCPCS,0409-1215-01,NDC,facility,both,1,ML,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ORPHENADRINE CITRATE 30 MG/ML INJ SOLN,51022,CDM,260,RC,J2360,HCPCS,0641-6182-01,NDC,facility,both,1,ML,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML INJ SOLN,51022,CDM,260,RC,J0171,HCPCS,76329-9060-0,NDC,facility,both,1,ML,,189,132.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYTOCIN 10 UNIT/ML INJ SOLN,51022,CDM,260,RC,J2590,HCPCS,63323-012-03,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),51022,CDM,450,RC,J1171,HCPCS,0409-4264-11,NDC,facility,both,1,ML,XU,43,30.1,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),51022,CDM,260,RC,J3490,HCPCS,0641-6236-01,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ICATIBANT 30 MG/3 ML SUBQ SYRG,51022,CDM,450,RC,J1744,HCPCS,69097-664-68,NDC,facility,both,1,ML,XS,29229,20460.3,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
HYDROCORTISONE SOD SUCC (PF) 100 MG/2 ML INJ SOLR,51022,CDM,260,RC,J1720,HCPCS,0009-0011-03,NDC,facility,both,1,EA,,126,88.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE (PF) 25 MG/ML INJ SOLN (FOR ECTOPIC PREGNANCY),51022,CDM,450,RC,0143-9519-01,NDC,,,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,16714-036-01,NDC,facility,both,1,ML,XU,94,65.8,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
GENTAMICIN 40 MG/ML INJ SOLN,51022,CDM,450,RC,J1580,HCPCS,63323-010-02,NDC,facility,both,1,ML,XU,93,65.1,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),51022,CDM,450,RC,J1630,HCPCS,0143-9319-25,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FILGRASTIM 300 (NEUPOGEN) MCG/ML INJ SOLN,51022,CDM,450,RC,J1442,HCPCS,55513-530-01,NDC,facility,both,1,ML,,1115,780.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),51022,CDM,450,RC,J2270,HCPCS,0641-6125-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",51022,CDM,260,RC,J3490,HCPCS,0409-4887-10,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,51022,CDM,260,RC,J2359,HCPCS,0781-3159-72,NDC,facility,both,1,EA,,406,284.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 100 MG/1 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,0075-0623-03,NDC,facility,both,1,ML,XU,146,102.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
OMALIZUMAB 150 MG SUBQ SOLR,51022,CDM,260,RC,J2357,HCPCS,50242-040-62,NDC,facility,both,1,ME,,3914,2739.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,51022,CDM,450,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,51022,CDM,450,RC,J2359,HCPCS,55150-308-01,NDC,facility,both,1,EA,,208,145.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),51022,CDM,450,RC,J2270,HCPCS,0409-1891-03,NDC,facility,both,1,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,0548-5604-00,NDC,facility,both,1,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,51022,CDM,260,RC,J1644,HCPCS,0409-2723-30,NDC,facility,both,1,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,16714-036-01,NDC,facility,both,1,ML,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN DEGLUDEC 100 UNITS/ML SUBQ SOLN,51022,CDM,450,RC,J1815,HCPCS,0169-2662-11,NDC,facility,both,1,ML,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),51022,CDM,450,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EXENATIDE 10 MCG/0.04 ML SUBQ PNIJ,51022,CDM,260,RC,J3490,HCPCS,0310-6524-01,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT  60 MCG/0.3 ML INJ SYRG,51022,CDM,260,RC,J0881,HCPCS,55513-023-04,NDC,facility,both,1,ML,,2564,1794.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 120 MG/0.8 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,0955-1012-01,NDC,facility,both,1,ML,,151,105.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,51022,CDM,260,RC,J3360,HCPCS,43598-106-11,NDC,facility,both,1,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE (PF) 25 MG/ML INJ SOLN (FOR ECTOPIC PREGNANCY),51022,CDM,450,RC,J9260,HCPCS,0143-9519-01,NDC,facility,both,1,ML,XS,40,28,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,51022,CDM,260,RC,J2354,HCPCS,0641-6174-01,NDC,facility,both,1,ML,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,51022,CDM,450,RC,J0690,HCPCS,60505-6142-0,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,51022,CDM,450,RC,J1885,HCPCS,63323-162-00,NDC,facility,both,1,ML,XU,19,13.3,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
DICYCLOMINE 10 MG/ML IM SOLN,51022,CDM,450,RC,J0500,HCPCS,72266-127-01,NDC,facility,both,1,ML,,145,101.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,51022,CDM,260,RC,J0696,HCPCS,0781-3208-85,NDC,facility,both,1,EA,,225,157.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,51022,CDM,260,RC,J1580,HCPCS,63323-010-01,NDC,facility,both,1,ML,XU,54,37.8,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,51022,CDM,450,RC,J1100,HCPCS,63323-506-00,NDC,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE (PF) 25 MG/ML INJ SOLN (FOR ECTOPIC PREGNANCY),51022,CDM,260,RC,J9260,HCPCS,0143-9519-01,NDC,facility,both,1,ML,,197,137.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),51022,CDM,260,RC,J1610,HCPCS,63323-593-03,NDC,facility,both,1,EA,,895,626.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE NA (PRESERV FREE) 25 MG/ML INJ SOLN,51022,CDM,260,RC,J9260,HCPCS,16729-277-03,NDC,facility,both,1,ML,,2021,1414.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL,51022,CDM,260,RC,J1071,HCPCS,0409-6562-01,NDC,facility,both,1,ML,,129,90.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 250 MG INJ SOLR,51022,CDM,260,RC,J0696,HCPCS,0409-7337-11,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,16714-016-01,NDC,facility,both,1,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,51022,CDM,450,RC,J2250,HCPCS,0409-2305-04,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,51022,CDM,450,RC,J3490,HCPCS,0143-9509-01,NDC,facility,both,1,ML,XU,36,25.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
EPHEDRINE 50 MG/ML IV SOLN (MERGE),51022,CDM,260,RC,J3490,HCPCS,70756-611-82,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),51022,CDM,450,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML (PEDS CALCLUATOR 0.5),51022,CDM,260,RC,J1815,HCPCS,0024-5924-10,NDC,facility,both,1,ML,,1695,1186.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE (CONTRACEPTIVE) 150 MG/ML IM SUSP,51022,CDM,450,RC,J1050,HCPCS,0548-5400-00,NDC,facility,both,1,ML,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 2400000 UNIT/4 ML IM SYRG,51022,CDM,260,RC,J0561,HCPCS,60793-702-04,NDC,facility,both,1,ML,,1898,1328.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),51022,CDM,260,RC,J1610,HCPCS,63323-596-11,NDC,facility,both,1,EA,,895,626.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 100 MG/1 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,0781-3268-05,NDC,facility,both,1,ML,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",51022,CDM,260,RC,J3490,HCPCS,0409-4887-17,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DENOSUMAB 60 MG/ML SUBQ SYRG,51022,CDM,260,RC,J0897,HCPCS,55513-710-01,NDC,facility,both,1,ML,,4930,3451,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 50 MG/ML INJECTION,51022,CDM,260,RC,J1200,HCPCS,0641-0376-21,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,16714-026-01,NDC,facility,both,1,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,51022,CDM,450,RC,J1644,HCPCS,0641-0400-37,NDC,facility,both,1,ML,XU,26,18.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),51022,CDM,450,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,1,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
LEVOTHYROXINE 500 MCG INJ SOLR,51022,CDM,260,RC,J3490,HCPCS,63323-648-10,NDC,facility,both,1,EA,,2915,2040.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,51022,CDM,260,RC,J1644,HCPCS,0409-2723-30,NDC,facility,both,1,ML,XS,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
HYALURONIDASE 150 UNIT/ML INJ SOLN,51022,CDM,260,RC,J3473,HCPCS,18657-117-01,NDC,facility,both,1,ML,,568,397.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,51022,CDM,260,RC,J0585,HCPCS,0023-1145-01,NDC,facility,both,1,EA,,4795,3356.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE (3 MONTH) 11.25 MG IM KIT,51022,CDM,260,RC,J1950,HCPCS,0074-3663-03,NDC,facility,both,1,EA,XU,14914,10439.8,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,51022,CDM,260,RC,J1644,HCPCS,25021-402-01,NDC,facility,both,1,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,16714-016-01,NDC,facility,both,1,ML,XU,53,37.1,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
DARBEPOETIN ALFA IN POLYSORBAT 100 MCG/0.5 ML INJ SYRG,51022,CDM,260,RC,J0881,HCPCS,55513-025-01,NDC,facility,both,1,ML,,2137,1495.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,51022,CDM,260,RC,J2270,HCPCS,0409-1890-03,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),51022,CDM,260,RC,J1815,HCPCS,0024-5926-05,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 10 MG/ML IM SOLN,51022,CDM,450,RC,J0500,HCPCS,17478-015-02,NDC,facility,both,1,ML,,385,269.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,51022,CDM,260,RC,J3360,HCPCS,0409-1273-03,NDC,facility,both,1,ML,,198,138.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),51022,CDM,450,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,1,ML,"XS,XU",16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
ENOXAPARIN 120 MG/0.8 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,16714-056-01,NDC,facility,both,1,ML,,141,98.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE 25 MG/ML INJ SOLN,51022,CDM,450,RC,J3230,HCPCS,70710-1850-1,NDC,facility,both,1,ML,,336,235.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,51022,CDM,450,RC,J0630,HCPCS,63323-865-02,NDC,facility,both,1,ML,,1248,873.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,51022,CDM,450,RC,J1100,HCPCS,0641-6145-01,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,51022,CDM,450,RC,J3360,HCPCS,43598-106-11,NDC,facility,both,1,ML,,145,101.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYTARABINE 100 MG/ML INJ SOLN,51022,CDM,260,RC,J9100,HCPCS,61703-319-22,NDC,facility,both,1,ML,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE (PEDIATRIC 6 MONTH) 45 MG IM SYKT,51022,CDM,260,RC,J1950,HCPCS,0074-3575-01,NDC,facility,both,1,EA,,71748,50223.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,51022,CDM,260,RC,J1644,HCPCS,0641-0400-37,NDC,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,51022,CDM,450,RC,J2354,HCPCS,25021-463-01,NDC,facility,both,1,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,51022,CDM,260,RC,J1815,HCPCS,0088-2220-33,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE 25 MG/ML INJ SOLN,51022,CDM,260,RC,J3230,HCPCS,55150-319-01,NDC,facility,both,1,ML,,195,136.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,51022,CDM,450,RC,J0630,HCPCS,42023-205-01,NDC,facility,both,1,ML,,6266,4386.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL,51022,CDM,260,RC,J1071,HCPCS,0574-0827-01,NDC,facility,both,1,ML,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE (PF) 1 MG/ML INJ SOLN,51022,CDM,260,RC,J0171,HCPCS,54288-103-01,NDC,facility,both,1,ML,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,51022,CDM,450,RC,J0690,HCPCS,44567-707-25,NDC,facility,both,1,EA,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
OCTREOTIDE ACETATE  100 MCG/ML INJ SOLN,51022,CDM,260,RC,J2354,HCPCS,23155-688-31,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,51022,CDM,450,RC,J0696,HCPCS,44567-701-25,NDC,facility,both,1,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"RHO(D) IMMUNE GLOBULIN (RHOPHYLAC) 1,500 UNIT (300 MCG)/2 ML INJ SYRG",51022,CDM,450,RC,J2791,HCPCS,44206-300-90,NDC,facility,both,1,ML,,693,485.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,51022,CDM,450,RC,J1885,HCPCS,62332-600-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,51022,CDM,260,RC,J1815,HCPCS,0088-2220-33,NDC,facility,both,1,ML,XS,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
DROPERIDOL 2.5 MG/ML INJ SOLN,51022,CDM,450,RC,J1790,HCPCS,0517-9702-01,NDC,facility,both,1,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,51022,CDM,450,RC,J1644,HCPCS,0641-0400-37,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ (MERGE),51022,CDM,260,RC,J2250,HCPCS,0409-0001-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),51022,CDM,450,RC,J2270,HCPCS,0409-1891-03,NDC,facility,both,1,ML,XS,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
"OCTREOTIDE,MICROSPHERES 30 MG IM SERR",51022,CDM,260,RC,J2353,HCPCS,0078-0825-81,NDC,facility,both,1,EA,,19079,13355.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN ASP PRT-INSULIN ASPART 100 UNIT/ML (70-30) SUBQ SOLN,51022,CDM,260,RC,J1817,HCPCS,0169-3685-12,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),51022,CDM,450,RC,J2270,HCPCS,0409-1891-03,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,16714-026-01,NDC,facility,both,1,ML,XS,70,49,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),51022,CDM,450,RC,J1630,HCPCS,63323-474-00,NDC,facility,both,1,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
METHOTREXATE (PF) 25 MG/ML INJ SOLN (FOR ECTOPIC PREGNANCY),51022,CDM,450,RC,J9260,HCPCS,0143-9519-01,NDC,facility,both,1,ML,XS,35,24.5,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),51022,CDM,450,RC,J1171,HCPCS,0409-4264-11,NDC,facility,both,1,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),51022,CDM,450,RC,J1171,HCPCS,0641-6206-01,NDC,facility,both,1,ML,XU,85,59.5,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
CHLORPROMAZINE 25 MG/ML INJ SOLN,51022,CDM,450,RC,J3230,HCPCS,55150-319-01,NDC,facility,both,1,ML,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ICATIBANT 30 MG/3 ML SUBQ SYRG,51022,CDM,450,RC,J1744,HCPCS,69097-664-68,NDC,facility,both,1,ML,,29229,20460.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),51022,CDM,260,RC,J1815,HCPCS,0024-5926-05,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),51022,CDM,260,RC,J1171,HCPCS,76045-009-96,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,51022,CDM,260,RC,J9041,HCPCS,70710-1411-1,NDC,facility,both,1,EA,,555,388.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),51022,CDM,260,RC,J3490,HCPCS,0641-6236-01,NDC,facility,both,1,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,51022,CDM,450,RC,J0696,HCPCS,0781-3208-85,NDC,facility,both,1,EA,,225,157.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENRALIZUMAB 30 MG/ML SUBQ SYRG,51022,CDM,260,RC,J0517,HCPCS,0310-1730-30,NDC,facility,both,1,ML,,13116,9181.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,51022,CDM,260,RC,J1644,HCPCS,0641-0400-12,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLERGONOVINE 0.2 MG/ML (1 ML) INJ SOLN,51022,CDM,260,RC,J2210,HCPCS,0517-0740-01,NDC,facility,both,1,ML,XU,184,128.8,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
DARBEPOETIN ALFA IN POLYSORBAT  40 MCG/0.4 ML INJ SYRG,51022,CDM,260,RC,J0881,HCPCS,55513-021-01,NDC,facility,both,1,ML,,1096,767.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLERGONOVINE 0.2 MG/ML (1 ML) INJ SOLN,51022,CDM,260,RC,J2210,HCPCS,0517-0740-01,NDC,facility,both,1,ML,,184,128.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,16714-046-01,NDC,facility,both,1,ML,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 100 MG/1 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,0781-3268-05,NDC,facility,both,1,ML,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,51022,CDM,450,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,1,ML,XS,35,24.5,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
DICYCLOMINE 10 MG/ML IM SOLN,51022,CDM,450,RC,J0500,HCPCS,58914-080-52,NDC,facility,both,1,ML,XS,364,254.8,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
INSULIN NPH & REGULAR HUMAN 100 UNIT/ML (70-30) SUBQ SUSP,51022,CDM,260,RC,J1815,HCPCS,0169-1837-11,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENTOLAMINE 5 MG INJ SOLR,51022,CDM,260,RC,J3490,HCPCS,0143-9564-01,NDC,facility,both,1,EA,,2461,1722.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZIPRASIDONE 20 MG IM,51022,CDM,450,RC,J3486,HCPCS,0049-3920-20,NDC,facility,both,1,EA,,328,229.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,25021-410-76,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML INJ SOLN,51022,CDM,260,RC,J0171,HCPCS,76329-9060-0,NDC,facility,both,1,ML,XU,797,557.9,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,51022,CDM,260,RC,J3420,HCPCS,69680-112-01,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),51022,CDM,260,RC,J2270,HCPCS,0409-1891-03,NDC,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),51022,CDM,450,RC,J1630,HCPCS,63323-474-00,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",51022,CDM,450,RC,J3490,HCPCS,0641-6147-01,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,51022,CDM,260,RC,J1885,HCPCS,72266-118-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),51022,CDM,260,RC,J1171,HCPCS,76045-009-96,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN PUMP LISPRO (PATIENT OWN PUMP PHS SUPPLIED),51022,CDM,260,RC,J1815,HCPCS,0002-7510-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,51022,CDM,260,RC,J0696,HCPCS,44567-701-25,NDC,facility,both,1,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 120 MG/0.8 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,0955-1012-01,NDC,facility,both,1,ML,XS,151,105.7,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,51022,CDM,260,RC,J1885,HCPCS,62332-600-01,NDC,facility,both,1,ML,XS,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
METHOTREXATE (PF) 25 MG/ML INJ SOLN (FOR ECTOPIC PREGNANCY),51022,CDM,260,RC,J9260,HCPCS,0143-9519-01,NDC,facility,both,1,ML,XU,41,28.7,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,51022,CDM,260,RC,J0630,HCPCS,42023-205-01,NDC,facility,both,1,ML,,8642,6049.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM BICARBONATE 8.4 % IV (PHS ERX MERGE),51022,CDM,450,RC,J3490,HCPCS,51754-5011-1,NDC,facility,both,1,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN DEGLUDEC 100 UNITS/ML SUBQ SOLN,51022,CDM,260,RC,J1815,HCPCS,0169-2662-11,NDC,facility,both,1,ML,XS,120,84,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,0781-3246-02,NDC,facility,both,1,ML,"XS,XU",55,38.5,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,16714-036-01,NDC,facility,both,1,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,51022,CDM,450,RC,J0561,HCPCS,60793-701-02,NDC,facility,both,1,ML,,1188,831.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),51022,CDM,260,RC,J1630,HCPCS,67457-426-00,NDC,facility,both,1,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,51022,CDM,450,RC,J1644,HCPCS,25021-402-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,51022,CDM,450,RC,J3010,HCPCS,0409-9094-12,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,51022,CDM,450,RC,J3490,HCPCS,0143-9509-01,NDC,facility,both,1,ML,XS,21,14.7,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),51022,CDM,260,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,2,ML,XS,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),51022,CDM,450,RC,J1630,HCPCS,63323-474-00,NDC,facility,both,1,ML,XS,40,28,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
MEDROXYPROGESTERONE (CONTRACEPTIVE) 150 MG/ML IM (MERGE),51022,CDM,260,RC,J1050,HCPCS,0009-7376-11,NDC,facility,both,1,ML,XU,280,196,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,0955-1004-01,NDC,facility,both,1,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 20 MG/ML INJ SOLN,51022,CDM,260,RC,J0360,HCPCS,0641-6231-01,NDC,facility,both,1,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,51022,CDM,450,RC,J3490,HCPCS,42023-115-10,NDC,facility,both,1,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML (PEDS CALCLUATOR 0.5),51022,CDM,260,RC,J1815,HCPCS,0024-5924-10,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,51022,CDM,260,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,1,EA,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,51022,CDM,450,RC,J1885,HCPCS,63323-162-03,NDC,facility,both,1,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  100 MCG/ML INJ SOLN,51022,CDM,260,RC,J2354,HCPCS,23155-688-31,NDC,facility,both,1,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALTREXONE MICROSPHERES 380 MG IM SERR,51022,CDM,260,RC,J2315,HCPCS,65757-300-01,NDC,facility,both,1,EA,,4666,3266.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG/ML INJ SOLN,51022,CDM,450,RC,J2550,HCPCS,0641-6084-01,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",51022,CDM,450,RC,J3490,HCPCS,63323-185-10,NDC,facility,both,1,ML,XU,30,21,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
INSULIN ASP PRT-INSULIN ASPART 100 UNIT/ML (70-30) SUBQ SOLN,51022,CDM,450,RC,J1817,HCPCS,73070-200-11,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE LAUROXIL 662 MG/2.4 ML IM SERS,51022,CDM,260,RC,J1944,HCPCS,65757-402-03,NDC,facility,both,1,ML,,6592,4614.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 250 MCG SUBQ SOLR,51022,CDM,260,RC,J2802,HCPCS,55513-221-01,NDC,facility,both,1,EA,,8780,6146,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,51022,CDM,450,RC,J1817,HCPCS,0169-1833-11,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL DECANOATE  50 MG/ML IM SOLN,51022,CDM,450,RC,J1631,HCPCS,70069-030-01,NDC,facility,both,1,ML,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIHYDROERGOTAMINE 1 MG/ML INJ SOLN,51022,CDM,260,RC,J1110,HCPCS,0143-9273-01,NDC,facility,both,1,ML,,646,452.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CERTOLIZUMAB PEGOL 400 MG (200 MG X 2) SUBQ KIT,51022,CDM,260,RC,J0717,HCPCS,50474-700-62,NDC,facility,both,2,EA,,6646,4652.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIRAGLUTIDE 0.6 MG/0.1 ML (18 MG/3 ML) SUBQ PNIJ,51022,CDM,260,RC,J3590,HCPCS,0480-3667-19,NDC,facility,both,1,ML,,1426,998.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 2400000 UNIT/4 ML IM SYRG,51022,CDM,450,RC,J0561,HCPCS,60793-702-04,NDC,facility,both,1,ML,,1725,1207.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT 25 MCG/0.42 ML INJ SYRG,51022,CDM,260,RC,J0881,HCPCS,55513-057-01,NDC,facility,both,1,ML,XU,836,585.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
EPINEPHRINE 1 MG/ML INJ SOLN,51022,CDM,260,RC,J0171,HCPCS,76329-9060-0,NDC,facility,both,1,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYTOCIN 10 UNIT/ML INJ SOLN,51022,CDM,260,RC,J2590,HCPCS,42023-116-25,NDC,facility,both,1,ML,XS,24,16.8,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
TERBUTALINE 1 MG/ML SUBQ SOLN,51022,CDM,450,RC,J3105,HCPCS,0143-9746-01,NDC,facility,both,1,ML,XS,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,51022,CDM,450,RC,J1815,HCPCS,0088-2220-33,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,51022,CDM,450,RC,J1644,HCPCS,0641-0400-12,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 120 MG/0.8 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,0955-1012-01,NDC,facility,both,1,ML,,151,105.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,51022,CDM,260,RC,J0630,HCPCS,42023-205-01,NDC,facility,both,1,ML,,6136,4295.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,51022,CDM,450,RC,J2250,HCPCS,0409-2308-02,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 2400000 UNIT/4 ML IM SYRG,51022,CDM,260,RC,J0561,HCPCS,60793-702-04,NDC,facility,both,1,ML,,1725,1207.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,51022,CDM,450,RC,J2310,HCPCS,36000-308-01,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALTREXONE MICROSPHERES 380 MG IM SERR,51022,CDM,450,RC,J2315,HCPCS,65757-302-02,NDC,facility,both,1,EA,XS,4666,3266.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
CHLORPROMAZINE 25 MG/ML INJ SOLN,51022,CDM,260,RC,J3230,HCPCS,43598-141-11,NDC,facility,both,1,ML,,336,235.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),51022,CDM,260,RC,J3490,HCPCS,70004-600-09,NDC,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMOSOZUMAB-AQQG 210MG/2.34ML ( 105MG/1.17MLX2) SUBQ SYRG,51022,CDM,260,RC,J3111,HCPCS,55513-998-02,NDC,facility,both,2,ML,,5894,4125.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),51022,CDM,450,RC,J1611,HCPCS,63323-596-11,NDC,facility,both,1,EA,,1789,1252.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,51022,CDM,260,RC,J1815,HCPCS,0002-8215-01,NDC,facility,both,1,ML,XS,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
CEFAZOLIN   1 GRAM INJ SOLR,51022,CDM,450,RC,J0690,HCPCS,60505-6142-0,NDC,facility,both,1,EA,XS,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
EPINEPHRINE 0.15 MG/0.3 ML IM PNIJ,51022,CDM,450,RC,J0169,HCPCS,49502-101-01,NDC,facility,both,1,EA,,675,472.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,51022,CDM,450,RC,J3420,HCPCS,63323-044-00,NDC,facility,both,1,ML,PLAD,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,51022,CDM,450,RC,J0780,HCPCS,0641-6135-01,NDC,facility,both,1,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  100 MCG/ML INJ SOLN,51022,CDM,260,RC,J2354,HCPCS,68462-896-01,NDC,facility,both,1,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,51022,CDM,450,RC,J2359,HCPCS,0781-3159-72,NDC,facility,both,1,EA,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,51022,CDM,260,RC,J0585,HCPCS,0023-1145-01,NDC,facility,both,1,EA,XS,6233,4363.1,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
DARBEPOETIN ALFA IN POLYSORBAT  40 MCG/0.4 ML INJ SYRG,51022,CDM,260,RC,J0881,HCPCS,55513-021-01,NDC,facility,both,1,ML,XU,1096,767.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),51022,CDM,260,RC,J1815,HCPCS,0024-5926-05,NDC,facility,both,2,ML,XS,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
METHYLERGONOVINE 0.2 MG/ML (1 ML) INJ SOLN,51022,CDM,260,RC,J2210,HCPCS,0517-0740-01,NDC,facility,both,1,ML,,1836,1285.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,51022,CDM,450,RC,J3490,HCPCS,0143-9509-01,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BORTEZOMIB 3.5 MG IV SOLR,51022,CDM,260,RC,J9041,HCPCS,10019-991-01,NDC,facility,both,1,EA,,266,186.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 10 MG/ML (PF) IV SOLN,51022,CDM,450,RC,J2270,HCPCS,0641-6127-01,NDC,facility,both,1,ML,XU,17,11.9,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
DARBEPOETIN ALFA IN POLYSORBAT  25 MCG/ML INJ SOLN,51022,CDM,450,RC,J0881,HCPCS,55513-002-01,NDC,facility,both,1,ML,,836,585.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),51022,CDM,260,RC,J3490,HCPCS,70004-600-09,NDC,facility,both,1,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML (PEDS CALCLUATOR 0.5),51022,CDM,260,RC,J1815,HCPCS,0024-5924-10,NDC,facility,both,1,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,51022,CDM,260,RC,J2597,HCPCS,70095-026-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN DETEMIR 100 UNIT/ML SUBQ SOLN,51022,CDM,450,RC,J1815,HCPCS,0169-3687-12,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,51022,CDM,450,RC,J0561,HCPCS,60793-700-01,NDC,facility,both,1,ML,,3018,2112.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 500 MG INJ SOLR,51022,CDM,260,RC,J0696,HCPCS,0409-7338-11,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,51022,CDM,260,RC,J1580,HCPCS,63323-010-01,NDC,facility,both,1,ML,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,0548-5603-00,NDC,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 30 MG/0.3 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,16714-006-01,NDC,facility,both,1,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,0548-5603-00,NDC,facility,both,1,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 1200000 UNIT/2 ML IM SYRG,51022,CDM,450,RC,J0561,HCPCS,60793-702-10,NDC,facility,both,1,ML,,1898,1328.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,51022,CDM,450,RC,J0630,HCPCS,42023-205-01,NDC,facility,both,1,ML,,5056,3539.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL DECANOATE  50 MG/ML IM SOLN,51022,CDM,260,RC,J1631,HCPCS,10147-0921-3,NDC,facility,both,1,ML,,152,106.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,51022,CDM,260,RC,J1644,HCPCS,0409-2723-30,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN NEO/PEDIATRIC SYRINGE < 30 MG,51022,CDM,260,RC,J1650,HCPCS,0548-5608-00,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,51022,CDM,450,RC,J0561,HCPCS,60793-701-02,NDC,facility,both,1,ML,XS,2613,1829.1,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
OXYTOCIN 10 UNIT/ML INJ SOLN,51022,CDM,260,RC,J2590,HCPCS,63323-012-11,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 2400000 UNIT/4 ML IM SYRG,51022,CDM,450,RC,J0561,HCPCS,60793-702-04,NDC,facility,both,1,ML,,2088,1461.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE (PF) 25 MG/ML INJ SOLN (FOR ECTOPIC PREGNANCY),51022,CDM,450,RC,J9260,HCPCS,0143-9519-01,NDC,facility,both,1,ML,XS,37,25.9,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,51022,CDM,260,RC,J0780,HCPCS,25021-790-02,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,51022,CDM,450,RC,J2597,HCPCS,43598-931-11,NDC,facility,both,1,ML,,910,637,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG SUBQ SOLR,51022,CDM,260,RC,J2802,HCPCS,55513-222-01,NDC,facility,both,1,EA,,8780,6146,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),51022,CDM,260,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,1,ML,XU,28,19.6,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
METHYLNALTREXONE 12 MG/0.6 ML SUBQ SYRG,51022,CDM,260,RC,J2212,HCPCS,65649-552-04,NDC,facility,both,1,ML,,735,514.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 100 MG/1 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,0781-3268-05,NDC,facility,both,1,ML,,233,163.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML IM SOLN,51022,CDM,450,RC,90375,HCPCS,13533-318-05,NDC,facility,both,1,ML,,7694,5385.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,51022,CDM,450,RC,J2354,HCPCS,23155-687-31,NDC,facility,both,1,ML,XS,20,14,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,51022,CDM,260,RC,J3420,HCPCS,63323-044-00,NDC,facility,both,1,ML,XS,23,16.1,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
OLANZAPINE 10 MG IM SOLR,51022,CDM,450,RC,J2359,HCPCS,55150-308-01,NDC,facility,both,1,EA,XU,208,145.6,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
ERTAPENEM 1 GRAM INJ SOLR,51022,CDM,450,RC,J1335,HCPCS,0143-9398-01,NDC,facility,both,1,EA,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,51022,CDM,450,RC,J3490,HCPCS,0143-9509-01,NDC,facility,both,1,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),51022,CDM,260,RC,J1610,HCPCS,63323-596-11,NDC,facility,both,1,EA,XU,895,626.5,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,51022,CDM,260,RC,J2597,HCPCS,43598-931-11,NDC,facility,both,1,ML,,892,624.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN 1 GRAM SOLUTION FOR INJECTION,51022,CDM,260,RC,J0290,HCPCS,0781-3404-85,NDC,facility,both,1,EA,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,51022,CDM,450,RC,J2359,HCPCS,0781-3159-72,NDC,facility,both,1,EA,,406,284.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 10 MG/ML IM SOLN,51022,CDM,450,RC,J0500,HCPCS,72266-127-01,NDC,facility,both,1,ML,XS,145,101.5,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,51022,CDM,260,RC,J2560,HCPCS,72162-1329-8,NDC,facility,both,1,ML,,257,179.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,51022,CDM,450,RC,J2270,HCPCS,0409-1890-03,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 150 MG/1 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,0955-1015-01,NDC,facility,both,1,ML,XU,170,119,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,51022,CDM,450,RC,J1815,HCPCS,49502-393-80,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,51022,CDM,260,RC,J1596,HCPCS,0143-9682-01,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,51022,CDM,450,RC,J0696,HCPCS,44567-701-25,NDC,facility,both,1,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 100 MG/1 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,63323-586-21,NDC,facility,both,1,ML,XU,55,38.5,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
ENOXAPARIN 150 MG/1 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,0548-5607-00,NDC,facility,both,1,ML,,133,93.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML IM SOLN,51022,CDM,450,RC,90375,HCPCS,13533-318-50,NDC,facility,both,1,ML,,9841,6888.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OMALIZUMAB 150 MG SUBQ SOLR,51022,CDM,260,RC,J2357,HCPCS,50242-040-62,NDC,facility,both,1,ME,,6524,4566.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE (CONTRACEPTIVE) 150 MG/ML IM SUSP,51022,CDM,450,RC,J1050,HCPCS,55150-329-01,NDC,facility,both,1,ML,XS,215,150.5,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
MORPHINE 10 MG/ML (PF) IV SOLN,51022,CDM,450,RC,J2270,HCPCS,0641-6127-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.3 MG/0.3 ML IM PNIJ,51022,CDM,450,RC,J0169,HCPCS,49502-500-01,NDC,facility,both,1,EA,XS,1078,754.6,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
INSULIN LISPRO 100 UNIT/ML (PEDS CALCLUATOR 0.5),51022,CDM,260,RC,J1815,HCPCS,0024-5924-10,NDC,facility,both,1,ML,XS,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,51022,CDM,450,RC,J1885,HCPCS,70860-700-41,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,51022,CDM,450,RC,J2310,HCPCS,0409-1215-01,NDC,facility,both,1,ML,XS,93,65.1,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
LEVOTHYROXINE 500 MCG INJ SOLR,51022,CDM,260,RC,J0650,HCPCS,63323-648-10,NDC,facility,both,1,EA,,1458,1020.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,51022,CDM,260,RC,J2359,HCPCS,0781-3159-72,NDC,facility,both,1,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",51022,CDM,260,RC,J3490,HCPCS,0409-4887-17,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),51022,CDM,450,RC,J1610,HCPCS,63323-596-11,NDC,facility,both,1,EA,XU,785,549.5,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,51022,CDM,260,RC,J0630,HCPCS,63323-865-02,NDC,facility,both,1,ML,,3809,2666.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,51022,CDM,260,RC,J2312,HCPCS,36000-308-01,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TERBUTALINE 1 MG/ML SUBQ SOLN,51022,CDM,450,RC,J3105,HCPCS,0143-9746-01,NDC,facility,both,1,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,51022,CDM,260,RC,J1815,HCPCS,83257-011-11,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),51022,CDM,260,RC,J2060,HCPCS,0641-6044-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,51022,CDM,260,RC,J1596,HCPCS,16714-536-01,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,51022,CDM,260,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG/ML INJ SOLN,51022,CDM,260,RC,J2550,HCPCS,0641-6084-01,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,51022,CDM,450,RC,J1644,HCPCS,0409-2723-30,NDC,facility,both,1,ML,XS,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
CERTOLIZUMAB PEGOL 400 MG (200 MG X 2) SUBQ KIT,51022,CDM,260,RC,J0717,HCPCS,50474-700-62,NDC,facility,both,1,EA,,3323,2326.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,0548-5603-00,NDC,facility,both,1,ML,XU,45,31.5,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
ENOXAPARIN 150 MG/1 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,0548-5607-00,NDC,facility,both,1,ML,XU,106,74.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
DIPHENHYDRAMINE 50 MG/ML INJECTION,51022,CDM,450,RC,J1200,HCPCS,0641-0376-21,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 10 MG/ML IM SOLN,51022,CDM,450,RC,J0500,HCPCS,0641-6173-01,NDC,facility,both,1,ML,XS,143,100.1,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
CEFTRIAXONE   2 GRAM INJ SOLR,51022,CDM,260,RC,J0696,HCPCS,0781-3209-90,NDC,facility,both,1,EA,,388,271.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE INFUSION 2MG/ML 100ML (FOR ANESTHESIA USE ONLY),51022,CDM,260,RC,J3490,HCPCS,0409-2051-05,NDC,facility,both,1,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,51022,CDM,260,RC,J0630,HCPCS,24201-400-02,NDC,facility,both,1,ML,,1756,1229.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,51022,CDM,450,RC,J0561,HCPCS,60793-700-01,NDC,facility,both,1,ML,,1509,1056.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 100 MG/1 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,0075-0623-03,NDC,facility,both,1,ML,,132,92.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,51022,CDM,450,RC,J2405,HCPCS,60505-6130-0,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.3 MG/0.3 ML IM PNIJ,51022,CDM,260,RC,J0169,HCPCS,0093-5986-19,NDC,facility,both,1,EA,XU,1024,716.8,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,51022,CDM,260,RC,J3301,HCPCS,70121-1049-2,NDC,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.3 MG/0.3 ML IM PNIJ,51022,CDM,260,RC,J0171,HCPCS,49502-500-01,NDC,facility,both,1,EA,,1078,754.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,51022,CDM,260,RC,J1815,HCPCS,0088-2220-33,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 30 MG/0.3 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,25021-410-70,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),51022,CDM,260,RC,J3490,HCPCS,73013-2002-2,NDC,facility,both,1,ML,,133,93.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 30 MG/0.3 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,0075-0624-01,NDC,facility,both,1,ML,XU,50,35,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,51022,CDM,260,RC,J1885,HCPCS,0409-3796-19,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOSTIGMINE METHYLSULFATE 1 MG/ML IV SOLN,51022,CDM,260,RC,J2710,HCPCS,42023-189-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,51022,CDM,260,RC,J2359,HCPCS,55150-308-01,NDC,facility,both,1,EA,,416,291.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ (MERGE),51022,CDM,260,RC,J2250,HCPCS,0409-2305-17,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,51022,CDM,450,RC,J0630,HCPCS,63323-865-02,NDC,facility,both,1,ML,,1999,1399.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,51022,CDM,450,RC,J1885,HCPCS,72611-722-25,NDC,facility,both,1,ML,XS,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
INSULIN DEGLUDEC 100 UNITS/ML SUBQ SOLN,51022,CDM,260,RC,J1815,HCPCS,0169-2662-11,NDC,facility,both,1,ML,XU,120,84,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
PALIPERIDONE PALMITATE 39 MG/0.25 ML IM SYRG,51022,CDM,260,RC,J2426,HCPCS,50458-560-01,NDC,facility,both,1,ML,,1642,1149.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZIPRASIDONE 20 MG IM,51022,CDM,260,RC,J3486,HCPCS,72205-205-01,NDC,facility,both,1,EA,XU,96,67.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),51022,CDM,260,RC,J3490,HCPCS,0641-6236-01,NDC,facility,both,1,ML,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,51022,CDM,450,RC,J0696,HCPCS,60505-6148-0,NDC,facility,both,1,EA,,450,315,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,16714-046-01,NDC,facility,both,1,ML,XS,115,80.5,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,51022,CDM,450,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,51022,CDM,450,RC,J2250,HCPCS,0409-2305-04,NDC,facility,both,1,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
INSULIN DEGLUDEC 100 UNITS/ML SUBQ SOLN,51022,CDM,260,RC,J1815,HCPCS,73070-400-11,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZIPRASIDONE 20 MG IM,51022,CDM,260,RC,J3486,HCPCS,43598-848-11,NDC,facility,both,1,EA,,240,168,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLNALTREXONE 12 MG/0.6 ML SUBQ SOLN,51022,CDM,260,RC,J2212,HCPCS,65649-551-02,NDC,facility,both,1,ML,XS,735,514.5,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
INSULIN ASP PRT-INSULIN ASPART 100 UNIT/ML (70-30) SUBQ SOLN,51022,CDM,450,RC,J1817,HCPCS,73070-200-11,NDC,facility,both,1,ML,XS,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
CEFTRIAXONE 500 MG INJ SOLR,51022,CDM,450,RC,J0696,HCPCS,0409-7338-11,NDC,facility,both,1,EA,XS,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
EPINEPHRINE 1 MG/ML INJ SOLN,51022,CDM,260,RC,J0171,HCPCS,76329-9060-0,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,51022,CDM,450,RC,J3490,HCPCS,0143-9509-01,NDC,facility,both,1,ML,XS,38,26.6,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),51022,CDM,260,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE (PF) 25 MG/ML INJ SOLN (FOR ECTOPIC PREGNANCY),51022,CDM,450,RC,J9260,HCPCS,0143-9519-01,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FONDAPARINUX 7.5 MG/0.6 ML SUBQ SYRG,51022,CDM,260,RC,J1652,HCPCS,55111-680-11,NDC,facility,both,1,ML,,489,342.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),51022,CDM,260,RC,J1815,HCPCS,0024-5926-05,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE NA (PRESERV FREE) 25 MG/ML INJ SOLN,51022,CDM,260,RC,J9260,HCPCS,0703-3678-01,NDC,facility,both,1,ML,,1114,779.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,51022,CDM,260,RC,J2359,HCPCS,72603-181-01,NDC,facility,both,1,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZIPRASIDONE 20 MG IM,51022,CDM,260,RC,J3486,HCPCS,72205-205-01,NDC,facility,both,1,EA,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN NPH HUMAN RECOMB 100 UNIT/ML SUBQ SUSP,51022,CDM,450,RC,J1815,HCPCS,0169-1834-11,NDC,facility,both,1,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
DROPERIDOL 2.5 MG/ML INJ SOLN,51022,CDM,450,RC,J1790,HCPCS,0143-9514-01,NDC,facility,both,1,ML,XS,57,39.9,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
DIAZEPAM 5 MG/ML INJ SYRG,51022,CDM,260,RC,J3360,HCPCS,69339-136-03,NDC,facility,both,1,ML,,867,606.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT  60 MCG/0.3 ML INJ SYRG,51022,CDM,260,RC,J0881,HCPCS,55513-023-01,NDC,facility,both,1,ML,PLAD,1282,897.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
ROCURONIUM 10 MG/ML IV SOLN,51022,CDM,260,RC,J3490,HCPCS,66794-228-02,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT 100 MCG/0.5 ML INJ SYRG,51022,CDM,260,RC,J0881,HCPCS,55513-025-01,NDC,facility,both,1,ML,XU,2137,1495.9,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,51022,CDM,260,RC,J0630,HCPCS,63323-865-02,NDC,facility,both,1,ML,,1734,1213.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,0548-5603-00,NDC,facility,both,1,ML,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FILGRASTIM-SNDZ 300 MCG/0.5 ML INJ SYRG,51022,CDM,260,RC,Q5101,HCPCS,61314-318-05,NDC,facility,both,1,ML,,1943,1360.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,63323-564-21,NDC,facility,both,1,ML,XS,25,17.5,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
INSULIN ASP PRT-INSULIN ASPART 100 UNIT/ML (70-30) SUBQ SOLN,51022,CDM,260,RC,J1817,HCPCS,73070-200-11,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMPICILLIN 250 MG SOLUTION FOR INJECTION,51022,CDM,260,RC,J0290,HCPCS,0781-3402-78,NDC,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 30 MG/0.3 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,0955-1003-01,NDC,facility,both,1,ML,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,0781-3246-02,NDC,facility,both,1,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEROPENEM 500 MG IV SOLR,51022,CDM,260,RC,J2185,HCPCS,0781-3000-95,NDC,facility,both,1,EA,,179,125.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 10 MG/ML (PF) IV SOLN,51022,CDM,260,RC,J2270,HCPCS,0641-6127-01,NDC,facility,both,1,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,51022,CDM,260,RC,J0630,HCPCS,42023-205-01,NDC,facility,both,1,ML,,4969,3478.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE 100 MG/0.5 ML SUBQ SLSY,51022,CDM,260,RC,Q9991,HCPCS,12496-0100-5,NDC,facility,both,1,ML,,2319,1623.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PALIPERIDONE PALMITATE 234 MG/1.5 ML IM SYRG,51022,CDM,260,RC,J2426,HCPCS,50458-564-01,NDC,facility,both,1,ML,,9602,6721.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 50 MG/ML INJECTION,51022,CDM,260,RC,J1200,HCPCS,63323-664-00,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,51022,CDM,450,RC,J3360,HCPCS,0409-1273-03,NDC,facility,both,1,ML,XU,198,138.6,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
INSULIN DEGLUDEC 100 UNITS/ML SUBQ SOLN,51022,CDM,260,RC,J1815,HCPCS,73070-400-11,NDC,facility,both,1,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,51022,CDM,260,RC,J0561,HCPCS,60793-700-01,NDC,facility,both,1,ML,,761,532.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYTOCIN 10 UNIT/ML INJ SOLN,51022,CDM,260,RC,J2590,HCPCS,42023-116-25,NDC,facility,both,1,ML,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT 25 MCG/0.42 ML INJ SYRG,51022,CDM,260,RC,J0881,HCPCS,55513-057-01,NDC,facility,both,1,ML,,836,585.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,51022,CDM,260,RC,J1885,HCPCS,0338-0069-10,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),51022,CDM,450,RC,J1171,HCPCS,76045-009-96,NDC,facility,both,1,ML,XU,56,39.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,51022,CDM,260,RC,J1815,HCPCS,0088-2220-33,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),51022,CDM,450,RC,J1171,HCPCS,0409-4264-11,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,0548-5603-00,NDC,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL,51022,CDM,260,RC,J1071,HCPCS,0143-9659-01,NDC,facility,both,1,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT  40 MCG/0.4 ML INJ SYRG,51022,CDM,450,RC,J0881,HCPCS,55513-021-01,NDC,facility,both,1,ML,,1096,767.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,51022,CDM,450,RC,J3490,HCPCS,0409-2051-15,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,51022,CDM,260,RC,J3420,HCPCS,63323-044-00,NDC,facility,both,1,ML,XS,92,64.4,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
EPOETIN ALFA 2000 UNIT/ML IV SYRINGE (PED/NEO),51022,CDM,260,RC,Q4081,HCPCS,59676-302-00,NDC,facility,both,1,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYTOCIN 10 UNIT/ML INJ SOLN,51022,CDM,260,RC,J2590,HCPCS,63323-012-11,NDC,facility,both,1,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,25021-410-76,NDC,facility,both,1,ML,XU,25,17.5,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
OLANZAPINE 10 MG IM SOLR,51022,CDM,450,RC,J2359,HCPCS,0781-3159-72,NDC,facility,both,1,EA,,203,142.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,51022,CDM,450,RC,J3490,HCPCS,0143-9509-01,NDC,facility,both,1,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),51022,CDM,260,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENTOLAMINE 5 MG INJ SOLR,51022,CDM,450,RC,J3490,HCPCS,0143-9564-01,NDC,facility,both,1,EA,,1231,861.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE NA (PRESERV FREE) 25 MG/ML INJ SOLN,51022,CDM,260,RC,J9260,HCPCS,16729-277-35,NDC,facility,both,1,ML,XS,202,141.4,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
MEDROXYPROGESTERONE 150 MG/ML IM SYRG,51022,CDM,260,RC,J1050,HCPCS,0548-5701-00,NDC,facility,both,1,ML,XU,147,102.9,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
INSULIN REGULAR HUM U-500 CONC 500 UNIT/ML INJ SOLN,51022,CDM,260,RC,J1815,HCPCS,0002-8501-01,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),51022,CDM,260,RC,J3490,HCPCS,0641-6236-01,NDC,facility,both,1,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLNALTREXONE 12 MG/0.6 ML SUBQ SOLN,51022,CDM,260,RC,J2212,HCPCS,65649-551-02,NDC,facility,both,1,ML,,693,485.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CANAKINUMAB (PF) 150 MG/ML SUBQ SOLN,51022,CDM,260,RC,J0638,HCPCS,0078-0734-61,NDC,facility,both,2,ML,,73854,51697.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPOETIN ALFA  4000 UNIT/ML INJ SOLN,51022,CDM,260,RC,Q4081,HCPCS,59676-304-00,NDC,facility,both,1,ML,PLAD,462,323.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
ROMIPLOSTIM 125 MCG SUBQ SOLR,51022,CDM,260,RC,J2796,HCPCS,55513-223-01,NDC,facility,both,1,EA,XS,10260,7182,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
CEFTRIAXONE 100 MG/ML FROM 1 GRAM VIAL (PRMC PEDS ONLY),51022,CDM,260,RC,J0696,HCPCS,0409-7332-11,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,16714-046-01,NDC,facility,both,1,ML,XU,115,80.5,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,51022,CDM,450,RC,J1815,HCPCS,49502-393-80,NDC,facility,both,1,ML,XS,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
METHOTREXATE NA (PRESERV FREE) 25 MG/ML INJ SOLN,51022,CDM,260,RC,J9260,HCPCS,16729-277-35,NDC,facility,both,1,ML,,403,282.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,51022,CDM,260,RC,J0630,HCPCS,24201-400-02,NDC,facility,both,1,ML,,1469,1028.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,0781-3246-02,NDC,facility,both,1,ML,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,51022,CDM,260,RC,J0780,HCPCS,0641-6135-01,NDC,facility,both,1,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLNALTREXONE 12 MG/0.6 ML SUBQ SOLN,51022,CDM,260,RC,J2212,HCPCS,65649-551-02,NDC,facility,both,1,ML,XU,735,514.5,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,51022,CDM,450,RC,J1815,HCPCS,49502-393-80,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,16714-016-01,NDC,facility,both,1,ML,"XS,PLAD",53,37.1,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure | Modifier PLAD: Modifier description not available"
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,51022,CDM,260,RC,J0630,HCPCS,42023-205-01,NDC,facility,both,1,ML,,1127,788.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 125 MCG SUBQ SOLR,51022,CDM,260,RC,J2802,HCPCS,55513-223-01,NDC,facility,both,1,EA,,1232,862.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,51022,CDM,260,RC,J0630,HCPCS,42023-205-01,NDC,facility,both,1,ML,,10025,7017.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  100 MCG/ML INJ SOLN,51022,CDM,260,RC,J2354,HCPCS,0641-6175-01,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT  60 MCG/0.3 ML INJ SYRG,51022,CDM,260,RC,J0881,HCPCS,55513-023-01,NDC,facility,both,1,ML,XU,1282,897.4,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,16714-036-01,NDC,facility,both,1,ML,,187,130.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),51022,CDM,450,RC,J1815,HCPCS,0024-5926-05,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  100 MCG/ML INJ SOLN,51022,CDM,260,RC,J2354,HCPCS,63323-376-00,NDC,facility,both,1,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZIPRASIDONE 20 MG IM,51022,CDM,450,RC,J3486,HCPCS,43598-848-11,NDC,facility,both,1,EA,,240,168,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FILGRASTIM 300 (NEUPOGEN) MCG/ML INJ SOLN,51022,CDM,260,RC,J1442,HCPCS,55513-530-01,NDC,facility,both,1,ML,XS,1115,780.5,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
KETAMINE 100 MG/ML INJ SOLN,51022,CDM,450,RC,J3490,HCPCS,0143-9509-01,NDC,facility,both,1,ML,XS,20,14,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
CERTOLIZUMAB PEGOL 400 MG (200 MG X 2) SUBQ KIT,51022,CDM,260,RC,J0717,HCPCS,50474-700-62,NDC,facility,both,1,EA,,6646,4652.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN PUMP LISPRO (PATIENT OWN PUMP PHS SUPPLIED),51022,CDM,260,RC,J1815,HCPCS,0002-7510-01,NDC,facility,both,1,ML,,338,236.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYALURONIDASE 150 UNIT/ML INJ SOLN,51022,CDM,260,RC,J3473,HCPCS,18657-117-02,NDC,facility,both,1,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN DETEMIR 100 UNIT/ML SUBQ SOLN,51022,CDM,260,RC,J1815,HCPCS,0169-3687-12,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",51022,CDM,260,RC,J3490,HCPCS,0641-6147-01,NDC,facility,both,1,ML,XS,21,14.7,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,51022,CDM,260,RC,J2597,HCPCS,43598-931-11,NDC,facility,both,1,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 50 MG/ML INJECTION,51022,CDM,450,RC,J1200,HCPCS,72485-101-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 6 MG/0.5 ML SUBQ PEN KIT,51022,CDM,260,RC,J3030,HCPCS,72603-141-01,NDC,facility,both,1,ML,XS,406,284.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
BETAMETHASONE ACET & SOD PHOS 6 MG/ML INJ SUSP,51022,CDM,260,RC,J0702,HCPCS,78206-118-01,NDC,facility,both,1,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 2 MG/ML IV SOLN (PHS/CDS MERGE),51022,CDM,260,RC,J2270,HCPCS,76045-004-01,NDC,facility,both,1,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FONDAPARINUX 2.5 MG/0.5 ML SUBQ SYRG,51022,CDM,260,RC,J1652,HCPCS,67457-582-00,NDC,facility,both,1,ML,,232,162.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DROPERIDOL 2.5 MG/ML INJ SOLN,51022,CDM,450,RC,J1790,HCPCS,0143-9514-01,NDC,facility,both,1,ML,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,51022,CDM,260,RC,J1885,HCPCS,0409-3795-19,NDC,facility,both,1,ML,XS,44,30.8,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
LORAZEPAM 2 MG/ML INJ SOLN,51022,CDM,450,RC,J2060,HCPCS,0409-1985-03,NDC,facility,both,1,ML,XU,48,33.6,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,51022,CDM,450,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,51022,CDM,450,RC,J1885,HCPCS,63323-161-00,NDC,facility,both,1,ML,XU,25,17.5,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
INSULIN REGULAR HUM U-500 CONC 500 UNIT/ML INJ SOLN,51022,CDM,260,RC,J1815,HCPCS,0002-8501-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",51022,CDM,260,RC,J3490,HCPCS,0409-4887-10,NDC,facility,both,1,ML,XS,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),51022,CDM,260,RC,J1630,HCPCS,63323-474-00,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 30 MG/0.3 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,25021-410-70,NDC,facility,both,1,ML,XS,18,12.6,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
EPOETIN ALFA  4000 UNIT/ML INJ SOLN,51022,CDM,260,RC,Q4081,HCPCS,59676-304-00,NDC,facility,both,1,ML,,462,323.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,0781-3246-02,NDC,facility,both,1,ML,,164,114.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,16714-046-01,NDC,facility,both,1,ML,XU,103,72.1,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,51022,CDM,450,RC,J2250,HCPCS,0409-2305-16,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 50 MG/ML INJECTION,51022,CDM,260,RC,J1200,HCPCS,72485-101-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,51022,CDM,450,RC,J3490,HCPCS,67457-108-00,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,51022,CDM,450,RC,J2359,HCPCS,55150-308-01,NDC,facility,both,1,EA,XS,104,72.8,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
ENOXAPARIN 120 MG/0.8 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,0548-5606-00,NDC,facility,both,1,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,51022,CDM,260,RC,J2359,HCPCS,55150-308-01,NDC,facility,both,1,EA,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,51022,CDM,260,RC,J1644,HCPCS,0641-0400-37,NDC,facility,both,1,ML,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,51022,CDM,260,RC,J0585,HCPCS,0023-1145-01,NDC,facility,both,1,EA,XU,2078,1454.6,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
INSULIN DETEMIR 100 UNIT/ML SUBQ SOLN,51022,CDM,260,RC,J1815,HCPCS,0169-3687-12,NDC,facility,both,1,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
OLANZAPINE 10 MG IM SOLR,51022,CDM,260,RC,J2359,HCPCS,0781-3159-72,NDC,facility,both,1,EA,,203,142.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUM U-500 CONC 500 UNIT/ML INJ SOLN,51022,CDM,260,RC,J1815,HCPCS,0002-8501-01,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,51022,CDM,260,RC,J0630,HCPCS,42023-205-01,NDC,facility,both,1,ML,,3932,2752.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,51022,CDM,260,RC,J1644,HCPCS,25021-402-01,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 1 MG/0.5 ML INJ SOLN,51022,CDM,260,RC,J3430,HCPCS,0409-9157-31,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 120 MG/0.8 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,16714-056-01,NDC,facility,both,1,ML,,141,98.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,51022,CDM,450,RC,J3360,HCPCS,0409-1273-03,NDC,facility,both,1,ML,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,25021-410-76,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PNEUMOC 20-VAL CONJ-DIP CR(PF) 0.5 ML IM SYRG,51022,CDM,260,RC,90677,HCPCS,0005-2000-01,NDC,facility,both,1,ML,,955,668.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,0548-5604-00,NDC,facility,both,1,ML,,141,98.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,51022,CDM,260,RC,J2359,HCPCS,55150-308-01,NDC,facility,both,1,EA,,208,145.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),51022,CDM,260,RC,J3490,HCPCS,51754-4250-1,NDC,facility,both,1,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL DECANOATE 100 MG/ML IM SOLN,51022,CDM,260,RC,J1631,HCPCS,70069-383-01,NDC,facility,both,1,ML,,475,332.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 10 MG/ML IM SOLN,51022,CDM,260,RC,J0500,HCPCS,72266-127-01,NDC,facility,both,1,ML,XU,145,101.5,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
BUPRENORPHINE 100 MG/0.5 ML SUBQ SLSY,51022,CDM,260,RC,Q9991,HCPCS,12496-0100-2,NDC,facility,both,1,ML,,4418,3092.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN DETEMIR 100 UNIT/ML SUBQ SOLN,51022,CDM,260,RC,J1815,HCPCS,0169-3687-12,NDC,facility,both,1,ML,XS,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
ENOXAPARIN 30 MG/0.3 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,16714-006-01,NDC,facility,both,1,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,51022,CDM,260,RC,J1644,HCPCS,0641-0400-12,NDC,facility,both,1,ML,XU,18,12.6,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
PENICILLIN G BENZATHINE 2400000 UNIT/4 ML IM SYRG,51022,CDM,260,RC,J0561,HCPCS,60793-702-04,NDC,facility,both,1,ML,,2088,1461.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,51022,CDM,450,RC,J0690,HCPCS,0143-9924-90,NDC,facility,both,1,EA,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),51022,CDM,260,RC,J3490,HCPCS,70004-600-09,NDC,facility,both,1,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALTREXONE MICROSPHERES 380 MG IM SERR,51022,CDM,450,RC,J2315,HCPCS,65757-300-01,NDC,facility,both,1,EA,XS,4666,3266.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
INSULIN NPH HUMAN RECOMB 100 UNIT/ML SUBQ SUSP,51022,CDM,260,RC,J1815,HCPCS,0169-1834-11,NDC,facility,both,1,ML,XS,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
FUROSEMIDE 10 MG/ML INJ SOLN,51022,CDM,260,RC,J1940,HCPCS,72603-251-01,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 120 MG/0.8 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,16714-056-10,NDC,facility,both,1,ML,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,51022,CDM,260,RC,J0630,HCPCS,63323-865-02,NDC,facility,both,1,ML,,2065,1445.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALDESLEUKIN 360,000 UNITS/ ML SOLUTION",51022,CDM,260,RC,J9015,HCPCS,65483-116-07,NDC,facility,both,1,EA,XU,5121,3584.7,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
CEFTRIAXONE 250 MG INJ SOLR,51022,CDM,450,RC,J0696,HCPCS,0409-7337-11,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,51022,CDM,260,RC,J3490,HCPCS,0409-4277-16,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,51022,CDM,450,RC,J3420,HCPCS,63323-044-00,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",51022,CDM,260,RC,J3490,HCPCS,0409-4887-17,NDC,facility,both,1,ML,KX,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier KX: Requirements specified in the medical policy have been met
"WATER FOR INJECTION, STERILE INJECTION",51022,CDM,260,RC,J3490,HCPCS,0641-6147-01,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),51022,CDM,450,RC,J1630,HCPCS,0143-9319-01,NDC,facility,both,1,ML,XS,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
INSULIN NPH & REGULAR HUMAN 100 UNIT/ML (70-30) SUBQ SUSP,51022,CDM,450,RC,J1815,HCPCS,0169-1837-11,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),51022,CDM,450,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),51022,CDM,450,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,1,ML,XS,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
INSULIN NPH HUMAN RECOMB 100 UNIT/ML SUBQ SUSP,51022,CDM,260,RC,J1815,HCPCS,0169-1834-11,NDC,facility,both,1,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),51022,CDM,260,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,1,ML,XU,20,14,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
ENOXAPARIN 100 MG/1 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,0781-3268-05,NDC,facility,both,1,ML,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,51022,CDM,260,RC,J0630,HCPCS,42023-205-01,NDC,facility,both,1,ML,,5272,3690.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,51022,CDM,260,RC,J0585,HCPCS,0023-1145-01,NDC,facility,both,1,EA,XS,4795,3356.5,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
INSULIN DETEMIR 100 UNIT/ML SUBQ SOLN,51022,CDM,260,RC,J1815,HCPCS,0169-3687-12,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,51022,CDM,450,RC,J1885,HCPCS,63323-162-03,NDC,facility,both,1,ML,XU,55,38.5,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
EPINEPHRINE 0.3 MG/0.3 ML IM PNIJ,51022,CDM,450,RC,J0171,HCPCS,49502-500-01,NDC,facility,both,1,EA,,3232,2262.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL DECANOATE 100 MG/ML IM SOLN,51022,CDM,260,RC,J1631,HCPCS,70069-383-10,NDC,facility,both,1,ML,,356,249.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 125 MCG SUBQ SOLR,51022,CDM,260,RC,J2802,HCPCS,55513-223-01,NDC,facility,both,1,EA,,2360,1652,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,51022,CDM,260,RC,J1815,HCPCS,0088-2220-33,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,51022,CDM,450,RC,J0630,HCPCS,63323-865-02,NDC,facility,both,1,ML,,1712,1198.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),51022,CDM,450,RC,J2270,HCPCS,0409-1891-01,NDC,facility,both,1,ML,XS,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,0955-1004-01,NDC,facility,both,1,ML,XU,51,35.7,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
NALTREXONE MICROSPHERES 380 MG IM SERR,51022,CDM,450,RC,J2315,HCPCS,65757-300-01,NDC,facility,both,1,EA,,4530,3171,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,51022,CDM,450,RC,J0561,HCPCS,60793-700-01,NDC,facility,both,1,ML,,1674,1171.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE 25 MG/ML INJ SOLN,51022,CDM,450,RC,J3230,HCPCS,55150-319-01,NDC,facility,both,1,ML,,195,136.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE 25 MG/ML INJ SOLN,51022,CDM,260,RC,J3230,HCPCS,70710-1850-1,NDC,facility,both,1,ML,,252,176.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,51022,CDM,260,RC,J2354,HCPCS,0641-6174-01,NDC,facility,both,1,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,51022,CDM,260,RC,J0630,HCPCS,24201-400-02,NDC,facility,both,1,ML,,1677,1173.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN DEGLUDEC 100 UNITS/ML SUBQ SOLN,51022,CDM,260,RC,J1815,HCPCS,73070-400-11,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,51022,CDM,450,RC,J3490,HCPCS,0143-9509-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,51022,CDM,260,RC,J0630,HCPCS,24201-400-02,NDC,facility,both,1,ML,,2691,1883.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ABOBOTULINUMTOXINA 500 UNITS IM SOLR,51022,CDM,260,RC,J0586,HCPCS,15054-0500-1,NDC,facility,both,1,EA,XU,4861,3402.7,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
SUMATRIPTAN 6 MG/0.5 ML SUBQ PEN KIT,51022,CDM,260,RC,J3030,HCPCS,72603-141-02,NDC,facility,both,1,ML,,406,284.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,51022,CDM,450,RC,J3420,HCPCS,63323-044-00,NDC,facility,both,1,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,51022,CDM,450,RC,J1100,HCPCS,0641-6145-01,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RISPERIDONE MICROSPHERES 25 MG/2 ML IM SYRG,51022,CDM,260,RC,J2794,HCPCS,50458-306-01,NDC,facility,both,1,EA,,1782,1247.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.3 MG/0.3 ML IM PNIJ,51022,CDM,450,RC,J0169,HCPCS,0093-5986-19,NDC,facility,both,1,EA,XS,1024,716.8,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
METHYLNALTREXONE 12 MG/0.6 ML SUBQ SYRG,51022,CDM,260,RC,J2212,HCPCS,65649-552-04,NDC,facility,both,1,ML,,368,257.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,51022,CDM,450,RC,J1885,HCPCS,63323-162-00,NDC,facility,both,1,ML,XS,19,13.3,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
INSULIN NPH & REGULAR HUMAN 100 UNIT/ML (70-30) SUBQ SUSP,51022,CDM,450,RC,J1815,HCPCS,0169-1837-11,NDC,facility,both,1,ML,XS,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
FENTANYL CITRATE (PF) 50 MCG/ML (ANESTHESIA INTRAOP ONLY),51022,CDM,450,RC,J3010,HCPCS,0641-6027-01,NDC,facility,both,1,ML,XU,29,20.3,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,16714-016-01,NDC,facility,both,2,ML,XS,53,37.1,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
INSULIN LISPRO 100 UNIT/ML (PEDS CALCLUATOR 0.5),51022,CDM,260,RC,J1815,HCPCS,0024-5924-10,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,16714-046-01,NDC,facility,both,1,ML,,195,136.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DENOSUMAB 60 MG/ML SUBQ SYRG,51022,CDM,260,RC,J0897,HCPCS,55513-710-21,NDC,facility,both,1,ML,XS,5177,3623.9,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,51022,CDM,260,RC,J2354,HCPCS,25021-463-01,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,51022,CDM,450,RC,J3420,HCPCS,0517-0031-01,NDC,facility,both,1,ML,XU,49,34.3,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
SOMATROPIN  5.8 MG SUBQ SOLR,51022,CDM,450,RC,J3490,HCPCS,0781-4004-36,NDC,facility,both,1,EA,,1207,844.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",51022,CDM,450,RC,J3490,HCPCS,63323-185-10,NDC,facility,both,1,ML,XS,30,21,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
FONDAPARINUX 2.5 MG/0.5 ML SUBQ SYRG,51022,CDM,260,RC,J1652,HCPCS,55150-230-00,NDC,facility,both,1,ML,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE (3 MONTH) 11.25 MG IM KIT,51022,CDM,260,RC,J1950,HCPCS,0074-3663-03,NDC,facility,both,1,EA,XS,14914,10439.8,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
ENOXAPARIN 150 MG/1 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,0955-1015-01,NDC,facility,both,1,ML,,170,119,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,51022,CDM,450,RC,J1100,HCPCS,63323-165-01,NDC,facility,both,1,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,51022,CDM,450,RC,J2560,HCPCS,0641-0477-21,NDC,facility,both,1,ML,,697,487.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",51022,CDM,450,RC,J3490,HCPCS,63323-185-10,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PALIPERIDONE PALMITATE 234 MG/1.5 ML IM SYRG,51022,CDM,260,RC,J2426,HCPCS,50458-564-01,NDC,facility,both,1,ML,,9851,6895.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,51022,CDM,260,RC,J0690,HCPCS,44567-707-25,NDC,facility,both,1,EA,XU,22,15.4,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
CANAKINUMAB (PF) 150 MG/ML SUBQ SOLN,51022,CDM,260,RC,J0638,HCPCS,0078-0734-61,NDC,facility,both,1,ML,,73854,51697.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,51022,CDM,260,RC,J0585,HCPCS,0023-1145-01,NDC,facility,both,1,EA,XU,3996,2797.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
METHOTREXATE (PF) 25 MG/ML INJ SOLN (FOR ECTOPIC PREGNANCY),51022,CDM,450,RC,J9260,HCPCS,0143-9519-01,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,51022,CDM,450,RC,J2359,HCPCS,0781-3159-72,NDC,facility,both,1,EA,XS,203,142.1,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,51022,CDM,260,RC,J0630,HCPCS,63323-865-02,NDC,facility,both,1,ML,,2496,1747.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML IV SOLN (MERGE),51022,CDM,260,RC,J3490,HCPCS,0781-3269-71,NDC,facility,both,1,ML,,251,175.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),51022,CDM,450,RC,J1630,HCPCS,25021-806-01,NDC,facility,both,1,ML,XS,34,23.8,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),51022,CDM,450,RC,J1630,HCPCS,63323-474-01,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  100 MCG/ML INJ SOLN,51022,CDM,260,RC,J2354,HCPCS,68462-896-01,NDC,facility,both,1,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 120 MG/0.8 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,0955-1012-01,NDC,facility,both,1,ML,XU,151,105.7,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
INSULIN DEGLUDEC 100 UNITS/ML SUBQ SOLN,51022,CDM,450,RC,J1815,HCPCS,73070-400-11,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),51022,CDM,450,RC,J2060,HCPCS,0641-6044-01,NDC,facility,both,1,ML,XS,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
CHLORPROMAZINE 25 MG/ML INJ SOLN,51022,CDM,260,RC,J3230,HCPCS,55150-319-01,NDC,facility,both,1,ML,,292,204.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,51022,CDM,260,RC,J0630,HCPCS,24201-400-02,NDC,facility,both,1,ML,,1988,1391.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE NA (PRESERV FREE) 25 MG/ML INJ SOLN,51022,CDM,260,RC,J9260,HCPCS,61703-408-41,NDC,facility,both,1,ML,,647,452.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML IV SOLN (MERGE),51022,CDM,260,RC,J3490,HCPCS,16714-037-01,NDC,facility,both,1,ML,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DROPERIDOL 2.5 MG/ML INJ SOLN,51022,CDM,450,RC,J1790,HCPCS,0517-9702-01,NDC,facility,both,1,ML,XS,57,39.9,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
EXENATIDE 5 MCG/0.02 ML SUBQ PNIJ,51022,CDM,260,RC,J3490,HCPCS,0310-6512-01,NDC,facility,both,1,ML,,2346,1642.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO PROTAM & LISPRO 100 UNIT/ML (75-25) SUBQ SUSP,51022,CDM,260,RC,J1815,HCPCS,0002-7511-01,NDC,facility,both,1,ML,XS,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
LORAZEPAM 2 MG/ML INJ SOLN,51022,CDM,450,RC,J2060,HCPCS,0409-6778-02,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE (PF) 25 MG/ML INJ SOLN (FOR ECTOPIC PREGNANCY),51022,CDM,260,RC,J9260,HCPCS,0143-9519-01,NDC,facility,both,1,ML,XU,102,71.4,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,51022,CDM,260,RC,J1817,HCPCS,0002-8215-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,16714-036-01,NDC,facility,both,1,ML,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,51022,CDM,450,RC,J1644,HCPCS,0641-0400-12,NDC,facility,both,1,ML,XS,18,12.6,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,51022,CDM,450,RC,J1885,HCPCS,0409-3795-19,NDC,facility,both,1,ML,XS,44,30.8,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
HYALURONIDASE 150 UNIT/ML INJ SOLN,51022,CDM,260,RC,J3473,HCPCS,18657-117-04,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,16714-046-01,NDC,facility,both,1,ML,XU,115,80.5,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
PALIPERIDONE PALMITATE 117 MG/0.75 ML IM SYRG,51022,CDM,260,RC,J2426,HCPCS,50458-562-01,NDC,facility,both,1,ML,,4926,3448.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML (PEDS CALCLUATOR 0.5),51022,CDM,260,RC,J1815,HCPCS,0024-5924-10,NDC,facility,both,1,ML,,424,296.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 500 MG INJ SOLR,51022,CDM,450,RC,J0696,HCPCS,0409-7338-11,NDC,facility,both,1,EA,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
INSULIN REGULAR HUM U-500 CONC 500 UNIT/ML INJ SOLN,51022,CDM,260,RC,J1815,HCPCS,0002-8501-01,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,51022,CDM,260,RC,J1644,HCPCS,0641-0400-37,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,51022,CDM,260,RC,J0561,HCPCS,60793-701-02,NDC,facility,both,1,ML,,2613,1829.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE 25 MG/ML INJ SOLN,51022,CDM,260,RC,J3230,HCPCS,43598-141-11,NDC,facility,both,1,ML,,252,176.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMOSOZUMAB-AQQG 210MG/2.34ML ( 105MG/1.17MLX2) SUBQ SYRG,51022,CDM,260,RC,J3111,HCPCS,55513-998-02,NDC,facility,both,1,ML,,2947,2062.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,51022,CDM,260,RC,J3420,HCPCS,0517-0031-01,NDC,facility,both,1,ML,XU,49,34.3,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
SUMATRIPTAN 6 MG/0.5 ML SUBQ PEN KIT,51022,CDM,260,RC,J3030,HCPCS,72603-141-01,NDC,facility,both,1,ML,XU,239,167.3,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
INSULIN LISPRO 100 UNIT/ML (PEDS CALCLUATOR 0.5),51022,CDM,260,RC,J1815,HCPCS,0024-5924-10,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ (MERGE),51022,CDM,260,RC,J2250,HCPCS,0409-0001-01,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALTREXONE MICROSPHERES 380 MG IM SERR,51022,CDM,260,RC,J2315,HCPCS,65757-300-01,NDC,facility,both,1,EA,,4529,3170.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN DEGLUDEC 100 UNITS/ML SUBQ SOLN,51022,CDM,260,RC,J1815,HCPCS,73070-400-11,NDC,facility,both,1,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,51022,CDM,260,RC,J3360,HCPCS,0409-1273-03,NDC,facility,both,1,ML,,1186,830.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUM U-500 CONC 500 UNIT/ML INJ SOLN,51022,CDM,450,RC,J1815,HCPCS,0002-8501-01,NDC,facility,both,1,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),51022,CDM,260,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZIPRASIDONE 20 MG IM,51022,CDM,450,RC,J3486,HCPCS,72205-205-01,NDC,facility,both,1,EA,,192,134.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TERBUTALINE 1 MG/ML SUBQ SOLN,51022,CDM,260,RC,J3105,HCPCS,0143-9746-01,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML (1ML) INJ SOLN,51022,CDM,450,RC,J0169,HCPCS,42023-159-01,NDC,facility,both,1,ML,XS,88,61.6,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),51022,CDM,450,RC,J1630,HCPCS,76045-737-01,NDC,facility,both,1,ML,XS,27,18.9,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
LANREOTIDE 90 MG/0.3 ML SUBQ SYRG,51022,CDM,260,RC,J1930,HCPCS,15054-1090-4,NDC,facility,both,1,ML,,22379,15665.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 250 MCG SUBQ SOLR,51022,CDM,260,RC,J2802,HCPCS,55513-221-01,NDC,facility,both,1,EA,,4390,3073,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROGESTERONE 50 MG/ML IM OIL,51022,CDM,260,RC,J2675,HCPCS,55150-306-10,NDC,facility,both,1,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,51022,CDM,450,RC,J2354,HCPCS,0641-6174-01,NDC,facility,both,1,ML,XU,30,21,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
DIAZEPAM 5 MG/ML INJ SYRG,51022,CDM,260,RC,J3360,HCPCS,0409-1273-03,NDC,facility,both,1,ML,XU,198,138.6,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,51022,CDM,260,RC,J2597,HCPCS,69918-899-01,NDC,facility,both,1,ML,,150,105,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,51022,CDM,260,RC,J3420,HCPCS,69680-112-01,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),51022,CDM,260,RC,J1630,HCPCS,63323-474-01,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 10 MG/ML IM SOLN,51022,CDM,450,RC,J0500,HCPCS,70436-147-80,NDC,facility,both,1,ML,XU,229,160.3,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,51022,CDM,260,RC,J1815,HCPCS,83257-011-11,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NEOSTIGMINE METHYLSULFATE 1 MG/ML IV SOLN,51022,CDM,260,RC,J2710,HCPCS,42023-189-01,NDC,facility,both,1,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
CEFTRIAXONE 500 MG INJ SOLR,51022,CDM,450,RC,J0696,HCPCS,44567-700-25,NDC,facility,both,1,EA,XS,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,51022,CDM,450,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),51022,CDM,260,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT  25 MCG/ML INJ SOLN,51022,CDM,260,RC,J0881,HCPCS,55513-002-01,NDC,facility,both,1,ML,,836,585.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,51022,CDM,450,RC,J1885,HCPCS,0409-3795-19,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,51022,CDM,450,RC,J3490,HCPCS,0409-2051-15,NDC,facility,both,1,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 50 MG/ML IM,51022,CDM,450,RC,J3410,HCPCS,0517-5601-25,NDC,facility,both,1,ML,,182,127.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,51022,CDM,450,RC,J3360,HCPCS,0641-6244-01,NDC,facility,both,1,ML,,145,101.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN ASP PRT-INSULIN ASPART 100 UNIT/ML (70-30) SUBQ SOLN,51022,CDM,450,RC,J1817,HCPCS,0169-3685-12,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,16714-016-01,NDC,facility,both,1,ML,XS,53,37.1,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
METHOTREXATE (PF) 25 MG/ML INJ SOLN (FOR ECTOPIC PREGNANCY),51022,CDM,450,RC,J9260,HCPCS,0143-9519-01,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,51022,CDM,260,RC,J0585,HCPCS,0023-1145-01,NDC,facility,both,1,EA,XU,480,336,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
ENOXAPARIN 30 MG/0.3 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,0075-0624-01,NDC,facility,both,1,ML,XS,50,35,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
ROMIPLOSTIM 125 MCG SUBQ SOLR,51022,CDM,260,RC,J2796,HCPCS,55513-223-01,NDC,facility,both,1,EA,XS,5130,3591,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,51022,CDM,260,RC,J2354,HCPCS,25021-463-01,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,51022,CDM,450,RC,J1817,HCPCS,0002-8215-01,NDC,facility,both,1,ML,XS,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
HEPARIN (PORCINE) 20000 UNIT/ML INJ SOLN,51022,CDM,260,RC,J1644,HCPCS,72603-224-01,NDC,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,51022,CDM,450,RC,J1817,HCPCS,0002-8215-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ORPHENADRINE CITRATE 30 MG/ML INJ SOLN,51022,CDM,260,RC,J2360,HCPCS,25021-651-02,NDC,facility,both,1,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MENING VAC A,C,Y,W135,TET (PF) 10 MCG/0.5 ML IM SOLN",51022,CDM,260,RC,90619,HCPCS,49281-590-58,NDC,facility,both,1,ML,,743,520.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DROPERIDOL 2.5 MG/ML INJ SOLN,51022,CDM,260,RC,J1790,HCPCS,0517-9702-01,NDC,facility,both,1,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE NA (PRESERV FREE) 25 MG/ML INJ SOLN,51022,CDM,260,RC,J9260,HCPCS,61703-408-41,NDC,facility,both,1,ML,,4312,3018.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,51022,CDM,450,RC,J1885,HCPCS,63323-162-03,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,51022,CDM,260,RC,J0630,HCPCS,42023-205-01,NDC,facility,both,1,ML,,7735,5414.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DROPERIDOL 2.5 MG/ML INJ SOLN,51022,CDM,450,RC,J1790,HCPCS,0517-9702-01,NDC,facility,both,1,ML,XU,63,44.1,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),51022,CDM,260,RC,J3490,HCPCS,70004-600-09,NDC,facility,both,1,ML,,127,88.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,51022,CDM,450,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,51022,CDM,260,RC,J0630,HCPCS,24201-400-02,NDC,facility,both,1,ML,,1888,1321.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE (PF) 1 MG/ML INJ SOLN,51022,CDM,450,RC,J0171,HCPCS,54288-103-01,NDC,facility,both,1,ML,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,51022,CDM,260,RC,J3490,HCPCS,42023-115-10,NDC,facility,both,1,ML,XU,79,55.3,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
DARBEPOETIN ALFA IN POLYSORBAT  60 MCG/0.3 ML INJ SYRG,51022,CDM,260,RC,J0881,HCPCS,55513-023-01,NDC,facility,both,1,ML,,1069,748.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 2 MG/ML IV SOLN (PHS/CDS MERGE),51022,CDM,450,RC,J2270,HCPCS,76045-004-01,NDC,facility,both,1,ML,XU,20,14,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
"WATER FOR INJECTION, STERILE INJECTION",51022,CDM,260,RC,J3490,HCPCS,0409-4887-10,NDC,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML (PEDS CALCLUATOR 0.5),51022,CDM,260,RC,J1815,HCPCS,0024-5924-10,NDC,facility,both,1,ML,GZ,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier GZ: Item or service expected to be denied as not reasonable and necessary
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),51022,CDM,450,RC,J2270,HCPCS,0409-1891-03,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML (PEDS CALCLUATOR 0.5),51022,CDM,260,RC,J1815,HCPCS,0024-5924-10,NDC,facility,both,1,ML,XU,17,11.9,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
BETAMETHASONE ACET & SOD PHOS 6 MG/ML INJ SUSP,51022,CDM,260,RC,J0702,HCPCS,78206-118-01,NDC,facility,both,1,ML,XU,89,62.3,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
HYDROXYZINE 50 MG/ML IM,51022,CDM,450,RC,J3410,HCPCS,0517-5601-25,NDC,facility,both,1,ML,,190,133,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL,51022,CDM,260,RC,J1071,HCPCS,0009-0417-01,NDC,facility,both,1,ML,,140,98,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL,51022,CDM,260,RC,J1071,HCPCS,0143-9659-01,NDC,facility,both,1,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLERGONOVINE 0.2 MG/ML (1 ML) INJ SOLN,51022,CDM,450,RC,J2210,HCPCS,51991-144-99,NDC,facility,both,1,ML,XS,116,81.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
INSULIN REGULAR HUM U-500 CONC 500 UNIT/ML INJ SOLN,51022,CDM,260,RC,J1815,HCPCS,0002-8501-01,NDC,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,0781-3246-02,NDC,facility,both,1,ML,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLNALTREXONE 12 MG/0.6 ML SUBQ SYRG,51022,CDM,260,RC,J2212,HCPCS,65649-551-03,NDC,facility,both,1,ML,,462,323.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),51022,CDM,260,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,51022,CDM,260,RC,J3420,HCPCS,63323-044-00,NDC,facility,both,1,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT  60 MCG/0.3 ML INJ SYRG,51022,CDM,260,RC,J0881,HCPCS,55513-023-04,NDC,facility,both,1,ML,,1282,897.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 10 MG/ML IM SOLN,51022,CDM,260,RC,J0500,HCPCS,72266-127-01,NDC,facility,both,1,ML,,145,101.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN DEGLUDEC 100 UNITS/ML SUBQ SOLN,51022,CDM,260,RC,J1815,HCPCS,73070-400-11,NDC,facility,both,1,ML,XU,29,20.3,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
HALOPERIDOL DECANOATE  50 MG/ML IM SOLN,51022,CDM,260,RC,J1631,HCPCS,70069-030-03,NDC,facility,both,1,ML,,383,268.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,51022,CDM,260,RC,J3301,HCPCS,0703-0241-01,NDC,facility,both,1,ML,XU,54,37.8,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
METHOTREXATE (PF) 25 MG/ML INJ SOLN (FOR ECTOPIC PREGNANCY),51022,CDM,260,RC,J9260,HCPCS,0143-9519-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"OCTREOTIDE,MICROSPHERES 20 MG IM SERR",51022,CDM,260,RC,J2353,HCPCS,0078-0818-81,NDC,facility,both,2,EA,,25482,17837.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ (MERGE),51022,CDM,450,RC,J2250,HCPCS,0409-2305-17,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,16714-016-01,NDC,facility,both,1,ML,,157,109.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 2 MG/ML IV SOLN (PHS/CDS MERGE),51022,CDM,260,RC,J2270,HCPCS,76045-004-01,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 6 MG/0.5 ML SUBQ PEN KIT,51022,CDM,450,RC,J3030,HCPCS,72603-141-01,NDC,facility,both,1,ML,XU,239,167.3,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
SUMATRIPTAN 6 MG/0.5 ML SUBQ PEN KIT,51022,CDM,260,RC,J3030,HCPCS,72603-141-01,NDC,facility,both,1,ML,"XU,LT",406,284.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,51022,CDM,260,RC,J1644,HCPCS,0409-2723-30,NDC,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,51022,CDM,260,RC,J0630,HCPCS,24201-400-02,NDC,facility,both,1,ML,,1127,788.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 6 MG/0.5 ML SUBQ PEN KIT,51022,CDM,260,RC,J3030,HCPCS,72603-141-01,NDC,facility,both,1,ML,,239,167.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUM U-500 CONC 500 UNIT/ML INJ SOLN,51022,CDM,260,RC,J1815,HCPCS,0002-8501-01,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ORPHENADRINE CITRATE 30 MG/ML INJ SOLN,51022,CDM,450,RC,J2360,HCPCS,0641-6182-01,NDC,facility,both,1,ML,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,51022,CDM,260,RC,J0630,HCPCS,43598-051-11,NDC,facility,both,1,ML,,4665,3265.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE NA (PRESERV FREE) 25 MG/ML INJ SOLN,51022,CDM,260,RC,J9260,HCPCS,0703-3678-01,NDC,facility,both,1,ML,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT 300 MCG/0.6 ML INJ SYRG,51022,CDM,450,RC,J0881,HCPCS,55513-111-01,NDC,facility,both,1,ML,,6409,4486.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE (PF) 25 MG/ML INJ SOLN (FOR ECTOPIC PREGNANCY),51022,CDM,260,RC,J9260,HCPCS,0143-9519-01,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,51022,CDM,450,RC,J3490,HCPCS,0409-2051-15,NDC,facility,both,1,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,51022,CDM,450,RC,J1644,HCPCS,0641-0400-37,NDC,facility,both,1,ML,PLAD,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,16714-026-01,NDC,facility,both,1,ML,XU,70,49,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
SUMATRIPTAN 6 MG/0.5 ML SUBQ PEN KIT,51022,CDM,450,RC,J3030,HCPCS,72603-141-01,NDC,facility,both,1,ML,,406,284.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,51022,CDM,450,RC,J2250,HCPCS,0409-2308-22,NDC,facility,both,1,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,51022,CDM,450,RC,J1644,HCPCS,0641-0400-37,NDC,facility,both,1,ML,XS,18,12.6,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
GLUCAGON 1 MG/ML INJ (MERGE),51022,CDM,260,RC,J1610,HCPCS,63323-596-03,NDC,facility,both,1,EA,XS,1342,939.4,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,0781-3246-02,NDC,facility,both,1,ML,,192,134.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML (1ML) INJ SOLN,51022,CDM,260,RC,J0169,HCPCS,63323-696-02,NDC,facility,both,1,ML,XU,30,21,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
EPINEPHRINE 1 MG/ML INJ SOLN,51022,CDM,260,RC,J0171,HCPCS,76329-9060-0,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUPHENAZINE DECANOATE 25 MG/ML INJ SOLN,51022,CDM,260,RC,J2680,HCPCS,63323-272-05,NDC,facility,both,1,ML,,670,469,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,51022,CDM,450,RC,J2250,HCPCS,0409-2308-02,NDC,facility,both,1,ML,XS,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),51022,CDM,260,RC,J0171,HCPCS,76329-3318-1,NDC,facility,both,1,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,51022,CDM,450,RC,J0561,HCPCS,60793-701-02,NDC,facility,both,1,ML,XS,1188,831.6,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
HYDROXYZINE 50 MG/ML IM,51022,CDM,450,RC,J3410,HCPCS,0517-5601-25,NDC,facility,both,1,ML,,174,121.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),51022,CDM,260,RC,J2270,HCPCS,0409-1891-03,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 500 MG INJ SOLR,51022,CDM,260,RC,J0696,HCPCS,0409-7338-01,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,16714-016-01,NDC,facility,both,1,ML,"XU,PLAD",53,37.1,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service | Modifier PLAD: Modifier description not available"
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,51022,CDM,450,RC,J2250,HCPCS,0409-2305-16,NDC,facility,both,1,ML,XU,24,16.8,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,25021-410-76,NDC,facility,both,1,ML,XS,25,17.5,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
OXYTOCIN 10 UNIT/ML INJ SOLN,51022,CDM,260,RC,J2590,HCPCS,42023-116-25,NDC,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLNALTREXONE 12 MG/0.6 ML SUBQ SYRG,51022,CDM,260,RC,J2212,HCPCS,65649-551-07,NDC,facility,both,1,ML,,693,485.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VARICELLA-ZOSTER IG-MALTOSE 125 UNIT/1.2 ML IM SOLN,51022,CDM,260,RC,90396,HCPCS,70257-126-51,NDC,facility,both,1,ML,,4980,3486,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML INJ SOLN,51022,CDM,260,RC,J2060,HCPCS,0409-1985-03,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZIPRASIDONE 20 MG IM,51022,CDM,450,RC,J3486,HCPCS,43598-848-11,NDC,facility,both,1,EA,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE  5 MG/ML INJ SOLN,51022,CDM,450,RC,J2765,HCPCS,0409-3414-21,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 150 MG/1 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,0548-5607-00,NDC,facility,both,1,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,51022,CDM,260,RC,J2597,HCPCS,70095-026-01,NDC,facility,both,1,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL,51022,CDM,260,RC,J1071,HCPCS,0143-9659-01,NDC,facility,both,1,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 10 MG/ML (PF) IV SOLN,51022,CDM,450,RC,J2270,HCPCS,0641-6127-01,NDC,facility,both,1,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
ENOXAPARIN 20 MG/ML IN NS NEONATAL INJECTION (REPACK),51022,CDM,260,RC,J1650,HCPCS,63323-565-86,NDC,facility,both,1,ML,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN ASP PRT-INSULIN ASPART 100 UNIT/ML (70-30) SUBQ SOLN,51022,CDM,260,RC,J1817,HCPCS,73070-200-11,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN NPH HUMAN RECOMB 100 UNIT/ML SUBQ SUSP,51022,CDM,260,RC,J1815,HCPCS,0169-1834-11,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL DECANOATE  50 MG/ML IM SOLN,51022,CDM,260,RC,J1631,HCPCS,70756-615-10,NDC,facility,both,1,ML,,419,293.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),51022,CDM,450,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,1,ML,XS,20,14,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
OLANZAPINE 10 MG IM SOLR,51022,CDM,260,RC,J2359,HCPCS,72603-181-01,NDC,facility,both,1,EA,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN DEGLUDEC 100 UNITS/ML SUBQ SOLN,51022,CDM,260,RC,J1815,HCPCS,73070-400-11,NDC,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,25021-410-76,NDC,facility,both,1,ML,XS,25,17.5,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,51022,CDM,260,RC,J2405,HCPCS,60505-6130-0,NDC,facility,both,1,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
INSULIN REGULAR HUM U-500 CONC 500 UNIT/ML INJ SOLN,51022,CDM,260,RC,J1815,HCPCS,0002-8501-01,NDC,facility,both,1,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,51022,CDM,450,RC,J3360,HCPCS,0641-6244-01,NDC,facility,both,1,ML,XS,145,101.5,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,51022,CDM,450,RC,J1885,HCPCS,0409-3796-19,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML IV SOLN (MERGE),51022,CDM,260,RC,J3490,HCPCS,70756-611-82,NDC,facility,both,1,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,51022,CDM,260,RC,J1815,HCPCS,83257-011-11,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML (PEDS CALCLUATOR 0.5),51022,CDM,260,RC,J1815,HCPCS,0024-5924-10,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,51022,CDM,260,RC,J1644,HCPCS,0641-0400-12,NDC,facility,both,1,ML,XS,26,18.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),51022,CDM,260,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN DEGLUDEC 100 UNITS/ML SUBQ SOLN,51022,CDM,450,RC,J1815,HCPCS,73070-400-11,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,51022,CDM,260,RC,J0630,HCPCS,42023-205-01,NDC,facility,both,1,ML,,4321,3024.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.15 MG/0.3 ML IM PNIJ,51022,CDM,260,RC,J0171,HCPCS,49502-101-01,NDC,facility,both,1,EA,,675,472.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,0075-0620-01,NDC,facility,both,1,ML,XS,59,41.3,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),51022,CDM,450,RC,J2270,HCPCS,0409-1891-03,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLN,51022,CDM,450,RC,J2560,HCPCS,14789-128-07,NDC,facility,both,1,ML,,224,156.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE 25 MG/ML INJ SOLN,51022,CDM,260,RC,J3230,HCPCS,0641-1397-31,NDC,facility,both,1,ML,,509,356.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  100 MCG/ML INJ SOLN,51022,CDM,260,RC,J2354,HCPCS,63323-376-00,NDC,facility,both,1,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN NPH & REGULAR HUMAN 100 UNIT/ML (70-30) SUBQ SUSP,51022,CDM,260,RC,J1815,HCPCS,0169-1837-11,NDC,facility,both,1,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
ENOXAPARIN 100 MG/1 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,0075-0623-03,NDC,facility,both,1,ML,,292,204.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,51022,CDM,450,RC,J3010,HCPCS,0409-9094-22,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALTREXONE MICROSPHERES 380 MG IM SERR,51022,CDM,450,RC,J2315,HCPCS,65757-302-02,NDC,facility,both,1,EA,,4530,3171,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIRAGLUTIDE 0.6 MG/0.1 ML (18 MG/3 ML) SUBQ PNIJ,51022,CDM,450,RC,J3590,HCPCS,0480-3667-20,NDC,facility,both,1,ML,XS,1426,998.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,51022,CDM,450,RC,J1885,HCPCS,63323-162-01,NDC,facility,both,1,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUM U-500 CONC 500 UNIT/ML INJ SOLN,51022,CDM,260,RC,J1815,HCPCS,0002-8501-01,NDC,facility,both,1,ML,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),51022,CDM,450,RC,J1815,HCPCS,0024-5926-05,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.3 MG/0.3 ML IM PNIJ,51022,CDM,450,RC,J0171,HCPCS,49502-500-01,NDC,facility,both,1,EA,,4309,3016.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL DECANOATE  50 MG/ML IM SOLN,51022,CDM,260,RC,J1631,HCPCS,70069-030-01,NDC,facility,both,1,ML,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE NA (PRESERV FREE) 25 MG/ML INJ SOLN,51022,CDM,260,RC,J9260,HCPCS,0703-3678-01,NDC,facility,both,1,ML,,192,134.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZIPRASIDONE 20 MG IM,51022,CDM,450,RC,J3486,HCPCS,43598-848-11,NDC,facility,both,1,EA,XU,120,84,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
ENOXAPARIN 150 MG/1 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,0548-5607-00,NDC,facility,both,1,ML,,265,185.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML INJECTION,51022,CDM,260,RC,J3411,HCPCS,0641-6228-01,NDC,facility,both,1,ML,,146,102.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FILGRASTIM-SNDZ 300 MCG/0.5 ML INJ SYRG,51022,CDM,450,RC,Q5101,HCPCS,61314-318-05,NDC,facility,both,1,ML,,972,680.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,51022,CDM,260,RC,J0585,HCPCS,0023-1145-01,NDC,facility,both,1,EA,,6393,4475.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,16714-036-01,NDC,facility,both,1,ML,XU,94,65.8,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
"OCTREOTIDE,MICROSPHERES 20 MG IM SERR",51022,CDM,260,RC,J2353,HCPCS,0078-0818-81,NDC,facility,both,1,EA,,12741,8918.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN NPH & REGULAR HUMAN 100 UNIT/ML (70-30) SUBQ SUSP,51022,CDM,260,RC,J1815,HCPCS,0002-8715-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML INJ SOLN,51022,CDM,450,RC,J2060,HCPCS,0641-6207-01,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),51022,CDM,450,RC,J1815,HCPCS,0024-5926-05,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,51022,CDM,260,RC,J3420,HCPCS,0517-0031-01,NDC,facility,both,1,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",51022,CDM,260,RC,J3490,HCPCS,63323-185-07,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE (PF) 25 MG/ML INJ SOLN (FOR ECTOPIC PREGNANCY),51022,CDM,450,RC,J9260,HCPCS,0143-9519-01,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYTOCIN 10 UNIT/ML INJ SOLN,51022,CDM,260,RC,J2590,HCPCS,42023-116-25,NDC,facility,both,1,ML,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN ASP PRT-INSULIN ASPART 100 UNIT/ML (70-30) SUBQ SOLN,51022,CDM,260,RC,J1817,HCPCS,73070-200-11,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,51022,CDM,450,RC,J0696,HCPCS,44567-702-25,NDC,facility,both,1,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE (3 MONTH) 11.25 MG IM KIT,51022,CDM,260,RC,J1950,HCPCS,0074-3663-03,NDC,facility,both,1,EA,,14914,10439.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,0781-3246-02,NDC,facility,both,1,ML,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML (ANESTHESIA INTRAOP ONLY),51022,CDM,450,RC,J3010,HCPCS,0641-6027-01,NDC,facility,both,1,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,51022,CDM,260,RC,J1644,HCPCS,0641-0400-37,NDC,facility,both,1,ML,XS,18,12.6,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,51022,CDM,260,RC,J1815,HCPCS,0088-2220-33,NDC,facility,both,1,ML,XU,23,16.1,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
ENOXAPARIN 30 MG/0.3 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,16714-006-01,NDC,facility,both,1,ML,XS,39,27.3,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
ROMIPLOSTIM 125 MCG SUBQ SOLR,51022,CDM,260,RC,J2802,HCPCS,55513-223-01,NDC,facility,both,1,EA,,5130,3591,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FAMOTIDINE (PF) 20 MG/2 ML IV SOLN,51022,CDM,260,RC,J3490,HCPCS,63323-739-41,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,51022,CDM,260,RC,J2359,HCPCS,0781-3159-72,NDC,facility,both,1,EA,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,51022,CDM,450,RC,J0630,HCPCS,24201-400-02,NDC,facility,both,1,ML,,2919,2043.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT 300 MCG/0.6 ML INJ SYRG,51022,CDM,260,RC,J0881,HCPCS,55513-111-01,NDC,facility,both,1,ML,,6409,4486.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 125 MCG SUBQ SOLR,51022,CDM,260,RC,J2802,HCPCS,55513-223-01,NDC,facility,both,1,EA,,1129,790.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEPERIDINE (PF) 50 MG/ML IV SOLN (PHS MERGE),51022,CDM,260,RC,J2175,HCPCS,0409-1178-03,NDC,facility,both,1,ML,XS,26,18.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
ENOXAPARIN 150 MG/1 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,16714-066-01,NDC,facility,both,1,ML,,156,109.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT 100 MCG/0.5 ML INJ SYRG,51022,CDM,450,RC,J0881,HCPCS,55513-025-01,NDC,facility,both,1,ML,"XU,PLAD",2137,1495.9,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service | Modifier PLAD: Modifier description not available"
ENOXAPARIN 150 MG/1 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,0955-1015-01,NDC,facility,both,1,ML,,189,132.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,51022,CDM,260,RC,J1815,HCPCS,0002-8215-01,NDC,facility,both,1,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),51022,CDM,450,RC,J2060,HCPCS,0641-6044-01,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,51022,CDM,450,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,51022,CDM,450,RC,J0630,HCPCS,42023-205-01,NDC,facility,both,1,ML,,5877,4113.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,51022,CDM,260,RC,J2597,HCPCS,43598-053-11,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ARIPIPRAZOLE LAUROXIL 882 MG/3.2 ML IM SERS,51022,CDM,260,RC,J1944,HCPCS,65757-403-03,NDC,facility,both,1,ME,,7575,5302.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TALQUETAMAB-TGVS  2 MG/ML SUBQ SOLN,51022,CDM,260,RC,J3055,HCPCS,57894-469-01,NDC,facility,both,1,ML,,2145,1501.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),51022,CDM,260,RC,J1630,HCPCS,25021-806-01,NDC,facility,both,1,ML,XU,34,23.8,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
SODIUM CHLORIDE 0.9 % INJ SYRG,51022,CDM,260,RC,J3490,HCPCS,8290306546,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 1200000 UNIT/2 ML IM SYRG,51022,CDM,260,RC,J0561,HCPCS,54569-5877-1,NDC,facility,both,1,ML,,281,196.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),51022,CDM,450,RC,J1610,HCPCS,63323-596-11,NDC,facility,both,1,EA,,1789,1252.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",51022,CDM,450,RC,J3490,HCPCS,0409-4887-17,NDC,facility,both,1,ML,XS,23,16.1,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
OCTREOTIDE ACETATE  100 MCG/ML INJ SOLN,51022,CDM,260,RC,J2354,HCPCS,68462-896-01,NDC,facility,both,1,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),51022,CDM,450,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,51022,CDM,260,RC,J2359,HCPCS,0781-3159-72,NDC,facility,both,1,EA,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,51022,CDM,260,RC,J0561,HCPCS,60793-701-02,NDC,facility,both,1,ML,,1188,831.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),51022,CDM,450,RC,J1171,HCPCS,0409-4264-11,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN DEGLUDEC 100 UNITS/ML SUBQ SOLN,51022,CDM,260,RC,J1815,HCPCS,73070-400-11,NDC,facility,both,1,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,51022,CDM,450,RC,J3420,HCPCS,70069-005-01,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,51022,CDM,450,RC,J0690,HCPCS,44567-707-25,NDC,facility,both,1,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FILGRASTIM-SNDZ 300 MCG/0.5 ML INJ SYRG,51022,CDM,260,RC,Q5101,HCPCS,61314-318-05,NDC,facility,both,1,ML,XS,972,680.4,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
PROMETHAZINE 25 MG/ML INJ SOLN,51022,CDM,260,RC,J2550,HCPCS,0641-0928-21,NDC,facility,both,1,ML,XU,25,17.5,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
LORAZEPAM 2 MG/ML INJ SOLN,51022,CDM,450,RC,J2060,HCPCS,0409-1985-03,NDC,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 30 MG/0.3 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,0955-1003-01,NDC,facility,both,1,ML,XS,43,30.1,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
"WATER FOR INJECTION, STERILE INJECTION",51022,CDM,450,RC,J3490,HCPCS,63323-185-07,NDC,facility,both,1,ML,XS,34,23.8,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
KETAMINE 100 MG/ML INJ SOLN,51022,CDM,450,RC,J3490,HCPCS,0409-2051-15,NDC,facility,both,1,ML,XS,35,24.5,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
HYALURONIDASE 150 UNIT/ML INJ SOLN,51022,CDM,260,RC,J3473,HCPCS,18657-117-01,NDC,facility,both,1,ML,,852,596.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OXYTOCIN 10 UNIT/ML INJ SOLN,51022,CDM,260,RC,J2590,HCPCS,42023-116-25,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,51022,CDM,260,RC,J0630,HCPCS,42023-205-01,NDC,facility,both,1,ML,,8426,5898.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML INJECTION,51022,CDM,450,RC,J3411,HCPCS,63323-013-01,NDC,facility,both,1,ML,XU,59,41.3,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,51022,CDM,260,RC,J1817,HCPCS,0002-8215-01,NDC,facility,both,1,ML,XS,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
DARBEPOETIN ALFA IN POLYSORBAT  40 MCG/0.4 ML INJ SYRG,51022,CDM,260,RC,J0881,HCPCS,55513-021-01,NDC,facility,both,1,ML,"XS,PLAD",1096,767.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure | Modifier PLAD: Modifier description not available"
INSULIN REGULAR HUM U-500 CONC 500 UNIT/ML INJ SOLN,51022,CDM,260,RC,J1815,HCPCS,0002-8501-01,NDC,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),51022,CDM,260,RC,J1815,HCPCS,0024-5926-05,NDC,facility,both,1,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
INSULIN LISPRO 100 UNIT/ML (PEDS CALCLUATOR 0.5),51022,CDM,260,RC,J1815,HCPCS,0024-5924-10,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,51022,CDM,450,RC,J1815,HCPCS,0169-1833-11,NDC,facility,both,1,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),51022,CDM,260,RC,J1815,HCPCS,0024-5926-05,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLERGONOVINE 0.2 MG/ML (1 ML) INJ SOLN,51022,CDM,260,RC,J2210,HCPCS,0517-0740-01,NDC,facility,both,1,ML,XS,179,125.3,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
EPHEDRINE 50 MG/ML IV SOLN (MERGE),51022,CDM,260,RC,J3490,HCPCS,70756-611-82,NDC,facility,both,1,ML,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 6 MG/0.5 ML SUBQ PEN KIT,51022,CDM,260,RC,J3030,HCPCS,72603-141-01,NDC,facility,both,1,ML,XU,406,284.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
"WATER FOR INJECTION, STERILE INJECTION",51022,CDM,260,RC,J3490,HCPCS,63323-185-10,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,51022,CDM,260,RC,J0585,HCPCS,0023-1145-01,NDC,facility,both,1,EA,XU,3197,2237.9,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
BORTEZOMIB 3.5 MG IV SOLR,51022,CDM,260,RC,J9041,HCPCS,70710-1411-1,NDC,facility,both,1,EA,,229,160.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",51022,CDM,450,RC,J3490,HCPCS,63323-185-07,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 120 MG/0.8 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,16714-056-10,NDC,facility,both,1,ML,,141,98.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DENOSUMAB-BBDZ 60 MG/ML SUBQ SYRG,51022,CDM,260,RC,Q5136,HCPCS,61314-240-63,NDC,facility,both,1,ML,,4428,3099.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN ASP PRT-INSULIN ASPART 100 UNIT/ML (70-30) SUBQ SOLN,51022,CDM,260,RC,J1817,HCPCS,73070-200-11,NDC,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML (PEDS CALCLUATOR 0.5),51022,CDM,450,RC,J1815,HCPCS,0024-5924-10,NDC,facility,both,1,ML,"PLAD,XS",16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PLAD: Modifier description not available | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),51022,CDM,260,RC,J1630,HCPCS,63323-474-00,NDC,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 500 MG INJ SOLR,51022,CDM,450,RC,J0696,HCPCS,0409-7338-11,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 120 MG/0.8 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,0955-1012-01,NDC,facility,both,1,ML,XU,151,105.7,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
ICATIBANT 30 MG/3 ML SUBQ SYRG,51022,CDM,450,RC,J1744,HCPCS,63323-574-86,NDC,facility,both,1,ML,XS,3588,2511.6,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
HYALURONIDASE 150 UNIT/ML INJ SOLN,51022,CDM,260,RC,J3473,HCPCS,18657-117-01,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,51022,CDM,450,RC,J1100,HCPCS,63323-165-01,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML INJ SOLN,51022,CDM,260,RC,J2060,HCPCS,0641-6207-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPOETIN ALFA-EPBX 10000 UNITS/ML INJ SOLN,51022,CDM,260,RC,Q5106,HCPCS,0069-1308-01,NDC,facility,both,1,ML,,191,133.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUPHENAZINE DECANOATE 25 MG/ML INJ SOLN,51022,CDM,260,RC,J2680,HCPCS,42023-129-01,NDC,facility,both,1,ML,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 10 MG/ML (PF) IV SOLN,51022,CDM,260,RC,J2270,HCPCS,0641-6127-01,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,51022,CDM,260,RC,J2354,HCPCS,23155-687-31,NDC,facility,both,1,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),51022,CDM,260,RC,J1611,HCPCS,63323-596-11,NDC,facility,both,1,EA,,895,626.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,51022,CDM,450,RC,J1885,HCPCS,72266-118-01,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,51022,CDM,450,RC,J1885,HCPCS,63323-162-00,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,51022,CDM,450,RC,J3490,HCPCS,0143-9509-01,NDC,facility,both,1,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE (PF) 25 MG/ML INJ SOLN (FOR ECTOPIC PREGNANCY),51022,CDM,450,RC,J9260,HCPCS,0143-9519-01,NDC,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO PROTAM & LISPRO 100 UNIT/ML (75-25) SUBQ SUSP,51022,CDM,260,RC,J1815,HCPCS,0002-7511-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,51022,CDM,450,RC,J2359,HCPCS,55150-308-01,NDC,facility,both,1,EA,XS,208,145.6,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
INSULIN DEGLUDEC 100 UNITS/ML SUBQ SOLN,51022,CDM,450,RC,J1815,HCPCS,0169-2662-11,NDC,facility,both,1,ML,XS,120,84,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
PHYTONADIONE 1 MG/0.5 ML INJ SYRG,51022,CDM,260,RC,J3430,HCPCS,76329-1240-1,NDC,facility,both,1,ML,,146,102.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,51022,CDM,260,RC,J1644,HCPCS,0409-2723-30,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),51022,CDM,450,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,51022,CDM,450,RC,J1100,HCPCS,70069-021-01,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,51022,CDM,450,RC,J1885,HCPCS,25021-701-01,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE NA (PRESERV FREE) 25 MG/ML INJ SOLN,51022,CDM,260,RC,J9260,HCPCS,61703-408-41,NDC,facility,both,1,ML,,1294,905.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT  40 MCG/0.4 ML INJ SYRG,51022,CDM,260,RC,J0881,HCPCS,55513-021-01,NDC,facility,both,1,ML,XS,1096,767.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,16714-036-01,NDC,facility,both,1,ML,XS,82,57.4,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
GLUCAGON 1 MG/ML INJ (MERGE),51022,CDM,450,RC,J1610,HCPCS,63323-596-11,NDC,facility,both,1,EA,,785,549.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE (PF) 25 MG/ML INJ SOLN (FOR ECTOPIC PREGNANCY),51022,CDM,450,RC,J9260,HCPCS,0143-9519-01,NDC,facility,both,1,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL DECANOATE  50 MG/ML IM SOLN,51022,CDM,450,RC,J1631,HCPCS,70069-030-01,NDC,facility,both,1,ML,,459,321.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),51022,CDM,260,RC,J3490,HCPCS,0409-4888-02,NDC,facility,both,1,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
ROMOSOZUMAB-AQQG 210MG/2.34ML ( 105MG/1.17MLX2) SUBQ SYRG,51022,CDM,260,RC,J3111,HCPCS,55513-880-02,NDC,facility,both,2,ML,,5894,4125.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT  60 MCG/0.3 ML INJ SYRG,51022,CDM,260,RC,J0881,HCPCS,55513-023-01,NDC,facility,both,1,ML,XS,1282,897.4,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,51022,CDM,450,RC,J1885,HCPCS,72611-722-25,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,51022,CDM,260,RC,J2354,HCPCS,0641-6174-10,NDC,facility,both,1,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,51022,CDM,260,RC,J0585,HCPCS,0023-1145-01,NDC,facility,both,1,EA,XS,2078,1454.6,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,51022,CDM,450,RC,J3301,HCPCS,0703-0241-01,NDC,facility,both,1,ML,XU,54,37.8,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,51022,CDM,450,RC,J3420,HCPCS,0517-0031-01,NDC,facility,both,1,ML,XS,49,34.3,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),51022,CDM,260,RC,J1630,HCPCS,76045-737-01,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEPOLIZUMAB 100 MG SUBQ SOLR,51022,CDM,260,RC,J2182,HCPCS,0173-0881-01,NDC,facility,both,2,EA,,21321,14924.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),51022,CDM,450,RC,J1630,HCPCS,63323-474-00,NDC,facility,both,1,ML,XU,40,28,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
ENOXAPARIN 100 MG/1 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,16714-046-10,NDC,facility,both,1,ML,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,51022,CDM,450,RC,J0630,HCPCS,24201-400-02,NDC,facility,both,1,ML,,2526,1768.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,51022,CDM,260,RC,J3360,HCPCS,0409-1273-03,NDC,facility,both,1,ML,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 6 MG/0.5 ML SUBQ PEN KIT,51022,CDM,450,RC,J3030,HCPCS,72603-141-01,NDC,facility,both,1,ML,,239,167.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ICATIBANT 30 MG/3 ML SUBQ SYRG,51022,CDM,450,RC,J1744,HCPCS,0093-3066-19,NDC,facility,both,1,ML,,29229,20460.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),51022,CDM,450,RC,J1630,HCPCS,63323-474-00,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,51022,CDM,450,RC,J2354,HCPCS,23155-687-31,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,51022,CDM,450,RC,J1815,HCPCS,49502-393-80,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,51022,CDM,450,RC,J1644,HCPCS,0641-0400-37,NDC,facility,both,1,ML,XU,18,12.6,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
DIAZEPAM 5 MG/ML INJ SYRG,51022,CDM,450,RC,J3360,HCPCS,69339-136-03,NDC,facility,both,1,ML,,145,101.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CERTOLIZUMAB PEGOL 400 MG/2 ML (200 MG/ML X 2) SUBQ SYKT,51022,CDM,260,RC,J0717,HCPCS,50474-710-79,NDC,facility,both,1,EA,,7893,5525.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,51022,CDM,260,RC,J1817,HCPCS,0002-8215-01,NDC,facility,both,1,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
NEOSTIGMINE 1MG/ML (UD) OR SYRINGE,51022,CDM,260,RC,J2710,HCPCS,76014-003-33,NDC,facility,both,1,ML,XU,142,99.4,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
TERBUTALINE 1 MG/ML SUBQ SOLN,51022,CDM,260,RC,J3105,HCPCS,63323-665-00,NDC,facility,both,1,ML,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,51022,CDM,450,RC,J1885,HCPCS,0409-3795-19,NDC,facility,both,1,ML,XU,44,30.8,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
GLUCAGON 1 MG/ML INJ (MERGE),51022,CDM,260,RC,J1610,HCPCS,0597-0053-45,NDC,facility,both,1,EA,,742,519.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,51022,CDM,260,RC,J1815,HCPCS,0169-1833-11,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE 25 MG/ML INJ SOLN,51022,CDM,260,RC,J3230,HCPCS,55150-319-01,NDC,facility,both,1,ML,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,51022,CDM,260,RC,J1100,HCPCS,63323-165-01,NDC,facility,both,1,ML,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,51022,CDM,260,RC,J1815,HCPCS,49502-393-80,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIRAGLUTIDE 0.6 MG/0.1 ML (18 MG/3 ML) SUBQ PNIJ,51022,CDM,260,RC,J3590,HCPCS,0169-4060-12,NDC,facility,both,1,ML,,1925,1347.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,51022,CDM,260,RC,J1644,HCPCS,25021-402-01,NDC,facility,both,1,ML,"XS,XU",16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
INCLISIRAN 284 MG/1.5 ML SUBQ SYRG,51022,CDM,260,RC,J1306,HCPCS,0078-1000-60,NDC,facility,both,1,ML,,8970,6279,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,16714-036-01,NDC,facility,both,1,ML,XU,187,130.9,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
METHOTREXATE NA (PRESERV FREE) 25 MG/ML INJ SOLN,51022,CDM,260,RC,J9260,HCPCS,0703-3678-01,NDC,facility,both,1,ML,,1121,784.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,51022,CDM,450,RC,J0561,HCPCS,60793-700-01,NDC,facility,both,1,ML,,761,532.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,51022,CDM,260,RC,J2354,HCPCS,23155-687-31,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,51022,CDM,450,RC,J0696,HCPCS,44567-701-25,NDC,facility,both,1,EA,XS,20,14,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
PEGFILGRASTIM (NEULASTA) 6 MG/0.6ML SUBQ SYRG,51022,CDM,260,RC,J2506,HCPCS,55513-190-01,NDC,facility,both,1,ML,,17714,12399.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE (CONTRACEPTIVE) 150 MG/ML IM SUSP,51022,CDM,260,RC,J1050,HCPCS,55150-329-01,NDC,facility,both,1,ML,,215,150.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLPREDNISOLONE 40 MG/ML SUSP (DEPO-MEDROL) INJECTION,51022,CDM,450,RC,J1010,HCPCS,70121-1573-1,NDC,facility,both,1,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FONDAPARINUX 10 MG/0.8 ML SUBQ SYRG,51022,CDM,450,RC,J1652,HCPCS,55150-233-00,NDC,facility,both,1,ML,,370,259,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),51022,CDM,450,RC,J2060,HCPCS,0641-6044-01,NDC,facility,both,1,ML,XU,19,13.3,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,51022,CDM,450,RC,J0561,HCPCS,60793-701-02,NDC,facility,both,1,ML,,1080,756,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,51022,CDM,450,RC,J3490,HCPCS,0143-9509-01,NDC,facility,both,1,ML,XS,51,35.7,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
DROPERIDOL 2.5 MG/ML INJ SOLN,51022,CDM,450,RC,J1790,HCPCS,0517-9702-01,NDC,facility,both,1,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLERGONOVINE 0.2 MG/ML (1 ML) INJ SOLN,51022,CDM,260,RC,J2210,HCPCS,0517-0740-01,NDC,facility,both,1,ML,XS,184,128.8,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
HYDROXYZINE 50 MG/ML IM,51022,CDM,260,RC,J3410,HCPCS,0517-5601-25,NDC,facility,both,1,ML,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,0955-1008-01,NDC,facility,both,1,ML,,101,70.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,51022,CDM,260,RC,J0630,HCPCS,24201-400-02,NDC,facility,both,1,ML,,1634,1143.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,51022,CDM,260,RC,J2405,HCPCS,60505-6130-0,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYALURONIDASE 150 UNIT/ML INJ SOLN,51022,CDM,450,RC,J3473,HCPCS,18657-117-01,NDC,facility,both,1,ML,,284,198.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),51022,CDM,260,RC,J1171,HCPCS,0409-4264-11,NDC,facility,both,1,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.3 MG/0.3 ML IM PNIJ,51022,CDM,450,RC,J0171,HCPCS,49502-102-01,NDC,facility,both,1,EA,XU,675,472.5,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),51022,CDM,260,RC,J1171,HCPCS,76045-009-96,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,16714-026-01,NDC,facility,both,1,ML,XS,70,49,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
DARBEPOETIN ALFA IN POLYSORBAT 200 MCG/0.4 ML INJ SYRG,51022,CDM,260,RC,J0881,HCPCS,55513-028-01,NDC,facility,both,1,ML,,4273,2991.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),51022,CDM,450,RC,J1171,HCPCS,76045-009-96,NDC,facility,both,1,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BETAMETHASONE ACET & SOD PHOS 6 MG/ML INJ SUSP,51022,CDM,260,RC,J0702,HCPCS,0517-0720-01,NDC,facility,both,1,ML,,281,196.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OMALIZUMAB 75 MG/0.5 ML SUBQ SYRG,51022,CDM,260,RC,J2357,HCPCS,50242-214-03,NDC,facility,both,1,ML,,1558,1090.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYALURONIDASE 150 UNIT/ML INJ SOLN,51022,CDM,260,RC,J3473,HCPCS,18657-117-01,NDC,facility,both,1,ML,,284,198.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,0781-3246-02,NDC,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,51022,CDM,260,RC,J3360,HCPCS,0409-1273-03,NDC,facility,both,1,ML,XS,198,138.6,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
ORPHENADRINE CITRATE 30 MG/ML INJ SOLN,51022,CDM,450,RC,J2360,HCPCS,25021-651-02,NDC,facility,both,2,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ICATIBANT 30 MG/3 ML SUBQ SYRG,51022,CDM,450,RC,J1744,HCPCS,69097-664-34,NDC,facility,both,1,ML,XS,29229,20460.3,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
"WATER FOR INJECTION, STERILE INJECTION",51022,CDM,260,RC,J3490,HCPCS,0641-6147-01,NDC,facility,both,2,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,51022,CDM,260,RC,J1885,HCPCS,63323-161-00,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 30 MG/0.3 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,0075-0624-01,NDC,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLYCOPYRROLATE 0.2 MG/ML INJ SOLN,51022,CDM,260,RC,J1596,HCPCS,0143-9682-01,NDC,facility,both,1,ML,XU,18,12.6,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
METHOTREXATE SODIUM 25 MG/ML INJ SOLN,51022,CDM,260,RC,J9260,HCPCS,16729-277-30,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),51022,CDM,260,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,1,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
DEXAMETHASONE 4 MG/ML INJECTION,51022,CDM,260,RC,J1100,HCPCS,63323-165-01,NDC,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN NPH HUMAN RECOMB 100 UNIT/ML SUBQ SUSP,51022,CDM,260,RC,J1815,HCPCS,0169-1834-11,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,0075-0622-01,NDC,facility,both,1,ML,XS,103,72.1,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
METHYLERGONOVINE 0.2 MG/ML (1 ML) INJ SOLN,51022,CDM,450,RC,J2210,HCPCS,0517-0740-01,NDC,facility,both,1,ML,,179,125.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,0781-3246-02,NDC,facility,both,1,ML,,151,105.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLNALTREXONE 12 MG/0.6 ML SUBQ SYRG,51022,CDM,260,RC,J2212,HCPCS,65649-551-03,NDC,facility,both,1,ML,,693,485.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",51022,CDM,450,RC,J3490,HCPCS,0409-4887-23,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BETAMETHASONE ACET & SOD PHOS 6 MG/ML INJ SUSP,51022,CDM,260,RC,J0702,HCPCS,78206-118-01,NDC,facility,both,1,ML,XS,89,62.3,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),51022,CDM,260,RC,J3490,HCPCS,0409-4888-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,51022,CDM,450,RC,J1815,HCPCS,0088-2220-33,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),51022,CDM,450,RC,J2060,HCPCS,0641-6001-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",51022,CDM,450,RC,J3490,HCPCS,0409-4887-17,NDC,facility,both,1,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,51022,CDM,450,RC,J1885,HCPCS,0338-0072-25,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,51022,CDM,450,RC,J1885,HCPCS,72266-118-01,NDC,facility,both,1,ML,XS,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,51022,CDM,260,RC,J0630,HCPCS,63323-865-02,NDC,facility,both,1,ML,,1469,1028.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML (PEDS CALCLUATOR 0.5),51022,CDM,450,RC,J1815,HCPCS,0024-5924-10,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,51022,CDM,450,RC,J3010,HCPCS,0409-9094-12,NDC,facility,both,1,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,51022,CDM,260,RC,J2560,HCPCS,0641-0476-21,NDC,facility,both,1,ML,,310,217,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML INJECTION,51022,CDM,450,RC,J3411,HCPCS,0641-6228-01,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,51022,CDM,260,RC,J0561,HCPCS,60793-701-02,NDC,facility,both,1,ML,,1080,756,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE 25 MG/ML INJ SOLN,51022,CDM,260,RC,J3230,HCPCS,0641-1398-31,NDC,facility,both,1,ML,,195,136.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),51022,CDM,450,RC,J2060,HCPCS,0641-6044-01,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,51022,CDM,260,RC,J3360,HCPCS,0641-6244-01,NDC,facility,both,1,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXMEDETOMIDINE 100 MCG/ML IV SOLN,51022,CDM,260,RC,J3490,HCPCS,0409-1638-32,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,51022,CDM,260,RC,J1815,HCPCS,83257-011-11,NDC,facility,both,1,ML,XU,29,20.3,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
"OCTREOTIDE,MICROSPHERES 20 MG IM SERR",51022,CDM,260,RC,J2353,HCPCS,0078-0818-81,NDC,facility,both,1,EA,,25482,17837.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,51022,CDM,450,RC,J1885,HCPCS,72266-118-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),51022,CDM,260,RC,J3490,HCPCS,0641-6236-01,NDC,facility,both,1,ML,,145,101.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,51022,CDM,260,RC,J0690,HCPCS,44567-707-25,NDC,facility,both,1,EA,XS,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,0075-0622-01,NDC,facility,both,1,ML,XS,103,72.1,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
OMALIZUMAB 150 MG SUBQ SOLR,51022,CDM,260,RC,J2357,HCPCS,50242-040-62,NDC,facility,both,2,ME,,5219,3653.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,51022,CDM,260,RC,J2359,HCPCS,0002-7597-01,NDC,facility,both,1,EA,,256,179.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 1 GRAM INJ SOLR,51022,CDM,260,RC,J0692,HCPCS,25021-121-20,NDC,facility,both,1,EA,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 10 MG/ML (PF) IV SOLN,51022,CDM,260,RC,J2270,HCPCS,0641-6127-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,51022,CDM,450,RC,J2359,HCPCS,55150-308-01,NDC,facility,both,1,EA,XU,104,72.8,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,51022,CDM,450,RC,J1885,HCPCS,72266-118-01,NDC,facility,both,1,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
DIPHENHYDRAMINE 50 MG/ML INJECTION,51022,CDM,450,RC,J1200,HCPCS,63323-664-00,NDC,facility,both,1,ML,XU,21,14.7,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,51022,CDM,260,RC,J2354,HCPCS,0641-6174-01,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHENOBARBITAL SODIUM  65 MG/ML INJ SOLN,51022,CDM,260,RC,J2560,HCPCS,0641-0476-21,NDC,facility,both,1,ML,,155,108.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,51022,CDM,260,RC,J2597,HCPCS,70095-026-01,NDC,facility,both,1,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,51022,CDM,450,RC,J1815,HCPCS,0002-8215-01,NDC,facility,both,1,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),51022,CDM,260,RC,J1815,HCPCS,0002-7737-01,NDC,facility,both,1,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,0781-3246-02,NDC,facility,both,1,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML (PEDS CALCLUATOR 0.5),51022,CDM,450,RC,J1815,HCPCS,0024-5924-10,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),51022,CDM,450,RC,J1630,HCPCS,76045-737-01,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.15 MG/0.3 ML IM PNIJ,51022,CDM,450,RC,J0171,HCPCS,49502-101-01,NDC,facility,both,1,EA,,675,472.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),51022,CDM,260,RC,J1610,HCPCS,63323-596-11,NDC,facility,both,1,EA,XS,895,626.5,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,16714-036-01,NDC,facility,both,1,ML,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,51022,CDM,450,RC,J3490,HCPCS,0143-9509-01,NDC,facility,both,1,ML,XS,35,24.5,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,51022,CDM,450,RC,J1885,HCPCS,63323-162-00,NDC,facility,both,1,ML,XS,38,26.6,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
ZIPRASIDONE 20 MG IM,51022,CDM,260,RC,J3486,HCPCS,72205-205-01,NDC,facility,both,1,EA,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML INJ SOLN,51022,CDM,260,RC,J0169,HCPCS,76329-9060-0,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,51022,CDM,450,RC,J3301,HCPCS,70121-1049-1,NDC,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN DEGLUDEC 100 UNITS/ML SUBQ SOLN,51022,CDM,260,RC,J1815,HCPCS,73070-400-11,NDC,facility,both,1,ML,XS,31,21.7,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
INSULIN DETEMIR 100 UNIT/ML SUBQ SOLN,51022,CDM,260,RC,J1815,HCPCS,0169-3687-12,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE (PF) 25 MG/ML INJ SOLN (FOR ECTOPIC PREGNANCY),51022,CDM,450,RC,0143-9519-01,NDC,,,facility,both,1,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FILGRASTIM-SNDZ 480 MCG/0.8 ML INJ SYRG,51022,CDM,260,RC,Q5101,HCPCS,61314-326-05,NDC,facility,both,1,ML,XS,1212,848.4,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
CEFTRIAXONE 1 GRAM INJ SOLR,51022,CDM,450,RC,J0696,HCPCS,0143-9857-01,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,51022,CDM,450,RC,J1885,HCPCS,63323-161-00,NDC,facility,both,1,ML,XS,25,17.5,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),51022,CDM,450,RC,J1171,HCPCS,0409-4264-11,NDC,facility,both,1,ML,XU,22,15.4,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
ORPHENADRINE CITRATE 30 MG/ML INJ SOLN,51022,CDM,450,RC,J2360,HCPCS,25021-651-02,NDC,facility,both,1,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,51022,CDM,260,RC,J3301,HCPCS,16714-130-01,NDC,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 10 MG/ML IM SOLN,51022,CDM,450,RC,J0500,HCPCS,0641-6173-01,NDC,facility,both,1,ML,,143,100.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,51022,CDM,260,RC,J0630,HCPCS,42023-205-01,NDC,facility,both,1,ML,,5488,3841.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 30 MG/0.3 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,16714-006-01,NDC,facility,both,1,ML,XU,39,27.3,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
METOCLOPRAMIDE  5 MG/ML INJ SOLN,51022,CDM,450,RC,J2765,HCPCS,0703-4502-01,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,51022,CDM,450,RC,J2354,HCPCS,23155-687-31,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE NA (PRESERV FREE) 25 MG/ML INJ SOLN,51022,CDM,260,RC,J9260,HCPCS,61703-408-41,NDC,facility,both,1,ML,,2156,1509.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,51022,CDM,450,RC,J2359,HCPCS,55150-308-01,NDC,facility,both,1,EA,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG/ML INJ SOLN,51022,CDM,260,RC,J2550,HCPCS,0641-0928-21,NDC,facility,both,1,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,0955-1008-01,NDC,facility,both,1,ML,XS,101,70.7,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
INSULIN REGULAR HUM U-500 CONC 500 UNIT/ML INJ SOLN,51022,CDM,260,RC,J1815,HCPCS,0002-8501-01,NDC,facility,both,1,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,51022,CDM,260,RC,J0630,HCPCS,42023-205-01,NDC,facility,both,1,ML,,6266,4386.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,51022,CDM,450,RC,J1100,HCPCS,25021-053-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN DEGLUDEC 100 UNITS/ML SUBQ SOLN,51022,CDM,260,RC,J1815,HCPCS,73070-400-11,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,51022,CDM,260,RC,J3490,HCPCS,0143-9509-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,51022,CDM,260,RC,J0561,HCPCS,60793-701-02,NDC,facility,both,1,ML,,2160,1512,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,51022,CDM,260,RC,J0630,HCPCS,42023-205-01,NDC,facility,both,1,ML,,6093,4265.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,51022,CDM,450,RC,J1644,HCPCS,0641-0400-12,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,51022,CDM,450,RC,J0561,HCPCS,60793-701-02,NDC,facility,both,1,ML,,2376,1663.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,0781-3246-02,NDC,facility,both,1,ML,XS,41,28.7,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,51022,CDM,260,RC,J0630,HCPCS,43598-051-11,NDC,facility,both,1,ML,,6391,4473.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LANREOTIDE 120 MG/0.5 ML SUBQ SYRG,51022,CDM,260,RC,J1930,HCPCS,69097-870-67,NDC,facility,both,1,ML,,24544,17180.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 10 MG/ML IM SOLN,51022,CDM,450,RC,J0500,HCPCS,70436-147-80,NDC,facility,both,1,ML,,229,160.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML INJ SOLN,51022,CDM,450,RC,J2060,HCPCS,0409-1985-03,NDC,facility,both,1,ML,XU,24,16.8,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,16714-026-01,NDC,facility,both,1,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML IV SOLN (MERGE),51022,CDM,260,RC,J3490,HCPCS,0781-3269-71,NDC,facility,both,1,ML,XS,251,175.7,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML INJ SOLR,51022,CDM,450,RC,J2919,HCPCS,0009-0047-25,NDC,facility,both,1,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,51022,CDM,260,RC,J1644,HCPCS,25021-402-01,NDC,facility,both,1,ML,XS,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
ZIPRASIDONE 20 MG IM,51022,CDM,450,RC,J3486,HCPCS,72205-205-01,NDC,facility,both,1,EA,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ (MERGE),51022,CDM,450,RC,J2250,HCPCS,0409-0001-01,NDC,facility,both,1,ML,XS,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,63323-564-21,NDC,facility,both,1,ML,XU,25,17.5,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),51022,CDM,260,RC,J2060,HCPCS,0641-6001-01,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SOMATROPIN  5.8 MG SUBQ SOLR,51022,CDM,260,RC,J3490,HCPCS,0781-4004-36,NDC,facility,both,1,EA,,1207,844.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BUPRENORPHINE 128 MG/0.36 ML SUBQ SLSY,51022,CDM,260,RC,J0578,HCPCS,58284-228-01,NDC,facility,both,1,ML,,4047,2832.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE NA (PRESERV FREE) 25 MG/ML INJ SOLN,51022,CDM,260,RC,J9260,HCPCS,61703-408-41,NDC,facility,both,1,ML,,2587,1810.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BENRALIZUMAB 30 MG/ML SUBQ SYRG,51022,CDM,260,RC,J0517,HCPCS,0310-1730-30,NDC,facility,both,1,ML,XS,13116,9181.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
ENOXAPARIN 30 MG/0.3 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,25021-410-70,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DROPERIDOL 2.5 MG/ML INJ SOLN,51022,CDM,450,RC,J1790,HCPCS,0143-9514-01,NDC,facility,both,1,ML,XU,57,39.9,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
METHYLERGONOVINE 0.2 MG/ML (1 ML) INJ SOLN,51022,CDM,450,RC,J2210,HCPCS,51991-144-99,NDC,facility,both,1,ML,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT 25 MCG/0.42 ML INJ SYRG,51022,CDM,260,RC,J0881,HCPCS,55513-057-04,NDC,facility,both,1,ML,,836,585.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,51022,CDM,450,RC,J2359,HCPCS,55150-308-01,NDC,facility,both,1,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,51022,CDM,260,RC,J2597,HCPCS,70095-026-01,NDC,facility,both,1,ML,,134,93.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALTREXONE MICROSPHERES 380 MG IM SERR,51022,CDM,260,RC,J2315,HCPCS,65757-302-02,NDC,facility,both,1,EA,,4666,3266.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,51022,CDM,260,RC,J2359,HCPCS,55150-308-01,NDC,facility,both,1,EA,XS,208,145.6,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
OLANZAPINE 10 MG IM SOLR,51022,CDM,260,RC,J2359,HCPCS,72603-181-01,NDC,facility,both,1,EA,,207,144.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 150 MG/1 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,16714-066-01,NDC,facility,both,1,ML,,173,121.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZIPRASIDONE 20 MG IM,51022,CDM,260,RC,J3486,HCPCS,43598-848-11,NDC,facility,both,1,EA,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPROST TROMETHAMINE 250 MCG/ML IM SOLN,51022,CDM,260,RC,J3490,HCPCS,81298-5010-1,NDC,facility,both,1,ML,,306,214.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,51022,CDM,260,RC,J2359,HCPCS,55150-308-01,NDC,facility,both,1,EA,XU,208,145.6,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
BETAMETHASONE ACET & SOD PHOS 6 MG/ML INJ SUSP,51022,CDM,260,RC,J0702,HCPCS,78206-118-01,NDC,facility,both,1,ML,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE (PEDIATRIC 3 MONTH) 30 MG IM SYKT,51022,CDM,260,RC,J1950,HCPCS,0074-9694-03,NDC,facility,both,1,EA,XS,34166,23916.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
DIAZEPAM 5 MG/ML INJ SYRG,51022,CDM,260,RC,J3360,HCPCS,0641-6244-01,NDC,facility,both,1,ML,,145,101.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,51022,CDM,260,RC,J3420,HCPCS,70069-005-01,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,51022,CDM,260,RC,J0585,HCPCS,0023-1145-01,NDC,facility,both,1,EA,XS,3676,2573.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,0075-0620-01,NDC,facility,both,1,ML,XU,59,41.3,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,0075-0621-01,NDC,facility,both,1,ML,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),51022,CDM,260,RC,J2270,HCPCS,0641-6125-01,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 10 MG/ML IM SOLN,51022,CDM,260,RC,J0500,HCPCS,0641-6173-01,NDC,facility,both,1,ML,,143,100.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,51022,CDM,450,RC,J1815,HCPCS,0088-2220-33,NDC,facility,both,1,ML,XU,23,16.1,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
DICYCLOMINE 10 MG/ML IM SOLN,51022,CDM,450,RC,J0500,HCPCS,0641-6173-01,NDC,facility,both,1,ML,XU,143,100.1,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,0781-3246-02,NDC,facility,both,1,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE (PEDIATRIC 3 MONTH) 30 MG IM SYKT,51022,CDM,260,RC,J1950,HCPCS,0074-9694-03,NDC,facility,both,1,EA,,34166,23916.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,0781-3246-02,NDC,facility,both,1,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT 100 MCG/0.5 ML INJ SYRG,51022,CDM,450,RC,J0881,HCPCS,55513-025-01,NDC,facility,both,1,ML,,2137,1495.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG/ML INJ SOLN,51022,CDM,450,RC,J2550,HCPCS,0641-6084-01,NDC,facility,both,1,ML,XU,23,16.1,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
PROMETHAZINE 25 MG/ML INJ SOLN,51022,CDM,260,RC,J2550,HCPCS,0641-0928-21,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 50 MG/5ML (10 MG/ML) SYRINGE (PHS MERGE),51022,CDM,260,RC,J3490,HCPCS,73013-2002-2,NDC,facility,both,1,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,51022,CDM,260,RC,J0561,HCPCS,60793-701-02,NDC,facility,both,1,ML,,2376,1663.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ (MERGE),51022,CDM,450,RC,J2250,HCPCS,0409-0001-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ICATIBANT 30 MG/3 ML SUBQ SYRG,51022,CDM,450,RC,J1744,HCPCS,0093-3066-34,NDC,facility,both,1,ML,,29229,20460.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ORPHENADRINE CITRATE 30 MG/ML INJ SOLN,51022,CDM,450,RC,J2360,HCPCS,25021-651-02,NDC,facility,both,1,ML,XU,36,25.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,51022,CDM,450,RC,J0561,HCPCS,60793-701-02,NDC,facility,both,1,ML,,2613,1829.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE (PEDIATRIC 6 MONTH) 45 MG SUBQ SYRG,51022,CDM,260,RC,J1951,HCPCS,62935-163-60,NDC,facility,both,1,EA,,75743,53020.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE  5 MG/ML INJ SOLN,51022,CDM,450,RC,J2765,HCPCS,0409-3414-18,NDC,facility,both,1,ML,XS,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,51022,CDM,260,RC,J0585,HCPCS,0023-1145-01,NDC,facility,both,1,EA,XS,6393,4475.1,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),51022,CDM,450,RC,J2270,HCPCS,0409-1891-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN ASP PRT-INSULIN ASPART 100 UNIT/ML (70-30) SUBQ SOLN,51022,CDM,450,RC,J1817,HCPCS,73070-200-11,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUM U-500 CONC 500 UNIT/ML INJ SOLN,51022,CDM,260,RC,J1815,HCPCS,0002-8501-01,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 10 MG/ML IM SOLN,51022,CDM,450,RC,J0500,HCPCS,72266-127-01,NDC,facility,both,1,ML,XU,145,101.5,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
LUPRON 3.75MG IM KIT,51022,CDM,260,RC,J1950,HCPCS,0074-3641-03,NDC,facility,both,1,EA,,4972,3480.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE NA (PRESERV FREE) 25 MG/ML INJ SOLN,51022,CDM,260,RC,J9260,HCPCS,16729-277-35,NDC,facility,both,1,ML,,202,141.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,51022,CDM,260,RC,J3490,HCPCS,0409-2051-15,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML (1ML) INJ SOLN,51022,CDM,260,RC,J0171,HCPCS,54288-119-01,NDC,facility,both,1,ML,XS,24,16.8,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
PROMETHAZINE 25 MG/ML INJ SOLN,51022,CDM,260,RC,J2550,HCPCS,0641-6208-01,NDC,facility,both,1,ML,XS,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
ENOXAPARIN 150 MG/1 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,0548-5607-00,NDC,facility,both,1,ML,,119,83.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN NEO/PEDIATRIC SYRINGE < 30 MG,51022,CDM,260,RC,J1650,HCPCS,0548-5608-00,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,51022,CDM,260,RC,J0630,HCPCS,43598-051-11,NDC,facility,both,1,ML,,6281,4396.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML INJ SOLN,51022,CDM,450,RC,J2060,HCPCS,0641-6207-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ (MERGE),51022,CDM,260,RC,J0330,HCPCS,31722-981-10,NDC,facility,both,1,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,51022,CDM,450,RC,J2359,HCPCS,55150-308-01,NDC,facility,both,1,EA,XS,52,36.4,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,25021-410-76,NDC,facility,both,1,ML,XU,25,17.5,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
MAGNESIUM SULFATE 50 % (4 MEQ/ML) INJ SOLN,51022,CDM,260,RC,J3475,HCPCS,63323-064-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DROPERIDOL 2.5 MG/ML INJ SOLN,51022,CDM,450,RC,J1790,HCPCS,0143-9514-01,NDC,facility,both,1,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),51022,CDM,450,RC,J2270,HCPCS,0409-1891-03,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE NA (PRESERV FREE) 25 MG/ML INJ SOLN,51022,CDM,260,RC,J9260,HCPCS,16729-277-35,NDC,facility,both,1,ML,,2416,1691.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),51022,CDM,260,RC,J2270,HCPCS,0409-1891-03,NDC,facility,both,1,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
PEGFILGRASTIM-JMDB (FULPHILA) 6 MG/0.6 ML SUBQ SYRG,51022,CDM,260,RC,Q5108,HCPCS,83257-005-41,NDC,facility,both,1,ML,,5762,4033.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,51022,CDM,450,RC,J2359,HCPCS,55150-308-01,NDC,facility,both,1,EA,XU,52,36.4,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,51022,CDM,260,RC,J1815,HCPCS,83257-011-11,NDC,facility,both,1,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,25021-410-76,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,51022,CDM,450,RC,J2354,HCPCS,25021-463-01,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PALIPERIDONE PALMITATE 117 MG/0.75 ML IM SYRG,51022,CDM,260,RC,J2426,HCPCS,50458-562-01,NDC,facility,both,1,ML,,4801,3360.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE  2 MG/ML INJ SYRG,51022,CDM,450,RC,J2270,HCPCS,0409-1890-03,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,51022,CDM,260,RC,J3301,HCPCS,16714-130-01,NDC,facility,both,1,ML,XU,50,35,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
DIAZEPAM 5 MG/ML INJ SYRG,51022,CDM,260,RC,J3360,HCPCS,0641-6244-01,NDC,facility,both,1,ML,,723,506.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),51022,CDM,450,RC,J1171,HCPCS,0409-4264-11,NDC,facility,both,1,ML,XS,22,15.4,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
METHOTREXATE NA (PRESERV FREE) 25 MG/ML INJ SOLN,51022,CDM,260,RC,J9260,HCPCS,0703-3678-01,NDC,facility,both,1,ML,,1087,760.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),51022,CDM,450,RC,J1171,HCPCS,0409-1283-03,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,51022,CDM,260,RC,J3360,HCPCS,69339-136-03,NDC,facility,both,1,ML,,145,101.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 6 MG/0.5 ML SUBQ PEN KIT,51022,CDM,450,RC,J3030,HCPCS,72603-141-01,NDC,facility,both,1,ML,XS,239,167.3,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,51022,CDM,450,RC,J1885,HCPCS,63323-161-00,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,51022,CDM,260,RC,J0690,HCPCS,44567-707-25,NDC,facility,both,1,EA,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
CEFTRIAXONE 1 GRAM INJ SOLR,51022,CDM,260,RC,J0696,HCPCS,60505-6148-0,NDC,facility,both,1,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ABOBOTULINUMTOXINA 500 UNITS IM SOLR,51022,CDM,260,RC,J0586,HCPCS,15054-0500-1,NDC,facility,both,1,EA,XS,3370,2359,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
METHYLNALTREXONE 12 MG/0.6 ML SUBQ SYRG,51022,CDM,450,RC,J2212,HCPCS,65649-551-07,NDC,facility,both,1,ML,,490,343,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL DECANOATE  50 MG/ML IM SOLN,51022,CDM,260,RC,J1631,HCPCS,70069-030-03,NDC,facility,both,1,ML,,459,321.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),51022,CDM,450,RC,J1171,HCPCS,0409-1283-03,NDC,facility,both,1,ML,XU,18,12.6,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,51022,CDM,260,RC,J1815,HCPCS,0088-2220-33,NDC,facility,both,1,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
INSULIN DEGLUDEC 100 UNITS/ML SUBQ SOLN,51022,CDM,260,RC,J1815,HCPCS,73070-400-11,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN DEGLUDEC 100 UNITS/ML SUBQ SOLN,51022,CDM,260,RC,J1815,HCPCS,73070-400-11,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE  100 MCG/ML INJ SOLN,51022,CDM,260,RC,J2354,HCPCS,0641-6175-01,NDC,facility,both,1,ML,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,51022,CDM,260,RC,J2354,HCPCS,23155-687-31,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,51022,CDM,450,RC,J1885,HCPCS,63323-161-00,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),51022,CDM,260,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,1,ML,REMOVED,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier REMOVED: Modifier description not available
HYDROXYZINE 50 MG/ML IM,51022,CDM,260,RC,J3410,HCPCS,0517-5601-25,NDC,facility,both,1,ML,,190,133,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 125 MCG SUBQ SOLR,51022,CDM,260,RC,J2802,HCPCS,55513-223-01,NDC,facility,both,1,EA,XS,10260,7182,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
DROPERIDOL 2.5 MG/ML INJ SOLN,51022,CDM,450,RC,J1790,HCPCS,0517-9702-25,NDC,facility,both,1,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",51022,CDM,260,RC,J3490,HCPCS,0409-4887-17,NDC,facility,both,1,ML,XU,23,16.1,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
FLUPHENAZINE DECANOATE 25 MG/ML INJ SOLN,51022,CDM,260,RC,J2680,HCPCS,55150-267-05,NDC,facility,both,1,ML,,195,136.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLNALTREXONE 12 MG/0.6 ML SUBQ SYRG,51022,CDM,450,RC,J2212,HCPCS,65649-552-04,NDC,facility,both,1,ML,,693,485.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DENOSUMAB 120 MG/1.7 ML (70 MG/ML) SUBQ SOLN,51022,CDM,260,RC,J0897,HCPCS,55513-730-01,NDC,facility,both,1,ML,,9522,6665.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),51022,CDM,450,RC,J2270,HCPCS,0409-1891-03,NDC,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,51022,CDM,450,RC,J1815,HCPCS,0169-1833-11,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 6 MG/0.5 ML SUBQ PEN KIT,51022,CDM,260,RC,J3030,HCPCS,72603-141-01,NDC,facility,both,1,ML,,406,284.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML INJ SOLN,51022,CDM,260,RC,J0171,HCPCS,76329-9060-0,NDC,facility,both,1,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,51022,CDM,450,RC,J1885,HCPCS,63323-162-00,NDC,facility,both,1,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),51022,CDM,260,RC,J1610,HCPCS,63323-593-03,NDC,facility,both,1,EA,,1342,939.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML INJ SOLN,51022,CDM,450,RC,J2060,HCPCS,0409-1985-03,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ICATIBANT 30 MG/3 ML SUBQ SYRG,51022,CDM,450,RC,J1744,HCPCS,69097-664-34,NDC,facility,both,1,ML,,29229,20460.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.3 MG/0.3 ML IM PNIJ,51022,CDM,260,RC,J0169,HCPCS,0093-5986-19,NDC,facility,both,1,EA,,1024,716.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ORPHENADRINE CITRATE 30 MG/ML INJ SOLN,51022,CDM,450,RC,J2360,HCPCS,0641-6182-01,NDC,facility,both,1,ML,XU,92,64.4,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
EPINEPHRINE 0.3 MG/0.3 ML IM PNIJ,51022,CDM,260,RC,J0169,HCPCS,49502-102-01,NDC,facility,both,1,EA,,675,472.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TECLISTAMAB-CQYV 10 MG/ML SUBQ SOLN,51022,CDM,260,RC,J9380,HCPCS,57894-449-01,NDC,facility,both,1,ML,,4886,3420.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,51022,CDM,260,RC,J3360,HCPCS,0409-1273-32,NDC,facility,both,1,ML,,198,138.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BETAMETHASONE ACET & SOD PHOS 6 MG/ML INJ SUSP,51022,CDM,260,RC,J0702,HCPCS,78206-118-01,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML INJ SOLN,51022,CDM,260,RC,J0169,HCPCS,76329-9060-0,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,51022,CDM,260,RC,J0630,HCPCS,42023-205-01,NDC,facility,both,1,ML,,5618,3932.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,51022,CDM,450,RC,J3360,HCPCS,0641-6244-01,NDC,facility,both,1,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OMALIZUMAB 150 MG SUBQ SOLR,51022,CDM,260,RC,J2357,HCPCS,50242-040-62,NDC,facility,both,1,ME,,5219,3653.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",51022,CDM,260,RC,J3490,HCPCS,63323-185-10,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,16714-036-01,NDC,facility,both,1,ML,XS,94,65.8,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,51022,CDM,450,RC,J1885,HCPCS,0409-3795-19,NDC,facility,both,1,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,51022,CDM,260,RC,J0561,HCPCS,60793-701-10,NDC,facility,both,1,ML,,1188,831.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DICYCLOMINE 10 MG/ML IM SOLN,51022,CDM,450,RC,J0500,HCPCS,17478-015-02,NDC,facility,both,1,ML,XS,385,269.5,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
HALOPERIDOL DECANOATE 100 MG/ML IM SOLN,51022,CDM,260,RC,J1631,HCPCS,70069-383-01,NDC,facility,both,1,ML,,356,249.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),51022,CDM,260,RC,J3490,HCPCS,70004-600-09,NDC,facility,both,1,ML,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,51022,CDM,450,RC,J1644,HCPCS,0641-0400-37,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DENOSUMAB 60 MG/ML SUBQ SYRG,51022,CDM,260,RC,J0897,HCPCS,55513-710-21,NDC,facility,both,1,ML,,4930,3451,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,51022,CDM,260,RC,J3420,HCPCS,70069-005-01,NDC,facility,both,1,ML,XU,25,17.5,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
AMPICILLIN 1 GRAM SOLUTION FOR INJECTION,51022,CDM,260,RC,J0290,HCPCS,0781-3404-85,NDC,facility,both,1,EA,XU,96,67.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,16714-016-01,NDC,facility,both,1,ML,PLAD,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
KETAMINE 100 MG/ML INJ SOLN,51022,CDM,450,RC,J3490,HCPCS,42023-115-10,NDC,facility,both,1,ML,XU,79,55.3,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
INSULIN NPH & REGULAR HUMAN 100 UNIT/ML (70-30) SUBQ SUSP,51022,CDM,450,RC,J1815,HCPCS,0002-8715-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,51022,CDM,260,RC,J0630,HCPCS,24201-400-02,NDC,facility,both,1,ML,,3209,2246.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN DEGLUDEC 100 UNITS/ML SUBQ SOLN,51022,CDM,260,RC,J1815,HCPCS,73070-400-11,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE NA (PRESERV FREE) 25 MG/ML INJ SOLN,51022,CDM,260,RC,J9260,HCPCS,61703-408-41,NDC,facility,both,1,ML,,1940,1358,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 10 MG/ML INJECTION,51022,CDM,450,RC,J1100,HCPCS,55150-305-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),51022,CDM,260,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,1,ML,XU,29,20.3,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,51022,CDM,260,RC,J1885,HCPCS,63323-162-00,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLNALTREXONE 12 MG/0.6 ML SUBQ SYRG,51022,CDM,260,RC,J2212,HCPCS,65649-552-04,NDC,facility,both,1,ML,,693,485.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,51022,CDM,450,RC,J2354,HCPCS,23155-687-31,NDC,facility,both,1,ML,XU,20,14,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,51022,CDM,260,RC,J0585,HCPCS,0023-1145-01,NDC,facility,both,1,EA,XU,1439,1007.3,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
OLANZAPINE 10 MG IM SOLR,51022,CDM,450,RC,J2359,HCPCS,0002-7597-01,NDC,facility,both,1,EA,,256,179.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PALIPERIDONE PALMITATE 78 MG/0.5 ML IM SYRG,51022,CDM,260,RC,J2426,HCPCS,50458-561-01,NDC,facility,both,1,ML,,3201,2240.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),51022,CDM,450,RC,J2270,HCPCS,0641-6125-01,NDC,facility,both,1,ML,XU,25,17.5,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
EPINEPHRINE 1 MG/ML (1ML) INJ SOLN,51022,CDM,260,RC,J0169,HCPCS,42023-159-01,NDC,facility,both,1,ML,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,0781-3246-64,NDC,facility,both,1,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,51022,CDM,450,RC,J1885,HCPCS,63323-162-00,NDC,facility,both,1,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),51022,CDM,450,RC,J2270,HCPCS,0641-6125-01,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN DEGLUDEC 100 UNITS/ML SUBQ SOLN,51022,CDM,260,RC,J1815,HCPCS,73070-400-11,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,51022,CDM,260,RC,J3420,HCPCS,63323-044-00,NDC,facility,both,1,ML,XU,46,32.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
PENICILLIN G BENZATHINE 1200000 UNIT/2 ML IM SYRG,51022,CDM,450,RC,J0561,HCPCS,60793-702-10,NDC,facility,both,1,ML,,2088,1461.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 30 MG/0.3 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,0955-1003-01,NDC,facility,both,1,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,51022,CDM,450,RC,J0630,HCPCS,24201-400-02,NDC,facility,both,1,ML,XS,3188,2231.6,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
HALOPERIDOL DECANOATE  50 MG/ML IM SOLN,51022,CDM,260,RC,J1631,HCPCS,70069-030-01,NDC,facility,both,1,ML,,367,256.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,51022,CDM,450,RC,J0561,HCPCS,60793-701-02,NDC,facility,both,1,ML,XS,2160,1512,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
METHOTREXATE SODIUM 25 MG/ML INJ SOLN,51022,CDM,450,RC,J9260,HCPCS,16729-277-30,NDC,facility,both,1,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,51022,CDM,450,RC,J1644,HCPCS,25021-402-01,NDC,facility,both,1,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
BUPRENORPHINE 100 MG/0.5 ML SUBQ SLSY,51022,CDM,260,RC,Q9991,HCPCS,12496-0100-1,NDC,facility,both,1,ML,,4418,3092.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SOLN (VIAL),51022,CDM,260,RC,J3490,HCPCS,63323-186-10,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,51022,CDM,450,RC,J2250,HCPCS,0409-2305-16,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT 25 MCG/0.42 ML INJ SYRG,51022,CDM,450,RC,J0881,HCPCS,55513-057-01,NDC,facility,both,1,ML,,836,585.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TALQUETAMAB-TGVS 40 MG/ML SUBQ SOLN,51022,CDM,260,RC,J3055,HCPCS,57894-470-01,NDC,facility,both,1,ML,,36314,25419.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,51022,CDM,260,RC,J1817,HCPCS,0169-1833-11,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 2 MG/ML IV SOLN (PHS/CDS MERGE),51022,CDM,260,RC,J2270,HCPCS,76045-004-01,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,0075-0620-01,NDC,facility,both,1,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,51022,CDM,260,RC,J1815,HCPCS,83257-011-11,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EXENATIDE 10 MCG/0.04 ML SUBQ PNIJ,51022,CDM,260,RC,J3490,HCPCS,66780-212-01,NDC,facility,both,1,ML,,1179,825.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,51022,CDM,450,RC,J3490,HCPCS,0409-2051-15,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,51022,CDM,450,RC,J1885,HCPCS,25021-701-01,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL DECANOATE  50 MG/ML IM SOLN,51022,CDM,260,RC,J1631,HCPCS,10147-0921-3,NDC,facility,both,1,ML,,380,266,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),51022,CDM,260,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,1,ML,XU,17,11.9,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
CEFAZOLIN   1 GRAM INJ SOLR,51022,CDM,260,RC,J0690,HCPCS,44567-707-25,NDC,facility,both,1,EA,XU,8227,5758.9,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
ENOXAPARIN 150 MG/1 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,16714-066-01,NDC,facility,both,1,ML,,173,121.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 500 MCG INJ SOLR,51022,CDM,260,RC,J3490,HCPCS,42023-203-01,NDC,facility,both,1,EA,,1458,1020.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,16714-046-01,NDC,facility,both,1,ML,XS,81,56.7,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
EPINEPHRINE 0.3 MG/0.3 ML IM PNIJ,51022,CDM,260,RC,J0171,HCPCS,0115-1694-30,NDC,facility,both,1,EA,,890,623,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZIPRASIDONE 20 MG IM,51022,CDM,450,RC,J3486,HCPCS,72205-205-01,NDC,facility,both,1,EA,XU,96,67.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
ENOXAPARIN 120 MG/0.8 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,0075-2912-00,NDC,facility,both,1,ML,,154,107.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLNALTREXONE 12 MG/0.6 ML SUBQ SOLN,51022,CDM,450,RC,J2212,HCPCS,65649-551-02,NDC,facility,both,1,ML,,735,514.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",51022,CDM,260,RC,J3490,HCPCS,0409-4887-17,NDC,facility,both,2,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPROST TROMETHAMINE 250 MCG/ML IM SOLN,51022,CDM,260,RC,J3490,HCPCS,0409-0064-01,NDC,facility,both,1,ML,,457,319.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),51022,CDM,260,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFEPIME 1 GRAM INJ SOLR,51022,CDM,260,RC,J0692,HCPCS,0409-9566-01,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,51022,CDM,450,RC,J2250,HCPCS,0409-2308-21,NDC,facility,both,1,ML,XS,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
HYALURONIDASE 150 UNIT/ML INJ SOLN,51022,CDM,260,RC,J3473,HCPCS,18657-117-02,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),51022,CDM,450,RC,J1630,HCPCS,67457-426-00,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML (PEDS CALCLUATOR 0.5),51022,CDM,260,RC,J1815,HCPCS,0024-5924-10,NDC,facility,both,1,ML,XU,24,16.8,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
EPHEDRINE SULFATE  25 MG/5 ML (5 MG/ML) IV SYRG (MERGE),51022,CDM,260,RC,J3490,HCPCS,70004-600-09,NDC,facility,both,1,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,51022,CDM,260,RC,J1644,HCPCS,25021-402-01,NDC,facility,both,1,ML,XS,20,14,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
DIPHENHYDRAMINE 50 MG/ML INJECTION,51022,CDM,450,RC,J1200,HCPCS,72485-101-01,NDC,facility,both,1,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
CARBOPROST TROMETHAMINE 250 MCG/ML IM SOLN,51022,CDM,260,RC,J3490,HCPCS,0009-0856-08,NDC,facility,both,1,ML,,605,423.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 50 MG/ML IM,51022,CDM,450,RC,J3410,HCPCS,0517-5601-01,NDC,facility,both,1,ML,XU,190,133,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
FLUPHENAZINE DECANOATE 25 MG/ML INJ SOLN,51022,CDM,260,RC,J2680,HCPCS,67457-359-59,NDC,facility,both,1,ML,,134,93.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,51022,CDM,450,RC,J0630,HCPCS,24201-400-02,NDC,facility,both,1,ML,,2112,1478.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DARBEPOETIN ALFA IN POLYSORBAT 500 MCG/ML INJ SYRG,51022,CDM,260,RC,J0881,HCPCS,55513-032-01,NDC,facility,both,1,ML,,10682,7477.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),51022,CDM,260,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,1,ML,"XS,XU",16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
MORPHINE  2 MG/ML INJ SYRG,51022,CDM,450,RC,J2270,HCPCS,0409-1890-03,NDC,facility,both,1,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
ENOXAPARIN 20 MG/ML IN NS NEONATAL INJECTION (REPACK),51022,CDM,260,RC,J1650,HCPCS,63323-565-86,NDC,facility,both,1,ML,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,51022,CDM,260,RC,J0585,HCPCS,0023-1145-01,NDC,facility,both,1,EA,XU,6393,4475.1,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,51022,CDM,450,RC,J1644,HCPCS,25021-402-01,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,51022,CDM,450,RC,J0561,HCPCS,60793-701-02,NDC,facility,both,1,ML,XS,1080,756,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
CHLORPROMAZINE 25 MG/ML INJ SOLN,51022,CDM,450,RC,J3230,HCPCS,55150-319-01,NDC,facility,both,1,ML,XS,98,68.6,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
LEVOTHYROXINE 200 MCG INJ SOLR,51022,CDM,260,RC,J3490,HCPCS,63323-647-10,NDC,facility,both,1,EA,,746,522.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE (PF) 25 MG/ML INJ SOLN (FOR ECTOPIC PREGNANCY),51022,CDM,450,RC,J9260,HCPCS,0143-9519-01,NDC,facility,both,1,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 100 MG/1 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,0075-0623-03,NDC,facility,both,1,ML,XS,146,102.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,0781-3246-02,NDC,facility,both,1,ML,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DROPERIDOL 2.5 MG/ML INJ SOLN,51022,CDM,450,RC,J1790,HCPCS,0143-9514-01,NDC,facility,both,1,ML,XU,114,79.8,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
CEFTRIAXONE 500 MG INJ SOLR,51022,CDM,450,RC,J0696,HCPCS,44567-700-25,NDC,facility,both,1,EA,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
DIPHENHYDRAMINE 50 MG/ML INJECTION,51022,CDM,450,RC,J1200,HCPCS,25021-481-01,NDC,facility,both,1,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,51022,CDM,260,RC,J2354,HCPCS,25021-463-01,NDC,facility,both,1,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE NA (PRESERV FREE) 25 MG/ML INJ SOLN,51022,CDM,260,RC,J9260,HCPCS,61703-408-41,NDC,facility,both,1,ML,,432,302.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,51022,CDM,450,RC,J3301,HCPCS,70121-1049-1,NDC,facility,both,1,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ (MERGE),51022,CDM,450,RC,J2250,HCPCS,0409-2305-17,NDC,facility,both,1,ML,XS,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,51022,CDM,450,RC,J0561,HCPCS,60793-701-02,NDC,facility,both,1,ML,,1307,914.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),51022,CDM,260,RC,J0171,HCPCS,76329-3318-1,NDC,facility,both,1,ML,,1694,1185.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,51022,CDM,450,RC,J2250,HCPCS,0409-2308-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE 25 MG/ML INJ SOLN,51022,CDM,260,RC,J3230,HCPCS,0641-1398-31,NDC,facility,both,1,ML,,389,272.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,51022,CDM,260,RC,J0630,HCPCS,42023-205-01,NDC,facility,both,1,ML,,4408,3085.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,0781-3246-02,NDC,facility,both,1,ML,XU,55,38.5,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
DARBEPOETIN ALFA IN POLYSORBAT 200 MCG/0.4 ML INJ SYRG,51022,CDM,260,RC,J0881,HCPCS,55513-028-01,NDC,facility,both,1,ML,XU,4273,2991.1,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,0781-3246-02,NDC,facility,both,1,ML,XU,55,38.5,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),51022,CDM,260,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYALURONIDASE 150 UNIT/ML INJ SOLN,51022,CDM,450,RC,J3473,HCPCS,18657-117-02,NDC,facility,both,1,ML,,284,198.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,51022,CDM,260,RC,J1815,HCPCS,0169-1833-11,NDC,facility,both,1,ML,XS,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
DARBEPOETIN ALFA IN POLYSORBAT  60 MCG/0.3 ML INJ SYRG,51022,CDM,260,RC,J0881,HCPCS,55513-023-01,NDC,facility,both,1,ML,,1282,897.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,51022,CDM,260,RC,J2359,HCPCS,55150-308-01,NDC,facility,both,1,EA,XU,52,36.4,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,51022,CDM,450,RC,J3010,HCPCS,0409-9093-32,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,51022,CDM,260,RC,J3420,HCPCS,70069-005-01,NDC,facility,both,1,ML,XS,25,17.5,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,51022,CDM,260,RC,J1644,HCPCS,0641-0400-12,NDC,facility,both,1,ML,XS,18,12.6,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
CEFTRIAXONE 1 GRAM INJ SOLR,51022,CDM,260,RC,J0696,HCPCS,0143-9857-01,NDC,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,51022,CDM,450,RC,J2250,HCPCS,0409-2308-22,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,51022,CDM,450,RC,J1815,HCPCS,0088-2220-33,NDC,facility,both,1,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,51022,CDM,450,RC,J1885,HCPCS,0409-3796-19,NDC,facility,both,1,ML,XS,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
GLUCAGON 1 MG/ML INJ (MERGE),51022,CDM,260,RC,J1610,HCPCS,63323-596-03,NDC,facility,both,1,EA,,1342,939.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FONDAPARINUX 7.5 MG/0.6 ML SUBQ SYRG,51022,CDM,260,RC,J1652,HCPCS,55111-680-11,NDC,facility,both,1,ML,,463,324.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,16714-036-01,NDC,facility,both,1,ML,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,51022,CDM,260,RC,J0630,HCPCS,24201-400-02,NDC,facility,both,1,ML,,1513,1059.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ SOLN,51022,CDM,260,RC,J2250,HCPCS,0409-2305-16,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) 20000 UNIT/ML INJ SOLN,51022,CDM,260,RC,J1644,HCPCS,72603-224-01,NDC,facility,both,1,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DROPERIDOL 2.5 MG/ML INJ SOLN,51022,CDM,450,RC,J1790,HCPCS,0517-9702-01,NDC,facility,both,1,ML,XS,63,44.1,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
ICATIBANT 30 MG/3 ML SUBQ SYRG,51022,CDM,260,RC,J1744,HCPCS,69097-664-34,NDC,facility,both,1,ML,,29229,20460.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,51022,CDM,260,RC,J2359,HCPCS,55150-308-01,NDC,facility,both,1,EA,,156,109.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),51022,CDM,450,RC,J1815,HCPCS,0024-5926-05,NDC,facility,both,1,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
EPHEDRINE 50 MG/ML IV SOLN (MERGE),51022,CDM,260,RC,J3490,HCPCS,0781-3269-71,NDC,facility,both,1,ML,XU,251,175.7,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
FENTANYL CITRATE (PF) 50 MCG/ML INJ SOLN,51022,CDM,450,RC,J3010,HCPCS,0409-9094-12,NDC,facility,both,1,ML,XU,19,13.3,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),51022,CDM,450,RC,J2270,HCPCS,0641-6125-01,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,51022,CDM,450,RC,J0696,HCPCS,44567-701-25,NDC,facility,both,1,EA,XU,20,14,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
HYALURONIDASE 150 UNIT/ML INJ SOLN,51022,CDM,450,RC,J3473,HCPCS,18657-117-02,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",51022,CDM,260,RC,J3490,HCPCS,0409-4887-10,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),51022,CDM,260,RC,J1610,HCPCS,63323-583-13,NDC,facility,both,1,EA,,991,693.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,51022,CDM,260,RC,J3420,HCPCS,63323-044-00,NDC,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,51022,CDM,450,RC,J0690,HCPCS,60505-6142-0,NDC,facility,both,1,EA,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,51022,CDM,260,RC,J1815,HCPCS,49502-393-80,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,0781-3246-02,NDC,facility,both,1,ML,XU,137,95.9,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,51022,CDM,260,RC,J0585,HCPCS,0023-1145-01,NDC,facility,both,1,EA,,1599,1119.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML IV SOLN (MERGE),51022,CDM,260,RC,J3490,HCPCS,16714-037-01,NDC,facility,both,1,ML,XU,127,88.9,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
METHYLERGONOVINE 0.2 MG/ML (1 ML) INJ SOLN,51022,CDM,260,RC,J2210,HCPCS,0517-0740-01,NDC,facility,both,1,ML,,179,125.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,51022,CDM,450,RC,J3490,HCPCS,0409-2051-15,NDC,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML INJ SOLN,51022,CDM,260,RC,J0171,HCPCS,76329-9060-0,NDC,facility,both,1,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,51022,CDM,260,RC,J2354,HCPCS,25021-463-01,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE (CONTRACEPTIVE) 150 MG/ML IM SUSP,51022,CDM,260,RC,J1050,HCPCS,0548-5400-00,NDC,facility,both,1,ML,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),51022,CDM,450,RC,J1630,HCPCS,67457-426-00,NDC,facility,both,1,ML,XS,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
BORTEZOMIB 3.5 MG IV SOLR,51022,CDM,260,RC,J9041,HCPCS,10019-991-01,NDC,facility,both,1,EA,,241,168.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),51022,CDM,260,RC,J1610,HCPCS,63323-596-03,NDC,facility,both,1,EA,,895,626.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,63323-564-21,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMIPLOSTIM 500 MCG SUBQ SOLR,51022,CDM,260,RC,J2796,HCPCS,55513-222-01,NDC,facility,both,1,EA,XU,8780,6146,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
DROPERIDOL 2.5 MG/ML INJ SOLN,51022,CDM,450,RC,J1790,HCPCS,0517-9702-01,NDC,facility,both,1,ML,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 1 MG/ML INJ SOLN,51022,CDM,260,RC,J0169,HCPCS,76329-9060-0,NDC,facility,both,1,ML,,797,557.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"HIB CONJ-TET,COMPNT 2 OF 2(PF) 10 MCG/0.5 ML IM SOLR",51022,CDM,260,RC,90698,HCPCS,49281-544-58,NDC,facility,both,1,EA,,493,345.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DROPERIDOL 2.5 MG/ML INJ SOLN,51022,CDM,450,RC,J1790,HCPCS,0517-9702-01,NDC,facility,both,1,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,51022,CDM,260,RC,J2310,HCPCS,0409-1215-21,NDC,facility,both,1,ML,,186,130.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML IV SOLN (MERGE),51022,CDM,260,RC,J3490,HCPCS,70756-611-82,NDC,facility,both,1,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),51022,CDM,260,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,1,ML,XS,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
HEPARIN (PORCINE) 20000 UNIT/ML INJ SOLN,51022,CDM,260,RC,J1644,HCPCS,72603-224-01,NDC,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OLANZAPINE 10 MG IM SOLR,51022,CDM,450,RC,J2359,HCPCS,55150-308-01,NDC,facility,both,1,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,51022,CDM,260,RC,J1815,HCPCS,0088-2220-33,NDC,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,51022,CDM,260,RC,J0696,HCPCS,0143-9856-01,NDC,facility,both,1,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,51022,CDM,260,RC,J2405,HCPCS,23155-547-31,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,16714-016-01,NDC,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),51022,CDM,260,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,1,ML,XU,25,17.5,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
ROMIPLOSTIM 125 MCG SUBQ SOLR,51022,CDM,260,RC,J2802,HCPCS,55513-223-01,NDC,facility,both,1,EA,XS,1129,790.3,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),51022,CDM,450,RC,J1815,HCPCS,0024-5926-05,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,51022,CDM,450,RC,J2250,HCPCS,0409-2308-21,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,51022,CDM,450,RC,J0630,HCPCS,42023-205-01,NDC,facility,both,1,ML,,5099,3569.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 6 MG/0.5 ML SUBQ PEN KIT,51022,CDM,450,RC,J3030,HCPCS,16714-040-01,NDC,facility,both,1,ML,,406,284.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),51022,CDM,450,RC,J1815,HCPCS,0024-5926-05,NDC,facility,both,1,ML,XS,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),51022,CDM,260,RC,J1815,HCPCS,0024-5926-05,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG/ML INJ SOLN,51022,CDM,260,RC,J2550,HCPCS,0641-6208-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,51022,CDM,260,RC,J0585,HCPCS,0023-1145-01,NDC,facility,both,1,EA,XU,5274,3691.8,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,16714-026-01,NDC,facility,both,1,ML,XU,58,40.6,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
METHOTREXATE NA (PRESERV FREE) 25 MG/ML INJ SOLN,51022,CDM,260,RC,J9260,HCPCS,61703-408-41,NDC,facility,both,1,ML,,1509,1056.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN (LANTUS/SEMGLEE) (MERGE),51022,CDM,260,RC,J1815,HCPCS,83257-014-11,NDC,facility,both,1,ML,"XU,PLAD",16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service | Modifier PLAD: Modifier description not available"
EPINEPHRINE 0.3 MG/0.3 ML IM PNIJ,51022,CDM,450,RC,J0171,HCPCS,49502-500-01,NDC,facility,both,1,EA,XS,1078,754.6,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
FONDAPARINUX 2.5 MG/0.5 ML SUBQ SYRG,51022,CDM,450,RC,J1652,HCPCS,55150-230-00,NDC,facility,both,1,ML,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 500 MG INJ SOLR,51022,CDM,260,RC,J0696,HCPCS,0409-7338-11,NDC,facility,both,1,EA,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
EPINEPHRINE 0.3 MG/0.3 ML IM PNIJ,51022,CDM,260,RC,J0169,HCPCS,49502-102-01,NDC,facility,both,1,EA,XU,675,472.5,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
BETAMETHASONE ACET & SOD PHOS 6 MG/ML INJ SUSP,51022,CDM,260,RC,J0702,HCPCS,78206-118-01,NDC,facility,both,1,ML,XS,98,68.6,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,0781-3246-02,NDC,facility,both,1,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,51022,CDM,450,RC,J1100,HCPCS,63323-165-01,NDC,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,51022,CDM,260,RC,J1644,HCPCS,0641-0400-12,NDC,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE 0.5 MG/0.5 ML INJ SYRG (PHS ERX MERGE),51022,CDM,260,RC,J1171,HCPCS,0409-4264-11,NDC,facility,both,1,ML,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VARICELLA-ZOSTER IG-MALTOSE 125 UNIT/1.2 ML IM SOLN,51022,CDM,260,RC,90396,HCPCS,49591-126-51,NDC,facility,both,1,ML,,31475,22032.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPINEPHRINE 0.3 MG/0.3 ML IM PNIJ,51022,CDM,450,RC,J0169,HCPCS,49502-500-01,NDC,facility,both,1,EA,,1078,754.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
OCTREOTIDE ACETATE   50 MCG/ML INJ SOLN,51022,CDM,260,RC,J2354,HCPCS,25021-463-01,NDC,facility,both,1,ML,XU,150,105,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,51022,CDM,260,RC,J1815,HCPCS,49502-393-80,NDC,facility,both,1,ML,,321,224.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL,51022,CDM,260,RC,J1071,HCPCS,0143-9659-01,NDC,facility,both,1,ML,XS,53,37.1,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,51022,CDM,450,RC,J0630,HCPCS,43598-051-11,NDC,facility,both,1,ML,,4665,3265.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THIAMINE 100 MG/ML INJECTION,51022,CDM,260,RC,J3411,HCPCS,0641-6228-01,NDC,facility,both,1,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,16714-046-01,NDC,facility,both,1,ML,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,51022,CDM,450,RC,J0630,HCPCS,24201-400-02,NDC,facility,both,1,ML,,3478,2434.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,51022,CDM,260,RC,J1815,HCPCS,49502-393-80,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLNALTREXONE 12 MG/0.6 ML SUBQ SYRG,51022,CDM,450,RC,J2212,HCPCS,65649-552-04,NDC,facility,both,1,ML,,735,514.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 1 MG/ML INJ (MERGE),51022,CDM,450,RC,J2250,HCPCS,0409-2305-17,NDC,facility,both,1,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
EPHEDRINE 50 MG/ML IV SOLN (MERGE),51022,CDM,260,RC,J3490,HCPCS,0781-3269-71,NDC,facility,both,1,ML,59,251,175.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier 59: Distinct Procedural Service
INSULIN DEGLUDEC 100 UNITS/ML SUBQ SOLN,51022,CDM,260,RC,J1815,HCPCS,73070-400-11,NDC,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,51022,CDM,260,RC,J1644,HCPCS,81952-111-01,NDC,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,51022,CDM,260,RC,J1644,HCPCS,0409-2723-30,NDC,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ABOBOTULINUMTOXINA 500 UNITS IM SOLR,51022,CDM,260,RC,J0586,HCPCS,15054-0500-1,NDC,facility,both,1,EA,XS,4212,2948.4,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
DIPHENHYDRAMINE 50 MG/ML INJECTION,51022,CDM,450,RC,J1200,HCPCS,25021-481-01,NDC,facility,both,1,ML,XS,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML IM SOLN,51022,CDM,450,RC,90375,HCPCS,13533-318-05,NDC,facility,both,1,ML,,11093,7765.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,51022,CDM,450,RC,J3490,HCPCS,0409-2051-15,NDC,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLERGONOVINE 0.2 MG/ML (1 ML) INJ SOLN,51022,CDM,260,RC,J2210,HCPCS,51991-144-99,NDC,facility,both,1,ML,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 500 MCG INJ SOLR,51022,CDM,260,RC,J3490,HCPCS,25021-470-10,NDC,facility,both,1,EA,,1313,919.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML IM SOLN,51022,CDM,450,RC,90375,HCPCS,13533-318-30,NDC,facility,both,1,ML,,5635,3944.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),51022,CDM,260,RC,J1630,HCPCS,67457-426-00,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,51022,CDM,450,RC,J1885,HCPCS,0409-3795-19,NDC,facility,both,1,ML,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,51022,CDM,450,RC,J1580,HCPCS,63323-010-01,NDC,facility,both,1,ML,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE (PF) 25 MG/ML INJ SOLN (FOR ECTOPIC PREGNANCY),51022,CDM,450,RC,J9260,HCPCS,0143-9519-01,NDC,facility,both,1,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,51022,CDM,260,RC,J1650,HCPCS,0781-3246-02,NDC,facility,both,1,ML,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),51022,CDM,260,RC,J2270,HCPCS,0641-6125-01,NDC,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN REGULAR HUMAN 100 UNIT/ML INJ SOLN,51022,CDM,450,RC,J1815,HCPCS,0002-8215-01,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,16714-016-01,NDC,facility,both,1,ML,XS,53,37.1,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,51022,CDM,260,RC,J3420,HCPCS,0517-0031-01,NDC,facility,both,1,ML,XS,49,34.3,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
DIAZEPAM 5 MG/ML INJ SYRG,51022,CDM,260,RC,J3360,HCPCS,43598-106-11,NDC,facility,both,1,ML,,145,101.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CHLORPROMAZINE 25 MG/ML INJ SOLN,51022,CDM,260,RC,J3230,HCPCS,43598-140-11,NDC,facility,both,1,ML,,440,308,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,0075-0622-01,NDC,facility,both,1,ML,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 50 MG/ML INJECTION,51022,CDM,450,RC,J1200,HCPCS,63323-664-00,NDC,facility,both,1,ML,XS,21,14.7,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
INSULIN LISPRO 100 UNIT/ML SUBQ SOLN (HUMALOG/ADMELOG),51022,CDM,260,RC,J1815,HCPCS,0024-5926-05,NDC,facility,both,1,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,51022,CDM,260,RC,J0630,HCPCS,42023-205-01,NDC,facility,both,1,ML,,1921,1344.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
EPHEDRINE 50 MG/ML IV SOLN (MERGE),51022,CDM,260,RC,J3490,HCPCS,16714-037-01,NDC,facility,both,1,ML,,253,177.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEVOTHYROXINE 500 MCG INJ SOLR,51022,CDM,260,RC,J3490,HCPCS,63323-648-10,NDC,facility,both,1,EA,,1457,1019.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMOSOZUMAB-AQQG 210MG/2.34ML ( 105MG/1.17MLX2) SUBQ SYRG,51022,CDM,260,RC,J3111,HCPCS,55513-998-02,NDC,facility,both,1,ML,,5894,4125.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CALCITONIN (SALMON) 200 UNIT/ML INJ SOLN,51022,CDM,450,RC,J0630,HCPCS,24201-400-02,NDC,facility,both,1,ML,,5877,4113.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETAMINE 100 MG/ML INJ SOLN,51022,CDM,450,RC,J3490,HCPCS,0143-9509-01,NDC,facility,both,1,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,51022,CDM,450,RC,J0696,HCPCS,60505-6148-0,NDC,facility,both,1,EA,XS,225,157.5,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
DARBEPOETIN ALFA IN POLYSORBAT  40 MCG/0.4 ML INJ SYRG,51022,CDM,260,RC,J0881,HCPCS,55513-021-01,NDC,facility,both,1,ML,,2192,1534.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,51022,CDM,260,RC,J3301,HCPCS,0703-0241-01,NDC,facility,both,1,ML,XS,54,37.8,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
EPINEPHRINE 0.1 MG/ML SYRINGE (ERX MERGE),51022,CDM,260,RC,J0171,HCPCS,76329-3318-1,NDC,facility,both,1,ML,XU,74,51.8,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
CEFAZOLIN   1 GRAM INJ SOLR,51022,CDM,260,RC,J0690,HCPCS,44567-707-25,NDC,facility,both,1,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,51022,CDM,450,RC,J1885,HCPCS,72603-161-01,NDC,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE SODIUM 25 MG/ML INJ SOLN,51022,CDM,260,RC,J9260,HCPCS,16729-277-30,NDC,facility,both,1,ML,XS,28,19.6,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
CEFAZOLIN PEDS SYRINGE (20MG/ML) IN DEXTROSE (CDS MIX,51022,CDM,260,RC,J0690,HCPCS,0781-3451-70,NDC,facility,both,1,EA,XS,84,58.8,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
MEDROXYPROGESTERONE 150 MG/ML IM SYRG,51022,CDM,260,RC,J1050,HCPCS,0548-5701-00,NDC,facility,both,1,ML,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),51022,CDM,260,RC,J2270,HCPCS,0409-1891-03,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"OCTREOTIDE,MICROSPHERES 20 MG IM SERR",51022,CDM,260,RC,J2353,HCPCS,0078-0818-81,NDC,facility,both,1,EA,XS,25482,17837.4,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
METHYLPREDNISOLONE 40 MG/ML SUSP (DEPO-MEDROL) INJECTION,51022,CDM,260,RC,J1010,HCPCS,0009-3073-01,NDC,facility,both,1,ML,XU,200,140,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
OCTREOTIDE ACETATE  100 MCG/ML INJ SOLN,51022,CDM,260,RC,J2354,HCPCS,0641-6175-01,NDC,facility,both,1,ML,XS,44,30.8,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
MEDROXYPROGESTERONE (CONTRACEPTIVE) 150 MG/ML IM SUSP,51022,CDM,260,RC,J1050,HCPCS,0009-0746-30,NDC,facility,both,1,ML,,268,187.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"WATER FOR INJECTION, STERILE INJECTION",51022,CDM,260,RC,J3490,HCPCS,0409-4887-10,NDC,facility,both,2,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,51022,CDM,450,RC,J2312,HCPCS,0409-1215-21,NDC,facility,both,1,ML,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 50 MG/ML INJECTION,51022,CDM,450,RC,J1200,HCPCS,0641-0376-21,NDC,facility,both,1,ML,XS,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,51022,CDM,260,RC,J0585,HCPCS,0023-1145-01,NDC,facility,both,1,EA,XS,1279,895.3,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
ESTRADIOL CYPIONATE 5 MG/ML IM OIL,51022,CDM,260,RC,J1000,HCPCS,0009-0271-01,NDC,facility,both,1,ML,,878,614.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VUTRISIRAN 25 MG/0.5 ML SUBQ SYRG,51022,CDM,260,RC,J0225,HCPCS,71336-1003-1,NDC,facility,both,1,ML,,329409,230586.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PENICILLIN G BENZATHINE 600000 UNIT/ML IM SYRG,51022,CDM,260,RC,J0561,HCPCS,60793-701-10,NDC,facility,both,1,ML,,2376,1663.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,16714-036-01,NDC,facility,both,1,ML,XU,82,57.4,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
METHOTREXATE (PF) 25 MG/ML INJ SOLN (FOR ECTOPIC PREGNANCY),51022,CDM,260,RC,J9260,HCPCS,0143-9519-01,NDC,facility,both,1,ML,XU,54,37.8,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
INSULIN REGULAR HUM U-500 CONC 500 UNIT/ML INJ SOLN,51022,CDM,260,RC,J1815,HCPCS,0002-8501-01,NDC,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLERGONOVINE 0.2 MG/ML (1 ML) INJ SOLN,51022,CDM,450,RC,J2210,HCPCS,0517-0740-01,NDC,facility,both,1,ML,XS,230,161,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
DIAZEPAM 5 MG/ML INJ SYRG,51022,CDM,450,RC,J3360,HCPCS,69339-136-03,NDC,facility,both,1,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROMORPHONE (PF) 1 MG/ML IV SOLN (PHS ERX MERGE),51022,CDM,450,RC,J1171,HCPCS,76045-009-96,NDC,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FENTANYL CITRATE (PF) 50 MCG/ML (ANESTHESIA INTRAOP ONLY),51022,CDM,260,RC,J3010,HCPCS,0641-6027-01,NDC,facility,both,1,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
INSULIN ASP PRT-INSULIN ASPART 100 UNIT/ML (70-30) SUBQ SOLN,51022,CDM,260,RC,J1817,HCPCS,73070-200-11,NDC,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROMOSOZUMAB-AQQG 210MG/2.34ML ( 105MG/1.17MLX2) SUBQ SYRG,51022,CDM,260,RC,J3111,HCPCS,55513-998-02,NDC,facility,both,2,ML,,5893,4125.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHYLERGONOVINE 0.2 MG/ML (1 ML) INJ SOLN,51022,CDM,450,RC,J2210,HCPCS,0517-0740-01,NDC,facility,both,1,ML,,184,128.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALDESLEUKIN 360,000 UNITS/ ML SOLUTION",51022,CDM,260,RC,J9015,HCPCS,65483-116-07,NDC,facility,both,1,EA,XS,5121,3584.7,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
EPINEPHRINE 1 MG/ML (1ML) INJ SOLN,51022,CDM,260,RC,J0171,HCPCS,42023-159-01,NDC,facility,both,1,ML,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE SODIUM 25 MG/ML INJ SOLN,51022,CDM,260,RC,J9260,HCPCS,61703-350-37,NDC,facility,both,1,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,51022,CDM,260,RC,J1815,HCPCS,83257-011-11,NDC,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,51022,CDM,450,RC,J1650,HCPCS,16714-046-01,NDC,facility,both,1,ML,XS,115,80.5,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
INSULIN GLARGINE 100 UNIT/ML SUBQ SOLN,51022,CDM,260,RC,J1815,HCPCS,0088-2220-33,NDC,facility,both,1,ML,XS,17,11.9,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
FILGRASTIM-SNDZ 300 MCG/0.5 ML INJ SYRG,51022,CDM,260,RC,Q5101,HCPCS,61314-304-01,NDC,facility,both,1,ML,,976,683.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,51022,CDM,450,RC,J3360,HCPCS,0409-1273-03,NDC,facility,both,1,ML,XS,198,138.6,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure"
DESMOPRESSIN 4 MCG/ML INJECTION SOLN,51022,CDM,260,RC,J2597,HCPCS,43598-931-11,NDC,facility,both,1,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,51022,CDM,260,RC,J1644,HCPCS,0641-0400-12,NDC,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
INSULIN LISPRO 100 UNIT/ML (PEDS CALCLUATOR 0.5),51022,CDM,260,RC,J1815,HCPCS,0024-5924-10,NDC,facility,both,1,ML,"XU,LT",16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service | Modifier LT: Left side (used to identify procedures performed on the left side of the body)"
OMALIZUMAB 150 MG SUBQ SOLR,51022,CDM,260,RC,J2357,HCPCS,50242-040-62,NDC,facility,both,1,ME,,2610,1827,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANAKINRA 100 MG/0.67 ML SUBQ SYRG,51022,CDM,260,RC,J3590,HCPCS,66658-234-01,NDC,facility,both,1,ML,,562,393.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC IV INFUSION HYDRAT 31-60 MIN,51024,CDM,450,RC,J0248,HCPCS,61958-2901-2,NDC,facility,both,1,EA,,2392,1674.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC IV INFUSION HYDRAT 31-60 MIN,51026,CDM,260,RC,J0248,HCPCS,61958-2901-2,NDC,facility,both,1,EA,,1196,837.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC IV INFUSION HYDRAT 31-60 MIN,51028,CDM,450,RC,J0248,HCPCS,61958-2901-2,NDC,facility,both,1,EA,,1196,837.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC IV INFUSION HYDRAT 31-60 MIN,51028,CDM,260,RC,J0248,HCPCS,61958-2901-2,NDC,facility,both,1,EA,,1196,837.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC IV INFUSION HYDRAT 31-60 MIN,51028,CDM,260,RC,J0248,HCPCS,61958-2901-2,NDC,facility,both,1,EA,XU,2392,1674.4,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
OFFICE/OUTPAT VISIT NEW LEVEL 1,51900001,CDM,519,RC,G0463,HCPCS,,,facility,both,,,,241,168.7,,,,,,,,,,,,,Gross Charge Type: Central
OFFICE/OUTPAT VISIT NEW LEVEL 2,51900002,CDM,519,RC,G0463,HCPCS,,,facility,both,,,,289,202.3,,,,,,,,,,,,,Gross Charge Type: Central
OFFICE/OUTPAT VISIT NEW LEVEL 3,51900003,CDM,519,RC,G0463,HCPCS,,,facility,both,,,,347,242.9,,,,,,,,,,,,,Gross Charge Type: Central
OFFICE/OUTPAT VISIT NEW LEVEL 4,51900004,CDM,519,RC,G0463,HCPCS,,,facility,both,,,,417,291.9,,,,,,,,,,,,,Gross Charge Type: Central
OFFICE/OUTPAT VISIT NEW LEVEL 5,51900005,CDM,519,RC,G0463,HCPCS,,,facility,both,,,,500,350,,,,,,,,,,,,,Gross Charge Type: Central
HC OFFICE/OUTPAT VISIT EST LEVEL 1,51900006,CDM,519,RC,G0463,HCPCS,,,facility,both,,,,241,168.7,,,,,,,,,,,,,Gross Charge Type: Central
HC OFFICE/OUTPAT VISIT EST LEVEL 2,51900007,CDM,519,RC,G0463,HCPCS,,,facility,both,,,,289,202.3,,,,,,,,,,,,,Gross Charge Type: Central
HC OFFICE/OUTPAT VISIT EST LEVEL 3,51900008,CDM,519,RC,G0463,HCPCS,,,facility,both,,,,347,242.9,,,,,,,,,,,,,Gross Charge Type: Central
HC OFFICE/OUTPAT VISIT EST LEVEL 4,51900009,CDM,519,RC,G0463,HCPCS,,,facility,both,,,,417,291.9,,,,,,,,,,,,,Gross Charge Type: Central
HC OFFICE/OUTPAT VISIT EST LEVEL 5,51900010,CDM,519,RC,G0463,HCPCS,,,facility,both,,,,500,350,,,,,,,,,,,,,Gross Charge Type: Central
HC T1017 INITIAL ASSESSMENT,51900011,CDM,519,RC,T1017,HCPCS,,,facility,both,,,,1002,701.4,,,,,,,,,,,,,Gross Charge Type: Central
HC T2022 CASE MANAGEMENT SUBSEQUENT,51900012,CDM,519,RC,T2022,HCPCS,,,facility,both,,,,792,554.4,,,,,,,,,,,,,Gross Charge Type: Central
HC CPHP ASSESSMENT PRIMARY,51900013,CDM,519,RC,51900013,HCPCS,,,facility,both,,,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Central
HC CPHP CASE MANAGEMENT,51900014,CDM,519,RC,51900014,HCPCS,,,facility,both,,,,772,540.4,,,,,,,,,,,,,Gross Charge Type: Central
HC OFFICE/OP VISIT NEW LEVEL 1,51900016,CDM,519,RC,G0463,HCPCS,,,facility,both,,,,241,168.7,,,,,,,,,,,,,Gross Charge Type: Central
HC OFFICE/OP VISIT NEW LEVEL 2,51900017,CDM,519,RC,G0463,HCPCS,,,facility,both,,,,289,202.3,,,,,,,,,,,,,Gross Charge Type: Central
HC OFFICE/OP VISIT NEW LEVEL 3,51900018,CDM,519,RC,G0463,HCPCS,,,facility,both,,,,347,242.9,,,,,,,,,,,,,Gross Charge Type: Central
HC OFFICE/OP VISIT NEW LEVEL 4,51900019,CDM,519,RC,G0463,HCPCS,,,facility,both,,,,417,291.9,,,,,,,,,,,,,Gross Charge Type: Central
HC OFFICE/OP VISIT NEW LEVEL 5,51900020,CDM,519,RC,G0463,HCPCS,,,facility,both,,,,500,350,,,,,,,,,,,,,Gross Charge Type: Central
HC OFFICE/OP VISIT EST LEVEL 1,51900021,CDM,519,RC,G0463,HCPCS,,,facility,both,,,,241,168.7,,,,,,,,,,,,,Gross Charge Type: Central
HC OFFICE/OP VISIT EST LEVEL 2,51900022,CDM,519,RC,G0463,HCPCS,,,facility,both,,,,289,202.3,,,,,,,,,,,,,Gross Charge Type: Central
HC OFFICE/OP VISIT EST LEVEL 3,51900023,CDM,519,RC,G0463,HCPCS,,,facility,both,,,,347,242.9,,,,,,,,,,,,,Gross Charge Type: Central
HC OFFICE/OP VISIT EST LEVEL 4,51900024,CDM,519,RC,G0463,HCPCS,,,facility,both,,,,417,291.9,,,,,,,,,,,,,Gross Charge Type: Central
HC OFFICE/OP VISIT EST LEVEL 5,51900025,CDM,519,RC,G0463,HCPCS,,,facility,both,,,,500,350,,,,,,,,,,,,,Gross Charge Type: Central
HC LACTATION CLASSES NON-PHYSICIAN PROVIDER PER SESSION,51900026,CDM,942,RC,S9443,HCPCS,,,facility,both,,,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Central
HC LACTATION CLASSES NON-PHYSICIAN PROVIDER PER SESSION 15 MIN,51900027,CDM,942,RC,S9443,HCPCS,,,facility,both,,,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Central
HC LACTATION CLASSES NON-PHYSICIAN PROVIDER PER SESSION 30 MIN,51900028,CDM,942,RC,S9443,HCPCS,,,facility,both,,,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Central
HC LACTATION CLASSES NON-PHYSICIAN PROVIDER PER SESSION 45 MIN,51900029,CDM,942,RC,S9443,HCPCS,,,facility,both,,,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Central
HC LACTATION CLASSES NON-PHYSICIAN PROVIDER PER SESSION 60 MIN,51900030,CDM,942,RC,S9443,HCPCS,,,facility,both,,,,120,84,,,,,,,,,,,,,Gross Charge Type: Central
AZACITIDINE 100 MG INJ SOLR,52836,CDM,331,RC,J9025,HCPCS,72485-201-01,NDC,facility,both,1,EA,,2089,1462.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,52836,CDM,331,RC,J9025,HCPCS,72485-201-01,NDC,facility,both,1,EA,,2334,1633.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,52836,CDM,331,RC,J9025,HCPCS,72485-201-01,NDC,facility,both,1,EA,,2057,1439.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,52836,CDM,331,RC,J9025,HCPCS,0143-9606-01,NDC,facility,both,1,EA,,360,252,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,52836,CDM,331,RC,J9025,HCPCS,72485-201-01,NDC,facility,both,1,EA,,1802,1261.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE (PF) 25 MG/ML INJ SOLN (FOR ECTOPIC PREGNANCY),52836,CDM,331,RC,J9260,HCPCS,0143-9519-01,NDC,facility,both,2,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,52836,CDM,331,RC,J9025,HCPCS,72485-201-01,NDC,facility,both,1,EA,,2472,1730.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE SODIUM 25 MG/ML INJ SOLN,52836,CDM,331,RC,J9260,HCPCS,61703-350-37,NDC,facility,both,2,ML,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALDESLEUKIN 360,000 UNITS/ ML SOLUTION",52836,CDM,331,RC,J9015,HCPCS,65483-116-07,NDC,facility,both,1,EA,XE,5121,3584.7,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XE: Separate encounter, a service that is distinct because it occurred during a separate encounter"
AZACITIDINE 100 MG INJ SOLR,52836,CDM,331,RC,J9025,HCPCS,72485-201-01,NDC,facility,both,1,EA,,1876,1313.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,52836,CDM,331,RC,J9025,HCPCS,72485-201-01,NDC,facility,both,1,EA,,2387,1670.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,52836,CDM,331,RC,J9025,HCPCS,72485-201-01,NDC,facility,both,1,EA,,2557,1789.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,52836,CDM,331,RC,J9025,HCPCS,72485-201-01,NDC,facility,both,1,EA,,1897,1327.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,52836,CDM,331,RC,J9025,HCPCS,72485-201-01,NDC,facility,both,1,EA,,1769,1238.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,52836,CDM,331,RC,J9025,HCPCS,72485-201-01,NDC,facility,both,1,EA,,1993,1395.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,52836,CDM,331,RC,J9025,HCPCS,72485-201-01,NDC,facility,both,1,EA,,2462,1723.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,52836,CDM,331,RC,J9025,HCPCS,72485-201-01,NDC,facility,both,1,EA,,1918,1342.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,52836,CDM,331,RC,J9025,HCPCS,72485-201-01,NDC,facility,both,1,EA,,2259,1581.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,52836,CDM,331,RC,J9025,HCPCS,72485-201-01,NDC,facility,both,1,EA,,2003,1402.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE SODIUM 25 MG/ML INJ SOLN,52836,CDM,331,RC,J9260,HCPCS,61703-350-37,NDC,facility,both,2,ML,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,52836,CDM,331,RC,J9025,HCPCS,72485-201-01,NDC,facility,both,1,EA,,2131,1491.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALDESLEUKIN 360,000 UNITS/ ML SOLUTION",52836,CDM,331,RC,J9015,HCPCS,65483-116-07,NDC,facility,both,1,EA,,5121,3584.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,52836,CDM,331,RC,J9025,HCPCS,72485-201-01,NDC,facility,both,1,EA,,1951,1365.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE SODIUM 25 MG/ML INJ SOLN,52836,CDM,331,RC,J9260,HCPCS,61703-350-37,NDC,facility,both,2,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,52836,CDM,331,RC,J9025,HCPCS,72485-201-01,NDC,facility,both,1,EA,,2228,1559.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,52836,CDM,331,RC,J9025,HCPCS,72485-201-01,NDC,facility,both,1,EA,,1418,992.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,52836,CDM,331,RC,J9025,HCPCS,72485-201-01,NDC,facility,both,1,EA,,1930,1351,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,52836,CDM,331,RC,J9025,HCPCS,72485-201-01,NDC,facility,both,1,EA,,2408,1685.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE SODIUM 25 MG/ML INJ SOLN,52836,CDM,331,RC,J9260,HCPCS,61703-350-37,NDC,facility,both,1,ML,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,52836,CDM,331,RC,J9025,HCPCS,72485-201-01,NDC,facility,both,1,EA,,1631,1141.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AZACITIDINE 100 MG INJ SOLR,52836,CDM,331,RC,J9025,HCPCS,72485-201-01,NDC,facility,both,1,EA,,2217,1551.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEGARELIX 120 MG SUBQ SOLR,52838,CDM,331,RC,J9155,HCPCS,55566-8402-0,NDC,facility,both,1,EA,,4207,2944.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE (3 MONTH) 22.5 MG IM SYRG,52838,CDM,331,RC,J9217,HCPCS,0074-3346-03,NDC,facility,both,1,EA,,1176,823.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE 22.5 MG SUBQ SYRG,52838,CDM,331,RC,J9217,HCPCS,62935-223-05,NDC,facility,both,1,EA,,1176,823.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE (6 MONTH) 45 MG SUBCUTANOUS KIT,52838,CDM,331,RC,J9217,HCPCS,62935-453-45,NDC,facility,both,1,EA,,1176,823.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE (6 MONTH) 45 MG IM SYKT,52838,CDM,331,RC,J9217,HCPCS,0074-3473-03,NDC,facility,both,1,EA,,1176,823.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE (4-MONTH) 30 MG SUBQ SYRG,52838,CDM,331,RC,J9217,HCPCS,62935-306-40,NDC,facility,both,1,EA,,1176,823.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE 1 MG/0.2 ML SUBQ KIT,52838,CDM,331,RC,J9218,HCPCS,41616-936-40,NDC,facility,both,1,EA,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE (6 MONTH) 45 MG SUBCUTANOUS KIT,52838,CDM,331,RC,J9217,HCPCS,62935-454-44,NDC,facility,both,1,EA,,1176,823.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE 1 MG/0.2 ML SUBQ KIT,52838,CDM,331,RC,J9218,HCPCS,0781-4003-32,NDC,facility,both,1,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEGARELIX 120 MG SUBQ SOLR,52838,CDM,331,RC,J9155,HCPCS,55566-8402-0,NDC,facility,both,2,EA,,4207,2944.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE 1 MG/0.2 ML SUBQ KIT,52838,CDM,331,RC,J9218,HCPCS,0781-4003-32,NDC,facility,both,1,EA,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE 1 MG/0.2 ML SUBQ KIT,52838,CDM,331,RC,J9218,HCPCS,0781-4003-32,NDC,facility,both,1,EA,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE 22.5 MG SUBQ SYRG,52838,CDM,331,RC,J9217,HCPCS,62935-227-10,NDC,facility,both,1,EA,,1176,823.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE 22.5 MG SUBQ SYRG,52838,CDM,331,RC,J9217,HCPCS,62935-221-04,NDC,facility,both,1,EA,,1176,823.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE (6 MONTH) 45 MG SUBCUTANOUS KIT,52838,CDM,331,RC,J9217,HCPCS,62935-461-50,NDC,facility,both,1,EA,,1176,823.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEGARELIX 120 MG SUBQ SOLR,52838,CDM,331,RC,J9155,HCPCS,55566-8403-1,NDC,facility,both,1,EA,,4207,2944.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE SODIUM 25 MG/ML INJ SOLN,52840,CDM,331,RC,J9260,HCPCS,61703-350-37,NDC,facility,both,1,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,5451,CDM,J1580,HCPCS,63323-010-01,NDC,,,facility,both,1,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLU VACCINE TS 2025-26 65 YR UP (PF) 180 MCG/0.5 ML IM SYRG,54864,CDM,771,RC,90662,HCPCS,49281-125-88,NDC,facility,both,1,ML,,372,260.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PNEUMOCOCCAL 23-VAL PS VACCINE 25 MCG/0.5 ML INJ SYRG,54864,CDM,771,RC,90732,HCPCS,0006-4837-01,NDC,facility,both,1,ML,,506,354.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLU VACCINE TS 2025-26 65 YR UP (PF) 180 MCG/0.5 ML IM SYRG,54864,CDM,771,RC,90662,HCPCS,49281-125-88,NDC,facility,both,1,ML,,403,282.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLU VACCINE TS 2024-25 65 YR UP (PF) 180 MCG/0.5 ML IM SYRG,54864,CDM,771,RC,90662,HCPCS,49281-124-88,NDC,facility,both,1,ML,,373,261.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLU VACCINE TS 2024-25 65 YR UP (PF) 180 MCG/0.5 ML IM SYRG,54864,CDM,761,RC,90662,HCPCS,49281-124-88,NDC,facility,both,1,ML,,373,261.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PNEUMOCOCCAL 23-VAL PS VACCINE 25 MCG/0.5 ML INJ SYRG,54866,CDM,771,RC,90732,HCPCS,0006-4837-01,NDC,facility,both,1,ML,,506,354.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PNEUMOCOCCAL 23-VALPS VACCINE 25 MCG/0.5 ML INJ,54866,CDM,771,RC,90732,HCPCS,0006-4943-01,NDC,facility,both,1,ML,,506,354.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPOTECAN 4 MG/4 ML (1 MG/ML) IV SOLN,55468,CDM,J9351,HCPCS,0409-0302-01,NDC,,,facility,both,12,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPOTECAN 4 MG/4 ML (1 MG/ML) IV SOLN,55468,CDM,J9351,HCPCS,0409-0302-01,NDC,,,facility,both,64,ML,,958,670.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPOTECAN 4 MG/4 ML (1 MG/ML) IV SOLN,55468,CDM,J9351,HCPCS,0409-0302-01,NDC,,,facility,both,68,ML,,600,420,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPOTECAN 4 MG/4 ML (1 MG/ML) IV SOLN,55468,CDM,J9351,HCPCS,0409-0302-01,NDC,,,facility,both,16,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPOTECAN 4 MG/4 ML (1 MG/ML) IV SOLN,55468,CDM,J9351,HCPCS,0409-0302-01,NDC,,,facility,both,68,ML,,1018,712.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPOTECAN 4 MG/4 ML (1 MG/ML) IV SOLN,55468,CDM,J9351,HCPCS,0409-0302-01,NDC,,,facility,both,80,ML,,706,494.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPOTECAN 4 MG IV SOLR,55468,CDM,J9351,HCPCS,63323-762-10,NDC,,,facility,both,40,EA,,832,582.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPOTECAN 4 MG/4 ML (1 MG/ML) IV SOLN,55468,CDM,J9351,HCPCS,0409-0302-01,NDC,,,facility,both,40,ML,,353,247.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TOPOTECAN 4 MG/4 ML (1 MG/ML) IV SOLN,55468,CDM,J9351,HCPCS,0409-0302-01,NDC,,,facility,both,12,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC MRI ORBIT/FACE/NECK W/O DYE,61000001,CDM,610,RC,70540,HCPCS,,,facility,both,,,,1963,1374.1,,,,,,,,,,,,,Gross Charge Type: Central
HC MRI CHEST W/O DYE,61000002,CDM,610,RC,71550,HCPCS,,,facility,both,,,,2133,1493.1,,,,,,,,,,,,,Gross Charge Type: Central
HC MRI CHEST W/WO DYE,61000003,CDM,610,RC,71552,HCPCS,,,facility,both,,,,2574,1801.8,,,,,,,,,,,,,Gross Charge Type: Central
HC MRA CHEST W/WO DYE,61000004,CDM,610,RC,71555,HCPCS,,,facility,both,,,,2176,1523.2,,,,,,,,,,,,,Gross Charge Type: Central
HC MRI PELVIS W/O DYE,61000005,CDM,610,RC,72195,HCPCS,,,facility,both,,,,1890,1323,,,,,,,,,,,,,Gross Charge Type: Central
HC MRI PELVIS W/DYE,61000006,CDM,610,RC,72196,HCPCS,,,facility,both,,,,2194,1535.8,,,,,,,,,,,,,Gross Charge Type: Central
HC MRI PELVIS W/WO DYE,61000007,CDM,610,RC,72197,HCPCS,,,facility,both,,,,2605,1823.5,,,,,,,,,,,,,Gross Charge Type: Central
HC MRI UPPER EXTR NOT JNT W/O DYE,61000008,CDM,610,RC,73218,HCPCS,,,facility,both,,,,1335,934.5,,,,,,,,,,,,,Gross Charge Type: Central
HC MRI UPPER EXTR NOT JNT W/DYE,61000009,CDM,610,RC,73219,HCPCS,,,facility,both,,,,1660,1162,,,,,,,,,,,,,Gross Charge Type: Central
HC MRI UPPR EXTREMITY W/WO DYE,61000010,CDM,610,RC,73220,HCPCS,,,facility,both,,,,1879,1315.3,,,,,,,,,,,,,Gross Charge Type: Central
HC MRI ANY JNT UPR EXT W/O DYE,61000011,CDM,610,RC,73221,HCPCS,,,facility,both,,,,1528,1069.6,,,,,,,,,,,,,Gross Charge Type: Central
HC MRI ANY JNT UPR EXT W/DYE,61000012,CDM,610,RC,73222,HCPCS,,,facility,both,,,,1794,1255.8,,,,,,,,,,,,,Gross Charge Type: Central
HC MRI ANY JOINT UPR EXT W/WO DYE,61000013,CDM,610,RC,73223,HCPCS,,,facility,both,,,,2377,1663.9,,,,,,,,,,,,,Gross Charge Type: Central
HC MRA UPPER EXT W/WO DYE,61000014,CDM,610,RC,73225,HCPCS,,,facility,both,,,,1630,1141,,,,,,,,,,,,,Gross Charge Type: Central
HC MRI LWR EXT NOT JNT W/O DYE,61000015,CDM,610,RC,73718,HCPCS,,,facility,both,,,,1470,1029,,,,,,,,,,,,,Gross Charge Type: Central
HC MRI LOWER EXT W/DYE,61000016,CDM,610,RC,73719,HCPCS,,,facility,both,,,,1537,1075.9,,,,,,,,,,,,,Gross Charge Type: Central
HC MRI LWR EXT W/WO DYE,61000017,CDM,610,RC,73720,HCPCS,,,facility,both,,,,2422,1695.4,,,,,,,,,,,,,Gross Charge Type: Central
HC MRI ANY JNT OF LWR EXT W/O DYE,61000018,CDM,610,RC,73721,HCPCS,,,facility,both,,,,1269,888.3,,,,,,,,,,,,,Gross Charge Type: Central
HC MRI ANY JOINT OF LWR EXT W/DYE,61000019,CDM,610,RC,73722,HCPCS,,,facility,both,,,,1978,1384.6,,,,,,,,,,,,,Gross Charge Type: Central
HC MRI ANY JOINT LWR EXT W/WO DYE,61000020,CDM,610,RC,73723,HCPCS,,,facility,both,,,,2356,1649.2,,,,,,,,,,,,,Gross Charge Type: Central
HC MRA LWR EXT W/WO DYE,61000021,CDM,610,RC,73725,HCPCS,,,facility,both,,,,1538,1076.6,,,,,,,,,,,,,Gross Charge Type: Central
HC MRI ABDOMEN W/O DYE,61000022,CDM,610,RC,74181,HCPCS,,,facility,both,,,,1329,930.3,,,,,,,,,,,,,Gross Charge Type: Central
HC MRI ABDOMEN W/DYE,61000023,CDM,610,RC,74182,HCPCS,,,facility,both,,,,1544,1080.8,,,,,,,,,,,,,Gross Charge Type: Central
HC MRI ABDOMEN W/WO DYE,61000024,CDM,610,RC,74183,HCPCS,,,facility,both,,,,1851,1295.7,,,,,,,,,,,,,Gross Charge Type: Central
HC MRA ABD W/WO DYE,61000025,CDM,610,RC,74185,HCPCS,,,facility,both,,,,1234,863.8,,,,,,,,,,,,,Gross Charge Type: Central
HC CARDIAC MRI FOR MORPH W/O DYE,61000026,CDM,610,RC,75557,HCPCS,,,facility,both,,,,1530,1071,,,,,,,,,,,,,Gross Charge Type: Central
HC CARDIAC MRI FOR MORPH W/DYE,61000027,CDM,610,RC,75561,HCPCS,,,facility,both,,,,1765,1235.5,,,,,,,,,,,,,Gross Charge Type: Central
HC CARD MRI VELOC FLOW MAPPING,61000028,CDM,610,RC,75565,HCPCS,,,facility,both,,,,1265,885.5,,,,,,,,,,,,,Gross Charge Type: Central
HC MRI SPECTROSCOPY,61000029,CDM,610,RC,76390,HCPCS,,,facility,both,,,,808,565.6,,,,,,,,,,,,,Gross Charge Type: Central
HC MAGNETIC RESONANCE ELASTOGRAPHY,61000036,CDM,610,RC,76391,HCPCS,,,facility,both,,,,1008,705.6,,,,,,,,,,,,,Gross Charge Type: Central
HC MRI FETAL INCL PLACENTAL/MATERNAL PELVIC IMG WHEN PERFORMED SINGLE OR FIRST GESTATION,61000038,CDM,610,RC,74712,HCPCS,,,facility,both,,,,879,615.3,,,,,,,,,,,,,Gross Charge Type: Central
HC CARDIAC MRI W/O CONTRAST W/STRESS IMAGING,61000040,CDM,610,RC,75559,HCPCS,,,facility,both,,,,1492,1044.4,,,,,,,,,,,,,Gross Charge Type: Central
HC CARDIAC MRI W/W/O CONTRAST W/STRESS,61000041,CDM,610,RC,75563,HCPCS,,,facility,both,,,,3304,2312.8,,,,,,,,,,,,,Gross Charge Type: Central
HC MAGNETIC RESONANCE ALYS TISSUE COMPOSITION W/MRI SINGLE ORGAN,61000042,CDM,610,RC,0694T,HCPCS,,,facility,both,,,,100,70,,,,,,,,,,,,,Gross Charge Type: Central
HC MRI ORBT/FAC/NCK W/WO DYE,61100002,CDM,611,RC,70543,HCPCS,,,facility,both,,,,2596,1817.2,,,,,,,,,,,,,Gross Charge Type: Central
HC MRI BRAIN W/O DYE,61100003,CDM,611,RC,70551,HCPCS,,,facility,both,,,,1834,1283.8,,,,,,,,,,,,,Gross Charge Type: Central
HC MRI BRAIN W/DYE,61100004,CDM,611,RC,70552,HCPCS,,,facility,both,,,,2107,1474.9,,,,,,,,,,,,,Gross Charge Type: Central
HC MRI BRAIN/STEM W/WO DYE,61100005,CDM,611,RC,70553,HCPCS,,,facility,both,,,,2530,1771,,,,,,,,,,,,,Gross Charge Type: Central
HC MRI NECK SPINE W/O DYE,61200001,CDM,612,RC,72141,HCPCS,,,facility,both,,,,1518,1062.6,,,,,,,,,,,,,Gross Charge Type: Central
HC MRI NECK SPINE W/DYE,61200002,CDM,612,RC,72142,HCPCS,,,facility,both,,,,1744,1220.8,,,,,,,,,,,,,Gross Charge Type: Central
HC MRI THORACIC SPINAL CANAL W/O DYE,61200003,CDM,612,RC,72146,HCPCS,,,facility,both,,,,1654,1157.8,,,,,,,,,,,,,Gross Charge Type: Central
HC MRI THORACIC SPINAL CANAL W/ DYE,61200004,CDM,612,RC,72147,HCPCS,,,facility,both,,,,1920,1344,,,,,,,,,,,,,Gross Charge Type: Central
HC MRI LUMBAR SPINE W/O DYE,61200005,CDM,612,RC,72148,HCPCS,,,facility,both,,,,1572,1100.4,,,,,,,,,,,,,Gross Charge Type: Central
HC MRI LUMBAR SPINE W/DYE,61200006,CDM,612,RC,72149,HCPCS,,,facility,both,,,,1825,1277.5,,,,,,,,,,,,,Gross Charge Type: Central
HC MRI CERVICAL SPINE W/WO DYE,61200007,CDM,612,RC,72156,HCPCS,,,facility,both,,,,2094,1465.8,,,,,,,,,,,,,Gross Charge Type: Central
HC MRI THORACIC SPINAL CANAL W/WO DYE,61200008,CDM,612,RC,72157,HCPCS,,,facility,both,,,,2284,1598.8,,,,,,,,,,,,,Gross Charge Type: Central
HC MRI LUMBAR SPINE W/WO DYE,61200009,CDM,612,RC,72158,HCPCS,,,facility,both,,,,2169,1518.3,,,,,,,,,,,,,Gross Charge Type: Central
HC MR ANGIO SPINE W/WO DYE,61200010,CDM,612,RC,72159,HCPCS,,,facility,both,,,,1218,852.6,,,,,,,,,,,,,Gross Charge Type: Central
HC MRA PELVIS W/WO DYE,61200011,CDM,612,RC,72198,HCPCS,,,facility,both,,,,1925,1347.5,,,,,,,,,,,,,Gross Charge Type: Central
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7020-38,NDC,facility,both,4,ML,,263,184.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-30,NDC,facility,both,42,ML,JW,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,130,ML,,485,339.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7020-38,NDC,facility,both,12,ML,,586,410.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,143,ML,JZ,533,373.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,300,ML,,594,415.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-95,NDC,facility,both,200,ML,,793,555.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,46,ML,JW,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GADOXETATE 2.5 MMOL/10 ML IV SOLN,61408,CDM,255,RC,A9581,HCPCS,50419-320-01,NDC,facility,both,6,ML,,368,257.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,100,ML,JZ,269,188.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,89,ML,,266,186.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,9,ML,JW,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,160,ML,JZ,597,417.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-02,NDC,facility,both,5,ML,JZ,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,Q9967,HCPCS,0270-1315-35,NDC,,,facility,both,99,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7020-38,NDC,facility,both,9,ML,,415,290.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,636,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,2,ML,JW,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,180,ML,,485,339.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-12,NDC,facility,both,4,ML,JW,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-52,NDC,facility,both,59,ML,,201,140.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,5,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-52,NDC,facility,both,100,ML,,300,210,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-02,NDC,facility,both,19,ML,JW,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-04,NDC,facility,both,200,ML,,756,529.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-52,NDC,facility,both,70,ML,JZ,238,166.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,636,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,15,ML,,473,331.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOHEXOL 240 MG/ML IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0407-1412-29,NDC,facility,both,50,ML,JZ,260,182,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,370,ML,,1379,965.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,30,ML,JW,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-04,NDC,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,145,ML,,541,378.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,14,ML,,119,83.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-02,NDC,facility,both,60,ML,,363,254.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % INJ SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-30,NDC,facility,both,800,ML,JZ,1515,1060.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-04,NDC,facility,both,150,ML,,567,396.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-02,NDC,facility,both,200,ML,JZ,470,329,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-01,NDC,facility,both,20,ML,JW,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-45,NDC,facility,both,100,ML,,279,195.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,82,ML,JZ,416,291.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,15,ML,,107,74.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,32,ML,JW,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,3,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-37,NDC,facility,both,80,ML,,250,175,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7020-38,NDC,facility,both,2,ML,,113,79.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-37,NDC,facility,both,5,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,90,ML,,269,188.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-02,NDC,facility,both,77,ML,,465,325.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOTERIDOL 279.3 MG/ML IV SOLN,61408,CDM,255,RC,A9576,HCPCS,0270-1111-04,NDC,facility,both,2,ML,JW,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-02,NDC,facility,both,100,ML,,445,311.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % (410 MG/ML) IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-15,NDC,facility,both,16,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-03,NDC,facility,both,131,ML,,536,375.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-04,NDC,facility,both,75,ML,JZ,385,269.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,636,RC,Q9967,HCPCS,0270-1315-25,NDC,facility,both,30,ML,JZ,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-01,NDC,facility,both,7,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % IT SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1411-11,NDC,facility,both,20,ML,JZ,559,391.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-02,NDC,facility,both,3,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML IV SUSP,61408,CDM,255,RC,Q9957,HCPCS,11994-011-01,NDC,facility,both,2,ML,,588,411.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-25,NDC,facility,both,8,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,155,ML,,578,404.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,13,ML,JW,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,152,ML,,567,396.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-04,NDC,facility,both,166,ML,,627,438.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,3,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,96,ML,,287,200.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,34,ML,JW,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,15,ML,JZ,368,257.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,Q9967,HCPCS,0270-1315-25,NDC,,,facility,both,90,ML,,389,272.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,636,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,30,ML,JW,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,636,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,5,ML,JW,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,325,ML,JZ,1211,847.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,89,ML,,272,190.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7025-40,NDC,facility,both,5,ML,,323,226.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-25,NDC,facility,both,10,ML,JW,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-95,NDC,facility,both,18,ML,,136,95.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,78,ML,,395,276.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,3,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOTERIDOL 279.3 MG/ML IV SOLN,61408,CDM,255,RC,A9576,HCPCS,0270-1111-04,NDC,facility,both,12,ML,,418,292.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-95,NDC,facility,both,100,ML,,397,277.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,12,ML,JW,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,636,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,20,ML,JW,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,370,ML,JZ,1379,965.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,50,ML,JZ,254,177.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,40,ML,JW,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-01,NDC,facility,both,1,ML,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,20,ML,JW,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-02,NDC,facility,both,50,ML,JZ,133,93.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,129,ML,,481,336.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,77,ML,JZ,390,273,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GADOTERIDOL 279.3 MG/ML IV SOLN,61408,CDM,255,RC,A9576,HCPCS,0270-1111-04,NDC,facility,both,40,ML,,1025,717.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % (410 MG/ML) IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-15,NDC,facility,both,8,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,75,ML,JZ,254,177.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GADOTERIDOL 279.3 MG/ML IV SOLN,61408,CDM,255,RC,A9576,HCPCS,0270-1111-04,NDC,facility,both,3,ML,JW,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,636,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,46,ML,,141,98.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,66,ML,,224,156.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,636,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,60,ML,,183,128.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,2,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,400,ML,,1491,1043.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-30,NDC,facility,both,48,ML,JW,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,100,ML,PLAD,269,188.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,73,ML,,223,156.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-04,NDC,facility,both,120,ML,,454,317.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,25,ML,JW,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-25,NDC,facility,both,21,ML,JW,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GADOTERIDOL 279.3 MG/ML IV SOLN,61408,CDM,255,RC,A9576,HCPCS,0270-1111-04,NDC,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOTERIDOL 279.3 MG/ML IV SOLN,61408,CDM,255,RC,A9576,HCPCS,0270-1111-04,NDC,facility,both,5,ML,JZ,198,138.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,636,RC,Q9967,HCPCS,0270-1315-25,NDC,facility,both,90,ML,,389,272.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-30,NDC,facility,both,44,ML,JW,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,Q9967,HCPCS,0270-1316-35,NDC,,,facility,both,80,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,46,ML,JW,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,40,ML,,136,95.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-04,NDC,facility,both,238,ML,,495,346.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % (410 MG/ML) IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-15,NDC,facility,both,100,ML,,360,252,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOTERIDOL 279.3 MG/ML IV SOLN,61408,CDM,255,RC,A9576,HCPCS,0270-1111-01,NDC,facility,both,10,ML,,342,239.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-01,NDC,facility,both,23,ML,JW,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,58,ML,,294,205.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOXETATE 2.5 MMOL/10 ML IV SOLN,61408,CDM,255,RC,A9581,HCPCS,50419-320-01,NDC,facility,both,5,ML,JZ,417,291.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-04,NDC,facility,both,350,ML,,728,509.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,19,ML,JW,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,19,ML,,130,91,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-01,NDC,facility,both,16,ML,,129,90.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % (410 MG/ML) IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-15,NDC,facility,both,10,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,104,ML,JZ,388,271.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,84,ML,JZ,426,298.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
DIATRIZOATE MEGLUMINE 30 % URTH SOLN,61408,CDM,255,RC,Q9958,HCPCS,0270-0149-60,NDC,facility,both,200,ML,,362,253.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,19,ML,JW,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-41,NDC,facility,both,125,ML,,390,273,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-13,NDC,facility,both,8,ML,,274,191.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,259,ML,,966,676.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,7,ML,JW,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,60,ML,,183,128.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOXETATE 2.5 MMOL/10 ML IV SOLN,61408,CDM,255,RC,A9581,HCPCS,50419-320-01,NDC,facility,both,4,ML,JW,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,636,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,10,ML,,333,233.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-02,NDC,facility,both,10,ML,JZ,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-12,NDC,facility,both,1,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,77,ML,,261,182.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7025-40,NDC,facility,both,5,ML,,283,198.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-04,NDC,facility,both,70,ML,,360,252,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % (410 MG/ML) IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-15,NDC,facility,both,39,ML,,159,111.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-03,NDC,facility,both,4,ML,JW,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,130,ML,JZ,485,339.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-02,NDC,facility,both,30,ML,JZ,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,636,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,17,ML,,386,270.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-02,NDC,facility,both,20,ML,JW,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,41,ML,JW,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7025-40,NDC,facility,both,7,ML,,435,304.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % INJ SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-30,NDC,facility,both,1,ML,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-25,NDC,facility,both,18,ML,JW,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-05,NDC,facility,both,50,ML,XE,150,105,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XE: Separate encounter, a service that is distinct because it occurred during a separate encounter"
IOPAMIDOL 41 % (410 MG/ML) IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-15,NDC,facility,both,197,ML,JW,145,101.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,2,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 41 % (410 MG/ML) IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-15,NDC,facility,both,197,ML,"XU,JW",145,101.5,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service | Modifier JW: Drug amount discarded/not administered to any patient"
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,13,ML,JZ,401,280.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-03,NDC,facility,both,221,ML,,904,632.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-25,NDC,facility,both,23,ML,JW,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,91,ML,JZ,461,322.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-02,NDC,facility,both,41,ML,JW,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-03,NDC,facility,both,102,ML,,418,292.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,306,ML,,1141,798.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-95,NDC,facility,both,6,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-02,NDC,facility,both,66,ML,,399,279.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-04,NDC,facility,both,234,ML,,487,340.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,19,ML,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-05,NDC,facility,both,5,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,99,ML,,296,207.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-01,NDC,facility,both,12,ML,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-25,NDC,facility,both,100,ML,,432,302.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,11,ML,,340,238,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-95,NDC,facility,both,350,ML,JW,214,149.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,Q9967,HCPCS,0270-1316-52,NDC,,,facility,both,70,ML,,238,166.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,54,ML,,274,191.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-01,NDC,facility,both,31,ML,,202,141.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-30,NDC,facility,both,45,ML,JZ,141,98.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-25,NDC,facility,both,60,ML,JZ,259,181.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,105,ML,,392,274.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,156,ML,,582,407.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7025-40,NDC,facility,both,6,ML,,362,253.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,339,ML,,1264,884.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-04,NDC,facility,both,30,ML,,175,122.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,430,ML,,1603,1122.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,5,ML,JZ,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,240,ML,,895,626.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-04,NDC,facility,both,215,ML,,812,568.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-04,NDC,facility,both,40,ML,JW,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,10,ML,JZ,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOXAGLATE MEGLUMINE & SODIUM INJ SOLN 39.3 %-19.6 % PHS,61408,CDM,255,RC,Q9967,HCPCS,0019-5505-08,NDC,facility,both,20,ML,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-03,NDC,facility,both,43,ML,JW,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,86,ML,,263,184.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,18,ML,JW,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,145,ML,JZ,433,303.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,20,ML,JZ,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 41 % IT SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1411-25,NDC,facility,both,20,ML,,383,268.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % (410 MG/ML) IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-15,NDC,facility,both,181,ML,JW,134,93.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 41 % IT SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1411-11,NDC,facility,both,5,ML,JW,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-05,NDC,facility,both,35,ML,JW,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-03,NDC,facility,both,42,ML,JW,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,95,ML,JZ,256,179.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,124,ML,,370,259,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,55,ML,,279,195.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,Q9967,HCPCS,0270-1316-41,NDC,,,facility,both,10,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-01,NDC,facility,both,25,ML,,163,114.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,636,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,12,ML,,387,270.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOHEXOL 240 MG/ML IV SOLN,61408,CDM,Q9966,HCPCS,0407-1412-30,NDC,,,facility,both,50,ML,,261,182.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,9,ML,JW,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,Q9967,HCPCS,0270-1316-35,NDC,,,facility,both,10,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,213,ML,,794,555.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,83,ML,JZ,421,294.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,162,ML,JZ,604,422.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-41,NDC,facility,both,170,ML,,530,371,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,390,ML,,1454,1017.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,26,ML,JZ,150,105,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,Q9967,HCPCS,0407-2223-02,NDC,,,facility,both,61,ML,,369,258.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,636,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,90,ML,,269,188.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-95,NDC,facility,both,10,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,28,ML,,161,112.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,636,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,11,ML,JW,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,65,ML,JZ,329,230.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,636,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,17,ML,JZ,386,270.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-05,NDC,facility,both,50,ML,JZ,150,105,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 41 % INJ SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-30,NDC,facility,both,2,ML,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,636,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,14,ML,,432,302.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,9,ML,,278,194.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,138,ML,,515,360.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7025-40,NDC,facility,both,6,ML,,358,250.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7025-40,NDC,facility,both,5,ML,,310,217,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-95,NDC,facility,both,400,ML,JW,244,170.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-25,NDC,facility,both,5,ML,JW,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,50,ML,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,200,ML,,440,308,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,Q9967,HCPCS,0270-1316-35,NDC,,,facility,both,200,ML,,440,308,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,11,ML,JW,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7020-38,NDC,facility,both,5,ML,,332,232.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-01,NDC,facility,both,46,ML,,265,185.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIATRIZOATE MEGLUMINE 30 % URTH SOLN,61408,CDM,Q9958,HCPCS,0270-0149-57,NDC,,,facility,both,300,ML,,325,227.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,150,ML,,404,282.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,48,ML,,290,203,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-25,NDC,facility,both,9,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,Q9967,HCPCS,0407-2223-01,NDC,,,facility,both,10,ML,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-02,NDC,facility,both,65,ML,,393,275.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-04,NDC,facility,both,115,ML,,325,227.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-25,NDC,facility,both,15,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,15,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-41,NDC,facility,both,80,ML,,339,237.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-02,NDC,facility,both,375,ML,JZ,648,453.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7030-42,NDC,facility,both,9,ML,,410,287,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-02,NDC,facility,both,45,ML,JW,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-41,NDC,facility,both,500,ML,,1557,1089.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,40,ML,JW,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,56,ML,JZ,284,198.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,890,ML,,1602,1121.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,97,ML,,362,253.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,169,ML,,630,441,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-09,NDC,facility,both,150,ML,XU,432,302.4,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-04,NDC,facility,both,110,ML,,311,217.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-95,NDC,facility,both,70,ML,,377,263.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,99,ML,JW,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,143,ML,,533,373.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7025-40,NDC,facility,both,10,ML,,461,322.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,6,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,55,ML,JW,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-01,NDC,facility,both,45,ML,JW,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-52,NDC,facility,both,72,ML,,245,171.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7020-38,NDC,facility,both,2,ML,,143,100.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-52,NDC,facility,both,65,ML,JZ,221,154.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,636,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,3,ML,JW,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,34,ML,,233,163.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,47,ML,,144,100.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,636,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,70,ML,,237,165.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7025-40,NDC,facility,both,7,ML,,448,313.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,23,ML,,158,110.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,636,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,3,ML,JW,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,205,ML,JZ,764,534.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-25,NDC,facility,both,70,ML,,302,211.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-25,NDC,facility,both,85,ML,JZ,367,256.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-02,NDC,facility,both,63,ML,,381,266.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,14,ML,JW,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-25,NDC,facility,both,29,ML,JW,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,82,ML,,275,192.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,57,ML,JZ,289,202.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,59,ML,JW,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,20,ML,,455,318.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,4,ML,JW,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-13,NDC,facility,both,8,ML,,256,179.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOTERIDOL 279.3 MG/ML IV SOLN,61408,CDM,255,RC,A9576,HCPCS,0270-1111-02,NDC,facility,both,12,ML,,400,280,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-25,NDC,facility,both,10,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IT SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1412-15,NDC,facility,both,7,ML,JW,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-01,NDC,facility,both,30,ML,,196,137.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-41,NDC,facility,both,360,ML,,1122,785.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,8,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,11,ML,JW,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 41 % (410 MG/ML) IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-15,NDC,facility,both,4,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,180,ML,,396,277.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,50,ML,,302,211.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-03,NDC,facility,both,30,ML,JW,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7025-40,NDC,facility,both,7,ML,,455,318.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-95,NDC,facility,both,96,ML,,381,266.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,636,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,140,ML,,418,292.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIATRIZOATE MEGLUMINE 30 % URTH SOLN,61408,CDM,255,RC,Q9958,HCPCS,0270-0149-60,NDC,facility,both,150,ML,,272,190.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-01,NDC,facility,both,29,ML,JW,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,1,ML,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7020-38,NDC,facility,both,8,ML,,391,273.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOTERIDOL 279.3 MG/ML IV SOLN,61408,CDM,255,RC,A9576,HCPCS,0270-1111-04,NDC,facility,both,1,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-03,NDC,facility,both,249,ML,,1019,713.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-25,NDC,facility,both,12,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,350,ML,,1305,913.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,85,ML,JZ,431,301.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-13,NDC,facility,both,20,ML,,503,352.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,18,ML,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % INJ SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-30,NDC,facility,both,48,ML,JW,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7025-40,NDC,facility,both,7,ML,,428,299.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-02,NDC,facility,both,1200,ML,,1700,1190,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-02,NDC,facility,both,300,ML,XU,519,363.3,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,15,ML,JZ,463,324.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,19,ML,JW,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML IV SUSP,61408,CDM,255,RC,Q9957,HCPCS,11994-011-01,NDC,facility,both,2,ML,JZ,588,411.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7030-42,NDC,facility,both,8,ML,,485,339.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % (410 MG/ML) IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-15,NDC,facility,both,47,ML,,192,134.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,51,ML,,259,181.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-95,NDC,facility,both,50,ML,,270,189,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,267,ML,,995,696.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,9,ML,JW,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-02,NDC,facility,both,11,ML,JW,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,87,ML,,441,308.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,Q9967,HCPCS,0270-1315-35,NDC,,,facility,both,65,ML,,199,139.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,636,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,200,ML,,440,308,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIATRIZOATE MEGLUMINE 18 % URTH SOLN,61408,CDM,255,RC,Q9958,HCPCS,0270-1410-30,NDC,facility,both,400,ML,,253,177.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % (410 MG/ML) IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-15,NDC,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % INJ SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-30,NDC,facility,both,50,ML,XU,146,102.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
DIATRIZOATE MEGLUMINE 30 % URTH SOLN,61408,CDM,255,RC,Q9958,HCPCS,0270-0149-57,NDC,facility,both,30,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-05,NDC,facility,both,10,ML,JW,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,59,ML,JZ,299,209.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-04,NDC,facility,both,104,ML,,294,205.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,12,ML,,400,280,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,Q9967,HCPCS,0270-1315-35,NDC,,,facility,both,30,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,20,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-05,NDC,facility,both,10,ML,JZ,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-30,NDC,facility,both,50,ML,,156,109.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,7,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIATRIZOATE MEGLUMINE 30 % URTH SOLN,61408,CDM,255,RC,Q9958,HCPCS,0270-0149-57,NDC,facility,both,200,ML,,245,171.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-13,NDC,facility,both,11,ML,,376,263.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-04,NDC,facility,both,180,ML,,680,476,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,111,ML,,414,289.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7025-40,NDC,facility,both,6,ML,,389,272.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-13,NDC,facility,both,3,ML,JW,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-02,NDC,facility,both,2,ML,JZ,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GADOTERIDOL 279.3 MG/ML IV SOLN,61408,CDM,255,RC,A9576,HCPCS,0270-1111-03,NDC,facility,both,20,ML,,455,318.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,209,ML,,779,545.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,24,ML,,165,115.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,1,ML,JZ,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GADOTERIDOL 279.3 MG/ML IV SOLN,61408,CDM,255,RC,A9576,HCPCS,0270-1111-04,NDC,facility,both,15,ML,,385,269.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-03,NDC,facility,both,230,ML,,941,658.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,14,ML,,432,302.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7025-40,NDC,facility,both,5,ML,,329,230.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % IT SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1411-11,NDC,facility,both,7,ML,JW,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-25,NDC,facility,both,15,ML,JW,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,41,ML,,236,165.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOHEXOL 240 MG/ML IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0407-1412-20,NDC,facility,both,40,ML,,398,278.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,70,ML,,355,248.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-25,NDC,facility,both,75,ML,JZ,324,226.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,Q9967,HCPCS,0270-1316-35,NDC,,,facility,both,75,ML,,254,177.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,65,ML,JZ,220,154,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-03,NDC,facility,both,125,ML,,512,358.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,44,ML,,253,177.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-05,NDC,facility,both,40,ML,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,76,ML,,385,269.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,50,ML,,169,118.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7030-42,NDC,facility,both,9,ML,,396,277.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-04,NDC,facility,both,41,ML,,239,167.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,20,ML,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,128,ML,,477,333.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7020-38,NDC,facility,both,8,ML,,367,256.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,11,ML,JW,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GADOTERIDOL 279.3 MG/ML IV SOLN,61408,CDM,255,RC,A9576,HCPCS,0270-1111-04,NDC,facility,both,5,ML,JW,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,8,ML,JW,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-13,NDC,facility,both,9,ML,,308,215.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-03,NDC,facility,both,70,ML,JW,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 41 % (410 MG/ML) IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-15,NDC,facility,both,6,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-02,NDC,facility,both,75,ML,,453,317.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,636,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,14,ML,,453,317.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7030-42,NDC,facility,both,14,ML,,666,466.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,73,ML,,370,259,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-13,NDC,facility,both,4,ML,,155,108.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,Q9967,HCPCS,0270-1315-47,NDC,,,facility,both,75,ML,,253,177.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,148,ML,,552,386.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOTERIDOL 279.3 MG/ML IV SOLN,61408,CDM,255,RC,A9576,HCPCS,0270-1111-04,NDC,facility,both,10,ML,,348,243.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-95,NDC,facility,both,95,ML,,377,263.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,149,ML,,445,311.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,13,ML,,433,303.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,18,ML,JZ,128,89.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,220,ML,,820,574,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,157,ML,,585,409.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,161,ML,,600,420,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,2,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-52,NDC,facility,both,219,ML,,483,338.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,80,ML,,271,189.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % (410 MG/ML) IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-15,NDC,facility,both,12,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-52,NDC,facility,both,60,ML,PLAD,204,142.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-04,NDC,facility,both,185,ML,,699,489.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,50,ML,JZ,302,211.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,34,ML,JW,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 41 % (410 MG/ML) IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-15,NDC,facility,both,26,ML,,131,91.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,636,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,1,ML,JW,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,136,ML,,507,354.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-04,NDC,facility,both,220,ML,,831,581.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,100,ML,,299,209.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,36,ML,,207,144.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-09,NDC,facility,both,112,ML,,863,604.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,97,ML,,261,182.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOTERIDOL 279.3 MG/ML IV SOLN,61408,CDM,255,RC,A9576,HCPCS,0270-1111-04,NDC,facility,both,4,ML,JW,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,39,ML,JZ,224,156.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,123,ML,,459,321.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,636,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,12,ML,,393,275.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-01,NDC,facility,both,42,ML,JW,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-30,NDC,facility,both,2,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,50,ML,JW,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,93,ML,,278,194.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-02,NDC,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,110,ML,,329,230.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-02,NDC,facility,both,16,ML,JW,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,636,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,15,ML,,368,257.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOTERIDOL 279.3 MG/ML IV SOLN,61408,CDM,255,RC,A9576,HCPCS,0270-1111-04,NDC,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,636,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,15,ML,,367,256.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,5,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-25,NDC,facility,both,90,ML,,389,272.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,636,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,10,ML,,309,216.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOTERIDOL 279.3 MG/ML IV SOLN,61408,CDM,255,RC,A9576,HCPCS,0270-1111-04,NDC,facility,both,4,ML,JW,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,13,ML,,401,280.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-52,NDC,facility,both,56,ML,,190,133,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,Q9967,HCPCS,0270-1316-35,NDC,,,facility,both,100,ML,,299,209.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,17,ML,JZ,386,270.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-25,NDC,facility,both,70,ML,JZ,302,211.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOHEXOL 240 MG/ML IV SOLN,61408,CDM,Q9966,HCPCS,0407-1412-29,NDC,,,facility,both,100,ML,,459,321.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-47,NDC,facility,both,225,ML,,493,345.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,260,ML,,969,678.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-95,NDC,facility,both,430,ML,JW,263,184.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,205,ML,,764,534.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,130,ML,,388,271.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,224,ML,,835,584.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,70,ML,JZ,355,248.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,184,ML,,686,480.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,5,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-37,NDC,facility,both,251,ML,,509,356.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,5,ML,JW,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,Q9967,HCPCS,0270-1315-95,NDC,,,facility,both,100,ML,,397,277.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,140,ML,,522,365.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,86,ML,,257,179.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-95,NDC,facility,both,90,ML,,485,339.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-03,NDC,facility,both,11,ML,JW,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,61,ML,,309,216.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 51 % IV SOLN,61408,CDM,Q9966,HCPCS,0270-1317-02,NDC,,,facility,both,100,ML,,266,186.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-52,NDC,facility,both,202,ML,,446,312.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,A9577,HCPCS,0270-5164-15,NDC,,,facility,both,17,ML,,386,270.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-01,NDC,facility,both,9,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-02,NDC,facility,both,59,ML,,357,249.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,Q9967,HCPCS,0270-1316-35,NDC,,,facility,both,20,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,10,ML,JZ,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,5,ML,JW,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,100,ML,PLAD,299,209.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,62,ML,JZ,314,219.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,44,ML,JW,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-02,NDC,facility,both,20,ML,JZ,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-37,NDC,facility,both,136,ML,,375,262.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % INJ SOLN,61408,CDM,255,RC,Q9966,HCPCS,70436-211-37,NDC,facility,both,1,ML,JZ,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-03,NDC,facility,both,10,ML,JW,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,26,ML,,178,124.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-95,NDC,facility,both,80,ML,,271,189.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,636,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,9,ML,,300,210,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,591,ML,,1805,1263.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,31,ML,JW,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-02,NDC,facility,both,20,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-04,NDC,facility,both,137,ML,,518,362.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,10,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,141,ML,,526,368.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,120,ML,,358,250.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,112,ML,,418,292.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-04,NDC,facility,both,121,ML,,342,239.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOTERIDOL 279.3 MG/ML IV SOLN,61408,CDM,255,RC,A9576,HCPCS,0270-1111-04,NDC,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-02,NDC,facility,both,80,ML,,483,338.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,41,ML,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,114,ML,JZ,425,297.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,66,ML,,202,141.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,35,ML,,201,140.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-95,NDC,facility,both,45,ML,,275,192.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-95,NDC,facility,both,85,ML,,458,320.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-04,NDC,facility,both,250,ML,,520,364,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % (410 MG/ML) IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-15,NDC,facility,both,10,ML,XU,51,35.7,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-02,NDC,facility,both,100,ML,JZ,445,311.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,54,ML,JW,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,38,ML,JZ,218,152.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-37,NDC,facility,both,150,ML,,413,289.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,21,ML,,144,100.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,280,ML,,1044,730.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-41,NDC,facility,both,200,ML,,699,489.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,320,ML,,1193,835.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % (410 MG/ML) IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-15,NDC,facility,both,4,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,25,ML,JW,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-02,NDC,facility,both,51,ML,,308,215.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % INJ SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-30,NDC,facility,both,46,ML,JW,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,12,ML,JZ,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,37,ML,JW,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-02,NDC,facility,both,34,ML,JW,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,64,ML,,324,226.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,125,ML,,373,261.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,8,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-01,NDC,facility,both,19,ML,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-04,NDC,facility,both,80,ML,,411,287.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7025-40,NDC,facility,both,10,ML,,448,313.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-02,NDC,facility,both,300,ML,,519,363.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-30,NDC,facility,both,50,ML,JZ,156,109.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,71,ML,,360,252,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-25,NDC,facility,both,120,ML,,382,267.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-05,NDC,facility,both,50,ML,XU,150,105,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-95,NDC,facility,both,170,ML,,674,471.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,187,ML,,697,487.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,81,ML,,274,191.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-13,NDC,facility,both,10,ML,,335,234.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-41,NDC,facility,both,134,ML,,418,292.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-01,NDC,facility,both,48,ML,,277,193.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,636,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,12,ML,,383,268.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,212,ML,JZ,790,553,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,117,ML,JZ,436,305.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-02,NDC,facility,both,69,ML,,417,291.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-52,NDC,facility,both,150,ML,,449,314.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOTERIDOL 279.3 MG/ML IV SOLN,61408,CDM,255,RC,A9576,HCPCS,0270-1111-04,NDC,facility,both,8,ML,,279,195.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,55,ML,,168,117.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,20,ML,,491,343.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-05,NDC,facility,both,20,ML,JW,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-41,NDC,facility,both,20,ML,JW,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,30,ML,,173,121.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-02,NDC,facility,both,98,ML,,436,305.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7025-40,NDC,facility,both,15,ML,,727,508.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,636,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,14,ML,,467,326.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,16,ML,,364,254.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7025-40,NDC,facility,both,7,ML,,402,281.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-01,NDC,facility,both,18,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-04,NDC,facility,both,245,ML,,509,356.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,195,ML,,727,508.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,75,ML,,380,266,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-04,NDC,facility,both,718,ML,,2222,1555.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-02,NDC,facility,both,30,ML,JW,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,35,ML,JW,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,Q9967,HCPCS,0270-1315-35,NDC,,,facility,both,60,ML,,183,128.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-05,NDC,facility,both,25,ML,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,170,ML,JZ,634,443.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,70,ML,JZ,214,149.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,78,ML,JZ,395,276.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-01,NDC,facility,both,8,ML,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,66,ML,,335,234.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-02,NDC,facility,both,2,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,54,ML,JZ,274,191.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,295,ML,,1100,770,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,26,ML,JW,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,35,ML,JW,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-05,NDC,facility,both,20,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIATRIZOATE MEGLUMINE 30 % URTH SOLN,61408,CDM,255,RC,Q9958,HCPCS,0270-0149-60,NDC,facility,both,40,ML,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,181,ML,,675,472.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,2,ML,JW,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,44,ML,,266,186.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-02,NDC,facility,both,28,ML,JW,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-05,NDC,facility,both,25,ML,JW,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7025-40,NDC,facility,both,4,ML,,264,184.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-02,NDC,facility,both,74,ML,,447,312.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7030-42,NDC,facility,both,3,ML,,186,130.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-02,NDC,facility,both,80,ML,,213,149.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,Q9967,HCPCS,0270-1316-35,NDC,,,facility,both,30,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,636,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,11,ML,JZ,340,238,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-95,NDC,facility,both,44,ML,,269,188.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7020-38,NDC,facility,both,2,ML,,151,105.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-95,NDC,facility,both,150,ML,,595,416.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,6,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % (410 MG/ML) IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-15,NDC,facility,both,160,ML,JW,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-01,NDC,facility,both,6,ML,JW,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,636,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,15,ML,,366,256.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7025-40,NDC,facility,both,9,ML,,436,305.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7020-38,NDC,facility,both,7,ML,,465,325.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-04,NDC,facility,both,130,ML,,491,343.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,85,ML,,431,301.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,70,ML,JW,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,13,ML,JZ,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,185,ML,,690,483,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7025-40,NDC,facility,both,14,ML,,679,475.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,44,ML,JW,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,215,ML,,802,561.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-02,NDC,facility,both,86,ML,,383,268.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,15,ML,JW,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-04,NDC,facility,both,230,ML,,478,334.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-25,NDC,facility,both,26,ML,JW,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 41 % (410 MG/ML) IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-15,NDC,facility,both,13,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-52,NDC,facility,both,5,ML,JW,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,25,ML,,172,120.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % (410 MG/ML) IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-15,NDC,facility,both,23,ML,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-01,NDC,facility,both,13,ML,JW,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 41 % INJ SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-30,NDC,facility,both,49,ML,JW,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,96,ML,,486,340.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-02,NDC,facility,both,8,ML,JZ,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7030-42,NDC,facility,both,9,ML,,435,304.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % IT SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1411-11,NDC,facility,both,2,ML,JW,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-52,NDC,facility,both,9,ML,JW,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-95,NDC,facility,both,1,ML,,1624,1136.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-02,NDC,facility,both,70,ML,,423,296.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,177,ML,,660,462,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,636,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,100,ML,,269,188.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7020-38,NDC,facility,both,2,ML,,121,84.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,Q9967,HCPCS,0270-1315-30,NDC,,,facility,both,50,ML,,156,109.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,45,ML,JW,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-01,NDC,facility,both,50,ML,JZ,288,201.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,636,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,9,ML,JW,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,130,ML,JZ,388,271.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7020-38,NDC,facility,both,9,ML,,425,297.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % (410 MG/ML) IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-15,NDC,facility,both,190,ML,JW,140,98,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 41 % (410 MG/ML) IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-15,NDC,facility,both,3,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % (410 MG/ML) IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-15,NDC,facility,both,50,ML,XU,204,142.8,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-02,NDC,facility,both,45,ML,JZ,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,49,ML,JZ,248,173.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,98,ML,,366,256.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,10,ML,JW,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,636,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,2,ML,JW,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-04,NDC,facility,both,300,ML,,1133,793.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,10,ML,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,118,ML,,440,308,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-01,NDC,facility,both,34,ML,,222,155.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,12,ML,,393,275.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,99,ML,,369,258.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-03,NDC,facility,both,141,ML,,577,403.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,229,ML,,854,597.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,66,ML,JZ,335,234.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,636,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,13,ML,,417,291.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7025-40,NDC,facility,both,3,ML,,224,156.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,82,ML,,416,291.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,80,ML,JW,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,36,ML,JZ,207,144.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7030-42,NDC,facility,both,1,ML,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-37,NDC,facility,both,29,ML,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,Q9967,HCPCS,0270-1316-35,NDC,,,facility,both,80,ML,,271,189.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,11,ML,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-95,NDC,facility,both,89,ML,,480,336,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-02,NDC,facility,both,80,ML,JZ,213,149.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-02,NDC,facility,both,26,ML,JW,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-25,NDC,facility,both,55,ML,,269,188.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,Q9967,HCPCS,0270-1315-35,NDC,,,facility,both,70,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7030-42,NDC,facility,both,15,ML,,724,506.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,175,ML,,385,269.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-04,NDC,facility,both,117,ML,,331,231.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,45,ML,,259,181.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,3,ML,JW,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML IV SUSP,61408,CDM,636,RC,Q9957,HCPCS,11994-011-01,NDC,facility,both,2,ML,,588,411.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,5,ML,JZ,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-02,NDC,facility,both,68,ML,,411,287.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,636,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,8,ML,,247,172.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,636,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,2,ML,JW,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,1,ML,JZ,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-03,NDC,facility,both,150,ML,,614,429.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,190,ML,JZ,708,495.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 41 % (410 MG/ML) IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-15,NDC,facility,both,60,ML,,245,171.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,95,ML,JZ,284,198.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,30,ML,JW,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7030-42,NDC,facility,both,10,ML,,449,314.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,3,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,636,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,20,ML,JZ,455,318.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,Q9967,HCPCS,0270-1315-35,NDC,,,facility,both,30,ML,,113,79.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML IV SUSP,61408,CDM,255,RC,Q9957,HCPCS,11994-011-01,NDC,facility,both,2,ML,PLAD,588,411.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,43,ML,,260,182,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-95,NDC,facility,both,230,ML,,912,638.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % IT SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1411-11,NDC,facility,both,8,ML,JW,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,74,ML,JZ,375,262.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,17,ML,,121,84.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,30,ML,JW,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,Q9967,HCPCS,0270-1315-25,NDC,,,facility,both,3,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,202,ML,,753,527.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,45,ML,JW,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,70,ML,,237,165.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,68,ML,,345,241.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % (410 MG/ML) IV SOLN,61408,CDM,Q9966,HCPCS,0270-1314-15,NDC,,,facility,both,5,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,636,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,12,ML,,400,280,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,235,ML,,876,613.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,Q9967,HCPCS,0270-1316-37,NDC,,,facility,both,150,ML,,413,289.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,150,ML,JZ,448,313.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,330,ML,,1230,861,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,60,ML,JZ,203,142.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,636,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,100,ML,JZ,269,188.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,5,ML,JW,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,131,ML,,489,342.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOTERIDOL 279.3 MG/ML IV SOLN,61408,CDM,255,RC,A9576,HCPCS,0270-1111-04,NDC,facility,both,4,ML,JW,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-04,NDC,facility,both,178,ML,,673,471.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-02,NDC,facility,both,40,ML,JZ,132,92.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7030-42,NDC,facility,both,8,ML,,386,270.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,15,ML,JW,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,49,ML,JW,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,144,ML,,537,375.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,10,ML,JW,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,636,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,1,ML,JW,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,636,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,6,ML,JW,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,140,ML,JZ,522,365.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,119,ML,,444,310.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7030-42,NDC,facility,both,13,ML,,603,422.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-03,NDC,facility,both,111,ML,,454,317.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,636,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,14,ML,,450,315,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,1,ML,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,59,ML,,180,126,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,20,ML,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,28,ML,,192,134.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,140,ML,JZ,418,292.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,A9577,HCPCS,0270-5164-12,NDC,,,facility,both,5,ML,,198,138.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7025-40,NDC,facility,both,9,ML,,412,288.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,90,ML,JZ,456,319.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,65,ML,,329,230.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,12,ML,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,10,ML,JW,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,134,ML,,500,350,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-02,NDC,facility,both,250,ML,,519,363.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % IT SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1411-25,NDC,facility,both,15,ML,,390,273,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,Q9967,HCPCS,0270-1316-01,NDC,,,facility,both,1,ML,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOTERIDOL 279.3 MG/ML IV SOLN,61408,CDM,255,RC,A9576,HCPCS,0270-1111-01,NDC,facility,both,10,ML,JZ,342,239.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,98,ML,,293,205.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,636,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,100,ML,JZ,299,209.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,65,ML,,199,139.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-05,NDC,facility,both,50,ML,,150,105,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,170,ML,,634,443.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % (410 MG/ML) IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-15,NDC,facility,both,9,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,300,ML,JZ,1491,1043.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,Q9967,HCPCS,0270-1316-01,NDC,,,facility,both,50,ML,,288,201.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,200,ML,,396,277.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,636,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,90,ML,,275,192.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,80,ML,JZ,405,283.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,88,ML,JZ,446,312.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-95,NDC,facility,both,48,ML,,259,181.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,190,ML,,418,292.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,7,ML,JZ,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 41 % (410 MG/ML) IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-15,NDC,facility,both,2,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,10,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,20,ML,"JW,PLAD",13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient | Modifier PLAD: Modifier description not available
IOPAMIDOL 61 % IV SOLN,61408,CDM,636,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,85,ML,,259,181.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,168,ML,,626,438.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-02,NDC,facility,both,56,ML,,338,236.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-95,NDC,facility,both,37,ML,,226,158.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,6,ML,JZ,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,92,ML,,466,326.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-05,NDC,facility,both,30,ML,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,69,ML,,350,245,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIATRIZOATE MEGLUMINE 30 % URTH SOLN,61408,CDM,Q9958,HCPCS,0270-0149-57,NDC,,,facility,both,200,ML,,245,171.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,214,ML,,798,558.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-52,NDC,facility,both,80,ML,JZ,272,190.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-95,NDC,facility,both,39,ML,,238,166.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,43,ML,JZ,247,172.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-25,NDC,facility,both,22,ML,JW,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,10,ML,JW,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,16,ML,JZ,364,254.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-04,NDC,facility,both,60,ML,JZ,308,215.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,35,ML,,240,168,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-25,NDC,facility,both,80,ML,,346,242.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,Q9967,HCPCS,0270-1315-30,NDC,,,facility,both,40,ML,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,636,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,14,ML,JW,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,110,ML,,410,287,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-41,NDC,facility,both,150,ML,,468,327.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,60,ML,PLAD,203,142.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,80,ML,JW,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,211,ML,,787,550.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOTERIDOL 279.3 MG/ML IV SOLN,61408,CDM,255,RC,A9576,HCPCS,0270-1111-04,NDC,facility,both,3,ML,,119,83.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,636,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,14,ML,,440,308,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,3,ML,JW,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7020-38,NDC,facility,both,3,ML,,173,121.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-03,NDC,facility,both,106,ML,,434,303.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,182,ML,,679,475.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-02,NDC,facility,both,8,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-02,NDC,facility,both,84,ML,,374,261.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,180,ML,,671,469.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-13,NDC,facility,both,16,ML,,403,282.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,226,ML,,843,590.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,45,ML,JZ,259,181.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-30,NDC,facility,both,45,ML,JW,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-01,NDC,facility,both,33,ML,,215,150.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % INJ SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-30,NDC,facility,both,150,ML,,386,270.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7030-42,NDC,facility,both,9,ML,,430,301,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,636,RC,A9577,HCPCS,0270-5164-13,NDC,facility,both,7,ML,,271,189.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,40,ML,JW,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,146,ML,,436,305.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,11,ML,JZ,367,256.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,310,ML,,1156,809.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,158,ML,,589,412.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,81,ML,,410,287,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,144,ML,JZ,537,375.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 41 % (410 MG/ML) IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-15,NDC,facility,both,600,ML,,1588,1111.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-03,NDC,facility,both,39,ML,JW,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-37,NDC,facility,both,139,ML,,383,268.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,15,ML,,127,88.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-04,NDC,facility,both,170,ML,,642,449.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,A9577,HCPCS,0270-5164-14,NDC,,,facility,both,12,ML,,400,280,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-01,NDC,facility,both,33,ML,JW,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,139,ML,,518,362.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,31,ML,,213,149.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-04,NDC,facility,both,500,ML,,1548,1083.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,72,ML,JZ,365,255.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,2,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,109,ML,,407,284.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,636,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,12,ML,JW,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-13,NDC,facility,both,18,ML,,453,317.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,245,ML,,913,639.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,188,ML,,701,490.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-47,NDC,facility,both,75,ML,,253,177.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-05,NDC,facility,both,45,ML,JW,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,79,ML,,400,280,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,147,ML,,548,383.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,15,ML,,463,324.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,636,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,13,ML,,430,301,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,132,ML,JZ,492,344.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,7,ML,,265,185.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,9,ML,,300,210,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,636,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,40,ML,,136,95.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,160,ML,,597,417.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % (410 MG/ML) IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-15,NDC,facility,both,40,ML,,163,114.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIATRIZOATE MEGLUMINE 30 % URTH SOLN,61408,CDM,255,RC,Q9958,HCPCS,0270-0149-57,NDC,facility,both,230,ML,,249,174.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7030-42,NDC,facility,both,8,ML,,362,253.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,234,ML,,872,610.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-02,NDC,facility,both,76,ML,,459,321.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,A9577,HCPCS,0270-5164-15,NDC,,,facility,both,10,ML,,309,216.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-03,NDC,facility,both,126,ML,,516,361.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-95,NDC,facility,both,75,ML,,404,282.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,91,ML,,272,190.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7020-38,NDC,facility,both,6,ML,,398,278.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7025-40,NDC,facility,both,10,ML,,485,339.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,Q9967,HCPCS,0270-1315-35,NDC,,,facility,both,150,ML,,404,282.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,7,ML,JZ,245,171.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,636,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,4,ML,JW,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-52,NDC,facility,both,60,ML,,204,142.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,636,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,80,ML,,271,189.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-52,NDC,facility,both,65,ML,,221,154.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-95,NDC,facility,both,75,ML,,254,177.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % (410 MG/ML) IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-15,NDC,facility,both,170,ML,JW,125,87.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-02,NDC,facility,both,10,ML,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-30,NDC,facility,both,6,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,18,ML,,409,286.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIATRIZOATE MEGLUMINE 18 % URTH SOLN,61408,CDM,Q9958,HCPCS,0270-1410-30,NDC,,,facility,both,300,ML,,215,150.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOTERIDOL 279.3 MG/ML IV SOLN,61408,CDM,255,RC,A9576,HCPCS,0270-1111-04,NDC,facility,both,280,ML,,5863,4104.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-04,NDC,facility,both,116,ML,,328,229.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,636,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,40,ML,JW,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,9,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-03,NDC,facility,both,19,ML,JW,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-41,NDC,facility,both,35,ML,JW,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7025-40,NDC,facility,both,6,ML,,395,276.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,12,ML,,396,277.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,248,ML,,925,647.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,258,ML,,962,673.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-95,NDC,facility,both,5,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % (410 MG/ML) IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-15,NDC,facility,both,25,ML,,126,88.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-01,NDC,facility,both,3,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,30,ML,,113,79.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,1,ML,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7025-40,NDC,facility,both,11,ML,,533,373.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,1,ML,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,27,ML,,185,129.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-01,NDC,facility,both,41,ML,,268,187.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-04,NDC,facility,both,71,ML,JW,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-02,NDC,facility,both,35,ML,JW,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,135,ML,JZ,504,352.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-25,NDC,facility,both,90,ML,JZ,389,272.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-02,NDC,facility,both,100,ML,XU,266,186.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,15,ML,,368,257.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,39,ML,,224,156.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,Q9967,HCPCS,0270-1316-35,NDC,,,facility,both,90,ML,,269,188.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,636,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,25,ML,JW,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-01,NDC,facility,both,40,ML,JW,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DIATRIZOATE MEGLUMINE 30 % URTH SOLN,61408,CDM,255,RC,Q9958,HCPCS,0270-0149-57,NDC,facility,both,300,ML,,325,227.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,10,ML,JZ,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,85,ML,JZ,254,177.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-13,NDC,facility,both,2,ML,JW,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-01,NDC,facility,both,35,ML,JW,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,95,ML,JZ,481,336.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-02,NDC,facility,both,52,ML,,314,219.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,43,ML,JW,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,11,ML,JW,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
DIATRIZOATE MEGLUMINE 30 % URTH SOLN,61408,CDM,255,RC,Q9958,HCPCS,0270-0149-57,NDC,facility,both,50,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,108,ML,,403,282.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIATRIZOATE MEGLUMINE 30 % URTH SOLN,61408,CDM,636,RC,Q9958,HCPCS,0270-0149-57,NDC,facility,both,30,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,103,ML,,384,268.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,10,ML,,309,216.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-04,NDC,facility,both,10,ML,JZ,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-52,NDC,facility,both,54,ML,,184,128.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,636,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,53,ML,,162,113.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,636,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,11,ML,,340,238,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML IV SUSP,61408,CDM,255,RC,Q9957,HCPCS,11994-011-01,NDC,facility,both,4,ML,,1176,823.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-52,NDC,facility,both,58,ML,,197,137.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-04,NDC,facility,both,380,ML,,1436,1005.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,636,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,85,ML,,254,177.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % (410 MG/ML) IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-15,NDC,facility,both,3,ML,XU,16,11.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-95,NDC,facility,both,300,ML,,1624,1136.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,140,ML,,418,292.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7025-40,NDC,facility,both,6,ML,,356,249.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,115,ML,,429,300.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,22,ML,,127,88.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,A9577,HCPCS,0270-5164-15,NDC,,,facility,both,15,ML,,463,324.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOTERIDOL 279.3 MG/ML IV SOLN,61408,CDM,255,RC,A9576,HCPCS,0270-1111-04,NDC,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,87,ML,,260,182,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOTERIDOL 279.3 MG/ML IV SOLN,61408,CDM,255,RC,A9576,HCPCS,0270-1111-04,NDC,facility,both,3,ML,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,120,ML,,448,313.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,636,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,19,ML,,432,302.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,90,ML,JZ,269,188.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-95,NDC,facility,both,55,ML,,297,207.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-52,NDC,facility,both,75,ML,JZ,255,178.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-30,NDC,facility,both,10,ML,JW,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,60,ML,JW,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,50,ML,JZ,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-13,NDC,facility,both,14,ML,,478,334.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,500,ML,,1527,1068.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-02,NDC,facility,both,31,ML,JW,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7025-40,NDC,facility,both,5,ML,,290,203,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-04,NDC,facility,both,15,ML,,108,75.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-25,NDC,facility,both,100,ML,JZ,432,302.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,636,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,40,ML,JW,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,127,ML,,474,331.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % INJ SOLN,61408,CDM,Q9966,HCPCS,0270-1314-30,NDC,,,facility,both,1,ML,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-01,NDC,facility,both,35,ML,,229,160.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-37,NDC,facility,both,140,ML,,386,270.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,67,ML,,227,158.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-95,NDC,facility,both,7,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,22,ML,JZ,127,88.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,190,ML,,708,495.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,125,ML,,466,326.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,241,ML,,898,628.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,80,ML,JZ,244,170.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,4,ML,JW,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-95,NDC,facility,both,1,ML,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,110,ML,JZ,410,287,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,75,ML,JW,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-25,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,Q9967,HCPCS,0270-1316-35,NDC,,,facility,both,85,ML,,254,177.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-03,NDC,facility,both,20,ML,JW,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,636,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,50,ML,JW,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-25,NDC,facility,both,7,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,65,ML,JW,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,265,ML,,988,691.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,43,ML,,247,172.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,3,ML,JW,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,78,ML,,264,184.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7030-42,NDC,facility,both,6,ML,,394,275.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % (410 MG/ML) IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-15,NDC,facility,both,180,ML,JW,133,93.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,25,ML,JZ,141,98.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-25,NDC,facility,both,28,ML,JW,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-01,NDC,facility,both,1,ML,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-02,NDC,facility,both,48,ML,JW,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,3,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-05,NDC,facility,both,10,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,31,ML,,209,146.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-04,NDC,facility,both,260,ML,,982,687.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % INJ SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-30,NDC,facility,both,100,ML,,258,180.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7025-40,NDC,facility,both,13,ML,,630,441,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % IT SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1411-11,NDC,facility,both,1,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-02,NDC,facility,both,24,ML,JW,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-41,NDC,facility,both,190,ML,,592,414.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,1,ML,JZ,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-05,NDC,facility,both,15,ML,JZ,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GADOTERIDOL 279.3 MG/ML IV SOLN,61408,CDM,255,RC,A9576,HCPCS,0270-1111-01,NDC,facility,both,8,ML,JZ,274,191.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-13,NDC,facility,both,12,ML,,410,287,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-13,NDC,facility,both,7,ML,,271,189.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,A9579,HCPCS,0270-7030-42,NDC,,,facility,both,10,ML,,459,321.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7025-40,NDC,facility,both,6,ML,,376,263.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,67,ML,JZ,340,238,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 41 % (410 MG/ML) IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-15,NDC,facility,both,200,ML,,530,371,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % (410 MG/ML) IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-15,NDC,facility,both,194,ML,JW,143,100.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,132,ML,,492,344.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-01,NDC,facility,both,2,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-41,NDC,facility,both,180,ML,,561,392.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-01,NDC,facility,both,44,ML,,254,177.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-25,NDC,facility,both,2,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-01,NDC,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-05,NDC,facility,both,15,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,88,ML,,269,188.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,14,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,35,ML,JZ,201,140.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,56,ML,,284,198.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-04,NDC,facility,both,145,ML,,548,383.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7025-40,NDC,facility,both,6,ML,,382,267.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOTERIDOL 279.3 MG/ML IV SOLN,61408,CDM,255,RC,A9576,HCPCS,0270-1111-04,NDC,facility,both,1,ML,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,Q9967,HCPCS,0270-1315-35,NDC,,,facility,both,200,ML,,396,277.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-01,NDC,facility,both,43,ML,,248,173.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,636,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,14,ML,JZ,432,302.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-02,NDC,facility,both,54,ML,,326,228.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-02,NDC,facility,both,55,ML,,332,232.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % (410 MG/ML) IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-15,NDC,facility,both,15,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-02,NDC,facility,both,10,ML,JW,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,636,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,13,ML,,433,303.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-01,NDC,facility,both,28,ML,,183,128.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,150,ML,,448,313.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-37,NDC,facility,both,134,ML,,369,258.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,80,ML,,405,283.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,46,ML,JZ,264,184.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-52,NDC,facility,both,80,ML,,272,190.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,153,ML,,571,399.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOTERIDOL 279.3 MG/ML IV SOLN,61408,CDM,255,RC,A9576,HCPCS,0270-1111-01,NDC,facility,both,6,ML,,233,163.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,63,ML,,319,223.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-01,NDC,facility,both,32,ML,,209,146.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-02,NDC,facility,both,5,ML,JZ,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,315,ML,,1174,821.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-12,NDC,facility,both,5,ML,,198,138.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7025-40,NDC,facility,both,8,ML,,487,340.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOXETATE 2.5 MMOL/10 ML IV SOLN,61408,CDM,255,RC,A9581,HCPCS,50419-320-01,NDC,facility,both,10,ML,JZ,614,429.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 41 % (410 MG/ML) IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-15,NDC,facility,both,35,ML,,143,100.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-02,NDC,facility,both,81,ML,,489,342.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-30,NDC,facility,both,25,ML,JZ,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-98,NDC,facility,both,85,ML,,230,161,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOTERIDOL 279.3 MG/ML IV SOLN,61408,CDM,255,RC,A9576,HCPCS,0270-1111-04,NDC,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-95,NDC,facility,both,9,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-04,NDC,facility,both,320,ML,,665,465.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7025-40,NDC,facility,both,8,ML,,474,331.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,Q9967,HCPCS,0270-1316-52,NDC,,,facility,both,60,ML,,204,142.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,17,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,7,ML,JW,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,Q9967,HCPCS,0270-1315-35,NDC,,,facility,both,75,ML,,229,160.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,292,ML,,1088,761.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-01,NDC,facility,both,26,ML,,170,119,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7025-40,NDC,facility,both,8,ML,,264,184.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIATRIZOATE MEGLUMINE 30 % URTH SOLN,61408,CDM,636,RC,Q9958,HCPCS,0270-0149-57,NDC,facility,both,300,ML,,325,227.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,450,ML,,1677,1173.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-25,NDC,facility,both,20,ML,JZ,121,84.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-95,NDC,facility,both,61,ML,,329,230.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,Q9967,HCPCS,0407-2223-01,NDC,,,facility,both,50,ML,,302,211.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,2,ML,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-13,NDC,facility,both,19,ML,,478,334.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,300,ML,,1342,939.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-01,NDC,facility,both,6,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-37,NDC,facility,both,300,ML,,609,426.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,133,ML,,496,347.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,4,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-13,NDC,facility,both,17,ML,,428,299.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-95,NDC,facility,both,35,ML,,214,149.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % IT SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1411-11,NDC,facility,both,8,ML,,304,212.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIATRIZOATE MEGLUMINE 30 % URTH SOLN,61408,CDM,255,RC,Q9958,HCPCS,0270-0149-57,NDC,facility,both,25,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,94,ML,,281,196.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,48,ML,JW,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,47,ML,,284,198.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,636,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,60,ML,JW,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,20,ML,JW,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7020-38,NDC,facility,both,6,ML,,378,264.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % (410 MG/ML) IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-15,NDC,facility,both,195,ML,JW,144,100.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,162,ML,,604,422.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,40,ML,,274,191.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-95,NDC,facility,both,60,ML,,324,226.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,200,ML,,746,522.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-52,NDC,facility,both,12,ML,JW,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,266,ML,,992,694.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-37,NDC,facility,both,280,ML,,568,397.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-04,NDC,facility,both,140,ML,,529,370.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOTERIDOL 279.3 MG/ML IV SOLN,61408,CDM,255,RC,A9576,HCPCS,0270-1111-04,NDC,facility,both,4,ML,,158,110.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-01,NDC,facility,both,1,ML,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-04,NDC,facility,both,34,ML,JW,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-04,NDC,facility,both,160,ML,,605,423.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-04,NDC,facility,both,125,ML,,353,247.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-03,NDC,facility,both,280,ML,,1146,802.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,28,ML,JZ,161,112.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-04,NDC,facility,both,105,ML,,297,207.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7030-42,NDC,facility,both,7,ML,,433,303.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,150,ML,,559,391.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % IT SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1411-11,NDC,facility,both,5,ML,JZ,215,150.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,94,ML,,476,333.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-95,NDC,facility,both,100,ML,,1624,1136.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % (410 MG/ML) IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-15,NDC,facility,both,193,ML,JW,142,99.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,8,ML,,267,186.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,165,ML,JZ,615,430.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,636,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,13,ML,,413,289.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,77,ML,,390,273,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,14,ML,,467,326.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-09,NDC,facility,both,250,ML,,863,604.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,300,ML,,659,461.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,300,ML,,1215,850.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,145,ML,JZ,541,378.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-25,NDC,facility,both,30,ML,JZ,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,18,ML,,442,309.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7030-42,NDC,facility,both,9,ML,,401,280.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-30,NDC,facility,both,1,ML,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOTERIDOL 279.3 MG/ML IV SOLN,61408,CDM,255,RC,A9576,HCPCS,0270-1111-02,NDC,facility,both,15,ML,,368,257.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % INJ SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-30,NDC,facility,both,4,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % (410 MG/ML) IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-15,NDC,facility,both,2,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7020-38,NDC,facility,both,2,ML,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-02,NDC,facility,both,40,ML,JW,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 41 % IT SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1411-11,NDC,facility,both,3,ML,,129,90.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOTERIDOL 279.3 MG/ML IV SOLN,61408,CDM,255,RC,A9576,HCPCS,0270-1111-04,NDC,facility,both,1,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-25,NDC,facility,both,30,ML,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7030-42,NDC,facility,both,8,ML,,377,263.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % (410 MG/ML) IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-15,NDC,facility,both,300,ML,,794,555.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,50,ML,JW,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-04,NDC,facility,both,55,ML,,283,198.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,18,ML,,128,89.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,Q9967,HCPCS,0270-1315-95,NDC,,,facility,both,60,ML,,324,226.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,50,ML,,254,177.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,42,ML,,128,89.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-01,NDC,facility,both,1,ML,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % IT SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1411-11,NDC,facility,both,10,ML,JZ,380,266,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-03,NDC,facility,both,108,ML,,442,309.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-95,NDC,facility,both,33,ML,,202,141.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML IV SUSP,61408,CDM,255,RC,Q9957,HCPCS,11994-011-04,NDC,facility,both,2,ML,,588,411.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,57,ML,,289,202.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,34,ML,,195,136.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-09,NDC,facility,both,200,ML,,863,604.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,217,ML,,809,566.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-37,NDC,facility,both,135,ML,,372,260.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,Q9967,HCPCS,0270-1315-25,NDC,,,facility,both,30,ML,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,Q9967,HCPCS,0270-1315-35,NDC,,,facility,both,25,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-95,NDC,facility,both,28,ML,,171,119.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,636,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,50,ML,,169,118.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-04,NDC,facility,both,85,ML,,437,305.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7030-42,NDC,facility,both,10,ML,,483,338.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-03,NDC,facility,both,146,ML,,598,418.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,400,ML,JZ,1491,1043.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,124,ML,,463,324.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7030-42,NDC,facility,both,12,ML,,579,405.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,3,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,A9577,HCPCS,0270-5164-15,NDC,,,facility,both,20,ML,,455,318.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-03,NDC,facility,both,120,ML,,491,343.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,70,ML,JZ,237,165.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,380,ML,,1416,991.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-41,NDC,facility,both,370,ML,,1153,807.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-13,NDC,facility,both,11,ML,,357,249.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,49,ML,,248,173.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,80,ML,,244,170.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,75,ML,,254,177.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % (410 MG/ML) IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-15,NDC,facility,both,19,ML,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-02,NDC,facility,both,90,ML,,400,280,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % (410 MG/ML) IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-15,NDC,facility,both,17,ML,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,33,ML,JW,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,300,ML,JZ,1118,782.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,116,ML,,433,303.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,126,ML,,470,329,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-95,NDC,facility,both,15,ML,,113,79.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,11,ML,JW,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,40,ML,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-52,NDC,facility,both,71,ML,,241,168.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % (410 MG/ML) IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-15,NDC,facility,both,5,ML,XU,26,18.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,90,ML,JZ,275,192.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,58,ML,JZ,294,205.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,636,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,15,ML,JW,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,636,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,15,ML,JW,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,80,ML,PLAD,271,189.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,636,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,1,ML,JW,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,60,ML,JZ,304,212.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,170,ML,,374,261.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7020-38,NDC,facility,both,1,ML,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,636,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,70,ML,,214,149.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-03,NDC,facility,both,127,ML,,520,364,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,275,ML,JZ,1025,717.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,74,ML,,375,262.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,85,ML,PLAD,254,177.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
IOHEXOL 240 MG/ML IV SOLN,61408,CDM,636,RC,Q9966,HCPCS,0407-1412-30,NDC,facility,both,50,ML,,261,182.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7030-42,NDC,facility,both,10,ML,,454,317.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,315,ML,JZ,1174,821.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,120,ML,JZ,358,250.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7025-40,NDC,facility,both,4,ML,,261,182.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-04,NDC,facility,both,102,ML,,288,201.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,18,ML,JZ,409,286.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-37,NDC,facility,both,285,ML,,578,404.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7030-42,NDC,facility,both,9,ML,,415,290.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % IT SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1411-11,NDC,facility,both,5,ML,,215,150.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,636,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,150,ML,,448,313.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,Q9967,HCPCS,0270-1316-35,NDC,,,facility,both,40,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,106,ML,,395,276.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,15,ML,JZ,107,74.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,160,ML,,478,334.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,90,ML,JW,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IT SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1412-15,NDC,facility,both,30,ML,JZ,742,519.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,300,ML,,1118,782.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-13,NDC,facility,both,3,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,151,ML,,563,394.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-04,NDC,facility,both,250,ML,,945,661.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,13,ML,,417,291.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7020-38,NDC,facility,both,9,ML,,430,301,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-47,NDC,facility,both,150,ML,,446,312.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,88,ML,,446,312.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,5,ML,,175,122.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,45,ML,JW,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7030-42,NDC,facility,both,10,ML,,459,321.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % IT SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1411-11,NDC,facility,both,9,ML,JW,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-04,NDC,facility,both,233,ML,,484,338.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-95,NDC,facility,both,38,ML,,232,162.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,160,ML,,431,301.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,102,ML,,381,266.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,76,ML,,257,179.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,12,ML,JZ,400,280,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-95,NDC,facility,both,80,ML,,431,301.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,6,ML,JW,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GADOTERIDOL 279.3 MG/ML IV SOLN,61408,CDM,255,RC,A9576,HCPCS,0270-1111-01,NDC,facility,both,12,ML,,410,287,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,52,ML,JZ,264,184.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-02,NDC,facility,both,186,ML,"JZ,XU",437,305.9,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,70,ML,PLAD,237,165.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
IOPAMIDOL 41 % (410 MG/ML) IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-15,NDC,facility,both,18,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,12,ML,JZ,371,259.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,10,ML,JW,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,636,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,11,ML,,367,256.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-95,NDC,facility,both,4,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,45,ML,,138,96.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-95,NDC,facility,both,100,ML,,299,209.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,20,ML,JZ,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,300,ML,,1405,983.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-03,NDC,facility,both,116,ML,,475,332.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIATRIZOATE MEGLUMINE 30 % URTH SOLN,61408,CDM,255,RC,Q9958,HCPCS,0270-0149-57,NDC,facility,both,275,ML,,298,208.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-03,NDC,facility,both,140,ML,,573,401.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-02,NDC,facility,both,5,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,23,ML,JW,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,32,ML,,219,153.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7030-42,NDC,facility,both,15,ML,,700,490,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,25,ML,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-02,NDC,facility,both,100,ML,XE,266,186.2,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XE: Separate encounter, a service that is distinct because it occurred during a separate encounter"
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,636,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,15,ML,JZ,368,257.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-04,NDC,facility,both,118,ML,,333,233.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-02,NDC,facility,both,15,ML,JZ,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7030-42,NDC,facility,both,9,ML,,406,284.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,75,ML,JZ,380,266,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,72,ML,,365,255.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-95,NDC,facility,both,500,ML,,1624,1136.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-04,NDC,facility,both,155,ML,,586,410.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,29,ML,,167,116.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,636,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,54,ML,JW,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-13,NDC,facility,both,10,ML,,342,239.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-04,NDC,facility,both,106,ML,,300,210,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,86,ML,,436,305.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-03,NDC,facility,both,138,ML,,565,395.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,Q9967,HCPCS,0270-1316-35,NDC,,,facility,both,60,ML,,203,142.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,36,ML,,247,172.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,14,ML,JW,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 41 % (410 MG/ML) IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-15,NDC,facility,both,50,ML,,204,142.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-25,NDC,facility,both,11,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,38,ML,JW,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7030-42,NDC,facility,both,10,ML,,478,334.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-95,NDC,facility,both,11,ML,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,636,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,20,ML,JW,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7030-42,NDC,facility,both,12,ML,,555,388.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,10,ML,,333,233.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,275,ML,,1025,717.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,84,ML,,426,298.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-95,NDC,facility,both,108,ML,,429,300.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-30,NDC,facility,both,40,ML,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,636,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,30,ML,JW,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,636,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,86,ML,,257,179.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-02,NDC,facility,both,120,ML,JZ,282,197.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,19,ML,,466,326.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,25,ML,JW,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,100,ML,,269,188.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % (410 MG/ML) IV SOLN,61408,CDM,Q9966,HCPCS,0270-1314-15,NDC,,,facility,both,6,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-41,NDC,facility,both,175,ML,,545,381.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-95,NDC,facility,both,30,ML,,183,128.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-52,NDC,facility,both,220,ML,,485,339.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,6,ML,JW,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-04,NDC,facility,both,300,ML,,779,545.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,47,ML,,270,189,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7030-42,NDC,facility,both,5,ML,,295,206.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % IT SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1411-11,NDC,facility,both,10,ML,,380,266,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOTERIDOL 279.3 MG/ML IV SOLN,61408,CDM,255,RC,A9576,HCPCS,0270-1111-03,NDC,facility,both,1,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7025-40,NDC,facility,both,12,ML,,558,390.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7020-38,NDC,facility,both,3,ML,,188,131.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-03,NDC,facility,both,105,ML,,430,301,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,45,ML,,269,188.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-01,NDC,facility,both,36,ML,JW,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,24,ML,JW,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-02,NDC,facility,both,500,ML,,864,604.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-25,NDC,facility,both,3,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7030-42,NDC,facility,both,10,ML,,463,324.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,636,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,13,ML,,423,296.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,40,ML,JZ,230,161,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,100,ML,JZ,299,209.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-02,NDC,facility,both,100,ML,JZ,266,186.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-04,NDC,facility,both,150,ML,JZ,567,396.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,636,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,15,ML,,463,324.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-04,NDC,facility,both,110,ML,,416,291.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7030-42,NDC,facility,both,7,ML,,426,298.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % INJ SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-30,NDC,facility,both,45,ML,JW,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7025-40,NDC,facility,both,8,ML,,481,336.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,636,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,12,ML,,371,259.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,41,ML,,248,173.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-01,NDC,facility,both,25,ML,JW,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,24,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,19,ML,JZ,432,302.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7025-40,NDC,facility,both,8,ML,,468,327.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-95,NDC,facility,both,120,ML,,476,333.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-03,NDC,facility,both,289,ML,,1182,827.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-02,NDC,facility,both,200,ML,,470,329,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-09,NDC,facility,both,150,ML,,432,302.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-04,NDC,facility,both,83,ML,,426,298.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,27,ML,JW,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,636,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,11,ML,,363,254.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-04,NDC,facility,both,48,ML,JW,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-01,NDC,facility,both,5,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,636,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,2,ML,JW,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,117,ML,,436,305.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % INJ SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-30,NDC,facility,both,5,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-01,NDC,facility,both,15,ML,JW,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-95,NDC,facility,both,70,ML,,237,165.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,230,ML,,857,599.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7030-42,NDC,facility,both,13,ML,,627,438.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7020-38,NDC,facility,both,5,ML,,299,209.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % (410 MG/ML) IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-15,NDC,facility,both,22,ML,,111,77.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,2,ML,JZ,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,12,ML,,383,268.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-02,NDC,facility,both,400,ML,,692,484.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,41,ML,JW,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 41 % (410 MG/ML) IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-15,NDC,facility,both,8,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,173,ML,,645,451.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,98,ML,,264,184.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,2,ML,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-03,NDC,facility,both,110,ML,,450,315,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,105,ML,JZ,392,274.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,210,ML,,783,548.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOTERIDOL 279.3 MG/ML IV SOLN,61408,CDM,255,RC,A9576,HCPCS,0270-1111-04,NDC,facility,both,2,ML,JZ,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-04,NDC,facility,both,60,ML,,308,215.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,193,ML,,720,504,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,165,ML,,615,430.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,155,ML,JZ,578,404.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,20,ML,JW,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-52,NDC,facility,both,55,ML,,187,130.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,636,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,25,ML,JW,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,30,ML,JZ,113,79.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,140,ML,,377,263.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,62,ML,,314,219.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-01,NDC,facility,both,37,ML,,242,169.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,200,ML,JZ,440,308,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-04,NDC,facility,both,120,ML,,339,237.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,636,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,80,ML,JZ,271,189.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,38,ML,,218,152.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,48,ML,JZ,276,193.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IT SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1412-15,NDC,facility,both,90,ML,,1824,1276.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-25,NDC,facility,both,20,ML,JW,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-03,NDC,facility,both,40,ML,JW,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,67,ML,,340,238,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,Q9967,HCPCS,0270-1315-35,NDC,,,facility,both,20,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-01,NDC,facility,both,4,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-02,NDC,facility,both,37,ML,JW,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,20,ML,JW,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-95,NDC,facility,both,25,ML,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,40,ML,,230,161,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,16,ML,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-02,NDC,facility,both,25,ML,JZ,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,250,ML,,932,652.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-25,NDC,facility,both,25,ML,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-02,NDC,facility,both,160,ML,JZ,376,263.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,85,ML,,254,177.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-01,NDC,facility,both,32,ML,JW,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-13,NDC,facility,both,20,ML,JZ,503,352.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 41 % INJ SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-30,NDC,facility,both,20,ML,JZ,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,40,ML,,909,636.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,7,ML,JW,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 41 % (410 MG/ML) IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-15,NDC,facility,both,5,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-95,NDC,facility,both,49,ML,,264,184.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,636,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,60,ML,JW,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-04,NDC,facility,both,176,ML,JW,186,130.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,70,ML,,214,149.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,39,ML,,267,186.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,170,ML,,458,320.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,5,ML,,189,132.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,55,ML,,186,130.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-37,NDC,facility,both,70,ML,,219,153.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,81,ML,JZ,410,287,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,55,ML,JZ,279,195.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,8,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,296,ML,,1103,772.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,636,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,10,ML,JW,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7030-42,NDC,facility,both,7,ML,,459,321.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,636,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,37,ML,JZ,113,79.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,95,ML,,284,198.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-95,NDC,facility,both,1,ML,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7020-38,NDC,facility,both,1,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,36,ML,JW,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-02,NDC,facility,both,35,ML,JZ,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-95,NDC,facility,both,32,ML,,196,137.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % (410 MG/ML) IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-15,NDC,facility,both,150,ML,JW,111,77.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,22,ML,JW,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-02,NDC,facility,both,20,ML,JW,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,A9579,HCPCS,0270-7025-40,NDC,,,facility,both,7,ML,,461,322.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,42,ML,,241,168.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-30,NDC,facility,both,47,ML,JW,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,Q9967,HCPCS,0270-1315-35,NDC,,,facility,both,80,ML,,244,170.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-52,NDC,facility,both,66,ML,,224,156.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,150,ML,JZ,559,391.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,636,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,60,ML,,203,142.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,16,ML,,393,275.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7025-40,NDC,facility,both,7,ML,,412,288.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7020-38,NDC,facility,both,3,ML,,226,158.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-41,NDC,facility,both,165,ML,,514,359.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,16,ML,,136,95.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,139,ML,JZ,518,362.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7030-42,NDC,facility,both,11,ML,,531,371.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,Q9967,HCPCS,0270-1315-35,NDC,,,facility,both,75,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-04,NDC,facility,both,152,ML,,575,402.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,2,ML,JW,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,2,ML,JW,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-52,NDC,facility,both,75,ML,,255,178.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,60,ML,JW,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,176,ML,,656,459.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % INJ SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-30,NDC,facility,both,2,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,636,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,9,ML,,278,194.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-52,NDC,facility,both,70,ML,,238,166.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-02,NDC,facility,both,2,ML,JZ,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-05,NDC,facility,both,30,ML,JW,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 41 % (410 MG/ML) IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-15,NDC,facility,both,41,ML,,167,116.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,15,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,56,ML,,171,119.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,34,ML,JZ,195,136.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,29,ML,,199,139.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,22,ML,JW,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,82,ML,,245,171.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,63,ML,,213,149.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7030-42,NDC,facility,both,11,ML,,507,354.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,225,ML,,839,587.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,Q9967,HCPCS,0270-1315-35,NDC,,,facility,both,35,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,27,ML,JZ,155,108.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-41,NDC,facility,both,164,ML,,511,357.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,60,ML,JZ,183,128.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-04,NDC,facility,both,329,ML,,1243,870.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,107,ML,,399,279.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,1,ML,JW,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-12,NDC,facility,both,10,ML,,348,243.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7030-42,NDC,facility,both,9,ML,,425,297.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,636,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,60,ML,JZ,203,142.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,Q9967,HCPCS,0270-1315-35,NDC,,,facility,both,85,ML,,259,181.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-04,NDC,facility,both,340,ML,,707,494.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-01,NDC,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-25,NDC,facility,both,4,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % INJ SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-30,NDC,facility,both,200,ML,,379,265.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,636,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,75,ML,,254,177.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-41,NDC,facility,both,400,ML,,1246,872.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-04,NDC,facility,both,10,ML,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-41,NDC,facility,both,340,ML,,1059,741.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,115,ML,JZ,429,300.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-01,NDC,facility,both,45,ML,,259,181.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,134,ML,JZ,500,350,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7020-38,NDC,facility,both,7,ML,,431,301.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7020-38,NDC,facility,both,2,ML,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,178,ML,,664,464.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,10,ML,JW,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-03,NDC,facility,both,149,ML,,610,427,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,42,ML,JW,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7030-42,NDC,facility,both,10,ML,,439,307.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,59,ML,,200,140,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,636,RC,Q9967,HCPCS,0270-1315-30,NDC,facility,both,50,ML,,156,109.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,237,ML,,884,618.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-03,NDC,facility,both,130,ML,,532,372.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-13,NDC,facility,both,6,ML,,201,140.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-04,NDC,facility,both,90,ML,,462,323.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,114,ML,,425,297.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,250,ML,JZ,932,652.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-41,NDC,facility,both,200,ML,,623,436.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,183,ML,,682,477.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,636,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,1,ML,JW,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,100,ML,JZ,373,261.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 41 % IT SOLN,61408,CDM,Q9966,HCPCS,0270-1411-11,NDC,,,facility,both,2,ML,,107,74.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,218,ML,,813,569.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,98,ML,JW,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-52,NDC,facility,both,53,ML,,180,126,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-52,NDC,facility,both,63,ML,,214,149.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,175,ML,,653,457.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOTERIDOL 279.3 MG/ML IV SOLN,61408,CDM,255,RC,A9576,HCPCS,0270-1111-04,NDC,facility,both,10,ML,JZ,348,243.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,29,ML,JW,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,65,ML,,220,154,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7025-40,NDC,facility,both,5,ML,,297,207.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,83,ML,,421,294.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,8,ML,JW,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,13,ML,JZ,433,303.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,12,ML,JW,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-37,NDC,facility,both,130,ML,,358,250.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,37,ML,,213,149.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,290,ML,,1081,756.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,142,ML,,530,371,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-04,NDC,facility,both,125,ML,,473,331.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,770,ML,,1691,1183.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,45,ML,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-95,NDC,facility,both,58,ML,,313,219.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,13,ML,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % (410 MG/ML) IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-15,NDC,facility,both,11,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-02,NDC,facility,both,89,ML,,396,277.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,17,ML,JW,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,69,ML,JZ,350,245,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7020-38,NDC,facility,both,4,ML,,266,186.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,100,ML,,373,261.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-95,NDC,facility,both,97,ML,,385,269.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,122,ML,,455,318.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIATRIZOATE MEGLUMINE 18 % URTH SOLN,61408,CDM,255,RC,Q9958,HCPCS,0270-1410-30,NDC,facility,both,40,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-01,NDC,facility,both,46,ML,JW,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-13,NDC,facility,both,10,ML,JZ,342,239.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7020-38,NDC,facility,both,10,ML,,489,342.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % (410 MG/ML) IV SOLN,61408,CDM,Q9966,HCPCS,0270-1314-15,NDC,,,facility,both,10,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IT SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1412-15,NDC,facility,both,15,ML,,371,259.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7030-42,NDC,facility,both,6,ML,,354,247.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-41,NDC,facility,both,800,ML,,2042,1429.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,17,ML,,386,270.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,48,ML,,276,193.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7025-40,NDC,facility,both,7,ML,,415,290.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7030-42,NDC,facility,both,8,ML,,381,266.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML IV SUSP,61408,CDM,255,RC,Q9957,HCPCS,11994-011-01,NDC,facility,both,2,ML,JZ,2408,1685.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,26,ML,,150,105,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-37,NDC,facility,both,132,ML,,364,254.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7030-42,NDC,facility,both,5,ML,,328,229.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,636,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,10,ML,JW,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-02,NDC,facility,both,17,ML,JZ,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-01,NDC,facility,both,27,ML,,176,123.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-02,NDC,facility,both,70,ML,JZ,187,130.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,25,ML,,144,100.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-50,NDC,facility,both,150,ML,,392,274.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-03,NDC,facility,both,25,ML,JW,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,200,ML,JZ,746,522.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,33,ML,,226,158.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-04,NDC,facility,both,162,ML,,612,428.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,38,ML,,260,182,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOXETATE 2.5 MMOL/10 ML IV SOLN,61408,CDM,255,RC,A9581,HCPCS,50419-320-01,NDC,facility,both,10,ML,,614,429.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,636,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,16,ML,,364,254.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,17,ML,,417,291.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,13,ML,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,149,ML,,556,389.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7030-42,NDC,facility,both,2,ML,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,90,ML,,456,319.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,25,ML,JZ,144,100.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-30,NDC,facility,both,49,ML,JW,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,636,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,17,ML,,398,278.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,84,ML,,251,175.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,53,ML,,269,188.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-95,NDC,facility,both,60,ML,,203,142.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,636,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,75,ML,,229,160.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIATRIZOATE MEGLUMINE 30 % URTH SOLN,61408,CDM,255,RC,Q9958,HCPCS,0270-0149-57,NDC,facility,both,600,ML,,478,334.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IT SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1412-15,NDC,facility,both,30,ML,,742,519.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,636,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,4,ML,JW,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,172,ML,,641,448.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,Q9967,HCPCS,0270-1316-35,NDC,,,facility,both,120,ML,,358,250.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,636,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,7,ML,,245,171.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,Q9967,HCPCS,0270-1315-25,NDC,,,facility,both,85,ML,,367,256.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,58,ML,JW,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,71,ML,,240,168,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,219,ML,,816,571.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,21,ML,,121,84.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,A9579,HCPCS,0270-7020-38,NDC,,,facility,both,6,ML,,398,278.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,30,ML,,126,88.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-30,NDC,facility,both,150,ML,,413,289.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOTERIDOL 279.3 MG/ML IV SOLN,61408,CDM,255,RC,A9576,HCPCS,0270-1111-04,NDC,facility,both,4,ML,JW,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,75,ML,JZ,229,160.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,1,ML,JW,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7025-40,NDC,facility,both,7,ML,,422,295.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7020-38,NDC,facility,both,9,ML,,440,308,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,90,ML,,275,192.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,120,ML,JZ,448,313.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-02,NDC,facility,both,200,ML,XU,470,329,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,297,ML,,1107,774.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,263,ML,,980,686,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,113,ML,,422,295.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-13,NDC,facility,both,10,ML,PLAD,342,239.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,49,ML,,296,207.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7025-40,NDC,facility,both,8,ML,,388,271.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,19,ML,,432,302.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,636,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,7,ML,JW,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7025-40,NDC,facility,both,6,ML,,369,258.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-01,NDC,facility,both,20,ML,,131,91.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,16,ML,JW,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,636,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,20,ML,,455,318.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7030-42,NDC,facility,both,6,ML,,361,252.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-02,NDC,facility,both,100,ML,,266,186.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7020-38,NDC,facility,both,6,ML,,359,251.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,27,ML,JW,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,75,ML,JW,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-01,NDC,facility,both,2,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,52,ML,,264,184.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-01,NDC,facility,both,47,ML,JW,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,30,ML,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-01,NDC,facility,both,49,ML,JW,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,240,ML,JZ,895,626.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,14,ML,JZ,467,326.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-13,NDC,facility,both,4,ML,JW,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-37,NDC,facility,both,291,ML,,590,413,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIATRIZOATE MEGLUMINE 30 % URTH SOLN,61408,CDM,255,RC,Q9958,HCPCS,0270-0149-57,NDC,facility,both,250,ML,,271,189.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,636,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,8,ML,,257,179.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-02,NDC,facility,both,57,ML,,344,240.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,636,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,15,ML,,483,338.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,30,ML,JW,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,8,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % IT SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1411-11,NDC,facility,both,2,ML,,107,74.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOHEXOL 240 MG/ML IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0407-1412-50,NDC,facility,both,50,ML,,253,177.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,14,ML,JZ,432,302.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-01,NDC,facility,both,9,ML,JW,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-13,NDC,facility,both,5,ML,JW,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,636,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,47,ML,JW,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,185,ML,JZ,690,483,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,179,ML,,667,466.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,Q9967,HCPCS,0270-1316-35,NDC,,,facility,both,70,ML,,237,165.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,11,ML,,367,256.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % INJ SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-30,NDC,facility,both,100,ML,JZ,258,180.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-25,NDC,facility,both,25,ML,JW,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,208,ML,,776,543.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,31,ML,,178,124.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-01,NDC,facility,both,10,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,135,ML,,504,352.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-25,NDC,facility,both,80,ML,JZ,346,242.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,85,ML,,259,181.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,164,ML,JZ,612,428.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-02,NDC,facility,both,32,ML,JW,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,636,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,10,ML,,317,221.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,35,ML,JW,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,22,ML,,151,105.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-02,NDC,facility,both,17,ML,JW,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 41 % (410 MG/ML) IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-15,NDC,facility,both,27,ML,,136,95.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7025-40,NDC,facility,both,7,ML,,408,285.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,200,ML,JZ,396,277.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,10,ML,JZ,309,216.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7025-40,NDC,facility,both,7,ML,,441,308.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-13,NDC,facility,both,13,ML,,444,310.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,60,ML,,304,212.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,215,ML,JZ,802,561.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 41 % INJ SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-30,NDC,facility,both,1,ML,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-03,NDC,facility,both,25,ML,,158,110.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,2,ML,JW,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,145,ML,,433,303.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,27,ML,,155,108.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-01,NDC,facility,both,40,ML,,261,182.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOTERIDOL 279.3 MG/ML IV SOLN,61408,CDM,255,RC,A9576,HCPCS,0270-1111-04,NDC,facility,both,2,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,A9577,HCPCS,0270-5164-15,NDC,,,facility,both,13,ML,,401,280.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-02,NDC,facility,both,43,ML,JW,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 41 % (410 MG/ML) IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-15,NDC,facility,both,196,ML,JW,145,101.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-04,NDC,facility,both,30,ML,JZ,175,122.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,24,ML,,138,96.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,636,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,3,ML,JW,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-09,NDC,facility,both,300,ML,,863,604.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-01,NDC,facility,both,10,ML,JW,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,196,ML,,731,511.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,104,ML,,388,271.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-95,NDC,facility,both,93,ML,,369,258.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,1,ML,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-37,NDC,facility,both,145,ML,,400,280,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,160,ML,JZ,478,334.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,75,ML,,229,160.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-30,NDC,facility,both,3,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,45,ML,,272,190.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IT SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1412-15,NDC,facility,both,8,ML,,269,188.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-95,NDC,facility,both,40,ML,,244,170.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,20,ML,JZ,455,318.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-01,NDC,facility,both,44,ML,JW,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,45,ML,,1104,772.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,80,ML,JZ,271,189.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,636,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,6,ML,JW,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,636,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,8,ML,JW,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,12,ML,JW,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-02,NDC,facility,both,2,ML,JW,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7020-38,NDC,facility,both,2,ML,,136,95.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-37,NDC,facility,both,60,ML,,188,131.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,14,ML,JW,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GADOTERIDOL 279.3 MG/ML IV SOLN,61408,CDM,255,RC,A9576,HCPCS,0270-1111-04,NDC,facility,both,2,ML,JW,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7030-42,NDC,facility,both,10,ML,,473,331.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,36,ML,JW,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-01,NDC,facility,both,4,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-04,NDC,facility,both,38,ML,JW,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-01,NDC,facility,both,17,ML,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,636,RC,Q9967,HCPCS,0270-1316-52,NDC,facility,both,75,ML,,255,178.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-30,NDC,facility,both,46,ML,JW,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-52,NDC,facility,both,60,ML,JZ,204,142.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 41 % (410 MG/ML) IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-15,NDC,facility,both,7,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-02,NDC,facility,both,60,ML,JZ,160,112,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,3,ML,JW,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,1,ML,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,317,ML,,1182,827.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-01,NDC,facility,both,15,ML,,121,84.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,64,ML,JZ,324,226.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,167,ML,,623,436.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,13,ML,,427,298.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-04,NDC,facility,both,312,ML,,1179,825.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % (410 MG/ML) IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-15,NDC,facility,both,195,ML,"JW,XU",144,100.8,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-01,NDC,facility,both,22,ML,,144,100.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOTERIDOL 279.3 MG/ML IV SOLN,61408,CDM,255,RC,A9576,HCPCS,0270-1111-04,NDC,facility,both,1,ML,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,Q9967,HCPCS,0270-1315-35,NDC,,,facility,both,90,ML,,275,192.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,636,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,80,ML,,244,170.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,262,ML,,977,683.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,7,ML,,245,171.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIATRIZOATE MEGLUMINE 30 % URTH SOLN,61408,CDM,255,RC,Q9958,HCPCS,0270-0149-57,NDC,facility,both,100,ML,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-25,NDC,facility,both,27,ML,JW,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,9,ML,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,89,ML,,451,315.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,155,ML,,463,324.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOTERIDOL 279.3 MG/ML IV SOLN,61408,CDM,255,RC,A9576,HCPCS,0270-1111-04,NDC,facility,both,2,ML,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-02,NDC,facility,both,82,ML,,365,255.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,70,ML,JW,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-05,NDC,facility,both,30,ML,"JW,XE",17,11.9,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient | Modifier XE: Separate encounter, a service that is distinct because it occurred during a separate encounter"
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-02,NDC,facility,both,72,ML,,435,304.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % (410 MG/ML) IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-15,NDC,facility,both,20,ML,,101,70.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOTERIDOL 279.3 MG/ML IV SOLN,61408,CDM,255,RC,A9576,HCPCS,0270-1111-04,NDC,facility,both,5,ML,,178,124.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7020-38,NDC,facility,both,3,ML,,181,126.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-25,NDC,facility,both,5,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-95,NDC,facility,both,98,ML,,389,272.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,335,ML,,1249,874.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,12,ML,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,15,ML,JW,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,46,ML,,264,184.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,85,ML,JZ,259,181.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,62,ML,,210,147,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,55,ML,JW,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-52,NDC,facility,both,51,ML,,173,121.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-02,NDC,facility,both,150,ML,JZ,353,247.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7020-38,NDC,facility,both,6,ML,,365,255.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-95,NDC,facility,both,63,ML,,340,238,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-37,NDC,facility,both,290,ML,,588,411.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,30,ML,JZ,173,121.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7030-42,NDC,facility,both,4,ML,,263,184.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,95,ML,,256,179.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,7,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-30,NDC,facility,both,8,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,112,ML,JZ,418,292.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-02,NDC,facility,both,14,ML,JW,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-52,NDC,facility,both,225,ML,,496,347.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,95,ML,,481,336.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,16,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOTERIDOL 279.3 MG/ML IV SOLN,61408,CDM,255,RC,A9576,HCPCS,0270-1111-04,NDC,facility,both,2,ML,JW,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,93,ML,,251,175.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,270,ML,,1007,704.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7030-42,NDC,facility,both,10,ML,,468,327.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIATRIZOATE MEGLUMINE 30 % URTH SOLN,61408,CDM,255,RC,Q9958,HCPCS,0270-0149-57,NDC,facility,both,20,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-03,NDC,facility,both,139,ML,,569,398.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-04,NDC,facility,both,190,ML,,718,502.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % (410 MG/ML) IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-15,NDC,facility,both,30,ML,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-01,NDC,facility,both,3,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,60,ML,,203,142.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,8,ML,JW,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 41 % (410 MG/ML) IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-15,NDC,facility,both,24,ML,,121,84.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,195,ML,JZ,727,508.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,12,ML,,371,259.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-95,NDC,facility,both,73,ML,,394,275.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,Q9967,HCPCS,0270-1315-35,NDC,,,facility,both,15,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,33,ML,,190,133,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,174,ML,JZ,649,454.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IT SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1412-15,NDC,facility,both,15,ML,JZ,371,259.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,23,ML,,132,92.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOTERIDOL 279.3 MG/ML IV SOLN,61408,CDM,255,RC,A9576,HCPCS,0270-1111-04,NDC,facility,both,1,ML,JW,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,Q9967,HCPCS,0270-1315-35,NDC,,,facility,both,25,ML,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,152,ML,JZ,567,396.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,135,ML,,403,282.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-52,NDC,facility,both,120,ML,,360,252,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7025-40,NDC,facility,both,6,ML,,343,240.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-52,NDC,facility,both,204,ML,,450,315,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-95,NDC,facility,both,74,ML,,399,279.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % (410 MG/ML) IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-15,NDC,facility,both,8,ML,XU,38,26.6,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
GADOTERIDOL 279.3 MG/ML IV SOLN,61408,CDM,255,RC,A9576,HCPCS,0270-1111-04,NDC,facility,both,5,ML,,198,138.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,Q9967,HCPCS,0270-1315-35,NDC,,,facility,both,10,ML,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,Q9967,HCPCS,0270-1315-35,NDC,,,facility,both,100,ML,,269,188.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,Q9967,HCPCS,0270-1316-35,NDC,,,facility,both,25,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-02,NDC,facility,both,83,ML,,369,258.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOTERIDOL 279.3 MG/ML IV SOLN,61408,CDM,255,RC,A9576,HCPCS,0270-1111-01,NDC,facility,both,2,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7030-42,NDC,facility,both,3,ML,,223,156.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7025-40,NDC,facility,both,7,ML,,456,319.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7030-42,NDC,facility,both,9,ML,,420,294,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-01,NDC,facility,both,21,ML,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,32,ML,,184,128.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-03,NDC,facility,both,107,ML,,438,306.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-02,NDC,facility,both,85,ML,,378,264.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,Q9967,HCPCS,0270-1315-35,NDC,,,facility,both,40,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,Q9967,HCPCS,0270-1315-35,NDC,,,facility,both,1,ML,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-01,NDC,facility,both,14,ML,,113,79.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-01,NDC,facility,both,24,ML,,157,109.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,42,ML,,254,177.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,4,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,180,ML,JZ,671,469.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-05,NDC,facility,both,20,ML,XE,75,52.5,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XE: Separate encounter, a service that is distinct because it occurred during a separate encounter"
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-12,NDC,facility,both,5,ML,JZ,198,138.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-05,NDC,facility,both,40,ML,JW,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-25,NDC,facility,both,60,ML,,259,181.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-30,NDC,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-04,NDC,facility,both,88,ML,JW,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,46,ML,,141,98.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,636,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,10,ML,JW,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,171,ML,,638,446.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML IV SUSP,61408,CDM,255,RC,Q9957,HCPCS,11994-011-01,NDC,facility,both,3,ML,JZ,882,617.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,1,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOTERIDOL 279.3 MG/ML IV SOLN,61408,CDM,255,RC,A9576,HCPCS,0270-1111-01,NDC,facility,both,1,ML,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7025-40,NDC,facility,both,8,ML,,364,254.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-02,NDC,facility,both,61,ML,,369,258.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,636,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,13,ML,,401,280.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,636,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,18,ML,,409,286.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,45,ML,JW,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-13,NDC,facility,both,5,ML,,194,135.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-95,NDC,facility,both,20,ML,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOHEXOL 240 MG/ML IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0407-1412-29,NDC,facility,both,50,ML,,260,182,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,59,ML,,299,209.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-13,NDC,facility,both,15,ML,,377,263.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-02,NDC,facility,both,250,ML,JZ,519,363.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOHEXOL 180 MG/ML IT SOLN,61408,CDM,255,RC,Q9966,HCPCS,0407-1411-10,NDC,facility,both,10,ML,,267,186.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-03,NDC,facility,both,103,ML,,422,295.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % (410 MG/ML) IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-15,NDC,facility,both,185,ML,JW,136,95.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-04,NDC,facility,both,30,ML,JW,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-02,NDC,facility,both,1,ML,JZ,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-25,NDC,facility,both,20,ML,,121,84.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIATRIZOATE MEGLUMINE 18 % URTH SOLN,61408,CDM,255,RC,Q9958,HCPCS,0270-1410-30,NDC,facility,both,300,ML,,215,150.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,93,ML,,471,329.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,636,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,40,ML,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-04,NDC,facility,both,100,ML,,378,264.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-95,NDC,facility,both,43,ML,,263,184.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,A9577,HCPCS,0270-5164-14,NDC,,,facility,both,15,ML,,368,257.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7020-38,NDC,facility,both,9,ML,,396,277.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,46,ML,,278,194.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7025-40,NDC,facility,both,5,ML,,316,221.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-05,NDC,facility,both,50,ML,PLAD,150,105,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,8,ML,,247,172.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7025-40,NDC,facility,both,7,ML,,461,322.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-52,NDC,facility,both,215,ML,,474,331.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,30,ML,,736,515.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,12,ML,JW,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,76,ML,JZ,385,269.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,636,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,86,ML,,263,184.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7025-40,NDC,facility,both,7,ML,,446,312.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-13,NDC,facility,both,6,ML,,233,163.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-41,NDC,facility,both,280,ML,,872,610.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-04,NDC,facility,both,20,ML,JW,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOHEXOL 240 MG/ML IV SOLN,61408,CDM,Q9966,HCPCS,0407-1412-29,NDC,,,facility,both,50,ML,,260,182,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7030-42,NDC,facility,both,14,ML,,676,473.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % INJ SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-30,NDC,facility,both,50,ML,,146,102.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,53,ML,JW,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,154,ML,,574,401.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7025-40,NDC,facility,both,5,ML,,303,212.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % (410 MG/ML) IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-15,NDC,facility,both,1,ML,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-98,NDC,facility,both,500,ML,,843,590.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-01,NDC,facility,both,30,ML,JW,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7020-38,NDC,facility,both,11,ML,,537,375.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-13,NDC,facility,both,1,ML,JW,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-25,NDC,facility,both,19,ML,JW,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,47,ML,JW,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,79,ML,JZ,400,280,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-95,NDC,facility,both,94,ML,,373,261.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,636,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,4,ML,JW,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,212,ML,,790,553,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,40,ML,JW,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,25,ML,JW,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOHEXOL 240 MG/ML IV SOLN,61408,CDM,Q9966,HCPCS,0407-1412-29,NDC,,,facility,both,30,ML,,156,109.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-04,NDC,facility,both,624,ML,,1930,1351,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-02,NDC,facility,both,49,ML,JW,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GADOPICLENOL 0.5 MMOL/ML IV SOLN,61408,CDM,255,RC,A9579,HCPCS,0270-7025-40,NDC,facility,both,4,ML,,251,175.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-01,NDC,facility,both,50,ML,,288,201.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % INJ SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-30,NDC,facility,both,49,ML,JW,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,5,ML,JW,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 51 % IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1317-02,NDC,facility,both,10,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-02,NDC,facility,both,40,ML,,274,191.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,636,RC,A9577,HCPCS,0270-5164-15,NDC,facility,both,5,ML,JW,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 41 % (410 MG/ML) IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-15,NDC,facility,both,173,ML,JW,128,89.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-95,NDC,facility,both,150,ML,,448,313.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,Q9967,HCPCS,0270-1315-35,NDC,,,facility,both,70,ML,,214,149.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 41 % (410 MG/ML) IV SOLN,61408,CDM,255,RC,Q9966,HCPCS,0270-1314-15,NDC,facility,both,2,ML,XU,11,7.7,,,,,,,,,,,,,"Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,64,ML,,196,137.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-30,NDC,facility,both,5,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-95,NDC,facility,both,130,ML,,516,361.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML IV SUSP,61408,CDM,Q9957,HCPCS,11994-011-01,NDC,,,facility,both,2,ML,,588,411.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-41,NDC,facility,both,137,ML,,511,357.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-01,NDC,facility,both,5,ML,JW,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,636,RC,A9577,HCPCS,0270-5164-14,NDC,facility,both,5,ML,JW,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,88,ML,,263,184.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOTERIDOL 279.3 MG/ML IV SOLN,61408,CDM,255,RC,A9576,HCPCS,0270-1111-04,NDC,facility,both,3,ML,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOTERIDOL 279.3 MG/ML IV SOLN,61408,CDM,255,RC,A9576,HCPCS,0270-1111-04,NDC,facility,both,2,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IODIXANOL 320 MG/ML IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0407-2223-01,NDC,facility,both,37,ML,,254,177.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1 MMOL/0.2 ML) IV SOLN,61408,CDM,255,RC,A9577,HCPCS,0270-5164-13,NDC,facility,both,9,ML,,295,206.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIATRIZOATE MEGLUMINE 30 % URTH SOLN,61408,CDM,255,RC,Q9958,HCPCS,0270-0149-57,NDC,facility,both,150,ML,,184,128.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,636,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,100,ML,,299,209.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-95,NDC,facility,both,140,ML,,555,388.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 61 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1315-35,NDC,facility,both,23,ML,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IOPAMIDOL 76 % IV SOLN,61408,CDM,255,RC,Q9967,HCPCS,0270-1316-35,NDC,facility,both,75,ML,PLAD,254,177.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier PL: Progressive addition lenses | Modifier AD: Medical supervision by a physician: more than four concurrent anesthesia procedures
HC MR ANGIO HEAD W/O DYE,61500001,CDM,615,RC,70544,HCPCS,,,facility,both,,,,1483,1038.1,,,,,,,,,,,,,Gross Charge Type: Central
HC MR ANGIO HEAD W/DYE,61500002,CDM,615,RC,70545,HCPCS,,,facility,both,,,,1799,1259.3,,,,,,,,,,,,,Gross Charge Type: Central
HC MR ANGIO HEAD W/WO DYE,61500003,CDM,615,RC,70546,HCPCS,,,facility,both,,,,2272,1590.4,,,,,,,,,,,,,Gross Charge Type: Central
HC MRA NECK W/O DYE,61500004,CDM,615,RC,70547,HCPCS,,,facility,both,,,,1589,1112.3,,,,,,,,,,,,,Gross Charge Type: Central
HC MRA NECK W/DYE,61500005,CDM,615,RC,70548,HCPCS,,,facility,both,,,,1853,1297.1,,,,,,,,,,,,,Gross Charge Type: Central
HC MRA NECK W/WO DYE,61500006,CDM,615,RC,70549,HCPCS,,,facility,both,,,,2331,1631.7,,,,,,,,,,,,,Gross Charge Type: Central
HC DRESSING FOAM SILICONE SMALL/MED,62300271,CDM,623,RC,A6212,HCPCS,,,facility,both,,,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Central
HC DRESSING FOAM SILICONE 7 X 7,62300272,CDM,623,RC,A6213,HCPCS,,,facility,both,,,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Central
HC BIATAIN ALGINATE AG 4 X 4 (COLOPLAST),62300273,CDM,623,RC,A6196,HCPCS,,,facility,both,,,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Central
HC BIATAIN SOFT-HOLD 4 X 4 (COLOPLAST),62300274,CDM,623,RC,A6209,HCPCS,,,facility,both,,,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Central
HC DRAWTEX 4 X 4,62300275,CDM,623,RC,A6196,HCPCS,,,facility,both,,,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Central
HC CUTIMED SORBACT WCL 4 X 5 (BSN),62300276,CDM,623,RC,A6207,HCPCS,,,facility,both,,,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Central
HC CUTIMED SORBACT HYDROACTIVE B 2.8 X 3.3 (BSN),62300277,CDM,623,RC,A6242,HCPCS,,,facility,both,,,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Central
HC CUTIMED SORBACT RIBBON .8 X 19.7 (BSN),62300278,CDM,623,RC,A6242,HCPCS,,,facility,both,,,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Central
"HC DRESSING AG AQUACEL 3.5""X10""",62300295,CDM,623,RC,62300295,HCPCS,,,facility,both,,,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Central
HC EDEMAWEAR SMALL,62300475,CDM,623,RC,A6457,HCPCS,,,facility,both,,,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Central
HC EDEMAWEAR MEDIUM,62300476,CDM,623,RC,A6457,HCPCS,,,facility,both,,,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Central
HC EDEMAWEAR LARGE,62300477,CDM,623,RC,A6457,HCPCS,,,facility,both,,,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PLUROGEL,62300488,CDM,623,RC,A6248,HCPCS,,,facility,both,,,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Central
HC SILICONE TRANSPARENT FILM 4X5IN,62300547,CDM,623,RC,A6258,HCPCS,,,facility,both,,,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Central
HC SILICONE TRANSPARENT FILM 2X3IN,62300548,CDM,623,RC,A6257,HCPCS,,,facility,both,,,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Central
HC MEPILEX BORDER FLEX 3 X 3 IN,62300718,CDM,623,RC,62300718,HCPCS,,,facility,both,,,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Central
HC MEPILEX BORDER FLEX 6 X 6 IN,62300719,CDM,623,RC,A6213,HCPCS,,,facility,both,,,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Central
HC MEPILEX BORDER FLEX OVAL 5.1 X 6.3 IN,62300720,CDM,623,RC,62300720,HCPCS,,,facility,both,,,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Central
HC MEPILEX BORDER FLEX OVAL 6 X 7.5 IN,62300721,CDM,623,RC,A6213,HCPCS,,,facility,both,,,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Central
HC MEPILEX BORDER FLEX LITE 1.6 X 2 IN,62300722,CDM,623,RC,62300722,HCPCS,,,facility,both,,,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Central
HC MEPILEX BORDER FLEX LITE 3 X 3 IN,62300723,CDM,623,RC,62300723,HCPCS,,,facility,both,,,,10,7,,,,,,,,,,,,,Gross Charge Type: Central
HC MEPILEX BORDER HEEL 8.7 X 9.1 IN,62300724,CDM,623,RC,62300724,HCPCS,,,facility,both,,,,60,42,,,,,,,,,,,,,Gross Charge Type: Central
HC MEPILEX 4 X 4 IN,62300725,CDM,623,RC,62300725,HCPCS,,,facility,both,,,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Central
HC MEPILEX 4 X 8 IN,62300726,CDM,623,RC,62300726,HCPCS,,,facility,both,,,,30,21,,,,,,,,,,,,,Gross Charge Type: Central
HC MEPILEX LITE 2.4 X 3.4 IN,62300727,CDM,623,RC,62300727,HCPCS,,,facility,both,,,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Central
HC MEPITEL BOTH SIDES 2 X 3 IN,62300728,CDM,623,RC,A6206,HCPCS,,,facility,both,,,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Central
HC MEPITEL BOTH SIDES 4 X 7 IN,62300729,CDM,623,RC,62300729,HCPCS,,,facility,both,,,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Central
HC MEPITEL BOTH SIDES 8 X 12 IN,62300730,CDM,623,RC,A6208,HCPCS,,,facility,both,,,,119,83.3,,,,,,,,,,,,,Gross Charge Type: Central
HC MEPILEX TRANSFER 6 X 8 IN,62300731,CDM,623,RC,62300731,HCPCS,,,facility,both,,,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Central
HC MEPILEX TRANSFER AG 6 X 8 IN,62300732,CDM,623,RC,62300732,HCPCS,,,facility,both,,,,133,93.1,,,,,,,,,,,,,Gross Charge Type: Central
HC EXUFIBER PEDS/NICU 4 X 4.8 IN,62300733,CDM,623,RC,62300733,HCPCS,,,facility,both,,,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Central
HC MELGISORB PLUS CALCIUM ALGINATE 2 X 2 IN,62300734,CDM,623,RC,62300734,HCPCS,,,facility,both,,,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Central
HC MELGISORB PLUS CALCIUM ALGINATE 4 X 4 IN,62300735,CDM,623,RC,62300735,HCPCS,,,facility,both,,,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Central
HC MELGISORB PLUS CALCIUM ALGINATE 1.25 X 17.7 IN,62300736,CDM,623,RC,62300736,HCPCS,,,facility,both,,,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Central
HC MELGISORB AG 2 X 2 IN,62300737,CDM,623,RC,62300737,HCPCS,,,facility,both,,,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Central
HC MELGISORB AG 4 X 4 IN,62300738,CDM,623,RC,62300738,HCPCS,,,facility,both,,,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Central
HC MELGISORB AG 1.2 X 18 IN,62300739,CDM,623,RC,62300739,HCPCS,,,facility,both,,,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Central
HC MEXTRA SUPERABSORBENT 5 X 7 IN,62300740,CDM,623,RC,62300740,HCPCS,,,facility,both,,,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Central
HC MEXTRA SUPERABSORBENT 7 X 9 IN,62300741,CDM,623,RC,62300741,HCPCS,,,facility,both,,,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Central
HC MEXTRA SUPERABSORBENT 9 X 11 IN,62300742,CDM,623,RC,A6198,HCPCS,,,facility,both,,,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Central
HC MEPORE PRO 3.6 X 4 IN,62300743,CDM,623,RC,62300743,HCPCS,,,facility,both,,,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Central
HC MEPORE ALL SIZES,62300744,CDM,623,RC,62300744,HCPCS,,,facility,both,,,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Central
HC MESALT 2 X 2 IN FOLDED / 4 X 4 IN,62300745,CDM,623,RC,62300745,HCPCS,,,facility,both,,,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Central
"HC DRESSING TRANSPARENT  MEPITEL NON-ADHERENT 3"" X 4""",62300750,CDM,623,RC,62300750,HCPCS,,,facility,both,,,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Central
HC DRESSING WOUND MEPITEL 4IN X 7IN 1- SIDED MESH TRANSPARENT,62300751,CDM,623,RC,62300751,HCPCS,,,facility,both,,,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Central
HC TAPE MEFIX ADHESIVE ROLL 4IN X 11YD,62300752,CDM,623,RC,62300752,HCPCS,,,facility,both,,,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Central
HC RESEARCH ONLY STEMI IMPELLA ALC PUMP SET 2.5 / 3.4 / 3.5,62400001,CDM,624,RC,62400001,HCPCS,,,facility,both,,,,55000,38500,,,,,,,,,,,,,Gross Charge Type: Central
HC RESEARCH ONLY BEAT HF STUDY IMPLANT/REPLACE CAROTID SINUS BAROREFLEX ACTIVATION DEVICE PULSE GEN,62400007,CDM,361,RC,0268T,HCPCS,,,facility,both,,,,15372,10760.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO RESEARCH ONLY BEAT HF STUDY IMPLANT/REPLACE CAROTID SINUS BAROREFLEX ACTIVATION DEVICE PULSE GEN,62400008,CDM,960,RC,0268T,HCPCS,,,facility,both,,,,850,595,,,,,,,,,,,,,Gross Charge Type: Central
HC RESEARCH ONLY PROMISE III LIMFLOW STENT GRAFT SYSTEM,62400009,CDM,624,RC,62400009,HCPCS,,,facility,both,,,,25000,17500,,,,,,,,,,,,,Gross Charge Type: Central
HC NC NATALIZUMAB INJ 1 MG,63600061,CDM,636,RC,J2323,HCPCS,,,facility,both,,,GZ,0.01,0.007,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier GZ: Item or service expected to be denied as not reasonable and necessary
HC NC EPO ALFA NON ESRD PER 1000,63600062,CDM,636,RC,J0885,HCPCS,,,facility,both,,,GZ,0.01,0.007,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier GZ: Item or service expected to be denied as not reasonable and necessary
HC NC INFLIXIMAB INJ 10MG IVPB,63600063,CDM,636,RC,J1745,HCPCS,,,facility,both,,,GZ,0.01,0.007,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier GZ: Item or service expected to be denied as not reasonable and necessary
HC NC AGALSIDASE BETA PER 1MG,63600064,CDM,636,RC,J0180,HCPCS,,,facility,both,,,GZ,0.01,0.007,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier GZ: Item or service expected to be denied as not reasonable and necessary
HC NC ALDESLEUKIN 22 MIL UNIT SOLR 2ND DOSE,63600065,CDM,636,RC,J9015,HCPCS,,,facility,both,,,GZ,0.01,0.007,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier GZ: Item or service expected to be denied as not reasonable and necessary
HC APLIGRAF APPLIED PER SQ CM (TOTAL 44 SQ CM),63600068,CDM,636,RC,Q4101,HCPCS,,,facility,both,,,JC,132,92.4,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier JC: Skin substitute used as a graft
HC NC GAMMUNEX IVIG,63600078,CDM,636,RC,J1561,HCPCS,,,facility,both,,,GZ,0.01,0.007,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier GZ: Item or service expected to be denied as not reasonable and necessary
HC NC XOLAIR,63600080,CDM,636,RC,J2357,HCPCS,,,facility,both,,,GZ,0.01,0.007,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier GZ: Item or service expected to be denied as not reasonable and necessary
HC NC PRIVIGEN IVIG 500 MG,63600085,CDM,636,RC,J1459,HCPCS,,,facility,both,,,GZ,0.01,0.007,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier GZ: Item or service expected to be denied as not reasonable and necessary
HC APLIGRAF WASTED PER SQ CM (TOTAL 44 SQ CM),63600103,CDM,636,RC,Q4101,HCPCS,,,facility,both,,,JW,33,23.1,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
HC NC INJECT IMMUNE GLOBULIN INTRA LYOPHILIZED (POWDER) NOS 500 MG,63600104,CDM,636,RC,J1566,HCPCS,,,facility,both,,,GZ,0.01,0.007,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier GZ: Item or service expected to be denied as not reasonable and necessary
HC NC ENTYVIO,63600109,CDM,636,RC,J3380,HCPCS,,,facility,both,,,,0.01,0.007,,,,,,,,,,,,,Gross Charge Type: Central
HC NC NUCALA (MEPOLIZUMAB) 1 MG,63600121,CDM,636,RC,J2182,HCPCS,,,facility,both,,,,0.01,0.007,,,,,,,,,,,,,Gross Charge Type: Central
HC NC BELATACEPT 250 MG SOLR 1 EACH VIAL,63600128,CDM,636,RC,J0485,HCPCS,,,facility,both,,,,0.01,0.007,,,,,,,,,,,,,Gross Charge Type: Central
HC NC INFLIXIMAB-ABDA 100 MG SOLR 1 EACH VIAL,63600130,CDM,636,RC,Q5104,HCPCS,,,facility,both,,,,0.01,0.007,,,,,,,,,,,,,Gross Charge Type: Central
HC NC NALTREXONE MICROSPHERES 380MG SERR,63600131,CDM,636,RC,J2315,HCPCS,,,facility,both,,,,0.01,0.007,,,,,,,,,,,,,Gross Charge Type: Central
HC NC LUPRON 7.5 MG,63600132,CDM,636,RC,J9217,HCPCS,,,facility,both,,,,0.01,0.007,,,,,,,,,,,,,Gross Charge Type: Central
HC NC LUPRON 3.75MG,63600133,CDM,636,RC,J1950,HCPCS,,,facility,both,,,,0.01,0.007,,,,,,,,,,,,,Gross Charge Type: Central
HC NC RAVULIZUMAB-CWVZ 10 MG,63600135,CDM,636,RC,J1303,HCPCS,,,facility,both,,,,0.01,0.007,,,,,,,,,,,,,Gross Charge Type: Central
HC NC RITUXIMAB-ABBS (TRUXIMA),63600138,CDM,636,RC,Q5115,HCPCS,,,facility,both,,,,0.01,0.007,,,,,,,,,,,,,Gross Charge Type: Central
HC HOSPICE SERVICE ROUTINE HOME CARE,65100001,CDM,651,RC,65100001,HCPCS,,,facility,both,,,,258,180.6,,,,,,,,,,,,,Gross Charge Type: Central
HC HOSPICE SERVICE INPATIENT RESPITE CARE,65500001,CDM,655,RC,65500001,HCPCS,,,facility,both,,,,599,419.3,,,,,,,,,,,,,Gross Charge Type: Central
HC HOSPICE SERVICE GENERAL INPATIENT CARE (NONRESPITE),65600001,CDM,656,RC,65600001,HCPCS,,,facility,both,,,,1351,945.7,,,,,,,,,,,,,Gross Charge Type: Central
JAPANESE ENCEPHALITIS VACC(PF) 6 MCG/0.5 ML IM SYRG,65656,CDM,90738,HCPCS,42515-002-01,NDC,,,facility,both,1,ML,,862,603.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC PRO IP/OBS CONSULT NEW/ESTABLISHED LOW LEVEL 45 MIN,65700002,CDM,657,RC,99253,HCPCS,,,facility,both,,,,316,221.2,,,,,,,,,,,,,Gross Charge Type: Central
FLU VACCINE TS 2025-26 65 YR UP (PF) 180 MCG/0.5 ML IM SYRG,66275,CDM,90662,HCPCS,49281-125-65,NDC,,,facility,both,1,ML,,403,282.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLU VACCINE TS 2024-25 65 YR UP (PF) 180 MCG/0.5 ML IM SYRG,66275,CDM,90662,HCPCS,49281-124-88,NDC,,,facility,both,1,ML,,373,261.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLU VACCINE TS 2025-26 65 YR UP (PF) 180 MCG/0.5 ML IM SYRG,66275,CDM,90662,HCPCS,49281-125-88,NDC,,,facility,both,1,ML,,403,282.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLU VACCINE TS 2024-25 65 YR UP (PF) 180 MCG/0.5 ML IM SYRG,66275,CDM,90662,HCPCS,49281-124-65,NDC,,,facility,both,1,ML,,373,261.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLU VACCINE TS 2025-26 65 YR UP (PF) 180 MCG/0.5 ML IM SYRG,66275,CDM,90662,HCPCS,49281-125-88,NDC,,,facility,both,1,ML,,372,260.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLU VACCINE TS 2025-26 65 YR UP (PF) 180 MCG/0.5 ML IM SYRG,66275,CDM,90662,HCPCS,49281-125-65,NDC,,,facility,both,1,ML,,372,260.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANTITHROMBIN III IV (PHS ERX MERGE),66385,CDM,250,RC,J7197,HCPCS,13533-606-12,NDC,facility,both,1,EA,,552,386.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 60 INT'L UNITS
COAGULATION FACTOR VIIA RECOMB (PHS ERX MERGE),66385,CDM,250,RC,J7189,HCPCS,0169-7205-01,NDC,facility,both,1,EA,,55200,38640,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 10000 MCG
ANTITHROMBIN III IV (PHS ERX MERGE),66385,CDM,250,RC,J7197,HCPCS,13533-605-21,NDC,facility,both,1,EA,,21436,15005.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 2000 INT'L UNITS
ANTITHROMBIN III IV (PHS ERX MERGE),66385,CDM,250,RC,J7197,HCPCS,13533-605-21,NDC,facility,both,1,EA,,7128,4989.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 665 INT'L UNITS
ANTITHROMBIN III IV (PHS ERX MERGE),66385,CDM,250,RC,J7197,HCPCS,13533-606-12,NDC,facility,both,1,EA,JW,1600,1120,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 400 INT'L UNITS | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
COAGULATION FACTOR VIIA RECOMB (PHS ERX MERGE),66385,CDM,250,RC,J7189,HCPCS,0169-7202-01,NDC,facility,both,1,EA,,22080,15456,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 4000 MCG
COAGULATION FACTOR VIIA RECOMB (PHS ERX MERGE),66385,CDM,250,RC,J7189,HCPCS,0169-7202-01,NDC,facility,both,1,EA,,44160,30912,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 8000 MCG
ANTITHROMBIN III IV (PHS ERX MERGE),66385,CDM,250,RC,J7197,HCPCS,13533-605-21,NDC,facility,both,1,EA,,1072,750.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 100 INT'L UNITS
ANTITHROMBIN III IV (PHS ERX MERGE),66385,CDM,250,RC,J7197,HCPCS,13533-605-21,NDC,facility,both,1,EA,,644,450.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 60 INT'L UNITS
ANTITHROMBIN III IV (PHS ERX MERGE),66385,CDM,250,RC,J7197,HCPCS,13533-606-12,NDC,facility,both,1,EA,JW,800,560,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 200 INT'L UNITS | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ANTITHROMBIN III IV (PHS ERX MERGE),66385,CDM,250,RC,J7197,HCPCS,13533-605-21,NDC,facility,both,1,EA,,16077,11253.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1500 INT'L UNITS
ANTITHROMBIN III IV (PHS ERX MERGE),66385,CDM,250,RC,J7197,HCPCS,13533-605-21,NDC,facility,both,1,EA,,2144,1500.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 200 INT'L UNITS
ANTITHROMBIN III IV (PHS ERX MERGE),66385,CDM,250,RC,J7197,HCPCS,13533-605-21,NDC,facility,both,1,EA,,3645,2551.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 340 INT'L UNITS
COAGULATION FACTOR VIIA RECOMB (PHS ERX MERGE),66385,CDM,250,RC,J7189,HCPCS,0169-7211-11,NDC,facility,both,1,EA,,12374,8661.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 2000 MCG
HUMATE-P: VWF CONCENTRATE (MERGE RECORD),66385,CDM,250,RC,J7187,HCPCS,63833-616-02,NDC,facility,both,500,UN,,1610,1127,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COAGULATION FACTOR VIIA RECOMB (PHS ERX MERGE),66385,CDM,J7189,HCPCS,0169-7010-01,NDC,,,facility,both,1,EA,,35696,24987.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 8000 MCG
ANTITHROMBIN III IV (PHS ERX MERGE),66385,CDM,250,RC,J7197,HCPCS,13533-603-20,NDC,facility,both,1,EA,,10718,7502.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1000 INT'L UNITS
COAGULATION FACTOR VIIA RECOMB (PHS ERX MERGE),66385,CDM,636,RC,J7189,HCPCS,0169-7212-11,NDC,facility,both,1,EA,,12374,8661.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 2000 MCG
ANTITHROMBIN III IV (PHS ERX MERGE),66385,CDM,250,RC,J7197,HCPCS,13533-605-21,NDC,facility,both,1,EA,,3580,2506,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 334 INT'L UNITS
COAGULATION FACTOR VIIA RECOMB (PHS ERX MERGE),66385,CDM,250,RC,J7189,HCPCS,0169-7215-11,NDC,facility,both,1,EA,,30935,21654.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 5000 MCG
ANTITHROMBIN III IV (PHS ERX MERGE),66385,CDM,250,RC,J7197,HCPCS,13533-606-12,NDC,facility,both,1,EA,JW,1200,840,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 300 INT'L UNITS | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
HUMATE-P: VWF CONCENTRATE (MERGE RECORD),66385,CDM,250,RC,J7187,HCPCS,63833-615-02,NDC,facility,both,1500,UN,,6195,4336.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COAGULATION FACTOR VIIA RECOMB (PHS ERX MERGE),66385,CDM,250,RC,J7189,HCPCS,0169-7201-01,NDC,facility,both,1,EA,,11040,7728,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 2000 MCG
COAGULATION FACTOR VIIA RECOMB (PHS ERX MERGE),66385,CDM,250,RC,J7189,HCPCS,0169-7205-01,NDC,facility,both,1,EA,,27600,19320,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 5000 MCG
ANTITHROMBIN III IV (PHS ERX MERGE),66385,CDM,250,RC,J7197,HCPCS,13533-606-12,NDC,facility,both,1,EA,,46000,32200,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 5000 INT'L UNITS
HUMATE-P: VWF CONCENTRATE (MERGE RECORD),66385,CDM,250,RC,J7187,HCPCS,63833-626-01,NDC,facility,both,500,UN,,1610,1127,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANTITHROMBIN III IV (PHS ERX MERGE),66385,CDM,250,RC,J7197,HCPCS,13533-605-21,NDC,facility,both,1,EA,JW,1864,1304.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 400 INT'L UNITS | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
HUMATE-P: VWF CONCENTRATE (MERGE RECORD),66385,CDM,250,RC,J7187,HCPCS,63833-627-01,NDC,facility,both,1000,UN,,3197,2237.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COAGULATION FACTOR VIIA RECOMB (PHS ERX MERGE),66385,CDM,250,RC,J7189,HCPCS,0169-7212-11,NDC,facility,both,1,EA,,49496,34647.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 8000 MCG
COAGULATION FACTOR VIIA RECOMB (PHS ERX MERGE),66385,CDM,250,RC,J7189,HCPCS,0169-7201-01,NDC,facility,both,1,EA,,5520,3864,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1000 MCG
COAGULATION FACTOR VIIA RECOMB (PHS ERX MERGE),66385,CDM,250,RC,J7189,HCPCS,0169-7202-01,NDC,facility,both,1,EA,,11040,7728,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 2000 MCG
ANTITHROMBIN III IV (PHS ERX MERGE),66385,CDM,250,RC,J7197,HCPCS,13533-605-21,NDC,facility,both,1,EA,,1930,1351,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 180 INT'L UNITS
COAGULATION FACTOR VIIA RECOMB (PHS ERX MERGE),66385,CDM,250,RC,J7189,HCPCS,0169-7201-01,NDC,facility,both,1,EA,,44160,30912,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 8000 MCG
ANTITHROMBIN III IV (PHS ERX MERGE),66385,CDM,250,RC,J7197,HCPCS,13533-605-21,NDC,facility,both,1,EA,JW,932,652.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 200 INT'L UNITS | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ANTITHROMBIN III IV (PHS ERX MERGE),66385,CDM,250,RC,J7197,HCPCS,13533-605-21,NDC,facility,both,1,EA,,1715,1200.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 160 INT'L UNITS
ANTITHROMBIN III IV (PHS ERX MERGE),66385,CDM,250,RC,J7197,HCPCS,13533-605-21,NDC,facility,both,1,EA,JW,1398,978.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 300 INT'L UNITS | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ANTITHROMBIN III IV (PHS ERX MERGE),66385,CDM,250,RC,J7197,HCPCS,13533-606-12,NDC,facility,both,1,EA,JW,1880,1316,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 470 INT'L UNITS | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ANTITHROMBIN III IV (PHS ERX MERGE),66385,CDM,250,RC,J7197,HCPCS,13533-606-12,NDC,facility,both,1,EA,,1242,869.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 135 INT'L UNITS
ANTITHROMBIN III IV (PHS ERX MERGE),66385,CDM,250,RC,J7197,HCPCS,13533-605-21,NDC,facility,both,1,EA,,26795,18756.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 2500 INT'L UNITS
COAGULATION FACTOR VIIA RECOMB (PHS ERX MERGE),66385,CDM,250,RC,J7189,HCPCS,0169-7201-01,NDC,facility,both,1,EA,,5520,3864,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1000 MCG
COAGULATION FACTOR VIIA RECOMB (PHS ERX MERGE),66385,CDM,J7189,HCPCS,0169-7212-11,NDC,,,facility,both,1,EA,,12374,8661.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 2000 MCG
ANTITHROMBIN III IV (PHS ERX MERGE),66385,CDM,250,RC,J7197,HCPCS,13533-606-12,NDC,facility,both,1,EA,JW,1760,1232,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 440 INT'L UNITS | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
COAGULATION FACTOR VIIA RECOMB (PHS ERX MERGE),66385,CDM,250,RC,J7189,HCPCS,0169-7201-01,NDC,facility,both,1,EA,,16560,11592,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 3000 MCG
ANTITHROMBIN III IV (PHS ERX MERGE),66385,CDM,250,RC,J7197,HCPCS,13533-603-20,NDC,facility,both,1,EA,,16077,11253.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1500 INT'L UNITS
ANTITHROMBIN III IV (PHS ERX MERGE),66385,CDM,250,RC,J7197,HCPCS,13533-605-21,NDC,facility,both,1,EA,,3913,2739.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 365 INT'L UNITS
ANTITHROMBIN III IV (PHS ERX MERGE),66385,CDM,250,RC,J7197,HCPCS,13533-605-21,NDC,facility,both,1,EA,,6431,4501.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 600 INT'L UNITS
ANTITHROMBIN III IV (PHS ERX MERGE),66385,CDM,250,RC,J7197,HCPCS,13533-606-12,NDC,facility,both,1,EA,,7360,5152,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 800 INT'L UNITS
ANTITHROMBIN III IV (PHS ERX MERGE),66385,CDM,250,RC,J7197,HCPCS,13533-605-21,NDC,facility,both,1,EA,JW,1678,1174.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 360 INT'L UNITS | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
COAGULATION FACTOR VIIA RECOMB (PHS ERX MERGE),66385,CDM,J7189,HCPCS,0169-7202-01,NDC,,,facility,both,1,EA,,11040,7728,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 2000 MCG
ANTITHROMBIN III IV (PHS ERX MERGE),66385,CDM,250,RC,J7197,HCPCS,13533-605-21,NDC,facility,both,1,EA,,53590,37513,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 5000 INT'L UNITS
COAGULATION FACTOR VIIA RECOMB (PHS ERX MERGE),66385,CDM,250,RC,J7189,HCPCS,0169-7215-11,NDC,facility,both,1,EA,,61870,43309,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 7000 MCG
COAGULATION FACTOR VIIA RECOMB (PHS ERX MERGE),66385,CDM,J7189,HCPCS,0169-7212-11,NDC,,,facility,both,1,EA,,49496,34647.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 8000 MCG
ANTITHROMBIN III IV (PHS ERX MERGE),66385,CDM,250,RC,J7197,HCPCS,13533-605-21,NDC,facility,both,1,EA,JZ,5359,3751.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 500 INT'L UNITS | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ANTITHROMBIN III IV (PHS ERX MERGE),66385,CDM,250,RC,J7197,HCPCS,13533-605-21,NDC,facility,both,1,EA,,4491,3143.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 419 INT'L UNITS
ANTITHROMBIN III IV (PHS ERX MERGE),66385,CDM,250,RC,J7197,HCPCS,13533-606-12,NDC,facility,both,1,EA,,36800,25760,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 4000 INT'L UNITS
COAGULATION FACTOR VIIA RECOMB (PHS ERX MERGE),66385,CDM,250,RC,J7189,HCPCS,0169-7010-01,NDC,facility,both,1,EA,,35696,24987.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 8000 MCG
ANTITHROMBIN III IV (PHS ERX MERGE),66385,CDM,250,RC,J7197,HCPCS,13533-606-12,NDC,facility,both,1,EA,,13800,9660,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1500 INT'L UNITS
ANTITHROMBIN III IV (PHS ERX MERGE),66385,CDM,250,RC,J7197,HCPCS,13533-606-12,NDC,facility,both,1,EA,,27600,19320,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 3000 INT'L UNITS
ANTITHROMBIN III IV (PHS ERX MERGE),66385,CDM,250,RC,J7197,HCPCS,13533-605-21,NDC,facility,both,1,EA,JW,1585,1109.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 340 INT'L UNITS | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ANTITHROMBIN III IV (PHS ERX MERGE),66385,CDM,250,RC,J7197,HCPCS,13533-605-21,NDC,facility,both,1,EA,,3259,2281.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 304 INT'L UNITS
COAGULATION FACTOR VIIA RECOMB (PHS ERX MERGE),66385,CDM,250,RC,J7189,HCPCS,0169-7215-11,NDC,facility,both,1,EA,,61870,43309,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 8000 MCG
ADVATE: FACTOR VIII CONCENTRATE (MERGE RECORD),66385,CDM,250,RC,J7190,HCPCS,0944-3053-03,NDC,facility,both,3000,UN,,15732,11012.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COAGULATION FACTOR VIIA RECOMB (PHS ERX MERGE),66385,CDM,250,RC,J7189,HCPCS,0169-7010-01,NDC,facility,both,1,EA,,8924,6246.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 2000 MCG
"ANTIHEMOPHILIC FACTOR-VWF 1,000-2,400 UNIT IV KIT",66385,CDM,250,RC,J7187,HCPCS,63833-617-02,NDC,facility,both,1000,UN,,3220,2254,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COAGULATION FACTOR VIIA RECOMB (PHS ERX MERGE),66385,CDM,250,RC,J7189,HCPCS,0169-7202-01,NDC,facility,both,1,EA,,11040,7728,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 2000 MCG
COAGULATION FACTOR VIIA RECOMB (PHS ERX MERGE),66385,CDM,250,RC,J7189,HCPCS,0169-7201-01,NDC,facility,both,1,EA,,11040,7728,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 2000 MCG
ANTITHROMBIN III IV (PHS ERX MERGE),66385,CDM,250,RC,J7197,HCPCS,13533-605-21,NDC,facility,both,1,EA,,12862,9003.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1200 INT'L UNITS
ANTITHROMBIN III IV (PHS ERX MERGE),66385,CDM,250,RC,J7197,HCPCS,13533-606-12,NDC,facility,both,1,EA,,920,644,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 100 INT'L UNITS
COAGULATION FACTOR VIIA RECOMB (PHS ERX MERGE),66385,CDM,J7189,HCPCS,0169-7211-11,NDC,,,facility,both,1,EA,,12374,8661.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 2000 MCG
ANTITHROMBIN III IV (PHS ERX MERGE),66385,CDM,250,RC,J7197,HCPCS,13533-606-12,NDC,facility,both,1,EA,,9200,6440,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1000 INT'L UNITS
COAGULATION FACTOR VIIA RECOMB (PHS ERX MERGE),66385,CDM,250,RC,J7189,HCPCS,0169-7215-11,NDC,facility,both,1,EA,,61870,43309,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 10000 MCG
ANTITHROMBIN III IV (PHS ERX MERGE),66385,CDM,250,RC,J7197,HCPCS,13533-605-21,NDC,facility,both,1,EA,,42872,30010.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 4000 INT'L UNITS
COAGULATION FACTOR VIIA RECOMB (PHS ERX MERGE),66385,CDM,636,RC,J7189,HCPCS,0169-7202-01,NDC,facility,both,1,EA,,11040,7728,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 2000 MCG
ANTITHROMBIN III IV (PHS ERX MERGE),66385,CDM,250,RC,J7197,HCPCS,13533-606-12,NDC,facility,both,1,EA,JW,1460,1022,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 365 INT'L UNITS | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
ANTITHROMBIN III IV (PHS ERX MERGE),66385,CDM,250,RC,J7197,HCPCS,13533-606-12,NDC,facility,both,1,EA,,4600,3220,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 500 INT'L UNITS
COAGULATION FACTOR VIIA RECOMB (PHS ERX MERGE),66385,CDM,250,RC,J7189,HCPCS,0169-7201-01,NDC,facility,both,1,EA,,22080,15456,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 4000 MCG
ANTITHROMBIN III IV (PHS ERX MERGE),66385,CDM,250,RC,J7197,HCPCS,13533-605-21,NDC,facility,both,1,EA,JW,1165,815.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 250 INT'L UNITS | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
HUMATE-P: VWF CONCENTRATE (MERGE RECORD),66385,CDM,636,RC,J7187,HCPCS,63833-626-01,NDC,facility,both,2303,UN,JZ,7416,5191.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ANTITHROMBIN III IV (PHS ERX MERGE),66385,CDM,250,RC,J7197,HCPCS,13533-605-21,NDC,facility,both,1,EA,,2659,1861.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 248 INT'L UNITS
ANTITHROMBIN III IV (PHS ERX MERGE),66385,CDM,250,RC,J7197,HCPCS,13533-605-21,NDC,facility,both,1,EA,,2841,1988.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 265 INT'L UNITS
ANTITHROMBIN III IV (PHS ERX MERGE),66385,CDM,250,RC,J7197,HCPCS,13533-606-12,NDC,facility,both,1,EA,,276,193.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 30 INT'L UNITS
ANTITHROMBIN III IV (PHS ERX MERGE),66385,CDM,250,RC,J7197,HCPCS,13533-606-12,NDC,facility,both,1,EA,,23000,16100,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 2500 INT'L UNITS
ANTITHROMBIN III IV (PHS ERX MERGE),66385,CDM,250,RC,J7197,HCPCS,13533-606-12,NDC,facility,both,1,EA,,1840,1288,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 200 INT'L UNITS
ANTITHROMBIN III IV (PHS ERX MERGE),66385,CDM,250,RC,J7197,HCPCS,13533-605-21,NDC,facility,both,1,EA,,2251,1575.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 210 INT'L UNITS
COAGULATION FACTOR VIIA RECOMB (PHS ERX MERGE),66385,CDM,250,RC,J7189,HCPCS,0169-7205-01,NDC,facility,both,1,EA,,55200,38640,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 8000 MCG
HUMATE-P: VWF CONCENTRATE (MERGE RECORD),66385,CDM,636,RC,J7187,HCPCS,63833-627-01,NDC,facility,both,1875,UN,JZ,5995,4196.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ANTITHROMBIN III IV (PHS ERX MERGE),66385,CDM,250,RC,J7197,HCPCS,13533-605-21,NDC,facility,both,1,EA,,15327,10728.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1430 INT'L UNITS
ANTITHROMBIN III IV (PHS ERX MERGE),66385,CDM,250,RC,J7197,HCPCS,13533-606-12,NDC,facility,both,1,EA,,32200,22540,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 3500 INT'L UNITS
ANTITHROMBIN III IV (PHS ERX MERGE),66385,CDM,250,RC,J7197,HCPCS,13533-605-21,NDC,facility,both,1,EA,,3355,2348.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 313 INT'L UNITS
ANTITHROMBIN III IV (PHS ERX MERGE),66385,CDM,250,RC,J7197,HCPCS,13533-605-21,NDC,facility,both,1,EA,,3216,2251.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 300 INT'L UNITS
COAGULATION FACTOR VIIA RECOMB (PHS ERX MERGE),66385,CDM,250,RC,J7189,HCPCS,0169-7212-11,NDC,facility,both,1,EA,,12374,8661.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 2000 MCG
ANTITHROMBIN III IV (PHS ERX MERGE),66385,CDM,250,RC,J7197,HCPCS,13533-605-21,NDC,facility,both,1,EA,,5359,3751.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 500 INT'L UNITS
"ANTIHEMOPHILIC FACTOR-VWF 1,000-2,400 UNIT IV KIT",66385,CDM,250,RC,J7187,HCPCS,63833-617-02,NDC,facility,both,1500,UN,,4830,3381,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HUMATE-P: VWF CONCENTRATE (MERGE RECORD),66385,CDM,250,RC,J7187,HCPCS,63833-626-01,NDC,facility,both,451,UN,,1453,1017.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANTITHROMBIN III IV (PHS ERX MERGE),66385,CDM,250,RC,J7197,HCPCS,13533-605-21,NDC,facility,both,1,EA,,1501,1050.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 140 INT'L UNITS
HUMATE-P: VWF CONCENTRATE (MERGE RECORD),66385,CDM,250,RC,J7187,HCPCS,63833-627-01,NDC,facility,both,500,UN,,1599,1119.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COAGULATION FACTOR VIIA RECOMB (PHS ERX MERGE),66385,CDM,250,RC,J7189,HCPCS,0169-7211-11,NDC,facility,both,1,EA,,6187,4330.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1000 MCG
ANTITHROMBIN III IV (PHS ERX MERGE),66385,CDM,250,RC,J7197,HCPCS,13533-605-21,NDC,facility,both,1,EA,,6120,4284,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 571 INT'L UNITS
HUMATE-P: VWF CONCENTRATE (MERGE RECORD),66385,CDM,636,RC,J7187,HCPCS,63833-626-01,NDC,facility,both,500,UN,JZ,1610,1127,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier JZ: Zero drug amount discarded/not administered to any patient
ANTITHROMBIN III IV (PHS ERX MERGE),66385,CDM,250,RC,J7197,HCPCS,13533-605-21,NDC,facility,both,1,EA,,10718,7502.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 1000 INT'L UNITS
ANTITHROMBIN III IV (PHS ERX MERGE),66385,CDM,250,RC,J7197,HCPCS,13533-605-21,NDC,facility,both,1,EA,,2680,1876,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 250 INT'L UNITS
HUMATE-P: VWF CONCENTRATE (MERGE RECORD),66385,CDM,250,RC,J7187,HCPCS,63833-627-01,NDC,facility,both,875,UN,,2798,1958.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANTITHROMBIN III IV (PHS ERX MERGE),66385,CDM,250,RC,J7197,HCPCS,13533-605-21,NDC,facility,both,1,EA,,3430,2401,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 320 INT'L UNITS
ANTITHROMBIN III IV (PHS ERX MERGE),66385,CDM,250,RC,J7197,HCPCS,13533-605-21,NDC,facility,both,1,EA,,4288,3001.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 400 INT'L UNITS
ANTITHROMBIN III IV (PHS ERX MERGE),66385,CDM,250,RC,J7197,HCPCS,13533-606-12,NDC,facility,both,1,EA,,18400,12880,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 2000 INT'L UNITS
HUMATE-P: VWF CONCENTRATE (MERGE RECORD),66385,CDM,250,RC,J7187,HCPCS,63833-616-02,NDC,facility,both,1000,UN,,3220,2254,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ANTITHROMBIN III IV (PHS ERX MERGE),66385,CDM,250,RC,J7197,HCPCS,13533-605-21,NDC,facility,both,1,EA,,32154,22507.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 3000 INT'L UNITS
ANTITHROMBIN III IV (PHS ERX MERGE),66385,CDM,250,RC,J7197,HCPCS,13533-605-21,NDC,facility,both,1,EA,JW,1096,767.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 235 INT'L UNITS | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient
COAGULATION FACTOR VIIA RECOMB (PHS ERX MERGE),66385,CDM,250,RC,J7189,HCPCS,0169-7212-11,NDC,facility,both,1,EA,,12374,8661.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy | NDC EA = 2000 MCG
HUMATE-P: VWF CONCENTRATE (MERGE RECORD),66385,CDM,250,RC,J7187,HCPCS,63833-616-02,NDC,facility,both,1500,UN,,4830,3381,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIPHTH,PERTUS(ACELL),TETANUS SYRG (INFANRIX) 25 LF UNIT-58MCG-10 LF/0.5ML IM SYRINGE",6640,CDM,90700,HCPCS,58160-810-43,NDC,,,facility,both,2,ML,,334,233.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIPHTH,PERTUS(ACELL),TETANUS SYRG (INFANRIX) 25 LF UNIT-58MCG-10 LF/0.5ML IM SYRINGE",6640,CDM,90700,HCPCS,58160-810-52,NDC,,,facility,both,2,ML,,343,240.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIPHTH,PERTUS(ACELL),TETANUS SYRG (INFANRIX) 25 LF UNIT-58MCG-10 LF/0.5ML IM SYRINGE",6640,CDM,90700,HCPCS,58160-810-43,NDC,,,facility,both,2,ML,,343,240.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIPHTH,PERTUS(ACELL),TETANUS SYRG (INFANRIX) 25 LF UNIT-58MCG-10 LF/0.5ML IM SYRINGE",6640,CDM,90700,HCPCS,58160-810-43,NDC,,,facility,both,1,ML,,334,233.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIPHTH,PERTUS(ACELL),TETANUS SYRG (INFANRIX) 25 LF UNIT-58MCG-10 LF/0.5ML IM SYRINGE",6640,CDM,90700,HCPCS,58160-810-43,NDC,,,facility,both,1,ML,,172,120.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIPH,PERTUS(ACEL),TET,POLIO(PF)(KINRIX) 25 LF-58 MCG-10 LF/0.5 ML IM SYRINGE",6640,CDM,90696,HCPCS,58160-812-43,NDC,,,facility,both,1,ML,,318,222.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIPHTH,PERTUS(ACELL),TETANUS SYRG (INFANRIX) 25 LF UNIT-58MCG-10 LF/0.5ML IM SYRINGE",6640,CDM,90700,HCPCS,58160-810-43,NDC,,,facility,both,1,ML,,343,240.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIPHTH,PERTUS(ACELL),TETANUS SYRG (INFANRIX) 25 LF UNIT-58MCG-10 LF/0.5ML IM SYRINGE",6640,CDM,90700,HCPCS,58160-810-52,NDC,,,facility,both,1,ML,,172,120.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MEASLES,MUMPS,RUBELLA VACC(PF) 10EXP3.4-4.2- 3.3CCID50/0.5ML SUBQ SUSR",6647,CDM,90707,HCPCS,58160-831-03,NDC,,,facility,both,1,EA,,410,287,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MEASLES,MUMPS&RUBELLA VACCIN(PF) 1,000-12,500 TCID50/0.5 ML SUB-Q SUSP",6647,CDM,90707,HCPCS,0006-4681-01,NDC,,,facility,both,1,EA,,387,270.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MEASLES,MUMPS&RUBELLA VACCIN(PF) 1,000-12,500 TCID50/0.5 ML SUB-Q SUSP",6647,CDM,90707,HCPCS,0006-4681-00,NDC,,,facility,both,1,EA,,410,287,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIPH,PERTUS(ACEL),TET,POLIO(PF)(KINRIX) 25 LF-58 MCG-10 LF/0.5 ML IM SYRINGE",6647,CDM,90710,HCPCS,0006-4171-01,NDC,,,facility,both,1,EA,,776,543.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MEASLES,MUMPS,RUBELLA VACC(PF) 10EXP3.4-4.2- 3.3CCID50/0.5ML SUBQ SUSR",6647,CDM,90707,HCPCS,58160-831-03,NDC,,,facility,both,1,EA,,398,278.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIPH,PERTUS(ACEL),TET,POLIO(PF)(KINRIX) 25 LF-58 MCG-10 LF/0.5 ML IM SYRINGE",6650,CDM,90710,HCPCS,0006-4171-01,NDC,,,facility,both,1,EA,,776,543.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"MEASLES,MUMPS,RUB,VARICEL (PF) 10EXP3-4.3-3-3.99TCID50/0.5ML SUB-Q",6650,CDM,90710,HCPCS,0006-4171-00,NDC,,,facility,both,1,EA,,776,543.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"DIPH,PERTUS(ACEL),TET,POLIO(PF)(KINRIX) 25 LF-58 MCG-10 LF/0.5 ML IM SYRINGE",6650,CDM,90710,HCPCS,0006-4171-01,NDC,,,facility,both,2,EA,,1552,1086.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLIOVIRUS VACCINE 40-8-32 UNIT/0.5 ML INJ SUSP,6653,CDM,90713,HCPCS,49281-860-10,NDC,,,facility,both,1,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLIOVIRUS VACCINE 40-8-32 UNIT/0.5 ML INJ SUSP,6653,CDM,90713,HCPCS,49281-860-78,NDC,,,facility,both,1,ML,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLIOVIRUS VACCINE 40-8-32 UNIT/0.5 ML INJ SUSP,6653,CDM,90713,HCPCS,49281-860-10,NDC,,,facility,both,1,ML,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POLIOVIRUS VACCINE 40-8-32 UNIT/0.5 ML INJ SUSP,6653,CDM,90713,HCPCS,49281-860-78,NDC,,,facility,both,1,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SUSP,6654,CDM,90714,HCPCS,49281-215-58,NDC,,,facility,both,1,ML,,214,149.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE,6654,CDM,90714,HCPCS,49281-215-10,NDC,,,facility,both,1,ML,,214,149.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE,6654,CDM,90714,HCPCS,14362-0111-3,NDC,,,facility,both,1,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE,6654,CDM,90714,HCPCS,49281-215-10,NDC,,,facility,both,1,ML,,236,165.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE,6654,CDM,90714,HCPCS,49281-215-88,NDC,,,facility,both,1,ML,,214,149.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SUSP,6654,CDM,90714,HCPCS,49281-215-58,NDC,,,facility,both,1,ML,,217,151.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SUSP,6654,CDM,90714,HCPCS,49281-215-58,NDC,,,facility,both,1,ML,,236,165.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SUSP,6654,CDM,90714,HCPCS,49281-215-58,NDC,,,facility,both,1,ML,,236,165.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE,6654,CDM,90714,HCPCS,13533-131-00,NDC,,,facility,both,1,ML,,165,115.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE,6654,CDM,90714,HCPCS,49281-215-10,NDC,,,facility,both,1,ML,,217,151.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE,6654,CDM,90714,HCPCS,49281-215-88,NDC,,,facility,both,1,ML,,236,165.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TETANUS AND DIPHTHERIA TOX (PF) 5 LF UNIT-2 LF UNIT/0.5 ML IM SYRINGE,6654,CDM,90714,HCPCS,49281-215-15,NDC,,,facility,both,1,ML,,236,165.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUB-Q SOLN",6655,CDM,90716,HCPCS,0006-4827-01,NDC,,,facility,both,1,EA,,465,325.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUB-Q SOLN",6655,CDM,90716,HCPCS,0006-4827-00,NDC,,,facility,both,1,EA,,465,325.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
YELLOW FEVER VACCINE (PF) 10 EXP4.74 UNIT/0.5 ML SUB-Q SUSP,6656,CDM,90717,HCPCS,49281-915-58,NDC,,,facility,both,1,EA,,1206,844.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PNEUMOCOCCAL 23-VALPS VACCINE 25 MCG/0.5 ML INJ MERGE (CAM USE ONLY),6667,CDM,90732,HCPCS,0006-4943-00,NDC,,,facility,both,1,ML,,506,354.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PNEUMOCOCCAL 23-VAL PS VACCINE 25 MCG/0.5 ML INJ SYRG,6667,CDM,90732,HCPCS,0006-4837-01,NDC,,,facility,both,1,ML,,506,354.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PNEUMOCOCCAL 23-VAL PS VACCINE 25 MCG/0.5 ML INJ SYRG,6667,CDM,90732,HCPCS,0006-4837-01,NDC,,,facility,both,1,ML,,506,354.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PNEUMOCOCCAL 23-VAL PS VACCINE 25 MCG/0.5 ML INJ SYRG,6667,CDM,90732,HCPCS,0006-4837-01,NDC,,,facility,both,1,ML,,506,354.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PNEUMOVAX 23 25 MCG/0.5 ML INJ SYRG,6667,CDM,90732,HCPCS,0006-4837-03,NDC,,,facility,both,1,ML,,506,354.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC MCARE ADMIN HEPATITIS B VACC,6673,CDM,90744,HCPCS,58160-820-43,NDC,,,facility,both,1,ML,,171,119.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML IM SYRINGE,6673,CDM,90744,HCPCS,58160-820-52,NDC,,,facility,both,1,ML,,171,119.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC MCARE ADMIN HEPATITIS B VACC,6673,CDM,90744,HCPCS,58160-820-43,NDC,,,facility,both,2,ML,,342,239.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPATITIS B VIRUS VACCINE (PF)  5 MCG/0.5 ML IM SYRG,6673,CDM,90744,HCPCS,0006-4093-01,NDC,,,facility,both,1,ML,,164,114.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC MCARE ADMIN HEPATITIS B VACC,6673,CDM,90744,HCPCS,58160-820-43,NDC,,,facility,both,1,ML,,342,239.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML IM SYRINGE,6673,CDM,90744,HCPCS,58160-820-52,NDC,,,facility,both,1,ML,,167,116.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC MCARE ADMIN HEPATITIS B VACC,6673,CDM,90744,HCPCS,58160-821-01,NDC,,,facility,both,2,ML,,367,256.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC MCARE ADMIN HEPATITIS B VACC,6673,CDM,90744,HCPCS,58160-820-43,NDC,,,facility,both,1,ML,,167,116.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC MCARE ADMIN HEPATITIS B VACC,6673,CDM,90744,HCPCS,58160-820-43,NDC,,,facility,both,2,ML,,333,233.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML IM SYRINGE,6673,CDM,90744,HCPCS,58160-820-52,NDC,,,facility,both,2,ML,,333,233.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPATITIS B VIRUS VACCINE (PF)  5 MCG/0.5 ML IM SYRG,6673,CDM,90744,HCPCS,0006-4093-01,NDC,,,facility,both,1,ML,,164,114.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC MCARE ADMIN HEPATITIS B VACC,6675,CDM,90746,HCPCS,58160-821-01,NDC,,,facility,both,1,ML,,367,256.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML IM SYRINGE,6675,CDM,90746,HCPCS,58160-821-43,NDC,,,facility,both,1,ML,,367,256.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML IM SYRINGE,6675,CDM,90746,HCPCS,58160-821-52,NDC,,,facility,both,1,ML,,367,256.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC MCARE ADMIN HEPATITIS B VACC,6675,CDM,90746,HCPCS,58160-821-01,NDC,,,facility,both,1,ML,,353,247.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML IM SYRINGE,6675,CDM,90746,HCPCS,58160-821-43,NDC,,,facility,both,1,ML,,353,247.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML IM SYRINGE,6675,CDM,90746,HCPCS,58160-821-52,NDC,,,facility,both,1,ML,,367,256.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML IM SYRINGE,6675,CDM,90746,HCPCS,58160-821-43,NDC,,,facility,both,1,ML,,367,256.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC MCARE ADMIN HEPATITIS B VACC,6675,CDM,90746,HCPCS,58160-821-01,NDC,,,facility,both,1,ML,,367,256.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML IM INJ MERGE (CAM USE ONLY),6675,CDM,90746,HCPCS,58160-821-11,NDC,,,facility,both,1,ML,,367,256.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC MCARE ADMIN HEPATITIS B VACC,6675,CDM,90744,HCPCS,58160-820-43,NDC,,,facility,both,1,ML,,333,233.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"ALDESLEUKIN 360,000 UNITS/ ML SOLUTION",66885,CDM,636,RC,J9015,HCPCS,65483-116-07,NDC,facility,both,1,EA,GZ,5121,3584.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy | The modified price is presented in the standard charge value. | Modifier GZ: Item or service expected to be denied as not reasonable and necessary
ZOLEDRONIC ACID 4 MG/5 ML IV SOLN,66997,CDM,J3489,HCPCS,55111-685-07,NDC,,,facility,both,4,ML,,382,267.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLEDRONIC ACID-MANNITOL-WATER 4 MG/100 ML IV PGBK,66997,CDM,J3489,HCPCS,25021-826-82,NDC,,,facility,both,4,ML,,778,544.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLEDRONIC ACID IN MANNITOL & WATER 5 MG/100 ML IV SOLN,66997,CDM,J3489,HCPCS,55111-688-52,NDC,,,facility,both,5,ML,,1062,743.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLEDRONIC ACID IN MANNITOL & WATER 5 MG/100 ML IV SOLN,66997,CDM,J3489,HCPCS,67457-619-10,NDC,,,facility,both,5,ML,,2311,1617.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLEDRONIC ACID IN MANNITOL & WATER 5 MG/100 ML IV SOLN,66997,CDM,J3489,HCPCS,25021-830-82,NDC,,,facility,both,5,ML,,1239,867.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLEDRONIC ACID 4 MG/5 ML IV SOLN,66997,CDM,J3489,HCPCS,54288-100-01,NDC,,,facility,both,4,ML,,193,135.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLEDRONIC ACID 4 MG/5 ML IV SOLN,66997,CDM,J3489,HCPCS,67457-390-54,NDC,,,facility,both,4,ML,,224,156.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLEDRONIC ACID 4 MG/5 ML IV SOLN,66997,CDM,J3489,HCPCS,55111-685-07,NDC,,,facility,both,3,ML,,287,200.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLEDRONIC ACID 4 MG/5 ML IV SOLN,66997,CDM,J3489,HCPCS,67457-390-54,NDC,,,facility,both,1,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLEDRONIC ACID 4 MG/5 ML IV SOLN,66997,CDM,J3489,HCPCS,0078-0387-25,NDC,,,facility,both,4,ML,,2547,1782.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLEDRONIC ACID 4 MG/5 ML IV SOLN,66997,CDM,J3489,HCPCS,55111-685-07,NDC,,,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLEDRONIC ACID 4 MG/5 ML IV SOLN,66997,CDM,J3489,HCPCS,54288-100-01,NDC,,,facility,both,3,ML,,166,116.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLEDRONIC ACID IN MANNITOL & WATER 5 MG/100 ML IV SOLN,66997,CDM,J3489,HCPCS,67457-619-10,NDC,,,facility,both,5,ML,,832,582.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ZOLEDRONIC ACID 4 MG/5 ML IV SOLN,66997,CDM,J3489,HCPCS,67457-390-54,NDC,,,facility,both,3,ML,,168,117.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CERTOLIZUMAB PEGOL 400 MG (200 MG X 2) SUBQ KIT,67227,CDM,J0717,HCPCS,50474-700-62,NDC,,,facility,both,400,EA,,6646,4652.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CERTOLIZUMAB PEGOL 400 MG/2 ML (200 MG/ML X 2) SUBQ SYKT,67227,CDM,J0717,HCPCS,50474-710-79,NDC,,,facility,both,200,EA,,3600,2520,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CERTOLIZUMAB PEGOL 400 MG (200 MG X 2) SUBQ KIT,67227,CDM,J0717,HCPCS,50474-700-62,NDC,,,facility,both,200,EA,,1445,1011.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CERTOLIZUMAB PEGOL 400 MG/2 ML (200 MG/ML X 2) SUBQ SYKT,67227,CDM,J0717,HCPCS,50474-710-79,NDC,,,facility,both,200,EA,,8280,5796,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CERTOLIZUMAB PEGOL 400 MG/2 ML (200 MG/ML X 2) SUBQ SYKT,67227,CDM,J0717,HCPCS,50474-710-79,NDC,,,facility,both,400,EA,,15785,11049.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CERTOLIZUMAB PEGOL 400 MG/2 ML (200 MG/ML X 2) SUBQ SYKT,67227,CDM,J0717,HCPCS,50474-710-79,NDC,,,facility,both,400,EA,,16559,11591.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CERTOLIZUMAB PEGOL 400 MG (200 MG X 2) SUBQ KIT,67227,CDM,J0717,HCPCS,50474-700-62,NDC,,,facility,both,200,EA,,3323,2326.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE HCL  2 % MM JELP,67372,CDM,J3490,HCPCS,76329-3013-5,NDC,,,facility,both,1,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC EXTENDED RECOVERY TIME EA 15 MIN,71000001,CDM,710,RC,71000001,HCPCS,,,facility,both,,,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Central
HC RECOVERY MIN CHARGE 1 HR,71000002,CDM,710,RC,71000002,HCPCS,,,facility,both,,,,2447,1712.9,,,,,,,,,,,,,Gross Charge Type: Central
HC RECOVERY ROOM 8.5,71000032,CDM,710,RC,71000032,HCPCS,,,facility,both,,,,4549,3184.3,,,,,,,,,,,,,Gross Charge Type: Central
HC RECOVERY ROOM 1ST HOUR EA 15 MIN,71000040,CDM,710,RC,71000040,HCPCS,,,facility,both,,,,635,444.5,,,,,,,,,,,,,Gross Charge Type: Central
HC RECOVERY ROOM EA 15 MIN,71000041,CDM,710,RC,71000041,HCPCS,,,facility,both,,,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Central
HC EXTERNAL CEPHALIC VERSION,72000003,CDM,720,RC,59412,HCPCS,,,facility,both,,,,11458,8020.6,,,,,,,,,,,,,Gross Charge Type: Central
HC OUT OF HOSPITAL DELIVERY,72000004,CDM,720,RC,72000004,HCPCS,,,facility,both,,,,2063,1444.1,,,,,,,,,,,,,Gross Charge Type: Central
HC LEVEL 1 LABOR/DELIVERY/RECOVERY,72000005,CDM,720,RC,72000005,HCPCS,,,facility,both,,,,5398,3778.6,,,,,,,,,,,,,Gross Charge Type: Central
HC LEVEL 2 LABOR/DELIVERY/RECOVERY,72000006,CDM,720,RC,72000006,HCPCS,,,facility,both,,,,7196,5037.2,,,,,,,,,,,,,Gross Charge Type: Central
HC LEVEL 1 RECOVERY LOW RISK,72000007,CDM,720,RC,72000007,HCPCS,,,facility,both,,,,416,291.2,,,,,,,,,,,,,Gross Charge Type: Central
HC LEVEL 2 RECOVERY HIGH RISK,72000008,CDM,720,RC,72000008,HCPCS,,,facility,both,,,,733,513.1,,,,,,,,,,,,,Gross Charge Type: Central
HC LEVEL 3 LABOR/DELIVERY/RECOVERY,72000009,CDM,720,RC,72000009,HCPCS,,,facility,both,,,,9246,6472.2,,,,,,,,,,,,,Gross Charge Type: Central
HC LEVEL 1 LABOR < 12 HOURS,72100001,CDM,721,RC,72100001,HCPCS,,,facility,both,,,,537,375.9,,,,,,,,,,,,,Gross Charge Type: Central
HC LEVEL 2 LABOR < 12 HOURS,72100002,CDM,721,RC,72100002,HCPCS,,,facility,both,,,,551,385.7,,,,,,,,,,,,,Gross Charge Type: Central
HC LEVEL 1 DELIVERY,72200001,CDM,722,RC,72200001,HCPCS,,,facility,both,,,,1762,1233.4,,,,,,,,,,,,,Gross Charge Type: Central
HC LEVEL 2 DELIVERY,72200002,CDM,722,RC,72200002,HCPCS,,,facility,both,,,,1762,1233.4,,,,,,,,,,,,,Gross Charge Type: Central
HC CIRCUMCISION W/REGIONL BLOCK,72300001,CDM,723,RC,54150,HCPCS,,,facility,both,,,,2389,1672.3,,,,,,,,,,,,,Gross Charge Type: Central
BCG LIVE 50 MG IVES SUSR,7270,CDM,J9030,HCPCS,0052-0602-01,NDC,,,facility,both,1,EA,,764,534.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % INJ SYRG,7274,CDM,J3490,HCPCS,8290306546,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC ECG TRACING ONLY,73000001,CDM,730,RC,93005,HCPCS,,,facility,both,,,,320,224,,,,,,,,,,,,,Gross Charge Type: Central
HC RHYTHM ECG TRACING,73000002,CDM,730,RC,93041,HCPCS,,,facility,both,,,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Central
HC REMOTE 30 DAY ECG RECORDING,73000003,CDM,730,RC,93270,HCPCS,,,facility,both,,,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Central
PRE-OP PM DEVICE EVAL,73000007,CDM,920,RC,93286,HCPCS,,,facility,both,,,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PERI-PROCEDURAL DEVICE EVALUATION (IN PERSON) SINGLE/DUAL/MULTIPLE LEAD IMPLANTABLE DEFIBRILLATOR SYSTEM,73000008,CDM,920,RC,93287,HCPCS,,,facility,both,,,,134,93.8,,,,,,,,,,,,,Gross Charge Type: Central
HC EKG TRACING ONLY,73000010,CDM,730,RC,93005,HCPCS,,,facility,both,,,,320,224,,,,,,,,,,,,,Gross Charge Type: Central
HC EXT ECG > 48HR UP TO 7 DAYS RCRD INCL CONNECT INITIAL RCRD,73000016,CDM,730,RC,93242,HCPCS,,,facility,both,,,,388,271.6,,,,,,,,,,,,,Gross Charge Type: Central
HC EXT ECG > 7 DAYS UP TO 15 DAYS RCRD INCL CONNECT INITIAL RCRD,73000017,CDM,730,RC,93246,HCPCS,,,facility,both,,,,388,271.6,,,,,,,,,,,,,Gross Charge Type: Central
HC EXT ECG> 48HR UP TO 7 DAYS SCAN ANLYS W/REPORT,73000018,CDM,730,RC,93243,HCPCS,,,facility,both,,,,388,271.6,,,,,,,,,,,,,Gross Charge Type: Central
HC EXT ECG> 7 DAYS UP TO 15 DAYS SCAN ANLYS W/REPORT,73000019,CDM,730,RC,93247,HCPCS,,,facility,both,,,,418,292.6,,,,,,,,,,,,,Gross Charge Type: Central
HC ECG EXTER MONIT UP TO 48 HOURS,73100001,CDM,731,RC,93225,HCPCS,,,facility,both,,,,469,328.3,,,,,,,,,,,,,Gross Charge Type: Central
HC ECG EXTER MONIT REPORT,73100002,CDM,731,RC,93226,HCPCS,,,facility,both,,,,416,291.2,,,,,,,,,,,,,Gross Charge Type: Central
HC REMOTE 30 DAY ECG TRANSMISSION AND ANALYSIS,73100003,CDM,731,RC,93271,HCPCS,,,facility,both,,,,556,389.2,,,,,,,,,,,,,Gross Charge Type: Central
HC ACTIGRAPHY TESTING 3-14 DAYS,74000001,CDM,920,RC,95803,HCPCS,,,facility,both,,,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Central
HC MULTIPLE SLEEP LATENCY TEST,74000002,CDM,920,RC,95805,HCPCS,,,facility,both,,,,2611,1827.7,,,,,,,,,,,,,Gross Charge Type: Central
SLEEP STUDY ATTENDED,74000003,CDM,920,RC,95807,HCPCS,,,facility,both,,,,2653,1857.1,,,,,,,,,,,,,Gross Charge Type: Central
HC POLYSOMNOGRAPHY 6 YRS OR OLDER 4> PARAM,74000004,CDM,920,RC,95810,HCPCS,,,facility,both,,,,4303,3012.1,,,,,,,,,,,,,Gross Charge Type: Central
HC POLYSOMNOG 4> PARAM W/ CPAP,74000005,CDM,920,RC,95811,HCPCS,,,facility,both,,,,4304,3012.8,,,,,,,,,,,,,Gross Charge Type: Central
HC EEG 41-60 MINUTES,74000006,CDM,740,RC,95812,HCPCS,,,facility,both,,,,561,392.7,,,,,,,,,,,,,Gross Charge Type: Central
HC EEG OVER 1 HOUR,74000007,CDM,740,RC,95813,HCPCS,,,facility,both,,,,643,450.1,,,,,,,,,,,,,Gross Charge Type: Central
HC EEG AWAKE AND DROWSY,74000008,CDM,740,RC,95816,HCPCS,,,facility,both,,,,672,470.4,,,,,,,,,,,,,Gross Charge Type: Central
HC EEG AWAKE AND ASLEEP,74000009,CDM,740,RC,95819,HCPCS,,,facility,both,,,,663,464.1,,,,,,,,,,,,,Gross Charge Type: Central
HC EEG COMA OR SLEEP ONLY,74000010,CDM,740,RC,95822,HCPCS,,,facility,both,,,,539,377.3,,,,,,,,,,,,,Gross Charge Type: Central
HC POLYSOMNOGRAPHY 6 YRS OR OLDER 4 > PARAM DISCONTINUED,74000013,CDM,920,RC,95810,HCPCS,,,facility,both,,,52,2151,1505.7,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 52: Reduced Services
HC POLYSOM > 4 PARAM W/ CPAP/BIPAP DISCONT,74000014,CDM,920,RC,95811,HCPCS,,,facility,both,,,52,4303,3012.1,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 52: Reduced Services
HC POLYSOMNOGRAPHY 6 YRS OR OLDER 4+ XTRA MON A,74000015,CDM,740,RC,95810,HCPCS,,,facility,both,,,,5198,3638.6,,,,,,,,,,,,,Gross Charge Type: Central
HC POLYSOM <6 YRS 4/> PARAMTRS,74000016,CDM,740,RC,95782,HCPCS,,,facility,both,,,,5198,3638.6,,,,,,,,,,,,,Gross Charge Type: Central
HC POLYSOM <6 YRS CPAP/BILVL,74000017,CDM,740,RC,95783,HCPCS,,,facility,both,,,,5198,3638.6,,,,,,,,,,,,,Gross Charge Type: Central
HC VEEG 2-12 HOURS W/INTERMITTENT MONITORING & MAINTENANCE,74000018,CDM,740,RC,95712,HCPCS,,,facility,both,,,,935,654.5,,,,,,,,,,,,,Gross Charge Type: Central
HC VEEG 12-26 HOURS W/INTERMITTENT MONITORING & MAINTENANCE,74000019,CDM,740,RC,95715,HCPCS,,,facility,both,,,,1795,1256.5,,,,,,,,,,,,,Gross Charge Type: Central
HC EEG CONTINUOUS RECORD W/VIDEO SETUP PATIENT EDUCATION & TAKEDOWN BY EEG TECH 8 CHANNELS,74000020,CDM,740,RC,95700,HCPCS,,,facility,both,,,,969,678.3,,,,,,,,,,,,,Gross Charge Type: Central
HC POLYSOMNOGRAPHY YOUNGER THAN 6YRS 4> PARAM DISCONTINUED,74000021,CDM,920,RC,95782,HCPCS,,,facility,both,,,52,2151,1505.7,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 52: Reduced Services
HC VEEG BY TECH 2-12 HR CONTINUOUS REAL TIME MONITORING,74000022,CDM,740,RC,95713,HCPCS,,,facility,both,,,,2262,1583.4,,,,,,,,,,,,,Gross Charge Type: Central
HC VEEG BY TECH EA INCREMENT 12-26 HR CONTINUOUS REAL TIME MONITORING,74000023,CDM,740,RC,95716,HCPCS,,,facility,both,,,,4332,3032.4,,,,,,,,,,,,,Gross Charge Type: Central
HC ESOPHAGUS MOTILITY STUDY,75000001,CDM,750,RC,91010,HCPCS,,,facility,both,,,,2155,1508.5,,,,,,,,,,,,,Gross Charge Type: Central
GASTROESOPHAGEAL REFLUX TEST,75000002,CDM,750,RC,91034,HCPCS,,,facility,both,,,,4396,3077.2,,,,,,,,,,,,,Gross Charge Type: Central
GI TRACT CAPSULE ENDOSCOPY,75000003,CDM,750,RC,75000003,HCPCS,,,facility,both,,,,1058,740.6,,,,,,,,,,,,,Gross Charge Type: Central
HC ABLATION/ARGON,75000006,CDM,750,RC,75000006,HCPCS,,,facility,both,,,,497,347.9,,,,,,,,,,,,,Gross Charge Type: Central
HC DILATION,75000007,CDM,750,RC,75000007,HCPCS,,,facility,both,,,,600,420,,,,,,,,,,,,,Gross Charge Type: Central
HC BIOPSY,75000008,CDM,750,RC,75000008,HCPCS,,,facility,both,,,,400,280,,,,,,,,,,,,,Gross Charge Type: Central
HC BLEEDING CONTROL,75000009,CDM,750,RC,75000009,HCPCS,,,facility,both,,,,991,693.7,,,,,,,,,,,,,Gross Charge Type: Central
HC BOTOX INJECTION,75000010,CDM,750,RC,75000010,HCPCS,,,facility,both,,,,497,347.9,,,,,,,,,,,,,Gross Charge Type: Central
HC BRUSHING,75000011,CDM,750,RC,75000011,HCPCS,,,facility,both,,,,301,210.7,,,,,,,,,,,,,Gross Charge Type: Central
HC COLONOSCOPY DIAGNOSTIC,75000012,CDM,750,RC,45378,HCPCS,,,facility,both,,,,3772,2640.4,,,,,,,,,,,,,Gross Charge Type: Central
HC COLONOSCOPY W/ BIOPSY,75000013,CDM,750,RC,45380,HCPCS,,,facility,both,,,,4172,2920.4,,,,,,,,,,,,,Gross Charge Type: Central
HC COLONOSCOPY W/ POLYP & BIOPSY,75000014,CDM,750,RC,75000014,HCPCS,,,facility,both,,,,3300,2310,,,,,,,,,,,,,Gross Charge Type: Central
HC DECOMPRESSION,75000015,CDM,750,RC,75000015,HCPCS,,,facility,both,,,,2266,1586.2,,,,,,,,,,,,,Gross Charge Type: Central
HC EGD,75000016,CDM,750,RC,75000016,HCPCS,,,facility,both,,,,3208,2245.6,,,,,,,,,,,,,Gross Charge Type: Central
HC EGD W/ POLYPECTOMY,75000019,CDM,750,RC,75000019,HCPCS,,,facility,both,,,,1613,1129.1,,,,,,,,,,,,,Gross Charge Type: Central
HC EGD W/ CONTROL BLEEDING,75000020,CDM,750,RC,75000020,HCPCS,,,facility,both,,,,2138,1496.6,,,,,,,,,,,,,Gross Charge Type: Central
HC EGD W/ FOREIGN BODY REMOVAL,75000021,CDM,750,RC,75000021,HCPCS,,,facility,both,,,,2982,2087.4,,,,,,,,,,,,,Gross Charge Type: Central
HC ERCP,75000022,CDM,750,RC,75000022,HCPCS,,,facility,both,,,,4714,3299.8,,,,,,,,,,,,,Gross Charge Type: Central
HC ESPOHAGEAL STENT PLACEMENT,75000023,CDM,750,RC,75000023,HCPCS,,,facility,both,,,,1966,1376.2,,,,,,,,,,,,,Gross Charge Type: Central
HC STENT PLACEMENT,75000024,CDM,750,RC,75000024,HCPCS,,,facility,both,,,,986,690.2,,,,,,,,,,,,,Gross Charge Type: Central
HC STENT REMOVAL,75000025,CDM,750,RC,75000025,HCPCS,,,facility,both,,,,400,280,,,,,,,,,,,,,Gross Charge Type: Central
HC EXTENDED GI LAB 15 MINUTES,75000026,CDM,750,RC,75000026,HCPCS,,,facility,both,,,,381,266.7,,,,,,,,,,,,,Gross Charge Type: Central
HC FLEXIBLE SIGMOIDOSCOPY,75000027,CDM,750,RC,75000027,HCPCS,,,facility,both,,,,3020,2114,,,,,,,,,,,,,Gross Charge Type: Central
HC EGD W/US FINE NEEDLE ASPIRATION/BIOPSY,75000028,CDM,750,RC,43238,HCPCS,,,facility,both,,,,5378,3764.6,,,,,,,,,,,,,Gross Charge Type: Central
HC FOREIGN BODY REMOVAL,75000029,CDM,750,RC,75000029,HCPCS,,,facility,both,,,,758,530.6,,,,,,,,,,,,,Gross Charge Type: Central
HC LIGATOR/BANDER,75000030,CDM,750,RC,75000030,HCPCS,,,facility,both,,,,1594,1115.8,,,,,,,,,,,,,Gross Charge Type: Central
HC LITHOTRIPSY,75000031,CDM,750,RC,75000031,HCPCS,,,facility,both,,,,945,661.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PAPILLOTOMY,75000032,CDM,750,RC,75000032,HCPCS,,,facility,both,,,,475,332.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PEG,75000033,CDM,750,RC,75000033,HCPCS,,,facility,both,,,,2266,1586.2,,,,,,,,,,,,,Gross Charge Type: Central
HC POLYPECTOMY,75000034,CDM,750,RC,75000034,HCPCS,,,facility,both,,,,497,347.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PROCTOSIGMOIDOSCOPY FLEXIBLE,75000035,CDM,750,RC,75000035,HCPCS,,,facility,both,,,,1359,951.3,,,,,,,,,,,,,Gross Charge Type: Central
HC REMOVE/REPLACE CATH/NON-INCIS,75000036,CDM,750,RC,75000036,HCPCS,,,facility,both,,,,595,416.5,,,,,,,,,,,,,Gross Charge Type: Central
HC SUBMUCOSAL INJECTION,75000037,CDM,750,RC,75000037,HCPCS,,,facility,both,,,,991,693.7,,,,,,,,,,,,,Gross Charge Type: Central
HC TATOO INJECTION,75000038,CDM,750,RC,75000038,HCPCS,,,facility,both,,,,991,693.7,,,,,,,,,,,,,Gross Charge Type: Central
HC ULTRASOUND EXAMINATION,75000039,CDM,750,RC,75000039,HCPCS,,,facility,both,,,,1058,740.6,,,,,,,,,,,,,Gross Charge Type: Central
HC ERCP W/ BIOPSY SINGLE/MULTIPLE,75000041,CDM,750,RC,43261,HCPCS,,,facility,both,,,,5114,3579.8,,,,,,,,,,,,,Gross Charge Type: Central
HC ERCP W/DESTRUCTION/LITHOTRIPSY OF CALCULI,75000042,CDM,750,RC,43265,HCPCS,,,facility,both,,,,5659,3961.3,,,,,,,,,,,,,Gross Charge Type: Central
HC ERCP DUCT SENT PLACEMENT BILLIARY/PANCREATIC DUCT,75000043,CDM,750,RC,43274,HCPCS,,,facility,both,,,,5700,3990,,,,,,,,,,,,,Gross Charge Type: Central
HC ERCP W/SPHINCTEROTOMY/PAPILLOTOMY,75000045,CDM,750,RC,43262,HCPCS,,,facility,both,,,,5189,3632.3,,,,,,,,,,,,,Gross Charge Type: Central
HC ERCP W/REMOVAL/EXCHANGE STENT/BILLIARY/PANCREATIC DUCT W/DILATE & GUIDEWIRE,75000046,CDM,750,RC,43276,HCPCS,,,facility,both,,,,6100,4270,,,,,,,,,,,,,Gross Charge Type: Central
HC ERCP W/SPECIMEN COLLECTION BY BRUSHING OR WASHING,75000047,CDM,750,RC,43260,HCPCS,,,facility,both,,,,5015,3510.5,,,,,,,,,,,,,Gross Charge Type: Central
HC EGD W/ ESOPHAGEAL STENT PLACEMENT,75000048,CDM,750,RC,43266,HCPCS,,,facility,both,,,,4797,3357.9,,,,,,,,,,,,,Gross Charge Type: Central
HC COLONOSCOPY W/ BLEEDING CONTROL,75000051,CDM,750,RC,45382,HCPCS,,,facility,both,,,,4763,3334.1,,,,,,,,,,,,,Gross Charge Type: Central
HC COLONOSCOPY W/ DILATION,75000052,CDM,750,RC,45386,HCPCS,,,facility,both,,,,4372,3060.4,,,,,,,,,,,,,Gross Charge Type: Central
HC COLONOSCOPY W/ FOREIGN BODY REMOVAL,75000053,CDM,750,RC,45379,HCPCS,,,facility,both,,,,4530,3171,,,,,,,,,,,,,Gross Charge Type: Central
HC FLEXIBLE SIGMOIDOSCOPY W/ BIOPSY,75000054,CDM,750,RC,45331,HCPCS,,,facility,both,,,,3420,2394,,,,,,,,,,,,,Gross Charge Type: Central
HC FLEXIBLE SIGMOIDOSCOPY W/ BLEEDING CONTROL,75000055,CDM,750,RC,45334,HCPCS,,,facility,both,,,,4011,2807.7,,,,,,,,,,,,,Gross Charge Type: Central
HC SIGMOIDOSCOPY W/REMOVAL TUMOR/POLYP/LESION,75000058,CDM,750,RC,45338,HCPCS,,,facility,both,,,,3517,2461.9,,,,,,,,,,,,,Gross Charge Type: Central
HC STONE EXTRACTION,75000059,CDM,750,RC,75000059,HCPCS,,,facility,both,,,,813,569.1,,,,,,,,,,,,,Gross Charge Type: Central
HC FECAL MICROBIOTA PREP INSTIL,75000060,CDM,750,RC,44705,HCPCS,,,facility,both,,,,4012,2808.4,,,,,,,,,,,,,Gross Charge Type: Central
HC COLONOSCOPY W/LESION REMOVAL BY SNARE TECHNIQUE,75000061,CDM,750,RC,45385,HCPCS,,,facility,both,,,,4269,2988.3,,,,,,,,,,,,,Gross Charge Type: Central
HC EGD DIAGNOSTIC BRUSH WASH,75000062,CDM,750,RC,43235,HCPCS,,,facility,both,,,,3509,2456.3,,,,,,,,,,,,,Gross Charge Type: Central
HC LIGATION OF HEMORRHOID(S) BY RUBBER BAND,75000063,CDM,750,RC,75000063,HCPCS,,,facility,both,,,,3651,2555.7,,,,,,,,,,,,,Gross Charge Type: Central
HC ENDOSCOPY OF BOWEL POUCH BRUSHING/WASHING,75000064,CDM,750,RC,44385,HCPCS,,,facility,both,,,,1213,849.1,,,,,,,,,,,,,Gross Charge Type: Central
HC ENDOSCOPY OF BOWEL POUCH W/BIOPSY SINGLE/MULTIPLE,75000065,CDM,750,RC,44386,HCPCS,,,facility,both,,,,1312,918.4,,,,,,,,,,,,,Gross Charge Type: Central
HC BANDING,75000067,CDM,750,RC,75000067,HCPCS,,,facility,both,,,,1896,1327.2,,,,,,,,,,,,,Gross Charge Type: Central
HC BREATH HYDROGEN OR METHANE TEST,75000068,CDM,750,RC,91065,HCPCS,,,facility,both,,,,650,455,,,,,,,,,,,,,Gross Charge Type: Central
HC ANORECTAL MANOMETRY,75000069,CDM,750,RC,75000069,HCPCS,,,facility,both,,,,1213,849.1,,,,,,,,,,,,,Gross Charge Type: Central
HC ENDOSCOPIC SUBMUCOSAL DISSECTION (ESD),75000070,CDM,750,RC,C9779,HCPCS,,,facility,both,,,,3772,2640.4,,,,,,,,,,,,,Gross Charge Type: Central
HC ILEOSCOPY THRU STOMA DX INCL COLLECTION SPECIMEN BRUSHING/WASHING,75000071,CDM,750,RC,44380,HCPCS,,,facility,both,,,,4263,2984.1,,,,,,,,,,,,,Gross Charge Type: Central
HC UNLISTED PROCEDURE SMALL INTESTINE,75000072,CDM,750,RC,44799,HCPCS,,,facility,both,,,,9207,6444.9,,,,,,,,,,,,,Gross Charge Type: Central
HC SIGMOIDOSCOPY W/BAND LIGATION,75000076,CDM,750,RC,45350,HCPCS,,,facility,both,,,,6671,4669.7,,,,,,,,,,,,,Gross Charge Type: Central
HC ESOPHAGEAL FUNCTION TEST GASTROESOPHAGEAL REFLEX W/IMPEDANCE,75000077,CDM,750,RC,91037,HCPCS,,,facility,both,,,,6551,4585.7,,,,,,,,,,,,,Gross Charge Type: Central
HC SIGMOIDOSCOPY W/ULTRASOUND,75000078,CDM,750,RC,45341,HCPCS,,,facility,both,,,,4078,2854.6,,,,,,,,,,,,,Gross Charge Type: Central
HC UNLISTED DX GI PROCEDURE,75000079,CDM,750,RC,91299,HCPCS,,,facility,both,,,,6551,4585.7,,,,,,,,,,,,,Gross Charge Type: Central
HC SIGMOIDOSCOPY W/ABLATION,75000080,CDM,750,RC,45346,HCPCS,,,facility,both,,,,3517,2461.9,,,,,,,,,,,,,Gross Charge Type: Central
HC SIGMOIDOSCOPY W/RESECTION,75000081,CDM,750,RC,45349,HCPCS,,,facility,both,,,,4011,2807.7,,,,,,,,,,,,,Gross Charge Type: Central
HC SIGMOIDOSCOPY W/SUBMUCOSAL INJECTION,75000082,CDM,750,RC,45335,HCPCS,,,facility,both,,,,4011,2807.7,,,,,,,,,,,,,Gross Charge Type: Central
HC ILEOSCOPY THRU STOMA W/BIOPSY SINGLE/MULTIPLE,75000083,CDM,750,RC,44382,HCPCS,,,facility,both,,,,1312,918.4,,,,,,,,,,,,,Gross Charge Type: Central
HC SMALL BOWEL ENDOSCOPY W/BIOPSY INCL ILEUM SINGLE/MULTIPLE,75000084,CDM,750,RC,44377,HCPCS,,,facility,both,,,,4172,2920.4,,,,,,,,,,,,,Gross Charge Type: Central
HC SMALL BOWEL ENDOSCOPY W/BIOPSY NOT INCL ILEUM SINGLE/MULTIPLE,75000085,CDM,750,RC,44361,HCPCS,,,facility,both,,,,3608,2525.6,,,,,,,,,,,,,Gross Charge Type: Central
HC UNLISTED PROCEDURE PANCREAS,75000086,CDM,750,RC,48999,HCPCS,,,facility,both,,,,3208,2245.6,,,,,,,,,,,,,Gross Charge Type: Central
HC COLONOSCOPY W/SUBMUCOSAL INJECTION,75000088,CDM,750,RC,45381,HCPCS,,,facility,both,,,,4763,3334.1,,,,,,,,,,,,,Gross Charge Type: Central
HC COLONOSCOPY W/ LESION REMOVAL BY HOT BIOPSY FORCEPS,75000089,CDM,750,RC,45384,HCPCS,,,facility,both,,,,4269,2988.3,,,,,,,,,,,,,Gross Charge Type: Central
HC COLONOSCOPY W/ABLATION,75000090,CDM,750,RC,45388,HCPCS,,,facility,both,,,,4269,2988.3,,,,,,,,,,,,,Gross Charge Type: Central
HC COLONOSCOPY W/STENT PLACEMENT,75000091,CDM,750,RC,45389,HCPCS,,,facility,both,,,,4758,3330.6,,,,,,,,,,,,,Gross Charge Type: Central
HC COLONOSCOPY W/RESECTION,75000092,CDM,750,RC,45390,HCPCS,,,facility,both,,,,4269,2988.3,,,,,,,,,,,,,Gross Charge Type: Central
HC COLONOSCOPY W/ENDOSCOPE US,75000093,CDM,750,RC,45391,HCPCS,,,facility,both,,,,4830,3381,,,,,,,,,,,,,Gross Charge Type: Central
HC COLONOSCOPY W/ENDOSCOPIC US FINE NEEDLE BIOPSY,75000094,CDM,750,RC,45392,HCPCS,,,facility,both,,,,5942,4159.4,,,,,,,,,,,,,Gross Charge Type: Central
HC COLONOSCOPY W/DECOMPRESSION,75000095,CDM,750,RC,45393,HCPCS,,,facility,both,,,,6038,4226.6,,,,,,,,,,,,,Gross Charge Type: Central
HC COLONOSCOPY W/BAND LIGATION,75000096,CDM,750,RC,45398,HCPCS,,,facility,both,,,,7423,5196.1,,,,,,,,,,,,,Gross Charge Type: Central
HC COLONOSCOPY THRU STOMA W/BIOPSY SINGLE/MULTIPLE,75000097,CDM,750,RC,44389,HCPCS,,,facility,both,,,,4172,2920.4,,,,,,,,,,,,,Gross Charge Type: Central
HC COLONOSCOPY THRU STOMA DX INCL COLLECTION OF SPECIMEN,75000098,CDM,750,RC,44388,HCPCS,,,facility,both,,,,4073,2851.1,,,,,,,,,,,,,Gross Charge Type: Central
HC COLONOSCOPY THRU STOMA W/SUBMUCOSAL INJECTION,75000099,CDM,750,RC,44404,HCPCS,,,facility,both,,,,4763,3334.1,,,,,,,,,,,,,Gross Charge Type: Central
HC COLONOSCOPY THRU STOMA W/REMOVAL TUMOR/POLYP/OTHER LESIONS BY SNARE,75000100,CDM,750,RC,44394,HCPCS,,,facility,both,,,,4269,2988.3,,,,,,,,,,,,,Gross Charge Type: Central
HC COLONOSCOPY SCREENING NOT HIGH RISK IND,75000101,CDM,750,RC,G0121,HCPCS,,,facility,both,,,,3772,2640.4,,,,,,,,,,,,,Gross Charge Type: Central
HC COLONOSCOPY SCREENING HIGH RISK IND,75000102,CDM,750,RC,G0105,HCPCS,,,facility,both,,,,3772,2640.4,,,,,,,,,,,,,Gross Charge Type: Central
HC ESOPHAGOSCOPY FLEXIBLE DX INCL COLLECTION OF SPECIMEN BRUSHING/WASHING,75000103,CDM,750,RC,43200,HCPCS,,,facility,both,,,,3509,2456.3,,,,,,,,,,,,,Gross Charge Type: Central
HC EGD BALLOON DILATION ESOPHAGUS 30MM OR LARGER,75000104,CDM,750,RC,43233,HCPCS,,,facility,both,,,,3808,2665.6,,,,,,,,,,,,,Gross Charge Type: Central
HC EGD FLEXIBLE TRANSORAL W/SUBMUCOSAL INJECTION,75000105,CDM,750,RC,43236,HCPCS,,,facility,both,,,,4199,2939.3,,,,,,,,,,,,,Gross Charge Type: Central
HC EGD FLEXIBLE TRANSORAL W/ULTRASOUND ESOPHAGUS/STOMACH/DUODENUM,75000106,CDM,750,RC,43237,HCPCS,,,facility,both,,,,4266,2986.2,,,,,,,,,,,,,Gross Charge Type: Central
HC EGD FLEXIBLE TRANSORAL W/TRANSMURAL DRAIN CYST AND ENDOSCOPIC US,75000107,CDM,750,RC,43240,HCPCS,,,facility,both,,,,4194,2935.8,,,,,,,,,,,,,Gross Charge Type: Central
HC EGD W/US FINE NEEDLE ASPIRATION/BIOPSY ALTERED ANATOMY,75000108,CDM,750,RC,43242,HCPCS,,,facility,both,,,,5378,3764.6,,,,,,,,,,,,,Gross Charge Type: Central
HC EGD DILATE STRICTURE,75000109,CDM,750,RC,43245,HCPCS,,,facility,both,,,,3808,2665.6,,,,,,,,,,,,,Gross Charge Type: Central
HC EGD W/BALLOON DILATION ESOPH LESS THAN 30MM,75000110,CDM,750,RC,43249,HCPCS,,,facility,both,,,,3808,2665.6,,,,,,,,,,,,,Gross Charge Type: Central
HC EGD CAUTERY TUMOR/POLYP/LESIONS,75000111,CDM,750,RC,43250,HCPCS,,,facility,both,,,,3705,2593.5,,,,,,,,,,,,,Gross Charge Type: Central
HC EGD REMOVAL OF TUMOR/POLYP/LESIONS BY SNARE,75000112,CDM,750,RC,43251,HCPCS,,,facility,both,,,,3705,2593.5,,,,,,,,,,,,,Gross Charge Type: Central
HC EGD ENDO MUCOSAL RESECTION,75000113,CDM,750,RC,43254,HCPCS,,,facility,both,,,,4199,2939.3,,,,,,,,,,,,,Gross Charge Type: Central
HC EGD US EXAM ESOPH/STOMACH/DUODENUM/JEJUNUM,75000114,CDM,750,RC,43259,HCPCS,,,facility,both,,,,4266,2986.2,,,,,,,,,,,,,Gross Charge Type: Central
HC EGD W/ABLATION TUMOR/POLYP/LESION,75000115,CDM,750,RC,43270,HCPCS,,,facility,both,,,,3705,2593.5,,,,,,,,,,,,,Gross Charge Type: Central
HC ERCP REMOVE FOREIGN BODY/STENT FROM BILLIARY/PANCREATIC DUCT,75000116,CDM,750,RC,43275,HCPCS,,,facility,both,,,,5872,4110.4,,,,,,,,,,,,,Gross Charge Type: Central
HC ERCP BALLOON DILATION BILLIARY/PNACREATIC DUCT AMPULLA,75000117,CDM,750,RC,43277,HCPCS,,,facility,both,,,,4714,3299.8,,,,,,,,,,,,,Gross Charge Type: Central
HC ERCP W/ABLATION TUMOR/POLYP/LESION W/DILATION & GUIDEWIRE,75000118,CDM,750,RC,43278,HCPCS,,,facility,both,,,,5211,3647.7,,,,,,,,,,,,,Gross Charge Type: Central
HC ILEOSCOPY THRU STOMA W/BALLOON DILATION,75000119,CDM,750,RC,44381,HCPCS,,,facility,both,,,,4562,3193.4,,,,,,,,,,,,,Gross Charge Type: Central
HC COLONOSCOPY THRU STOMA US FINE NEEDLE ASPIRATION/BIOPSY,75000120,CDM,750,RC,44407,HCPCS,,,facility,both,,,,5942,4159.4,,,,,,,,,,,,,Gross Charge Type: Central
HC ILEOSCOPY THRU STOMA W/STENT PLACEMENT,75000121,CDM,750,RC,44384,HCPCS,,,facility,both,,,,4948,3463.6,,,,,,,,,,,,,Gross Charge Type: Central
HC COLONOSCOPY THRU STOMA W/ENDO US,75000122,CDM,750,RC,44406,HCPCS,,,facility,both,,,,4830,3381,,,,,,,,,,,,,Gross Charge Type: Central
HC SIGMOIDOSCOPY FLEXIBLE W/TRANSENDO US GUIDED FINE NEEDLE ASPIRATON/BIOPSY,75000123,CDM,750,RC,45342,HCPCS,,,facility,both,,,,5190,3633,,,,,,,,,,,,,Gross Charge Type: Central
HC ERCP REMOVAL CALCULI/DEBRIS BILLIARY/PANCREATIC DUCT,75000124,CDM,750,RC,43264,HCPCS,,,facility,both,,,,5527,3868.9,,,,,,,,,,,,,Gross Charge Type: Central
HC ESOPH FLEX TRANSORAL W/ABLATION TUMOR/POLYP/OTHER LESIONS,75000125,CDM,750,RC,43229,HCPCS,,,facility,both,,,,16197,11337.9,,,,,,,,,,,,,Gross Charge Type: Central
HC LOWER ESOPHAGEAL MYOTOMY TRANSORAL (POEM),75000126,CDM,750,RC,43497,HCPCS,,,facility,both,,,,25343,17740.1,,,,,,,,,,,,,Gross Charge Type: Central
HC ENDOSCOPIC CANNULATION OF PAPILLA WITH DIRECT VISUALIZATION OF PANCREATIC/COMMON BILE DUCT(S),75000127,CDM,750,RC,43273,HCPCS,,,facility,both,,,,7099,4969.3,,,,,,,,,,,,,Gross Charge Type: Central
HC DUODENAL INTUBATION/ASPIRATION DX INCL IMAGE GUIDANCE COLLECT MULTIPLE SPECIMENS SINGLE OR DOUBLE LUMEN  TUBE INCL DRUG ADMIN,75000128,CDM,750,RC,43757,HCPCS,,,facility,both,,,,3912,2738.4,,,,,,,,,,,,,Gross Charge Type: Central
HC EGD FLEXIBLE TRANSNASAL DX INCL COLLECT SPECIMEN(S) BRUSHING/WASHING,75000129,CDM,750,RC,0652T,HCPCS,,,facility,both,,,,7915,5540.5,,,,,,,,,,,,,Gross Charge Type: Central
HC EGD FLEXIBLE TRANSNASAL W/BIOPSY SINGLE/MULTIPLE,75000130,CDM,750,RC,0653T,HCPCS,,,facility,both,,,,7915,5540.5,,,,,,,,,,,,,Gross Charge Type: Central
HC EGD FLEXIBLE TRANSNASAL W/INSERTION INTRALUMINAL TUBE/CATHETER,75000131,CDM,750,RC,0654T,HCPCS,,,facility,both,,,,15873,11111.1,,,,,,,,,,,,,Gross Charge Type: Central
HC DRAINAGE OF FINGER ABSCESS,76000004,CDM,760,RC,26010,HCPCS,,,facility,both,,,,243,170.1,,,,,,,,,,,,,Gross Charge Type: Central
HC CHANGE OF WINDPIPE AIRWAY,76100001,CDM,761,RC,31502,HCPCS,,,facility,both,,,,160,112,,,,,,,,,,,,,Gross Charge Type: Central
HC TRANSCATHETER MITRAL VALVE REPAIR PERCUTANEOUS INCL TRANSSEPTAL PUNCTURE INITIAL PROSTHESIS,76100006,CDM,761,RC,33418,HCPCS,,,facility,both,,,,2139,1497.3,,,,,,,,,,,,,Gross Charge Type: Central
HC TRANSCATHETER MITRAL VALVE REPAIR PERCU INCL TRANSSEPTAL PUNCT ADDTL PROSTHESIS(ES) SAME SESSION,76100008,CDM,761,RC,33419,HCPCS,,,facility,both,,,,539,377.3,,,,,,,,,,,,,Gross Charge Type: Central
HC ESOPH FUNCT TEST GASTROESOPH REFLUX TEST W/ NASAL CATH INTRALUMINAL IMPED ELECTRODE(S) PLACE/RECORD/ANALYSIS/INTERP PROLONG (GREATER THAN 1 HR UP TO 24 HRS),76100013,CDM,750,RC,91038,HCPCS,,,facility,both,,,,2155,1508.5,,,,,,,,,,,,,Gross Charge Type: Central
HC TRANSCATHETER AORTIC VALVE REPLACEMENT (TAVR/TAVI) W/PROSTHETIC VALVE PERCUTANEOUS FEMORAL ARTERY,76100014,CDM,761,RC,33361,HCPCS,,,facility,both,,,,27691,19383.7,,,,,,,,,,,,,Gross Charge Type: Central
HC TRANSCATHETER AORTIC VALVE REPLACEMENT (TAVR/TAVI) W/PROSTHETIC VALVE OPEN FEMORAL ARTERY APPROAC,76100015,CDM,761,RC,33362,HCPCS,,,facility,both,,,,27691,19383.7,,,,,,,,,,,,,Gross Charge Type: Central
HC TRANSCATHETER AORTIC VALVE REPLACEMENT (TAVR/TAVI) W/PROSTHETIC VALVE OPEN AXILLARY ARTERY APPROA,76100016,CDM,761,RC,33363,HCPCS,,,facility,both,,,,24079,16855.3,,,,,,,,,,,,,Gross Charge Type: Central
HC FINE NEEDLE ASPIRATION BIOPSY INCL ULTRASOUND GUIDANCE FIRST LESION,76100035,CDM,761,RC,10005,HCPCS,,,facility,both,,,,2308,1615.6,,,,,,,,,,,,,Gross Charge Type: Central
HC FINE NEEDLE ASPIRATION BIOPSY INCL ULTRASOUND GUIDANCE EACH ADDTL LESION,76100036,CDM,761,RC,10006,HCPCS,,,facility,both,,,,1154,807.8,,,,,,,,,,,,,Gross Charge Type: Central
HC FINE NEEDLE ASPIRATION BIOPSY INCL FLUORO GUIDANCE FIRST LESION,76100037,CDM,761,RC,10007,HCPCS,,,facility,both,,,,2308,1615.6,,,,,,,,,,,,,Gross Charge Type: Central
HC FINE NEEDLE ASPIRATION BIOPSY INCL CT GUIDANCE FIRST LESION,76100039,CDM,761,RC,10009,HCPCS,,,facility,both,,,,2539,1777.3,,,,,,,,,,,,,Gross Charge Type: Central
HC FINE NEEDLE ASPIRATION BIOPSY INCL CT GUIDANCE EACH ADDTL LESION,76100040,CDM,761,RC,10010,HCPCS,,,facility,both,,,,294,205.8,,,,,,,,,,,,,Gross Charge Type: Central
HC FINE NEEDLE ASPIRATION BIOPSY INCL MRI GUIDANCE FIRST LESION,76100041,CDM,761,RC,10011,HCPCS,,,facility,both,,,,2542,1779.4,,,,,,,,,,,,,Gross Charge Type: Central
HC FINE NEEDLE ASPIRATION BIOPSY INCL MRI GUIDANCE EACH ADDTL LESION,76100042,CDM,761,RC,10012,HCPCS,,,facility,both,,,,947,662.9,,,,,,,,,,,,,Gross Charge Type: Central
HC FINE NEEDLE ASPIRATION BIOPSY W/O IMAGE GUIDE EACH ADDTL LESION,76100043,CDM,761,RC,10004,HCPCS,,,facility,both,,,,213,149.1,,,,,,,,,,,,,Gross Charge Type: Central
HC OPTHALMOSCOPY EXTENDED W/RETINAL DRAWING/SCLERAL DEPRESSION W/INTERP & REPORT UNILAT/BILAT,76100044,CDM,761,RC,92201,HCPCS,,,facility,both,,,,298,208.6,,,,,,,,,,,,,Gross Charge Type: Central
ROOM & CARE OBS ACUTE,76200004,CDM,762,RC,G0378,HCPCS,,,facility,both,,,,39.9,27.93,,,,,,,,,,,,,Gross Charge Type: Central
HC ROOM & CARE OBS SAC,76200005,CDM,762,RC,G0378,HCPCS,,,facility,both,,,,100.8,70.56,,,,,,,,,,,,,Gross Charge Type: Central
HC ROOM & CARE OBS ICU,76200006,CDM,762,RC,G0378,HCPCS,,,facility,both,,,,145.95,102.16,,,,,,,,,,,,,Gross Charge Type: Central
OBSERVATION DA,76200007,CDM,762,RC,G0379,HCPCS,,,facility,both,,,,2566,1796.2,,,,,,,,,,,,,Gross Charge Type: Central
HC OBS CARVE OUT ACUTE,76200008,CDM,762,RC,G0378,HCPCS,,,facility,both,,,,40,28,,,,,,,,,,,,,Gross Charge Type: Central
HC OBS CARVE OUT SAC,76200009,CDM,762,RC,G0378,HCPCS,,,facility,both,,,,101,70.7,,,,,,,,,,,,,Gross Charge Type: Central
HC OBS CARVE OUT ICU,76200013,CDM,762,RC,G0378,HCPCS,,,facility,both,,,,146,102.2,,,,,,,,,,,,,Gross Charge Type: Central
TECHNETIUM TC 99M SESTAMIBI - CARDIOLITE,7663,CDM,A9500,HCPCS,65857-500-20,NDC,,,facility,both,1,EA,,214,149.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IMMUN ADMIN I VAC,77100001,CDM,771,RC,90471,HCPCS,,,facility,both,,,,221,154.7,,,,,,,,,,,,,Gross Charge Type: Central
IMMUN ADMIN EA ADDL VAC,77100002,CDM,771,RC,90472,HCPCS,,,facility,both,,,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Central
HC MCARE ADMIN FLU VACC,77100003,CDM,771,RC,90471,HCPCS,,,facility,both,,,,221,154.7,,,,,,,,,,,,,Gross Charge Type: Central
HC MCARE ADMIN PNEUMO VACC,77100004,CDM,771,RC,90471,HCPCS,,,facility,both,,,,221,154.7,,,,,,,,,,,,,Gross Charge Type: Central
HC MCARE ADMIN HEPATITIS B VACC,77100005,CDM,771,RC,90471,HCPCS,,,facility,both,,,,221,154.7,,,,,,,,,,,,,Gross Charge Type: Central
HC ADMIN TOCILIZUMAB COVID-19 1ST DOSE,77100013,CDM,771,RC,M0249,HCPCS,,,facility,both,,,,474,331.8,,,,,,,,,,,,,Gross Charge Type: Central
HC ADMIN TOCILIZUMAB COVID-19 2ND DOSE,77100014,CDM,771,RC,M0250,HCPCS,,,facility,both,,,,474,331.8,,,,,,,,,,,,,Gross Charge Type: Central
HC ADMIN RESPIRATORY SYNCYTIAL VIRUS MONOCLONAL ANTIBODY SEASONAL DOSE INTRAMUSCULAR INJECTION W/COUNSELING PHYSICIAN/OTH QUALIFIED HEALTH CARE PROFESSIONAL,77100048,CDM,771,RC,96380,HCPCS,,,facility,both,,,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Central
HC ADMIN RESPIRATORY SYNCYTIAL VIRUS MONOCLONAL ANTIBODY SEASONAL DOSE INTRAMUSCULAR INJECTION,77100049,CDM,771,RC,96381,HCPCS,,,facility,both,,,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Central
HC IV INFUSION PEMIVIBART,77100050,CDM,771,RC,M0224,HCPCS,,,facility,both,,,,475,332.5,,,,,,,,,,,,,Gross Charge Type: Central
HC TELEPHONE ASSESS/MGMT SERV NONPHYSICIAN  5-10 MIN,78000020,CDM,780,RC,98966,HCPCS,,,facility,both,,,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Central
HC TELEPHONE ASSESS/MGMT SERV NONPHYSICIAN 11-20 MIN,78000021,CDM,780,RC,98967,HCPCS,,,facility,both,,,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Central
HC TELEPHONE ASSESS/MGMT SERV NONPHYSICIAN 21-30 MIN,78000022,CDM,780,RC,98968,HCPCS,,,facility,both,,,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Central
HEMODIALYSIS ONE EVALUATION,80100001,CDM,801,RC,90935,HCPCS,,,facility,both,,,,2129,1490.3,,,,,,,,,,,,,Gross Charge Type: Central
HC CVVH SET UP FEE,80100002,CDM,801,RC,80100002,HCPCS,,,facility,both,,,,2084,1458.8,,,,,,,,,,,,,Gross Charge Type: Central
HC HEMODIALYSIS INITITAION,80100003,CDM,801,RC,80100003,HCPCS,,,facility,both,,,,1073,751.1,,,,,,,,,,,,,Gross Charge Type: Central
HC KIDNEY ACQUISITION LIVE,81100001,CDM,811,RC,81100001,HCPCS,,,facility,both,,,,100000,70000,,,,,,,,,,,,,Gross Charge Type: Central
HC KIDNEY ACQUISITION CADAVER,81200001,CDM,812,RC,81200001,HCPCS,,,facility,both,,,,100000,70000,,,,,,,,,,,,,Gross Charge Type: Central
HC KIDNEY AND PANCREAS ACQUISITION,81200002,CDM,812,RC,81200002,HCPCS,,,facility,both,,,,200000,140000,,,,,,,,,,,,,Gross Charge Type: Central
HC PANCREAS ACQUISITION CADAVER,81200003,CDM,812,RC,81200003,HCPCS,,,facility,both,,,,100000,70000,,,,,,,,,,,,,Gross Charge Type: Central
FLU VACCINE TS 2025-26 6 MO UP (PF) 45 MCG (15 MCG X 3)/0.5 ML IM SYRG,8505,CDM,90656,HCPCS,49281-425-88,NDC,,,facility,both,1,ML,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLU VACCINE TS 2024-25 65 YR UP (PF) 180 MCG/0.5 ML IM SYRG,8505,CDM,90662,HCPCS,49281-124-88,NDC,,,facility,both,1,ML,,373,261.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLU VACCINE TS 2024-25 6MOS UP (PF) 45 MCG (15 MCG X 3)/0.5 ML IM SYRG,8505,CDM,90656,HCPCS,49281-424-88,NDC,,,facility,both,1,ML,,121,84.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMINOPHYLLINE 500 MG/20 ML IV SOLN,8548,CDM,J0280,HCPCS,0409-5922-01,NDC,,,facility,both,2,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMINOPHYLLINE 500 MG/20 ML IV SOLN,8548,CDM,J0280,HCPCS,0409-5921-01,NDC,,,facility,both,1,ML,,107,74.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMINOPHYLLINE 500 MG/20 ML IV SOLN,8548,CDM,J0280,HCPCS,0409-5922-16,NDC,,,facility,both,2,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMINOPHYLLINE 500 MG/20 ML IV SOLN,8548,CDM,J0280,HCPCS,0409-5922-16,NDC,,,facility,both,2,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
AMINOPHYLLINE 500 MG/20 ML IV SOLN,8548,CDM,J0280,HCPCS,0409-5922-16,NDC,,,facility,both,2,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 20 MG/ML INJ SOLN,8555,CDM,J0360,HCPCS,63323-614-00,NDC,,,facility,both,1,ML,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 20 MG/ML INJ SOLN,8555,CDM,J0360,HCPCS,0641-6231-01,NDC,,,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDRALAZINE 20 MG/ML INJ SOLN,8555,CDM,J0360,HCPCS,63323-614-00,NDC,,,facility,both,1,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONABOTULINUMTOXINA 200 UNIT INJ SOLR,8572,CDM,J0585,HCPCS,0023-3921-02,NDC,,,facility,both,100,EA,,1599,1119.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,8572,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,57,EA,,911,637.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONABOTULINUMTOXINA 200 UNIT INJ SOLR,8572,CDM,J0585,HCPCS,0023-3921-02,NDC,,,facility,both,200,EA,,3197,2237.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,8572,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,10,EA,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,8572,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,72,EA,,504,352.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,8572,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,33,EA,,528,369.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONABOTULINUMTOXINA 200 UNIT INJ SOLR,8572,CDM,J0585,HCPCS,0023-3921-02,NDC,,,facility,both,45,EA,,313,219.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,8572,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,43,EA,,299,209.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,8572,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,155,EA,,1599,1119.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,8572,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,45,EA,,1599,1119.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,8572,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,65,EA,,1039,727.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,8572,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,35,EA,,244,170.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,8572,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,40,EA,,640,448,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,8572,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,64,EA,,1023,716.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,8572,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,70,EA,,487,340.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,8572,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,225,EA,,3596,2517.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,8572,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,95,EA,,661,462.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,8572,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,37,EA,,261,182.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,8572,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,40,EA,,278,194.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,8572,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,75,EA,,1199,839.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,8572,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,75,EA,,522,365.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,8572,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,155,EA,,3197,2237.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,8572,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,67,EA,,466,326.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,8572,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,53,EA,,847,592.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,8572,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,5,EA,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONABOTULINUMTOXINA 200 UNIT INJ SOLR,8572,CDM,J0585,HCPCS,0023-3921-02,NDC,,,facility,both,155,EA,,2477,1733.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,8572,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,22,EA,,352,246.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,8572,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,30,EA,,209,146.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,8572,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,50,EA,,800,560,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,8572,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,39,EA,,271,189.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,8572,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,30,EA,,480,336,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,8572,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,400,EA,,6393,4475.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,8572,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,200,EA,,3197,2237.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,8572,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,50,EA,,348,243.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,8572,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,155,EA,,2477,1733.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,8572,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,43,EA,,688,481.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,8572,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,32,EA,,223,156.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,8572,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,61,EA,,975,682.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,8572,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,60,EA,,417,291.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,8572,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,25,EA,,174,121.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,8572,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,45,EA,,720,504,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,8572,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,37,EA,,258,180.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,8572,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,47,EA,,327,228.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,8572,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,15,EA,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,8572,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,55,EA,,87893,61525.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,8572,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,62,EA,,435,304.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,8572,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,63,EA,,438,306.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,8572,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,37,EA,,592,414.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,8572,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,45,EA,,879,615.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,8572,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,59,EA,,943,660.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,8572,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,29,EA,,202,141.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,8572,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,20,EA,,139,97.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,8572,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,78,EA,,542,379.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,8572,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,100,EA,,879,615.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,8572,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,85,EA,,1359,951.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,8572,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,100,EA,,1599,1119.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,8572,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,55,EA,,383,268.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,8572,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,28,EA,,440,308,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,8572,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,63,EA,,999,699.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,8572,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,60,EA,,959,671.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,8572,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,90,EA,,1439,1007.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,8572,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,55,EA,,1599,1119.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,8572,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,63,EA,,1007,704.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONABOTULINUMTOXINA 200 UNIT INJ SOLR,8572,CDM,J0585,HCPCS,0023-3921-02,NDC,,,facility,both,35,EA,,244,170.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,8572,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,25,EA,,400,280,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,8572,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,36,EA,,251,175.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,8572,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,55,EA,,879,615.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,8572,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,71,EA,,1135,794.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,8572,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,38,EA,,600,420,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,8572,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,155,EA,,879,615.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,8572,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,57,EA,,397,277.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,8572,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,41,EA,,285,199.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONABOTULINUMTOXINA 200 UNIT INJ SOLR,8572,CDM,J0585,HCPCS,0023-3921-02,NDC,,,facility,both,100,EA,,695,486.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONABOTULINUMTOXINA 200 UNIT INJ SOLR,8572,CDM,J0585,HCPCS,0023-3921-02,NDC,,,facility,both,165,EA,,2637,1845.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONABOTULINUMTOXINA 200 UNIT INJ SOLR,8572,CDM,J0585,HCPCS,0023-3921-02,NDC,,,facility,both,55,EA,,879,615.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,8572,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,80,EA,,1279,895.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONABOTULINUMTOXINA 200 UNIT INJ SOLR,8572,CDM,J0585,HCPCS,0023-3921-02,NDC,,,facility,both,100,EA,,2477,1733.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,8572,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,70,EA,,1119,783.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,8572,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,45,EA,,313,219.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BOTULINUM TOXIN TYPE A 100 UNIT IM SOLR,8572,CDM,J0585,HCPCS,0023-1145-01,NDC,,,facility,both,68,EA,,1087,760.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,67457-528-10,NDC,,,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,6,EA,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,67457-528-10,NDC,,,facility,both,2,EA,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,1,EA,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,3,EA,,139,97.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,2,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,19,EA,,941,658.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-814-30,NDC,,,facility,both,4,EA,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,17,EA,,371,259.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,18,EA,,912,638.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,6,EA,,280,196,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,2,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,4,EA,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,12,EA,,595,416.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,11,EA,,558,390.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,7,EA,,151,105.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-161-20,NDC,,,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,9,EA,,412,288.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-814-30,NDC,,,facility,both,1,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,2,EA,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,20,EA,,422,295.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,16,EA,,344,240.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,12,EA,,254,177.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,15,EA,,323,226.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,7,EA,,132,92.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9552-01,NDC,,,facility,both,14,EA,,306,214.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,2,EA,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,5,EA,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,17,EA,,843,590.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9552-01,NDC,,,facility,both,12,EA,,253,177.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,13,EA,,275,192.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,67457-528-10,NDC,,,facility,both,3,EA,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9552-01,NDC,,,facility,both,16,EA,,330,231,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,4,EA,,188,131.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,13,EA,,267,186.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,12,EA,,248,173.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,5,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,11,EA,,220,154,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-161-20,NDC,,,facility,both,3,EA,,136,95.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,17,EA,,361,252.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9552-01,NDC,,,facility,both,7,EA,,150,105,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,17,EA,,352,246.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,12,EA,,252,176.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,5,EA,,231,161.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,14,EA,,300,210,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,4,EA,,184,128.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,14,EA,,705,493.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,4,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,18,EA,,382,267.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,13,EA,,281,196.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,10,EA,,509,356.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,16,EA,,806,564.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-161-20,NDC,,,facility,both,12,EA,,564,394.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,7,EA,,143,100.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,2,EA,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,11,EA,,544,380.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,21,EA,,442,309.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-161-20,NDC,,,facility,both,4,EA,,173,121.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,4,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,5,EA,,239,167.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,2,EA,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,1,EA,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9552-01,NDC,,,facility,both,10,EA,,218,152.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,14,EA,,692,484.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,6,EA,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,17,EA,,358,250.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,9,EA,,178,124.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,14,EA,,291,203.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-814-30,NDC,,,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,20,EA,,419,293.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,7,EA,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,14,EA,,285,199.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,1,EA,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,6,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,13,EA,,274,191.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,5,EA,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,2,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,6,EA,,258,180.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,5,EA,,215,150.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,8,EA,,165,115.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,11,EA,,540,378,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,16,EA,,335,234.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-161-20,NDC,,,facility,both,2,EA,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,9,EA,,185,129.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,2,EA,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,4,EA,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-814-30,NDC,,,facility,both,3,EA,,174,121.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,4,EA,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,4,EA,,185,129.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-161-20,NDC,,,facility,both,3,EA,,128,89.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-161-20,NDC,,,facility,both,3,EA,,139,97.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,20,EA,,421,294.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,5,EA,,220,154,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,3,EA,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,14,EA,,302,211.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,14,EA,,680,476,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,8,EA,,164,114.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,20,EA,,417,291.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,18,EA,,867,606.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,19,EA,,400,280,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,19,EA,,937,655.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,2,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,18,EA,,391,273.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,4,EA,,175,122.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9552-01,NDC,,,facility,both,14,EA,,304,212.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-161-20,NDC,,,facility,both,4,EA,,185,129.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,12,EA,,611,427.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,4,EA,,204,142.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,20,EA,,428,299.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,21,EA,,445,311.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,17,EA,,831,581.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9552-01,NDC,,,facility,both,16,EA,,346,242.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,12,EA,,260,182,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,17,EA,,367,256.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,4,EA,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,1,EA,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-161-20,NDC,,,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,1,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,4,EA,,164,114.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,5,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9552-01,NDC,,,facility,both,14,EA,,285,199.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,4,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9552-01,NDC,,,facility,both,10,EA,,213,149.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,18,EA,,872,610.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,15,EA,,325,227.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,14,EA,,701,490.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,15,EA,,327,228.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-161-20,NDC,,,facility,both,2,EA,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,11,EA,,224,156.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,2,EA,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9552-01,NDC,,,facility,both,16,EA,,349,244.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,14,EA,,290,203,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-814-30,NDC,,,facility,both,2,EA,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,6,EA,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,18,EA,,908,635.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,4,EA,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,5,EA,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,12,EA,,253,177.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,6,EA,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,14,EA,,306,214.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,21,EA,,1030,721,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-814-30,NDC,,,facility,both,2,EA,,108,75.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-161-20,NDC,,,facility,both,4,EA,,183,128.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,3,EA,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,12,EA,,243,170.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-814-30,NDC,,,facility,both,2,EA,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-161-20,NDC,,,facility,both,4,EA,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9552-01,NDC,,,facility,both,16,EA,,332,232.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,17,EA,,368,257.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-161-20,NDC,,,facility,both,2,EA,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,2,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,14,EA,,664,464.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,13,EA,,283,198.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,6,EA,,260,182,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,1,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,6,EA,,246,172.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,15,EA,,314,219.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-814-30,NDC,,,facility,both,1,EA,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-814-30,NDC,,,facility,both,1,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-161-20,NDC,,,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,11,EA,,550,385,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-814-30,NDC,,,facility,both,5,EA,,263,184.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,1,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,15,EA,,725,507.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,3,EA,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,9,EA,,179,125.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,4,EA,,143,100.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,67457-528-10,NDC,,,facility,both,11,EA,,639,447.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,10,EA,,218,152.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,20,EA,,435,304.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,2,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,18,EA,,389,272.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,18,EA,,888,621.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9552-01,NDC,,,facility,both,11,EA,,222,155.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,13,EA,,276,193.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,1,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,3,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,3,EA,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,3,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,11,EA,,222,155.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,2,EA,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,1,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-161-20,NDC,,,facility,both,2,EA,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,11,EA,,238,166.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-161-20,NDC,,,facility,both,3,EA,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,8,EA,,376,263.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,4,EA,,183,128.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,16,EA,,815,570.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,14,EA,,288,201.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,17,EA,,827,578.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9552-01,NDC,,,facility,both,15,EA,,327,228.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,14,EA,,712,498.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,1,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,5,EA,,209,146.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,18,EA,,377,263.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,13,EA,,652,456.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,12,EA,,241,168.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-814-30,NDC,,,facility,both,1,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,17,EA,,363,254.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,1,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-161-20,NDC,,,facility,both,6,EA,,262,183.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-161-20,NDC,,,facility,both,1,EA,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,16,EA,,766,536.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,3,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,9,EA,,176,123.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,2,EA,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-161-20,NDC,,,facility,both,3,EA,,121,84.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,16,EA,,786,550.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,10,EA,,210,147,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,4,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,18,EA,,372,260.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,12,EA,,255,178.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9552-01,NDC,,,facility,both,12,EA,,250,175,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,3,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,6,EA,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9552-01,NDC,,,facility,both,17,EA,,356,249.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,3,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,1,EA,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,10,EA,,479,335.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-161-20,NDC,,,facility,both,4,EA,,158,110.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,17,EA,,370,259,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,6,EA,,277,193.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,12,EA,,246,172.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-814-30,NDC,,,facility,both,4,EA,,231,161.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,1,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,11,EA,,231,161.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-161-20,NDC,,,facility,both,4,EA,,151,105.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,9,EA,,442,309.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,4,EA,,150,105,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,4,EA,,154,107.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9552-01,NDC,,,facility,both,14,EA,,293,205.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,11,EA,,229,160.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,2,EA,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,13,EA,,273,191.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,12,EA,,262,183.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,14,EA,,297,207.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,21,EA,,1069,748.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,9,EA,,184,128.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,14,EA,,668,467.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,3,EA,,111,77.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,13,EA,,269,188.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,6,EA,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,2,EA,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,13,EA,,272,190.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,1,EA,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,10,EA,,204,142.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,3,EA,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,12,EA,,583,408.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,3,EA,,141,98.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,4,EA,,158,110.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,2,EA,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,3,EA,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,17,EA,,839,587.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,10,EA,,213,149.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,16,EA,,346,242.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,4,EA,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,6,EA,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,19,EA,,405,283.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,17,EA,,365,255.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM  50 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9555-01,NDC,,,facility,both,1,EA,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,3,EA,,136,95.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,1,EA,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,9,EA,,418,292.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,14,EA,,299,209.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,14,EA,,713,499.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,8,EA,,166,116.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,2,EA,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,16,EA,,328,229.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,3,EA,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,3,EA,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,15,EA,,758,530.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,16,EA,,342,239.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,2,EA,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9552-01,NDC,,,facility,both,14,EA,,302,211.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,3,EA,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,15,EA,,321,224.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,12,EA,,250,175,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,5,EA,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,5,EA,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,14,EA,,697,487.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,13,EA,,648,453.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,5,EA,,213,149.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9552-01,NDC,,,facility,both,18,EA,,391,273.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,67457-530-35,NDC,,,facility,both,21,EA,,458,320.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,5,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,4,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,16,EA,,782,547.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,16,EA,,349,244.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,5,EA,,218,152.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,1,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,6,EA,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,14,EA,,295,206.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,1,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,67457-530-35,NDC,,,facility,both,14,EA,,306,214.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-161-20,NDC,,,facility,both,2,EA,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-814-30,NDC,,,facility,both,2,EA,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,18,EA,,393,275.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,9,EA,,188,131.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,4,EA,,151,105.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,14,EA,,293,205.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,3,EA,,132,92.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,6,EA,,282,197.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,5,EA,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,1,EA,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,7,EA,,316,221.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,3,EA,,129,90.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,19,EA,,396,277.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,12,EA,,249,174.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,6,EA,,130,91,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,2,EA,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,7,EA,,310,217,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9552-01,NDC,,,facility,both,7,EA,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,3,EA,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,5,EA,,196,137.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,14,EA,,688,481.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-814-30,NDC,,,facility,both,2,EA,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,16,EA,,339,237.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-161-20,NDC,,,facility,both,2,EA,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,16,EA,,802,561.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,2,EA,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9552-01,NDC,,,facility,both,13,EA,,281,196.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,1,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,2,EA,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-161-20,NDC,,,facility,both,4,EA,,169,118.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,4,EA,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,9,EA,,191,133.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,19,EA,,410,287,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,18,EA,,388,271.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,13,EA,,266,186.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,4,EA,,160,112,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,14,EA,,286,200.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-161-20,NDC,,,facility,both,2,EA,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,3,EA,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,5,EA,,211,147.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,18,EA,,374,261.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,14,EA,,305,213.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,10,EA,,489,342.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,10,EA,,208,145.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,11,EA,,236,165.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,7,EA,,356,249.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,17,EA,,355,248.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,7,EA,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,1,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,4,EA,,162,113.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,18,EA,,896,627.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,6,EA,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,13,EA,,278,194.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-814-30,NDC,,,facility,both,1,EA,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,3,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,1,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,14,EA,,292,204.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,8,EA,,361,252.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,2,EA,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,2,EA,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-161-20,NDC,,,facility,both,1,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,16,EA,,332,232.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-161-20,NDC,,,facility,both,1,EA,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9552-01,NDC,,,facility,both,18,EA,,388,271.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,17,EA,,360,252,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,19,EA,,407,284.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,14,EA,,684,478.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-814-30,NDC,,,facility,both,4,EA,,188,131.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-161-20,NDC,,,facility,both,2,EA,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,1,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,10,EA,,465,325.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,19,EA,,403,282.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-814-30,NDC,,,facility,both,4,EA,,198,138.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,2,EA,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,11,EA,,234,163.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9552-01,NDC,,,facility,both,12,EA,,262,183.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,6,EA,,265,185.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,1,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,1,EA,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,16,EA,,337,235.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9552-01,NDC,,,facility,both,15,EA,,323,226.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,13,EA,,271,189.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,11,EA,,232,162.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,67457-530-35,NDC,,,facility,both,7,EA,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,7,EA,,357,249.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,3,EA,,128,89.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,16,EA,,790,553,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,6,EA,,296,207.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9552-01,NDC,,,facility,both,17,EA,,370,259,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,18,EA,,904,632.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,19,EA,,408,285.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,5,EA,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-161-20,NDC,,,facility,both,3,EA,,132,92.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-161-20,NDC,,,facility,both,3,EA,,141,98.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,2,EA,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-161-20,NDC,,,facility,both,6,EA,,282,197.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,3,EA,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9552-01,NDC,,,facility,both,17,EA,,368,257.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,4,EA,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,15,EA,,749,524.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9552-01,NDC,,,facility,both,9,EA,,191,133.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,4,EA,,166,116.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,13,EA,,660,462,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,3,EA,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,18,EA,,379,265.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,8,EA,,174,121.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,2,EA,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,8,EA,,167,116.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,4,EA,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,1,EA,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,2,EA,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,14,EA,,304,212.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-161-20,NDC,,,facility,both,4,EA,,175,122.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,2,EA,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-161-20,NDC,,,facility,both,1,EA,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,2,EA,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-161-20,NDC,,,facility,both,3,EA,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,3,EA,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,8,EA,,383,268.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-161-20,NDC,,,facility,both,5,EA,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,17,EA,,351,245.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9552-01,NDC,,,facility,both,13,EA,,278,194.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,7,EA,,141,98.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,7,EA,,150,105,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,6,EA,,269,188.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,7,EA,,340,238,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,6,EA,,241,168.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,3,EA,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,15,EA,,315,220.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-814-30,NDC,,,facility,both,1,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-161-20,NDC,,,facility,both,6,EA,,263,184.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,16,EA,,334,233.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,12,EA,,245,171.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,19,EA,,945,661.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,18,EA,,375,262.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,3,EA,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,18,EA,,381,266.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,12,EA,,591,413.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,13,EA,,279,195.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,7,EA,,134,93.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9552-01,NDC,,,facility,both,14,EA,,300,210,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,2,EA,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-816-30,NDC,,,facility,both,15,EA,,751,525.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,6,EA,,273,191.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9552-01,NDC,,,facility,both,20,EA,,435,304.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,11,EA,,239,167.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,11,EA,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,25021-814-30,NDC,,,facility,both,3,EA,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,4,EA,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,0143-9554-01,NDC,,,facility,both,2,EA,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,4,EA,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-161-20,NDC,,,facility,both,4,EA,,188,131.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 100 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-161-20,NDC,,,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUCOVORIN CALCIUM 350 MG INJ SOLR,8579,CDM,J0640,HCPCS,71288-163-30,NDC,,,facility,both,4,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,8581,CDM,J0690,HCPCS,0143-9924-90,NDC,,,facility,both,4,EA,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,8581,CDM,J0690,HCPCS,60505-6142-0,NDC,,,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,8581,CDM,J0690,HCPCS,0143-9924-90,NDC,,,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,8581,CDM,J0690,HCPCS,44567-707-25,NDC,,,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFAZOLIN   1 GRAM INJ SOLR,8581,CDM,J0690,HCPCS,44567-707-25,NDC,,,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 250 MG INJ SOLR,8584,CDM,J0696,HCPCS,0781-3206-95,NDC,,,facility,both,2,EA,,146,102.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE NEO/PEDS (CDS MIXTURE),8584,CDM,J0696,HCPCS,0143-9857-25,NDC,,,facility,both,4,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,8584,CDM,J0696,HCPCS,44567-701-25,NDC,,,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 100 MG/ML FROM 1 GRAM VIAL (PRMC PEDS ONLY),8584,CDM,J0696,HCPCS,0409-7332-11,NDC,,,facility,both,4,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 500 MG INJ SOLR,8584,CDM,J0696,HCPCS,0409-7338-11,NDC,,,facility,both,316,EA,,1014,709.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 100 MG/ML FROM 1 GRAM VIAL (PRMC PEDS ONLY),8584,CDM,J0696,HCPCS,0409-7332-11,NDC,,,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,8584,CDM,J0696,HCPCS,25021-107-20,NDC,,,facility,both,8,EA,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,8584,CDM,J0696,HCPCS,60505-6148-0,NDC,,,facility,both,4,EA,,225,157.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 100 MG/ML FROM 1 GRAM VIAL (PRMC PEDS ONLY),8584,CDM,J0696,HCPCS,0409-7332-11,NDC,,,facility,both,3,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,8584,CDM,J0696,HCPCS,60505-6148-0,NDC,,,facility,both,4,EA,,193,135.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 500 MG INJ SOLR,8584,CDM,J0696,HCPCS,0409-7338-11,NDC,,,facility,both,2000,EA,,6416,4491.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE IN DEXTROSE (ISO-OSMOTIC) 1 GRAM/50 ML IV PIGGY BACK,8584,CDM,J0696,HCPCS,0264-3153-11,NDC,,,facility,both,4,EA,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,8584,CDM,J0696,HCPCS,60505-6148-0,NDC,,,facility,both,3,EA,,143,100.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,8584,CDM,J0696,HCPCS,60505-6148-0,NDC,,,facility,both,2,EA,,113,79.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 100 MG/ML FROM 1 GRAM VIAL (PRMC PEDS ONLY),8584,CDM,J0696,HCPCS,0409-7332-11,NDC,,,facility,both,1,EA,,4163,2914.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 500 MG INJ SOLR,8584,CDM,J0696,HCPCS,44567-700-25,NDC,,,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,8584,CDM,J0696,HCPCS,60505-6148-0,NDC,,,facility,both,1,EA,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 500 MG INJ SOLR,8584,CDM,J0696,HCPCS,60505-6152-4,NDC,,,facility,both,2,EA,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 500 MG INJ SOLR,8584,CDM,J0696,HCPCS,0409-7338-11,NDC,,,facility,both,1,EA,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,8584,CDM,J0696,HCPCS,44567-701-25,NDC,,,facility,both,8,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 250 MG INJ SOLR,8584,CDM,J0696,HCPCS,0409-7337-11,NDC,,,facility,both,1,EA,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,8584,CDM,J0696,HCPCS,44567-701-25,NDC,,,facility,both,3,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 250 MG INJ SOLR,8584,CDM,J0696,HCPCS,0781-3206-85,NDC,,,facility,both,2,EA,,146,102.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,8584,CDM,J0696,HCPCS,0143-9857-01,NDC,,,facility,both,4,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,8584,CDM,J0696,HCPCS,63323-347-20,NDC,,,facility,both,4,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 500 MG INJ SOLR,8584,CDM,J0696,HCPCS,44567-700-25,NDC,,,facility,both,3,EA,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,8584,CDM,J0696,HCPCS,44567-702-25,NDC,,,facility,both,8,EA,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,8584,CDM,J0696,HCPCS,60505-0752-4,NDC,,,facility,both,4,EA,,225,157.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,8584,CDM,J0696,HCPCS,60505-6148-0,NDC,,,facility,both,3,EA,,151,105.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,8584,CDM,J0696,HCPCS,0409-7332-01,NDC,,,facility,both,4,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 250 MG INJ SOLR,8584,CDM,J0696,HCPCS,0781-3206-85,NDC,,,facility,both,4,EA,,291,203.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 500 MG INJ SOLR,8584,CDM,J0696,HCPCS,0409-7338-11,NDC,,,facility,both,3,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,8584,CDM,J0696,HCPCS,60505-6149-0,NDC,,,facility,both,4,EA,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,8584,CDM,J0696,HCPCS,60505-6149-0,NDC,,,facility,both,4,EA,,194,135.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 500 MG INJ SOLR,8584,CDM,J0696,HCPCS,44567-700-25,NDC,,,facility,both,1,EA,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 500 MG INJ SOLR,8584,CDM,J0696,HCPCS,25021-105-10,NDC,,,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,8584,CDM,J0696,HCPCS,60505-0753-4,NDC,,,facility,both,8,EA,,388,271.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,8584,CDM,J0696,HCPCS,0781-3208-85,NDC,,,facility,both,4,EA,,225,157.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 250 MG INJ SOLR,8584,CDM,J0696,HCPCS,60505-6151-4,NDC,,,facility,both,2,EA,,156,109.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 100 MG/ML FROM 1 GRAM VIAL (PRMC PEDS ONLY),8584,CDM,J0696,HCPCS,0409-7332-11,NDC,,,facility,both,2,EA,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,8584,CDM,J0696,HCPCS,44567-702-25,NDC,,,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 250 MG INJ SOLR,8584,CDM,J0696,HCPCS,0409-7337-11,NDC,,,facility,both,3,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 500 MG INJ SOLR,8584,CDM,J0696,HCPCS,0409-7338-11,NDC,,,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 250 MG INJ SOLR,8584,CDM,J0696,HCPCS,0409-7337-11,NDC,,,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,8584,CDM,J0696,HCPCS,0409-7335-13,NDC,,,facility,both,8,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 500 MG INJ SOLR,8584,CDM,J0696,HCPCS,60505-6152-4,NDC,,,facility,both,2,EA,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 500 MG INJ SOLR,8584,CDM,J0696,HCPCS,0409-7338-11,NDC,,,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 100 MG/ML FROM 1 GRAM VIAL (PRMC PEDS ONLY),8584,CDM,J0696,HCPCS,0409-7332-11,NDC,,,facility,both,1,EA,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,8584,CDM,J0696,HCPCS,0781-3209-90,NDC,,,facility,both,8,EA,,388,271.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,8584,CDM,J0696,HCPCS,60505-6148-4,NDC,,,facility,both,4,EA,,225,157.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 250 MG INJ SOLR,8584,CDM,J0696,HCPCS,60505-0750-4,NDC,,,facility,both,5,EA,,293,205.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,8584,CDM,J0696,HCPCS,0143-9857-01,NDC,,,facility,both,8,EA,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,8584,CDM,J0696,HCPCS,60505-6149-0,NDC,,,facility,both,8,EA,,388,271.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,8584,CDM,J0696,HCPCS,44567-701-25,NDC,,,facility,both,4,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,8584,CDM,J0696,HCPCS,0409-7332-21,NDC,,,facility,both,4,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 500 MG INJ SOLR,8584,CDM,J0696,HCPCS,60505-6152-4,NDC,,,facility,both,2,EA,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE   2 GRAM INJ SOLR,8584,CDM,J0696,HCPCS,44567-702-25,NDC,,,facility,both,4,EA,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,8584,CDM,J0696,HCPCS,25021-106-10,NDC,,,facility,both,4,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 500 MG INJ SOLR,8584,CDM,J0696,HCPCS,44567-700-25,NDC,,,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,8584,CDM,J0696,HCPCS,44567-701-25,NDC,,,facility,both,5,EA,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 500 MG INJ SOLR,8584,CDM,J0696,HCPCS,0409-7338-11,NDC,,,facility,both,4,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 250 MG INJ SOLR,8584,CDM,J0696,HCPCS,0409-7337-11,NDC,,,facility,both,1,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 500 MG INJ SOLR,8584,CDM,J0696,HCPCS,0409-7338-01,NDC,,,facility,both,4,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 250 MG INJ SOLR,8584,CDM,J0696,HCPCS,0781-3206-85,NDC,,,facility,both,1,EA,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 100 MG/ML FROM 1 GRAM VIAL (PRMC PEDS ONLY),8584,CDM,J0696,HCPCS,0409-7332-11,NDC,,,facility,both,8,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 500 MG INJ SOLR,8584,CDM,J0696,HCPCS,25021-105-10,NDC,,,facility,both,4,EA,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 250 MG INJ SOLR,8584,CDM,J0696,HCPCS,0409-7337-11,NDC,,,facility,both,4,EA,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 250 MG INJ SOLR,8584,CDM,J0696,HCPCS,60505-6151-4,NDC,,,facility,both,1,EA,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 1 GRAM INJ SOLR,8584,CDM,J0696,HCPCS,63323-346-01,NDC,,,facility,both,4,EA,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CEFTRIAXONE 500 MG INJ SOLR,8584,CDM,J0696,HCPCS,0409-7338-01,NDC,,,facility,both,2,EA,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BETAMETHASONE ACET & SOD PHOS 6 MG/ML INJ SUSP,8587,CDM,J0702,HCPCS,0517-0720-01,NDC,,,facility,both,3,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BETAMETHASONE ACET & SOD PHOS 6 MG/ML INJ SUSP,8587,CDM,J0702,HCPCS,78206-118-01,NDC,,,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BETAMETHASONE ACET & SOD PHOS 6 MG/ML INJ SUSP,8587,CDM,J0702,HCPCS,0517-0720-01,NDC,,,facility,both,2,ML,,113,79.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BETAMETHASONE ACET & SOD PHOS 6 MG/ML INJ SUSP,8587,CDM,J0702,HCPCS,0517-0720-01,NDC,,,facility,both,1,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BETAMETHASONE ACET & SOD PHOS 6 MG/ML INJ SUSP,8587,CDM,J0702,HCPCS,0517-0720-01,NDC,,,facility,both,1,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BETAMETHASONE ACET & SOD PHOS 6 MG/ML INJ SUSP,8587,CDM,J0702,HCPCS,0517-0799-01,NDC,,,facility,both,2,ML,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BETAMETHASONE ACET & SOD PHOS 6 MG/ML INJ SUSP,8587,CDM,J0702,HCPCS,0517-0720-01,NDC,,,facility,both,6,ML,,337,235.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BETAMETHASONE ACET & SOD PHOS 6 MG/ML INJ SUSP,8587,CDM,J0702,HCPCS,78206-118-01,NDC,,,facility,both,2,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BETAMETHASONE ACET & SOD PHOS 6 MG/ML INJ SUSP,8587,CDM,J0702,HCPCS,0517-0720-01,NDC,,,facility,both,1,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BETAMETHASONE ACET & SOD PHOS 6 MG/ML INJ SUSP,8587,CDM,J0702,HCPCS,0517-0720-01,NDC,,,facility,both,20,ML,,1121,784.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BETAMETHASONE ACET & SOD PHOS 6 MG/ML INJ SUSP,8587,CDM,J0702,HCPCS,0517-0720-01,NDC,,,facility,both,8,ML,,449,314.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BETAMETHASONE ACET & SOD PHOS 6 MG/ML INJ SUSP,8587,CDM,J0702,HCPCS,78206-118-01,NDC,,,facility,both,2,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BETAMETHASONE ACET & SOD PHOS 6 MG/ML INJ SUSP,8587,CDM,J0702,HCPCS,78206-118-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BETAMETHASONE ACET & SOD PHOS 6 MG/ML INJ SUSP,8587,CDM,J0702,HCPCS,78206-118-01,NDC,,,facility,both,1,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BETAMETHASONE ACET & SOD PHOS 6 MG/ML INJ SUSP,8587,CDM,J0702,HCPCS,0517-0720-01,NDC,,,facility,both,3,ML,,169,118.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BETAMETHASONE ACET & SOD PHOS 6 MG/ML INJ SUSP,8587,CDM,J0702,HCPCS,0517-0720-01,NDC,,,facility,both,4,ML,,225,157.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BETAMETHASONE ACET & SOD PHOS 6 MG/ML INJ SUSP,8587,CDM,J0702,HCPCS,0517-0720-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BETAMETHASONE ACET & SOD PHOS 6 MG/ML INJ SUSP,8587,CDM,J0702,HCPCS,0517-0720-01,NDC,,,facility,both,5,ML,,281,196.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,8599,CDM,J0780,HCPCS,0641-6135-25,NDC,,,facility,both,1,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,8599,CDM,J0780,HCPCS,23155-294-31,NDC,,,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,8599,CDM,J0780,HCPCS,55390-077-10,NDC,,,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,8599,CDM,J0780,HCPCS,0641-6135-25,NDC,,,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,8599,CDM,J0780,HCPCS,23155-294-31,NDC,,,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,8599,CDM,J0780,HCPCS,23155-294-31,NDC,,,facility,both,1,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,8599,CDM,J0780,HCPCS,23155-294-31,NDC,,,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,8599,CDM,J0780,HCPCS,23155-294-31,NDC,,,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN,8599,CDM,J0780,HCPCS,0713-0351-02,NDC,,,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE (CONTRACEPTIVE) 150 MG/ML IM SUSP,8612,CDM,J1050,HCPCS,0009-0746-35,NDC,,,facility,both,150,ML,,268,187.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE (CONTRACEPTIVE) 150 MG/ML IM (MERGE),8612,CDM,J1050,HCPCS,67457-887-00,NDC,,,facility,both,150,ML,,202,141.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE (CONTRACEPTIVE) 150 MG/ML IM (MERGE),8612,CDM,J1050,HCPCS,66993-370-83,NDC,,,facility,both,150,ML,,415,290.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE (CONTRACEPTIVE) 150 MG/ML IM SUSP,8612,CDM,J1050,HCPCS,0009-0746-30,NDC,,,facility,both,150,ML,,268,187.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE (CONTRACEPTIVE) 150 MG/ML IM (MERGE),8612,CDM,J1050,HCPCS,0009-7376-11,NDC,,,facility,both,150,ML,,280,196,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE (CONTRACEPTIVE) 150 MG/ML IM SUSP,8612,CDM,J1050,HCPCS,0009-0746-30,NDC,,,facility,both,150,ML,,268,187.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE (CONTRACEPTIVE) 150 MG/ML IM (MERGE),8612,CDM,J1050,HCPCS,67457-887-00,NDC,,,facility,both,150,ML,,202,141.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE (CONTRACEPTIVE) 150 MG/ML IM (MERGE),8612,CDM,J1050,HCPCS,66993-370-83,NDC,,,facility,both,150,ML,,415,290.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE (CONTRACEPTIVE) 150 MG/ML IM (MERGE),8612,CDM,J1050,HCPCS,59762-4537-1,NDC,,,facility,both,150,ML,,415,290.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE (CONTRACEPTIVE) 150 MG/ML IM (MERGE),8612,CDM,J1050,HCPCS,0009-7376-11,NDC,,,facility,both,150,ML,,280,196,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE 150 MG/ML IM SYRG,8612,CDM,J1050,HCPCS,0548-5701-00,NDC,,,facility,both,150,ML,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE (CONTRACEPTIVE) 150 MG/ML IM (MERGE),8612,CDM,J1050,HCPCS,55150-330-01,NDC,,,facility,both,150,ML,,357,249.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE (CONTRACEPTIVE) 150 MG/ML IM SUSP,8612,CDM,J1050,HCPCS,55150-329-01,NDC,,,facility,both,150,ML,,216,151.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE (CONTRACEPTIVE) 150 MG/ML IM (MERGE),8612,CDM,J1050,HCPCS,0548-5400-25,NDC,,,facility,both,150,ML,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE (CONTRACEPTIVE) 150 MG/ML IM (MERGE),8612,CDM,J1050,HCPCS,0703-6801-01,NDC,,,facility,both,150,ML,,415,290.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE (CONTRACEPTIVE) 150 MG/ML IM (MERGE),8612,CDM,J1050,HCPCS,66993-371-79,NDC,,,facility,both,150,ML,,415,290.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEDROXYPROGESTERONE (CONTRACEPTIVE) 150 MG/ML IM (MERGE),8612,CDM,J1050,HCPCS,67457-887-00,NDC,,,facility,both,150,ML,,202,141.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,8618,CDM,J1100,HCPCS,67457-423-12,NDC,,,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,8618,CDM,J1100,HCPCS,63323-506-00,NDC,,,facility,both,10,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,8618,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,1,ML,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,8618,CDM,J1100,HCPCS,63323-165-01,NDC,,,facility,both,6,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,8618,CDM,J1100,HCPCS,63323-506-41,NDC,,,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,8618,CDM,J1100,HCPCS,67457-423-00,NDC,,,facility,both,2,ML,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,8618,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,7,ML,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,8618,CDM,J1100,HCPCS,63323-506-41,NDC,,,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,8618,CDM,J1100,HCPCS,63323-165-01,NDC,,,facility,both,12,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,8618,CDM,J1100,HCPCS,25021-053-01,NDC,,,facility,both,3,ML,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 10 MG/ML INJECTION,8618,CDM,J1100,HCPCS,0641-0367-21,NDC,,,facility,both,20,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,8618,CDM,J1100,HCPCS,67457-421-00,NDC,,,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,8618,CDM,J1100,HCPCS,63323-506-01,NDC,,,facility,both,10,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 10 MG/ML FOR ORAL OR INJECTION (PEDS ONC),8618,CDM,J1100,HCPCS,55150-305-10,NDC,,,facility,both,10,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,8618,CDM,J1100,HCPCS,63323-165-30,NDC,,,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,8618,CDM,J1100,HCPCS,0641-6145-01,NDC,,,facility,both,10,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,8618,CDM,J1100,HCPCS,0641-6145-01,NDC,,,facility,both,2,ML,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,8618,CDM,J1100,HCPCS,0641-6145-01,NDC,,,facility,both,9,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,8618,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,9,ML,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 20MG/55 ML IVPB IN NS (ONCOLOGY),8618,CDM,J1100,HCPCS,63323-165-02,NDC,,,facility,both,20,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,8618,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,7,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,8618,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,8,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,8618,CDM,J1100,HCPCS,67457-421-00,NDC,,,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,8618,CDM,J1100,HCPCS,25021-053-01,NDC,,,facility,both,7,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,8618,CDM,J1100,HCPCS,67457-421-00,NDC,,,facility,both,40,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,8618,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,10,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,8618,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,9,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,8618,CDM,J1100,HCPCS,63323-165-30,NDC,,,facility,both,116,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 10 MG/ML INJECTION,8618,CDM,J1100,HCPCS,63323-516-10,NDC,,,facility,both,100,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,8618,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,8618,CDM,J1100,HCPCS,63323-506-41,NDC,,,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,8618,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,15,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,8618,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,8,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,8618,CDM,J1100,HCPCS,55150-304-01,NDC,,,facility,both,10,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 20MG/55 ML IVPB IN NS (ONCOLOGY),8618,CDM,J1100,HCPCS,63323-165-02,NDC,,,facility,both,6,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,8618,CDM,J1100,HCPCS,63323-506-41,NDC,,,facility,both,3,ML,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,8618,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,7,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,8618,CDM,J1100,HCPCS,67457-423-12,NDC,,,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,8618,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,6,ML,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,8618,CDM,J2003,HCPCS,63323-492-09,NDC,,,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,8618,CDM,J1100,HCPCS,0641-6145-25,NDC,,,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,8618,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,8,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 10 MG/ML INJECTION,8618,CDM,J1100,HCPCS,0641-0367-25,NDC,,,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,8618,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,2,ML,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,8618,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,8,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,8618,CDM,J1100,HCPCS,67457-423-00,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,8618,CDM,J1100,HCPCS,63323-165-01,NDC,,,facility,both,8,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,8618,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,5,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,8618,CDM,J1940,HCPCS,23155-473-32,NDC,,,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,8618,CDM,J1100,HCPCS,67457-423-00,NDC,,,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,8618,CDM,J1100,HCPCS,63323-165-01,NDC,,,facility,both,2,ML,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 10 MG/ML INJECTION,8618,CDM,J1100,HCPCS,67457-420-10,NDC,,,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 10 MG/ML INJECTION,8618,CDM,J1100,HCPCS,67457-420-10,NDC,,,facility,both,92,ML,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,8618,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,11,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,8618,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,16,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,8618,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,6,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,8618,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,8,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,8618,CDM,J1100,HCPCS,63323-506-41,NDC,,,facility,both,7,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 20MG/55 ML IVPB IN NS (ONCOLOGY),8618,CDM,J1100,HCPCS,63323-165-02,NDC,,,facility,both,10,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 10 MG/ML INJECTION,8618,CDM,J1100,HCPCS,0641-0367-21,NDC,,,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,8618,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,6,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,8618,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,7,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,8618,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,8618,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,9,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,8618,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,9,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,8618,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,7,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,8618,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,10,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,8618,CDM,J1100,HCPCS,67457-423-00,NDC,,,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 20MG/55 ML IVPB IN NS (ONCOLOGY),8618,CDM,J1100,HCPCS,63323-165-02,NDC,,,facility,both,10,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,8618,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,5,ML,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 10 MG/ML INJECTION,8618,CDM,J1100,HCPCS,67457-420-00,NDC,,,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,8618,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,8,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,8618,CDM,J1100,HCPCS,63323-506-41,NDC,,,facility,both,6,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,8618,CDM,J1100,HCPCS,0641-6145-01,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,8618,CDM,J1100,HCPCS,67457-421-00,NDC,,,facility,both,20,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,8618,CDM,J1100,HCPCS,67457-421-00,NDC,,,facility,both,12,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,8618,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,12,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,8618,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,4,ML,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,8618,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,8618,CDM,J1100,HCPCS,63323-165-01,NDC,,,facility,both,4,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,8618,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,9,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,8618,CDM,J1100,HCPCS,63323-165-30,NDC,,,facility,both,20,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,8618,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,6,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,8618,CDM,J1100,HCPCS,63323-506-01,NDC,,,facility,both,10,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,8618,CDM,J1100,HCPCS,25021-053-01,NDC,,,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,8618,CDM,J1100,HCPCS,55150-304-01,NDC,,,facility,both,10,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,8618,CDM,J1100,HCPCS,0641-6145-01,NDC,,,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,8618,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,8618,CDM,J1100,HCPCS,63323-165-01,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,8618,CDM,J1100,HCPCS,63323-506-41,NDC,,,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,8618,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,8,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,8618,CDM,J1100,HCPCS,67457-421-00,NDC,,,facility,both,16,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,8618,CDM,J1100,HCPCS,67457-423-00,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 20MG/55 ML IVPB IN NS (ONCOLOGY),8618,CDM,J1100,HCPCS,63323-165-02,NDC,,,facility,both,12,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 4 MG/ML INJECTION,8618,CDM,J1100,HCPCS,67457-423-00,NDC,,,facility,both,3,ML,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,8618,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,8618,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,6,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE SODIUM PHOS (PF) 10MG/ML INJ SOLN,8618,CDM,J1100,HCPCS,70069-021-01,NDC,,,facility,both,8,ML,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXAMETHASONE 20MG/55 ML IVPB IN NS (ONCOLOGY),8618,CDM,J1100,HCPCS,63323-165-02,NDC,,,facility,both,8,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 50 MG/ML INJECTION,8625,CDM,J1200,HCPCS,63323-664-00,NDC,,,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 50 MG/ML INJECTION,8625,CDM,J1200,HCPCS,25021-481-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 50 MG/ML INJECTION,8625,CDM,J1200,HCPCS,0641-0376-25,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 50 MG/ML INJECTION,8625,CDM,J1200,HCPCS,0641-0376-21,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIPHENHYDRAMINE 50 MG/ML INJECTION,8625,CDM,J1200,HCPCS,72485-101-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOBUTAMINE IN D5W 500 MG/250 ML (2 MG/ML) INFUSION (PREMIX),8631,CDM,J1250,HCPCS,0338-1075-02,NDC,,,facility,both,2,ML,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESTRADIOL VALERATE 20 MG/ML IM OIL,8636,CDM,J1380,HCPCS,70700-274-22,NDC,,,facility,both,1,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ESTRADIOL VALERATE 20 MG/ML IM OIL,8636,CDM,J1380,HCPCS,0517-0420-01,NDC,,,facility,both,1,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-21,NDC,,,facility,both,10,ML,,1415,990.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-25,NDC,,,facility,both,20,ML,,1230,861,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-25,NDC,,,facility,both,80,ML,,11316,7921.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-41,NDC,,,facility,both,90,ML,,12730,8911,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 40 GRAM/400 ML (10 %) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-20,NDC,,,facility,both,100,ML,,14144,9900.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-21,NDC,,,facility,both,180,ML,,25459,17821.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-41,NDC,,,facility,both,120,ML,,16973,11881.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 10 GRAM/100 ML (10%) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-72,NDC,,,facility,both,20,ML,,2829,1980.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-24,NDC,,,facility,both,240,ML,,33946,23762.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 1 GRAM/10 ML (10 %) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-12,NDC,,,facility,both,80,ML,,17711,12397.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 10 GRAM/100 ML (10%) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-72,NDC,,,facility,both,130,ML,,18388,12871.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-24,NDC,,,facility,both,130,ML,,18388,12871.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-41,NDC,,,facility,both,50,ML,,3075,2152.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 1 GRAM/10 ML (10 %) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-12,NDC,,,facility,both,40,ML,,8856,6199.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-25,NDC,,,facility,both,50,ML,,7072,4950.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-25,NDC,,,facility,both,80,ML,,11316,7921.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN (NEW TX NON-NEURO INDICATION)",8655,CDM,J1561,HCPCS,13533-800-71,NDC,,,facility,both,100,ML,,14144,9900.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-25,NDC,,,facility,both,80,ML,,11316,7921.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-21,NDC,,,facility,both,60,ML,,8487,5940.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 1 GRAM/10 ML (10 %) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-12,NDC,,,facility,both,60,ML,,13283,9298.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-41,NDC,,,facility,both,40,ML,,2460,1722,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-25,NDC,,,facility,both,40,ML,,5658,3960.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 40 GRAM/400 ML (10 %) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-20,NDC,,,facility,both,190,ML,,26874,18811.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 40 GRAM/400 ML (10 %) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-20,NDC,,,facility,both,60,ML,,8487,5940.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-41,NDC,,,facility,both,80,ML,,11316,7921.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN (NEW TX NON-NEURO INDICATION)",8655,CDM,J1561,HCPCS,13533-800-71,NDC,,,facility,both,80,ML,,11316,7921.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-41,NDC,,,facility,both,60,ML,,3690,2583,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-41,NDC,,,facility,both,100,ML,,14144,9900.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 10 GRAM/100 ML (10%) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-72,NDC,,,facility,both,20,ML,,2829,1980.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 40 GRAM/400 ML (10 %) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-20,NDC,,,facility,both,80,ML,,11316,7921.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-21,NDC,,,facility,both,50,ML,,7072,4950.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 40 GRAM/400 ML (10 %) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-20,NDC,,,facility,both,160,ML,,22631,15841.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-21,NDC,,,facility,both,190,ML,,26874,18811.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 40 GRAM/400 ML (10 %) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-20,NDC,,,facility,both,110,ML,,15559,10891.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-41,NDC,,,facility,both,80,ML,,11316,7921.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-41,NDC,,,facility,both,160,ML,,22631,15841.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-21,NDC,,,facility,both,70,ML,,9901,6930.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-41,NDC,,,facility,both,120,ML,,16973,11881.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-21,NDC,,,facility,both,170,ML,,24045,16831.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-25,NDC,,,facility,both,10,ML,,615,430.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-41,NDC,,,facility,both,80,ML,,11316,7921.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-25,NDC,,,facility,both,40,ML,,5658,3960.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-41,NDC,,,facility,both,100,ML,,14144,9900.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 1 GRAM/10 ML (10 %) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-12,NDC,,,facility,both,70,ML,,15497,10847.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-25,NDC,,,facility,both,70,ML,,9901,6930.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-25,NDC,,,facility,both,40,ML,,5658,3960.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-41,NDC,,,facility,both,80,ML,,11316,7921.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 10 GRAM/100 ML (10%) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-72,NDC,,,facility,both,80,ML,,11316,7921.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 10 GRAM/100 ML (10%) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-72,NDC,,,facility,both,40,ML,,5658,3960.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-21,NDC,,,facility,both,50,ML,,7072,4950.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 10 GRAM/100 ML (10%) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-72,NDC,,,facility,both,100,ML,,14144,9900.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-21,NDC,,,facility,both,150,ML,,21216,14851.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 40 GRAM/400 ML (10 %) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-20,NDC,,,facility,both,100,ML,,14144,9900.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-41,NDC,,,facility,both,190,ML,,26874,18811.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-21,NDC,,,facility,both,50,ML,,7072,4950.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-25,NDC,,,facility,both,70,ML,,9901,6930.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-21,NDC,,,facility,both,10,ML,,1415,990.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-24,NDC,,,facility,both,40,ML,,5658,3960.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-25,NDC,,,facility,both,40,ML,,5658,3960.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 40 GRAM/400 ML (10 %) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-20,NDC,,,facility,both,50,ML,,7072,4950.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN (NEW TX NON-NEURO INDICATION)",8655,CDM,J1561,HCPCS,13533-800-71,NDC,,,facility,both,20,ML,,2829,1980.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 10 GRAM/100 ML (10%) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-72,NDC,,,facility,both,180,ML,,25459,17821.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 10 GRAM/100 ML (10%) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-72,NDC,,,facility,both,20,ML,,2829,1980.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 40 GRAM/400 ML (10 %) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-20,NDC,,,facility,both,150,ML,,21216,14851.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-21,NDC,,,facility,both,10,ML,,1415,990.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 40 GRAM/400 ML (10 %) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-20,NDC,,,facility,both,40,ML,,5658,3960.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN (NEW TX NON-NEURO INDICATION)",8655,CDM,J1561,HCPCS,13533-800-71,NDC,,,facility,both,90,ML,,12730,8911,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 40 GRAM/400 ML (10 %) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-20,NDC,,,facility,both,50,ML,,7072,4950.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 40 GRAM/400 ML (10 %) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-20,NDC,,,facility,both,90,ML,,12730,8911,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN (NEW TX NON-NEURO INDICATION)",8655,CDM,J1561,HCPCS,13533-800-71,NDC,,,facility,both,60,ML,,8487,5940.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-24,NDC,,,facility,both,50,ML,,7072,4950.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-25,NDC,,,facility,both,70,ML,,9901,6930.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-41,NDC,,,facility,both,40,ML,,2460,1722,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 1 GRAM/10 ML (10 %) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-12,NDC,,,facility,both,50,ML,,11070,7749,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-25,NDC,,,facility,both,30,ML,,1845,1291.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-25,NDC,,,facility,both,10,ML,,615,430.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-21,NDC,,,facility,both,70,ML,,9901,6930.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 40 GRAM/400 ML (10 %) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-20,NDC,,,facility,both,10,ML,,1415,990.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-25,NDC,,,facility,both,50,ML,,7072,4950.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-21,NDC,,,facility,both,90,ML,,12730,8911,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-25,NDC,,,facility,both,60,ML,,8487,5940.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 40 GRAM/400 ML (10 %) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-20,NDC,,,facility,both,60,ML,,8487,5940.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-25,NDC,,,facility,both,10,ML,,615,430.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN (NEW TX NON-NEURO INDICATION)",8655,CDM,J1561,HCPCS,13533-800-71,NDC,,,facility,both,140,ML,,19802,13861.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-24,NDC,,,facility,both,120,ML,,16973,11881.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-25,NDC,,,facility,both,20,ML,,1230,861,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 40 GRAM/400 ML (10 %) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-20,NDC,,,facility,both,80,ML,,11316,7921.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-25,NDC,,,facility,both,80,ML,,11316,7921.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-41,NDC,,,facility,both,70,ML,,4305,3013.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-41,NDC,,,facility,both,240,ML,,33946,23762.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 10 GRAM/100 ML (10%) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-72,NDC,,,facility,both,60,ML,,8487,5940.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 40 GRAM/400 ML (10 %) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-20,NDC,,,facility,both,130,ML,,18388,12871.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 40 GRAM/400 ML (10 %) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-20,NDC,,,facility,both,70,ML,,9901,6930.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-21,NDC,,,facility,both,80,ML,,11316,7921.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-21,NDC,,,facility,both,130,ML,,18388,12871.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN (NEW TX NON-NEURO INDICATION)",8655,CDM,J1561,HCPCS,13533-800-71,NDC,,,facility,both,70,ML,,9901,6930.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-41,NDC,,,facility,both,60,ML,,3690,2583,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-25,NDC,,,facility,both,30,ML,,1845,1291.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN (NEW TX NON-NEURO INDICATION)",8655,CDM,J1561,HCPCS,13533-800-71,NDC,,,facility,both,50,ML,,7072,4950.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN (NEW TX NON-NEURO INDICATION)",8655,CDM,J1561,HCPCS,13533-800-71,NDC,,,facility,both,120,ML,,16973,11881.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-21,NDC,,,facility,both,110,ML,,15559,10891.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 1 GRAM/10 ML (10 %) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-12,NDC,,,facility,both,100,ML,,22139,15497.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 5 GRAM/50 ML (10 %) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-21,NDC,,,facility,both,10,ML,,1415,990.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 40 GRAM/400 ML (10 %) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-40,NDC,,,facility,both,80,ML,,11316,7921.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 40 GRAM/400 ML (10 %) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-20,NDC,,,facility,both,70,ML,,9901,6930.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-25,NDC,,,facility,both,60,ML,,8487,5940.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
"IMMUNE GLOBULIN(HUM),CAPR(IGG) 20 GRAM/200 ML (10%) INJ SOLN",8655,CDM,J1561,HCPCS,13533-800-41,NDC,,,facility,both,80,ML,,11316,7921.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,8658,CDM,J1580,HCPCS,63323-010-03,NDC,,,facility,both,4,ML,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,8658,CDM,J1580,HCPCS,63323-010-01,NDC,,,facility,both,4,ML,,101,70.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,8658,CDM,J1580,HCPCS,0409-1207-13,NDC,,,facility,both,5,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,8658,CDM,J1580,HCPCS,63323-010-01,NDC,,,facility,both,2,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,8658,CDM,J1580,HCPCS,63323-010-01,NDC,,,facility,both,3,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,8658,CDM,J1580,HCPCS,0409-1207-13,NDC,,,facility,both,3,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,8658,CDM,J1580,HCPCS,63323-010-02,NDC,,,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,8658,CDM,J1580,HCPCS,63323-010-01,NDC,,,facility,both,4,ML,,108,75.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,8658,CDM,J1580,HCPCS,63323-010-01,NDC,,,facility,both,3,ML,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,8658,CDM,J1580,HCPCS,63323-010-03,NDC,,,facility,both,3,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,8658,CDM,J1580,HCPCS,63323-010-01,NDC,,,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,8658,CDM,J1580,HCPCS,63323-010-01,NDC,,,facility,both,3,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,8658,CDM,J1580,HCPCS,55150-402-01,NDC,,,facility,both,2,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,8658,CDM,J1580,HCPCS,0409-1207-13,NDC,,,facility,both,4,ML,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,8658,CDM,J1580,HCPCS,0409-1207-13,NDC,,,facility,both,2,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,8658,CDM,J1580,HCPCS,55150-402-01,NDC,,,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,8658,CDM,J1580,HCPCS,63323-010-01,NDC,,,facility,both,2,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,8658,CDM,J1580,HCPCS,63323-010-01,NDC,,,facility,both,3,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,8658,CDM,J1580,HCPCS,63323-010-01,NDC,,,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,8658,CDM,J1580,HCPCS,63323-010-01,NDC,,,facility,both,5,ML,,155,108.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,8658,CDM,J1580,HCPCS,0409-1207-13,NDC,,,facility,both,3,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,8658,CDM,J1580,HCPCS,63323-010-01,NDC,,,facility,both,3,ML,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,8658,CDM,J1580,HCPCS,63323-010-03,NDC,,,facility,both,3,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,8658,CDM,J1580,HCPCS,63323-010-01,NDC,,,facility,both,2,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,8658,CDM,J1580,HCPCS,63323-010-01,NDC,,,facility,both,4,ML,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,8658,CDM,J1580,HCPCS,63323-010-01,NDC,,,facility,both,3,ML,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,8658,CDM,J1580,HCPCS,0409-1207-13,NDC,,,facility,both,4,ML,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,8658,CDM,J1580,HCPCS,63323-010-02,NDC,,,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,8658,CDM,J1580,HCPCS,63323-010-01,NDC,,,facility,both,3,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,8658,CDM,J1580,HCPCS,63323-010-01,NDC,,,facility,both,2,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,8658,CDM,J1580,HCPCS,63323-010-02,NDC,,,facility,both,3,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GENTAMICIN 40 MG/ML INJ SOLN,8658,CDM,J1580,HCPCS,63323-010-01,NDC,,,facility,both,3,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GLUCAGON 1 MG/ML INJ (MERGE),8660,CDM,J1610,HCPCS,63323-596-11,NDC,,,facility,both,1,EA,,785,549.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),8663,CDM,J1630,HCPCS,67457-426-00,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL LACTATE 5 MG/ML INJECTION (MERGE),8663,CDM,J1630,HCPCS,67457-426-00,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HALOPERIDOL DECANOATE 100 MG/ML IM SOLN,8664,CDM,J1631,HCPCS,70756-616-81,NDC,,,facility,both,4,ML,,317,221.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN LOCK FLUSH 100 UNIT/ML IV SOLN,8665,CDM,J1642,HCPCS,6425333335,NDC,,,facility,both,50,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,8666,CDM,J1644,HCPCS,0409-2720-31,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,8666,CDM,J1644,HCPCS,0409-2723-01,NDC,,,facility,both,25000,ML,,67145,47001.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,8666,CDM,J1644,HCPCS,0409-2723-02,NDC,,,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,8666,CDM,J1644,HCPCS,0641-0400-37,NDC,,,facility,both,10,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,8666,CDM,J1644,HCPCS,63323-047-10,NDC,,,facility,both,10,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) 10000 UNIT/ML INJ SOLN,8666,CDM,J1644,HCPCS,0641-0410-12,NDC,,,facility,both,10,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE) 10000 UNIT/ML INJ SOLN,8666,CDM,J1644,HCPCS,0641-0410-37,NDC,,,facility,both,10,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  1000 UNIT/ML INJ SOLN,8666,CDM,J1644,HCPCS,0409-2720-30,NDC,,,facility,both,3,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HEPARIN (PORCINE)  5000 UNIT/ML INJ SOLN,8666,CDM,J1644,HCPCS,0409-2723-01,NDC,,,facility,both,10,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,8667,CDM,J1650,HCPCS,0955-1004-01,NDC,,,facility,both,4,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,8667,CDM,J1650,HCPCS,0548-5603-00,NDC,,,facility,both,10,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,8667,CDM,J1650,HCPCS,0548-5604-00,NDC,,,facility,both,8,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 100 MG/1 ML SUBQ SYRG,8667,CDM,J1650,HCPCS,0548-5605-00,NDC,,,facility,both,10,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 100 MG/1 ML SUBQ SYRG,8667,CDM,J1650,HCPCS,0548-5605-00,NDC,,,facility,both,20,ML,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 100 MG/1 ML SUBQ SYRG,8667,CDM,J1650,HCPCS,0548-5605-00,NDC,,,facility,both,2,ML,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 100 MG/1 ML SUBQ SYRG,8667,CDM,J1650,HCPCS,0548-5605-00,NDC,,,facility,both,8,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,8667,CDM,J1650,HCPCS,0548-5603-00,NDC,,,facility,both,3,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 100 MG/1 ML SUBQ SYRG,8667,CDM,J1650,HCPCS,0548-5605-00,NDC,,,facility,both,4,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,8667,CDM,J1650,HCPCS,0548-5603-00,NDC,,,facility,both,10,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 30 MG/0.3 ML SUBQ SYRG,8667,CDM,J1650,HCPCS,0955-1003-01,NDC,,,facility,both,3,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRG,8667,CDM,J1650,HCPCS,16714-016-01,NDC,,,facility,both,4,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 100 MG/1 ML SUBQ SYRG,8667,CDM,J1650,HCPCS,0075-0623-00,NDC,,,facility,both,10,ML,,146,102.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,8667,CDM,J1650,HCPCS,0548-5603-00,NDC,,,facility,both,6,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 100 MG/1 ML SUBQ SYRG,8667,CDM,J1650,HCPCS,0548-5605-00,NDC,,,facility,both,10,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRG,8667,CDM,J1650,HCPCS,0548-5603-00,NDC,,,facility,both,12,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 100 MG/1 ML SUBQ SYRG,8667,CDM,J1650,HCPCS,0548-5605-00,NDC,,,facility,both,6,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRG,8667,CDM,J1650,HCPCS,0955-1008-01,NDC,,,facility,both,8,ML,,101,70.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 120 MG/0.8 ML SUBQ SYRG,8667,CDM,J1650,HCPCS,16714-056-01,NDC,,,facility,both,12,ML,,141,98.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ENOXAPARIN 100 MG/1 ML SUBQ SYRG,8667,CDM,J1650,HCPCS,63323-586-21,NDC,,,facility,both,6,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE SOD SUCC (PF) 100 MG/2 ML INJ SOLR,8672,CDM,J1720,HCPCS,0009-0011-03,NDC,,,facility,both,1,EA,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE SOD SUCC (PF) 100 MG/2 ML INJ SOLR,8672,CDM,J1720,HCPCS,0009-0011-03,NDC,,,facility,both,25,EA,,3362,2353.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE 100 MG SOLUTION FOR INJECTION,8672,CDM,J1720,HCPCS,0009-0825-01,NDC,,,facility,both,1,EA,,108,75.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE SOD SUCC (PF) 100 MG/2 ML INJ SOLR,8672,CDM,J1720,HCPCS,0009-0011-03,NDC,,,facility,both,2,EA,,252,176.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE SOD SUCC (PF) 100 MG/2 ML INJ SOLR,8672,CDM,J1720,HCPCS,0009-0011-03,NDC,,,facility,both,1,EA,,126,88.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROCORTISONE SOD SUCC (PF) 100 MG/2 ML INJ SOLR,8672,CDM,J1720,HCPCS,0009-0011-03,NDC,,,facility,both,1,EA,,142,99.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DROPERIDOL 2.5 MG/ML INJ SOLN,8680,CDM,J1790,HCPCS,0517-9702-01,NDC,,,facility,both,1,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,8687,CDM,J1885,HCPCS,72266-119-01,NDC,,,facility,both,1,ML,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,8687,CDM,J1885,HCPCS,68462-756-01,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,8687,CDM,J1885,HCPCS,63323-162-03,NDC,,,facility,both,2,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,8687,CDM,J1885,HCPCS,0409-3796-19,NDC,,,facility,both,2,ML,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,8687,CDM,J1885,HCPCS,72266-118-01,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,8687,CDM,J1885,HCPCS,63323-162-01,NDC,,,facility,both,2,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,8687,CDM,J1885,HCPCS,0409-3796-19,NDC,,,facility,both,3,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,8687,CDM,J1885,HCPCS,63323-162-03,NDC,,,facility,both,4,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,8687,CDM,J1885,HCPCS,72266-119-01,NDC,,,facility,both,2,ML,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,8687,CDM,J1885,HCPCS,0641-6042-25,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,8687,CDM,J1885,HCPCS,55154-0120-5,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,8687,CDM,J1885,HCPCS,63323-162-00,NDC,,,facility,both,1,ML,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,8687,CDM,J1885,HCPCS,62332-600-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,8687,CDM,J1885,HCPCS,0409-3795-19,NDC,,,facility,both,2,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,8687,CDM,J1885,HCPCS,62332-601-02,NDC,,,facility,both,2,ML,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,8687,CDM,J1885,HCPCS,72266-118-25,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,8687,CDM,J1885,HCPCS,72266-119-01,NDC,,,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 15 MG/ML INJ SOLN,8687,CDM,J1885,HCPCS,0641-6041-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,8687,CDM,J1885,HCPCS,72266-118-01,NDC,,,facility,both,2,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,8687,CDM,J1885,HCPCS,63323-162-03,NDC,,,facility,both,1,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,8687,CDM,J1885,HCPCS,63323-162-12,NDC,,,facility,both,2,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,8687,CDM,J1885,HCPCS,72266-118-01,NDC,,,facility,both,1,ML,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,8687,CDM,J1885,HCPCS,0409-3796-01,NDC,,,facility,both,4,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,8687,CDM,J1885,HCPCS,72266-118-01,NDC,,,facility,both,4,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,8687,CDM,J1885,HCPCS,0409-3796-19,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,8687,CDM,J1885,HCPCS,72611-722-25,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,8687,CDM,J1885,HCPCS,55390-481-02,NDC,,,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,8687,CDM,J1885,HCPCS,63323-162-03,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,8687,CDM,J1885,HCPCS,25021-701-01,NDC,,,facility,both,2,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,8687,CDM,J1885,HCPCS,0338-0072-25,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,8687,CDM,J1885,HCPCS,0641-6042-01,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,8687,CDM,J1885,HCPCS,70860-701-04,NDC,,,facility,both,2,ML,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,8687,CDM,J1885,HCPCS,25021-701-01,NDC,,,facility,both,1,ML,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,8687,CDM,J1885,HCPCS,0338-0072-25,NDC,,,facility,both,4,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,8687,CDM,J1885,HCPCS,0409-3796-19,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,8687,CDM,J1885,HCPCS,55390-481-02,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,8687,CDM,J1885,HCPCS,63323-162-02,NDC,,,facility,both,4,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,8687,CDM,J1885,HCPCS,72266-119-25,NDC,,,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,8687,CDM,J1885,HCPCS,72266-119-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,8687,CDM,J1885,HCPCS,62332-601-02,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,8687,CDM,J1885,HCPCS,72266-118-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,8687,CDM,J1885,HCPCS,0409-3795-19,NDC,,,facility,both,4,ML,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,8687,CDM,J1885,HCPCS,63323-162-00,NDC,,,facility,both,4,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,8687,CDM,J1885,HCPCS,63323-162-45,NDC,,,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,8687,CDM,J1885,HCPCS,0409-3795-01,NDC,,,facility,both,2,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,8687,CDM,J1885,HCPCS,72266-119-25,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,8687,CDM,J1885,HCPCS,63323-162-03,NDC,,,facility,both,3,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,8687,CDM,J1885,HCPCS,0409-3795-19,NDC,,,facility,both,1,ML,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,8687,CDM,J1885,HCPCS,62332-600-01,NDC,,,facility,both,1,ML,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,8687,CDM,J1885,HCPCS,72266-118-25,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,8687,CDM,J1885,HCPCS,55390-481-01,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,8687,CDM,J1885,HCPCS,72266-119-01,NDC,,,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,8687,CDM,J1885,HCPCS,0409-3796-19,NDC,,,facility,both,4,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,8687,CDM,J1885,HCPCS,0338-0072-25,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,8687,CDM,J1885,HCPCS,63323-162-03,NDC,,,facility,both,3,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,8687,CDM,J1885,HCPCS,72266-119-01,NDC,,,facility,both,3,ML,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,8687,CDM,J1885,HCPCS,63323-162-03,NDC,,,facility,both,2,ML,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,8687,CDM,J1885,HCPCS,55390-481-02,NDC,,,facility,both,2,ML,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,8687,CDM,J1885,HCPCS,63323-162-03,NDC,,,facility,both,1,ML,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,8687,CDM,J1885,HCPCS,25021-701-01,NDC,,,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,8687,CDM,J1885,HCPCS,63323-162-00,NDC,,,facility,both,2,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,8687,CDM,J1885,HCPCS,0338-0072-25,NDC,,,facility,both,1,ML,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,8687,CDM,J1885,HCPCS,70860-701-04,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,8687,CDM,J1885,HCPCS,47781-584-93,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,8687,CDM,J1885,HCPCS,63323-162-00,NDC,,,facility,both,2,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,8687,CDM,J1885,HCPCS,63323-162-00,NDC,,,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,8687,CDM,J1885,HCPCS,0409-3795-19,NDC,,,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,8687,CDM,J1885,HCPCS,72266-119-01,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,8687,CDM,J1885,HCPCS,62332-600-01,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,8687,CDM,J1885,HCPCS,0409-3796-19,NDC,,,facility,both,3,ML,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,8687,CDM,J1885,HCPCS,72266-119-25,NDC,,,facility,both,3,ML,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,8687,CDM,J1885,HCPCS,72266-119-01,NDC,,,facility,both,1,ML,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 30 MG/ML INJ SOLN,8687,CDM,J1885,HCPCS,72266-118-25,NDC,,,facility,both,1,ML,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
KETOROLAC TROMETHAMINE 60 MG/2 ML IM SOLN,8687,CDM,J1885,HCPCS,62332-601-02,NDC,,,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LANREOTIDE 120 MG/0.5 ML SUBQ SYRG,8690,CDM,J1930,HCPCS,15054-1120-4,NDC,,,facility,both,120,ML,,26392,18474.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LANREOTIDE 60 MG/0.2 ML SUBQ SYRG,8690,CDM,J1930,HCPCS,15054-1060-4,NDC,,,facility,both,60,ML,,16803,11762.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LANREOTIDE 120 MG/0.5 ML SUBQ SYRG,8690,CDM,J1930,HCPCS,15054-1120-4,NDC,,,facility,both,60,ML,,13196,9237.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,8691,CDM,J1940,HCPCS,63323-280-02,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,8691,CDM,J1940,HCPCS,0409-6102-19,NDC,,,facility,both,2,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,8691,CDM,J1940,HCPCS,36000-283-25,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,8691,CDM,J1940,HCPCS,23155-473-32,NDC,,,facility,both,6,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,8691,CDM,J1940,HCPCS,23155-473-32,NDC,,,facility,both,2,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,8691,CDM,J1940,HCPCS,23155-473-32,NDC,,,facility,both,4,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,8691,CDM,J1940,HCPCS,63323-280-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,8691,CDM,J1940,HCPCS,63323-280-01,NDC,,,facility,both,2,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FUROSEMIDE 10 MG/ML INJ SOLN,8691,CDM,J1940,HCPCS,0409-6102-19,NDC,,,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUPRON 3.75MG IM KIT,8692,CDM,J1950,HCPCS,0074-3641-03,NDC,,,facility,both,3,EA,,14204,9942.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE (3 MONTH) 11.25 MG IM KIT,8692,CDM,J1950,HCPCS,0074-3663-03,NDC,,,facility,both,3,EA,,14914,10439.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUPRON 3.75MG IM KIT,8692,CDM,J1950,HCPCS,0074-3641-03,NDC,,,facility,both,1,EA,,4972,3480.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LUPRON 3.75MG IM KIT,8692,CDM,J1950,HCPCS,0074-3641-03,NDC,,,facility,both,1,EA,,4735,3314.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE (3 MONTH) 11.25 MG IM KIT,8692,CDM,J1950,HCPCS,0074-3663-03,NDC,,,facility,both,3,EA,,14203,9942.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE (3 MONTH) 11.25 MG IM KIT,8692,CDM,J1950,HCPCS,0074-3663-03,NDC,,,facility,both,3,EA,,14204,9942.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML INJ SOLN,8702,CDM,J2060,HCPCS,0409-6778-02,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),8702,CDM,J2060,HCPCS,0641-6044-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LORAZEPAM 2 MG/ML IV SOLN (PHS MERGE - ALL SITES),8702,CDM,J2060,HCPCS,0641-6044-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MANNITOL 25 % IV SOLN,8703,CDM,J2150,HCPCS,0409-4031-16,NDC,,,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MANNITOL 25 % IV SOLN,8703,CDM,J2150,HCPCS,0409-4031-16,NDC,,,facility,both,1,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEPERIDINE (PF) 25 MG/ML IV SOLN (PHS MERGE),8704,CDM,J2175,HCPCS,0409-1176-03,NDC,,,facility,both,1,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEPERIDINE (PF) 25 MG/ML IV SOLN (PHS MERGE),8704,CDM,J2175,HCPCS,0409-1176-03,NDC,,,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEPERIDINE (PF) 25 MG/ML IV SOLN (PHS MERGE),8704,CDM,J2175,HCPCS,0409-1176-30,NDC,,,facility,both,1,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEPERIDINE (PF) 25 MG/ML IV SOLN (PHS MERGE),8704,CDM,J2175,HCPCS,0409-1176-30,NDC,,,facility,both,1,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MEPERIDINE (PF) 25 MG/ML IV SOLN (PHS MERGE),8704,CDM,J2175,HCPCS,0641-6052-01,NDC,,,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MIDAZOLAM (PF) 5 MG/ML INJ SOLN,8708,CDM,J2250,HCPCS,0409-2308-21,NDC,,,facility,both,3,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),8710,CDM,J2270,HCPCS,0641-6125-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),8710,CDM,J2270,HCPCS,0641-6125-01,NDC,,,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MORPHINE 4 MG/ML IV SOLN (PHS/CDS MERGE),8710,CDM,J2270,HCPCS,0409-1891-03,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NALOXONE 0.4 MG/ML INJ SOLN,8713,CDM,J2310,HCPCS,0641-6132-01,NDC,,,facility,both,2,ML,,200,140,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ORPHENADRINE CITRATE 30 MG/ML INJ SOLN,8719,CDM,J2360,HCPCS,0641-6182-01,NDC,,,facility,both,1,ML,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ORPHENADRINE CITRATE 30 MG/ML INJ SOLN,8719,CDM,J2360,HCPCS,0641-6182-01,NDC,,,facility,both,15,ML,,1374,961.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ORPHENADRINE CITRATE 30 MG/ML INJ SOLN,8719,CDM,J2360,HCPCS,0641-6182-10,NDC,,,facility,both,1,ML,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ORPHENADRINE CITRATE 30 MG/ML INJ SOLN,8719,CDM,J2360,HCPCS,25021-651-02,NDC,,,facility,both,1,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ORPHENADRINE CITRATE 30 MG/ML INJ SOLN,8719,CDM,J2360,HCPCS,17478-538-02,NDC,,,facility,both,1,ML,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ORPHENADRINE CITRATE 30 MG/ML INJ SOLN,8719,CDM,J2360,HCPCS,25021-651-02,NDC,,,facility,both,1,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,8722,CDM,J2405,HCPCS,0409-4755-18,NDC,,,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,8722,CDM,J2405,HCPCS,23155-547-31,NDC,,,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,8722,CDM,J2405,HCPCS,70860-776-41,NDC,,,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,8722,CDM,J2405,HCPCS,63323-373-02,NDC,,,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,8722,CDM,J2405,HCPCS,60505-6130-0,NDC,,,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,8722,CDM,J2405,HCPCS,23155-547-31,NDC,,,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,8722,CDM,J2405,HCPCS,70860-776-41,NDC,,,facility,both,8,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,8722,CDM,J2405,HCPCS,0641-6078-01,NDC,,,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLN,8722,CDM,J2405,HCPCS,60505-6130-0,NDC,,,facility,both,4,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAMIDRONATE 9 MG/ML IV SOLN,8724,CDM,J2430,HCPCS,61703-326-18,NDC,,,facility,both,3,ML,,214,149.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PAMIDRONATE 9 MG/ML IV SOLN,8724,CDM,J2430,HCPCS,61703-326-18,NDC,,,facility,both,3,ML,,220,154,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG/ML INJ SOLN,8733,CDM,J2550,HCPCS,0641-6084-01,NDC,,,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG/ML INJ SOLN,8733,CDM,J2550,HCPCS,0641-0928-21,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PROMETHAZINE 25 MG/ML INJ SOLN,8733,CDM,J2550,HCPCS,0641-6208-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUPHENAZINE DECANOATE 25 MG/ML INJ SOLN,8741,CDM,J2680,HCPCS,67457-359-59,NDC,,,facility,both,1,ML,,134,93.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUPHENAZINE DECANOATE 25 MG/ML INJ SOLN,8741,CDM,J2680,HCPCS,63323-272-05,NDC,,,facility,both,5,ML,,670,469,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE  5 MG/ML INJ SOLN,8749,CDM,J2765,HCPCS,0409-3414-18,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE  5 MG/ML INJ SOLN,8749,CDM,J2765,HCPCS,0409-3414-11,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE  5 MG/ML INJ SOLN,8749,CDM,J2765,HCPCS,0409-3414-21,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE  5 MG/ML INJ SOLN,8749,CDM,J2765,HCPCS,23155-240-31,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE  5 MG/ML INJ SOLN,8749,CDM,J2765,HCPCS,0409-3414-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METOCLOPRAMIDE  5 MG/ML INJ SOLN,8749,CDM,J2765,HCPCS,0703-4502-01,NDC,,,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RHO D IMMUNE GLOBULIN 300 MCG IM SYRG,8750,CDM,J2790,HCPCS,13533-631-03,NDC,,,facility,both,1,EA,,422,295.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
RHO(D) IMMUNE GLOBULIN IV (PHS ERX MERGE),8750,CDM,J2790,HCPCS,13533-631-20,NDC,,,facility,both,1,EA,,405,283.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 6 MG/0.5 ML SUBQ PEN KIT,8766,CDM,J3030,HCPCS,55111-693-05,NDC,,,facility,both,1,ML,,379,265.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 6 MG/0.5 ML SUB-Q,8766,CDM,J3030,HCPCS,55150-173-01,NDC,,,facility,both,1,ML,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 6 MG/0.5 ML SUB-Q,8766,CDM,J3030,HCPCS,0143-9638-01,NDC,,,facility,both,1,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SUMATRIPTAN 6 MG/0.5 ML SUBQ PEN KIT,8766,CDM,J3030,HCPCS,72603-141-01,NDC,,,facility,both,1,ML,,406,284.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROTROPIN ALFA 0.9 MG IM SOLR,8775,CDM,J3240,HCPCS,58468-0030-1,NDC,,,facility,both,1,EA,,8208,5745.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
THYROTROPIN ALFA 0.9 MG IM SOLR,8775,CDM,J3240,HCPCS,58468-0030-2,NDC,,,facility,both,1,EA,,8208,5745.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,16714-130-01,NDC,,,facility,both,4,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,16714-140-01,NDC,,,facility,both,16,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,70121-1049-5,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,70121-1651-5,NDC,,,facility,both,8,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,70121-1049-1,NDC,,,facility,both,4,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,0003-0293-05,NDC,,,facility,both,2,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,0143-9387-25,NDC,,,facility,both,8,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,70121-1049-1,NDC,,,facility,both,3,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,70121-1169-1,NDC,,,facility,both,2,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,70121-1169-1,NDC,,,facility,both,4,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,0703-0241-01,NDC,,,facility,both,4,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,70121-1049-1,NDC,,,facility,both,12,ML,,150,105,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,70121-1169-1,NDC,,,facility,both,8,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,81298-5781-1,NDC,,,facility,both,8,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,70121-1168-1,NDC,,,facility,both,2,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,70121-1049-1,NDC,,,facility,both,2,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,70121-1049-5,NDC,,,facility,both,2,ML,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,70121-1049-1,NDC,,,facility,both,2,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,81298-5781-1,NDC,,,facility,both,4,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,70121-1657-1,NDC,,,facility,both,4,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,81298-5781-1,NDC,,,facility,both,2,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,0703-0243-01,NDC,,,facility,both,4,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,0003-0293-20,NDC,,,facility,both,8,ML,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 10 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,0003-0494-20,NDC,,,facility,both,2,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,70121-1168-1,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,70121-1651-5,NDC,,,facility,both,2,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,81298-5781-5,NDC,,,facility,both,8,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,70121-1655-1,NDC,,,facility,both,4,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,70121-1168-1,NDC,,,facility,both,16,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,16714-130-01,NDC,,,facility,both,8,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,0003-0293-20,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,0143-9387-25,NDC,,,facility,both,6,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,16714-130-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,0143-9387-25,NDC,,,facility,both,2,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 10 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,50090-0295-1,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,81298-5781-1,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,70121-1049-1,NDC,,,facility,both,6,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,0003-0293-20,NDC,,,facility,both,6,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,67457-621-02,NDC,,,facility,both,2,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,70121-1651-5,NDC,,,facility,both,4,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,70121-1049-1,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,16714-130-01,NDC,,,facility,both,6,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,0003-0293-20,NDC,,,facility,both,18,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,70121-1049-1,NDC,,,facility,both,1,ML,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,70121-1049-5,NDC,,,facility,both,6,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,70121-1168-1,NDC,,,facility,both,20,ML,,221,154.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,70121-1168-1,NDC,,,facility,both,4,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 10 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,0003-0494-20,NDC,,,facility,both,5,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,70121-1049-5,NDC,,,facility,both,6,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,0143-9387-01,NDC,,,facility,both,4,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,16714-130-01,NDC,,,facility,both,2,ML,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,70121-1049-5,NDC,,,facility,both,16,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,81298-5783-3,NDC,,,facility,both,4,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,0003-0293-28,NDC,,,facility,both,4,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,16714-140-01,NDC,,,facility,both,4,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,16714-140-01,NDC,,,facility,both,8,ML,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,70121-1049-1,NDC,,,facility,both,16,ML,,200,140,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,0143-9387-01,NDC,,,facility,both,3,ML,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,70121-1651-1,NDC,,,facility,both,4,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,0003-0293-20,NDC,,,facility,both,2,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,0143-9387-01,NDC,,,facility,both,6,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,0143-9387-25,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,0003-0293-20,NDC,,,facility,both,4,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,70121-1049-1,NDC,,,facility,both,4,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,70121-1049-1,NDC,,,facility,both,3,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,0143-9387-01,NDC,,,facility,both,3,ML,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,81298-5781-5,NDC,,,facility,both,2,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,70121-1049-5,NDC,,,facility,both,6,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,81298-5785-3,NDC,,,facility,both,2,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,70121-1049-2,NDC,,,facility,both,2,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,16714-130-25,NDC,,,facility,both,4,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,81298-5781-1,NDC,,,facility,both,3,ML,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,70121-1049-5,NDC,,,facility,both,2,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,0003-0293-05,NDC,,,facility,both,8,ML,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,0143-9387-25,NDC,,,facility,both,2,ML,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,70121-1049-1,NDC,,,facility,both,3,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,70121-1049-2,NDC,,,facility,both,2,ML,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,16714-130-01,NDC,,,facility,both,2,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,0143-9387-01,NDC,,,facility,both,16,ML,,139,97.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,0143-9387-01,NDC,,,facility,both,2,ML,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,70121-1168-1,NDC,,,facility,both,18,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,70121-1049-5,NDC,,,facility,both,8,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,63187-661-01,NDC,,,facility,both,4,ML,,108,75.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,0143-9387-25,NDC,,,facility,both,4,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,81298-5781-1,NDC,,,facility,both,12,ML,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,0003-0293-05,NDC,,,facility,both,2,ML,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,70121-1653-1,NDC,,,facility,both,4,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,81298-5781-5,NDC,,,facility,both,4,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,70121-1652-1,NDC,,,facility,both,4,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,16714-130-01,NDC,,,facility,both,3,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,81298-5781-1,NDC,,,facility,both,16,ML,,140,98,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,0003-0293-05,NDC,,,facility,both,16,ML,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,0143-9387-01,NDC,,,facility,both,8,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,70121-1049-1,NDC,,,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,0143-9387-01,NDC,,,facility,both,2,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,16714-140-01,NDC,,,facility,both,6,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,81298-5781-1,NDC,,,facility,both,2,ML,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,0003-0293-28,NDC,,,facility,both,36,ML,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,70121-1654-1,NDC,,,facility,both,4,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,0003-0293-05,NDC,,,facility,both,2,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,0143-9387-01,NDC,,,facility,both,3,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,0003-0293-20,NDC,,,facility,both,20,ML,,242,169.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,0143-9387-01,NDC,,,facility,both,1,ML,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,70121-1049-5,NDC,,,facility,both,8,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,81298-5781-1,NDC,,,facility,both,6,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,67457-622-05,NDC,,,facility,both,4,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,0003-0293-20,NDC,,,facility,both,16,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,81298-5781-1,NDC,,,facility,both,3,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,0003-0293-05,NDC,,,facility,both,6,ML,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,67457-623-10,NDC,,,facility,both,6,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,70121-1049-2,NDC,,,facility,both,8,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,81298-5785-3,NDC,,,facility,both,4,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,76420-085-01,NDC,,,facility,both,4,ML,,623,436.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,70121-1049-1,NDC,,,facility,both,8,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,16714-140-01,NDC,,,facility,both,2,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,16714-130-25,NDC,,,facility,both,2,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,0143-9387-25,NDC,,,facility,both,3,ML,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,70121-1049-2,NDC,,,facility,both,4,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,16714-130-25,NDC,,,facility,both,8,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,70121-1169-1,NDC,,,facility,both,6,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,70121-1049-1,NDC,,,facility,both,2,ML,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,70121-1049-5,NDC,,,facility,both,3,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,0003-0293-05,NDC,,,facility,both,4,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,70121-1169-1,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,0143-9387-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,70121-1049-5,NDC,,,facility,both,4,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,70121-1651-1,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,0003-0293-05,NDC,,,facility,both,8,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,70121-1049-5,NDC,,,facility,both,4,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSP,8781,CDM,J3301,HCPCS,0143-9387-01,NDC,,,facility,both,8,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DIAZEPAM 5 MG/ML INJ SYRG,8788,CDM,J3360,HCPCS,0409-1273-03,NDC,,,facility,both,2,ML,,198,138.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VANCOMYCIN IN D5W 1 GRAM/200 ML IV PGBK,8791,CDM,J3370,HCPCS,0338-3552-48,NDC,,,facility,both,2,ML,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 50 MG/ML IM,8794,CDM,J3410,HCPCS,0517-5601-25,NDC,,,facility,both,2,ML,,182,127.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 50 MG/ML IM,8794,CDM,J3410,HCPCS,0517-5602-25,NDC,,,facility,both,4,ML,,239,167.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 50 MG/ML IM,8794,CDM,J3410,HCPCS,0517-5601-25,NDC,,,facility,both,2,ML,,190,133,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HYDROXYZINE 50 MG/ML IM,8794,CDM,J3410,HCPCS,0517-5601-01,NDC,,,facility,both,2,ML,,190,133,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,8795,CDM,J3420,HCPCS,0143-9620-01,NDC,,,facility,both,9,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,8795,CDM,J3420,HCPCS,70756-635-81,NDC,,,facility,both,1,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,8795,CDM,J3420,HCPCS,0143-9620-01,NDC,,,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,8795,CDM,J3420,HCPCS,0143-9621-25,NDC,,,facility,both,1,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,8795,CDM,J3420,HCPCS,0517-0031-01,NDC,,,facility,both,1,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,8795,CDM,J3420,HCPCS,70069-005-01,NDC,,,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,8795,CDM,J3420,HCPCS,70069-172-01,NDC,,,facility,both,9,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,8795,CDM,J3420,HCPCS,63323-044-00,NDC,,,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,8795,CDM,J3420,HCPCS,72603-650-01,NDC,,,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,8795,CDM,J3420,HCPCS,0517-0031-25,NDC,,,facility,both,1,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,8795,CDM,J3420,HCPCS,0517-0032-25,NDC,,,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,8795,CDM,J3420,HCPCS,63323-044-01,NDC,,,facility,both,1,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,8795,CDM,J3420,HCPCS,63323-044-01,NDC,,,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,8795,CDM,J3420,HCPCS,0143-9619-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,8795,CDM,J3420,HCPCS,0143-9619-01,NDC,,,facility,both,29,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,8795,CDM,J3420,HCPCS,0143-9621-01,NDC,,,facility,both,1,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,8795,CDM,J3420,HCPCS,63323-044-44,NDC,,,facility,both,1,ML,,410,287,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,8795,CDM,J3420,HCPCS,71288-303-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,8795,CDM,J3420,HCPCS,70069-172-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,8795,CDM,J3420,HCPCS,69680-112-01,NDC,,,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,8795,CDM,J3420,HCPCS,0143-9620-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,8795,CDM,J3420,HCPCS,0143-9621-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,8795,CDM,J3420,HCPCS,63323-044-00,NDC,,,facility,both,1,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,8795,CDM,J3420,HCPCS,0143-9620-10,NDC,,,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,8795,CDM,J3420,HCPCS,69680-112-01,NDC,,,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYANOCOBALAMIN 1000 MCG/ML INJ SOLN,8795,CDM,J3420,HCPCS,0143-9619-10,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 1 MG/0.5 ML INJ SYRG,8796,CDM,J3430,HCPCS,76329-1240-1,NDC,,,facility,both,1,ML,,146,102.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PHYTONADIONE 10 MG/ML INJ SOLN,8796,CDM,J3430,HCPCS,0409-9158-31,NDC,,,facility,both,10,ML,,250,175,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE IN D5W 1 GRAM/100 ML IV PGBK,8799,CDM,J3475,HCPCS,63323-108-00,NDC,,,facility,both,2,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 50 % (4 MEQ/ML) INJ SOLN,8799,CDM,J3475,HCPCS,63323-064-04,NDC,,,facility,both,10,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 50 % (4 MEQ/ML) INJ SOLN,8799,CDM,J3475,HCPCS,63323-064-02,NDC,,,facility,both,4,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 50 % (4 MEQ/ML) INJ SOLN,8799,CDM,J3475,HCPCS,63323-064-01,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 50 % (4 MEQ/ML) INJ SOLN,8799,CDM,J3475,HCPCS,63323-064-01,NDC,,,facility,both,4,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 50 % (4 MEQ/ML) INJ SOLN,8799,CDM,J3475,HCPCS,63323-064-04,NDC,,,facility,both,10,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MAGNESIUM SULFATE 50 % (4 MEQ/ML) INJ SOLN,8799,CDM,J3475,HCPCS,63323-064-02,NDC,,,facility,both,2,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLP,8800,CDM,J3480,HCPCS,63323-965-01,NDC,,,facility,both,15,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
NS WITH POTASSIUM CHLORIDE 20 MEQ/L IV SOLP,8800,CDM,J3480,HCPCS,0338-0691-04,NDC,,,facility,both,10,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLP,8800,CDM,J3480,HCPCS,63323-965-10,NDC,,,facility,both,20,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLP,8800,CDM,J3480,HCPCS,0409-6635-18,NDC,,,facility,both,5,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 10 MEQ/100 ML IV PGBK (USE NON-PROTOCOL PANEL),8800,CDM,J3480,HCPCS,0338-0709-48,NDC,,,facility,both,5,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLP,8800,CDM,J3480,HCPCS,0409-6635-18,NDC,,,facility,both,10,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLP,8800,CDM,J3480,HCPCS,63323-965-01,NDC,,,facility,both,5,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLP,8800,CDM,J3480,HCPCS,0409-6651-19,NDC,,,facility,both,5,ML,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLP,8800,CDM,J3480,HCPCS,63323-965-03,NDC,,,facility,both,20,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLP,8800,CDM,J3480,HCPCS,63323-965-03,NDC,,,facility,both,5,ML,,2,1.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLP,8800,CDM,J3480,HCPCS,63323-965-03,NDC,,,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLP,8800,CDM,J3480,HCPCS,63323-965-03,NDC,,,facility,both,10,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLP,8800,CDM,J3480,HCPCS,63323-965-03,NDC,,,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLP,8800,CDM,J3480,HCPCS,0409-6635-18,NDC,,,facility,both,15,ML,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLP,8800,CDM,J3480,HCPCS,63323-965-10,NDC,,,facility,both,10,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLP,8800,CDM,J3480,HCPCS,63323-965-01,NDC,,,facility,both,10,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLP,8800,CDM,J3480,HCPCS,0409-6635-18,NDC,,,facility,both,20,ML,,132,92.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLP,8800,CDM,J3480,HCPCS,63323-965-01,NDC,,,facility,both,5,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLP,8800,CDM,J3480,HCPCS,0409-6651-19,NDC,,,facility,both,10,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
POTASSIUM CHLORIDE 2 MEQ/ML IV SOLP,8800,CDM,J3480,HCPCS,0409-6651-19,NDC,,,facility,both,5,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC UNSCHED/EMERGENT DIALYSIS,88000001,CDM,880,RC,G0257,HCPCS,,,facility,both,,,,2129,1490.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PERITONEAL DIALYSIS,88000002,CDM,880,RC,90945,HCPCS,,,facility,both,,,,668,467.6,,,,,,,,,,,,,Gross Charge Type: Central
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,8801,CDM,J2003,HCPCS,63323-492-04,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,8801,CDM,J2003,HCPCS,0409-4277-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,8801,CDM,J2003,HCPCS,0409-4279-16,NDC,,,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,8801,CDM,J2003,HCPCS,63323-486-05,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,8801,CDM,J2001,HCPCS,0409-4277-16,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,8801,CDM,J2003,HCPCS,63323-492-27,NDC,,,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,8801,CDM,J2003,HCPCS,63323-492-07,NDC,,,facility,both,1,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,8801,CDM,J2003,HCPCS,63323-492-37,NDC,,,facility,both,1,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,8801,CDM,J2003,HCPCS,63323-486-20,NDC,,,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,8801,CDM,J7060,HCPCS,63323-624-06,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,8801,CDM,J2003,HCPCS,63323-492-04,NDC,,,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,8801,CDM,J2003,HCPCS,0409-4279-16,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE 20 MG/ML (2 %) INJECTION,8801,CDM,J2003,HCPCS,0409-4277-16,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,8801,CDM,J2003,HCPCS,0409-4279-02,NDC,,,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,8801,CDM,J2003,HCPCS,63323-492-04,NDC,,,facility,both,1,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLN,8801,CDM,J2001,HCPCS,63323-492-07,NDC,,,facility,both,1,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8806,CDM,J7030,HCPCS,0264-7800-00,NDC,,,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8806,CDM,J7030,HCPCS,0264-7800-00,NDC,,,facility,both,1,ML,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8806,CDM,J7030,HCPCS,0338-0049-04,NDC,,,facility,both,2,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8806,CDM,J7030,HCPCS,0990-7983-09,NDC,,,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9% IV (PEDS) BOLUS,8806,CDM,J7030,HCPCS,0264-7800-09,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8806,CDM,J7030,HCPCS,17271-701-07,NDC,,,facility,both,1,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9% IV (PEDS) BOLUS,8806,CDM,J7030,HCPCS,0264-7800-09,NDC,,,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8806,CDM,J7030,HCPCS,0338-0049-04,NDC,,,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8806,CDM,J7030,HCPCS,0338-0049-04,NDC,,,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8806,CDM,J7030,HCPCS,0338-0049-04,NDC,,,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8806,CDM,J7030,HCPCS,17271-701-07,NDC,,,facility,both,1,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8806,CDM,J7030,HCPCS,0338-0049-04,NDC,,,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV (BOLUS),8806,CDM,J7030,HCPCS,0264-5802-00,NDC,,,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8806,CDM,J7030,HCPCS,0264-7800-00,NDC,,,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8806,CDM,J7030,HCPCS,0338-0049-04,NDC,,,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8806,CDM,J7030,HCPCS,0264-7800-00,NDC,,,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8806,CDM,J7030,HCPCS,0338-0049-04,NDC,,,facility,both,1,ML,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8806,CDM,J7030,HCPCS,0338-0049-04,NDC,,,facility,both,2,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8806,CDM,J7030,HCPCS,0338-0049-04,NDC,,,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8806,CDM,J7030,HCPCS,17271-701-07,NDC,,,facility,both,1,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9% IV (PEDS) BOLUS,8806,CDM,J7030,HCPCS,0264-7800-09,NDC,,,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8806,CDM,J7030,HCPCS,0338-0049-04,NDC,,,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9% IV (PEDS) BOLUS,8806,CDM,J7030,HCPCS,0264-7800-09,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8807,CDM,J7040,HCPCS,0338-0049-03,NDC,,,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8807,CDM,J7040,HCPCS,0264-5802-10,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8807,CDM,J7040,HCPCS,0338-0049-02,NDC,,,facility,both,2,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8807,CDM,J7040,HCPCS,0264-1800-31,NDC,,,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8807,CDM,J7040,HCPCS,0338-0049-02,NDC,,,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8807,CDM,J7040,HCPCS,0338-0049-03,NDC,,,facility,both,3,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8807,CDM,J7040,HCPCS,17271-701-06,NDC,,,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8807,CDM,J7040,HCPCS,0264-7800-00,NDC,,,facility,both,2,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8807,CDM,J7040,HCPCS,17271-701-06,NDC,,,facility,both,1,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8807,CDM,J7040,HCPCS,0338-0049-48,NDC,,,facility,both,1,ML,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8807,CDM,J7040,HCPCS,0338-0049-04,NDC,,,facility,both,4,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8807,CDM,J7040,HCPCS,0264-7800-10,NDC,,,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8807,CDM,J7040,HCPCS,0338-0049-03,NDC,,,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8807,CDM,J7040,HCPCS,0264-7800-10,NDC,,,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8807,CDM,J7040,HCPCS,0264-7800-10,NDC,,,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8807,CDM,J7040,HCPCS,0338-0049-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8807,CDM,J7040,HCPCS,0338-0049-03,NDC,,,facility,both,2,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8807,CDM,J7040,HCPCS,17271-701-06,NDC,,,facility,both,1,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8807,CDM,J7040,HCPCS,0264-5802-10,NDC,,,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8807,CDM,J7040,HCPCS,0264-7800-20,NDC,,,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8807,CDM,J7040,HCPCS,17271-701-06,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8807,CDM,J7040,HCPCS,17271-701-06,NDC,,,facility,both,1,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8807,CDM,J7040,HCPCS,17271-701-06,NDC,,,facility,both,1,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8807,CDM,J7040,HCPCS,17271-701-06,NDC,,,facility,both,1,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8807,CDM,J7040,HCPCS,0338-0049-18,NDC,,,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8807,CDM,J7040,HCPCS,0338-0049-31,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8807,CDM,J7040,HCPCS,0338-0049-03,NDC,,,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8807,CDM,J7040,HCPCS,0990-7983-03,NDC,,,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8807,CDM,J7040,HCPCS,0338-0049-41,NDC,,,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8807,CDM,J7040,HCPCS,0338-0049-04,NDC,,,facility,both,2,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8807,CDM,J7040,HCPCS,0338-0049-03,NDC,,,facility,both,3,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8807,CDM,J7040,HCPCS,0338-0049-04,NDC,,,facility,both,2,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8807,CDM,J7040,HCPCS,0338-0049-02,NDC,,,facility,both,1,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8807,CDM,J7040,HCPCS,0338-0049-04,NDC,,,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8807,CDM,J7040,HCPCS,0990-7983-03,NDC,,,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8807,CDM,J7040,HCPCS,0338-0049-03,NDC,,,facility,both,2,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8807,CDM,J7040,HCPCS,0338-9806-01,NDC,,,facility,both,2,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8807,CDM,J7040,HCPCS,0338-0049-31,NDC,,,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5%-1/2 NORMAL SALINE IV (PEDS ONCOLOGY),8808,CDM,J7042,HCPCS,0338-0085-04,NDC,,,facility,both,4,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5%-1/2 NORMAL SALINE IV (PEDS ONCOLOGY),8808,CDM,J7042,HCPCS,0338-0085-04,NDC,,,facility,both,2,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8809,CDM,J7050,HCPCS,0338-0049-03,NDC,,,facility,both,2,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8809,CDM,J7050,HCPCS,0338-0049-11,NDC,,,facility,both,1,ML,,350,245,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV (CLINIC BOLUS),8809,CDM,J7050,HCPCS,76297-001-42,NDC,,,facility,both,1,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8809,CDM,J7050,HCPCS,0338-0049-02,NDC,,,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8809,CDM,J7050,HCPCS,0338-0049-02,NDC,,,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8809,CDM,J7050,HCPCS,0264-7800-00,NDC,,,facility,both,1,ML,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV (BOLUS),8809,CDM,J7050,HCPCS,0338-0049-10,NDC,,,facility,both,2,ML,,372,260.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV (CLINIC BOLUS),8809,CDM,J7050,HCPCS,63323-623-10,NDC,,,facility,both,1,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8809,CDM,J7050,HCPCS,0338-0049-31,NDC,,,facility,both,6,ML,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8809,CDM,J7050,HCPCS,0338-0049-02,NDC,,,facility,both,4,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8809,CDM,J7050,HCPCS,0264-1800-31,NDC,,,facility,both,1,ML,,361,252.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8809,CDM,J7050,HCPCS,0264-1800-31,NDC,,,facility,both,2,ML,,361,252.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8809,CDM,J7050,HCPCS,0338-0049-03,NDC,,,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8809,CDM,J7050,HCPCS,0338-0049-31,NDC,,,facility,both,6,ML,,316,221.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8809,CDM,J7050,HCPCS,0338-0049-02,NDC,,,facility,both,2,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8809,CDM,J7050,HCPCS,0338-9806-01,NDC,,,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8809,CDM,J7050,HCPCS,76297-001-32,NDC,,,facility,both,4,ML,,111,77.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8809,CDM,J7050,HCPCS,0264-1800-31,NDC,,,facility,both,20,ML,,361,252.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8809,CDM,J7050,HCPCS,0338-0049-04,NDC,,,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8809,CDM,J7050,HCPCS,0338-0049-02,NDC,,,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV (CLINIC BOLUS),8809,CDM,J7050,HCPCS,63323-623-76,NDC,,,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8809,CDM,J7050,HCPCS,0264-1800-31,NDC,,,facility,both,1,ML,,181,126.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8809,CDM,J7050,HCPCS,0264-1800-31,NDC,,,facility,both,6,ML,,361,252.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8809,CDM,J7050,HCPCS,0264-7800-20,NDC,,,facility,both,1,ML,,20,14,,,,,,,,,,,,,Gross Charge Type: Pharmacy
SODIUM CHLORIDE 0.9 % IV SOLP,8809,CDM,J7050,HCPCS,0264-7800-00,NDC,,,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,8811,CDM,J7060,HCPCS,0990-7922-03,NDC,,,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,8811,CDM,J7060,HCPCS,0338-0017-03,NDC,,,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,8811,CDM,J7060,HCPCS,0990-7923-37,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,8811,CDM,J7060,HCPCS,0990-7922-03,NDC,,,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,8811,CDM,J7060,HCPCS,0338-0017-02,NDC,,,facility,both,1,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,8811,CDM,J7060,HCPCS,0990-7923-23,NDC,,,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,8811,CDM,J7060,HCPCS,0338-0017-02,NDC,,,facility,both,1,ML,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,8811,CDM,J7060,HCPCS,0338-0017-03,NDC,,,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,8811,CDM,J7060,HCPCS,63323-624-06,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,8811,CDM,J7060,HCPCS,0338-0017-38,NDC,,,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,8811,CDM,J7060,HCPCS,0338-0017-38,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,8811,CDM,J7060,HCPCS,65219-238-01,NDC,,,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,8811,CDM,J7060,HCPCS,0338-0017-48,NDC,,,facility,both,1,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,8811,CDM,J7060,HCPCS,0338-0017-02,NDC,,,facility,both,2,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,8811,CDM,J7060,HCPCS,0990-7923-37,NDC,,,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,8811,CDM,J7060,HCPCS,0990-7923-23,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,8811,CDM,J7060,HCPCS,0990-7923-37,NDC,,,facility,both,1,ML,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER FLUSH,8811,CDM,J7060,HCPCS,0264-7510-20,NDC,,,facility,both,1,ML,,50,35,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (NEO) <2 KG,8811,CDM,J7060,HCPCS,0338-0017-41,NDC,,,facility,both,1,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,8811,CDM,J7060,HCPCS,0338-0017-03,NDC,,,facility,both,2,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,8811,CDM,J7060,HCPCS,0338-0017-02,NDC,,,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (NEO) <2 KG,8811,CDM,J7060,HCPCS,0338-0017-41,NDC,,,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,8811,CDM,J7060,HCPCS,0264-1510-32,NDC,,,facility,both,1,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,8811,CDM,J7060,HCPCS,0338-0017-04,NDC,,,facility,both,2,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,8811,CDM,J7060,HCPCS,0990-7922-02,NDC,,,facility,both,1,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,8811,CDM,J7060,HCPCS,0990-7922-02,NDC,,,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,8811,CDM,J7060,HCPCS,0338-0017-03,NDC,,,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,8811,CDM,J7060,HCPCS,0338-0017-48,NDC,,,facility,both,1,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER FLUSH,8811,CDM,J7060,HCPCS,0264-7510-20,NDC,,,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,8811,CDM,J7060,HCPCS,0338-0017-02,NDC,,,facility,both,1,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DEXTROSE 5% IN WATER (D5W) IV,8811,CDM,J7060,HCPCS,0264-7510-10,NDC,,,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV,8815,CDM,J7120,HCPCS,0338-0117-03,NDC,,,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IRRIGATION SOLN,8815,CDM,J7120,HCPCS,0338-0137-27,NDC,,,facility,both,3,ML,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV,8815,CDM,J7120,HCPCS,0338-0117-04,NDC,,,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV (BOLUS),8815,CDM,J7120,HCPCS,0264-7750-07,NDC,,,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV (CLINIC BOLUS),8815,CDM,J7120,HCPCS,63323-164-26,NDC,,,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV,8815,CDM,J7120,HCPCS,0338-0117-03,NDC,,,facility,both,2,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV,8815,CDM,J7120,HCPCS,0338-0117-04,NDC,,,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV (BOLUS),8815,CDM,J7120,HCPCS,0264-7750-00,NDC,,,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV,8815,CDM,J7120,HCPCS,0338-0117-04,NDC,,,facility,both,1,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LACTATED RINGERS IV,8815,CDM,J7120,HCPCS,0338-0117-03,NDC,,,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COPPER 380 SQUARE MM IU IUD,8825,CDM,J7300,HCPCS,59365-5128-1,NDC,,,facility,both,2,EA,,6284,4398.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COPPER 380 SQUARE MM IU IUD,8825,CDM,J7300,HCPCS,59365-5128-1,NDC,,,facility,both,1,EA,,6284,4398.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COPPER 380 SQUARE MM IU IUD,8825,CDM,J7300,HCPCS,59365-5128-1,NDC,,,facility,both,1,EA,,3142,2199.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COPPER 380 SQUARE MM IU IUD,8825,CDM,J7300,HCPCS,59365-5129-1,NDC,,,facility,both,1,EA,,3142,2199.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
COPPER 380 SQUARE MM IU IUD,8825,CDM,J7300,HCPCS,59365-5128-1,NDC,,,facility,both,1,EA,,858,600.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,8836,CDM,J7510,HCPCS,17856-0759-5,NDC,,,facility,both,3,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,8836,CDM,J7510,HCPCS,17856-0815-1,NDC,,,facility,both,7,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,8836,CDM,J7510,HCPCS,17856-0759-5,NDC,,,facility,both,9,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,8836,CDM,J7510,HCPCS,17856-0815-1,NDC,,,facility,both,6,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,8836,CDM,J7510,HCPCS,17856-0815-1,NDC,,,facility,both,2,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,8836,CDM,J7510,HCPCS,17856-0815-1,NDC,,,facility,both,3,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,8836,CDM,J7510,HCPCS,17856-0815-1,NDC,,,facility,both,3,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,8836,CDM,J7510,HCPCS,17856-0759-5,NDC,,,facility,both,6,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,8836,CDM,J7510,HCPCS,17856-0815-1,NDC,,,facility,both,8,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,8836,CDM,J7510,HCPCS,17856-0815-1,NDC,,,facility,both,4,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,8836,CDM,J7510,HCPCS,17856-0815-1,NDC,,,facility,both,6,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,8836,CDM,J7510,HCPCS,17856-0815-1,NDC,,,facility,both,2,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLN,8836,CDM,J7510,HCPCS,17856-0815-1,NDC,,,facility,both,5,ML,,18,12.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 2 MG/ML IV SOLN,8865,CDM,J9000,HCPCS,0069-3034-20,NDC,,,facility,both,10,ML,,151,105.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,11,ML,,173,121.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,45963-733-60,NDC,,,facility,both,11,ML,,304,212.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,45963-733-60,NDC,,,facility,both,10,ML,,287,200.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,6,ML,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,45963-733-60,NDC,,,facility,both,13,ML,,368,257.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 2 MG/ML IV SOLN,8865,CDM,J9000,HCPCS,25021-207-51,NDC,,,facility,both,5,ML,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,9,ML,,139,97.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 2 MG/ML IV SOLN,8865,CDM,J9000,HCPCS,0143-9546-01,NDC,,,facility,both,11,ML,,315,220.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,6,ML,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,45963-733-60,NDC,,,facility,both,13,ML,,371,259.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,13,ML,,212,148.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,7,ML,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,11,ML,,170,119,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,45963-733-60,NDC,,,facility,both,4,ML,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 2 MG/ML IV SOLN,8865,CDM,J9000,HCPCS,25021-207-51,NDC,,,facility,both,12,ML,,338,236.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,9,ML,,149,104.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,5,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,9,ML,,144,100.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,7,ML,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,45963-733-60,NDC,,,facility,both,10,ML,,297,207.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 2 MG/ML IV SOLN,8865,CDM,J9000,HCPCS,25021-207-51,NDC,,,facility,both,5,ML,,129,90.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,14,ML,,222,155.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,11,ML,,175,122.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 2 MG/ML IV SOLN,8865,CDM,J9000,HCPCS,25021-207-51,NDC,,,facility,both,12,ML,,322,225.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-3032-20,NDC,,,facility,both,15,ML,,433,303.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,45963-733-60,NDC,,,facility,both,11,ML,,306,214.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,3,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 2 MG/ML IV SOLN,8865,CDM,J9000,HCPCS,25021-207-51,NDC,,,facility,both,6,ML,,169,118.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,10,ML,,163,114.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,10,ML,,161,112.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,5,ML,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,11,ML,,178,124.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,2,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,4,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,4,ML,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,8,ML,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,5,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,8,ML,,119,83.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 2 MG/ML IV SOLN,8865,CDM,J9000,HCPCS,0069-3034-20,NDC,,,facility,both,8,ML,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 2 MG/ML IV SOLN,8865,CDM,J9000,HCPCS,0069-3033-20,NDC,,,facility,both,11,ML,,225,157.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,12,ML,,186,130.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 2 MG/ML IV SOLN,8865,CDM,J9000,HCPCS,0069-3034-20,NDC,,,facility,both,9,ML,,141,98.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,10,ML,,161,112.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 2 MG/ML IV SOLN,8865,CDM,J9000,HCPCS,0069-3034-20,NDC,,,facility,both,3,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 2 MG/ML IV SOLN,8865,CDM,J9000,HCPCS,25021-207-51,NDC,,,facility,both,9,ML,,253,177.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,5,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 2 MG/ML IV SOLN,8865,CDM,J9000,HCPCS,25021-207-51,NDC,,,facility,both,6,ML,,152,106.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,9,ML,,146,102.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,12,ML,,200,140,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,11,ML,,179,125.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,10,ML,,159,111.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,12,ML,,190,133,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,5,ML,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,45963-733-60,NDC,,,facility,both,5,ML,,126,88.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,12,ML,,195,136.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,45963-733-60,NDC,,,facility,both,6,ML,,163,114.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-3032-20,NDC,,,facility,both,10,ML,,289,202.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,10,ML,,167,116.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,45963-733-60,NDC,,,facility,both,12,ML,,343,240.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,8,ML,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,11,ML,,176,123.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,11,ML,,167,116.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,13,ML,,209,146.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,5,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 2 MG/ML IV SOLN,8865,CDM,J9000,HCPCS,25021-207-51,NDC,,,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,6,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,9,ML,,138,96.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,12,ML,,187,130.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,6,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,12,ML,,199,139.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 2 MG/ML IV SOLN,8865,CDM,J9000,HCPCS,0069-3033-20,NDC,,,facility,both,9,ML,,168,117.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,45963-733-60,NDC,,,facility,both,7,ML,,184,128.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 2 MG/ML IV SOLN,8865,CDM,J9000,HCPCS,25021-207-51,NDC,,,facility,both,11,ML,,316,221.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 2 MG/ML IV SOLN,8865,CDM,J9000,HCPCS,25021-207-51,NDC,,,facility,both,7,ML,,175,122.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,45963-733-60,NDC,,,facility,both,5,ML,,134,93.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,10,ML,,156,109.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,6,ML,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 2 MG/ML IV SOLN,8865,CDM,J9000,HCPCS,0069-3034-20,NDC,,,facility,both,10,ML,,163,114.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,5,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,45963-733-60,NDC,,,facility,both,8,ML,,228,159.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,8,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,5,ML,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,13,ML,,210,147,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 2 MG/ML IV SOLN,8865,CDM,J9000,HCPCS,0069-3034-20,NDC,,,facility,both,3,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,4,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,8,ML,,131,91.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 2 MG/ML IV SOLN,8865,CDM,J9000,HCPCS,25021-207-51,NDC,,,facility,both,6,ML,,158,110.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,5,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,13,ML,,202,141.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,45963-733-60,NDC,,,facility,both,9,ML,,250,175,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 2 MG/ML IV SOLN,8865,CDM,J9000,HCPCS,0069-3034-20,NDC,,,facility,both,5,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,63323-883-30,NDC,,,facility,both,10,ML,,392,274.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,9,ML,,146,102.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,9,ML,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,45963-733-60,NDC,,,facility,both,5,ML,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,12,ML,,189,132.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,1,ML,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,11,ML,,174,121.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 2 MG/ML IV SOLN,8865,CDM,J9000,HCPCS,0069-3033-20,NDC,,,facility,both,2,ML,,36,25.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 2 MG/ML IV SOLN,8865,CDM,J9000,HCPCS,0069-3034-20,NDC,,,facility,both,13,ML,,211,147.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,10,ML,,166,116.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,45963-733-60,NDC,,,facility,both,9,ML,,253,177.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,12,ML,,198,138.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 2 MG/ML IV SOLN,8865,CDM,J9000,HCPCS,25021-207-51,NDC,,,facility,both,6,ML,,148,103.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,10,ML,,152,106.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,45963-733-60,NDC,,,facility,both,13,ML,,383,268.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,45963-733-60,NDC,,,facility,both,10,ML,,303,212.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,13,ML,,211,147.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 2 MG/ML IV SOLN,8865,CDM,J9000,HCPCS,0069-3034-20,NDC,,,facility,both,6,ML,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,12,ML,,184,128.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,45963-733-60,NDC,,,facility,both,3,ML,,82,57.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,4,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 2 MG/ML IV SOLN,8865,CDM,J9000,HCPCS,0069-3033-20,NDC,,,facility,both,12,ML,,238,166.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,45963-733-60,NDC,,,facility,both,8,ML,,222,155.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,45963-733-60,NDC,,,facility,both,2,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,10,ML,,158,110.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 2 MG/ML IV SOLN,8865,CDM,J9000,HCPCS,25021-207-51,NDC,,,facility,both,4,ML,,107,74.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,13,ML,,207,144.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,45963-733-60,NDC,,,facility,both,11,ML,,321,224.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 2 MG/ML IV SOLN,8865,CDM,J9000,HCPCS,0069-3034-20,NDC,,,facility,both,2,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,9,ML,,143,100.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,10,ML,,160,112,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,2,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,45963-733-60,NDC,,,facility,both,12,ML,,356,249.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,45963-733-60,NDC,,,facility,both,5,ML,,132,92.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,2,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,11,ML,,176,123.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,6,ML,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,45963-733-60,NDC,,,facility,both,8,ML,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,12,ML,,196,137.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,9,ML,,148,103.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,45963-733-60,NDC,,,facility,both,5,ML,,149,104.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,7,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,45963-733-60,NDC,,,facility,both,12,ML,,361,252.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,12,ML,,197,137.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 2 MG/ML IV SOLN,8865,CDM,J9000,HCPCS,25021-207-51,NDC,,,facility,both,12,ML,,345,241.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,11,ML,,175,122.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,45963-733-60,NDC,,,facility,both,6,ML,,170,119,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,13,ML,,204,142.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 2 MG/ML IV SOLN,8865,CDM,J9000,HCPCS,25021-207-51,NDC,,,facility,both,9,ML,,237,165.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,7,ML,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,8,ML,,129,90.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,9,ML,,138,96.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,8,ML,,132,92.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,45963-733-60,NDC,,,facility,both,7,ML,,208,145.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,10,ML,,165,115.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,6,ML,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,7,ML,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 2 MG/ML IV SOLN,8865,CDM,J9000,HCPCS,25021-207-51,NDC,,,facility,both,10,ML,,284,198.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 2 MG/ML IV SOLN,8865,CDM,J9000,HCPCS,25021-207-51,NDC,,,facility,both,18,ML,,499,349.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,10,ML,,166,116.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,13,ML,,203,142.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,3,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,45963-733-60,NDC,,,facility,both,11,ML,,320,224,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,4,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,3,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,45963-733-60,NDC,,,facility,both,6,ML,,161,112.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,5,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DOXORUBICIN 50 MG/25 ML IV SOLN,8865,CDM,J9000,HCPCS,0069-1542-20,NDC,,,facility,both,8,ML,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BLEOMYCIN 30 UNIT INJ SOLR,8870,CDM,J9040,HCPCS,71288-107-20,NDC,,,facility,both,2,EA,,204,142.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BLEOMYCIN 30 UNIT INJ SOLR,8870,CDM,J9040,HCPCS,71288-107-20,NDC,,,facility,both,2,EA,,214,149.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BLEOMYCIN 15 UNITS/5 ML INJ SOLR (WET SOLR VIAL),8870,CDM,J9040,HCPCS,61703-332-18,NDC,,,facility,both,2,EA,,509,356.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BLEOMYCIN 30 UNIT INJ SOLR,8870,CDM,J9040,HCPCS,71288-107-20,NDC,,,facility,both,2,EA,,224,156.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BLEOMYCIN 30 UNITS/10 ML INJ SOLR (WET SOLR VIAL),8870,CDM,J9040,HCPCS,63323-137-20,NDC,,,facility,both,2,EA,,389,272.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BLEOMYCIN 30 UNIT INJ SOLR,8870,CDM,J9040,HCPCS,71288-107-20,NDC,,,facility,both,1,EA,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BLEOMYCIN 30 UNIT INJ SOLR,8870,CDM,J9040,HCPCS,71288-107-20,NDC,,,facility,both,2,EA,,340,238,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BLEOMYCIN 30 UNIT INJ SOLR,8870,CDM,J9040,HCPCS,71288-107-20,NDC,,,facility,both,2,EA,,228,159.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BLEOMYCIN 30 UNIT INJ SOLR,8870,CDM,J9040,HCPCS,0703-3155-01,NDC,,,facility,both,2,EA,,459,321.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BLEOMYCIN 30 UNIT INJ SOLR,8870,CDM,J9040,HCPCS,71288-107-20,NDC,,,facility,both,2,EA,,215,150.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BLEOMYCIN 30 UNIT INJ SOLR,8870,CDM,J9040,HCPCS,0143-9241-01,NDC,,,facility,both,2,EA,,459,321.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BLEOMYCIN 30 UNIT INJ SOLR,8870,CDM,J9040,HCPCS,71288-107-20,NDC,,,facility,both,2,EA,,340,238,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BLEOMYCIN 30 UNIT INJ SOLR,8870,CDM,J9040,HCPCS,71288-107-20,NDC,,,facility,both,2,EA,,205,143.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
BLEOMYCIN 30 UNIT INJ SOLR,8870,CDM,J9040,HCPCS,71288-107-20,NDC,,,facility,both,2,EA,,218,152.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,7,ML,,200,140,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,4,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,4,ML,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,4,ML,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,7,ML,,188,131.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,13,ML,,347,242.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,12,ML,,317,221.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,2,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,3,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,4,ML,,113,79.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,4,ML,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,11,ML,,327,228.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,5,ML,,140,98,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,4,ML,,107,74.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,15,ML,,398,278.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,9,ML,,228,159.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,16,ML,,428,299.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,4,ML,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,6,ML,,164,114.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,10,ML,,265,185.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,7,ML,,185,129.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,10,ML,,255,178.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,15,ML,,418,292.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,4,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,14,ML,,370,259,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,4,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,8,ML,,208,145.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,4,ML,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,12,ML,,356,249.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,9,ML,,251,175.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,21,ML,,577,403.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,7,ML,,187,130.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,8,ML,,203,142.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,10,ML,,261,182.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,17,ML,,501,350.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,10,ML,,300,210,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,10,ML,,298,208.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,4,ML,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,4,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,15,ML,,397,277.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,4,ML,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,18,ML,,502,351.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,8,ML,,207,144.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,12,ML,,337,235.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,8,ML,,239,167.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,17,ML,,463,324.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,6,ML,,155,108.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,4,ML,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,3,ML,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,7,ML,,191,133.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,7,ML,,197,137.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,12,ML,,313,219.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,9,ML,,269,188.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,7,ML,,185,129.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,7,ML,,198,138.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,5,ML,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,17,ML,,470,329,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,6,ML,,167,116.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,2,ML,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,6,ML,,141,98.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,10,ML,,257,179.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,11,ML,,309,216.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,4,ML,,111,77.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,4,ML,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,6,ML,,152,106.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,3,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,10,ML,,271,189.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,8,ML,,199,139.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,10,ML,,292,204.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,5,ML,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,15,ML,,402,281.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,6,ML,,169,118.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,5,ML,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,9,ML,,259,181.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,12,ML,,312,218.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,13,ML,,364,254.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,15,ML,,396,277.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,9,ML,,267,186.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,3,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,11,ML,,314,219.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,8,ML,,214,149.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,13,ML,,358,250.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,10,ML,,266,186.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,9,ML,,227,158.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,2,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,10,ML,,273,191.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,16,ML,,437,305.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,7,ML,,172,120.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,5,ML,,127,88.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,4,ML,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,11,ML,,301,210.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,11,ML,,303,212.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,6,ML,,154,107.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,5,ML,,130,91,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,9,ML,,234,163.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,7,ML,,190,133,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,9,ML,,252,176.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,18,ML,,505,353.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,11,ML,,308,215.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,5,ML,,131,91.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4246-01,NDC,,,facility,both,3,ML,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,3,ML,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,12,ML,,334,233.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,3,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,14,ML,,379,265.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,6,ML,,158,110.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,8,ML,,221,154.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,10,ML,,280,196,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,5,ML,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,9,ML,,257,179.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,7,ML,,195,136.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,15,ML,,401,280.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,10,ML,,290,203,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,2,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,7,ML,,169,118.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,3,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,5,ML,,140,98,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,18,ML,,498,348.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,16,ML,,430,301,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,6,ML,,162,113.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,14,ML,,386,270.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,9,ML,,239,167.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,5,ML,,119,83.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,2,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,11,ML,,305,213.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,5,ML,,128,89.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,13,ML,,339,237.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,13,ML,,365,255.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,61703-339-56,NDC,,,facility,both,24,ML,,602,421.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,8,ML,,211,147.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,3,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,6,ML,,159,111.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,13,ML,,352,246.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4246-01,NDC,,,facility,both,6,ML,,247,172.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,11,ML,,292,204.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,14,ML,,367,256.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,12,ML,,331,231.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,61703-339-56,NDC,,,facility,both,12,ML,,301,210.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,6,ML,,146,102.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,3,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,15,ML,,395,276.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,13,ML,,349,244.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,15,ML,,411,287.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,6,ML,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,3,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,6,ML,,164,114.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,4,ML,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,9,ML,,243,170.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,5,ML,,152,106.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,4,ML,,101,70.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,10,ML,,267,186.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,1,ML,,16,11.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,14,ML,,383,268.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,5,ML,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,8,ML,,223,156.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,4,ML,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,7,ML,,181,126.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,61703-339-56,NDC,,,facility,both,18,ML,,602,421.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,3,ML,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,5,ML,,130,91,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,4,ML,,107,74.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,18,ML,,495,346.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,17,ML,,469,328.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,8,ML,,213,149.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,15,ML,,399,279.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,12,ML,,318,222.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,7,ML,,170,119,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,6,ML,,171,119.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,11,ML,,334,233.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,7,ML,,186,130.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,2,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,11,ML,,287,200.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,7,ML,,182,127.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,9,ML,,236,165.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,15,ML,,413,289.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,3,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,11,ML,,304,212.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,2,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,6,ML,,174,121.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,2,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,2,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,17,ML,,460,322,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,3,ML,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,3,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,10,ML,,262,183.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,8,ML,,198,138.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,11,ML,,286,200.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,9,ML,,233,163.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,5,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,4,ML,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4246-01,NDC,,,facility,both,15,ML,,617,431.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,3,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,17,ML,,509,356.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,63323-172-60,NDC,,,facility,both,10,ML,,376,263.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,5,ML,,129,90.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,4,ML,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,10,ML,,254,177.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,7,ML,,190,133,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,7,ML,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,7,ML,,180,126,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,12,ML,,320,224,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,7,ML,,179,125.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,5,ML,,138,96.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,9,ML,,225,157.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,8,ML,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,8,ML,,204,142.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,17,ML,,453,317.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,6,ML,,150,105,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,14,ML,,391,273.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,14,ML,,387,270.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,6,ML,,183,128.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,10,ML,,258,180.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,6,ML,,144,100.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,1,ML,,22,15.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,5,ML,,128,89.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,5,ML,,145,101.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,2,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,8,ML,,220,154,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,12,ML,,310,217,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,9,ML,,229,160.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,8,ML,,220,154,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,11,ML,,289,202.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,13,ML,,343,240.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,10,ML,,274,191.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,12,ML,,352,246.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,6,ML,,157,109.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,8,ML,,205,143.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,4,ML,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,5,ML,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,5,ML,,126,88.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,13,ML,,346,242.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,12,ML,,327,228.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,14,ML,,375,262.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,2,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,3,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,5,ML,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,13,ML,,350,245,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,5,ML,,139,97.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,18,ML,,485,339.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,7,ML,,174,121.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,14,ML,,407,284.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,5,ML,,134,93.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,12,ML,,311,217.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,5,ML,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,17,ML,,457,319.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,4,ML,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,17,ML,,490,343,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,15,ML,,403,282.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,10,ML,,278,194.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,3,ML,,78,54.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,11,ML,,307,214.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,4,ML,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,7,ML,,210,147,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,6,ML,,157,109.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,2,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,4,ML,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,11,ML,,302,211.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,13,ML,,360,252,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,8,ML,,234,163.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,11,ML,,290,203,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,6,ML,,161,112.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,16,ML,,425,297.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4248-01,NDC,,,facility,both,9,ML,,331,231.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,10,ML,,268,187.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,9,ML,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,2,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,6,ML,,156,109.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,10,ML,,276,193.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,7,ML,,191,133.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,15,ML,,406,284.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,4,ML,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,12,ML,,329,230.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,12,ML,,337,235.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,4,ML,,117,81.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,12,ML,,315,220.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,4,ML,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,61703-339-56,NDC,,,facility,both,22,ML,,602,421.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,10,ML,,264,184.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,16,ML,,433,303.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,12,ML,,314,219.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,14,ML,,392,274.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,7,ML,,213,149.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,11,ML,,296,207.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,6,ML,,143,100.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,8,ML,,200,140,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,14,ML,,371,259.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,5,ML,,136,95.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,12,ML,,330,231,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,4,ML,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,7,ML,,189,132.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,9,ML,,242,169.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,11,ML,,283,198.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,14,ML,,406,284.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,11,ML,,291,203.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,7,ML,,193,135.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,3,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,9,ML,,253,177.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,5,ML,,131,91.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,7,ML,,184,128.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,13,ML,,354,247.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,17,ML,,458,320.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,1,ML,,30,21,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,11,ML,,298,208.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,13,ML,,344,240.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,5,ML,,134,93.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,7,ML,,208,145.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,18,ML,,478,334.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,7,ML,,194,135.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,15,ML,,417,291.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,18,ML,,490,343,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,9,ML,,245,171.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,3,ML,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,5,ML,,132,92.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,5,ML,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,4,ML,,108,75.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,12,ML,,326,228.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,63323-172-60,NDC,,,facility,both,15,ML,,558,390.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,7,ML,,196,137.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,3,ML,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,15,ML,,419,293.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,15,ML,,421,294.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,5,ML,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,11,ML,,307,214.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,8,ML,,212,148.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,3,ML,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,5,ML,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,4,ML,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,9,ML,,240,168,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,10,ML,,275,192.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,10,ML,,288,201.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,4,ML,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,12,ML,,316,221.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,9,ML,,241,168.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,13,ML,,348,243.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,10,ML,,272,190.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,3,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,15,ML,,457,319.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,7,ML,,178,124.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,6,ML,,176,123.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,10,ML,,277,193.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,3,ML,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,14,ML,,374,261.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,11,ML,,288,201.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,17,ML,,462,323.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,3,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,5,ML,,133,93.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,12,ML,,336,235.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,10,ML,,303,212.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,10,ML,,256,179.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4248-01,NDC,,,facility,both,18,ML,,662,463.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,10,ML,,279,195.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,9,ML,,248,173.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,6,ML,,166,116.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,11,ML,,282,197.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,6,ML,,145,101.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,3,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,8,ML,,216,151.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,16,ML,,443,310.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,8,ML,,221,154.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,9,ML,,246,172.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,11,ML,,312,218.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,11,ML,,293,205.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,12,ML,,321,224.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,14,ML,,388,271.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,13,ML,,341,238.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,9,ML,,247,172.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,12,ML,,323,226.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,10,ML,,270,189,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,3,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,15,ML,,437,305.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,10,ML,,259,181.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,13,ML,,355,248.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,4,ML,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,7,ML,,173,121.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,12,ML,,335,234.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,13,ML,,361,252.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,16,ML,,434,303.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,9,ML,,226,158.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,13,ML,,340,238,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,9,ML,,249,174.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,11,ML,,294,205.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,6,ML,,165,115.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,8,ML,,222,155.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,5,ML,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,18,ML,,479,335.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,14,ML,,381,266.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,9,ML,,237,165.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,8,ML,,217,151.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,12,ML,,342,239.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,16,ML,,471,329.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,9,ML,,238,166.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,13,ML,,366,256.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,16729-295-12,NDC,,,facility,both,3,ML,,65,45.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CARBOPLATIN 10 MG/ML IV,8871,CDM,J9045,HCPCS,0703-4239-01,NDC,,,facility,both,9,ML,,250,175,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,0703-5748-11,NDC,,,facility,both,5,ML,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,0703-5748-11,NDC,,,facility,both,6,ML,,138,96.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,6,ML,,111,77.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,3,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,5,ML,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,0703-5748-11,NDC,,,facility,both,8,ML,,169,118.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,0703-5748-11,NDC,,,facility,both,4,ML,,95,66.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,0703-5748-11,NDC,,,facility,both,5,ML,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,6,ML,,119,83.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,13,ML,,276,193.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,6,ML,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,3,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,8,ML,,170,119,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,6,ML,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,0703-5748-11,NDC,,,facility,both,1,ML,,19,13.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,9,ML,,172,120.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,13,ML,,259,181.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,5,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,0703-5748-11,NDC,,,facility,both,4,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,4,ML,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,0703-5748-11,NDC,,,facility,both,4,ML,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,0703-5748-11,NDC,,,facility,both,10,ML,,237,165.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,11,ML,,233,163.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,0703-5748-11,NDC,,,facility,both,6,ML,,140,98,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,0703-5748-11,NDC,,,facility,both,1,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,8,ML,,166,116.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,1,ML,,7,4.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,7,ML,,140,98,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,6,ML,,113,79.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,8,ML,,161,112.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,13,ML,,263,184.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,3,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,0703-5748-11,NDC,,,facility,both,9,ML,,195,136.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,4,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,5,ML,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,0703-5748-11,NDC,,,facility,both,8,ML,,183,128.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,0703-5748-11,NDC,,,facility,both,6,ML,,142,99.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,0703-5748-11,NDC,,,facility,both,10,ML,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,0703-5748-11,NDC,,,facility,both,3,ML,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,17,ML,,348,243.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,15,ML,,316,221.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,0703-5748-11,NDC,,,facility,both,22,ML,,509,356.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,9,ML,,176,123.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,17,ML,,352,246.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,0703-5748-11,NDC,,,facility,both,6,ML,,126,88.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,11,ML,,229,160.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,7,ML,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,0703-5748-11,NDC,,,facility,both,4,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,0703-5748-11,NDC,,,facility,both,19,ML,,431,301.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,0703-5748-11,NDC,,,facility,both,1,ML,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,0703-5748-11,NDC,,,facility,both,7,ML,,166,116.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,9,ML,,187,130.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,0703-5748-11,NDC,,,facility,both,4,ML,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,13,ML,,257,179.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,0703-5748-11,NDC,,,facility,both,8,ML,,173,121.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,16,ML,,324,226.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,6,ML,,128,89.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,9,ML,,174,121.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,7,ML,,149,104.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,8,ML,,155,108.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,0703-5748-11,NDC,,,facility,both,2,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,7,ML,,130,91,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,8,ML,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,0703-5748-11,NDC,,,facility,both,3,ML,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,7,ML,,138,96.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,0703-5748-11,NDC,,,facility,both,9,ML,,199,139.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,0703-5748-11,NDC,,,facility,both,3,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,6,ML,,121,84.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,0703-5748-11,NDC,,,facility,both,9,ML,,214,149.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,0703-5748-11,NDC,,,facility,both,7,ML,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,0703-5748-11,NDC,,,facility,both,16,ML,,365,255.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,0703-5748-11,NDC,,,facility,both,5,ML,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,4,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,2,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,0703-5748-11,NDC,,,facility,both,3,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,2,ML,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,5,ML,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,0703-5748-11,NDC,,,facility,both,5,ML,,107,74.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,4,ML,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,3,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,5,ML,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,7,ML,,132,92.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,9,ML,,191,133.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,1,ML,,3,2.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,15,ML,,303,212.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,15,ML,,318,222.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,8,ML,,151,105.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,4,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,0703-5748-11,NDC,,,facility,both,4,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,0703-5748-11,NDC,,,facility,both,2,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,0703-5748-11,NDC,,,facility,both,7,ML,,154,107.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,15,ML,,301,210.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,3,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,4,ML,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,6,ML,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,0703-5748-11,NDC,,,facility,both,1,ML,,5,3.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,0703-5748-11,NDC,,,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,0703-5748-11,NDC,,,facility,both,5,ML,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,4,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,2,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,0703-5748-11,NDC,,,facility,both,7,ML,,161,112.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,0703-5748-11,NDC,,,facility,both,5,ML,,114,79.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,0703-5748-11,NDC,,,facility,both,4,ML,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,5,ML,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,0703-5748-11,NDC,,,facility,both,7,ML,,164,114.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,6,ML,,108,75.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,0703-5748-11,NDC,,,facility,both,5,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,0703-5748-11,NDC,,,facility,both,6,ML,,133,93.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,7,ML,,144,100.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,0703-5747-11,NDC,,,facility,both,5,ML,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,0703-5748-11,NDC,,,facility,both,6,ML,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,0703-5748-11,NDC,,,facility,both,6,ML,,143,100.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,9,ML,,178,124.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,2,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,10,ML,,210,147,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,5,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,0703-5748-11,NDC,,,facility,both,8,ML,,171,119.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,0703-5748-11,NDC,,,facility,both,14,ML,,311,217.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,3,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,0703-5748-11,NDC,,,facility,both,15,ML,,356,249.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,5,ML,,96,67.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,0703-5748-11,NDC,,,facility,both,6,ML,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,5,ML,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,0703-5748-11,NDC,,,facility,both,6,ML,,121,84.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,17,ML,,358,250.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,0703-5748-11,NDC,,,facility,both,14,ML,,313,219.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,0703-5748-11,NDC,,,facility,both,3,ML,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CISPLATIN 1 MG/ML IV,8873,CDM,J9060,HCPCS,16729-288-38,NDC,,,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
CYTARABINE 100 MG/ML INJ SOLN,8886,CDM,J9100,HCPCS,61703-319-22,NDC,,,facility,both,20,ML,,120,84,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DACARBAZINE 200 MG IV SOLR,8889,CDM,J9130,HCPCS,0143-9245-01,NDC,,,facility,both,6,EA,,212,148.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DACARBAZINE 200 MG IV SOLR,8889,CDM,J9130,HCPCS,63323-128-00,NDC,,,facility,both,2,EA,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DACARBAZINE 200 MG IV SOLR,8889,CDM,J9130,HCPCS,63323-128-00,NDC,,,facility,both,8,EA,,282,197.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DACARBAZINE 200 MG IV SOLR,8889,CDM,J9130,HCPCS,0143-9245-01,NDC,,,facility,both,4,EA,,141,98.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DACARBAZINE 200 MG IV SOLR,8889,CDM,J9130,HCPCS,0143-9245-01,NDC,,,facility,both,6,EA,,208,145.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DACARBAZINE 200 MG IV SOLR,8889,CDM,J9130,HCPCS,0143-9245-01,NDC,,,facility,both,14,EA,,474,331.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DACARBAZINE 200 MG IV SOLR,8889,CDM,J9130,HCPCS,0143-9245-01,NDC,,,facility,both,7,EA,,231,161.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DACARBAZINE 200 MG IV SOLR,8889,CDM,J9130,HCPCS,63323-128-00,NDC,,,facility,both,8,EA,,261,182.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DACARBAZINE 200 MG IV SOLR,8889,CDM,J9130,HCPCS,63323-128-00,NDC,,,facility,both,7,EA,,231,161.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DACARBAZINE 200 MG IV SOLR,8889,CDM,J9130,HCPCS,0143-9245-01,NDC,,,facility,both,8,EA,,282,197.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DACARBAZINE 200 MG IV SOLR,8889,CDM,J9130,HCPCS,0143-9245-01,NDC,,,facility,both,8,EA,,256,179.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DACARBAZINE 200 MG IV SOLR,8889,CDM,J9130,HCPCS,63323-128-00,NDC,,,facility,both,3,EA,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DACARBAZINE 100 MG IV SOLR,8889,CDM,J9130,HCPCS,63323-127-00,NDC,,,facility,both,1,EA,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DACARBAZINE 100 MG IV SOLR,8889,CDM,J9130,HCPCS,63323-127-00,NDC,,,facility,both,1,EA,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DACARBAZINE 200 MG IV SOLR,8889,CDM,J9130,HCPCS,0143-9245-01,NDC,,,facility,both,8,EA,,279,195.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DACARBAZINE 200 MG IV SOLR,8889,CDM,J9130,HCPCS,0143-9245-01,NDC,,,facility,both,8,EA,,261,182.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DACARBAZINE 200 MG IV SOLR,8889,CDM,J9130,HCPCS,0143-9245-01,NDC,,,facility,both,7,EA,,229,160.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
DACARBAZINE 200 MG IV SOLR,8889,CDM,J9130,HCPCS,0143-9245-01,NDC,,,facility,both,8,EA,,266,186.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,63323-104-25,NDC,,,facility,both,3,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,0143-9511-01,NDC,,,facility,both,25,ML,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,16729-114-08,NDC,,,facility,both,28,ML,,135,94.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,16729-114-08,NDC,,,facility,both,22,ML,,107,74.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,16729-114-08,NDC,,,facility,both,19,ML,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,63323-104-25,NDC,,,facility,both,20,ML,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,16729-114-08,NDC,,,facility,both,22,ML,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,63323-104-25,NDC,,,facility,both,10,ML,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,16729-114-08,NDC,,,facility,both,21,ML,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,16729-114-08,NDC,,,facility,both,27,ML,,128,89.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,0143-9511-01,NDC,,,facility,both,16,ML,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,0143-9511-01,NDC,,,facility,both,20,ML,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,16729-114-08,NDC,,,facility,both,15,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,0143-9511-01,NDC,,,facility,both,25,ML,,108,75.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,0143-9511-01,NDC,,,facility,both,13,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,63323-104-25,NDC,,,facility,both,20,ML,,127,88.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,0143-9511-01,NDC,,,facility,both,17,ML,,73,51.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,0143-9511-01,NDC,,,facility,both,22,ML,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,16729-114-08,NDC,,,facility,both,18,ML,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,16729-114-08,NDC,,,facility,both,3,ML,,14,9.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,0143-9511-01,NDC,,,facility,both,10,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,63323-104-25,NDC,,,facility,both,19,ML,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,16729-114-08,NDC,,,facility,both,21,ML,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,16729-114-08,NDC,,,facility,both,23,ML,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,16729-114-08,NDC,,,facility,both,25,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,0143-9511-01,NDC,,,facility,both,7,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,16729-114-08,NDC,,,facility,both,9,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,63323-104-25,NDC,,,facility,both,11,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,0143-9511-01,NDC,,,facility,both,2,ML,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,63323-104-25,NDC,,,facility,both,7,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,0143-9511-01,NDC,,,facility,both,8,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,16729-114-08,NDC,,,facility,both,16,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,63323-104-25,NDC,,,facility,both,18,ML,,113,79.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,16729-114-08,NDC,,,facility,both,19,ML,,90,63,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,63323-104-25,NDC,,,facility,both,21,ML,,128,89.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,63323-104-25,NDC,,,facility,both,11,ML,,66,46.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,63323-104-25,NDC,,,facility,both,3,ML,,17,11.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,63323-104-25,NDC,,,facility,both,22,ML,,136,95.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,16729-114-08,NDC,,,facility,both,26,ML,,124,86.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,63323-104-25,NDC,,,facility,both,5,ML,,27,18.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,63323-104-25,NDC,,,facility,both,6,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,0143-9511-01,NDC,,,facility,both,26,ML,,115,80.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,16729-114-08,NDC,,,facility,both,20,ML,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,63323-104-25,NDC,,,facility,both,15,ML,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,16729-114-08,NDC,,,facility,both,25,ML,,119,83.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,63323-104-25,NDC,,,facility,both,11,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,16729-114-08,NDC,,,facility,both,2,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,0143-9511-01,NDC,,,facility,both,9,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,16729-114-08,NDC,,,facility,both,1,ML,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,16729-114-08,NDC,,,facility,both,9,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,0143-9511-01,NDC,,,facility,both,28,ML,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,16729-114-08,NDC,,,facility,both,23,ML,,108,75.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,16729-114-08,NDC,,,facility,both,10,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,16729-114-31,NDC,,,facility,both,22,ML,,119,83.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,0143-9511-01,NDC,,,facility,both,14,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,16729-114-08,NDC,,,facility,both,9,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,16729-114-08,NDC,,,facility,both,21,ML,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,0143-9511-01,NDC,,,facility,both,3,ML,,11,7.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,16729-114-08,NDC,,,facility,both,1,ML,,4,2.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,63323-104-25,NDC,,,facility,both,23,ML,,145,101.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,16729-114-08,NDC,,,facility,both,20,ML,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,0143-9511-01,NDC,,,facility,both,10,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,63323-104-25,NDC,,,facility,both,16,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,63323-104-05,NDC,,,facility,both,10,ML,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,63323-104-25,NDC,,,facility,both,19,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,0143-9511-01,NDC,,,facility,both,23,ML,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,63323-104-25,NDC,,,facility,both,2,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,63323-104-25,NDC,,,facility,both,25,ML,,154,107.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,0143-9511-01,NDC,,,facility,both,16,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,16729-114-08,NDC,,,facility,both,18,ML,,83,58.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,63323-104-25,NDC,,,facility,both,12,ML,,75,52.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,63323-104-25,NDC,,,facility,both,14,ML,,88,61.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,16729-114-08,NDC,,,facility,both,15,ML,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,0143-9511-01,NDC,,,facility,both,21,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,16729-114-08,NDC,,,facility,both,12,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,0143-9511-01,NDC,,,facility,both,15,ML,,64,44.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,0143-9511-01,NDC,,,facility,both,23,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,0143-9511-01,NDC,,,facility,both,11,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,16729-114-08,NDC,,,facility,both,22,ML,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,63323-104-25,NDC,,,facility,both,17,ML,,104,72.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,16729-114-08,NDC,,,facility,both,11,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,16729-114-08,NDC,,,facility,both,17,ML,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,0143-9511-01,NDC,,,facility,both,24,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,16729-114-08,NDC,,,facility,both,17,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,0143-9511-01,NDC,,,facility,both,7,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,0143-9511-01,NDC,,,facility,both,18,ML,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,0143-9511-01,NDC,,,facility,both,19,ML,,85,59.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,63323-104-25,NDC,,,facility,both,7,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,63323-104-25,NDC,,,facility,both,19,ML,,121,84.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,63323-104-25,NDC,,,facility,both,17,ML,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,16729-114-08,NDC,,,facility,both,17,ML,,80,56,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,16729-114-08,NDC,,,facility,both,10,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,63323-104-25,NDC,,,facility,both,12,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,16729-114-08,NDC,,,facility,both,18,ML,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,16729-114-08,NDC,,,facility,both,12,ML,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,63323-104-25,NDC,,,facility,both,22,ML,,140,98,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ETOPOSIDE 20 MG/ML IV SOLN,8893,CDM,J9181,HCPCS,0143-9511-01,NDC,,,facility,both,27,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,3,ML,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,12,ML,,316,221.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 500 MG/10 ML IV SOLN,8896,CDM,J9190,HCPCS,16729-276-38,NDC,,,facility,both,2,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,10,ML,,274,191.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,9,ML,,229,160.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,6,ML,,157,109.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,2,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 500 MG/10 ML IV SOLN,8896,CDM,J9190,HCPCS,63323-117-01,NDC,,,facility,both,8,ML,,182,127.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,10,ML,,260,182,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 500 MG/10 ML IV SOLN,8896,CDM,J9190,HCPCS,62332-751-50,NDC,,,facility,both,7,ML,,212,148.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,70700-189-22,NDC,,,facility,both,12,ML,,330,231,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,10139-063-01,NDC,,,facility,both,9,ML,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 500 MG/10 ML IV SOLN,8896,CDM,J9190,HCPCS,63323-117-10,NDC,,,facility,both,2,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,5,ML,,138,96.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,5,ML,,118,82.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,7,ML,,175,122.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,8,ML,,202,141.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,70700-189-22,NDC,,,facility,both,9,ML,,254,177.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,6,ML,,162,113.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,6,ML,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,6,ML,,166,116.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,11,ML,,301,210.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 500 MG/10 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-98,NDC,,,facility,both,1,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,6,ML,,153,107.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,4,ML,,110,77,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,7,ML,,185,129.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,12,ML,,313,219.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,7,ML,,173,121.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,7,ML,,171,119.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,9,ML,,230,161,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,10139-063-01,NDC,,,facility,both,10,ML,,132,92.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,9,ML,,228,159.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,8,ML,,206,144.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,9,ML,,241,168.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 500 MG/10 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-98,NDC,,,facility,both,2,ML,,60,42,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,8,ML,,209,146.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 500 MG/10 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-98,NDC,,,facility,both,2,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,9,ML,,238,166.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,2,ML,,31,21.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 500 MG/10 ML IV SOLN,8896,CDM,J9190,HCPCS,63323-117-61,NDC,,,facility,both,10,ML,,173,121.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,11,ML,,293,205.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,9,ML,,246,172.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 1 GRAM/20 ML IV SOLN,8896,CDM,J9190,HCPCS,63323-117-00,NDC,,,facility,both,2,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,2,ML,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,70700-189-22,NDC,,,facility,both,9,ML,,251,175.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,6,ML,,143,100.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,11,ML,,292,204.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,11,ML,,303,212.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,7,ML,,192,134.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,8,ML,,213,149.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,2,ML,,43,30.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,4,ML,,100,70,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,8,ML,,218,152.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,10,ML,,264,184.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,11,ML,,288,201.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,10,ML,,253,177.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 500 MG/10 ML IV SOLN,8896,CDM,J9190,HCPCS,63323-117-61,NDC,,,facility,both,20,ML,,344,240.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,2,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,10,ML,,269,188.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 500 MG/10 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-98,NDC,,,facility,both,2,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,7,ML,,180,126,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,12,ML,,312,218.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,9,ML,,244,170.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,10,ML,,265,185.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,9,ML,,233,163.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,9,ML,,225,157.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,11,ML,,296,207.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,70700-189-22,NDC,,,facility,both,12,ML,,327,228.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,10,ML,,276,193.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,12,ML,,324,226.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,2,ML,,52,36.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 500 MG/10 ML IV SOLN,8896,CDM,J9190,HCPCS,16729-276-38,NDC,,,facility,both,8,ML,,223,156.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 500 MG/10 ML IV SOLN,8896,CDM,J9190,HCPCS,16729-276-38,NDC,,,facility,both,10,ML,,275,192.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,11,ML,,308,215.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,8,ML,,203,142.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 500 MG/10 ML IV SOLN,8896,CDM,J9190,HCPCS,62332-751-50,NDC,,,facility,both,10,ML,,323,226.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,10139-063-01,NDC,,,facility,both,8,ML,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,8,ML,,217,151.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,1,ML,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,10139-063-01,NDC,,,facility,both,9,ML,,113,79.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,10139-063-01,NDC,,,facility,both,10,ML,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,5,ML,,133,93.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,10139-063-01,NDC,,,facility,both,9,ML,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 500 MG/10 ML IV SOLN,8896,CDM,J9190,HCPCS,62332-751-50,NDC,,,facility,both,2,ML,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,2,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,13,ML,,343,240.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 500 MG/10 ML IV SOLN,8896,CDM,J9190,HCPCS,63323-117-61,NDC,,,facility,both,16,ML,,345,241.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,2,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,11,ML,,299,209.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 500 MG/10 ML IV SOLN,8896,CDM,J9190,HCPCS,63323-117-61,NDC,,,facility,both,10,ML,,172,120.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,8,ML,,222,155.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,9,ML,,249,174.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,5,ML,,130,91,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 500 MG/10 ML IV SOLN,8896,CDM,J9190,HCPCS,63323-117-01,NDC,,,facility,both,3,ML,,69,48.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,6,ML,,150,105,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,7,ML,,194,135.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,63323-117-51,NDC,,,facility,both,15,ML,,259,181.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 500 MG/10 ML IV SOLN,8896,CDM,J9190,HCPCS,63323-117-01,NDC,,,facility,both,4,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 500 MG/10 ML IV SOLN,8896,CDM,J9190,HCPCS,63323-117-01,NDC,,,facility,both,2,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,2,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,63323-117-51,NDC,,,facility,both,10,ML,,173,121.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,11,ML,,281,196.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 500 MG/10 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-98,NDC,,,facility,both,2,ML,,58,40.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,7,ML,,181,126.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,10,ML,,262,183.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,9,ML,,250,175,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 500 MG/10 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-98,NDC,,,facility,both,1,ML,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,4,ML,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,9,ML,,248,173.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,10,ML,,256,179.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 500 MG/10 ML IV SOLN,8896,CDM,J9190,HCPCS,63323-117-61,NDC,,,facility,both,10,ML,,173,121.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,11,ML,,304,212.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 500 MG/10 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-98,NDC,,,facility,both,2,ML,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 500 MG/10 ML IV SOLN,8896,CDM,J9190,HCPCS,62332-751-50,NDC,,,facility,both,10,ML,,304,212.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,2,ML,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,70700-189-22,NDC,,,facility,both,10,ML,,278,194.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,8,ML,,219,153.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 500 MG/10 ML IV SOLN,8896,CDM,J9190,HCPCS,63323-117-01,NDC,,,facility,both,2,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,2,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 500 MG/10 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-98,NDC,,,facility,both,1,ML,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 500 MG/10 ML IV SOLN,8896,CDM,J9190,HCPCS,70700-188-22,NDC,,,facility,both,2,ML,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 500 MG/10 ML IV SOLN,8896,CDM,J9190,HCPCS,63323-117-01,NDC,,,facility,both,2,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,11,ML,,300,210,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,2,ML,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,10139-063-01,NDC,,,facility,both,5,ML,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,6,ML,,155,108.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,3,ML,,70,49,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 500 MG/10 ML IV SOLN,8896,CDM,J9190,HCPCS,16729-276-38,NDC,,,facility,both,10,ML,,292,204.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,6,ML,,154,107.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,10,ML,,257,179.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,1,ML,,1,0.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,10139-063-01,NDC,,,facility,both,6,ML,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,10,ML,,280,196,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,9,ML,,242,169.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,4,ML,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 500 MG/10 ML IV SOLN,8896,CDM,J9190,HCPCS,16729-276-38,NDC,,,facility,both,8,ML,,230,161,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 500 MG/10 ML IV SOLN,8896,CDM,J9190,HCPCS,63323-117-01,NDC,,,facility,both,2,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,1,ML,,13,9.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,9,ML,,243,170.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,2,ML,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,8,ML,,215,150.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,1,ML,,6,4.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,10,ML,,259,181.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 500 MG/10 ML IV SOLN,8896,CDM,J9190,HCPCS,63323-117-01,NDC,,,facility,both,4,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,13,ML,,340,238,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,70700-189-22,NDC,,,facility,both,10,ML,,286,200.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 500 MG/10 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-98,NDC,,,facility,both,2,ML,,49,34.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,5,ML,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,12,ML,,330,231,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,70700-189-22,NDC,,,facility,both,9,ML,,239,167.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,8,ML,,201,140.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,5,ML,,140,98,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,9,ML,,234,163.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,10,ML,,266,186.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,6,ML,,168,117.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 500 MG/10 ML IV SOLN,8896,CDM,J9190,HCPCS,63323-117-01,NDC,,,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 500 MG/10 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-98,NDC,,,facility,both,1,ML,,25,17.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,10,ML,,261,182.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 500 MG/10 ML IV SOLN,8896,CDM,J9190,HCPCS,63323-117-61,NDC,,,facility,both,10,ML,,345,241.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,2,ML,,41,28.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,8,ML,,224,156.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,70700-189-22,NDC,,,facility,both,9,ML,,243,170.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,2,ML,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,6,ML,,158,110.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 500 MG/10 ML IV SOLN,8896,CDM,J9190,HCPCS,63323-117-61,NDC,,,facility,both,20,ML,,345,241.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,9,ML,,226,158.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,7,ML,,187,130.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 500 MG/10 ML IV SOLN,8896,CDM,J9190,HCPCS,16729-276-38,NDC,,,facility,both,9,ML,,234,163.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,9,ML,,239,167.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,70700-189-22,NDC,,,facility,both,11,ML,,314,219.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,6,ML,,159,111.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,8,ML,,221,154.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,1,ML,,9,6.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,6,ML,,163,114.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,8,ML,,214,149.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 500 MG/10 ML IV SOLN,8896,CDM,J9190,HCPCS,16729-276-38,NDC,,,facility,both,2,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,9,ML,,232,162.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 500 MG/10 ML IV SOLN,8896,CDM,J9190,HCPCS,62332-751-50,NDC,,,facility,both,7,ML,,234,163.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,2,ML,,47,32.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,8,ML,,210,147,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 500 MG/10 ML IV SOLN,8896,CDM,J9190,HCPCS,70700-188-22,NDC,,,facility,both,2,ML,,42,29.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,2,ML,,39,27.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 500 MG/10 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-98,NDC,,,facility,both,2,ML,,37,25.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,11,ML,,291,203.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,10,ML,,258,180.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,63323-117-51,NDC,,,facility,both,5,ML,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,12,ML,,309,216.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,2,ML,,40,28,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,11,ML,,285,199.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 500 MG/10 ML IV SOLN,8896,CDM,J9190,HCPCS,63323-117-01,NDC,,,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,5,ML,,127,88.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,10,ML,,271,189.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,63323-117-51,NDC,,,facility,both,5,ML,,87,60.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,10,ML,,277,193.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 500 MG/10 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-98,NDC,,,facility,both,1,ML,,21,14.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,7,ML,,178,124.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,7,ML,,195,136.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,9,ML,,227,158.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 500 MG/10 ML IV SOLN,8896,CDM,J9190,HCPCS,62332-751-50,NDC,,,facility,both,2,ML,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,70700-189-22,NDC,,,facility,both,7,ML,,202,141.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,3,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,11,ML,,284,198.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,12,ML,,311,217.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 1 GRAM/20 ML IV SOLN,8896,CDM,J9190,HCPCS,63323-117-00,NDC,,,facility,both,1,ML,,23,16.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,10,ML,,279,195.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,70700-189-22,NDC,,,facility,both,9,ML,,241,168.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,7,ML,,183,128.1,,,,,,,,,,,,,Gross Charge Type: Pharmacy
FLUOROURACIL 5 GRAM/100 ML IV SOLN,8896,CDM,J9190,HCPCS,25021-215-99,NDC,,,facility,both,9,ML,,252,176.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GOSERELIN  3.6 MG SUBQ IMPL,8898,CDM,J9202,HCPCS,0310-0950-36,NDC,,,facility,both,3,EA,,4559,3191.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GOSERELIN  3.6 MG SUBQ IMPL,8898,CDM,J9202,HCPCS,70720-950-36,NDC,,,facility,both,1,EA,,1670,1169,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GOSERELIN  3.6 MG SUBQ IMPL,8898,CDM,J9202,HCPCS,0310-0950-36,NDC,,,facility,both,1,EA,,1520,1064,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GOSERELIN 10.8 MG SUBQ IMPL,8898,CDM,J9202,HCPCS,70720-951-30,NDC,,,facility,both,3,EA,,5010,3507,,,,,,,,,,,,,Gross Charge Type: Pharmacy
GOSERELIN 10.8 MG SUBQ IMPL,8898,CDM,J9202,HCPCS,0310-0951-30,NDC,,,facility,both,3,EA,,4559,3191.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESNA 100 MG/ML IV SOLN,8900,CDM,J9209,HCPCS,0338-1305-01,NDC,,,facility,both,2,ML,,62,43.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESNA 100 MG/ML IV SOLN,8900,CDM,J9209,HCPCS,0338-1305-01,NDC,,,facility,both,5,ML,,167,116.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESNA 100 MG/ML IV SOLN,8900,CDM,J9209,HCPCS,0338-1305-01,NDC,,,facility,both,2,ML,,61,42.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MESNA 100 MG/ML IV SOLN,8900,CDM,J9209,HCPCS,0338-1305-01,NDC,,,facility,both,5,ML,,169,118.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE 22.5 MG SUBQ SYRG,8906,CDM,J9217,HCPCS,62935-221-04,NDC,,,facility,both,3,EA,,1176,823.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE (3 MONTH) 22.5 MG IM SYRG,8906,CDM,J9217,HCPCS,0074-3346-03,NDC,,,facility,both,3,EA,,1175,822.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE (4 MONTH) 30 MG IM KIT,8906,CDM,J9217,HCPCS,0074-3683-03,NDC,,,facility,both,4,EA,,22567,15796.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE  7.5 MG SUBQ SYRG,8906,CDM,J9217,HCPCS,62935-754-74,NDC,,,facility,both,1,EA,,1176,823.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE (3 MONTH) 22.5 MG IM SYRG,8906,CDM,J9217,HCPCS,0074-3346-03,NDC,,,facility,both,6,EA,,2351,1645.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE  7.5 MG IM SYKT,8906,CDM,J9217,HCPCS,0074-3642-03,NDC,,,facility,both,3,EA,,3527,2468.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE (4 MONTH) 30 MG IM KIT,8906,CDM,J9217,HCPCS,0074-3683-03,NDC,,,facility,both,4,EA,,23696,16587.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE 22.5 MG SUBQ SYRG,8906,CDM,J9217,HCPCS,62935-223-05,NDC,,,facility,both,3,EA,,1176,823.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE (6 MONTH) 45 MG IM SYKT,8906,CDM,J9217,HCPCS,0074-3473-03,NDC,,,facility,both,6,EA,,1176,823.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE (6 MONTH) 45 MG SUBCUTANOUS KIT,8906,CDM,J9217,HCPCS,62935-453-45,NDC,,,facility,both,3,EA,,588,411.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE  7.5 MG SUBQ SYRG,8906,CDM,J9217,HCPCS,62935-753-75,NDC,,,facility,both,1,EA,,1176,823.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE (6 MONTH) 45 MG SUBCUTANOUS KIT,8906,CDM,J9217,HCPCS,62935-453-45,NDC,,,facility,both,3,EA,,200,140,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE (3 MONTH) 22.5 MG IM SYRG,8906,CDM,J9217,HCPCS,0074-3346-03,NDC,,,facility,both,3,EA,,1176,823.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE (6 MONTH) 45 MG SUBCUTANOUS KIT,8906,CDM,J9217,HCPCS,62935-453-45,NDC,,,facility,both,6,EA,,1176,823.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE (6 MONTH) 45 MG SUBCUTANOUS KIT,8906,CDM,J9217,HCPCS,62935-461-50,NDC,,,facility,both,6,EA,,1176,823.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE 22.5 MG SUBQ SYRG,8906,CDM,J9217,HCPCS,62935-227-10,NDC,,,facility,both,3,EA,,1175,822.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE (4-MONTH) 30 MG SUBQ SYRG,8906,CDM,J9217,HCPCS,62935-306-40,NDC,,,facility,both,4,EA,,1176,823.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE 22.5 MG SUBQ SYRG,8906,CDM,J9217,HCPCS,62935-227-10,NDC,,,facility,both,3,EA,,1176,823.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE  7.5 MG IM SYKT,8906,CDM,J9217,HCPCS,0074-3642-03,NDC,,,facility,both,1,EA,,1176,823.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
LEUPROLIDE  7.5 MG SUBQ SYRG,8906,CDM,J9217,HCPCS,62935-756-80,NDC,,,facility,both,1,EA,,1176,823.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE SODIUM 25 MG/ML INJ SOLN,8911,CDM,J9260,HCPCS,61703-350-37,NDC,,,facility,both,2,ML,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
METHOTREXATE SODIUM 25 MG/ML INJ SOLN,8911,CDM,J9260,HCPCS,16729-277-30,NDC,,,facility,both,1,ML,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MITOMYCIN 20 MG IV SOLR,8916,CDM,J9280,HCPCS,71288-138-50,NDC,,,facility,both,4,EA,,994,695.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MITOMYCIN 20 MG IV SOLR,8916,CDM,J9280,HCPCS,71288-138-50,NDC,,,facility,both,4,EA,,1242,869.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MITOMYCIN 20 MG IV SOLR,8916,CDM,J9280,HCPCS,16729-108-11,NDC,,,facility,both,4,EA,,1628,1139.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MITOMYCIN 20 MG IV SOLR,8916,CDM,J9280,HCPCS,67457-519-20,NDC,,,facility,both,4,EA,,1628,1139.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MITOMYCIN 20 MG IV SOLR,8916,CDM,J9280,HCPCS,71288-138-50,NDC,,,facility,both,4,EA,,1081,756.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MITOMYCIN 20 MG IV SOLR,8916,CDM,J9280,HCPCS,67457-519-20,NDC,,,facility,both,3,EA,,1221,854.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MITOMYCIN 20 MG IV SOLR,8916,CDM,J9280,HCPCS,71288-138-50,NDC,,,facility,both,4,EA,,957,669.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
MITOMYCIN  5 MG IV SOLR,8916,CDM,J9280,HCPCS,25021-250-20,NDC,,,facility,both,1,EA,,707,494.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VINBLASTINE 1 MG/ML IV SOLN,8922,CDM,J9360,HCPCS,63323-278-10,NDC,,,facility,both,20,ML,,548,383.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VINBLASTINE 1 MG/ML IV SOLN,8922,CDM,J9360,HCPCS,63323-278-10,NDC,,,facility,both,10,ML,,274,191.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VINCRISTINE 2 MG/2 ML IV SOLN,8923,CDM,J9370,HCPCS,61703-309-06,NDC,,,facility,both,1,ML,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VINCRISTINE 2 MG/2 ML IV SOLN,8923,CDM,J9370,HCPCS,61703-309-06,NDC,,,facility,both,1,ML,,105,73.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VINCRISTINE 2 MG/2 ML IV SOLN,8923,CDM,J9370,HCPCS,61703-309-16,NDC,,,facility,both,1,ML,,46,32.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VINCRISTINE 2 MG/2 ML IV SOLN,8923,CDM,J9370,HCPCS,61703-309-16,NDC,,,facility,both,2,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VINCRISTINE 2 MG/2 ML IV SOLN,8923,CDM,J9370,HCPCS,61703-309-16,NDC,,,facility,both,2,ML,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VINCRISTINE 2 MG/2 ML IV SOLN,8923,CDM,J9370,HCPCS,0703-4412-11,NDC,,,facility,both,2,ML,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VINCRISTINE 2 MG/2 ML IV SOLN,8923,CDM,J9370,HCPCS,61703-309-16,NDC,,,facility,both,1,ML,,10,7,,,,,,,,,,,,,Gross Charge Type: Pharmacy
VINCRISTINE 2 MG/2 ML IV SOLN,8923,CDM,J9370,HCPCS,61703-309-06,NDC,,,facility,both,2,ML,,209,146.3,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TECLISTAMAB-CQYV 10 MG/ML SUBQ SOLN,8925,CDM,J9380,HCPCS,57894-449-01,NDC,,,facility,both,60,ML,,4886,3420.2,,,,,,,,,,,,,Gross Charge Type: Pharmacy
TECLISTAMAB-CQYV 90 MG/ML SUBQ SOLN,8925,CDM,J9380,HCPCS,57894-450-01,NDC,,,facility,both,306,ML,,24915,17440.5,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IMETELSTAT  47 MG IV SOLR,8927,CDM,J9999,HCPCS,82959-112-01,NDC,,,facility,both,1,EA,,6702,4691.4,,,,,,,,,,,,,Gross Charge Type: Pharmacy
ROPEGINTERFERON ALFA-2B-NJFT 500 MCG/ML SUBQ SYRG,8927,CDM,J9999,HCPCS,73536-500-01,NDC,,,facility,both,1,ML,,23234,16263.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IMETELSTAT  47 MG IV SOLR,8927,CDM,J9999,HCPCS,82959-112-01,NDC,,,facility,both,1,EA,,6748,4723.6,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IMETELSTAT 188 MG IV SOLR,8927,CDM,J9999,HCPCS,82959-111-01,NDC,,,facility,both,3,EA,,81790,57253,,,,,,,,,,,,,Gross Charge Type: Pharmacy
IMETELSTAT 188 MG IV SOLR,8927,CDM,J9999,HCPCS,82959-111-01,NDC,,,facility,both,2,EA,,54674,38271.8,,,,,,,,,,,,,Gross Charge Type: Pharmacy
HC ELECTROCONVULSIVE THERAPY,90100001,CDM,901,RC,90870,HCPCS,,,facility,both,,,,2366,1656.2,,,,,,,,,,,,,Gross Charge Type: Central
HC GROUP PSYCHOTHERAPY,91500001,CDM,915,RC,90853,HCPCS,,,facility,both,,,,370,259,,,,,,,,,,,,,Gross Charge Type: Central
HC MULTI-FAM GROUP BHV MGMT/MODIFICAJ TRAINING FACE-TO-FACE W/MULTI SETS PARENT/GUARDIAN/CAREGIVER INITIAL 60 MIN,91500003,CDM,915,RC,96202,HCPCS,,,facility,both,,,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Central
HC MULTI-FAM GROUP BHV MGMT/MODIFICAJ TRAINING FACE-TO-FACE W/MULTI SETS PARENT/GUARDIAN/CAREGIVER EA ADDTL 15 MIN,91500004,CDM,915,RC,96203,HCPCS,,,facility,both,,,,12,8.4,,,,,,,,,,,,,Gross Charge Type: Central
HC UNLISTED PROCEDURE HEMIC OR LYMPHATIC SYSTEM,92000001,CDM,920,RC,38999,HCPCS,,,facility,both,,,,7888,5521.6,,,,,,,,,,,,,Gross Charge Type: Central
HC FETAL CONTRACT STRESS TEST,92000003,CDM,920,RC,59020,HCPCS,,,facility,both,,,,707,494.9,,,,,,,,,,,,,Gross Charge Type: Central
HC FETAL NON-STRESS TEST,92000004,CDM,920,RC,59025,HCPCS,,,facility,both,,,,490,343,,,,,,,,,,,,,Gross Charge Type: Central
HC SLEEP STUDY UNATTENDED W/RECORDING OF HEART RATE/OXYGEN SATURATION/RESPIRATORY AIRFLOW/RESPIRATOR,92000006,CDM,920,RC,95806,HCPCS,,,facility,both,,,,529,370.3,,,,,,,,,,,,,Gross Charge Type: Central
HC HOME SLEEP TEST W/TYPE III PORTABLE MONITOR UNATTEND MIN 4 CHANNELS 2 RESPIRATORY MOV/AIRFLOW 1 ECG/HEARL RATE & 1 OXYGEN SATURATION,92000013,CDM,920,RC,G0399,HCPCS,,,facility,both,,,,641,448.7,,,,,,,,,,,,,Gross Charge Type: Central
HC ELEC ANALYSIS IMPLT NEUROSTIM PULSE GENERATOR PHYS/QHP W/O PROGRAMMING,92000015,CDM,920,RC,95970,HCPCS,,,facility,both,,,,145,101.5,,,,,,,,,,,,,Gross Charge Type: Central
HC US EXTRACRANIAL ARTERIES BILAT,92100001,CDM,921,RC,93880,HCPCS,,,facility,both,,,,1036,725.2,,,,,,,,,,,,,Gross Charge Type: Central
HC DOPP UP OR LWR EXTR  1-2 ART BILAT,92100004,CDM,921,RC,93922,HCPCS,,,facility,both,,,,535,374.5,,,,,,,,,,,,,Gross Charge Type: Central
HC DOPP UP OR LWR EXTR  3> ART BILAT,92100005,CDM,921,RC,93923,HCPCS,,,facility,both,,,,821,574.7,,,,,,,,,,,,,Gross Charge Type: Central
HC US LWR EXT ART BYPASS  BILAT,92100006,CDM,921,RC,93925,HCPCS,,,facility,both,,,,1244,870.8,,,,,,,,,,,,,Gross Charge Type: Central
HC US LWR EXT ART BYPASS  UNILAT,92100007,CDM,921,RC,93926,HCPCS,,,facility,both,,,,255,178.5,,,,,,,,,,,,,Gross Charge Type: Central
HC US UPPER EXT ART BYPASS BILAT,92100008,CDM,921,RC,93930,HCPCS,,,facility,both,,,,555,388.5,,,,,,,,,,,,,Gross Charge Type: Central
HC US UPPER EXT ART BYPASS UNILAT,92100009,CDM,921,RC,93931,HCPCS,,,facility,both,,,,371,259.7,,,,,,,,,,,,,Gross Charge Type: Central
HC DUP SCAN EXT VEINS INCL COMPR/MNVR COMP BILAT,92100011,CDM,921,RC,93970,HCPCS,,,facility,both,,,,634,443.8,,,,,,,,,,,,,Gross Charge Type: Central
HC US EXT VEINS UNILAT MANEUVERS,92100012,CDM,921,RC,93971,HCPCS,,,facility,both,,,,409,286.3,,,,,,,,,,,,,Gross Charge Type: Central
HC DUPLEX SCAN ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMNINAL PELVIC SCROTAL AND/OR RETROPERITONEAL ORGANS COMPLETE STUDY,92100013,CDM,921,RC,93975,HCPCS,,,facility,both,,,,757,529.9,,,,,,,,,,,,,Gross Charge Type: Central
HC US VASC ABD PEL SCROT RETPER LMTD,92100014,CDM,921,RC,93976,HCPCS,,,facility,both,,,,239,167.3,,,,,,,,,,,,,Gross Charge Type: Central
HC US AORTA INFVC ILIAC COMP,92100015,CDM,921,RC,93978,HCPCS,,,facility,both,,,,596,417.2,,,,,,,,,,,,,Gross Charge Type: Central
HC US AORTA INFVC ILIAC LMTD,92100016,CDM,921,RC,93979,HCPCS,,,facility,both,,,,361,252.7,,,,,,,,,,,,,Gross Charge Type: Central
HC DUPLEX SCAN ARTERIAL INFLOW AND VENOUS OUTFLOW PREOP VESSEL ASSESS COMPLETE BILAT STUDY,92100031,CDM,921,RC,93985,HCPCS,,,facility,both,,,,749,524.3,,,,,,,,,,,,,Gross Charge Type: Central
HC DUPLEX SCAN ARTERIAL INFLOW AND VENOUS OUTFLOW PREOP BESSEL ASSESS COMPLETE UNILATERAL STUDY,92100032,CDM,921,RC,93986,HCPCS,,,facility,both,,,,360,252,,,,,,,,,,,,,Gross Charge Type: Central
HC VASOREACTIVITY STUDY PERFORMED W/TRANSCRANIAL DOPPLER STUDY OF INTRACRANIAL ARTERIES COMPLETE,92100034,CDM,921,RC,93896,HCPCS,,,facility,both,,,,454,317.8,,,,,,,,,,,,,Gross Charge Type: Central
HC EMG ONE LIMB,92200001,CDM,922,RC,95860,HCPCS,,,facility,both,,,,132,92.4,,,,,,,,,,,,,Gross Charge Type: Central
HC EMG TWO LIMBS,92200002,CDM,922,RC,95861,HCPCS,,,facility,both,,,,238,166.6,,,,,,,,,,,,,Gross Charge Type: Central
HC SOMATOSEN TEST UP LIMBS,92200009,CDM,922,RC,95925,HCPCS,,,facility,both,,,,1278,894.6,,,,,,,,,,,,,Gross Charge Type: Central
HC VISUAL EVOKED POTENTIAL CHECKERBOARD/FLASH TESTING CENTRAL NERVOUS SYST EXCEPT GLAUCOMA W/I&R,92200011,CDM,922,RC,95930,HCPCS,,,facility,both,,,,500,350,,,,,,,,,,,,,Gross Charge Type: Central
HC ELEC STIM FOR GUIDE,92200014,CDM,922,RC,95873,HCPCS,,,facility,both,,,,119,83.3,,,,,,,,,,,,,Gross Charge Type: Central
HC NEEDLE EMG FOR GUIDE,92200015,CDM,922,RC,95874,HCPCS,,,facility,both,,,,128,89.6,,,,,,,,,,,,,Gross Charge Type: Central
HC NERVE CONDUCTION STUDIES 3-4 STUDIES,92200028,CDM,922,RC,95908,HCPCS,,,facility,both,,,,1326,928.2,,,,,,,,,,,,,Gross Charge Type: Central
HC NERVE CONDUCTION STUDIES 5-6 STUDIES,92200029,CDM,922,RC,95909,HCPCS,,,facility,both,,,,459,321.3,,,,,,,,,,,,,Gross Charge Type: Central
HC NERVE CONDUCTION STUDIES 7-8 STUDIES,92200030,CDM,922,RC,95910,HCPCS,,,facility,both,,,,459,321.3,,,,,,,,,,,,,Gross Charge Type: Central
ELECTROCARDIOGRAM REPORT,93010,CDM,985,RC,93010,HCPCS,,,facility,both,,,,20,14,,,,,,,,,,,,,Gross Charge Type: Central
HC PLACE NEEDLE / CATH IN VEIN,94000001,CDM,940,RC,36000,HCPCS,,,facility,both,,,,154,107.8,,,,,,,,,,,,,Gross Charge Type: Central
HC APHERESIS WBC,94000002,CDM,940,RC,36511,HCPCS,,,facility,both,,,,3360,2352,,,,,,,,,,,,,Gross Charge Type: Central
HC APHERESIS RBC,94000003,CDM,940,RC,36512,HCPCS,,,facility,both,,,,3360,2352,,,,,,,,,,,,,Gross Charge Type: Central
HC APHERESIS PLATELETS,94000004,CDM,940,RC,36513,HCPCS,,,facility,both,,,,3360,2352,,,,,,,,,,,,,Gross Charge Type: Central
HC APHERESIS PLASMA,94000005,CDM,940,RC,36514,HCPCS,,,facility,both,,,,3360,2352,,,,,,,,,,,,,Gross Charge Type: Central
HC PHOTOPHERESIS,94000006,CDM,940,RC,36522,HCPCS,,,facility,both,,,,8954,6267.8,,,,,,,,,,,,,Gross Charge Type: Central
ARTERIAL BLOOD DRAW,94000007,CDM,761,RC,36600,HCPCS,,,facility,both,,,,198,138.6,,,,,,,,,,,,,Gross Charge Type: Central
HC REFILL IMPLANTABLE PUMP,94000008,CDM,940,RC,95991,HCPCS,,,facility,both,,,,256,179.2,,,,,,,,,,,,,Gross Charge Type: Central
HC REFILL/MAINT PORTABLE PUMP,94000009,CDM,940,RC,96521,HCPCS,,,facility,both,,,,271,189.7,,,,,,,,,,,,,Gross Charge Type: Central
HC IRRIGATE CENTRAL LINE/DEVICE,94000010,CDM,940,RC,96523,HCPCS,,,facility,both,,,,202,141.4,,,,,,,,,,,,,Gross Charge Type: Central
PHLEBOTOMY,94000011,CDM,940,RC,99195,HCPCS,,,facility,both,,,,361,252.7,,,,,,,,,,,,,Gross Charge Type: Central
HC INTENSIVE INFANT RECOVERY,94000012,CDM,940,RC,94000012,HCPCS,,,facility,both,,,,1206,844.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PROLONGED ECMO INITAL 24 HRS,94000013,CDM,940,RC,94000013,HCPCS,,,facility,both,,,,53236,37265.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PROLONGED ECMO EA. ADD'L 24 HR,94000014,CDM,940,RC,94000014,HCPCS,,,facility,both,,,,19102,13371.4,,,,,,,,,,,,,Gross Charge Type: Central
HC XRAY CYSTOGRAPHY,94000018,CDM,940,RC,51600,HCPCS,,,facility,both,,,,225,157.5,,,,,,,,,,,,,Gross Charge Type: Central
HC BEHAV CHNG SMOKING 3-10 MIN,94200001,CDM,942,RC,99406,HCPCS,,,facility,both,,,,45,31.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PHYSN SERV CARD REHAB W/O ECG,94300001,CDM,943,RC,93797,HCPCS,,,facility,both,,,,275,192.5,,,,,,,,,,,,,Gross Charge Type: Central
PHYSN SERV CARD REHAB /W ECG,94300002,CDM,943,RC,93798,HCPCS,,,facility,both,,,,548,383.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO DRESS/DEBRID P-THICK BURN SMALL < 5%,96000002,CDM,960,RC,16020,HCPCS,,,facility,both,,,,247,172.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO DRESS/DEBRID P-THICK BURN MED 5% - 10%,96000003,CDM,960,RC,16025,HCPCS,,,facility,both,,,,246,172.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO DRESS/DEBRID P-THICK BURN LARGE > 10%,96000004,CDM,960,RC,16030,HCPCS,,,facility,both,,,,173,121.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO ARTHROCENTESIS ASPIRATION/INJ MAJOR JOINT/BURSA W/O US GUIDE,96000005,CDM,960,RC,20610,HCPCS,,,facility,both,,,,365,255.5,,,,,,,,,,,,,Gross Charge Type: Central
HC  PRO ARTHROCENTESIS ASPIRATION/INJ INTERMEDIATE JOINT/BURSA W/O US GUIDE,96000006,CDM,960,RC,20605,HCPCS,,,facility,both,,,,192,134.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO ARTHROCENTESIS ASPIRATION/INJ SMALL JOINT/BURSA W/O US GUIDE,96000007,CDM,960,RC,20600,HCPCS,,,facility,both,,,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO INSERT TEMP INDWELLING BLADDER CATH SIMPLE,96000010,CDM,960,RC,51702,HCPCS,,,facility,both,,,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO INSERT TEMP INDWELLING BLADDER CATH COMPLICATED,96000011,CDM,960,RC,51703,HCPCS,,,facility,both,,,,289,202.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO INSERT NON-TUNN CV CATH >5 YRS,96000012,CDM,960,RC,36556,HCPCS,,,facility,both,,,,531,371.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CARDIOVERSION ELECTRIC EXT,96000014,CDM,960,RC,92960,HCPCS,,,facility,both,,,,648,453.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO REMOVAL OF ARM FOREIGN BODY,96000016,CDM,960,RC,24200,HCPCS,,,facility,both,,,,382,267.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO REMOVAL FOREIGN BODY MOUTH,96000018,CDM,960,RC,40804,HCPCS,,,facility,both,,,,285,199.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO REMV VAG FOREIGN BODY,96000019,CDM,960,RC,57415,HCPCS,,,facility,both,,,,406,284.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO DRAINAGE OF FINGER ABSCESS,96000020,CDM,960,RC,26010,HCPCS,,,facility,both,,,,189,132.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO DRAINAGE ABSCESS PALATE UVULA,96000022,CDM,960,RC,42000,HCPCS,,,facility,both,,,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO I&D TONSIL ABSCESS,96000023,CDM,960,RC,42700,HCPCS,,,facility,both,,,,459,321.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO I&D VULVA/PERINEUM ABSCESS,96000024,CDM,960,RC,56405,HCPCS,,,facility,both,,,,163,114.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO I&D BARTHOLIN'S GLAND ABSCESS,96000025,CDM,960,RC,56420,HCPCS,,,facility,both,,,,266,186.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO DRAIN EXTRNL EAR LESN SMPL,96000028,CDM,960,RC,69000,HCPCS,,,facility,both,,,,243,170.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO I&D SKIN SUBQ ABSCESS SIMPLE,96000029,CDM,960,RC,10060,HCPCS,,,facility,both,,,,347,242.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO I&D SKIN SUBQ ABSCESS COMPLEX,96000030,CDM,960,RC,10061,HCPCS,,,facility,both,,,,1030,721,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO I&D HEMATOMA SEROMA,96000031,CDM,960,RC,10140,HCPCS,,,facility,both,,,,215,150.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO EXC NAIL BED,96000032,CDM,960,RC,11750,HCPCS,,,facility,both,,,,299,209.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO REPAIR NAIL BED,96000033,CDM,960,RC,11760,HCPCS,,,facility,both,,,,1041,728.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO EXCISION OF NAIL FOLD TOE,96000034,CDM,960,RC,11765,HCPCS,,,facility,both,,,,194,135.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO REM NAIL PLATE SINGLE,96000035,CDM,960,RC,11730,HCPCS,,,facility,both,,,,157,109.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO AVULSION NAIL PLATE COMPLETE/SIMPLE EACH ADDITIONAL NAIL PLATE,96000036,CDM,960,RC,11732,HCPCS,,,facility,both,,,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO NERVE BLOCK TRIGEMINAL,96000037,CDM,960,RC,64400,HCPCS,,,facility,both,,,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO INJ NERVE BLOCK OCCIPITAL,96000038,CDM,960,RC,64405,HCPCS,,,facility,both,,,,120,84,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO INJECTION ANESTHETIC AGENT(S)/STEROID FEMORAL NERVE INCL IMAGE GUIDE,96000043,CDM,960,RC,64447,HCPCS,,,facility,both,,,,166,116.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO INJ NERVE BLOCK OTHER PERIPH,96000044,CDM,960,RC,64450,HCPCS,,,facility,both,,,,659,461.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO TREAT HUM GR TUB FX W/ MAN,96000049,CDM,960,RC,23625,HCPCS,,,facility,both,,,,460,322,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CLOSED TX SHOULDER DISLOC W/ FX,96000050,CDM,960,RC,23665,HCPCS,,,facility,both,,,,515,360.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CLOSED TX HUMERAL SHAFT FX W/MANIPULATION W/WO SKELETAL TRACTION,96000052,CDM,960,RC,24505,HCPCS,,,facility,both,,,,933,653.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO TREAT HUM SUPRAC FX W/ MAN,96000054,CDM,960,RC,24535,HCPCS,,,facility,both,,,,887,620.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO TREAT RAD HEAD NECK FX W/ MAN,96000057,CDM,960,RC,24655,HCPCS,,,facility,both,,,,791,553.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO TREAT FX RAD SHAFT W/ MAN,96000059,CDM,960,RC,25505,HCPCS,,,facility,both,,,,987,690.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CLOSED TX ULNAR SHAFT FX W/MANIPULATION,96000061,CDM,960,RC,25535,HCPCS,,,facility,both,,,,988,691.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO TREAT FX RAD ULNA SHAFT W/ MAN,96000063,CDM,960,RC,25565,HCPCS,,,facility,both,,,,1029,720.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO TREAT FX RAD ULNA DISTAL,96000064,CDM,960,RC,25600,HCPCS,,,facility,both,,,,862,603.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO TREAT FX RAD ULNA DISTAL W/ MAN,96000065,CDM,960,RC,25605,HCPCS,,,facility,both,,,,1100,770,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CLOSED TX ULNAR STYLOID FX,96000069,CDM,960,RC,25650,HCPCS,,,facility,both,,,,696,487.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CLOSED TX METACARPAL FX SINGLE W/O MANIPULATION EACH BONE,96000070,CDM,960,RC,26600,HCPCS,,,facility,both,,,,728,509.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO TREAT METACARPAL FX EA W/ MAN,96000071,CDM,960,RC,26605,HCPCS,,,facility,both,,,,987,690.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO TREAT THUMB FX,96000072,CDM,960,RC,26645,HCPCS,,,facility,both,,,,635,444.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CLOSED TX PHALANGEAL SHAFT FX PROXIMAL/MIDDLE PHALANX FINGER/THUMB W/MANIPULATE W/WO SKIN/SKELETAL TRACTION EACH,96000073,CDM,960,RC,26725,HCPCS,,,facility,both,,,,821,574.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO TREAT FINGER FX EA W/O MANIP,96000074,CDM,960,RC,26740,HCPCS,,,facility,both,,,,506,354.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO TREAT THIGH FX,96000078,CDM,960,RC,27502,HCPCS,,,facility,both,,,,1297,907.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CLOSED RX TIBIA,96000082,CDM,960,RC,27750,HCPCS,,,facility,both,,,,521,364.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO TX MEDIAL MALLEOLUS FX W/O MANIPULATION,96000084,CDM,960,RC,27760,HCPCS,,,facility,both,,,,1004,702.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CLOSED TX MEDIAL MALLEOLUS FX W/MANIPULATION W/WO SKIN OR SKELETAL TRACTION,96000085,CDM,960,RC,27762,HCPCS,,,facility,both,,,,978,684.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO TREAT PROX FIBULA FX W/O MANIP,96000087,CDM,960,RC,27780,HCPCS,,,facility,both,,,,609,426.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO TREAT PROX FIBULA FX W/ MANIP,96000088,CDM,960,RC,27781,HCPCS,,,facility,both,,,,814,569.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CLOSED TX DISTAL FIBULAR FX W/O MANIPULATION,96000089,CDM,960,RC,27786,HCPCS,,,facility,both,,,,764,534.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO TREAT LAT MALLEOLUS FX W/ MAN,96000090,CDM,960,RC,27788,HCPCS,,,facility,both,,,,959,671.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO TREAT BIMALLEOLAR FX W/O MANIP,96000091,CDM,960,RC,27808,HCPCS,,,facility,both,,,,775,542.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO TREAT BIMALLEOLAR FX W/ MAN,96000092,CDM,960,RC,27810,HCPCS,,,facility,both,,,,1011,707.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO TREAT TRIMALLEOLAR FX W/MANIP,96000095,CDM,960,RC,27818,HCPCS,,,facility,both,,,,1028,719.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CLOSED TX CALCANEAL FX W/O MANIPULATION,96000096,CDM,960,RC,28400,HCPCS,,,facility,both,,,,516,361.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO TREAT TALUS FX,96000098,CDM,960,RC,28435,HCPCS,,,facility,both,,,,418,292.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO TREAT TOE FX W/ MANIP,96000099,CDM,960,RC,28515,HCPCS,,,facility,both,,,,255,178.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO RESET DISLOCATED JAW,96000100,CDM,960,RC,21480,HCPCS,,,facility,both,,,,379,265.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO TREAT SHOULDER DISLOCATION,96000103,CDM,960,RC,23650,HCPCS,,,facility,both,,,,1339,937.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO TREAT ELBOW DISL W/O ANESTH,96000104,CDM,960,RC,24600,HCPCS,,,facility,both,,,,583,408.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO TREAT RAD HEAD DISL W/ MANIP,96000105,CDM,960,RC,24640,HCPCS,,,facility,both,,,,227,158.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CLSD TX DISTAL RADIOULNAR DISLOC,96000107,CDM,960,RC,25675,HCPCS,,,facility,both,,,,649,454.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO TREAT THUMB DISLOCATION,96000108,CDM,960,RC,26641,HCPCS,,,facility,both,,,,401,280.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO TREAT FINGER DISLOCATION,96000109,CDM,960,RC,26770,HCPCS,,,facility,both,,,,718,502.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO TREAT HIP DISL W/O ANESTH,96000110,CDM,960,RC,27250,HCPCS,,,facility,both,,,,1088,761.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CLOSED TX POST HIP ARTHROPLASTY DISLOCATION W/O ANESTHESIA,96000111,CDM,960,RC,27265,HCPCS,,,facility,both,,,,493,345.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CLOSED TX POST HIP ARTHROPL DISLOC REQ ANESTH,96000112,CDM,960,RC,27266,HCPCS,,,facility,both,,,,717,501.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO TREAT KNEECAP DISL W/O ANESTH,96000113,CDM,960,RC,27560,HCPCS,,,facility,both,,,,601,420.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO TREAT KNEECAP DISL W/ ANESTH,96000114,CDM,960,RC,27562,HCPCS,,,facility,both,,,,1592,1114.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO TX CLOSED ANKLE DISLOCATION W/O ANESTHESIA,96000115,CDM,960,RC,27840,HCPCS,,,facility,both,,,,1983,1388.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CLSD FOOT DISLOC W/O ANESTH,96000116,CDM,960,RC,28570,HCPCS,,,facility,both,,,,204,142.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO TARSOMETATRSL DIS W/O ANESTH,96000117,CDM,960,RC,28600,HCPCS,,,facility,both,,,,431,301.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO TARSOMETATRSL DIS W/ ANESTH,96000118,CDM,960,RC,28605,HCPCS,,,facility,both,,,,687,480.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO TREAT MP TOE DISLOC,96000119,CDM,960,RC,28630,HCPCS,,,facility,both,,,,478,334.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CLSD TRMT INTRPHLNGL JT DL W/O,96000120,CDM,960,RC,28660,HCPCS,,,facility,both,,,,180,126,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO APPLY LONG ARM SPLINT,96000121,CDM,960,RC,29105,HCPCS,,,facility,both,,,,831,581.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO APPLY FOREARM SPLINT,96000122,CDM,960,RC,29125,HCPCS,,,facility,both,,,,295,206.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO APPLY FINGER SPLINT,96000124,CDM,960,RC,29130,HCPCS,,,facility,both,,,,154,107.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO APPLY LOWER LEG SPLINT,96000125,CDM,960,RC,29515,HCPCS,,,facility,both,,,,328,229.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO APPLY LONG LEG SPLINT,96000126,CDM,960,RC,29505,HCPCS,,,facility,both,,,,380,266,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO HEART/LUNG RESUSCITATION CPR,96000130,CDM,960,RC,92950,HCPCS,,,facility,both,,,,1449,1014.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO INSERT EMERGENCY AIRWAY,96000131,CDM,960,RC,31500,HCPCS,,,facility,both,,,,229,160.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO DX BRONCHOSCOPE/WASH,96000136,CDM,960,RC,31622,HCPCS,,,facility,both,,,,573,401.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO PARACENTESIS ABD,96000137,CDM,960,RC,49082,HCPCS,,,facility,both,,,,669,468.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO ABDOMINAL PARACENTESIS DX/THERAPEUTIC W/IMAGING GUIDANCE,96000139,CDM,960,RC,49083,HCPCS,,,facility,both,,,,374,261.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO INSERT CANNULA FOR HEMODIALYSIS,96000140,CDM,960,RC,36800,HCPCS,,,facility,both,,,,300,210,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO OPEN BX BREAST W/O IMAGE,96000153,CDM,960,RC,19101,HCPCS,,,facility,both,,,,380,266,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO OPERATIVE UPPER GI ENDOSCOPY W/ REM FB,96000157,CDM,960,RC,43247,HCPCS,,,facility,both,,,,850,595,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO REMOVE IUD,96000160,CDM,960,RC,58301,HCPCS,,,facility,both,,,,154,107.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO REMOVAL OF SKIN TAGS,96000163,CDM,960,RC,11200,HCPCS,,,facility,both,,,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO IRRIGATION CORPORA CAVERNOSA FOR PRIAPRISM,96000164,CDM,960,RC,54220,HCPCS,,,facility,both,,,,234,163.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CHANGE BLADDER CATH SIMPLE,96000167,CDM,960,RC,51705,HCPCS,,,facility,both,,,,143,100.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CHANGE OF CYSTOSTOMY TUBE COMPLICATED,96000168,CDM,960,RC,51710,HCPCS,,,facility,both,,,,189,132.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO INSERTION CHEST TUBE,96000173,CDM,960,RC,32551,HCPCS,,,facility,both,,,,912,638.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO REMOVE IMPACTED CERUMEN,96000174,CDM,960,RC,69210,HCPCS,,,facility,both,,,,338,236.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO I&D GUM LESION,96000175,CDM,960,RC,41800,HCPCS,,,facility,both,,,,227,158.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO INSERT NEEDLE BONE CAVITY,96000176,CDM,960,RC,36680,HCPCS,,,facility,both,,,,508,355.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO INSERT EMERGENCY AIRWAY,96000177,CDM,960,RC,31500,HCPCS,,,facility,both,,,,627,438.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO LUMBAR PUNCTURE,96000178,CDM,960,RC,62270,HCPCS,,,facility,both,,,,853,597.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO SIMPLE REPAIR SUPRFCL WNDS S/N/A/GEN/TNK EXT INCL HANDS & FEET 2.5 CM OR LESS,96000182,CDM,960,RC,12001,HCPCS,,,facility,both,,,,569,398.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO SIMPLE REPAIR SUPRFCL WNDS S/N/AX/GEN/TRNK EXT INCL HANDS & FEET 2.6 -7.5 CM,96000183,CDM,960,RC,12002,HCPCS,,,facility,both,,,,711,497.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO SIMPLE REPAIR SUPRFCL WNDS S/N/AX/GEN/TRK EXT INCL HANDS & FEET 7.6-12.5 CM,96000184,CDM,960,RC,12004,HCPCS,,,facility,both,,,,851,595.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO SIMPLE REPAIR SUPRFCL WNDS S/N/A/GEN/TRK EXT INCL HANDS & FEET 12.6-20.0 CM,96000185,CDM,960,RC,12005,HCPCS,,,facility,both,,,,1088,761.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO SIMPLE REPAIR SUPRFCL WNDS S/N/A/GEN/TRK EXT INCL HANDS & FEET 20.1-30.0 CM,96000186,CDM,960,RC,12006,HCPCS,,,facility,both,,,,1378,964.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO SIMPLE REPAIR SUPRFCL WNDS S/N/A/GEN/TRNK EXT INCL HANDS & FEET OVER 30.0 CM,96000187,CDM,960,RC,12007,HCPCS,,,facility,both,,,,1357,949.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO SIMPLE REPAIR SUPRFCL WNDS F/E/E/N/L/M 2.5 CM LESS,96000188,CDM,960,RC,12011,HCPCS,,,facility,both,,,,621,434.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO SIMPLE REPAIR SUPRFCL WNDS F/E/E/N/L/M 2.6-5.0 CM,96000189,CDM,960,RC,12013,HCPCS,,,facility,both,,,,858,600.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO SIMPLE REPAIR SUPRFCL WNDS F/E/E/N/L/M 5.1-7.5 CM,96000190,CDM,960,RC,12014,HCPCS,,,facility,both,,,,980,686,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO SIMPLE REPAIR SUPRFCL WNDS F/E/E/N/L/M 5.1-7.5 CM,96000191,CDM,960,RC,12015,HCPCS,,,facility,both,,,,1008,705.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO SIMPLE REPAIR SUPRFCL WNDS F/E/E/N/L/M 12.6-20.0 CM,96000192,CDM,960,RC,12016,HCPCS,,,facility,both,,,,1092,764.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO REP INT WND S/A/T/EXT <2.5CM,96000195,CDM,960,RC,12031,HCPCS,,,facility,both,,,,822,575.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO REP INT WND S/A/T/EXT 2.6-7.5CM,96000196,CDM,960,RC,12032,HCPCS,,,facility,both,,,,880,616,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO REP INT WND S/A/T/EXT 7.6-12.5,96000197,CDM,960,RC,12034,HCPCS,,,facility,both,,,,1518,1062.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO REP INT WND S/A/T/EXT 12.6-20.0,96000198,CDM,960,RC,12035,HCPCS,,,facility,both,,,,1093,765.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO REP INT WND S/A/T/EXT 20.1-30,96000199,CDM,960,RC,12036,HCPCS,,,facility,both,,,,1376,963.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO REPAIR INTERMED WND S/A/T/EXT (EXCL HANDS & FEET) OVER 30.0 CM,96000200,CDM,960,RC,12037,HCPCS,,,facility,both,,,,1682,1177.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO REP INT WND N/H/F/GNT<2.5CM,96000201,CDM,960,RC,12041,HCPCS,,,facility,both,,,,803,562.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO REP INT WND N/H/F/GNT2.6-7.5,96000202,CDM,960,RC,12042,HCPCS,,,facility,both,,,,983,688.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO REP INT WND N/H/F/GNT7.6-12.5,96000203,CDM,960,RC,12044,HCPCS,,,facility,both,,,,271,189.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO REP INT WND N/H/F/GNT 12.6-20.0,96000204,CDM,960,RC,12045,HCPCS,,,facility,both,,,,1167,816.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO REP INT WND N/H/F/GNT20.1-30,96000205,CDM,960,RC,12046,HCPCS,,,facility,both,,,,836,585.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO REPAIR INTERMED WOUNDS NCK/HNDS/FT/EXTERNAL GENITALIA OVER 30.0 CM,96000206,CDM,960,RC,12047,HCPCS,,,facility,both,,,,812,568.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO REPAIR INTERMED WNDS F/E/E/N/L/M 2.5 CM OR LESS,96000207,CDM,960,RC,12051,HCPCS,,,facility,both,,,,873,611.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO REPAIR INTERMED WNDS F/E/E/N/L/M 2.6-5.0 CM,96000208,CDM,960,RC,12052,HCPCS,,,facility,both,,,,1070,749,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO REPAIR INTERMED WNDS F/E/E/N/L/M 5.1-7.5 CM,96000209,CDM,960,RC,12053,HCPCS,,,facility,both,,,,1230,861,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO REPAIR INTERMED WNDS F/E/E/N/L/M 7.6-12.5 CM,96000210,CDM,960,RC,12054,HCPCS,,,facility,both,,,,1674,1171.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO REPAIR INTERMED WNDS F/E/E/N/L/M 20.1-30.0 CM,96000212,CDM,960,RC,12056,HCPCS,,,facility,both,,,,851,595.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO REPAIR COMPLEX TRUNK EACH ADDL 5 CM OR LESS,96000216,CDM,960,RC,13102,HCPCS,,,facility,both,,,,136,95.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO REP COM WND S/A/L 2.6-7.5CM,96000218,CDM,960,RC,13121,HCPCS,,,facility,both,,,,776,543.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO REP COM WND S/A/L ADDL 5CM OR LESS,96000219,CDM,960,RC,13122,HCPCS,,,facility,both,,,,148,103.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO REP COM WND E/N/E/L 1.0-2.5CM,96000221,CDM,960,RC,13151,HCPCS,,,facility,both,,,,931,651.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO REP COM WND E/N/E/L 2.6-7.5CM,96000222,CDM,960,RC,13152,HCPCS,,,facility,both,,,,1200,840,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CMPLX RPR E/N/E/L ADDL 5CM/<,96000223,CDM,960,RC,13153,HCPCS,,,facility,both,,,,171,119.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO REPAIR LIP> 1/2 HEIGHT,96000225,CDM,960,RC,40654,HCPCS,,,facility,both,,,,744,520.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO REP MOUTH LACERATION <2.5CM,96000226,CDM,960,RC,40830,HCPCS,,,facility,both,,,,202,141.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO MOUTH LACRTN >2.5CM,96000227,CDM,960,RC,40831,HCPCS,,,facility,both,,,,517,361.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO REP ANT TONGUE MOUTH FLOOR <2.5CM,96000228,CDM,960,RC,41250,HCPCS,,,facility,both,,,,236,165.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO REP TONGUE MOUTH FLOOR >2.5 CM,96000229,CDM,960,RC,41252,HCPCS,,,facility,both,,,,446,312.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO THORACENTESIS NEEDLE/CATH W/O IMAGE GUIDE,96000235,CDM,960,RC,32554,HCPCS,,,facility,both,,,,214,149.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO THORACENTESIS NEEDLE/CATH W/ IMAGE GUIDE,96000236,CDM,960,RC,32555,HCPCS,,,facility,both,,,,612,428.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CIRCUMCISION W/ REGIONAL DORSAL OR RING BLOCK,96000243,CDM,960,RC,54150,HCPCS,,,facility,both,,,,1786,1250.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO HEART MUSC IMAGE SPECT MULT,96000244,CDM,960,RC,78452,HCPCS,,,facility,both,,,26,769,538.3,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO REMOTE 30 DAY ECG REVIEW AND INTERP,96000245,CDM,960,RC,93272,HCPCS,,,facility,both,,,,54,37.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CV STRESS TEST INTERP AND REPORT,96000247,CDM,985,RC,93018,HCPCS,,,facility,both,,,,30,21,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO ECHO TRANSESOPHAGEAL,96000249,CDM,960,RC,93312,HCPCS,,,facility,both,,,26,1379,965.3,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO ECHO TRANSTHOR W/ DOPPLER,96000250,CDM,960,RC,93306,HCPCS,,,facility,both,,,26,269,188.3,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO ECHO DOPPLER FLOW MAP ADD-ON,96000251,CDM,960,RC,93325,HCPCS,,,facility,both,,,26,8,5.6,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO ECHO DOPPLER LIMITED FUP ADD-ON,96000252,CDM,960,RC,93321,HCPCS,,,facility,both,,,26,33,23.1,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO ECHO TRANSTHOR LIMITED FUP,96000253,CDM,960,RC,93308,HCPCS,,,facility,both,,,26,147,102.9,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO US EXTRACRANIAL ARTERIES BILAT,96000262,CDM,960,RC,93880,HCPCS,,,facility,both,,,26,403,282.1,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO US EXT VEINS UNILAT MANEUVERS,96000265,CDM,960,RC,93971,HCPCS,,,facility,both,,,26,149,104.3,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO US EXT VEINS BILAT MANEUVERS,96000270,CDM,960,RC,93970,HCPCS,,,facility,both,,,26,233,163.1,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO DOPP UP OR LWR EXTR 1-2 ART BILAT,96000273,CDM,960,RC,93922,HCPCS,,,facility,both,,,26,200,140,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO ANESTH PROCEDURE ON MOUTH,96000277,CDM,960,RC,170,HCPCS,,,facility,both,,,,156,109.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO ANESTH FACIAL BONE SURGERY,96000278,CDM,960,RC,190,HCPCS,,,facility,both,,,,156,109.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO ANESTH SKIN SURG HEAD / NECK,96000279,CDM,960,RC,300,HCPCS,,,facility,both,,,,353,247.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO ANESTH ANORECTAL SURGERY,96000281,CDM,960,RC,902,HCPCS,,,facility,both,,,,156,109.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO ANESTH HIP JOINT PROCEDURE,96000282,CDM,960,RC,1200,HCPCS,,,facility,both,,,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO ANESTH CLOSED PROC UPPER 2/3 FEMUR,96000283,CDM,960,RC,1220,HCPCS,,,facility,both,,,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO ANESTH OPEN PROC UPPER 2/3 FEMUR,96000284,CDM,960,RC,1230,HCPCS,,,facility,both,,,,188,131.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO ANESTH KNEE AREA SURGERY,96000285,CDM,960,RC,1320,HCPCS,,,facility,both,,,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO ANESTH LOWER 1/3 FEMUR CLOSED PROC,96000286,CDM,960,RC,1340,HCPCS,,,facility,both,,,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO ANESTH KNEE JOINT CLOSED PROCEDURE,96000287,CDM,960,RC,1380,HCPCS,,,facility,both,,,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO ANESTH UPPER LEG CLOSED PROCEDURE,96000288,CDM,960,RC,1390,HCPCS,,,facility,both,,,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO ANESTH LOWER LEG CLOSED PROCEDURE,96000289,CDM,960,RC,1462,HCPCS,,,facility,both,,,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO ANESTH SHOULDER CLOSED PROCEDURE,96000290,CDM,960,RC,1620,HCPCS,,,facility,both,,,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO ANESTH ARM / ELBOW BONES CLOSED PROCEDURE,96000291,CDM,960,RC,1730,HCPCS,,,facility,both,,,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO ANESTH FOREARM BONES CLOSED PROC,96000292,CDM,960,RC,1820,HCPCS,,,facility,both,,,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO ANESTH CAT / MRI SCAN RADIATION THERAPY,96000293,CDM,960,RC,1922,HCPCS,,,facility,both,,,,218,152.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO INSERT CATH ARTERY,96000296,CDM,960,RC,36620,HCPCS,,,facility,both,,,,100,70,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO OFFICE/OUTPT E&M  NP 15 MIN,96000298,CDM,960,RC,99202,HCPCS,,,facility,both,,,,67,46.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO OFFICE/OUTPT E&M NP 30 MIN,96000299,CDM,960,RC,99203,HCPCS,,,facility,both,,,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO OFFICE/OUTPT E&M NP 45 MIN,96000300,CDM,960,RC,99204,HCPCS,,,facility,both,,,,170,119,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO OFFICE/OUTPT E&M NP 60 MIN,96000301,CDM,960,RC,99205,HCPCS,,,facility,both,,,,220,154,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO OFFICE/OUTPT E&M EST 5 MIN,96000302,CDM,960,RC,99211,HCPCS,,,facility,both,,,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO OFFICE/OUTPT E&M EST 10 MIN,96000303,CDM,960,RC,99212,HCPCS,,,facility,both,,,,129,90.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO OFFICE/OUTPT E&M EST 20 MIN,96000304,CDM,960,RC,99213,HCPCS,,,facility,both,,,,159,111.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO OFFICE/OUTPT E&M EST 30 MIN,96000305,CDM,960,RC,99214,HCPCS,,,facility,both,,,,219,153.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO OFFICE/OUTPT E&M EST 40 MIN,96000306,CDM,960,RC,99215,HCPCS,,,facility,both,,,,304,212.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO INSERT VAG BRACHYTX DEVICE,96000310,CDM,960,RC,57156,HCPCS,,,facility,both,,,,244,170.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO SUBSEQUENT HOSPITAL INPT OR OBS CARE PER DAY 35 MIN,96000312,CDM,960,RC,99232,HCPCS,,,facility,both,,,,147,102.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO SUBSEQUENT HOSPITAL INPT OR OBS CARE PER DAY 50 MIN,96000314,CDM,960,RC,99233,HCPCS,,,facility,both,,,,210,147,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO NEG PRESS WOUND THERAPY DME LESS THAN OR EQUAL TO 50 SQ CM,96000322,CDM,960,RC,97605,HCPCS,,,facility,both,,,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO APPLICATION OF TOTAL CONTRACT CAST (TCC),96000324,CDM,960,RC,29445,HCPCS,,,facility,both,,,,377,263.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO ANESTH CARDIAC ELECTROPHYS,96000327,CDM,960,RC,537,HCPCS,,,facility,both,,,,225,157.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO APPLY MULTILAY COMPRS LWR LEG,96000329,CDM,960,RC,29581,HCPCS,,,facility,both,,,,60,42,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO APPLC SKIN SUB 25SQ CM,96000330,CDM,960,RC,15271,HCPCS,,,facility,both,,,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO APPLIC SKIN SUB EA ADD 25SQ CM,96000331,CDM,960,RC,15272,HCPCS,,,facility,both,,,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO SKIN SUB APP FT 1ST 25SQ CM,96000332,CDM,960,RC,15275,HCPCS,,,facility,both,,,,227,158.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO DEBRID SKIN UP TO 10% BODY SURF,96000333,CDM,960,RC,11000,HCPCS,,,facility,both,,,,56,39.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO ANESTH SKIN EXT/PER/ATRUNK,96000340,CDM,960,RC,400,HCPCS,,,facility,both,,,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO SPLIT-THICKNESS AUTOGRAFT TRUNK/ARMS/LEGS FIRST 100 SQ CM OR LESS OR 1% OF BODY AREA OF INFANTS/CHILDREN,96000343,CDM,960,RC,15100,HCPCS,,,facility,both,,,,1366,956.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CLSD TX HUMERAL CONDYLAR FX MEDIAL/LATERAL W/MANIPULATION,96000346,CDM,960,RC,24577,HCPCS,,,facility,both,,,,1170,819,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CLOSED TX NASAL BONE FX W/MANIP W/O STABLIZATION,96000353,CDM,960,RC,21315,HCPCS,,,facility,both,,,,257,179.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO FNA W/O IMAGE,96000364,CDM,960,RC,10021,HCPCS,,,facility,both,,,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO BIOPSY OROPHARYNX,96000376,CDM,960,RC,42800,HCPCS,,,facility,both,,,,213,149.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO BIOPSY OF MOUTH LESION,96000378,CDM,960,RC,40808,HCPCS,,,facility,both,,,,137,95.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO BIOPSY BONE OPEN SUPERFICIAL,96000388,CDM,960,RC,20240,HCPCS,,,facility,both,,,,274,191.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO BIOPSY BONE OPEN DEEP,96000389,CDM,960,RC,20245,HCPCS,,,facility,both,,,,780,546,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO ANESTHESIA PX LUMBAR REGION DIAGNOSTIC/THERAPEUTIC PUNCTURE,96000400,CDM,960,RC,635,HCPCS,,,facility,both,,,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO ASP PUNCTURE CYST BREA,96000409,CDM,960,RC,19000,HCPCS,,,facility,both,,,,123,86.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CLSD TX OF INTER/PERI/SUBTROCHANTERIC FEMORAL FX W/MANIPULATION W/W/O SKIN/SKELETAL TRACTION,96000451,CDM,960,RC,27240,HCPCS,,,facility,both,,,,1220,854,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO BONE MARROW ASPIRATION W/BONE MARROW BIOPSY SAME INCISION SAME DOS,96000453,CDM,960,RC,38222,HCPCS,,,facility,both,,,,244,170.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO PT CAT PN CAT/HISTOLOGICAL GRADE NOT DOC IN PATH REPORT REASON NOT GIVEN,96000454,CDM,960,RC,G8724,HCPCS,,,facility,both,,,,0.01,0.007,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO SPECIMEN SITE NOT ANATOMIC LOCATION OF ESOPHAGUS,96000455,CDM,960,RC,G8797,HCPCS,,,facility,both,,,,0.01,0.007,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO SPECIMEN SITE NOT ANATOMIC LOCATION OF PROSTATE,96000456,CDM,960,RC,G8798,HCPCS,,,facility,both,,,,0.01,0.007,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CLOSED TX ULNAR FX PROX END W/MANIP,96000459,CDM,960,RC,24675,HCPCS,,,facility,both,,,,514,359.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CLSD TX FEMORAL FX DISTAL END MEDIAL/LATERAL CONDYLE MANIP,96000460,CDM,960,RC,27510,HCPCS,,,facility,both,,,,863,604.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO TX MIDFOOT FRACTURE EACH,96000461,CDM,960,RC,28455,HCPCS,,,facility,both,,,,618,432.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO METATARSAL FX W/MANIP,96000462,CDM,960,RC,28475,HCPCS,,,facility,both,,,,377,263.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CLOSED TX KNEE DISLOCATION W/ANESTHESIA,96000464,CDM,960,RC,27552,HCPCS,,,facility,both,,,,791,553.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO REPAIR LACERATION 2.5CM/< POSTERIOR ONE-THIRD TONGUE,96000465,CDM,960,RC,41251,HCPCS,,,facility,both,,,,235,164.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CLSD TX SHOULDER DISLOCATION W/SURGICAL/ANATOMICAL NECK FX W/MANIP,96000466,CDM,960,RC,23675,HCPCS,,,facility,both,,,,632,442.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE UNILATERAL,96000472,CDM,960,RC,69209,HCPCS,,,facility,both,,,,15,10.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO  INTRAORAL INCISION & DRAINAGE OF ABSCESS/CYST/HEMATOMA OF TONGUE/FLOOR OF MOUTH LINGUAL,96000473,CDM,960,RC,41000,HCPCS,,,facility,both,,,,144,100.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO XRAY SURGICAL SPECIMEN,96000475,CDM,960,RC,76098,HCPCS,,,facility,both,,,26,11,7.7,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO BONE BX TROCAR/NEEDLE SUP,96000478,CDM,960,RC,20220,HCPCS,,,facility,both,,,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CLSD TX TIBIAL FX PROXIMAL (PLATEAU) W/WO MANIP W/SKELETAL TRACTION,96000484,CDM,960,RC,27532,HCPCS,,,facility,both,,,,913,639.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO TRACHEOSTOMY EMERGENCY PROCEDURE TRANSTRACHEAL,96000487,CDM,960,RC,31603,HCPCS,,,facility,both,,,,290,203,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO ARTHROCENTESIS ASPIRATION/INJECTION INTERMEDIATE JOINT OR BURSA W/ US GUIDE W/RECORDING & REPORTING,96000500,CDM,960,RC,20606,HCPCS,,,facility,both,,,,68,47.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO PINCH GRAFT SINGLE/MULTIPLE COVER SMALL ULCER/TIP OF DIGIT/MINIMAL OPEN AREA UP TO 2CM DIAMETER,96000508,CDM,960,RC,15050,HCPCS,,,facility,both,,,,555,388.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO PARTIAL EXCISION (CRATERIZATION/SAUCERIZATION/SEQUESTRECTOMY/DIAPHYSECTOMY) BONE PHALANX OF TOE,96000512,CDM,960,RC,28124,HCPCS,,,facility,both,,,,806,564.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO ANESTHESIA FOR PROCEDURES ON UPPER ANTERIOR ABDOMINAL WALL NOT OTHERWISE SPECIFIED,96000527,CDM,960,RC,700,HCPCS,,,facility,both,,,,273,191.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO ANESTHESIA FOR PROCEDURES ON LOWER ANTERIOR ABDOMINAL WALL NOT OTHERWISE SPECIFIED,96000528,CDM,960,RC,800,HCPCS,,,facility,both,,,,248,173.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO ESOPH FUNCT TEST GASTROESOPH REFLUX TEST W/ NASAL CATH INTRALUMINAL IMPED ELECTRODE(S) PLACE/RECORD/ANALYSIS/INTERP PROLONG (GREATER THAN 1 HR UP TO 24 HRS),96000529,CDM,960,RC,91038,HCPCS,,,facility,both,,,,660,462,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO REMOVAL EMBEDDED FOREIGN BODY FROM EYELID,96000530,CDM,960,RC,67938,HCPCS,,,facility,both,,,,259,181.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO VAGINAL DELIVERY,96000548,CDM,960,RC,59409,HCPCS,,,facility,both,,,,1393,975.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO UNLISTED PROCEDURE RECTUM,96000549,CDM,960,RC,45999,HCPCS,,,facility,both,,,,499,349.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CLOSED TX ACROMIOCLAVICULAR DISLOCATION W/MANIPULATION,96000550,CDM,960,RC,23545,HCPCS,,,facility,both,,,,745,521.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO REMOVAL CONTRACEPTIVE CAP,96000551,CDM,960,RC,11976,HCPCS,,,facility,both,,,,162,113.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO BRONCHOSCOPY RIGID/FLEX INCL FLUORO GUIDE W/BRONCHIAL OR ENDOBRON BIOPSY(S) SINGLE/MULTI SITE,96000559,CDM,960,RC,31625,HCPCS,,,facility,both,,,,287,200.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO TANGENTIAL BIOPSY OF SKIN SINGLE LESION,96000561,CDM,960,RC,11102,HCPCS,,,facility,both,,,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO PUNCH BIOPSY OF SKIN INCL SIMPLE CLOSURE SINGLE LESION,96000562,CDM,960,RC,11104,HCPCS,,,facility,both,,,,234,163.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO INCISIONAL BIOPSY OF SKIN INCL SIMPLE CLOSURE SINGLE LESION,96000563,CDM,960,RC,11106,HCPCS,,,facility,both,,,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO TANGENTIAL BIOPSY OF SKIN EACH SEPARATE/ADDTL LESION,96000564,CDM,960,RC,11103,HCPCS,,,facility,both,,,,60,42,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO PUNCH BIOPSY OF SKIN INCL SIMPLE CLOSURE EACH SEPARATE/ADDTL LESION,96000565,CDM,960,RC,11105,HCPCS,,,facility,both,,,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO INCISIONAL BIOPSY OF SKIN EACH SEPARATE/ADDT LESION,96000566,CDM,960,RC,11107,HCPCS,,,facility,both,,,,102,71.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO FINE NEEDLE ASPIRATION BIOPSY INCL ULTRASOUND GUIDANCE FIRST LESION,96000567,CDM,960,RC,10005,HCPCS,,,facility,both,,,,172,120.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO REMOTE MONITOR OF PHYSIOLOGIC PARAMETER INITIAL SET-UP/PATIENT EDUCATION ON USE OF EQUIPMENT,96000575,CDM,960,RC,99453,HCPCS,,,facility,both,,,,33,23.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO REMOTE MONITOR OF PHYSIOLOGIC PARAMETER INITIAL DEVICE SUPPLY W/DIALY REC/PROGRAM ALERT,96000576,CDM,960,RC,99454,HCPCS,,,facility,both,,,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO REMOTE PHYSIOLOGIC MONITOR TREATMENT MGMT SERV 20 MIN/MORE OF CLIN STAFF/PHYSICIAN/QUAL PROFN,96000577,CDM,960,RC,99457,HCPCS,,,facility,both,,,,55,38.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO ARTHOCENTISIS ASPIR/INJECT SM JOINT/BURSA W/ULTRA SOUND GUIDE W/PERM RECORDING & REPORTING,96000581,CDM,960,RC,20604,HCPCS,,,facility,both,,,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO FINE NEEDLE ASPIRATION BIOPSY W/O IMAGE GUIDE EACH ADDTL LESION,96000583,CDM,960,RC,10004,HCPCS,,,facility,both,,,,79,55.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CACNA1A GENE ANALYSIS FULL GENE SEQUENCE,96000588,CDM,960,RC,81185,HCPCS,,,facility,both,,,,356,249.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO EXTRACTION ERUPTED TOOTH OR EXPOSED ROOT (EVELATION AND/OR FORCEPS REMOVAL),96000590,CDM,960,RC,D7140,HCPCS,,,facility,both,,,,84,58.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO INCISION AND DRAINAGE OF ABSCESS-INTRAORAL SOFT TISSUE,96000591,CDM,960,RC,D7510,HCPCS,,,facility,both,,,,166,116.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO INCISION AND DRAINAGE OF ABSCESS-INTRAORAL SOFT TISSUE COMPLICATED,96000592,CDM,960,RC,D7511,HCPCS,,,facility,both,,,,250,175,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO TELEHEALTH PSYCHOTHERAPY W/PATIENT 30 MINUTES,96000593,CDM,960,RC,90832,HCPCS,,,facility,both,,,,100,70,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO TELEHEALTH PSYCHOTHERAPY W/PATIENT 45 MINUTES,96000594,CDM,960,RC,90834,HCPCS,,,facility,both,,,,133,93.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO TELEHEALTH PSYCHOTHERAPY 30 MIN W/PATIENT WHEN PERFORMED WITH E&M SERVICE,96000597,CDM,960,RC,90833,HCPCS,,,facility,both,,,,103,72.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO TELEHEALTH PSYCHOTHERAPY 45 MIN W/PATIENT WHEN PERFORMED WITH E&M SERVICE,96000598,CDM,960,RC,90836,HCPCS,,,facility,both,,,,129,90.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO TELEHEALTH TRACKING PSYCHOTHERAPY 60 MIN W/PATIENT WHEN PERFORMED WITH E&M SERVICE,96000599,CDM,960,RC,90838,HCPCS,,,facility,both,,,,185,129.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO TELEHEALTH PSYCHOTHERAPY FOR CRISIS FIRST 60 MIN,96000600,CDM,960,RC,90839,HCPCS,,,facility,both,,,,203,142.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO TELEHEALTH PSYCHOTHERAPY FOR CRISIS EACH ADDITIONAL 30 MIN,96000601,CDM,960,RC,90840,HCPCS,,,facility,both,,,,97,67.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO TELEHEALTH PSYCHOANALYSIS,96000602,CDM,960,RC,90845,HCPCS,,,facility,both,,,,139,97.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO TELEHEALTH ADVANCE CARE PLANNING INCL E & D OF ADVANCE DIRECTIVES FIRST 30 MINUTES FACE-TO-FACE W/PATIENT/FAMILY MEMBER/SURROGATE,96000625,CDM,960,RC,99497,HCPCS,,,facility,both,,,,134,93.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO TELEHEALTH ADVANCE CARE PLANNING INCL E &D OF ADVANCE DIRECTIVES EACH ADDTL 30 MIN,96000626,CDM,960,RC,99498,HCPCS,,,facility,both,,,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO PERINEOPLASTY REPAIR OF PERINEUM NONOBSTETRICAL,96000629,CDM,960,RC,56810,HCPCS,,,facility,both,,,,614,429.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO ASPIRATE/INJ GANGLION CYST(S),96000633,CDM,960,RC,20612,HCPCS,,,facility,both,,,,94,65.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CORPORA CAVERNOSA-GLANS PENIS FISTULIZATION FOR PRIAPISM,96000641,CDM,960,RC,54435,HCPCS,,,facility,both,,,,1231,861.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO EXT ECG>48HR UPT TO 7 DAYS REVIEW & INTERP,96000666,CDM,960,RC,93244,HCPCS,,,facility,both,,,,162,113.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO EXT ECG>7 DAYS UP TO 15 DAYS REVIEW & INTERP,96000667,CDM,960,RC,93248,HCPCS,,,facility,both,,,,162,113.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO ANESTH CLOSED CHEST INCL BRONCHOSCOPY,96000668,CDM,960,RC,520,HCPCS,,,facility,both,,,,327,228.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO ANESTH THORACOTOMY/THORACOSCOPY,96000671,CDM,960,RC,540,HCPCS,,,facility,both,,,,781,546.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO INJ N BLOCK SPHENOPAL GANG,96000675,CDM,960,RC,64505,HCPCS,,,facility,both,,,,260,182,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CLOSED TX VERTEBRAL BODY FX(S) W/O MANIP INCL CASTING/BRACING,96000676,CDM,960,RC,22310,HCPCS,,,facility,both,,,,654,457.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO STRAPPING HAND OR FINGER,96000681,CDM,960,RC,29280,HCPCS,,,facility,both,,,,63,44.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO INJECTION(S) ANESTHETIC AGENT(S) AND/OR STERIOD GENICULAR NERVE BRANCHES INCL IMAGE GUIDE WHEN PERFORMED,96000682,CDM,960,RC,64454,HCPCS,,,facility,both,,,,222,155.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO USE OF ECHO CONTRAST AGENT DURING STRESS ECHOCARDIOGRAPHY,96000683,CDM,960,RC,93352,HCPCS,,,facility,both,,,,74,51.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO BIOPSY MUSCLE SUPERFICIAL,96000684,CDM,960,RC,20200,HCPCS,,,facility,both,,,,215,150.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO BIOPSY MUSCLE DEEP,96000685,CDM,960,RC,20205,HCPCS,,,facility,both,,,,353,247.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREADMILL OR BICYCLE EXERCISE CONT ECG W/O INTERP & REPORT,96000686,CDM,960,RC,93016,HCPCS,,,facility,both,,,,50,35,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO NASO/OROGASTRIC TUBE PLACE FLUORO GUIDE,96000687,CDM,960,RC,43752,HCPCS,,,facility,both,,,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO INCISION & DRAINAGE COMPLEX POSTOPERATIVE WOUND INFECTION,96000689,CDM,960,RC,10180,HCPCS,,,facility,both,,,,409,286.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO OPEN TX BIMALLEOLAR ANKLE FX INCL INTERNAL FIX,96000690,CDM,960,RC,27814,HCPCS,,,facility,both,,,,1771,1239.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO UNLISTED PROCEDURE PHARYNX ADENOIDS AND TONSILS,96000691,CDM,960,RC,42999,HCPCS,,,facility,both,,,,887,620.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO AMPUTATION TOE METATARSOPHALANGEAL JOINT,96000692,CDM,960,RC,28820,HCPCS,,,facility,both,,,,700,490,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO EXC H-F-NK-SP BEN MARG 2.1-3,96000693,CDM,960,RC,11423,HCPCS,,,facility,both,,,,351,245.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO OPEN TX DISTAL PHALANGEAL FRACTURE FINGER/THUMB INCL INTERNAL FIXATION EA,96000694,CDM,960,RC,26765,HCPCS,,,facility,both,,,,1148,803.6,,,,,,,,,,,,,Gross Charge Type: Central
HC  PRO EXTRAORAL INCISION & DRAINAGE ABSCESS/CYSTS/HEMATOMA OF MOUTH MASTICATOR SPACE,96000695,CDM,960,RC,41018,HCPCS,,,facility,both,,,,905,633.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO INTRAORAL INCISION/DRAINAGE OF ABSCESS/CYST/HEMATOMA OF TONGUE OR FLOOR OF MOUTH SUBMENTAL SPACE,96000697,CDM,960,RC,41007,HCPCS,,,facility,both,,,,501,350.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO DRAINAGE ABSCESS/HEMATOMA NASAL SEPTUM,96000698,CDM,960,RC,30020,HCPCS,,,facility,both,,,,271,189.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO I&D SUBMUCOSAL ABSCESS RECTUM,96000699,CDM,960,RC,45005,HCPCS,,,facility,both,,,,377,263.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO PUNCTURE ASPIRATION HYDROCELE TUNICA VAGIS W/WO INJECTION OF MEDICATION,96000700,CDM,960,RC,55000,HCPCS,,,facility,both,,,,194,135.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO ANESTH VAGINAL PX INCL BIOPSY CULDOSCOPY,96000701,CDM,960,RC,950,HCPCS,,,facility,both,,,,197,137.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO PLACEMENT OF NEEDLE PELVIC ORGAN RADIOELEMENT APPL,96000702,CDM,960,RC,55920,HCPCS,,,facility,both,,,,1045,731.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO PLACEMENT SOFT TISS LOC DEVICE PLMT W/GUIDANCE 1ST LESION,96000703,CDM,960,RC,10035,HCPCS,,,facility,both,,,,589,412.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO PLACEMENT SOFT TISS LOC DEVICE PLMT W/GUIDANCE EACH ADDTL LESION,96000704,CDM,960,RC,10036,HCPCS,,,facility,both,,,,509,356.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO INJECTION ANESTHETIC AGENT(S)/STEROID AXILLARY NERVE INCL IMAGE GUIDE,96000705,CDM,960,RC,64417,HCPCS,,,facility,both,,,,152,106.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO OPEN TX DISTAL RADIAL EXTRA ARTICULAR FX/EPIPHYSEAL SEP W/INT FIX,96000706,CDM,960,RC,25607,HCPCS,,,facility,both,,,,1700,1190,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO IMPLANT BIO IMPLANT SOFT TISSUE REINFORCE ADD-ON,96000707,CDM,960,RC,15777,HCPCS,,,facility,both,,,,502,351.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO EGD INTRALUMINAL TUBE/CATHETER INSERTION,96000708,CDM,960,RC,43241,HCPCS,,,facility,both,,,,328,229.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO FLEXIBLE ENDOSCOPIC EVAL LARYNGEAL SENSORY TESTING BY CINE/VIDEO REC INTERP & REPORT ONLY,96000709,CDM,960,RC,92615,HCPCS,,,facility,both,,,,261,182.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO ANESTH HERNIA REPAIRS LOWER ABDOMEN NOS,96000710,CDM,960,RC,830,HCPCS,,,facility,both,,,,318,222.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO REMOVAL INFLATABLE PENILE PROSTHESIS W/O RPLCMT PROSTHESIS,96000711,CDM,960,RC,54406,HCPCS,,,facility,both,,,,1622,1135.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CLOSD TX METACARPOPHALANGEAL DISLOCATION SINGLE W/ MANIP & ANES,96000712,CDM,960,RC,26705,HCPCS,,,facility,both,,,,892,624.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO TRIMMING NONDYSTROPHIC NAILS ANY NUMBER,96000713,CDM,960,RC,11719,HCPCS,,,facility,both,,,,20,14,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO REMOVAL OF SUTURES OR STAPLES NOT REQ ANESTHESIA,96000714,CDM,960,RC,15853,HCPCS,,,facility,both,,,,24,16.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO REMOVAL OF SUTURES & STAPLES NOT REQ ANESTHESIA,96000715,CDM,960,RC,15854,HCPCS,,,facility,both,,,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CLOSED TREATMENT OF DISTAL PHLNGL FRACTURE FINGER OR THUMB W/O MANIPULATION EACH,96000716,CDM,960,RC,26750,HCPCS,,,facility,both,,,,426,298.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO ANESTH MALE GENITALIA INCL OPEN URETHRAL PROCEDURES NOS,96000717,CDM,960,RC,920,HCPCS,,,facility,both,,,,395,276.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO REMOVAL OF FOREIGN BODY DEEP THIGH REGION OR KNEE AREA,96000718,CDM,960,RC,27372,HCPCS,,,facility,both,,,,919,643.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CLOSED TREATMENT MANDIBULAR/MAXILLARY ALVEOLAR RIDGE FX,96000720,CDM,960,RC,21440,HCPCS,,,facility,both,,,,1213,849.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO VENIPUNCTURE YOUNGER THAN AGE 3 YEAR NECESSITATING SKILL OF A PHYSICIAN OTHER VEIN,96000721,CDM,960,RC,36406,HCPCS,,,facility,both,,,,32,22.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO ANESTHESIA PX HEART PERICARDIAL SAC GREAT VESSELS OF CHEST W/O PUMP OXYGENATOR,96000722,CDM,960,RC,560,HCPCS,,,facility,both,,,,794,555.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO HC BL DRAW < 3 YRS SCALP VEIN,96000723,CDM,960,RC,36405,HCPCS,,,facility,both,,,,34,23.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO INSERT PICC CATH <5 YRS,96000724,CDM,960,RC,36568,HCPCS,,,facility,both,,,,562,393.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO INSERT OF PICC W/O SUB PORT/PUMP INCLUD ALL IMAGE GUIDE IMAGE DOC/ASSOC RADIOLOGICAL < 5 YRS,96000725,CDM,960,RC,36572,HCPCS,,,facility,both,,,,468,327.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO INSERT OF PICC W/O SUB PORT/PUMP INCLUD ALL IMAGE GUIDE IMAGE DOC/ASSOC RADIOLOGICAL >5 YRS,96000726,CDM,960,RC,36573,HCPCS,,,facility,both,,,,441,308.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CLOSED TREATMENT OF GREATER HUMERAL TUBEROSITY FRACTURE W/O MANIPULATION,96000727,CDM,960,RC,23620,HCPCS,,,facility,both,,,,590,413,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID VAGUS NERVE,96000728,CDM,960,RC,64408,HCPCS,,,facility,both,,,,211,147.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID BRACHIAL PLEXUS INCL IMAGE GUIDE,96000729,CDM,960,RC,64415,HCPCS,,,facility,both,,,,192,134.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID BRACHIAL PLEXUS CONT INFUSION BY CATHETER INCL IMAGE GUIDE,96000730,CDM,960,RC,64416,HCPCS,,,facility,both,,,,409,286.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID PARACERVICAL UTERINE NERVE,96000731,CDM,960,RC,64435,HCPCS,,,facility,both,,,,204,142.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID SCIATIC NERVE CONT INFUSION BY CATHETER INCL IMAGE GUIDE,96000732,CDM,960,RC,64446,HCPCS,,,facility,both,,,,400,280,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO INJECTION(S) ANESTHETIC AGENT(S) AND/OR STEROID FEMORAL NERVE CONT INFUSION BY CATHETER INCL IMAGE GUIDE,96000733,CDM,960,RC,64448,HCPCS,,,facility,both,,,,358,250.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO INJECTION(S) AGENT(S) AND/OR STEROID LUMBAR PLEXUS POSTERIOR APPROACH CONT INFUSION BY CATHETER INCL CATHETER PLACEMENT,96000734,CDM,960,RC,64449,HCPCS,,,facility,both,,,,367,256.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO SHAVING EPIDERMAL/DERMAL LESION SINGLE LESION TRUNK/ARMS/LEGS 0.6-1.0 CM,96000735,CDM,960,RC,11301,HCPCS,,,facility,both,,,,173,121.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CLOSED TX HUMERAL CONDYLAR FX MEDIAL/LATERAL W/O MANIPULATION,96000736,CDM,960,RC,24576,HCPCS,,,facility,both,,,,725,507.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO REMOVAL FOREIGN BODY IN SCROTUM,96000737,CDM,960,RC,55120,HCPCS,,,facility,both,,,,858,600.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO PTA PULMONARY ARTERY BALLOON ANGIOPLASTY SINGLE VESSEL,96000738,CDM,960,RC,92997,HCPCS,,,facility,both,,,,1556,1089.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO PTA PULMONARY ARTERY BALLOON ANGIOPLASTY EA ADDTL VESSEL,96000739,CDM,960,RC,92998,HCPCS,,,facility,both,,,,778,544.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO REMOVAL FOREIGN BODY FROM DEEP PENILE TISSUE,96000740,CDM,960,RC,54115,HCPCS,,,facility,both,,,,967,676.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO BRIEF COMMUNICATION TECH-BASED SERVICE PHYSICIAN OR QHP ESTABLISHED PATIENT 5-10 MINUTES,96000750,CDM,960,RC,98016,HCPCS,,,facility,both,,,,29,20.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO SUTURE PHARYNX FOR WOUND OR INJURY,96000752,CDM,960,RC,42900,HCPCS,,,facility,both,,,,840,588,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO EXCISION TUMOR SOFT TISSUE FOOT/TOE SUBFASCIAL LESS THAN 1.5CM,96000756,CDM,960,RC,28045,HCPCS,,,facility,both,,,,796,557.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO PT NO GRADE MED REASON,96900002,CDM,969,RC,3260F,HCPCS,,,facility,both,,,1P,0.01,0.007,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 1P: Performance Measure Exclusion Modifier due to Medical Reasons
HC PRO SPECIMEN SITE NOT PRIM TUMOR,9693250F,CDM,969,RC,3250F,HCPCS,,,facility,both,,,,0.01,0.007,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO PATH REPORT HISTOLOGIC GRADE,9693260F,CDM,969,RC,3260F,HCPCS,,,facility,both,,,,0.01,0.007,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO PATH RPRT W/ PT PN CAT ET AL,9693267F,CDM,969,RC,3267F,HCPCS,,,facility,both,,,,0.01,0.007,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO QUANT HER2 IHC EVAL BRST CX,9693394F,CDM,969,RC,3394F,HCPCS,,,facility,both,,,,0.01,0.007,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO QUANT NONHER2 IHC BRST CX,9693395F,CDM,969,RC,3395F,HCPCS,,,facility,both,,,,0.01,0.007,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO PROTEIN E-PHORESIS/URINE/CSF,96984166,CDM,969,RC,84166,HCPCS,,,facility,both,,,26,58,40.6,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO PT PN HIST GRADE DOC,969G8721,CDM,969,RC,G8721,HCPCS,,,facility,both,,,,0.01,0.007,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO ESOPHAGEAL BIOPSY REPORT WITH A STATEMENT ABOUT DYSPLASIA,97100004,CDM,971,RC,3126F,HCPCS,,,facility,both,,,,0.01,0.007,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CONSULTATION AND REPORT ON REFERRED MATERIAL REQUIRING PREP OF SLIDES,97100005,CDM,971,RC,88323,HCPCS,,,facility,both,,,26,183,128.1,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO CONSULTATION COMPREHENSIVE W/ REVIEW OF RECORDS/SPECIMENS W/ REPORT ON REFERRED MATERIAL,97100006,CDM,971,RC,88325,HCPCS,,,facility,both,,,,169,118.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO ELECTRON MICROSCOPY DIAGNOSTIC,97100007,CDM,971,RC,88348,HCPCS,,,facility,both,,,,407,284.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO SURG PATH GROSS/MICROSCOPIC EXAM PROSTATE NEEDLE BIOPSY ANY METHOD,97100009,CDM,971,RC,88305,HCPCS,,,facility,both,,,26,758,530.6,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO MICRODISSECTION MANUAL,97100011,CDM,971,RC,88381,HCPCS,,,facility,both,,,26,461,322.7,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO CYTOPATH EVAL OF FNA EA ADDTL EVAL EPISODE,97100012,CDM,971,RC,88177,HCPCS,,,facility,both,,,,44,30.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PQRS PATHOLOGY REPORT INCL PT CATEGORY THICKNESS/ULCERATION/MITOTIC RATE PERIPHERAL DEEP MARGIN STATUS & PRESENCE/ABSENCE MICROSATELLITOSIS INVASIVE TUMORS,97100013,CDM,969,RC,G9428,HCPCS,,,facility,both,,,,0.01,0.007,,,,,,,,,,,,,Gross Charge Type: Central
HC PQRS SPECIMEN SITE OTHER THAN ANATOMIC CUTANEOUS LOCATION,97100015,CDM,969,RC,G9430,HCPCS,,,facility,both,,,,0.01,0.007,,,,,,,,,,,,,Gross Charge Type: Central
HC PQRS PATHOLOGY REPORT DOES NOT INCL PT CATEGORY THICKNESS/ULCERATION/MITOTIC RATE PERIPHERAL DEEP MARGIN STATUS & PRESENCE/ABSENCE MICROSATELLITOSIS INVASIVE TUMORS,97100016,CDM,969,RC,G9431,HCPCS,,,facility,both,,,,0.01,0.007,,,,,,,,,,,,,Gross Charge Type: Central
HC PQRS NON-SMALL CELL LUNG CANCER BIOPSY AND CYTOLOGY SPECIMEN REPORT DOCUMENTS CLASSIFICATION INTO SPECIFIC HISTOLOGIC TYPE OR CLASSIFIED AS NSCLC-NOS WITH AN EXPLANATION,97100017,CDM,969,RC,G9422,HCPCS,,,facility,both,,,,0.01,0.007,,,,,,,,,,,,,Gross Charge Type: Central
HC PQRS DOCUMENTATION OF MEDICAL REASON(S) FOR NOT REPORTING THE HISTOLOGICAL TYPE OR NSCLC-NOS CLASSIFICATION WITH AN EXPLANATION (EQ A SOLITARY FIBROUS TUMOR IN A PERSON WITH A HISTORY O*,97100018,CDM,969,RC,G9423,HCPCS,,,facility,both,,,,0.01,0.007,,,,,,,,,,,,,Gross Charge Type: Central
HC PQRS SPECIMEN SITE OTHER THAN ANATOMIC LOCATION OF LUNG IS NOT CLASSIFIED AS NON-SMALL CELL LUNG CANCER OR CLASSIFIED AS NSCLC-NOS,97100019,CDM,969,RC,G9424,HCPCS,,,facility,both,,,,0.01,0.007,,,,,,,,,,,,,Gross Charge Type: Central
HC PQRS NON SMALL CELL LUNG CANCER BIOPSY AND CYTOLOGY SPECIMEN REPORT DOES NOT DOCUMENT CLASSIFICATION INTO SPECIFIC HISTOLGIC TYPE OR CLASSIFIED AS NSCLC-NOS WITH AN EXPLANATION,97100020,CDM,969,RC,G9425,HCPCS,,,facility,both,,,,0.01,0.007,,,,,,,,,,,,,Gross Charge Type: Central
HC PQRS PRIMARY NON-SMALL CELL LUNG CANCER LUNG BIOPSY/CYTOLOGY SPECIMEN REP DOCS CLASS SPECIFIC HISTOLOGIC TYPE FOLLOWING IASLC GUIDE OR CLASS,97100021,CDM,969,RC,G9418,HCPCS,,,facility,both,,,,0.01,0.007,,,,,,,,,,,,,Gross Charge Type: Central
HC PQRS DOCUMENTATION OF MEDICAL REASON(S) FOR NOT REPORTING THE HISTOLOGICAL TYPE OR NSCLC-NOS CLASSIFICATION WITH AN EXPLANATION,97100022,CDM,969,RC,G9419,HCPCS,,,facility,both,,,,0.01,0.007,,,,,,,,,,,,,Gross Charge Type: Central
HC PQRS SPECIMEN SITE OTHER THAN ANATOMIC LOCATION OF LUNG OR IS NOT CLASSIFIED AS PRIMARY NON-SMALL CELL LUNG CANCER,97100023,CDM,969,RC,G9420,HCPCS,,,facility,both,,,,0.01,0.007,,,,,,,,,,,,,Gross Charge Type: Central
HC PQRS PRIMARY NON-SMALL CELL LUNG CANCER LUNG BIOPSY AND CYTOLOGY SPECIMEN REPORT DOES NOT DOCUMENT CLASSIFICATION INTO SPECIFIC HISTOLIGIC TYPE OR CLASS,97100024,CDM,969,RC,G9421,HCPCS,,,facility,both,,,,0.01,0.007,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO IMMUNOFLUORESCENCE PER SPECIMEN EA ADDTL SINGLE ANTIBODY STAIN PROCEDURE,97100025,CDM,971,RC,88350,HCPCS,,,facility,both,,,26,86,60.2,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO FIBRINOLYSINS OR COAGULOPATHY SCREEN INTERP AND REPORT,97100051,CDM,971,RC,85390,HCPCS,,,facility,both,,,26,20,14,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO SURG PATH GROSS/MICROSCOPIC EXAM PROSTATE NEEDLE BIOPSY ANY METHOD,97100053,CDM,971,RC,G0416,HCPCS,,,facility,both,,,26,1366,956.2,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO PATH CLINICAL CONSULT LIMITED 5-20 MINUTES,97100060,CDM,971,RC,80503,HCPCS,,,facility,both,,,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO PATH CLINICAL CONSULT MODERATELY COMPLEX 21-40 MINUTES,97100061,CDM,971,RC,80504,HCPCS,,,facility,both,,,,109,76.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO PATH CLINICAL CONSULT HIGHLY COMPLEX 41-60 MINUTES,97100062,CDM,971,RC,80505,HCPCS,,,facility,both,,,,205,143.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO PATH CLINICAL CONSULT PROLONGED SERVICE EA ADDTL 30 MINUTES,97100063,CDM,971,RC,80506,HCPCS,,,facility,both,,,,98,68.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO DPYD GENE ANALYSIS COMMON VARIANTS,97100064,CDM,971,RC,81232,HCPCS,,,facility,both,,,,156,109.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CYTOGEN CONSTITUT CHROMOSMAL ABNORM GENOMIC REGIONS COPY NUMBER VARIANTS CGH,97100065,CDM,971,RC,81228,HCPCS,,,facility,both,,,,1390,973,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CNS DNA/RNA AMP PROBE MULTIPLE SUBTYPES 12-25,97100066,CDM,971,RC,87483,HCPCS,,,facility,both,,,,485,339.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO GENETIC TEST SEVERE INHERITED CONDITIONS GENOMIC SEQ ALYS PANEL MUST INCL SEQ AT LEAST 15 GENES,97100067,CDM,971,RC,81443,HCPCS,,,facility,both,,,,2174,1521.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO MORPHOMETRIC ALYS ISH QUANT/SEM-QUANT COMPUTER ASSISTED TECH EA MULTI PROBE STAIN PROCEDURE,97100068,CDM,971,RC,88374,HCPCS,,,facility,both,,,,313,219.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO UNLISTED MOLECULAR PATHOLOGY PROCEDURE,97100069,CDM,971,RC,81479,HCPCS,,,facility,both,,,,232,162.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO MOLECULAR PATHOLOGY PROCEDURE LEVEL 5,97100070,CDM,971,RC,81404,HCPCS,,,facility,both,,,,477,333.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO MOLECULAR PATHOLOGY PROCEDURE LEVEL 6,97100071,CDM,971,RC,81405,HCPCS,,,facility,both,,,,867,606.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO MOLECULAR PATHOLOGY PROCEDURE LEVEL 7,97100072,CDM,971,RC,81406,HCPCS,,,facility,both,,,,1201,840.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO MOLECULAR PATHOLOGY PROCEDURE LEVEL 9,97100073,CDM,971,RC,81408,HCPCS,,,facility,both,,,,3941,2758.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO MICROBE SUSCEPT MACROBROTH,97100075,CDM,971,RC,87188,HCPCS,,,facility,both,,,,8,5.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO SCRN CYTO CERVICAL/VAGINAL AUTO THIN LAYER PREP REQUIRE INTERP,97100076,CDM,971,RC,G0124,HCPCS,,,facility,both,,,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO HEREDITARY BRST CANCER-RELATED GEN SEQ ANALYSIS PANEL 5 OR MORE GENES INTERROGATION FOR SEQUENCE VARIANTS & COPY NUMBER VARIANTS,97100077,CDM,971,RC,81432,HCPCS,,,facility,both,,,,603,422.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO HLA CLASS II TYPING HIGH RESOLUTION ON LOCUS EA,97100079,CDM,971,RC,81382,HCPCS,,,facility,both,,,,144,100.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO BRCA1 BRCA2 GENE ANALYSIS FULL SEQ FULL DUPLICATION/DELETION ANALYSIS,97100080,CDM,971,RC,81162,HCPCS,,,facility,both,,,,2121,1484.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO PDGFRA GENE ANALYSIS TARGETED SEQ ANALYSIS,97100081,CDM,971,RC,81314,HCPCS,,,facility,both,,,,293,205.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO NOONAN SPECTRUM DISORDERS GENOMIC SEQ ANALYSIS PANEL INCL SEQ 12 GENES BRAF/CBL/HRAS/KRAS/MAP2K1/MAP2K2/NRAS/PTPN11/RAF1/RIT1/SHOC2/SOS1,97100082,CDM,971,RC,81442,HCPCS,,,facility,both,,,,1903,1332.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO AORTIC DYSFUNCTION/DILATION GENOMIC SEQ ANALYSIS PANEL INC SEQ 9 GENES FBN1/TGFBR1/TGFBR2/COL3A1/MYH11/ACTA2/SLC2A10/SMAD3/MYLK,97100083,CDM,971,RC,81410,HCPCS,,,facility,both,,,,448,313.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO ONCOLOGY (TUMOR UNKNOWN ORIGIN) MRNA GENE EXPRESS PROFIL REAL-TIME RT-PCR 92 GENES CLASSIFY MAIN CANCER TYPE/SUBTYPE USE FORMALIN-FIXED PARRIFIN-EMBEDDED TISSUE,97100084,CDM,971,RC,81540,HCPCS,,,facility,both,,,,3329,2330.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO SOLID ORGAN/HEMATOLYMPHOID NEOPLASM/DISORDER 51 OR GREATER GENES GENOMIC SEQ ANALYSIS PANEL DNA ANALYSIS/COMBINED DNA & RNA ANALYSIS,97100086,CDM,971,RC,81455,HCPCS,,,facility,both,,,,2592,1814.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO PROTEIN ANALYSIS W/ PROBE,97100087,CDM,971,RC,88372,HCPCS,,,facility,both,,,,57,39.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CYTPTH CERV/VAG FLUID THIN AUTO,97100088,CDM,971,RC,88142,HCPCS,,,facility,both,,,,51,35.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO PALB2 GENE ANALYSIS FULL GENE SEQUENCE,97100089,CDM,971,RC,81307,HCPCS,,,facility,both,,,,1394,975.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO PTEN GENE ANALYSIS FULL SEQUENCE ANALYSIS,97100090,CDM,971,RC,81321,HCPCS,,,facility,both,,,,1484,1038.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO PTEN GENE ANALYSIS DUPLICATION/DELETION VARIANT,97100091,CDM,971,RC,81323,HCPCS,,,facility,both,,,,618,432.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO PMP22 GENE ANALYSIS FULL SEQUENCE ANALYSIS,97100092,CDM,971,RC,81325,HCPCS,,,facility,both,,,,1586,1110.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO MICRODISSECTION LASER CAPTURE,97100093,CDM,971,RC,88380,HCPCS,,,facility,both,,,26,277,193.9,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO ONCOLOGY BREAST MRNA GENE EXPRESSION PROFILING REAL-TIME RT-PCR OF 11 GENE FORMALIN-FIXED PARAFFIN-EMBEDDED TISSUE,97100094,CDM,971,RC,81518,HCPCS,,,facility,both,,,,9575,6702.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CFTR GENE DUP/DELET VARIANTS,97100095,CDM,971,RC,81222,HCPCS,,,facility,both,,,,843,590.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CFTR GENE FULL SEQUENCE,97100096,CDM,971,RC,81223,HCPCS,,,facility,both,,,,2975,2082.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO TP53 GENE ANALYSIS TARGETED SEQUENCE ANALYSIS,97100097,CDM,971,RC,81352,HCPCS,,,facility,both,,,,293,205.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO BRAF GENE ANALYSIS V600 VARIANT(S),97100098,CDM,971,RC,81210,HCPCS,,,facility,both,,,,434,303.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO KRAS GENE ANALYSIS VARIANTS IN EXON 2,97100099,CDM,971,RC,81275,HCPCS,,,facility,both,,,,478,334.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO KRAS GENE ANALYSIS VARIANT(S) ADDITIONAL VARIANT(S),97100100,CDM,971,RC,81276,HCPCS,,,facility,both,,,,172,120.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO NRAS GENE ANALYSIS VARIANTS IN EXON 2 AND EXON 3,97100101,CDM,971,RC,81311,HCPCS,,,facility,both,,,,263,184.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO ATXN1 GENE ANALYSIS EVAL TO DETECT ABNORMAL ALLELES,97100102,CDM,971,RC,81178,HCPCS,,,facility,both,,,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO ATXN2 GENE ANALYSIS EVAL TO DETECT ABNORMAL ALLELES,97100103,CDM,971,RC,81179,HCPCS,,,facility,both,,,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CACNA1A GENE ANALYSIS EVAL TO DETECT ABNORMAL ALLELES,97100104,CDM,971,RC,81184,HCPCS,,,facility,both,,,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO ATXN7 GENE ANALYSIS EVAL TO DETECT ABNORMAL ALLELES,97100105,CDM,971,RC,81181,HCPCS,,,facility,both,,,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO MSH2 GENE ANALYSIS FULL SEQUENCE ANALYSIS,97100106,CDM,971,RC,81295,HCPCS,,,facility,both,,,,944,660.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO MSH2 GENE ANALYSIS DUPLICATION/DELETION VARIANTS,97100107,CDM,971,RC,81297,HCPCS,,,facility,both,,,,528,369.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO MSH6 GENE ANALYSIS FULL SEQUENCE ANALYSIS,97100108,CDM,971,RC,81298,HCPCS,,,facility,both,,,,1587,1110.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO MSH6 GENE ANALYSIS DUPLICATION/DELETION VARIANTS,97100109,CDM,971,RC,81300,HCPCS,,,facility,both,,,,589,412.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO SOLID ORGAN NEOPLASM GENOMIC SEQ ANALYSIS PANEL 5-50 GENES DNA ANALYSIS/COMBINED DNA & RNA ANALYSIS,97100110,CDM,971,RC,81445,HCPCS,,,facility,both,,,,531,371.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO EGFR GENE COM VARIANTS,97100111,CDM,971,RC,81235,HCPCS,,,facility,both,,,,803,562.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO MOPATH PROCEDURE LEVEL 4,97100112,CDM,971,RC,81403,HCPCS,,,facility,both,,,,695,486.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO HEMATOLYMPHOID NEOPLASM/DISORDER GENOMIC SEQ ANALYSIS PANEL 5-50 GENES DNA ANALYSIS/COMBINED DNA & RNA ANALYSIS,97100113,CDM,971,RC,81450,HCPCS,,,facility,both,,,,675,472.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO HC TPMT GENE ANALYSIS COMMON VARIANTS,97100114,CDM,971,RC,81335,HCPCS,,,facility,both,,,,156,109.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO DMD DELETION ANALYSIS AND DUPLICATION ANALYSIS,97100115,CDM,971,RC,81161,HCPCS,,,facility,both,,,,248,173.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO ATXN3 GENE ANALYSIS EVAL DETECT ABNORMAL ALLELES,97100116,CDM,971,RC,81180,HCPCS,,,facility,both,,,,122,85.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO ABL1 GENE ANALYSIS VARIANTS IN KINASE DOMAIN,97100117,CDM,971,RC,81170,HCPCS,,,facility,both,,,,618,432.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO HBB FULL GENE SEQUENCE,97100118,CDM,971,RC,81364,HCPCS,,,facility,both,,,,669,468.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO DIAGNOSTIC BONE MARROW ASPIRATION(S),97138220,CDM,971,RC,38220,HCPCS,,,facility,both,,,,126,88.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO MOPATH PROCEDURE LEVEL 8,97181407,CDM,971,RC,81407,HCPCS,,,facility,both,,,,3370,2359,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO BLOOD SMEAR INTERP,97185060,CDM,971,RC,85060,HCPCS,,,facility,both,,,,77,53.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO BONE MARROW SMEAR INTERP,97185097,CDM,971,RC,85097,HCPCS,,,facility,both,,,,283,198.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO IMMNFIX ELECT OTR FLUID PATH INTERP,97186335,CDM,971,RC,86335,HCPCS,,,facility,both,,,26,25,17.5,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO CYTOPATH CONCENTRATE TECH,97188108,CDM,971,RC,88108,HCPCS,,,facility,both,,,26,170,119,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO CYTOPATH CELL ENHANCE TECH,97188112,CDM,971,RC,88112,HCPCS,,,facility,both,,,26,233,163.1,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO CYTP URNE 3-5 PROBES EA SPEC,97188120,CDM,971,RC,88120,HCPCS,,,facility,both,,,26,721,504.7,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO CYTOPATH C/V INTERPRET,97188141,CDM,971,RC,88141,HCPCS,,,facility,both,,,,40,28,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CYTP DX EVAL FNA 1ST EA SITE,97188172,CDM,971,RC,88172,HCPCS,,,facility,both,,,26,84,58.8,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO CYTOPATH EVAL FNA REPORT,97188173,CDM,971,RC,88173,HCPCS,,,facility,both,,,26,175,122.5,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO FLOWCYTOMETRY/TC ADD-ON,97188185,CDM,971,RC,88185,HCPCS,,,facility,both,,,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO FLOWCYTOMETRY/READ 2-8,97188187,CDM,971,RC,88187,HCPCS,,,facility,both,,,,89,62.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO FLOWCYTOMETRY/READ 16 & >,97188189,CDM,971,RC,88189,HCPCS,,,facility,both,,,,140,98,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CYTOGENETICS DNA PROBE,97188271,CDM,971,RC,88271,HCPCS,,,facility,both,,,,53,37.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CYTO/MOLECULAR REPORT,97188291,CDM,971,RC,88291,HCPCS,,,facility,both,,,,146,102.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO SURGICAL PATH GROSS,97188300,CDM,971,RC,88300,HCPCS,,,facility,both,,,26,57,39.9,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO SURG PATH GROSS AND MICROSCOP II,97188302,CDM,971,RC,88302,HCPCS,,,facility,both,,,26,106,74.2,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO TISSUE EXAM BY PATHOLOGIST,97188304,CDM,971,RC,88304,HCPCS,,,facility,both,,,26,139,97.3,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO TISSUE EXAM BY PATHOLOGIST,97188305,CDM,971,RC,88305,HCPCS,,,facility,both,,,26,182,127.4,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO SURG PATH GROSS AND MICROSC V,97188307,CDM,971,RC,88307,HCPCS,,,facility,both,,,26,423,296.1,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO SURG PATH GROSS AND MICROSC VI,97188309,CDM,971,RC,88309,HCPCS,,,facility,both,,,26,510,357,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO DECALCIFY TISSUE,97188311,CDM,971,RC,88311,HCPCS,,,facility,both,,,26,37,25.9,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO SPECIAL STAINS GROUP 2,97188312,CDM,971,RC,88312,HCPCS,,,facility,both,,,26,115,80.5,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO SPECIAL STAINS GROUP 2,97188313,CDM,971,RC,88313,HCPCS,,,facility,both,,,26,83,58.1,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO ENZYME HISTOCHEMISTRY,97188319,CDM,971,RC,88319,HCPCS,,,facility,both,,,26,105,73.5,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO MICROSLIDE CONSULTATION,97188321,CDM,971,RC,88321,HCPCS,,,facility,both,,,,129,90.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO PATH CONSULT INTROP,97188329,CDM,971,RC,88329,HCPCS,,,facility,both,,,,154,107.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO PATH CONSULT INTRAOP 1 BLOC,97188331,CDM,971,RC,88331,HCPCS,,,facility,both,,,26,233,163.1,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO PATH CONSULT INTRAOP ADDL,97188332,CDM,971,RC,88332,HCPCS,,,facility,both,,,26,160,112,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO INTRAOP CYTO PATH CONSULT 1ST,97188333,CDM,971,RC,88333,HCPCS,,,facility,both,,,26,131,91.7,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO INTRAOP CYTO PATH CONSULT ADDL,97188334,CDM,971,RC,88334,HCPCS,,,facility,both,,,26,67,46.9,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO IMMHISTO/CYTO PER SPEC EA ADDL SINGLE ANTIBODY,97188341,CDM,971,RC,88341,HCPCS,,,facility,both,,,26,80,56,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO IMMUNOHISTOCHEMISTRY,97188342,CDM,971,RC,88342,HCPCS,,,facility,both,,,26,128,89.6,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO IMMHISTO/CYTO PER SPEC EA MULTI ANTIBODY STAIN,97188344,CDM,971,RC,88344,HCPCS,,,facility,both,,,26,138,96.6,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO IMMUNOFLUORESCENCE PER SPECIMEN INITIAL SINGLE ANTIBODY STAIN PROCEDURE,97188346,CDM,971,RC,88346,HCPCS,,,facility,both,,,26,117,81.9,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO TUMOR IMMUNOHISTOCHEM/MAN,97188360,CDM,971,RC,88360,HCPCS,,,facility,both,,,26,170,119,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO INSITU HYBRIDIZATION (FISH) PER SPEC EA ADDTL SINGLE STAIN,97188364,CDM,971,RC,88364,HCPCS,,,facility,both,,,26,114,79.8,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO INSITU HYBRIDIZATION (FISH),97188365,CDM,971,RC,88365,HCPCS,,,facility,both,,,26,197,137.9,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO INSITU HYBRIDIZATION PER SPECIMEN EACH MULTIPLEX PROBE STAIN,97188366,CDM,971,RC,88366,HCPCS,,,facility,both,,,,177,123.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO FISH ALK,97188368,CDM,971,RC,88368,HCPCS,,,facility,both,,,26,125,87.5,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO MORPHOMETRIC ANALYSIS IN SITU HYBRIDIZATION MANUAL PER SPECIMEN EACH ADDITIONAL SINGLE PROBE STAIN,97188369,CDM,310,RC,88369,HCPCS,,,facility,both,,,,171,119.7,,,,,,,,,,,,,Gross Charge Type: Central
"HC PRO MORPHOMETRIC ANALYSIS, IN SITU HYBRIDIZATION, MANUAL, PER SPECIMEN",97188377,CDM,971,RC,88377,HCPCS,,,facility,both,,,,81,56.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO MOLECULAR PATHOLOGY INTERP,971G0452,CDM,971,RC,G0452,HCPCS,,,facility,both,,,26,42,29.4,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO SPEC SIT NOT PRIM TUMOR,971G8723,CDM,969,RC,G8723,HCPCS,,,facility,both,,,,0.01,0.007,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO US GUIDE VASCULAR ACCESS,97200002,CDM,972,RC,76937,HCPCS,,,facility,both,,,,38,26.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO US EVAL ABDOMINAL AORTA REAL TIME W/IMAGE DOC SCREENING ABDOMINAL AORTIC ANEURYSM (AAA),97200004,CDM,972,RC,76706,HCPCS,,,facility,both,,,,201,140.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CARDIAC MRI FOR MORPH W/O DYE,97200009,CDM,972,RC,75557,HCPCS,,,facility,both,,,26,893,625.1,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO CARD MRI VELOC FLOW MAPPING,97200010,CDM,972,RC,75565,HCPCS,,,facility,both,,,26,182,127.4,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO CARDIAC MRI FOR MORPH W/DYE,97200011,CDM,972,RC,75561,HCPCS,,,facility,both,,,26,1261,882.7,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO CARDIAC MRI W/W/O CONTRAST W/STRESS,97200012,CDM,972,RC,75563,HCPCS,,,facility,both,,,26,1313,919.1,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO CT ANGIO HEART W/3D IMAGE,97200013,CDM,972,RC,75574,HCPCS,,,facility,both,,,26,796,557.2,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO CT HEART W/3D IMAGE,97200014,CDM,972,RC,75572,HCPCS,,,facility,both,,,26,591,413.7,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO CT HEART  W/CONTRAST EVAL CHD INCL 3D IMAGE LV RV EVAL VASCULAR STRUCTURES,97200015,CDM,972,RC,75573,HCPCS,,,facility,both,,,26,775,542.5,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO CT HEART W/O CONTRAST W/ QUAL EVAL CORONARY CALCIUM,97200016,CDM,972,RC,75571,HCPCS,,,facility,both,,,26,226,158.2,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO CARDIAC MRI W/O CONTRAST W/STRESS IMAGING,97200017,CDM,972,RC,75559,HCPCS,,,facility,both,,,,1007,704.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO MAGNETIC RESONANCE ALYS TISSUE COMPOSITION W/MRI SINGLE ORGAN,97200018,CDM,972,RC,0694T,HCPCS,,,facility,both,,,,35,24.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO NONINVASIVE EST CORONARY FFR DERIVED SOFTWARE ANALYSIS DATA SET FROM CTA W/INTERP /REPORT BY PHY/QHP,97200021,CDM,972,RC,75580,HCPCS,,,facility,both,,,26,1907,1334.9,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO MRA ABD W/WO DYE,97200022,CDM,972,RC,74185,HCPCS,,,facility,both,,,26,1270,889,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO MRA CHEST W/WO DYE,97200023,CDM,972,RC,71555,HCPCS,,,facility,both,,,26,1271,889.7,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO 3D RENDER W/O POSTPROCESS,97200024,CDM,972,RC,76376,HCPCS,,,facility,both,,,26,201,140.7,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO LARYNGOSCOPY FLEXIBLE DIAGNOSTIC,97300001,CDM,960,RC,31575,HCPCS,,,facility,both,,,,186,130.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO DIAGNOSTIC BONE MARROW BIOPSY(IES),97300002,CDM,973,RC,38221,HCPCS,,,facility,both,,,,403,282.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO PLACE INTERST DEVICE(S) RAD THER GUIDE SING/MULT,97300004,CDM,960,RC,55876,HCPCS,,,facility,both,,,,199,139.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO INSRT UTERINE TANDEM/VAG OVOIDS BRACHYTHERAPY,97300005,CDM,960,RC,57155,HCPCS,,,facility,both,,,,1414,989.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO US GUIDE INTERSTITIAL RADIOELEMENT APPLICATION,97300008,CDM,972,RC,76965,HCPCS,,,facility,both,,,26,234,163.8,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO CT GUIDE STEREOTACTIC LOCALIZATION,97300009,CDM,972,RC,77011,HCPCS,,,facility,both,,,,244,170.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO 3D CT GUIDE FOR PLACEMENT OF RADIATION THERAPY FIELDS,97300010,CDM,972,RC,77014,HCPCS,,,facility,both,,,26,296,207.2,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO THERAPEUTIC RAD TX PLANNING SIMPLE,97300011,CDM,973,RC,77261,HCPCS,,,facility,both,,,,678,474.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO THERAPEUTIC RAD TX PLANNING INTERMEDIATE,97300012,CDM,973,RC,77262,HCPCS,,,facility,both,,,,905,633.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO THERAPEUTIC RAD TX PLANNING COMPLEX,97300013,CDM,973,RC,77263,HCPCS,,,facility,both,,,,1357,949.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO THERAPEUTIC RAD SIM-AIDED FIELD SETTING SIMPLE,97300014,CDM,973,RC,77280,HCPCS,,,facility,both,,,26,277,193.9,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO THERAPEUTIC RAD SIM-AIDED FIELD SETTING INTERMED,97300015,CDM,973,RC,77285,HCPCS,,,facility,both,,,26,431,301.7,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO THERAPEUTIC RAD SIM-AIDED FIELD SETTING COMPLEX,97300016,CDM,973,RC,77290,HCPCS,,,facility,both,,,26,633,443.1,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO THERAPEUTIC RAD SIM-AIDED FIELD SETTING 3D,97300017,CDM,973,RC,77295,HCPCS,,,facility,both,,,26,1185,829.5,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO RAD DOSIMETRY CALCULATION,97300018,CDM,973,RC,77300,HCPCS,,,facility,both,,,26,158,110.6,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO IMRT PLAN,97300019,CDM,973,RC,77301,HCPCS,,,facility,both,,,26,2266,1586.2,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO SPECIAL TELETHERAPY PORT PLAN,97300023,CDM,973,RC,77321,HCPCS,,,facility,both,,,26,250,175,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO SPECIAL DOSIMETRY,97300027,CDM,973,RC,77331,HCPCS,,,facility,both,,,26,201,140.7,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO TX DEVICES SIMPLE,97300028,CDM,973,RC,77332,HCPCS,,,facility,both,,,26,122,85.4,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO TX DEVICES INTERMEDIATE,97300029,CDM,973,RC,77333,HCPCS,,,facility,both,,,26,203,142.1,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO TX DEVICES COMPLEX,97300030,CDM,973,RC,77334,HCPCS,,,facility,both,,,26,314,219.8,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO MULTI-LEAF COLLIMATOR DEVICE(S) FOR IMRT,97300031,CDM,973,RC,77338,HCPCS,,,facility,both,,,26,930,651,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO RADIATION TX MANAGEMENT 5 TX,97300033,CDM,973,RC,77427,HCPCS,,,facility,both,,,,1330,931,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO RADIATION TX MANAGEMENT 1-2 FRACTIONS,97300034,CDM,973,RC,77431,HCPCS,,,facility,both,,,,699,489.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO SPECIAL RAD TX,97300035,CDM,973,RC,77470,HCPCS,,,facility,both,,,26,796,557.2,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO INTRACAVITARY RAD SOURCE APPLICATION SIMPLE,97300036,CDM,973,RC,77761,HCPCS,,,facility,both,,,26,934,653.8,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO INTRACAVITARY RAD SOURCE APPLICATION INTERMEDIATE,97300037,CDM,973,RC,77762,HCPCS,,,facility,both,,,26,1445,1011.5,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO INTRACAVITARY RAD SOURCE APPLICATION COMPLEX,97300038,CDM,973,RC,77763,HCPCS,,,facility,both,,,26,2105,1473.5,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO INTERSTITIAL RAD SOURCE APPLICATION COMPLEX,97300041,CDM,973,RC,77778,HCPCS,,,facility,both,,,26,3599,2519.3,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO SURFACE APPLICATION RADIATION SOURCE,97300044,CDM,973,RC,77789,HCPCS,,,facility,both,,,26,279,195.3,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO SBRT MANAGEMENT NOT TO EXCEED 5 FRACTIONS,97300047,CDM,973,RC,77435,HCPCS,,,facility,both,,,,778,544.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO RESPIRATORY MOTION MGMT SIMULATION,97300048,CDM,972,RC,77293,HCPCS,,,facility,both,,,26,536,375.2,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO GUIDE FOR LOCALIZATION OF TARGET VOLUME FOR RADIATION TREATMENT DELIVERY,97300049,CDM,973,RC,77387,HCPCS,,,facility,both,,,,101,70.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO TELETHERAPY ISODOSE PLAN SIMPLE INCLUDES BASIC DOSIMETRY CALCULATION(S),97300050,CDM,973,RC,77306,HCPCS,,,facility,both,,,,161,112.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO TELETHERAPY ISODOSE PLAN COMPLEX INCLUDES BASIC DOSIMETRY CALCULATION(S),97300051,CDM,973,RC,77307,HCPCS,,,facility,both,,,,352,246.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO BRACHYTHERAPY ISODOSE PLAN SIMPLE INCLUDES BASIC DOSIMETRY CALCULATION(S),97300052,CDM,973,RC,77316,HCPCS,,,facility,both,,,,223,156.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO BRACHYTHERAPY ISODOSE PLAN INTERMEDIATE INCLUDES BASIC DOSIMETRY CALCULATION(S),97300053,CDM,973,RC,77317,HCPCS,,,facility,both,,,,354,247.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO BRACHYTHERAPY ISODOSE PLAN COMPLEX INCLUDES BASIC DOSIMETRY CALCULATION(S),97300054,CDM,973,RC,77318,HCPCS,,,facility,both,,,,346,242.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO HC REMOTE AFTERLOADING HIGH DOSE RATE RADIONUCLIDE INTERSTITIAL/INTRACAVITARY BRACHYTHERAPY INCL BASIC DOSIMETRY 1 CHANNEL,97300060,CDM,973,RC,77770,HCPCS,,,facility,both,,,26,464,324.8,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO REMOTE AFTERLOADING HIGH DOSE RATE RADIONUCLIDE INTERSTITIAL/INTRACAVITARY BRACHYTHERAPY INCL BASIC DOSIMETRY 2-12 CHANNELS,97300061,CDM,973,RC,77771,HCPCS,,,facility,both,,,26,579,405.3,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO REMOTE AFTERLOADING HIGH DOSE RATE RADIONUCLIDE INTERSTITIAL/INTRACAVITARY BRACHYTHERAPY INCL BASIC DOSIMETRY OVER 12 CHANNELS,97300062,CDM,973,RC,77772,HCPCS,,,facility,both,,,26,1822,1275.4,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO 4D CT GUIDE FOR PLACEMENT OF RADIATION THERAPY FIELDS,97300063,CDM,973,RC,77014,HCPCS,,,facility,both,,,26,296,207.2,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC PRO STEREOTACTIC RADIATION TX MGMT CRANIAL LESION(S) 1 SESSION,97300064,CDM,973,RC,77432,HCPCS,,,facility,both,,,,1000,700,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO TUMOR IMAGING PLANAR SINGLE AREA SINGLE DAY IMAGING,97400001,CDM,974,RC,78800,HCPCS,,,facility,both,,,,1351,945.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO TUMOR SPECT SINGLE AREA/ACQUISITION SINGLE DAY IMAGING,97400002,CDM,974,RC,78803,HCPCS,,,facility,both,,,,4664,3264.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CARD BLOOD POOL GATED PLANAR 1 STUDY REST/STRESS,97400003,CDM,974,RC,78472,HCPCS,,,facility,both,,,,522,365.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CRITICAL CARE 1ST 30-74 MIN,98100001,CDM,981,RC,99291,HCPCS,,,facility,both,,,,1479,1035.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CRITICAL CARE EA ADDL 30 MIN,98100002,CDM,981,RC,99292,HCPCS,,,facility,both,,,,556,389.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CONTROL OF NOSEBLEED,98100003,CDM,981,RC,30903,HCPCS,,,facility,both,,,,631,441.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CONTROL OF NOSEBLEED SIMPLE,98100004,CDM,981,RC,30901,HCPCS,,,facility,both,,,,469,328.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CONTROL OF NOSEBLEED,98100005,CDM,981,RC,30905,HCPCS,,,facility,both,,,,1182,827.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO REM OF FOOT FB SUBQ,98100007,CDM,981,RC,28190,HCPCS,,,facility,both,,,,217,151.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO REMOVE NASAL FB,98100008,CDM,981,RC,30300,HCPCS,,,facility,both,,,,385,269.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO REM FB CORNEA W/SLIT LAMP,98100009,CDM,981,RC,65222,HCPCS,,,facility,both,,,,99,69.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO REM FB CORNEA /WO SLIT LAMP,98100010,CDM,981,RC,65220,HCPCS,,,facility,both,,,,298,208.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO REM FB EXTERNAL EAR CANAL,98100011,CDM,981,RC,69200,HCPCS,,,facility,both,,,,401,280.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO I&D REM FB SUBQ SIMPLE,98100012,CDM,981,RC,10120,HCPCS,,,facility,both,,,,411,287.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO  I&D REM FB SUBQ COMPLICAT,98100013,CDM,981,RC,10121,HCPCS,,,facility,both,,,,781,546.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO I&D PILONIDAL CYST SIMPLE,98100014,CDM,981,RC,10080,HCPCS,,,facility,both,,,,455,318.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO I&D PILONIDAL CYST COMPLEX,98100015,CDM,981,RC,10081,HCPCS,,,facility,both,,,,554,387.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO DRAIN BLOOD FROM UNDER NAIL,98100016,CDM,981,RC,11740,HCPCS,,,facility,both,,,,106,74.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CL TX DIS PHALANG FX FNGR/THUMB W/ MANIP,98100021,CDM,981,RC,26755,HCPCS,,,facility,both,,,,383,268.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO PUNCTURE ASPIRATION ABSCESS/HEMATOMA/BULLA/CYST,98100027,CDM,981,RC,10160,HCPCS,,,facility,both,,,,157,109.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO DEBRIDE SUBQ TISSUE FIRST 20 SQ CM OR LESS,98100029,CDM,981,RC,11042,HCPCS,,,facility,both,,,,101,70.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO DEBRIDE MUSC/FASCIA FIRST 20SQ CM OR LESS,98100030,CDM,981,RC,11043,HCPCS,,,facility,both,,,,1008,705.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO RPR CMPLX FRHD 1.1 TO 2.5CM,98100034,CDM,981,RC,13131,HCPCS,,,facility,both,,,,675,472.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO REPAIR COMPLEX FOREHEAD/CHEEKS/CHIN/MOUTH/NECK/AXILLAE/GENITALIA/HANDS/FEET 2.6-7.5 CM,98100035,CDM,981,RC,13132,HCPCS,,,facility,both,,,,1028,719.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO RPR CMPLX F/C/C/M/N/AX/G/H/F EA AD 5CM OR LESS,98100036,CDM,981,RC,13133,HCPCS,,,facility,both,,,,373,261.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CHEMICAL CAUTERY TISSUE,98100038,CDM,981,RC,17250,HCPCS,,,facility,both,,,,143,100.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO INCISION OF BREAST LESION/ABSC,98100039,CDM,981,RC,19020,HCPCS,,,facility,both,,,,716,501.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO REMOVE FB SIMPLE,98100041,CDM,981,RC,20520,HCPCS,,,facility,both,,,,368,257.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO REMOVAL FOREIGN BODY MUSCLE/TENDON SHEATH DEEP OR COMPLICATED,98100042,CDM,981,RC,20525,HCPCS,,,facility,both,,,,662,463.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO INJ TENDON SHEATH/LIGAMENT,98100043,CDM,981,RC,20550,HCPCS,,,facility,both,,,,91,63.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO INJ SING/MULT TRIGGER POINT(S) 1 OR 2 MUSC,98100045,CDM,981,RC,20552,HCPCS,,,facility,both,,,,121,84.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO SING/MULT TRIGGER POINT(S) 3 OR MORE MUSC,98100046,CDM,981,RC,20553,HCPCS,,,facility,both,,,,131,91.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CLOSED TX PROX HUMERUS FX W/O MANIPULATION,98100052,CDM,981,RC,23600,HCPCS,,,facility,both,,,,716,501.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CLOSED TX SHOULDER DISL W/ MANIP W/ ANESTH,98100053,CDM,981,RC,23655,HCPCS,,,facility,both,,,,486,340.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CLOSED TX ELBOW DISL REQ ANESTHESIA,98100055,CDM,981,RC,24605,HCPCS,,,facility,both,,,,769,538.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO DRAIN FINGER ABSCESS COMPLICATED,98100057,CDM,981,RC,26011,HCPCS,,,facility,both,,,,472,330.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CLOSED TX KNUCKLE DISL SINGLE W/ MANIP W/O ANESTH,98100058,CDM,981,RC,26700,HCPCS,,,facility,both,,,,752,526.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CLOSED TX PHALANGEAL SHAFT FX PROXIMAL/MIDDLE PHALANX FINGER/THUMB W/O MANIPULATION EACH,98100059,CDM,981,RC,26720,HCPCS,,,facility,both,,,,452,316.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CLOSED TX HIP SOCKET FX W/ MANIP,98100060,CDM,981,RC,27222,HCPCS,,,facility,both,,,,2418,1692.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CLOSED TX FEMORAL FX W/O MANIPULATION,98100061,CDM,981,RC,27230,HCPCS,,,facility,both,,,,1098,768.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CLOSED TX PATELLAR FX W/O MANIPULATION,98100062,CDM,981,RC,27520,HCPCS,,,facility,both,,,,683,478.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CLOSED TX TIBIAL FX PROXIMAL W/O MANIP,98100063,CDM,981,RC,27530,HCPCS,,,facility,both,,,,486,340.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CLOSED TX TIBIAL SHAFT FX W/WO FIBULAR FX W/MANIPULATION W/W/O SKELETAL TRACTION,98100064,CDM,981,RC,27752,HCPCS,,,facility,both,,,,926,648.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CLOSED TX TALUS FX W/O MANIPULATION,98100068,CDM,981,RC,28430,HCPCS,,,facility,both,,,,441,308.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO TX TARSAL BONE FX W/O MANIP EACH,98100069,CDM,981,RC,28450,HCPCS,,,facility,both,,,,414,289.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CLOSED TX METATARSAL FX W/O MANIP EACH,98100070,CDM,981,RC,28470,HCPCS,,,facility,both,,,,472,330.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CLOSED TX GREAT TOE FX W/O MANIPULATION,98100071,CDM,981,RC,28490,HCPCS,,,facility,both,,,,275,192.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CLOSED TX GREAT TOE FX W/ MANIPULATION,98100072,CDM,981,RC,28495,HCPCS,,,facility,both,,,,271,189.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CLOSED TX OTH THAN GREAT TOE FX W/O MANIP EACH,98100073,CDM,981,RC,28510,HCPCS,,,facility,both,,,,271,189.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO STRAPPING THORAX,98100077,CDM,981,RC,29200,HCPCS,,,facility,both,,,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO STRAPPING TOES,98100083,CDM,981,RC,29550,HCPCS,,,facility,both,,,,140,98,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO LARYNOGOSCOP,98100089,CDM,981,RC,31511,HCPCS,,,facility,both,,,,252,176.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO TRACH EMERG CRICOTHYROID,98100091,CDM,981,RC,31605,HCPCS,,,facility,both,,,,537,375.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO NON-ROUTINE BLD DRAW>3 YRS,98100094,CDM,981,RC,36410,HCPCS,,,facility,both,,,,72,50.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO DRAIN THROAT ABSCSS INTRAORAL,98100098,CDM,981,RC,42720,HCPCS,,,facility,both,,,,885,619.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO INTUBATE GASTRIC WITH ASP,98100100,CDM,981,RC,43753,HCPCS,,,facility,both,,,,394,275.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO INC ISCHRCTL/PERIRECTAL ABSCES,98100101,CDM,981,RC,46040,HCPCS,,,facility,both,,,,642,449.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO INCISION OF ANAL ABSCESS,98100102,CDM,981,RC,46050,HCPCS,,,facility,both,,,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO INCISE EXTERNAL HEMORRHOID,98100103,CDM,981,RC,46083,HCPCS,,,facility,both,,,,316,221.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO REMOVAL OF HEMORRHOID CLOT,98100105,CDM,981,RC,46320,HCPCS,,,facility,both,,,,226,158.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO ANOSCOPY DIAGNOSTIC,98100106,CDM,981,RC,46600,HCPCS,,,facility,both,,,,107,74.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO ANOSCOPY REMOVE FOR BODY,98100107,CDM,981,RC,46608,HCPCS,,,facility,both,,,,664,464.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO PENILE INJECTION,98100111,CDM,981,RC,54235,HCPCS,,,facility,both,,,,113,79.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO INCISION & DRAINAGE EPIDIDYMIS/TESTIS/SCROTAL SPACE,98100112,CDM,981,RC,54700,HCPCS,,,facility,both,,,,258,180.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO N BLOCK INJ INTERCOST MLT,98100117,CDM,981,RC,64421,HCPCS,,,facility,both,,,,181,126.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO REMOVAL OF FOREGIN BODY EYE,98100118,CDM,981,RC,65205,HCPCS,,,facility,both,,,,276,193.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO REMOVE FB EYE,98100119,CDM,981,RC,65210,HCPCS,,,facility,both,,,,364,254.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO DRAINAGE OF EYELID ABSCESS,98100120,CDM,981,RC,67700,HCPCS,,,facility,both,,,,338,236.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CANALITH REPOSITIONING PROC,98100123,CDM,960,RC,95992,HCPCS,,,facility,both,,,,125,87.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO DEBRIDEMENT OPEN WOUND FIRST 20 SQ CM OR LESS,98100124,CDM,981,RC,97597,HCPCS,,,facility,both,,,,92,64.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO RMVL DEVITAL TISSUE ADDL 20 SQ CM,98100125,CDM,977,RC,97598,HCPCS,,,facility,both,,,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO EMERGENCY DEPT VISIT LEVEL 1,98100132,CDM,981,RC,99281,HCPCS,,,facility,both,,,,178,124.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO EMERGENCY DEPT VISIT LEVEL 2,98100133,CDM,981,RC,99282,HCPCS,,,facility,both,,,,232,162.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO EMERGENCY DEPT VISIT LEVEL 3,98100134,CDM,981,RC,99283,HCPCS,,,facility,both,,,,363,254.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO EMERGENCY DEPT VISIT LEVEL 4,98100135,CDM,981,RC,99284,HCPCS,,,facility,both,,,,610,427,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO EMERGENCY DEPT VISIT LEVEL 5,98100136,CDM,981,RC,99285,HCPCS,,,facility,both,,,,1036,725.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO SMOKING CESSATION < 10 MIN,98100137,CDM,981,RC,99406,HCPCS,,,facility,both,,,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO PQRS O2 SATURATION DOC REV,98100139,CDM,981,RC,3028F,HCPCS,,,facility,both,,,,0.01,0.007,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO PQRS 12 LEAD ECG PERFORMED (EM),98100140,CDM,981,RC,3120F,HCPCS,,,facility,both,,,,0.01,0.007,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO WOUND CLOSU,98100141,CDM,981,RC,G0168,HCPCS,,,facility,both,,,,108,75.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO PQRS VITAL SIGNS RECORDED,98100147,CDM,981,RC,2010F,HCPCS,,,facility,both,,,,0.01,0.007,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO MED REASON FOR NO GRADE REPORT,98100153,CDM,969,RC,G8722,HCPCS,,,facility,both,,,,0.01,0.007,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO PQRS ASPIRIN RECEIVED WITHIN 24 HOURS,98100154,CDM,981,RC,4084F,HCPCS,,,facility,both,,,,0.01,0.007,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO PQRS EMPIRIC ANTIBIOTIC RX,98100155,CDM,981,RC,4045F,HCPCS,,,facility,both,,,,0.01,0.007,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO PQRS TRANSABD/TRANSVAG ULTRASOUND,98100156,CDM,969,RC,G8806,HCPCS,,,facility,both,,,,0.01,0.007,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO PQRS TRANSABD/TRANSVAG US NOT PERF DOC REASONS,98100157,CDM,969,RC,G8807,HCPCS,,,facility,both,,,,0.01,0.007,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO PQRS TRANSABD/TRANSVAG US NOT PERF REAS NOT GIVEN,98100158,CDM,969,RC,G8808,HCPCS,,,facility,both,,,,0.01,0.007,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO-TREAT ELBOW FRACTURE,98100163,CDM,981,RC,24620,HCPCS,,,facility,both,,,,900,630,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CLOSED TX KNEE DISLOC W/O ANESTH,98100164,CDM,981,RC,27550,HCPCS,,,facility,both,,,,608,425.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO DRAIN EXTERNAL EAR ABSCESS/HEMATOMA COMPLICATED,98100165,CDM,981,RC,69005,HCPCS,,,facility,both,,,,355,248.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO REPAIR LIP HALF VERTICAL,98100166,CDM,981,RC,40652,HCPCS,,,facility,both,,,,608,425.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO DEBRID BONE 1ST 20 SQ CM,98100167,CDM,981,RC,11044,HCPCS,,,facility,both,,,,390,273,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO DRAIN THIGH/KNEE LESION,98100168,CDM,981,RC,27301,HCPCS,,,facility,both,,,,801,560.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO TX CLOSED TX ANKLE DISLOCATION W/ANESTHESIA W/ OR W/O PERCUT SKELETAL FIXATION,98100169,CDM,981,RC,27842,HCPCS,,,facility,both,,,,604,422.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO REPAIR LIP VERMILION ONLY,98100170,CDM,981,RC,40650,HCPCS,,,facility,both,,,,548,383.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO DRAINAGE OF SCROTUM ABSCESS,98100171,CDM,981,RC,55100,HCPCS,,,facility,both,,,,262,183.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO FORESKIN MANIPULATION INCL LYSIS PREPUTIAL ADHESIONS AND STRETCHING,98100172,CDM,981,RC,54450,HCPCS,,,facility,both,,,,86,60.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO TREAT WRIST DISLOCATION,98100173,CDM,981,RC,25690,HCPCS,,,facility,both,,,,589,412.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CLOSURE OF SPLIT WOUND,98100174,CDM,981,RC,12020,HCPCS,,,facility,both,,,,341,238.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO EXC TR-EXT BEN MARG 0.5<CM,98100176,CDM,981,RC,11400,HCPCS,,,facility,both,,,,145,101.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO DRAIN ABSC/CYST/HEMA MOUTH SIMPLE,98100179,CDM,981,RC,40800,HCPCS,,,facility,both,,,,257,179.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CLSD TX CARPOMETACARP DISL W/ MANIP EA JOINT W/O ANESTH,98100180,CDM,981,RC,26670,HCPCS,,,facility,both,,,,379,265.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO DRAINAGE OF ARM BURSA,98100182,CDM,981,RC,23931,HCPCS,,,facility,both,,,,430,301,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CLSD TX FX DISTAL TIBIA W/ OR W/O ANESTH W/ TRACTION OR MANIP,98100184,CDM,981,RC,27825,HCPCS,,,facility,both,,,,625,437.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO DX LARYNGOSCOPY EXCL NB,98100185,CDM,981,RC,31525,HCPCS,,,facility,both,,,,203,142.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO HC CRPRA CVRNSA SAPHNS VEIN SHUNT UNI/BIL,98100186,CDM,981,RC,54420,HCPCS,,,facility,both,,,,876,613.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO TREAT CLAVICLE FRACTURE W/MANIP,98100188,CDM,981,RC,23505,HCPCS,,,facility,both,,,,408,285.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO DRAINAGE OF MOUTH LESION,98100189,CDM,981,RC,41008,HCPCS,,,facility,both,,,,579,405.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO TREAT HIP DISLOCATION REQ ANES,98100190,CDM,981,RC,27252,HCPCS,,,facility,both,,,,947,662.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CANTHOTOMY,98100195,CDM,981,RC,67715,HCPCS,,,facility,both,,,,132,92.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CLOSED TX INTERPHALANGEAL JOINT DISLOC SINGLE W/ MANIP REQ ANESTH,98100196,CDM,981,RC,26775,HCPCS,,,facility,both,,,,427,298.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO ANESTH FOR PROCEDURES ON INTEGUMENTARY SYST ON EXTREMITIES/ANTERIOR TRUNK/PERINEUM ELECTRICAL CONVERSION OF ARRHYTHMIAS,98100197,CDM,981,RC,410,HCPCS,,,facility,both,,,,128,89.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO ARTHROCENTESIS ASPIRATION/INJECTION MAJOR JOINT/BURSA W/ ULTRASOUND GUIDANCE,98100198,CDM,981,RC,20611,HCPCS,,,facility,both,,,,93,65.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO MOD SEDATION SAME PHYS/QHP INITIAL 15 MIN PATIENT YOUNGER THAN 5 YEARS OF AGE,98100199,CDM,981,RC,99151,HCPCS,,,facility,both,,,,145,101.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO MOD SEDATION SAME PHYS/QHP INITIAL 15 MIN PATIENT AGE 5 YEARS OR OLDER,98100200,CDM,960,RC,99152,HCPCS,,,facility,both,,,,145,101.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO MOD SEDATION OTHER PHYS/QHP INITIAL 15 MIN INTRASERVICE TIME PATIENT YOUNGER THAN 5 YEARS OF AGE,98100202,CDM,981,RC,99155,HCPCS,,,facility,both,,,,76,53.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO MOD SEDATION OTHER PHYS/QHP INITIAL 15 MIN INTRASERVICE TIME PATIENT AGE 5 YEARS OR OLDER,98100203,CDM,981,RC,99156,HCPCS,,,facility,both,,,,112,78.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO MOD SEDATION OTHER PHYS/QHP EACH ADDTL 15 MIN INTRASERVICE TIME (LIST SEP IN ADDT TO CODE FOR PRIMARY SERVICE),98100204,CDM,981,RC,99157,HCPCS,,,facility,both,,,,71,49.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CLOSED TREATMENT OF RADIOCARPAL/INTERCARPAL DISLOCATION 1 OR MORE BONES W/ MANIPULATION,98100205,CDM,981,RC,25660,HCPCS,,,facility,both,,,,507,354.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO OSTEOPATHIC MANIPULATIVE TREATMENT (OMT) 1-2 BODY REGIONS INVOLVED,98100206,CDM,981,RC,98925,HCPCS,,,facility,both,,,,28,19.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO REDUCTION OF PROCIDENTIA UNDER ANESTHESIA,98100207,CDM,981,RC,45900,HCPCS,,,facility,both,,,,524,366.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO ANESTHESIA FOR PROCEDURES ON NOSE AND ACCESSORY SINUSES NOT OTHERWISE SPECIFIED,98100208,CDM,981,RC,160,HCPCS,,,facility,both,,,,302,211.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO REMOVAL FOREIGN BODY INTRANASAL REQUIRING GENERAL ANESTHESIA,98100209,CDM,981,RC,30310,HCPCS,,,facility,both,,,,468,327.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CLOSED TX OF TARSAL BONE DISLOCATION OTHER THAN TALOTARSAL W/O ANESTH,98100221,CDM,981,RC,28540,HCPCS,,,facility,both,,,,418,292.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO ARTERIAL PUNCTURE WITHDRAWAL OF BLOOD FOR DIAGNOSIS,98100223,CDM,981,RC,36600,HCPCS,,,facility,both,,,,26,18.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO REPLACE OF GASTRO TUBE PERCUTANEOUS INCL REMOVE W/O IMAGE OR ENDO GUIDE NOT REQ REV OF GASTRO,98100227,CDM,981,RC,43762,HCPCS,,,facility,both,,,,59,41.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO REPLACE OF GASTRO TUBE PERCUTANEOUS INCL REMOVE W/O IMAGE OR ENDO GUIDE REQ REV OF GASTRO,98100228,CDM,981,RC,43763,HCPCS,,,facility,both,,,,146,102.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO INITIATION OF MED FOR TX OPIOID USE DISORDER IN THE ER,98100233,CDM,981,RC,G2213,HCPCS,,,facility,both,,,,148,103.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO OPEN TX TRIMALLEOLAR ANKLE FX INCL INT FIXATION MEDIAL/ LATERAL MALLEOLUS W/O FIXATION POST LIP,98100234,CDM,981,RC,27822,HCPCS,,,facility,both,,,,2022,1415.4,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO TX OF MISSED ABORTION COMPLETED SURGICALLY FIRST TRIMESTER,98100235,CDM,981,RC,59820,HCPCS,,,facility,both,,,,895,626.5,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO INDUCED ABORTION 1 OR MORE VAGINAL SUPPOSITORIES W/WO CERVICAL DILATION INCL DELIVERY FETUS/SECUNDINES,98100236,CDM,981,RC,59855,HCPCS,,,facility,both,,,,1000,700,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO INDUCED ABORTION 1 OR MORE VAGINAL SUPPOSITORIES W/WO CERVICAL DILATION & CURETTAGE/EVACUATION,98100237,CDM,981,RC,59856,HCPCS,,,facility,both,,,,1173,821.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO INDUCED ABORTION 1 OR MORE VAGINAL SUPPOSITORIES W/WO CERVICAL DILATION INCL DELIVERY FETUS/SECUNDINES W/HYSTEROTOMY,98100238,CDM,981,RC,59857,HCPCS,,,facility,both,,,,1370,959,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO COLPORRHAPHY SUTURE OF INJURY OF VAGINA NON-OBSTETRICAL,98100239,CDM,981,RC,57200,HCPCS,,,facility,both,,,,757,529.9,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO INJ AA(S) / STEROID INTERCOSTAL NERVE SINGLE LEVEL,98100240,CDM,981,RC,64420,HCPCS,,,facility,both,,,,139,97.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO PELVIC EXAMINATION,98100241,CDM,981,RC,99459,HCPCS,,,facility,both,,,,48,33.6,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CLOSED TX RADIAL HEAD NECK FX W/O MANIPULATION,98100242,CDM,981,RC,24650,HCPCS,,,facility,both,,,,559,391.3,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO HYMENOTOMY SIMPLE INCISION,98100243,CDM,981,RC,56442,HCPCS,,,facility,both,,,,116,81.2,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO CLOSED TX TARSAL BONE DISLOCATION OTHER THAN TALOTARSAL REQUIRING ANESTHESIA,98100244,CDM,981,RC,28545,HCPCS,,,facility,both,,,,621,434.7,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO DRAINAGE ABSCESS/CYST/HEMATOMA/VESTIBULE OF MOUTH COMPLICATED,98100245,CDM,981,RC,40801,HCPCS,,,facility,both,,,,503,352.1,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO EXTERNAL PATIENT WHEN PERFORMED AUTO ACTIVATED ECG RHYTHM EVENT RECORDING REMOTE DOWNLOAD 30 DAYS 24 HR MONITORING TRANSMISSION/ANALYSIS,98500001,CDM,985,RC,93271,HCPCS,,,facility,both,,,,414,289.8,,,,,,,,,,,,,Gross Charge Type: Central
HC PRO TRNSTH ECHO CONGENITAL CAR ANOM INTERP/REPORT ONLY,98500002,CDM,960,RC,93317,HCPCS,,,facility,both,,,26,459,321.3,,,,,,,,,,,,,Gross Charge Type: Central | The modified price is presented in the standard charge value. | Modifier 26: Professional Component
HC APHERESIS SET-UP CBT-STUDY,99900001,CDM,999,RC,99900001,HCPCS,,,facility,both,,,,899,629.3,,,,,,,,,,,,,Gross Charge Type: Central
HC LEUKOPHERESIS CBT STUDY,99900002,CDM,999,RC,99900002,HCPCS,,,facility,both,,,,1723,1206.1,,,,,,,,,,,,,Gross Charge Type: Central
Adm sarscov2 30mcg/0.3ml 1st,0001A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,156.95,,,,,,,fee schedule,125.81,156.95,
Adm sarscov2 30mcg/0.3ml 1st,0001A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,125.81,,,,,,,fee schedule,125.81,156.95,
Adm sarscov2 30mcg/0.3ml 1st,0001A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,137.43,,,,,,,fee schedule,125.81,156.95,
Adm sarscov2 30mcg/0.3ml 1st,0001A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,144.49,,,,,,,fee schedule,125.81,156.95,
Rbc dna hea 35 ag 11 bld grp,0001U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,648,,,,,,,fee schedule,648,1260,Laboratory
Rbc dna hea 35 ag 11 bld grp,0001U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,756,,,,,,,fee schedule,648,1260,APC
Rbc dna hea 35 ag 11 bld grp,0001U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,748.8,,,,,,,fee schedule,648,1260,APC
Rbc dna hea 35 ag 11 bld grp,0001U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,720,,,,,,,fee schedule,648,1260,APC
Rbc dna hea 35 ag 11 bld grp,0001U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1101.6,,,,,,,fee schedule,648,1260,Radiology
Rbc dna hea 35 ag 11 bld grp,0001U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1008,,,,,,,fee schedule,648,1260,APC
Rbc dna hea 35 ag 11 bld grp,0001U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1260,,,,,,,fee schedule,648,1260,APC
Adm sarscov2 30mcg/0.3ml 2nd,0002A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,156.95,,,,,,,fee schedule,125.81,156.95,
Adm sarscov2 30mcg/0.3ml 2nd,0002A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,125.81,,,,,,,fee schedule,125.81,156.95,
Adm sarscov2 30mcg/0.3ml 2nd,0002A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,137.43,,,,,,,fee schedule,125.81,156.95,
Adm sarscov2 30mcg/0.3ml 2nd,0002A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,144.49,,,,,,,fee schedule,125.81,156.95,
Liver dis 10 assays w/ash,0002M,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,453.06,,,,,,,fee schedule,453.06,880.95,Laboratory
Liver dis 10 assays w/ash,0002M,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,528.57,,,,,,,fee schedule,453.06,880.95,APC
Liver dis 10 assays w/ash,0002M,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,523.54,,,,,,,fee schedule,453.06,880.95,APC
Liver dis 10 assays w/ash,0002M,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,503.4,,,,,,,fee schedule,453.06,880.95,APC
Liver dis 10 assays w/ash,0002M,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,770.2,,,,,,,fee schedule,453.06,880.95,Radiology
Liver dis 10 assays w/ash,0002M,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,704.76,,,,,,,fee schedule,453.06,880.95,APC
Liver dis 10 assays w/ash,0002M,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,880.95,,,,,,,fee schedule,453.06,880.95,APC
Onc clrct 3 ur metab alg plp,0002U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22.5,,,,,,,fee schedule,22.5,43.75,Laboratory
Onc clrct 3 ur metab alg plp,0002U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,26.25,,,,,,,fee schedule,22.5,43.75,APC
Onc clrct 3 ur metab alg plp,0002U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,26,,,,,,,fee schedule,22.5,43.75,APC
Onc clrct 3 ur metab alg plp,0002U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,25,,,,,,,fee schedule,22.5,43.75,APC
Onc clrct 3 ur metab alg plp,0002U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,38.25,,,,,,,fee schedule,22.5,43.75,Radiology
Onc clrct 3 ur metab alg plp,0002U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,35,,,,,,,fee schedule,22.5,43.75,APC
Onc clrct 3 ur metab alg plp,0002U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,43.75,,,,,,,fee schedule,22.5,43.75,APC
Fee covid-19 vac 1 booster,0003A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,156.95,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 1 booster,0003A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,125.81,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 1 booster,0003A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,137.43,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 1 booster,0003A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,144.49,,,,,,,fee schedule,125.81,156.95,
Liver dis 10 assays w/nash,0003M,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,453.06,,,,,,,fee schedule,453.06,880.95,Laboratory
Liver dis 10 assays w/nash,0003M,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,528.57,,,,,,,fee schedule,453.06,880.95,APC
Liver dis 10 assays w/nash,0003M,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,523.54,,,,,,,fee schedule,453.06,880.95,APC
Liver dis 10 assays w/nash,0003M,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,503.4,,,,,,,fee schedule,453.06,880.95,APC
Liver dis 10 assays w/nash,0003M,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,770.2,,,,,,,fee schedule,453.06,880.95,Radiology
Liver dis 10 assays w/nash,0003M,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,704.76,,,,,,,fee schedule,453.06,880.95,APC
Liver dis 10 assays w/nash,0003M,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,880.95,,,,,,,fee schedule,453.06,880.95,APC
Onc ovar 5 prtn ser alg scor,0003U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,855,,,,,,,fee schedule,855,1662.5,Laboratory
Onc ovar 5 prtn ser alg scor,0003U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,997.5,,,,,,,fee schedule,855,1662.5,APC
Onc ovar 5 prtn ser alg scor,0003U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,988,,,,,,,fee schedule,855,1662.5,APC
Onc ovar 5 prtn ser alg scor,0003U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,950,,,,,,,fee schedule,855,1662.5,APC
Onc ovar 5 prtn ser alg scor,0003U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1453.5,,,,,,,fee schedule,855,1662.5,Radiology
Onc ovar 5 prtn ser alg scor,0003U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1330,,,,,,,fee schedule,855,1662.5,APC
Onc ovar 5 prtn ser alg scor,0003U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1662.5,,,,,,,fee schedule,855,1662.5,APC
Fee covid-19 vac 1 res,0004A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,156.95,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 1 res,0004A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,125.81,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 1 res,0004A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,137.43,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 1 res,0004A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,144.49,,,,,,,fee schedule,125.81,156.95,
Scoliosis dna alys,0004M,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,71.1,,,,,,,fee schedule,71.1,138.25,Laboratory
Scoliosis dna alys,0004M,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,82.95,,,,,,,fee schedule,71.1,138.25,APC
Scoliosis dna alys,0004M,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,82.16,,,,,,,fee schedule,71.1,138.25,APC
Scoliosis dna alys,0004M,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,79,,,,,,,fee schedule,71.1,138.25,APC
Scoliosis dna alys,0004M,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.87,,,,,,,fee schedule,71.1,138.25,Radiology
Scoliosis dna alys,0004M,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,110.6,,,,,,,fee schedule,71.1,138.25,APC
Scoliosis dna alys,0004M,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,138.25,,,,,,,fee schedule,71.1,138.25,APC
Onco prst8 3 gene ur alg,0005U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,684,,,,,,,fee schedule,684,1330,Laboratory
Onco prst8 3 gene ur alg,0005U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,798,,,,,,,fee schedule,684,1330,APC
Onco prst8 3 gene ur alg,0005U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,790.4,,,,,,,fee schedule,684,1330,APC
Onco prst8 3 gene ur alg,0005U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,760,,,,,,,fee schedule,684,1330,APC
Onco prst8 3 gene ur alg,0005U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1162.8,,,,,,,fee schedule,684,1330,Radiology
Onco prst8 3 gene ur alg,0005U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1064,,,,,,,fee schedule,684,1330,APC
Onco prst8 3 gene ur alg,0005U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1330,,,,,,,fee schedule,684,1330,APC
Onc hep gene risk classifier,0006M,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,135,,,,,,,fee schedule,135,262.5,Laboratory
Onc hep gene risk classifier,0006M,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,157.5,,,,,,,fee schedule,135,262.5,APC
Onc hep gene risk classifier,0006M,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,156,,,,,,,fee schedule,135,262.5,APC
Onc hep gene risk classifier,0006M,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,150,,,,,,,fee schedule,135,262.5,APC
Onc hep gene risk classifier,0006M,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,229.5,,,,,,,fee schedule,135,262.5,Radiology
Onc hep gene risk classifier,0006M,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,210,,,,,,,fee schedule,135,262.5,APC
Onc hep gene risk classifier,0006M,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,262.5,,,,,,,fee schedule,135,262.5,APC
Onc gastro 51 gene nomogram,0007M,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,337.5,,,,,,,fee schedule,337.5,656.25,Laboratory
Onc gastro 51 gene nomogram,0007M,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,393.75,,,,,,,fee schedule,337.5,656.25,APC
Onc gastro 51 gene nomogram,0007M,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,390,,,,,,,fee schedule,337.5,656.25,APC
Onc gastro 51 gene nomogram,0007M,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,375,,,,,,,fee schedule,337.5,656.25,APC
Onc gastro 51 gene nomogram,0007M,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,573.75,,,,,,,fee schedule,337.5,656.25,Radiology
Onc gastro 51 gene nomogram,0007M,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,525,,,,,,,fee schedule,337.5,656.25,APC
Onc gastro 51 gene nomogram,0007M,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,656.25,,,,,,,fee schedule,337.5,656.25,APC
Rx test prsmv ur w/def conf,0007U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,102.99,,,,,,,fee schedule,102.99,200.25,Laboratory
Rx test prsmv ur w/def conf,0007U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,120.15,,,,,,,fee schedule,102.99,200.25,APC
Rx test prsmv ur w/def conf,0007U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,119.01,,,,,,,fee schedule,102.99,200.25,APC
Rx test prsmv ur w/def conf,0007U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,114.43,,,,,,,fee schedule,102.99,200.25,APC
Rx test prsmv ur w/def conf,0007U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,175.08,,,,,,,fee schedule,102.99,200.25,Radiology
Rx test prsmv ur w/def conf,0007U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,160.2,,,,,,,fee schedule,102.99,200.25,APC
Rx test prsmv ur w/def conf,0007U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,200.25,,,,,,,fee schedule,102.99,200.25,APC
Hpylori detcj abx rstnc dna,0008U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,538.12,,,,,,,fee schedule,538.12,1046.34,Laboratory
Hpylori detcj abx rstnc dna,0008U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,627.81,,,,,,,fee schedule,538.12,1046.34,APC
Hpylori detcj abx rstnc dna,0008U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,621.83,,,,,,,fee schedule,538.12,1046.34,APC
Hpylori detcj abx rstnc dna,0008U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,597.91,,,,,,,fee schedule,538.12,1046.34,APC
Hpylori detcj abx rstnc dna,0008U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,914.8,,,,,,,fee schedule,538.12,1046.34,Radiology
Hpylori detcj abx rstnc dna,0008U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,837.07,,,,,,,fee schedule,538.12,1046.34,APC
Hpylori detcj abx rstnc dna,0008U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1046.34,,,,,,,fee schedule,538.12,1046.34,APC
Onc brst ca erbb2 amp/nonamp,0009U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,96.3,,,,,,,fee schedule,96.3,187.25,Laboratory
Onc brst ca erbb2 amp/nonamp,0009U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,112.35,,,,,,,fee schedule,96.3,187.25,APC
Onc brst ca erbb2 amp/nonamp,0009U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,111.28,,,,,,,fee schedule,96.3,187.25,APC
Onc brst ca erbb2 amp/nonamp,0009U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,107,,,,,,,fee schedule,96.3,187.25,APC
Onc brst ca erbb2 amp/nonamp,0009U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,163.71,,,,,,,fee schedule,96.3,187.25,Radiology
Onc brst ca erbb2 amp/nonamp,0009U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,149.8,,,,,,,fee schedule,96.3,187.25,APC
Onc brst ca erbb2 amp/nonamp,0009U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,187.25,,,,,,,fee schedule,96.3,187.25,APC
Nfct ds strn typ whl gen seq,0010U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,384.53,,,,,,,fee schedule,384.53,747.7,Laboratory
Nfct ds strn typ whl gen seq,0010U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,448.62,,,,,,,fee schedule,384.53,747.7,APC
Nfct ds strn typ whl gen seq,0010U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,444.35,,,,,,,fee schedule,384.53,747.7,APC
Nfct ds strn typ whl gen seq,0010U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,427.26,,,,,,,fee schedule,384.53,747.7,APC
Nfct ds strn typ whl gen seq,0010U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,653.71,,,,,,,fee schedule,384.53,747.7,Radiology
Nfct ds strn typ whl gen seq,0010U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,598.16,,,,,,,fee schedule,384.53,747.7,APC
Nfct ds strn typ whl gen seq,0010U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,747.7,,,,,,,fee schedule,384.53,747.7,APC
Adm sarscov2 100mcg/0.5ml1st,0011A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,156.95,,,,,,,fee schedule,125.81,156.95,
Adm sarscov2 100mcg/0.5ml1st,0011A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,125.81,,,,,,,fee schedule,125.81,156.95,
Adm sarscov2 100mcg/0.5ml1st,0011A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,137.43,,,,,,,fee schedule,125.81,156.95,
Adm sarscov2 100mcg/0.5ml1st,0011A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,144.49,,,,,,,fee schedule,125.81,156.95,
Onc prst8 ca mrna 12 gen alg,0011M,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,684,,,,,,,fee schedule,684,1330,Laboratory
Onc prst8 ca mrna 12 gen alg,0011M,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,798,,,,,,,fee schedule,684,1330,APC
Onc prst8 ca mrna 12 gen alg,0011M,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,790.4,,,,,,,fee schedule,684,1330,APC
Onc prst8 ca mrna 12 gen alg,0011M,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,760,,,,,,,fee schedule,684,1330,APC
Onc prst8 ca mrna 12 gen alg,0011M,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1162.8,,,,,,,fee schedule,684,1330,Radiology
Onc prst8 ca mrna 12 gen alg,0011M,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1064,,,,,,,fee schedule,684,1330,APC
Onc prst8 ca mrna 12 gen alg,0011M,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1330,,,,,,,fee schedule,684,1330,APC
Rx mntr lc-ms/ms oral fluid,0011U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,102.99,,,,,,,fee schedule,102.99,200.25,Laboratory
Rx mntr lc-ms/ms oral fluid,0011U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,120.15,,,,,,,fee schedule,102.99,200.25,APC
Rx mntr lc-ms/ms oral fluid,0011U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,119.01,,,,,,,fee schedule,102.99,200.25,APC
Rx mntr lc-ms/ms oral fluid,0011U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,114.43,,,,,,,fee schedule,102.99,200.25,APC
Rx mntr lc-ms/ms oral fluid,0011U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,175.08,,,,,,,fee schedule,102.99,200.25,Radiology
Rx mntr lc-ms/ms oral fluid,0011U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,160.2,,,,,,,fee schedule,102.99,200.25,APC
Rx mntr lc-ms/ms oral fluid,0011U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,200.25,,,,,,,fee schedule,102.99,200.25,APC
Adm sarscov2 100mcg/0.5ml2nd,0012A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,156.95,,,,,,,fee schedule,125.81,156.95,
Adm sarscov2 100mcg/0.5ml2nd,0012A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,125.81,,,,,,,fee schedule,125.81,156.95,
Adm sarscov2 100mcg/0.5ml2nd,0012A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,137.43,,,,,,,fee schedule,125.81,156.95,
Adm sarscov2 100mcg/0.5ml2nd,0012A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,144.49,,,,,,,fee schedule,125.81,156.95,
Onc mrna 5 gen rsk urthl ca,0012M,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,684,,,,,,,fee schedule,684,1330,Laboratory
Onc mrna 5 gen rsk urthl ca,0012M,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,798,,,,,,,fee schedule,684,1330,APC
Onc mrna 5 gen rsk urthl ca,0012M,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,790.4,,,,,,,fee schedule,684,1330,APC
Onc mrna 5 gen rsk urthl ca,0012M,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,760,,,,,,,fee schedule,684,1330,APC
Onc mrna 5 gen rsk urthl ca,0012M,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1162.8,,,,,,,fee schedule,684,1330,Radiology
Onc mrna 5 gen rsk urthl ca,0012M,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1064,,,,,,,fee schedule,684,1330,APC
Onc mrna 5 gen rsk urthl ca,0012M,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1330,,,,,,,fee schedule,684,1330,APC
Fee covid-19 vac 2 booster,0013A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,156.95,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 2 booster,0013A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,125.81,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 2 booster,0013A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,137.43,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 2 booster,0013A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,144.49,,,,,,,fee schedule,125.81,156.95,
Onc mrna 5 gen recr urthl ca,0013M,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,684,,,,,,,fee schedule,684,1330,Laboratory
Onc mrna 5 gen recr urthl ca,0013M,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,798,,,,,,,fee schedule,684,1330,APC
Onc mrna 5 gen recr urthl ca,0013M,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,790.4,,,,,,,fee schedule,684,1330,APC
Onc mrna 5 gen recr urthl ca,0013M,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,760,,,,,,,fee schedule,684,1330,APC
Onc mrna 5 gen recr urthl ca,0013M,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1162.8,,,,,,,fee schedule,684,1330,Radiology
Onc mrna 5 gen recr urthl ca,0013M,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1064,,,,,,,fee schedule,684,1330,APC
Onc mrna 5 gen recr urthl ca,0013M,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1330,,,,,,,fee schedule,684,1330,APC
Adrnl cortcl tum bchm asy 25,0015M,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1174.83,,,,,,,fee schedule,1174.83,2284.4,Laboratory
Adrnl cortcl tum bchm asy 25,0015M,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1370.64,,,,,,,fee schedule,1174.83,2284.4,APC
Adrnl cortcl tum bchm asy 25,0015M,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1357.58,,,,,,,fee schedule,1174.83,2284.4,APC
Adrnl cortcl tum bchm asy 25,0015M,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1305.37,,,,,,,fee schedule,1174.83,2284.4,APC
Adrnl cortcl tum bchm asy 25,0015M,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1997.22,,,,,,,fee schedule,1174.83,2284.4,Radiology
Adrnl cortcl tum bchm asy 25,0015M,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1827.52,,,,,,,fee schedule,1174.83,2284.4,APC
Adrnl cortcl tum bchm asy 25,0015M,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2284.4,,,,,,,fee schedule,1174.83,2284.4,APC
Onc bladder mrna 209 gen alg,0016M,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3140.67,,,,,,,fee schedule,3140.67,6106.85,Laboratory
Onc bladder mrna 209 gen alg,0016M,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.11,,,,,,,fee schedule,3140.67,6106.85,APC
Onc bladder mrna 209 gen alg,0016M,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.22,,,,,,,fee schedule,3140.67,6106.85,APC
Onc bladder mrna 209 gen alg,0016M,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.63,,,,,,,fee schedule,3140.67,6106.85,APC
Onc bladder mrna 209 gen alg,0016M,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.13,,,,,,,fee schedule,3140.67,6106.85,Radiology
Onc bladder mrna 209 gen alg,0016M,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.48,,,,,,,fee schedule,3140.67,6106.85,APC
Onc bladder mrna 209 gen alg,0016M,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.85,,,,,,,fee schedule,3140.67,6106.85,APC
Onc hmtlmf neo rna bcr/abl1,0016U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,147.56,,,,,,,fee schedule,147.56,286.93,Laboratory
Onc hmtlmf neo rna bcr/abl1,0016U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,172.16,,,,,,,fee schedule,147.56,286.93,APC
Onc hmtlmf neo rna bcr/abl1,0016U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,170.52,,,,,,,fee schedule,147.56,286.93,APC
Onc hmtlmf neo rna bcr/abl1,0016U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,163.96,,,,,,,fee schedule,147.56,286.93,APC
Onc hmtlmf neo rna bcr/abl1,0016U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,250.86,,,,,,,fee schedule,147.56,286.93,Radiology
Onc hmtlmf neo rna bcr/abl1,0016U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,229.54,,,,,,,fee schedule,147.56,286.93,APC
Onc hmtlmf neo rna bcr/abl1,0016U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,286.93,,,,,,,fee schedule,147.56,286.93,APC
Onc dlbcl mrna 20 genes alg,0017M,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2259.19,,,,,,,fee schedule,2259.19,4392.87,Laboratory
Onc dlbcl mrna 20 genes alg,0017M,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2635.72,,,,,,,fee schedule,2259.19,4392.87,APC
Onc dlbcl mrna 20 genes alg,0017M,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2610.62,,,,,,,fee schedule,2259.19,4392.87,APC
Onc dlbcl mrna 20 genes alg,0017M,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2510.21,,,,,,,fee schedule,2259.19,4392.87,APC
Onc dlbcl mrna 20 genes alg,0017M,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3840.62,,,,,,,fee schedule,2259.19,4392.87,Radiology
Onc dlbcl mrna 20 genes alg,0017M,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3514.29,,,,,,,fee schedule,2259.19,4392.87,APC
Onc dlbcl mrna 20 genes alg,0017M,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4392.87,,,,,,,fee schedule,2259.19,4392.87,APC
Onc hmtlmf neo jak2 mut dna,0017U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,82.49,,,,,,,fee schedule,82.49,160.4,Laboratory
Onc hmtlmf neo jak2 mut dna,0017U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,96.24,,,,,,,fee schedule,82.49,160.4,APC
Onc hmtlmf neo jak2 mut dna,0017U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,95.33,,,,,,,fee schedule,82.49,160.4,APC
Onc hmtlmf neo jak2 mut dna,0017U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,91.66,,,,,,,fee schedule,82.49,160.4,APC
Onc hmtlmf neo jak2 mut dna,0017U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,140.24,,,,,,,fee schedule,82.49,160.4,Radiology
Onc hmtlmf neo jak2 mut dna,0017U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,128.32,,,,,,,fee schedule,82.49,160.4,APC
Onc hmtlmf neo jak2 mut dna,0017U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,160.4,,,,,,,fee schedule,82.49,160.4,APC
Trnsplj rnl meas cd154+cll,0018M,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,576.66,,,,,,,fee schedule,576.66,1121.28,Laboratory
Trnsplj rnl meas cd154+cll,0018M,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672.77,,,,,,,fee schedule,576.66,1121.28,APC
Trnsplj rnl meas cd154+cll,0018M,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,666.36,,,,,,,fee schedule,576.66,1121.28,APC
Trnsplj rnl meas cd154+cll,0018M,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640.73,,,,,,,fee schedule,576.66,1121.28,APC
Trnsplj rnl meas cd154+cll,0018M,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,980.32,,,,,,,fee schedule,576.66,1121.28,Radiology
Trnsplj rnl meas cd154+cll,0018M,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,897.02,,,,,,,fee schedule,576.66,1121.28,APC
Trnsplj rnl meas cd154+cll,0018M,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1121.28,,,,,,,fee schedule,576.66,1121.28,APC
Onc thyr 10 microrna seq alg,0018U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2701.88,,,,,,,fee schedule,2701.88,5253.66,Laboratory
Onc thyr 10 microrna seq alg,0018U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3152.19,,,,,,,fee schedule,2701.88,5253.66,APC
Onc thyr 10 microrna seq alg,0018U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3122.17,,,,,,,fee schedule,2701.88,5253.66,APC
Onc thyr 10 microrna seq alg,0018U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3002.09,,,,,,,fee schedule,2701.88,5253.66,APC
Onc thyr 10 microrna seq alg,0018U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4593.2,,,,,,,fee schedule,2701.88,5253.66,Radiology
Onc thyr 10 microrna seq alg,0018U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4202.93,,,,,,,fee schedule,2701.88,5253.66,APC
Onc thyr 10 microrna seq alg,0018U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5253.66,,,,,,,fee schedule,2701.88,5253.66,APC
Cv ds plasma alys prtn bmrk,0019M,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,641.16,,,,,,,fee schedule,641.16,1246.7,Laboratory
Cv ds plasma alys prtn bmrk,0019M,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,748.02,,,,,,,fee schedule,641.16,1246.7,APC
Cv ds plasma alys prtn bmrk,0019M,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,740.9,,,,,,,fee schedule,641.16,1246.7,APC
Cv ds plasma alys prtn bmrk,0019M,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,712.4,,,,,,,fee schedule,641.16,1246.7,APC
Cv ds plasma alys prtn bmrk,0019M,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1089.97,,,,,,,fee schedule,641.16,1246.7,Radiology
Cv ds plasma alys prtn bmrk,0019M,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,997.36,,,,,,,fee schedule,641.16,1246.7,APC
Cv ds plasma alys prtn bmrk,0019M,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1246.7,,,,,,,fee schedule,641.16,1246.7,APC
Onc rna tiss predict alg,0019U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3307.5,,,,,,,fee schedule,3307.5,6431.25,Laboratory
Onc rna tiss predict alg,0019U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3858.75,,,,,,,fee schedule,3307.5,6431.25,APC
Onc rna tiss predict alg,0019U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3822,,,,,,,fee schedule,3307.5,6431.25,APC
Onc rna tiss predict alg,0019U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3675,,,,,,,fee schedule,3307.5,6431.25,APC
Onc rna tiss predict alg,0019U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5622.75,,,,,,,fee schedule,3307.5,6431.25,Radiology
Onc rna tiss predict alg,0019U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5145,,,,,,,fee schedule,3307.5,6431.25,APC
Onc rna tiss predict alg,0019U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6431.25,,,,,,,fee schedule,3307.5,6431.25,APC
Onc prst8 detcj 8 autoantb,0021U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,684,,,,,,,fee schedule,684,1330,Laboratory
Onc prst8 detcj 8 autoantb,0021U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,798,,,,,,,fee schedule,684,1330,APC
Onc prst8 detcj 8 autoantb,0021U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,790.4,,,,,,,fee schedule,684,1330,APC
Onc prst8 detcj 8 autoantb,0021U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,760,,,,,,,fee schedule,684,1330,APC
Onc prst8 detcj 8 autoantb,0021U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1162.8,,,,,,,fee schedule,684,1330,Radiology
Onc prst8 detcj 8 autoantb,0021U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1064,,,,,,,fee schedule,684,1330,APC
Onc prst8 detcj 8 autoantb,0021U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1330,,,,,,,fee schedule,684,1330,APC
Trgt gen seq dna&rna 23 gene,0022U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755,,,,,,,fee schedule,1755,3412.5,Laboratory
Trgt gen seq dna&rna 23 gene,0022U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2047.5,,,,,,,fee schedule,1755,3412.5,APC
Trgt gen seq dna&rna 23 gene,0022U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2028,,,,,,,fee schedule,1755,3412.5,APC
Trgt gen seq dna&rna 23 gene,0022U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1950,,,,,,,fee schedule,1755,3412.5,APC
Trgt gen seq dna&rna 23 gene,0022U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2983.5,,,,,,,fee schedule,1755,3412.5,Radiology
Trgt gen seq dna&rna 23 gene,0022U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2730,,,,,,,fee schedule,1755,3412.5,APC
Trgt gen seq dna&rna 23 gene,0022U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3412.5,,,,,,,fee schedule,1755,3412.5,APC
Onc aml dna detcj/nondetcj,0023U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,223.66,,,,,,,fee schedule,223.66,434.89,Laboratory
Onc aml dna detcj/nondetcj,0023U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,260.94,,,,,,,fee schedule,223.66,434.89,APC
Onc aml dna detcj/nondetcj,0023U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,258.45,,,,,,,fee schedule,223.66,434.89,APC
Onc aml dna detcj/nondetcj,0023U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,248.51,,,,,,,fee schedule,223.66,434.89,APC
Onc aml dna detcj/nondetcj,0023U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,380.22,,,,,,,fee schedule,223.66,434.89,Radiology
Onc aml dna detcj/nondetcj,0023U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,347.91,,,,,,,fee schedule,223.66,434.89,APC
Onc aml dna detcj/nondetcj,0023U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,434.89,,,,,,,fee schedule,223.66,434.89,APC
Glyca nuc mr spectrsc quan,0024U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,30.77,,,,,,,fee schedule,30.77,59.83,Laboratory
Glyca nuc mr spectrsc quan,0024U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,35.9,,,,,,,fee schedule,30.77,59.83,APC
Glyca nuc mr spectrsc quan,0024U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,35.56,,,,,,,fee schedule,30.77,59.83,APC
Glyca nuc mr spectrsc quan,0024U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,34.19,,,,,,,fee schedule,30.77,59.83,APC
Glyca nuc mr spectrsc quan,0024U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,52.31,,,,,,,fee schedule,30.77,59.83,Radiology
Glyca nuc mr spectrsc quan,0024U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,47.87,,,,,,,fee schedule,30.77,59.83,APC
Glyca nuc mr spectrsc quan,0024U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,59.83,,,,,,,fee schedule,30.77,59.83,APC
Tenofovir liq chrom ur quan,0025U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,102.99,,,,,,,fee schedule,102.99,200.25,Laboratory
Tenofovir liq chrom ur quan,0025U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,120.15,,,,,,,fee schedule,102.99,200.25,APC
Tenofovir liq chrom ur quan,0025U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,119.01,,,,,,,fee schedule,102.99,200.25,APC
Tenofovir liq chrom ur quan,0025U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,114.43,,,,,,,fee schedule,102.99,200.25,APC
Tenofovir liq chrom ur quan,0025U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,175.08,,,,,,,fee schedule,102.99,200.25,Radiology
Tenofovir liq chrom ur quan,0025U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,160.2,,,,,,,fee schedule,102.99,200.25,APC
Tenofovir liq chrom ur quan,0025U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,200.25,,,,,,,fee schedule,102.99,200.25,APC
Onc thyr dna&mrna 112 genes,0026U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3240,,,,,,,fee schedule,3240,6300,Laboratory
Onc thyr dna&mrna 112 genes,0026U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3780,,,,,,,fee schedule,3240,6300,APC
Onc thyr dna&mrna 112 genes,0026U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3744,,,,,,,fee schedule,3240,6300,APC
Onc thyr dna&mrna 112 genes,0026U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3600,,,,,,,fee schedule,3240,6300,APC
Onc thyr dna&mrna 112 genes,0026U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5508,,,,,,,fee schedule,3240,6300,Radiology
Onc thyr dna&mrna 112 genes,0026U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5040,,,,,,,fee schedule,3240,6300,APC
Onc thyr dna&mrna 112 genes,0026U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6300,,,,,,,fee schedule,3240,6300,APC
Jak2 gene trgt seq alys,0027U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,109.72,,,,,,,fee schedule,109.72,213.34,Laboratory
Jak2 gene trgt seq alys,0027U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,128.01,,,,,,,fee schedule,109.72,213.34,APC
Jak2 gene trgt seq alys,0027U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,126.79,,,,,,,fee schedule,109.72,213.34,APC
Jak2 gene trgt seq alys,0027U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,121.91,,,,,,,fee schedule,109.72,213.34,APC
Jak2 gene trgt seq alys,0027U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,186.52,,,,,,,fee schedule,109.72,213.34,Radiology
Jak2 gene trgt seq alys,0027U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,170.67,,,,,,,fee schedule,109.72,213.34,APC
Jak2 gene trgt seq alys,0027U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,213.34,,,,,,,fee schedule,109.72,213.34,APC
Rx metab advrs trgt seq alys,0029U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,668.04,,,,,,,fee schedule,668.04,1298.97,Laboratory
Rx metab advrs trgt seq alys,0029U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,779.38,,,,,,,fee schedule,668.04,1298.97,APC
Rx metab advrs trgt seq alys,0029U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,771.96,,,,,,,fee schedule,668.04,1298.97,APC
Rx metab advrs trgt seq alys,0029U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,742.27,,,,,,,fee schedule,668.04,1298.97,APC
Rx metab advrs trgt seq alys,0029U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1135.67,,,,,,,fee schedule,668.04,1298.97,Radiology
Rx metab advrs trgt seq alys,0029U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1039.18,,,,,,,fee schedule,668.04,1298.97,APC
Rx metab advrs trgt seq alys,0029U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1298.97,,,,,,,fee schedule,668.04,1298.97,APC
Rx metab warf trgt seq alys,0030U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,120.72,,,,,,,fee schedule,120.72,234.73,Laboratory
Rx metab warf trgt seq alys,0030U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,140.84,,,,,,,fee schedule,120.72,234.73,APC
Rx metab warf trgt seq alys,0030U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,139.5,,,,,,,fee schedule,120.72,234.73,APC
Rx metab warf trgt seq alys,0030U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,134.13,,,,,,,fee schedule,120.72,234.73,APC
Rx metab warf trgt seq alys,0030U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,205.22,,,,,,,fee schedule,120.72,234.73,Radiology
Rx metab warf trgt seq alys,0030U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,187.78,,,,,,,fee schedule,120.72,234.73,APC
Rx metab warf trgt seq alys,0030U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,234.73,,,,,,,fee schedule,120.72,234.73,APC
Fee covid-19 vac 4 dose 1,0031A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,156.95,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 4 dose 1,0031A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,125.81,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 4 dose 1,0031A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,137.43,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 4 dose 1,0031A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,144.49,,,,,,,fee schedule,125.81,156.95,
Cyp1a2 gene,0031U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,157.33,,,,,,,fee schedule,157.33,305.92,Laboratory
Cyp1a2 gene,0031U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.55,,,,,,,fee schedule,157.33,305.92,APC
Cyp1a2 gene,0031U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,181.8,,,,,,,fee schedule,157.33,305.92,APC
Cyp1a2 gene,0031U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,174.81,,,,,,,fee schedule,157.33,305.92,APC
Cyp1a2 gene,0031U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,267.46,,,,,,,fee schedule,157.33,305.92,Radiology
Cyp1a2 gene,0031U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,244.73,,,,,,,fee schedule,157.33,305.92,APC
Cyp1a2 gene,0031U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,305.92,,,,,,,fee schedule,157.33,305.92,APC
Comt gene,0032U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,157.33,,,,,,,fee schedule,157.33,305.92,Laboratory
Comt gene,0032U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.55,,,,,,,fee schedule,157.33,305.92,APC
Comt gene,0032U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,181.8,,,,,,,fee schedule,157.33,305.92,APC
Comt gene,0032U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,174.81,,,,,,,fee schedule,157.33,305.92,APC
Comt gene,0032U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,267.46,,,,,,,fee schedule,157.33,305.92,Radiology
Comt gene,0032U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,244.73,,,,,,,fee schedule,157.33,305.92,APC
Comt gene,0032U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,305.92,,,,,,,fee schedule,157.33,305.92,APC
Fee covid-19 vac 4 res,0034A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,156.95,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 4 res,0034A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,125.81,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 4 res,0034A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,137.43,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 4 res,0034A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,144.49,,,,,,,fee schedule,125.81,156.95,
Tpmt nudt15 genes,0034U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,419.55,,,,,,,fee schedule,419.55,815.8,Laboratory
Tpmt nudt15 genes,0034U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,489.48,,,,,,,fee schedule,419.55,815.8,APC
Tpmt nudt15 genes,0034U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,484.82,,,,,,,fee schedule,419.55,815.8,APC
Tpmt nudt15 genes,0034U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,466.17,,,,,,,fee schedule,419.55,815.8,APC
Tpmt nudt15 genes,0034U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,713.24,,,,,,,fee schedule,419.55,815.8,Radiology
Tpmt nudt15 genes,0034U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,652.64,,,,,,,fee schedule,419.55,815.8,APC
Tpmt nudt15 genes,0034U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,815.8,,,,,,,fee schedule,419.55,815.8,APC
Neuro csf prion prtn qual,0035U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,486.89,,,,,,,fee schedule,486.89,946.73,Laboratory
Neuro csf prion prtn qual,0035U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,568.04,,,,,,,fee schedule,486.89,946.73,APC
Neuro csf prion prtn qual,0035U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,562.63,,,,,,,fee schedule,486.89,946.73,APC
Neuro csf prion prtn qual,0035U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,540.99,,,,,,,fee schedule,486.89,946.73,APC
Neuro csf prion prtn qual,0035U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,827.71,,,,,,,fee schedule,486.89,946.73,Radiology
Neuro csf prion prtn qual,0035U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,757.39,,,,,,,fee schedule,486.89,946.73,APC
Neuro csf prion prtn qual,0035U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,946.73,,,,,,,fee schedule,486.89,946.73,APC
Xome tum & nml spec seq alys,0036U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4302,,,,,,,fee schedule,4302,8365,Laboratory
Xome tum & nml spec seq alys,0036U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5019,,,,,,,fee schedule,4302,8365,APC
Xome tum & nml spec seq alys,0036U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4971.2,,,,,,,fee schedule,4302,8365,APC
Xome tum & nml spec seq alys,0036U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4780,,,,,,,fee schedule,4302,8365,APC
Xome tum & nml spec seq alys,0036U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7313.4,,,,,,,fee schedule,4302,8365,Radiology
Xome tum & nml spec seq alys,0036U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6692,,,,,,,fee schedule,4302,8365,APC
Xome tum & nml spec seq alys,0036U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8365,,,,,,,fee schedule,4302,8365,APC
Trgt gen seq dna 324 genes,0037U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3150,,,,,,,fee schedule,3150,6125,Laboratory
Trgt gen seq dna 324 genes,0037U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3675,,,,,,,fee schedule,3150,6125,APC
Trgt gen seq dna 324 genes,0037U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3640,,,,,,,fee schedule,3150,6125,APC
Trgt gen seq dna 324 genes,0037U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3500,,,,,,,fee schedule,3150,6125,APC
Trgt gen seq dna 324 genes,0037U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5355,,,,,,,fee schedule,3150,6125,Radiology
Trgt gen seq dna 324 genes,0037U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4900,,,,,,,fee schedule,3150,6125,APC
Trgt gen seq dna 324 genes,0037U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6125,,,,,,,fee schedule,3150,6125,APC
Vitamin d srm microsamp quan,0038U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26.64,,,,,,,fee schedule,26.64,51.8,Laboratory
Vitamin d srm microsamp quan,0038U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,31.08,,,,,,,fee schedule,26.64,51.8,APC
Vitamin d srm microsamp quan,0038U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,30.78,,,,,,,fee schedule,26.64,51.8,APC
Vitamin d srm microsamp quan,0038U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,29.6,,,,,,,fee schedule,26.64,51.8,APC
Vitamin d srm microsamp quan,0038U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,45.29,,,,,,,fee schedule,26.64,51.8,Radiology
Vitamin d srm microsamp quan,0038U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,41.44,,,,,,,fee schedule,26.64,51.8,APC
Vitamin d srm microsamp quan,0038U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,51.8,,,,,,,fee schedule,26.64,51.8,APC
Dna antb 2strand hi avidity,0039U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.37,,,,,,,fee schedule,12.37,24.04,Laboratory
Dna antb 2strand hi avidity,0039U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.43,,,,,,,fee schedule,12.37,24.04,APC
Dna antb 2strand hi avidity,0039U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,14.29,,,,,,,fee schedule,12.37,24.04,APC
Dna antb 2strand hi avidity,0039U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.74,,,,,,,fee schedule,12.37,24.04,APC
Dna antb 2strand hi avidity,0039U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21.02,,,,,,,fee schedule,12.37,24.04,Radiology
Dna antb 2strand hi avidity,0039U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.24,,,,,,,fee schedule,12.37,24.04,APC
Dna antb 2strand hi avidity,0039U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,24.04,,,,,,,fee schedule,12.37,24.04,APC
Bcr/abl1 gene major bp quan,0040U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,368.91,,,,,,,fee schedule,368.91,717.32,Laboratory
Bcr/abl1 gene major bp quan,0040U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,430.4,,,,,,,fee schedule,368.91,717.32,APC
Bcr/abl1 gene major bp quan,0040U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,426.3,,,,,,,fee schedule,368.91,717.32,APC
Bcr/abl1 gene major bp quan,0040U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,409.9,,,,,,,fee schedule,368.91,717.32,APC
Bcr/abl1 gene major bp quan,0040U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,627.15,,,,,,,fee schedule,368.91,717.32,Radiology
Bcr/abl1 gene major bp quan,0040U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,573.86,,,,,,,fee schedule,368.91,717.32,APC
Bcr/abl1 gene major bp quan,0040U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,717.32,,,,,,,fee schedule,368.91,717.32,APC
Fee covid-19 vac 5 dose 1,0041A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,156.95,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 5 dose 1,0041A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,125.81,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 5 dose 1,0041A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,137.43,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 5 dose 1,0041A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,144.49,,,,,,,fee schedule,125.81,156.95,
B brgdrferi antb 5 prtn igm,0041U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.49,,,,,,,fee schedule,15.49,30.12,Laboratory
B brgdrferi antb 5 prtn igm,0041U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.07,,,,,,,fee schedule,15.49,30.12,APC
B brgdrferi antb 5 prtn igm,0041U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,17.9,,,,,,,fee schedule,15.49,30.12,APC
B brgdrferi antb 5 prtn igm,0041U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17.21,,,,,,,fee schedule,15.49,30.12,APC
B brgdrferi antb 5 prtn igm,0041U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26.33,,,,,,,fee schedule,15.49,30.12,Radiology
B brgdrferi antb 5 prtn igm,0041U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24.09,,,,,,,fee schedule,15.49,30.12,APC
B brgdrferi antb 5 prtn igm,0041U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30.12,,,,,,,fee schedule,15.49,30.12,APC
Fee covid-19 vac 5 dose 2,0042A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,156.95,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 5 dose 2,0042A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,125.81,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 5 dose 2,0042A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,137.43,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 5 dose 2,0042A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,144.49,,,,,,,fee schedule,125.81,156.95,
B brgdrferi antb 12 prtn igg,0042U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.49,,,,,,,fee schedule,15.49,30.12,Laboratory
B brgdrferi antb 12 prtn igg,0042U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.07,,,,,,,fee schedule,15.49,30.12,APC
B brgdrferi antb 12 prtn igg,0042U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,17.9,,,,,,,fee schedule,15.49,30.12,APC
B brgdrferi antb 12 prtn igg,0042U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17.21,,,,,,,fee schedule,15.49,30.12,APC
B brgdrferi antb 12 prtn igg,0042U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26.33,,,,,,,fee schedule,15.49,30.12,Radiology
B brgdrferi antb 12 prtn igg,0042U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24.09,,,,,,,fee schedule,15.49,30.12,APC
B brgdrferi antb 12 prtn igg,0042U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30.12,,,,,,,fee schedule,15.49,30.12,APC
Tbrf b grp antb 4 prtn igm,0043U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.37,,,,,,,fee schedule,13.37,26,Laboratory
Tbrf b grp antb 4 prtn igm,0043U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.6,,,,,,,fee schedule,13.37,26,APC
Tbrf b grp antb 4 prtn igm,0043U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,15.45,,,,,,,fee schedule,13.37,26,APC
Tbrf b grp antb 4 prtn igm,0043U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14.86,,,,,,,fee schedule,13.37,26,APC
Tbrf b grp antb 4 prtn igm,0043U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.74,,,,,,,fee schedule,13.37,26,Radiology
Tbrf b grp antb 4 prtn igm,0043U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.8,,,,,,,fee schedule,13.37,26,APC
Tbrf b grp antb 4 prtn igm,0043U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,26,,,,,,,fee schedule,13.37,26,APC
Fee covid-19 vac 5 res,0044A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,156.95,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 5 res,0044A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,125.81,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 5 res,0044A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,137.43,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 5 res,0044A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,144.49,,,,,,,fee schedule,125.81,156.95,
Tbrf b grp antb 4 prtn igg,0044U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.37,,,,,,,fee schedule,13.37,26,Laboratory
Tbrf b grp antb 4 prtn igg,0044U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.6,,,,,,,fee schedule,13.37,26,APC
Tbrf b grp antb 4 prtn igg,0044U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,15.45,,,,,,,fee schedule,13.37,26,APC
Tbrf b grp antb 4 prtn igg,0044U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14.86,,,,,,,fee schedule,13.37,26,APC
Tbrf b grp antb 4 prtn igg,0044U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.74,,,,,,,fee schedule,13.37,26,Radiology
Tbrf b grp antb 4 prtn igg,0044U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.8,,,,,,,fee schedule,13.37,26,APC
Tbrf b grp antb 4 prtn igg,0044U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,26,,,,,,,fee schedule,13.37,26,APC
Onc brst dux carc is 12 gene,0045U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3485.7,,,,,,,fee schedule,3485.7,6777.75,Laboratory
Onc brst dux carc is 12 gene,0045U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4066.65,,,,,,,fee schedule,3485.7,6777.75,APC
Onc brst dux carc is 12 gene,0045U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4027.92,,,,,,,fee schedule,3485.7,6777.75,APC
Onc brst dux carc is 12 gene,0045U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3873,,,,,,,fee schedule,3485.7,6777.75,APC
Onc brst dux carc is 12 gene,0045U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5925.69,,,,,,,fee schedule,3485.7,6777.75,Radiology
Onc brst dux carc is 12 gene,0045U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5422.2,,,,,,,fee schedule,3485.7,6777.75,APC
Onc brst dux carc is 12 gene,0045U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6777.75,,,,,,,fee schedule,3485.7,6777.75,APC
Flt3 gene itd variants quan,0046U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,366.69,,,,,,,fee schedule,366.69,713,Laboratory
Flt3 gene itd variants quan,0046U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,427.8,,,,,,,fee schedule,366.69,713,APC
Flt3 gene itd variants quan,0046U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,423.73,,,,,,,fee schedule,366.69,713,APC
Flt3 gene itd variants quan,0046U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,407.43,,,,,,,fee schedule,366.69,713,APC
Flt3 gene itd variants quan,0046U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,623.37,,,,,,,fee schedule,366.69,713,Radiology
Flt3 gene itd variants quan,0046U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,570.4,,,,,,,fee schedule,366.69,713,APC
Flt3 gene itd variants quan,0046U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,713,,,,,,,fee schedule,366.69,713,APC
Onc prst8 mrna 17 gene alg,0047U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3485.7,,,,,,,fee schedule,3485.7,6777.75,Laboratory
Onc prst8 mrna 17 gene alg,0047U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4066.65,,,,,,,fee schedule,3485.7,6777.75,APC
Onc prst8 mrna 17 gene alg,0047U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4027.92,,,,,,,fee schedule,3485.7,6777.75,APC
Onc prst8 mrna 17 gene alg,0047U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3873,,,,,,,fee schedule,3485.7,6777.75,APC
Onc prst8 mrna 17 gene alg,0047U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5925.69,,,,,,,fee schedule,3485.7,6777.75,Radiology
Onc prst8 mrna 17 gene alg,0047U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5422.2,,,,,,,fee schedule,3485.7,6777.75,APC
Onc prst8 mrna 17 gene alg,0047U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6777.75,,,,,,,fee schedule,3485.7,6777.75,APC
Onc sld org neo dna 468 gene,0048U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2627.64,,,,,,,fee schedule,2627.64,5109.3,Laboratory
Onc sld org neo dna 468 gene,0048U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3065.58,,,,,,,fee schedule,2627.64,5109.3,APC
Onc sld org neo dna 468 gene,0048U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3036.38,,,,,,,fee schedule,2627.64,5109.3,APC
Onc sld org neo dna 468 gene,0048U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2919.6,,,,,,,fee schedule,2627.64,5109.3,APC
Onc sld org neo dna 468 gene,0048U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4466.99,,,,,,,fee schedule,2627.64,5109.3,Radiology
Onc sld org neo dna 468 gene,0048U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4087.44,,,,,,,fee schedule,2627.64,5109.3,APC
Onc sld org neo dna 468 gene,0048U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5109.3,,,,,,,fee schedule,2627.64,5109.3,APC
Npm1 gene analysis quan,0049U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,366.69,,,,,,,fee schedule,366.69,713,Laboratory
Npm1 gene analysis quan,0049U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,427.8,,,,,,,fee schedule,366.69,713,APC
Npm1 gene analysis quan,0049U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,423.73,,,,,,,fee schedule,366.69,713,APC
Npm1 gene analysis quan,0049U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,407.43,,,,,,,fee schedule,366.69,713,APC
Npm1 gene analysis quan,0049U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,623.37,,,,,,,fee schedule,366.69,713,Radiology
Npm1 gene analysis quan,0049U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,570.4,,,,,,,fee schedule,366.69,713,APC
Npm1 gene analysis quan,0049U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,713,,,,,,,fee schedule,366.69,713,APC
Trgt gen seq dna 194 genes,0050U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2624.94,,,,,,,fee schedule,2624.94,5104.05,Laboratory
Trgt gen seq dna 194 genes,0050U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3062.43,,,,,,,fee schedule,2624.94,5104.05,APC
Trgt gen seq dna 194 genes,0050U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3033.26,,,,,,,fee schedule,2624.94,5104.05,APC
Trgt gen seq dna 194 genes,0050U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2916.6,,,,,,,fee schedule,2624.94,5104.05,APC
Trgt gen seq dna 194 genes,0050U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4462.4,,,,,,,fee schedule,2624.94,5104.05,Radiology
Trgt gen seq dna 194 genes,0050U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4083.24,,,,,,,fee schedule,2624.94,5104.05,APC
Trgt gen seq dna 194 genes,0050U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5104.05,,,,,,,fee schedule,2624.94,5104.05,APC
Fee covid-19 vac 6 dose 1,0051A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,156.95,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 6 dose 1,0051A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,125.81,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 6 dose 1,0051A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,137.43,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 6 dose 1,0051A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,144.49,,,,,,,fee schedule,125.81,156.95,
Rx mntr lc-ms/ms ur 31 pnl,0051U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,222.23,,,,,,,fee schedule,222.23,432.11,Laboratory
Rx mntr lc-ms/ms ur 31 pnl,0051U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,259.27,,,,,,,fee schedule,222.23,432.11,APC
Rx mntr lc-ms/ms ur 31 pnl,0051U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,256.8,,,,,,,fee schedule,222.23,432.11,APC
Rx mntr lc-ms/ms ur 31 pnl,0051U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,246.92,,,,,,,fee schedule,222.23,432.11,APC
Rx mntr lc-ms/ms ur 31 pnl,0051U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,377.79,,,,,,,fee schedule,222.23,432.11,Radiology
Rx mntr lc-ms/ms ur 31 pnl,0051U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,345.69,,,,,,,fee schedule,222.23,432.11,APC
Rx mntr lc-ms/ms ur 31 pnl,0051U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,432.11,,,,,,,fee schedule,222.23,432.11,APC
Fee covid-19 vac 6 dose 2,0052A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,156.95,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 6 dose 2,0052A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,125.81,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 6 dose 2,0052A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,137.43,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 6 dose 2,0052A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,144.49,,,,,,,fee schedule,125.81,156.95,
Lpoprtn bld w/5 maj classes,0052U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,30.47,,,,,,,fee schedule,30.47,59.26,Laboratory
Lpoprtn bld w/5 maj classes,0052U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,35.55,,,,,,,fee schedule,30.47,59.26,APC
Lpoprtn bld w/5 maj classes,0052U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,35.21,,,,,,,fee schedule,30.47,59.26,APC
Lpoprtn bld w/5 maj classes,0052U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,33.86,,,,,,,fee schedule,30.47,59.26,APC
Lpoprtn bld w/5 maj classes,0052U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.81,,,,,,,fee schedule,30.47,59.26,Radiology
Lpoprtn bld w/5 maj classes,0052U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,47.4,,,,,,,fee schedule,30.47,59.26,APC
Lpoprtn bld w/5 maj classes,0052U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,59.26,,,,,,,fee schedule,30.47,59.26,APC
Fee covid-19 vac 6 booster,0053A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,156.95,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 6 booster,0053A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,125.81,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 6 booster,0053A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,137.43,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 6 booster,0053A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,144.49,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 6 res,0054A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,156.95,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 6 res,0054A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,125.81,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 6 res,0054A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,137.43,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 6 res,0054A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,144.49,,,,,,,fee schedule,125.81,156.95,
Rx mntr 14+ drugs & sbsts,0054U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,178.87,,,,,,,fee schedule,178.87,347.8,Laboratory
Rx mntr 14+ drugs & sbsts,0054U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.68,,,,,,,fee schedule,178.87,347.8,APC
Rx mntr 14+ drugs & sbsts,0054U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,206.69,,,,,,,fee schedule,178.87,347.8,APC
Rx mntr 14+ drugs & sbsts,0054U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.74,,,,,,,fee schedule,178.87,347.8,APC
Rx mntr 14+ drugs & sbsts,0054U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,304.07,,,,,,,fee schedule,178.87,347.8,Radiology
Rx mntr 14+ drugs & sbsts,0054U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,278.24,,,,,,,fee schedule,178.87,347.8,APC
Rx mntr 14+ drugs & sbsts,0054U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,347.8,,,,,,,fee schedule,178.87,347.8,APC
Card hrt trnspl 96 dna seq,0055U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2916,,,,,,,fee schedule,2916,5670,Laboratory
Card hrt trnspl 96 dna seq,0055U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3402,,,,,,,fee schedule,2916,5670,APC
Card hrt trnspl 96 dna seq,0055U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3369.6,,,,,,,fee schedule,2916,5670,APC
Card hrt trnspl 96 dna seq,0055U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3240,,,,,,,fee schedule,2916,5670,APC
Card hrt trnspl 96 dna seq,0055U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4957.2,,,,,,,fee schedule,2916,5670,Radiology
Card hrt trnspl 96 dna seq,0055U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4536,,,,,,,fee schedule,2916,5670,APC
Card hrt trnspl 96 dna seq,0055U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5670,,,,,,,fee schedule,2916,5670,APC
Onc merkel cll carc srm quan,0058U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,290.66,,,,,,,fee schedule,290.66,565.18,Laboratory
Onc merkel cll carc srm quan,0058U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,339.11,,,,,,,fee schedule,290.66,565.18,APC
Onc merkel cll carc srm quan,0058U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,335.88,,,,,,,fee schedule,290.66,565.18,APC
Onc merkel cll carc srm quan,0058U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,322.96,,,,,,,fee schedule,290.66,565.18,APC
Onc merkel cll carc srm quan,0058U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,494.13,,,,,,,fee schedule,290.66,565.18,Radiology
Onc merkel cll carc srm quan,0058U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,452.14,,,,,,,fee schedule,290.66,565.18,APC
Onc merkel cll carc srm quan,0058U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,565.18,,,,,,,fee schedule,290.66,565.18,APC
Onc merkel cll carc srm +/-,0059U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,290.66,,,,,,,fee schedule,290.66,565.18,Laboratory
Onc merkel cll carc srm +/-,0059U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,339.11,,,,,,,fee schedule,290.66,565.18,APC
Onc merkel cll carc srm +/-,0059U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,335.88,,,,,,,fee schedule,290.66,565.18,APC
Onc merkel cll carc srm +/-,0059U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,322.96,,,,,,,fee schedule,290.66,565.18,APC
Onc merkel cll carc srm +/-,0059U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,494.13,,,,,,,fee schedule,290.66,565.18,Radiology
Onc merkel cll carc srm +/-,0059U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,452.14,,,,,,,fee schedule,290.66,565.18,APC
Onc merkel cll carc srm +/-,0059U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,565.18,,,,,,,fee schedule,290.66,565.18,APC
Twn zyg gen seq alys chrms2,0060U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,683.14,,,,,,,fee schedule,683.14,1328.34,Laboratory
Twn zyg gen seq alys chrms2,0060U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,797,,,,,,,fee schedule,683.14,1328.34,APC
Twn zyg gen seq alys chrms2,0060U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,789.41,,,,,,,fee schedule,683.14,1328.34,APC
Twn zyg gen seq alys chrms2,0060U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,759.05,,,,,,,fee schedule,683.14,1328.34,APC
Twn zyg gen seq alys chrms2,0060U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1161.35,,,,,,,fee schedule,683.14,1328.34,Radiology
Twn zyg gen seq alys chrms2,0060U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1062.67,,,,,,,fee schedule,683.14,1328.34,APC
Twn zyg gen seq alys chrms2,0060U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1328.34,,,,,,,fee schedule,683.14,1328.34,APC
Tc meas 5 bmrk sfdi m-s alys,0061U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22.59,,,,,,,fee schedule,22.59,43.92,Laboratory
Tc meas 5 bmrk sfdi m-s alys,0061U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,26.36,,,,,,,fee schedule,22.59,43.92,APC
Tc meas 5 bmrk sfdi m-s alys,0061U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,26.1,,,,,,,fee schedule,22.59,43.92,APC
Tc meas 5 bmrk sfdi m-s alys,0061U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,25.1,,,,,,,fee schedule,22.59,43.92,APC
Tc meas 5 bmrk sfdi m-s alys,0061U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,38.4,,,,,,,fee schedule,22.59,43.92,Radiology
Tc meas 5 bmrk sfdi m-s alys,0061U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,35.14,,,,,,,fee schedule,22.59,43.92,APC
Tc meas 5 bmrk sfdi m-s alys,0061U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,43.92,,,,,,,fee schedule,22.59,43.92,APC
Ai sle igg&igm alys 80 bmrk,0062U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,342.65,,,,,,,fee schedule,342.65,666.26,Laboratory
Ai sle igg&igm alys 80 bmrk,0062U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,399.76,,,,,,,fee schedule,342.65,666.26,APC
Ai sle igg&igm alys 80 bmrk,0062U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,395.95,,,,,,,fee schedule,342.65,666.26,APC
Ai sle igg&igm alys 80 bmrk,0062U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,380.72,,,,,,,fee schedule,342.65,666.26,APC
Ai sle igg&igm alys 80 bmrk,0062U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,582.5,,,,,,,fee schedule,342.65,666.26,Radiology
Ai sle igg&igm alys 80 bmrk,0062U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,533.01,,,,,,,fee schedule,342.65,666.26,APC
Ai sle igg&igm alys 80 bmrk,0062U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,666.26,,,,,,,fee schedule,342.65,666.26,APC
Neuro autism 32 amines alg,0063U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,675,,,,,,,fee schedule,675,1312.5,Laboratory
Neuro autism 32 amines alg,0063U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,787.5,,,,,,,fee schedule,675,1312.5,APC
Neuro autism 32 amines alg,0063U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,780,,,,,,,fee schedule,675,1312.5,APC
Neuro autism 32 amines alg,0063U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,750,,,,,,,fee schedule,675,1312.5,APC
Neuro autism 32 amines alg,0063U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1147.5,,,,,,,fee schedule,675,1312.5,Radiology
Neuro autism 32 amines alg,0063U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1050,,,,,,,fee schedule,675,1312.5,APC
Neuro autism 32 amines alg,0063U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1312.5,,,,,,,fee schedule,675,1312.5,APC
Fee covid-19 vac 7 res,0064A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,156.95,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 7 res,0064A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,125.81,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 7 res,0064A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,137.43,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 7 res,0064A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,144.49,,,,,,,fee schedule,125.81,156.95,
Antb tp total&rpr ia qual,0064U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,28.2,,,,,,,fee schedule,28.2,54.83,Laboratory
Antb tp total&rpr ia qual,0064U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,32.9,,,,,,,fee schedule,28.2,54.83,APC
Antb tp total&rpr ia qual,0064U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,32.58,,,,,,,fee schedule,28.2,54.83,APC
Antb tp total&rpr ia qual,0064U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,31.33,,,,,,,fee schedule,28.2,54.83,APC
Antb tp total&rpr ia qual,0064U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,47.93,,,,,,,fee schedule,28.2,54.83,Radiology
Antb tp total&rpr ia qual,0064U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43.86,,,,,,,fee schedule,28.2,54.83,APC
Antb tp total&rpr ia qual,0064U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,54.83,,,,,,,fee schedule,28.2,54.83,APC
Syfls tst nontreponemal antb,0065U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.28,,,,,,,fee schedule,16.28,31.66,Laboratory
Syfls tst nontreponemal antb,0065U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.99,,,,,,,fee schedule,16.28,31.66,APC
Syfls tst nontreponemal antb,0065U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18.81,,,,,,,fee schedule,16.28,31.66,APC
Syfls tst nontreponemal antb,0065U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18.09,,,,,,,fee schedule,16.28,31.66,APC
Syfls tst nontreponemal antb,0065U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27.68,,,,,,,fee schedule,16.28,31.66,Radiology
Syfls tst nontreponemal antb,0065U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.33,,,,,,,fee schedule,16.28,31.66,APC
Syfls tst nontreponemal antb,0065U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31.66,,,,,,,fee schedule,16.28,31.66,APC
Onc brst imhchem prfl 4 bmrk,0067U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1707.3,,,,,,,fee schedule,1707.3,3319.75,Laboratory
Onc brst imhchem prfl 4 bmrk,0067U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1991.85,,,,,,,fee schedule,1707.3,3319.75,APC
Onc brst imhchem prfl 4 bmrk,0067U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1972.88,,,,,,,fee schedule,1707.3,3319.75,APC
Onc brst imhchem prfl 4 bmrk,0067U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1897,,,,,,,fee schedule,1707.3,3319.75,APC
Onc brst imhchem prfl 4 bmrk,0067U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2902.41,,,,,,,fee schedule,1707.3,3319.75,Radiology
Onc brst imhchem prfl 4 bmrk,0067U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2655.8,,,,,,,fee schedule,1707.3,3319.75,APC
Onc brst imhchem prfl 4 bmrk,0067U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3319.75,,,,,,,fee schedule,1707.3,3319.75,APC
Candida species pnl amp prb,0068U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,128.37,,,,,,,fee schedule,128.37,249.6,Laboratory
Candida species pnl amp prb,0068U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,149.76,,,,,,,fee schedule,128.37,249.6,APC
Candida species pnl amp prb,0068U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,148.34,,,,,,,fee schedule,128.37,249.6,APC
Candida species pnl amp prb,0068U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,142.63,,,,,,,fee schedule,128.37,249.6,APC
Candida species pnl amp prb,0068U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,218.22,,,,,,,fee schedule,128.37,249.6,Radiology
Candida species pnl amp prb,0068U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,199.68,,,,,,,fee schedule,128.37,249.6,APC
Candida species pnl amp prb,0068U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,249.6,,,,,,,fee schedule,128.37,249.6,APC
Onc clrct microrna mir-31-3p,0069U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,342,,,,,,,fee schedule,342,665,Laboratory
Onc clrct microrna mir-31-3p,0069U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,399,,,,,,,fee schedule,342,665,APC
Onc clrct microrna mir-31-3p,0069U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,395.2,,,,,,,fee schedule,342,665,APC
Onc clrct microrna mir-31-3p,0069U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,380,,,,,,,fee schedule,342,665,APC
Onc clrct microrna mir-31-3p,0069U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,581.4,,,,,,,fee schedule,342,665,Radiology
Onc clrct microrna mir-31-3p,0069U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,532,,,,,,,fee schedule,342,665,APC
Onc clrct microrna mir-31-3p,0069U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,665,,,,,,,fee schedule,342,665,APC
Cyp2d6 gen com&slct rar vrnt,0070U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,608.73,,,,,,,fee schedule,608.73,1183.65,Laboratory
Cyp2d6 gen com&slct rar vrnt,0070U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,710.19,,,,,,,fee schedule,608.73,1183.65,APC
Cyp2d6 gen com&slct rar vrnt,0070U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,703.42,,,,,,,fee schedule,608.73,1183.65,APC
Cyp2d6 gen com&slct rar vrnt,0070U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,676.37,,,,,,,fee schedule,608.73,1183.65,APC
Cyp2d6 gen com&slct rar vrnt,0070U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1034.85,,,,,,,fee schedule,608.73,1183.65,Radiology
Cyp2d6 gen com&slct rar vrnt,0070U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,946.92,,,,,,,fee schedule,608.73,1183.65,APC
Cyp2d6 gen com&slct rar vrnt,0070U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1183.65,,,,,,,fee schedule,608.73,1183.65,APC
Fee covid-19 vac 8 dose 1,0071A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,156.95,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 8 dose 1,0071A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,125.81,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 8 dose 1,0071A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,137.43,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 8 dose 1,0071A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,144.49,,,,,,,fee schedule,125.81,156.95,
Us leiomyomata ablate <200,0071T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15397.94,,,,,,,fee schedule,3204.65,15397.94,
Us leiomyomata ablate <200,0071T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12342.8,,,,,,,fee schedule,3204.65,15397.94,
Us leiomyomata ablate <200,0071T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13483.38,,,,,,,fee schedule,3204.65,15397.94,
Us leiomyomata ablate <200,0071T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14175.88,,,,,,,fee schedule,3204.65,15397.94,
Us leiomyomata ablate <200,0071T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14217.94,,,,,,,fee schedule,3204.65,15397.94,APC 378
Us leiomyomata ablate <200,0071T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3364.88,,,,,,,fee schedule,3204.65,15397.94,APC
Us leiomyomata ablate <200,0071T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3332.84,,,,,,,fee schedule,3204.65,15397.94,APC
Us leiomyomata ablate <200,0071T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3204.65,,,,,,,fee schedule,3204.65,15397.94,APC
Us leiomyomata ablate <200,0071T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4903.11,,,,,,,fee schedule,3204.65,15397.94,Radiology
Us leiomyomata ablate <200,0071T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4486.51,,,,,,,fee schedule,3204.65,15397.94,APC
Us leiomyomata ablate <200,0071T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5608.14,,,,,,,fee schedule,3204.65,15397.94,APC
Cyp2d6 full gene sequence,0071U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1139.1,,,,,,,fee schedule,540,1139.1,
Cyp2d6 full gene sequence,0071U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,913.09,,,,,,,fee schedule,540,1139.1,
Cyp2d6 full gene sequence,0071U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,997.47,,,,,,,fee schedule,540,1139.1,
Cyp2d6 full gene sequence,0071U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1048.7,,,,,,,fee schedule,540,1139.1,
Cyp2d6 full gene sequence,0071U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,540,,,,,,,fee schedule,540,1139.1,Laboratory
Cyp2d6 full gene sequence,0071U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,630,,,,,,,fee schedule,540,1139.1,APC
Cyp2d6 full gene sequence,0071U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,624,,,,,,,fee schedule,540,1139.1,APC
Cyp2d6 full gene sequence,0071U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,600,,,,,,,fee schedule,540,1139.1,APC
Cyp2d6 full gene sequence,0071U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,918,,,,,,,fee schedule,540,1139.1,Radiology
Cyp2d6 full gene sequence,0071U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,840,,,,,,,fee schedule,540,1139.1,APC
Cyp2d6 full gene sequence,0071U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1050,,,,,,,fee schedule,540,1139.1,APC
Fee covid-19 vac 8 dose 2,0072A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,156.95,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 8 dose 2,0072A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,125.81,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 8 dose 2,0072A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,137.43,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 8 dose 2,0072A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,144.49,,,,,,,fee schedule,125.81,156.95,
Us leiomyomata ablate >200,0072T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15397.94,,,,,,,fee schedule,3204.65,15397.94,
Us leiomyomata ablate >200,0072T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12342.8,,,,,,,fee schedule,3204.65,15397.94,
Us leiomyomata ablate >200,0072T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13483.38,,,,,,,fee schedule,3204.65,15397.94,
Us leiomyomata ablate >200,0072T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14175.88,,,,,,,fee schedule,3204.65,15397.94,
Us leiomyomata ablate >200,0072T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14217.94,,,,,,,fee schedule,3204.65,15397.94,APC 378
Us leiomyomata ablate >200,0072T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3364.88,,,,,,,fee schedule,3204.65,15397.94,APC
Us leiomyomata ablate >200,0072T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3332.84,,,,,,,fee schedule,3204.65,15397.94,APC
Us leiomyomata ablate >200,0072T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3204.65,,,,,,,fee schedule,3204.65,15397.94,APC
Us leiomyomata ablate >200,0072T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4903.11,,,,,,,fee schedule,3204.65,15397.94,Radiology
Us leiomyomata ablate >200,0072T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4486.51,,,,,,,fee schedule,3204.65,15397.94,APC
Us leiomyomata ablate >200,0072T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5608.14,,,,,,,fee schedule,3204.65,15397.94,APC
Cyp2d6 gen cyp2d6-2d7 hybrid,0072U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1704.44,,,,,,,fee schedule,405.82,1704.44,
Cyp2d6 gen cyp2d6-2d7 hybrid,0072U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1366.26,,,,,,,fee schedule,405.82,1704.44,
Cyp2d6 gen cyp2d6-2d7 hybrid,0072U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1492.51,,,,,,,fee schedule,405.82,1704.44,
Cyp2d6 gen cyp2d6-2d7 hybrid,0072U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1569.17,,,,,,,fee schedule,405.82,1704.44,
Cyp2d6 gen cyp2d6-2d7 hybrid,0072U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,405.82,,,,,,,fee schedule,405.82,1704.44,Laboratory
Cyp2d6 gen cyp2d6-2d7 hybrid,0072U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,473.46,,,,,,,fee schedule,405.82,1704.44,APC
Cyp2d6 gen cyp2d6-2d7 hybrid,0072U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,468.95,,,,,,,fee schedule,405.82,1704.44,APC
Cyp2d6 gen cyp2d6-2d7 hybrid,0072U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,450.91,,,,,,,fee schedule,405.82,1704.44,APC
Cyp2d6 gen cyp2d6-2d7 hybrid,0072U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,689.89,,,,,,,fee schedule,405.82,1704.44,Radiology
Cyp2d6 gen cyp2d6-2d7 hybrid,0072U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,631.27,,,,,,,fee schedule,405.82,1704.44,APC
Cyp2d6 gen cyp2d6-2d7 hybrid,0072U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,789.09,,,,,,,fee schedule,405.82,1704.44,APC
Fee covid-19 vac 8 booster,0073A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,156.95,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 8 booster,0073A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,125.81,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 8 booster,0073A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,137.43,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 8 booster,0073A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,144.49,,,,,,,fee schedule,125.81,156.95,
Cyp2d6 gen cyp2d7-2d6 hybrid,0073U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1704.44,,,,,,,fee schedule,405.82,1704.44,
Cyp2d6 gen cyp2d7-2d6 hybrid,0073U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1366.26,,,,,,,fee schedule,405.82,1704.44,
Cyp2d6 gen cyp2d7-2d6 hybrid,0073U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1492.51,,,,,,,fee schedule,405.82,1704.44,
Cyp2d6 gen cyp2d7-2d6 hybrid,0073U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1569.17,,,,,,,fee schedule,405.82,1704.44,
Cyp2d6 gen cyp2d7-2d6 hybrid,0073U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,405.82,,,,,,,fee schedule,405.82,1704.44,Laboratory
Cyp2d6 gen cyp2d7-2d6 hybrid,0073U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,473.46,,,,,,,fee schedule,405.82,1704.44,APC
Cyp2d6 gen cyp2d7-2d6 hybrid,0073U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,468.95,,,,,,,fee schedule,405.82,1704.44,APC
Cyp2d6 gen cyp2d7-2d6 hybrid,0073U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,450.91,,,,,,,fee schedule,405.82,1704.44,APC
Cyp2d6 gen cyp2d7-2d6 hybrid,0073U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,689.89,,,,,,,fee schedule,405.82,1704.44,Radiology
Cyp2d6 gen cyp2d7-2d6 hybrid,0073U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,631.27,,,,,,,fee schedule,405.82,1704.44,APC
Cyp2d6 gen cyp2d7-2d6 hybrid,0073U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,789.09,,,,,,,fee schedule,405.82,1704.44,APC
Fee covid-19 vac 8 res,0074A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,156.95,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 8 res,0074A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,125.81,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 8 res,0074A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,137.43,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 8 res,0074A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,144.49,,,,,,,fee schedule,125.81,156.95,
Cyp2d6 nonduplicated gene,0074U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1704.44,,,,,,,fee schedule,405.82,1704.44,
Cyp2d6 nonduplicated gene,0074U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1366.26,,,,,,,fee schedule,405.82,1704.44,
Cyp2d6 nonduplicated gene,0074U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1492.51,,,,,,,fee schedule,405.82,1704.44,
Cyp2d6 nonduplicated gene,0074U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1569.17,,,,,,,fee schedule,405.82,1704.44,
Cyp2d6 nonduplicated gene,0074U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,405.82,,,,,,,fee schedule,405.82,1704.44,Laboratory
Cyp2d6 nonduplicated gene,0074U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,473.46,,,,,,,fee schedule,405.82,1704.44,APC
Cyp2d6 nonduplicated gene,0074U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,468.95,,,,,,,fee schedule,405.82,1704.44,APC
Cyp2d6 nonduplicated gene,0074U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,450.91,,,,,,,fee schedule,405.82,1704.44,APC
Cyp2d6 nonduplicated gene,0074U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,689.89,,,,,,,fee schedule,405.82,1704.44,Radiology
Cyp2d6 nonduplicated gene,0074U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,631.27,,,,,,,fee schedule,405.82,1704.44,APC
Cyp2d6 nonduplicated gene,0074U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,789.09,,,,,,,fee schedule,405.82,1704.44,APC
Cyp2d6 5' gene dup/mlt,0075U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1704.44,,,,,,,fee schedule,405.82,1704.44,
Cyp2d6 5' gene dup/mlt,0075U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1366.26,,,,,,,fee schedule,405.82,1704.44,
Cyp2d6 5' gene dup/mlt,0075U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1492.51,,,,,,,fee schedule,405.82,1704.44,
Cyp2d6 5' gene dup/mlt,0075U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1569.17,,,,,,,fee schedule,405.82,1704.44,
Cyp2d6 5' gene dup/mlt,0075U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,405.82,,,,,,,fee schedule,405.82,1704.44,Laboratory
Cyp2d6 5' gene dup/mlt,0075U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,473.46,,,,,,,fee schedule,405.82,1704.44,APC
Cyp2d6 5' gene dup/mlt,0075U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,468.95,,,,,,,fee schedule,405.82,1704.44,APC
Cyp2d6 5' gene dup/mlt,0075U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,450.91,,,,,,,fee schedule,405.82,1704.44,APC
Cyp2d6 5' gene dup/mlt,0075U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,689.89,,,,,,,fee schedule,405.82,1704.44,Radiology
Cyp2d6 5' gene dup/mlt,0075U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,631.27,,,,,,,fee schedule,405.82,1704.44,APC
Cyp2d6 5' gene dup/mlt,0075U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,789.09,,,,,,,fee schedule,405.82,1704.44,APC
Cyp2d6 3' gene dup/mlt,0076U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1704.44,,,,,,,fee schedule,405.82,1704.44,
Cyp2d6 3' gene dup/mlt,0076U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1366.26,,,,,,,fee schedule,405.82,1704.44,
Cyp2d6 3' gene dup/mlt,0076U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1492.51,,,,,,,fee schedule,405.82,1704.44,
Cyp2d6 3' gene dup/mlt,0076U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1569.17,,,,,,,fee schedule,405.82,1704.44,
Cyp2d6 3' gene dup/mlt,0076U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,405.82,,,,,,,fee schedule,405.82,1704.44,Laboratory
Cyp2d6 3' gene dup/mlt,0076U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,473.46,,,,,,,fee schedule,405.82,1704.44,APC
Cyp2d6 3' gene dup/mlt,0076U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,468.95,,,,,,,fee schedule,405.82,1704.44,APC
Cyp2d6 3' gene dup/mlt,0076U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,450.91,,,,,,,fee schedule,405.82,1704.44,APC
Cyp2d6 3' gene dup/mlt,0076U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,689.89,,,,,,,fee schedule,405.82,1704.44,Radiology
Cyp2d6 3' gene dup/mlt,0076U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,631.27,,,,,,,fee schedule,405.82,1704.44,APC
Cyp2d6 3' gene dup/mlt,0076U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,789.09,,,,,,,fee schedule,405.82,1704.44,APC
Ig paraprotein qual bld/ur,0077U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,39.09,,,,,,,fee schedule,39.09,76,Laboratory
Ig paraprotein qual bld/ur,0077U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,45.6,,,,,,,fee schedule,39.09,76,APC
Ig paraprotein qual bld/ur,0077U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,45.17,,,,,,,fee schedule,39.09,76,APC
Ig paraprotein qual bld/ur,0077U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,43.43,,,,,,,fee schedule,39.09,76,APC
Ig paraprotein qual bld/ur,0077U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,66.45,,,,,,,fee schedule,39.09,76,Radiology
Ig paraprotein qual bld/ur,0077U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,60.8,,,,,,,fee schedule,39.09,76,APC
Ig paraprotein qual bld/ur,0077U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,76,,,,,,,fee schedule,39.09,76,APC
Onc lng 5 clin rsk factr alg,0080U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13305.6,,,,,,,fee schedule,3168,13305.6,
Onc lng 5 clin rsk factr alg,0080U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10665.6,,,,,,,fee schedule,3168,13305.6,
Onc lng 5 clin rsk factr alg,0080U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11651.2,,,,,,,fee schedule,3168,13305.6,
Onc lng 5 clin rsk factr alg,0080U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12249.6,,,,,,,fee schedule,3168,13305.6,
Onc lng 5 clin rsk factr alg,0080U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3168,,,,,,,fee schedule,3168,13305.6,Laboratory
Onc lng 5 clin rsk factr alg,0080U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3696,,,,,,,fee schedule,3168,13305.6,APC
Onc lng 5 clin rsk factr alg,0080U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3660.8,,,,,,,fee schedule,3168,13305.6,APC
Onc lng 5 clin rsk factr alg,0080U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3520,,,,,,,fee schedule,3168,13305.6,APC
Onc lng 5 clin rsk factr alg,0080U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5385.6,,,,,,,fee schedule,3168,13305.6,Radiology
Onc lng 5 clin rsk factr alg,0080U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4928,,,,,,,fee schedule,3168,13305.6,APC
Onc lng 5 clin rsk factr alg,0080U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6160,,,,,,,fee schedule,3168,13305.6,APC
Fee covid-19 vac 9 dose 1,0081A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,156.95,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 9 dose 1,0081A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,125.81,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 9 dose 1,0081A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,137.43,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 9 dose 1,0081A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,144.49,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 9 dose 2,0082A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,156.95,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 9 dose 2,0082A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,125.81,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 9 dose 2,0082A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,137.43,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 9 dose 2,0082A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,144.49,,,,,,,fee schedule,125.81,156.95,
Rx test def 90+ rx/sbsts ur,0082U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,933.36,,,,,,,fee schedule,222.23,933.36,
Rx test def 90+ rx/sbsts ur,0082U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,748.17,,,,,,,fee schedule,222.23,933.36,
Rx test def 90+ rx/sbsts ur,0082U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,817.31,,,,,,,fee schedule,222.23,933.36,
Rx test def 90+ rx/sbsts ur,0082U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,859.28,,,,,,,fee schedule,222.23,933.36,
Rx test def 90+ rx/sbsts ur,0082U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,222.23,,,,,,,fee schedule,222.23,933.36,Laboratory
Rx test def 90+ rx/sbsts ur,0082U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,259.27,,,,,,,fee schedule,222.23,933.36,APC
Rx test def 90+ rx/sbsts ur,0082U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,256.8,,,,,,,fee schedule,222.23,933.36,APC
Rx test def 90+ rx/sbsts ur,0082U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,246.92,,,,,,,fee schedule,222.23,933.36,APC
Rx test def 90+ rx/sbsts ur,0082U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,377.79,,,,,,,fee schedule,222.23,933.36,Radiology
Rx test def 90+ rx/sbsts ur,0082U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,345.69,,,,,,,fee schedule,222.23,933.36,APC
Rx test def 90+ rx/sbsts ur,0082U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,432.11,,,,,,,fee schedule,222.23,933.36,APC
Fee covid-19 vac 9 booster,0083A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,156.95,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 9 booster,0083A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,125.81,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 9 booster,0083A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,137.43,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 9 booster,0083A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,144.49,,,,,,,fee schedule,125.81,156.95,
Onc rspse chemo cntrst tomog,0083U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,150.62,,,,,,,fee schedule,150.62,292.86,Laboratory
Onc rspse chemo cntrst tomog,0083U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,175.72,,,,,,,fee schedule,150.62,292.86,APC
Onc rspse chemo cntrst tomog,0083U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,174.04,,,,,,,fee schedule,150.62,292.86,APC
Onc rspse chemo cntrst tomog,0083U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,167.35,,,,,,,fee schedule,150.62,292.86,APC
Onc rspse chemo cntrst tomog,0083U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,256.05,,,,,,,fee schedule,150.62,292.86,Radiology
Onc rspse chemo cntrst tomog,0083U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,234.29,,,,,,,fee schedule,150.62,292.86,APC
Onc rspse chemo cntrst tomog,0083U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,292.86,,,,,,,fee schedule,150.62,292.86,APC
Rbc dna gnotyp 10 bld groups,0084U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2721.6,,,,,,,fee schedule,648,2721.6,
Rbc dna gnotyp 10 bld groups,0084U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2181.6,,,,,,,fee schedule,648,2721.6,
Rbc dna gnotyp 10 bld groups,0084U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2383.2,,,,,,,fee schedule,648,2721.6,
Rbc dna gnotyp 10 bld groups,0084U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2505.6,,,,,,,fee schedule,648,2721.6,
Rbc dna gnotyp 10 bld groups,0084U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,648,,,,,,,fee schedule,648,2721.6,Laboratory
Rbc dna gnotyp 10 bld groups,0084U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,756,,,,,,,fee schedule,648,2721.6,APC
Rbc dna gnotyp 10 bld groups,0084U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,748.8,,,,,,,fee schedule,648,2721.6,APC
Rbc dna gnotyp 10 bld groups,0084U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,720,,,,,,,fee schedule,648,2721.6,APC
Rbc dna gnotyp 10 bld groups,0084U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1101.6,,,,,,,fee schedule,648,2721.6,Radiology
Rbc dna gnotyp 10 bld groups,0084U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1008,,,,,,,fee schedule,648,2721.6,APC
Rbc dna gnotyp 10 bld groups,0084U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1260,,,,,,,fee schedule,648,2721.6,APC
Nfct ds bact&fng org id 6+,0086U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,180,,,,,,,fee schedule,180,350,Laboratory
Nfct ds bact&fng org id 6+,0086U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,210,,,,,,,fee schedule,180,350,APC
Nfct ds bact&fng org id 6+,0086U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,208,,,,,,,fee schedule,180,350,APC
Nfct ds bact&fng org id 6+,0086U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,200,,,,,,,fee schedule,180,350,APC
Nfct ds bact&fng org id 6+,0086U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,306,,,,,,,fee schedule,180,350,Radiology
Nfct ds bact&fng org id 6+,0086U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,280,,,,,,,fee schedule,180,350,APC
Nfct ds bact&fng org id 6+,0086U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,350,,,,,,,fee schedule,180,350,APC
Crd hrt trnspl mrna 1283 gen,0087U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2843.48,,,,,,,fee schedule,2843.48,5528.98,Laboratory
Crd hrt trnspl mrna 1283 gen,0087U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3317.39,,,,,,,fee schedule,2843.48,5528.98,APC
Crd hrt trnspl mrna 1283 gen,0087U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3285.8,,,,,,,fee schedule,2843.48,5528.98,APC
Crd hrt trnspl mrna 1283 gen,0087U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3159.42,,,,,,,fee schedule,2843.48,5528.98,APC
Crd hrt trnspl mrna 1283 gen,0087U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4833.91,,,,,,,fee schedule,2843.48,5528.98,Radiology
Crd hrt trnspl mrna 1283 gen,0087U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4423.19,,,,,,,fee schedule,2843.48,5528.98,APC
Crd hrt trnspl mrna 1283 gen,0087U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5528.98,,,,,,,fee schedule,2843.48,5528.98,APC
Trnsplj kdn algrft rej 1494,0088U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2843.48,,,,,,,fee schedule,2843.48,5528.98,Laboratory
Trnsplj kdn algrft rej 1494,0088U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3317.39,,,,,,,fee schedule,2843.48,5528.98,APC
Trnsplj kdn algrft rej 1494,0088U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3285.8,,,,,,,fee schedule,2843.48,5528.98,APC
Trnsplj kdn algrft rej 1494,0088U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3159.42,,,,,,,fee schedule,2843.48,5528.98,APC
Trnsplj kdn algrft rej 1494,0088U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4833.91,,,,,,,fee schedule,2843.48,5528.98,Radiology
Trnsplj kdn algrft rej 1494,0088U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4423.19,,,,,,,fee schedule,2843.48,5528.98,APC
Trnsplj kdn algrft rej 1494,0088U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5528.98,,,,,,,fee schedule,2843.48,5528.98,APC
Onc mlnma prame & linc00518,0089U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2872.8,,,,,,,fee schedule,684,2872.8,
Onc mlnma prame & linc00518,0089U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2302.8,,,,,,,fee schedule,684,2872.8,
Onc mlnma prame & linc00518,0089U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2515.6,,,,,,,fee schedule,684,2872.8,
Onc mlnma prame & linc00518,0089U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2644.8,,,,,,,fee schedule,684,2872.8,
Onc mlnma prame & linc00518,0089U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,684,,,,,,,fee schedule,684,2872.8,Laboratory
Onc mlnma prame & linc00518,0089U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,798,,,,,,,fee schedule,684,2872.8,APC
Onc mlnma prame & linc00518,0089U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,790.4,,,,,,,fee schedule,684,2872.8,APC
Onc mlnma prame & linc00518,0089U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,760,,,,,,,fee schedule,684,2872.8,APC
Onc mlnma prame & linc00518,0089U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1162.8,,,,,,,fee schedule,684,2872.8,Radiology
Onc mlnma prame & linc00518,0089U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1064,,,,,,,fee schedule,684,2872.8,APC
Onc mlnma prame & linc00518,0089U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1330,,,,,,,fee schedule,684,2872.8,APC
Onc cutan mlnma mrna 23 gene,0090U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7371,,,,,,,fee schedule,1755,7371,
Onc cutan mlnma mrna 23 gene,0090U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5908.5,,,,,,,fee schedule,1755,7371,
Onc cutan mlnma mrna 23 gene,0090U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6454.5,,,,,,,fee schedule,1755,7371,
Onc cutan mlnma mrna 23 gene,0090U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6786,,,,,,,fee schedule,1755,7371,
Onc cutan mlnma mrna 23 gene,0090U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755,,,,,,,fee schedule,1755,7371,Laboratory
Onc cutan mlnma mrna 23 gene,0090U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2047.5,,,,,,,fee schedule,1755,7371,APC
Onc cutan mlnma mrna 23 gene,0090U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2028,,,,,,,fee schedule,1755,7371,APC
Onc cutan mlnma mrna 23 gene,0090U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1950,,,,,,,fee schedule,1755,7371,APC
Onc cutan mlnma mrna 23 gene,0090U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2983.5,,,,,,,fee schedule,1755,7371,Radiology
Onc cutan mlnma mrna 23 gene,0090U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2730,,,,,,,fee schedule,1755,7371,APC
Onc cutan mlnma mrna 23 gene,0090U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3412.5,,,,,,,fee schedule,1755,7371,APC
Fee covid-19 vac 10 dose 1,0091A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,156.95,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 10 dose 1,0091A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,125.81,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 10 dose 1,0091A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,137.43,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 10 dose 1,0091A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,144.49,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 10 dose 2,0092A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,156.95,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 10 dose 2,0092A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,125.81,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 10 dose 2,0092A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,137.43,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 10 dose 2,0092A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,144.49,,,,,,,fee schedule,125.81,156.95,
Onc lng 3 prtn bmrk plsm alg,0092U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2239.2,,,,,,,fee schedule,2239.2,4354,Laboratory
Onc lng 3 prtn bmrk plsm alg,0092U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2612.4,,,,,,,fee schedule,2239.2,4354,APC
Onc lng 3 prtn bmrk plsm alg,0092U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2587.52,,,,,,,fee schedule,2239.2,4354,APC
Onc lng 3 prtn bmrk plsm alg,0092U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2488,,,,,,,fee schedule,2239.2,4354,APC
Onc lng 3 prtn bmrk plsm alg,0092U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3806.64,,,,,,,fee schedule,2239.2,4354,Radiology
Onc lng 3 prtn bmrk plsm alg,0092U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3483.2,,,,,,,fee schedule,2239.2,4354,APC
Onc lng 3 prtn bmrk plsm alg,0092U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4354,,,,,,,fee schedule,2239.2,4354,APC
Fee covid-19 vac 10 booster,0093A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,156.95,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 10 booster,0093A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,125.81,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 10 booster,0093A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,137.43,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 10 booster,0093A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,144.49,,,,,,,fee schedule,125.81,156.95,
Rx mntr 65 com drugs urine,0093U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,234.89,,,,,,,fee schedule,55.93,234.89,
Rx mntr 65 com drugs urine,0093U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,188.28,,,,,,,fee schedule,55.93,234.89,
Rx mntr 65 com drugs urine,0093U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,205.68,,,,,,,fee schedule,55.93,234.89,
Rx mntr 65 com drugs urine,0093U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,216.25,,,,,,,fee schedule,55.93,234.89,
Rx mntr 65 com drugs urine,0093U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,55.93,,,,,,,fee schedule,55.93,234.89,Laboratory
Rx mntr 65 com drugs urine,0093U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,65.25,,,,,,,fee schedule,55.93,234.89,APC
Rx mntr 65 com drugs urine,0093U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,64.63,,,,,,,fee schedule,55.93,234.89,APC
Rx mntr 65 com drugs urine,0093U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,62.14,,,,,,,fee schedule,55.93,234.89,APC
Rx mntr 65 com drugs urine,0093U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,95.07,,,,,,,fee schedule,55.93,234.89,Radiology
Rx mntr 65 com drugs urine,0093U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,87,,,,,,,fee schedule,55.93,234.89,APC
Rx mntr 65 com drugs urine,0093U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,108.74,,,,,,,fee schedule,55.93,234.89,APC
Fee covid-19 vac 10 res,0094A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,156.95,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 10 res,0094A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,125.81,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 10 res,0094A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,137.43,,,,,,,fee schedule,125.81,156.95,
Fee covid-19 vac 10 res,0094A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,144.49,,,,,,,fee schedule,125.81,156.95,
Genome rapid sequence alys,0094U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6823.98,,,,,,,fee schedule,6823.98,13268.85,Laboratory
Genome rapid sequence alys,0094U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7961.31,,,,,,,fee schedule,6823.98,13268.85,APC
Genome rapid sequence alys,0094U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7885.49,,,,,,,fee schedule,6823.98,13268.85,APC
Genome rapid sequence alys,0094U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7582.2,,,,,,,fee schedule,6823.98,13268.85,APC
Genome rapid sequence alys,0094U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11600.77,,,,,,,fee schedule,6823.98,13268.85,Radiology
Genome rapid sequence alys,0094U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10615.08,,,,,,,fee schedule,6823.98,13268.85,APC
Genome rapid sequence alys,0094U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,13268.85,,,,,,,fee schedule,6823.98,13268.85,APC
Inflm ee elisa alys alg,0095U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,694.78,,,,,,,fee schedule,694.78,1350.96,Laboratory
Inflm ee elisa alys alg,0095U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,810.58,,,,,,,fee schedule,694.78,1350.96,APC
Inflm ee elisa alys alg,0095U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,802.86,,,,,,,fee schedule,694.78,1350.96,APC
Inflm ee elisa alys alg,0095U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,771.98,,,,,,,fee schedule,694.78,1350.96,APC
Inflm ee elisa alys alg,0095U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1181.13,,,,,,,fee schedule,694.78,1350.96,Radiology
Inflm ee elisa alys alg,0095U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1080.77,,,,,,,fee schedule,694.78,1350.96,APC
Inflm ee elisa alys alg,0095U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1350.96,,,,,,,fee schedule,694.78,1350.96,APC
Hpv hi risk types male urine,0096U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,132.64,,,,,,,fee schedule,31.58,132.64,
Hpv hi risk types male urine,0096U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,106.32,,,,,,,fee schedule,31.58,132.64,
Hpv hi risk types male urine,0096U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,116.15,,,,,,,fee schedule,31.58,132.64,
Hpv hi risk types male urine,0096U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,122.11,,,,,,,fee schedule,31.58,132.64,
Hpv hi risk types male urine,0096U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31.58,,,,,,,fee schedule,31.58,132.64,Laboratory
Hpv hi risk types male urine,0096U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,31.58,132.64,APC
Hpv hi risk types male urine,0096U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,36.49,,,,,,,fee schedule,31.58,132.64,APC
Hpv hi risk types male urine,0096U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,35.09,,,,,,,fee schedule,31.58,132.64,APC
Hpv hi risk types male urine,0096U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,53.69,,,,,,,fee schedule,31.58,132.64,Radiology
Hpv hi risk types male urine,0096U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49.13,,,,,,,fee schedule,31.58,132.64,APC
Hpv hi risk types male urine,0096U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,61.41,,,,,,,fee schedule,31.58,132.64,APC
Prosth Retina Receive&Gen,0100T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9286.14,,,,,,,fee schedule,7443.65,9286.14,
Prosth Retina Receive&Gen,0100T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7443.65,,,,,,,fee schedule,7443.65,9286.14,
Prosth Retina Receive&Gen,0100T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8131.51,,,,,,,fee schedule,7443.65,9286.14,
Prosth Retina Receive&Gen,0100T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8549.14,,,,,,,fee schedule,7443.65,9286.14,
Extracorp shockwv tx hi enrg,0101T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,244.19,7285.12,
Extracorp shockwv tx hi enrg,0101T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,244.19,7285.12,
Extracorp shockwv tx hi enrg,0101T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,244.19,7285.12,
Extracorp shockwv tx hi enrg,0101T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,244.19,7285.12,
Extracorp shockwv tx hi enrg,0101T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,7285.12,APC 378
Extracorp shockwv tx hi enrg,0101T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,7285.12,APC
Extracorp shockwv tx hi enrg,0101T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,7285.12,APC
Extracorp shockwv tx hi enrg,0101T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,7285.12,APC
Extracorp shockwv tx hi enrg,0101T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,7285.12,Radiology
Extracorp shockwv tx hi enrg,0101T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,7285.12,APC
Extracorp shockwv tx hi enrg,0101T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,7285.12,APC
Hered colon ca do 15 genes,0101U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4421.84,,,,,,,fee schedule,1569.56,4421.84,
Hered colon ca do 15 genes,0101U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3544.49,,,,,,,fee schedule,1569.56,4421.84,
Hered colon ca do 15 genes,0101U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3872.04,,,,,,,fee schedule,1569.56,4421.84,
Hered colon ca do 15 genes,0101U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4070.9,,,,,,,fee schedule,1569.56,4421.84,
Hered colon ca do 15 genes,0101U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1569.56,,,,,,,fee schedule,1569.56,4421.84,Laboratory
Hered colon ca do 15 genes,0101U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1831.15,,,,,,,fee schedule,1569.56,4421.84,APC
Hered colon ca do 15 genes,0101U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1813.71,,,,,,,fee schedule,1569.56,4421.84,APC
Hered colon ca do 15 genes,0101U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1743.95,,,,,,,fee schedule,1569.56,4421.84,APC
Hered colon ca do 15 genes,0101U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2668.24,,,,,,,fee schedule,1569.56,4421.84,Radiology
Hered colon ca do 15 genes,0101U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2441.53,,,,,,,fee schedule,1569.56,4421.84,APC
Hered colon ca do 15 genes,0101U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3051.91,,,,,,,fee schedule,1569.56,4421.84,APC
Extracorp shockwv tx anesth,0102T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,3239.17,14371.12,
Extracorp shockwv tx anesth,0102T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,3239.17,14371.12,
Extracorp shockwv tx anesth,0102T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,3239.17,14371.12,
Extracorp shockwv tx anesth,0102T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,3239.17,14371.12,
Extracorp shockwv tx anesth,0102T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Extracorp shockwv tx anesth,0102T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Extracorp shockwv tx anesth,0102T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Extracorp shockwv tx anesth,0102T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Extracorp shockwv tx anesth,0102T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Extracorp shockwv tx anesth,0102T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Extracorp shockwv tx anesth,0102T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Hered brst ca rltd do 17 gen,0102U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4225.96,,,,,,,fee schedule,1173.56,4225.96,
Hered brst ca rltd do 17 gen,0102U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3387.48,,,,,,,fee schedule,1173.56,4225.96,
Hered brst ca rltd do 17 gen,0102U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3700.51,,,,,,,fee schedule,1173.56,4225.96,
Hered brst ca rltd do 17 gen,0102U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3890.57,,,,,,,fee schedule,1173.56,4225.96,
Hered brst ca rltd do 17 gen,0102U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1173.56,,,,,,,fee schedule,1173.56,4225.96,Laboratory
Hered brst ca rltd do 17 gen,0102U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1369.15,,,,,,,fee schedule,1173.56,4225.96,APC
Hered brst ca rltd do 17 gen,0102U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1356.11,,,,,,,fee schedule,1173.56,4225.96,APC
Hered brst ca rltd do 17 gen,0102U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1303.95,,,,,,,fee schedule,1173.56,4225.96,APC
Hered brst ca rltd do 17 gen,0102U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1995.04,,,,,,,fee schedule,1173.56,4225.96,Radiology
Hered brst ca rltd do 17 gen,0102U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1825.53,,,,,,,fee schedule,1173.56,4225.96,APC
Hered brst ca rltd do 17 gen,0102U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2281.91,,,,,,,fee schedule,1173.56,4225.96,APC
Hered ova ca pnl 24 genes,0103U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4225.96,,,,,,,fee schedule,1569.56,4225.96,
Hered ova ca pnl 24 genes,0103U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3387.48,,,,,,,fee schedule,1569.56,4225.96,
Hered ova ca pnl 24 genes,0103U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3700.51,,,,,,,fee schedule,1569.56,4225.96,
Hered ova ca pnl 24 genes,0103U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3890.57,,,,,,,fee schedule,1569.56,4225.96,
Hered ova ca pnl 24 genes,0103U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1569.56,,,,,,,fee schedule,1569.56,4225.96,Laboratory
Hered ova ca pnl 24 genes,0103U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1831.15,,,,,,,fee schedule,1569.56,4225.96,APC
Hered ova ca pnl 24 genes,0103U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1813.71,,,,,,,fee schedule,1569.56,4225.96,APC
Hered ova ca pnl 24 genes,0103U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1743.95,,,,,,,fee schedule,1569.56,4225.96,APC
Hered ova ca pnl 24 genes,0103U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2668.24,,,,,,,fee schedule,1569.56,4225.96,Radiology
Hered ova ca pnl 24 genes,0103U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2441.53,,,,,,,fee schedule,1569.56,4225.96,APC
Hered ova ca pnl 24 genes,0103U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3051.91,,,,,,,fee schedule,1569.56,4225.96,APC
Neph ckd mult eclia tum nec,0105U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3591,,,,,,,fee schedule,855,3591,
Neph ckd mult eclia tum nec,0105U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2878.5,,,,,,,fee schedule,855,3591,
Neph ckd mult eclia tum nec,0105U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3144.5,,,,,,,fee schedule,855,3591,
Neph ckd mult eclia tum nec,0105U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3306,,,,,,,fee schedule,855,3591,
Neph ckd mult eclia tum nec,0105U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,855,,,,,,,fee schedule,855,3591,Laboratory
Neph ckd mult eclia tum nec,0105U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,997.5,,,,,,,fee schedule,855,3591,APC
Neph ckd mult eclia tum nec,0105U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,988,,,,,,,fee schedule,855,3591,APC
Neph ckd mult eclia tum nec,0105U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,950,,,,,,,fee schedule,855,3591,APC
Neph ckd mult eclia tum nec,0105U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1453.5,,,,,,,fee schedule,855,3591,Radiology
Neph ckd mult eclia tum nec,0105U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1330,,,,,,,fee schedule,855,3591,APC
Neph ckd mult eclia tum nec,0105U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1662.5,,,,,,,fee schedule,855,3591,APC
Touch Quant Sensory Test,0106T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21.09,,,,,,,fee schedule,16.91,164.05,
Touch Quant Sensory Test,0106T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.91,,,,,,,fee schedule,16.91,164.05,
Touch Quant Sensory Test,0106T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18.47,,,,,,,fee schedule,16.91,164.05,
Touch Quant Sensory Test,0106T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19.42,,,,,,,fee schedule,16.91,164.05,
Touch Quant Sensory Test,0106T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.05,,,,,,,fee schedule,16.91,164.05,APC 378
Touch Quant Sensory Test,0106T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.83,,,,,,,fee schedule,16.91,164.05,APC
Touch Quant Sensory Test,0106T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.46,,,,,,,fee schedule,16.91,164.05,APC
Touch Quant Sensory Test,0106T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.98,,,,,,,fee schedule,16.91,164.05,APC
Touch Quant Sensory Test,0106T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.57,,,,,,,fee schedule,16.91,164.05,Radiology
Touch Quant Sensory Test,0106T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.77,,,,,,,fee schedule,16.91,164.05,APC
Touch Quant Sensory Test,0106T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.71,,,,,,,fee schedule,16.91,164.05,APC
Gstr emptg 7 timed brth spec,0106U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,787.04,,,,,,,fee schedule,787.04,1530.36,Laboratory
Gstr emptg 7 timed brth spec,0106U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,918.21,,,,,,,fee schedule,787.04,1530.36,APC
Gstr emptg 7 timed brth spec,0106U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,909.47,,,,,,,fee schedule,787.04,1530.36,APC
Gstr emptg 7 timed brth spec,0106U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,874.49,,,,,,,fee schedule,787.04,1530.36,APC
Gstr emptg 7 timed brth spec,0106U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1337.97,,,,,,,fee schedule,787.04,1530.36,Radiology
Gstr emptg 7 timed brth spec,0106U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1224.29,,,,,,,fee schedule,787.04,1530.36,APC
Gstr emptg 7 timed brth spec,0106U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1530.36,,,,,,,fee schedule,787.04,1530.36,APC
Vibrate Quant Sensory Test,0107T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21.09,,,,,,,fee schedule,16.91,164.05,
Vibrate Quant Sensory Test,0107T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.91,,,,,,,fee schedule,16.91,164.05,
Vibrate Quant Sensory Test,0107T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18.47,,,,,,,fee schedule,16.91,164.05,
Vibrate Quant Sensory Test,0107T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19.42,,,,,,,fee schedule,16.91,164.05,
Vibrate Quant Sensory Test,0107T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.05,,,,,,,fee schedule,16.91,164.05,APC 378
Vibrate Quant Sensory Test,0107T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.83,,,,,,,fee schedule,16.91,164.05,APC
Vibrate Quant Sensory Test,0107T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.46,,,,,,,fee schedule,16.91,164.05,APC
Vibrate Quant Sensory Test,0107T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.98,,,,,,,fee schedule,16.91,164.05,APC
Vibrate Quant Sensory Test,0107T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.57,,,,,,,fee schedule,16.91,164.05,Radiology
Vibrate Quant Sensory Test,0107T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.77,,,,,,,fee schedule,16.91,164.05,APC
Vibrate Quant Sensory Test,0107T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.71,,,,,,,fee schedule,16.91,164.05,APC
C diff tox ag detcj ia stool,0107U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.48,,,,,,,fee schedule,14.4,60.48,
C diff tox ag detcj ia stool,0107U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48.48,,,,,,,fee schedule,14.4,60.48,
C diff tox ag detcj ia stool,0107U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52.96,,,,,,,fee schedule,14.4,60.48,
C diff tox ag detcj ia stool,0107U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55.68,,,,,,,fee schedule,14.4,60.48,
C diff tox ag detcj ia stool,0107U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.4,,,,,,,fee schedule,14.4,60.48,Laboratory
C diff tox ag detcj ia stool,0107U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.8,,,,,,,fee schedule,14.4,60.48,APC
C diff tox ag detcj ia stool,0107U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,16.64,,,,,,,fee schedule,14.4,60.48,APC
C diff tox ag detcj ia stool,0107U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16,,,,,,,fee schedule,14.4,60.48,APC
C diff tox ag detcj ia stool,0107U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24.48,,,,,,,fee schedule,14.4,60.48,Radiology
C diff tox ag detcj ia stool,0107U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.4,,,,,,,fee schedule,14.4,60.48,APC
C diff tox ag detcj ia stool,0107U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,28,,,,,,,fee schedule,14.4,60.48,APC
Cool Quant Sensory Test,0108T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21.09,,,,,,,fee schedule,16.91,259.1,
Cool Quant Sensory Test,0108T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.91,,,,,,,fee schedule,16.91,259.1,
Cool Quant Sensory Test,0108T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18.47,,,,,,,fee schedule,16.91,259.1,
Cool Quant Sensory Test,0108T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19.42,,,,,,,fee schedule,16.91,259.1,
Cool Quant Sensory Test,0108T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,16.91,259.1,APC 378
Cool Quant Sensory Test,0108T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,16.91,259.1,APC
Cool Quant Sensory Test,0108T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,16.91,259.1,APC
Cool Quant Sensory Test,0108T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,16.91,259.1,APC
Cool Quant Sensory Test,0108T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,16.91,259.1,Radiology
Cool Quant Sensory Test,0108T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,16.91,259.1,APC
Cool Quant Sensory Test,0108T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,16.91,259.1,APC
Gi barrett esoph 9 prtn bmrk,0108U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4455,,,,,,,fee schedule,4455,8662.5,Laboratory
Gi barrett esoph 9 prtn bmrk,0108U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5197.5,,,,,,,fee schedule,4455,8662.5,APC
Gi barrett esoph 9 prtn bmrk,0108U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5148,,,,,,,fee schedule,4455,8662.5,APC
Gi barrett esoph 9 prtn bmrk,0108U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4950,,,,,,,fee schedule,4455,8662.5,APC
Gi barrett esoph 9 prtn bmrk,0108U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7573.5,,,,,,,fee schedule,4455,8662.5,Radiology
Gi barrett esoph 9 prtn bmrk,0108U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6930,,,,,,,fee schedule,4455,8662.5,APC
Gi barrett esoph 9 prtn bmrk,0108U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8662.5,,,,,,,fee schedule,4455,8662.5,APC
Heat Quant Sensory Test,0109T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21.09,,,,,,,fee schedule,16.91,164.05,
Heat Quant Sensory Test,0109T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.91,,,,,,,fee schedule,16.91,164.05,
Heat Quant Sensory Test,0109T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18.47,,,,,,,fee schedule,16.91,164.05,
Heat Quant Sensory Test,0109T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19.42,,,,,,,fee schedule,16.91,164.05,
Heat Quant Sensory Test,0109T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.05,,,,,,,fee schedule,16.91,164.05,APC 378
Heat Quant Sensory Test,0109T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.83,,,,,,,fee schedule,16.91,164.05,APC
Heat Quant Sensory Test,0109T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.46,,,,,,,fee schedule,16.91,164.05,APC
Heat Quant Sensory Test,0109T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.98,,,,,,,fee schedule,16.91,164.05,APC
Heat Quant Sensory Test,0109T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.57,,,,,,,fee schedule,16.91,164.05,Radiology
Heat Quant Sensory Test,0109T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.77,,,,,,,fee schedule,16.91,164.05,APC
Heat Quant Sensory Test,0109T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.71,,,,,,,fee schedule,16.91,164.05,APC
Id aspergillus dna 4 species,0109U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,539.14,,,,,,,fee schedule,128.37,539.14,
Id aspergillus dna 4 species,0109U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,432.17,,,,,,,fee schedule,128.37,539.14,
Id aspergillus dna 4 species,0109U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,472.11,,,,,,,fee schedule,128.37,539.14,
Id aspergillus dna 4 species,0109U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,496.35,,,,,,,fee schedule,128.37,539.14,
Id aspergillus dna 4 species,0109U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,128.37,,,,,,,fee schedule,128.37,539.14,Laboratory
Id aspergillus dna 4 species,0109U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,149.76,,,,,,,fee schedule,128.37,539.14,APC
Id aspergillus dna 4 species,0109U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,148.34,,,,,,,fee schedule,128.37,539.14,APC
Id aspergillus dna 4 species,0109U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,142.63,,,,,,,fee schedule,128.37,539.14,APC
Id aspergillus dna 4 species,0109U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,218.22,,,,,,,fee schedule,128.37,539.14,Radiology
Id aspergillus dna 4 species,0109U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,199.68,,,,,,,fee schedule,128.37,539.14,APC
Id aspergillus dna 4 species,0109U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,249.6,,,,,,,fee schedule,128.37,539.14,APC
Nos Quant Sensory Test,0110T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21.09,,,,,,,fee schedule,16.91,584.37,
Nos Quant Sensory Test,0110T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.91,,,,,,,fee schedule,16.91,584.37,
Nos Quant Sensory Test,0110T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18.47,,,,,,,fee schedule,16.91,584.37,
Nos Quant Sensory Test,0110T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19.42,,,,,,,fee schedule,16.91,584.37,
Nos Quant Sensory Test,0110T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,16.91,584.37,APC 378
Nos Quant Sensory Test,0110T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,16.91,584.37,APC
Nos Quant Sensory Test,0110T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,16.91,584.37,APC
Nos Quant Sensory Test,0110T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,16.91,584.37,APC
Nos Quant Sensory Test,0110T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,16.91,584.37,Radiology
Nos Quant Sensory Test,0110T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,16.91,584.37,APC
Nos Quant Sensory Test,0110T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,16.91,584.37,APC
Rx mntr 1+oral onc rx&sbsts,0110U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,102.48,,,,,,,fee schedule,24.4,102.48,
Rx mntr 1+oral onc rx&sbsts,0110U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,82.14,,,,,,,fee schedule,24.4,102.48,
Rx mntr 1+oral onc rx&sbsts,0110U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,89.73,,,,,,,fee schedule,24.4,102.48,
Rx mntr 1+oral onc rx&sbsts,0110U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,94.34,,,,,,,fee schedule,24.4,102.48,
Rx mntr 1+oral onc rx&sbsts,0110U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24.4,,,,,,,fee schedule,24.4,102.48,Laboratory
Rx mntr 1+oral onc rx&sbsts,0110U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,28.47,,,,,,,fee schedule,24.4,102.48,APC
Rx mntr 1+oral onc rx&sbsts,0110U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,28.19,,,,,,,fee schedule,24.4,102.48,APC
Rx mntr 1+oral onc rx&sbsts,0110U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,27.11,,,,,,,fee schedule,24.4,102.48,APC
Rx mntr 1+oral onc rx&sbsts,0110U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,41.48,,,,,,,fee schedule,24.4,102.48,Radiology
Rx mntr 1+oral onc rx&sbsts,0110U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,37.95,,,,,,,fee schedule,24.4,102.48,APC
Rx mntr 1+oral onc rx&sbsts,0110U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,47.44,,,,,,,fee schedule,24.4,102.48,APC
Adm sarscov2 25mcg/0.25ml1st,0111A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,151.2,,,,,,,fee schedule,121.2,151.2,
Adm sarscov2 25mcg/0.25ml1st,0111A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,121.2,,,,,,,fee schedule,121.2,151.2,
Adm sarscov2 25mcg/0.25ml1st,0111A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,132.4,,,,,,,fee schedule,121.2,151.2,
Adm sarscov2 25mcg/0.25ml1st,0111A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,139.2,,,,,,,fee schedule,121.2,151.2,
Onc colon ca kras&nras alys,0111U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2579.06,,,,,,,fee schedule,614.06,2579.06,
Onc colon ca kras&nras alys,0111U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2067.34,,,,,,,fee schedule,614.06,2579.06,
Onc colon ca kras&nras alys,0111U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2258.38,,,,,,,fee schedule,614.06,2579.06,
Onc colon ca kras&nras alys,0111U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2374.37,,,,,,,fee schedule,614.06,2579.06,
Onc colon ca kras&nras alys,0111U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,614.06,,,,,,,fee schedule,614.06,2579.06,Laboratory
Onc colon ca kras&nras alys,0111U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,716.4,,,,,,,fee schedule,614.06,2579.06,APC
Onc colon ca kras&nras alys,0111U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,709.58,,,,,,,fee schedule,614.06,2579.06,APC
Onc colon ca kras&nras alys,0111U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,682.29,,,,,,,fee schedule,614.06,2579.06,APC
Onc colon ca kras&nras alys,0111U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1043.9,,,,,,,fee schedule,614.06,2579.06,Radiology
Onc colon ca kras&nras alys,0111U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,955.21,,,,,,,fee schedule,614.06,2579.06,APC
Onc colon ca kras&nras alys,0111U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1194.01,,,,,,,fee schedule,614.06,2579.06,APC
Adm sarscov2 25mcg/0.25ml2nd,0112A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,151.2,,,,,,,fee schedule,121.2,151.2,
Adm sarscov2 25mcg/0.25ml2nd,0112A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,121.2,,,,,,,fee schedule,121.2,151.2,
Adm sarscov2 25mcg/0.25ml2nd,0112A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,132.4,,,,,,,fee schedule,121.2,151.2,
Adm sarscov2 25mcg/0.25ml2nd,0112A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,139.2,,,,,,,fee schedule,121.2,151.2,
Iadi 16s&18s rrna genes,0112U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,320.52,,,,,,,fee schedule,320.52,623.23,Laboratory
Iadi 16s&18s rrna genes,0112U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,373.94,,,,,,,fee schedule,320.52,623.23,APC
Iadi 16s&18s rrna genes,0112U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,370.38,,,,,,,fee schedule,320.52,623.23,APC
Iadi 16s&18s rrna genes,0112U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,356.13,,,,,,,fee schedule,320.52,623.23,APC
Iadi 16s&18s rrna genes,0112U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,544.88,,,,,,,fee schedule,320.52,623.23,Radiology
Iadi 16s&18s rrna genes,0112U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,498.58,,,,,,,fee schedule,320.52,623.23,APC
Iadi 16s&18s rrna genes,0112U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,623.23,,,,,,,fee schedule,320.52,623.23,APC
Adm sarscov2 25mcg/0.25ml3rd,0113A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,151.2,,,,,,,fee schedule,121.2,151.2,
Adm sarscov2 25mcg/0.25ml3rd,0113A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,121.2,,,,,,,fee schedule,121.2,151.2,
Adm sarscov2 25mcg/0.25ml3rd,0113A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,132.4,,,,,,,fee schedule,121.2,151.2,
Adm sarscov2 25mcg/0.25ml3rd,0113A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,139.2,,,,,,,fee schedule,121.2,151.2,
Onc prst8 pca3&tmprss2-erg,0113U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2872.8,,,,,,,fee schedule,684,2872.8,
Onc prst8 pca3&tmprss2-erg,0113U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2302.8,,,,,,,fee schedule,684,2872.8,
Onc prst8 pca3&tmprss2-erg,0113U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2515.6,,,,,,,fee schedule,684,2872.8,
Onc prst8 pca3&tmprss2-erg,0113U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2644.8,,,,,,,fee schedule,684,2872.8,
Onc prst8 pca3&tmprss2-erg,0113U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,684,,,,,,,fee schedule,684,2872.8,Laboratory
Onc prst8 pca3&tmprss2-erg,0113U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,798,,,,,,,fee schedule,684,2872.8,APC
Onc prst8 pca3&tmprss2-erg,0113U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,790.4,,,,,,,fee schedule,684,2872.8,APC
Onc prst8 pca3&tmprss2-erg,0113U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,760,,,,,,,fee schedule,684,2872.8,APC
Onc prst8 pca3&tmprss2-erg,0113U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1162.8,,,,,,,fee schedule,684,2872.8,Radiology
Onc prst8 pca3&tmprss2-erg,0113U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1064,,,,,,,fee schedule,684,2872.8,APC
Onc prst8 pca3&tmprss2-erg,0113U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1330,,,,,,,fee schedule,684,2872.8,APC
Gi barretts esoph vim&ccna1,0114U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1744.21,,,,,,,fee schedule,1744.21,3391.52,Laboratory
Gi barretts esoph vim&ccna1,0114U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2034.91,,,,,,,fee schedule,1744.21,3391.52,APC
Gi barretts esoph vim&ccna1,0114U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2015.53,,,,,,,fee schedule,1744.21,3391.52,APC
Gi barretts esoph vim&ccna1,0114U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1938.01,,,,,,,fee schedule,1744.21,3391.52,APC
Gi barretts esoph vim&ccna1,0114U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2965.16,,,,,,,fee schedule,1744.21,3391.52,Radiology
Gi barretts esoph vim&ccna1,0114U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2713.21,,,,,,,fee schedule,1744.21,3391.52,APC
Gi barretts esoph vim&ccna1,0114U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3391.52,,,,,,,fee schedule,1744.21,3391.52,APC
Respir iadna 18 viral&2 bact,0115U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,247.82,,,,,,,fee schedule,247.82,481.86,Laboratory
Respir iadna 18 viral&2 bact,0115U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,289.12,,,,,,,fee schedule,247.82,481.86,APC
Respir iadna 18 viral&2 bact,0115U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,286.36,,,,,,,fee schedule,247.82,481.86,APC
Respir iadna 18 viral&2 bact,0115U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,275.35,,,,,,,fee schedule,247.82,481.86,APC
Respir iadna 18 viral&2 bact,0115U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,421.29,,,,,,,fee schedule,247.82,481.86,Radiology
Respir iadna 18 viral&2 bact,0115U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,385.49,,,,,,,fee schedule,247.82,481.86,APC
Respir iadna 18 viral&2 bact,0115U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,481.86,,,,,,,fee schedule,247.82,481.86,APC
Rx mntr nzm ia 35+oral flu,0116U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,933.36,,,,,,,fee schedule,222.23,933.36,
Rx mntr nzm ia 35+oral flu,0116U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,748.17,,,,,,,fee schedule,222.23,933.36,
Rx mntr nzm ia 35+oral flu,0116U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,817.31,,,,,,,fee schedule,222.23,933.36,
Rx mntr nzm ia 35+oral flu,0116U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,859.28,,,,,,,fee schedule,222.23,933.36,
Rx mntr nzm ia 35+oral flu,0116U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,222.23,,,,,,,fee schedule,222.23,933.36,Laboratory
Rx mntr nzm ia 35+oral flu,0116U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,259.27,,,,,,,fee schedule,222.23,933.36,APC
Rx mntr nzm ia 35+oral flu,0116U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,256.8,,,,,,,fee schedule,222.23,933.36,APC
Rx mntr nzm ia 35+oral flu,0116U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,246.92,,,,,,,fee schedule,222.23,933.36,APC
Rx mntr nzm ia 35+oral flu,0116U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,377.79,,,,,,,fee schedule,222.23,933.36,Radiology
Rx mntr nzm ia 35+oral flu,0116U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,345.69,,,,,,,fee schedule,222.23,933.36,APC
Rx mntr nzm ia 35+oral flu,0116U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,432.11,,,,,,,fee schedule,222.23,933.36,APC
Pain mgmt 11 endogenous anal,0117U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,756.58,,,,,,,fee schedule,756.58,1471.14,Laboratory
Pain mgmt 11 endogenous anal,0117U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,882.68,,,,,,,fee schedule,756.58,1471.14,APC
Pain mgmt 11 endogenous anal,0117U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,874.28,,,,,,,fee schedule,756.58,1471.14,APC
Pain mgmt 11 endogenous anal,0117U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,840.65,,,,,,,fee schedule,756.58,1471.14,APC
Pain mgmt 11 endogenous anal,0117U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1286.19,,,,,,,fee schedule,756.58,1471.14,Radiology
Pain mgmt 11 endogenous anal,0117U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1176.91,,,,,,,fee schedule,756.58,1471.14,APC
Pain mgmt 11 endogenous anal,0117U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1471.14,,,,,,,fee schedule,756.58,1471.14,APC
Trnsplj don-drv cll-fr dna,0118U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2477.93,,,,,,,fee schedule,2477.93,4818.19,Laboratory
Trnsplj don-drv cll-fr dna,0118U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2890.91,,,,,,,fee schedule,2477.93,4818.19,APC
Trnsplj don-drv cll-fr dna,0118U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2863.38,,,,,,,fee schedule,2477.93,4818.19,APC
Trnsplj don-drv cll-fr dna,0118U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2753.25,,,,,,,fee schedule,2477.93,4818.19,APC
Trnsplj don-drv cll-fr dna,0118U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4212.47,,,,,,,fee schedule,2477.93,4818.19,Radiology
Trnsplj don-drv cll-fr dna,0118U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3854.55,,,,,,,fee schedule,2477.93,4818.19,APC
Trnsplj don-drv cll-fr dna,0118U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4818.19,,,,,,,fee schedule,2477.93,4818.19,APC
Crd ceramides liq chrom plsm,0119U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,75.38,,,,,,,fee schedule,75.38,146.58,Laboratory
Crd ceramides liq chrom plsm,0119U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,87.95,,,,,,,fee schedule,75.38,146.58,APC
Crd ceramides liq chrom plsm,0119U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,87.11,,,,,,,fee schedule,75.38,146.58,APC
Crd ceramides liq chrom plsm,0119U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,83.76,,,,,,,fee schedule,75.38,146.58,APC
Crd ceramides liq chrom plsm,0119U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,128.15,,,,,,,fee schedule,75.38,146.58,Radiology
Crd ceramides liq chrom plsm,0119U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,117.26,,,,,,,fee schedule,75.38,146.58,APC
Crd ceramides liq chrom plsm,0119U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,146.58,,,,,,,fee schedule,75.38,146.58,APC
Onc b cll lymphm mrna 58 gen,0120U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10542.87,,,,,,,fee schedule,2259.19,10542.87,
Onc b cll lymphm mrna 58 gen,0120U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8451.03,,,,,,,fee schedule,2259.19,10542.87,
Onc b cll lymphm mrna 58 gen,0120U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9231.99,,,,,,,fee schedule,2259.19,10542.87,
Onc b cll lymphm mrna 58 gen,0120U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9706.14,,,,,,,fee schedule,2259.19,10542.87,
Onc b cll lymphm mrna 58 gen,0120U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2259.19,,,,,,,fee schedule,2259.19,10542.87,Laboratory
Onc b cll lymphm mrna 58 gen,0120U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2635.72,,,,,,,fee schedule,2259.19,10542.87,APC
Onc b cll lymphm mrna 58 gen,0120U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2610.62,,,,,,,fee schedule,2259.19,10542.87,APC
Onc b cll lymphm mrna 58 gen,0120U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2510.21,,,,,,,fee schedule,2259.19,10542.87,APC
Onc b cll lymphm mrna 58 gen,0120U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3840.62,,,,,,,fee schedule,2259.19,10542.87,Radiology
Onc b cll lymphm mrna 58 gen,0120U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3514.29,,,,,,,fee schedule,2259.19,10542.87,APC
Onc b cll lymphm mrna 58 gen,0120U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4392.87,,,,,,,fee schedule,2259.19,10542.87,APC
Sc dis vcam-1 whole blood,0121U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,458.28,,,,,,,fee schedule,458.28,891.1,Laboratory
Sc dis vcam-1 whole blood,0121U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,534.66,,,,,,,fee schedule,458.28,891.1,APC
Sc dis vcam-1 whole blood,0121U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,529.57,,,,,,,fee schedule,458.28,891.1,APC
Sc dis vcam-1 whole blood,0121U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,509.2,,,,,,,fee schedule,458.28,891.1,APC
Sc dis vcam-1 whole blood,0121U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,779.08,,,,,,,fee schedule,458.28,891.1,Radiology
Sc dis vcam-1 whole blood,0121U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,712.88,,,,,,,fee schedule,458.28,891.1,APC
Sc dis vcam-1 whole blood,0121U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,891.1,,,,,,,fee schedule,458.28,891.1,APC
Sc dis p-selectin whl blood,0122U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,473.61,,,,,,,fee schedule,473.61,920.9,Laboratory
Sc dis p-selectin whl blood,0122U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,552.54,,,,,,,fee schedule,473.61,920.9,APC
Sc dis p-selectin whl blood,0122U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,547.28,,,,,,,fee schedule,473.61,920.9,APC
Sc dis p-selectin whl blood,0122U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,526.23,,,,,,,fee schedule,473.61,920.9,APC
Sc dis p-selectin whl blood,0122U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,805.13,,,,,,,fee schedule,473.61,920.9,Radiology
Sc dis p-selectin whl blood,0122U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,736.72,,,,,,,fee schedule,473.61,920.9,APC
Sc dis p-selectin whl blood,0122U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,920.9,,,,,,,fee schedule,473.61,920.9,APC
Mchnl fragility rbc prflg,0123U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,321.87,,,,,,,fee schedule,321.87,625.85,Laboratory
Mchnl fragility rbc prflg,0123U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,375.51,,,,,,,fee schedule,321.87,625.85,APC
Mchnl fragility rbc prflg,0123U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,371.94,,,,,,,fee schedule,321.87,625.85,APC
Mchnl fragility rbc prflg,0123U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,357.63,,,,,,,fee schedule,321.87,625.85,APC
Mchnl fragility rbc prflg,0123U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,547.17,,,,,,,fee schedule,321.87,625.85,Radiology
Mchnl fragility rbc prflg,0123U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,500.68,,,,,,,fee schedule,321.87,625.85,APC
Mchnl fragility rbc prflg,0123U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,625.85,,,,,,,fee schedule,321.87,625.85,APC
Adm sarscv2 bvl 30mcg/.3ml b,0124A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,151.2,,,,,,,fee schedule,121.2,151.2,
Adm sarscv2 bvl 30mcg/.3ml b,0124A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,121.2,,,,,,,fee schedule,121.2,151.2,
Adm sarscv2 bvl 30mcg/.3ml b,0124A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,132.4,,,,,,,fee schedule,121.2,151.2,
Adm sarscv2 bvl 30mcg/.3ml b,0124A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,139.2,,,,,,,fee schedule,121.2,151.2,
Hered brst ca rltd do panel,0129U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4225.96,,,,,,,fee schedule,1173.56,4225.96,
Hered brst ca rltd do panel,0129U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3387.48,,,,,,,fee schedule,1173.56,4225.96,
Hered brst ca rltd do panel,0129U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3700.51,,,,,,,fee schedule,1173.56,4225.96,
Hered brst ca rltd do panel,0129U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3890.57,,,,,,,fee schedule,1173.56,4225.96,
Hered brst ca rltd do panel,0129U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1173.56,,,,,,,fee schedule,1173.56,4225.96,Laboratory
Hered brst ca rltd do panel,0129U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1369.15,,,,,,,fee schedule,1173.56,4225.96,APC
Hered brst ca rltd do panel,0129U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1356.11,,,,,,,fee schedule,1173.56,4225.96,APC
Hered brst ca rltd do panel,0129U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1303.95,,,,,,,fee schedule,1173.56,4225.96,APC
Hered brst ca rltd do panel,0129U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1995.04,,,,,,,fee schedule,1173.56,4225.96,Radiology
Hered brst ca rltd do panel,0129U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1825.53,,,,,,,fee schedule,1173.56,4225.96,APC
Hered brst ca rltd do panel,0129U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2281.91,,,,,,,fee schedule,1173.56,4225.96,APC
Hered colon ca do mrna pnl,0130U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2210.92,,,,,,,fee schedule,526.41,2210.92,
Hered colon ca do mrna pnl,0130U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1772.25,,,,,,,fee schedule,526.41,2210.92,
Hered colon ca do mrna pnl,0130U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1936.02,,,,,,,fee schedule,526.41,2210.92,
Hered colon ca do mrna pnl,0130U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2035.45,,,,,,,fee schedule,526.41,2210.92,
Hered colon ca do mrna pnl,0130U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,526.41,,,,,,,fee schedule,526.41,2210.92,Laboratory
Hered colon ca do mrna pnl,0130U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,614.14,,,,,,,fee schedule,526.41,2210.92,APC
Hered colon ca do mrna pnl,0130U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,608.3,,,,,,,fee schedule,526.41,2210.92,APC
Hered colon ca do mrna pnl,0130U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,584.9,,,,,,,fee schedule,526.41,2210.92,APC
Hered colon ca do mrna pnl,0130U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,894.9,,,,,,,fee schedule,526.41,2210.92,Radiology
Hered colon ca do mrna pnl,0130U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,818.86,,,,,,,fee schedule,526.41,2210.92,APC
Hered colon ca do mrna pnl,0130U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1023.58,,,,,,,fee schedule,526.41,2210.92,APC
Hered prst8 ca rltd do 11,0133U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,621.26,,,,,,,fee schedule,621.26,1208.01,Laboratory
Hered prst8 ca rltd do 11,0133U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,724.8,,,,,,,fee schedule,621.26,1208.01,APC
Hered prst8 ca rltd do 11,0133U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,717.9,,,,,,,fee schedule,621.26,1208.01,APC
Hered prst8 ca rltd do 11,0133U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,690.29,,,,,,,fee schedule,621.26,1208.01,APC
Hered prst8 ca rltd do 11,0133U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1056.14,,,,,,,fee schedule,621.26,1208.01,Radiology
Hered prst8 ca rltd do 11,0133U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,966.41,,,,,,,fee schedule,621.26,1208.01,APC
Hered prst8 ca rltd do 11,0133U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1208.01,,,,,,,fee schedule,621.26,1208.01,APC
Adm sarscv2 bvl 50mcg/.5ml b,0134A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,151.2,,,,,,,fee schedule,121.2,151.2,
Adm sarscv2 bvl 50mcg/.5ml b,0134A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,121.2,,,,,,,fee schedule,121.2,151.2,
Adm sarscv2 bvl 50mcg/.5ml b,0134A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,132.4,,,,,,,fee schedule,121.2,151.2,
Adm sarscv2 bvl 50mcg/.5ml b,0134A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,139.2,,,,,,,fee schedule,121.2,151.2,
Hered pan ca mrna pnl 18 gen,0134U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,673.55,,,,,,,fee schedule,673.55,1309.68,Laboratory
Hered pan ca mrna pnl 18 gen,0134U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,785.81,,,,,,,fee schedule,673.55,1309.68,APC
Hered pan ca mrna pnl 18 gen,0134U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,778.33,,,,,,,fee schedule,673.55,1309.68,APC
Hered pan ca mrna pnl 18 gen,0134U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,748.39,,,,,,,fee schedule,673.55,1309.68,APC
Hered pan ca mrna pnl 18 gen,0134U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1145.04,,,,,,,fee schedule,673.55,1309.68,Radiology
Hered pan ca mrna pnl 18 gen,0134U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1047.75,,,,,,,fee schedule,673.55,1309.68,APC
Hered pan ca mrna pnl 18 gen,0134U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1309.68,,,,,,,fee schedule,673.55,1309.68,APC
Atm mrna seq alys,0136U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,366.69,,,,,,,fee schedule,366.69,713,Laboratory
Atm mrna seq alys,0136U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,427.8,,,,,,,fee schedule,366.69,713,APC
Atm mrna seq alys,0136U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,423.73,,,,,,,fee schedule,366.69,713,APC
Atm mrna seq alys,0136U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,407.43,,,,,,,fee schedule,366.69,713,APC
Atm mrna seq alys,0136U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,623.37,,,,,,,fee schedule,366.69,713,Radiology
Atm mrna seq alys,0136U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,570.4,,,,,,,fee schedule,366.69,713,APC
Atm mrna seq alys,0136U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,713,,,,,,,fee schedule,366.69,713,APC
Palb2 mrna seq alys,0137U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,254.59,,,,,,,fee schedule,254.59,495.04,Laboratory
Palb2 mrna seq alys,0137U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,297.02,,,,,,,fee schedule,254.59,495.04,APC
Palb2 mrna seq alys,0137U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,294.2,,,,,,,fee schedule,254.59,495.04,APC
Palb2 mrna seq alys,0137U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,282.88,,,,,,,fee schedule,254.59,495.04,APC
Palb2 mrna seq alys,0137U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,432.81,,,,,,,fee schedule,254.59,495.04,Radiology
Palb2 mrna seq alys,0137U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,396.03,,,,,,,fee schedule,254.59,495.04,APC
Palb2 mrna seq alys,0137U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,495.04,,,,,,,fee schedule,254.59,495.04,APC
Brca1 brca2 mrna seq alys,0138U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,421.5,,,,,,,fee schedule,421.5,819.58,Laboratory
Brca1 brca2 mrna seq alys,0138U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,491.75,,,,,,,fee schedule,421.5,819.58,APC
Brca1 brca2 mrna seq alys,0138U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,487.06,,,,,,,fee schedule,421.5,819.58,APC
Brca1 brca2 mrna seq alys,0138U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,468.33,,,,,,,fee schedule,421.5,819.58,APC
Brca1 brca2 mrna seq alys,0138U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,716.54,,,,,,,fee schedule,421.5,819.58,Radiology
Brca1 brca2 mrna seq alys,0138U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,655.66,,,,,,,fee schedule,421.5,819.58,APC
Brca1 brca2 mrna seq alys,0138U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,819.58,,,,,,,fee schedule,421.5,819.58,APC
Nfct ds fungi dna 15 trgt,0140U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,141.08,,,,,,,fee schedule,141.07,274.31,Laboratory
Nfct ds fungi dna 15 trgt,0140U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,164.59,,,,,,,fee schedule,141.07,274.31,APC
Nfct ds fungi dna 15 trgt,0140U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,163.02,,,,,,,fee schedule,141.07,274.31,APC
Nfct ds fungi dna 15 trgt,0140U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,156.75,,,,,,,fee schedule,141.07,274.31,APC
Nfct ds fungi dna 15 trgt,0140U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,239.83,,,,,,,fee schedule,141.07,274.31,Radiology
Nfct ds fungi dna 15 trgt,0140U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,219.45,,,,,,,fee schedule,141.07,274.31,APC
Nfct ds fungi dna 15 trgt,0140U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,274.31,,,,,,,fee schedule,141.07,274.31,APC
Nfct ds bact&fng gram pos,0141U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,141.08,,,,,,,fee schedule,141.07,274.31,Laboratory
Nfct ds bact&fng gram pos,0141U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,164.59,,,,,,,fee schedule,141.07,274.31,APC
Nfct ds bact&fng gram pos,0141U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,163.02,,,,,,,fee schedule,141.07,274.31,APC
Nfct ds bact&fng gram pos,0141U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,156.75,,,,,,,fee schedule,141.07,274.31,APC
Nfct ds bact&fng gram pos,0141U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,239.83,,,,,,,fee schedule,141.07,274.31,Radiology
Nfct ds bact&fng gram pos,0141U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,219.45,,,,,,,fee schedule,141.07,274.31,APC
Nfct ds bact&fng gram pos,0141U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,274.31,,,,,,,fee schedule,141.07,274.31,APC
Nfct ds bact&fng gram neg,0142U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,141.08,,,,,,,fee schedule,141.07,274.31,Laboratory
Nfct ds bact&fng gram neg,0142U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,164.59,,,,,,,fee schedule,141.07,274.31,APC
Nfct ds bact&fng gram neg,0142U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,163.02,,,,,,,fee schedule,141.07,274.31,APC
Nfct ds bact&fng gram neg,0142U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,156.75,,,,,,,fee schedule,141.07,274.31,APC
Nfct ds bact&fng gram neg,0142U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,239.83,,,,,,,fee schedule,141.07,274.31,Radiology
Nfct ds bact&fng gram neg,0142U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,219.45,,,,,,,fee schedule,141.07,274.31,APC
Nfct ds bact&fng gram neg,0142U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,274.31,,,,,,,fee schedule,141.07,274.31,APC
Adm srscv2 bvl 25mcg/.25ml b,0144A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,151.2,,,,,,,fee schedule,121.2,151.2,
Adm srscv2 bvl 25mcg/.25ml b,0144A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,121.2,,,,,,,fee schedule,121.2,151.2,
Adm srscv2 bvl 25mcg/.25ml b,0144A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,132.4,,,,,,,fee schedule,121.2,151.2,
Adm srscv2 bvl 25mcg/.25ml b,0144A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,139.2,,,,,,,fee schedule,121.2,151.2,
Nfct bct fng prst dna >1000,0152U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1913.58,,,,,,,fee schedule,1913.58,3720.85,Laboratory
Nfct bct fng prst dna >1000,0152U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2232.51,,,,,,,fee schedule,1913.58,3720.85,APC
Nfct bct fng prst dna >1000,0152U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2211.25,,,,,,,fee schedule,1913.58,3720.85,APC
Nfct bct fng prst dna >1000,0152U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2126.2,,,,,,,fee schedule,1913.58,3720.85,APC
Nfct bct fng prst dna >1000,0152U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3253.09,,,,,,,fee schedule,1913.58,3720.85,Radiology
Nfct bct fng prst dna >1000,0152U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2976.68,,,,,,,fee schedule,1913.58,3720.85,APC
Nfct bct fng prst dna >1000,0152U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3720.85,,,,,,,fee schedule,1913.58,3720.85,APC
Onc breast mrna 101 genes,0153U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2843.48,,,,,,,fee schedule,2843.48,5528.98,Laboratory
Onc breast mrna 101 genes,0153U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3317.39,,,,,,,fee schedule,2843.48,5528.98,APC
Onc breast mrna 101 genes,0153U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3285.8,,,,,,,fee schedule,2843.48,5528.98,APC
Onc breast mrna 101 genes,0153U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3159.42,,,,,,,fee schedule,2843.48,5528.98,APC
Onc breast mrna 101 genes,0153U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4833.91,,,,,,,fee schedule,2843.48,5528.98,Radiology
Onc breast mrna 101 genes,0153U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4423.19,,,,,,,fee schedule,2843.48,5528.98,APC
Onc breast mrna 101 genes,0153U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5528.98,,,,,,,fee schedule,2843.48,5528.98,APC
Adm sarscv2 bvl 10mcg/.2ml b,0154A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,151.2,,,,,,,fee schedule,121.2,151.2,
Adm sarscv2 bvl 10mcg/.2ml b,0154A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,121.2,,,,,,,fee schedule,121.2,151.2,
Adm sarscv2 bvl 10mcg/.2ml b,0154A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,132.4,,,,,,,fee schedule,121.2,151.2,
Adm sarscv2 bvl 10mcg/.2ml b,0154A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,139.2,,,,,,,fee schedule,121.2,151.2,
Fgfr3 gene analysis,0154U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,433.93,,,,,,,fee schedule,433.93,843.74,Laboratory
Fgfr3 gene analysis,0154U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,506.25,,,,,,,fee schedule,433.93,843.74,APC
Fgfr3 gene analysis,0154U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,501.43,,,,,,,fee schedule,433.93,843.74,APC
Fgfr3 gene analysis,0154U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,482.14,,,,,,,fee schedule,433.93,843.74,APC
Fgfr3 gene analysis,0154U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,737.67,,,,,,,fee schedule,433.93,843.74,Radiology
Fgfr3 gene analysis,0154U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,675,,,,,,,fee schedule,433.93,843.74,APC
Fgfr3 gene analysis,0154U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,843.74,,,,,,,fee schedule,433.93,843.74,APC
Pik3ca gene analysis,0155U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,247.35,,,,,,,fee schedule,247.35,480.95,Laboratory
Pik3ca gene analysis,0155U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,288.57,,,,,,,fee schedule,247.35,480.95,APC
Pik3ca gene analysis,0155U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,285.82,,,,,,,fee schedule,247.35,480.95,APC
Pik3ca gene analysis,0155U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,274.83,,,,,,,fee schedule,247.35,480.95,APC
Pik3ca gene analysis,0155U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,420.49,,,,,,,fee schedule,247.35,480.95,Radiology
Pik3ca gene analysis,0155U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,384.76,,,,,,,fee schedule,247.35,480.95,APC
Pik3ca gene analysis,0155U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,480.95,,,,,,,fee schedule,247.35,480.95,APC
Copy number sequence alys,0156U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1566,,,,,,,fee schedule,1566,3045,Laboratory
Copy number sequence alys,0156U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1827,,,,,,,fee schedule,1566,3045,APC
Copy number sequence alys,0156U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1809.6,,,,,,,fee schedule,1566,3045,APC
Copy number sequence alys,0156U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1740,,,,,,,fee schedule,1566,3045,APC
Copy number sequence alys,0156U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2662.2,,,,,,,fee schedule,1566,3045,Radiology
Copy number sequence alys,0156U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2436,,,,,,,fee schedule,1566,3045,APC
Copy number sequence alys,0156U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3045,,,,,,,fee schedule,1566,3045,APC
Apc mrna seq alys,0157U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,254.59,,,,,,,fee schedule,254.59,495.04,Laboratory
Apc mrna seq alys,0157U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,297.02,,,,,,,fee schedule,254.59,495.04,APC
Apc mrna seq alys,0157U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,294.2,,,,,,,fee schedule,254.59,495.04,APC
Apc mrna seq alys,0157U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,282.88,,,,,,,fee schedule,254.59,495.04,APC
Apc mrna seq alys,0157U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,432.81,,,,,,,fee schedule,254.59,495.04,Radiology
Apc mrna seq alys,0157U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,396.03,,,,,,,fee schedule,254.59,495.04,APC
Apc mrna seq alys,0157U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,495.04,,,,,,,fee schedule,254.59,495.04,APC
Mlh1 mrna seq alys,0158U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,254.59,,,,,,,fee schedule,254.59,495.04,Laboratory
Mlh1 mrna seq alys,0158U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,297.02,,,,,,,fee schedule,254.59,495.04,APC
Mlh1 mrna seq alys,0158U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,294.2,,,,,,,fee schedule,254.59,495.04,APC
Mlh1 mrna seq alys,0158U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,282.88,,,,,,,fee schedule,254.59,495.04,APC
Mlh1 mrna seq alys,0158U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,432.81,,,,,,,fee schedule,254.59,495.04,Radiology
Mlh1 mrna seq alys,0158U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,396.03,,,,,,,fee schedule,254.59,495.04,APC
Mlh1 mrna seq alys,0158U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,495.04,,,,,,,fee schedule,254.59,495.04,APC
Msh2 mrna seq alys,0159U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,254.59,,,,,,,fee schedule,254.59,495.04,Laboratory
Msh2 mrna seq alys,0159U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,297.02,,,,,,,fee schedule,254.59,495.04,APC
Msh2 mrna seq alys,0159U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,294.2,,,,,,,fee schedule,254.59,495.04,APC
Msh2 mrna seq alys,0159U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,282.88,,,,,,,fee schedule,254.59,495.04,APC
Msh2 mrna seq alys,0159U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,432.81,,,,,,,fee schedule,254.59,495.04,Radiology
Msh2 mrna seq alys,0159U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,396.03,,,,,,,fee schedule,254.59,495.04,APC
Msh2 mrna seq alys,0159U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,495.04,,,,,,,fee schedule,254.59,495.04,APC
Msh6 mrna seq alys,0160U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,254.59,,,,,,,fee schedule,254.59,495.04,Laboratory
Msh6 mrna seq alys,0160U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,297.02,,,,,,,fee schedule,254.59,495.04,APC
Msh6 mrna seq alys,0160U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,294.2,,,,,,,fee schedule,254.59,495.04,APC
Msh6 mrna seq alys,0160U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,282.88,,,,,,,fee schedule,254.59,495.04,APC
Msh6 mrna seq alys,0160U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,432.81,,,,,,,fee schedule,254.59,495.04,Radiology
Msh6 mrna seq alys,0160U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,396.03,,,,,,,fee schedule,254.59,495.04,APC
Msh6 mrna seq alys,0160U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,495.04,,,,,,,fee schedule,254.59,495.04,APC
Pms2 mrna seq alys,0161U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,254.59,,,,,,,fee schedule,254.59,495.04,Laboratory
Pms2 mrna seq alys,0161U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,297.02,,,,,,,fee schedule,254.59,495.04,APC
Pms2 mrna seq alys,0161U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,294.2,,,,,,,fee schedule,254.59,495.04,APC
Pms2 mrna seq alys,0161U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,282.88,,,,,,,fee schedule,254.59,495.04,APC
Pms2 mrna seq alys,0161U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,432.81,,,,,,,fee schedule,254.59,495.04,Radiology
Pms2 mrna seq alys,0161U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,396.03,,,,,,,fee schedule,254.59,495.04,APC
Pms2 mrna seq alys,0161U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,495.04,,,,,,,fee schedule,254.59,495.04,APC
Hered colon ca trgt mrna pnl,0162U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,437.89,,,,,,,fee schedule,437.89,851.44,Laboratory
Hered colon ca trgt mrna pnl,0162U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,510.87,,,,,,,fee schedule,437.89,851.44,APC
Hered colon ca trgt mrna pnl,0162U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,506,,,,,,,fee schedule,437.89,851.44,APC
Hered colon ca trgt mrna pnl,0162U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,486.54,,,,,,,fee schedule,437.89,851.44,APC
Hered colon ca trgt mrna pnl,0162U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,744.41,,,,,,,fee schedule,437.89,851.44,Radiology
Hered colon ca trgt mrna pnl,0162U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,681.16,,,,,,,fee schedule,437.89,851.44,APC
Hered colon ca trgt mrna pnl,0162U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,851.44,,,,,,,fee schedule,437.89,851.44,APC
Gi ibs ia anti-cdtb&vinculin,0164U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,100.82,,,,,,,fee schedule,100.82,196.04,Laboratory
Gi ibs ia anti-cdtb&vinculin,0164U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,117.62,,,,,,,fee schedule,100.82,196.04,APC
Gi ibs ia anti-cdtb&vinculin,0164U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,116.5,,,,,,,fee schedule,100.82,196.04,APC
Gi ibs ia anti-cdtb&vinculin,0164U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,112.02,,,,,,,fee schedule,100.82,196.04,APC
Gi ibs ia anti-cdtb&vinculin,0164U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,171.39,,,,,,,fee schedule,100.82,196.04,Radiology
Gi ibs ia anti-cdtb&vinculin,0164U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,156.83,,,,,,,fee schedule,100.82,196.04,APC
Gi ibs ia anti-cdtb&vinculin,0164U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,196.04,,,,,,,fee schedule,100.82,196.04,APC
Peanut allg spec asmt 64 epi,0165U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,417.38,,,,,,,fee schedule,417.38,811.58,Laboratory
Peanut allg spec asmt 64 epi,0165U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,486.95,,,,,,,fee schedule,417.38,811.58,APC
Peanut allg spec asmt 64 epi,0165U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,482.31,,,,,,,fee schedule,417.38,811.58,APC
Peanut allg spec asmt 64 epi,0165U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,463.76,,,,,,,fee schedule,417.38,811.58,APC
Peanut allg spec asmt 64 epi,0165U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,709.55,,,,,,,fee schedule,417.38,811.58,Radiology
Peanut allg spec asmt 64 epi,0165U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,649.26,,,,,,,fee schedule,417.38,811.58,APC
Peanut allg spec asmt 64 epi,0165U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,811.58,,,,,,,fee schedule,417.38,811.58,APC
Liver ds 10 biochem asy srm,0166U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,453.06,,,,,,,fee schedule,453.06,880.95,Laboratory
Liver ds 10 biochem asy srm,0166U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,528.57,,,,,,,fee schedule,453.06,880.95,APC
Liver ds 10 biochem asy srm,0166U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,523.54,,,,,,,fee schedule,453.06,880.95,APC
Liver ds 10 biochem asy srm,0166U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,503.4,,,,,,,fee schedule,453.06,880.95,APC
Liver ds 10 biochem asy srm,0166U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,770.2,,,,,,,fee schedule,453.06,880.95,Radiology
Liver ds 10 biochem asy srm,0166U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,704.76,,,,,,,fee schedule,453.06,880.95,APC
Liver ds 10 biochem asy srm,0166U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,880.95,,,,,,,fee schedule,453.06,880.95,APC
Nudt15&tpmt gene com vrnt,0169U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,419.55,,,,,,,fee schedule,419.55,815.8,Laboratory
Nudt15&tpmt gene com vrnt,0169U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,489.48,,,,,,,fee schedule,419.55,815.8,APC
Nudt15&tpmt gene com vrnt,0169U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,484.82,,,,,,,fee schedule,419.55,815.8,APC
Nudt15&tpmt gene com vrnt,0169U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,466.17,,,,,,,fee schedule,419.55,815.8,APC
Nudt15&tpmt gene com vrnt,0169U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,713.24,,,,,,,fee schedule,419.55,815.8,Radiology
Nudt15&tpmt gene com vrnt,0169U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,652.64,,,,,,,fee schedule,419.55,815.8,APC
Nudt15&tpmt gene com vrnt,0169U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,815.8,,,,,,,fee schedule,419.55,815.8,APC
Neuro asd rna next gen seq,0170U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755,,,,,,,fee schedule,1755,3412.5,Laboratory
Neuro asd rna next gen seq,0170U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2047.5,,,,,,,fee schedule,1755,3412.5,APC
Neuro asd rna next gen seq,0170U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2028,,,,,,,fee schedule,1755,3412.5,APC
Neuro asd rna next gen seq,0170U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1950,,,,,,,fee schedule,1755,3412.5,APC
Neuro asd rna next gen seq,0170U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2983.5,,,,,,,fee schedule,1755,3412.5,Radiology
Neuro asd rna next gen seq,0170U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2730,,,,,,,fee schedule,1755,3412.5,APC
Neuro asd rna next gen seq,0170U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3412.5,,,,,,,fee schedule,1755,3412.5,APC
Trgt gen seq alys pnl dna 23,0171U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1367.15,,,,,,,fee schedule,1367.15,2658.36,Laboratory
Trgt gen seq alys pnl dna 23,0171U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1595.01,,,,,,,fee schedule,1367.15,2658.36,APC
Trgt gen seq alys pnl dna 23,0171U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1579.82,,,,,,,fee schedule,1367.15,2658.36,APC
Trgt gen seq alys pnl dna 23,0171U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1519.06,,,,,,,fee schedule,1367.15,2658.36,APC
Trgt gen seq alys pnl dna 23,0171U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2324.16,,,,,,,fee schedule,1367.15,2658.36,Radiology
Trgt gen seq alys pnl dna 23,0171U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2126.68,,,,,,,fee schedule,1367.15,2658.36,APC
Trgt gen seq alys pnl dna 23,0171U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2658.36,,,,,,,fee schedule,1367.15,2658.36,APC
Onc sld tum alys brca1 brca2,0172U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2727,,,,,,,fee schedule,2727,5302.5,Laboratory
Onc sld tum alys brca1 brca2,0172U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3181.5,,,,,,,fee schedule,2727,5302.5,APC
Onc sld tum alys brca1 brca2,0172U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3151.2,,,,,,,fee schedule,2727,5302.5,APC
Onc sld tum alys brca1 brca2,0172U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3030,,,,,,,fee schedule,2727,5302.5,APC
Onc sld tum alys brca1 brca2,0172U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4635.9,,,,,,,fee schedule,2727,5302.5,Radiology
Onc sld tum alys brca1 brca2,0172U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4242,,,,,,,fee schedule,2727,5302.5,APC
Onc sld tum alys brca1 brca2,0172U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5302.5,,,,,,,fee schedule,2727,5302.5,APC
Psyc gen alys panel 14 genes,0173U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,419.55,,,,,,,fee schedule,419.55,815.8,Laboratory
Psyc gen alys panel 14 genes,0173U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,489.48,,,,,,,fee schedule,419.55,815.8,APC
Psyc gen alys panel 14 genes,0173U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,484.82,,,,,,,fee schedule,419.55,815.8,APC
Psyc gen alys panel 14 genes,0173U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,466.17,,,,,,,fee schedule,419.55,815.8,APC
Psyc gen alys panel 14 genes,0173U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,713.24,,,,,,,fee schedule,419.55,815.8,Radiology
Psyc gen alys panel 14 genes,0173U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,652.64,,,,,,,fee schedule,419.55,815.8,APC
Psyc gen alys panel 14 genes,0173U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,815.8,,,,,,,fee schedule,419.55,815.8,APC
Adm sarscv2 bvl 3mcg/0.2ml b,0174A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,151.2,,,,,,,fee schedule,121.2,151.2,
Adm sarscv2 bvl 3mcg/0.2ml b,0174A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,121.2,,,,,,,fee schedule,121.2,151.2,
Adm sarscv2 bvl 3mcg/0.2ml b,0174A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,132.4,,,,,,,fee schedule,121.2,151.2,
Adm sarscv2 bvl 3mcg/0.2ml b,0174A,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,139.2,,,,,,,fee schedule,121.2,151.2,
Onc solid tumor 30 prtn trgt,0174U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1174.83,,,,,,,fee schedule,1174.83,2284.4,Laboratory
Onc solid tumor 30 prtn trgt,0174U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1370.64,,,,,,,fee schedule,1174.83,2284.4,APC
Onc solid tumor 30 prtn trgt,0174U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1357.58,,,,,,,fee schedule,1174.83,2284.4,APC
Onc solid tumor 30 prtn trgt,0174U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1305.37,,,,,,,fee schedule,1174.83,2284.4,APC
Onc solid tumor 30 prtn trgt,0174U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1997.22,,,,,,,fee schedule,1174.83,2284.4,Radiology
Onc solid tumor 30 prtn trgt,0174U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1827.52,,,,,,,fee schedule,1174.83,2284.4,APC
Onc solid tumor 30 prtn trgt,0174U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2284.4,,,,,,,fee schedule,1174.83,2284.4,APC
Psyc gen alys panel 15 genes,0175U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1202.48,,,,,,,fee schedule,1202.48,2338.16,Laboratory
Psyc gen alys panel 15 genes,0175U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1402.89,,,,,,,fee schedule,1202.48,2338.16,APC
Psyc gen alys panel 15 genes,0175U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1389.53,,,,,,,fee schedule,1202.48,2338.16,APC
Psyc gen alys panel 15 genes,0175U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1336.09,,,,,,,fee schedule,1202.48,2338.16,APC
Psyc gen alys panel 15 genes,0175U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2044.22,,,,,,,fee schedule,1202.48,2338.16,Radiology
Psyc gen alys panel 15 genes,0175U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1870.53,,,,,,,fee schedule,1202.48,2338.16,APC
Psyc gen alys panel 15 genes,0175U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2338.16,,,,,,,fee schedule,1202.48,2338.16,APC
Cdtb&vinculin igg antb ia,0176U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,57.77,,,,,,,fee schedule,57.77,112.33,Laboratory
Cdtb&vinculin igg antb ia,0176U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,67.4,,,,,,,fee schedule,57.77,112.33,APC
Cdtb&vinculin igg antb ia,0176U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,66.76,,,,,,,fee schedule,57.77,112.33,APC
Cdtb&vinculin igg antb ia,0176U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,64.19,,,,,,,fee schedule,57.77,112.33,APC
Cdtb&vinculin igg antb ia,0176U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,98.21,,,,,,,fee schedule,57.77,112.33,Radiology
Cdtb&vinculin igg antb ia,0176U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.87,,,,,,,fee schedule,57.77,112.33,APC
Cdtb&vinculin igg antb ia,0176U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,112.33,,,,,,,fee schedule,57.77,112.33,APC
Onc brst ca dna pik3ca 11,0177U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,247.35,,,,,,,fee schedule,247.35,480.95,Laboratory
Onc brst ca dna pik3ca 11,0177U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,288.57,,,,,,,fee schedule,247.35,480.95,APC
Onc brst ca dna pik3ca 11,0177U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,285.82,,,,,,,fee schedule,247.35,480.95,APC
Onc brst ca dna pik3ca 11,0177U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,274.83,,,,,,,fee schedule,247.35,480.95,APC
Onc brst ca dna pik3ca 11,0177U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,420.49,,,,,,,fee schedule,247.35,480.95,Radiology
Onc brst ca dna pik3ca 11,0177U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,384.76,,,,,,,fee schedule,247.35,480.95,APC
Onc brst ca dna pik3ca 11,0177U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,480.95,,,,,,,fee schedule,247.35,480.95,APC
Peanut allg asmt epi clin rx,0178U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,413.87,,,,,,,fee schedule,413.87,804.76,Laboratory
Peanut allg asmt epi clin rx,0178U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,482.85,,,,,,,fee schedule,413.87,804.76,APC
Peanut allg asmt epi clin rx,0178U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,478.25,,,,,,,fee schedule,413.87,804.76,APC
Peanut allg asmt epi clin rx,0178U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,459.86,,,,,,,fee schedule,413.87,804.76,APC
Peanut allg asmt epi clin rx,0178U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,703.59,,,,,,,fee schedule,413.87,804.76,Radiology
Peanut allg asmt epi clin rx,0178U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,643.8,,,,,,,fee schedule,413.87,804.76,APC
Peanut allg asmt epi clin rx,0178U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,804.76,,,,,,,fee schedule,413.87,804.76,APC
Onc nonsm cll lng ca alys 23,0179U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1748.89,,,,,,,fee schedule,1748.89,3400.62,Laboratory
Onc nonsm cll lng ca alys 23,0179U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2040.37,,,,,,,fee schedule,1748.89,3400.62,APC
Onc nonsm cll lng ca alys 23,0179U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2020.94,,,,,,,fee schedule,1748.89,3400.62,APC
Onc nonsm cll lng ca alys 23,0179U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1943.21,,,,,,,fee schedule,1748.89,3400.62,APC
Onc nonsm cll lng ca alys 23,0179U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2973.11,,,,,,,fee schedule,1748.89,3400.62,Radiology
Onc nonsm cll lng ca alys 23,0179U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2720.49,,,,,,,fee schedule,1748.89,3400.62,APC
Onc nonsm cll lng ca alys 23,0179U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3400.62,,,,,,,fee schedule,1748.89,3400.62,APC
Abo gnotyp abo 7 exons,0180U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,247.35,,,,,,,fee schedule,247.35,480.95,Laboratory
Abo gnotyp abo 7 exons,0180U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,288.57,,,,,,,fee schedule,247.35,480.95,APC
Abo gnotyp abo 7 exons,0180U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,285.82,,,,,,,fee schedule,247.35,480.95,APC
Abo gnotyp abo 7 exons,0180U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,274.83,,,,,,,fee schedule,247.35,480.95,APC
Abo gnotyp abo 7 exons,0180U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,420.49,,,,,,,fee schedule,247.35,480.95,Radiology
Abo gnotyp abo 7 exons,0180U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,384.76,,,,,,,fee schedule,247.35,480.95,APC
Abo gnotyp abo 7 exons,0180U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,480.95,,,,,,,fee schedule,247.35,480.95,APC
Co gnotyp aqp1 exon 1,0181U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,166.68,,,,,,,fee schedule,166.68,324.1,Laboratory
Co gnotyp aqp1 exon 1,0181U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,194.46,,,,,,,fee schedule,166.68,324.1,APC
Co gnotyp aqp1 exon 1,0181U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,192.61,,,,,,,fee schedule,166.68,324.1,APC
Co gnotyp aqp1 exon 1,0181U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,185.2,,,,,,,fee schedule,166.68,324.1,APC
Co gnotyp aqp1 exon 1,0181U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,283.36,,,,,,,fee schedule,166.68,324.1,Radiology
Co gnotyp aqp1 exon 1,0181U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,259.28,,,,,,,fee schedule,166.68,324.1,APC
Co gnotyp aqp1 exon 1,0181U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,324.1,,,,,,,fee schedule,166.68,324.1,APC
Crom gnotyp cd55 exons 1-10,0182U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,271.22,,,,,,,fee schedule,271.21,527.36,Laboratory
Crom gnotyp cd55 exons 1-10,0182U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,316.42,,,,,,,fee schedule,271.21,527.36,APC
Crom gnotyp cd55 exons 1-10,0182U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,313.4,,,,,,,fee schedule,271.21,527.36,APC
Crom gnotyp cd55 exons 1-10,0182U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,301.35,,,,,,,fee schedule,271.21,527.36,APC
Crom gnotyp cd55 exons 1-10,0182U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,461.07,,,,,,,fee schedule,271.21,527.36,Radiology
Crom gnotyp cd55 exons 1-10,0182U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,421.89,,,,,,,fee schedule,271.21,527.36,APC
Crom gnotyp cd55 exons 1-10,0182U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,527.36,,,,,,,fee schedule,271.21,527.36,APC
Di gnotyp slc4a1 exon 19,0183U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,166.68,,,,,,,fee schedule,166.68,324.1,Laboratory
Di gnotyp slc4a1 exon 19,0183U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,194.46,,,,,,,fee schedule,166.68,324.1,APC
Di gnotyp slc4a1 exon 19,0183U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,192.61,,,,,,,fee schedule,166.68,324.1,APC
Di gnotyp slc4a1 exon 19,0183U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,185.2,,,,,,,fee schedule,166.68,324.1,APC
Di gnotyp slc4a1 exon 19,0183U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,283.36,,,,,,,fee schedule,166.68,324.1,Radiology
Di gnotyp slc4a1 exon 19,0183U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,259.28,,,,,,,fee schedule,166.68,324.1,APC
Di gnotyp slc4a1 exon 19,0183U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,324.1,,,,,,,fee schedule,166.68,324.1,APC
Exc rectal tumor endoscopic,0184T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14895.51,,,,,,,fee schedule,6009.99,26664.3,
Exc rectal tumor endoscopic,0184T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11940.05,,,,,,,fee schedule,6009.99,26664.3,
Exc rectal tumor endoscopic,0184T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13043.42,,,,,,,fee schedule,6009.99,26664.3,
Exc rectal tumor endoscopic,0184T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13713.32,,,,,,,fee schedule,6009.99,26664.3,
Exc rectal tumor endoscopic,0184T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26664.3,,,,,,,fee schedule,6009.99,26664.3,APC 378
Exc rectal tumor endoscopic,0184T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6310.49,,,,,,,fee schedule,6009.99,26664.3,APC
Exc rectal tumor endoscopic,0184T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6250.39,,,,,,,fee schedule,6009.99,26664.3,APC
Exc rectal tumor endoscopic,0184T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6009.99,,,,,,,fee schedule,6009.99,26664.3,APC
Exc rectal tumor endoscopic,0184T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9195.29,,,,,,,fee schedule,6009.99,26664.3,Radiology
Exc rectal tumor endoscopic,0184T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8413.99,,,,,,,fee schedule,6009.99,26664.3,APC
Exc rectal tumor endoscopic,0184T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10517.49,,,,,,,fee schedule,6009.99,26664.3,APC
Do gnotyp art4 exon 2,0184U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,166.68,,,,,,,fee schedule,166.68,324.1,Laboratory
Do gnotyp art4 exon 2,0184U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,194.46,,,,,,,fee schedule,166.68,324.1,APC
Do gnotyp art4 exon 2,0184U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,192.61,,,,,,,fee schedule,166.68,324.1,APC
Do gnotyp art4 exon 2,0184U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,185.2,,,,,,,fee schedule,166.68,324.1,APC
Do gnotyp art4 exon 2,0184U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,283.36,,,,,,,fee schedule,166.68,324.1,Radiology
Do gnotyp art4 exon 2,0184U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,259.28,,,,,,,fee schedule,166.68,324.1,APC
Do gnotyp art4 exon 2,0184U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,324.1,,,,,,,fee schedule,166.68,324.1,APC
Fut1 gnotyp fut1 exon 4,0185U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,166.68,,,,,,,fee schedule,166.68,324.1,Laboratory
Fut1 gnotyp fut1 exon 4,0185U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,194.46,,,,,,,fee schedule,166.68,324.1,APC
Fut1 gnotyp fut1 exon 4,0185U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,192.61,,,,,,,fee schedule,166.68,324.1,APC
Fut1 gnotyp fut1 exon 4,0185U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,185.2,,,,,,,fee schedule,166.68,324.1,APC
Fut1 gnotyp fut1 exon 4,0185U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,283.36,,,,,,,fee schedule,166.68,324.1,Radiology
Fut1 gnotyp fut1 exon 4,0185U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,259.28,,,,,,,fee schedule,166.68,324.1,APC
Fut1 gnotyp fut1 exon 4,0185U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,324.1,,,,,,,fee schedule,166.68,324.1,APC
Fut2 gnotyp fut2 exon 2,0186U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,166.68,,,,,,,fee schedule,166.68,324.1,Laboratory
Fut2 gnotyp fut2 exon 2,0186U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,194.46,,,,,,,fee schedule,166.68,324.1,APC
Fut2 gnotyp fut2 exon 2,0186U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,192.61,,,,,,,fee schedule,166.68,324.1,APC
Fut2 gnotyp fut2 exon 2,0186U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,185.2,,,,,,,fee schedule,166.68,324.1,APC
Fut2 gnotyp fut2 exon 2,0186U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,283.36,,,,,,,fee schedule,166.68,324.1,Radiology
Fut2 gnotyp fut2 exon 2,0186U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,259.28,,,,,,,fee schedule,166.68,324.1,APC
Fut2 gnotyp fut2 exon 2,0186U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,324.1,,,,,,,fee schedule,166.68,324.1,APC
Fy gnotyp ackr1 exons 1-2,0187U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,247.35,,,,,,,fee schedule,247.35,480.95,Laboratory
Fy gnotyp ackr1 exons 1-2,0187U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,288.57,,,,,,,fee schedule,247.35,480.95,APC
Fy gnotyp ackr1 exons 1-2,0187U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,285.82,,,,,,,fee schedule,247.35,480.95,APC
Fy gnotyp ackr1 exons 1-2,0187U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,274.83,,,,,,,fee schedule,247.35,480.95,APC
Fy gnotyp ackr1 exons 1-2,0187U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,420.49,,,,,,,fee schedule,247.35,480.95,Radiology
Fy gnotyp ackr1 exons 1-2,0187U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,384.76,,,,,,,fee schedule,247.35,480.95,APC
Fy gnotyp ackr1 exons 1-2,0187U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,480.95,,,,,,,fee schedule,247.35,480.95,APC
Ge gnotyp gypc exons 1-4,0188U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,247.35,,,,,,,fee schedule,247.35,480.95,Laboratory
Ge gnotyp gypc exons 1-4,0188U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,288.57,,,,,,,fee schedule,247.35,480.95,APC
Ge gnotyp gypc exons 1-4,0188U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,285.82,,,,,,,fee schedule,247.35,480.95,APC
Ge gnotyp gypc exons 1-4,0188U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,274.83,,,,,,,fee schedule,247.35,480.95,APC
Ge gnotyp gypc exons 1-4,0188U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,420.49,,,,,,,fee schedule,247.35,480.95,Radiology
Ge gnotyp gypc exons 1-4,0188U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,384.76,,,,,,,fee schedule,247.35,480.95,APC
Ge gnotyp gypc exons 1-4,0188U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,480.95,,,,,,,fee schedule,247.35,480.95,APC
Gypa gnotyp ntrns 1 5 exon 2,0189U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,247.35,,,,,,,fee schedule,247.35,480.95,Laboratory
Gypa gnotyp ntrns 1 5 exon 2,0189U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,288.57,,,,,,,fee schedule,247.35,480.95,APC
Gypa gnotyp ntrns 1 5 exon 2,0189U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,285.82,,,,,,,fee schedule,247.35,480.95,APC
Gypa gnotyp ntrns 1 5 exon 2,0189U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,274.83,,,,,,,fee schedule,247.35,480.95,APC
Gypa gnotyp ntrns 1 5 exon 2,0189U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,420.49,,,,,,,fee schedule,247.35,480.95,Radiology
Gypa gnotyp ntrns 1 5 exon 2,0189U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,384.76,,,,,,,fee schedule,247.35,480.95,APC
Gypa gnotyp ntrns 1 5 exon 2,0189U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,480.95,,,,,,,fee schedule,247.35,480.95,APC
Gypb gnotyp ntrns 1 5 seux 3,0190U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,247.35,,,,,,,fee schedule,247.35,480.95,Laboratory
Gypb gnotyp ntrns 1 5 seux 3,0190U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,288.57,,,,,,,fee schedule,247.35,480.95,APC
Gypb gnotyp ntrns 1 5 seux 3,0190U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,285.82,,,,,,,fee schedule,247.35,480.95,APC
Gypb gnotyp ntrns 1 5 seux 3,0190U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,274.83,,,,,,,fee schedule,247.35,480.95,APC
Gypb gnotyp ntrns 1 5 seux 3,0190U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,420.49,,,,,,,fee schedule,247.35,480.95,Radiology
Gypb gnotyp ntrns 1 5 seux 3,0190U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,384.76,,,,,,,fee schedule,247.35,480.95,APC
Gypb gnotyp ntrns 1 5 seux 3,0190U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,480.95,,,,,,,fee schedule,247.35,480.95,APC
In gnotyp cd44 exons 2 3 6,0191U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,247.35,,,,,,,fee schedule,247.35,480.95,Laboratory
In gnotyp cd44 exons 2 3 6,0191U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,288.57,,,,,,,fee schedule,247.35,480.95,APC
In gnotyp cd44 exons 2 3 6,0191U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,285.82,,,,,,,fee schedule,247.35,480.95,APC
In gnotyp cd44 exons 2 3 6,0191U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,274.83,,,,,,,fee schedule,247.35,480.95,APC
In gnotyp cd44 exons 2 3 6,0191U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,420.49,,,,,,,fee schedule,247.35,480.95,Radiology
In gnotyp cd44 exons 2 3 6,0191U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,384.76,,,,,,,fee schedule,247.35,480.95,APC
In gnotyp cd44 exons 2 3 6,0191U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,480.95,,,,,,,fee schedule,247.35,480.95,APC
Jk gnotyp slc14a1 exon 9,0192U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,247.35,,,,,,,fee schedule,247.35,480.95,Laboratory
Jk gnotyp slc14a1 exon 9,0192U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,288.57,,,,,,,fee schedule,247.35,480.95,APC
Jk gnotyp slc14a1 exon 9,0192U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,285.82,,,,,,,fee schedule,247.35,480.95,APC
Jk gnotyp slc14a1 exon 9,0192U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,274.83,,,,,,,fee schedule,247.35,480.95,APC
Jk gnotyp slc14a1 exon 9,0192U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,420.49,,,,,,,fee schedule,247.35,480.95,Radiology
Jk gnotyp slc14a1 exon 9,0192U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,384.76,,,,,,,fee schedule,247.35,480.95,APC
Jk gnotyp slc14a1 exon 9,0192U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,480.95,,,,,,,fee schedule,247.35,480.95,APC
Jr gnotyp abcg2 exons 2-26,0193U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,254.59,,,,,,,fee schedule,254.59,495.04,Laboratory
Jr gnotyp abcg2 exons 2-26,0193U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,297.02,,,,,,,fee schedule,254.59,495.04,APC
Jr gnotyp abcg2 exons 2-26,0193U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,294.2,,,,,,,fee schedule,254.59,495.04,APC
Jr gnotyp abcg2 exons 2-26,0193U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,282.88,,,,,,,fee schedule,254.59,495.04,APC
Jr gnotyp abcg2 exons 2-26,0193U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,432.81,,,,,,,fee schedule,254.59,495.04,Radiology
Jr gnotyp abcg2 exons 2-26,0193U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,396.03,,,,,,,fee schedule,254.59,495.04,APC
Jr gnotyp abcg2 exons 2-26,0193U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,495.04,,,,,,,fee schedule,254.59,495.04,APC
Kel gnotyp kel exon 8,0194U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,166.68,,,,,,,fee schedule,166.68,324.1,Laboratory
Kel gnotyp kel exon 8,0194U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,194.46,,,,,,,fee schedule,166.68,324.1,APC
Kel gnotyp kel exon 8,0194U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,192.61,,,,,,,fee schedule,166.68,324.1,APC
Kel gnotyp kel exon 8,0194U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,185.2,,,,,,,fee schedule,166.68,324.1,APC
Kel gnotyp kel exon 8,0194U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,283.36,,,,,,,fee schedule,166.68,324.1,Radiology
Kel gnotyp kel exon 8,0194U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,259.28,,,,,,,fee schedule,166.68,324.1,APC
Kel gnotyp kel exon 8,0194U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,324.1,,,,,,,fee schedule,166.68,324.1,APC
Klf1 targeted sequencing,0195U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,337.72,,,,,,,fee schedule,337.72,656.69,Laboratory
Klf1 targeted sequencing,0195U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,394.01,,,,,,,fee schedule,337.72,656.69,APC
Klf1 targeted sequencing,0195U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,390.26,,,,,,,fee schedule,337.72,656.69,APC
Klf1 targeted sequencing,0195U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,375.25,,,,,,,fee schedule,337.72,656.69,APC
Klf1 targeted sequencing,0195U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,574.13,,,,,,,fee schedule,337.72,656.69,Radiology
Klf1 targeted sequencing,0195U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,525.35,,,,,,,fee schedule,337.72,656.69,APC
Klf1 targeted sequencing,0195U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,656.69,,,,,,,fee schedule,337.72,656.69,APC
Lu gnotyp bcam exon 3,0196U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,166.68,,,,,,,fee schedule,166.68,324.1,Laboratory
Lu gnotyp bcam exon 3,0196U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,194.46,,,,,,,fee schedule,166.68,324.1,APC
Lu gnotyp bcam exon 3,0196U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,192.61,,,,,,,fee schedule,166.68,324.1,APC
Lu gnotyp bcam exon 3,0196U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,185.2,,,,,,,fee schedule,166.68,324.1,APC
Lu gnotyp bcam exon 3,0196U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,283.36,,,,,,,fee schedule,166.68,324.1,Radiology
Lu gnotyp bcam exon 3,0196U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,259.28,,,,,,,fee schedule,166.68,324.1,APC
Lu gnotyp bcam exon 3,0196U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,324.1,,,,,,,fee schedule,166.68,324.1,APC
Lw gnotyp icam4 exon 1,0197U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,166.68,,,,,,,fee schedule,166.68,324.1,Laboratory
Lw gnotyp icam4 exon 1,0197U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,194.46,,,,,,,fee schedule,166.68,324.1,APC
Lw gnotyp icam4 exon 1,0197U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,192.61,,,,,,,fee schedule,166.68,324.1,APC
Lw gnotyp icam4 exon 1,0197U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,185.2,,,,,,,fee schedule,166.68,324.1,APC
Lw gnotyp icam4 exon 1,0197U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,283.36,,,,,,,fee schedule,166.68,324.1,Radiology
Lw gnotyp icam4 exon 1,0197U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,259.28,,,,,,,fee schedule,166.68,324.1,APC
Lw gnotyp icam4 exon 1,0197U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,324.1,,,,,,,fee schedule,166.68,324.1,APC
Ocular blood flow measure,0198T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,279.98,,,,,,,fee schedule,131.71,584.37,
Ocular blood flow measure,0198T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,224.43,,,,,,,fee schedule,131.71,584.37,
Ocular blood flow measure,0198T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,245.17,,,,,,,fee schedule,131.71,584.37,
Ocular blood flow measure,0198T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,257.76,,,,,,,fee schedule,131.71,584.37,
Ocular blood flow measure,0198T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,131.71,584.37,APC 378
Ocular blood flow measure,0198T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,131.71,584.37,APC
Ocular blood flow measure,0198T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,131.71,584.37,APC
Ocular blood flow measure,0198T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,131.71,584.37,APC
Ocular blood flow measure,0198T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,131.71,584.37,Radiology
Ocular blood flow measure,0198T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,131.71,584.37,APC
Ocular blood flow measure,0198T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,131.71,584.37,APC
Rhd&rhce gntyp rhd1-10&rhce5,0198U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,254.59,,,,,,,fee schedule,254.59,495.04,Laboratory
Rhd&rhce gntyp rhd1-10&rhce5,0198U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,297.02,,,,,,,fee schedule,254.59,495.04,APC
Rhd&rhce gntyp rhd1-10&rhce5,0198U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,294.2,,,,,,,fee schedule,254.59,495.04,APC
Rhd&rhce gntyp rhd1-10&rhce5,0198U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,282.88,,,,,,,fee schedule,254.59,495.04,APC
Rhd&rhce gntyp rhd1-10&rhce5,0198U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,432.81,,,,,,,fee schedule,254.59,495.04,Radiology
Rhd&rhce gntyp rhd1-10&rhce5,0198U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,396.03,,,,,,,fee schedule,254.59,495.04,APC
Rhd&rhce gntyp rhd1-10&rhce5,0198U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,495.04,,,,,,,fee schedule,254.59,495.04,APC
Sc gnotyp ermap exons 4 12,0199U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,247.35,,,,,,,fee schedule,247.35,480.95,Laboratory
Sc gnotyp ermap exons 4 12,0199U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,288.57,,,,,,,fee schedule,247.35,480.95,APC
Sc gnotyp ermap exons 4 12,0199U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,285.82,,,,,,,fee schedule,247.35,480.95,APC
Sc gnotyp ermap exons 4 12,0199U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,274.83,,,,,,,fee schedule,247.35,480.95,APC
Sc gnotyp ermap exons 4 12,0199U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,420.49,,,,,,,fee schedule,247.35,480.95,Radiology
Sc gnotyp ermap exons 4 12,0199U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,384.76,,,,,,,fee schedule,247.35,480.95,APC
Sc gnotyp ermap exons 4 12,0199U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,480.95,,,,,,,fee schedule,247.35,480.95,APC
Perq sacral augmt unilat inj,0200T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8719.59,,,,,,,fee schedule,6989.51,31870.39,
Perq sacral augmt unilat inj,0200T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6989.51,,,,,,,fee schedule,6989.51,31870.39,
Perq sacral augmt unilat inj,0200T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7635.41,,,,,,,fee schedule,6989.51,31870.39,
Perq sacral augmt unilat inj,0200T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8027.56,,,,,,,fee schedule,6989.51,31870.39,
Perq sacral augmt unilat inj,0200T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,6989.51,31870.39,APC 378
Perq sacral augmt unilat inj,0200T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,6989.51,31870.39,APC
Perq sacral augmt unilat inj,0200T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,6989.51,31870.39,APC
Perq sacral augmt unilat inj,0200T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,6989.51,31870.39,APC
Perq sacral augmt unilat inj,0200T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,6989.51,31870.39,Radiology
Perq sacral augmt unilat inj,0200T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,6989.51,31870.39,APC
Perq sacral augmt unilat inj,0200T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,6989.51,31870.39,APC
Xk gnotyp xk exons 1-3,0200U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,247.35,,,,,,,fee schedule,247.35,480.95,Laboratory
Xk gnotyp xk exons 1-3,0200U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,288.57,,,,,,,fee schedule,247.35,480.95,APC
Xk gnotyp xk exons 1-3,0200U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,285.82,,,,,,,fee schedule,247.35,480.95,APC
Xk gnotyp xk exons 1-3,0200U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,274.83,,,,,,,fee schedule,247.35,480.95,APC
Xk gnotyp xk exons 1-3,0200U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,420.49,,,,,,,fee schedule,247.35,480.95,Radiology
Xk gnotyp xk exons 1-3,0200U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,384.76,,,,,,,fee schedule,247.35,480.95,APC
Xk gnotyp xk exons 1-3,0200U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,480.95,,,,,,,fee schedule,247.35,480.95,APC
Perq sacral augmt bilat inj,0201T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8719.59,,,,,,,fee schedule,6989.51,31870.39,
Perq sacral augmt bilat inj,0201T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6989.51,,,,,,,fee schedule,6989.51,31870.39,
Perq sacral augmt bilat inj,0201T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7635.41,,,,,,,fee schedule,6989.51,31870.39,
Perq sacral augmt bilat inj,0201T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8027.56,,,,,,,fee schedule,6989.51,31870.39,
Perq sacral augmt bilat inj,0201T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,6989.51,31870.39,APC 378
Perq sacral augmt bilat inj,0201T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,6989.51,31870.39,APC
Perq sacral augmt bilat inj,0201T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,6989.51,31870.39,APC
Perq sacral augmt bilat inj,0201T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,6989.51,31870.39,APC
Perq sacral augmt bilat inj,0201T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,6989.51,31870.39,Radiology
Perq sacral augmt bilat inj,0201T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,6989.51,31870.39,APC
Perq sacral augmt bilat inj,0201T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,6989.51,31870.39,APC
Yt gnotyp ache exon 2,0201U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,166.68,,,,,,,fee schedule,166.68,324.1,Laboratory
Yt gnotyp ache exon 2,0201U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,194.46,,,,,,,fee schedule,166.68,324.1,APC
Yt gnotyp ache exon 2,0201U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,192.61,,,,,,,fee schedule,166.68,324.1,APC
Yt gnotyp ache exon 2,0201U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,185.2,,,,,,,fee schedule,166.68,324.1,APC
Yt gnotyp ache exon 2,0201U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,283.36,,,,,,,fee schedule,166.68,324.1,Radiology
Yt gnotyp ache exon 2,0201U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,259.28,,,,,,,fee schedule,166.68,324.1,APC
Yt gnotyp ache exon 2,0201U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,324.1,,,,,,,fee schedule,166.68,324.1,APC
Post vert arthrplst 1 lumbar,0202T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46549.79,,,,,,,fee schedule,12709.88,56389.43,
Post vert arthrplst 1 lumbar,0202T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37313.72,,,,,,,fee schedule,12709.88,56389.43,
Post vert arthrplst 1 lumbar,0202T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40761.86,,,,,,,fee schedule,12709.88,56389.43,
Post vert arthrplst 1 lumbar,0202T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42855.36,,,,,,,fee schedule,12709.88,56389.43,
Post vert arthrplst 1 lumbar,0202T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,12709.88,56389.43,APC 378
Post vert arthrplst 1 lumbar,0202T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,12709.88,56389.43,APC
Post vert arthrplst 1 lumbar,0202T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,12709.88,56389.43,APC
Post vert arthrplst 1 lumbar,0202T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,12709.88,56389.43,APC
Post vert arthrplst 1 lumbar,0202T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,12709.88,56389.43,Radiology
Post vert arthrplst 1 lumbar,0202T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,12709.88,56389.43,APC
Post vert arthrplst 1 lumbar,0202T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,12709.88,56389.43,APC
Nfct ds 22 trgt sars-cov-2,0202U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,375.1,,,,,,,fee schedule,375.1,729.36,Laboratory
Nfct ds 22 trgt sars-cov-2,0202U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,437.62,,,,,,,fee schedule,375.1,729.36,APC
Nfct ds 22 trgt sars-cov-2,0202U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,433.45,,,,,,,fee schedule,375.1,729.36,APC
Nfct ds 22 trgt sars-cov-2,0202U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,416.78,,,,,,,fee schedule,375.1,729.36,APC
Nfct ds 22 trgt sars-cov-2,0202U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,637.67,,,,,,,fee schedule,375.1,729.36,Radiology
Nfct ds 22 trgt sars-cov-2,0202U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,583.49,,,,,,,fee schedule,375.1,729.36,APC
Nfct ds 22 trgt sars-cov-2,0202U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,729.36,,,,,,,fee schedule,375.1,729.36,APC
Ai ibd mrna xprsn prfl 17,0203U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,684,,,,,,,fee schedule,684,1330,Laboratory
Ai ibd mrna xprsn prfl 17,0203U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,798,,,,,,,fee schedule,684,1330,APC
Ai ibd mrna xprsn prfl 17,0203U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,790.4,,,,,,,fee schedule,684,1330,APC
Ai ibd mrna xprsn prfl 17,0203U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,760,,,,,,,fee schedule,684,1330,APC
Ai ibd mrna xprsn prfl 17,0203U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1162.8,,,,,,,fee schedule,684,1330,Radiology
Ai ibd mrna xprsn prfl 17,0203U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1064,,,,,,,fee schedule,684,1330,APC
Ai ibd mrna xprsn prfl 17,0203U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1330,,,,,,,fee schedule,684,1330,APC
Oph amd alys 3 gene variants,0205U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,42.3,,,,,,,fee schedule,42.3,82.25,Laboratory
Oph amd alys 3 gene variants,0205U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,49.35,,,,,,,fee schedule,42.3,82.25,APC
Oph amd alys 3 gene variants,0205U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,48.88,,,,,,,fee schedule,42.3,82.25,APC
Oph amd alys 3 gene variants,0205U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,47,,,,,,,fee schedule,42.3,82.25,APC
Oph amd alys 3 gene variants,0205U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,71.91,,,,,,,fee schedule,42.3,82.25,Radiology
Oph amd alys 3 gene variants,0205U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,65.8,,,,,,,fee schedule,42.3,82.25,APC
Oph amd alys 3 gene variants,0205U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,82.25,,,,,,,fee schedule,42.3,82.25,APC
Neuro alzheimer cell aggregj,0206U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1993.86,,,,,,,fee schedule,1993.86,3876.95,Laboratory
Neuro alzheimer cell aggregj,0206U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2326.17,,,,,,,fee schedule,1993.86,3876.95,APC
Neuro alzheimer cell aggregj,0206U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2304.02,,,,,,,fee schedule,1993.86,3876.95,APC
Neuro alzheimer cell aggregj,0206U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2215.4,,,,,,,fee schedule,1993.86,3876.95,APC
Neuro alzheimer cell aggregj,0206U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3389.56,,,,,,,fee schedule,1993.86,3876.95,Radiology
Neuro alzheimer cell aggregj,0206U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3101.56,,,,,,,fee schedule,1993.86,3876.95,APC
Neuro alzheimer cell aggregj,0206U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3876.95,,,,,,,fee schedule,1993.86,3876.95,APC
Clear eyelid gland w/heat,0207T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,182.99,,,,,,,fee schedule,131.71,584.37,
Clear eyelid gland w/heat,0207T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,146.68,,,,,,,fee schedule,131.71,584.37,
Clear eyelid gland w/heat,0207T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,160.24,,,,,,,fee schedule,131.71,584.37,
Clear eyelid gland w/heat,0207T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,168.47,,,,,,,fee schedule,131.71,584.37,
Clear eyelid gland w/heat,0207T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,131.71,584.37,APC 378
Clear eyelid gland w/heat,0207T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,131.71,584.37,APC
Clear eyelid gland w/heat,0207T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,131.71,584.37,APC
Clear eyelid gland w/heat,0207T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,131.71,584.37,APC
Clear eyelid gland w/heat,0207T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,131.71,584.37,Radiology
Clear eyelid gland w/heat,0207T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,131.71,584.37,APC
Clear eyelid gland w/heat,0207T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,131.71,584.37,APC
Audiometry air only,0208T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,88.57,,,,,,,fee schedule,36.98,164.05,
Audiometry air only,0208T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,70.99,,,,,,,fee schedule,36.98,164.05,
Audiometry air only,0208T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,77.55,,,,,,,fee schedule,36.98,164.05,
Audiometry air only,0208T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,81.54,,,,,,,fee schedule,36.98,164.05,
Audiometry air only,0208T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.05,,,,,,,fee schedule,36.98,164.05,APC 378
Audiometry air only,0208T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.83,,,,,,,fee schedule,36.98,164.05,APC
Audiometry air only,0208T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.46,,,,,,,fee schedule,36.98,164.05,APC
Audiometry air only,0208T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.98,,,,,,,fee schedule,36.98,164.05,APC
Audiometry air only,0208T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.57,,,,,,,fee schedule,36.98,164.05,Radiology
Audiometry air only,0208T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.77,,,,,,,fee schedule,36.98,164.05,APC
Audiometry air only,0208T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.71,,,,,,,fee schedule,36.98,164.05,APC
Audiometry air & bone,0209T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,88.57,,,,,,,fee schedule,36.98,164.05,
Audiometry air & bone,0209T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,70.99,,,,,,,fee schedule,36.98,164.05,
Audiometry air & bone,0209T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,77.55,,,,,,,fee schedule,36.98,164.05,
Audiometry air & bone,0209T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,81.54,,,,,,,fee schedule,36.98,164.05,
Audiometry air & bone,0209T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.05,,,,,,,fee schedule,36.98,164.05,APC 378
Audiometry air & bone,0209T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.83,,,,,,,fee schedule,36.98,164.05,APC
Audiometry air & bone,0209T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.46,,,,,,,fee schedule,36.98,164.05,APC
Audiometry air & bone,0209T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.98,,,,,,,fee schedule,36.98,164.05,APC
Audiometry air & bone,0209T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.57,,,,,,,fee schedule,36.98,164.05,Radiology
Audiometry air & bone,0209T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.77,,,,,,,fee schedule,36.98,164.05,APC
Audiometry air & bone,0209T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.71,,,,,,,fee schedule,36.98,164.05,APC
Cytog const alys interrog,0209U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,708.44,,,,,,,fee schedule,708.44,1377.51,Laboratory
Cytog const alys interrog,0209U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,826.51,,,,,,,fee schedule,708.44,1377.51,APC
Cytog const alys interrog,0209U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,818.64,,,,,,,fee schedule,708.44,1377.51,APC
Cytog const alys interrog,0209U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,787.15,,,,,,,fee schedule,708.44,1377.51,APC
Cytog const alys interrog,0209U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1204.34,,,,,,,fee schedule,708.44,1377.51,Radiology
Cytog const alys interrog,0209U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1102.01,,,,,,,fee schedule,708.44,1377.51,APC
Cytog const alys interrog,0209U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1377.51,,,,,,,fee schedule,708.44,1377.51,APC
Speech audiometry threshold,0210T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,88.57,,,,,,,fee schedule,36.98,164.05,
Speech audiometry threshold,0210T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,70.99,,,,,,,fee schedule,36.98,164.05,
Speech audiometry threshold,0210T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,77.55,,,,,,,fee schedule,36.98,164.05,
Speech audiometry threshold,0210T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,81.54,,,,,,,fee schedule,36.98,164.05,
Speech audiometry threshold,0210T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.05,,,,,,,fee schedule,36.98,164.05,APC 378
Speech audiometry threshold,0210T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.83,,,,,,,fee schedule,36.98,164.05,APC
Speech audiometry threshold,0210T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.46,,,,,,,fee schedule,36.98,164.05,APC
Speech audiometry threshold,0210T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.98,,,,,,,fee schedule,36.98,164.05,APC
Speech audiometry threshold,0210T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.57,,,,,,,fee schedule,36.98,164.05,Radiology
Speech audiometry threshold,0210T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.77,,,,,,,fee schedule,36.98,164.05,APC
Speech audiometry threshold,0210T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.71,,,,,,,fee schedule,36.98,164.05,APC
Syphilis tst antb ia quan,0210U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.77,,,,,,,fee schedule,16.77,32.6,Laboratory
Syphilis tst antb ia quan,0210U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.56,,,,,,,fee schedule,16.77,32.6,APC
Syphilis tst antb ia quan,0210U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,19.38,,,,,,,fee schedule,16.77,32.6,APC
Syphilis tst antb ia quan,0210U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18.63,,,,,,,fee schedule,16.77,32.6,APC
Syphilis tst antb ia quan,0210U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.5,,,,,,,fee schedule,16.77,32.6,Radiology
Syphilis tst antb ia quan,0210U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26.08,,,,,,,fee schedule,16.77,32.6,APC
Syphilis tst antb ia quan,0210U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,32.6,,,,,,,fee schedule,16.77,32.6,APC
Speech audiom thresh & recog,0211T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,88.57,,,,,,,fee schedule,36.98,164.05,
Speech audiom thresh & recog,0211T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,70.99,,,,,,,fee schedule,36.98,164.05,
Speech audiom thresh & recog,0211T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,77.55,,,,,,,fee schedule,36.98,164.05,
Speech audiom thresh & recog,0211T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,81.54,,,,,,,fee schedule,36.98,164.05,
Speech audiom thresh & recog,0211T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.05,,,,,,,fee schedule,36.98,164.05,APC 378
Speech audiom thresh & recog,0211T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.83,,,,,,,fee schedule,36.98,164.05,APC
Speech audiom thresh & recog,0211T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.46,,,,,,,fee schedule,36.98,164.05,APC
Speech audiom thresh & recog,0211T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.98,,,,,,,fee schedule,36.98,164.05,APC
Speech audiom thresh & recog,0211T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.57,,,,,,,fee schedule,36.98,164.05,Radiology
Speech audiom thresh & recog,0211T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.77,,,,,,,fee schedule,36.98,164.05,APC
Speech audiom thresh & recog,0211T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.71,,,,,,,fee schedule,36.98,164.05,APC
Onc pan-tum dna&rna gnrj seq,0211U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7609.5,,,,,,,fee schedule,7609.5,14796.25,Laboratory
Onc pan-tum dna&rna gnrj seq,0211U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8877.75,,,,,,,fee schedule,7609.5,14796.25,APC
Onc pan-tum dna&rna gnrj seq,0211U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8793.2,,,,,,,fee schedule,7609.5,14796.25,APC
Onc pan-tum dna&rna gnrj seq,0211U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8455,,,,,,,fee schedule,7609.5,14796.25,APC
Onc pan-tum dna&rna gnrj seq,0211U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12936.15,,,,,,,fee schedule,7609.5,14796.25,Radiology
Onc pan-tum dna&rna gnrj seq,0211U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11837,,,,,,,fee schedule,7609.5,14796.25,APC
Onc pan-tum dna&rna gnrj seq,0211U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14796.25,,,,,,,fee schedule,7609.5,14796.25,APC
Compre audiometry evaluation,0212T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,334.91,,,,,,,fee schedule,127.38,565.15,
Compre audiometry evaluation,0212T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,268.46,,,,,,,fee schedule,127.38,565.15,
Compre audiometry evaluation,0212T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,293.27,,,,,,,fee schedule,127.38,565.15,
Compre audiometry evaluation,0212T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,308.33,,,,,,,fee schedule,127.38,565.15,
Compre audiometry evaluation,0212T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,565.15,,,,,,,fee schedule,127.38,565.15,APC 378
Compre audiometry evaluation,0212T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,133.75,,,,,,,fee schedule,127.38,565.15,APC
Compre audiometry evaluation,0212T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,132.48,,,,,,,fee schedule,127.38,565.15,APC
Compre audiometry evaluation,0212T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,127.38,,,,,,,fee schedule,127.38,565.15,APC
Compre audiometry evaluation,0212T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,194.89,,,,,,,fee schedule,127.38,565.15,Radiology
Compre audiometry evaluation,0212T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,178.33,,,,,,,fee schedule,127.38,565.15,APC
Compre audiometry evaluation,0212T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,222.92,,,,,,,fee schedule,127.38,565.15,APC
Rare ds gen dna alys proband,0212U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4927.68,,,,,,,fee schedule,4927.68,9581.6,Laboratory
Rare ds gen dna alys proband,0212U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5748.96,,,,,,,fee schedule,4927.68,9581.6,APC
Rare ds gen dna alys proband,0212U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5694.21,,,,,,,fee schedule,4927.68,9581.6,APC
Rare ds gen dna alys proband,0212U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5475.2,,,,,,,fee schedule,4927.68,9581.6,APC
Rare ds gen dna alys proband,0212U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8377.06,,,,,,,fee schedule,4927.68,9581.6,Radiology
Rare ds gen dna alys proband,0212U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7665.28,,,,,,,fee schedule,4927.68,9581.6,APC
Rare ds gen dna alys proband,0212U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9581.6,,,,,,,fee schedule,4927.68,9581.6,APC
Njx paravert w/us cer/thor,0213T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2138.54,,,,,,,fee schedule,875.6,3884.74,
Njx paravert w/us cer/thor,0213T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1714.22,,,,,,,fee schedule,875.6,3884.74,
Njx paravert w/us cer/thor,0213T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1872.63,,,,,,,fee schedule,875.6,3884.74,
Njx paravert w/us cer/thor,0213T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1968.81,,,,,,,fee schedule,875.6,3884.74,
Njx paravert w/us cer/thor,0213T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3884.74,,,,,,,fee schedule,875.6,3884.74,APC 378
Njx paravert w/us cer/thor,0213T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,919.38,,,,,,,fee schedule,875.6,3884.74,APC
Njx paravert w/us cer/thor,0213T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,910.62,,,,,,,fee schedule,875.6,3884.74,APC
Njx paravert w/us cer/thor,0213T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,875.6,,,,,,,fee schedule,875.6,3884.74,APC
Njx paravert w/us cer/thor,0213T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1339.67,,,,,,,fee schedule,875.6,3884.74,Radiology
Njx paravert w/us cer/thor,0213T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1225.84,,,,,,,fee schedule,875.6,3884.74,APC
Njx paravert w/us cer/thor,0213T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1532.3,,,,,,,fee schedule,875.6,3884.74,APC
Rare ds gen dna alys ea comp,0213U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2438.96,,,,,,,fee schedule,2438.96,4742.41,Laboratory
Rare ds gen dna alys ea comp,0213U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2845.45,,,,,,,fee schedule,2438.96,4742.41,APC
Rare ds gen dna alys ea comp,0213U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2818.35,,,,,,,fee schedule,2438.96,4742.41,APC
Rare ds gen dna alys ea comp,0213U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2709.95,,,,,,,fee schedule,2438.96,4742.41,APC
Rare ds gen dna alys ea comp,0213U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4146.22,,,,,,,fee schedule,2438.96,4742.41,Radiology
Rare ds gen dna alys ea comp,0213U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3793.93,,,,,,,fee schedule,2438.96,4742.41,APC
Rare ds gen dna alys ea comp,0213U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4742.41,,,,,,,fee schedule,2438.96,4742.41,APC
Njx paravert w/us cer/thor,0214T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,690.27,,,,,,,fee schedule,553.31,690.27,
Njx paravert w/us cer/thor,0214T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,553.31,,,,,,,fee schedule,553.31,690.27,
Njx paravert w/us cer/thor,0214T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,604.44,,,,,,,fee schedule,553.31,690.27,
Njx paravert w/us cer/thor,0214T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,635.48,,,,,,,fee schedule,553.31,690.27,
Rare ds xom dna alys proband,0214U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4702.14,,,,,,,fee schedule,4702.14,9143.05,Laboratory
Rare ds xom dna alys proband,0214U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5485.83,,,,,,,fee schedule,4702.14,9143.05,APC
Rare ds xom dna alys proband,0214U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5433.58,,,,,,,fee schedule,4702.14,9143.05,APC
Rare ds xom dna alys proband,0214U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5224.6,,,,,,,fee schedule,4702.14,9143.05,APC
Rare ds xom dna alys proband,0214U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7993.64,,,,,,,fee schedule,4702.14,9143.05,Radiology
Rare ds xom dna alys proband,0214U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7314.44,,,,,,,fee schedule,4702.14,9143.05,APC
Rare ds xom dna alys proband,0214U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9143.05,,,,,,,fee schedule,4702.14,9143.05,APC
Njx paravert w/us cer/thor,0215T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,690.27,,,,,,,fee schedule,553.31,690.27,
Njx paravert w/us cer/thor,0215T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,553.31,,,,,,,fee schedule,553.31,690.27,
Njx paravert w/us cer/thor,0215T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,604.44,,,,,,,fee schedule,553.31,690.27,
Njx paravert w/us cer/thor,0215T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,635.48,,,,,,,fee schedule,553.31,690.27,
Rare ds xom dna alys ea comp,0215U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2317.18,,,,,,,fee schedule,2317.18,4505.64,Laboratory
Rare ds xom dna alys ea comp,0215U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2703.38,,,,,,,fee schedule,2317.18,4505.64,APC
Rare ds xom dna alys ea comp,0215U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2677.64,,,,,,,fee schedule,2317.18,4505.64,APC
Rare ds xom dna alys ea comp,0215U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2574.65,,,,,,,fee schedule,2317.18,4505.64,APC
Rare ds xom dna alys ea comp,0215U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3939.21,,,,,,,fee schedule,2317.18,4505.64,Radiology
Rare ds xom dna alys ea comp,0215U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3604.51,,,,,,,fee schedule,2317.18,4505.64,APC
Rare ds xom dna alys ea comp,0215U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4505.64,,,,,,,fee schedule,2317.18,4505.64,APC
Njx paravert w/us lumb/sac,0216T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2138.54,,,,,,,fee schedule,875.6,3884.74,
Njx paravert w/us lumb/sac,0216T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1714.22,,,,,,,fee schedule,875.6,3884.74,
Njx paravert w/us lumb/sac,0216T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1872.63,,,,,,,fee schedule,875.6,3884.74,
Njx paravert w/us lumb/sac,0216T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1968.81,,,,,,,fee schedule,875.6,3884.74,
Njx paravert w/us lumb/sac,0216T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3884.74,,,,,,,fee schedule,875.6,3884.74,APC 378
Njx paravert w/us lumb/sac,0216T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,919.38,,,,,,,fee schedule,875.6,3884.74,APC
Njx paravert w/us lumb/sac,0216T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,910.62,,,,,,,fee schedule,875.6,3884.74,APC
Njx paravert w/us lumb/sac,0216T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,875.6,,,,,,,fee schedule,875.6,3884.74,APC
Njx paravert w/us lumb/sac,0216T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1339.67,,,,,,,fee schedule,875.6,3884.74,Radiology
Njx paravert w/us lumb/sac,0216T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1225.84,,,,,,,fee schedule,875.6,3884.74,APC
Njx paravert w/us lumb/sac,0216T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1532.3,,,,,,,fee schedule,875.6,3884.74,APC
Neuro inh ataxia dna 12 com,0216U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1383.32,,,,,,,fee schedule,1383.32,2689.78,Laboratory
Neuro inh ataxia dna 12 com,0216U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1613.87,,,,,,,fee schedule,1383.32,2689.78,APC
Neuro inh ataxia dna 12 com,0216U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1598.5,,,,,,,fee schedule,1383.32,2689.78,APC
Neuro inh ataxia dna 12 com,0216U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1537.02,,,,,,,fee schedule,1383.32,2689.78,APC
Neuro inh ataxia dna 12 com,0216U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2351.64,,,,,,,fee schedule,1383.32,2689.78,Radiology
Neuro inh ataxia dna 12 com,0216U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2151.83,,,,,,,fee schedule,1383.32,2689.78,APC
Neuro inh ataxia dna 12 com,0216U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2689.78,,,,,,,fee schedule,1383.32,2689.78,APC
Njx paravert w/us lumb/sac,0217T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,690.27,,,,,,,fee schedule,553.31,690.27,
Njx paravert w/us lumb/sac,0217T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,553.31,,,,,,,fee schedule,553.31,690.27,
Njx paravert w/us lumb/sac,0217T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,604.44,,,,,,,fee schedule,553.31,690.27,
Njx paravert w/us lumb/sac,0217T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,635.48,,,,,,,fee schedule,553.31,690.27,
Neuro inh ataxia dna 51 gene,0217U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1978.52,,,,,,,fee schedule,1978.52,3847.11,Laboratory
Neuro inh ataxia dna 51 gene,0217U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2308.27,,,,,,,fee schedule,1978.52,3847.11,APC
Neuro inh ataxia dna 51 gene,0217U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2286.28,,,,,,,fee schedule,1978.52,3847.11,APC
Neuro inh ataxia dna 51 gene,0217U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2198.35,,,,,,,fee schedule,1978.52,3847.11,APC
Neuro inh ataxia dna 51 gene,0217U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3363.48,,,,,,,fee schedule,1978.52,3847.11,Radiology
Neuro inh ataxia dna 51 gene,0217U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3077.69,,,,,,,fee schedule,1978.52,3847.11,APC
Neuro inh ataxia dna 51 gene,0217U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3847.11,,,,,,,fee schedule,1978.52,3847.11,APC
Njx paravert w/us lumb/sac,0218T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,690.27,,,,,,,fee schedule,553.31,690.27,
Njx paravert w/us lumb/sac,0218T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,553.31,,,,,,,fee schedule,553.31,690.27,
Njx paravert w/us lumb/sac,0218T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,604.44,,,,,,,fee schedule,553.31,690.27,
Njx paravert w/us lumb/sac,0218T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,635.48,,,,,,,fee schedule,553.31,690.27,
Neuro musc dys dmd seq alys,0218U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2051.1,,,,,,,fee schedule,2051.1,3988.25,Laboratory
Neuro musc dys dmd seq alys,0218U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2392.95,,,,,,,fee schedule,2051.1,3988.25,APC
Neuro musc dys dmd seq alys,0218U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2370.16,,,,,,,fee schedule,2051.1,3988.25,APC
Neuro musc dys dmd seq alys,0218U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2279,,,,,,,fee schedule,2051.1,3988.25,APC
Neuro musc dys dmd seq alys,0218U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3486.87,,,,,,,fee schedule,2051.1,3988.25,Radiology
Neuro musc dys dmd seq alys,0218U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3190.6,,,,,,,fee schedule,2051.1,3988.25,APC
Neuro musc dys dmd seq alys,0218U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3988.25,,,,,,,fee schedule,2051.1,3988.25,APC
Plmt post facet implt cerv,0219T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46549.79,,,,,,,fee schedule,12709.88,56389.43,
Plmt post facet implt cerv,0219T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37313.72,,,,,,,fee schedule,12709.88,56389.43,
Plmt post facet implt cerv,0219T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40761.86,,,,,,,fee schedule,12709.88,56389.43,
Plmt post facet implt cerv,0219T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42855.36,,,,,,,fee schedule,12709.88,56389.43,
Plmt post facet implt cerv,0219T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,12709.88,56389.43,APC 378
Plmt post facet implt cerv,0219T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,12709.88,56389.43,APC
Plmt post facet implt cerv,0219T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,12709.88,56389.43,APC
Plmt post facet implt cerv,0219T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,12709.88,56389.43,APC
Plmt post facet implt cerv,0219T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,12709.88,56389.43,Radiology
Plmt post facet implt cerv,0219T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,12709.88,56389.43,APC
Plmt post facet implt cerv,0219T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,12709.88,56389.43,APC
Nfct agt hiv gnrj seq alys,0219U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,652.5,,,,,,,fee schedule,652.5,1268.75,Laboratory
Nfct agt hiv gnrj seq alys,0219U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,761.25,,,,,,,fee schedule,652.5,1268.75,APC
Nfct agt hiv gnrj seq alys,0219U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,754,,,,,,,fee schedule,652.5,1268.75,APC
Nfct agt hiv gnrj seq alys,0219U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,725,,,,,,,fee schedule,652.5,1268.75,APC
Nfct agt hiv gnrj seq alys,0219U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1109.25,,,,,,,fee schedule,652.5,1268.75,Radiology
Nfct agt hiv gnrj seq alys,0219U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1015,,,,,,,fee schedule,652.5,1268.75,APC
Nfct agt hiv gnrj seq alys,0219U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1268.75,,,,,,,fee schedule,652.5,1268.75,APC
Plmt post facet implt thor,0220T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46549.79,,,,,,,fee schedule,12709.88,56389.43,
Plmt post facet implt thor,0220T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37313.72,,,,,,,fee schedule,12709.88,56389.43,
Plmt post facet implt thor,0220T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40761.86,,,,,,,fee schedule,12709.88,56389.43,
Plmt post facet implt thor,0220T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42855.36,,,,,,,fee schedule,12709.88,56389.43,
Plmt post facet implt thor,0220T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,12709.88,56389.43,APC 378
Plmt post facet implt thor,0220T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,12709.88,56389.43,APC
Plmt post facet implt thor,0220T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,12709.88,56389.43,APC
Plmt post facet implt thor,0220T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,12709.88,56389.43,APC
Plmt post facet implt thor,0220T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,12709.88,56389.43,Radiology
Plmt post facet implt thor,0220T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,12709.88,56389.43,APC
Plmt post facet implt thor,0220T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,12709.88,56389.43,APC
Onc brst ca ai assmt 12 feat,0220U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,635.62,,,,,,,fee schedule,635.62,1235.94,Laboratory
Onc brst ca ai assmt 12 feat,0220U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,741.56,,,,,,,fee schedule,635.62,1235.94,APC
Onc brst ca ai assmt 12 feat,0220U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,734.5,,,,,,,fee schedule,635.62,1235.94,APC
Onc brst ca ai assmt 12 feat,0220U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,706.25,,,,,,,fee schedule,635.62,1235.94,APC
Onc brst ca ai assmt 12 feat,0220U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1080.56,,,,,,,fee schedule,635.62,1235.94,Radiology
Onc brst ca ai assmt 12 feat,0220U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,988.75,,,,,,,fee schedule,635.62,1235.94,APC
Onc brst ca ai assmt 12 feat,0220U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1235.94,,,,,,,fee schedule,635.62,1235.94,APC
Plmt post facet implt lumb,0221T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8719.59,,,,,,,fee schedule,6989.51,31870.39,
Plmt post facet implt lumb,0221T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6989.51,,,,,,,fee schedule,6989.51,31870.39,
Plmt post facet implt lumb,0221T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7635.41,,,,,,,fee schedule,6989.51,31870.39,
Plmt post facet implt lumb,0221T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8027.56,,,,,,,fee schedule,6989.51,31870.39,
Plmt post facet implt lumb,0221T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,6989.51,31870.39,APC 378
Plmt post facet implt lumb,0221T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,6989.51,31870.39,APC
Plmt post facet implt lumb,0221T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,6989.51,31870.39,APC
Plmt post facet implt lumb,0221T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,6989.51,31870.39,APC
Plmt post facet implt lumb,0221T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,6989.51,31870.39,Radiology
Plmt post facet implt lumb,0221T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,6989.51,31870.39,APC
Plmt post facet implt lumb,0221T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,6989.51,31870.39,APC
Abo gnotyp next gnrj seq abo,0221U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1038.86,,,,,,,fee schedule,247.35,1038.86,
Abo gnotyp next gnrj seq abo,0221U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,832.73,,,,,,,fee schedule,247.35,1038.86,
Abo gnotyp next gnrj seq abo,0221U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,909.69,,,,,,,fee schedule,247.35,1038.86,
Abo gnotyp next gnrj seq abo,0221U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,956.41,,,,,,,fee schedule,247.35,1038.86,
Abo gnotyp next gnrj seq abo,0221U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,247.35,,,,,,,fee schedule,247.35,1038.86,Laboratory
Abo gnotyp next gnrj seq abo,0221U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,288.57,,,,,,,fee schedule,247.35,1038.86,APC
Abo gnotyp next gnrj seq abo,0221U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,285.82,,,,,,,fee schedule,247.35,1038.86,APC
Abo gnotyp next gnrj seq abo,0221U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,274.83,,,,,,,fee schedule,247.35,1038.86,APC
Abo gnotyp next gnrj seq abo,0221U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,420.49,,,,,,,fee schedule,247.35,1038.86,Radiology
Abo gnotyp next gnrj seq abo,0221U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,384.76,,,,,,,fee schedule,247.35,1038.86,APC
Abo gnotyp next gnrj seq abo,0221U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,480.95,,,,,,,fee schedule,247.35,1038.86,APC
Plmt post facet implt addl,0222T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8719.59,,,,,,,fee schedule,6989.51,8719.59,
Plmt post facet implt addl,0222T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6989.51,,,,,,,fee schedule,6989.51,8719.59,
Plmt post facet implt addl,0222T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7635.41,,,,,,,fee schedule,6989.51,8719.59,
Plmt post facet implt addl,0222T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8027.56,,,,,,,fee schedule,6989.51,8719.59,
Rhd&rhce gntyp next gnrj seq,0222U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1069.29,,,,,,,fee schedule,254.59,1069.29,
Rhd&rhce gntyp next gnrj seq,0222U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,857.13,,,,,,,fee schedule,254.59,1069.29,
Rhd&rhce gntyp next gnrj seq,0222U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,936.33,,,,,,,fee schedule,254.59,1069.29,
Rhd&rhce gntyp next gnrj seq,0222U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,984.42,,,,,,,fee schedule,254.59,1069.29,
Rhd&rhce gntyp next gnrj seq,0222U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,254.59,,,,,,,fee schedule,254.59,1069.29,Laboratory
Rhd&rhce gntyp next gnrj seq,0222U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,297.02,,,,,,,fee schedule,254.59,1069.29,APC
Rhd&rhce gntyp next gnrj seq,0222U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,294.2,,,,,,,fee schedule,254.59,1069.29,APC
Rhd&rhce gntyp next gnrj seq,0222U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,282.88,,,,,,,fee schedule,254.59,1069.29,APC
Rhd&rhce gntyp next gnrj seq,0222U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,432.81,,,,,,,fee schedule,254.59,1069.29,Radiology
Rhd&rhce gntyp next gnrj seq,0222U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,396.03,,,,,,,fee schedule,254.59,1069.29,APC
Rhd&rhce gntyp next gnrj seq,0222U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,495.04,,,,,,,fee schedule,254.59,1069.29,APC
Nfct ds 22 trgt sars-cov-2,0223U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1575.43,,,,,,,fee schedule,375.1,1575.43,
Nfct ds 22 trgt sars-cov-2,0223U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1262.84,,,,,,,fee schedule,375.1,1575.43,
Nfct ds 22 trgt sars-cov-2,0223U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1379.54,,,,,,,fee schedule,375.1,1575.43,
Nfct ds 22 trgt sars-cov-2,0223U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1450.39,,,,,,,fee schedule,375.1,1575.43,
Nfct ds 22 trgt sars-cov-2,0223U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,375.1,,,,,,,fee schedule,375.1,1575.43,Laboratory
Nfct ds 22 trgt sars-cov-2,0223U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,437.62,,,,,,,fee schedule,375.1,1575.43,APC
Nfct ds 22 trgt sars-cov-2,0223U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,433.45,,,,,,,fee schedule,375.1,1575.43,APC
Nfct ds 22 trgt sars-cov-2,0223U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,416.78,,,,,,,fee schedule,375.1,1575.43,APC
Nfct ds 22 trgt sars-cov-2,0223U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,637.67,,,,,,,fee schedule,375.1,1575.43,Radiology
Nfct ds 22 trgt sars-cov-2,0223U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,583.49,,,,,,,fee schedule,375.1,1575.43,APC
Nfct ds 22 trgt sars-cov-2,0223U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,729.36,,,,,,,fee schedule,375.1,1575.43,APC
Antibody sars-cov-2 titer(s),0224U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,159.25,,,,,,,fee schedule,46.29,159.25,
Antibody sars-cov-2 titer(s),0224U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,127.65,,,,,,,fee schedule,46.29,159.25,
Antibody sars-cov-2 titer(s),0224U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,139.45,,,,,,,fee schedule,46.29,159.25,
Antibody sars-cov-2 titer(s),0224U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,146.61,,,,,,,fee schedule,46.29,159.25,
Antibody sars-cov-2 titer(s),0224U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46.29,,,,,,,fee schedule,46.29,159.25,Laboratory
Antibody sars-cov-2 titer(s),0224U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54,,,,,,,fee schedule,46.29,159.25,APC
Antibody sars-cov-2 titer(s),0224U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,53.49,,,,,,,fee schedule,46.29,159.25,APC
Antibody sars-cov-2 titer(s),0224U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,51.43,,,,,,,fee schedule,46.29,159.25,APC
Antibody sars-cov-2 titer(s),0224U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,78.69,,,,,,,fee schedule,46.29,159.25,Radiology
Antibody sars-cov-2 titer(s),0224U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,72,,,,,,,fee schedule,46.29,159.25,APC
Antibody sars-cov-2 titer(s),0224U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,90,,,,,,,fee schedule,46.29,159.25,APC
Nfct ds dna&rna 21 sarscov2,0225U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1575.43,,,,,,,fee schedule,375.1,1575.43,
Nfct ds dna&rna 21 sarscov2,0225U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1262.84,,,,,,,fee schedule,375.1,1575.43,
Nfct ds dna&rna 21 sarscov2,0225U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1379.54,,,,,,,fee schedule,375.1,1575.43,
Nfct ds dna&rna 21 sarscov2,0225U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1450.39,,,,,,,fee schedule,375.1,1575.43,
Nfct ds dna&rna 21 sarscov2,0225U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,375.1,,,,,,,fee schedule,375.1,1575.43,Laboratory
Nfct ds dna&rna 21 sarscov2,0225U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,437.62,,,,,,,fee schedule,375.1,1575.43,APC
Nfct ds dna&rna 21 sarscov2,0225U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,433.45,,,,,,,fee schedule,375.1,1575.43,APC
Nfct ds dna&rna 21 sarscov2,0225U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,416.78,,,,,,,fee schedule,375.1,1575.43,APC
Nfct ds dna&rna 21 sarscov2,0225U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,637.67,,,,,,,fee schedule,375.1,1575.43,Radiology
Nfct ds dna&rna 21 sarscov2,0225U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,583.49,,,,,,,fee schedule,375.1,1575.43,APC
Nfct ds dna&rna 21 sarscov2,0225U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,729.36,,,,,,,fee schedule,375.1,1575.43,APC
Svnt sarscov2 elisa plsm srm,0226U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,159.82,,,,,,,fee schedule,38.05,159.82,
Svnt sarscov2 elisa plsm srm,0226U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,128.11,,,,,,,fee schedule,38.05,159.82,
Svnt sarscov2 elisa plsm srm,0226U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,139.95,,,,,,,fee schedule,38.05,159.82,
Svnt sarscov2 elisa plsm srm,0226U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,147.13,,,,,,,fee schedule,38.05,159.82,
Svnt sarscov2 elisa plsm srm,0226U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,38.05,,,,,,,fee schedule,38.05,159.82,Laboratory
Svnt sarscov2 elisa plsm srm,0226U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,44.39,,,,,,,fee schedule,38.05,159.82,APC
Svnt sarscov2 elisa plsm srm,0226U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,43.97,,,,,,,fee schedule,38.05,159.82,APC
Svnt sarscov2 elisa plsm srm,0226U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,42.28,,,,,,,fee schedule,38.05,159.82,APC
Svnt sarscov2 elisa plsm srm,0226U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,64.69,,,,,,,fee schedule,38.05,159.82,Radiology
Svnt sarscov2 elisa plsm srm,0226U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,59.19,,,,,,,fee schedule,38.05,159.82,APC
Svnt sarscov2 elisa plsm srm,0226U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,73.99,,,,,,,fee schedule,38.05,159.82,APC
Rx asy prsmv 30+rx/metablt,0227U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,234.89,,,,,,,fee schedule,55.93,234.89,
Rx asy prsmv 30+rx/metablt,0227U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,188.28,,,,,,,fee schedule,55.93,234.89,
Rx asy prsmv 30+rx/metablt,0227U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,205.68,,,,,,,fee schedule,55.93,234.89,
Rx asy prsmv 30+rx/metablt,0227U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,216.25,,,,,,,fee schedule,55.93,234.89,
Rx asy prsmv 30+rx/metablt,0227U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,55.93,,,,,,,fee schedule,55.93,234.89,Laboratory
Rx asy prsmv 30+rx/metablt,0227U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,65.25,,,,,,,fee schedule,55.93,234.89,APC
Rx asy prsmv 30+rx/metablt,0227U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,64.63,,,,,,,fee schedule,55.93,234.89,APC
Rx asy prsmv 30+rx/metablt,0227U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,62.14,,,,,,,fee schedule,55.93,234.89,APC
Rx asy prsmv 30+rx/metablt,0227U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,95.07,,,,,,,fee schedule,55.93,234.89,Radiology
Rx asy prsmv 30+rx/metablt,0227U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,87,,,,,,,fee schedule,55.93,234.89,APC
Rx asy prsmv 30+rx/metablt,0227U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,108.74,,,,,,,fee schedule,55.93,234.89,APC
Onc prst8 ma molec prfl alg,0228U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,155.73,,,,,,,fee schedule,155.73,302.8,Laboratory
Onc prst8 ma molec prfl alg,0228U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,181.68,,,,,,,fee schedule,155.73,302.8,APC
Onc prst8 ma molec prfl alg,0228U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,179.95,,,,,,,fee schedule,155.73,302.8,APC
Onc prst8 ma molec prfl alg,0228U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,173.03,,,,,,,fee schedule,155.73,302.8,APC
Onc prst8 ma molec prfl alg,0228U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,264.74,,,,,,,fee schedule,155.73,302.8,Radiology
Onc prst8 ma molec prfl alg,0228U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,242.24,,,,,,,fee schedule,155.73,302.8,APC
Onc prst8 ma molec prfl alg,0228U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,302.8,,,,,,,fee schedule,155.73,302.8,APC
Bcat1 promoter mthyltn alys,0229U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,725.76,,,,,,,fee schedule,345.6,725.76,
Bcat1 promoter mthyltn alys,0229U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,581.76,,,,,,,fee schedule,345.6,725.76,
Bcat1 promoter mthyltn alys,0229U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,635.52,,,,,,,fee schedule,345.6,725.76,
Bcat1 promoter mthyltn alys,0229U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,668.16,,,,,,,fee schedule,345.6,725.76,
Bcat1 promoter mthyltn alys,0229U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,345.6,,,,,,,fee schedule,345.6,725.76,Laboratory
Bcat1 promoter mthyltn alys,0229U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,403.2,,,,,,,fee schedule,345.6,725.76,APC
Bcat1 promoter mthyltn alys,0229U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,399.36,,,,,,,fee schedule,345.6,725.76,APC
Bcat1 promoter mthyltn alys,0229U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,384,,,,,,,fee schedule,345.6,725.76,APC
Bcat1 promoter mthyltn alys,0229U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,587.52,,,,,,,fee schedule,345.6,725.76,Radiology
Bcat1 promoter mthyltn alys,0229U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,537.6,,,,,,,fee schedule,345.6,725.76,APC
Bcat1 promoter mthyltn alys,0229U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,672,,,,,,,fee schedule,345.6,725.76,APC
Ar full sequence analysis,0230U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1139.1,,,,,,,fee schedule,271.21,1139.1,
Ar full sequence analysis,0230U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,913.09,,,,,,,fee schedule,271.21,1139.1,
Ar full sequence analysis,0230U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,997.47,,,,,,,fee schedule,271.21,1139.1,
Ar full sequence analysis,0230U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1048.7,,,,,,,fee schedule,271.21,1139.1,
Ar full sequence analysis,0230U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,271.22,,,,,,,fee schedule,271.21,1139.1,Laboratory
Ar full sequence analysis,0230U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,316.42,,,,,,,fee schedule,271.21,1139.1,APC
Ar full sequence analysis,0230U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,313.4,,,,,,,fee schedule,271.21,1139.1,APC
Ar full sequence analysis,0230U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,301.35,,,,,,,fee schedule,271.21,1139.1,APC
Ar full sequence analysis,0230U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,461.07,,,,,,,fee schedule,271.21,1139.1,Radiology
Ar full sequence analysis,0230U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,421.89,,,,,,,fee schedule,271.21,1139.1,APC
Ar full sequence analysis,0230U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,527.36,,,,,,,fee schedule,271.21,1139.1,APC
Cacna1a full gene analysis,0231U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3198.9,,,,,,,fee schedule,761.64,3198.9,
Cacna1a full gene analysis,0231U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2564.2,,,,,,,fee schedule,761.64,3198.9,
Cacna1a full gene analysis,0231U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2801.15,,,,,,,fee schedule,761.64,3198.9,
Cacna1a full gene analysis,0231U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2945.02,,,,,,,fee schedule,761.64,3198.9,
Cacna1a full gene analysis,0231U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,761.64,,,,,,,fee schedule,761.64,3198.9,Laboratory
Cacna1a full gene analysis,0231U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,888.58,,,,,,,fee schedule,761.64,3198.9,APC
Cacna1a full gene analysis,0231U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,880.12,,,,,,,fee schedule,761.64,3198.9,APC
Cacna1a full gene analysis,0231U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,846.27,,,,,,,fee schedule,761.64,3198.9,APC
Cacna1a full gene analysis,0231U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1294.79,,,,,,,fee schedule,761.64,3198.9,Radiology
Cacna1a full gene analysis,0231U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1184.78,,,,,,,fee schedule,761.64,3198.9,APC
Cacna1a full gene analysis,0231U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1480.97,,,,,,,fee schedule,761.64,3198.9,APC
Njx platelet plasma,0232T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,187.64,,,,,,,fee schedule,150.41,1962.08,
Njx platelet plasma,0232T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,150.41,,,,,,,fee schedule,150.41,1962.08,
Njx platelet plasma,0232T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,164.31,,,,,,,fee schedule,150.41,1962.08,
Njx platelet plasma,0232T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,172.75,,,,,,,fee schedule,150.41,1962.08,
Njx platelet plasma,0232T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1962.08,,,,,,,fee schedule,150.41,1962.08,APC 378
Njx platelet plasma,0232T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,464.35,,,,,,,fee schedule,150.41,1962.08,APC
Njx platelet plasma,0232T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,459.93,,,,,,,fee schedule,150.41,1962.08,APC
Njx platelet plasma,0232T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,442.24,,,,,,,fee schedule,150.41,1962.08,APC
Njx platelet plasma,0232T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,676.63,,,,,,,fee schedule,150.41,1962.08,Radiology
Njx platelet plasma,0232T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,619.14,,,,,,,fee schedule,150.41,1962.08,APC
Njx platelet plasma,0232T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,773.92,,,,,,,fee schedule,150.41,1962.08,APC
Cstb full gene analysis,0232U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,247.35,,,,,,,fee schedule,247.35,480.95,Laboratory
Cstb full gene analysis,0232U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,288.57,,,,,,,fee schedule,247.35,480.95,APC
Cstb full gene analysis,0232U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,285.82,,,,,,,fee schedule,247.35,480.95,APC
Cstb full gene analysis,0232U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,274.83,,,,,,,fee schedule,247.35,480.95,APC
Cstb full gene analysis,0232U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,420.49,,,,,,,fee schedule,247.35,480.95,Radiology
Cstb full gene analysis,0232U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,384.76,,,,,,,fee schedule,247.35,480.95,APC
Cstb full gene analysis,0232U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,480.95,,,,,,,fee schedule,247.35,480.95,APC
Fxn gene analysis,0233U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,247.35,,,,,,,fee schedule,247.35,480.95,Laboratory
Fxn gene analysis,0233U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,288.57,,,,,,,fee schedule,247.35,480.95,APC
Fxn gene analysis,0233U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,285.82,,,,,,,fee schedule,247.35,480.95,APC
Fxn gene analysis,0233U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,274.83,,,,,,,fee schedule,247.35,480.95,APC
Fxn gene analysis,0233U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,420.49,,,,,,,fee schedule,247.35,480.95,Radiology
Fxn gene analysis,0233U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,384.76,,,,,,,fee schedule,247.35,480.95,APC
Fxn gene analysis,0233U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,480.95,,,,,,,fee schedule,247.35,480.95,APC
Trluml perip athrc renal art,0234T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,28997.06,,,,,,,fee schedule,11428.37,50703.82,
Trluml perip athrc renal art,0234T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23243.68,,,,,,,fee schedule,11428.37,50703.82,
Trluml perip athrc renal art,0234T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,25391.61,,,,,,,fee schedule,11428.37,50703.82,
Trluml perip athrc renal art,0234T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26695.71,,,,,,,fee schedule,11428.37,50703.82,
Trluml perip athrc renal art,0234T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,50703.82,,,,,,,fee schedule,11428.37,50703.82,APC 378
Trluml perip athrc renal art,0234T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11999.79,,,,,,,fee schedule,11428.37,50703.82,APC
Trluml perip athrc renal art,0234T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11885.51,,,,,,,fee schedule,11428.37,50703.82,APC
Trluml perip athrc renal art,0234T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11428.37,,,,,,,fee schedule,11428.37,50703.82,APC
Trluml perip athrc renal art,0234T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17485.41,,,,,,,fee schedule,11428.37,50703.82,Radiology
Trluml perip athrc renal art,0234T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15999.72,,,,,,,fee schedule,11428.37,50703.82,APC
Trluml perip athrc renal art,0234T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19999.65,,,,,,,fee schedule,11428.37,50703.82,APC
Mecp2 full gene analysis,0234U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,475.08,,,,,,,fee schedule,475.08,923.77,Laboratory
Mecp2 full gene analysis,0234U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,554.26,,,,,,,fee schedule,475.08,923.77,APC
Mecp2 full gene analysis,0234U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,548.98,,,,,,,fee schedule,475.08,923.77,APC
Mecp2 full gene analysis,0234U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,527.87,,,,,,,fee schedule,475.08,923.77,APC
Mecp2 full gene analysis,0234U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,807.64,,,,,,,fee schedule,475.08,923.77,Radiology
Mecp2 full gene analysis,0234U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,739.02,,,,,,,fee schedule,475.08,923.77,APC
Mecp2 full gene analysis,0234U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,923.77,,,,,,,fee schedule,475.08,923.77,APC
Pten full gene analysis,0235U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,540,,,,,,,fee schedule,540,1050,Laboratory
Pten full gene analysis,0235U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,630,,,,,,,fee schedule,540,1050,APC
Pten full gene analysis,0235U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,624,,,,,,,fee schedule,540,1050,APC
Pten full gene analysis,0235U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,600,,,,,,,fee schedule,540,1050,APC
Pten full gene analysis,0235U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,918,,,,,,,fee schedule,540,1050,Radiology
Pten full gene analysis,0235U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,840,,,,,,,fee schedule,540,1050,APC
Pten full gene analysis,0235U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1050,,,,,,,fee schedule,540,1050,APC
Trluml perip athrc abd aorta,0236T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,28997.06,,,,,,,fee schedule,11428.37,50703.82,
Trluml perip athrc abd aorta,0236T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23243.68,,,,,,,fee schedule,11428.37,50703.82,
Trluml perip athrc abd aorta,0236T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,25391.61,,,,,,,fee schedule,11428.37,50703.82,
Trluml perip athrc abd aorta,0236T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26695.71,,,,,,,fee schedule,11428.37,50703.82,
Trluml perip athrc abd aorta,0236T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,50703.82,,,,,,,fee schedule,11428.37,50703.82,APC 378
Trluml perip athrc abd aorta,0236T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11999.79,,,,,,,fee schedule,11428.37,50703.82,APC
Trluml perip athrc abd aorta,0236T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11885.51,,,,,,,fee schedule,11428.37,50703.82,APC
Trluml perip athrc abd aorta,0236T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11428.37,,,,,,,fee schedule,11428.37,50703.82,APC
Trluml perip athrc abd aorta,0236T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17485.41,,,,,,,fee schedule,11428.37,50703.82,Radiology
Trluml perip athrc abd aorta,0236T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15999.72,,,,,,,fee schedule,11428.37,50703.82,APC
Trluml perip athrc abd aorta,0236T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19999.65,,,,,,,fee schedule,11428.37,50703.82,APC
Smn1&smn2 full gene analysis,0236U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,542.43,,,,,,,fee schedule,542.43,1054.72,Laboratory
Smn1&smn2 full gene analysis,0236U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,632.84,,,,,,,fee schedule,542.43,1054.72,APC
Smn1&smn2 full gene analysis,0236U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,626.81,,,,,,,fee schedule,542.43,1054.72,APC
Smn1&smn2 full gene analysis,0236U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,602.7,,,,,,,fee schedule,542.43,1054.72,APC
Smn1&smn2 full gene analysis,0236U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,922.13,,,,,,,fee schedule,542.43,1054.72,Radiology
Smn1&smn2 full gene analysis,0236U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,843.78,,,,,,,fee schedule,542.43,1054.72,APC
Smn1&smn2 full gene analysis,0236U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1054.73,,,,,,,fee schedule,542.43,1054.72,APC
Trluml perip athrc brchiocph,0237T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,28997.06,,,,,,,fee schedule,11428.37,50703.82,
Trluml perip athrc brchiocph,0237T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23243.68,,,,,,,fee schedule,11428.37,50703.82,
Trluml perip athrc brchiocph,0237T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,25391.61,,,,,,,fee schedule,11428.37,50703.82,
Trluml perip athrc brchiocph,0237T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26695.71,,,,,,,fee schedule,11428.37,50703.82,
Trluml perip athrc brchiocph,0237T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,50703.82,,,,,,,fee schedule,11428.37,50703.82,APC 378
Trluml perip athrc brchiocph,0237T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11999.79,,,,,,,fee schedule,11428.37,50703.82,APC
Trluml perip athrc brchiocph,0237T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11885.51,,,,,,,fee schedule,11428.37,50703.82,APC
Trluml perip athrc brchiocph,0237T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11428.37,,,,,,,fee schedule,11428.37,50703.82,APC
Trluml perip athrc brchiocph,0237T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17485.41,,,,,,,fee schedule,11428.37,50703.82,Radiology
Trluml perip athrc brchiocph,0237T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15999.72,,,,,,,fee schedule,11428.37,50703.82,APC
Trluml perip athrc brchiocph,0237T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19999.65,,,,,,,fee schedule,11428.37,50703.82,APC
Car ion chnlpthy gen seq pnl,0237U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,526.41,,,,,,,fee schedule,526.41,1023.58,Laboratory
Car ion chnlpthy gen seq pnl,0237U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,614.14,,,,,,,fee schedule,526.41,1023.58,APC
Car ion chnlpthy gen seq pnl,0237U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,608.3,,,,,,,fee schedule,526.41,1023.58,APC
Car ion chnlpthy gen seq pnl,0237U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,584.9,,,,,,,fee schedule,526.41,1023.58,APC
Car ion chnlpthy gen seq pnl,0237U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,894.9,,,,,,,fee schedule,526.41,1023.58,Radiology
Car ion chnlpthy gen seq pnl,0237U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,818.86,,,,,,,fee schedule,526.41,1023.58,APC
Car ion chnlpthy gen seq pnl,0237U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1023.58,,,,,,,fee schedule,526.41,1023.58,APC
Trluml perip athrc iliac art,0238T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,28997.06,,,,,,,fee schedule,18147.73,80515.32,
Trluml perip athrc iliac art,0238T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23243.68,,,,,,,fee schedule,18147.73,80515.32,
Trluml perip athrc iliac art,0238T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,25391.61,,,,,,,fee schedule,18147.73,80515.32,
Trluml perip athrc iliac art,0238T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26695.71,,,,,,,fee schedule,18147.73,80515.32,
Trluml perip athrc iliac art,0238T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,80515.32,,,,,,,fee schedule,18147.73,80515.32,APC 378
Trluml perip athrc iliac art,0238T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19055.11,,,,,,,fee schedule,18147.73,80515.32,APC
Trluml perip athrc iliac art,0238T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18873.64,,,,,,,fee schedule,18147.73,80515.32,APC
Trluml perip athrc iliac art,0238T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18147.73,,,,,,,fee schedule,18147.73,80515.32,APC
Trluml perip athrc iliac art,0238T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27766.02,,,,,,,fee schedule,18147.73,80515.32,Radiology
Trluml perip athrc iliac art,0238T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25406.82,,,,,,,fee schedule,18147.73,80515.32,APC
Trluml perip athrc iliac art,0238T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31758.52,,,,,,,fee schedule,18147.73,80515.32,APC
Onc lnch syn gen dna seq aly,0238U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,526.41,,,,,,,fee schedule,526.41,1023.58,Laboratory
Onc lnch syn gen dna seq aly,0238U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,614.14,,,,,,,fee schedule,526.41,1023.58,APC
Onc lnch syn gen dna seq aly,0238U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,608.3,,,,,,,fee schedule,526.41,1023.58,APC
Onc lnch syn gen dna seq aly,0238U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,584.9,,,,,,,fee schedule,526.41,1023.58,APC
Onc lnch syn gen dna seq aly,0238U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,894.9,,,,,,,fee schedule,526.41,1023.58,Radiology
Onc lnch syn gen dna seq aly,0238U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,818.86,,,,,,,fee schedule,526.41,1023.58,APC
Onc lnch syn gen dna seq aly,0238U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1023.58,,,,,,,fee schedule,526.41,1023.58,APC
Trgt gen seq alys pnl 311+,0239U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3150,,,,,,,fee schedule,3150,6125,Laboratory
Trgt gen seq alys pnl 311+,0239U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3675,,,,,,,fee schedule,3150,6125,APC
Trgt gen seq alys pnl 311+,0239U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3640,,,,,,,fee schedule,3150,6125,APC
Trgt gen seq alys pnl 311+,0239U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3500,,,,,,,fee schedule,3150,6125,APC
Trgt gen seq alys pnl 311+,0239U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5355,,,,,,,fee schedule,3150,6125,Radiology
Trgt gen seq alys pnl 311+,0239U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4900,,,,,,,fee schedule,3150,6125,APC
Trgt gen seq alys pnl 311+,0239U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6125,,,,,,,fee schedule,3150,6125,APC
Nfct ds vir resp rna 3 trgt,0240U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,539.14,,,,,,,fee schedule,432.17,539.14,
Nfct ds vir resp rna 3 trgt,0240U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,432.17,,,,,,,fee schedule,432.17,539.14,
Nfct ds vir resp rna 3 trgt,0240U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,472.11,,,,,,,fee schedule,432.17,539.14,
Nfct ds vir resp rna 3 trgt,0240U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,496.35,,,,,,,fee schedule,432.17,539.14,
Nfct ds vir resp rna 4 trgt,0241U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,539.14,,,,,,,fee schedule,432.17,539.14,
Nfct ds vir resp rna 4 trgt,0241U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,432.17,,,,,,,fee schedule,432.17,539.14,
Nfct ds vir resp rna 4 trgt,0241U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,472.11,,,,,,,fee schedule,432.17,539.14,
Nfct ds vir resp rna 4 trgt,0241U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,496.35,,,,,,,fee schedule,432.17,539.14,
Trgt gen seq alys pnl 55-74,0242U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4500,,,,,,,fee schedule,4500,8750,Laboratory
Trgt gen seq alys pnl 55-74,0242U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5250,,,,,,,fee schedule,4500,8750,APC
Trgt gen seq alys pnl 55-74,0242U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5200,,,,,,,fee schedule,4500,8750,APC
Trgt gen seq alys pnl 55-74,0242U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5000,,,,,,,fee schedule,4500,8750,APC
Trgt gen seq alys pnl 55-74,0242U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7650,,,,,,,fee schedule,4500,8750,Radiology
Trgt gen seq alys pnl 55-74,0242U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7000,,,,,,,fee schedule,4500,8750,APC
Trgt gen seq alys pnl 55-74,0242U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8750,,,,,,,fee schedule,4500,8750,APC
Ob pe biochem assay pgf alg,0243U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,57.97,,,,,,,fee schedule,57.97,112.72,Laboratory
Ob pe biochem assay pgf alg,0243U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,67.63,,,,,,,fee schedule,57.97,112.72,APC
Ob pe biochem assay pgf alg,0243U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,66.99,,,,,,,fee schedule,57.97,112.72,APC
Ob pe biochem assay pgf alg,0243U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,64.41,,,,,,,fee schedule,57.97,112.72,APC
Ob pe biochem assay pgf alg,0243U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,98.55,,,,,,,fee schedule,57.97,112.72,Radiology
Ob pe biochem assay pgf alg,0243U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,90.17,,,,,,,fee schedule,57.97,112.72,APC
Ob pe biochem assay pgf alg,0243U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,112.72,,,,,,,fee schedule,57.97,112.72,APC
Onc solid orgn dna 257 genes,0244U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3150,,,,,,,fee schedule,3150,6125,Laboratory
Onc solid orgn dna 257 genes,0244U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3675,,,,,,,fee schedule,3150,6125,APC
Onc solid orgn dna 257 genes,0244U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3640,,,,,,,fee schedule,3150,6125,APC
Onc solid orgn dna 257 genes,0244U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3500,,,,,,,fee schedule,3150,6125,APC
Onc solid orgn dna 257 genes,0244U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5355,,,,,,,fee schedule,3150,6125,Radiology
Onc solid orgn dna 257 genes,0244U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4900,,,,,,,fee schedule,3150,6125,APC
Onc solid orgn dna 257 genes,0244U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6125,,,,,,,fee schedule,3150,6125,APC
Onc thyr mut alys 10 gen&37,0245U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1139.46,,,,,,,fee schedule,1139.46,2215.62,Laboratory
Onc thyr mut alys 10 gen&37,0245U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1329.37,,,,,,,fee schedule,1139.46,2215.62,APC
Onc thyr mut alys 10 gen&37,0245U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1316.71,,,,,,,fee schedule,1139.46,2215.62,APC
Onc thyr mut alys 10 gen&37,0245U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1266.07,,,,,,,fee schedule,1139.46,2215.62,APC
Onc thyr mut alys 10 gen&37,0245U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1937.09,,,,,,,fee schedule,1139.46,2215.62,Radiology
Onc thyr mut alys 10 gen&37,0245U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1772.5,,,,,,,fee schedule,1139.46,2215.62,APC
Onc thyr mut alys 10 gen&37,0245U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2215.62,,,,,,,fee schedule,1139.46,2215.62,APC
Rbc dna gnotyp 16 bld groups,0246U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,648,,,,,,,fee schedule,648,1260,Laboratory
Rbc dna gnotyp 16 bld groups,0246U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,756,,,,,,,fee schedule,648,1260,APC
Rbc dna gnotyp 16 bld groups,0246U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,748.8,,,,,,,fee schedule,648,1260,APC
Rbc dna gnotyp 16 bld groups,0246U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,720,,,,,,,fee schedule,648,1260,APC
Rbc dna gnotyp 16 bld groups,0246U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1101.6,,,,,,,fee schedule,648,1260,Radiology
Rbc dna gnotyp 16 bld groups,0246U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1008,,,,,,,fee schedule,648,1260,APC
Rbc dna gnotyp 16 bld groups,0246U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1260,,,,,,,fee schedule,648,1260,APC
Ob prtrm brth ibp4 shbg meas,0247U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,675,,,,,,,fee schedule,675,1312.5,Laboratory
Ob prtrm brth ibp4 shbg meas,0247U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,787.5,,,,,,,fee schedule,675,1312.5,APC
Ob prtrm brth ibp4 shbg meas,0247U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,780,,,,,,,fee schedule,675,1312.5,APC
Ob prtrm brth ibp4 shbg meas,0247U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,750,,,,,,,fee schedule,675,1312.5,APC
Ob prtrm brth ibp4 shbg meas,0247U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1147.5,,,,,,,fee schedule,675,1312.5,Radiology
Ob prtrm brth ibp4 shbg meas,0247U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1050,,,,,,,fee schedule,675,1312.5,APC
Ob prtrm brth ibp4 shbg meas,0247U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1312.5,,,,,,,fee schedule,675,1312.5,APC
Onc brn sphrd cll 12 rx pnl,0248U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2730.47,,,,,,,fee schedule,2730.47,5309.26,Laboratory
Onc brn sphrd cll 12 rx pnl,0248U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3185.55,,,,,,,fee schedule,2730.47,5309.26,APC
Onc brn sphrd cll 12 rx pnl,0248U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3155.21,,,,,,,fee schedule,2730.47,5309.26,APC
Onc brn sphrd cll 12 rx pnl,0248U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3033.86,,,,,,,fee schedule,2730.47,5309.26,APC
Onc brn sphrd cll 12 rx pnl,0248U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4641.81,,,,,,,fee schedule,2730.47,5309.26,Radiology
Onc brn sphrd cll 12 rx pnl,0248U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4247.4,,,,,,,fee schedule,2730.47,5309.26,APC
Onc brn sphrd cll 12 rx pnl,0248U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5309.26,,,,,,,fee schedule,2730.47,5309.26,APC
Onc brst alys 32 phsprtn alg,0249U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1997.22,,,,,,,fee schedule,1997.22,3883.48,Laboratory
Onc brst alys 32 phsprtn alg,0249U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2330.09,,,,,,,fee schedule,1997.22,3883.48,APC
Onc brst alys 32 phsprtn alg,0249U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2307.9,,,,,,,fee schedule,1997.22,3883.48,APC
Onc brst alys 32 phsprtn alg,0249U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2219.13,,,,,,,fee schedule,1997.22,3883.48,APC
Onc brst alys 32 phsprtn alg,0249U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3395.27,,,,,,,fee schedule,1997.22,3883.48,Radiology
Onc brst alys 32 phsprtn alg,0249U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3106.78,,,,,,,fee schedule,1997.22,3883.48,APC
Onc brst alys 32 phsprtn alg,0249U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3883.48,,,,,,,fee schedule,1997.22,3883.48,APC
Onc sld org neo dna 505 gene,0250U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2627.64,,,,,,,fee schedule,2627.64,5109.3,Laboratory
Onc sld org neo dna 505 gene,0250U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3065.58,,,,,,,fee schedule,2627.64,5109.3,APC
Onc sld org neo dna 505 gene,0250U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3036.38,,,,,,,fee schedule,2627.64,5109.3,APC
Onc sld org neo dna 505 gene,0250U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2919.6,,,,,,,fee schedule,2627.64,5109.3,APC
Onc sld org neo dna 505 gene,0250U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4466.99,,,,,,,fee schedule,2627.64,5109.3,Radiology
Onc sld org neo dna 505 gene,0250U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4087.44,,,,,,,fee schedule,2627.64,5109.3,APC
Onc sld org neo dna 505 gene,0250U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5109.3,,,,,,,fee schedule,2627.64,5109.3,APC
Hepcidin-25 elisa serum/plsm,0251U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.54,,,,,,,fee schedule,15.54,30.22,Laboratory
Hepcidin-25 elisa serum/plsm,0251U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.13,,,,,,,fee schedule,15.54,30.22,APC
Hepcidin-25 elisa serum/plsm,0251U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,17.96,,,,,,,fee schedule,15.54,30.22,APC
Hepcidin-25 elisa serum/plsm,0251U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17.27,,,,,,,fee schedule,15.54,30.22,APC
Hepcidin-25 elisa serum/plsm,0251U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26.42,,,,,,,fee schedule,15.54,30.22,Radiology
Hepcidin-25 elisa serum/plsm,0251U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24.18,,,,,,,fee schedule,15.54,30.22,APC
Hepcidin-25 elisa serum/plsm,0251U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30.22,,,,,,,fee schedule,15.54,30.22,APC
Ftl aneuploidy str alys dna,0252U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,683.14,,,,,,,fee schedule,683.14,1328.34,Laboratory
Ftl aneuploidy str alys dna,0252U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,797,,,,,,,fee schedule,683.14,1328.34,APC
Ftl aneuploidy str alys dna,0252U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,789.41,,,,,,,fee schedule,683.14,1328.34,APC
Ftl aneuploidy str alys dna,0252U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,759.05,,,,,,,fee schedule,683.14,1328.34,APC
Ftl aneuploidy str alys dna,0252U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1161.35,,,,,,,fee schedule,683.14,1328.34,Radiology
Ftl aneuploidy str alys dna,0252U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1062.67,,,,,,,fee schedule,683.14,1328.34,APC
Ftl aneuploidy str alys dna,0252U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1328.34,,,,,,,fee schedule,683.14,1328.34,APC
Insert aqueous drain device,0253T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11256.58,,,,,,,fee schedule,4091.95,18154.62,
Insert aqueous drain device,0253T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9023.13,,,,,,,fee schedule,4091.95,18154.62,
Insert aqueous drain device,0253T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9856.95,,,,,,,fee schedule,4091.95,18154.62,
Insert aqueous drain device,0253T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10363.2,,,,,,,fee schedule,4091.95,18154.62,
Insert aqueous drain device,0253T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18154.62,,,,,,,fee schedule,4091.95,18154.62,APC 378
Insert aqueous drain device,0253T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4296.55,,,,,,,fee schedule,4091.95,18154.62,APC
Insert aqueous drain device,0253T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4255.63,,,,,,,fee schedule,4091.95,18154.62,APC
Insert aqueous drain device,0253T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4091.95,,,,,,,fee schedule,4091.95,18154.62,APC
Insert aqueous drain device,0253T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6260.69,,,,,,,fee schedule,4091.95,18154.62,Radiology
Insert aqueous drain device,0253T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5728.74,,,,,,,fee schedule,4091.95,18154.62,APC
Insert aqueous drain device,0253T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7160.92,,,,,,,fee schedule,4091.95,18154.62,APC
Rprdtve med rna gen prfl 238,0253U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2843.48,,,,,,,fee schedule,2843.48,5528.98,Laboratory
Rprdtve med rna gen prfl 238,0253U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3317.39,,,,,,,fee schedule,2843.48,5528.98,APC
Rprdtve med rna gen prfl 238,0253U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3285.8,,,,,,,fee schedule,2843.48,5528.98,APC
Rprdtve med rna gen prfl 238,0253U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3159.42,,,,,,,fee schedule,2843.48,5528.98,APC
Rprdtve med rna gen prfl 238,0253U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4833.91,,,,,,,fee schedule,2843.48,5528.98,Radiology
Rprdtve med rna gen prfl 238,0253U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4423.19,,,,,,,fee schedule,2843.48,5528.98,APC
Rprdtve med rna gen prfl 238,0253U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5528.98,,,,,,,fee schedule,2843.48,5528.98,APC
Reprdtve med alys 24 chrmsm,0254U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,683.14,,,,,,,fee schedule,683.14,1328.34,Laboratory
Reprdtve med alys 24 chrmsm,0254U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,797,,,,,,,fee schedule,683.14,1328.34,APC
Reprdtve med alys 24 chrmsm,0254U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,789.41,,,,,,,fee schedule,683.14,1328.34,APC
Reprdtve med alys 24 chrmsm,0254U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,759.05,,,,,,,fee schedule,683.14,1328.34,APC
Reprdtve med alys 24 chrmsm,0254U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1161.35,,,,,,,fee schedule,683.14,1328.34,Radiology
Reprdtve med alys 24 chrmsm,0254U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1062.67,,,,,,,fee schedule,683.14,1328.34,APC
Reprdtve med alys 24 chrmsm,0254U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1328.34,,,,,,,fee schedule,683.14,1328.34,APC
Andrology infertility assmt,0255U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,28.44,,,,,,,fee schedule,28.44,55.3,Laboratory
Andrology infertility assmt,0255U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,33.18,,,,,,,fee schedule,28.44,55.3,APC
Andrology infertility assmt,0255U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,32.86,,,,,,,fee schedule,28.44,55.3,APC
Andrology infertility assmt,0255U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,31.6,,,,,,,fee schedule,28.44,55.3,APC
Andrology infertility assmt,0255U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,48.35,,,,,,,fee schedule,28.44,55.3,Radiology
Andrology infertility assmt,0255U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,44.24,,,,,,,fee schedule,28.44,55.3,APC
Andrology infertility assmt,0255U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,55.3,,,,,,,fee schedule,28.44,55.3,APC
Tma/tmao prfl ms/ms ur alg,0256U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,143.95,,,,,,,fee schedule,143.96,279.91,Laboratory
Tma/tmao prfl ms/ms ur alg,0256U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,167.95,,,,,,,fee schedule,143.96,279.91,APC
Tma/tmao prfl ms/ms ur alg,0256U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,166.35,,,,,,,fee schedule,143.96,279.91,APC
Tma/tmao prfl ms/ms ur alg,0256U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,159.95,,,,,,,fee schedule,143.96,279.91,APC
Tma/tmao prfl ms/ms ur alg,0256U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,244.72,,,,,,,fee schedule,143.96,279.91,Radiology
Tma/tmao prfl ms/ms ur alg,0256U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,223.93,,,,,,,fee schedule,143.96,279.91,APC
Tma/tmao prfl ms/ms ur alg,0256U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,279.91,,,,,,,fee schedule,143.96,279.91,APC
Vlcad leuk nzm actv whl bld,0257U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,641.22,,,,,,,fee schedule,641.22,1246.82,Laboratory
Vlcad leuk nzm actv whl bld,0257U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,748.09,,,,,,,fee schedule,641.22,1246.82,APC
Vlcad leuk nzm actv whl bld,0257U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,740.97,,,,,,,fee schedule,641.22,1246.82,APC
Vlcad leuk nzm actv whl bld,0257U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,712.47,,,,,,,fee schedule,641.22,1246.82,APC
Vlcad leuk nzm actv whl bld,0257U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1090.08,,,,,,,fee schedule,641.22,1246.82,Radiology
Vlcad leuk nzm actv whl bld,0257U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,997.46,,,,,,,fee schedule,641.22,1246.82,APC
Vlcad leuk nzm actv whl bld,0257U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1246.82,,,,,,,fee schedule,641.22,1246.82,APC
Ai psor mrna 50-100 gen alg,0258U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3307.5,,,,,,,fee schedule,3307.5,6431.25,Laboratory
Ai psor mrna 50-100 gen alg,0258U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3858.75,,,,,,,fee schedule,3307.5,6431.25,APC
Ai psor mrna 50-100 gen alg,0258U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3822,,,,,,,fee schedule,3307.5,6431.25,APC
Ai psor mrna 50-100 gen alg,0258U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3675,,,,,,,fee schedule,3307.5,6431.25,APC
Ai psor mrna 50-100 gen alg,0258U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5622.75,,,,,,,fee schedule,3307.5,6431.25,Radiology
Ai psor mrna 50-100 gen alg,0258U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5145,,,,,,,fee schedule,3307.5,6431.25,APC
Ai psor mrna 50-100 gen alg,0258U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6431.25,,,,,,,fee schedule,3307.5,6431.25,APC
Neph ckd nuc mrs meas gfr,0259U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,47.44,,,,,,,fee schedule,47.44,92.24,Laboratory
Neph ckd nuc mrs meas gfr,0259U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,55.35,,,,,,,fee schedule,47.44,92.24,APC
Neph ckd nuc mrs meas gfr,0259U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,54.82,,,,,,,fee schedule,47.44,92.24,APC
Neph ckd nuc mrs meas gfr,0259U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,52.71,,,,,,,fee schedule,47.44,92.24,APC
Neph ckd nuc mrs meas gfr,0259U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,80.65,,,,,,,fee schedule,47.44,92.24,Radiology
Neph ckd nuc mrs meas gfr,0259U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,73.79,,,,,,,fee schedule,47.44,92.24,APC
Neph ckd nuc mrs meas gfr,0259U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,92.24,,,,,,,fee schedule,47.44,92.24,APC
Rare ds id opt genome mapg,0260U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1137.18,,,,,,,fee schedule,1137.18,2211.18,Laboratory
Rare ds id opt genome mapg,0260U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1326.71,,,,,,,fee schedule,1137.18,2211.18,APC
Rare ds id opt genome mapg,0260U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1314.07,,,,,,,fee schedule,1137.18,2211.18,APC
Rare ds id opt genome mapg,0260U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1263.53,,,,,,,fee schedule,1137.18,2211.18,APC
Rare ds id opt genome mapg,0260U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1933.2,,,,,,,fee schedule,1137.18,2211.18,Radiology
Rare ds id opt genome mapg,0260U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1768.94,,,,,,,fee schedule,1137.18,2211.18,APC
Rare ds id opt genome mapg,0260U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2211.18,,,,,,,fee schedule,1137.18,2211.18,APC
Onc clrct ca img alys w/ai,0261U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2261.93,,,,,,,fee schedule,2261.93,4398.19,Laboratory
Onc clrct ca img alys w/ai,0261U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2638.91,,,,,,,fee schedule,2261.93,4398.19,APC
Onc clrct ca img alys w/ai,0261U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2613.78,,,,,,,fee schedule,2261.93,4398.19,APC
Onc clrct ca img alys w/ai,0261U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2513.25,,,,,,,fee schedule,2261.93,4398.19,APC
Onc clrct ca img alys w/ai,0261U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3845.27,,,,,,,fee schedule,2261.93,4398.19,Radiology
Onc clrct ca img alys w/ai,0261U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3518.55,,,,,,,fee schedule,2261.93,4398.19,APC
Onc clrct ca img alys w/ai,0261U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4398.19,,,,,,,fee schedule,2261.93,4398.19,APC
Onc sld tum rt-pcr 7 gen,0262U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2880,,,,,,,fee schedule,2880,5600,Laboratory
Onc sld tum rt-pcr 7 gen,0262U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3360,,,,,,,fee schedule,2880,5600,APC
Onc sld tum rt-pcr 7 gen,0262U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3328,,,,,,,fee schedule,2880,5600,APC
Onc sld tum rt-pcr 7 gen,0262U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3200,,,,,,,fee schedule,2880,5600,APC
Onc sld tum rt-pcr 7 gen,0262U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4896,,,,,,,fee schedule,2880,5600,Radiology
Onc sld tum rt-pcr 7 gen,0262U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4480,,,,,,,fee schedule,2880,5600,APC
Onc sld tum rt-pcr 7 gen,0262U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5600,,,,,,,fee schedule,2880,5600,APC
Im b1 mrw cel ther cmpl,0263T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10919.29,,,,,,,fee schedule,4311.81,19130.02,
Im b1 mrw cel ther cmpl,0263T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8752.76,,,,,,,fee schedule,4311.81,19130.02,
Im b1 mrw cel ther cmpl,0263T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9561.6,,,,,,,fee schedule,4311.81,19130.02,
Im b1 mrw cel ther cmpl,0263T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10052.68,,,,,,,fee schedule,4311.81,19130.02,
Im b1 mrw cel ther cmpl,0263T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19130.02,,,,,,,fee schedule,4311.81,19130.02,APC 378
Im b1 mrw cel ther cmpl,0263T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4527.4,,,,,,,fee schedule,4311.81,19130.02,APC
Im b1 mrw cel ther cmpl,0263T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4484.28,,,,,,,fee schedule,4311.81,19130.02,APC
Im b1 mrw cel ther cmpl,0263T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4311.81,,,,,,,fee schedule,4311.81,19130.02,APC
Im b1 mrw cel ther cmpl,0263T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6597.06,,,,,,,fee schedule,4311.81,19130.02,Radiology
Im b1 mrw cel ther cmpl,0263T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6036.53,,,,,,,fee schedule,4311.81,19130.02,APC
Im b1 mrw cel ther cmpl,0263T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7545.66,,,,,,,fee schedule,4311.81,19130.02,APC
Neuro asd meas 16 c metblt,0263U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,675,,,,,,,fee schedule,675,1312.5,Laboratory
Neuro asd meas 16 c metblt,0263U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,787.5,,,,,,,fee schedule,675,1312.5,APC
Neuro asd meas 16 c metblt,0263U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,780,,,,,,,fee schedule,675,1312.5,APC
Neuro asd meas 16 c metblt,0263U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,750,,,,,,,fee schedule,675,1312.5,APC
Neuro asd meas 16 c metblt,0263U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1147.5,,,,,,,fee schedule,675,1312.5,Radiology
Neuro asd meas 16 c metblt,0263U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1050,,,,,,,fee schedule,675,1312.5,APC
Neuro asd meas 16 c metblt,0263U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1312.5,,,,,,,fee schedule,675,1312.5,APC
Im b1 mrw cel ther xcl hrvst,0264T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10919.29,,,,,,,fee schedule,4311.81,19130.02,
Im b1 mrw cel ther xcl hrvst,0264T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8752.76,,,,,,,fee schedule,4311.81,19130.02,
Im b1 mrw cel ther xcl hrvst,0264T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9561.6,,,,,,,fee schedule,4311.81,19130.02,
Im b1 mrw cel ther xcl hrvst,0264T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10052.68,,,,,,,fee schedule,4311.81,19130.02,
Im b1 mrw cel ther xcl hrvst,0264T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19130.02,,,,,,,fee schedule,4311.81,19130.02,APC 378
Im b1 mrw cel ther xcl hrvst,0264T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4527.4,,,,,,,fee schedule,4311.81,19130.02,APC
Im b1 mrw cel ther xcl hrvst,0264T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4484.28,,,,,,,fee schedule,4311.81,19130.02,APC
Im b1 mrw cel ther xcl hrvst,0264T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4311.81,,,,,,,fee schedule,4311.81,19130.02,APC
Im b1 mrw cel ther xcl hrvst,0264T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6597.06,,,,,,,fee schedule,4311.81,19130.02,Radiology
Im b1 mrw cel ther xcl hrvst,0264T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6036.53,,,,,,,fee schedule,4311.81,19130.02,APC
Im b1 mrw cel ther xcl hrvst,0264T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7545.66,,,,,,,fee schedule,4311.81,19130.02,APC
Rare ds id opt genome mapg,0264U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1137.18,,,,,,,fee schedule,1137.18,2211.18,Laboratory
Rare ds id opt genome mapg,0264U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1326.71,,,,,,,fee schedule,1137.18,2211.18,APC
Rare ds id opt genome mapg,0264U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1314.07,,,,,,,fee schedule,1137.18,2211.18,APC
Rare ds id opt genome mapg,0264U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1263.53,,,,,,,fee schedule,1137.18,2211.18,APC
Rare ds id opt genome mapg,0264U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1933.2,,,,,,,fee schedule,1137.18,2211.18,Radiology
Rare ds id opt genome mapg,0264U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1768.94,,,,,,,fee schedule,1137.18,2211.18,APC
Rare ds id opt genome mapg,0264U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2211.18,,,,,,,fee schedule,1137.18,2211.18,APC
Im b1 mrw cel ther hrvst onl,0265T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10919.29,,,,,,,fee schedule,4311.81,19130.02,
Im b1 mrw cel ther hrvst onl,0265T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8752.76,,,,,,,fee schedule,4311.81,19130.02,
Im b1 mrw cel ther hrvst onl,0265T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9561.6,,,,,,,fee schedule,4311.81,19130.02,
Im b1 mrw cel ther hrvst onl,0265T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10052.68,,,,,,,fee schedule,4311.81,19130.02,
Im b1 mrw cel ther hrvst onl,0265T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19130.02,,,,,,,fee schedule,4311.81,19130.02,APC 378
Im b1 mrw cel ther hrvst onl,0265T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4527.4,,,,,,,fee schedule,4311.81,19130.02,APC
Im b1 mrw cel ther hrvst onl,0265T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4484.28,,,,,,,fee schedule,4311.81,19130.02,APC
Im b1 mrw cel ther hrvst onl,0265T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4311.81,,,,,,,fee schedule,4311.81,19130.02,APC
Im b1 mrw cel ther hrvst onl,0265T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6597.06,,,,,,,fee schedule,4311.81,19130.02,Radiology
Im b1 mrw cel ther hrvst onl,0265T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6036.53,,,,,,,fee schedule,4311.81,19130.02,APC
Im b1 mrw cel ther hrvst onl,0265T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7545.66,,,,,,,fee schedule,4311.81,19130.02,APC
Rar do whl gn&mtcdrl dna als,0265U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4928.22,,,,,,,fee schedule,4928.22,9582.65,Laboratory
Rar do whl gn&mtcdrl dna als,0265U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5749.59,,,,,,,fee schedule,4928.22,9582.65,APC
Rar do whl gn&mtcdrl dna als,0265U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5694.83,,,,,,,fee schedule,4928.22,9582.65,APC
Rar do whl gn&mtcdrl dna als,0265U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5475.8,,,,,,,fee schedule,4928.22,9582.65,APC
Rar do whl gn&mtcdrl dna als,0265U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8377.97,,,,,,,fee schedule,4928.22,9582.65,Radiology
Rar do whl gn&mtcdrl dna als,0265U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7666.12,,,,,,,fee schedule,4928.22,9582.65,APC
Rar do whl gn&mtcdrl dna als,0265U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9582.65,,,,,,,fee schedule,4928.22,9582.65,APC
Implt/rpl crtd sns dev total,0266T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,111300.29,,,,,,,fee schedule,89216.9,111300.29,
Implt/rpl crtd sns dev total,0266T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,89216.9,,,,,,,fee schedule,89216.9,111300.29,
Implt/rpl crtd sns dev total,0266T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,97461.36,,,,,,,fee schedule,89216.9,111300.29,
Implt/rpl crtd sns dev total,0266T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,102466.93,,,,,,,fee schedule,89216.9,111300.29,
Unxpl cnst hrtbl do gn xprsn,0266U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2880,,,,,,,fee schedule,2880,5600,Laboratory
Unxpl cnst hrtbl do gn xprsn,0266U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3360,,,,,,,fee schedule,2880,5600,APC
Unxpl cnst hrtbl do gn xprsn,0266U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3328,,,,,,,fee schedule,2880,5600,APC
Unxpl cnst hrtbl do gn xprsn,0266U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3200,,,,,,,fee schedule,2880,5600,APC
Unxpl cnst hrtbl do gn xprsn,0266U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4896,,,,,,,fee schedule,2880,5600,Radiology
Unxpl cnst hrtbl do gn xprsn,0266U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4480,,,,,,,fee schedule,2880,5600,APC
Unxpl cnst hrtbl do gn xprsn,0266U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5600,,,,,,,fee schedule,2880,5600,APC
Implt/rpl crtd sns dev lead,0267T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5711.88,,,,,,,fee schedule,4578.57,5711.88,
Implt/rpl crtd sns dev lead,0267T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4578.57,,,,,,,fee schedule,4578.57,5711.88,
Implt/rpl crtd sns dev lead,0267T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5001.67,,,,,,,fee schedule,4578.57,5711.88,
Implt/rpl crtd sns dev lead,0267T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5258.56,,,,,,,fee schedule,4578.57,5711.88,
Rare do id opt gen mapg&seq,0267U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6065.4,,,,,,,fee schedule,6065.4,11793.83,Laboratory
Rare do id opt gen mapg&seq,0267U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7076.3,,,,,,,fee schedule,6065.4,11793.83,APC
Rare do id opt gen mapg&seq,0267U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7008.9,,,,,,,fee schedule,6065.4,11793.83,APC
Rare do id opt gen mapg&seq,0267U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6739.33,,,,,,,fee schedule,6065.4,11793.83,APC
Rare do id opt gen mapg&seq,0267U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10311.17,,,,,,,fee schedule,6065.4,11793.83,Radiology
Rare do id opt gen mapg&seq,0267U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9435.06,,,,,,,fee schedule,6065.4,11793.83,APC
Rare do id opt gen mapg&seq,0267U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11793.83,,,,,,,fee schedule,6065.4,11793.83,APC
Implt/rpl crtd sns dev gen,0268T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,61972.08,,,,,,,fee schedule,49676.03,61972.08,
Implt/rpl crtd sns dev gen,0268T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,49676.03,,,,,,,fee schedule,49676.03,61972.08,
Implt/rpl crtd sns dev gen,0268T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,54266.56,,,,,,,fee schedule,49676.03,61972.08,
Implt/rpl crtd sns dev gen,0268T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,57053.66,,,,,,,fee schedule,49676.03,61972.08,
Hem ahus gen seq alys 15 gen,0268U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,547.35,,,,,,,fee schedule,547.35,1064.3,Laboratory
Hem ahus gen seq alys 15 gen,0268U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,638.58,,,,,,,fee schedule,547.35,1064.3,APC
Hem ahus gen seq alys 15 gen,0268U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,632.5,,,,,,,fee schedule,547.35,1064.3,APC
Hem ahus gen seq alys 15 gen,0268U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,608.17,,,,,,,fee schedule,547.35,1064.3,APC
Hem ahus gen seq alys 15 gen,0268U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,930.5,,,,,,,fee schedule,547.35,1064.3,Radiology
Hem ahus gen seq alys 15 gen,0268U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,851.44,,,,,,,fee schedule,547.35,1064.3,APC
Hem ahus gen seq alys 15 gen,0268U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1064.3,,,,,,,fee schedule,547.35,1064.3,APC
Rev/remvl crtd sns dev total,0269T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9380.37,,,,,,,fee schedule,7519.19,9380.37,
Rev/remvl crtd sns dev total,0269T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7519.19,,,,,,,fee schedule,7519.19,9380.37,
Rev/remvl crtd sns dev total,0269T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8214.03,,,,,,,fee schedule,7519.19,9380.37,
Rev/remvl crtd sns dev total,0269T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8635.9,,,,,,,fee schedule,7519.19,9380.37,
Hem aut dm cgen trmbctpna 14,0269U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,547.35,,,,,,,fee schedule,547.35,1064.3,Laboratory
Hem aut dm cgen trmbctpna 14,0269U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,638.58,,,,,,,fee schedule,547.35,1064.3,APC
Hem aut dm cgen trmbctpna 14,0269U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,632.5,,,,,,,fee schedule,547.35,1064.3,APC
Hem aut dm cgen trmbctpna 14,0269U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,608.17,,,,,,,fee schedule,547.35,1064.3,APC
Hem aut dm cgen trmbctpna 14,0269U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,930.5,,,,,,,fee schedule,547.35,1064.3,Radiology
Hem aut dm cgen trmbctpna 14,0269U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,851.44,,,,,,,fee schedule,547.35,1064.3,APC
Hem aut dm cgen trmbctpna 14,0269U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1064.3,,,,,,,fee schedule,547.35,1064.3,APC
Rev/remvl crtd sns dev lead,0270T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5711.88,,,,,,,fee schedule,4578.57,5711.88,
Rev/remvl crtd sns dev lead,0270T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4578.57,,,,,,,fee schedule,4578.57,5711.88,
Rev/remvl crtd sns dev lead,0270T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5001.67,,,,,,,fee schedule,4578.57,5711.88,
Rev/remvl crtd sns dev lead,0270T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5258.56,,,,,,,fee schedule,4578.57,5711.88,
Hem cgen coagj do 20 genes,0270U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,547.35,,,,,,,fee schedule,547.35,1064.3,Laboratory
Hem cgen coagj do 20 genes,0270U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,638.58,,,,,,,fee schedule,547.35,1064.3,APC
Hem cgen coagj do 20 genes,0270U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,632.5,,,,,,,fee schedule,547.35,1064.3,APC
Hem cgen coagj do 20 genes,0270U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,608.17,,,,,,,fee schedule,547.35,1064.3,APC
Hem cgen coagj do 20 genes,0270U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,930.5,,,,,,,fee schedule,547.35,1064.3,Radiology
Hem cgen coagj do 20 genes,0270U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,851.44,,,,,,,fee schedule,547.35,1064.3,APC
Hem cgen coagj do 20 genes,0270U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1064.3,,,,,,,fee schedule,547.35,1064.3,APC
Rev/remvl crtd sns dev gen,0271T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9821.42,,,,,,,fee schedule,7872.73,9821.42,
Rev/remvl crtd sns dev gen,0271T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7872.73,,,,,,,fee schedule,7872.73,9821.42,
Rev/remvl crtd sns dev gen,0271T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8600.24,,,,,,,fee schedule,7872.73,9821.42,
Rev/remvl crtd sns dev gen,0271T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9041.94,,,,,,,fee schedule,7872.73,9821.42,
Hem cgen neutropenia 23 gen,0271U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,547.35,,,,,,,fee schedule,547.35,1064.3,Laboratory
Hem cgen neutropenia 23 gen,0271U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,638.58,,,,,,,fee schedule,547.35,1064.3,APC
Hem cgen neutropenia 23 gen,0271U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,632.5,,,,,,,fee schedule,547.35,1064.3,APC
Hem cgen neutropenia 23 gen,0271U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,608.17,,,,,,,fee schedule,547.35,1064.3,APC
Hem cgen neutropenia 23 gen,0271U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,930.5,,,,,,,fee schedule,547.35,1064.3,Radiology
Hem cgen neutropenia 23 gen,0271U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,851.44,,,,,,,fee schedule,547.35,1064.3,APC
Hem cgen neutropenia 23 gen,0271U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1064.3,,,,,,,fee schedule,547.35,1064.3,APC
Interrogate crtd sns dev,0272T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,301.76,,,,,,,fee schedule,241.88,301.76,
Interrogate crtd sns dev,0272T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,241.88,,,,,,,fee schedule,241.88,301.76,
Interrogate crtd sns dev,0272T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,264.24,,,,,,,fee schedule,241.88,301.76,
Interrogate crtd sns dev,0272T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,277.81,,,,,,,fee schedule,241.88,301.76,
Hem genetic bld do 51 genes,0272U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,547.35,,,,,,,fee schedule,547.35,1064.3,Laboratory
Hem genetic bld do 51 genes,0272U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,638.58,,,,,,,fee schedule,547.35,1064.3,APC
Hem genetic bld do 51 genes,0272U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,632.5,,,,,,,fee schedule,547.35,1064.3,APC
Hem genetic bld do 51 genes,0272U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,608.17,,,,,,,fee schedule,547.35,1064.3,APC
Hem genetic bld do 51 genes,0272U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,930.5,,,,,,,fee schedule,547.35,1064.3,Radiology
Hem genetic bld do 51 genes,0272U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,851.44,,,,,,,fee schedule,547.35,1064.3,APC
Hem genetic bld do 51 genes,0272U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1064.3,,,,,,,fee schedule,547.35,1064.3,APC
Interrogate crtd sns w/pgrmg,0273T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,301.76,,,,,,,fee schedule,241.88,301.76,
Interrogate crtd sns w/pgrmg,0273T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,241.88,,,,,,,fee schedule,241.88,301.76,
Interrogate crtd sns w/pgrmg,0273T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,264.24,,,,,,,fee schedule,241.88,301.76,
Interrogate crtd sns w/pgrmg,0273T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,277.81,,,,,,,fee schedule,241.88,301.76,
Hem gen hyprfibrnlysis 8 gen,0273U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,547.35,,,,,,,fee schedule,547.35,1064.3,Laboratory
Hem gen hyprfibrnlysis 8 gen,0273U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,638.58,,,,,,,fee schedule,547.35,1064.3,APC
Hem gen hyprfibrnlysis 8 gen,0273U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,632.5,,,,,,,fee schedule,547.35,1064.3,APC
Hem gen hyprfibrnlysis 8 gen,0273U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,608.17,,,,,,,fee schedule,547.35,1064.3,APC
Hem gen hyprfibrnlysis 8 gen,0273U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,930.5,,,,,,,fee schedule,547.35,1064.3,Radiology
Hem gen hyprfibrnlysis 8 gen,0273U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,851.44,,,,,,,fee schedule,547.35,1064.3,APC
Hem gen hyprfibrnlysis 8 gen,0273U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1064.3,,,,,,,fee schedule,547.35,1064.3,APC
Perq lamot/lam crv/thrc,0274T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14207.47,,,,,,,fee schedule,7183.42,31870.39,
Perq lamot/lam crv/thrc,0274T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11388.53,,,,,,,fee schedule,7183.42,31870.39,
Perq lamot/lam crv/thrc,0274T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12440.93,,,,,,,fee schedule,7183.42,31870.39,
Perq lamot/lam crv/thrc,0274T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13079.89,,,,,,,fee schedule,7183.42,31870.39,
Perq lamot/lam crv/thrc,0274T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Perq lamot/lam crv/thrc,0274T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Perq lamot/lam crv/thrc,0274T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Perq lamot/lam crv/thrc,0274T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Perq lamot/lam crv/thrc,0274T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Perq lamot/lam crv/thrc,0274T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Perq lamot/lam crv/thrc,0274T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Hem gen pltlt do 43 genes,0274U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,547.35,,,,,,,fee schedule,547.35,1064.3,Laboratory
Hem gen pltlt do 43 genes,0274U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,638.58,,,,,,,fee schedule,547.35,1064.3,APC
Hem gen pltlt do 43 genes,0274U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,632.5,,,,,,,fee schedule,547.35,1064.3,APC
Hem gen pltlt do 43 genes,0274U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,608.17,,,,,,,fee schedule,547.35,1064.3,APC
Hem gen pltlt do 43 genes,0274U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,930.5,,,,,,,fee schedule,547.35,1064.3,Radiology
Hem gen pltlt do 43 genes,0274U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,851.44,,,,,,,fee schedule,547.35,1064.3,APC
Hem gen pltlt do 43 genes,0274U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1064.3,,,,,,,fee schedule,547.35,1064.3,APC
Perq lamot/lam lumbar,0275T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14207.47,,,,,,,fee schedule,11388.53,14207.47,
Perq lamot/lam lumbar,0275T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11388.53,,,,,,,fee schedule,11388.53,14207.47,
Perq lamot/lam lumbar,0275T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12440.93,,,,,,,fee schedule,11388.53,14207.47,
Perq lamot/lam lumbar,0275T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13079.89,,,,,,,fee schedule,11388.53,14207.47,
Hem heprn nduc trmbctpna srm,0275U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.53,,,,,,,fee schedule,16.53,32.15,Laboratory
Hem heprn nduc trmbctpna srm,0275U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.29,,,,,,,fee schedule,16.53,32.15,APC
Hem heprn nduc trmbctpna srm,0275U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,19.1,,,,,,,fee schedule,16.53,32.15,APC
Hem heprn nduc trmbctpna srm,0275U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18.37,,,,,,,fee schedule,16.53,32.15,APC
Hem heprn nduc trmbctpna srm,0275U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.11,,,,,,,fee schedule,16.53,32.15,Radiology
Hem heprn nduc trmbctpna srm,0275U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.72,,,,,,,fee schedule,16.53,32.15,APC
Hem heprn nduc trmbctpna srm,0275U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,32.15,,,,,,,fee schedule,16.53,32.15,APC
Hem inh thrombocytopenia 23,0276U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2203.7,,,,,,,fee schedule,2203.7,4284.98,Laboratory
Hem inh thrombocytopenia 23,0276U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2570.99,,,,,,,fee schedule,2203.7,4284.98,APC
Hem inh thrombocytopenia 23,0276U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2546.5,,,,,,,fee schedule,2203.7,4284.98,APC
Hem inh thrombocytopenia 23,0276U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2448.56,,,,,,,fee schedule,2203.7,4284.98,APC
Hem inh thrombocytopenia 23,0276U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3746.3,,,,,,,fee schedule,2203.7,4284.98,Radiology
Hem inh thrombocytopenia 23,0276U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3427.98,,,,,,,fee schedule,2203.7,4284.98,APC
Hem inh thrombocytopenia 23,0276U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4284.98,,,,,,,fee schedule,2203.7,4284.98,APC
Hem gen pltlt funcj do 31,0277U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,547.35,,,,,,,fee schedule,547.35,1064.3,Laboratory
Hem gen pltlt funcj do 31,0277U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,638.58,,,,,,,fee schedule,547.35,1064.3,APC
Hem gen pltlt funcj do 31,0277U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,632.5,,,,,,,fee schedule,547.35,1064.3,APC
Hem gen pltlt funcj do 31,0277U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,608.17,,,,,,,fee schedule,547.35,1064.3,APC
Hem gen pltlt funcj do 31,0277U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,930.5,,,,,,,fee schedule,547.35,1064.3,Radiology
Hem gen pltlt funcj do 31,0277U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,851.44,,,,,,,fee schedule,547.35,1064.3,APC
Hem gen pltlt funcj do 31,0277U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1064.3,,,,,,,fee schedule,547.35,1064.3,APC
Tempr,0278T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,162.96,,,,,,,fee schedule,127.38,565.15,
Tempr,0278T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,130.62,,,,,,,fee schedule,127.38,565.15,
Tempr,0278T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,142.69,,,,,,,fee schedule,127.38,565.15,
Tempr,0278T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,150.02,,,,,,,fee schedule,127.38,565.15,
Tempr,0278T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,565.15,,,,,,,fee schedule,127.38,565.15,APC 378
Tempr,0278T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,133.75,,,,,,,fee schedule,127.38,565.15,APC
Tempr,0278T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,132.48,,,,,,,fee schedule,127.38,565.15,APC
Tempr,0278T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,127.38,,,,,,,fee schedule,127.38,565.15,APC
Tempr,0278T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,194.89,,,,,,,fee schedule,127.38,565.15,Radiology
Tempr,0278T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,178.33,,,,,,,fee schedule,127.38,565.15,APC
Tempr,0278T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,222.92,,,,,,,fee schedule,127.38,565.15,APC
Hem gen thrombosis 12 genes,0278U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,547.35,,,,,,,fee schedule,547.35,1064.3,Laboratory
Hem gen thrombosis 12 genes,0278U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,638.58,,,,,,,fee schedule,547.35,1064.3,APC
Hem gen thrombosis 12 genes,0278U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,632.5,,,,,,,fee schedule,547.35,1064.3,APC
Hem gen thrombosis 12 genes,0278U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,608.17,,,,,,,fee schedule,547.35,1064.3,APC
Hem gen thrombosis 12 genes,0278U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,930.5,,,,,,,fee schedule,547.35,1064.3,Radiology
Hem gen thrombosis 12 genes,0278U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,851.44,,,,,,,fee schedule,547.35,1064.3,APC
Hem gen thrombosis 12 genes,0278U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1064.3,,,,,,,fee schedule,547.35,1064.3,APC
Hem vw factor&clgn iii bndg,0279U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.38,,,,,,,fee schedule,10.38,20.18,Laboratory
Hem vw factor&clgn iii bndg,0279U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.11,,,,,,,fee schedule,10.38,20.18,APC
Hem vw factor&clgn iii bndg,0279U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11.99,,,,,,,fee schedule,10.38,20.18,APC
Hem vw factor&clgn iii bndg,0279U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11.53,,,,,,,fee schedule,10.38,20.18,APC
Hem vw factor&clgn iii bndg,0279U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.64,,,,,,,fee schedule,10.38,20.18,Radiology
Hem vw factor&clgn iii bndg,0279U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.14,,,,,,,fee schedule,10.38,20.18,APC
Hem vw factor&clgn iii bndg,0279U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20.18,,,,,,,fee schedule,10.38,20.18,APC
Hem vw factor&clgn iv bndg,0280U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.54,,,,,,,fee schedule,15.54,30.22,Laboratory
Hem vw factor&clgn iv bndg,0280U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.13,,,,,,,fee schedule,15.54,30.22,APC
Hem vw factor&clgn iv bndg,0280U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,17.96,,,,,,,fee schedule,15.54,30.22,APC
Hem vw factor&clgn iv bndg,0280U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17.27,,,,,,,fee schedule,15.54,30.22,APC
Hem vw factor&clgn iv bndg,0280U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26.42,,,,,,,fee schedule,15.54,30.22,Radiology
Hem vw factor&clgn iv bndg,0280U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24.18,,,,,,,fee schedule,15.54,30.22,APC
Hem vw factor&clgn iv bndg,0280U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30.22,,,,,,,fee schedule,15.54,30.22,APC
Hem vwd propeptide ag lvl,0281U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.54,,,,,,,fee schedule,15.54,30.22,Laboratory
Hem vwd propeptide ag lvl,0281U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.13,,,,,,,fee schedule,15.54,30.22,APC
Hem vwd propeptide ag lvl,0281U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,17.96,,,,,,,fee schedule,15.54,30.22,APC
Hem vwd propeptide ag lvl,0281U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17.27,,,,,,,fee schedule,15.54,30.22,APC
Hem vwd propeptide ag lvl,0281U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26.42,,,,,,,fee schedule,15.54,30.22,Radiology
Hem vwd propeptide ag lvl,0281U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24.18,,,,,,,fee schedule,15.54,30.22,APC
Hem vwd propeptide ag lvl,0281U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30.22,,,,,,,fee schedule,15.54,30.22,APC
Rbc dna gntyp 12 bld grp gen,0282U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,648,,,,,,,fee schedule,648,1260,Laboratory
Rbc dna gntyp 12 bld grp gen,0282U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,756,,,,,,,fee schedule,648,1260,APC
Rbc dna gntyp 12 bld grp gen,0282U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,748.8,,,,,,,fee schedule,648,1260,APC
Rbc dna gntyp 12 bld grp gen,0282U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,720,,,,,,,fee schedule,648,1260,APC
Rbc dna gntyp 12 bld grp gen,0282U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1101.6,,,,,,,fee schedule,648,1260,Radiology
Rbc dna gntyp 12 bld grp gen,0282U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1008,,,,,,,fee schedule,648,1260,APC
Rbc dna gntyp 12 bld grp gen,0282U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1260,,,,,,,fee schedule,648,1260,APC
Vw factor type 2b eval plsm,0283U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.56,,,,,,,fee schedule,16.56,32.2,Laboratory
Vw factor type 2b eval plsm,0283U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.32,,,,,,,fee schedule,16.56,32.2,APC
Vw factor type 2b eval plsm,0283U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,19.14,,,,,,,fee schedule,16.56,32.2,APC
Vw factor type 2b eval plsm,0283U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18.4,,,,,,,fee schedule,16.56,32.2,APC
Vw factor type 2b eval plsm,0283U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.15,,,,,,,fee schedule,16.56,32.2,Radiology
Vw factor type 2b eval plsm,0283U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.76,,,,,,,fee schedule,16.56,32.2,APC
Vw factor type 2b eval plsm,0283U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,32.2,,,,,,,fee schedule,16.56,32.2,APC
Vw factor type 2n eval plsm,0284U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.54,,,,,,,fee schedule,15.54,30.22,Laboratory
Vw factor type 2n eval plsm,0284U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.13,,,,,,,fee schedule,15.54,30.22,APC
Vw factor type 2n eval plsm,0284U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,17.96,,,,,,,fee schedule,15.54,30.22,APC
Vw factor type 2n eval plsm,0284U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17.27,,,,,,,fee schedule,15.54,30.22,APC
Vw factor type 2n eval plsm,0284U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26.42,,,,,,,fee schedule,15.54,30.22,Radiology
Vw factor type 2n eval plsm,0284U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24.18,,,,,,,fee schedule,15.54,30.22,APC
Vw factor type 2n eval plsm,0284U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30.22,,,,,,,fee schedule,15.54,30.22,APC
Onc rsps radj cll fr dna tox,0285U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,398.98,,,,,,,fee schedule,398.98,775.79,Laboratory
Onc rsps radj cll fr dna tox,0285U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,465.48,,,,,,,fee schedule,398.98,775.79,APC
Onc rsps radj cll fr dna tox,0285U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,461.04,,,,,,,fee schedule,398.98,775.79,APC
Onc rsps radj cll fr dna tox,0285U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,443.31,,,,,,,fee schedule,398.98,775.79,APC
Onc rsps radj cll fr dna tox,0285U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,678.26,,,,,,,fee schedule,398.98,775.79,Radiology
Onc rsps radj cll fr dna tox,0285U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,620.63,,,,,,,fee schedule,398.98,775.79,APC
Onc rsps radj cll fr dna tox,0285U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,775.79,,,,,,,fee schedule,398.98,775.79,APC
Cep72 nudt15&tpmt gene alys,0286U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,120.72,,,,,,,fee schedule,120.72,234.73,Laboratory
Cep72 nudt15&tpmt gene alys,0286U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,140.84,,,,,,,fee schedule,120.72,234.73,APC
Cep72 nudt15&tpmt gene alys,0286U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,139.5,,,,,,,fee schedule,120.72,234.73,APC
Cep72 nudt15&tpmt gene alys,0286U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,134.13,,,,,,,fee schedule,120.72,234.73,APC
Cep72 nudt15&tpmt gene alys,0286U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,205.22,,,,,,,fee schedule,120.72,234.73,Radiology
Cep72 nudt15&tpmt gene alys,0286U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,187.78,,,,,,,fee schedule,120.72,234.73,APC
Cep72 nudt15&tpmt gene alys,0286U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,234.73,,,,,,,fee schedule,120.72,234.73,APC
Onc thyr dna&mrna 112 genes,0287U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3240,,,,,,,fee schedule,3240,6300,Laboratory
Onc thyr dna&mrna 112 genes,0287U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3780,,,,,,,fee schedule,3240,6300,APC
Onc thyr dna&mrna 112 genes,0287U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3744,,,,,,,fee schedule,3240,6300,APC
Onc thyr dna&mrna 112 genes,0287U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3600,,,,,,,fee schedule,3240,6300,APC
Onc thyr dna&mrna 112 genes,0287U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5508,,,,,,,fee schedule,3240,6300,Radiology
Onc thyr dna&mrna 112 genes,0287U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5040,,,,,,,fee schedule,3240,6300,APC
Onc thyr dna&mrna 112 genes,0287U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6300,,,,,,,fee schedule,3240,6300,APC
Onc lung mrna quan pcr 11&3,0288U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3485.7,,,,,,,fee schedule,3485.7,6777.75,Laboratory
Onc lung mrna quan pcr 11&3,0288U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4066.65,,,,,,,fee schedule,3485.7,6777.75,APC
Onc lung mrna quan pcr 11&3,0288U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4027.92,,,,,,,fee schedule,3485.7,6777.75,APC
Onc lung mrna quan pcr 11&3,0288U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3873,,,,,,,fee schedule,3485.7,6777.75,APC
Onc lung mrna quan pcr 11&3,0288U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5925.69,,,,,,,fee schedule,3485.7,6777.75,Radiology
Onc lung mrna quan pcr 11&3,0288U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5422.2,,,,,,,fee schedule,3485.7,6777.75,APC
Onc lung mrna quan pcr 11&3,0288U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6777.75,,,,,,,fee schedule,3485.7,6777.75,APC
Neuro alzheimer mrna 24 gen,0289U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,684,,,,,,,fee schedule,684,1330,Laboratory
Neuro alzheimer mrna 24 gen,0289U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,798,,,,,,,fee schedule,684,1330,APC
Neuro alzheimer mrna 24 gen,0289U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,790.4,,,,,,,fee schedule,684,1330,APC
Neuro alzheimer mrna 24 gen,0289U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,760,,,,,,,fee schedule,684,1330,APC
Neuro alzheimer mrna 24 gen,0289U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1162.8,,,,,,,fee schedule,684,1330,Radiology
Neuro alzheimer mrna 24 gen,0289U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1064,,,,,,,fee schedule,684,1330,APC
Neuro alzheimer mrna 24 gen,0289U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1330,,,,,,,fee schedule,684,1330,APC
Pain mgmt mrna gen xprsn 36,0290U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,684,,,,,,,fee schedule,684,1330,Laboratory
Pain mgmt mrna gen xprsn 36,0290U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,798,,,,,,,fee schedule,684,1330,APC
Pain mgmt mrna gen xprsn 36,0290U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,790.4,,,,,,,fee schedule,684,1330,APC
Pain mgmt mrna gen xprsn 36,0290U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,760,,,,,,,fee schedule,684,1330,APC
Pain mgmt mrna gen xprsn 36,0290U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1162.8,,,,,,,fee schedule,684,1330,Radiology
Pain mgmt mrna gen xprsn 36,0290U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1064,,,,,,,fee schedule,684,1330,APC
Pain mgmt mrna gen xprsn 36,0290U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1330,,,,,,,fee schedule,684,1330,APC
Psyc mood do mrna 144 genes,0291U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1579.5,,,,,,,fee schedule,1579.5,3071.25,Laboratory
Psyc mood do mrna 144 genes,0291U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1842.75,,,,,,,fee schedule,1579.5,3071.25,APC
Psyc mood do mrna 144 genes,0291U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1825.2,,,,,,,fee schedule,1579.5,3071.25,APC
Psyc mood do mrna 144 genes,0291U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1755,,,,,,,fee schedule,1579.5,3071.25,APC
Psyc mood do mrna 144 genes,0291U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2685.15,,,,,,,fee schedule,1579.5,3071.25,Radiology
Psyc mood do mrna 144 genes,0291U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2457,,,,,,,fee schedule,1579.5,3071.25,APC
Psyc mood do mrna 144 genes,0291U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3071.25,,,,,,,fee schedule,1579.5,3071.25,APC
Psyc strs do mrna 72 genes,0292U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1579.5,,,,,,,fee schedule,1579.5,3071.25,Laboratory
Psyc strs do mrna 72 genes,0292U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1842.75,,,,,,,fee schedule,1579.5,3071.25,APC
Psyc strs do mrna 72 genes,0292U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1825.2,,,,,,,fee schedule,1579.5,3071.25,APC
Psyc strs do mrna 72 genes,0292U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1755,,,,,,,fee schedule,1579.5,3071.25,APC
Psyc strs do mrna 72 genes,0292U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2685.15,,,,,,,fee schedule,1579.5,3071.25,Radiology
Psyc strs do mrna 72 genes,0292U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2457,,,,,,,fee schedule,1579.5,3071.25,APC
Psyc strs do mrna 72 genes,0292U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3071.25,,,,,,,fee schedule,1579.5,3071.25,APC
Psyc suicidal idea mrna 54,0293U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,684,,,,,,,fee schedule,684,1330,Laboratory
Psyc suicidal idea mrna 54,0293U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,798,,,,,,,fee schedule,684,1330,APC
Psyc suicidal idea mrna 54,0293U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,790.4,,,,,,,fee schedule,684,1330,APC
Psyc suicidal idea mrna 54,0293U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,760,,,,,,,fee schedule,684,1330,APC
Psyc suicidal idea mrna 54,0293U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1162.8,,,,,,,fee schedule,684,1330,Radiology
Psyc suicidal idea mrna 54,0293U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1064,,,,,,,fee schedule,684,1330,APC
Psyc suicidal idea mrna 54,0293U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1330,,,,,,,fee schedule,684,1330,APC
Onc brst dux carc 7 proteins,0295U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4891.5,,,,,,,fee schedule,4891.5,9511.25,Laboratory
Onc brst dux carc 7 proteins,0295U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5706.75,,,,,,,fee schedule,4891.5,9511.25,APC
Onc brst dux carc 7 proteins,0295U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5652.4,,,,,,,fee schedule,4891.5,9511.25,APC
Onc brst dux carc 7 proteins,0295U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5435,,,,,,,fee schedule,4891.5,9511.25,APC
Onc brst dux carc 7 proteins,0295U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8315.55,,,,,,,fee schedule,4891.5,9511.25,Radiology
Onc brst dux carc 7 proteins,0295U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7609,,,,,,,fee schedule,4891.5,9511.25,APC
Onc brst dux carc 7 proteins,0295U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9511.25,,,,,,,fee schedule,4891.5,9511.25,APC
Onc orl&/orop ca 20 mlc feat,0296U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755,,,,,,,fee schedule,1755,3412.5,Laboratory
Onc orl&/orop ca 20 mlc feat,0296U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2047.5,,,,,,,fee schedule,1755,3412.5,APC
Onc orl&/orop ca 20 mlc feat,0296U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2028,,,,,,,fee schedule,1755,3412.5,APC
Onc orl&/orop ca 20 mlc feat,0296U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1950,,,,,,,fee schedule,1755,3412.5,APC
Onc orl&/orop ca 20 mlc feat,0296U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2983.5,,,,,,,fee schedule,1755,3412.5,Radiology
Onc orl&/orop ca 20 mlc feat,0296U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2730,,,,,,,fee schedule,1755,3412.5,APC
Onc orl&/orop ca 20 mlc feat,0296U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3412.5,,,,,,,fee schedule,1755,3412.5,APC
Onc pan tum whl gen seq dna,0297U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2627.64,,,,,,,fee schedule,2627.64,5109.3,Laboratory
Onc pan tum whl gen seq dna,0297U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3065.58,,,,,,,fee schedule,2627.64,5109.3,APC
Onc pan tum whl gen seq dna,0297U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3036.38,,,,,,,fee schedule,2627.64,5109.3,APC
Onc pan tum whl gen seq dna,0297U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2919.6,,,,,,,fee schedule,2627.64,5109.3,APC
Onc pan tum whl gen seq dna,0297U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4466.99,,,,,,,fee schedule,2627.64,5109.3,Radiology
Onc pan tum whl gen seq dna,0297U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4087.44,,,,,,,fee schedule,2627.64,5109.3,APC
Onc pan tum whl gen seq dna,0297U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5109.3,,,,,,,fee schedule,2627.64,5109.3,APC
Onc pan tum whl trns seq rna,0298U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2627.64,,,,,,,fee schedule,2627.64,5109.3,Laboratory
Onc pan tum whl trns seq rna,0298U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3065.58,,,,,,,fee schedule,2627.64,5109.3,APC
Onc pan tum whl trns seq rna,0298U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3036.38,,,,,,,fee schedule,2627.64,5109.3,APC
Onc pan tum whl trns seq rna,0298U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2919.6,,,,,,,fee schedule,2627.64,5109.3,APC
Onc pan tum whl trns seq rna,0298U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4466.99,,,,,,,fee schedule,2627.64,5109.3,Radiology
Onc pan tum whl trns seq rna,0298U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4087.44,,,,,,,fee schedule,2627.64,5109.3,APC
Onc pan tum whl trns seq rna,0298U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5109.3,,,,,,,fee schedule,2627.64,5109.3,APC
Onc pan tum whl gen opt mapg,0299U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1676.9,,,,,,,fee schedule,1676.9,3260.64,Laboratory
Onc pan tum whl gen opt mapg,0299U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1956.38,,,,,,,fee schedule,1676.9,3260.64,APC
Onc pan tum whl gen opt mapg,0299U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1937.75,,,,,,,fee schedule,1676.9,3260.64,APC
Onc pan tum whl gen opt mapg,0299U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1863.22,,,,,,,fee schedule,1676.9,3260.64,APC
Onc pan tum whl gen opt mapg,0299U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2850.73,,,,,,,fee schedule,1676.9,3260.64,Radiology
Onc pan tum whl gen opt mapg,0299U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2608.51,,,,,,,fee schedule,1676.9,3260.64,APC
Onc pan tum whl gen opt mapg,0299U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3260.64,,,,,,,fee schedule,1676.9,3260.64,APC
Onc pan tum whl gen seq&opt,0300U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3764.82,,,,,,,fee schedule,3764.82,7320.48,Laboratory
Onc pan tum whl gen seq&opt,0300U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4392.29,,,,,,,fee schedule,3764.82,7320.48,APC
Onc pan tum whl gen seq&opt,0300U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4350.46,,,,,,,fee schedule,3764.82,7320.48,APC
Onc pan tum whl gen seq&opt,0300U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4183.13,,,,,,,fee schedule,3764.82,7320.48,APC
Onc pan tum whl gen seq&opt,0300U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6400.19,,,,,,,fee schedule,3764.82,7320.48,Radiology
Onc pan tum whl gen seq&opt,0300U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5856.38,,,,,,,fee schedule,3764.82,7320.48,APC
Onc pan tum whl gen seq&opt,0300U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7320.48,,,,,,,fee schedule,3764.82,7320.48,APC
Iadna bartonella ddpcr,0301U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,236.45,,,,,,,fee schedule,236.45,459.76,Laboratory
Iadna bartonella ddpcr,0301U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,275.86,,,,,,,fee schedule,236.45,459.76,APC
Iadna bartonella ddpcr,0301U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,273.23,,,,,,,fee schedule,236.45,459.76,APC
Iadna bartonella ddpcr,0301U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,262.72,,,,,,,fee schedule,236.45,459.76,APC
Iadna bartonella ddpcr,0301U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,401.96,,,,,,,fee schedule,236.45,459.76,Radiology
Iadna bartonella ddpcr,0301U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,367.81,,,,,,,fee schedule,236.45,459.76,APC
Iadna bartonella ddpcr,0301U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,459.76,,,,,,,fee schedule,236.45,459.76,APC
Iadna brtnla ddpcr flwg liq,0302U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,325.23,,,,,,,fee schedule,325.23,632.4,Laboratory
Iadna brtnla ddpcr flwg liq,0302U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,379.44,,,,,,,fee schedule,325.23,632.4,APC
Iadna brtnla ddpcr flwg liq,0302U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,375.82,,,,,,,fee schedule,325.23,632.4,APC
Iadna brtnla ddpcr flwg liq,0302U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,361.37,,,,,,,fee schedule,325.23,632.4,APC
Iadna brtnla ddpcr flwg liq,0302U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,552.9,,,,,,,fee schedule,325.23,632.4,Radiology
Iadna brtnla ddpcr flwg liq,0302U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,505.92,,,,,,,fee schedule,325.23,632.4,APC
Iadna brtnla ddpcr flwg liq,0302U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,632.4,,,,,,,fee schedule,325.23,632.4,APC
Hem rbc ads whl bld hypoxic,0303U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1981.46,,,,,,,fee schedule,1981.46,3852.84,Laboratory
Hem rbc ads whl bld hypoxic,0303U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2311.7,,,,,,,fee schedule,1981.46,3852.84,APC
Hem rbc ads whl bld hypoxic,0303U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2289.68,,,,,,,fee schedule,1981.46,3852.84,APC
Hem rbc ads whl bld hypoxic,0303U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2201.62,,,,,,,fee schedule,1981.46,3852.84,APC
Hem rbc ads whl bld hypoxic,0303U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3368.48,,,,,,,fee schedule,1981.46,3852.84,Radiology
Hem rbc ads whl bld hypoxic,0303U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3082.27,,,,,,,fee schedule,1981.46,3852.84,APC
Hem rbc ads whl bld hypoxic,0303U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3852.84,,,,,,,fee schedule,1981.46,3852.84,APC
Hem rbc ads whl bld normoxic,0304U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1868.22,,,,,,,fee schedule,1868.22,3632.65,Laboratory
Hem rbc ads whl bld normoxic,0304U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2179.59,,,,,,,fee schedule,1868.22,3632.65,APC
Hem rbc ads whl bld normoxic,0304U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2158.83,,,,,,,fee schedule,1868.22,3632.65,APC
Hem rbc ads whl bld normoxic,0304U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2075.8,,,,,,,fee schedule,1868.22,3632.65,APC
Hem rbc ads whl bld normoxic,0304U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3175.97,,,,,,,fee schedule,1868.22,3632.65,Radiology
Hem rbc ads whl bld normoxic,0304U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2906.12,,,,,,,fee schedule,1868.22,3632.65,APC
Hem rbc ads whl bld normoxic,0304U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3632.65,,,,,,,fee schedule,1868.22,3632.65,APC
Hem rbc fnclty&dfrm shr strs,0305U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,596.32,,,,,,,fee schedule,596.32,1159.52,Laboratory
Hem rbc fnclty&dfrm shr strs,0305U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,695.71,,,,,,,fee schedule,596.32,1159.52,APC
Hem rbc fnclty&dfrm shr strs,0305U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,689.08,,,,,,,fee schedule,596.32,1159.52,APC
Hem rbc fnclty&dfrm shr strs,0305U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,662.58,,,,,,,fee schedule,596.32,1159.52,APC
Hem rbc fnclty&dfrm shr strs,0305U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1013.75,,,,,,,fee schedule,596.32,1159.52,Radiology
Hem rbc fnclty&dfrm shr strs,0305U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,927.61,,,,,,,fee schedule,596.32,1159.52,APC
Hem rbc fnclty&dfrm shr strs,0305U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1159.52,,,,,,,fee schedule,596.32,1159.52,APC
Onc mrd nxt-gnrj alys 1st,0306U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3490.6,,,,,,,fee schedule,3490.6,6787.29,Laboratory
Onc mrd nxt-gnrj alys 1st,0306U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4072.37,,,,,,,fee schedule,3490.6,6787.29,APC
Onc mrd nxt-gnrj alys 1st,0306U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4033.59,,,,,,,fee schedule,3490.6,6787.29,APC
Onc mrd nxt-gnrj alys 1st,0306U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3878.45,,,,,,,fee schedule,3490.6,6787.29,APC
Onc mrd nxt-gnrj alys 1st,0306U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5934.03,,,,,,,fee schedule,3490.6,6787.29,Radiology
Onc mrd nxt-gnrj alys 1st,0306U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5429.83,,,,,,,fee schedule,3490.6,6787.29,APC
Onc mrd nxt-gnrj alys 1st,0306U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6787.29,,,,,,,fee schedule,3490.6,6787.29,APC
Onc mrd nxt-gnrj alys sbsq,0307U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,715.04,,,,,,,fee schedule,715.04,1390.36,Laboratory
Onc mrd nxt-gnrj alys sbsq,0307U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,834.21,,,,,,,fee schedule,715.04,1390.36,APC
Onc mrd nxt-gnrj alys sbsq,0307U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,826.27,,,,,,,fee schedule,715.04,1390.36,APC
Onc mrd nxt-gnrj alys sbsq,0307U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,794.49,,,,,,,fee schedule,715.04,1390.36,APC
Onc mrd nxt-gnrj alys sbsq,0307U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1215.57,,,,,,,fee schedule,715.04,1390.36,Radiology
Onc mrd nxt-gnrj alys sbsq,0307U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1112.29,,,,,,,fee schedule,715.04,1390.36,APC
Onc mrd nxt-gnrj alys sbsq,0307U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1390.36,,,,,,,fee schedule,715.04,1390.36,APC
Insj ocular telescope prosth,0308T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6337.62,,,,,,,fee schedule,5080.16,72298.44,
Insj ocular telescope prosth,0308T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5080.16,,,,,,,fee schedule,5080.16,72298.44,
Insj ocular telescope prosth,0308T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5549.61,,,,,,,fee schedule,5080.16,72298.44,
Insj ocular telescope prosth,0308T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5834.64,,,,,,,fee schedule,5080.16,72298.44,
Insj ocular telescope prosth,0308T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,72298.44,,,,,,,fee schedule,5080.16,72298.44,APC 378
Insj ocular telescope prosth,0308T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17110.47,,,,,,,fee schedule,5080.16,72298.44,APC
Insj ocular telescope prosth,0308T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,16947.51,,,,,,,fee schedule,5080.16,72298.44,APC
Insj ocular telescope prosth,0308T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16295.69,,,,,,,fee schedule,5080.16,72298.44,APC
Insj ocular telescope prosth,0308T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24932.4,,,,,,,fee schedule,5080.16,72298.44,Radiology
Insj ocular telescope prosth,0308T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22813.96,,,,,,,fee schedule,5080.16,72298.44,APC
Insj ocular telescope prosth,0308T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,28517.45,,,,,,,fee schedule,5080.16,72298.44,APC
Crd cad alys 3 prtn plsm alg,0308U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,351.68,,,,,,,fee schedule,351.68,683.81,Laboratory
Crd cad alys 3 prtn plsm alg,0308U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,410.29,,,,,,,fee schedule,351.68,683.81,APC
Crd cad alys 3 prtn plsm alg,0308U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,406.38,,,,,,,fee schedule,351.68,683.81,APC
Crd cad alys 3 prtn plsm alg,0308U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,390.75,,,,,,,fee schedule,351.68,683.81,APC
Crd cad alys 3 prtn plsm alg,0308U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,597.85,,,,,,,fee schedule,351.68,683.81,Radiology
Crd cad alys 3 prtn plsm alg,0308U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,547.05,,,,,,,fee schedule,351.68,683.81,APC
Crd cad alys 3 prtn plsm alg,0308U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,683.81,,,,,,,fee schedule,351.68,683.81,APC
Crd cv ds aly 4 prtn plm alg,0309U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,351.68,,,,,,,fee schedule,351.68,683.81,Laboratory
Crd cv ds aly 4 prtn plm alg,0309U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,410.29,,,,,,,fee schedule,351.68,683.81,APC
Crd cv ds aly 4 prtn plm alg,0309U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,406.38,,,,,,,fee schedule,351.68,683.81,APC
Crd cv ds aly 4 prtn plm alg,0309U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,390.75,,,,,,,fee schedule,351.68,683.81,APC
Crd cv ds aly 4 prtn plm alg,0309U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,597.85,,,,,,,fee schedule,351.68,683.81,Radiology
Crd cv ds aly 4 prtn plm alg,0309U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,547.05,,,,,,,fee schedule,351.68,683.81,APC
Crd cv ds aly 4 prtn plm alg,0309U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,683.81,,,,,,,fee schedule,351.68,683.81,APC
Ped vsclts kd alys 3 bmrks,0310U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,351.68,,,,,,,fee schedule,351.68,683.81,Laboratory
Ped vsclts kd alys 3 bmrks,0310U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,410.29,,,,,,,fee schedule,351.68,683.81,APC
Ped vsclts kd alys 3 bmrks,0310U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,406.38,,,,,,,fee schedule,351.68,683.81,APC
Ped vsclts kd alys 3 bmrks,0310U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,390.75,,,,,,,fee schedule,351.68,683.81,APC
Ped vsclts kd alys 3 bmrks,0310U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,597.85,,,,,,,fee schedule,351.68,683.81,Radiology
Ped vsclts kd alys 3 bmrks,0310U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,547.05,,,,,,,fee schedule,351.68,683.81,APC
Ped vsclts kd alys 3 bmrks,0310U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,683.81,,,,,,,fee schedule,351.68,683.81,APC
Nfct ds bct quan antmcrb sc,0311U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.27,,,,,,,fee schedule,7.27,14.14,Laboratory
Nfct ds bct quan antmcrb sc,0311U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.48,,,,,,,fee schedule,7.27,14.14,APC
Nfct ds bct quan antmcrb sc,0311U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8.4,,,,,,,fee schedule,7.27,14.14,APC
Nfct ds bct quan antmcrb sc,0311U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8.08,,,,,,,fee schedule,7.27,14.14,APC
Nfct ds bct quan antmcrb sc,0311U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12.36,,,,,,,fee schedule,7.27,14.14,Radiology
Nfct ds bct quan antmcrb sc,0311U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11.31,,,,,,,fee schedule,7.27,14.14,APC
Nfct ds bct quan antmcrb sc,0311U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14.14,,,,,,,fee schedule,7.27,14.14,APC
Ai ds sle alys 8 igg autoant,0312U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,756.58,,,,,,,fee schedule,756.58,1471.14,Laboratory
Ai ds sle alys 8 igg autoant,0312U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,882.68,,,,,,,fee schedule,756.58,1471.14,APC
Ai ds sle alys 8 igg autoant,0312U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,874.28,,,,,,,fee schedule,756.58,1471.14,APC
Ai ds sle alys 8 igg autoant,0312U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,840.65,,,,,,,fee schedule,756.58,1471.14,APC
Ai ds sle alys 8 igg autoant,0312U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1286.19,,,,,,,fee schedule,756.58,1471.14,Radiology
Ai ds sle alys 8 igg autoant,0312U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1176.91,,,,,,,fee schedule,756.58,1471.14,APC
Ai ds sle alys 8 igg autoant,0312U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1471.14,,,,,,,fee schedule,756.58,1471.14,APC
Onc pncrs dna&mrna seq 74,0313U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3240,,,,,,,fee schedule,3240,6300,Laboratory
Onc pncrs dna&mrna seq 74,0313U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3780,,,,,,,fee schedule,3240,6300,APC
Onc pncrs dna&mrna seq 74,0313U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3744,,,,,,,fee schedule,3240,6300,APC
Onc pncrs dna&mrna seq 74,0313U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3600,,,,,,,fee schedule,3240,6300,APC
Onc pncrs dna&mrna seq 74,0313U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5508,,,,,,,fee schedule,3240,6300,Radiology
Onc pncrs dna&mrna seq 74,0313U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5040,,,,,,,fee schedule,3240,6300,APC
Onc pncrs dna&mrna seq 74,0313U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6300,,,,,,,fee schedule,3240,6300,APC
Onc cutan mlnma mrna 35 gene,0314U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755,,,,,,,fee schedule,1755,3412.5,Laboratory
Onc cutan mlnma mrna 35 gene,0314U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2047.5,,,,,,,fee schedule,1755,3412.5,APC
Onc cutan mlnma mrna 35 gene,0314U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2028,,,,,,,fee schedule,1755,3412.5,APC
Onc cutan mlnma mrna 35 gene,0314U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1950,,,,,,,fee schedule,1755,3412.5,APC
Onc cutan mlnma mrna 35 gene,0314U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2983.5,,,,,,,fee schedule,1755,3412.5,Radiology
Onc cutan mlnma mrna 35 gene,0314U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2730,,,,,,,fee schedule,1755,3412.5,APC
Onc cutan mlnma mrna 35 gene,0314U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3412.5,,,,,,,fee schedule,1755,3412.5,APC
Onc cutan sq cll ca mrna 40,0315U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7650,,,,,,,fee schedule,7650,14875,Laboratory
Onc cutan sq cll ca mrna 40,0315U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8925,,,,,,,fee schedule,7650,14875,APC
Onc cutan sq cll ca mrna 40,0315U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8840,,,,,,,fee schedule,7650,14875,APC
Onc cutan sq cll ca mrna 40,0315U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8500,,,,,,,fee schedule,7650,14875,APC
Onc cutan sq cll ca mrna 40,0315U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13005,,,,,,,fee schedule,7650,14875,Radiology
Onc cutan sq cll ca mrna 40,0315U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11900,,,,,,,fee schedule,7650,14875,APC
Onc cutan sq cll ca mrna 40,0315U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14875,,,,,,,fee schedule,7650,14875,APC
B brgdrferi lyme ds ospa evl,0316U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.79,,,,,,,fee schedule,16.79,32.66,Laboratory
B brgdrferi lyme ds ospa evl,0316U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.59,,,,,,,fee schedule,16.79,32.66,APC
B brgdrferi lyme ds ospa evl,0316U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,19.41,,,,,,,fee schedule,16.79,32.66,APC
B brgdrferi lyme ds ospa evl,0316U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18.66,,,,,,,fee schedule,16.79,32.66,APC
B brgdrferi lyme ds ospa evl,0316U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.55,,,,,,,fee schedule,16.79,32.66,Radiology
B brgdrferi lyme ds ospa evl,0316U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26.12,,,,,,,fee schedule,16.79,32.66,APC
B brgdrferi lyme ds ospa evl,0316U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,32.66,,,,,,,fee schedule,16.79,32.66,APC
Onc lung ca 4-prb fish assay,0317U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1827,,,,,,,fee schedule,1827,3552.5,Laboratory
Onc lung ca 4-prb fish assay,0317U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2131.5,,,,,,,fee schedule,1827,3552.5,APC
Onc lung ca 4-prb fish assay,0317U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2111.2,,,,,,,fee schedule,1827,3552.5,APC
Onc lung ca 4-prb fish assay,0317U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2030,,,,,,,fee schedule,1827,3552.5,APC
Onc lung ca 4-prb fish assay,0317U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3105.9,,,,,,,fee schedule,1827,3552.5,Radiology
Onc lung ca 4-prb fish assay,0317U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2842,,,,,,,fee schedule,1827,3552.5,APC
Onc lung ca 4-prb fish assay,0317U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3552.5,,,,,,,fee schedule,1827,3552.5,APC
Ped whl gen mthyltn alys 50+,0318U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1593.43,,,,,,,fee schedule,1593.43,3098.34,Laboratory
Ped whl gen mthyltn alys 50+,0318U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1859,,,,,,,fee schedule,1593.43,3098.34,APC
Ped whl gen mthyltn alys 50+,0318U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1841.3,,,,,,,fee schedule,1593.43,3098.34,APC
Ped whl gen mthyltn alys 50+,0318U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1770.48,,,,,,,fee schedule,1593.43,3098.34,APC
Ped whl gen mthyltn alys 50+,0318U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2708.83,,,,,,,fee schedule,1593.43,3098.34,Radiology
Ped whl gen mthyltn alys 50+,0318U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2478.67,,,,,,,fee schedule,1593.43,3098.34,APC
Ped whl gen mthyltn alys 50+,0318U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3098.34,,,,,,,fee schedule,1593.43,3098.34,APC
Neph rna pretrnspl perph bld,0319U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2385,,,,,,,fee schedule,2385,4637.5,Laboratory
Neph rna pretrnspl perph bld,0319U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2782.5,,,,,,,fee schedule,2385,4637.5,APC
Neph rna pretrnspl perph bld,0319U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2756,,,,,,,fee schedule,2385,4637.5,APC
Neph rna pretrnspl perph bld,0319U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2650,,,,,,,fee schedule,2385,4637.5,APC
Neph rna pretrnspl perph bld,0319U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4054.5,,,,,,,fee schedule,2385,4637.5,Radiology
Neph rna pretrnspl perph bld,0319U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3710,,,,,,,fee schedule,2385,4637.5,APC
Neph rna pretrnspl perph bld,0319U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4637.5,,,,,,,fee schedule,2385,4637.5,APC
Neph rna psttrnspl perph bld,0320U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2385,,,,,,,fee schedule,2385,4637.5,Laboratory
Neph rna psttrnspl perph bld,0320U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2782.5,,,,,,,fee schedule,2385,4637.5,APC
Neph rna psttrnspl perph bld,0320U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2756,,,,,,,fee schedule,2385,4637.5,APC
Neph rna psttrnspl perph bld,0320U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2650,,,,,,,fee schedule,2385,4637.5,APC
Neph rna psttrnspl perph bld,0320U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4054.5,,,,,,,fee schedule,2385,4637.5,Radiology
Neph rna psttrnspl perph bld,0320U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3710,,,,,,,fee schedule,2385,4637.5,APC
Neph rna psttrnspl perph bld,0320U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4637.5,,,,,,,fee schedule,2385,4637.5,APC
Iadna gu pthgn 20bct&fng org,0321U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,571.36,,,,,,,fee schedule,571.36,1110.97,Laboratory
Iadna gu pthgn 20bct&fng org,0321U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,666.58,,,,,,,fee schedule,571.36,1110.97,APC
Iadna gu pthgn 20bct&fng org,0321U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,660.23,,,,,,,fee schedule,571.36,1110.97,APC
Iadna gu pthgn 20bct&fng org,0321U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,634.84,,,,,,,fee schedule,571.36,1110.97,APC
Iadna gu pthgn 20bct&fng org,0321U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,971.31,,,,,,,fee schedule,571.36,1110.97,Radiology
Iadna gu pthgn 20bct&fng org,0321U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,888.78,,,,,,,fee schedule,571.36,1110.97,APC
Iadna gu pthgn 20bct&fng org,0321U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1110.97,,,,,,,fee schedule,571.36,1110.97,APC
Neuro asd meas 14 acyl carn,0322U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,675,,,,,,,fee schedule,675,1312.5,Laboratory
Neuro asd meas 14 acyl carn,0322U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,787.5,,,,,,,fee schedule,675,1312.5,APC
Neuro asd meas 14 acyl carn,0322U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,780,,,,,,,fee schedule,675,1312.5,APC
Neuro asd meas 14 acyl carn,0322U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,750,,,,,,,fee schedule,675,1312.5,APC
Neuro asd meas 14 acyl carn,0322U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1147.5,,,,,,,fee schedule,675,1312.5,Radiology
Neuro asd meas 14 acyl carn,0322U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1050,,,,,,,fee schedule,675,1312.5,APC
Neuro asd meas 14 acyl carn,0322U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1312.5,,,,,,,fee schedule,675,1312.5,APC
Iadna cns pthgn next gen seq,0323U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1913.58,,,,,,,fee schedule,1913.58,3720.85,Laboratory
Iadna cns pthgn next gen seq,0323U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2232.51,,,,,,,fee schedule,1913.58,3720.85,APC
Iadna cns pthgn next gen seq,0323U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2211.25,,,,,,,fee schedule,1913.58,3720.85,APC
Iadna cns pthgn next gen seq,0323U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2126.2,,,,,,,fee schedule,1913.58,3720.85,APC
Iadna cns pthgn next gen seq,0323U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3253.09,,,,,,,fee schedule,1913.58,3720.85,Radiology
Iadna cns pthgn next gen seq,0323U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2976.68,,,,,,,fee schedule,1913.58,3720.85,APC
Iadna cns pthgn next gen seq,0323U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3720.85,,,,,,,fee schedule,1913.58,3720.85,APC
Trgt gen seq alys pnl 83+,0326U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4500,,,,,,,fee schedule,4500,8750,Laboratory
Trgt gen seq alys pnl 83+,0326U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5250,,,,,,,fee schedule,4500,8750,APC
Trgt gen seq alys pnl 83+,0326U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5200,,,,,,,fee schedule,4500,8750,APC
Trgt gen seq alys pnl 83+,0326U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5000,,,,,,,fee schedule,4500,8750,APC
Trgt gen seq alys pnl 83+,0326U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7650,,,,,,,fee schedule,4500,8750,Radiology
Trgt gen seq alys pnl 83+,0326U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7000,,,,,,,fee schedule,4500,8750,APC
Trgt gen seq alys pnl 83+,0326U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8750,,,,,,,fee schedule,4500,8750,APC
Ftl aneuploidy trsmy dna seq,0327U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,715.5,,,,,,,fee schedule,715.5,1391.25,Laboratory
Ftl aneuploidy trsmy dna seq,0327U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,834.75,,,,,,,fee schedule,715.5,1391.25,APC
Ftl aneuploidy trsmy dna seq,0327U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,826.8,,,,,,,fee schedule,715.5,1391.25,APC
Ftl aneuploidy trsmy dna seq,0327U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,795,,,,,,,fee schedule,715.5,1391.25,APC
Ftl aneuploidy trsmy dna seq,0327U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1216.35,,,,,,,fee schedule,715.5,1391.25,Radiology
Ftl aneuploidy trsmy dna seq,0327U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1113,,,,,,,fee schedule,715.5,1391.25,APC
Ftl aneuploidy trsmy dna seq,0327U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1391.25,,,,,,,fee schedule,715.5,1391.25,APC
Drug assay 120+ rx&metablt,0328U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,102.99,,,,,,,fee schedule,102.99,200.25,Laboratory
Drug assay 120+ rx&metablt,0328U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,120.15,,,,,,,fee schedule,102.99,200.25,APC
Drug assay 120+ rx&metablt,0328U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,119.01,,,,,,,fee schedule,102.99,200.25,APC
Drug assay 120+ rx&metablt,0328U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,114.43,,,,,,,fee schedule,102.99,200.25,APC
Drug assay 120+ rx&metablt,0328U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,175.08,,,,,,,fee schedule,102.99,200.25,Radiology
Drug assay 120+ rx&metablt,0328U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,160.2,,,,,,,fee schedule,102.99,200.25,APC
Drug assay 120+ rx&metablt,0328U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,200.25,,,,,,,fee schedule,102.99,200.25,APC
Onc neo xome&trns seq alys,0329U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3094.18,,,,,,,fee schedule,3094.18,6016.46,Laboratory
Onc neo xome&trns seq alys,0329U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3609.88,,,,,,,fee schedule,3094.18,6016.46,APC
Onc neo xome&trns seq alys,0329U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3575.5,,,,,,,fee schedule,3094.18,6016.46,APC
Onc neo xome&trns seq alys,0329U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3437.98,,,,,,,fee schedule,3094.18,6016.46,APC
Onc neo xome&trns seq alys,0329U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5260.11,,,,,,,fee schedule,3094.18,6016.46,Radiology
Onc neo xome&trns seq alys,0329U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4813.17,,,,,,,fee schedule,3094.18,6016.46,APC
Onc neo xome&trns seq alys,0329U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6016.46,,,,,,,fee schedule,3094.18,6016.46,APC
Tear film img uni/bi w/i&r,0330T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,182.99,,,,,,,fee schedule,36.98,182.99,
Tear film img uni/bi w/i&r,0330T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,146.68,,,,,,,fee schedule,36.98,182.99,
Tear film img uni/bi w/i&r,0330T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,160.24,,,,,,,fee schedule,36.98,182.99,
Tear film img uni/bi w/i&r,0330T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,168.47,,,,,,,fee schedule,36.98,182.99,
Tear film img uni/bi w/i&r,0330T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.05,,,,,,,fee schedule,36.98,182.99,APC 378
Tear film img uni/bi w/i&r,0330T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.83,,,,,,,fee schedule,36.98,182.99,APC
Tear film img uni/bi w/i&r,0330T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.46,,,,,,,fee schedule,36.98,182.99,APC
Tear film img uni/bi w/i&r,0330T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.98,,,,,,,fee schedule,36.98,182.99,APC
Tear film img uni/bi w/i&r,0330T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.57,,,,,,,fee schedule,36.98,182.99,Radiology
Tear film img uni/bi w/i&r,0330T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.77,,,,,,,fee schedule,36.98,182.99,APC
Tear film img uni/bi w/i&r,0330T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.71,,,,,,,fee schedule,36.98,182.99,APC
Iadna vag pthgn panel 27 org,0330U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,375.1,,,,,,,fee schedule,375.1,729.36,Laboratory
Iadna vag pthgn panel 27 org,0330U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,437.62,,,,,,,fee schedule,375.1,729.36,APC
Iadna vag pthgn panel 27 org,0330U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,433.45,,,,,,,fee schedule,375.1,729.36,APC
Iadna vag pthgn panel 27 org,0330U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,416.78,,,,,,,fee schedule,375.1,729.36,APC
Iadna vag pthgn panel 27 org,0330U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,637.67,,,,,,,fee schedule,375.1,729.36,Radiology
Iadna vag pthgn panel 27 org,0330U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,583.49,,,,,,,fee schedule,375.1,729.36,APC
Iadna vag pthgn panel 27 org,0330U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,729.36,,,,,,,fee schedule,375.1,729.36,APC
Heart symp image plnr,0331T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1167.98,,,,,,,fee schedule,936.24,5686.29,
Heart symp image plnr,0331T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,936.24,,,,,,,fee schedule,936.24,5686.29,
Heart symp image plnr,0331T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1022.76,,,,,,,fee schedule,936.24,5686.29,
Heart symp image plnr,0331T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1075.29,,,,,,,fee schedule,936.24,5686.29,
Heart symp image plnr,0331T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5686.29,,,,,,,fee schedule,936.24,5686.29,APC 378
Heart symp image plnr,0331T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1345.74,,,,,,,fee schedule,936.24,5686.29,APC
Heart symp image plnr,0331T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1332.93,,,,,,,fee schedule,936.24,5686.29,APC
Heart symp image plnr,0331T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1281.66,,,,,,,fee schedule,936.24,5686.29,APC
Heart symp image plnr,0331T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1960.94,,,,,,,fee schedule,936.24,5686.29,Radiology
Heart symp image plnr,0331T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1794.32,,,,,,,fee schedule,936.24,5686.29,APC
Heart symp image plnr,0331T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2242.91,,,,,,,fee schedule,936.24,5686.29,APC
Onc hl neo opt gen mapping,0331U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1676.9,,,,,,,fee schedule,1676.9,3260.64,Laboratory
Onc hl neo opt gen mapping,0331U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1956.38,,,,,,,fee schedule,1676.9,3260.64,APC
Onc hl neo opt gen mapping,0331U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1937.75,,,,,,,fee schedule,1676.9,3260.64,APC
Onc hl neo opt gen mapping,0331U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1863.22,,,,,,,fee schedule,1676.9,3260.64,APC
Onc hl neo opt gen mapping,0331U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2850.73,,,,,,,fee schedule,1676.9,3260.64,Radiology
Onc hl neo opt gen mapping,0331U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2608.51,,,,,,,fee schedule,1676.9,3260.64,APC
Onc hl neo opt gen mapping,0331U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3260.64,,,,,,,fee schedule,1676.9,3260.64,APC
Heart symp image plnr spect,0332T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1167.98,,,,,,,fee schedule,936.24,5686.29,
Heart symp image plnr spect,0332T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,936.24,,,,,,,fee schedule,936.24,5686.29,
Heart symp image plnr spect,0332T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1022.76,,,,,,,fee schedule,936.24,5686.29,
Heart symp image plnr spect,0332T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1075.29,,,,,,,fee schedule,936.24,5686.29,
Heart symp image plnr spect,0332T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5686.29,,,,,,,fee schedule,936.24,5686.29,APC 378
Heart symp image plnr spect,0332T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1345.74,,,,,,,fee schedule,936.24,5686.29,APC
Heart symp image plnr spect,0332T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1332.93,,,,,,,fee schedule,936.24,5686.29,APC
Heart symp image plnr spect,0332T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1281.66,,,,,,,fee schedule,936.24,5686.29,APC
Heart symp image plnr spect,0332T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1960.94,,,,,,,fee schedule,936.24,5686.29,Radiology
Heart symp image plnr spect,0332T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1794.32,,,,,,,fee schedule,936.24,5686.29,APC
Heart symp image plnr spect,0332T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2242.91,,,,,,,fee schedule,936.24,5686.29,APC
Onc pan tum gen prflg 8 dna,0332U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1027.85,,,,,,,fee schedule,1027.85,1998.6,Laboratory
Onc pan tum gen prflg 8 dna,0332U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1199.16,,,,,,,fee schedule,1027.85,1998.6,APC
Onc pan tum gen prflg 8 dna,0332U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1187.74,,,,,,,fee schedule,1027.85,1998.6,APC
Onc pan tum gen prflg 8 dna,0332U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1142.06,,,,,,,fee schedule,1027.85,1998.6,APC
Onc pan tum gen prflg 8 dna,0332U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1747.35,,,,,,,fee schedule,1027.85,1998.6,Radiology
Onc pan tum gen prflg 8 dna,0332U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1598.88,,,,,,,fee schedule,1027.85,1998.6,APC
Onc pan tum gen prflg 8 dna,0332U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1998.6,,,,,,,fee schedule,1027.85,1998.6,APC
Onc lvr surveilanc hcc cfdna,0333U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,596.09,,,,,,,fee schedule,596.09,1159.06,Laboratory
Onc lvr surveilanc hcc cfdna,0333U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,695.44,,,,,,,fee schedule,596.09,1159.06,APC
Onc lvr surveilanc hcc cfdna,0333U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,688.81,,,,,,,fee schedule,596.09,1159.06,APC
Onc lvr surveilanc hcc cfdna,0333U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,662.32,,,,,,,fee schedule,596.09,1159.06,APC
Onc lvr surveilanc hcc cfdna,0333U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1013.35,,,,,,,fee schedule,596.09,1159.06,Radiology
Onc lvr surveilanc hcc cfdna,0333U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,927.25,,,,,,,fee schedule,596.09,1159.06,APC
Onc lvr surveilanc hcc cfdna,0333U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1159.06,,,,,,,fee schedule,596.09,1159.06,APC
Onc sld orgn tgsa dna 84/+,0334U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3150,,,,,,,fee schedule,3150,6125,Laboratory
Onc sld orgn tgsa dna 84/+,0334U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3675,,,,,,,fee schedule,3150,6125,APC
Onc sld orgn tgsa dna 84/+,0334U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3640,,,,,,,fee schedule,3150,6125,APC
Onc sld orgn tgsa dna 84/+,0334U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3500,,,,,,,fee schedule,3150,6125,APC
Onc sld orgn tgsa dna 84/+,0334U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5355,,,,,,,fee schedule,3150,6125,Radiology
Onc sld orgn tgsa dna 84/+,0334U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4900,,,,,,,fee schedule,3150,6125,APC
Onc sld orgn tgsa dna 84/+,0334U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6125,,,,,,,fee schedule,3150,6125,APC
Extraosseous joint stblztion,0335T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7721.22,,,,,,,fee schedule,6189.23,31870.39,
Extraosseous joint stblztion,0335T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6189.23,,,,,,,fee schedule,6189.23,31870.39,
Extraosseous joint stblztion,0335T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6761.17,,,,,,,fee schedule,6189.23,31870.39,
Extraosseous joint stblztion,0335T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7108.42,,,,,,,fee schedule,6189.23,31870.39,
Extraosseous joint stblztion,0335T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,6189.23,31870.39,APC 378
Extraosseous joint stblztion,0335T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,6189.23,31870.39,APC
Extraosseous joint stblztion,0335T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,6189.23,31870.39,APC
Extraosseous joint stblztion,0335T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,6189.23,31870.39,APC
Extraosseous joint stblztion,0335T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,6189.23,31870.39,Radiology
Extraosseous joint stblztion,0335T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,6189.23,31870.39,APC
Extraosseous joint stblztion,0335T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,6189.23,31870.39,APC
Rare ds whl gen seq fetal,0335U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4702.14,,,,,,,fee schedule,4702.14,9143.05,Laboratory
Rare ds whl gen seq fetal,0335U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5485.83,,,,,,,fee schedule,4702.14,9143.05,APC
Rare ds whl gen seq fetal,0335U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5433.58,,,,,,,fee schedule,4702.14,9143.05,APC
Rare ds whl gen seq fetal,0335U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5224.6,,,,,,,fee schedule,4702.14,9143.05,APC
Rare ds whl gen seq fetal,0335U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7993.64,,,,,,,fee schedule,4702.14,9143.05,Radiology
Rare ds whl gen seq fetal,0335U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7314.44,,,,,,,fee schedule,4702.14,9143.05,APC
Rare ds whl gen seq fetal,0335U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9143.05,,,,,,,fee schedule,4702.14,9143.05,APC
Rare ds whl gen seq bld/slv,0336U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2317.18,,,,,,,fee schedule,2317.18,4505.64,Laboratory
Rare ds whl gen seq bld/slv,0336U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2703.38,,,,,,,fee schedule,2317.18,4505.64,APC
Rare ds whl gen seq bld/slv,0336U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2677.64,,,,,,,fee schedule,2317.18,4505.64,APC
Rare ds whl gen seq bld/slv,0336U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2574.65,,,,,,,fee schedule,2317.18,4505.64,APC
Rare ds whl gen seq bld/slv,0336U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3939.21,,,,,,,fee schedule,2317.18,4505.64,Radiology
Rare ds whl gen seq bld/slv,0336U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3604.51,,,,,,,fee schedule,2317.18,4505.64,APC
Rare ds whl gen seq bld/slv,0336U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4505.64,,,,,,,fee schedule,2317.18,4505.64,APC
Onc plsm cell do&myeloma id,0337U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2191.5,,,,,,,fee schedule,2191.5,4261.25,Laboratory
Onc plsm cell do&myeloma id,0337U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2556.75,,,,,,,fee schedule,2191.5,4261.25,APC
Onc plsm cell do&myeloma id,0337U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2532.4,,,,,,,fee schedule,2191.5,4261.25,APC
Onc plsm cell do&myeloma id,0337U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2435,,,,,,,fee schedule,2191.5,4261.25,APC
Onc plsm cell do&myeloma id,0337U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3725.55,,,,,,,fee schedule,2191.5,4261.25,Radiology
Onc plsm cell do&myeloma id,0337U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3409,,,,,,,fee schedule,2191.5,4261.25,APC
Onc plsm cell do&myeloma id,0337U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4261.25,,,,,,,fee schedule,2191.5,4261.25,APC
Trnscth renal symp denrv unl,0338T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9678.39,,,,,,,fee schedule,5634.46,24998.21,
Trnscth renal symp denrv unl,0338T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7758.07,,,,,,,fee schedule,5634.46,24998.21,
Trnscth renal symp denrv unl,0338T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8474.99,,,,,,,fee schedule,5634.46,24998.21,
Trnscth renal symp denrv unl,0338T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8910.26,,,,,,,fee schedule,5634.46,24998.21,
Trnscth renal symp denrv unl,0338T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24998.21,,,,,,,fee schedule,5634.46,24998.21,APC 378
Trnscth renal symp denrv unl,0338T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5916.19,,,,,,,fee schedule,5634.46,24998.21,APC
Trnscth renal symp denrv unl,0338T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5859.84,,,,,,,fee schedule,5634.46,24998.21,APC
Trnscth renal symp denrv unl,0338T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5634.46,,,,,,,fee schedule,5634.46,24998.21,APC
Trnscth renal symp denrv unl,0338T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8620.73,,,,,,,fee schedule,5634.46,24998.21,Radiology
Trnscth renal symp denrv unl,0338T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7888.25,,,,,,,fee schedule,5634.46,24998.21,APC
Trnscth renal symp denrv unl,0338T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9860.31,,,,,,,fee schedule,5634.46,24998.21,APC
Onc sld tum crcg tum cl slct,0338U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2191.5,,,,,,,fee schedule,2191.5,4261.25,Laboratory
Onc sld tum crcg tum cl slct,0338U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2556.75,,,,,,,fee schedule,2191.5,4261.25,APC
Onc sld tum crcg tum cl slct,0338U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2532.4,,,,,,,fee schedule,2191.5,4261.25,APC
Onc sld tum crcg tum cl slct,0338U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2435,,,,,,,fee schedule,2191.5,4261.25,APC
Onc sld tum crcg tum cl slct,0338U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3725.55,,,,,,,fee schedule,2191.5,4261.25,Radiology
Onc sld tum crcg tum cl slct,0338U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3409,,,,,,,fee schedule,2191.5,4261.25,APC
Onc sld tum crcg tum cl slct,0338U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4261.25,,,,,,,fee schedule,2191.5,4261.25,APC
Trnscth renal symp denrv bil,0339T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9678.39,,,,,,,fee schedule,5634.46,24998.21,
Trnscth renal symp denrv bil,0339T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7758.07,,,,,,,fee schedule,5634.46,24998.21,
Trnscth renal symp denrv bil,0339T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8474.99,,,,,,,fee schedule,5634.46,24998.21,
Trnscth renal symp denrv bil,0339T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8910.26,,,,,,,fee schedule,5634.46,24998.21,
Trnscth renal symp denrv bil,0339T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24998.21,,,,,,,fee schedule,5634.46,24998.21,APC 378
Trnscth renal symp denrv bil,0339T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5916.19,,,,,,,fee schedule,5634.46,24998.21,APC
Trnscth renal symp denrv bil,0339T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5859.84,,,,,,,fee schedule,5634.46,24998.21,APC
Trnscth renal symp denrv bil,0339T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5634.46,,,,,,,fee schedule,5634.46,24998.21,APC
Trnscth renal symp denrv bil,0339T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8620.73,,,,,,,fee schedule,5634.46,24998.21,Radiology
Trnscth renal symp denrv bil,0339T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7888.25,,,,,,,fee schedule,5634.46,24998.21,APC
Trnscth renal symp denrv bil,0339T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9860.31,,,,,,,fee schedule,5634.46,24998.21,APC
Onc prst8 mrna hoxc6 & dlx1,0339U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,684,,,,,,,fee schedule,684,1330,Laboratory
Onc prst8 mrna hoxc6 & dlx1,0339U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,798,,,,,,,fee schedule,684,1330,APC
Onc prst8 mrna hoxc6 & dlx1,0339U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,790.4,,,,,,,fee schedule,684,1330,APC
Onc prst8 mrna hoxc6 & dlx1,0339U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,760,,,,,,,fee schedule,684,1330,APC
Onc prst8 mrna hoxc6 & dlx1,0339U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1162.8,,,,,,,fee schedule,684,1330,Radiology
Onc prst8 mrna hoxc6 & dlx1,0339U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1064,,,,,,,fee schedule,684,1330,APC
Onc prst8 mrna hoxc6 & dlx1,0339U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1330,,,,,,,fee schedule,684,1330,APC
Onc pan ca alys mrd plasma,0340U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3231,,,,,,,fee schedule,3231,6282.5,Laboratory
Onc pan ca alys mrd plasma,0340U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3769.5,,,,,,,fee schedule,3231,6282.5,APC
Onc pan ca alys mrd plasma,0340U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3733.6,,,,,,,fee schedule,3231,6282.5,APC
Onc pan ca alys mrd plasma,0340U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3590,,,,,,,fee schedule,3231,6282.5,APC
Onc pan ca alys mrd plasma,0340U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5492.7,,,,,,,fee schedule,3231,6282.5,Radiology
Onc pan ca alys mrd plasma,0340U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5026,,,,,,,fee schedule,3231,6282.5,APC
Onc pan ca alys mrd plasma,0340U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6282.5,,,,,,,fee schedule,3231,6282.5,APC
Ftl aneup dna seq cmpr alys,0341U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1710.18,,,,,,,fee schedule,1710.18,3325.35,Laboratory
Ftl aneup dna seq cmpr alys,0341U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1995.21,,,,,,,fee schedule,1710.18,3325.35,APC
Ftl aneup dna seq cmpr alys,0341U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1976.21,,,,,,,fee schedule,1710.18,3325.35,APC
Ftl aneup dna seq cmpr alys,0341U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1900.2,,,,,,,fee schedule,1710.18,3325.35,APC
Ftl aneup dna seq cmpr alys,0341U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2907.31,,,,,,,fee schedule,1710.18,3325.35,Radiology
Ftl aneup dna seq cmpr alys,0341U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2660.28,,,,,,,fee schedule,1710.18,3325.35,APC
Ftl aneup dna seq cmpr alys,0341U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3325.35,,,,,,,fee schedule,1710.18,3325.35,APC
Thxp apheresis w/hdl delip,0342T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10757.12,,,,,,,fee schedule,4311.81,19130.02,
Thxp apheresis w/hdl delip,0342T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8622.77,,,,,,,fee schedule,4311.81,19130.02,
Thxp apheresis w/hdl delip,0342T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9419.6,,,,,,,fee schedule,4311.81,19130.02,
Thxp apheresis w/hdl delip,0342T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9903.38,,,,,,,fee schedule,4311.81,19130.02,
Thxp apheresis w/hdl delip,0342T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19130.02,,,,,,,fee schedule,4311.81,19130.02,APC 378
Thxp apheresis w/hdl delip,0342T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4527.4,,,,,,,fee schedule,4311.81,19130.02,APC
Thxp apheresis w/hdl delip,0342T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4484.28,,,,,,,fee schedule,4311.81,19130.02,APC
Thxp apheresis w/hdl delip,0342T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4311.81,,,,,,,fee schedule,4311.81,19130.02,APC
Thxp apheresis w/hdl delip,0342T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6597.06,,,,,,,fee schedule,4311.81,19130.02,Radiology
Thxp apheresis w/hdl delip,0342T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6036.53,,,,,,,fee schedule,4311.81,19130.02,APC
Thxp apheresis w/hdl delip,0342T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7545.66,,,,,,,fee schedule,4311.81,19130.02,APC
Onc prst8 xom aly 442 sncrna,0343U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,684,,,,,,,fee schedule,684,1330,Laboratory
Onc prst8 xom aly 442 sncrna,0343U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,798,,,,,,,fee schedule,684,1330,APC
Onc prst8 xom aly 442 sncrna,0343U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,790.4,,,,,,,fee schedule,684,1330,APC
Onc prst8 xom aly 442 sncrna,0343U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,760,,,,,,,fee schedule,684,1330,APC
Onc prst8 xom aly 442 sncrna,0343U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1162.8,,,,,,,fee schedule,684,1330,Radiology
Onc prst8 xom aly 442 sncrna,0343U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1064,,,,,,,fee schedule,684,1330,APC
Onc prst8 xom aly 442 sncrna,0343U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1330,,,,,,,fee schedule,684,1330,APC
Hep nafld semiq evl 28 lipid,0344U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,712.95,,,,,,,fee schedule,712.95,1386.3,Laboratory
Hep nafld semiq evl 28 lipid,0344U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,831.78,,,,,,,fee schedule,712.95,1386.3,APC
Hep nafld semiq evl 28 lipid,0344U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,823.86,,,,,,,fee schedule,712.95,1386.3,APC
Hep nafld semiq evl 28 lipid,0344U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,792.17,,,,,,,fee schedule,712.95,1386.3,APC
Hep nafld semiq evl 28 lipid,0344U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1212.02,,,,,,,fee schedule,712.95,1386.3,Radiology
Hep nafld semiq evl 28 lipid,0344U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1109.04,,,,,,,fee schedule,712.95,1386.3,APC
Hep nafld semiq evl 28 lipid,0344U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1386.3,,,,,,,fee schedule,712.95,1386.3,APC
Psyc genom alys pnl 15 gen,0345U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1202.48,,,,,,,fee schedule,1202.48,2338.16,Laboratory
Psyc genom alys pnl 15 gen,0345U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1402.89,,,,,,,fee schedule,1202.48,2338.16,APC
Psyc genom alys pnl 15 gen,0345U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1389.53,,,,,,,fee schedule,1202.48,2338.16,APC
Psyc genom alys pnl 15 gen,0345U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1336.09,,,,,,,fee schedule,1202.48,2338.16,APC
Psyc genom alys pnl 15 gen,0345U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2044.22,,,,,,,fee schedule,1202.48,2338.16,Radiology
Psyc genom alys pnl 15 gen,0345U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1870.53,,,,,,,fee schedule,1202.48,2338.16,APC
Psyc genom alys pnl 15 gen,0345U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2338.16,,,,,,,fee schedule,1202.48,2338.16,APC
Ins bone device for rsa,0347T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,498.02,,,,,,,fee schedule,58.4,498.02,
Ins bone device for rsa,0347T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,399.2,,,,,,,fee schedule,58.4,498.02,
Ins bone device for rsa,0347T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,436.09,,,,,,,fee schedule,58.4,498.02,
Ins bone device for rsa,0347T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,458.49,,,,,,,fee schedule,58.4,498.02,
Ins bone device for rsa,0347T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,58.4,498.02,APC 378
Ins bone device for rsa,0347T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,58.4,498.02,APC
Ins bone device for rsa,0347T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,58.4,498.02,APC
Ins bone device for rsa,0347T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,58.4,498.02,APC
Ins bone device for rsa,0347T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,58.4,498.02,Radiology
Ins bone device for rsa,0347T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,58.4,498.02,APC
Ins bone device for rsa,0347T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,58.4,498.02,APC
Rx metab/pcx dna 16 gen alys,0347U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1202.48,,,,,,,fee schedule,1202.48,2338.16,Laboratory
Rx metab/pcx dna 16 gen alys,0347U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1402.89,,,,,,,fee schedule,1202.48,2338.16,APC
Rx metab/pcx dna 16 gen alys,0347U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1389.53,,,,,,,fee schedule,1202.48,2338.16,APC
Rx metab/pcx dna 16 gen alys,0347U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1336.09,,,,,,,fee schedule,1202.48,2338.16,APC
Rx metab/pcx dna 16 gen alys,0347U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2044.22,,,,,,,fee schedule,1202.48,2338.16,Radiology
Rx metab/pcx dna 16 gen alys,0347U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1870.53,,,,,,,fee schedule,1202.48,2338.16,APC
Rx metab/pcx dna 16 gen alys,0347U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2338.16,,,,,,,fee schedule,1202.48,2338.16,APC
RSA spine exam,0348T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,359.18,,,,,,,fee schedule,103.5,459.18,
RSA spine exam,0348T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,287.91,,,,,,,fee schedule,103.5,459.18,
RSA spine exam,0348T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,314.52,,,,,,,fee schedule,103.5,459.18,
RSA spine exam,0348T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,330.67,,,,,,,fee schedule,103.5,459.18,
RSA spine exam,0348T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
RSA spine exam,0348T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
RSA spine exam,0348T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
RSA spine exam,0348T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
RSA spine exam,0348T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
RSA spine exam,0348T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
RSA spine exam,0348T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Rx metab/pcx dna 25 gen alys,0348U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,668.04,,,,,,,fee schedule,668.04,1298.97,Laboratory
Rx metab/pcx dna 25 gen alys,0348U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,779.38,,,,,,,fee schedule,668.04,1298.97,APC
Rx metab/pcx dna 25 gen alys,0348U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,771.96,,,,,,,fee schedule,668.04,1298.97,APC
Rx metab/pcx dna 25 gen alys,0348U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,742.27,,,,,,,fee schedule,668.04,1298.97,APC
Rx metab/pcx dna 25 gen alys,0348U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1135.67,,,,,,,fee schedule,668.04,1298.97,Radiology
Rx metab/pcx dna 25 gen alys,0348U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1039.18,,,,,,,fee schedule,668.04,1298.97,APC
Rx metab/pcx dna 25 gen alys,0348U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1298.97,,,,,,,fee schedule,668.04,1298.97,APC
RSA upper extr exam,0349T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,359.18,,,,,,,fee schedule,103.5,459.18,
RSA upper extr exam,0349T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,287.91,,,,,,,fee schedule,103.5,459.18,
RSA upper extr exam,0349T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,314.52,,,,,,,fee schedule,103.5,459.18,
RSA upper extr exam,0349T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,330.67,,,,,,,fee schedule,103.5,459.18,
RSA upper extr exam,0349T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
RSA upper extr exam,0349T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
RSA upper extr exam,0349T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
RSA upper extr exam,0349T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
RSA upper extr exam,0349T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
RSA upper extr exam,0349T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
RSA upper extr exam,0349T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Rx metab/pcx dna 27gen rx ia,0349U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,668.04,,,,,,,fee schedule,668.04,1298.97,Laboratory
Rx metab/pcx dna 27gen rx ia,0349U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,779.38,,,,,,,fee schedule,668.04,1298.97,APC
Rx metab/pcx dna 27gen rx ia,0349U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,771.96,,,,,,,fee schedule,668.04,1298.97,APC
Rx metab/pcx dna 27gen rx ia,0349U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,742.27,,,,,,,fee schedule,668.04,1298.97,APC
Rx metab/pcx dna 27gen rx ia,0349U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1135.67,,,,,,,fee schedule,668.04,1298.97,Radiology
Rx metab/pcx dna 27gen rx ia,0349U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1039.18,,,,,,,fee schedule,668.04,1298.97,APC
Rx metab/pcx dna 27gen rx ia,0349U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1298.97,,,,,,,fee schedule,668.04,1298.97,APC
RSA lower extr exam,0350T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,359.18,,,,,,,fee schedule,86.15,382.23,
RSA lower extr exam,0350T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,287.91,,,,,,,fee schedule,86.15,382.23,
RSA lower extr exam,0350T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,314.52,,,,,,,fee schedule,86.15,382.23,
RSA lower extr exam,0350T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,330.67,,,,,,,fee schedule,86.15,382.23,
RSA lower extr exam,0350T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
RSA lower extr exam,0350T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
RSA lower extr exam,0350T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
RSA lower extr exam,0350T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
RSA lower extr exam,0350T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
RSA lower extr exam,0350T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
RSA lower extr exam,0350T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
Rx metab/pcx dna 27 gen alys,0350U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1202.48,,,,,,,fee schedule,1202.48,2338.16,Laboratory
Rx metab/pcx dna 27 gen alys,0350U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1402.89,,,,,,,fee schedule,1202.48,2338.16,APC
Rx metab/pcx dna 27 gen alys,0350U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1389.53,,,,,,,fee schedule,1202.48,2338.16,APC
Rx metab/pcx dna 27 gen alys,0350U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1336.09,,,,,,,fee schedule,1202.48,2338.16,APC
Rx metab/pcx dna 27 gen alys,0350U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2044.22,,,,,,,fee schedule,1202.48,2338.16,Radiology
Rx metab/pcx dna 27 gen alys,0350U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1870.53,,,,,,,fee schedule,1202.48,2338.16,APC
Rx metab/pcx dna 27 gen alys,0350U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2338.16,,,,,,,fee schedule,1202.48,2338.16,APC
Nfct ds bct/viral trail ip10,0351U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,234.45,,,,,,,fee schedule,234.45,455.88,Laboratory
Nfct ds bct/viral trail ip10,0351U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,273.53,,,,,,,fee schedule,234.45,455.88,APC
Nfct ds bct/viral trail ip10,0351U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,270.92,,,,,,,fee schedule,234.45,455.88,APC
Nfct ds bct/viral trail ip10,0351U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,260.5,,,,,,,fee schedule,234.45,455.88,APC
Nfct ds bct/viral trail ip10,0351U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,398.56,,,,,,,fee schedule,234.45,455.88,Radiology
Nfct ds bct/viral trail ip10,0351U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,364.7,,,,,,,fee schedule,234.45,455.88,APC
Nfct ds bct/viral trail ip10,0351U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,455.88,,,,,,,fee schedule,234.45,455.88,APC
Apol1 risk variants,0355U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,123.3,,,,,,,fee schedule,123.3,239.75,Laboratory
Apol1 risk variants,0355U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,143.85,,,,,,,fee schedule,123.3,239.75,APC
Apol1 risk variants,0355U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,142.48,,,,,,,fee schedule,123.3,239.75,APC
Apol1 risk variants,0355U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,137,,,,,,,fee schedule,123.3,239.75,APC
Apol1 risk variants,0355U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,209.61,,,,,,,fee schedule,123.3,239.75,Radiology
Apol1 risk variants,0355U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,191.8,,,,,,,fee schedule,123.3,239.75,APC
Apol1 risk variants,0355U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,239.75,,,,,,,fee schedule,123.3,239.75,APC
Onc orop 17 dna ddpcr alg,0356U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1620,,,,,,,fee schedule,1620,3150,Laboratory
Onc orop 17 dna ddpcr alg,0356U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1890,,,,,,,fee schedule,1620,3150,APC
Onc orop 17 dna ddpcr alg,0356U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1872,,,,,,,fee schedule,1620,3150,APC
Onc orop 17 dna ddpcr alg,0356U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1800,,,,,,,fee schedule,1620,3150,APC
Onc orop 17 dna ddpcr alg,0356U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2754,,,,,,,fee schedule,1620,3150,Radiology
Onc orop 17 dna ddpcr alg,0356U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2520,,,,,,,fee schedule,1620,3150,APC
Onc orop 17 dna ddpcr alg,0356U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3150,,,,,,,fee schedule,1620,3150,APC
BIA whole body,0358T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,197.96,,,,,,,fee schedule,28.63,197.96,
BIA whole body,0358T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,158.68,,,,,,,fee schedule,28.63,197.96,
BIA whole body,0358T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,173.34,,,,,,,fee schedule,28.63,197.96,
BIA whole body,0358T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,182.25,,,,,,,fee schedule,28.63,197.96,
BIA whole body,0358T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,127.04,,,,,,,fee schedule,28.63,197.96,APC 378
BIA whole body,0358T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.07,,,,,,,fee schedule,28.63,197.96,APC
BIA whole body,0358T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,29.78,,,,,,,fee schedule,28.63,197.96,APC
BIA whole body,0358T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,28.63,,,,,,,fee schedule,28.63,197.96,APC
BIA whole body,0358T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43.81,,,,,,,fee schedule,28.63,197.96,Radiology
BIA whole body,0358T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40.09,,,,,,,fee schedule,28.63,197.96,APC
BIA whole body,0358T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,50.11,,,,,,,fee schedule,28.63,197.96,APC
Neuro alys b-amyl 1-42&1-40,0358U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,234.45,,,,,,,fee schedule,234.45,455.88,Laboratory
Neuro alys b-amyl 1-42&1-40,0358U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,273.53,,,,,,,fee schedule,234.45,455.88,APC
Neuro alys b-amyl 1-42&1-40,0358U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,270.92,,,,,,,fee schedule,234.45,455.88,APC
Neuro alys b-amyl 1-42&1-40,0358U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,260.5,,,,,,,fee schedule,234.45,455.88,APC
Neuro alys b-amyl 1-42&1-40,0358U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,398.56,,,,,,,fee schedule,234.45,455.88,Radiology
Neuro alys b-amyl 1-42&1-40,0358U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,364.7,,,,,,,fee schedule,234.45,455.88,APC
Neuro alys b-amyl 1-42&1-40,0358U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,455.88,,,,,,,fee schedule,234.45,455.88,APC
Onc prst8 ca alys all psa,0359U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,684,,,,,,,fee schedule,684,1330,Laboratory
Onc prst8 ca alys all psa,0359U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,798,,,,,,,fee schedule,684,1330,APC
Onc prst8 ca alys all psa,0359U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,790.4,,,,,,,fee schedule,684,1330,APC
Onc prst8 ca alys all psa,0359U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,760,,,,,,,fee schedule,684,1330,APC
Onc prst8 ca alys all psa,0359U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1162.8,,,,,,,fee schedule,684,1330,Radiology
Onc prst8 ca alys all psa,0359U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1064,,,,,,,fee schedule,684,1330,APC
Onc prst8 ca alys all psa,0359U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1330,,,,,,,fee schedule,684,1330,APC
Onc lung elisa 7 autoant alg,0360U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,756.58,,,,,,,fee schedule,756.58,1471.14,Laboratory
Onc lung elisa 7 autoant alg,0360U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,882.68,,,,,,,fee schedule,756.58,1471.14,APC
Onc lung elisa 7 autoant alg,0360U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,874.28,,,,,,,fee schedule,756.58,1471.14,APC
Onc lung elisa 7 autoant alg,0360U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,840.65,,,,,,,fee schedule,756.58,1471.14,APC
Onc lung elisa 7 autoant alg,0360U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1286.19,,,,,,,fee schedule,756.58,1471.14,Radiology
Onc lung elisa 7 autoant alg,0360U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1176.91,,,,,,,fee schedule,756.58,1471.14,APC
Onc lung elisa 7 autoant alg,0360U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1471.14,,,,,,,fee schedule,756.58,1471.14,APC
Expose behav assessment,0362T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,401.7,,,,,,,fee schedule,37.09,401.7,
Expose behav assessment,0362T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,322,,,,,,,fee schedule,37.09,401.7,
Expose behav assessment,0362T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,351.75,,,,,,,fee schedule,37.09,401.7,
Expose behav assessment,0362T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,369.82,,,,,,,fee schedule,37.09,401.7,
Expose behav assessment,0362T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.57,,,,,,,fee schedule,37.09,401.7,APC 378
Expose behav assessment,0362T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.95,,,,,,,fee schedule,37.09,401.7,APC
Expose behav assessment,0362T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.58,,,,,,,fee schedule,37.09,401.7,APC
Expose behav assessment,0362T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,37.09,,,,,,,fee schedule,37.09,401.7,APC
Expose behav assessment,0362T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.75,,,,,,,fee schedule,37.09,401.7,Radiology
Expose behav assessment,0362T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.93,,,,,,,fee schedule,37.09,401.7,APC
Expose behav assessment,0362T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.91,,,,,,,fee schedule,37.09,401.7,APC
Onc pap thyr ca rna 82&10,0362U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3240,,,,,,,fee schedule,3240,6300,Laboratory
Onc pap thyr ca rna 82&10,0362U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3780,,,,,,,fee schedule,3240,6300,APC
Onc pap thyr ca rna 82&10,0362U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3744,,,,,,,fee schedule,3240,6300,APC
Onc pap thyr ca rna 82&10,0362U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3600,,,,,,,fee schedule,3240,6300,APC
Onc pap thyr ca rna 82&10,0362U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5508,,,,,,,fee schedule,3240,6300,Radiology
Onc pap thyr ca rna 82&10,0362U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5040,,,,,,,fee schedule,3240,6300,APC
Onc pap thyr ca rna 82&10,0362U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6300,,,,,,,fee schedule,3240,6300,APC
Onc urthl mrna 5 gen alg,0363U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,684,,,,,,,fee schedule,684,1330,Laboratory
Onc urthl mrna 5 gen alg,0363U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,798,,,,,,,fee schedule,684,1330,APC
Onc urthl mrna 5 gen alg,0363U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,790.4,,,,,,,fee schedule,684,1330,APC
Onc urthl mrna 5 gen alg,0363U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,760,,,,,,,fee schedule,684,1330,APC
Onc urthl mrna 5 gen alg,0363U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1162.8,,,,,,,fee schedule,684,1330,Radiology
Onc urthl mrna 5 gen alg,0363U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1064,,,,,,,fee schedule,684,1330,APC
Onc urthl mrna 5 gen alg,0363U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1330,,,,,,,fee schedule,684,1330,APC
Onc hl neo gen seq alys alg,0364U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1806.52,,,,,,,fee schedule,1806.52,3512.69,Laboratory
Onc hl neo gen seq alys alg,0364U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2107.61,,,,,,,fee schedule,1806.52,3512.69,APC
Onc hl neo gen seq alys alg,0364U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2087.54,,,,,,,fee schedule,1806.52,3512.69,APC
Onc hl neo gen seq alys alg,0364U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2007.25,,,,,,,fee schedule,1806.52,3512.69,APC
Onc hl neo gen seq alys alg,0364U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3071.09,,,,,,,fee schedule,1806.52,3512.69,Radiology
Onc hl neo gen seq alys alg,0364U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2810.15,,,,,,,fee schedule,1806.52,3512.69,APC
Onc hl neo gen seq alys alg,0364U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3512.69,,,,,,,fee schedule,1806.52,3512.69,APC
Onc bldr 10 prb bldr ca,0365U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,807.3,,,,,,,fee schedule,807.3,1569.75,Laboratory
Onc bldr 10 prb bldr ca,0365U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,941.85,,,,,,,fee schedule,807.3,1569.75,APC
Onc bldr 10 prb bldr ca,0365U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,932.88,,,,,,,fee schedule,807.3,1569.75,APC
Onc bldr 10 prb bldr ca,0365U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,897,,,,,,,fee schedule,807.3,1569.75,APC
Onc bldr 10 prb bldr ca,0365U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1372.41,,,,,,,fee schedule,807.3,1569.75,Radiology
Onc bldr 10 prb bldr ca,0365U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1255.8,,,,,,,fee schedule,807.3,1569.75,APC
Onc bldr 10 prb bldr ca,0365U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1569.75,,,,,,,fee schedule,807.3,1569.75,APC
Onc bldr 10 prb recr bldr ca,0366U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,807.3,,,,,,,fee schedule,807.3,1569.75,Laboratory
Onc bldr 10 prb recr bldr ca,0366U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,941.85,,,,,,,fee schedule,807.3,1569.75,APC
Onc bldr 10 prb recr bldr ca,0366U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,932.88,,,,,,,fee schedule,807.3,1569.75,APC
Onc bldr 10 prb recr bldr ca,0366U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,897,,,,,,,fee schedule,807.3,1569.75,APC
Onc bldr 10 prb recr bldr ca,0366U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1372.41,,,,,,,fee schedule,807.3,1569.75,Radiology
Onc bldr 10 prb recr bldr ca,0366U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1255.8,,,,,,,fee schedule,807.3,1569.75,APC
Onc bldr 10 prb recr bldr ca,0366U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1569.75,,,,,,,fee schedule,807.3,1569.75,APC
Onc bldr 10 flwg trurl rescj,0367U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,811.96,,,,,,,fee schedule,811.96,1578.82,Laboratory
Onc bldr 10 flwg trurl rescj,0367U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,947.29,,,,,,,fee schedule,811.96,1578.82,APC
Onc bldr 10 flwg trurl rescj,0367U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,938.27,,,,,,,fee schedule,811.96,1578.82,APC
Onc bldr 10 flwg trurl rescj,0367U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,902.18,,,,,,,fee schedule,811.96,1578.82,APC
Onc bldr 10 flwg trurl rescj,0367U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1380.34,,,,,,,fee schedule,811.96,1578.82,Radiology
Onc bldr 10 flwg trurl rescj,0367U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1263.05,,,,,,,fee schedule,811.96,1578.82,APC
Onc bldr 10 flwg trurl rescj,0367U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1578.81,,,,,,,fee schedule,811.96,1578.82,APC
Iadna gu pthgn semiq dna16&1,0371U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,375.1,,,,,,,fee schedule,375.1,729.36,Laboratory
Iadna gu pthgn semiq dna16&1,0371U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,437.62,,,,,,,fee schedule,375.1,729.36,APC
Iadna gu pthgn semiq dna16&1,0371U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,433.45,,,,,,,fee schedule,375.1,729.36,APC
Iadna gu pthgn semiq dna16&1,0371U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,416.78,,,,,,,fee schedule,375.1,729.36,APC
Iadna gu pthgn semiq dna16&1,0371U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,637.67,,,,,,,fee schedule,375.1,729.36,Radiology
Iadna gu pthgn semiq dna16&1,0371U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,583.49,,,,,,,fee schedule,375.1,729.36,APC
Iadna gu pthgn semiq dna16&1,0371U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,729.36,,,,,,,fee schedule,375.1,729.36,APC
Nfct ds gu pthgn arg detcj,0372U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,375.1,,,,,,,fee schedule,375.1,729.36,Laboratory
Nfct ds gu pthgn arg detcj,0372U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,437.62,,,,,,,fee schedule,375.1,729.36,APC
Nfct ds gu pthgn arg detcj,0372U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,433.45,,,,,,,fee schedule,375.1,729.36,APC
Nfct ds gu pthgn arg detcj,0372U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,416.78,,,,,,,fee schedule,375.1,729.36,APC
Nfct ds gu pthgn arg detcj,0372U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,637.67,,,,,,,fee schedule,375.1,729.36,Radiology
Nfct ds gu pthgn arg detcj,0372U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,583.49,,,,,,,fee schedule,375.1,729.36,APC
Nfct ds gu pthgn arg detcj,0372U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,729.36,,,,,,,fee schedule,375.1,729.36,APC
Exposure behavior treatment,0373T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,436.67,,,,,,,fee schedule,37.09,436.67,
Exposure behavior treatment,0373T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,350.03,,,,,,,fee schedule,37.09,436.67,
Exposure behavior treatment,0373T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,382.37,,,,,,,fee schedule,37.09,436.67,
Exposure behavior treatment,0373T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,402.01,,,,,,,fee schedule,37.09,436.67,
Exposure behavior treatment,0373T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.57,,,,,,,fee schedule,37.09,436.67,APC 378
Exposure behavior treatment,0373T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.95,,,,,,,fee schedule,37.09,436.67,APC
Exposure behavior treatment,0373T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.58,,,,,,,fee schedule,37.09,436.67,APC
Exposure behavior treatment,0373T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,37.09,,,,,,,fee schedule,37.09,436.67,APC
Exposure behavior treatment,0373T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.75,,,,,,,fee schedule,37.09,436.67,Radiology
Exposure behavior treatment,0373T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.93,,,,,,,fee schedule,37.09,436.67,APC
Exposure behavior treatment,0373T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.91,,,,,,,fee schedule,37.09,436.67,APC
Onc ovrn bchm asy 7 prtn alg,0375U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,807.3,,,,,,,fee schedule,807.3,1569.75,Laboratory
Onc ovrn bchm asy 7 prtn alg,0375U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,941.85,,,,,,,fee schedule,807.3,1569.75,APC
Onc ovrn bchm asy 7 prtn alg,0375U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,932.88,,,,,,,fee schedule,807.3,1569.75,APC
Onc ovrn bchm asy 7 prtn alg,0375U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,897,,,,,,,fee schedule,807.3,1569.75,APC
Onc ovrn bchm asy 7 prtn alg,0375U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1372.41,,,,,,,fee schedule,807.3,1569.75,Radiology
Onc ovrn bchm asy 7 prtn alg,0375U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1255.8,,,,,,,fee schedule,807.3,1569.75,APC
Onc ovrn bchm asy 7 prtn alg,0375U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1569.75,,,,,,,fee schedule,807.3,1569.75,APC
Onc prst8 ca img alys 128,0376U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,635.62,,,,,,,fee schedule,635.62,1235.94,Laboratory
Onc prst8 ca img alys 128,0376U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,741.56,,,,,,,fee schedule,635.62,1235.94,APC
Onc prst8 ca img alys 128,0376U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,734.5,,,,,,,fee schedule,635.62,1235.94,APC
Onc prst8 ca img alys 128,0376U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,706.25,,,,,,,fee schedule,635.62,1235.94,APC
Onc prst8 ca img alys 128,0376U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1080.56,,,,,,,fee schedule,635.62,1235.94,Radiology
Onc prst8 ca img alys 128,0376U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,988.75,,,,,,,fee schedule,635.62,1235.94,APC
Onc prst8 ca img alys 128,0376U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1235.94,,,,,,,fee schedule,635.62,1235.94,APC
Cv ds quan advsrm/plsm lprtn,0377U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,42.82,,,,,,,fee schedule,42.82,83.26,Laboratory
Cv ds quan advsrm/plsm lprtn,0377U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,49.96,,,,,,,fee schedule,42.82,83.26,APC
Cv ds quan advsrm/plsm lprtn,0377U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,49.48,,,,,,,fee schedule,42.82,83.26,APC
Cv ds quan advsrm/plsm lprtn,0377U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,47.58,,,,,,,fee schedule,42.82,83.26,APC
Cv ds quan advsrm/plsm lprtn,0377U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,72.8,,,,,,,fee schedule,42.82,83.26,Radiology
Cv ds quan advsrm/plsm lprtn,0377U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,66.61,,,,,,,fee schedule,42.82,83.26,APC
Cv ds quan advsrm/plsm lprtn,0377U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,83.26,,,,,,,fee schedule,42.82,83.26,APC
Rfc1 repeat xpnsj vrnt alys,0378U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,123.3,,,,,,,fee schedule,123.3,239.75,Laboratory
Rfc1 repeat xpnsj vrnt alys,0378U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,143.85,,,,,,,fee schedule,123.3,239.75,APC
Rfc1 repeat xpnsj vrnt alys,0378U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,142.48,,,,,,,fee schedule,123.3,239.75,APC
Rfc1 repeat xpnsj vrnt alys,0378U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,137,,,,,,,fee schedule,123.3,239.75,APC
Rfc1 repeat xpnsj vrnt alys,0378U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,209.61,,,,,,,fee schedule,123.3,239.75,Radiology
Rfc1 repeat xpnsj vrnt alys,0378U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,191.8,,,,,,,fee schedule,123.3,239.75,APC
Rfc1 repeat xpnsj vrnt alys,0378U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,239.75,,,,,,,fee schedule,123.3,239.75,APC
Vis field assmnt tech suppt,0379T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,196.79,,,,,,,fee schedule,36.98,196.79,
Vis field assmnt tech suppt,0379T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,157.74,,,,,,,fee schedule,36.98,196.79,
Vis field assmnt tech suppt,0379T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,172.32,,,,,,,fee schedule,36.98,196.79,
Vis field assmnt tech suppt,0379T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,181.17,,,,,,,fee schedule,36.98,196.79,
Vis field assmnt tech suppt,0379T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.05,,,,,,,fee schedule,36.98,196.79,APC 378
Vis field assmnt tech suppt,0379T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.83,,,,,,,fee schedule,36.98,196.79,APC
Vis field assmnt tech suppt,0379T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.46,,,,,,,fee schedule,36.98,196.79,APC
Vis field assmnt tech suppt,0379T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.98,,,,,,,fee schedule,36.98,196.79,APC
Vis field assmnt tech suppt,0379T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.57,,,,,,,fee schedule,36.98,196.79,Radiology
Vis field assmnt tech suppt,0379T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.77,,,,,,,fee schedule,36.98,196.79,APC
Vis field assmnt tech suppt,0379T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.71,,,,,,,fee schedule,36.98,196.79,APC
Tgsap sl or neo dna523&rna55,0379U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2959.66,,,,,,,fee schedule,2959.66,5754.89,Laboratory
Tgsap sl or neo dna523&rna55,0379U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3452.94,,,,,,,fee schedule,2959.66,5754.89,APC
Tgsap sl or neo dna523&rna55,0379U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3420.05,,,,,,,fee schedule,2959.66,5754.89,APC
Tgsap sl or neo dna523&rna55,0379U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3288.51,,,,,,,fee schedule,2959.66,5754.89,APC
Tgsap sl or neo dna523&rna55,0379U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5031.42,,,,,,,fee schedule,2959.66,5754.89,Radiology
Tgsap sl or neo dna523&rna55,0379U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4603.91,,,,,,,fee schedule,2959.66,5754.89,APC
Tgsap sl or neo dna523&rna55,0379U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5754.89,,,,,,,fee schedule,2959.66,5754.89,APC
Maple syrup ur ds mntr quan,0381U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,39.71,,,,,,,fee schedule,39.71,77.21,Laboratory
Maple syrup ur ds mntr quan,0381U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,46.33,,,,,,,fee schedule,39.71,77.21,APC
Maple syrup ur ds mntr quan,0381U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,45.88,,,,,,,fee schedule,39.71,77.21,APC
Maple syrup ur ds mntr quan,0381U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,44.12,,,,,,,fee schedule,39.71,77.21,APC
Maple syrup ur ds mntr quan,0381U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,67.5,,,,,,,fee schedule,39.71,77.21,Radiology
Maple syrup ur ds mntr quan,0381U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,61.77,,,,,,,fee schedule,39.71,77.21,APC
Maple syrup ur ds mntr quan,0381U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,77.21,,,,,,,fee schedule,39.71,77.21,APC
Hyprphenylalninmia mntr quan,0382U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46.48,,,,,,,fee schedule,46.48,90.37,Laboratory
Hyprphenylalninmia mntr quan,0382U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.22,,,,,,,fee schedule,46.48,90.37,APC
Hyprphenylalninmia mntr quan,0382U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,53.71,,,,,,,fee schedule,46.48,90.37,APC
Hyprphenylalninmia mntr quan,0382U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,51.64,,,,,,,fee schedule,46.48,90.37,APC
Hyprphenylalninmia mntr quan,0382U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,79.01,,,,,,,fee schedule,46.48,90.37,Radiology
Hyprphenylalninmia mntr quan,0382U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,72.3,,,,,,,fee schedule,46.48,90.37,APC
Hyprphenylalninmia mntr quan,0382U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,90.37,,,,,,,fee schedule,46.48,90.37,APC
Tyrosinemia typ i mntr quan,0383U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46.84,,,,,,,fee schedule,46.84,91.09,Laboratory
Tyrosinemia typ i mntr quan,0383U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.65,,,,,,,fee schedule,46.84,91.09,APC
Tyrosinemia typ i mntr quan,0383U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,54.13,,,,,,,fee schedule,46.84,91.09,APC
Tyrosinemia typ i mntr quan,0383U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,52.05,,,,,,,fee schedule,46.84,91.09,APC
Tyrosinemia typ i mntr quan,0383U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,79.64,,,,,,,fee schedule,46.84,91.09,Radiology
Tyrosinemia typ i mntr quan,0383U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,72.87,,,,,,,fee schedule,46.84,91.09,APC
Tyrosinemia typ i mntr quan,0383U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,91.09,,,,,,,fee schedule,46.84,91.09,APC
Neph ckd rsk hi stg kdn ds,0384U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,675,,,,,,,fee schedule,675,1312.5,Laboratory
Neph ckd rsk hi stg kdn ds,0384U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,787.5,,,,,,,fee schedule,675,1312.5,APC
Neph ckd rsk hi stg kdn ds,0384U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,780,,,,,,,fee schedule,675,1312.5,APC
Neph ckd rsk hi stg kdn ds,0384U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,750,,,,,,,fee schedule,675,1312.5,APC
Neph ckd rsk hi stg kdn ds,0384U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1147.5,,,,,,,fee schedule,675,1312.5,Radiology
Neph ckd rsk hi stg kdn ds,0384U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1050,,,,,,,fee schedule,675,1312.5,APC
Neph ckd rsk hi stg kdn ds,0384U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1312.5,,,,,,,fee schedule,675,1312.5,APC
Neph ckd alg rsk dbtc kdn ds,0385U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,351.68,,,,,,,fee schedule,351.68,683.81,Laboratory
Neph ckd alg rsk dbtc kdn ds,0385U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,410.29,,,,,,,fee schedule,351.68,683.81,APC
Neph ckd alg rsk dbtc kdn ds,0385U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,406.38,,,,,,,fee schedule,351.68,683.81,APC
Neph ckd alg rsk dbtc kdn ds,0385U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,390.75,,,,,,,fee schedule,351.68,683.81,APC
Neph ckd alg rsk dbtc kdn ds,0385U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,597.85,,,,,,,fee schedule,351.68,683.81,Radiology
Neph ckd alg rsk dbtc kdn ds,0385U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,547.05,,,,,,,fee schedule,351.68,683.81,APC
Neph ckd alg rsk dbtc kdn ds,0385U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,683.81,,,,,,,fee schedule,351.68,683.81,APC
Onc mlnma ambra1&amlo,0387U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,853.65,,,,,,,fee schedule,853.65,1659.88,Laboratory
Onc mlnma ambra1&amlo,0387U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,995.92,,,,,,,fee schedule,853.65,1659.88,APC
Onc mlnma ambra1&amlo,0387U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,986.44,,,,,,,fee schedule,853.65,1659.88,APC
Onc mlnma ambra1&amlo,0387U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,948.5,,,,,,,fee schedule,853.65,1659.88,APC
Onc mlnma ambra1&amlo,0387U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1451.2,,,,,,,fee schedule,853.65,1659.88,Radiology
Onc mlnma ambra1&amlo,0387U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1327.9,,,,,,,fee schedule,853.65,1659.88,APC
Onc mlnma ambra1&amlo,0387U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1659.88,,,,,,,fee schedule,853.65,1659.88,APC
Onc nonsm cll lng ca 37 gen,0388U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3150,,,,,,,fee schedule,3150,6125,Laboratory
Onc nonsm cll lng ca 37 gen,0388U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3675,,,,,,,fee schedule,3150,6125,APC
Onc nonsm cll lng ca 37 gen,0388U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3640,,,,,,,fee schedule,3150,6125,APC
Onc nonsm cll lng ca 37 gen,0388U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3500,,,,,,,fee schedule,3150,6125,APC
Onc nonsm cll lng ca 37 gen,0388U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5355,,,,,,,fee schedule,3150,6125,Radiology
Onc nonsm cll lng ca 37 gen,0388U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4900,,,,,,,fee schedule,3150,6125,APC
Onc nonsm cll lng ca 37 gen,0388U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6125,,,,,,,fee schedule,3150,6125,APC
Ped fbrl kd ifi27&mcemp1 rna,0389U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,63.18,,,,,,,fee schedule,63.18,122.85,Laboratory
Ped fbrl kd ifi27&mcemp1 rna,0389U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,73.71,,,,,,,fee schedule,63.18,122.85,APC
Ped fbrl kd ifi27&mcemp1 rna,0389U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,73.01,,,,,,,fee schedule,63.18,122.85,APC
Ped fbrl kd ifi27&mcemp1 rna,0389U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,70.2,,,,,,,fee schedule,63.18,122.85,APC
Ped fbrl kd ifi27&mcemp1 rna,0389U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,107.41,,,,,,,fee schedule,63.18,122.85,Radiology
Ped fbrl kd ifi27&mcemp1 rna,0389U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,98.28,,,,,,,fee schedule,63.18,122.85,APC
Ped fbrl kd ifi27&mcemp1 rna,0389U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,122.85,,,,,,,fee schedule,63.18,122.85,APC
Ob pe kdr eng&rbp4 ia alg,0390U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,57.97,,,,,,,fee schedule,57.97,112.72,Laboratory
Ob pe kdr eng&rbp4 ia alg,0390U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,67.63,,,,,,,fee schedule,57.97,112.72,APC
Ob pe kdr eng&rbp4 ia alg,0390U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,66.99,,,,,,,fee schedule,57.97,112.72,APC
Ob pe kdr eng&rbp4 ia alg,0390U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,64.41,,,,,,,fee schedule,57.97,112.72,APC
Ob pe kdr eng&rbp4 ia alg,0390U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,98.55,,,,,,,fee schedule,57.97,112.72,Radiology
Ob pe kdr eng&rbp4 ia alg,0390U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,90.17,,,,,,,fee schedule,57.97,112.72,APC
Ob pe kdr eng&rbp4 ia alg,0390U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,112.72,,,,,,,fee schedule,57.97,112.72,APC
Onc sld tum dna&rna 437 gen,0391U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3240,,,,,,,fee schedule,3240,6300,Laboratory
Onc sld tum dna&rna 437 gen,0391U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3780,,,,,,,fee schedule,3240,6300,APC
Onc sld tum dna&rna 437 gen,0391U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3744,,,,,,,fee schedule,3240,6300,APC
Onc sld tum dna&rna 437 gen,0391U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3600,,,,,,,fee schedule,3240,6300,APC
Onc sld tum dna&rna 437 gen,0391U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5508,,,,,,,fee schedule,3240,6300,Radiology
Onc sld tum dna&rna 437 gen,0391U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5040,,,,,,,fee schedule,3240,6300,APC
Onc sld tum dna&rna 437 gen,0391U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6300,,,,,,,fee schedule,3240,6300,APC
Rx metab genrx ia 16 genes,0392U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1202.48,,,,,,,fee schedule,1202.48,2338.16,Laboratory
Rx metab genrx ia 16 genes,0392U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1402.89,,,,,,,fee schedule,1202.48,2338.16,APC
Rx metab genrx ia 16 genes,0392U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1389.53,,,,,,,fee schedule,1202.48,2338.16,APC
Rx metab genrx ia 16 genes,0392U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1336.09,,,,,,,fee schedule,1202.48,2338.16,APC
Rx metab genrx ia 16 genes,0392U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2044.22,,,,,,,fee schedule,1202.48,2338.16,Radiology
Rx metab genrx ia 16 genes,0392U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1870.53,,,,,,,fee schedule,1202.48,2338.16,APC
Rx metab genrx ia 16 genes,0392U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2338.16,,,,,,,fee schedule,1202.48,2338.16,APC
Neu prksn msfl ?-syncln prtn,0393U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,486.89,,,,,,,fee schedule,486.89,946.73,Laboratory
Neu prksn msfl ?-syncln prtn,0393U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,568.04,,,,,,,fee schedule,486.89,946.73,APC
Neu prksn msfl ?-syncln prtn,0393U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,562.63,,,,,,,fee schedule,486.89,946.73,APC
Neu prksn msfl ?-syncln prtn,0393U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,540.99,,,,,,,fee schedule,486.89,946.73,APC
Neu prksn msfl ?-syncln prtn,0393U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,827.71,,,,,,,fee schedule,486.89,946.73,Radiology
Neu prksn msfl ?-syncln prtn,0393U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,757.39,,,,,,,fee schedule,486.89,946.73,APC
Neu prksn msfl ?-syncln prtn,0393U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,946.73,,,,,,,fee schedule,486.89,946.73,APC
Hdr elctrnc skn surf brchytx,0394T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,734.64,,,,,,,fee schedule,588.88,734.64,
Hdr elctrnc skn surf brchytx,0394T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,588.88,,,,,,,fee schedule,588.88,734.64,
Hdr elctrnc skn surf brchytx,0394T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,643.3,,,,,,,fee schedule,588.88,734.64,
Hdr elctrnc skn surf brchytx,0394T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,676.34,,,,,,,fee schedule,588.88,734.64,
Pfas 16 pfas compnd lc ms/ms,0394U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,178.87,,,,,,,fee schedule,178.87,347.8,Laboratory
Pfas 16 pfas compnd lc ms/ms,0394U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.68,,,,,,,fee schedule,178.87,347.8,APC
Pfas 16 pfas compnd lc ms/ms,0394U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,206.69,,,,,,,fee schedule,178.87,347.8,APC
Pfas 16 pfas compnd lc ms/ms,0394U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.74,,,,,,,fee schedule,178.87,347.8,APC
Pfas 16 pfas compnd lc ms/ms,0394U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,304.07,,,,,,,fee schedule,178.87,347.8,Radiology
Pfas 16 pfas compnd lc ms/ms,0394U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,278.24,,,,,,,fee schedule,178.87,347.8,APC
Pfas 16 pfas compnd lc ms/ms,0394U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,347.8,,,,,,,fee schedule,178.87,347.8,APC
Hdr elctr ntrst/ntrcv brchtx,0395T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2631.67,,,,,,,fee schedule,689.49,3059.02,
Hdr elctr ntrst/ntrcv brchtx,0395T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2109.52,,,,,,,fee schedule,689.49,3059.02,
Hdr elctr ntrst/ntrcv brchtx,0395T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2304.46,,,,,,,fee schedule,689.49,3059.02,
Hdr elctr ntrst/ntrcv brchtx,0395T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2422.81,,,,,,,fee schedule,689.49,3059.02,
Hdr elctr ntrst/ntrcv brchtx,0395T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3059.02,,,,,,,fee schedule,689.49,3059.02,APC 378
Hdr elctr ntrst/ntrcv brchtx,0395T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,723.96,,,,,,,fee schedule,689.49,3059.02,APC
Hdr elctr ntrst/ntrcv brchtx,0395T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,717.07,,,,,,,fee schedule,689.49,3059.02,APC
Hdr elctr ntrst/ntrcv brchtx,0395T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,689.49,,,,,,,fee schedule,689.49,3059.02,APC
Hdr elctr ntrst/ntrcv brchtx,0395T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1054.92,,,,,,,fee schedule,689.49,3059.02,Radiology
Hdr elctr ntrst/ntrcv brchtx,0395T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,965.28,,,,,,,fee schedule,689.49,3059.02,APC
Hdr elctr ntrst/ntrcv brchtx,0395T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1206.6,,,,,,,fee schedule,689.49,3059.02,APC
Onc lng multiomics plsm alg,0395U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,717.7,,,,,,,fee schedule,717.7,1395.54,Laboratory
Onc lng multiomics plsm alg,0395U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,837.32,,,,,,,fee schedule,717.7,1395.54,APC
Onc lng multiomics plsm alg,0395U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,829.35,,,,,,,fee schedule,717.7,1395.54,APC
Onc lng multiomics plsm alg,0395U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,797.45,,,,,,,fee schedule,717.7,1395.54,APC
Onc lng multiomics plsm alg,0395U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1220.1,,,,,,,fee schedule,717.7,1395.54,Radiology
Onc lng multiomics plsm alg,0395U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1116.43,,,,,,,fee schedule,717.7,1395.54,APC
Onc lng multiomics plsm alg,0395U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1395.54,,,,,,,fee schedule,717.7,1395.54,APC
Mrgfus strtctc les abltj,0398T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,36856.89,,,,,,,fee schedule,29544.02,36856.89,
Mrgfus strtctc les abltj,0398T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29544.02,,,,,,,fee schedule,29544.02,36856.89,
Mrgfus strtctc les abltj,0398T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32274.16,,,,,,,fee schedule,29544.02,36856.89,
Mrgfus strtctc les abltj,0398T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33931.74,,,,,,,fee schedule,29544.02,36856.89,
Gi baret esph dna mthyln aly,0398U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1579.5,,,,,,,fee schedule,1579.5,3071.25,Laboratory
Gi baret esph dna mthyln aly,0398U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1842.75,,,,,,,fee schedule,1579.5,3071.25,APC
Gi baret esph dna mthyln aly,0398U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1825.2,,,,,,,fee schedule,1579.5,3071.25,APC
Gi baret esph dna mthyln aly,0398U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1755,,,,,,,fee schedule,1579.5,3071.25,APC
Gi baret esph dna mthyln aly,0398U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2685.15,,,,,,,fee schedule,1579.5,3071.25,Radiology
Gi baret esph dna mthyln aly,0398U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2457,,,,,,,fee schedule,1579.5,3071.25,APC
Gi baret esph dna mthyln aly,0398U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3071.25,,,,,,,fee schedule,1579.5,3071.25,APC
Neuro cere folate defncy srm,0399U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,270,,,,,,,fee schedule,270,525,Laboratory
Neuro cere folate defncy srm,0399U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,315,,,,,,,fee schedule,270,525,APC
Neuro cere folate defncy srm,0399U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,312,,,,,,,fee schedule,270,525,APC
Neuro cere folate defncy srm,0399U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,300,,,,,,,fee schedule,270,525,APC
Neuro cere folate defncy srm,0399U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,459,,,,,,,fee schedule,270,525,Radiology
Neuro cere folate defncy srm,0399U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,420,,,,,,,fee schedule,270,525,APC
Neuro cere folate defncy srm,0399U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,525,,,,,,,fee schedule,270,525,APC
Crd c hrt ds 9 gen 12 vrnts,0401U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,440.71,,,,,,,fee schedule,440.71,856.94,Laboratory
Crd c hrt ds 9 gen 12 vrnts,0401U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,514.16,,,,,,,fee schedule,440.71,856.94,APC
Crd c hrt ds 9 gen 12 vrnts,0401U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,509.27,,,,,,,fee schedule,440.71,856.94,APC
Crd c hrt ds 9 gen 12 vrnts,0401U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,489.68,,,,,,,fee schedule,440.71,856.94,APC
Crd c hrt ds 9 gen 12 vrnts,0401U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,749.21,,,,,,,fee schedule,440.71,856.94,Radiology
Crd c hrt ds 9 gen 12 vrnts,0401U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,685.55,,,,,,,fee schedule,440.71,856.94,APC
Crd c hrt ds 9 gen 12 vrnts,0401U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,856.94,,,,,,,fee schedule,440.71,856.94,APC
Collagen crosslinking cornea,0402T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2633.56,,,,,,,fee schedule,2111.03,10442.27,
Collagen crosslinking cornea,0402T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2111.03,,,,,,,fee schedule,2111.03,10442.27,
Collagen crosslinking cornea,0402T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2306.11,,,,,,,fee schedule,2111.03,10442.27,
Collagen crosslinking cornea,0402T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2424.55,,,,,,,fee schedule,2111.03,10442.27,
Collagen crosslinking cornea,0402T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2111.03,10442.27,APC 378
Collagen crosslinking cornea,0402T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2111.03,10442.27,APC
Collagen crosslinking cornea,0402T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2111.03,10442.27,APC
Collagen crosslinking cornea,0402T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2111.03,10442.27,APC
Collagen crosslinking cornea,0402T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2111.03,10442.27,Radiology
Collagen crosslinking cornea,0402T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2111.03,10442.27,APC
Collagen crosslinking cornea,0402T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2111.03,10442.27,APC
Nfct agt sti mult amp prb tq,0402U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,128.37,,,,,,,fee schedule,128.37,249.6,Laboratory
Nfct agt sti mult amp prb tq,0402U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,149.76,,,,,,,fee schedule,128.37,249.6,APC
Nfct agt sti mult amp prb tq,0402U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,148.34,,,,,,,fee schedule,128.37,249.6,APC
Nfct agt sti mult amp prb tq,0402U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,142.63,,,,,,,fee schedule,128.37,249.6,APC
Nfct agt sti mult amp prb tq,0402U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,218.22,,,,,,,fee schedule,128.37,249.6,Radiology
Nfct agt sti mult amp prb tq,0402U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,199.68,,,,,,,fee schedule,128.37,249.6,APC
Nfct agt sti mult amp prb tq,0402U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,249.6,,,,,,,fee schedule,128.37,249.6,APC
Onc prst8 mrna 18 gen dre ur,0403U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,684,,,,,,,fee schedule,684,1330,Laboratory
Onc prst8 mrna 18 gen dre ur,0403U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,798,,,,,,,fee schedule,684,1330,APC
Onc prst8 mrna 18 gen dre ur,0403U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,790.4,,,,,,,fee schedule,684,1330,APC
Onc prst8 mrna 18 gen dre ur,0403U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,760,,,,,,,fee schedule,684,1330,APC
Onc prst8 mrna 18 gen dre ur,0403U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1162.8,,,,,,,fee schedule,684,1330,Radiology
Onc prst8 mrna 18 gen dre ur,0403U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1064,,,,,,,fee schedule,684,1330,APC
Onc prst8 mrna 18 gen dre ur,0403U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1330,,,,,,,fee schedule,684,1330,APC
Trnscrv uterin fibroid abltj,0404T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21542.03,,,,,,,fee schedule,17267.82,21542.03,
Trnscrv uterin fibroid abltj,0404T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17267.82,,,,,,,fee schedule,17267.82,21542.03,
Trnscrv uterin fibroid abltj,0404T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18863.52,,,,,,,fee schedule,17267.82,21542.03,
Trnscrv uterin fibroid abltj,0404T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19832.35,,,,,,,fee schedule,17267.82,21542.03,
Onc brst semiq meas thym kn,0404U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,290.66,,,,,,,fee schedule,290.66,565.18,Laboratory
Onc brst semiq meas thym kn,0404U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,339.11,,,,,,,fee schedule,290.66,565.18,APC
Onc brst semiq meas thym kn,0404U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,335.88,,,,,,,fee schedule,290.66,565.18,APC
Onc brst semiq meas thym kn,0404U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,322.96,,,,,,,fee schedule,290.66,565.18,APC
Onc brst semiq meas thym kn,0404U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,494.13,,,,,,,fee schedule,290.66,565.18,Radiology
Onc brst semiq meas thym kn,0404U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,452.14,,,,,,,fee schedule,290.66,565.18,APC
Onc brst semiq meas thym kn,0404U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,565.18,,,,,,,fee schedule,290.66,565.18,APC
Onc pncrtc 59 mthltn blk mrk,0405U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1593.43,,,,,,,fee schedule,1593.43,3098.34,Laboratory
Onc pncrtc 59 mthltn blk mrk,0405U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1859,,,,,,,fee schedule,1593.43,3098.34,APC
Onc pncrtc 59 mthltn blk mrk,0405U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1841.3,,,,,,,fee schedule,1593.43,3098.34,APC
Onc pncrtc 59 mthltn blk mrk,0405U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1770.48,,,,,,,fee schedule,1593.43,3098.34,APC
Onc pncrtc 59 mthltn blk mrk,0405U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2708.83,,,,,,,fee schedule,1593.43,3098.34,Radiology
Onc pncrtc 59 mthltn blk mrk,0405U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2478.67,,,,,,,fee schedule,1593.43,3098.34,APC
Onc pncrtc 59 mthltn blk mrk,0405U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3098.34,,,,,,,fee schedule,1593.43,3098.34,APC
Onc lung flow cytmtry 5 mrk,0406U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,684,,,,,,,fee schedule,684,1330,Laboratory
Onc lung flow cytmtry 5 mrk,0406U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,798,,,,,,,fee schedule,684,1330,APC
Onc lung flow cytmtry 5 mrk,0406U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,790.4,,,,,,,fee schedule,684,1330,APC
Onc lung flow cytmtry 5 mrk,0406U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,760,,,,,,,fee schedule,684,1330,APC
Onc lung flow cytmtry 5 mrk,0406U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1162.8,,,,,,,fee schedule,684,1330,Radiology
Onc lung flow cytmtry 5 mrk,0406U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1064,,,,,,,fee schedule,684,1330,APC
Onc lung flow cytmtry 5 mrk,0406U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1330,,,,,,,fee schedule,684,1330,APC
Neph dbtc ckd mult eclia alg,0407U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,855,,,,,,,fee schedule,855,1662.5,Laboratory
Neph dbtc ckd mult eclia alg,0407U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,997.5,,,,,,,fee schedule,855,1662.5,APC
Neph dbtc ckd mult eclia alg,0407U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,988,,,,,,,fee schedule,855,1662.5,APC
Neph dbtc ckd mult eclia alg,0407U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,950,,,,,,,fee schedule,855,1662.5,APC
Neph dbtc ckd mult eclia alg,0407U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1453.5,,,,,,,fee schedule,855,1662.5,Radiology
Neph dbtc ckd mult eclia alg,0407U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1330,,,,,,,fee schedule,855,1662.5,APC
Neph dbtc ckd mult eclia alg,0407U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1662.5,,,,,,,fee schedule,855,1662.5,APC
Insj/rplc cardiac modulj sys,0408T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,82895.51,,,,,,,fee schedule,31073.96,137864.64,
Insj/rplc cardiac modulj sys,0408T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66447.99,,,,,,,fee schedule,31073.96,137864.64,
Insj/rplc cardiac modulj sys,0408T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,72588.4,,,,,,,fee schedule,31073.96,137864.64,
Insj/rplc cardiac modulj sys,0408T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,76316.5,,,,,,,fee schedule,31073.96,137864.64,
Insj/rplc cardiac modulj sys,0408T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,137864.64,,,,,,,fee schedule,31073.96,137864.64,APC 378
Insj/rplc cardiac modulj sys,0408T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,32627.66,,,,,,,fee schedule,31073.96,137864.64,APC
Insj/rplc cardiac modulj sys,0408T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,32316.92,,,,,,,fee schedule,31073.96,137864.64,APC
Insj/rplc cardiac modulj sys,0408T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,31073.96,,,,,,,fee schedule,31073.96,137864.64,APC
Insj/rplc cardiac modulj sys,0408T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,47543.16,,,,,,,fee schedule,31073.96,137864.64,Radiology
Insj/rplc cardiac modulj sys,0408T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43503.54,,,,,,,fee schedule,31073.96,137864.64,APC
Insj/rplc cardiac modulj sys,0408T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,54379.43,,,,,,,fee schedule,31073.96,137864.64,APC
Iaad blk ac wv bsnsr sarscv2,0408U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.72,,,,,,,fee schedule,12.72,24.73,Laboratory
Iaad blk ac wv bsnsr sarscv2,0408U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.84,,,,,,,fee schedule,12.72,24.73,APC
Iaad blk ac wv bsnsr sarscv2,0408U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,14.7,,,,,,,fee schedule,12.72,24.73,APC
Iaad blk ac wv bsnsr sarscv2,0408U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14.13,,,,,,,fee schedule,12.72,24.73,APC
Iaad blk ac wv bsnsr sarscv2,0408U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21.62,,,,,,,fee schedule,12.72,24.73,Radiology
Iaad blk ac wv bsnsr sarscv2,0408U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.78,,,,,,,fee schedule,12.72,24.73,APC
Iaad blk ac wv bsnsr sarscv2,0408U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,24.73,,,,,,,fee schedule,12.72,24.73,APC
Insj/rplc car modulj pls gn,0409T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,82895.51,,,,,,,fee schedule,22020.42,97697.15,
Insj/rplc car modulj pls gn,0409T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66447.99,,,,,,,fee schedule,22020.42,97697.15,
Insj/rplc car modulj pls gn,0409T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,72588.4,,,,,,,fee schedule,22020.42,97697.15,
Insj/rplc car modulj pls gn,0409T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,76316.5,,,,,,,fee schedule,22020.42,97697.15,
Insj/rplc car modulj pls gn,0409T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,97697.15,,,,,,,fee schedule,22020.42,97697.15,APC 378
Insj/rplc car modulj pls gn,0409T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,23121.44,,,,,,,fee schedule,22020.42,97697.15,APC
Insj/rplc car modulj pls gn,0409T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,22901.24,,,,,,,fee schedule,22020.42,97697.15,APC
Insj/rplc car modulj pls gn,0409T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,22020.42,,,,,,,fee schedule,22020.42,97697.15,APC
Insj/rplc car modulj pls gn,0409T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,33691.24,,,,,,,fee schedule,22020.42,97697.15,Radiology
Insj/rplc car modulj pls gn,0409T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,30828.59,,,,,,,fee schedule,22020.42,97697.15,APC
Insj/rplc car modulj pls gn,0409T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,38535.73,,,,,,,fee schedule,22020.42,97697.15,APC
Onc sld tum dna 80 & rna 36,0409U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2627.64,,,,,,,fee schedule,2627.64,5109.3,Laboratory
Onc sld tum dna 80 & rna 36,0409U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3065.58,,,,,,,fee schedule,2627.64,5109.3,APC
Onc sld tum dna 80 & rna 36,0409U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3036.38,,,,,,,fee schedule,2627.64,5109.3,APC
Onc sld tum dna 80 & rna 36,0409U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2919.6,,,,,,,fee schedule,2627.64,5109.3,APC
Onc sld tum dna 80 & rna 36,0409U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4466.99,,,,,,,fee schedule,2627.64,5109.3,Radiology
Onc sld tum dna 80 & rna 36,0409U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4087.44,,,,,,,fee schedule,2627.64,5109.3,APC
Onc sld tum dna 80 & rna 36,0409U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5109.3,,,,,,,fee schedule,2627.64,5109.3,APC
Insj/rplc car modulj atr elt,0410T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,25314.09,,,,,,,fee schedule,8192.37,36346.76,
Insj/rplc car modulj atr elt,0410T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20291.46,,,,,,,fee schedule,8192.37,36346.76,
Insj/rplc car modulj atr elt,0410T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22166.57,,,,,,,fee schedule,8192.37,36346.76,
Insj/rplc car modulj atr elt,0410T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23305.04,,,,,,,fee schedule,8192.37,36346.76,
Insj/rplc car modulj atr elt,0410T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,36346.76,,,,,,,fee schedule,8192.37,36346.76,APC 378
Insj/rplc car modulj atr elt,0410T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8601.99,,,,,,,fee schedule,8192.37,36346.76,APC
Insj/rplc car modulj atr elt,0410T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8520.06,,,,,,,fee schedule,8192.37,36346.76,APC
Insj/rplc car modulj atr elt,0410T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8192.37,,,,,,,fee schedule,8192.37,36346.76,APC
Insj/rplc car modulj atr elt,0410T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12534.32,,,,,,,fee schedule,8192.37,36346.76,Radiology
Insj/rplc car modulj atr elt,0410T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11469.31,,,,,,,fee schedule,8192.37,36346.76,APC
Insj/rplc car modulj atr elt,0410T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14336.64,,,,,,,fee schedule,8192.37,36346.76,APC
Onc pncrtc dna whl gn seq 5-,0410U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1044,,,,,,,fee schedule,1044,2030,Laboratory
Onc pncrtc dna whl gn seq 5-,0410U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1218,,,,,,,fee schedule,1044,2030,APC
Onc pncrtc dna whl gn seq 5-,0410U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1206.4,,,,,,,fee schedule,1044,2030,APC
Onc pncrtc dna whl gn seq 5-,0410U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1160,,,,,,,fee schedule,1044,2030,APC
Onc pncrtc dna whl gn seq 5-,0410U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1774.8,,,,,,,fee schedule,1044,2030,Radiology
Onc pncrtc dna whl gn seq 5-,0410U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1624,,,,,,,fee schedule,1044,2030,APC
Onc pncrtc dna whl gn seq 5-,0410U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2030,,,,,,,fee schedule,1044,2030,APC
Insj/rplc car modulj vnt elt,0411T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,25314.09,,,,,,,fee schedule,8192.37,36346.76,
Insj/rplc car modulj vnt elt,0411T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20291.46,,,,,,,fee schedule,8192.37,36346.76,
Insj/rplc car modulj vnt elt,0411T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22166.57,,,,,,,fee schedule,8192.37,36346.76,
Insj/rplc car modulj vnt elt,0411T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23305.04,,,,,,,fee schedule,8192.37,36346.76,
Insj/rplc car modulj vnt elt,0411T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,36346.76,,,,,,,fee schedule,8192.37,36346.76,APC 378
Insj/rplc car modulj vnt elt,0411T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8601.99,,,,,,,fee schedule,8192.37,36346.76,APC
Insj/rplc car modulj vnt elt,0411T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8520.06,,,,,,,fee schedule,8192.37,36346.76,APC
Insj/rplc car modulj vnt elt,0411T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8192.37,,,,,,,fee schedule,8192.37,36346.76,APC
Insj/rplc car modulj vnt elt,0411T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12534.32,,,,,,,fee schedule,8192.37,36346.76,Radiology
Insj/rplc car modulj vnt elt,0411T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11469.31,,,,,,,fee schedule,8192.37,36346.76,APC
Insj/rplc car modulj vnt elt,0411T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14336.64,,,,,,,fee schedule,8192.37,36346.76,APC
Psyc genom alys pnl 15 gen,0411U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1202.48,,,,,,,fee schedule,1202.48,2338.16,Laboratory
Psyc genom alys pnl 15 gen,0411U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1402.89,,,,,,,fee schedule,1202.48,2338.16,APC
Psyc genom alys pnl 15 gen,0411U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1389.53,,,,,,,fee schedule,1202.48,2338.16,APC
Psyc genom alys pnl 15 gen,0411U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1336.09,,,,,,,fee schedule,1202.48,2338.16,APC
Psyc genom alys pnl 15 gen,0411U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2044.22,,,,,,,fee schedule,1202.48,2338.16,Radiology
Psyc genom alys pnl 15 gen,0411U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1870.53,,,,,,,fee schedule,1202.48,2338.16,APC
Psyc genom alys pnl 15 gen,0411U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2338.16,,,,,,,fee schedule,1202.48,2338.16,APC
Rmvl cardiac modulj pls gen,0412T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9411.03,,,,,,,fee schedule,3699.47,16413.29,
Rmvl cardiac modulj pls gen,0412T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7543.76,,,,,,,fee schedule,3699.47,16413.29,
Rmvl cardiac modulj pls gen,0412T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8240.87,,,,,,,fee schedule,3699.47,16413.29,
Rmvl cardiac modulj pls gen,0412T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8664.12,,,,,,,fee schedule,3699.47,16413.29,
Rmvl cardiac modulj pls gen,0412T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16413.29,,,,,,,fee schedule,3699.47,16413.29,APC 378
Rmvl cardiac modulj pls gen,0412T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3884.44,,,,,,,fee schedule,3699.47,16413.29,APC
Rmvl cardiac modulj pls gen,0412T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3847.45,,,,,,,fee schedule,3699.47,16413.29,APC
Rmvl cardiac modulj pls gen,0412T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3699.47,,,,,,,fee schedule,3699.47,16413.29,APC
Rmvl cardiac modulj pls gen,0412T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5660.19,,,,,,,fee schedule,3699.47,16413.29,Radiology
Rmvl cardiac modulj pls gen,0412T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5179.26,,,,,,,fee schedule,3699.47,16413.29,APC
Rmvl cardiac modulj pls gen,0412T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6474.07,,,,,,,fee schedule,3699.47,16413.29,APC
Beta amyloid a?42/40 imprcip,0412U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,675,,,,,,,fee schedule,675,1312.5,Laboratory
Beta amyloid a?42/40 imprcip,0412U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,787.5,,,,,,,fee schedule,675,1312.5,APC
Beta amyloid a?42/40 imprcip,0412U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,780,,,,,,,fee schedule,675,1312.5,APC
Beta amyloid a?42/40 imprcip,0412U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,750,,,,,,,fee schedule,675,1312.5,APC
Beta amyloid a?42/40 imprcip,0412U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1147.5,,,,,,,fee schedule,675,1312.5,Radiology
Beta amyloid a?42/40 imprcip,0412U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1050,,,,,,,fee schedule,675,1312.5,APC
Beta amyloid a?42/40 imprcip,0412U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1312.5,,,,,,,fee schedule,675,1312.5,APC
Rmvl car modulj tranvns elt,0413T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9411.03,,,,,,,fee schedule,3699.47,16413.29,
Rmvl car modulj tranvns elt,0413T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7543.76,,,,,,,fee schedule,3699.47,16413.29,
Rmvl car modulj tranvns elt,0413T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8240.87,,,,,,,fee schedule,3699.47,16413.29,
Rmvl car modulj tranvns elt,0413T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8664.12,,,,,,,fee schedule,3699.47,16413.29,
Rmvl car modulj tranvns elt,0413T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16413.29,,,,,,,fee schedule,3699.47,16413.29,APC 378
Rmvl car modulj tranvns elt,0413T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3884.44,,,,,,,fee schedule,3699.47,16413.29,APC
Rmvl car modulj tranvns elt,0413T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3847.45,,,,,,,fee schedule,3699.47,16413.29,APC
Rmvl car modulj tranvns elt,0413T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3699.47,,,,,,,fee schedule,3699.47,16413.29,APC
Rmvl car modulj tranvns elt,0413T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5660.19,,,,,,,fee schedule,3699.47,16413.29,Radiology
Rmvl car modulj tranvns elt,0413T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5179.26,,,,,,,fee schedule,3699.47,16413.29,APC
Rmvl car modulj tranvns elt,0413T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6474.07,,,,,,,fee schedule,3699.47,16413.29,APC
Onc hl neo opt gen mapg dna,0413U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1137.18,,,,,,,fee schedule,1137.18,2211.18,Laboratory
Onc hl neo opt gen mapg dna,0413U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1326.71,,,,,,,fee schedule,1137.18,2211.18,APC
Onc hl neo opt gen mapg dna,0413U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1314.07,,,,,,,fee schedule,1137.18,2211.18,APC
Onc hl neo opt gen mapg dna,0413U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1263.53,,,,,,,fee schedule,1137.18,2211.18,APC
Onc hl neo opt gen mapg dna,0413U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1933.2,,,,,,,fee schedule,1137.18,2211.18,Radiology
Onc hl neo opt gen mapg dna,0413U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1768.94,,,,,,,fee schedule,1137.18,2211.18,APC
Onc hl neo opt gen mapg dna,0413U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2211.18,,,,,,,fee schedule,1137.18,2211.18,APC
Rmvl & rpl car modulj pls gn,0414T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,82895.51,,,,,,,fee schedule,22020.42,97697.15,
Rmvl & rpl car modulj pls gn,0414T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66447.99,,,,,,,fee schedule,22020.42,97697.15,
Rmvl & rpl car modulj pls gn,0414T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,72588.4,,,,,,,fee schedule,22020.42,97697.15,
Rmvl & rpl car modulj pls gn,0414T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,76316.5,,,,,,,fee schedule,22020.42,97697.15,
Rmvl & rpl car modulj pls gn,0414T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,97697.15,,,,,,,fee schedule,22020.42,97697.15,APC 378
Rmvl & rpl car modulj pls gn,0414T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,23121.44,,,,,,,fee schedule,22020.42,97697.15,APC
Rmvl & rpl car modulj pls gn,0414T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,22901.24,,,,,,,fee schedule,22020.42,97697.15,APC
Rmvl & rpl car modulj pls gn,0414T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,22020.42,,,,,,,fee schedule,22020.42,97697.15,APC
Rmvl & rpl car modulj pls gn,0414T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,33691.24,,,,,,,fee schedule,22020.42,97697.15,Radiology
Rmvl & rpl car modulj pls gn,0414T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,30828.59,,,,,,,fee schedule,22020.42,97697.15,APC
Rmvl & rpl car modulj pls gn,0414T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,38535.73,,,,,,,fee schedule,22020.42,97697.15,APC
Onc lng aug alg aly whl sld8,0414U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,635.62,,,,,,,fee schedule,635.62,1235.94,Laboratory
Onc lng aug alg aly whl sld8,0414U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,741.56,,,,,,,fee schedule,635.62,1235.94,APC
Onc lng aug alg aly whl sld8,0414U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,734.5,,,,,,,fee schedule,635.62,1235.94,APC
Onc lng aug alg aly whl sld8,0414U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,706.25,,,,,,,fee schedule,635.62,1235.94,APC
Onc lng aug alg aly whl sld8,0414U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1080.56,,,,,,,fee schedule,635.62,1235.94,Radiology
Onc lng aug alg aly whl sld8,0414U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,988.75,,,,,,,fee schedule,635.62,1235.94,APC
Onc lng aug alg aly whl sld8,0414U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1235.94,,,,,,,fee schedule,635.62,1235.94,APC
Repos car modulj tranvns elt,0415T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3260.29,,,,,,,fee schedule,621.01,3260.29,
Repos car modulj tranvns elt,0415T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2613.41,,,,,,,fee schedule,621.01,3260.29,
Repos car modulj tranvns elt,0415T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2854.91,,,,,,,fee schedule,621.01,3260.29,
Repos car modulj tranvns elt,0415T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3001.53,,,,,,,fee schedule,621.01,3260.29,
Repos car modulj tranvns elt,0415T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2755.21,,,,,,,fee schedule,621.01,3260.29,APC 378
Repos car modulj tranvns elt,0415T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,652.06,,,,,,,fee schedule,621.01,3260.29,APC
Repos car modulj tranvns elt,0415T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,645.85,,,,,,,fee schedule,621.01,3260.29,APC
Repos car modulj tranvns elt,0415T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,621.01,,,,,,,fee schedule,621.01,3260.29,APC
Repos car modulj tranvns elt,0415T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,950.14,,,,,,,fee schedule,621.01,3260.29,Radiology
Repos car modulj tranvns elt,0415T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,869.41,,,,,,,fee schedule,621.01,3260.29,APC
Repos car modulj tranvns elt,0415T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1086.77,,,,,,,fee schedule,621.01,3260.29,APC
Cv ds acs bld alg 5 yr score,0415U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,351.68,,,,,,,fee schedule,351.68,683.81,Laboratory
Cv ds acs bld alg 5 yr score,0415U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,410.29,,,,,,,fee schedule,351.68,683.81,APC
Cv ds acs bld alg 5 yr score,0415U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,406.38,,,,,,,fee schedule,351.68,683.81,APC
Cv ds acs bld alg 5 yr score,0415U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,390.75,,,,,,,fee schedule,351.68,683.81,APC
Cv ds acs bld alg 5 yr score,0415U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,597.85,,,,,,,fee schedule,351.68,683.81,Radiology
Cv ds acs bld alg 5 yr score,0415U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,547.05,,,,,,,fee schedule,351.68,683.81,APC
Cv ds acs bld alg 5 yr score,0415U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,683.81,,,,,,,fee schedule,351.68,683.81,APC
Reloc skin pocket pls gen,0416T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5334.37,,,,,,,fee schedule,2042.58,9062.24,
Reloc skin pocket pls gen,0416T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4275.97,,,,,,,fee schedule,2042.58,9062.24,
Reloc skin pocket pls gen,0416T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4671.11,,,,,,,fee schedule,2042.58,9062.24,
Reloc skin pocket pls gen,0416T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4911.01,,,,,,,fee schedule,2042.58,9062.24,
Reloc skin pocket pls gen,0416T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,2042.58,9062.24,APC 378
Reloc skin pocket pls gen,0416T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,2042.58,9062.24,APC
Reloc skin pocket pls gen,0416T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,2042.58,9062.24,APC
Reloc skin pocket pls gen,0416T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,2042.58,9062.24,APC
Reloc skin pocket pls gen,0416T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,2042.58,9062.24,Radiology
Reloc skin pocket pls gen,0416T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,2042.58,9062.24,APC
Reloc skin pocket pls gen,0416T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,2042.58,9062.24,APC
Prgrmg eval cardiac modulj,0417T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,127.08,,,,,,,fee schedule,36.95,163.92,
Prgrmg eval cardiac modulj,0417T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,101.87,,,,,,,fee schedule,36.95,163.92,
Prgrmg eval cardiac modulj,0417T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,111.28,,,,,,,fee schedule,36.95,163.92,
Prgrmg eval cardiac modulj,0417T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,117,,,,,,,fee schedule,36.95,163.92,
Prgrmg eval cardiac modulj,0417T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,163.92,,,,,,,fee schedule,36.95,163.92,APC 378
Prgrmg eval cardiac modulj,0417T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.79,,,,,,,fee schedule,36.95,163.92,APC
Prgrmg eval cardiac modulj,0417T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.43,,,,,,,fee schedule,36.95,163.92,APC
Prgrmg eval cardiac modulj,0417T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.95,,,,,,,fee schedule,36.95,163.92,APC
Prgrmg eval cardiac modulj,0417T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.53,,,,,,,fee schedule,36.95,163.92,Radiology
Prgrmg eval cardiac modulj,0417T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.73,,,,,,,fee schedule,36.95,163.92,APC
Prgrmg eval cardiac modulj,0417T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.66,,,,,,,fee schedule,36.95,163.92,APC
Rare ds alys 335 nuc genes,0417U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2558.28,,,,,,,fee schedule,2558.28,4974.43,Laboratory
Rare ds alys 335 nuc genes,0417U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2984.66,,,,,,,fee schedule,2558.28,4974.43,APC
Rare ds alys 335 nuc genes,0417U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2956.23,,,,,,,fee schedule,2558.28,4974.43,APC
Rare ds alys 335 nuc genes,0417U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2842.53,,,,,,,fee schedule,2558.28,4974.43,APC
Rare ds alys 335 nuc genes,0417U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4349.07,,,,,,,fee schedule,2558.28,4974.43,Radiology
Rare ds alys 335 nuc genes,0417U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3979.54,,,,,,,fee schedule,2558.28,4974.43,APC
Rare ds alys 335 nuc genes,0417U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4974.43,,,,,,,fee schedule,2558.28,4974.43,APC
Interro eval cardiac modulj,0418T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,127.08,,,,,,,fee schedule,36.95,163.92,
Interro eval cardiac modulj,0418T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,101.87,,,,,,,fee schedule,36.95,163.92,
Interro eval cardiac modulj,0418T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,111.28,,,,,,,fee schedule,36.95,163.92,
Interro eval cardiac modulj,0418T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,117,,,,,,,fee schedule,36.95,163.92,
Interro eval cardiac modulj,0418T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,163.92,,,,,,,fee schedule,36.95,163.92,APC 378
Interro eval cardiac modulj,0418T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.79,,,,,,,fee schedule,36.95,163.92,APC
Interro eval cardiac modulj,0418T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.43,,,,,,,fee schedule,36.95,163.92,APC
Interro eval cardiac modulj,0418T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.95,,,,,,,fee schedule,36.95,163.92,APC
Interro eval cardiac modulj,0418T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.53,,,,,,,fee schedule,36.95,163.92,Radiology
Interro eval cardiac modulj,0418T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.73,,,,,,,fee schedule,36.95,163.92,APC
Interro eval cardiac modulj,0418T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.66,,,,,,,fee schedule,36.95,163.92,APC
Onc brst aug alg aly whl sl8,0418U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,635.62,,,,,,,fee schedule,635.62,1235.94,Laboratory
Onc brst aug alg aly whl sl8,0418U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,741.56,,,,,,,fee schedule,635.62,1235.94,APC
Onc brst aug alg aly whl sl8,0418U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,734.5,,,,,,,fee schedule,635.62,1235.94,APC
Onc brst aug alg aly whl sl8,0418U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,706.25,,,,,,,fee schedule,635.62,1235.94,APC
Onc brst aug alg aly whl sl8,0418U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1080.56,,,,,,,fee schedule,635.62,1235.94,Radiology
Onc brst aug alg aly whl sl8,0418U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,988.75,,,,,,,fee schedule,635.62,1235.94,APC
Onc brst aug alg aly whl sl8,0418U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1235.94,,,,,,,fee schedule,635.62,1235.94,APC
Dstrj neurofibroma xtnsv,0419T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1620.37,,,,,,,fee schedule,731.66,3246.12,
Dstrj neurofibroma xtnsv,0419T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1298.87,,,,,,,fee schedule,731.66,3246.12,
Dstrj neurofibroma xtnsv,0419T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1418.9,,,,,,,fee schedule,731.66,3246.12,
Dstrj neurofibroma xtnsv,0419T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1491.77,,,,,,,fee schedule,731.66,3246.12,
Dstrj neurofibroma xtnsv,0419T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3246.12,,,,,,,fee schedule,731.66,3246.12,APC 378
Dstrj neurofibroma xtnsv,0419T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,768.24,,,,,,,fee schedule,731.66,3246.12,APC
Dstrj neurofibroma xtnsv,0419T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,760.92,,,,,,,fee schedule,731.66,3246.12,APC
Dstrj neurofibroma xtnsv,0419T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,731.66,,,,,,,fee schedule,731.66,3246.12,APC
Dstrj neurofibroma xtnsv,0419T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1119.44,,,,,,,fee schedule,731.66,3246.12,Radiology
Dstrj neurofibroma xtnsv,0419T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1024.32,,,,,,,fee schedule,731.66,3246.12,APC
Dstrj neurofibroma xtnsv,0419T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1280.4,,,,,,,fee schedule,731.66,3246.12,APC
Nrpsyc gen seq vrnt aly 13,0419U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1202.48,,,,,,,fee schedule,1202.48,2338.16,Laboratory
Nrpsyc gen seq vrnt aly 13,0419U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1402.89,,,,,,,fee schedule,1202.48,2338.16,APC
Nrpsyc gen seq vrnt aly 13,0419U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1389.53,,,,,,,fee schedule,1202.48,2338.16,APC
Nrpsyc gen seq vrnt aly 13,0419U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1336.09,,,,,,,fee schedule,1202.48,2338.16,APC
Nrpsyc gen seq vrnt aly 13,0419U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2044.22,,,,,,,fee schedule,1202.48,2338.16,Radiology
Nrpsyc gen seq vrnt aly 13,0419U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1870.53,,,,,,,fee schedule,1202.48,2338.16,APC
Nrpsyc gen seq vrnt aly 13,0419U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2338.16,,,,,,,fee schedule,1202.48,2338.16,APC
Dstrj neurofibroma xtnsv,0420T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1620.37,,,,,,,fee schedule,731.66,3246.12,
Dstrj neurofibroma xtnsv,0420T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1298.87,,,,,,,fee schedule,731.66,3246.12,
Dstrj neurofibroma xtnsv,0420T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1418.9,,,,,,,fee schedule,731.66,3246.12,
Dstrj neurofibroma xtnsv,0420T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1491.77,,,,,,,fee schedule,731.66,3246.12,
Dstrj neurofibroma xtnsv,0420T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3246.12,,,,,,,fee schedule,731.66,3246.12,APC 378
Dstrj neurofibroma xtnsv,0420T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,768.24,,,,,,,fee schedule,731.66,3246.12,APC
Dstrj neurofibroma xtnsv,0420T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,760.92,,,,,,,fee schedule,731.66,3246.12,APC
Dstrj neurofibroma xtnsv,0420T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,731.66,,,,,,,fee schedule,731.66,3246.12,APC
Dstrj neurofibroma xtnsv,0420T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1119.44,,,,,,,fee schedule,731.66,3246.12,Radiology
Dstrj neurofibroma xtnsv,0420T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1024.32,,,,,,,fee schedule,731.66,3246.12,APC
Dstrj neurofibroma xtnsv,0420T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1280.4,,,,,,,fee schedule,731.66,3246.12,APC
Onc urthl mrna xprsn 6 snp,0420U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1195.49,,,,,,,fee schedule,1195.49,2324.56,Laboratory
Onc urthl mrna xprsn 6 snp,0420U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1394.74,,,,,,,fee schedule,1195.49,2324.56,APC
Onc urthl mrna xprsn 6 snp,0420U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1381.45,,,,,,,fee schedule,1195.49,2324.56,APC
Onc urthl mrna xprsn 6 snp,0420U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1328.32,,,,,,,fee schedule,1195.49,2324.56,APC
Onc urthl mrna xprsn 6 snp,0420U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2032.33,,,,,,,fee schedule,1195.49,2324.56,Radiology
Onc urthl mrna xprsn 6 snp,0420U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1859.65,,,,,,,fee schedule,1195.49,2324.56,APC
Onc urthl mrna xprsn 6 snp,0420U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2324.56,,,,,,,fee schedule,1195.49,2324.56,APC
Tactile breast img uni/bi,0422T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,348.02,,,,,,,fee schedule,86.15,382.23,
Tactile breast img uni/bi,0422T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,278.97,,,,,,,fee schedule,86.15,382.23,
Tactile breast img uni/bi,0422T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,304.75,,,,,,,fee schedule,86.15,382.23,
Tactile breast img uni/bi,0422T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,320.4,,,,,,,fee schedule,86.15,382.23,
Tactile breast img uni/bi,0422T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
Tactile breast img uni/bi,0422T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
Tactile breast img uni/bi,0422T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
Tactile breast img uni/bi,0422T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
Tactile breast img uni/bi,0422T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
Tactile breast img uni/bi,0422T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
Tactile breast img uni/bi,0422T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
Onc pan solid tum alys dna,0422U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1748.89,,,,,,,fee schedule,1748.89,3400.62,Laboratory
Onc pan solid tum alys dna,0422U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2040.37,,,,,,,fee schedule,1748.89,3400.62,APC
Onc pan solid tum alys dna,0422U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2020.94,,,,,,,fee schedule,1748.89,3400.62,APC
Onc pan solid tum alys dna,0422U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1943.21,,,,,,,fee schedule,1748.89,3400.62,APC
Onc pan solid tum alys dna,0422U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2973.11,,,,,,,fee schedule,1748.89,3400.62,Radiology
Onc pan solid tum alys dna,0422U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2720.49,,,,,,,fee schedule,1748.89,3400.62,APC
Onc pan solid tum alys dna,0422U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3400.62,,,,,,,fee schedule,1748.89,3400.62,APC
Psyc genomic alys pnl 26 gen,0423U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,375.1,,,,,,,fee schedule,375.1,729.36,Laboratory
Psyc genomic alys pnl 26 gen,0423U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,437.62,,,,,,,fee schedule,375.1,729.36,APC
Psyc genomic alys pnl 26 gen,0423U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,433.45,,,,,,,fee schedule,375.1,729.36,APC
Psyc genomic alys pnl 26 gen,0423U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,416.78,,,,,,,fee schedule,375.1,729.36,APC
Psyc genomic alys pnl 26 gen,0423U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,637.67,,,,,,,fee schedule,375.1,729.36,Radiology
Psyc genomic alys pnl 26 gen,0423U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,583.49,,,,,,,fee schedule,375.1,729.36,APC
Psyc genomic alys pnl 26 gen,0423U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,729.36,,,,,,,fee schedule,375.1,729.36,APC
Insj/rplc nstim apnea compl,0424T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,101033.31,,,,,,,fee schedule,80987.02,101033.31,
Insj/rplc nstim apnea compl,0424T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,80987.02,,,,,,,fee schedule,80987.02,101033.31,
Insj/rplc nstim apnea compl,0424T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,88470.97,,,,,,,fee schedule,80987.02,101033.31,
Insj/rplc nstim apnea compl,0424T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,93014.8,,,,,,,fee schedule,80987.02,101033.31,
Onc prst8 xom alys 53 sncrna,0424U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,684,,,,,,,fee schedule,684,1330,Laboratory
Onc prst8 xom alys 53 sncrna,0424U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,798,,,,,,,fee schedule,684,1330,APC
Onc prst8 xom alys 53 sncrna,0424U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,790.4,,,,,,,fee schedule,684,1330,APC
Onc prst8 xom alys 53 sncrna,0424U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,760,,,,,,,fee schedule,684,1330,APC
Onc prst8 xom alys 53 sncrna,0424U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1162.8,,,,,,,fee schedule,684,1330,Radiology
Onc prst8 xom alys 53 sncrna,0424U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1064,,,,,,,fee schedule,684,1330,APC
Onc prst8 xom alys 53 sncrna,0424U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1330,,,,,,,fee schedule,684,1330,APC
Insj/rplc nstim apnea sen ld,0425T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19823.72,,,,,,,fee schedule,15890.44,19823.72,
Insj/rplc nstim apnea sen ld,0425T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15890.44,,,,,,,fee schedule,15890.44,19823.72,
Insj/rplc nstim apnea sen ld,0425T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17358.86,,,,,,,fee schedule,15890.44,19823.72,
Insj/rplc nstim apnea sen ld,0425T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18250.41,,,,,,,fee schedule,15890.44,19823.72,
Genom rpd seq alys ea cmprtr,0425U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3684.95,,,,,,,fee schedule,3684.95,7165.18,Laboratory
Genom rpd seq alys ea cmprtr,0425U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4299.11,,,,,,,fee schedule,3684.95,7165.18,APC
Genom rpd seq alys ea cmprtr,0425U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4258.17,,,,,,,fee schedule,3684.95,7165.18,APC
Genom rpd seq alys ea cmprtr,0425U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4094.39,,,,,,,fee schedule,3684.95,7165.18,APC
Genom rpd seq alys ea cmprtr,0425U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6264.42,,,,,,,fee schedule,3684.95,7165.18,Radiology
Genom rpd seq alys ea cmprtr,0425U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5732.15,,,,,,,fee schedule,3684.95,7165.18,APC
Genom rpd seq alys ea cmprtr,0425U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7165.18,,,,,,,fee schedule,3684.95,7165.18,APC
Insj/rplc nstim apnea stm ld,0426T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,65618.42,,,,,,,fee schedule,52598.89,65618.42,
Insj/rplc nstim apnea stm ld,0426T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52598.89,,,,,,,fee schedule,52598.89,65618.42,
Insj/rplc nstim apnea stm ld,0426T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57459.51,,,,,,,fee schedule,52598.89,65618.42,
Insj/rplc nstim apnea stm ld,0426T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60410.61,,,,,,,fee schedule,52598.89,65618.42,
Genome ultra-rapid seq alys,0426U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6823.98,,,,,,,fee schedule,6823.98,13268.85,Laboratory
Genome ultra-rapid seq alys,0426U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7961.31,,,,,,,fee schedule,6823.98,13268.85,APC
Genome ultra-rapid seq alys,0426U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7885.49,,,,,,,fee schedule,6823.98,13268.85,APC
Genome ultra-rapid seq alys,0426U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7582.2,,,,,,,fee schedule,6823.98,13268.85,APC
Genome ultra-rapid seq alys,0426U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11600.77,,,,,,,fee schedule,6823.98,13268.85,Radiology
Genome ultra-rapid seq alys,0426U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10615.08,,,,,,,fee schedule,6823.98,13268.85,APC
Genome ultra-rapid seq alys,0426U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,13268.85,,,,,,,fee schedule,6823.98,13268.85,APC
Insj/rplc nstim apnea pls gn,0427T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,65618.42,,,,,,,fee schedule,52598.89,65618.42,
Insj/rplc nstim apnea pls gn,0427T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52598.89,,,,,,,fee schedule,52598.89,65618.42,
Insj/rplc nstim apnea pls gn,0427T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57459.51,,,,,,,fee schedule,52598.89,65618.42,
Insj/rplc nstim apnea pls gn,0427T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60410.61,,,,,,,fee schedule,52598.89,65618.42,
Monocyte dstrbj wdth whl bld,0427U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.03,,,,,,,fee schedule,4.03,7.84,Laboratory
Monocyte dstrbj wdth whl bld,0427U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.7,,,,,,,fee schedule,4.03,7.84,APC
Monocyte dstrbj wdth whl bld,0427U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4.66,,,,,,,fee schedule,4.03,7.84,APC
Monocyte dstrbj wdth whl bld,0427U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4.48,,,,,,,fee schedule,4.03,7.84,APC
Monocyte dstrbj wdth whl bld,0427U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.85,,,,,,,fee schedule,4.03,7.84,Radiology
Monocyte dstrbj wdth whl bld,0427U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.27,,,,,,,fee schedule,4.03,7.84,APC
Monocyte dstrbj wdth whl bld,0427U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7.84,,,,,,,fee schedule,4.03,7.84,APC
Rmvl nstim apnea pls gen,0428T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8273.06,,,,,,,fee schedule,6631.58,8273.06,
Rmvl nstim apnea pls gen,0428T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6631.58,,,,,,,fee schedule,6631.58,8273.06,
Rmvl nstim apnea pls gen,0428T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7244.4,,,,,,,fee schedule,6631.58,8273.06,
Rmvl nstim apnea pls gen,0428T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7616.47,,,,,,,fee schedule,6631.58,8273.06,
Rmvl nstim apnea sen ld,0429T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8273.06,,,,,,,fee schedule,6631.58,8273.06,
Rmvl nstim apnea sen ld,0429T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6631.58,,,,,,,fee schedule,6631.58,8273.06,
Rmvl nstim apnea sen ld,0429T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7244.4,,,,,,,fee schedule,6631.58,8273.06,
Rmvl nstim apnea sen ld,0429T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7616.47,,,,,,,fee schedule,6631.58,8273.06,
Hpv orop swab 14 hi-risk typ,0429U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31.58,,,,,,,fee schedule,31.58,61.41,Laboratory
Hpv orop swab 14 hi-risk typ,0429U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,31.58,61.41,APC
Hpv orop swab 14 hi-risk typ,0429U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,36.49,,,,,,,fee schedule,31.58,61.41,APC
Hpv orop swab 14 hi-risk typ,0429U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,35.09,,,,,,,fee schedule,31.58,61.41,APC
Hpv orop swab 14 hi-risk typ,0429U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,53.69,,,,,,,fee schedule,31.58,61.41,Radiology
Hpv orop swab 14 hi-risk typ,0429U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49.13,,,,,,,fee schedule,31.58,61.41,APC
Hpv orop swab 14 hi-risk typ,0429U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,61.41,,,,,,,fee schedule,31.58,61.41,APC
Rmvl nstim apnea stimj ld,0430T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8273.06,,,,,,,fee schedule,6631.58,8273.06,
Rmvl nstim apnea stimj ld,0430T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6631.58,,,,,,,fee schedule,6631.58,8273.06,
Rmvl nstim apnea stimj ld,0430T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7244.4,,,,,,,fee schedule,6631.58,8273.06,
Rmvl nstim apnea stimj ld,0430T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7616.47,,,,,,,fee schedule,6631.58,8273.06,
Gi malabs aat calpro pncrtc,0430U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,55.39,,,,,,,fee schedule,55.39,107.7,Laboratory
Gi malabs aat calpro pncrtc,0430U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,64.62,,,,,,,fee schedule,55.39,107.7,APC
Gi malabs aat calpro pncrtc,0430U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,64,,,,,,,fee schedule,55.39,107.7,APC
Gi malabs aat calpro pncrtc,0430U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,61.54,,,,,,,fee schedule,55.39,107.7,APC
Gi malabs aat calpro pncrtc,0430U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,94.16,,,,,,,fee schedule,55.39,107.7,Radiology
Gi malabs aat calpro pncrtc,0430U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,86.16,,,,,,,fee schedule,55.39,107.7,APC
Gi malabs aat calpro pncrtc,0430U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,107.7,,,,,,,fee schedule,55.39,107.7,APC
Rmvl/rplc nstim apnea pls gn,0431T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,65618.42,,,,,,,fee schedule,52598.89,65618.42,
Rmvl/rplc nstim apnea pls gn,0431T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52598.89,,,,,,,fee schedule,52598.89,65618.42,
Rmvl/rplc nstim apnea pls gn,0431T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57459.51,,,,,,,fee schedule,52598.89,65618.42,
Rmvl/rplc nstim apnea pls gn,0431T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60410.61,,,,,,,fee schedule,52598.89,65618.42,
Gly rcptr alpha1 igg srm/csf,0431U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,32.91,,,,,,,fee schedule,32.91,64,Laboratory
Gly rcptr alpha1 igg srm/csf,0431U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.4,,,,,,,fee schedule,32.91,64,APC
Gly rcptr alpha1 igg srm/csf,0431U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.03,,,,,,,fee schedule,32.91,64,APC
Gly rcptr alpha1 igg srm/csf,0431U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.57,,,,,,,fee schedule,32.91,64,APC
Gly rcptr alpha1 igg srm/csf,0431U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,55.95,,,,,,,fee schedule,32.91,64,Radiology
Gly rcptr alpha1 igg srm/csf,0431U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.2,,,,,,,fee schedule,32.91,64,APC
Gly rcptr alpha1 igg srm/csf,0431U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64,,,,,,,fee schedule,32.91,64,APC
Repos nstim apnea stimj ld,0432T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8273.06,,,,,,,fee schedule,6631.58,8273.06,
Repos nstim apnea stimj ld,0432T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6631.58,,,,,,,fee schedule,6631.58,8273.06,
Repos nstim apnea stimj ld,0432T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7244.4,,,,,,,fee schedule,6631.58,8273.06,
Repos nstim apnea stimj ld,0432T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7616.47,,,,,,,fee schedule,6631.58,8273.06,
Klhl11 antb sr/csf asy qual,0432U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,32.91,,,,,,,fee schedule,32.91,64,Laboratory
Klhl11 antb sr/csf asy qual,0432U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.4,,,,,,,fee schedule,32.91,64,APC
Klhl11 antb sr/csf asy qual,0432U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.03,,,,,,,fee schedule,32.91,64,APC
Klhl11 antb sr/csf asy qual,0432U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.57,,,,,,,fee schedule,32.91,64,APC
Klhl11 antb sr/csf asy qual,0432U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,55.95,,,,,,,fee schedule,32.91,64,Radiology
Klhl11 antb sr/csf asy qual,0432U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.2,,,,,,,fee schedule,32.91,64,APC
Klhl11 antb sr/csf asy qual,0432U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64,,,,,,,fee schedule,32.91,64,APC
Repos nstim apnea sensing ld,0433T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8273.06,,,,,,,fee schedule,6631.58,8273.06,
Repos nstim apnea sensing ld,0433T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6631.58,,,,,,,fee schedule,6631.58,8273.06,
Repos nstim apnea sensing ld,0433T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7244.4,,,,,,,fee schedule,6631.58,8273.06,
Repos nstim apnea sensing ld,0433T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7616.47,,,,,,,fee schedule,6631.58,8273.06,
Onc prst8 5 dna reg mrk pcr,0433U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,684,,,,,,,fee schedule,684,1330,Laboratory
Onc prst8 5 dna reg mrk pcr,0433U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,798,,,,,,,fee schedule,684,1330,APC
Onc prst8 5 dna reg mrk pcr,0433U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,790.4,,,,,,,fee schedule,684,1330,APC
Onc prst8 5 dna reg mrk pcr,0433U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,760,,,,,,,fee schedule,684,1330,APC
Onc prst8 5 dna reg mrk pcr,0433U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1162.8,,,,,,,fee schedule,684,1330,Radiology
Onc prst8 5 dna reg mrk pcr,0433U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1064,,,,,,,fee schedule,684,1330,APC
Onc prst8 5 dna reg mrk pcr,0433U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1330,,,,,,,fee schedule,684,1330,APC
Interro eval npgs apnea,0434T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,402.34,,,,,,,fee schedule,322.51,402.34,
Interro eval npgs apnea,0434T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,322.51,,,,,,,fee schedule,322.51,402.34,
Interro eval npgs apnea,0434T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,352.32,,,,,,,fee schedule,322.51,402.34,
Interro eval npgs apnea,0434T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,370.41,,,,,,,fee schedule,322.51,402.34,
Rx metab advrs vrnt alys 25,0434U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,375.1,,,,,,,fee schedule,375.1,729.36,Laboratory
Rx metab advrs vrnt alys 25,0434U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,437.62,,,,,,,fee schedule,375.1,729.36,APC
Rx metab advrs vrnt alys 25,0434U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,433.45,,,,,,,fee schedule,375.1,729.36,APC
Rx metab advrs vrnt alys 25,0434U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,416.78,,,,,,,fee schedule,375.1,729.36,APC
Rx metab advrs vrnt alys 25,0434U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,637.67,,,,,,,fee schedule,375.1,729.36,Radiology
Rx metab advrs vrnt alys 25,0434U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,583.49,,,,,,,fee schedule,375.1,729.36,APC
Rx metab advrs vrnt alys 25,0434U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,729.36,,,,,,,fee schedule,375.1,729.36,APC
Prgrmg eval npgs apnea 1 ses,0435T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,402.34,,,,,,,fee schedule,322.51,402.34,
Prgrmg eval npgs apnea 1 ses,0435T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,322.51,,,,,,,fee schedule,322.51,402.34,
Prgrmg eval npgs apnea 1 ses,0435T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,352.32,,,,,,,fee schedule,322.51,402.34,
Prgrmg eval npgs apnea 1 ses,0435T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,370.41,,,,,,,fee schedule,322.51,402.34,
Onc chemo rx cytox csc 14 rx,0435U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2730.47,,,,,,,fee schedule,2730.47,5309.26,Laboratory
Onc chemo rx cytox csc 14 rx,0435U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3185.55,,,,,,,fee schedule,2730.47,5309.26,APC
Onc chemo rx cytox csc 14 rx,0435U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3155.21,,,,,,,fee schedule,2730.47,5309.26,APC
Onc chemo rx cytox csc 14 rx,0435U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3033.86,,,,,,,fee schedule,2730.47,5309.26,APC
Onc chemo rx cytox csc 14 rx,0435U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4641.81,,,,,,,fee schedule,2730.47,5309.26,Radiology
Onc chemo rx cytox csc 14 rx,0435U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4247.4,,,,,,,fee schedule,2730.47,5309.26,APC
Onc chemo rx cytox csc 14 rx,0435U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5309.26,,,,,,,fee schedule,2730.47,5309.26,APC
Prgrmg eval npgs apnea study,0436T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3237.34,,,,,,,fee schedule,2595.01,3237.34,
Prgrmg eval npgs apnea study,0436T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2595.01,,,,,,,fee schedule,2595.01,3237.34,
Prgrmg eval npgs apnea study,0436T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2834.82,,,,,,,fee schedule,2595.01,3237.34,
Prgrmg eval npgs apnea study,0436T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2980.41,,,,,,,fee schedule,2595.01,3237.34,
Onc lng plsm alys 388 prtn,0436U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1353.82,,,,,,,fee schedule,1353.82,2632.42,Laboratory
Onc lng plsm alys 388 prtn,0436U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1579.45,,,,,,,fee schedule,1353.82,2632.42,APC
Onc lng plsm alys 388 prtn,0436U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1564.41,,,,,,,fee schedule,1353.82,2632.42,APC
Onc lng plsm alys 388 prtn,0436U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1504.24,,,,,,,fee schedule,1353.82,2632.42,APC
Onc lng plsm alys 388 prtn,0436U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2301.49,,,,,,,fee schedule,1353.82,2632.42,Radiology
Onc lng plsm alys 388 prtn,0436U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2105.94,,,,,,,fee schedule,1353.82,2632.42,APC
Onc lng plsm alys 388 prtn,0436U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2632.42,,,,,,,fee schedule,1353.82,2632.42,APC
Psyc anxiety do mrna 15 bmrk,0437U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,684,,,,,,,fee schedule,684,1330,Laboratory
Psyc anxiety do mrna 15 bmrk,0437U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,798,,,,,,,fee schedule,684,1330,APC
Psyc anxiety do mrna 15 bmrk,0437U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,790.4,,,,,,,fee schedule,684,1330,APC
Psyc anxiety do mrna 15 bmrk,0437U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,760,,,,,,,fee schedule,684,1330,APC
Psyc anxiety do mrna 15 bmrk,0437U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1162.8,,,,,,,fee schedule,684,1330,Radiology
Psyc anxiety do mrna 15 bmrk,0437U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1064,,,,,,,fee schedule,684,1330,APC
Psyc anxiety do mrna 15 bmrk,0437U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1330,,,,,,,fee schedule,684,1330,APC
Rx metab advrs vrnt alys 33,0438U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,375.1,,,,,,,fee schedule,375.1,729.36,Laboratory
Rx metab advrs vrnt alys 33,0438U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,437.62,,,,,,,fee schedule,375.1,729.36,APC
Rx metab advrs vrnt alys 33,0438U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,433.45,,,,,,,fee schedule,375.1,729.36,APC
Rx metab advrs vrnt alys 33,0438U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,416.78,,,,,,,fee schedule,375.1,729.36,APC
Rx metab advrs vrnt alys 33,0438U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,637.67,,,,,,,fee schedule,375.1,729.36,Radiology
Rx metab advrs vrnt alys 33,0438U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,583.49,,,,,,,fee schedule,375.1,729.36,APC
Rx metab advrs vrnt alys 33,0438U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,729.36,,,,,,,fee schedule,375.1,729.36,APC
Crd chd dna alys 5 snp 3 dna,0439U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,768.6,,,,,,,fee schedule,768.6,1494.5,Laboratory
Crd chd dna alys 5 snp 3 dna,0439U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,896.7,,,,,,,fee schedule,768.6,1494.5,APC
Crd chd dna alys 5 snp 3 dna,0439U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,888.16,,,,,,,fee schedule,768.6,1494.5,APC
Crd chd dna alys 5 snp 3 dna,0439U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,854,,,,,,,fee schedule,768.6,1494.5,APC
Crd chd dna alys 5 snp 3 dna,0439U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1306.62,,,,,,,fee schedule,768.6,1494.5,Radiology
Crd chd dna alys 5 snp 3 dna,0439U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1195.6,,,,,,,fee schedule,768.6,1494.5,APC
Crd chd dna alys 5 snp 3 dna,0439U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1494.5,,,,,,,fee schedule,768.6,1494.5,APC
Abltj perc uxtr/perph nrv,0440T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15694.03,,,,,,,fee schedule,1933.13,15694.03,
Abltj perc uxtr/perph nrv,0440T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12580.14,,,,,,,fee schedule,1933.13,15694.03,
Abltj perc uxtr/perph nrv,0440T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13742.66,,,,,,,fee schedule,1933.13,15694.03,
Abltj perc uxtr/perph nrv,0440T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14448.47,,,,,,,fee schedule,1933.13,15694.03,
Abltj perc uxtr/perph nrv,0440T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8576.66,,,,,,,fee schedule,1933.13,15694.03,APC 378
Abltj perc uxtr/perph nrv,0440T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2029.79,,,,,,,fee schedule,1933.13,15694.03,APC
Abltj perc uxtr/perph nrv,0440T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2010.46,,,,,,,fee schedule,1933.13,15694.03,APC
Abltj perc uxtr/perph nrv,0440T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1933.13,,,,,,,fee schedule,1933.13,15694.03,APC
Abltj perc uxtr/perph nrv,0440T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2957.7,,,,,,,fee schedule,1933.13,15694.03,Radiology
Abltj perc uxtr/perph nrv,0440T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2706.39,,,,,,,fee schedule,1933.13,15694.03,APC
Abltj perc uxtr/perph nrv,0440T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3382.99,,,,,,,fee schedule,1933.13,15694.03,APC
Crd chd dna alys 10 snp 6dna,0440U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,768.6,,,,,,,fee schedule,768.6,1494.5,Laboratory
Crd chd dna alys 10 snp 6dna,0440U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,896.7,,,,,,,fee schedule,768.6,1494.5,APC
Crd chd dna alys 10 snp 6dna,0440U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,888.16,,,,,,,fee schedule,768.6,1494.5,APC
Crd chd dna alys 10 snp 6dna,0440U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,854,,,,,,,fee schedule,768.6,1494.5,APC
Crd chd dna alys 10 snp 6dna,0440U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1306.62,,,,,,,fee schedule,768.6,1494.5,Radiology
Crd chd dna alys 10 snp 6dna,0440U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1195.6,,,,,,,fee schedule,768.6,1494.5,APC
Crd chd dna alys 10 snp 6dna,0440U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1494.5,,,,,,,fee schedule,768.6,1494.5,APC
Abltj perc lxtr/perph nrv,0441T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15694.03,,,,,,,fee schedule,1933.13,15694.03,
Abltj perc lxtr/perph nrv,0441T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12580.14,,,,,,,fee schedule,1933.13,15694.03,
Abltj perc lxtr/perph nrv,0441T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13742.66,,,,,,,fee schedule,1933.13,15694.03,
Abltj perc lxtr/perph nrv,0441T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14448.47,,,,,,,fee schedule,1933.13,15694.03,
Abltj perc lxtr/perph nrv,0441T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8576.66,,,,,,,fee schedule,1933.13,15694.03,APC 378
Abltj perc lxtr/perph nrv,0441T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2029.79,,,,,,,fee schedule,1933.13,15694.03,APC
Abltj perc lxtr/perph nrv,0441T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2010.46,,,,,,,fee schedule,1933.13,15694.03,APC
Abltj perc lxtr/perph nrv,0441T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1933.13,,,,,,,fee schedule,1933.13,15694.03,APC
Abltj perc lxtr/perph nrv,0441T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2957.7,,,,,,,fee schedule,1933.13,15694.03,Radiology
Abltj perc lxtr/perph nrv,0441T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2706.39,,,,,,,fee schedule,1933.13,15694.03,APC
Abltj perc lxtr/perph nrv,0441T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3382.99,,,,,,,fee schedule,1933.13,15694.03,APC
Nfct ds bct fngl/viral semiq,0441U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,399.67,,,,,,,fee schedule,399.67,777.14,Laboratory
Nfct ds bct fngl/viral semiq,0441U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,466.28,,,,,,,fee schedule,399.67,777.14,APC
Nfct ds bct fngl/viral semiq,0441U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,461.84,,,,,,,fee schedule,399.67,777.14,APC
Nfct ds bct fngl/viral semiq,0441U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,444.08,,,,,,,fee schedule,399.67,777.14,APC
Nfct ds bct fngl/viral semiq,0441U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,679.44,,,,,,,fee schedule,399.67,777.14,Radiology
Nfct ds bct fngl/viral semiq,0441U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,621.71,,,,,,,fee schedule,399.67,777.14,APC
Nfct ds bct fngl/viral semiq,0441U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,777.14,,,,,,,fee schedule,399.67,777.14,APC
Abltj perc plex/trncl nrv,0442T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15694.03,,,,,,,fee schedule,8687.81,38544.86,
Abltj perc plex/trncl nrv,0442T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12580.14,,,,,,,fee schedule,8687.81,38544.86,
Abltj perc plex/trncl nrv,0442T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13742.66,,,,,,,fee schedule,8687.81,38544.86,
Abltj perc plex/trncl nrv,0442T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14448.47,,,,,,,fee schedule,8687.81,38544.86,
Abltj perc plex/trncl nrv,0442T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,38544.86,,,,,,,fee schedule,8687.81,38544.86,APC 378
Abltj perc plex/trncl nrv,0442T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9122.2,,,,,,,fee schedule,8687.81,38544.86,APC
Abltj perc plex/trncl nrv,0442T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9035.32,,,,,,,fee schedule,8687.81,38544.86,APC
Abltj perc plex/trncl nrv,0442T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8687.81,,,,,,,fee schedule,8687.81,38544.86,APC
Abltj perc plex/trncl nrv,0442T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13292.34,,,,,,,fee schedule,8687.81,38544.86,Radiology
Abltj perc plex/trncl nrv,0442T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12162.93,,,,,,,fee schedule,8687.81,38544.86,APC
Abltj perc plex/trncl nrv,0442T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15203.66,,,,,,,fee schedule,8687.81,38544.86,APC
Nfct ds respir nfctj mxa&crp,0442U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,37.24,,,,,,,fee schedule,37.24,72.42,Laboratory
Nfct ds respir nfctj mxa&crp,0442U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,43.45,,,,,,,fee schedule,37.24,72.42,APC
Nfct ds respir nfctj mxa&crp,0442U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,43.04,,,,,,,fee schedule,37.24,72.42,APC
Nfct ds respir nfctj mxa&crp,0442U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,41.38,,,,,,,fee schedule,37.24,72.42,APC
Nfct ds respir nfctj mxa&crp,0442U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,63.31,,,,,,,fee schedule,37.24,72.42,Radiology
Nfct ds respir nfctj mxa&crp,0442U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,57.93,,,,,,,fee schedule,37.24,72.42,APC
Nfct ds respir nfctj mxa&crp,0442U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,72.42,,,,,,,fee schedule,37.24,72.42,APC
Neurflmnt lt chn ultrsens ia,0443U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,104.61,,,,,,,fee schedule,104.61,203.4,Laboratory
Neurflmnt lt chn ultrsens ia,0443U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,122.04,,,,,,,fee schedule,104.61,203.4,APC
Neurflmnt lt chn ultrsens ia,0443U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,120.88,,,,,,,fee schedule,104.61,203.4,APC
Neurflmnt lt chn ultrsens ia,0443U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,116.23,,,,,,,fee schedule,104.61,203.4,APC
Neurflmnt lt chn ultrsens ia,0443U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,177.83,,,,,,,fee schedule,104.61,203.4,Radiology
Neurflmnt lt chn ultrsens ia,0443U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,162.72,,,,,,,fee schedule,104.61,203.4,APC
Neurflmnt lt chn ultrsens ia,0443U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,203.4,,,,,,,fee schedule,104.61,203.4,APC
Onc sld orgn neo tgsap 361,0444U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2627.64,,,,,,,fee schedule,2627.64,5109.3,Laboratory
Onc sld orgn neo tgsap 361,0444U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3065.58,,,,,,,fee schedule,2627.64,5109.3,APC
Onc sld orgn neo tgsap 361,0444U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3036.38,,,,,,,fee schedule,2627.64,5109.3,APC
Onc sld orgn neo tgsap 361,0444U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2919.6,,,,,,,fee schedule,2627.64,5109.3,APC
Onc sld orgn neo tgsap 361,0444U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4466.99,,,,,,,fee schedule,2627.64,5109.3,Radiology
Onc sld orgn neo tgsap 361,0444U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4087.44,,,,,,,fee schedule,2627.64,5109.3,APC
Onc sld orgn neo tgsap 361,0444U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5109.3,,,,,,,fee schedule,2627.64,5109.3,APC
Abeta42 & ptau181 eclia csf,0445U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,234.45,,,,,,,fee schedule,234.45,455.88,Laboratory
Abeta42 & ptau181 eclia csf,0445U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,273.53,,,,,,,fee schedule,234.45,455.88,APC
Abeta42 & ptau181 eclia csf,0445U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,270.92,,,,,,,fee schedule,234.45,455.88,APC
Abeta42 & ptau181 eclia csf,0445U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,260.5,,,,,,,fee schedule,234.45,455.88,APC
Abeta42 & ptau181 eclia csf,0445U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,398.56,,,,,,,fee schedule,234.45,455.88,Radiology
Abeta42 & ptau181 eclia csf,0445U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,364.7,,,,,,,fee schedule,234.45,455.88,APC
Abeta42 & ptau181 eclia csf,0445U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,455.88,,,,,,,fee schedule,234.45,455.88,APC
Insj impltbl glucose sensor,0446T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1712.72,,,,,,,fee schedule,1372.89,18273.05,
Insj impltbl glucose sensor,0446T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1372.89,,,,,,,fee schedule,1372.89,18273.05,
Insj impltbl glucose sensor,0446T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1499.76,,,,,,,fee schedule,1372.89,18273.05,
Insj impltbl glucose sensor,0446T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1576.79,,,,,,,fee schedule,1372.89,18273.05,
Insj impltbl glucose sensor,0446T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18273.05,,,,,,,fee schedule,1372.89,18273.05,APC 378
Insj impltbl glucose sensor,0446T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4324.58,,,,,,,fee schedule,1372.89,18273.05,APC
Insj impltbl glucose sensor,0446T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4283.4,,,,,,,fee schedule,1372.89,18273.05,APC
Insj impltbl glucose sensor,0446T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4118.65,,,,,,,fee schedule,1372.89,18273.05,APC
Insj impltbl glucose sensor,0446T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6301.53,,,,,,,fee schedule,1372.89,18273.05,Radiology
Insj impltbl glucose sensor,0446T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5766.11,,,,,,,fee schedule,1372.89,18273.05,APC
Insj impltbl glucose sensor,0446T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7207.64,,,,,,,fee schedule,1372.89,18273.05,APC
Ai ds sle alys 10 cytokine,0446U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,756.58,,,,,,,fee schedule,756.58,1471.14,Laboratory
Ai ds sle alys 10 cytokine,0446U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,882.68,,,,,,,fee schedule,756.58,1471.14,APC
Ai ds sle alys 10 cytokine,0446U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,874.28,,,,,,,fee schedule,756.58,1471.14,APC
Ai ds sle alys 10 cytokine,0446U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,840.65,,,,,,,fee schedule,756.58,1471.14,APC
Ai ds sle alys 10 cytokine,0446U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1286.19,,,,,,,fee schedule,756.58,1471.14,Radiology
Ai ds sle alys 10 cytokine,0446U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1176.91,,,,,,,fee schedule,756.58,1471.14,APC
Ai ds sle alys 10 cytokine,0446U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1471.14,,,,,,,fee schedule,756.58,1471.14,APC
Rmvl impltbl glucose sensor,0447T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,578.79,,,,,,,fee schedule,198.62,881.22,
Rmvl impltbl glucose sensor,0447T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,463.95,,,,,,,fee schedule,198.62,881.22,
Rmvl impltbl glucose sensor,0447T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,506.83,,,,,,,fee schedule,198.62,881.22,
Rmvl impltbl glucose sensor,0447T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,532.86,,,,,,,fee schedule,198.62,881.22,
Rmvl impltbl glucose sensor,0447T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,881.22,,,,,,,fee schedule,198.62,881.22,APC 378
Rmvl impltbl glucose sensor,0447T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.55,,,,,,,fee schedule,198.62,881.22,APC
Rmvl impltbl glucose sensor,0447T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,206.57,,,,,,,fee schedule,198.62,881.22,APC
Rmvl impltbl glucose sensor,0447T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.62,,,,,,,fee schedule,198.62,881.22,APC
Rmvl impltbl glucose sensor,0447T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.89,,,,,,,fee schedule,198.62,881.22,Radiology
Rmvl impltbl glucose sensor,0447T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,278.07,,,,,,,fee schedule,198.62,881.22,APC
Rmvl impltbl glucose sensor,0447T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,347.59,,,,,,,fee schedule,198.62,881.22,APC
Ai ds sle alys 11 cytokine,0447U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,756.58,,,,,,,fee schedule,756.58,1471.14,Laboratory
Ai ds sle alys 11 cytokine,0447U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,882.68,,,,,,,fee schedule,756.58,1471.14,APC
Ai ds sle alys 11 cytokine,0447U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,874.28,,,,,,,fee schedule,756.58,1471.14,APC
Ai ds sle alys 11 cytokine,0447U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,840.65,,,,,,,fee schedule,756.58,1471.14,APC
Ai ds sle alys 11 cytokine,0447U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1286.19,,,,,,,fee schedule,756.58,1471.14,Radiology
Ai ds sle alys 11 cytokine,0447U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1176.91,,,,,,,fee schedule,756.58,1471.14,APC
Ai ds sle alys 11 cytokine,0447U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1471.14,,,,,,,fee schedule,756.58,1471.14,APC
Remvl insj impltbl gluc sens,0448T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1712.72,,,,,,,fee schedule,1372.89,18273.05,
Remvl insj impltbl gluc sens,0448T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1372.89,,,,,,,fee schedule,1372.89,18273.05,
Remvl insj impltbl gluc sens,0448T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1499.76,,,,,,,fee schedule,1372.89,18273.05,
Remvl insj impltbl gluc sens,0448T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1576.79,,,,,,,fee schedule,1372.89,18273.05,
Remvl insj impltbl gluc sens,0448T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18273.05,,,,,,,fee schedule,1372.89,18273.05,APC 378
Remvl insj impltbl gluc sens,0448T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4324.58,,,,,,,fee schedule,1372.89,18273.05,APC
Remvl insj impltbl gluc sens,0448T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4283.4,,,,,,,fee schedule,1372.89,18273.05,APC
Remvl insj impltbl gluc sens,0448T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4118.65,,,,,,,fee schedule,1372.89,18273.05,APC
Remvl insj impltbl gluc sens,0448T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6301.53,,,,,,,fee schedule,1372.89,18273.05,Radiology
Remvl insj impltbl gluc sens,0448T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5766.11,,,,,,,fee schedule,1372.89,18273.05,APC
Remvl insj impltbl gluc sens,0448T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7207.64,,,,,,,fee schedule,1372.89,18273.05,APC
Insj aqueous drain dev 1st,0449T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12922.91,,,,,,,fee schedule,5267.92,23371.97,
Insj aqueous drain dev 1st,0449T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10358.84,,,,,,,fee schedule,5267.92,23371.97,
Insj aqueous drain dev 1st,0449T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11316.1,,,,,,,fee schedule,5267.92,23371.97,
Insj aqueous drain dev 1st,0449T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11897.28,,,,,,,fee schedule,5267.92,23371.97,
Insj aqueous drain dev 1st,0449T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23371.97,,,,,,,fee schedule,5267.92,23371.97,APC 378
Insj aqueous drain dev 1st,0449T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5531.31,,,,,,,fee schedule,5267.92,23371.97,APC
Insj aqueous drain dev 1st,0449T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5478.63,,,,,,,fee schedule,5267.92,23371.97,APC
Insj aqueous drain dev 1st,0449T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5267.92,,,,,,,fee schedule,5267.92,23371.97,APC
Insj aqueous drain dev 1st,0449T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8059.91,,,,,,,fee schedule,5267.92,23371.97,Radiology
Insj aqueous drain dev 1st,0449T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7375.09,,,,,,,fee schedule,5267.92,23371.97,APC
Insj aqueous drain dev 1st,0449T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9218.86,,,,,,,fee schedule,5267.92,23371.97,APC
Onc bldr mthyl penk lte-qmsp,0452U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,172.8,,,,,,,fee schedule,172.8,336,Laboratory
Onc bldr mthyl penk lte-qmsp,0452U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,201.6,,,,,,,fee schedule,172.8,336,APC
Onc bldr mthyl penk lte-qmsp,0452U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,199.68,,,,,,,fee schedule,172.8,336,APC
Onc bldr mthyl penk lte-qmsp,0452U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,192,,,,,,,fee schedule,172.8,336,APC
Onc bldr mthyl penk lte-qmsp,0452U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,293.76,,,,,,,fee schedule,172.8,336,Radiology
Onc bldr mthyl penk lte-qmsp,0452U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,268.8,,,,,,,fee schedule,172.8,336,APC
Onc bldr mthyl penk lte-qmsp,0452U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,336,,,,,,,fee schedule,172.8,336,APC
Onc clrct ca cfdna qpcr asy,0453U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,172.8,,,,,,,fee schedule,172.8,336,Laboratory
Onc clrct ca cfdna qpcr asy,0453U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,201.6,,,,,,,fee schedule,172.8,336,APC
Onc clrct ca cfdna qpcr asy,0453U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,199.68,,,,,,,fee schedule,172.8,336,APC
Onc clrct ca cfdna qpcr asy,0453U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,192,,,,,,,fee schedule,172.8,336,APC
Onc clrct ca cfdna qpcr asy,0453U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,293.76,,,,,,,fee schedule,172.8,336,Radiology
Onc clrct ca cfdna qpcr asy,0453U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,268.8,,,,,,,fee schedule,172.8,336,APC
Onc clrct ca cfdna qpcr asy,0453U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,336,,,,,,,fee schedule,172.8,336,APC
U rare ds id opt genome mapg,0454U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1137.18,,,,,,,fee schedule,1137.18,2211.18,Laboratory
U rare ds id opt genome mapg,0454U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1326.71,,,,,,,fee schedule,1137.18,2211.18,APC
U rare ds id opt genome mapg,0454U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1314.07,,,,,,,fee schedule,1137.18,2211.18,APC
U rare ds id opt genome mapg,0454U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1263.53,,,,,,,fee schedule,1137.18,2211.18,APC
U rare ds id opt genome mapg,0454U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1933.2,,,,,,,fee schedule,1137.18,2211.18,Radiology
U rare ds id opt genome mapg,0454U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1768.94,,,,,,,fee schedule,1137.18,2211.18,APC
U rare ds id opt genome mapg,0454U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2211.18,,,,,,,fee schedule,1137.18,2211.18,APC
Nfct agt sti mult amp prb ur,0455U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,128.37,,,,,,,fee schedule,128.37,249.6,Laboratory
Nfct agt sti mult amp prb ur,0455U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,149.76,,,,,,,fee schedule,128.37,249.6,APC
Nfct agt sti mult amp prb ur,0455U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,148.34,,,,,,,fee schedule,128.37,249.6,APC
Nfct agt sti mult amp prb ur,0455U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,142.63,,,,,,,fee schedule,128.37,249.6,APC
Nfct agt sti mult amp prb ur,0455U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,218.22,,,,,,,fee schedule,128.37,249.6,Radiology
Nfct agt sti mult amp prb ur,0455U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,199.68,,,,,,,fee schedule,128.37,249.6,APC
Nfct agt sti mult amp prb ur,0455U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,249.6,,,,,,,fee schedule,128.37,249.6,APC
Pfas 9 cmpnd lcms/ms pls/sr,0457U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,178.87,,,,,,,fee schedule,178.87,347.8,Laboratory
Pfas 9 cmpnd lcms/ms pls/sr,0457U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.68,,,,,,,fee schedule,178.87,347.8,APC
Pfas 9 cmpnd lcms/ms pls/sr,0457U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,206.69,,,,,,,fee schedule,178.87,347.8,APC
Pfas 9 cmpnd lcms/ms pls/sr,0457U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.74,,,,,,,fee schedule,178.87,347.8,APC
Pfas 9 cmpnd lcms/ms pls/sr,0457U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,304.07,,,,,,,fee schedule,178.87,347.8,Radiology
Pfas 9 cmpnd lcms/ms pls/sr,0457U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,278.24,,,,,,,fee schedule,178.87,347.8,APC
Pfas 9 cmpnd lcms/ms pls/sr,0457U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,347.8,,,,,,,fee schedule,178.87,347.8,APC
Onc brst ca s100 a8&a9 elisa,0458U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,234.45,,,,,,,fee schedule,234.45,455.88,Laboratory
Onc brst ca s100 a8&a9 elisa,0458U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,273.53,,,,,,,fee schedule,234.45,455.88,APC
Onc brst ca s100 a8&a9 elisa,0458U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,270.92,,,,,,,fee schedule,234.45,455.88,APC
Onc brst ca s100 a8&a9 elisa,0458U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,260.5,,,,,,,fee schedule,234.45,455.88,APC
Onc brst ca s100 a8&a9 elisa,0458U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,398.56,,,,,,,fee schedule,234.45,455.88,Radiology
Onc brst ca s100 a8&a9 elisa,0458U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,364.7,,,,,,,fee schedule,234.45,455.88,APC
Onc brst ca s100 a8&a9 elisa,0458U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,455.88,,,,,,,fee schedule,234.45,455.88,APC
Abeta42 & ttau eclia csf,0459U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,234.45,,,,,,,fee schedule,234.45,455.88,Laboratory
Abeta42 & ttau eclia csf,0459U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,273.53,,,,,,,fee schedule,234.45,455.88,APC
Abeta42 & ttau eclia csf,0459U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,270.92,,,,,,,fee schedule,234.45,455.88,APC
Abeta42 & ttau eclia csf,0459U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,260.5,,,,,,,fee schedule,234.45,455.88,APC
Abeta42 & ttau eclia csf,0459U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,398.56,,,,,,,fee schedule,234.45,455.88,Radiology
Abeta42 & ttau eclia csf,0459U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,364.7,,,,,,,fee schedule,234.45,455.88,APC
Abeta42 & ttau eclia csf,0459U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,455.88,,,,,,,fee schedule,234.45,455.88,APC
Onc whl bld/bucc rtpcr 24gen,0460U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,825.37,,,,,,,fee schedule,825.37,1604.89,Laboratory
Onc whl bld/bucc rtpcr 24gen,0460U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,962.93,,,,,,,fee schedule,825.37,1604.89,APC
Onc whl bld/bucc rtpcr 24gen,0460U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,953.76,,,,,,,fee schedule,825.37,1604.89,APC
Onc whl bld/bucc rtpcr 24gen,0460U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,917.08,,,,,,,fee schedule,825.37,1604.89,APC
Onc whl bld/bucc rtpcr 24gen,0460U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1403.13,,,,,,,fee schedule,825.37,1604.89,Radiology
Onc whl bld/bucc rtpcr 24gen,0460U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1283.91,,,,,,,fee schedule,825.37,1604.89,APC
Onc whl bld/bucc rtpcr 24gen,0460U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1604.89,,,,,,,fee schedule,825.37,1604.89,APC
Onc rxgenom alys rtpcr 24gen,0461U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,825.37,,,,,,,fee schedule,825.37,1604.89,Laboratory
Onc rxgenom alys rtpcr 24gen,0461U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,962.93,,,,,,,fee schedule,825.37,1604.89,APC
Onc rxgenom alys rtpcr 24gen,0461U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,953.76,,,,,,,fee schedule,825.37,1604.89,APC
Onc rxgenom alys rtpcr 24gen,0461U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,917.08,,,,,,,fee schedule,825.37,1604.89,APC
Onc rxgenom alys rtpcr 24gen,0461U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1403.13,,,,,,,fee schedule,825.37,1604.89,Radiology
Onc rxgenom alys rtpcr 24gen,0461U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1283.91,,,,,,,fee schedule,825.37,1604.89,APC
Onc rxgenom alys rtpcr 24gen,0461U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1604.89,,,,,,,fee schedule,825.37,1604.89,APC
Melatonin lvl tst slp std7/9,0462U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.54,,,,,,,fee schedule,15.54,30.22,Laboratory
Melatonin lvl tst slp std7/9,0462U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.13,,,,,,,fee schedule,15.54,30.22,APC
Melatonin lvl tst slp std7/9,0462U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,17.96,,,,,,,fee schedule,15.54,30.22,APC
Melatonin lvl tst slp std7/9,0462U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17.27,,,,,,,fee schedule,15.54,30.22,APC
Melatonin lvl tst slp std7/9,0462U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26.42,,,,,,,fee schedule,15.54,30.22,Radiology
Melatonin lvl tst slp std7/9,0462U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24.18,,,,,,,fee schedule,15.54,30.22,APC
Melatonin lvl tst slp std7/9,0462U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30.22,,,,,,,fee schedule,15.54,30.22,APC
Onc crvx mrna genxprsn 14bmk,0463U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,684,,,,,,,fee schedule,684,1330,Laboratory
Onc crvx mrna genxprsn 14bmk,0463U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,798,,,,,,,fee schedule,684,1330,APC
Onc crvx mrna genxprsn 14bmk,0463U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,790.4,,,,,,,fee schedule,684,1330,APC
Onc crvx mrna genxprsn 14bmk,0463U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,760,,,,,,,fee schedule,684,1330,APC
Onc crvx mrna genxprsn 14bmk,0463U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1162.8,,,,,,,fee schedule,684,1330,Radiology
Onc crvx mrna genxprsn 14bmk,0463U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1064,,,,,,,fee schedule,684,1330,APC
Onc crvx mrna genxprsn 14bmk,0463U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1330,,,,,,,fee schedule,684,1330,APC
Visual ep test for glaucoma,0464T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,480.44,,,,,,,fee schedule,127.38,565.15,
Visual ep test for glaucoma,0464T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,385.11,,,,,,,fee schedule,127.38,565.15,
Visual ep test for glaucoma,0464T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,420.7,,,,,,,fee schedule,127.38,565.15,
Visual ep test for glaucoma,0464T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,442.31,,,,,,,fee schedule,127.38,565.15,
Visual ep test for glaucoma,0464T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,565.15,,,,,,,fee schedule,127.38,565.15,APC 378
Visual ep test for glaucoma,0464T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,133.75,,,,,,,fee schedule,127.38,565.15,APC
Visual ep test for glaucoma,0464T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,132.48,,,,,,,fee schedule,127.38,565.15,APC
Visual ep test for glaucoma,0464T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,127.38,,,,,,,fee schedule,127.38,565.15,APC
Visual ep test for glaucoma,0464T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,194.89,,,,,,,fee schedule,127.38,565.15,Radiology
Visual ep test for glaucoma,0464T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,178.33,,,,,,,fee schedule,127.38,565.15,APC
Visual ep test for glaucoma,0464T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,222.92,,,,,,,fee schedule,127.38,565.15,APC
Onc clrct scr qrtsa dna mrk,0464U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,532.73,,,,,,,fee schedule,532.73,1035.86,Laboratory
Onc clrct scr qrtsa dna mrk,0464U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,621.52,,,,,,,fee schedule,532.73,1035.86,APC
Onc clrct scr qrtsa dna mrk,0464U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,615.6,,,,,,,fee schedule,532.73,1035.86,APC
Onc clrct scr qrtsa dna mrk,0464U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,591.92,,,,,,,fee schedule,532.73,1035.86,APC
Onc clrct scr qrtsa dna mrk,0464U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,905.64,,,,,,,fee schedule,532.73,1035.86,Radiology
Onc clrct scr qrtsa dna mrk,0464U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,828.69,,,,,,,fee schedule,532.73,1035.86,APC
Onc clrct scr qrtsa dna mrk,0464U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1035.86,,,,,,,fee schedule,532.73,1035.86,APC
Supchrdl njx rxw/o supply,0465T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1056.32,,,,,,,fee schedule,846.73,1056.32,
Supchrdl njx rxw/o supply,0465T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,846.73,,,,,,,fee schedule,846.73,1056.32,
Supchrdl njx rxw/o supply,0465T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,924.98,,,,,,,fee schedule,846.73,1056.32,
Supchrdl njx rxw/o supply,0465T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,972.49,,,,,,,fee schedule,846.73,1056.32,
Onc urthl carc dna qmsp 2gen,0465U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1744.21,,,,,,,fee schedule,1744.21,3391.52,Laboratory
Onc urthl carc dna qmsp 2gen,0465U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2034.91,,,,,,,fee schedule,1744.21,3391.52,APC
Onc urthl carc dna qmsp 2gen,0465U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2015.53,,,,,,,fee schedule,1744.21,3391.52,APC
Onc urthl carc dna qmsp 2gen,0465U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1938.01,,,,,,,fee schedule,1744.21,3391.52,APC
Onc urthl carc dna qmsp 2gen,0465U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2965.16,,,,,,,fee schedule,1744.21,3391.52,Radiology
Onc urthl carc dna qmsp 2gen,0465U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2713.21,,,,,,,fee schedule,1744.21,3391.52,APC
Onc urthl carc dna qmsp 2gen,0465U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3391.52,,,,,,,fee schedule,1744.21,3391.52,APC
Crd cad dna gwas 564856 snp,0466U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,310.89,,,,,,,fee schedule,310.89,604.5,Laboratory
Crd cad dna gwas 564856 snp,0466U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,362.7,,,,,,,fee schedule,310.89,604.5,APC
Crd cad dna gwas 564856 snp,0466U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,359.25,,,,,,,fee schedule,310.89,604.5,APC
Crd cad dna gwas 564856 snp,0466U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,345.43,,,,,,,fee schedule,310.89,604.5,APC
Crd cad dna gwas 564856 snp,0466U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,528.51,,,,,,,fee schedule,310.89,604.5,Radiology
Crd cad dna gwas 564856 snp,0466U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,483.6,,,,,,,fee schedule,310.89,604.5,APC
Crd cad dna gwas 564856 snp,0466U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,604.5,,,,,,,fee schedule,310.89,604.5,APC
Onc bldr dna ngs 60gen&aneup,0467U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1367.15,,,,,,,fee schedule,1367.15,2658.36,Laboratory
Onc bldr dna ngs 60gen&aneup,0467U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1595.01,,,,,,,fee schedule,1367.15,2658.36,APC
Onc bldr dna ngs 60gen&aneup,0467U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1579.82,,,,,,,fee schedule,1367.15,2658.36,APC
Onc bldr dna ngs 60gen&aneup,0467U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1519.06,,,,,,,fee schedule,1367.15,2658.36,APC
Onc bldr dna ngs 60gen&aneup,0467U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2324.16,,,,,,,fee schedule,1367.15,2658.36,Radiology
Onc bldr dna ngs 60gen&aneup,0467U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2126.68,,,,,,,fee schedule,1367.15,2658.36,APC
Onc bldr dna ngs 60gen&aneup,0467U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2658.36,,,,,,,fee schedule,1367.15,2658.36,APC
Hep nash mir34a5p ?2m ykl40,0468U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,226.53,,,,,,,fee schedule,226.53,440.48,Laboratory
Hep nash mir34a5p ?2m ykl40,0468U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,264.29,,,,,,,fee schedule,226.53,440.48,APC
Hep nash mir34a5p ?2m ykl40,0468U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,261.77,,,,,,,fee schedule,226.53,440.48,APC
Hep nash mir34a5p ?2m ykl40,0468U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,251.7,,,,,,,fee schedule,226.53,440.48,APC
Hep nash mir34a5p ?2m ykl40,0468U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,385.1,,,,,,,fee schedule,226.53,440.48,Radiology
Hep nash mir34a5p ?2m ykl40,0468U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,352.38,,,,,,,fee schedule,226.53,440.48,APC
Hep nash mir34a5p ?2m ykl40,0468U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,440.48,,,,,,,fee schedule,226.53,440.48,APC
Rare ds whl gen seq ftl samp,0469U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1078.15,,,,,,,fee schedule,1078.15,2096.4,Laboratory
Rare ds whl gen seq ftl samp,0469U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1257.84,,,,,,,fee schedule,1078.15,2096.4,APC
Rare ds whl gen seq ftl samp,0469U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1245.86,,,,,,,fee schedule,1078.15,2096.4,APC
Rare ds whl gen seq ftl samp,0469U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1197.94,,,,,,,fee schedule,1078.15,2096.4,APC
Rare ds whl gen seq ftl samp,0469U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1832.85,,,,,,,fee schedule,1078.15,2096.4,Radiology
Rare ds whl gen seq ftl samp,0469U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1677.12,,,,,,,fee schedule,1078.15,2096.4,APC
Rare ds whl gen seq ftl samp,0469U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2096.4,,,,,,,fee schedule,1078.15,2096.4,APC
Onc orop detcj mrd 8 dna hpv,0470U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,538.12,,,,,,,fee schedule,538.12,1046.34,Laboratory
Onc orop detcj mrd 8 dna hpv,0470U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,627.81,,,,,,,fee schedule,538.12,1046.34,APC
Onc orop detcj mrd 8 dna hpv,0470U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,621.83,,,,,,,fee schedule,538.12,1046.34,APC
Onc orop detcj mrd 8 dna hpv,0470U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,597.91,,,,,,,fee schedule,538.12,1046.34,APC
Onc orop detcj mrd 8 dna hpv,0470U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,914.8,,,,,,,fee schedule,538.12,1046.34,Radiology
Onc orop detcj mrd 8 dna hpv,0470U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,837.07,,,,,,,fee schedule,538.12,1046.34,APC
Onc orop detcj mrd 8 dna hpv,0470U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1046.34,,,,,,,fee schedule,538.12,1046.34,APC
Onc clrc ca 35 vrn kras&nras,0471U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,684,,,,,,,fee schedule,684,1330,Laboratory
Onc clrc ca 35 vrn kras&nras,0471U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,798,,,,,,,fee schedule,684,1330,APC
Onc clrc ca 35 vrn kras&nras,0471U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,790.4,,,,,,,fee schedule,684,1330,APC
Onc clrc ca 35 vrn kras&nras,0471U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,760,,,,,,,fee schedule,684,1330,APC
Onc clrc ca 35 vrn kras&nras,0471U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1162.8,,,,,,,fee schedule,684,1330,Radiology
Onc clrc ca 35 vrn kras&nras,0471U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1064,,,,,,,fee schedule,684,1330,APC
Onc clrc ca 35 vrn kras&nras,0471U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1330,,,,,,,fee schedule,684,1330,APC
Prgrmg io rta eltrd ra,0472T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1059.95,,,,,,,fee schedule,304.06,1348.99,
Prgrmg io rta eltrd ra,0472T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,849.64,,,,,,,fee schedule,304.06,1348.99,
Prgrmg io rta eltrd ra,0472T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,928.16,,,,,,,fee schedule,304.06,1348.99,
Prgrmg io rta eltrd ra,0472T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,975.83,,,,,,,fee schedule,304.06,1348.99,
Prgrmg io rta eltrd ra,0472T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1348.99,,,,,,,fee schedule,304.06,1348.99,APC 378
Prgrmg io rta eltrd ra,0472T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,319.26,,,,,,,fee schedule,304.06,1348.99,APC
Prgrmg io rta eltrd ra,0472T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,316.22,,,,,,,fee schedule,304.06,1348.99,APC
Prgrmg io rta eltrd ra,0472T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,304.06,,,,,,,fee schedule,304.06,1348.99,APC
Prgrmg io rta eltrd ra,0472T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,465.21,,,,,,,fee schedule,304.06,1348.99,Radiology
Prgrmg io rta eltrd ra,0472T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,425.68,,,,,,,fee schedule,304.06,1348.99,APC
Prgrmg io rta eltrd ra,0472T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,532.1,,,,,,,fee schedule,304.06,1348.99,APC
Ca vi psp&sp1 antb sj?gren,0472U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25.11,,,,,,,fee schedule,25.11,48.82,Laboratory
Ca vi psp&sp1 antb sj?gren,0472U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,29.3,,,,,,,fee schedule,25.11,48.82,APC
Ca vi psp&sp1 antb sj?gren,0472U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,29.02,,,,,,,fee schedule,25.11,48.82,APC
Ca vi psp&sp1 antb sj?gren,0472U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,27.9,,,,,,,fee schedule,25.11,48.82,APC
Ca vi psp&sp1 antb sj?gren,0472U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,42.69,,,,,,,fee schedule,25.11,48.82,Radiology
Ca vi psp&sp1 antb sj?gren,0472U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,39.06,,,,,,,fee schedule,25.11,48.82,APC
Ca vi psp&sp1 antb sj?gren,0472U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,48.82,,,,,,,fee schedule,25.11,48.82,APC
Reprgrmg io rta eltrd ra,0473T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,444.3,,,,,,,fee schedule,94.12,444.3,
Reprgrmg io rta eltrd ra,0473T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,356.15,,,,,,,fee schedule,94.12,444.3,
Reprgrmg io rta eltrd ra,0473T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,389.06,,,,,,,fee schedule,94.12,444.3,
Reprgrmg io rta eltrd ra,0473T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,409.04,,,,,,,fee schedule,94.12,444.3,
Reprgrmg io rta eltrd ra,0473T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,417.57,,,,,,,fee schedule,94.12,444.3,APC 378
Reprgrmg io rta eltrd ra,0473T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,98.82,,,,,,,fee schedule,94.12,444.3,APC
Reprgrmg io rta eltrd ra,0473T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,97.88,,,,,,,fee schedule,94.12,444.3,APC
Reprgrmg io rta eltrd ra,0473T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,94.12,,,,,,,fee schedule,94.12,444.3,APC
Reprgrmg io rta eltrd ra,0473T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144,,,,,,,fee schedule,94.12,444.3,Radiology
Reprgrmg io rta eltrd ra,0473T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.76,,,,,,,fee schedule,94.12,444.3,APC
Reprgrmg io rta eltrd ra,0473T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,164.7,,,,,,,fee schedule,94.12,444.3,APC
Onc sld tum bld/slv 648 gene,0473U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4050,,,,,,,fee schedule,4050,7875,Laboratory
Onc sld tum bld/slv 648 gene,0473U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4725,,,,,,,fee schedule,4050,7875,APC
Onc sld tum bld/slv 648 gene,0473U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4680,,,,,,,fee schedule,4050,7875,APC
Onc sld tum bld/slv 648 gene,0473U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4500,,,,,,,fee schedule,4050,7875,APC
Onc sld tum bld/slv 648 gene,0473U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6885,,,,,,,fee schedule,4050,7875,Radiology
Onc sld tum bld/slv 648 gene,0473U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6300,,,,,,,fee schedule,4050,7875,APC
Onc sld tum bld/slv 648 gene,0473U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7875,,,,,,,fee schedule,4050,7875,APC
Insj aqueous drg dev io rsvr,0474T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1391.12,,,,,,,fee schedule,1115.1,1391.12,
Insj aqueous drg dev io rsvr,0474T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1115.1,,,,,,,fee schedule,1115.1,1391.12,
Insj aqueous drg dev io rsvr,0474T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1218.15,,,,,,,fee schedule,1115.1,1391.12,
Insj aqueous drg dev io rsvr,0474T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1280.71,,,,,,,fee schedule,1115.1,1391.12,
Hered pan ca gsap 88gene ngs,0474U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1173.56,,,,,,,fee schedule,1173.56,2281.91,Laboratory
Hered pan ca gsap 88gene ngs,0474U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1369.15,,,,,,,fee schedule,1173.56,2281.91,APC
Hered pan ca gsap 88gene ngs,0474U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1356.11,,,,,,,fee schedule,1173.56,2281.91,APC
Hered pan ca gsap 88gene ngs,0474U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1303.95,,,,,,,fee schedule,1173.56,2281.91,APC
Hered pan ca gsap 88gene ngs,0474U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1995.04,,,,,,,fee schedule,1173.56,2281.91,Radiology
Hered pan ca gsap 88gene ngs,0474U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1825.53,,,,,,,fee schedule,1173.56,2281.91,APC
Hered pan ca gsap 88gene ngs,0474U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2281.91,,,,,,,fee schedule,1173.56,2281.91,APC
Hered prst8 ca gsap 23 genes,0475U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1173.56,,,,,,,fee schedule,1173.56,2281.91,Laboratory
Hered prst8 ca gsap 23 genes,0475U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1369.15,,,,,,,fee schedule,1173.56,2281.91,APC
Hered prst8 ca gsap 23 genes,0475U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1356.11,,,,,,,fee schedule,1173.56,2281.91,APC
Hered prst8 ca gsap 23 genes,0475U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1303.95,,,,,,,fee schedule,1173.56,2281.91,APC
Hered prst8 ca gsap 23 genes,0475U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1995.04,,,,,,,fee schedule,1173.56,2281.91,Radiology
Hered prst8 ca gsap 23 genes,0475U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1825.53,,,,,,,fee schedule,1173.56,2281.91,APC
Hered prst8 ca gsap 23 genes,0475U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2281.91,,,,,,,fee schedule,1173.56,2281.91,APC
Rx metab psyc 14gen&cyp2d6,0476U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,375.1,,,,,,,fee schedule,375.1,729.36,Laboratory
Rx metab psyc 14gen&cyp2d6,0476U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,437.62,,,,,,,fee schedule,375.1,729.36,APC
Rx metab psyc 14gen&cyp2d6,0476U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,433.45,,,,,,,fee schedule,375.1,729.36,APC
Rx metab psyc 14gen&cyp2d6,0476U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,416.78,,,,,,,fee schedule,375.1,729.36,APC
Rx metab psyc 14gen&cyp2d6,0476U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,637.67,,,,,,,fee schedule,375.1,729.36,Radiology
Rx metab psyc 14gen&cyp2d6,0476U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,583.49,,,,,,,fee schedule,375.1,729.36,APC
Rx metab psyc 14gen&cyp2d6,0476U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,729.36,,,,,,,fee schedule,375.1,729.36,APC
Rx metab psy 14&cyp2d6 gn-rx,0477U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,375.1,,,,,,,fee schedule,375.1,729.36,Laboratory
Rx metab psy 14&cyp2d6 gn-rx,0477U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,437.62,,,,,,,fee schedule,375.1,729.36,APC
Rx metab psy 14&cyp2d6 gn-rx,0477U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,433.45,,,,,,,fee schedule,375.1,729.36,APC
Rx metab psy 14&cyp2d6 gn-rx,0477U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,416.78,,,,,,,fee schedule,375.1,729.36,APC
Rx metab psy 14&cyp2d6 gn-rx,0477U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,637.67,,,,,,,fee schedule,375.1,729.36,Radiology
Rx metab psy 14&cyp2d6 gn-rx,0477U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,583.49,,,,,,,fee schedule,375.1,729.36,APC
Rx metab psy 14&cyp2d6 gn-rx,0477U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,729.36,,,,,,,fee schedule,375.1,729.36,APC
Onc nsclc dna&rna dpcr 9 gen,0478U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,497.69,,,,,,,fee schedule,497.69,967.73,Laboratory
Onc nsclc dna&rna dpcr 9 gen,0478U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,580.64,,,,,,,fee schedule,497.69,967.73,APC
Onc nsclc dna&rna dpcr 9 gen,0478U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,575.11,,,,,,,fee schedule,497.69,967.73,APC
Onc nsclc dna&rna dpcr 9 gen,0478U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,552.99,,,,,,,fee schedule,497.69,967.73,APC
Onc nsclc dna&rna dpcr 9 gen,0478U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,846.07,,,,,,,fee schedule,497.69,967.73,Radiology
Onc nsclc dna&rna dpcr 9 gen,0478U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,774.19,,,,,,,fee schedule,497.69,967.73,APC
Onc nsclc dna&rna dpcr 9 gen,0478U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,967.73,,,,,,,fee schedule,497.69,967.73,APC
Fxjl abl lsr 1st 100 sq cm,0479T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1187.22,,,,,,,fee schedule,731.66,3246.12,
Fxjl abl lsr 1st 100 sq cm,0479T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,951.66,,,,,,,fee schedule,731.66,3246.12,
Fxjl abl lsr 1st 100 sq cm,0479T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1039.6,,,,,,,fee schedule,731.66,3246.12,
Fxjl abl lsr 1st 100 sq cm,0479T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1093,,,,,,,fee schedule,731.66,3246.12,
Fxjl abl lsr 1st 100 sq cm,0479T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3246.12,,,,,,,fee schedule,731.66,3246.12,APC 378
Fxjl abl lsr 1st 100 sq cm,0479T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,768.24,,,,,,,fee schedule,731.66,3246.12,APC
Fxjl abl lsr 1st 100 sq cm,0479T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,760.92,,,,,,,fee schedule,731.66,3246.12,APC
Fxjl abl lsr 1st 100 sq cm,0479T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,731.66,,,,,,,fee schedule,731.66,3246.12,APC
Fxjl abl lsr 1st 100 sq cm,0479T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1119.44,,,,,,,fee schedule,731.66,3246.12,Radiology
Fxjl abl lsr 1st 100 sq cm,0479T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1024.32,,,,,,,fee schedule,731.66,3246.12,APC
Fxjl abl lsr 1st 100 sq cm,0479T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1280.4,,,,,,,fee schedule,731.66,3246.12,APC
Tau phosphorylated ptau217,0479U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.54,,,,,,,fee schedule,15.54,30.22,Laboratory
Tau phosphorylated ptau217,0479U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.13,,,,,,,fee schedule,15.54,30.22,APC
Tau phosphorylated ptau217,0479U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,17.96,,,,,,,fee schedule,15.54,30.22,APC
Tau phosphorylated ptau217,0479U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17.27,,,,,,,fee schedule,15.54,30.22,APC
Tau phosphorylated ptau217,0479U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26.42,,,,,,,fee schedule,15.54,30.22,Radiology
Tau phosphorylated ptau217,0479U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24.18,,,,,,,fee schedule,15.54,30.22,APC
Tau phosphorylated ptau217,0479U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30.22,,,,,,,fee schedule,15.54,30.22,APC
Fxjl abl lsr ea addl 100sqcm,0480T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,281.23,,,,,,,fee schedule,225.43,281.23,
Fxjl abl lsr ea addl 100sqcm,0480T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,225.43,,,,,,,fee schedule,225.43,281.23,
Fxjl abl lsr ea addl 100sqcm,0480T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,246.26,,,,,,,fee schedule,225.43,281.23,
Fxjl abl lsr ea addl 100sqcm,0480T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,258.91,,,,,,,fee schedule,225.43,281.23,
Nfct ds csf metag ngs alys,0480U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1913.58,,,,,,,fee schedule,1913.58,3720.85,Laboratory
Nfct ds csf metag ngs alys,0480U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2232.51,,,,,,,fee schedule,1913.58,3720.85,APC
Nfct ds csf metag ngs alys,0480U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2211.25,,,,,,,fee schedule,1913.58,3720.85,APC
Nfct ds csf metag ngs alys,0480U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2126.2,,,,,,,fee schedule,1913.58,3720.85,APC
Nfct ds csf metag ngs alys,0480U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3253.09,,,,,,,fee schedule,1913.58,3720.85,Radiology
Nfct ds csf metag ngs alys,0480U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2976.68,,,,,,,fee schedule,1913.58,3720.85,APC
Nfct ds csf metag ngs alys,0480U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3720.85,,,,,,,fee schedule,1913.58,3720.85,APC
Njx autol wbc concentrate,0481T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1316.04,,,,,,,fee schedule,442.24,1962.08,
Njx autol wbc concentrate,0481T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1054.92,,,,,,,fee schedule,442.24,1962.08,
Njx autol wbc concentrate,0481T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1152.41,,,,,,,fee schedule,442.24,1962.08,
Njx autol wbc concentrate,0481T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1211.6,,,,,,,fee schedule,442.24,1962.08,
Njx autol wbc concentrate,0481T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1962.08,,,,,,,fee schedule,442.24,1962.08,APC 378
Njx autol wbc concentrate,0481T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,464.35,,,,,,,fee schedule,442.24,1962.08,APC
Njx autol wbc concentrate,0481T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,459.93,,,,,,,fee schedule,442.24,1962.08,APC
Njx autol wbc concentrate,0481T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,442.24,,,,,,,fee schedule,442.24,1962.08,APC
Njx autol wbc concentrate,0481T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,676.63,,,,,,,fee schedule,442.24,1962.08,Radiology
Njx autol wbc concentrate,0481T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,619.14,,,,,,,fee schedule,442.24,1962.08,APC
Njx autol wbc concentrate,0481T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,773.92,,,,,,,fee schedule,442.24,1962.08,APC
Idh1 idh2&tert promoter ngs,0481U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,606.82,,,,,,,fee schedule,606.82,1179.92,Laboratory
Idh1 idh2&tert promoter ngs,0481U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,707.95,,,,,,,fee schedule,606.82,1179.92,APC
Idh1 idh2&tert promoter ngs,0481U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,701.21,,,,,,,fee schedule,606.82,1179.92,APC
Idh1 idh2&tert promoter ngs,0481U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,674.24,,,,,,,fee schedule,606.82,1179.92,APC
Idh1 idh2&tert promoter ngs,0481U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1031.59,,,,,,,fee schedule,606.82,1179.92,Radiology
Idh1 idh2&tert promoter ngs,0481U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,943.94,,,,,,,fee schedule,606.82,1179.92,APC
Idh1 idh2&tert promoter ngs,0481U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1179.92,,,,,,,fee schedule,606.82,1179.92,APC
Ob pe biochem asy sfit1&pigf,0482U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,115.94,,,,,,,fee schedule,115.94,225.44,Laboratory
Ob pe biochem asy sfit1&pigf,0482U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,135.26,,,,,,,fee schedule,115.94,225.44,APC
Ob pe biochem asy sfit1&pigf,0482U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,133.97,,,,,,,fee schedule,115.94,225.44,APC
Ob pe biochem asy sfit1&pigf,0482U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,128.82,,,,,,,fee schedule,115.94,225.44,APC
Ob pe biochem asy sfit1&pigf,0482U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,197.09,,,,,,,fee schedule,115.94,225.44,Radiology
Ob pe biochem asy sfit1&pigf,0482U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,180.35,,,,,,,fee schedule,115.94,225.44,APC
Ob pe biochem asy sfit1&pigf,0482U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,225.44,,,,,,,fee schedule,115.94,225.44,APC
Tmvi percutaneous approach,0483T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5368.36,,,,,,,fee schedule,4303.21,5368.36,
Tmvi percutaneous approach,0483T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4303.21,,,,,,,fee schedule,4303.21,5368.36,
Tmvi percutaneous approach,0483T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4700.86,,,,,,,fee schedule,4303.21,5368.36,
Tmvi percutaneous approach,0483T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4942.3,,,,,,,fee schedule,4303.21,5368.36,
Nfct ds ng gyra s91f pt mut,0483U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31.58,,,,,,,fee schedule,31.58,61.41,Laboratory
Nfct ds ng gyra s91f pt mut,0483U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,31.58,61.41,APC
Nfct ds ng gyra s91f pt mut,0483U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,36.49,,,,,,,fee schedule,31.58,61.41,APC
Nfct ds ng gyra s91f pt mut,0483U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,35.09,,,,,,,fee schedule,31.58,61.41,APC
Nfct ds ng gyra s91f pt mut,0483U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,53.69,,,,,,,fee schedule,31.58,61.41,Radiology
Nfct ds ng gyra s91f pt mut,0483U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49.13,,,,,,,fee schedule,31.58,61.41,APC
Nfct ds ng gyra s91f pt mut,0483U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,61.41,,,,,,,fee schedule,31.58,61.41,APC
Tmvi transthoracic exposure,0484T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6779.66,,,,,,,fee schedule,5434.49,6779.66,
Tmvi transthoracic exposure,0484T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5434.49,,,,,,,fee schedule,5434.49,6779.66,
Tmvi transthoracic exposure,0484T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5936.68,,,,,,,fee schedule,5434.49,6779.66,
Tmvi transthoracic exposure,0484T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6241.59,,,,,,,fee schedule,5434.49,6779.66,
Nfct ds mgen 23s rrna pt mut,0484U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31.58,,,,,,,fee schedule,31.58,61.41,Laboratory
Nfct ds mgen 23s rrna pt mut,0484U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,31.58,61.41,APC
Nfct ds mgen 23s rrna pt mut,0484U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,36.49,,,,,,,fee schedule,31.58,61.41,APC
Nfct ds mgen 23s rrna pt mut,0484U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,35.09,,,,,,,fee schedule,31.58,61.41,APC
Nfct ds mgen 23s rrna pt mut,0484U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,53.69,,,,,,,fee schedule,31.58,61.41,Radiology
Nfct ds mgen 23s rrna pt mut,0484U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49.13,,,,,,,fee schedule,31.58,61.41,APC
Nfct ds mgen 23s rrna pt mut,0484U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,61.41,,,,,,,fee schedule,31.58,61.41,APC
Oct mid ear i&r unilateral,0485T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,121.41,,,,,,,fee schedule,36.98,164.05,
Oct mid ear i&r unilateral,0485T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,97.32,,,,,,,fee schedule,36.98,164.05,
Oct mid ear i&r unilateral,0485T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,106.32,,,,,,,fee schedule,36.98,164.05,
Oct mid ear i&r unilateral,0485T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,111.78,,,,,,,fee schedule,36.98,164.05,
Oct mid ear i&r unilateral,0485T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.05,,,,,,,fee schedule,36.98,164.05,APC 378
Oct mid ear i&r unilateral,0485T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.83,,,,,,,fee schedule,36.98,164.05,APC
Oct mid ear i&r unilateral,0485T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.46,,,,,,,fee schedule,36.98,164.05,APC
Oct mid ear i&r unilateral,0485T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.98,,,,,,,fee schedule,36.98,164.05,APC
Oct mid ear i&r unilateral,0485T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.57,,,,,,,fee schedule,36.98,164.05,Radiology
Oct mid ear i&r unilateral,0485T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.77,,,,,,,fee schedule,36.98,164.05,APC
Oct mid ear i&r unilateral,0485T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.71,,,,,,,fee schedule,36.98,164.05,APC
Onc sol tum cfdna&rna ngs gm,0485U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3284.53,,,,,,,fee schedule,3284.53,6386.59,Laboratory
Onc sol tum cfdna&rna ngs gm,0485U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3831.95,,,,,,,fee schedule,3284.53,6386.59,APC
Onc sol tum cfdna&rna ngs gm,0485U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3795.46,,,,,,,fee schedule,3284.53,6386.59,APC
Onc sol tum cfdna&rna ngs gm,0485U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3649.48,,,,,,,fee schedule,3284.53,6386.59,APC
Onc sol tum cfdna&rna ngs gm,0485U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5583.7,,,,,,,fee schedule,3284.53,6386.59,Radiology
Onc sol tum cfdna&rna ngs gm,0485U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5109.27,,,,,,,fee schedule,3284.53,6386.59,APC
Onc sol tum cfdna&rna ngs gm,0485U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6386.59,,,,,,,fee schedule,3284.53,6386.59,APC
Oct mid ear i&r bilateral,0486T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,121.41,,,,,,,fee schedule,36.98,164.05,
Oct mid ear i&r bilateral,0486T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,97.32,,,,,,,fee schedule,36.98,164.05,
Oct mid ear i&r bilateral,0486T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,106.32,,,,,,,fee schedule,36.98,164.05,
Oct mid ear i&r bilateral,0486T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,111.78,,,,,,,fee schedule,36.98,164.05,
Oct mid ear i&r bilateral,0486T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.05,,,,,,,fee schedule,36.98,164.05,APC 378
Oct mid ear i&r bilateral,0486T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.83,,,,,,,fee schedule,36.98,164.05,APC
Oct mid ear i&r bilateral,0486T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.46,,,,,,,fee schedule,36.98,164.05,APC
Oct mid ear i&r bilateral,0486T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.98,,,,,,,fee schedule,36.98,164.05,APC
Oct mid ear i&r bilateral,0486T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.57,,,,,,,fee schedule,36.98,164.05,Radiology
Oct mid ear i&r bilateral,0486T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.77,,,,,,,fee schedule,36.98,164.05,APC
Oct mid ear i&r bilateral,0486T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.71,,,,,,,fee schedule,36.98,164.05,APC
Onc pan sol tum ngs cfctdna,0486U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1479.82,,,,,,,fee schedule,1479.82,2877.44,Laboratory
Onc pan sol tum ngs cfctdna,0486U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1726.46,,,,,,,fee schedule,1479.82,2877.44,APC
Onc pan sol tum ngs cfctdna,0486U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1710.02,,,,,,,fee schedule,1479.82,2877.44,APC
Onc pan sol tum ngs cfctdna,0486U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1644.25,,,,,,,fee schedule,1479.82,2877.44,APC
Onc pan sol tum ngs cfctdna,0486U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2515.7,,,,,,,fee schedule,1479.82,2877.44,Radiology
Onc pan sol tum ngs cfctdna,0486U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2301.95,,,,,,,fee schedule,1479.82,2877.44,APC
Onc pan sol tum ngs cfctdna,0486U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2877.44,,,,,,,fee schedule,1479.82,2877.44,APC
Onc sol tum cfcdna tgsap 84,0487U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2627.64,,,,,,,fee schedule,2627.64,5109.3,Laboratory
Onc sol tum cfcdna tgsap 84,0487U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3065.58,,,,,,,fee schedule,2627.64,5109.3,APC
Onc sol tum cfcdna tgsap 84,0487U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3036.38,,,,,,,fee schedule,2627.64,5109.3,APC
Onc sol tum cfcdna tgsap 84,0487U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2919.6,,,,,,,fee schedule,2627.64,5109.3,APC
Onc sol tum cfcdna tgsap 84,0487U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4466.99,,,,,,,fee schedule,2627.64,5109.3,Radiology
Onc sol tum cfcdna tgsap 84,0487U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4087.44,,,,,,,fee schedule,2627.64,5109.3,APC
Onc sol tum cfcdna tgsap 84,0487U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5109.3,,,,,,,fee schedule,2627.64,5109.3,APC
Onc cutan/uveal mlnma cd146,0490U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2191.5,,,,,,,fee schedule,2191.5,4261.25,Laboratory
Onc cutan/uveal mlnma cd146,0490U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2556.75,,,,,,,fee schedule,2191.5,4261.25,APC
Onc cutan/uveal mlnma cd146,0490U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2532.4,,,,,,,fee schedule,2191.5,4261.25,APC
Onc cutan/uveal mlnma cd146,0490U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2435,,,,,,,fee schedule,2191.5,4261.25,APC
Onc cutan/uveal mlnma cd146,0490U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3725.55,,,,,,,fee schedule,2191.5,4261.25,Radiology
Onc cutan/uveal mlnma cd146,0490U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3409,,,,,,,fee schedule,2191.5,4261.25,APC
Onc cutan/uveal mlnma cd146,0490U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4261.25,,,,,,,fee schedule,2191.5,4261.25,APC
Onc sol tum ctc slct er prtn,0491U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2191.5,,,,,,,fee schedule,2191.5,4261.25,Laboratory
Onc sol tum ctc slct er prtn,0491U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2556.75,,,,,,,fee schedule,2191.5,4261.25,APC
Onc sol tum ctc slct er prtn,0491U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2532.4,,,,,,,fee schedule,2191.5,4261.25,APC
Onc sol tum ctc slct er prtn,0491U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2435,,,,,,,fee schedule,2191.5,4261.25,APC
Onc sol tum ctc slct er prtn,0491U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3725.55,,,,,,,fee schedule,2191.5,4261.25,Radiology
Onc sol tum ctc slct er prtn,0491U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3409,,,,,,,fee schedule,2191.5,4261.25,APC
Onc sol tum ctc slct er prtn,0491U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4261.25,,,,,,,fee schedule,2191.5,4261.25,APC
Onc sol tum ctc slctn pd-l1,0492U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2191.5,,,,,,,fee schedule,2191.5,4261.25,Laboratory
Onc sol tum ctc slctn pd-l1,0492U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2556.75,,,,,,,fee schedule,2191.5,4261.25,APC
Onc sol tum ctc slctn pd-l1,0492U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2532.4,,,,,,,fee schedule,2191.5,4261.25,APC
Onc sol tum ctc slctn pd-l1,0492U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2435,,,,,,,fee schedule,2191.5,4261.25,APC
Onc sol tum ctc slctn pd-l1,0492U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3725.55,,,,,,,fee schedule,2191.5,4261.25,Radiology
Onc sol tum ctc slctn pd-l1,0492U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3409,,,,,,,fee schedule,2191.5,4261.25,APC
Onc sol tum ctc slctn pd-l1,0492U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4261.25,,,,,,,fee schedule,2191.5,4261.25,APC
Trnspl med quan dd-cfdna ngs,0493U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2477.93,,,,,,,fee schedule,2477.93,4818.19,Laboratory
Trnspl med quan dd-cfdna ngs,0493U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2890.91,,,,,,,fee schedule,2477.93,4818.19,APC
Trnspl med quan dd-cfdna ngs,0493U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2863.38,,,,,,,fee schedule,2477.93,4818.19,APC
Trnspl med quan dd-cfdna ngs,0493U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2753.25,,,,,,,fee schedule,2477.93,4818.19,APC
Trnspl med quan dd-cfdna ngs,0493U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4212.47,,,,,,,fee schedule,2477.93,4818.19,Radiology
Trnspl med quan dd-cfdna ngs,0493U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3854.55,,,,,,,fee schedule,2477.93,4818.19,APC
Trnspl med quan dd-cfdna ngs,0493U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4818.19,,,,,,,fee schedule,2477.93,4818.19,APC
Rbc ag ftl rhd gene alys ngs,0494U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,683.14,,,,,,,fee schedule,683.14,1328.34,Laboratory
Rbc ag ftl rhd gene alys ngs,0494U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,797,,,,,,,fee schedule,683.14,1328.34,APC
Rbc ag ftl rhd gene alys ngs,0494U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,789.41,,,,,,,fee schedule,683.14,1328.34,APC
Rbc ag ftl rhd gene alys ngs,0494U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,759.05,,,,,,,fee schedule,683.14,1328.34,APC
Rbc ag ftl rhd gene alys ngs,0494U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1161.35,,,,,,,fee schedule,683.14,1328.34,Radiology
Rbc ag ftl rhd gene alys ngs,0494U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1062.67,,,,,,,fee schedule,683.14,1328.34,APC
Rbc ag ftl rhd gene alys ngs,0494U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1328.34,,,,,,,fee schedule,683.14,1328.34,APC
Onc prst8 alys crcg plsm prt,0495U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,684,,,,,,,fee schedule,684,1330,Laboratory
Onc prst8 alys crcg plsm prt,0495U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,798,,,,,,,fee schedule,684,1330,APC
Onc prst8 alys crcg plsm prt,0495U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,790.4,,,,,,,fee schedule,684,1330,APC
Onc prst8 alys crcg plsm prt,0495U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,760,,,,,,,fee schedule,684,1330,APC
Onc prst8 alys crcg plsm prt,0495U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1162.8,,,,,,,fee schedule,684,1330,Radiology
Onc prst8 alys crcg plsm prt,0495U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1064,,,,,,,fee schedule,684,1330,APC
Onc prst8 alys crcg plsm prt,0495U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1330,,,,,,,fee schedule,684,1330,APC
Onc clrct cfdna 8/7 genes,0496U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,437.27,,,,,,,fee schedule,437.27,850.26,Laboratory
Onc clrct cfdna 8/7 genes,0496U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,510.15,,,,,,,fee schedule,437.27,850.26,APC
Onc clrct cfdna 8/7 genes,0496U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,505.29,,,,,,,fee schedule,437.27,850.26,APC
Onc clrct cfdna 8/7 genes,0496U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,485.86,,,,,,,fee schedule,437.27,850.26,APC
Onc clrct cfdna 8/7 genes,0496U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,743.37,,,,,,,fee schedule,437.27,850.26,Radiology
Onc clrct cfdna 8/7 genes,0496U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,680.2,,,,,,,fee schedule,437.27,850.26,APC
Onc clrct cfdna 8/7 genes,0496U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,850.26,,,,,,,fee schedule,437.27,850.26,APC
Onc prst8 mrna rt-pcr 6 gene,0497U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3485.7,,,,,,,fee schedule,3485.7,6777.75,Laboratory
Onc prst8 mrna rt-pcr 6 gene,0497U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4066.65,,,,,,,fee schedule,3485.7,6777.75,APC
Onc prst8 mrna rt-pcr 6 gene,0497U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4027.92,,,,,,,fee schedule,3485.7,6777.75,APC
Onc prst8 mrna rt-pcr 6 gene,0497U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3873,,,,,,,fee schedule,3485.7,6777.75,APC
Onc prst8 mrna rt-pcr 6 gene,0497U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5925.69,,,,,,,fee schedule,3485.7,6777.75,Radiology
Onc prst8 mrna rt-pcr 6 gene,0497U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5422.2,,,,,,,fee schedule,3485.7,6777.75,APC
Onc prst8 mrna rt-pcr 6 gene,0497U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6777.75,,,,,,,fee schedule,3485.7,6777.75,APC
Onc clrct ngs mut detc 43gen,0498U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1210.78,,,,,,,fee schedule,1210.78,2354.29,Laboratory
Onc clrct ngs mut detc 43gen,0498U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1412.58,,,,,,,fee schedule,1210.78,2354.29,APC
Onc clrct ngs mut detc 43gen,0498U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1399.12,,,,,,,fee schedule,1210.78,2354.29,APC
Onc clrct ngs mut detc 43gen,0498U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1345.31,,,,,,,fee schedule,1210.78,2354.29,APC
Onc clrct ngs mut detc 43gen,0498U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2058.32,,,,,,,fee schedule,1210.78,2354.29,Radiology
Onc clrct ngs mut detc 43gen,0498U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1883.43,,,,,,,fee schedule,1210.78,2354.29,APC
Onc clrct ngs mut detc 43gen,0498U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2354.29,,,,,,,fee schedule,1210.78,2354.29,APC
Cysto f/urtl strix/stenosis,0499T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6576.26,,,,,,,fee schedule,5271.44,6576.26,
Cysto f/urtl strix/stenosis,0499T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5271.44,,,,,,,fee schedule,5271.44,6576.26,
Cysto f/urtl strix/stenosis,0499T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5758.57,,,,,,,fee schedule,5271.44,6576.26,
Cysto f/urtl strix/stenosis,0499T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6054.33,,,,,,,fee schedule,5271.44,6576.26,
Onc clrct&lng dna ngs 8gene,0499U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,538.12,,,,,,,fee schedule,538.12,1046.34,Laboratory
Onc clrct&lng dna ngs 8gene,0499U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,627.81,,,,,,,fee schedule,538.12,1046.34,APC
Onc clrct&lng dna ngs 8gene,0499U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,621.83,,,,,,,fee schedule,538.12,1046.34,APC
Onc clrct&lng dna ngs 8gene,0499U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,597.91,,,,,,,fee schedule,538.12,1046.34,APC
Onc clrct&lng dna ngs 8gene,0499U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,914.8,,,,,,,fee schedule,538.12,1046.34,Radiology
Onc clrct&lng dna ngs 8gene,0499U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,837.07,,,,,,,fee schedule,538.12,1046.34,APC
Onc clrct&lng dna ngs 8gene,0499U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1046.34,,,,,,,fee schedule,538.12,1046.34,APC
Autoinflam ds vexas synd dna,0500U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,157.86,,,,,,,fee schedule,157.86,306.95,Laboratory
Autoinflam ds vexas synd dna,0500U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,184.17,,,,,,,fee schedule,157.86,306.95,APC
Autoinflam ds vexas synd dna,0500U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,182.42,,,,,,,fee schedule,157.86,306.95,APC
Autoinflam ds vexas synd dna,0500U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,175.4,,,,,,,fee schedule,157.86,306.95,APC
Autoinflam ds vexas synd dna,0500U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,268.36,,,,,,,fee schedule,157.86,306.95,Radiology
Autoinflam ds vexas synd dna,0500U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,245.56,,,,,,,fee schedule,157.86,306.95,APC
Autoinflam ds vexas synd dna,0500U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,306.95,,,,,,,fee schedule,157.86,306.95,APC
Cor ffr derived cor cta data,0501T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,296.31,,,,,,,fee schedule,237.52,296.31,
Cor ffr derived cor cta data,0501T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,237.52,,,,,,,fee schedule,237.52,296.31,
Cor ffr derived cor cta data,0501T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,259.47,,,,,,,fee schedule,237.52,296.31,
Cor ffr derived cor cta data,0501T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,272.8,,,,,,,fee schedule,237.52,296.31,
Cor ffr data prep & transmis,0502T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,183.67,,,,,,,fee schedule,147.23,183.67,
Cor ffr data prep & transmis,0502T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,147.23,,,,,,,fee schedule,147.23,183.67,
Cor ffr data prep & transmis,0502T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,160.83,,,,,,,fee schedule,147.23,183.67,
Cor ffr data prep & transmis,0502T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,169.09,,,,,,,fee schedule,147.23,183.67,
Hpv e6/e7 mrk hi-rsk typ crv,0502U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31.58,,,,,,,fee schedule,31.58,61.41,Laboratory
Hpv e6/e7 mrk hi-rsk typ crv,0502U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,31.58,61.41,APC
Hpv e6/e7 mrk hi-rsk typ crv,0502U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,36.49,,,,,,,fee schedule,31.58,61.41,APC
Hpv e6/e7 mrk hi-rsk typ crv,0502U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,35.09,,,,,,,fee schedule,31.58,61.41,APC
Hpv e6/e7 mrk hi-rsk typ crv,0502U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,53.69,,,,,,,fee schedule,31.58,61.41,Radiology
Hpv e6/e7 mrk hi-rsk typ crv,0502U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49.13,,,,,,,fee schedule,31.58,61.41,APC
Hpv e6/e7 mrk hi-rsk typ crv,0502U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,61.41,,,,,,,fee schedule,31.58,61.41,APC
Cor ffr alys gnrj ffr mdl,0503T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5482.89,,,,,,,fee schedule,4395.02,5482.89,
Cor ffr alys gnrj ffr mdl,0503T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4395.02,,,,,,,fee schedule,4395.02,5482.89,
Cor ffr alys gnrj ffr mdl,0503T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4801.16,,,,,,,fee schedule,4395.02,5482.89,
Cor ffr alys gnrj ffr mdl,0503T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5047.74,,,,,,,fee schedule,4395.02,5482.89,
Neuro alz ds ?amyl&tau prtn,0503U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,675,,,,,,,fee schedule,675,1312.5,Laboratory
Neuro alz ds ?amyl&tau prtn,0503U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,787.5,,,,,,,fee schedule,675,1312.5,APC
Neuro alz ds ?amyl&tau prtn,0503U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,780,,,,,,,fee schedule,675,1312.5,APC
Neuro alz ds ?amyl&tau prtn,0503U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,750,,,,,,,fee schedule,675,1312.5,APC
Neuro alz ds ?amyl&tau prtn,0503U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1147.5,,,,,,,fee schedule,675,1312.5,Radiology
Neuro alz ds ?amyl&tau prtn,0503U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1050,,,,,,,fee schedule,675,1312.5,APC
Neuro alz ds ?amyl&tau prtn,0503U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1312.5,,,,,,,fee schedule,675,1312.5,APC
Cor ffr data review i&r,0504T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,198.87,,,,,,,fee schedule,159.41,198.87,
Cor ffr data review i&r,0504T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,159.41,,,,,,,fee schedule,159.41,198.87,
Cor ffr data review i&r,0504T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,174.14,,,,,,,fee schedule,159.41,198.87,
Cor ffr data review i&r,0504T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,183.08,,,,,,,fee schedule,159.41,198.87,
Nfct ds uti id 17 path orgs,0504U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,375.1,,,,,,,fee schedule,375.1,729.36,Laboratory
Nfct ds uti id 17 path orgs,0504U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,437.62,,,,,,,fee schedule,375.1,729.36,APC
Nfct ds uti id 17 path orgs,0504U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,433.45,,,,,,,fee schedule,375.1,729.36,APC
Nfct ds uti id 17 path orgs,0504U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,416.78,,,,,,,fee schedule,375.1,729.36,APC
Nfct ds uti id 17 path orgs,0504U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,637.67,,,,,,,fee schedule,375.1,729.36,Radiology
Nfct ds uti id 17 path orgs,0504U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,583.49,,,,,,,fee schedule,375.1,729.36,APC
Nfct ds uti id 17 path orgs,0504U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,729.36,,,,,,,fee schedule,375.1,729.36,APC
Ev fempop artl revsc,0505T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,36548.97,,,,,,,fee schedule,11428.37,50703.82,
Ev fempop artl revsc,0505T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29297.19,,,,,,,fee schedule,11428.37,50703.82,
Ev fempop artl revsc,0505T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32004.52,,,,,,,fee schedule,11428.37,50703.82,
Ev fempop artl revsc,0505T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33648.26,,,,,,,fee schedule,11428.37,50703.82,
Ev fempop artl revsc,0505T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,50703.82,,,,,,,fee schedule,11428.37,50703.82,APC 378
Ev fempop artl revsc,0505T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11999.79,,,,,,,fee schedule,11428.37,50703.82,APC
Ev fempop artl revsc,0505T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11885.51,,,,,,,fee schedule,11428.37,50703.82,APC
Ev fempop artl revsc,0505T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11428.37,,,,,,,fee schedule,11428.37,50703.82,APC
Ev fempop artl revsc,0505T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17485.41,,,,,,,fee schedule,11428.37,50703.82,Radiology
Ev fempop artl revsc,0505T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15999.72,,,,,,,fee schedule,11428.37,50703.82,APC
Ev fempop artl revsc,0505T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19999.65,,,,,,,fee schedule,11428.37,50703.82,APC
Nfct ds vag infctj id 32orgs,0505U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,611.79,,,,,,,fee schedule,611.79,1189.6,Laboratory
Nfct ds vag infctj id 32orgs,0505U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,713.76,,,,,,,fee schedule,611.79,1189.6,APC
Nfct ds vag infctj id 32orgs,0505U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,706.96,,,,,,,fee schedule,611.79,1189.6,APC
Nfct ds vag infctj id 32orgs,0505U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,679.77,,,,,,,fee schedule,611.79,1189.6,APC
Nfct ds vag infctj id 32orgs,0505U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1040.05,,,,,,,fee schedule,611.79,1189.6,Radiology
Nfct ds vag infctj id 32orgs,0505U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,951.68,,,,,,,fee schedule,611.79,1189.6,APC
Nfct ds vag infctj id 32orgs,0505U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1189.6,,,,,,,fee schedule,611.79,1189.6,APC
Mac pgmt opt dns meas hfp,0506T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,211.3,,,,,,,fee schedule,58.4,259.1,
Mac pgmt opt dns meas hfp,0506T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,169.38,,,,,,,fee schedule,58.4,259.1,
Mac pgmt opt dns meas hfp,0506T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,185.03,,,,,,,fee schedule,58.4,259.1,
Mac pgmt opt dns meas hfp,0506T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,194.53,,,,,,,fee schedule,58.4,259.1,
Mac pgmt opt dns meas hfp,0506T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,58.4,259.1,APC 378
Mac pgmt opt dns meas hfp,0506T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,58.4,259.1,APC
Mac pgmt opt dns meas hfp,0506T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,58.4,259.1,APC
Mac pgmt opt dns meas hfp,0506T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,58.4,259.1,APC
Mac pgmt opt dns meas hfp,0506T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,58.4,259.1,Radiology
Mac pgmt opt dns meas hfp,0506T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,58.4,259.1,APC
Mac pgmt opt dns meas hfp,0506T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,58.4,259.1,APC
Gi barretts esophgl cell 89,0506U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1744.21,,,,,,,fee schedule,1744.21,3391.52,Laboratory
Gi barretts esophgl cell 89,0506U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2034.91,,,,,,,fee schedule,1744.21,3391.52,APC
Gi barretts esophgl cell 89,0506U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2015.53,,,,,,,fee schedule,1744.21,3391.52,APC
Gi barretts esophgl cell 89,0506U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1938.01,,,,,,,fee schedule,1744.21,3391.52,APC
Gi barretts esophgl cell 89,0506U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2965.16,,,,,,,fee schedule,1744.21,3391.52,Radiology
Gi barretts esophgl cell 89,0506U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2713.21,,,,,,,fee schedule,1744.21,3391.52,APC
Gi barretts esophgl cell 89,0506U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3391.52,,,,,,,fee schedule,1744.21,3391.52,APC
Near ifr 2img mibmn glnd i&r,0507T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,211.3,,,,,,,fee schedule,58.4,259.1,
Near ifr 2img mibmn glnd i&r,0507T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,169.38,,,,,,,fee schedule,58.4,259.1,
Near ifr 2img mibmn glnd i&r,0507T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,185.03,,,,,,,fee schedule,58.4,259.1,
Near ifr 2img mibmn glnd i&r,0507T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,194.53,,,,,,,fee schedule,58.4,259.1,
Near ifr 2img mibmn glnd i&r,0507T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,58.4,259.1,APC 378
Near ifr 2img mibmn glnd i&r,0507T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,58.4,259.1,APC
Near ifr 2img mibmn glnd i&r,0507T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,58.4,259.1,APC
Near ifr 2img mibmn glnd i&r,0507T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,58.4,259.1,APC
Near ifr 2img mibmn glnd i&r,0507T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,58.4,259.1,Radiology
Near ifr 2img mibmn glnd i&r,0507T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,58.4,259.1,APC
Near ifr 2img mibmn glnd i&r,0507T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,58.4,259.1,APC
Onc ovr dna whole gen w/5hmc,0507U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1044,,,,,,,fee schedule,1044,2030,Laboratory
Onc ovr dna whole gen w/5hmc,0507U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1218,,,,,,,fee schedule,1044,2030,APC
Onc ovr dna whole gen w/5hmc,0507U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1206.4,,,,,,,fee schedule,1044,2030,APC
Onc ovr dna whole gen w/5hmc,0507U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1160,,,,,,,fee schedule,1044,2030,APC
Onc ovr dna whole gen w/5hmc,0507U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1774.8,,,,,,,fee schedule,1044,2030,Radiology
Onc ovr dna whole gen w/5hmc,0507U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1624,,,,,,,fee schedule,1044,2030,APC
Onc ovr dna whole gen w/5hmc,0507U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2030,,,,,,,fee schedule,1044,2030,APC
Pls echo us b1 dns meas tib,0508T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,425.29,,,,,,,fee schedule,340.91,425.29,
Pls echo us b1 dns meas tib,0508T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,340.91,,,,,,,fee schedule,340.91,425.29,
Pls echo us b1 dns meas tib,0508T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,372.41,,,,,,,fee schedule,340.91,425.29,
Pls echo us b1 dns meas tib,0508T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,391.53,,,,,,,fee schedule,340.91,425.29,
Pattern erg w/i&r,0509T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,513.89,,,,,,,fee schedule,213.76,948.37,
Pattern erg w/i&r,0509T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,411.93,,,,,,,fee schedule,213.76,948.37,
Pattern erg w/i&r,0509T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,449.99,,,,,,,fee schedule,213.76,948.37,
Pattern erg w/i&r,0509T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,473.11,,,,,,,fee schedule,213.76,948.37,
Pattern erg w/i&r,0509T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,213.76,948.37,APC 378
Pattern erg w/i&r,0509T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,213.76,948.37,APC
Pattern erg w/i&r,0509T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,213.76,948.37,APC
Pattern erg w/i&r,0509T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,213.76,948.37,APC
Pattern erg w/i&r,0509T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,213.76,948.37,Radiology
Pattern erg w/i&r,0509T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,213.76,948.37,APC
Pattern erg w/i&r,0509T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,213.76,948.37,APC
Rmvl sinus tarsi implant,0510T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9916.23,,,,,,,fee schedule,3239.17,14371.12,
Rmvl sinus tarsi implant,0510T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7948.72,,,,,,,fee schedule,3239.17,14371.12,
Rmvl sinus tarsi implant,0510T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8683.26,,,,,,,fee schedule,3239.17,14371.12,
Rmvl sinus tarsi implant,0510T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9129.22,,,,,,,fee schedule,3239.17,14371.12,
Rmvl sinus tarsi implant,0510T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Rmvl sinus tarsi implant,0510T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Rmvl sinus tarsi implant,0510T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Rmvl sinus tarsi implant,0510T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Rmvl sinus tarsi implant,0510T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Rmvl sinus tarsi implant,0510T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Rmvl sinus tarsi implant,0510T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Onc pncrtc ca alg alys 16gen,0510U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,426.52,,,,,,,fee schedule,426.52,829.34,Laboratory
Onc pncrtc ca alg alys 16gen,0510U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,497.61,,,,,,,fee schedule,426.52,829.34,APC
Onc pncrtc ca alg alys 16gen,0510U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,492.87,,,,,,,fee schedule,426.52,829.34,APC
Onc pncrtc ca alg alys 16gen,0510U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,473.91,,,,,,,fee schedule,426.52,829.34,APC
Onc pncrtc ca alg alys 16gen,0510U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,725.08,,,,,,,fee schedule,426.52,829.34,Radiology
Onc pncrtc ca alg alys 16gen,0510U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,663.47,,,,,,,fee schedule,426.52,829.34,APC
Onc pncrtc ca alg alys 16gen,0510U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,829.34,,,,,,,fee schedule,426.52,829.34,APC
Rmvl&rinsj sinus tarsi implt,0511T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21544.45,,,,,,,fee schedule,7183.42,31870.39,
Rmvl&rinsj sinus tarsi implt,0511T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17269.76,,,,,,,fee schedule,7183.42,31870.39,
Rmvl&rinsj sinus tarsi implt,0511T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18865.64,,,,,,,fee schedule,7183.42,31870.39,
Rmvl&rinsj sinus tarsi implt,0511T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19834.57,,,,,,,fee schedule,7183.42,31870.39,
Rmvl&rinsj sinus tarsi implt,0511T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Rmvl&rinsj sinus tarsi implt,0511T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Rmvl&rinsj sinus tarsi implt,0511T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Rmvl&rinsj sinus tarsi implt,0511T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Rmvl&rinsj sinus tarsi implt,0511T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Rmvl&rinsj sinus tarsi implt,0511T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Rmvl&rinsj sinus tarsi implt,0511T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Onc sol tum 3dmicroenvir 36+,0511U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2730.47,,,,,,,fee schedule,2730.47,5309.26,Laboratory
Onc sol tum 3dmicroenvir 36+,0511U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3185.55,,,,,,,fee schedule,2730.47,5309.26,APC
Onc sol tum 3dmicroenvir 36+,0511U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3155.21,,,,,,,fee schedule,2730.47,5309.26,APC
Onc sol tum 3dmicroenvir 36+,0511U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3033.86,,,,,,,fee schedule,2730.47,5309.26,APC
Onc sol tum 3dmicroenvir 36+,0511U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4641.81,,,,,,,fee schedule,2730.47,5309.26,Radiology
Onc sol tum 3dmicroenvir 36+,0511U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4247.4,,,,,,,fee schedule,2730.47,5309.26,APC
Onc sol tum 3dmicroenvir 36+,0511U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5309.26,,,,,,,fee schedule,2730.47,5309.26,APC
Esw integ wnd hlg 1st wnd,0512T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1187.22,,,,,,,fee schedule,198.62,1187.22,
Esw integ wnd hlg 1st wnd,0512T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,951.66,,,,,,,fee schedule,198.62,1187.22,
Esw integ wnd hlg 1st wnd,0512T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1039.6,,,,,,,fee schedule,198.62,1187.22,
Esw integ wnd hlg 1st wnd,0512T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1093,,,,,,,fee schedule,198.62,1187.22,
Esw integ wnd hlg 1st wnd,0512T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,881.22,,,,,,,fee schedule,198.62,1187.22,APC 378
Esw integ wnd hlg 1st wnd,0512T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.55,,,,,,,fee schedule,198.62,1187.22,APC
Esw integ wnd hlg 1st wnd,0512T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,206.57,,,,,,,fee schedule,198.62,1187.22,APC
Esw integ wnd hlg 1st wnd,0512T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.62,,,,,,,fee schedule,198.62,1187.22,APC
Esw integ wnd hlg 1st wnd,0512T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.89,,,,,,,fee schedule,198.62,1187.22,Radiology
Esw integ wnd hlg 1st wnd,0512T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,278.07,,,,,,,fee schedule,198.62,1187.22,APC
Esw integ wnd hlg 1st wnd,0512T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,347.59,,,,,,,fee schedule,198.62,1187.22,APC
Onc prst8 alys dgtz img msi,0512U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,635.62,,,,,,,fee schedule,635.62,1235.94,Laboratory
Onc prst8 alys dgtz img msi,0512U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,741.56,,,,,,,fee schedule,635.62,1235.94,APC
Onc prst8 alys dgtz img msi,0512U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,734.5,,,,,,,fee schedule,635.62,1235.94,APC
Onc prst8 alys dgtz img msi,0512U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,706.25,,,,,,,fee schedule,635.62,1235.94,APC
Onc prst8 alys dgtz img msi,0512U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1080.56,,,,,,,fee schedule,635.62,1235.94,Radiology
Onc prst8 alys dgtz img msi,0512U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,988.75,,,,,,,fee schedule,635.62,1235.94,APC
Onc prst8 alys dgtz img msi,0512U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1235.94,,,,,,,fee schedule,635.62,1235.94,APC
Onc prst8 alg alys msi&hrd,0513U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,635.62,,,,,,,fee schedule,635.62,1235.94,Laboratory
Onc prst8 alg alys msi&hrd,0513U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,741.56,,,,,,,fee schedule,635.62,1235.94,APC
Onc prst8 alg alys msi&hrd,0513U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,734.5,,,,,,,fee schedule,635.62,1235.94,APC
Onc prst8 alg alys msi&hrd,0513U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,706.25,,,,,,,fee schedule,635.62,1235.94,APC
Onc prst8 alg alys msi&hrd,0513U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1080.56,,,,,,,fee schedule,635.62,1235.94,Radiology
Onc prst8 alg alys msi&hrd,0513U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,988.75,,,,,,,fee schedule,635.62,1235.94,APC
Onc prst8 alg alys msi&hrd,0513U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1235.94,,,,,,,fee schedule,635.62,1235.94,APC
Gi ibd ia quan deter adl lvl,0514U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,34.71,,,,,,,fee schedule,34.71,67.5,Laboratory
Gi ibd ia quan deter adl lvl,0514U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,40.5,,,,,,,fee schedule,34.71,67.5,APC
Gi ibd ia quan deter adl lvl,0514U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,40.11,,,,,,,fee schedule,34.71,67.5,APC
Gi ibd ia quan deter adl lvl,0514U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,38.57,,,,,,,fee schedule,34.71,67.5,APC
Gi ibd ia quan deter adl lvl,0514U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,59.01,,,,,,,fee schedule,34.71,67.5,Radiology
Gi ibd ia quan deter adl lvl,0514U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,54,,,,,,,fee schedule,34.71,67.5,APC
Gi ibd ia quan deter adl lvl,0514U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,67.5,,,,,,,fee schedule,34.71,67.5,APC
Insj wcs lv compl sys,0515T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83146.62,,,,,,,fee schedule,22020.42,97697.15,
Insj wcs lv compl sys,0515T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66649.27,,,,,,,fee schedule,22020.42,97697.15,
Insj wcs lv compl sys,0515T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,72808.28,,,,,,,fee schedule,22020.42,97697.15,
Insj wcs lv compl sys,0515T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,76547.68,,,,,,,fee schedule,22020.42,97697.15,
Insj wcs lv compl sys,0515T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,97697.15,,,,,,,fee schedule,22020.42,97697.15,APC 378
Insj wcs lv compl sys,0515T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,23121.44,,,,,,,fee schedule,22020.42,97697.15,APC
Insj wcs lv compl sys,0515T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,22901.24,,,,,,,fee schedule,22020.42,97697.15,APC
Insj wcs lv compl sys,0515T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,22020.42,,,,,,,fee schedule,22020.42,97697.15,APC
Insj wcs lv compl sys,0515T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,33691.24,,,,,,,fee schedule,22020.42,97697.15,Radiology
Insj wcs lv compl sys,0515T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,30828.59,,,,,,,fee schedule,22020.42,97697.15,APC
Insj wcs lv compl sys,0515T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,38535.73,,,,,,,fee schedule,22020.42,97697.15,APC
Gi ibd ia quan deter ifx lvl,0515U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,34.71,,,,,,,fee schedule,34.71,67.5,Laboratory
Gi ibd ia quan deter ifx lvl,0515U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,40.5,,,,,,,fee schedule,34.71,67.5,APC
Gi ibd ia quan deter ifx lvl,0515U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,40.11,,,,,,,fee schedule,34.71,67.5,APC
Gi ibd ia quan deter ifx lvl,0515U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,38.57,,,,,,,fee schedule,34.71,67.5,APC
Gi ibd ia quan deter ifx lvl,0515U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,59.01,,,,,,,fee schedule,34.71,67.5,Radiology
Gi ibd ia quan deter ifx lvl,0515U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,54,,,,,,,fee schedule,34.71,67.5,APC
Gi ibd ia quan deter ifx lvl,0515U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,67.5,,,,,,,fee schedule,34.71,67.5,APC
Insj wcs lv eltrd only,0516T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27987.54,,,,,,,fee schedule,10347.14,45906.74,
Insj wcs lv eltrd only,0516T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22434.45,,,,,,,fee schedule,10347.14,45906.74,
Insj wcs lv eltrd only,0516T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24507.6,,,,,,,fee schedule,10347.14,45906.74,
Insj wcs lv eltrd only,0516T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,25766.3,,,,,,,fee schedule,10347.14,45906.74,
Insj wcs lv eltrd only,0516T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,45906.74,,,,,,,fee schedule,10347.14,45906.74,APC 378
Insj wcs lv eltrd only,0516T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10864.49,,,,,,,fee schedule,10347.14,45906.74,APC
Insj wcs lv eltrd only,0516T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10761.02,,,,,,,fee schedule,10347.14,45906.74,APC
Insj wcs lv eltrd only,0516T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10347.14,,,,,,,fee schedule,10347.14,45906.74,APC
Insj wcs lv eltrd only,0516T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15831.12,,,,,,,fee schedule,10347.14,45906.74,Radiology
Insj wcs lv eltrd only,0516T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14485.99,,,,,,,fee schedule,10347.14,45906.74,APC
Insj wcs lv eltrd only,0516T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18107.49,,,,,,,fee schedule,10347.14,45906.74,APC
Rx metab rxgenomic gnotyp 40,0516U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,375.1,,,,,,,fee schedule,375.1,729.36,Laboratory
Rx metab rxgenomic gnotyp 40,0516U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,437.62,,,,,,,fee schedule,375.1,729.36,APC
Rx metab rxgenomic gnotyp 40,0516U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,433.45,,,,,,,fee schedule,375.1,729.36,APC
Rx metab rxgenomic gnotyp 40,0516U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,416.78,,,,,,,fee schedule,375.1,729.36,APC
Rx metab rxgenomic gnotyp 40,0516U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,637.67,,,,,,,fee schedule,375.1,729.36,Radiology
Rx metab rxgenomic gnotyp 40,0516U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,583.49,,,,,,,fee schedule,375.1,729.36,APC
Rx metab rxgenomic gnotyp 40,0516U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,729.36,,,,,,,fee schedule,375.1,729.36,APC
Insj wcs lv pg compnt,0517T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27987.54,,,,,,,fee schedule,10347.14,45906.74,
Insj wcs lv pg compnt,0517T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22434.45,,,,,,,fee schedule,10347.14,45906.74,
Insj wcs lv pg compnt,0517T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24507.6,,,,,,,fee schedule,10347.14,45906.74,
Insj wcs lv pg compnt,0517T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,25766.3,,,,,,,fee schedule,10347.14,45906.74,
Insj wcs lv pg compnt,0517T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,45906.74,,,,,,,fee schedule,10347.14,45906.74,APC 378
Insj wcs lv pg compnt,0517T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10864.49,,,,,,,fee schedule,10347.14,45906.74,APC
Insj wcs lv pg compnt,0517T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10761.02,,,,,,,fee schedule,10347.14,45906.74,APC
Insj wcs lv pg compnt,0517T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10347.14,,,,,,,fee schedule,10347.14,45906.74,APC
Insj wcs lv pg compnt,0517T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15831.12,,,,,,,fee schedule,10347.14,45906.74,Radiology
Insj wcs lv pg compnt,0517T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14485.99,,,,,,,fee schedule,10347.14,45906.74,APC
Insj wcs lv pg compnt,0517T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18107.49,,,,,,,fee schedule,10347.14,45906.74,APC
Ther rx mntr 80+ psyactiv rx,0517U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,222.23,,,,,,,fee schedule,222.23,432.11,Laboratory
Ther rx mntr 80+ psyactiv rx,0517U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,259.27,,,,,,,fee schedule,222.23,432.11,APC
Ther rx mntr 80+ psyactiv rx,0517U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,256.8,,,,,,,fee schedule,222.23,432.11,APC
Ther rx mntr 80+ psyactiv rx,0517U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,246.92,,,,,,,fee schedule,222.23,432.11,APC
Ther rx mntr 80+ psyactiv rx,0517U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,377.79,,,,,,,fee schedule,222.23,432.11,Radiology
Ther rx mntr 80+ psyactiv rx,0517U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,345.69,,,,,,,fee schedule,222.23,432.11,APC
Ther rx mntr 80+ psyactiv rx,0517U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,432.11,,,,,,,fee schedule,222.23,432.11,APC
Rmvl pg compnt wcs,0518T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11833.4,,,,,,,fee schedule,3699.47,16413.29,
Rmvl pg compnt wcs,0518T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9485.51,,,,,,,fee schedule,3699.47,16413.29,
Rmvl pg compnt wcs,0518T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10362.05,,,,,,,fee schedule,3699.47,16413.29,
Rmvl pg compnt wcs,0518T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10894.24,,,,,,,fee schedule,3699.47,16413.29,
Rmvl pg compnt wcs,0518T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16413.29,,,,,,,fee schedule,3699.47,16413.29,APC 378
Rmvl pg compnt wcs,0518T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3884.44,,,,,,,fee schedule,3699.47,16413.29,APC
Rmvl pg compnt wcs,0518T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3847.45,,,,,,,fee schedule,3699.47,16413.29,APC
Rmvl pg compnt wcs,0518T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3699.47,,,,,,,fee schedule,3699.47,16413.29,APC
Rmvl pg compnt wcs,0518T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5660.19,,,,,,,fee schedule,3699.47,16413.29,Radiology
Rmvl pg compnt wcs,0518T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5179.26,,,,,,,fee schedule,3699.47,16413.29,APC
Rmvl pg compnt wcs,0518T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6474.07,,,,,,,fee schedule,3699.47,16413.29,APC
Ther rx mntr 90+ pn&mtl hlth,0518U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,222.23,,,,,,,fee schedule,222.23,432.11,Laboratory
Ther rx mntr 90+ pn&mtl hlth,0518U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,259.27,,,,,,,fee schedule,222.23,432.11,APC
Ther rx mntr 90+ pn&mtl hlth,0518U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,256.8,,,,,,,fee schedule,222.23,432.11,APC
Ther rx mntr 90+ pn&mtl hlth,0518U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,246.92,,,,,,,fee schedule,222.23,432.11,APC
Ther rx mntr 90+ pn&mtl hlth,0518U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,377.79,,,,,,,fee schedule,222.23,432.11,Radiology
Ther rx mntr 90+ pn&mtl hlth,0518U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,345.69,,,,,,,fee schedule,222.23,432.11,APC
Ther rx mntr 90+ pn&mtl hlth,0518U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,432.11,,,,,,,fee schedule,222.23,432.11,APC
Rmvl & rplcmt pg compnt wcs,0519T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11833.4,,,,,,,fee schedule,9485.51,45906.74,
Rmvl & rplcmt pg compnt wcs,0519T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9485.51,,,,,,,fee schedule,9485.51,45906.74,
Rmvl & rplcmt pg compnt wcs,0519T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10362.05,,,,,,,fee schedule,9485.51,45906.74,
Rmvl & rplcmt pg compnt wcs,0519T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10894.24,,,,,,,fee schedule,9485.51,45906.74,
Rmvl & rplcmt pg compnt wcs,0519T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,45906.74,,,,,,,fee schedule,9485.51,45906.74,APC 378
Rmvl & rplcmt pg compnt wcs,0519T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10864.49,,,,,,,fee schedule,9485.51,45906.74,APC
Rmvl & rplcmt pg compnt wcs,0519T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10761.02,,,,,,,fee schedule,9485.51,45906.74,APC
Rmvl & rplcmt pg compnt wcs,0519T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10347.14,,,,,,,fee schedule,9485.51,45906.74,APC
Rmvl & rplcmt pg compnt wcs,0519T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15831.12,,,,,,,fee schedule,9485.51,45906.74,Radiology
Rmvl & rplcmt pg compnt wcs,0519T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14485.99,,,,,,,fee schedule,9485.51,45906.74,APC
Rmvl & rplcmt pg compnt wcs,0519T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18107.49,,,,,,,fee schedule,9485.51,45906.74,APC
Ther rx mntr meds p/d/a 110+,0519U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,222.23,,,,,,,fee schedule,222.23,432.11,Laboratory
Ther rx mntr meds p/d/a 110+,0519U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,259.27,,,,,,,fee schedule,222.23,432.11,APC
Ther rx mntr meds p/d/a 110+,0519U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,256.8,,,,,,,fee schedule,222.23,432.11,APC
Ther rx mntr meds p/d/a 110+,0519U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,246.92,,,,,,,fee schedule,222.23,432.11,APC
Ther rx mntr meds p/d/a 110+,0519U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,377.79,,,,,,,fee schedule,222.23,432.11,Radiology
Ther rx mntr meds p/d/a 110+,0519U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,345.69,,,,,,,fee schedule,222.23,432.11,APC
Ther rx mntr meds p/d/a 110+,0519U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,432.11,,,,,,,fee schedule,222.23,432.11,APC
Rmvl&rplcmt pg wcs new eltrd,0520T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83146.62,,,,,,,fee schedule,10347.14,83146.62,
Rmvl&rplcmt pg wcs new eltrd,0520T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66649.27,,,,,,,fee schedule,10347.14,83146.62,
Rmvl&rplcmt pg wcs new eltrd,0520T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,72808.28,,,,,,,fee schedule,10347.14,83146.62,
Rmvl&rplcmt pg wcs new eltrd,0520T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,76547.68,,,,,,,fee schedule,10347.14,83146.62,
Rmvl&rplcmt pg wcs new eltrd,0520T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,45906.74,,,,,,,fee schedule,10347.14,83146.62,APC 378
Rmvl&rplcmt pg wcs new eltrd,0520T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10864.49,,,,,,,fee schedule,10347.14,83146.62,APC
Rmvl&rplcmt pg wcs new eltrd,0520T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10761.02,,,,,,,fee schedule,10347.14,83146.62,APC
Rmvl&rplcmt pg wcs new eltrd,0520T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10347.14,,,,,,,fee schedule,10347.14,83146.62,APC
Rmvl&rplcmt pg wcs new eltrd,0520T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15831.12,,,,,,,fee schedule,10347.14,83146.62,Radiology
Rmvl&rplcmt pg wcs new eltrd,0520T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14485.99,,,,,,,fee schedule,10347.14,83146.62,APC
Rmvl&rplcmt pg wcs new eltrd,0520T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18107.49,,,,,,,fee schedule,10347.14,83146.62,APC
Ther rx mntr 200+ rx/sbsts,0520U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,222.23,,,,,,,fee schedule,222.23,432.11,Laboratory
Ther rx mntr 200+ rx/sbsts,0520U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,259.27,,,,,,,fee schedule,222.23,432.11,APC
Ther rx mntr 200+ rx/sbsts,0520U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,256.8,,,,,,,fee schedule,222.23,432.11,APC
Ther rx mntr 200+ rx/sbsts,0520U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,246.92,,,,,,,fee schedule,222.23,432.11,APC
Ther rx mntr 200+ rx/sbsts,0520U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,377.79,,,,,,,fee schedule,222.23,432.11,Radiology
Ther rx mntr 200+ rx/sbsts,0520U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,345.69,,,,,,,fee schedule,222.23,432.11,APC
Ther rx mntr 200+ rx/sbsts,0520U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,432.11,,,,,,,fee schedule,222.23,432.11,APC
Interrog dev eval wcs ip,0521T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,64.9,,,,,,,fee schedule,28.63,127.04,
Interrog dev eval wcs ip,0521T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52.03,,,,,,,fee schedule,28.63,127.04,
Interrog dev eval wcs ip,0521T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56.83,,,,,,,fee schedule,28.63,127.04,
Interrog dev eval wcs ip,0521T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59.75,,,,,,,fee schedule,28.63,127.04,
Interrog dev eval wcs ip,0521T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,127.04,,,,,,,fee schedule,28.63,127.04,APC 378
Interrog dev eval wcs ip,0521T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.07,,,,,,,fee schedule,28.63,127.04,APC
Interrog dev eval wcs ip,0521T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,29.78,,,,,,,fee schedule,28.63,127.04,APC
Interrog dev eval wcs ip,0521T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,28.63,,,,,,,fee schedule,28.63,127.04,APC
Interrog dev eval wcs ip,0521T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43.81,,,,,,,fee schedule,28.63,127.04,Radiology
Interrog dev eval wcs ip,0521T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40.09,,,,,,,fee schedule,28.63,127.04,APC
Interrog dev eval wcs ip,0521T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,50.11,,,,,,,fee schedule,28.63,127.04,APC
Rf iga&igm ccp antb sr-a ia,0521U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46.62,,,,,,,fee schedule,46.62,90.65,Laboratory
Rf iga&igm ccp antb sr-a ia,0521U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.39,,,,,,,fee schedule,46.62,90.65,APC
Rf iga&igm ccp antb sr-a ia,0521U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,53.87,,,,,,,fee schedule,46.62,90.65,APC
Rf iga&igm ccp antb sr-a ia,0521U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,51.8,,,,,,,fee schedule,46.62,90.65,APC
Rf iga&igm ccp antb sr-a ia,0521U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,79.25,,,,,,,fee schedule,46.62,90.65,Radiology
Rf iga&igm ccp antb sr-a ia,0521U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,72.52,,,,,,,fee schedule,46.62,90.65,APC
Rf iga&igm ccp antb sr-a ia,0521U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,90.65,,,,,,,fee schedule,46.62,90.65,APC
Prgrmg dev eval wcs ip,0522T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,140.46,,,,,,,fee schedule,36.95,163.92,
Prgrmg dev eval wcs ip,0522T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,112.59,,,,,,,fee schedule,36.95,163.92,
Prgrmg dev eval wcs ip,0522T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,123,,,,,,,fee schedule,36.95,163.92,
Prgrmg dev eval wcs ip,0522T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,129.32,,,,,,,fee schedule,36.95,163.92,
Prgrmg dev eval wcs ip,0522T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,163.92,,,,,,,fee schedule,36.95,163.92,APC 378
Prgrmg dev eval wcs ip,0522T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.79,,,,,,,fee schedule,36.95,163.92,APC
Prgrmg dev eval wcs ip,0522T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.43,,,,,,,fee schedule,36.95,163.92,APC
Prgrmg dev eval wcs ip,0522T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.95,,,,,,,fee schedule,36.95,163.92,APC
Prgrmg dev eval wcs ip,0522T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.53,,,,,,,fee schedule,36.95,163.92,Radiology
Prgrmg dev eval wcs ip,0522T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.73,,,,,,,fee schedule,36.95,163.92,APC
Prgrmg dev eval wcs ip,0522T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.66,,,,,,,fee schedule,36.95,163.92,APC
Ca vi psp&sp1 antb cl semiql,0522U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,234.45,,,,,,,fee schedule,234.45,455.88,Laboratory
Ca vi psp&sp1 antb cl semiql,0522U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,273.53,,,,,,,fee schedule,234.45,455.88,APC
Ca vi psp&sp1 antb cl semiql,0522U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,270.92,,,,,,,fee schedule,234.45,455.88,APC
Ca vi psp&sp1 antb cl semiql,0522U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,260.5,,,,,,,fee schedule,234.45,455.88,APC
Ca vi psp&sp1 antb cl semiql,0522U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,398.56,,,,,,,fee schedule,234.45,455.88,Radiology
Ca vi psp&sp1 antb cl semiql,0522U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,364.7,,,,,,,fee schedule,234.45,455.88,APC
Ca vi psp&sp1 antb cl semiql,0522U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,455.88,,,,,,,fee schedule,234.45,455.88,APC
Onc soltum dna ngs snv 22gen,0523U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1216.88,,,,,,,fee schedule,1216.88,2366.16,Laboratory
Onc soltum dna ngs snv 22gen,0523U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1419.69,,,,,,,fee schedule,1216.88,2366.16,APC
Onc soltum dna ngs snv 22gen,0523U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1406.17,,,,,,,fee schedule,1216.88,2366.16,APC
Onc soltum dna ngs snv 22gen,0523U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1352.09,,,,,,,fee schedule,1216.88,2366.16,APC
Onc soltum dna ngs snv 22gen,0523U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2068.7,,,,,,,fee schedule,1216.88,2366.16,Radiology
Onc soltum dna ngs snv 22gen,0523U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1892.93,,,,,,,fee schedule,1216.88,2366.16,APC
Onc soltum dna ngs snv 22gen,0523U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2366.16,,,,,,,fee schedule,1216.88,2366.16,APC
Ev cath dir chem abltj w/img,0524T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9984.95,,,,,,,fee schedule,3125.8,13868.13,
Ev cath dir chem abltj w/img,0524T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8003.81,,,,,,,fee schedule,3125.8,13868.13,
Ev cath dir chem abltj w/img,0524T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8743.43,,,,,,,fee schedule,3125.8,13868.13,
Ev cath dir chem abltj w/img,0524T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9192.49,,,,,,,fee schedule,3125.8,13868.13,
Ev cath dir chem abltj w/img,0524T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Ev cath dir chem abltj w/img,0524T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Ev cath dir chem abltj w/img,0524T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Ev cath dir chem abltj w/img,0524T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Ev cath dir chem abltj w/img,0524T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Ev cath dir chem abltj w/img,0524T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Ev cath dir chem abltj w/img,0524T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Ob pe sflt-1/plgf ia srm/pls,0524U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,115.94,,,,,,,fee schedule,115.94,225.44,Laboratory
Ob pe sflt-1/plgf ia srm/pls,0524U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,135.26,,,,,,,fee schedule,115.94,225.44,APC
Ob pe sflt-1/plgf ia srm/pls,0524U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,133.97,,,,,,,fee schedule,115.94,225.44,APC
Ob pe sflt-1/plgf ia srm/pls,0524U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,128.82,,,,,,,fee schedule,115.94,225.44,APC
Ob pe sflt-1/plgf ia srm/pls,0524U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,197.09,,,,,,,fee schedule,115.94,225.44,Radiology
Ob pe sflt-1/plgf ia srm/pls,0524U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,180.35,,,,,,,fee schedule,115.94,225.44,APC
Ob pe sflt-1/plgf ia srm/pls,0524U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,225.44,,,,,,,fee schedule,115.94,225.44,APC
Insj/rplcmt compl iims,0525T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37343.91,,,,,,,fee schedule,19068.45,84600.26,
Insj/rplcmt compl iims,0525T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29934.4,,,,,,,fee schedule,19068.45,84600.26,
Insj/rplcmt compl iims,0525T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32700.62,,,,,,,fee schedule,19068.45,84600.26,
Insj/rplcmt compl iims,0525T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,34380.1,,,,,,,fee schedule,19068.45,84600.26,
Insj/rplcmt compl iims,0525T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,84600.26,,,,,,,fee schedule,19068.45,84600.26,APC 378
Insj/rplcmt compl iims,0525T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20021.87,,,,,,,fee schedule,19068.45,84600.26,APC
Insj/rplcmt compl iims,0525T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,19831.19,,,,,,,fee schedule,19068.45,84600.26,APC
Insj/rplcmt compl iims,0525T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,19068.45,,,,,,,fee schedule,19068.45,84600.26,APC
Insj/rplcmt compl iims,0525T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29174.73,,,,,,,fee schedule,19068.45,84600.26,Radiology
Insj/rplcmt compl iims,0525T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26695.83,,,,,,,fee schedule,19068.45,84600.26,APC
Insj/rplcmt compl iims,0525T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,33369.79,,,,,,,fee schedule,19068.45,84600.26,APC
Onc sphrd cell cul 11-rx pnl,0525U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2730.47,,,,,,,fee schedule,2730.47,5309.26,Laboratory
Onc sphrd cell cul 11-rx pnl,0525U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3185.55,,,,,,,fee schedule,2730.47,5309.26,APC
Onc sphrd cell cul 11-rx pnl,0525U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3155.21,,,,,,,fee schedule,2730.47,5309.26,APC
Onc sphrd cell cul 11-rx pnl,0525U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3033.86,,,,,,,fee schedule,2730.47,5309.26,APC
Onc sphrd cell cul 11-rx pnl,0525U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4641.81,,,,,,,fee schedule,2730.47,5309.26,Radiology
Onc sphrd cell cul 11-rx pnl,0525U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4247.4,,,,,,,fee schedule,2730.47,5309.26,APC
Onc sphrd cell cul 11-rx pnl,0525U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5309.26,,,,,,,fee schedule,2730.47,5309.26,APC
Insj/rplcmt iims eltrd only,0526T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27987.54,,,,,,,fee schedule,8192.37,36346.76,
Insj/rplcmt iims eltrd only,0526T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22434.45,,,,,,,fee schedule,8192.37,36346.76,
Insj/rplcmt iims eltrd only,0526T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24507.6,,,,,,,fee schedule,8192.37,36346.76,
Insj/rplcmt iims eltrd only,0526T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,25766.3,,,,,,,fee schedule,8192.37,36346.76,
Insj/rplcmt iims eltrd only,0526T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,36346.76,,,,,,,fee schedule,8192.37,36346.76,APC 378
Insj/rplcmt iims eltrd only,0526T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8601.99,,,,,,,fee schedule,8192.37,36346.76,APC
Insj/rplcmt iims eltrd only,0526T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8520.06,,,,,,,fee schedule,8192.37,36346.76,APC
Insj/rplcmt iims eltrd only,0526T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8192.37,,,,,,,fee schedule,8192.37,36346.76,APC
Insj/rplcmt iims eltrd only,0526T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12534.32,,,,,,,fee schedule,8192.37,36346.76,Radiology
Insj/rplcmt iims eltrd only,0526T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11469.31,,,,,,,fee schedule,8192.37,36346.76,APC
Insj/rplcmt iims eltrd only,0526T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14336.64,,,,,,,fee schedule,8192.37,36346.76,APC
Insj/rplcmt iims implt mntr,0527T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27987.54,,,,,,,fee schedule,8192.37,36346.76,
Insj/rplcmt iims implt mntr,0527T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22434.45,,,,,,,fee schedule,8192.37,36346.76,
Insj/rplcmt iims implt mntr,0527T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24507.6,,,,,,,fee schedule,8192.37,36346.76,
Insj/rplcmt iims implt mntr,0527T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,25766.3,,,,,,,fee schedule,8192.37,36346.76,
Insj/rplcmt iims implt mntr,0527T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,36346.76,,,,,,,fee schedule,8192.37,36346.76,APC 378
Insj/rplcmt iims implt mntr,0527T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8601.99,,,,,,,fee schedule,8192.37,36346.76,APC
Insj/rplcmt iims implt mntr,0527T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8520.06,,,,,,,fee schedule,8192.37,36346.76,APC
Insj/rplcmt iims implt mntr,0527T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8192.37,,,,,,,fee schedule,8192.37,36346.76,APC
Insj/rplcmt iims implt mntr,0527T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12534.32,,,,,,,fee schedule,8192.37,36346.76,Radiology
Insj/rplcmt iims implt mntr,0527T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11469.31,,,,,,,fee schedule,8192.37,36346.76,APC
Insj/rplcmt iims implt mntr,0527T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14336.64,,,,,,,fee schedule,8192.37,36346.76,APC
Hsv 1&2 vzv amp prb tq pthgn,0527U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,128.37,,,,,,,fee schedule,128.37,249.6,Laboratory
Hsv 1&2 vzv amp prb tq pthgn,0527U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,149.76,,,,,,,fee schedule,128.37,249.6,APC
Hsv 1&2 vzv amp prb tq pthgn,0527U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,148.34,,,,,,,fee schedule,128.37,249.6,APC
Hsv 1&2 vzv amp prb tq pthgn,0527U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,142.63,,,,,,,fee schedule,128.37,249.6,APC
Hsv 1&2 vzv amp prb tq pthgn,0527U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,218.22,,,,,,,fee schedule,128.37,249.6,Radiology
Hsv 1&2 vzv amp prb tq pthgn,0527U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,199.68,,,,,,,fee schedule,128.37,249.6,APC
Hsv 1&2 vzv amp prb tq pthgn,0527U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,249.6,,,,,,,fee schedule,128.37,249.6,APC
Prgrmg dev eval iims ip,0528T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,140.46,,,,,,,fee schedule,36.95,163.92,
Prgrmg dev eval iims ip,0528T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,112.59,,,,,,,fee schedule,36.95,163.92,
Prgrmg dev eval iims ip,0528T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,123,,,,,,,fee schedule,36.95,163.92,
Prgrmg dev eval iims ip,0528T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,129.32,,,,,,,fee schedule,36.95,163.92,
Prgrmg dev eval iims ip,0528T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,163.92,,,,,,,fee schedule,36.95,163.92,APC 378
Prgrmg dev eval iims ip,0528T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.79,,,,,,,fee schedule,36.95,163.92,APC
Prgrmg dev eval iims ip,0528T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.43,,,,,,,fee schedule,36.95,163.92,APC
Prgrmg dev eval iims ip,0528T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.95,,,,,,,fee schedule,36.95,163.92,APC
Prgrmg dev eval iims ip,0528T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.53,,,,,,,fee schedule,36.95,163.92,Radiology
Prgrmg dev eval iims ip,0528T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.73,,,,,,,fee schedule,36.95,163.92,APC
Prgrmg dev eval iims ip,0528T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.66,,,,,,,fee schedule,36.95,163.92,APC
Lrt iad 18bct/8vir&7arg rna,0528U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,571.36,,,,,,,fee schedule,571.36,1110.97,Laboratory
Lrt iad 18bct/8vir&7arg rna,0528U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,666.58,,,,,,,fee schedule,571.36,1110.97,APC
Lrt iad 18bct/8vir&7arg rna,0528U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,660.23,,,,,,,fee schedule,571.36,1110.97,APC
Lrt iad 18bct/8vir&7arg rna,0528U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,634.84,,,,,,,fee schedule,571.36,1110.97,APC
Lrt iad 18bct/8vir&7arg rna,0528U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,971.31,,,,,,,fee schedule,571.36,1110.97,Radiology
Lrt iad 18bct/8vir&7arg rna,0528U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,888.78,,,,,,,fee schedule,571.36,1110.97,APC
Lrt iad 18bct/8vir&7arg rna,0528U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1110.97,,,,,,,fee schedule,571.36,1110.97,APC
Interrog dev eval iims ip,0529T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,140.46,,,,,,,fee schedule,36.95,163.92,
Interrog dev eval iims ip,0529T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,112.59,,,,,,,fee schedule,36.95,163.92,
Interrog dev eval iims ip,0529T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,123,,,,,,,fee schedule,36.95,163.92,
Interrog dev eval iims ip,0529T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,129.32,,,,,,,fee schedule,36.95,163.92,
Interrog dev eval iims ip,0529T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,163.92,,,,,,,fee schedule,36.95,163.92,APC 378
Interrog dev eval iims ip,0529T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.79,,,,,,,fee schedule,36.95,163.92,APC
Interrog dev eval iims ip,0529T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.43,,,,,,,fee schedule,36.95,163.92,APC
Interrog dev eval iims ip,0529T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.95,,,,,,,fee schedule,36.95,163.92,APC
Interrog dev eval iims ip,0529T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.53,,,,,,,fee schedule,36.95,163.92,Radiology
Interrog dev eval iims ip,0529T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.73,,,,,,,fee schedule,36.95,163.92,APC
Interrog dev eval iims ip,0529T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.66,,,,,,,fee schedule,36.95,163.92,APC
Removal complete iims,0530T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11833.4,,,,,,,fee schedule,3699.47,16413.29,
Removal complete iims,0530T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9485.51,,,,,,,fee schedule,3699.47,16413.29,
Removal complete iims,0530T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10362.05,,,,,,,fee schedule,3699.47,16413.29,
Removal complete iims,0530T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10894.24,,,,,,,fee schedule,3699.47,16413.29,
Removal complete iims,0530T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16413.29,,,,,,,fee schedule,3699.47,16413.29,APC 378
Removal complete iims,0530T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3884.44,,,,,,,fee schedule,3699.47,16413.29,APC
Removal complete iims,0530T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3847.45,,,,,,,fee schedule,3699.47,16413.29,APC
Removal complete iims,0530T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3699.47,,,,,,,fee schedule,3699.47,16413.29,APC
Removal complete iims,0530T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5660.19,,,,,,,fee schedule,3699.47,16413.29,Radiology
Removal complete iims,0530T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5179.26,,,,,,,fee schedule,3699.47,16413.29,APC
Removal complete iims,0530T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6474.07,,,,,,,fee schedule,3699.47,16413.29,APC
Onc pan-sol tum ctdna 77 gen,0530U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2627.64,,,,,,,fee schedule,2627.64,5109.3,Laboratory
Onc pan-sol tum ctdna 77 gen,0530U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3065.58,,,,,,,fee schedule,2627.64,5109.3,APC
Onc pan-sol tum ctdna 77 gen,0530U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3036.38,,,,,,,fee schedule,2627.64,5109.3,APC
Onc pan-sol tum ctdna 77 gen,0530U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2919.6,,,,,,,fee schedule,2627.64,5109.3,APC
Onc pan-sol tum ctdna 77 gen,0530U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4466.99,,,,,,,fee schedule,2627.64,5109.3,Radiology
Onc pan-sol tum ctdna 77 gen,0530U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4087.44,,,,,,,fee schedule,2627.64,5109.3,APC
Onc pan-sol tum ctdna 77 gen,0530U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5109.3,,,,,,,fee schedule,2627.64,5109.3,APC
Removal iims electrode only,0531T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11833.4,,,,,,,fee schedule,3699.47,16413.29,
Removal iims electrode only,0531T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9485.51,,,,,,,fee schedule,3699.47,16413.29,
Removal iims electrode only,0531T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10362.05,,,,,,,fee schedule,3699.47,16413.29,
Removal iims electrode only,0531T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10894.24,,,,,,,fee schedule,3699.47,16413.29,
Removal iims electrode only,0531T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16413.29,,,,,,,fee schedule,3699.47,16413.29,APC 378
Removal iims electrode only,0531T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3884.44,,,,,,,fee schedule,3699.47,16413.29,APC
Removal iims electrode only,0531T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3847.45,,,,,,,fee schedule,3699.47,16413.29,APC
Removal iims electrode only,0531T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3699.47,,,,,,,fee schedule,3699.47,16413.29,APC
Removal iims electrode only,0531T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5660.19,,,,,,,fee schedule,3699.47,16413.29,Radiology
Removal iims electrode only,0531T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5179.26,,,,,,,fee schedule,3699.47,16413.29,APC
Removal iims electrode only,0531T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6474.07,,,,,,,fee schedule,3699.47,16413.29,APC
Removal iims implt mntr only,0532T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11833.4,,,,,,,fee schedule,3699.47,16413.29,
Removal iims implt mntr only,0532T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9485.51,,,,,,,fee schedule,3699.47,16413.29,
Removal iims implt mntr only,0532T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10362.05,,,,,,,fee schedule,3699.47,16413.29,
Removal iims implt mntr only,0532T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10894.24,,,,,,,fee schedule,3699.47,16413.29,
Removal iims implt mntr only,0532T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16413.29,,,,,,,fee schedule,3699.47,16413.29,APC 378
Removal iims implt mntr only,0532T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3884.44,,,,,,,fee schedule,3699.47,16413.29,APC
Removal iims implt mntr only,0532T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3847.45,,,,,,,fee schedule,3699.47,16413.29,APC
Removal iims implt mntr only,0532T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3699.47,,,,,,,fee schedule,3699.47,16413.29,APC
Removal iims implt mntr only,0532T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5660.19,,,,,,,fee schedule,3699.47,16413.29,Radiology
Removal iims implt mntr only,0532T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5179.26,,,,,,,fee schedule,3699.47,16413.29,APC
Removal iims implt mntr only,0532T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6474.07,,,,,,,fee schedule,3699.47,16413.29,APC
Rare ds whlgen&mitochdrl dna,0532U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4528.08,,,,,,,fee schedule,4528.08,8804.6,Laboratory
Rare ds whlgen&mitochdrl dna,0532U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5282.76,,,,,,,fee schedule,4528.08,8804.6,APC
Rare ds whlgen&mitochdrl dna,0532U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5232.45,,,,,,,fee schedule,4528.08,8804.6,APC
Rare ds whlgen&mitochdrl dna,0532U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5031.2,,,,,,,fee schedule,4528.08,8804.6,APC
Rare ds whlgen&mitochdrl dna,0532U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7697.74,,,,,,,fee schedule,4528.08,8804.6,Radiology
Rare ds whlgen&mitochdrl dna,0532U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7043.68,,,,,,,fee schedule,4528.08,8804.6,APC
Rare ds whlgen&mitochdrl dna,0532U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8804.6,,,,,,,fee schedule,4528.08,8804.6,APC
Rx metab advrs gnotyp 16gens,0533U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,375.1,,,,,,,fee schedule,375.1,729.36,Laboratory
Rx metab advrs gnotyp 16gens,0533U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,437.62,,,,,,,fee schedule,375.1,729.36,APC
Rx metab advrs gnotyp 16gens,0533U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,433.45,,,,,,,fee schedule,375.1,729.36,APC
Rx metab advrs gnotyp 16gens,0533U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,416.78,,,,,,,fee schedule,375.1,729.36,APC
Rx metab advrs gnotyp 16gens,0533U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,637.67,,,,,,,fee schedule,375.1,729.36,Radiology
Rx metab advrs gnotyp 16gens,0533U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,583.49,,,,,,,fee schedule,375.1,729.36,APC
Rx metab advrs gnotyp 16gens,0533U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,729.36,,,,,,,fee schedule,375.1,729.36,APC
Cont rec mvmt do setup&train,0534T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,140.46,,,,,,,fee schedule,112.59,140.46,
Cont rec mvmt do setup&train,0534T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,112.59,,,,,,,fee schedule,112.59,140.46,
Cont rec mvmt do setup&train,0534T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,123,,,,,,,fee schedule,112.59,140.46,
Cont rec mvmt do setup&train,0534T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,129.32,,,,,,,fee schedule,112.59,140.46,
Cont rec mvmt do reprt cnfig,0535T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,140.46,,,,,,,fee schedule,112.59,140.46,
Cont rec mvmt do reprt cnfig,0535T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,112.59,,,,,,,fee schedule,112.59,140.46,
Cont rec mvmt do reprt cnfig,0535T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,123,,,,,,,fee schedule,112.59,140.46,
Cont rec mvmt do reprt cnfig,0535T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,129.32,,,,,,,fee schedule,112.59,140.46,
Pfas lc-ms/ms plsm/srm quan,0535U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,55.93,,,,,,,fee schedule,55.93,108.74,Laboratory
Pfas lc-ms/ms plsm/srm quan,0535U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,65.25,,,,,,,fee schedule,55.93,108.74,APC
Pfas lc-ms/ms plsm/srm quan,0535U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,64.63,,,,,,,fee schedule,55.93,108.74,APC
Pfas lc-ms/ms plsm/srm quan,0535U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,62.14,,,,,,,fee schedule,55.93,108.74,APC
Pfas lc-ms/ms plsm/srm quan,0535U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,95.07,,,,,,,fee schedule,55.93,108.74,Radiology
Pfas lc-ms/ms plsm/srm quan,0535U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,87,,,,,,,fee schedule,55.93,108.74,APC
Pfas lc-ms/ms plsm/srm quan,0535U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,108.74,,,,,,,fee schedule,55.93,108.74,APC
Rbcag ftl rhd pcr alys exon4,0536U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,172.8,,,,,,,fee schedule,172.8,336,Laboratory
Rbcag ftl rhd pcr alys exon4,0536U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,201.6,,,,,,,fee schedule,172.8,336,APC
Rbcag ftl rhd pcr alys exon4,0536U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,199.68,,,,,,,fee schedule,172.8,336,APC
Rbcag ftl rhd pcr alys exon4,0536U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,192,,,,,,,fee schedule,172.8,336,APC
Rbcag ftl rhd pcr alys exon4,0536U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,293.76,,,,,,,fee schedule,172.8,336,Radiology
Rbcag ftl rhd pcr alys exon4,0536U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,268.8,,,,,,,fee schedule,172.8,336,APC
Rbcag ftl rhd pcr alys exon4,0536U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,336,,,,,,,fee schedule,172.8,336,APC
Onc clrct ca cfdna >2500 dmr,0537U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1345.5,,,,,,,fee schedule,1345.5,2616.25,Laboratory
Onc clrct ca cfdna >2500 dmr,0537U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1569.75,,,,,,,fee schedule,1345.5,2616.25,APC
Onc clrct ca cfdna >2500 dmr,0537U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1554.8,,,,,,,fee schedule,1345.5,2616.25,APC
Onc clrct ca cfdna >2500 dmr,0537U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1495,,,,,,,fee schedule,1345.5,2616.25,APC
Onc clrct ca cfdna >2500 dmr,0537U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2287.35,,,,,,,fee schedule,1345.5,2616.25,Radiology
Onc clrct ca cfdna >2500 dmr,0537U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2093,,,,,,,fee schedule,1345.5,2616.25,APC
Onc clrct ca cfdna >2500 dmr,0537U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2616.25,,,,,,,fee schedule,1345.5,2616.25,APC
Onc sol tum ngts ffpe 600gen,0538U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2690.6,,,,,,,fee schedule,2690.6,5231.71,Laboratory
Onc sol tum ngts ffpe 600gen,0538U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3139.03,,,,,,,fee schedule,2690.6,5231.71,APC
Onc sol tum ngts ffpe 600gen,0538U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3109.13,,,,,,,fee schedule,2690.6,5231.71,APC
Onc sol tum ngts ffpe 600gen,0538U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2989.55,,,,,,,fee schedule,2690.6,5231.71,APC
Onc sol tum ngts ffpe 600gen,0538U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4574.01,,,,,,,fee schedule,2690.6,5231.71,Radiology
Onc sol tum ngts ffpe 600gen,0538U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4185.37,,,,,,,fee schedule,2690.6,5231.71,APC
Onc sol tum ngts ffpe 600gen,0538U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5231.71,,,,,,,fee schedule,2690.6,5231.71,APC
Onc sol tumor cfctdna 152gen,0539U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2959.66,,,,,,,fee schedule,2959.66,5754.89,Laboratory
Onc sol tumor cfctdna 152gen,0539U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3452.94,,,,,,,fee schedule,2959.66,5754.89,APC
Onc sol tumor cfctdna 152gen,0539U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3420.05,,,,,,,fee schedule,2959.66,5754.89,APC
Onc sol tumor cfctdna 152gen,0539U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3288.51,,,,,,,fee schedule,2959.66,5754.89,APC
Onc sol tumor cfctdna 152gen,0539U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5031.42,,,,,,,fee schedule,2959.66,5754.89,Radiology
Onc sol tumor cfctdna 152gen,0539U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4603.91,,,,,,,fee schedule,2959.66,5754.89,APC
Onc sol tumor cfctdna 152gen,0539U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5754.89,,,,,,,fee schedule,2959.66,5754.89,APC
Car-t cll admn autologous,0540T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1090.08,,,,,,,fee schedule,873.79,1090.08,
Car-t cll admn autologous,0540T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,873.79,,,,,,,fee schedule,873.79,1090.08,
Car-t cll admn autologous,0540T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,954.54,,,,,,,fee schedule,873.79,1090.08,
Car-t cll admn autologous,0540T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1003.56,,,,,,,fee schedule,873.79,1090.08,
Trnsplj med quan dd-cfdna,0540U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2477.93,,,,,,,fee schedule,2477.93,4818.19,Laboratory
Trnsplj med quan dd-cfdna,0540U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2890.91,,,,,,,fee schedule,2477.93,4818.19,APC
Trnsplj med quan dd-cfdna,0540U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2863.38,,,,,,,fee schedule,2477.93,4818.19,APC
Trnsplj med quan dd-cfdna,0540U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2753.25,,,,,,,fee schedule,2477.93,4818.19,APC
Trnsplj med quan dd-cfdna,0540U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4212.47,,,,,,,fee schedule,2477.93,4818.19,Radiology
Trnsplj med quan dd-cfdna,0540U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3854.55,,,,,,,fee schedule,2477.93,4818.19,APC
Trnsplj med quan dd-cfdna,0540U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4818.19,,,,,,,fee schedule,2477.93,4818.19,APC
Myocardial imaging mcg,0541T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1835.61,,,,,,,fee schedule,369.41,1835.61,
Myocardial imaging mcg,0541T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1471.4,,,,,,,fee schedule,369.41,1835.61,
Myocardial imaging mcg,0541T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1607.37,,,,,,,fee schedule,369.41,1835.61,
Myocardial imaging mcg,0541T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1689.92,,,,,,,fee schedule,369.41,1835.61,
Myocardial imaging mcg,0541T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1638.96,,,,,,,fee schedule,369.41,1835.61,APC 378
Myocardial imaging mcg,0541T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,387.88,,,,,,,fee schedule,369.41,1835.61,APC
Myocardial imaging mcg,0541T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,384.19,,,,,,,fee schedule,369.41,1835.61,APC
Myocardial imaging mcg,0541T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,369.41,,,,,,,fee schedule,369.41,1835.61,APC
Myocardial imaging mcg,0541T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,565.2,,,,,,,fee schedule,369.41,1835.61,Radiology
Myocardial imaging mcg,0541T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,517.18,,,,,,,fee schedule,369.41,1835.61,APC
Myocardial imaging mcg,0541T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,646.47,,,,,,,fee schedule,369.41,1835.61,APC
Ta mv rpr w/artif chord tend,0543T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7644.48,,,,,,,fee schedule,6127.72,7644.48,
Ta mv rpr w/artif chord tend,0543T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6127.72,,,,,,,fee schedule,6127.72,7644.48,
Ta mv rpr w/artif chord tend,0543T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6693.98,,,,,,,fee schedule,6127.72,7644.48,
Ta mv rpr w/artif chord tend,0543T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7037.78,,,,,,,fee schedule,6127.72,7644.48,
Onc sol tum ngs dna 517 gens,0543U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2690.6,,,,,,,fee schedule,2690.6,5231.71,Laboratory
Onc sol tum ngs dna 517 gens,0543U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3139.03,,,,,,,fee schedule,2690.6,5231.71,APC
Onc sol tum ngs dna 517 gens,0543U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3109.13,,,,,,,fee schedule,2690.6,5231.71,APC
Onc sol tum ngs dna 517 gens,0543U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2989.55,,,,,,,fee schedule,2690.6,5231.71,APC
Onc sol tum ngs dna 517 gens,0543U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4574.01,,,,,,,fee schedule,2690.6,5231.71,Radiology
Onc sol tum ngs dna 517 gens,0543U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4185.37,,,,,,,fee schedule,2690.6,5231.71,APC
Onc sol tum ngs dna 517 gens,0543U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5231.71,,,,,,,fee schedule,2690.6,5231.71,APC
Tcat mv annulus rcnstj,0544T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7109.95,,,,,,,fee schedule,5699.25,7109.95,
Tcat mv annulus rcnstj,0544T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5699.25,,,,,,,fee schedule,5699.25,7109.95,
Tcat mv annulus rcnstj,0544T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6225.91,,,,,,,fee schedule,5699.25,7109.95,
Tcat mv annulus rcnstj,0544T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6545.67,,,,,,,fee schedule,5699.25,7109.95,
Tcat tv annulus rcnstj,0545T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6887.69,,,,,,,fee schedule,5521.08,6887.69,
Tcat tv annulus rcnstj,0545T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5521.08,,,,,,,fee schedule,5521.08,6887.69,
Tcat tv annulus rcnstj,0545T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6031.28,,,,,,,fee schedule,5521.08,6887.69,
Tcat tv annulus rcnstj,0545T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6341.05,,,,,,,fee schedule,5521.08,6887.69,
Achr antb id imfluor livecll,0545U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,33.96,,,,,,,fee schedule,33.96,66.03,Laboratory
Achr antb id imfluor livecll,0545U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.62,,,,,,,fee schedule,33.96,66.03,APC
Achr antb id imfluor livecll,0545U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,39.24,,,,,,,fee schedule,33.96,66.03,APC
Achr antb id imfluor livecll,0545U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,37.73,,,,,,,fee schedule,33.96,66.03,APC
Achr antb id imfluor livecll,0545U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,57.73,,,,,,,fee schedule,33.96,66.03,Radiology
Achr antb id imfluor livecll,0545U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,52.82,,,,,,,fee schedule,33.96,66.03,APC
Achr antb id imfluor livecll,0545U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,66.03,,,,,,,fee schedule,33.96,66.03,APC
Ldns lrp4 antb imflr livecll,0546U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,33.96,,,,,,,fee schedule,33.96,66.03,Laboratory
Ldns lrp4 antb imflr livecll,0546U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.62,,,,,,,fee schedule,33.96,66.03,APC
Ldns lrp4 antb imflr livecll,0546U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,39.24,,,,,,,fee schedule,33.96,66.03,APC
Ldns lrp4 antb imflr livecll,0546U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,37.73,,,,,,,fee schedule,33.96,66.03,APC
Ldns lrp4 antb imflr livecll,0546U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,57.73,,,,,,,fee schedule,33.96,66.03,Radiology
Ldns lrp4 antb imflr livecll,0546U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,52.82,,,,,,,fee schedule,33.96,66.03,APC
Ldns lrp4 antb imflr livecll,0546U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,66.03,,,,,,,fee schedule,33.96,66.03,APC
Neurflmnt lt chn cleia plsm,0547U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,104.61,,,,,,,fee schedule,104.61,203.4,Laboratory
Neurflmnt lt chn cleia plsm,0547U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,122.04,,,,,,,fee schedule,104.61,203.4,APC
Neurflmnt lt chn cleia plsm,0547U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,120.88,,,,,,,fee schedule,104.61,203.4,APC
Neurflmnt lt chn cleia plsm,0547U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,116.23,,,,,,,fee schedule,104.61,203.4,APC
Neurflmnt lt chn cleia plsm,0547U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,177.83,,,,,,,fee schedule,104.61,203.4,Radiology
Neurflmnt lt chn cleia plsm,0547U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,162.72,,,,,,,fee schedule,104.61,203.4,APC
Neurflmnt lt chn cleia plsm,0547U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,203.4,,,,,,,fee schedule,104.61,203.4,APC
Gfap cleia plasma,0548U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,104.61,,,,,,,fee schedule,104.61,203.4,Laboratory
Gfap cleia plasma,0548U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,122.04,,,,,,,fee schedule,104.61,203.4,APC
Gfap cleia plasma,0548U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,120.88,,,,,,,fee schedule,104.61,203.4,APC
Gfap cleia plasma,0548U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,116.23,,,,,,,fee schedule,104.61,203.4,APC
Gfap cleia plasma,0548U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,177.83,,,,,,,fee schedule,104.61,203.4,Radiology
Gfap cleia plasma,0548U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,162.72,,,,,,,fee schedule,104.61,203.4,APC
Gfap cleia plasma,0548U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,203.4,,,,,,,fee schedule,104.61,203.4,APC
Onc urthl dna mthyltd rt pcr,0549U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,684,,,,,,,fee schedule,684,1330,Laboratory
Onc urthl dna mthyltd rt pcr,0549U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,798,,,,,,,fee schedule,684,1330,APC
Onc urthl dna mthyltd rt pcr,0549U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,790.4,,,,,,,fee schedule,684,1330,APC
Onc urthl dna mthyltd rt pcr,0549U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,760,,,,,,,fee schedule,684,1330,APC
Onc urthl dna mthyltd rt pcr,0549U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1162.8,,,,,,,fee schedule,684,1330,Radiology
Onc urthl dna mthyltd rt pcr,0549U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1064,,,,,,,fee schedule,684,1330,APC
Onc urthl dna mthyltd rt pcr,0549U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1330,,,,,,,fee schedule,684,1330,APC
Perq tcat iliac anast implt,0553T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10735.5,,,,,,,fee schedule,8605.44,10735.5,
Perq tcat iliac anast implt,0553T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8605.44,,,,,,,fee schedule,8605.44,10735.5,
Perq tcat iliac anast implt,0553T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9400.66,,,,,,,fee schedule,8605.44,10735.5,
Perq tcat iliac anast implt,0553T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9883.48,,,,,,,fee schedule,8605.44,10735.5,
Repr med pga embry te strux,0553U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,683.14,,,,,,,fee schedule,683.14,1328.34,Laboratory
Repr med pga embry te strux,0553U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,797,,,,,,,fee schedule,683.14,1328.34,APC
Repr med pga embry te strux,0553U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,789.41,,,,,,,fee schedule,683.14,1328.34,APC
Repr med pga embry te strux,0553U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,759.05,,,,,,,fee schedule,683.14,1328.34,APC
Repr med pga embry te strux,0553U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1161.35,,,,,,,fee schedule,683.14,1328.34,Radiology
Repr med pga embry te strux,0553U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1062.67,,,,,,,fee schedule,683.14,1328.34,APC
Repr med pga embry te strux,0553U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1328.34,,,,,,,fee schedule,683.14,1328.34,APC
B1 str & fx rsk analysis,0554T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,139.33,,,,,,,fee schedule,111.69,139.33,
B1 str & fx rsk analysis,0554T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,111.69,,,,,,,fee schedule,111.69,139.33,
B1 str & fx rsk analysis,0554T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,122.01,,,,,,,fee schedule,111.69,139.33,
B1 str & fx rsk analysis,0554T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,128.27,,,,,,,fee schedule,111.69,139.33,
Repr med pga 24chrm te bx qc,0554U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,683.14,,,,,,,fee schedule,683.14,1328.34,Laboratory
Repr med pga 24chrm te bx qc,0554U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,797,,,,,,,fee schedule,683.14,1328.34,APC
Repr med pga 24chrm te bx qc,0554U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,789.41,,,,,,,fee schedule,683.14,1328.34,APC
Repr med pga 24chrm te bx qc,0554U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,759.05,,,,,,,fee schedule,683.14,1328.34,APC
Repr med pga 24chrm te bx qc,0554U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1161.35,,,,,,,fee schedule,683.14,1328.34,Radiology
Repr med pga 24chrm te bx qc,0554U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1062.67,,,,,,,fee schedule,683.14,1328.34,APC
Repr med pga 24chrm te bx qc,0554U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1328.34,,,,,,,fee schedule,683.14,1328.34,APC
B1 str&fx rsk transmis data,0555T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,86.9,,,,,,,fee schedule,28.63,127.04,
B1 str&fx rsk transmis data,0555T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,69.66,,,,,,,fee schedule,28.63,127.04,
B1 str&fx rsk transmis data,0555T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,76.1,,,,,,,fee schedule,28.63,127.04,
B1 str&fx rsk transmis data,0555T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,80.01,,,,,,,fee schedule,28.63,127.04,
B1 str&fx rsk transmis data,0555T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,127.04,,,,,,,fee schedule,28.63,127.04,APC 378
B1 str&fx rsk transmis data,0555T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.07,,,,,,,fee schedule,28.63,127.04,APC
B1 str&fx rsk transmis data,0555T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,29.78,,,,,,,fee schedule,28.63,127.04,APC
B1 str&fx rsk transmis data,0555T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,28.63,,,,,,,fee schedule,28.63,127.04,APC
B1 str&fx rsk transmis data,0555T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43.81,,,,,,,fee schedule,28.63,127.04,Radiology
B1 str&fx rsk transmis data,0555T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40.09,,,,,,,fee schedule,28.63,127.04,APC
B1 str&fx rsk transmis data,0555T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,50.11,,,,,,,fee schedule,28.63,127.04,APC
Repr med pga embryonic te qc,0555U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,683.14,,,,,,,fee schedule,683.14,1328.34,Laboratory
Repr med pga embryonic te qc,0555U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,797,,,,,,,fee schedule,683.14,1328.34,APC
Repr med pga embryonic te qc,0555U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,789.41,,,,,,,fee schedule,683.14,1328.34,APC
Repr med pga embryonic te qc,0555U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,759.05,,,,,,,fee schedule,683.14,1328.34,APC
Repr med pga embryonic te qc,0555U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1161.35,,,,,,,fee schedule,683.14,1328.34,Radiology
Repr med pga embryonic te qc,0555U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1062.67,,,,,,,fee schedule,683.14,1328.34,APC
Repr med pga embryonic te qc,0555U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1328.34,,,,,,,fee schedule,683.14,1328.34,APC
B1 str & fx rsk assessment,0556T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,880.89,,,,,,,fee schedule,236.21,1047.98,
B1 str & fx rsk assessment,0556T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,706.11,,,,,,,fee schedule,236.21,1047.98,
B1 str & fx rsk assessment,0556T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,771.36,,,,,,,fee schedule,236.21,1047.98,
B1 str & fx rsk assessment,0556T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,810.98,,,,,,,fee schedule,236.21,1047.98,
B1 str & fx rsk assessment,0556T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,236.21,1047.98,APC 378
B1 str & fx rsk assessment,0556T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,236.21,1047.98,APC
B1 str & fx rsk assessment,0556T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,236.21,1047.98,APC
B1 str & fx rsk assessment,0556T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,236.21,1047.98,APC
B1 str & fx rsk assessment,0556T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,236.21,1047.98,Radiology
B1 str & fx rsk assessment,0556T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,236.21,1047.98,APC
B1 str & fx rsk assessment,0556T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,236.21,1047.98,APC
Nfct ds p-s dna&rna 12 trgts,0556U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,128.37,,,,,,,fee schedule,128.37,249.6,Laboratory
Nfct ds p-s dna&rna 12 trgts,0556U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,149.76,,,,,,,fee schedule,128.37,249.6,APC
Nfct ds p-s dna&rna 12 trgts,0556U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,148.34,,,,,,,fee schedule,128.37,249.6,APC
Nfct ds p-s dna&rna 12 trgts,0556U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,142.63,,,,,,,fee schedule,128.37,249.6,APC
Nfct ds p-s dna&rna 12 trgts,0556U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,218.22,,,,,,,fee schedule,128.37,249.6,Radiology
Nfct ds p-s dna&rna 12 trgts,0556U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,199.68,,,,,,,fee schedule,128.37,249.6,APC
Nfct ds p-s dna&rna 12 trgts,0556U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,249.6,,,,,,,fee schedule,128.37,249.6,APC
B1 str & fx rsk i&r,0557T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,34.85,,,,,,,fee schedule,27.94,34.85,
B1 str & fx rsk i&r,0557T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,27.94,,,,,,,fee schedule,27.94,34.85,
B1 str & fx rsk i&r,0557T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,30.52,,,,,,,fee schedule,27.94,34.85,
B1 str & fx rsk i&r,0557T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,32.09,,,,,,,fee schedule,27.94,34.85,
Nfct ds bv dna mrk vag fluid,0557U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,236.69,,,,,,,fee schedule,236.69,460.23,Laboratory
Nfct ds bv dna mrk vag fluid,0557U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,276.14,,,,,,,fee schedule,236.69,460.23,APC
Nfct ds bv dna mrk vag fluid,0557U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,273.51,,,,,,,fee schedule,236.69,460.23,APC
Nfct ds bv dna mrk vag fluid,0557U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,262.99,,,,,,,fee schedule,236.69,460.23,APC
Nfct ds bv dna mrk vag fluid,0557U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,402.37,,,,,,,fee schedule,236.69,460.23,Radiology
Nfct ds bv dna mrk vag fluid,0557U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,368.19,,,,,,,fee schedule,236.69,460.23,APC
Nfct ds bv dna mrk vag fluid,0557U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,460.23,,,,,,,fee schedule,236.69,460.23,APC
Ct scan f/biomchn ct alys,0558T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,301.68,,,,,,,fee schedule,86.15,382.23,
Ct scan f/biomchn ct alys,0558T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,241.82,,,,,,,fee schedule,86.15,382.23,
Ct scan f/biomchn ct alys,0558T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,264.17,,,,,,,fee schedule,86.15,382.23,
Ct scan f/biomchn ct alys,0558T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,277.74,,,,,,,fee schedule,86.15,382.23,
Ct scan f/biomchn ct alys,0558T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
Ct scan f/biomchn ct alys,0558T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
Ct scan f/biomchn ct alys,0558T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
Ct scan f/biomchn ct alys,0558T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
Ct scan f/biomchn ct alys,0558T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
Ct scan f/biomchn ct alys,0558T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
Ct scan f/biomchn ct alys,0558T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
Onc clrct elisa bf7 ag serum,0558U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.73,,,,,,,fee schedule,18.73,36.42,Laboratory
Onc clrct elisa bf7 ag serum,0558U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.85,,,,,,,fee schedule,18.73,36.42,APC
Onc clrct elisa bf7 ag serum,0558U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,21.64,,,,,,,fee schedule,18.73,36.42,APC
Onc clrct elisa bf7 ag serum,0558U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,20.81,,,,,,,fee schedule,18.73,36.42,APC
Onc clrct elisa bf7 ag serum,0558U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,31.84,,,,,,,fee schedule,18.73,36.42,Radiology
Onc clrct elisa bf7 ag serum,0558U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29.13,,,,,,,fee schedule,18.73,36.42,APC
Onc clrct elisa bf7 ag serum,0558U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,36.42,,,,,,,fee schedule,18.73,36.42,APC
Antmc mdl 3d print 1st cmpnt,0559T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,207.94,,,,,,,fee schedule,131.71,584.37,
Antmc mdl 3d print 1st cmpnt,0559T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,166.68,,,,,,,fee schedule,131.71,584.37,
Antmc mdl 3d print 1st cmpnt,0559T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,182.08,,,,,,,fee schedule,131.71,584.37,
Antmc mdl 3d print 1st cmpnt,0559T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,191.43,,,,,,,fee schedule,131.71,584.37,
Antmc mdl 3d print 1st cmpnt,0559T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,131.71,584.37,APC 378
Antmc mdl 3d print 1st cmpnt,0559T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,131.71,584.37,APC
Antmc mdl 3d print 1st cmpnt,0559T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,131.71,584.37,APC
Antmc mdl 3d print 1st cmpnt,0559T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,131.71,584.37,APC
Antmc mdl 3d print 1st cmpnt,0559T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,131.71,584.37,Radiology
Antmc mdl 3d print 1st cmpnt,0559T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,131.71,584.37,APC
Antmc mdl 3d print 1st cmpnt,0559T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,131.71,584.37,APC
Onc brs quan elisa bf9ag srm,0559U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.73,,,,,,,fee schedule,18.73,36.42,Laboratory
Onc brs quan elisa bf9ag srm,0559U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.85,,,,,,,fee schedule,18.73,36.42,APC
Onc brs quan elisa bf9ag srm,0559U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,21.64,,,,,,,fee schedule,18.73,36.42,APC
Onc brs quan elisa bf9ag srm,0559U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,20.81,,,,,,,fee schedule,18.73,36.42,APC
Onc brs quan elisa bf9ag srm,0559U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,31.84,,,,,,,fee schedule,18.73,36.42,Radiology
Onc brs quan elisa bf9ag srm,0559U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29.13,,,,,,,fee schedule,18.73,36.42,APC
Onc brs quan elisa bf9ag srm,0559U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,36.42,,,,,,,fee schedule,18.73,36.42,APC
Onc mrd gsa cfdna baseline,0560U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3490.6,,,,,,,fee schedule,3490.6,6787.29,Laboratory
Onc mrd gsa cfdna baseline,0560U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4072.37,,,,,,,fee schedule,3490.6,6787.29,APC
Onc mrd gsa cfdna baseline,0560U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4033.59,,,,,,,fee schedule,3490.6,6787.29,APC
Onc mrd gsa cfdna baseline,0560U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3878.45,,,,,,,fee schedule,3490.6,6787.29,APC
Onc mrd gsa cfdna baseline,0560U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5934.03,,,,,,,fee schedule,3490.6,6787.29,Radiology
Onc mrd gsa cfdna baseline,0560U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5429.83,,,,,,,fee schedule,3490.6,6787.29,APC
Onc mrd gsa cfdna baseline,0560U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6787.29,,,,,,,fee schedule,3490.6,6787.29,APC
Antmc guide 3d print 1st gd,0561T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,207.94,,,,,,,fee schedule,131.71,584.37,
Antmc guide 3d print 1st gd,0561T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,166.68,,,,,,,fee schedule,131.71,584.37,
Antmc guide 3d print 1st gd,0561T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,182.08,,,,,,,fee schedule,131.71,584.37,
Antmc guide 3d print 1st gd,0561T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,191.43,,,,,,,fee schedule,131.71,584.37,
Antmc guide 3d print 1st gd,0561T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,131.71,584.37,APC 378
Antmc guide 3d print 1st gd,0561T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,131.71,584.37,APC
Antmc guide 3d print 1st gd,0561T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,131.71,584.37,APC
Antmc guide 3d print 1st gd,0561T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,131.71,584.37,APC
Antmc guide 3d print 1st gd,0561T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,131.71,584.37,Radiology
Antmc guide 3d print 1st gd,0561T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,131.71,584.37,APC
Antmc guide 3d print 1st gd,0561T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,131.71,584.37,APC
Onc mrd gsa cfdna subsequent,0561U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,715.04,,,,,,,fee schedule,715.04,1390.36,Laboratory
Onc mrd gsa cfdna subsequent,0561U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,834.21,,,,,,,fee schedule,715.04,1390.36,APC
Onc mrd gsa cfdna subsequent,0561U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,826.27,,,,,,,fee schedule,715.04,1390.36,APC
Onc mrd gsa cfdna subsequent,0561U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,794.49,,,,,,,fee schedule,715.04,1390.36,APC
Onc mrd gsa cfdna subsequent,0561U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1215.57,,,,,,,fee schedule,715.04,1390.36,Radiology
Onc mrd gsa cfdna subsequent,0561U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1112.29,,,,,,,fee schedule,715.04,1390.36,APC
Onc mrd gsa cfdna subsequent,0561U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1390.36,,,,,,,fee schedule,715.04,1390.36,APC
Onc sol tum tgsa 33gens snvs,0562U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,538.12,,,,,,,fee schedule,538.12,1046.34,Laboratory
Onc sol tum tgsa 33gens snvs,0562U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,627.81,,,,,,,fee schedule,538.12,1046.34,APC
Onc sol tum tgsa 33gens snvs,0562U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,621.83,,,,,,,fee schedule,538.12,1046.34,APC
Onc sol tum tgsa 33gens snvs,0562U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,597.91,,,,,,,fee schedule,538.12,1046.34,APC
Onc sol tum tgsa 33gens snvs,0562U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,914.8,,,,,,,fee schedule,538.12,1046.34,Radiology
Onc sol tum tgsa 33gens snvs,0562U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,837.07,,,,,,,fee schedule,538.12,1046.34,APC
Onc sol tum tgsa 33gens snvs,0562U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1046.34,,,,,,,fee schedule,538.12,1046.34,APC
Evac meibomian glnd heat bi,0563T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,207.94,,,,,,,fee schedule,58.4,259.1,
Evac meibomian glnd heat bi,0563T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,166.68,,,,,,,fee schedule,58.4,259.1,
Evac meibomian glnd heat bi,0563T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,182.08,,,,,,,fee schedule,58.4,259.1,
Evac meibomian glnd heat bi,0563T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,191.43,,,,,,,fee schedule,58.4,259.1,
Evac meibomian glnd heat bi,0563T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,58.4,259.1,APC 378
Evac meibomian glnd heat bi,0563T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,58.4,259.1,APC
Evac meibomian glnd heat bi,0563T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,58.4,259.1,APC
Evac meibomian glnd heat bi,0563T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,58.4,259.1,APC
Evac meibomian glnd heat bi,0563T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,58.4,259.1,Radiology
Evac meibomian glnd heat bi,0563T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,58.4,259.1,APC
Evac meibomian glnd heat bi,0563T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,58.4,259.1,APC
Nfct ds pthgn-sna 11vir&4bct,0563U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,375.1,,,,,,,fee schedule,375.1,729.36,Laboratory
Nfct ds pthgn-sna 11vir&4bct,0563U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,437.62,,,,,,,fee schedule,375.1,729.36,APC
Nfct ds pthgn-sna 11vir&4bct,0563U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,433.45,,,,,,,fee schedule,375.1,729.36,APC
Nfct ds pthgn-sna 11vir&4bct,0563U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,416.78,,,,,,,fee schedule,375.1,729.36,APC
Nfct ds pthgn-sna 11vir&4bct,0563U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,637.67,,,,,,,fee schedule,375.1,729.36,Radiology
Nfct ds pthgn-sna 11vir&4bct,0563U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,583.49,,,,,,,fee schedule,375.1,729.36,APC
Nfct ds pthgn-sna 11vir&4bct,0563U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,729.36,,,,,,,fee schedule,375.1,729.36,APC
Onc chemo rx cytotox csc 14,0564T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,187,,,,,,,fee schedule,149.89,187,
Onc chemo rx cytotox csc 14,0564T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,149.89,,,,,,,fee schedule,149.89,187,
Onc chemo rx cytotox csc 14,0564T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,163.75,,,,,,,fee schedule,149.89,187,
Onc chemo rx cytotox csc 14,0564T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,172.16,,,,,,,fee schedule,149.89,187,
Nfct ds pthgn-sna 10vir&4bct,0564U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,375.1,,,,,,,fee schedule,375.1,729.36,Laboratory
Nfct ds pthgn-sna 10vir&4bct,0564U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,437.62,,,,,,,fee schedule,375.1,729.36,APC
Nfct ds pthgn-sna 10vir&4bct,0564U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,433.45,,,,,,,fee schedule,375.1,729.36,APC
Nfct ds pthgn-sna 10vir&4bct,0564U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,416.78,,,,,,,fee schedule,375.1,729.36,APC
Nfct ds pthgn-sna 10vir&4bct,0564U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,637.67,,,,,,,fee schedule,375.1,729.36,Radiology
Nfct ds pthgn-sna 10vir&4bct,0564U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,583.49,,,,,,,fee schedule,375.1,729.36,APC
Nfct ds pthgn-sna 10vir&4bct,0564U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,729.36,,,,,,,fee schedule,375.1,729.36,APC
Autol cell implt adps hrvg,0565T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,207.94,,,,,,,fee schedule,166.68,207.94,
Autol cell implt adps hrvg,0565T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,166.68,,,,,,,fee schedule,166.68,207.94,
Autol cell implt adps hrvg,0565T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,182.08,,,,,,,fee schedule,166.68,207.94,
Autol cell implt adps hrvg,0565T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,191.43,,,,,,,fee schedule,166.68,207.94,
Onc hcc ngs detc 6626epigalt,0565U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1044,,,,,,,fee schedule,1044,2030,Laboratory
Onc hcc ngs detc 6626epigalt,0565U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1218,,,,,,,fee schedule,1044,2030,APC
Onc hcc ngs detc 6626epigalt,0565U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1206.4,,,,,,,fee schedule,1044,2030,APC
Onc hcc ngs detc 6626epigalt,0565U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1160,,,,,,,fee schedule,1044,2030,APC
Onc hcc ngs detc 6626epigalt,0565U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1774.8,,,,,,,fee schedule,1044,2030,Radiology
Onc hcc ngs detc 6626epigalt,0565U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1624,,,,,,,fee schedule,1044,2030,APC
Onc hcc ngs detc 6626epigalt,0565U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2030,,,,,,,fee schedule,1044,2030,APC
Autol cell implt adps njx,0566T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,989.49,,,,,,,fee schedule,793.16,989.49,
Autol cell implt adps njx,0566T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,793.16,,,,,,,fee schedule,793.16,989.49,
Autol cell implt adps njx,0566T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,866.46,,,,,,,fee schedule,793.16,989.49,
Autol cell implt adps njx,0566T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,910.96,,,,,,,fee schedule,793.16,989.49,
Onc lng qpcr-bsd alys 13dmrs,0566U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,375.1,,,,,,,fee schedule,375.1,729.36,Laboratory
Onc lng qpcr-bsd alys 13dmrs,0566U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,437.62,,,,,,,fee schedule,375.1,729.36,APC
Onc lng qpcr-bsd alys 13dmrs,0566U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,433.45,,,,,,,fee schedule,375.1,729.36,APC
Onc lng qpcr-bsd alys 13dmrs,0566U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,416.78,,,,,,,fee schedule,375.1,729.36,APC
Onc lng qpcr-bsd alys 13dmrs,0566U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,637.67,,,,,,,fee schedule,375.1,729.36,Radiology
Onc lng qpcr-bsd alys 13dmrs,0566U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,583.49,,,,,,,fee schedule,375.1,729.36,APC
Onc lng qpcr-bsd alys 13dmrs,0566U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,729.36,,,,,,,fee schedule,375.1,729.36,APC
Rare ds whl gen seq srs&lrs,0567U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4528.08,,,,,,,fee schedule,4528.08,8804.6,Laboratory
Rare ds whl gen seq srs&lrs,0567U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5282.76,,,,,,,fee schedule,4528.08,8804.6,APC
Rare ds whl gen seq srs&lrs,0567U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5232.45,,,,,,,fee schedule,4528.08,8804.6,APC
Rare ds whl gen seq srs&lrs,0567U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5031.2,,,,,,,fee schedule,4528.08,8804.6,APC
Rare ds whl gen seq srs&lrs,0567U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7697.74,,,,,,,fee schedule,4528.08,8804.6,Radiology
Rare ds whl gen seq srs&lrs,0567U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7043.68,,,,,,,fee schedule,4528.08,8804.6,APC
Rare ds whl gen seq srs&lrs,0567U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8804.6,,,,,,,fee schedule,4528.08,8804.6,APC
Neurol dementia ?amyl ptau,0568U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,807.3,,,,,,,fee schedule,807.3,1569.75,Laboratory
Neurol dementia ?amyl ptau,0568U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,941.85,,,,,,,fee schedule,807.3,1569.75,APC
Neurol dementia ?amyl ptau,0568U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,932.88,,,,,,,fee schedule,807.3,1569.75,APC
Neurol dementia ?amyl ptau,0568U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,897,,,,,,,fee schedule,807.3,1569.75,APC
Neurol dementia ?amyl ptau,0568U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1372.41,,,,,,,fee schedule,807.3,1569.75,Radiology
Neurol dementia ?amyl ptau,0568U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1255.8,,,,,,,fee schedule,807.3,1569.75,APC
Neurol dementia ?amyl ptau,0568U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1569.75,,,,,,,fee schedule,807.3,1569.75,APC
Neurol tbi alys gfap&uch-l1,0570U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,234.45,,,,,,,fee schedule,234.45,455.88,Laboratory
Neurol tbi alys gfap&uch-l1,0570U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,273.53,,,,,,,fee schedule,234.45,455.88,APC
Neurol tbi alys gfap&uch-l1,0570U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,270.92,,,,,,,fee schedule,234.45,455.88,APC
Neurol tbi alys gfap&uch-l1,0570U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,260.5,,,,,,,fee schedule,234.45,455.88,APC
Neurol tbi alys gfap&uch-l1,0570U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,398.56,,,,,,,fee schedule,234.45,455.88,Radiology
Neurol tbi alys gfap&uch-l1,0570U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,364.7,,,,,,,fee schedule,234.45,455.88,APC
Neurol tbi alys gfap&uch-l1,0570U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,455.88,,,,,,,fee schedule,234.45,455.88,APC
Insj/rplcmt icds ss eltrd,0571T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,124131,,,,,,,fee schedule,31073.96,137864.64,
Insj/rplcmt icds ss eltrd,0571T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,99501.84,,,,,,,fee schedule,31073.96,137864.64,
Insj/rplcmt icds ss eltrd,0571T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,108696.73,,,,,,,fee schedule,31073.96,137864.64,
Insj/rplcmt icds ss eltrd,0571T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,114279.34,,,,,,,fee schedule,31073.96,137864.64,
Insj/rplcmt icds ss eltrd,0571T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,137864.64,,,,,,,fee schedule,31073.96,137864.64,APC 378
Insj/rplcmt icds ss eltrd,0571T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,32627.66,,,,,,,fee schedule,31073.96,137864.64,APC
Insj/rplcmt icds ss eltrd,0571T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,32316.92,,,,,,,fee schedule,31073.96,137864.64,APC
Insj/rplcmt icds ss eltrd,0571T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,31073.96,,,,,,,fee schedule,31073.96,137864.64,APC
Insj/rplcmt icds ss eltrd,0571T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,47543.16,,,,,,,fee schedule,31073.96,137864.64,Radiology
Insj/rplcmt icds ss eltrd,0571T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43503.54,,,,,,,fee schedule,31073.96,137864.64,APC
Insj/rplcmt icds ss eltrd,0571T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,54379.43,,,,,,,fee schedule,31073.96,137864.64,APC
Onc sol tum dna80&rna10g ngs,0571U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2627.64,,,,,,,fee schedule,2627.64,5109.3,Laboratory
Onc sol tum dna80&rna10g ngs,0571U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3065.58,,,,,,,fee schedule,2627.64,5109.3,APC
Onc sol tum dna80&rna10g ngs,0571U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3036.38,,,,,,,fee schedule,2627.64,5109.3,APC
Onc sol tum dna80&rna10g ngs,0571U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2919.6,,,,,,,fee schedule,2627.64,5109.3,APC
Onc sol tum dna80&rna10g ngs,0571U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4466.99,,,,,,,fee schedule,2627.64,5109.3,Radiology
Onc sol tum dna80&rna10g ngs,0571U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4087.44,,,,,,,fee schedule,2627.64,5109.3,APC
Onc sol tum dna80&rna10g ngs,0571U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5109.3,,,,,,,fee schedule,2627.64,5109.3,APC
Insertion ss dfb electrode,0572T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30816.75,,,,,,,fee schedule,8192.37,36346.76,
Insertion ss dfb electrode,0572T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24702.32,,,,,,,fee schedule,8192.37,36346.76,
Insertion ss dfb electrode,0572T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26985.04,,,,,,,fee schedule,8192.37,36346.76,
Insertion ss dfb electrode,0572T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,28370.98,,,,,,,fee schedule,8192.37,36346.76,
Insertion ss dfb electrode,0572T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,36346.76,,,,,,,fee schedule,8192.37,36346.76,APC 378
Insertion ss dfb electrode,0572T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8601.99,,,,,,,fee schedule,8192.37,36346.76,APC
Insertion ss dfb electrode,0572T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8520.06,,,,,,,fee schedule,8192.37,36346.76,APC
Insertion ss dfb electrode,0572T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8192.37,,,,,,,fee schedule,8192.37,36346.76,APC
Insertion ss dfb electrode,0572T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12534.32,,,,,,,fee schedule,8192.37,36346.76,Radiology
Insertion ss dfb electrode,0572T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11469.31,,,,,,,fee schedule,8192.37,36346.76,APC
Insertion ss dfb electrode,0572T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14336.64,,,,,,,fee schedule,8192.37,36346.76,APC
Removal ss dfb electrode,0573T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13004.6,,,,,,,fee schedule,3699.47,16413.29,
Removal ss dfb electrode,0573T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10424.32,,,,,,,fee schedule,3699.47,16413.29,
Removal ss dfb electrode,0573T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11387.62,,,,,,,fee schedule,3699.47,16413.29,
Removal ss dfb electrode,0573T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11972.49,,,,,,,fee schedule,3699.47,16413.29,
Removal ss dfb electrode,0573T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16413.29,,,,,,,fee schedule,3699.47,16413.29,APC 378
Removal ss dfb electrode,0573T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3884.44,,,,,,,fee schedule,3699.47,16413.29,APC
Removal ss dfb electrode,0573T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3847.45,,,,,,,fee schedule,3699.47,16413.29,APC
Removal ss dfb electrode,0573T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3699.47,,,,,,,fee schedule,3699.47,16413.29,APC
Removal ss dfb electrode,0573T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5660.19,,,,,,,fee schedule,3699.47,16413.29,Radiology
Removal ss dfb electrode,0573T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5179.26,,,,,,,fee schedule,3699.47,16413.29,APC
Removal ss dfb electrode,0573T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6474.07,,,,,,,fee schedule,3699.47,16413.29,APC
Repos prev ss impl dfb eltrd,0574T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13004.6,,,,,,,fee schedule,3699.47,16413.29,
Repos prev ss impl dfb eltrd,0574T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10424.32,,,,,,,fee schedule,3699.47,16413.29,
Repos prev ss impl dfb eltrd,0574T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11387.62,,,,,,,fee schedule,3699.47,16413.29,
Repos prev ss impl dfb eltrd,0574T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11972.49,,,,,,,fee schedule,3699.47,16413.29,
Repos prev ss impl dfb eltrd,0574T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16413.29,,,,,,,fee schedule,3699.47,16413.29,APC 378
Repos prev ss impl dfb eltrd,0574T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3884.44,,,,,,,fee schedule,3699.47,16413.29,APC
Repos prev ss impl dfb eltrd,0574T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3847.45,,,,,,,fee schedule,3699.47,16413.29,APC
Repos prev ss impl dfb eltrd,0574T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3699.47,,,,,,,fee schedule,3699.47,16413.29,APC
Repos prev ss impl dfb eltrd,0574T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5660.19,,,,,,,fee schedule,3699.47,16413.29,Radiology
Repos prev ss impl dfb eltrd,0574T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5179.26,,,,,,,fee schedule,3699.47,16413.29,APC
Repos prev ss impl dfb eltrd,0574T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6474.07,,,,,,,fee schedule,3699.47,16413.29,APC
Prgrmg dev eval icds ss ip,0575T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,140.43,,,,,,,fee schedule,36.95,163.92,
Prgrmg dev eval icds ss ip,0575T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,112.56,,,,,,,fee schedule,36.95,163.92,
Prgrmg dev eval icds ss ip,0575T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,122.97,,,,,,,fee schedule,36.95,163.92,
Prgrmg dev eval icds ss ip,0575T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,129.28,,,,,,,fee schedule,36.95,163.92,
Prgrmg dev eval icds ss ip,0575T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,163.92,,,,,,,fee schedule,36.95,163.92,APC 378
Prgrmg dev eval icds ss ip,0575T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.79,,,,,,,fee schedule,36.95,163.92,APC
Prgrmg dev eval icds ss ip,0575T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.43,,,,,,,fee schedule,36.95,163.92,APC
Prgrmg dev eval icds ss ip,0575T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.95,,,,,,,fee schedule,36.95,163.92,APC
Prgrmg dev eval icds ss ip,0575T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.53,,,,,,,fee schedule,36.95,163.92,Radiology
Prgrmg dev eval icds ss ip,0575T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.73,,,,,,,fee schedule,36.95,163.92,APC
Prgrmg dev eval icds ss ip,0575T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.66,,,,,,,fee schedule,36.95,163.92,APC
Trnsplj med lar rtpcr 4genes,0575U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,342,,,,,,,fee schedule,342,665,Laboratory
Trnsplj med lar rtpcr 4genes,0575U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,399,,,,,,,fee schedule,342,665,APC
Trnsplj med lar rtpcr 4genes,0575U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,395.2,,,,,,,fee schedule,342,665,APC
Trnsplj med lar rtpcr 4genes,0575U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,380,,,,,,,fee schedule,342,665,APC
Trnsplj med lar rtpcr 4genes,0575U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,581.4,,,,,,,fee schedule,342,665,Radiology
Trnsplj med lar rtpcr 4genes,0575U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,532,,,,,,,fee schedule,342,665,APC
Trnsplj med lar rtpcr 4genes,0575U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,665,,,,,,,fee schedule,342,665,APC
Interrog dev eval icds ss ip,0576T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,140.43,,,,,,,fee schedule,36.95,163.92,
Interrog dev eval icds ss ip,0576T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,112.56,,,,,,,fee schedule,36.95,163.92,
Interrog dev eval icds ss ip,0576T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,122.97,,,,,,,fee schedule,36.95,163.92,
Interrog dev eval icds ss ip,0576T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,129.28,,,,,,,fee schedule,36.95,163.92,
Interrog dev eval icds ss ip,0576T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,163.92,,,,,,,fee schedule,36.95,163.92,APC 378
Interrog dev eval icds ss ip,0576T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.79,,,,,,,fee schedule,36.95,163.92,APC
Interrog dev eval icds ss ip,0576T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.43,,,,,,,fee schedule,36.95,163.92,APC
Interrog dev eval icds ss ip,0576T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.95,,,,,,,fee schedule,36.95,163.92,APC
Interrog dev eval icds ss ip,0576T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.53,,,,,,,fee schedule,36.95,163.92,Radiology
Interrog dev eval icds ss ip,0576T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.73,,,,,,,fee schedule,36.95,163.92,APC
Interrog dev eval icds ss ip,0576T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.66,,,,,,,fee schedule,36.95,163.92,APC
Trnsplj med lar quan ddcfdna,0576U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2916,,,,,,,fee schedule,2916,5670,Laboratory
Trnsplj med lar quan ddcfdna,0576U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3402,,,,,,,fee schedule,2916,5670,APC
Trnsplj med lar quan ddcfdna,0576U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3369.6,,,,,,,fee schedule,2916,5670,APC
Trnsplj med lar quan ddcfdna,0576U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3240,,,,,,,fee schedule,2916,5670,APC
Trnsplj med lar quan ddcfdna,0576U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4957.2,,,,,,,fee schedule,2916,5670,Radiology
Trnsplj med lar quan ddcfdna,0576U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4536,,,,,,,fee schedule,2916,5670,APC
Trnsplj med lar quan ddcfdna,0576U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5670,,,,,,,fee schedule,2916,5670,APC
Ephys eval icds ss,0577T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4206.31,,,,,,,fee schedule,1205.32,5347.61,
Ephys eval icds ss,0577T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3371.72,,,,,,,fee schedule,1205.32,5347.61,
Ephys eval icds ss,0577T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3683.3,,,,,,,fee schedule,1205.32,5347.61,
Ephys eval icds ss,0577T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3872.47,,,,,,,fee schedule,1205.32,5347.61,
Ephys eval icds ss,0577T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5347.61,,,,,,,fee schedule,1205.32,5347.61,APC 378
Ephys eval icds ss,0577T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1265.59,,,,,,,fee schedule,1205.32,5347.61,APC
Ephys eval icds ss,0577T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1253.54,,,,,,,fee schedule,1205.32,5347.61,APC
Ephys eval icds ss,0577T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1205.32,,,,,,,fee schedule,1205.32,5347.61,APC
Ephys eval icds ss,0577T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1844.15,,,,,,,fee schedule,1205.32,5347.61,Radiology
Ephys eval icds ss,0577T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1687.45,,,,,,,fee schedule,1205.32,5347.61,APC
Ephys eval icds ss,0577T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2109.32,,,,,,,fee schedule,1205.32,5347.61,APC
Onc ovr serum alys 39 gps,0577U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,222.23,,,,,,,fee schedule,222.23,432.11,Laboratory
Onc ovr serum alys 39 gps,0577U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,259.27,,,,,,,fee schedule,222.23,432.11,APC
Onc ovr serum alys 39 gps,0577U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,256.8,,,,,,,fee schedule,222.23,432.11,APC
Onc ovr serum alys 39 gps,0577U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,246.92,,,,,,,fee schedule,222.23,432.11,APC
Onc ovr serum alys 39 gps,0577U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,377.79,,,,,,,fee schedule,222.23,432.11,Radiology
Onc ovr serum alys 39 gps,0577U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,345.69,,,,,,,fee schedule,222.23,432.11,APC
Onc ovr serum alys 39 gps,0577U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,432.11,,,,,,,fee schedule,222.23,432.11,APC
Onc cutan mln rna qpcr 10gen,0578U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3485.7,,,,,,,fee schedule,3485.7,6777.75,Laboratory
Onc cutan mln rna qpcr 10gen,0578U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4066.65,,,,,,,fee schedule,3485.7,6777.75,APC
Onc cutan mln rna qpcr 10gen,0578U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4027.92,,,,,,,fee schedule,3485.7,6777.75,APC
Onc cutan mln rna qpcr 10gen,0578U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3873,,,,,,,fee schedule,3485.7,6777.75,APC
Onc cutan mln rna qpcr 10gen,0578U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5925.69,,,,,,,fee schedule,3485.7,6777.75,Radiology
Onc cutan mln rna qpcr 10gen,0578U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5422.2,,,,,,,fee schedule,3485.7,6777.75,APC
Onc cutan mln rna qpcr 10gen,0578U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6777.75,,,,,,,fee schedule,3485.7,6777.75,APC
Rem interrog dev icds tech,0579T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,140.43,,,,,,,fee schedule,36.95,163.92,
Rem interrog dev icds tech,0579T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,112.56,,,,,,,fee schedule,36.95,163.92,
Rem interrog dev icds tech,0579T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,122.97,,,,,,,fee schedule,36.95,163.92,
Rem interrog dev icds tech,0579T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,129.28,,,,,,,fee schedule,36.95,163.92,
Rem interrog dev icds tech,0579T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,163.92,,,,,,,fee schedule,36.95,163.92,APC 378
Rem interrog dev icds tech,0579T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.79,,,,,,,fee schedule,36.95,163.92,APC
Rem interrog dev icds tech,0579T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.43,,,,,,,fee schedule,36.95,163.92,APC
Rem interrog dev icds tech,0579T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.95,,,,,,,fee schedule,36.95,163.92,APC
Rem interrog dev icds tech,0579T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.53,,,,,,,fee schedule,36.95,163.92,Radiology
Rem interrog dev icds tech,0579T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.73,,,,,,,fee schedule,36.95,163.92,APC
Rem interrog dev icds tech,0579T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.66,,,,,,,fee schedule,36.95,163.92,APC
Nfro dbtc ckd elisa apoa4,0579U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,351.68,,,,,,,fee schedule,351.68,683.81,Laboratory
Nfro dbtc ckd elisa apoa4,0579U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,410.29,,,,,,,fee schedule,351.68,683.81,APC
Nfro dbtc ckd elisa apoa4,0579U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,406.38,,,,,,,fee schedule,351.68,683.81,APC
Nfro dbtc ckd elisa apoa4,0579U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,390.75,,,,,,,fee schedule,351.68,683.81,APC
Nfro dbtc ckd elisa apoa4,0579U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,597.85,,,,,,,fee schedule,351.68,683.81,Radiology
Nfro dbtc ckd elisa apoa4,0579U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,547.05,,,,,,,fee schedule,351.68,683.81,APC
Nfro dbtc ckd elisa apoa4,0579U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,683.81,,,,,,,fee schedule,351.68,683.81,APC
Rmvl ss impl dfb pg only,0580T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13004.6,,,,,,,fee schedule,3699.47,16413.29,
Rmvl ss impl dfb pg only,0580T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10424.32,,,,,,,fee schedule,3699.47,16413.29,
Rmvl ss impl dfb pg only,0580T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11387.62,,,,,,,fee schedule,3699.47,16413.29,
Rmvl ss impl dfb pg only,0580T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11972.49,,,,,,,fee schedule,3699.47,16413.29,
Rmvl ss impl dfb pg only,0580T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16413.29,,,,,,,fee schedule,3699.47,16413.29,APC 378
Rmvl ss impl dfb pg only,0580T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3884.44,,,,,,,fee schedule,3699.47,16413.29,APC
Rmvl ss impl dfb pg only,0580T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3847.45,,,,,,,fee schedule,3699.47,16413.29,APC
Rmvl ss impl dfb pg only,0580T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3699.47,,,,,,,fee schedule,3699.47,16413.29,APC
Rmvl ss impl dfb pg only,0580T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5660.19,,,,,,,fee schedule,3699.47,16413.29,Radiology
Rmvl ss impl dfb pg only,0580T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5179.26,,,,,,,fee schedule,3699.47,16413.29,APC
Rmvl ss impl dfb pg only,0580T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6474.07,,,,,,,fee schedule,3699.47,16413.29,APC
Bbrgdrferi antb detc 24rprtn,0580U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.49,,,,,,,fee schedule,15.49,30.12,Laboratory
Bbrgdrferi antb detc 24rprtn,0580U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.07,,,,,,,fee schedule,15.49,30.12,APC
Bbrgdrferi antb detc 24rprtn,0580U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,17.9,,,,,,,fee schedule,15.49,30.12,APC
Bbrgdrferi antb detc 24rprtn,0580U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17.21,,,,,,,fee schedule,15.49,30.12,APC
Bbrgdrferi antb detc 24rprtn,0580U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26.33,,,,,,,fee schedule,15.49,30.12,Radiology
Bbrgdrferi antb detc 24rprtn,0580U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24.09,,,,,,,fee schedule,15.49,30.12,APC
Bbrgdrferi antb detc 24rprtn,0580U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30.12,,,,,,,fee schedule,15.49,30.12,APC
Abltj mal brst tum perq crtx,0581T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17197.18,,,,,,,fee schedule,3876.15,17197.18,APC 378
Abltj mal brst tum perq crtx,0581T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4069.96,,,,,,,fee schedule,3876.15,17197.18,APC
Abltj mal brst tum perq crtx,0581T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4031.2,,,,,,,fee schedule,3876.15,17197.18,APC
Abltj mal brst tum perq crtx,0581T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3876.15,,,,,,,fee schedule,3876.15,17197.18,APC
Abltj mal brst tum perq crtx,0581T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5930.51,,,,,,,fee schedule,3876.15,17197.18,Radiology
Abltj mal brst tum perq crtx,0581T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5426.61,,,,,,,fee schedule,3876.15,17197.18,APC
Abltj mal brst tum perq crtx,0581T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6783.27,,,,,,,fee schedule,3876.15,17197.18,APC
Trnspl med antb nohla 39trgt,0581U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,293.22,,,,,,,fee schedule,293.22,570.15,Laboratory
Trnspl med antb nohla 39trgt,0581U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,342.09,,,,,,,fee schedule,293.22,570.15,APC
Trnspl med antb nohla 39trgt,0581U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,338.83,,,,,,,fee schedule,293.22,570.15,APC
Trnspl med antb nohla 39trgt,0581U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,325.8,,,,,,,fee schedule,293.22,570.15,APC
Trnspl med antb nohla 39trgt,0581U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,498.47,,,,,,,fee schedule,293.22,570.15,Radiology
Trnspl med antb nohla 39trgt,0581U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,456.12,,,,,,,fee schedule,293.22,570.15,APC
Trnspl med antb nohla 39trgt,0581U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,570.15,,,,,,,fee schedule,293.22,570.15,APC
Rare ds rpd whlgen dna vrnts,0582U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6823.98,,,,,,,fee schedule,6823.98,13268.85,Laboratory
Rare ds rpd whlgen dna vrnts,0582U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7961.31,,,,,,,fee schedule,6823.98,13268.85,APC
Rare ds rpd whlgen dna vrnts,0582U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7885.49,,,,,,,fee schedule,6823.98,13268.85,APC
Rare ds rpd whlgen dna vrnts,0582U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7582.2,,,,,,,fee schedule,6823.98,13268.85,APC
Rare ds rpd whlgen dna vrnts,0582U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11600.77,,,,,,,fee schedule,6823.98,13268.85,Radiology
Rare ds rpd whlgen dna vrnts,0582U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10615.08,,,,,,,fee schedule,6823.98,13268.85,APC
Rare ds rpd whlgen dna vrnts,0582U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,13268.85,,,,,,,fee schedule,6823.98,13268.85,APC
Tmpst auto tube dlvr sys,0583T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5113.55,,,,,,,fee schedule,1536.02,6814.79,
Tmpst auto tube dlvr sys,0583T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4098.95,,,,,,,fee schedule,1536.02,6814.79,
Tmpst auto tube dlvr sys,0583T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4477.73,,,,,,,fee schedule,1536.02,6814.79,
Tmpst auto tube dlvr sys,0583T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4707.71,,,,,,,fee schedule,1536.02,6814.79,
Tmpst auto tube dlvr sys,0583T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1536.02,6814.79,APC 378
Tmpst auto tube dlvr sys,0583T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1536.02,6814.79,APC
Tmpst auto tube dlvr sys,0583T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1536.02,6814.79,APC
Tmpst auto tube dlvr sys,0583T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1536.02,6814.79,APC
Tmpst auto tube dlvr sys,0583T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1536.02,6814.79,Radiology
Tmpst auto tube dlvr sys,0583T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1536.02,6814.79,APC
Tmpst auto tube dlvr sys,0583T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1536.02,6814.79,APC
Rare ds rpd whlgen cmptr dna,0583U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3411.99,,,,,,,fee schedule,3411.99,6634.42,Laboratory
Rare ds rpd whlgen cmptr dna,0583U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3980.66,,,,,,,fee schedule,3411.99,6634.42,APC
Rare ds rpd whlgen cmptr dna,0583U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3942.74,,,,,,,fee schedule,3411.99,6634.42,APC
Rare ds rpd whlgen cmptr dna,0583U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3791.1,,,,,,,fee schedule,3411.99,6634.42,APC
Rare ds rpd whlgen cmptr dna,0583U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5800.38,,,,,,,fee schedule,3411.99,6634.42,Radiology
Rare ds rpd whlgen cmptr dna,0583U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5307.54,,,,,,,fee schedule,3411.99,6634.42,APC
Rare ds rpd whlgen cmptr dna,0583U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6634.42,,,,,,,fee schedule,3411.99,6634.42,APC
Neuro csf prion prtn qual,0584U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,486.89,,,,,,,fee schedule,486.89,946.73,Laboratory
Neuro csf prion prtn qual,0584U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,568.04,,,,,,,fee schedule,486.89,946.73,APC
Neuro csf prion prtn qual,0584U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,562.63,,,,,,,fee schedule,486.89,946.73,APC
Neuro csf prion prtn qual,0584U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,540.99,,,,,,,fee schedule,486.89,946.73,APC
Neuro csf prion prtn qual,0584U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,827.71,,,,,,,fee schedule,486.89,946.73,Radiology
Neuro csf prion prtn qual,0584U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,757.39,,,,,,,fee schedule,486.89,946.73,APC
Neuro csf prion prtn qual,0584U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,946.73,,,,,,,fee schedule,486.89,946.73,APC
Tgsap so neo cfdna 521 genes,0585U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2627.64,,,,,,,fee schedule,2627.64,5109.3,Laboratory
Tgsap so neo cfdna 521 genes,0585U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3065.58,,,,,,,fee schedule,2627.64,5109.3,APC
Tgsap so neo cfdna 521 genes,0585U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3036.38,,,,,,,fee schedule,2627.64,5109.3,APC
Tgsap so neo cfdna 521 genes,0585U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2919.6,,,,,,,fee schedule,2627.64,5109.3,APC
Tgsap so neo cfdna 521 genes,0585U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4466.99,,,,,,,fee schedule,2627.64,5109.3,Radiology
Tgsap so neo cfdna 521 genes,0585U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4087.44,,,,,,,fee schedule,2627.64,5109.3,APC
Tgsap so neo cfdna 521 genes,0585U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5109.3,,,,,,,fee schedule,2627.64,5109.3,APC
Onc mrna gen xprsn 216 genes,0586U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2627.64,,,,,,,fee schedule,2627.64,5109.3,Laboratory
Onc mrna gen xprsn 216 genes,0586U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3065.58,,,,,,,fee schedule,2627.64,5109.3,APC
Onc mrna gen xprsn 216 genes,0586U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3036.38,,,,,,,fee schedule,2627.64,5109.3,APC
Onc mrna gen xprsn 216 genes,0586U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2919.6,,,,,,,fee schedule,2627.64,5109.3,APC
Onc mrna gen xprsn 216 genes,0586U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4466.99,,,,,,,fee schedule,2627.64,5109.3,Radiology
Onc mrna gen xprsn 216 genes,0586U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4087.44,,,,,,,fee schedule,2627.64,5109.3,APC
Onc mrna gen xprsn 216 genes,0586U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5109.3,,,,,,,fee schedule,2627.64,5109.3,APC
Perq impltj/rplcmt isdns ptn,0587T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2362.69,,,,,,,fee schedule,1893.9,27991.15,
Perq impltj/rplcmt isdns ptn,0587T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1893.9,,,,,,,fee schedule,1893.9,27991.15,
Perq impltj/rplcmt isdns ptn,0587T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2068.92,,,,,,,fee schedule,1893.9,27991.15,
Perq impltj/rplcmt isdns ptn,0587T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2175.17,,,,,,,fee schedule,1893.9,27991.15,
Perq impltj/rplcmt isdns ptn,0587T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,27991.15,,,,,,,fee schedule,1893.9,27991.15,APC 378
Perq impltj/rplcmt isdns ptn,0587T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6624.51,,,,,,,fee schedule,1893.9,27991.15,APC
Perq impltj/rplcmt isdns ptn,0587T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6561.42,,,,,,,fee schedule,1893.9,27991.15,APC
Perq impltj/rplcmt isdns ptn,0587T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6309.06,,,,,,,fee schedule,1893.9,27991.15,APC
Perq impltj/rplcmt isdns ptn,0587T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9652.86,,,,,,,fee schedule,1893.9,27991.15,Radiology
Perq impltj/rplcmt isdns ptn,0587T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8832.68,,,,,,,fee schedule,1893.9,27991.15,APC
Perq impltj/rplcmt isdns ptn,0587T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11040.85,,,,,,,fee schedule,1893.9,27991.15,APC
Ther rx mntr 60-150rx&metabl,0587U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,102.99,,,,,,,fee schedule,102.99,200.25,Laboratory
Ther rx mntr 60-150rx&metabl,0587U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,120.15,,,,,,,fee schedule,102.99,200.25,APC
Ther rx mntr 60-150rx&metabl,0587U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,119.01,,,,,,,fee schedule,102.99,200.25,APC
Ther rx mntr 60-150rx&metabl,0587U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,114.43,,,,,,,fee schedule,102.99,200.25,APC
Ther rx mntr 60-150rx&metabl,0587U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,175.08,,,,,,,fee schedule,102.99,200.25,Radiology
Ther rx mntr 60-150rx&metabl,0587U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,160.2,,,,,,,fee schedule,102.99,200.25,APC
Ther rx mntr 60-150rx&metabl,0587U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,200.25,,,,,,,fee schedule,102.99,200.25,APC
Revision/removal isdns ptn,0588T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,989.49,,,,,,,fee schedule,793.16,15355.43,
Revision/removal isdns ptn,0588T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,793.16,,,,,,,fee schedule,793.16,15355.43,
Revision/removal isdns ptn,0588T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,866.46,,,,,,,fee schedule,793.16,15355.43,
Revision/removal isdns ptn,0588T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,910.96,,,,,,,fee schedule,793.16,15355.43,
Revision/removal isdns ptn,0588T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15355.43,,,,,,,fee schedule,793.16,15355.43,APC 378
Revision/removal isdns ptn,0588T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3634.08,,,,,,,fee schedule,793.16,15355.43,APC
Revision/removal isdns ptn,0588T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3599.47,,,,,,,fee schedule,793.16,15355.43,APC
Revision/removal isdns ptn,0588T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3461.03,,,,,,,fee schedule,793.16,15355.43,APC
Revision/removal isdns ptn,0588T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5295.38,,,,,,,fee schedule,793.16,15355.43,Radiology
Revision/removal isdns ptn,0588T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4845.44,,,,,,,fee schedule,793.16,15355.43,APC
Revision/removal isdns ptn,0588T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6056.81,,,,,,,fee schedule,793.16,15355.43,APC
Nfct ds bct/vir 32genes mrna,0588U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,684,,,,,,,fee schedule,684,1330,Laboratory
Nfct ds bct/vir 32genes mrna,0588U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,798,,,,,,,fee schedule,684,1330,APC
Nfct ds bct/vir 32genes mrna,0588U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,790.4,,,,,,,fee schedule,684,1330,APC
Nfct ds bct/vir 32genes mrna,0588U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,760,,,,,,,fee schedule,684,1330,APC
Nfct ds bct/vir 32genes mrna,0588U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1162.8,,,,,,,fee schedule,684,1330,Radiology
Nfct ds bct/vir 32genes mrna,0588U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1064,,,,,,,fee schedule,684,1330,APC
Nfct ds bct/vir 32genes mrna,0588U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1330,,,,,,,fee schedule,684,1330,APC
Elec alys smpl prgrmg iins,0589T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,428.77,,,,,,,fee schedule,94.12,428.77,
Elec alys smpl prgrmg iins,0589T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,343.69,,,,,,,fee schedule,94.12,428.77,
Elec alys smpl prgrmg iins,0589T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,375.45,,,,,,,fee schedule,94.12,428.77,
Elec alys smpl prgrmg iins,0589T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,394.74,,,,,,,fee schedule,94.12,428.77,
Elec alys smpl prgrmg iins,0589T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,417.57,,,,,,,fee schedule,94.12,428.77,APC 378
Elec alys smpl prgrmg iins,0589T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,98.82,,,,,,,fee schedule,94.12,428.77,APC
Elec alys smpl prgrmg iins,0589T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,97.88,,,,,,,fee schedule,94.12,428.77,APC
Elec alys smpl prgrmg iins,0589T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,94.12,,,,,,,fee schedule,94.12,428.77,APC
Elec alys smpl prgrmg iins,0589T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144,,,,,,,fee schedule,94.12,428.77,Radiology
Elec alys smpl prgrmg iins,0589T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.76,,,,,,,fee schedule,94.12,428.77,APC
Elec alys smpl prgrmg iins,0589T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,164.7,,,,,,,fee schedule,94.12,428.77,APC
Pfas24cmpnd hi-perf lc-ms/ms,0589U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,178.87,,,,,,,fee schedule,178.87,347.8,Laboratory
Pfas24cmpnd hi-perf lc-ms/ms,0589U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.68,,,,,,,fee schedule,178.87,347.8,APC
Pfas24cmpnd hi-perf lc-ms/ms,0589U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,206.69,,,,,,,fee schedule,178.87,347.8,APC
Pfas24cmpnd hi-perf lc-ms/ms,0589U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.74,,,,,,,fee schedule,178.87,347.8,APC
Pfas24cmpnd hi-perf lc-ms/ms,0589U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,304.07,,,,,,,fee schedule,178.87,347.8,Radiology
Pfas24cmpnd hi-perf lc-ms/ms,0589U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,278.24,,,,,,,fee schedule,178.87,347.8,APC
Pfas24cmpnd hi-perf lc-ms/ms,0589U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,347.8,,,,,,,fee schedule,178.87,347.8,APC
Elec alys cplx prgrmg iins,0590T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,428.77,,,,,,,fee schedule,94.12,428.77,
Elec alys cplx prgrmg iins,0590T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,343.69,,,,,,,fee schedule,94.12,428.77,
Elec alys cplx prgrmg iins,0590T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,375.45,,,,,,,fee schedule,94.12,428.77,
Elec alys cplx prgrmg iins,0590T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,394.74,,,,,,,fee schedule,94.12,428.77,
Elec alys cplx prgrmg iins,0590T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,417.57,,,,,,,fee schedule,94.12,428.77,APC 378
Elec alys cplx prgrmg iins,0590T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,98.82,,,,,,,fee schedule,94.12,428.77,APC
Elec alys cplx prgrmg iins,0590T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,97.88,,,,,,,fee schedule,94.12,428.77,APC
Elec alys cplx prgrmg iins,0590T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,94.12,,,,,,,fee schedule,94.12,428.77,APC
Elec alys cplx prgrmg iins,0590T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144,,,,,,,fee schedule,94.12,428.77,Radiology
Elec alys cplx prgrmg iins,0590T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.76,,,,,,,fee schedule,94.12,428.77,APC
Elec alys cplx prgrmg iins,0590T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,164.7,,,,,,,fee schedule,94.12,428.77,APC
Onc prst8 ca 3prtns plsm srm,0591U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,684,,,,,,,fee schedule,684,1330,Laboratory
Onc prst8 ca 3prtns plsm srm,0591U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,798,,,,,,,fee schedule,684,1330,APC
Onc prst8 ca 3prtns plsm srm,0591U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,790.4,,,,,,,fee schedule,684,1330,APC
Onc prst8 ca 3prtns plsm srm,0591U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,760,,,,,,,fee schedule,684,1330,APC
Onc prst8 ca 3prtns plsm srm,0591U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1162.8,,,,,,,fee schedule,684,1330,Radiology
Onc prst8 ca 3prtns plsm srm,0591U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1064,,,,,,,fee schedule,684,1330,APC
Onc prst8 ca 3prtns plsm srm,0591U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1330,,,,,,,fee schedule,684,1330,APC
Onc hl neo dna tgs 417 genes,0592U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2627.64,,,,,,,fee schedule,2627.64,5109.3,Laboratory
Onc hl neo dna tgs 417 genes,0592U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3065.58,,,,,,,fee schedule,2627.64,5109.3,APC
Onc hl neo dna tgs 417 genes,0592U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3036.38,,,,,,,fee schedule,2627.64,5109.3,APC
Onc hl neo dna tgs 417 genes,0592U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2919.6,,,,,,,fee schedule,2627.64,5109.3,APC
Onc hl neo dna tgs 417 genes,0592U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4466.99,,,,,,,fee schedule,2627.64,5109.3,Radiology
Onc hl neo dna tgs 417 genes,0592U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4087.44,,,,,,,fee schedule,2627.64,5109.3,APC
Onc hl neo dna tgs 417 genes,0592U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5109.3,,,,,,,fee schedule,2627.64,5109.3,APC
Nfct ds gu pthgn dna 46trgt,0593U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,571.36,,,,,,,fee schedule,571.36,1110.97,Laboratory
Nfct ds gu pthgn dna 46trgt,0593U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,666.58,,,,,,,fee schedule,571.36,1110.97,APC
Nfct ds gu pthgn dna 46trgt,0593U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,660.23,,,,,,,fee schedule,571.36,1110.97,APC
Nfct ds gu pthgn dna 46trgt,0593U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,634.84,,,,,,,fee schedule,571.36,1110.97,APC
Nfct ds gu pthgn dna 46trgt,0593U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,971.31,,,,,,,fee schedule,571.36,1110.97,Radiology
Nfct ds gu pthgn dna 46trgt,0593U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,888.78,,,,,,,fee schedule,571.36,1110.97,APC
Nfct ds gu pthgn dna 46trgt,0593U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1110.97,,,,,,,fee schedule,571.36,1110.97,APC
Osteot hum xtrnl lngth dev,0594T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Osteot hum xtrnl lngth dev,0594T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Osteot hum xtrnl lngth dev,0594T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Osteot hum xtrnl lngth dev,0594T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Osteot hum xtrnl lngth dev,0594T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Osteot hum xtrnl lngth dev,0594T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Osteot hum xtrnl lngth dev,0594T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Osteot hum xtrnl lngth dev,0594T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Osteot hum xtrnl lngth dev,0594T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Osteot hum xtrnl lngth dev,0594T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Osteot hum xtrnl lngth dev,0594T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Nfct ds tfp vctrbrn&zoonotic,0595U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,236.69,,,,,,,fee schedule,236.69,460.23,Laboratory
Nfct ds tfp vctrbrn&zoonotic,0595U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,276.14,,,,,,,fee schedule,236.69,460.23,APC
Nfct ds tfp vctrbrn&zoonotic,0595U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,273.51,,,,,,,fee schedule,236.69,460.23,APC
Nfct ds tfp vctrbrn&zoonotic,0595U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,262.99,,,,,,,fee schedule,236.69,460.23,APC
Nfct ds tfp vctrbrn&zoonotic,0595U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,402.37,,,,,,,fee schedule,236.69,460.23,Radiology
Nfct ds tfp vctrbrn&zoonotic,0595U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,368.19,,,,,,,fee schedule,236.69,460.23,APC
Nfct ds tfp vctrbrn&zoonotic,0595U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,460.23,,,,,,,fee schedule,236.69,460.23,APC
Temp fml iu vlv-pmp 1st insj,0596T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2172.63,,,,,,,fee schedule,690.3,3062.63,
Temp fml iu vlv-pmp 1st insj,0596T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1741.55,,,,,,,fee schedule,690.3,3062.63,
Temp fml iu vlv-pmp 1st insj,0596T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1902.49,,,,,,,fee schedule,690.3,3062.63,
Temp fml iu vlv-pmp 1st insj,0596T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2000.2,,,,,,,fee schedule,690.3,3062.63,
Temp fml iu vlv-pmp 1st insj,0596T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3062.63,,,,,,,fee schedule,690.3,3062.63,APC 378
Temp fml iu vlv-pmp 1st insj,0596T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,724.82,,,,,,,fee schedule,690.3,3062.63,APC
Temp fml iu vlv-pmp 1st insj,0596T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,717.91,,,,,,,fee schedule,690.3,3062.63,APC
Temp fml iu vlv-pmp 1st insj,0596T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,690.3,,,,,,,fee schedule,690.3,3062.63,APC
Temp fml iu vlv-pmp 1st insj,0596T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1056.16,,,,,,,fee schedule,690.3,3062.63,Radiology
Temp fml iu vlv-pmp 1st insj,0596T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,966.42,,,,,,,fee schedule,690.3,3062.63,APC
Temp fml iu vlv-pmp 1st insj,0596T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1208.03,,,,,,,fee schedule,690.3,3062.63,APC
Temp fml iu valve-pmp rplcmt,0597T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2172.63,,,,,,,fee schedule,690.3,3062.63,
Temp fml iu valve-pmp rplcmt,0597T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1741.55,,,,,,,fee schedule,690.3,3062.63,
Temp fml iu valve-pmp rplcmt,0597T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1902.49,,,,,,,fee schedule,690.3,3062.63,
Temp fml iu valve-pmp rplcmt,0597T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2000.2,,,,,,,fee schedule,690.3,3062.63,
Temp fml iu valve-pmp rplcmt,0597T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3062.63,,,,,,,fee schedule,690.3,3062.63,APC 378
Temp fml iu valve-pmp rplcmt,0597T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,724.82,,,,,,,fee schedule,690.3,3062.63,APC
Temp fml iu valve-pmp rplcmt,0597T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,717.91,,,,,,,fee schedule,690.3,3062.63,APC
Temp fml iu valve-pmp rplcmt,0597T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,690.3,,,,,,,fee schedule,690.3,3062.63,APC
Temp fml iu valve-pmp rplcmt,0597T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1056.16,,,,,,,fee schedule,690.3,3062.63,Radiology
Temp fml iu valve-pmp rplcmt,0597T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,966.42,,,,,,,fee schedule,690.3,3062.63,APC
Temp fml iu valve-pmp rplcmt,0597T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1208.03,,,,,,,fee schedule,690.3,3062.63,APC
Ncntc r-t fluor wnd img 1st,0598T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,999.62,,,,,,,fee schedule,213.76,999.62,
Ncntc r-t fluor wnd img 1st,0598T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,801.28,,,,,,,fee schedule,213.76,999.62,
Ncntc r-t fluor wnd img 1st,0598T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,875.33,,,,,,,fee schedule,213.76,999.62,
Ncntc r-t fluor wnd img 1st,0598T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,920.29,,,,,,,fee schedule,213.76,999.62,
Ncntc r-t fluor wnd img 1st,0598T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,213.76,999.62,APC 378
Ncntc r-t fluor wnd img 1st,0598T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,213.76,999.62,APC
Ncntc r-t fluor wnd img 1st,0598T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,213.76,999.62,APC
Ncntc r-t fluor wnd img 1st,0598T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,213.76,999.62,APC
Ncntc r-t fluor wnd img 1st,0598T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,213.76,999.62,Radiology
Ncntc r-t fluor wnd img 1st,0598T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,213.76,999.62,APC
Ncntc r-t fluor wnd img 1st,0598T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,213.76,999.62,APC
Gi ibs igg antb 18food items,0598U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,270,,,,,,,fee schedule,270,525,Laboratory
Gi ibs igg antb 18food items,0598U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,315,,,,,,,fee schedule,270,525,APC
Gi ibs igg antb 18food items,0598U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,312,,,,,,,fee schedule,270,525,APC
Gi ibs igg antb 18food items,0598U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,300,,,,,,,fee schedule,270,525,APC
Gi ibs igg antb 18food items,0598U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,459,,,,,,,fee schedule,270,525,Radiology
Gi ibs igg antb 18food items,0598U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,420,,,,,,,fee schedule,270,525,APC
Gi ibs igg antb 18food items,0598U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,525,,,,,,,fee schedule,270,525,APC
Onc pncrtc ca mult ia serum,0599U,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,807.3,,,,,,,fee schedule,807.3,1569.75,Laboratory
Onc pncrtc ca mult ia serum,0599U,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,941.85,,,,,,,fee schedule,807.3,1569.75,APC
Onc pncrtc ca mult ia serum,0599U,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,932.88,,,,,,,fee schedule,807.3,1569.75,APC
Onc pncrtc ca mult ia serum,0599U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,897,,,,,,,fee schedule,807.3,1569.75,APC
Onc pncrtc ca mult ia serum,0599U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1372.41,,,,,,,fee schedule,807.3,1569.75,Radiology
Onc pncrtc ca mult ia serum,0599U,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1255.8,,,,,,,fee schedule,807.3,1569.75,APC
Onc pncrtc ca mult ia serum,0599U,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1569.75,,,,,,,fee schedule,807.3,1569.75,APC
Ire abltj 1+tum organ perq,0600T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33670.95,,,,,,,fee schedule,10523.19,46687.84,
Ire abltj 1+tum organ perq,0600T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26990.21,,,,,,,fee schedule,10523.19,46687.84,
Ire abltj 1+tum organ perq,0600T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29484.35,,,,,,,fee schedule,10523.19,46687.84,
Ire abltj 1+tum organ perq,0600T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30998.66,,,,,,,fee schedule,10523.19,46687.84,
Ire abltj 1+tum organ perq,0600T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46687.84,,,,,,,fee schedule,10523.19,46687.84,APC 378
Ire abltj 1+tum organ perq,0600T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11049.35,,,,,,,fee schedule,10523.19,46687.84,APC
Ire abltj 1+tum organ perq,0600T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10944.12,,,,,,,fee schedule,10523.19,46687.84,APC
Ire abltj 1+tum organ perq,0600T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10523.19,,,,,,,fee schedule,10523.19,46687.84,APC
Ire abltj 1+tum organ perq,0600T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16100.48,,,,,,,fee schedule,10523.19,46687.84,Radiology
Ire abltj 1+tum organ perq,0600T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14732.47,,,,,,,fee schedule,10523.19,46687.84,APC
Ire abltj 1+tum organ perq,0600T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18415.58,,,,,,,fee schedule,10523.19,46687.84,APC
Ire abltj 1+tumors open,0601T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33670.95,,,,,,,fee schedule,10523.19,46687.84,
Ire abltj 1+tumors open,0601T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26990.21,,,,,,,fee schedule,10523.19,46687.84,
Ire abltj 1+tumors open,0601T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29484.35,,,,,,,fee schedule,10523.19,46687.84,
Ire abltj 1+tumors open,0601T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30998.66,,,,,,,fee schedule,10523.19,46687.84,
Ire abltj 1+tumors open,0601T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46687.84,,,,,,,fee schedule,10523.19,46687.84,APC 378
Ire abltj 1+tumors open,0601T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11049.35,,,,,,,fee schedule,10523.19,46687.84,APC
Ire abltj 1+tumors open,0601T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10944.12,,,,,,,fee schedule,10523.19,46687.84,APC
Ire abltj 1+tumors open,0601T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10523.19,,,,,,,fee schedule,10523.19,46687.84,APC
Ire abltj 1+tumors open,0601T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16100.48,,,,,,,fee schedule,10523.19,46687.84,Radiology
Ire abltj 1+tumors open,0601T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14732.47,,,,,,,fee schedule,10523.19,46687.84,APC
Ire abltj 1+tumors open,0601T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18415.58,,,,,,,fee schedule,10523.19,46687.84,APC
Rem oct rta dev setup&educaj,0604T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,448.84,,,,,,,fee schedule,359.78,448.84,
Rem oct rta dev setup&educaj,0604T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,359.78,,,,,,,fee schedule,359.78,448.84,
Rem oct rta dev setup&educaj,0604T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,393.03,,,,,,,fee schedule,359.78,448.84,
Rem oct rta dev setup&educaj,0604T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,413.22,,,,,,,fee schedule,359.78,448.84,
Rem oct rta techl sprt min 8,0605T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,140.43,,,,,,,fee schedule,112.56,140.43,
Rem oct rta techl sprt min 8,0605T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,112.56,,,,,,,fee schedule,112.56,140.43,
Rem oct rta techl sprt min 8,0605T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,122.97,,,,,,,fee schedule,112.56,140.43,
Rem oct rta techl sprt min 8,0605T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,129.28,,,,,,,fee schedule,112.56,140.43,
Rem mntr pulm flu mntr setup,0607T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,448.84,,,,,,,fee schedule,359.78,448.84,
Rem mntr pulm flu mntr setup,0607T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,359.78,,,,,,,fee schedule,359.78,448.84,
Rem mntr pulm flu mntr setup,0607T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,393.03,,,,,,,fee schedule,359.78,448.84,
Rem mntr pulm flu mntr setup,0607T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,413.22,,,,,,,fee schedule,359.78,448.84,
Rem mntr pulm flu mntr alys,0608T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,140.43,,,,,,,fee schedule,112.56,140.43,
Rem mntr pulm flu mntr alys,0608T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,112.56,,,,,,,fee schedule,112.56,140.43,
Rem mntr pulm flu mntr alys,0608T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,122.97,,,,,,,fee schedule,112.56,140.43,
Rem mntr pulm flu mntr alys,0608T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,129.28,,,,,,,fee schedule,112.56,140.43,
Mrs disc pain acquisj data,0609T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,869.89,,,,,,,fee schedule,236.21,1047.98,
Mrs disc pain acquisj data,0609T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,697.29,,,,,,,fee schedule,236.21,1047.98,
Mrs disc pain acquisj data,0609T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,761.73,,,,,,,fee schedule,236.21,1047.98,
Mrs disc pain acquisj data,0609T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,800.85,,,,,,,fee schedule,236.21,1047.98,
Mrs disc pain acquisj data,0609T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,236.21,1047.98,APC 378
Mrs disc pain acquisj data,0609T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,236.21,1047.98,APC
Mrs disc pain acquisj data,0609T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,236.21,1047.98,APC
Mrs disc pain acquisj data,0609T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,236.21,1047.98,APC
Mrs disc pain acquisj data,0609T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,236.21,1047.98,Radiology
Mrs disc pain acquisj data,0609T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,236.21,1047.98,APC
Mrs disc pain acquisj data,0609T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,236.21,1047.98,APC
Mrs disc pain alg alys data,0611T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,869.89,,,,,,,fee schedule,236.21,1047.98,
Mrs disc pain alg alys data,0611T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,697.29,,,,,,,fee schedule,236.21,1047.98,
Mrs disc pain alg alys data,0611T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,761.73,,,,,,,fee schedule,236.21,1047.98,
Mrs disc pain alg alys data,0611T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,800.85,,,,,,,fee schedule,236.21,1047.98,
Mrs disc pain alg alys data,0611T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,236.21,1047.98,APC 378
Mrs disc pain alg alys data,0611T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,236.21,1047.98,APC
Mrs disc pain alg alys data,0611T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,236.21,1047.98,APC
Mrs disc pain alg alys data,0611T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,236.21,1047.98,APC
Mrs disc pain alg alys data,0611T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,236.21,1047.98,Radiology
Mrs disc pain alg alys data,0611T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,236.21,1047.98,APC
Mrs disc pain alg alys data,0611T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,236.21,1047.98,APC
Rmvl&rplcmt ss impl dfb pg,0614T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,87091.8,,,,,,,fee schedule,22020.42,97697.15,
Rmvl&rplcmt ss impl dfb pg,0614T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,69811.68,,,,,,,fee schedule,22020.42,97697.15,
Rmvl&rplcmt ss impl dfb pg,0614T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,76262.93,,,,,,,fee schedule,22020.42,97697.15,
Rmvl&rplcmt ss impl dfb pg,0614T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,80179.76,,,,,,,fee schedule,22020.42,97697.15,
Rmvl&rplcmt ss impl dfb pg,0614T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,97697.15,,,,,,,fee schedule,22020.42,97697.15,APC 378
Rmvl&rplcmt ss impl dfb pg,0614T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,23121.44,,,,,,,fee schedule,22020.42,97697.15,APC
Rmvl&rplcmt ss impl dfb pg,0614T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,22901.24,,,,,,,fee schedule,22020.42,97697.15,APC
Rmvl&rplcmt ss impl dfb pg,0614T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,22020.42,,,,,,,fee schedule,22020.42,97697.15,APC
Rmvl&rplcmt ss impl dfb pg,0614T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,33691.24,,,,,,,fee schedule,22020.42,97697.15,Radiology
Rmvl&rplcmt ss impl dfb pg,0614T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,30828.59,,,,,,,fee schedule,22020.42,97697.15,APC
Rmvl&rplcmt ss impl dfb pg,0614T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,38535.73,,,,,,,fee schedule,22020.42,97697.15,APC
Eye mvmt alys w/o calbrj i&r,0615T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,423.17,,,,,,,fee schedule,131.71,584.37,
Eye mvmt alys w/o calbrj i&r,0615T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,339.21,,,,,,,fee schedule,131.71,584.37,
Eye mvmt alys w/o calbrj i&r,0615T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,370.55,,,,,,,fee schedule,131.71,584.37,
Eye mvmt alys w/o calbrj i&r,0615T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,389.59,,,,,,,fee schedule,131.71,584.37,
Eye mvmt alys w/o calbrj i&r,0615T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,131.71,584.37,APC 378
Eye mvmt alys w/o calbrj i&r,0615T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,131.71,584.37,APC
Eye mvmt alys w/o calbrj i&r,0615T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,131.71,584.37,APC
Eye mvmt alys w/o calbrj i&r,0615T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,131.71,584.37,APC
Eye mvmt alys w/o calbrj i&r,0615T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,131.71,584.37,Radiology
Eye mvmt alys w/o calbrj i&r,0615T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,131.71,584.37,APC
Eye mvmt alys w/o calbrj i&r,0615T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,131.71,584.37,APC
Insertion of iris prosthesis,0616T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7859.22,,,,,,,fee schedule,6299.85,7859.22,
Insertion of iris prosthesis,0616T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6299.85,,,,,,,fee schedule,6299.85,7859.22,
Insertion of iris prosthesis,0616T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6882.02,,,,,,,fee schedule,6299.85,7859.22,
Insertion of iris prosthesis,0616T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7235.48,,,,,,,fee schedule,6299.85,7859.22,
Insj iris prosth w/rmvl&insj,0617T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14809.06,,,,,,,fee schedule,11870.75,14809.06,
Insj iris prosth w/rmvl&insj,0617T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11870.75,,,,,,,fee schedule,11870.75,14809.06,
Insj iris prosth w/rmvl&insj,0617T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12967.72,,,,,,,fee schedule,11870.75,14809.06,
Insj iris prosth w/rmvl&insj,0617T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13633.74,,,,,,,fee schedule,11870.75,14809.06,
Insj iris prosth sec io lens,0618T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14809.06,,,,,,,fee schedule,11870.75,14809.06,
Insj iris prosth sec io lens,0618T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11870.75,,,,,,,fee schedule,11870.75,14809.06,
Insj iris prosth sec io lens,0618T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12967.72,,,,,,,fee schedule,11870.75,14809.06,
Insj iris prosth sec io lens,0618T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13633.74,,,,,,,fee schedule,11870.75,14809.06,
Cysto w/prst8 commissurotomy,0619T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16684.54,,,,,,,fee schedule,13374.12,16684.54,
Cysto w/prst8 commissurotomy,0619T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13374.12,,,,,,,fee schedule,13374.12,16684.54,
Cysto w/prst8 commissurotomy,0619T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14610.01,,,,,,,fee schedule,13374.12,16684.54,
Cysto w/prst8 commissurotomy,0619T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15360.37,,,,,,,fee schedule,13374.12,16684.54,
Evasc ven artlz tibl/prnl vn,0620T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60721.92,,,,,,,fee schedule,43604.58,193458.78,
Evasc ven artlz tibl/prnl vn,0620T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48673.92,,,,,,,fee schedule,43604.58,193458.78,
Evasc ven artlz tibl/prnl vn,0620T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53171.84,,,,,,,fee schedule,43604.58,193458.78,
Evasc ven artlz tibl/prnl vn,0620T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55902.72,,,,,,,fee schedule,43604.58,193458.78,
Evasc ven artlz tibl/prnl vn,0620T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,193458.78,,,,,,,fee schedule,43604.58,193458.78,APC 378
Evasc ven artlz tibl/prnl vn,0620T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,45784.81,,,,,,,fee schedule,43604.58,193458.78,APC
Evasc ven artlz tibl/prnl vn,0620T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,45348.77,,,,,,,fee schedule,43604.58,193458.78,APC
Evasc ven artlz tibl/prnl vn,0620T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,43604.58,,,,,,,fee schedule,43604.58,193458.78,APC
Evasc ven artlz tibl/prnl vn,0620T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,66715.01,,,,,,,fee schedule,43604.58,193458.78,Radiology
Evasc ven artlz tibl/prnl vn,0620T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,61046.42,,,,,,,fee schedule,43604.58,193458.78,APC
Evasc ven artlz tibl/prnl vn,0620T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,76308.02,,,,,,,fee schedule,43604.58,193458.78,APC
Auto quan c plaq cptr alys,0625T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3592.89,,,,,,,fee schedule,2880.02,3592.89,
Auto quan c plaq cptr alys,0625T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2880.02,,,,,,,fee schedule,2880.02,3592.89,
Auto quan c plaq cptr alys,0625T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3146.16,,,,,,,fee schedule,2880.02,3592.89,
Auto quan c plaq cptr alys,0625T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3307.74,,,,,,,fee schedule,2880.02,3592.89,
Perq njx algc fluor lmbr 1st,0627T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46549.79,,,,,,,fee schedule,12709.88,56389.43,
Perq njx algc fluor lmbr 1st,0627T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37313.72,,,,,,,fee schedule,12709.88,56389.43,
Perq njx algc fluor lmbr 1st,0627T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40761.86,,,,,,,fee schedule,12709.88,56389.43,
Perq njx algc fluor lmbr 1st,0627T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42855.36,,,,,,,fee schedule,12709.88,56389.43,
Perq njx algc fluor lmbr 1st,0627T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,12709.88,56389.43,APC 378
Perq njx algc fluor lmbr 1st,0627T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,12709.88,56389.43,APC
Perq njx algc fluor lmbr 1st,0627T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,12709.88,56389.43,APC
Perq njx algc fluor lmbr 1st,0627T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,12709.88,56389.43,APC
Perq njx algc fluor lmbr 1st,0627T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,12709.88,56389.43,Radiology
Perq njx algc fluor lmbr 1st,0627T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,12709.88,56389.43,APC
Perq njx algc fluor lmbr 1st,0627T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,12709.88,56389.43,APC
Perq njx algc ct lmbr 1st,0629T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46549.79,,,,,,,fee schedule,12709.88,56389.43,
Perq njx algc ct lmbr 1st,0629T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37313.72,,,,,,,fee schedule,12709.88,56389.43,
Perq njx algc ct lmbr 1st,0629T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40761.86,,,,,,,fee schedule,12709.88,56389.43,
Perq njx algc ct lmbr 1st,0629T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42855.36,,,,,,,fee schedule,12709.88,56389.43,
Perq njx algc ct lmbr 1st,0629T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,12709.88,56389.43,APC 378
Perq njx algc ct lmbr 1st,0629T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,12709.88,56389.43,APC
Perq njx algc ct lmbr 1st,0629T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,12709.88,56389.43,APC
Perq njx algc ct lmbr 1st,0629T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,12709.88,56389.43,APC
Perq njx algc ct lmbr 1st,0629T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,12709.88,56389.43,Radiology
Perq njx algc ct lmbr 1st,0629T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,12709.88,56389.43,APC
Perq njx algc ct lmbr 1st,0629T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,12709.88,56389.43,APC
Tc vis lit hyperspectral img,0631T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,93.25,,,,,,,fee schedule,74.75,93.25,
Tc vis lit hyperspectral img,0631T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,74.75,,,,,,,fee schedule,74.75,93.25,
Tc vis lit hyperspectral img,0631T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,81.66,,,,,,,fee schedule,74.75,93.25,
Tc vis lit hyperspectral img,0631T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,85.85,,,,,,,fee schedule,74.75,93.25,
Perq tcat us abltj nrv p-art,0632T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,62000.73,,,,,,,fee schedule,18147.73,80515.32,
Perq tcat us abltj nrv p-art,0632T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,49699,,,,,,,fee schedule,18147.73,80515.32,
Perq tcat us abltj nrv p-art,0632T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,54291.65,,,,,,,fee schedule,18147.73,80515.32,
Perq tcat us abltj nrv p-art,0632T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,57080.04,,,,,,,fee schedule,18147.73,80515.32,
Perq tcat us abltj nrv p-art,0632T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,80515.32,,,,,,,fee schedule,18147.73,80515.32,APC 378
Perq tcat us abltj nrv p-art,0632T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19055.11,,,,,,,fee schedule,18147.73,80515.32,APC
Perq tcat us abltj nrv p-art,0632T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18873.64,,,,,,,fee schedule,18147.73,80515.32,APC
Perq tcat us abltj nrv p-art,0632T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18147.73,,,,,,,fee schedule,18147.73,80515.32,APC
Perq tcat us abltj nrv p-art,0632T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27766.02,,,,,,,fee schedule,18147.73,80515.32,Radiology
Perq tcat us abltj nrv p-art,0632T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25406.82,,,,,,,fee schedule,18147.73,80515.32,APC
Perq tcat us abltj nrv p-art,0632T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31758.52,,,,,,,fee schedule,18147.73,80515.32,APC
Ct breast w/3d uni c-,0633T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,411.91,,,,,,,fee schedule,103.5,459.18,
Ct breast w/3d uni c-,0633T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,330.18,,,,,,,fee schedule,103.5,459.18,
Ct breast w/3d uni c-,0633T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,360.69,,,,,,,fee schedule,103.5,459.18,
Ct breast w/3d uni c-,0633T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,379.22,,,,,,,fee schedule,103.5,459.18,
Ct breast w/3d uni c-,0633T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
Ct breast w/3d uni c-,0633T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
Ct breast w/3d uni c-,0633T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
Ct breast w/3d uni c-,0633T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
Ct breast w/3d uni c-,0633T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
Ct breast w/3d uni c-,0633T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
Ct breast w/3d uni c-,0633T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Ct breast w/3d uni c+,0634T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,674.92,,,,,,,fee schedule,173.64,770.39,
Ct breast w/3d uni c+,0634T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,541.01,,,,,,,fee schedule,173.64,770.39,
Ct breast w/3d uni c+,0634T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,591,,,,,,,fee schedule,173.64,770.39,
Ct breast w/3d uni c+,0634T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,621.35,,,,,,,fee schedule,173.64,770.39,
Ct breast w/3d uni c+,0634T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,770.39,,,,,,,fee schedule,173.64,770.39,APC 378
Ct breast w/3d uni c+,0634T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,182.32,,,,,,,fee schedule,173.64,770.39,APC
Ct breast w/3d uni c+,0634T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,180.59,,,,,,,fee schedule,173.64,770.39,APC
Ct breast w/3d uni c+,0634T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,173.64,,,,,,,fee schedule,173.64,770.39,APC
Ct breast w/3d uni c+,0634T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,265.67,,,,,,,fee schedule,173.64,770.39,Radiology
Ct breast w/3d uni c+,0634T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,243.1,,,,,,,fee schedule,173.64,770.39,APC
Ct breast w/3d uni c+,0634T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,303.87,,,,,,,fee schedule,173.64,770.39,APC
Ct breast w/3d uni c-/c+,0635T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,674.92,,,,,,,fee schedule,173.64,770.39,
Ct breast w/3d uni c-/c+,0635T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,541.01,,,,,,,fee schedule,173.64,770.39,
Ct breast w/3d uni c-/c+,0635T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,591,,,,,,,fee schedule,173.64,770.39,
Ct breast w/3d uni c-/c+,0635T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,621.35,,,,,,,fee schedule,173.64,770.39,
Ct breast w/3d uni c-/c+,0635T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,770.39,,,,,,,fee schedule,173.64,770.39,APC 378
Ct breast w/3d uni c-/c+,0635T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,182.32,,,,,,,fee schedule,173.64,770.39,APC
Ct breast w/3d uni c-/c+,0635T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,180.59,,,,,,,fee schedule,173.64,770.39,APC
Ct breast w/3d uni c-/c+,0635T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,173.64,,,,,,,fee schedule,173.64,770.39,APC
Ct breast w/3d uni c-/c+,0635T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,265.67,,,,,,,fee schedule,173.64,770.39,Radiology
Ct breast w/3d uni c-/c+,0635T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,243.1,,,,,,,fee schedule,173.64,770.39,APC
Ct breast w/3d uni c-/c+,0635T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,303.87,,,,,,,fee schedule,173.64,770.39,APC
Ct breast w/3d bi c-,0636T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,869.89,,,,,,,fee schedule,236.21,1047.98,
Ct breast w/3d bi c-,0636T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,697.29,,,,,,,fee schedule,236.21,1047.98,
Ct breast w/3d bi c-,0636T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,761.73,,,,,,,fee schedule,236.21,1047.98,
Ct breast w/3d bi c-,0636T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,800.85,,,,,,,fee schedule,236.21,1047.98,
Ct breast w/3d bi c-,0636T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,236.21,1047.98,APC 378
Ct breast w/3d bi c-,0636T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,236.21,1047.98,APC
Ct breast w/3d bi c-,0636T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,236.21,1047.98,APC
Ct breast w/3d bi c-,0636T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,236.21,1047.98,APC
Ct breast w/3d bi c-,0636T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,236.21,1047.98,Radiology
Ct breast w/3d bi c-,0636T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,236.21,1047.98,APC
Ct breast w/3d bi c-,0636T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,236.21,1047.98,APC
Ct breast w/3d bi c+,0637T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1391.49,,,,,,,fee schedule,345.37,1532.31,
Ct breast w/3d bi c+,0637T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1115.4,,,,,,,fee schedule,345.37,1532.31,
Ct breast w/3d bi c+,0637T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1218.48,,,,,,,fee schedule,345.37,1532.31,
Ct breast w/3d bi c+,0637T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1281.06,,,,,,,fee schedule,345.37,1532.31,
Ct breast w/3d bi c+,0637T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1532.31,,,,,,,fee schedule,345.37,1532.31,APC 378
Ct breast w/3d bi c+,0637T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,362.64,,,,,,,fee schedule,345.37,1532.31,APC
Ct breast w/3d bi c+,0637T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,359.19,,,,,,,fee schedule,345.37,1532.31,APC
Ct breast w/3d bi c+,0637T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,345.37,,,,,,,fee schedule,345.37,1532.31,APC
Ct breast w/3d bi c+,0637T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,528.42,,,,,,,fee schedule,345.37,1532.31,Radiology
Ct breast w/3d bi c+,0637T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,483.52,,,,,,,fee schedule,345.37,1532.31,APC
Ct breast w/3d bi c+,0637T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,604.4,,,,,,,fee schedule,345.37,1532.31,APC
Ct breast w/3d bi c-/c+,0638T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1391.49,,,,,,,fee schedule,345.37,1532.31,
Ct breast w/3d bi c-/c+,0638T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1115.4,,,,,,,fee schedule,345.37,1532.31,
Ct breast w/3d bi c-/c+,0638T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1218.48,,,,,,,fee schedule,345.37,1532.31,
Ct breast w/3d bi c-/c+,0638T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1281.06,,,,,,,fee schedule,345.37,1532.31,
Ct breast w/3d bi c-/c+,0638T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1532.31,,,,,,,fee schedule,345.37,1532.31,APC 378
Ct breast w/3d bi c-/c+,0638T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,362.64,,,,,,,fee schedule,345.37,1532.31,APC
Ct breast w/3d bi c-/c+,0638T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,359.19,,,,,,,fee schedule,345.37,1532.31,APC
Ct breast w/3d bi c-/c+,0638T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,345.37,,,,,,,fee schedule,345.37,1532.31,APC
Ct breast w/3d bi c-/c+,0638T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,528.42,,,,,,,fee schedule,345.37,1532.31,Radiology
Ct breast w/3d bi c-/c+,0638T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,483.52,,,,,,,fee schedule,345.37,1532.31,APC
Ct breast w/3d bi c-/c+,0638T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,604.4,,,,,,,fee schedule,345.37,1532.31,APC
Ncntc nr ifr spctrsc wnd,0640T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.05,,,,,,,fee schedule,36.98,164.05,APC 378
Ncntc nr ifr spctrsc wnd,0640T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.83,,,,,,,fee schedule,36.98,164.05,APC
Ncntc nr ifr spctrsc wnd,0640T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.46,,,,,,,fee schedule,36.98,164.05,APC
Ncntc nr ifr spctrsc wnd,0640T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.98,,,,,,,fee schedule,36.98,164.05,APC
Ncntc nr ifr spctrsc wnd,0640T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.57,,,,,,,fee schedule,36.98,164.05,Radiology
Ncntc nr ifr spctrsc wnd,0640T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.77,,,,,,,fee schedule,36.98,164.05,APC
Ncntc nr ifr spctrsc wnd,0640T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.71,,,,,,,fee schedule,36.98,164.05,APC
Ncntc nr ifr spctrsc wnd img,0641T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,130.67,,,,,,,fee schedule,104.75,130.67,
Ncntc nr ifr spctrsc wnd img,0641T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,104.75,,,,,,,fee schedule,104.75,130.67,
Ncntc nr ifr spctrsc wnd img,0641T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,114.43,,,,,,,fee schedule,104.75,130.67,
Ncntc nr ifr spctrsc wnd img,0641T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,120.3,,,,,,,fee schedule,104.75,130.67,
Tcat rmvl/dblk icar mas perq,0644T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19133.94,,,,,,,fee schedule,5634.46,24998.21,
Tcat rmvl/dblk icar mas perq,0644T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15337.53,,,,,,,fee schedule,5634.46,24998.21,
Tcat rmvl/dblk icar mas perq,0644T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16754.86,,,,,,,fee schedule,5634.46,24998.21,
Tcat rmvl/dblk icar mas perq,0644T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17615.38,,,,,,,fee schedule,5634.46,24998.21,
Tcat rmvl/dblk icar mas perq,0644T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24998.21,,,,,,,fee schedule,5634.46,24998.21,APC 378
Tcat rmvl/dblk icar mas perq,0644T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5916.19,,,,,,,fee schedule,5634.46,24998.21,APC
Tcat rmvl/dblk icar mas perq,0644T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5859.84,,,,,,,fee schedule,5634.46,24998.21,APC
Tcat rmvl/dblk icar mas perq,0644T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5634.46,,,,,,,fee schedule,5634.46,24998.21,APC
Tcat rmvl/dblk icar mas perq,0644T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8620.73,,,,,,,fee schedule,5634.46,24998.21,Radiology
Tcat rmvl/dblk icar mas perq,0644T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7888.25,,,,,,,fee schedule,5634.46,24998.21,APC
Tcat rmvl/dblk icar mas perq,0644T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9860.31,,,,,,,fee schedule,5634.46,24998.21,APC
Tcat impltj c sins rdctj dev,0645T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,64931.33,,,,,,,fee schedule,18147.73,80515.32,
Tcat impltj c sins rdctj dev,0645T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52048.13,,,,,,,fee schedule,18147.73,80515.32,
Tcat impltj c sins rdctj dev,0645T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56857.86,,,,,,,fee schedule,18147.73,80515.32,
Tcat impltj c sins rdctj dev,0645T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59778.05,,,,,,,fee schedule,18147.73,80515.32,
Tcat impltj c sins rdctj dev,0645T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,80515.32,,,,,,,fee schedule,18147.73,80515.32,APC 378
Tcat impltj c sins rdctj dev,0645T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19055.11,,,,,,,fee schedule,18147.73,80515.32,APC
Tcat impltj c sins rdctj dev,0645T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18873.64,,,,,,,fee schedule,18147.73,80515.32,APC
Tcat impltj c sins rdctj dev,0645T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18147.73,,,,,,,fee schedule,18147.73,80515.32,APC
Tcat impltj c sins rdctj dev,0645T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27766.02,,,,,,,fee schedule,18147.73,80515.32,Radiology
Tcat impltj c sins rdctj dev,0645T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25406.82,,,,,,,fee schedule,18147.73,80515.32,APC
Tcat impltj c sins rdctj dev,0645T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31758.52,,,,,,,fee schedule,18147.73,80515.32,APC
Insj gtube perq mag gastrpxy,0647T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6270.3,,,,,,,fee schedule,1899.66,8428.13,
Insj gtube perq mag gastrpxy,0647T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5026.19,,,,,,,fee schedule,1899.66,8428.13,
Insj gtube perq mag gastrpxy,0647T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5490.66,,,,,,,fee schedule,1899.66,8428.13,
Insj gtube perq mag gastrpxy,0647T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5772.66,,,,,,,fee schedule,1899.66,8428.13,
Insj gtube perq mag gastrpxy,0647T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8428.13,,,,,,,fee schedule,1899.66,8428.13,APC 378
Insj gtube perq mag gastrpxy,0647T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1994.64,,,,,,,fee schedule,1899.66,8428.13,APC
Insj gtube perq mag gastrpxy,0647T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1975.64,,,,,,,fee schedule,1899.66,8428.13,APC
Insj gtube perq mag gastrpxy,0647T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1899.66,,,,,,,fee schedule,1899.66,8428.13,APC
Insj gtube perq mag gastrpxy,0647T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2906.47,,,,,,,fee schedule,1899.66,8428.13,Radiology
Insj gtube perq mag gastrpxy,0647T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2659.52,,,,,,,fee schedule,1899.66,8428.13,APC
Insj gtube perq mag gastrpxy,0647T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3324.4,,,,,,,fee schedule,1899.66,8428.13,APC
Quan mr alys tiss w/o mri,0648T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3592.89,,,,,,,fee schedule,921.02,4086.23,
Quan mr alys tiss w/o mri,0648T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2880.02,,,,,,,fee schedule,921.02,4086.23,
Quan mr alys tiss w/o mri,0648T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3146.16,,,,,,,fee schedule,921.02,4086.23,
Quan mr alys tiss w/o mri,0648T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3307.74,,,,,,,fee schedule,921.02,4086.23,
Quan mr alys tiss w/o mri,0648T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4086.23,,,,,,,fee schedule,921.02,4086.23,APC 378
Quan mr alys tiss w/o mri,0648T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,967.07,,,,,,,fee schedule,921.02,4086.23,APC
Quan mr alys tiss w/o mri,0648T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,957.86,,,,,,,fee schedule,921.02,4086.23,APC
Quan mr alys tiss w/o mri,0648T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,921.02,,,,,,,fee schedule,921.02,4086.23,APC
Quan mr alys tiss w/o mri,0648T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1409.15,,,,,,,fee schedule,921.02,4086.23,Radiology
Quan mr alys tiss w/o mri,0648T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1289.42,,,,,,,fee schedule,921.02,4086.23,APC
Quan mr alys tiss w/o mri,0648T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1611.78,,,,,,,fee schedule,921.02,4086.23,APC
Quan mr alys tiss w/mri,0649T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3592.89,,,,,,,fee schedule,921.02,4086.23,
Quan mr alys tiss w/mri,0649T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2880.02,,,,,,,fee schedule,921.02,4086.23,
Quan mr alys tiss w/mri,0649T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3146.16,,,,,,,fee schedule,921.02,4086.23,
Quan mr alys tiss w/mri,0649T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3307.74,,,,,,,fee schedule,921.02,4086.23,
Quan mr alys tiss w/mri,0649T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4086.23,,,,,,,fee schedule,921.02,4086.23,APC 378
Quan mr alys tiss w/mri,0649T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,967.07,,,,,,,fee schedule,921.02,4086.23,APC
Quan mr alys tiss w/mri,0649T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,957.86,,,,,,,fee schedule,921.02,4086.23,APC
Quan mr alys tiss w/mri,0649T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,921.02,,,,,,,fee schedule,921.02,4086.23,APC
Quan mr alys tiss w/mri,0649T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1409.15,,,,,,,fee schedule,921.02,4086.23,Radiology
Quan mr alys tiss w/mri,0649T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1289.42,,,,,,,fee schedule,921.02,4086.23,APC
Quan mr alys tiss w/mri,0649T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1611.78,,,,,,,fee schedule,921.02,4086.23,APC
Prgrmg dev eval scrms remote,0650T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,143.75,,,,,,,fee schedule,36.95,163.92,
Prgrmg dev eval scrms remote,0650T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,115.23,,,,,,,fee schedule,36.95,163.92,
Prgrmg dev eval scrms remote,0650T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,125.88,,,,,,,fee schedule,36.95,163.92,
Prgrmg dev eval scrms remote,0650T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,132.34,,,,,,,fee schedule,36.95,163.92,
Prgrmg dev eval scrms remote,0650T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,163.92,,,,,,,fee schedule,36.95,163.92,APC 378
Prgrmg dev eval scrms remote,0650T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.79,,,,,,,fee schedule,36.95,163.92,APC
Prgrmg dev eval scrms remote,0650T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.43,,,,,,,fee schedule,36.95,163.92,APC
Prgrmg dev eval scrms remote,0650T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.95,,,,,,,fee schedule,36.95,163.92,APC
Prgrmg dev eval scrms remote,0650T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.53,,,,,,,fee schedule,36.95,163.92,Radiology
Prgrmg dev eval scrms remote,0650T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.73,,,,,,,fee schedule,36.95,163.92,APC
Prgrmg dev eval scrms remote,0650T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.66,,,,,,,fee schedule,36.95,163.92,APC
Mag ctrld capsule endoscopy,0651T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3123.75,,,,,,,fee schedule,897.89,3983.62,
Mag ctrld capsule endoscopy,0651T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2503.96,,,,,,,fee schedule,897.89,3983.62,
Mag ctrld capsule endoscopy,0651T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2735.35,,,,,,,fee schedule,897.89,3983.62,
Mag ctrld capsule endoscopy,0651T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2875.84,,,,,,,fee schedule,897.89,3983.62,
Mag ctrld capsule endoscopy,0651T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3983.62,,,,,,,fee schedule,897.89,3983.62,APC 378
Mag ctrld capsule endoscopy,0651T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,942.78,,,,,,,fee schedule,897.89,3983.62,APC
Mag ctrld capsule endoscopy,0651T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,933.8,,,,,,,fee schedule,897.89,3983.62,APC
Mag ctrld capsule endoscopy,0651T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,897.89,,,,,,,fee schedule,897.89,3983.62,APC
Mag ctrld capsule endoscopy,0651T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1373.77,,,,,,,fee schedule,897.89,3983.62,Radiology
Mag ctrld capsule endoscopy,0651T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1257.04,,,,,,,fee schedule,897.89,3983.62,APC
Mag ctrld capsule endoscopy,0651T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1571.3,,,,,,,fee schedule,897.89,3983.62,APC
Egd flx transnasal dx br/wa,0652T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3123.75,,,,,,,fee schedule,1899.66,8428.13,
Egd flx transnasal dx br/wa,0652T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2503.96,,,,,,,fee schedule,1899.66,8428.13,
Egd flx transnasal dx br/wa,0652T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2735.35,,,,,,,fee schedule,1899.66,8428.13,
Egd flx transnasal dx br/wa,0652T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2875.84,,,,,,,fee schedule,1899.66,8428.13,
Egd flx transnasal dx br/wa,0652T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8428.13,,,,,,,fee schedule,1899.66,8428.13,APC 378
Egd flx transnasal dx br/wa,0652T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1994.64,,,,,,,fee schedule,1899.66,8428.13,APC
Egd flx transnasal dx br/wa,0652T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1975.64,,,,,,,fee schedule,1899.66,8428.13,APC
Egd flx transnasal dx br/wa,0652T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1899.66,,,,,,,fee schedule,1899.66,8428.13,APC
Egd flx transnasal dx br/wa,0652T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2906.47,,,,,,,fee schedule,1899.66,8428.13,Radiology
Egd flx transnasal dx br/wa,0652T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2659.52,,,,,,,fee schedule,1899.66,8428.13,APC
Egd flx transnasal dx br/wa,0652T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3324.4,,,,,,,fee schedule,1899.66,8428.13,APC
Egd flx transnasal bx 1/ml,0653T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3123.75,,,,,,,fee schedule,1899.66,8428.13,
Egd flx transnasal bx 1/ml,0653T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2503.96,,,,,,,fee schedule,1899.66,8428.13,
Egd flx transnasal bx 1/ml,0653T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2735.35,,,,,,,fee schedule,1899.66,8428.13,
Egd flx transnasal bx 1/ml,0653T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2875.84,,,,,,,fee schedule,1899.66,8428.13,
Egd flx transnasal bx 1/ml,0653T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8428.13,,,,,,,fee schedule,1899.66,8428.13,APC 378
Egd flx transnasal bx 1/ml,0653T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1994.64,,,,,,,fee schedule,1899.66,8428.13,APC
Egd flx transnasal bx 1/ml,0653T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1975.64,,,,,,,fee schedule,1899.66,8428.13,APC
Egd flx transnasal bx 1/ml,0653T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1899.66,,,,,,,fee schedule,1899.66,8428.13,APC
Egd flx transnasal bx 1/ml,0653T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2906.47,,,,,,,fee schedule,1899.66,8428.13,Radiology
Egd flx transnasal bx 1/ml,0653T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2659.52,,,,,,,fee schedule,1899.66,8428.13,APC
Egd flx transnasal bx 1/ml,0653T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3324.4,,,,,,,fee schedule,1899.66,8428.13,APC
Egd flx transnasal tube/cath,0654T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6270.3,,,,,,,fee schedule,3816.79,16933.82,
Egd flx transnasal tube/cath,0654T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5026.19,,,,,,,fee schedule,3816.79,16933.82,
Egd flx transnasal tube/cath,0654T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5490.66,,,,,,,fee schedule,3816.79,16933.82,
Egd flx transnasal tube/cath,0654T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5772.66,,,,,,,fee schedule,3816.79,16933.82,
Egd flx transnasal tube/cath,0654T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16933.82,,,,,,,fee schedule,3816.79,16933.82,APC 378
Egd flx transnasal tube/cath,0654T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4007.63,,,,,,,fee schedule,3816.79,16933.82,APC
Egd flx transnasal tube/cath,0654T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3969.46,,,,,,,fee schedule,3816.79,16933.82,APC
Egd flx transnasal tube/cath,0654T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3816.79,,,,,,,fee schedule,3816.79,16933.82,APC
Egd flx transnasal tube/cath,0654T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5839.69,,,,,,,fee schedule,3816.79,16933.82,Radiology
Egd flx transnasal tube/cath,0654T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5343.51,,,,,,,fee schedule,3816.79,16933.82,APC
Egd flx transnasal tube/cath,0654T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6679.39,,,,,,,fee schedule,3816.79,16933.82,APC
Tprnl focal abltj mal prst8,0655T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11869.35,,,,,,,fee schedule,5308,23549.82,
Tprnl focal abltj mal prst8,0655T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9514.32,,,,,,,fee schedule,5308,23549.82,
Tprnl focal abltj mal prst8,0655T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10393.53,,,,,,,fee schedule,5308,23549.82,
Tprnl focal abltj mal prst8,0655T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10927.34,,,,,,,fee schedule,5308,23549.82,
Tprnl focal abltj mal prst8,0655T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23549.82,,,,,,,fee schedule,5308,23549.82,APC 378
Tprnl focal abltj mal prst8,0655T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5573.4,,,,,,,fee schedule,5308,23549.82,APC
Tprnl focal abltj mal prst8,0655T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5520.32,,,,,,,fee schedule,5308,23549.82,APC
Tprnl focal abltj mal prst8,0655T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5308,,,,,,,fee schedule,5308,23549.82,APC
Tprnl focal abltj mal prst8,0655T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8121.25,,,,,,,fee schedule,5308,23549.82,Radiology
Tprnl focal abltj mal prst8,0655T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7431.21,,,,,,,fee schedule,5308,23549.82,APC
Tprnl focal abltj mal prst8,0655T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9289.01,,,,,,,fee schedule,5308,23549.82,APC
Vrt bdy tethering ant,0656T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,77011.17,,,,,,,fee schedule,17357.91,77011.17,APC 378
Vrt bdy tethering ant,0656T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18225.81,,,,,,,fee schedule,17357.91,77011.17,APC
Vrt bdy tethering ant,0656T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18052.23,,,,,,,fee schedule,17357.91,77011.17,APC
Vrt bdy tethering ant,0656T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17357.91,,,,,,,fee schedule,17357.91,77011.17,APC
Vrt bdy tethering ant,0656T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26557.6,,,,,,,fee schedule,17357.91,77011.17,Radiology
Vrt bdy tethering ant,0656T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24301.07,,,,,,,fee schedule,17357.91,77011.17,APC
Vrt bdy tethering ant,0656T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30376.34,,,,,,,fee schedule,17357.91,77011.17,APC
Vrt bdy tethering ant 8+ seg,0657T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,77011.17,,,,,,,fee schedule,17357.91,77011.17,APC 378
Vrt bdy tethering ant 8+ seg,0657T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18225.81,,,,,,,fee schedule,17357.91,77011.17,APC
Vrt bdy tethering ant 8+ seg,0657T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18052.23,,,,,,,fee schedule,17357.91,77011.17,APC
Vrt bdy tethering ant 8+ seg,0657T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17357.91,,,,,,,fee schedule,17357.91,77011.17,APC
Vrt bdy tethering ant 8+ seg,0657T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26557.6,,,,,,,fee schedule,17357.91,77011.17,Radiology
Vrt bdy tethering ant 8+ seg,0657T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24301.07,,,,,,,fee schedule,17357.91,77011.17,APC
Vrt bdy tethering ant 8+ seg,0657T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30376.34,,,,,,,fee schedule,17357.91,77011.17,APC
Elec impd spectrsc 1+skn les,0658T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,214.89,,,,,,,fee schedule,58.4,259.1,
Elec impd spectrsc 1+skn les,0658T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,172.26,,,,,,,fee schedule,58.4,259.1,
Elec impd spectrsc 1+skn les,0658T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,188.17,,,,,,,fee schedule,58.4,259.1,
Elec impd spectrsc 1+skn les,0658T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,197.84,,,,,,,fee schedule,58.4,259.1,
Elec impd spectrsc 1+skn les,0658T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,58.4,259.1,APC 378
Elec impd spectrsc 1+skn les,0658T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,58.4,259.1,APC
Elec impd spectrsc 1+skn les,0658T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,58.4,259.1,APC
Elec impd spectrsc 1+skn les,0658T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,58.4,259.1,APC
Elec impd spectrsc 1+skn les,0658T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,58.4,259.1,Radiology
Elec impd spectrsc 1+skn les,0658T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,58.4,259.1,APC
Elec impd spectrsc 1+skn les,0658T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,58.4,259.1,APC
Scalp cool 1st meas&calbrj,0662T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6994.89,,,,,,,fee schedule,5607.02,6994.89,
Scalp cool 1st meas&calbrj,0662T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5607.02,,,,,,,fee schedule,5607.02,6994.89,
Scalp cool 1st meas&calbrj,0662T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6125.16,,,,,,,fee schedule,5607.02,6994.89,
Scalp cool 1st meas&calbrj,0662T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6439.74,,,,,,,fee schedule,5607.02,6994.89,
Insj ant sgm aq drg dev 1+,0671T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8016.85,,,,,,,fee schedule,5267.92,23371.97,
Insj ant sgm aq drg dev 1+,0671T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6426.21,,,,,,,fee schedule,5267.92,23371.97,
Insj ant sgm aq drg dev 1+,0671T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7020.05,,,,,,,fee schedule,5267.92,23371.97,
Insj ant sgm aq drg dev 1+,0671T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7380.59,,,,,,,fee schedule,5267.92,23371.97,
Insj ant sgm aq drg dev 1+,0671T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23371.97,,,,,,,fee schedule,5267.92,23371.97,APC 378
Insj ant sgm aq drg dev 1+,0671T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5531.31,,,,,,,fee schedule,5267.92,23371.97,APC
Insj ant sgm aq drg dev 1+,0671T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5478.63,,,,,,,fee schedule,5267.92,23371.97,APC
Insj ant sgm aq drg dev 1+,0671T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5267.92,,,,,,,fee schedule,5267.92,23371.97,APC
Insj ant sgm aq drg dev 1+,0671T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8059.91,,,,,,,fee schedule,5267.92,23371.97,Radiology
Insj ant sgm aq drg dev 1+,0671T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7375.09,,,,,,,fee schedule,5267.92,23371.97,APC
Insj ant sgm aq drg dev 1+,0671T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9218.86,,,,,,,fee schedule,5267.92,23371.97,APC
Abltj b9 thyr ndul perq lasr,0673T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5431.82,,,,,,,fee schedule,1635.03,7254.06,
Abltj b9 thyr ndul perq lasr,0673T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4354.08,,,,,,,fee schedule,1635.03,7254.06,
Abltj b9 thyr ndul perq lasr,0673T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4756.44,,,,,,,fee schedule,1635.03,7254.06,
Abltj b9 thyr ndul perq lasr,0673T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5000.73,,,,,,,fee schedule,1635.03,7254.06,
Abltj b9 thyr ndul perq lasr,0673T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,7254.06,APC 378
Abltj b9 thyr ndul perq lasr,0673T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,7254.06,APC
Abltj b9 thyr ndul perq lasr,0673T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,7254.06,APC
Abltj b9 thyr ndul perq lasr,0673T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,7254.06,APC
Abltj b9 thyr ndul perq lasr,0673T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,7254.06,Radiology
Abltj b9 thyr ndul perq lasr,0673T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,7254.06,APC
Abltj b9 thyr ndul perq lasr,0673T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,7254.06,APC
Laps insj nw/rpcmt prm isdss,0674T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,135531.68,,,,,,,fee schedule,30548.12,135531.68,APC 378
Laps insj nw/rpcmt prm isdss,0674T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,32075.53,,,,,,,fee schedule,30548.12,135531.68,APC
Laps insj nw/rpcmt prm isdss,0674T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,31770.05,,,,,,,fee schedule,30548.12,135531.68,APC
Laps insj nw/rpcmt prm isdss,0674T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,30548.12,,,,,,,fee schedule,30548.12,135531.68,APC
Laps insj nw/rpcmt prm isdss,0674T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,46738.63,,,,,,,fee schedule,30548.12,135531.68,Radiology
Laps insj nw/rpcmt prm isdss,0674T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,42767.37,,,,,,,fee schedule,30548.12,135531.68,APC
Laps insj nw/rpcmt prm isdss,0674T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,53459.21,,,,,,,fee schedule,30548.12,135531.68,APC
Laps repos lead isdss 1st ld,0677T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46687.84,,,,,,,fee schedule,10523.19,46687.84,APC 378
Laps repos lead isdss 1st ld,0677T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11049.35,,,,,,,fee schedule,10523.19,46687.84,APC
Laps repos lead isdss 1st ld,0677T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10944.12,,,,,,,fee schedule,10523.19,46687.84,APC
Laps repos lead isdss 1st ld,0677T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10523.19,,,,,,,fee schedule,10523.19,46687.84,APC
Laps repos lead isdss 1st ld,0677T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16100.48,,,,,,,fee schedule,10523.19,46687.84,Radiology
Laps repos lead isdss 1st ld,0677T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14732.47,,,,,,,fee schedule,10523.19,46687.84,APC
Laps repos lead isdss 1st ld,0677T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18415.58,,,,,,,fee schedule,10523.19,46687.84,APC
Laps rmvl lead isdss,0679T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46687.84,,,,,,,fee schedule,10523.19,46687.84,APC 378
Laps rmvl lead isdss,0679T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11049.35,,,,,,,fee schedule,10523.19,46687.84,APC
Laps rmvl lead isdss,0679T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10944.12,,,,,,,fee schedule,10523.19,46687.84,APC
Laps rmvl lead isdss,0679T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10523.19,,,,,,,fee schedule,10523.19,46687.84,APC
Laps rmvl lead isdss,0679T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16100.48,,,,,,,fee schedule,10523.19,46687.84,Radiology
Laps rmvl lead isdss,0679T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14732.47,,,,,,,fee schedule,10523.19,46687.84,APC
Laps rmvl lead isdss,0679T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18415.58,,,,,,,fee schedule,10523.19,46687.84,APC
Insj/rplcmt pg only isdss,0680T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,85208.23,,,,,,,fee schedule,19205.48,85208.23,APC 378
Insj/rplcmt pg only isdss,0680T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20165.76,,,,,,,fee schedule,19205.48,85208.23,APC
Insj/rplcmt pg only isdss,0680T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,19973.7,,,,,,,fee schedule,19205.48,85208.23,APC
Insj/rplcmt pg only isdss,0680T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,19205.48,,,,,,,fee schedule,19205.48,85208.23,APC
Insj/rplcmt pg only isdss,0680T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29384.39,,,,,,,fee schedule,19205.48,85208.23,Radiology
Insj/rplcmt pg only isdss,0680T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26887.68,,,,,,,fee schedule,19205.48,85208.23,APC
Insj/rplcmt pg only isdss,0680T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,33609.6,,,,,,,fee schedule,19205.48,85208.23,APC
Rlcj pulse gen only isdss,0681T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15355.43,,,,,,,fee schedule,3461.03,15355.43,APC 378
Rlcj pulse gen only isdss,0681T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3634.08,,,,,,,fee schedule,3461.03,15355.43,APC
Rlcj pulse gen only isdss,0681T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3599.47,,,,,,,fee schedule,3461.03,15355.43,APC
Rlcj pulse gen only isdss,0681T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3461.03,,,,,,,fee schedule,3461.03,15355.43,APC
Rlcj pulse gen only isdss,0681T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5295.38,,,,,,,fee schedule,3461.03,15355.43,Radiology
Rlcj pulse gen only isdss,0681T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4845.44,,,,,,,fee schedule,3461.03,15355.43,APC
Rlcj pulse gen only isdss,0681T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6056.81,,,,,,,fee schedule,3461.03,15355.43,APC
Removal pulse gen only isdss,0682T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15355.43,,,,,,,fee schedule,3461.03,15355.43,APC 378
Removal pulse gen only isdss,0682T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3634.08,,,,,,,fee schedule,3461.03,15355.43,APC
Removal pulse gen only isdss,0682T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3599.47,,,,,,,fee schedule,3461.03,15355.43,APC
Removal pulse gen only isdss,0682T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3461.03,,,,,,,fee schedule,3461.03,15355.43,APC
Removal pulse gen only isdss,0682T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5295.38,,,,,,,fee schedule,3461.03,15355.43,Radiology
Removal pulse gen only isdss,0682T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4845.44,,,,,,,fee schedule,3461.03,15355.43,APC
Removal pulse gen only isdss,0682T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6056.81,,,,,,,fee schedule,3461.03,15355.43,APC
Histotripsy mal hepatcel tis,0686T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,47251.89,,,,,,,fee schedule,16957.63,75235.29,
Histotripsy mal hepatcel tis,0686T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37876.52,,,,,,,fee schedule,16957.63,75235.29,
Histotripsy mal hepatcel tis,0686T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,41376.66,,,,,,,fee schedule,16957.63,75235.29,
Histotripsy mal hepatcel tis,0686T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,43501.74,,,,,,,fee schedule,16957.63,75235.29,
Histotripsy mal hepatcel tis,0686T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,75235.29,,,,,,,fee schedule,16957.63,75235.29,APC 378
Histotripsy mal hepatcel tis,0686T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17805.52,,,,,,,fee schedule,16957.63,75235.29,APC
Histotripsy mal hepatcel tis,0686T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,17635.94,,,,,,,fee schedule,16957.63,75235.29,APC
Histotripsy mal hepatcel tis,0686T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16957.63,,,,,,,fee schedule,16957.63,75235.29,APC
Histotripsy mal hepatcel tis,0686T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25945.18,,,,,,,fee schedule,16957.63,75235.29,Radiology
Histotripsy mal hepatcel tis,0686T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23740.69,,,,,,,fee schedule,16957.63,75235.29,APC
Histotripsy mal hepatcel tis,0686T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,29675.86,,,,,,,fee schedule,16957.63,75235.29,APC
Quan us tis charac w/o dx us,0689T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,312.27,,,,,,,fee schedule,86.15,382.23,
Quan us tis charac w/o dx us,0689T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,250.31,,,,,,,fee schedule,86.15,382.23,
Quan us tis charac w/o dx us,0689T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,273.44,,,,,,,fee schedule,86.15,382.23,
Quan us tis charac w/o dx us,0689T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,287.48,,,,,,,fee schedule,86.15,382.23,
Quan us tis charac w/o dx us,0689T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
Quan us tis charac w/o dx us,0689T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
Quan us tis charac w/o dx us,0689T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
Quan us tis charac w/o dx us,0689T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
Quan us tis charac w/o dx us,0689T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
Quan us tis charac w/o dx us,0689T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
Quan us tis charac w/o dx us,0689T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
Therapeutic ultrafiltration,0692T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1532.3,,,,,,,fee schedule,1228.27,6840.45,
Therapeutic ultrafiltration,0692T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1228.27,,,,,,,fee schedule,1228.27,6840.45,
Therapeutic ultrafiltration,0692T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1341.77,,,,,,,fee schedule,1228.27,6840.45,
Therapeutic ultrafiltration,0692T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1410.69,,,,,,,fee schedule,1228.27,6840.45,
Therapeutic ultrafiltration,0692T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6840.45,,,,,,,fee schedule,1228.27,6840.45,APC 378
Therapeutic ultrafiltration,0692T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1618.89,,,,,,,fee schedule,1228.27,6840.45,APC
Therapeutic ultrafiltration,0692T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1603.47,,,,,,,fee schedule,1228.27,6840.45,APC
Therapeutic ultrafiltration,0692T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1541.8,,,,,,,fee schedule,1228.27,6840.45,APC
Therapeutic ultrafiltration,0692T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2358.96,,,,,,,fee schedule,1228.27,6840.45,Radiology
Therapeutic ultrafiltration,0692T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2158.52,,,,,,,fee schedule,1228.27,6840.45,APC
Therapeutic ultrafiltration,0692T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2698.15,,,,,,,fee schedule,1228.27,6840.45,APC
Compre ful bdy 3d mtn alys,0693T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1324.89,,,,,,,fee schedule,339.63,1506.81,
Compre ful bdy 3d mtn alys,0693T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1062.02,,,,,,,fee schedule,339.63,1506.81,
Compre ful bdy 3d mtn alys,0693T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1160.16,,,,,,,fee schedule,339.63,1506.81,
Compre ful bdy 3d mtn alys,0693T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1219.74,,,,,,,fee schedule,339.63,1506.81,
Compre ful bdy 3d mtn alys,0693T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1506.81,,,,,,,fee schedule,339.63,1506.81,APC 378
Compre ful bdy 3d mtn alys,0693T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,356.61,,,,,,,fee schedule,339.63,1506.81,APC
Compre ful bdy 3d mtn alys,0693T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,353.21,,,,,,,fee schedule,339.63,1506.81,APC
Compre ful bdy 3d mtn alys,0693T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,339.63,,,,,,,fee schedule,339.63,1506.81,APC
Compre ful bdy 3d mtn alys,0693T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,519.63,,,,,,,fee schedule,339.63,1506.81,Radiology
Compre ful bdy 3d mtn alys,0693T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,475.48,,,,,,,fee schedule,339.63,1506.81,APC
Compre ful bdy 3d mtn alys,0693T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,594.35,,,,,,,fee schedule,339.63,1506.81,APC
Bdy surf mapg pm/cvdfb f/up,0696T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,143.75,,,,,,,fee schedule,36.95,163.92,
Bdy surf mapg pm/cvdfb f/up,0696T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,115.23,,,,,,,fee schedule,36.95,163.92,
Bdy surf mapg pm/cvdfb f/up,0696T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,125.88,,,,,,,fee schedule,36.95,163.92,
Bdy surf mapg pm/cvdfb f/up,0696T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,132.34,,,,,,,fee schedule,36.95,163.92,
Bdy surf mapg pm/cvdfb f/up,0696T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,163.92,,,,,,,fee schedule,36.95,163.92,APC 378
Bdy surf mapg pm/cvdfb f/up,0696T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.79,,,,,,,fee schedule,36.95,163.92,APC
Bdy surf mapg pm/cvdfb f/up,0696T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.43,,,,,,,fee schedule,36.95,163.92,APC
Bdy surf mapg pm/cvdfb f/up,0696T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.95,,,,,,,fee schedule,36.95,163.92,APC
Bdy surf mapg pm/cvdfb f/up,0696T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.53,,,,,,,fee schedule,36.95,163.92,Radiology
Bdy surf mapg pm/cvdfb f/up,0696T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.73,,,,,,,fee schedule,36.95,163.92,APC
Bdy surf mapg pm/cvdfb f/up,0696T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.66,,,,,,,fee schedule,36.95,163.92,APC
Quan mr tis wo mri mlt orgn,0697T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,888.3,,,,,,,fee schedule,712.05,4086.23,
Quan mr tis wo mri mlt orgn,0697T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,712.05,,,,,,,fee schedule,712.05,4086.23,
Quan mr tis wo mri mlt orgn,0697T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,777.85,,,,,,,fee schedule,712.05,4086.23,
Quan mr tis wo mri mlt orgn,0697T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,817.8,,,,,,,fee schedule,712.05,4086.23,
Quan mr tis wo mri mlt orgn,0697T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4086.23,,,,,,,fee schedule,712.05,4086.23,APC 378
Quan mr tis wo mri mlt orgn,0697T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,967.07,,,,,,,fee schedule,712.05,4086.23,APC
Quan mr tis wo mri mlt orgn,0697T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,957.86,,,,,,,fee schedule,712.05,4086.23,APC
Quan mr tis wo mri mlt orgn,0697T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,921.02,,,,,,,fee schedule,712.05,4086.23,APC
Quan mr tis wo mri mlt orgn,0697T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1409.15,,,,,,,fee schedule,712.05,4086.23,Radiology
Quan mr tis wo mri mlt orgn,0697T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1289.42,,,,,,,fee schedule,712.05,4086.23,APC
Quan mr tis wo mri mlt orgn,0697T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1611.78,,,,,,,fee schedule,712.05,4086.23,APC
Njx pst chmbr eye medication,0699T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8016.85,,,,,,,fee schedule,2284.67,10136.31,
Njx pst chmbr eye medication,0699T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6426.21,,,,,,,fee schedule,2284.67,10136.31,
Njx pst chmbr eye medication,0699T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7020.05,,,,,,,fee schedule,2284.67,10136.31,
Njx pst chmbr eye medication,0699T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7380.59,,,,,,,fee schedule,2284.67,10136.31,
Njx pst chmbr eye medication,0699T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10136.31,,,,,,,fee schedule,2284.67,10136.31,APC 378
Njx pst chmbr eye medication,0699T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2398.9,,,,,,,fee schedule,2284.67,10136.31,APC
Njx pst chmbr eye medication,0699T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2376.06,,,,,,,fee schedule,2284.67,10136.31,APC
Njx pst chmbr eye medication,0699T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2284.67,,,,,,,fee schedule,2284.67,10136.31,APC
Njx pst chmbr eye medication,0699T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3495.55,,,,,,,fee schedule,2284.67,10136.31,Radiology
Njx pst chmbr eye medication,0699T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3198.54,,,,,,,fee schedule,2284.67,10136.31,APC
Njx pst chmbr eye medication,0699T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3998.17,,,,,,,fee schedule,2284.67,10136.31,APC
Njx b1 sub mtrl sbchdrl dfct,0707T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10932.82,,,,,,,fee schedule,3239.17,14371.12,
Njx b1 sub mtrl sbchdrl dfct,0707T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8763.61,,,,,,,fee schedule,3239.17,14371.12,
Njx b1 sub mtrl sbchdrl dfct,0707T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9573.45,,,,,,,fee schedule,3239.17,14371.12,
Njx b1 sub mtrl sbchdrl dfct,0707T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10065.13,,,,,,,fee schedule,3239.17,14371.12,
Njx b1 sub mtrl sbchdrl dfct,0707T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Njx b1 sub mtrl sbchdrl dfct,0707T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Njx b1 sub mtrl sbchdrl dfct,0707T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Njx b1 sub mtrl sbchdrl dfct,0707T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Njx b1 sub mtrl sbchdrl dfct,0707T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Njx b1 sub mtrl sbchdrl dfct,0707T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Njx b1 sub mtrl sbchdrl dfct,0707T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
N-nvs artl plaq alys quan,0712T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,312.27,,,,,,,fee schedule,213.76,948.37,
N-nvs artl plaq alys quan,0712T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,250.31,,,,,,,fee schedule,213.76,948.37,
N-nvs artl plaq alys quan,0712T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,273.44,,,,,,,fee schedule,213.76,948.37,
N-nvs artl plaq alys quan,0712T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,287.48,,,,,,,fee schedule,213.76,948.37,
N-nvs artl plaq alys quan,0712T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,213.76,948.37,APC 378
N-nvs artl plaq alys quan,0712T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,213.76,948.37,APC
N-nvs artl plaq alys quan,0712T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,213.76,948.37,APC
N-nvs artl plaq alys quan,0712T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,213.76,948.37,APC
N-nvs artl plaq alys quan,0712T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,213.76,948.37,Radiology
N-nvs artl plaq alys quan,0712T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,213.76,948.37,APC
N-nvs artl plaq alys quan,0712T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,213.76,948.37,APC
Tprnl lsr ablt b9 prst8 hypr,0714T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17032.26,,,,,,,fee schedule,5308,23549.82,
Tprnl lsr ablt b9 prst8 hypr,0714T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13652.85,,,,,,,fee schedule,5308,23549.82,
Tprnl lsr ablt b9 prst8 hypr,0714T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14914.5,,,,,,,fee schedule,5308,23549.82,
Tprnl lsr ablt b9 prst8 hypr,0714T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15680.5,,,,,,,fee schedule,5308,23549.82,
Tprnl lsr ablt b9 prst8 hypr,0714T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23549.82,,,,,,,fee schedule,5308,23549.82,APC 378
Tprnl lsr ablt b9 prst8 hypr,0714T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5573.4,,,,,,,fee schedule,5308,23549.82,APC
Tprnl lsr ablt b9 prst8 hypr,0714T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5520.32,,,,,,,fee schedule,5308,23549.82,APC
Tprnl lsr ablt b9 prst8 hypr,0714T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5308,,,,,,,fee schedule,5308,23549.82,APC
Tprnl lsr ablt b9 prst8 hypr,0714T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8121.25,,,,,,,fee schedule,5308,23549.82,Radiology
Tprnl lsr ablt b9 prst8 hypr,0714T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7431.21,,,,,,,fee schedule,5308,23549.82,APC
Tprnl lsr ablt b9 prst8 hypr,0714T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9289.01,,,,,,,fee schedule,5308,23549.82,APC
Car acous wavfrm rec cad rsk,0716T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,214.89,,,,,,,fee schedule,58.4,259.1,
Car acous wavfrm rec cad rsk,0716T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,172.26,,,,,,,fee schedule,58.4,259.1,
Car acous wavfrm rec cad rsk,0716T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,188.17,,,,,,,fee schedule,58.4,259.1,
Car acous wavfrm rec cad rsk,0716T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,197.84,,,,,,,fee schedule,58.4,259.1,
Car acous wavfrm rec cad rsk,0716T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,58.4,259.1,APC 378
Car acous wavfrm rec cad rsk,0716T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,58.4,259.1,APC
Car acous wavfrm rec cad rsk,0716T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,58.4,259.1,APC
Car acous wavfrm rec cad rsk,0716T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,58.4,259.1,APC
Car acous wavfrm rec cad rsk,0716T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,58.4,259.1,Radiology
Car acous wavfrm rec cad rsk,0716T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,58.4,259.1,APC
Car acous wavfrm rec cad rsk,0716T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,58.4,259.1,APC
Adrc ther prtl rc tear,0717T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15564.58,,,,,,,fee schedule,3508.17,15564.58,APC 378
Adrc ther prtl rc tear,0717T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3683.58,,,,,,,fee schedule,3508.17,15564.58,APC
Adrc ther prtl rc tear,0717T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3648.5,,,,,,,fee schedule,3508.17,15564.58,APC
Adrc ther prtl rc tear,0717T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3508.17,,,,,,,fee schedule,3508.17,15564.58,APC
Adrc ther prtl rc tear,0717T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5367.5,,,,,,,fee schedule,3508.17,15564.58,Radiology
Adrc ther prtl rc tear,0717T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4911.44,,,,,,,fee schedule,3508.17,15564.58,APC
Adrc ther prtl rc tear,0717T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6139.3,,,,,,,fee schedule,3508.17,15564.58,APC
Adrc ther prtl rc tear njx,0718T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15564.58,,,,,,,fee schedule,3508.17,15564.58,APC 378
Adrc ther prtl rc tear njx,0718T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3683.58,,,,,,,fee schedule,3508.17,15564.58,APC
Adrc ther prtl rc tear njx,0718T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3648.5,,,,,,,fee schedule,3508.17,15564.58,APC
Adrc ther prtl rc tear njx,0718T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3508.17,,,,,,,fee schedule,3508.17,15564.58,APC
Adrc ther prtl rc tear njx,0718T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5367.5,,,,,,,fee schedule,3508.17,15564.58,Radiology
Adrc ther prtl rc tear njx,0718T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4911.44,,,,,,,fee schedule,3508.17,15564.58,APC
Adrc ther prtl rc tear njx,0718T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6139.3,,,,,,,fee schedule,3508.17,15564.58,APC
Prq elc nrv stim cn wo implt,0720T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1021.7,,,,,,,fee schedule,818.98,1021.7,
Prq elc nrv stim cn wo implt,0720T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,818.98,,,,,,,fee schedule,818.98,1021.7,
Prq elc nrv stim cn wo implt,0720T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,894.66,,,,,,,fee schedule,818.98,1021.7,
Prq elc nrv stim cn wo implt,0720T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,940.61,,,,,,,fee schedule,818.98,1021.7,
Quan ct tiss charac w/o ct,0721T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2458.89,,,,,,,fee schedule,630.32,2796.52,
Quan ct tiss charac w/o ct,0721T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1971.02,,,,,,,fee schedule,630.32,2796.52,
Quan ct tiss charac w/o ct,0721T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2153.16,,,,,,,fee schedule,630.32,2796.52,
Quan ct tiss charac w/o ct,0721T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2263.74,,,,,,,fee schedule,630.32,2796.52,
Quan ct tiss charac w/o ct,0721T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2796.52,,,,,,,fee schedule,630.32,2796.52,APC 378
Quan ct tiss charac w/o ct,0721T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,661.84,,,,,,,fee schedule,630.32,2796.52,APC
Quan ct tiss charac w/o ct,0721T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,655.53,,,,,,,fee schedule,630.32,2796.52,APC
Quan ct tiss charac w/o ct,0721T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,630.32,,,,,,,fee schedule,630.32,2796.52,APC
Quan ct tiss charac w/o ct,0721T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,964.39,,,,,,,fee schedule,630.32,2796.52,Radiology
Quan ct tiss charac w/o ct,0721T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,882.45,,,,,,,fee schedule,630.32,2796.52,APC
Quan ct tiss charac w/o ct,0721T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1103.06,,,,,,,fee schedule,630.32,2796.52,APC
Qmrcp w/o dx mri sm anat ses,0723T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3592.89,,,,,,,fee schedule,921.02,4086.23,
Qmrcp w/o dx mri sm anat ses,0723T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2880.02,,,,,,,fee schedule,921.02,4086.23,
Qmrcp w/o dx mri sm anat ses,0723T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3146.16,,,,,,,fee schedule,921.02,4086.23,
Qmrcp w/o dx mri sm anat ses,0723T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3307.74,,,,,,,fee schedule,921.02,4086.23,
Qmrcp w/o dx mri sm anat ses,0723T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4086.23,,,,,,,fee schedule,921.02,4086.23,APC 378
Qmrcp w/o dx mri sm anat ses,0723T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,967.07,,,,,,,fee schedule,921.02,4086.23,APC
Qmrcp w/o dx mri sm anat ses,0723T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,957.86,,,,,,,fee schedule,921.02,4086.23,APC
Qmrcp w/o dx mri sm anat ses,0723T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,921.02,,,,,,,fee schedule,921.02,4086.23,APC
Qmrcp w/o dx mri sm anat ses,0723T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1409.15,,,,,,,fee schedule,921.02,4086.23,Radiology
Qmrcp w/o dx mri sm anat ses,0723T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1289.42,,,,,,,fee schedule,921.02,4086.23,APC
Qmrcp w/o dx mri sm anat ses,0723T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1611.78,,,,,,,fee schedule,921.02,4086.23,APC
Augmnt ai-based fcl phnt a/r,0731T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,214.89,,,,,,,fee schedule,58.4,259.1,
Augmnt ai-based fcl phnt a/r,0731T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,172.26,,,,,,,fee schedule,58.4,259.1,
Augmnt ai-based fcl phnt a/r,0731T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,188.17,,,,,,,fee schedule,58.4,259.1,
Augmnt ai-based fcl phnt a/r,0731T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,197.84,,,,,,,fee schedule,58.4,259.1,
Augmnt ai-based fcl phnt a/r,0731T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,58.4,259.1,APC 378
Augmnt ai-based fcl phnt a/r,0731T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,58.4,259.1,APC
Augmnt ai-based fcl phnt a/r,0731T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,58.4,259.1,APC
Augmnt ai-based fcl phnt a/r,0731T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,58.4,259.1,APC
Augmnt ai-based fcl phnt a/r,0731T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,58.4,259.1,Radiology
Augmnt ai-based fcl phnt a/r,0731T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,58.4,259.1,APC
Augmnt ai-based fcl phnt a/r,0731T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,58.4,259.1,APC
Rem bdy&lmb knmtc ther sply,0733T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,143.75,,,,,,,fee schedule,115.23,1506.81,
Rem bdy&lmb knmtc ther sply,0733T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,115.23,,,,,,,fee schedule,115.23,1506.81,
Rem bdy&lmb knmtc ther sply,0733T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,125.88,,,,,,,fee schedule,115.23,1506.81,
Rem bdy&lmb knmtc ther sply,0733T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,132.34,,,,,,,fee schedule,115.23,1506.81,
Rem bdy&lmb knmtc ther sply,0733T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1506.81,,,,,,,fee schedule,115.23,1506.81,APC 378
Rem bdy&lmb knmtc ther sply,0733T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,356.61,,,,,,,fee schedule,115.23,1506.81,APC
Rem bdy&lmb knmtc ther sply,0733T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,353.21,,,,,,,fee schedule,115.23,1506.81,APC
Rem bdy&lmb knmtc ther sply,0733T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,339.63,,,,,,,fee schedule,115.23,1506.81,APC
Rem bdy&lmb knmtc ther sply,0733T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,519.63,,,,,,,fee schedule,115.23,1506.81,Radiology
Rem bdy&lmb knmtc ther sply,0733T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,475.48,,,,,,,fee schedule,115.23,1506.81,APC
Rem bdy&lmb knmtc ther sply,0733T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,594.35,,,,,,,fee schedule,115.23,1506.81,APC
Colonic lavage 35+l water,0736T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,214.89,,,,,,,fee schedule,127.38,565.15,
Colonic lavage 35+l water,0736T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,172.26,,,,,,,fee schedule,127.38,565.15,
Colonic lavage 35+l water,0736T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,188.17,,,,,,,fee schedule,127.38,565.15,
Colonic lavage 35+l water,0736T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,197.84,,,,,,,fee schedule,127.38,565.15,
Colonic lavage 35+l water,0736T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,565.15,,,,,,,fee schedule,127.38,565.15,APC 378
Colonic lavage 35+l water,0736T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,133.75,,,,,,,fee schedule,127.38,565.15,APC
Colonic lavage 35+l water,0736T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,132.48,,,,,,,fee schedule,127.38,565.15,APC
Colonic lavage 35+l water,0736T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,127.38,,,,,,,fee schedule,127.38,565.15,APC
Colonic lavage 35+l water,0736T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,194.89,,,,,,,fee schedule,127.38,565.15,Radiology
Colonic lavage 35+l water,0736T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,178.33,,,,,,,fee schedule,127.38,565.15,APC
Colonic lavage 35+l water,0736T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,222.92,,,,,,,fee schedule,127.38,565.15,APC
Xenograft impltj artclr surf,0737T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,12709.88,56389.43,APC 378
Xenograft impltj artclr surf,0737T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,12709.88,56389.43,APC
Xenograft impltj artclr surf,0737T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,12709.88,56389.43,APC
Xenograft impltj artclr surf,0737T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,12709.88,56389.43,APC
Xenograft impltj artclr surf,0737T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,12709.88,56389.43,Radiology
Xenograft impltj artclr surf,0737T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,12709.88,56389.43,APC
Xenograft impltj artclr surf,0737T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,12709.88,56389.43,APC
Rem auton alg nsln cal setup,0740T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,217.27,,,,,,,fee schedule,58.4,259.1,
Rem auton alg nsln cal setup,0740T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,174.16,,,,,,,fee schedule,58.4,259.1,
Rem auton alg nsln cal setup,0740T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,190.26,,,,,,,fee schedule,58.4,259.1,
Rem auton alg nsln cal setup,0740T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,200.03,,,,,,,fee schedule,58.4,259.1,
Rem auton alg nsln cal setup,0740T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,58.4,259.1,APC 378
Rem auton alg nsln cal setup,0740T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,58.4,259.1,APC
Rem auton alg nsln cal setup,0740T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,58.4,259.1,APC
Rem auton alg nsln cal setup,0740T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,58.4,259.1,APC
Rem auton alg nsln cal setup,0740T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,58.4,259.1,Radiology
Rem auton alg nsln cal setup,0740T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,58.4,259.1,APC
Rem auton alg nsln cal setup,0740T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,58.4,259.1,APC
Rem auton alg nsln data coll,0741T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,132.3,,,,,,,fee schedule,36.95,163.92,
Rem auton alg nsln data coll,0741T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,106.05,,,,,,,fee schedule,36.95,163.92,
Rem auton alg nsln data coll,0741T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,115.85,,,,,,,fee schedule,36.95,163.92,
Rem auton alg nsln data coll,0741T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,121.8,,,,,,,fee schedule,36.95,163.92,
Rem auton alg nsln data coll,0741T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,163.92,,,,,,,fee schedule,36.95,163.92,APC 378
Rem auton alg nsln data coll,0741T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.79,,,,,,,fee schedule,36.95,163.92,APC
Rem auton alg nsln data coll,0741T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.43,,,,,,,fee schedule,36.95,163.92,APC
Rem auton alg nsln data coll,0741T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.95,,,,,,,fee schedule,36.95,163.92,APC
Rem auton alg nsln data coll,0741T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.53,,,,,,,fee schedule,36.95,163.92,Radiology
Rem auton alg nsln data coll,0741T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.73,,,,,,,fee schedule,36.95,163.92,APC
Rem auton alg nsln data coll,0741T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.66,,,,,,,fee schedule,36.95,163.92,APC
B1 str & fx rsk vrt fx assmt,0743T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,236.21,1047.98,APC 378
B1 str & fx rsk vrt fx assmt,0743T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,236.21,1047.98,APC
B1 str & fx rsk vrt fx assmt,0743T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,236.21,1047.98,APC
B1 str & fx rsk vrt fx assmt,0743T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,236.21,1047.98,APC
B1 str & fx rsk vrt fx assmt,0743T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,236.21,1047.98,Radiology
B1 str & fx rsk vrt fx assmt,0743T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,236.21,1047.98,APC
B1 str & fx rsk vrt fx assmt,0743T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,236.21,1047.98,APC
Insj bioprostc vlv fem vn,0744T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19428.29,,,,,,,fee schedule,5508.66,24440.06,
Insj bioprostc vlv fem vn,0744T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15573.47,,,,,,,fee schedule,5508.66,24440.06,
Insj bioprostc vlv fem vn,0744T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17012.61,,,,,,,fee schedule,5508.66,24440.06,
Insj bioprostc vlv fem vn,0744T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17886.36,,,,,,,fee schedule,5508.66,24440.06,
Insj bioprostc vlv fem vn,0744T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24440.06,,,,,,,fee schedule,5508.66,24440.06,APC 378
Insj bioprostc vlv fem vn,0744T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5784.09,,,,,,,fee schedule,5508.66,24440.06,APC
Insj bioprostc vlv fem vn,0744T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5729.01,,,,,,,fee schedule,5508.66,24440.06,APC
Insj bioprostc vlv fem vn,0744T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5508.66,,,,,,,fee schedule,5508.66,24440.06,APC
Insj bioprostc vlv fem vn,0744T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8428.25,,,,,,,fee schedule,5508.66,24440.06,Radiology
Insj bioprostc vlv fem vn,0744T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7712.13,,,,,,,fee schedule,5508.66,24440.06,APC
Insj bioprostc vlv fem vn,0744T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9640.16,,,,,,,fee schedule,5508.66,24440.06,APC
Asstv alg ecg rsk asmt cncrt,0764T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,131.71,584.37,APC 378
Asstv alg ecg rsk asmt cncrt,0764T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,131.71,584.37,APC
Asstv alg ecg rsk asmt cncrt,0764T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,131.71,584.37,APC
Asstv alg ecg rsk asmt cncrt,0764T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,131.71,584.37,APC
Asstv alg ecg rsk asmt cncrt,0764T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,131.71,584.37,Radiology
Asstv alg ecg rsk asmt cncrt,0764T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,131.71,584.37,APC
Asstv alg ecg rsk asmt cncrt,0764T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,131.71,584.37,APC
Asstv alg ecg rsk asmt prev,0765T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,131.71,584.37,APC 378
Asstv alg ecg rsk asmt prev,0765T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,131.71,584.37,APC
Asstv alg ecg rsk asmt prev,0765T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,131.71,584.37,APC
Asstv alg ecg rsk asmt prev,0765T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,131.71,584.37,APC
Asstv alg ecg rsk asmt prev,0765T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,131.71,584.37,Radiology
Asstv alg ecg rsk asmt prev,0765T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,131.71,584.37,APC
Asstv alg ecg rsk asmt prev,0765T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,131.71,584.37,APC
Tc mag stimj pn 1st tx 1nrv,0766T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,549.73,,,,,,,fee schedule,213.76,948.37,
Tc mag stimj pn 1st tx 1nrv,0766T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,440.65,,,,,,,fee schedule,213.76,948.37,
Tc mag stimj pn 1st tx 1nrv,0766T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,481.37,,,,,,,fee schedule,213.76,948.37,
Tc mag stimj pn 1st tx 1nrv,0766T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,506.1,,,,,,,fee schedule,213.76,948.37,
Tc mag stimj pn 1st tx 1nrv,0766T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,213.76,948.37,APC 378
Tc mag stimj pn 1st tx 1nrv,0766T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,213.76,948.37,APC
Tc mag stimj pn 1st tx 1nrv,0766T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,213.76,948.37,APC
Tc mag stimj pn 1st tx 1nrv,0766T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,213.76,948.37,APC
Tc mag stimj pn 1st tx 1nrv,0766T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,213.76,948.37,Radiology
Tc mag stimj pn 1st tx 1nrv,0766T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,213.76,948.37,APC
Tc mag stimj pn 1st tx 1nrv,0766T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,213.76,948.37,APC
Tc mag stimj pn sbsq tx 1nrv,0768T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,549.73,,,,,,,fee schedule,440.65,549.73,
Tc mag stimj pn sbsq tx 1nrv,0768T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,440.65,,,,,,,fee schedule,440.65,549.73,
Tc mag stimj pn sbsq tx 1nrv,0768T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,481.37,,,,,,,fee schedule,440.65,549.73,
Tc mag stimj pn sbsq tx 1nrv,0768T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,506.1,,,,,,,fee schedule,440.65,549.73,
Arthrd si jt prq iartic impl,0775T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,82773.04,,,,,,,fee schedule,66349.82,82773.04,
Arthrd si jt prq iartic impl,0775T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66349.82,,,,,,,fee schedule,66349.82,82773.04,
Arthrd si jt prq iartic impl,0775T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,72481.16,,,,,,,fee schedule,66349.82,82773.04,
Arthrd si jt prq iartic impl,0775T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,76203.75,,,,,,,fee schedule,66349.82,82773.04,
Smmg cncrnt appl imu snr,0778T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,549.73,,,,,,,fee schedule,127.38,565.15,
Smmg cncrnt appl imu snr,0778T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,440.65,,,,,,,fee schedule,127.38,565.15,
Smmg cncrnt appl imu snr,0778T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,481.37,,,,,,,fee schedule,127.38,565.15,
Smmg cncrnt appl imu snr,0778T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,506.1,,,,,,,fee schedule,127.38,565.15,
Smmg cncrnt appl imu snr,0778T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,565.15,,,,,,,fee schedule,127.38,565.15,APC 378
Smmg cncrnt appl imu snr,0778T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,133.75,,,,,,,fee schedule,127.38,565.15,APC
Smmg cncrnt appl imu snr,0778T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,132.48,,,,,,,fee schedule,127.38,565.15,APC
Smmg cncrnt appl imu snr,0778T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,127.38,,,,,,,fee schedule,127.38,565.15,APC
Smmg cncrnt appl imu snr,0778T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,194.89,,,,,,,fee schedule,127.38,565.15,Radiology
Smmg cncrnt appl imu snr,0778T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,178.33,,,,,,,fee schedule,127.38,565.15,APC
Smmg cncrnt appl imu snr,0778T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,222.92,,,,,,,fee schedule,127.38,565.15,APC
Gi myoelectrical actv study,0779T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1827.37,,,,,,,fee schedule,369.41,1827.37,
Gi myoelectrical actv study,0779T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1464.79,,,,,,,fee schedule,369.41,1827.37,
Gi myoelectrical actv study,0779T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1600.15,,,,,,,fee schedule,369.41,1827.37,
Gi myoelectrical actv study,0779T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1682.34,,,,,,,fee schedule,369.41,1827.37,
Gi myoelectrical actv study,0779T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1638.96,,,,,,,fee schedule,369.41,1827.37,APC 378
Gi myoelectrical actv study,0779T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,387.88,,,,,,,fee schedule,369.41,1827.37,APC
Gi myoelectrical actv study,0779T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,384.19,,,,,,,fee schedule,369.41,1827.37,APC
Gi myoelectrical actv study,0779T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,369.41,,,,,,,fee schedule,369.41,1827.37,APC
Gi myoelectrical actv study,0779T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,565.2,,,,,,,fee schedule,369.41,1827.37,Radiology
Gi myoelectrical actv study,0779T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,517.18,,,,,,,fee schedule,369.41,1827.37,APC
Gi myoelectrical actv study,0779T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,646.47,,,,,,,fee schedule,369.41,1827.37,APC
Instlj fecal microbiota ssp,0780T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,131.71,584.37,APC 378
Instlj fecal microbiota ssp,0780T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,131.71,584.37,APC
Instlj fecal microbiota ssp,0780T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,131.71,584.37,APC
Instlj fecal microbiota ssp,0780T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,131.71,584.37,APC
Instlj fecal microbiota ssp,0780T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,131.71,584.37,Radiology
Instlj fecal microbiota ssp,0780T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,131.71,584.37,APC
Instlj fecal microbiota ssp,0780T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,131.71,584.37,APC
Tc auriculr neurostimulation,0783T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,549.73,,,,,,,fee schedule,127.38,565.15,
Tc auriculr neurostimulation,0783T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,440.65,,,,,,,fee schedule,127.38,565.15,
Tc auriculr neurostimulation,0783T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,481.37,,,,,,,fee schedule,127.38,565.15,
Tc auriculr neurostimulation,0783T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,506.1,,,,,,,fee schedule,127.38,565.15,
Tc auriculr neurostimulation,0783T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,565.15,,,,,,,fee schedule,127.38,565.15,APC 378
Tc auriculr neurostimulation,0783T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,133.75,,,,,,,fee schedule,127.38,565.15,APC
Tc auriculr neurostimulation,0783T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,132.48,,,,,,,fee schedule,127.38,565.15,APC
Tc auriculr neurostimulation,0783T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,127.38,,,,,,,fee schedule,127.38,565.15,APC
Tc auriculr neurostimulation,0783T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,194.89,,,,,,,fee schedule,127.38,565.15,Radiology
Tc auriculr neurostimulation,0783T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,178.33,,,,,,,fee schedule,127.38,565.15,APC
Tc auriculr neurostimulation,0783T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,222.92,,,,,,,fee schedule,127.38,565.15,APC
Ins/rplmt eltrd ra spi nstim,0784T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,49111.5,,,,,,,fee schedule,11030.91,49111.5,
Ins/rplmt eltrd ra spi nstim,0784T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39367.15,,,,,,,fee schedule,11030.91,49111.5,
Ins/rplmt eltrd ra spi nstim,0784T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,43005.04,,,,,,,fee schedule,11030.91,49111.5,
Ins/rplmt eltrd ra spi nstim,0784T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45213.76,,,,,,,fee schedule,11030.91,49111.5,
Ins/rplmt eltrd ra spi nstim,0784T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,48940.4,,,,,,,fee schedule,11030.91,49111.5,APC 378
Ins/rplmt eltrd ra spi nstim,0784T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11582.45,,,,,,,fee schedule,11030.91,49111.5,APC
Ins/rplmt eltrd ra spi nstim,0784T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11472.14,,,,,,,fee schedule,11030.91,49111.5,APC
Ins/rplmt eltrd ra spi nstim,0784T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11030.91,,,,,,,fee schedule,11030.91,49111.5,APC
Ins/rplmt eltrd ra spi nstim,0784T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16877.29,,,,,,,fee schedule,11030.91,49111.5,Radiology
Ins/rplmt eltrd ra spi nstim,0784T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15443.27,,,,,,,fee schedule,11030.91,49111.5,APC
Ins/rplmt eltrd ra spi nstim,0784T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19304.09,,,,,,,fee schedule,11030.91,49111.5,APC
Revj/rmvl nea spi w/nstim,0785T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12267.12,,,,,,,fee schedule,3461.03,15355.43,
Revj/rmvl nea spi w/nstim,0785T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9833.17,,,,,,,fee schedule,3461.03,15355.43,
Revj/rmvl nea spi w/nstim,0785T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10741.84,,,,,,,fee schedule,3461.03,15355.43,
Revj/rmvl nea spi w/nstim,0785T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11293.54,,,,,,,fee schedule,3461.03,15355.43,
Revj/rmvl nea spi w/nstim,0785T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15355.43,,,,,,,fee schedule,3461.03,15355.43,APC 378
Revj/rmvl nea spi w/nstim,0785T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3634.08,,,,,,,fee schedule,3461.03,15355.43,APC
Revj/rmvl nea spi w/nstim,0785T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3599.47,,,,,,,fee schedule,3461.03,15355.43,APC
Revj/rmvl nea spi w/nstim,0785T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3461.03,,,,,,,fee schedule,3461.03,15355.43,APC
Revj/rmvl nea spi w/nstim,0785T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5295.38,,,,,,,fee schedule,3461.03,15355.43,Radiology
Revj/rmvl nea spi w/nstim,0785T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4845.44,,,,,,,fee schedule,3461.03,15355.43,APC
Revj/rmvl nea spi w/nstim,0785T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6056.81,,,,,,,fee schedule,3461.03,15355.43,APC
Insj/rplcmt prq ra sac nstim,0786T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,49111.5,,,,,,,fee schedule,11030.91,49111.5,
Insj/rplcmt prq ra sac nstim,0786T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39367.15,,,,,,,fee schedule,11030.91,49111.5,
Insj/rplcmt prq ra sac nstim,0786T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,43005.04,,,,,,,fee schedule,11030.91,49111.5,
Insj/rplcmt prq ra sac nstim,0786T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45213.76,,,,,,,fee schedule,11030.91,49111.5,
Insj/rplcmt prq ra sac nstim,0786T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,48940.4,,,,,,,fee schedule,11030.91,49111.5,APC 378
Insj/rplcmt prq ra sac nstim,0786T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11582.45,,,,,,,fee schedule,11030.91,49111.5,APC
Insj/rplcmt prq ra sac nstim,0786T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11472.14,,,,,,,fee schedule,11030.91,49111.5,APC
Insj/rplcmt prq ra sac nstim,0786T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11030.91,,,,,,,fee schedule,11030.91,49111.5,APC
Insj/rplcmt prq ra sac nstim,0786T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16877.29,,,,,,,fee schedule,11030.91,49111.5,Radiology
Insj/rplcmt prq ra sac nstim,0786T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15443.27,,,,,,,fee schedule,11030.91,49111.5,APC
Insj/rplcmt prq ra sac nstim,0786T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19304.09,,,,,,,fee schedule,11030.91,49111.5,APC
Revj/rmvl nea sac w/nstim,0787T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12267.12,,,,,,,fee schedule,3461.03,15355.43,
Revj/rmvl nea sac w/nstim,0787T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9833.17,,,,,,,fee schedule,3461.03,15355.43,
Revj/rmvl nea sac w/nstim,0787T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10741.84,,,,,,,fee schedule,3461.03,15355.43,
Revj/rmvl nea sac w/nstim,0787T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11293.54,,,,,,,fee schedule,3461.03,15355.43,
Revj/rmvl nea sac w/nstim,0787T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15355.43,,,,,,,fee schedule,3461.03,15355.43,APC 378
Revj/rmvl nea sac w/nstim,0787T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3634.08,,,,,,,fee schedule,3461.03,15355.43,APC
Revj/rmvl nea sac w/nstim,0787T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3599.47,,,,,,,fee schedule,3461.03,15355.43,APC
Revj/rmvl nea sac w/nstim,0787T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3461.03,,,,,,,fee schedule,3461.03,15355.43,APC
Revj/rmvl nea sac w/nstim,0787T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5295.38,,,,,,,fee schedule,3461.03,15355.43,Radiology
Revj/rmvl nea sac w/nstim,0787T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4845.44,,,,,,,fee schedule,3461.03,15355.43,APC
Revj/rmvl nea sac w/nstim,0787T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6056.81,,,,,,,fee schedule,3461.03,15355.43,APC
Elec aly smp iins sp/sac nrv,0788T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,349.01,,,,,,,fee schedule,94.12,417.57,
Elec aly smp iins sp/sac nrv,0788T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,279.76,,,,,,,fee schedule,94.12,417.57,
Elec aly smp iins sp/sac nrv,0788T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,305.61,,,,,,,fee schedule,94.12,417.57,
Elec aly smp iins sp/sac nrv,0788T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,321.31,,,,,,,fee schedule,94.12,417.57,
Elec aly smp iins sp/sac nrv,0788T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,417.57,,,,,,,fee schedule,94.12,417.57,APC 378
Elec aly smp iins sp/sac nrv,0788T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,98.82,,,,,,,fee schedule,94.12,417.57,APC
Elec aly smp iins sp/sac nrv,0788T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,97.88,,,,,,,fee schedule,94.12,417.57,APC
Elec aly smp iins sp/sac nrv,0788T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,94.12,,,,,,,fee schedule,94.12,417.57,APC
Elec aly smp iins sp/sac nrv,0788T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144,,,,,,,fee schedule,94.12,417.57,Radiology
Elec aly smp iins sp/sac nrv,0788T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.76,,,,,,,fee schedule,94.12,417.57,APC
Elec aly smp iins sp/sac nrv,0788T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,164.7,,,,,,,fee schedule,94.12,417.57,APC
Elec aly cpx iins sp/sac nrv,0789T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,349.01,,,,,,,fee schedule,94.12,417.57,
Elec aly cpx iins sp/sac nrv,0789T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,279.76,,,,,,,fee schedule,94.12,417.57,
Elec aly cpx iins sp/sac nrv,0789T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,305.61,,,,,,,fee schedule,94.12,417.57,
Elec aly cpx iins sp/sac nrv,0789T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,321.31,,,,,,,fee schedule,94.12,417.57,
Elec aly cpx iins sp/sac nrv,0789T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,417.57,,,,,,,fee schedule,94.12,417.57,APC 378
Elec aly cpx iins sp/sac nrv,0789T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,98.82,,,,,,,fee schedule,94.12,417.57,APC
Elec aly cpx iins sp/sac nrv,0789T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,97.88,,,,,,,fee schedule,94.12,417.57,APC
Elec aly cpx iins sp/sac nrv,0789T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,94.12,,,,,,,fee schedule,94.12,417.57,APC
Elec aly cpx iins sp/sac nrv,0789T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144,,,,,,,fee schedule,94.12,417.57,Radiology
Elec aly cpx iins sp/sac nrv,0789T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.76,,,,,,,fee schedule,94.12,417.57,APC
Elec aly cpx iins sp/sac nrv,0789T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,164.7,,,,,,,fee schedule,94.12,417.57,APC
Revj rplcmt/rmvl vrt tethrg,0790T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,77011.17,,,,,,,fee schedule,17357.91,77011.17,APC 378
Revj rplcmt/rmvl vrt tethrg,0790T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18225.81,,,,,,,fee schedule,17357.91,77011.17,APC
Revj rplcmt/rmvl vrt tethrg,0790T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18052.23,,,,,,,fee schedule,17357.91,77011.17,APC
Revj rplcmt/rmvl vrt tethrg,0790T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17357.91,,,,,,,fee schedule,17357.91,77011.17,APC
Revj rplcmt/rmvl vrt tethrg,0790T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26557.6,,,,,,,fee schedule,17357.91,77011.17,Radiology
Revj rplcmt/rmvl vrt tethrg,0790T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24301.07,,,,,,,fee schedule,17357.91,77011.17,APC
Revj rplcmt/rmvl vrt tethrg,0790T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30376.34,,,,,,,fee schedule,17357.91,77011.17,APC
Prq tcat thrm ablt nrv p-art,0793T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,63219.37,,,,,,,fee schedule,18147.73,80515.32,
Prq tcat thrm ablt nrv p-art,0793T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,50675.84,,,,,,,fee schedule,18147.73,80515.32,
Prq tcat thrm ablt nrv p-art,0793T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55358.76,,,,,,,fee schedule,18147.73,80515.32,
Prq tcat thrm ablt nrv p-art,0793T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,58201.96,,,,,,,fee schedule,18147.73,80515.32,
Prq tcat thrm ablt nrv p-art,0793T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,80515.32,,,,,,,fee schedule,18147.73,80515.32,APC 378
Prq tcat thrm ablt nrv p-art,0793T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19055.11,,,,,,,fee schedule,18147.73,80515.32,APC
Prq tcat thrm ablt nrv p-art,0793T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18873.64,,,,,,,fee schedule,18147.73,80515.32,APC
Prq tcat thrm ablt nrv p-art,0793T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18147.73,,,,,,,fee schedule,18147.73,80515.32,APC
Prq tcat thrm ablt nrv p-art,0793T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27766.02,,,,,,,fee schedule,18147.73,80515.32,Radiology
Prq tcat thrm ablt nrv p-art,0793T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25406.82,,,,,,,fee schedule,18147.73,80515.32,APC
Prq tcat thrm ablt nrv p-art,0793T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31758.52,,,,,,,fee schedule,18147.73,80515.32,APC
Pt spec alg rx-onc tx option,0794T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,220.53,,,,,,,fee schedule,58.4,259.1,
Pt spec alg rx-onc tx option,0794T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,176.77,,,,,,,fee schedule,58.4,259.1,
Pt spec alg rx-onc tx option,0794T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,193.11,,,,,,,fee schedule,58.4,259.1,
Pt spec alg rx-onc tx option,0794T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,203.02,,,,,,,fee schedule,58.4,259.1,
Pt spec alg rx-onc tx option,0794T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,58.4,259.1,APC 378
Pt spec alg rx-onc tx option,0794T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,58.4,259.1,APC
Pt spec alg rx-onc tx option,0794T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,58.4,259.1,APC
Pt spec alg rx-onc tx option,0794T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,58.4,259.1,APC
Pt spec alg rx-onc tx option,0794T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,58.4,259.1,Radiology
Pt spec alg rx-onc tx option,0794T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,58.4,259.1,APC
Pt spec alg rx-onc tx option,0794T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,58.4,259.1,APC
Tcat ins 2chmbr ldls pm cmpl,0795T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,70250.05,,,,,,,fee schedule,19068.45,84600.26,
Tcat ins 2chmbr ldls pm cmpl,0795T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56311.55,,,,,,,fee schedule,19068.45,84600.26,
Tcat ins 2chmbr ldls pm cmpl,0795T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,61515.26,,,,,,,fee schedule,19068.45,84600.26,
Tcat ins 2chmbr ldls pm cmpl,0795T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,64674.65,,,,,,,fee schedule,19068.45,84600.26,
Tcat ins 2chmbr ldls pm cmpl,0795T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,84600.26,,,,,,,fee schedule,19068.45,84600.26,APC 378
Tcat ins 2chmbr ldls pm cmpl,0795T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20021.87,,,,,,,fee schedule,19068.45,84600.26,APC
Tcat ins 2chmbr ldls pm cmpl,0795T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,19831.19,,,,,,,fee schedule,19068.45,84600.26,APC
Tcat ins 2chmbr ldls pm cmpl,0795T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,19068.45,,,,,,,fee schedule,19068.45,84600.26,APC
Tcat ins 2chmbr ldls pm cmpl,0795T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29174.73,,,,,,,fee schedule,19068.45,84600.26,Radiology
Tcat ins 2chmbr ldls pm cmpl,0795T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26695.83,,,,,,,fee schedule,19068.45,84600.26,APC
Tcat ins 2chmbr ldls pm cmpl,0795T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,33369.79,,,,,,,fee schedule,19068.45,84600.26,APC
Tcat ins 2chmbr ldls pm ra,0796T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,70250.05,,,,,,,fee schedule,22020.42,97697.15,
Tcat ins 2chmbr ldls pm ra,0796T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56311.55,,,,,,,fee schedule,22020.42,97697.15,
Tcat ins 2chmbr ldls pm ra,0796T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,61515.26,,,,,,,fee schedule,22020.42,97697.15,
Tcat ins 2chmbr ldls pm ra,0796T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,64674.65,,,,,,,fee schedule,22020.42,97697.15,
Tcat ins 2chmbr ldls pm ra,0796T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,97697.15,,,,,,,fee schedule,22020.42,97697.15,APC 378
Tcat ins 2chmbr ldls pm ra,0796T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,23121.44,,,,,,,fee schedule,22020.42,97697.15,APC
Tcat ins 2chmbr ldls pm ra,0796T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,22901.24,,,,,,,fee schedule,22020.42,97697.15,APC
Tcat ins 2chmbr ldls pm ra,0796T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,22020.42,,,,,,,fee schedule,22020.42,97697.15,APC
Tcat ins 2chmbr ldls pm ra,0796T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,33691.24,,,,,,,fee schedule,22020.42,97697.15,Radiology
Tcat ins 2chmbr ldls pm ra,0796T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,30828.59,,,,,,,fee schedule,22020.42,97697.15,APC
Tcat ins 2chmbr ldls pm ra,0796T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,38535.73,,,,,,,fee schedule,22020.42,97697.15,APC
Tcat ins 2chmbr ldls pm rv,0797T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,70250.05,,,,,,,fee schedule,19068.45,84600.26,
Tcat ins 2chmbr ldls pm rv,0797T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56311.55,,,,,,,fee schedule,19068.45,84600.26,
Tcat ins 2chmbr ldls pm rv,0797T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,61515.26,,,,,,,fee schedule,19068.45,84600.26,
Tcat ins 2chmbr ldls pm rv,0797T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,64674.65,,,,,,,fee schedule,19068.45,84600.26,
Tcat ins 2chmbr ldls pm rv,0797T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,84600.26,,,,,,,fee schedule,19068.45,84600.26,APC 378
Tcat ins 2chmbr ldls pm rv,0797T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20021.87,,,,,,,fee schedule,19068.45,84600.26,APC
Tcat ins 2chmbr ldls pm rv,0797T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,19831.19,,,,,,,fee schedule,19068.45,84600.26,APC
Tcat ins 2chmbr ldls pm rv,0797T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,19068.45,,,,,,,fee schedule,19068.45,84600.26,APC
Tcat ins 2chmbr ldls pm rv,0797T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29174.73,,,,,,,fee schedule,19068.45,84600.26,Radiology
Tcat ins 2chmbr ldls pm rv,0797T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26695.83,,,,,,,fee schedule,19068.45,84600.26,APC
Tcat ins 2chmbr ldls pm rv,0797T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,33369.79,,,,,,,fee schedule,19068.45,84600.26,APC
Tcat rmv 2chmbr ldls pm cmpl,0798T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11491.88,,,,,,,fee schedule,3125.8,13868.13,
Tcat rmv 2chmbr ldls pm cmpl,0798T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9211.75,,,,,,,fee schedule,3125.8,13868.13,
Tcat rmv 2chmbr ldls pm cmpl,0798T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10063,,,,,,,fee schedule,3125.8,13868.13,
Tcat rmv 2chmbr ldls pm cmpl,0798T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10579.83,,,,,,,fee schedule,3125.8,13868.13,
Tcat rmv 2chmbr ldls pm cmpl,0798T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Tcat rmv 2chmbr ldls pm cmpl,0798T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Tcat rmv 2chmbr ldls pm cmpl,0798T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Tcat rmv 2chmbr ldls pm cmpl,0798T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Tcat rmv 2chmbr ldls pm cmpl,0798T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Tcat rmv 2chmbr ldls pm cmpl,0798T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Tcat rmv 2chmbr ldls pm cmpl,0798T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Tcat rmvl 2chmbr ldls pm ra,0799T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11491.88,,,,,,,fee schedule,3125.8,13868.13,
Tcat rmvl 2chmbr ldls pm ra,0799T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9211.75,,,,,,,fee schedule,3125.8,13868.13,
Tcat rmvl 2chmbr ldls pm ra,0799T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10063,,,,,,,fee schedule,3125.8,13868.13,
Tcat rmvl 2chmbr ldls pm ra,0799T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10579.83,,,,,,,fee schedule,3125.8,13868.13,
Tcat rmvl 2chmbr ldls pm ra,0799T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Tcat rmvl 2chmbr ldls pm ra,0799T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Tcat rmvl 2chmbr ldls pm ra,0799T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Tcat rmvl 2chmbr ldls pm ra,0799T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Tcat rmvl 2chmbr ldls pm ra,0799T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Tcat rmvl 2chmbr ldls pm ra,0799T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Tcat rmvl 2chmbr ldls pm ra,0799T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Tcat rmvl 2chmbr ldls pm rv,0800T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11491.88,,,,,,,fee schedule,3125.8,13868.13,
Tcat rmvl 2chmbr ldls pm rv,0800T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9211.75,,,,,,,fee schedule,3125.8,13868.13,
Tcat rmvl 2chmbr ldls pm rv,0800T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10063,,,,,,,fee schedule,3125.8,13868.13,
Tcat rmvl 2chmbr ldls pm rv,0800T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10579.83,,,,,,,fee schedule,3125.8,13868.13,
Tcat rmvl 2chmbr ldls pm rv,0800T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Tcat rmvl 2chmbr ldls pm rv,0800T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Tcat rmvl 2chmbr ldls pm rv,0800T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Tcat rmvl 2chmbr ldls pm rv,0800T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Tcat rmvl 2chmbr ldls pm rv,0800T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Tcat rmvl 2chmbr ldls pm rv,0800T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Tcat rmvl 2chmbr ldls pm rv,0800T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Tcat rmv&rpl 2chmbr ldls pm,0801T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,70250.05,,,,,,,fee schedule,19068.45,84600.26,
Tcat rmv&rpl 2chmbr ldls pm,0801T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56311.55,,,,,,,fee schedule,19068.45,84600.26,
Tcat rmv&rpl 2chmbr ldls pm,0801T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,61515.26,,,,,,,fee schedule,19068.45,84600.26,
Tcat rmv&rpl 2chmbr ldls pm,0801T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,64674.65,,,,,,,fee schedule,19068.45,84600.26,
Tcat rmv&rpl 2chmbr ldls pm,0801T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,84600.26,,,,,,,fee schedule,19068.45,84600.26,APC 378
Tcat rmv&rpl 2chmbr ldls pm,0801T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20021.87,,,,,,,fee schedule,19068.45,84600.26,APC
Tcat rmv&rpl 2chmbr ldls pm,0801T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,19831.19,,,,,,,fee schedule,19068.45,84600.26,APC
Tcat rmv&rpl 2chmbr ldls pm,0801T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,19068.45,,,,,,,fee schedule,19068.45,84600.26,APC
Tcat rmv&rpl 2chmbr ldls pm,0801T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29174.73,,,,,,,fee schedule,19068.45,84600.26,Radiology
Tcat rmv&rpl 2chmbr ldls pm,0801T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26695.83,,,,,,,fee schedule,19068.45,84600.26,APC
Tcat rmv&rpl 2chmbr ldls pm,0801T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,33369.79,,,,,,,fee schedule,19068.45,84600.26,APC
Tcat rmv&rpl2chmb ldls pm ra,0802T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,70250.05,,,,,,,fee schedule,19068.45,84600.26,
Tcat rmv&rpl2chmb ldls pm ra,0802T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56311.55,,,,,,,fee schedule,19068.45,84600.26,
Tcat rmv&rpl2chmb ldls pm ra,0802T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,61515.26,,,,,,,fee schedule,19068.45,84600.26,
Tcat rmv&rpl2chmb ldls pm ra,0802T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,64674.65,,,,,,,fee schedule,19068.45,84600.26,
Tcat rmv&rpl2chmb ldls pm ra,0802T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,84600.26,,,,,,,fee schedule,19068.45,84600.26,APC 378
Tcat rmv&rpl2chmb ldls pm ra,0802T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20021.87,,,,,,,fee schedule,19068.45,84600.26,APC
Tcat rmv&rpl2chmb ldls pm ra,0802T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,19831.19,,,,,,,fee schedule,19068.45,84600.26,APC
Tcat rmv&rpl2chmb ldls pm ra,0802T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,19068.45,,,,,,,fee schedule,19068.45,84600.26,APC
Tcat rmv&rpl2chmb ldls pm ra,0802T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29174.73,,,,,,,fee schedule,19068.45,84600.26,Radiology
Tcat rmv&rpl2chmb ldls pm ra,0802T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26695.83,,,,,,,fee schedule,19068.45,84600.26,APC
Tcat rmv&rpl2chmb ldls pm ra,0802T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,33369.79,,,,,,,fee schedule,19068.45,84600.26,APC
Tcat rmv&rpl2chmb ldls pm rv,0803T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,70250.05,,,,,,,fee schedule,19068.45,84600.26,
Tcat rmv&rpl2chmb ldls pm rv,0803T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56311.55,,,,,,,fee schedule,19068.45,84600.26,
Tcat rmv&rpl2chmb ldls pm rv,0803T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,61515.26,,,,,,,fee schedule,19068.45,84600.26,
Tcat rmv&rpl2chmb ldls pm rv,0803T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,64674.65,,,,,,,fee schedule,19068.45,84600.26,
Tcat rmv&rpl2chmb ldls pm rv,0803T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,84600.26,,,,,,,fee schedule,19068.45,84600.26,APC 378
Tcat rmv&rpl2chmb ldls pm rv,0803T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20021.87,,,,,,,fee schedule,19068.45,84600.26,APC
Tcat rmv&rpl2chmb ldls pm rv,0803T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,19831.19,,,,,,,fee schedule,19068.45,84600.26,APC
Tcat rmv&rpl2chmb ldls pm rv,0803T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,19068.45,,,,,,,fee schedule,19068.45,84600.26,APC
Tcat rmv&rpl2chmb ldls pm rv,0803T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29174.73,,,,,,,fee schedule,19068.45,84600.26,Radiology
Tcat rmv&rpl2chmb ldls pm rv,0803T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26695.83,,,,,,,fee schedule,19068.45,84600.26,APC
Tcat rmv&rpl2chmb ldls pm rv,0803T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,33369.79,,,,,,,fee schedule,19068.45,84600.26,APC
Prgrmg evl ldls pm 2chmbr ip,0804T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,136,,,,,,,fee schedule,36.95,163.92,
Prgrmg evl ldls pm 2chmbr ip,0804T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,109.02,,,,,,,fee schedule,36.95,163.92,
Prgrmg evl ldls pm 2chmbr ip,0804T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,119.09,,,,,,,fee schedule,36.95,163.92,
Prgrmg evl ldls pm 2chmbr ip,0804T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,125.21,,,,,,,fee schedule,36.95,163.92,
Prgrmg evl ldls pm 2chmbr ip,0804T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,163.92,,,,,,,fee schedule,36.95,163.92,APC 378
Prgrmg evl ldls pm 2chmbr ip,0804T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.79,,,,,,,fee schedule,36.95,163.92,APC
Prgrmg evl ldls pm 2chmbr ip,0804T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.43,,,,,,,fee schedule,36.95,163.92,APC
Prgrmg evl ldls pm 2chmbr ip,0804T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.95,,,,,,,fee schedule,36.95,163.92,APC
Prgrmg evl ldls pm 2chmbr ip,0804T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.53,,,,,,,fee schedule,36.95,163.92,Radiology
Prgrmg evl ldls pm 2chmbr ip,0804T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.73,,,,,,,fee schedule,36.95,163.92,APC
Prgrmg evl ldls pm 2chmbr ip,0804T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.66,,,,,,,fee schedule,36.95,163.92,APC
Pulm tiss vntj alys prev ct,0807T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1131.62,,,,,,,fee schedule,213.76,1131.62,
Pulm tiss vntj alys prev ct,0807T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,907.09,,,,,,,fee schedule,213.76,1131.62,
Pulm tiss vntj alys prev ct,0807T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,990.91,,,,,,,fee schedule,213.76,1131.62,
Pulm tiss vntj alys prev ct,0807T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1041.81,,,,,,,fee schedule,213.76,1131.62,
Pulm tiss vntj alys prev ct,0807T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,213.76,1131.62,APC 378
Pulm tiss vntj alys prev ct,0807T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,213.76,1131.62,APC
Pulm tiss vntj alys prev ct,0807T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,213.76,1131.62,APC
Pulm tiss vntj alys prev ct,0807T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,213.76,1131.62,APC
Pulm tiss vntj alys prev ct,0807T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,213.76,1131.62,Radiology
Pulm tiss vntj alys prev ct,0807T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,213.76,1131.62,APC
Pulm tiss vntj alys prev ct,0807T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,213.76,1131.62,APC
Pulm tiss vntj alys w/ct,0808T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1131.62,,,,,,,fee schedule,213.76,1131.62,
Pulm tiss vntj alys w/ct,0808T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,907.09,,,,,,,fee schedule,213.76,1131.62,
Pulm tiss vntj alys w/ct,0808T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,990.91,,,,,,,fee schedule,213.76,1131.62,
Pulm tiss vntj alys w/ct,0808T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1041.81,,,,,,,fee schedule,213.76,1131.62,
Pulm tiss vntj alys w/ct,0808T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,213.76,1131.62,APC 378
Pulm tiss vntj alys w/ct,0808T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,213.76,1131.62,APC
Pulm tiss vntj alys w/ct,0808T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,213.76,1131.62,APC
Pulm tiss vntj alys w/ct,0808T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,213.76,1131.62,APC
Pulm tiss vntj alys w/ct,0808T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,213.76,1131.62,Radiology
Pulm tiss vntj alys w/ct,0808T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,213.76,1131.62,APC
Pulm tiss vntj alys w/ct,0808T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,213.76,1131.62,APC
Subrta njx rx agt w/vtrc,0810T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16066.89,,,,,,,fee schedule,4118.65,18273.05,
Subrta njx rx agt w/vtrc,0810T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12879.02,,,,,,,fee schedule,4118.65,18273.05,
Subrta njx rx agt w/vtrc,0810T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14069.16,,,,,,,fee schedule,4118.65,18273.05,
Subrta njx rx agt w/vtrc,0810T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14791.74,,,,,,,fee schedule,4118.65,18273.05,
Subrta njx rx agt w/vtrc,0810T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18273.05,,,,,,,fee schedule,4118.65,18273.05,APC 378
Subrta njx rx agt w/vtrc,0810T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4324.58,,,,,,,fee schedule,4118.65,18273.05,APC
Subrta njx rx agt w/vtrc,0810T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4283.4,,,,,,,fee schedule,4118.65,18273.05,APC
Subrta njx rx agt w/vtrc,0810T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4118.65,,,,,,,fee schedule,4118.65,18273.05,APC
Subrta njx rx agt w/vtrc,0810T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6301.53,,,,,,,fee schedule,4118.65,18273.05,Radiology
Subrta njx rx agt w/vtrc,0810T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5766.11,,,,,,,fee schedule,4118.65,18273.05,APC
Subrta njx rx agt w/vtrc,0810T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7207.64,,,,,,,fee schedule,4118.65,18273.05,APC
Rem mlt day uroflow setup,0811T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,476.58,,,,,,,fee schedule,131.8,584.75,
Rem mlt day uroflow setup,0811T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,382.02,,,,,,,fee schedule,131.8,584.75,
Rem mlt day uroflow setup,0811T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,417.32,,,,,,,fee schedule,131.8,584.75,
Rem mlt day uroflow setup,0811T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,438.76,,,,,,,fee schedule,131.8,584.75,
Rem mlt day uroflow setup,0811T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.75,,,,,,,fee schedule,131.8,584.75,APC 378
Rem mlt day uroflow setup,0811T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.39,,,,,,,fee schedule,131.8,584.75,APC
Rem mlt day uroflow setup,0811T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,137.07,,,,,,,fee schedule,131.8,584.75,APC
Rem mlt day uroflow setup,0811T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.8,,,,,,,fee schedule,131.8,584.75,APC
Rem mlt day uroflow setup,0811T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.66,,,,,,,fee schedule,131.8,584.75,Radiology
Rem mlt day uroflow setup,0811T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.52,,,,,,,fee schedule,131.8,584.75,APC
Rem mlt day uroflow setup,0811T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.65,,,,,,,fee schedule,131.8,584.75,APC
Rem mlt day uroflow dev sply,0812T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,136,,,,,,,fee schedule,109.02,565.15,
Rem mlt day uroflow dev sply,0812T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,109.02,,,,,,,fee schedule,109.02,565.15,
Rem mlt day uroflow dev sply,0812T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,119.09,,,,,,,fee schedule,109.02,565.15,
Rem mlt day uroflow dev sply,0812T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,125.21,,,,,,,fee schedule,109.02,565.15,
Rem mlt day uroflow dev sply,0812T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,565.15,,,,,,,fee schedule,109.02,565.15,APC 378
Rem mlt day uroflow dev sply,0812T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,133.75,,,,,,,fee schedule,109.02,565.15,APC
Rem mlt day uroflow dev sply,0812T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,132.48,,,,,,,fee schedule,109.02,565.15,APC
Rem mlt day uroflow dev sply,0812T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,127.38,,,,,,,fee schedule,109.02,565.15,APC
Rem mlt day uroflow dev sply,0812T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,194.89,,,,,,,fee schedule,109.02,565.15,Radiology
Rem mlt day uroflow dev sply,0812T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,178.33,,,,,,,fee schedule,109.02,565.15,APC
Rem mlt day uroflow dev sply,0812T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,222.92,,,,,,,fee schedule,109.02,565.15,APC
Egd vol adjmt bariatric balo,0813T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3268.15,,,,,,,fee schedule,897.89,3983.62,
Egd vol adjmt bariatric balo,0813T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2619.71,,,,,,,fee schedule,897.89,3983.62,
Egd vol adjmt bariatric balo,0813T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2861.79,,,,,,,fee schedule,897.89,3983.62,
Egd vol adjmt bariatric balo,0813T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3008.77,,,,,,,fee schedule,897.89,3983.62,
Egd vol adjmt bariatric balo,0813T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3983.62,,,,,,,fee schedule,897.89,3983.62,APC 378
Egd vol adjmt bariatric balo,0813T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,942.78,,,,,,,fee schedule,897.89,3983.62,APC
Egd vol adjmt bariatric balo,0813T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,933.8,,,,,,,fee schedule,897.89,3983.62,APC
Egd vol adjmt bariatric balo,0813T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,897.89,,,,,,,fee schedule,897.89,3983.62,APC
Egd vol adjmt bariatric balo,0813T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1373.77,,,,,,,fee schedule,897.89,3983.62,Radiology
Egd vol adjmt bariatric balo,0813T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1257.04,,,,,,,fee schedule,897.89,3983.62,APC
Egd vol adjmt bariatric balo,0813T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1571.3,,,,,,,fee schedule,897.89,3983.62,APC
Opn insj/rplcmt ins ptn subq,0816T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,78867.89,,,,,,,fee schedule,19205.48,85208.23,
Opn insj/rplcmt ins ptn subq,0816T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,63219.5,,,,,,,fee schedule,19205.48,85208.23,
Opn insj/rplcmt ins ptn subq,0816T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,69061.56,,,,,,,fee schedule,19205.48,85208.23,
Opn insj/rplcmt ins ptn subq,0816T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,72608.53,,,,,,,fee schedule,19205.48,85208.23,
Opn insj/rplcmt ins ptn subq,0816T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,85208.23,,,,,,,fee schedule,19205.48,85208.23,APC 378
Opn insj/rplcmt ins ptn subq,0816T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20165.76,,,,,,,fee schedule,19205.48,85208.23,APC
Opn insj/rplcmt ins ptn subq,0816T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,19973.7,,,,,,,fee schedule,19205.48,85208.23,APC
Opn insj/rplcmt ins ptn subq,0816T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,19205.48,,,,,,,fee schedule,19205.48,85208.23,APC
Opn insj/rplcmt ins ptn subq,0816T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29384.39,,,,,,,fee schedule,19205.48,85208.23,Radiology
Opn insj/rplcmt ins ptn subq,0816T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26887.68,,,,,,,fee schedule,19205.48,85208.23,APC
Opn insj/rplcmt ins ptn subq,0816T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,33609.6,,,,,,,fee schedule,19205.48,85208.23,APC
Opn insj/rplcmt ins ptn subf,0817T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,78867.89,,,,,,,fee schedule,19205.48,85208.23,
Opn insj/rplcmt ins ptn subf,0817T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,63219.5,,,,,,,fee schedule,19205.48,85208.23,
Opn insj/rplcmt ins ptn subf,0817T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,69061.56,,,,,,,fee schedule,19205.48,85208.23,
Opn insj/rplcmt ins ptn subf,0817T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,72608.53,,,,,,,fee schedule,19205.48,85208.23,
Opn insj/rplcmt ins ptn subf,0817T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,85208.23,,,,,,,fee schedule,19205.48,85208.23,APC 378
Opn insj/rplcmt ins ptn subf,0817T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20165.76,,,,,,,fee schedule,19205.48,85208.23,APC
Opn insj/rplcmt ins ptn subf,0817T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,19973.7,,,,,,,fee schedule,19205.48,85208.23,APC
Opn insj/rplcmt ins ptn subf,0817T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,19205.48,,,,,,,fee schedule,19205.48,85208.23,APC
Opn insj/rplcmt ins ptn subf,0817T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29384.39,,,,,,,fee schedule,19205.48,85208.23,Radiology
Opn insj/rplcmt ins ptn subf,0817T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26887.68,,,,,,,fee schedule,19205.48,85208.23,APC
Opn insj/rplcmt ins ptn subf,0817T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,33609.6,,,,,,,fee schedule,19205.48,85208.23,APC
Revj/rmvl ins ptn subq,0818T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12267.12,,,,,,,fee schedule,3461.03,15355.43,
Revj/rmvl ins ptn subq,0818T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9833.17,,,,,,,fee schedule,3461.03,15355.43,
Revj/rmvl ins ptn subq,0818T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10741.84,,,,,,,fee schedule,3461.03,15355.43,
Revj/rmvl ins ptn subq,0818T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11293.54,,,,,,,fee schedule,3461.03,15355.43,
Revj/rmvl ins ptn subq,0818T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15355.43,,,,,,,fee schedule,3461.03,15355.43,APC 378
Revj/rmvl ins ptn subq,0818T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3634.08,,,,,,,fee schedule,3461.03,15355.43,APC
Revj/rmvl ins ptn subq,0818T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3599.47,,,,,,,fee schedule,3461.03,15355.43,APC
Revj/rmvl ins ptn subq,0818T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3461.03,,,,,,,fee schedule,3461.03,15355.43,APC
Revj/rmvl ins ptn subq,0818T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5295.38,,,,,,,fee schedule,3461.03,15355.43,Radiology
Revj/rmvl ins ptn subq,0818T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4845.44,,,,,,,fee schedule,3461.03,15355.43,APC
Revj/rmvl ins ptn subq,0818T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6056.81,,,,,,,fee schedule,3461.03,15355.43,APC
Revj/rmvl ins ptn subf,0819T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12267.12,,,,,,,fee schedule,3461.03,15355.43,
Revj/rmvl ins ptn subf,0819T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9833.17,,,,,,,fee schedule,3461.03,15355.43,
Revj/rmvl ins ptn subf,0819T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10741.84,,,,,,,fee schedule,3461.03,15355.43,
Revj/rmvl ins ptn subf,0819T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11293.54,,,,,,,fee schedule,3461.03,15355.43,
Revj/rmvl ins ptn subf,0819T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15355.43,,,,,,,fee schedule,3461.03,15355.43,APC 378
Revj/rmvl ins ptn subf,0819T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3634.08,,,,,,,fee schedule,3461.03,15355.43,APC
Revj/rmvl ins ptn subf,0819T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3599.47,,,,,,,fee schedule,3461.03,15355.43,APC
Revj/rmvl ins ptn subf,0819T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3461.03,,,,,,,fee schedule,3461.03,15355.43,APC
Revj/rmvl ins ptn subf,0819T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5295.38,,,,,,,fee schedule,3461.03,15355.43,Radiology
Revj/rmvl ins ptn subf,0819T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4845.44,,,,,,,fee schedule,3461.03,15355.43,APC
Revj/rmvl ins ptn subf,0819T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6056.81,,,,,,,fee schedule,3461.03,15355.43,APC
Tcat ins 1chmbr ldls pm ra,0823T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,70250.05,,,,,,,fee schedule,22020.42,97697.15,
Tcat ins 1chmbr ldls pm ra,0823T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56311.55,,,,,,,fee schedule,22020.42,97697.15,
Tcat ins 1chmbr ldls pm ra,0823T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,61515.26,,,,,,,fee schedule,22020.42,97697.15,
Tcat ins 1chmbr ldls pm ra,0823T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,64674.65,,,,,,,fee schedule,22020.42,97697.15,
Tcat ins 1chmbr ldls pm ra,0823T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,97697.15,,,,,,,fee schedule,22020.42,97697.15,APC 378
Tcat ins 1chmbr ldls pm ra,0823T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,23121.44,,,,,,,fee schedule,22020.42,97697.15,APC
Tcat ins 1chmbr ldls pm ra,0823T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,22901.24,,,,,,,fee schedule,22020.42,97697.15,APC
Tcat ins 1chmbr ldls pm ra,0823T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,22020.42,,,,,,,fee schedule,22020.42,97697.15,APC
Tcat ins 1chmbr ldls pm ra,0823T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,33691.24,,,,,,,fee schedule,22020.42,97697.15,Radiology
Tcat ins 1chmbr ldls pm ra,0823T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,30828.59,,,,,,,fee schedule,22020.42,97697.15,APC
Tcat ins 1chmbr ldls pm ra,0823T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,38535.73,,,,,,,fee schedule,22020.42,97697.15,APC
Tcat rmv 1chmbr ldls pm ra,0824T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11491.88,,,,,,,fee schedule,3125.8,13868.13,
Tcat rmv 1chmbr ldls pm ra,0824T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9211.75,,,,,,,fee schedule,3125.8,13868.13,
Tcat rmv 1chmbr ldls pm ra,0824T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10063,,,,,,,fee schedule,3125.8,13868.13,
Tcat rmv 1chmbr ldls pm ra,0824T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10579.83,,,,,,,fee schedule,3125.8,13868.13,
Tcat rmv 1chmbr ldls pm ra,0824T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Tcat rmv 1chmbr ldls pm ra,0824T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Tcat rmv 1chmbr ldls pm ra,0824T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Tcat rmv 1chmbr ldls pm ra,0824T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Tcat rmv 1chmbr ldls pm ra,0824T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Tcat rmv 1chmbr ldls pm ra,0824T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Tcat rmv 1chmbr ldls pm ra,0824T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Tcat rmv&rpl1chmb ldls pm ra,0825T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,70250.05,,,,,,,fee schedule,19068.45,84600.26,
Tcat rmv&rpl1chmb ldls pm ra,0825T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56311.55,,,,,,,fee schedule,19068.45,84600.26,
Tcat rmv&rpl1chmb ldls pm ra,0825T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,61515.26,,,,,,,fee schedule,19068.45,84600.26,
Tcat rmv&rpl1chmb ldls pm ra,0825T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,64674.65,,,,,,,fee schedule,19068.45,84600.26,
Tcat rmv&rpl1chmb ldls pm ra,0825T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,84600.26,,,,,,,fee schedule,19068.45,84600.26,APC 378
Tcat rmv&rpl1chmb ldls pm ra,0825T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20021.87,,,,,,,fee schedule,19068.45,84600.26,APC
Tcat rmv&rpl1chmb ldls pm ra,0825T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,19831.19,,,,,,,fee schedule,19068.45,84600.26,APC
Tcat rmv&rpl1chmb ldls pm ra,0825T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,19068.45,,,,,,,fee schedule,19068.45,84600.26,APC
Tcat rmv&rpl1chmb ldls pm ra,0825T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29174.73,,,,,,,fee schedule,19068.45,84600.26,Radiology
Tcat rmv&rpl1chmb ldls pm ra,0825T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26695.83,,,,,,,fee schedule,19068.45,84600.26,APC
Tcat rmv&rpl1chmb ldls pm ra,0825T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,33369.79,,,,,,,fee schedule,19068.45,84600.26,APC
Prgrmg evl ldls pm 1chmbr ip,0826T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,136,,,,,,,fee schedule,36.95,163.92,
Prgrmg evl ldls pm 1chmbr ip,0826T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,109.02,,,,,,,fee schedule,36.95,163.92,
Prgrmg evl ldls pm 1chmbr ip,0826T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,119.09,,,,,,,fee schedule,36.95,163.92,
Prgrmg evl ldls pm 1chmbr ip,0826T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,125.21,,,,,,,fee schedule,36.95,163.92,
Prgrmg evl ldls pm 1chmbr ip,0826T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,163.92,,,,,,,fee schedule,36.95,163.92,APC 378
Prgrmg evl ldls pm 1chmbr ip,0826T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.79,,,,,,,fee schedule,36.95,163.92,APC
Prgrmg evl ldls pm 1chmbr ip,0826T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.43,,,,,,,fee schedule,36.95,163.92,APC
Prgrmg evl ldls pm 1chmbr ip,0826T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.95,,,,,,,fee schedule,36.95,163.92,APC
Prgrmg evl ldls pm 1chmbr ip,0826T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.53,,,,,,,fee schedule,36.95,163.92,Radiology
Prgrmg evl ldls pm 1chmbr ip,0826T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.73,,,,,,,fee schedule,36.95,163.92,APC
Prgrmg evl ldls pm 1chmbr ip,0826T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.66,,,,,,,fee schedule,36.95,163.92,APC
Opto-acoustic img breast uni,0857T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,396.41,,,,,,,fee schedule,103.5,459.18,
Opto-acoustic img breast uni,0857T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,317.76,,,,,,,fee schedule,103.5,459.18,
Opto-acoustic img breast uni,0857T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,347.12,,,,,,,fee schedule,103.5,459.18,
Opto-acoustic img breast uni,0857T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,364.95,,,,,,,fee schedule,103.5,459.18,
Opto-acoustic img breast uni,0857T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
Opto-acoustic img breast uni,0857T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
Opto-acoustic img breast uni,0857T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
Opto-acoustic img breast uni,0857T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
Opto-acoustic img breast uni,0857T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
Opto-acoustic img breast uni,0857T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
Opto-acoustic img breast uni,0857T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Rmvl pg wcs lv both compnt,0861T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14158.07,,,,,,,fee schedule,3699.47,16413.29,
Rmvl pg wcs lv both compnt,0861T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11348.93,,,,,,,fee schedule,3699.47,16413.29,
Rmvl pg wcs lv both compnt,0861T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12397.67,,,,,,,fee schedule,3699.47,16413.29,
Rmvl pg wcs lv both compnt,0861T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13034.41,,,,,,,fee schedule,3699.47,16413.29,
Rmvl pg wcs lv both compnt,0861T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16413.29,,,,,,,fee schedule,3699.47,16413.29,APC 378
Rmvl pg wcs lv both compnt,0861T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3884.44,,,,,,,fee schedule,3699.47,16413.29,APC
Rmvl pg wcs lv both compnt,0861T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3847.45,,,,,,,fee schedule,3699.47,16413.29,APC
Rmvl pg wcs lv both compnt,0861T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3699.47,,,,,,,fee schedule,3699.47,16413.29,APC
Rmvl pg wcs lv both compnt,0861T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5660.19,,,,,,,fee schedule,3699.47,16413.29,Radiology
Rmvl pg wcs lv both compnt,0861T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5179.26,,,,,,,fee schedule,3699.47,16413.29,APC
Rmvl pg wcs lv both compnt,0861T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6474.07,,,,,,,fee schedule,3699.47,16413.29,APC
Rlcj pg wcs lv battery only,0862T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6574.67,,,,,,,fee schedule,2042.58,9062.24,
Rlcj pg wcs lv battery only,0862T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5270.17,,,,,,,fee schedule,2042.58,9062.24,
Rlcj pg wcs lv battery only,0862T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5757.18,,,,,,,fee schedule,2042.58,9062.24,
Rlcj pg wcs lv battery only,0862T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6052.87,,,,,,,fee schedule,2042.58,9062.24,
Rlcj pg wcs lv battery only,0862T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,2042.58,9062.24,APC 378
Rlcj pg wcs lv battery only,0862T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,2042.58,9062.24,APC
Rlcj pg wcs lv battery only,0862T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,2042.58,9062.24,APC
Rlcj pg wcs lv battery only,0862T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,2042.58,9062.24,APC
Rlcj pg wcs lv battery only,0862T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,2042.58,9062.24,Radiology
Rlcj pg wcs lv battery only,0862T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,2042.58,9062.24,APC
Rlcj pg wcs lv battery only,0862T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,2042.58,9062.24,APC
Rlcj pg wcs lv trnsmtr only,0863T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6574.67,,,,,,,fee schedule,2042.58,9062.24,
Rlcj pg wcs lv trnsmtr only,0863T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5270.17,,,,,,,fee schedule,2042.58,9062.24,
Rlcj pg wcs lv trnsmtr only,0863T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5757.18,,,,,,,fee schedule,2042.58,9062.24,
Rlcj pg wcs lv trnsmtr only,0863T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6052.87,,,,,,,fee schedule,2042.58,9062.24,
Rlcj pg wcs lv trnsmtr only,0863T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,2042.58,9062.24,APC 378
Rlcj pg wcs lv trnsmtr only,0863T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,2042.58,9062.24,APC
Rlcj pg wcs lv trnsmtr only,0863T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,2042.58,9062.24,APC
Rlcj pg wcs lv trnsmtr only,0863T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,2042.58,9062.24,APC
Rlcj pg wcs lv trnsmtr only,0863T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,2042.58,9062.24,Radiology
Rlcj pg wcs lv trnsmtr only,0863T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,2042.58,9062.24,APC
Rlcj pg wcs lv trnsmtr only,0863T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,2042.58,9062.24,APC
Low ntsty eswt corpus cvrnsm,0864T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,891.02,,,,,,,fee schedule,247.34,1097.37,
Low ntsty eswt corpus cvrnsm,0864T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,714.23,,,,,,,fee schedule,247.34,1097.37,
Low ntsty eswt corpus cvrnsm,0864T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,780.23,,,,,,,fee schedule,247.34,1097.37,
Low ntsty eswt corpus cvrnsm,0864T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,820.31,,,,,,,fee schedule,247.34,1097.37,
Low ntsty eswt corpus cvrnsm,0864T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1097.37,,,,,,,fee schedule,247.34,1097.37,APC 378
Low ntsty eswt corpus cvrnsm,0864T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,259.71,,,,,,,fee schedule,247.34,1097.37,APC
Low ntsty eswt corpus cvrnsm,0864T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,257.24,,,,,,,fee schedule,247.34,1097.37,APC
Low ntsty eswt corpus cvrnsm,0864T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,247.34,,,,,,,fee schedule,247.34,1097.37,APC
Low ntsty eswt corpus cvrnsm,0864T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,378.43,,,,,,,fee schedule,247.34,1097.37,Radiology
Low ntsty eswt corpus cvrnsm,0864T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,346.28,,,,,,,fee schedule,247.34,1097.37,APC
Low ntsty eswt corpus cvrnsm,0864T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,432.85,,,,,,,fee schedule,247.34,1097.37,APC
Quan mri alys brn w/o dx mri,0865T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,883.42,,,,,,,fee schedule,236.21,1047.98,
Quan mri alys brn w/o dx mri,0865T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,708.14,,,,,,,fee schedule,236.21,1047.98,
Quan mri alys brn w/o dx mri,0865T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,773.58,,,,,,,fee schedule,236.21,1047.98,
Quan mri alys brn w/o dx mri,0865T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,813.31,,,,,,,fee schedule,236.21,1047.98,
Quan mri alys brn w/o dx mri,0865T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,236.21,1047.98,APC 378
Quan mri alys brn w/o dx mri,0865T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,236.21,1047.98,APC
Quan mri alys brn w/o dx mri,0865T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,236.21,1047.98,APC
Quan mri alys brn w/o dx mri,0865T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,236.21,1047.98,APC
Quan mri alys brn w/o dx mri,0865T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,236.21,1047.98,Radiology
Quan mri alys brn w/o dx mri,0865T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,236.21,1047.98,APC
Quan mri alys brn w/o dx mri,0865T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,236.21,1047.98,APC
Quan mri alys brn w/dx mri,0866T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,883.42,,,,,,,fee schedule,236.21,1047.98,
Quan mri alys brn w/dx mri,0866T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,708.14,,,,,,,fee schedule,236.21,1047.98,
Quan mri alys brn w/dx mri,0866T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,773.58,,,,,,,fee schedule,236.21,1047.98,
Quan mri alys brn w/dx mri,0866T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,813.31,,,,,,,fee schedule,236.21,1047.98,
Quan mri alys brn w/dx mri,0866T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,236.21,1047.98,APC 378
Quan mri alys brn w/dx mri,0866T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,236.21,1047.98,APC
Quan mri alys brn w/dx mri,0866T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,236.21,1047.98,APC
Quan mri alys brn w/dx mri,0866T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,236.21,1047.98,APC
Quan mri alys brn w/dx mri,0866T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,236.21,1047.98,Radiology
Quan mri alys brn w/dx mri,0866T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,236.21,1047.98,APC
Quan mri alys brn w/dx mri,0866T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,236.21,1047.98,APC
Tpla b9 prst8 hyprplsa>=50ml,0867T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23549.82,,,,,,,fee schedule,5308,23549.82,APC 378
Tpla b9 prst8 hyprplsa>=50ml,0867T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5573.4,,,,,,,fee schedule,5308,23549.82,APC
Tpla b9 prst8 hyprplsa>=50ml,0867T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5520.32,,,,,,,fee schedule,5308,23549.82,APC
Tpla b9 prst8 hyprplsa>=50ml,0867T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5308,,,,,,,fee schedule,5308,23549.82,APC
Tpla b9 prst8 hyprplsa>=50ml,0867T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8121.25,,,,,,,fee schedule,5308,23549.82,Radiology
Tpla b9 prst8 hyprplsa>=50ml,0867T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7431.21,,,,,,,fee schedule,5308,23549.82,APC
Tpla b9 prst8 hyprplsa>=50ml,0867T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9289.01,,,,,,,fee schedule,5308,23549.82,APC
Hi-res gastric ep mapping,0868T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1638.96,,,,,,,fee schedule,369.41,1638.96,APC 378
Hi-res gastric ep mapping,0868T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,387.88,,,,,,,fee schedule,369.41,1638.96,APC
Hi-res gastric ep mapping,0868T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,384.19,,,,,,,fee schedule,369.41,1638.96,APC
Hi-res gastric ep mapping,0868T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,369.41,,,,,,,fee schedule,369.41,1638.96,APC
Hi-res gastric ep mapping,0868T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,565.2,,,,,,,fee schedule,369.41,1638.96,Radiology
Hi-res gastric ep mapping,0868T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,517.18,,,,,,,fee schedule,369.41,1638.96,APC
Hi-res gastric ep mapping,0868T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,646.47,,,,,,,fee schedule,369.41,1638.96,APC
Njx b1 sub mtrl hw fixj aug,0869T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Njx b1 sub mtrl hw fixj aug,0869T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Njx b1 sub mtrl hw fixj aug,0869T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Njx b1 sub mtrl hw fixj aug,0869T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Njx b1 sub mtrl hw fixj aug,0869T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Njx b1 sub mtrl hw fixj aug,0869T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Njx b1 sub mtrl hw fixj aug,0869T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Rplcmt ndwllg bldr&prtl cath,0872T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15725.66,,,,,,,fee schedule,3544.48,15725.66,APC 378
Rplcmt ndwllg bldr&prtl cath,0872T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3721.7,,,,,,,fee schedule,3544.48,15725.66,APC
Rplcmt ndwllg bldr&prtl cath,0872T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3686.26,,,,,,,fee schedule,3544.48,15725.66,APC
Rplcmt ndwllg bldr&prtl cath,0872T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3544.48,,,,,,,fee schedule,3544.48,15725.66,APC
Rplcmt ndwllg bldr&prtl cath,0872T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5423.05,,,,,,,fee schedule,3544.48,15725.66,Radiology
Rplcmt ndwllg bldr&prtl cath,0872T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4962.27,,,,,,,fee schedule,3544.48,15725.66,APC
Rplcmt ndwllg bldr&prtl cath,0872T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6202.84,,,,,,,fee schedule,3544.48,15725.66,APC
Revj subq prtl asct pmp sys,0873T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15725.66,,,,,,,fee schedule,3544.48,15725.66,APC 378
Revj subq prtl asct pmp sys,0873T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3721.7,,,,,,,fee schedule,3544.48,15725.66,APC
Revj subq prtl asct pmp sys,0873T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3686.26,,,,,,,fee schedule,3544.48,15725.66,APC
Revj subq prtl asct pmp sys,0873T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3544.48,,,,,,,fee schedule,3544.48,15725.66,APC
Revj subq prtl asct pmp sys,0873T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5423.05,,,,,,,fee schedule,3544.48,15725.66,Radiology
Revj subq prtl asct pmp sys,0873T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4962.27,,,,,,,fee schedule,3544.48,15725.66,APC
Revj subq prtl asct pmp sys,0873T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6202.84,,,,,,,fee schedule,3544.48,15725.66,APC
Rmvl pertl ascites pmp sys,0874T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15725.66,,,,,,,fee schedule,3544.48,15725.66,APC 378
Rmvl pertl ascites pmp sys,0874T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3721.7,,,,,,,fee schedule,3544.48,15725.66,APC
Rmvl pertl ascites pmp sys,0874T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3686.26,,,,,,,fee schedule,3544.48,15725.66,APC
Rmvl pertl ascites pmp sys,0874T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3544.48,,,,,,,fee schedule,3544.48,15725.66,APC
Rmvl pertl ascites pmp sys,0874T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5423.05,,,,,,,fee schedule,3544.48,15725.66,Radiology
Rmvl pertl ascites pmp sys,0874T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4962.27,,,,,,,fee schedule,3544.48,15725.66,APC
Rmvl pertl ascites pmp sys,0874T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6202.84,,,,,,,fee schedule,3544.48,15725.66,APC
Esphgsc flx 1st tndsc dilat,0884T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26664.3,,,,,,,fee schedule,6009.99,26664.3,APC 378
Esphgsc flx 1st tndsc dilat,0884T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6310.49,,,,,,,fee schedule,6009.99,26664.3,APC
Esphgsc flx 1st tndsc dilat,0884T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6250.39,,,,,,,fee schedule,6009.99,26664.3,APC
Esphgsc flx 1st tndsc dilat,0884T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6009.99,,,,,,,fee schedule,6009.99,26664.3,APC
Esphgsc flx 1st tndsc dilat,0884T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9195.29,,,,,,,fee schedule,6009.99,26664.3,Radiology
Esphgsc flx 1st tndsc dilat,0884T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8413.99,,,,,,,fee schedule,6009.99,26664.3,APC
Esphgsc flx 1st tndsc dilat,0884T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10517.49,,,,,,,fee schedule,6009.99,26664.3,APC
Colsc flx 1st tndsc dilat,0885T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26664.3,,,,,,,fee schedule,6009.99,26664.3,APC 378
Colsc flx 1st tndsc dilat,0885T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6310.49,,,,,,,fee schedule,6009.99,26664.3,APC
Colsc flx 1st tndsc dilat,0885T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6250.39,,,,,,,fee schedule,6009.99,26664.3,APC
Colsc flx 1st tndsc dilat,0885T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6009.99,,,,,,,fee schedule,6009.99,26664.3,APC
Colsc flx 1st tndsc dilat,0885T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9195.29,,,,,,,fee schedule,6009.99,26664.3,Radiology
Colsc flx 1st tndsc dilat,0885T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8413.99,,,,,,,fee schedule,6009.99,26664.3,APC
Colsc flx 1st tndsc dilat,0885T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10517.49,,,,,,,fee schedule,6009.99,26664.3,APC
Sgmdsc flx 1st tndsc dilat,0886T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26664.3,,,,,,,fee schedule,6009.99,26664.3,APC 378
Sgmdsc flx 1st tndsc dilat,0886T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6310.49,,,,,,,fee schedule,6009.99,26664.3,APC
Sgmdsc flx 1st tndsc dilat,0886T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6250.39,,,,,,,fee schedule,6009.99,26664.3,APC
Sgmdsc flx 1st tndsc dilat,0886T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6009.99,,,,,,,fee schedule,6009.99,26664.3,APC
Sgmdsc flx 1st tndsc dilat,0886T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9195.29,,,,,,,fee schedule,6009.99,26664.3,Radiology
Sgmdsc flx 1st tndsc dilat,0886T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8413.99,,,,,,,fee schedule,6009.99,26664.3,APC
Sgmdsc flx 1st tndsc dilat,0886T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10517.49,,,,,,,fee schedule,6009.99,26664.3,APC
N-invas assmt bld oxygnation,0893T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,131.71,584.37,APC 378
N-invas assmt bld oxygnation,0893T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,131.71,584.37,APC
N-invas assmt bld oxygnation,0893T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,131.71,584.37,APC
N-invas assmt bld oxygnation,0893T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,131.71,584.37,APC
N-invas assmt bld oxygnation,0893T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,131.71,584.37,Radiology
N-invas assmt bld oxygnation,0893T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,131.71,584.37,APC
N-invas assmt bld oxygnation,0893T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,131.71,584.37,APC
N-invas augmnt arrhyt alys,0897T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3771.72,,,,,,,fee schedule,850.12,3771.72,APC 378
N-invas augmnt arrhyt alys,0897T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,892.63,,,,,,,fee schedule,850.12,3771.72,APC
N-invas augmnt arrhyt alys,0897T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,884.13,,,,,,,fee schedule,850.12,3771.72,APC
N-invas augmnt arrhyt alys,0897T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,850.12,,,,,,,fee schedule,850.12,3771.72,APC
N-invas augmnt arrhyt alys,0897T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1300.69,,,,,,,fee schedule,850.12,3771.72,Radiology
N-invas augmnt arrhyt alys,0897T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1190.17,,,,,,,fee schedule,850.12,3771.72,APC
N-invas augmnt arrhyt alys,0897T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1487.72,,,,,,,fee schedule,850.12,3771.72,APC
N-invas prst8 cancer est map,0898T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3771.72,,,,,,,fee schedule,850.12,3771.72,APC 378
N-invas prst8 cancer est map,0898T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,892.63,,,,,,,fee schedule,850.12,3771.72,APC
N-invas prst8 cancer est map,0898T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,884.13,,,,,,,fee schedule,850.12,3771.72,APC
N-invas prst8 cancer est map,0898T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,850.12,,,,,,,fee schedule,850.12,3771.72,APC
N-invas prst8 cancer est map,0898T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1300.69,,,,,,,fee schedule,850.12,3771.72,Radiology
N-invas prst8 cancer est map,0898T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1190.17,,,,,,,fee schedule,850.12,3771.72,APC
N-invas prst8 cancer est map,0898T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1487.72,,,,,,,fee schedule,850.12,3771.72,APC
Qtc ntrvl augmnt alg aly ecg,0902T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,131.71,584.37,APC 378
Qtc ntrvl augmnt alg aly ecg,0902T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,131.71,584.37,APC
Qtc ntrvl augmnt alg aly ecg,0902T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,131.71,584.37,APC
Qtc ntrvl augmnt alg aly ecg,0902T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,131.71,584.37,APC
Qtc ntrvl augmnt alg aly ecg,0902T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,131.71,584.37,Radiology
Qtc ntrvl augmnt alg aly ecg,0902T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,131.71,584.37,APC
Qtc ntrvl augmnt alg aly ecg,0902T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,131.71,584.37,APC
Ecg alg 12 ld rdcd trcg only,0904T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,58.4,259.1,APC 378
Ecg alg 12 ld rdcd trcg only,0904T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,58.4,259.1,APC
Ecg alg 12 ld rdcd trcg only,0904T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,58.4,259.1,APC
Ecg alg 12 ld rdcd trcg only,0904T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,58.4,259.1,APC
Ecg alg 12 ld rdcd trcg only,0904T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,58.4,259.1,Radiology
Ecg alg 12 ld rdcd trcg only,0904T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,58.4,259.1,APC
Ecg alg 12 ld rdcd trcg only,0904T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,58.4,259.1,APC
Coms ther 1st appl<=50 sq cm,0906T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,881.22,,,,,,,fee schedule,198.62,881.22,APC 378
Coms ther 1st appl<=50 sq cm,0906T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.55,,,,,,,fee schedule,198.62,881.22,APC
Coms ther 1st appl<=50 sq cm,0906T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,206.57,,,,,,,fee schedule,198.62,881.22,APC
Coms ther 1st appl<=50 sq cm,0906T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.62,,,,,,,fee schedule,198.62,881.22,APC
Coms ther 1st appl<=50 sq cm,0906T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.89,,,,,,,fee schedule,198.62,881.22,Radiology
Coms ther 1st appl<=50 sq cm,0906T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,278.07,,,,,,,fee schedule,198.62,881.22,APC
Coms ther 1st appl<=50 sq cm,0906T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,347.59,,,,,,,fee schedule,198.62,881.22,APC
Opn imp int nstm sys vgs nrv,0908T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,135531.68,,,,,,,fee schedule,30548.12,135531.68,APC 378
Opn imp int nstm sys vgs nrv,0908T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,32075.53,,,,,,,fee schedule,30548.12,135531.68,APC
Opn imp int nstm sys vgs nrv,0908T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,31770.05,,,,,,,fee schedule,30548.12,135531.68,APC
Opn imp int nstm sys vgs nrv,0908T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,30548.12,,,,,,,fee schedule,30548.12,135531.68,APC
Opn imp int nstm sys vgs nrv,0908T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,46738.63,,,,,,,fee schedule,30548.12,135531.68,Radiology
Opn imp int nstm sys vgs nrv,0908T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,42767.37,,,,,,,fee schedule,30548.12,135531.68,APC
Opn imp int nstm sys vgs nrv,0908T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,53459.21,,,,,,,fee schedule,30548.12,135531.68,APC
Rplcmt int nstim sys vgs nrv,0909T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,135531.68,,,,,,,fee schedule,30548.12,135531.68,APC 378
Rplcmt int nstim sys vgs nrv,0909T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,32075.53,,,,,,,fee schedule,30548.12,135531.68,APC
Rplcmt int nstim sys vgs nrv,0909T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,31770.05,,,,,,,fee schedule,30548.12,135531.68,APC
Rplcmt int nstim sys vgs nrv,0909T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,30548.12,,,,,,,fee schedule,30548.12,135531.68,APC
Rplcmt int nstim sys vgs nrv,0909T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,46738.63,,,,,,,fee schedule,30548.12,135531.68,Radiology
Rplcmt int nstim sys vgs nrv,0909T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,42767.37,,,,,,,fee schedule,30548.12,135531.68,APC
Rplcmt int nstim sys vgs nrv,0909T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,53459.21,,,,,,,fee schedule,30548.12,135531.68,APC
Rmvl int nstim sys vagus nrv,0910T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15355.43,,,,,,,fee schedule,3461.03,15355.43,APC 378
Rmvl int nstim sys vagus nrv,0910T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3634.08,,,,,,,fee schedule,3461.03,15355.43,APC
Rmvl int nstim sys vagus nrv,0910T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3599.47,,,,,,,fee schedule,3461.03,15355.43,APC
Rmvl int nstim sys vagus nrv,0910T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3461.03,,,,,,,fee schedule,3461.03,15355.43,APC
Rmvl int nstim sys vagus nrv,0910T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5295.38,,,,,,,fee schedule,3461.03,15355.43,Radiology
Rmvl int nstim sys vagus nrv,0910T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4845.44,,,,,,,fee schedule,3461.03,15355.43,APC
Rmvl int nstim sys vagus nrv,0910T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6056.81,,,,,,,fee schedule,3461.03,15355.43,APC
Elec aly nstm sys vgs nrv wo,0911T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,58.4,259.1,APC 378
Elec aly nstm sys vgs nrv wo,0911T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,58.4,259.1,APC
Elec aly nstm sys vgs nrv wo,0911T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,58.4,259.1,APC
Elec aly nstm sys vgs nrv wo,0911T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,58.4,259.1,APC
Elec aly nstm sys vgs nrv wo,0911T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,58.4,259.1,Radiology
Elec aly nstm sys vgs nrv wo,0911T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,58.4,259.1,APC
Elec aly nstm sys vgs nrv wo,0911T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,58.4,259.1,APC
Prq tcat ther rx ntrac balo1,0913T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,50703.82,,,,,,,fee schedule,11428.37,50703.82,APC 378
Prq tcat ther rx ntrac balo1,0913T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11999.79,,,,,,,fee schedule,11428.37,50703.82,APC
Prq tcat ther rx ntrac balo1,0913T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11885.51,,,,,,,fee schedule,11428.37,50703.82,APC
Prq tcat ther rx ntrac balo1,0913T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11428.37,,,,,,,fee schedule,11428.37,50703.82,APC
Prq tcat ther rx ntrac balo1,0913T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17485.41,,,,,,,fee schedule,11428.37,50703.82,Radiology
Prq tcat ther rx ntrac balo1,0913T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15999.72,,,,,,,fee schedule,11428.37,50703.82,APC
Prq tcat ther rx ntrac balo1,0913T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19999.65,,,,,,,fee schedule,11428.37,50703.82,APC
Insj perm ccm-d sys pg&eltrd,0915T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,137864.64,,,,,,,fee schedule,31073.96,137864.64,APC 378
Insj perm ccm-d sys pg&eltrd,0915T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,32627.66,,,,,,,fee schedule,31073.96,137864.64,APC
Insj perm ccm-d sys pg&eltrd,0915T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,32316.92,,,,,,,fee schedule,31073.96,137864.64,APC
Insj perm ccm-d sys pg&eltrd,0915T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,31073.96,,,,,,,fee schedule,31073.96,137864.64,APC
Insj perm ccm-d sys pg&eltrd,0915T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,47543.16,,,,,,,fee schedule,31073.96,137864.64,Radiology
Insj perm ccm-d sys pg&eltrd,0915T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43503.54,,,,,,,fee schedule,31073.96,137864.64,APC
Insj perm ccm-d sys pg&eltrd,0915T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,54379.43,,,,,,,fee schedule,31073.96,137864.64,APC
Insj perm ccm-d sys pg only,0916T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,97697.15,,,,,,,fee schedule,22020.42,97697.15,APC 378
Insj perm ccm-d sys pg only,0916T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,23121.44,,,,,,,fee schedule,22020.42,97697.15,APC
Insj perm ccm-d sys pg only,0916T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,22901.24,,,,,,,fee schedule,22020.42,97697.15,APC
Insj perm ccm-d sys pg only,0916T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,22020.42,,,,,,,fee schedule,22020.42,97697.15,APC
Insj perm ccm-d sys pg only,0916T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,33691.24,,,,,,,fee schedule,22020.42,97697.15,Radiology
Insj perm ccm-d sys pg only,0916T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,30828.59,,,,,,,fee schedule,22020.42,97697.15,APC
Insj perm ccm-d sys pg only,0916T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,38535.73,,,,,,,fee schedule,22020.42,97697.15,APC
Insj perm ccm-d sys 1 lead,0917T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,36346.76,,,,,,,fee schedule,8192.37,36346.76,APC 378
Insj perm ccm-d sys 1 lead,0917T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8601.99,,,,,,,fee schedule,8192.37,36346.76,APC
Insj perm ccm-d sys 1 lead,0917T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8520.06,,,,,,,fee schedule,8192.37,36346.76,APC
Insj perm ccm-d sys 1 lead,0917T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8192.37,,,,,,,fee schedule,8192.37,36346.76,APC
Insj perm ccm-d sys 1 lead,0917T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12534.32,,,,,,,fee schedule,8192.37,36346.76,Radiology
Insj perm ccm-d sys 1 lead,0917T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11469.31,,,,,,,fee schedule,8192.37,36346.76,APC
Insj perm ccm-d sys 1 lead,0917T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14336.64,,,,,,,fee schedule,8192.37,36346.76,APC
Insj perm ccm-d sys dual ld,0918T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,36346.76,,,,,,,fee schedule,8192.37,36346.76,APC 378
Insj perm ccm-d sys dual ld,0918T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8601.99,,,,,,,fee schedule,8192.37,36346.76,APC
Insj perm ccm-d sys dual ld,0918T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8520.06,,,,,,,fee schedule,8192.37,36346.76,APC
Insj perm ccm-d sys dual ld,0918T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8192.37,,,,,,,fee schedule,8192.37,36346.76,APC
Insj perm ccm-d sys dual ld,0918T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12534.32,,,,,,,fee schedule,8192.37,36346.76,Radiology
Insj perm ccm-d sys dual ld,0918T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11469.31,,,,,,,fee schedule,8192.37,36346.76,APC
Insj perm ccm-d sys dual ld,0918T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14336.64,,,,,,,fee schedule,8192.37,36346.76,APC
Rmvl&rplcmt perm ccm-d pg,0923T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,97697.15,,,,,,,fee schedule,22020.42,97697.15,APC 378
Rmvl&rplcmt perm ccm-d pg,0923T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,23121.44,,,,,,,fee schedule,22020.42,97697.15,APC
Rmvl&rplcmt perm ccm-d pg,0923T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,22901.24,,,,,,,fee schedule,22020.42,97697.15,APC
Rmvl&rplcmt perm ccm-d pg,0923T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,22020.42,,,,,,,fee schedule,22020.42,97697.15,APC
Rmvl&rplcmt perm ccm-d pg,0923T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,33691.24,,,,,,,fee schedule,22020.42,97697.15,Radiology
Rmvl&rplcmt perm ccm-d pg,0923T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,30828.59,,,,,,,fee schedule,22020.42,97697.15,APC
Rmvl&rplcmt perm ccm-d pg,0923T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,38535.73,,,,,,,fee schedule,22020.42,97697.15,APC
Rpos prv ccm-d trnsvns eltrd,0924T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2755.21,,,,,,,fee schedule,621.01,2755.21,APC 378
Rpos prv ccm-d trnsvns eltrd,0924T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,652.06,,,,,,,fee schedule,621.01,2755.21,APC
Rpos prv ccm-d trnsvns eltrd,0924T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,645.85,,,,,,,fee schedule,621.01,2755.21,APC
Rpos prv ccm-d trnsvns eltrd,0924T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,621.01,,,,,,,fee schedule,621.01,2755.21,APC
Rpos prv ccm-d trnsvns eltrd,0924T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,950.14,,,,,,,fee schedule,621.01,2755.21,Radiology
Rpos prv ccm-d trnsvns eltrd,0924T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,869.41,,,,,,,fee schedule,621.01,2755.21,APC
Rpos prv ccm-d trnsvns eltrd,0924T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1086.77,,,,,,,fee schedule,621.01,2755.21,APC
Rlcj skin pocket ccm-d pg,0925T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,2042.58,9062.24,APC 378
Rlcj skin pocket ccm-d pg,0925T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,2042.58,9062.24,APC
Rlcj skin pocket ccm-d pg,0925T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,2042.58,9062.24,APC
Rlcj skin pocket ccm-d pg,0925T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,2042.58,9062.24,APC
Rlcj skin pocket ccm-d pg,0925T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,2042.58,9062.24,Radiology
Rlcj skin pocket ccm-d pg,0925T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,2042.58,9062.24,APC
Rlcj skin pocket ccm-d pg,0925T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,2042.58,9062.24,APC
N-invs det hrt fail aug echo,0932T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1348.99,,,,,,,fee schedule,304.06,1348.99,APC 378
N-invs det hrt fail aug echo,0932T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,319.26,,,,,,,fee schedule,304.06,1348.99,APC
N-invs det hrt fail aug echo,0932T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,316.22,,,,,,,fee schedule,304.06,1348.99,APC
N-invs det hrt fail aug echo,0932T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,304.06,,,,,,,fee schedule,304.06,1348.99,APC
N-invs det hrt fail aug echo,0932T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,465.21,,,,,,,fee schedule,304.06,1348.99,Radiology
N-invs det hrt fail aug echo,0932T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,425.68,,,,,,,fee schedule,304.06,1348.99,APC
N-invs det hrt fail aug echo,0932T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,532.1,,,,,,,fee schedule,304.06,1348.99,APC
Tcat impl wrls l atr prs snr,0933T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14239.05,,,,,,,fee schedule,3209.41,14239.05,APC 378
Tcat impl wrls l atr prs snr,0933T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3369.88,,,,,,,fee schedule,3209.41,14239.05,APC
Tcat impl wrls l atr prs snr,0933T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3337.78,,,,,,,fee schedule,3209.41,14239.05,APC
Tcat impl wrls l atr prs snr,0933T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3209.41,,,,,,,fee schedule,3209.41,14239.05,APC
Tcat impl wrls l atr prs snr,0933T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4910.39,,,,,,,fee schedule,3209.41,14239.05,Radiology
Tcat impl wrls l atr prs snr,0933T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4493.17,,,,,,,fee schedule,3209.41,14239.05,APC
Tcat impl wrls l atr prs snr,0933T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5616.46,,,,,,,fee schedule,3209.41,14239.05,APC
Cysto flx ins&xpns urtl scaf,0941T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,41578.13,,,,,,,fee schedule,9371.49,41578.13,APC 378
Cysto flx ins&xpns urtl scaf,0941T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9840.06,,,,,,,fee schedule,9371.49,41578.13,APC
Cysto flx ins&xpns urtl scaf,0941T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9746.35,,,,,,,fee schedule,9371.49,41578.13,APC
Cysto flx ins&xpns urtl scaf,0941T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9371.49,,,,,,,fee schedule,9371.49,41578.13,APC
Cysto flx ins&xpns urtl scaf,0941T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14338.38,,,,,,,fee schedule,9371.49,41578.13,Radiology
Cysto flx ins&xpns urtl scaf,0941T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13120.09,,,,,,,fee schedule,9371.49,41578.13,APC
Cysto flx ins&xpns urtl scaf,0941T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16400.11,,,,,,,fee schedule,9371.49,41578.13,APC
Cysto flx rmv&rplc urtl scaf,0942T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,41578.13,,,,,,,fee schedule,9371.49,41578.13,APC 378
Cysto flx rmv&rplc urtl scaf,0942T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9840.06,,,,,,,fee schedule,9371.49,41578.13,APC
Cysto flx rmv&rplc urtl scaf,0942T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9746.35,,,,,,,fee schedule,9371.49,41578.13,APC
Cysto flx rmv&rplc urtl scaf,0942T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9371.49,,,,,,,fee schedule,9371.49,41578.13,APC
Cysto flx rmv&rplc urtl scaf,0942T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14338.38,,,,,,,fee schedule,9371.49,41578.13,Radiology
Cysto flx rmv&rplc urtl scaf,0942T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13120.09,,,,,,,fee schedule,9371.49,41578.13,APC
Cysto flx rmv&rplc urtl scaf,0942T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16400.11,,,,,,,fee schedule,9371.49,41578.13,APC
Cysto flx rmvl urtl scaffold,0943T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9181.28,,,,,,,fee schedule,2069.41,9181.28,APC 378
Cysto flx rmvl urtl scaffold,0943T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2172.88,,,,,,,fee schedule,2069.41,9181.28,APC
Cysto flx rmvl urtl scaffold,0943T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2152.19,,,,,,,fee schedule,2069.41,9181.28,APC
Cysto flx rmvl urtl scaffold,0943T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2069.41,,,,,,,fee schedule,2069.41,9181.28,APC
Cysto flx rmvl urtl scaffold,0943T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3166.2,,,,,,,fee schedule,2069.41,9181.28,Radiology
Cysto flx rmvl urtl scaffold,0943T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2897.18,,,,,,,fee schedule,2069.41,9181.28,APC
Cysto flx rmvl urtl scaffold,0943T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3621.47,,,,,,,fee schedule,2069.41,9181.28,APC
3d cntr simula trgt lvr les,0944T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,236.21,1047.98,APC 378
3d cntr simula trgt lvr les,0944T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,236.21,1047.98,APC
3d cntr simula trgt lvr les,0944T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,236.21,1047.98,APC
3d cntr simula trgt lvr les,0944T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,236.21,1047.98,APC
3d cntr simula trgt lvr les,0944T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,236.21,1047.98,Radiology
3d cntr simula trgt lvr les,0944T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,236.21,1047.98,APC
3d cntr simula trgt lvr les,0944T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,236.21,1047.98,APC
Ortho impl mvmt alys pair ct,0946T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
Ortho impl mvmt alys pair ct,0946T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
Ortho impl mvmt alys pair ct,0946T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
Ortho impl mvmt alys pair ct,0946T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
Ortho impl mvmt alys pair ct,0946T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
Ortho impl mvmt alys pair ct,0946T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
Ortho impl mvmt alys pair ct,0946T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Abltj b9 prst8 tissue hifu,0950T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,41578.13,,,,,,,fee schedule,9371.49,41578.13,APC 378
Abltj b9 prst8 tissue hifu,0950T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9840.06,,,,,,,fee schedule,9371.49,41578.13,APC
Abltj b9 prst8 tissue hifu,0950T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9746.35,,,,,,,fee schedule,9371.49,41578.13,APC
Abltj b9 prst8 tissue hifu,0950T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9371.49,,,,,,,fee schedule,9371.49,41578.13,APC
Abltj b9 prst8 tissue hifu,0950T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14338.38,,,,,,,fee schedule,9371.49,41578.13,Radiology
Abltj b9 prst8 tissue hifu,0950T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13120.09,,,,,,,fee schedule,9371.49,41578.13,APC
Abltj b9 prst8 tissue hifu,0950T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16400.11,,,,,,,fee schedule,9371.49,41578.13,APC
Rev s-sclp eltr ra rcvr&tlmt,0957T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Rev s-sclp eltr ra rcvr&tlmt,0957T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Rev s-sclp eltr ra rcvr&tlmt,0957T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Rev s-sclp eltr ra rcvr&tlmt,0957T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Rev s-sclp eltr ra rcvr&tlmt,0957T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Rev s-sclp eltr ra rcvr&tlmt,0957T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Rev s-sclp eltr ra rcvr&tlmt,0957T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Rmv s-sclp eltr ra rcvr&tlmt,0958T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Rmv s-sclp eltr ra rcvr&tlmt,0958T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Rmv s-sclp eltr ra rcvr&tlmt,0958T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Rmv s-sclp eltr ra rcvr&tlmt,0958T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Rmv s-sclp eltr ra rcvr&tlmt,0958T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Rmv s-sclp eltr ra rcvr&tlmt,0958T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Rmv s-sclp eltr ra rcvr&tlmt,0958T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Rmv/rplc magnet coil assem,0959T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,7254.06,APC 378
Rmv/rplc magnet coil assem,0959T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,7254.06,APC
Rmv/rplc magnet coil assem,0959T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,7254.06,APC
Rmv/rplc magnet coil assem,0959T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,7254.06,APC
Rmv/rplc magnet coil assem,0959T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,7254.06,Radiology
Rmv/rplc magnet coil assem,0959T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,7254.06,APC
Rmv/rplc magnet coil assem,0959T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,7254.06,APC
Asstv alg alys acous&ecg rec,0962T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,131.71,584.37,APC 378
Asstv alg alys acous&ecg rec,0962T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,131.71,584.37,APC
Asstv alg alys acous&ecg rec,0962T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,131.71,584.37,APC
Asstv alg alys acous&ecg rec,0962T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,131.71,584.37,APC
Asstv alg alys acous&ecg rec,0962T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,131.71,584.37,Radiology
Asstv alg alys acous&ecg rec,0962T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,131.71,584.37,APC
Asstv alg alys acous&ecg rec,0962T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,131.71,584.37,APC
Anosc sbmcsl njx bulking agt,0963T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5255.83,,,,,,,fee schedule,1184.64,5255.83,APC 378
Anosc sbmcsl njx bulking agt,0963T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1243.87,,,,,,,fee schedule,1184.64,5255.83,APC
Anosc sbmcsl njx bulking agt,0963T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1232.02,,,,,,,fee schedule,1184.64,5255.83,APC
Anosc sbmcsl njx bulking agt,0963T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1184.64,,,,,,,fee schedule,1184.64,5255.83,APC
Anosc sbmcsl njx bulking agt,0963T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1812.49,,,,,,,fee schedule,1184.64,5255.83,Radiology
Anosc sbmcsl njx bulking agt,0963T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1658.49,,,,,,,fee schedule,1184.64,5255.83,APC
Anosc sbmcsl njx bulking agt,0963T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2073.11,,,,,,,fee schedule,1184.64,5255.83,APC
I&cust prep jaw xpnsj 1arch,0964T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
I&cust prep jaw xpnsj 1arch,0964T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
I&cust prep jaw xpnsj 1arch,0964T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
I&cust prep jaw xpnsj 1arch,0964T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
I&cust prep jaw xpnsj 1arch,0964T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
I&cust prep jaw xpnsj 1arch,0964T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
I&cust prep jaw xpnsj 1arch,0964T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
I&cst prp jw xpn dl arch non,0965T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
I&cst prp jw xpn dl arch non,0965T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
I&cst prp jw xpn dl arch non,0965T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
I&cst prp jw xpn dl arch non,0965T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
I&cst prp jw xpn dl arch non,0965T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
I&cst prp jw xpn dl arch non,0965T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
I&cst prp jw xpn dl arch non,0965T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
I&cst prp jw xpn dl arch fxd,0966T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
I&cst prp jw xpn dl arch fxd,0966T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
I&cst prp jw xpn dl arch fxd,0966T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
I&cst prp jw xpn dl arch fxd,0966T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
I&cst prp jw xpn dl arch fxd,0966T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
I&cst prp jw xpn dl arch fxd,0966T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
I&cst prp jw xpn dl arch fxd,0966T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Tranal ins tmp clrc anst dev,0967T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5255.83,,,,,,,fee schedule,1184.64,5255.83,APC 378
Tranal ins tmp clrc anst dev,0967T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1243.87,,,,,,,fee schedule,1184.64,5255.83,APC
Tranal ins tmp clrc anst dev,0967T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1232.02,,,,,,,fee schedule,1184.64,5255.83,APC
Tranal ins tmp clrc anst dev,0967T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1184.64,,,,,,,fee schedule,1184.64,5255.83,APC
Tranal ins tmp clrc anst dev,0967T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1812.49,,,,,,,fee schedule,1184.64,5255.83,Radiology
Tranal ins tmp clrc anst dev,0967T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1658.49,,,,,,,fee schedule,1184.64,5255.83,APC
Tranal ins tmp clrc anst dev,0967T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2073.11,,,,,,,fee schedule,1184.64,5255.83,APC
Ablt b9 brst tum perq lsr ea,0970T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17197.18,,,,,,,fee schedule,3876.15,17197.18,APC 378
Ablt b9 brst tum perq lsr ea,0970T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4069.96,,,,,,,fee schedule,3876.15,17197.18,APC
Ablt b9 brst tum perq lsr ea,0970T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4031.2,,,,,,,fee schedule,3876.15,17197.18,APC
Ablt b9 brst tum perq lsr ea,0970T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3876.15,,,,,,,fee schedule,3876.15,17197.18,APC
Ablt b9 brst tum perq lsr ea,0970T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5930.51,,,,,,,fee schedule,3876.15,17197.18,Radiology
Ablt b9 brst tum perq lsr ea,0970T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5426.61,,,,,,,fee schedule,3876.15,17197.18,APC
Ablt b9 brst tum perq lsr ea,0970T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6783.27,,,,,,,fee schedule,3876.15,17197.18,APC
Ablt mal brst tum pq lsr uni,0971T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17197.18,,,,,,,fee schedule,3876.15,17197.18,APC 378
Ablt mal brst tum pq lsr uni,0971T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4069.96,,,,,,,fee schedule,3876.15,17197.18,APC
Ablt mal brst tum pq lsr uni,0971T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4031.2,,,,,,,fee schedule,3876.15,17197.18,APC
Ablt mal brst tum pq lsr uni,0971T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3876.15,,,,,,,fee schedule,3876.15,17197.18,APC
Ablt mal brst tum pq lsr uni,0971T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5930.51,,,,,,,fee schedule,3876.15,17197.18,Radiology
Ablt mal brst tum pq lsr uni,0971T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5426.61,,,,,,,fee schedule,3876.15,17197.18,APC
Ablt mal brst tum pq lsr uni,0971T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6783.27,,,,,,,fee schedule,3876.15,17197.18,APC
Slctv nzmtc dbrdmt t/a/l 1st,0973T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1785.48,,,,,,,fee schedule,402.44,1785.48,APC 378
Slctv nzmtc dbrdmt t/a/l 1st,0973T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,422.56,,,,,,,fee schedule,402.44,1785.48,APC
Slctv nzmtc dbrdmt t/a/l 1st,0973T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,418.53,,,,,,,fee schedule,402.44,1785.48,APC
Slctv nzmtc dbrdmt t/a/l 1st,0973T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,402.44,,,,,,,fee schedule,402.44,1785.48,APC
Slctv nzmtc dbrdmt t/a/l 1st,0973T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,615.73,,,,,,,fee schedule,402.44,1785.48,Radiology
Slctv nzmtc dbrdmt t/a/l 1st,0973T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,563.41,,,,,,,fee schedule,402.44,1785.48,APC
Slctv nzmtc dbrdmt t/a/l 1st,0973T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,704.26,,,,,,,fee schedule,402.44,1785.48,APC
Slctv nzmtc dbrdmt s/n/hf 1,0975T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1785.48,,,,,,,fee schedule,402.44,1785.48,APC 378
Slctv nzmtc dbrdmt s/n/hf 1,0975T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,422.56,,,,,,,fee schedule,402.44,1785.48,APC
Slctv nzmtc dbrdmt s/n/hf 1,0975T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,418.53,,,,,,,fee schedule,402.44,1785.48,APC
Slctv nzmtc dbrdmt s/n/hf 1,0975T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,402.44,,,,,,,fee schedule,402.44,1785.48,APC
Slctv nzmtc dbrdmt s/n/hf 1,0975T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,615.73,,,,,,,fee schedule,402.44,1785.48,Radiology
Slctv nzmtc dbrdmt s/n/hf 1,0975T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,563.41,,,,,,,fee schedule,402.44,1785.48,APC
Slctv nzmtc dbrdmt s/n/hf 1,0975T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,704.26,,,,,,,fee schedule,402.44,1785.48,APC
Upr gi bld detcj snr capsule,0977T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3983.62,,,,,,,fee schedule,897.89,3983.62,APC 378
Upr gi bld detcj snr capsule,0977T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,942.78,,,,,,,fee schedule,897.89,3983.62,APC
Upr gi bld detcj snr capsule,0977T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,933.8,,,,,,,fee schedule,897.89,3983.62,APC
Upr gi bld detcj snr capsule,0977T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,897.89,,,,,,,fee schedule,897.89,3983.62,APC
Upr gi bld detcj snr capsule,0977T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1373.77,,,,,,,fee schedule,897.89,3983.62,Radiology
Upr gi bld detcj snr capsule,0977T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1257.04,,,,,,,fee schedule,897.89,3983.62,APC
Upr gi bld detcj snr capsule,0977T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1571.3,,,,,,,fee schedule,897.89,3983.62,APC
Tcat impl wrls ivc snr,0981T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,80515.32,,,,,,,fee schedule,18147.73,80515.32,APC 378
Tcat impl wrls ivc snr,0981T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19055.11,,,,,,,fee schedule,18147.73,80515.32,APC
Tcat impl wrls ivc snr,0981T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18873.64,,,,,,,fee schedule,18147.73,80515.32,APC
Tcat impl wrls ivc snr,0981T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18147.73,,,,,,,fee schedule,18147.73,80515.32,APC
Tcat impl wrls ivc snr,0981T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27766.02,,,,,,,fee schedule,18147.73,80515.32,Radiology
Tcat impl wrls ivc snr,0981T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25406.82,,,,,,,fee schedule,18147.73,80515.32,APC
Tcat impl wrls ivc snr,0981T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31758.52,,,,,,,fee schedule,18147.73,80515.32,APC
Rem mntr impl ivc snr set-up,0982T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.75,,,,,,,fee schedule,131.8,584.75,APC 378
Rem mntr impl ivc snr set-up,0982T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.39,,,,,,,fee schedule,131.8,584.75,APC
Rem mntr impl ivc snr set-up,0982T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,137.07,,,,,,,fee schedule,131.8,584.75,APC
Rem mntr impl ivc snr set-up,0982T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.8,,,,,,,fee schedule,131.8,584.75,APC
Rem mntr impl ivc snr set-up,0982T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.66,,,,,,,fee schedule,131.8,584.75,Radiology
Rem mntr impl ivc snr set-up,0982T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.52,,,,,,,fee schedule,131.8,584.75,APC
Rem mntr impl ivc snr set-up,0982T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.65,,,,,,,fee schedule,131.8,584.75,APC
Revj/rmvl ins ptn subq&subf,0989T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15355.43,,,,,,,fee schedule,3461.03,15355.43,APC 378
Revj/rmvl ins ptn subq&subf,0989T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3634.08,,,,,,,fee schedule,3461.03,15355.43,APC
Revj/rmvl ins ptn subq&subf,0989T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3599.47,,,,,,,fee schedule,3461.03,15355.43,APC
Revj/rmvl ins ptn subq&subf,0989T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3461.03,,,,,,,fee schedule,3461.03,15355.43,APC
Revj/rmvl ins ptn subq&subf,0989T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5295.38,,,,,,,fee schedule,3461.03,15355.43,Radiology
Revj/rmvl ins ptn subq&subf,0989T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4845.44,,,,,,,fee schedule,3461.03,15355.43,APC
Revj/rmvl ins ptn subq&subf,0989T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6056.81,,,,,,,fee schedule,3461.03,15355.43,APC
Cysto lo-nrg lithtrp&mcrsphr,0991T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,41578.13,,,,,,,fee schedule,9371.49,41578.13,APC 378
Cysto lo-nrg lithtrp&mcrsphr,0991T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9840.06,,,,,,,fee schedule,9371.49,41578.13,APC
Cysto lo-nrg lithtrp&mcrsphr,0991T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9746.35,,,,,,,fee schedule,9371.49,41578.13,APC
Cysto lo-nrg lithtrp&mcrsphr,0991T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9371.49,,,,,,,fee schedule,9371.49,41578.13,APC
Cysto lo-nrg lithtrp&mcrsphr,0991T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14338.38,,,,,,,fee schedule,9371.49,41578.13,Radiology
Cysto lo-nrg lithtrp&mcrsphr,0991T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13120.09,,,,,,,fee schedule,9371.49,41578.13,APC
Cysto lo-nrg lithtrp&mcrsphr,0991T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16400.11,,,,,,,fee schedule,9371.49,41578.13,APC
N-invas assmt car rsk w/o ct,0992T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,236.21,1047.98,APC 378
N-invas assmt car rsk w/o ct,0992T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,236.21,1047.98,APC
N-invas assmt car rsk w/o ct,0992T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,236.21,1047.98,APC
N-invas assmt car rsk w/o ct,0992T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,236.21,1047.98,APC
N-invas assmt car rsk w/o ct,0992T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,236.21,1047.98,Radiology
N-invas assmt car rsk w/o ct,0992T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,236.21,1047.98,APC
N-invas assmt car rsk w/o ct,0992T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,236.21,1047.98,APC
N-invas assmt car rsk w/ct,0993T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,236.21,1047.98,APC 378
N-invas assmt car rsk w/ct,0993T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,236.21,1047.98,APC
N-invas assmt car rsk w/ct,0993T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,236.21,1047.98,APC
N-invas assmt car rsk w/ct,0993T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,236.21,1047.98,APC
N-invas assmt car rsk w/ct,0993T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,236.21,1047.98,Radiology
N-invas assmt car rsk w/ct,0993T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,236.21,1047.98,APC
N-invas assmt car rsk w/ct,0993T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,236.21,1047.98,APC
Fna bx w/o img gdn ea addl,10004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,168.29,,,,,,,fee schedule,134.9,168.29,
Fna bx w/o img gdn ea addl,10004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,134.9,,,,,,,fee schedule,134.9,168.29,
Fna bx w/o img gdn ea addl,10004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,147.36,,,,,,,fee schedule,134.9,168.29,
Fna bx w/o img gdn ea addl,10004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,154.93,,,,,,,fee schedule,134.9,168.29,
Fna bx w/us gdn 1st les,10005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2189.91,,,,,,,fee schedule,701.03,3110.22,
Fna bx w/us gdn 1st les,10005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1755.4,,,,,,,fee schedule,701.03,3110.22,
Fna bx w/us gdn 1st les,10005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1917.62,,,,,,,fee schedule,701.03,3110.22,
Fna bx w/us gdn 1st les,10005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2016.1,,,,,,,fee schedule,701.03,3110.22,
Fna bx w/us gdn 1st les,10005,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3110.22,,,,,,,fee schedule,701.03,3110.22,APC 378
Fna bx w/us gdn 1st les,10005,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,736.08,,,,,,,fee schedule,701.03,3110.22,APC
Fna bx w/us gdn 1st les,10005,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,729.07,,,,,,,fee schedule,701.03,3110.22,APC
Fna bx w/us gdn 1st les,10005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,701.03,,,,,,,fee schedule,701.03,3110.22,APC
Fna bx w/us gdn 1st les,10005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1072.57,,,,,,,fee schedule,701.03,3110.22,Radiology
Fna bx w/us gdn 1st les,10005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,981.44,,,,,,,fee schedule,701.03,3110.22,APC
Fna bx w/us gdn 1st les,10005,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1226.8,,,,,,,fee schedule,701.03,3110.22,APC
Fna bx w/us gdn ea addl,10006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,190.74,,,,,,,fee schedule,152.89,190.74,
Fna bx w/us gdn ea addl,10006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,152.89,,,,,,,fee schedule,152.89,190.74,
Fna bx w/us gdn ea addl,10006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,167.02,,,,,,,fee schedule,152.89,190.74,
Fna bx w/us gdn ea addl,10006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,175.6,,,,,,,fee schedule,152.89,190.74,
Fna bx w/fluor gdn 1st les,10007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2189.91,,,,,,,fee schedule,701.03,3110.22,
Fna bx w/fluor gdn 1st les,10007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1755.4,,,,,,,fee schedule,701.03,3110.22,
Fna bx w/fluor gdn 1st les,10007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1917.62,,,,,,,fee schedule,701.03,3110.22,
Fna bx w/fluor gdn 1st les,10007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2016.1,,,,,,,fee schedule,701.03,3110.22,
Fna bx w/fluor gdn 1st les,10007,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3110.22,,,,,,,fee schedule,701.03,3110.22,APC 378
Fna bx w/fluor gdn 1st les,10007,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,736.08,,,,,,,fee schedule,701.03,3110.22,APC
Fna bx w/fluor gdn 1st les,10007,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,729.07,,,,,,,fee schedule,701.03,3110.22,APC
Fna bx w/fluor gdn 1st les,10007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,701.03,,,,,,,fee schedule,701.03,3110.22,APC
Fna bx w/fluor gdn 1st les,10007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1072.57,,,,,,,fee schedule,701.03,3110.22,Radiology
Fna bx w/fluor gdn 1st les,10007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,981.44,,,,,,,fee schedule,701.03,3110.22,APC
Fna bx w/fluor gdn 1st les,10007,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1226.8,,,,,,,fee schedule,701.03,3110.22,APC
Fna bx w/fluor gdn ea addl,10008,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,236.1,,,,,,,fee schedule,189.25,236.1,
Fna bx w/fluor gdn ea addl,10008,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,189.25,,,,,,,fee schedule,189.25,236.1,
Fna bx w/fluor gdn ea addl,10008,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,206.74,,,,,,,fee schedule,189.25,236.1,
Fna bx w/fluor gdn ea addl,10008,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,217.36,,,,,,,fee schedule,189.25,236.1,
Fna bx w/ct gdn 1st les,10009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2189.91,,,,,,,fee schedule,701.03,3110.22,
Fna bx w/ct gdn 1st les,10009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1755.4,,,,,,,fee schedule,701.03,3110.22,
Fna bx w/ct gdn 1st les,10009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1917.62,,,,,,,fee schedule,701.03,3110.22,
Fna bx w/ct gdn 1st les,10009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2016.1,,,,,,,fee schedule,701.03,3110.22,
Fna bx w/ct gdn 1st les,10009,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3110.22,,,,,,,fee schedule,701.03,3110.22,APC 378
Fna bx w/ct gdn 1st les,10009,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,736.08,,,,,,,fee schedule,701.03,3110.22,APC
Fna bx w/ct gdn 1st les,10009,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,729.07,,,,,,,fee schedule,701.03,3110.22,APC
Fna bx w/ct gdn 1st les,10009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,701.03,,,,,,,fee schedule,701.03,3110.22,APC
Fna bx w/ct gdn 1st les,10009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1072.57,,,,,,,fee schedule,701.03,3110.22,Radiology
Fna bx w/ct gdn 1st les,10009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,981.44,,,,,,,fee schedule,701.03,3110.22,APC
Fna bx w/ct gdn 1st les,10009,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1226.8,,,,,,,fee schedule,701.03,3110.22,APC
Fna bx w/ct gdn ea addl,10010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,319.37,,,,,,,fee schedule,256,319.37,
Fna bx w/ct gdn ea addl,10010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,256,,,,,,,fee schedule,256,319.37,
Fna bx w/ct gdn ea addl,10010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,279.66,,,,,,,fee schedule,256,319.37,
Fna bx w/ct gdn ea addl,10010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,294.03,,,,,,,fee schedule,256,319.37,
Fna bx w/mr gdn 1st les,10011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2189.91,,,,,,,fee schedule,701.03,3110.22,
Fna bx w/mr gdn 1st les,10011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1755.4,,,,,,,fee schedule,701.03,3110.22,
Fna bx w/mr gdn 1st les,10011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1917.62,,,,,,,fee schedule,701.03,3110.22,
Fna bx w/mr gdn 1st les,10011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2016.1,,,,,,,fee schedule,701.03,3110.22,
Fna bx w/mr gdn 1st les,10011,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3110.22,,,,,,,fee schedule,701.03,3110.22,APC 378
Fna bx w/mr gdn 1st les,10011,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,736.08,,,,,,,fee schedule,701.03,3110.22,APC
Fna bx w/mr gdn 1st les,10011,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,729.07,,,,,,,fee schedule,701.03,3110.22,APC
Fna bx w/mr gdn 1st les,10011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,701.03,,,,,,,fee schedule,701.03,3110.22,APC
Fna bx w/mr gdn 1st les,10011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1072.57,,,,,,,fee schedule,701.03,3110.22,Radiology
Fna bx w/mr gdn 1st les,10011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,981.44,,,,,,,fee schedule,701.03,3110.22,APC
Fna bx w/mr gdn 1st les,10011,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1226.8,,,,,,,fee schedule,701.03,3110.22,APC
Fna bx w/mr gdn ea addl,10012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1087.13,,,,,,,fee schedule,871.43,1087.13,
Fna bx w/mr gdn ea addl,10012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,871.43,,,,,,,fee schedule,871.43,1087.13,
Fna bx w/mr gdn ea addl,10012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,951.96,,,,,,,fee schedule,871.43,1087.13,
Fna bx w/mr gdn ea addl,10012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1000.85,,,,,,,fee schedule,871.43,1087.13,
Fna w/o image,10021,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,276.96,,,,,,,fee schedule,222.01,1785.48,
Fna w/o image,10021,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,222.01,,,,,,,fee schedule,222.01,1785.48,
Fna w/o image,10021,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,242.52,,,,,,,fee schedule,222.01,1785.48,
Fna w/o image,10021,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,254.98,,,,,,,fee schedule,222.01,1785.48,
Fna w/o image,10021,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1785.48,,,,,,,fee schedule,222.01,1785.48,APC 378
Fna w/o image,10021,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,422.56,,,,,,,fee schedule,222.01,1785.48,APC
Fna w/o image,10021,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,418.53,,,,,,,fee schedule,222.01,1785.48,APC
Fna w/o image,10021,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,402.44,,,,,,,fee schedule,222.01,1785.48,APC
Fna w/o image,10021,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,615.73,,,,,,,fee schedule,222.01,1785.48,Radiology
Fna w/o image,10021,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,563.41,,,,,,,fee schedule,222.01,1785.48,APC
Fna w/o image,10021,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,704.26,,,,,,,fee schedule,222.01,1785.48,APC
Air displacmnt plethysmograp,1002T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,127.04,,,,,,,fee schedule,28.63,127.04,APC 378
Air displacmnt plethysmograp,1002T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.07,,,,,,,fee schedule,28.63,127.04,APC
Air displacmnt plethysmograp,1002T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,29.78,,,,,,,fee schedule,28.63,127.04,APC
Air displacmnt plethysmograp,1002T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,28.63,,,,,,,fee schedule,28.63,127.04,APC
Air displacmnt plethysmograp,1002T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43.81,,,,,,,fee schedule,28.63,127.04,Radiology
Air displacmnt plethysmograp,1002T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40.09,,,,,,,fee schedule,28.63,127.04,APC
Air displacmnt plethysmograp,1002T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,50.11,,,,,,,fee schedule,28.63,127.04,APC
Guide cathet fluid drainage,10030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1215.8,,,,,,,fee schedule,701.03,3110.22,
Guide cathet fluid drainage,10030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,974.57,,,,,,,fee schedule,701.03,3110.22,
Guide cathet fluid drainage,10030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1064.63,,,,,,,fee schedule,701.03,3110.22,
Guide cathet fluid drainage,10030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1119.31,,,,,,,fee schedule,701.03,3110.22,
Guide cathet fluid drainage,10030,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3110.22,,,,,,,fee schedule,701.03,3110.22,APC 378
Guide cathet fluid drainage,10030,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,736.08,,,,,,,fee schedule,701.03,3110.22,APC
Guide cathet fluid drainage,10030,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,729.07,,,,,,,fee schedule,701.03,3110.22,APC
Guide cathet fluid drainage,10030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,701.03,,,,,,,fee schedule,701.03,3110.22,APC
Guide cathet fluid drainage,10030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1072.57,,,,,,,fee schedule,701.03,3110.22,Radiology
Guide cathet fluid drainage,10030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,981.44,,,,,,,fee schedule,701.03,3110.22,APC
Guide cathet fluid drainage,10030,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1226.8,,,,,,,fee schedule,701.03,3110.22,APC
Perq dev soft tiss 1st imag,10035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1816.82,,,,,,,fee schedule,701.03,3110.22,
Perq dev soft tiss 1st imag,10035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1456.34,,,,,,,fee schedule,701.03,3110.22,
Perq dev soft tiss 1st imag,10035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1590.92,,,,,,,fee schedule,701.03,3110.22,
Perq dev soft tiss 1st imag,10035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1672.63,,,,,,,fee schedule,701.03,3110.22,
Perq dev soft tiss 1st imag,10035,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3110.22,,,,,,,fee schedule,701.03,3110.22,APC 378
Perq dev soft tiss 1st imag,10035,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,736.08,,,,,,,fee schedule,701.03,3110.22,APC
Perq dev soft tiss 1st imag,10035,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,729.07,,,,,,,fee schedule,701.03,3110.22,APC
Perq dev soft tiss 1st imag,10035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,701.03,,,,,,,fee schedule,701.03,3110.22,APC
Perq dev soft tiss 1st imag,10035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1072.57,,,,,,,fee schedule,701.03,3110.22,Radiology
Perq dev soft tiss 1st imag,10035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,981.44,,,,,,,fee schedule,701.03,3110.22,APC
Perq dev soft tiss 1st imag,10035,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1226.8,,,,,,,fee schedule,701.03,3110.22,APC
Perq dev soft tiss add imag,10036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,168.97,,,,,,,fee schedule,135.44,168.97,
Perq dev soft tiss add imag,10036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,135.44,,,,,,,fee schedule,135.44,168.97,
Perq dev soft tiss add imag,10036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,147.96,,,,,,,fee schedule,135.44,168.97,
Perq dev soft tiss add imag,10036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,155.56,,,,,,,fee schedule,135.44,168.97,
Arthrp 1st crp/mtcrpl prostc,1003T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,12709.88,56389.43,APC 378
Arthrp 1st crp/mtcrpl prostc,1003T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,12709.88,56389.43,APC
Arthrp 1st crp/mtcrpl prostc,1003T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,12709.88,56389.43,APC
Arthrp 1st crp/mtcrpl prostc,1003T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,12709.88,56389.43,APC
Arthrp 1st crp/mtcrpl prostc,1003T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,12709.88,56389.43,Radiology
Arthrp 1st crp/mtcrpl prostc,1003T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,12709.88,56389.43,APC
Arthrp 1st crp/mtcrpl prostc,1003T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,12709.88,56389.43,APC
Acne surgery,10040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,197.92,,,,,,,fee schedule,158.65,881.22,
Acne surgery,10040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,158.65,,,,,,,fee schedule,158.65,881.22,
Acne surgery,10040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,173.31,,,,,,,fee schedule,158.65,881.22,
Acne surgery,10040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,182.21,,,,,,,fee schedule,158.65,881.22,
Acne surgery,10040,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,881.22,,,,,,,fee schedule,158.65,881.22,APC 378
Acne surgery,10040,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.55,,,,,,,fee schedule,158.65,881.22,APC
Acne surgery,10040,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,206.57,,,,,,,fee schedule,158.65,881.22,APC
Acne surgery,10040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.62,,,,,,,fee schedule,158.65,881.22,APC
Acne surgery,10040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.89,,,,,,,fee schedule,158.65,881.22,Radiology
Acne surgery,10040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,278.07,,,,,,,fee schedule,158.65,881.22,APC
Acne surgery,10040,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,347.59,,,,,,,fee schedule,158.65,881.22,APC
Elec alys s-scl eeg wo prgrm,1004T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,131.71,584.37,APC 378
Elec alys s-scl eeg wo prgrm,1004T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,131.71,584.37,APC
Elec alys s-scl eeg wo prgrm,1004T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,131.71,584.37,APC
Elec alys s-scl eeg wo prgrm,1004T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,131.71,584.37,APC
Elec alys s-scl eeg wo prgrm,1004T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,131.71,584.37,Radiology
Elec alys s-scl eeg wo prgrm,1004T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,131.71,584.37,APC
Elec alys s-scl eeg wo prgrm,1004T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,131.71,584.37,APC
Drainage of skin abscess,10060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,949.72,,,,,,,fee schedule,198.62,949.72,
Drainage of skin abscess,10060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,761.28,,,,,,,fee schedule,198.62,949.72,
Drainage of skin abscess,10060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,831.63,,,,,,,fee schedule,198.62,949.72,
Drainage of skin abscess,10060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,874.35,,,,,,,fee schedule,198.62,949.72,
Drainage of skin abscess,10060,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,881.22,,,,,,,fee schedule,198.62,949.72,APC 378
Drainage of skin abscess,10060,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.55,,,,,,,fee schedule,198.62,949.72,APC
Drainage of skin abscess,10060,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,206.57,,,,,,,fee schedule,198.62,949.72,APC
Drainage of skin abscess,10060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.62,,,,,,,fee schedule,198.62,949.72,APC
Drainage of skin abscess,10060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.89,,,,,,,fee schedule,198.62,949.72,Radiology
Drainage of skin abscess,10060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,278.07,,,,,,,fee schedule,198.62,949.72,APC
Drainage of skin abscess,10060,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,347.59,,,,,,,fee schedule,198.62,949.72,APC
Drainage of skin abscess,10061,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,269.82,,,,,,,fee schedule,216.28,1785.48,
Drainage of skin abscess,10061,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,216.28,,,,,,,fee schedule,216.28,1785.48,
Drainage of skin abscess,10061,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,236.27,,,,,,,fee schedule,216.28,1785.48,
Drainage of skin abscess,10061,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,248.4,,,,,,,fee schedule,216.28,1785.48,
Drainage of skin abscess,10061,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1785.48,,,,,,,fee schedule,216.28,1785.48,APC 378
Drainage of skin abscess,10061,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,422.56,,,,,,,fee schedule,216.28,1785.48,APC
Drainage of skin abscess,10061,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,418.53,,,,,,,fee schedule,216.28,1785.48,APC
Drainage of skin abscess,10061,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,402.44,,,,,,,fee schedule,216.28,1785.48,APC
Drainage of skin abscess,10061,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,615.73,,,,,,,fee schedule,216.28,1785.48,Radiology
Drainage of skin abscess,10061,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,563.41,,,,,,,fee schedule,216.28,1785.48,APC
Drainage of skin abscess,10061,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,704.26,,,,,,,fee schedule,216.28,1785.48,APC
Drainage of pilonidal cyst,10080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,218.89,,,,,,,fee schedule,175.46,3110.22,
Drainage of pilonidal cyst,10080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,175.46,,,,,,,fee schedule,175.46,3110.22,
Drainage of pilonidal cyst,10080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,191.67,,,,,,,fee schedule,175.46,3110.22,
Drainage of pilonidal cyst,10080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,201.52,,,,,,,fee schedule,175.46,3110.22,
Drainage of pilonidal cyst,10080,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3110.22,,,,,,,fee schedule,175.46,3110.22,APC 378
Drainage of pilonidal cyst,10080,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,736.08,,,,,,,fee schedule,175.46,3110.22,APC
Drainage of pilonidal cyst,10080,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,729.07,,,,,,,fee schedule,175.46,3110.22,APC
Drainage of pilonidal cyst,10080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,701.03,,,,,,,fee schedule,175.46,3110.22,APC
Drainage of pilonidal cyst,10080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1072.57,,,,,,,fee schedule,175.46,3110.22,Radiology
Drainage of pilonidal cyst,10080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,981.44,,,,,,,fee schedule,175.46,3110.22,APC
Drainage of pilonidal cyst,10080,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1226.8,,,,,,,fee schedule,175.46,3110.22,APC
Drainage of pilonidal cyst,10081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2884.93,,,,,,,fee schedule,701.03,3110.22,
Drainage of pilonidal cyst,10081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2312.53,,,,,,,fee schedule,701.03,3110.22,
Drainage of pilonidal cyst,10081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2526.23,,,,,,,fee schedule,701.03,3110.22,
Drainage of pilonidal cyst,10081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2655.97,,,,,,,fee schedule,701.03,3110.22,
Drainage of pilonidal cyst,10081,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3110.22,,,,,,,fee schedule,701.03,3110.22,APC 378
Drainage of pilonidal cyst,10081,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,736.08,,,,,,,fee schedule,701.03,3110.22,APC
Drainage of pilonidal cyst,10081,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,729.07,,,,,,,fee schedule,701.03,3110.22,APC
Drainage of pilonidal cyst,10081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,701.03,,,,,,,fee schedule,701.03,3110.22,APC
Drainage of pilonidal cyst,10081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1072.57,,,,,,,fee schedule,701.03,3110.22,Radiology
Drainage of pilonidal cyst,10081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,981.44,,,,,,,fee schedule,701.03,3110.22,APC
Drainage of pilonidal cyst,10081,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1226.8,,,,,,,fee schedule,701.03,3110.22,APC
Rem mntr s-scl eeg sys setup,1008T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.75,,,,,,,fee schedule,131.8,584.75,APC 378
Rem mntr s-scl eeg sys setup,1008T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.39,,,,,,,fee schedule,131.8,584.75,APC
Rem mntr s-scl eeg sys setup,1008T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,137.07,,,,,,,fee schedule,131.8,584.75,APC
Rem mntr s-scl eeg sys setup,1008T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.8,,,,,,,fee schedule,131.8,584.75,APC
Rem mntr s-scl eeg sys setup,1008T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.66,,,,,,,fee schedule,131.8,584.75,Radiology
Rem mntr s-scl eeg sys setup,1008T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.52,,,,,,,fee schedule,131.8,584.75,APC
Rem mntr s-scl eeg sys setup,1008T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.65,,,,,,,fee schedule,131.8,584.75,APC
Cptr oph alys monoc eye mvmt,1010T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,131.71,584.37,APC 378
Cptr oph alys monoc eye mvmt,1010T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,131.71,584.37,APC
Cptr oph alys monoc eye mvmt,1010T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,131.71,584.37,APC
Cptr oph alys monoc eye mvmt,1010T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,131.71,584.37,APC
Cptr oph alys monoc eye mvmt,1010T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,131.71,584.37,Radiology
Cptr oph alys monoc eye mvmt,1010T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,131.71,584.37,APC
Cptr oph alys monoc eye mvmt,1010T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,131.71,584.37,APC
Remove foreign body,10120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1867.31,,,,,,,fee schedule,402.44,1867.31,
Remove foreign body,10120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1496.81,,,,,,,fee schedule,402.44,1867.31,
Remove foreign body,10120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1635.13,,,,,,,fee schedule,402.44,1867.31,
Remove foreign body,10120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1719.11,,,,,,,fee schedule,402.44,1867.31,
Remove foreign body,10120,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1785.48,,,,,,,fee schedule,402.44,1867.31,APC 378
Remove foreign body,10120,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,422.56,,,,,,,fee schedule,402.44,1867.31,APC
Remove foreign body,10120,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,418.53,,,,,,,fee schedule,402.44,1867.31,APC
Remove foreign body,10120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,402.44,,,,,,,fee schedule,402.44,1867.31,APC
Remove foreign body,10120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,615.73,,,,,,,fee schedule,402.44,1867.31,Radiology
Remove foreign body,10120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,563.41,,,,,,,fee schedule,402.44,1867.31,APC
Remove foreign body,10120,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,704.26,,,,,,,fee schedule,402.44,1867.31,APC
Remove foreign body,10121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5785.34,,,,,,,fee schedule,1635.03,7254.06,
Remove foreign body,10121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4637.46,,,,,,,fee schedule,1635.03,7254.06,
Remove foreign body,10121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5066,,,,,,,fee schedule,1635.03,7254.06,
Remove foreign body,10121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5326.19,,,,,,,fee schedule,1635.03,7254.06,
Remove foreign body,10121,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,7254.06,APC 378
Remove foreign body,10121,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,7254.06,APC
Remove foreign body,10121,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,7254.06,APC
Remove foreign body,10121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,7254.06,APC
Remove foreign body,10121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,7254.06,Radiology
Remove foreign body,10121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,7254.06,APC
Remove foreign body,10121,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,7254.06,APC
Drainage of hematoma/fluid,10140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10205.34,,,,,,,fee schedule,1635.03,10205.34,
Drainage of hematoma/fluid,10140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8180.47,,,,,,,fee schedule,1635.03,10205.34,
Drainage of hematoma/fluid,10140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8936.43,,,,,,,fee schedule,1635.03,10205.34,
Drainage of hematoma/fluid,10140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9395.4,,,,,,,fee schedule,1635.03,10205.34,
Drainage of hematoma/fluid,10140,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,10205.34,APC 378
Drainage of hematoma/fluid,10140,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,10205.34,APC
Drainage of hematoma/fluid,10140,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,10205.34,APC
Drainage of hematoma/fluid,10140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,10205.34,APC
Drainage of hematoma/fluid,10140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,10205.34,Radiology
Drainage of hematoma/fluid,10140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,10205.34,APC
Drainage of hematoma/fluid,10140,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,10205.34,APC
Puncture drainage of lesion,10160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3978.44,,,,,,,fee schedule,402.44,3978.44,
Puncture drainage of lesion,10160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3189.06,,,,,,,fee schedule,402.44,3978.44,
Puncture drainage of lesion,10160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3483.76,,,,,,,fee schedule,402.44,3978.44,
Puncture drainage of lesion,10160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3662.69,,,,,,,fee schedule,402.44,3978.44,
Puncture drainage of lesion,10160,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1785.48,,,,,,,fee schedule,402.44,3978.44,APC 378
Puncture drainage of lesion,10160,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,422.56,,,,,,,fee schedule,402.44,3978.44,APC
Puncture drainage of lesion,10160,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,418.53,,,,,,,fee schedule,402.44,3978.44,APC
Puncture drainage of lesion,10160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,402.44,,,,,,,fee schedule,402.44,3978.44,APC
Puncture drainage of lesion,10160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,615.73,,,,,,,fee schedule,402.44,3978.44,Radiology
Puncture drainage of lesion,10160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,563.41,,,,,,,fee schedule,402.44,3978.44,APC
Puncture drainage of lesion,10160,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,704.26,,,,,,,fee schedule,402.44,3978.44,APC
Complex drainage wound,10180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5860.38,,,,,,,fee schedule,2875.57,12757.95,
Complex drainage wound,10180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4697.61,,,,,,,fee schedule,2875.57,12757.95,
Complex drainage wound,10180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5131.71,,,,,,,fee schedule,2875.57,12757.95,
Complex drainage wound,10180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5395.27,,,,,,,fee schedule,2875.57,12757.95,
Complex drainage wound,10180,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Complex drainage wound,10180,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Complex drainage wound,10180,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Complex drainage wound,10180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Complex drainage wound,10180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Complex drainage wound,10180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Complex drainage wound,10180,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Lymphovenous bypass per xtr,1019T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,29164.62,,,,,,,fee schedule,6573.55,29164.62,APC 378
Lymphovenous bypass per xtr,1019T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6902.23,,,,,,,fee schedule,6573.55,29164.62,APC
Lymphovenous bypass per xtr,1019T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6836.49,,,,,,,fee schedule,6573.55,29164.62,APC
Lymphovenous bypass per xtr,1019T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6573.55,,,,,,,fee schedule,6573.55,29164.62,APC
Lymphovenous bypass per xtr,1019T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10057.53,,,,,,,fee schedule,6573.55,29164.62,Radiology
Lymphovenous bypass per xtr,1019T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9202.97,,,,,,,fee schedule,6573.55,29164.62,APC
Lymphovenous bypass per xtr,1019T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11503.71,,,,,,,fee schedule,6573.55,29164.62,APC
Raman spectroscopy 1+skn les,1020T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,58.4,259.1,APC 378
Raman spectroscopy 1+skn les,1020T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,58.4,259.1,APC
Raman spectroscopy 1+skn les,1020T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,58.4,259.1,APC
Raman spectroscopy 1+skn les,1020T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,58.4,259.1,APC
Raman spectroscopy 1+skn les,1020T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,58.4,259.1,Radiology
Raman spectroscopy 1+skn les,1020T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,58.4,259.1,APC
Raman spectroscopy 1+skn les,1020T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,58.4,259.1,APC
Active thrc irrigation spx,1021T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2755.21,,,,,,,fee schedule,621.01,2755.21,APC 378
Active thrc irrigation spx,1021T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,652.06,,,,,,,fee schedule,621.01,2755.21,APC
Active thrc irrigation spx,1021T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,645.85,,,,,,,fee schedule,621.01,2755.21,APC
Active thrc irrigation spx,1021T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,621.01,,,,,,,fee schedule,621.01,2755.21,APC
Active thrc irrigation spx,1021T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,950.14,,,,,,,fee schedule,621.01,2755.21,Radiology
Active thrc irrigation spx,1021T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,869.41,,,,,,,fee schedule,621.01,2755.21,APC
Active thrc irrigation spx,1021T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1086.77,,,,,,,fee schedule,621.01,2755.21,APC
Alt elec fld dos&dlv sim mdl,1025T,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,590.34,,,,,,,fee schedule,133.06,590.34,APC 378
Alt elec fld dos&dlv sim mdl,1025T,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.71,,,,,,,fee schedule,133.06,590.34,APC
Alt elec fld dos&dlv sim mdl,1025T,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,138.38,,,,,,,fee schedule,133.06,590.34,APC
Alt elec fld dos&dlv sim mdl,1025T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,133.06,,,,,,,fee schedule,133.06,590.34,APC
Alt elec fld dos&dlv sim mdl,1025T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,203.58,,,,,,,fee schedule,133.06,590.34,Radiology
Alt elec fld dos&dlv sim mdl,1025T,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,186.28,,,,,,,fee schedule,133.06,590.34,APC
Alt elec fld dos&dlv sim mdl,1025T,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,232.86,,,,,,,fee schedule,133.06,590.34,APC
Debride infected skin,11000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1635.42,,,,,,,fee schedule,402.44,1785.48,
Debride infected skin,11000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1310.93,,,,,,,fee schedule,402.44,1785.48,
Debride infected skin,11000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1432.08,,,,,,,fee schedule,402.44,1785.48,
Debride infected skin,11000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1505.63,,,,,,,fee schedule,402.44,1785.48,
Debride infected skin,11000,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1785.48,,,,,,,fee schedule,402.44,1785.48,APC 378
Debride infected skin,11000,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,422.56,,,,,,,fee schedule,402.44,1785.48,APC
Debride infected skin,11000,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,418.53,,,,,,,fee schedule,402.44,1785.48,APC
Debride infected skin,11000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,402.44,,,,,,,fee schedule,402.44,1785.48,APC
Debride infected skin,11000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,615.73,,,,,,,fee schedule,402.44,1785.48,Radiology
Debride infected skin,11000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,563.41,,,,,,,fee schedule,402.44,1785.48,APC
Debride infected skin,11000,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,704.26,,,,,,,fee schedule,402.44,1785.48,APC
Debride infected skin add-on,11001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,197.92,,,,,,,fee schedule,158.65,197.92,
Debride infected skin add-on,11001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,158.65,,,,,,,fee schedule,158.65,197.92,
Debride infected skin add-on,11001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,173.31,,,,,,,fee schedule,158.65,197.92,
Debride infected skin add-on,11001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,182.21,,,,,,,fee schedule,158.65,197.92,
Debride skin at fx site,11010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1074.12,,,,,,,fee schedule,701.03,3110.22,
Debride skin at fx site,11010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,861,,,,,,,fee schedule,701.03,3110.22,
Debride skin at fx site,11010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,940.57,,,,,,,fee schedule,701.03,3110.22,
Debride skin at fx site,11010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,988.88,,,,,,,fee schedule,701.03,3110.22,
Debride skin at fx site,11010,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3110.22,,,,,,,fee schedule,701.03,3110.22,APC 378
Debride skin at fx site,11010,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,736.08,,,,,,,fee schedule,701.03,3110.22,APC
Debride skin at fx site,11010,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,729.07,,,,,,,fee schedule,701.03,3110.22,APC
Debride skin at fx site,11010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,701.03,,,,,,,fee schedule,701.03,3110.22,APC
Debride skin at fx site,11010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1072.57,,,,,,,fee schedule,701.03,3110.22,Radiology
Debride skin at fx site,11010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,981.44,,,,,,,fee schedule,701.03,3110.22,APC
Debride skin at fx site,11010,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1226.8,,,,,,,fee schedule,701.03,3110.22,APC
Debride skin musc at fx site,11011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1074.12,,,,,,,fee schedule,701.03,3110.22,
Debride skin musc at fx site,11011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,861,,,,,,,fee schedule,701.03,3110.22,
Debride skin musc at fx site,11011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,940.57,,,,,,,fee schedule,701.03,3110.22,
Debride skin musc at fx site,11011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,988.88,,,,,,,fee schedule,701.03,3110.22,
Debride skin musc at fx site,11011,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3110.22,,,,,,,fee schedule,701.03,3110.22,APC 378
Debride skin musc at fx site,11011,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,736.08,,,,,,,fee schedule,701.03,3110.22,APC
Debride skin musc at fx site,11011,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,729.07,,,,,,,fee schedule,701.03,3110.22,APC
Debride skin musc at fx site,11011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,701.03,,,,,,,fee schedule,701.03,3110.22,APC
Debride skin musc at fx site,11011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1072.57,,,,,,,fee schedule,701.03,3110.22,Radiology
Debride skin musc at fx site,11011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,981.44,,,,,,,fee schedule,701.03,3110.22,APC
Debride skin musc at fx site,11011,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1226.8,,,,,,,fee schedule,701.03,3110.22,APC
Deb skin bone at fx site,11012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2708.63,,,,,,,fee schedule,2171.2,12757.95,
Deb skin bone at fx site,11012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2171.2,,,,,,,fee schedule,2171.2,12757.95,
Deb skin bone at fx site,11012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2371.84,,,,,,,fee schedule,2171.2,12757.95,
Deb skin bone at fx site,11012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2493.66,,,,,,,fee schedule,2171.2,12757.95,
Deb skin bone at fx site,11012,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2171.2,12757.95,APC 378
Deb skin bone at fx site,11012,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2171.2,12757.95,APC
Deb skin bone at fx site,11012,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2171.2,12757.95,APC
Deb skin bone at fx site,11012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2171.2,12757.95,APC
Deb skin bone at fx site,11012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2171.2,12757.95,Radiology
Deb skin bone at fx site,11012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2171.2,12757.95,APC
Deb skin bone at fx site,11012,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2171.2,12757.95,APC
Deb subq tissue 20 sq cm/<,11042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5017.3,,,,,,,fee schedule,402.44,5017.3,
Deb subq tissue 20 sq cm/<,11042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4021.8,,,,,,,fee schedule,402.44,5017.3,
Deb subq tissue 20 sq cm/<,11042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4393.45,,,,,,,fee schedule,402.44,5017.3,
Deb subq tissue 20 sq cm/<,11042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4619.1,,,,,,,fee schedule,402.44,5017.3,
Deb subq tissue 20 sq cm/<,11042,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1785.48,,,,,,,fee schedule,402.44,5017.3,APC 378
Deb subq tissue 20 sq cm/<,11042,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,422.56,,,,,,,fee schedule,402.44,5017.3,APC
Deb subq tissue 20 sq cm/<,11042,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,418.53,,,,,,,fee schedule,402.44,5017.3,APC
Deb subq tissue 20 sq cm/<,11042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,402.44,,,,,,,fee schedule,402.44,5017.3,APC
Deb subq tissue 20 sq cm/<,11042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,615.73,,,,,,,fee schedule,402.44,5017.3,Radiology
Deb subq tissue 20 sq cm/<,11042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,563.41,,,,,,,fee schedule,402.44,5017.3,APC
Deb subq tissue 20 sq cm/<,11042,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,704.26,,,,,,,fee schedule,402.44,5017.3,APC
Deb musc/fascia 20 sq cm/<,11043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3024.05,,,,,,,fee schedule,731.66,3246.12,
Deb musc/fascia 20 sq cm/<,11043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2424.04,,,,,,,fee schedule,731.66,3246.12,
Deb musc/fascia 20 sq cm/<,11043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2648.04,,,,,,,fee schedule,731.66,3246.12,
Deb musc/fascia 20 sq cm/<,11043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2784.04,,,,,,,fee schedule,731.66,3246.12,
Deb musc/fascia 20 sq cm/<,11043,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3246.12,,,,,,,fee schedule,731.66,3246.12,APC 378
Deb musc/fascia 20 sq cm/<,11043,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,768.24,,,,,,,fee schedule,731.66,3246.12,APC
Deb musc/fascia 20 sq cm/<,11043,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,760.92,,,,,,,fee schedule,731.66,3246.12,APC
Deb musc/fascia 20 sq cm/<,11043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,731.66,,,,,,,fee schedule,731.66,3246.12,APC
Deb musc/fascia 20 sq cm/<,11043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1119.44,,,,,,,fee schedule,731.66,3246.12,Radiology
Deb musc/fascia 20 sq cm/<,11043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1024.32,,,,,,,fee schedule,731.66,3246.12,APC
Deb musc/fascia 20 sq cm/<,11043,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1280.4,,,,,,,fee schedule,731.66,3246.12,APC
Deb bone 20 sq cm/<,11044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6253.46,,,,,,,fee schedule,1635.03,7254.06,
Deb bone 20 sq cm/<,11044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5012.69,,,,,,,fee schedule,1635.03,7254.06,
Deb bone 20 sq cm/<,11044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5475.91,,,,,,,fee schedule,1635.03,7254.06,
Deb bone 20 sq cm/<,11044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5757.15,,,,,,,fee schedule,1635.03,7254.06,
Deb bone 20 sq cm/<,11044,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,7254.06,APC 378
Deb bone 20 sq cm/<,11044,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,7254.06,APC
Deb bone 20 sq cm/<,11044,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,7254.06,APC
Deb bone 20 sq cm/<,11044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,7254.06,APC
Deb bone 20 sq cm/<,11044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,7254.06,Radiology
Deb bone 20 sq cm/<,11044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,7254.06,APC
Deb bone 20 sq cm/<,11044,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,7254.06,APC
Deb subq tissue add-on,11045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,711.24,,,,,,,fee schedule,570.12,711.24,
Deb subq tissue add-on,11045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,570.12,,,,,,,fee schedule,570.12,711.24,
Deb subq tissue add-on,11045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,622.81,,,,,,,fee schedule,570.12,711.24,
Deb subq tissue add-on,11045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,654.8,,,,,,,fee schedule,570.12,711.24,
Deb musc/fascia add-on,11046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1870.44,,,,,,,fee schedule,1499.32,1870.44,
Deb musc/fascia add-on,11046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1499.32,,,,,,,fee schedule,1499.32,1870.44,
Deb musc/fascia add-on,11046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1637.87,,,,,,,fee schedule,1499.32,1870.44,
Deb musc/fascia add-on,11046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1721.99,,,,,,,fee schedule,1499.32,1870.44,
Deb bone add-on,11047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2211.15,,,,,,,fee schedule,1772.43,2211.15,
Deb bone add-on,11047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1772.43,,,,,,,fee schedule,1772.43,2211.15,
Deb bone add-on,11047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1936.22,,,,,,,fee schedule,1772.43,2211.15,
Deb bone add-on,11047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2035.66,,,,,,,fee schedule,1772.43,2211.15,
Trim skin lesion,11055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,197.92,,,,,,,fee schedule,158.65,881.22,
Trim skin lesion,11055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,158.65,,,,,,,fee schedule,158.65,881.22,
Trim skin lesion,11055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,173.31,,,,,,,fee schedule,158.65,881.22,
Trim skin lesion,11055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,182.21,,,,,,,fee schedule,158.65,881.22,
Trim skin lesion,11055,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,881.22,,,,,,,fee schedule,158.65,881.22,APC 378
Trim skin lesion,11055,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.55,,,,,,,fee schedule,158.65,881.22,APC
Trim skin lesion,11055,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,206.57,,,,,,,fee schedule,158.65,881.22,APC
Trim skin lesion,11055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.62,,,,,,,fee schedule,158.65,881.22,APC
Trim skin lesion,11055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.89,,,,,,,fee schedule,158.65,881.22,Radiology
Trim skin lesion,11055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,278.07,,,,,,,fee schedule,158.65,881.22,APC
Trim skin lesion,11055,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,347.59,,,,,,,fee schedule,158.65,881.22,APC
Trim skin lesions 2 to 4,11056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,197.92,,,,,,,fee schedule,158.65,881.22,
Trim skin lesions 2 to 4,11056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,158.65,,,,,,,fee schedule,158.65,881.22,
Trim skin lesions 2 to 4,11056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,173.31,,,,,,,fee schedule,158.65,881.22,
Trim skin lesions 2 to 4,11056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,182.21,,,,,,,fee schedule,158.65,881.22,
Trim skin lesions 2 to 4,11056,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,881.22,,,,,,,fee schedule,158.65,881.22,APC 378
Trim skin lesions 2 to 4,11056,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.55,,,,,,,fee schedule,158.65,881.22,APC
Trim skin lesions 2 to 4,11056,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,206.57,,,,,,,fee schedule,158.65,881.22,APC
Trim skin lesions 2 to 4,11056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.62,,,,,,,fee schedule,158.65,881.22,APC
Trim skin lesions 2 to 4,11056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.89,,,,,,,fee schedule,158.65,881.22,Radiology
Trim skin lesions 2 to 4,11056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,278.07,,,,,,,fee schedule,158.65,881.22,APC
Trim skin lesions 2 to 4,11056,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,347.59,,,,,,,fee schedule,158.65,881.22,APC
Trim skin lesions over 4,11057,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,364.24,,,,,,,fee schedule,198.62,881.22,
Trim skin lesions over 4,11057,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,291.97,,,,,,,fee schedule,198.62,881.22,
Trim skin lesions over 4,11057,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,318.95,,,,,,,fee schedule,198.62,881.22,
Trim skin lesions over 4,11057,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,335.33,,,,,,,fee schedule,198.62,881.22,
Trim skin lesions over 4,11057,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,881.22,,,,,,,fee schedule,198.62,881.22,APC 378
Trim skin lesions over 4,11057,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.55,,,,,,,fee schedule,198.62,881.22,APC
Trim skin lesions over 4,11057,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,206.57,,,,,,,fee schedule,198.62,881.22,APC
Trim skin lesions over 4,11057,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.62,,,,,,,fee schedule,198.62,881.22,APC
Trim skin lesions over 4,11057,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.89,,,,,,,fee schedule,198.62,881.22,Radiology
Trim skin lesions over 4,11057,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,278.07,,,,,,,fee schedule,198.62,881.22,APC
Trim skin lesions over 4,11057,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,347.59,,,,,,,fee schedule,198.62,881.22,APC
Tangntl bx skin single les,11102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,666.98,,,,,,,fee schedule,402.44,1785.48,
Tangntl bx skin single les,11102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,534.64,,,,,,,fee schedule,402.44,1785.48,
Tangntl bx skin single les,11102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,584.05,,,,,,,fee schedule,402.44,1785.48,
Tangntl bx skin single les,11102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,614.05,,,,,,,fee schedule,402.44,1785.48,
Tangntl bx skin single les,11102,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1785.48,,,,,,,fee schedule,402.44,1785.48,APC 378
Tangntl bx skin single les,11102,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,422.56,,,,,,,fee schedule,402.44,1785.48,APC
Tangntl bx skin single les,11102,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,418.53,,,,,,,fee schedule,402.44,1785.48,APC
Tangntl bx skin single les,11102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,402.44,,,,,,,fee schedule,402.44,1785.48,APC
Tangntl bx skin single les,11102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,615.73,,,,,,,fee schedule,402.44,1785.48,Radiology
Tangntl bx skin single les,11102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,563.41,,,,,,,fee schedule,402.44,1785.48,APC
Tangntl bx skin single les,11102,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,704.26,,,,,,,fee schedule,402.44,1785.48,APC
Tangntl bx skin ea sep/addl,11103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,86.79,,,,,,,fee schedule,69.57,86.79,
Tangntl bx skin ea sep/addl,11103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,69.57,,,,,,,fee schedule,69.57,86.79,
Tangntl bx skin ea sep/addl,11103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,76,,,,,,,fee schedule,69.57,86.79,
Tangntl bx skin ea sep/addl,11103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,79.9,,,,,,,fee schedule,69.57,86.79,
Punch bx skin single lesion,11104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,666.98,,,,,,,fee schedule,402.44,1785.48,
Punch bx skin single lesion,11104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,534.64,,,,,,,fee schedule,402.44,1785.48,
Punch bx skin single lesion,11104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,584.05,,,,,,,fee schedule,402.44,1785.48,
Punch bx skin single lesion,11104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,614.05,,,,,,,fee schedule,402.44,1785.48,
Punch bx skin single lesion,11104,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1785.48,,,,,,,fee schedule,402.44,1785.48,APC 378
Punch bx skin single lesion,11104,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,422.56,,,,,,,fee schedule,402.44,1785.48,APC
Punch bx skin single lesion,11104,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,418.53,,,,,,,fee schedule,402.44,1785.48,APC
Punch bx skin single lesion,11104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,402.44,,,,,,,fee schedule,402.44,1785.48,APC
Punch bx skin single lesion,11104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,615.73,,,,,,,fee schedule,402.44,1785.48,Radiology
Punch bx skin single lesion,11104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,563.41,,,,,,,fee schedule,402.44,1785.48,APC
Punch bx skin single lesion,11104,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,704.26,,,,,,,fee schedule,402.44,1785.48,APC
Punch bx skin ea sep/addl,11105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,101.23,,,,,,,fee schedule,81.14,101.23,
Punch bx skin ea sep/addl,11105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,81.14,,,,,,,fee schedule,81.14,101.23,
Punch bx skin ea sep/addl,11105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,88.64,,,,,,,fee schedule,81.14,101.23,
Punch bx skin ea sep/addl,11105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,93.19,,,,,,,fee schedule,81.14,101.23,
Incal bx skn single les,11106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1187.22,,,,,,,fee schedule,731.66,3246.12,
Incal bx skn single les,11106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,951.66,,,,,,,fee schedule,731.66,3246.12,
Incal bx skn single les,11106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1039.6,,,,,,,fee schedule,731.66,3246.12,
Incal bx skn single les,11106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1093,,,,,,,fee schedule,731.66,3246.12,
Incal bx skn single les,11106,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3246.12,,,,,,,fee schedule,731.66,3246.12,APC 378
Incal bx skn single les,11106,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,768.24,,,,,,,fee schedule,731.66,3246.12,APC
Incal bx skn single les,11106,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,760.92,,,,,,,fee schedule,731.66,3246.12,APC
Incal bx skn single les,11106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,731.66,,,,,,,fee schedule,731.66,3246.12,APC
Incal bx skn single les,11106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1119.44,,,,,,,fee schedule,731.66,3246.12,Radiology
Incal bx skn single les,11106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1024.32,,,,,,,fee schedule,731.66,3246.12,APC
Incal bx skn single les,11106,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1280.4,,,,,,,fee schedule,731.66,3246.12,APC
Incal bx skn ea sep/addl,11107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,120.81,,,,,,,fee schedule,96.84,120.81,
Incal bx skn ea sep/addl,11107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,96.84,,,,,,,fee schedule,96.84,120.81,
Incal bx skn ea sep/addl,11107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,105.79,,,,,,,fee schedule,96.84,120.81,
Incal bx skn ea sep/addl,11107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,111.22,,,,,,,fee schedule,96.84,120.81,
Removal of skin tags <w/15,11200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6731.32,,,,,,,fee schedule,198.62,6731.32,
Removal of skin tags <w/15,11200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5395.74,,,,,,,fee schedule,198.62,6731.32,
Removal of skin tags <w/15,11200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5894.36,,,,,,,fee schedule,198.62,6731.32,
Removal of skin tags <w/15,11200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6197.09,,,,,,,fee schedule,198.62,6731.32,
Removal of skin tags <w/15,11200,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,881.22,,,,,,,fee schedule,198.62,6731.32,APC 378
Removal of skin tags <w/15,11200,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.55,,,,,,,fee schedule,198.62,6731.32,APC
Removal of skin tags <w/15,11200,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,206.57,,,,,,,fee schedule,198.62,6731.32,APC
Removal of skin tags <w/15,11200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.62,,,,,,,fee schedule,198.62,6731.32,APC
Removal of skin tags <w/15,11200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.89,,,,,,,fee schedule,198.62,6731.32,Radiology
Removal of skin tags <w/15,11200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,278.07,,,,,,,fee schedule,198.62,6731.32,APC
Removal of skin tags <w/15,11200,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,347.59,,,,,,,fee schedule,198.62,6731.32,APC
Remove skin tags add-on,11201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,364.24,,,,,,,fee schedule,291.97,364.24,
Remove skin tags add-on,11201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,291.97,,,,,,,fee schedule,291.97,364.24,
Remove skin tags add-on,11201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,318.95,,,,,,,fee schedule,291.97,364.24,
Remove skin tags add-on,11201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,335.33,,,,,,,fee schedule,291.97,364.24,
Shave skin lesion 0.5 cm/<,11300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,197.92,,,,,,,fee schedule,158.65,1785.48,
Shave skin lesion 0.5 cm/<,11300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,158.65,,,,,,,fee schedule,158.65,1785.48,
Shave skin lesion 0.5 cm/<,11300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,173.31,,,,,,,fee schedule,158.65,1785.48,
Shave skin lesion 0.5 cm/<,11300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,182.21,,,,,,,fee schedule,158.65,1785.48,
Shave skin lesion 0.5 cm/<,11300,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1785.48,,,,,,,fee schedule,158.65,1785.48,APC 378
Shave skin lesion 0.5 cm/<,11300,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,422.56,,,,,,,fee schedule,158.65,1785.48,APC
Shave skin lesion 0.5 cm/<,11300,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,418.53,,,,,,,fee schedule,158.65,1785.48,APC
Shave skin lesion 0.5 cm/<,11300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,402.44,,,,,,,fee schedule,158.65,1785.48,APC
Shave skin lesion 0.5 cm/<,11300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,615.73,,,,,,,fee schedule,158.65,1785.48,Radiology
Shave skin lesion 0.5 cm/<,11300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,563.41,,,,,,,fee schedule,158.65,1785.48,APC
Shave skin lesion 0.5 cm/<,11300,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,704.26,,,,,,,fee schedule,158.65,1785.48,APC
Shave skin lesion 0.6-1.0 cm,11301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,197.92,,,,,,,fee schedule,158.65,881.22,
Shave skin lesion 0.6-1.0 cm,11301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,158.65,,,,,,,fee schedule,158.65,881.22,
Shave skin lesion 0.6-1.0 cm,11301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,173.31,,,,,,,fee schedule,158.65,881.22,
Shave skin lesion 0.6-1.0 cm,11301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,182.21,,,,,,,fee schedule,158.65,881.22,
Shave skin lesion 0.6-1.0 cm,11301,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,881.22,,,,,,,fee schedule,158.65,881.22,APC 378
Shave skin lesion 0.6-1.0 cm,11301,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.55,,,,,,,fee schedule,158.65,881.22,APC
Shave skin lesion 0.6-1.0 cm,11301,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,206.57,,,,,,,fee schedule,158.65,881.22,APC
Shave skin lesion 0.6-1.0 cm,11301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.62,,,,,,,fee schedule,158.65,881.22,APC
Shave skin lesion 0.6-1.0 cm,11301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.89,,,,,,,fee schedule,158.65,881.22,Radiology
Shave skin lesion 0.6-1.0 cm,11301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,278.07,,,,,,,fee schedule,158.65,881.22,APC
Shave skin lesion 0.6-1.0 cm,11301,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,347.59,,,,,,,fee schedule,158.65,881.22,APC
Shave skin lesion 1.1-2.0 cm,11302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2785.39,,,,,,,fee schedule,198.62,2785.39,
Shave skin lesion 1.1-2.0 cm,11302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2232.74,,,,,,,fee schedule,198.62,2785.39,
Shave skin lesion 1.1-2.0 cm,11302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2439.06,,,,,,,fee schedule,198.62,2785.39,
Shave skin lesion 1.1-2.0 cm,11302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2564.33,,,,,,,fee schedule,198.62,2785.39,
Shave skin lesion 1.1-2.0 cm,11302,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,881.22,,,,,,,fee schedule,198.62,2785.39,APC 378
Shave skin lesion 1.1-2.0 cm,11302,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.55,,,,,,,fee schedule,198.62,2785.39,APC
Shave skin lesion 1.1-2.0 cm,11302,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,206.57,,,,,,,fee schedule,198.62,2785.39,APC
Shave skin lesion 1.1-2.0 cm,11302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.62,,,,,,,fee schedule,198.62,2785.39,APC
Shave skin lesion 1.1-2.0 cm,11302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.89,,,,,,,fee schedule,198.62,2785.39,Radiology
Shave skin lesion 1.1-2.0 cm,11302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,278.07,,,,,,,fee schedule,198.62,2785.39,APC
Shave skin lesion 1.1-2.0 cm,11302,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,347.59,,,,,,,fee schedule,198.62,2785.39,APC
Shave skin lesion >2.0 cm,11303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3360.79,,,,,,,fee schedule,402.44,3360.79,
Shave skin lesion >2.0 cm,11303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2693.96,,,,,,,fee schedule,402.44,3360.79,
Shave skin lesion >2.0 cm,11303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2942.91,,,,,,,fee schedule,402.44,3360.79,
Shave skin lesion >2.0 cm,11303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3094.06,,,,,,,fee schedule,402.44,3360.79,
Shave skin lesion >2.0 cm,11303,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1785.48,,,,,,,fee schedule,402.44,3360.79,APC 378
Shave skin lesion >2.0 cm,11303,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,422.56,,,,,,,fee schedule,402.44,3360.79,APC
Shave skin lesion >2.0 cm,11303,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,418.53,,,,,,,fee schedule,402.44,3360.79,APC
Shave skin lesion >2.0 cm,11303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,402.44,,,,,,,fee schedule,402.44,3360.79,APC
Shave skin lesion >2.0 cm,11303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,615.73,,,,,,,fee schedule,402.44,3360.79,Radiology
Shave skin lesion >2.0 cm,11303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,563.41,,,,,,,fee schedule,402.44,3360.79,APC
Shave skin lesion >2.0 cm,11303,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,704.26,,,,,,,fee schedule,402.44,3360.79,APC
Shave skin lesion 0.5 cm/<,11305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,197.92,,,,,,,fee schedule,158.65,881.22,
Shave skin lesion 0.5 cm/<,11305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,158.65,,,,,,,fee schedule,158.65,881.22,
Shave skin lesion 0.5 cm/<,11305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,173.31,,,,,,,fee schedule,158.65,881.22,
Shave skin lesion 0.5 cm/<,11305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,182.21,,,,,,,fee schedule,158.65,881.22,
Shave skin lesion 0.5 cm/<,11305,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,881.22,,,,,,,fee schedule,158.65,881.22,APC 378
Shave skin lesion 0.5 cm/<,11305,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.55,,,,,,,fee schedule,158.65,881.22,APC
Shave skin lesion 0.5 cm/<,11305,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,206.57,,,,,,,fee schedule,158.65,881.22,APC
Shave skin lesion 0.5 cm/<,11305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.62,,,,,,,fee schedule,158.65,881.22,APC
Shave skin lesion 0.5 cm/<,11305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.89,,,,,,,fee schedule,158.65,881.22,Radiology
Shave skin lesion 0.5 cm/<,11305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,278.07,,,,,,,fee schedule,158.65,881.22,APC
Shave skin lesion 0.5 cm/<,11305,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,347.59,,,,,,,fee schedule,158.65,881.22,APC
Shave skin lesion 0.6-1.0 cm,11306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,197.92,,,,,,,fee schedule,158.65,881.22,
Shave skin lesion 0.6-1.0 cm,11306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,158.65,,,,,,,fee schedule,158.65,881.22,
Shave skin lesion 0.6-1.0 cm,11306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,173.31,,,,,,,fee schedule,158.65,881.22,
Shave skin lesion 0.6-1.0 cm,11306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,182.21,,,,,,,fee schedule,158.65,881.22,
Shave skin lesion 0.6-1.0 cm,11306,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,881.22,,,,,,,fee schedule,158.65,881.22,APC 378
Shave skin lesion 0.6-1.0 cm,11306,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.55,,,,,,,fee schedule,158.65,881.22,APC
Shave skin lesion 0.6-1.0 cm,11306,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,206.57,,,,,,,fee schedule,158.65,881.22,APC
Shave skin lesion 0.6-1.0 cm,11306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.62,,,,,,,fee schedule,158.65,881.22,APC
Shave skin lesion 0.6-1.0 cm,11306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.89,,,,,,,fee schedule,158.65,881.22,Radiology
Shave skin lesion 0.6-1.0 cm,11306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,278.07,,,,,,,fee schedule,158.65,881.22,APC
Shave skin lesion 0.6-1.0 cm,11306,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,347.59,,,,,,,fee schedule,158.65,881.22,APC
Shave skin lesion 1.1-2.0 cm,11307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,197.92,,,,,,,fee schedule,158.65,881.22,
Shave skin lesion 1.1-2.0 cm,11307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,158.65,,,,,,,fee schedule,158.65,881.22,
Shave skin lesion 1.1-2.0 cm,11307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,173.31,,,,,,,fee schedule,158.65,881.22,
Shave skin lesion 1.1-2.0 cm,11307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,182.21,,,,,,,fee schedule,158.65,881.22,
Shave skin lesion 1.1-2.0 cm,11307,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,881.22,,,,,,,fee schedule,158.65,881.22,APC 378
Shave skin lesion 1.1-2.0 cm,11307,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.55,,,,,,,fee schedule,158.65,881.22,APC
Shave skin lesion 1.1-2.0 cm,11307,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,206.57,,,,,,,fee schedule,158.65,881.22,APC
Shave skin lesion 1.1-2.0 cm,11307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.62,,,,,,,fee schedule,158.65,881.22,APC
Shave skin lesion 1.1-2.0 cm,11307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.89,,,,,,,fee schedule,158.65,881.22,Radiology
Shave skin lesion 1.1-2.0 cm,11307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,278.07,,,,,,,fee schedule,158.65,881.22,APC
Shave skin lesion 1.1-2.0 cm,11307,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,347.59,,,,,,,fee schedule,158.65,881.22,APC
Shave skin lesion >2.0 cm,11308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,197.92,,,,,,,fee schedule,158.65,1785.48,
Shave skin lesion >2.0 cm,11308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,158.65,,,,,,,fee schedule,158.65,1785.48,
Shave skin lesion >2.0 cm,11308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,173.31,,,,,,,fee schedule,158.65,1785.48,
Shave skin lesion >2.0 cm,11308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,182.21,,,,,,,fee schedule,158.65,1785.48,
Shave skin lesion >2.0 cm,11308,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1785.48,,,,,,,fee schedule,158.65,1785.48,APC 378
Shave skin lesion >2.0 cm,11308,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,422.56,,,,,,,fee schedule,158.65,1785.48,APC
Shave skin lesion >2.0 cm,11308,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,418.53,,,,,,,fee schedule,158.65,1785.48,APC
Shave skin lesion >2.0 cm,11308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,402.44,,,,,,,fee schedule,158.65,1785.48,APC
Shave skin lesion >2.0 cm,11308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,615.73,,,,,,,fee schedule,158.65,1785.48,Radiology
Shave skin lesion >2.0 cm,11308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,563.41,,,,,,,fee schedule,158.65,1785.48,APC
Shave skin lesion >2.0 cm,11308,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,704.26,,,,,,,fee schedule,158.65,1785.48,APC
Shave skin lesion 0.5 cm/<,11310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,197.92,,,,,,,fee schedule,158.65,881.22,
Shave skin lesion 0.5 cm/<,11310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,158.65,,,,,,,fee schedule,158.65,881.22,
Shave skin lesion 0.5 cm/<,11310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,173.31,,,,,,,fee schedule,158.65,881.22,
Shave skin lesion 0.5 cm/<,11310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,182.21,,,,,,,fee schedule,158.65,881.22,
Shave skin lesion 0.5 cm/<,11310,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,881.22,,,,,,,fee schedule,158.65,881.22,APC 378
Shave skin lesion 0.5 cm/<,11310,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.55,,,,,,,fee schedule,158.65,881.22,APC
Shave skin lesion 0.5 cm/<,11310,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,206.57,,,,,,,fee schedule,158.65,881.22,APC
Shave skin lesion 0.5 cm/<,11310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.62,,,,,,,fee schedule,158.65,881.22,APC
Shave skin lesion 0.5 cm/<,11310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.89,,,,,,,fee schedule,158.65,881.22,Radiology
Shave skin lesion 0.5 cm/<,11310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,278.07,,,,,,,fee schedule,158.65,881.22,APC
Shave skin lesion 0.5 cm/<,11310,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,347.59,,,,,,,fee schedule,158.65,881.22,APC
Shave skin lesion 0.6-1.0 cm,11311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,197.92,,,,,,,fee schedule,158.65,881.22,
Shave skin lesion 0.6-1.0 cm,11311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,158.65,,,,,,,fee schedule,158.65,881.22,
Shave skin lesion 0.6-1.0 cm,11311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,173.31,,,,,,,fee schedule,158.65,881.22,
Shave skin lesion 0.6-1.0 cm,11311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,182.21,,,,,,,fee schedule,158.65,881.22,
Shave skin lesion 0.6-1.0 cm,11311,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,881.22,,,,,,,fee schedule,158.65,881.22,APC 378
Shave skin lesion 0.6-1.0 cm,11311,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.55,,,,,,,fee schedule,158.65,881.22,APC
Shave skin lesion 0.6-1.0 cm,11311,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,206.57,,,,,,,fee schedule,158.65,881.22,APC
Shave skin lesion 0.6-1.0 cm,11311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.62,,,,,,,fee schedule,158.65,881.22,APC
Shave skin lesion 0.6-1.0 cm,11311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.89,,,,,,,fee schedule,158.65,881.22,Radiology
Shave skin lesion 0.6-1.0 cm,11311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,278.07,,,,,,,fee schedule,158.65,881.22,APC
Shave skin lesion 0.6-1.0 cm,11311,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,347.59,,,,,,,fee schedule,158.65,881.22,APC
Shave skin lesion 1.1-2.0 cm,11312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,197.92,,,,,,,fee schedule,158.65,1785.48,
Shave skin lesion 1.1-2.0 cm,11312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,158.65,,,,,,,fee schedule,158.65,1785.48,
Shave skin lesion 1.1-2.0 cm,11312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,173.31,,,,,,,fee schedule,158.65,1785.48,
Shave skin lesion 1.1-2.0 cm,11312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,182.21,,,,,,,fee schedule,158.65,1785.48,
Shave skin lesion 1.1-2.0 cm,11312,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1785.48,,,,,,,fee schedule,158.65,1785.48,APC 378
Shave skin lesion 1.1-2.0 cm,11312,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,422.56,,,,,,,fee schedule,158.65,1785.48,APC
Shave skin lesion 1.1-2.0 cm,11312,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,418.53,,,,,,,fee schedule,158.65,1785.48,APC
Shave skin lesion 1.1-2.0 cm,11312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,402.44,,,,,,,fee schedule,158.65,1785.48,APC
Shave skin lesion 1.1-2.0 cm,11312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,615.73,,,,,,,fee schedule,158.65,1785.48,Radiology
Shave skin lesion 1.1-2.0 cm,11312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,563.41,,,,,,,fee schedule,158.65,1785.48,APC
Shave skin lesion 1.1-2.0 cm,11312,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,704.26,,,,,,,fee schedule,158.65,1785.48,APC
Shave skin lesion >2.0 cm,11313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,197.92,,,,,,,fee schedule,158.65,1785.48,
Shave skin lesion >2.0 cm,11313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,158.65,,,,,,,fee schedule,158.65,1785.48,
Shave skin lesion >2.0 cm,11313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,173.31,,,,,,,fee schedule,158.65,1785.48,
Shave skin lesion >2.0 cm,11313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,182.21,,,,,,,fee schedule,158.65,1785.48,
Shave skin lesion >2.0 cm,11313,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1785.48,,,,,,,fee schedule,158.65,1785.48,APC 378
Shave skin lesion >2.0 cm,11313,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,422.56,,,,,,,fee schedule,158.65,1785.48,APC
Shave skin lesion >2.0 cm,11313,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,418.53,,,,,,,fee schedule,158.65,1785.48,APC
Shave skin lesion >2.0 cm,11313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,402.44,,,,,,,fee schedule,158.65,1785.48,APC
Shave skin lesion >2.0 cm,11313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,615.73,,,,,,,fee schedule,158.65,1785.48,Radiology
Shave skin lesion >2.0 cm,11313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,563.41,,,,,,,fee schedule,158.65,1785.48,APC
Shave skin lesion >2.0 cm,11313,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,704.26,,,,,,,fee schedule,158.65,1785.48,APC
Exc tr-ext b9+marg 0.5 cm<,11400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5098.34,,,,,,,fee schedule,701.03,5098.34,
Exc tr-ext b9+marg 0.5 cm<,11400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4086.76,,,,,,,fee schedule,701.03,5098.34,
Exc tr-ext b9+marg 0.5 cm<,11400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4464.42,,,,,,,fee schedule,701.03,5098.34,
Exc tr-ext b9+marg 0.5 cm<,11400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4693.71,,,,,,,fee schedule,701.03,5098.34,
Exc tr-ext b9+marg 0.5 cm<,11400,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3110.22,,,,,,,fee schedule,701.03,5098.34,APC 378
Exc tr-ext b9+marg 0.5 cm<,11400,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,736.08,,,,,,,fee schedule,701.03,5098.34,APC
Exc tr-ext b9+marg 0.5 cm<,11400,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,729.07,,,,,,,fee schedule,701.03,5098.34,APC
Exc tr-ext b9+marg 0.5 cm<,11400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,701.03,,,,,,,fee schedule,701.03,5098.34,APC
Exc tr-ext b9+marg 0.5 cm<,11400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1072.57,,,,,,,fee schedule,701.03,5098.34,Radiology
Exc tr-ext b9+marg 0.5 cm<,11400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,981.44,,,,,,,fee schedule,701.03,5098.34,APC
Exc tr-ext b9+marg 0.5 cm<,11400,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1226.8,,,,,,,fee schedule,701.03,5098.34,APC
Exc tr-ext b9+marg 0.6-1 cm,11401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1074.12,,,,,,,fee schedule,402.44,1785.48,
Exc tr-ext b9+marg 0.6-1 cm,11401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,861,,,,,,,fee schedule,402.44,1785.48,
Exc tr-ext b9+marg 0.6-1 cm,11401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,940.57,,,,,,,fee schedule,402.44,1785.48,
Exc tr-ext b9+marg 0.6-1 cm,11401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,988.88,,,,,,,fee schedule,402.44,1785.48,
Exc tr-ext b9+marg 0.6-1 cm,11401,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1785.48,,,,,,,fee schedule,402.44,1785.48,APC 378
Exc tr-ext b9+marg 0.6-1 cm,11401,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,422.56,,,,,,,fee schedule,402.44,1785.48,APC
Exc tr-ext b9+marg 0.6-1 cm,11401,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,418.53,,,,,,,fee schedule,402.44,1785.48,APC
Exc tr-ext b9+marg 0.6-1 cm,11401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,402.44,,,,,,,fee schedule,402.44,1785.48,APC
Exc tr-ext b9+marg 0.6-1 cm,11401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,615.73,,,,,,,fee schedule,402.44,1785.48,Radiology
Exc tr-ext b9+marg 0.6-1 cm,11401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,563.41,,,,,,,fee schedule,402.44,1785.48,APC
Exc tr-ext b9+marg 0.6-1 cm,11401,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,704.26,,,,,,,fee schedule,402.44,1785.48,APC
Exc tr-ext b9+marg 1.1-2 cm,11402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2552.61,,,,,,,fee schedule,701.03,3110.22,
Exc tr-ext b9+marg 1.1-2 cm,11402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2046.14,,,,,,,fee schedule,701.03,3110.22,
Exc tr-ext b9+marg 1.1-2 cm,11402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2235.23,,,,,,,fee schedule,701.03,3110.22,
Exc tr-ext b9+marg 1.1-2 cm,11402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2350.03,,,,,,,fee schedule,701.03,3110.22,
Exc tr-ext b9+marg 1.1-2 cm,11402,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3110.22,,,,,,,fee schedule,701.03,3110.22,APC 378
Exc tr-ext b9+marg 1.1-2 cm,11402,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,736.08,,,,,,,fee schedule,701.03,3110.22,APC
Exc tr-ext b9+marg 1.1-2 cm,11402,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,729.07,,,,,,,fee schedule,701.03,3110.22,APC
Exc tr-ext b9+marg 1.1-2 cm,11402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,701.03,,,,,,,fee schedule,701.03,3110.22,APC
Exc tr-ext b9+marg 1.1-2 cm,11402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1072.57,,,,,,,fee schedule,701.03,3110.22,Radiology
Exc tr-ext b9+marg 1.1-2 cm,11402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,981.44,,,,,,,fee schedule,701.03,3110.22,APC
Exc tr-ext b9+marg 1.1-2 cm,11402,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1226.8,,,,,,,fee schedule,701.03,3110.22,APC
Exc tr-ext b9+marg 2.1-3cm/<,11403,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4932.1,,,,,,,fee schedule,701.03,4932.1,
Exc tr-ext b9+marg 2.1-3cm/<,11403,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3953.51,,,,,,,fee schedule,701.03,4932.1,
Exc tr-ext b9+marg 2.1-3cm/<,11403,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4318.85,,,,,,,fee schedule,701.03,4932.1,
Exc tr-ext b9+marg 2.1-3cm/<,11403,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4540.66,,,,,,,fee schedule,701.03,4932.1,
Exc tr-ext b9+marg 2.1-3cm/<,11403,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3110.22,,,,,,,fee schedule,701.03,4932.1,APC 378
Exc tr-ext b9+marg 2.1-3cm/<,11403,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,736.08,,,,,,,fee schedule,701.03,4932.1,APC
Exc tr-ext b9+marg 2.1-3cm/<,11403,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,729.07,,,,,,,fee schedule,701.03,4932.1,APC
Exc tr-ext b9+marg 2.1-3cm/<,11403,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,701.03,,,,,,,fee schedule,701.03,4932.1,APC
Exc tr-ext b9+marg 2.1-3cm/<,11403,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1072.57,,,,,,,fee schedule,701.03,4932.1,Radiology
Exc tr-ext b9+marg 2.1-3cm/<,11403,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,981.44,,,,,,,fee schedule,701.03,4932.1,APC
Exc tr-ext b9+marg 2.1-3cm/<,11403,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1226.8,,,,,,,fee schedule,701.03,4932.1,APC
Exc tr-ext b9+marg 3.1-4 cm,11404,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6112.86,,,,,,,fee schedule,1635.03,7254.06,
Exc tr-ext b9+marg 3.1-4 cm,11404,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4899.99,,,,,,,fee schedule,1635.03,7254.06,
Exc tr-ext b9+marg 3.1-4 cm,11404,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5352.79,,,,,,,fee schedule,1635.03,7254.06,
Exc tr-ext b9+marg 3.1-4 cm,11404,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5627.71,,,,,,,fee schedule,1635.03,7254.06,
Exc tr-ext b9+marg 3.1-4 cm,11404,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,7254.06,APC 378
Exc tr-ext b9+marg 3.1-4 cm,11404,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,7254.06,APC
Exc tr-ext b9+marg 3.1-4 cm,11404,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,7254.06,APC
Exc tr-ext b9+marg 3.1-4 cm,11404,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,7254.06,APC
Exc tr-ext b9+marg 3.1-4 cm,11404,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,7254.06,Radiology
Exc tr-ext b9+marg 3.1-4 cm,11404,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,7254.06,APC
Exc tr-ext b9+marg 3.1-4 cm,11404,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,7254.06,APC
Exc tr-ext b9+marg >4.0 cm,11406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2617.56,,,,,,,fee schedule,1635.03,7254.06,
Exc tr-ext b9+marg >4.0 cm,11406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2098.21,,,,,,,fee schedule,1635.03,7254.06,
Exc tr-ext b9+marg >4.0 cm,11406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2292.1,,,,,,,fee schedule,1635.03,7254.06,
Exc tr-ext b9+marg >4.0 cm,11406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2409.82,,,,,,,fee schedule,1635.03,7254.06,
Exc tr-ext b9+marg >4.0 cm,11406,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,7254.06,APC 378
Exc tr-ext b9+marg >4.0 cm,11406,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,7254.06,APC
Exc tr-ext b9+marg >4.0 cm,11406,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,7254.06,APC
Exc tr-ext b9+marg >4.0 cm,11406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,7254.06,APC
Exc tr-ext b9+marg >4.0 cm,11406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,7254.06,Radiology
Exc tr-ext b9+marg >4.0 cm,11406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,7254.06,APC
Exc tr-ext b9+marg >4.0 cm,11406,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,7254.06,APC
Exc h-f-nk-sp b9+marg 0.5/<,11420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6721.57,,,,,,,fee schedule,1635.03,7254.06,
Exc h-f-nk-sp b9+marg 0.5/<,11420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5387.93,,,,,,,fee schedule,1635.03,7254.06,
Exc h-f-nk-sp b9+marg 0.5/<,11420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5885.82,,,,,,,fee schedule,1635.03,7254.06,
Exc h-f-nk-sp b9+marg 0.5/<,11420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6188.11,,,,,,,fee schedule,1635.03,7254.06,
Exc h-f-nk-sp b9+marg 0.5/<,11420,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,7254.06,APC 378
Exc h-f-nk-sp b9+marg 0.5/<,11420,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,7254.06,APC
Exc h-f-nk-sp b9+marg 0.5/<,11420,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,7254.06,APC
Exc h-f-nk-sp b9+marg 0.5/<,11420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,7254.06,APC
Exc h-f-nk-sp b9+marg 0.5/<,11420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,7254.06,Radiology
Exc h-f-nk-sp b9+marg 0.5/<,11420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,7254.06,APC
Exc h-f-nk-sp b9+marg 0.5/<,11420,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,7254.06,APC
Exc h-f-nk-sp b9+marg 0.6-1,11421,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3711.87,,,,,,,fee schedule,701.03,3711.87,
Exc h-f-nk-sp b9+marg 0.6-1,11421,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2975.39,,,,,,,fee schedule,701.03,3711.87,
Exc h-f-nk-sp b9+marg 0.6-1,11421,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3250.34,,,,,,,fee schedule,701.03,3711.87,
Exc h-f-nk-sp b9+marg 0.6-1,11421,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3417.28,,,,,,,fee schedule,701.03,3711.87,
Exc h-f-nk-sp b9+marg 0.6-1,11421,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3110.22,,,,,,,fee schedule,701.03,3711.87,APC 378
Exc h-f-nk-sp b9+marg 0.6-1,11421,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,736.08,,,,,,,fee schedule,701.03,3711.87,APC
Exc h-f-nk-sp b9+marg 0.6-1,11421,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,729.07,,,,,,,fee schedule,701.03,3711.87,APC
Exc h-f-nk-sp b9+marg 0.6-1,11421,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,701.03,,,,,,,fee schedule,701.03,3711.87,APC
Exc h-f-nk-sp b9+marg 0.6-1,11421,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1072.57,,,,,,,fee schedule,701.03,3711.87,Radiology
Exc h-f-nk-sp b9+marg 0.6-1,11421,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,981.44,,,,,,,fee schedule,701.03,3711.87,APC
Exc h-f-nk-sp b9+marg 0.6-1,11421,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1226.8,,,,,,,fee schedule,701.03,3711.87,APC
Exc h-f-nk-sp b9+marg 1.1-2,11422,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6253.46,,,,,,,fee schedule,1635.03,7254.06,
Exc h-f-nk-sp b9+marg 1.1-2,11422,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5012.69,,,,,,,fee schedule,1635.03,7254.06,
Exc h-f-nk-sp b9+marg 1.1-2,11422,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5475.91,,,,,,,fee schedule,1635.03,7254.06,
Exc h-f-nk-sp b9+marg 1.1-2,11422,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5757.15,,,,,,,fee schedule,1635.03,7254.06,
Exc h-f-nk-sp b9+marg 1.1-2,11422,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,7254.06,APC 378
Exc h-f-nk-sp b9+marg 1.1-2,11422,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,7254.06,APC
Exc h-f-nk-sp b9+marg 1.1-2,11422,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,7254.06,APC
Exc h-f-nk-sp b9+marg 1.1-2,11422,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,7254.06,APC
Exc h-f-nk-sp b9+marg 1.1-2,11422,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,7254.06,Radiology
Exc h-f-nk-sp b9+marg 1.1-2,11422,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,7254.06,APC
Exc h-f-nk-sp b9+marg 1.1-2,11422,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,7254.06,APC
Exc h-f-nk-sp b9+marg 2.1-3,11423,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4094.22,,,,,,,fee schedule,1635.03,7254.06,
Exc h-f-nk-sp b9+marg 2.1-3,11423,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3281.87,,,,,,,fee schedule,1635.03,7254.06,
Exc h-f-nk-sp b9+marg 2.1-3,11423,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3585.15,,,,,,,fee schedule,1635.03,7254.06,
Exc h-f-nk-sp b9+marg 2.1-3,11423,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3769.28,,,,,,,fee schedule,1635.03,7254.06,
Exc h-f-nk-sp b9+marg 2.1-3,11423,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,7254.06,APC 378
Exc h-f-nk-sp b9+marg 2.1-3,11423,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,7254.06,APC
Exc h-f-nk-sp b9+marg 2.1-3,11423,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,7254.06,APC
Exc h-f-nk-sp b9+marg 2.1-3,11423,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,7254.06,APC
Exc h-f-nk-sp b9+marg 2.1-3,11423,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,7254.06,Radiology
Exc h-f-nk-sp b9+marg 2.1-3,11423,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,7254.06,APC
Exc h-f-nk-sp b9+marg 2.1-3,11423,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,7254.06,APC
Exc h-f-nk-sp b9+marg 3.1-4,11424,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3594.84,,,,,,,fee schedule,1635.03,7254.06,
Exc h-f-nk-sp b9+marg 3.1-4,11424,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2881.58,,,,,,,fee schedule,1635.03,7254.06,
Exc h-f-nk-sp b9+marg 3.1-4,11424,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3147.87,,,,,,,fee schedule,1635.03,7254.06,
Exc h-f-nk-sp b9+marg 3.1-4,11424,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3309.54,,,,,,,fee schedule,1635.03,7254.06,
Exc h-f-nk-sp b9+marg 3.1-4,11424,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,7254.06,APC 378
Exc h-f-nk-sp b9+marg 3.1-4,11424,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,7254.06,APC
Exc h-f-nk-sp b9+marg 3.1-4,11424,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,7254.06,APC
Exc h-f-nk-sp b9+marg 3.1-4,11424,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,7254.06,APC
Exc h-f-nk-sp b9+marg 3.1-4,11424,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,7254.06,Radiology
Exc h-f-nk-sp b9+marg 3.1-4,11424,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,7254.06,APC
Exc h-f-nk-sp b9+marg 3.1-4,11424,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,7254.06,APC
Exc h-f-nk-sp b9+marg >4 cm,11426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3497.45,,,,,,,fee schedule,2803.52,12757.95,
Exc h-f-nk-sp b9+marg >4 cm,11426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2803.52,,,,,,,fee schedule,2803.52,12757.95,
Exc h-f-nk-sp b9+marg >4 cm,11426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3062.59,,,,,,,fee schedule,2803.52,12757.95,
Exc h-f-nk-sp b9+marg >4 cm,11426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3219.88,,,,,,,fee schedule,2803.52,12757.95,
Exc h-f-nk-sp b9+marg >4 cm,11426,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2803.52,12757.95,APC 378
Exc h-f-nk-sp b9+marg >4 cm,11426,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2803.52,12757.95,APC
Exc h-f-nk-sp b9+marg >4 cm,11426,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2803.52,12757.95,APC
Exc h-f-nk-sp b9+marg >4 cm,11426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2803.52,12757.95,APC
Exc h-f-nk-sp b9+marg >4 cm,11426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2803.52,12757.95,Radiology
Exc h-f-nk-sp b9+marg >4 cm,11426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2803.52,12757.95,APC
Exc h-f-nk-sp b9+marg >4 cm,11426,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2803.52,12757.95,APC
Exc face-mm b9+marg 0.5 cm/<,11440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6721.57,,,,,,,fee schedule,701.03,6721.57,
Exc face-mm b9+marg 0.5 cm/<,11440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5387.93,,,,,,,fee schedule,701.03,6721.57,
Exc face-mm b9+marg 0.5 cm/<,11440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5885.82,,,,,,,fee schedule,701.03,6721.57,
Exc face-mm b9+marg 0.5 cm/<,11440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6188.11,,,,,,,fee schedule,701.03,6721.57,
Exc face-mm b9+marg 0.5 cm/<,11440,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3110.22,,,,,,,fee schedule,701.03,6721.57,APC 378
Exc face-mm b9+marg 0.5 cm/<,11440,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,736.08,,,,,,,fee schedule,701.03,6721.57,APC
Exc face-mm b9+marg 0.5 cm/<,11440,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,729.07,,,,,,,fee schedule,701.03,6721.57,APC
Exc face-mm b9+marg 0.5 cm/<,11440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,701.03,,,,,,,fee schedule,701.03,6721.57,APC
Exc face-mm b9+marg 0.5 cm/<,11440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1072.57,,,,,,,fee schedule,701.03,6721.57,Radiology
Exc face-mm b9+marg 0.5 cm/<,11440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,981.44,,,,,,,fee schedule,701.03,6721.57,APC
Exc face-mm b9+marg 0.5 cm/<,11440,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1226.8,,,,,,,fee schedule,701.03,6721.57,APC
Exc face-mm b9+marg 0.6-1 cm,11441,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7657.8,,,,,,,fee schedule,701.03,7657.8,
Exc face-mm b9+marg 0.6-1 cm,11441,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6138.4,,,,,,,fee schedule,701.03,7657.8,
Exc face-mm b9+marg 0.6-1 cm,11441,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6705.64,,,,,,,fee schedule,701.03,7657.8,
Exc face-mm b9+marg 0.6-1 cm,11441,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7050.04,,,,,,,fee schedule,701.03,7657.8,
Exc face-mm b9+marg 0.6-1 cm,11441,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3110.22,,,,,,,fee schedule,701.03,7657.8,APC 378
Exc face-mm b9+marg 0.6-1 cm,11441,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,736.08,,,,,,,fee schedule,701.03,7657.8,APC
Exc face-mm b9+marg 0.6-1 cm,11441,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,729.07,,,,,,,fee schedule,701.03,7657.8,APC
Exc face-mm b9+marg 0.6-1 cm,11441,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,701.03,,,,,,,fee schedule,701.03,7657.8,APC
Exc face-mm b9+marg 0.6-1 cm,11441,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1072.57,,,,,,,fee schedule,701.03,7657.8,Radiology
Exc face-mm b9+marg 0.6-1 cm,11441,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,981.44,,,,,,,fee schedule,701.03,7657.8,APC
Exc face-mm b9+marg 0.6-1 cm,11441,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1226.8,,,,,,,fee schedule,701.03,7657.8,APC
Exc face-mm b9+marg 1.1-2 cm,11442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2764.89,,,,,,,fee schedule,701.03,3110.22,
Exc face-mm b9+marg 1.1-2 cm,11442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2216.3,,,,,,,fee schedule,701.03,3110.22,
Exc face-mm b9+marg 1.1-2 cm,11442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2421.11,,,,,,,fee schedule,701.03,3110.22,
Exc face-mm b9+marg 1.1-2 cm,11442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2545.46,,,,,,,fee schedule,701.03,3110.22,
Exc face-mm b9+marg 1.1-2 cm,11442,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3110.22,,,,,,,fee schedule,701.03,3110.22,APC 378
Exc face-mm b9+marg 1.1-2 cm,11442,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,736.08,,,,,,,fee schedule,701.03,3110.22,APC
Exc face-mm b9+marg 1.1-2 cm,11442,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,729.07,,,,,,,fee schedule,701.03,3110.22,APC
Exc face-mm b9+marg 1.1-2 cm,11442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,701.03,,,,,,,fee schedule,701.03,3110.22,APC
Exc face-mm b9+marg 1.1-2 cm,11442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1072.57,,,,,,,fee schedule,701.03,3110.22,Radiology
Exc face-mm b9+marg 1.1-2 cm,11442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,981.44,,,,,,,fee schedule,701.03,3110.22,APC
Exc face-mm b9+marg 1.1-2 cm,11442,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1226.8,,,,,,,fee schedule,701.03,3110.22,APC
Exc face-mm b9+marg 2.1-3 cm,11443,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3594.84,,,,,,,fee schedule,1635.03,7254.06,
Exc face-mm b9+marg 2.1-3 cm,11443,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2881.58,,,,,,,fee schedule,1635.03,7254.06,
Exc face-mm b9+marg 2.1-3 cm,11443,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3147.87,,,,,,,fee schedule,1635.03,7254.06,
Exc face-mm b9+marg 2.1-3 cm,11443,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3309.54,,,,,,,fee schedule,1635.03,7254.06,
Exc face-mm b9+marg 2.1-3 cm,11443,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,7254.06,APC 378
Exc face-mm b9+marg 2.1-3 cm,11443,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,7254.06,APC
Exc face-mm b9+marg 2.1-3 cm,11443,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,7254.06,APC
Exc face-mm b9+marg 2.1-3 cm,11443,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,7254.06,APC
Exc face-mm b9+marg 2.1-3 cm,11443,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,7254.06,Radiology
Exc face-mm b9+marg 2.1-3 cm,11443,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,7254.06,APC
Exc face-mm b9+marg 2.1-3 cm,11443,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,7254.06,APC
Exc face-mm b9+marg 3.1-4 cm,11444,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3711.87,,,,,,,fee schedule,1635.03,7254.06,
Exc face-mm b9+marg 3.1-4 cm,11444,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2975.39,,,,,,,fee schedule,1635.03,7254.06,
Exc face-mm b9+marg 3.1-4 cm,11444,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3250.34,,,,,,,fee schedule,1635.03,7254.06,
Exc face-mm b9+marg 3.1-4 cm,11444,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3417.28,,,,,,,fee schedule,1635.03,7254.06,
Exc face-mm b9+marg 3.1-4 cm,11444,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,7254.06,APC 378
Exc face-mm b9+marg 3.1-4 cm,11444,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,7254.06,APC
Exc face-mm b9+marg 3.1-4 cm,11444,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,7254.06,APC
Exc face-mm b9+marg 3.1-4 cm,11444,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,7254.06,APC
Exc face-mm b9+marg 3.1-4 cm,11444,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,7254.06,Radiology
Exc face-mm b9+marg 3.1-4 cm,11444,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,7254.06,APC
Exc face-mm b9+marg 3.1-4 cm,11444,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,7254.06,APC
Exc face-mm b9+marg >4 cm,11446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5268.49,,,,,,,fee schedule,2875.57,12757.95,
Exc face-mm b9+marg >4 cm,11446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4223.15,,,,,,,fee schedule,2875.57,12757.95,
Exc face-mm b9+marg >4 cm,11446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4613.41,,,,,,,fee schedule,2875.57,12757.95,
Exc face-mm b9+marg >4 cm,11446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4850.35,,,,,,,fee schedule,2875.57,12757.95,
Exc face-mm b9+marg >4 cm,11446,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Exc face-mm b9+marg >4 cm,11446,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Exc face-mm b9+marg >4 cm,11446,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Exc face-mm b9+marg >4 cm,11446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Exc face-mm b9+marg >4 cm,11446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Exc face-mm b9+marg >4 cm,11446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Exc face-mm b9+marg >4 cm,11446,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Removal sweat gland lesion,11450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5268.49,,,,,,,fee schedule,2875.57,12757.95,
Removal sweat gland lesion,11450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4223.15,,,,,,,fee schedule,2875.57,12757.95,
Removal sweat gland lesion,11450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4613.41,,,,,,,fee schedule,2875.57,12757.95,
Removal sweat gland lesion,11450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4850.35,,,,,,,fee schedule,2875.57,12757.95,
Removal sweat gland lesion,11450,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Removal sweat gland lesion,11450,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Removal sweat gland lesion,11450,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Removal sweat gland lesion,11450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Removal sweat gland lesion,11450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Removal sweat gland lesion,11450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Removal sweat gland lesion,11450,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Removal sweat gland lesion,11451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5268.49,,,,,,,fee schedule,2875.57,12757.95,
Removal sweat gland lesion,11451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4223.15,,,,,,,fee schedule,2875.57,12757.95,
Removal sweat gland lesion,11451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4613.41,,,,,,,fee schedule,2875.57,12757.95,
Removal sweat gland lesion,11451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4850.35,,,,,,,fee schedule,2875.57,12757.95,
Removal sweat gland lesion,11451,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Removal sweat gland lesion,11451,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Removal sweat gland lesion,11451,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Removal sweat gland lesion,11451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Removal sweat gland lesion,11451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Removal sweat gland lesion,11451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Removal sweat gland lesion,11451,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Removal sweat gland lesion,11462,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8125.92,,,,,,,fee schedule,2875.57,12757.95,
Removal sweat gland lesion,11462,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6513.63,,,,,,,fee schedule,2875.57,12757.95,
Removal sweat gland lesion,11462,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7115.55,,,,,,,fee schedule,2875.57,12757.95,
Removal sweat gland lesion,11462,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7481,,,,,,,fee schedule,2875.57,12757.95,
Removal sweat gland lesion,11462,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Removal sweat gland lesion,11462,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Removal sweat gland lesion,11462,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Removal sweat gland lesion,11462,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Removal sweat gland lesion,11462,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Removal sweat gland lesion,11462,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Removal sweat gland lesion,11462,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Removal sweat gland lesion,11463,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5268.49,,,,,,,fee schedule,2875.57,12757.95,
Removal sweat gland lesion,11463,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4223.15,,,,,,,fee schedule,2875.57,12757.95,
Removal sweat gland lesion,11463,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4613.41,,,,,,,fee schedule,2875.57,12757.95,
Removal sweat gland lesion,11463,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4850.35,,,,,,,fee schedule,2875.57,12757.95,
Removal sweat gland lesion,11463,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Removal sweat gland lesion,11463,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Removal sweat gland lesion,11463,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Removal sweat gland lesion,11463,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Removal sweat gland lesion,11463,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Removal sweat gland lesion,11463,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Removal sweat gland lesion,11463,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Removal sweat gland lesion,11470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5268.49,,,,,,,fee schedule,2875.57,12757.95,
Removal sweat gland lesion,11470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4223.15,,,,,,,fee schedule,2875.57,12757.95,
Removal sweat gland lesion,11470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4613.41,,,,,,,fee schedule,2875.57,12757.95,
Removal sweat gland lesion,11470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4850.35,,,,,,,fee schedule,2875.57,12757.95,
Removal sweat gland lesion,11470,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Removal sweat gland lesion,11470,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Removal sweat gland lesion,11470,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Removal sweat gland lesion,11470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Removal sweat gland lesion,11470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Removal sweat gland lesion,11470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Removal sweat gland lesion,11470,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Removal sweat gland lesion,11471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5268.49,,,,,,,fee schedule,2875.57,12757.95,
Removal sweat gland lesion,11471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4223.15,,,,,,,fee schedule,2875.57,12757.95,
Removal sweat gland lesion,11471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4613.41,,,,,,,fee schedule,2875.57,12757.95,
Removal sweat gland lesion,11471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4850.35,,,,,,,fee schedule,2875.57,12757.95,
Removal sweat gland lesion,11471,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Removal sweat gland lesion,11471,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Removal sweat gland lesion,11471,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Removal sweat gland lesion,11471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Removal sweat gland lesion,11471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Removal sweat gland lesion,11471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Removal sweat gland lesion,11471,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Exc tr-ext mal+marg 0.5 cm/<,11600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1074.12,,,,,,,fee schedule,701.03,3110.22,
Exc tr-ext mal+marg 0.5 cm/<,11600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,861,,,,,,,fee schedule,701.03,3110.22,
Exc tr-ext mal+marg 0.5 cm/<,11600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,940.57,,,,,,,fee schedule,701.03,3110.22,
Exc tr-ext mal+marg 0.5 cm/<,11600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,988.88,,,,,,,fee schedule,701.03,3110.22,
Exc tr-ext mal+marg 0.5 cm/<,11600,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3110.22,,,,,,,fee schedule,701.03,3110.22,APC 378
Exc tr-ext mal+marg 0.5 cm/<,11600,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,736.08,,,,,,,fee schedule,701.03,3110.22,APC
Exc tr-ext mal+marg 0.5 cm/<,11600,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,729.07,,,,,,,fee schedule,701.03,3110.22,APC
Exc tr-ext mal+marg 0.5 cm/<,11600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,701.03,,,,,,,fee schedule,701.03,3110.22,APC
Exc tr-ext mal+marg 0.5 cm/<,11600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1072.57,,,,,,,fee schedule,701.03,3110.22,Radiology
Exc tr-ext mal+marg 0.5 cm/<,11600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,981.44,,,,,,,fee schedule,701.03,3110.22,APC
Exc tr-ext mal+marg 0.5 cm/<,11600,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1226.8,,,,,,,fee schedule,701.03,3110.22,APC
Exc tr-ext mal+marg 0.6-1 cm,11601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3913.2,,,,,,,fee schedule,701.03,3913.2,
Exc tr-ext mal+marg 0.6-1 cm,11601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3136.78,,,,,,,fee schedule,701.03,3913.2,
Exc tr-ext mal+marg 0.6-1 cm,11601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3426.64,,,,,,,fee schedule,701.03,3913.2,
Exc tr-ext mal+marg 0.6-1 cm,11601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3602.63,,,,,,,fee schedule,701.03,3913.2,
Exc tr-ext mal+marg 0.6-1 cm,11601,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3110.22,,,,,,,fee schedule,701.03,3913.2,APC 378
Exc tr-ext mal+marg 0.6-1 cm,11601,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,736.08,,,,,,,fee schedule,701.03,3913.2,APC
Exc tr-ext mal+marg 0.6-1 cm,11601,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,729.07,,,,,,,fee schedule,701.03,3913.2,APC
Exc tr-ext mal+marg 0.6-1 cm,11601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,701.03,,,,,,,fee schedule,701.03,3913.2,APC
Exc tr-ext mal+marg 0.6-1 cm,11601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1072.57,,,,,,,fee schedule,701.03,3913.2,Radiology
Exc tr-ext mal+marg 0.6-1 cm,11601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,981.44,,,,,,,fee schedule,701.03,3913.2,APC
Exc tr-ext mal+marg 0.6-1 cm,11601,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1226.8,,,,,,,fee schedule,701.03,3913.2,APC
Exc tr-ext mal+marg 1.1-2 cm,11602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1074.12,,,,,,,fee schedule,402.44,1785.48,
Exc tr-ext mal+marg 1.1-2 cm,11602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,861,,,,,,,fee schedule,402.44,1785.48,
Exc tr-ext mal+marg 1.1-2 cm,11602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,940.57,,,,,,,fee schedule,402.44,1785.48,
Exc tr-ext mal+marg 1.1-2 cm,11602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,988.88,,,,,,,fee schedule,402.44,1785.48,
Exc tr-ext mal+marg 1.1-2 cm,11602,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1785.48,,,,,,,fee schedule,402.44,1785.48,APC 378
Exc tr-ext mal+marg 1.1-2 cm,11602,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,422.56,,,,,,,fee schedule,402.44,1785.48,APC
Exc tr-ext mal+marg 1.1-2 cm,11602,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,418.53,,,,,,,fee schedule,402.44,1785.48,APC
Exc tr-ext mal+marg 1.1-2 cm,11602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,402.44,,,,,,,fee schedule,402.44,1785.48,APC
Exc tr-ext mal+marg 1.1-2 cm,11602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,615.73,,,,,,,fee schedule,402.44,1785.48,Radiology
Exc tr-ext mal+marg 1.1-2 cm,11602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,563.41,,,,,,,fee schedule,402.44,1785.48,APC
Exc tr-ext mal+marg 1.1-2 cm,11602,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,704.26,,,,,,,fee schedule,402.44,1785.48,APC
Exc tr-ext mal+marg 2.1-3 cm,11603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3360.79,,,,,,,fee schedule,701.03,3360.79,
Exc tr-ext mal+marg 2.1-3 cm,11603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2693.96,,,,,,,fee schedule,701.03,3360.79,
Exc tr-ext mal+marg 2.1-3 cm,11603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2942.91,,,,,,,fee schedule,701.03,3360.79,
Exc tr-ext mal+marg 2.1-3 cm,11603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3094.06,,,,,,,fee schedule,701.03,3360.79,
Exc tr-ext mal+marg 2.1-3 cm,11603,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3110.22,,,,,,,fee schedule,701.03,3360.79,APC 378
Exc tr-ext mal+marg 2.1-3 cm,11603,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,736.08,,,,,,,fee schedule,701.03,3360.79,APC
Exc tr-ext mal+marg 2.1-3 cm,11603,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,729.07,,,,,,,fee schedule,701.03,3360.79,APC
Exc tr-ext mal+marg 2.1-3 cm,11603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,701.03,,,,,,,fee schedule,701.03,3360.79,APC
Exc tr-ext mal+marg 2.1-3 cm,11603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1072.57,,,,,,,fee schedule,701.03,3360.79,Radiology
Exc tr-ext mal+marg 2.1-3 cm,11603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,981.44,,,,,,,fee schedule,701.03,3360.79,APC
Exc tr-ext mal+marg 2.1-3 cm,11603,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1226.8,,,,,,,fee schedule,701.03,3360.79,APC
Exc tr-ext mal+marg 3.1-4 cm,11604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3360.79,,,,,,,fee schedule,701.03,3360.79,
Exc tr-ext mal+marg 3.1-4 cm,11604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2693.96,,,,,,,fee schedule,701.03,3360.79,
Exc tr-ext mal+marg 3.1-4 cm,11604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2942.91,,,,,,,fee schedule,701.03,3360.79,
Exc tr-ext mal+marg 3.1-4 cm,11604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3094.06,,,,,,,fee schedule,701.03,3360.79,
Exc tr-ext mal+marg 3.1-4 cm,11604,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3110.22,,,,,,,fee schedule,701.03,3360.79,APC 378
Exc tr-ext mal+marg 3.1-4 cm,11604,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,736.08,,,,,,,fee schedule,701.03,3360.79,APC
Exc tr-ext mal+marg 3.1-4 cm,11604,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,729.07,,,,,,,fee schedule,701.03,3360.79,APC
Exc tr-ext mal+marg 3.1-4 cm,11604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,701.03,,,,,,,fee schedule,701.03,3360.79,APC
Exc tr-ext mal+marg 3.1-4 cm,11604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1072.57,,,,,,,fee schedule,701.03,3360.79,Radiology
Exc tr-ext mal+marg 3.1-4 cm,11604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,981.44,,,,,,,fee schedule,701.03,3360.79,APC
Exc tr-ext mal+marg 3.1-4 cm,11604,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1226.8,,,,,,,fee schedule,701.03,3360.79,APC
Exc tr-ext mal+marg >4 cm,11606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4924.15,,,,,,,fee schedule,1635.03,7254.06,
Exc tr-ext mal+marg >4 cm,11606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3947.14,,,,,,,fee schedule,1635.03,7254.06,
Exc tr-ext mal+marg >4 cm,11606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4311.89,,,,,,,fee schedule,1635.03,7254.06,
Exc tr-ext mal+marg >4 cm,11606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4533.34,,,,,,,fee schedule,1635.03,7254.06,
Exc tr-ext mal+marg >4 cm,11606,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,7254.06,APC 378
Exc tr-ext mal+marg >4 cm,11606,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,7254.06,APC
Exc tr-ext mal+marg >4 cm,11606,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,7254.06,APC
Exc tr-ext mal+marg >4 cm,11606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,7254.06,APC
Exc tr-ext mal+marg >4 cm,11606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,7254.06,Radiology
Exc tr-ext mal+marg >4 cm,11606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,7254.06,APC
Exc tr-ext mal+marg >4 cm,11606,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,7254.06,APC
Exc h-f-nk-sp mal+marg 0.5/<,11620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2167.57,,,,,,,fee schedule,1635.03,7254.06,
Exc h-f-nk-sp mal+marg 0.5/<,11620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1737.49,,,,,,,fee schedule,1635.03,7254.06,
Exc h-f-nk-sp mal+marg 0.5/<,11620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1898.05,,,,,,,fee schedule,1635.03,7254.06,
Exc h-f-nk-sp mal+marg 0.5/<,11620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1995.54,,,,,,,fee schedule,1635.03,7254.06,
Exc h-f-nk-sp mal+marg 0.5/<,11620,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,7254.06,APC 378
Exc h-f-nk-sp mal+marg 0.5/<,11620,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,7254.06,APC
Exc h-f-nk-sp mal+marg 0.5/<,11620,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,7254.06,APC
Exc h-f-nk-sp mal+marg 0.5/<,11620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,7254.06,APC
Exc h-f-nk-sp mal+marg 0.5/<,11620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,7254.06,Radiology
Exc h-f-nk-sp mal+marg 0.5/<,11620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,7254.06,APC
Exc h-f-nk-sp mal+marg 0.5/<,11620,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,7254.06,APC
Exc s/n/h/f/g mal+mrg 0.6-1,11621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6721.57,,,,,,,fee schedule,701.03,6721.57,
Exc s/n/h/f/g mal+mrg 0.6-1,11621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5387.93,,,,,,,fee schedule,701.03,6721.57,
Exc s/n/h/f/g mal+mrg 0.6-1,11621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5885.82,,,,,,,fee schedule,701.03,6721.57,
Exc s/n/h/f/g mal+mrg 0.6-1,11621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6188.11,,,,,,,fee schedule,701.03,6721.57,
Exc s/n/h/f/g mal+mrg 0.6-1,11621,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3110.22,,,,,,,fee schedule,701.03,6721.57,APC 378
Exc s/n/h/f/g mal+mrg 0.6-1,11621,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,736.08,,,,,,,fee schedule,701.03,6721.57,APC
Exc s/n/h/f/g mal+mrg 0.6-1,11621,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,729.07,,,,,,,fee schedule,701.03,6721.57,APC
Exc s/n/h/f/g mal+mrg 0.6-1,11621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,701.03,,,,,,,fee schedule,701.03,6721.57,APC
Exc s/n/h/f/g mal+mrg 0.6-1,11621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1072.57,,,,,,,fee schedule,701.03,6721.57,Radiology
Exc s/n/h/f/g mal+mrg 0.6-1,11621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,981.44,,,,,,,fee schedule,701.03,6721.57,APC
Exc s/n/h/f/g mal+mrg 0.6-1,11621,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1226.8,,,,,,,fee schedule,701.03,6721.57,APC
Exc s/n/h/f/g mal+mrg 1.1-2,11622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2167.57,,,,,,,fee schedule,701.03,3110.22,
Exc s/n/h/f/g mal+mrg 1.1-2,11622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1737.49,,,,,,,fee schedule,701.03,3110.22,
Exc s/n/h/f/g mal+mrg 1.1-2,11622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1898.05,,,,,,,fee schedule,701.03,3110.22,
Exc s/n/h/f/g mal+mrg 1.1-2,11622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1995.54,,,,,,,fee schedule,701.03,3110.22,
Exc s/n/h/f/g mal+mrg 1.1-2,11622,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3110.22,,,,,,,fee schedule,701.03,3110.22,APC 378
Exc s/n/h/f/g mal+mrg 1.1-2,11622,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,736.08,,,,,,,fee schedule,701.03,3110.22,APC
Exc s/n/h/f/g mal+mrg 1.1-2,11622,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,729.07,,,,,,,fee schedule,701.03,3110.22,APC
Exc s/n/h/f/g mal+mrg 1.1-2,11622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,701.03,,,,,,,fee schedule,701.03,3110.22,APC
Exc s/n/h/f/g mal+mrg 1.1-2,11622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1072.57,,,,,,,fee schedule,701.03,3110.22,Radiology
Exc s/n/h/f/g mal+mrg 1.1-2,11622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,981.44,,,,,,,fee schedule,701.03,3110.22,APC
Exc s/n/h/f/g mal+mrg 1.1-2,11622,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1226.8,,,,,,,fee schedule,701.03,3110.22,APC
Exc s/n/h/f/g mal+mrg 2.1-3,11623,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3009.7,,,,,,,fee schedule,1635.03,7254.06,
Exc s/n/h/f/g mal+mrg 2.1-3,11623,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2412.54,,,,,,,fee schedule,1635.03,7254.06,
Exc s/n/h/f/g mal+mrg 2.1-3,11623,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2635.48,,,,,,,fee schedule,1635.03,7254.06,
Exc s/n/h/f/g mal+mrg 2.1-3,11623,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2770.83,,,,,,,fee schedule,1635.03,7254.06,
Exc s/n/h/f/g mal+mrg 2.1-3,11623,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,7254.06,APC 378
Exc s/n/h/f/g mal+mrg 2.1-3,11623,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,7254.06,APC
Exc s/n/h/f/g mal+mrg 2.1-3,11623,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,7254.06,APC
Exc s/n/h/f/g mal+mrg 2.1-3,11623,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,7254.06,APC
Exc s/n/h/f/g mal+mrg 2.1-3,11623,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,7254.06,Radiology
Exc s/n/h/f/g mal+mrg 2.1-3,11623,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,7254.06,APC
Exc s/n/h/f/g mal+mrg 2.1-3,11623,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,7254.06,APC
Exc s/n/h/f/g mal+mrg 3.1-4,11624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4018.18,,,,,,,fee schedule,1635.03,7254.06,
Exc s/n/h/f/g mal+mrg 3.1-4,11624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3220.92,,,,,,,fee schedule,1635.03,7254.06,
Exc s/n/h/f/g mal+mrg 3.1-4,11624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3518.56,,,,,,,fee schedule,1635.03,7254.06,
Exc s/n/h/f/g mal+mrg 3.1-4,11624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3699.27,,,,,,,fee schedule,1635.03,7254.06,
Exc s/n/h/f/g mal+mrg 3.1-4,11624,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,7254.06,APC 378
Exc s/n/h/f/g mal+mrg 3.1-4,11624,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,7254.06,APC
Exc s/n/h/f/g mal+mrg 3.1-4,11624,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,7254.06,APC
Exc s/n/h/f/g mal+mrg 3.1-4,11624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,7254.06,APC
Exc s/n/h/f/g mal+mrg 3.1-4,11624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,7254.06,Radiology
Exc s/n/h/f/g mal+mrg 3.1-4,11624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,7254.06,APC
Exc s/n/h/f/g mal+mrg 3.1-4,11624,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,7254.06,APC
Exc s/n/h/f/g mal+mrg >4 cm,11626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3360.79,,,,,,,fee schedule,2693.96,12757.95,
Exc s/n/h/f/g mal+mrg >4 cm,11626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2693.96,,,,,,,fee schedule,2693.96,12757.95,
Exc s/n/h/f/g mal+mrg >4 cm,11626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2942.91,,,,,,,fee schedule,2693.96,12757.95,
Exc s/n/h/f/g mal+mrg >4 cm,11626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3094.06,,,,,,,fee schedule,2693.96,12757.95,
Exc s/n/h/f/g mal+mrg >4 cm,11626,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2693.96,12757.95,APC 378
Exc s/n/h/f/g mal+mrg >4 cm,11626,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2693.96,12757.95,APC
Exc s/n/h/f/g mal+mrg >4 cm,11626,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2693.96,12757.95,APC
Exc s/n/h/f/g mal+mrg >4 cm,11626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2693.96,12757.95,APC
Exc s/n/h/f/g mal+mrg >4 cm,11626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2693.96,12757.95,Radiology
Exc s/n/h/f/g mal+mrg >4 cm,11626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2693.96,12757.95,APC
Exc s/n/h/f/g mal+mrg >4 cm,11626,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2693.96,12757.95,APC
Exc f/e/e/n/l mal+mrg 0.5cm<,11640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1074.12,,,,,,,fee schedule,701.03,3110.22,
Exc f/e/e/n/l mal+mrg 0.5cm<,11640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,861,,,,,,,fee schedule,701.03,3110.22,
Exc f/e/e/n/l mal+mrg 0.5cm<,11640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,940.57,,,,,,,fee schedule,701.03,3110.22,
Exc f/e/e/n/l mal+mrg 0.5cm<,11640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,988.88,,,,,,,fee schedule,701.03,3110.22,
Exc f/e/e/n/l mal+mrg 0.5cm<,11640,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3110.22,,,,,,,fee schedule,701.03,3110.22,APC 378
Exc f/e/e/n/l mal+mrg 0.5cm<,11640,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,736.08,,,,,,,fee schedule,701.03,3110.22,APC
Exc f/e/e/n/l mal+mrg 0.5cm<,11640,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,729.07,,,,,,,fee schedule,701.03,3110.22,APC
Exc f/e/e/n/l mal+mrg 0.5cm<,11640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,701.03,,,,,,,fee schedule,701.03,3110.22,APC
Exc f/e/e/n/l mal+mrg 0.5cm<,11640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1072.57,,,,,,,fee schedule,701.03,3110.22,Radiology
Exc f/e/e/n/l mal+mrg 0.5cm<,11640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,981.44,,,,,,,fee schedule,701.03,3110.22,APC
Exc f/e/e/n/l mal+mrg 0.5cm<,11640,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1226.8,,,,,,,fee schedule,701.03,3110.22,APC
Exc f/e/e/n/l mal+mrg 0.6-1,11641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1074.12,,,,,,,fee schedule,701.03,3110.22,
Exc f/e/e/n/l mal+mrg 0.6-1,11641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,861,,,,,,,fee schedule,701.03,3110.22,
Exc f/e/e/n/l mal+mrg 0.6-1,11641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,940.57,,,,,,,fee schedule,701.03,3110.22,
Exc f/e/e/n/l mal+mrg 0.6-1,11641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,988.88,,,,,,,fee schedule,701.03,3110.22,
Exc f/e/e/n/l mal+mrg 0.6-1,11641,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3110.22,,,,,,,fee schedule,701.03,3110.22,APC 378
Exc f/e/e/n/l mal+mrg 0.6-1,11641,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,736.08,,,,,,,fee schedule,701.03,3110.22,APC
Exc f/e/e/n/l mal+mrg 0.6-1,11641,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,729.07,,,,,,,fee schedule,701.03,3110.22,APC
Exc f/e/e/n/l mal+mrg 0.6-1,11641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,701.03,,,,,,,fee schedule,701.03,3110.22,APC
Exc f/e/e/n/l mal+mrg 0.6-1,11641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1072.57,,,,,,,fee schedule,701.03,3110.22,Radiology
Exc f/e/e/n/l mal+mrg 0.6-1,11641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,981.44,,,,,,,fee schedule,701.03,3110.22,APC
Exc f/e/e/n/l mal+mrg 0.6-1,11641,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1226.8,,,,,,,fee schedule,701.03,3110.22,APC
Exc f/e/e/n/l mal+mrg 1.1-2,11642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5336.73,,,,,,,fee schedule,701.03,5336.73,
Exc f/e/e/n/l mal+mrg 1.1-2,11642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4277.86,,,,,,,fee schedule,701.03,5336.73,
Exc f/e/e/n/l mal+mrg 1.1-2,11642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4673.17,,,,,,,fee schedule,701.03,5336.73,
Exc f/e/e/n/l mal+mrg 1.1-2,11642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4913.18,,,,,,,fee schedule,701.03,5336.73,
Exc f/e/e/n/l mal+mrg 1.1-2,11642,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3110.22,,,,,,,fee schedule,701.03,5336.73,APC 378
Exc f/e/e/n/l mal+mrg 1.1-2,11642,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,736.08,,,,,,,fee schedule,701.03,5336.73,APC
Exc f/e/e/n/l mal+mrg 1.1-2,11642,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,729.07,,,,,,,fee schedule,701.03,5336.73,APC
Exc f/e/e/n/l mal+mrg 1.1-2,11642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,701.03,,,,,,,fee schedule,701.03,5336.73,APC
Exc f/e/e/n/l mal+mrg 1.1-2,11642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1072.57,,,,,,,fee schedule,701.03,5336.73,Radiology
Exc f/e/e/n/l mal+mrg 1.1-2,11642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,981.44,,,,,,,fee schedule,701.03,5336.73,APC
Exc f/e/e/n/l mal+mrg 1.1-2,11642,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1226.8,,,,,,,fee schedule,701.03,5336.73,APC
Exc f/e/e/n/l mal+mrg 2.1-3,11643,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1797.42,,,,,,,fee schedule,1440.79,7254.06,
Exc f/e/e/n/l mal+mrg 2.1-3,11643,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1440.79,,,,,,,fee schedule,1440.79,7254.06,
Exc f/e/e/n/l mal+mrg 2.1-3,11643,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1573.93,,,,,,,fee schedule,1440.79,7254.06,
Exc f/e/e/n/l mal+mrg 2.1-3,11643,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1654.77,,,,,,,fee schedule,1440.79,7254.06,
Exc f/e/e/n/l mal+mrg 2.1-3,11643,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1440.79,7254.06,APC 378
Exc f/e/e/n/l mal+mrg 2.1-3,11643,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1440.79,7254.06,APC
Exc f/e/e/n/l mal+mrg 2.1-3,11643,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1440.79,7254.06,APC
Exc f/e/e/n/l mal+mrg 2.1-3,11643,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1440.79,7254.06,APC
Exc f/e/e/n/l mal+mrg 2.1-3,11643,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1440.79,7254.06,Radiology
Exc f/e/e/n/l mal+mrg 2.1-3,11643,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1440.79,7254.06,APC
Exc f/e/e/n/l mal+mrg 2.1-3,11643,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1440.79,7254.06,APC
Exc f/e/e/n/l mal+mrg 3.1-4,11644,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4018.18,,,,,,,fee schedule,1635.03,7254.06,
Exc f/e/e/n/l mal+mrg 3.1-4,11644,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3220.92,,,,,,,fee schedule,1635.03,7254.06,
Exc f/e/e/n/l mal+mrg 3.1-4,11644,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3518.56,,,,,,,fee schedule,1635.03,7254.06,
Exc f/e/e/n/l mal+mrg 3.1-4,11644,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3699.27,,,,,,,fee schedule,1635.03,7254.06,
Exc f/e/e/n/l mal+mrg 3.1-4,11644,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,7254.06,APC 378
Exc f/e/e/n/l mal+mrg 3.1-4,11644,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,7254.06,APC
Exc f/e/e/n/l mal+mrg 3.1-4,11644,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,7254.06,APC
Exc f/e/e/n/l mal+mrg 3.1-4,11644,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,7254.06,APC
Exc f/e/e/n/l mal+mrg 3.1-4,11644,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,7254.06,Radiology
Exc f/e/e/n/l mal+mrg 3.1-4,11644,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,7254.06,APC
Exc f/e/e/n/l mal+mrg 3.1-4,11644,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,7254.06,APC
Exc f/e/e/n/l mal+mrg >4 cm,11646,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3307.78,,,,,,,fee schedule,2651.47,12757.95,
Exc f/e/e/n/l mal+mrg >4 cm,11646,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2651.47,,,,,,,fee schedule,2651.47,12757.95,
Exc f/e/e/n/l mal+mrg >4 cm,11646,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2896.49,,,,,,,fee schedule,2651.47,12757.95,
Exc f/e/e/n/l mal+mrg >4 cm,11646,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3045.26,,,,,,,fee schedule,2651.47,12757.95,
Exc f/e/e/n/l mal+mrg >4 cm,11646,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2651.47,12757.95,APC 378
Exc f/e/e/n/l mal+mrg >4 cm,11646,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2651.47,12757.95,APC
Exc f/e/e/n/l mal+mrg >4 cm,11646,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2651.47,12757.95,APC
Exc f/e/e/n/l mal+mrg >4 cm,11646,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2651.47,12757.95,APC
Exc f/e/e/n/l mal+mrg >4 cm,11646,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2651.47,12757.95,Radiology
Exc f/e/e/n/l mal+mrg >4 cm,11646,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2651.47,12757.95,APC
Exc f/e/e/n/l mal+mrg >4 cm,11646,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2651.47,12757.95,APC
Trim nail(s) any number,11719,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,197.92,,,,,,,fee schedule,58.4,259.1,
Trim nail(s) any number,11719,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,158.65,,,,,,,fee schedule,58.4,259.1,
Trim nail(s) any number,11719,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,173.31,,,,,,,fee schedule,58.4,259.1,
Trim nail(s) any number,11719,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,182.21,,,,,,,fee schedule,58.4,259.1,
Trim nail(s) any number,11719,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,58.4,259.1,APC 378
Trim nail(s) any number,11719,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,58.4,259.1,APC
Trim nail(s) any number,11719,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,58.4,259.1,APC
Trim nail(s) any number,11719,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,58.4,259.1,APC
Trim nail(s) any number,11719,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,58.4,259.1,Radiology
Trim nail(s) any number,11719,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,58.4,259.1,APC
Trim nail(s) any number,11719,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,58.4,259.1,APC
Debride nail 1-5,11720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,197.92,,,,,,,fee schedule,58.4,259.1,
Debride nail 1-5,11720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,158.65,,,,,,,fee schedule,58.4,259.1,
Debride nail 1-5,11720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,173.31,,,,,,,fee schedule,58.4,259.1,
Debride nail 1-5,11720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,182.21,,,,,,,fee schedule,58.4,259.1,
Debride nail 1-5,11720,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,58.4,259.1,APC 378
Debride nail 1-5,11720,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,58.4,259.1,APC
Debride nail 1-5,11720,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,58.4,259.1,APC
Debride nail 1-5,11720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,58.4,259.1,APC
Debride nail 1-5,11720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,58.4,259.1,Radiology
Debride nail 1-5,11720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,58.4,259.1,APC
Debride nail 1-5,11720,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,58.4,259.1,APC
Debride nail 6 or more,11721,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,197.92,,,,,,,fee schedule,58.4,259.1,
Debride nail 6 or more,11721,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,158.65,,,,,,,fee schedule,58.4,259.1,
Debride nail 6 or more,11721,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,173.31,,,,,,,fee schedule,58.4,259.1,
Debride nail 6 or more,11721,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,182.21,,,,,,,fee schedule,58.4,259.1,
Debride nail 6 or more,11721,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,58.4,259.1,APC 378
Debride nail 6 or more,11721,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,58.4,259.1,APC
Debride nail 6 or more,11721,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,58.4,259.1,APC
Debride nail 6 or more,11721,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,58.4,259.1,APC
Debride nail 6 or more,11721,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,58.4,259.1,Radiology
Debride nail 6 or more,11721,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,58.4,259.1,APC
Debride nail 6 or more,11721,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,58.4,259.1,APC
Removal of nail plate,11730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,589.8,,,,,,,fee schedule,198.62,881.22,
Removal of nail plate,11730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,472.78,,,,,,,fee schedule,198.62,881.22,
Removal of nail plate,11730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,516.47,,,,,,,fee schedule,198.62,881.22,
Removal of nail plate,11730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,542.99,,,,,,,fee schedule,198.62,881.22,
Removal of nail plate,11730,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,881.22,,,,,,,fee schedule,198.62,881.22,APC 378
Removal of nail plate,11730,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.55,,,,,,,fee schedule,198.62,881.22,APC
Removal of nail plate,11730,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,206.57,,,,,,,fee schedule,198.62,881.22,APC
Removal of nail plate,11730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.62,,,,,,,fee schedule,198.62,881.22,APC
Removal of nail plate,11730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.89,,,,,,,fee schedule,198.62,881.22,Radiology
Removal of nail plate,11730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,278.07,,,,,,,fee schedule,198.62,881.22,APC
Removal of nail plate,11730,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,347.59,,,,,,,fee schedule,198.62,881.22,APC
Remove nail plate add-on,11732,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,973.72,,,,,,,fee schedule,780.52,973.72,
Remove nail plate add-on,11732,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,780.52,,,,,,,fee schedule,780.52,973.72,
Remove nail plate add-on,11732,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,852.65,,,,,,,fee schedule,780.52,973.72,
Remove nail plate add-on,11732,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,896.44,,,,,,,fee schedule,780.52,973.72,
Drain blood from under nail,11740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,105.11,,,,,,,fee schedule,84.25,584.37,
Drain blood from under nail,11740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,84.25,,,,,,,fee schedule,84.25,584.37,
Drain blood from under nail,11740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,92.04,,,,,,,fee schedule,84.25,584.37,
Drain blood from under nail,11740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,96.77,,,,,,,fee schedule,84.25,584.37,
Drain blood from under nail,11740,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,84.25,584.37,APC 378
Drain blood from under nail,11740,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,84.25,584.37,APC
Drain blood from under nail,11740,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,84.25,584.37,APC
Drain blood from under nail,11740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,84.25,584.37,APC
Drain blood from under nail,11740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,84.25,584.37,Radiology
Drain blood from under nail,11740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,84.25,584.37,APC
Drain blood from under nail,11740,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,84.25,584.37,APC
Removal of nail bed,11750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4787.48,,,,,,,fee schedule,402.44,4787.48,
Removal of nail bed,11750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3837.58,,,,,,,fee schedule,402.44,4787.48,
Removal of nail bed,11750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4192.21,,,,,,,fee schedule,402.44,4787.48,
Removal of nail bed,11750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4407.52,,,,,,,fee schedule,402.44,4787.48,
Removal of nail bed,11750,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1785.48,,,,,,,fee schedule,402.44,4787.48,APC 378
Removal of nail bed,11750,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,422.56,,,,,,,fee schedule,402.44,4787.48,APC
Removal of nail bed,11750,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,418.53,,,,,,,fee schedule,402.44,4787.48,APC
Removal of nail bed,11750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,402.44,,,,,,,fee schedule,402.44,4787.48,APC
Removal of nail bed,11750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,615.73,,,,,,,fee schedule,402.44,4787.48,Radiology
Removal of nail bed,11750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,563.41,,,,,,,fee schedule,402.44,4787.48,APC
Removal of nail bed,11750,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,704.26,,,,,,,fee schedule,402.44,4787.48,APC
Biopsy nail unit,11755,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1074.12,,,,,,,fee schedule,701.03,3110.22,
Biopsy nail unit,11755,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,861,,,,,,,fee schedule,701.03,3110.22,
Biopsy nail unit,11755,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,940.57,,,,,,,fee schedule,701.03,3110.22,
Biopsy nail unit,11755,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,988.88,,,,,,,fee schedule,701.03,3110.22,
Biopsy nail unit,11755,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3110.22,,,,,,,fee schedule,701.03,3110.22,APC 378
Biopsy nail unit,11755,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,736.08,,,,,,,fee schedule,701.03,3110.22,APC
Biopsy nail unit,11755,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,729.07,,,,,,,fee schedule,701.03,3110.22,APC
Biopsy nail unit,11755,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,701.03,,,,,,,fee schedule,701.03,3110.22,APC
Biopsy nail unit,11755,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1072.57,,,,,,,fee schedule,701.03,3110.22,Radiology
Biopsy nail unit,11755,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,981.44,,,,,,,fee schedule,701.03,3110.22,APC
Biopsy nail unit,11755,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1226.8,,,,,,,fee schedule,701.03,3110.22,APC
Repair of nail bed,11760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,330.5,,,,,,,fee schedule,264.92,3246.12,
Repair of nail bed,11760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,264.92,,,,,,,fee schedule,264.92,3246.12,
Repair of nail bed,11760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,289.4,,,,,,,fee schedule,264.92,3246.12,
Repair of nail bed,11760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,304.27,,,,,,,fee schedule,264.92,3246.12,
Repair of nail bed,11760,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3246.12,,,,,,,fee schedule,264.92,3246.12,APC 378
Repair of nail bed,11760,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,768.24,,,,,,,fee schedule,264.92,3246.12,APC
Repair of nail bed,11760,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,760.92,,,,,,,fee schedule,264.92,3246.12,APC
Repair of nail bed,11760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,731.66,,,,,,,fee schedule,264.92,3246.12,APC
Repair of nail bed,11760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1119.44,,,,,,,fee schedule,264.92,3246.12,Radiology
Repair of nail bed,11760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1024.32,,,,,,,fee schedule,264.92,3246.12,APC
Repair of nail bed,11760,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1280.4,,,,,,,fee schedule,264.92,3246.12,APC
Reconstruction of nail bed,11762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3755.05,,,,,,,fee schedule,2042.58,9062.24,
Reconstruction of nail bed,11762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3010,,,,,,,fee schedule,2042.58,9062.24,
Reconstruction of nail bed,11762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3288.15,,,,,,,fee schedule,2042.58,9062.24,
Reconstruction of nail bed,11762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3457.03,,,,,,,fee schedule,2042.58,9062.24,
Reconstruction of nail bed,11762,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,2042.58,9062.24,APC 378
Reconstruction of nail bed,11762,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,2042.58,9062.24,APC
Reconstruction of nail bed,11762,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,2042.58,9062.24,APC
Reconstruction of nail bed,11762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,2042.58,9062.24,APC
Reconstruction of nail bed,11762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,2042.58,9062.24,Radiology
Reconstruction of nail bed,11762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,2042.58,9062.24,APC
Reconstruction of nail bed,11762,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,2042.58,9062.24,APC
Excision of nail fold toe,11765,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,364.24,,,,,,,fee schedule,291.97,1785.48,
Excision of nail fold toe,11765,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,291.97,,,,,,,fee schedule,291.97,1785.48,
Excision of nail fold toe,11765,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,318.95,,,,,,,fee schedule,291.97,1785.48,
Excision of nail fold toe,11765,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,335.33,,,,,,,fee schedule,291.97,1785.48,
Excision of nail fold toe,11765,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1785.48,,,,,,,fee schedule,291.97,1785.48,APC 378
Excision of nail fold toe,11765,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,422.56,,,,,,,fee schedule,291.97,1785.48,APC
Excision of nail fold toe,11765,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,418.53,,,,,,,fee schedule,291.97,1785.48,APC
Excision of nail fold toe,11765,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,402.44,,,,,,,fee schedule,291.97,1785.48,APC
Excision of nail fold toe,11765,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,615.73,,,,,,,fee schedule,291.97,1785.48,Radiology
Excision of nail fold toe,11765,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,563.41,,,,,,,fee schedule,291.97,1785.48,APC
Excision of nail fold toe,11765,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,704.26,,,,,,,fee schedule,291.97,1785.48,APC
Remove pilonidal cyst simple,11770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7423.74,,,,,,,fee schedule,2875.57,12757.95,
Remove pilonidal cyst simple,11770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5950.78,,,,,,,fee schedule,2875.57,12757.95,
Remove pilonidal cyst simple,11770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6500.69,,,,,,,fee schedule,2875.57,12757.95,
Remove pilonidal cyst simple,11770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6834.56,,,,,,,fee schedule,2875.57,12757.95,
Remove pilonidal cyst simple,11770,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Remove pilonidal cyst simple,11770,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Remove pilonidal cyst simple,11770,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Remove pilonidal cyst simple,11770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Remove pilonidal cyst simple,11770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Remove pilonidal cyst simple,11770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Remove pilonidal cyst simple,11770,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Remove pilonidal cyst exten,11771,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7096.06,,,,,,,fee schedule,2875.57,12757.95,
Remove pilonidal cyst exten,11771,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5688.11,,,,,,,fee schedule,2875.57,12757.95,
Remove pilonidal cyst exten,11771,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6213.75,,,,,,,fee schedule,2875.57,12757.95,
Remove pilonidal cyst exten,11771,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6532.88,,,,,,,fee schedule,2875.57,12757.95,
Remove pilonidal cyst exten,11771,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Remove pilonidal cyst exten,11771,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Remove pilonidal cyst exten,11771,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Remove pilonidal cyst exten,11771,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Remove pilonidal cyst exten,11771,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Remove pilonidal cyst exten,11771,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Remove pilonidal cyst exten,11771,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Remove pilonidal cyst compl,11772,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7189.69,,,,,,,fee schedule,2875.57,12757.95,
Remove pilonidal cyst compl,11772,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5763.16,,,,,,,fee schedule,2875.57,12757.95,
Remove pilonidal cyst compl,11772,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6295.73,,,,,,,fee schedule,2875.57,12757.95,
Remove pilonidal cyst compl,11772,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6619.08,,,,,,,fee schedule,2875.57,12757.95,
Remove pilonidal cyst compl,11772,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Remove pilonidal cyst compl,11772,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Remove pilonidal cyst compl,11772,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Remove pilonidal cyst compl,11772,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Remove pilonidal cyst compl,11772,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Remove pilonidal cyst compl,11772,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Remove pilonidal cyst compl,11772,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Inject skin lesions <=w 7,11900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,197.92,,,,,,,fee schedule,158.65,881.22,
Inject skin lesions <=w 7,11900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,158.65,,,,,,,fee schedule,158.65,881.22,
Inject skin lesions <=w 7,11900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,173.31,,,,,,,fee schedule,158.65,881.22,
Inject skin lesions <=w 7,11900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,182.21,,,,,,,fee schedule,158.65,881.22,
Inject skin lesions <=w 7,11900,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,881.22,,,,,,,fee schedule,158.65,881.22,APC 378
Inject skin lesions <=w 7,11900,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.55,,,,,,,fee schedule,158.65,881.22,APC
Inject skin lesions <=w 7,11900,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,206.57,,,,,,,fee schedule,158.65,881.22,APC
Inject skin lesions <=w 7,11900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.62,,,,,,,fee schedule,158.65,881.22,APC
Inject skin lesions <=w 7,11900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.89,,,,,,,fee schedule,158.65,881.22,Radiology
Inject skin lesions <=w 7,11900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,278.07,,,,,,,fee schedule,158.65,881.22,APC
Inject skin lesions <=w 7,11900,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,347.59,,,,,,,fee schedule,158.65,881.22,APC
Inject skin lesions >7,11901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,197.92,,,,,,,fee schedule,158.65,881.22,
Inject skin lesions >7,11901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,158.65,,,,,,,fee schedule,158.65,881.22,
Inject skin lesions >7,11901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,173.31,,,,,,,fee schedule,158.65,881.22,
Inject skin lesions >7,11901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,182.21,,,,,,,fee schedule,158.65,881.22,
Inject skin lesions >7,11901,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,881.22,,,,,,,fee schedule,158.65,881.22,APC 378
Inject skin lesions >7,11901,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.55,,,,,,,fee schedule,158.65,881.22,APC
Inject skin lesions >7,11901,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,206.57,,,,,,,fee schedule,158.65,881.22,APC
Inject skin lesions >7,11901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.62,,,,,,,fee schedule,158.65,881.22,APC
Inject skin lesions >7,11901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.89,,,,,,,fee schedule,158.65,881.22,Radiology
Inject skin lesions >7,11901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,278.07,,,,,,,fee schedule,158.65,881.22,APC
Inject skin lesions >7,11901,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,347.59,,,,,,,fee schedule,158.65,881.22,APC
Correct skin color 6.0 cm/<,11920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,525.38,,,,,,,fee schedule,421.14,3246.12,
Correct skin color 6.0 cm/<,11920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,421.14,,,,,,,fee schedule,421.14,3246.12,
Correct skin color 6.0 cm/<,11920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,460.06,,,,,,,fee schedule,421.14,3246.12,
Correct skin color 6.0 cm/<,11920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,483.69,,,,,,,fee schedule,421.14,3246.12,
Correct skin color 6.0 cm/<,11920,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3246.12,,,,,,,fee schedule,421.14,3246.12,APC 378
Correct skin color 6.0 cm/<,11920,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,768.24,,,,,,,fee schedule,421.14,3246.12,APC
Correct skin color 6.0 cm/<,11920,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,760.92,,,,,,,fee schedule,421.14,3246.12,APC
Correct skin color 6.0 cm/<,11920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,731.66,,,,,,,fee schedule,421.14,3246.12,APC
Correct skin color 6.0 cm/<,11920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1119.44,,,,,,,fee schedule,421.14,3246.12,Radiology
Correct skin color 6.0 cm/<,11920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1024.32,,,,,,,fee schedule,421.14,3246.12,APC
Correct skin color 6.0 cm/<,11920,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1280.4,,,,,,,fee schedule,421.14,3246.12,APC
Correct skn color 6.1-20.0cm,11921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,525.38,,,,,,,fee schedule,421.14,3246.12,
Correct skn color 6.1-20.0cm,11921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,421.14,,,,,,,fee schedule,421.14,3246.12,
Correct skn color 6.1-20.0cm,11921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,460.06,,,,,,,fee schedule,421.14,3246.12,
Correct skn color 6.1-20.0cm,11921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,483.69,,,,,,,fee schedule,421.14,3246.12,
Correct skn color 6.1-20.0cm,11921,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3246.12,,,,,,,fee schedule,421.14,3246.12,APC 378
Correct skn color 6.1-20.0cm,11921,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,768.24,,,,,,,fee schedule,421.14,3246.12,APC
Correct skn color 6.1-20.0cm,11921,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,760.92,,,,,,,fee schedule,421.14,3246.12,APC
Correct skn color 6.1-20.0cm,11921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,731.66,,,,,,,fee schedule,421.14,3246.12,APC
Correct skn color 6.1-20.0cm,11921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1119.44,,,,,,,fee schedule,421.14,3246.12,Radiology
Correct skn color 6.1-20.0cm,11921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1024.32,,,,,,,fee schedule,421.14,3246.12,APC
Correct skn color 6.1-20.0cm,11921,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1280.4,,,,,,,fee schedule,421.14,3246.12,APC
Correct skin color ea 20.0cm,11922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,525.38,,,,,,,fee schedule,421.14,525.38,
Correct skin color ea 20.0cm,11922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,421.14,,,,,,,fee schedule,421.14,525.38,
Correct skin color ea 20.0cm,11922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,460.06,,,,,,,fee schedule,421.14,525.38,
Correct skin color ea 20.0cm,11922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,483.69,,,,,,,fee schedule,421.14,525.38,
Tx contour defects 1 cc/<,11950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,319.26,,,,,,,fee schedule,198.62,881.22,
Tx contour defects 1 cc/<,11950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,255.91,,,,,,,fee schedule,198.62,881.22,
Tx contour defects 1 cc/<,11950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,279.56,,,,,,,fee schedule,198.62,881.22,
Tx contour defects 1 cc/<,11950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,293.92,,,,,,,fee schedule,198.62,881.22,
Tx contour defects 1 cc/<,11950,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,881.22,,,,,,,fee schedule,198.62,881.22,APC 378
Tx contour defects 1 cc/<,11950,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.55,,,,,,,fee schedule,198.62,881.22,APC
Tx contour defects 1 cc/<,11950,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,206.57,,,,,,,fee schedule,198.62,881.22,APC
Tx contour defects 1 cc/<,11950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.62,,,,,,,fee schedule,198.62,881.22,APC
Tx contour defects 1 cc/<,11950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.89,,,,,,,fee schedule,198.62,881.22,Radiology
Tx contour defects 1 cc/<,11950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,278.07,,,,,,,fee schedule,198.62,881.22,APC
Tx contour defects 1 cc/<,11950,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,347.59,,,,,,,fee schedule,198.62,881.22,APC
Tx contour defects 1.1-5.0cc,11951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,319.26,,,,,,,fee schedule,255.91,3246.12,
Tx contour defects 1.1-5.0cc,11951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,255.91,,,,,,,fee schedule,255.91,3246.12,
Tx contour defects 1.1-5.0cc,11951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,279.56,,,,,,,fee schedule,255.91,3246.12,
Tx contour defects 1.1-5.0cc,11951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,293.92,,,,,,,fee schedule,255.91,3246.12,
Tx contour defects 1.1-5.0cc,11951,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3246.12,,,,,,,fee schedule,255.91,3246.12,APC 378
Tx contour defects 1.1-5.0cc,11951,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,768.24,,,,,,,fee schedule,255.91,3246.12,APC
Tx contour defects 1.1-5.0cc,11951,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,760.92,,,,,,,fee schedule,255.91,3246.12,APC
Tx contour defects 1.1-5.0cc,11951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,731.66,,,,,,,fee schedule,255.91,3246.12,APC
Tx contour defects 1.1-5.0cc,11951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1119.44,,,,,,,fee schedule,255.91,3246.12,Radiology
Tx contour defects 1.1-5.0cc,11951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1024.32,,,,,,,fee schedule,255.91,3246.12,APC
Tx contour defects 1.1-5.0cc,11951,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1280.4,,,,,,,fee schedule,255.91,3246.12,APC
Tx contour defects 5.1-10cc,11952,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,319.26,,,,,,,fee schedule,255.91,3246.12,
Tx contour defects 5.1-10cc,11952,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,255.91,,,,,,,fee schedule,255.91,3246.12,
Tx contour defects 5.1-10cc,11952,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,279.56,,,,,,,fee schedule,255.91,3246.12,
Tx contour defects 5.1-10cc,11952,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,293.92,,,,,,,fee schedule,255.91,3246.12,
Tx contour defects 5.1-10cc,11952,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3246.12,,,,,,,fee schedule,255.91,3246.12,APC 378
Tx contour defects 5.1-10cc,11952,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,768.24,,,,,,,fee schedule,255.91,3246.12,APC
Tx contour defects 5.1-10cc,11952,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,760.92,,,,,,,fee schedule,255.91,3246.12,APC
Tx contour defects 5.1-10cc,11952,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,731.66,,,,,,,fee schedule,255.91,3246.12,APC
Tx contour defects 5.1-10cc,11952,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1119.44,,,,,,,fee schedule,255.91,3246.12,Radiology
Tx contour defects 5.1-10cc,11952,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1024.32,,,,,,,fee schedule,255.91,3246.12,APC
Tx contour defects 5.1-10cc,11952,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1280.4,,,,,,,fee schedule,255.91,3246.12,APC
Tx contour defects >10.0 cc,11954,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,319.26,,,,,,,fee schedule,255.91,3246.12,
Tx contour defects >10.0 cc,11954,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,255.91,,,,,,,fee schedule,255.91,3246.12,
Tx contour defects >10.0 cc,11954,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,279.56,,,,,,,fee schedule,255.91,3246.12,
Tx contour defects >10.0 cc,11954,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,293.92,,,,,,,fee schedule,255.91,3246.12,
Tx contour defects >10.0 cc,11954,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3246.12,,,,,,,fee schedule,255.91,3246.12,APC 378
Tx contour defects >10.0 cc,11954,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,768.24,,,,,,,fee schedule,255.91,3246.12,APC
Tx contour defects >10.0 cc,11954,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,760.92,,,,,,,fee schedule,255.91,3246.12,APC
Tx contour defects >10.0 cc,11954,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,731.66,,,,,,,fee schedule,255.91,3246.12,APC
Tx contour defects >10.0 cc,11954,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1119.44,,,,,,,fee schedule,255.91,3246.12,Radiology
Tx contour defects >10.0 cc,11954,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1024.32,,,,,,,fee schedule,255.91,3246.12,APC
Tx contour defects >10.0 cc,11954,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1280.4,,,,,,,fee schedule,255.91,3246.12,APC
Insert tissue expander(s),11960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5043.16,,,,,,,fee schedule,3508.17,15564.58,
Insert tissue expander(s),11960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4042.54,,,,,,,fee schedule,3508.17,15564.58,
Insert tissue expander(s),11960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4416.1,,,,,,,fee schedule,3508.17,15564.58,
Insert tissue expander(s),11960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4642.91,,,,,,,fee schedule,3508.17,15564.58,
Insert tissue expander(s),11960,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15564.58,,,,,,,fee schedule,3508.17,15564.58,APC 378
Insert tissue expander(s),11960,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3683.58,,,,,,,fee schedule,3508.17,15564.58,APC
Insert tissue expander(s),11960,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3648.5,,,,,,,fee schedule,3508.17,15564.58,APC
Insert tissue expander(s),11960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3508.17,,,,,,,fee schedule,3508.17,15564.58,APC
Insert tissue expander(s),11960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5367.5,,,,,,,fee schedule,3508.17,15564.58,Radiology
Insert tissue expander(s),11960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4911.44,,,,,,,fee schedule,3508.17,15564.58,APC
Insert tissue expander(s),11960,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6139.3,,,,,,,fee schedule,3508.17,15564.58,APC
Replace tissue expander,11970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6119.45,,,,,,,fee schedule,4905.27,31870.39,
Replace tissue expander,11970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4905.27,,,,,,,fee schedule,4905.27,31870.39,
Replace tissue expander,11970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5358.57,,,,,,,fee schedule,4905.27,31870.39,
Replace tissue expander,11970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5633.78,,,,,,,fee schedule,4905.27,31870.39,
Replace tissue expander,11970,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,4905.27,31870.39,APC 378
Replace tissue expander,11970,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,4905.27,31870.39,APC
Replace tissue expander,11970,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,4905.27,31870.39,APC
Replace tissue expander,11970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,4905.27,31870.39,APC
Replace tissue expander,11970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,4905.27,31870.39,Radiology
Replace tissue expander,11970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,4905.27,31870.39,APC
Replace tissue expander,11970,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,4905.27,31870.39,APC
Remove tissue expander(s),11971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3424.81,,,,,,,fee schedule,2745.28,12757.95,
Remove tissue expander(s),11971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2745.28,,,,,,,fee schedule,2745.28,12757.95,
Remove tissue expander(s),11971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2998.97,,,,,,,fee schedule,2745.28,12757.95,
Remove tissue expander(s),11971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3153,,,,,,,fee schedule,2745.28,12757.95,
Remove tissue expander(s),11971,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2745.28,12757.95,APC 378
Remove tissue expander(s),11971,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2745.28,12757.95,APC
Remove tissue expander(s),11971,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2745.28,12757.95,APC
Remove tissue expander(s),11971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2745.28,12757.95,APC
Remove tissue expander(s),11971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2745.28,12757.95,Radiology
Remove tissue expander(s),11971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2745.28,12757.95,APC
Remove tissue expander(s),11971,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2745.28,12757.95,APC
Remove contraceptive capsule,11976,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1074.12,,,,,,,fee schedule,701.03,3110.22,
Remove contraceptive capsule,11976,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,861,,,,,,,fee schedule,701.03,3110.22,
Remove contraceptive capsule,11976,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,940.57,,,,,,,fee schedule,701.03,3110.22,
Remove contraceptive capsule,11976,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,988.88,,,,,,,fee schedule,701.03,3110.22,
Remove contraceptive capsule,11976,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3110.22,,,,,,,fee schedule,701.03,3110.22,APC 378
Remove contraceptive capsule,11976,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,736.08,,,,,,,fee schedule,701.03,3110.22,APC
Remove contraceptive capsule,11976,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,729.07,,,,,,,fee schedule,701.03,3110.22,APC
Remove contraceptive capsule,11976,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,701.03,,,,,,,fee schedule,701.03,3110.22,APC
Remove contraceptive capsule,11976,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1072.57,,,,,,,fee schedule,701.03,3110.22,Radiology
Remove contraceptive capsule,11976,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,981.44,,,,,,,fee schedule,701.03,3110.22,APC
Remove contraceptive capsule,11976,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1226.8,,,,,,,fee schedule,701.03,3110.22,APC
Implant hormone pellet(s),11980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,157.47,,,,,,,fee schedule,126.23,1962.08,
Implant hormone pellet(s),11980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,126.23,,,,,,,fee schedule,126.23,1962.08,
Implant hormone pellet(s),11980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,137.89,,,,,,,fee schedule,126.23,1962.08,
Implant hormone pellet(s),11980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,144.98,,,,,,,fee schedule,126.23,1962.08,
Implant hormone pellet(s),11980,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1962.08,,,,,,,fee schedule,126.23,1962.08,APC 378
Implant hormone pellet(s),11980,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,464.35,,,,,,,fee schedule,126.23,1962.08,APC
Implant hormone pellet(s),11980,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,459.93,,,,,,,fee schedule,126.23,1962.08,APC
Implant hormone pellet(s),11980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,442.24,,,,,,,fee schedule,126.23,1962.08,APC
Implant hormone pellet(s),11980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,676.63,,,,,,,fee schedule,126.23,1962.08,Radiology
Implant hormone pellet(s),11980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,619.14,,,,,,,fee schedule,126.23,1962.08,APC
Implant hormone pellet(s),11980,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,773.92,,,,,,,fee schedule,126.23,1962.08,APC
Insert drug implant device,11981,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,157.47,,,,,,,fee schedule,126.23,584.37,
Insert drug implant device,11981,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,126.23,,,,,,,fee schedule,126.23,584.37,
Insert drug implant device,11981,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,137.89,,,,,,,fee schedule,126.23,584.37,
Insert drug implant device,11981,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,144.98,,,,,,,fee schedule,126.23,584.37,
Insert drug implant device,11981,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,126.23,584.37,APC 378
Insert drug implant device,11981,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,126.23,584.37,APC
Insert drug implant device,11981,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,126.23,584.37,APC
Insert drug implant device,11981,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,126.23,584.37,APC
Insert drug implant device,11981,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,126.23,584.37,Radiology
Insert drug implant device,11981,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,126.23,584.37,APC
Insert drug implant device,11981,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,126.23,584.37,APC
Remove drug implant device,11982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3360.79,,,,,,,fee schedule,442.24,3360.79,
Remove drug implant device,11982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2693.96,,,,,,,fee schedule,442.24,3360.79,
Remove drug implant device,11982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2942.91,,,,,,,fee schedule,442.24,3360.79,
Remove drug implant device,11982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3094.06,,,,,,,fee schedule,442.24,3360.79,
Remove drug implant device,11982,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1962.08,,,,,,,fee schedule,442.24,3360.79,APC 378
Remove drug implant device,11982,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,464.35,,,,,,,fee schedule,442.24,3360.79,APC
Remove drug implant device,11982,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,459.93,,,,,,,fee schedule,442.24,3360.79,APC
Remove drug implant device,11982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,442.24,,,,,,,fee schedule,442.24,3360.79,APC
Remove drug implant device,11982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,676.63,,,,,,,fee schedule,442.24,3360.79,Radiology
Remove drug implant device,11982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,619.14,,,,,,,fee schedule,442.24,3360.79,APC
Remove drug implant device,11982,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,773.92,,,,,,,fee schedule,442.24,3360.79,APC
Remove/insert drug implant,11983,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,157.47,,,,,,,fee schedule,126.23,1962.08,
Remove/insert drug implant,11983,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,126.23,,,,,,,fee schedule,126.23,1962.08,
Remove/insert drug implant,11983,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,137.89,,,,,,,fee schedule,126.23,1962.08,
Remove/insert drug implant,11983,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,144.98,,,,,,,fee schedule,126.23,1962.08,
Remove/insert drug implant,11983,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1962.08,,,,,,,fee schedule,126.23,1962.08,APC 378
Remove/insert drug implant,11983,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,464.35,,,,,,,fee schedule,126.23,1962.08,APC
Remove/insert drug implant,11983,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,459.93,,,,,,,fee schedule,126.23,1962.08,APC
Remove/insert drug implant,11983,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,442.24,,,,,,,fee schedule,126.23,1962.08,APC
Remove/insert drug implant,11983,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,676.63,,,,,,,fee schedule,126.23,1962.08,Radiology
Remove/insert drug implant,11983,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,619.14,,,,,,,fee schedule,126.23,1962.08,APC
Remove/insert drug implant,11983,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,773.92,,,,,,,fee schedule,126.23,1962.08,APC
Rpr s/n/ax/gen/trnk 2.5cm/<,12001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,453.89,,,,,,,fee schedule,198.62,881.22,
Rpr s/n/ax/gen/trnk 2.5cm/<,12001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,363.83,,,,,,,fee schedule,198.62,881.22,
Rpr s/n/ax/gen/trnk 2.5cm/<,12001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,397.45,,,,,,,fee schedule,198.62,881.22,
Rpr s/n/ax/gen/trnk 2.5cm/<,12001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,417.87,,,,,,,fee schedule,198.62,881.22,
Rpr s/n/ax/gen/trnk 2.5cm/<,12001,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,881.22,,,,,,,fee schedule,198.62,881.22,APC 378
Rpr s/n/ax/gen/trnk 2.5cm/<,12001,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.55,,,,,,,fee schedule,198.62,881.22,APC
Rpr s/n/ax/gen/trnk 2.5cm/<,12001,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,206.57,,,,,,,fee schedule,198.62,881.22,APC
Rpr s/n/ax/gen/trnk 2.5cm/<,12001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.62,,,,,,,fee schedule,198.62,881.22,APC
Rpr s/n/ax/gen/trnk 2.5cm/<,12001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.89,,,,,,,fee schedule,198.62,881.22,Radiology
Rpr s/n/ax/gen/trnk 2.5cm/<,12001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,278.07,,,,,,,fee schedule,198.62,881.22,APC
Rpr s/n/ax/gen/trnk 2.5cm/<,12001,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,347.59,,,,,,,fee schedule,198.62,881.22,APC
Rpr s/n/ax/gen/trnk2.6-7.5cm,12002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,443.82,,,,,,,fee schedule,198.62,881.22,
Rpr s/n/ax/gen/trnk2.6-7.5cm,12002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,355.76,,,,,,,fee schedule,198.62,881.22,
Rpr s/n/ax/gen/trnk2.6-7.5cm,12002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,388.64,,,,,,,fee schedule,198.62,881.22,
Rpr s/n/ax/gen/trnk2.6-7.5cm,12002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,408.6,,,,,,,fee schedule,198.62,881.22,
Rpr s/n/ax/gen/trnk2.6-7.5cm,12002,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,881.22,,,,,,,fee schedule,198.62,881.22,APC 378
Rpr s/n/ax/gen/trnk2.6-7.5cm,12002,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.55,,,,,,,fee schedule,198.62,881.22,APC
Rpr s/n/ax/gen/trnk2.6-7.5cm,12002,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,206.57,,,,,,,fee schedule,198.62,881.22,APC
Rpr s/n/ax/gen/trnk2.6-7.5cm,12002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.62,,,,,,,fee schedule,198.62,881.22,APC
Rpr s/n/ax/gen/trnk2.6-7.5cm,12002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.89,,,,,,,fee schedule,198.62,881.22,Radiology
Rpr s/n/ax/gen/trnk2.6-7.5cm,12002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,278.07,,,,,,,fee schedule,198.62,881.22,APC
Rpr s/n/ax/gen/trnk2.6-7.5cm,12002,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,347.59,,,,,,,fee schedule,198.62,881.22,APC
Rpr s/n/ax/gen/trk7.6-12.5cm,12004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,499.08,,,,,,,fee schedule,198.62,881.22,
Rpr s/n/ax/gen/trk7.6-12.5cm,12004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,400.05,,,,,,,fee schedule,198.62,881.22,
Rpr s/n/ax/gen/trk7.6-12.5cm,12004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,437.02,,,,,,,fee schedule,198.62,881.22,
Rpr s/n/ax/gen/trk7.6-12.5cm,12004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,459.47,,,,,,,fee schedule,198.62,881.22,
Rpr s/n/ax/gen/trk7.6-12.5cm,12004,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,881.22,,,,,,,fee schedule,198.62,881.22,APC 378
Rpr s/n/ax/gen/trk7.6-12.5cm,12004,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.55,,,,,,,fee schedule,198.62,881.22,APC
Rpr s/n/ax/gen/trk7.6-12.5cm,12004,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,206.57,,,,,,,fee schedule,198.62,881.22,APC
Rpr s/n/ax/gen/trk7.6-12.5cm,12004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.62,,,,,,,fee schedule,198.62,881.22,APC
Rpr s/n/ax/gen/trk7.6-12.5cm,12004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.89,,,,,,,fee schedule,198.62,881.22,Radiology
Rpr s/n/ax/gen/trk7.6-12.5cm,12004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,278.07,,,,,,,fee schedule,198.62,881.22,APC
Rpr s/n/ax/gen/trk7.6-12.5cm,12004,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,347.59,,,,,,,fee schedule,198.62,881.22,APC
Rpr s/n/a/gen/trk12.6-20.0cm,12005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,489.79,,,,,,,fee schedule,392.61,1785.48,
Rpr s/n/a/gen/trk12.6-20.0cm,12005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,392.61,,,,,,,fee schedule,392.61,1785.48,
Rpr s/n/a/gen/trk12.6-20.0cm,12005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,428.89,,,,,,,fee schedule,392.61,1785.48,
Rpr s/n/a/gen/trk12.6-20.0cm,12005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,450.92,,,,,,,fee schedule,392.61,1785.48,
Rpr s/n/a/gen/trk12.6-20.0cm,12005,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1785.48,,,,,,,fee schedule,392.61,1785.48,APC 378
Rpr s/n/a/gen/trk12.6-20.0cm,12005,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,422.56,,,,,,,fee schedule,392.61,1785.48,APC
Rpr s/n/a/gen/trk12.6-20.0cm,12005,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,418.53,,,,,,,fee schedule,392.61,1785.48,APC
Rpr s/n/a/gen/trk12.6-20.0cm,12005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,402.44,,,,,,,fee schedule,392.61,1785.48,APC
Rpr s/n/a/gen/trk12.6-20.0cm,12005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,615.73,,,,,,,fee schedule,392.61,1785.48,Radiology
Rpr s/n/a/gen/trk12.6-20.0cm,12005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,563.41,,,,,,,fee schedule,392.61,1785.48,APC
Rpr s/n/a/gen/trk12.6-20.0cm,12005,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,704.26,,,,,,,fee schedule,392.61,1785.48,APC
Rpr s/n/a/gen/trk20.1-30.0cm,12006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,932.98,,,,,,,fee schedule,402.44,1785.48,
Rpr s/n/a/gen/trk20.1-30.0cm,12006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,747.86,,,,,,,fee schedule,402.44,1785.48,
Rpr s/n/a/gen/trk20.1-30.0cm,12006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,816.97,,,,,,,fee schedule,402.44,1785.48,
Rpr s/n/a/gen/trk20.1-30.0cm,12006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,858.93,,,,,,,fee schedule,402.44,1785.48,
Rpr s/n/a/gen/trk20.1-30.0cm,12006,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1785.48,,,,,,,fee schedule,402.44,1785.48,APC 378
Rpr s/n/a/gen/trk20.1-30.0cm,12006,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,422.56,,,,,,,fee schedule,402.44,1785.48,APC
Rpr s/n/a/gen/trk20.1-30.0cm,12006,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,418.53,,,,,,,fee schedule,402.44,1785.48,APC
Rpr s/n/a/gen/trk20.1-30.0cm,12006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,402.44,,,,,,,fee schedule,402.44,1785.48,APC
Rpr s/n/a/gen/trk20.1-30.0cm,12006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,615.73,,,,,,,fee schedule,402.44,1785.48,Radiology
Rpr s/n/a/gen/trk20.1-30.0cm,12006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,563.41,,,,,,,fee schedule,402.44,1785.48,APC
Rpr s/n/a/gen/trk20.1-30.0cm,12006,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,704.26,,,,,,,fee schedule,402.44,1785.48,APC
Rpr s/n/ax/gen/trnk >30.0 cm,12007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,589.48,,,,,,,fee schedule,198.62,881.22,
Rpr s/n/ax/gen/trnk >30.0 cm,12007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,472.52,,,,,,,fee schedule,198.62,881.22,
Rpr s/n/ax/gen/trnk >30.0 cm,12007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,516.18,,,,,,,fee schedule,198.62,881.22,
Rpr s/n/ax/gen/trnk >30.0 cm,12007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,542.69,,,,,,,fee schedule,198.62,881.22,
Rpr s/n/ax/gen/trnk >30.0 cm,12007,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,881.22,,,,,,,fee schedule,198.62,881.22,APC 378
Rpr s/n/ax/gen/trnk >30.0 cm,12007,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.55,,,,,,,fee schedule,198.62,881.22,APC
Rpr s/n/ax/gen/trnk >30.0 cm,12007,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,206.57,,,,,,,fee schedule,198.62,881.22,APC
Rpr s/n/ax/gen/trnk >30.0 cm,12007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.62,,,,,,,fee schedule,198.62,881.22,APC
Rpr s/n/ax/gen/trnk >30.0 cm,12007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.89,,,,,,,fee schedule,198.62,881.22,Radiology
Rpr s/n/ax/gen/trnk >30.0 cm,12007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,278.07,,,,,,,fee schedule,198.62,881.22,APC
Rpr s/n/ax/gen/trnk >30.0 cm,12007,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,347.59,,,,,,,fee schedule,198.62,881.22,APC
Rpr f/e/e/n/l/m 2.5 cm/<,12011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,407.32,,,,,,,fee schedule,198.62,881.22,
Rpr f/e/e/n/l/m 2.5 cm/<,12011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,326.5,,,,,,,fee schedule,198.62,881.22,
Rpr f/e/e/n/l/m 2.5 cm/<,12011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,356.67,,,,,,,fee schedule,198.62,881.22,
Rpr f/e/e/n/l/m 2.5 cm/<,12011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,374.99,,,,,,,fee schedule,198.62,881.22,
Rpr f/e/e/n/l/m 2.5 cm/<,12011,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,881.22,,,,,,,fee schedule,198.62,881.22,APC 378
Rpr f/e/e/n/l/m 2.5 cm/<,12011,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.55,,,,,,,fee schedule,198.62,881.22,APC
Rpr f/e/e/n/l/m 2.5 cm/<,12011,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,206.57,,,,,,,fee schedule,198.62,881.22,APC
Rpr f/e/e/n/l/m 2.5 cm/<,12011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.62,,,,,,,fee schedule,198.62,881.22,APC
Rpr f/e/e/n/l/m 2.5 cm/<,12011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.89,,,,,,,fee schedule,198.62,881.22,Radiology
Rpr f/e/e/n/l/m 2.5 cm/<,12011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,278.07,,,,,,,fee schedule,198.62,881.22,APC
Rpr f/e/e/n/l/m 2.5 cm/<,12011,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,347.59,,,,,,,fee schedule,198.62,881.22,APC
Rpr f/e/e/n/l/m 2.6-5.0 cm,12013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,405.63,,,,,,,fee schedule,198.62,881.22,
Rpr f/e/e/n/l/m 2.6-5.0 cm,12013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,325.15,,,,,,,fee schedule,198.62,881.22,
Rpr f/e/e/n/l/m 2.6-5.0 cm,12013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,355.19,,,,,,,fee schedule,198.62,881.22,
Rpr f/e/e/n/l/m 2.6-5.0 cm,12013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,373.43,,,,,,,fee schedule,198.62,881.22,
Rpr f/e/e/n/l/m 2.6-5.0 cm,12013,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,881.22,,,,,,,fee schedule,198.62,881.22,APC 378
Rpr f/e/e/n/l/m 2.6-5.0 cm,12013,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.55,,,,,,,fee schedule,198.62,881.22,APC
Rpr f/e/e/n/l/m 2.6-5.0 cm,12013,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,206.57,,,,,,,fee schedule,198.62,881.22,APC
Rpr f/e/e/n/l/m 2.6-5.0 cm,12013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.62,,,,,,,fee schedule,198.62,881.22,APC
Rpr f/e/e/n/l/m 2.6-5.0 cm,12013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.89,,,,,,,fee schedule,198.62,881.22,Radiology
Rpr f/e/e/n/l/m 2.6-5.0 cm,12013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,278.07,,,,,,,fee schedule,198.62,881.22,APC
Rpr f/e/e/n/l/m 2.6-5.0 cm,12013,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,347.59,,,,,,,fee schedule,198.62,881.22,APC
Rpr f/e/e/n/l/m 5.1-7.5 cm,12014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.35,,,,,,,fee schedule,198.62,881.22,
Rpr f/e/e/n/l/m 5.1-7.5 cm,12014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,325.73,,,,,,,fee schedule,198.62,881.22,
Rpr f/e/e/n/l/m 5.1-7.5 cm,12014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,355.83,,,,,,,fee schedule,198.62,881.22,
Rpr f/e/e/n/l/m 5.1-7.5 cm,12014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,374.1,,,,,,,fee schedule,198.62,881.22,
Rpr f/e/e/n/l/m 5.1-7.5 cm,12014,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,881.22,,,,,,,fee schedule,198.62,881.22,APC 378
Rpr f/e/e/n/l/m 5.1-7.5 cm,12014,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.55,,,,,,,fee schedule,198.62,881.22,APC
Rpr f/e/e/n/l/m 5.1-7.5 cm,12014,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,206.57,,,,,,,fee schedule,198.62,881.22,APC
Rpr f/e/e/n/l/m 5.1-7.5 cm,12014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.62,,,,,,,fee schedule,198.62,881.22,APC
Rpr f/e/e/n/l/m 5.1-7.5 cm,12014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.89,,,,,,,fee schedule,198.62,881.22,Radiology
Rpr f/e/e/n/l/m 5.1-7.5 cm,12014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,278.07,,,,,,,fee schedule,198.62,881.22,APC
Rpr f/e/e/n/l/m 5.1-7.5 cm,12014,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,347.59,,,,,,,fee schedule,198.62,881.22,APC
Rpr f/e/e/n/l/m 7.6-12.5 cm,12015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,449.69,,,,,,,fee schedule,198.62,881.22,
Rpr f/e/e/n/l/m 7.6-12.5 cm,12015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,360.47,,,,,,,fee schedule,198.62,881.22,
Rpr f/e/e/n/l/m 7.6-12.5 cm,12015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,393.78,,,,,,,fee schedule,198.62,881.22,
Rpr f/e/e/n/l/m 7.6-12.5 cm,12015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,414,,,,,,,fee schedule,198.62,881.22,
Rpr f/e/e/n/l/m 7.6-12.5 cm,12015,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,881.22,,,,,,,fee schedule,198.62,881.22,APC 378
Rpr f/e/e/n/l/m 7.6-12.5 cm,12015,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.55,,,,,,,fee schedule,198.62,881.22,APC
Rpr f/e/e/n/l/m 7.6-12.5 cm,12015,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,206.57,,,,,,,fee schedule,198.62,881.22,APC
Rpr f/e/e/n/l/m 7.6-12.5 cm,12015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.62,,,,,,,fee schedule,198.62,881.22,APC
Rpr f/e/e/n/l/m 7.6-12.5 cm,12015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.89,,,,,,,fee schedule,198.62,881.22,Radiology
Rpr f/e/e/n/l/m 7.6-12.5 cm,12015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,278.07,,,,,,,fee schedule,198.62,881.22,APC
Rpr f/e/e/n/l/m 7.6-12.5 cm,12015,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,347.59,,,,,,,fee schedule,198.62,881.22,APC
Rpr fe/e/en/l/m 12.6-20.0 cm,12016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,469.2,,,,,,,fee schedule,376.1,1785.48,
Rpr fe/e/en/l/m 12.6-20.0 cm,12016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,376.1,,,,,,,fee schedule,376.1,1785.48,
Rpr fe/e/en/l/m 12.6-20.0 cm,12016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,410.86,,,,,,,fee schedule,376.1,1785.48,
Rpr fe/e/en/l/m 12.6-20.0 cm,12016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,431.96,,,,,,,fee schedule,376.1,1785.48,
Rpr fe/e/en/l/m 12.6-20.0 cm,12016,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1785.48,,,,,,,fee schedule,376.1,1785.48,APC 378
Rpr fe/e/en/l/m 12.6-20.0 cm,12016,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,422.56,,,,,,,fee schedule,376.1,1785.48,APC
Rpr fe/e/en/l/m 12.6-20.0 cm,12016,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,418.53,,,,,,,fee schedule,376.1,1785.48,APC
Rpr fe/e/en/l/m 12.6-20.0 cm,12016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,402.44,,,,,,,fee schedule,376.1,1785.48,APC
Rpr fe/e/en/l/m 12.6-20.0 cm,12016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,615.73,,,,,,,fee schedule,376.1,1785.48,Radiology
Rpr fe/e/en/l/m 12.6-20.0 cm,12016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,563.41,,,,,,,fee schedule,376.1,1785.48,APC
Rpr fe/e/en/l/m 12.6-20.0 cm,12016,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,704.26,,,,,,,fee schedule,376.1,1785.48,APC
Rpr fe/e/en/l/m 20.1-30.0 cm,12017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,319.26,,,,,,,fee schedule,255.91,1785.48,
Rpr fe/e/en/l/m 20.1-30.0 cm,12017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,255.91,,,,,,,fee schedule,255.91,1785.48,
Rpr fe/e/en/l/m 20.1-30.0 cm,12017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,279.56,,,,,,,fee schedule,255.91,1785.48,
Rpr fe/e/en/l/m 20.1-30.0 cm,12017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,293.92,,,,,,,fee schedule,255.91,1785.48,
Rpr fe/e/en/l/m 20.1-30.0 cm,12017,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1785.48,,,,,,,fee schedule,255.91,1785.48,APC 378
Rpr fe/e/en/l/m 20.1-30.0 cm,12017,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,422.56,,,,,,,fee schedule,255.91,1785.48,APC
Rpr fe/e/en/l/m 20.1-30.0 cm,12017,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,418.53,,,,,,,fee schedule,255.91,1785.48,APC
Rpr fe/e/en/l/m 20.1-30.0 cm,12017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,402.44,,,,,,,fee schedule,255.91,1785.48,APC
Rpr fe/e/en/l/m 20.1-30.0 cm,12017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,615.73,,,,,,,fee schedule,255.91,1785.48,Radiology
Rpr fe/e/en/l/m 20.1-30.0 cm,12017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,563.41,,,,,,,fee schedule,255.91,1785.48,APC
Rpr fe/e/en/l/m 20.1-30.0 cm,12017,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,704.26,,,,,,,fee schedule,255.91,1785.48,APC
Rpr f/e/e/n/l/m >30.0 cm,12018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,319.26,,,,,,,fee schedule,198.62,881.22,
Rpr f/e/e/n/l/m >30.0 cm,12018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,255.91,,,,,,,fee schedule,198.62,881.22,
Rpr f/e/e/n/l/m >30.0 cm,12018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,279.56,,,,,,,fee schedule,198.62,881.22,
Rpr f/e/e/n/l/m >30.0 cm,12018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,293.92,,,,,,,fee schedule,198.62,881.22,
Rpr f/e/e/n/l/m >30.0 cm,12018,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,881.22,,,,,,,fee schedule,198.62,881.22,APC 378
Rpr f/e/e/n/l/m >30.0 cm,12018,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.55,,,,,,,fee schedule,198.62,881.22,APC
Rpr f/e/e/n/l/m >30.0 cm,12018,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,206.57,,,,,,,fee schedule,198.62,881.22,APC
Rpr f/e/e/n/l/m >30.0 cm,12018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.62,,,,,,,fee schedule,198.62,881.22,APC
Rpr f/e/e/n/l/m >30.0 cm,12018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.89,,,,,,,fee schedule,198.62,881.22,Radiology
Rpr f/e/e/n/l/m >30.0 cm,12018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,278.07,,,,,,,fee schedule,198.62,881.22,APC
Rpr f/e/e/n/l/m >30.0 cm,12018,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,347.59,,,,,,,fee schedule,198.62,881.22,APC
Closure of split wound,12020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4116.6,,,,,,,fee schedule,731.66,4116.6,
Closure of split wound,12020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3299.81,,,,,,,fee schedule,731.66,4116.6,
Closure of split wound,12020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3604.74,,,,,,,fee schedule,731.66,4116.6,
Closure of split wound,12020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3789.88,,,,,,,fee schedule,731.66,4116.6,
Closure of split wound,12020,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3246.12,,,,,,,fee schedule,731.66,4116.6,APC 378
Closure of split wound,12020,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,768.24,,,,,,,fee schedule,731.66,4116.6,APC
Closure of split wound,12020,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,760.92,,,,,,,fee schedule,731.66,4116.6,APC
Closure of split wound,12020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,731.66,,,,,,,fee schedule,731.66,4116.6,APC
Closure of split wound,12020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1119.44,,,,,,,fee schedule,731.66,4116.6,Radiology
Closure of split wound,12020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1024.32,,,,,,,fee schedule,731.66,4116.6,APC
Closure of split wound,12020,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1280.4,,,,,,,fee schedule,731.66,4116.6,APC
Closure of split wound,12021,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1129.65,,,,,,,fee schedule,402.44,1785.48,
Closure of split wound,12021,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,905.52,,,,,,,fee schedule,402.44,1785.48,
Closure of split wound,12021,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,989.19,,,,,,,fee schedule,402.44,1785.48,
Closure of split wound,12021,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1040,,,,,,,fee schedule,402.44,1785.48,
Closure of split wound,12021,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1785.48,,,,,,,fee schedule,402.44,1785.48,APC 378
Closure of split wound,12021,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,422.56,,,,,,,fee schedule,402.44,1785.48,APC
Closure of split wound,12021,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,418.53,,,,,,,fee schedule,402.44,1785.48,APC
Closure of split wound,12021,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,402.44,,,,,,,fee schedule,402.44,1785.48,APC
Closure of split wound,12021,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,615.73,,,,,,,fee schedule,402.44,1785.48,Radiology
Closure of split wound,12021,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,563.41,,,,,,,fee schedule,402.44,1785.48,APC
Closure of split wound,12021,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,704.26,,,,,,,fee schedule,402.44,1785.48,APC
Intmd rpr s/a/t/ext 2.5 cm/<,12031,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,929.64,,,,,,,fee schedule,402.44,1785.48,
Intmd rpr s/a/t/ext 2.5 cm/<,12031,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,745.19,,,,,,,fee schedule,402.44,1785.48,
Intmd rpr s/a/t/ext 2.5 cm/<,12031,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,814.05,,,,,,,fee schedule,402.44,1785.48,
Intmd rpr s/a/t/ext 2.5 cm/<,12031,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,855.86,,,,,,,fee schedule,402.44,1785.48,
Intmd rpr s/a/t/ext 2.5 cm/<,12031,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1785.48,,,,,,,fee schedule,402.44,1785.48,APC 378
Intmd rpr s/a/t/ext 2.5 cm/<,12031,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,422.56,,,,,,,fee schedule,402.44,1785.48,APC
Intmd rpr s/a/t/ext 2.5 cm/<,12031,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,418.53,,,,,,,fee schedule,402.44,1785.48,APC
Intmd rpr s/a/t/ext 2.5 cm/<,12031,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,402.44,,,,,,,fee schedule,402.44,1785.48,APC
Intmd rpr s/a/t/ext 2.5 cm/<,12031,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,615.73,,,,,,,fee schedule,402.44,1785.48,Radiology
Intmd rpr s/a/t/ext 2.5 cm/<,12031,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,563.41,,,,,,,fee schedule,402.44,1785.48,APC
Intmd rpr s/a/t/ext 2.5 cm/<,12031,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,704.26,,,,,,,fee schedule,402.44,1785.48,APC
Intmd rpr s/a/t/ext 2.6-7.5,12032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1091.29,,,,,,,fee schedule,402.44,1785.48,
Intmd rpr s/a/t/ext 2.6-7.5,12032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,874.77,,,,,,,fee schedule,402.44,1785.48,
Intmd rpr s/a/t/ext 2.6-7.5,12032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,955.6,,,,,,,fee schedule,402.44,1785.48,
Intmd rpr s/a/t/ext 2.6-7.5,12032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1004.68,,,,,,,fee schedule,402.44,1785.48,
Intmd rpr s/a/t/ext 2.6-7.5,12032,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1785.48,,,,,,,fee schedule,402.44,1785.48,APC 378
Intmd rpr s/a/t/ext 2.6-7.5,12032,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,422.56,,,,,,,fee schedule,402.44,1785.48,APC
Intmd rpr s/a/t/ext 2.6-7.5,12032,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,418.53,,,,,,,fee schedule,402.44,1785.48,APC
Intmd rpr s/a/t/ext 2.6-7.5,12032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,402.44,,,,,,,fee schedule,402.44,1785.48,APC
Intmd rpr s/a/t/ext 2.6-7.5,12032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,615.73,,,,,,,fee schedule,402.44,1785.48,Radiology
Intmd rpr s/a/t/ext 2.6-7.5,12032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,563.41,,,,,,,fee schedule,402.44,1785.48,APC
Intmd rpr s/a/t/ext 2.6-7.5,12032,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,704.26,,,,,,,fee schedule,402.44,1785.48,APC
Intmd rpr s/tr/ext 7.6-12.5,12034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2281.74,,,,,,,fee schedule,402.44,2281.74,
Intmd rpr s/tr/ext 7.6-12.5,12034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1829.01,,,,,,,fee schedule,402.44,2281.74,
Intmd rpr s/tr/ext 7.6-12.5,12034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1998.03,,,,,,,fee schedule,402.44,2281.74,
Intmd rpr s/tr/ext 7.6-12.5,12034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2100.65,,,,,,,fee schedule,402.44,2281.74,
Intmd rpr s/tr/ext 7.6-12.5,12034,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1785.48,,,,,,,fee schedule,402.44,2281.74,APC 378
Intmd rpr s/tr/ext 7.6-12.5,12034,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,422.56,,,,,,,fee schedule,402.44,2281.74,APC
Intmd rpr s/tr/ext 7.6-12.5,12034,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,418.53,,,,,,,fee schedule,402.44,2281.74,APC
Intmd rpr s/tr/ext 7.6-12.5,12034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,402.44,,,,,,,fee schedule,402.44,2281.74,APC
Intmd rpr s/tr/ext 7.6-12.5,12034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,615.73,,,,,,,fee schedule,402.44,2281.74,Radiology
Intmd rpr s/tr/ext 7.6-12.5,12034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,563.41,,,,,,,fee schedule,402.44,2281.74,APC
Intmd rpr s/tr/ext 7.6-12.5,12034,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,704.26,,,,,,,fee schedule,402.44,2281.74,APC
Intmd rpr s/a/t/ext 12.6-20,12035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,519.04,,,,,,,fee schedule,402.44,1785.48,
Intmd rpr s/a/t/ext 12.6-20,12035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,416.06,,,,,,,fee schedule,402.44,1785.48,
Intmd rpr s/a/t/ext 12.6-20,12035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,454.51,,,,,,,fee schedule,402.44,1785.48,
Intmd rpr s/a/t/ext 12.6-20,12035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,477.85,,,,,,,fee schedule,402.44,1785.48,
Intmd rpr s/a/t/ext 12.6-20,12035,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1785.48,,,,,,,fee schedule,402.44,1785.48,APC 378
Intmd rpr s/a/t/ext 12.6-20,12035,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,422.56,,,,,,,fee schedule,402.44,1785.48,APC
Intmd rpr s/a/t/ext 12.6-20,12035,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,418.53,,,,,,,fee schedule,402.44,1785.48,APC
Intmd rpr s/a/t/ext 12.6-20,12035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,402.44,,,,,,,fee schedule,402.44,1785.48,APC
Intmd rpr s/a/t/ext 12.6-20,12035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,615.73,,,,,,,fee schedule,402.44,1785.48,Radiology
Intmd rpr s/a/t/ext 12.6-20,12035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,563.41,,,,,,,fee schedule,402.44,1785.48,APC
Intmd rpr s/a/t/ext 12.6-20,12035,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,704.26,,,,,,,fee schedule,402.44,1785.48,APC
Intmd rpr s/a/t/ext 20.1-30,12036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,539.63,,,,,,,fee schedule,432.56,3246.12,
Intmd rpr s/a/t/ext 20.1-30,12036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,432.56,,,,,,,fee schedule,432.56,3246.12,
Intmd rpr s/a/t/ext 20.1-30,12036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,472.54,,,,,,,fee schedule,432.56,3246.12,
Intmd rpr s/a/t/ext 20.1-30,12036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,496.8,,,,,,,fee schedule,432.56,3246.12,
Intmd rpr s/a/t/ext 20.1-30,12036,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3246.12,,,,,,,fee schedule,432.56,3246.12,APC 378
Intmd rpr s/a/t/ext 20.1-30,12036,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,768.24,,,,,,,fee schedule,432.56,3246.12,APC
Intmd rpr s/a/t/ext 20.1-30,12036,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,760.92,,,,,,,fee schedule,432.56,3246.12,APC
Intmd rpr s/a/t/ext 20.1-30,12036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,731.66,,,,,,,fee schedule,432.56,3246.12,APC
Intmd rpr s/a/t/ext 20.1-30,12036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1119.44,,,,,,,fee schedule,432.56,3246.12,Radiology
Intmd rpr s/a/t/ext 20.1-30,12036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1024.32,,,,,,,fee schedule,432.56,3246.12,APC
Intmd rpr s/a/t/ext 20.1-30,12036,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1280.4,,,,,,,fee schedule,432.56,3246.12,APC
Intmd rpr s/tr/ext >30.0 cm,12037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4999.19,,,,,,,fee schedule,2042.58,9062.24,
Intmd rpr s/tr/ext >30.0 cm,12037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4007.29,,,,,,,fee schedule,2042.58,9062.24,
Intmd rpr s/tr/ext >30.0 cm,12037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4377.6,,,,,,,fee schedule,2042.58,9062.24,
Intmd rpr s/tr/ext >30.0 cm,12037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4602.43,,,,,,,fee schedule,2042.58,9062.24,
Intmd rpr s/tr/ext >30.0 cm,12037,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,2042.58,9062.24,APC 378
Intmd rpr s/tr/ext >30.0 cm,12037,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,2042.58,9062.24,APC
Intmd rpr s/tr/ext >30.0 cm,12037,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,2042.58,9062.24,APC
Intmd rpr s/tr/ext >30.0 cm,12037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,2042.58,9062.24,APC
Intmd rpr s/tr/ext >30.0 cm,12037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,2042.58,9062.24,Radiology
Intmd rpr s/tr/ext >30.0 cm,12037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,2042.58,9062.24,APC
Intmd rpr s/tr/ext >30.0 cm,12037,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,2042.58,9062.24,APC
Intmd rpr n-hf/genit 2.5cm/<,12041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2011.43,,,,,,,fee schedule,402.44,2011.43,
Intmd rpr n-hf/genit 2.5cm/<,12041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1612.34,,,,,,,fee schedule,402.44,2011.43,
Intmd rpr n-hf/genit 2.5cm/<,12041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1761.33,,,,,,,fee schedule,402.44,2011.43,
Intmd rpr n-hf/genit 2.5cm/<,12041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1851.8,,,,,,,fee schedule,402.44,2011.43,
Intmd rpr n-hf/genit 2.5cm/<,12041,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1785.48,,,,,,,fee schedule,402.44,2011.43,APC 378
Intmd rpr n-hf/genit 2.5cm/<,12041,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,422.56,,,,,,,fee schedule,402.44,2011.43,APC
Intmd rpr n-hf/genit 2.5cm/<,12041,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,418.53,,,,,,,fee schedule,402.44,2011.43,APC
Intmd rpr n-hf/genit 2.5cm/<,12041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,402.44,,,,,,,fee schedule,402.44,2011.43,APC
Intmd rpr n-hf/genit 2.5cm/<,12041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,615.73,,,,,,,fee schedule,402.44,2011.43,Radiology
Intmd rpr n-hf/genit 2.5cm/<,12041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,563.41,,,,,,,fee schedule,402.44,2011.43,APC
Intmd rpr n-hf/genit 2.5cm/<,12041,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,704.26,,,,,,,fee schedule,402.44,2011.43,APC
Intmd rpr n-hf/genit2.6-7.5,12042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1417.44,,,,,,,fee schedule,402.44,1785.48,
Intmd rpr n-hf/genit2.6-7.5,12042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1136.2,,,,,,,fee schedule,402.44,1785.48,
Intmd rpr n-hf/genit2.6-7.5,12042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1241.2,,,,,,,fee schedule,402.44,1785.48,
Intmd rpr n-hf/genit2.6-7.5,12042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1304.94,,,,,,,fee schedule,402.44,1785.48,
Intmd rpr n-hf/genit2.6-7.5,12042,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1785.48,,,,,,,fee schedule,402.44,1785.48,APC 378
Intmd rpr n-hf/genit2.6-7.5,12042,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,422.56,,,,,,,fee schedule,402.44,1785.48,APC
Intmd rpr n-hf/genit2.6-7.5,12042,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,418.53,,,,,,,fee schedule,402.44,1785.48,APC
Intmd rpr n-hf/genit2.6-7.5,12042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,402.44,,,,,,,fee schedule,402.44,1785.48,APC
Intmd rpr n-hf/genit2.6-7.5,12042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,615.73,,,,,,,fee schedule,402.44,1785.48,Radiology
Intmd rpr n-hf/genit2.6-7.5,12042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,563.41,,,,,,,fee schedule,402.44,1785.48,APC
Intmd rpr n-hf/genit2.6-7.5,12042,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,704.26,,,,,,,fee schedule,402.44,1785.48,APC
Intmd rpr n-hf/genit7.6-12.5,12044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3828.9,,,,,,,fee schedule,731.66,3828.9,
Intmd rpr n-hf/genit7.6-12.5,12044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3069.2,,,,,,,fee schedule,731.66,3828.9,
Intmd rpr n-hf/genit7.6-12.5,12044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3352.82,,,,,,,fee schedule,731.66,3828.9,
Intmd rpr n-hf/genit7.6-12.5,12044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3525.02,,,,,,,fee schedule,731.66,3828.9,
Intmd rpr n-hf/genit7.6-12.5,12044,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3246.12,,,,,,,fee schedule,731.66,3828.9,APC 378
Intmd rpr n-hf/genit7.6-12.5,12044,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,768.24,,,,,,,fee schedule,731.66,3828.9,APC
Intmd rpr n-hf/genit7.6-12.5,12044,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,760.92,,,,,,,fee schedule,731.66,3828.9,APC
Intmd rpr n-hf/genit7.6-12.5,12044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,731.66,,,,,,,fee schedule,731.66,3828.9,APC
Intmd rpr n-hf/genit7.6-12.5,12044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1119.44,,,,,,,fee schedule,731.66,3828.9,Radiology
Intmd rpr n-hf/genit7.6-12.5,12044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1024.32,,,,,,,fee schedule,731.66,3828.9,APC
Intmd rpr n-hf/genit7.6-12.5,12044,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1280.4,,,,,,,fee schedule,731.66,3828.9,APC
Intmd rpr n-hf/genit12.6-20,12045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2086.47,,,,,,,fee schedule,731.66,3246.12,
Intmd rpr n-hf/genit12.6-20,12045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1672.49,,,,,,,fee schedule,731.66,3246.12,
Intmd rpr n-hf/genit12.6-20,12045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1827.04,,,,,,,fee schedule,731.66,3246.12,
Intmd rpr n-hf/genit12.6-20,12045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1920.88,,,,,,,fee schedule,731.66,3246.12,
Intmd rpr n-hf/genit12.6-20,12045,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3246.12,,,,,,,fee schedule,731.66,3246.12,APC 378
Intmd rpr n-hf/genit12.6-20,12045,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,768.24,,,,,,,fee schedule,731.66,3246.12,APC
Intmd rpr n-hf/genit12.6-20,12045,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,760.92,,,,,,,fee schedule,731.66,3246.12,APC
Intmd rpr n-hf/genit12.6-20,12045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,731.66,,,,,,,fee schedule,731.66,3246.12,APC
Intmd rpr n-hf/genit12.6-20,12045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1119.44,,,,,,,fee schedule,731.66,3246.12,Radiology
Intmd rpr n-hf/genit12.6-20,12045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1024.32,,,,,,,fee schedule,731.66,3246.12,APC
Intmd rpr n-hf/genit12.6-20,12045,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1280.4,,,,,,,fee schedule,731.66,3246.12,APC
Intmd rpr n-hf/genit20.1-30,12046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,525.38,,,,,,,fee schedule,421.14,3246.12,
Intmd rpr n-hf/genit20.1-30,12046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,421.14,,,,,,,fee schedule,421.14,3246.12,
Intmd rpr n-hf/genit20.1-30,12046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,460.06,,,,,,,fee schedule,421.14,3246.12,
Intmd rpr n-hf/genit20.1-30,12046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,483.69,,,,,,,fee schedule,421.14,3246.12,
Intmd rpr n-hf/genit20.1-30,12046,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3246.12,,,,,,,fee schedule,421.14,3246.12,APC 378
Intmd rpr n-hf/genit20.1-30,12046,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,768.24,,,,,,,fee schedule,421.14,3246.12,APC
Intmd rpr n-hf/genit20.1-30,12046,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,760.92,,,,,,,fee schedule,421.14,3246.12,APC
Intmd rpr n-hf/genit20.1-30,12046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,731.66,,,,,,,fee schedule,421.14,3246.12,APC
Intmd rpr n-hf/genit20.1-30,12046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1119.44,,,,,,,fee schedule,421.14,3246.12,Radiology
Intmd rpr n-hf/genit20.1-30,12046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1024.32,,,,,,,fee schedule,421.14,3246.12,APC
Intmd rpr n-hf/genit20.1-30,12046,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1280.4,,,,,,,fee schedule,421.14,3246.12,APC
Intmd rpr n-hf/genit >30.0cm,12047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,525.38,,,,,,,fee schedule,421.14,9062.24,
Intmd rpr n-hf/genit >30.0cm,12047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,421.14,,,,,,,fee schedule,421.14,9062.24,
Intmd rpr n-hf/genit >30.0cm,12047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,460.06,,,,,,,fee schedule,421.14,9062.24,
Intmd rpr n-hf/genit >30.0cm,12047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,483.69,,,,,,,fee schedule,421.14,9062.24,
Intmd rpr n-hf/genit >30.0cm,12047,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,421.14,9062.24,APC 378
Intmd rpr n-hf/genit >30.0cm,12047,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,421.14,9062.24,APC
Intmd rpr n-hf/genit >30.0cm,12047,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,421.14,9062.24,APC
Intmd rpr n-hf/genit >30.0cm,12047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,421.14,9062.24,APC
Intmd rpr n-hf/genit >30.0cm,12047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,421.14,9062.24,Radiology
Intmd rpr n-hf/genit >30.0cm,12047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,421.14,9062.24,APC
Intmd rpr n-hf/genit >30.0cm,12047,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,421.14,9062.24,APC
Intmd rpr face/mm 2.5 cm/<,12051,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2406.85,,,,,,,fee schedule,402.44,2406.85,
Intmd rpr face/mm 2.5 cm/<,12051,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1929.3,,,,,,,fee schedule,402.44,2406.85,
Intmd rpr face/mm 2.5 cm/<,12051,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2107.59,,,,,,,fee schedule,402.44,2406.85,
Intmd rpr face/mm 2.5 cm/<,12051,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2215.83,,,,,,,fee schedule,402.44,2406.85,
Intmd rpr face/mm 2.5 cm/<,12051,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1785.48,,,,,,,fee schedule,402.44,2406.85,APC 378
Intmd rpr face/mm 2.5 cm/<,12051,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,422.56,,,,,,,fee schedule,402.44,2406.85,APC
Intmd rpr face/mm 2.5 cm/<,12051,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,418.53,,,,,,,fee schedule,402.44,2406.85,APC
Intmd rpr face/mm 2.5 cm/<,12051,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,402.44,,,,,,,fee schedule,402.44,2406.85,APC
Intmd rpr face/mm 2.5 cm/<,12051,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,615.73,,,,,,,fee schedule,402.44,2406.85,Radiology
Intmd rpr face/mm 2.5 cm/<,12051,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,563.41,,,,,,,fee schedule,402.44,2406.85,APC
Intmd rpr face/mm 2.5 cm/<,12051,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,704.26,,,,,,,fee schedule,402.44,2406.85,APC
Intmd rpr face/mm 2.6-5.0 cm,12052,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,454.57,,,,,,,fee schedule,364.38,1785.48,
Intmd rpr face/mm 2.6-5.0 cm,12052,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,364.38,,,,,,,fee schedule,364.38,1785.48,
Intmd rpr face/mm 2.6-5.0 cm,12052,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,398.05,,,,,,,fee schedule,364.38,1785.48,
Intmd rpr face/mm 2.6-5.0 cm,12052,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,418.49,,,,,,,fee schedule,364.38,1785.48,
Intmd rpr face/mm 2.6-5.0 cm,12052,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1785.48,,,,,,,fee schedule,364.38,1785.48,APC 378
Intmd rpr face/mm 2.6-5.0 cm,12052,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,422.56,,,,,,,fee schedule,364.38,1785.48,APC
Intmd rpr face/mm 2.6-5.0 cm,12052,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,418.53,,,,,,,fee schedule,364.38,1785.48,APC
Intmd rpr face/mm 2.6-5.0 cm,12052,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,402.44,,,,,,,fee schedule,364.38,1785.48,APC
Intmd rpr face/mm 2.6-5.0 cm,12052,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,615.73,,,,,,,fee schedule,364.38,1785.48,Radiology
Intmd rpr face/mm 2.6-5.0 cm,12052,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,563.41,,,,,,,fee schedule,364.38,1785.48,APC
Intmd rpr face/mm 2.6-5.0 cm,12052,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,704.26,,,,,,,fee schedule,364.38,1785.48,APC
Intmd rpr face/mm 5.1-7.5 cm,12053,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,525.38,,,,,,,fee schedule,402.44,1785.48,
Intmd rpr face/mm 5.1-7.5 cm,12053,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,421.14,,,,,,,fee schedule,402.44,1785.48,
Intmd rpr face/mm 5.1-7.5 cm,12053,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,460.06,,,,,,,fee schedule,402.44,1785.48,
Intmd rpr face/mm 5.1-7.5 cm,12053,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,483.69,,,,,,,fee schedule,402.44,1785.48,
Intmd rpr face/mm 5.1-7.5 cm,12053,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1785.48,,,,,,,fee schedule,402.44,1785.48,APC 378
Intmd rpr face/mm 5.1-7.5 cm,12053,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,422.56,,,,,,,fee schedule,402.44,1785.48,APC
Intmd rpr face/mm 5.1-7.5 cm,12053,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,418.53,,,,,,,fee schedule,402.44,1785.48,APC
Intmd rpr face/mm 5.1-7.5 cm,12053,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,402.44,,,,,,,fee schedule,402.44,1785.48,APC
Intmd rpr face/mm 5.1-7.5 cm,12053,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,615.73,,,,,,,fee schedule,402.44,1785.48,Radiology
Intmd rpr face/mm 5.1-7.5 cm,12053,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,563.41,,,,,,,fee schedule,402.44,1785.48,APC
Intmd rpr face/mm 5.1-7.5 cm,12053,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,704.26,,,,,,,fee schedule,402.44,1785.48,APC
Intmd rpr face/mm 7.6-12.5cm,12054,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,515.79,,,,,,,fee schedule,402.44,1785.48,
Intmd rpr face/mm 7.6-12.5cm,12054,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,413.45,,,,,,,fee schedule,402.44,1785.48,
Intmd rpr face/mm 7.6-12.5cm,12054,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,451.66,,,,,,,fee schedule,402.44,1785.48,
Intmd rpr face/mm 7.6-12.5cm,12054,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,474.86,,,,,,,fee schedule,402.44,1785.48,
Intmd rpr face/mm 7.6-12.5cm,12054,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1785.48,,,,,,,fee schedule,402.44,1785.48,APC 378
Intmd rpr face/mm 7.6-12.5cm,12054,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,422.56,,,,,,,fee schedule,402.44,1785.48,APC
Intmd rpr face/mm 7.6-12.5cm,12054,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,418.53,,,,,,,fee schedule,402.44,1785.48,APC
Intmd rpr face/mm 7.6-12.5cm,12054,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,402.44,,,,,,,fee schedule,402.44,1785.48,APC
Intmd rpr face/mm 7.6-12.5cm,12054,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,615.73,,,,,,,fee schedule,402.44,1785.48,Radiology
Intmd rpr face/mm 7.6-12.5cm,12054,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,563.41,,,,,,,fee schedule,402.44,1785.48,APC
Intmd rpr face/mm 7.6-12.5cm,12054,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,704.26,,,,,,,fee schedule,402.44,1785.48,APC
Intmd rpr face/mm 12.6-20 cm,12055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,525.38,,,,,,,fee schedule,402.44,1785.48,
Intmd rpr face/mm 12.6-20 cm,12055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,421.14,,,,,,,fee schedule,402.44,1785.48,
Intmd rpr face/mm 12.6-20 cm,12055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,460.06,,,,,,,fee schedule,402.44,1785.48,
Intmd rpr face/mm 12.6-20 cm,12055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,483.69,,,,,,,fee schedule,402.44,1785.48,
Intmd rpr face/mm 12.6-20 cm,12055,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1785.48,,,,,,,fee schedule,402.44,1785.48,APC 378
Intmd rpr face/mm 12.6-20 cm,12055,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,422.56,,,,,,,fee schedule,402.44,1785.48,APC
Intmd rpr face/mm 12.6-20 cm,12055,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,418.53,,,,,,,fee schedule,402.44,1785.48,APC
Intmd rpr face/mm 12.6-20 cm,12055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,402.44,,,,,,,fee schedule,402.44,1785.48,APC
Intmd rpr face/mm 12.6-20 cm,12055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,615.73,,,,,,,fee schedule,402.44,1785.48,Radiology
Intmd rpr face/mm 12.6-20 cm,12055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,563.41,,,,,,,fee schedule,402.44,1785.48,APC
Intmd rpr face/mm 12.6-20 cm,12055,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,704.26,,,,,,,fee schedule,402.44,1785.48,APC
Intmd rpr face/mm 20.1-30.0,12056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,525.38,,,,,,,fee schedule,402.44,1785.48,
Intmd rpr face/mm 20.1-30.0,12056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,421.14,,,,,,,fee schedule,402.44,1785.48,
Intmd rpr face/mm 20.1-30.0,12056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,460.06,,,,,,,fee schedule,402.44,1785.48,
Intmd rpr face/mm 20.1-30.0,12056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,483.69,,,,,,,fee schedule,402.44,1785.48,
Intmd rpr face/mm 20.1-30.0,12056,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1785.48,,,,,,,fee schedule,402.44,1785.48,APC 378
Intmd rpr face/mm 20.1-30.0,12056,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,422.56,,,,,,,fee schedule,402.44,1785.48,APC
Intmd rpr face/mm 20.1-30.0,12056,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,418.53,,,,,,,fee schedule,402.44,1785.48,APC
Intmd rpr face/mm 20.1-30.0,12056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,402.44,,,,,,,fee schedule,402.44,1785.48,APC
Intmd rpr face/mm 20.1-30.0,12056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,615.73,,,,,,,fee schedule,402.44,1785.48,Radiology
Intmd rpr face/mm 20.1-30.0,12056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,563.41,,,,,,,fee schedule,402.44,1785.48,APC
Intmd rpr face/mm 20.1-30.0,12056,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,704.26,,,,,,,fee schedule,402.44,1785.48,APC
Intmd rpr face/mm >30.0 cm,12057,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,525.38,,,,,,,fee schedule,402.44,1785.48,
Intmd rpr face/mm >30.0 cm,12057,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,421.14,,,,,,,fee schedule,402.44,1785.48,
Intmd rpr face/mm >30.0 cm,12057,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,460.06,,,,,,,fee schedule,402.44,1785.48,
Intmd rpr face/mm >30.0 cm,12057,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,483.69,,,,,,,fee schedule,402.44,1785.48,
Intmd rpr face/mm >30.0 cm,12057,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1785.48,,,,,,,fee schedule,402.44,1785.48,APC 378
Intmd rpr face/mm >30.0 cm,12057,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,422.56,,,,,,,fee schedule,402.44,1785.48,APC
Intmd rpr face/mm >30.0 cm,12057,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,418.53,,,,,,,fee schedule,402.44,1785.48,APC
Intmd rpr face/mm >30.0 cm,12057,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,402.44,,,,,,,fee schedule,402.44,1785.48,APC
Intmd rpr face/mm >30.0 cm,12057,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,615.73,,,,,,,fee schedule,402.44,1785.48,Radiology
Intmd rpr face/mm >30.0 cm,12057,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,563.41,,,,,,,fee schedule,402.44,1785.48,APC
Intmd rpr face/mm >30.0 cm,12057,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,704.26,,,,,,,fee schedule,402.44,1785.48,APC
Cmplx rpr trunk 1.1-2.5 cm,13100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2093.3,,,,,,,fee schedule,731.66,3246.12,
Cmplx rpr trunk 1.1-2.5 cm,13100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1677.96,,,,,,,fee schedule,731.66,3246.12,
Cmplx rpr trunk 1.1-2.5 cm,13100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1833.02,,,,,,,fee schedule,731.66,3246.12,
Cmplx rpr trunk 1.1-2.5 cm,13100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1927.16,,,,,,,fee schedule,731.66,3246.12,
Cmplx rpr trunk 1.1-2.5 cm,13100,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3246.12,,,,,,,fee schedule,731.66,3246.12,APC 378
Cmplx rpr trunk 1.1-2.5 cm,13100,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,768.24,,,,,,,fee schedule,731.66,3246.12,APC
Cmplx rpr trunk 1.1-2.5 cm,13100,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,760.92,,,,,,,fee schedule,731.66,3246.12,APC
Cmplx rpr trunk 1.1-2.5 cm,13100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,731.66,,,,,,,fee schedule,731.66,3246.12,APC
Cmplx rpr trunk 1.1-2.5 cm,13100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1119.44,,,,,,,fee schedule,731.66,3246.12,Radiology
Cmplx rpr trunk 1.1-2.5 cm,13100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1024.32,,,,,,,fee schedule,731.66,3246.12,APC
Cmplx rpr trunk 1.1-2.5 cm,13100,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1280.4,,,,,,,fee schedule,731.66,3246.12,APC
Cmplx rpr trunk 2.6-7.5 cm,13101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4062.96,,,,,,,fee schedule,731.66,4062.96,
Cmplx rpr trunk 2.6-7.5 cm,13101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3256.82,,,,,,,fee schedule,731.66,4062.96,
Cmplx rpr trunk 2.6-7.5 cm,13101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3557.78,,,,,,,fee schedule,731.66,4062.96,
Cmplx rpr trunk 2.6-7.5 cm,13101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3740.5,,,,,,,fee schedule,731.66,4062.96,
Cmplx rpr trunk 2.6-7.5 cm,13101,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3246.12,,,,,,,fee schedule,731.66,4062.96,APC 378
Cmplx rpr trunk 2.6-7.5 cm,13101,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,768.24,,,,,,,fee schedule,731.66,4062.96,APC
Cmplx rpr trunk 2.6-7.5 cm,13101,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,760.92,,,,,,,fee schedule,731.66,4062.96,APC
Cmplx rpr trunk 2.6-7.5 cm,13101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,731.66,,,,,,,fee schedule,731.66,4062.96,APC
Cmplx rpr trunk 2.6-7.5 cm,13101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1119.44,,,,,,,fee schedule,731.66,4062.96,Radiology
Cmplx rpr trunk 2.6-7.5 cm,13101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1024.32,,,,,,,fee schedule,731.66,4062.96,APC
Cmplx rpr trunk 2.6-7.5 cm,13101,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1280.4,,,,,,,fee schedule,731.66,4062.96,APC
Cmplx rpr trunk addl 5cm/<,13102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,680.73,,,,,,,fee schedule,545.67,680.73,
Cmplx rpr trunk addl 5cm/<,13102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,545.67,,,,,,,fee schedule,545.67,680.73,
Cmplx rpr trunk addl 5cm/<,13102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,596.09,,,,,,,fee schedule,545.67,680.73,
Cmplx rpr trunk addl 5cm/<,13102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,626.71,,,,,,,fee schedule,545.67,680.73,
Cmplx rpr s/a/l 1.1-2.5 cm,13120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4025.93,,,,,,,fee schedule,402.44,4025.93,
Cmplx rpr s/a/l 1.1-2.5 cm,13120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3227.14,,,,,,,fee schedule,402.44,4025.93,
Cmplx rpr s/a/l 1.1-2.5 cm,13120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3525.35,,,,,,,fee schedule,402.44,4025.93,
Cmplx rpr s/a/l 1.1-2.5 cm,13120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3706.41,,,,,,,fee schedule,402.44,4025.93,
Cmplx rpr s/a/l 1.1-2.5 cm,13120,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1785.48,,,,,,,fee schedule,402.44,4025.93,APC 378
Cmplx rpr s/a/l 1.1-2.5 cm,13120,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,422.56,,,,,,,fee schedule,402.44,4025.93,APC
Cmplx rpr s/a/l 1.1-2.5 cm,13120,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,418.53,,,,,,,fee schedule,402.44,4025.93,APC
Cmplx rpr s/a/l 1.1-2.5 cm,13120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,402.44,,,,,,,fee schedule,402.44,4025.93,APC
Cmplx rpr s/a/l 1.1-2.5 cm,13120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,615.73,,,,,,,fee schedule,402.44,4025.93,Radiology
Cmplx rpr s/a/l 1.1-2.5 cm,13120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,563.41,,,,,,,fee schedule,402.44,4025.93,APC
Cmplx rpr s/a/l 1.1-2.5 cm,13120,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,704.26,,,,,,,fee schedule,402.44,4025.93,APC
Cmplx rpr s/a/l 2.6-7.5 cm,13121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1508.73,,,,,,,fee schedule,402.44,1785.48,
Cmplx rpr s/a/l 2.6-7.5 cm,13121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1209.38,,,,,,,fee schedule,402.44,1785.48,
Cmplx rpr s/a/l 2.6-7.5 cm,13121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1321.14,,,,,,,fee schedule,402.44,1785.48,
Cmplx rpr s/a/l 2.6-7.5 cm,13121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1388.99,,,,,,,fee schedule,402.44,1785.48,
Cmplx rpr s/a/l 2.6-7.5 cm,13121,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1785.48,,,,,,,fee schedule,402.44,1785.48,APC 378
Cmplx rpr s/a/l 2.6-7.5 cm,13121,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,422.56,,,,,,,fee schedule,402.44,1785.48,APC
Cmplx rpr s/a/l 2.6-7.5 cm,13121,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,418.53,,,,,,,fee schedule,402.44,1785.48,APC
Cmplx rpr s/a/l 2.6-7.5 cm,13121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,402.44,,,,,,,fee schedule,402.44,1785.48,APC
Cmplx rpr s/a/l 2.6-7.5 cm,13121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,615.73,,,,,,,fee schedule,402.44,1785.48,Radiology
Cmplx rpr s/a/l 2.6-7.5 cm,13121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,563.41,,,,,,,fee schedule,402.44,1785.48,APC
Cmplx rpr s/a/l 2.6-7.5 cm,13121,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,704.26,,,,,,,fee schedule,402.44,1785.48,APC
Cmplx rpr s/a/l addl 5 cm/>,13122,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2396.55,,,,,,,fee schedule,1921.05,2396.55,
Cmplx rpr s/a/l addl 5 cm/>,13122,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1921.05,,,,,,,fee schedule,1921.05,2396.55,
Cmplx rpr s/a/l addl 5 cm/>,13122,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2098.57,,,,,,,fee schedule,1921.05,2396.55,
Cmplx rpr s/a/l addl 5 cm/>,13122,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2206.35,,,,,,,fee schedule,1921.05,2396.55,
Cmplx rpr f/c/c/m/n/ax/g/h/f,13131,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3360.79,,,,,,,fee schedule,402.44,3360.79,
Cmplx rpr f/c/c/m/n/ax/g/h/f,13131,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2693.96,,,,,,,fee schedule,402.44,3360.79,
Cmplx rpr f/c/c/m/n/ax/g/h/f,13131,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2942.91,,,,,,,fee schedule,402.44,3360.79,
Cmplx rpr f/c/c/m/n/ax/g/h/f,13131,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3094.06,,,,,,,fee schedule,402.44,3360.79,
Cmplx rpr f/c/c/m/n/ax/g/h/f,13131,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1785.48,,,,,,,fee schedule,402.44,3360.79,APC 378
Cmplx rpr f/c/c/m/n/ax/g/h/f,13131,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,422.56,,,,,,,fee schedule,402.44,3360.79,APC
Cmplx rpr f/c/c/m/n/ax/g/h/f,13131,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,418.53,,,,,,,fee schedule,402.44,3360.79,APC
Cmplx rpr f/c/c/m/n/ax/g/h/f,13131,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,402.44,,,,,,,fee schedule,402.44,3360.79,APC
Cmplx rpr f/c/c/m/n/ax/g/h/f,13131,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,615.73,,,,,,,fee schedule,402.44,3360.79,Radiology
Cmplx rpr f/c/c/m/n/ax/g/h/f,13131,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,563.41,,,,,,,fee schedule,402.44,3360.79,APC
Cmplx rpr f/c/c/m/n/ax/g/h/f,13131,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,704.26,,,,,,,fee schedule,402.44,3360.79,APC
Cmplx rpr f/c/c/m/n/ax/g/h/f,13132,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1508.74,,,,,,,fee schedule,402.44,1785.48,
Cmplx rpr f/c/c/m/n/ax/g/h/f,13132,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1209.39,,,,,,,fee schedule,402.44,1785.48,
Cmplx rpr f/c/c/m/n/ax/g/h/f,13132,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1321.15,,,,,,,fee schedule,402.44,1785.48,
Cmplx rpr f/c/c/m/n/ax/g/h/f,13132,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1389,,,,,,,fee schedule,402.44,1785.48,
Cmplx rpr f/c/c/m/n/ax/g/h/f,13132,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1785.48,,,,,,,fee schedule,402.44,1785.48,APC 378
Cmplx rpr f/c/c/m/n/ax/g/h/f,13132,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,422.56,,,,,,,fee schedule,402.44,1785.48,APC
Cmplx rpr f/c/c/m/n/ax/g/h/f,13132,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,418.53,,,,,,,fee schedule,402.44,1785.48,APC
Cmplx rpr f/c/c/m/n/ax/g/h/f,13132,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,402.44,,,,,,,fee schedule,402.44,1785.48,APC
Cmplx rpr f/c/c/m/n/ax/g/h/f,13132,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,615.73,,,,,,,fee schedule,402.44,1785.48,Radiology
Cmplx rpr f/c/c/m/n/ax/g/h/f,13132,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,563.41,,,,,,,fee schedule,402.44,1785.48,APC
Cmplx rpr f/c/c/m/n/ax/g/h/f,13132,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,704.26,,,,,,,fee schedule,402.44,1785.48,APC
Cmplx rpr f/c/c/m/n/ax/g/h/f,13133,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2396.55,,,,,,,fee schedule,1921.05,2396.55,
Cmplx rpr f/c/c/m/n/ax/g/h/f,13133,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1921.05,,,,,,,fee schedule,1921.05,2396.55,
Cmplx rpr f/c/c/m/n/ax/g/h/f,13133,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2098.57,,,,,,,fee schedule,1921.05,2396.55,
Cmplx rpr f/c/c/m/n/ax/g/h/f,13133,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2206.35,,,,,,,fee schedule,1921.05,2396.55,
Cmplx rpr e/n/e/l 1.1-2.5 cm,13151,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3594.84,,,,,,,fee schedule,731.66,3594.84,
Cmplx rpr e/n/e/l 1.1-2.5 cm,13151,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2881.58,,,,,,,fee schedule,731.66,3594.84,
Cmplx rpr e/n/e/l 1.1-2.5 cm,13151,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3147.87,,,,,,,fee schedule,731.66,3594.84,
Cmplx rpr e/n/e/l 1.1-2.5 cm,13151,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3309.54,,,,,,,fee schedule,731.66,3594.84,
Cmplx rpr e/n/e/l 1.1-2.5 cm,13151,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3246.12,,,,,,,fee schedule,731.66,3594.84,APC 378
Cmplx rpr e/n/e/l 1.1-2.5 cm,13151,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,768.24,,,,,,,fee schedule,731.66,3594.84,APC
Cmplx rpr e/n/e/l 1.1-2.5 cm,13151,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,760.92,,,,,,,fee schedule,731.66,3594.84,APC
Cmplx rpr e/n/e/l 1.1-2.5 cm,13151,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,731.66,,,,,,,fee schedule,731.66,3594.84,APC
Cmplx rpr e/n/e/l 1.1-2.5 cm,13151,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1119.44,,,,,,,fee schedule,731.66,3594.84,Radiology
Cmplx rpr e/n/e/l 1.1-2.5 cm,13151,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1024.32,,,,,,,fee schedule,731.66,3594.84,APC
Cmplx rpr e/n/e/l 1.1-2.5 cm,13151,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1280.4,,,,,,,fee schedule,731.66,3594.84,APC
Cmplx rpr e/n/e/l 2.6-7.5 cm,13152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1129.65,,,,,,,fee schedule,731.66,3246.12,
Cmplx rpr e/n/e/l 2.6-7.5 cm,13152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,905.52,,,,,,,fee schedule,731.66,3246.12,
Cmplx rpr e/n/e/l 2.6-7.5 cm,13152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,989.19,,,,,,,fee schedule,731.66,3246.12,
Cmplx rpr e/n/e/l 2.6-7.5 cm,13152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1040,,,,,,,fee schedule,731.66,3246.12,
Cmplx rpr e/n/e/l 2.6-7.5 cm,13152,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3246.12,,,,,,,fee schedule,731.66,3246.12,APC 378
Cmplx rpr e/n/e/l 2.6-7.5 cm,13152,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,768.24,,,,,,,fee schedule,731.66,3246.12,APC
Cmplx rpr e/n/e/l 2.6-7.5 cm,13152,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,760.92,,,,,,,fee schedule,731.66,3246.12,APC
Cmplx rpr e/n/e/l 2.6-7.5 cm,13152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,731.66,,,,,,,fee schedule,731.66,3246.12,APC
Cmplx rpr e/n/e/l 2.6-7.5 cm,13152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1119.44,,,,,,,fee schedule,731.66,3246.12,Radiology
Cmplx rpr e/n/e/l 2.6-7.5 cm,13152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1024.32,,,,,,,fee schedule,731.66,3246.12,APC
Cmplx rpr e/n/e/l 2.6-7.5 cm,13152,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1280.4,,,,,,,fee schedule,731.66,3246.12,APC
Cmplx rpr e/n/e/l addl 5cm/<,13153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,525.38,,,,,,,fee schedule,421.14,525.38,
Cmplx rpr e/n/e/l addl 5cm/<,13153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,421.14,,,,,,,fee schedule,421.14,525.38,
Cmplx rpr e/n/e/l addl 5cm/<,13153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,460.06,,,,,,,fee schedule,421.14,525.38,
Cmplx rpr e/n/e/l addl 5cm/<,13153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,483.69,,,,,,,fee schedule,421.14,525.38,
Late closure of wound,13160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5336.73,,,,,,,fee schedule,3508.17,15564.58,
Late closure of wound,13160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4277.86,,,,,,,fee schedule,3508.17,15564.58,
Late closure of wound,13160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4673.17,,,,,,,fee schedule,3508.17,15564.58,
Late closure of wound,13160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4913.18,,,,,,,fee schedule,3508.17,15564.58,
Late closure of wound,13160,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15564.58,,,,,,,fee schedule,3508.17,15564.58,APC 378
Late closure of wound,13160,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3683.58,,,,,,,fee schedule,3508.17,15564.58,APC
Late closure of wound,13160,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3648.5,,,,,,,fee schedule,3508.17,15564.58,APC
Late closure of wound,13160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3508.17,,,,,,,fee schedule,3508.17,15564.58,APC
Late closure of wound,13160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5367.5,,,,,,,fee schedule,3508.17,15564.58,Radiology
Late closure of wound,13160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4911.44,,,,,,,fee schedule,3508.17,15564.58,APC
Late closure of wound,13160,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6139.3,,,,,,,fee schedule,3508.17,15564.58,APC
Tis trnfr trunk 10 sq cm/<,14000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2843.91,,,,,,,fee schedule,2042.58,9062.24,
Tis trnfr trunk 10 sq cm/<,14000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2279.64,,,,,,,fee schedule,2042.58,9062.24,
Tis trnfr trunk 10 sq cm/<,14000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2490.3,,,,,,,fee schedule,2042.58,9062.24,
Tis trnfr trunk 10 sq cm/<,14000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2618.2,,,,,,,fee schedule,2042.58,9062.24,
Tis trnfr trunk 10 sq cm/<,14000,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,2042.58,9062.24,APC 378
Tis trnfr trunk 10 sq cm/<,14000,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,2042.58,9062.24,APC
Tis trnfr trunk 10 sq cm/<,14000,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,2042.58,9062.24,APC
Tis trnfr trunk 10 sq cm/<,14000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,2042.58,9062.24,APC
Tis trnfr trunk 10 sq cm/<,14000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,2042.58,9062.24,Radiology
Tis trnfr trunk 10 sq cm/<,14000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,2042.58,9062.24,APC
Tis trnfr trunk 10 sq cm/<,14000,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,2042.58,9062.24,APC
Tis trnfr trunk 10.1-30sqcm,14001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2902.42,,,,,,,fee schedule,2042.58,9062.24,
Tis trnfr trunk 10.1-30sqcm,14001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2326.55,,,,,,,fee schedule,2042.58,9062.24,
Tis trnfr trunk 10.1-30sqcm,14001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2541.54,,,,,,,fee schedule,2042.58,9062.24,
Tis trnfr trunk 10.1-30sqcm,14001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2672.07,,,,,,,fee schedule,2042.58,9062.24,
Tis trnfr trunk 10.1-30sqcm,14001,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,2042.58,9062.24,APC 378
Tis trnfr trunk 10.1-30sqcm,14001,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,2042.58,9062.24,APC
Tis trnfr trunk 10.1-30sqcm,14001,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,2042.58,9062.24,APC
Tis trnfr trunk 10.1-30sqcm,14001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,2042.58,9062.24,APC
Tis trnfr trunk 10.1-30sqcm,14001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,2042.58,9062.24,Radiology
Tis trnfr trunk 10.1-30sqcm,14001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,2042.58,9062.24,APC
Tis trnfr trunk 10.1-30sqcm,14001,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,2042.58,9062.24,APC
Tis trnfr s/a/l 10 sq cm/<,14020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4062.96,,,,,,,fee schedule,2042.58,9062.24,
Tis trnfr s/a/l 10 sq cm/<,14020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3256.82,,,,,,,fee schedule,2042.58,9062.24,
Tis trnfr s/a/l 10 sq cm/<,14020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3557.78,,,,,,,fee schedule,2042.58,9062.24,
Tis trnfr s/a/l 10 sq cm/<,14020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3740.5,,,,,,,fee schedule,2042.58,9062.24,
Tis trnfr s/a/l 10 sq cm/<,14020,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,2042.58,9062.24,APC 378
Tis trnfr s/a/l 10 sq cm/<,14020,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,2042.58,9062.24,APC
Tis trnfr s/a/l 10 sq cm/<,14020,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,2042.58,9062.24,APC
Tis trnfr s/a/l 10 sq cm/<,14020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,2042.58,9062.24,APC
Tis trnfr s/a/l 10 sq cm/<,14020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,2042.58,9062.24,Radiology
Tis trnfr s/a/l 10 sq cm/<,14020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,2042.58,9062.24,APC
Tis trnfr s/a/l 10 sq cm/<,14020,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,2042.58,9062.24,APC
Tis trnfr s/a/l 10.1-30 sqcm,14021,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3644.88,,,,,,,fee schedule,2042.58,9062.24,
Tis trnfr s/a/l 10.1-30 sqcm,14021,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2921.69,,,,,,,fee schedule,2042.58,9062.24,
Tis trnfr s/a/l 10.1-30 sqcm,14021,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3191.68,,,,,,,fee schedule,2042.58,9062.24,
Tis trnfr s/a/l 10.1-30 sqcm,14021,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3355.61,,,,,,,fee schedule,2042.58,9062.24,
Tis trnfr s/a/l 10.1-30 sqcm,14021,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,2042.58,9062.24,APC 378
Tis trnfr s/a/l 10.1-30 sqcm,14021,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,2042.58,9062.24,APC
Tis trnfr s/a/l 10.1-30 sqcm,14021,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,2042.58,9062.24,APC
Tis trnfr s/a/l 10.1-30 sqcm,14021,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,2042.58,9062.24,APC
Tis trnfr s/a/l 10.1-30 sqcm,14021,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,2042.58,9062.24,Radiology
Tis trnfr s/a/l 10.1-30 sqcm,14021,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,2042.58,9062.24,APC
Tis trnfr s/a/l 10.1-30 sqcm,14021,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,2042.58,9062.24,APC
Tis trnfr f/c/c/m/n/a/g/h/f,14040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3089.7,,,,,,,fee schedule,2042.58,9062.24,
Tis trnfr f/c/c/m/n/a/g/h/f,14040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2476.67,,,,,,,fee schedule,2042.58,9062.24,
Tis trnfr f/c/c/m/n/a/g/h/f,14040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2705.53,,,,,,,fee schedule,2042.58,9062.24,
Tis trnfr f/c/c/m/n/a/g/h/f,14040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2844.49,,,,,,,fee schedule,2042.58,9062.24,
Tis trnfr f/c/c/m/n/a/g/h/f,14040,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,2042.58,9062.24,APC 378
Tis trnfr f/c/c/m/n/a/g/h/f,14040,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,2042.58,9062.24,APC
Tis trnfr f/c/c/m/n/a/g/h/f,14040,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,2042.58,9062.24,APC
Tis trnfr f/c/c/m/n/a/g/h/f,14040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,2042.58,9062.24,APC
Tis trnfr f/c/c/m/n/a/g/h/f,14040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,2042.58,9062.24,Radiology
Tis trnfr f/c/c/m/n/a/g/h/f,14040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,2042.58,9062.24,APC
Tis trnfr f/c/c/m/n/a/g/h/f,14040,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,2042.58,9062.24,APC
Tis trnfr f/c/c/m/n/a/g/h/f,14041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3828.9,,,,,,,fee schedule,2042.58,9062.24,
Tis trnfr f/c/c/m/n/a/g/h/f,14041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3069.2,,,,,,,fee schedule,2042.58,9062.24,
Tis trnfr f/c/c/m/n/a/g/h/f,14041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3352.82,,,,,,,fee schedule,2042.58,9062.24,
Tis trnfr f/c/c/m/n/a/g/h/f,14041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3525.02,,,,,,,fee schedule,2042.58,9062.24,
Tis trnfr f/c/c/m/n/a/g/h/f,14041,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,2042.58,9062.24,APC 378
Tis trnfr f/c/c/m/n/a/g/h/f,14041,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,2042.58,9062.24,APC
Tis trnfr f/c/c/m/n/a/g/h/f,14041,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,2042.58,9062.24,APC
Tis trnfr f/c/c/m/n/a/g/h/f,14041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,2042.58,9062.24,APC
Tis trnfr f/c/c/m/n/a/g/h/f,14041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,2042.58,9062.24,Radiology
Tis trnfr f/c/c/m/n/a/g/h/f,14041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,2042.58,9062.24,APC
Tis trnfr f/c/c/m/n/a/g/h/f,14041,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,2042.58,9062.24,APC
Tis trnfr e/n/e/l 10 sq cm/<,14060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3819.57,,,,,,,fee schedule,2042.58,9062.24,
Tis trnfr e/n/e/l 10 sq cm/<,14060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3061.72,,,,,,,fee schedule,2042.58,9062.24,
Tis trnfr e/n/e/l 10 sq cm/<,14060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3344.65,,,,,,,fee schedule,2042.58,9062.24,
Tis trnfr e/n/e/l 10 sq cm/<,14060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3516.43,,,,,,,fee schedule,2042.58,9062.24,
Tis trnfr e/n/e/l 10 sq cm/<,14060,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,2042.58,9062.24,APC 378
Tis trnfr e/n/e/l 10 sq cm/<,14060,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,2042.58,9062.24,APC
Tis trnfr e/n/e/l 10 sq cm/<,14060,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,2042.58,9062.24,APC
Tis trnfr e/n/e/l 10 sq cm/<,14060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,2042.58,9062.24,APC
Tis trnfr e/n/e/l 10 sq cm/<,14060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,2042.58,9062.24,Radiology
Tis trnfr e/n/e/l 10 sq cm/<,14060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,2042.58,9062.24,APC
Tis trnfr e/n/e/l 10 sq cm/<,14060,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,2042.58,9062.24,APC
Tis trnfr e/n/e/l10.1-30sqcm,14061,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3755.05,,,,,,,fee schedule,2042.58,9062.24,
Tis trnfr e/n/e/l10.1-30sqcm,14061,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3010,,,,,,,fee schedule,2042.58,9062.24,
Tis trnfr e/n/e/l10.1-30sqcm,14061,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3288.15,,,,,,,fee schedule,2042.58,9062.24,
Tis trnfr e/n/e/l10.1-30sqcm,14061,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3457.03,,,,,,,fee schedule,2042.58,9062.24,
Tis trnfr e/n/e/l10.1-30sqcm,14061,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,2042.58,9062.24,APC 378
Tis trnfr e/n/e/l10.1-30sqcm,14061,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,2042.58,9062.24,APC
Tis trnfr e/n/e/l10.1-30sqcm,14061,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,2042.58,9062.24,APC
Tis trnfr e/n/e/l10.1-30sqcm,14061,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,2042.58,9062.24,APC
Tis trnfr e/n/e/l10.1-30sqcm,14061,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,2042.58,9062.24,Radiology
Tis trnfr e/n/e/l10.1-30sqcm,14061,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,2042.58,9062.24,APC
Tis trnfr e/n/e/l10.1-30sqcm,14061,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,2042.58,9062.24,APC
Tis trnfr any 30.1-60 sq cm,14301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7189.69,,,,,,,fee schedule,3508.17,15564.58,
Tis trnfr any 30.1-60 sq cm,14301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5763.16,,,,,,,fee schedule,3508.17,15564.58,
Tis trnfr any 30.1-60 sq cm,14301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6295.73,,,,,,,fee schedule,3508.17,15564.58,
Tis trnfr any 30.1-60 sq cm,14301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6619.08,,,,,,,fee schedule,3508.17,15564.58,
Tis trnfr any 30.1-60 sq cm,14301,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15564.58,,,,,,,fee schedule,3508.17,15564.58,APC 378
Tis trnfr any 30.1-60 sq cm,14301,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3683.58,,,,,,,fee schedule,3508.17,15564.58,APC
Tis trnfr any 30.1-60 sq cm,14301,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3648.5,,,,,,,fee schedule,3508.17,15564.58,APC
Tis trnfr any 30.1-60 sq cm,14301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3508.17,,,,,,,fee schedule,3508.17,15564.58,APC
Tis trnfr any 30.1-60 sq cm,14301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5367.5,,,,,,,fee schedule,3508.17,15564.58,Radiology
Tis trnfr any 30.1-60 sq cm,14301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4911.44,,,,,,,fee schedule,3508.17,15564.58,APC
Tis trnfr any 30.1-60 sq cm,14301,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6139.3,,,,,,,fee schedule,3508.17,15564.58,APC
Tis trnfr addl 30 sq cm/<,14302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1457.9,,,,,,,fee schedule,1168.63,1457.9,
Tis trnfr addl 30 sq cm/<,14302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1168.63,,,,,,,fee schedule,1168.63,1457.9,
Tis trnfr addl 30 sq cm/<,14302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1276.62,,,,,,,fee schedule,1168.63,1457.9,
Tis trnfr addl 30 sq cm/<,14302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1342.19,,,,,,,fee schedule,1168.63,1457.9,
Filleted finger/toe flap,14350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5043.16,,,,,,,fee schedule,2042.58,9062.24,
Filleted finger/toe flap,14350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4042.54,,,,,,,fee schedule,2042.58,9062.24,
Filleted finger/toe flap,14350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4416.1,,,,,,,fee schedule,2042.58,9062.24,
Filleted finger/toe flap,14350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4642.91,,,,,,,fee schedule,2042.58,9062.24,
Filleted finger/toe flap,14350,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,2042.58,9062.24,APC 378
Filleted finger/toe flap,14350,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,2042.58,9062.24,APC
Filleted finger/toe flap,14350,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,2042.58,9062.24,APC
Filleted finger/toe flap,14350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,2042.58,9062.24,APC
Filleted finger/toe flap,14350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,2042.58,9062.24,Radiology
Filleted finger/toe flap,14350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,2042.58,9062.24,APC
Filleted finger/toe flap,14350,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,2042.58,9062.24,APC
Wound prep trk/arm/leg,15002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2382.57,,,,,,,fee schedule,731.66,3246.12,
Wound prep trk/arm/leg,15002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1909.83,,,,,,,fee schedule,731.66,3246.12,
Wound prep trk/arm/leg,15002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2086.32,,,,,,,fee schedule,731.66,3246.12,
Wound prep trk/arm/leg,15002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2193.47,,,,,,,fee schedule,731.66,3246.12,
Wound prep trk/arm/leg,15002,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3246.12,,,,,,,fee schedule,731.66,3246.12,APC 378
Wound prep trk/arm/leg,15002,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,768.24,,,,,,,fee schedule,731.66,3246.12,APC
Wound prep trk/arm/leg,15002,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,760.92,,,,,,,fee schedule,731.66,3246.12,APC
Wound prep trk/arm/leg,15002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,731.66,,,,,,,fee schedule,731.66,3246.12,APC
Wound prep trk/arm/leg,15002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1119.44,,,,,,,fee schedule,731.66,3246.12,Radiology
Wound prep trk/arm/leg,15002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1024.32,,,,,,,fee schedule,731.66,3246.12,APC
Wound prep trk/arm/leg,15002,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1280.4,,,,,,,fee schedule,731.66,3246.12,APC
Wound prep addl 100 cm,15003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1129.65,,,,,,,fee schedule,905.52,1129.65,
Wound prep addl 100 cm,15003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,905.52,,,,,,,fee schedule,905.52,1129.65,
Wound prep addl 100 cm,15003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,989.19,,,,,,,fee schedule,905.52,1129.65,
Wound prep addl 100 cm,15003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1040,,,,,,,fee schedule,905.52,1129.65,
Wound prep f/n/hf/g,15004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5336.73,,,,,,,fee schedule,402.44,5336.73,
Wound prep f/n/hf/g,15004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4277.86,,,,,,,fee schedule,402.44,5336.73,
Wound prep f/n/hf/g,15004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4673.17,,,,,,,fee schedule,402.44,5336.73,
Wound prep f/n/hf/g,15004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4913.18,,,,,,,fee schedule,402.44,5336.73,
Wound prep f/n/hf/g,15004,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1785.48,,,,,,,fee schedule,402.44,5336.73,APC 378
Wound prep f/n/hf/g,15004,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,422.56,,,,,,,fee schedule,402.44,5336.73,APC
Wound prep f/n/hf/g,15004,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,418.53,,,,,,,fee schedule,402.44,5336.73,APC
Wound prep f/n/hf/g,15004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,402.44,,,,,,,fee schedule,402.44,5336.73,APC
Wound prep f/n/hf/g,15004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,615.73,,,,,,,fee schedule,402.44,5336.73,Radiology
Wound prep f/n/hf/g,15004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,563.41,,,,,,,fee schedule,402.44,5336.73,APC
Wound prep f/n/hf/g,15004,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,704.26,,,,,,,fee schedule,402.44,5336.73,APC
Wnd prep f/n/hf/g addl cm,15005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1129.65,,,,,,,fee schedule,905.52,1129.65,
Wnd prep f/n/hf/g addl cm,15005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,905.52,,,,,,,fee schedule,905.52,1129.65,
Wnd prep f/n/hf/g addl cm,15005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,989.19,,,,,,,fee schedule,905.52,1129.65,
Wnd prep f/n/hf/g addl cm,15005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1040,,,,,,,fee schedule,905.52,1129.65,
Hrv skn cll ssp agrft 1st 25,15011,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,2042.58,9062.24,APC 378
Hrv skn cll ssp agrft 1st 25,15011,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,2042.58,9062.24,APC
Hrv skn cll ssp agrft 1st 25,15011,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,2042.58,9062.24,APC
Hrv skn cll ssp agrft 1st 25,15011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,2042.58,9062.24,APC
Hrv skn cll ssp agrft 1st 25,15011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,2042.58,9062.24,Radiology
Hrv skn cll ssp agrft 1st 25,15011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,2042.58,9062.24,APC
Hrv skn cll ssp agrft 1st 25,15011,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,2042.58,9062.24,APC
App skn cl ssp agrft t/a/l 1,15015,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,2042.58,9062.24,APC 378
App skn cl ssp agrft t/a/l 1,15015,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,2042.58,9062.24,APC
App skn cl ssp agrft t/a/l 1,15015,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,2042.58,9062.24,APC
App skn cl ssp agrft t/a/l 1,15015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,2042.58,9062.24,APC
App skn cl ssp agrft t/a/l 1,15015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,2042.58,9062.24,Radiology
App skn cl ssp agrft t/a/l 1,15015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,2042.58,9062.24,APC
App skn cl ssp agrft t/a/l 1,15015,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,2042.58,9062.24,APC
App skn cll ssp f/n/g/hf 1st,15017,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,2042.58,9062.24,APC 378
App skn cll ssp f/n/g/hf 1st,15017,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,2042.58,9062.24,APC
App skn cll ssp f/n/g/hf 1st,15017,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,2042.58,9062.24,APC
App skn cll ssp f/n/g/hf 1st,15017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,2042.58,9062.24,APC
App skn cll ssp f/n/g/hf 1st,15017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,2042.58,9062.24,Radiology
App skn cll ssp f/n/g/hf 1st,15017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,2042.58,9062.24,APC
App skn cll ssp f/n/g/hf 1st,15017,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,2042.58,9062.24,APC
Harvest cultured skin graft,15040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,525.38,,,,,,,fee schedule,421.14,9062.24,
Harvest cultured skin graft,15040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,421.14,,,,,,,fee schedule,421.14,9062.24,
Harvest cultured skin graft,15040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,460.06,,,,,,,fee schedule,421.14,9062.24,
Harvest cultured skin graft,15040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,483.69,,,,,,,fee schedule,421.14,9062.24,
Harvest cultured skin graft,15040,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,421.14,9062.24,APC 378
Harvest cultured skin graft,15040,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,421.14,9062.24,APC
Harvest cultured skin graft,15040,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,421.14,9062.24,APC
Harvest cultured skin graft,15040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,421.14,9062.24,APC
Harvest cultured skin graft,15040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,421.14,9062.24,Radiology
Harvest cultured skin graft,15040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,421.14,9062.24,APC
Harvest cultured skin graft,15040,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,421.14,9062.24,APC
Skin pinch graft,15050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1129.65,,,,,,,fee schedule,731.66,3246.12,
Skin pinch graft,15050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,905.52,,,,,,,fee schedule,731.66,3246.12,
Skin pinch graft,15050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,989.19,,,,,,,fee schedule,731.66,3246.12,
Skin pinch graft,15050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1040,,,,,,,fee schedule,731.66,3246.12,
Skin pinch graft,15050,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3246.12,,,,,,,fee schedule,731.66,3246.12,APC 378
Skin pinch graft,15050,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,768.24,,,,,,,fee schedule,731.66,3246.12,APC
Skin pinch graft,15050,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,760.92,,,,,,,fee schedule,731.66,3246.12,APC
Skin pinch graft,15050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,731.66,,,,,,,fee schedule,731.66,3246.12,APC
Skin pinch graft,15050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1119.44,,,,,,,fee schedule,731.66,3246.12,Radiology
Skin pinch graft,15050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1024.32,,,,,,,fee schedule,731.66,3246.12,APC
Skin pinch graft,15050,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1280.4,,,,,,,fee schedule,731.66,3246.12,APC
Skin splt grft trnk/arm/leg,15100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11609.69,,,,,,,fee schedule,2042.58,11609.69,
Skin splt grft trnk/arm/leg,15100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9306.18,,,,,,,fee schedule,2042.58,11609.69,
Skin splt grft trnk/arm/leg,15100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10166.16,,,,,,,fee schedule,2042.58,11609.69,
Skin splt grft trnk/arm/leg,15100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10688.29,,,,,,,fee schedule,2042.58,11609.69,
Skin splt grft trnk/arm/leg,15100,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,2042.58,11609.69,APC 378
Skin splt grft trnk/arm/leg,15100,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,2042.58,11609.69,APC
Skin splt grft trnk/arm/leg,15100,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,2042.58,11609.69,APC
Skin splt grft trnk/arm/leg,15100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,2042.58,11609.69,APC
Skin splt grft trnk/arm/leg,15100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,2042.58,11609.69,Radiology
Skin splt grft trnk/arm/leg,15100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,2042.58,11609.69,APC
Skin splt grft trnk/arm/leg,15100,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,2042.58,11609.69,APC
Skin splt grft t/a/l add-on,15101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5043.16,,,,,,,fee schedule,4042.54,5043.16,
Skin splt grft t/a/l add-on,15101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4042.54,,,,,,,fee schedule,4042.54,5043.16,
Skin splt grft t/a/l add-on,15101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4416.1,,,,,,,fee schedule,4042.54,5043.16,
Skin splt grft t/a/l add-on,15101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4642.91,,,,,,,fee schedule,4042.54,5043.16,
Epidrm autogrft trnk/arm/leg,15110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1129.65,,,,,,,fee schedule,905.52,9062.24,
Epidrm autogrft trnk/arm/leg,15110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,905.52,,,,,,,fee schedule,905.52,9062.24,
Epidrm autogrft trnk/arm/leg,15110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,989.19,,,,,,,fee schedule,905.52,9062.24,
Epidrm autogrft trnk/arm/leg,15110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1040,,,,,,,fee schedule,905.52,9062.24,
Epidrm autogrft trnk/arm/leg,15110,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,905.52,9062.24,APC 378
Epidrm autogrft trnk/arm/leg,15110,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,905.52,9062.24,APC
Epidrm autogrft trnk/arm/leg,15110,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,905.52,9062.24,APC
Epidrm autogrft trnk/arm/leg,15110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,905.52,9062.24,APC
Epidrm autogrft trnk/arm/leg,15110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,905.52,9062.24,Radiology
Epidrm autogrft trnk/arm/leg,15110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,905.52,9062.24,APC
Epidrm autogrft trnk/arm/leg,15110,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,905.52,9062.24,APC
Epidrm autogrft t/a/l add-on,15111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1129.65,,,,,,,fee schedule,905.52,1129.65,
Epidrm autogrft t/a/l add-on,15111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,905.52,,,,,,,fee schedule,905.52,1129.65,
Epidrm autogrft t/a/l add-on,15111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,989.19,,,,,,,fee schedule,905.52,1129.65,
Epidrm autogrft t/a/l add-on,15111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1040,,,,,,,fee schedule,905.52,1129.65,
Epidrm a-grft face/nck/hf/g,15115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1129.65,,,,,,,fee schedule,905.52,9062.24,
Epidrm a-grft face/nck/hf/g,15115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,905.52,,,,,,,fee schedule,905.52,9062.24,
Epidrm a-grft face/nck/hf/g,15115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,989.19,,,,,,,fee schedule,905.52,9062.24,
Epidrm a-grft face/nck/hf/g,15115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1040,,,,,,,fee schedule,905.52,9062.24,
Epidrm a-grft face/nck/hf/g,15115,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,905.52,9062.24,APC 378
Epidrm a-grft face/nck/hf/g,15115,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,905.52,9062.24,APC
Epidrm a-grft face/nck/hf/g,15115,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,905.52,9062.24,APC
Epidrm a-grft face/nck/hf/g,15115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,905.52,9062.24,APC
Epidrm a-grft face/nck/hf/g,15115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,905.52,9062.24,Radiology
Epidrm a-grft face/nck/hf/g,15115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,905.52,9062.24,APC
Epidrm a-grft face/nck/hf/g,15115,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,905.52,9062.24,APC
Epidrm a-grft f/n/hf/g addl,15116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1129.65,,,,,,,fee schedule,905.52,1129.65,
Epidrm a-grft f/n/hf/g addl,15116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,905.52,,,,,,,fee schedule,905.52,1129.65,
Epidrm a-grft f/n/hf/g addl,15116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,989.19,,,,,,,fee schedule,905.52,1129.65,
Epidrm a-grft f/n/hf/g addl,15116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1040,,,,,,,fee schedule,905.52,1129.65,
Skn splt a-grft fac/nck/hf/g,15120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5336.73,,,,,,,fee schedule,3508.17,15564.58,
Skn splt a-grft fac/nck/hf/g,15120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4277.86,,,,,,,fee schedule,3508.17,15564.58,
Skn splt a-grft fac/nck/hf/g,15120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4673.17,,,,,,,fee schedule,3508.17,15564.58,
Skn splt a-grft fac/nck/hf/g,15120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4913.18,,,,,,,fee schedule,3508.17,15564.58,
Skn splt a-grft fac/nck/hf/g,15120,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15564.58,,,,,,,fee schedule,3508.17,15564.58,APC 378
Skn splt a-grft fac/nck/hf/g,15120,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3683.58,,,,,,,fee schedule,3508.17,15564.58,APC
Skn splt a-grft fac/nck/hf/g,15120,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3648.5,,,,,,,fee schedule,3508.17,15564.58,APC
Skn splt a-grft fac/nck/hf/g,15120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3508.17,,,,,,,fee schedule,3508.17,15564.58,APC
Skn splt a-grft fac/nck/hf/g,15120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5367.5,,,,,,,fee schedule,3508.17,15564.58,Radiology
Skn splt a-grft fac/nck/hf/g,15120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4911.44,,,,,,,fee schedule,3508.17,15564.58,APC
Skn splt a-grft fac/nck/hf/g,15120,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6139.3,,,,,,,fee schedule,3508.17,15564.58,APC
Skn splt a-grft f/n/hf/g add,15121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5043.16,,,,,,,fee schedule,4042.54,5043.16,
Skn splt a-grft f/n/hf/g add,15121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4042.54,,,,,,,fee schedule,4042.54,5043.16,
Skn splt a-grft f/n/hf/g add,15121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4416.1,,,,,,,fee schedule,4042.54,5043.16,
Skn splt a-grft f/n/hf/g add,15121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4642.91,,,,,,,fee schedule,4042.54,5043.16,
Derm autograft trnk/arm/leg,15130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3755.05,,,,,,,fee schedule,2042.58,9062.24,
Derm autograft trnk/arm/leg,15130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3010,,,,,,,fee schedule,2042.58,9062.24,
Derm autograft trnk/arm/leg,15130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3288.15,,,,,,,fee schedule,2042.58,9062.24,
Derm autograft trnk/arm/leg,15130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3457.03,,,,,,,fee schedule,2042.58,9062.24,
Derm autograft trnk/arm/leg,15130,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,2042.58,9062.24,APC 378
Derm autograft trnk/arm/leg,15130,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,2042.58,9062.24,APC
Derm autograft trnk/arm/leg,15130,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,2042.58,9062.24,APC
Derm autograft trnk/arm/leg,15130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,2042.58,9062.24,APC
Derm autograft trnk/arm/leg,15130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,2042.58,9062.24,Radiology
Derm autograft trnk/arm/leg,15130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,2042.58,9062.24,APC
Derm autograft trnk/arm/leg,15130,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,2042.58,9062.24,APC
Derm autograft t/a/l add-on,15131,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3755.05,,,,,,,fee schedule,3010,3755.05,
Derm autograft t/a/l add-on,15131,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3010,,,,,,,fee schedule,3010,3755.05,
Derm autograft t/a/l add-on,15131,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3288.15,,,,,,,fee schedule,3010,3755.05,
Derm autograft t/a/l add-on,15131,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3457.03,,,,,,,fee schedule,3010,3755.05,
Derm autograft face/nck/hf/g,15135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3755.05,,,,,,,fee schedule,3010,15564.58,
Derm autograft face/nck/hf/g,15135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3010,,,,,,,fee schedule,3010,15564.58,
Derm autograft face/nck/hf/g,15135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3288.15,,,,,,,fee schedule,3010,15564.58,
Derm autograft face/nck/hf/g,15135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3457.03,,,,,,,fee schedule,3010,15564.58,
Derm autograft face/nck/hf/g,15135,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15564.58,,,,,,,fee schedule,3010,15564.58,APC 378
Derm autograft face/nck/hf/g,15135,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3683.58,,,,,,,fee schedule,3010,15564.58,APC
Derm autograft face/nck/hf/g,15135,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3648.5,,,,,,,fee schedule,3010,15564.58,APC
Derm autograft face/nck/hf/g,15135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3508.17,,,,,,,fee schedule,3010,15564.58,APC
Derm autograft face/nck/hf/g,15135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5367.5,,,,,,,fee schedule,3010,15564.58,Radiology
Derm autograft face/nck/hf/g,15135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4911.44,,,,,,,fee schedule,3010,15564.58,APC
Derm autograft face/nck/hf/g,15135,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6139.3,,,,,,,fee schedule,3010,15564.58,APC
Derm autograft f/n/hf/g add,15136,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3755.05,,,,,,,fee schedule,3010,3755.05,
Derm autograft f/n/hf/g add,15136,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3010,,,,,,,fee schedule,3010,3755.05,
Derm autograft f/n/hf/g add,15136,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3288.15,,,,,,,fee schedule,3010,3755.05,
Derm autograft f/n/hf/g add,15136,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3457.03,,,,,,,fee schedule,3010,3755.05,
Cult skin grft t/arm/leg,15150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1129.65,,,,,,,fee schedule,905.52,9062.24,
Cult skin grft t/arm/leg,15150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,905.52,,,,,,,fee schedule,905.52,9062.24,
Cult skin grft t/arm/leg,15150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,989.19,,,,,,,fee schedule,905.52,9062.24,
Cult skin grft t/arm/leg,15150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1040,,,,,,,fee schedule,905.52,9062.24,
Cult skin grft t/arm/leg,15150,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,905.52,9062.24,APC 378
Cult skin grft t/arm/leg,15150,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,905.52,9062.24,APC
Cult skin grft t/arm/leg,15150,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,905.52,9062.24,APC
Cult skin grft t/arm/leg,15150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,905.52,9062.24,APC
Cult skin grft t/arm/leg,15150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,905.52,9062.24,Radiology
Cult skin grft t/arm/leg,15150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,905.52,9062.24,APC
Cult skin grft t/arm/leg,15150,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,905.52,9062.24,APC
Cult skin grft t/a/l addl,15151,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1129.65,,,,,,,fee schedule,905.52,1129.65,
Cult skin grft t/a/l addl,15151,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,905.52,,,,,,,fee schedule,905.52,1129.65,
Cult skin grft t/a/l addl,15151,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,989.19,,,,,,,fee schedule,905.52,1129.65,
Cult skin grft t/a/l addl,15151,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1040,,,,,,,fee schedule,905.52,1129.65,
Cult skin graft t/a/l +%,15152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1129.65,,,,,,,fee schedule,905.52,1129.65,
Cult skin graft t/a/l +%,15152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,905.52,,,,,,,fee schedule,905.52,1129.65,
Cult skin graft t/a/l +%,15152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,989.19,,,,,,,fee schedule,905.52,1129.65,
Cult skin graft t/a/l +%,15152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1040,,,,,,,fee schedule,905.52,1129.65,
Cult skin graft f/n/hf/g,15155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1129.65,,,,,,,fee schedule,905.52,15564.58,
Cult skin graft f/n/hf/g,15155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,905.52,,,,,,,fee schedule,905.52,15564.58,
Cult skin graft f/n/hf/g,15155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,989.19,,,,,,,fee schedule,905.52,15564.58,
Cult skin graft f/n/hf/g,15155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1040,,,,,,,fee schedule,905.52,15564.58,
Cult skin graft f/n/hf/g,15155,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15564.58,,,,,,,fee schedule,905.52,15564.58,APC 378
Cult skin graft f/n/hf/g,15155,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3683.58,,,,,,,fee schedule,905.52,15564.58,APC
Cult skin graft f/n/hf/g,15155,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3648.5,,,,,,,fee schedule,905.52,15564.58,APC
Cult skin graft f/n/hf/g,15155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3508.17,,,,,,,fee schedule,905.52,15564.58,APC
Cult skin graft f/n/hf/g,15155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5367.5,,,,,,,fee schedule,905.52,15564.58,Radiology
Cult skin graft f/n/hf/g,15155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4911.44,,,,,,,fee schedule,905.52,15564.58,APC
Cult skin graft f/n/hf/g,15155,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6139.3,,,,,,,fee schedule,905.52,15564.58,APC
Cult skin grft f/n/hfg add,15156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1129.65,,,,,,,fee schedule,905.52,1129.65,
Cult skin grft f/n/hfg add,15156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,905.52,,,,,,,fee schedule,905.52,1129.65,
Cult skin grft f/n/hfg add,15156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,989.19,,,,,,,fee schedule,905.52,1129.65,
Cult skin grft f/n/hfg add,15156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1040,,,,,,,fee schedule,905.52,1129.65,
Cult epiderm grft f/n/hfg +%,15157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1129.65,,,,,,,fee schedule,905.52,1129.65,
Cult epiderm grft f/n/hfg +%,15157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,905.52,,,,,,,fee schedule,905.52,1129.65,
Cult epiderm grft f/n/hfg +%,15157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,989.19,,,,,,,fee schedule,905.52,1129.65,
Cult epiderm grft f/n/hfg +%,15157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1040,,,,,,,fee schedule,905.52,1129.65,
Skin full graft trunk,15200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3755.05,,,,,,,fee schedule,2042.58,9062.24,
Skin full graft trunk,15200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3010,,,,,,,fee schedule,2042.58,9062.24,
Skin full graft trunk,15200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3288.15,,,,,,,fee schedule,2042.58,9062.24,
Skin full graft trunk,15200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3457.03,,,,,,,fee schedule,2042.58,9062.24,
Skin full graft trunk,15200,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,2042.58,9062.24,APC 378
Skin full graft trunk,15200,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,2042.58,9062.24,APC
Skin full graft trunk,15200,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,2042.58,9062.24,APC
Skin full graft trunk,15200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,2042.58,9062.24,APC
Skin full graft trunk,15200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,2042.58,9062.24,Radiology
Skin full graft trunk,15200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,2042.58,9062.24,APC
Skin full graft trunk,15200,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,2042.58,9062.24,APC
Skin full graft trunk add-on,15201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3755.05,,,,,,,fee schedule,3010,3755.05,
Skin full graft trunk add-on,15201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3010,,,,,,,fee schedule,3010,3755.05,
Skin full graft trunk add-on,15201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3288.15,,,,,,,fee schedule,3010,3755.05,
Skin full graft trunk add-on,15201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3457.03,,,,,,,fee schedule,3010,3755.05,
Skin full graft sclp/arm/leg,15220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3755.05,,,,,,,fee schedule,2042.58,9062.24,
Skin full graft sclp/arm/leg,15220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3010,,,,,,,fee schedule,2042.58,9062.24,
Skin full graft sclp/arm/leg,15220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3288.15,,,,,,,fee schedule,2042.58,9062.24,
Skin full graft sclp/arm/leg,15220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3457.03,,,,,,,fee schedule,2042.58,9062.24,
Skin full graft sclp/arm/leg,15220,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,2042.58,9062.24,APC 378
Skin full graft sclp/arm/leg,15220,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,2042.58,9062.24,APC
Skin full graft sclp/arm/leg,15220,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,2042.58,9062.24,APC
Skin full graft sclp/arm/leg,15220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,2042.58,9062.24,APC
Skin full graft sclp/arm/leg,15220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,2042.58,9062.24,Radiology
Skin full graft sclp/arm/leg,15220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,2042.58,9062.24,APC
Skin full graft sclp/arm/leg,15220,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,2042.58,9062.24,APC
Skin full graft add-on,15221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1129.65,,,,,,,fee schedule,905.52,1129.65,
Skin full graft add-on,15221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,905.52,,,,,,,fee schedule,905.52,1129.65,
Skin full graft add-on,15221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,989.19,,,,,,,fee schedule,905.52,1129.65,
Skin full graft add-on,15221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1040,,,,,,,fee schedule,905.52,1129.65,
Skin full grft face/genit/hf,15240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4062.96,,,,,,,fee schedule,2042.58,9062.24,
Skin full grft face/genit/hf,15240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3256.82,,,,,,,fee schedule,2042.58,9062.24,
Skin full grft face/genit/hf,15240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3557.78,,,,,,,fee schedule,2042.58,9062.24,
Skin full grft face/genit/hf,15240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3740.5,,,,,,,fee schedule,2042.58,9062.24,
Skin full grft face/genit/hf,15240,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,2042.58,9062.24,APC 378
Skin full grft face/genit/hf,15240,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,2042.58,9062.24,APC
Skin full grft face/genit/hf,15240,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,2042.58,9062.24,APC
Skin full grft face/genit/hf,15240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,2042.58,9062.24,APC
Skin full grft face/genit/hf,15240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,2042.58,9062.24,Radiology
Skin full grft face/genit/hf,15240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,2042.58,9062.24,APC
Skin full grft face/genit/hf,15240,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,2042.58,9062.24,APC
Skin full graft add-on,15241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1129.65,,,,,,,fee schedule,905.52,1129.65,
Skin full graft add-on,15241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,905.52,,,,,,,fee schedule,905.52,1129.65,
Skin full graft add-on,15241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,989.19,,,,,,,fee schedule,905.52,1129.65,
Skin full graft add-on,15241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1040,,,,,,,fee schedule,905.52,1129.65,
Skin full graft een & lips,15260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5336.73,,,,,,,fee schedule,2042.58,9062.24,
Skin full graft een & lips,15260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4277.86,,,,,,,fee schedule,2042.58,9062.24,
Skin full graft een & lips,15260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4673.17,,,,,,,fee schedule,2042.58,9062.24,
Skin full graft een & lips,15260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4913.18,,,,,,,fee schedule,2042.58,9062.24,
Skin full graft een & lips,15260,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,2042.58,9062.24,APC 378
Skin full graft een & lips,15260,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,2042.58,9062.24,APC
Skin full graft een & lips,15260,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,2042.58,9062.24,APC
Skin full graft een & lips,15260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,2042.58,9062.24,APC
Skin full graft een & lips,15260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,2042.58,9062.24,Radiology
Skin full graft een & lips,15260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,2042.58,9062.24,APC
Skin full graft een & lips,15260,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,2042.58,9062.24,APC
Skin full graft add-on,15261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3755.05,,,,,,,fee schedule,3010,3755.05,
Skin full graft add-on,15261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3010,,,,,,,fee schedule,3010,3755.05,
Skin full graft add-on,15261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3288.15,,,,,,,fee schedule,3010,3755.05,
Skin full graft add-on,15261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3457.03,,,,,,,fee schedule,3010,3755.05,
Skin sub graft trnk/arm/leg,15271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3430.41,,,,,,,fee schedule,731.66,3430.41,
Skin sub graft trnk/arm/leg,15271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2749.78,,,,,,,fee schedule,731.66,3430.41,
Skin sub graft trnk/arm/leg,15271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3003.88,,,,,,,fee schedule,731.66,3430.41,
Skin sub graft trnk/arm/leg,15271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3158.16,,,,,,,fee schedule,731.66,3430.41,
Skin sub graft trnk/arm/leg,15271,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3246.12,,,,,,,fee schedule,731.66,3430.41,APC 378
Skin sub graft trnk/arm/leg,15271,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,768.24,,,,,,,fee schedule,731.66,3430.41,APC
Skin sub graft trnk/arm/leg,15271,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,760.92,,,,,,,fee schedule,731.66,3430.41,APC
Skin sub graft trnk/arm/leg,15271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,731.66,,,,,,,fee schedule,731.66,3430.41,APC
Skin sub graft trnk/arm/leg,15271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1119.44,,,,,,,fee schedule,731.66,3430.41,Radiology
Skin sub graft trnk/arm/leg,15271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1024.32,,,,,,,fee schedule,731.66,3430.41,APC
Skin sub graft trnk/arm/leg,15271,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1280.4,,,,,,,fee schedule,731.66,3430.41,APC
Skin sub graft t/a/l add-on,15272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,324.14,,,,,,,fee schedule,259.82,324.14,
Skin sub graft t/a/l add-on,15272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,259.82,,,,,,,fee schedule,259.82,324.14,
Skin sub graft t/a/l add-on,15272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,283.83,,,,,,,fee schedule,259.82,324.14,
Skin sub graft t/a/l add-on,15272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,298.41,,,,,,,fee schedule,259.82,324.14,
Skin sub grft t/arm/lg child,15273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1486.98,,,,,,,fee schedule,1191.94,9062.24,
Skin sub grft t/arm/lg child,15273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1191.94,,,,,,,fee schedule,1191.94,9062.24,
Skin sub grft t/arm/lg child,15273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1302.09,,,,,,,fee schedule,1191.94,9062.24,
Skin sub grft t/arm/lg child,15273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1368.96,,,,,,,fee schedule,1191.94,9062.24,
Skin sub grft t/arm/lg child,15273,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,1191.94,9062.24,APC 378
Skin sub grft t/arm/lg child,15273,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,1191.94,9062.24,APC
Skin sub grft t/arm/lg child,15273,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,1191.94,9062.24,APC
Skin sub grft t/arm/lg child,15273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,1191.94,9062.24,APC
Skin sub grft t/arm/lg child,15273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,1191.94,9062.24,Radiology
Skin sub grft t/arm/lg child,15273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,1191.94,9062.24,APC
Skin sub grft t/arm/lg child,15273,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,1191.94,9062.24,APC
Skn sub grft t/a/l child add,15274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,950.59,,,,,,,fee schedule,761.98,950.59,
Skn sub grft t/a/l child add,15274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,761.98,,,,,,,fee schedule,761.98,950.59,
Skn sub grft t/a/l child add,15274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,832.4,,,,,,,fee schedule,761.98,950.59,
Skn sub grft t/a/l child add,15274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,875.15,,,,,,,fee schedule,761.98,950.59,
Skin sub graft face/nk/hf/g,15275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2960.94,,,,,,,fee schedule,731.66,3246.12,
Skin sub graft face/nk/hf/g,15275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2373.45,,,,,,,fee schedule,731.66,3246.12,
Skin sub graft face/nk/hf/g,15275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2592.78,,,,,,,fee schedule,731.66,3246.12,
Skin sub graft face/nk/hf/g,15275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2725.94,,,,,,,fee schedule,731.66,3246.12,
Skin sub graft face/nk/hf/g,15275,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3246.12,,,,,,,fee schedule,731.66,3246.12,APC 378
Skin sub graft face/nk/hf/g,15275,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,768.24,,,,,,,fee schedule,731.66,3246.12,APC
Skin sub graft face/nk/hf/g,15275,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,760.92,,,,,,,fee schedule,731.66,3246.12,APC
Skin sub graft face/nk/hf/g,15275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,731.66,,,,,,,fee schedule,731.66,3246.12,APC
Skin sub graft face/nk/hf/g,15275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1119.44,,,,,,,fee schedule,731.66,3246.12,Radiology
Skin sub graft face/nk/hf/g,15275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1024.32,,,,,,,fee schedule,731.66,3246.12,APC
Skin sub graft face/nk/hf/g,15275,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1280.4,,,,,,,fee schedule,731.66,3246.12,APC
Skin sub graft f/n/hf/g addl,15276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,324.14,,,,,,,fee schedule,259.82,324.14,
Skin sub graft f/n/hf/g addl,15276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,259.82,,,,,,,fee schedule,259.82,324.14,
Skin sub graft f/n/hf/g addl,15276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,283.83,,,,,,,fee schedule,259.82,324.14,
Skin sub graft f/n/hf/g addl,15276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,298.41,,,,,,,fee schedule,259.82,324.14,
Skn sub grft f/n/hf/g child,15277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4181.98,,,,,,,fee schedule,2042.58,9062.24,
Skn sub grft f/n/hf/g child,15277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3352.22,,,,,,,fee schedule,2042.58,9062.24,
Skn sub grft f/n/hf/g child,15277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3662,,,,,,,fee schedule,2042.58,9062.24,
Skn sub grft f/n/hf/g child,15277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3850.08,,,,,,,fee schedule,2042.58,9062.24,
Skn sub grft f/n/hf/g child,15277,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,2042.58,9062.24,APC 378
Skn sub grft f/n/hf/g child,15277,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,2042.58,9062.24,APC
Skn sub grft f/n/hf/g child,15277,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,2042.58,9062.24,APC
Skn sub grft f/n/hf/g child,15277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,2042.58,9062.24,APC
Skn sub grft f/n/hf/g child,15277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,2042.58,9062.24,Radiology
Skn sub grft f/n/hf/g child,15277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,2042.58,9062.24,APC
Skn sub grft f/n/hf/g child,15277,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,2042.58,9062.24,APC
Skn sub grft f/n/hf/g ch add,15278,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,950.59,,,,,,,fee schedule,761.98,950.59,
Skn sub grft f/n/hf/g ch add,15278,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,761.98,,,,,,,fee schedule,761.98,950.59,
Skn sub grft f/n/hf/g ch add,15278,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,832.4,,,,,,,fee schedule,761.98,950.59,
Skn sub grft f/n/hf/g ch add,15278,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,875.15,,,,,,,fee schedule,761.98,950.59,
Skin pedicle flap trunk,15570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5043.16,,,,,,,fee schedule,2042.58,9062.24,
Skin pedicle flap trunk,15570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4042.54,,,,,,,fee schedule,2042.58,9062.24,
Skin pedicle flap trunk,15570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4416.1,,,,,,,fee schedule,2042.58,9062.24,
Skin pedicle flap trunk,15570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4642.91,,,,,,,fee schedule,2042.58,9062.24,
Skin pedicle flap trunk,15570,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,2042.58,9062.24,APC 378
Skin pedicle flap trunk,15570,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,2042.58,9062.24,APC
Skin pedicle flap trunk,15570,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,2042.58,9062.24,APC
Skin pedicle flap trunk,15570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,2042.58,9062.24,APC
Skin pedicle flap trunk,15570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,2042.58,9062.24,Radiology
Skin pedicle flap trunk,15570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,2042.58,9062.24,APC
Skin pedicle flap trunk,15570,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,2042.58,9062.24,APC
Skin pedicle flap arms/legs,15572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5043.16,,,,,,,fee schedule,3508.17,15564.58,
Skin pedicle flap arms/legs,15572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4042.54,,,,,,,fee schedule,3508.17,15564.58,
Skin pedicle flap arms/legs,15572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4416.1,,,,,,,fee schedule,3508.17,15564.58,
Skin pedicle flap arms/legs,15572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4642.91,,,,,,,fee schedule,3508.17,15564.58,
Skin pedicle flap arms/legs,15572,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15564.58,,,,,,,fee schedule,3508.17,15564.58,APC 378
Skin pedicle flap arms/legs,15572,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3683.58,,,,,,,fee schedule,3508.17,15564.58,APC
Skin pedicle flap arms/legs,15572,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3648.5,,,,,,,fee schedule,3508.17,15564.58,APC
Skin pedicle flap arms/legs,15572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3508.17,,,,,,,fee schedule,3508.17,15564.58,APC
Skin pedicle flap arms/legs,15572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5367.5,,,,,,,fee schedule,3508.17,15564.58,Radiology
Skin pedicle flap arms/legs,15572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4911.44,,,,,,,fee schedule,3508.17,15564.58,APC
Skin pedicle flap arms/legs,15572,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6139.3,,,,,,,fee schedule,3508.17,15564.58,APC
Pedcle fh/ch/ch/m/n/ax/g/h/f,15574,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5043.16,,,,,,,fee schedule,2042.58,9062.24,
Pedcle fh/ch/ch/m/n/ax/g/h/f,15574,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4042.54,,,,,,,fee schedule,2042.58,9062.24,
Pedcle fh/ch/ch/m/n/ax/g/h/f,15574,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4416.1,,,,,,,fee schedule,2042.58,9062.24,
Pedcle fh/ch/ch/m/n/ax/g/h/f,15574,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4642.91,,,,,,,fee schedule,2042.58,9062.24,
Pedcle fh/ch/ch/m/n/ax/g/h/f,15574,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,2042.58,9062.24,APC 378
Pedcle fh/ch/ch/m/n/ax/g/h/f,15574,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,2042.58,9062.24,APC
Pedcle fh/ch/ch/m/n/ax/g/h/f,15574,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,2042.58,9062.24,APC
Pedcle fh/ch/ch/m/n/ax/g/h/f,15574,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,2042.58,9062.24,APC
Pedcle fh/ch/ch/m/n/ax/g/h/f,15574,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,2042.58,9062.24,Radiology
Pedcle fh/ch/ch/m/n/ax/g/h/f,15574,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,2042.58,9062.24,APC
Pedcle fh/ch/ch/m/n/ax/g/h/f,15574,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,2042.58,9062.24,APC
Pedicle e/n/e/l/ntroral,15576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4181.97,,,,,,,fee schedule,2042.58,9062.24,
Pedicle e/n/e/l/ntroral,15576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3352.21,,,,,,,fee schedule,2042.58,9062.24,
Pedicle e/n/e/l/ntroral,15576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3661.99,,,,,,,fee schedule,2042.58,9062.24,
Pedicle e/n/e/l/ntroral,15576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3850.07,,,,,,,fee schedule,2042.58,9062.24,
Pedicle e/n/e/l/ntroral,15576,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,2042.58,9062.24,APC 378
Pedicle e/n/e/l/ntroral,15576,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,2042.58,9062.24,APC
Pedicle e/n/e/l/ntroral,15576,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,2042.58,9062.24,APC
Pedicle e/n/e/l/ntroral,15576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,2042.58,9062.24,APC
Pedicle e/n/e/l/ntroral,15576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,2042.58,9062.24,Radiology
Pedicle e/n/e/l/ntroral,15576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,2042.58,9062.24,APC
Pedicle e/n/e/l/ntroral,15576,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,2042.58,9062.24,APC
Delay flap trunk,15600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5043.16,,,,,,,fee schedule,3508.17,15564.58,
Delay flap trunk,15600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4042.54,,,,,,,fee schedule,3508.17,15564.58,
Delay flap trunk,15600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4416.1,,,,,,,fee schedule,3508.17,15564.58,
Delay flap trunk,15600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4642.91,,,,,,,fee schedule,3508.17,15564.58,
Delay flap trunk,15600,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15564.58,,,,,,,fee schedule,3508.17,15564.58,APC 378
Delay flap trunk,15600,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3683.58,,,,,,,fee schedule,3508.17,15564.58,APC
Delay flap trunk,15600,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3648.5,,,,,,,fee schedule,3508.17,15564.58,APC
Delay flap trunk,15600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3508.17,,,,,,,fee schedule,3508.17,15564.58,APC
Delay flap trunk,15600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5367.5,,,,,,,fee schedule,3508.17,15564.58,Radiology
Delay flap trunk,15600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4911.44,,,,,,,fee schedule,3508.17,15564.58,APC
Delay flap trunk,15600,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6139.3,,,,,,,fee schedule,3508.17,15564.58,APC
Delay flap arms/legs,15610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5043.16,,,,,,,fee schedule,2042.58,9062.24,
Delay flap arms/legs,15610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4042.54,,,,,,,fee schedule,2042.58,9062.24,
Delay flap arms/legs,15610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4416.1,,,,,,,fee schedule,2042.58,9062.24,
Delay flap arms/legs,15610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4642.91,,,,,,,fee schedule,2042.58,9062.24,
Delay flap arms/legs,15610,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,2042.58,9062.24,APC 378
Delay flap arms/legs,15610,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,2042.58,9062.24,APC
Delay flap arms/legs,15610,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,2042.58,9062.24,APC
Delay flap arms/legs,15610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,2042.58,9062.24,APC
Delay flap arms/legs,15610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,2042.58,9062.24,Radiology
Delay flap arms/legs,15610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,2042.58,9062.24,APC
Delay flap arms/legs,15610,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,2042.58,9062.24,APC
Delay flap f/c/c/n/ax/g/h/f,15620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5043.16,,,,,,,fee schedule,2042.58,9062.24,
Delay flap f/c/c/n/ax/g/h/f,15620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4042.54,,,,,,,fee schedule,2042.58,9062.24,
Delay flap f/c/c/n/ax/g/h/f,15620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4416.1,,,,,,,fee schedule,2042.58,9062.24,
Delay flap f/c/c/n/ax/g/h/f,15620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4642.91,,,,,,,fee schedule,2042.58,9062.24,
Delay flap f/c/c/n/ax/g/h/f,15620,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,2042.58,9062.24,APC 378
Delay flap f/c/c/n/ax/g/h/f,15620,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,2042.58,9062.24,APC
Delay flap f/c/c/n/ax/g/h/f,15620,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,2042.58,9062.24,APC
Delay flap f/c/c/n/ax/g/h/f,15620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,2042.58,9062.24,APC
Delay flap f/c/c/n/ax/g/h/f,15620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,2042.58,9062.24,Radiology
Delay flap f/c/c/n/ax/g/h/f,15620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,2042.58,9062.24,APC
Delay flap f/c/c/n/ax/g/h/f,15620,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,2042.58,9062.24,APC
Delay flap eye/nos/ear/lip,15630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5043.16,,,,,,,fee schedule,2042.58,9062.24,
Delay flap eye/nos/ear/lip,15630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4042.54,,,,,,,fee schedule,2042.58,9062.24,
Delay flap eye/nos/ear/lip,15630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4416.1,,,,,,,fee schedule,2042.58,9062.24,
Delay flap eye/nos/ear/lip,15630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4642.91,,,,,,,fee schedule,2042.58,9062.24,
Delay flap eye/nos/ear/lip,15630,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,2042.58,9062.24,APC 378
Delay flap eye/nos/ear/lip,15630,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,2042.58,9062.24,APC
Delay flap eye/nos/ear/lip,15630,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,2042.58,9062.24,APC
Delay flap eye/nos/ear/lip,15630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,2042.58,9062.24,APC
Delay flap eye/nos/ear/lip,15630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,2042.58,9062.24,Radiology
Delay flap eye/nos/ear/lip,15630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,2042.58,9062.24,APC
Delay flap eye/nos/ear/lip,15630,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,2042.58,9062.24,APC
Transfer skin pedicle flap,15650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3360.79,,,,,,,fee schedule,2042.58,9062.24,
Transfer skin pedicle flap,15650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2693.96,,,,,,,fee schedule,2042.58,9062.24,
Transfer skin pedicle flap,15650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2942.91,,,,,,,fee schedule,2042.58,9062.24,
Transfer skin pedicle flap,15650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3094.06,,,,,,,fee schedule,2042.58,9062.24,
Transfer skin pedicle flap,15650,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,2042.58,9062.24,APC 378
Transfer skin pedicle flap,15650,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,2042.58,9062.24,APC
Transfer skin pedicle flap,15650,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,2042.58,9062.24,APC
Transfer skin pedicle flap,15650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,2042.58,9062.24,APC
Transfer skin pedicle flap,15650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,2042.58,9062.24,Radiology
Transfer skin pedicle flap,15650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,2042.58,9062.24,APC
Transfer skin pedicle flap,15650,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,2042.58,9062.24,APC
Mdfc flap w/prsrv vasc pedcl,15730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10455.97,,,,,,,fee schedule,3508.17,15564.58,
Mdfc flap w/prsrv vasc pedcl,15730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8381.37,,,,,,,fee schedule,3508.17,15564.58,
Mdfc flap w/prsrv vasc pedcl,15730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9155.89,,,,,,,fee schedule,3508.17,15564.58,
Mdfc flap w/prsrv vasc pedcl,15730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9626.13,,,,,,,fee schedule,3508.17,15564.58,
Mdfc flap w/prsrv vasc pedcl,15730,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15564.58,,,,,,,fee schedule,3508.17,15564.58,APC 378
Mdfc flap w/prsrv vasc pedcl,15730,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3683.58,,,,,,,fee schedule,3508.17,15564.58,APC
Mdfc flap w/prsrv vasc pedcl,15730,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3648.5,,,,,,,fee schedule,3508.17,15564.58,APC
Mdfc flap w/prsrv vasc pedcl,15730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3508.17,,,,,,,fee schedule,3508.17,15564.58,APC
Mdfc flap w/prsrv vasc pedcl,15730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5367.5,,,,,,,fee schedule,3508.17,15564.58,Radiology
Mdfc flap w/prsrv vasc pedcl,15730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4911.44,,,,,,,fee schedule,3508.17,15564.58,APC
Mdfc flap w/prsrv vasc pedcl,15730,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6139.3,,,,,,,fee schedule,3508.17,15564.58,APC
Forehead Flap w/Vasc Pedicle,15731,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5043.16,,,,,,,fee schedule,3508.17,15564.58,
Forehead Flap w/Vasc Pedicle,15731,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4042.54,,,,,,,fee schedule,3508.17,15564.58,
Forehead Flap w/Vasc Pedicle,15731,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4416.1,,,,,,,fee schedule,3508.17,15564.58,
Forehead Flap w/Vasc Pedicle,15731,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4642.91,,,,,,,fee schedule,3508.17,15564.58,
Forehead Flap w/Vasc Pedicle,15731,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15564.58,,,,,,,fee schedule,3508.17,15564.58,APC 378
Forehead Flap w/Vasc Pedicle,15731,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3683.58,,,,,,,fee schedule,3508.17,15564.58,APC
Forehead Flap w/Vasc Pedicle,15731,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3648.5,,,,,,,fee schedule,3508.17,15564.58,APC
Forehead Flap w/Vasc Pedicle,15731,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3508.17,,,,,,,fee schedule,3508.17,15564.58,APC
Forehead Flap w/Vasc Pedicle,15731,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5367.5,,,,,,,fee schedule,3508.17,15564.58,Radiology
Forehead Flap w/Vasc Pedicle,15731,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4911.44,,,,,,,fee schedule,3508.17,15564.58,APC
Forehead Flap w/Vasc Pedicle,15731,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6139.3,,,,,,,fee schedule,3508.17,15564.58,APC
Musc myoq/fscq flp h&n pedcl,15733,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10455.97,,,,,,,fee schedule,3508.17,15564.58,
Musc myoq/fscq flp h&n pedcl,15733,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8381.37,,,,,,,fee schedule,3508.17,15564.58,
Musc myoq/fscq flp h&n pedcl,15733,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9155.89,,,,,,,fee schedule,3508.17,15564.58,
Musc myoq/fscq flp h&n pedcl,15733,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9626.13,,,,,,,fee schedule,3508.17,15564.58,
Musc myoq/fscq flp h&n pedcl,15733,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15564.58,,,,,,,fee schedule,3508.17,15564.58,APC 378
Musc myoq/fscq flp h&n pedcl,15733,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3683.58,,,,,,,fee schedule,3508.17,15564.58,APC
Musc myoq/fscq flp h&n pedcl,15733,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3648.5,,,,,,,fee schedule,3508.17,15564.58,APC
Musc myoq/fscq flp h&n pedcl,15733,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3508.17,,,,,,,fee schedule,3508.17,15564.58,APC
Musc myoq/fscq flp h&n pedcl,15733,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5367.5,,,,,,,fee schedule,3508.17,15564.58,Radiology
Musc myoq/fscq flp h&n pedcl,15733,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4911.44,,,,,,,fee schedule,3508.17,15564.58,APC
Musc myoq/fscq flp h&n pedcl,15733,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6139.3,,,,,,,fee schedule,3508.17,15564.58,APC
Muscle-skin graft trunk,15734,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3644.88,,,,,,,fee schedule,2921.69,15564.58,
Muscle-skin graft trunk,15734,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2921.69,,,,,,,fee schedule,2921.69,15564.58,
Muscle-skin graft trunk,15734,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3191.68,,,,,,,fee schedule,2921.69,15564.58,
Muscle-skin graft trunk,15734,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3355.61,,,,,,,fee schedule,2921.69,15564.58,
Muscle-skin graft trunk,15734,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15564.58,,,,,,,fee schedule,2921.69,15564.58,APC 378
Muscle-skin graft trunk,15734,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3683.58,,,,,,,fee schedule,2921.69,15564.58,APC
Muscle-skin graft trunk,15734,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3648.5,,,,,,,fee schedule,2921.69,15564.58,APC
Muscle-skin graft trunk,15734,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3508.17,,,,,,,fee schedule,2921.69,15564.58,APC
Muscle-skin graft trunk,15734,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5367.5,,,,,,,fee schedule,2921.69,15564.58,Radiology
Muscle-skin graft trunk,15734,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4911.44,,,,,,,fee schedule,2921.69,15564.58,APC
Muscle-skin graft trunk,15734,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6139.3,,,,,,,fee schedule,2921.69,15564.58,APC
Muscle-skin graft arm,15736,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5336.73,,,,,,,fee schedule,2042.58,9062.24,
Muscle-skin graft arm,15736,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4277.86,,,,,,,fee schedule,2042.58,9062.24,
Muscle-skin graft arm,15736,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4673.17,,,,,,,fee schedule,2042.58,9062.24,
Muscle-skin graft arm,15736,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4913.18,,,,,,,fee schedule,2042.58,9062.24,
Muscle-skin graft arm,15736,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,2042.58,9062.24,APC 378
Muscle-skin graft arm,15736,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,2042.58,9062.24,APC
Muscle-skin graft arm,15736,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,2042.58,9062.24,APC
Muscle-skin graft arm,15736,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,2042.58,9062.24,APC
Muscle-skin graft arm,15736,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,2042.58,9062.24,Radiology
Muscle-skin graft arm,15736,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,2042.58,9062.24,APC
Muscle-skin graft arm,15736,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,2042.58,9062.24,APC
Muscle-skin graft leg,15738,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5043.16,,,,,,,fee schedule,3508.17,15564.58,
Muscle-skin graft leg,15738,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4042.54,,,,,,,fee schedule,3508.17,15564.58,
Muscle-skin graft leg,15738,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4416.1,,,,,,,fee schedule,3508.17,15564.58,
Muscle-skin graft leg,15738,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4642.91,,,,,,,fee schedule,3508.17,15564.58,
Muscle-skin graft leg,15738,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15564.58,,,,,,,fee schedule,3508.17,15564.58,APC 378
Muscle-skin graft leg,15738,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3683.58,,,,,,,fee schedule,3508.17,15564.58,APC
Muscle-skin graft leg,15738,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3648.5,,,,,,,fee schedule,3508.17,15564.58,APC
Muscle-skin graft leg,15738,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3508.17,,,,,,,fee schedule,3508.17,15564.58,APC
Muscle-skin graft leg,15738,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5367.5,,,,,,,fee schedule,3508.17,15564.58,Radiology
Muscle-skin graft leg,15738,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4911.44,,,,,,,fee schedule,3508.17,15564.58,APC
Muscle-skin graft leg,15738,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6139.3,,,,,,,fee schedule,3508.17,15564.58,APC
Island pedicle flap graft,15740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3755.05,,,,,,,fee schedule,2042.58,9062.24,
Island pedicle flap graft,15740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3010,,,,,,,fee schedule,2042.58,9062.24,
Island pedicle flap graft,15740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3288.15,,,,,,,fee schedule,2042.58,9062.24,
Island pedicle flap graft,15740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3457.03,,,,,,,fee schedule,2042.58,9062.24,
Island pedicle flap graft,15740,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,2042.58,9062.24,APC 378
Island pedicle flap graft,15740,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,2042.58,9062.24,APC
Island pedicle flap graft,15740,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,2042.58,9062.24,APC
Island pedicle flap graft,15740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,2042.58,9062.24,APC
Island pedicle flap graft,15740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,2042.58,9062.24,Radiology
Island pedicle flap graft,15740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,2042.58,9062.24,APC
Island pedicle flap graft,15740,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,2042.58,9062.24,APC
Neurovascular pedicle flap,15750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5043.16,,,,,,,fee schedule,3508.17,15564.58,
Neurovascular pedicle flap,15750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4042.54,,,,,,,fee schedule,3508.17,15564.58,
Neurovascular pedicle flap,15750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4416.1,,,,,,,fee schedule,3508.17,15564.58,
Neurovascular pedicle flap,15750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4642.91,,,,,,,fee schedule,3508.17,15564.58,
Neurovascular pedicle flap,15750,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15564.58,,,,,,,fee schedule,3508.17,15564.58,APC 378
Neurovascular pedicle flap,15750,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3683.58,,,,,,,fee schedule,3508.17,15564.58,APC
Neurovascular pedicle flap,15750,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3648.5,,,,,,,fee schedule,3508.17,15564.58,APC
Neurovascular pedicle flap,15750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3508.17,,,,,,,fee schedule,3508.17,15564.58,APC
Neurovascular pedicle flap,15750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5367.5,,,,,,,fee schedule,3508.17,15564.58,Radiology
Neurovascular pedicle flap,15750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4911.44,,,,,,,fee schedule,3508.17,15564.58,APC
Neurovascular pedicle flap,15750,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6139.3,,,,,,,fee schedule,3508.17,15564.58,APC
Composite skin graft,15760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5043.16,,,,,,,fee schedule,2042.58,9062.24,
Composite skin graft,15760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4042.54,,,,,,,fee schedule,2042.58,9062.24,
Composite skin graft,15760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4416.1,,,,,,,fee schedule,2042.58,9062.24,
Composite skin graft,15760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4642.91,,,,,,,fee schedule,2042.58,9062.24,
Composite skin graft,15760,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,2042.58,9062.24,APC 378
Composite skin graft,15760,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,2042.58,9062.24,APC
Composite skin graft,15760,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,2042.58,9062.24,APC
Composite skin graft,15760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,2042.58,9062.24,APC
Composite skin graft,15760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,2042.58,9062.24,Radiology
Composite skin graft,15760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,2042.58,9062.24,APC
Composite skin graft,15760,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,2042.58,9062.24,APC
Grfg autol soft tiss dir exc,15769,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11254.16,,,,,,,fee schedule,3508.17,15564.58,
Grfg autol soft tiss dir exc,15769,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9021.19,,,,,,,fee schedule,3508.17,15564.58,
Grfg autol soft tiss dir exc,15769,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9854.83,,,,,,,fee schedule,3508.17,15564.58,
Grfg autol soft tiss dir exc,15769,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10360.97,,,,,,,fee schedule,3508.17,15564.58,
Grfg autol soft tiss dir exc,15769,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15564.58,,,,,,,fee schedule,3508.17,15564.58,APC 378
Grfg autol soft tiss dir exc,15769,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3683.58,,,,,,,fee schedule,3508.17,15564.58,APC
Grfg autol soft tiss dir exc,15769,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3648.5,,,,,,,fee schedule,3508.17,15564.58,APC
Grfg autol soft tiss dir exc,15769,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3508.17,,,,,,,fee schedule,3508.17,15564.58,APC
Grfg autol soft tiss dir exc,15769,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5367.5,,,,,,,fee schedule,3508.17,15564.58,Radiology
Grfg autol soft tiss dir exc,15769,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4911.44,,,,,,,fee schedule,3508.17,15564.58,APC
Grfg autol soft tiss dir exc,15769,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6139.3,,,,,,,fee schedule,3508.17,15564.58,APC
Derma-fat-fascia graft,15770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5043.16,,,,,,,fee schedule,3508.17,15564.58,
Derma-fat-fascia graft,15770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4042.54,,,,,,,fee schedule,3508.17,15564.58,
Derma-fat-fascia graft,15770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4416.1,,,,,,,fee schedule,3508.17,15564.58,
Derma-fat-fascia graft,15770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4642.91,,,,,,,fee schedule,3508.17,15564.58,
Derma-fat-fascia graft,15770,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15564.58,,,,,,,fee schedule,3508.17,15564.58,APC 378
Derma-fat-fascia graft,15770,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3683.58,,,,,,,fee schedule,3508.17,15564.58,APC
Derma-fat-fascia graft,15770,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3648.5,,,,,,,fee schedule,3508.17,15564.58,APC
Derma-fat-fascia graft,15770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3508.17,,,,,,,fee schedule,3508.17,15564.58,APC
Derma-fat-fascia graft,15770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5367.5,,,,,,,fee schedule,3508.17,15564.58,Radiology
Derma-fat-fascia graft,15770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4911.44,,,,,,,fee schedule,3508.17,15564.58,APC
Derma-fat-fascia graft,15770,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6139.3,,,,,,,fee schedule,3508.17,15564.58,APC
Grfg autol fat lipo 50 cc/<,15771,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11254.16,,,,,,,fee schedule,3508.17,15564.58,
Grfg autol fat lipo 50 cc/<,15771,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9021.19,,,,,,,fee schedule,3508.17,15564.58,
Grfg autol fat lipo 50 cc/<,15771,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9854.83,,,,,,,fee schedule,3508.17,15564.58,
Grfg autol fat lipo 50 cc/<,15771,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10360.97,,,,,,,fee schedule,3508.17,15564.58,
Grfg autol fat lipo 50 cc/<,15771,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15564.58,,,,,,,fee schedule,3508.17,15564.58,APC 378
Grfg autol fat lipo 50 cc/<,15771,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3683.58,,,,,,,fee schedule,3508.17,15564.58,APC
Grfg autol fat lipo 50 cc/<,15771,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3648.5,,,,,,,fee schedule,3508.17,15564.58,APC
Grfg autol fat lipo 50 cc/<,15771,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3508.17,,,,,,,fee schedule,3508.17,15564.58,APC
Grfg autol fat lipo 50 cc/<,15771,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5367.5,,,,,,,fee schedule,3508.17,15564.58,Radiology
Grfg autol fat lipo 50 cc/<,15771,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4911.44,,,,,,,fee schedule,3508.17,15564.58,APC
Grfg autol fat lipo 50 cc/<,15771,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6139.3,,,,,,,fee schedule,3508.17,15564.58,APC
Grfg autol fat lipo ea addl,15772,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,549.65,,,,,,,fee schedule,440.59,549.65,
Grfg autol fat lipo ea addl,15772,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,440.59,,,,,,,fee schedule,440.59,549.65,
Grfg autol fat lipo ea addl,15772,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,481.31,,,,,,,fee schedule,440.59,549.65,
Grfg autol fat lipo ea addl,15772,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,506.03,,,,,,,fee schedule,440.59,549.65,
Grfg autol fat lipo 25 cc/<,15773,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6133.96,,,,,,,fee schedule,2042.58,9062.24,
Grfg autol fat lipo 25 cc/<,15773,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4916.9,,,,,,,fee schedule,2042.58,9062.24,
Grfg autol fat lipo 25 cc/<,15773,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5371.27,,,,,,,fee schedule,2042.58,9062.24,
Grfg autol fat lipo 25 cc/<,15773,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5647.14,,,,,,,fee schedule,2042.58,9062.24,
Grfg autol fat lipo 25 cc/<,15773,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,2042.58,9062.24,APC 378
Grfg autol fat lipo 25 cc/<,15773,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,2042.58,9062.24,APC
Grfg autol fat lipo 25 cc/<,15773,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,2042.58,9062.24,APC
Grfg autol fat lipo 25 cc/<,15773,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,2042.58,9062.24,APC
Grfg autol fat lipo 25 cc/<,15773,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,2042.58,9062.24,Radiology
Grfg autol fat lipo 25 cc/<,15773,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,2042.58,9062.24,APC
Grfg autol fat lipo 25 cc/<,15773,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,2042.58,9062.24,APC
Gfrg autol fat lipo ea addl,15774,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,527.61,,,,,,,fee schedule,422.93,527.61,
Gfrg autol fat lipo ea addl,15774,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,422.93,,,,,,,fee schedule,422.93,527.61,
Gfrg autol fat lipo ea addl,15774,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,462.01,,,,,,,fee schedule,422.93,527.61,
Gfrg autol fat lipo ea addl,15774,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,485.74,,,,,,,fee schedule,422.93,527.61,
Hair trnspl 1-15 punch grfts,15775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,319.26,,,,,,,fee schedule,255.91,1785.48,
Hair trnspl 1-15 punch grfts,15775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,255.91,,,,,,,fee schedule,255.91,1785.48,
Hair trnspl 1-15 punch grfts,15775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,279.56,,,,,,,fee schedule,255.91,1785.48,
Hair trnspl 1-15 punch grfts,15775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,293.92,,,,,,,fee schedule,255.91,1785.48,
Hair trnspl 1-15 punch grfts,15775,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1785.48,,,,,,,fee schedule,255.91,1785.48,APC 378
Hair trnspl 1-15 punch grfts,15775,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,422.56,,,,,,,fee schedule,255.91,1785.48,APC
Hair trnspl 1-15 punch grfts,15775,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,418.53,,,,,,,fee schedule,255.91,1785.48,APC
Hair trnspl 1-15 punch grfts,15775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,402.44,,,,,,,fee schedule,255.91,1785.48,APC
Hair trnspl 1-15 punch grfts,15775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,615.73,,,,,,,fee schedule,255.91,1785.48,Radiology
Hair trnspl 1-15 punch grfts,15775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,563.41,,,,,,,fee schedule,255.91,1785.48,APC
Hair trnspl 1-15 punch grfts,15775,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,704.26,,,,,,,fee schedule,255.91,1785.48,APC
Hair trnspl >15 punch grafts,15776,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,319.26,,,,,,,fee schedule,255.91,1785.48,
Hair trnspl >15 punch grafts,15776,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,255.91,,,,,,,fee schedule,255.91,1785.48,
Hair trnspl >15 punch grafts,15776,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,279.56,,,,,,,fee schedule,255.91,1785.48,
Hair trnspl >15 punch grafts,15776,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,293.92,,,,,,,fee schedule,255.91,1785.48,
Hair trnspl >15 punch grafts,15776,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1785.48,,,,,,,fee schedule,255.91,1785.48,APC 378
Hair trnspl >15 punch grafts,15776,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,422.56,,,,,,,fee schedule,255.91,1785.48,APC
Hair trnspl >15 punch grafts,15776,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,418.53,,,,,,,fee schedule,255.91,1785.48,APC
Hair trnspl >15 punch grafts,15776,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,402.44,,,,,,,fee schedule,255.91,1785.48,APC
Hair trnspl >15 punch grafts,15776,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,615.73,,,,,,,fee schedule,255.91,1785.48,Radiology
Hair trnspl >15 punch grafts,15776,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,563.41,,,,,,,fee schedule,255.91,1785.48,APC
Hair trnspl >15 punch grafts,15776,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,704.26,,,,,,,fee schedule,255.91,1785.48,APC
Acellular derm matrix implt,15777,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3267.42,,,,,,,fee schedule,2619.12,3267.42,
Acellular derm matrix implt,15777,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2619.12,,,,,,,fee schedule,2619.12,3267.42,
Acellular derm matrix implt,15777,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2861.15,,,,,,,fee schedule,2619.12,3267.42,
Acellular derm matrix implt,15777,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3008.1,,,,,,,fee schedule,2619.12,3267.42,
Dermabrasion total face,15780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5268.49,,,,,,,fee schedule,2875.57,12757.95,
Dermabrasion total face,15780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4223.15,,,,,,,fee schedule,2875.57,12757.95,
Dermabrasion total face,15780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4613.41,,,,,,,fee schedule,2875.57,12757.95,
Dermabrasion total face,15780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4850.35,,,,,,,fee schedule,2875.57,12757.95,
Dermabrasion total face,15780,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Dermabrasion total face,15780,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Dermabrasion total face,15780,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Dermabrasion total face,15780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Dermabrasion total face,15780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Dermabrasion total face,15780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Dermabrasion total face,15780,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Dermabrasion segmental face,15781,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1074.12,,,,,,,fee schedule,701.03,3110.22,
Dermabrasion segmental face,15781,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,861,,,,,,,fee schedule,701.03,3110.22,
Dermabrasion segmental face,15781,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,940.57,,,,,,,fee schedule,701.03,3110.22,
Dermabrasion segmental face,15781,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,988.88,,,,,,,fee schedule,701.03,3110.22,
Dermabrasion segmental face,15781,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3110.22,,,,,,,fee schedule,701.03,3110.22,APC 378
Dermabrasion segmental face,15781,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,736.08,,,,,,,fee schedule,701.03,3110.22,APC
Dermabrasion segmental face,15781,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,729.07,,,,,,,fee schedule,701.03,3110.22,APC
Dermabrasion segmental face,15781,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,701.03,,,,,,,fee schedule,701.03,3110.22,APC
Dermabrasion segmental face,15781,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1072.57,,,,,,,fee schedule,701.03,3110.22,Radiology
Dermabrasion segmental face,15781,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,981.44,,,,,,,fee schedule,701.03,3110.22,APC
Dermabrasion segmental face,15781,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1226.8,,,,,,,fee schedule,701.03,3110.22,APC
Dermabrasion other than face,15782,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1074.12,,,,,,,fee schedule,861,12757.95,
Dermabrasion other than face,15782,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,861,,,,,,,fee schedule,861,12757.95,
Dermabrasion other than face,15782,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,940.57,,,,,,,fee schedule,861,12757.95,
Dermabrasion other than face,15782,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,988.88,,,,,,,fee schedule,861,12757.95,
Dermabrasion other than face,15782,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,861,12757.95,APC 378
Dermabrasion other than face,15782,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,861,12757.95,APC
Dermabrasion other than face,15782,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,861,12757.95,APC
Dermabrasion other than face,15782,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,861,12757.95,APC
Dermabrasion other than face,15782,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,861,12757.95,Radiology
Dermabrasion other than face,15782,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,861,12757.95,APC
Dermabrasion other than face,15782,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,861,12757.95,APC
Dermabrasion suprfl any site,15783,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,663.96,,,,,,,fee schedule,402.44,1785.48,
Dermabrasion suprfl any site,15783,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,532.22,,,,,,,fee schedule,402.44,1785.48,
Dermabrasion suprfl any site,15783,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,581.4,,,,,,,fee schedule,402.44,1785.48,
Dermabrasion suprfl any site,15783,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,611.26,,,,,,,fee schedule,402.44,1785.48,
Dermabrasion suprfl any site,15783,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1785.48,,,,,,,fee schedule,402.44,1785.48,APC 378
Dermabrasion suprfl any site,15783,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,422.56,,,,,,,fee schedule,402.44,1785.48,APC
Dermabrasion suprfl any site,15783,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,418.53,,,,,,,fee schedule,402.44,1785.48,APC
Dermabrasion suprfl any site,15783,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,402.44,,,,,,,fee schedule,402.44,1785.48,APC
Dermabrasion suprfl any site,15783,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,615.73,,,,,,,fee schedule,402.44,1785.48,Radiology
Dermabrasion suprfl any site,15783,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,563.41,,,,,,,fee schedule,402.44,1785.48,APC
Dermabrasion suprfl any site,15783,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,704.26,,,,,,,fee schedule,402.44,1785.48,APC
Abrasion lesion single,15786,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,197.92,,,,,,,fee schedule,158.65,881.22,
Abrasion lesion single,15786,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,158.65,,,,,,,fee schedule,158.65,881.22,
Abrasion lesion single,15786,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,173.31,,,,,,,fee schedule,158.65,881.22,
Abrasion lesion single,15786,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,182.21,,,,,,,fee schedule,158.65,881.22,
Abrasion lesion single,15786,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,881.22,,,,,,,fee schedule,158.65,881.22,APC 378
Abrasion lesion single,15786,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.55,,,,,,,fee schedule,158.65,881.22,APC
Abrasion lesion single,15786,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,206.57,,,,,,,fee schedule,158.65,881.22,APC
Abrasion lesion single,15786,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.62,,,,,,,fee schedule,158.65,881.22,APC
Abrasion lesion single,15786,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.89,,,,,,,fee schedule,158.65,881.22,Radiology
Abrasion lesion single,15786,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,278.07,,,,,,,fee schedule,158.65,881.22,APC
Abrasion lesion single,15786,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,347.59,,,,,,,fee schedule,158.65,881.22,APC
Abrasion lesions add-on,15787,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,197.92,,,,,,,fee schedule,158.65,197.92,
Abrasion lesions add-on,15787,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,158.65,,,,,,,fee schedule,158.65,197.92,
Abrasion lesions add-on,15787,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,173.31,,,,,,,fee schedule,158.65,197.92,
Abrasion lesions add-on,15787,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,182.21,,,,,,,fee schedule,158.65,197.92,
Chemical peel face epiderm,15788,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,197.92,,,,,,,fee schedule,158.65,1785.48,
Chemical peel face epiderm,15788,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,158.65,,,,,,,fee schedule,158.65,1785.48,
Chemical peel face epiderm,15788,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,173.31,,,,,,,fee schedule,158.65,1785.48,
Chemical peel face epiderm,15788,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,182.21,,,,,,,fee schedule,158.65,1785.48,
Chemical peel face epiderm,15788,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1785.48,,,,,,,fee schedule,158.65,1785.48,APC 378
Chemical peel face epiderm,15788,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,422.56,,,,,,,fee schedule,158.65,1785.48,APC
Chemical peel face epiderm,15788,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,418.53,,,,,,,fee schedule,158.65,1785.48,APC
Chemical peel face epiderm,15788,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,402.44,,,,,,,fee schedule,158.65,1785.48,APC
Chemical peel face epiderm,15788,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,615.73,,,,,,,fee schedule,158.65,1785.48,Radiology
Chemical peel face epiderm,15788,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,563.41,,,,,,,fee schedule,158.65,1785.48,APC
Chemical peel face epiderm,15788,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,704.26,,,,,,,fee schedule,158.65,1785.48,APC
Chemical peel face dermal,15789,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,364.24,,,,,,,fee schedule,291.97,3246.12,
Chemical peel face dermal,15789,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,291.97,,,,,,,fee schedule,291.97,3246.12,
Chemical peel face dermal,15789,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,318.95,,,,,,,fee schedule,291.97,3246.12,
Chemical peel face dermal,15789,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,335.33,,,,,,,fee schedule,291.97,3246.12,
Chemical peel face dermal,15789,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3246.12,,,,,,,fee schedule,291.97,3246.12,APC 378
Chemical peel face dermal,15789,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,768.24,,,,,,,fee schedule,291.97,3246.12,APC
Chemical peel face dermal,15789,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,760.92,,,,,,,fee schedule,291.97,3246.12,APC
Chemical peel face dermal,15789,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,731.66,,,,,,,fee schedule,291.97,3246.12,APC
Chemical peel face dermal,15789,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1119.44,,,,,,,fee schedule,291.97,3246.12,Radiology
Chemical peel face dermal,15789,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1024.32,,,,,,,fee schedule,291.97,3246.12,APC
Chemical peel face dermal,15789,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1280.4,,,,,,,fee schedule,291.97,3246.12,APC
Chemical peel nonfacial,15792,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,364.24,,,,,,,fee schedule,291.97,3246.12,
Chemical peel nonfacial,15792,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,291.97,,,,,,,fee schedule,291.97,3246.12,
Chemical peel nonfacial,15792,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,318.95,,,,,,,fee schedule,291.97,3246.12,
Chemical peel nonfacial,15792,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,335.33,,,,,,,fee schedule,291.97,3246.12,
Chemical peel nonfacial,15792,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3246.12,,,,,,,fee schedule,291.97,3246.12,APC 378
Chemical peel nonfacial,15792,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,768.24,,,,,,,fee schedule,291.97,3246.12,APC
Chemical peel nonfacial,15792,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,760.92,,,,,,,fee schedule,291.97,3246.12,APC
Chemical peel nonfacial,15792,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,731.66,,,,,,,fee schedule,291.97,3246.12,APC
Chemical peel nonfacial,15792,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1119.44,,,,,,,fee schedule,291.97,3246.12,Radiology
Chemical peel nonfacial,15792,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1024.32,,,,,,,fee schedule,291.97,3246.12,APC
Chemical peel nonfacial,15792,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1280.4,,,,,,,fee schedule,291.97,3246.12,APC
Chemical peel nonfacial,15793,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,197.92,,,,,,,fee schedule,158.65,1785.48,
Chemical peel nonfacial,15793,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,158.65,,,,,,,fee schedule,158.65,1785.48,
Chemical peel nonfacial,15793,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,173.31,,,,,,,fee schedule,158.65,1785.48,
Chemical peel nonfacial,15793,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,182.21,,,,,,,fee schedule,158.65,1785.48,
Chemical peel nonfacial,15793,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1785.48,,,,,,,fee schedule,158.65,1785.48,APC 378
Chemical peel nonfacial,15793,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,422.56,,,,,,,fee schedule,158.65,1785.48,APC
Chemical peel nonfacial,15793,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,418.53,,,,,,,fee schedule,158.65,1785.48,APC
Chemical peel nonfacial,15793,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,402.44,,,,,,,fee schedule,158.65,1785.48,APC
Chemical peel nonfacial,15793,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,615.73,,,,,,,fee schedule,158.65,1785.48,Radiology
Chemical peel nonfacial,15793,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,563.41,,,,,,,fee schedule,158.65,1785.48,APC
Chemical peel nonfacial,15793,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,704.26,,,,,,,fee schedule,158.65,1785.48,APC
Plastic surgery neck,15819,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,525.38,,,,,,,fee schedule,421.14,525.38,
Plastic surgery neck,15819,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,421.14,,,,,,,fee schedule,421.14,525.38,
Plastic surgery neck,15819,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,460.06,,,,,,,fee schedule,421.14,525.38,
Plastic surgery neck,15819,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,483.69,,,,,,,fee schedule,421.14,525.38,
Revision of lower eyelid,15820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5043.16,,,,,,,fee schedule,2042.58,9062.24,
Revision of lower eyelid,15820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4042.54,,,,,,,fee schedule,2042.58,9062.24,
Revision of lower eyelid,15820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4416.1,,,,,,,fee schedule,2042.58,9062.24,
Revision of lower eyelid,15820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4642.91,,,,,,,fee schedule,2042.58,9062.24,
Revision of lower eyelid,15820,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,2042.58,9062.24,APC 378
Revision of lower eyelid,15820,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,2042.58,9062.24,APC
Revision of lower eyelid,15820,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,2042.58,9062.24,APC
Revision of lower eyelid,15820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,2042.58,9062.24,APC
Revision of lower eyelid,15820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,2042.58,9062.24,Radiology
Revision of lower eyelid,15820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,2042.58,9062.24,APC
Revision of lower eyelid,15820,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,2042.58,9062.24,APC
Revision of lower eyelid,15821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5043.16,,,,,,,fee schedule,2042.58,9062.24,
Revision of lower eyelid,15821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4042.54,,,,,,,fee schedule,2042.58,9062.24,
Revision of lower eyelid,15821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4416.1,,,,,,,fee schedule,2042.58,9062.24,
Revision of lower eyelid,15821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4642.91,,,,,,,fee schedule,2042.58,9062.24,
Revision of lower eyelid,15821,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,2042.58,9062.24,APC 378
Revision of lower eyelid,15821,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,2042.58,9062.24,APC
Revision of lower eyelid,15821,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,2042.58,9062.24,APC
Revision of lower eyelid,15821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,2042.58,9062.24,APC
Revision of lower eyelid,15821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,2042.58,9062.24,Radiology
Revision of lower eyelid,15821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,2042.58,9062.24,APC
Revision of lower eyelid,15821,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,2042.58,9062.24,APC
Revision of upper eyelid,15822,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5043.16,,,,,,,fee schedule,2042.58,9062.24,
Revision of upper eyelid,15822,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4042.54,,,,,,,fee schedule,2042.58,9062.24,
Revision of upper eyelid,15822,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4416.1,,,,,,,fee schedule,2042.58,9062.24,
Revision of upper eyelid,15822,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4642.91,,,,,,,fee schedule,2042.58,9062.24,
Revision of upper eyelid,15822,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,2042.58,9062.24,APC 378
Revision of upper eyelid,15822,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,2042.58,9062.24,APC
Revision of upper eyelid,15822,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,2042.58,9062.24,APC
Revision of upper eyelid,15822,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,2042.58,9062.24,APC
Revision of upper eyelid,15822,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,2042.58,9062.24,Radiology
Revision of upper eyelid,15822,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,2042.58,9062.24,APC
Revision of upper eyelid,15822,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,2042.58,9062.24,APC
Revision of upper eyelid,15823,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5043.16,,,,,,,fee schedule,2042.58,9062.24,
Revision of upper eyelid,15823,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4042.54,,,,,,,fee schedule,2042.58,9062.24,
Revision of upper eyelid,15823,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4416.1,,,,,,,fee schedule,2042.58,9062.24,
Revision of upper eyelid,15823,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4642.91,,,,,,,fee schedule,2042.58,9062.24,
Revision of upper eyelid,15823,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,2042.58,9062.24,APC 378
Revision of upper eyelid,15823,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,2042.58,9062.24,APC
Revision of upper eyelid,15823,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,2042.58,9062.24,APC
Revision of upper eyelid,15823,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,2042.58,9062.24,APC
Revision of upper eyelid,15823,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,2042.58,9062.24,Radiology
Revision of upper eyelid,15823,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,2042.58,9062.24,APC
Revision of upper eyelid,15823,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,2042.58,9062.24,APC
Removal of forehead wrinkles,15824,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5043.16,,,,,,,fee schedule,2042.58,9062.24,
Removal of forehead wrinkles,15824,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4042.54,,,,,,,fee schedule,2042.58,9062.24,
Removal of forehead wrinkles,15824,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4416.1,,,,,,,fee schedule,2042.58,9062.24,
Removal of forehead wrinkles,15824,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4642.91,,,,,,,fee schedule,2042.58,9062.24,
Removal of forehead wrinkles,15824,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,2042.58,9062.24,APC 378
Removal of forehead wrinkles,15824,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,2042.58,9062.24,APC
Removal of forehead wrinkles,15824,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,2042.58,9062.24,APC
Removal of forehead wrinkles,15824,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,2042.58,9062.24,APC
Removal of forehead wrinkles,15824,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,2042.58,9062.24,Radiology
Removal of forehead wrinkles,15824,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,2042.58,9062.24,APC
Removal of forehead wrinkles,15824,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,2042.58,9062.24,APC
Removal of neck wrinkles,15825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5043.16,,,,,,,fee schedule,3508.17,15564.58,
Removal of neck wrinkles,15825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4042.54,,,,,,,fee schedule,3508.17,15564.58,
Removal of neck wrinkles,15825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4416.1,,,,,,,fee schedule,3508.17,15564.58,
Removal of neck wrinkles,15825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4642.91,,,,,,,fee schedule,3508.17,15564.58,
Removal of neck wrinkles,15825,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15564.58,,,,,,,fee schedule,3508.17,15564.58,APC 378
Removal of neck wrinkles,15825,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3683.58,,,,,,,fee schedule,3508.17,15564.58,APC
Removal of neck wrinkles,15825,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3648.5,,,,,,,fee schedule,3508.17,15564.58,APC
Removal of neck wrinkles,15825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3508.17,,,,,,,fee schedule,3508.17,15564.58,APC
Removal of neck wrinkles,15825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5367.5,,,,,,,fee schedule,3508.17,15564.58,Radiology
Removal of neck wrinkles,15825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4911.44,,,,,,,fee schedule,3508.17,15564.58,APC
Removal of neck wrinkles,15825,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6139.3,,,,,,,fee schedule,3508.17,15564.58,APC
Removal of brow wrinkles,15826,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5043.16,,,,,,,fee schedule,3508.17,15564.58,
Removal of brow wrinkles,15826,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4042.54,,,,,,,fee schedule,3508.17,15564.58,
Removal of brow wrinkles,15826,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4416.1,,,,,,,fee schedule,3508.17,15564.58,
Removal of brow wrinkles,15826,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4642.91,,,,,,,fee schedule,3508.17,15564.58,
Removal of brow wrinkles,15826,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15564.58,,,,,,,fee schedule,3508.17,15564.58,APC 378
Removal of brow wrinkles,15826,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3683.58,,,,,,,fee schedule,3508.17,15564.58,APC
Removal of brow wrinkles,15826,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3648.5,,,,,,,fee schedule,3508.17,15564.58,APC
Removal of brow wrinkles,15826,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3508.17,,,,,,,fee schedule,3508.17,15564.58,APC
Removal of brow wrinkles,15826,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5367.5,,,,,,,fee schedule,3508.17,15564.58,Radiology
Removal of brow wrinkles,15826,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4911.44,,,,,,,fee schedule,3508.17,15564.58,APC
Removal of brow wrinkles,15826,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6139.3,,,,,,,fee schedule,3508.17,15564.58,APC
Removal of face wrinkles,15828,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5043.16,,,,,,,fee schedule,3508.17,15564.58,
Removal of face wrinkles,15828,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4042.54,,,,,,,fee schedule,3508.17,15564.58,
Removal of face wrinkles,15828,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4416.1,,,,,,,fee schedule,3508.17,15564.58,
Removal of face wrinkles,15828,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4642.91,,,,,,,fee schedule,3508.17,15564.58,
Removal of face wrinkles,15828,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15564.58,,,,,,,fee schedule,3508.17,15564.58,APC 378
Removal of face wrinkles,15828,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3683.58,,,,,,,fee schedule,3508.17,15564.58,APC
Removal of face wrinkles,15828,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3648.5,,,,,,,fee schedule,3508.17,15564.58,APC
Removal of face wrinkles,15828,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3508.17,,,,,,,fee schedule,3508.17,15564.58,APC
Removal of face wrinkles,15828,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5367.5,,,,,,,fee schedule,3508.17,15564.58,Radiology
Removal of face wrinkles,15828,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4911.44,,,,,,,fee schedule,3508.17,15564.58,APC
Removal of face wrinkles,15828,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6139.3,,,,,,,fee schedule,3508.17,15564.58,APC
Removal of skin wrinkles,15829,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5043.16,,,,,,,fee schedule,3508.17,15564.58,
Removal of skin wrinkles,15829,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4042.54,,,,,,,fee schedule,3508.17,15564.58,
Removal of skin wrinkles,15829,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4416.1,,,,,,,fee schedule,3508.17,15564.58,
Removal of skin wrinkles,15829,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4642.91,,,,,,,fee schedule,3508.17,15564.58,
Removal of skin wrinkles,15829,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15564.58,,,,,,,fee schedule,3508.17,15564.58,APC 378
Removal of skin wrinkles,15829,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3683.58,,,,,,,fee schedule,3508.17,15564.58,APC
Removal of skin wrinkles,15829,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3648.5,,,,,,,fee schedule,3508.17,15564.58,APC
Removal of skin wrinkles,15829,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3508.17,,,,,,,fee schedule,3508.17,15564.58,APC
Removal of skin wrinkles,15829,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5367.5,,,,,,,fee schedule,3508.17,15564.58,Radiology
Removal of skin wrinkles,15829,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4911.44,,,,,,,fee schedule,3508.17,15564.58,APC
Removal of skin wrinkles,15829,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6139.3,,,,,,,fee schedule,3508.17,15564.58,APC
Exc Skin Abd,15830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7169.1,,,,,,,fee schedule,5746.66,29164.62,
Exc Skin Abd,15830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5746.66,,,,,,,fee schedule,5746.66,29164.62,
Exc Skin Abd,15830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6277.7,,,,,,,fee schedule,5746.66,29164.62,
Exc Skin Abd,15830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6600.12,,,,,,,fee schedule,5746.66,29164.62,
Exc Skin Abd,15830,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,29164.62,,,,,,,fee schedule,5746.66,29164.62,APC 378
Exc Skin Abd,15830,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6902.23,,,,,,,fee schedule,5746.66,29164.62,APC
Exc Skin Abd,15830,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6836.49,,,,,,,fee schedule,5746.66,29164.62,APC
Exc Skin Abd,15830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6573.55,,,,,,,fee schedule,5746.66,29164.62,APC
Exc Skin Abd,15830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10057.53,,,,,,,fee schedule,5746.66,29164.62,Radiology
Exc Skin Abd,15830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9202.97,,,,,,,fee schedule,5746.66,29164.62,APC
Exc Skin Abd,15830,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11503.71,,,,,,,fee schedule,5746.66,29164.62,APC
Excise excessive skin thigh,15832,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5268.49,,,,,,,fee schedule,2875.57,12757.95,
Excise excessive skin thigh,15832,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4223.15,,,,,,,fee schedule,2875.57,12757.95,
Excise excessive skin thigh,15832,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4613.41,,,,,,,fee schedule,2875.57,12757.95,
Excise excessive skin thigh,15832,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4850.35,,,,,,,fee schedule,2875.57,12757.95,
Excise excessive skin thigh,15832,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Excise excessive skin thigh,15832,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Excise excessive skin thigh,15832,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Excise excessive skin thigh,15832,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Excise excessive skin thigh,15832,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Excise excessive skin thigh,15832,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Excise excessive skin thigh,15832,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Excise excessive skin leg,15833,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5268.49,,,,,,,fee schedule,2875.57,12757.95,
Excise excessive skin leg,15833,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4223.15,,,,,,,fee schedule,2875.57,12757.95,
Excise excessive skin leg,15833,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4613.41,,,,,,,fee schedule,2875.57,12757.95,
Excise excessive skin leg,15833,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4850.35,,,,,,,fee schedule,2875.57,12757.95,
Excise excessive skin leg,15833,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Excise excessive skin leg,15833,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Excise excessive skin leg,15833,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Excise excessive skin leg,15833,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Excise excessive skin leg,15833,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Excise excessive skin leg,15833,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Excise excessive skin leg,15833,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Excise excessive skin hip,15834,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5268.49,,,,,,,fee schedule,2875.57,12757.95,
Excise excessive skin hip,15834,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4223.15,,,,,,,fee schedule,2875.57,12757.95,
Excise excessive skin hip,15834,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4613.41,,,,,,,fee schedule,2875.57,12757.95,
Excise excessive skin hip,15834,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4850.35,,,,,,,fee schedule,2875.57,12757.95,
Excise excessive skin hip,15834,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Excise excessive skin hip,15834,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Excise excessive skin hip,15834,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Excise excessive skin hip,15834,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Excise excessive skin hip,15834,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Excise excessive skin hip,15834,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Excise excessive skin hip,15834,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Excise excessive skin buttck,15835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5268.49,,,,,,,fee schedule,2875.57,12757.95,
Excise excessive skin buttck,15835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4223.15,,,,,,,fee schedule,2875.57,12757.95,
Excise excessive skin buttck,15835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4613.41,,,,,,,fee schedule,2875.57,12757.95,
Excise excessive skin buttck,15835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4850.35,,,,,,,fee schedule,2875.57,12757.95,
Excise excessive skin buttck,15835,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Excise excessive skin buttck,15835,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Excise excessive skin buttck,15835,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Excise excessive skin buttck,15835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Excise excessive skin buttck,15835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Excise excessive skin buttck,15835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Excise excessive skin buttck,15835,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Excise excessive skin arm,15836,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4018.18,,,,,,,fee schedule,2875.57,12757.95,
Excise excessive skin arm,15836,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3220.92,,,,,,,fee schedule,2875.57,12757.95,
Excise excessive skin arm,15836,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3518.56,,,,,,,fee schedule,2875.57,12757.95,
Excise excessive skin arm,15836,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3699.27,,,,,,,fee schedule,2875.57,12757.95,
Excise excessive skin arm,15836,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Excise excessive skin arm,15836,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Excise excessive skin arm,15836,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Excise excessive skin arm,15836,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Excise excessive skin arm,15836,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Excise excessive skin arm,15836,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Excise excessive skin arm,15836,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Excise excess skin arm/hand,15837,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4018.18,,,,,,,fee schedule,2875.57,12757.95,
Excise excess skin arm/hand,15837,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3220.92,,,,,,,fee schedule,2875.57,12757.95,
Excise excess skin arm/hand,15837,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3518.56,,,,,,,fee schedule,2875.57,12757.95,
Excise excess skin arm/hand,15837,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3699.27,,,,,,,fee schedule,2875.57,12757.95,
Excise excess skin arm/hand,15837,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Excise excess skin arm/hand,15837,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Excise excess skin arm/hand,15837,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Excise excess skin arm/hand,15837,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Excise excess skin arm/hand,15837,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Excise excess skin arm/hand,15837,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Excise excess skin arm/hand,15837,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Excise excess skin fat pad,15838,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4018.18,,,,,,,fee schedule,2875.57,12757.95,
Excise excess skin fat pad,15838,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3220.92,,,,,,,fee schedule,2875.57,12757.95,
Excise excess skin fat pad,15838,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3518.56,,,,,,,fee schedule,2875.57,12757.95,
Excise excess skin fat pad,15838,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3699.27,,,,,,,fee schedule,2875.57,12757.95,
Excise excess skin fat pad,15838,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Excise excess skin fat pad,15838,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Excise excess skin fat pad,15838,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Excise excess skin fat pad,15838,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Excise excess skin fat pad,15838,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Excise excess skin fat pad,15838,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Excise excess skin fat pad,15838,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Excise excess skin & tissue,15839,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4018.18,,,,,,,fee schedule,2875.57,12757.95,
Excise excess skin & tissue,15839,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3220.92,,,,,,,fee schedule,2875.57,12757.95,
Excise excess skin & tissue,15839,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3518.56,,,,,,,fee schedule,2875.57,12757.95,
Excise excess skin & tissue,15839,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3699.27,,,,,,,fee schedule,2875.57,12757.95,
Excise excess skin & tissue,15839,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Excise excess skin & tissue,15839,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Excise excess skin & tissue,15839,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Excise excess skin & tissue,15839,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Excise excess skin & tissue,15839,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Excise excess skin & tissue,15839,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Excise excess skin & tissue,15839,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Nerve palsy fascial graft,15840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5043.16,,,,,,,fee schedule,3508.17,15564.58,
Nerve palsy fascial graft,15840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4042.54,,,,,,,fee schedule,3508.17,15564.58,
Nerve palsy fascial graft,15840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4416.1,,,,,,,fee schedule,3508.17,15564.58,
Nerve palsy fascial graft,15840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4642.91,,,,,,,fee schedule,3508.17,15564.58,
Nerve palsy fascial graft,15840,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15564.58,,,,,,,fee schedule,3508.17,15564.58,APC 378
Nerve palsy fascial graft,15840,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3683.58,,,,,,,fee schedule,3508.17,15564.58,APC
Nerve palsy fascial graft,15840,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3648.5,,,,,,,fee schedule,3508.17,15564.58,APC
Nerve palsy fascial graft,15840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3508.17,,,,,,,fee schedule,3508.17,15564.58,APC
Nerve palsy fascial graft,15840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5367.5,,,,,,,fee schedule,3508.17,15564.58,Radiology
Nerve palsy fascial graft,15840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4911.44,,,,,,,fee schedule,3508.17,15564.58,APC
Nerve palsy fascial graft,15840,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6139.3,,,,,,,fee schedule,3508.17,15564.58,APC
Nerve palsy muscle graft,15841,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5043.16,,,,,,,fee schedule,3508.17,15564.58,
Nerve palsy muscle graft,15841,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4042.54,,,,,,,fee schedule,3508.17,15564.58,
Nerve palsy muscle graft,15841,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4416.1,,,,,,,fee schedule,3508.17,15564.58,
Nerve palsy muscle graft,15841,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4642.91,,,,,,,fee schedule,3508.17,15564.58,
Nerve palsy muscle graft,15841,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15564.58,,,,,,,fee schedule,3508.17,15564.58,APC 378
Nerve palsy muscle graft,15841,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3683.58,,,,,,,fee schedule,3508.17,15564.58,APC
Nerve palsy muscle graft,15841,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3648.5,,,,,,,fee schedule,3508.17,15564.58,APC
Nerve palsy muscle graft,15841,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3508.17,,,,,,,fee schedule,3508.17,15564.58,APC
Nerve palsy muscle graft,15841,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5367.5,,,,,,,fee schedule,3508.17,15564.58,Radiology
Nerve palsy muscle graft,15841,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4911.44,,,,,,,fee schedule,3508.17,15564.58,APC
Nerve palsy muscle graft,15841,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6139.3,,,,,,,fee schedule,3508.17,15564.58,APC
Nerve palsy microsurg graft,15842,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5043.16,,,,,,,fee schedule,2042.58,9062.24,
Nerve palsy microsurg graft,15842,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4042.54,,,,,,,fee schedule,2042.58,9062.24,
Nerve palsy microsurg graft,15842,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4416.1,,,,,,,fee schedule,2042.58,9062.24,
Nerve palsy microsurg graft,15842,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4642.91,,,,,,,fee schedule,2042.58,9062.24,
Nerve palsy microsurg graft,15842,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,2042.58,9062.24,APC 378
Nerve palsy microsurg graft,15842,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,2042.58,9062.24,APC
Nerve palsy microsurg graft,15842,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,2042.58,9062.24,APC
Nerve palsy microsurg graft,15842,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,2042.58,9062.24,APC
Nerve palsy microsurg graft,15842,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,2042.58,9062.24,Radiology
Nerve palsy microsurg graft,15842,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,2042.58,9062.24,APC
Nerve palsy microsurg graft,15842,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,2042.58,9062.24,APC
Skin and muscle repair face,15845,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5043.16,,,,,,,fee schedule,3508.17,15564.58,
Skin and muscle repair face,15845,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4042.54,,,,,,,fee schedule,3508.17,15564.58,
Skin and muscle repair face,15845,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4416.1,,,,,,,fee schedule,3508.17,15564.58,
Skin and muscle repair face,15845,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4642.91,,,,,,,fee schedule,3508.17,15564.58,
Skin and muscle repair face,15845,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15564.58,,,,,,,fee schedule,3508.17,15564.58,APC 378
Skin and muscle repair face,15845,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3683.58,,,,,,,fee schedule,3508.17,15564.58,APC
Skin and muscle repair face,15845,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3648.5,,,,,,,fee schedule,3508.17,15564.58,APC
Skin and muscle repair face,15845,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3508.17,,,,,,,fee schedule,3508.17,15564.58,APC
Skin and muscle repair face,15845,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5367.5,,,,,,,fee schedule,3508.17,15564.58,Radiology
Skin and muscle repair face,15845,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4911.44,,,,,,,fee schedule,3508.17,15564.58,APC
Skin and muscle repair face,15845,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6139.3,,,,,,,fee schedule,3508.17,15564.58,APC
Exc Skin Abd Add-on,15847,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5268.49,,,,,,,fee schedule,4223.15,5268.49,
Exc Skin Abd Add-on,15847,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4223.15,,,,,,,fee schedule,4223.15,5268.49,
Exc Skin Abd Add-on,15847,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4613.41,,,,,,,fee schedule,4223.15,5268.49,
Exc Skin Abd Add-on,15847,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4850.35,,,,,,,fee schedule,4223.15,5268.49,
Remove sutures diff surgeon,15851,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3360.79,,,,,,,fee schedule,2042.58,9062.24,
Remove sutures diff surgeon,15851,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2693.96,,,,,,,fee schedule,2042.58,9062.24,
Remove sutures diff surgeon,15851,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2942.91,,,,,,,fee schedule,2042.58,9062.24,
Remove sutures diff surgeon,15851,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3094.06,,,,,,,fee schedule,2042.58,9062.24,
Remove sutures diff surgeon,15851,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,2042.58,9062.24,APC 378
Remove sutures diff surgeon,15851,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,2042.58,9062.24,APC
Remove sutures diff surgeon,15851,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,2042.58,9062.24,APC
Remove sutures diff surgeon,15851,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,2042.58,9062.24,APC
Remove sutures diff surgeon,15851,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,2042.58,9062.24,Radiology
Remove sutures diff surgeon,15851,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,2042.58,9062.24,APC
Remove sutures diff surgeon,15851,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,2042.58,9062.24,APC
Dressing change not for burn,15852,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3360.79,,,,,,,fee schedule,731.66,3360.79,
Dressing change not for burn,15852,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2693.96,,,,,,,fee schedule,731.66,3360.79,
Dressing change not for burn,15852,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2942.91,,,,,,,fee schedule,731.66,3360.79,
Dressing change not for burn,15852,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3094.06,,,,,,,fee schedule,731.66,3360.79,
Dressing change not for burn,15852,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3246.12,,,,,,,fee schedule,731.66,3360.79,APC 378
Dressing change not for burn,15852,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,768.24,,,,,,,fee schedule,731.66,3360.79,APC
Dressing change not for burn,15852,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,760.92,,,,,,,fee schedule,731.66,3360.79,APC
Dressing change not for burn,15852,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,731.66,,,,,,,fee schedule,731.66,3360.79,APC
Dressing change not for burn,15852,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1119.44,,,,,,,fee schedule,731.66,3360.79,Radiology
Dressing change not for burn,15852,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1024.32,,,,,,,fee schedule,731.66,3360.79,APC
Dressing change not for burn,15852,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1280.4,,,,,,,fee schedule,731.66,3360.79,APC
Test for blood flow in graft,15860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,157.47,,,,,,,fee schedule,126.23,1962.08,
Test for blood flow in graft,15860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,126.23,,,,,,,fee schedule,126.23,1962.08,
Test for blood flow in graft,15860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,137.89,,,,,,,fee schedule,126.23,1962.08,
Test for blood flow in graft,15860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,144.98,,,,,,,fee schedule,126.23,1962.08,
Test for blood flow in graft,15860,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1962.08,,,,,,,fee schedule,126.23,1962.08,APC 378
Test for blood flow in graft,15860,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,464.35,,,,,,,fee schedule,126.23,1962.08,APC
Test for blood flow in graft,15860,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,459.93,,,,,,,fee schedule,126.23,1962.08,APC
Test for blood flow in graft,15860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,442.24,,,,,,,fee schedule,126.23,1962.08,APC
Test for blood flow in graft,15860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,676.63,,,,,,,fee schedule,126.23,1962.08,Radiology
Test for blood flow in graft,15860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,619.14,,,,,,,fee schedule,126.23,1962.08,APC
Test for blood flow in graft,15860,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,773.92,,,,,,,fee schedule,126.23,1962.08,APC
Suction lipectomy head&neck,15876,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5043.16,,,,,,,fee schedule,3508.17,15564.58,
Suction lipectomy head&neck,15876,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4042.54,,,,,,,fee schedule,3508.17,15564.58,
Suction lipectomy head&neck,15876,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4416.1,,,,,,,fee schedule,3508.17,15564.58,
Suction lipectomy head&neck,15876,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4642.91,,,,,,,fee schedule,3508.17,15564.58,
Suction lipectomy head&neck,15876,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15564.58,,,,,,,fee schedule,3508.17,15564.58,APC 378
Suction lipectomy head&neck,15876,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3683.58,,,,,,,fee schedule,3508.17,15564.58,APC
Suction lipectomy head&neck,15876,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3648.5,,,,,,,fee schedule,3508.17,15564.58,APC
Suction lipectomy head&neck,15876,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3508.17,,,,,,,fee schedule,3508.17,15564.58,APC
Suction lipectomy head&neck,15876,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5367.5,,,,,,,fee schedule,3508.17,15564.58,Radiology
Suction lipectomy head&neck,15876,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4911.44,,,,,,,fee schedule,3508.17,15564.58,APC
Suction lipectomy head&neck,15876,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6139.3,,,,,,,fee schedule,3508.17,15564.58,APC
Suction lipectomy trunk,15877,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5043.16,,,,,,,fee schedule,3508.17,15564.58,
Suction lipectomy trunk,15877,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4042.54,,,,,,,fee schedule,3508.17,15564.58,
Suction lipectomy trunk,15877,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4416.1,,,,,,,fee schedule,3508.17,15564.58,
Suction lipectomy trunk,15877,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4642.91,,,,,,,fee schedule,3508.17,15564.58,
Suction lipectomy trunk,15877,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15564.58,,,,,,,fee schedule,3508.17,15564.58,APC 378
Suction lipectomy trunk,15877,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3683.58,,,,,,,fee schedule,3508.17,15564.58,APC
Suction lipectomy trunk,15877,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3648.5,,,,,,,fee schedule,3508.17,15564.58,APC
Suction lipectomy trunk,15877,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3508.17,,,,,,,fee schedule,3508.17,15564.58,APC
Suction lipectomy trunk,15877,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5367.5,,,,,,,fee schedule,3508.17,15564.58,Radiology
Suction lipectomy trunk,15877,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4911.44,,,,,,,fee schedule,3508.17,15564.58,APC
Suction lipectomy trunk,15877,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6139.3,,,,,,,fee schedule,3508.17,15564.58,APC
Suction lipectomy upr extrem,15878,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5043.16,,,,,,,fee schedule,2042.58,9062.24,
Suction lipectomy upr extrem,15878,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4042.54,,,,,,,fee schedule,2042.58,9062.24,
Suction lipectomy upr extrem,15878,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4416.1,,,,,,,fee schedule,2042.58,9062.24,
Suction lipectomy upr extrem,15878,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4642.91,,,,,,,fee schedule,2042.58,9062.24,
Suction lipectomy upr extrem,15878,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,2042.58,9062.24,APC 378
Suction lipectomy upr extrem,15878,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,2042.58,9062.24,APC
Suction lipectomy upr extrem,15878,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,2042.58,9062.24,APC
Suction lipectomy upr extrem,15878,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,2042.58,9062.24,APC
Suction lipectomy upr extrem,15878,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,2042.58,9062.24,Radiology
Suction lipectomy upr extrem,15878,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,2042.58,9062.24,APC
Suction lipectomy upr extrem,15878,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,2042.58,9062.24,APC
Suction lipectomy lwr extrem,15879,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5043.16,,,,,,,fee schedule,3508.17,15564.58,
Suction lipectomy lwr extrem,15879,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4042.54,,,,,,,fee schedule,3508.17,15564.58,
Suction lipectomy lwr extrem,15879,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4416.1,,,,,,,fee schedule,3508.17,15564.58,
Suction lipectomy lwr extrem,15879,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4642.91,,,,,,,fee schedule,3508.17,15564.58,
Suction lipectomy lwr extrem,15879,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15564.58,,,,,,,fee schedule,3508.17,15564.58,APC 378
Suction lipectomy lwr extrem,15879,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3683.58,,,,,,,fee schedule,3508.17,15564.58,APC
Suction lipectomy lwr extrem,15879,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3648.5,,,,,,,fee schedule,3508.17,15564.58,APC
Suction lipectomy lwr extrem,15879,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3508.17,,,,,,,fee schedule,3508.17,15564.58,APC
Suction lipectomy lwr extrem,15879,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5367.5,,,,,,,fee schedule,3508.17,15564.58,Radiology
Suction lipectomy lwr extrem,15879,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4911.44,,,,,,,fee schedule,3508.17,15564.58,APC
Suction lipectomy lwr extrem,15879,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6139.3,,,,,,,fee schedule,3508.17,15564.58,APC
Removal of tail bone ulcer,15920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1074.12,,,,,,,fee schedule,861,12757.95,
Removal of tail bone ulcer,15920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,861,,,,,,,fee schedule,861,12757.95,
Removal of tail bone ulcer,15920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,940.57,,,,,,,fee schedule,861,12757.95,
Removal of tail bone ulcer,15920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,988.88,,,,,,,fee schedule,861,12757.95,
Removal of tail bone ulcer,15920,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,861,12757.95,APC 378
Removal of tail bone ulcer,15920,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,861,12757.95,APC
Removal of tail bone ulcer,15920,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,861,12757.95,APC
Removal of tail bone ulcer,15920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,861,12757.95,APC
Removal of tail bone ulcer,15920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,861,12757.95,Radiology
Removal of tail bone ulcer,15920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,861,12757.95,APC
Removal of tail bone ulcer,15920,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,861,12757.95,APC
Removal of tail bone ulcer,15922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5043.16,,,,,,,fee schedule,3508.17,15564.58,
Removal of tail bone ulcer,15922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4042.54,,,,,,,fee schedule,3508.17,15564.58,
Removal of tail bone ulcer,15922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4416.1,,,,,,,fee schedule,3508.17,15564.58,
Removal of tail bone ulcer,15922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4642.91,,,,,,,fee schedule,3508.17,15564.58,
Removal of tail bone ulcer,15922,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15564.58,,,,,,,fee schedule,3508.17,15564.58,APC 378
Removal of tail bone ulcer,15922,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3683.58,,,,,,,fee schedule,3508.17,15564.58,APC
Removal of tail bone ulcer,15922,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3648.5,,,,,,,fee schedule,3508.17,15564.58,APC
Removal of tail bone ulcer,15922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3508.17,,,,,,,fee schedule,3508.17,15564.58,APC
Removal of tail bone ulcer,15922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5367.5,,,,,,,fee schedule,3508.17,15564.58,Radiology
Removal of tail bone ulcer,15922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4911.44,,,,,,,fee schedule,3508.17,15564.58,APC
Removal of tail bone ulcer,15922,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6139.3,,,,,,,fee schedule,3508.17,15564.58,APC
Remove sacrum pressure sore,15931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5268.49,,,,,,,fee schedule,2875.57,12757.95,
Remove sacrum pressure sore,15931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4223.15,,,,,,,fee schedule,2875.57,12757.95,
Remove sacrum pressure sore,15931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4613.41,,,,,,,fee schedule,2875.57,12757.95,
Remove sacrum pressure sore,15931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4850.35,,,,,,,fee schedule,2875.57,12757.95,
Remove sacrum pressure sore,15931,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Remove sacrum pressure sore,15931,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Remove sacrum pressure sore,15931,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Remove sacrum pressure sore,15931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Remove sacrum pressure sore,15931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Remove sacrum pressure sore,15931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Remove sacrum pressure sore,15931,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Remove sacrum pressure sore,15933,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5268.49,,,,,,,fee schedule,2875.57,12757.95,
Remove sacrum pressure sore,15933,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4223.15,,,,,,,fee schedule,2875.57,12757.95,
Remove sacrum pressure sore,15933,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4613.41,,,,,,,fee schedule,2875.57,12757.95,
Remove sacrum pressure sore,15933,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4850.35,,,,,,,fee schedule,2875.57,12757.95,
Remove sacrum pressure sore,15933,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Remove sacrum pressure sore,15933,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Remove sacrum pressure sore,15933,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Remove sacrum pressure sore,15933,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Remove sacrum pressure sore,15933,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Remove sacrum pressure sore,15933,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Remove sacrum pressure sore,15933,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Remove sacrum pressure sore,15934,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5043.16,,,,,,,fee schedule,3508.17,15564.58,
Remove sacrum pressure sore,15934,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4042.54,,,,,,,fee schedule,3508.17,15564.58,
Remove sacrum pressure sore,15934,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4416.1,,,,,,,fee schedule,3508.17,15564.58,
Remove sacrum pressure sore,15934,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4642.91,,,,,,,fee schedule,3508.17,15564.58,
Remove sacrum pressure sore,15934,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15564.58,,,,,,,fee schedule,3508.17,15564.58,APC 378
Remove sacrum pressure sore,15934,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3683.58,,,,,,,fee schedule,3508.17,15564.58,APC
Remove sacrum pressure sore,15934,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3648.5,,,,,,,fee schedule,3508.17,15564.58,APC
Remove sacrum pressure sore,15934,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3508.17,,,,,,,fee schedule,3508.17,15564.58,APC
Remove sacrum pressure sore,15934,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5367.5,,,,,,,fee schedule,3508.17,15564.58,Radiology
Remove sacrum pressure sore,15934,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4911.44,,,,,,,fee schedule,3508.17,15564.58,APC
Remove sacrum pressure sore,15934,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6139.3,,,,,,,fee schedule,3508.17,15564.58,APC
Remove sacrum pressure sore,15935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5043.16,,,,,,,fee schedule,3508.17,15564.58,
Remove sacrum pressure sore,15935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4042.54,,,,,,,fee schedule,3508.17,15564.58,
Remove sacrum pressure sore,15935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4416.1,,,,,,,fee schedule,3508.17,15564.58,
Remove sacrum pressure sore,15935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4642.91,,,,,,,fee schedule,3508.17,15564.58,
Remove sacrum pressure sore,15935,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15564.58,,,,,,,fee schedule,3508.17,15564.58,APC 378
Remove sacrum pressure sore,15935,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3683.58,,,,,,,fee schedule,3508.17,15564.58,APC
Remove sacrum pressure sore,15935,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3648.5,,,,,,,fee schedule,3508.17,15564.58,APC
Remove sacrum pressure sore,15935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3508.17,,,,,,,fee schedule,3508.17,15564.58,APC
Remove sacrum pressure sore,15935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5367.5,,,,,,,fee schedule,3508.17,15564.58,Radiology
Remove sacrum pressure sore,15935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4911.44,,,,,,,fee schedule,3508.17,15564.58,APC
Remove sacrum pressure sore,15935,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6139.3,,,,,,,fee schedule,3508.17,15564.58,APC
Remove sacrum pressure sore,15936,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3755.05,,,,,,,fee schedule,2042.58,9062.24,
Remove sacrum pressure sore,15936,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3010,,,,,,,fee schedule,2042.58,9062.24,
Remove sacrum pressure sore,15936,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3288.15,,,,,,,fee schedule,2042.58,9062.24,
Remove sacrum pressure sore,15936,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3457.03,,,,,,,fee schedule,2042.58,9062.24,
Remove sacrum pressure sore,15936,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,2042.58,9062.24,APC 378
Remove sacrum pressure sore,15936,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,2042.58,9062.24,APC
Remove sacrum pressure sore,15936,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,2042.58,9062.24,APC
Remove sacrum pressure sore,15936,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,2042.58,9062.24,APC
Remove sacrum pressure sore,15936,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,2042.58,9062.24,Radiology
Remove sacrum pressure sore,15936,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,2042.58,9062.24,APC
Remove sacrum pressure sore,15936,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,2042.58,9062.24,APC
Remove sacrum pressure sore,15937,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5043.16,,,,,,,fee schedule,2042.58,9062.24,
Remove sacrum pressure sore,15937,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4042.54,,,,,,,fee schedule,2042.58,9062.24,
Remove sacrum pressure sore,15937,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4416.1,,,,,,,fee schedule,2042.58,9062.24,
Remove sacrum pressure sore,15937,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4642.91,,,,,,,fee schedule,2042.58,9062.24,
Remove sacrum pressure sore,15937,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,2042.58,9062.24,APC 378
Remove sacrum pressure sore,15937,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,2042.58,9062.24,APC
Remove sacrum pressure sore,15937,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,2042.58,9062.24,APC
Remove sacrum pressure sore,15937,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,2042.58,9062.24,APC
Remove sacrum pressure sore,15937,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,2042.58,9062.24,Radiology
Remove sacrum pressure sore,15937,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,2042.58,9062.24,APC
Remove sacrum pressure sore,15937,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,2042.58,9062.24,APC
Remove hip pressure sore,15940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5268.49,,,,,,,fee schedule,2875.57,12757.95,
Remove hip pressure sore,15940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4223.15,,,,,,,fee schedule,2875.57,12757.95,
Remove hip pressure sore,15940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4613.41,,,,,,,fee schedule,2875.57,12757.95,
Remove hip pressure sore,15940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4850.35,,,,,,,fee schedule,2875.57,12757.95,
Remove hip pressure sore,15940,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Remove hip pressure sore,15940,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Remove hip pressure sore,15940,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Remove hip pressure sore,15940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Remove hip pressure sore,15940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Remove hip pressure sore,15940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Remove hip pressure sore,15940,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Remove hip pressure sore,15941,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5268.49,,,,,,,fee schedule,2875.57,12757.95,
Remove hip pressure sore,15941,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4223.15,,,,,,,fee schedule,2875.57,12757.95,
Remove hip pressure sore,15941,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4613.41,,,,,,,fee schedule,2875.57,12757.95,
Remove hip pressure sore,15941,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4850.35,,,,,,,fee schedule,2875.57,12757.95,
Remove hip pressure sore,15941,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Remove hip pressure sore,15941,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Remove hip pressure sore,15941,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Remove hip pressure sore,15941,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Remove hip pressure sore,15941,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Remove hip pressure sore,15941,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Remove hip pressure sore,15941,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Remove hip pressure sore,15944,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5043.16,,,,,,,fee schedule,3508.17,15564.58,
Remove hip pressure sore,15944,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4042.54,,,,,,,fee schedule,3508.17,15564.58,
Remove hip pressure sore,15944,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4416.1,,,,,,,fee schedule,3508.17,15564.58,
Remove hip pressure sore,15944,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4642.91,,,,,,,fee schedule,3508.17,15564.58,
Remove hip pressure sore,15944,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15564.58,,,,,,,fee schedule,3508.17,15564.58,APC 378
Remove hip pressure sore,15944,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3683.58,,,,,,,fee schedule,3508.17,15564.58,APC
Remove hip pressure sore,15944,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3648.5,,,,,,,fee schedule,3508.17,15564.58,APC
Remove hip pressure sore,15944,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3508.17,,,,,,,fee schedule,3508.17,15564.58,APC
Remove hip pressure sore,15944,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5367.5,,,,,,,fee schedule,3508.17,15564.58,Radiology
Remove hip pressure sore,15944,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4911.44,,,,,,,fee schedule,3508.17,15564.58,APC
Remove hip pressure sore,15944,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6139.3,,,,,,,fee schedule,3508.17,15564.58,APC
Remove hip pressure sore,15945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5043.16,,,,,,,fee schedule,2042.58,9062.24,
Remove hip pressure sore,15945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4042.54,,,,,,,fee schedule,2042.58,9062.24,
Remove hip pressure sore,15945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4416.1,,,,,,,fee schedule,2042.58,9062.24,
Remove hip pressure sore,15945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4642.91,,,,,,,fee schedule,2042.58,9062.24,
Remove hip pressure sore,15945,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,2042.58,9062.24,APC 378
Remove hip pressure sore,15945,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,2042.58,9062.24,APC
Remove hip pressure sore,15945,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,2042.58,9062.24,APC
Remove hip pressure sore,15945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,2042.58,9062.24,APC
Remove hip pressure sore,15945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,2042.58,9062.24,Radiology
Remove hip pressure sore,15945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,2042.58,9062.24,APC
Remove hip pressure sore,15945,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,2042.58,9062.24,APC
Remove hip pressure sore,15946,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5043.16,,,,,,,fee schedule,2042.58,9062.24,
Remove hip pressure sore,15946,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4042.54,,,,,,,fee schedule,2042.58,9062.24,
Remove hip pressure sore,15946,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4416.1,,,,,,,fee schedule,2042.58,9062.24,
Remove hip pressure sore,15946,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4642.91,,,,,,,fee schedule,2042.58,9062.24,
Remove hip pressure sore,15946,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,2042.58,9062.24,APC 378
Remove hip pressure sore,15946,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,2042.58,9062.24,APC
Remove hip pressure sore,15946,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,2042.58,9062.24,APC
Remove hip pressure sore,15946,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,2042.58,9062.24,APC
Remove hip pressure sore,15946,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,2042.58,9062.24,Radiology
Remove hip pressure sore,15946,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,2042.58,9062.24,APC
Remove hip pressure sore,15946,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,2042.58,9062.24,APC
Remove thigh pressure sore,15950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5268.49,,,,,,,fee schedule,1635.03,7254.06,
Remove thigh pressure sore,15950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4223.15,,,,,,,fee schedule,1635.03,7254.06,
Remove thigh pressure sore,15950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4613.41,,,,,,,fee schedule,1635.03,7254.06,
Remove thigh pressure sore,15950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4850.35,,,,,,,fee schedule,1635.03,7254.06,
Remove thigh pressure sore,15950,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,7254.06,APC 378
Remove thigh pressure sore,15950,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,7254.06,APC
Remove thigh pressure sore,15950,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,7254.06,APC
Remove thigh pressure sore,15950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,7254.06,APC
Remove thigh pressure sore,15950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,7254.06,Radiology
Remove thigh pressure sore,15950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,7254.06,APC
Remove thigh pressure sore,15950,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,7254.06,APC
Remove thigh pressure sore,15951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5268.49,,,,,,,fee schedule,2875.57,12757.95,
Remove thigh pressure sore,15951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4223.15,,,,,,,fee schedule,2875.57,12757.95,
Remove thigh pressure sore,15951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4613.41,,,,,,,fee schedule,2875.57,12757.95,
Remove thigh pressure sore,15951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4850.35,,,,,,,fee schedule,2875.57,12757.95,
Remove thigh pressure sore,15951,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Remove thigh pressure sore,15951,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Remove thigh pressure sore,15951,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Remove thigh pressure sore,15951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Remove thigh pressure sore,15951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Remove thigh pressure sore,15951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Remove thigh pressure sore,15951,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Remove thigh pressure sore,15952,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3755.05,,,,,,,fee schedule,2042.58,9062.24,
Remove thigh pressure sore,15952,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3010,,,,,,,fee schedule,2042.58,9062.24,
Remove thigh pressure sore,15952,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3288.15,,,,,,,fee schedule,2042.58,9062.24,
Remove thigh pressure sore,15952,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3457.03,,,,,,,fee schedule,2042.58,9062.24,
Remove thigh pressure sore,15952,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,2042.58,9062.24,APC 378
Remove thigh pressure sore,15952,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,2042.58,9062.24,APC
Remove thigh pressure sore,15952,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,2042.58,9062.24,APC
Remove thigh pressure sore,15952,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,2042.58,9062.24,APC
Remove thigh pressure sore,15952,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,2042.58,9062.24,Radiology
Remove thigh pressure sore,15952,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,2042.58,9062.24,APC
Remove thigh pressure sore,15952,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,2042.58,9062.24,APC
Remove thigh pressure sore,15953,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3755.05,,,,,,,fee schedule,3010,15564.58,
Remove thigh pressure sore,15953,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3010,,,,,,,fee schedule,3010,15564.58,
Remove thigh pressure sore,15953,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3288.15,,,,,,,fee schedule,3010,15564.58,
Remove thigh pressure sore,15953,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3457.03,,,,,,,fee schedule,3010,15564.58,
Remove thigh pressure sore,15953,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15564.58,,,,,,,fee schedule,3010,15564.58,APC 378
Remove thigh pressure sore,15953,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3683.58,,,,,,,fee schedule,3010,15564.58,APC
Remove thigh pressure sore,15953,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3648.5,,,,,,,fee schedule,3010,15564.58,APC
Remove thigh pressure sore,15953,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3508.17,,,,,,,fee schedule,3010,15564.58,APC
Remove thigh pressure sore,15953,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5367.5,,,,,,,fee schedule,3010,15564.58,Radiology
Remove thigh pressure sore,15953,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4911.44,,,,,,,fee schedule,3010,15564.58,APC
Remove thigh pressure sore,15953,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6139.3,,,,,,,fee schedule,3010,15564.58,APC
Remove thigh pressure sore,15956,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3755.05,,,,,,,fee schedule,2042.58,9062.24,
Remove thigh pressure sore,15956,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3010,,,,,,,fee schedule,2042.58,9062.24,
Remove thigh pressure sore,15956,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3288.15,,,,,,,fee schedule,2042.58,9062.24,
Remove thigh pressure sore,15956,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3457.03,,,,,,,fee schedule,2042.58,9062.24,
Remove thigh pressure sore,15956,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,2042.58,9062.24,APC 378
Remove thigh pressure sore,15956,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,2042.58,9062.24,APC
Remove thigh pressure sore,15956,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,2042.58,9062.24,APC
Remove thigh pressure sore,15956,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,2042.58,9062.24,APC
Remove thigh pressure sore,15956,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,2042.58,9062.24,Radiology
Remove thigh pressure sore,15956,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,2042.58,9062.24,APC
Remove thigh pressure sore,15956,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,2042.58,9062.24,APC
Remove thigh pressure sore,15958,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3755.05,,,,,,,fee schedule,3010,15564.58,
Remove thigh pressure sore,15958,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3010,,,,,,,fee schedule,3010,15564.58,
Remove thigh pressure sore,15958,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3288.15,,,,,,,fee schedule,3010,15564.58,
Remove thigh pressure sore,15958,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3457.03,,,,,,,fee schedule,3010,15564.58,
Remove thigh pressure sore,15958,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15564.58,,,,,,,fee schedule,3010,15564.58,APC 378
Remove thigh pressure sore,15958,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3683.58,,,,,,,fee schedule,3010,15564.58,APC
Remove thigh pressure sore,15958,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3648.5,,,,,,,fee schedule,3010,15564.58,APC
Remove thigh pressure sore,15958,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3508.17,,,,,,,fee schedule,3010,15564.58,APC
Remove thigh pressure sore,15958,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5367.5,,,,,,,fee schedule,3010,15564.58,Radiology
Remove thigh pressure sore,15958,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4911.44,,,,,,,fee schedule,3010,15564.58,APC
Remove thigh pressure sore,15958,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6139.3,,,,,,,fee schedule,3010,15564.58,APC
Removal of pressure sore,15999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1074.12,,,,,,,fee schedule,701.03,3110.22,
Removal of pressure sore,15999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,861,,,,,,,fee schedule,701.03,3110.22,
Removal of pressure sore,15999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,940.57,,,,,,,fee schedule,701.03,3110.22,
Removal of pressure sore,15999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,988.88,,,,,,,fee schedule,701.03,3110.22,
Removal of pressure sore,15999,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3110.22,,,,,,,fee schedule,701.03,3110.22,APC 378
Removal of pressure sore,15999,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,736.08,,,,,,,fee schedule,701.03,3110.22,APC
Removal of pressure sore,15999,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,729.07,,,,,,,fee schedule,701.03,3110.22,APC
Removal of pressure sore,15999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,701.03,,,,,,,fee schedule,701.03,3110.22,APC
Removal of pressure sore,15999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1072.57,,,,,,,fee schedule,701.03,3110.22,Radiology
Removal of pressure sore,15999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,981.44,,,,,,,fee schedule,701.03,3110.22,APC
Removal of pressure sore,15999,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1226.8,,,,,,,fee schedule,701.03,3110.22,APC
Initial treatment of burn(s),16000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,377.09,,,,,,,fee schedule,198.62,881.22,
Initial treatment of burn(s),16000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,302.27,,,,,,,fee schedule,198.62,881.22,
Initial treatment of burn(s),16000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,330.21,,,,,,,fee schedule,198.62,881.22,
Initial treatment of burn(s),16000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,347.16,,,,,,,fee schedule,198.62,881.22,
Initial treatment of burn(s),16000,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,881.22,,,,,,,fee schedule,198.62,881.22,APC 378
Initial treatment of burn(s),16000,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.55,,,,,,,fee schedule,198.62,881.22,APC
Initial treatment of burn(s),16000,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,206.57,,,,,,,fee schedule,198.62,881.22,APC
Initial treatment of burn(s),16000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.62,,,,,,,fee schedule,198.62,881.22,APC
Initial treatment of burn(s),16000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.89,,,,,,,fee schedule,198.62,881.22,Radiology
Initial treatment of burn(s),16000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,278.07,,,,,,,fee schedule,198.62,881.22,APC
Initial treatment of burn(s),16000,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,347.59,,,,,,,fee schedule,198.62,881.22,APC
Dress/debrid p-thick burn s,16020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,377.09,,,,,,,fee schedule,198.62,881.22,
Dress/debrid p-thick burn s,16020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,302.27,,,,,,,fee schedule,198.62,881.22,
Dress/debrid p-thick burn s,16020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,330.21,,,,,,,fee schedule,198.62,881.22,
Dress/debrid p-thick burn s,16020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,347.16,,,,,,,fee schedule,198.62,881.22,
Dress/debrid p-thick burn s,16020,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,881.22,,,,,,,fee schedule,198.62,881.22,APC 378
Dress/debrid p-thick burn s,16020,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.55,,,,,,,fee schedule,198.62,881.22,APC
Dress/debrid p-thick burn s,16020,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,206.57,,,,,,,fee schedule,198.62,881.22,APC
Dress/debrid p-thick burn s,16020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.62,,,,,,,fee schedule,198.62,881.22,APC
Dress/debrid p-thick burn s,16020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.89,,,,,,,fee schedule,198.62,881.22,Radiology
Dress/debrid p-thick burn s,16020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,278.07,,,,,,,fee schedule,198.62,881.22,APC
Dress/debrid p-thick burn s,16020,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,347.59,,,,,,,fee schedule,198.62,881.22,APC
Dress/debrid p-thick burn m,16025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,663.96,,,,,,,fee schedule,198.62,881.22,
Dress/debrid p-thick burn m,16025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,532.22,,,,,,,fee schedule,198.62,881.22,
Dress/debrid p-thick burn m,16025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,581.4,,,,,,,fee schedule,198.62,881.22,
Dress/debrid p-thick burn m,16025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,611.26,,,,,,,fee schedule,198.62,881.22,
Dress/debrid p-thick burn m,16025,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,881.22,,,,,,,fee schedule,198.62,881.22,APC 378
Dress/debrid p-thick burn m,16025,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.55,,,,,,,fee schedule,198.62,881.22,APC
Dress/debrid p-thick burn m,16025,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,206.57,,,,,,,fee schedule,198.62,881.22,APC
Dress/debrid p-thick burn m,16025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.62,,,,,,,fee schedule,198.62,881.22,APC
Dress/debrid p-thick burn m,16025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.89,,,,,,,fee schedule,198.62,881.22,Radiology
Dress/debrid p-thick burn m,16025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,278.07,,,,,,,fee schedule,198.62,881.22,APC
Dress/debrid p-thick burn m,16025,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,347.59,,,,,,,fee schedule,198.62,881.22,APC
Dress/debrid p-thick burn l,16030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,398.76,,,,,,,fee schedule,319.64,1785.48,
Dress/debrid p-thick burn l,16030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,319.64,,,,,,,fee schedule,319.64,1785.48,
Dress/debrid p-thick burn l,16030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,349.18,,,,,,,fee schedule,319.64,1785.48,
Dress/debrid p-thick burn l,16030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,367.12,,,,,,,fee schedule,319.64,1785.48,
Dress/debrid p-thick burn l,16030,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1785.48,,,,,,,fee schedule,319.64,1785.48,APC 378
Dress/debrid p-thick burn l,16030,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,422.56,,,,,,,fee schedule,319.64,1785.48,APC
Dress/debrid p-thick burn l,16030,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,418.53,,,,,,,fee schedule,319.64,1785.48,APC
Dress/debrid p-thick burn l,16030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,402.44,,,,,,,fee schedule,319.64,1785.48,APC
Dress/debrid p-thick burn l,16030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,615.73,,,,,,,fee schedule,319.64,1785.48,Radiology
Dress/debrid p-thick burn l,16030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,563.41,,,,,,,fee schedule,319.64,1785.48,APC
Dress/debrid p-thick burn l,16030,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,704.26,,,,,,,fee schedule,319.64,1785.48,APC
Incision of burn scab initi,16035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,663.96,,,,,,,fee schedule,402.44,1785.48,
Incision of burn scab initi,16035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,532.22,,,,,,,fee schedule,402.44,1785.48,
Incision of burn scab initi,16035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,581.4,,,,,,,fee schedule,402.44,1785.48,
Incision of burn scab initi,16035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,611.26,,,,,,,fee schedule,402.44,1785.48,
Incision of burn scab initi,16035,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1785.48,,,,,,,fee schedule,402.44,1785.48,APC 378
Incision of burn scab initi,16035,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,422.56,,,,,,,fee schedule,402.44,1785.48,APC
Incision of burn scab initi,16035,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,418.53,,,,,,,fee schedule,402.44,1785.48,APC
Incision of burn scab initi,16035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,402.44,,,,,,,fee schedule,402.44,1785.48,APC
Incision of burn scab initi,16035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,615.73,,,,,,,fee schedule,402.44,1785.48,Radiology
Incision of burn scab initi,16035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,563.41,,,,,,,fee schedule,402.44,1785.48,APC
Incision of burn scab initi,16035,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,704.26,,,,,,,fee schedule,402.44,1785.48,APC
Destruct premalg lesion,17000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,197.92,,,,,,,fee schedule,158.65,881.22,
Destruct premalg lesion,17000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,158.65,,,,,,,fee schedule,158.65,881.22,
Destruct premalg lesion,17000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,173.31,,,,,,,fee schedule,158.65,881.22,
Destruct premalg lesion,17000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,182.21,,,,,,,fee schedule,158.65,881.22,
Destruct premalg lesion,17000,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,881.22,,,,,,,fee schedule,158.65,881.22,APC 378
Destruct premalg lesion,17000,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.55,,,,,,,fee schedule,158.65,881.22,APC
Destruct premalg lesion,17000,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,206.57,,,,,,,fee schedule,158.65,881.22,APC
Destruct premalg lesion,17000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.62,,,,,,,fee schedule,158.65,881.22,APC
Destruct premalg lesion,17000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.89,,,,,,,fee schedule,158.65,881.22,Radiology
Destruct premalg lesion,17000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,278.07,,,,,,,fee schedule,158.65,881.22,APC
Destruct premalg lesion,17000,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,347.59,,,,,,,fee schedule,158.65,881.22,APC
Destruct premalg les 2-14,17003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,73.94,,,,,,,fee schedule,59.27,73.94,
Destruct premalg les 2-14,17003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,59.27,,,,,,,fee schedule,59.27,73.94,
Destruct premalg les 2-14,17003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,64.74,,,,,,,fee schedule,59.27,73.94,
Destruct premalg les 2-14,17003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,68.07,,,,,,,fee schedule,59.27,73.94,
Destroy premal lesions 15/>,17004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,663.96,,,,,,,fee schedule,402.44,1785.48,
Destroy premal lesions 15/>,17004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,532.22,,,,,,,fee schedule,402.44,1785.48,
Destroy premal lesions 15/>,17004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,581.4,,,,,,,fee schedule,402.44,1785.48,
Destroy premal lesions 15/>,17004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,611.26,,,,,,,fee schedule,402.44,1785.48,
Destroy premal lesions 15/>,17004,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1785.48,,,,,,,fee schedule,402.44,1785.48,APC 378
Destroy premal lesions 15/>,17004,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,422.56,,,,,,,fee schedule,402.44,1785.48,APC
Destroy premal lesions 15/>,17004,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,418.53,,,,,,,fee schedule,402.44,1785.48,APC
Destroy premal lesions 15/>,17004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,402.44,,,,,,,fee schedule,402.44,1785.48,APC
Destroy premal lesions 15/>,17004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,615.73,,,,,,,fee schedule,402.44,1785.48,Radiology
Destroy premal lesions 15/>,17004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,563.41,,,,,,,fee schedule,402.44,1785.48,APC
Destroy premal lesions 15/>,17004,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,704.26,,,,,,,fee schedule,402.44,1785.48,APC
Destruction of skin lesions,17106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,663.96,,,,,,,fee schedule,402.44,1785.48,
Destruction of skin lesions,17106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,532.22,,,,,,,fee schedule,402.44,1785.48,
Destruction of skin lesions,17106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,581.4,,,,,,,fee schedule,402.44,1785.48,
Destruction of skin lesions,17106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,611.26,,,,,,,fee schedule,402.44,1785.48,
Destruction of skin lesions,17106,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1785.48,,,,,,,fee schedule,402.44,1785.48,APC 378
Destruction of skin lesions,17106,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,422.56,,,,,,,fee schedule,402.44,1785.48,APC
Destruction of skin lesions,17106,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,418.53,,,,,,,fee schedule,402.44,1785.48,APC
Destruction of skin lesions,17106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,402.44,,,,,,,fee schedule,402.44,1785.48,APC
Destruction of skin lesions,17106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,615.73,,,,,,,fee schedule,402.44,1785.48,Radiology
Destruction of skin lesions,17106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,563.41,,,,,,,fee schedule,402.44,1785.48,APC
Destruction of skin lesions,17106,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,704.26,,,,,,,fee schedule,402.44,1785.48,APC
Destruction of skin lesions,17107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,663.96,,,,,,,fee schedule,532.22,3246.12,
Destruction of skin lesions,17107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,532.22,,,,,,,fee schedule,532.22,3246.12,
Destruction of skin lesions,17107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,581.4,,,,,,,fee schedule,532.22,3246.12,
Destruction of skin lesions,17107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,611.26,,,,,,,fee schedule,532.22,3246.12,
Destruction of skin lesions,17107,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3246.12,,,,,,,fee schedule,532.22,3246.12,APC 378
Destruction of skin lesions,17107,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,768.24,,,,,,,fee schedule,532.22,3246.12,APC
Destruction of skin lesions,17107,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,760.92,,,,,,,fee schedule,532.22,3246.12,APC
Destruction of skin lesions,17107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,731.66,,,,,,,fee schedule,532.22,3246.12,APC
Destruction of skin lesions,17107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1119.44,,,,,,,fee schedule,532.22,3246.12,Radiology
Destruction of skin lesions,17107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1024.32,,,,,,,fee schedule,532.22,3246.12,APC
Destruction of skin lesions,17107,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1280.4,,,,,,,fee schedule,532.22,3246.12,APC
Destruction of skin lesions,17108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,663.96,,,,,,,fee schedule,532.22,9062.24,
Destruction of skin lesions,17108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,532.22,,,,,,,fee schedule,532.22,9062.24,
Destruction of skin lesions,17108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,581.4,,,,,,,fee schedule,532.22,9062.24,
Destruction of skin lesions,17108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,611.26,,,,,,,fee schedule,532.22,9062.24,
Destruction of skin lesions,17108,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,532.22,9062.24,APC 378
Destruction of skin lesions,17108,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,532.22,9062.24,APC
Destruction of skin lesions,17108,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,532.22,9062.24,APC
Destruction of skin lesions,17108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,532.22,9062.24,APC
Destruction of skin lesions,17108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,532.22,9062.24,Radiology
Destruction of skin lesions,17108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,532.22,9062.24,APC
Destruction of skin lesions,17108,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,532.22,9062.24,APC
Destruct b9 lesion 1-14,17110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,197.92,,,,,,,fee schedule,158.65,881.22,
Destruct b9 lesion 1-14,17110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,158.65,,,,,,,fee schedule,158.65,881.22,
Destruct b9 lesion 1-14,17110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,173.31,,,,,,,fee schedule,158.65,881.22,
Destruct b9 lesion 1-14,17110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,182.21,,,,,,,fee schedule,158.65,881.22,
Destruct b9 lesion 1-14,17110,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,881.22,,,,,,,fee schedule,158.65,881.22,APC 378
Destruct b9 lesion 1-14,17110,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.55,,,,,,,fee schedule,158.65,881.22,APC
Destruct b9 lesion 1-14,17110,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,206.57,,,,,,,fee schedule,158.65,881.22,APC
Destruct b9 lesion 1-14,17110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.62,,,,,,,fee schedule,158.65,881.22,APC
Destruct b9 lesion 1-14,17110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.89,,,,,,,fee schedule,158.65,881.22,Radiology
Destruct b9 lesion 1-14,17110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,278.07,,,,,,,fee schedule,158.65,881.22,APC
Destruct b9 lesion 1-14,17110,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,347.59,,,,,,,fee schedule,158.65,881.22,APC
Destruct lesion 15 or more,17111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,364.24,,,,,,,fee schedule,198.62,881.22,
Destruct lesion 15 or more,17111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,291.97,,,,,,,fee schedule,198.62,881.22,
Destruct lesion 15 or more,17111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,318.95,,,,,,,fee schedule,198.62,881.22,
Destruct lesion 15 or more,17111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,335.33,,,,,,,fee schedule,198.62,881.22,
Destruct lesion 15 or more,17111,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,881.22,,,,,,,fee schedule,198.62,881.22,APC 378
Destruct lesion 15 or more,17111,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.55,,,,,,,fee schedule,198.62,881.22,APC
Destruct lesion 15 or more,17111,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,206.57,,,,,,,fee schedule,198.62,881.22,APC
Destruct lesion 15 or more,17111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.62,,,,,,,fee schedule,198.62,881.22,APC
Destruct lesion 15 or more,17111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.89,,,,,,,fee schedule,198.62,881.22,Radiology
Destruct lesion 15 or more,17111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,278.07,,,,,,,fee schedule,198.62,881.22,APC
Destruct lesion 15 or more,17111,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,347.59,,,,,,,fee schedule,198.62,881.22,APC
Chemical cautery tissue,17250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,212.39,,,,,,,fee schedule,170.25,881.22,
Chemical cautery tissue,17250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,170.25,,,,,,,fee schedule,170.25,881.22,
Chemical cautery tissue,17250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,185.98,,,,,,,fee schedule,170.25,881.22,
Chemical cautery tissue,17250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,195.53,,,,,,,fee schedule,170.25,881.22,
Chemical cautery tissue,17250,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,881.22,,,,,,,fee schedule,170.25,881.22,APC 378
Chemical cautery tissue,17250,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.55,,,,,,,fee schedule,170.25,881.22,APC
Chemical cautery tissue,17250,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,206.57,,,,,,,fee schedule,170.25,881.22,APC
Chemical cautery tissue,17250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.62,,,,,,,fee schedule,170.25,881.22,APC
Chemical cautery tissue,17250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.89,,,,,,,fee schedule,170.25,881.22,Radiology
Chemical cautery tissue,17250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,278.07,,,,,,,fee schedule,170.25,881.22,APC
Chemical cautery tissue,17250,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,347.59,,,,,,,fee schedule,170.25,881.22,APC
Destruction of skin lesions,17260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,364.24,,,,,,,fee schedule,198.62,881.22,
Destruction of skin lesions,17260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,291.97,,,,,,,fee schedule,198.62,881.22,
Destruction of skin lesions,17260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,318.95,,,,,,,fee schedule,198.62,881.22,
Destruction of skin lesions,17260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,335.33,,,,,,,fee schedule,198.62,881.22,
Destruction of skin lesions,17260,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,881.22,,,,,,,fee schedule,198.62,881.22,APC 378
Destruction of skin lesions,17260,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.55,,,,,,,fee schedule,198.62,881.22,APC
Destruction of skin lesions,17260,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,206.57,,,,,,,fee schedule,198.62,881.22,APC
Destruction of skin lesions,17260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.62,,,,,,,fee schedule,198.62,881.22,APC
Destruction of skin lesions,17260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.89,,,,,,,fee schedule,198.62,881.22,Radiology
Destruction of skin lesions,17260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,278.07,,,,,,,fee schedule,198.62,881.22,APC
Destruction of skin lesions,17260,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,347.59,,,,,,,fee schedule,198.62,881.22,APC
Destruction of skin lesions,17261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,364.24,,,,,,,fee schedule,198.62,881.22,
Destruction of skin lesions,17261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,291.97,,,,,,,fee schedule,198.62,881.22,
Destruction of skin lesions,17261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,318.95,,,,,,,fee schedule,198.62,881.22,
Destruction of skin lesions,17261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,335.33,,,,,,,fee schedule,198.62,881.22,
Destruction of skin lesions,17261,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,881.22,,,,,,,fee schedule,198.62,881.22,APC 378
Destruction of skin lesions,17261,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.55,,,,,,,fee schedule,198.62,881.22,APC
Destruction of skin lesions,17261,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,206.57,,,,,,,fee schedule,198.62,881.22,APC
Destruction of skin lesions,17261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.62,,,,,,,fee schedule,198.62,881.22,APC
Destruction of skin lesions,17261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.89,,,,,,,fee schedule,198.62,881.22,Radiology
Destruction of skin lesions,17261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,278.07,,,,,,,fee schedule,198.62,881.22,APC
Destruction of skin lesions,17261,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,347.59,,,,,,,fee schedule,198.62,881.22,APC
Destruction of skin lesions,17262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,364.24,,,,,,,fee schedule,198.62,881.22,
Destruction of skin lesions,17262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,291.97,,,,,,,fee schedule,198.62,881.22,
Destruction of skin lesions,17262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,318.95,,,,,,,fee schedule,198.62,881.22,
Destruction of skin lesions,17262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,335.33,,,,,,,fee schedule,198.62,881.22,
Destruction of skin lesions,17262,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,881.22,,,,,,,fee schedule,198.62,881.22,APC 378
Destruction of skin lesions,17262,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.55,,,,,,,fee schedule,198.62,881.22,APC
Destruction of skin lesions,17262,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,206.57,,,,,,,fee schedule,198.62,881.22,APC
Destruction of skin lesions,17262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.62,,,,,,,fee schedule,198.62,881.22,APC
Destruction of skin lesions,17262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.89,,,,,,,fee schedule,198.62,881.22,Radiology
Destruction of skin lesions,17262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,278.07,,,,,,,fee schedule,198.62,881.22,APC
Destruction of skin lesions,17262,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,347.59,,,,,,,fee schedule,198.62,881.22,APC
Destruction of skin lesions,17263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,364.24,,,,,,,fee schedule,198.62,881.22,
Destruction of skin lesions,17263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,291.97,,,,,,,fee schedule,198.62,881.22,
Destruction of skin lesions,17263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,318.95,,,,,,,fee schedule,198.62,881.22,
Destruction of skin lesions,17263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,335.33,,,,,,,fee schedule,198.62,881.22,
Destruction of skin lesions,17263,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,881.22,,,,,,,fee schedule,198.62,881.22,APC 378
Destruction of skin lesions,17263,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.55,,,,,,,fee schedule,198.62,881.22,APC
Destruction of skin lesions,17263,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,206.57,,,,,,,fee schedule,198.62,881.22,APC
Destruction of skin lesions,17263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.62,,,,,,,fee schedule,198.62,881.22,APC
Destruction of skin lesions,17263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.89,,,,,,,fee schedule,198.62,881.22,Radiology
Destruction of skin lesions,17263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,278.07,,,,,,,fee schedule,198.62,881.22,APC
Destruction of skin lesions,17263,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,347.59,,,,,,,fee schedule,198.62,881.22,APC
Destruction of skin lesions,17264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,364.24,,,,,,,fee schedule,291.97,1785.48,
Destruction of skin lesions,17264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,291.97,,,,,,,fee schedule,291.97,1785.48,
Destruction of skin lesions,17264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,318.95,,,,,,,fee schedule,291.97,1785.48,
Destruction of skin lesions,17264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,335.33,,,,,,,fee schedule,291.97,1785.48,
Destruction of skin lesions,17264,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1785.48,,,,,,,fee schedule,291.97,1785.48,APC 378
Destruction of skin lesions,17264,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,422.56,,,,,,,fee schedule,291.97,1785.48,APC
Destruction of skin lesions,17264,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,418.53,,,,,,,fee schedule,291.97,1785.48,APC
Destruction of skin lesions,17264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,402.44,,,,,,,fee schedule,291.97,1785.48,APC
Destruction of skin lesions,17264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,615.73,,,,,,,fee schedule,291.97,1785.48,Radiology
Destruction of skin lesions,17264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,563.41,,,,,,,fee schedule,291.97,1785.48,APC
Destruction of skin lesions,17264,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,704.26,,,,,,,fee schedule,291.97,1785.48,APC
Destruction of skin lesions,17266,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,663.96,,,,,,,fee schedule,402.44,1785.48,
Destruction of skin lesions,17266,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,532.22,,,,,,,fee schedule,402.44,1785.48,
Destruction of skin lesions,17266,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,581.4,,,,,,,fee schedule,402.44,1785.48,
Destruction of skin lesions,17266,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,611.26,,,,,,,fee schedule,402.44,1785.48,
Destruction of skin lesions,17266,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1785.48,,,,,,,fee schedule,402.44,1785.48,APC 378
Destruction of skin lesions,17266,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,422.56,,,,,,,fee schedule,402.44,1785.48,APC
Destruction of skin lesions,17266,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,418.53,,,,,,,fee schedule,402.44,1785.48,APC
Destruction of skin lesions,17266,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,402.44,,,,,,,fee schedule,402.44,1785.48,APC
Destruction of skin lesions,17266,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,615.73,,,,,,,fee schedule,402.44,1785.48,Radiology
Destruction of skin lesions,17266,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,563.41,,,,,,,fee schedule,402.44,1785.48,APC
Destruction of skin lesions,17266,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,704.26,,,,,,,fee schedule,402.44,1785.48,APC
Destruction of skin lesions,17270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,364.24,,,,,,,fee schedule,198.62,881.22,
Destruction of skin lesions,17270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,291.97,,,,,,,fee schedule,198.62,881.22,
Destruction of skin lesions,17270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,318.95,,,,,,,fee schedule,198.62,881.22,
Destruction of skin lesions,17270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,335.33,,,,,,,fee schedule,198.62,881.22,
Destruction of skin lesions,17270,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,881.22,,,,,,,fee schedule,198.62,881.22,APC 378
Destruction of skin lesions,17270,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.55,,,,,,,fee schedule,198.62,881.22,APC
Destruction of skin lesions,17270,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,206.57,,,,,,,fee schedule,198.62,881.22,APC
Destruction of skin lesions,17270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.62,,,,,,,fee schedule,198.62,881.22,APC
Destruction of skin lesions,17270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.89,,,,,,,fee schedule,198.62,881.22,Radiology
Destruction of skin lesions,17270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,278.07,,,,,,,fee schedule,198.62,881.22,APC
Destruction of skin lesions,17270,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,347.59,,,,,,,fee schedule,198.62,881.22,APC
Destruction of skin lesions,17271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,364.24,,,,,,,fee schedule,198.62,881.22,
Destruction of skin lesions,17271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,291.97,,,,,,,fee schedule,198.62,881.22,
Destruction of skin lesions,17271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,318.95,,,,,,,fee schedule,198.62,881.22,
Destruction of skin lesions,17271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,335.33,,,,,,,fee schedule,198.62,881.22,
Destruction of skin lesions,17271,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,881.22,,,,,,,fee schedule,198.62,881.22,APC 378
Destruction of skin lesions,17271,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.55,,,,,,,fee schedule,198.62,881.22,APC
Destruction of skin lesions,17271,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,206.57,,,,,,,fee schedule,198.62,881.22,APC
Destruction of skin lesions,17271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.62,,,,,,,fee schedule,198.62,881.22,APC
Destruction of skin lesions,17271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.89,,,,,,,fee schedule,198.62,881.22,Radiology
Destruction of skin lesions,17271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,278.07,,,,,,,fee schedule,198.62,881.22,APC
Destruction of skin lesions,17271,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,347.59,,,,,,,fee schedule,198.62,881.22,APC
Destruction of skin lesions,17272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,364.24,,,,,,,fee schedule,198.62,881.22,
Destruction of skin lesions,17272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,291.97,,,,,,,fee schedule,198.62,881.22,
Destruction of skin lesions,17272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,318.95,,,,,,,fee schedule,198.62,881.22,
Destruction of skin lesions,17272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,335.33,,,,,,,fee schedule,198.62,881.22,
Destruction of skin lesions,17272,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,881.22,,,,,,,fee schedule,198.62,881.22,APC 378
Destruction of skin lesions,17272,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.55,,,,,,,fee schedule,198.62,881.22,APC
Destruction of skin lesions,17272,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,206.57,,,,,,,fee schedule,198.62,881.22,APC
Destruction of skin lesions,17272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.62,,,,,,,fee schedule,198.62,881.22,APC
Destruction of skin lesions,17272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.89,,,,,,,fee schedule,198.62,881.22,Radiology
Destruction of skin lesions,17272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,278.07,,,,,,,fee schedule,198.62,881.22,APC
Destruction of skin lesions,17272,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,347.59,,,,,,,fee schedule,198.62,881.22,APC
Destruction of skin lesions,17273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,663.96,,,,,,,fee schedule,402.44,1785.48,
Destruction of skin lesions,17273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,532.22,,,,,,,fee schedule,402.44,1785.48,
Destruction of skin lesions,17273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,581.4,,,,,,,fee schedule,402.44,1785.48,
Destruction of skin lesions,17273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,611.26,,,,,,,fee schedule,402.44,1785.48,
Destruction of skin lesions,17273,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1785.48,,,,,,,fee schedule,402.44,1785.48,APC 378
Destruction of skin lesions,17273,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,422.56,,,,,,,fee schedule,402.44,1785.48,APC
Destruction of skin lesions,17273,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,418.53,,,,,,,fee schedule,402.44,1785.48,APC
Destruction of skin lesions,17273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,402.44,,,,,,,fee schedule,402.44,1785.48,APC
Destruction of skin lesions,17273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,615.73,,,,,,,fee schedule,402.44,1785.48,Radiology
Destruction of skin lesions,17273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,563.41,,,,,,,fee schedule,402.44,1785.48,APC
Destruction of skin lesions,17273,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,704.26,,,,,,,fee schedule,402.44,1785.48,APC
Destruction of skin lesions,17274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,663.96,,,,,,,fee schedule,402.44,1785.48,
Destruction of skin lesions,17274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,532.22,,,,,,,fee schedule,402.44,1785.48,
Destruction of skin lesions,17274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,581.4,,,,,,,fee schedule,402.44,1785.48,
Destruction of skin lesions,17274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,611.26,,,,,,,fee schedule,402.44,1785.48,
Destruction of skin lesions,17274,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1785.48,,,,,,,fee schedule,402.44,1785.48,APC 378
Destruction of skin lesions,17274,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,422.56,,,,,,,fee schedule,402.44,1785.48,APC
Destruction of skin lesions,17274,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,418.53,,,,,,,fee schedule,402.44,1785.48,APC
Destruction of skin lesions,17274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,402.44,,,,,,,fee schedule,402.44,1785.48,APC
Destruction of skin lesions,17274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,615.73,,,,,,,fee schedule,402.44,1785.48,Radiology
Destruction of skin lesions,17274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,563.41,,,,,,,fee schedule,402.44,1785.48,APC
Destruction of skin lesions,17274,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,704.26,,,,,,,fee schedule,402.44,1785.48,APC
Destruction of skin lesions,17276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,663.96,,,,,,,fee schedule,402.44,1785.48,
Destruction of skin lesions,17276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,532.22,,,,,,,fee schedule,402.44,1785.48,
Destruction of skin lesions,17276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,581.4,,,,,,,fee schedule,402.44,1785.48,
Destruction of skin lesions,17276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,611.26,,,,,,,fee schedule,402.44,1785.48,
Destruction of skin lesions,17276,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1785.48,,,,,,,fee schedule,402.44,1785.48,APC 378
Destruction of skin lesions,17276,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,422.56,,,,,,,fee schedule,402.44,1785.48,APC
Destruction of skin lesions,17276,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,418.53,,,,,,,fee schedule,402.44,1785.48,APC
Destruction of skin lesions,17276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,402.44,,,,,,,fee schedule,402.44,1785.48,APC
Destruction of skin lesions,17276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,615.73,,,,,,,fee schedule,402.44,1785.48,Radiology
Destruction of skin lesions,17276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,563.41,,,,,,,fee schedule,402.44,1785.48,APC
Destruction of skin lesions,17276,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,704.26,,,,,,,fee schedule,402.44,1785.48,APC
Destruction of skin lesions,17280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1680.39,,,,,,,fee schedule,198.62,1680.39,
Destruction of skin lesions,17280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1346.98,,,,,,,fee schedule,198.62,1680.39,
Destruction of skin lesions,17280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1471.45,,,,,,,fee schedule,198.62,1680.39,
Destruction of skin lesions,17280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1547.03,,,,,,,fee schedule,198.62,1680.39,
Destruction of skin lesions,17280,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,881.22,,,,,,,fee schedule,198.62,1680.39,APC 378
Destruction of skin lesions,17280,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.55,,,,,,,fee schedule,198.62,1680.39,APC
Destruction of skin lesions,17280,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,206.57,,,,,,,fee schedule,198.62,1680.39,APC
Destruction of skin lesions,17280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.62,,,,,,,fee schedule,198.62,1680.39,APC
Destruction of skin lesions,17280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.89,,,,,,,fee schedule,198.62,1680.39,Radiology
Destruction of skin lesions,17280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,278.07,,,,,,,fee schedule,198.62,1680.39,APC
Destruction of skin lesions,17280,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,347.59,,,,,,,fee schedule,198.62,1680.39,APC
Destruction of skin lesions,17281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,663.96,,,,,,,fee schedule,198.62,881.22,
Destruction of skin lesions,17281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,532.22,,,,,,,fee schedule,198.62,881.22,
Destruction of skin lesions,17281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,581.4,,,,,,,fee schedule,198.62,881.22,
Destruction of skin lesions,17281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,611.26,,,,,,,fee schedule,198.62,881.22,
Destruction of skin lesions,17281,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,881.22,,,,,,,fee schedule,198.62,881.22,APC 378
Destruction of skin lesions,17281,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.55,,,,,,,fee schedule,198.62,881.22,APC
Destruction of skin lesions,17281,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,206.57,,,,,,,fee schedule,198.62,881.22,APC
Destruction of skin lesions,17281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.62,,,,,,,fee schedule,198.62,881.22,APC
Destruction of skin lesions,17281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.89,,,,,,,fee schedule,198.62,881.22,Radiology
Destruction of skin lesions,17281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,278.07,,,,,,,fee schedule,198.62,881.22,APC
Destruction of skin lesions,17281,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,347.59,,,,,,,fee schedule,198.62,881.22,APC
Destruction of skin lesions,17282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,663.96,,,,,,,fee schedule,198.62,881.22,
Destruction of skin lesions,17282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,532.22,,,,,,,fee schedule,198.62,881.22,
Destruction of skin lesions,17282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,581.4,,,,,,,fee schedule,198.62,881.22,
Destruction of skin lesions,17282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,611.26,,,,,,,fee schedule,198.62,881.22,
Destruction of skin lesions,17282,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,881.22,,,,,,,fee schedule,198.62,881.22,APC 378
Destruction of skin lesions,17282,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.55,,,,,,,fee schedule,198.62,881.22,APC
Destruction of skin lesions,17282,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,206.57,,,,,,,fee schedule,198.62,881.22,APC
Destruction of skin lesions,17282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.62,,,,,,,fee schedule,198.62,881.22,APC
Destruction of skin lesions,17282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.89,,,,,,,fee schedule,198.62,881.22,Radiology
Destruction of skin lesions,17282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,278.07,,,,,,,fee schedule,198.62,881.22,APC
Destruction of skin lesions,17282,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,347.59,,,,,,,fee schedule,198.62,881.22,APC
Destruction of skin lesions,17283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,663.96,,,,,,,fee schedule,402.44,1785.48,
Destruction of skin lesions,17283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,532.22,,,,,,,fee schedule,402.44,1785.48,
Destruction of skin lesions,17283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,581.4,,,,,,,fee schedule,402.44,1785.48,
Destruction of skin lesions,17283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,611.26,,,,,,,fee schedule,402.44,1785.48,
Destruction of skin lesions,17283,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1785.48,,,,,,,fee schedule,402.44,1785.48,APC 378
Destruction of skin lesions,17283,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,422.56,,,,,,,fee schedule,402.44,1785.48,APC
Destruction of skin lesions,17283,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,418.53,,,,,,,fee schedule,402.44,1785.48,APC
Destruction of skin lesions,17283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,402.44,,,,,,,fee schedule,402.44,1785.48,APC
Destruction of skin lesions,17283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,615.73,,,,,,,fee schedule,402.44,1785.48,Radiology
Destruction of skin lesions,17283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,563.41,,,,,,,fee schedule,402.44,1785.48,APC
Destruction of skin lesions,17283,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,704.26,,,,,,,fee schedule,402.44,1785.48,APC
Destruction of skin lesions,17284,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,663.96,,,,,,,fee schedule,532.22,3246.12,
Destruction of skin lesions,17284,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,532.22,,,,,,,fee schedule,532.22,3246.12,
Destruction of skin lesions,17284,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,581.4,,,,,,,fee schedule,532.22,3246.12,
Destruction of skin lesions,17284,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,611.26,,,,,,,fee schedule,532.22,3246.12,
Destruction of skin lesions,17284,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3246.12,,,,,,,fee schedule,532.22,3246.12,APC 378
Destruction of skin lesions,17284,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,768.24,,,,,,,fee schedule,532.22,3246.12,APC
Destruction of skin lesions,17284,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,760.92,,,,,,,fee schedule,532.22,3246.12,APC
Destruction of skin lesions,17284,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,731.66,,,,,,,fee schedule,532.22,3246.12,APC
Destruction of skin lesions,17284,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1119.44,,,,,,,fee schedule,532.22,3246.12,Radiology
Destruction of skin lesions,17284,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1024.32,,,,,,,fee schedule,532.22,3246.12,APC
Destruction of skin lesions,17284,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1280.4,,,,,,,fee schedule,532.22,3246.12,APC
Destruction of skin lesions,17286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,663.96,,,,,,,fee schedule,532.22,3246.12,
Destruction of skin lesions,17286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,532.22,,,,,,,fee schedule,532.22,3246.12,
Destruction of skin lesions,17286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,581.4,,,,,,,fee schedule,532.22,3246.12,
Destruction of skin lesions,17286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,611.26,,,,,,,fee schedule,532.22,3246.12,
Destruction of skin lesions,17286,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3246.12,,,,,,,fee schedule,532.22,3246.12,APC 378
Destruction of skin lesions,17286,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,768.24,,,,,,,fee schedule,532.22,3246.12,APC
Destruction of skin lesions,17286,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,760.92,,,,,,,fee schedule,532.22,3246.12,APC
Destruction of skin lesions,17286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,731.66,,,,,,,fee schedule,532.22,3246.12,APC
Destruction of skin lesions,17286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1119.44,,,,,,,fee schedule,532.22,3246.12,Radiology
Destruction of skin lesions,17286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1024.32,,,,,,,fee schedule,532.22,3246.12,APC
Destruction of skin lesions,17286,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1280.4,,,,,,,fee schedule,532.22,3246.12,APC
Mohs 1 stage h/n/hf/g,17311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,906.48,,,,,,,fee schedule,726.62,3246.12,
Mohs 1 stage h/n/hf/g,17311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,726.62,,,,,,,fee schedule,726.62,3246.12,
Mohs 1 stage h/n/hf/g,17311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,793.77,,,,,,,fee schedule,726.62,3246.12,
Mohs 1 stage h/n/hf/g,17311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,834.54,,,,,,,fee schedule,726.62,3246.12,
Mohs 1 stage h/n/hf/g,17311,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3246.12,,,,,,,fee schedule,726.62,3246.12,APC 378
Mohs 1 stage h/n/hf/g,17311,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,768.24,,,,,,,fee schedule,726.62,3246.12,APC
Mohs 1 stage h/n/hf/g,17311,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,760.92,,,,,,,fee schedule,726.62,3246.12,APC
Mohs 1 stage h/n/hf/g,17311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,731.66,,,,,,,fee schedule,726.62,3246.12,APC
Mohs 1 stage h/n/hf/g,17311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1119.44,,,,,,,fee schedule,726.62,3246.12,Radiology
Mohs 1 stage h/n/hf/g,17311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1024.32,,,,,,,fee schedule,726.62,3246.12,APC
Mohs 1 stage h/n/hf/g,17311,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1280.4,,,,,,,fee schedule,726.62,3246.12,APC
Mohs Addl Stage,17312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,906.48,,,,,,,fee schedule,726.62,906.48,
Mohs Addl Stage,17312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,726.62,,,,,,,fee schedule,726.62,906.48,
Mohs Addl Stage,17312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,793.77,,,,,,,fee schedule,726.62,906.48,
Mohs Addl Stage,17312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,834.54,,,,,,,fee schedule,726.62,906.48,
Mohs 1 stage t/a/l,17313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,906.48,,,,,,,fee schedule,726.62,3246.12,
Mohs 1 stage t/a/l,17313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,726.62,,,,,,,fee schedule,726.62,3246.12,
Mohs 1 stage t/a/l,17313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,793.77,,,,,,,fee schedule,726.62,3246.12,
Mohs 1 stage t/a/l,17313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,834.54,,,,,,,fee schedule,726.62,3246.12,
Mohs 1 stage t/a/l,17313,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3246.12,,,,,,,fee schedule,726.62,3246.12,APC 378
Mohs 1 stage t/a/l,17313,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,768.24,,,,,,,fee schedule,726.62,3246.12,APC
Mohs 1 stage t/a/l,17313,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,760.92,,,,,,,fee schedule,726.62,3246.12,APC
Mohs 1 stage t/a/l,17313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,731.66,,,,,,,fee schedule,726.62,3246.12,APC
Mohs 1 stage t/a/l,17313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1119.44,,,,,,,fee schedule,726.62,3246.12,Radiology
Mohs 1 stage t/a/l,17313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1024.32,,,,,,,fee schedule,726.62,3246.12,APC
Mohs 1 stage t/a/l,17313,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1280.4,,,,,,,fee schedule,726.62,3246.12,APC
Mohs addl stage t/a/l,17314,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,906.48,,,,,,,fee schedule,726.62,906.48,
Mohs addl stage t/a/l,17314,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,726.62,,,,,,,fee schedule,726.62,906.48,
Mohs addl stage t/a/l,17314,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,793.77,,,,,,,fee schedule,726.62,906.48,
Mohs addl stage t/a/l,17314,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,834.54,,,,,,,fee schedule,726.62,906.48,
Mohs surg addl block,17315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,906.48,,,,,,,fee schedule,726.62,906.48,
Mohs surg addl block,17315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,726.62,,,,,,,fee schedule,726.62,906.48,
Mohs surg addl block,17315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,793.77,,,,,,,fee schedule,726.62,906.48,
Mohs surg addl block,17315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,834.54,,,,,,,fee schedule,726.62,906.48,
Cryotherapy of skin,17340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,197.92,,,,,,,fee schedule,58.4,259.1,
Cryotherapy of skin,17340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,158.65,,,,,,,fee schedule,58.4,259.1,
Cryotherapy of skin,17340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,173.31,,,,,,,fee schedule,58.4,259.1,
Cryotherapy of skin,17340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,182.21,,,,,,,fee schedule,58.4,259.1,
Cryotherapy of skin,17340,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,58.4,259.1,APC 378
Cryotherapy of skin,17340,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,58.4,259.1,APC
Cryotherapy of skin,17340,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,58.4,259.1,APC
Cryotherapy of skin,17340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,58.4,259.1,APC
Cryotherapy of skin,17340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,58.4,259.1,Radiology
Cryotherapy of skin,17340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,58.4,259.1,APC
Cryotherapy of skin,17340,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,58.4,259.1,APC
Skin peel therapy,17360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,197.92,,,,,,,fee schedule,158.65,881.22,
Skin peel therapy,17360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,158.65,,,,,,,fee schedule,158.65,881.22,
Skin peel therapy,17360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,173.31,,,,,,,fee schedule,158.65,881.22,
Skin peel therapy,17360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,182.21,,,,,,,fee schedule,158.65,881.22,
Skin peel therapy,17360,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,881.22,,,,,,,fee schedule,158.65,881.22,APC 378
Skin peel therapy,17360,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.55,,,,,,,fee schedule,158.65,881.22,APC
Skin peel therapy,17360,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,206.57,,,,,,,fee schedule,158.65,881.22,APC
Skin peel therapy,17360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.62,,,,,,,fee schedule,158.65,881.22,APC
Skin peel therapy,17360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.89,,,,,,,fee schedule,158.65,881.22,Radiology
Skin peel therapy,17360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,278.07,,,,,,,fee schedule,158.65,881.22,APC
Skin peel therapy,17360,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,347.59,,,,,,,fee schedule,158.65,881.22,APC
Hair removal by electrolysis,17380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,197.92,,,,,,,fee schedule,158.65,3246.12,
Hair removal by electrolysis,17380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,158.65,,,,,,,fee schedule,158.65,3246.12,
Hair removal by electrolysis,17380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,173.31,,,,,,,fee schedule,158.65,3246.12,
Hair removal by electrolysis,17380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,182.21,,,,,,,fee schedule,158.65,3246.12,
Hair removal by electrolysis,17380,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3246.12,,,,,,,fee schedule,158.65,3246.12,APC 378
Hair removal by electrolysis,17380,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,768.24,,,,,,,fee schedule,158.65,3246.12,APC
Hair removal by electrolysis,17380,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,760.92,,,,,,,fee schedule,158.65,3246.12,APC
Hair removal by electrolysis,17380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,731.66,,,,,,,fee schedule,158.65,3246.12,APC
Hair removal by electrolysis,17380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1119.44,,,,,,,fee schedule,158.65,3246.12,Radiology
Hair removal by electrolysis,17380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1024.32,,,,,,,fee schedule,158.65,3246.12,APC
Hair removal by electrolysis,17380,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1280.4,,,,,,,fee schedule,158.65,3246.12,APC
Skin tissue procedure,17999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,73.94,,,,,,,fee schedule,59.27,881.22,
Skin tissue procedure,17999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,59.27,,,,,,,fee schedule,59.27,881.22,
Skin tissue procedure,17999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,64.74,,,,,,,fee schedule,59.27,881.22,
Skin tissue procedure,17999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,68.07,,,,,,,fee schedule,59.27,881.22,
Skin tissue procedure,17999,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,881.22,,,,,,,fee schedule,59.27,881.22,APC 378
Skin tissue procedure,17999,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.55,,,,,,,fee schedule,59.27,881.22,APC
Skin tissue procedure,17999,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,206.57,,,,,,,fee schedule,59.27,881.22,APC
Skin tissue procedure,17999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.62,,,,,,,fee schedule,59.27,881.22,APC
Skin tissue procedure,17999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.89,,,,,,,fee schedule,59.27,881.22,Radiology
Skin tissue procedure,17999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,278.07,,,,,,,fee schedule,59.27,881.22,APC
Skin tissue procedure,17999,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,347.59,,,,,,,fee schedule,59.27,881.22,APC
Drainage of breast lesion,19000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,491.95,,,,,,,fee schedule,394.34,3110.22,
Drainage of breast lesion,19000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,394.34,,,,,,,fee schedule,394.34,3110.22,
Drainage of breast lesion,19000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,430.79,,,,,,,fee schedule,394.34,3110.22,
Drainage of breast lesion,19000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,452.91,,,,,,,fee schedule,394.34,3110.22,
Drainage of breast lesion,19000,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3110.22,,,,,,,fee schedule,394.34,3110.22,APC 378
Drainage of breast lesion,19000,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,736.08,,,,,,,fee schedule,394.34,3110.22,APC
Drainage of breast lesion,19000,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,729.07,,,,,,,fee schedule,394.34,3110.22,APC
Drainage of breast lesion,19000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,701.03,,,,,,,fee schedule,394.34,3110.22,APC
Drainage of breast lesion,19000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1072.57,,,,,,,fee schedule,394.34,3110.22,Radiology
Drainage of breast lesion,19000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,981.44,,,,,,,fee schedule,394.34,3110.22,APC
Drainage of breast lesion,19000,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1226.8,,,,,,,fee schedule,394.34,3110.22,APC
Drain breast lesion add-on,19001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,276.96,,,,,,,fee schedule,222.01,276.96,
Drain breast lesion add-on,19001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,222.01,,,,,,,fee schedule,222.01,276.96,
Drain breast lesion add-on,19001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,242.52,,,,,,,fee schedule,222.01,276.96,
Drain breast lesion add-on,19001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,254.98,,,,,,,fee schedule,222.01,276.96,
Incision of breast lesion,19020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6253.46,,,,,,,fee schedule,1635.03,7254.06,
Incision of breast lesion,19020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5012.69,,,,,,,fee schedule,1635.03,7254.06,
Incision of breast lesion,19020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5475.91,,,,,,,fee schedule,1635.03,7254.06,
Incision of breast lesion,19020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5757.15,,,,,,,fee schedule,1635.03,7254.06,
Incision of breast lesion,19020,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,7254.06,APC 378
Incision of breast lesion,19020,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,7254.06,APC
Incision of breast lesion,19020,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,7254.06,APC
Incision of breast lesion,19020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,7254.06,APC
Incision of breast lesion,19020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,7254.06,Radiology
Incision of breast lesion,19020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,7254.06,APC
Incision of breast lesion,19020,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,7254.06,APC
Bx breast 1st lesion strtctc,19081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3978.94,,,,,,,fee schedule,1635.03,7254.06,
Bx breast 1st lesion strtctc,19081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3189.47,,,,,,,fee schedule,1635.03,7254.06,
Bx breast 1st lesion strtctc,19081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3484.21,,,,,,,fee schedule,1635.03,7254.06,
Bx breast 1st lesion strtctc,19081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3663.15,,,,,,,fee schedule,1635.03,7254.06,
Bx breast 1st lesion strtctc,19081,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,7254.06,APC 378
Bx breast 1st lesion strtctc,19081,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,7254.06,APC
Bx breast 1st lesion strtctc,19081,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,7254.06,APC
Bx breast 1st lesion strtctc,19081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,7254.06,APC
Bx breast 1st lesion strtctc,19081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,7254.06,Radiology
Bx breast 1st lesion strtctc,19081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,7254.06,APC
Bx breast 1st lesion strtctc,19081,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,7254.06,APC
Bx breast add lesion strtctc,19082,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,323.87,,,,,,,fee schedule,259.61,323.87,
Bx breast add lesion strtctc,19082,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,259.61,,,,,,,fee schedule,259.61,323.87,
Bx breast add lesion strtctc,19082,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,283.6,,,,,,,fee schedule,259.61,323.87,
Bx breast add lesion strtctc,19082,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,298.17,,,,,,,fee schedule,259.61,323.87,
Bx breast 1st lesion us imag,19083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3978.94,,,,,,,fee schedule,1635.03,7254.06,
Bx breast 1st lesion us imag,19083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3189.47,,,,,,,fee schedule,1635.03,7254.06,
Bx breast 1st lesion us imag,19083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3484.21,,,,,,,fee schedule,1635.03,7254.06,
Bx breast 1st lesion us imag,19083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3663.15,,,,,,,fee schedule,1635.03,7254.06,
Bx breast 1st lesion us imag,19083,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,7254.06,APC 378
Bx breast 1st lesion us imag,19083,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,7254.06,APC
Bx breast 1st lesion us imag,19083,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,7254.06,APC
Bx breast 1st lesion us imag,19083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,7254.06,APC
Bx breast 1st lesion us imag,19083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,7254.06,Radiology
Bx breast 1st lesion us imag,19083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,7254.06,APC
Bx breast 1st lesion us imag,19083,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,7254.06,APC
Bx breast add lesion us imag,19084,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,305.05,,,,,,,fee schedule,244.52,305.05,
Bx breast add lesion us imag,19084,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,244.52,,,,,,,fee schedule,244.52,305.05,
Bx breast add lesion us imag,19084,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,267.12,,,,,,,fee schedule,244.52,305.05,
Bx breast add lesion us imag,19084,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,280.84,,,,,,,fee schedule,244.52,305.05,
Bx breast 1st lesion mr imag,19085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3978.94,,,,,,,fee schedule,1635.03,7254.06,
Bx breast 1st lesion mr imag,19085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3189.47,,,,,,,fee schedule,1635.03,7254.06,
Bx breast 1st lesion mr imag,19085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3484.21,,,,,,,fee schedule,1635.03,7254.06,
Bx breast 1st lesion mr imag,19085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3663.15,,,,,,,fee schedule,1635.03,7254.06,
Bx breast 1st lesion mr imag,19085,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,7254.06,APC 378
Bx breast 1st lesion mr imag,19085,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,7254.06,APC
Bx breast 1st lesion mr imag,19085,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,7254.06,APC
Bx breast 1st lesion mr imag,19085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,7254.06,APC
Bx breast 1st lesion mr imag,19085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,7254.06,Radiology
Bx breast 1st lesion mr imag,19085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,7254.06,APC
Bx breast 1st lesion mr imag,19085,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,7254.06,APC
Bx breast add lesion mr imag,19086,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,366.51,,,,,,,fee schedule,293.79,366.51,
Bx breast add lesion mr imag,19086,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,293.79,,,,,,,fee schedule,293.79,366.51,
Bx breast add lesion mr imag,19086,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,320.94,,,,,,,fee schedule,293.79,366.51,
Bx breast add lesion mr imag,19086,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,337.42,,,,,,,fee schedule,293.79,366.51,
Bx breast percut w/o image,19100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1079.91,,,,,,,fee schedule,865.64,7254.06,
Bx breast percut w/o image,19100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,865.64,,,,,,,fee schedule,865.64,7254.06,
Bx breast percut w/o image,19100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,945.63,,,,,,,fee schedule,865.64,7254.06,
Bx breast percut w/o image,19100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,994.2,,,,,,,fee schedule,865.64,7254.06,
Bx breast percut w/o image,19100,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,865.64,7254.06,APC 378
Bx breast percut w/o image,19100,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,865.64,7254.06,APC
Bx breast percut w/o image,19100,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,865.64,7254.06,APC
Bx breast percut w/o image,19100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,865.64,7254.06,APC
Bx breast percut w/o image,19100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,865.64,7254.06,Radiology
Bx breast percut w/o image,19100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,865.64,7254.06,APC
Bx breast percut w/o image,19100,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,865.64,7254.06,APC
Biopsy of breast open,19101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3594.84,,,,,,,fee schedule,2881.58,17197.18,
Biopsy of breast open,19101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2881.58,,,,,,,fee schedule,2881.58,17197.18,
Biopsy of breast open,19101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3147.87,,,,,,,fee schedule,2881.58,17197.18,
Biopsy of breast open,19101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3309.54,,,,,,,fee schedule,2881.58,17197.18,
Biopsy of breast open,19101,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17197.18,,,,,,,fee schedule,2881.58,17197.18,APC 378
Biopsy of breast open,19101,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4069.96,,,,,,,fee schedule,2881.58,17197.18,APC
Biopsy of breast open,19101,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4031.2,,,,,,,fee schedule,2881.58,17197.18,APC
Biopsy of breast open,19101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3876.15,,,,,,,fee schedule,2881.58,17197.18,APC
Biopsy of breast open,19101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5930.51,,,,,,,fee schedule,2881.58,17197.18,Radiology
Biopsy of breast open,19101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5426.61,,,,,,,fee schedule,2881.58,17197.18,APC
Biopsy of breast open,19101,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6783.27,,,,,,,fee schedule,2881.58,17197.18,APC
Cryosurg ablate fa each,19105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7914.87,,,,,,,fee schedule,3876.15,17197.18,
Cryosurg ablate fa each,19105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6344.46,,,,,,,fee schedule,3876.15,17197.18,
Cryosurg ablate fa each,19105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6930.74,,,,,,,fee schedule,3876.15,17197.18,
Cryosurg ablate fa each,19105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7286.7,,,,,,,fee schedule,3876.15,17197.18,
Cryosurg ablate fa each,19105,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17197.18,,,,,,,fee schedule,3876.15,17197.18,APC 378
Cryosurg ablate fa each,19105,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4069.96,,,,,,,fee schedule,3876.15,17197.18,APC
Cryosurg ablate fa each,19105,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4031.2,,,,,,,fee schedule,3876.15,17197.18,APC
Cryosurg ablate fa each,19105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3876.15,,,,,,,fee schedule,3876.15,17197.18,APC
Cryosurg ablate fa each,19105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5930.51,,,,,,,fee schedule,3876.15,17197.18,Radiology
Cryosurg ablate fa each,19105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5426.61,,,,,,,fee schedule,3876.15,17197.18,APC
Cryosurg ablate fa each,19105,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6783.27,,,,,,,fee schedule,3876.15,17197.18,APC
Nipple exploration,19110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6955.63,,,,,,,fee schedule,3876.15,17197.18,
Nipple exploration,19110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5575.54,,,,,,,fee schedule,3876.15,17197.18,
Nipple exploration,19110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6090.78,,,,,,,fee schedule,3876.15,17197.18,
Nipple exploration,19110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6403.59,,,,,,,fee schedule,3876.15,17197.18,
Nipple exploration,19110,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17197.18,,,,,,,fee schedule,3876.15,17197.18,APC 378
Nipple exploration,19110,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4069.96,,,,,,,fee schedule,3876.15,17197.18,APC
Nipple exploration,19110,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4031.2,,,,,,,fee schedule,3876.15,17197.18,APC
Nipple exploration,19110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3876.15,,,,,,,fee schedule,3876.15,17197.18,APC
Nipple exploration,19110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5930.51,,,,,,,fee schedule,3876.15,17197.18,Radiology
Nipple exploration,19110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5426.61,,,,,,,fee schedule,3876.15,17197.18,APC
Nipple exploration,19110,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6783.27,,,,,,,fee schedule,3876.15,17197.18,APC
Excise breast duct fistula,19112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6721.57,,,,,,,fee schedule,3876.15,17197.18,
Excise breast duct fistula,19112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5387.93,,,,,,,fee schedule,3876.15,17197.18,
Excise breast duct fistula,19112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5885.82,,,,,,,fee schedule,3876.15,17197.18,
Excise breast duct fistula,19112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6188.11,,,,,,,fee schedule,3876.15,17197.18,
Excise breast duct fistula,19112,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17197.18,,,,,,,fee schedule,3876.15,17197.18,APC 378
Excise breast duct fistula,19112,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4069.96,,,,,,,fee schedule,3876.15,17197.18,APC
Excise breast duct fistula,19112,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4031.2,,,,,,,fee schedule,3876.15,17197.18,APC
Excise breast duct fistula,19112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3876.15,,,,,,,fee schedule,3876.15,17197.18,APC
Excise breast duct fistula,19112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5930.51,,,,,,,fee schedule,3876.15,17197.18,Radiology
Excise breast duct fistula,19112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5426.61,,,,,,,fee schedule,3876.15,17197.18,APC
Excise breast duct fistula,19112,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6783.27,,,,,,,fee schedule,3876.15,17197.18,APC
Removal of breast lesion,19120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9003.81,,,,,,,fee schedule,3876.15,17197.18,
Removal of breast lesion,19120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7217.34,,,,,,,fee schedule,3876.15,17197.18,
Removal of breast lesion,19120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7884.29,,,,,,,fee schedule,3876.15,17197.18,
Removal of breast lesion,19120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8289.22,,,,,,,fee schedule,3876.15,17197.18,
Removal of breast lesion,19120,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17197.18,,,,,,,fee schedule,3876.15,17197.18,APC 378
Removal of breast lesion,19120,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4069.96,,,,,,,fee schedule,3876.15,17197.18,APC
Removal of breast lesion,19120,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4031.2,,,,,,,fee schedule,3876.15,17197.18,APC
Removal of breast lesion,19120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3876.15,,,,,,,fee schedule,3876.15,17197.18,APC
Removal of breast lesion,19120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5930.51,,,,,,,fee schedule,3876.15,17197.18,Radiology
Removal of breast lesion,19120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5426.61,,,,,,,fee schedule,3876.15,17197.18,APC
Removal of breast lesion,19120,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6783.27,,,,,,,fee schedule,3876.15,17197.18,APC
Excision breast lesion,19125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4652.67,,,,,,,fee schedule,3729.52,17197.18,
Excision breast lesion,19125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3729.52,,,,,,,fee schedule,3729.52,17197.18,
Excision breast lesion,19125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4074.16,,,,,,,fee schedule,3729.52,17197.18,
Excision breast lesion,19125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4283.41,,,,,,,fee schedule,3729.52,17197.18,
Excision breast lesion,19125,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17197.18,,,,,,,fee schedule,3729.52,17197.18,APC 378
Excision breast lesion,19125,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4069.96,,,,,,,fee schedule,3729.52,17197.18,APC
Excision breast lesion,19125,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4031.2,,,,,,,fee schedule,3729.52,17197.18,APC
Excision breast lesion,19125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3876.15,,,,,,,fee schedule,3729.52,17197.18,APC
Excision breast lesion,19125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5930.51,,,,,,,fee schedule,3729.52,17197.18,Radiology
Excision breast lesion,19125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5426.61,,,,,,,fee schedule,3729.52,17197.18,APC
Excision breast lesion,19125,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6783.27,,,,,,,fee schedule,3729.52,17197.18,APC
Excision addl breast lesion,19126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3828.9,,,,,,,fee schedule,3069.2,3828.9,
Excision addl breast lesion,19126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3069.2,,,,,,,fee schedule,3069.2,3828.9,
Excision addl breast lesion,19126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3352.82,,,,,,,fee schedule,3069.2,3828.9,
Excision addl breast lesion,19126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3525.02,,,,,,,fee schedule,3069.2,3828.9,
Perq device breast 1st imag,19281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,498.02,,,,,,,fee schedule,399.2,7254.06,
Perq device breast 1st imag,19281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,399.2,,,,,,,fee schedule,399.2,7254.06,
Perq device breast 1st imag,19281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,436.09,,,,,,,fee schedule,399.2,7254.06,
Perq device breast 1st imag,19281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,458.49,,,,,,,fee schedule,399.2,7254.06,
Perq device breast 1st imag,19281,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,399.2,7254.06,APC 378
Perq device breast 1st imag,19281,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,399.2,7254.06,APC
Perq device breast 1st imag,19281,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,399.2,7254.06,APC
Perq device breast 1st imag,19281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,399.2,7254.06,APC
Perq device breast 1st imag,19281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,399.2,7254.06,Radiology
Perq device breast 1st imag,19281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,399.2,7254.06,APC
Perq device breast 1st imag,19281,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,399.2,7254.06,APC
Perq device breast ea imag,19282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,199.92,,,,,,,fee schedule,160.26,199.92,
Perq device breast ea imag,19282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,160.26,,,,,,,fee schedule,160.26,199.92,
Perq device breast ea imag,19282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,175.07,,,,,,,fee schedule,160.26,199.92,
Perq device breast ea imag,19282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,184.06,,,,,,,fee schedule,160.26,199.92,
Perq dev breast 1st strtctc,19283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2995.7,,,,,,,fee schedule,701.03,3110.22,
Perq dev breast 1st strtctc,19283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2401.32,,,,,,,fee schedule,701.03,3110.22,
Perq dev breast 1st strtctc,19283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2623.22,,,,,,,fee schedule,701.03,3110.22,
Perq dev breast 1st strtctc,19283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2757.95,,,,,,,fee schedule,701.03,3110.22,
Perq dev breast 1st strtctc,19283,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3110.22,,,,,,,fee schedule,701.03,3110.22,APC 378
Perq dev breast 1st strtctc,19283,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,736.08,,,,,,,fee schedule,701.03,3110.22,APC
Perq dev breast 1st strtctc,19283,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,729.07,,,,,,,fee schedule,701.03,3110.22,APC
Perq dev breast 1st strtctc,19283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,701.03,,,,,,,fee schedule,701.03,3110.22,APC
Perq dev breast 1st strtctc,19283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1072.57,,,,,,,fee schedule,701.03,3110.22,Radiology
Perq dev breast 1st strtctc,19283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,981.44,,,,,,,fee schedule,701.03,3110.22,APC
Perq dev breast 1st strtctc,19283,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1226.8,,,,,,,fee schedule,701.03,3110.22,APC
Perq dev breast add strtctc,19284,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,201.17,,,,,,,fee schedule,161.26,201.17,
Perq dev breast add strtctc,19284,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,161.26,,,,,,,fee schedule,161.26,201.17,
Perq dev breast add strtctc,19284,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,176.16,,,,,,,fee schedule,161.26,201.17,
Perq dev breast add strtctc,19284,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,185.21,,,,,,,fee schedule,161.26,201.17,
Perq dev breast 1st us imag,19285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3629.84,,,,,,,fee schedule,701.03,3629.84,
Perq dev breast 1st us imag,19285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2909.63,,,,,,,fee schedule,701.03,3629.84,
Perq dev breast 1st us imag,19285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3178.51,,,,,,,fee schedule,701.03,3629.84,
Perq dev breast 1st us imag,19285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3341.76,,,,,,,fee schedule,701.03,3629.84,
Perq dev breast 1st us imag,19285,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3110.22,,,,,,,fee schedule,701.03,3629.84,APC 378
Perq dev breast 1st us imag,19285,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,736.08,,,,,,,fee schedule,701.03,3629.84,APC
Perq dev breast 1st us imag,19285,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,729.07,,,,,,,fee schedule,701.03,3629.84,APC
Perq dev breast 1st us imag,19285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,701.03,,,,,,,fee schedule,701.03,3629.84,APC
Perq dev breast 1st us imag,19285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1072.57,,,,,,,fee schedule,701.03,3629.84,Radiology
Perq dev breast 1st us imag,19285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,981.44,,,,,,,fee schedule,701.03,3629.84,APC
Perq dev breast 1st us imag,19285,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1226.8,,,,,,,fee schedule,701.03,3629.84,APC
Perq dev breast add us imag,19286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,170.33,,,,,,,fee schedule,136.53,170.33,
Perq dev breast add us imag,19286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,136.53,,,,,,,fee schedule,136.53,170.33,
Perq dev breast add us imag,19286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,149.15,,,,,,,fee schedule,136.53,170.33,
Perq dev breast add us imag,19286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,156.81,,,,,,,fee schedule,136.53,170.33,
Perq dev breast 1st mr guide,19287,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,498.02,,,,,,,fee schedule,399.2,3110.22,
Perq dev breast 1st mr guide,19287,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,399.2,,,,,,,fee schedule,399.2,3110.22,
Perq dev breast 1st mr guide,19287,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,436.09,,,,,,,fee schedule,399.2,3110.22,
Perq dev breast 1st mr guide,19287,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,458.49,,,,,,,fee schedule,399.2,3110.22,
Perq dev breast 1st mr guide,19287,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3110.22,,,,,,,fee schedule,399.2,3110.22,APC 378
Perq dev breast 1st mr guide,19287,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,736.08,,,,,,,fee schedule,399.2,3110.22,APC
Perq dev breast 1st mr guide,19287,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,729.07,,,,,,,fee schedule,399.2,3110.22,APC
Perq dev breast 1st mr guide,19287,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,701.03,,,,,,,fee schedule,399.2,3110.22,APC
Perq dev breast 1st mr guide,19287,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1072.57,,,,,,,fee schedule,399.2,3110.22,Radiology
Perq dev breast 1st mr guide,19287,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,981.44,,,,,,,fee schedule,399.2,3110.22,APC
Perq dev breast 1st mr guide,19287,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1226.8,,,,,,,fee schedule,399.2,3110.22,APC
Perq dev breast add mr guide,19288,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,258.97,,,,,,,fee schedule,207.59,258.97,
Perq dev breast add mr guide,19288,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,207.59,,,,,,,fee schedule,207.59,258.97,
Perq dev breast add mr guide,19288,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,226.77,,,,,,,fee schedule,207.59,258.97,
Perq dev breast add mr guide,19288,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,238.41,,,,,,,fee schedule,207.59,258.97,
Prep tum cav iort prtl mast,19294,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,658.74,,,,,,,fee schedule,528.04,658.74,
Prep tum cav iort prtl mast,19294,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,528.04,,,,,,,fee schedule,528.04,658.74,
Prep tum cav iort prtl mast,19294,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,576.83,,,,,,,fee schedule,528.04,658.74,
Prep tum cav iort prtl mast,19294,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,606.46,,,,,,,fee schedule,528.04,658.74,
Place po breast cath for rad,19296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14120.3,,,,,,,fee schedule,8091.39,35898.76,
Place po breast cath for rad,19296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11318.66,,,,,,,fee schedule,8091.39,35898.76,
Place po breast cath for rad,19296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12364.6,,,,,,,fee schedule,8091.39,35898.76,
Place po breast cath for rad,19296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12999.64,,,,,,,fee schedule,8091.39,35898.76,
Place po breast cath for rad,19296,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,35898.76,,,,,,,fee schedule,8091.39,35898.76,APC 378
Place po breast cath for rad,19296,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8495.96,,,,,,,fee schedule,8091.39,35898.76,APC
Place po breast cath for rad,19296,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8415.05,,,,,,,fee schedule,8091.39,35898.76,APC
Place po breast cath for rad,19296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8091.39,,,,,,,fee schedule,8091.39,35898.76,APC
Place po breast cath for rad,19296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12379.83,,,,,,,fee schedule,8091.39,35898.76,Radiology
Place po breast cath for rad,19296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11327.95,,,,,,,fee schedule,8091.39,35898.76,APC
Place po breast cath for rad,19296,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14159.93,,,,,,,fee schedule,8091.39,35898.76,APC
Place breast cath for rad,19297,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14120.3,,,,,,,fee schedule,11318.66,14120.3,
Place breast cath for rad,19297,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11318.66,,,,,,,fee schedule,11318.66,14120.3,
Place breast cath for rad,19297,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12364.6,,,,,,,fee schedule,11318.66,14120.3,
Place breast cath for rad,19297,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12999.64,,,,,,,fee schedule,11318.66,14120.3,
Place breast rad tube/caths,19298,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14120.3,,,,,,,fee schedule,11318.66,60528.02,
Place breast rad tube/caths,19298,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11318.66,,,,,,,fee schedule,11318.66,60528.02,
Place breast rad tube/caths,19298,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12364.6,,,,,,,fee schedule,11318.66,60528.02,
Place breast rad tube/caths,19298,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12999.64,,,,,,,fee schedule,11318.66,60528.02,
Place breast rad tube/caths,19298,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,60528.02,,,,,,,fee schedule,11318.66,60528.02,APC 378
Place breast rad tube/caths,19298,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14324.83,,,,,,,fee schedule,11318.66,60528.02,APC
Place breast rad tube/caths,19298,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,14188.4,,,,,,,fee schedule,11318.66,60528.02,APC
Place breast rad tube/caths,19298,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13642.7,,,,,,,fee schedule,11318.66,60528.02,APC
Place breast rad tube/caths,19298,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20873.32,,,,,,,fee schedule,11318.66,60528.02,Radiology
Place breast rad tube/caths,19298,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19099.77,,,,,,,fee schedule,11318.66,60528.02,APC
Place breast rad tube/caths,19298,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23874.72,,,,,,,fee schedule,11318.66,60528.02,APC
Removal of Breast Tissue,19300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4531.07,,,,,,,fee schedule,3632.05,17197.18,
Removal of Breast Tissue,19300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3632.05,,,,,,,fee schedule,3632.05,17197.18,
Removal of Breast Tissue,19300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3967.69,,,,,,,fee schedule,3632.05,17197.18,
Removal of Breast Tissue,19300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4171.46,,,,,,,fee schedule,3632.05,17197.18,
Removal of Breast Tissue,19300,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17197.18,,,,,,,fee schedule,3632.05,17197.18,APC 378
Removal of Breast Tissue,19300,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4069.96,,,,,,,fee schedule,3632.05,17197.18,APC
Removal of Breast Tissue,19300,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4031.2,,,,,,,fee schedule,3632.05,17197.18,APC
Removal of Breast Tissue,19300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3876.15,,,,,,,fee schedule,3632.05,17197.18,APC
Removal of Breast Tissue,19300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5930.51,,,,,,,fee schedule,3632.05,17197.18,Radiology
Removal of Breast Tissue,19300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5426.61,,,,,,,fee schedule,3632.05,17197.18,APC
Removal of Breast Tissue,19300,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6783.27,,,,,,,fee schedule,3632.05,17197.18,APC
Partial Mastectomy,19301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5640.73,,,,,,,fee schedule,3876.15,17197.18,
Partial Mastectomy,19301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4521.54,,,,,,,fee schedule,3876.15,17197.18,
Partial Mastectomy,19301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4939.37,,,,,,,fee schedule,3876.15,17197.18,
Partial Mastectomy,19301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5193.05,,,,,,,fee schedule,3876.15,17197.18,
Partial Mastectomy,19301,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17197.18,,,,,,,fee schedule,3876.15,17197.18,APC 378
Partial Mastectomy,19301,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4069.96,,,,,,,fee schedule,3876.15,17197.18,APC
Partial Mastectomy,19301,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4031.2,,,,,,,fee schedule,3876.15,17197.18,APC
Partial Mastectomy,19301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3876.15,,,,,,,fee schedule,3876.15,17197.18,APC
Partial Mastectomy,19301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5930.51,,,,,,,fee schedule,3876.15,17197.18,Radiology
Partial Mastectomy,19301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5426.61,,,,,,,fee schedule,3876.15,17197.18,APC
Partial Mastectomy,19301,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6783.27,,,,,,,fee schedule,3876.15,17197.18,APC
P-Mastectomy w/LN Removal,19302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6080,,,,,,,fee schedule,4873.65,29164.62,
P-Mastectomy w/LN Removal,19302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4873.65,,,,,,,fee schedule,4873.65,29164.62,
P-Mastectomy w/LN Removal,19302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5324.02,,,,,,,fee schedule,4873.65,29164.62,
P-Mastectomy w/LN Removal,19302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5597.46,,,,,,,fee schedule,4873.65,29164.62,
P-Mastectomy w/LN Removal,19302,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,29164.62,,,,,,,fee schedule,4873.65,29164.62,APC 378
P-Mastectomy w/LN Removal,19302,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6902.23,,,,,,,fee schedule,4873.65,29164.62,APC
P-Mastectomy w/LN Removal,19302,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6836.49,,,,,,,fee schedule,4873.65,29164.62,APC
P-Mastectomy w/LN Removal,19302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6573.55,,,,,,,fee schedule,4873.65,29164.62,APC
P-Mastectomy w/LN Removal,19302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10057.53,,,,,,,fee schedule,4873.65,29164.62,Radiology
P-Mastectomy w/LN Removal,19302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9202.97,,,,,,,fee schedule,4873.65,29164.62,APC
P-Mastectomy w/LN Removal,19302,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11503.71,,,,,,,fee schedule,4873.65,29164.62,APC
Mast simple complete,19303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5728.67,,,,,,,fee schedule,4592.03,29164.62,
Mast simple complete,19303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4592.03,,,,,,,fee schedule,4592.03,29164.62,
Mast simple complete,19303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5016.37,,,,,,,fee schedule,4592.03,29164.62,
Mast simple complete,19303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5274.01,,,,,,,fee schedule,4592.03,29164.62,
Mast simple complete,19303,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,29164.62,,,,,,,fee schedule,4592.03,29164.62,APC 378
Mast simple complete,19303,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6902.23,,,,,,,fee schedule,4592.03,29164.62,APC
Mast simple complete,19303,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6836.49,,,,,,,fee schedule,4592.03,29164.62,APC
Mast simple complete,19303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6573.55,,,,,,,fee schedule,4592.03,29164.62,APC
Mast simple complete,19303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10057.53,,,,,,,fee schedule,4592.03,29164.62,Radiology
Mast simple complete,19303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9202.97,,,,,,,fee schedule,4592.03,29164.62,APC
Mast simple complete,19303,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11503.71,,,,,,,fee schedule,4592.03,29164.62,APC
Mast mod rad,19307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8819.57,,,,,,,fee schedule,6573.55,29164.62,
Mast mod rad,19307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7069.65,,,,,,,fee schedule,6573.55,29164.62,
Mast mod rad,19307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7722.95,,,,,,,fee schedule,6573.55,29164.62,
Mast mod rad,19307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8119.6,,,,,,,fee schedule,6573.55,29164.62,
Mast mod rad,19307,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,29164.62,,,,,,,fee schedule,6573.55,29164.62,APC 378
Mast mod rad,19307,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6902.23,,,,,,,fee schedule,6573.55,29164.62,APC
Mast mod rad,19307,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6836.49,,,,,,,fee schedule,6573.55,29164.62,APC
Mast mod rad,19307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6573.55,,,,,,,fee schedule,6573.55,29164.62,APC
Mast mod rad,19307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10057.53,,,,,,,fee schedule,6573.55,29164.62,Radiology
Mast mod rad,19307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9202.97,,,,,,,fee schedule,6573.55,29164.62,APC
Mast mod rad,19307,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11503.71,,,,,,,fee schedule,6573.55,29164.62,APC
Suspension of breast,19316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4173.09,,,,,,,fee schedule,3345.1,29164.62,
Suspension of breast,19316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3345.1,,,,,,,fee schedule,3345.1,29164.62,
Suspension of breast,19316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3654.22,,,,,,,fee schedule,3345.1,29164.62,
Suspension of breast,19316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3841.89,,,,,,,fee schedule,3345.1,29164.62,
Suspension of breast,19316,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,29164.62,,,,,,,fee schedule,3345.1,29164.62,APC 378
Suspension of breast,19316,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6902.23,,,,,,,fee schedule,3345.1,29164.62,APC
Suspension of breast,19316,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6836.49,,,,,,,fee schedule,3345.1,29164.62,APC
Suspension of breast,19316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6573.55,,,,,,,fee schedule,3345.1,29164.62,APC
Suspension of breast,19316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10057.53,,,,,,,fee schedule,3345.1,29164.62,Radiology
Suspension of breast,19316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9202.97,,,,,,,fee schedule,3345.1,29164.62,APC
Suspension of breast,19316,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11503.71,,,,,,,fee schedule,3345.1,29164.62,APC
Reduction of large breast,19318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10750.75,,,,,,,fee schedule,6573.55,29164.62,
Reduction of large breast,19318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8617.67,,,,,,,fee schedule,6573.55,29164.62,
Reduction of large breast,19318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9414.02,,,,,,,fee schedule,6573.55,29164.62,
Reduction of large breast,19318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9897.52,,,,,,,fee schedule,6573.55,29164.62,
Reduction of large breast,19318,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,29164.62,,,,,,,fee schedule,6573.55,29164.62,APC 378
Reduction of large breast,19318,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6902.23,,,,,,,fee schedule,6573.55,29164.62,APC
Reduction of large breast,19318,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6836.49,,,,,,,fee schedule,6573.55,29164.62,APC
Reduction of large breast,19318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6573.55,,,,,,,fee schedule,6573.55,29164.62,APC
Reduction of large breast,19318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10057.53,,,,,,,fee schedule,6573.55,29164.62,Radiology
Reduction of large breast,19318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9202.97,,,,,,,fee schedule,6573.55,29164.62,APC
Reduction of large breast,19318,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11503.71,,,,,,,fee schedule,6573.55,29164.62,APC
Enlarge breast with implant,19325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2967.71,,,,,,,fee schedule,2378.88,35898.76,
Enlarge breast with implant,19325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2378.88,,,,,,,fee schedule,2378.88,35898.76,
Enlarge breast with implant,19325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2598.71,,,,,,,fee schedule,2378.88,35898.76,
Enlarge breast with implant,19325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2732.18,,,,,,,fee schedule,2378.88,35898.76,
Enlarge breast with implant,19325,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,35898.76,,,,,,,fee schedule,2378.88,35898.76,APC 378
Enlarge breast with implant,19325,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8495.96,,,,,,,fee schedule,2378.88,35898.76,APC
Enlarge breast with implant,19325,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8415.05,,,,,,,fee schedule,2378.88,35898.76,APC
Enlarge breast with implant,19325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8091.39,,,,,,,fee schedule,2378.88,35898.76,APC
Enlarge breast with implant,19325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12379.83,,,,,,,fee schedule,2378.88,35898.76,Radiology
Enlarge breast with implant,19325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11327.95,,,,,,,fee schedule,2378.88,35898.76,APC
Enlarge breast with implant,19325,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14159.93,,,,,,,fee schedule,2378.88,35898.76,APC
Removal of breast implant,19328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3594.84,,,,,,,fee schedule,2881.58,17197.18,
Removal of breast implant,19328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2881.58,,,,,,,fee schedule,2881.58,17197.18,
Removal of breast implant,19328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3147.87,,,,,,,fee schedule,2881.58,17197.18,
Removal of breast implant,19328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3309.54,,,,,,,fee schedule,2881.58,17197.18,
Removal of breast implant,19328,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17197.18,,,,,,,fee schedule,2881.58,17197.18,APC 378
Removal of breast implant,19328,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4069.96,,,,,,,fee schedule,2881.58,17197.18,APC
Removal of breast implant,19328,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4031.2,,,,,,,fee schedule,2881.58,17197.18,APC
Removal of breast implant,19328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3876.15,,,,,,,fee schedule,2881.58,17197.18,APC
Removal of breast implant,19328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5930.51,,,,,,,fee schedule,2881.58,17197.18,Radiology
Removal of breast implant,19328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5426.61,,,,,,,fee schedule,2881.58,17197.18,APC
Removal of breast implant,19328,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6783.27,,,,,,,fee schedule,2881.58,17197.18,APC
Removal of implant material,19330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3498.32,,,,,,,fee schedule,2804.21,17197.18,
Removal of implant material,19330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2804.21,,,,,,,fee schedule,2804.21,17197.18,
Removal of implant material,19330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3063.34,,,,,,,fee schedule,2804.21,17197.18,
Removal of implant material,19330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3220.67,,,,,,,fee schedule,2804.21,17197.18,
Removal of implant material,19330,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17197.18,,,,,,,fee schedule,2804.21,17197.18,APC 378
Removal of implant material,19330,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4069.96,,,,,,,fee schedule,2804.21,17197.18,APC
Removal of implant material,19330,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4031.2,,,,,,,fee schedule,2804.21,17197.18,APC
Removal of implant material,19330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3876.15,,,,,,,fee schedule,2804.21,17197.18,APC
Removal of implant material,19330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5930.51,,,,,,,fee schedule,2804.21,17197.18,Radiology
Removal of implant material,19330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5426.61,,,,,,,fee schedule,2804.21,17197.18,APC
Removal of implant material,19330,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6783.27,,,,,,,fee schedule,2804.21,17197.18,APC
Immediate breast prosthesis,19340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4122.46,,,,,,,fee schedule,3304.51,35898.76,
Immediate breast prosthesis,19340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3304.51,,,,,,,fee schedule,3304.51,35898.76,
Immediate breast prosthesis,19340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3609.88,,,,,,,fee schedule,3304.51,35898.76,
Immediate breast prosthesis,19340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3795.28,,,,,,,fee schedule,3304.51,35898.76,
Immediate breast prosthesis,19340,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,35898.76,,,,,,,fee schedule,3304.51,35898.76,APC 378
Immediate breast prosthesis,19340,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8495.96,,,,,,,fee schedule,3304.51,35898.76,APC
Immediate breast prosthesis,19340,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8415.05,,,,,,,fee schedule,3304.51,35898.76,APC
Immediate breast prosthesis,19340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8091.39,,,,,,,fee schedule,3304.51,35898.76,APC
Immediate breast prosthesis,19340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12379.83,,,,,,,fee schedule,3304.51,35898.76,Radiology
Immediate breast prosthesis,19340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11327.95,,,,,,,fee schedule,3304.51,35898.76,APC
Immediate breast prosthesis,19340,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14159.93,,,,,,,fee schedule,3304.51,35898.76,APC
Delayed breast prosthesis,19342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4765.13,,,,,,,fee schedule,3819.67,35898.76,
Delayed breast prosthesis,19342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3819.67,,,,,,,fee schedule,3819.67,35898.76,
Delayed breast prosthesis,19342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4172.64,,,,,,,fee schedule,3819.67,35898.76,
Delayed breast prosthesis,19342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4386.95,,,,,,,fee schedule,3819.67,35898.76,
Delayed breast prosthesis,19342,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,35898.76,,,,,,,fee schedule,3819.67,35898.76,APC 378
Delayed breast prosthesis,19342,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8495.96,,,,,,,fee schedule,3819.67,35898.76,APC
Delayed breast prosthesis,19342,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8415.05,,,,,,,fee schedule,3819.67,35898.76,APC
Delayed breast prosthesis,19342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8091.39,,,,,,,fee schedule,3819.67,35898.76,APC
Delayed breast prosthesis,19342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12379.83,,,,,,,fee schedule,3819.67,35898.76,Radiology
Delayed breast prosthesis,19342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11327.95,,,,,,,fee schedule,3819.67,35898.76,APC
Delayed breast prosthesis,19342,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14159.93,,,,,,,fee schedule,3819.67,35898.76,APC
Breast reconstruction,19350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5511.28,,,,,,,fee schedule,3876.15,17197.18,
Breast reconstruction,19350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4417.77,,,,,,,fee schedule,3876.15,17197.18,
Breast reconstruction,19350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4826.01,,,,,,,fee schedule,3876.15,17197.18,
Breast reconstruction,19350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5073.88,,,,,,,fee schedule,3876.15,17197.18,
Breast reconstruction,19350,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17197.18,,,,,,,fee schedule,3876.15,17197.18,APC 378
Breast reconstruction,19350,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4069.96,,,,,,,fee schedule,3876.15,17197.18,APC
Breast reconstruction,19350,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4031.2,,,,,,,fee schedule,3876.15,17197.18,APC
Breast reconstruction,19350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3876.15,,,,,,,fee schedule,3876.15,17197.18,APC
Breast reconstruction,19350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5930.51,,,,,,,fee schedule,3876.15,17197.18,Radiology
Breast reconstruction,19350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5426.61,,,,,,,fee schedule,3876.15,17197.18,APC
Breast reconstruction,19350,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6783.27,,,,,,,fee schedule,3876.15,17197.18,APC
Correct inverted nipple(s),19355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7914.87,,,,,,,fee schedule,3876.15,17197.18,
Correct inverted nipple(s),19355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6344.46,,,,,,,fee schedule,3876.15,17197.18,
Correct inverted nipple(s),19355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6930.74,,,,,,,fee schedule,3876.15,17197.18,
Correct inverted nipple(s),19355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7286.7,,,,,,,fee schedule,3876.15,17197.18,
Correct inverted nipple(s),19355,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17197.18,,,,,,,fee schedule,3876.15,17197.18,APC 378
Correct inverted nipple(s),19355,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4069.96,,,,,,,fee schedule,3876.15,17197.18,APC
Correct inverted nipple(s),19355,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4031.2,,,,,,,fee schedule,3876.15,17197.18,APC
Correct inverted nipple(s),19355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3876.15,,,,,,,fee schedule,3876.15,17197.18,APC
Correct inverted nipple(s),19355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5930.51,,,,,,,fee schedule,3876.15,17197.18,Radiology
Correct inverted nipple(s),19355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5426.61,,,,,,,fee schedule,3876.15,17197.18,APC
Correct inverted nipple(s),19355,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6783.27,,,,,,,fee schedule,3876.15,17197.18,APC
Breast reconstruction,19357,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4094.67,,,,,,,fee schedule,3282.24,60528.02,
Breast reconstruction,19357,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3282.24,,,,,,,fee schedule,3282.24,60528.02,
Breast reconstruction,19357,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3585.55,,,,,,,fee schedule,3282.24,60528.02,
Breast reconstruction,19357,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3769.7,,,,,,,fee schedule,3282.24,60528.02,
Breast reconstruction,19357,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,60528.02,,,,,,,fee schedule,3282.24,60528.02,APC 378
Breast reconstruction,19357,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14324.83,,,,,,,fee schedule,3282.24,60528.02,APC
Breast reconstruction,19357,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,14188.4,,,,,,,fee schedule,3282.24,60528.02,APC
Breast reconstruction,19357,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13642.7,,,,,,,fee schedule,3282.24,60528.02,APC
Breast reconstruction,19357,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20873.32,,,,,,,fee schedule,3282.24,60528.02,Radiology
Breast reconstruction,19357,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19099.77,,,,,,,fee schedule,3282.24,60528.02,APC
Breast reconstruction,19357,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23874.72,,,,,,,fee schedule,3282.24,60528.02,APC
Breast reconstr w/lat flap,19361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5898.39,,,,,,,fee schedule,4728.08,5898.39,
Breast reconstr w/lat flap,19361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4728.08,,,,,,,fee schedule,4728.08,5898.39,
Breast reconstr w/lat flap,19361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5164.99,,,,,,,fee schedule,4728.08,5898.39,
Breast reconstr w/lat flap,19361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5430.27,,,,,,,fee schedule,4728.08,5898.39,
Surgery of breast capsule,19370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3615.34,,,,,,,fee schedule,2898.01,17197.18,
Surgery of breast capsule,19370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2898.01,,,,,,,fee schedule,2898.01,17197.18,
Surgery of breast capsule,19370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3165.81,,,,,,,fee schedule,2898.01,17197.18,
Surgery of breast capsule,19370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3328.41,,,,,,,fee schedule,2898.01,17197.18,
Surgery of breast capsule,19370,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17197.18,,,,,,,fee schedule,2898.01,17197.18,APC 378
Surgery of breast capsule,19370,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4069.96,,,,,,,fee schedule,2898.01,17197.18,APC
Surgery of breast capsule,19370,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4031.2,,,,,,,fee schedule,2898.01,17197.18,APC
Surgery of breast capsule,19370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3876.15,,,,,,,fee schedule,2898.01,17197.18,APC
Surgery of breast capsule,19370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5930.51,,,,,,,fee schedule,2898.01,17197.18,Radiology
Surgery of breast capsule,19370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5426.61,,,,,,,fee schedule,2898.01,17197.18,APC
Surgery of breast capsule,19370,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6783.27,,,,,,,fee schedule,2898.01,17197.18,APC
Removal of breast capsule,19371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11141.58,,,,,,,fee schedule,3876.15,17197.18,
Removal of breast capsule,19371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8930.95,,,,,,,fee schedule,3876.15,17197.18,
Removal of breast capsule,19371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9756.25,,,,,,,fee schedule,3876.15,17197.18,
Removal of breast capsule,19371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10257.32,,,,,,,fee schedule,3876.15,17197.18,
Removal of breast capsule,19371,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17197.18,,,,,,,fee schedule,3876.15,17197.18,APC 378
Removal of breast capsule,19371,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4069.96,,,,,,,fee schedule,3876.15,17197.18,APC
Removal of breast capsule,19371,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4031.2,,,,,,,fee schedule,3876.15,17197.18,APC
Removal of breast capsule,19371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3876.15,,,,,,,fee schedule,3876.15,17197.18,APC
Removal of breast capsule,19371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5930.51,,,,,,,fee schedule,3876.15,17197.18,Radiology
Removal of breast capsule,19371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5426.61,,,,,,,fee schedule,3876.15,17197.18,APC
Removal of breast capsule,19371,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6783.27,,,,,,,fee schedule,3876.15,17197.18,APC
Revise breast reconstruction,19380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6026.29,,,,,,,fee schedule,4830.59,29164.62,
Revise breast reconstruction,19380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4830.59,,,,,,,fee schedule,4830.59,29164.62,
Revise breast reconstruction,19380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5276.99,,,,,,,fee schedule,4830.59,29164.62,
Revise breast reconstruction,19380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5548.01,,,,,,,fee schedule,4830.59,29164.62,
Revise breast reconstruction,19380,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,29164.62,,,,,,,fee schedule,4830.59,29164.62,APC 378
Revise breast reconstruction,19380,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6902.23,,,,,,,fee schedule,4830.59,29164.62,APC
Revise breast reconstruction,19380,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6836.49,,,,,,,fee schedule,4830.59,29164.62,APC
Revise breast reconstruction,19380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6573.55,,,,,,,fee schedule,4830.59,29164.62,APC
Revise breast reconstruction,19380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10057.53,,,,,,,fee schedule,4830.59,29164.62,Radiology
Revise breast reconstruction,19380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9202.97,,,,,,,fee schedule,4830.59,29164.62,APC
Revise breast reconstruction,19380,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11503.71,,,,,,,fee schedule,4830.59,29164.62,APC
Design custom breast implant,19396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7914.87,,,,,,,fee schedule,3876.15,17197.18,
Design custom breast implant,19396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6344.46,,,,,,,fee schedule,3876.15,17197.18,
Design custom breast implant,19396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6930.74,,,,,,,fee schedule,3876.15,17197.18,
Design custom breast implant,19396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7286.7,,,,,,,fee schedule,3876.15,17197.18,
Design custom breast implant,19396,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17197.18,,,,,,,fee schedule,3876.15,17197.18,APC 378
Design custom breast implant,19396,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4069.96,,,,,,,fee schedule,3876.15,17197.18,APC
Design custom breast implant,19396,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4031.2,,,,,,,fee schedule,3876.15,17197.18,APC
Design custom breast implant,19396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3876.15,,,,,,,fee schedule,3876.15,17197.18,APC
Design custom breast implant,19396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5930.51,,,,,,,fee schedule,3876.15,17197.18,Radiology
Design custom breast implant,19396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5426.61,,,,,,,fee schedule,3876.15,17197.18,APC
Design custom breast implant,19396,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6783.27,,,,,,,fee schedule,3876.15,17197.18,APC
Breast surgery procedure,19499,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5151.65,,,,,,,fee schedule,3876.15,17197.18,
Breast surgery procedure,19499,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4129.5,,,,,,,fee schedule,3876.15,17197.18,
Breast surgery procedure,19499,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4511.1,,,,,,,fee schedule,3876.15,17197.18,
Breast surgery procedure,19499,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4742.79,,,,,,,fee schedule,3876.15,17197.18,
Breast surgery procedure,19499,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17197.18,,,,,,,fee schedule,3876.15,17197.18,APC 378
Breast surgery procedure,19499,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4069.96,,,,,,,fee schedule,3876.15,17197.18,APC
Breast surgery procedure,19499,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4031.2,,,,,,,fee schedule,3876.15,17197.18,APC
Breast surgery procedure,19499,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3876.15,,,,,,,fee schedule,3876.15,17197.18,APC
Breast surgery procedure,19499,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5930.51,,,,,,,fee schedule,3876.15,17197.18,Radiology
Breast surgery procedure,19499,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5426.61,,,,,,,fee schedule,3876.15,17197.18,APC
Breast surgery procedure,19499,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6783.27,,,,,,,fee schedule,3876.15,17197.18,APC
Explore wound neck,20100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2404.42,,,,,,,fee schedule,533.92,2404.42,
Explore wound neck,20100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1927.35,,,,,,,fee schedule,533.92,2404.42,
Explore wound neck,20100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2105.46,,,,,,,fee schedule,533.92,2404.42,
Explore wound neck,20100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2213.59,,,,,,,fee schedule,533.92,2404.42,
Explore wound neck,20100,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2368.81,,,,,,,fee schedule,533.92,2404.42,APC 378
Explore wound neck,20100,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,560.61,,,,,,,fee schedule,533.92,2404.42,APC
Explore wound neck,20100,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,555.27,,,,,,,fee schedule,533.92,2404.42,APC
Explore wound neck,20100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,533.92,,,,,,,fee schedule,533.92,2404.42,APC
Explore wound neck,20100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,816.89,,,,,,,fee schedule,533.92,2404.42,Radiology
Explore wound neck,20100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,747.48,,,,,,,fee schedule,533.92,2404.42,APC
Explore wound neck,20100,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,934.36,,,,,,,fee schedule,533.92,2404.42,APC
Explore wound chest,20101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5043.16,,,,,,,fee schedule,2042.58,9062.24,
Explore wound chest,20101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4042.54,,,,,,,fee schedule,2042.58,9062.24,
Explore wound chest,20101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4416.1,,,,,,,fee schedule,2042.58,9062.24,
Explore wound chest,20101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4642.91,,,,,,,fee schedule,2042.58,9062.24,
Explore wound chest,20101,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,2042.58,9062.24,APC 378
Explore wound chest,20101,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,2042.58,9062.24,APC
Explore wound chest,20101,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,2042.58,9062.24,APC
Explore wound chest,20101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,2042.58,9062.24,APC
Explore wound chest,20101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,2042.58,9062.24,Radiology
Explore wound chest,20101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,2042.58,9062.24,APC
Explore wound chest,20101,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,2042.58,9062.24,APC
Explore wound abdomen,20102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5043.16,,,,,,,fee schedule,2042.58,9062.24,
Explore wound abdomen,20102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4042.54,,,,,,,fee schedule,2042.58,9062.24,
Explore wound abdomen,20102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4416.1,,,,,,,fee schedule,2042.58,9062.24,
Explore wound abdomen,20102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4642.91,,,,,,,fee schedule,2042.58,9062.24,
Explore wound abdomen,20102,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,2042.58,9062.24,APC 378
Explore wound abdomen,20102,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,2042.58,9062.24,APC
Explore wound abdomen,20102,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,2042.58,9062.24,APC
Explore wound abdomen,20102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,2042.58,9062.24,APC
Explore wound abdomen,20102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,2042.58,9062.24,Radiology
Explore wound abdomen,20102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,2042.58,9062.24,APC
Explore wound abdomen,20102,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,2042.58,9062.24,APC
Explore wound extremity,20103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3321.96,,,,,,,fee schedule,1635.03,7254.06,
Explore wound extremity,20103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2662.84,,,,,,,fee schedule,1635.03,7254.06,
Explore wound extremity,20103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2908.91,,,,,,,fee schedule,1635.03,7254.06,
Explore wound extremity,20103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3058.31,,,,,,,fee schedule,1635.03,7254.06,
Explore wound extremity,20103,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,7254.06,APC 378
Explore wound extremity,20103,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,7254.06,APC
Explore wound extremity,20103,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,7254.06,APC
Explore wound extremity,20103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,7254.06,APC
Explore wound extremity,20103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,7254.06,Radiology
Explore wound extremity,20103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,7254.06,APC
Explore wound extremity,20103,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,7254.06,APC
Excise epiphyseal bar,20150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10728.02,,,,,,,fee schedule,3239.17,14371.12,
Excise epiphyseal bar,20150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8599.44,,,,,,,fee schedule,3239.17,14371.12,
Excise epiphyseal bar,20150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9394.11,,,,,,,fee schedule,3239.17,14371.12,
Excise epiphyseal bar,20150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9876.59,,,,,,,fee schedule,3239.17,14371.12,
Excise epiphyseal bar,20150,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Excise epiphyseal bar,20150,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Excise epiphyseal bar,20150,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Excise epiphyseal bar,20150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Excise epiphyseal bar,20150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Excise epiphyseal bar,20150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Excise epiphyseal bar,20150,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Muscle biopsy,20200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4018.18,,,,,,,fee schedule,1635.03,7254.06,
Muscle biopsy,20200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3220.92,,,,,,,fee schedule,1635.03,7254.06,
Muscle biopsy,20200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3518.56,,,,,,,fee schedule,1635.03,7254.06,
Muscle biopsy,20200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3699.27,,,,,,,fee schedule,1635.03,7254.06,
Muscle biopsy,20200,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,7254.06,APC 378
Muscle biopsy,20200,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,7254.06,APC
Muscle biopsy,20200,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,7254.06,APC
Muscle biopsy,20200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,7254.06,APC
Muscle biopsy,20200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,7254.06,Radiology
Muscle biopsy,20200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,7254.06,APC
Muscle biopsy,20200,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,7254.06,APC
Deep muscle biopsy,20205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4924.15,,,,,,,fee schedule,2875.57,12757.95,
Deep muscle biopsy,20205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3947.14,,,,,,,fee schedule,2875.57,12757.95,
Deep muscle biopsy,20205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4311.89,,,,,,,fee schedule,2875.57,12757.95,
Deep muscle biopsy,20205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4533.34,,,,,,,fee schedule,2875.57,12757.95,
Deep muscle biopsy,20205,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Deep muscle biopsy,20205,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Deep muscle biopsy,20205,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Deep muscle biopsy,20205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Deep muscle biopsy,20205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Deep muscle biopsy,20205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Deep muscle biopsy,20205,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Needle biopsy muscle,20206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1476.95,,,,,,,fee schedule,1183.9,7254.06,
Needle biopsy muscle,20206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1183.9,,,,,,,fee schedule,1183.9,7254.06,
Needle biopsy muscle,20206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1293.31,,,,,,,fee schedule,1183.9,7254.06,
Needle biopsy muscle,20206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1359.73,,,,,,,fee schedule,1183.9,7254.06,
Needle biopsy muscle,20206,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1183.9,7254.06,APC 378
Needle biopsy muscle,20206,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1183.9,7254.06,APC
Needle biopsy muscle,20206,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1183.9,7254.06,APC
Needle biopsy muscle,20206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1183.9,7254.06,APC
Needle biopsy muscle,20206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1183.9,7254.06,Radiology
Needle biopsy muscle,20206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1183.9,7254.06,APC
Needle biopsy muscle,20206,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1183.9,7254.06,APC
Bone biopsy trocar/needle,20220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1267.81,,,,,,,fee schedule,1016.26,7254.06,
Bone biopsy trocar/needle,20220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1016.26,,,,,,,fee schedule,1016.26,7254.06,
Bone biopsy trocar/needle,20220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1110.17,,,,,,,fee schedule,1016.26,7254.06,
Bone biopsy trocar/needle,20220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1167.19,,,,,,,fee schedule,1016.26,7254.06,
Bone biopsy trocar/needle,20220,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1016.26,7254.06,APC 378
Bone biopsy trocar/needle,20220,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1016.26,7254.06,APC
Bone biopsy trocar/needle,20220,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1016.26,7254.06,APC
Bone biopsy trocar/needle,20220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1016.26,7254.06,APC
Bone biopsy trocar/needle,20220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1016.26,7254.06,Radiology
Bone biopsy trocar/needle,20220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1016.26,7254.06,APC
Bone biopsy trocar/needle,20220,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1016.26,7254.06,APC
Bone biopsy trocar/needle,20225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1981.9,,,,,,,fee schedule,1588.67,7254.06,
Bone biopsy trocar/needle,20225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1588.67,,,,,,,fee schedule,1588.67,7254.06,
Bone biopsy trocar/needle,20225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1735.48,,,,,,,fee schedule,1588.67,7254.06,
Bone biopsy trocar/needle,20225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1824.61,,,,,,,fee schedule,1588.67,7254.06,
Bone biopsy trocar/needle,20225,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1588.67,7254.06,APC 378
Bone biopsy trocar/needle,20225,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1588.67,7254.06,APC
Bone biopsy trocar/needle,20225,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1588.67,7254.06,APC
Bone biopsy trocar/needle,20225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1588.67,7254.06,APC
Bone biopsy trocar/needle,20225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1588.67,7254.06,Radiology
Bone biopsy trocar/needle,20225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1588.67,7254.06,APC
Bone biopsy trocar/needle,20225,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1588.67,7254.06,APC
Bone biopsy open superficial,20240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5268.49,,,,,,,fee schedule,2875.57,12757.95,
Bone biopsy open superficial,20240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4223.15,,,,,,,fee schedule,2875.57,12757.95,
Bone biopsy open superficial,20240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4613.41,,,,,,,fee schedule,2875.57,12757.95,
Bone biopsy open superficial,20240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4850.35,,,,,,,fee schedule,2875.57,12757.95,
Bone biopsy open superficial,20240,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Bone biopsy open superficial,20240,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Bone biopsy open superficial,20240,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Bone biopsy open superficial,20240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Bone biopsy open superficial,20240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Bone biopsy open superficial,20240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Bone biopsy open superficial,20240,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Bone biopsy open deep,20245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4062.96,,,,,,,fee schedule,2875.57,12757.95,
Bone biopsy open deep,20245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3256.82,,,,,,,fee schedule,2875.57,12757.95,
Bone biopsy open deep,20245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3557.78,,,,,,,fee schedule,2875.57,12757.95,
Bone biopsy open deep,20245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3740.5,,,,,,,fee schedule,2875.57,12757.95,
Bone biopsy open deep,20245,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Bone biopsy open deep,20245,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Bone biopsy open deep,20245,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Bone biopsy open deep,20245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Bone biopsy open deep,20245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Bone biopsy open deep,20245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Bone biopsy open deep,20245,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Open bone biopsy,20250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,3239.17,14371.12,
Open bone biopsy,20250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,3239.17,14371.12,
Open bone biopsy,20250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,3239.17,14371.12,
Open bone biopsy,20250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,3239.17,14371.12,
Open bone biopsy,20250,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Open bone biopsy,20250,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Open bone biopsy,20250,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Open bone biopsy,20250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Open bone biopsy,20250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Open bone biopsy,20250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Open bone biopsy,20250,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Open bone biopsy,20251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,4254.97,31870.39,
Open bone biopsy,20251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,4254.97,31870.39,
Open bone biopsy,20251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,4254.97,31870.39,
Open bone biopsy,20251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,4254.97,31870.39,
Open bone biopsy,20251,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,4254.97,31870.39,APC 378
Open bone biopsy,20251,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,4254.97,31870.39,APC
Open bone biopsy,20251,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,4254.97,31870.39,APC
Open bone biopsy,20251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,4254.97,31870.39,APC
Open bone biopsy,20251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,4254.97,31870.39,Radiology
Open bone biopsy,20251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,4254.97,31870.39,APC
Open bone biopsy,20251,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,4254.97,31870.39,APC
Injection of sinus tract,20500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,624,,,,,,,fee schedule,500.19,6814.79,
Injection of sinus tract,20500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,500.19,,,,,,,fee schedule,500.19,6814.79,
Injection of sinus tract,20500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,546.41,,,,,,,fee schedule,500.19,6814.79,
Injection of sinus tract,20500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,574.48,,,,,,,fee schedule,500.19,6814.79,
Injection of sinus tract,20500,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,500.19,6814.79,APC 378
Injection of sinus tract,20500,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,500.19,6814.79,APC
Injection of sinus tract,20500,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,500.19,6814.79,APC
Injection of sinus tract,20500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,500.19,6814.79,APC
Injection of sinus tract,20500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,500.19,6814.79,Radiology
Injection of sinus tract,20500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,500.19,6814.79,APC
Injection of sinus tract,20500,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,500.19,6814.79,APC
Removal of foreign body,20520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5785.34,,,,,,,fee schedule,1635.03,7254.06,
Removal of foreign body,20520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4637.46,,,,,,,fee schedule,1635.03,7254.06,
Removal of foreign body,20520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5066,,,,,,,fee schedule,1635.03,7254.06,
Removal of foreign body,20520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5326.19,,,,,,,fee schedule,1635.03,7254.06,
Removal of foreign body,20520,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,7254.06,APC 378
Removal of foreign body,20520,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,7254.06,APC
Removal of foreign body,20520,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,7254.06,APC
Removal of foreign body,20520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,7254.06,APC
Removal of foreign body,20520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,7254.06,Radiology
Removal of foreign body,20520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,7254.06,APC
Removal of foreign body,20520,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,7254.06,APC
Removal of foreign body,20525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1797.42,,,,,,,fee schedule,1440.79,12757.95,
Removal of foreign body,20525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1440.79,,,,,,,fee schedule,1440.79,12757.95,
Removal of foreign body,20525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1573.93,,,,,,,fee schedule,1440.79,12757.95,
Removal of foreign body,20525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1654.77,,,,,,,fee schedule,1440.79,12757.95,
Removal of foreign body,20525,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,1440.79,12757.95,APC 378
Removal of foreign body,20525,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,1440.79,12757.95,APC
Removal of foreign body,20525,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,1440.79,12757.95,APC
Removal of foreign body,20525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,1440.79,12757.95,APC
Removal of foreign body,20525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,1440.79,12757.95,Radiology
Removal of foreign body,20525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,1440.79,12757.95,APC
Removal of foreign body,20525,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,1440.79,12757.95,APC
Ther injection carp tunnel,20526,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2084.5,,,,,,,fee schedule,303.87,2084.5,
Ther injection carp tunnel,20526,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1670.91,,,,,,,fee schedule,303.87,2084.5,
Ther injection carp tunnel,20526,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1825.32,,,,,,,fee schedule,303.87,2084.5,
Ther injection carp tunnel,20526,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1919.06,,,,,,,fee schedule,303.87,2084.5,
Ther injection carp tunnel,20526,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1348.18,,,,,,,fee schedule,303.87,2084.5,APC 378
Ther injection carp tunnel,20526,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,319.07,,,,,,,fee schedule,303.87,2084.5,APC
Ther injection carp tunnel,20526,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,316.03,,,,,,,fee schedule,303.87,2084.5,APC
Ther injection carp tunnel,20526,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,303.87,,,,,,,fee schedule,303.87,2084.5,APC
Ther injection carp tunnel,20526,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,464.92,,,,,,,fee schedule,303.87,2084.5,Radiology
Ther injection carp tunnel,20526,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,425.42,,,,,,,fee schedule,303.87,2084.5,APC
Ther injection carp tunnel,20526,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,531.78,,,,,,,fee schedule,303.87,2084.5,APC
Inj dupuytren cord w/enzyme,20527,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,690.27,,,,,,,fee schedule,303.87,1348.18,
Inj dupuytren cord w/enzyme,20527,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,553.31,,,,,,,fee schedule,303.87,1348.18,
Inj dupuytren cord w/enzyme,20527,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,604.44,,,,,,,fee schedule,303.87,1348.18,
Inj dupuytren cord w/enzyme,20527,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,635.48,,,,,,,fee schedule,303.87,1348.18,
Inj dupuytren cord w/enzyme,20527,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1348.18,,,,,,,fee schedule,303.87,1348.18,APC 378
Inj dupuytren cord w/enzyme,20527,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,319.07,,,,,,,fee schedule,303.87,1348.18,APC
Inj dupuytren cord w/enzyme,20527,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,316.03,,,,,,,fee schedule,303.87,1348.18,APC
Inj dupuytren cord w/enzyme,20527,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,303.87,,,,,,,fee schedule,303.87,1348.18,APC
Inj dupuytren cord w/enzyme,20527,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,464.92,,,,,,,fee schedule,303.87,1348.18,Radiology
Inj dupuytren cord w/enzyme,20527,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,425.42,,,,,,,fee schedule,303.87,1348.18,APC
Inj dupuytren cord w/enzyme,20527,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,531.78,,,,,,,fee schedule,303.87,1348.18,APC
Inj tendon sheath/ligament,20550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3893.92,,,,,,,fee schedule,303.87,3893.92,
Inj tendon sheath/ligament,20550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3121.31,,,,,,,fee schedule,303.87,3893.92,
Inj tendon sheath/ligament,20550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3409.75,,,,,,,fee schedule,303.87,3893.92,
Inj tendon sheath/ligament,20550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3584.88,,,,,,,fee schedule,303.87,3893.92,
Inj tendon sheath/ligament,20550,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1348.18,,,,,,,fee schedule,303.87,3893.92,APC 378
Inj tendon sheath/ligament,20550,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,319.07,,,,,,,fee schedule,303.87,3893.92,APC
Inj tendon sheath/ligament,20550,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,316.03,,,,,,,fee schedule,303.87,3893.92,APC
Inj tendon sheath/ligament,20550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,303.87,,,,,,,fee schedule,303.87,3893.92,APC
Inj tendon sheath/ligament,20550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,464.92,,,,,,,fee schedule,303.87,3893.92,Radiology
Inj tendon sheath/ligament,20550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,425.42,,,,,,,fee schedule,303.87,3893.92,APC
Inj tendon sheath/ligament,20550,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,531.78,,,,,,,fee schedule,303.87,3893.92,APC
Inj tendon origin/insertion,20551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,579.32,,,,,,,fee schedule,303.87,1348.18,
Inj tendon origin/insertion,20551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,464.38,,,,,,,fee schedule,303.87,1348.18,
Inj tendon origin/insertion,20551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,507.29,,,,,,,fee schedule,303.87,1348.18,
Inj tendon origin/insertion,20551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,533.34,,,,,,,fee schedule,303.87,1348.18,
Inj tendon origin/insertion,20551,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1348.18,,,,,,,fee schedule,303.87,1348.18,APC 378
Inj tendon origin/insertion,20551,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,319.07,,,,,,,fee schedule,303.87,1348.18,APC
Inj tendon origin/insertion,20551,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,316.03,,,,,,,fee schedule,303.87,1348.18,APC
Inj tendon origin/insertion,20551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,303.87,,,,,,,fee schedule,303.87,1348.18,APC
Inj tendon origin/insertion,20551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,464.92,,,,,,,fee schedule,303.87,1348.18,Radiology
Inj tendon origin/insertion,20551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,425.42,,,,,,,fee schedule,303.87,1348.18,APC
Inj tendon origin/insertion,20551,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,531.78,,,,,,,fee schedule,303.87,1348.18,APC
Inj trigger point 1/2 muscl,20552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,258.98,,,,,,,fee schedule,207.6,1348.18,
Inj trigger point 1/2 muscl,20552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,207.6,,,,,,,fee schedule,207.6,1348.18,
Inj trigger point 1/2 muscl,20552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,226.78,,,,,,,fee schedule,207.6,1348.18,
Inj trigger point 1/2 muscl,20552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,238.43,,,,,,,fee schedule,207.6,1348.18,
Inj trigger point 1/2 muscl,20552,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1348.18,,,,,,,fee schedule,207.6,1348.18,APC 378
Inj trigger point 1/2 muscl,20552,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,319.07,,,,,,,fee schedule,207.6,1348.18,APC
Inj trigger point 1/2 muscl,20552,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,316.03,,,,,,,fee schedule,207.6,1348.18,APC
Inj trigger point 1/2 muscl,20552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,303.87,,,,,,,fee schedule,207.6,1348.18,APC
Inj trigger point 1/2 muscl,20552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,464.92,,,,,,,fee schedule,207.6,1348.18,Radiology
Inj trigger point 1/2 muscl,20552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,425.42,,,,,,,fee schedule,207.6,1348.18,APC
Inj trigger point 1/2 muscl,20552,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,531.78,,,,,,,fee schedule,207.6,1348.18,APC
Inject trigger points 3/>,20553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,276.72,,,,,,,fee schedule,221.82,1348.18,
Inject trigger points 3/>,20553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,221.82,,,,,,,fee schedule,221.82,1348.18,
Inject trigger points 3/>,20553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,242.32,,,,,,,fee schedule,221.82,1348.18,
Inject trigger points 3/>,20553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,254.76,,,,,,,fee schedule,221.82,1348.18,
Inject trigger points 3/>,20553,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1348.18,,,,,,,fee schedule,221.82,1348.18,APC 378
Inject trigger points 3/>,20553,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,319.07,,,,,,,fee schedule,221.82,1348.18,APC
Inject trigger points 3/>,20553,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,316.03,,,,,,,fee schedule,221.82,1348.18,APC
Inject trigger points 3/>,20553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,303.87,,,,,,,fee schedule,221.82,1348.18,APC
Inject trigger points 3/>,20553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,464.92,,,,,,,fee schedule,221.82,1348.18,Radiology
Inject trigger points 3/>,20553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,425.42,,,,,,,fee schedule,221.82,1348.18,APC
Inject trigger points 3/>,20553,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,531.78,,,,,,,fee schedule,221.82,1348.18,APC
Place ndl musc/tis for rt,20555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,3239.17,14371.12,
Place ndl musc/tis for rt,20555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,3239.17,14371.12,
Place ndl musc/tis for rt,20555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,3239.17,14371.12,
Place ndl musc/tis for rt,20555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,3239.17,14371.12,
Place ndl musc/tis for rt,20555,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Place ndl musc/tis for rt,20555,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Place ndl musc/tis for rt,20555,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Place ndl musc/tis for rt,20555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Place ndl musc/tis for rt,20555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Place ndl musc/tis for rt,20555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Place ndl musc/tis for rt,20555,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Ndl insj w/o njx 1 or 2 musc,20560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,63.01,,,,,,,fee schedule,28.63,127.04,
Ndl insj w/o njx 1 or 2 musc,20560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,50.51,,,,,,,fee schedule,28.63,127.04,
Ndl insj w/o njx 1 or 2 musc,20560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55.18,,,,,,,fee schedule,28.63,127.04,
Ndl insj w/o njx 1 or 2 musc,20560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,58.01,,,,,,,fee schedule,28.63,127.04,
Ndl insj w/o njx 1 or 2 musc,20560,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,127.04,,,,,,,fee schedule,28.63,127.04,APC 378
Ndl insj w/o njx 1 or 2 musc,20560,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.07,,,,,,,fee schedule,28.63,127.04,APC
Ndl insj w/o njx 1 or 2 musc,20560,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,29.78,,,,,,,fee schedule,28.63,127.04,APC
Ndl insj w/o njx 1 or 2 musc,20560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,28.63,,,,,,,fee schedule,28.63,127.04,APC
Ndl insj w/o njx 1 or 2 musc,20560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43.81,,,,,,,fee schedule,28.63,127.04,Radiology
Ndl insj w/o njx 1 or 2 musc,20560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40.09,,,,,,,fee schedule,28.63,127.04,APC
Ndl insj w/o njx 1 or 2 musc,20560,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,50.11,,,,,,,fee schedule,28.63,127.04,APC
Ndl insj w/o njx 3+ musc,20561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,95.37,,,,,,,fee schedule,28.63,127.04,
Ndl insj w/o njx 3+ musc,20561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,76.45,,,,,,,fee schedule,28.63,127.04,
Ndl insj w/o njx 3+ musc,20561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,83.51,,,,,,,fee schedule,28.63,127.04,
Ndl insj w/o njx 3+ musc,20561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,87.8,,,,,,,fee schedule,28.63,127.04,
Ndl insj w/o njx 3+ musc,20561,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,127.04,,,,,,,fee schedule,28.63,127.04,APC 378
Ndl insj w/o njx 3+ musc,20561,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.07,,,,,,,fee schedule,28.63,127.04,APC
Ndl insj w/o njx 3+ musc,20561,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,29.78,,,,,,,fee schedule,28.63,127.04,APC
Ndl insj w/o njx 3+ musc,20561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,28.63,,,,,,,fee schedule,28.63,127.04,APC
Ndl insj w/o njx 3+ musc,20561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43.81,,,,,,,fee schedule,28.63,127.04,Radiology
Ndl insj w/o njx 3+ musc,20561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40.09,,,,,,,fee schedule,28.63,127.04,APC
Ndl insj w/o njx 3+ musc,20561,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,50.11,,,,,,,fee schedule,28.63,127.04,APC
Drain/inj joint/bursa w/o us,20600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,548.17,,,,,,,fee schedule,303.87,1348.18,
Drain/inj joint/bursa w/o us,20600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,439.4,,,,,,,fee schedule,303.87,1348.18,
Drain/inj joint/bursa w/o us,20600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,480.01,,,,,,,fee schedule,303.87,1348.18,
Drain/inj joint/bursa w/o us,20600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,504.66,,,,,,,fee schedule,303.87,1348.18,
Drain/inj joint/bursa w/o us,20600,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1348.18,,,,,,,fee schedule,303.87,1348.18,APC 378
Drain/inj joint/bursa w/o us,20600,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,319.07,,,,,,,fee schedule,303.87,1348.18,APC
Drain/inj joint/bursa w/o us,20600,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,316.03,,,,,,,fee schedule,303.87,1348.18,APC
Drain/inj joint/bursa w/o us,20600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,303.87,,,,,,,fee schedule,303.87,1348.18,APC
Drain/inj joint/bursa w/o us,20600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,464.92,,,,,,,fee schedule,303.87,1348.18,Radiology
Drain/inj joint/bursa w/o us,20600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,425.42,,,,,,,fee schedule,303.87,1348.18,APC
Drain/inj joint/bursa w/o us,20600,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,531.78,,,,,,,fee schedule,303.87,1348.18,APC
Drain/inj joint/bursa w/us,20604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,798.37,,,,,,,fee schedule,303.87,1348.18,
Drain/inj joint/bursa w/us,20604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,639.97,,,,,,,fee schedule,303.87,1348.18,
Drain/inj joint/bursa w/us,20604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,699.11,,,,,,,fee schedule,303.87,1348.18,
Drain/inj joint/bursa w/us,20604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,735.01,,,,,,,fee schedule,303.87,1348.18,
Drain/inj joint/bursa w/us,20604,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1348.18,,,,,,,fee schedule,303.87,1348.18,APC 378
Drain/inj joint/bursa w/us,20604,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,319.07,,,,,,,fee schedule,303.87,1348.18,APC
Drain/inj joint/bursa w/us,20604,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,316.03,,,,,,,fee schedule,303.87,1348.18,APC
Drain/inj joint/bursa w/us,20604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,303.87,,,,,,,fee schedule,303.87,1348.18,APC
Drain/inj joint/bursa w/us,20604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,464.92,,,,,,,fee schedule,303.87,1348.18,Radiology
Drain/inj joint/bursa w/us,20604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,425.42,,,,,,,fee schedule,303.87,1348.18,APC
Drain/inj joint/bursa w/us,20604,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,531.78,,,,,,,fee schedule,303.87,1348.18,APC
Drain/inj joint/bursa w/o us,20605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,559.86,,,,,,,fee schedule,303.87,1348.18,
Drain/inj joint/bursa w/o us,20605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,448.78,,,,,,,fee schedule,303.87,1348.18,
Drain/inj joint/bursa w/o us,20605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,490.25,,,,,,,fee schedule,303.87,1348.18,
Drain/inj joint/bursa w/o us,20605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,515.43,,,,,,,fee schedule,303.87,1348.18,
Drain/inj joint/bursa w/o us,20605,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1348.18,,,,,,,fee schedule,303.87,1348.18,APC 378
Drain/inj joint/bursa w/o us,20605,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,319.07,,,,,,,fee schedule,303.87,1348.18,APC
Drain/inj joint/bursa w/o us,20605,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,316.03,,,,,,,fee schedule,303.87,1348.18,APC
Drain/inj joint/bursa w/o us,20605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,303.87,,,,,,,fee schedule,303.87,1348.18,APC
Drain/inj joint/bursa w/o us,20605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,464.92,,,,,,,fee schedule,303.87,1348.18,Radiology
Drain/inj joint/bursa w/o us,20605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,425.42,,,,,,,fee schedule,303.87,1348.18,APC
Drain/inj joint/bursa w/o us,20605,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,531.78,,,,,,,fee schedule,303.87,1348.18,APC
Drain/inj joint/bursa w/us,20606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,798.37,,,,,,,fee schedule,639.97,3100.34,
Drain/inj joint/bursa w/us,20606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,639.97,,,,,,,fee schedule,639.97,3100.34,
Drain/inj joint/bursa w/us,20606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,699.11,,,,,,,fee schedule,639.97,3100.34,
Drain/inj joint/bursa w/us,20606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,735.01,,,,,,,fee schedule,639.97,3100.34,
Drain/inj joint/bursa w/us,20606,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3100.34,,,,,,,fee schedule,639.97,3100.34,APC 378
Drain/inj joint/bursa w/us,20606,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,733.74,,,,,,,fee schedule,639.97,3100.34,APC
Drain/inj joint/bursa w/us,20606,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,726.75,,,,,,,fee schedule,639.97,3100.34,APC
Drain/inj joint/bursa w/us,20606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,698.8,,,,,,,fee schedule,639.97,3100.34,APC
Drain/inj joint/bursa w/us,20606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1069.16,,,,,,,fee schedule,639.97,3100.34,Radiology
Drain/inj joint/bursa w/us,20606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,978.32,,,,,,,fee schedule,639.97,3100.34,APC
Drain/inj joint/bursa w/us,20606,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1222.9,,,,,,,fee schedule,639.97,3100.34,APC
Drain/inj joint/bursa w/o us,20610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,724,,,,,,,fee schedule,303.87,1348.18,
Drain/inj joint/bursa w/o us,20610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,580.35,,,,,,,fee schedule,303.87,1348.18,
Drain/inj joint/bursa w/o us,20610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,633.98,,,,,,,fee schedule,303.87,1348.18,
Drain/inj joint/bursa w/o us,20610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,666.54,,,,,,,fee schedule,303.87,1348.18,
Drain/inj joint/bursa w/o us,20610,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1348.18,,,,,,,fee schedule,303.87,1348.18,APC 378
Drain/inj joint/bursa w/o us,20610,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,319.07,,,,,,,fee schedule,303.87,1348.18,APC
Drain/inj joint/bursa w/o us,20610,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,316.03,,,,,,,fee schedule,303.87,1348.18,APC
Drain/inj joint/bursa w/o us,20610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,303.87,,,,,,,fee schedule,303.87,1348.18,APC
Drain/inj joint/bursa w/o us,20610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,464.92,,,,,,,fee schedule,303.87,1348.18,Radiology
Drain/inj joint/bursa w/o us,20610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,425.42,,,,,,,fee schedule,303.87,1348.18,APC
Drain/inj joint/bursa w/o us,20610,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,531.78,,,,,,,fee schedule,303.87,1348.18,APC
Drain/inj joint/bursa w/us,20611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,798.37,,,,,,,fee schedule,303.87,1348.18,
Drain/inj joint/bursa w/us,20611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,639.97,,,,,,,fee schedule,303.87,1348.18,
Drain/inj joint/bursa w/us,20611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,699.11,,,,,,,fee schedule,303.87,1348.18,
Drain/inj joint/bursa w/us,20611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,735.01,,,,,,,fee schedule,303.87,1348.18,
Drain/inj joint/bursa w/us,20611,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1348.18,,,,,,,fee schedule,303.87,1348.18,APC 378
Drain/inj joint/bursa w/us,20611,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,319.07,,,,,,,fee schedule,303.87,1348.18,APC
Drain/inj joint/bursa w/us,20611,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,316.03,,,,,,,fee schedule,303.87,1348.18,APC
Drain/inj joint/bursa w/us,20611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,303.87,,,,,,,fee schedule,303.87,1348.18,APC
Drain/inj joint/bursa w/us,20611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,464.92,,,,,,,fee schedule,303.87,1348.18,Radiology
Drain/inj joint/bursa w/us,20611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,425.42,,,,,,,fee schedule,303.87,1348.18,APC
Drain/inj joint/bursa w/us,20611,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,531.78,,,,,,,fee schedule,303.87,1348.18,APC
Aspirate/inj ganglion cyst,20612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3360.79,,,,,,,fee schedule,303.87,3360.79,
Aspirate/inj ganglion cyst,20612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2693.96,,,,,,,fee schedule,303.87,3360.79,
Aspirate/inj ganglion cyst,20612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2942.91,,,,,,,fee schedule,303.87,3360.79,
Aspirate/inj ganglion cyst,20612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3094.06,,,,,,,fee schedule,303.87,3360.79,
Aspirate/inj ganglion cyst,20612,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1348.18,,,,,,,fee schedule,303.87,3360.79,APC 378
Aspirate/inj ganglion cyst,20612,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,319.07,,,,,,,fee schedule,303.87,3360.79,APC
Aspirate/inj ganglion cyst,20612,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,316.03,,,,,,,fee schedule,303.87,3360.79,APC
Aspirate/inj ganglion cyst,20612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,303.87,,,,,,,fee schedule,303.87,3360.79,APC
Aspirate/inj ganglion cyst,20612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,464.92,,,,,,,fee schedule,303.87,3360.79,Radiology
Aspirate/inj ganglion cyst,20612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,425.42,,,,,,,fee schedule,303.87,3360.79,APC
Aspirate/inj ganglion cyst,20612,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,531.78,,,,,,,fee schedule,303.87,3360.79,APC
Treatment of bone cyst,20615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1079.91,,,,,,,fee schedule,701.03,3110.22,
Treatment of bone cyst,20615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,865.64,,,,,,,fee schedule,701.03,3110.22,
Treatment of bone cyst,20615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,945.63,,,,,,,fee schedule,701.03,3110.22,
Treatment of bone cyst,20615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,994.2,,,,,,,fee schedule,701.03,3110.22,
Treatment of bone cyst,20615,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3110.22,,,,,,,fee schedule,701.03,3110.22,APC 378
Treatment of bone cyst,20615,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,736.08,,,,,,,fee schedule,701.03,3110.22,APC
Treatment of bone cyst,20615,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,729.07,,,,,,,fee schedule,701.03,3110.22,APC
Treatment of bone cyst,20615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,701.03,,,,,,,fee schedule,701.03,3110.22,APC
Treatment of bone cyst,20615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1072.57,,,,,,,fee schedule,701.03,3110.22,Radiology
Treatment of bone cyst,20615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,981.44,,,,,,,fee schedule,701.03,3110.22,APC
Treatment of bone cyst,20615,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1226.8,,,,,,,fee schedule,701.03,3110.22,APC
Insert and remove bone pin,20650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,3239.17,14371.12,
Insert and remove bone pin,20650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,3239.17,14371.12,
Insert and remove bone pin,20650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,3239.17,14371.12,
Insert and remove bone pin,20650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,3239.17,14371.12,
Insert and remove bone pin,20650,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Insert and remove bone pin,20650,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Insert and remove bone pin,20650,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Insert and remove bone pin,20650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Insert and remove bone pin,20650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Insert and remove bone pin,20650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Insert and remove bone pin,20650,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Apply rem fixation device,20660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4601.85,,,,,,,fee schedule,1591.86,7062.54,
Apply rem fixation device,20660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3688.78,,,,,,,fee schedule,1591.86,7062.54,
Apply rem fixation device,20660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4029.66,,,,,,,fee schedule,1591.86,7062.54,
Apply rem fixation device,20660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4236.62,,,,,,,fee schedule,1591.86,7062.54,
Apply rem fixation device,20660,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Apply rem fixation device,20660,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Apply rem fixation device,20660,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Apply rem fixation device,20660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Apply rem fixation device,20660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Apply rem fixation device,20660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Apply rem fixation device,20660,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Application of head brace,20661,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10698.91,,,,,,,fee schedule,1591.86,10698.91,
Application of head brace,20661,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8576.11,,,,,,,fee schedule,1591.86,10698.91,
Application of head brace,20661,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9368.62,,,,,,,fee schedule,1591.86,10698.91,
Application of head brace,20661,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9849.79,,,,,,,fee schedule,1591.86,10698.91,
Application of head brace,20661,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,10698.91,APC 378
Application of head brace,20661,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,10698.91,APC
Application of head brace,20661,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,10698.91,APC
Application of head brace,20661,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,10698.91,APC
Application of head brace,20661,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,10698.91,Radiology
Application of head brace,20661,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,10698.91,APC
Application of head brace,20661,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,10698.91,APC
Application of pelvis brace,20662,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,1591.86,7062.54,
Application of pelvis brace,20662,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,1591.86,7062.54,
Application of pelvis brace,20662,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,1591.86,7062.54,
Application of pelvis brace,20662,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,1591.86,7062.54,
Application of pelvis brace,20662,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Application of pelvis brace,20662,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Application of pelvis brace,20662,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Application of pelvis brace,20662,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Application of pelvis brace,20662,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Application of pelvis brace,20662,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Application of pelvis brace,20662,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Application of thigh brace,20663,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,3239.17,14371.12,
Application of thigh brace,20663,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,3239.17,14371.12,
Application of thigh brace,20663,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,3239.17,14371.12,
Application of thigh brace,20663,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,3239.17,14371.12,
Application of thigh brace,20663,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Application of thigh brace,20663,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Application of thigh brace,20663,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Application of thigh brace,20663,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Application of thigh brace,20663,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Application of thigh brace,20663,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Application of thigh brace,20663,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Application of halo,20664,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10698.91,,,,,,,fee schedule,1591.86,10698.91,
Application of halo,20664,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8576.11,,,,,,,fee schedule,1591.86,10698.91,
Application of halo,20664,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9368.62,,,,,,,fee schedule,1591.86,10698.91,
Application of halo,20664,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9849.79,,,,,,,fee schedule,1591.86,10698.91,
Application of halo,20664,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,10698.91,APC 378
Application of halo,20664,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,10698.91,APC
Application of halo,20664,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,10698.91,APC
Application of halo,20664,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,10698.91,APC
Application of halo,20664,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,10698.91,Radiology
Application of halo,20664,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,10698.91,APC
Application of halo,20664,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,10698.91,APC
Removal of fixation device,20665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,157.47,,,,,,,fee schedule,126.23,1962.08,
Removal of fixation device,20665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,126.23,,,,,,,fee schedule,126.23,1962.08,
Removal of fixation device,20665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,137.89,,,,,,,fee schedule,126.23,1962.08,
Removal of fixation device,20665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,144.98,,,,,,,fee schedule,126.23,1962.08,
Removal of fixation device,20665,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1962.08,,,,,,,fee schedule,126.23,1962.08,APC 378
Removal of fixation device,20665,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,464.35,,,,,,,fee schedule,126.23,1962.08,APC
Removal of fixation device,20665,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,459.93,,,,,,,fee schedule,126.23,1962.08,APC
Removal of fixation device,20665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,442.24,,,,,,,fee schedule,126.23,1962.08,APC
Removal of fixation device,20665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,676.63,,,,,,,fee schedule,126.23,1962.08,Radiology
Removal of fixation device,20665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,619.14,,,,,,,fee schedule,126.23,1962.08,APC
Removal of fixation device,20665,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,773.92,,,,,,,fee schedule,126.23,1962.08,APC
Removal of support implant,20670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4018.18,,,,,,,fee schedule,1635.03,7254.06,
Removal of support implant,20670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3220.92,,,,,,,fee schedule,1635.03,7254.06,
Removal of support implant,20670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3518.56,,,,,,,fee schedule,1635.03,7254.06,
Removal of support implant,20670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3699.27,,,,,,,fee schedule,1635.03,7254.06,
Removal of support implant,20670,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,7254.06,APC 378
Removal of support implant,20670,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,7254.06,APC
Removal of support implant,20670,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,7254.06,APC
Removal of support implant,20670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,7254.06,APC
Removal of support implant,20670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,7254.06,Radiology
Removal of support implant,20670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,7254.06,APC
Removal of support implant,20670,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,7254.06,APC
Removal of support implant,20680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5829,,,,,,,fee schedule,2875.57,12757.95,
Removal of support implant,20680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4672.45,,,,,,,fee schedule,2875.57,12757.95,
Removal of support implant,20680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5104.23,,,,,,,fee schedule,2875.57,12757.95,
Removal of support implant,20680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5366.38,,,,,,,fee schedule,2875.57,12757.95,
Removal of support implant,20680,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Removal of support implant,20680,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Removal of support implant,20680,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Removal of support implant,20680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Removal of support implant,20680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Removal of support implant,20680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Removal of support implant,20680,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Apply bone fixation device,20690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5804.85,,,,,,,fee schedule,4653.09,31870.39,
Apply bone fixation device,20690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4653.09,,,,,,,fee schedule,4653.09,31870.39,
Apply bone fixation device,20690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5083.08,,,,,,,fee schedule,4653.09,31870.39,
Apply bone fixation device,20690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5344.14,,,,,,,fee schedule,4653.09,31870.39,
Apply bone fixation device,20690,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,4653.09,31870.39,APC 378
Apply bone fixation device,20690,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,4653.09,31870.39,APC
Apply bone fixation device,20690,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,4653.09,31870.39,APC
Apply bone fixation device,20690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,4653.09,31870.39,APC
Apply bone fixation device,20690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,4653.09,31870.39,Radiology
Apply bone fixation device,20690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,4653.09,31870.39,APC
Apply bone fixation device,20690,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,4653.09,31870.39,APC
Apply bone fixation device,20692,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3828.9,,,,,,,fee schedule,3069.2,56389.43,
Apply bone fixation device,20692,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3069.2,,,,,,,fee schedule,3069.2,56389.43,
Apply bone fixation device,20692,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3352.82,,,,,,,fee schedule,3069.2,56389.43,
Apply bone fixation device,20692,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3525.02,,,,,,,fee schedule,3069.2,56389.43,
Apply bone fixation device,20692,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,3069.2,56389.43,APC 378
Apply bone fixation device,20692,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,3069.2,56389.43,APC
Apply bone fixation device,20692,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,3069.2,56389.43,APC
Apply bone fixation device,20692,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,3069.2,56389.43,APC
Apply bone fixation device,20692,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,3069.2,56389.43,Radiology
Apply bone fixation device,20692,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,3069.2,56389.43,APC
Apply bone fixation device,20692,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,3069.2,56389.43,APC
Adjust bone fixation device,20693,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,4254.97,31870.39,
Adjust bone fixation device,20693,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,4254.97,31870.39,
Adjust bone fixation device,20693,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,4254.97,31870.39,
Adjust bone fixation device,20693,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,4254.97,31870.39,
Adjust bone fixation device,20693,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,4254.97,31870.39,APC 378
Adjust bone fixation device,20693,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,4254.97,31870.39,APC
Adjust bone fixation device,20693,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,4254.97,31870.39,APC
Adjust bone fixation device,20693,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,4254.97,31870.39,APC
Adjust bone fixation device,20693,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,4254.97,31870.39,Radiology
Adjust bone fixation device,20693,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,4254.97,31870.39,APC
Adjust bone fixation device,20693,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,4254.97,31870.39,APC
Remove bone fixation device,20694,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4962.16,,,,,,,fee schedule,1591.86,7062.54,
Remove bone fixation device,20694,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3977.61,,,,,,,fee schedule,1591.86,7062.54,
Remove bone fixation device,20694,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4345.17,,,,,,,fee schedule,1591.86,7062.54,
Remove bone fixation device,20694,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4568.34,,,,,,,fee schedule,1591.86,7062.54,
Remove bone fixation device,20694,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Remove bone fixation device,20694,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Remove bone fixation device,20694,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Remove bone fixation device,20694,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Remove bone fixation device,20694,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Remove bone fixation device,20694,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Remove bone fixation device,20694,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Comp multiplane ext fixation,20696,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3754.45,,,,,,,fee schedule,3009.52,119176.72,
Comp multiplane ext fixation,20696,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3009.52,,,,,,,fee schedule,3009.52,119176.72,
Comp multiplane ext fixation,20696,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3287.62,,,,,,,fee schedule,3009.52,119176.72,
Comp multiplane ext fixation,20696,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3456.48,,,,,,,fee schedule,3009.52,119176.72,
Comp multiplane ext fixation,20696,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,119176.72,,,,,,,fee schedule,3009.52,119176.72,APC 378
Comp multiplane ext fixation,20696,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,28204.89,,,,,,,fee schedule,3009.52,119176.72,APC
Comp multiplane ext fixation,20696,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,27936.27,,,,,,,fee schedule,3009.52,119176.72,APC
Comp multiplane ext fixation,20696,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,26861.8,,,,,,,fee schedule,3009.52,119176.72,APC
Comp multiplane ext fixation,20696,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,41098.56,,,,,,,fee schedule,3009.52,119176.72,Radiology
Comp multiplane ext fixation,20696,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,37606.52,,,,,,,fee schedule,3009.52,119176.72,APC
Comp multiplane ext fixation,20696,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,47008.15,,,,,,,fee schedule,3009.52,119176.72,APC
Comp ext fixate strut change,20697,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4015.27,,,,,,,fee schedule,1591.86,7062.54,
Comp ext fixate strut change,20697,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3218.59,,,,,,,fee schedule,1591.86,7062.54,
Comp ext fixate strut change,20697,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3516.01,,,,,,,fee schedule,1591.86,7062.54,
Comp ext fixate strut change,20697,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3696.6,,,,,,,fee schedule,1591.86,7062.54,
Comp ext fixate strut change,20697,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Comp ext fixate strut change,20697,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Comp ext fixate strut change,20697,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Comp ext fixate strut change,20697,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Comp ext fixate strut change,20697,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Comp ext fixate strut change,20697,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Comp ext fixate strut change,20697,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Mnl prep&insj dp rx dlvr dev,20700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,330.03,,,,,,,fee schedule,264.55,330.03,
Mnl prep&insj dp rx dlvr dev,20700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,264.55,,,,,,,fee schedule,264.55,330.03,
Mnl prep&insj dp rx dlvr dev,20700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,289,,,,,,,fee schedule,264.55,330.03,
Mnl prep&insj dp rx dlvr dev,20700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,303.84,,,,,,,fee schedule,264.55,330.03,
Rmvl deep rx delivery device,20701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,245.81,,,,,,,fee schedule,197.04,245.81,
Rmvl deep rx delivery device,20701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,197.04,,,,,,,fee schedule,197.04,245.81,
Rmvl deep rx delivery device,20701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,215.25,,,,,,,fee schedule,197.04,245.81,
Rmvl deep rx delivery device,20701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,226.3,,,,,,,fee schedule,197.04,245.81,
Mnl prep&insj imed rx dev,20702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,549.65,,,,,,,fee schedule,440.59,549.65,
Mnl prep&insj imed rx dev,20702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,440.59,,,,,,,fee schedule,440.59,549.65,
Mnl prep&insj imed rx dev,20702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,481.31,,,,,,,fee schedule,440.59,549.65,
Mnl prep&insj imed rx dev,20702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,506.03,,,,,,,fee schedule,440.59,549.65,
Rmvl imed rx delivery device,20703,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,393.23,,,,,,,fee schedule,315.21,393.23,
Rmvl imed rx delivery device,20703,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,315.21,,,,,,,fee schedule,315.21,393.23,
Rmvl imed rx delivery device,20703,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,344.34,,,,,,,fee schedule,315.21,393.23,
Rmvl imed rx delivery device,20703,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,362.02,,,,,,,fee schedule,315.21,393.23,
Mnl prep&insj i-artic rx dev,20704,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,572.63,,,,,,,fee schedule,459.01,572.63,
Mnl prep&insj i-artic rx dev,20704,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,459.01,,,,,,,fee schedule,459.01,572.63,
Mnl prep&insj i-artic rx dev,20704,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,501.43,,,,,,,fee schedule,459.01,572.63,
Mnl prep&insj i-artic rx dev,20704,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,527.19,,,,,,,fee schedule,459.01,572.63,
Rmvl i-artic rx delivery dev,20705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,470.61,,,,,,,fee schedule,377.24,470.61,
Rmvl i-artic rx delivery dev,20705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,377.24,,,,,,,fee schedule,377.24,470.61,
Rmvl i-artic rx delivery dev,20705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,412.1,,,,,,,fee schedule,377.24,470.61,
Rmvl i-artic rx delivery dev,20705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,433.26,,,,,,,fee schedule,377.24,470.61,
Replantation arm complete,20802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59981.53,,,,,,,fee schedule,17357.91,77011.17,
Replantation arm complete,20802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48080.43,,,,,,,fee schedule,17357.91,77011.17,
Replantation arm complete,20802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52523.51,,,,,,,fee schedule,17357.91,77011.17,
Replantation arm complete,20802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55221.09,,,,,,,fee schedule,17357.91,77011.17,
Replantation arm complete,20802,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,77011.17,,,,,,,fee schedule,17357.91,77011.17,APC 378
Replantation arm complete,20802,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18225.81,,,,,,,fee schedule,17357.91,77011.17,APC
Replantation arm complete,20802,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18052.23,,,,,,,fee schedule,17357.91,77011.17,APC
Replantation arm complete,20802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17357.91,,,,,,,fee schedule,17357.91,77011.17,APC
Replantation arm complete,20802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26557.6,,,,,,,fee schedule,17357.91,77011.17,Radiology
Replantation arm complete,20802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24301.07,,,,,,,fee schedule,17357.91,77011.17,APC
Replantation arm complete,20802,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30376.34,,,,,,,fee schedule,17357.91,77011.17,APC
Replant forearm complete,20805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59981.53,,,,,,,fee schedule,17357.91,77011.17,
Replant forearm complete,20805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48080.43,,,,,,,fee schedule,17357.91,77011.17,
Replant forearm complete,20805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52523.51,,,,,,,fee schedule,17357.91,77011.17,
Replant forearm complete,20805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55221.09,,,,,,,fee schedule,17357.91,77011.17,
Replant forearm complete,20805,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,77011.17,,,,,,,fee schedule,17357.91,77011.17,APC 378
Replant forearm complete,20805,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18225.81,,,,,,,fee schedule,17357.91,77011.17,APC
Replant forearm complete,20805,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18052.23,,,,,,,fee schedule,17357.91,77011.17,APC
Replant forearm complete,20805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17357.91,,,,,,,fee schedule,17357.91,77011.17,APC
Replant forearm complete,20805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26557.6,,,,,,,fee schedule,17357.91,77011.17,Radiology
Replant forearm complete,20805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24301.07,,,,,,,fee schedule,17357.91,77011.17,APC
Replant forearm complete,20805,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30376.34,,,,,,,fee schedule,17357.91,77011.17,APC
Replantation hand complete,20808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59981.53,,,,,,,fee schedule,17357.91,77011.17,
Replantation hand complete,20808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48080.43,,,,,,,fee schedule,17357.91,77011.17,
Replantation hand complete,20808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52523.51,,,,,,,fee schedule,17357.91,77011.17,
Replantation hand complete,20808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55221.09,,,,,,,fee schedule,17357.91,77011.17,
Replantation hand complete,20808,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,77011.17,,,,,,,fee schedule,17357.91,77011.17,APC 378
Replantation hand complete,20808,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18225.81,,,,,,,fee schedule,17357.91,77011.17,APC
Replantation hand complete,20808,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18052.23,,,,,,,fee schedule,17357.91,77011.17,APC
Replantation hand complete,20808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17357.91,,,,,,,fee schedule,17357.91,77011.17,APC
Replantation hand complete,20808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26557.6,,,,,,,fee schedule,17357.91,77011.17,Radiology
Replantation hand complete,20808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24301.07,,,,,,,fee schedule,17357.91,77011.17,APC
Replantation hand complete,20808,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30376.34,,,,,,,fee schedule,17357.91,77011.17,APC
Replantation digit complete,20816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,1591.86,23681.51,
Replantation digit complete,20816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,1591.86,23681.51,
Replantation digit complete,20816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,1591.86,23681.51,
Replantation digit complete,20816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,1591.86,23681.51,
Replantation digit complete,20816,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,23681.51,APC 378
Replantation digit complete,20816,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,23681.51,APC
Replantation digit complete,20816,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,23681.51,APC
Replantation digit complete,20816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,23681.51,APC
Replantation digit complete,20816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,23681.51,Radiology
Replantation digit complete,20816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,23681.51,APC
Replantation digit complete,20816,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,23681.51,APC
Replantation digit complete,20822,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6566.46,,,,,,,fee schedule,1591.86,7062.54,
Replantation digit complete,20822,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5263.59,,,,,,,fee schedule,1591.86,7062.54,
Replantation digit complete,20822,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5750,,,,,,,fee schedule,1591.86,7062.54,
Replantation digit complete,20822,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6045.32,,,,,,,fee schedule,1591.86,7062.54,
Replantation digit complete,20822,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Replantation digit complete,20822,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Replantation digit complete,20822,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Replantation digit complete,20822,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Replantation digit complete,20822,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Replantation digit complete,20822,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Replantation digit complete,20822,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Replantation thumb complete,20824,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,1591.86,23681.51,
Replantation thumb complete,20824,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,1591.86,23681.51,
Replantation thumb complete,20824,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,1591.86,23681.51,
Replantation thumb complete,20824,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,1591.86,23681.51,
Replantation thumb complete,20824,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,23681.51,APC 378
Replantation thumb complete,20824,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,23681.51,APC
Replantation thumb complete,20824,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,23681.51,APC
Replantation thumb complete,20824,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,23681.51,APC
Replantation thumb complete,20824,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,23681.51,Radiology
Replantation thumb complete,20824,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,23681.51,APC
Replantation thumb complete,20824,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,23681.51,APC
Replantation thumb complete,20827,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,1591.86,23681.51,
Replantation thumb complete,20827,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,1591.86,23681.51,
Replantation thumb complete,20827,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,1591.86,23681.51,
Replantation thumb complete,20827,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,1591.86,23681.51,
Replantation thumb complete,20827,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,23681.51,APC 378
Replantation thumb complete,20827,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,23681.51,APC
Replantation thumb complete,20827,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,23681.51,APC
Replantation thumb complete,20827,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,23681.51,APC
Replantation thumb complete,20827,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,23681.51,Radiology
Replantation thumb complete,20827,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,23681.51,APC
Replantation thumb complete,20827,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,23681.51,APC
Replantation foot complete,20838,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59981.53,,,,,,,fee schedule,17357.91,77011.17,
Replantation foot complete,20838,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48080.43,,,,,,,fee schedule,17357.91,77011.17,
Replantation foot complete,20838,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52523.51,,,,,,,fee schedule,17357.91,77011.17,
Replantation foot complete,20838,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55221.09,,,,,,,fee schedule,17357.91,77011.17,
Replantation foot complete,20838,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,77011.17,,,,,,,fee schedule,17357.91,77011.17,APC 378
Replantation foot complete,20838,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18225.81,,,,,,,fee schedule,17357.91,77011.17,APC
Replantation foot complete,20838,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18052.23,,,,,,,fee schedule,17357.91,77011.17,APC
Replantation foot complete,20838,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17357.91,,,,,,,fee schedule,17357.91,77011.17,APC
Replantation foot complete,20838,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26557.6,,,,,,,fee schedule,17357.91,77011.17,Radiology
Replantation foot complete,20838,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24301.07,,,,,,,fee schedule,17357.91,77011.17,APC
Replantation foot complete,20838,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30376.34,,,,,,,fee schedule,17357.91,77011.17,APC
Removal of bone for graft,20900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4531.07,,,,,,,fee schedule,3632.05,31870.39,
Removal of bone for graft,20900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3632.05,,,,,,,fee schedule,3632.05,31870.39,
Removal of bone for graft,20900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3967.69,,,,,,,fee schedule,3632.05,31870.39,
Removal of bone for graft,20900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4171.46,,,,,,,fee schedule,3632.05,31870.39,
Removal of bone for graft,20900,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,3632.05,31870.39,APC 378
Removal of bone for graft,20900,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,3632.05,31870.39,APC
Removal of bone for graft,20900,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,3632.05,31870.39,APC
Removal of bone for graft,20900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,3632.05,31870.39,APC
Removal of bone for graft,20900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,3632.05,31870.39,Radiology
Removal of bone for graft,20900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,3632.05,31870.39,APC
Removal of bone for graft,20900,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,3632.05,31870.39,APC
Removal of bone for graft,20902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3300.19,,,,,,,fee schedule,2645.39,31870.39,
Removal of bone for graft,20902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2645.39,,,,,,,fee schedule,2645.39,31870.39,
Removal of bone for graft,20902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2889.84,,,,,,,fee schedule,2645.39,31870.39,
Removal of bone for graft,20902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3038.27,,,,,,,fee schedule,2645.39,31870.39,
Removal of bone for graft,20902,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,2645.39,31870.39,APC 378
Removal of bone for graft,20902,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,2645.39,31870.39,APC
Removal of bone for graft,20902,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,2645.39,31870.39,APC
Removal of bone for graft,20902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,2645.39,31870.39,APC
Removal of bone for graft,20902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,2645.39,31870.39,Radiology
Removal of bone for graft,20902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,2645.39,31870.39,APC
Removal of bone for graft,20902,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,2645.39,31870.39,APC
Remove cartilage for graft,20910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5043.16,,,,,,,fee schedule,731.66,5043.16,
Remove cartilage for graft,20910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4042.54,,,,,,,fee schedule,731.66,5043.16,
Remove cartilage for graft,20910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4416.1,,,,,,,fee schedule,731.66,5043.16,
Remove cartilage for graft,20910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4642.91,,,,,,,fee schedule,731.66,5043.16,
Remove cartilage for graft,20910,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3246.12,,,,,,,fee schedule,731.66,5043.16,APC 378
Remove cartilage for graft,20910,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,768.24,,,,,,,fee schedule,731.66,5043.16,APC
Remove cartilage for graft,20910,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,760.92,,,,,,,fee schedule,731.66,5043.16,APC
Remove cartilage for graft,20910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,731.66,,,,,,,fee schedule,731.66,5043.16,APC
Remove cartilage for graft,20910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1119.44,,,,,,,fee schedule,731.66,5043.16,Radiology
Remove cartilage for graft,20910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1024.32,,,,,,,fee schedule,731.66,5043.16,APC
Remove cartilage for graft,20910,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1280.4,,,,,,,fee schedule,731.66,5043.16,APC
Remove cartilage for graft,20912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2902.42,,,,,,,fee schedule,2326.55,15564.58,
Remove cartilage for graft,20912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2326.55,,,,,,,fee schedule,2326.55,15564.58,
Remove cartilage for graft,20912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2541.54,,,,,,,fee schedule,2326.55,15564.58,
Remove cartilage for graft,20912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2672.07,,,,,,,fee schedule,2326.55,15564.58,
Remove cartilage for graft,20912,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15564.58,,,,,,,fee schedule,2326.55,15564.58,APC 378
Remove cartilage for graft,20912,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3683.58,,,,,,,fee schedule,2326.55,15564.58,APC
Remove cartilage for graft,20912,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3648.5,,,,,,,fee schedule,2326.55,15564.58,APC
Remove cartilage for graft,20912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3508.17,,,,,,,fee schedule,2326.55,15564.58,APC
Remove cartilage for graft,20912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5367.5,,,,,,,fee schedule,2326.55,15564.58,Radiology
Remove cartilage for graft,20912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4911.44,,,,,,,fee schedule,2326.55,15564.58,APC
Remove cartilage for graft,20912,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6139.3,,,,,,,fee schedule,2326.55,15564.58,APC
Removal of fascia for graft,20920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3755.05,,,,,,,fee schedule,2042.58,9062.24,
Removal of fascia for graft,20920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3010,,,,,,,fee schedule,2042.58,9062.24,
Removal of fascia for graft,20920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3288.15,,,,,,,fee schedule,2042.58,9062.24,
Removal of fascia for graft,20920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3457.03,,,,,,,fee schedule,2042.58,9062.24,
Removal of fascia for graft,20920,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,2042.58,9062.24,APC 378
Removal of fascia for graft,20920,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,2042.58,9062.24,APC
Removal of fascia for graft,20920,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,2042.58,9062.24,APC
Removal of fascia for graft,20920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,2042.58,9062.24,APC
Removal of fascia for graft,20920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,2042.58,9062.24,Radiology
Removal of fascia for graft,20920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,2042.58,9062.24,APC
Removal of fascia for graft,20920,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,2042.58,9062.24,APC
Removal of fascia for graft,20922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3755.05,,,,,,,fee schedule,2042.58,9062.24,
Removal of fascia for graft,20922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3010,,,,,,,fee schedule,2042.58,9062.24,
Removal of fascia for graft,20922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3288.15,,,,,,,fee schedule,2042.58,9062.24,
Removal of fascia for graft,20922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3457.03,,,,,,,fee schedule,2042.58,9062.24,
Removal of fascia for graft,20922,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,2042.58,9062.24,APC 378
Removal of fascia for graft,20922,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,2042.58,9062.24,APC
Removal of fascia for graft,20922,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,2042.58,9062.24,APC
Removal of fascia for graft,20922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,2042.58,9062.24,APC
Removal of fascia for graft,20922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,2042.58,9062.24,Radiology
Removal of fascia for graft,20922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,2042.58,9062.24,APC
Removal of fascia for graft,20922,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,2042.58,9062.24,APC
Removal of tendon for graft,20924,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4035.19,,,,,,,fee schedule,3234.56,31870.39,
Removal of tendon for graft,20924,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3234.56,,,,,,,fee schedule,3234.56,31870.39,
Removal of tendon for graft,20924,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3533.46,,,,,,,fee schedule,3234.56,31870.39,
Removal of tendon for graft,20924,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3714.94,,,,,,,fee schedule,3234.56,31870.39,
Removal of tendon for graft,20924,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,3234.56,31870.39,APC 378
Removal of tendon for graft,20924,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,3234.56,31870.39,APC
Removal of tendon for graft,20924,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,3234.56,31870.39,APC
Removal of tendon for graft,20924,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,3234.56,31870.39,APC
Removal of tendon for graft,20924,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,3234.56,31870.39,Radiology
Removal of tendon for graft,20924,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,3234.56,31870.39,APC
Removal of tendon for graft,20924,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,3234.56,31870.39,APC
Osteoart algrft w/surf & b1,20932,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2783.74,,,,,,,fee schedule,2231.41,2783.74,
Osteoart algrft w/surf & b1,20932,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2231.41,,,,,,,fee schedule,2231.41,2783.74,
Osteoart algrft w/surf & b1,20932,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2437.62,,,,,,,fee schedule,2231.41,2783.74,
Osteoart algrft w/surf & b1,20932,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2562.81,,,,,,,fee schedule,2231.41,2783.74,
Hemicrt intrclry algrft prtl,20933,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2558.8,,,,,,,fee schedule,2051.1,2558.8,
Hemicrt intrclry algrft prtl,20933,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2051.1,,,,,,,fee schedule,2051.1,2558.8,
Hemicrt intrclry algrft prtl,20933,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2240.64,,,,,,,fee schedule,2051.1,2558.8,
Hemicrt intrclry algrft prtl,20933,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2355.72,,,,,,,fee schedule,2051.1,2558.8,
Intercalary algrft compl,20934,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2782.38,,,,,,,fee schedule,2230.32,2782.38,
Intercalary algrft compl,20934,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2230.32,,,,,,,fee schedule,2230.32,2782.38,
Intercalary algrft compl,20934,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2436.42,,,,,,,fee schedule,2230.32,2782.38,
Intercalary algrft compl,20934,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2561.56,,,,,,,fee schedule,2230.32,2782.38,
Sp bone agrft local add-on,20936,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1007.9,,,,,,,fee schedule,807.92,1007.9,
Sp bone agrft local add-on,20936,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,807.92,,,,,,,fee schedule,807.92,1007.9,
Sp bone agrft local add-on,20936,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,882.58,,,,,,,fee schedule,807.92,1007.9,
Sp bone agrft local add-on,20936,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,927.91,,,,,,,fee schedule,807.92,1007.9,
Bone marrow aspir bone grfg,20939,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,277.07,,,,,,,fee schedule,222.1,277.07,
Bone marrow aspir bone grfg,20939,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,222.1,,,,,,,fee schedule,222.1,277.07,
Bone marrow aspir bone grfg,20939,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,242.62,,,,,,,fee schedule,222.1,277.07,
Bone marrow aspir bone grfg,20939,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,255.08,,,,,,,fee schedule,222.1,277.07,
Fluid pressure muscle,20950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,351.05,,,,,,,fee schedule,281.4,3110.22,
Fluid pressure muscle,20950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,281.4,,,,,,,fee schedule,281.4,3110.22,
Fluid pressure muscle,20950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,307.4,,,,,,,fee schedule,281.4,3110.22,
Fluid pressure muscle,20950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,323.19,,,,,,,fee schedule,281.4,3110.22,
Fluid pressure muscle,20950,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3110.22,,,,,,,fee schedule,281.4,3110.22,APC 378
Fluid pressure muscle,20950,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,736.08,,,,,,,fee schedule,281.4,3110.22,APC
Fluid pressure muscle,20950,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,729.07,,,,,,,fee schedule,281.4,3110.22,APC
Fluid pressure muscle,20950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,701.03,,,,,,,fee schedule,281.4,3110.22,APC
Fluid pressure muscle,20950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1072.57,,,,,,,fee schedule,281.4,3110.22,Radiology
Fluid pressure muscle,20950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,981.44,,,,,,,fee schedule,281.4,3110.22,APC
Fluid pressure muscle,20950,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1226.8,,,,,,,fee schedule,281.4,3110.22,APC
Fibula bone graft microvasc,20955,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Fibula bone graft microvasc,20955,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Fibula bone graft microvasc,20955,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Fibula bone graft microvasc,20955,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Fibula bone graft microvasc,20955,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Fibula bone graft microvasc,20955,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Fibula bone graft microvasc,20955,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Fibula bone graft microvasc,20955,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Fibula bone graft microvasc,20955,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Fibula bone graft microvasc,20955,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Fibula bone graft microvasc,20955,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Iliac bone graft microvasc,20956,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Iliac bone graft microvasc,20956,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Iliac bone graft microvasc,20956,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Iliac bone graft microvasc,20956,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Iliac bone graft microvasc,20956,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Iliac bone graft microvasc,20956,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Iliac bone graft microvasc,20956,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Iliac bone graft microvasc,20956,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Iliac bone graft microvasc,20956,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Iliac bone graft microvasc,20956,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Iliac bone graft microvasc,20956,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Mt bone graft microvasc,20957,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Mt bone graft microvasc,20957,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Mt bone graft microvasc,20957,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Mt bone graft microvasc,20957,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Mt bone graft microvasc,20957,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Mt bone graft microvasc,20957,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Mt bone graft microvasc,20957,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Mt bone graft microvasc,20957,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Mt bone graft microvasc,20957,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Mt bone graft microvasc,20957,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Mt bone graft microvasc,20957,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Other bone graft microvasc,20962,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Other bone graft microvasc,20962,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Other bone graft microvasc,20962,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Other bone graft microvasc,20962,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Other bone graft microvasc,20962,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Other bone graft microvasc,20962,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Other bone graft microvasc,20962,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Other bone graft microvasc,20962,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Other bone graft microvasc,20962,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Other bone graft microvasc,20962,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Other bone graft microvasc,20962,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Bone/skin graft microvasc,20969,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Bone/skin graft microvasc,20969,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Bone/skin graft microvasc,20969,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Bone/skin graft microvasc,20969,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Bone/skin graft microvasc,20969,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Bone/skin graft microvasc,20969,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Bone/skin graft microvasc,20969,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Bone/skin graft microvasc,20969,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Bone/skin graft microvasc,20969,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Bone/skin graft microvasc,20969,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Bone/skin graft microvasc,20969,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Bone/skin graft iliac crest,20970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Bone/skin graft iliac crest,20970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Bone/skin graft iliac crest,20970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Bone/skin graft iliac crest,20970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Bone/skin graft iliac crest,20970,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Bone/skin graft iliac crest,20970,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Bone/skin graft iliac crest,20970,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Bone/skin graft iliac crest,20970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Bone/skin graft iliac crest,20970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Bone/skin graft iliac crest,20970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Bone/skin graft iliac crest,20970,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Bone/skin graft metatarsal,20972,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11048.37,,,,,,,fee schedule,7183.42,31870.39,
Bone/skin graft metatarsal,20972,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8856.24,,,,,,,fee schedule,7183.42,31870.39,
Bone/skin graft metatarsal,20972,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9674.63,,,,,,,fee schedule,7183.42,31870.39,
Bone/skin graft metatarsal,20972,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10171.52,,,,,,,fee schedule,7183.42,31870.39,
Bone/skin graft metatarsal,20972,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Bone/skin graft metatarsal,20972,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Bone/skin graft metatarsal,20972,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Bone/skin graft metatarsal,20972,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Bone/skin graft metatarsal,20972,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Bone/skin graft metatarsal,20972,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Bone/skin graft metatarsal,20972,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Bone/skin graft great toe,20973,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11048.37,,,,,,,fee schedule,7183.42,31870.39,
Bone/skin graft great toe,20973,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8856.24,,,,,,,fee schedule,7183.42,31870.39,
Bone/skin graft great toe,20973,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9674.63,,,,,,,fee schedule,7183.42,31870.39,
Bone/skin graft great toe,20973,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10171.52,,,,,,,fee schedule,7183.42,31870.39,
Bone/skin graft great toe,20973,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Bone/skin graft great toe,20973,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Bone/skin graft great toe,20973,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Bone/skin graft great toe,20973,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Bone/skin graft great toe,20973,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Bone/skin graft great toe,20973,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Bone/skin graft great toe,20973,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Electrical bone stimulation,20974,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3065.1,,,,,,,fee schedule,49.74,3065.1,
Electrical bone stimulation,20974,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2456.94,,,,,,,fee schedule,49.74,3065.1,
Electrical bone stimulation,20974,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2683.99,,,,,,,fee schedule,49.74,3065.1,
Electrical bone stimulation,20974,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2821.84,,,,,,,fee schedule,49.74,3065.1,
Electrical bone stimulation,20974,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,49.74,,,,,,,fee schedule,49.74,3065.1,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Electrical bone stimulation,20974,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,52.23,,,,,,,fee schedule,49.74,3065.1,APC
Electrical bone stimulation,20974,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,51.73,,,,,,,fee schedule,49.74,3065.1,APC
Electrical bone stimulation,20974,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,76.1,,,,,,,fee schedule,49.74,3065.1,Radiology
Electrical bone stimulation,20974,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,69.64,,,,,,,fee schedule,49.74,3065.1,APC
Electrical bone stimulation,20974,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,87.04,,,,,,,fee schedule,49.74,3065.1,APC
Us bone stimulation,20979,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,157.47,,,,,,,fee schedule,28.63,157.47,
Us bone stimulation,20979,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,126.23,,,,,,,fee schedule,28.63,157.47,
Us bone stimulation,20979,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,137.89,,,,,,,fee schedule,28.63,157.47,
Us bone stimulation,20979,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,144.98,,,,,,,fee schedule,28.63,157.47,
Us bone stimulation,20979,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,127.04,,,,,,,fee schedule,28.63,157.47,APC 378
Us bone stimulation,20979,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.07,,,,,,,fee schedule,28.63,157.47,APC
Us bone stimulation,20979,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,29.78,,,,,,,fee schedule,28.63,157.47,APC
Us bone stimulation,20979,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,28.63,,,,,,,fee schedule,28.63,157.47,APC
Us bone stimulation,20979,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43.81,,,,,,,fee schedule,28.63,157.47,Radiology
Us bone stimulation,20979,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40.09,,,,,,,fee schedule,28.63,157.47,APC
Us bone stimulation,20979,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,50.11,,,,,,,fee schedule,28.63,157.47,APC
Ablate bone tumor(s) perq,20982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5012.73,,,,,,,fee schedule,4018.14,77011.17,
Ablate bone tumor(s) perq,20982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4018.14,,,,,,,fee schedule,4018.14,77011.17,
Ablate bone tumor(s) perq,20982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4389.46,,,,,,,fee schedule,4018.14,77011.17,
Ablate bone tumor(s) perq,20982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4614.9,,,,,,,fee schedule,4018.14,77011.17,
Ablate bone tumor(s) perq,20982,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,77011.17,,,,,,,fee schedule,4018.14,77011.17,APC 378
Ablate bone tumor(s) perq,20982,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18225.81,,,,,,,fee schedule,4018.14,77011.17,APC
Ablate bone tumor(s) perq,20982,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18052.23,,,,,,,fee schedule,4018.14,77011.17,APC
Ablate bone tumor(s) perq,20982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17357.91,,,,,,,fee schedule,4018.14,77011.17,APC
Ablate bone tumor(s) perq,20982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26557.6,,,,,,,fee schedule,4018.14,77011.17,Radiology
Ablate bone tumor(s) perq,20982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24301.07,,,,,,,fee schedule,4018.14,77011.17,APC
Ablate bone tumor(s) perq,20982,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30376.34,,,,,,,fee schedule,4018.14,77011.17,APC
Ablate bone tumor(s) perq,20983,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14224.14,,,,,,,fee schedule,7183.42,31870.39,
Ablate bone tumor(s) perq,20983,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11401.89,,,,,,,fee schedule,7183.42,31870.39,
Ablate bone tumor(s) perq,20983,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12455.53,,,,,,,fee schedule,7183.42,31870.39,
Ablate bone tumor(s) perq,20983,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13095.24,,,,,,,fee schedule,7183.42,31870.39,
Ablate bone tumor(s) perq,20983,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Ablate bone tumor(s) perq,20983,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Ablate bone tumor(s) perq,20983,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Ablate bone tumor(s) perq,20983,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Ablate bone tumor(s) perq,20983,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Ablate bone tumor(s) perq,20983,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Ablate bone tumor(s) perq,20983,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Musculoskeletal surgery,20999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3243.76,,,,,,,fee schedule,244.19,3243.76,
Musculoskeletal surgery,20999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2600.15,,,,,,,fee schedule,244.19,3243.76,
Musculoskeletal surgery,20999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2840.43,,,,,,,fee schedule,244.19,3243.76,
Musculoskeletal surgery,20999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2986.32,,,,,,,fee schedule,244.19,3243.76,
Musculoskeletal surgery,20999,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,3243.76,APC 378
Musculoskeletal surgery,20999,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,3243.76,APC
Musculoskeletal surgery,20999,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,3243.76,APC
Musculoskeletal surgery,20999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,3243.76,APC
Musculoskeletal surgery,20999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,3243.76,Radiology
Musculoskeletal surgery,20999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,3243.76,APC
Musculoskeletal surgery,20999,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,3243.76,APC
Incision of jaw joint,21010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5983.93,,,,,,,fee schedule,3282.2,14562,
Incision of jaw joint,21010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4796.64,,,,,,,fee schedule,3282.2,14562,
Incision of jaw joint,21010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5239.9,,,,,,,fee schedule,3282.2,14562,
Incision of jaw joint,21010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.01,,,,,,,fee schedule,3282.2,14562,
Incision of jaw joint,21010,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Incision of jaw joint,21010,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Incision of jaw joint,21010,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Incision of jaw joint,21010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Incision of jaw joint,21010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Incision of jaw joint,21010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Incision of jaw joint,21010,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Exc face les sc <2 cm,21011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6721.57,,,,,,,fee schedule,1635.03,7254.06,
Exc face les sc <2 cm,21011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5387.93,,,,,,,fee schedule,1635.03,7254.06,
Exc face les sc <2 cm,21011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5885.82,,,,,,,fee schedule,1635.03,7254.06,
Exc face les sc <2 cm,21011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6188.11,,,,,,,fee schedule,1635.03,7254.06,
Exc face les sc <2 cm,21011,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,7254.06,APC 378
Exc face les sc <2 cm,21011,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,7254.06,APC
Exc face les sc <2 cm,21011,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,7254.06,APC
Exc face les sc <2 cm,21011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,7254.06,APC
Exc face les sc <2 cm,21011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,7254.06,Radiology
Exc face les sc <2 cm,21011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,7254.06,APC
Exc face les sc <2 cm,21011,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,7254.06,APC
Exc face les sbq 2 cm/>,21012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3594.84,,,,,,,fee schedule,1635.03,7254.06,
Exc face les sbq 2 cm/>,21012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2881.58,,,,,,,fee schedule,1635.03,7254.06,
Exc face les sbq 2 cm/>,21012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3147.87,,,,,,,fee schedule,1635.03,7254.06,
Exc face les sbq 2 cm/>,21012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3309.54,,,,,,,fee schedule,1635.03,7254.06,
Exc face les sbq 2 cm/>,21012,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,7254.06,APC 378
Exc face les sbq 2 cm/>,21012,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,7254.06,APC
Exc face les sbq 2 cm/>,21012,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,7254.06,APC
Exc face les sbq 2 cm/>,21012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,7254.06,APC
Exc face les sbq 2 cm/>,21012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,7254.06,Radiology
Exc face les sbq 2 cm/>,21012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,7254.06,APC
Exc face les sbq 2 cm/>,21012,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,7254.06,APC
Exc face tum deep < 2 cm,21013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2166.54,,,,,,,fee schedule,1635.03,7254.06,
Exc face tum deep < 2 cm,21013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1736.67,,,,,,,fee schedule,1635.03,7254.06,
Exc face tum deep < 2 cm,21013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1897.16,,,,,,,fee schedule,1635.03,7254.06,
Exc face tum deep < 2 cm,21013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1994.6,,,,,,,fee schedule,1635.03,7254.06,
Exc face tum deep < 2 cm,21013,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,7254.06,APC 378
Exc face tum deep < 2 cm,21013,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,7254.06,APC
Exc face tum deep < 2 cm,21013,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,7254.06,APC
Exc face tum deep < 2 cm,21013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,7254.06,APC
Exc face tum deep < 2 cm,21013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,7254.06,Radiology
Exc face tum deep < 2 cm,21013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,7254.06,APC
Exc face tum deep < 2 cm,21013,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,7254.06,APC
Exc face tum deep 2 cm/>,21014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2166.54,,,,,,,fee schedule,1736.67,12757.95,
Exc face tum deep 2 cm/>,21014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1736.67,,,,,,,fee schedule,1736.67,12757.95,
Exc face tum deep 2 cm/>,21014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1897.16,,,,,,,fee schedule,1736.67,12757.95,
Exc face tum deep 2 cm/>,21014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1994.6,,,,,,,fee schedule,1736.67,12757.95,
Exc face tum deep 2 cm/>,21014,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,1736.67,12757.95,APC 378
Exc face tum deep 2 cm/>,21014,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,1736.67,12757.95,APC
Exc face tum deep 2 cm/>,21014,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,1736.67,12757.95,APC
Exc face tum deep 2 cm/>,21014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,1736.67,12757.95,APC
Exc face tum deep 2 cm/>,21014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,1736.67,12757.95,Radiology
Exc face tum deep 2 cm/>,21014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,1736.67,12757.95,APC
Exc face tum deep 2 cm/>,21014,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,1736.67,12757.95,APC
Resect face/scalp tum < 2 cm,21015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4075.29,,,,,,,fee schedule,2875.57,12757.95,
Resect face/scalp tum < 2 cm,21015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3266.7,,,,,,,fee schedule,2875.57,12757.95,
Resect face/scalp tum < 2 cm,21015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3568.58,,,,,,,fee schedule,2875.57,12757.95,
Resect face/scalp tum < 2 cm,21015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3751.86,,,,,,,fee schedule,2875.57,12757.95,
Resect face/scalp tum < 2 cm,21015,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Resect face/scalp tum < 2 cm,21015,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Resect face/scalp tum < 2 cm,21015,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Resect face/scalp tum < 2 cm,21015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Resect face/scalp tum < 2 cm,21015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Resect face/scalp tum < 2 cm,21015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Resect face/scalp tum < 2 cm,21015,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Resect face/scalp tum 2 cm/>,21016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6177.24,,,,,,,fee schedule,2875.57,12757.95,
Resect face/scalp tum 2 cm/>,21016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4951.6,,,,,,,fee schedule,2875.57,12757.95,
Resect face/scalp tum 2 cm/>,21016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5409.17,,,,,,,fee schedule,2875.57,12757.95,
Resect face/scalp tum 2 cm/>,21016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5686.98,,,,,,,fee schedule,2875.57,12757.95,
Resect face/scalp tum 2 cm/>,21016,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Resect face/scalp tum 2 cm/>,21016,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Resect face/scalp tum 2 cm/>,21016,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Resect face/scalp tum 2 cm/>,21016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Resect face/scalp tum 2 cm/>,21016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Resect face/scalp tum 2 cm/>,21016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Resect face/scalp tum 2 cm/>,21016,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Excision of bone lower jaw,21025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Excision of bone lower jaw,21025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Excision of bone lower jaw,21025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Excision of bone lower jaw,21025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Excision of bone lower jaw,21025,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Excision of bone lower jaw,21025,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Excision of bone lower jaw,21025,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Excision of bone lower jaw,21025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Excision of bone lower jaw,21025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Excision of bone lower jaw,21025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Excision of bone lower jaw,21025,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Excision of facial bone(s),21026,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Excision of facial bone(s),21026,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Excision of facial bone(s),21026,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Excision of facial bone(s),21026,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Excision of facial bone(s),21026,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Excision of facial bone(s),21026,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Excision of facial bone(s),21026,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Excision of facial bone(s),21026,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Excision of facial bone(s),21026,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Excision of facial bone(s),21026,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Excision of facial bone(s),21026,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Contour of face bone lesion,21029,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,3282.2,14562,
Contour of face bone lesion,21029,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,3282.2,14562,
Contour of face bone lesion,21029,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,3282.2,14562,
Contour of face bone lesion,21029,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,3282.2,14562,
Contour of face bone lesion,21029,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Contour of face bone lesion,21029,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Contour of face bone lesion,21029,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Contour of face bone lesion,21029,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Contour of face bone lesion,21029,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Contour of face bone lesion,21029,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Contour of face bone lesion,21029,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Excise max/zygoma b9 tumor,21030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8594.03,,,,,,,fee schedule,5860.44,26000.79,
Excise max/zygoma b9 tumor,21030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6888.87,,,,,,,fee schedule,5860.44,26000.79,
Excise max/zygoma b9 tumor,21030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7525.46,,,,,,,fee schedule,5860.44,26000.79,
Excise max/zygoma b9 tumor,21030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7911.97,,,,,,,fee schedule,5860.44,26000.79,
Excise max/zygoma b9 tumor,21030,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Excise max/zygoma b9 tumor,21030,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Excise max/zygoma b9 tumor,21030,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Excise max/zygoma b9 tumor,21030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Excise max/zygoma b9 tumor,21030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Excise max/zygoma b9 tumor,21030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Excise max/zygoma b9 tumor,21030,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Remove exostosis mandible,21031,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5983.93,,,,,,,fee schedule,3282.2,14562,
Remove exostosis mandible,21031,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4796.64,,,,,,,fee schedule,3282.2,14562,
Remove exostosis mandible,21031,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5239.9,,,,,,,fee schedule,3282.2,14562,
Remove exostosis mandible,21031,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.01,,,,,,,fee schedule,3282.2,14562,
Remove exostosis mandible,21031,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Remove exostosis mandible,21031,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Remove exostosis mandible,21031,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Remove exostosis mandible,21031,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Remove exostosis mandible,21031,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Remove exostosis mandible,21031,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Remove exostosis mandible,21031,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Remove exostosis maxilla,21032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5983.93,,,,,,,fee schedule,3282.2,14562,
Remove exostosis maxilla,21032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4796.64,,,,,,,fee schedule,3282.2,14562,
Remove exostosis maxilla,21032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5239.9,,,,,,,fee schedule,3282.2,14562,
Remove exostosis maxilla,21032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.01,,,,,,,fee schedule,3282.2,14562,
Remove exostosis maxilla,21032,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Remove exostosis maxilla,21032,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Remove exostosis maxilla,21032,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Remove exostosis maxilla,21032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Remove exostosis maxilla,21032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Remove exostosis maxilla,21032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Remove exostosis maxilla,21032,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Excise max/zygoma mal tumor,21034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Excise max/zygoma mal tumor,21034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Excise max/zygoma mal tumor,21034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Excise max/zygoma mal tumor,21034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Excise max/zygoma mal tumor,21034,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Excise max/zygoma mal tumor,21034,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Excise max/zygoma mal tumor,21034,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Excise max/zygoma mal tumor,21034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Excise max/zygoma mal tumor,21034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Excise max/zygoma mal tumor,21034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Excise max/zygoma mal tumor,21034,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Excise mandible lesion,21040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5983.93,,,,,,,fee schedule,3282.2,14562,
Excise mandible lesion,21040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4796.64,,,,,,,fee schedule,3282.2,14562,
Excise mandible lesion,21040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5239.9,,,,,,,fee schedule,3282.2,14562,
Excise mandible lesion,21040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.01,,,,,,,fee schedule,3282.2,14562,
Excise mandible lesion,21040,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Excise mandible lesion,21040,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Excise mandible lesion,21040,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Excise mandible lesion,21040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Excise mandible lesion,21040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Excise mandible lesion,21040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Excise mandible lesion,21040,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Removal of jaw bone lesion,21044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Removal of jaw bone lesion,21044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Removal of jaw bone lesion,21044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Removal of jaw bone lesion,21044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Removal of jaw bone lesion,21044,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Removal of jaw bone lesion,21044,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of jaw bone lesion,21044,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of jaw bone lesion,21044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of jaw bone lesion,21044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Removal of jaw bone lesion,21044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of jaw bone lesion,21044,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Extensive jaw surgery,21045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19225.27,,,,,,,fee schedule,5860.44,26000.79,
Extensive jaw surgery,21045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15410.73,,,,,,,fee schedule,5860.44,26000.79,
Extensive jaw surgery,21045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16834.83,,,,,,,fee schedule,5860.44,26000.79,
Extensive jaw surgery,21045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17699.45,,,,,,,fee schedule,5860.44,26000.79,
Extensive jaw surgery,21045,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Extensive jaw surgery,21045,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Extensive jaw surgery,21045,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Extensive jaw surgery,21045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Extensive jaw surgery,21045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Extensive jaw surgery,21045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Extensive jaw surgery,21045,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Remove mandible cyst complex,21046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6721.57,,,,,,,fee schedule,5387.93,26000.79,
Remove mandible cyst complex,21046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5387.93,,,,,,,fee schedule,5387.93,26000.79,
Remove mandible cyst complex,21046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5885.82,,,,,,,fee schedule,5387.93,26000.79,
Remove mandible cyst complex,21046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6188.11,,,,,,,fee schedule,5387.93,26000.79,
Remove mandible cyst complex,21046,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5387.93,26000.79,APC 378
Remove mandible cyst complex,21046,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5387.93,26000.79,APC
Remove mandible cyst complex,21046,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5387.93,26000.79,APC
Remove mandible cyst complex,21046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5387.93,26000.79,APC
Remove mandible cyst complex,21046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5387.93,26000.79,Radiology
Remove mandible cyst complex,21046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5387.93,26000.79,APC
Remove mandible cyst complex,21046,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5387.93,26000.79,APC
Excise lwr jaw cyst w/repair,21047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Excise lwr jaw cyst w/repair,21047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Excise lwr jaw cyst w/repair,21047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Excise lwr jaw cyst w/repair,21047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Excise lwr jaw cyst w/repair,21047,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Excise lwr jaw cyst w/repair,21047,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Excise lwr jaw cyst w/repair,21047,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Excise lwr jaw cyst w/repair,21047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Excise lwr jaw cyst w/repair,21047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Excise lwr jaw cyst w/repair,21047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Excise lwr jaw cyst w/repair,21047,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Remove maxilla cyst complex,21048,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Remove maxilla cyst complex,21048,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Remove maxilla cyst complex,21048,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Remove maxilla cyst complex,21048,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Remove maxilla cyst complex,21048,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Remove maxilla cyst complex,21048,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Remove maxilla cyst complex,21048,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Remove maxilla cyst complex,21048,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Remove maxilla cyst complex,21048,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Remove maxilla cyst complex,21048,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Remove maxilla cyst complex,21048,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Excis uppr jaw cyst w/repair,21049,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Excis uppr jaw cyst w/repair,21049,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Excis uppr jaw cyst w/repair,21049,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Excis uppr jaw cyst w/repair,21049,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Excis uppr jaw cyst w/repair,21049,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Excis uppr jaw cyst w/repair,21049,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Excis uppr jaw cyst w/repair,21049,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Excis uppr jaw cyst w/repair,21049,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Excis uppr jaw cyst w/repair,21049,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Excis uppr jaw cyst w/repair,21049,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Excis uppr jaw cyst w/repair,21049,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of jaw joint,21050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Removal of jaw joint,21050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Removal of jaw joint,21050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Removal of jaw joint,21050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Removal of jaw joint,21050,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Removal of jaw joint,21050,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of jaw joint,21050,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of jaw joint,21050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of jaw joint,21050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Removal of jaw joint,21050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of jaw joint,21050,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Remove jaw joint cartilage,21060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Remove jaw joint cartilage,21060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Remove jaw joint cartilage,21060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Remove jaw joint cartilage,21060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Remove jaw joint cartilage,21060,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Remove jaw joint cartilage,21060,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Remove jaw joint cartilage,21060,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Remove jaw joint cartilage,21060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Remove jaw joint cartilage,21060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Remove jaw joint cartilage,21060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Remove jaw joint cartilage,21060,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Remove coronoid process,21070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2148.51,,,,,,,fee schedule,1722.22,26000.79,
Remove coronoid process,21070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1722.22,,,,,,,fee schedule,1722.22,26000.79,
Remove coronoid process,21070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1881.37,,,,,,,fee schedule,1722.22,26000.79,
Remove coronoid process,21070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1977.99,,,,,,,fee schedule,1722.22,26000.79,
Remove coronoid process,21070,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,1722.22,26000.79,APC 378
Remove coronoid process,21070,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,1722.22,26000.79,APC
Remove coronoid process,21070,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,1722.22,26000.79,APC
Remove coronoid process,21070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,1722.22,26000.79,APC
Remove coronoid process,21070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,1722.22,26000.79,Radiology
Remove coronoid process,21070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,1722.22,26000.79,APC
Remove coronoid process,21070,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,1722.22,26000.79,APC
Mnpj of tmj w/anesth,21073,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1858.66,,,,,,,fee schedule,1489.88,6814.79,
Mnpj of tmj w/anesth,21073,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1489.88,,,,,,,fee schedule,1489.88,6814.79,
Mnpj of tmj w/anesth,21073,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1627.56,,,,,,,fee schedule,1489.88,6814.79,
Mnpj of tmj w/anesth,21073,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1711.15,,,,,,,fee schedule,1489.88,6814.79,
Mnpj of tmj w/anesth,21073,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1489.88,6814.79,APC 378
Mnpj of tmj w/anesth,21073,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1489.88,6814.79,APC
Mnpj of tmj w/anesth,21073,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1489.88,6814.79,APC
Mnpj of tmj w/anesth,21073,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1489.88,6814.79,APC
Mnpj of tmj w/anesth,21073,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1489.88,6814.79,Radiology
Mnpj of tmj w/anesth,21073,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1489.88,6814.79,APC
Mnpj of tmj w/anesth,21073,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1489.88,6814.79,APC
Prepare face/oral prosthesis,21076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5983.93,,,,,,,fee schedule,1536.02,6814.79,
Prepare face/oral prosthesis,21076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4796.64,,,,,,,fee schedule,1536.02,6814.79,
Prepare face/oral prosthesis,21076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5239.9,,,,,,,fee schedule,1536.02,6814.79,
Prepare face/oral prosthesis,21076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.01,,,,,,,fee schedule,1536.02,6814.79,
Prepare face/oral prosthesis,21076,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1536.02,6814.79,APC 378
Prepare face/oral prosthesis,21076,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1536.02,6814.79,APC
Prepare face/oral prosthesis,21076,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1536.02,6814.79,APC
Prepare face/oral prosthesis,21076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1536.02,6814.79,APC
Prepare face/oral prosthesis,21076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1536.02,6814.79,Radiology
Prepare face/oral prosthesis,21076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1536.02,6814.79,APC
Prepare face/oral prosthesis,21076,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1536.02,6814.79,APC
Prepare face/oral prosthesis,21077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Prepare face/oral prosthesis,21077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Prepare face/oral prosthesis,21077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Prepare face/oral prosthesis,21077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Prepare face/oral prosthesis,21077,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Prepare face/oral prosthesis,21077,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Prepare face/oral prosthesis,21077,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Prepare face/oral prosthesis,21077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Prepare face/oral prosthesis,21077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Prepare face/oral prosthesis,21077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Prepare face/oral prosthesis,21077,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Prepare face/oral prosthesis,21079,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,3282.2,14562,
Prepare face/oral prosthesis,21079,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,3282.2,14562,
Prepare face/oral prosthesis,21079,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,3282.2,14562,
Prepare face/oral prosthesis,21079,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,3282.2,14562,
Prepare face/oral prosthesis,21079,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Prepare face/oral prosthesis,21079,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Prepare face/oral prosthesis,21079,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Prepare face/oral prosthesis,21079,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Prepare face/oral prosthesis,21079,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Prepare face/oral prosthesis,21079,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Prepare face/oral prosthesis,21079,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Prepare face/oral prosthesis,21080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,3282.2,14562,
Prepare face/oral prosthesis,21080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,3282.2,14562,
Prepare face/oral prosthesis,21080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,3282.2,14562,
Prepare face/oral prosthesis,21080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,3282.2,14562,
Prepare face/oral prosthesis,21080,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Prepare face/oral prosthesis,21080,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Prepare face/oral prosthesis,21080,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Prepare face/oral prosthesis,21080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Prepare face/oral prosthesis,21080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Prepare face/oral prosthesis,21080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Prepare face/oral prosthesis,21080,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Prepare face/oral prosthesis,21081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Prepare face/oral prosthesis,21081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Prepare face/oral prosthesis,21081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Prepare face/oral prosthesis,21081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Prepare face/oral prosthesis,21081,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Prepare face/oral prosthesis,21081,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Prepare face/oral prosthesis,21081,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Prepare face/oral prosthesis,21081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Prepare face/oral prosthesis,21081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Prepare face/oral prosthesis,21081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Prepare face/oral prosthesis,21081,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Prepare face/oral prosthesis,21082,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,3282.2,14562,
Prepare face/oral prosthesis,21082,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,3282.2,14562,
Prepare face/oral prosthesis,21082,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,3282.2,14562,
Prepare face/oral prosthesis,21082,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,3282.2,14562,
Prepare face/oral prosthesis,21082,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Prepare face/oral prosthesis,21082,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Prepare face/oral prosthesis,21082,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Prepare face/oral prosthesis,21082,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Prepare face/oral prosthesis,21082,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Prepare face/oral prosthesis,21082,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Prepare face/oral prosthesis,21082,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Prepare face/oral prosthesis,21083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,3282.2,14562,
Prepare face/oral prosthesis,21083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,3282.2,14562,
Prepare face/oral prosthesis,21083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,3282.2,14562,
Prepare face/oral prosthesis,21083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,3282.2,14562,
Prepare face/oral prosthesis,21083,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Prepare face/oral prosthesis,21083,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Prepare face/oral prosthesis,21083,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Prepare face/oral prosthesis,21083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Prepare face/oral prosthesis,21083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Prepare face/oral prosthesis,21083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Prepare face/oral prosthesis,21083,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Prepare face/oral prosthesis,21084,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,3282.2,14562,
Prepare face/oral prosthesis,21084,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,3282.2,14562,
Prepare face/oral prosthesis,21084,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,3282.2,14562,
Prepare face/oral prosthesis,21084,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,3282.2,14562,
Prepare face/oral prosthesis,21084,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Prepare face/oral prosthesis,21084,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Prepare face/oral prosthesis,21084,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Prepare face/oral prosthesis,21084,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Prepare face/oral prosthesis,21084,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Prepare face/oral prosthesis,21084,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Prepare face/oral prosthesis,21084,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Prepare face/oral prosthesis,21085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4075.29,,,,,,,fee schedule,234.47,4075.29,
Prepare face/oral prosthesis,21085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3266.7,,,,,,,fee schedule,234.47,4075.29,
Prepare face/oral prosthesis,21085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3568.58,,,,,,,fee schedule,234.47,4075.29,
Prepare face/oral prosthesis,21085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3751.86,,,,,,,fee schedule,234.47,4075.29,
Prepare face/oral prosthesis,21085,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1040.28,,,,,,,fee schedule,234.47,4075.29,APC 378
Prepare face/oral prosthesis,21085,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,246.2,,,,,,,fee schedule,234.47,4075.29,APC
Prepare face/oral prosthesis,21085,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,243.85,,,,,,,fee schedule,234.47,4075.29,APC
Prepare face/oral prosthesis,21085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,234.47,,,,,,,fee schedule,234.47,4075.29,APC
Prepare face/oral prosthesis,21085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,358.74,,,,,,,fee schedule,234.47,4075.29,Radiology
Prepare face/oral prosthesis,21085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,328.26,,,,,,,fee schedule,234.47,4075.29,APC
Prepare face/oral prosthesis,21085,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,410.33,,,,,,,fee schedule,234.47,4075.29,APC
Prepare face/oral prosthesis,21086,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,3282.2,14562,
Prepare face/oral prosthesis,21086,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,3282.2,14562,
Prepare face/oral prosthesis,21086,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,3282.2,14562,
Prepare face/oral prosthesis,21086,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,3282.2,14562,
Prepare face/oral prosthesis,21086,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Prepare face/oral prosthesis,21086,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Prepare face/oral prosthesis,21086,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Prepare face/oral prosthesis,21086,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Prepare face/oral prosthesis,21086,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Prepare face/oral prosthesis,21086,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Prepare face/oral prosthesis,21086,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Prepare face/oral prosthesis,21087,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Prepare face/oral prosthesis,21087,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Prepare face/oral prosthesis,21087,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Prepare face/oral prosthesis,21087,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Prepare face/oral prosthesis,21087,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Prepare face/oral prosthesis,21087,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Prepare face/oral prosthesis,21087,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Prepare face/oral prosthesis,21087,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Prepare face/oral prosthesis,21087,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Prepare face/oral prosthesis,21087,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Prepare face/oral prosthesis,21087,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Prepare face/oral prosthesis,21088,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,3282.2,14562,
Prepare face/oral prosthesis,21088,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,3282.2,14562,
Prepare face/oral prosthesis,21088,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,3282.2,14562,
Prepare face/oral prosthesis,21088,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,3282.2,14562,
Prepare face/oral prosthesis,21088,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Prepare face/oral prosthesis,21088,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Prepare face/oral prosthesis,21088,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Prepare face/oral prosthesis,21088,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Prepare face/oral prosthesis,21088,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Prepare face/oral prosthesis,21088,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Prepare face/oral prosthesis,21088,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Prepare face/oral prosthesis,21089,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,624,,,,,,,fee schedule,234.47,1040.28,
Prepare face/oral prosthesis,21089,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,500.19,,,,,,,fee schedule,234.47,1040.28,
Prepare face/oral prosthesis,21089,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,546.41,,,,,,,fee schedule,234.47,1040.28,
Prepare face/oral prosthesis,21089,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,574.48,,,,,,,fee schedule,234.47,1040.28,
Prepare face/oral prosthesis,21089,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1040.28,,,,,,,fee schedule,234.47,1040.28,APC 378
Prepare face/oral prosthesis,21089,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,246.2,,,,,,,fee schedule,234.47,1040.28,APC
Prepare face/oral prosthesis,21089,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,243.85,,,,,,,fee schedule,234.47,1040.28,APC
Prepare face/oral prosthesis,21089,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,234.47,,,,,,,fee schedule,234.47,1040.28,APC
Prepare face/oral prosthesis,21089,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,358.74,,,,,,,fee schedule,234.47,1040.28,Radiology
Prepare face/oral prosthesis,21089,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,328.26,,,,,,,fee schedule,234.47,1040.28,APC
Prepare face/oral prosthesis,21089,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,410.33,,,,,,,fee schedule,234.47,1040.28,APC
Maxillofacial fixation,21100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Maxillofacial fixation,21100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Maxillofacial fixation,21100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Maxillofacial fixation,21100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Maxillofacial fixation,21100,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Maxillofacial fixation,21100,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Maxillofacial fixation,21100,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Maxillofacial fixation,21100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Maxillofacial fixation,21100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Maxillofacial fixation,21100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Maxillofacial fixation,21100,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Interdental fixation,21110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1858.66,,,,,,,fee schedule,1489.88,6814.79,
Interdental fixation,21110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1489.88,,,,,,,fee schedule,1489.88,6814.79,
Interdental fixation,21110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1627.56,,,,,,,fee schedule,1489.88,6814.79,
Interdental fixation,21110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1711.15,,,,,,,fee schedule,1489.88,6814.79,
Interdental fixation,21110,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1489.88,6814.79,APC 378
Interdental fixation,21110,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1489.88,6814.79,APC
Interdental fixation,21110,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1489.88,6814.79,APC
Interdental fixation,21110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1489.88,6814.79,APC
Interdental fixation,21110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1489.88,6814.79,Radiology
Interdental fixation,21110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1489.88,6814.79,APC
Interdental fixation,21110,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1489.88,6814.79,APC
Reconstruction of chin,21120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5983.93,,,,,,,fee schedule,4796.64,26000.79,
Reconstruction of chin,21120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4796.64,,,,,,,fee schedule,4796.64,26000.79,
Reconstruction of chin,21120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5239.9,,,,,,,fee schedule,4796.64,26000.79,
Reconstruction of chin,21120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.01,,,,,,,fee schedule,4796.64,26000.79,
Reconstruction of chin,21120,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,4796.64,26000.79,APC 378
Reconstruction of chin,21120,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,4796.64,26000.79,APC
Reconstruction of chin,21120,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,4796.64,26000.79,APC
Reconstruction of chin,21120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,4796.64,26000.79,APC
Reconstruction of chin,21120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,4796.64,26000.79,Radiology
Reconstruction of chin,21120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,4796.64,26000.79,APC
Reconstruction of chin,21120,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,4796.64,26000.79,APC
Reconstruction of chin,21121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5983.93,,,,,,,fee schedule,3282.2,14562,
Reconstruction of chin,21121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4796.64,,,,,,,fee schedule,3282.2,14562,
Reconstruction of chin,21121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5239.9,,,,,,,fee schedule,3282.2,14562,
Reconstruction of chin,21121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.01,,,,,,,fee schedule,3282.2,14562,
Reconstruction of chin,21121,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Reconstruction of chin,21121,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Reconstruction of chin,21121,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Reconstruction of chin,21121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Reconstruction of chin,21121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Reconstruction of chin,21121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Reconstruction of chin,21121,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Reconstruction of chin,21122,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5983.93,,,,,,,fee schedule,4796.64,26000.79,
Reconstruction of chin,21122,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4796.64,,,,,,,fee schedule,4796.64,26000.79,
Reconstruction of chin,21122,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5239.9,,,,,,,fee schedule,4796.64,26000.79,
Reconstruction of chin,21122,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.01,,,,,,,fee schedule,4796.64,26000.79,
Reconstruction of chin,21122,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,4796.64,26000.79,APC 378
Reconstruction of chin,21122,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,4796.64,26000.79,APC
Reconstruction of chin,21122,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,4796.64,26000.79,APC
Reconstruction of chin,21122,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,4796.64,26000.79,APC
Reconstruction of chin,21122,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,4796.64,26000.79,Radiology
Reconstruction of chin,21122,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,4796.64,26000.79,APC
Reconstruction of chin,21122,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,4796.64,26000.79,APC
Reconstruction of chin,21123,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5983.93,,,,,,,fee schedule,3282.2,14562,
Reconstruction of chin,21123,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4796.64,,,,,,,fee schedule,3282.2,14562,
Reconstruction of chin,21123,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5239.9,,,,,,,fee schedule,3282.2,14562,
Reconstruction of chin,21123,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.01,,,,,,,fee schedule,3282.2,14562,
Reconstruction of chin,21123,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Reconstruction of chin,21123,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Reconstruction of chin,21123,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Reconstruction of chin,21123,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Reconstruction of chin,21123,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Reconstruction of chin,21123,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Reconstruction of chin,21123,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Augmentation lower jaw bone,21125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5983.93,,,,,,,fee schedule,4796.64,26000.79,
Augmentation lower jaw bone,21125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4796.64,,,,,,,fee schedule,4796.64,26000.79,
Augmentation lower jaw bone,21125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5239.9,,,,,,,fee schedule,4796.64,26000.79,
Augmentation lower jaw bone,21125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.01,,,,,,,fee schedule,4796.64,26000.79,
Augmentation lower jaw bone,21125,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,4796.64,26000.79,APC 378
Augmentation lower jaw bone,21125,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,4796.64,26000.79,APC
Augmentation lower jaw bone,21125,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,4796.64,26000.79,APC
Augmentation lower jaw bone,21125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,4796.64,26000.79,APC
Augmentation lower jaw bone,21125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,4796.64,26000.79,Radiology
Augmentation lower jaw bone,21125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,4796.64,26000.79,APC
Augmentation lower jaw bone,21125,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,4796.64,26000.79,APC
Augmentation lower jaw bone,21127,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Augmentation lower jaw bone,21127,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Augmentation lower jaw bone,21127,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Augmentation lower jaw bone,21127,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Augmentation lower jaw bone,21127,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Augmentation lower jaw bone,21127,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Augmentation lower jaw bone,21127,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Augmentation lower jaw bone,21127,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Augmentation lower jaw bone,21127,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Augmentation lower jaw bone,21127,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Augmentation lower jaw bone,21127,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Reduction of forehead,21137,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5983.93,,,,,,,fee schedule,3282.2,14562,
Reduction of forehead,21137,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4796.64,,,,,,,fee schedule,3282.2,14562,
Reduction of forehead,21137,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5239.9,,,,,,,fee schedule,3282.2,14562,
Reduction of forehead,21137,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.01,,,,,,,fee schedule,3282.2,14562,
Reduction of forehead,21137,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Reduction of forehead,21137,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Reduction of forehead,21137,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Reduction of forehead,21137,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Reduction of forehead,21137,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Reduction of forehead,21137,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Reduction of forehead,21137,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Reduction of forehead,21138,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Reduction of forehead,21138,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Reduction of forehead,21138,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Reduction of forehead,21138,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Reduction of forehead,21138,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Reduction of forehead,21138,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Reduction of forehead,21138,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Reduction of forehead,21138,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Reduction of forehead,21138,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Reduction of forehead,21138,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Reduction of forehead,21138,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Reduction of forehead,21139,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Reduction of forehead,21139,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Reduction of forehead,21139,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Reduction of forehead,21139,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Reduction of forehead,21139,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Reduction of forehead,21139,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Reduction of forehead,21139,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Reduction of forehead,21139,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Reduction of forehead,21139,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Reduction of forehead,21139,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Reduction of forehead,21139,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Lefort i-1 piece w/o graft,21141,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4463.89,,,,,,,fee schedule,3578.2,26000.79,
Lefort i-1 piece w/o graft,21141,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3578.2,,,,,,,fee schedule,3578.2,26000.79,
Lefort i-1 piece w/o graft,21141,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3908.86,,,,,,,fee schedule,3578.2,26000.79,
Lefort i-1 piece w/o graft,21141,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4109.61,,,,,,,fee schedule,3578.2,26000.79,
Lefort i-1 piece w/o graft,21141,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,3578.2,26000.79,APC 378
Lefort i-1 piece w/o graft,21141,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,3578.2,26000.79,APC
Lefort i-1 piece w/o graft,21141,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,3578.2,26000.79,APC
Lefort i-1 piece w/o graft,21141,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,3578.2,26000.79,APC
Lefort i-1 piece w/o graft,21141,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,3578.2,26000.79,Radiology
Lefort i-1 piece w/o graft,21141,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,3578.2,26000.79,APC
Lefort i-1 piece w/o graft,21141,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,3578.2,26000.79,APC
Lefort i-2 piece w/o graft,21142,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4935.26,,,,,,,fee schedule,3956.04,26000.79,
Lefort i-2 piece w/o graft,21142,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3956.04,,,,,,,fee schedule,3956.04,26000.79,
Lefort i-2 piece w/o graft,21142,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4321.61,,,,,,,fee schedule,3956.04,26000.79,
Lefort i-2 piece w/o graft,21142,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4543.57,,,,,,,fee schedule,3956.04,26000.79,
Lefort i-2 piece w/o graft,21142,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,3956.04,26000.79,APC 378
Lefort i-2 piece w/o graft,21142,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,3956.04,26000.79,APC
Lefort i-2 piece w/o graft,21142,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,3956.04,26000.79,APC
Lefort i-2 piece w/o graft,21142,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,3956.04,26000.79,APC
Lefort i-2 piece w/o graft,21142,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,3956.04,26000.79,Radiology
Lefort i-2 piece w/o graft,21142,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,3956.04,26000.79,APC
Lefort i-2 piece w/o graft,21142,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,3956.04,26000.79,APC
Lefort i-3/> piece w/o graft,21143,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5563.74,,,,,,,fee schedule,4459.83,26000.79,
Lefort i-3/> piece w/o graft,21143,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4459.83,,,,,,,fee schedule,4459.83,26000.79,
Lefort i-3/> piece w/o graft,21143,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4871.96,,,,,,,fee schedule,4459.83,26000.79,
Lefort i-3/> piece w/o graft,21143,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5122.18,,,,,,,fee schedule,4459.83,26000.79,
Lefort i-3/> piece w/o graft,21143,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,4459.83,26000.79,APC 378
Lefort i-3/> piece w/o graft,21143,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,4459.83,26000.79,APC
Lefort i-3/> piece w/o graft,21143,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,4459.83,26000.79,APC
Lefort i-3/> piece w/o graft,21143,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,4459.83,26000.79,APC
Lefort i-3/> piece w/o graft,21143,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,4459.83,26000.79,Radiology
Lefort i-3/> piece w/o graft,21143,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,4459.83,26000.79,APC
Lefort i-3/> piece w/o graft,21143,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,4459.83,26000.79,APC
Lefort i-1 piece w/ graft,21145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19225.27,,,,,,,fee schedule,5860.44,26000.79,
Lefort i-1 piece w/ graft,21145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15410.73,,,,,,,fee schedule,5860.44,26000.79,
Lefort i-1 piece w/ graft,21145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16834.83,,,,,,,fee schedule,5860.44,26000.79,
Lefort i-1 piece w/ graft,21145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17699.45,,,,,,,fee schedule,5860.44,26000.79,
Lefort i-1 piece w/ graft,21145,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Lefort i-1 piece w/ graft,21145,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Lefort i-1 piece w/ graft,21145,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Lefort i-1 piece w/ graft,21145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Lefort i-1 piece w/ graft,21145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Lefort i-1 piece w/ graft,21145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Lefort i-1 piece w/ graft,21145,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Lefort i-2 piece w/ graft,21146,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19225.27,,,,,,,fee schedule,5860.44,26000.79,
Lefort i-2 piece w/ graft,21146,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15410.73,,,,,,,fee schedule,5860.44,26000.79,
Lefort i-2 piece w/ graft,21146,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16834.83,,,,,,,fee schedule,5860.44,26000.79,
Lefort i-2 piece w/ graft,21146,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17699.45,,,,,,,fee schedule,5860.44,26000.79,
Lefort i-2 piece w/ graft,21146,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Lefort i-2 piece w/ graft,21146,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Lefort i-2 piece w/ graft,21146,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Lefort i-2 piece w/ graft,21146,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Lefort i-2 piece w/ graft,21146,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Lefort i-2 piece w/ graft,21146,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Lefort i-2 piece w/ graft,21146,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Lefort i-3/> piece w/ graft,21147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11870.84,,,,,,,fee schedule,5860.44,26000.79,
Lefort i-3/> piece w/ graft,21147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9515.51,,,,,,,fee schedule,5860.44,26000.79,
Lefort i-3/> piece w/ graft,21147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10394.83,,,,,,,fee schedule,5860.44,26000.79,
Lefort i-3/> piece w/ graft,21147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10928.71,,,,,,,fee schedule,5860.44,26000.79,
Lefort i-3/> piece w/ graft,21147,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Lefort i-3/> piece w/ graft,21147,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Lefort i-3/> piece w/ graft,21147,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Lefort i-3/> piece w/ graft,21147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Lefort i-3/> piece w/ graft,21147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Lefort i-3/> piece w/ graft,21147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Lefort i-3/> piece w/ graft,21147,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Lefort ii anterior intrusion,21150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Lefort ii anterior intrusion,21150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Lefort ii anterior intrusion,21150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Lefort ii anterior intrusion,21150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Lefort ii anterior intrusion,21150,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Lefort ii anterior intrusion,21150,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Lefort ii anterior intrusion,21150,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Lefort ii anterior intrusion,21150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Lefort ii anterior intrusion,21150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Lefort ii anterior intrusion,21150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Lefort ii anterior intrusion,21150,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Lefort ii w/bone grafts,21151,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19225.27,,,,,,,fee schedule,5860.44,26000.79,
Lefort ii w/bone grafts,21151,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15410.73,,,,,,,fee schedule,5860.44,26000.79,
Lefort ii w/bone grafts,21151,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16834.83,,,,,,,fee schedule,5860.44,26000.79,
Lefort ii w/bone grafts,21151,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17699.45,,,,,,,fee schedule,5860.44,26000.79,
Lefort ii w/bone grafts,21151,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Lefort ii w/bone grafts,21151,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Lefort ii w/bone grafts,21151,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Lefort ii w/bone grafts,21151,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Lefort ii w/bone grafts,21151,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Lefort ii w/bone grafts,21151,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Lefort ii w/bone grafts,21151,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Lefort iii w/o lefort i,21154,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19225.27,,,,,,,fee schedule,5860.44,26000.79,
Lefort iii w/o lefort i,21154,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15410.73,,,,,,,fee schedule,5860.44,26000.79,
Lefort iii w/o lefort i,21154,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16834.83,,,,,,,fee schedule,5860.44,26000.79,
Lefort iii w/o lefort i,21154,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17699.45,,,,,,,fee schedule,5860.44,26000.79,
Lefort iii w/o lefort i,21154,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Lefort iii w/o lefort i,21154,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Lefort iii w/o lefort i,21154,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Lefort iii w/o lefort i,21154,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Lefort iii w/o lefort i,21154,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Lefort iii w/o lefort i,21154,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Lefort iii w/o lefort i,21154,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Lefort iii w/ lefort i,21155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19225.27,,,,,,,fee schedule,5860.44,26000.79,
Lefort iii w/ lefort i,21155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15410.73,,,,,,,fee schedule,5860.44,26000.79,
Lefort iii w/ lefort i,21155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16834.83,,,,,,,fee schedule,5860.44,26000.79,
Lefort iii w/ lefort i,21155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17699.45,,,,,,,fee schedule,5860.44,26000.79,
Lefort iii w/ lefort i,21155,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Lefort iii w/ lefort i,21155,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Lefort iii w/ lefort i,21155,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Lefort iii w/ lefort i,21155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Lefort iii w/ lefort i,21155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Lefort iii w/ lefort i,21155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Lefort iii w/ lefort i,21155,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Lefort iii w/fhdw/o lefort i,21159,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19225.27,,,,,,,fee schedule,5860.44,26000.79,
Lefort iii w/fhdw/o lefort i,21159,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15410.73,,,,,,,fee schedule,5860.44,26000.79,
Lefort iii w/fhdw/o lefort i,21159,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16834.83,,,,,,,fee schedule,5860.44,26000.79,
Lefort iii w/fhdw/o lefort i,21159,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17699.45,,,,,,,fee schedule,5860.44,26000.79,
Lefort iii w/fhdw/o lefort i,21159,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Lefort iii w/fhdw/o lefort i,21159,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Lefort iii w/fhdw/o lefort i,21159,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Lefort iii w/fhdw/o lefort i,21159,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Lefort iii w/fhdw/o lefort i,21159,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Lefort iii w/fhdw/o lefort i,21159,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Lefort iii w/fhdw/o lefort i,21159,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Lefort iii w/fhd w/ lefort i,21160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19225.27,,,,,,,fee schedule,5860.44,26000.79,
Lefort iii w/fhd w/ lefort i,21160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15410.73,,,,,,,fee schedule,5860.44,26000.79,
Lefort iii w/fhd w/ lefort i,21160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16834.83,,,,,,,fee schedule,5860.44,26000.79,
Lefort iii w/fhd w/ lefort i,21160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17699.45,,,,,,,fee schedule,5860.44,26000.79,
Lefort iii w/fhd w/ lefort i,21160,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Lefort iii w/fhd w/ lefort i,21160,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Lefort iii w/fhd w/ lefort i,21160,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Lefort iii w/fhd w/ lefort i,21160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Lefort iii w/fhd w/ lefort i,21160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Lefort iii w/fhd w/ lefort i,21160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Lefort iii w/fhd w/ lefort i,21160,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruct orbit/forehead,21172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15614.95,,,,,,,fee schedule,5860.44,26000.79,
Reconstruct orbit/forehead,21172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12516.75,,,,,,,fee schedule,5860.44,26000.79,
Reconstruct orbit/forehead,21172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13673.41,,,,,,,fee schedule,5860.44,26000.79,
Reconstruct orbit/forehead,21172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14375.67,,,,,,,fee schedule,5860.44,26000.79,
Reconstruct orbit/forehead,21172,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Reconstruct orbit/forehead,21172,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruct orbit/forehead,21172,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruct orbit/forehead,21172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruct orbit/forehead,21172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Reconstruct orbit/forehead,21172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruct orbit/forehead,21172,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruct orbit/forehead,21175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Reconstruct orbit/forehead,21175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Reconstruct orbit/forehead,21175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Reconstruct orbit/forehead,21175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Reconstruct orbit/forehead,21175,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Reconstruct orbit/forehead,21175,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruct orbit/forehead,21175,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruct orbit/forehead,21175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruct orbit/forehead,21175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Reconstruct orbit/forehead,21175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruct orbit/forehead,21175,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruct entire forehead,21179,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19225.27,,,,,,,fee schedule,5860.44,26000.79,
Reconstruct entire forehead,21179,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15410.73,,,,,,,fee schedule,5860.44,26000.79,
Reconstruct entire forehead,21179,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16834.83,,,,,,,fee schedule,5860.44,26000.79,
Reconstruct entire forehead,21179,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17699.45,,,,,,,fee schedule,5860.44,26000.79,
Reconstruct entire forehead,21179,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Reconstruct entire forehead,21179,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruct entire forehead,21179,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruct entire forehead,21179,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruct entire forehead,21179,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Reconstruct entire forehead,21179,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruct entire forehead,21179,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruct entire forehead,21180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19225.27,,,,,,,fee schedule,5860.44,26000.79,
Reconstruct entire forehead,21180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15410.73,,,,,,,fee schedule,5860.44,26000.79,
Reconstruct entire forehead,21180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16834.83,,,,,,,fee schedule,5860.44,26000.79,
Reconstruct entire forehead,21180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17699.45,,,,,,,fee schedule,5860.44,26000.79,
Reconstruct entire forehead,21180,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Reconstruct entire forehead,21180,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruct entire forehead,21180,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruct entire forehead,21180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruct entire forehead,21180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Reconstruct entire forehead,21180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruct entire forehead,21180,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Contour cranial bone lesion,21181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5983.93,,,,,,,fee schedule,4796.64,26000.79,
Contour cranial bone lesion,21181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4796.64,,,,,,,fee schedule,4796.64,26000.79,
Contour cranial bone lesion,21181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5239.9,,,,,,,fee schedule,4796.64,26000.79,
Contour cranial bone lesion,21181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.01,,,,,,,fee schedule,4796.64,26000.79,
Contour cranial bone lesion,21181,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,4796.64,26000.79,APC 378
Contour cranial bone lesion,21181,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,4796.64,26000.79,APC
Contour cranial bone lesion,21181,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,4796.64,26000.79,APC
Contour cranial bone lesion,21181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,4796.64,26000.79,APC
Contour cranial bone lesion,21181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,4796.64,26000.79,Radiology
Contour cranial bone lesion,21181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,4796.64,26000.79,APC
Contour cranial bone lesion,21181,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,4796.64,26000.79,APC
Reconstruct cranial bone,21182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19225.27,,,,,,,fee schedule,5860.44,26000.79,
Reconstruct cranial bone,21182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15410.73,,,,,,,fee schedule,5860.44,26000.79,
Reconstruct cranial bone,21182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16834.83,,,,,,,fee schedule,5860.44,26000.79,
Reconstruct cranial bone,21182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17699.45,,,,,,,fee schedule,5860.44,26000.79,
Reconstruct cranial bone,21182,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Reconstruct cranial bone,21182,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruct cranial bone,21182,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruct cranial bone,21182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruct cranial bone,21182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Reconstruct cranial bone,21182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruct cranial bone,21182,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruct cranial bone,21183,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19225.27,,,,,,,fee schedule,5860.44,26000.79,
Reconstruct cranial bone,21183,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15410.73,,,,,,,fee schedule,5860.44,26000.79,
Reconstruct cranial bone,21183,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16834.83,,,,,,,fee schedule,5860.44,26000.79,
Reconstruct cranial bone,21183,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17699.45,,,,,,,fee schedule,5860.44,26000.79,
Reconstruct cranial bone,21183,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Reconstruct cranial bone,21183,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruct cranial bone,21183,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruct cranial bone,21183,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruct cranial bone,21183,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Reconstruct cranial bone,21183,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruct cranial bone,21183,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruct cranial bone,21184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19225.27,,,,,,,fee schedule,5860.44,26000.79,
Reconstruct cranial bone,21184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15410.73,,,,,,,fee schedule,5860.44,26000.79,
Reconstruct cranial bone,21184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16834.83,,,,,,,fee schedule,5860.44,26000.79,
Reconstruct cranial bone,21184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17699.45,,,,,,,fee schedule,5860.44,26000.79,
Reconstruct cranial bone,21184,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Reconstruct cranial bone,21184,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruct cranial bone,21184,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruct cranial bone,21184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruct cranial bone,21184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Reconstruct cranial bone,21184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruct cranial bone,21184,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruction of midface,21188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19225.27,,,,,,,fee schedule,5860.44,26000.79,
Reconstruction of midface,21188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15410.73,,,,,,,fee schedule,5860.44,26000.79,
Reconstruction of midface,21188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16834.83,,,,,,,fee schedule,5860.44,26000.79,
Reconstruction of midface,21188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17699.45,,,,,,,fee schedule,5860.44,26000.79,
Reconstruction of midface,21188,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Reconstruction of midface,21188,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruction of midface,21188,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruction of midface,21188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruction of midface,21188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Reconstruction of midface,21188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruction of midface,21188,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Reconst lwr jaw w/o graft,21193,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15614.95,,,,,,,fee schedule,5860.44,26000.79,
Reconst lwr jaw w/o graft,21193,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12516.75,,,,,,,fee schedule,5860.44,26000.79,
Reconst lwr jaw w/o graft,21193,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13673.41,,,,,,,fee schedule,5860.44,26000.79,
Reconst lwr jaw w/o graft,21193,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14375.67,,,,,,,fee schedule,5860.44,26000.79,
Reconst lwr jaw w/o graft,21193,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Reconst lwr jaw w/o graft,21193,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Reconst lwr jaw w/o graft,21193,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Reconst lwr jaw w/o graft,21193,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Reconst lwr jaw w/o graft,21193,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Reconst lwr jaw w/o graft,21193,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Reconst lwr jaw w/o graft,21193,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Reconst lwr jaw w/graft,21194,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19225.27,,,,,,,fee schedule,5860.44,26000.79,
Reconst lwr jaw w/graft,21194,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15410.73,,,,,,,fee schedule,5860.44,26000.79,
Reconst lwr jaw w/graft,21194,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16834.83,,,,,,,fee schedule,5860.44,26000.79,
Reconst lwr jaw w/graft,21194,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17699.45,,,,,,,fee schedule,5860.44,26000.79,
Reconst lwr jaw w/graft,21194,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Reconst lwr jaw w/graft,21194,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Reconst lwr jaw w/graft,21194,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Reconst lwr jaw w/graft,21194,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Reconst lwr jaw w/graft,21194,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Reconst lwr jaw w/graft,21194,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Reconst lwr jaw w/graft,21194,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Reconst lwr jaw w/o fixation,21195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Reconst lwr jaw w/o fixation,21195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Reconst lwr jaw w/o fixation,21195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Reconst lwr jaw w/o fixation,21195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Reconst lwr jaw w/o fixation,21195,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Reconst lwr jaw w/o fixation,21195,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Reconst lwr jaw w/o fixation,21195,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Reconst lwr jaw w/o fixation,21195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Reconst lwr jaw w/o fixation,21195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Reconst lwr jaw w/o fixation,21195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Reconst lwr jaw w/o fixation,21195,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Reconst lwr jaw w/fixation,21196,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6924.9,,,,,,,fee schedule,5550.91,26000.79,
Reconst lwr jaw w/fixation,21196,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5550.91,,,,,,,fee schedule,5550.91,26000.79,
Reconst lwr jaw w/fixation,21196,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6063.87,,,,,,,fee schedule,5550.91,26000.79,
Reconst lwr jaw w/fixation,21196,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6375.31,,,,,,,fee schedule,5550.91,26000.79,
Reconst lwr jaw w/fixation,21196,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5550.91,26000.79,APC 378
Reconst lwr jaw w/fixation,21196,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5550.91,26000.79,APC
Reconst lwr jaw w/fixation,21196,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5550.91,26000.79,APC
Reconst lwr jaw w/fixation,21196,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5550.91,26000.79,APC
Reconst lwr jaw w/fixation,21196,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5550.91,26000.79,Radiology
Reconst lwr jaw w/fixation,21196,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5550.91,26000.79,APC
Reconst lwr jaw w/fixation,21196,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5550.91,26000.79,APC
Reconstr lwr jaw segment,21198,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9530.26,,,,,,,fee schedule,5860.44,26000.79,
Reconstr lwr jaw segment,21198,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7639.34,,,,,,,fee schedule,5860.44,26000.79,
Reconstr lwr jaw segment,21198,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8345.28,,,,,,,fee schedule,5860.44,26000.79,
Reconstr lwr jaw segment,21198,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8773.89,,,,,,,fee schedule,5860.44,26000.79,
Reconstr lwr jaw segment,21198,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Reconstr lwr jaw segment,21198,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstr lwr jaw segment,21198,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstr lwr jaw segment,21198,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstr lwr jaw segment,21198,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Reconstr lwr jaw segment,21198,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstr lwr jaw segment,21198,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstr Lwr Jaw W/Advance,21199,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Reconstr Lwr Jaw W/Advance,21199,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Reconstr Lwr Jaw W/Advance,21199,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Reconstr Lwr Jaw W/Advance,21199,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Reconstr Lwr Jaw W/Advance,21199,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Reconstr Lwr Jaw W/Advance,21199,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstr Lwr Jaw W/Advance,21199,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstr Lwr Jaw W/Advance,21199,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstr Lwr Jaw W/Advance,21199,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Reconstr Lwr Jaw W/Advance,21199,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstr Lwr Jaw W/Advance,21199,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruct upper jaw bone,21206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Reconstruct upper jaw bone,21206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Reconstruct upper jaw bone,21206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Reconstruct upper jaw bone,21206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Reconstruct upper jaw bone,21206,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Reconstruct upper jaw bone,21206,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruct upper jaw bone,21206,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruct upper jaw bone,21206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruct upper jaw bone,21206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Reconstruct upper jaw bone,21206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruct upper jaw bone,21206,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Augmentation of facial bones,21208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Augmentation of facial bones,21208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Augmentation of facial bones,21208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Augmentation of facial bones,21208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Augmentation of facial bones,21208,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Augmentation of facial bones,21208,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Augmentation of facial bones,21208,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Augmentation of facial bones,21208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Augmentation of facial bones,21208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Augmentation of facial bones,21208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Augmentation of facial bones,21208,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Reduction of facial bones,21209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Reduction of facial bones,21209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Reduction of facial bones,21209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Reduction of facial bones,21209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Reduction of facial bones,21209,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Reduction of facial bones,21209,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Reduction of facial bones,21209,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Reduction of facial bones,21209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Reduction of facial bones,21209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Reduction of facial bones,21209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Reduction of facial bones,21209,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Face bone graft,21210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4765.13,,,,,,,fee schedule,3819.67,26000.79,
Face bone graft,21210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3819.67,,,,,,,fee schedule,3819.67,26000.79,
Face bone graft,21210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4172.64,,,,,,,fee schedule,3819.67,26000.79,
Face bone graft,21210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4386.95,,,,,,,fee schedule,3819.67,26000.79,
Face bone graft,21210,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,3819.67,26000.79,APC 378
Face bone graft,21210,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,3819.67,26000.79,APC
Face bone graft,21210,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,3819.67,26000.79,APC
Face bone graft,21210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,3819.67,26000.79,APC
Face bone graft,21210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,3819.67,26000.79,Radiology
Face bone graft,21210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,3819.67,26000.79,APC
Face bone graft,21210,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,3819.67,26000.79,APC
Lower jaw bone graft,21215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Lower jaw bone graft,21215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Lower jaw bone graft,21215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Lower jaw bone graft,21215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Lower jaw bone graft,21215,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Lower jaw bone graft,21215,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Lower jaw bone graft,21215,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Lower jaw bone graft,21215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Lower jaw bone graft,21215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Lower jaw bone graft,21215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Lower jaw bone graft,21215,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Rib cartilage graft,21230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Rib cartilage graft,21230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Rib cartilage graft,21230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Rib cartilage graft,21230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Rib cartilage graft,21230,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Rib cartilage graft,21230,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Rib cartilage graft,21230,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Rib cartilage graft,21230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Rib cartilage graft,21230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Rib cartilage graft,21230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Rib cartilage graft,21230,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Ear cartilage graft,21235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4609.09,,,,,,,fee schedule,3694.59,26000.79,
Ear cartilage graft,21235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3694.59,,,,,,,fee schedule,3694.59,26000.79,
Ear cartilage graft,21235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4036,,,,,,,fee schedule,3694.59,26000.79,
Ear cartilage graft,21235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4243.29,,,,,,,fee schedule,3694.59,26000.79,
Ear cartilage graft,21235,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,3694.59,26000.79,APC 378
Ear cartilage graft,21235,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,3694.59,26000.79,APC
Ear cartilage graft,21235,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,3694.59,26000.79,APC
Ear cartilage graft,21235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,3694.59,26000.79,APC
Ear cartilage graft,21235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,3694.59,26000.79,Radiology
Ear cartilage graft,21235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,3694.59,26000.79,APC
Ear cartilage graft,21235,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,3694.59,26000.79,APC
Reconstruction of jaw joint,21240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Reconstruction of jaw joint,21240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Reconstruction of jaw joint,21240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Reconstruction of jaw joint,21240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Reconstruction of jaw joint,21240,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Reconstruction of jaw joint,21240,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruction of jaw joint,21240,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruction of jaw joint,21240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruction of jaw joint,21240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Reconstruction of jaw joint,21240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruction of jaw joint,21240,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruction of jaw joint,21242,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Reconstruction of jaw joint,21242,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Reconstruction of jaw joint,21242,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Reconstruction of jaw joint,21242,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Reconstruction of jaw joint,21242,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Reconstruction of jaw joint,21242,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruction of jaw joint,21242,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruction of jaw joint,21242,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruction of jaw joint,21242,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Reconstruction of jaw joint,21242,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruction of jaw joint,21242,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruction of jaw joint,21243,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,7977.75,119176.72,
Reconstruction of jaw joint,21243,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,7977.75,119176.72,
Reconstruction of jaw joint,21243,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,7977.75,119176.72,
Reconstruction of jaw joint,21243,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,7977.75,119176.72,
Reconstruction of jaw joint,21243,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,119176.72,,,,,,,fee schedule,7977.75,119176.72,APC 378
Reconstruction of jaw joint,21243,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,28204.89,,,,,,,fee schedule,7977.75,119176.72,APC
Reconstruction of jaw joint,21243,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,27936.27,,,,,,,fee schedule,7977.75,119176.72,APC
Reconstruction of jaw joint,21243,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,26861.8,,,,,,,fee schedule,7977.75,119176.72,APC
Reconstruction of jaw joint,21243,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,41098.56,,,,,,,fee schedule,7977.75,119176.72,Radiology
Reconstruction of jaw joint,21243,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,37606.52,,,,,,,fee schedule,7977.75,119176.72,APC
Reconstruction of jaw joint,21243,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,47008.15,,,,,,,fee schedule,7977.75,119176.72,APC
Reconstruction of lower jaw,21244,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Reconstruction of lower jaw,21244,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Reconstruction of lower jaw,21244,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Reconstruction of lower jaw,21244,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Reconstruction of lower jaw,21244,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Reconstruction of lower jaw,21244,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruction of lower jaw,21244,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruction of lower jaw,21244,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruction of lower jaw,21244,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Reconstruction of lower jaw,21244,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruction of lower jaw,21244,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruction of jaw,21245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Reconstruction of jaw,21245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Reconstruction of jaw,21245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Reconstruction of jaw,21245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Reconstruction of jaw,21245,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Reconstruction of jaw,21245,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruction of jaw,21245,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruction of jaw,21245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruction of jaw,21245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Reconstruction of jaw,21245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruction of jaw,21245,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruction of jaw,21246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Reconstruction of jaw,21246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Reconstruction of jaw,21246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Reconstruction of jaw,21246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Reconstruction of jaw,21246,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Reconstruction of jaw,21246,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruction of jaw,21246,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruction of jaw,21246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruction of jaw,21246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Reconstruction of jaw,21246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruction of jaw,21246,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruct lower jaw bone,21247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19225.27,,,,,,,fee schedule,5860.44,26000.79,
Reconstruct lower jaw bone,21247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15410.73,,,,,,,fee schedule,5860.44,26000.79,
Reconstruct lower jaw bone,21247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16834.83,,,,,,,fee schedule,5860.44,26000.79,
Reconstruct lower jaw bone,21247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17699.45,,,,,,,fee schedule,5860.44,26000.79,
Reconstruct lower jaw bone,21247,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Reconstruct lower jaw bone,21247,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruct lower jaw bone,21247,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruct lower jaw bone,21247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruct lower jaw bone,21247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Reconstruct lower jaw bone,21247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruct lower jaw bone,21247,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruction of jaw,21248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Reconstruction of jaw,21248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Reconstruction of jaw,21248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Reconstruction of jaw,21248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Reconstruction of jaw,21248,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Reconstruction of jaw,21248,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruction of jaw,21248,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruction of jaw,21248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruction of jaw,21248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Reconstruction of jaw,21248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruction of jaw,21248,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruction of jaw,21249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Reconstruction of jaw,21249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Reconstruction of jaw,21249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Reconstruction of jaw,21249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Reconstruction of jaw,21249,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Reconstruction of jaw,21249,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruction of jaw,21249,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruction of jaw,21249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruction of jaw,21249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Reconstruction of jaw,21249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruction of jaw,21249,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruct lower jaw bone,21255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19225.27,,,,,,,fee schedule,5860.44,26000.79,
Reconstruct lower jaw bone,21255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15410.73,,,,,,,fee schedule,5860.44,26000.79,
Reconstruct lower jaw bone,21255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16834.83,,,,,,,fee schedule,5860.44,26000.79,
Reconstruct lower jaw bone,21255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17699.45,,,,,,,fee schedule,5860.44,26000.79,
Reconstruct lower jaw bone,21255,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Reconstruct lower jaw bone,21255,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruct lower jaw bone,21255,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruct lower jaw bone,21255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruct lower jaw bone,21255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Reconstruct lower jaw bone,21255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruct lower jaw bone,21255,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruction of orbit,21256,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15614.95,,,,,,,fee schedule,5860.44,26000.79,
Reconstruction of orbit,21256,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12516.75,,,,,,,fee schedule,5860.44,26000.79,
Reconstruction of orbit,21256,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13673.41,,,,,,,fee schedule,5860.44,26000.79,
Reconstruction of orbit,21256,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14375.67,,,,,,,fee schedule,5860.44,26000.79,
Reconstruction of orbit,21256,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Reconstruction of orbit,21256,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruction of orbit,21256,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruction of orbit,21256,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruction of orbit,21256,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Reconstruction of orbit,21256,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruction of orbit,21256,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Revise eye sockets,21260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Revise eye sockets,21260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Revise eye sockets,21260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Revise eye sockets,21260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Revise eye sockets,21260,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Revise eye sockets,21260,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Revise eye sockets,21260,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Revise eye sockets,21260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Revise eye sockets,21260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Revise eye sockets,21260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Revise eye sockets,21260,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Revise eye sockets,21261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Revise eye sockets,21261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Revise eye sockets,21261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Revise eye sockets,21261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Revise eye sockets,21261,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Revise eye sockets,21261,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Revise eye sockets,21261,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Revise eye sockets,21261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Revise eye sockets,21261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Revise eye sockets,21261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Revise eye sockets,21261,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Revise eye sockets,21263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Revise eye sockets,21263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Revise eye sockets,21263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Revise eye sockets,21263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Revise eye sockets,21263,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Revise eye sockets,21263,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Revise eye sockets,21263,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Revise eye sockets,21263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Revise eye sockets,21263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Revise eye sockets,21263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Revise eye sockets,21263,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Revise eye sockets,21267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Revise eye sockets,21267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Revise eye sockets,21267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Revise eye sockets,21267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Revise eye sockets,21267,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Revise eye sockets,21267,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Revise eye sockets,21267,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Revise eye sockets,21267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Revise eye sockets,21267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Revise eye sockets,21267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Revise eye sockets,21267,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Revise eye sockets,21268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19225.27,,,,,,,fee schedule,5860.44,26000.79,
Revise eye sockets,21268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15410.73,,,,,,,fee schedule,5860.44,26000.79,
Revise eye sockets,21268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16834.83,,,,,,,fee schedule,5860.44,26000.79,
Revise eye sockets,21268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17699.45,,,,,,,fee schedule,5860.44,26000.79,
Revise eye sockets,21268,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Revise eye sockets,21268,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Revise eye sockets,21268,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Revise eye sockets,21268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Revise eye sockets,21268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Revise eye sockets,21268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Revise eye sockets,21268,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Augmentation cheek bone,21270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2708.63,,,,,,,fee schedule,2171.2,26000.79,
Augmentation cheek bone,21270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2171.2,,,,,,,fee schedule,2171.2,26000.79,
Augmentation cheek bone,21270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2371.84,,,,,,,fee schedule,2171.2,26000.79,
Augmentation cheek bone,21270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2493.66,,,,,,,fee schedule,2171.2,26000.79,
Augmentation cheek bone,21270,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,2171.2,26000.79,APC 378
Augmentation cheek bone,21270,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,2171.2,26000.79,APC
Augmentation cheek bone,21270,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,2171.2,26000.79,APC
Augmentation cheek bone,21270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,2171.2,26000.79,APC
Augmentation cheek bone,21270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,2171.2,26000.79,Radiology
Augmentation cheek bone,21270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,2171.2,26000.79,APC
Augmentation cheek bone,21270,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,2171.2,26000.79,APC
Revision orbitofacial bones,21275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Revision orbitofacial bones,21275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Revision orbitofacial bones,21275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Revision orbitofacial bones,21275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Revision orbitofacial bones,21275,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Revision orbitofacial bones,21275,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Revision orbitofacial bones,21275,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Revision orbitofacial bones,21275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Revision orbitofacial bones,21275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Revision orbitofacial bones,21275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Revision orbitofacial bones,21275,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Revision of eyelid,21280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,3282.2,14562,
Revision of eyelid,21280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,3282.2,14562,
Revision of eyelid,21280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,3282.2,14562,
Revision of eyelid,21280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,3282.2,14562,
Revision of eyelid,21280,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Revision of eyelid,21280,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Revision of eyelid,21280,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Revision of eyelid,21280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Revision of eyelid,21280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Revision of eyelid,21280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Revision of eyelid,21280,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Revision of eyelid,21282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4075.29,,,,,,,fee schedule,3266.7,14562,
Revision of eyelid,21282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3266.7,,,,,,,fee schedule,3266.7,14562,
Revision of eyelid,21282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3568.58,,,,,,,fee schedule,3266.7,14562,
Revision of eyelid,21282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3751.86,,,,,,,fee schedule,3266.7,14562,
Revision of eyelid,21282,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3266.7,14562,APC 378
Revision of eyelid,21282,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3266.7,14562,APC
Revision of eyelid,21282,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3266.7,14562,APC
Revision of eyelid,21282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3266.7,14562,APC
Revision of eyelid,21282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3266.7,14562,Radiology
Revision of eyelid,21282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3266.7,14562,APC
Revision of eyelid,21282,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3266.7,14562,APC
Revision of jaw muscle/bone,21295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1858.66,,,,,,,fee schedule,1489.88,6814.79,
Revision of jaw muscle/bone,21295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1489.88,,,,,,,fee schedule,1489.88,6814.79,
Revision of jaw muscle/bone,21295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1627.56,,,,,,,fee schedule,1489.88,6814.79,
Revision of jaw muscle/bone,21295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1711.15,,,,,,,fee schedule,1489.88,6814.79,
Revision of jaw muscle/bone,21295,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1489.88,6814.79,APC 378
Revision of jaw muscle/bone,21295,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1489.88,6814.79,APC
Revision of jaw muscle/bone,21295,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1489.88,6814.79,APC
Revision of jaw muscle/bone,21295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1489.88,6814.79,APC
Revision of jaw muscle/bone,21295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1489.88,6814.79,Radiology
Revision of jaw muscle/bone,21295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1489.88,6814.79,APC
Revision of jaw muscle/bone,21295,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1489.88,6814.79,APC
Revision of jaw muscle/bone,21296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5983.93,,,,,,,fee schedule,3282.2,14562,
Revision of jaw muscle/bone,21296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4796.64,,,,,,,fee schedule,3282.2,14562,
Revision of jaw muscle/bone,21296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5239.9,,,,,,,fee schedule,3282.2,14562,
Revision of jaw muscle/bone,21296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.01,,,,,,,fee schedule,3282.2,14562,
Revision of jaw muscle/bone,21296,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Revision of jaw muscle/bone,21296,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Revision of jaw muscle/bone,21296,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Revision of jaw muscle/bone,21296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Revision of jaw muscle/bone,21296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Revision of jaw muscle/bone,21296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Revision of jaw muscle/bone,21296,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Cranio/maxillofacial surgery,21299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,624,,,,,,,fee schedule,234.47,1040.28,
Cranio/maxillofacial surgery,21299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,500.19,,,,,,,fee schedule,234.47,1040.28,
Cranio/maxillofacial surgery,21299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,546.41,,,,,,,fee schedule,234.47,1040.28,
Cranio/maxillofacial surgery,21299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,574.48,,,,,,,fee schedule,234.47,1040.28,
Cranio/maxillofacial surgery,21299,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1040.28,,,,,,,fee schedule,234.47,1040.28,APC 378
Cranio/maxillofacial surgery,21299,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,246.2,,,,,,,fee schedule,234.47,1040.28,APC
Cranio/maxillofacial surgery,21299,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,243.85,,,,,,,fee schedule,234.47,1040.28,APC
Cranio/maxillofacial surgery,21299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,234.47,,,,,,,fee schedule,234.47,1040.28,APC
Cranio/maxillofacial surgery,21299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,358.74,,,,,,,fee schedule,234.47,1040.28,Radiology
Cranio/maxillofacial surgery,21299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,328.26,,,,,,,fee schedule,234.47,1040.28,APC
Cranio/maxillofacial surgery,21299,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,410.33,,,,,,,fee schedule,234.47,1040.28,APC
Closed tx nose fx w/o stablj,21315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3058.28,,,,,,,fee schedule,1536.02,6814.79,
Closed tx nose fx w/o stablj,21315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2451.48,,,,,,,fee schedule,1536.02,6814.79,
Closed tx nose fx w/o stablj,21315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2678.02,,,,,,,fee schedule,1536.02,6814.79,
Closed tx nose fx w/o stablj,21315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2815.56,,,,,,,fee schedule,1536.02,6814.79,
Closed tx nose fx w/o stablj,21315,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1536.02,6814.79,APC 378
Closed tx nose fx w/o stablj,21315,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1536.02,6814.79,APC
Closed tx nose fx w/o stablj,21315,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1536.02,6814.79,APC
Closed tx nose fx w/o stablj,21315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1536.02,6814.79,APC
Closed tx nose fx w/o stablj,21315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1536.02,6814.79,Radiology
Closed tx nose fx w/o stablj,21315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1536.02,6814.79,APC
Closed tx nose fx w/o stablj,21315,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1536.02,6814.79,APC
Closed tx nose fx w/ stablj,21320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5049.34,,,,,,,fee schedule,3282.2,14562,
Closed tx nose fx w/ stablj,21320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4047.48,,,,,,,fee schedule,3282.2,14562,
Closed tx nose fx w/ stablj,21320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4421.51,,,,,,,fee schedule,3282.2,14562,
Closed tx nose fx w/ stablj,21320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4648.6,,,,,,,fee schedule,3282.2,14562,
Closed tx nose fx w/ stablj,21320,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Closed tx nose fx w/ stablj,21320,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Closed tx nose fx w/ stablj,21320,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Closed tx nose fx w/ stablj,21320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Closed tx nose fx w/ stablj,21320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Closed tx nose fx w/ stablj,21320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Closed tx nose fx w/ stablj,21320,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Open tx nose fx uncomplicatd,21325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4494.06,,,,,,,fee schedule,3282.2,14562,
Open tx nose fx uncomplicatd,21325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3602.38,,,,,,,fee schedule,3282.2,14562,
Open tx nose fx uncomplicatd,21325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3935.27,,,,,,,fee schedule,3282.2,14562,
Open tx nose fx uncomplicatd,21325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4137.39,,,,,,,fee schedule,3282.2,14562,
Open tx nose fx uncomplicatd,21325,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Open tx nose fx uncomplicatd,21325,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Open tx nose fx uncomplicatd,21325,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Open tx nose fx uncomplicatd,21325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Open tx nose fx uncomplicatd,21325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Open tx nose fx uncomplicatd,21325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Open tx nose fx uncomplicatd,21325,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Open tx nose fx w/skele fixj,21330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5983.93,,,,,,,fee schedule,4796.64,26000.79,
Open tx nose fx w/skele fixj,21330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4796.64,,,,,,,fee schedule,4796.64,26000.79,
Open tx nose fx w/skele fixj,21330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5239.9,,,,,,,fee schedule,4796.64,26000.79,
Open tx nose fx w/skele fixj,21330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.01,,,,,,,fee schedule,4796.64,26000.79,
Open tx nose fx w/skele fixj,21330,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,4796.64,26000.79,APC 378
Open tx nose fx w/skele fixj,21330,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,4796.64,26000.79,APC
Open tx nose fx w/skele fixj,21330,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,4796.64,26000.79,APC
Open tx nose fx w/skele fixj,21330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,4796.64,26000.79,APC
Open tx nose fx w/skele fixj,21330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,4796.64,26000.79,Radiology
Open tx nose fx w/skele fixj,21330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,4796.64,26000.79,APC
Open tx nose fx w/skele fixj,21330,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,4796.64,26000.79,APC
Open tx nose & septal fx,21335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5983.93,,,,,,,fee schedule,3282.2,14562,
Open tx nose & septal fx,21335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4796.64,,,,,,,fee schedule,3282.2,14562,
Open tx nose & septal fx,21335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5239.9,,,,,,,fee schedule,3282.2,14562,
Open tx nose & septal fx,21335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.01,,,,,,,fee schedule,3282.2,14562,
Open tx nose & septal fx,21335,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Open tx nose & septal fx,21335,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Open tx nose & septal fx,21335,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Open tx nose & septal fx,21335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Open tx nose & septal fx,21335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Open tx nose & septal fx,21335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Open tx nose & septal fx,21335,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Open tx septal fx w/wo stabj,21336,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6528.66,,,,,,,fee schedule,3239.17,14371.12,
Open tx septal fx w/wo stabj,21336,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5233.29,,,,,,,fee schedule,3239.17,14371.12,
Open tx septal fx w/wo stabj,21336,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5716.9,,,,,,,fee schedule,3239.17,14371.12,
Open tx septal fx w/wo stabj,21336,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6010.52,,,,,,,fee schedule,3239.17,14371.12,
Open tx septal fx w/wo stabj,21336,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Open tx septal fx w/wo stabj,21336,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Open tx septal fx w/wo stabj,21336,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Open tx septal fx w/wo stabj,21336,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Open tx septal fx w/wo stabj,21336,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Open tx septal fx w/wo stabj,21336,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Open tx septal fx w/wo stabj,21336,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Closed tx septal&nose fx,21337,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3126.73,,,,,,,fee schedule,2506.35,14562,
Closed tx septal&nose fx,21337,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2506.35,,,,,,,fee schedule,2506.35,14562,
Closed tx septal&nose fx,21337,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2737.95,,,,,,,fee schedule,2506.35,14562,
Closed tx septal&nose fx,21337,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2878.57,,,,,,,fee schedule,2506.35,14562,
Closed tx septal&nose fx,21337,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,2506.35,14562,APC 378
Closed tx septal&nose fx,21337,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,2506.35,14562,APC
Closed tx septal&nose fx,21337,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,2506.35,14562,APC
Closed tx septal&nose fx,21337,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,2506.35,14562,APC
Closed tx septal&nose fx,21337,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,2506.35,14562,Radiology
Closed tx septal&nose fx,21337,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,2506.35,14562,APC
Closed tx septal&nose fx,21337,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,2506.35,14562,APC
Open nasoethmoid fx w/o fixj,21338,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5983.93,,,,,,,fee schedule,4796.64,26000.79,
Open nasoethmoid fx w/o fixj,21338,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4796.64,,,,,,,fee schedule,4796.64,26000.79,
Open nasoethmoid fx w/o fixj,21338,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5239.9,,,,,,,fee schedule,4796.64,26000.79,
Open nasoethmoid fx w/o fixj,21338,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.01,,,,,,,fee schedule,4796.64,26000.79,
Open nasoethmoid fx w/o fixj,21338,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,4796.64,26000.79,APC 378
Open nasoethmoid fx w/o fixj,21338,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,4796.64,26000.79,APC
Open nasoethmoid fx w/o fixj,21338,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,4796.64,26000.79,APC
Open nasoethmoid fx w/o fixj,21338,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,4796.64,26000.79,APC
Open nasoethmoid fx w/o fixj,21338,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,4796.64,26000.79,Radiology
Open nasoethmoid fx w/o fixj,21338,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,4796.64,26000.79,APC
Open nasoethmoid fx w/o fixj,21338,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,4796.64,26000.79,APC
Open nasoethmoid fx w/ fixj,21339,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5983.93,,,,,,,fee schedule,4796.64,26000.79,
Open nasoethmoid fx w/ fixj,21339,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4796.64,,,,,,,fee schedule,4796.64,26000.79,
Open nasoethmoid fx w/ fixj,21339,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5239.9,,,,,,,fee schedule,4796.64,26000.79,
Open nasoethmoid fx w/ fixj,21339,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.01,,,,,,,fee schedule,4796.64,26000.79,
Open nasoethmoid fx w/ fixj,21339,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,4796.64,26000.79,APC 378
Open nasoethmoid fx w/ fixj,21339,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,4796.64,26000.79,APC
Open nasoethmoid fx w/ fixj,21339,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,4796.64,26000.79,APC
Open nasoethmoid fx w/ fixj,21339,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,4796.64,26000.79,APC
Open nasoethmoid fx w/ fixj,21339,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,4796.64,26000.79,Radiology
Open nasoethmoid fx w/ fixj,21339,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,4796.64,26000.79,APC
Open nasoethmoid fx w/ fixj,21339,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,4796.64,26000.79,APC
Perq tx nasoethmoid fx,21340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,3282.2,14562,
Perq tx nasoethmoid fx,21340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,3282.2,14562,
Perq tx nasoethmoid fx,21340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,3282.2,14562,
Perq tx nasoethmoid fx,21340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,3282.2,14562,
Perq tx nasoethmoid fx,21340,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Perq tx nasoethmoid fx,21340,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Perq tx nasoethmoid fx,21340,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Perq tx nasoethmoid fx,21340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Perq tx nasoethmoid fx,21340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Perq tx nasoethmoid fx,21340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Perq tx nasoethmoid fx,21340,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Open tx dprsd front sinus fx,21343,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19225.27,,,,,,,fee schedule,5860.44,26000.79,
Open tx dprsd front sinus fx,21343,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15410.73,,,,,,,fee schedule,5860.44,26000.79,
Open tx dprsd front sinus fx,21343,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16834.83,,,,,,,fee schedule,5860.44,26000.79,
Open tx dprsd front sinus fx,21343,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17699.45,,,,,,,fee schedule,5860.44,26000.79,
Open tx dprsd front sinus fx,21343,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Open tx dprsd front sinus fx,21343,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Open tx dprsd front sinus fx,21343,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Open tx dprsd front sinus fx,21343,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Open tx dprsd front sinus fx,21343,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Open tx dprsd front sinus fx,21343,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Open tx dprsd front sinus fx,21343,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Open tx compl front sinus fx,21344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19225.27,,,,,,,fee schedule,5860.44,26000.79,
Open tx compl front sinus fx,21344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15410.73,,,,,,,fee schedule,5860.44,26000.79,
Open tx compl front sinus fx,21344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16834.83,,,,,,,fee schedule,5860.44,26000.79,
Open tx compl front sinus fx,21344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17699.45,,,,,,,fee schedule,5860.44,26000.79,
Open tx compl front sinus fx,21344,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Open tx compl front sinus fx,21344,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Open tx compl front sinus fx,21344,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Open tx compl front sinus fx,21344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Open tx compl front sinus fx,21344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Open tx compl front sinus fx,21344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Open tx compl front sinus fx,21344,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Closed tx nose/jaw fx,21345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5983.93,,,,,,,fee schedule,1536.02,6814.79,
Closed tx nose/jaw fx,21345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4796.64,,,,,,,fee schedule,1536.02,6814.79,
Closed tx nose/jaw fx,21345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5239.9,,,,,,,fee schedule,1536.02,6814.79,
Closed tx nose/jaw fx,21345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.01,,,,,,,fee schedule,1536.02,6814.79,
Closed tx nose/jaw fx,21345,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1536.02,6814.79,APC 378
Closed tx nose/jaw fx,21345,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1536.02,6814.79,APC
Closed tx nose/jaw fx,21345,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1536.02,6814.79,APC
Closed tx nose/jaw fx,21345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1536.02,6814.79,APC
Closed tx nose/jaw fx,21345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1536.02,6814.79,Radiology
Closed tx nose/jaw fx,21345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1536.02,6814.79,APC
Closed tx nose/jaw fx,21345,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1536.02,6814.79,APC
Opn tx nasomax fx w/fixj,21346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15614.95,,,,,,,fee schedule,5860.44,26000.79,
Opn tx nasomax fx w/fixj,21346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12516.75,,,,,,,fee schedule,5860.44,26000.79,
Opn tx nasomax fx w/fixj,21346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13673.41,,,,,,,fee schedule,5860.44,26000.79,
Opn tx nasomax fx w/fixj,21346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14375.67,,,,,,,fee schedule,5860.44,26000.79,
Opn tx nasomax fx w/fixj,21346,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Opn tx nasomax fx w/fixj,21346,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Opn tx nasomax fx w/fixj,21346,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Opn tx nasomax fx w/fixj,21346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Opn tx nasomax fx w/fixj,21346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Opn tx nasomax fx w/fixj,21346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Opn tx nasomax fx w/fixj,21346,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Opn tx nasomax fx multple,21347,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19225.27,,,,,,,fee schedule,5860.44,26000.79,
Opn tx nasomax fx multple,21347,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15410.73,,,,,,,fee schedule,5860.44,26000.79,
Opn tx nasomax fx multple,21347,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16834.83,,,,,,,fee schedule,5860.44,26000.79,
Opn tx nasomax fx multple,21347,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17699.45,,,,,,,fee schedule,5860.44,26000.79,
Opn tx nasomax fx multple,21347,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Opn tx nasomax fx multple,21347,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Opn tx nasomax fx multple,21347,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Opn tx nasomax fx multple,21347,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Opn tx nasomax fx multple,21347,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Opn tx nasomax fx multple,21347,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Opn tx nasomax fx multple,21347,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Opn tx nasomax fx w/graft,21348,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19225.27,,,,,,,fee schedule,5860.44,26000.79,
Opn tx nasomax fx w/graft,21348,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15410.73,,,,,,,fee schedule,5860.44,26000.79,
Opn tx nasomax fx w/graft,21348,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16834.83,,,,,,,fee schedule,5860.44,26000.79,
Opn tx nasomax fx w/graft,21348,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17699.45,,,,,,,fee schedule,5860.44,26000.79,
Opn tx nasomax fx w/graft,21348,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Opn tx nasomax fx w/graft,21348,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Opn tx nasomax fx w/graft,21348,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Opn tx nasomax fx w/graft,21348,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Opn tx nasomax fx w/graft,21348,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Opn tx nasomax fx w/graft,21348,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Opn tx nasomax fx w/graft,21348,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Perq tx malar fracture,21355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,3282.2,14562,
Perq tx malar fracture,21355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,3282.2,14562,
Perq tx malar fracture,21355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,3282.2,14562,
Perq tx malar fracture,21355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,3282.2,14562,
Perq tx malar fracture,21355,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Perq tx malar fracture,21355,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Perq tx malar fracture,21355,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Perq tx malar fracture,21355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Perq tx malar fracture,21355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Perq tx malar fracture,21355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Perq tx malar fracture,21355,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Opn tx dprsd zygomatic arch,21356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5983.93,,,,,,,fee schedule,4796.64,26000.79,
Opn tx dprsd zygomatic arch,21356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4796.64,,,,,,,fee schedule,4796.64,26000.79,
Opn tx dprsd zygomatic arch,21356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5239.9,,,,,,,fee schedule,4796.64,26000.79,
Opn tx dprsd zygomatic arch,21356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.01,,,,,,,fee schedule,4796.64,26000.79,
Opn tx dprsd zygomatic arch,21356,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,4796.64,26000.79,APC 378
Opn tx dprsd zygomatic arch,21356,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,4796.64,26000.79,APC
Opn tx dprsd zygomatic arch,21356,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,4796.64,26000.79,APC
Opn tx dprsd zygomatic arch,21356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,4796.64,26000.79,APC
Opn tx dprsd zygomatic arch,21356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,4796.64,26000.79,Radiology
Opn tx dprsd zygomatic arch,21356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,4796.64,26000.79,APC
Opn tx dprsd zygomatic arch,21356,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,4796.64,26000.79,APC
Opn tx dprsd malar fracture,21360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5983.93,,,,,,,fee schedule,4796.64,26000.79,
Opn tx dprsd malar fracture,21360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4796.64,,,,,,,fee schedule,4796.64,26000.79,
Opn tx dprsd malar fracture,21360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5239.9,,,,,,,fee schedule,4796.64,26000.79,
Opn tx dprsd malar fracture,21360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.01,,,,,,,fee schedule,4796.64,26000.79,
Opn tx dprsd malar fracture,21360,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,4796.64,26000.79,APC 378
Opn tx dprsd malar fracture,21360,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,4796.64,26000.79,APC
Opn tx dprsd malar fracture,21360,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,4796.64,26000.79,APC
Opn tx dprsd malar fracture,21360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,4796.64,26000.79,APC
Opn tx dprsd malar fracture,21360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,4796.64,26000.79,Radiology
Opn tx dprsd malar fracture,21360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,4796.64,26000.79,APC
Opn tx dprsd malar fracture,21360,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,4796.64,26000.79,APC
Opn tx complx malar fx,21365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Opn tx complx malar fx,21365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Opn tx complx malar fx,21365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Opn tx complx malar fx,21365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Opn tx complx malar fx,21365,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Opn tx complx malar fx,21365,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Opn tx complx malar fx,21365,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Opn tx complx malar fx,21365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Opn tx complx malar fx,21365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Opn tx complx malar fx,21365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Opn tx complx malar fx,21365,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Opn tx complx malar w/grft,21366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19225.27,,,,,,,fee schedule,5860.44,26000.79,
Opn tx complx malar w/grft,21366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15410.73,,,,,,,fee schedule,5860.44,26000.79,
Opn tx complx malar w/grft,21366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16834.83,,,,,,,fee schedule,5860.44,26000.79,
Opn tx complx malar w/grft,21366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17699.45,,,,,,,fee schedule,5860.44,26000.79,
Opn tx complx malar w/grft,21366,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Opn tx complx malar w/grft,21366,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Opn tx complx malar w/grft,21366,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Opn tx complx malar w/grft,21366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Opn tx complx malar w/grft,21366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Opn tx complx malar w/grft,21366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Opn tx complx malar w/grft,21366,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Opn tx orbit fx transantral,21385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Opn tx orbit fx transantral,21385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Opn tx orbit fx transantral,21385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Opn tx orbit fx transantral,21385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Opn tx orbit fx transantral,21385,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Opn tx orbit fx transantral,21385,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Opn tx orbit fx transantral,21385,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Opn tx orbit fx transantral,21385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Opn tx orbit fx transantral,21385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Opn tx orbit fx transantral,21385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Opn tx orbit fx transantral,21385,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Opn tx orbit fx periorbital,21386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15614.95,,,,,,,fee schedule,5860.44,26000.79,
Opn tx orbit fx periorbital,21386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12516.75,,,,,,,fee schedule,5860.44,26000.79,
Opn tx orbit fx periorbital,21386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13673.41,,,,,,,fee schedule,5860.44,26000.79,
Opn tx orbit fx periorbital,21386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14375.67,,,,,,,fee schedule,5860.44,26000.79,
Opn tx orbit fx periorbital,21386,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Opn tx orbit fx periorbital,21386,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Opn tx orbit fx periorbital,21386,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Opn tx orbit fx periorbital,21386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Opn tx orbit fx periorbital,21386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Opn tx orbit fx periorbital,21386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Opn tx orbit fx periorbital,21386,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Opn tx orbit fx combined,21387,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15614.95,,,,,,,fee schedule,5860.44,26000.79,
Opn tx orbit fx combined,21387,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12516.75,,,,,,,fee schedule,5860.44,26000.79,
Opn tx orbit fx combined,21387,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13673.41,,,,,,,fee schedule,5860.44,26000.79,
Opn tx orbit fx combined,21387,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14375.67,,,,,,,fee schedule,5860.44,26000.79,
Opn tx orbit fx combined,21387,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Opn tx orbit fx combined,21387,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Opn tx orbit fx combined,21387,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Opn tx orbit fx combined,21387,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Opn tx orbit fx combined,21387,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Opn tx orbit fx combined,21387,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Opn tx orbit fx combined,21387,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Opn tx orbit periorbtl implt,21390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7189.69,,,,,,,fee schedule,5763.16,26000.79,
Opn tx orbit periorbtl implt,21390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5763.16,,,,,,,fee schedule,5763.16,26000.79,
Opn tx orbit periorbtl implt,21390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6295.73,,,,,,,fee schedule,5763.16,26000.79,
Opn tx orbit periorbtl implt,21390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6619.08,,,,,,,fee schedule,5763.16,26000.79,
Opn tx orbit periorbtl implt,21390,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5763.16,26000.79,APC 378
Opn tx orbit periorbtl implt,21390,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5763.16,26000.79,APC
Opn tx orbit periorbtl implt,21390,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5763.16,26000.79,APC
Opn tx orbit periorbtl implt,21390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5763.16,26000.79,APC
Opn tx orbit periorbtl implt,21390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5763.16,26000.79,Radiology
Opn tx orbit periorbtl implt,21390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5763.16,26000.79,APC
Opn tx orbit periorbtl implt,21390,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5763.16,26000.79,APC
Opn tx orbit periorbt w/grft,21395,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15614.95,,,,,,,fee schedule,5860.44,26000.79,
Opn tx orbit periorbt w/grft,21395,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12516.75,,,,,,,fee schedule,5860.44,26000.79,
Opn tx orbit periorbt w/grft,21395,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13673.41,,,,,,,fee schedule,5860.44,26000.79,
Opn tx orbit periorbt w/grft,21395,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14375.67,,,,,,,fee schedule,5860.44,26000.79,
Opn tx orbit periorbt w/grft,21395,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Opn tx orbit periorbt w/grft,21395,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Opn tx orbit periorbt w/grft,21395,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Opn tx orbit periorbt w/grft,21395,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Opn tx orbit periorbt w/grft,21395,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Opn tx orbit periorbt w/grft,21395,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Opn tx orbit periorbt w/grft,21395,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Closed tx orbit w/o manipulj,21400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1858.66,,,,,,,fee schedule,533.92,2368.81,
Closed tx orbit w/o manipulj,21400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1489.88,,,,,,,fee schedule,533.92,2368.81,
Closed tx orbit w/o manipulj,21400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1627.56,,,,,,,fee schedule,533.92,2368.81,
Closed tx orbit w/o manipulj,21400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1711.15,,,,,,,fee schedule,533.92,2368.81,
Closed tx orbit w/o manipulj,21400,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2368.81,,,,,,,fee schedule,533.92,2368.81,APC 378
Closed tx orbit w/o manipulj,21400,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,560.61,,,,,,,fee schedule,533.92,2368.81,APC
Closed tx orbit w/o manipulj,21400,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,555.27,,,,,,,fee schedule,533.92,2368.81,APC
Closed tx orbit w/o manipulj,21400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,533.92,,,,,,,fee schedule,533.92,2368.81,APC
Closed tx orbit w/o manipulj,21400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,816.89,,,,,,,fee schedule,533.92,2368.81,Radiology
Closed tx orbit w/o manipulj,21400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,747.48,,,,,,,fee schedule,533.92,2368.81,APC
Closed tx orbit w/o manipulj,21400,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,934.36,,,,,,,fee schedule,533.92,2368.81,APC
Closed tx orbit w/manipulj,21401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4075.29,,,,,,,fee schedule,1536.02,6814.79,
Closed tx orbit w/manipulj,21401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3266.7,,,,,,,fee schedule,1536.02,6814.79,
Closed tx orbit w/manipulj,21401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3568.58,,,,,,,fee schedule,1536.02,6814.79,
Closed tx orbit w/manipulj,21401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3751.86,,,,,,,fee schedule,1536.02,6814.79,
Closed tx orbit w/manipulj,21401,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1536.02,6814.79,APC 378
Closed tx orbit w/manipulj,21401,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1536.02,6814.79,APC
Closed tx orbit w/manipulj,21401,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1536.02,6814.79,APC
Closed tx orbit w/manipulj,21401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1536.02,6814.79,APC
Closed tx orbit w/manipulj,21401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1536.02,6814.79,Radiology
Closed tx orbit w/manipulj,21401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1536.02,6814.79,APC
Closed tx orbit w/manipulj,21401,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1536.02,6814.79,APC
Opn tx orbit fx w/o implant,21406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Opn tx orbit fx w/o implant,21406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Opn tx orbit fx w/o implant,21406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Opn tx orbit fx w/o implant,21406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Opn tx orbit fx w/o implant,21406,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Opn tx orbit fx w/o implant,21406,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Opn tx orbit fx w/o implant,21406,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Opn tx orbit fx w/o implant,21406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Opn tx orbit fx w/o implant,21406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Opn tx orbit fx w/o implant,21406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Opn tx orbit fx w/o implant,21406,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Opn tx orbit fx w/implant,21407,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Opn tx orbit fx w/implant,21407,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Opn tx orbit fx w/implant,21407,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Opn tx orbit fx w/implant,21407,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Opn tx orbit fx w/implant,21407,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Opn tx orbit fx w/implant,21407,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Opn tx orbit fx w/implant,21407,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Opn tx orbit fx w/implant,21407,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Opn tx orbit fx w/implant,21407,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Opn tx orbit fx w/implant,21407,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Opn tx orbit fx w/implant,21407,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Opn tx orbit fx w/bone grft,21408,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Opn tx orbit fx w/bone grft,21408,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Opn tx orbit fx w/bone grft,21408,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Opn tx orbit fx w/bone grft,21408,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Opn tx orbit fx w/bone grft,21408,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Opn tx orbit fx w/bone grft,21408,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Opn tx orbit fx w/bone grft,21408,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Opn tx orbit fx w/bone grft,21408,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Opn tx orbit fx w/bone grft,21408,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Opn tx orbit fx w/bone grft,21408,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Opn tx orbit fx w/bone grft,21408,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Treat mouth roof fracture,21421,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4765.13,,,,,,,fee schedule,3282.2,14562,
Treat mouth roof fracture,21421,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3819.67,,,,,,,fee schedule,3282.2,14562,
Treat mouth roof fracture,21421,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4172.64,,,,,,,fee schedule,3282.2,14562,
Treat mouth roof fracture,21421,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4386.95,,,,,,,fee schedule,3282.2,14562,
Treat mouth roof fracture,21421,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Treat mouth roof fracture,21421,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Treat mouth roof fracture,21421,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Treat mouth roof fracture,21421,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Treat mouth roof fracture,21421,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Treat mouth roof fracture,21421,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Treat mouth roof fracture,21421,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Treat mouth roof fracture,21422,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19225.27,,,,,,,fee schedule,5860.44,26000.79,
Treat mouth roof fracture,21422,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15410.73,,,,,,,fee schedule,5860.44,26000.79,
Treat mouth roof fracture,21422,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16834.83,,,,,,,fee schedule,5860.44,26000.79,
Treat mouth roof fracture,21422,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17699.45,,,,,,,fee schedule,5860.44,26000.79,
Treat mouth roof fracture,21422,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Treat mouth roof fracture,21422,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Treat mouth roof fracture,21422,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Treat mouth roof fracture,21422,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Treat mouth roof fracture,21422,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Treat mouth roof fracture,21422,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Treat mouth roof fracture,21422,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Treat mouth roof fracture,21423,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19225.27,,,,,,,fee schedule,5860.44,26000.79,
Treat mouth roof fracture,21423,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15410.73,,,,,,,fee schedule,5860.44,26000.79,
Treat mouth roof fracture,21423,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16834.83,,,,,,,fee schedule,5860.44,26000.79,
Treat mouth roof fracture,21423,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17699.45,,,,,,,fee schedule,5860.44,26000.79,
Treat mouth roof fracture,21423,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Treat mouth roof fracture,21423,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Treat mouth roof fracture,21423,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Treat mouth roof fracture,21423,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Treat mouth roof fracture,21423,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Treat mouth roof fracture,21423,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Treat mouth roof fracture,21423,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Treat craniofacial fracture,21431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19225.27,,,,,,,fee schedule,5860.44,26000.79,
Treat craniofacial fracture,21431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15410.73,,,,,,,fee schedule,5860.44,26000.79,
Treat craniofacial fracture,21431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16834.83,,,,,,,fee schedule,5860.44,26000.79,
Treat craniofacial fracture,21431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17699.45,,,,,,,fee schedule,5860.44,26000.79,
Treat craniofacial fracture,21431,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Treat craniofacial fracture,21431,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Treat craniofacial fracture,21431,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Treat craniofacial fracture,21431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Treat craniofacial fracture,21431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Treat craniofacial fracture,21431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Treat craniofacial fracture,21431,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Treat craniofacial fracture,21432,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19225.27,,,,,,,fee schedule,5860.44,26000.79,
Treat craniofacial fracture,21432,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15410.73,,,,,,,fee schedule,5860.44,26000.79,
Treat craniofacial fracture,21432,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16834.83,,,,,,,fee schedule,5860.44,26000.79,
Treat craniofacial fracture,21432,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17699.45,,,,,,,fee schedule,5860.44,26000.79,
Treat craniofacial fracture,21432,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Treat craniofacial fracture,21432,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Treat craniofacial fracture,21432,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Treat craniofacial fracture,21432,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Treat craniofacial fracture,21432,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Treat craniofacial fracture,21432,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Treat craniofacial fracture,21432,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Treat craniofacial fracture,21433,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19225.27,,,,,,,fee schedule,5860.44,26000.79,
Treat craniofacial fracture,21433,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15410.73,,,,,,,fee schedule,5860.44,26000.79,
Treat craniofacial fracture,21433,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16834.83,,,,,,,fee schedule,5860.44,26000.79,
Treat craniofacial fracture,21433,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17699.45,,,,,,,fee schedule,5860.44,26000.79,
Treat craniofacial fracture,21433,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Treat craniofacial fracture,21433,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Treat craniofacial fracture,21433,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Treat craniofacial fracture,21433,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Treat craniofacial fracture,21433,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Treat craniofacial fracture,21433,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Treat craniofacial fracture,21433,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Treat craniofacial fracture,21435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19225.27,,,,,,,fee schedule,5860.44,26000.79,
Treat craniofacial fracture,21435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15410.73,,,,,,,fee schedule,5860.44,26000.79,
Treat craniofacial fracture,21435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16834.83,,,,,,,fee schedule,5860.44,26000.79,
Treat craniofacial fracture,21435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17699.45,,,,,,,fee schedule,5860.44,26000.79,
Treat craniofacial fracture,21435,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Treat craniofacial fracture,21435,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Treat craniofacial fracture,21435,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Treat craniofacial fracture,21435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Treat craniofacial fracture,21435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Treat craniofacial fracture,21435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Treat craniofacial fracture,21435,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Treat craniofacial fracture,21436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19225.27,,,,,,,fee schedule,5860.44,26000.79,
Treat craniofacial fracture,21436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15410.73,,,,,,,fee schedule,5860.44,26000.79,
Treat craniofacial fracture,21436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16834.83,,,,,,,fee schedule,5860.44,26000.79,
Treat craniofacial fracture,21436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17699.45,,,,,,,fee schedule,5860.44,26000.79,
Treat craniofacial fracture,21436,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Treat craniofacial fracture,21436,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Treat craniofacial fracture,21436,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Treat craniofacial fracture,21436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Treat craniofacial fracture,21436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Treat craniofacial fracture,21436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Treat craniofacial fracture,21436,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Treat dental ridge fracture,21440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5983.93,,,,,,,fee schedule,3282.2,14562,
Treat dental ridge fracture,21440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4796.64,,,,,,,fee schedule,3282.2,14562,
Treat dental ridge fracture,21440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5239.9,,,,,,,fee schedule,3282.2,14562,
Treat dental ridge fracture,21440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.01,,,,,,,fee schedule,3282.2,14562,
Treat dental ridge fracture,21440,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Treat dental ridge fracture,21440,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Treat dental ridge fracture,21440,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Treat dental ridge fracture,21440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Treat dental ridge fracture,21440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Treat dental ridge fracture,21440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Treat dental ridge fracture,21440,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Treat dental ridge fracture,21445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5983.93,,,,,,,fee schedule,4796.64,26000.79,
Treat dental ridge fracture,21445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4796.64,,,,,,,fee schedule,4796.64,26000.79,
Treat dental ridge fracture,21445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5239.9,,,,,,,fee schedule,4796.64,26000.79,
Treat dental ridge fracture,21445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.01,,,,,,,fee schedule,4796.64,26000.79,
Treat dental ridge fracture,21445,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,4796.64,26000.79,APC 378
Treat dental ridge fracture,21445,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,4796.64,26000.79,APC
Treat dental ridge fracture,21445,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,4796.64,26000.79,APC
Treat dental ridge fracture,21445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,4796.64,26000.79,APC
Treat dental ridge fracture,21445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,4796.64,26000.79,Radiology
Treat dental ridge fracture,21445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,4796.64,26000.79,APC
Treat dental ridge fracture,21445,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,4796.64,26000.79,APC
Treat lower jaw fracture,21450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,624,,,,,,,fee schedule,500.19,2368.81,
Treat lower jaw fracture,21450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,500.19,,,,,,,fee schedule,500.19,2368.81,
Treat lower jaw fracture,21450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,546.41,,,,,,,fee schedule,500.19,2368.81,
Treat lower jaw fracture,21450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,574.48,,,,,,,fee schedule,500.19,2368.81,
Treat lower jaw fracture,21450,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2368.81,,,,,,,fee schedule,500.19,2368.81,APC 378
Treat lower jaw fracture,21450,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,560.61,,,,,,,fee schedule,500.19,2368.81,APC
Treat lower jaw fracture,21450,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,555.27,,,,,,,fee schedule,500.19,2368.81,APC
Treat lower jaw fracture,21450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,533.92,,,,,,,fee schedule,500.19,2368.81,APC
Treat lower jaw fracture,21450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,816.89,,,,,,,fee schedule,500.19,2368.81,Radiology
Treat lower jaw fracture,21450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,747.48,,,,,,,fee schedule,500.19,2368.81,APC
Treat lower jaw fracture,21450,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,934.36,,,,,,,fee schedule,500.19,2368.81,APC
Treat lower jaw fracture,21451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1858.66,,,,,,,fee schedule,1489.88,6814.79,
Treat lower jaw fracture,21451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1489.88,,,,,,,fee schedule,1489.88,6814.79,
Treat lower jaw fracture,21451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1627.56,,,,,,,fee schedule,1489.88,6814.79,
Treat lower jaw fracture,21451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1711.15,,,,,,,fee schedule,1489.88,6814.79,
Treat lower jaw fracture,21451,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1489.88,6814.79,APC 378
Treat lower jaw fracture,21451,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1489.88,6814.79,APC
Treat lower jaw fracture,21451,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1489.88,6814.79,APC
Treat lower jaw fracture,21451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1489.88,6814.79,APC
Treat lower jaw fracture,21451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1489.88,6814.79,Radiology
Treat lower jaw fracture,21451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1489.88,6814.79,APC
Treat lower jaw fracture,21451,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1489.88,6814.79,APC
Treat lower jaw fracture,21452,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4075.29,,,,,,,fee schedule,3266.7,26000.79,
Treat lower jaw fracture,21452,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3266.7,,,,,,,fee schedule,3266.7,26000.79,
Treat lower jaw fracture,21452,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3568.58,,,,,,,fee schedule,3266.7,26000.79,
Treat lower jaw fracture,21452,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3751.86,,,,,,,fee schedule,3266.7,26000.79,
Treat lower jaw fracture,21452,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,3266.7,26000.79,APC 378
Treat lower jaw fracture,21452,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,3266.7,26000.79,APC
Treat lower jaw fracture,21452,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,3266.7,26000.79,APC
Treat lower jaw fracture,21452,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,3266.7,26000.79,APC
Treat lower jaw fracture,21452,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,3266.7,26000.79,Radiology
Treat lower jaw fracture,21452,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,3266.7,26000.79,APC
Treat lower jaw fracture,21452,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,3266.7,26000.79,APC
Treat lower jaw fracture,21453,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Treat lower jaw fracture,21453,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Treat lower jaw fracture,21453,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Treat lower jaw fracture,21453,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Treat lower jaw fracture,21453,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Treat lower jaw fracture,21453,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Treat lower jaw fracture,21453,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Treat lower jaw fracture,21453,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Treat lower jaw fracture,21453,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Treat lower jaw fracture,21453,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Treat lower jaw fracture,21453,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Treat lower jaw fracture,21454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5983.93,,,,,,,fee schedule,4796.64,26000.79,
Treat lower jaw fracture,21454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4796.64,,,,,,,fee schedule,4796.64,26000.79,
Treat lower jaw fracture,21454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5239.9,,,,,,,fee schedule,4796.64,26000.79,
Treat lower jaw fracture,21454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.01,,,,,,,fee schedule,4796.64,26000.79,
Treat lower jaw fracture,21454,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,4796.64,26000.79,APC 378
Treat lower jaw fracture,21454,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,4796.64,26000.79,APC
Treat lower jaw fracture,21454,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,4796.64,26000.79,APC
Treat lower jaw fracture,21454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,4796.64,26000.79,APC
Treat lower jaw fracture,21454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,4796.64,26000.79,Radiology
Treat lower jaw fracture,21454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,4796.64,26000.79,APC
Treat lower jaw fracture,21454,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,4796.64,26000.79,APC
Treat lower jaw fracture,21461,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Treat lower jaw fracture,21461,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Treat lower jaw fracture,21461,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Treat lower jaw fracture,21461,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Treat lower jaw fracture,21461,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Treat lower jaw fracture,21461,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Treat lower jaw fracture,21461,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Treat lower jaw fracture,21461,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Treat lower jaw fracture,21461,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Treat lower jaw fracture,21461,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Treat lower jaw fracture,21461,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Treat lower jaw fracture,21462,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13950.27,,,,,,,fee schedule,5860.44,26000.79,
Treat lower jaw fracture,21462,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11182.36,,,,,,,fee schedule,5860.44,26000.79,
Treat lower jaw fracture,21462,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12215.71,,,,,,,fee schedule,5860.44,26000.79,
Treat lower jaw fracture,21462,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12843.1,,,,,,,fee schedule,5860.44,26000.79,
Treat lower jaw fracture,21462,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Treat lower jaw fracture,21462,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Treat lower jaw fracture,21462,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Treat lower jaw fracture,21462,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Treat lower jaw fracture,21462,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Treat lower jaw fracture,21462,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Treat lower jaw fracture,21462,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Treat lower jaw fracture,21465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Treat lower jaw fracture,21465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Treat lower jaw fracture,21465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Treat lower jaw fracture,21465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Treat lower jaw fracture,21465,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Treat lower jaw fracture,21465,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Treat lower jaw fracture,21465,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Treat lower jaw fracture,21465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Treat lower jaw fracture,21465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Treat lower jaw fracture,21465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Treat lower jaw fracture,21465,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Treat lower jaw fracture,21470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Treat lower jaw fracture,21470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Treat lower jaw fracture,21470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Treat lower jaw fracture,21470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Treat lower jaw fracture,21470,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Treat lower jaw fracture,21470,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Treat lower jaw fracture,21470,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Treat lower jaw fracture,21470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Treat lower jaw fracture,21470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Treat lower jaw fracture,21470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Treat lower jaw fracture,21470,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Reset dislocated jaw,21480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,624,,,,,,,fee schedule,244.19,1083.4,
Reset dislocated jaw,21480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,500.19,,,,,,,fee schedule,244.19,1083.4,
Reset dislocated jaw,21480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,546.41,,,,,,,fee schedule,244.19,1083.4,
Reset dislocated jaw,21480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,574.48,,,,,,,fee schedule,244.19,1083.4,
Reset dislocated jaw,21480,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Reset dislocated jaw,21480,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Reset dislocated jaw,21480,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Reset dislocated jaw,21480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Reset dislocated jaw,21480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Reset dislocated jaw,21480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Reset dislocated jaw,21480,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Reset dislocated jaw,21485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4075.29,,,,,,,fee schedule,1536.02,6814.79,
Reset dislocated jaw,21485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3266.7,,,,,,,fee schedule,1536.02,6814.79,
Reset dislocated jaw,21485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3568.58,,,,,,,fee schedule,1536.02,6814.79,
Reset dislocated jaw,21485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3751.86,,,,,,,fee schedule,1536.02,6814.79,
Reset dislocated jaw,21485,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1536.02,6814.79,APC 378
Reset dislocated jaw,21485,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1536.02,6814.79,APC
Reset dislocated jaw,21485,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1536.02,6814.79,APC
Reset dislocated jaw,21485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1536.02,6814.79,APC
Reset dislocated jaw,21485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1536.02,6814.79,Radiology
Reset dislocated jaw,21485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1536.02,6814.79,APC
Reset dislocated jaw,21485,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1536.02,6814.79,APC
Repair dislocated jaw,21490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,3282.2,14562,
Repair dislocated jaw,21490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,3282.2,14562,
Repair dislocated jaw,21490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,3282.2,14562,
Repair dislocated jaw,21490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,3282.2,14562,
Repair dislocated jaw,21490,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Repair dislocated jaw,21490,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Repair dislocated jaw,21490,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Repair dislocated jaw,21490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Repair dislocated jaw,21490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Repair dislocated jaw,21490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Repair dislocated jaw,21490,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Interdental wiring,21497,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4075.29,,,,,,,fee schedule,1536.02,6814.79,
Interdental wiring,21497,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3266.7,,,,,,,fee schedule,1536.02,6814.79,
Interdental wiring,21497,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3568.58,,,,,,,fee schedule,1536.02,6814.79,
Interdental wiring,21497,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3751.86,,,,,,,fee schedule,1536.02,6814.79,
Interdental wiring,21497,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1536.02,6814.79,APC 378
Interdental wiring,21497,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1536.02,6814.79,APC
Interdental wiring,21497,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1536.02,6814.79,APC
Interdental wiring,21497,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1536.02,6814.79,APC
Interdental wiring,21497,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1536.02,6814.79,Radiology
Interdental wiring,21497,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1536.02,6814.79,APC
Interdental wiring,21497,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1536.02,6814.79,APC
Head surgery procedure,21499,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,624,,,,,,,fee schedule,234.47,1040.28,
Head surgery procedure,21499,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,500.19,,,,,,,fee schedule,234.47,1040.28,
Head surgery procedure,21499,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,546.41,,,,,,,fee schedule,234.47,1040.28,
Head surgery procedure,21499,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,574.48,,,,,,,fee schedule,234.47,1040.28,
Head surgery procedure,21499,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1040.28,,,,,,,fee schedule,234.47,1040.28,APC 378
Head surgery procedure,21499,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,246.2,,,,,,,fee schedule,234.47,1040.28,APC
Head surgery procedure,21499,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,243.85,,,,,,,fee schedule,234.47,1040.28,APC
Head surgery procedure,21499,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,234.47,,,,,,,fee schedule,234.47,1040.28,APC
Head surgery procedure,21499,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,358.74,,,,,,,fee schedule,234.47,1040.28,Radiology
Head surgery procedure,21499,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,328.26,,,,,,,fee schedule,234.47,1040.28,APC
Head surgery procedure,21499,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,410.33,,,,,,,fee schedule,234.47,1040.28,APC
Drain neck/chest lesion,21501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4572.14,,,,,,,fee schedule,2875.57,12757.95,
Drain neck/chest lesion,21501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3664.97,,,,,,,fee schedule,2875.57,12757.95,
Drain neck/chest lesion,21501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4003.64,,,,,,,fee schedule,2875.57,12757.95,
Drain neck/chest lesion,21501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4209.27,,,,,,,fee schedule,2875.57,12757.95,
Drain neck/chest lesion,21501,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Drain neck/chest lesion,21501,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Drain neck/chest lesion,21501,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Drain neck/chest lesion,21501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Drain neck/chest lesion,21501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Drain neck/chest lesion,21501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Drain neck/chest lesion,21501,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Drain chest lesion,21502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,3239.17,14371.12,
Drain chest lesion,21502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,3239.17,14371.12,
Drain chest lesion,21502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,3239.17,14371.12,
Drain chest lesion,21502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,3239.17,14371.12,
Drain chest lesion,21502,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Drain chest lesion,21502,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Drain chest lesion,21502,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Drain chest lesion,21502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Drain chest lesion,21502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Drain chest lesion,21502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Drain chest lesion,21502,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Drainage of bone lesion,21510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,3239.17,23681.51,
Drainage of bone lesion,21510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,3239.17,23681.51,
Drainage of bone lesion,21510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,3239.17,23681.51,
Drainage of bone lesion,21510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,3239.17,23681.51,
Drainage of bone lesion,21510,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,23681.51,APC 378
Drainage of bone lesion,21510,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,23681.51,APC
Drainage of bone lesion,21510,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,23681.51,APC
Drainage of bone lesion,21510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,23681.51,APC
Drainage of bone lesion,21510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,23681.51,Radiology
Drainage of bone lesion,21510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,23681.51,APC
Drainage of bone lesion,21510,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,23681.51,APC
Biopsy of neck/chest,21550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2108.69,,,,,,,fee schedule,1635.03,7254.06,
Biopsy of neck/chest,21550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1690.3,,,,,,,fee schedule,1635.03,7254.06,
Biopsy of neck/chest,21550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1846.49,,,,,,,fee schedule,1635.03,7254.06,
Biopsy of neck/chest,21550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1941.33,,,,,,,fee schedule,1635.03,7254.06,
Biopsy of neck/chest,21550,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,7254.06,APC 378
Biopsy of neck/chest,21550,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,7254.06,APC
Biopsy of neck/chest,21550,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,7254.06,APC
Biopsy of neck/chest,21550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,7254.06,APC
Biopsy of neck/chest,21550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,7254.06,Radiology
Biopsy of neck/chest,21550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,7254.06,APC
Biopsy of neck/chest,21550,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,7254.06,APC
Exc neck les sc 3 cm/>,21552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6078.75,,,,,,,fee schedule,2875.57,12757.95,
Exc neck les sc 3 cm/>,21552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4872.65,,,,,,,fee schedule,2875.57,12757.95,
Exc neck les sc 3 cm/>,21552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5322.93,,,,,,,fee schedule,2875.57,12757.95,
Exc neck les sc 3 cm/>,21552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5596.31,,,,,,,fee schedule,2875.57,12757.95,
Exc neck les sc 3 cm/>,21552,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Exc neck les sc 3 cm/>,21552,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Exc neck les sc 3 cm/>,21552,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Exc neck les sc 3 cm/>,21552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Exc neck les sc 3 cm/>,21552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Exc neck les sc 3 cm/>,21552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Exc neck les sc 3 cm/>,21552,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Exc neck tum deep 5 cm/>,21554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4975.66,,,,,,,fee schedule,2875.57,12757.95,
Exc neck tum deep 5 cm/>,21554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3988.43,,,,,,,fee schedule,2875.57,12757.95,
Exc neck tum deep 5 cm/>,21554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4357,,,,,,,fee schedule,2875.57,12757.95,
Exc neck tum deep 5 cm/>,21554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4580.77,,,,,,,fee schedule,2875.57,12757.95,
Exc neck tum deep 5 cm/>,21554,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Exc neck tum deep 5 cm/>,21554,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Exc neck tum deep 5 cm/>,21554,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Exc neck tum deep 5 cm/>,21554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Exc neck tum deep 5 cm/>,21554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Exc neck tum deep 5 cm/>,21554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Exc neck tum deep 5 cm/>,21554,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Exc neck les sc < 3 cm,21555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3273.44,,,,,,,fee schedule,1635.03,7254.06,
Exc neck les sc < 3 cm,21555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2623.95,,,,,,,fee schedule,1635.03,7254.06,
Exc neck les sc < 3 cm,21555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2866.42,,,,,,,fee schedule,1635.03,7254.06,
Exc neck les sc < 3 cm,21555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3013.64,,,,,,,fee schedule,1635.03,7254.06,
Exc neck les sc < 3 cm,21555,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,7254.06,APC 378
Exc neck les sc < 3 cm,21555,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,7254.06,APC
Exc neck les sc < 3 cm,21555,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,7254.06,APC
Exc neck les sc < 3 cm,21555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,7254.06,APC
Exc neck les sc < 3 cm,21555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,7254.06,Radiology
Exc neck les sc < 3 cm,21555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,7254.06,APC
Exc neck les sc < 3 cm,21555,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,7254.06,APC
Exc neck tum deep < 5 cm,21556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7189.69,,,,,,,fee schedule,2875.57,12757.95,
Exc neck tum deep < 5 cm,21556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5763.16,,,,,,,fee schedule,2875.57,12757.95,
Exc neck tum deep < 5 cm,21556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6295.73,,,,,,,fee schedule,2875.57,12757.95,
Exc neck tum deep < 5 cm,21556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6619.08,,,,,,,fee schedule,2875.57,12757.95,
Exc neck tum deep < 5 cm,21556,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Exc neck tum deep < 5 cm,21556,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Exc neck tum deep < 5 cm,21556,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Exc neck tum deep < 5 cm,21556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Exc neck tum deep < 5 cm,21556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Exc neck tum deep < 5 cm,21556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Exc neck tum deep < 5 cm,21556,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Resect neck thorax tumor<5cm,21557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5268.49,,,,,,,fee schedule,2875.57,12757.95,
Resect neck thorax tumor<5cm,21557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4223.15,,,,,,,fee schedule,2875.57,12757.95,
Resect neck thorax tumor<5cm,21557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4613.41,,,,,,,fee schedule,2875.57,12757.95,
Resect neck thorax tumor<5cm,21557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4850.35,,,,,,,fee schedule,2875.57,12757.95,
Resect neck thorax tumor<5cm,21557,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Resect neck thorax tumor<5cm,21557,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Resect neck thorax tumor<5cm,21557,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Resect neck thorax tumor<5cm,21557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Resect neck thorax tumor<5cm,21557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Resect neck thorax tumor<5cm,21557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Resect neck thorax tumor<5cm,21557,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Resect neck tumor 5 cm/>,21558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6177.24,,,,,,,fee schedule,2875.57,12757.95,
Resect neck tumor 5 cm/>,21558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4951.6,,,,,,,fee schedule,2875.57,12757.95,
Resect neck tumor 5 cm/>,21558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5409.17,,,,,,,fee schedule,2875.57,12757.95,
Resect neck tumor 5 cm/>,21558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5686.98,,,,,,,fee schedule,2875.57,12757.95,
Resect neck tumor 5 cm/>,21558,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Resect neck tumor 5 cm/>,21558,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Resect neck tumor 5 cm/>,21558,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Resect neck tumor 5 cm/>,21558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Resect neck tumor 5 cm/>,21558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Resect neck tumor 5 cm/>,21558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Resect neck tumor 5 cm/>,21558,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Partial removal of rib,21600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,5839.66,31870.39,
Partial removal of rib,21600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,5839.66,31870.39,
Partial removal of rib,21600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,5839.66,31870.39,
Partial removal of rib,21600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,5839.66,31870.39,
Partial removal of rib,21600,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5839.66,31870.39,APC 378
Partial removal of rib,21600,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5839.66,31870.39,APC
Partial removal of rib,21600,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5839.66,31870.39,APC
Partial removal of rib,21600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5839.66,31870.39,APC
Partial removal of rib,21600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5839.66,31870.39,Radiology
Partial removal of rib,21600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5839.66,31870.39,APC
Partial removal of rib,21600,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5839.66,31870.39,APC
Exc chest wall tumor w/ribs,21601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8765.4,,,,,,,fee schedule,2875.57,12757.95,
Exc chest wall tumor w/ribs,21601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7026.24,,,,,,,fee schedule,2875.57,12757.95,
Exc chest wall tumor w/ribs,21601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7675.53,,,,,,,fee schedule,2875.57,12757.95,
Exc chest wall tumor w/ribs,21601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8069.74,,,,,,,fee schedule,2875.57,12757.95,
Exc chest wall tumor w/ribs,21601,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Exc chest wall tumor w/ribs,21601,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Exc chest wall tumor w/ribs,21601,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Exc chest wall tumor w/ribs,21601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Exc chest wall tumor w/ribs,21601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Exc chest wall tumor w/ribs,21601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Exc chest wall tumor w/ribs,21601,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Exc ch wal tum w/o lymphadec,21602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6130.67,,,,,,,fee schedule,4914.27,31870.39,
Exc ch wal tum w/o lymphadec,21602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4914.27,,,,,,,fee schedule,4914.27,31870.39,
Exc ch wal tum w/o lymphadec,21602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5368.39,,,,,,,fee schedule,4914.27,31870.39,
Exc ch wal tum w/o lymphadec,21602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5644.11,,,,,,,fee schedule,4914.27,31870.39,
Exc ch wal tum w/o lymphadec,21602,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,4914.27,31870.39,APC 378
Exc ch wal tum w/o lymphadec,21602,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,4914.27,31870.39,APC
Exc ch wal tum w/o lymphadec,21602,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,4914.27,31870.39,APC
Exc ch wal tum w/o lymphadec,21602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,4914.27,31870.39,APC
Exc ch wal tum w/o lymphadec,21602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,4914.27,31870.39,Radiology
Exc ch wal tum w/o lymphadec,21602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,4914.27,31870.39,APC
Exc ch wal tum w/o lymphadec,21602,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,4914.27,31870.39,APC
Exc ch wal tum w/lymphadec,21603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6802.37,,,,,,,fee schedule,5452.7,31870.39,
Exc ch wal tum w/lymphadec,21603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5452.7,,,,,,,fee schedule,5452.7,31870.39,
Exc ch wal tum w/lymphadec,21603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5956.58,,,,,,,fee schedule,5452.7,31870.39,
Exc ch wal tum w/lymphadec,21603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6262.5,,,,,,,fee schedule,5452.7,31870.39,
Exc ch wal tum w/lymphadec,21603,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5452.7,31870.39,APC 378
Exc ch wal tum w/lymphadec,21603,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5452.7,31870.39,APC
Exc ch wal tum w/lymphadec,21603,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5452.7,31870.39,APC
Exc ch wal tum w/lymphadec,21603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5452.7,31870.39,APC
Exc ch wal tum w/lymphadec,21603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5452.7,31870.39,Radiology
Exc ch wal tum w/lymphadec,21603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5452.7,31870.39,APC
Exc ch wal tum w/lymphadec,21603,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5452.7,31870.39,APC
Partial removal of rib,21610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,3239.17,14371.12,
Partial removal of rib,21610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,3239.17,14371.12,
Partial removal of rib,21610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,3239.17,14371.12,
Partial removal of rib,21610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,3239.17,14371.12,
Partial removal of rib,21610,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Partial removal of rib,21610,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Partial removal of rib,21610,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Partial removal of rib,21610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Partial removal of rib,21610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Partial removal of rib,21610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Partial removal of rib,21610,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of rib,21615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Removal of rib,21615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Removal of rib,21615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Removal of rib,21615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Removal of rib,21615,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Removal of rib,21615,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Removal of rib,21615,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Removal of rib,21615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Removal of rib,21615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Removal of rib,21615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Removal of rib,21615,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Removal of rib and nerves,21616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Removal of rib and nerves,21616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Removal of rib and nerves,21616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Removal of rib and nerves,21616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Removal of rib and nerves,21616,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Removal of rib and nerves,21616,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Removal of rib and nerves,21616,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Removal of rib and nerves,21616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Removal of rib and nerves,21616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Removal of rib and nerves,21616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Removal of rib and nerves,21616,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Partial removal of sternum,21620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,3239.17,23681.51,
Partial removal of sternum,21620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,3239.17,23681.51,
Partial removal of sternum,21620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,3239.17,23681.51,
Partial removal of sternum,21620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,3239.17,23681.51,
Partial removal of sternum,21620,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,23681.51,APC 378
Partial removal of sternum,21620,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,23681.51,APC
Partial removal of sternum,21620,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,23681.51,APC
Partial removal of sternum,21620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,23681.51,APC
Partial removal of sternum,21620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,23681.51,Radiology
Partial removal of sternum,21620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,23681.51,APC
Partial removal of sternum,21620,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,23681.51,APC
Sternal debridement,21627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,3239.17,23681.51,
Sternal debridement,21627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,3239.17,23681.51,
Sternal debridement,21627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,3239.17,23681.51,
Sternal debridement,21627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,3239.17,23681.51,
Sternal debridement,21627,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,23681.51,APC 378
Sternal debridement,21627,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,23681.51,APC
Sternal debridement,21627,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,23681.51,APC
Sternal debridement,21627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,23681.51,APC
Sternal debridement,21627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,23681.51,Radiology
Sternal debridement,21627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,23681.51,APC
Sternal debridement,21627,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,23681.51,APC
Extensive sternum surgery,21630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Extensive sternum surgery,21630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Extensive sternum surgery,21630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Extensive sternum surgery,21630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Extensive sternum surgery,21630,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Extensive sternum surgery,21630,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Extensive sternum surgery,21630,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Extensive sternum surgery,21630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Extensive sternum surgery,21630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Extensive sternum surgery,21630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Extensive sternum surgery,21630,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Extensive sternum surgery,21632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,18982.8,23681.51,
Extensive sternum surgery,21632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,18982.8,23681.51,
Extensive sternum surgery,21632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,18982.8,23681.51,
Extensive sternum surgery,21632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,18982.8,23681.51,
Hyoid myotomy & suspension,21685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1858.66,,,,,,,fee schedule,1489.88,26000.79,
Hyoid myotomy & suspension,21685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1489.88,,,,,,,fee schedule,1489.88,26000.79,
Hyoid myotomy & suspension,21685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1627.56,,,,,,,fee schedule,1489.88,26000.79,
Hyoid myotomy & suspension,21685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1711.15,,,,,,,fee schedule,1489.88,26000.79,
Hyoid myotomy & suspension,21685,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,1489.88,26000.79,APC 378
Hyoid myotomy & suspension,21685,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,1489.88,26000.79,APC
Hyoid myotomy & suspension,21685,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,1489.88,26000.79,APC
Hyoid myotomy & suspension,21685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,1489.88,26000.79,APC
Hyoid myotomy & suspension,21685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,1489.88,26000.79,Radiology
Hyoid myotomy & suspension,21685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,1489.88,26000.79,APC
Hyoid myotomy & suspension,21685,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,1489.88,26000.79,APC
Revision of neck muscle,21700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,4254.97,31870.39,
Revision of neck muscle,21700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,4254.97,31870.39,
Revision of neck muscle,21700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,4254.97,31870.39,
Revision of neck muscle,21700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,4254.97,31870.39,
Revision of neck muscle,21700,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,4254.97,31870.39,APC 378
Revision of neck muscle,21700,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,4254.97,31870.39,APC
Revision of neck muscle,21700,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,4254.97,31870.39,APC
Revision of neck muscle,21700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,4254.97,31870.39,APC
Revision of neck muscle,21700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,4254.97,31870.39,Radiology
Revision of neck muscle,21700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,4254.97,31870.39,APC
Revision of neck muscle,21700,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,4254.97,31870.39,APC
Revision of neck muscle/rib,21705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Revision of neck muscle/rib,21705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Revision of neck muscle/rib,21705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Revision of neck muscle/rib,21705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Revision of neck muscle/rib,21705,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Revision of neck muscle/rib,21705,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Revision of neck muscle/rib,21705,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Revision of neck muscle/rib,21705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Revision of neck muscle/rib,21705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Revision of neck muscle/rib,21705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Revision of neck muscle/rib,21705,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Revision of neck muscle,21720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,3239.17,14371.12,
Revision of neck muscle,21720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,3239.17,14371.12,
Revision of neck muscle,21720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,3239.17,14371.12,
Revision of neck muscle,21720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,3239.17,14371.12,
Revision of neck muscle,21720,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Revision of neck muscle,21720,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Revision of neck muscle,21720,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Revision of neck muscle,21720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Revision of neck muscle,21720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Revision of neck muscle,21720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Revision of neck muscle,21720,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Revision of neck muscle,21725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,351.05,,,,,,,fee schedule,281.4,3110.22,
Revision of neck muscle,21725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,281.4,,,,,,,fee schedule,281.4,3110.22,
Revision of neck muscle,21725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,307.4,,,,,,,fee schedule,281.4,3110.22,
Revision of neck muscle,21725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,323.19,,,,,,,fee schedule,281.4,3110.22,
Revision of neck muscle,21725,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3110.22,,,,,,,fee schedule,281.4,3110.22,APC 378
Revision of neck muscle,21725,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,736.08,,,,,,,fee schedule,281.4,3110.22,APC
Revision of neck muscle,21725,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,729.07,,,,,,,fee schedule,281.4,3110.22,APC
Revision of neck muscle,21725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,701.03,,,,,,,fee schedule,281.4,3110.22,APC
Revision of neck muscle,21725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1072.57,,,,,,,fee schedule,281.4,3110.22,Radiology
Revision of neck muscle,21725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,981.44,,,,,,,fee schedule,281.4,3110.22,APC
Revision of neck muscle,21725,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1226.8,,,,,,,fee schedule,281.4,3110.22,APC
Reconstruction of sternum,21740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Reconstruction of sternum,21740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Reconstruction of sternum,21740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Reconstruction of sternum,21740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Reconstruction of sternum,21740,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Reconstruction of sternum,21740,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Reconstruction of sternum,21740,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Reconstruction of sternum,21740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Reconstruction of sternum,21740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Reconstruction of sternum,21740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Reconstruction of sternum,21740,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Repair stern/nuss w/o scope,21742,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10728.02,,,,,,,fee schedule,3239.17,14371.12,
Repair stern/nuss w/o scope,21742,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8599.44,,,,,,,fee schedule,3239.17,14371.12,
Repair stern/nuss w/o scope,21742,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9394.11,,,,,,,fee schedule,3239.17,14371.12,
Repair stern/nuss w/o scope,21742,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9876.59,,,,,,,fee schedule,3239.17,14371.12,
Repair stern/nuss w/o scope,21742,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Repair stern/nuss w/o scope,21742,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Repair stern/nuss w/o scope,21742,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Repair stern/nuss w/o scope,21742,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Repair stern/nuss w/o scope,21742,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Repair stern/nuss w/o scope,21742,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Repair stern/nuss w/o scope,21742,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Repair sternum/nuss w/scope,21743,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10728.02,,,,,,,fee schedule,3239.17,14371.12,
Repair sternum/nuss w/scope,21743,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8599.44,,,,,,,fee schedule,3239.17,14371.12,
Repair sternum/nuss w/scope,21743,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9394.11,,,,,,,fee schedule,3239.17,14371.12,
Repair sternum/nuss w/scope,21743,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9876.59,,,,,,,fee schedule,3239.17,14371.12,
Repair sternum/nuss w/scope,21743,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Repair sternum/nuss w/scope,21743,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Repair sternum/nuss w/scope,21743,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Repair sternum/nuss w/scope,21743,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Repair sternum/nuss w/scope,21743,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Repair sternum/nuss w/scope,21743,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Repair sternum/nuss w/scope,21743,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Repair of sternum separation,21750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Repair of sternum separation,21750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Repair of sternum separation,21750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Repair of sternum separation,21750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Repair of sternum separation,21750,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Repair of sternum separation,21750,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Repair of sternum separation,21750,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Repair of sternum separation,21750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Repair of sternum separation,21750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Repair of sternum separation,21750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Repair of sternum separation,21750,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Optx of rib fx w/fixj scope,21811,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7721.22,,,,,,,fee schedule,6189.23,31870.39,
Optx of rib fx w/fixj scope,21811,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6189.23,,,,,,,fee schedule,6189.23,31870.39,
Optx of rib fx w/fixj scope,21811,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6761.17,,,,,,,fee schedule,6189.23,31870.39,
Optx of rib fx w/fixj scope,21811,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7108.42,,,,,,,fee schedule,6189.23,31870.39,
Optx of rib fx w/fixj scope,21811,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,6189.23,31870.39,APC 378
Optx of rib fx w/fixj scope,21811,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,6189.23,31870.39,APC
Optx of rib fx w/fixj scope,21811,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,6189.23,31870.39,APC
Optx of rib fx w/fixj scope,21811,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,6189.23,31870.39,APC
Optx of rib fx w/fixj scope,21811,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,6189.23,31870.39,Radiology
Optx of rib fx w/fixj scope,21811,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,6189.23,31870.39,APC
Optx of rib fx w/fixj scope,21811,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,6189.23,31870.39,APC
Treatment of rib fracture,21812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7721.22,,,,,,,fee schedule,6189.23,31870.39,
Treatment of rib fracture,21812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6189.23,,,,,,,fee schedule,6189.23,31870.39,
Treatment of rib fracture,21812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6761.17,,,,,,,fee schedule,6189.23,31870.39,
Treatment of rib fracture,21812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7108.42,,,,,,,fee schedule,6189.23,31870.39,
Treatment of rib fracture,21812,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,6189.23,31870.39,APC 378
Treatment of rib fracture,21812,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,6189.23,31870.39,APC
Treatment of rib fracture,21812,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,6189.23,31870.39,APC
Treatment of rib fracture,21812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,6189.23,31870.39,APC
Treatment of rib fracture,21812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,6189.23,31870.39,Radiology
Treatment of rib fracture,21812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,6189.23,31870.39,APC
Treatment of rib fracture,21812,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,6189.23,31870.39,APC
Treatment of rib fracture,21813,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7721.22,,,,,,,fee schedule,1591.86,7721.22,
Treatment of rib fracture,21813,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6189.23,,,,,,,fee schedule,1591.86,7721.22,
Treatment of rib fracture,21813,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6761.17,,,,,,,fee schedule,1591.86,7721.22,
Treatment of rib fracture,21813,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7108.42,,,,,,,fee schedule,1591.86,7721.22,
Treatment of rib fracture,21813,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7721.22,APC 378
Treatment of rib fracture,21813,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7721.22,APC
Treatment of rib fracture,21813,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7721.22,APC
Treatment of rib fracture,21813,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7721.22,APC
Treatment of rib fracture,21813,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7721.22,Radiology
Treatment of rib fracture,21813,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7721.22,APC
Treatment of rib fracture,21813,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7721.22,APC
Treat sternum fracture,21820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,244.19,1083.4,
Treat sternum fracture,21820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,244.19,1083.4,
Treat sternum fracture,21820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,244.19,1083.4,
Treat sternum fracture,21820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,244.19,1083.4,
Treat sternum fracture,21820,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treat sternum fracture,21820,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treat sternum fracture,21820,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treat sternum fracture,21820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treat sternum fracture,21820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treat sternum fracture,21820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treat sternum fracture,21820,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treat sternum fracture,21825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Treat sternum fracture,21825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Treat sternum fracture,21825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Treat sternum fracture,21825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Treat sternum fracture,21825,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Treat sternum fracture,21825,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Treat sternum fracture,21825,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Treat sternum fracture,21825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Treat sternum fracture,21825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Treat sternum fracture,21825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Treat sternum fracture,21825,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Neck/chest surgery procedure,21899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,624,,,,,,,fee schedule,234.47,1040.28,
Neck/chest surgery procedure,21899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,500.19,,,,,,,fee schedule,234.47,1040.28,
Neck/chest surgery procedure,21899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,546.41,,,,,,,fee schedule,234.47,1040.28,
Neck/chest surgery procedure,21899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,574.48,,,,,,,fee schedule,234.47,1040.28,
Neck/chest surgery procedure,21899,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1040.28,,,,,,,fee schedule,234.47,1040.28,APC 378
Neck/chest surgery procedure,21899,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,246.2,,,,,,,fee schedule,234.47,1040.28,APC
Neck/chest surgery procedure,21899,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,243.85,,,,,,,fee schedule,234.47,1040.28,APC
Neck/chest surgery procedure,21899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,234.47,,,,,,,fee schedule,234.47,1040.28,APC
Neck/chest surgery procedure,21899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,358.74,,,,,,,fee schedule,234.47,1040.28,Radiology
Neck/chest surgery procedure,21899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,328.26,,,,,,,fee schedule,234.47,1040.28,APC
Neck/chest surgery procedure,21899,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,410.33,,,,,,,fee schedule,234.47,1040.28,APC
Biopsy soft tissue of back,21920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2167.57,,,,,,,fee schedule,1635.03,7254.06,
Biopsy soft tissue of back,21920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1737.49,,,,,,,fee schedule,1635.03,7254.06,
Biopsy soft tissue of back,21920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1898.05,,,,,,,fee schedule,1635.03,7254.06,
Biopsy soft tissue of back,21920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1995.54,,,,,,,fee schedule,1635.03,7254.06,
Biopsy soft tissue of back,21920,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,7254.06,APC 378
Biopsy soft tissue of back,21920,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,7254.06,APC
Biopsy soft tissue of back,21920,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,7254.06,APC
Biopsy soft tissue of back,21920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,7254.06,APC
Biopsy soft tissue of back,21920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,7254.06,Radiology
Biopsy soft tissue of back,21920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,7254.06,APC
Biopsy soft tissue of back,21920,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,7254.06,APC
Biopsy soft tissue of back,21925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5268.49,,,,,,,fee schedule,1635.03,7254.06,
Biopsy soft tissue of back,21925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4223.15,,,,,,,fee schedule,1635.03,7254.06,
Biopsy soft tissue of back,21925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4613.41,,,,,,,fee schedule,1635.03,7254.06,
Biopsy soft tissue of back,21925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4850.35,,,,,,,fee schedule,1635.03,7254.06,
Biopsy soft tissue of back,21925,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,7254.06,APC 378
Biopsy soft tissue of back,21925,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,7254.06,APC
Biopsy soft tissue of back,21925,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,7254.06,APC
Biopsy soft tissue of back,21925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,7254.06,APC
Biopsy soft tissue of back,21925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,7254.06,Radiology
Biopsy soft tissue of back,21925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,7254.06,APC
Biopsy soft tissue of back,21925,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,7254.06,APC
Exc back les sc < 3 cm,21930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1597.7,,,,,,,fee schedule,1280.7,7254.06,
Exc back les sc < 3 cm,21930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1280.7,,,,,,,fee schedule,1280.7,7254.06,
Exc back les sc < 3 cm,21930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1399.05,,,,,,,fee schedule,1280.7,7254.06,
Exc back les sc < 3 cm,21930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1470.9,,,,,,,fee schedule,1280.7,7254.06,
Exc back les sc < 3 cm,21930,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1280.7,7254.06,APC 378
Exc back les sc < 3 cm,21930,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1280.7,7254.06,APC
Exc back les sc < 3 cm,21930,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1280.7,7254.06,APC
Exc back les sc < 3 cm,21930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1280.7,7254.06,APC
Exc back les sc < 3 cm,21930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1280.7,7254.06,Radiology
Exc back les sc < 3 cm,21930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1280.7,7254.06,APC
Exc back les sc < 3 cm,21930,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1280.7,7254.06,APC
Exc back les sc 3 cm/>,21931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6095.71,,,,,,,fee schedule,1635.03,7254.06,
Exc back les sc 3 cm/>,21931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4886.25,,,,,,,fee schedule,1635.03,7254.06,
Exc back les sc 3 cm/>,21931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5337.78,,,,,,,fee schedule,1635.03,7254.06,
Exc back les sc 3 cm/>,21931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5611.93,,,,,,,fee schedule,1635.03,7254.06,
Exc back les sc 3 cm/>,21931,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,7254.06,APC 378
Exc back les sc 3 cm/>,21931,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,7254.06,APC
Exc back les sc 3 cm/>,21931,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,7254.06,APC
Exc back les sc 3 cm/>,21931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,7254.06,APC
Exc back les sc 3 cm/>,21931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,7254.06,Radiology
Exc back les sc 3 cm/>,21931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,7254.06,APC
Exc back les sc 3 cm/>,21931,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,7254.06,APC
Exc back tum deep < 5 cm,21932,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6721.57,,,,,,,fee schedule,2875.57,12757.95,
Exc back tum deep < 5 cm,21932,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5387.93,,,,,,,fee schedule,2875.57,12757.95,
Exc back tum deep < 5 cm,21932,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5885.82,,,,,,,fee schedule,2875.57,12757.95,
Exc back tum deep < 5 cm,21932,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6188.11,,,,,,,fee schedule,2875.57,12757.95,
Exc back tum deep < 5 cm,21932,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Exc back tum deep < 5 cm,21932,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Exc back tum deep < 5 cm,21932,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Exc back tum deep < 5 cm,21932,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Exc back tum deep < 5 cm,21932,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Exc back tum deep < 5 cm,21932,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Exc back tum deep < 5 cm,21932,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Exc back tum deep 5 cm/>,21933,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6955.63,,,,,,,fee schedule,2875.57,12757.95,
Exc back tum deep 5 cm/>,21933,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5575.54,,,,,,,fee schedule,2875.57,12757.95,
Exc back tum deep 5 cm/>,21933,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6090.78,,,,,,,fee schedule,2875.57,12757.95,
Exc back tum deep 5 cm/>,21933,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6403.59,,,,,,,fee schedule,2875.57,12757.95,
Exc back tum deep 5 cm/>,21933,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Exc back tum deep 5 cm/>,21933,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Exc back tum deep 5 cm/>,21933,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Exc back tum deep 5 cm/>,21933,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Exc back tum deep 5 cm/>,21933,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Exc back tum deep 5 cm/>,21933,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Exc back tum deep 5 cm/>,21933,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Resect back tum < 5 cm,21935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5268.49,,,,,,,fee schedule,2875.57,12757.95,
Resect back tum < 5 cm,21935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4223.15,,,,,,,fee schedule,2875.57,12757.95,
Resect back tum < 5 cm,21935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4613.41,,,,,,,fee schedule,2875.57,12757.95,
Resect back tum < 5 cm,21935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4850.35,,,,,,,fee schedule,2875.57,12757.95,
Resect back tum < 5 cm,21935,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Resect back tum < 5 cm,21935,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Resect back tum < 5 cm,21935,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Resect back tum < 5 cm,21935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Resect back tum < 5 cm,21935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Resect back tum < 5 cm,21935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Resect back tum < 5 cm,21935,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Resect back tum 5 cm/>,21936,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6177.24,,,,,,,fee schedule,2875.57,12757.95,
Resect back tum 5 cm/>,21936,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4951.6,,,,,,,fee schedule,2875.57,12757.95,
Resect back tum 5 cm/>,21936,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5409.17,,,,,,,fee schedule,2875.57,12757.95,
Resect back tum 5 cm/>,21936,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5686.98,,,,,,,fee schedule,2875.57,12757.95,
Resect back tum 5 cm/>,21936,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Resect back tum 5 cm/>,21936,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Resect back tum 5 cm/>,21936,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Resect back tum 5 cm/>,21936,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Resect back tum 5 cm/>,21936,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Resect back tum 5 cm/>,21936,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Resect back tum 5 cm/>,21936,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
I&d p-spine c/t/cerv-thor,22010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
I&d p-spine c/t/cerv-thor,22010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
I&d p-spine c/t/cerv-thor,22010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
I&d p-spine c/t/cerv-thor,22010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
I&d p-spine c/t/cerv-thor,22010,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
I&d p-spine c/t/cerv-thor,22010,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
I&d p-spine c/t/cerv-thor,22010,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
I&d p-spine c/t/cerv-thor,22010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
I&d p-spine c/t/cerv-thor,22010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
I&d p-spine c/t/cerv-thor,22010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
I&d p-spine c/t/cerv-thor,22010,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
I&d abscess p-spine l/s/ls,22015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
I&d abscess p-spine l/s/ls,22015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
I&d abscess p-spine l/s/ls,22015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
I&d abscess p-spine l/s/ls,22015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
I&d abscess p-spine l/s/ls,22015,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
I&d abscess p-spine l/s/ls,22015,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
I&d abscess p-spine l/s/ls,22015,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
I&d abscess p-spine l/s/ls,22015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
I&d abscess p-spine l/s/ls,22015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
I&d abscess p-spine l/s/ls,22015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
I&d abscess p-spine l/s/ls,22015,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Remove part of neck vertebra,22100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11673.24,,,,,,,fee schedule,7183.42,31870.39,
Remove part of neck vertebra,22100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9357.12,,,,,,,fee schedule,7183.42,31870.39,
Remove part of neck vertebra,22100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10221.81,,,,,,,fee schedule,7183.42,31870.39,
Remove part of neck vertebra,22100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10746.8,,,,,,,fee schedule,7183.42,31870.39,
Remove part of neck vertebra,22100,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Remove part of neck vertebra,22100,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Remove part of neck vertebra,22100,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Remove part of neck vertebra,22100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Remove part of neck vertebra,22100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Remove part of neck vertebra,22100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Remove part of neck vertebra,22100,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Remove part thorax vertebra,22101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11673.24,,,,,,,fee schedule,7183.42,31870.39,
Remove part thorax vertebra,22101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9357.12,,,,,,,fee schedule,7183.42,31870.39,
Remove part thorax vertebra,22101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10221.81,,,,,,,fee schedule,7183.42,31870.39,
Remove part thorax vertebra,22101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10746.8,,,,,,,fee schedule,7183.42,31870.39,
Remove part thorax vertebra,22101,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Remove part thorax vertebra,22101,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Remove part thorax vertebra,22101,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Remove part thorax vertebra,22101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Remove part thorax vertebra,22101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Remove part thorax vertebra,22101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Remove part thorax vertebra,22101,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Remove part lumbar vertebra,22102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11673.24,,,,,,,fee schedule,7183.42,31870.39,
Remove part lumbar vertebra,22102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9357.12,,,,,,,fee schedule,7183.42,31870.39,
Remove part lumbar vertebra,22102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10221.81,,,,,,,fee schedule,7183.42,31870.39,
Remove part lumbar vertebra,22102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10746.8,,,,,,,fee schedule,7183.42,31870.39,
Remove part lumbar vertebra,22102,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Remove part lumbar vertebra,22102,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Remove part lumbar vertebra,22102,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Remove part lumbar vertebra,22102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Remove part lumbar vertebra,22102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Remove part lumbar vertebra,22102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Remove part lumbar vertebra,22102,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Remove extra spine segment,22103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11673.24,,,,,,,fee schedule,9357.12,11673.24,
Remove extra spine segment,22103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9357.12,,,,,,,fee schedule,9357.12,11673.24,
Remove extra spine segment,22103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10221.81,,,,,,,fee schedule,9357.12,11673.24,
Remove extra spine segment,22103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10746.8,,,,,,,fee schedule,9357.12,11673.24,
Remove part of neck vertebra,22110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Remove part of neck vertebra,22110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Remove part of neck vertebra,22110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Remove part of neck vertebra,22110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Remove part of neck vertebra,22110,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Remove part of neck vertebra,22110,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Remove part of neck vertebra,22110,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Remove part of neck vertebra,22110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Remove part of neck vertebra,22110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Remove part of neck vertebra,22110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Remove part of neck vertebra,22110,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Remove part thorax vertebra,22112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Remove part thorax vertebra,22112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Remove part thorax vertebra,22112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Remove part thorax vertebra,22112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Remove part thorax vertebra,22112,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Remove part thorax vertebra,22112,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Remove part thorax vertebra,22112,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Remove part thorax vertebra,22112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Remove part thorax vertebra,22112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Remove part thorax vertebra,22112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Remove part thorax vertebra,22112,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Remove part lumbar vertebra,22114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Remove part lumbar vertebra,22114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Remove part lumbar vertebra,22114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Remove part lumbar vertebra,22114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Remove part lumbar vertebra,22114,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Remove part lumbar vertebra,22114,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Remove part lumbar vertebra,22114,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Remove part lumbar vertebra,22114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Remove part lumbar vertebra,22114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Remove part lumbar vertebra,22114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Remove part lumbar vertebra,22114,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Incis spine 3 column thorac,22206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Incis spine 3 column thorac,22206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Incis spine 3 column thorac,22206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Incis spine 3 column thorac,22206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Incis spine 3 column thorac,22206,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Incis spine 3 column thorac,22206,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Incis spine 3 column thorac,22206,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Incis spine 3 column thorac,22206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Incis spine 3 column thorac,22206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Incis spine 3 column thorac,22206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Incis spine 3 column thorac,22206,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Incis spine 3 column lumbar,22207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Incis spine 3 column lumbar,22207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Incis spine 3 column lumbar,22207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Incis spine 3 column lumbar,22207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Incis spine 3 column lumbar,22207,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Incis spine 3 column lumbar,22207,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Incis spine 3 column lumbar,22207,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Incis spine 3 column lumbar,22207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Incis spine 3 column lumbar,22207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Incis spine 3 column lumbar,22207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Incis spine 3 column lumbar,22207,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Incis 1 vertebral seg cerv,22210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Incis 1 vertebral seg cerv,22210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Incis 1 vertebral seg cerv,22210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Incis 1 vertebral seg cerv,22210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Incis 1 vertebral seg cerv,22210,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Incis 1 vertebral seg cerv,22210,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Incis 1 vertebral seg cerv,22210,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Incis 1 vertebral seg cerv,22210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Incis 1 vertebral seg cerv,22210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Incis 1 vertebral seg cerv,22210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Incis 1 vertebral seg cerv,22210,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Incis 1 vertebral seg thorac,22212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Incis 1 vertebral seg thorac,22212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Incis 1 vertebral seg thorac,22212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Incis 1 vertebral seg thorac,22212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Incis 1 vertebral seg thorac,22212,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Incis 1 vertebral seg thorac,22212,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Incis 1 vertebral seg thorac,22212,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Incis 1 vertebral seg thorac,22212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Incis 1 vertebral seg thorac,22212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Incis 1 vertebral seg thorac,22212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Incis 1 vertebral seg thorac,22212,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Incis 1 vertebral seg lumbar,22214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Incis 1 vertebral seg lumbar,22214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Incis 1 vertebral seg lumbar,22214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Incis 1 vertebral seg lumbar,22214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Incis 1 vertebral seg lumbar,22214,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Incis 1 vertebral seg lumbar,22214,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Incis 1 vertebral seg lumbar,22214,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Incis 1 vertebral seg lumbar,22214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Incis 1 vertebral seg lumbar,22214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Incis 1 vertebral seg lumbar,22214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Incis 1 vertebral seg lumbar,22214,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Incis w/discectomy cervical,22220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Incis w/discectomy cervical,22220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Incis w/discectomy cervical,22220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Incis w/discectomy cervical,22220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Incis w/discectomy cervical,22220,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Incis w/discectomy cervical,22220,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Incis w/discectomy cervical,22220,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Incis w/discectomy cervical,22220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Incis w/discectomy cervical,22220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Incis w/discectomy cervical,22220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Incis w/discectomy cervical,22220,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Incis w/discectomy thoracic,22222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11673.24,,,,,,,fee schedule,7183.42,31870.39,
Incis w/discectomy thoracic,22222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9357.12,,,,,,,fee schedule,7183.42,31870.39,
Incis w/discectomy thoracic,22222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10221.81,,,,,,,fee schedule,7183.42,31870.39,
Incis w/discectomy thoracic,22222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10746.8,,,,,,,fee schedule,7183.42,31870.39,
Incis w/discectomy thoracic,22222,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Incis w/discectomy thoracic,22222,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Incis w/discectomy thoracic,22222,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Incis w/discectomy thoracic,22222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Incis w/discectomy thoracic,22222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Incis w/discectomy thoracic,22222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Incis w/discectomy thoracic,22222,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Incis w/discectomy lumbar,22224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Incis w/discectomy lumbar,22224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Incis w/discectomy lumbar,22224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Incis w/discectomy lumbar,22224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Incis w/discectomy lumbar,22224,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Incis w/discectomy lumbar,22224,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Incis w/discectomy lumbar,22224,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Incis w/discectomy lumbar,22224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Incis w/discectomy lumbar,22224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Incis w/discectomy lumbar,22224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Incis w/discectomy lumbar,22224,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Closed tx vert fx w/o manj,22310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,244.19,1083.4,
Closed tx vert fx w/o manj,22310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,244.19,1083.4,
Closed tx vert fx w/o manj,22310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,244.19,1083.4,
Closed tx vert fx w/o manj,22310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,244.19,1083.4,
Closed tx vert fx w/o manj,22310,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Closed tx vert fx w/o manj,22310,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Closed tx vert fx w/o manj,22310,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Closed tx vert fx w/o manj,22310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Closed tx vert fx w/o manj,22310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Closed tx vert fx w/o manj,22310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Closed tx vert fx w/o manj,22310,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Closed tx vert fx w/manj,22315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,353.72,14371.12,
Closed tx vert fx w/manj,22315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,353.72,14371.12,
Closed tx vert fx w/manj,22315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,353.72,14371.12,
Closed tx vert fx w/manj,22315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,353.72,14371.12,
Closed tx vert fx w/manj,22315,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,353.72,14371.12,APC 378
Closed tx vert fx w/manj,22315,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,353.72,14371.12,APC
Closed tx vert fx w/manj,22315,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,353.72,14371.12,APC
Closed tx vert fx w/manj,22315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,353.72,14371.12,APC
Closed tx vert fx w/manj,22315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,353.72,14371.12,Radiology
Closed tx vert fx w/manj,22315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,353.72,14371.12,APC
Closed tx vert fx w/manj,22315,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,353.72,14371.12,APC
Treat odontoid fx w/o graft,22318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46549.79,,,,,,,fee schedule,12709.88,56389.43,
Treat odontoid fx w/o graft,22318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37313.72,,,,,,,fee schedule,12709.88,56389.43,
Treat odontoid fx w/o graft,22318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40761.86,,,,,,,fee schedule,12709.88,56389.43,
Treat odontoid fx w/o graft,22318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42855.36,,,,,,,fee schedule,12709.88,56389.43,
Treat odontoid fx w/o graft,22318,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,12709.88,56389.43,APC 378
Treat odontoid fx w/o graft,22318,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,12709.88,56389.43,APC
Treat odontoid fx w/o graft,22318,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,12709.88,56389.43,APC
Treat odontoid fx w/o graft,22318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,12709.88,56389.43,APC
Treat odontoid fx w/o graft,22318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,12709.88,56389.43,Radiology
Treat odontoid fx w/o graft,22318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,12709.88,56389.43,APC
Treat odontoid fx w/o graft,22318,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,12709.88,56389.43,APC
Treat odontoid fx w/graft,22319,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46549.79,,,,,,,fee schedule,12709.88,56389.43,
Treat odontoid fx w/graft,22319,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37313.72,,,,,,,fee schedule,12709.88,56389.43,
Treat odontoid fx w/graft,22319,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40761.86,,,,,,,fee schedule,12709.88,56389.43,
Treat odontoid fx w/graft,22319,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42855.36,,,,,,,fee schedule,12709.88,56389.43,
Treat odontoid fx w/graft,22319,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,12709.88,56389.43,APC 378
Treat odontoid fx w/graft,22319,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,12709.88,56389.43,APC
Treat odontoid fx w/graft,22319,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,12709.88,56389.43,APC
Treat odontoid fx w/graft,22319,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,12709.88,56389.43,APC
Treat odontoid fx w/graft,22319,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,12709.88,56389.43,Radiology
Treat odontoid fx w/graft,22319,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,12709.88,56389.43,APC
Treat odontoid fx w/graft,22319,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,12709.88,56389.43,APC
Treat spine fracture,22325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46549.79,,,,,,,fee schedule,12709.88,56389.43,
Treat spine fracture,22325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37313.72,,,,,,,fee schedule,12709.88,56389.43,
Treat spine fracture,22325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40761.86,,,,,,,fee schedule,12709.88,56389.43,
Treat spine fracture,22325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42855.36,,,,,,,fee schedule,12709.88,56389.43,
Treat spine fracture,22325,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,12709.88,56389.43,APC 378
Treat spine fracture,22325,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,12709.88,56389.43,APC
Treat spine fracture,22325,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,12709.88,56389.43,APC
Treat spine fracture,22325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,12709.88,56389.43,APC
Treat spine fracture,22325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,12709.88,56389.43,Radiology
Treat spine fracture,22325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,12709.88,56389.43,APC
Treat spine fracture,22325,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,12709.88,56389.43,APC
Treat neck spine fracture,22326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46549.79,,,,,,,fee schedule,12709.88,56389.43,
Treat neck spine fracture,22326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37313.72,,,,,,,fee schedule,12709.88,56389.43,
Treat neck spine fracture,22326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40761.86,,,,,,,fee schedule,12709.88,56389.43,
Treat neck spine fracture,22326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42855.36,,,,,,,fee schedule,12709.88,56389.43,
Treat neck spine fracture,22326,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,12709.88,56389.43,APC 378
Treat neck spine fracture,22326,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,12709.88,56389.43,APC
Treat neck spine fracture,22326,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,12709.88,56389.43,APC
Treat neck spine fracture,22326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,12709.88,56389.43,APC
Treat neck spine fracture,22326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,12709.88,56389.43,Radiology
Treat neck spine fracture,22326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,12709.88,56389.43,APC
Treat neck spine fracture,22326,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,12709.88,56389.43,APC
Treat thorax spine fracture,22327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46549.79,,,,,,,fee schedule,12709.88,56389.43,
Treat thorax spine fracture,22327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37313.72,,,,,,,fee schedule,12709.88,56389.43,
Treat thorax spine fracture,22327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40761.86,,,,,,,fee schedule,12709.88,56389.43,
Treat thorax spine fracture,22327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42855.36,,,,,,,fee schedule,12709.88,56389.43,
Treat thorax spine fracture,22327,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,12709.88,56389.43,APC 378
Treat thorax spine fracture,22327,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,12709.88,56389.43,APC
Treat thorax spine fracture,22327,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,12709.88,56389.43,APC
Treat thorax spine fracture,22327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,12709.88,56389.43,APC
Treat thorax spine fracture,22327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,12709.88,56389.43,Radiology
Treat thorax spine fracture,22327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,12709.88,56389.43,APC
Treat thorax spine fracture,22327,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,12709.88,56389.43,APC
Manipulation of spine,22505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3685.16,,,,,,,fee schedule,1591.86,7062.54,
Manipulation of spine,22505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2953.98,,,,,,,fee schedule,1591.86,7062.54,
Manipulation of spine,22505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3226.95,,,,,,,fee schedule,1591.86,7062.54,
Manipulation of spine,22505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3392.69,,,,,,,fee schedule,1591.86,7062.54,
Manipulation of spine,22505,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Manipulation of spine,22505,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Manipulation of spine,22505,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Manipulation of spine,22505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Manipulation of spine,22505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Manipulation of spine,22505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Manipulation of spine,22505,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Perq cervicothoracic inject,22510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9836.05,,,,,,,fee schedule,3239.17,14371.12,
Perq cervicothoracic inject,22510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7884.45,,,,,,,fee schedule,3239.17,14371.12,
Perq cervicothoracic inject,22510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8613.05,,,,,,,fee schedule,3239.17,14371.12,
Perq cervicothoracic inject,22510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9055.41,,,,,,,fee schedule,3239.17,14371.12,
Perq cervicothoracic inject,22510,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Perq cervicothoracic inject,22510,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Perq cervicothoracic inject,22510,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Perq cervicothoracic inject,22510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Perq cervicothoracic inject,22510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Perq cervicothoracic inject,22510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Perq cervicothoracic inject,22510,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Perq lumbosacral injection,22511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9836.05,,,,,,,fee schedule,3239.17,14371.12,
Perq lumbosacral injection,22511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7884.45,,,,,,,fee schedule,3239.17,14371.12,
Perq lumbosacral injection,22511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8613.05,,,,,,,fee schedule,3239.17,14371.12,
Perq lumbosacral injection,22511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9055.41,,,,,,,fee schedule,3239.17,14371.12,
Perq lumbosacral injection,22511,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Perq lumbosacral injection,22511,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Perq lumbosacral injection,22511,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Perq lumbosacral injection,22511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Perq lumbosacral injection,22511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Perq lumbosacral injection,22511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Perq lumbosacral injection,22511,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Vertebroplasty addl inject,22512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,824.19,,,,,,,fee schedule,660.66,824.19,
Vertebroplasty addl inject,22512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,660.66,,,,,,,fee schedule,660.66,824.19,
Vertebroplasty addl inject,22512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,721.71,,,,,,,fee schedule,660.66,824.19,
Vertebroplasty addl inject,22512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,758.78,,,,,,,fee schedule,660.66,824.19,
Perq vertebral augmentation,22513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7657.8,,,,,,,fee schedule,6138.4,31870.39,
Perq vertebral augmentation,22513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6138.4,,,,,,,fee schedule,6138.4,31870.39,
Perq vertebral augmentation,22513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6705.64,,,,,,,fee schedule,6138.4,31870.39,
Perq vertebral augmentation,22513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7050.04,,,,,,,fee schedule,6138.4,31870.39,
Perq vertebral augmentation,22513,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,6138.4,31870.39,APC 378
Perq vertebral augmentation,22513,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,6138.4,31870.39,APC
Perq vertebral augmentation,22513,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,6138.4,31870.39,APC
Perq vertebral augmentation,22513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,6138.4,31870.39,APC
Perq vertebral augmentation,22513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,6138.4,31870.39,Radiology
Perq vertebral augmentation,22513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,6138.4,31870.39,APC
Perq vertebral augmentation,22513,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,6138.4,31870.39,APC
Perq vertebral augmentation,22514,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9260.45,,,,,,,fee schedule,7183.42,31870.39,
Perq vertebral augmentation,22514,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7423.06,,,,,,,fee schedule,7183.42,31870.39,
Perq vertebral augmentation,22514,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8109.01,,,,,,,fee schedule,7183.42,31870.39,
Perq vertebral augmentation,22514,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8525.49,,,,,,,fee schedule,7183.42,31870.39,
Perq vertebral augmentation,22514,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Perq vertebral augmentation,22514,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Perq vertebral augmentation,22514,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Perq vertebral augmentation,22514,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Perq vertebral augmentation,22514,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Perq vertebral augmentation,22514,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Perq vertebral augmentation,22514,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Perq vertebral augmentation,22515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,892.91,,,,,,,fee schedule,715.75,892.91,
Perq vertebral augmentation,22515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,715.75,,,,,,,fee schedule,715.75,892.91,
Perq vertebral augmentation,22515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,781.89,,,,,,,fee schedule,715.75,892.91,
Perq vertebral augmentation,22515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,822.05,,,,,,,fee schedule,715.75,892.91,
Idet single level,22526,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,5839.66,7285.12,
Idet single level,22526,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,5839.66,7285.12,
Idet single level,22526,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,5839.66,7285.12,
Idet single level,22526,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,5839.66,7285.12,
Idet 1 or more levels,22527,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,5839.66,7285.12,
Idet 1 or more levels,22527,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,5839.66,7285.12,
Idet 1 or more levels,22527,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,5839.66,7285.12,
Idet 1 or more levels,22527,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,5839.66,7285.12,
Lat thorax spine fusion,22532,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59981.53,,,,,,,fee schedule,12709.88,59981.53,
Lat thorax spine fusion,22532,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48080.43,,,,,,,fee schedule,12709.88,59981.53,
Lat thorax spine fusion,22532,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52523.51,,,,,,,fee schedule,12709.88,59981.53,
Lat thorax spine fusion,22532,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55221.09,,,,,,,fee schedule,12709.88,59981.53,
Lat thorax spine fusion,22532,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,12709.88,59981.53,APC 378
Lat thorax spine fusion,22532,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,12709.88,59981.53,APC
Lat thorax spine fusion,22532,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,12709.88,59981.53,APC
Lat thorax spine fusion,22532,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,12709.88,59981.53,APC
Lat thorax spine fusion,22532,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,12709.88,59981.53,Radiology
Lat thorax spine fusion,22532,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,12709.88,59981.53,APC
Lat thorax spine fusion,22532,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,12709.88,59981.53,APC
Lat lumbar spine fusion,22533,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59981.53,,,,,,,fee schedule,17357.91,77011.17,
Lat lumbar spine fusion,22533,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48080.43,,,,,,,fee schedule,17357.91,77011.17,
Lat lumbar spine fusion,22533,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52523.51,,,,,,,fee schedule,17357.91,77011.17,
Lat lumbar spine fusion,22533,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55221.09,,,,,,,fee schedule,17357.91,77011.17,
Lat lumbar spine fusion,22533,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,77011.17,,,,,,,fee schedule,17357.91,77011.17,APC 378
Lat lumbar spine fusion,22533,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18225.81,,,,,,,fee schedule,17357.91,77011.17,APC
Lat lumbar spine fusion,22533,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18052.23,,,,,,,fee schedule,17357.91,77011.17,APC
Lat lumbar spine fusion,22533,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17357.91,,,,,,,fee schedule,17357.91,77011.17,APC
Lat lumbar spine fusion,22533,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26557.6,,,,,,,fee schedule,17357.91,77011.17,Radiology
Lat lumbar spine fusion,22533,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24301.07,,,,,,,fee schedule,17357.91,77011.17,APC
Lat lumbar spine fusion,22533,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30376.34,,,,,,,fee schedule,17357.91,77011.17,APC
Neck spine fusion,22548,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59981.53,,,,,,,fee schedule,12709.88,59981.53,
Neck spine fusion,22548,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48080.43,,,,,,,fee schedule,12709.88,59981.53,
Neck spine fusion,22548,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52523.51,,,,,,,fee schedule,12709.88,59981.53,
Neck spine fusion,22548,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55221.09,,,,,,,fee schedule,12709.88,59981.53,
Neck spine fusion,22548,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,12709.88,59981.53,APC 378
Neck spine fusion,22548,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,12709.88,59981.53,APC
Neck spine fusion,22548,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,12709.88,59981.53,APC
Neck spine fusion,22548,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,12709.88,59981.53,APC
Neck spine fusion,22548,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,12709.88,59981.53,Radiology
Neck spine fusion,22548,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,12709.88,59981.53,APC
Neck spine fusion,22548,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,12709.88,59981.53,APC
Neck spine fuse&remov bel c2,22551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3869.9,,,,,,,fee schedule,3102.07,56389.43,
Neck spine fuse&remov bel c2,22551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3102.07,,,,,,,fee schedule,3102.07,56389.43,
Neck spine fuse&remov bel c2,22551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3388.73,,,,,,,fee schedule,3102.07,56389.43,
Neck spine fuse&remov bel c2,22551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3562.77,,,,,,,fee schedule,3102.07,56389.43,
Neck spine fuse&remov bel c2,22551,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,3102.07,56389.43,APC 378
Neck spine fuse&remov bel c2,22551,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,3102.07,56389.43,APC
Neck spine fuse&remov bel c2,22551,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,3102.07,56389.43,APC
Neck spine fuse&remov bel c2,22551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,3102.07,56389.43,APC
Neck spine fuse&remov bel c2,22551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,3102.07,56389.43,Radiology
Neck spine fuse&remov bel c2,22551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,3102.07,56389.43,APC
Neck spine fuse&remov bel c2,22551,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,3102.07,56389.43,APC
Addl neck spine fusion,22552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3290.83,,,,,,,fee schedule,2637.89,3290.83,
Addl neck spine fusion,22552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2637.89,,,,,,,fee schedule,2637.89,3290.83,
Addl neck spine fusion,22552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2881.65,,,,,,,fee schedule,2637.89,3290.83,
Addl neck spine fusion,22552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3029.65,,,,,,,fee schedule,2637.89,3290.83,
Neck spine fusion,22554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,36141.45,,,,,,,fee schedule,12709.88,56389.43,
Neck spine fusion,22554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28970.53,,,,,,,fee schedule,12709.88,56389.43,
Neck spine fusion,22554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31647.67,,,,,,,fee schedule,12709.88,56389.43,
Neck spine fusion,22554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33273.08,,,,,,,fee schedule,12709.88,56389.43,
Neck spine fusion,22554,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,12709.88,56389.43,APC 378
Neck spine fusion,22554,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,12709.88,56389.43,APC
Neck spine fusion,22554,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,12709.88,56389.43,APC
Neck spine fusion,22554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,12709.88,56389.43,APC
Neck spine fusion,22554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,12709.88,56389.43,Radiology
Neck spine fusion,22554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,12709.88,56389.43,APC
Neck spine fusion,22554,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,12709.88,56389.43,APC
Thorax spine fusion,22556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59981.53,,,,,,,fee schedule,17357.91,77011.17,
Thorax spine fusion,22556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48080.43,,,,,,,fee schedule,17357.91,77011.17,
Thorax spine fusion,22556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52523.51,,,,,,,fee schedule,17357.91,77011.17,
Thorax spine fusion,22556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55221.09,,,,,,,fee schedule,17357.91,77011.17,
Thorax spine fusion,22556,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,77011.17,,,,,,,fee schedule,17357.91,77011.17,APC 378
Thorax spine fusion,22556,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18225.81,,,,,,,fee schedule,17357.91,77011.17,APC
Thorax spine fusion,22556,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18052.23,,,,,,,fee schedule,17357.91,77011.17,APC
Thorax spine fusion,22556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17357.91,,,,,,,fee schedule,17357.91,77011.17,APC
Thorax spine fusion,22556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26557.6,,,,,,,fee schedule,17357.91,77011.17,Radiology
Thorax spine fusion,22556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24301.07,,,,,,,fee schedule,17357.91,77011.17,APC
Thorax spine fusion,22556,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30376.34,,,,,,,fee schedule,17357.91,77011.17,APC
Lumbar spine fusion,22558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12405.39,,,,,,,fee schedule,9944.01,119176.72,
Lumbar spine fusion,22558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9944.01,,,,,,,fee schedule,9944.01,119176.72,
Lumbar spine fusion,22558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10862.92,,,,,,,fee schedule,9944.01,119176.72,
Lumbar spine fusion,22558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11420.84,,,,,,,fee schedule,9944.01,119176.72,
Lumbar spine fusion,22558,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,119176.72,,,,,,,fee schedule,9944.01,119176.72,APC 378
Lumbar spine fusion,22558,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,28204.89,,,,,,,fee schedule,9944.01,119176.72,APC
Lumbar spine fusion,22558,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,27936.27,,,,,,,fee schedule,9944.01,119176.72,APC
Lumbar spine fusion,22558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,26861.8,,,,,,,fee schedule,9944.01,119176.72,APC
Lumbar spine fusion,22558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,41098.56,,,,,,,fee schedule,9944.01,119176.72,Radiology
Lumbar spine fusion,22558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,37606.52,,,,,,,fee schedule,9944.01,119176.72,APC
Lumbar spine fusion,22558,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,47008.15,,,,,,,fee schedule,9944.01,119176.72,APC
Prescrl fuse w/ instr l5-s1,22586,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5704.81,,,,,,,fee schedule,4572.91,77011.17,
Prescrl fuse w/ instr l5-s1,22586,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4572.91,,,,,,,fee schedule,4572.91,77011.17,
Prescrl fuse w/ instr l5-s1,22586,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4995.49,,,,,,,fee schedule,4572.91,77011.17,
Prescrl fuse w/ instr l5-s1,22586,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5252.05,,,,,,,fee schedule,4572.91,77011.17,
Prescrl fuse w/ instr l5-s1,22586,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,77011.17,,,,,,,fee schedule,4572.91,77011.17,APC 378
Prescrl fuse w/ instr l5-s1,22586,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18225.81,,,,,,,fee schedule,4572.91,77011.17,APC
Prescrl fuse w/ instr l5-s1,22586,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18052.23,,,,,,,fee schedule,4572.91,77011.17,APC
Prescrl fuse w/ instr l5-s1,22586,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17357.91,,,,,,,fee schedule,4572.91,77011.17,APC
Prescrl fuse w/ instr l5-s1,22586,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26557.6,,,,,,,fee schedule,4572.91,77011.17,Radiology
Prescrl fuse w/ instr l5-s1,22586,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24301.07,,,,,,,fee schedule,4572.91,77011.17,APC
Prescrl fuse w/ instr l5-s1,22586,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30376.34,,,,,,,fee schedule,4572.91,77011.17,APC
Spine & skull spinal fusion,22590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59981.53,,,,,,,fee schedule,12709.88,59981.53,
Spine & skull spinal fusion,22590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48080.43,,,,,,,fee schedule,12709.88,59981.53,
Spine & skull spinal fusion,22590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52523.51,,,,,,,fee schedule,12709.88,59981.53,
Spine & skull spinal fusion,22590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55221.09,,,,,,,fee schedule,12709.88,59981.53,
Spine & skull spinal fusion,22590,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,12709.88,59981.53,APC 378
Spine & skull spinal fusion,22590,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,12709.88,59981.53,APC
Spine & skull spinal fusion,22590,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,12709.88,59981.53,APC
Spine & skull spinal fusion,22590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,12709.88,59981.53,APC
Spine & skull spinal fusion,22590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,12709.88,59981.53,Radiology
Spine & skull spinal fusion,22590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,12709.88,59981.53,APC
Spine & skull spinal fusion,22590,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,12709.88,59981.53,APC
Neck spinal fusion,22595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59981.53,,,,,,,fee schedule,12709.88,59981.53,
Neck spinal fusion,22595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48080.43,,,,,,,fee schedule,12709.88,59981.53,
Neck spinal fusion,22595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52523.51,,,,,,,fee schedule,12709.88,59981.53,
Neck spinal fusion,22595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55221.09,,,,,,,fee schedule,12709.88,59981.53,
Neck spinal fusion,22595,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,12709.88,59981.53,APC 378
Neck spinal fusion,22595,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,12709.88,59981.53,APC
Neck spinal fusion,22595,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,12709.88,59981.53,APC
Neck spinal fusion,22595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,12709.88,59981.53,APC
Neck spinal fusion,22595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,12709.88,59981.53,Radiology
Neck spinal fusion,22595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,12709.88,59981.53,APC
Neck spinal fusion,22595,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,12709.88,59981.53,APC
Neck spine fusion,22600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59981.53,,,,,,,fee schedule,17357.91,77011.17,
Neck spine fusion,22600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48080.43,,,,,,,fee schedule,17357.91,77011.17,
Neck spine fusion,22600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52523.51,,,,,,,fee schedule,17357.91,77011.17,
Neck spine fusion,22600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55221.09,,,,,,,fee schedule,17357.91,77011.17,
Neck spine fusion,22600,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,77011.17,,,,,,,fee schedule,17357.91,77011.17,APC 378
Neck spine fusion,22600,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18225.81,,,,,,,fee schedule,17357.91,77011.17,APC
Neck spine fusion,22600,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18052.23,,,,,,,fee schedule,17357.91,77011.17,APC
Neck spine fusion,22600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17357.91,,,,,,,fee schedule,17357.91,77011.17,APC
Neck spine fusion,22600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26557.6,,,,,,,fee schedule,17357.91,77011.17,Radiology
Neck spine fusion,22600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24301.07,,,,,,,fee schedule,17357.91,77011.17,APC
Neck spine fusion,22600,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30376.34,,,,,,,fee schedule,17357.91,77011.17,APC
Thorax spine fusion,22610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59981.53,,,,,,,fee schedule,17357.91,77011.17,
Thorax spine fusion,22610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48080.43,,,,,,,fee schedule,17357.91,77011.17,
Thorax spine fusion,22610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52523.51,,,,,,,fee schedule,17357.91,77011.17,
Thorax spine fusion,22610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55221.09,,,,,,,fee schedule,17357.91,77011.17,
Thorax spine fusion,22610,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,77011.17,,,,,,,fee schedule,17357.91,77011.17,APC 378
Thorax spine fusion,22610,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18225.81,,,,,,,fee schedule,17357.91,77011.17,APC
Thorax spine fusion,22610,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18052.23,,,,,,,fee schedule,17357.91,77011.17,APC
Thorax spine fusion,22610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17357.91,,,,,,,fee schedule,17357.91,77011.17,APC
Thorax spine fusion,22610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26557.6,,,,,,,fee schedule,17357.91,77011.17,Radiology
Thorax spine fusion,22610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24301.07,,,,,,,fee schedule,17357.91,77011.17,APC
Thorax spine fusion,22610,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30376.34,,,,,,,fee schedule,17357.91,77011.17,APC
Lumbar spine fusion,22612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11673.24,,,,,,,fee schedule,9357.12,77011.17,
Lumbar spine fusion,22612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9357.12,,,,,,,fee schedule,9357.12,77011.17,
Lumbar spine fusion,22612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10221.81,,,,,,,fee schedule,9357.12,77011.17,
Lumbar spine fusion,22612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10746.8,,,,,,,fee schedule,9357.12,77011.17,
Lumbar spine fusion,22612,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,77011.17,,,,,,,fee schedule,9357.12,77011.17,APC 378
Lumbar spine fusion,22612,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18225.81,,,,,,,fee schedule,9357.12,77011.17,APC
Lumbar spine fusion,22612,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18052.23,,,,,,,fee schedule,9357.12,77011.17,APC
Lumbar spine fusion,22612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17357.91,,,,,,,fee schedule,9357.12,77011.17,APC
Lumbar spine fusion,22612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26557.6,,,,,,,fee schedule,9357.12,77011.17,Radiology
Lumbar spine fusion,22612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24301.07,,,,,,,fee schedule,9357.12,77011.17,APC
Lumbar spine fusion,22612,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30376.34,,,,,,,fee schedule,9357.12,77011.17,APC
Spine fusion extra segment,22614,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11673.24,,,,,,,fee schedule,9357.12,11673.24,
Spine fusion extra segment,22614,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9357.12,,,,,,,fee schedule,9357.12,11673.24,
Spine fusion extra segment,22614,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10221.81,,,,,,,fee schedule,9357.12,11673.24,
Spine fusion extra segment,22614,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10746.8,,,,,,,fee schedule,9357.12,11673.24,
Lumbar spine fusion,22630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12698.62,,,,,,,fee schedule,10179.06,119176.72,
Lumbar spine fusion,22630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10179.06,,,,,,,fee schedule,10179.06,119176.72,
Lumbar spine fusion,22630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11119.69,,,,,,,fee schedule,10179.06,119176.72,
Lumbar spine fusion,22630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11690.8,,,,,,,fee schedule,10179.06,119176.72,
Lumbar spine fusion,22630,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,119176.72,,,,,,,fee schedule,10179.06,119176.72,APC 378
Lumbar spine fusion,22630,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,28204.89,,,,,,,fee schedule,10179.06,119176.72,APC
Lumbar spine fusion,22630,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,27936.27,,,,,,,fee schedule,10179.06,119176.72,APC
Lumbar spine fusion,22630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,26861.8,,,,,,,fee schedule,10179.06,119176.72,APC
Lumbar spine fusion,22630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,41098.56,,,,,,,fee schedule,10179.06,119176.72,Radiology
Lumbar spine fusion,22630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,37606.52,,,,,,,fee schedule,10179.06,119176.72,APC
Lumbar spine fusion,22630,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,47008.15,,,,,,,fee schedule,10179.06,119176.72,APC
Lumbar spine fusion combined,22633,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6802.56,,,,,,,fee schedule,5452.85,119176.72,
Lumbar spine fusion combined,22633,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5452.85,,,,,,,fee schedule,5452.85,119176.72,
Lumbar spine fusion combined,22633,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5956.74,,,,,,,fee schedule,5452.85,119176.72,
Lumbar spine fusion combined,22633,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6262.68,,,,,,,fee schedule,5452.85,119176.72,
Lumbar spine fusion combined,22633,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,119176.72,,,,,,,fee schedule,5452.85,119176.72,APC 378
Lumbar spine fusion combined,22633,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,28204.89,,,,,,,fee schedule,5452.85,119176.72,APC
Lumbar spine fusion combined,22633,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,27936.27,,,,,,,fee schedule,5452.85,119176.72,APC
Lumbar spine fusion combined,22633,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,26861.8,,,,,,,fee schedule,5452.85,119176.72,APC
Lumbar spine fusion combined,22633,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,41098.56,,,,,,,fee schedule,5452.85,119176.72,Radiology
Lumbar spine fusion combined,22633,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,37606.52,,,,,,,fee schedule,5452.85,119176.72,APC
Lumbar spine fusion combined,22633,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,47008.15,,,,,,,fee schedule,5452.85,119176.72,APC
Spine fusion extra segment,22634,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1836.25,,,,,,,fee schedule,1471.91,1836.25,
Spine fusion extra segment,22634,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1471.91,,,,,,,fee schedule,1471.91,1836.25,
Spine fusion extra segment,22634,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1607.93,,,,,,,fee schedule,1471.91,1836.25,
Spine fusion extra segment,22634,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1690.51,,,,,,,fee schedule,1471.91,1836.25,
Post fusion <=6 vert seg,22800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59981.53,,,,,,,fee schedule,17357.91,77011.17,
Post fusion <=6 vert seg,22800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48080.43,,,,,,,fee schedule,17357.91,77011.17,
Post fusion <=6 vert seg,22800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52523.51,,,,,,,fee schedule,17357.91,77011.17,
Post fusion <=6 vert seg,22800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55221.09,,,,,,,fee schedule,17357.91,77011.17,
Post fusion <=6 vert seg,22800,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,77011.17,,,,,,,fee schedule,17357.91,77011.17,APC 378
Post fusion <=6 vert seg,22800,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18225.81,,,,,,,fee schedule,17357.91,77011.17,APC
Post fusion <=6 vert seg,22800,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18052.23,,,,,,,fee schedule,17357.91,77011.17,APC
Post fusion <=6 vert seg,22800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17357.91,,,,,,,fee schedule,17357.91,77011.17,APC
Post fusion <=6 vert seg,22800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26557.6,,,,,,,fee schedule,17357.91,77011.17,Radiology
Post fusion <=6 vert seg,22800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24301.07,,,,,,,fee schedule,17357.91,77011.17,APC
Post fusion <=6 vert seg,22800,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30376.34,,,,,,,fee schedule,17357.91,77011.17,APC
Post fusion 7-12 vert seg,22802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59981.53,,,,,,,fee schedule,17357.91,77011.17,
Post fusion 7-12 vert seg,22802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48080.43,,,,,,,fee schedule,17357.91,77011.17,
Post fusion 7-12 vert seg,22802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52523.51,,,,,,,fee schedule,17357.91,77011.17,
Post fusion 7-12 vert seg,22802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55221.09,,,,,,,fee schedule,17357.91,77011.17,
Post fusion 7-12 vert seg,22802,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,77011.17,,,,,,,fee schedule,17357.91,77011.17,APC 378
Post fusion 7-12 vert seg,22802,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18225.81,,,,,,,fee schedule,17357.91,77011.17,APC
Post fusion 7-12 vert seg,22802,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18052.23,,,,,,,fee schedule,17357.91,77011.17,APC
Post fusion 7-12 vert seg,22802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17357.91,,,,,,,fee schedule,17357.91,77011.17,APC
Post fusion 7-12 vert seg,22802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26557.6,,,,,,,fee schedule,17357.91,77011.17,Radiology
Post fusion 7-12 vert seg,22802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24301.07,,,,,,,fee schedule,17357.91,77011.17,APC
Post fusion 7-12 vert seg,22802,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30376.34,,,,,,,fee schedule,17357.91,77011.17,APC
Post fusion 13/> vert seg,22804,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59981.53,,,,,,,fee schedule,17357.91,77011.17,
Post fusion 13/> vert seg,22804,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48080.43,,,,,,,fee schedule,17357.91,77011.17,
Post fusion 13/> vert seg,22804,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52523.51,,,,,,,fee schedule,17357.91,77011.17,
Post fusion 13/> vert seg,22804,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55221.09,,,,,,,fee schedule,17357.91,77011.17,
Post fusion 13/> vert seg,22804,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,77011.17,,,,,,,fee schedule,17357.91,77011.17,APC 378
Post fusion 13/> vert seg,22804,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18225.81,,,,,,,fee schedule,17357.91,77011.17,APC
Post fusion 13/> vert seg,22804,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18052.23,,,,,,,fee schedule,17357.91,77011.17,APC
Post fusion 13/> vert seg,22804,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17357.91,,,,,,,fee schedule,17357.91,77011.17,APC
Post fusion 13/> vert seg,22804,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26557.6,,,,,,,fee schedule,17357.91,77011.17,Radiology
Post fusion 13/> vert seg,22804,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24301.07,,,,,,,fee schedule,17357.91,77011.17,APC
Post fusion 13/> vert seg,22804,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30376.34,,,,,,,fee schedule,17357.91,77011.17,APC
Ant fusion 2-3 vert seg,22808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59981.53,,,,,,,fee schedule,17357.91,77011.17,
Ant fusion 2-3 vert seg,22808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48080.43,,,,,,,fee schedule,17357.91,77011.17,
Ant fusion 2-3 vert seg,22808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52523.51,,,,,,,fee schedule,17357.91,77011.17,
Ant fusion 2-3 vert seg,22808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55221.09,,,,,,,fee schedule,17357.91,77011.17,
Ant fusion 2-3 vert seg,22808,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,77011.17,,,,,,,fee schedule,17357.91,77011.17,APC 378
Ant fusion 2-3 vert seg,22808,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18225.81,,,,,,,fee schedule,17357.91,77011.17,APC
Ant fusion 2-3 vert seg,22808,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18052.23,,,,,,,fee schedule,17357.91,77011.17,APC
Ant fusion 2-3 vert seg,22808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17357.91,,,,,,,fee schedule,17357.91,77011.17,APC
Ant fusion 2-3 vert seg,22808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26557.6,,,,,,,fee schedule,17357.91,77011.17,Radiology
Ant fusion 2-3 vert seg,22808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24301.07,,,,,,,fee schedule,17357.91,77011.17,APC
Ant fusion 2-3 vert seg,22808,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30376.34,,,,,,,fee schedule,17357.91,77011.17,APC
Ant fusion 4-7 vert seg,22810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59981.53,,,,,,,fee schedule,17357.91,77011.17,
Ant fusion 4-7 vert seg,22810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48080.43,,,,,,,fee schedule,17357.91,77011.17,
Ant fusion 4-7 vert seg,22810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52523.51,,,,,,,fee schedule,17357.91,77011.17,
Ant fusion 4-7 vert seg,22810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55221.09,,,,,,,fee schedule,17357.91,77011.17,
Ant fusion 4-7 vert seg,22810,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,77011.17,,,,,,,fee schedule,17357.91,77011.17,APC 378
Ant fusion 4-7 vert seg,22810,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18225.81,,,,,,,fee schedule,17357.91,77011.17,APC
Ant fusion 4-7 vert seg,22810,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18052.23,,,,,,,fee schedule,17357.91,77011.17,APC
Ant fusion 4-7 vert seg,22810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17357.91,,,,,,,fee schedule,17357.91,77011.17,APC
Ant fusion 4-7 vert seg,22810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26557.6,,,,,,,fee schedule,17357.91,77011.17,Radiology
Ant fusion 4-7 vert seg,22810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24301.07,,,,,,,fee schedule,17357.91,77011.17,APC
Ant fusion 4-7 vert seg,22810,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30376.34,,,,,,,fee schedule,17357.91,77011.17,APC
Ant fusion 8/> vert seg,22812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59981.53,,,,,,,fee schedule,17357.91,77011.17,
Ant fusion 8/> vert seg,22812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48080.43,,,,,,,fee schedule,17357.91,77011.17,
Ant fusion 8/> vert seg,22812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52523.51,,,,,,,fee schedule,17357.91,77011.17,
Ant fusion 8/> vert seg,22812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55221.09,,,,,,,fee schedule,17357.91,77011.17,
Ant fusion 8/> vert seg,22812,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,77011.17,,,,,,,fee schedule,17357.91,77011.17,APC 378
Ant fusion 8/> vert seg,22812,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18225.81,,,,,,,fee schedule,17357.91,77011.17,APC
Ant fusion 8/> vert seg,22812,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18052.23,,,,,,,fee schedule,17357.91,77011.17,APC
Ant fusion 8/> vert seg,22812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17357.91,,,,,,,fee schedule,17357.91,77011.17,APC
Ant fusion 8/> vert seg,22812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26557.6,,,,,,,fee schedule,17357.91,77011.17,Radiology
Ant fusion 8/> vert seg,22812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24301.07,,,,,,,fee schedule,17357.91,77011.17,APC
Ant fusion 8/> vert seg,22812,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30376.34,,,,,,,fee schedule,17357.91,77011.17,APC
Kyphectomy 1-2 segments,22818,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59981.53,,,,,,,fee schedule,17357.91,77011.17,
Kyphectomy 1-2 segments,22818,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48080.43,,,,,,,fee schedule,17357.91,77011.17,
Kyphectomy 1-2 segments,22818,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52523.51,,,,,,,fee schedule,17357.91,77011.17,
Kyphectomy 1-2 segments,22818,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55221.09,,,,,,,fee schedule,17357.91,77011.17,
Kyphectomy 1-2 segments,22818,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,77011.17,,,,,,,fee schedule,17357.91,77011.17,APC 378
Kyphectomy 1-2 segments,22818,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18225.81,,,,,,,fee schedule,17357.91,77011.17,APC
Kyphectomy 1-2 segments,22818,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18052.23,,,,,,,fee schedule,17357.91,77011.17,APC
Kyphectomy 1-2 segments,22818,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17357.91,,,,,,,fee schedule,17357.91,77011.17,APC
Kyphectomy 1-2 segments,22818,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26557.6,,,,,,,fee schedule,17357.91,77011.17,Radiology
Kyphectomy 1-2 segments,22818,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24301.07,,,,,,,fee schedule,17357.91,77011.17,APC
Kyphectomy 1-2 segments,22818,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30376.34,,,,,,,fee schedule,17357.91,77011.17,APC
Kyphectomy 3 or more,22819,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59981.53,,,,,,,fee schedule,17357.91,77011.17,
Kyphectomy 3 or more,22819,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48080.43,,,,,,,fee schedule,17357.91,77011.17,
Kyphectomy 3 or more,22819,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52523.51,,,,,,,fee schedule,17357.91,77011.17,
Kyphectomy 3 or more,22819,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55221.09,,,,,,,fee schedule,17357.91,77011.17,
Kyphectomy 3 or more,22819,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,77011.17,,,,,,,fee schedule,17357.91,77011.17,APC 378
Kyphectomy 3 or more,22819,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18225.81,,,,,,,fee schedule,17357.91,77011.17,APC
Kyphectomy 3 or more,22819,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18052.23,,,,,,,fee schedule,17357.91,77011.17,APC
Kyphectomy 3 or more,22819,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17357.91,,,,,,,fee schedule,17357.91,77011.17,APC
Kyphectomy 3 or more,22819,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26557.6,,,,,,,fee schedule,17357.91,77011.17,Radiology
Kyphectomy 3 or more,22819,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24301.07,,,,,,,fee schedule,17357.91,77011.17,APC
Kyphectomy 3 or more,22819,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30376.34,,,,,,,fee schedule,17357.91,77011.17,APC
Exploration of spinal fusion,22830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46549.79,,,,,,,fee schedule,7183.42,46549.79,
Exploration of spinal fusion,22830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37313.72,,,,,,,fee schedule,7183.42,46549.79,
Exploration of spinal fusion,22830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40761.86,,,,,,,fee schedule,7183.42,46549.79,
Exploration of spinal fusion,22830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42855.36,,,,,,,fee schedule,7183.42,46549.79,
Exploration of spinal fusion,22830,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,46549.79,APC 378
Exploration of spinal fusion,22830,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,46549.79,APC
Exploration of spinal fusion,22830,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,46549.79,APC
Exploration of spinal fusion,22830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,46549.79,APC
Exploration of spinal fusion,22830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,46549.79,Radiology
Exploration of spinal fusion,22830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,46549.79,APC
Exploration of spinal fusion,22830,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,46549.79,APC
Ant thrc vrt body tethrg <7,22836,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,77011.17,,,,,,,fee schedule,17357.91,77011.17,APC 378
Ant thrc vrt body tethrg <7,22836,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18225.81,,,,,,,fee schedule,17357.91,77011.17,APC
Ant thrc vrt body tethrg <7,22836,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18052.23,,,,,,,fee schedule,17357.91,77011.17,APC
Ant thrc vrt body tethrg <7,22836,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17357.91,,,,,,,fee schedule,17357.91,77011.17,APC
Ant thrc vrt body tethrg <7,22836,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26557.6,,,,,,,fee schedule,17357.91,77011.17,Radiology
Ant thrc vrt body tethrg <7,22836,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24301.07,,,,,,,fee schedule,17357.91,77011.17,APC
Ant thrc vrt body tethrg <7,22836,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30376.34,,,,,,,fee schedule,17357.91,77011.17,APC
Ant thrc vrt body tethrg 8+,22837,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,77011.17,,,,,,,fee schedule,17357.91,77011.17,APC 378
Ant thrc vrt body tethrg 8+,22837,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18225.81,,,,,,,fee schedule,17357.91,77011.17,APC
Ant thrc vrt body tethrg 8+,22837,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18052.23,,,,,,,fee schedule,17357.91,77011.17,APC
Ant thrc vrt body tethrg 8+,22837,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17357.91,,,,,,,fee schedule,17357.91,77011.17,APC
Ant thrc vrt body tethrg 8+,22837,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26557.6,,,,,,,fee schedule,17357.91,77011.17,Radiology
Ant thrc vrt body tethrg 8+,22837,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24301.07,,,,,,,fee schedule,17357.91,77011.17,APC
Ant thrc vrt body tethrg 8+,22837,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30376.34,,,,,,,fee schedule,17357.91,77011.17,APC
Rev rplc/rmv thrc vrt tethrg,22838,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,77011.17,,,,,,,fee schedule,17357.91,77011.17,APC 378
Rev rplc/rmv thrc vrt tethrg,22838,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18225.81,,,,,,,fee schedule,17357.91,77011.17,APC
Rev rplc/rmv thrc vrt tethrg,22838,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18052.23,,,,,,,fee schedule,17357.91,77011.17,APC
Rev rplc/rmv thrc vrt tethrg,22838,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17357.91,,,,,,,fee schedule,17357.91,77011.17,APC
Rev rplc/rmv thrc vrt tethrg,22838,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26557.6,,,,,,,fee schedule,17357.91,77011.17,Radiology
Rev rplc/rmv thrc vrt tethrg,22838,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24301.07,,,,,,,fee schedule,17357.91,77011.17,APC
Rev rplc/rmv thrc vrt tethrg,22838,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30376.34,,,,,,,fee schedule,17357.91,77011.17,APC
Insert spine fixation device,22840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6242.55,,,,,,,fee schedule,5003.95,6242.55,
Insert spine fixation device,22840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5003.95,,,,,,,fee schedule,5003.95,6242.55,
Insert spine fixation device,22840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5466.36,,,,,,,fee schedule,5003.95,6242.55,
Insert spine fixation device,22840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5747.11,,,,,,,fee schedule,5003.95,6242.55,
Insert spine fixation device,22845,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3713.85,,,,,,,fee schedule,2976.98,3713.85,
Insert spine fixation device,22845,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2976.98,,,,,,,fee schedule,2976.98,3713.85,
Insert spine fixation device,22845,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3252.08,,,,,,,fee schedule,2976.98,3713.85,
Insert spine fixation device,22845,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3419.1,,,,,,,fee schedule,2976.98,3713.85,
Reinsert spinal fixation,22849,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59981.53,,,,,,,fee schedule,12709.88,59981.53,
Reinsert spinal fixation,22849,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48080.43,,,,,,,fee schedule,12709.88,59981.53,
Reinsert spinal fixation,22849,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52523.51,,,,,,,fee schedule,12709.88,59981.53,
Reinsert spinal fixation,22849,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55221.09,,,,,,,fee schedule,12709.88,59981.53,
Reinsert spinal fixation,22849,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,12709.88,59981.53,APC 378
Reinsert spinal fixation,22849,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,12709.88,59981.53,APC
Reinsert spinal fixation,22849,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,12709.88,59981.53,APC
Reinsert spinal fixation,22849,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,12709.88,59981.53,APC
Reinsert spinal fixation,22849,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,12709.88,59981.53,Radiology
Reinsert spinal fixation,22849,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,12709.88,59981.53,APC
Reinsert spinal fixation,22849,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,12709.88,59981.53,APC
Remove spine fixation device,22850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46549.79,,,,,,,fee schedule,7183.42,46549.79,
Remove spine fixation device,22850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37313.72,,,,,,,fee schedule,7183.42,46549.79,
Remove spine fixation device,22850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40761.86,,,,,,,fee schedule,7183.42,46549.79,
Remove spine fixation device,22850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42855.36,,,,,,,fee schedule,7183.42,46549.79,
Remove spine fixation device,22850,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,46549.79,APC 378
Remove spine fixation device,22850,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,46549.79,APC
Remove spine fixation device,22850,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,46549.79,APC
Remove spine fixation device,22850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,46549.79,APC
Remove spine fixation device,22850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,46549.79,Radiology
Remove spine fixation device,22850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,46549.79,APC
Remove spine fixation device,22850,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,46549.79,APC
Remove spine fixation device,22852,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46549.79,,,,,,,fee schedule,7183.42,46549.79,
Remove spine fixation device,22852,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37313.72,,,,,,,fee schedule,7183.42,46549.79,
Remove spine fixation device,22852,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40761.86,,,,,,,fee schedule,7183.42,46549.79,
Remove spine fixation device,22852,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42855.36,,,,,,,fee schedule,7183.42,46549.79,
Remove spine fixation device,22852,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,46549.79,APC 378
Remove spine fixation device,22852,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,46549.79,APC
Remove spine fixation device,22852,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,46549.79,APC
Remove spine fixation device,22852,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,46549.79,APC
Remove spine fixation device,22852,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,46549.79,Radiology
Remove spine fixation device,22852,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,46549.79,APC
Remove spine fixation device,22852,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,46549.79,APC
Insj biomechanical device,22853,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1052.05,,,,,,,fee schedule,843.31,1052.05,
Insj biomechanical device,22853,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,843.31,,,,,,,fee schedule,843.31,1052.05,
Insj biomechanical device,22853,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,921.24,,,,,,,fee schedule,843.31,1052.05,
Insj biomechanical device,22853,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,968.55,,,,,,,fee schedule,843.31,1052.05,
Insj biomechanical device,22854,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1361.83,,,,,,,fee schedule,1091.63,1361.83,
Insj biomechanical device,22854,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1091.63,,,,,,,fee schedule,1091.63,1361.83,
Insj biomechanical device,22854,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1192.51,,,,,,,fee schedule,1091.63,1361.83,
Insj biomechanical device,22854,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1253.75,,,,,,,fee schedule,1091.63,1361.83,
Remove spine fixation device,22855,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46549.79,,,,,,,fee schedule,7183.42,46549.79,
Remove spine fixation device,22855,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37313.72,,,,,,,fee schedule,7183.42,46549.79,
Remove spine fixation device,22855,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40761.86,,,,,,,fee schedule,7183.42,46549.79,
Remove spine fixation device,22855,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42855.36,,,,,,,fee schedule,7183.42,46549.79,
Remove spine fixation device,22855,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,46549.79,APC 378
Remove spine fixation device,22855,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,46549.79,APC
Remove spine fixation device,22855,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,46549.79,APC
Remove spine fixation device,22855,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,46549.79,APC
Remove spine fixation device,22855,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,46549.79,Radiology
Remove spine fixation device,22855,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,46549.79,APC
Remove spine fixation device,22855,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,46549.79,APC
Cerv artific diskectomy,22856,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11141.58,,,,,,,fee schedule,8930.95,77011.17,
Cerv artific diskectomy,22856,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8930.95,,,,,,,fee schedule,8930.95,77011.17,
Cerv artific diskectomy,22856,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9756.25,,,,,,,fee schedule,8930.95,77011.17,
Cerv artific diskectomy,22856,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10257.32,,,,,,,fee schedule,8930.95,77011.17,
Cerv artific diskectomy,22856,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,77011.17,,,,,,,fee schedule,8930.95,77011.17,APC 378
Cerv artific diskectomy,22856,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18225.81,,,,,,,fee schedule,8930.95,77011.17,APC
Cerv artific diskectomy,22856,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18052.23,,,,,,,fee schedule,8930.95,77011.17,APC
Cerv artific diskectomy,22856,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17357.91,,,,,,,fee schedule,8930.95,77011.17,APC
Cerv artific diskectomy,22856,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26557.6,,,,,,,fee schedule,8930.95,77011.17,Radiology
Cerv artific diskectomy,22856,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24301.07,,,,,,,fee schedule,8930.95,77011.17,APC
Cerv artific diskectomy,22856,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30376.34,,,,,,,fee schedule,8930.95,77011.17,APC
Lumbar Artif Diskectomy,22857,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59981.53,,,,,,,fee schedule,17357.91,77011.17,
Lumbar Artif Diskectomy,22857,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48080.43,,,,,,,fee schedule,17357.91,77011.17,
Lumbar Artif Diskectomy,22857,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52523.51,,,,,,,fee schedule,17357.91,77011.17,
Lumbar Artif Diskectomy,22857,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55221.09,,,,,,,fee schedule,17357.91,77011.17,
Lumbar Artif Diskectomy,22857,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,77011.17,,,,,,,fee schedule,17357.91,77011.17,APC 378
Lumbar Artif Diskectomy,22857,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18225.81,,,,,,,fee schedule,17357.91,77011.17,APC
Lumbar Artif Diskectomy,22857,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18052.23,,,,,,,fee schedule,17357.91,77011.17,APC
Lumbar Artif Diskectomy,22857,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17357.91,,,,,,,fee schedule,17357.91,77011.17,APC
Lumbar Artif Diskectomy,22857,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26557.6,,,,,,,fee schedule,17357.91,77011.17,Radiology
Lumbar Artif Diskectomy,22857,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24301.07,,,,,,,fee schedule,17357.91,77011.17,APC
Lumbar Artif Diskectomy,22857,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30376.34,,,,,,,fee schedule,17357.91,77011.17,APC
Second level cer diskectomy,22858,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1977.2,,,,,,,fee schedule,1584.9,1977.2,
Second level cer diskectomy,22858,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1584.9,,,,,,,fee schedule,1584.9,1977.2,
Second level cer diskectomy,22858,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1731.36,,,,,,,fee schedule,1584.9,1977.2,
Second level cer diskectomy,22858,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1820.28,,,,,,,fee schedule,1584.9,1977.2,
Insj biomechanical device,22859,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1361.83,,,,,,,fee schedule,1091.63,1361.83,
Insj biomechanical device,22859,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1091.63,,,,,,,fee schedule,1091.63,1361.83,
Insj biomechanical device,22859,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1192.51,,,,,,,fee schedule,1091.63,1361.83,
Insj biomechanical device,22859,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1253.75,,,,,,,fee schedule,1091.63,1361.83,
Revise cerv artific disc,22861,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6990.77,,,,,,,fee schedule,5603.71,77011.17,
Revise cerv artific disc,22861,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5603.71,,,,,,,fee schedule,5603.71,77011.17,
Revise cerv artific disc,22861,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6121.55,,,,,,,fee schedule,5603.71,77011.17,
Revise cerv artific disc,22861,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6435.95,,,,,,,fee schedule,5603.71,77011.17,
Revise cerv artific disc,22861,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,77011.17,,,,,,,fee schedule,5603.71,77011.17,APC 378
Revise cerv artific disc,22861,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18225.81,,,,,,,fee schedule,5603.71,77011.17,APC
Revise cerv artific disc,22861,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18052.23,,,,,,,fee schedule,5603.71,77011.17,APC
Revise cerv artific disc,22861,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17357.91,,,,,,,fee schedule,5603.71,77011.17,APC
Revise cerv artific disc,22861,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26557.6,,,,,,,fee schedule,5603.71,77011.17,Radiology
Revise cerv artific disc,22861,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24301.07,,,,,,,fee schedule,5603.71,77011.17,APC
Revise cerv artific disc,22861,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30376.34,,,,,,,fee schedule,5603.71,77011.17,APC
Revise Lumbar Artif Disc,22862,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59981.53,,,,,,,fee schedule,17357.91,77011.17,
Revise Lumbar Artif Disc,22862,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48080.43,,,,,,,fee schedule,17357.91,77011.17,
Revise Lumbar Artif Disc,22862,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52523.51,,,,,,,fee schedule,17357.91,77011.17,
Revise Lumbar Artif Disc,22862,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55221.09,,,,,,,fee schedule,17357.91,77011.17,
Revise Lumbar Artif Disc,22862,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,77011.17,,,,,,,fee schedule,17357.91,77011.17,APC 378
Revise Lumbar Artif Disc,22862,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18225.81,,,,,,,fee schedule,17357.91,77011.17,APC
Revise Lumbar Artif Disc,22862,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18052.23,,,,,,,fee schedule,17357.91,77011.17,APC
Revise Lumbar Artif Disc,22862,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17357.91,,,,,,,fee schedule,17357.91,77011.17,APC
Revise Lumbar Artif Disc,22862,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26557.6,,,,,,,fee schedule,17357.91,77011.17,Radiology
Revise Lumbar Artif Disc,22862,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24301.07,,,,,,,fee schedule,17357.91,77011.17,APC
Revise Lumbar Artif Disc,22862,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30376.34,,,,,,,fee schedule,17357.91,77011.17,APC
Remove cerv artif disc,22864,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6522.35,,,,,,,fee schedule,5228.23,31870.39,
Remove cerv artif disc,22864,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5228.23,,,,,,,fee schedule,5228.23,31870.39,
Remove cerv artif disc,22864,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5711.37,,,,,,,fee schedule,5228.23,31870.39,
Remove cerv artif disc,22864,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6004.71,,,,,,,fee schedule,5228.23,31870.39,
Remove cerv artif disc,22864,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5228.23,31870.39,APC 378
Remove cerv artif disc,22864,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5228.23,31870.39,APC
Remove cerv artif disc,22864,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5228.23,31870.39,APC
Remove cerv artif disc,22864,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5228.23,31870.39,APC
Remove cerv artif disc,22864,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5228.23,31870.39,Radiology
Remove cerv artif disc,22864,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5228.23,31870.39,APC
Remove cerv artif disc,22864,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5228.23,31870.39,APC
Remove Lumb Artif Disc,22865,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46549.79,,,,,,,fee schedule,7183.42,46549.79,
Remove Lumb Artif Disc,22865,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37313.72,,,,,,,fee schedule,7183.42,46549.79,
Remove Lumb Artif Disc,22865,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40761.86,,,,,,,fee schedule,7183.42,46549.79,
Remove Lumb Artif Disc,22865,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42855.36,,,,,,,fee schedule,7183.42,46549.79,
Remove Lumb Artif Disc,22865,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,46549.79,APC 378
Remove Lumb Artif Disc,22865,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,46549.79,APC
Remove Lumb Artif Disc,22865,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,46549.79,APC
Remove Lumb Artif Disc,22865,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,46549.79,APC
Remove Lumb Artif Disc,22865,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,46549.79,Radiology
Remove Lumb Artif Disc,22865,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,46549.79,APC
Remove Lumb Artif Disc,22865,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,46549.79,APC
Insj stablj dev w/dcmprn,22867,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55581.61,,,,,,,fee schedule,17357.91,77011.17,
Insj stablj dev w/dcmprn,22867,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,44553.51,,,,,,,fee schedule,17357.91,77011.17,
Insj stablj dev w/dcmprn,22867,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48670.67,,,,,,,fee schedule,17357.91,77011.17,
Insj stablj dev w/dcmprn,22867,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,51170.37,,,,,,,fee schedule,17357.91,77011.17,
Insj stablj dev w/dcmprn,22867,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,77011.17,,,,,,,fee schedule,17357.91,77011.17,APC 378
Insj stablj dev w/dcmprn,22867,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18225.81,,,,,,,fee schedule,17357.91,77011.17,APC
Insj stablj dev w/dcmprn,22867,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18052.23,,,,,,,fee schedule,17357.91,77011.17,APC
Insj stablj dev w/dcmprn,22867,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17357.91,,,,,,,fee schedule,17357.91,77011.17,APC
Insj stablj dev w/dcmprn,22867,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26557.6,,,,,,,fee schedule,17357.91,77011.17,Radiology
Insj stablj dev w/dcmprn,22867,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24301.07,,,,,,,fee schedule,17357.91,77011.17,APC
Insj stablj dev w/dcmprn,22867,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30376.34,,,,,,,fee schedule,17357.91,77011.17,APC
Insj stablj dev w/dcmprn,22868,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,981.53,,,,,,,fee schedule,786.78,981.53,
Insj stablj dev w/dcmprn,22868,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,786.78,,,,,,,fee schedule,786.78,981.53,
Insj stablj dev w/dcmprn,22868,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,859.49,,,,,,,fee schedule,786.78,981.53,
Insj stablj dev w/dcmprn,22868,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,903.63,,,,,,,fee schedule,786.78,981.53,
Insj stablj dev w/o dcmprn,22869,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55581.61,,,,,,,fee schedule,12709.88,56389.43,
Insj stablj dev w/o dcmprn,22869,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,44553.51,,,,,,,fee schedule,12709.88,56389.43,
Insj stablj dev w/o dcmprn,22869,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48670.67,,,,,,,fee schedule,12709.88,56389.43,
Insj stablj dev w/o dcmprn,22869,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,51170.37,,,,,,,fee schedule,12709.88,56389.43,
Insj stablj dev w/o dcmprn,22869,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,12709.88,56389.43,APC 378
Insj stablj dev w/o dcmprn,22869,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,12709.88,56389.43,APC
Insj stablj dev w/o dcmprn,22869,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,12709.88,56389.43,APC
Insj stablj dev w/o dcmprn,22869,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,12709.88,56389.43,APC
Insj stablj dev w/o dcmprn,22869,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,12709.88,56389.43,Radiology
Insj stablj dev w/o dcmprn,22869,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,12709.88,56389.43,APC
Insj stablj dev w/o dcmprn,22869,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,12709.88,56389.43,APC
Insj stablj dev w/o dcmprn,22870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,571.17,,,,,,,fee schedule,457.85,571.17,
Insj stablj dev w/o dcmprn,22870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,457.85,,,,,,,fee schedule,457.85,571.17,
Insj stablj dev w/o dcmprn,22870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,500.16,,,,,,,fee schedule,457.85,571.17,
Insj stablj dev w/o dcmprn,22870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,525.84,,,,,,,fee schedule,457.85,571.17,
Spine surgery procedure,22899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,244.19,5308.18,
Spine surgery procedure,22899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,244.19,5308.18,
Spine surgery procedure,22899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,244.19,5308.18,
Spine surgery procedure,22899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,244.19,5308.18,
Spine surgery procedure,22899,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,5308.18,APC 378
Spine surgery procedure,22899,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,5308.18,APC
Spine surgery procedure,22899,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,5308.18,APC
Spine surgery procedure,22899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,5308.18,APC
Spine surgery procedure,22899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,5308.18,Radiology
Spine surgery procedure,22899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,5308.18,APC
Spine surgery procedure,22899,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,5308.18,APC
Exc abdl tum deep < 5 cm,22900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6721.57,,,,,,,fee schedule,2875.57,12757.95,
Exc abdl tum deep < 5 cm,22900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5387.93,,,,,,,fee schedule,2875.57,12757.95,
Exc abdl tum deep < 5 cm,22900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5885.82,,,,,,,fee schedule,2875.57,12757.95,
Exc abdl tum deep < 5 cm,22900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6188.11,,,,,,,fee schedule,2875.57,12757.95,
Exc abdl tum deep < 5 cm,22900,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Exc abdl tum deep < 5 cm,22900,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Exc abdl tum deep < 5 cm,22900,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Exc abdl tum deep < 5 cm,22900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Exc abdl tum deep < 5 cm,22900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Exc abdl tum deep < 5 cm,22900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Exc abdl tum deep < 5 cm,22900,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Exc abdl tum deep 5 cm/>,22901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6721.57,,,,,,,fee schedule,2875.57,12757.95,
Exc abdl tum deep 5 cm/>,22901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5387.93,,,,,,,fee schedule,2875.57,12757.95,
Exc abdl tum deep 5 cm/>,22901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5885.82,,,,,,,fee schedule,2875.57,12757.95,
Exc abdl tum deep 5 cm/>,22901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6188.11,,,,,,,fee schedule,2875.57,12757.95,
Exc abdl tum deep 5 cm/>,22901,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Exc abdl tum deep 5 cm/>,22901,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Exc abdl tum deep 5 cm/>,22901,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Exc abdl tum deep 5 cm/>,22901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Exc abdl tum deep 5 cm/>,22901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Exc abdl tum deep 5 cm/>,22901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Exc abdl tum deep 5 cm/>,22901,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Exc abd les sc < 3 cm,22902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6644.64,,,,,,,fee schedule,1635.03,7254.06,
Exc abd les sc < 3 cm,22902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5326.26,,,,,,,fee schedule,1635.03,7254.06,
Exc abd les sc < 3 cm,22902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5818.45,,,,,,,fee schedule,1635.03,7254.06,
Exc abd les sc < 3 cm,22902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6117.28,,,,,,,fee schedule,1635.03,7254.06,
Exc abd les sc < 3 cm,22902,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,7254.06,APC 378
Exc abd les sc < 3 cm,22902,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,7254.06,APC
Exc abd les sc < 3 cm,22902,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,7254.06,APC
Exc abd les sc < 3 cm,22902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,7254.06,APC
Exc abd les sc < 3 cm,22902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,7254.06,Radiology
Exc abd les sc < 3 cm,22902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,7254.06,APC
Exc abd les sc < 3 cm,22902,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,7254.06,APC
Exc abd les sc 3 cm/>,22903,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3792.06,,,,,,,fee schedule,2875.57,12757.95,
Exc abd les sc 3 cm/>,22903,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3039.67,,,,,,,fee schedule,2875.57,12757.95,
Exc abd les sc 3 cm/>,22903,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3320.56,,,,,,,fee schedule,2875.57,12757.95,
Exc abd les sc 3 cm/>,22903,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3491.1,,,,,,,fee schedule,2875.57,12757.95,
Exc abd les sc 3 cm/>,22903,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Exc abd les sc 3 cm/>,22903,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Exc abd les sc 3 cm/>,22903,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Exc abd les sc 3 cm/>,22903,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Exc abd les sc 3 cm/>,22903,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Exc abd les sc 3 cm/>,22903,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Exc abd les sc 3 cm/>,22903,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Radical resect abd tumor<5cm,22904,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4621.47,,,,,,,fee schedule,2875.57,12757.95,
Radical resect abd tumor<5cm,22904,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3704.51,,,,,,,fee schedule,2875.57,12757.95,
Radical resect abd tumor<5cm,22904,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4046.84,,,,,,,fee schedule,2875.57,12757.95,
Radical resect abd tumor<5cm,22904,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4254.68,,,,,,,fee schedule,2875.57,12757.95,
Radical resect abd tumor<5cm,22904,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Radical resect abd tumor<5cm,22904,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Radical resect abd tumor<5cm,22904,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Radical resect abd tumor<5cm,22904,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Radical resect abd tumor<5cm,22904,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Radical resect abd tumor<5cm,22904,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Radical resect abd tumor<5cm,22904,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Rad resect abd tumor 5 cm/>,22905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6177.24,,,,,,,fee schedule,2875.57,12757.95,
Rad resect abd tumor 5 cm/>,22905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4951.6,,,,,,,fee schedule,2875.57,12757.95,
Rad resect abd tumor 5 cm/>,22905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5409.17,,,,,,,fee schedule,2875.57,12757.95,
Rad resect abd tumor 5 cm/>,22905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5686.98,,,,,,,fee schedule,2875.57,12757.95,
Rad resect abd tumor 5 cm/>,22905,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Rad resect abd tumor 5 cm/>,22905,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Rad resect abd tumor 5 cm/>,22905,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Rad resect abd tumor 5 cm/>,22905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Rad resect abd tumor 5 cm/>,22905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Rad resect abd tumor 5 cm/>,22905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Rad resect abd tumor 5 cm/>,22905,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Abdomen surgery procedure,22999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,244.19,5308.18,
Abdomen surgery procedure,22999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,244.19,5308.18,
Abdomen surgery procedure,22999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,244.19,5308.18,
Abdomen surgery procedure,22999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,244.19,5308.18,
Abdomen surgery procedure,22999,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,5308.18,APC 378
Abdomen surgery procedure,22999,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,5308.18,APC
Abdomen surgery procedure,22999,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,5308.18,APC
Abdomen surgery procedure,22999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,5308.18,APC
Abdomen surgery procedure,22999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,5308.18,Radiology
Abdomen surgery procedure,22999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,5308.18,APC
Abdomen surgery procedure,22999,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,5308.18,APC
Removal of calcium deposits,23000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4018.18,,,,,,,fee schedule,2875.57,12757.95,
Removal of calcium deposits,23000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3220.92,,,,,,,fee schedule,2875.57,12757.95,
Removal of calcium deposits,23000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3518.56,,,,,,,fee schedule,2875.57,12757.95,
Removal of calcium deposits,23000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3699.27,,,,,,,fee schedule,2875.57,12757.95,
Removal of calcium deposits,23000,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Removal of calcium deposits,23000,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Removal of calcium deposits,23000,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Removal of calcium deposits,23000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Removal of calcium deposits,23000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Removal of calcium deposits,23000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Removal of calcium deposits,23000,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Release shoulder joint,23020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10728.02,,,,,,,fee schedule,3239.17,14371.12,
Release shoulder joint,23020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8599.44,,,,,,,fee schedule,3239.17,14371.12,
Release shoulder joint,23020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9394.11,,,,,,,fee schedule,3239.17,14371.12,
Release shoulder joint,23020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9876.59,,,,,,,fee schedule,3239.17,14371.12,
Release shoulder joint,23020,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Release shoulder joint,23020,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Release shoulder joint,23020,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Release shoulder joint,23020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Release shoulder joint,23020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Release shoulder joint,23020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Release shoulder joint,23020,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Drain shoulder lesion,23030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4572.14,,,,,,,fee schedule,2875.57,12757.95,
Drain shoulder lesion,23030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3664.97,,,,,,,fee schedule,2875.57,12757.95,
Drain shoulder lesion,23030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4003.64,,,,,,,fee schedule,2875.57,12757.95,
Drain shoulder lesion,23030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4209.27,,,,,,,fee schedule,2875.57,12757.95,
Drain shoulder lesion,23030,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Drain shoulder lesion,23030,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Drain shoulder lesion,23030,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Drain shoulder lesion,23030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Drain shoulder lesion,23030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Drain shoulder lesion,23030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Drain shoulder lesion,23030,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Drain shoulder bursa,23031,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4572.14,,,,,,,fee schedule,2875.57,12757.95,
Drain shoulder bursa,23031,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3664.97,,,,,,,fee schedule,2875.57,12757.95,
Drain shoulder bursa,23031,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4003.64,,,,,,,fee schedule,2875.57,12757.95,
Drain shoulder bursa,23031,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4209.27,,,,,,,fee schedule,2875.57,12757.95,
Drain shoulder bursa,23031,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Drain shoulder bursa,23031,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Drain shoulder bursa,23031,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Drain shoulder bursa,23031,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Drain shoulder bursa,23031,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Drain shoulder bursa,23031,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Drain shoulder bursa,23031,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Drain shoulder bone lesion,23035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,1591.86,7062.54,
Drain shoulder bone lesion,23035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,1591.86,7062.54,
Drain shoulder bone lesion,23035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,1591.86,7062.54,
Drain shoulder bone lesion,23035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,1591.86,7062.54,
Drain shoulder bone lesion,23035,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Drain shoulder bone lesion,23035,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Drain shoulder bone lesion,23035,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Drain shoulder bone lesion,23035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Drain shoulder bone lesion,23035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Drain shoulder bone lesion,23035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Drain shoulder bone lesion,23035,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Exploratory shoulder surgery,23040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,3239.17,14371.12,
Exploratory shoulder surgery,23040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,3239.17,14371.12,
Exploratory shoulder surgery,23040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,3239.17,14371.12,
Exploratory shoulder surgery,23040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,3239.17,14371.12,
Exploratory shoulder surgery,23040,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Exploratory shoulder surgery,23040,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Exploratory shoulder surgery,23040,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Exploratory shoulder surgery,23040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Exploratory shoulder surgery,23040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Exploratory shoulder surgery,23040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Exploratory shoulder surgery,23040,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Exploratory shoulder surgery,23044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,3239.17,14371.12,
Exploratory shoulder surgery,23044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,3239.17,14371.12,
Exploratory shoulder surgery,23044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,3239.17,14371.12,
Exploratory shoulder surgery,23044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,3239.17,14371.12,
Exploratory shoulder surgery,23044,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Exploratory shoulder surgery,23044,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Exploratory shoulder surgery,23044,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Exploratory shoulder surgery,23044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Exploratory shoulder surgery,23044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Exploratory shoulder surgery,23044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Exploratory shoulder surgery,23044,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Biopsy shoulder tissues,23065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2167.57,,,,,,,fee schedule,1635.03,7254.06,
Biopsy shoulder tissues,23065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1737.49,,,,,,,fee schedule,1635.03,7254.06,
Biopsy shoulder tissues,23065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1898.05,,,,,,,fee schedule,1635.03,7254.06,
Biopsy shoulder tissues,23065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1995.54,,,,,,,fee schedule,1635.03,7254.06,
Biopsy shoulder tissues,23065,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,7254.06,APC 378
Biopsy shoulder tissues,23065,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,7254.06,APC
Biopsy shoulder tissues,23065,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,7254.06,APC
Biopsy shoulder tissues,23065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,7254.06,APC
Biopsy shoulder tissues,23065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,7254.06,Radiology
Biopsy shoulder tissues,23065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,7254.06,APC
Biopsy shoulder tissues,23065,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,7254.06,APC
Biopsy shoulder tissues,23066,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5268.49,,,,,,,fee schedule,2875.57,12757.95,
Biopsy shoulder tissues,23066,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4223.15,,,,,,,fee schedule,2875.57,12757.95,
Biopsy shoulder tissues,23066,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4613.41,,,,,,,fee schedule,2875.57,12757.95,
Biopsy shoulder tissues,23066,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4850.35,,,,,,,fee schedule,2875.57,12757.95,
Biopsy shoulder tissues,23066,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Biopsy shoulder tissues,23066,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Biopsy shoulder tissues,23066,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Biopsy shoulder tissues,23066,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Biopsy shoulder tissues,23066,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Biopsy shoulder tissues,23066,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Biopsy shoulder tissues,23066,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Exc shoulder les sc 3 cm/>,23071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6721.57,,,,,,,fee schedule,1635.03,7254.06,
Exc shoulder les sc 3 cm/>,23071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5387.93,,,,,,,fee schedule,1635.03,7254.06,
Exc shoulder les sc 3 cm/>,23071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5885.82,,,,,,,fee schedule,1635.03,7254.06,
Exc shoulder les sc 3 cm/>,23071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6188.11,,,,,,,fee schedule,1635.03,7254.06,
Exc shoulder les sc 3 cm/>,23071,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,7254.06,APC 378
Exc shoulder les sc 3 cm/>,23071,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,7254.06,APC
Exc shoulder les sc 3 cm/>,23071,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,7254.06,APC
Exc shoulder les sc 3 cm/>,23071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,7254.06,APC
Exc shoulder les sc 3 cm/>,23071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,7254.06,Radiology
Exc shoulder les sc 3 cm/>,23071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,7254.06,APC
Exc shoulder les sc 3 cm/>,23071,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,7254.06,APC
Exc shoulder tum deep 5 cm/>,23073,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6177.24,,,,,,,fee schedule,2875.57,12757.95,
Exc shoulder tum deep 5 cm/>,23073,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4951.6,,,,,,,fee schedule,2875.57,12757.95,
Exc shoulder tum deep 5 cm/>,23073,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5409.17,,,,,,,fee schedule,2875.57,12757.95,
Exc shoulder tum deep 5 cm/>,23073,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5686.98,,,,,,,fee schedule,2875.57,12757.95,
Exc shoulder tum deep 5 cm/>,23073,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Exc shoulder tum deep 5 cm/>,23073,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Exc shoulder tum deep 5 cm/>,23073,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Exc shoulder tum deep 5 cm/>,23073,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Exc shoulder tum deep 5 cm/>,23073,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Exc shoulder tum deep 5 cm/>,23073,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Exc shoulder tum deep 5 cm/>,23073,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Exc shoulder les sc < 3 cm,23075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3594.84,,,,,,,fee schedule,1635.03,7254.06,
Exc shoulder les sc < 3 cm,23075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2881.58,,,,,,,fee schedule,1635.03,7254.06,
Exc shoulder les sc < 3 cm,23075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3147.87,,,,,,,fee schedule,1635.03,7254.06,
Exc shoulder les sc < 3 cm,23075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3309.54,,,,,,,fee schedule,1635.03,7254.06,
Exc shoulder les sc < 3 cm,23075,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,7254.06,APC 378
Exc shoulder les sc < 3 cm,23075,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,7254.06,APC
Exc shoulder les sc < 3 cm,23075,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,7254.06,APC
Exc shoulder les sc < 3 cm,23075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,7254.06,APC
Exc shoulder les sc < 3 cm,23075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,7254.06,Radiology
Exc shoulder les sc < 3 cm,23075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,7254.06,APC
Exc shoulder les sc < 3 cm,23075,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,7254.06,APC
Exc shoulder tum deep < 5 cm,23076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5268.49,,,,,,,fee schedule,2875.57,12757.95,
Exc shoulder tum deep < 5 cm,23076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4223.15,,,,,,,fee schedule,2875.57,12757.95,
Exc shoulder tum deep < 5 cm,23076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4613.41,,,,,,,fee schedule,2875.57,12757.95,
Exc shoulder tum deep < 5 cm,23076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4850.35,,,,,,,fee schedule,2875.57,12757.95,
Exc shoulder tum deep < 5 cm,23076,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Exc shoulder tum deep < 5 cm,23076,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Exc shoulder tum deep < 5 cm,23076,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Exc shoulder tum deep < 5 cm,23076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Exc shoulder tum deep < 5 cm,23076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Exc shoulder tum deep < 5 cm,23076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Exc shoulder tum deep < 5 cm,23076,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Resect shoulder tumor < 5 cm,23077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5268.49,,,,,,,fee schedule,2875.57,12757.95,
Resect shoulder tumor < 5 cm,23077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4223.15,,,,,,,fee schedule,2875.57,12757.95,
Resect shoulder tumor < 5 cm,23077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4613.41,,,,,,,fee schedule,2875.57,12757.95,
Resect shoulder tumor < 5 cm,23077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4850.35,,,,,,,fee schedule,2875.57,12757.95,
Resect shoulder tumor < 5 cm,23077,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Resect shoulder tumor < 5 cm,23077,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Resect shoulder tumor < 5 cm,23077,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Resect shoulder tumor < 5 cm,23077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Resect shoulder tumor < 5 cm,23077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Resect shoulder tumor < 5 cm,23077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Resect shoulder tumor < 5 cm,23077,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Resect shoulder tumor 5 cm/>,23078,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6177.24,,,,,,,fee schedule,2875.57,12757.95,
Resect shoulder tumor 5 cm/>,23078,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4951.6,,,,,,,fee schedule,2875.57,12757.95,
Resect shoulder tumor 5 cm/>,23078,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5409.17,,,,,,,fee schedule,2875.57,12757.95,
Resect shoulder tumor 5 cm/>,23078,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5686.98,,,,,,,fee schedule,2875.57,12757.95,
Resect shoulder tumor 5 cm/>,23078,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Resect shoulder tumor 5 cm/>,23078,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Resect shoulder tumor 5 cm/>,23078,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Resect shoulder tumor 5 cm/>,23078,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Resect shoulder tumor 5 cm/>,23078,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Resect shoulder tumor 5 cm/>,23078,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Resect shoulder tumor 5 cm/>,23078,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Biopsy of shoulder joint,23100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,3239.17,14371.12,
Biopsy of shoulder joint,23100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,3239.17,14371.12,
Biopsy of shoulder joint,23100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,3239.17,14371.12,
Biopsy of shoulder joint,23100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,3239.17,14371.12,
Biopsy of shoulder joint,23100,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Biopsy of shoulder joint,23100,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Biopsy of shoulder joint,23100,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Biopsy of shoulder joint,23100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Biopsy of shoulder joint,23100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Biopsy of shoulder joint,23100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Biopsy of shoulder joint,23100,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Shoulder joint surgery,23101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,3239.17,14371.12,
Shoulder joint surgery,23101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,3239.17,14371.12,
Shoulder joint surgery,23101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,3239.17,14371.12,
Shoulder joint surgery,23101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,3239.17,14371.12,
Shoulder joint surgery,23101,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Shoulder joint surgery,23101,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Shoulder joint surgery,23101,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Shoulder joint surgery,23101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Shoulder joint surgery,23101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Shoulder joint surgery,23101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Shoulder joint surgery,23101,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Remove shoulder joint lining,23105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,5839.66,31870.39,
Remove shoulder joint lining,23105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,5839.66,31870.39,
Remove shoulder joint lining,23105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,5839.66,31870.39,
Remove shoulder joint lining,23105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,5839.66,31870.39,
Remove shoulder joint lining,23105,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5839.66,31870.39,APC 378
Remove shoulder joint lining,23105,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5839.66,31870.39,APC
Remove shoulder joint lining,23105,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5839.66,31870.39,APC
Remove shoulder joint lining,23105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5839.66,31870.39,APC
Remove shoulder joint lining,23105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5839.66,31870.39,Radiology
Remove shoulder joint lining,23105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5839.66,31870.39,APC
Remove shoulder joint lining,23105,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5839.66,31870.39,APC
Incision of collarbone joint,23106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,3239.17,14371.12,
Incision of collarbone joint,23106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,3239.17,14371.12,
Incision of collarbone joint,23106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,3239.17,14371.12,
Incision of collarbone joint,23106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,3239.17,14371.12,
Incision of collarbone joint,23106,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Incision of collarbone joint,23106,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Incision of collarbone joint,23106,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Incision of collarbone joint,23106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Incision of collarbone joint,23106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Incision of collarbone joint,23106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Incision of collarbone joint,23106,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Explore treat shoulder joint,23107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,5839.66,31870.39,
Explore treat shoulder joint,23107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,5839.66,31870.39,
Explore treat shoulder joint,23107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,5839.66,31870.39,
Explore treat shoulder joint,23107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,5839.66,31870.39,
Explore treat shoulder joint,23107,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5839.66,31870.39,APC 378
Explore treat shoulder joint,23107,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5839.66,31870.39,APC
Explore treat shoulder joint,23107,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5839.66,31870.39,APC
Explore treat shoulder joint,23107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5839.66,31870.39,APC
Explore treat shoulder joint,23107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5839.66,31870.39,Radiology
Explore treat shoulder joint,23107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5839.66,31870.39,APC
Explore treat shoulder joint,23107,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5839.66,31870.39,APC
Partial removal collar bone,23120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6721.57,,,,,,,fee schedule,3239.17,14371.12,
Partial removal collar bone,23120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5387.93,,,,,,,fee schedule,3239.17,14371.12,
Partial removal collar bone,23120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5885.82,,,,,,,fee schedule,3239.17,14371.12,
Partial removal collar bone,23120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6188.11,,,,,,,fee schedule,3239.17,14371.12,
Partial removal collar bone,23120,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Partial removal collar bone,23120,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Partial removal collar bone,23120,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Partial removal collar bone,23120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Partial removal collar bone,23120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Partial removal collar bone,23120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Partial removal collar bone,23120,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of collar bone,23125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,3239.17,14371.12,
Removal of collar bone,23125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,3239.17,14371.12,
Removal of collar bone,23125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,3239.17,14371.12,
Removal of collar bone,23125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,3239.17,14371.12,
Removal of collar bone,23125,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Removal of collar bone,23125,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of collar bone,23125,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of collar bone,23125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of collar bone,23125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Removal of collar bone,23125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of collar bone,23125,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Remove shoulder bone part,23130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10728.02,,,,,,,fee schedule,3239.17,14371.12,
Remove shoulder bone part,23130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8599.44,,,,,,,fee schedule,3239.17,14371.12,
Remove shoulder bone part,23130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9394.11,,,,,,,fee schedule,3239.17,14371.12,
Remove shoulder bone part,23130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9876.59,,,,,,,fee schedule,3239.17,14371.12,
Remove shoulder bone part,23130,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Remove shoulder bone part,23130,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Remove shoulder bone part,23130,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Remove shoulder bone part,23130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Remove shoulder bone part,23130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Remove shoulder bone part,23130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Remove shoulder bone part,23130,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of bone lesion,23140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6721.57,,,,,,,fee schedule,3239.17,14371.12,
Removal of bone lesion,23140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5387.93,,,,,,,fee schedule,3239.17,14371.12,
Removal of bone lesion,23140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5885.82,,,,,,,fee schedule,3239.17,14371.12,
Removal of bone lesion,23140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6188.11,,,,,,,fee schedule,3239.17,14371.12,
Removal of bone lesion,23140,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Removal of bone lesion,23140,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of bone lesion,23140,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of bone lesion,23140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of bone lesion,23140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Removal of bone lesion,23140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of bone lesion,23140,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of bone lesion,23145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,3239.17,14371.12,
Removal of bone lesion,23145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,3239.17,14371.12,
Removal of bone lesion,23145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,3239.17,14371.12,
Removal of bone lesion,23145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,3239.17,14371.12,
Removal of bone lesion,23145,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Removal of bone lesion,23145,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of bone lesion,23145,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of bone lesion,23145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of bone lesion,23145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Removal of bone lesion,23145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of bone lesion,23145,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of bone lesion,23146,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,5839.66,31870.39,
Removal of bone lesion,23146,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,5839.66,31870.39,
Removal of bone lesion,23146,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,5839.66,31870.39,
Removal of bone lesion,23146,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,5839.66,31870.39,
Removal of bone lesion,23146,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5839.66,31870.39,APC 378
Removal of bone lesion,23146,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5839.66,31870.39,APC
Removal of bone lesion,23146,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5839.66,31870.39,APC
Removal of bone lesion,23146,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5839.66,31870.39,APC
Removal of bone lesion,23146,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5839.66,31870.39,Radiology
Removal of bone lesion,23146,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5839.66,31870.39,APC
Removal of bone lesion,23146,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5839.66,31870.39,APC
Removal of humerus lesion,23150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8125.92,,,,,,,fee schedule,3239.17,14371.12,
Removal of humerus lesion,23150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6513.63,,,,,,,fee schedule,3239.17,14371.12,
Removal of humerus lesion,23150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7115.55,,,,,,,fee schedule,3239.17,14371.12,
Removal of humerus lesion,23150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7481,,,,,,,fee schedule,3239.17,14371.12,
Removal of humerus lesion,23150,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Removal of humerus lesion,23150,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of humerus lesion,23150,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of humerus lesion,23150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of humerus lesion,23150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Removal of humerus lesion,23150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of humerus lesion,23150,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of humerus lesion,23155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,5839.66,31870.39,
Removal of humerus lesion,23155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,5839.66,31870.39,
Removal of humerus lesion,23155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,5839.66,31870.39,
Removal of humerus lesion,23155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,5839.66,31870.39,
Removal of humerus lesion,23155,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5839.66,31870.39,APC 378
Removal of humerus lesion,23155,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5839.66,31870.39,APC
Removal of humerus lesion,23155,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5839.66,31870.39,APC
Removal of humerus lesion,23155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5839.66,31870.39,APC
Removal of humerus lesion,23155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5839.66,31870.39,Radiology
Removal of humerus lesion,23155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5839.66,31870.39,APC
Removal of humerus lesion,23155,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5839.66,31870.39,APC
Removal of humerus lesion,23156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,5839.66,31870.39,
Removal of humerus lesion,23156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,5839.66,31870.39,
Removal of humerus lesion,23156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,5839.66,31870.39,
Removal of humerus lesion,23156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,5839.66,31870.39,
Removal of humerus lesion,23156,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5839.66,31870.39,APC 378
Removal of humerus lesion,23156,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5839.66,31870.39,APC
Removal of humerus lesion,23156,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5839.66,31870.39,APC
Removal of humerus lesion,23156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5839.66,31870.39,APC
Removal of humerus lesion,23156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5839.66,31870.39,Radiology
Removal of humerus lesion,23156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5839.66,31870.39,APC
Removal of humerus lesion,23156,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5839.66,31870.39,APC
Remove collar bone lesion,23170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,3239.17,14371.12,
Remove collar bone lesion,23170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,3239.17,14371.12,
Remove collar bone lesion,23170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,3239.17,14371.12,
Remove collar bone lesion,23170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,3239.17,14371.12,
Remove collar bone lesion,23170,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Remove collar bone lesion,23170,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Remove collar bone lesion,23170,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Remove collar bone lesion,23170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Remove collar bone lesion,23170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Remove collar bone lesion,23170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Remove collar bone lesion,23170,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Remove shoulder blade lesion,23172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,3239.17,14371.12,
Remove shoulder blade lesion,23172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,3239.17,14371.12,
Remove shoulder blade lesion,23172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,3239.17,14371.12,
Remove shoulder blade lesion,23172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,3239.17,14371.12,
Remove shoulder blade lesion,23172,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Remove shoulder blade lesion,23172,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Remove shoulder blade lesion,23172,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Remove shoulder blade lesion,23172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Remove shoulder blade lesion,23172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Remove shoulder blade lesion,23172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Remove shoulder blade lesion,23172,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Remove humerus lesion,23174,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,5839.66,31870.39,
Remove humerus lesion,23174,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,5839.66,31870.39,
Remove humerus lesion,23174,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,5839.66,31870.39,
Remove humerus lesion,23174,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,5839.66,31870.39,
Remove humerus lesion,23174,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5839.66,31870.39,APC 378
Remove humerus lesion,23174,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5839.66,31870.39,APC
Remove humerus lesion,23174,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5839.66,31870.39,APC
Remove humerus lesion,23174,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5839.66,31870.39,APC
Remove humerus lesion,23174,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5839.66,31870.39,Radiology
Remove humerus lesion,23174,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5839.66,31870.39,APC
Remove humerus lesion,23174,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5839.66,31870.39,APC
Remove collar bone lesion,23180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,5839.66,31870.39,
Remove collar bone lesion,23180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,5839.66,31870.39,
Remove collar bone lesion,23180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,5839.66,31870.39,
Remove collar bone lesion,23180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,5839.66,31870.39,
Remove collar bone lesion,23180,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5839.66,31870.39,APC 378
Remove collar bone lesion,23180,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5839.66,31870.39,APC
Remove collar bone lesion,23180,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5839.66,31870.39,APC
Remove collar bone lesion,23180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5839.66,31870.39,APC
Remove collar bone lesion,23180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5839.66,31870.39,Radiology
Remove collar bone lesion,23180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5839.66,31870.39,APC
Remove collar bone lesion,23180,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5839.66,31870.39,APC
Remove shoulder blade lesion,23182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,5839.66,31870.39,
Remove shoulder blade lesion,23182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,5839.66,31870.39,
Remove shoulder blade lesion,23182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,5839.66,31870.39,
Remove shoulder blade lesion,23182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,5839.66,31870.39,
Remove shoulder blade lesion,23182,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5839.66,31870.39,APC 378
Remove shoulder blade lesion,23182,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5839.66,31870.39,APC
Remove shoulder blade lesion,23182,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5839.66,31870.39,APC
Remove shoulder blade lesion,23182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5839.66,31870.39,APC
Remove shoulder blade lesion,23182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5839.66,31870.39,Radiology
Remove shoulder blade lesion,23182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5839.66,31870.39,APC
Remove shoulder blade lesion,23182,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5839.66,31870.39,APC
Remove humerus lesion,23184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,5839.66,31870.39,
Remove humerus lesion,23184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,5839.66,31870.39,
Remove humerus lesion,23184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,5839.66,31870.39,
Remove humerus lesion,23184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,5839.66,31870.39,
Remove humerus lesion,23184,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5839.66,31870.39,APC 378
Remove humerus lesion,23184,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5839.66,31870.39,APC
Remove humerus lesion,23184,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5839.66,31870.39,APC
Remove humerus lesion,23184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5839.66,31870.39,APC
Remove humerus lesion,23184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5839.66,31870.39,Radiology
Remove humerus lesion,23184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5839.66,31870.39,APC
Remove humerus lesion,23184,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5839.66,31870.39,APC
Partial removal of scapula,23190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5336.73,,,,,,,fee schedule,3239.17,14371.12,
Partial removal of scapula,23190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4277.86,,,,,,,fee schedule,3239.17,14371.12,
Partial removal of scapula,23190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4673.17,,,,,,,fee schedule,3239.17,14371.12,
Partial removal of scapula,23190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4913.18,,,,,,,fee schedule,3239.17,14371.12,
Partial removal of scapula,23190,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Partial removal of scapula,23190,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Partial removal of scapula,23190,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Partial removal of scapula,23190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Partial removal of scapula,23190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Partial removal of scapula,23190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Partial removal of scapula,23190,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of head of humerus,23195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,5839.66,31870.39,
Removal of head of humerus,23195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,5839.66,31870.39,
Removal of head of humerus,23195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,5839.66,31870.39,
Removal of head of humerus,23195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,5839.66,31870.39,
Removal of head of humerus,23195,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5839.66,31870.39,APC 378
Removal of head of humerus,23195,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5839.66,31870.39,APC
Removal of head of humerus,23195,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5839.66,31870.39,APC
Removal of head of humerus,23195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5839.66,31870.39,APC
Removal of head of humerus,23195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5839.66,31870.39,Radiology
Removal of head of humerus,23195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5839.66,31870.39,APC
Removal of head of humerus,23195,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5839.66,31870.39,APC
Resect clavicle tumor,23200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Resect clavicle tumor,23200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Resect clavicle tumor,23200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Resect clavicle tumor,23200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Resect clavicle tumor,23200,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Resect clavicle tumor,23200,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Resect clavicle tumor,23200,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Resect clavicle tumor,23200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Resect clavicle tumor,23200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Resect clavicle tumor,23200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Resect clavicle tumor,23200,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Resect scapula tumor,23210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Resect scapula tumor,23210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Resect scapula tumor,23210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Resect scapula tumor,23210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Resect scapula tumor,23210,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Resect scapula tumor,23210,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Resect scapula tumor,23210,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Resect scapula tumor,23210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Resect scapula tumor,23210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Resect scapula tumor,23210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Resect scapula tumor,23210,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Resect prox humerus tumor,23220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Resect prox humerus tumor,23220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Resect prox humerus tumor,23220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Resect prox humerus tumor,23220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Resect prox humerus tumor,23220,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Resect prox humerus tumor,23220,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Resect prox humerus tumor,23220,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Resect prox humerus tumor,23220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Resect prox humerus tumor,23220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Resect prox humerus tumor,23220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Resect prox humerus tumor,23220,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Remove shoulder foreign body,23330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2167.57,,,,,,,fee schedule,1635.03,7254.06,
Remove shoulder foreign body,23330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1737.49,,,,,,,fee schedule,1635.03,7254.06,
Remove shoulder foreign body,23330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1898.05,,,,,,,fee schedule,1635.03,7254.06,
Remove shoulder foreign body,23330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1995.54,,,,,,,fee schedule,1635.03,7254.06,
Remove shoulder foreign body,23330,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,7254.06,APC 378
Remove shoulder foreign body,23330,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,7254.06,APC
Remove shoulder foreign body,23330,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,7254.06,APC
Remove shoulder foreign body,23330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,7254.06,APC
Remove shoulder foreign body,23330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,7254.06,Radiology
Remove shoulder foreign body,23330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,7254.06,APC
Remove shoulder foreign body,23330,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,7254.06,APC
Remove shoulder fb deep,23333,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3124.47,,,,,,,fee schedule,2504.54,12757.95,
Remove shoulder fb deep,23333,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2504.54,,,,,,,fee schedule,2504.54,12757.95,
Remove shoulder fb deep,23333,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2735.98,,,,,,,fee schedule,2504.54,12757.95,
Remove shoulder fb deep,23333,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2876.5,,,,,,,fee schedule,2504.54,12757.95,
Remove shoulder fb deep,23333,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2504.54,12757.95,APC 378
Remove shoulder fb deep,23333,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2504.54,12757.95,APC
Remove shoulder fb deep,23333,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2504.54,12757.95,APC
Remove shoulder fb deep,23333,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2504.54,12757.95,APC
Remove shoulder fb deep,23333,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2504.54,12757.95,Radiology
Remove shoulder fb deep,23333,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2504.54,12757.95,APC
Remove shoulder fb deep,23333,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2504.54,12757.95,APC
Shoulder prosthesis removal,23334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6895.89,,,,,,,fee schedule,5527.66,31870.39,
Shoulder prosthesis removal,23334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5527.66,,,,,,,fee schedule,5527.66,31870.39,
Shoulder prosthesis removal,23334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6038.47,,,,,,,fee schedule,5527.66,31870.39,
Shoulder prosthesis removal,23334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6348.6,,,,,,,fee schedule,5527.66,31870.39,
Shoulder prosthesis removal,23334,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5527.66,31870.39,APC 378
Shoulder prosthesis removal,23334,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5527.66,31870.39,APC
Shoulder prosthesis removal,23334,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5527.66,31870.39,APC
Shoulder prosthesis removal,23334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5527.66,31870.39,APC
Shoulder prosthesis removal,23334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5527.66,31870.39,Radiology
Shoulder prosthesis removal,23334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5527.66,31870.39,APC
Shoulder prosthesis removal,23334,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5527.66,31870.39,APC
Shoulder prosthesis removal,23335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4897.29,,,,,,,fee schedule,3925.61,31870.39,
Shoulder prosthesis removal,23335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3925.61,,,,,,,fee schedule,3925.61,31870.39,
Shoulder prosthesis removal,23335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4288.37,,,,,,,fee schedule,3925.61,31870.39,
Shoulder prosthesis removal,23335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4508.62,,,,,,,fee schedule,3925.61,31870.39,
Shoulder prosthesis removal,23335,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,3925.61,31870.39,APC 378
Shoulder prosthesis removal,23335,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,3925.61,31870.39,APC
Shoulder prosthesis removal,23335,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,3925.61,31870.39,APC
Shoulder prosthesis removal,23335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,3925.61,31870.39,APC
Shoulder prosthesis removal,23335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,3925.61,31870.39,Radiology
Shoulder prosthesis removal,23335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,3925.61,31870.39,APC
Shoulder prosthesis removal,23335,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,3925.61,31870.39,APC
Muscle transfer shoulder/arm,23395,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10728.02,,,,,,,fee schedule,7183.42,31870.39,
Muscle transfer shoulder/arm,23395,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8599.44,,,,,,,fee schedule,7183.42,31870.39,
Muscle transfer shoulder/arm,23395,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9394.11,,,,,,,fee schedule,7183.42,31870.39,
Muscle transfer shoulder/arm,23395,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9876.59,,,,,,,fee schedule,7183.42,31870.39,
Muscle transfer shoulder/arm,23395,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Muscle transfer shoulder/arm,23395,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Muscle transfer shoulder/arm,23395,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Muscle transfer shoulder/arm,23395,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Muscle transfer shoulder/arm,23395,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Muscle transfer shoulder/arm,23395,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Muscle transfer shoulder/arm,23395,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Muscle transfers,23397,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19822.36,,,,,,,fee schedule,7183.42,31870.39,
Muscle transfers,23397,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15889.35,,,,,,,fee schedule,7183.42,31870.39,
Muscle transfers,23397,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17357.67,,,,,,,fee schedule,7183.42,31870.39,
Muscle transfers,23397,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18249.15,,,,,,,fee schedule,7183.42,31870.39,
Muscle transfers,23397,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Muscle transfers,23397,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Muscle transfers,23397,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Muscle transfers,23397,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Muscle transfers,23397,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Muscle transfers,23397,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Muscle transfers,23397,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Fixation of shoulder blade,23400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,5839.66,31870.39,
Fixation of shoulder blade,23400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,5839.66,31870.39,
Fixation of shoulder blade,23400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,5839.66,31870.39,
Fixation of shoulder blade,23400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,5839.66,31870.39,
Fixation of shoulder blade,23400,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5839.66,31870.39,APC 378
Fixation of shoulder blade,23400,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5839.66,31870.39,APC
Fixation of shoulder blade,23400,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5839.66,31870.39,APC
Fixation of shoulder blade,23400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5839.66,31870.39,APC
Fixation of shoulder blade,23400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5839.66,31870.39,Radiology
Fixation of shoulder blade,23400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5839.66,31870.39,APC
Fixation of shoulder blade,23400,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5839.66,31870.39,APC
Incision of tendon & muscle,23405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4412.15,,,,,,,fee schedule,3536.73,31870.39,
Incision of tendon & muscle,23405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3536.73,,,,,,,fee schedule,3536.73,31870.39,
Incision of tendon & muscle,23405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3863.55,,,,,,,fee schedule,3536.73,31870.39,
Incision of tendon & muscle,23405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4061.98,,,,,,,fee schedule,3536.73,31870.39,
Incision of tendon & muscle,23405,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,3536.73,31870.39,APC 378
Incision of tendon & muscle,23405,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,3536.73,31870.39,APC
Incision of tendon & muscle,23405,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,3536.73,31870.39,APC
Incision of tendon & muscle,23405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,3536.73,31870.39,APC
Incision of tendon & muscle,23405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,3536.73,31870.39,Radiology
Incision of tendon & muscle,23405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,3536.73,31870.39,APC
Incision of tendon & muscle,23405,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,3536.73,31870.39,APC
Incise tendon(s) & muscle(s),23406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,5839.66,31870.39,
Incise tendon(s) & muscle(s),23406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,5839.66,31870.39,
Incise tendon(s) & muscle(s),23406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,5839.66,31870.39,
Incise tendon(s) & muscle(s),23406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,5839.66,31870.39,
Incise tendon(s) & muscle(s),23406,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5839.66,31870.39,APC 378
Incise tendon(s) & muscle(s),23406,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5839.66,31870.39,APC
Incise tendon(s) & muscle(s),23406,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5839.66,31870.39,APC
Incise tendon(s) & muscle(s),23406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5839.66,31870.39,APC
Incise tendon(s) & muscle(s),23406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5839.66,31870.39,Radiology
Incise tendon(s) & muscle(s),23406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5839.66,31870.39,APC
Incise tendon(s) & muscle(s),23406,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5839.66,31870.39,APC
Repair rotator cuff acute,23410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4705.72,,,,,,,fee schedule,3772.04,31870.39,
Repair rotator cuff acute,23410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3772.04,,,,,,,fee schedule,3772.04,31870.39,
Repair rotator cuff acute,23410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4120.61,,,,,,,fee schedule,3772.04,31870.39,
Repair rotator cuff acute,23410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4332.25,,,,,,,fee schedule,3772.04,31870.39,
Repair rotator cuff acute,23410,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,3772.04,31870.39,APC 378
Repair rotator cuff acute,23410,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,3772.04,31870.39,APC
Repair rotator cuff acute,23410,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,3772.04,31870.39,APC
Repair rotator cuff acute,23410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,3772.04,31870.39,APC
Repair rotator cuff acute,23410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,3772.04,31870.39,Radiology
Repair rotator cuff acute,23410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,3772.04,31870.39,APC
Repair rotator cuff acute,23410,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,3772.04,31870.39,APC
Repair rotator cuff chronic,23412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4417.36,,,,,,,fee schedule,3540.9,31870.39,
Repair rotator cuff chronic,23412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3540.9,,,,,,,fee schedule,3540.9,31870.39,
Repair rotator cuff chronic,23412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3868.11,,,,,,,fee schedule,3540.9,31870.39,
Repair rotator cuff chronic,23412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4066.78,,,,,,,fee schedule,3540.9,31870.39,
Repair rotator cuff chronic,23412,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,3540.9,31870.39,APC 378
Repair rotator cuff chronic,23412,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,3540.9,31870.39,APC
Repair rotator cuff chronic,23412,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,3540.9,31870.39,APC
Repair rotator cuff chronic,23412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,3540.9,31870.39,APC
Repair rotator cuff chronic,23412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,3540.9,31870.39,Radiology
Repair rotator cuff chronic,23412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,3540.9,31870.39,APC
Repair rotator cuff chronic,23412,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,3540.9,31870.39,APC
Release of shoulder ligament,23415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3456.68,,,,,,,fee schedule,2770.83,31870.39,
Release of shoulder ligament,23415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2770.83,,,,,,,fee schedule,2770.83,31870.39,
Release of shoulder ligament,23415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3026.88,,,,,,,fee schedule,2770.83,31870.39,
Release of shoulder ligament,23415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3182.34,,,,,,,fee schedule,2770.83,31870.39,
Release of shoulder ligament,23415,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,2770.83,31870.39,APC 378
Release of shoulder ligament,23415,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,2770.83,31870.39,APC
Release of shoulder ligament,23415,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,2770.83,31870.39,APC
Release of shoulder ligament,23415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,2770.83,31870.39,APC
Release of shoulder ligament,23415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,2770.83,31870.39,Radiology
Release of shoulder ligament,23415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,2770.83,31870.39,APC
Release of shoulder ligament,23415,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,2770.83,31870.39,APC
Repair of shoulder,23420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5485.73,,,,,,,fee schedule,4397.29,31870.39,
Repair of shoulder,23420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4397.29,,,,,,,fee schedule,4397.29,31870.39,
Repair of shoulder,23420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4803.64,,,,,,,fee schedule,4397.29,31870.39,
Repair of shoulder,23420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5050.35,,,,,,,fee schedule,4397.29,31870.39,
Repair of shoulder,23420,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,4397.29,31870.39,APC 378
Repair of shoulder,23420,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,4397.29,31870.39,APC
Repair of shoulder,23420,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,4397.29,31870.39,APC
Repair of shoulder,23420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,4397.29,31870.39,APC
Repair of shoulder,23420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,4397.29,31870.39,Radiology
Repair of shoulder,23420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,4397.29,31870.39,APC
Repair of shoulder,23420,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,4397.29,31870.39,APC
Repair biceps tendon,23430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3183.3,,,,,,,fee schedule,2551.69,31870.39,
Repair biceps tendon,23430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2551.69,,,,,,,fee schedule,2551.69,31870.39,
Repair biceps tendon,23430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2787.5,,,,,,,fee schedule,2551.69,31870.39,
Repair biceps tendon,23430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2930.66,,,,,,,fee schedule,2551.69,31870.39,
Repair biceps tendon,23430,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,2551.69,31870.39,APC 378
Repair biceps tendon,23430,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,2551.69,31870.39,APC
Repair biceps tendon,23430,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,2551.69,31870.39,APC
Repair biceps tendon,23430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,2551.69,31870.39,APC
Repair biceps tendon,23430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,2551.69,31870.39,Radiology
Repair biceps tendon,23430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,2551.69,31870.39,APC
Repair biceps tendon,23430,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,2551.69,31870.39,APC
Remove/transplant tendon,23440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10728.02,,,,,,,fee schedule,7183.42,31870.39,
Remove/transplant tendon,23440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8599.44,,,,,,,fee schedule,7183.42,31870.39,
Remove/transplant tendon,23440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9394.11,,,,,,,fee schedule,7183.42,31870.39,
Remove/transplant tendon,23440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9876.59,,,,,,,fee schedule,7183.42,31870.39,
Remove/transplant tendon,23440,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Remove/transplant tendon,23440,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Remove/transplant tendon,23440,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Remove/transplant tendon,23440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Remove/transplant tendon,23440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Remove/transplant tendon,23440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Remove/transplant tendon,23440,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Repair shoulder capsule,23450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19822.36,,,,,,,fee schedule,7183.42,31870.39,
Repair shoulder capsule,23450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15889.35,,,,,,,fee schedule,7183.42,31870.39,
Repair shoulder capsule,23450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17357.67,,,,,,,fee schedule,7183.42,31870.39,
Repair shoulder capsule,23450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18249.15,,,,,,,fee schedule,7183.42,31870.39,
Repair shoulder capsule,23450,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Repair shoulder capsule,23450,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Repair shoulder capsule,23450,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Repair shoulder capsule,23450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Repair shoulder capsule,23450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Repair shoulder capsule,23450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Repair shoulder capsule,23450,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Repair shoulder capsule,23455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19822.36,,,,,,,fee schedule,7183.42,31870.39,
Repair shoulder capsule,23455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15889.35,,,,,,,fee schedule,7183.42,31870.39,
Repair shoulder capsule,23455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17357.67,,,,,,,fee schedule,7183.42,31870.39,
Repair shoulder capsule,23455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18249.15,,,,,,,fee schedule,7183.42,31870.39,
Repair shoulder capsule,23455,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Repair shoulder capsule,23455,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Repair shoulder capsule,23455,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Repair shoulder capsule,23455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Repair shoulder capsule,23455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Repair shoulder capsule,23455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Repair shoulder capsule,23455,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Repair shoulder capsule,23460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19822.36,,,,,,,fee schedule,7183.42,31870.39,
Repair shoulder capsule,23460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15889.35,,,,,,,fee schedule,7183.42,31870.39,
Repair shoulder capsule,23460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17357.67,,,,,,,fee schedule,7183.42,31870.39,
Repair shoulder capsule,23460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18249.15,,,,,,,fee schedule,7183.42,31870.39,
Repair shoulder capsule,23460,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Repair shoulder capsule,23460,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Repair shoulder capsule,23460,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Repair shoulder capsule,23460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Repair shoulder capsule,23460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Repair shoulder capsule,23460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Repair shoulder capsule,23460,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Repair shoulder capsule,23462,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13482.15,,,,,,,fee schedule,7183.42,31870.39,
Repair shoulder capsule,23462,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10807.12,,,,,,,fee schedule,7183.42,31870.39,
Repair shoulder capsule,23462,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11805.8,,,,,,,fee schedule,7183.42,31870.39,
Repair shoulder capsule,23462,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12412.14,,,,,,,fee schedule,7183.42,31870.39,
Repair shoulder capsule,23462,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Repair shoulder capsule,23462,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Repair shoulder capsule,23462,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Repair shoulder capsule,23462,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Repair shoulder capsule,23462,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Repair shoulder capsule,23462,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Repair shoulder capsule,23462,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Repair shoulder capsule,23465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19822.36,,,,,,,fee schedule,7183.42,31870.39,
Repair shoulder capsule,23465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15889.35,,,,,,,fee schedule,7183.42,31870.39,
Repair shoulder capsule,23465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17357.67,,,,,,,fee schedule,7183.42,31870.39,
Repair shoulder capsule,23465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18249.15,,,,,,,fee schedule,7183.42,31870.39,
Repair shoulder capsule,23465,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Repair shoulder capsule,23465,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Repair shoulder capsule,23465,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Repair shoulder capsule,23465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Repair shoulder capsule,23465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Repair shoulder capsule,23465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Repair shoulder capsule,23465,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Repair shoulder capsule,23466,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10728.02,,,,,,,fee schedule,7183.42,31870.39,
Repair shoulder capsule,23466,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8599.44,,,,,,,fee schedule,7183.42,31870.39,
Repair shoulder capsule,23466,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9394.11,,,,,,,fee schedule,7183.42,31870.39,
Repair shoulder capsule,23466,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9876.59,,,,,,,fee schedule,7183.42,31870.39,
Repair shoulder capsule,23466,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Repair shoulder capsule,23466,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Repair shoulder capsule,23466,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Repair shoulder capsule,23466,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Repair shoulder capsule,23466,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Repair shoulder capsule,23466,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Repair shoulder capsule,23466,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Reconstruct shoulder joint,23470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30499.53,,,,,,,fee schedule,12709.88,56389.43,
Reconstruct shoulder joint,23470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24448.04,,,,,,,fee schedule,12709.88,56389.43,
Reconstruct shoulder joint,23470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26707.26,,,,,,,fee schedule,12709.88,56389.43,
Reconstruct shoulder joint,23470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,28078.94,,,,,,,fee schedule,12709.88,56389.43,
Reconstruct shoulder joint,23470,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,12709.88,56389.43,APC 378
Reconstruct shoulder joint,23470,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,12709.88,56389.43,APC
Reconstruct shoulder joint,23470,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,12709.88,56389.43,APC
Reconstruct shoulder joint,23470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,12709.88,56389.43,APC
Reconstruct shoulder joint,23470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,12709.88,56389.43,Radiology
Reconstruct shoulder joint,23470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,12709.88,56389.43,APC
Reconstruct shoulder joint,23470,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,12709.88,56389.43,APC
Reconstruct shoulder joint,23472,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11792.5,,,,,,,fee schedule,9452.72,77011.17,
Reconstruct shoulder joint,23472,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9452.72,,,,,,,fee schedule,9452.72,77011.17,
Reconstruct shoulder joint,23472,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10326.24,,,,,,,fee schedule,9452.72,77011.17,
Reconstruct shoulder joint,23472,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10856.59,,,,,,,fee schedule,9452.72,77011.17,
Reconstruct shoulder joint,23472,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,77011.17,,,,,,,fee schedule,9452.72,77011.17,APC 378
Reconstruct shoulder joint,23472,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18225.81,,,,,,,fee schedule,9452.72,77011.17,APC
Reconstruct shoulder joint,23472,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18052.23,,,,,,,fee schedule,9452.72,77011.17,APC
Reconstruct shoulder joint,23472,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17357.91,,,,,,,fee schedule,9452.72,77011.17,APC
Reconstruct shoulder joint,23472,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26557.6,,,,,,,fee schedule,9452.72,77011.17,Radiology
Reconstruct shoulder joint,23472,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24301.07,,,,,,,fee schedule,9452.72,77011.17,APC
Reconstruct shoulder joint,23472,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30376.34,,,,,,,fee schedule,9452.72,77011.17,APC
Revis reconst shoulder joint,23473,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,36295.11,,,,,,,fee schedule,12709.88,56389.43,
Revis reconst shoulder joint,23473,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29093.7,,,,,,,fee schedule,12709.88,56389.43,
Revis reconst shoulder joint,23473,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31782.22,,,,,,,fee schedule,12709.88,56389.43,
Revis reconst shoulder joint,23473,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33414.54,,,,,,,fee schedule,12709.88,56389.43,
Revis reconst shoulder joint,23473,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,12709.88,56389.43,APC 378
Revis reconst shoulder joint,23473,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,12709.88,56389.43,APC
Revis reconst shoulder joint,23473,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,12709.88,56389.43,APC
Revis reconst shoulder joint,23473,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,12709.88,56389.43,APC
Revis reconst shoulder joint,23473,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,12709.88,56389.43,Radiology
Revis reconst shoulder joint,23473,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,12709.88,56389.43,APC
Revis reconst shoulder joint,23473,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,12709.88,56389.43,APC
Revis reconst shoulder joint,23474,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14246.14,,,,,,,fee schedule,11419.52,56389.43,
Revis reconst shoulder joint,23474,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11419.52,,,,,,,fee schedule,11419.52,56389.43,
Revis reconst shoulder joint,23474,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12474.79,,,,,,,fee schedule,11419.52,56389.43,
Revis reconst shoulder joint,23474,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13115.49,,,,,,,fee schedule,11419.52,56389.43,
Revis reconst shoulder joint,23474,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,11419.52,56389.43,APC 378
Revis reconst shoulder joint,23474,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,11419.52,56389.43,APC
Revis reconst shoulder joint,23474,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,11419.52,56389.43,APC
Revis reconst shoulder joint,23474,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,11419.52,56389.43,APC
Revis reconst shoulder joint,23474,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,11419.52,56389.43,Radiology
Revis reconst shoulder joint,23474,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,11419.52,56389.43,APC
Revis reconst shoulder joint,23474,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,11419.52,56389.43,APC
Revision of collar bone,23480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10728.02,,,,,,,fee schedule,7183.42,31870.39,
Revision of collar bone,23480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8599.44,,,,,,,fee schedule,7183.42,31870.39,
Revision of collar bone,23480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9394.11,,,,,,,fee schedule,7183.42,31870.39,
Revision of collar bone,23480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9876.59,,,,,,,fee schedule,7183.42,31870.39,
Revision of collar bone,23480,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Revision of collar bone,23480,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Revision of collar bone,23480,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Revision of collar bone,23480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Revision of collar bone,23480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Revision of collar bone,23480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Revision of collar bone,23480,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Revision of collar bone,23485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19822.36,,,,,,,fee schedule,12709.88,56389.43,
Revision of collar bone,23485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15889.35,,,,,,,fee schedule,12709.88,56389.43,
Revision of collar bone,23485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17357.67,,,,,,,fee schedule,12709.88,56389.43,
Revision of collar bone,23485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18249.15,,,,,,,fee schedule,12709.88,56389.43,
Revision of collar bone,23485,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,12709.88,56389.43,APC 378
Revision of collar bone,23485,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,12709.88,56389.43,APC
Revision of collar bone,23485,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,12709.88,56389.43,APC
Revision of collar bone,23485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,12709.88,56389.43,APC
Revision of collar bone,23485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,12709.88,56389.43,Radiology
Revision of collar bone,23485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,12709.88,56389.43,APC
Revision of collar bone,23485,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,12709.88,56389.43,APC
Reinforce clavicle,23490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10728.02,,,,,,,fee schedule,7183.42,31870.39,
Reinforce clavicle,23490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8599.44,,,,,,,fee schedule,7183.42,31870.39,
Reinforce clavicle,23490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9394.11,,,,,,,fee schedule,7183.42,31870.39,
Reinforce clavicle,23490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9876.59,,,,,,,fee schedule,7183.42,31870.39,
Reinforce clavicle,23490,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Reinforce clavicle,23490,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Reinforce clavicle,23490,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Reinforce clavicle,23490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Reinforce clavicle,23490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Reinforce clavicle,23490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Reinforce clavicle,23490,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Reinforce shoulder bones,23491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19822.36,,,,,,,fee schedule,12709.88,56389.43,
Reinforce shoulder bones,23491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15889.35,,,,,,,fee schedule,12709.88,56389.43,
Reinforce shoulder bones,23491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17357.67,,,,,,,fee schedule,12709.88,56389.43,
Reinforce shoulder bones,23491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18249.15,,,,,,,fee schedule,12709.88,56389.43,
Reinforce shoulder bones,23491,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,12709.88,56389.43,APC 378
Reinforce shoulder bones,23491,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,12709.88,56389.43,APC
Reinforce shoulder bones,23491,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,12709.88,56389.43,APC
Reinforce shoulder bones,23491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,12709.88,56389.43,APC
Reinforce shoulder bones,23491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,12709.88,56389.43,Radiology
Reinforce shoulder bones,23491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,12709.88,56389.43,APC
Reinforce shoulder bones,23491,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,12709.88,56389.43,APC
Treat clavicle fracture,23500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,244.19,1083.4,
Treat clavicle fracture,23500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,244.19,1083.4,
Treat clavicle fracture,23500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,244.19,1083.4,
Treat clavicle fracture,23500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,244.19,1083.4,
Treat clavicle fracture,23500,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treat clavicle fracture,23500,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treat clavicle fracture,23500,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treat clavicle fracture,23500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treat clavicle fracture,23500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treat clavicle fracture,23500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treat clavicle fracture,23500,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treat clavicle fracture,23505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,353.72,7062.54,
Treat clavicle fracture,23505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,353.72,7062.54,
Treat clavicle fracture,23505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,353.72,7062.54,
Treat clavicle fracture,23505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,353.72,7062.54,
Treat clavicle fracture,23505,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,353.72,7062.54,APC 378
Treat clavicle fracture,23505,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,353.72,7062.54,APC
Treat clavicle fracture,23505,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,353.72,7062.54,APC
Treat clavicle fracture,23505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,353.72,7062.54,APC
Treat clavicle fracture,23505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,353.72,7062.54,Radiology
Treat clavicle fracture,23505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,353.72,7062.54,APC
Treat clavicle fracture,23505,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,353.72,7062.54,APC
Treat clavicle fracture,23515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8750.07,,,,,,,fee schedule,7013.95,31870.39,
Treat clavicle fracture,23515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7013.95,,,,,,,fee schedule,7013.95,31870.39,
Treat clavicle fracture,23515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7662.1,,,,,,,fee schedule,7013.95,31870.39,
Treat clavicle fracture,23515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8055.62,,,,,,,fee schedule,7013.95,31870.39,
Treat clavicle fracture,23515,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7013.95,31870.39,APC 378
Treat clavicle fracture,23515,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7013.95,31870.39,APC
Treat clavicle fracture,23515,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7013.95,31870.39,APC
Treat clavicle fracture,23515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7013.95,31870.39,APC
Treat clavicle fracture,23515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7013.95,31870.39,Radiology
Treat clavicle fracture,23515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7013.95,31870.39,APC
Treat clavicle fracture,23515,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7013.95,31870.39,APC
Treat clavicle dislocation,23520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,353.72,7062.54,
Treat clavicle dislocation,23520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,353.72,7062.54,
Treat clavicle dislocation,23520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,353.72,7062.54,
Treat clavicle dislocation,23520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,353.72,7062.54,
Treat clavicle dislocation,23520,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,353.72,7062.54,APC 378
Treat clavicle dislocation,23520,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,353.72,7062.54,APC
Treat clavicle dislocation,23520,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,353.72,7062.54,APC
Treat clavicle dislocation,23520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,353.72,7062.54,APC
Treat clavicle dislocation,23520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,353.72,7062.54,Radiology
Treat clavicle dislocation,23520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,353.72,7062.54,APC
Treat clavicle dislocation,23520,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,353.72,7062.54,APC
Treat clavicle dislocation,23525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,244.19,1083.4,
Treat clavicle dislocation,23525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,244.19,1083.4,
Treat clavicle dislocation,23525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,244.19,1083.4,
Treat clavicle dislocation,23525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,244.19,1083.4,
Treat clavicle dislocation,23525,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treat clavicle dislocation,23525,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treat clavicle dislocation,23525,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treat clavicle dislocation,23525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treat clavicle dislocation,23525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treat clavicle dislocation,23525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treat clavicle dislocation,23525,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treat clavicle dislocation,23530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10259.79,,,,,,,fee schedule,7183.42,31870.39,
Treat clavicle dislocation,23530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8224.12,,,,,,,fee schedule,7183.42,31870.39,
Treat clavicle dislocation,23530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8984.1,,,,,,,fee schedule,7183.42,31870.39,
Treat clavicle dislocation,23530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9445.52,,,,,,,fee schedule,7183.42,31870.39,
Treat clavicle dislocation,23530,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Treat clavicle dislocation,23530,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Treat clavicle dislocation,23530,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Treat clavicle dislocation,23530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Treat clavicle dislocation,23530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Treat clavicle dislocation,23530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Treat clavicle dislocation,23530,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Treat clavicle dislocation,23532,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6528.66,,,,,,,fee schedule,5233.29,31870.39,
Treat clavicle dislocation,23532,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5233.29,,,,,,,fee schedule,5233.29,31870.39,
Treat clavicle dislocation,23532,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5716.9,,,,,,,fee schedule,5233.29,31870.39,
Treat clavicle dislocation,23532,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6010.52,,,,,,,fee schedule,5233.29,31870.39,
Treat clavicle dislocation,23532,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5233.29,31870.39,APC 378
Treat clavicle dislocation,23532,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5233.29,31870.39,APC
Treat clavicle dislocation,23532,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5233.29,31870.39,APC
Treat clavicle dislocation,23532,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5233.29,31870.39,APC
Treat clavicle dislocation,23532,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5233.29,31870.39,Radiology
Treat clavicle dislocation,23532,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5233.29,31870.39,APC
Treat clavicle dislocation,23532,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5233.29,31870.39,APC
Treat clavicle dislocation,23540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,244.19,1083.4,
Treat clavicle dislocation,23540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,244.19,1083.4,
Treat clavicle dislocation,23540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,244.19,1083.4,
Treat clavicle dislocation,23540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,244.19,1083.4,
Treat clavicle dislocation,23540,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treat clavicle dislocation,23540,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treat clavicle dislocation,23540,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treat clavicle dislocation,23540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treat clavicle dislocation,23540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treat clavicle dislocation,23540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treat clavicle dislocation,23540,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treat clavicle dislocation,23545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,244.19,1083.4,
Treat clavicle dislocation,23545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,244.19,1083.4,
Treat clavicle dislocation,23545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,244.19,1083.4,
Treat clavicle dislocation,23545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,244.19,1083.4,
Treat clavicle dislocation,23545,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treat clavicle dislocation,23545,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treat clavicle dislocation,23545,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treat clavicle dislocation,23545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treat clavicle dislocation,23545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treat clavicle dislocation,23545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treat clavicle dislocation,23545,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treat clavicle dislocation,23550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10259.79,,,,,,,fee schedule,7183.42,31870.39,
Treat clavicle dislocation,23550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8224.12,,,,,,,fee schedule,7183.42,31870.39,
Treat clavicle dislocation,23550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8984.1,,,,,,,fee schedule,7183.42,31870.39,
Treat clavicle dislocation,23550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9445.52,,,,,,,fee schedule,7183.42,31870.39,
Treat clavicle dislocation,23550,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Treat clavicle dislocation,23550,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Treat clavicle dislocation,23550,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Treat clavicle dislocation,23550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Treat clavicle dislocation,23550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Treat clavicle dislocation,23550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Treat clavicle dislocation,23550,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Treat clavicle dislocation,23552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10259.79,,,,,,,fee schedule,7183.42,31870.39,
Treat clavicle dislocation,23552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8224.12,,,,,,,fee schedule,7183.42,31870.39,
Treat clavicle dislocation,23552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8984.1,,,,,,,fee schedule,7183.42,31870.39,
Treat clavicle dislocation,23552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9445.52,,,,,,,fee schedule,7183.42,31870.39,
Treat clavicle dislocation,23552,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Treat clavicle dislocation,23552,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Treat clavicle dislocation,23552,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Treat clavicle dislocation,23552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Treat clavicle dislocation,23552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Treat clavicle dislocation,23552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Treat clavicle dislocation,23552,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Treat shoulder blade fx,23570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,244.19,1083.4,
Treat shoulder blade fx,23570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,244.19,1083.4,
Treat shoulder blade fx,23570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,244.19,1083.4,
Treat shoulder blade fx,23570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,244.19,1083.4,
Treat shoulder blade fx,23570,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treat shoulder blade fx,23570,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treat shoulder blade fx,23570,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treat shoulder blade fx,23570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treat shoulder blade fx,23570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treat shoulder blade fx,23570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treat shoulder blade fx,23570,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treat shoulder blade fx,23575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,353.72,7062.54,
Treat shoulder blade fx,23575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,353.72,7062.54,
Treat shoulder blade fx,23575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,353.72,7062.54,
Treat shoulder blade fx,23575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,353.72,7062.54,
Treat shoulder blade fx,23575,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,353.72,7062.54,APC 378
Treat shoulder blade fx,23575,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,353.72,7062.54,APC
Treat shoulder blade fx,23575,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,353.72,7062.54,APC
Treat shoulder blade fx,23575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,353.72,7062.54,APC
Treat shoulder blade fx,23575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,353.72,7062.54,Radiology
Treat shoulder blade fx,23575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,353.72,7062.54,APC
Treat shoulder blade fx,23575,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,353.72,7062.54,APC
Treat scapula fracture,23585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14780.67,,,,,,,fee schedule,7183.42,31870.39,
Treat scapula fracture,23585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11848,,,,,,,fee schedule,7183.42,31870.39,
Treat scapula fracture,23585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12942.86,,,,,,,fee schedule,7183.42,31870.39,
Treat scapula fracture,23585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13607.6,,,,,,,fee schedule,7183.42,31870.39,
Treat scapula fracture,23585,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Treat scapula fracture,23585,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Treat scapula fracture,23585,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Treat scapula fracture,23585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Treat scapula fracture,23585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Treat scapula fracture,23585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Treat scapula fracture,23585,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Treat humerus fracture,23600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,244.19,1083.4,
Treat humerus fracture,23600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,244.19,1083.4,
Treat humerus fracture,23600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,244.19,1083.4,
Treat humerus fracture,23600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,244.19,1083.4,
Treat humerus fracture,23600,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treat humerus fracture,23600,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treat humerus fracture,23600,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treat humerus fracture,23600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treat humerus fracture,23600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treat humerus fracture,23600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treat humerus fracture,23600,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treat humerus fracture,23605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,353.72,7062.54,
Treat humerus fracture,23605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,353.72,7062.54,
Treat humerus fracture,23605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,353.72,7062.54,
Treat humerus fracture,23605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,353.72,7062.54,
Treat humerus fracture,23605,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,353.72,7062.54,APC 378
Treat humerus fracture,23605,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,353.72,7062.54,APC
Treat humerus fracture,23605,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,353.72,7062.54,APC
Treat humerus fracture,23605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,353.72,7062.54,APC
Treat humerus fracture,23605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,353.72,7062.54,Radiology
Treat humerus fracture,23605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,353.72,7062.54,APC
Treat humerus fracture,23605,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,353.72,7062.54,APC
Treat humerus fracture,23615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14780.67,,,,,,,fee schedule,11848,56389.43,
Treat humerus fracture,23615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11848,,,,,,,fee schedule,11848,56389.43,
Treat humerus fracture,23615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12942.86,,,,,,,fee schedule,11848,56389.43,
Treat humerus fracture,23615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13607.6,,,,,,,fee schedule,11848,56389.43,
Treat humerus fracture,23615,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,11848,56389.43,APC 378
Treat humerus fracture,23615,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,11848,56389.43,APC
Treat humerus fracture,23615,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,11848,56389.43,APC
Treat humerus fracture,23615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,11848,56389.43,APC
Treat humerus fracture,23615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,11848,56389.43,Radiology
Treat humerus fracture,23615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,11848,56389.43,APC
Treat humerus fracture,23615,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,11848,56389.43,APC
Treat humerus fracture,23616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14780.67,,,,,,,fee schedule,11848,77011.17,
Treat humerus fracture,23616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11848,,,,,,,fee schedule,11848,77011.17,
Treat humerus fracture,23616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12942.86,,,,,,,fee schedule,11848,77011.17,
Treat humerus fracture,23616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13607.6,,,,,,,fee schedule,11848,77011.17,
Treat humerus fracture,23616,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,77011.17,,,,,,,fee schedule,11848,77011.17,APC 378
Treat humerus fracture,23616,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18225.81,,,,,,,fee schedule,11848,77011.17,APC
Treat humerus fracture,23616,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18052.23,,,,,,,fee schedule,11848,77011.17,APC
Treat humerus fracture,23616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17357.91,,,,,,,fee schedule,11848,77011.17,APC
Treat humerus fracture,23616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26557.6,,,,,,,fee schedule,11848,77011.17,Radiology
Treat humerus fracture,23616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24301.07,,,,,,,fee schedule,11848,77011.17,APC
Treat humerus fracture,23616,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30376.34,,,,,,,fee schedule,11848,77011.17,APC
Treat humerus fracture,23620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,244.19,1083.4,
Treat humerus fracture,23620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,244.19,1083.4,
Treat humerus fracture,23620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,244.19,1083.4,
Treat humerus fracture,23620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,244.19,1083.4,
Treat humerus fracture,23620,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treat humerus fracture,23620,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treat humerus fracture,23620,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treat humerus fracture,23620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treat humerus fracture,23620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treat humerus fracture,23620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treat humerus fracture,23620,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treat humerus fracture,23625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,353.72,7062.54,
Treat humerus fracture,23625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,353.72,7062.54,
Treat humerus fracture,23625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,353.72,7062.54,
Treat humerus fracture,23625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,353.72,7062.54,
Treat humerus fracture,23625,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,353.72,7062.54,APC 378
Treat humerus fracture,23625,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,353.72,7062.54,APC
Treat humerus fracture,23625,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,353.72,7062.54,APC
Treat humerus fracture,23625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,353.72,7062.54,APC
Treat humerus fracture,23625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,353.72,7062.54,Radiology
Treat humerus fracture,23625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,353.72,7062.54,APC
Treat humerus fracture,23625,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,353.72,7062.54,APC
Treat humerus fracture,23630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14780.67,,,,,,,fee schedule,7183.42,31870.39,
Treat humerus fracture,23630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11848,,,,,,,fee schedule,7183.42,31870.39,
Treat humerus fracture,23630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12942.86,,,,,,,fee schedule,7183.42,31870.39,
Treat humerus fracture,23630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13607.6,,,,,,,fee schedule,7183.42,31870.39,
Treat humerus fracture,23630,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Treat humerus fracture,23630,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Treat humerus fracture,23630,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Treat humerus fracture,23630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Treat humerus fracture,23630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Treat humerus fracture,23630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Treat humerus fracture,23630,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Treat shoulder dislocation,23650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,253.43,,,,,,,fee schedule,203.14,1083.4,
Treat shoulder dislocation,23650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,203.14,,,,,,,fee schedule,203.14,1083.4,
Treat shoulder dislocation,23650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,221.92,,,,,,,fee schedule,203.14,1083.4,
Treat shoulder dislocation,23650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,233.31,,,,,,,fee schedule,203.14,1083.4,
Treat shoulder dislocation,23650,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,203.14,1083.4,APC 378
Treat shoulder dislocation,23650,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,203.14,1083.4,APC
Treat shoulder dislocation,23650,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,203.14,1083.4,APC
Treat shoulder dislocation,23650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,203.14,1083.4,APC
Treat shoulder dislocation,23650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,203.14,1083.4,Radiology
Treat shoulder dislocation,23650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,203.14,1083.4,APC
Treat shoulder dislocation,23650,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,203.14,1083.4,APC
Treat shoulder dislocation,23655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1630.97,,,,,,,fee schedule,1307.37,7062.54,
Treat shoulder dislocation,23655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1307.37,,,,,,,fee schedule,1307.37,7062.54,
Treat shoulder dislocation,23655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1428.18,,,,,,,fee schedule,1307.37,7062.54,
Treat shoulder dislocation,23655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1501.53,,,,,,,fee schedule,1307.37,7062.54,
Treat shoulder dislocation,23655,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1307.37,7062.54,APC 378
Treat shoulder dislocation,23655,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1307.37,7062.54,APC
Treat shoulder dislocation,23655,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1307.37,7062.54,APC
Treat shoulder dislocation,23655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1307.37,7062.54,APC
Treat shoulder dislocation,23655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1307.37,7062.54,Radiology
Treat shoulder dislocation,23655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1307.37,7062.54,APC
Treat shoulder dislocation,23655,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1307.37,7062.54,APC
Treat shoulder dislocation,23660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10259.79,,,,,,,fee schedule,7183.42,31870.39,
Treat shoulder dislocation,23660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8224.12,,,,,,,fee schedule,7183.42,31870.39,
Treat shoulder dislocation,23660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8984.1,,,,,,,fee schedule,7183.42,31870.39,
Treat shoulder dislocation,23660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9445.52,,,,,,,fee schedule,7183.42,31870.39,
Treat shoulder dislocation,23660,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Treat shoulder dislocation,23660,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Treat shoulder dislocation,23660,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Treat shoulder dislocation,23660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Treat shoulder dislocation,23660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Treat shoulder dislocation,23660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Treat shoulder dislocation,23660,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Treat dislocation/fracture,23665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,353.72,7062.54,
Treat dislocation/fracture,23665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,353.72,7062.54,
Treat dislocation/fracture,23665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,353.72,7062.54,
Treat dislocation/fracture,23665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,353.72,7062.54,
Treat dislocation/fracture,23665,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,353.72,7062.54,APC 378
Treat dislocation/fracture,23665,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,353.72,7062.54,APC
Treat dislocation/fracture,23665,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,353.72,7062.54,APC
Treat dislocation/fracture,23665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,353.72,7062.54,APC
Treat dislocation/fracture,23665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,353.72,7062.54,Radiology
Treat dislocation/fracture,23665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,353.72,7062.54,APC
Treat dislocation/fracture,23665,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,353.72,7062.54,APC
Treat dislocation/fracture,23670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14780.67,,,,,,,fee schedule,7183.42,31870.39,
Treat dislocation/fracture,23670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11848,,,,,,,fee schedule,7183.42,31870.39,
Treat dislocation/fracture,23670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12942.86,,,,,,,fee schedule,7183.42,31870.39,
Treat dislocation/fracture,23670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13607.6,,,,,,,fee schedule,7183.42,31870.39,
Treat dislocation/fracture,23670,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Treat dislocation/fracture,23670,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Treat dislocation/fracture,23670,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Treat dislocation/fracture,23670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Treat dislocation/fracture,23670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Treat dislocation/fracture,23670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Treat dislocation/fracture,23670,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Treat dislocation/fracture,23675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,353.72,7062.54,
Treat dislocation/fracture,23675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,353.72,7062.54,
Treat dislocation/fracture,23675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,353.72,7062.54,
Treat dislocation/fracture,23675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,353.72,7062.54,
Treat dislocation/fracture,23675,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,353.72,7062.54,APC 378
Treat dislocation/fracture,23675,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,353.72,7062.54,APC
Treat dislocation/fracture,23675,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,353.72,7062.54,APC
Treat dislocation/fracture,23675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,353.72,7062.54,APC
Treat dislocation/fracture,23675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,353.72,7062.54,Radiology
Treat dislocation/fracture,23675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,353.72,7062.54,APC
Treat dislocation/fracture,23675,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,353.72,7062.54,APC
Treat dislocation/fracture,23680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10259.79,,,,,,,fee schedule,8224.12,56389.43,
Treat dislocation/fracture,23680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8224.12,,,,,,,fee schedule,8224.12,56389.43,
Treat dislocation/fracture,23680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8984.1,,,,,,,fee schedule,8224.12,56389.43,
Treat dislocation/fracture,23680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9445.52,,,,,,,fee schedule,8224.12,56389.43,
Treat dislocation/fracture,23680,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,8224.12,56389.43,APC 378
Treat dislocation/fracture,23680,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,8224.12,56389.43,APC
Treat dislocation/fracture,23680,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,8224.12,56389.43,APC
Treat dislocation/fracture,23680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,8224.12,56389.43,APC
Treat dislocation/fracture,23680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,8224.12,56389.43,Radiology
Treat dislocation/fracture,23680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,8224.12,56389.43,APC
Treat dislocation/fracture,23680,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,8224.12,56389.43,APC
Fixation of shoulder,23700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3685.16,,,,,,,fee schedule,1591.86,7062.54,
Fixation of shoulder,23700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2953.98,,,,,,,fee schedule,1591.86,7062.54,
Fixation of shoulder,23700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3226.95,,,,,,,fee schedule,1591.86,7062.54,
Fixation of shoulder,23700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3392.69,,,,,,,fee schedule,1591.86,7062.54,
Fixation of shoulder,23700,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Fixation of shoulder,23700,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Fixation of shoulder,23700,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Fixation of shoulder,23700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Fixation of shoulder,23700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Fixation of shoulder,23700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Fixation of shoulder,23700,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Fusion of shoulder joint,23800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19822.36,,,,,,,fee schedule,7183.42,31870.39,
Fusion of shoulder joint,23800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15889.35,,,,,,,fee schedule,7183.42,31870.39,
Fusion of shoulder joint,23800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17357.67,,,,,,,fee schedule,7183.42,31870.39,
Fusion of shoulder joint,23800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18249.15,,,,,,,fee schedule,7183.42,31870.39,
Fusion of shoulder joint,23800,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Fusion of shoulder joint,23800,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Fusion of shoulder joint,23800,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Fusion of shoulder joint,23800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Fusion of shoulder joint,23800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Fusion of shoulder joint,23800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Fusion of shoulder joint,23800,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Fusion of shoulder joint,23802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10728.02,,,,,,,fee schedule,8599.44,56389.43,
Fusion of shoulder joint,23802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8599.44,,,,,,,fee schedule,8599.44,56389.43,
Fusion of shoulder joint,23802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9394.11,,,,,,,fee schedule,8599.44,56389.43,
Fusion of shoulder joint,23802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9876.59,,,,,,,fee schedule,8599.44,56389.43,
Fusion of shoulder joint,23802,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,8599.44,56389.43,APC 378
Fusion of shoulder joint,23802,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,8599.44,56389.43,APC
Fusion of shoulder joint,23802,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,8599.44,56389.43,APC
Fusion of shoulder joint,23802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,8599.44,56389.43,APC
Fusion of shoulder joint,23802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,8599.44,56389.43,Radiology
Fusion of shoulder joint,23802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,8599.44,56389.43,APC
Fusion of shoulder joint,23802,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,8599.44,56389.43,APC
Amputation of arm & girdle,23900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46549.79,,,,,,,fee schedule,12709.88,56389.43,
Amputation of arm & girdle,23900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37313.72,,,,,,,fee schedule,12709.88,56389.43,
Amputation of arm & girdle,23900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40761.86,,,,,,,fee schedule,12709.88,56389.43,
Amputation of arm & girdle,23900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42855.36,,,,,,,fee schedule,12709.88,56389.43,
Amputation of arm & girdle,23900,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,12709.88,56389.43,APC 378
Amputation of arm & girdle,23900,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,12709.88,56389.43,APC
Amputation of arm & girdle,23900,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,12709.88,56389.43,APC
Amputation of arm & girdle,23900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,12709.88,56389.43,APC
Amputation of arm & girdle,23900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,12709.88,56389.43,Radiology
Amputation of arm & girdle,23900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,12709.88,56389.43,APC
Amputation of arm & girdle,23900,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,12709.88,56389.43,APC
Amputation at shoulder joint,23920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46549.79,,,,,,,fee schedule,12709.88,56389.43,
Amputation at shoulder joint,23920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37313.72,,,,,,,fee schedule,12709.88,56389.43,
Amputation at shoulder joint,23920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40761.86,,,,,,,fee schedule,12709.88,56389.43,
Amputation at shoulder joint,23920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42855.36,,,,,,,fee schedule,12709.88,56389.43,
Amputation at shoulder joint,23920,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,12709.88,56389.43,APC 378
Amputation at shoulder joint,23920,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,12709.88,56389.43,APC
Amputation at shoulder joint,23920,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,12709.88,56389.43,APC
Amputation at shoulder joint,23920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,12709.88,56389.43,APC
Amputation at shoulder joint,23920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,12709.88,56389.43,Radiology
Amputation at shoulder joint,23920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,12709.88,56389.43,APC
Amputation at shoulder joint,23920,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,12709.88,56389.43,APC
Amputation follow-up surgery,23921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3755.05,,,,,,,fee schedule,2042.58,9062.24,
Amputation follow-up surgery,23921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3010,,,,,,,fee schedule,2042.58,9062.24,
Amputation follow-up surgery,23921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3288.15,,,,,,,fee schedule,2042.58,9062.24,
Amputation follow-up surgery,23921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3457.03,,,,,,,fee schedule,2042.58,9062.24,
Amputation follow-up surgery,23921,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,2042.58,9062.24,APC 378
Amputation follow-up surgery,23921,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,2042.58,9062.24,APC
Amputation follow-up surgery,23921,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,2042.58,9062.24,APC
Amputation follow-up surgery,23921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,2042.58,9062.24,APC
Amputation follow-up surgery,23921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,2042.58,9062.24,Radiology
Amputation follow-up surgery,23921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,2042.58,9062.24,APC
Amputation follow-up surgery,23921,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,2042.58,9062.24,APC
Shoulder surgery procedure,23929,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8594.03,,,,,,,fee schedule,244.19,8594.03,
Shoulder surgery procedure,23929,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6888.87,,,,,,,fee schedule,244.19,8594.03,
Shoulder surgery procedure,23929,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7525.46,,,,,,,fee schedule,244.19,8594.03,
Shoulder surgery procedure,23929,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7911.97,,,,,,,fee schedule,244.19,8594.03,
Shoulder surgery procedure,23929,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,8594.03,APC 378
Shoulder surgery procedure,23929,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,8594.03,APC
Shoulder surgery procedure,23929,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,8594.03,APC
Shoulder surgery procedure,23929,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,8594.03,APC
Shoulder surgery procedure,23929,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,8594.03,Radiology
Shoulder surgery procedure,23929,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,8594.03,APC
Shoulder surgery procedure,23929,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,8594.03,APC
Drainage of arm lesion,23930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4572.14,,,,,,,fee schedule,2875.57,12757.95,
Drainage of arm lesion,23930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3664.97,,,,,,,fee schedule,2875.57,12757.95,
Drainage of arm lesion,23930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4003.64,,,,,,,fee schedule,2875.57,12757.95,
Drainage of arm lesion,23930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4209.27,,,,,,,fee schedule,2875.57,12757.95,
Drainage of arm lesion,23930,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Drainage of arm lesion,23930,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Drainage of arm lesion,23930,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Drainage of arm lesion,23930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Drainage of arm lesion,23930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Drainage of arm lesion,23930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Drainage of arm lesion,23930,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Drainage of arm bursa,23931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4572.14,,,,,,,fee schedule,1635.03,7254.06,
Drainage of arm bursa,23931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3664.97,,,,,,,fee schedule,1635.03,7254.06,
Drainage of arm bursa,23931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4003.64,,,,,,,fee schedule,1635.03,7254.06,
Drainage of arm bursa,23931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4209.27,,,,,,,fee schedule,1635.03,7254.06,
Drainage of arm bursa,23931,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,7254.06,APC 378
Drainage of arm bursa,23931,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,7254.06,APC
Drainage of arm bursa,23931,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,7254.06,APC
Drainage of arm bursa,23931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,7254.06,APC
Drainage of arm bursa,23931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,7254.06,Radiology
Drainage of arm bursa,23931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,7254.06,APC
Drainage of arm bursa,23931,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,7254.06,APC
Drain arm/elbow bone lesion,23935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,3239.17,14371.12,
Drain arm/elbow bone lesion,23935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,3239.17,14371.12,
Drain arm/elbow bone lesion,23935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,3239.17,14371.12,
Drain arm/elbow bone lesion,23935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,3239.17,14371.12,
Drain arm/elbow bone lesion,23935,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Drain arm/elbow bone lesion,23935,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Drain arm/elbow bone lesion,23935,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Drain arm/elbow bone lesion,23935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Drain arm/elbow bone lesion,23935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Drain arm/elbow bone lesion,23935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Drain arm/elbow bone lesion,23935,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Exploratory elbow surgery,24000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,3239.17,14371.12,
Exploratory elbow surgery,24000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,3239.17,14371.12,
Exploratory elbow surgery,24000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,3239.17,14371.12,
Exploratory elbow surgery,24000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,3239.17,14371.12,
Exploratory elbow surgery,24000,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Exploratory elbow surgery,24000,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Exploratory elbow surgery,24000,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Exploratory elbow surgery,24000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Exploratory elbow surgery,24000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Exploratory elbow surgery,24000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Exploratory elbow surgery,24000,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Release elbow joint,24006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,3239.17,14371.12,
Release elbow joint,24006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,3239.17,14371.12,
Release elbow joint,24006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,3239.17,14371.12,
Release elbow joint,24006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,3239.17,14371.12,
Release elbow joint,24006,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Release elbow joint,24006,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Release elbow joint,24006,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Release elbow joint,24006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Release elbow joint,24006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Release elbow joint,24006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Release elbow joint,24006,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Biopsy arm/elbow soft tissue,24065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4018.18,,,,,,,fee schedule,1635.03,7254.06,
Biopsy arm/elbow soft tissue,24065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3220.92,,,,,,,fee schedule,1635.03,7254.06,
Biopsy arm/elbow soft tissue,24065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3518.56,,,,,,,fee schedule,1635.03,7254.06,
Biopsy arm/elbow soft tissue,24065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3699.27,,,,,,,fee schedule,1635.03,7254.06,
Biopsy arm/elbow soft tissue,24065,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,7254.06,APC 378
Biopsy arm/elbow soft tissue,24065,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,7254.06,APC
Biopsy arm/elbow soft tissue,24065,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,7254.06,APC
Biopsy arm/elbow soft tissue,24065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,7254.06,APC
Biopsy arm/elbow soft tissue,24065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,7254.06,Radiology
Biopsy arm/elbow soft tissue,24065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,7254.06,APC
Biopsy arm/elbow soft tissue,24065,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,7254.06,APC
Biopsy arm/elbow soft tissue,24066,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4018.18,,,,,,,fee schedule,2875.57,12757.95,
Biopsy arm/elbow soft tissue,24066,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3220.92,,,,,,,fee schedule,2875.57,12757.95,
Biopsy arm/elbow soft tissue,24066,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3518.56,,,,,,,fee schedule,2875.57,12757.95,
Biopsy arm/elbow soft tissue,24066,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3699.27,,,,,,,fee schedule,2875.57,12757.95,
Biopsy arm/elbow soft tissue,24066,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Biopsy arm/elbow soft tissue,24066,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Biopsy arm/elbow soft tissue,24066,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Biopsy arm/elbow soft tissue,24066,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Biopsy arm/elbow soft tissue,24066,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Biopsy arm/elbow soft tissue,24066,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Biopsy arm/elbow soft tissue,24066,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Exc arm/elbow les sc 3 cm/>,24071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6253.46,,,,,,,fee schedule,2875.57,12757.95,
Exc arm/elbow les sc 3 cm/>,24071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5012.69,,,,,,,fee schedule,2875.57,12757.95,
Exc arm/elbow les sc 3 cm/>,24071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5475.91,,,,,,,fee schedule,2875.57,12757.95,
Exc arm/elbow les sc 3 cm/>,24071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5757.15,,,,,,,fee schedule,2875.57,12757.95,
Exc arm/elbow les sc 3 cm/>,24071,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Exc arm/elbow les sc 3 cm/>,24071,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Exc arm/elbow les sc 3 cm/>,24071,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Exc arm/elbow les sc 3 cm/>,24071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Exc arm/elbow les sc 3 cm/>,24071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Exc arm/elbow les sc 3 cm/>,24071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Exc arm/elbow les sc 3 cm/>,24071,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Ex arm/elbow tum deep 5 cm/>,24073,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7189.69,,,,,,,fee schedule,2875.57,12757.95,
Ex arm/elbow tum deep 5 cm/>,24073,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5763.16,,,,,,,fee schedule,2875.57,12757.95,
Ex arm/elbow tum deep 5 cm/>,24073,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6295.73,,,,,,,fee schedule,2875.57,12757.95,
Ex arm/elbow tum deep 5 cm/>,24073,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6619.08,,,,,,,fee schedule,2875.57,12757.95,
Ex arm/elbow tum deep 5 cm/>,24073,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Ex arm/elbow tum deep 5 cm/>,24073,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Ex arm/elbow tum deep 5 cm/>,24073,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Ex arm/elbow tum deep 5 cm/>,24073,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Ex arm/elbow tum deep 5 cm/>,24073,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Ex arm/elbow tum deep 5 cm/>,24073,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Ex arm/elbow tum deep 5 cm/>,24073,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Exc arm/elbow les sc < 3 cm,24075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1437.94,,,,,,,fee schedule,1152.63,7254.06,
Exc arm/elbow les sc < 3 cm,24075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1152.63,,,,,,,fee schedule,1152.63,7254.06,
Exc arm/elbow les sc < 3 cm,24075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1259.15,,,,,,,fee schedule,1152.63,7254.06,
Exc arm/elbow les sc < 3 cm,24075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1323.82,,,,,,,fee schedule,1152.63,7254.06,
Exc arm/elbow les sc < 3 cm,24075,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1152.63,7254.06,APC 378
Exc arm/elbow les sc < 3 cm,24075,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1152.63,7254.06,APC
Exc arm/elbow les sc < 3 cm,24075,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1152.63,7254.06,APC
Exc arm/elbow les sc < 3 cm,24075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1152.63,7254.06,APC
Exc arm/elbow les sc < 3 cm,24075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1152.63,7254.06,Radiology
Exc arm/elbow les sc < 3 cm,24075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1152.63,7254.06,APC
Exc arm/elbow les sc < 3 cm,24075,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1152.63,7254.06,APC
Ex arm/elbow tum deep < 5 cm,24076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5804.85,,,,,,,fee schedule,2875.57,12757.95,
Ex arm/elbow tum deep < 5 cm,24076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4653.09,,,,,,,fee schedule,2875.57,12757.95,
Ex arm/elbow tum deep < 5 cm,24076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5083.08,,,,,,,fee schedule,2875.57,12757.95,
Ex arm/elbow tum deep < 5 cm,24076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5344.14,,,,,,,fee schedule,2875.57,12757.95,
Ex arm/elbow tum deep < 5 cm,24076,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Ex arm/elbow tum deep < 5 cm,24076,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Ex arm/elbow tum deep < 5 cm,24076,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Ex arm/elbow tum deep < 5 cm,24076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Ex arm/elbow tum deep < 5 cm,24076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Ex arm/elbow tum deep < 5 cm,24076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Ex arm/elbow tum deep < 5 cm,24076,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Resect arm/elbow tum < 5 cm,24077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5268.49,,,,,,,fee schedule,2875.57,12757.95,
Resect arm/elbow tum < 5 cm,24077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4223.15,,,,,,,fee schedule,2875.57,12757.95,
Resect arm/elbow tum < 5 cm,24077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4613.41,,,,,,,fee schedule,2875.57,12757.95,
Resect arm/elbow tum < 5 cm,24077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4850.35,,,,,,,fee schedule,2875.57,12757.95,
Resect arm/elbow tum < 5 cm,24077,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Resect arm/elbow tum < 5 cm,24077,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Resect arm/elbow tum < 5 cm,24077,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Resect arm/elbow tum < 5 cm,24077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Resect arm/elbow tum < 5 cm,24077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Resect arm/elbow tum < 5 cm,24077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Resect arm/elbow tum < 5 cm,24077,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Resect arm/elbow tum 5 cm/>,24079,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6177.24,,,,,,,fee schedule,2875.57,12757.95,
Resect arm/elbow tum 5 cm/>,24079,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4951.6,,,,,,,fee schedule,2875.57,12757.95,
Resect arm/elbow tum 5 cm/>,24079,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5409.17,,,,,,,fee schedule,2875.57,12757.95,
Resect arm/elbow tum 5 cm/>,24079,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5686.98,,,,,,,fee schedule,2875.57,12757.95,
Resect arm/elbow tum 5 cm/>,24079,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Resect arm/elbow tum 5 cm/>,24079,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Resect arm/elbow tum 5 cm/>,24079,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Resect arm/elbow tum 5 cm/>,24079,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Resect arm/elbow tum 5 cm/>,24079,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Resect arm/elbow tum 5 cm/>,24079,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Resect arm/elbow tum 5 cm/>,24079,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Biopsy elbow joint lining,24100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,3239.17,14371.12,
Biopsy elbow joint lining,24100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,3239.17,14371.12,
Biopsy elbow joint lining,24100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,3239.17,14371.12,
Biopsy elbow joint lining,24100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,3239.17,14371.12,
Biopsy elbow joint lining,24100,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Biopsy elbow joint lining,24100,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Biopsy elbow joint lining,24100,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Biopsy elbow joint lining,24100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Biopsy elbow joint lining,24100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Biopsy elbow joint lining,24100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Biopsy elbow joint lining,24100,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Explore/treat elbow joint,24101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,3239.17,14371.12,
Explore/treat elbow joint,24101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,3239.17,14371.12,
Explore/treat elbow joint,24101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,3239.17,14371.12,
Explore/treat elbow joint,24101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,3239.17,14371.12,
Explore/treat elbow joint,24101,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Explore/treat elbow joint,24101,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Explore/treat elbow joint,24101,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Explore/treat elbow joint,24101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Explore/treat elbow joint,24101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Explore/treat elbow joint,24101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Explore/treat elbow joint,24101,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Remove elbow joint lining,24102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,3239.17,14371.12,
Remove elbow joint lining,24102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,3239.17,14371.12,
Remove elbow joint lining,24102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,3239.17,14371.12,
Remove elbow joint lining,24102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,3239.17,14371.12,
Remove elbow joint lining,24102,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Remove elbow joint lining,24102,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Remove elbow joint lining,24102,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Remove elbow joint lining,24102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Remove elbow joint lining,24102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Remove elbow joint lining,24102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Remove elbow joint lining,24102,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of elbow bursa,24105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,3239.17,14371.12,
Removal of elbow bursa,24105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,3239.17,14371.12,
Removal of elbow bursa,24105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,3239.17,14371.12,
Removal of elbow bursa,24105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,3239.17,14371.12,
Removal of elbow bursa,24105,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Removal of elbow bursa,24105,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of elbow bursa,24105,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of elbow bursa,24105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of elbow bursa,24105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Removal of elbow bursa,24105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of elbow bursa,24105,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Remove humerus lesion,24110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,3239.17,14371.12,
Remove humerus lesion,24110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,3239.17,14371.12,
Remove humerus lesion,24110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,3239.17,14371.12,
Remove humerus lesion,24110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,3239.17,14371.12,
Remove humerus lesion,24110,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Remove humerus lesion,24110,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Remove humerus lesion,24110,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Remove humerus lesion,24110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Remove humerus lesion,24110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Remove humerus lesion,24110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Remove humerus lesion,24110,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Remove/graft bone lesion,24115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,5839.66,31870.39,
Remove/graft bone lesion,24115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,5839.66,31870.39,
Remove/graft bone lesion,24115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,5839.66,31870.39,
Remove/graft bone lesion,24115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,5839.66,31870.39,
Remove/graft bone lesion,24115,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5839.66,31870.39,APC 378
Remove/graft bone lesion,24115,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5839.66,31870.39,APC
Remove/graft bone lesion,24115,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5839.66,31870.39,APC
Remove/graft bone lesion,24115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5839.66,31870.39,APC
Remove/graft bone lesion,24115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5839.66,31870.39,Radiology
Remove/graft bone lesion,24115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5839.66,31870.39,APC
Remove/graft bone lesion,24115,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5839.66,31870.39,APC
Remove/graft bone lesion,24116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,5839.66,31870.39,
Remove/graft bone lesion,24116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,5839.66,31870.39,
Remove/graft bone lesion,24116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,5839.66,31870.39,
Remove/graft bone lesion,24116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,5839.66,31870.39,
Remove/graft bone lesion,24116,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5839.66,31870.39,APC 378
Remove/graft bone lesion,24116,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5839.66,31870.39,APC
Remove/graft bone lesion,24116,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5839.66,31870.39,APC
Remove/graft bone lesion,24116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5839.66,31870.39,APC
Remove/graft bone lesion,24116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5839.66,31870.39,Radiology
Remove/graft bone lesion,24116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5839.66,31870.39,APC
Remove/graft bone lesion,24116,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5839.66,31870.39,APC
Remove elbow lesion,24120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,3239.17,14371.12,
Remove elbow lesion,24120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,3239.17,14371.12,
Remove elbow lesion,24120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,3239.17,14371.12,
Remove elbow lesion,24120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,3239.17,14371.12,
Remove elbow lesion,24120,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Remove elbow lesion,24120,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Remove elbow lesion,24120,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Remove elbow lesion,24120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Remove elbow lesion,24120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Remove elbow lesion,24120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Remove elbow lesion,24120,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Remove/graft bone lesion,24125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,3239.17,14371.12,
Remove/graft bone lesion,24125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,3239.17,14371.12,
Remove/graft bone lesion,24125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,3239.17,14371.12,
Remove/graft bone lesion,24125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,3239.17,14371.12,
Remove/graft bone lesion,24125,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Remove/graft bone lesion,24125,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Remove/graft bone lesion,24125,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Remove/graft bone lesion,24125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Remove/graft bone lesion,24125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Remove/graft bone lesion,24125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Remove/graft bone lesion,24125,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Remove/graft bone lesion,24126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,5839.66,31870.39,
Remove/graft bone lesion,24126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,5839.66,31870.39,
Remove/graft bone lesion,24126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,5839.66,31870.39,
Remove/graft bone lesion,24126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,5839.66,31870.39,
Remove/graft bone lesion,24126,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5839.66,31870.39,APC 378
Remove/graft bone lesion,24126,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5839.66,31870.39,APC
Remove/graft bone lesion,24126,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5839.66,31870.39,APC
Remove/graft bone lesion,24126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5839.66,31870.39,APC
Remove/graft bone lesion,24126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5839.66,31870.39,Radiology
Remove/graft bone lesion,24126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5839.66,31870.39,APC
Remove/graft bone lesion,24126,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5839.66,31870.39,APC
Removal of head of radius,24130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,3239.17,14371.12,
Removal of head of radius,24130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,3239.17,14371.12,
Removal of head of radius,24130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,3239.17,14371.12,
Removal of head of radius,24130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,3239.17,14371.12,
Removal of head of radius,24130,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Removal of head of radius,24130,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of head of radius,24130,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of head of radius,24130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of head of radius,24130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Removal of head of radius,24130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of head of radius,24130,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of arm bone lesion,24134,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,5839.66,31870.39,
Removal of arm bone lesion,24134,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,5839.66,31870.39,
Removal of arm bone lesion,24134,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,5839.66,31870.39,
Removal of arm bone lesion,24134,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,5839.66,31870.39,
Removal of arm bone lesion,24134,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5839.66,31870.39,APC 378
Removal of arm bone lesion,24134,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5839.66,31870.39,APC
Removal of arm bone lesion,24134,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5839.66,31870.39,APC
Removal of arm bone lesion,24134,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5839.66,31870.39,APC
Removal of arm bone lesion,24134,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5839.66,31870.39,Radiology
Removal of arm bone lesion,24134,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5839.66,31870.39,APC
Removal of arm bone lesion,24134,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5839.66,31870.39,APC
Remove radius bone lesion,24136,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,3239.17,14371.12,
Remove radius bone lesion,24136,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,3239.17,14371.12,
Remove radius bone lesion,24136,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,3239.17,14371.12,
Remove radius bone lesion,24136,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,3239.17,14371.12,
Remove radius bone lesion,24136,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Remove radius bone lesion,24136,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Remove radius bone lesion,24136,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Remove radius bone lesion,24136,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Remove radius bone lesion,24136,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Remove radius bone lesion,24136,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Remove radius bone lesion,24136,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Remove elbow bone lesion,24138,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,5839.66,31870.39,
Remove elbow bone lesion,24138,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,5839.66,31870.39,
Remove elbow bone lesion,24138,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,5839.66,31870.39,
Remove elbow bone lesion,24138,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,5839.66,31870.39,
Remove elbow bone lesion,24138,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5839.66,31870.39,APC 378
Remove elbow bone lesion,24138,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5839.66,31870.39,APC
Remove elbow bone lesion,24138,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5839.66,31870.39,APC
Remove elbow bone lesion,24138,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5839.66,31870.39,APC
Remove elbow bone lesion,24138,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5839.66,31870.39,Radiology
Remove elbow bone lesion,24138,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5839.66,31870.39,APC
Remove elbow bone lesion,24138,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5839.66,31870.39,APC
Partial removal of arm bone,24140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,3239.17,14371.12,
Partial removal of arm bone,24140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,3239.17,14371.12,
Partial removal of arm bone,24140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,3239.17,14371.12,
Partial removal of arm bone,24140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,3239.17,14371.12,
Partial removal of arm bone,24140,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Partial removal of arm bone,24140,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Partial removal of arm bone,24140,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Partial removal of arm bone,24140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Partial removal of arm bone,24140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Partial removal of arm bone,24140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Partial removal of arm bone,24140,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Partial removal of radius,24145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,5839.66,31870.39,
Partial removal of radius,24145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,5839.66,31870.39,
Partial removal of radius,24145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,5839.66,31870.39,
Partial removal of radius,24145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,5839.66,31870.39,
Partial removal of radius,24145,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5839.66,31870.39,APC 378
Partial removal of radius,24145,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5839.66,31870.39,APC
Partial removal of radius,24145,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5839.66,31870.39,APC
Partial removal of radius,24145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5839.66,31870.39,APC
Partial removal of radius,24145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5839.66,31870.39,Radiology
Partial removal of radius,24145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5839.66,31870.39,APC
Partial removal of radius,24145,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5839.66,31870.39,APC
Partial removal of elbow,24147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,3239.17,14371.12,
Partial removal of elbow,24147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,3239.17,14371.12,
Partial removal of elbow,24147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,3239.17,14371.12,
Partial removal of elbow,24147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,3239.17,14371.12,
Partial removal of elbow,24147,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Partial removal of elbow,24147,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Partial removal of elbow,24147,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Partial removal of elbow,24147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Partial removal of elbow,24147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Partial removal of elbow,24147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Partial removal of elbow,24147,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Radical resection of elbow,24149,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,5839.66,31870.39,
Radical resection of elbow,24149,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,5839.66,31870.39,
Radical resection of elbow,24149,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,5839.66,31870.39,
Radical resection of elbow,24149,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,5839.66,31870.39,
Radical resection of elbow,24149,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5839.66,31870.39,APC 378
Radical resection of elbow,24149,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5839.66,31870.39,APC
Radical resection of elbow,24149,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5839.66,31870.39,APC
Radical resection of elbow,24149,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5839.66,31870.39,APC
Radical resection of elbow,24149,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5839.66,31870.39,Radiology
Radical resection of elbow,24149,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5839.66,31870.39,APC
Radical resection of elbow,24149,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5839.66,31870.39,APC
Resect distal humerus tumor,24150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10728.02,,,,,,,fee schedule,7183.42,31870.39,
Resect distal humerus tumor,24150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8599.44,,,,,,,fee schedule,7183.42,31870.39,
Resect distal humerus tumor,24150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9394.11,,,,,,,fee schedule,7183.42,31870.39,
Resect distal humerus tumor,24150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9876.59,,,,,,,fee schedule,7183.42,31870.39,
Resect distal humerus tumor,24150,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Resect distal humerus tumor,24150,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Resect distal humerus tumor,24150,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Resect distal humerus tumor,24150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Resect distal humerus tumor,24150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Resect distal humerus tumor,24150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Resect distal humerus tumor,24150,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Resect radius tumor,24152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10728.02,,,,,,,fee schedule,7183.42,31870.39,
Resect radius tumor,24152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8599.44,,,,,,,fee schedule,7183.42,31870.39,
Resect radius tumor,24152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9394.11,,,,,,,fee schedule,7183.42,31870.39,
Resect radius tumor,24152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9876.59,,,,,,,fee schedule,7183.42,31870.39,
Resect radius tumor,24152,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Resect radius tumor,24152,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Resect radius tumor,24152,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Resect radius tumor,24152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Resect radius tumor,24152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Resect radius tumor,24152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Resect radius tumor,24152,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Removal of elbow joint,24155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10728.02,,,,,,,fee schedule,3239.17,14371.12,
Removal of elbow joint,24155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8599.44,,,,,,,fee schedule,3239.17,14371.12,
Removal of elbow joint,24155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9394.11,,,,,,,fee schedule,3239.17,14371.12,
Removal of elbow joint,24155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9876.59,,,,,,,fee schedule,3239.17,14371.12,
Removal of elbow joint,24155,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Removal of elbow joint,24155,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of elbow joint,24155,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of elbow joint,24155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of elbow joint,24155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Removal of elbow joint,24155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of elbow joint,24155,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Remove elbow joint implant,24160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,3239.17,14371.12,
Remove elbow joint implant,24160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,3239.17,14371.12,
Remove elbow joint implant,24160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,3239.17,14371.12,
Remove elbow joint implant,24160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,3239.17,14371.12,
Remove elbow joint implant,24160,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Remove elbow joint implant,24160,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Remove elbow joint implant,24160,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Remove elbow joint implant,24160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Remove elbow joint implant,24160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Remove elbow joint implant,24160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Remove elbow joint implant,24160,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Remove radius head implant,24164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,3239.17,14371.12,
Remove radius head implant,24164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,3239.17,14371.12,
Remove radius head implant,24164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,3239.17,14371.12,
Remove radius head implant,24164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,3239.17,14371.12,
Remove radius head implant,24164,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Remove radius head implant,24164,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Remove radius head implant,24164,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Remove radius head implant,24164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Remove radius head implant,24164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Remove radius head implant,24164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Remove radius head implant,24164,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of arm foreign body,24200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1074.12,,,,,,,fee schedule,861,7254.06,
Removal of arm foreign body,24200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,861,,,,,,,fee schedule,861,7254.06,
Removal of arm foreign body,24200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,940.57,,,,,,,fee schedule,861,7254.06,
Removal of arm foreign body,24200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,988.88,,,,,,,fee schedule,861,7254.06,
Removal of arm foreign body,24200,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,861,7254.06,APC 378
Removal of arm foreign body,24200,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,861,7254.06,APC
Removal of arm foreign body,24200,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,861,7254.06,APC
Removal of arm foreign body,24200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,861,7254.06,APC
Removal of arm foreign body,24200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,861,7254.06,Radiology
Removal of arm foreign body,24200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,861,7254.06,APC
Removal of arm foreign body,24200,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,861,7254.06,APC
Removal of arm foreign body,24201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4018.18,,,,,,,fee schedule,2875.57,12757.95,
Removal of arm foreign body,24201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3220.92,,,,,,,fee schedule,2875.57,12757.95,
Removal of arm foreign body,24201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3518.56,,,,,,,fee schedule,2875.57,12757.95,
Removal of arm foreign body,24201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3699.27,,,,,,,fee schedule,2875.57,12757.95,
Removal of arm foreign body,24201,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Removal of arm foreign body,24201,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Removal of arm foreign body,24201,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Removal of arm foreign body,24201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Removal of arm foreign body,24201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Removal of arm foreign body,24201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Removal of arm foreign body,24201,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Manipulate elbow w/anesth,24300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3685.16,,,,,,,fee schedule,1591.86,7062.54,
Manipulate elbow w/anesth,24300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2953.98,,,,,,,fee schedule,1591.86,7062.54,
Manipulate elbow w/anesth,24300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3226.95,,,,,,,fee schedule,1591.86,7062.54,
Manipulate elbow w/anesth,24300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3392.69,,,,,,,fee schedule,1591.86,7062.54,
Manipulate elbow w/anesth,24300,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Manipulate elbow w/anesth,24300,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Manipulate elbow w/anesth,24300,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Manipulate elbow w/anesth,24300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Manipulate elbow w/anesth,24300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Manipulate elbow w/anesth,24300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Manipulate elbow w/anesth,24300,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Muscle/tendon transfer,24301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,5839.66,31870.39,
Muscle/tendon transfer,24301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,5839.66,31870.39,
Muscle/tendon transfer,24301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,5839.66,31870.39,
Muscle/tendon transfer,24301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,5839.66,31870.39,
Muscle/tendon transfer,24301,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5839.66,31870.39,APC 378
Muscle/tendon transfer,24301,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5839.66,31870.39,APC
Muscle/tendon transfer,24301,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5839.66,31870.39,APC
Muscle/tendon transfer,24301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5839.66,31870.39,APC
Muscle/tendon transfer,24301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5839.66,31870.39,Radiology
Muscle/tendon transfer,24301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5839.66,31870.39,APC
Muscle/tendon transfer,24301,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5839.66,31870.39,APC
Arm tendon lengthening,24305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,3239.17,14371.12,
Arm tendon lengthening,24305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,3239.17,14371.12,
Arm tendon lengthening,24305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,3239.17,14371.12,
Arm tendon lengthening,24305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,3239.17,14371.12,
Arm tendon lengthening,24305,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Arm tendon lengthening,24305,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Arm tendon lengthening,24305,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Arm tendon lengthening,24305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Arm tendon lengthening,24305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Arm tendon lengthening,24305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Arm tendon lengthening,24305,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Revision of arm tendon,24310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,3239.17,14371.12,
Revision of arm tendon,24310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,3239.17,14371.12,
Revision of arm tendon,24310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,3239.17,14371.12,
Revision of arm tendon,24310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,3239.17,14371.12,
Revision of arm tendon,24310,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Revision of arm tendon,24310,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Revision of arm tendon,24310,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Revision of arm tendon,24310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Revision of arm tendon,24310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Revision of arm tendon,24310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Revision of arm tendon,24310,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Repair of arm tendon,24320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10728.02,,,,,,,fee schedule,7183.42,31870.39,
Repair of arm tendon,24320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8599.44,,,,,,,fee schedule,7183.42,31870.39,
Repair of arm tendon,24320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9394.11,,,,,,,fee schedule,7183.42,31870.39,
Repair of arm tendon,24320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9876.59,,,,,,,fee schedule,7183.42,31870.39,
Repair of arm tendon,24320,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Repair of arm tendon,24320,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Repair of arm tendon,24320,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Repair of arm tendon,24320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Repair of arm tendon,24320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Repair of arm tendon,24320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Repair of arm tendon,24320,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Revision of arm muscles,24330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19822.36,,,,,,,fee schedule,7183.42,31870.39,
Revision of arm muscles,24330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15889.35,,,,,,,fee schedule,7183.42,31870.39,
Revision of arm muscles,24330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17357.67,,,,,,,fee schedule,7183.42,31870.39,
Revision of arm muscles,24330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18249.15,,,,,,,fee schedule,7183.42,31870.39,
Revision of arm muscles,24330,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Revision of arm muscles,24330,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Revision of arm muscles,24330,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Revision of arm muscles,24330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Revision of arm muscles,24330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Revision of arm muscles,24330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Revision of arm muscles,24330,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Revision of arm muscles,24331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10728.02,,,,,,,fee schedule,7183.42,31870.39,
Revision of arm muscles,24331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8599.44,,,,,,,fee schedule,7183.42,31870.39,
Revision of arm muscles,24331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9394.11,,,,,,,fee schedule,7183.42,31870.39,
Revision of arm muscles,24331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9876.59,,,,,,,fee schedule,7183.42,31870.39,
Revision of arm muscles,24331,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Revision of arm muscles,24331,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Revision of arm muscles,24331,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Revision of arm muscles,24331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Revision of arm muscles,24331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Revision of arm muscles,24331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Revision of arm muscles,24331,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Tenolysis triceps,24332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,3239.17,14371.12,
Tenolysis triceps,24332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,3239.17,14371.12,
Tenolysis triceps,24332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,3239.17,14371.12,
Tenolysis triceps,24332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,3239.17,14371.12,
Tenolysis triceps,24332,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Tenolysis triceps,24332,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Tenolysis triceps,24332,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Tenolysis triceps,24332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Tenolysis triceps,24332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Tenolysis triceps,24332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Tenolysis triceps,24332,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Repair of biceps tendon,24340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4330.25,,,,,,,fee schedule,3471.07,31870.39,
Repair of biceps tendon,24340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3471.07,,,,,,,fee schedule,3471.07,31870.39,
Repair of biceps tendon,24340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3791.83,,,,,,,fee schedule,3471.07,31870.39,
Repair of biceps tendon,24340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3986.58,,,,,,,fee schedule,3471.07,31870.39,
Repair of biceps tendon,24340,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,3471.07,31870.39,APC 378
Repair of biceps tendon,24340,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,3471.07,31870.39,APC
Repair of biceps tendon,24340,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,3471.07,31870.39,APC
Repair of biceps tendon,24340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,3471.07,31870.39,APC
Repair of biceps tendon,24340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,3471.07,31870.39,Radiology
Repair of biceps tendon,24340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,3471.07,31870.39,APC
Repair of biceps tendon,24340,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,3471.07,31870.39,APC
Repair arm tendon/muscle,24341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10682.49,,,,,,,fee schedule,7183.42,31870.39,
Repair arm tendon/muscle,24341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8562.95,,,,,,,fee schedule,7183.42,31870.39,
Repair arm tendon/muscle,24341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9354.24,,,,,,,fee schedule,7183.42,31870.39,
Repair arm tendon/muscle,24341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9834.67,,,,,,,fee schedule,7183.42,31870.39,
Repair arm tendon/muscle,24341,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Repair arm tendon/muscle,24341,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Repair arm tendon/muscle,24341,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Repair arm tendon/muscle,24341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Repair arm tendon/muscle,24341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Repair arm tendon/muscle,24341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Repair arm tendon/muscle,24341,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Repair of ruptured tendon,24342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9530.26,,,,,,,fee schedule,7183.42,31870.39,
Repair of ruptured tendon,24342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7639.34,,,,,,,fee schedule,7183.42,31870.39,
Repair of ruptured tendon,24342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8345.28,,,,,,,fee schedule,7183.42,31870.39,
Repair of ruptured tendon,24342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8773.89,,,,,,,fee schedule,7183.42,31870.39,
Repair of ruptured tendon,24342,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Repair of ruptured tendon,24342,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Repair of ruptured tendon,24342,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Repair of ruptured tendon,24342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Repair of ruptured tendon,24342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Repair of ruptured tendon,24342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Repair of ruptured tendon,24342,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Repr elbow lat ligmnt w/tiss,24343,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2977.3,,,,,,,fee schedule,2386.57,14371.12,
Repr elbow lat ligmnt w/tiss,24343,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2386.57,,,,,,,fee schedule,2386.57,14371.12,
Repr elbow lat ligmnt w/tiss,24343,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2607.11,,,,,,,fee schedule,2386.57,14371.12,
Repr elbow lat ligmnt w/tiss,24343,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2741.01,,,,,,,fee schedule,2386.57,14371.12,
Repr elbow lat ligmnt w/tiss,24343,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,2386.57,14371.12,APC 378
Repr elbow lat ligmnt w/tiss,24343,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,2386.57,14371.12,APC
Repr elbow lat ligmnt w/tiss,24343,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,2386.57,14371.12,APC
Repr elbow lat ligmnt w/tiss,24343,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,2386.57,14371.12,APC
Repr elbow lat ligmnt w/tiss,24343,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,2386.57,14371.12,Radiology
Repr elbow lat ligmnt w/tiss,24343,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,2386.57,14371.12,APC
Repr elbow lat ligmnt w/tiss,24343,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,2386.57,14371.12,APC
Reconstruct elbow lat ligmnt,24344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19822.36,,,,,,,fee schedule,7183.42,31870.39,
Reconstruct elbow lat ligmnt,24344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15889.35,,,,,,,fee schedule,7183.42,31870.39,
Reconstruct elbow lat ligmnt,24344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17357.67,,,,,,,fee schedule,7183.42,31870.39,
Reconstruct elbow lat ligmnt,24344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18249.15,,,,,,,fee schedule,7183.42,31870.39,
Reconstruct elbow lat ligmnt,24344,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Reconstruct elbow lat ligmnt,24344,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Reconstruct elbow lat ligmnt,24344,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Reconstruct elbow lat ligmnt,24344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Reconstruct elbow lat ligmnt,24344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Reconstruct elbow lat ligmnt,24344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Reconstruct elbow lat ligmnt,24344,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Repr elbw med ligmnt w/tissu,24345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2977.3,,,,,,,fee schedule,2386.57,31870.39,
Repr elbw med ligmnt w/tissu,24345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2386.57,,,,,,,fee schedule,2386.57,31870.39,
Repr elbw med ligmnt w/tissu,24345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2607.11,,,,,,,fee schedule,2386.57,31870.39,
Repr elbw med ligmnt w/tissu,24345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2741.01,,,,,,,fee schedule,2386.57,31870.39,
Repr elbw med ligmnt w/tissu,24345,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,2386.57,31870.39,APC 378
Repr elbw med ligmnt w/tissu,24345,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,2386.57,31870.39,APC
Repr elbw med ligmnt w/tissu,24345,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,2386.57,31870.39,APC
Repr elbw med ligmnt w/tissu,24345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,2386.57,31870.39,APC
Repr elbw med ligmnt w/tissu,24345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,2386.57,31870.39,Radiology
Repr elbw med ligmnt w/tissu,24345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,2386.57,31870.39,APC
Repr elbw med ligmnt w/tissu,24345,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,2386.57,31870.39,APC
Reconstruct elbow med ligmnt,24346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10728.02,,,,,,,fee schedule,8599.44,56389.43,
Reconstruct elbow med ligmnt,24346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8599.44,,,,,,,fee schedule,8599.44,56389.43,
Reconstruct elbow med ligmnt,24346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9394.11,,,,,,,fee schedule,8599.44,56389.43,
Reconstruct elbow med ligmnt,24346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9876.59,,,,,,,fee schedule,8599.44,56389.43,
Reconstruct elbow med ligmnt,24346,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,8599.44,56389.43,APC 378
Reconstruct elbow med ligmnt,24346,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,8599.44,56389.43,APC
Reconstruct elbow med ligmnt,24346,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,8599.44,56389.43,APC
Reconstruct elbow med ligmnt,24346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,8599.44,56389.43,APC
Reconstruct elbow med ligmnt,24346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,8599.44,56389.43,Radiology
Reconstruct elbow med ligmnt,24346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,8599.44,56389.43,APC
Reconstruct elbow med ligmnt,24346,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,8599.44,56389.43,APC
Repair elbow perc,24357,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,3239.17,14371.12,
Repair elbow perc,24357,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,3239.17,14371.12,
Repair elbow perc,24357,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,3239.17,14371.12,
Repair elbow perc,24357,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,3239.17,14371.12,
Repair elbow perc,24357,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Repair elbow perc,24357,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Repair elbow perc,24357,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Repair elbow perc,24357,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Repair elbow perc,24357,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Repair elbow perc,24357,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Repair elbow perc,24357,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Repair elbow w/deb open,24358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7079.16,,,,,,,fee schedule,3239.17,14371.12,
Repair elbow w/deb open,24358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5674.56,,,,,,,fee schedule,3239.17,14371.12,
Repair elbow w/deb open,24358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6198.95,,,,,,,fee schedule,3239.17,14371.12,
Repair elbow w/deb open,24358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6517.32,,,,,,,fee schedule,3239.17,14371.12,
Repair elbow w/deb open,24358,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Repair elbow w/deb open,24358,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Repair elbow w/deb open,24358,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Repair elbow w/deb open,24358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Repair elbow w/deb open,24358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Repair elbow w/deb open,24358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Repair elbow w/deb open,24358,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Repair elbow deb/attch open,24359,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10673.46,,,,,,,fee schedule,3239.17,14371.12,
Repair elbow deb/attch open,24359,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8555.71,,,,,,,fee schedule,3239.17,14371.12,
Repair elbow deb/attch open,24359,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9346.34,,,,,,,fee schedule,3239.17,14371.12,
Repair elbow deb/attch open,24359,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9826.36,,,,,,,fee schedule,3239.17,14371.12,
Repair elbow deb/attch open,24359,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Repair elbow deb/attch open,24359,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Repair elbow deb/attch open,24359,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Repair elbow deb/attch open,24359,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Repair elbow deb/attch open,24359,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Repair elbow deb/attch open,24359,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Repair elbow deb/attch open,24359,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Reconstruct elbow joint,24360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8960.75,,,,,,,fee schedule,7182.83,31870.39,
Reconstruct elbow joint,24360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7182.83,,,,,,,fee schedule,7182.83,31870.39,
Reconstruct elbow joint,24360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7846.59,,,,,,,fee schedule,7182.83,31870.39,
Reconstruct elbow joint,24360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8249.58,,,,,,,fee schedule,7182.83,31870.39,
Reconstruct elbow joint,24360,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7182.83,31870.39,APC 378
Reconstruct elbow joint,24360,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7182.83,31870.39,APC
Reconstruct elbow joint,24360,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7182.83,31870.39,APC
Reconstruct elbow joint,24360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7182.83,31870.39,APC
Reconstruct elbow joint,24360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7182.83,31870.39,Radiology
Reconstruct elbow joint,24360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7182.83,31870.39,APC
Reconstruct elbow joint,24360,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7182.83,31870.39,APC
Reconstruct elbow joint,24361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30499.53,,,,,,,fee schedule,17357.91,77011.17,
Reconstruct elbow joint,24361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24448.04,,,,,,,fee schedule,17357.91,77011.17,
Reconstruct elbow joint,24361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26707.26,,,,,,,fee schedule,17357.91,77011.17,
Reconstruct elbow joint,24361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,28078.94,,,,,,,fee schedule,17357.91,77011.17,
Reconstruct elbow joint,24361,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,77011.17,,,,,,,fee schedule,17357.91,77011.17,APC 378
Reconstruct elbow joint,24361,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18225.81,,,,,,,fee schedule,17357.91,77011.17,APC
Reconstruct elbow joint,24361,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18052.23,,,,,,,fee schedule,17357.91,77011.17,APC
Reconstruct elbow joint,24361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17357.91,,,,,,,fee schedule,17357.91,77011.17,APC
Reconstruct elbow joint,24361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26557.6,,,,,,,fee schedule,17357.91,77011.17,Radiology
Reconstruct elbow joint,24361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24301.07,,,,,,,fee schedule,17357.91,77011.17,APC
Reconstruct elbow joint,24361,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30376.34,,,,,,,fee schedule,17357.91,77011.17,APC
Reconstruct elbow joint,24362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12700.27,,,,,,,fee schedule,10180.38,56389.43,
Reconstruct elbow joint,24362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10180.38,,,,,,,fee schedule,10180.38,56389.43,
Reconstruct elbow joint,24362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11121.14,,,,,,,fee schedule,10180.38,56389.43,
Reconstruct elbow joint,24362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11692.31,,,,,,,fee schedule,10180.38,56389.43,
Reconstruct elbow joint,24362,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,10180.38,56389.43,APC 378
Reconstruct elbow joint,24362,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,10180.38,56389.43,APC
Reconstruct elbow joint,24362,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,10180.38,56389.43,APC
Reconstruct elbow joint,24362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,10180.38,56389.43,APC
Reconstruct elbow joint,24362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,10180.38,56389.43,Radiology
Reconstruct elbow joint,24362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,10180.38,56389.43,APC
Reconstruct elbow joint,24362,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,10180.38,56389.43,APC
Replace elbow joint,24363,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30499.53,,,,,,,fee schedule,17357.91,77011.17,
Replace elbow joint,24363,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24448.04,,,,,,,fee schedule,17357.91,77011.17,
Replace elbow joint,24363,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26707.26,,,,,,,fee schedule,17357.91,77011.17,
Replace elbow joint,24363,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,28078.94,,,,,,,fee schedule,17357.91,77011.17,
Replace elbow joint,24363,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,77011.17,,,,,,,fee schedule,17357.91,77011.17,APC 378
Replace elbow joint,24363,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18225.81,,,,,,,fee schedule,17357.91,77011.17,APC
Replace elbow joint,24363,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18052.23,,,,,,,fee schedule,17357.91,77011.17,APC
Replace elbow joint,24363,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17357.91,,,,,,,fee schedule,17357.91,77011.17,APC
Replace elbow joint,24363,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26557.6,,,,,,,fee schedule,17357.91,77011.17,Radiology
Replace elbow joint,24363,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24301.07,,,,,,,fee schedule,17357.91,77011.17,APC
Replace elbow joint,24363,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30376.34,,,,,,,fee schedule,17357.91,77011.17,APC
Reconstruct head of radius,24365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8960.75,,,,,,,fee schedule,7182.83,56389.43,
Reconstruct head of radius,24365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7182.83,,,,,,,fee schedule,7182.83,56389.43,
Reconstruct head of radius,24365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7846.59,,,,,,,fee schedule,7182.83,56389.43,
Reconstruct head of radius,24365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8249.58,,,,,,,fee schedule,7182.83,56389.43,
Reconstruct head of radius,24365,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,7182.83,56389.43,APC 378
Reconstruct head of radius,24365,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,7182.83,56389.43,APC
Reconstruct head of radius,24365,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,7182.83,56389.43,APC
Reconstruct head of radius,24365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,7182.83,56389.43,APC
Reconstruct head of radius,24365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,7182.83,56389.43,Radiology
Reconstruct head of radius,24365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,7182.83,56389.43,APC
Reconstruct head of radius,24365,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,7182.83,56389.43,APC
Reconstruct head of radius,24366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2977.3,,,,,,,fee schedule,2386.57,56389.43,
Reconstruct head of radius,24366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2386.57,,,,,,,fee schedule,2386.57,56389.43,
Reconstruct head of radius,24366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2607.11,,,,,,,fee schedule,2386.57,56389.43,
Reconstruct head of radius,24366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2741.01,,,,,,,fee schedule,2386.57,56389.43,
Reconstruct head of radius,24366,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,2386.57,56389.43,APC 378
Reconstruct head of radius,24366,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,2386.57,56389.43,APC
Reconstruct head of radius,24366,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,2386.57,56389.43,APC
Reconstruct head of radius,24366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,2386.57,56389.43,APC
Reconstruct head of radius,24366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,2386.57,56389.43,Radiology
Reconstruct head of radius,24366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,2386.57,56389.43,APC
Reconstruct head of radius,24366,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,2386.57,56389.43,APC
Revise reconst elbow joint,24370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,36295.11,,,,,,,fee schedule,12709.88,56389.43,
Revise reconst elbow joint,24370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29093.7,,,,,,,fee schedule,12709.88,56389.43,
Revise reconst elbow joint,24370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31782.22,,,,,,,fee schedule,12709.88,56389.43,
Revise reconst elbow joint,24370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33414.54,,,,,,,fee schedule,12709.88,56389.43,
Revise reconst elbow joint,24370,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,12709.88,56389.43,APC 378
Revise reconst elbow joint,24370,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,12709.88,56389.43,APC
Revise reconst elbow joint,24370,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,12709.88,56389.43,APC
Revise reconst elbow joint,24370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,12709.88,56389.43,APC
Revise reconst elbow joint,24370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,12709.88,56389.43,Radiology
Revise reconst elbow joint,24370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,12709.88,56389.43,APC
Revise reconst elbow joint,24370,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,12709.88,56389.43,APC
Revise reconst elbow joint,24371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,36295.11,,,,,,,fee schedule,17357.91,77011.17,
Revise reconst elbow joint,24371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29093.7,,,,,,,fee schedule,17357.91,77011.17,
Revise reconst elbow joint,24371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31782.22,,,,,,,fee schedule,17357.91,77011.17,
Revise reconst elbow joint,24371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33414.54,,,,,,,fee schedule,17357.91,77011.17,
Revise reconst elbow joint,24371,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,77011.17,,,,,,,fee schedule,17357.91,77011.17,APC 378
Revise reconst elbow joint,24371,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18225.81,,,,,,,fee schedule,17357.91,77011.17,APC
Revise reconst elbow joint,24371,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18052.23,,,,,,,fee schedule,17357.91,77011.17,APC
Revise reconst elbow joint,24371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17357.91,,,,,,,fee schedule,17357.91,77011.17,APC
Revise reconst elbow joint,24371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26557.6,,,,,,,fee schedule,17357.91,77011.17,Radiology
Revise reconst elbow joint,24371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24301.07,,,,,,,fee schedule,17357.91,77011.17,APC
Revise reconst elbow joint,24371,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30376.34,,,,,,,fee schedule,17357.91,77011.17,APC
Revision of humerus,24400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,5839.66,31870.39,
Revision of humerus,24400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,5839.66,31870.39,
Revision of humerus,24400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,5839.66,31870.39,
Revision of humerus,24400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,5839.66,31870.39,
Revision of humerus,24400,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5839.66,31870.39,APC 378
Revision of humerus,24400,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5839.66,31870.39,APC
Revision of humerus,24400,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5839.66,31870.39,APC
Revision of humerus,24400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5839.66,31870.39,APC
Revision of humerus,24400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5839.66,31870.39,Radiology
Revision of humerus,24400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5839.66,31870.39,APC
Revision of humerus,24400,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5839.66,31870.39,APC
Revision of humerus,24410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,5839.66,56389.43,
Revision of humerus,24410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,5839.66,56389.43,
Revision of humerus,24410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,5839.66,56389.43,
Revision of humerus,24410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,5839.66,56389.43,
Revision of humerus,24410,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,5839.66,56389.43,APC 378
Revision of humerus,24410,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,5839.66,56389.43,APC
Revision of humerus,24410,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,5839.66,56389.43,APC
Revision of humerus,24410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,5839.66,56389.43,APC
Revision of humerus,24410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,5839.66,56389.43,Radiology
Revision of humerus,24410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,5839.66,56389.43,APC
Revision of humerus,24410,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,5839.66,56389.43,APC
Revision of humerus,24420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10728.02,,,,,,,fee schedule,7183.42,31870.39,
Revision of humerus,24420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8599.44,,,,,,,fee schedule,7183.42,31870.39,
Revision of humerus,24420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9394.11,,,,,,,fee schedule,7183.42,31870.39,
Revision of humerus,24420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9876.59,,,,,,,fee schedule,7183.42,31870.39,
Revision of humerus,24420,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Revision of humerus,24420,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Revision of humerus,24420,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Revision of humerus,24420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Revision of humerus,24420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Revision of humerus,24420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Revision of humerus,24420,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Repair of humerus,24430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19822.36,,,,,,,fee schedule,12709.88,56389.43,
Repair of humerus,24430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15889.35,,,,,,,fee schedule,12709.88,56389.43,
Repair of humerus,24430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17357.67,,,,,,,fee schedule,12709.88,56389.43,
Repair of humerus,24430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18249.15,,,,,,,fee schedule,12709.88,56389.43,
Repair of humerus,24430,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,12709.88,56389.43,APC 378
Repair of humerus,24430,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,12709.88,56389.43,APC
Repair of humerus,24430,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,12709.88,56389.43,APC
Repair of humerus,24430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,12709.88,56389.43,APC
Repair of humerus,24430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,12709.88,56389.43,Radiology
Repair of humerus,24430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,12709.88,56389.43,APC
Repair of humerus,24430,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,12709.88,56389.43,APC
Repair humerus with graft,24435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14886.5,,,,,,,fee schedule,11932.83,56389.43,
Repair humerus with graft,24435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11932.83,,,,,,,fee schedule,11932.83,56389.43,
Repair humerus with graft,24435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13035.53,,,,,,,fee schedule,11932.83,56389.43,
Repair humerus with graft,24435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13705.03,,,,,,,fee schedule,11932.83,56389.43,
Repair humerus with graft,24435,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,11932.83,56389.43,APC 378
Repair humerus with graft,24435,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,11932.83,56389.43,APC
Repair humerus with graft,24435,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,11932.83,56389.43,APC
Repair humerus with graft,24435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,11932.83,56389.43,APC
Repair humerus with graft,24435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,11932.83,56389.43,Radiology
Repair humerus with graft,24435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,11932.83,56389.43,APC
Repair humerus with graft,24435,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,11932.83,56389.43,APC
Revision of elbow joint,24470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10728.02,,,,,,,fee schedule,3239.17,14371.12,
Revision of elbow joint,24470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8599.44,,,,,,,fee schedule,3239.17,14371.12,
Revision of elbow joint,24470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9394.11,,,,,,,fee schedule,3239.17,14371.12,
Revision of elbow joint,24470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9876.59,,,,,,,fee schedule,3239.17,14371.12,
Revision of elbow joint,24470,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Revision of elbow joint,24470,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Revision of elbow joint,24470,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Revision of elbow joint,24470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Revision of elbow joint,24470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Revision of elbow joint,24470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Revision of elbow joint,24470,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Decompression of forearm,24495,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,5839.66,31870.39,
Decompression of forearm,24495,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,5839.66,31870.39,
Decompression of forearm,24495,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,5839.66,31870.39,
Decompression of forearm,24495,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,5839.66,31870.39,
Decompression of forearm,24495,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5839.66,31870.39,APC 378
Decompression of forearm,24495,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5839.66,31870.39,APC
Decompression of forearm,24495,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5839.66,31870.39,APC
Decompression of forearm,24495,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5839.66,31870.39,APC
Decompression of forearm,24495,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5839.66,31870.39,Radiology
Decompression of forearm,24495,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5839.66,31870.39,APC
Decompression of forearm,24495,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5839.66,31870.39,APC
Reinforce humerus,24498,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19822.36,,,,,,,fee schedule,12709.88,56389.43,
Reinforce humerus,24498,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15889.35,,,,,,,fee schedule,12709.88,56389.43,
Reinforce humerus,24498,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17357.67,,,,,,,fee schedule,12709.88,56389.43,
Reinforce humerus,24498,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18249.15,,,,,,,fee schedule,12709.88,56389.43,
Reinforce humerus,24498,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,12709.88,56389.43,APC 378
Reinforce humerus,24498,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,12709.88,56389.43,APC
Reinforce humerus,24498,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,12709.88,56389.43,APC
Reinforce humerus,24498,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,12709.88,56389.43,APC
Reinforce humerus,24498,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,12709.88,56389.43,Radiology
Reinforce humerus,24498,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,12709.88,56389.43,APC
Reinforce humerus,24498,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,12709.88,56389.43,APC
Treat humerus fracture,24500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,244.19,1083.4,
Treat humerus fracture,24500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,244.19,1083.4,
Treat humerus fracture,24500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,244.19,1083.4,
Treat humerus fracture,24500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,244.19,1083.4,
Treat humerus fracture,24500,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treat humerus fracture,24500,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treat humerus fracture,24500,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treat humerus fracture,24500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treat humerus fracture,24500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treat humerus fracture,24500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treat humerus fracture,24500,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treat humerus fracture,24505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,353.72,7062.54,
Treat humerus fracture,24505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,353.72,7062.54,
Treat humerus fracture,24505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,353.72,7062.54,
Treat humerus fracture,24505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,353.72,7062.54,
Treat humerus fracture,24505,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,353.72,7062.54,APC 378
Treat humerus fracture,24505,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,353.72,7062.54,APC
Treat humerus fracture,24505,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,353.72,7062.54,APC
Treat humerus fracture,24505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,353.72,7062.54,APC
Treat humerus fracture,24505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,353.72,7062.54,Radiology
Treat humerus fracture,24505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,353.72,7062.54,APC
Treat humerus fracture,24505,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,353.72,7062.54,APC
Treat humerus fracture,24515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10466.49,,,,,,,fee schedule,8389.81,56389.43,
Treat humerus fracture,24515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8389.81,,,,,,,fee schedule,8389.81,56389.43,
Treat humerus fracture,24515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9165.1,,,,,,,fee schedule,8389.81,56389.43,
Treat humerus fracture,24515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9635.82,,,,,,,fee schedule,8389.81,56389.43,
Treat humerus fracture,24515,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,8389.81,56389.43,APC 378
Treat humerus fracture,24515,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,8389.81,56389.43,APC
Treat humerus fracture,24515,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,8389.81,56389.43,APC
Treat humerus fracture,24515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,8389.81,56389.43,APC
Treat humerus fracture,24515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,8389.81,56389.43,Radiology
Treat humerus fracture,24515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,8389.81,56389.43,APC
Treat humerus fracture,24515,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,8389.81,56389.43,APC
Treat humerus fracture,24516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14780.67,,,,,,,fee schedule,11848,56389.43,
Treat humerus fracture,24516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11848,,,,,,,fee schedule,11848,56389.43,
Treat humerus fracture,24516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12942.86,,,,,,,fee schedule,11848,56389.43,
Treat humerus fracture,24516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13607.6,,,,,,,fee schedule,11848,56389.43,
Treat humerus fracture,24516,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,11848,56389.43,APC 378
Treat humerus fracture,24516,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,11848,56389.43,APC
Treat humerus fracture,24516,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,11848,56389.43,APC
Treat humerus fracture,24516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,11848,56389.43,APC
Treat humerus fracture,24516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,11848,56389.43,Radiology
Treat humerus fracture,24516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,11848,56389.43,APC
Treat humerus fracture,24516,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,11848,56389.43,APC
Treat humerus fracture,24530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,244.19,1083.4,
Treat humerus fracture,24530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,244.19,1083.4,
Treat humerus fracture,24530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,244.19,1083.4,
Treat humerus fracture,24530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,244.19,1083.4,
Treat humerus fracture,24530,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treat humerus fracture,24530,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treat humerus fracture,24530,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treat humerus fracture,24530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treat humerus fracture,24530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treat humerus fracture,24530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treat humerus fracture,24530,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treat humerus fracture,24535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,353.72,7062.54,
Treat humerus fracture,24535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,353.72,7062.54,
Treat humerus fracture,24535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,353.72,7062.54,
Treat humerus fracture,24535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,353.72,7062.54,
Treat humerus fracture,24535,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,353.72,7062.54,APC 378
Treat humerus fracture,24535,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,353.72,7062.54,APC
Treat humerus fracture,24535,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,353.72,7062.54,APC
Treat humerus fracture,24535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,353.72,7062.54,APC
Treat humerus fracture,24535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,353.72,7062.54,Radiology
Treat humerus fracture,24535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,353.72,7062.54,APC
Treat humerus fracture,24535,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,353.72,7062.54,APC
Treat humerus fracture,24538,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7657.8,,,,,,,fee schedule,6138.4,31870.39,
Treat humerus fracture,24538,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6138.4,,,,,,,fee schedule,6138.4,31870.39,
Treat humerus fracture,24538,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6705.64,,,,,,,fee schedule,6138.4,31870.39,
Treat humerus fracture,24538,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7050.04,,,,,,,fee schedule,6138.4,31870.39,
Treat humerus fracture,24538,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,6138.4,31870.39,APC 378
Treat humerus fracture,24538,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,6138.4,31870.39,APC
Treat humerus fracture,24538,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,6138.4,31870.39,APC
Treat humerus fracture,24538,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,6138.4,31870.39,APC
Treat humerus fracture,24538,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,6138.4,31870.39,Radiology
Treat humerus fracture,24538,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,6138.4,31870.39,APC
Treat humerus fracture,24538,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,6138.4,31870.39,APC
Treat humerus fracture,24545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10954.11,,,,,,,fee schedule,8780.68,56389.43,
Treat humerus fracture,24545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8780.68,,,,,,,fee schedule,8780.68,56389.43,
Treat humerus fracture,24545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9592.09,,,,,,,fee schedule,8780.68,56389.43,
Treat humerus fracture,24545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10084.74,,,,,,,fee schedule,8780.68,56389.43,
Treat humerus fracture,24545,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,8780.68,56389.43,APC 378
Treat humerus fracture,24545,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,8780.68,56389.43,APC
Treat humerus fracture,24545,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,8780.68,56389.43,APC
Treat humerus fracture,24545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,8780.68,56389.43,APC
Treat humerus fracture,24545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,8780.68,56389.43,Radiology
Treat humerus fracture,24545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,8780.68,56389.43,APC
Treat humerus fracture,24545,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,8780.68,56389.43,APC
Treat humerus fracture,24546,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14780.67,,,,,,,fee schedule,11848,56389.43,
Treat humerus fracture,24546,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11848,,,,,,,fee schedule,11848,56389.43,
Treat humerus fracture,24546,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12942.86,,,,,,,fee schedule,11848,56389.43,
Treat humerus fracture,24546,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13607.6,,,,,,,fee schedule,11848,56389.43,
Treat humerus fracture,24546,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,11848,56389.43,APC 378
Treat humerus fracture,24546,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,11848,56389.43,APC
Treat humerus fracture,24546,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,11848,56389.43,APC
Treat humerus fracture,24546,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,11848,56389.43,APC
Treat humerus fracture,24546,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,11848,56389.43,Radiology
Treat humerus fracture,24546,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,11848,56389.43,APC
Treat humerus fracture,24546,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,11848,56389.43,APC
Treat humerus fracture,24560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,244.19,1083.4,
Treat humerus fracture,24560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,244.19,1083.4,
Treat humerus fracture,24560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,244.19,1083.4,
Treat humerus fracture,24560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,244.19,1083.4,
Treat humerus fracture,24560,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treat humerus fracture,24560,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treat humerus fracture,24560,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treat humerus fracture,24560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treat humerus fracture,24560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treat humerus fracture,24560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treat humerus fracture,24560,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treat humerus fracture,24565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,353.72,7062.54,
Treat humerus fracture,24565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,353.72,7062.54,
Treat humerus fracture,24565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,353.72,7062.54,
Treat humerus fracture,24565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,353.72,7062.54,
Treat humerus fracture,24565,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,353.72,7062.54,APC 378
Treat humerus fracture,24565,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,353.72,7062.54,APC
Treat humerus fracture,24565,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,353.72,7062.54,APC
Treat humerus fracture,24565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,353.72,7062.54,APC
Treat humerus fracture,24565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,353.72,7062.54,Radiology
Treat humerus fracture,24565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,353.72,7062.54,APC
Treat humerus fracture,24565,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,353.72,7062.54,APC
Treat humerus fracture,24566,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6528.66,,,,,,,fee schedule,1591.86,7062.54,
Treat humerus fracture,24566,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5233.29,,,,,,,fee schedule,1591.86,7062.54,
Treat humerus fracture,24566,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5716.9,,,,,,,fee schedule,1591.86,7062.54,
Treat humerus fracture,24566,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6010.52,,,,,,,fee schedule,1591.86,7062.54,
Treat humerus fracture,24566,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Treat humerus fracture,24566,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Treat humerus fracture,24566,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Treat humerus fracture,24566,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Treat humerus fracture,24566,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Treat humerus fracture,24566,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Treat humerus fracture,24566,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Treat humerus fracture,24575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14780.67,,,,,,,fee schedule,11848,56389.43,
Treat humerus fracture,24575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11848,,,,,,,fee schedule,11848,56389.43,
Treat humerus fracture,24575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12942.86,,,,,,,fee schedule,11848,56389.43,
Treat humerus fracture,24575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13607.6,,,,,,,fee schedule,11848,56389.43,
Treat humerus fracture,24575,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,11848,56389.43,APC 378
Treat humerus fracture,24575,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,11848,56389.43,APC
Treat humerus fracture,24575,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,11848,56389.43,APC
Treat humerus fracture,24575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,11848,56389.43,APC
Treat humerus fracture,24575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,11848,56389.43,Radiology
Treat humerus fracture,24575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,11848,56389.43,APC
Treat humerus fracture,24575,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,11848,56389.43,APC
Treat humerus fracture,24576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,244.19,1083.4,
Treat humerus fracture,24576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,244.19,1083.4,
Treat humerus fracture,24576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,244.19,1083.4,
Treat humerus fracture,24576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,244.19,1083.4,
Treat humerus fracture,24576,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treat humerus fracture,24576,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treat humerus fracture,24576,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treat humerus fracture,24576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treat humerus fracture,24576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treat humerus fracture,24576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treat humerus fracture,24576,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treat humerus fracture,24577,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,353.72,7062.54,
Treat humerus fracture,24577,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,353.72,7062.54,
Treat humerus fracture,24577,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,353.72,7062.54,
Treat humerus fracture,24577,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,353.72,7062.54,
Treat humerus fracture,24577,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,353.72,7062.54,APC 378
Treat humerus fracture,24577,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,353.72,7062.54,APC
Treat humerus fracture,24577,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,353.72,7062.54,APC
Treat humerus fracture,24577,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,353.72,7062.54,APC
Treat humerus fracture,24577,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,353.72,7062.54,Radiology
Treat humerus fracture,24577,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,353.72,7062.54,APC
Treat humerus fracture,24577,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,353.72,7062.54,APC
Treat humerus fracture,24579,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14780.67,,,,,,,fee schedule,11848,56389.43,
Treat humerus fracture,24579,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11848,,,,,,,fee schedule,11848,56389.43,
Treat humerus fracture,24579,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12942.86,,,,,,,fee schedule,11848,56389.43,
Treat humerus fracture,24579,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13607.6,,,,,,,fee schedule,11848,56389.43,
Treat humerus fracture,24579,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,11848,56389.43,APC 378
Treat humerus fracture,24579,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,11848,56389.43,APC
Treat humerus fracture,24579,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,11848,56389.43,APC
Treat humerus fracture,24579,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,11848,56389.43,APC
Treat humerus fracture,24579,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,11848,56389.43,Radiology
Treat humerus fracture,24579,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,11848,56389.43,APC
Treat humerus fracture,24579,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,11848,56389.43,APC
Treat humerus fracture,24582,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6528.66,,,,,,,fee schedule,5233.29,31870.39,
Treat humerus fracture,24582,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5233.29,,,,,,,fee schedule,5233.29,31870.39,
Treat humerus fracture,24582,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5716.9,,,,,,,fee schedule,5233.29,31870.39,
Treat humerus fracture,24582,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6010.52,,,,,,,fee schedule,5233.29,31870.39,
Treat humerus fracture,24582,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5233.29,31870.39,APC 378
Treat humerus fracture,24582,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5233.29,31870.39,APC
Treat humerus fracture,24582,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5233.29,31870.39,APC
Treat humerus fracture,24582,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5233.29,31870.39,APC
Treat humerus fracture,24582,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5233.29,31870.39,Radiology
Treat humerus fracture,24582,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5233.29,31870.39,APC
Treat humerus fracture,24582,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5233.29,31870.39,APC
Treat elbow fracture,24586,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9530.26,,,,,,,fee schedule,7639.34,56389.43,
Treat elbow fracture,24586,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7639.34,,,,,,,fee schedule,7639.34,56389.43,
Treat elbow fracture,24586,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8345.28,,,,,,,fee schedule,7639.34,56389.43,
Treat elbow fracture,24586,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8773.89,,,,,,,fee schedule,7639.34,56389.43,
Treat elbow fracture,24586,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,7639.34,56389.43,APC 378
Treat elbow fracture,24586,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,7639.34,56389.43,APC
Treat elbow fracture,24586,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,7639.34,56389.43,APC
Treat elbow fracture,24586,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,7639.34,56389.43,APC
Treat elbow fracture,24586,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,7639.34,56389.43,Radiology
Treat elbow fracture,24586,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,7639.34,56389.43,APC
Treat elbow fracture,24586,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,7639.34,56389.43,APC
Treat elbow fracture,24587,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14780.67,,,,,,,fee schedule,11848,56389.43,
Treat elbow fracture,24587,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11848,,,,,,,fee schedule,11848,56389.43,
Treat elbow fracture,24587,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12942.86,,,,,,,fee schedule,11848,56389.43,
Treat elbow fracture,24587,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13607.6,,,,,,,fee schedule,11848,56389.43,
Treat elbow fracture,24587,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,11848,56389.43,APC 378
Treat elbow fracture,24587,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,11848,56389.43,APC
Treat elbow fracture,24587,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,11848,56389.43,APC
Treat elbow fracture,24587,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,11848,56389.43,APC
Treat elbow fracture,24587,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,11848,56389.43,Radiology
Treat elbow fracture,24587,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,11848,56389.43,APC
Treat elbow fracture,24587,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,11848,56389.43,APC
Treat elbow dislocation,24600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,651.24,,,,,,,fee schedule,244.19,1083.4,
Treat elbow dislocation,24600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,522.03,,,,,,,fee schedule,244.19,1083.4,
Treat elbow dislocation,24600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,570.27,,,,,,,fee schedule,244.19,1083.4,
Treat elbow dislocation,24600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,599.56,,,,,,,fee schedule,244.19,1083.4,
Treat elbow dislocation,24600,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treat elbow dislocation,24600,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treat elbow dislocation,24600,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treat elbow dislocation,24600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treat elbow dislocation,24600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treat elbow dislocation,24600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treat elbow dislocation,24600,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treat elbow dislocation,24605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3685.16,,,,,,,fee schedule,1591.86,7062.54,
Treat elbow dislocation,24605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2953.98,,,,,,,fee schedule,1591.86,7062.54,
Treat elbow dislocation,24605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3226.95,,,,,,,fee schedule,1591.86,7062.54,
Treat elbow dislocation,24605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3392.69,,,,,,,fee schedule,1591.86,7062.54,
Treat elbow dislocation,24605,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Treat elbow dislocation,24605,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Treat elbow dislocation,24605,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Treat elbow dislocation,24605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Treat elbow dislocation,24605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Treat elbow dislocation,24605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Treat elbow dislocation,24605,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Treat elbow dislocation,24615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14780.67,,,,,,,fee schedule,7183.42,31870.39,
Treat elbow dislocation,24615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11848,,,,,,,fee schedule,7183.42,31870.39,
Treat elbow dislocation,24615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12942.86,,,,,,,fee schedule,7183.42,31870.39,
Treat elbow dislocation,24615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13607.6,,,,,,,fee schedule,7183.42,31870.39,
Treat elbow dislocation,24615,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Treat elbow dislocation,24615,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Treat elbow dislocation,24615,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Treat elbow dislocation,24615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Treat elbow dislocation,24615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Treat elbow dislocation,24615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Treat elbow dislocation,24615,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Treat elbow fracture,24620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1689.33,,,,,,,fee schedule,1354.15,7062.54,
Treat elbow fracture,24620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1354.15,,,,,,,fee schedule,1354.15,7062.54,
Treat elbow fracture,24620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1479.28,,,,,,,fee schedule,1354.15,7062.54,
Treat elbow fracture,24620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1555.26,,,,,,,fee schedule,1354.15,7062.54,
Treat elbow fracture,24620,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1354.15,7062.54,APC 378
Treat elbow fracture,24620,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1354.15,7062.54,APC
Treat elbow fracture,24620,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1354.15,7062.54,APC
Treat elbow fracture,24620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1354.15,7062.54,APC
Treat elbow fracture,24620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1354.15,7062.54,Radiology
Treat elbow fracture,24620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1354.15,7062.54,APC
Treat elbow fracture,24620,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1354.15,7062.54,APC
Treat elbow fracture,24635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14780.67,,,,,,,fee schedule,7183.42,31870.39,
Treat elbow fracture,24635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11848,,,,,,,fee schedule,7183.42,31870.39,
Treat elbow fracture,24635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12942.86,,,,,,,fee schedule,7183.42,31870.39,
Treat elbow fracture,24635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13607.6,,,,,,,fee schedule,7183.42,31870.39,
Treat elbow fracture,24635,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Treat elbow fracture,24635,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Treat elbow fracture,24635,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Treat elbow fracture,24635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Treat elbow fracture,24635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Treat elbow fracture,24635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Treat elbow fracture,24635,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Treat elbow dislocation,24640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,339.17,,,,,,,fee schedule,244.19,1083.4,
Treat elbow dislocation,24640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,271.87,,,,,,,fee schedule,244.19,1083.4,
Treat elbow dislocation,24640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,297,,,,,,,fee schedule,244.19,1083.4,
Treat elbow dislocation,24640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,312.25,,,,,,,fee schedule,244.19,1083.4,
Treat elbow dislocation,24640,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treat elbow dislocation,24640,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treat elbow dislocation,24640,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treat elbow dislocation,24640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treat elbow dislocation,24640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treat elbow dislocation,24640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treat elbow dislocation,24640,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treat radius fracture,24650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,244.19,1083.4,
Treat radius fracture,24650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,244.19,1083.4,
Treat radius fracture,24650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,244.19,1083.4,
Treat radius fracture,24650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,244.19,1083.4,
Treat radius fracture,24650,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treat radius fracture,24650,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treat radius fracture,24650,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treat radius fracture,24650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treat radius fracture,24650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treat radius fracture,24650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treat radius fracture,24650,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treat radius fracture,24655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,564.56,,,,,,,fee schedule,452.54,7062.54,
Treat radius fracture,24655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,452.54,,,,,,,fee schedule,452.54,7062.54,
Treat radius fracture,24655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,494.36,,,,,,,fee schedule,452.54,7062.54,
Treat radius fracture,24655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,519.75,,,,,,,fee schedule,452.54,7062.54,
Treat radius fracture,24655,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,452.54,7062.54,APC 378
Treat radius fracture,24655,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,452.54,7062.54,APC
Treat radius fracture,24655,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,452.54,7062.54,APC
Treat radius fracture,24655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,452.54,7062.54,APC
Treat radius fracture,24655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,452.54,7062.54,Radiology
Treat radius fracture,24655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,452.54,7062.54,APC
Treat radius fracture,24655,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,452.54,7062.54,APC
Treat radius fracture,24665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12545.92,,,,,,,fee schedule,7183.42,31870.39,
Treat radius fracture,24665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10056.65,,,,,,,fee schedule,7183.42,31870.39,
Treat radius fracture,24665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10985.98,,,,,,,fee schedule,7183.42,31870.39,
Treat radius fracture,24665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11550.21,,,,,,,fee schedule,7183.42,31870.39,
Treat radius fracture,24665,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Treat radius fracture,24665,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Treat radius fracture,24665,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Treat radius fracture,24665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Treat radius fracture,24665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Treat radius fracture,24665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Treat radius fracture,24665,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Treat radius fracture,24666,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14780.67,,,,,,,fee schedule,11848,56389.43,
Treat radius fracture,24666,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11848,,,,,,,fee schedule,11848,56389.43,
Treat radius fracture,24666,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12942.86,,,,,,,fee schedule,11848,56389.43,
Treat radius fracture,24666,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13607.6,,,,,,,fee schedule,11848,56389.43,
Treat radius fracture,24666,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,11848,56389.43,APC 378
Treat radius fracture,24666,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,11848,56389.43,APC
Treat radius fracture,24666,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,11848,56389.43,APC
Treat radius fracture,24666,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,11848,56389.43,APC
Treat radius fracture,24666,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,11848,56389.43,Radiology
Treat radius fracture,24666,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,11848,56389.43,APC
Treat radius fracture,24666,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,11848,56389.43,APC
Treat ulnar fracture,24670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,244.19,1083.4,
Treat ulnar fracture,24670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,244.19,1083.4,
Treat ulnar fracture,24670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,244.19,1083.4,
Treat ulnar fracture,24670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,244.19,1083.4,
Treat ulnar fracture,24670,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treat ulnar fracture,24670,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treat ulnar fracture,24670,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treat ulnar fracture,24670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treat ulnar fracture,24670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treat ulnar fracture,24670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treat ulnar fracture,24670,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treat ulnar fracture,24675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,601.4,,,,,,,fee schedule,482.07,7062.54,
Treat ulnar fracture,24675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,482.07,,,,,,,fee schedule,482.07,7062.54,
Treat ulnar fracture,24675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,526.62,,,,,,,fee schedule,482.07,7062.54,
Treat ulnar fracture,24675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,553.67,,,,,,,fee schedule,482.07,7062.54,
Treat ulnar fracture,24675,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,482.07,7062.54,APC 378
Treat ulnar fracture,24675,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,482.07,7062.54,APC
Treat ulnar fracture,24675,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,482.07,7062.54,APC
Treat ulnar fracture,24675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,482.07,7062.54,APC
Treat ulnar fracture,24675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,482.07,7062.54,Radiology
Treat ulnar fracture,24675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,482.07,7062.54,APC
Treat ulnar fracture,24675,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,482.07,7062.54,APC
Treat ulnar fracture,24685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2977.3,,,,,,,fee schedule,2386.57,31870.39,
Treat ulnar fracture,24685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2386.57,,,,,,,fee schedule,2386.57,31870.39,
Treat ulnar fracture,24685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2607.11,,,,,,,fee schedule,2386.57,31870.39,
Treat ulnar fracture,24685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2741.01,,,,,,,fee schedule,2386.57,31870.39,
Treat ulnar fracture,24685,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,2386.57,31870.39,APC 378
Treat ulnar fracture,24685,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,2386.57,31870.39,APC
Treat ulnar fracture,24685,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,2386.57,31870.39,APC
Treat ulnar fracture,24685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,2386.57,31870.39,APC
Treat ulnar fracture,24685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,2386.57,31870.39,Radiology
Treat ulnar fracture,24685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,2386.57,31870.39,APC
Treat ulnar fracture,24685,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,2386.57,31870.39,APC
Fusion of elbow joint,24800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10728.02,,,,,,,fee schedule,7183.42,31870.39,
Fusion of elbow joint,24800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8599.44,,,,,,,fee schedule,7183.42,31870.39,
Fusion of elbow joint,24800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9394.11,,,,,,,fee schedule,7183.42,31870.39,
Fusion of elbow joint,24800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9876.59,,,,,,,fee schedule,7183.42,31870.39,
Fusion of elbow joint,24800,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Fusion of elbow joint,24800,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Fusion of elbow joint,24800,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Fusion of elbow joint,24800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Fusion of elbow joint,24800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Fusion of elbow joint,24800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Fusion of elbow joint,24800,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Fusion/graft of elbow joint,24802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10728.02,,,,,,,fee schedule,8599.44,56389.43,
Fusion/graft of elbow joint,24802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8599.44,,,,,,,fee schedule,8599.44,56389.43,
Fusion/graft of elbow joint,24802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9394.11,,,,,,,fee schedule,8599.44,56389.43,
Fusion/graft of elbow joint,24802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9876.59,,,,,,,fee schedule,8599.44,56389.43,
Fusion/graft of elbow joint,24802,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,8599.44,56389.43,APC 378
Fusion/graft of elbow joint,24802,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,8599.44,56389.43,APC
Fusion/graft of elbow joint,24802,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,8599.44,56389.43,APC
Fusion/graft of elbow joint,24802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,8599.44,56389.43,APC
Fusion/graft of elbow joint,24802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,8599.44,56389.43,Radiology
Fusion/graft of elbow joint,24802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,8599.44,56389.43,APC
Fusion/graft of elbow joint,24802,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,8599.44,56389.43,APC
Amputation of upper arm,24900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46549.79,,,,,,,fee schedule,12709.88,56389.43,
Amputation of upper arm,24900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37313.72,,,,,,,fee schedule,12709.88,56389.43,
Amputation of upper arm,24900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40761.86,,,,,,,fee schedule,12709.88,56389.43,
Amputation of upper arm,24900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42855.36,,,,,,,fee schedule,12709.88,56389.43,
Amputation of upper arm,24900,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,12709.88,56389.43,APC 378
Amputation of upper arm,24900,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,12709.88,56389.43,APC
Amputation of upper arm,24900,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,12709.88,56389.43,APC
Amputation of upper arm,24900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,12709.88,56389.43,APC
Amputation of upper arm,24900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,12709.88,56389.43,Radiology
Amputation of upper arm,24900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,12709.88,56389.43,APC
Amputation of upper arm,24900,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,12709.88,56389.43,APC
Amputation of upper arm,24920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46549.79,,,,,,,fee schedule,12709.88,56389.43,
Amputation of upper arm,24920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37313.72,,,,,,,fee schedule,12709.88,56389.43,
Amputation of upper arm,24920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40761.86,,,,,,,fee schedule,12709.88,56389.43,
Amputation of upper arm,24920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42855.36,,,,,,,fee schedule,12709.88,56389.43,
Amputation of upper arm,24920,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,12709.88,56389.43,APC 378
Amputation of upper arm,24920,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,12709.88,56389.43,APC
Amputation of upper arm,24920,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,12709.88,56389.43,APC
Amputation of upper arm,24920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,12709.88,56389.43,APC
Amputation of upper arm,24920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,12709.88,56389.43,Radiology
Amputation of upper arm,24920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,12709.88,56389.43,APC
Amputation of upper arm,24920,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,12709.88,56389.43,APC
Amputation follow-up surgery,24925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,3239.17,14371.12,
Amputation follow-up surgery,24925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,3239.17,14371.12,
Amputation follow-up surgery,24925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,3239.17,14371.12,
Amputation follow-up surgery,24925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,3239.17,14371.12,
Amputation follow-up surgery,24925,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Amputation follow-up surgery,24925,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Amputation follow-up surgery,24925,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Amputation follow-up surgery,24925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Amputation follow-up surgery,24925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Amputation follow-up surgery,24925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Amputation follow-up surgery,24925,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Amputation follow-up surgery,24930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Amputation follow-up surgery,24930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Amputation follow-up surgery,24930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Amputation follow-up surgery,24930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Amputation follow-up surgery,24930,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Amputation follow-up surgery,24930,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Amputation follow-up surgery,24930,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Amputation follow-up surgery,24930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Amputation follow-up surgery,24930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Amputation follow-up surgery,24930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Amputation follow-up surgery,24930,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Amputate upper arm & implant,24931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46549.79,,,,,,,fee schedule,12709.88,56389.43,
Amputate upper arm & implant,24931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37313.72,,,,,,,fee schedule,12709.88,56389.43,
Amputate upper arm & implant,24931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40761.86,,,,,,,fee schedule,12709.88,56389.43,
Amputate upper arm & implant,24931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42855.36,,,,,,,fee schedule,12709.88,56389.43,
Amputate upper arm & implant,24931,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,12709.88,56389.43,APC 378
Amputate upper arm & implant,24931,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,12709.88,56389.43,APC
Amputate upper arm & implant,24931,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,12709.88,56389.43,APC
Amputate upper arm & implant,24931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,12709.88,56389.43,APC
Amputate upper arm & implant,24931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,12709.88,56389.43,Radiology
Amputate upper arm & implant,24931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,12709.88,56389.43,APC
Amputate upper arm & implant,24931,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,12709.88,56389.43,APC
Revision of amputation,24935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19822.36,,,,,,,fee schedule,7183.42,31870.39,
Revision of amputation,24935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15889.35,,,,,,,fee schedule,7183.42,31870.39,
Revision of amputation,24935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17357.67,,,,,,,fee schedule,7183.42,31870.39,
Revision of amputation,24935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18249.15,,,,,,,fee schedule,7183.42,31870.39,
Revision of amputation,24935,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Revision of amputation,24935,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Revision of amputation,24935,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Revision of amputation,24935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Revision of amputation,24935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Revision of amputation,24935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Revision of amputation,24935,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Revision of upper arm,24940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46549.79,,,,,,,fee schedule,12709.88,56389.43,
Revision of upper arm,24940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37313.72,,,,,,,fee schedule,12709.88,56389.43,
Revision of upper arm,24940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40761.86,,,,,,,fee schedule,12709.88,56389.43,
Revision of upper arm,24940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42855.36,,,,,,,fee schedule,12709.88,56389.43,
Revision of upper arm,24940,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,12709.88,56389.43,APC 378
Revision of upper arm,24940,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,12709.88,56389.43,APC
Revision of upper arm,24940,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,12709.88,56389.43,APC
Revision of upper arm,24940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,12709.88,56389.43,APC
Revision of upper arm,24940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,12709.88,56389.43,Radiology
Revision of upper arm,24940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,12709.88,56389.43,APC
Revision of upper arm,24940,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,12709.88,56389.43,APC
Upper arm/elbow surgery,24999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,244.19,1083.4,
Upper arm/elbow surgery,24999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,244.19,1083.4,
Upper arm/elbow surgery,24999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,244.19,1083.4,
Upper arm/elbow surgery,24999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,244.19,1083.4,
Upper arm/elbow surgery,24999,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Upper arm/elbow surgery,24999,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Upper arm/elbow surgery,24999,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Upper arm/elbow surgery,24999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Upper arm/elbow surgery,24999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Upper arm/elbow surgery,24999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Upper arm/elbow surgery,24999,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Incision of tendon sheath,25000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6721.57,,,,,,,fee schedule,1591.86,7062.54,
Incision of tendon sheath,25000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5387.93,,,,,,,fee schedule,1591.86,7062.54,
Incision of tendon sheath,25000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5885.82,,,,,,,fee schedule,1591.86,7062.54,
Incision of tendon sheath,25000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6188.11,,,,,,,fee schedule,1591.86,7062.54,
Incision of tendon sheath,25000,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Incision of tendon sheath,25000,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Incision of tendon sheath,25000,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Incision of tendon sheath,25000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Incision of tendon sheath,25000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Incision of tendon sheath,25000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Incision of tendon sheath,25000,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Incise flexor carpi radialis,25001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,3239.17,14371.12,
Incise flexor carpi radialis,25001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,3239.17,14371.12,
Incise flexor carpi radialis,25001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,3239.17,14371.12,
Incise flexor carpi radialis,25001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,3239.17,14371.12,
Incise flexor carpi radialis,25001,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Incise flexor carpi radialis,25001,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Incise flexor carpi radialis,25001,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Incise flexor carpi radialis,25001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Incise flexor carpi radialis,25001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Incise flexor carpi radialis,25001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Incise flexor carpi radialis,25001,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Decompress forearm 1 space,25020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,1591.86,7062.54,
Decompress forearm 1 space,25020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,1591.86,7062.54,
Decompress forearm 1 space,25020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,1591.86,7062.54,
Decompress forearm 1 space,25020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,1591.86,7062.54,
Decompress forearm 1 space,25020,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Decompress forearm 1 space,25020,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Decompress forearm 1 space,25020,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Decompress forearm 1 space,25020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Decompress forearm 1 space,25020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Decompress forearm 1 space,25020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Decompress forearm 1 space,25020,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Decompress forearm 1 space,25023,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,3239.17,14371.12,
Decompress forearm 1 space,25023,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,3239.17,14371.12,
Decompress forearm 1 space,25023,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,3239.17,14371.12,
Decompress forearm 1 space,25023,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,3239.17,14371.12,
Decompress forearm 1 space,25023,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Decompress forearm 1 space,25023,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Decompress forearm 1 space,25023,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Decompress forearm 1 space,25023,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Decompress forearm 1 space,25023,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Decompress forearm 1 space,25023,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Decompress forearm 1 space,25023,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Decompress forearm 2 spaces,25024,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,3239.17,14371.12,
Decompress forearm 2 spaces,25024,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,3239.17,14371.12,
Decompress forearm 2 spaces,25024,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,3239.17,14371.12,
Decompress forearm 2 spaces,25024,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,3239.17,14371.12,
Decompress forearm 2 spaces,25024,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Decompress forearm 2 spaces,25024,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Decompress forearm 2 spaces,25024,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Decompress forearm 2 spaces,25024,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Decompress forearm 2 spaces,25024,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Decompress forearm 2 spaces,25024,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Decompress forearm 2 spaces,25024,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Decompress forearm 2 spaces,25025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,1591.86,7285.12,
Decompress forearm 2 spaces,25025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,1591.86,7285.12,
Decompress forearm 2 spaces,25025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,1591.86,7285.12,
Decompress forearm 2 spaces,25025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,1591.86,7285.12,
Decompress forearm 2 spaces,25025,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7285.12,APC 378
Decompress forearm 2 spaces,25025,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7285.12,APC
Decompress forearm 2 spaces,25025,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7285.12,APC
Decompress forearm 2 spaces,25025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7285.12,APC
Decompress forearm 2 spaces,25025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7285.12,Radiology
Decompress forearm 2 spaces,25025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7285.12,APC
Decompress forearm 2 spaces,25025,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7285.12,APC
Drainage of forearm lesion,25028,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,3239.17,14371.12,
Drainage of forearm lesion,25028,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,3239.17,14371.12,
Drainage of forearm lesion,25028,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,3239.17,14371.12,
Drainage of forearm lesion,25028,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,3239.17,14371.12,
Drainage of forearm lesion,25028,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Drainage of forearm lesion,25028,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Drainage of forearm lesion,25028,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Drainage of forearm lesion,25028,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Drainage of forearm lesion,25028,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Drainage of forearm lesion,25028,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Drainage of forearm lesion,25028,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Drainage of forearm bursa,25031,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,1591.86,7062.54,
Drainage of forearm bursa,25031,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,1591.86,7062.54,
Drainage of forearm bursa,25031,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,1591.86,7062.54,
Drainage of forearm bursa,25031,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,1591.86,7062.54,
Drainage of forearm bursa,25031,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Drainage of forearm bursa,25031,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Drainage of forearm bursa,25031,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Drainage of forearm bursa,25031,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Drainage of forearm bursa,25031,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Drainage of forearm bursa,25031,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Drainage of forearm bursa,25031,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Treat forearm bone lesion,25035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,4254.97,31870.39,
Treat forearm bone lesion,25035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,4254.97,31870.39,
Treat forearm bone lesion,25035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,4254.97,31870.39,
Treat forearm bone lesion,25035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,4254.97,31870.39,
Treat forearm bone lesion,25035,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,4254.97,31870.39,APC 378
Treat forearm bone lesion,25035,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,4254.97,31870.39,APC
Treat forearm bone lesion,25035,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,4254.97,31870.39,APC
Treat forearm bone lesion,25035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,4254.97,31870.39,APC
Treat forearm bone lesion,25035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,4254.97,31870.39,Radiology
Treat forearm bone lesion,25035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,4254.97,31870.39,APC
Treat forearm bone lesion,25035,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,4254.97,31870.39,APC
Explore/treat wrist joint,25040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,3239.17,14371.12,
Explore/treat wrist joint,25040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,3239.17,14371.12,
Explore/treat wrist joint,25040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,3239.17,14371.12,
Explore/treat wrist joint,25040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,3239.17,14371.12,
Explore/treat wrist joint,25040,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Explore/treat wrist joint,25040,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Explore/treat wrist joint,25040,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Explore/treat wrist joint,25040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Explore/treat wrist joint,25040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Explore/treat wrist joint,25040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Explore/treat wrist joint,25040,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Biopsy forearm soft tissues,25065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2167.57,,,,,,,fee schedule,1635.03,7254.06,
Biopsy forearm soft tissues,25065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1737.49,,,,,,,fee schedule,1635.03,7254.06,
Biopsy forearm soft tissues,25065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1898.05,,,,,,,fee schedule,1635.03,7254.06,
Biopsy forearm soft tissues,25065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1995.54,,,,,,,fee schedule,1635.03,7254.06,
Biopsy forearm soft tissues,25065,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,7254.06,APC 378
Biopsy forearm soft tissues,25065,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,7254.06,APC
Biopsy forearm soft tissues,25065,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,7254.06,APC
Biopsy forearm soft tissues,25065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,7254.06,APC
Biopsy forearm soft tissues,25065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,7254.06,Radiology
Biopsy forearm soft tissues,25065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,7254.06,APC
Biopsy forearm soft tissues,25065,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,7254.06,APC
Biopsy forearm soft tissues,25066,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5268.49,,,,,,,fee schedule,2875.57,12757.95,
Biopsy forearm soft tissues,25066,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4223.15,,,,,,,fee schedule,2875.57,12757.95,
Biopsy forearm soft tissues,25066,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4613.41,,,,,,,fee schedule,2875.57,12757.95,
Biopsy forearm soft tissues,25066,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4850.35,,,,,,,fee schedule,2875.57,12757.95,
Biopsy forearm soft tissues,25066,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Biopsy forearm soft tissues,25066,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Biopsy forearm soft tissues,25066,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Biopsy forearm soft tissues,25066,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Biopsy forearm soft tissues,25066,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Biopsy forearm soft tissues,25066,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Biopsy forearm soft tissues,25066,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Exc forearm les sc 3 cm/>,25071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2743.97,,,,,,,fee schedule,1635.03,7254.06,
Exc forearm les sc 3 cm/>,25071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2199.54,,,,,,,fee schedule,1635.03,7254.06,
Exc forearm les sc 3 cm/>,25071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2402.79,,,,,,,fee schedule,1635.03,7254.06,
Exc forearm les sc 3 cm/>,25071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2526.2,,,,,,,fee schedule,1635.03,7254.06,
Exc forearm les sc 3 cm/>,25071,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,7254.06,APC 378
Exc forearm les sc 3 cm/>,25071,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,7254.06,APC
Exc forearm les sc 3 cm/>,25071,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,7254.06,APC
Exc forearm les sc 3 cm/>,25071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,7254.06,APC
Exc forearm les sc 3 cm/>,25071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,7254.06,Radiology
Exc forearm les sc 3 cm/>,25071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,7254.06,APC
Exc forearm les sc 3 cm/>,25071,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,7254.06,APC
Exc forearm tum deep 3 cm/>,25073,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6177.24,,,,,,,fee schedule,2875.57,12757.95,
Exc forearm tum deep 3 cm/>,25073,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4951.6,,,,,,,fee schedule,2875.57,12757.95,
Exc forearm tum deep 3 cm/>,25073,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5409.17,,,,,,,fee schedule,2875.57,12757.95,
Exc forearm tum deep 3 cm/>,25073,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5686.98,,,,,,,fee schedule,2875.57,12757.95,
Exc forearm tum deep 3 cm/>,25073,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Exc forearm tum deep 3 cm/>,25073,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Exc forearm tum deep 3 cm/>,25073,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Exc forearm tum deep 3 cm/>,25073,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Exc forearm tum deep 3 cm/>,25073,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Exc forearm tum deep 3 cm/>,25073,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Exc forearm tum deep 3 cm/>,25073,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Exc forearm les sc < 3 cm,25075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,958.62,,,,,,,fee schedule,768.42,7254.06,
Exc forearm les sc < 3 cm,25075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,768.42,,,,,,,fee schedule,768.42,7254.06,
Exc forearm les sc < 3 cm,25075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,839.43,,,,,,,fee schedule,768.42,7254.06,
Exc forearm les sc < 3 cm,25075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,882.54,,,,,,,fee schedule,768.42,7254.06,
Exc forearm les sc < 3 cm,25075,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,768.42,7254.06,APC 378
Exc forearm les sc < 3 cm,25075,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,768.42,7254.06,APC
Exc forearm les sc < 3 cm,25075,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,768.42,7254.06,APC
Exc forearm les sc < 3 cm,25075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,768.42,7254.06,APC
Exc forearm les sc < 3 cm,25075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,768.42,7254.06,Radiology
Exc forearm les sc < 3 cm,25075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,768.42,7254.06,APC
Exc forearm les sc < 3 cm,25075,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,768.42,7254.06,APC
Exc forearm tum deep < 3 cm,25076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6721.57,,,,,,,fee schedule,1635.03,7254.06,
Exc forearm tum deep < 3 cm,25076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5387.93,,,,,,,fee schedule,1635.03,7254.06,
Exc forearm tum deep < 3 cm,25076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5885.82,,,,,,,fee schedule,1635.03,7254.06,
Exc forearm tum deep < 3 cm,25076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6188.11,,,,,,,fee schedule,1635.03,7254.06,
Exc forearm tum deep < 3 cm,25076,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,7254.06,APC 378
Exc forearm tum deep < 3 cm,25076,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,7254.06,APC
Exc forearm tum deep < 3 cm,25076,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,7254.06,APC
Exc forearm tum deep < 3 cm,25076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,7254.06,APC
Exc forearm tum deep < 3 cm,25076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,7254.06,Radiology
Exc forearm tum deep < 3 cm,25076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,7254.06,APC
Exc forearm tum deep < 3 cm,25076,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,7254.06,APC
Resect forearm/wrist tum<3cm,25077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5268.49,,,,,,,fee schedule,2875.57,12757.95,
Resect forearm/wrist tum<3cm,25077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4223.15,,,,,,,fee schedule,2875.57,12757.95,
Resect forearm/wrist tum<3cm,25077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4613.41,,,,,,,fee schedule,2875.57,12757.95,
Resect forearm/wrist tum<3cm,25077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4850.35,,,,,,,fee schedule,2875.57,12757.95,
Resect forearm/wrist tum<3cm,25077,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Resect forearm/wrist tum<3cm,25077,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Resect forearm/wrist tum<3cm,25077,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Resect forearm/wrist tum<3cm,25077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Resect forearm/wrist tum<3cm,25077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Resect forearm/wrist tum<3cm,25077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Resect forearm/wrist tum<3cm,25077,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Resect forarm/wrist tum 3cm>,25078,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6177.24,,,,,,,fee schedule,2875.57,12757.95,
Resect forarm/wrist tum 3cm>,25078,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4951.6,,,,,,,fee schedule,2875.57,12757.95,
Resect forarm/wrist tum 3cm>,25078,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5409.17,,,,,,,fee schedule,2875.57,12757.95,
Resect forarm/wrist tum 3cm>,25078,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5686.98,,,,,,,fee schedule,2875.57,12757.95,
Resect forarm/wrist tum 3cm>,25078,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Resect forarm/wrist tum 3cm>,25078,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Resect forarm/wrist tum 3cm>,25078,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Resect forarm/wrist tum 3cm>,25078,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Resect forarm/wrist tum 3cm>,25078,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Resect forarm/wrist tum 3cm>,25078,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Resect forarm/wrist tum 3cm>,25078,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Incision of wrist capsule,25085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,3239.17,14371.12,
Incision of wrist capsule,25085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,3239.17,14371.12,
Incision of wrist capsule,25085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,3239.17,14371.12,
Incision of wrist capsule,25085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,3239.17,14371.12,
Incision of wrist capsule,25085,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Incision of wrist capsule,25085,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Incision of wrist capsule,25085,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Incision of wrist capsule,25085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Incision of wrist capsule,25085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Incision of wrist capsule,25085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Incision of wrist capsule,25085,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Biopsy of wrist joint,25100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,3239.17,14371.12,
Biopsy of wrist joint,25100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,3239.17,14371.12,
Biopsy of wrist joint,25100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,3239.17,14371.12,
Biopsy of wrist joint,25100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,3239.17,14371.12,
Biopsy of wrist joint,25100,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Biopsy of wrist joint,25100,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Biopsy of wrist joint,25100,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Biopsy of wrist joint,25100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Biopsy of wrist joint,25100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Biopsy of wrist joint,25100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Biopsy of wrist joint,25100,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Explore/treat wrist joint,25101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6253.46,,,,,,,fee schedule,3239.17,14371.12,
Explore/treat wrist joint,25101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5012.69,,,,,,,fee schedule,3239.17,14371.12,
Explore/treat wrist joint,25101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5475.91,,,,,,,fee schedule,3239.17,14371.12,
Explore/treat wrist joint,25101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5757.15,,,,,,,fee schedule,3239.17,14371.12,
Explore/treat wrist joint,25101,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Explore/treat wrist joint,25101,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Explore/treat wrist joint,25101,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Explore/treat wrist joint,25101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Explore/treat wrist joint,25101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Explore/treat wrist joint,25101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Explore/treat wrist joint,25101,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Remove wrist joint lining,25105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,3239.17,14371.12,
Remove wrist joint lining,25105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,3239.17,14371.12,
Remove wrist joint lining,25105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,3239.17,14371.12,
Remove wrist joint lining,25105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,3239.17,14371.12,
Remove wrist joint lining,25105,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Remove wrist joint lining,25105,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Remove wrist joint lining,25105,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Remove wrist joint lining,25105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Remove wrist joint lining,25105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Remove wrist joint lining,25105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Remove wrist joint lining,25105,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Remove wrist joint cartilage,25107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,3239.17,14371.12,
Remove wrist joint cartilage,25107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,3239.17,14371.12,
Remove wrist joint cartilage,25107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,3239.17,14371.12,
Remove wrist joint cartilage,25107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,3239.17,14371.12,
Remove wrist joint cartilage,25107,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Remove wrist joint cartilage,25107,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Remove wrist joint cartilage,25107,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Remove wrist joint cartilage,25107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Remove wrist joint cartilage,25107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Remove wrist joint cartilage,25107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Remove wrist joint cartilage,25107,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Excise tendon forearm/wrist,25109,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,3239.17,14371.12,
Excise tendon forearm/wrist,25109,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,3239.17,14371.12,
Excise tendon forearm/wrist,25109,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,3239.17,14371.12,
Excise tendon forearm/wrist,25109,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,3239.17,14371.12,
Excise tendon forearm/wrist,25109,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Excise tendon forearm/wrist,25109,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Excise tendon forearm/wrist,25109,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Excise tendon forearm/wrist,25109,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Excise tendon forearm/wrist,25109,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Excise tendon forearm/wrist,25109,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Excise tendon forearm/wrist,25109,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Remove wrist tendon lesion,25110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,1591.86,7062.54,
Remove wrist tendon lesion,25110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,1591.86,7062.54,
Remove wrist tendon lesion,25110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,1591.86,7062.54,
Remove wrist tendon lesion,25110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,1591.86,7062.54,
Remove wrist tendon lesion,25110,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Remove wrist tendon lesion,25110,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Remove wrist tendon lesion,25110,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Remove wrist tendon lesion,25110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Remove wrist tendon lesion,25110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Remove wrist tendon lesion,25110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Remove wrist tendon lesion,25110,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Remove wrist tendon lesion,25111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6721.57,,,,,,,fee schedule,1591.86,7062.54,
Remove wrist tendon lesion,25111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5387.93,,,,,,,fee schedule,1591.86,7062.54,
Remove wrist tendon lesion,25111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5885.82,,,,,,,fee schedule,1591.86,7062.54,
Remove wrist tendon lesion,25111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6188.11,,,,,,,fee schedule,1591.86,7062.54,
Remove wrist tendon lesion,25111,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Remove wrist tendon lesion,25111,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Remove wrist tendon lesion,25111,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Remove wrist tendon lesion,25111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Remove wrist tendon lesion,25111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Remove wrist tendon lesion,25111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Remove wrist tendon lesion,25111,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Reremove wrist tendon lesion,25112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4108.94,,,,,,,fee schedule,1591.86,7062.54,
Reremove wrist tendon lesion,25112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3293.67,,,,,,,fee schedule,1591.86,7062.54,
Reremove wrist tendon lesion,25112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3598.04,,,,,,,fee schedule,1591.86,7062.54,
Reremove wrist tendon lesion,25112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3782.83,,,,,,,fee schedule,1591.86,7062.54,
Reremove wrist tendon lesion,25112,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Reremove wrist tendon lesion,25112,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Reremove wrist tendon lesion,25112,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Reremove wrist tendon lesion,25112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Reremove wrist tendon lesion,25112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Reremove wrist tendon lesion,25112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Reremove wrist tendon lesion,25112,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Remove wrist/forearm lesion,25115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,1591.86,7062.54,
Remove wrist/forearm lesion,25115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,1591.86,7062.54,
Remove wrist/forearm lesion,25115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,1591.86,7062.54,
Remove wrist/forearm lesion,25115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,1591.86,7062.54,
Remove wrist/forearm lesion,25115,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Remove wrist/forearm lesion,25115,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Remove wrist/forearm lesion,25115,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Remove wrist/forearm lesion,25115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Remove wrist/forearm lesion,25115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Remove wrist/forearm lesion,25115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Remove wrist/forearm lesion,25115,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Remove wrist/forearm lesion,25116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,3239.17,14371.12,
Remove wrist/forearm lesion,25116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,3239.17,14371.12,
Remove wrist/forearm lesion,25116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,3239.17,14371.12,
Remove wrist/forearm lesion,25116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,3239.17,14371.12,
Remove wrist/forearm lesion,25116,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Remove wrist/forearm lesion,25116,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Remove wrist/forearm lesion,25116,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Remove wrist/forearm lesion,25116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Remove wrist/forearm lesion,25116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Remove wrist/forearm lesion,25116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Remove wrist/forearm lesion,25116,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Excise wrist tendon sheath,25118,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,1591.86,7285.12,
Excise wrist tendon sheath,25118,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,1591.86,7285.12,
Excise wrist tendon sheath,25118,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,1591.86,7285.12,
Excise wrist tendon sheath,25118,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,1591.86,7285.12,
Excise wrist tendon sheath,25118,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7285.12,APC 378
Excise wrist tendon sheath,25118,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7285.12,APC
Excise wrist tendon sheath,25118,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7285.12,APC
Excise wrist tendon sheath,25118,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7285.12,APC
Excise wrist tendon sheath,25118,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7285.12,Radiology
Excise wrist tendon sheath,25118,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7285.12,APC
Excise wrist tendon sheath,25118,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7285.12,APC
Partial removal of ulna,25119,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,3239.17,14371.12,
Partial removal of ulna,25119,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,3239.17,14371.12,
Partial removal of ulna,25119,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,3239.17,14371.12,
Partial removal of ulna,25119,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,3239.17,14371.12,
Partial removal of ulna,25119,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Partial removal of ulna,25119,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Partial removal of ulna,25119,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Partial removal of ulna,25119,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Partial removal of ulna,25119,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Partial removal of ulna,25119,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Partial removal of ulna,25119,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of forearm lesion,25120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10205.34,,,,,,,fee schedule,3239.17,14371.12,
Removal of forearm lesion,25120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8180.47,,,,,,,fee schedule,3239.17,14371.12,
Removal of forearm lesion,25120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8936.43,,,,,,,fee schedule,3239.17,14371.12,
Removal of forearm lesion,25120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9395.4,,,,,,,fee schedule,3239.17,14371.12,
Removal of forearm lesion,25120,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Removal of forearm lesion,25120,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of forearm lesion,25120,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of forearm lesion,25120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of forearm lesion,25120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Removal of forearm lesion,25120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of forearm lesion,25120,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Remove/graft forearm lesion,25125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,1591.86,7285.12,
Remove/graft forearm lesion,25125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,1591.86,7285.12,
Remove/graft forearm lesion,25125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,1591.86,7285.12,
Remove/graft forearm lesion,25125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,1591.86,7285.12,
Remove/graft forearm lesion,25125,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7285.12,APC 378
Remove/graft forearm lesion,25125,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7285.12,APC
Remove/graft forearm lesion,25125,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7285.12,APC
Remove/graft forearm lesion,25125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7285.12,APC
Remove/graft forearm lesion,25125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7285.12,Radiology
Remove/graft forearm lesion,25125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7285.12,APC
Remove/graft forearm lesion,25125,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7285.12,APC
Remove/graft forearm lesion,25126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,3239.17,14371.12,
Remove/graft forearm lesion,25126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,3239.17,14371.12,
Remove/graft forearm lesion,25126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,3239.17,14371.12,
Remove/graft forearm lesion,25126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,3239.17,14371.12,
Remove/graft forearm lesion,25126,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Remove/graft forearm lesion,25126,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Remove/graft forearm lesion,25126,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Remove/graft forearm lesion,25126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Remove/graft forearm lesion,25126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Remove/graft forearm lesion,25126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Remove/graft forearm lesion,25126,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of wrist lesion,25130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,3239.17,14371.12,
Removal of wrist lesion,25130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,3239.17,14371.12,
Removal of wrist lesion,25130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,3239.17,14371.12,
Removal of wrist lesion,25130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,3239.17,14371.12,
Removal of wrist lesion,25130,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Removal of wrist lesion,25130,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of wrist lesion,25130,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of wrist lesion,25130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of wrist lesion,25130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Removal of wrist lesion,25130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of wrist lesion,25130,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Remove & graft wrist lesion,25135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,5839.66,31870.39,
Remove & graft wrist lesion,25135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,5839.66,31870.39,
Remove & graft wrist lesion,25135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,5839.66,31870.39,
Remove & graft wrist lesion,25135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,5839.66,31870.39,
Remove & graft wrist lesion,25135,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5839.66,31870.39,APC 378
Remove & graft wrist lesion,25135,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5839.66,31870.39,APC
Remove & graft wrist lesion,25135,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5839.66,31870.39,APC
Remove & graft wrist lesion,25135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5839.66,31870.39,APC
Remove & graft wrist lesion,25135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5839.66,31870.39,Radiology
Remove & graft wrist lesion,25135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5839.66,31870.39,APC
Remove & graft wrist lesion,25135,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5839.66,31870.39,APC
Remove & graft wrist lesion,25136,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,5839.66,31870.39,
Remove & graft wrist lesion,25136,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,5839.66,31870.39,
Remove & graft wrist lesion,25136,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,5839.66,31870.39,
Remove & graft wrist lesion,25136,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,5839.66,31870.39,
Remove & graft wrist lesion,25136,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5839.66,31870.39,APC 378
Remove & graft wrist lesion,25136,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5839.66,31870.39,APC
Remove & graft wrist lesion,25136,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5839.66,31870.39,APC
Remove & graft wrist lesion,25136,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5839.66,31870.39,APC
Remove & graft wrist lesion,25136,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5839.66,31870.39,Radiology
Remove & graft wrist lesion,25136,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5839.66,31870.39,APC
Remove & graft wrist lesion,25136,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5839.66,31870.39,APC
Remove forearm bone lesion,25145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,3239.17,14371.12,
Remove forearm bone lesion,25145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,3239.17,14371.12,
Remove forearm bone lesion,25145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,3239.17,14371.12,
Remove forearm bone lesion,25145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,3239.17,14371.12,
Remove forearm bone lesion,25145,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Remove forearm bone lesion,25145,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Remove forearm bone lesion,25145,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Remove forearm bone lesion,25145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Remove forearm bone lesion,25145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Remove forearm bone lesion,25145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Remove forearm bone lesion,25145,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Partial removal of ulna,25150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,3239.17,14371.12,
Partial removal of ulna,25150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,3239.17,14371.12,
Partial removal of ulna,25150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,3239.17,14371.12,
Partial removal of ulna,25150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,3239.17,14371.12,
Partial removal of ulna,25150,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Partial removal of ulna,25150,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Partial removal of ulna,25150,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Partial removal of ulna,25150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Partial removal of ulna,25150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Partial removal of ulna,25150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Partial removal of ulna,25150,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Partial removal of radius,25151,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,3239.17,14371.12,
Partial removal of radius,25151,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,3239.17,14371.12,
Partial removal of radius,25151,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,3239.17,14371.12,
Partial removal of radius,25151,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,3239.17,14371.12,
Partial removal of radius,25151,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Partial removal of radius,25151,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Partial removal of radius,25151,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Partial removal of radius,25151,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Partial removal of radius,25151,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Partial removal of radius,25151,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Partial removal of radius,25151,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Resect radius/ulnar tumor,25170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10728.02,,,,,,,fee schedule,7183.42,31870.39,
Resect radius/ulnar tumor,25170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8599.44,,,,,,,fee schedule,7183.42,31870.39,
Resect radius/ulnar tumor,25170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9394.11,,,,,,,fee schedule,7183.42,31870.39,
Resect radius/ulnar tumor,25170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9876.59,,,,,,,fee schedule,7183.42,31870.39,
Resect radius/ulnar tumor,25170,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Resect radius/ulnar tumor,25170,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Resect radius/ulnar tumor,25170,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Resect radius/ulnar tumor,25170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Resect radius/ulnar tumor,25170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Resect radius/ulnar tumor,25170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Resect radius/ulnar tumor,25170,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Removal of wrist bone,25210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6566.46,,,,,,,fee schedule,3239.17,14371.12,
Removal of wrist bone,25210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5263.59,,,,,,,fee schedule,3239.17,14371.12,
Removal of wrist bone,25210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5750,,,,,,,fee schedule,3239.17,14371.12,
Removal of wrist bone,25210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6045.32,,,,,,,fee schedule,3239.17,14371.12,
Removal of wrist bone,25210,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Removal of wrist bone,25210,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of wrist bone,25210,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of wrist bone,25210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of wrist bone,25210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Removal of wrist bone,25210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of wrist bone,25210,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of wrist bones,25215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6566.46,,,,,,,fee schedule,3239.17,14371.12,
Removal of wrist bones,25215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5263.59,,,,,,,fee schedule,3239.17,14371.12,
Removal of wrist bones,25215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5750,,,,,,,fee schedule,3239.17,14371.12,
Removal of wrist bones,25215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6045.32,,,,,,,fee schedule,3239.17,14371.12,
Removal of wrist bones,25215,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Removal of wrist bones,25215,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of wrist bones,25215,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of wrist bones,25215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of wrist bones,25215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Removal of wrist bones,25215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of wrist bones,25215,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Partial removal of radius,25230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4297.02,,,,,,,fee schedule,3239.17,14371.12,
Partial removal of radius,25230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3444.43,,,,,,,fee schedule,3239.17,14371.12,
Partial removal of radius,25230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3762.73,,,,,,,fee schedule,3239.17,14371.12,
Partial removal of radius,25230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3955.98,,,,,,,fee schedule,3239.17,14371.12,
Partial removal of radius,25230,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Partial removal of radius,25230,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Partial removal of radius,25230,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Partial removal of radius,25230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Partial removal of radius,25230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Partial removal of radius,25230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Partial removal of radius,25230,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Partial removal of ulna,25240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3539.04,,,,,,,fee schedule,2836.85,14371.12,
Partial removal of ulna,25240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2836.85,,,,,,,fee schedule,2836.85,14371.12,
Partial removal of ulna,25240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3099,,,,,,,fee schedule,2836.85,14371.12,
Partial removal of ulna,25240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3258.16,,,,,,,fee schedule,2836.85,14371.12,
Partial removal of ulna,25240,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,2836.85,14371.12,APC 378
Partial removal of ulna,25240,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,2836.85,14371.12,APC
Partial removal of ulna,25240,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,2836.85,14371.12,APC
Partial removal of ulna,25240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,2836.85,14371.12,APC
Partial removal of ulna,25240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,2836.85,14371.12,Radiology
Partial removal of ulna,25240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,2836.85,14371.12,APC
Partial removal of ulna,25240,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,2836.85,14371.12,APC
Remove forearm foreign body,25248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,1591.86,7062.54,
Remove forearm foreign body,25248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,1591.86,7062.54,
Remove forearm foreign body,25248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,1591.86,7062.54,
Remove forearm foreign body,25248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,1591.86,7062.54,
Remove forearm foreign body,25248,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Remove forearm foreign body,25248,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Remove forearm foreign body,25248,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Remove forearm foreign body,25248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Remove forearm foreign body,25248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Remove forearm foreign body,25248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Remove forearm foreign body,25248,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Removal of wrist prosthesis,25250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,1591.86,7285.12,
Removal of wrist prosthesis,25250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,1591.86,7285.12,
Removal of wrist prosthesis,25250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,1591.86,7285.12,
Removal of wrist prosthesis,25250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,1591.86,7285.12,
Removal of wrist prosthesis,25250,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7285.12,APC 378
Removal of wrist prosthesis,25250,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7285.12,APC
Removal of wrist prosthesis,25250,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7285.12,APC
Removal of wrist prosthesis,25250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7285.12,APC
Removal of wrist prosthesis,25250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7285.12,Radiology
Removal of wrist prosthesis,25250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7285.12,APC
Removal of wrist prosthesis,25250,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7285.12,APC
Removal of wrist prosthesis,25251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,3239.17,14371.12,
Removal of wrist prosthesis,25251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,3239.17,14371.12,
Removal of wrist prosthesis,25251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,3239.17,14371.12,
Removal of wrist prosthesis,25251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,3239.17,14371.12,
Removal of wrist prosthesis,25251,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Removal of wrist prosthesis,25251,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of wrist prosthesis,25251,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of wrist prosthesis,25251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of wrist prosthesis,25251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Removal of wrist prosthesis,25251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of wrist prosthesis,25251,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Manipulate wrist w/anesthes,25259,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,353.72,7062.54,
Manipulate wrist w/anesthes,25259,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,353.72,7062.54,
Manipulate wrist w/anesthes,25259,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,353.72,7062.54,
Manipulate wrist w/anesthes,25259,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,353.72,7062.54,
Manipulate wrist w/anesthes,25259,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,353.72,7062.54,APC 378
Manipulate wrist w/anesthes,25259,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,353.72,7062.54,APC
Manipulate wrist w/anesthes,25259,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,353.72,7062.54,APC
Manipulate wrist w/anesthes,25259,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,353.72,7062.54,APC
Manipulate wrist w/anesthes,25259,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,353.72,7062.54,Radiology
Manipulate wrist w/anesthes,25259,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,353.72,7062.54,APC
Manipulate wrist w/anesthes,25259,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,353.72,7062.54,APC
Repair forearm tendon/muscle,25260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,3239.17,14371.12,
Repair forearm tendon/muscle,25260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,3239.17,14371.12,
Repair forearm tendon/muscle,25260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,3239.17,14371.12,
Repair forearm tendon/muscle,25260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,3239.17,14371.12,
Repair forearm tendon/muscle,25260,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Repair forearm tendon/muscle,25260,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Repair forearm tendon/muscle,25260,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Repair forearm tendon/muscle,25260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Repair forearm tendon/muscle,25260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Repair forearm tendon/muscle,25260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Repair forearm tendon/muscle,25260,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Repair forearm tendon/muscle,25263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,5839.66,31870.39,
Repair forearm tendon/muscle,25263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,5839.66,31870.39,
Repair forearm tendon/muscle,25263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,5839.66,31870.39,
Repair forearm tendon/muscle,25263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,5839.66,31870.39,
Repair forearm tendon/muscle,25263,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5839.66,31870.39,APC 378
Repair forearm tendon/muscle,25263,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5839.66,31870.39,APC
Repair forearm tendon/muscle,25263,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5839.66,31870.39,APC
Repair forearm tendon/muscle,25263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5839.66,31870.39,APC
Repair forearm tendon/muscle,25263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5839.66,31870.39,Radiology
Repair forearm tendon/muscle,25263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5839.66,31870.39,APC
Repair forearm tendon/muscle,25263,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5839.66,31870.39,APC
Repair forearm tendon/muscle,25265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,3239.17,14371.12,
Repair forearm tendon/muscle,25265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,3239.17,14371.12,
Repair forearm tendon/muscle,25265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,3239.17,14371.12,
Repair forearm tendon/muscle,25265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,3239.17,14371.12,
Repair forearm tendon/muscle,25265,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Repair forearm tendon/muscle,25265,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Repair forearm tendon/muscle,25265,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Repair forearm tendon/muscle,25265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Repair forearm tendon/muscle,25265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Repair forearm tendon/muscle,25265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Repair forearm tendon/muscle,25265,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Repair forearm tendon/muscle,25270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4531.07,,,,,,,fee schedule,3239.17,14371.12,
Repair forearm tendon/muscle,25270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3632.05,,,,,,,fee schedule,3239.17,14371.12,
Repair forearm tendon/muscle,25270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3967.69,,,,,,,fee schedule,3239.17,14371.12,
Repair forearm tendon/muscle,25270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4171.46,,,,,,,fee schedule,3239.17,14371.12,
Repair forearm tendon/muscle,25270,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Repair forearm tendon/muscle,25270,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Repair forearm tendon/muscle,25270,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Repair forearm tendon/muscle,25270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Repair forearm tendon/muscle,25270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Repair forearm tendon/muscle,25270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Repair forearm tendon/muscle,25270,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Repair forearm tendon/muscle,25272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,3239.17,14371.12,
Repair forearm tendon/muscle,25272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,3239.17,14371.12,
Repair forearm tendon/muscle,25272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,3239.17,14371.12,
Repair forearm tendon/muscle,25272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,3239.17,14371.12,
Repair forearm tendon/muscle,25272,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Repair forearm tendon/muscle,25272,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Repair forearm tendon/muscle,25272,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Repair forearm tendon/muscle,25272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Repair forearm tendon/muscle,25272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Repair forearm tendon/muscle,25272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Repair forearm tendon/muscle,25272,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Repair forearm tendon/muscle,25274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,3239.17,14371.12,
Repair forearm tendon/muscle,25274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,3239.17,14371.12,
Repair forearm tendon/muscle,25274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,3239.17,14371.12,
Repair forearm tendon/muscle,25274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,3239.17,14371.12,
Repair forearm tendon/muscle,25274,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Repair forearm tendon/muscle,25274,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Repair forearm tendon/muscle,25274,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Repair forearm tendon/muscle,25274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Repair forearm tendon/muscle,25274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Repair forearm tendon/muscle,25274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Repair forearm tendon/muscle,25274,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Repair forearm tendon sheath,25275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11609.69,,,,,,,fee schedule,3239.17,14371.12,
Repair forearm tendon sheath,25275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9306.18,,,,,,,fee schedule,3239.17,14371.12,
Repair forearm tendon sheath,25275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10166.16,,,,,,,fee schedule,3239.17,14371.12,
Repair forearm tendon sheath,25275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10688.29,,,,,,,fee schedule,3239.17,14371.12,
Repair forearm tendon sheath,25275,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Repair forearm tendon sheath,25275,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Repair forearm tendon sheath,25275,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Repair forearm tendon sheath,25275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Repair forearm tendon sheath,25275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Repair forearm tendon sheath,25275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Repair forearm tendon sheath,25275,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Revise wrist/forearm tendon,25280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,3239.17,14371.12,
Revise wrist/forearm tendon,25280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,3239.17,14371.12,
Revise wrist/forearm tendon,25280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,3239.17,14371.12,
Revise wrist/forearm tendon,25280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,3239.17,14371.12,
Revise wrist/forearm tendon,25280,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Revise wrist/forearm tendon,25280,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Revise wrist/forearm tendon,25280,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Revise wrist/forearm tendon,25280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Revise wrist/forearm tendon,25280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Revise wrist/forearm tendon,25280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Revise wrist/forearm tendon,25280,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Incise wrist/forearm tendon,25290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,3239.17,14371.12,
Incise wrist/forearm tendon,25290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,3239.17,14371.12,
Incise wrist/forearm tendon,25290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,3239.17,14371.12,
Incise wrist/forearm tendon,25290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,3239.17,14371.12,
Incise wrist/forearm tendon,25290,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Incise wrist/forearm tendon,25290,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Incise wrist/forearm tendon,25290,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Incise wrist/forearm tendon,25290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Incise wrist/forearm tendon,25290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Incise wrist/forearm tendon,25290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Incise wrist/forearm tendon,25290,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Release wrist/forearm tendon,25295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,3239.17,14371.12,
Release wrist/forearm tendon,25295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,3239.17,14371.12,
Release wrist/forearm tendon,25295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,3239.17,14371.12,
Release wrist/forearm tendon,25295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,3239.17,14371.12,
Release wrist/forearm tendon,25295,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Release wrist/forearm tendon,25295,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Release wrist/forearm tendon,25295,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Release wrist/forearm tendon,25295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Release wrist/forearm tendon,25295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Release wrist/forearm tendon,25295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Release wrist/forearm tendon,25295,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Fusion of tendons at wrist,25300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,3239.17,14371.12,
Fusion of tendons at wrist,25300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,3239.17,14371.12,
Fusion of tendons at wrist,25300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,3239.17,14371.12,
Fusion of tendons at wrist,25300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,3239.17,14371.12,
Fusion of tendons at wrist,25300,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Fusion of tendons at wrist,25300,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Fusion of tendons at wrist,25300,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Fusion of tendons at wrist,25300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Fusion of tendons at wrist,25300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Fusion of tendons at wrist,25300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Fusion of tendons at wrist,25300,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Fusion of tendons at wrist,25301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,3239.17,14371.12,
Fusion of tendons at wrist,25301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,3239.17,14371.12,
Fusion of tendons at wrist,25301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,3239.17,14371.12,
Fusion of tendons at wrist,25301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,3239.17,14371.12,
Fusion of tendons at wrist,25301,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Fusion of tendons at wrist,25301,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Fusion of tendons at wrist,25301,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Fusion of tendons at wrist,25301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Fusion of tendons at wrist,25301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Fusion of tendons at wrist,25301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Fusion of tendons at wrist,25301,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Transplant forearm tendon,25310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5570.79,,,,,,,fee schedule,3239.17,14371.12,
Transplant forearm tendon,25310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4465.47,,,,,,,fee schedule,3239.17,14371.12,
Transplant forearm tendon,25310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4878.12,,,,,,,fee schedule,3239.17,14371.12,
Transplant forearm tendon,25310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5128.66,,,,,,,fee schedule,3239.17,14371.12,
Transplant forearm tendon,25310,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Transplant forearm tendon,25310,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Transplant forearm tendon,25310,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Transplant forearm tendon,25310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Transplant forearm tendon,25310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Transplant forearm tendon,25310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Transplant forearm tendon,25310,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Transplant forearm tendon,25312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10728.02,,,,,,,fee schedule,3239.17,14371.12,
Transplant forearm tendon,25312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8599.44,,,,,,,fee schedule,3239.17,14371.12,
Transplant forearm tendon,25312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9394.11,,,,,,,fee schedule,3239.17,14371.12,
Transplant forearm tendon,25312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9876.59,,,,,,,fee schedule,3239.17,14371.12,
Transplant forearm tendon,25312,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Transplant forearm tendon,25312,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Transplant forearm tendon,25312,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Transplant forearm tendon,25312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Transplant forearm tendon,25312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Transplant forearm tendon,25312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Transplant forearm tendon,25312,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Revise palsy hand tendon(s),25315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10728.02,,,,,,,fee schedule,7183.42,31870.39,
Revise palsy hand tendon(s),25315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8599.44,,,,,,,fee schedule,7183.42,31870.39,
Revise palsy hand tendon(s),25315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9394.11,,,,,,,fee schedule,7183.42,31870.39,
Revise palsy hand tendon(s),25315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9876.59,,,,,,,fee schedule,7183.42,31870.39,
Revise palsy hand tendon(s),25315,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Revise palsy hand tendon(s),25315,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Revise palsy hand tendon(s),25315,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Revise palsy hand tendon(s),25315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Revise palsy hand tendon(s),25315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Revise palsy hand tendon(s),25315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Revise palsy hand tendon(s),25315,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Revise palsy hand tendon(s),25316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19822.36,,,,,,,fee schedule,7183.42,31870.39,
Revise palsy hand tendon(s),25316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15889.35,,,,,,,fee schedule,7183.42,31870.39,
Revise palsy hand tendon(s),25316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17357.67,,,,,,,fee schedule,7183.42,31870.39,
Revise palsy hand tendon(s),25316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18249.15,,,,,,,fee schedule,7183.42,31870.39,
Revise palsy hand tendon(s),25316,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Revise palsy hand tendon(s),25316,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Revise palsy hand tendon(s),25316,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Revise palsy hand tendon(s),25316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Revise palsy hand tendon(s),25316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Revise palsy hand tendon(s),25316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Revise palsy hand tendon(s),25316,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Repair/revise wrist joint,25320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5116.22,,,,,,,fee schedule,4101.09,31870.39,
Repair/revise wrist joint,25320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4101.09,,,,,,,fee schedule,4101.09,31870.39,
Repair/revise wrist joint,25320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4480.07,,,,,,,fee schedule,4101.09,31870.39,
Repair/revise wrist joint,25320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4710.17,,,,,,,fee schedule,4101.09,31870.39,
Repair/revise wrist joint,25320,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,4101.09,31870.39,APC 378
Repair/revise wrist joint,25320,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,4101.09,31870.39,APC
Repair/revise wrist joint,25320,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,4101.09,31870.39,APC
Repair/revise wrist joint,25320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,4101.09,31870.39,APC
Repair/revise wrist joint,25320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,4101.09,31870.39,Radiology
Repair/revise wrist joint,25320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,4101.09,31870.39,APC
Repair/revise wrist joint,25320,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,4101.09,31870.39,APC
Revise wrist joint,25332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8960.75,,,,,,,fee schedule,3239.17,14371.12,
Revise wrist joint,25332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7182.83,,,,,,,fee schedule,3239.17,14371.12,
Revise wrist joint,25332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7846.59,,,,,,,fee schedule,3239.17,14371.12,
Revise wrist joint,25332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8249.58,,,,,,,fee schedule,3239.17,14371.12,
Revise wrist joint,25332,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Revise wrist joint,25332,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Revise wrist joint,25332,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Revise wrist joint,25332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Revise wrist joint,25332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Revise wrist joint,25332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Revise wrist joint,25332,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Realignment of hand,25335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10728.02,,,,,,,fee schedule,3239.17,14371.12,
Realignment of hand,25335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8599.44,,,,,,,fee schedule,3239.17,14371.12,
Realignment of hand,25335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9394.11,,,,,,,fee schedule,3239.17,14371.12,
Realignment of hand,25335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9876.59,,,,,,,fee schedule,3239.17,14371.12,
Realignment of hand,25335,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Realignment of hand,25335,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Realignment of hand,25335,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Realignment of hand,25335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Realignment of hand,25335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Realignment of hand,25335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Realignment of hand,25335,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Reconstruct ulna/radioulnar,25337,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10728.02,,,,,,,fee schedule,7183.42,31870.39,
Reconstruct ulna/radioulnar,25337,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8599.44,,,,,,,fee schedule,7183.42,31870.39,
Reconstruct ulna/radioulnar,25337,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9394.11,,,,,,,fee schedule,7183.42,31870.39,
Reconstruct ulna/radioulnar,25337,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9876.59,,,,,,,fee schedule,7183.42,31870.39,
Reconstruct ulna/radioulnar,25337,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Reconstruct ulna/radioulnar,25337,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Reconstruct ulna/radioulnar,25337,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Reconstruct ulna/radioulnar,25337,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Reconstruct ulna/radioulnar,25337,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Reconstruct ulna/radioulnar,25337,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Reconstruct ulna/radioulnar,25337,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Revision of radius,25350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19822.36,,,,,,,fee schedule,7183.42,31870.39,
Revision of radius,25350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15889.35,,,,,,,fee schedule,7183.42,31870.39,
Revision of radius,25350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17357.67,,,,,,,fee schedule,7183.42,31870.39,
Revision of radius,25350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18249.15,,,,,,,fee schedule,7183.42,31870.39,
Revision of radius,25350,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Revision of radius,25350,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Revision of radius,25350,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Revision of radius,25350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Revision of radius,25350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Revision of radius,25350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Revision of radius,25350,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Revision of radius,25355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10728.02,,,,,,,fee schedule,3239.17,14371.12,
Revision of radius,25355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8599.44,,,,,,,fee schedule,3239.17,14371.12,
Revision of radius,25355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9394.11,,,,,,,fee schedule,3239.17,14371.12,
Revision of radius,25355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9876.59,,,,,,,fee schedule,3239.17,14371.12,
Revision of radius,25355,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Revision of radius,25355,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Revision of radius,25355,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Revision of radius,25355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Revision of radius,25355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Revision of radius,25355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Revision of radius,25355,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Revision of ulna,25360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,5839.66,31870.39,
Revision of ulna,25360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,5839.66,31870.39,
Revision of ulna,25360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,5839.66,31870.39,
Revision of ulna,25360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,5839.66,31870.39,
Revision of ulna,25360,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5839.66,31870.39,APC 378
Revision of ulna,25360,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5839.66,31870.39,APC
Revision of ulna,25360,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5839.66,31870.39,APC
Revision of ulna,25360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5839.66,31870.39,APC
Revision of ulna,25360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5839.66,31870.39,Radiology
Revision of ulna,25360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5839.66,31870.39,APC
Revision of ulna,25360,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5839.66,31870.39,APC
Revise radius & ulna,25365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,5839.66,56389.43,
Revise radius & ulna,25365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,5839.66,56389.43,
Revise radius & ulna,25365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,5839.66,56389.43,
Revise radius & ulna,25365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,5839.66,56389.43,
Revise radius & ulna,25365,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,5839.66,56389.43,APC 378
Revise radius & ulna,25365,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,5839.66,56389.43,APC
Revise radius & ulna,25365,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,5839.66,56389.43,APC
Revise radius & ulna,25365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,5839.66,56389.43,APC
Revise radius & ulna,25365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,5839.66,56389.43,Radiology
Revise radius & ulna,25365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,5839.66,56389.43,APC
Revise radius & ulna,25365,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,5839.66,56389.43,APC
Revise radius or ulna,25370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10728.02,,,,,,,fee schedule,3239.17,14371.12,
Revise radius or ulna,25370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8599.44,,,,,,,fee schedule,3239.17,14371.12,
Revise radius or ulna,25370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9394.11,,,,,,,fee schedule,3239.17,14371.12,
Revise radius or ulna,25370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9876.59,,,,,,,fee schedule,3239.17,14371.12,
Revise radius or ulna,25370,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Revise radius or ulna,25370,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Revise radius or ulna,25370,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Revise radius or ulna,25370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Revise radius or ulna,25370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Revise radius or ulna,25370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Revise radius or ulna,25370,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Revise radius & ulna,25375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10728.02,,,,,,,fee schedule,3239.17,14371.12,
Revise radius & ulna,25375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8599.44,,,,,,,fee schedule,3239.17,14371.12,
Revise radius & ulna,25375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9394.11,,,,,,,fee schedule,3239.17,14371.12,
Revise radius & ulna,25375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9876.59,,,,,,,fee schedule,3239.17,14371.12,
Revise radius & ulna,25375,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Revise radius & ulna,25375,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Revise radius & ulna,25375,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Revise radius & ulna,25375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Revise radius & ulna,25375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Revise radius & ulna,25375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Revise radius & ulna,25375,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Shorten radius or ulna,25390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,5839.66,31870.39,
Shorten radius or ulna,25390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,5839.66,31870.39,
Shorten radius or ulna,25390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,5839.66,31870.39,
Shorten radius or ulna,25390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,5839.66,31870.39,
Shorten radius or ulna,25390,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5839.66,31870.39,APC 378
Shorten radius or ulna,25390,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5839.66,31870.39,APC
Shorten radius or ulna,25390,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5839.66,31870.39,APC
Shorten radius or ulna,25390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5839.66,31870.39,APC
Shorten radius or ulna,25390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5839.66,31870.39,Radiology
Shorten radius or ulna,25390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5839.66,31870.39,APC
Shorten radius or ulna,25390,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5839.66,31870.39,APC
Lengthen radius or ulna,25391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10728.02,,,,,,,fee schedule,8599.44,56389.43,
Lengthen radius or ulna,25391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8599.44,,,,,,,fee schedule,8599.44,56389.43,
Lengthen radius or ulna,25391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9394.11,,,,,,,fee schedule,8599.44,56389.43,
Lengthen radius or ulna,25391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9876.59,,,,,,,fee schedule,8599.44,56389.43,
Lengthen radius or ulna,25391,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,8599.44,56389.43,APC 378
Lengthen radius or ulna,25391,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,8599.44,56389.43,APC
Lengthen radius or ulna,25391,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,8599.44,56389.43,APC
Lengthen radius or ulna,25391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,8599.44,56389.43,APC
Lengthen radius or ulna,25391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,8599.44,56389.43,Radiology
Lengthen radius or ulna,25391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,8599.44,56389.43,APC
Lengthen radius or ulna,25391,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,8599.44,56389.43,APC
Shorten radius & ulna,25392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,5839.66,31870.39,
Shorten radius & ulna,25392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,5839.66,31870.39,
Shorten radius & ulna,25392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,5839.66,31870.39,
Shorten radius & ulna,25392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,5839.66,31870.39,
Shorten radius & ulna,25392,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5839.66,31870.39,APC 378
Shorten radius & ulna,25392,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5839.66,31870.39,APC
Shorten radius & ulna,25392,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5839.66,31870.39,APC
Shorten radius & ulna,25392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5839.66,31870.39,APC
Shorten radius & ulna,25392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5839.66,31870.39,Radiology
Shorten radius & ulna,25392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5839.66,31870.39,APC
Shorten radius & ulna,25392,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5839.66,31870.39,APC
Lengthen radius & ulna,25393,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10728.02,,,,,,,fee schedule,7183.42,31870.39,
Lengthen radius & ulna,25393,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8599.44,,,,,,,fee schedule,7183.42,31870.39,
Lengthen radius & ulna,25393,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9394.11,,,,,,,fee schedule,7183.42,31870.39,
Lengthen radius & ulna,25393,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9876.59,,,,,,,fee schedule,7183.42,31870.39,
Lengthen radius & ulna,25393,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Lengthen radius & ulna,25393,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Lengthen radius & ulna,25393,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Lengthen radius & ulna,25393,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Lengthen radius & ulna,25393,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Lengthen radius & ulna,25393,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Lengthen radius & ulna,25393,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Repair carpal bone shorten,25394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4108.94,,,,,,,fee schedule,3239.17,14371.12,
Repair carpal bone shorten,25394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3293.67,,,,,,,fee schedule,3239.17,14371.12,
Repair carpal bone shorten,25394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3598.04,,,,,,,fee schedule,3239.17,14371.12,
Repair carpal bone shorten,25394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3782.83,,,,,,,fee schedule,3239.17,14371.12,
Repair carpal bone shorten,25394,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Repair carpal bone shorten,25394,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Repair carpal bone shorten,25394,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Repair carpal bone shorten,25394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Repair carpal bone shorten,25394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Repair carpal bone shorten,25394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Repair carpal bone shorten,25394,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Repair radius or ulna,25400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6975.13,,,,,,,fee schedule,5591.18,31870.39,
Repair radius or ulna,25400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5591.18,,,,,,,fee schedule,5591.18,31870.39,
Repair radius or ulna,25400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6107.85,,,,,,,fee schedule,5591.18,31870.39,
Repair radius or ulna,25400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6421.55,,,,,,,fee schedule,5591.18,31870.39,
Repair radius or ulna,25400,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5591.18,31870.39,APC 378
Repair radius or ulna,25400,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5591.18,31870.39,APC
Repair radius or ulna,25400,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5591.18,31870.39,APC
Repair radius or ulna,25400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5591.18,31870.39,APC
Repair radius or ulna,25400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5591.18,31870.39,Radiology
Repair radius or ulna,25400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5591.18,31870.39,APC
Repair radius or ulna,25400,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5591.18,31870.39,APC
Repair/graft radius or ulna,25405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19822.36,,,,,,,fee schedule,7183.42,31870.39,
Repair/graft radius or ulna,25405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15889.35,,,,,,,fee schedule,7183.42,31870.39,
Repair/graft radius or ulna,25405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17357.67,,,,,,,fee schedule,7183.42,31870.39,
Repair/graft radius or ulna,25405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18249.15,,,,,,,fee schedule,7183.42,31870.39,
Repair/graft radius or ulna,25405,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Repair/graft radius or ulna,25405,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Repair/graft radius or ulna,25405,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Repair/graft radius or ulna,25405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Repair/graft radius or ulna,25405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Repair/graft radius or ulna,25405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Repair/graft radius or ulna,25405,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Repair radius & ulna,25415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19822.36,,,,,,,fee schedule,7183.42,31870.39,
Repair radius & ulna,25415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15889.35,,,,,,,fee schedule,7183.42,31870.39,
Repair radius & ulna,25415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17357.67,,,,,,,fee schedule,7183.42,31870.39,
Repair radius & ulna,25415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18249.15,,,,,,,fee schedule,7183.42,31870.39,
Repair radius & ulna,25415,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Repair radius & ulna,25415,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Repair radius & ulna,25415,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Repair radius & ulna,25415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Repair radius & ulna,25415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Repair radius & ulna,25415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Repair radius & ulna,25415,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Repair/graft radius & ulna,25420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19822.36,,,,,,,fee schedule,7183.42,31870.39,
Repair/graft radius & ulna,25420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15889.35,,,,,,,fee schedule,7183.42,31870.39,
Repair/graft radius & ulna,25420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17357.67,,,,,,,fee schedule,7183.42,31870.39,
Repair/graft radius & ulna,25420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18249.15,,,,,,,fee schedule,7183.42,31870.39,
Repair/graft radius & ulna,25420,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Repair/graft radius & ulna,25420,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Repair/graft radius & ulna,25420,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Repair/graft radius & ulna,25420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Repair/graft radius & ulna,25420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Repair/graft radius & ulna,25420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Repair/graft radius & ulna,25420,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Repair/graft radius or ulna,25425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10728.02,,,,,,,fee schedule,7183.42,31870.39,
Repair/graft radius or ulna,25425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8599.44,,,,,,,fee schedule,7183.42,31870.39,
Repair/graft radius or ulna,25425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9394.11,,,,,,,fee schedule,7183.42,31870.39,
Repair/graft radius or ulna,25425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9876.59,,,,,,,fee schedule,7183.42,31870.39,
Repair/graft radius or ulna,25425,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Repair/graft radius or ulna,25425,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Repair/graft radius or ulna,25425,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Repair/graft radius or ulna,25425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Repair/graft radius or ulna,25425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Repair/graft radius or ulna,25425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Repair/graft radius or ulna,25425,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Repair/graft radius & ulna,25426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10728.02,,,,,,,fee schedule,3239.17,14371.12,
Repair/graft radius & ulna,25426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8599.44,,,,,,,fee schedule,3239.17,14371.12,
Repair/graft radius & ulna,25426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9394.11,,,,,,,fee schedule,3239.17,14371.12,
Repair/graft radius & ulna,25426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9876.59,,,,,,,fee schedule,3239.17,14371.12,
Repair/graft radius & ulna,25426,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Repair/graft radius & ulna,25426,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Repair/graft radius & ulna,25426,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Repair/graft radius & ulna,25426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Repair/graft radius & ulna,25426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Repair/graft radius & ulna,25426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Repair/graft radius & ulna,25426,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Vasc graft into carpal bone,25430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6566.46,,,,,,,fee schedule,3239.17,14371.12,
Vasc graft into carpal bone,25430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5263.59,,,,,,,fee schedule,3239.17,14371.12,
Vasc graft into carpal bone,25430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5750,,,,,,,fee schedule,3239.17,14371.12,
Vasc graft into carpal bone,25430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6045.32,,,,,,,fee schedule,3239.17,14371.12,
Vasc graft into carpal bone,25430,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Vasc graft into carpal bone,25430,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Vasc graft into carpal bone,25430,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Vasc graft into carpal bone,25430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Vasc graft into carpal bone,25430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Vasc graft into carpal bone,25430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Vasc graft into carpal bone,25430,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Repair nonunion carpal bone,25431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6566.46,,,,,,,fee schedule,5263.59,31870.39,
Repair nonunion carpal bone,25431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5263.59,,,,,,,fee schedule,5263.59,31870.39,
Repair nonunion carpal bone,25431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5750,,,,,,,fee schedule,5263.59,31870.39,
Repair nonunion carpal bone,25431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6045.32,,,,,,,fee schedule,5263.59,31870.39,
Repair nonunion carpal bone,25431,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5263.59,31870.39,APC 378
Repair nonunion carpal bone,25431,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5263.59,31870.39,APC
Repair nonunion carpal bone,25431,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5263.59,31870.39,APC
Repair nonunion carpal bone,25431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5263.59,31870.39,APC
Repair nonunion carpal bone,25431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5263.59,31870.39,Radiology
Repair nonunion carpal bone,25431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5263.59,31870.39,APC
Repair nonunion carpal bone,25431,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5263.59,31870.39,APC
Repair/graft wrist bone,25440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8594.03,,,,,,,fee schedule,6888.87,31870.39,
Repair/graft wrist bone,25440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6888.87,,,,,,,fee schedule,6888.87,31870.39,
Repair/graft wrist bone,25440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7525.46,,,,,,,fee schedule,6888.87,31870.39,
Repair/graft wrist bone,25440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7911.97,,,,,,,fee schedule,6888.87,31870.39,
Repair/graft wrist bone,25440,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,6888.87,31870.39,APC 378
Repair/graft wrist bone,25440,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,6888.87,31870.39,APC
Repair/graft wrist bone,25440,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,6888.87,31870.39,APC
Repair/graft wrist bone,25440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,6888.87,31870.39,APC
Repair/graft wrist bone,25440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,6888.87,31870.39,Radiology
Repair/graft wrist bone,25440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,6888.87,31870.39,APC
Repair/graft wrist bone,25440,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,6888.87,31870.39,APC
Reconstruct wrist joint,25441,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30499.53,,,,,,,fee schedule,12709.88,56389.43,
Reconstruct wrist joint,25441,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24448.04,,,,,,,fee schedule,12709.88,56389.43,
Reconstruct wrist joint,25441,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26707.26,,,,,,,fee schedule,12709.88,56389.43,
Reconstruct wrist joint,25441,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,28078.94,,,,,,,fee schedule,12709.88,56389.43,
Reconstruct wrist joint,25441,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,12709.88,56389.43,APC 378
Reconstruct wrist joint,25441,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,12709.88,56389.43,APC
Reconstruct wrist joint,25441,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,12709.88,56389.43,APC
Reconstruct wrist joint,25441,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,12709.88,56389.43,APC
Reconstruct wrist joint,25441,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,12709.88,56389.43,Radiology
Reconstruct wrist joint,25441,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,12709.88,56389.43,APC
Reconstruct wrist joint,25441,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,12709.88,56389.43,APC
Reconstruct wrist joint,25442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30499.53,,,,,,,fee schedule,17357.91,77011.17,
Reconstruct wrist joint,25442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24448.04,,,,,,,fee schedule,17357.91,77011.17,
Reconstruct wrist joint,25442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26707.26,,,,,,,fee schedule,17357.91,77011.17,
Reconstruct wrist joint,25442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,28078.94,,,,,,,fee schedule,17357.91,77011.17,
Reconstruct wrist joint,25442,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,77011.17,,,,,,,fee schedule,17357.91,77011.17,APC 378
Reconstruct wrist joint,25442,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18225.81,,,,,,,fee schedule,17357.91,77011.17,APC
Reconstruct wrist joint,25442,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18052.23,,,,,,,fee schedule,17357.91,77011.17,APC
Reconstruct wrist joint,25442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17357.91,,,,,,,fee schedule,17357.91,77011.17,APC
Reconstruct wrist joint,25442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26557.6,,,,,,,fee schedule,17357.91,77011.17,Radiology
Reconstruct wrist joint,25442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24301.07,,,,,,,fee schedule,17357.91,77011.17,APC
Reconstruct wrist joint,25442,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30376.34,,,,,,,fee schedule,17357.91,77011.17,APC
Reconstruct wrist joint,25443,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12700.27,,,,,,,fee schedule,7183.42,31870.39,
Reconstruct wrist joint,25443,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10180.38,,,,,,,fee schedule,7183.42,31870.39,
Reconstruct wrist joint,25443,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11121.14,,,,,,,fee schedule,7183.42,31870.39,
Reconstruct wrist joint,25443,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11692.31,,,,,,,fee schedule,7183.42,31870.39,
Reconstruct wrist joint,25443,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Reconstruct wrist joint,25443,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Reconstruct wrist joint,25443,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Reconstruct wrist joint,25443,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Reconstruct wrist joint,25443,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Reconstruct wrist joint,25443,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Reconstruct wrist joint,25443,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Reconstruct wrist joint,25444,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12700.27,,,,,,,fee schedule,10180.38,56389.43,
Reconstruct wrist joint,25444,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10180.38,,,,,,,fee schedule,10180.38,56389.43,
Reconstruct wrist joint,25444,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11121.14,,,,,,,fee schedule,10180.38,56389.43,
Reconstruct wrist joint,25444,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11692.31,,,,,,,fee schedule,10180.38,56389.43,
Reconstruct wrist joint,25444,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,10180.38,56389.43,APC 378
Reconstruct wrist joint,25444,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,10180.38,56389.43,APC
Reconstruct wrist joint,25444,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,10180.38,56389.43,APC
Reconstruct wrist joint,25444,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,10180.38,56389.43,APC
Reconstruct wrist joint,25444,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,10180.38,56389.43,Radiology
Reconstruct wrist joint,25444,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,10180.38,56389.43,APC
Reconstruct wrist joint,25444,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,10180.38,56389.43,APC
Reconstruct wrist joint,25445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12700.27,,,,,,,fee schedule,7183.42,31870.39,
Reconstruct wrist joint,25445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10180.38,,,,,,,fee schedule,7183.42,31870.39,
Reconstruct wrist joint,25445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11121.14,,,,,,,fee schedule,7183.42,31870.39,
Reconstruct wrist joint,25445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11692.31,,,,,,,fee schedule,7183.42,31870.39,
Reconstruct wrist joint,25445,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Reconstruct wrist joint,25445,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Reconstruct wrist joint,25445,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Reconstruct wrist joint,25445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Reconstruct wrist joint,25445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Reconstruct wrist joint,25445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Reconstruct wrist joint,25445,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Wrist replacement,25446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30499.53,,,,,,,fee schedule,17357.91,77011.17,
Wrist replacement,25446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24448.04,,,,,,,fee schedule,17357.91,77011.17,
Wrist replacement,25446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26707.26,,,,,,,fee schedule,17357.91,77011.17,
Wrist replacement,25446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,28078.94,,,,,,,fee schedule,17357.91,77011.17,
Wrist replacement,25446,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,77011.17,,,,,,,fee schedule,17357.91,77011.17,APC 378
Wrist replacement,25446,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18225.81,,,,,,,fee schedule,17357.91,77011.17,APC
Wrist replacement,25446,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18052.23,,,,,,,fee schedule,17357.91,77011.17,APC
Wrist replacement,25446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17357.91,,,,,,,fee schedule,17357.91,77011.17,APC
Wrist replacement,25446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26557.6,,,,,,,fee schedule,17357.91,77011.17,Radiology
Wrist replacement,25446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24301.07,,,,,,,fee schedule,17357.91,77011.17,APC
Wrist replacement,25446,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30376.34,,,,,,,fee schedule,17357.91,77011.17,APC
Repair wrist joints,25447,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8145.54,,,,,,,fee schedule,3239.17,14371.12,
Repair wrist joints,25447,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6529.36,,,,,,,fee schedule,3239.17,14371.12,
Repair wrist joints,25447,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7132.74,,,,,,,fee schedule,3239.17,14371.12,
Repair wrist joints,25447,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7499.07,,,,,,,fee schedule,3239.17,14371.12,
Repair wrist joints,25447,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Repair wrist joints,25447,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Repair wrist joints,25447,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Repair wrist joints,25447,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Repair wrist joints,25447,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Repair wrist joints,25447,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Repair wrist joints,25447,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Arthrp ntrcrpl/crp/mtcrp ssp,25448,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Arthrp ntrcrpl/crp/mtcrp ssp,25448,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Arthrp ntrcrpl/crp/mtcrp ssp,25448,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Arthrp ntrcrpl/crp/mtcrp ssp,25448,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Arthrp ntrcrpl/crp/mtcrp ssp,25448,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Arthrp ntrcrpl/crp/mtcrp ssp,25448,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Arthrp ntrcrpl/crp/mtcrp ssp,25448,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Remove wrist joint implant,25449,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8960.75,,,,,,,fee schedule,7182.83,31870.39,
Remove wrist joint implant,25449,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7182.83,,,,,,,fee schedule,7182.83,31870.39,
Remove wrist joint implant,25449,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7846.59,,,,,,,fee schedule,7182.83,31870.39,
Remove wrist joint implant,25449,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8249.58,,,,,,,fee schedule,7182.83,31870.39,
Remove wrist joint implant,25449,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7182.83,31870.39,APC 378
Remove wrist joint implant,25449,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7182.83,31870.39,APC
Remove wrist joint implant,25449,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7182.83,31870.39,APC
Remove wrist joint implant,25449,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7182.83,31870.39,APC
Remove wrist joint implant,25449,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7182.83,31870.39,Radiology
Remove wrist joint implant,25449,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7182.83,31870.39,APC
Remove wrist joint implant,25449,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7182.83,31870.39,APC
Revision of wrist joint,25450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10728.02,,,,,,,fee schedule,3239.17,14371.12,
Revision of wrist joint,25450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8599.44,,,,,,,fee schedule,3239.17,14371.12,
Revision of wrist joint,25450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9394.11,,,,,,,fee schedule,3239.17,14371.12,
Revision of wrist joint,25450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9876.59,,,,,,,fee schedule,3239.17,14371.12,
Revision of wrist joint,25450,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Revision of wrist joint,25450,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Revision of wrist joint,25450,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Revision of wrist joint,25450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Revision of wrist joint,25450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Revision of wrist joint,25450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Revision of wrist joint,25450,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Revision of wrist joint,25455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10728.02,,,,,,,fee schedule,3239.17,14371.12,
Revision of wrist joint,25455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8599.44,,,,,,,fee schedule,3239.17,14371.12,
Revision of wrist joint,25455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9394.11,,,,,,,fee schedule,3239.17,14371.12,
Revision of wrist joint,25455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9876.59,,,,,,,fee schedule,3239.17,14371.12,
Revision of wrist joint,25455,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Revision of wrist joint,25455,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Revision of wrist joint,25455,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Revision of wrist joint,25455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Revision of wrist joint,25455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Revision of wrist joint,25455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Revision of wrist joint,25455,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Reinforce radius,25490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10728.02,,,,,,,fee schedule,7183.42,31870.39,
Reinforce radius,25490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8599.44,,,,,,,fee schedule,7183.42,31870.39,
Reinforce radius,25490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9394.11,,,,,,,fee schedule,7183.42,31870.39,
Reinforce radius,25490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9876.59,,,,,,,fee schedule,7183.42,31870.39,
Reinforce radius,25490,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Reinforce radius,25490,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Reinforce radius,25490,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Reinforce radius,25490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Reinforce radius,25490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Reinforce radius,25490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Reinforce radius,25490,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Reinforce ulna,25491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10728.02,,,,,,,fee schedule,8599.44,56389.43,
Reinforce ulna,25491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8599.44,,,,,,,fee schedule,8599.44,56389.43,
Reinforce ulna,25491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9394.11,,,,,,,fee schedule,8599.44,56389.43,
Reinforce ulna,25491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9876.59,,,,,,,fee schedule,8599.44,56389.43,
Reinforce ulna,25491,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,8599.44,56389.43,APC 378
Reinforce ulna,25491,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,8599.44,56389.43,APC
Reinforce ulna,25491,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,8599.44,56389.43,APC
Reinforce ulna,25491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,8599.44,56389.43,APC
Reinforce ulna,25491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,8599.44,56389.43,Radiology
Reinforce ulna,25491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,8599.44,56389.43,APC
Reinforce ulna,25491,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,8599.44,56389.43,APC
Reinforce radius and ulna,25492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10728.02,,,,,,,fee schedule,3239.17,14371.12,
Reinforce radius and ulna,25492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8599.44,,,,,,,fee schedule,3239.17,14371.12,
Reinforce radius and ulna,25492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9394.11,,,,,,,fee schedule,3239.17,14371.12,
Reinforce radius and ulna,25492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9876.59,,,,,,,fee schedule,3239.17,14371.12,
Reinforce radius and ulna,25492,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Reinforce radius and ulna,25492,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Reinforce radius and ulna,25492,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Reinforce radius and ulna,25492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Reinforce radius and ulna,25492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Reinforce radius and ulna,25492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Reinforce radius and ulna,25492,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Treat fracture of radius,25500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,244.19,1083.4,
Treat fracture of radius,25500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,244.19,1083.4,
Treat fracture of radius,25500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,244.19,1083.4,
Treat fracture of radius,25500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,244.19,1083.4,
Treat fracture of radius,25500,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treat fracture of radius,25500,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treat fracture of radius,25500,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treat fracture of radius,25500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treat fracture of radius,25500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treat fracture of radius,25500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treat fracture of radius,25500,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treat fracture of radius,25505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1001.25,,,,,,,fee schedule,802.59,7062.54,
Treat fracture of radius,25505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,802.59,,,,,,,fee schedule,802.59,7062.54,
Treat fracture of radius,25505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,876.75,,,,,,,fee schedule,802.59,7062.54,
Treat fracture of radius,25505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,921.78,,,,,,,fee schedule,802.59,7062.54,
Treat fracture of radius,25505,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,802.59,7062.54,APC 378
Treat fracture of radius,25505,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,802.59,7062.54,APC
Treat fracture of radius,25505,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,802.59,7062.54,APC
Treat fracture of radius,25505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,802.59,7062.54,APC
Treat fracture of radius,25505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,802.59,7062.54,Radiology
Treat fracture of radius,25505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,802.59,7062.54,APC
Treat fracture of radius,25505,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,802.59,7062.54,APC
Treat fracture of radius,25515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8745.92,,,,,,,fee schedule,7010.62,31870.39,
Treat fracture of radius,25515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7010.62,,,,,,,fee schedule,7010.62,31870.39,
Treat fracture of radius,25515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7658.46,,,,,,,fee schedule,7010.62,31870.39,
Treat fracture of radius,25515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8051.8,,,,,,,fee schedule,7010.62,31870.39,
Treat fracture of radius,25515,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7010.62,31870.39,APC 378
Treat fracture of radius,25515,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7010.62,31870.39,APC
Treat fracture of radius,25515,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7010.62,31870.39,APC
Treat fracture of radius,25515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7010.62,31870.39,APC
Treat fracture of radius,25515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7010.62,31870.39,Radiology
Treat fracture of radius,25515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7010.62,31870.39,APC
Treat fracture of radius,25515,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7010.62,31870.39,APC
Treat fracture of radius,25520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,353.72,7062.54,
Treat fracture of radius,25520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,353.72,7062.54,
Treat fracture of radius,25520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,353.72,7062.54,
Treat fracture of radius,25520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,353.72,7062.54,
Treat fracture of radius,25520,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,353.72,7062.54,APC 378
Treat fracture of radius,25520,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,353.72,7062.54,APC
Treat fracture of radius,25520,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,353.72,7062.54,APC
Treat fracture of radius,25520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,353.72,7062.54,APC
Treat fracture of radius,25520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,353.72,7062.54,Radiology
Treat fracture of radius,25520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,353.72,7062.54,APC
Treat fracture of radius,25520,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,353.72,7062.54,APC
Treat fracture of radius,25525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10259.79,,,,,,,fee schedule,7183.42,31870.39,
Treat fracture of radius,25525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8224.12,,,,,,,fee schedule,7183.42,31870.39,
Treat fracture of radius,25525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8984.1,,,,,,,fee schedule,7183.42,31870.39,
Treat fracture of radius,25525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9445.52,,,,,,,fee schedule,7183.42,31870.39,
Treat fracture of radius,25525,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Treat fracture of radius,25525,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Treat fracture of radius,25525,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Treat fracture of radius,25525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Treat fracture of radius,25525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Treat fracture of radius,25525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Treat fracture of radius,25525,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Treat fracture of radius,25526,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10259.79,,,,,,,fee schedule,7183.42,31870.39,
Treat fracture of radius,25526,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8224.12,,,,,,,fee schedule,7183.42,31870.39,
Treat fracture of radius,25526,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8984.1,,,,,,,fee schedule,7183.42,31870.39,
Treat fracture of radius,25526,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9445.52,,,,,,,fee schedule,7183.42,31870.39,
Treat fracture of radius,25526,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Treat fracture of radius,25526,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Treat fracture of radius,25526,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Treat fracture of radius,25526,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Treat fracture of radius,25526,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Treat fracture of radius,25526,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Treat fracture of radius,25526,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Treat fracture of ulna,25530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,244.19,1083.4,
Treat fracture of ulna,25530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,244.19,1083.4,
Treat fracture of ulna,25530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,244.19,1083.4,
Treat fracture of ulna,25530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,244.19,1083.4,
Treat fracture of ulna,25530,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treat fracture of ulna,25530,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treat fracture of ulna,25530,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treat fracture of ulna,25530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treat fracture of ulna,25530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treat fracture of ulna,25530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treat fracture of ulna,25530,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treat fracture of ulna,25535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,244.19,1083.4,
Treat fracture of ulna,25535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,244.19,1083.4,
Treat fracture of ulna,25535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,244.19,1083.4,
Treat fracture of ulna,25535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,244.19,1083.4,
Treat fracture of ulna,25535,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treat fracture of ulna,25535,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treat fracture of ulna,25535,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treat fracture of ulna,25535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treat fracture of ulna,25535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treat fracture of ulna,25535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treat fracture of ulna,25535,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treat fracture of ulna,25545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7368.21,,,,,,,fee schedule,5906.26,31870.39,
Treat fracture of ulna,25545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5906.26,,,,,,,fee schedule,5906.26,31870.39,
Treat fracture of ulna,25545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6452.06,,,,,,,fee schedule,5906.26,31870.39,
Treat fracture of ulna,25545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6783.43,,,,,,,fee schedule,5906.26,31870.39,
Treat fracture of ulna,25545,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5906.26,31870.39,APC 378
Treat fracture of ulna,25545,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5906.26,31870.39,APC
Treat fracture of ulna,25545,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5906.26,31870.39,APC
Treat fracture of ulna,25545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5906.26,31870.39,APC
Treat fracture of ulna,25545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5906.26,31870.39,Radiology
Treat fracture of ulna,25545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5906.26,31870.39,APC
Treat fracture of ulna,25545,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5906.26,31870.39,APC
Treat fracture radius & ulna,25560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,244.19,1083.4,
Treat fracture radius & ulna,25560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,244.19,1083.4,
Treat fracture radius & ulna,25560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,244.19,1083.4,
Treat fracture radius & ulna,25560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,244.19,1083.4,
Treat fracture radius & ulna,25560,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treat fracture radius & ulna,25560,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treat fracture radius & ulna,25560,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treat fracture radius & ulna,25560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treat fracture radius & ulna,25560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treat fracture radius & ulna,25560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treat fracture radius & ulna,25560,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treat fracture radius & ulna,25565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,690.25,,,,,,,fee schedule,553.3,7062.54,
Treat fracture radius & ulna,25565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,553.3,,,,,,,fee schedule,553.3,7062.54,
Treat fracture radius & ulna,25565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,604.43,,,,,,,fee schedule,553.3,7062.54,
Treat fracture radius & ulna,25565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,635.47,,,,,,,fee schedule,553.3,7062.54,
Treat fracture radius & ulna,25565,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,553.3,7062.54,APC 378
Treat fracture radius & ulna,25565,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,553.3,7062.54,APC
Treat fracture radius & ulna,25565,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,553.3,7062.54,APC
Treat fracture radius & ulna,25565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,553.3,7062.54,APC
Treat fracture radius & ulna,25565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,553.3,7062.54,Radiology
Treat fracture radius & ulna,25565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,553.3,7062.54,APC
Treat fracture radius & ulna,25565,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,553.3,7062.54,APC
Treat fracture radius & ulna,25574,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14780.67,,,,,,,fee schedule,7183.42,31870.39,
Treat fracture radius & ulna,25574,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11848,,,,,,,fee schedule,7183.42,31870.39,
Treat fracture radius & ulna,25574,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12942.86,,,,,,,fee schedule,7183.42,31870.39,
Treat fracture radius & ulna,25574,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13607.6,,,,,,,fee schedule,7183.42,31870.39,
Treat fracture radius & ulna,25574,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Treat fracture radius & ulna,25574,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Treat fracture radius & ulna,25574,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Treat fracture radius & ulna,25574,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Treat fracture radius & ulna,25574,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Treat fracture radius & ulna,25574,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Treat fracture radius & ulna,25574,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Treat fracture radius/ulna,25575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10954.11,,,,,,,fee schedule,7183.42,31870.39,
Treat fracture radius/ulna,25575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8780.68,,,,,,,fee schedule,7183.42,31870.39,
Treat fracture radius/ulna,25575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9592.09,,,,,,,fee schedule,7183.42,31870.39,
Treat fracture radius/ulna,25575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10084.74,,,,,,,fee schedule,7183.42,31870.39,
Treat fracture radius/ulna,25575,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Treat fracture radius/ulna,25575,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Treat fracture radius/ulna,25575,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Treat fracture radius/ulna,25575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Treat fracture radius/ulna,25575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Treat fracture radius/ulna,25575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Treat fracture radius/ulna,25575,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Treat fracture radius/ulna,25600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10205.34,,,,,,,fee schedule,244.19,10205.34,
Treat fracture radius/ulna,25600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8180.47,,,,,,,fee schedule,244.19,10205.34,
Treat fracture radius/ulna,25600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8936.43,,,,,,,fee schedule,244.19,10205.34,
Treat fracture radius/ulna,25600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9395.4,,,,,,,fee schedule,244.19,10205.34,
Treat fracture radius/ulna,25600,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,10205.34,APC 378
Treat fracture radius/ulna,25600,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,10205.34,APC
Treat fracture radius/ulna,25600,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,10205.34,APC
Treat fracture radius/ulna,25600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,10205.34,APC
Treat fracture radius/ulna,25600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,10205.34,Radiology
Treat fracture radius/ulna,25600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,10205.34,APC
Treat fracture radius/ulna,25600,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,10205.34,APC
Treat fracture radius/ulna,25605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,973.15,,,,,,,fee schedule,780.06,7062.54,
Treat fracture radius/ulna,25605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,780.06,,,,,,,fee schedule,780.06,7062.54,
Treat fracture radius/ulna,25605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,852.15,,,,,,,fee schedule,780.06,7062.54,
Treat fracture radius/ulna,25605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,895.91,,,,,,,fee schedule,780.06,7062.54,
Treat fracture radius/ulna,25605,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,780.06,7062.54,APC 378
Treat fracture radius/ulna,25605,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,780.06,7062.54,APC
Treat fracture radius/ulna,25605,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,780.06,7062.54,APC
Treat fracture radius/ulna,25605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,780.06,7062.54,APC
Treat fracture radius/ulna,25605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,780.06,7062.54,Radiology
Treat fracture radius/ulna,25605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,780.06,7062.54,APC
Treat fracture radius/ulna,25605,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,780.06,7062.54,APC
Treat Fx Distal Radial,25606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5392.26,,,,,,,fee schedule,3239.17,14371.12,
Treat Fx Distal Radial,25606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4322.37,,,,,,,fee schedule,3239.17,14371.12,
Treat Fx Distal Radial,25606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4721.8,,,,,,,fee schedule,3239.17,14371.12,
Treat Fx Distal Radial,25606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4964.31,,,,,,,fee schedule,3239.17,14371.12,
Treat Fx Distal Radial,25606,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Treat Fx Distal Radial,25606,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Treat Fx Distal Radial,25606,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Treat Fx Distal Radial,25606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Treat Fx Distal Radial,25606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Treat Fx Distal Radial,25606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Treat Fx Distal Radial,25606,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Treat Fx Rad Extra-Articul,25607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10101.86,,,,,,,fee schedule,7183.42,31870.39,
Treat Fx Rad Extra-Articul,25607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8097.52,,,,,,,fee schedule,7183.42,31870.39,
Treat Fx Rad Extra-Articul,25607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8845.81,,,,,,,fee schedule,7183.42,31870.39,
Treat Fx Rad Extra-Articul,25607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9300.13,,,,,,,fee schedule,7183.42,31870.39,
Treat Fx Rad Extra-Articul,25607,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Treat Fx Rad Extra-Articul,25607,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Treat Fx Rad Extra-Articul,25607,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Treat Fx Rad Extra-Articul,25607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Treat Fx Rad Extra-Articul,25607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Treat Fx Rad Extra-Articul,25607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Treat Fx Rad Extra-Articul,25607,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Treat Fx Rad Intra-Articul,25608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9006.61,,,,,,,fee schedule,7183.42,31870.39,
Treat Fx Rad Intra-Articul,25608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7219.59,,,,,,,fee schedule,7183.42,31870.39,
Treat Fx Rad Intra-Articul,25608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7886.74,,,,,,,fee schedule,7183.42,31870.39,
Treat Fx Rad Intra-Articul,25608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8291.8,,,,,,,fee schedule,7183.42,31870.39,
Treat Fx Rad Intra-Articul,25608,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Treat Fx Rad Intra-Articul,25608,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Treat Fx Rad Intra-Articul,25608,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Treat Fx Rad Intra-Articul,25608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Treat Fx Rad Intra-Articul,25608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Treat Fx Rad Intra-Articul,25608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Treat Fx Rad Intra-Articul,25608,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Treat Fx Radial 3+ Frag,25609,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9867.8,,,,,,,fee schedule,7183.42,31870.39,
Treat Fx Radial 3+ Frag,25609,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7909.91,,,,,,,fee schedule,7183.42,31870.39,
Treat Fx Radial 3+ Frag,25609,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8640.85,,,,,,,fee schedule,7183.42,31870.39,
Treat Fx Radial 3+ Frag,25609,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9084.64,,,,,,,fee schedule,7183.42,31870.39,
Treat Fx Radial 3+ Frag,25609,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Treat Fx Radial 3+ Frag,25609,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Treat Fx Radial 3+ Frag,25609,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Treat Fx Radial 3+ Frag,25609,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Treat Fx Radial 3+ Frag,25609,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Treat Fx Radial 3+ Frag,25609,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Treat Fx Radial 3+ Frag,25609,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Treat wrist bone fracture,25622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,244.19,1083.4,
Treat wrist bone fracture,25622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,244.19,1083.4,
Treat wrist bone fracture,25622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,244.19,1083.4,
Treat wrist bone fracture,25622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,244.19,1083.4,
Treat wrist bone fracture,25622,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treat wrist bone fracture,25622,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treat wrist bone fracture,25622,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treat wrist bone fracture,25622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treat wrist bone fracture,25622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treat wrist bone fracture,25622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treat wrist bone fracture,25622,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treat wrist bone fracture,25624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5006.23,,,,,,,fee schedule,1591.86,7062.54,
Treat wrist bone fracture,25624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4012.93,,,,,,,fee schedule,1591.86,7062.54,
Treat wrist bone fracture,25624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4383.76,,,,,,,fee schedule,1591.86,7062.54,
Treat wrist bone fracture,25624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4608.91,,,,,,,fee schedule,1591.86,7062.54,
Treat wrist bone fracture,25624,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Treat wrist bone fracture,25624,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Treat wrist bone fracture,25624,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Treat wrist bone fracture,25624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Treat wrist bone fracture,25624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Treat wrist bone fracture,25624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Treat wrist bone fracture,25624,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Treat wrist bone fracture,25628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4531.07,,,,,,,fee schedule,3632.05,31870.39,
Treat wrist bone fracture,25628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3632.05,,,,,,,fee schedule,3632.05,31870.39,
Treat wrist bone fracture,25628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3967.69,,,,,,,fee schedule,3632.05,31870.39,
Treat wrist bone fracture,25628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4171.46,,,,,,,fee schedule,3632.05,31870.39,
Treat wrist bone fracture,25628,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,3632.05,31870.39,APC 378
Treat wrist bone fracture,25628,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,3632.05,31870.39,APC
Treat wrist bone fracture,25628,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,3632.05,31870.39,APC
Treat wrist bone fracture,25628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,3632.05,31870.39,APC
Treat wrist bone fracture,25628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,3632.05,31870.39,Radiology
Treat wrist bone fracture,25628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,3632.05,31870.39,APC
Treat wrist bone fracture,25628,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,3632.05,31870.39,APC
Treat wrist bone fracture,25630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,244.19,1083.4,
Treat wrist bone fracture,25630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,244.19,1083.4,
Treat wrist bone fracture,25630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,244.19,1083.4,
Treat wrist bone fracture,25630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,244.19,1083.4,
Treat wrist bone fracture,25630,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treat wrist bone fracture,25630,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treat wrist bone fracture,25630,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treat wrist bone fracture,25630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treat wrist bone fracture,25630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treat wrist bone fracture,25630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treat wrist bone fracture,25630,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treat wrist bone fracture,25635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,353.72,7062.54,
Treat wrist bone fracture,25635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,353.72,7062.54,
Treat wrist bone fracture,25635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,353.72,7062.54,
Treat wrist bone fracture,25635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,353.72,7062.54,
Treat wrist bone fracture,25635,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,353.72,7062.54,APC 378
Treat wrist bone fracture,25635,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,353.72,7062.54,APC
Treat wrist bone fracture,25635,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,353.72,7062.54,APC
Treat wrist bone fracture,25635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,353.72,7062.54,APC
Treat wrist bone fracture,25635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,353.72,7062.54,Radiology
Treat wrist bone fracture,25635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,353.72,7062.54,APC
Treat wrist bone fracture,25635,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,353.72,7062.54,APC
Treat wrist bone fracture,25645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10259.79,,,,,,,fee schedule,3239.17,14371.12,
Treat wrist bone fracture,25645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8224.12,,,,,,,fee schedule,3239.17,14371.12,
Treat wrist bone fracture,25645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8984.1,,,,,,,fee schedule,3239.17,14371.12,
Treat wrist bone fracture,25645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9445.52,,,,,,,fee schedule,3239.17,14371.12,
Treat wrist bone fracture,25645,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Treat wrist bone fracture,25645,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Treat wrist bone fracture,25645,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Treat wrist bone fracture,25645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Treat wrist bone fracture,25645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Treat wrist bone fracture,25645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Treat wrist bone fracture,25645,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Treat wrist bone fracture,25650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,244.19,1083.4,
Treat wrist bone fracture,25650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,244.19,1083.4,
Treat wrist bone fracture,25650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,244.19,1083.4,
Treat wrist bone fracture,25650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,244.19,1083.4,
Treat wrist bone fracture,25650,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treat wrist bone fracture,25650,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treat wrist bone fracture,25650,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treat wrist bone fracture,25650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treat wrist bone fracture,25650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treat wrist bone fracture,25650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treat wrist bone fracture,25650,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Pin ulnar styloid fracture,25651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6528.66,,,,,,,fee schedule,3239.17,14371.12,
Pin ulnar styloid fracture,25651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5233.29,,,,,,,fee schedule,3239.17,14371.12,
Pin ulnar styloid fracture,25651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5716.9,,,,,,,fee schedule,3239.17,14371.12,
Pin ulnar styloid fracture,25651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6010.52,,,,,,,fee schedule,3239.17,14371.12,
Pin ulnar styloid fracture,25651,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Pin ulnar styloid fracture,25651,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Pin ulnar styloid fracture,25651,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Pin ulnar styloid fracture,25651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Pin ulnar styloid fracture,25651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Pin ulnar styloid fracture,25651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Pin ulnar styloid fracture,25651,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Treat fracture ulnar styloid,25652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3478.9,,,,,,,fee schedule,2788.64,31870.39,
Treat fracture ulnar styloid,25652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2788.64,,,,,,,fee schedule,2788.64,31870.39,
Treat fracture ulnar styloid,25652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3046.34,,,,,,,fee schedule,2788.64,31870.39,
Treat fracture ulnar styloid,25652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3202.79,,,,,,,fee schedule,2788.64,31870.39,
Treat fracture ulnar styloid,25652,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,2788.64,31870.39,APC 378
Treat fracture ulnar styloid,25652,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,2788.64,31870.39,APC
Treat fracture ulnar styloid,25652,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,2788.64,31870.39,APC
Treat fracture ulnar styloid,25652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,2788.64,31870.39,APC
Treat fracture ulnar styloid,25652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,2788.64,31870.39,Radiology
Treat fracture ulnar styloid,25652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,2788.64,31870.39,APC
Treat fracture ulnar styloid,25652,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,2788.64,31870.39,APC
Treat wrist dislocation,25660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,309.91,,,,,,,fee schedule,244.19,1083.4,
Treat wrist dislocation,25660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,248.42,,,,,,,fee schedule,244.19,1083.4,
Treat wrist dislocation,25660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,271.38,,,,,,,fee schedule,244.19,1083.4,
Treat wrist dislocation,25660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,285.31,,,,,,,fee schedule,244.19,1083.4,
Treat wrist dislocation,25660,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treat wrist dislocation,25660,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treat wrist dislocation,25660,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treat wrist dislocation,25660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treat wrist dislocation,25660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treat wrist dislocation,25660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treat wrist dislocation,25660,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treat wrist dislocation,25670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6528.66,,,,,,,fee schedule,5233.29,31870.39,
Treat wrist dislocation,25670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5233.29,,,,,,,fee schedule,5233.29,31870.39,
Treat wrist dislocation,25670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5716.9,,,,,,,fee schedule,5233.29,31870.39,
Treat wrist dislocation,25670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6010.52,,,,,,,fee schedule,5233.29,31870.39,
Treat wrist dislocation,25670,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5233.29,31870.39,APC 378
Treat wrist dislocation,25670,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5233.29,31870.39,APC
Treat wrist dislocation,25670,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5233.29,31870.39,APC
Treat wrist dislocation,25670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5233.29,31870.39,APC
Treat wrist dislocation,25670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5233.29,31870.39,Radiology
Treat wrist dislocation,25670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5233.29,31870.39,APC
Treat wrist dislocation,25670,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5233.29,31870.39,APC
Pin radioulnar dislocation,25671,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6528.66,,,,,,,fee schedule,3239.17,14371.12,
Pin radioulnar dislocation,25671,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5233.29,,,,,,,fee schedule,3239.17,14371.12,
Pin radioulnar dislocation,25671,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5716.9,,,,,,,fee schedule,3239.17,14371.12,
Pin radioulnar dislocation,25671,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6010.52,,,,,,,fee schedule,3239.17,14371.12,
Pin radioulnar dislocation,25671,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Pin radioulnar dislocation,25671,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Pin radioulnar dislocation,25671,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Pin radioulnar dislocation,25671,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Pin radioulnar dislocation,25671,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Pin radioulnar dislocation,25671,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Pin radioulnar dislocation,25671,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Treat wrist dislocation,25675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,244.19,1083.4,
Treat wrist dislocation,25675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,244.19,1083.4,
Treat wrist dislocation,25675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,244.19,1083.4,
Treat wrist dislocation,25675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,244.19,1083.4,
Treat wrist dislocation,25675,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treat wrist dislocation,25675,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treat wrist dislocation,25675,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treat wrist dislocation,25675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treat wrist dislocation,25675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treat wrist dislocation,25675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treat wrist dislocation,25675,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treat wrist dislocation,25676,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6528.66,,,,,,,fee schedule,5233.29,31870.39,
Treat wrist dislocation,25676,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5233.29,,,,,,,fee schedule,5233.29,31870.39,
Treat wrist dislocation,25676,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5716.9,,,,,,,fee schedule,5233.29,31870.39,
Treat wrist dislocation,25676,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6010.52,,,,,,,fee schedule,5233.29,31870.39,
Treat wrist dislocation,25676,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5233.29,31870.39,APC 378
Treat wrist dislocation,25676,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5233.29,31870.39,APC
Treat wrist dislocation,25676,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5233.29,31870.39,APC
Treat wrist dislocation,25676,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5233.29,31870.39,APC
Treat wrist dislocation,25676,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5233.29,31870.39,Radiology
Treat wrist dislocation,25676,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5233.29,31870.39,APC
Treat wrist dislocation,25676,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5233.29,31870.39,APC
Treat wrist fracture,25680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,244.19,1083.4,
Treat wrist fracture,25680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,244.19,1083.4,
Treat wrist fracture,25680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,244.19,1083.4,
Treat wrist fracture,25680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,244.19,1083.4,
Treat wrist fracture,25680,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treat wrist fracture,25680,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treat wrist fracture,25680,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treat wrist fracture,25680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treat wrist fracture,25680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treat wrist fracture,25680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treat wrist fracture,25680,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treat wrist fracture,25685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6528.66,,,,,,,fee schedule,5233.29,31870.39,
Treat wrist fracture,25685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5233.29,,,,,,,fee schedule,5233.29,31870.39,
Treat wrist fracture,25685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5716.9,,,,,,,fee schedule,5233.29,31870.39,
Treat wrist fracture,25685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6010.52,,,,,,,fee schedule,5233.29,31870.39,
Treat wrist fracture,25685,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5233.29,31870.39,APC 378
Treat wrist fracture,25685,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5233.29,31870.39,APC
Treat wrist fracture,25685,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5233.29,31870.39,APC
Treat wrist fracture,25685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5233.29,31870.39,APC
Treat wrist fracture,25685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5233.29,31870.39,Radiology
Treat wrist fracture,25685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5233.29,31870.39,APC
Treat wrist fracture,25685,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5233.29,31870.39,APC
Treat wrist dislocation,25690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,353.72,7062.54,
Treat wrist dislocation,25690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,353.72,7062.54,
Treat wrist dislocation,25690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,353.72,7062.54,
Treat wrist dislocation,25690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,353.72,7062.54,
Treat wrist dislocation,25690,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,353.72,7062.54,APC 378
Treat wrist dislocation,25690,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,353.72,7062.54,APC
Treat wrist dislocation,25690,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,353.72,7062.54,APC
Treat wrist dislocation,25690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,353.72,7062.54,APC
Treat wrist dislocation,25690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,353.72,7062.54,Radiology
Treat wrist dislocation,25690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,353.72,7062.54,APC
Treat wrist dislocation,25690,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,353.72,7062.54,APC
Treat wrist dislocation,25695,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6528.66,,,,,,,fee schedule,5233.29,31870.39,
Treat wrist dislocation,25695,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5233.29,,,,,,,fee schedule,5233.29,31870.39,
Treat wrist dislocation,25695,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5716.9,,,,,,,fee schedule,5233.29,31870.39,
Treat wrist dislocation,25695,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6010.52,,,,,,,fee schedule,5233.29,31870.39,
Treat wrist dislocation,25695,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5233.29,31870.39,APC 378
Treat wrist dislocation,25695,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5233.29,31870.39,APC
Treat wrist dislocation,25695,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5233.29,31870.39,APC
Treat wrist dislocation,25695,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5233.29,31870.39,APC
Treat wrist dislocation,25695,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5233.29,31870.39,Radiology
Treat wrist dislocation,25695,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5233.29,31870.39,APC
Treat wrist dislocation,25695,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5233.29,31870.39,APC
Fusion of wrist joint,25800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19822.36,,,,,,,fee schedule,7183.42,31870.39,
Fusion of wrist joint,25800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15889.35,,,,,,,fee schedule,7183.42,31870.39,
Fusion of wrist joint,25800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17357.67,,,,,,,fee schedule,7183.42,31870.39,
Fusion of wrist joint,25800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18249.15,,,,,,,fee schedule,7183.42,31870.39,
Fusion of wrist joint,25800,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Fusion of wrist joint,25800,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Fusion of wrist joint,25800,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Fusion of wrist joint,25800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Fusion of wrist joint,25800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Fusion of wrist joint,25800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Fusion of wrist joint,25800,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Fusion/graft of wrist joint,25805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10728.02,,,,,,,fee schedule,7183.42,31870.39,
Fusion/graft of wrist joint,25805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8599.44,,,,,,,fee schedule,7183.42,31870.39,
Fusion/graft of wrist joint,25805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9394.11,,,,,,,fee schedule,7183.42,31870.39,
Fusion/graft of wrist joint,25805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9876.59,,,,,,,fee schedule,7183.42,31870.39,
Fusion/graft of wrist joint,25805,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Fusion/graft of wrist joint,25805,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Fusion/graft of wrist joint,25805,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Fusion/graft of wrist joint,25805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Fusion/graft of wrist joint,25805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Fusion/graft of wrist joint,25805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Fusion/graft of wrist joint,25805,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Fusion/graft of wrist joint,25810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19822.36,,,,,,,fee schedule,12709.88,56389.43,
Fusion/graft of wrist joint,25810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15889.35,,,,,,,fee schedule,12709.88,56389.43,
Fusion/graft of wrist joint,25810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17357.67,,,,,,,fee schedule,12709.88,56389.43,
Fusion/graft of wrist joint,25810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18249.15,,,,,,,fee schedule,12709.88,56389.43,
Fusion/graft of wrist joint,25810,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,12709.88,56389.43,APC 378
Fusion/graft of wrist joint,25810,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,12709.88,56389.43,APC
Fusion/graft of wrist joint,25810,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,12709.88,56389.43,APC
Fusion/graft of wrist joint,25810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,12709.88,56389.43,APC
Fusion/graft of wrist joint,25810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,12709.88,56389.43,Radiology
Fusion/graft of wrist joint,25810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,12709.88,56389.43,APC
Fusion/graft of wrist joint,25810,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,12709.88,56389.43,APC
Fusion of hand bones,25820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4108.94,,,,,,,fee schedule,3293.67,31870.39,
Fusion of hand bones,25820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3293.67,,,,,,,fee schedule,3293.67,31870.39,
Fusion of hand bones,25820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3598.04,,,,,,,fee schedule,3293.67,31870.39,
Fusion of hand bones,25820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3782.83,,,,,,,fee schedule,3293.67,31870.39,
Fusion of hand bones,25820,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,3293.67,31870.39,APC 378
Fusion of hand bones,25820,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,3293.67,31870.39,APC
Fusion of hand bones,25820,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,3293.67,31870.39,APC
Fusion of hand bones,25820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,3293.67,31870.39,APC
Fusion of hand bones,25820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,3293.67,31870.39,Radiology
Fusion of hand bones,25820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,3293.67,31870.39,APC
Fusion of hand bones,25820,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,3293.67,31870.39,APC
Fuse hand bones with graft,25825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19822.36,,,,,,,fee schedule,7183.42,31870.39,
Fuse hand bones with graft,25825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15889.35,,,,,,,fee schedule,7183.42,31870.39,
Fuse hand bones with graft,25825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17357.67,,,,,,,fee schedule,7183.42,31870.39,
Fuse hand bones with graft,25825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18249.15,,,,,,,fee schedule,7183.42,31870.39,
Fuse hand bones with graft,25825,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Fuse hand bones with graft,25825,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Fuse hand bones with graft,25825,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Fuse hand bones with graft,25825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Fuse hand bones with graft,25825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Fuse hand bones with graft,25825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Fuse hand bones with graft,25825,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Fusion radioulnar jnt/ulna,25830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19822.36,,,,,,,fee schedule,7183.42,31870.39,
Fusion radioulnar jnt/ulna,25830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15889.35,,,,,,,fee schedule,7183.42,31870.39,
Fusion radioulnar jnt/ulna,25830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17357.67,,,,,,,fee schedule,7183.42,31870.39,
Fusion radioulnar jnt/ulna,25830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18249.15,,,,,,,fee schedule,7183.42,31870.39,
Fusion radioulnar jnt/ulna,25830,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Fusion radioulnar jnt/ulna,25830,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Fusion radioulnar jnt/ulna,25830,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Fusion radioulnar jnt/ulna,25830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Fusion radioulnar jnt/ulna,25830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Fusion radioulnar jnt/ulna,25830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Fusion radioulnar jnt/ulna,25830,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Amputation of forearm,25900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46549.79,,,,,,,fee schedule,7183.42,46549.79,
Amputation of forearm,25900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37313.72,,,,,,,fee schedule,7183.42,46549.79,
Amputation of forearm,25900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40761.86,,,,,,,fee schedule,7183.42,46549.79,
Amputation of forearm,25900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42855.36,,,,,,,fee schedule,7183.42,46549.79,
Amputation of forearm,25900,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,46549.79,APC 378
Amputation of forearm,25900,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,46549.79,APC
Amputation of forearm,25900,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,46549.79,APC
Amputation of forearm,25900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,46549.79,APC
Amputation of forearm,25900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,46549.79,Radiology
Amputation of forearm,25900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,46549.79,APC
Amputation of forearm,25900,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,46549.79,APC
Amputation of forearm,25905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46549.79,,,,,,,fee schedule,7183.42,46549.79,
Amputation of forearm,25905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37313.72,,,,,,,fee schedule,7183.42,46549.79,
Amputation of forearm,25905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40761.86,,,,,,,fee schedule,7183.42,46549.79,
Amputation of forearm,25905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42855.36,,,,,,,fee schedule,7183.42,46549.79,
Amputation of forearm,25905,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,46549.79,APC 378
Amputation of forearm,25905,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,46549.79,APC
Amputation of forearm,25905,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,46549.79,APC
Amputation of forearm,25905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,46549.79,APC
Amputation of forearm,25905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,46549.79,Radiology
Amputation of forearm,25905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,46549.79,APC
Amputation of forearm,25905,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,46549.79,APC
Amputation follow-up surgery,25907,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,3239.17,14371.12,
Amputation follow-up surgery,25907,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,3239.17,14371.12,
Amputation follow-up surgery,25907,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,3239.17,14371.12,
Amputation follow-up surgery,25907,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,3239.17,14371.12,
Amputation follow-up surgery,25907,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Amputation follow-up surgery,25907,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Amputation follow-up surgery,25907,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Amputation follow-up surgery,25907,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Amputation follow-up surgery,25907,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Amputation follow-up surgery,25907,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Amputation follow-up surgery,25907,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Amputation follow-up surgery,25909,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9216.93,,,,,,,fee schedule,7183.42,31870.39,
Amputation follow-up surgery,25909,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7388.17,,,,,,,fee schedule,7183.42,31870.39,
Amputation follow-up surgery,25909,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8070.91,,,,,,,fee schedule,7183.42,31870.39,
Amputation follow-up surgery,25909,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8485.42,,,,,,,fee schedule,7183.42,31870.39,
Amputation follow-up surgery,25909,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Amputation follow-up surgery,25909,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Amputation follow-up surgery,25909,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Amputation follow-up surgery,25909,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Amputation follow-up surgery,25909,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Amputation follow-up surgery,25909,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Amputation follow-up surgery,25909,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Amputation of forearm,25915,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Amputation of forearm,25915,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Amputation of forearm,25915,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Amputation of forearm,25915,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Amputation of forearm,25915,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Amputation of forearm,25915,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Amputation of forearm,25915,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Amputation of forearm,25915,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Amputation of forearm,25915,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Amputation of forearm,25915,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Amputation of forearm,25915,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Amputate hand at wrist,25920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,3239.17,23681.51,
Amputate hand at wrist,25920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,3239.17,23681.51,
Amputate hand at wrist,25920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,3239.17,23681.51,
Amputate hand at wrist,25920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,3239.17,23681.51,
Amputate hand at wrist,25920,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,23681.51,APC 378
Amputate hand at wrist,25920,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,23681.51,APC
Amputate hand at wrist,25920,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,23681.51,APC
Amputate hand at wrist,25920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,23681.51,APC
Amputate hand at wrist,25920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,23681.51,Radiology
Amputate hand at wrist,25920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,23681.51,APC
Amputate hand at wrist,25920,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,23681.51,APC
Amputate hand at wrist,25922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,1591.86,7062.54,
Amputate hand at wrist,25922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,1591.86,7062.54,
Amputate hand at wrist,25922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,1591.86,7062.54,
Amputate hand at wrist,25922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,1591.86,7062.54,
Amputate hand at wrist,25922,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Amputate hand at wrist,25922,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Amputate hand at wrist,25922,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Amputate hand at wrist,25922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Amputate hand at wrist,25922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Amputate hand at wrist,25922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Amputate hand at wrist,25922,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Amputation follow-up surgery,25924,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,3239.17,23681.51,
Amputation follow-up surgery,25924,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,3239.17,23681.51,
Amputation follow-up surgery,25924,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,3239.17,23681.51,
Amputation follow-up surgery,25924,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,3239.17,23681.51,
Amputation follow-up surgery,25924,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,23681.51,APC 378
Amputation follow-up surgery,25924,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,23681.51,APC
Amputation follow-up surgery,25924,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,23681.51,APC
Amputation follow-up surgery,25924,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,23681.51,APC
Amputation follow-up surgery,25924,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,23681.51,Radiology
Amputation follow-up surgery,25924,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,23681.51,APC
Amputation follow-up surgery,25924,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,23681.51,APC
Amputation of hand,25927,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10698.91,,,,,,,fee schedule,3239.17,14371.12,
Amputation of hand,25927,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8576.11,,,,,,,fee schedule,3239.17,14371.12,
Amputation of hand,25927,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9368.62,,,,,,,fee schedule,3239.17,14371.12,
Amputation of hand,25927,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9849.79,,,,,,,fee schedule,3239.17,14371.12,
Amputation of hand,25927,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Amputation of hand,25927,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Amputation of hand,25927,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Amputation of hand,25927,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Amputation of hand,25927,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Amputation of hand,25927,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Amputation of hand,25927,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Amputation follow-up surgery,25929,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3755.05,,,,,,,fee schedule,2042.58,9062.24,
Amputation follow-up surgery,25929,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3010,,,,,,,fee schedule,2042.58,9062.24,
Amputation follow-up surgery,25929,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3288.15,,,,,,,fee schedule,2042.58,9062.24,
Amputation follow-up surgery,25929,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3457.03,,,,,,,fee schedule,2042.58,9062.24,
Amputation follow-up surgery,25929,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,2042.58,9062.24,APC 378
Amputation follow-up surgery,25929,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,2042.58,9062.24,APC
Amputation follow-up surgery,25929,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,2042.58,9062.24,APC
Amputation follow-up surgery,25929,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,2042.58,9062.24,APC
Amputation follow-up surgery,25929,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,2042.58,9062.24,Radiology
Amputation follow-up surgery,25929,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,2042.58,9062.24,APC
Amputation follow-up surgery,25929,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,2042.58,9062.24,APC
Amputation follow-up surgery,25931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,3239.17,14371.12,
Amputation follow-up surgery,25931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,3239.17,14371.12,
Amputation follow-up surgery,25931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,3239.17,14371.12,
Amputation follow-up surgery,25931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,3239.17,14371.12,
Amputation follow-up surgery,25931,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Amputation follow-up surgery,25931,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Amputation follow-up surgery,25931,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Amputation follow-up surgery,25931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Amputation follow-up surgery,25931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Amputation follow-up surgery,25931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Amputation follow-up surgery,25931,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Forearm or wrist surgery,25999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,244.19,1083.4,
Forearm or wrist surgery,25999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,244.19,1083.4,
Forearm or wrist surgery,25999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,244.19,1083.4,
Forearm or wrist surgery,25999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,244.19,1083.4,
Forearm or wrist surgery,25999,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Forearm or wrist surgery,25999,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Forearm or wrist surgery,25999,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Forearm or wrist surgery,25999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Forearm or wrist surgery,25999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Forearm or wrist surgery,25999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Forearm or wrist surgery,25999,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Drainage of finger abscess,26010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,209.5,,,,,,,fee schedule,167.93,881.22,
Drainage of finger abscess,26010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,167.93,,,,,,,fee schedule,167.93,881.22,
Drainage of finger abscess,26010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,183.45,,,,,,,fee schedule,167.93,881.22,
Drainage of finger abscess,26010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,192.87,,,,,,,fee schedule,167.93,881.22,
Drainage of finger abscess,26010,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,881.22,,,,,,,fee schedule,167.93,881.22,APC 378
Drainage of finger abscess,26010,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.55,,,,,,,fee schedule,167.93,881.22,APC
Drainage of finger abscess,26010,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,206.57,,,,,,,fee schedule,167.93,881.22,APC
Drainage of finger abscess,26010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.62,,,,,,,fee schedule,167.93,881.22,APC
Drainage of finger abscess,26010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.89,,,,,,,fee schedule,167.93,881.22,Radiology
Drainage of finger abscess,26010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,278.07,,,,,,,fee schedule,167.93,881.22,APC
Drainage of finger abscess,26010,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,347.59,,,,,,,fee schedule,167.93,881.22,APC
Drainage of finger abscess,26011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2884.93,,,,,,,fee schedule,1635.03,7254.06,
Drainage of finger abscess,26011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2312.53,,,,,,,fee schedule,1635.03,7254.06,
Drainage of finger abscess,26011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2526.23,,,,,,,fee schedule,1635.03,7254.06,
Drainage of finger abscess,26011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2655.97,,,,,,,fee schedule,1635.03,7254.06,
Drainage of finger abscess,26011,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,7254.06,APC 378
Drainage of finger abscess,26011,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,7254.06,APC
Drainage of finger abscess,26011,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,7254.06,APC
Drainage of finger abscess,26011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,7254.06,APC
Drainage of finger abscess,26011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,7254.06,Radiology
Drainage of finger abscess,26011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,7254.06,APC
Drainage of finger abscess,26011,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,7254.06,APC
Drain hand tendon sheath,26020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4108.94,,,,,,,fee schedule,3239.17,14371.12,
Drain hand tendon sheath,26020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3293.67,,,,,,,fee schedule,3239.17,14371.12,
Drain hand tendon sheath,26020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3598.04,,,,,,,fee schedule,3239.17,14371.12,
Drain hand tendon sheath,26020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3782.83,,,,,,,fee schedule,3239.17,14371.12,
Drain hand tendon sheath,26020,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Drain hand tendon sheath,26020,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Drain hand tendon sheath,26020,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Drain hand tendon sheath,26020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Drain hand tendon sheath,26020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Drain hand tendon sheath,26020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Drain hand tendon sheath,26020,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Drainage of palm bursa,26025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4108.94,,,,,,,fee schedule,3239.17,14371.12,
Drainage of palm bursa,26025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3293.67,,,,,,,fee schedule,3239.17,14371.12,
Drainage of palm bursa,26025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3598.04,,,,,,,fee schedule,3239.17,14371.12,
Drainage of palm bursa,26025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3782.83,,,,,,,fee schedule,3239.17,14371.12,
Drainage of palm bursa,26025,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Drainage of palm bursa,26025,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Drainage of palm bursa,26025,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Drainage of palm bursa,26025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Drainage of palm bursa,26025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Drainage of palm bursa,26025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Drainage of palm bursa,26025,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Drainage of palm bursas,26030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4108.94,,,,,,,fee schedule,3239.17,14371.12,
Drainage of palm bursas,26030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3293.67,,,,,,,fee schedule,3239.17,14371.12,
Drainage of palm bursas,26030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3598.04,,,,,,,fee schedule,3239.17,14371.12,
Drainage of palm bursas,26030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3782.83,,,,,,,fee schedule,3239.17,14371.12,
Drainage of palm bursas,26030,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Drainage of palm bursas,26030,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Drainage of palm bursas,26030,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Drainage of palm bursas,26030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Drainage of palm bursas,26030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Drainage of palm bursas,26030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Drainage of palm bursas,26030,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Treat hand bone lesion,26034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6721.57,,,,,,,fee schedule,1591.86,7062.54,
Treat hand bone lesion,26034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5387.93,,,,,,,fee schedule,1591.86,7062.54,
Treat hand bone lesion,26034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5885.82,,,,,,,fee schedule,1591.86,7062.54,
Treat hand bone lesion,26034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6188.11,,,,,,,fee schedule,1591.86,7062.54,
Treat hand bone lesion,26034,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Treat hand bone lesion,26034,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Treat hand bone lesion,26034,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Treat hand bone lesion,26034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Treat hand bone lesion,26034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Treat hand bone lesion,26034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Treat hand bone lesion,26034,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Decompress fingers/hand,26035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4108.94,,,,,,,fee schedule,3239.17,14371.12,
Decompress fingers/hand,26035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3293.67,,,,,,,fee schedule,3239.17,14371.12,
Decompress fingers/hand,26035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3598.04,,,,,,,fee schedule,3239.17,14371.12,
Decompress fingers/hand,26035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3782.83,,,,,,,fee schedule,3239.17,14371.12,
Decompress fingers/hand,26035,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Decompress fingers/hand,26035,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Decompress fingers/hand,26035,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Decompress fingers/hand,26035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Decompress fingers/hand,26035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Decompress fingers/hand,26035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Decompress fingers/hand,26035,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Decompress fingers/hand,26037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4108.94,,,,,,,fee schedule,3239.17,14371.12,
Decompress fingers/hand,26037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3293.67,,,,,,,fee schedule,3239.17,14371.12,
Decompress fingers/hand,26037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3598.04,,,,,,,fee schedule,3239.17,14371.12,
Decompress fingers/hand,26037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3782.83,,,,,,,fee schedule,3239.17,14371.12,
Decompress fingers/hand,26037,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Decompress fingers/hand,26037,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Decompress fingers/hand,26037,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Decompress fingers/hand,26037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Decompress fingers/hand,26037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Decompress fingers/hand,26037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Decompress fingers/hand,26037,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Release palm contracture,26040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6566.46,,,,,,,fee schedule,1591.86,7062.54,
Release palm contracture,26040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5263.59,,,,,,,fee schedule,1591.86,7062.54,
Release palm contracture,26040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5750,,,,,,,fee schedule,1591.86,7062.54,
Release palm contracture,26040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6045.32,,,,,,,fee schedule,1591.86,7062.54,
Release palm contracture,26040,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Release palm contracture,26040,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Release palm contracture,26040,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Release palm contracture,26040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Release palm contracture,26040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Release palm contracture,26040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Release palm contracture,26040,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Release palm contracture,26045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6566.46,,,,,,,fee schedule,3239.17,14371.12,
Release palm contracture,26045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5263.59,,,,,,,fee schedule,3239.17,14371.12,
Release palm contracture,26045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5750,,,,,,,fee schedule,3239.17,14371.12,
Release palm contracture,26045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6045.32,,,,,,,fee schedule,3239.17,14371.12,
Release palm contracture,26045,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Release palm contracture,26045,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Release palm contracture,26045,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Release palm contracture,26045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Release palm contracture,26045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Release palm contracture,26045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Release palm contracture,26045,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Incise finger tendon sheath,26055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4857.27,,,,,,,fee schedule,1591.86,7062.54,
Incise finger tendon sheath,26055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3893.53,,,,,,,fee schedule,1591.86,7062.54,
Incise finger tendon sheath,26055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4253.33,,,,,,,fee schedule,1591.86,7062.54,
Incise finger tendon sheath,26055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4471.77,,,,,,,fee schedule,1591.86,7062.54,
Incise finger tendon sheath,26055,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Incise finger tendon sheath,26055,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Incise finger tendon sheath,26055,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Incise finger tendon sheath,26055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Incise finger tendon sheath,26055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Incise finger tendon sheath,26055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Incise finger tendon sheath,26055,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Incision of finger tendon,26060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4108.94,,,,,,,fee schedule,1591.86,7062.54,
Incision of finger tendon,26060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3293.67,,,,,,,fee schedule,1591.86,7062.54,
Incision of finger tendon,26060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3598.04,,,,,,,fee schedule,1591.86,7062.54,
Incision of finger tendon,26060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3782.83,,,,,,,fee schedule,1591.86,7062.54,
Incision of finger tendon,26060,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Incision of finger tendon,26060,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Incision of finger tendon,26060,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Incision of finger tendon,26060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Incision of finger tendon,26060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Incision of finger tendon,26060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Incision of finger tendon,26060,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Explore/treat hand joint,26070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4108.94,,,,,,,fee schedule,1591.86,7062.54,
Explore/treat hand joint,26070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3293.67,,,,,,,fee schedule,1591.86,7062.54,
Explore/treat hand joint,26070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3598.04,,,,,,,fee schedule,1591.86,7062.54,
Explore/treat hand joint,26070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3782.83,,,,,,,fee schedule,1591.86,7062.54,
Explore/treat hand joint,26070,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Explore/treat hand joint,26070,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Explore/treat hand joint,26070,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Explore/treat hand joint,26070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Explore/treat hand joint,26070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Explore/treat hand joint,26070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Explore/treat hand joint,26070,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Explore/treat finger joint,26075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4108.94,,,,,,,fee schedule,3239.17,14371.12,
Explore/treat finger joint,26075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3293.67,,,,,,,fee schedule,3239.17,14371.12,
Explore/treat finger joint,26075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3598.04,,,,,,,fee schedule,3239.17,14371.12,
Explore/treat finger joint,26075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3782.83,,,,,,,fee schedule,3239.17,14371.12,
Explore/treat finger joint,26075,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Explore/treat finger joint,26075,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Explore/treat finger joint,26075,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Explore/treat finger joint,26075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Explore/treat finger joint,26075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Explore/treat finger joint,26075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Explore/treat finger joint,26075,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Explore/treat finger joint,26080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10470.83,,,,,,,fee schedule,1591.86,10470.83,
Explore/treat finger joint,26080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8393.28,,,,,,,fee schedule,1591.86,10470.83,
Explore/treat finger joint,26080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9168.9,,,,,,,fee schedule,1591.86,10470.83,
Explore/treat finger joint,26080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9639.81,,,,,,,fee schedule,1591.86,10470.83,
Explore/treat finger joint,26080,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,10470.83,APC 378
Explore/treat finger joint,26080,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,10470.83,APC
Explore/treat finger joint,26080,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,10470.83,APC
Explore/treat finger joint,26080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,10470.83,APC
Explore/treat finger joint,26080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,10470.83,Radiology
Explore/treat finger joint,26080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,10470.83,APC
Explore/treat finger joint,26080,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,10470.83,APC
Biopsy hand joint lining,26100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4108.94,,,,,,,fee schedule,3239.17,14371.12,
Biopsy hand joint lining,26100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3293.67,,,,,,,fee schedule,3239.17,14371.12,
Biopsy hand joint lining,26100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3598.04,,,,,,,fee schedule,3239.17,14371.12,
Biopsy hand joint lining,26100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3782.83,,,,,,,fee schedule,3239.17,14371.12,
Biopsy hand joint lining,26100,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Biopsy hand joint lining,26100,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Biopsy hand joint lining,26100,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Biopsy hand joint lining,26100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Biopsy hand joint lining,26100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Biopsy hand joint lining,26100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Biopsy hand joint lining,26100,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Biopsy finger joint lining,26105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4108.94,,,,,,,fee schedule,3239.17,14371.12,
Biopsy finger joint lining,26105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3293.67,,,,,,,fee schedule,3239.17,14371.12,
Biopsy finger joint lining,26105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3598.04,,,,,,,fee schedule,3239.17,14371.12,
Biopsy finger joint lining,26105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3782.83,,,,,,,fee schedule,3239.17,14371.12,
Biopsy finger joint lining,26105,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Biopsy finger joint lining,26105,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Biopsy finger joint lining,26105,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Biopsy finger joint lining,26105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Biopsy finger joint lining,26105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Biopsy finger joint lining,26105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Biopsy finger joint lining,26105,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Biopsy finger joint lining,26110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2084.48,,,,,,,fee schedule,1591.86,7062.54,
Biopsy finger joint lining,26110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1670.89,,,,,,,fee schedule,1591.86,7062.54,
Biopsy finger joint lining,26110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1825.3,,,,,,,fee schedule,1591.86,7062.54,
Biopsy finger joint lining,26110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1919.04,,,,,,,fee schedule,1591.86,7062.54,
Biopsy finger joint lining,26110,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Biopsy finger joint lining,26110,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Biopsy finger joint lining,26110,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Biopsy finger joint lining,26110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Biopsy finger joint lining,26110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Biopsy finger joint lining,26110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Biopsy finger joint lining,26110,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Exc hand les sc 1.5 cm/>,26111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6177.24,,,,,,,fee schedule,1635.03,7254.06,
Exc hand les sc 1.5 cm/>,26111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4951.6,,,,,,,fee schedule,1635.03,7254.06,
Exc hand les sc 1.5 cm/>,26111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5409.17,,,,,,,fee schedule,1635.03,7254.06,
Exc hand les sc 1.5 cm/>,26111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5686.98,,,,,,,fee schedule,1635.03,7254.06,
Exc hand les sc 1.5 cm/>,26111,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,7254.06,APC 378
Exc hand les sc 1.5 cm/>,26111,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,7254.06,APC
Exc hand les sc 1.5 cm/>,26111,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,7254.06,APC
Exc hand les sc 1.5 cm/>,26111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,7254.06,APC
Exc hand les sc 1.5 cm/>,26111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,7254.06,Radiology
Exc hand les sc 1.5 cm/>,26111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,7254.06,APC
Exc hand les sc 1.5 cm/>,26111,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,7254.06,APC
Exc hand tum deep 1.5 cm/>,26113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6177.24,,,,,,,fee schedule,1635.03,7254.06,
Exc hand tum deep 1.5 cm/>,26113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4951.6,,,,,,,fee schedule,1635.03,7254.06,
Exc hand tum deep 1.5 cm/>,26113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5409.17,,,,,,,fee schedule,1635.03,7254.06,
Exc hand tum deep 1.5 cm/>,26113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5686.98,,,,,,,fee schedule,1635.03,7254.06,
Exc hand tum deep 1.5 cm/>,26113,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,7254.06,APC 378
Exc hand tum deep 1.5 cm/>,26113,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,7254.06,APC
Exc hand tum deep 1.5 cm/>,26113,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,7254.06,APC
Exc hand tum deep 1.5 cm/>,26113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,7254.06,APC
Exc hand tum deep 1.5 cm/>,26113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,7254.06,Radiology
Exc hand tum deep 1.5 cm/>,26113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,7254.06,APC
Exc hand tum deep 1.5 cm/>,26113,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,7254.06,APC
Exc hand les sc < 1.5 cm,26115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6019.4,,,,,,,fee schedule,1635.03,7254.06,
Exc hand les sc < 1.5 cm,26115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4825.07,,,,,,,fee schedule,1635.03,7254.06,
Exc hand les sc < 1.5 cm,26115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5270.95,,,,,,,fee schedule,1635.03,7254.06,
Exc hand les sc < 1.5 cm,26115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5541.67,,,,,,,fee schedule,1635.03,7254.06,
Exc hand les sc < 1.5 cm,26115,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,7254.06,APC 378
Exc hand les sc < 1.5 cm,26115,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,7254.06,APC
Exc hand les sc < 1.5 cm,26115,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,7254.06,APC
Exc hand les sc < 1.5 cm,26115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,7254.06,APC
Exc hand les sc < 1.5 cm,26115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,7254.06,Radiology
Exc hand les sc < 1.5 cm,26115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,7254.06,APC
Exc hand les sc < 1.5 cm,26115,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,7254.06,APC
Exc hand tum deep < 1.5 cm,26116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7189.69,,,,,,,fee schedule,1635.03,7254.06,
Exc hand tum deep < 1.5 cm,26116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5763.16,,,,,,,fee schedule,1635.03,7254.06,
Exc hand tum deep < 1.5 cm,26116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6295.73,,,,,,,fee schedule,1635.03,7254.06,
Exc hand tum deep < 1.5 cm,26116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6619.08,,,,,,,fee schedule,1635.03,7254.06,
Exc hand tum deep < 1.5 cm,26116,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,7254.06,APC 378
Exc hand tum deep < 1.5 cm,26116,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,7254.06,APC
Exc hand tum deep < 1.5 cm,26116,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,7254.06,APC
Exc hand tum deep < 1.5 cm,26116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,7254.06,APC
Exc hand tum deep < 1.5 cm,26116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,7254.06,Radiology
Exc hand tum deep < 1.5 cm,26116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,7254.06,APC
Exc hand tum deep < 1.5 cm,26116,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,7254.06,APC
Rad resect hand tumor < 3 cm,26117,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5268.49,,,,,,,fee schedule,2875.57,12757.95,
Rad resect hand tumor < 3 cm,26117,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4223.15,,,,,,,fee schedule,2875.57,12757.95,
Rad resect hand tumor < 3 cm,26117,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4613.41,,,,,,,fee schedule,2875.57,12757.95,
Rad resect hand tumor < 3 cm,26117,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4850.35,,,,,,,fee schedule,2875.57,12757.95,
Rad resect hand tumor < 3 cm,26117,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Rad resect hand tumor < 3 cm,26117,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Rad resect hand tumor < 3 cm,26117,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Rad resect hand tumor < 3 cm,26117,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Rad resect hand tumor < 3 cm,26117,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Rad resect hand tumor < 3 cm,26117,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Rad resect hand tumor < 3 cm,26117,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Rad resect hand tumor 3 cm/>,26118,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6177.24,,,,,,,fee schedule,2875.57,12757.95,
Rad resect hand tumor 3 cm/>,26118,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4951.6,,,,,,,fee schedule,2875.57,12757.95,
Rad resect hand tumor 3 cm/>,26118,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5409.17,,,,,,,fee schedule,2875.57,12757.95,
Rad resect hand tumor 3 cm/>,26118,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5686.98,,,,,,,fee schedule,2875.57,12757.95,
Rad resect hand tumor 3 cm/>,26118,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Rad resect hand tumor 3 cm/>,26118,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Rad resect hand tumor 3 cm/>,26118,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Rad resect hand tumor 3 cm/>,26118,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Rad resect hand tumor 3 cm/>,26118,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Rad resect hand tumor 3 cm/>,26118,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Rad resect hand tumor 3 cm/>,26118,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Release palm contracture,26121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6566.46,,,,,,,fee schedule,3239.17,14371.12,
Release palm contracture,26121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5263.59,,,,,,,fee schedule,3239.17,14371.12,
Release palm contracture,26121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5750,,,,,,,fee schedule,3239.17,14371.12,
Release palm contracture,26121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6045.32,,,,,,,fee schedule,3239.17,14371.12,
Release palm contracture,26121,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Release palm contracture,26121,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Release palm contracture,26121,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Release palm contracture,26121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Release palm contracture,26121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Release palm contracture,26121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Release palm contracture,26121,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Release palm contracture,26123,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6566.46,,,,,,,fee schedule,3239.17,14371.12,
Release palm contracture,26123,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5263.59,,,,,,,fee schedule,3239.17,14371.12,
Release palm contracture,26123,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5750,,,,,,,fee schedule,3239.17,14371.12,
Release palm contracture,26123,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6045.32,,,,,,,fee schedule,3239.17,14371.12,
Release palm contracture,26123,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Release palm contracture,26123,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Release palm contracture,26123,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Release palm contracture,26123,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Release palm contracture,26123,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Release palm contracture,26123,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Release palm contracture,26123,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Release palm contracture,26125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4108.94,,,,,,,fee schedule,3293.67,4108.94,
Release palm contracture,26125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3293.67,,,,,,,fee schedule,3293.67,4108.94,
Release palm contracture,26125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3598.04,,,,,,,fee schedule,3293.67,4108.94,
Release palm contracture,26125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3782.83,,,,,,,fee schedule,3293.67,4108.94,
Remove wrist joint lining,26130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4062.96,,,,,,,fee schedule,3239.17,14371.12,
Remove wrist joint lining,26130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3256.82,,,,,,,fee schedule,3239.17,14371.12,
Remove wrist joint lining,26130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3557.78,,,,,,,fee schedule,3239.17,14371.12,
Remove wrist joint lining,26130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3740.5,,,,,,,fee schedule,3239.17,14371.12,
Remove wrist joint lining,26130,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Remove wrist joint lining,26130,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Remove wrist joint lining,26130,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Remove wrist joint lining,26130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Remove wrist joint lining,26130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Remove wrist joint lining,26130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Remove wrist joint lining,26130,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Revise finger joint each,26135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6566.46,,,,,,,fee schedule,3239.17,14371.12,
Revise finger joint each,26135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5263.59,,,,,,,fee schedule,3239.17,14371.12,
Revise finger joint each,26135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5750,,,,,,,fee schedule,3239.17,14371.12,
Revise finger joint each,26135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6045.32,,,,,,,fee schedule,3239.17,14371.12,
Revise finger joint each,26135,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Revise finger joint each,26135,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Revise finger joint each,26135,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Revise finger joint each,26135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Revise finger joint each,26135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Revise finger joint each,26135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Revise finger joint each,26135,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Revise finger joint each,26140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4108.94,,,,,,,fee schedule,1591.86,7062.54,
Revise finger joint each,26140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3293.67,,,,,,,fee schedule,1591.86,7062.54,
Revise finger joint each,26140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3598.04,,,,,,,fee schedule,1591.86,7062.54,
Revise finger joint each,26140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3782.83,,,,,,,fee schedule,1591.86,7062.54,
Revise finger joint each,26140,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Revise finger joint each,26140,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Revise finger joint each,26140,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Revise finger joint each,26140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Revise finger joint each,26140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Revise finger joint each,26140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Revise finger joint each,26140,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Tendon excision palm/finger,26145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3360.79,,,,,,,fee schedule,1591.86,7062.54,
Tendon excision palm/finger,26145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2693.96,,,,,,,fee schedule,1591.86,7062.54,
Tendon excision palm/finger,26145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2942.91,,,,,,,fee schedule,1591.86,7062.54,
Tendon excision palm/finger,26145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3094.06,,,,,,,fee schedule,1591.86,7062.54,
Tendon excision palm/finger,26145,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Tendon excision palm/finger,26145,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Tendon excision palm/finger,26145,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Tendon excision palm/finger,26145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Tendon excision palm/finger,26145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Tendon excision palm/finger,26145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Tendon excision palm/finger,26145,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Remove tendon sheath lesion,26160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5250.49,,,,,,,fee schedule,1591.86,7062.54,
Remove tendon sheath lesion,26160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4208.73,,,,,,,fee schedule,1591.86,7062.54,
Remove tendon sheath lesion,26160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4597.65,,,,,,,fee schedule,1591.86,7062.54,
Remove tendon sheath lesion,26160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4833.79,,,,,,,fee schedule,1591.86,7062.54,
Remove tendon sheath lesion,26160,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Remove tendon sheath lesion,26160,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Remove tendon sheath lesion,26160,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Remove tendon sheath lesion,26160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Remove tendon sheath lesion,26160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Remove tendon sheath lesion,26160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Remove tendon sheath lesion,26160,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Removal of palm tendon each,26170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4108.94,,,,,,,fee schedule,1591.86,7062.54,
Removal of palm tendon each,26170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3293.67,,,,,,,fee schedule,1591.86,7062.54,
Removal of palm tendon each,26170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3598.04,,,,,,,fee schedule,1591.86,7062.54,
Removal of palm tendon each,26170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3782.83,,,,,,,fee schedule,1591.86,7062.54,
Removal of palm tendon each,26170,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Removal of palm tendon each,26170,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Removal of palm tendon each,26170,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Removal of palm tendon each,26170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Removal of palm tendon each,26170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Removal of palm tendon each,26170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Removal of palm tendon each,26170,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Removal of finger tendon,26180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4108.94,,,,,,,fee schedule,1591.86,7062.54,
Removal of finger tendon,26180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3293.67,,,,,,,fee schedule,1591.86,7062.54,
Removal of finger tendon,26180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3598.04,,,,,,,fee schedule,1591.86,7062.54,
Removal of finger tendon,26180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3782.83,,,,,,,fee schedule,1591.86,7062.54,
Removal of finger tendon,26180,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Removal of finger tendon,26180,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Removal of finger tendon,26180,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Removal of finger tendon,26180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Removal of finger tendon,26180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Removal of finger tendon,26180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Removal of finger tendon,26180,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Remove finger bone,26185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4108.94,,,,,,,fee schedule,1591.86,7062.54,
Remove finger bone,26185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3293.67,,,,,,,fee schedule,1591.86,7062.54,
Remove finger bone,26185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3598.04,,,,,,,fee schedule,1591.86,7062.54,
Remove finger bone,26185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3782.83,,,,,,,fee schedule,1591.86,7062.54,
Remove finger bone,26185,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Remove finger bone,26185,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Remove finger bone,26185,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Remove finger bone,26185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Remove finger bone,26185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Remove finger bone,26185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Remove finger bone,26185,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Remove hand bone lesion,26200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4108.94,,,,,,,fee schedule,1591.86,7062.54,
Remove hand bone lesion,26200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3293.67,,,,,,,fee schedule,1591.86,7062.54,
Remove hand bone lesion,26200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3598.04,,,,,,,fee schedule,1591.86,7062.54,
Remove hand bone lesion,26200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3782.83,,,,,,,fee schedule,1591.86,7062.54,
Remove hand bone lesion,26200,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Remove hand bone lesion,26200,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Remove hand bone lesion,26200,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Remove hand bone lesion,26200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Remove hand bone lesion,26200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Remove hand bone lesion,26200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Remove hand bone lesion,26200,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Remove/graft bone lesion,26205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6566.46,,,,,,,fee schedule,5263.59,31870.39,
Remove/graft bone lesion,26205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5263.59,,,,,,,fee schedule,5263.59,31870.39,
Remove/graft bone lesion,26205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5750,,,,,,,fee schedule,5263.59,31870.39,
Remove/graft bone lesion,26205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6045.32,,,,,,,fee schedule,5263.59,31870.39,
Remove/graft bone lesion,26205,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5263.59,31870.39,APC 378
Remove/graft bone lesion,26205,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5263.59,31870.39,APC
Remove/graft bone lesion,26205,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5263.59,31870.39,APC
Remove/graft bone lesion,26205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5263.59,31870.39,APC
Remove/graft bone lesion,26205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5263.59,31870.39,Radiology
Remove/graft bone lesion,26205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5263.59,31870.39,APC
Remove/graft bone lesion,26205,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5263.59,31870.39,APC
Removal of finger lesion,26210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4108.94,,,,,,,fee schedule,1591.86,7062.54,
Removal of finger lesion,26210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3293.67,,,,,,,fee schedule,1591.86,7062.54,
Removal of finger lesion,26210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3598.04,,,,,,,fee schedule,1591.86,7062.54,
Removal of finger lesion,26210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3782.83,,,,,,,fee schedule,1591.86,7062.54,
Removal of finger lesion,26210,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Removal of finger lesion,26210,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Removal of finger lesion,26210,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Removal of finger lesion,26210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Removal of finger lesion,26210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Removal of finger lesion,26210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Removal of finger lesion,26210,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Remove/graft finger lesion,26215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4108.94,,,,,,,fee schedule,3239.17,14371.12,
Remove/graft finger lesion,26215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3293.67,,,,,,,fee schedule,3239.17,14371.12,
Remove/graft finger lesion,26215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3598.04,,,,,,,fee schedule,3239.17,14371.12,
Remove/graft finger lesion,26215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3782.83,,,,,,,fee schedule,3239.17,14371.12,
Remove/graft finger lesion,26215,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Remove/graft finger lesion,26215,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Remove/graft finger lesion,26215,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Remove/graft finger lesion,26215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Remove/graft finger lesion,26215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Remove/graft finger lesion,26215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Remove/graft finger lesion,26215,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Partial removal of hand bone,26230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4108.94,,,,,,,fee schedule,3239.17,14371.12,
Partial removal of hand bone,26230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3293.67,,,,,,,fee schedule,3239.17,14371.12,
Partial removal of hand bone,26230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3598.04,,,,,,,fee schedule,3239.17,14371.12,
Partial removal of hand bone,26230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3782.83,,,,,,,fee schedule,3239.17,14371.12,
Partial removal of hand bone,26230,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Partial removal of hand bone,26230,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Partial removal of hand bone,26230,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Partial removal of hand bone,26230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Partial removal of hand bone,26230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Partial removal of hand bone,26230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Partial removal of hand bone,26230,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Partial removal finger bone,26235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4108.94,,,,,,,fee schedule,1591.86,7062.54,
Partial removal finger bone,26235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3293.67,,,,,,,fee schedule,1591.86,7062.54,
Partial removal finger bone,26235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3598.04,,,,,,,fee schedule,1591.86,7062.54,
Partial removal finger bone,26235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3782.83,,,,,,,fee schedule,1591.86,7062.54,
Partial removal finger bone,26235,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Partial removal finger bone,26235,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Partial removal finger bone,26235,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Partial removal finger bone,26235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Partial removal finger bone,26235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Partial removal finger bone,26235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Partial removal finger bone,26235,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Partial removal finger bone,26236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4108.94,,,,,,,fee schedule,1591.86,7062.54,
Partial removal finger bone,26236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3293.67,,,,,,,fee schedule,1591.86,7062.54,
Partial removal finger bone,26236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3598.04,,,,,,,fee schedule,1591.86,7062.54,
Partial removal finger bone,26236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3782.83,,,,,,,fee schedule,1591.86,7062.54,
Partial removal finger bone,26236,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Partial removal finger bone,26236,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Partial removal finger bone,26236,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Partial removal finger bone,26236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Partial removal finger bone,26236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Partial removal finger bone,26236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Partial removal finger bone,26236,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Extensive hand surgery,26250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4108.94,,,,,,,fee schedule,3239.17,14371.12,
Extensive hand surgery,26250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3293.67,,,,,,,fee schedule,3239.17,14371.12,
Extensive hand surgery,26250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3598.04,,,,,,,fee schedule,3239.17,14371.12,
Extensive hand surgery,26250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3782.83,,,,,,,fee schedule,3239.17,14371.12,
Extensive hand surgery,26250,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Extensive hand surgery,26250,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Extensive hand surgery,26250,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Extensive hand surgery,26250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Extensive hand surgery,26250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Extensive hand surgery,26250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Extensive hand surgery,26250,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Resect prox finger tumor,26260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4108.94,,,,,,,fee schedule,3239.17,14371.12,
Resect prox finger tumor,26260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3293.67,,,,,,,fee schedule,3239.17,14371.12,
Resect prox finger tumor,26260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3598.04,,,,,,,fee schedule,3239.17,14371.12,
Resect prox finger tumor,26260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3782.83,,,,,,,fee schedule,3239.17,14371.12,
Resect prox finger tumor,26260,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Resect prox finger tumor,26260,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Resect prox finger tumor,26260,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Resect prox finger tumor,26260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Resect prox finger tumor,26260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Resect prox finger tumor,26260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Resect prox finger tumor,26260,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Resect distal finger tumor,26262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4108.94,,,,,,,fee schedule,1591.86,7062.54,
Resect distal finger tumor,26262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3293.67,,,,,,,fee schedule,1591.86,7062.54,
Resect distal finger tumor,26262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3598.04,,,,,,,fee schedule,1591.86,7062.54,
Resect distal finger tumor,26262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3782.83,,,,,,,fee schedule,1591.86,7062.54,
Resect distal finger tumor,26262,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Resect distal finger tumor,26262,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Resect distal finger tumor,26262,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Resect distal finger tumor,26262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Resect distal finger tumor,26262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Resect distal finger tumor,26262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Resect distal finger tumor,26262,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Removal of implant from hand,26320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4018.18,,,,,,,fee schedule,1635.03,7254.06,
Removal of implant from hand,26320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3220.92,,,,,,,fee schedule,1635.03,7254.06,
Removal of implant from hand,26320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3518.56,,,,,,,fee schedule,1635.03,7254.06,
Removal of implant from hand,26320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3699.27,,,,,,,fee schedule,1635.03,7254.06,
Removal of implant from hand,26320,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,7254.06,APC 378
Removal of implant from hand,26320,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,7254.06,APC
Removal of implant from hand,26320,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,7254.06,APC
Removal of implant from hand,26320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,7254.06,APC
Removal of implant from hand,26320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,7254.06,Radiology
Removal of implant from hand,26320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,7254.06,APC
Removal of implant from hand,26320,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,7254.06,APC
Manipulate finger w/anesth,26340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,353.72,7062.54,
Manipulate finger w/anesth,26340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,353.72,7062.54,
Manipulate finger w/anesth,26340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,353.72,7062.54,
Manipulate finger w/anesth,26340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,353.72,7062.54,
Manipulate finger w/anesth,26340,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,353.72,7062.54,APC 378
Manipulate finger w/anesth,26340,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,353.72,7062.54,APC
Manipulate finger w/anesth,26340,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,353.72,7062.54,APC
Manipulate finger w/anesth,26340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,353.72,7062.54,APC
Manipulate finger w/anesth,26340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,353.72,7062.54,Radiology
Manipulate finger w/anesth,26340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,353.72,7062.54,APC
Manipulate finger w/anesth,26340,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,353.72,7062.54,APC
Manipulat palm cord post inj,26341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1507.69,,,,,,,fee schedule,244.19,1507.69,
Manipulat palm cord post inj,26341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1208.55,,,,,,,fee schedule,244.19,1507.69,
Manipulat palm cord post inj,26341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1320.23,,,,,,,fee schedule,244.19,1507.69,
Manipulat palm cord post inj,26341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1388.03,,,,,,,fee schedule,244.19,1507.69,
Manipulat palm cord post inj,26341,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1507.69,APC 378
Manipulat palm cord post inj,26341,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1507.69,APC
Manipulat palm cord post inj,26341,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1507.69,APC
Manipulat palm cord post inj,26341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1507.69,APC
Manipulat palm cord post inj,26341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1507.69,Radiology
Manipulat palm cord post inj,26341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1507.69,APC
Manipulat palm cord post inj,26341,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1507.69,APC
Repair finger/hand tendon,26350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8594.03,,,,,,,fee schedule,3239.17,14371.12,
Repair finger/hand tendon,26350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6888.87,,,,,,,fee schedule,3239.17,14371.12,
Repair finger/hand tendon,26350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7525.46,,,,,,,fee schedule,3239.17,14371.12,
Repair finger/hand tendon,26350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7911.97,,,,,,,fee schedule,3239.17,14371.12,
Repair finger/hand tendon,26350,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Repair finger/hand tendon,26350,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Repair finger/hand tendon,26350,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Repair finger/hand tendon,26350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Repair finger/hand tendon,26350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Repair finger/hand tendon,26350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Repair finger/hand tendon,26350,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Repair/graft hand tendon,26352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6566.46,,,,,,,fee schedule,5263.59,31870.39,
Repair/graft hand tendon,26352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5263.59,,,,,,,fee schedule,5263.59,31870.39,
Repair/graft hand tendon,26352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5750,,,,,,,fee schedule,5263.59,31870.39,
Repair/graft hand tendon,26352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6045.32,,,,,,,fee schedule,5263.59,31870.39,
Repair/graft hand tendon,26352,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5263.59,31870.39,APC 378
Repair/graft hand tendon,26352,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5263.59,31870.39,APC
Repair/graft hand tendon,26352,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5263.59,31870.39,APC
Repair/graft hand tendon,26352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5263.59,31870.39,APC
Repair/graft hand tendon,26352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5263.59,31870.39,Radiology
Repair/graft hand tendon,26352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5263.59,31870.39,APC
Repair/graft hand tendon,26352,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5263.59,31870.39,APC
Repair finger/hand tendon,26356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4531.07,,,,,,,fee schedule,3239.17,14371.12,
Repair finger/hand tendon,26356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3632.05,,,,,,,fee schedule,3239.17,14371.12,
Repair finger/hand tendon,26356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3967.69,,,,,,,fee schedule,3239.17,14371.12,
Repair finger/hand tendon,26356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4171.46,,,,,,,fee schedule,3239.17,14371.12,
Repair finger/hand tendon,26356,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Repair finger/hand tendon,26356,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Repair finger/hand tendon,26356,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Repair finger/hand tendon,26356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Repair finger/hand tendon,26356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Repair finger/hand tendon,26356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Repair finger/hand tendon,26356,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Repair finger/hand tendon,26357,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6566.46,,,,,,,fee schedule,3239.17,14371.12,
Repair finger/hand tendon,26357,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5263.59,,,,,,,fee schedule,3239.17,14371.12,
Repair finger/hand tendon,26357,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5750,,,,,,,fee schedule,3239.17,14371.12,
Repair finger/hand tendon,26357,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6045.32,,,,,,,fee schedule,3239.17,14371.12,
Repair finger/hand tendon,26357,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Repair finger/hand tendon,26357,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Repair finger/hand tendon,26357,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Repair finger/hand tendon,26357,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Repair finger/hand tendon,26357,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Repair finger/hand tendon,26357,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Repair finger/hand tendon,26357,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Repair/graft hand tendon,26358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6566.46,,,,,,,fee schedule,5263.59,31870.39,
Repair/graft hand tendon,26358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5263.59,,,,,,,fee schedule,5263.59,31870.39,
Repair/graft hand tendon,26358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5750,,,,,,,fee schedule,5263.59,31870.39,
Repair/graft hand tendon,26358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6045.32,,,,,,,fee schedule,5263.59,31870.39,
Repair/graft hand tendon,26358,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5263.59,31870.39,APC 378
Repair/graft hand tendon,26358,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5263.59,31870.39,APC
Repair/graft hand tendon,26358,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5263.59,31870.39,APC
Repair/graft hand tendon,26358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5263.59,31870.39,APC
Repair/graft hand tendon,26358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5263.59,31870.39,Radiology
Repair/graft hand tendon,26358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5263.59,31870.39,APC
Repair/graft hand tendon,26358,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5263.59,31870.39,APC
Repair finger/hand tendon,26370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6566.46,,,,,,,fee schedule,3239.17,14371.12,
Repair finger/hand tendon,26370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5263.59,,,,,,,fee schedule,3239.17,14371.12,
Repair finger/hand tendon,26370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5750,,,,,,,fee schedule,3239.17,14371.12,
Repair finger/hand tendon,26370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6045.32,,,,,,,fee schedule,3239.17,14371.12,
Repair finger/hand tendon,26370,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Repair finger/hand tendon,26370,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Repair finger/hand tendon,26370,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Repair finger/hand tendon,26370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Repair finger/hand tendon,26370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Repair finger/hand tendon,26370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Repair finger/hand tendon,26370,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Repair/graft hand tendon,26372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6566.46,,,,,,,fee schedule,5263.59,31870.39,
Repair/graft hand tendon,26372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5263.59,,,,,,,fee schedule,5263.59,31870.39,
Repair/graft hand tendon,26372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5750,,,,,,,fee schedule,5263.59,31870.39,
Repair/graft hand tendon,26372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6045.32,,,,,,,fee schedule,5263.59,31870.39,
Repair/graft hand tendon,26372,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5263.59,31870.39,APC 378
Repair/graft hand tendon,26372,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5263.59,31870.39,APC
Repair/graft hand tendon,26372,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5263.59,31870.39,APC
Repair/graft hand tendon,26372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5263.59,31870.39,APC
Repair/graft hand tendon,26372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5263.59,31870.39,Radiology
Repair/graft hand tendon,26372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5263.59,31870.39,APC
Repair/graft hand tendon,26372,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5263.59,31870.39,APC
Repair finger/hand tendon,26373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6566.46,,,,,,,fee schedule,3239.17,14371.12,
Repair finger/hand tendon,26373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5263.59,,,,,,,fee schedule,3239.17,14371.12,
Repair finger/hand tendon,26373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5750,,,,,,,fee schedule,3239.17,14371.12,
Repair finger/hand tendon,26373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6045.32,,,,,,,fee schedule,3239.17,14371.12,
Repair finger/hand tendon,26373,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Repair finger/hand tendon,26373,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Repair finger/hand tendon,26373,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Repair finger/hand tendon,26373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Repair finger/hand tendon,26373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Repair finger/hand tendon,26373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Repair finger/hand tendon,26373,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Revise hand/finger tendon,26390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6566.46,,,,,,,fee schedule,5263.59,31870.39,
Revise hand/finger tendon,26390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5263.59,,,,,,,fee schedule,5263.59,31870.39,
Revise hand/finger tendon,26390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5750,,,,,,,fee schedule,5263.59,31870.39,
Revise hand/finger tendon,26390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6045.32,,,,,,,fee schedule,5263.59,31870.39,
Revise hand/finger tendon,26390,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5263.59,31870.39,APC 378
Revise hand/finger tendon,26390,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5263.59,31870.39,APC
Revise hand/finger tendon,26390,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5263.59,31870.39,APC
Revise hand/finger tendon,26390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5263.59,31870.39,APC
Revise hand/finger tendon,26390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5263.59,31870.39,Radiology
Revise hand/finger tendon,26390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5263.59,31870.39,APC
Revise hand/finger tendon,26390,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5263.59,31870.39,APC
Repair/graft hand tendon,26392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6566.46,,,,,,,fee schedule,5263.59,31870.39,
Repair/graft hand tendon,26392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5263.59,,,,,,,fee schedule,5263.59,31870.39,
Repair/graft hand tendon,26392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5750,,,,,,,fee schedule,5263.59,31870.39,
Repair/graft hand tendon,26392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6045.32,,,,,,,fee schedule,5263.59,31870.39,
Repair/graft hand tendon,26392,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5263.59,31870.39,APC 378
Repair/graft hand tendon,26392,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5263.59,31870.39,APC
Repair/graft hand tendon,26392,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5263.59,31870.39,APC
Repair/graft hand tendon,26392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5263.59,31870.39,APC
Repair/graft hand tendon,26392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5263.59,31870.39,Radiology
Repair/graft hand tendon,26392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5263.59,31870.39,APC
Repair/graft hand tendon,26392,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5263.59,31870.39,APC
Repair hand tendon,26410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1897.38,,,,,,,fee schedule,1520.92,7062.54,
Repair hand tendon,26410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1520.92,,,,,,,fee schedule,1520.92,7062.54,
Repair hand tendon,26410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1661.47,,,,,,,fee schedule,1520.92,7062.54,
Repair hand tendon,26410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1746.8,,,,,,,fee schedule,1520.92,7062.54,
Repair hand tendon,26410,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1520.92,7062.54,APC 378
Repair hand tendon,26410,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1520.92,7062.54,APC
Repair hand tendon,26410,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1520.92,7062.54,APC
Repair hand tendon,26410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1520.92,7062.54,APC
Repair hand tendon,26410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1520.92,7062.54,Radiology
Repair hand tendon,26410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1520.92,7062.54,APC
Repair hand tendon,26410,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1520.92,7062.54,APC
Repair/graft hand tendon,26412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6566.46,,,,,,,fee schedule,3239.17,14371.12,
Repair/graft hand tendon,26412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5263.59,,,,,,,fee schedule,3239.17,14371.12,
Repair/graft hand tendon,26412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5750,,,,,,,fee schedule,3239.17,14371.12,
Repair/graft hand tendon,26412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6045.32,,,,,,,fee schedule,3239.17,14371.12,
Repair/graft hand tendon,26412,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Repair/graft hand tendon,26412,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Repair/graft hand tendon,26412,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Repair/graft hand tendon,26412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Repair/graft hand tendon,26412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Repair/graft hand tendon,26412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Repair/graft hand tendon,26412,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Excision hand/finger tendon,26415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6566.46,,,,,,,fee schedule,3239.17,14371.12,
Excision hand/finger tendon,26415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5263.59,,,,,,,fee schedule,3239.17,14371.12,
Excision hand/finger tendon,26415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5750,,,,,,,fee schedule,3239.17,14371.12,
Excision hand/finger tendon,26415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6045.32,,,,,,,fee schedule,3239.17,14371.12,
Excision hand/finger tendon,26415,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Excision hand/finger tendon,26415,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Excision hand/finger tendon,26415,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Excision hand/finger tendon,26415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Excision hand/finger tendon,26415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Excision hand/finger tendon,26415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Excision hand/finger tendon,26415,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Graft hand or finger tendon,26416,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6566.46,,,,,,,fee schedule,3239.17,14371.12,
Graft hand or finger tendon,26416,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5263.59,,,,,,,fee schedule,3239.17,14371.12,
Graft hand or finger tendon,26416,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5750,,,,,,,fee schedule,3239.17,14371.12,
Graft hand or finger tendon,26416,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6045.32,,,,,,,fee schedule,3239.17,14371.12,
Graft hand or finger tendon,26416,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Graft hand or finger tendon,26416,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Graft hand or finger tendon,26416,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Graft hand or finger tendon,26416,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Graft hand or finger tendon,26416,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Graft hand or finger tendon,26416,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Graft hand or finger tendon,26416,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Repair finger tendon,26418,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5105.2,,,,,,,fee schedule,1591.86,7062.54,
Repair finger tendon,26418,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4092.26,,,,,,,fee schedule,1591.86,7062.54,
Repair finger tendon,26418,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4470.42,,,,,,,fee schedule,1591.86,7062.54,
Repair finger tendon,26418,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4700.02,,,,,,,fee schedule,1591.86,7062.54,
Repair finger tendon,26418,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Repair finger tendon,26418,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Repair finger tendon,26418,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Repair finger tendon,26418,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Repair finger tendon,26418,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Repair finger tendon,26418,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Repair finger tendon,26418,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Repair/graft finger tendon,26420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6566.46,,,,,,,fee schedule,3239.17,14371.12,
Repair/graft finger tendon,26420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5263.59,,,,,,,fee schedule,3239.17,14371.12,
Repair/graft finger tendon,26420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5750,,,,,,,fee schedule,3239.17,14371.12,
Repair/graft finger tendon,26420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6045.32,,,,,,,fee schedule,3239.17,14371.12,
Repair/graft finger tendon,26420,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Repair/graft finger tendon,26420,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Repair/graft finger tendon,26420,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Repair/graft finger tendon,26420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Repair/graft finger tendon,26420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Repair/graft finger tendon,26420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Repair/graft finger tendon,26420,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Repair finger/hand tendon,26426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6566.46,,,,,,,fee schedule,3239.17,14371.12,
Repair finger/hand tendon,26426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5263.59,,,,,,,fee schedule,3239.17,14371.12,
Repair finger/hand tendon,26426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5750,,,,,,,fee schedule,3239.17,14371.12,
Repair finger/hand tendon,26426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6045.32,,,,,,,fee schedule,3239.17,14371.12,
Repair finger/hand tendon,26426,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Repair finger/hand tendon,26426,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Repair finger/hand tendon,26426,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Repair finger/hand tendon,26426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Repair finger/hand tendon,26426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Repair finger/hand tendon,26426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Repair finger/hand tendon,26426,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Repair/graft finger tendon,26428,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6566.46,,,,,,,fee schedule,3239.17,14371.12,
Repair/graft finger tendon,26428,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5263.59,,,,,,,fee schedule,3239.17,14371.12,
Repair/graft finger tendon,26428,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5750,,,,,,,fee schedule,3239.17,14371.12,
Repair/graft finger tendon,26428,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6045.32,,,,,,,fee schedule,3239.17,14371.12,
Repair/graft finger tendon,26428,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Repair/graft finger tendon,26428,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Repair/graft finger tendon,26428,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Repair/graft finger tendon,26428,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Repair/graft finger tendon,26428,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Repair/graft finger tendon,26428,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Repair/graft finger tendon,26428,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Repair finger tendon,26432,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4108.94,,,,,,,fee schedule,1591.86,7062.54,
Repair finger tendon,26432,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3293.67,,,,,,,fee schedule,1591.86,7062.54,
Repair finger tendon,26432,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3598.04,,,,,,,fee schedule,1591.86,7062.54,
Repair finger tendon,26432,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3782.83,,,,,,,fee schedule,1591.86,7062.54,
Repair finger tendon,26432,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Repair finger tendon,26432,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Repair finger tendon,26432,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Repair finger tendon,26432,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Repair finger tendon,26432,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Repair finger tendon,26432,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Repair finger tendon,26432,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Repair finger tendon,26433,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4108.94,,,,,,,fee schedule,3239.17,14371.12,
Repair finger tendon,26433,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3293.67,,,,,,,fee schedule,3239.17,14371.12,
Repair finger tendon,26433,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3598.04,,,,,,,fee schedule,3239.17,14371.12,
Repair finger tendon,26433,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3782.83,,,,,,,fee schedule,3239.17,14371.12,
Repair finger tendon,26433,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Repair finger tendon,26433,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Repair finger tendon,26433,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Repair finger tendon,26433,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Repair finger tendon,26433,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Repair finger tendon,26433,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Repair finger tendon,26433,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Repair/graft finger tendon,26434,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6566.46,,,,,,,fee schedule,3239.17,14371.12,
Repair/graft finger tendon,26434,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5263.59,,,,,,,fee schedule,3239.17,14371.12,
Repair/graft finger tendon,26434,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5750,,,,,,,fee schedule,3239.17,14371.12,
Repair/graft finger tendon,26434,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6045.32,,,,,,,fee schedule,3239.17,14371.12,
Repair/graft finger tendon,26434,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Repair/graft finger tendon,26434,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Repair/graft finger tendon,26434,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Repair/graft finger tendon,26434,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Repair/graft finger tendon,26434,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Repair/graft finger tendon,26434,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Repair/graft finger tendon,26434,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Realignment of tendons,26437,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4108.94,,,,,,,fee schedule,3239.17,14371.12,
Realignment of tendons,26437,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3293.67,,,,,,,fee schedule,3239.17,14371.12,
Realignment of tendons,26437,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3598.04,,,,,,,fee schedule,3239.17,14371.12,
Realignment of tendons,26437,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3782.83,,,,,,,fee schedule,3239.17,14371.12,
Realignment of tendons,26437,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Realignment of tendons,26437,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Realignment of tendons,26437,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Realignment of tendons,26437,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Realignment of tendons,26437,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Realignment of tendons,26437,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Realignment of tendons,26437,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Release palm/finger tendon,26440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4108.94,,,,,,,fee schedule,1591.86,7062.54,
Release palm/finger tendon,26440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3293.67,,,,,,,fee schedule,1591.86,7062.54,
Release palm/finger tendon,26440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3598.04,,,,,,,fee schedule,1591.86,7062.54,
Release palm/finger tendon,26440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3782.83,,,,,,,fee schedule,1591.86,7062.54,
Release palm/finger tendon,26440,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Release palm/finger tendon,26440,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Release palm/finger tendon,26440,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Release palm/finger tendon,26440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Release palm/finger tendon,26440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Release palm/finger tendon,26440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Release palm/finger tendon,26440,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Release palm & finger tendon,26442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6566.46,,,,,,,fee schedule,3239.17,14371.12,
Release palm & finger tendon,26442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5263.59,,,,,,,fee schedule,3239.17,14371.12,
Release palm & finger tendon,26442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5750,,,,,,,fee schedule,3239.17,14371.12,
Release palm & finger tendon,26442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6045.32,,,,,,,fee schedule,3239.17,14371.12,
Release palm & finger tendon,26442,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Release palm & finger tendon,26442,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Release palm & finger tendon,26442,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Release palm & finger tendon,26442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Release palm & finger tendon,26442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Release palm & finger tendon,26442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Release palm & finger tendon,26442,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Release hand/finger tendon,26445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4108.94,,,,,,,fee schedule,3239.17,14371.12,
Release hand/finger tendon,26445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3293.67,,,,,,,fee schedule,3239.17,14371.12,
Release hand/finger tendon,26445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3598.04,,,,,,,fee schedule,3239.17,14371.12,
Release hand/finger tendon,26445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3782.83,,,,,,,fee schedule,3239.17,14371.12,
Release hand/finger tendon,26445,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Release hand/finger tendon,26445,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Release hand/finger tendon,26445,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Release hand/finger tendon,26445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Release hand/finger tendon,26445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Release hand/finger tendon,26445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Release hand/finger tendon,26445,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Release forearm/hand tendon,26449,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6566.46,,,,,,,fee schedule,3239.17,14371.12,
Release forearm/hand tendon,26449,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5263.59,,,,,,,fee schedule,3239.17,14371.12,
Release forearm/hand tendon,26449,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5750,,,,,,,fee schedule,3239.17,14371.12,
Release forearm/hand tendon,26449,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6045.32,,,,,,,fee schedule,3239.17,14371.12,
Release forearm/hand tendon,26449,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Release forearm/hand tendon,26449,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Release forearm/hand tendon,26449,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Release forearm/hand tendon,26449,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Release forearm/hand tendon,26449,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Release forearm/hand tendon,26449,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Release forearm/hand tendon,26449,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Incision of palm tendon,26450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4108.94,,,,,,,fee schedule,3239.17,14371.12,
Incision of palm tendon,26450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3293.67,,,,,,,fee schedule,3239.17,14371.12,
Incision of palm tendon,26450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3598.04,,,,,,,fee schedule,3239.17,14371.12,
Incision of palm tendon,26450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3782.83,,,,,,,fee schedule,3239.17,14371.12,
Incision of palm tendon,26450,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Incision of palm tendon,26450,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Incision of palm tendon,26450,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Incision of palm tendon,26450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Incision of palm tendon,26450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Incision of palm tendon,26450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Incision of palm tendon,26450,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Incision of finger tendon,26455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4108.94,,,,,,,fee schedule,1591.86,7062.54,
Incision of finger tendon,26455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3293.67,,,,,,,fee schedule,1591.86,7062.54,
Incision of finger tendon,26455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3598.04,,,,,,,fee schedule,1591.86,7062.54,
Incision of finger tendon,26455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3782.83,,,,,,,fee schedule,1591.86,7062.54,
Incision of finger tendon,26455,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Incision of finger tendon,26455,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Incision of finger tendon,26455,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Incision of finger tendon,26455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Incision of finger tendon,26455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Incision of finger tendon,26455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Incision of finger tendon,26455,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Incise hand/finger tendon,26460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3360.79,,,,,,,fee schedule,1591.86,7062.54,
Incise hand/finger tendon,26460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2693.96,,,,,,,fee schedule,1591.86,7062.54,
Incise hand/finger tendon,26460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2942.91,,,,,,,fee schedule,1591.86,7062.54,
Incise hand/finger tendon,26460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3094.06,,,,,,,fee schedule,1591.86,7062.54,
Incise hand/finger tendon,26460,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Incise hand/finger tendon,26460,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Incise hand/finger tendon,26460,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Incise hand/finger tendon,26460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Incise hand/finger tendon,26460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Incise hand/finger tendon,26460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Incise hand/finger tendon,26460,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Fusion of finger tendons,26471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4108.94,,,,,,,fee schedule,3239.17,14371.12,
Fusion of finger tendons,26471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3293.67,,,,,,,fee schedule,3239.17,14371.12,
Fusion of finger tendons,26471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3598.04,,,,,,,fee schedule,3239.17,14371.12,
Fusion of finger tendons,26471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3782.83,,,,,,,fee schedule,3239.17,14371.12,
Fusion of finger tendons,26471,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Fusion of finger tendons,26471,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Fusion of finger tendons,26471,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Fusion of finger tendons,26471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Fusion of finger tendons,26471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Fusion of finger tendons,26471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Fusion of finger tendons,26471,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Fusion of finger tendons,26474,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4108.94,,,,,,,fee schedule,1591.86,7062.54,
Fusion of finger tendons,26474,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3293.67,,,,,,,fee schedule,1591.86,7062.54,
Fusion of finger tendons,26474,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3598.04,,,,,,,fee schedule,1591.86,7062.54,
Fusion of finger tendons,26474,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3782.83,,,,,,,fee schedule,1591.86,7062.54,
Fusion of finger tendons,26474,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Fusion of finger tendons,26474,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Fusion of finger tendons,26474,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Fusion of finger tendons,26474,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Fusion of finger tendons,26474,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Fusion of finger tendons,26474,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Fusion of finger tendons,26474,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Tendon lengthening,26476,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4108.94,,,,,,,fee schedule,3239.17,14371.12,
Tendon lengthening,26476,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3293.67,,,,,,,fee schedule,3239.17,14371.12,
Tendon lengthening,26476,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3598.04,,,,,,,fee schedule,3239.17,14371.12,
Tendon lengthening,26476,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3782.83,,,,,,,fee schedule,3239.17,14371.12,
Tendon lengthening,26476,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Tendon lengthening,26476,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Tendon lengthening,26476,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Tendon lengthening,26476,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Tendon lengthening,26476,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Tendon lengthening,26476,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Tendon lengthening,26476,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Tendon shortening,26477,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4108.94,,,,,,,fee schedule,3239.17,14371.12,
Tendon shortening,26477,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3293.67,,,,,,,fee schedule,3239.17,14371.12,
Tendon shortening,26477,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3598.04,,,,,,,fee schedule,3239.17,14371.12,
Tendon shortening,26477,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3782.83,,,,,,,fee schedule,3239.17,14371.12,
Tendon shortening,26477,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Tendon shortening,26477,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Tendon shortening,26477,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Tendon shortening,26477,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Tendon shortening,26477,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Tendon shortening,26477,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Tendon shortening,26477,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Lengthening of hand tendon,26478,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4108.94,,,,,,,fee schedule,3239.17,14371.12,
Lengthening of hand tendon,26478,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3293.67,,,,,,,fee schedule,3239.17,14371.12,
Lengthening of hand tendon,26478,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3598.04,,,,,,,fee schedule,3239.17,14371.12,
Lengthening of hand tendon,26478,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3782.83,,,,,,,fee schedule,3239.17,14371.12,
Lengthening of hand tendon,26478,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Lengthening of hand tendon,26478,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Lengthening of hand tendon,26478,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Lengthening of hand tendon,26478,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Lengthening of hand tendon,26478,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Lengthening of hand tendon,26478,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Lengthening of hand tendon,26478,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Shortening of hand tendon,26479,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4108.94,,,,,,,fee schedule,3239.17,14371.12,
Shortening of hand tendon,26479,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3293.67,,,,,,,fee schedule,3239.17,14371.12,
Shortening of hand tendon,26479,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3598.04,,,,,,,fee schedule,3239.17,14371.12,
Shortening of hand tendon,26479,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3782.83,,,,,,,fee schedule,3239.17,14371.12,
Shortening of hand tendon,26479,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Shortening of hand tendon,26479,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Shortening of hand tendon,26479,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Shortening of hand tendon,26479,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Shortening of hand tendon,26479,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Shortening of hand tendon,26479,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Shortening of hand tendon,26479,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Transplant hand tendon,26480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4699.84,,,,,,,fee schedule,3239.17,14371.12,
Transplant hand tendon,26480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3767.34,,,,,,,fee schedule,3239.17,14371.12,
Transplant hand tendon,26480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4115.47,,,,,,,fee schedule,3239.17,14371.12,
Transplant hand tendon,26480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4326.84,,,,,,,fee schedule,3239.17,14371.12,
Transplant hand tendon,26480,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Transplant hand tendon,26480,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Transplant hand tendon,26480,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Transplant hand tendon,26480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Transplant hand tendon,26480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Transplant hand tendon,26480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Transplant hand tendon,26480,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Transplant/graft hand tendon,26483,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6566.46,,,,,,,fee schedule,3239.17,14371.12,
Transplant/graft hand tendon,26483,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5263.59,,,,,,,fee schedule,3239.17,14371.12,
Transplant/graft hand tendon,26483,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5750,,,,,,,fee schedule,3239.17,14371.12,
Transplant/graft hand tendon,26483,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6045.32,,,,,,,fee schedule,3239.17,14371.12,
Transplant/graft hand tendon,26483,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Transplant/graft hand tendon,26483,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Transplant/graft hand tendon,26483,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Transplant/graft hand tendon,26483,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Transplant/graft hand tendon,26483,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Transplant/graft hand tendon,26483,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Transplant/graft hand tendon,26483,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Transplant palm tendon,26485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6566.46,,,,,,,fee schedule,3239.17,14371.12,
Transplant palm tendon,26485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5263.59,,,,,,,fee schedule,3239.17,14371.12,
Transplant palm tendon,26485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5750,,,,,,,fee schedule,3239.17,14371.12,
Transplant palm tendon,26485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6045.32,,,,,,,fee schedule,3239.17,14371.12,
Transplant palm tendon,26485,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Transplant palm tendon,26485,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Transplant palm tendon,26485,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Transplant palm tendon,26485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Transplant palm tendon,26485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Transplant palm tendon,26485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Transplant palm tendon,26485,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Transplant/graft palm tendon,26489,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6566.46,,,,,,,fee schedule,3239.17,14371.12,
Transplant/graft palm tendon,26489,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5263.59,,,,,,,fee schedule,3239.17,14371.12,
Transplant/graft palm tendon,26489,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5750,,,,,,,fee schedule,3239.17,14371.12,
Transplant/graft palm tendon,26489,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6045.32,,,,,,,fee schedule,3239.17,14371.12,
Transplant/graft palm tendon,26489,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Transplant/graft palm tendon,26489,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Transplant/graft palm tendon,26489,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Transplant/graft palm tendon,26489,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Transplant/graft palm tendon,26489,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Transplant/graft palm tendon,26489,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Transplant/graft palm tendon,26489,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Revise thumb tendon,26490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6566.46,,,,,,,fee schedule,3239.17,14371.12,
Revise thumb tendon,26490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5263.59,,,,,,,fee schedule,3239.17,14371.12,
Revise thumb tendon,26490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5750,,,,,,,fee schedule,3239.17,14371.12,
Revise thumb tendon,26490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6045.32,,,,,,,fee schedule,3239.17,14371.12,
Revise thumb tendon,26490,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Revise thumb tendon,26490,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Revise thumb tendon,26490,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Revise thumb tendon,26490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Revise thumb tendon,26490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Revise thumb tendon,26490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Revise thumb tendon,26490,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Tendon transfer with graft,26492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6566.46,,,,,,,fee schedule,3239.17,14371.12,
Tendon transfer with graft,26492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5263.59,,,,,,,fee schedule,3239.17,14371.12,
Tendon transfer with graft,26492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5750,,,,,,,fee schedule,3239.17,14371.12,
Tendon transfer with graft,26492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6045.32,,,,,,,fee schedule,3239.17,14371.12,
Tendon transfer with graft,26492,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Tendon transfer with graft,26492,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Tendon transfer with graft,26492,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Tendon transfer with graft,26492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Tendon transfer with graft,26492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Tendon transfer with graft,26492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Tendon transfer with graft,26492,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Hand tendon/muscle transfer,26494,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6566.46,,,,,,,fee schedule,3239.17,14371.12,
Hand tendon/muscle transfer,26494,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5263.59,,,,,,,fee schedule,3239.17,14371.12,
Hand tendon/muscle transfer,26494,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5750,,,,,,,fee schedule,3239.17,14371.12,
Hand tendon/muscle transfer,26494,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6045.32,,,,,,,fee schedule,3239.17,14371.12,
Hand tendon/muscle transfer,26494,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Hand tendon/muscle transfer,26494,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Hand tendon/muscle transfer,26494,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Hand tendon/muscle transfer,26494,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Hand tendon/muscle transfer,26494,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Hand tendon/muscle transfer,26494,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Hand tendon/muscle transfer,26494,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Revise thumb tendon,26496,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6566.46,,,,,,,fee schedule,3239.17,14371.12,
Revise thumb tendon,26496,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5263.59,,,,,,,fee schedule,3239.17,14371.12,
Revise thumb tendon,26496,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5750,,,,,,,fee schedule,3239.17,14371.12,
Revise thumb tendon,26496,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6045.32,,,,,,,fee schedule,3239.17,14371.12,
Revise thumb tendon,26496,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Revise thumb tendon,26496,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Revise thumb tendon,26496,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Revise thumb tendon,26496,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Revise thumb tendon,26496,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Revise thumb tendon,26496,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Revise thumb tendon,26496,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Finger tendon transfer,26497,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6566.46,,,,,,,fee schedule,3239.17,14371.12,
Finger tendon transfer,26497,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5263.59,,,,,,,fee schedule,3239.17,14371.12,
Finger tendon transfer,26497,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5750,,,,,,,fee schedule,3239.17,14371.12,
Finger tendon transfer,26497,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6045.32,,,,,,,fee schedule,3239.17,14371.12,
Finger tendon transfer,26497,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Finger tendon transfer,26497,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Finger tendon transfer,26497,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Finger tendon transfer,26497,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Finger tendon transfer,26497,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Finger tendon transfer,26497,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Finger tendon transfer,26497,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Finger tendon transfer,26498,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6566.46,,,,,,,fee schedule,3239.17,14371.12,
Finger tendon transfer,26498,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5263.59,,,,,,,fee schedule,3239.17,14371.12,
Finger tendon transfer,26498,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5750,,,,,,,fee schedule,3239.17,14371.12,
Finger tendon transfer,26498,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6045.32,,,,,,,fee schedule,3239.17,14371.12,
Finger tendon transfer,26498,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Finger tendon transfer,26498,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Finger tendon transfer,26498,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Finger tendon transfer,26498,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Finger tendon transfer,26498,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Finger tendon transfer,26498,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Finger tendon transfer,26498,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Revision of finger,26499,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6566.46,,,,,,,fee schedule,3239.17,14371.12,
Revision of finger,26499,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5263.59,,,,,,,fee schedule,3239.17,14371.12,
Revision of finger,26499,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5750,,,,,,,fee schedule,3239.17,14371.12,
Revision of finger,26499,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6045.32,,,,,,,fee schedule,3239.17,14371.12,
Revision of finger,26499,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Revision of finger,26499,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Revision of finger,26499,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Revision of finger,26499,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Revision of finger,26499,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Revision of finger,26499,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Revision of finger,26499,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Hand tendon reconstruction,26500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4108.94,,,,,,,fee schedule,3293.67,31870.39,
Hand tendon reconstruction,26500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3293.67,,,,,,,fee schedule,3293.67,31870.39,
Hand tendon reconstruction,26500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3598.04,,,,,,,fee schedule,3293.67,31870.39,
Hand tendon reconstruction,26500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3782.83,,,,,,,fee schedule,3293.67,31870.39,
Hand tendon reconstruction,26500,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,3293.67,31870.39,APC 378
Hand tendon reconstruction,26500,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,3293.67,31870.39,APC
Hand tendon reconstruction,26500,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,3293.67,31870.39,APC
Hand tendon reconstruction,26500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,3293.67,31870.39,APC
Hand tendon reconstruction,26500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,3293.67,31870.39,Radiology
Hand tendon reconstruction,26500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,3293.67,31870.39,APC
Hand tendon reconstruction,26500,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,3293.67,31870.39,APC
Hand tendon reconstruction,26502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6566.46,,,,,,,fee schedule,3239.17,14371.12,
Hand tendon reconstruction,26502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5263.59,,,,,,,fee schedule,3239.17,14371.12,
Hand tendon reconstruction,26502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5750,,,,,,,fee schedule,3239.17,14371.12,
Hand tendon reconstruction,26502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6045.32,,,,,,,fee schedule,3239.17,14371.12,
Hand tendon reconstruction,26502,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Hand tendon reconstruction,26502,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Hand tendon reconstruction,26502,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Hand tendon reconstruction,26502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Hand tendon reconstruction,26502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Hand tendon reconstruction,26502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Hand tendon reconstruction,26502,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Release thumb contracture,26508,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4108.94,,,,,,,fee schedule,3239.17,14371.12,
Release thumb contracture,26508,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3293.67,,,,,,,fee schedule,3239.17,14371.12,
Release thumb contracture,26508,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3598.04,,,,,,,fee schedule,3239.17,14371.12,
Release thumb contracture,26508,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3782.83,,,,,,,fee schedule,3239.17,14371.12,
Release thumb contracture,26508,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Release thumb contracture,26508,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Release thumb contracture,26508,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Release thumb contracture,26508,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Release thumb contracture,26508,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Release thumb contracture,26508,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Release thumb contracture,26508,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Thumb tendon transfer,26510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6566.46,,,,,,,fee schedule,3239.17,14371.12,
Thumb tendon transfer,26510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5263.59,,,,,,,fee schedule,3239.17,14371.12,
Thumb tendon transfer,26510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5750,,,,,,,fee schedule,3239.17,14371.12,
Thumb tendon transfer,26510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6045.32,,,,,,,fee schedule,3239.17,14371.12,
Thumb tendon transfer,26510,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Thumb tendon transfer,26510,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Thumb tendon transfer,26510,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Thumb tendon transfer,26510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Thumb tendon transfer,26510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Thumb tendon transfer,26510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Thumb tendon transfer,26510,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Fusion of knuckle joint,26516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6566.46,,,,,,,fee schedule,3239.17,14371.12,
Fusion of knuckle joint,26516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5263.59,,,,,,,fee schedule,3239.17,14371.12,
Fusion of knuckle joint,26516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5750,,,,,,,fee schedule,3239.17,14371.12,
Fusion of knuckle joint,26516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6045.32,,,,,,,fee schedule,3239.17,14371.12,
Fusion of knuckle joint,26516,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Fusion of knuckle joint,26516,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Fusion of knuckle joint,26516,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Fusion of knuckle joint,26516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Fusion of knuckle joint,26516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Fusion of knuckle joint,26516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Fusion of knuckle joint,26516,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Fusion of knuckle joints,26517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6566.46,,,,,,,fee schedule,3239.17,14371.12,
Fusion of knuckle joints,26517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5263.59,,,,,,,fee schedule,3239.17,14371.12,
Fusion of knuckle joints,26517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5750,,,,,,,fee schedule,3239.17,14371.12,
Fusion of knuckle joints,26517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6045.32,,,,,,,fee schedule,3239.17,14371.12,
Fusion of knuckle joints,26517,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Fusion of knuckle joints,26517,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Fusion of knuckle joints,26517,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Fusion of knuckle joints,26517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Fusion of knuckle joints,26517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Fusion of knuckle joints,26517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Fusion of knuckle joints,26517,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Fusion of knuckle joints,26518,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6566.46,,,,,,,fee schedule,5263.59,31870.39,
Fusion of knuckle joints,26518,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5263.59,,,,,,,fee schedule,5263.59,31870.39,
Fusion of knuckle joints,26518,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5750,,,,,,,fee schedule,5263.59,31870.39,
Fusion of knuckle joints,26518,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6045.32,,,,,,,fee schedule,5263.59,31870.39,
Fusion of knuckle joints,26518,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5263.59,31870.39,APC 378
Fusion of knuckle joints,26518,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5263.59,31870.39,APC
Fusion of knuckle joints,26518,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5263.59,31870.39,APC
Fusion of knuckle joints,26518,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5263.59,31870.39,APC
Fusion of knuckle joints,26518,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5263.59,31870.39,Radiology
Fusion of knuckle joints,26518,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5263.59,31870.39,APC
Fusion of knuckle joints,26518,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5263.59,31870.39,APC
Release knuckle contracture,26520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4108.94,,,,,,,fee schedule,3239.17,14371.12,
Release knuckle contracture,26520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3293.67,,,,,,,fee schedule,3239.17,14371.12,
Release knuckle contracture,26520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3598.04,,,,,,,fee schedule,3239.17,14371.12,
Release knuckle contracture,26520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3782.83,,,,,,,fee schedule,3239.17,14371.12,
Release knuckle contracture,26520,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Release knuckle contracture,26520,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Release knuckle contracture,26520,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Release knuckle contracture,26520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Release knuckle contracture,26520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Release knuckle contracture,26520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Release knuckle contracture,26520,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Release finger contracture,26525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4108.94,,,,,,,fee schedule,1591.86,7062.54,
Release finger contracture,26525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3293.67,,,,,,,fee schedule,1591.86,7062.54,
Release finger contracture,26525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3598.04,,,,,,,fee schedule,1591.86,7062.54,
Release finger contracture,26525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3782.83,,,,,,,fee schedule,1591.86,7062.54,
Release finger contracture,26525,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Release finger contracture,26525,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Release finger contracture,26525,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Release finger contracture,26525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Release finger contracture,26525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Release finger contracture,26525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Release finger contracture,26525,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Revise knuckle joint,26530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2552.61,,,,,,,fee schedule,2046.14,31870.39,
Revise knuckle joint,26530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2046.14,,,,,,,fee schedule,2046.14,31870.39,
Revise knuckle joint,26530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2235.23,,,,,,,fee schedule,2046.14,31870.39,
Revise knuckle joint,26530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2350.03,,,,,,,fee schedule,2046.14,31870.39,
Revise knuckle joint,26530,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,2046.14,31870.39,APC 378
Revise knuckle joint,26530,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,2046.14,31870.39,APC
Revise knuckle joint,26530,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,2046.14,31870.39,APC
Revise knuckle joint,26530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,2046.14,31870.39,APC
Revise knuckle joint,26530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,2046.14,31870.39,Radiology
Revise knuckle joint,26530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,2046.14,31870.39,APC
Revise knuckle joint,26530,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,2046.14,31870.39,APC
Revise knuckle with implant,26531,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12700.27,,,,,,,fee schedule,7183.42,31870.39,
Revise knuckle with implant,26531,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10180.38,,,,,,,fee schedule,7183.42,31870.39,
Revise knuckle with implant,26531,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11121.14,,,,,,,fee schedule,7183.42,31870.39,
Revise knuckle with implant,26531,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11692.31,,,,,,,fee schedule,7183.42,31870.39,
Revise knuckle with implant,26531,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Revise knuckle with implant,26531,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Revise knuckle with implant,26531,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Revise knuckle with implant,26531,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Revise knuckle with implant,26531,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Revise knuckle with implant,26531,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Revise knuckle with implant,26531,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Revise finger joint,26535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8960.75,,,,,,,fee schedule,3239.17,14371.12,
Revise finger joint,26535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7182.83,,,,,,,fee schedule,3239.17,14371.12,
Revise finger joint,26535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7846.59,,,,,,,fee schedule,3239.17,14371.12,
Revise finger joint,26535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8249.58,,,,,,,fee schedule,3239.17,14371.12,
Revise finger joint,26535,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Revise finger joint,26535,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Revise finger joint,26535,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Revise finger joint,26535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Revise finger joint,26535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Revise finger joint,26535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Revise finger joint,26535,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Revise/implant finger joint,26536,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3893.37,,,,,,,fee schedule,3120.88,31870.39,
Revise/implant finger joint,26536,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3120.88,,,,,,,fee schedule,3120.88,31870.39,
Revise/implant finger joint,26536,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3409.28,,,,,,,fee schedule,3120.88,31870.39,
Revise/implant finger joint,26536,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3584.38,,,,,,,fee schedule,3120.88,31870.39,
Revise/implant finger joint,26536,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,3120.88,31870.39,APC 378
Revise/implant finger joint,26536,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,3120.88,31870.39,APC
Revise/implant finger joint,26536,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,3120.88,31870.39,APC
Revise/implant finger joint,26536,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,3120.88,31870.39,APC
Revise/implant finger joint,26536,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,3120.88,31870.39,Radiology
Revise/implant finger joint,26536,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,3120.88,31870.39,APC
Revise/implant finger joint,26536,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,3120.88,31870.39,APC
Repair hand joint,26540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7657.8,,,,,,,fee schedule,3239.17,14371.12,
Repair hand joint,26540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6138.4,,,,,,,fee schedule,3239.17,14371.12,
Repair hand joint,26540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6705.64,,,,,,,fee schedule,3239.17,14371.12,
Repair hand joint,26540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7050.04,,,,,,,fee schedule,3239.17,14371.12,
Repair hand joint,26540,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Repair hand joint,26540,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Repair hand joint,26540,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Repair hand joint,26540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Repair hand joint,26540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Repair hand joint,26540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Repair hand joint,26540,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Repair hand joint with graft,26541,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6566.46,,,,,,,fee schedule,3239.17,14371.12,
Repair hand joint with graft,26541,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5263.59,,,,,,,fee schedule,3239.17,14371.12,
Repair hand joint with graft,26541,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5750,,,,,,,fee schedule,3239.17,14371.12,
Repair hand joint with graft,26541,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6045.32,,,,,,,fee schedule,3239.17,14371.12,
Repair hand joint with graft,26541,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Repair hand joint with graft,26541,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Repair hand joint with graft,26541,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Repair hand joint with graft,26541,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Repair hand joint with graft,26541,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Repair hand joint with graft,26541,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Repair hand joint with graft,26541,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Repair hand joint with graft,26542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4108.94,,,,,,,fee schedule,3239.17,14371.12,
Repair hand joint with graft,26542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3293.67,,,,,,,fee schedule,3239.17,14371.12,
Repair hand joint with graft,26542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3598.04,,,,,,,fee schedule,3239.17,14371.12,
Repair hand joint with graft,26542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3782.83,,,,,,,fee schedule,3239.17,14371.12,
Repair hand joint with graft,26542,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Repair hand joint with graft,26542,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Repair hand joint with graft,26542,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Repair hand joint with graft,26542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Repair hand joint with graft,26542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Repair hand joint with graft,26542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Repair hand joint with graft,26542,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Reconstruct finger joint,26545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6566.46,,,,,,,fee schedule,3239.17,14371.12,
Reconstruct finger joint,26545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5263.59,,,,,,,fee schedule,3239.17,14371.12,
Reconstruct finger joint,26545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5750,,,,,,,fee schedule,3239.17,14371.12,
Reconstruct finger joint,26545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6045.32,,,,,,,fee schedule,3239.17,14371.12,
Reconstruct finger joint,26545,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Reconstruct finger joint,26545,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Reconstruct finger joint,26545,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Reconstruct finger joint,26545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Reconstruct finger joint,26545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Reconstruct finger joint,26545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Reconstruct finger joint,26545,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Repair nonunion hand,26546,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6566.46,,,,,,,fee schedule,5263.59,31870.39,
Repair nonunion hand,26546,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5263.59,,,,,,,fee schedule,5263.59,31870.39,
Repair nonunion hand,26546,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5750,,,,,,,fee schedule,5263.59,31870.39,
Repair nonunion hand,26546,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6045.32,,,,,,,fee schedule,5263.59,31870.39,
Repair nonunion hand,26546,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5263.59,31870.39,APC 378
Repair nonunion hand,26546,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5263.59,31870.39,APC
Repair nonunion hand,26546,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5263.59,31870.39,APC
Repair nonunion hand,26546,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5263.59,31870.39,APC
Repair nonunion hand,26546,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5263.59,31870.39,Radiology
Repair nonunion hand,26546,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5263.59,31870.39,APC
Repair nonunion hand,26546,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5263.59,31870.39,APC
Reconstruct finger joint,26548,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6566.46,,,,,,,fee schedule,3239.17,14371.12,
Reconstruct finger joint,26548,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5263.59,,,,,,,fee schedule,3239.17,14371.12,
Reconstruct finger joint,26548,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5750,,,,,,,fee schedule,3239.17,14371.12,
Reconstruct finger joint,26548,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6045.32,,,,,,,fee schedule,3239.17,14371.12,
Reconstruct finger joint,26548,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Reconstruct finger joint,26548,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Reconstruct finger joint,26548,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Reconstruct finger joint,26548,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Reconstruct finger joint,26548,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Reconstruct finger joint,26548,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Reconstruct finger joint,26548,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Construct thumb replacement,26550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6566.46,,,,,,,fee schedule,3239.17,14371.12,
Construct thumb replacement,26550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5263.59,,,,,,,fee schedule,3239.17,14371.12,
Construct thumb replacement,26550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5750,,,,,,,fee schedule,3239.17,14371.12,
Construct thumb replacement,26550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6045.32,,,,,,,fee schedule,3239.17,14371.12,
Construct thumb replacement,26550,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Construct thumb replacement,26550,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Construct thumb replacement,26550,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Construct thumb replacement,26550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Construct thumb replacement,26550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Construct thumb replacement,26550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Construct thumb replacement,26550,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Great toe-hand transfer,26551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Great toe-hand transfer,26551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Great toe-hand transfer,26551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Great toe-hand transfer,26551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Great toe-hand transfer,26551,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Great toe-hand transfer,26551,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Great toe-hand transfer,26551,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Great toe-hand transfer,26551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Great toe-hand transfer,26551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Great toe-hand transfer,26551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Great toe-hand transfer,26551,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Single transfer toe-hand,26553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Single transfer toe-hand,26553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Single transfer toe-hand,26553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Single transfer toe-hand,26553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Single transfer toe-hand,26553,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Single transfer toe-hand,26553,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Single transfer toe-hand,26553,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Single transfer toe-hand,26553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Single transfer toe-hand,26553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Single transfer toe-hand,26553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Single transfer toe-hand,26553,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Double transfer toe-hand,26554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Double transfer toe-hand,26554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Double transfer toe-hand,26554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Double transfer toe-hand,26554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Double transfer toe-hand,26554,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Double transfer toe-hand,26554,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Double transfer toe-hand,26554,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Double transfer toe-hand,26554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Double transfer toe-hand,26554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Double transfer toe-hand,26554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Double transfer toe-hand,26554,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Positional change of finger,26555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6566.46,,,,,,,fee schedule,5263.59,31870.39,
Positional change of finger,26555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5263.59,,,,,,,fee schedule,5263.59,31870.39,
Positional change of finger,26555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5750,,,,,,,fee schedule,5263.59,31870.39,
Positional change of finger,26555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6045.32,,,,,,,fee schedule,5263.59,31870.39,
Positional change of finger,26555,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5263.59,31870.39,APC 378
Positional change of finger,26555,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5263.59,31870.39,APC
Positional change of finger,26555,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5263.59,31870.39,APC
Positional change of finger,26555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5263.59,31870.39,APC
Positional change of finger,26555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5263.59,31870.39,Radiology
Positional change of finger,26555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5263.59,31870.39,APC
Positional change of finger,26555,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5263.59,31870.39,APC
Toe joint transfer,26556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Toe joint transfer,26556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Toe joint transfer,26556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Toe joint transfer,26556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Toe joint transfer,26556,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Toe joint transfer,26556,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Toe joint transfer,26556,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Toe joint transfer,26556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Toe joint transfer,26556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Toe joint transfer,26556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Toe joint transfer,26556,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Repair of web finger,26560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4108.94,,,,,,,fee schedule,1591.86,7062.54,
Repair of web finger,26560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3293.67,,,,,,,fee schedule,1591.86,7062.54,
Repair of web finger,26560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3598.04,,,,,,,fee schedule,1591.86,7062.54,
Repair of web finger,26560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3782.83,,,,,,,fee schedule,1591.86,7062.54,
Repair of web finger,26560,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Repair of web finger,26560,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Repair of web finger,26560,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Repair of web finger,26560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Repair of web finger,26560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Repair of web finger,26560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Repair of web finger,26560,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Repair of web finger,26561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6566.46,,,,,,,fee schedule,3239.17,14371.12,
Repair of web finger,26561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5263.59,,,,,,,fee schedule,3239.17,14371.12,
Repair of web finger,26561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5750,,,,,,,fee schedule,3239.17,14371.12,
Repair of web finger,26561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6045.32,,,,,,,fee schedule,3239.17,14371.12,
Repair of web finger,26561,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Repair of web finger,26561,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Repair of web finger,26561,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Repair of web finger,26561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Repair of web finger,26561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Repair of web finger,26561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Repair of web finger,26561,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Repair of web finger,26562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6566.46,,,,,,,fee schedule,3239.17,14371.12,
Repair of web finger,26562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5263.59,,,,,,,fee schedule,3239.17,14371.12,
Repair of web finger,26562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5750,,,,,,,fee schedule,3239.17,14371.12,
Repair of web finger,26562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6045.32,,,,,,,fee schedule,3239.17,14371.12,
Repair of web finger,26562,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Repair of web finger,26562,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Repair of web finger,26562,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Repair of web finger,26562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Repair of web finger,26562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Repair of web finger,26562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Repair of web finger,26562,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Correct metacarpal flaw,26565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6566.46,,,,,,,fee schedule,3239.17,14371.12,
Correct metacarpal flaw,26565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5263.59,,,,,,,fee schedule,3239.17,14371.12,
Correct metacarpal flaw,26565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5750,,,,,,,fee schedule,3239.17,14371.12,
Correct metacarpal flaw,26565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6045.32,,,,,,,fee schedule,3239.17,14371.12,
Correct metacarpal flaw,26565,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Correct metacarpal flaw,26565,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Correct metacarpal flaw,26565,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Correct metacarpal flaw,26565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Correct metacarpal flaw,26565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Correct metacarpal flaw,26565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Correct metacarpal flaw,26565,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Correct finger deformity,26567,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6566.46,,,,,,,fee schedule,3239.17,14371.12,
Correct finger deformity,26567,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5263.59,,,,,,,fee schedule,3239.17,14371.12,
Correct finger deformity,26567,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5750,,,,,,,fee schedule,3239.17,14371.12,
Correct finger deformity,26567,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6045.32,,,,,,,fee schedule,3239.17,14371.12,
Correct finger deformity,26567,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Correct finger deformity,26567,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Correct finger deformity,26567,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Correct finger deformity,26567,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Correct finger deformity,26567,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Correct finger deformity,26567,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Correct finger deformity,26567,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Lengthen metacarpal/finger,26568,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6566.46,,,,,,,fee schedule,5263.59,31870.39,
Lengthen metacarpal/finger,26568,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5263.59,,,,,,,fee schedule,5263.59,31870.39,
Lengthen metacarpal/finger,26568,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5750,,,,,,,fee schedule,5263.59,31870.39,
Lengthen metacarpal/finger,26568,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6045.32,,,,,,,fee schedule,5263.59,31870.39,
Lengthen metacarpal/finger,26568,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5263.59,31870.39,APC 378
Lengthen metacarpal/finger,26568,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5263.59,31870.39,APC
Lengthen metacarpal/finger,26568,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5263.59,31870.39,APC
Lengthen metacarpal/finger,26568,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5263.59,31870.39,APC
Lengthen metacarpal/finger,26568,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5263.59,31870.39,Radiology
Lengthen metacarpal/finger,26568,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5263.59,31870.39,APC
Lengthen metacarpal/finger,26568,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5263.59,31870.39,APC
Repair hand deformity,26580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4108.94,,,,,,,fee schedule,3239.17,14371.12,
Repair hand deformity,26580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3293.67,,,,,,,fee schedule,3239.17,14371.12,
Repair hand deformity,26580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3598.04,,,,,,,fee schedule,3239.17,14371.12,
Repair hand deformity,26580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3782.83,,,,,,,fee schedule,3239.17,14371.12,
Repair hand deformity,26580,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Repair hand deformity,26580,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Repair hand deformity,26580,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Repair hand deformity,26580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Repair hand deformity,26580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Repair hand deformity,26580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Repair hand deformity,26580,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Reconstruct extra finger,26587,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4108.94,,,,,,,fee schedule,3239.17,14371.12,
Reconstruct extra finger,26587,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3293.67,,,,,,,fee schedule,3239.17,14371.12,
Reconstruct extra finger,26587,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3598.04,,,,,,,fee schedule,3239.17,14371.12,
Reconstruct extra finger,26587,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3782.83,,,,,,,fee schedule,3239.17,14371.12,
Reconstruct extra finger,26587,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Reconstruct extra finger,26587,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Reconstruct extra finger,26587,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Reconstruct extra finger,26587,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Reconstruct extra finger,26587,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Reconstruct extra finger,26587,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Reconstruct extra finger,26587,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Repair finger deformity,26590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4108.94,,,,,,,fee schedule,1591.86,7062.54,
Repair finger deformity,26590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3293.67,,,,,,,fee schedule,1591.86,7062.54,
Repair finger deformity,26590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3598.04,,,,,,,fee schedule,1591.86,7062.54,
Repair finger deformity,26590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3782.83,,,,,,,fee schedule,1591.86,7062.54,
Repair finger deformity,26590,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Repair finger deformity,26590,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Repair finger deformity,26590,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Repair finger deformity,26590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Repair finger deformity,26590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Repair finger deformity,26590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Repair finger deformity,26590,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Repair muscles of hand,26591,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6566.46,,,,,,,fee schedule,3239.17,14371.12,
Repair muscles of hand,26591,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5263.59,,,,,,,fee schedule,3239.17,14371.12,
Repair muscles of hand,26591,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5750,,,,,,,fee schedule,3239.17,14371.12,
Repair muscles of hand,26591,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6045.32,,,,,,,fee schedule,3239.17,14371.12,
Repair muscles of hand,26591,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Repair muscles of hand,26591,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Repair muscles of hand,26591,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Repair muscles of hand,26591,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Repair muscles of hand,26591,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Repair muscles of hand,26591,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Repair muscles of hand,26591,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Release muscles of hand,26593,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4108.94,,,,,,,fee schedule,3239.17,14371.12,
Release muscles of hand,26593,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3293.67,,,,,,,fee schedule,3239.17,14371.12,
Release muscles of hand,26593,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3598.04,,,,,,,fee schedule,3239.17,14371.12,
Release muscles of hand,26593,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3782.83,,,,,,,fee schedule,3239.17,14371.12,
Release muscles of hand,26593,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Release muscles of hand,26593,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Release muscles of hand,26593,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Release muscles of hand,26593,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Release muscles of hand,26593,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Release muscles of hand,26593,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Release muscles of hand,26593,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Excision constricting tissue,26596,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4108.94,,,,,,,fee schedule,3239.17,14371.12,
Excision constricting tissue,26596,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3293.67,,,,,,,fee schedule,3239.17,14371.12,
Excision constricting tissue,26596,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3598.04,,,,,,,fee schedule,3239.17,14371.12,
Excision constricting tissue,26596,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3782.83,,,,,,,fee schedule,3239.17,14371.12,
Excision constricting tissue,26596,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Excision constricting tissue,26596,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Excision constricting tissue,26596,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Excision constricting tissue,26596,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Excision constricting tissue,26596,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Excision constricting tissue,26596,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Excision constricting tissue,26596,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Treat metacarpal fracture,26600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,244.19,1083.4,
Treat metacarpal fracture,26600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,244.19,1083.4,
Treat metacarpal fracture,26600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,244.19,1083.4,
Treat metacarpal fracture,26600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,244.19,1083.4,
Treat metacarpal fracture,26600,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treat metacarpal fracture,26600,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treat metacarpal fracture,26600,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treat metacarpal fracture,26600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treat metacarpal fracture,26600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treat metacarpal fracture,26600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treat metacarpal fracture,26600,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treat metacarpal fracture,26605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,318.58,,,,,,,fee schedule,244.19,1083.4,
Treat metacarpal fracture,26605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,255.37,,,,,,,fee schedule,244.19,1083.4,
Treat metacarpal fracture,26605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,278.97,,,,,,,fee schedule,244.19,1083.4,
Treat metacarpal fracture,26605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,293.29,,,,,,,fee schedule,244.19,1083.4,
Treat metacarpal fracture,26605,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treat metacarpal fracture,26605,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treat metacarpal fracture,26605,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treat metacarpal fracture,26605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treat metacarpal fracture,26605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treat metacarpal fracture,26605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treat metacarpal fracture,26605,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treat metacarpal fracture,26607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,353.72,14371.12,
Treat metacarpal fracture,26607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,353.72,14371.12,
Treat metacarpal fracture,26607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,353.72,14371.12,
Treat metacarpal fracture,26607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,353.72,14371.12,
Treat metacarpal fracture,26607,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,353.72,14371.12,APC 378
Treat metacarpal fracture,26607,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,353.72,14371.12,APC
Treat metacarpal fracture,26607,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,353.72,14371.12,APC
Treat metacarpal fracture,26607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,353.72,14371.12,APC
Treat metacarpal fracture,26607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,353.72,14371.12,Radiology
Treat metacarpal fracture,26607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,353.72,14371.12,APC
Treat metacarpal fracture,26607,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,353.72,14371.12,APC
Treat metacarpal fracture,26608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6721.57,,,,,,,fee schedule,3239.17,14371.12,
Treat metacarpal fracture,26608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5387.93,,,,,,,fee schedule,3239.17,14371.12,
Treat metacarpal fracture,26608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5885.82,,,,,,,fee schedule,3239.17,14371.12,
Treat metacarpal fracture,26608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6188.11,,,,,,,fee schedule,3239.17,14371.12,
Treat metacarpal fracture,26608,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Treat metacarpal fracture,26608,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Treat metacarpal fracture,26608,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Treat metacarpal fracture,26608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Treat metacarpal fracture,26608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Treat metacarpal fracture,26608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Treat metacarpal fracture,26608,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Treat metacarpal fracture,26615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5386.61,,,,,,,fee schedule,3239.17,14371.12,
Treat metacarpal fracture,26615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4317.84,,,,,,,fee schedule,3239.17,14371.12,
Treat metacarpal fracture,26615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4716.84,,,,,,,fee schedule,3239.17,14371.12,
Treat metacarpal fracture,26615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4959.1,,,,,,,fee schedule,3239.17,14371.12,
Treat metacarpal fracture,26615,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Treat metacarpal fracture,26615,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Treat metacarpal fracture,26615,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Treat metacarpal fracture,26615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Treat metacarpal fracture,26615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Treat metacarpal fracture,26615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Treat metacarpal fracture,26615,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Treat thumb dislocation,26641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,244.19,1083.4,
Treat thumb dislocation,26641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,244.19,1083.4,
Treat thumb dislocation,26641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,244.19,1083.4,
Treat thumb dislocation,26641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,244.19,1083.4,
Treat thumb dislocation,26641,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treat thumb dislocation,26641,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treat thumb dislocation,26641,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treat thumb dislocation,26641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treat thumb dislocation,26641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treat thumb dislocation,26641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treat thumb dislocation,26641,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treat thumb fracture,26645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,353.72,7062.54,
Treat thumb fracture,26645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,353.72,7062.54,
Treat thumb fracture,26645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,353.72,7062.54,
Treat thumb fracture,26645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,353.72,7062.54,
Treat thumb fracture,26645,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,353.72,7062.54,APC 378
Treat thumb fracture,26645,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,353.72,7062.54,APC
Treat thumb fracture,26645,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,353.72,7062.54,APC
Treat thumb fracture,26645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,353.72,7062.54,APC
Treat thumb fracture,26645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,353.72,7062.54,Radiology
Treat thumb fracture,26645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,353.72,7062.54,APC
Treat thumb fracture,26645,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,353.72,7062.54,APC
Treat thumb fracture,26650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7657.8,,,,,,,fee schedule,3239.17,14371.12,
Treat thumb fracture,26650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6138.4,,,,,,,fee schedule,3239.17,14371.12,
Treat thumb fracture,26650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6705.64,,,,,,,fee schedule,3239.17,14371.12,
Treat thumb fracture,26650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7050.04,,,,,,,fee schedule,3239.17,14371.12,
Treat thumb fracture,26650,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Treat thumb fracture,26650,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Treat thumb fracture,26650,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Treat thumb fracture,26650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Treat thumb fracture,26650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Treat thumb fracture,26650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Treat thumb fracture,26650,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Treat thumb fracture,26665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10259.79,,,,,,,fee schedule,3239.17,14371.12,
Treat thumb fracture,26665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8224.12,,,,,,,fee schedule,3239.17,14371.12,
Treat thumb fracture,26665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8984.1,,,,,,,fee schedule,3239.17,14371.12,
Treat thumb fracture,26665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9445.52,,,,,,,fee schedule,3239.17,14371.12,
Treat thumb fracture,26665,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Treat thumb fracture,26665,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Treat thumb fracture,26665,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Treat thumb fracture,26665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Treat thumb fracture,26665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Treat thumb fracture,26665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Treat thumb fracture,26665,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Treat hand dislocation,26670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,237.31,,,,,,,fee schedule,190.22,1083.4,
Treat hand dislocation,26670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,190.22,,,,,,,fee schedule,190.22,1083.4,
Treat hand dislocation,26670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,207.8,,,,,,,fee schedule,190.22,1083.4,
Treat hand dislocation,26670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,218.47,,,,,,,fee schedule,190.22,1083.4,
Treat hand dislocation,26670,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,190.22,1083.4,APC 378
Treat hand dislocation,26670,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,190.22,1083.4,APC
Treat hand dislocation,26670,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,190.22,1083.4,APC
Treat hand dislocation,26670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,190.22,1083.4,APC
Treat hand dislocation,26670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,190.22,1083.4,Radiology
Treat hand dislocation,26670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,190.22,1083.4,APC
Treat hand dislocation,26670,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,190.22,1083.4,APC
Treat hand dislocation,26675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,353.72,7062.54,
Treat hand dislocation,26675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,353.72,7062.54,
Treat hand dislocation,26675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,353.72,7062.54,
Treat hand dislocation,26675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,353.72,7062.54,
Treat hand dislocation,26675,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,353.72,7062.54,APC 378
Treat hand dislocation,26675,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,353.72,7062.54,APC
Treat hand dislocation,26675,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,353.72,7062.54,APC
Treat hand dislocation,26675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,353.72,7062.54,APC
Treat hand dislocation,26675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,353.72,7062.54,Radiology
Treat hand dislocation,26675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,353.72,7062.54,APC
Treat hand dislocation,26675,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,353.72,7062.54,APC
Pin hand dislocation,26676,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6528.66,,,,,,,fee schedule,3239.17,14371.12,
Pin hand dislocation,26676,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5233.29,,,,,,,fee schedule,3239.17,14371.12,
Pin hand dislocation,26676,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5716.9,,,,,,,fee schedule,3239.17,14371.12,
Pin hand dislocation,26676,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6010.52,,,,,,,fee schedule,3239.17,14371.12,
Pin hand dislocation,26676,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Pin hand dislocation,26676,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Pin hand dislocation,26676,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Pin hand dislocation,26676,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Pin hand dislocation,26676,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Pin hand dislocation,26676,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Pin hand dislocation,26676,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Treat hand dislocation,26685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6528.66,,,,,,,fee schedule,3239.17,14371.12,
Treat hand dislocation,26685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5233.29,,,,,,,fee schedule,3239.17,14371.12,
Treat hand dislocation,26685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5716.9,,,,,,,fee schedule,3239.17,14371.12,
Treat hand dislocation,26685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6010.52,,,,,,,fee schedule,3239.17,14371.12,
Treat hand dislocation,26685,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Treat hand dislocation,26685,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Treat hand dislocation,26685,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Treat hand dislocation,26685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Treat hand dislocation,26685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Treat hand dislocation,26685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Treat hand dislocation,26685,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Treat hand dislocation,26686,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14780.67,,,,,,,fee schedule,3239.17,14780.67,
Treat hand dislocation,26686,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11848,,,,,,,fee schedule,3239.17,14780.67,
Treat hand dislocation,26686,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12942.86,,,,,,,fee schedule,3239.17,14780.67,
Treat hand dislocation,26686,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13607.6,,,,,,,fee schedule,3239.17,14780.67,
Treat hand dislocation,26686,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14780.67,APC 378
Treat hand dislocation,26686,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14780.67,APC
Treat hand dislocation,26686,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14780.67,APC
Treat hand dislocation,26686,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14780.67,APC
Treat hand dislocation,26686,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14780.67,Radiology
Treat hand dislocation,26686,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14780.67,APC
Treat hand dislocation,26686,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14780.67,APC
Treat knuckle dislocation,26700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,335.92,,,,,,,fee schedule,244.19,1083.4,
Treat knuckle dislocation,26700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,269.27,,,,,,,fee schedule,244.19,1083.4,
Treat knuckle dislocation,26700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,294.15,,,,,,,fee schedule,244.19,1083.4,
Treat knuckle dislocation,26700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,309.26,,,,,,,fee schedule,244.19,1083.4,
Treat knuckle dislocation,26700,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treat knuckle dislocation,26700,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treat knuckle dislocation,26700,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treat knuckle dislocation,26700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treat knuckle dislocation,26700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treat knuckle dislocation,26700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treat knuckle dislocation,26700,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treat knuckle dislocation,26705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5785.34,,,,,,,fee schedule,1591.86,7062.54,
Treat knuckle dislocation,26705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4637.46,,,,,,,fee schedule,1591.86,7062.54,
Treat knuckle dislocation,26705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5066,,,,,,,fee schedule,1591.86,7062.54,
Treat knuckle dislocation,26705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5326.19,,,,,,,fee schedule,1591.86,7062.54,
Treat knuckle dislocation,26705,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Treat knuckle dislocation,26705,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Treat knuckle dislocation,26705,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Treat knuckle dislocation,26705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Treat knuckle dislocation,26705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Treat knuckle dislocation,26705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Treat knuckle dislocation,26705,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Pin knuckle dislocation,26706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,353.72,14371.12,
Pin knuckle dislocation,26706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,353.72,14371.12,
Pin knuckle dislocation,26706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,353.72,14371.12,
Pin knuckle dislocation,26706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,353.72,14371.12,
Pin knuckle dislocation,26706,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,353.72,14371.12,APC 378
Pin knuckle dislocation,26706,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,353.72,14371.12,APC
Pin knuckle dislocation,26706,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,353.72,14371.12,APC
Pin knuckle dislocation,26706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,353.72,14371.12,APC
Pin knuckle dislocation,26706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,353.72,14371.12,Radiology
Pin knuckle dislocation,26706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,353.72,14371.12,APC
Pin knuckle dislocation,26706,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,353.72,14371.12,APC
Treat knuckle dislocation,26715,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6528.66,,,,,,,fee schedule,3239.17,14371.12,
Treat knuckle dislocation,26715,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5233.29,,,,,,,fee schedule,3239.17,14371.12,
Treat knuckle dislocation,26715,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5716.9,,,,,,,fee schedule,3239.17,14371.12,
Treat knuckle dislocation,26715,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6010.52,,,,,,,fee schedule,3239.17,14371.12,
Treat knuckle dislocation,26715,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Treat knuckle dislocation,26715,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Treat knuckle dislocation,26715,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Treat knuckle dislocation,26715,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Treat knuckle dislocation,26715,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Treat knuckle dislocation,26715,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Treat knuckle dislocation,26715,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Treat finger fracture each,26720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,244.19,1083.4,
Treat finger fracture each,26720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,244.19,1083.4,
Treat finger fracture each,26720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,244.19,1083.4,
Treat finger fracture each,26720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,244.19,1083.4,
Treat finger fracture each,26720,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treat finger fracture each,26720,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treat finger fracture each,26720,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treat finger fracture each,26720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treat finger fracture each,26720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treat finger fracture each,26720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treat finger fracture each,26720,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treat finger fracture each,26725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1481.1,,,,,,,fee schedule,244.19,1481.1,
Treat finger fracture each,26725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1187.23,,,,,,,fee schedule,244.19,1481.1,
Treat finger fracture each,26725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1296.94,,,,,,,fee schedule,244.19,1481.1,
Treat finger fracture each,26725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1363.55,,,,,,,fee schedule,244.19,1481.1,
Treat finger fracture each,26725,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1481.1,APC 378
Treat finger fracture each,26725,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1481.1,APC
Treat finger fracture each,26725,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1481.1,APC
Treat finger fracture each,26725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1481.1,APC
Treat finger fracture each,26725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1481.1,Radiology
Treat finger fracture each,26725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1481.1,APC
Treat finger fracture each,26725,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1481.1,APC
Treat finger fracture each,26727,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9062.15,,,,,,,fee schedule,3239.17,14371.12,
Treat finger fracture each,26727,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7264.1,,,,,,,fee schedule,3239.17,14371.12,
Treat finger fracture each,26727,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7935.37,,,,,,,fee schedule,3239.17,14371.12,
Treat finger fracture each,26727,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8342.93,,,,,,,fee schedule,3239.17,14371.12,
Treat finger fracture each,26727,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Treat finger fracture each,26727,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Treat finger fracture each,26727,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Treat finger fracture each,26727,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Treat finger fracture each,26727,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Treat finger fracture each,26727,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Treat finger fracture each,26727,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Treat finger fracture each,26735,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7969.88,,,,,,,fee schedule,3239.17,14371.12,
Treat finger fracture each,26735,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6388.55,,,,,,,fee schedule,3239.17,14371.12,
Treat finger fracture each,26735,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6978.91,,,,,,,fee schedule,3239.17,14371.12,
Treat finger fracture each,26735,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7337.35,,,,,,,fee schedule,3239.17,14371.12,
Treat finger fracture each,26735,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Treat finger fracture each,26735,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Treat finger fracture each,26735,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Treat finger fracture each,26735,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Treat finger fracture each,26735,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Treat finger fracture each,26735,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Treat finger fracture each,26735,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Treat finger fracture each,26740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,244.19,1083.4,
Treat finger fracture each,26740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,244.19,1083.4,
Treat finger fracture each,26740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,244.19,1083.4,
Treat finger fracture each,26740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,244.19,1083.4,
Treat finger fracture each,26740,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treat finger fracture each,26740,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treat finger fracture each,26740,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treat finger fracture each,26740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treat finger fracture each,26740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treat finger fracture each,26740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treat finger fracture each,26740,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treat finger fracture each,26742,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,353.72,7062.54,
Treat finger fracture each,26742,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,353.72,7062.54,
Treat finger fracture each,26742,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,353.72,7062.54,
Treat finger fracture each,26742,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,353.72,7062.54,
Treat finger fracture each,26742,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,353.72,7062.54,APC 378
Treat finger fracture each,26742,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,353.72,7062.54,APC
Treat finger fracture each,26742,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,353.72,7062.54,APC
Treat finger fracture each,26742,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,353.72,7062.54,APC
Treat finger fracture each,26742,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,353.72,7062.54,Radiology
Treat finger fracture each,26742,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,353.72,7062.54,APC
Treat finger fracture each,26742,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,353.72,7062.54,APC
Treat finger fracture each,26746,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7189.69,,,,,,,fee schedule,3239.17,14371.12,
Treat finger fracture each,26746,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5763.16,,,,,,,fee schedule,3239.17,14371.12,
Treat finger fracture each,26746,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6295.73,,,,,,,fee schedule,3239.17,14371.12,
Treat finger fracture each,26746,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6619.08,,,,,,,fee schedule,3239.17,14371.12,
Treat finger fracture each,26746,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Treat finger fracture each,26746,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Treat finger fracture each,26746,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Treat finger fracture each,26746,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Treat finger fracture each,26746,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Treat finger fracture each,26746,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Treat finger fracture each,26746,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Treat finger fracture each,26750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,244.19,1083.4,
Treat finger fracture each,26750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,244.19,1083.4,
Treat finger fracture each,26750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,244.19,1083.4,
Treat finger fracture each,26750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,244.19,1083.4,
Treat finger fracture each,26750,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treat finger fracture each,26750,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treat finger fracture each,26750,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treat finger fracture each,26750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treat finger fracture each,26750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treat finger fracture each,26750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treat finger fracture each,26750,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treat finger fracture each,26755,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,300.16,,,,,,,fee schedule,240.6,1083.4,
Treat finger fracture each,26755,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,240.6,,,,,,,fee schedule,240.6,1083.4,
Treat finger fracture each,26755,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,262.84,,,,,,,fee schedule,240.6,1083.4,
Treat finger fracture each,26755,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,276.34,,,,,,,fee schedule,240.6,1083.4,
Treat finger fracture each,26755,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,240.6,1083.4,APC 378
Treat finger fracture each,26755,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,240.6,1083.4,APC
Treat finger fracture each,26755,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,240.6,1083.4,APC
Treat finger fracture each,26755,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,240.6,1083.4,APC
Treat finger fracture each,26755,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,240.6,1083.4,Radiology
Treat finger fracture each,26755,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,240.6,1083.4,APC
Treat finger fracture each,26755,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,240.6,1083.4,APC
Pin finger fracture each,26756,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6528.66,,,,,,,fee schedule,3239.17,14371.12,
Pin finger fracture each,26756,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5233.29,,,,,,,fee schedule,3239.17,14371.12,
Pin finger fracture each,26756,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5716.9,,,,,,,fee schedule,3239.17,14371.12,
Pin finger fracture each,26756,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6010.52,,,,,,,fee schedule,3239.17,14371.12,
Pin finger fracture each,26756,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Pin finger fracture each,26756,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Pin finger fracture each,26756,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Pin finger fracture each,26756,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Pin finger fracture each,26756,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Pin finger fracture each,26756,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Pin finger fracture each,26756,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Treat finger fracture each,26765,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7189.69,,,,,,,fee schedule,3239.17,14371.12,
Treat finger fracture each,26765,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5763.16,,,,,,,fee schedule,3239.17,14371.12,
Treat finger fracture each,26765,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6295.73,,,,,,,fee schedule,3239.17,14371.12,
Treat finger fracture each,26765,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6619.08,,,,,,,fee schedule,3239.17,14371.12,
Treat finger fracture each,26765,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Treat finger fracture each,26765,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Treat finger fracture each,26765,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Treat finger fracture each,26765,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Treat finger fracture each,26765,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Treat finger fracture each,26765,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Treat finger fracture each,26765,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Treat finger dislocation,26770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,338.73,,,,,,,fee schedule,244.19,1083.4,
Treat finger dislocation,26770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,271.52,,,,,,,fee schedule,244.19,1083.4,
Treat finger dislocation,26770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,296.62,,,,,,,fee schedule,244.19,1083.4,
Treat finger dislocation,26770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,311.85,,,,,,,fee schedule,244.19,1083.4,
Treat finger dislocation,26770,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treat finger dislocation,26770,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treat finger dislocation,26770,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treat finger dislocation,26770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treat finger dislocation,26770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treat finger dislocation,26770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treat finger dislocation,26770,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treat finger dislocation,26775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3685.16,,,,,,,fee schedule,276.89,3685.16,
Treat finger dislocation,26775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2953.98,,,,,,,fee schedule,276.89,3685.16,
Treat finger dislocation,26775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3226.95,,,,,,,fee schedule,276.89,3685.16,
Treat finger dislocation,26775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3392.69,,,,,,,fee schedule,276.89,3685.16,
Treat finger dislocation,26775,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1228.45,,,,,,,fee schedule,276.89,3685.16,APC 378
Treat finger dislocation,26775,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,290.73,,,,,,,fee schedule,276.89,3685.16,APC
Treat finger dislocation,26775,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,287.96,,,,,,,fee schedule,276.89,3685.16,APC
Treat finger dislocation,26775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,276.89,,,,,,,fee schedule,276.89,3685.16,APC
Treat finger dislocation,26775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,423.64,,,,,,,fee schedule,276.89,3685.16,Radiology
Treat finger dislocation,26775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,387.64,,,,,,,fee schedule,276.89,3685.16,APC
Treat finger dislocation,26775,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,484.55,,,,,,,fee schedule,276.89,3685.16,APC
Pin finger dislocation,26776,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6528.66,,,,,,,fee schedule,3239.17,14371.12,
Pin finger dislocation,26776,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5233.29,,,,,,,fee schedule,3239.17,14371.12,
Pin finger dislocation,26776,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5716.9,,,,,,,fee schedule,3239.17,14371.12,
Pin finger dislocation,26776,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6010.52,,,,,,,fee schedule,3239.17,14371.12,
Pin finger dislocation,26776,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Pin finger dislocation,26776,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Pin finger dislocation,26776,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Pin finger dislocation,26776,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Pin finger dislocation,26776,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Pin finger dislocation,26776,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Pin finger dislocation,26776,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Treat finger dislocation,26785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3020.71,,,,,,,fee schedule,2421.36,14371.12,
Treat finger dislocation,26785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2421.36,,,,,,,fee schedule,2421.36,14371.12,
Treat finger dislocation,26785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2645.12,,,,,,,fee schedule,2421.36,14371.12,
Treat finger dislocation,26785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2780.97,,,,,,,fee schedule,2421.36,14371.12,
Treat finger dislocation,26785,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,2421.36,14371.12,APC 378
Treat finger dislocation,26785,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,2421.36,14371.12,APC
Treat finger dislocation,26785,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,2421.36,14371.12,APC
Treat finger dislocation,26785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,2421.36,14371.12,APC
Treat finger dislocation,26785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,2421.36,14371.12,Radiology
Treat finger dislocation,26785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,2421.36,14371.12,APC
Treat finger dislocation,26785,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,2421.36,14371.12,APC
Thumb fusion with graft,26820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6566.46,,,,,,,fee schedule,5263.59,31870.39,
Thumb fusion with graft,26820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5263.59,,,,,,,fee schedule,5263.59,31870.39,
Thumb fusion with graft,26820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5750,,,,,,,fee schedule,5263.59,31870.39,
Thumb fusion with graft,26820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6045.32,,,,,,,fee schedule,5263.59,31870.39,
Thumb fusion with graft,26820,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5263.59,31870.39,APC 378
Thumb fusion with graft,26820,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5263.59,31870.39,APC
Thumb fusion with graft,26820,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5263.59,31870.39,APC
Thumb fusion with graft,26820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5263.59,31870.39,APC
Thumb fusion with graft,26820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5263.59,31870.39,Radiology
Thumb fusion with graft,26820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5263.59,31870.39,APC
Thumb fusion with graft,26820,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5263.59,31870.39,APC
Fusion of thumb,26841,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6566.46,,,,,,,fee schedule,5263.59,31870.39,
Fusion of thumb,26841,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5263.59,,,,,,,fee schedule,5263.59,31870.39,
Fusion of thumb,26841,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5750,,,,,,,fee schedule,5263.59,31870.39,
Fusion of thumb,26841,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6045.32,,,,,,,fee schedule,5263.59,31870.39,
Fusion of thumb,26841,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5263.59,31870.39,APC 378
Fusion of thumb,26841,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5263.59,31870.39,APC
Fusion of thumb,26841,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5263.59,31870.39,APC
Fusion of thumb,26841,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5263.59,31870.39,APC
Fusion of thumb,26841,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5263.59,31870.39,Radiology
Fusion of thumb,26841,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5263.59,31870.39,APC
Fusion of thumb,26841,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5263.59,31870.39,APC
Thumb fusion with graft,26842,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6566.46,,,,,,,fee schedule,5263.59,31870.39,
Thumb fusion with graft,26842,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5263.59,,,,,,,fee schedule,5263.59,31870.39,
Thumb fusion with graft,26842,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5750,,,,,,,fee schedule,5263.59,31870.39,
Thumb fusion with graft,26842,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6045.32,,,,,,,fee schedule,5263.59,31870.39,
Thumb fusion with graft,26842,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5263.59,31870.39,APC 378
Thumb fusion with graft,26842,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5263.59,31870.39,APC
Thumb fusion with graft,26842,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5263.59,31870.39,APC
Thumb fusion with graft,26842,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5263.59,31870.39,APC
Thumb fusion with graft,26842,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5263.59,31870.39,Radiology
Thumb fusion with graft,26842,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5263.59,31870.39,APC
Thumb fusion with graft,26842,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5263.59,31870.39,APC
Fusion of hand joint,26843,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6566.46,,,,,,,fee schedule,5263.59,31870.39,
Fusion of hand joint,26843,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5263.59,,,,,,,fee schedule,5263.59,31870.39,
Fusion of hand joint,26843,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5750,,,,,,,fee schedule,5263.59,31870.39,
Fusion of hand joint,26843,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6045.32,,,,,,,fee schedule,5263.59,31870.39,
Fusion of hand joint,26843,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5263.59,31870.39,APC 378
Fusion of hand joint,26843,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5263.59,31870.39,APC
Fusion of hand joint,26843,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5263.59,31870.39,APC
Fusion of hand joint,26843,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5263.59,31870.39,APC
Fusion of hand joint,26843,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5263.59,31870.39,Radiology
Fusion of hand joint,26843,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5263.59,31870.39,APC
Fusion of hand joint,26843,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5263.59,31870.39,APC
Fusion/graft of hand joint,26844,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6566.46,,,,,,,fee schedule,5263.59,31870.39,
Fusion/graft of hand joint,26844,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5263.59,,,,,,,fee schedule,5263.59,31870.39,
Fusion/graft of hand joint,26844,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5750,,,,,,,fee schedule,5263.59,31870.39,
Fusion/graft of hand joint,26844,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6045.32,,,,,,,fee schedule,5263.59,31870.39,
Fusion/graft of hand joint,26844,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5263.59,31870.39,APC 378
Fusion/graft of hand joint,26844,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5263.59,31870.39,APC
Fusion/graft of hand joint,26844,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5263.59,31870.39,APC
Fusion/graft of hand joint,26844,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5263.59,31870.39,APC
Fusion/graft of hand joint,26844,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5263.59,31870.39,Radiology
Fusion/graft of hand joint,26844,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5263.59,31870.39,APC
Fusion/graft of hand joint,26844,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5263.59,31870.39,APC
Fusion of knuckle,26850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6566.46,,,,,,,fee schedule,5263.59,31870.39,
Fusion of knuckle,26850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5263.59,,,,,,,fee schedule,5263.59,31870.39,
Fusion of knuckle,26850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5750,,,,,,,fee schedule,5263.59,31870.39,
Fusion of knuckle,26850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6045.32,,,,,,,fee schedule,5263.59,31870.39,
Fusion of knuckle,26850,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5263.59,31870.39,APC 378
Fusion of knuckle,26850,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5263.59,31870.39,APC
Fusion of knuckle,26850,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5263.59,31870.39,APC
Fusion of knuckle,26850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5263.59,31870.39,APC
Fusion of knuckle,26850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5263.59,31870.39,Radiology
Fusion of knuckle,26850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5263.59,31870.39,APC
Fusion of knuckle,26850,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5263.59,31870.39,APC
Fusion of knuckle with graft,26852,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6566.46,,,,,,,fee schedule,5263.59,31870.39,
Fusion of knuckle with graft,26852,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5263.59,,,,,,,fee schedule,5263.59,31870.39,
Fusion of knuckle with graft,26852,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5750,,,,,,,fee schedule,5263.59,31870.39,
Fusion of knuckle with graft,26852,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6045.32,,,,,,,fee schedule,5263.59,31870.39,
Fusion of knuckle with graft,26852,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5263.59,31870.39,APC 378
Fusion of knuckle with graft,26852,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5263.59,31870.39,APC
Fusion of knuckle with graft,26852,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5263.59,31870.39,APC
Fusion of knuckle with graft,26852,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5263.59,31870.39,APC
Fusion of knuckle with graft,26852,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5263.59,31870.39,Radiology
Fusion of knuckle with graft,26852,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5263.59,31870.39,APC
Fusion of knuckle with graft,26852,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5263.59,31870.39,APC
Fusion of finger joint,26860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3360.79,,,,,,,fee schedule,2693.96,14371.12,
Fusion of finger joint,26860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2693.96,,,,,,,fee schedule,2693.96,14371.12,
Fusion of finger joint,26860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2942.91,,,,,,,fee schedule,2693.96,14371.12,
Fusion of finger joint,26860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3094.06,,,,,,,fee schedule,2693.96,14371.12,
Fusion of finger joint,26860,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,2693.96,14371.12,APC 378
Fusion of finger joint,26860,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,2693.96,14371.12,APC
Fusion of finger joint,26860,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,2693.96,14371.12,APC
Fusion of finger joint,26860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,2693.96,14371.12,APC
Fusion of finger joint,26860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,2693.96,14371.12,Radiology
Fusion of finger joint,26860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,2693.96,14371.12,APC
Fusion of finger joint,26860,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,2693.96,14371.12,APC
Fusion of finger jnt add-on,26861,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6566.46,,,,,,,fee schedule,5263.59,6566.46,
Fusion of finger jnt add-on,26861,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5263.59,,,,,,,fee schedule,5263.59,6566.46,
Fusion of finger jnt add-on,26861,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5750,,,,,,,fee schedule,5263.59,6566.46,
Fusion of finger jnt add-on,26861,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6045.32,,,,,,,fee schedule,5263.59,6566.46,
Fusion/graft of finger joint,26862,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12545.92,,,,,,,fee schedule,3239.17,14371.12,
Fusion/graft of finger joint,26862,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10056.65,,,,,,,fee schedule,3239.17,14371.12,
Fusion/graft of finger joint,26862,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10985.98,,,,,,,fee schedule,3239.17,14371.12,
Fusion/graft of finger joint,26862,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11550.21,,,,,,,fee schedule,3239.17,14371.12,
Fusion/graft of finger joint,26862,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Fusion/graft of finger joint,26862,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Fusion/graft of finger joint,26862,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Fusion/graft of finger joint,26862,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Fusion/graft of finger joint,26862,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Fusion/graft of finger joint,26862,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Fusion/graft of finger joint,26862,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Fuse/graft added joint,26863,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6566.46,,,,,,,fee schedule,5263.59,6566.46,
Fuse/graft added joint,26863,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5263.59,,,,,,,fee schedule,5263.59,6566.46,
Fuse/graft added joint,26863,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5750,,,,,,,fee schedule,5263.59,6566.46,
Fuse/graft added joint,26863,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6045.32,,,,,,,fee schedule,5263.59,6566.46,
Amputate metacarpal bone,26910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6566.46,,,,,,,fee schedule,3239.17,14371.12,
Amputate metacarpal bone,26910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5263.59,,,,,,,fee schedule,3239.17,14371.12,
Amputate metacarpal bone,26910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5750,,,,,,,fee schedule,3239.17,14371.12,
Amputate metacarpal bone,26910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6045.32,,,,,,,fee schedule,3239.17,14371.12,
Amputate metacarpal bone,26910,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Amputate metacarpal bone,26910,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Amputate metacarpal bone,26910,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Amputate metacarpal bone,26910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Amputate metacarpal bone,26910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Amputate metacarpal bone,26910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Amputate metacarpal bone,26910,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Amputation of finger/thumb,26951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4108.94,,,,,,,fee schedule,3239.17,14371.12,
Amputation of finger/thumb,26951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3293.67,,,,,,,fee schedule,3239.17,14371.12,
Amputation of finger/thumb,26951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3598.04,,,,,,,fee schedule,3239.17,14371.12,
Amputation of finger/thumb,26951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3782.83,,,,,,,fee schedule,3239.17,14371.12,
Amputation of finger/thumb,26951,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Amputation of finger/thumb,26951,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Amputation of finger/thumb,26951,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Amputation of finger/thumb,26951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Amputation of finger/thumb,26951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Amputation of finger/thumb,26951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Amputation of finger/thumb,26951,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Amputation of finger/thumb,26952,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3196.08,,,,,,,fee schedule,2561.94,14371.12,
Amputation of finger/thumb,26952,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2561.94,,,,,,,fee schedule,2561.94,14371.12,
Amputation of finger/thumb,26952,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2798.68,,,,,,,fee schedule,2561.94,14371.12,
Amputation of finger/thumb,26952,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2942.42,,,,,,,fee schedule,2561.94,14371.12,
Amputation of finger/thumb,26952,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,2561.94,14371.12,APC 378
Amputation of finger/thumb,26952,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,2561.94,14371.12,APC
Amputation of finger/thumb,26952,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,2561.94,14371.12,APC
Amputation of finger/thumb,26952,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,2561.94,14371.12,APC
Amputation of finger/thumb,26952,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,2561.94,14371.12,Radiology
Amputation of finger/thumb,26952,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,2561.94,14371.12,APC
Amputation of finger/thumb,26952,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,2561.94,14371.12,APC
Hand/finger surgery,26989,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,244.19,1083.4,
Hand/finger surgery,26989,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,244.19,1083.4,
Hand/finger surgery,26989,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,244.19,1083.4,
Hand/finger surgery,26989,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,244.19,1083.4,
Hand/finger surgery,26989,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Hand/finger surgery,26989,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Hand/finger surgery,26989,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Hand/finger surgery,26989,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Hand/finger surgery,26989,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Hand/finger surgery,26989,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Hand/finger surgery,26989,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Drainage of pelvis lesion,26990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,3239.17,14371.12,
Drainage of pelvis lesion,26990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,3239.17,14371.12,
Drainage of pelvis lesion,26990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,3239.17,14371.12,
Drainage of pelvis lesion,26990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,3239.17,14371.12,
Drainage of pelvis lesion,26990,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Drainage of pelvis lesion,26990,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Drainage of pelvis lesion,26990,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Drainage of pelvis lesion,26990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Drainage of pelvis lesion,26990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Drainage of pelvis lesion,26990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Drainage of pelvis lesion,26990,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Drainage of pelvis bursa,26991,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,1591.86,7062.54,
Drainage of pelvis bursa,26991,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,1591.86,7062.54,
Drainage of pelvis bursa,26991,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,1591.86,7062.54,
Drainage of pelvis bursa,26991,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,1591.86,7062.54,
Drainage of pelvis bursa,26991,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Drainage of pelvis bursa,26991,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Drainage of pelvis bursa,26991,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Drainage of pelvis bursa,26991,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Drainage of pelvis bursa,26991,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Drainage of pelvis bursa,26991,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Drainage of pelvis bursa,26991,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Drainage of bone lesion,26992,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,3239.17,23681.51,
Drainage of bone lesion,26992,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,3239.17,23681.51,
Drainage of bone lesion,26992,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,3239.17,23681.51,
Drainage of bone lesion,26992,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,3239.17,23681.51,
Drainage of bone lesion,26992,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,23681.51,APC 378
Drainage of bone lesion,26992,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,23681.51,APC
Drainage of bone lesion,26992,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,23681.51,APC
Drainage of bone lesion,26992,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,23681.51,APC
Drainage of bone lesion,26992,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,23681.51,Radiology
Drainage of bone lesion,26992,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,23681.51,APC
Drainage of bone lesion,26992,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,23681.51,APC
Incision of hip tendon,27000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,1591.86,7062.54,
Incision of hip tendon,27000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,1591.86,7062.54,
Incision of hip tendon,27000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,1591.86,7062.54,
Incision of hip tendon,27000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,1591.86,7062.54,
Incision of hip tendon,27000,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Incision of hip tendon,27000,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Incision of hip tendon,27000,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Incision of hip tendon,27000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Incision of hip tendon,27000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Incision of hip tendon,27000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Incision of hip tendon,27000,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Incision of hip tendon,27001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,3239.17,14371.12,
Incision of hip tendon,27001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,3239.17,14371.12,
Incision of hip tendon,27001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,3239.17,14371.12,
Incision of hip tendon,27001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,3239.17,14371.12,
Incision of hip tendon,27001,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Incision of hip tendon,27001,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Incision of hip tendon,27001,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Incision of hip tendon,27001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Incision of hip tendon,27001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Incision of hip tendon,27001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Incision of hip tendon,27001,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Incision of hip tendon,27003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,5839.66,31870.39,
Incision of hip tendon,27003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,5839.66,31870.39,
Incision of hip tendon,27003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,5839.66,31870.39,
Incision of hip tendon,27003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,5839.66,31870.39,
Incision of hip tendon,27003,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5839.66,31870.39,APC 378
Incision of hip tendon,27003,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5839.66,31870.39,APC
Incision of hip tendon,27003,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5839.66,31870.39,APC
Incision of hip tendon,27003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5839.66,31870.39,APC
Incision of hip tendon,27003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5839.66,31870.39,Radiology
Incision of hip tendon,27003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5839.66,31870.39,APC
Incision of hip tendon,27003,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5839.66,31870.39,APC
Incision of hip tendon,27005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,3239.17,23681.51,
Incision of hip tendon,27005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,3239.17,23681.51,
Incision of hip tendon,27005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,3239.17,23681.51,
Incision of hip tendon,27005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,3239.17,23681.51,
Incision of hip tendon,27005,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,23681.51,APC 378
Incision of hip tendon,27005,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,23681.51,APC
Incision of hip tendon,27005,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,23681.51,APC
Incision of hip tendon,27005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,23681.51,APC
Incision of hip tendon,27005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,23681.51,Radiology
Incision of hip tendon,27005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,23681.51,APC
Incision of hip tendon,27005,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,23681.51,APC
Incision of hip tendons,27006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,3239.17,14371.12,
Incision of hip tendons,27006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,3239.17,14371.12,
Incision of hip tendons,27006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,3239.17,14371.12,
Incision of hip tendons,27006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,3239.17,14371.12,
Incision of hip tendons,27006,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Incision of hip tendons,27006,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Incision of hip tendons,27006,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Incision of hip tendons,27006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Incision of hip tendons,27006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Incision of hip tendons,27006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Incision of hip tendons,27006,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Incision of hip/thigh fascia,27025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,3239.17,23681.51,
Incision of hip/thigh fascia,27025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,3239.17,23681.51,
Incision of hip/thigh fascia,27025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,3239.17,23681.51,
Incision of hip/thigh fascia,27025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,3239.17,23681.51,
Incision of hip/thigh fascia,27025,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,23681.51,APC 378
Incision of hip/thigh fascia,27025,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,23681.51,APC
Incision of hip/thigh fascia,27025,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,23681.51,APC
Incision of hip/thigh fascia,27025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,23681.51,APC
Incision of hip/thigh fascia,27025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,23681.51,Radiology
Incision of hip/thigh fascia,27025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,23681.51,APC
Incision of hip/thigh fascia,27025,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,23681.51,APC
Buttock fasciotomy,27027,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2959.59,,,,,,,fee schedule,2372.37,31870.39,
Buttock fasciotomy,27027,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2372.37,,,,,,,fee schedule,2372.37,31870.39,
Buttock fasciotomy,27027,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2591.6,,,,,,,fee schedule,2372.37,31870.39,
Buttock fasciotomy,27027,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2724.7,,,,,,,fee schedule,2372.37,31870.39,
Buttock fasciotomy,27027,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,2372.37,31870.39,APC 378
Buttock fasciotomy,27027,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,2372.37,31870.39,APC
Buttock fasciotomy,27027,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,2372.37,31870.39,APC
Buttock fasciotomy,27027,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,2372.37,31870.39,APC
Buttock fasciotomy,27027,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,2372.37,31870.39,Radiology
Buttock fasciotomy,27027,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,2372.37,31870.39,APC
Buttock fasciotomy,27027,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,2372.37,31870.39,APC
Drainage of hip joint,27030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Drainage of hip joint,27030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Drainage of hip joint,27030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Drainage of hip joint,27030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Drainage of hip joint,27030,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Drainage of hip joint,27030,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Drainage of hip joint,27030,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Drainage of hip joint,27030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Drainage of hip joint,27030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Drainage of hip joint,27030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Drainage of hip joint,27030,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Exploration of hip joint,27033,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10728.02,,,,,,,fee schedule,7183.42,31870.39,
Exploration of hip joint,27033,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8599.44,,,,,,,fee schedule,7183.42,31870.39,
Exploration of hip joint,27033,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9394.11,,,,,,,fee schedule,7183.42,31870.39,
Exploration of hip joint,27033,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9876.59,,,,,,,fee schedule,7183.42,31870.39,
Exploration of hip joint,27033,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Exploration of hip joint,27033,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Exploration of hip joint,27033,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Exploration of hip joint,27033,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Exploration of hip joint,27033,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Exploration of hip joint,27033,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Exploration of hip joint,27033,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Denervation of hip joint,27035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10728.02,,,,,,,fee schedule,3239.17,14371.12,
Denervation of hip joint,27035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8599.44,,,,,,,fee schedule,3239.17,14371.12,
Denervation of hip joint,27035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9394.11,,,,,,,fee schedule,3239.17,14371.12,
Denervation of hip joint,27035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9876.59,,,,,,,fee schedule,3239.17,14371.12,
Denervation of hip joint,27035,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Denervation of hip joint,27035,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Denervation of hip joint,27035,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Denervation of hip joint,27035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Denervation of hip joint,27035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Denervation of hip joint,27035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Denervation of hip joint,27035,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Excision of hip joint/muscle,27036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Excision of hip joint/muscle,27036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Excision of hip joint/muscle,27036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Excision of hip joint/muscle,27036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Excision of hip joint/muscle,27036,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Excision of hip joint/muscle,27036,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Excision of hip joint/muscle,27036,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Excision of hip joint/muscle,27036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Excision of hip joint/muscle,27036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Excision of hip joint/muscle,27036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Excision of hip joint/muscle,27036,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Biopsy of soft tissues,27040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2167.57,,,,,,,fee schedule,1635.03,7254.06,
Biopsy of soft tissues,27040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1737.49,,,,,,,fee schedule,1635.03,7254.06,
Biopsy of soft tissues,27040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1898.05,,,,,,,fee schedule,1635.03,7254.06,
Biopsy of soft tissues,27040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1995.54,,,,,,,fee schedule,1635.03,7254.06,
Biopsy of soft tissues,27040,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,7254.06,APC 378
Biopsy of soft tissues,27040,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,7254.06,APC
Biopsy of soft tissues,27040,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,7254.06,APC
Biopsy of soft tissues,27040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,7254.06,APC
Biopsy of soft tissues,27040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,7254.06,Radiology
Biopsy of soft tissues,27040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,7254.06,APC
Biopsy of soft tissues,27040,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,7254.06,APC
Biopsy of soft tissues,27041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2167.57,,,,,,,fee schedule,1635.03,7254.06,
Biopsy of soft tissues,27041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1737.49,,,,,,,fee schedule,1635.03,7254.06,
Biopsy of soft tissues,27041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1898.05,,,,,,,fee schedule,1635.03,7254.06,
Biopsy of soft tissues,27041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1995.54,,,,,,,fee schedule,1635.03,7254.06,
Biopsy of soft tissues,27041,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,7254.06,APC 378
Biopsy of soft tissues,27041,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,7254.06,APC
Biopsy of soft tissues,27041,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,7254.06,APC
Biopsy of soft tissues,27041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,7254.06,APC
Biopsy of soft tissues,27041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,7254.06,Radiology
Biopsy of soft tissues,27041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,7254.06,APC
Biopsy of soft tissues,27041,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,7254.06,APC
Exc hip pelvis les sc 3 cm/>,27043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6253.46,,,,,,,fee schedule,2875.57,12757.95,
Exc hip pelvis les sc 3 cm/>,27043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5012.69,,,,,,,fee schedule,2875.57,12757.95,
Exc hip pelvis les sc 3 cm/>,27043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5475.91,,,,,,,fee schedule,2875.57,12757.95,
Exc hip pelvis les sc 3 cm/>,27043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5757.15,,,,,,,fee schedule,2875.57,12757.95,
Exc hip pelvis les sc 3 cm/>,27043,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Exc hip pelvis les sc 3 cm/>,27043,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Exc hip pelvis les sc 3 cm/>,27043,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Exc hip pelvis les sc 3 cm/>,27043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Exc hip pelvis les sc 3 cm/>,27043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Exc hip pelvis les sc 3 cm/>,27043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Exc hip pelvis les sc 3 cm/>,27043,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Exc hip/pelv tum deep 5 cm/>,27045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6177.24,,,,,,,fee schedule,2875.57,12757.95,
Exc hip/pelv tum deep 5 cm/>,27045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4951.6,,,,,,,fee schedule,2875.57,12757.95,
Exc hip/pelv tum deep 5 cm/>,27045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5409.17,,,,,,,fee schedule,2875.57,12757.95,
Exc hip/pelv tum deep 5 cm/>,27045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5686.98,,,,,,,fee schedule,2875.57,12757.95,
Exc hip/pelv tum deep 5 cm/>,27045,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Exc hip/pelv tum deep 5 cm/>,27045,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Exc hip/pelv tum deep 5 cm/>,27045,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Exc hip/pelv tum deep 5 cm/>,27045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Exc hip/pelv tum deep 5 cm/>,27045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Exc hip/pelv tum deep 5 cm/>,27045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Exc hip/pelv tum deep 5 cm/>,27045,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Exc hip/pelvis les sc < 3 cm,27047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5268.49,,,,,,,fee schedule,2875.57,12757.95,
Exc hip/pelvis les sc < 3 cm,27047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4223.15,,,,,,,fee schedule,2875.57,12757.95,
Exc hip/pelvis les sc < 3 cm,27047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4613.41,,,,,,,fee schedule,2875.57,12757.95,
Exc hip/pelvis les sc < 3 cm,27047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4850.35,,,,,,,fee schedule,2875.57,12757.95,
Exc hip/pelvis les sc < 3 cm,27047,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Exc hip/pelvis les sc < 3 cm,27047,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Exc hip/pelvis les sc < 3 cm,27047,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Exc hip/pelvis les sc < 3 cm,27047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Exc hip/pelvis les sc < 3 cm,27047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Exc hip/pelvis les sc < 3 cm,27047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Exc hip/pelvis les sc < 3 cm,27047,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Exc hip/pelv tum deep < 5 cm,27048,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5268.49,,,,,,,fee schedule,2875.57,12757.95,
Exc hip/pelv tum deep < 5 cm,27048,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4223.15,,,,,,,fee schedule,2875.57,12757.95,
Exc hip/pelv tum deep < 5 cm,27048,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4613.41,,,,,,,fee schedule,2875.57,12757.95,
Exc hip/pelv tum deep < 5 cm,27048,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4850.35,,,,,,,fee schedule,2875.57,12757.95,
Exc hip/pelv tum deep < 5 cm,27048,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Exc hip/pelv tum deep < 5 cm,27048,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Exc hip/pelv tum deep < 5 cm,27048,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Exc hip/pelv tum deep < 5 cm,27048,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Exc hip/pelv tum deep < 5 cm,27048,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Exc hip/pelv tum deep < 5 cm,27048,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Exc hip/pelv tum deep < 5 cm,27048,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Resect hip/pelv tum < 5 cm,27049,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5268.49,,,,,,,fee schedule,2875.57,12757.95,
Resect hip/pelv tum < 5 cm,27049,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4223.15,,,,,,,fee schedule,2875.57,12757.95,
Resect hip/pelv tum < 5 cm,27049,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4613.41,,,,,,,fee schedule,2875.57,12757.95,
Resect hip/pelv tum < 5 cm,27049,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4850.35,,,,,,,fee schedule,2875.57,12757.95,
Resect hip/pelv tum < 5 cm,27049,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Resect hip/pelv tum < 5 cm,27049,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Resect hip/pelv tum < 5 cm,27049,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Resect hip/pelv tum < 5 cm,27049,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Resect hip/pelv tum < 5 cm,27049,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Resect hip/pelv tum < 5 cm,27049,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Resect hip/pelv tum < 5 cm,27049,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Biopsy of sacroiliac joint,27050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,1591.86,7062.54,
Biopsy of sacroiliac joint,27050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,1591.86,7062.54,
Biopsy of sacroiliac joint,27050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,1591.86,7062.54,
Biopsy of sacroiliac joint,27050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,1591.86,7062.54,
Biopsy of sacroiliac joint,27050,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Biopsy of sacroiliac joint,27050,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Biopsy of sacroiliac joint,27050,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Biopsy of sacroiliac joint,27050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Biopsy of sacroiliac joint,27050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Biopsy of sacroiliac joint,27050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Biopsy of sacroiliac joint,27050,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Biopsy of hip joint,27052,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,1591.86,7062.54,
Biopsy of hip joint,27052,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,1591.86,7062.54,
Biopsy of hip joint,27052,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,1591.86,7062.54,
Biopsy of hip joint,27052,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,1591.86,7062.54,
Biopsy of hip joint,27052,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Biopsy of hip joint,27052,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Biopsy of hip joint,27052,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Biopsy of hip joint,27052,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Biopsy of hip joint,27052,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Biopsy of hip joint,27052,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Biopsy of hip joint,27052,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Removal of hip joint lining,27054,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10698.91,,,,,,,fee schedule,3239.17,14371.12,
Removal of hip joint lining,27054,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8576.11,,,,,,,fee schedule,3239.17,14371.12,
Removal of hip joint lining,27054,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9368.62,,,,,,,fee schedule,3239.17,14371.12,
Removal of hip joint lining,27054,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9849.79,,,,,,,fee schedule,3239.17,14371.12,
Removal of hip joint lining,27054,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Removal of hip joint lining,27054,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of hip joint lining,27054,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of hip joint lining,27054,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of hip joint lining,27054,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Removal of hip joint lining,27054,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of hip joint lining,27054,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Buttock fasciotomy w/dbrdmt,27057,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3250.23,,,,,,,fee schedule,1591.86,7062.54,
Buttock fasciotomy w/dbrdmt,27057,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2605.35,,,,,,,fee schedule,1591.86,7062.54,
Buttock fasciotomy w/dbrdmt,27057,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2846.1,,,,,,,fee schedule,1591.86,7062.54,
Buttock fasciotomy w/dbrdmt,27057,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2992.28,,,,,,,fee schedule,1591.86,7062.54,
Buttock fasciotomy w/dbrdmt,27057,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Buttock fasciotomy w/dbrdmt,27057,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Buttock fasciotomy w/dbrdmt,27057,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Buttock fasciotomy w/dbrdmt,27057,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Buttock fasciotomy w/dbrdmt,27057,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Buttock fasciotomy w/dbrdmt,27057,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Buttock fasciotomy w/dbrdmt,27057,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Resect hip/pelv tum 5 cm/>,27059,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7189.69,,,,,,,fee schedule,2875.57,12757.95,
Resect hip/pelv tum 5 cm/>,27059,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5763.16,,,,,,,fee schedule,2875.57,12757.95,
Resect hip/pelv tum 5 cm/>,27059,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6295.73,,,,,,,fee schedule,2875.57,12757.95,
Resect hip/pelv tum 5 cm/>,27059,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6619.08,,,,,,,fee schedule,2875.57,12757.95,
Resect hip/pelv tum 5 cm/>,27059,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Resect hip/pelv tum 5 cm/>,27059,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Resect hip/pelv tum 5 cm/>,27059,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Resect hip/pelv tum 5 cm/>,27059,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Resect hip/pelv tum 5 cm/>,27059,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Resect hip/pelv tum 5 cm/>,27059,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Resect hip/pelv tum 5 cm/>,27059,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Removal of ischial bursa,27060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,4254.97,31870.39,
Removal of ischial bursa,27060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,4254.97,31870.39,
Removal of ischial bursa,27060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,4254.97,31870.39,
Removal of ischial bursa,27060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,4254.97,31870.39,
Removal of ischial bursa,27060,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,4254.97,31870.39,APC 378
Removal of ischial bursa,27060,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,4254.97,31870.39,APC
Removal of ischial bursa,27060,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,4254.97,31870.39,APC
Removal of ischial bursa,27060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,4254.97,31870.39,APC
Removal of ischial bursa,27060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,4254.97,31870.39,Radiology
Removal of ischial bursa,27060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,4254.97,31870.39,APC
Removal of ischial bursa,27060,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,4254.97,31870.39,APC
Remove femur lesion/bursa,27062,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,3239.17,14371.12,
Remove femur lesion/bursa,27062,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,3239.17,14371.12,
Remove femur lesion/bursa,27062,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,3239.17,14371.12,
Remove femur lesion/bursa,27062,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,3239.17,14371.12,
Remove femur lesion/bursa,27062,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Remove femur lesion/bursa,27062,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Remove femur lesion/bursa,27062,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Remove femur lesion/bursa,27062,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Remove femur lesion/bursa,27062,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Remove femur lesion/bursa,27062,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Remove femur lesion/bursa,27062,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Remove hip bone les super,27065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,4254.97,31870.39,
Remove hip bone les super,27065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,4254.97,31870.39,
Remove hip bone les super,27065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,4254.97,31870.39,
Remove hip bone les super,27065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,4254.97,31870.39,
Remove hip bone les super,27065,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,4254.97,31870.39,APC 378
Remove hip bone les super,27065,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,4254.97,31870.39,APC
Remove hip bone les super,27065,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,4254.97,31870.39,APC
Remove hip bone les super,27065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,4254.97,31870.39,APC
Remove hip bone les super,27065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,4254.97,31870.39,Radiology
Remove hip bone les super,27065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,4254.97,31870.39,APC
Remove hip bone les super,27065,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,4254.97,31870.39,APC
Remove hip bone les deep,27066,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,3239.17,14371.12,
Remove hip bone les deep,27066,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,3239.17,14371.12,
Remove hip bone les deep,27066,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,3239.17,14371.12,
Remove hip bone les deep,27066,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,3239.17,14371.12,
Remove hip bone les deep,27066,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Remove hip bone les deep,27066,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Remove hip bone les deep,27066,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Remove hip bone les deep,27066,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Remove hip bone les deep,27066,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Remove hip bone les deep,27066,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Remove hip bone les deep,27066,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Remove/graft hip bone lesion,27067,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,5839.66,31870.39,
Remove/graft hip bone lesion,27067,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,5839.66,31870.39,
Remove/graft hip bone lesion,27067,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,5839.66,31870.39,
Remove/graft hip bone lesion,27067,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,5839.66,31870.39,
Remove/graft hip bone lesion,27067,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5839.66,31870.39,APC 378
Remove/graft hip bone lesion,27067,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5839.66,31870.39,APC
Remove/graft hip bone lesion,27067,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5839.66,31870.39,APC
Remove/graft hip bone lesion,27067,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5839.66,31870.39,APC
Remove/graft hip bone lesion,27067,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5839.66,31870.39,Radiology
Remove/graft hip bone lesion,27067,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5839.66,31870.39,APC
Remove/graft hip bone lesion,27067,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5839.66,31870.39,APC
Part remove hip bone super,27070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,3239.17,23681.51,
Part remove hip bone super,27070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,3239.17,23681.51,
Part remove hip bone super,27070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,3239.17,23681.51,
Part remove hip bone super,27070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,3239.17,23681.51,
Part remove hip bone super,27070,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,23681.51,APC 378
Part remove hip bone super,27070,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,23681.51,APC
Part remove hip bone super,27070,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,23681.51,APC
Part remove hip bone super,27070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,23681.51,APC
Part remove hip bone super,27070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,23681.51,Radiology
Part remove hip bone super,27070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,23681.51,APC
Part remove hip bone super,27070,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,23681.51,APC
Part removal hip bone deep,27071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,3239.17,23681.51,
Part removal hip bone deep,27071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,3239.17,23681.51,
Part removal hip bone deep,27071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,3239.17,23681.51,
Part removal hip bone deep,27071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,3239.17,23681.51,
Part removal hip bone deep,27071,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,23681.51,APC 378
Part removal hip bone deep,27071,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,23681.51,APC
Part removal hip bone deep,27071,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,23681.51,APC
Part removal hip bone deep,27071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,23681.51,APC
Part removal hip bone deep,27071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,23681.51,Radiology
Part removal hip bone deep,27071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,23681.51,APC
Part removal hip bone deep,27071,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,23681.51,APC
Resect hip tumor,27075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Resect hip tumor,27075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Resect hip tumor,27075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Resect hip tumor,27075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Resect hip tumor,27075,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Resect hip tumor,27075,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Resect hip tumor,27075,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Resect hip tumor,27075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Resect hip tumor,27075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Resect hip tumor,27075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Resect hip tumor,27075,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Resect hip tum incl acetabul,27076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Resect hip tum incl acetabul,27076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Resect hip tum incl acetabul,27076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Resect hip tum incl acetabul,27076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Resect hip tum incl acetabul,27076,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Resect hip tum incl acetabul,27076,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Resect hip tum incl acetabul,27076,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Resect hip tum incl acetabul,27076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Resect hip tum incl acetabul,27076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Resect hip tum incl acetabul,27076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Resect hip tum incl acetabul,27076,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Resect hip tum w/innom bone,27077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46549.79,,,,,,,fee schedule,7183.42,46549.79,
Resect hip tum w/innom bone,27077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37313.72,,,,,,,fee schedule,7183.42,46549.79,
Resect hip tum w/innom bone,27077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40761.86,,,,,,,fee schedule,7183.42,46549.79,
Resect hip tum w/innom bone,27077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42855.36,,,,,,,fee schedule,7183.42,46549.79,
Resect hip tum w/innom bone,27077,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,46549.79,APC 378
Resect hip tum w/innom bone,27077,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,46549.79,APC
Resect hip tum w/innom bone,27077,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,46549.79,APC
Resect hip tum w/innom bone,27077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,46549.79,APC
Resect hip tum w/innom bone,27077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,46549.79,Radiology
Resect hip tum w/innom bone,27077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,46549.79,APC
Resect hip tum w/innom bone,27077,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,46549.79,APC
Rsect hip tum incl femur,27078,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46549.79,,,,,,,fee schedule,7183.42,46549.79,
Rsect hip tum incl femur,27078,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37313.72,,,,,,,fee schedule,7183.42,46549.79,
Rsect hip tum incl femur,27078,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40761.86,,,,,,,fee schedule,7183.42,46549.79,
Rsect hip tum incl femur,27078,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42855.36,,,,,,,fee schedule,7183.42,46549.79,
Rsect hip tum incl femur,27078,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,46549.79,APC 378
Rsect hip tum incl femur,27078,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,46549.79,APC
Rsect hip tum incl femur,27078,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,46549.79,APC
Rsect hip tum incl femur,27078,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,46549.79,APC
Rsect hip tum incl femur,27078,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,46549.79,Radiology
Rsect hip tum incl femur,27078,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,46549.79,APC
Rsect hip tum incl femur,27078,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,46549.79,APC
Removal of tail bone,27080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,3239.17,14371.12,
Removal of tail bone,27080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,3239.17,14371.12,
Removal of tail bone,27080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,3239.17,14371.12,
Removal of tail bone,27080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,3239.17,14371.12,
Removal of tail bone,27080,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Removal of tail bone,27080,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of tail bone,27080,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of tail bone,27080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of tail bone,27080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Removal of tail bone,27080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of tail bone,27080,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Remove hip foreign body,27086,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2167.57,,,,,,,fee schedule,1737.49,12757.95,
Remove hip foreign body,27086,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1737.49,,,,,,,fee schedule,1737.49,12757.95,
Remove hip foreign body,27086,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1898.05,,,,,,,fee schedule,1737.49,12757.95,
Remove hip foreign body,27086,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1995.54,,,,,,,fee schedule,1737.49,12757.95,
Remove hip foreign body,27086,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,1737.49,12757.95,APC 378
Remove hip foreign body,27086,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,1737.49,12757.95,APC
Remove hip foreign body,27086,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,1737.49,12757.95,APC
Remove hip foreign body,27086,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,1737.49,12757.95,APC
Remove hip foreign body,27086,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,1737.49,12757.95,Radiology
Remove hip foreign body,27086,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,1737.49,12757.95,APC
Remove hip foreign body,27086,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,1737.49,12757.95,APC
Remove hip foreign body,27087,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,3239.17,14371.12,
Remove hip foreign body,27087,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,3239.17,14371.12,
Remove hip foreign body,27087,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,3239.17,14371.12,
Remove hip foreign body,27087,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,3239.17,14371.12,
Remove hip foreign body,27087,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Remove hip foreign body,27087,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Remove hip foreign body,27087,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Remove hip foreign body,27087,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Remove hip foreign body,27087,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Remove hip foreign body,27087,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Remove hip foreign body,27087,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of hip prosthesis,27090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8958.64,,,,,,,fee schedule,7181.13,31870.39,
Removal of hip prosthesis,27090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7181.13,,,,,,,fee schedule,7181.13,31870.39,
Removal of hip prosthesis,27090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7844.73,,,,,,,fee schedule,7181.13,31870.39,
Removal of hip prosthesis,27090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8247.63,,,,,,,fee schedule,7181.13,31870.39,
Removal of hip prosthesis,27090,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7181.13,31870.39,APC 378
Removal of hip prosthesis,27090,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7181.13,31870.39,APC
Removal of hip prosthesis,27090,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7181.13,31870.39,APC
Removal of hip prosthesis,27090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7181.13,31870.39,APC
Removal of hip prosthesis,27090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7181.13,31870.39,Radiology
Removal of hip prosthesis,27090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7181.13,31870.39,APC
Removal of hip prosthesis,27090,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7181.13,31870.39,APC
Removal of hip prosthesis,27091,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8958.64,,,,,,,fee schedule,7181.13,56389.43,
Removal of hip prosthesis,27091,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7181.13,,,,,,,fee schedule,7181.13,56389.43,
Removal of hip prosthesis,27091,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7844.73,,,,,,,fee schedule,7181.13,56389.43,
Removal of hip prosthesis,27091,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8247.63,,,,,,,fee schedule,7181.13,56389.43,
Removal of hip prosthesis,27091,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,7181.13,56389.43,APC 378
Removal of hip prosthesis,27091,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,7181.13,56389.43,APC
Removal of hip prosthesis,27091,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,7181.13,56389.43,APC
Removal of hip prosthesis,27091,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,7181.13,56389.43,APC
Removal of hip prosthesis,27091,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,7181.13,56389.43,Radiology
Removal of hip prosthesis,27091,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,7181.13,56389.43,APC
Removal of hip prosthesis,27091,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,7181.13,56389.43,APC
Inject sacroiliac joint,27096,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,245.28,,,,,,,fee schedule,196.62,245.28,
Inject sacroiliac joint,27096,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,196.62,,,,,,,fee schedule,196.62,245.28,
Inject sacroiliac joint,27096,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,214.79,,,,,,,fee schedule,196.62,245.28,
Inject sacroiliac joint,27096,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,225.82,,,,,,,fee schedule,196.62,245.28,
Revision of hip tendon,27097,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,3239.17,14371.12,
Revision of hip tendon,27097,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,3239.17,14371.12,
Revision of hip tendon,27097,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,3239.17,14371.12,
Revision of hip tendon,27097,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,3239.17,14371.12,
Revision of hip tendon,27097,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Revision of hip tendon,27097,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Revision of hip tendon,27097,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Revision of hip tendon,27097,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Revision of hip tendon,27097,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Revision of hip tendon,27097,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Revision of hip tendon,27097,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Transfer tendon to pelvis,27098,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,3239.17,14371.12,
Transfer tendon to pelvis,27098,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,3239.17,14371.12,
Transfer tendon to pelvis,27098,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,3239.17,14371.12,
Transfer tendon to pelvis,27098,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,3239.17,14371.12,
Transfer tendon to pelvis,27098,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Transfer tendon to pelvis,27098,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Transfer tendon to pelvis,27098,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Transfer tendon to pelvis,27098,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Transfer tendon to pelvis,27098,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Transfer tendon to pelvis,27098,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Transfer tendon to pelvis,27098,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Transfer of abdominal muscle,27100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10728.02,,,,,,,fee schedule,7183.42,31870.39,
Transfer of abdominal muscle,27100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8599.44,,,,,,,fee schedule,7183.42,31870.39,
Transfer of abdominal muscle,27100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9394.11,,,,,,,fee schedule,7183.42,31870.39,
Transfer of abdominal muscle,27100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9876.59,,,,,,,fee schedule,7183.42,31870.39,
Transfer of abdominal muscle,27100,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Transfer of abdominal muscle,27100,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Transfer of abdominal muscle,27100,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Transfer of abdominal muscle,27100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Transfer of abdominal muscle,27100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Transfer of abdominal muscle,27100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Transfer of abdominal muscle,27100,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Transfer of spinal muscle,27105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10728.02,,,,,,,fee schedule,3239.17,14371.12,
Transfer of spinal muscle,27105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8599.44,,,,,,,fee schedule,3239.17,14371.12,
Transfer of spinal muscle,27105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9394.11,,,,,,,fee schedule,3239.17,14371.12,
Transfer of spinal muscle,27105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9876.59,,,,,,,fee schedule,3239.17,14371.12,
Transfer of spinal muscle,27105,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Transfer of spinal muscle,27105,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Transfer of spinal muscle,27105,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Transfer of spinal muscle,27105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Transfer of spinal muscle,27105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Transfer of spinal muscle,27105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Transfer of spinal muscle,27105,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Transfer of iliopsoas muscle,27110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10728.02,,,,,,,fee schedule,7183.42,31870.39,
Transfer of iliopsoas muscle,27110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8599.44,,,,,,,fee schedule,7183.42,31870.39,
Transfer of iliopsoas muscle,27110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9394.11,,,,,,,fee schedule,7183.42,31870.39,
Transfer of iliopsoas muscle,27110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9876.59,,,,,,,fee schedule,7183.42,31870.39,
Transfer of iliopsoas muscle,27110,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Transfer of iliopsoas muscle,27110,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Transfer of iliopsoas muscle,27110,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Transfer of iliopsoas muscle,27110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Transfer of iliopsoas muscle,27110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Transfer of iliopsoas muscle,27110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Transfer of iliopsoas muscle,27110,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Transfer of iliopsoas muscle,27111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10728.02,,,,,,,fee schedule,3239.17,14371.12,
Transfer of iliopsoas muscle,27111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8599.44,,,,,,,fee schedule,3239.17,14371.12,
Transfer of iliopsoas muscle,27111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9394.11,,,,,,,fee schedule,3239.17,14371.12,
Transfer of iliopsoas muscle,27111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9876.59,,,,,,,fee schedule,3239.17,14371.12,
Transfer of iliopsoas muscle,27111,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Transfer of iliopsoas muscle,27111,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Transfer of iliopsoas muscle,27111,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Transfer of iliopsoas muscle,27111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Transfer of iliopsoas muscle,27111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Transfer of iliopsoas muscle,27111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Transfer of iliopsoas muscle,27111,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Reconstruction of hip socket,27120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46549.79,,,,,,,fee schedule,12709.88,56389.43,
Reconstruction of hip socket,27120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37313.72,,,,,,,fee schedule,12709.88,56389.43,
Reconstruction of hip socket,27120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40761.86,,,,,,,fee schedule,12709.88,56389.43,
Reconstruction of hip socket,27120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42855.36,,,,,,,fee schedule,12709.88,56389.43,
Reconstruction of hip socket,27120,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,12709.88,56389.43,APC 378
Reconstruction of hip socket,27120,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,12709.88,56389.43,APC
Reconstruction of hip socket,27120,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,12709.88,56389.43,APC
Reconstruction of hip socket,27120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,12709.88,56389.43,APC
Reconstruction of hip socket,27120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,12709.88,56389.43,Radiology
Reconstruction of hip socket,27120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,12709.88,56389.43,APC
Reconstruction of hip socket,27120,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,12709.88,56389.43,APC
Reconstruction of hip socket,27122,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46549.79,,,,,,,fee schedule,7183.42,46549.79,
Reconstruction of hip socket,27122,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37313.72,,,,,,,fee schedule,7183.42,46549.79,
Reconstruction of hip socket,27122,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40761.86,,,,,,,fee schedule,7183.42,46549.79,
Reconstruction of hip socket,27122,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42855.36,,,,,,,fee schedule,7183.42,46549.79,
Reconstruction of hip socket,27122,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,46549.79,APC 378
Reconstruction of hip socket,27122,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,46549.79,APC
Reconstruction of hip socket,27122,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,46549.79,APC
Reconstruction of hip socket,27122,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,46549.79,APC
Reconstruction of hip socket,27122,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,46549.79,Radiology
Reconstruction of hip socket,27122,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,46549.79,APC
Reconstruction of hip socket,27122,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,46549.79,APC
Partial hip replacement,27125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46549.79,,,,,,,fee schedule,12709.88,56389.43,
Partial hip replacement,27125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37313.72,,,,,,,fee schedule,12709.88,56389.43,
Partial hip replacement,27125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40761.86,,,,,,,fee schedule,12709.88,56389.43,
Partial hip replacement,27125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42855.36,,,,,,,fee schedule,12709.88,56389.43,
Partial hip replacement,27125,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,12709.88,56389.43,APC 378
Partial hip replacement,27125,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,12709.88,56389.43,APC
Partial hip replacement,27125,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,12709.88,56389.43,APC
Partial hip replacement,27125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,12709.88,56389.43,APC
Partial hip replacement,27125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,12709.88,56389.43,Radiology
Partial hip replacement,27125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,12709.88,56389.43,APC
Partial hip replacement,27125,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,12709.88,56389.43,APC
Total hip arthroplasty,27130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46549.79,,,,,,,fee schedule,12709.88,56389.43,
Total hip arthroplasty,27130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37313.72,,,,,,,fee schedule,12709.88,56389.43,
Total hip arthroplasty,27130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40761.86,,,,,,,fee schedule,12709.88,56389.43,
Total hip arthroplasty,27130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42855.36,,,,,,,fee schedule,12709.88,56389.43,
Total hip arthroplasty,27130,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,12709.88,56389.43,APC 378
Total hip arthroplasty,27130,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,12709.88,56389.43,APC
Total hip arthroplasty,27130,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,12709.88,56389.43,APC
Total hip arthroplasty,27130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,12709.88,56389.43,APC
Total hip arthroplasty,27130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,12709.88,56389.43,Radiology
Total hip arthroplasty,27130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,12709.88,56389.43,APC
Total hip arthroplasty,27130,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,12709.88,56389.43,APC
Total hip arthroplasty,27132,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46549.79,,,,,,,fee schedule,12709.88,56389.43,
Total hip arthroplasty,27132,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37313.72,,,,,,,fee schedule,12709.88,56389.43,
Total hip arthroplasty,27132,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40761.86,,,,,,,fee schedule,12709.88,56389.43,
Total hip arthroplasty,27132,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42855.36,,,,,,,fee schedule,12709.88,56389.43,
Total hip arthroplasty,27132,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,12709.88,56389.43,APC 378
Total hip arthroplasty,27132,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,12709.88,56389.43,APC
Total hip arthroplasty,27132,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,12709.88,56389.43,APC
Total hip arthroplasty,27132,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,12709.88,56389.43,APC
Total hip arthroplasty,27132,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,12709.88,56389.43,Radiology
Total hip arthroplasty,27132,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,12709.88,56389.43,APC
Total hip arthroplasty,27132,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,12709.88,56389.43,APC
Revise hip joint replacement,27134,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46549.79,,,,,,,fee schedule,12709.88,56389.43,
Revise hip joint replacement,27134,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37313.72,,,,,,,fee schedule,12709.88,56389.43,
Revise hip joint replacement,27134,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40761.86,,,,,,,fee schedule,12709.88,56389.43,
Revise hip joint replacement,27134,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42855.36,,,,,,,fee schedule,12709.88,56389.43,
Revise hip joint replacement,27134,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,12709.88,56389.43,APC 378
Revise hip joint replacement,27134,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,12709.88,56389.43,APC
Revise hip joint replacement,27134,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,12709.88,56389.43,APC
Revise hip joint replacement,27134,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,12709.88,56389.43,APC
Revise hip joint replacement,27134,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,12709.88,56389.43,Radiology
Revise hip joint replacement,27134,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,12709.88,56389.43,APC
Revise hip joint replacement,27134,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,12709.88,56389.43,APC
Revise hip joint replacement,27137,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46549.79,,,,,,,fee schedule,12709.88,56389.43,
Revise hip joint replacement,27137,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37313.72,,,,,,,fee schedule,12709.88,56389.43,
Revise hip joint replacement,27137,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40761.86,,,,,,,fee schedule,12709.88,56389.43,
Revise hip joint replacement,27137,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42855.36,,,,,,,fee schedule,12709.88,56389.43,
Revise hip joint replacement,27137,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,12709.88,56389.43,APC 378
Revise hip joint replacement,27137,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,12709.88,56389.43,APC
Revise hip joint replacement,27137,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,12709.88,56389.43,APC
Revise hip joint replacement,27137,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,12709.88,56389.43,APC
Revise hip joint replacement,27137,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,12709.88,56389.43,Radiology
Revise hip joint replacement,27137,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,12709.88,56389.43,APC
Revise hip joint replacement,27137,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,12709.88,56389.43,APC
Revise hip joint replacement,27138,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46549.79,,,,,,,fee schedule,12709.88,56389.43,
Revise hip joint replacement,27138,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37313.72,,,,,,,fee schedule,12709.88,56389.43,
Revise hip joint replacement,27138,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40761.86,,,,,,,fee schedule,12709.88,56389.43,
Revise hip joint replacement,27138,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42855.36,,,,,,,fee schedule,12709.88,56389.43,
Revise hip joint replacement,27138,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,12709.88,56389.43,APC 378
Revise hip joint replacement,27138,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,12709.88,56389.43,APC
Revise hip joint replacement,27138,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,12709.88,56389.43,APC
Revise hip joint replacement,27138,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,12709.88,56389.43,APC
Revise hip joint replacement,27138,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,12709.88,56389.43,Radiology
Revise hip joint replacement,27138,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,12709.88,56389.43,APC
Revise hip joint replacement,27138,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,12709.88,56389.43,APC
Transplant femur ridge,27140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46549.79,,,,,,,fee schedule,7183.42,46549.79,
Transplant femur ridge,27140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37313.72,,,,,,,fee schedule,7183.42,46549.79,
Transplant femur ridge,27140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40761.86,,,,,,,fee schedule,7183.42,46549.79,
Transplant femur ridge,27140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42855.36,,,,,,,fee schedule,7183.42,46549.79,
Transplant femur ridge,27140,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,46549.79,APC 378
Transplant femur ridge,27140,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,46549.79,APC
Transplant femur ridge,27140,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,46549.79,APC
Transplant femur ridge,27140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,46549.79,APC
Transplant femur ridge,27140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,46549.79,Radiology
Transplant femur ridge,27140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,46549.79,APC
Transplant femur ridge,27140,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,46549.79,APC
Incision of hip bone,27146,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Incision of hip bone,27146,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Incision of hip bone,27146,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Incision of hip bone,27146,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Incision of hip bone,27146,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Incision of hip bone,27146,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Incision of hip bone,27146,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Incision of hip bone,27146,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Incision of hip bone,27146,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Incision of hip bone,27146,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Incision of hip bone,27146,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Revision of hip bone,27147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Revision of hip bone,27147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Revision of hip bone,27147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Revision of hip bone,27147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Revision of hip bone,27147,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Revision of hip bone,27147,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Revision of hip bone,27147,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Revision of hip bone,27147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Revision of hip bone,27147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Revision of hip bone,27147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Revision of hip bone,27147,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Incision of hip bones,27151,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Incision of hip bones,27151,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Incision of hip bones,27151,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Incision of hip bones,27151,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Incision of hip bones,27151,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Incision of hip bones,27151,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Incision of hip bones,27151,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Incision of hip bones,27151,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Incision of hip bones,27151,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Incision of hip bones,27151,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Incision of hip bones,27151,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Revision of hip bones,27156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Revision of hip bones,27156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Revision of hip bones,27156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Revision of hip bones,27156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Revision of hip bones,27156,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Revision of hip bones,27156,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Revision of hip bones,27156,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Revision of hip bones,27156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Revision of hip bones,27156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Revision of hip bones,27156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Revision of hip bones,27156,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Revision of pelvis,27158,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Revision of pelvis,27158,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Revision of pelvis,27158,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Revision of pelvis,27158,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Revision of pelvis,27158,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Revision of pelvis,27158,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Revision of pelvis,27158,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Revision of pelvis,27158,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Revision of pelvis,27158,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Revision of pelvis,27158,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Revision of pelvis,27158,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Incision of neck of femur,27161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Incision of neck of femur,27161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Incision of neck of femur,27161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Incision of neck of femur,27161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Incision of neck of femur,27161,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Incision of neck of femur,27161,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Incision of neck of femur,27161,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Incision of neck of femur,27161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Incision of neck of femur,27161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Incision of neck of femur,27161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Incision of neck of femur,27161,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Incision/fixation of femur,27165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Incision/fixation of femur,27165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Incision/fixation of femur,27165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Incision/fixation of femur,27165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Incision/fixation of femur,27165,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Incision/fixation of femur,27165,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Incision/fixation of femur,27165,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Incision/fixation of femur,27165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Incision/fixation of femur,27165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Incision/fixation of femur,27165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Incision/fixation of femur,27165,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Repair/graft femur head/neck,27170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Repair/graft femur head/neck,27170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Repair/graft femur head/neck,27170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Repair/graft femur head/neck,27170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Repair/graft femur head/neck,27170,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Repair/graft femur head/neck,27170,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Repair/graft femur head/neck,27170,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Repair/graft femur head/neck,27170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Repair/graft femur head/neck,27170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Repair/graft femur head/neck,27170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Repair/graft femur head/neck,27170,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Treat slipped epiphysis,27175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,3239.17,23681.51,
Treat slipped epiphysis,27175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,3239.17,23681.51,
Treat slipped epiphysis,27175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,3239.17,23681.51,
Treat slipped epiphysis,27175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,3239.17,23681.51,
Treat slipped epiphysis,27175,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,23681.51,APC 378
Treat slipped epiphysis,27175,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,23681.51,APC
Treat slipped epiphysis,27175,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,23681.51,APC
Treat slipped epiphysis,27175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,23681.51,APC
Treat slipped epiphysis,27175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,23681.51,Radiology
Treat slipped epiphysis,27175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,23681.51,APC
Treat slipped epiphysis,27175,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,23681.51,APC
Treat slipped epiphysis,27176,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46549.79,,,,,,,fee schedule,3239.17,46549.79,
Treat slipped epiphysis,27176,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37313.72,,,,,,,fee schedule,3239.17,46549.79,
Treat slipped epiphysis,27176,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40761.86,,,,,,,fee schedule,3239.17,46549.79,
Treat slipped epiphysis,27176,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42855.36,,,,,,,fee schedule,3239.17,46549.79,
Treat slipped epiphysis,27176,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,46549.79,APC 378
Treat slipped epiphysis,27176,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,46549.79,APC
Treat slipped epiphysis,27176,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,46549.79,APC
Treat slipped epiphysis,27176,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,46549.79,APC
Treat slipped epiphysis,27176,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,46549.79,Radiology
Treat slipped epiphysis,27176,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,46549.79,APC
Treat slipped epiphysis,27176,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,46549.79,APC
Treat slipped epiphysis,27177,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,3239.17,23681.51,
Treat slipped epiphysis,27177,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,3239.17,23681.51,
Treat slipped epiphysis,27177,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,3239.17,23681.51,
Treat slipped epiphysis,27177,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,3239.17,23681.51,
Treat slipped epiphysis,27177,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,23681.51,APC 378
Treat slipped epiphysis,27177,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,23681.51,APC
Treat slipped epiphysis,27177,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,23681.51,APC
Treat slipped epiphysis,27177,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,23681.51,APC
Treat slipped epiphysis,27177,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,23681.51,Radiology
Treat slipped epiphysis,27177,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,23681.51,APC
Treat slipped epiphysis,27177,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,23681.51,APC
Treat slipped epiphysis,27178,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,3239.17,23681.51,
Treat slipped epiphysis,27178,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,3239.17,23681.51,
Treat slipped epiphysis,27178,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,3239.17,23681.51,
Treat slipped epiphysis,27178,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,3239.17,23681.51,
Treat slipped epiphysis,27178,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,23681.51,APC 378
Treat slipped epiphysis,27178,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,23681.51,APC
Treat slipped epiphysis,27178,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,23681.51,APC
Treat slipped epiphysis,27178,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,23681.51,APC
Treat slipped epiphysis,27178,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,23681.51,Radiology
Treat slipped epiphysis,27178,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,23681.51,APC
Treat slipped epiphysis,27178,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,23681.51,APC
Revise head/neck of femur,27179,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19737.53,,,,,,,fee schedule,7183.42,31870.39,
Revise head/neck of femur,27179,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15821.36,,,,,,,fee schedule,7183.42,31870.39,
Revise head/neck of femur,27179,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17283.4,,,,,,,fee schedule,7183.42,31870.39,
Revise head/neck of femur,27179,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18171.06,,,,,,,fee schedule,7183.42,31870.39,
Revise head/neck of femur,27179,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Revise head/neck of femur,27179,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Revise head/neck of femur,27179,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Revise head/neck of femur,27179,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Revise head/neck of femur,27179,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Revise head/neck of femur,27179,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Revise head/neck of femur,27179,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Treat slipped epiphysis,27181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Treat slipped epiphysis,27181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Treat slipped epiphysis,27181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Treat slipped epiphysis,27181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Treat slipped epiphysis,27181,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Treat slipped epiphysis,27181,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Treat slipped epiphysis,27181,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Treat slipped epiphysis,27181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Treat slipped epiphysis,27181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Treat slipped epiphysis,27181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Treat slipped epiphysis,27181,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Revision of femur epiphysis,27185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,3239.17,23681.51,
Revision of femur epiphysis,27185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,3239.17,23681.51,
Revision of femur epiphysis,27185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,3239.17,23681.51,
Revision of femur epiphysis,27185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,3239.17,23681.51,
Revision of femur epiphysis,27185,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,23681.51,APC 378
Revision of femur epiphysis,27185,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,23681.51,APC
Revision of femur epiphysis,27185,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,23681.51,APC
Revision of femur epiphysis,27185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,23681.51,APC
Revision of femur epiphysis,27185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,23681.51,Radiology
Revision of femur epiphysis,27185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,23681.51,APC
Revision of femur epiphysis,27185,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,23681.51,APC
Reinforce hip bones,27187,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Reinforce hip bones,27187,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Reinforce hip bones,27187,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Reinforce hip bones,27187,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Reinforce hip bones,27187,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Reinforce hip bones,27187,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Reinforce hip bones,27187,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Reinforce hip bones,27187,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Reinforce hip bones,27187,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Reinforce hip bones,27187,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Reinforce hip bones,27187,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Clsd tx pelvic ring fx,27197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,755.36,,,,,,,fee schedule,244.19,1083.4,
Clsd tx pelvic ring fx,27197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,605.48,,,,,,,fee schedule,244.19,1083.4,
Clsd tx pelvic ring fx,27197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,661.44,,,,,,,fee schedule,244.19,1083.4,
Clsd tx pelvic ring fx,27197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,695.41,,,,,,,fee schedule,244.19,1083.4,
Clsd tx pelvic ring fx,27197,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Clsd tx pelvic ring fx,27197,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Clsd tx pelvic ring fx,27197,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Clsd tx pelvic ring fx,27197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Clsd tx pelvic ring fx,27197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Clsd tx pelvic ring fx,27197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Clsd tx pelvic ring fx,27197,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Clsd tx pelvic ring fx,27198,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,755.36,,,,,,,fee schedule,244.19,1083.4,
Clsd tx pelvic ring fx,27198,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,605.48,,,,,,,fee schedule,244.19,1083.4,
Clsd tx pelvic ring fx,27198,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,661.44,,,,,,,fee schedule,244.19,1083.4,
Clsd tx pelvic ring fx,27198,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,695.41,,,,,,,fee schedule,244.19,1083.4,
Clsd tx pelvic ring fx,27198,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Clsd tx pelvic ring fx,27198,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Clsd tx pelvic ring fx,27198,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Clsd tx pelvic ring fx,27198,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Clsd tx pelvic ring fx,27198,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Clsd tx pelvic ring fx,27198,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Clsd tx pelvic ring fx,27198,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treat tail bone fracture,27200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,244.19,1083.4,
Treat tail bone fracture,27200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,244.19,1083.4,
Treat tail bone fracture,27200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,244.19,1083.4,
Treat tail bone fracture,27200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,244.19,1083.4,
Treat tail bone fracture,27200,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treat tail bone fracture,27200,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treat tail bone fracture,27200,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treat tail bone fracture,27200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treat tail bone fracture,27200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treat tail bone fracture,27200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treat tail bone fracture,27200,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treat tail bone fracture,27202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10259.79,,,,,,,fee schedule,3239.17,14371.12,
Treat tail bone fracture,27202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8224.12,,,,,,,fee schedule,3239.17,14371.12,
Treat tail bone fracture,27202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8984.1,,,,,,,fee schedule,3239.17,14371.12,
Treat tail bone fracture,27202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9445.52,,,,,,,fee schedule,3239.17,14371.12,
Treat tail bone fracture,27202,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Treat tail bone fracture,27202,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Treat tail bone fracture,27202,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Treat tail bone fracture,27202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Treat tail bone fracture,27202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Treat tail bone fracture,27202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Treat tail bone fracture,27202,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Treat pelvic ring fracture,27216,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,5839.66,7285.12,
Treat pelvic ring fracture,27216,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,5839.66,7285.12,
Treat pelvic ring fracture,27216,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,5839.66,7285.12,
Treat pelvic ring fracture,27216,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,5839.66,7285.12,
Treat hip socket fracture,27220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,244.19,1083.4,
Treat hip socket fracture,27220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,244.19,1083.4,
Treat hip socket fracture,27220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,244.19,1083.4,
Treat hip socket fracture,27220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,244.19,1083.4,
Treat hip socket fracture,27220,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treat hip socket fracture,27220,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treat hip socket fracture,27220,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treat hip socket fracture,27220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treat hip socket fracture,27220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treat hip socket fracture,27220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treat hip socket fracture,27220,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treat hip socket fracture,27222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,779.4,,,,,,,fee schedule,244.19,1083.4,
Treat hip socket fracture,27222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,624.76,,,,,,,fee schedule,244.19,1083.4,
Treat hip socket fracture,27222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,682.49,,,,,,,fee schedule,244.19,1083.4,
Treat hip socket fracture,27222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,717.54,,,,,,,fee schedule,244.19,1083.4,
Treat hip socket fracture,27222,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treat hip socket fracture,27222,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treat hip socket fracture,27222,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treat hip socket fracture,27222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treat hip socket fracture,27222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treat hip socket fracture,27222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treat hip socket fracture,27222,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treat hip wall fracture,27226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Treat hip wall fracture,27226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Treat hip wall fracture,27226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Treat hip wall fracture,27226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Treat hip wall fracture,27226,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Treat hip wall fracture,27226,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Treat hip wall fracture,27226,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Treat hip wall fracture,27226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Treat hip wall fracture,27226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Treat hip wall fracture,27226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Treat hip wall fracture,27226,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Treat hip fracture(s),27227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Treat hip fracture(s),27227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Treat hip fracture(s),27227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Treat hip fracture(s),27227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Treat hip fracture(s),27227,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Treat hip fracture(s),27227,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Treat hip fracture(s),27227,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Treat hip fracture(s),27227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Treat hip fracture(s),27227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Treat hip fracture(s),27227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Treat hip fracture(s),27227,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Treat hip fracture(s),27228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Treat hip fracture(s),27228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Treat hip fracture(s),27228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Treat hip fracture(s),27228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Treat hip fracture(s),27228,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Treat hip fracture(s),27228,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Treat hip fracture(s),27228,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Treat hip fracture(s),27228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Treat hip fracture(s),27228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Treat hip fracture(s),27228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Treat hip fracture(s),27228,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Treat thigh fracture,27230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,244.19,1083.4,
Treat thigh fracture,27230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,244.19,1083.4,
Treat thigh fracture,27230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,244.19,1083.4,
Treat thigh fracture,27230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,244.19,1083.4,
Treat thigh fracture,27230,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treat thigh fracture,27230,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treat thigh fracture,27230,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treat thigh fracture,27230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treat thigh fracture,27230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treat thigh fracture,27230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treat thigh fracture,27230,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treat thigh fracture,27232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5263.08,,,,,,,fee schedule,1591.86,7062.54,
Treat thigh fracture,27232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4218.82,,,,,,,fee schedule,1591.86,7062.54,
Treat thigh fracture,27232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4608.68,,,,,,,fee schedule,1591.86,7062.54,
Treat thigh fracture,27232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4845.38,,,,,,,fee schedule,1591.86,7062.54,
Treat thigh fracture,27232,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Treat thigh fracture,27232,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Treat thigh fracture,27232,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Treat thigh fracture,27232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Treat thigh fracture,27232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Treat thigh fracture,27232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Treat thigh fracture,27232,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Treat thigh fracture,27235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,5839.66,31870.39,
Treat thigh fracture,27235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,5839.66,31870.39,
Treat thigh fracture,27235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,5839.66,31870.39,
Treat thigh fracture,27235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,5839.66,31870.39,
Treat thigh fracture,27235,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5839.66,31870.39,APC 378
Treat thigh fracture,27235,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5839.66,31870.39,APC
Treat thigh fracture,27235,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5839.66,31870.39,APC
Treat thigh fracture,27235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5839.66,31870.39,APC
Treat thigh fracture,27235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5839.66,31870.39,Radiology
Treat thigh fracture,27235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5839.66,31870.39,APC
Treat thigh fracture,27235,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5839.66,31870.39,APC
Treat thigh fracture,27236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Treat thigh fracture,27236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Treat thigh fracture,27236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Treat thigh fracture,27236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Treat thigh fracture,27236,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Treat thigh fracture,27236,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Treat thigh fracture,27236,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Treat thigh fracture,27236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Treat thigh fracture,27236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Treat thigh fracture,27236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Treat thigh fracture,27236,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Treat thigh fracture,27238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,353.72,7062.54,
Treat thigh fracture,27238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,353.72,7062.54,
Treat thigh fracture,27238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,353.72,7062.54,
Treat thigh fracture,27238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,353.72,7062.54,
Treat thigh fracture,27238,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,353.72,7062.54,APC 378
Treat thigh fracture,27238,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,353.72,7062.54,APC
Treat thigh fracture,27238,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,353.72,7062.54,APC
Treat thigh fracture,27238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,353.72,7062.54,APC
Treat thigh fracture,27238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,353.72,7062.54,Radiology
Treat thigh fracture,27238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,353.72,7062.54,APC
Treat thigh fracture,27238,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,353.72,7062.54,APC
Treat thigh fracture,27240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5263.08,,,,,,,fee schedule,1591.86,7062.54,
Treat thigh fracture,27240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4218.82,,,,,,,fee schedule,1591.86,7062.54,
Treat thigh fracture,27240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4608.68,,,,,,,fee schedule,1591.86,7062.54,
Treat thigh fracture,27240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4845.38,,,,,,,fee schedule,1591.86,7062.54,
Treat thigh fracture,27240,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Treat thigh fracture,27240,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Treat thigh fracture,27240,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Treat thigh fracture,27240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Treat thigh fracture,27240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Treat thigh fracture,27240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Treat thigh fracture,27240,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Treat thigh fracture,27244,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Treat thigh fracture,27244,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Treat thigh fracture,27244,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Treat thigh fracture,27244,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Treat thigh fracture,27244,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Treat thigh fracture,27244,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Treat thigh fracture,27244,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Treat thigh fracture,27244,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Treat thigh fracture,27244,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Treat thigh fracture,27244,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Treat thigh fracture,27244,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Treat thigh fracture,27245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Treat thigh fracture,27245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Treat thigh fracture,27245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Treat thigh fracture,27245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Treat thigh fracture,27245,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Treat thigh fracture,27245,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Treat thigh fracture,27245,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Treat thigh fracture,27245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Treat thigh fracture,27245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Treat thigh fracture,27245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Treat thigh fracture,27245,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Treat thigh fracture,27246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,244.19,1083.4,
Treat thigh fracture,27246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,244.19,1083.4,
Treat thigh fracture,27246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,244.19,1083.4,
Treat thigh fracture,27246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,244.19,1083.4,
Treat thigh fracture,27246,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treat thigh fracture,27246,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treat thigh fracture,27246,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treat thigh fracture,27246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treat thigh fracture,27246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treat thigh fracture,27246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treat thigh fracture,27246,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treat thigh fracture,27248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Treat thigh fracture,27248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Treat thigh fracture,27248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Treat thigh fracture,27248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Treat thigh fracture,27248,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Treat thigh fracture,27248,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Treat thigh fracture,27248,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Treat thigh fracture,27248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Treat thigh fracture,27248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Treat thigh fracture,27248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Treat thigh fracture,27248,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Treat hip dislocation,27250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,444.28,,,,,,,fee schedule,244.19,1083.4,
Treat hip dislocation,27250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,356.13,,,,,,,fee schedule,244.19,1083.4,
Treat hip dislocation,27250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,389.04,,,,,,,fee schedule,244.19,1083.4,
Treat hip dislocation,27250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,409.02,,,,,,,fee schedule,244.19,1083.4,
Treat hip dislocation,27250,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treat hip dislocation,27250,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treat hip dislocation,27250,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treat hip dislocation,27250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treat hip dislocation,27250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treat hip dislocation,27250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treat hip dislocation,27250,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treat hip dislocation,27252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3685.16,,,,,,,fee schedule,1591.86,7062.54,
Treat hip dislocation,27252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2953.98,,,,,,,fee schedule,1591.86,7062.54,
Treat hip dislocation,27252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3226.95,,,,,,,fee schedule,1591.86,7062.54,
Treat hip dislocation,27252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3392.69,,,,,,,fee schedule,1591.86,7062.54,
Treat hip dislocation,27252,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Treat hip dislocation,27252,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Treat hip dislocation,27252,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Treat hip dislocation,27252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Treat hip dislocation,27252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Treat hip dislocation,27252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Treat hip dislocation,27252,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Treat hip dislocation,27253,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10698.91,,,,,,,fee schedule,3239.17,14371.12,
Treat hip dislocation,27253,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8576.11,,,,,,,fee schedule,3239.17,14371.12,
Treat hip dislocation,27253,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9368.62,,,,,,,fee schedule,3239.17,14371.12,
Treat hip dislocation,27253,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9849.79,,,,,,,fee schedule,3239.17,14371.12,
Treat hip dislocation,27253,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Treat hip dislocation,27253,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Treat hip dislocation,27253,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Treat hip dislocation,27253,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Treat hip dislocation,27253,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Treat hip dislocation,27253,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Treat hip dislocation,27253,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Treat hip dislocation,27254,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10698.91,,,,,,,fee schedule,7183.42,31870.39,
Treat hip dislocation,27254,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8576.11,,,,,,,fee schedule,7183.42,31870.39,
Treat hip dislocation,27254,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9368.62,,,,,,,fee schedule,7183.42,31870.39,
Treat hip dislocation,27254,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9849.79,,,,,,,fee schedule,7183.42,31870.39,
Treat hip dislocation,27254,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Treat hip dislocation,27254,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Treat hip dislocation,27254,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Treat hip dislocation,27254,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Treat hip dislocation,27254,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Treat hip dislocation,27254,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Treat hip dislocation,27254,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Treat hip dislocation,27256,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,244.19,1083.4,
Treat hip dislocation,27256,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,244.19,1083.4,
Treat hip dislocation,27256,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,244.19,1083.4,
Treat hip dislocation,27256,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,244.19,1083.4,
Treat hip dislocation,27256,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treat hip dislocation,27256,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treat hip dislocation,27256,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treat hip dislocation,27256,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treat hip dislocation,27256,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treat hip dislocation,27256,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treat hip dislocation,27256,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treat hip dislocation,27257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3685.16,,,,,,,fee schedule,1591.86,7062.54,
Treat hip dislocation,27257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2953.98,,,,,,,fee schedule,1591.86,7062.54,
Treat hip dislocation,27257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3226.95,,,,,,,fee schedule,1591.86,7062.54,
Treat hip dislocation,27257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3392.69,,,,,,,fee schedule,1591.86,7062.54,
Treat hip dislocation,27257,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Treat hip dislocation,27257,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Treat hip dislocation,27257,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Treat hip dislocation,27257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Treat hip dislocation,27257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Treat hip dislocation,27257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Treat hip dislocation,27257,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Treat hip dislocation,27258,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10698.91,,,,,,,fee schedule,3239.17,14371.12,
Treat hip dislocation,27258,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8576.11,,,,,,,fee schedule,3239.17,14371.12,
Treat hip dislocation,27258,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9368.62,,,,,,,fee schedule,3239.17,14371.12,
Treat hip dislocation,27258,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9849.79,,,,,,,fee schedule,3239.17,14371.12,
Treat hip dislocation,27258,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Treat hip dislocation,27258,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Treat hip dislocation,27258,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Treat hip dislocation,27258,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Treat hip dislocation,27258,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Treat hip dislocation,27258,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Treat hip dislocation,27258,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Treat hip dislocation,27259,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10698.91,,,,,,,fee schedule,3239.17,14371.12,
Treat hip dislocation,27259,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8576.11,,,,,,,fee schedule,3239.17,14371.12,
Treat hip dislocation,27259,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9368.62,,,,,,,fee schedule,3239.17,14371.12,
Treat hip dislocation,27259,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9849.79,,,,,,,fee schedule,3239.17,14371.12,
Treat hip dislocation,27259,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Treat hip dislocation,27259,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Treat hip dislocation,27259,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Treat hip dislocation,27259,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Treat hip dislocation,27259,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Treat hip dislocation,27259,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Treat hip dislocation,27259,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Treat hip dislocation,27265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,244.19,1083.4,
Treat hip dislocation,27265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,244.19,1083.4,
Treat hip dislocation,27265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,244.19,1083.4,
Treat hip dislocation,27265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,244.19,1083.4,
Treat hip dislocation,27265,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treat hip dislocation,27265,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treat hip dislocation,27265,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treat hip dislocation,27265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treat hip dislocation,27265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treat hip dislocation,27265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treat hip dislocation,27265,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treat hip dislocation,27266,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1629.73,,,,,,,fee schedule,1306.37,7062.54,
Treat hip dislocation,27266,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1306.37,,,,,,,fee schedule,1306.37,7062.54,
Treat hip dislocation,27266,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1427.1,,,,,,,fee schedule,1306.37,7062.54,
Treat hip dislocation,27266,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1500.39,,,,,,,fee schedule,1306.37,7062.54,
Treat hip dislocation,27266,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1306.37,7062.54,APC 378
Treat hip dislocation,27266,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1306.37,7062.54,APC
Treat hip dislocation,27266,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1306.37,7062.54,APC
Treat hip dislocation,27266,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1306.37,7062.54,APC
Treat hip dislocation,27266,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1306.37,7062.54,Radiology
Treat hip dislocation,27266,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1306.37,7062.54,APC
Treat hip dislocation,27266,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1306.37,7062.54,APC
Cltx thigh fx,27267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,353.72,14371.12,
Cltx thigh fx,27267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,353.72,14371.12,
Cltx thigh fx,27267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,353.72,14371.12,
Cltx thigh fx,27267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,353.72,14371.12,
Cltx thigh fx,27267,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,353.72,14371.12,APC 378
Cltx thigh fx,27267,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,353.72,14371.12,APC
Cltx thigh fx,27267,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,353.72,14371.12,APC
Cltx thigh fx,27267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,353.72,14371.12,APC
Cltx thigh fx,27267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,353.72,14371.12,Radiology
Cltx thigh fx,27267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,353.72,14371.12,APC
Cltx thigh fx,27267,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,353.72,14371.12,APC
Cltx thigh fx w/mnpj,27268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10698.91,,,,,,,fee schedule,1591.86,10698.91,
Cltx thigh fx w/mnpj,27268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8576.11,,,,,,,fee schedule,1591.86,10698.91,
Cltx thigh fx w/mnpj,27268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9368.62,,,,,,,fee schedule,1591.86,10698.91,
Cltx thigh fx w/mnpj,27268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9849.79,,,,,,,fee schedule,1591.86,10698.91,
Cltx thigh fx w/mnpj,27268,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,10698.91,APC 378
Cltx thigh fx w/mnpj,27268,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,10698.91,APC
Cltx thigh fx w/mnpj,27268,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,10698.91,APC
Cltx thigh fx w/mnpj,27268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,10698.91,APC
Cltx thigh fx w/mnpj,27268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,10698.91,Radiology
Cltx thigh fx w/mnpj,27268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,10698.91,APC
Cltx thigh fx w/mnpj,27268,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,10698.91,APC
Optx thigh fx,27269,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5263.08,,,,,,,fee schedule,4218.82,31870.39,
Optx thigh fx,27269,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4218.82,,,,,,,fee schedule,4218.82,31870.39,
Optx thigh fx,27269,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4608.68,,,,,,,fee schedule,4218.82,31870.39,
Optx thigh fx,27269,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4845.38,,,,,,,fee schedule,4218.82,31870.39,
Optx thigh fx,27269,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,4218.82,31870.39,APC 378
Optx thigh fx,27269,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,4218.82,31870.39,APC
Optx thigh fx,27269,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,4218.82,31870.39,APC
Optx thigh fx,27269,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,4218.82,31870.39,APC
Optx thigh fx,27269,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,4218.82,31870.39,Radiology
Optx thigh fx,27269,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,4218.82,31870.39,APC
Optx thigh fx,27269,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,4218.82,31870.39,APC
Manipulation of hip joint,27275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3685.16,,,,,,,fee schedule,1591.86,7062.54,
Manipulation of hip joint,27275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2953.98,,,,,,,fee schedule,1591.86,7062.54,
Manipulation of hip joint,27275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3226.95,,,,,,,fee schedule,1591.86,7062.54,
Manipulation of hip joint,27275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3392.69,,,,,,,fee schedule,1591.86,7062.54,
Manipulation of hip joint,27275,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Manipulation of hip joint,27275,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Manipulation of hip joint,27275,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Manipulation of hip joint,27275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Manipulation of hip joint,27275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Manipulation of hip joint,27275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Manipulation of hip joint,27275,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Arthrd si jt prq wo tfxj dev,27278,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,67188.59,,,,,,,fee schedule,17357.91,77011.17,
Arthrd si jt prq wo tfxj dev,27278,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53857.52,,,,,,,fee schedule,17357.91,77011.17,
Arthrd si jt prq wo tfxj dev,27278,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,58834.46,,,,,,,fee schedule,17357.91,77011.17,
Arthrd si jt prq wo tfxj dev,27278,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,61856.16,,,,,,,fee schedule,17357.91,77011.17,
Arthrd si jt prq wo tfxj dev,27278,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,77011.17,,,,,,,fee schedule,17357.91,77011.17,APC 378
Arthrd si jt prq wo tfxj dev,27278,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18225.81,,,,,,,fee schedule,17357.91,77011.17,APC
Arthrd si jt prq wo tfxj dev,27278,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18052.23,,,,,,,fee schedule,17357.91,77011.17,APC
Arthrd si jt prq wo tfxj dev,27278,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17357.91,,,,,,,fee schedule,17357.91,77011.17,APC
Arthrd si jt prq wo tfxj dev,27278,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26557.6,,,,,,,fee schedule,17357.91,77011.17,Radiology
Arthrd si jt prq wo tfxj dev,27278,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24301.07,,,,,,,fee schedule,17357.91,77011.17,APC
Arthrd si jt prq wo tfxj dev,27278,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30376.34,,,,,,,fee schedule,17357.91,77011.17,APC
Arthrodesis sacroiliac joint,27279,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,38646.72,,,,,,,fee schedule,17357.91,77011.17,
Arthrodesis sacroiliac joint,27279,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,30978.72,,,,,,,fee schedule,17357.91,77011.17,
Arthrodesis sacroiliac joint,27279,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,33841.44,,,,,,,fee schedule,17357.91,77011.17,
Arthrodesis sacroiliac joint,27279,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,35579.52,,,,,,,fee schedule,17357.91,77011.17,
Arthrodesis sacroiliac joint,27279,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,77011.17,,,,,,,fee schedule,17357.91,77011.17,APC 378
Arthrodesis sacroiliac joint,27279,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18225.81,,,,,,,fee schedule,17357.91,77011.17,APC
Arthrodesis sacroiliac joint,27279,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18052.23,,,,,,,fee schedule,17357.91,77011.17,APC
Arthrodesis sacroiliac joint,27279,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17357.91,,,,,,,fee schedule,17357.91,77011.17,APC
Arthrodesis sacroiliac joint,27279,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26557.6,,,,,,,fee schedule,17357.91,77011.17,Radiology
Arthrodesis sacroiliac joint,27279,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24301.07,,,,,,,fee schedule,17357.91,77011.17,APC
Arthrodesis sacroiliac joint,27279,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30376.34,,,,,,,fee schedule,17357.91,77011.17,APC
Fusion of sacroiliac joint,27280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59981.53,,,,,,,fee schedule,17357.91,77011.17,
Fusion of sacroiliac joint,27280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48080.43,,,,,,,fee schedule,17357.91,77011.17,
Fusion of sacroiliac joint,27280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52523.51,,,,,,,fee schedule,17357.91,77011.17,
Fusion of sacroiliac joint,27280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55221.09,,,,,,,fee schedule,17357.91,77011.17,
Fusion of sacroiliac joint,27280,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,77011.17,,,,,,,fee schedule,17357.91,77011.17,APC 378
Fusion of sacroiliac joint,27280,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18225.81,,,,,,,fee schedule,17357.91,77011.17,APC
Fusion of sacroiliac joint,27280,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18052.23,,,,,,,fee schedule,17357.91,77011.17,APC
Fusion of sacroiliac joint,27280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17357.91,,,,,,,fee schedule,17357.91,77011.17,APC
Fusion of sacroiliac joint,27280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26557.6,,,,,,,fee schedule,17357.91,77011.17,Radiology
Fusion of sacroiliac joint,27280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24301.07,,,,,,,fee schedule,17357.91,77011.17,APC
Fusion of sacroiliac joint,27280,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30376.34,,,,,,,fee schedule,17357.91,77011.17,APC
Fusion of pubic bones,27282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46549.79,,,,,,,fee schedule,3239.17,46549.79,
Fusion of pubic bones,27282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37313.72,,,,,,,fee schedule,3239.17,46549.79,
Fusion of pubic bones,27282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40761.86,,,,,,,fee schedule,3239.17,46549.79,
Fusion of pubic bones,27282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42855.36,,,,,,,fee schedule,3239.17,46549.79,
Fusion of pubic bones,27282,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,46549.79,APC 378
Fusion of pubic bones,27282,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,46549.79,APC
Fusion of pubic bones,27282,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,46549.79,APC
Fusion of pubic bones,27282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,46549.79,APC
Fusion of pubic bones,27282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,46549.79,Radiology
Fusion of pubic bones,27282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,46549.79,APC
Fusion of pubic bones,27282,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,46549.79,APC
Fusion of hip joint,27284,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59981.53,,,,,,,fee schedule,12709.88,59981.53,
Fusion of hip joint,27284,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48080.43,,,,,,,fee schedule,12709.88,59981.53,
Fusion of hip joint,27284,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52523.51,,,,,,,fee schedule,12709.88,59981.53,
Fusion of hip joint,27284,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55221.09,,,,,,,fee schedule,12709.88,59981.53,
Fusion of hip joint,27284,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,12709.88,59981.53,APC 378
Fusion of hip joint,27284,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,12709.88,59981.53,APC
Fusion of hip joint,27284,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,12709.88,59981.53,APC
Fusion of hip joint,27284,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,12709.88,59981.53,APC
Fusion of hip joint,27284,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,12709.88,59981.53,Radiology
Fusion of hip joint,27284,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,12709.88,59981.53,APC
Fusion of hip joint,27284,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,12709.88,59981.53,APC
Fusion of hip joint,27286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59981.53,,,,,,,fee schedule,12709.88,59981.53,
Fusion of hip joint,27286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48080.43,,,,,,,fee schedule,12709.88,59981.53,
Fusion of hip joint,27286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52523.51,,,,,,,fee schedule,12709.88,59981.53,
Fusion of hip joint,27286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55221.09,,,,,,,fee schedule,12709.88,59981.53,
Fusion of hip joint,27286,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,12709.88,59981.53,APC 378
Fusion of hip joint,27286,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,12709.88,59981.53,APC
Fusion of hip joint,27286,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,12709.88,59981.53,APC
Fusion of hip joint,27286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,12709.88,59981.53,APC
Fusion of hip joint,27286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,12709.88,59981.53,Radiology
Fusion of hip joint,27286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,12709.88,59981.53,APC
Fusion of hip joint,27286,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,12709.88,59981.53,APC
Amputation of leg at hip,27290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59981.53,,,,,,,fee schedule,17357.91,77011.17,
Amputation of leg at hip,27290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48080.43,,,,,,,fee schedule,17357.91,77011.17,
Amputation of leg at hip,27290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52523.51,,,,,,,fee schedule,17357.91,77011.17,
Amputation of leg at hip,27290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55221.09,,,,,,,fee schedule,17357.91,77011.17,
Amputation of leg at hip,27290,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,77011.17,,,,,,,fee schedule,17357.91,77011.17,APC 378
Amputation of leg at hip,27290,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18225.81,,,,,,,fee schedule,17357.91,77011.17,APC
Amputation of leg at hip,27290,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18052.23,,,,,,,fee schedule,17357.91,77011.17,APC
Amputation of leg at hip,27290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17357.91,,,,,,,fee schedule,17357.91,77011.17,APC
Amputation of leg at hip,27290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26557.6,,,,,,,fee schedule,17357.91,77011.17,Radiology
Amputation of leg at hip,27290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24301.07,,,,,,,fee schedule,17357.91,77011.17,APC
Amputation of leg at hip,27290,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30376.34,,,,,,,fee schedule,17357.91,77011.17,APC
Amputation of leg at hip,27295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59981.53,,,,,,,fee schedule,17357.91,77011.17,
Amputation of leg at hip,27295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48080.43,,,,,,,fee schedule,17357.91,77011.17,
Amputation of leg at hip,27295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52523.51,,,,,,,fee schedule,17357.91,77011.17,
Amputation of leg at hip,27295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55221.09,,,,,,,fee schedule,17357.91,77011.17,
Amputation of leg at hip,27295,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,77011.17,,,,,,,fee schedule,17357.91,77011.17,APC 378
Amputation of leg at hip,27295,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18225.81,,,,,,,fee schedule,17357.91,77011.17,APC
Amputation of leg at hip,27295,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18052.23,,,,,,,fee schedule,17357.91,77011.17,APC
Amputation of leg at hip,27295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17357.91,,,,,,,fee schedule,17357.91,77011.17,APC
Amputation of leg at hip,27295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26557.6,,,,,,,fee schedule,17357.91,77011.17,Radiology
Amputation of leg at hip,27295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24301.07,,,,,,,fee schedule,17357.91,77011.17,APC
Amputation of leg at hip,27295,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30376.34,,,,,,,fee schedule,17357.91,77011.17,APC
Pelvis/hip joint surgery,27299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10673.46,,,,,,,fee schedule,244.19,10673.46,
Pelvis/hip joint surgery,27299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8555.71,,,,,,,fee schedule,244.19,10673.46,
Pelvis/hip joint surgery,27299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9346.34,,,,,,,fee schedule,244.19,10673.46,
Pelvis/hip joint surgery,27299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9826.36,,,,,,,fee schedule,244.19,10673.46,
Pelvis/hip joint surgery,27299,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,10673.46,APC 378
Pelvis/hip joint surgery,27299,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,10673.46,APC
Pelvis/hip joint surgery,27299,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,10673.46,APC
Pelvis/hip joint surgery,27299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,10673.46,APC
Pelvis/hip joint surgery,27299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,10673.46,Radiology
Pelvis/hip joint surgery,27299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,10673.46,APC
Pelvis/hip joint surgery,27299,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,10673.46,APC
Drain thigh/knee lesion,27301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4572.14,,,,,,,fee schedule,2875.57,12757.95,
Drain thigh/knee lesion,27301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3664.97,,,,,,,fee schedule,2875.57,12757.95,
Drain thigh/knee lesion,27301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4003.64,,,,,,,fee schedule,2875.57,12757.95,
Drain thigh/knee lesion,27301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4209.27,,,,,,,fee schedule,2875.57,12757.95,
Drain thigh/knee lesion,27301,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Drain thigh/knee lesion,27301,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Drain thigh/knee lesion,27301,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Drain thigh/knee lesion,27301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Drain thigh/knee lesion,27301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Drain thigh/knee lesion,27301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Drain thigh/knee lesion,27301,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Drainage of bone lesion,27303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,3239.17,23681.51,
Drainage of bone lesion,27303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,3239.17,23681.51,
Drainage of bone lesion,27303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,3239.17,23681.51,
Drainage of bone lesion,27303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,3239.17,23681.51,
Drainage of bone lesion,27303,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,23681.51,APC 378
Drainage of bone lesion,27303,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,23681.51,APC
Drainage of bone lesion,27303,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,23681.51,APC
Drainage of bone lesion,27303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,23681.51,APC
Drainage of bone lesion,27303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,23681.51,Radiology
Drainage of bone lesion,27303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,23681.51,APC
Drainage of bone lesion,27303,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,23681.51,APC
Incise thigh tendon & fascia,27305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,3239.17,14371.12,
Incise thigh tendon & fascia,27305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,3239.17,14371.12,
Incise thigh tendon & fascia,27305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,3239.17,14371.12,
Incise thigh tendon & fascia,27305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,3239.17,14371.12,
Incise thigh tendon & fascia,27305,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Incise thigh tendon & fascia,27305,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Incise thigh tendon & fascia,27305,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Incise thigh tendon & fascia,27305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Incise thigh tendon & fascia,27305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Incise thigh tendon & fascia,27305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Incise thigh tendon & fascia,27305,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Incision of thigh tendon,27306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,3239.17,14371.12,
Incision of thigh tendon,27306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,3239.17,14371.12,
Incision of thigh tendon,27306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,3239.17,14371.12,
Incision of thigh tendon,27306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,3239.17,14371.12,
Incision of thigh tendon,27306,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Incision of thigh tendon,27306,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Incision of thigh tendon,27306,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Incision of thigh tendon,27306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Incision of thigh tendon,27306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Incision of thigh tendon,27306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Incision of thigh tendon,27306,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Incision of thigh tendons,27307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,3239.17,14371.12,
Incision of thigh tendons,27307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,3239.17,14371.12,
Incision of thigh tendons,27307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,3239.17,14371.12,
Incision of thigh tendons,27307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,3239.17,14371.12,
Incision of thigh tendons,27307,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Incision of thigh tendons,27307,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Incision of thigh tendons,27307,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Incision of thigh tendons,27307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Incision of thigh tendons,27307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Incision of thigh tendons,27307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Incision of thigh tendons,27307,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Exploration of knee joint,27310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,3239.17,14371.12,
Exploration of knee joint,27310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,3239.17,14371.12,
Exploration of knee joint,27310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,3239.17,14371.12,
Exploration of knee joint,27310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,3239.17,14371.12,
Exploration of knee joint,27310,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Exploration of knee joint,27310,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Exploration of knee joint,27310,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Exploration of knee joint,27310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Exploration of knee joint,27310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Exploration of knee joint,27310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Exploration of knee joint,27310,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Biopsy thigh soft tissues,27323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2167.57,,,,,,,fee schedule,1635.03,7254.06,
Biopsy thigh soft tissues,27323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1737.49,,,,,,,fee schedule,1635.03,7254.06,
Biopsy thigh soft tissues,27323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1898.05,,,,,,,fee schedule,1635.03,7254.06,
Biopsy thigh soft tissues,27323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1995.54,,,,,,,fee schedule,1635.03,7254.06,
Biopsy thigh soft tissues,27323,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,7254.06,APC 378
Biopsy thigh soft tissues,27323,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,7254.06,APC
Biopsy thigh soft tissues,27323,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,7254.06,APC
Biopsy thigh soft tissues,27323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,7254.06,APC
Biopsy thigh soft tissues,27323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,7254.06,Radiology
Biopsy thigh soft tissues,27323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,7254.06,APC
Biopsy thigh soft tissues,27323,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,7254.06,APC
Biopsy thigh soft tissues,27324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5268.49,,,,,,,fee schedule,2875.57,12757.95,
Biopsy thigh soft tissues,27324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4223.15,,,,,,,fee schedule,2875.57,12757.95,
Biopsy thigh soft tissues,27324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4613.41,,,,,,,fee schedule,2875.57,12757.95,
Biopsy thigh soft tissues,27324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4850.35,,,,,,,fee schedule,2875.57,12757.95,
Biopsy thigh soft tissues,27324,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Biopsy thigh soft tissues,27324,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Biopsy thigh soft tissues,27324,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Biopsy thigh soft tissues,27324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Biopsy thigh soft tissues,27324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Biopsy thigh soft tissues,27324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Biopsy thigh soft tissues,27324,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Neurectomy hamstring,27325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4505.27,,,,,,,fee schedule,1933.13,8576.66,
Neurectomy hamstring,27325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3611.37,,,,,,,fee schedule,1933.13,8576.66,
Neurectomy hamstring,27325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3945.09,,,,,,,fee schedule,1933.13,8576.66,
Neurectomy hamstring,27325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4147.71,,,,,,,fee schedule,1933.13,8576.66,
Neurectomy hamstring,27325,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8576.66,,,,,,,fee schedule,1933.13,8576.66,APC 378
Neurectomy hamstring,27325,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2029.79,,,,,,,fee schedule,1933.13,8576.66,APC
Neurectomy hamstring,27325,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2010.46,,,,,,,fee schedule,1933.13,8576.66,APC
Neurectomy hamstring,27325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1933.13,,,,,,,fee schedule,1933.13,8576.66,APC
Neurectomy hamstring,27325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2957.7,,,,,,,fee schedule,1933.13,8576.66,Radiology
Neurectomy hamstring,27325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2706.39,,,,,,,fee schedule,1933.13,8576.66,APC
Neurectomy hamstring,27325,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3382.99,,,,,,,fee schedule,1933.13,8576.66,APC
Neurectomy popliteal,27326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4505.27,,,,,,,fee schedule,1933.13,8576.66,
Neurectomy popliteal,27326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3611.37,,,,,,,fee schedule,1933.13,8576.66,
Neurectomy popliteal,27326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3945.09,,,,,,,fee schedule,1933.13,8576.66,
Neurectomy popliteal,27326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4147.71,,,,,,,fee schedule,1933.13,8576.66,
Neurectomy popliteal,27326,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8576.66,,,,,,,fee schedule,1933.13,8576.66,APC 378
Neurectomy popliteal,27326,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2029.79,,,,,,,fee schedule,1933.13,8576.66,APC
Neurectomy popliteal,27326,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2010.46,,,,,,,fee schedule,1933.13,8576.66,APC
Neurectomy popliteal,27326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1933.13,,,,,,,fee schedule,1933.13,8576.66,APC
Neurectomy popliteal,27326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2957.7,,,,,,,fee schedule,1933.13,8576.66,Radiology
Neurectomy popliteal,27326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2706.39,,,,,,,fee schedule,1933.13,8576.66,APC
Neurectomy popliteal,27326,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3382.99,,,,,,,fee schedule,1933.13,8576.66,APC
Exc thigh/knee les sc < 3 cm,27327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4375.26,,,,,,,fee schedule,1635.03,7254.06,
Exc thigh/knee les sc < 3 cm,27327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3507.15,,,,,,,fee schedule,1635.03,7254.06,
Exc thigh/knee les sc < 3 cm,27327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3831.25,,,,,,,fee schedule,1635.03,7254.06,
Exc thigh/knee les sc < 3 cm,27327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4028.02,,,,,,,fee schedule,1635.03,7254.06,
Exc thigh/knee les sc < 3 cm,27327,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,7254.06,APC 378
Exc thigh/knee les sc < 3 cm,27327,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,7254.06,APC
Exc thigh/knee les sc < 3 cm,27327,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,7254.06,APC
Exc thigh/knee les sc < 3 cm,27327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,7254.06,APC
Exc thigh/knee les sc < 3 cm,27327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,7254.06,Radiology
Exc thigh/knee les sc < 3 cm,27327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,7254.06,APC
Exc thigh/knee les sc < 3 cm,27327,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,7254.06,APC
Exc thigh/knee tum deep <5cm,27328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5268.49,,,,,,,fee schedule,2875.57,12757.95,
Exc thigh/knee tum deep <5cm,27328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4223.15,,,,,,,fee schedule,2875.57,12757.95,
Exc thigh/knee tum deep <5cm,27328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4613.41,,,,,,,fee schedule,2875.57,12757.95,
Exc thigh/knee tum deep <5cm,27328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4850.35,,,,,,,fee schedule,2875.57,12757.95,
Exc thigh/knee tum deep <5cm,27328,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Exc thigh/knee tum deep <5cm,27328,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Exc thigh/knee tum deep <5cm,27328,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Exc thigh/knee tum deep <5cm,27328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Exc thigh/knee tum deep <5cm,27328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Exc thigh/knee tum deep <5cm,27328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Exc thigh/knee tum deep <5cm,27328,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Resect thigh/knee tum < 5 cm,27329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5268.49,,,,,,,fee schedule,2875.57,12757.95,
Resect thigh/knee tum < 5 cm,27329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4223.15,,,,,,,fee schedule,2875.57,12757.95,
Resect thigh/knee tum < 5 cm,27329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4613.41,,,,,,,fee schedule,2875.57,12757.95,
Resect thigh/knee tum < 5 cm,27329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4850.35,,,,,,,fee schedule,2875.57,12757.95,
Resect thigh/knee tum < 5 cm,27329,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Resect thigh/knee tum < 5 cm,27329,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Resect thigh/knee tum < 5 cm,27329,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Resect thigh/knee tum < 5 cm,27329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Resect thigh/knee tum < 5 cm,27329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Resect thigh/knee tum < 5 cm,27329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Resect thigh/knee tum < 5 cm,27329,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Biopsy knee joint lining,27330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,3239.17,14371.12,
Biopsy knee joint lining,27330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,3239.17,14371.12,
Biopsy knee joint lining,27330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,3239.17,14371.12,
Biopsy knee joint lining,27330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,3239.17,14371.12,
Biopsy knee joint lining,27330,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Biopsy knee joint lining,27330,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Biopsy knee joint lining,27330,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Biopsy knee joint lining,27330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Biopsy knee joint lining,27330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Biopsy knee joint lining,27330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Biopsy knee joint lining,27330,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Explore/treat knee joint,27331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,3239.17,14371.12,
Explore/treat knee joint,27331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,3239.17,14371.12,
Explore/treat knee joint,27331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,3239.17,14371.12,
Explore/treat knee joint,27331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,3239.17,14371.12,
Explore/treat knee joint,27331,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Explore/treat knee joint,27331,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Explore/treat knee joint,27331,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Explore/treat knee joint,27331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Explore/treat knee joint,27331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Explore/treat knee joint,27331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Explore/treat knee joint,27331,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of knee cartilage,27332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,3239.17,14371.12,
Removal of knee cartilage,27332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,3239.17,14371.12,
Removal of knee cartilage,27332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,3239.17,14371.12,
Removal of knee cartilage,27332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,3239.17,14371.12,
Removal of knee cartilage,27332,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Removal of knee cartilage,27332,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of knee cartilage,27332,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of knee cartilage,27332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of knee cartilage,27332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Removal of knee cartilage,27332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of knee cartilage,27332,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of knee cartilage,27333,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,3239.17,14371.12,
Removal of knee cartilage,27333,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,3239.17,14371.12,
Removal of knee cartilage,27333,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,3239.17,14371.12,
Removal of knee cartilage,27333,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,3239.17,14371.12,
Removal of knee cartilage,27333,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Removal of knee cartilage,27333,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of knee cartilage,27333,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of knee cartilage,27333,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of knee cartilage,27333,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Removal of knee cartilage,27333,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of knee cartilage,27333,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Remove knee joint lining,27334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,3239.17,14371.12,
Remove knee joint lining,27334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,3239.17,14371.12,
Remove knee joint lining,27334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,3239.17,14371.12,
Remove knee joint lining,27334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,3239.17,14371.12,
Remove knee joint lining,27334,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Remove knee joint lining,27334,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Remove knee joint lining,27334,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Remove knee joint lining,27334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Remove knee joint lining,27334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Remove knee joint lining,27334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Remove knee joint lining,27334,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Remove knee joint lining,27335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,5839.66,31870.39,
Remove knee joint lining,27335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,5839.66,31870.39,
Remove knee joint lining,27335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,5839.66,31870.39,
Remove knee joint lining,27335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,5839.66,31870.39,
Remove knee joint lining,27335,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5839.66,31870.39,APC 378
Remove knee joint lining,27335,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5839.66,31870.39,APC
Remove knee joint lining,27335,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5839.66,31870.39,APC
Remove knee joint lining,27335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5839.66,31870.39,APC
Remove knee joint lining,27335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5839.66,31870.39,Radiology
Remove knee joint lining,27335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5839.66,31870.39,APC
Remove knee joint lining,27335,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5839.66,31870.39,APC
Exc thigh/knee les sc 3 cm/>,27337,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6253.46,,,,,,,fee schedule,2875.57,12757.95,
Exc thigh/knee les sc 3 cm/>,27337,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5012.69,,,,,,,fee schedule,2875.57,12757.95,
Exc thigh/knee les sc 3 cm/>,27337,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5475.91,,,,,,,fee schedule,2875.57,12757.95,
Exc thigh/knee les sc 3 cm/>,27337,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5757.15,,,,,,,fee schedule,2875.57,12757.95,
Exc thigh/knee les sc 3 cm/>,27337,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Exc thigh/knee les sc 3 cm/>,27337,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Exc thigh/knee les sc 3 cm/>,27337,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Exc thigh/knee les sc 3 cm/>,27337,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Exc thigh/knee les sc 3 cm/>,27337,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Exc thigh/knee les sc 3 cm/>,27337,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Exc thigh/knee les sc 3 cm/>,27337,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Exc thigh/knee tum dep 5cm/>,27339,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6177.24,,,,,,,fee schedule,2875.57,12757.95,
Exc thigh/knee tum dep 5cm/>,27339,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4951.6,,,,,,,fee schedule,2875.57,12757.95,
Exc thigh/knee tum dep 5cm/>,27339,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5409.17,,,,,,,fee schedule,2875.57,12757.95,
Exc thigh/knee tum dep 5cm/>,27339,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5686.98,,,,,,,fee schedule,2875.57,12757.95,
Exc thigh/knee tum dep 5cm/>,27339,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Exc thigh/knee tum dep 5cm/>,27339,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Exc thigh/knee tum dep 5cm/>,27339,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Exc thigh/knee tum dep 5cm/>,27339,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Exc thigh/knee tum dep 5cm/>,27339,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Exc thigh/knee tum dep 5cm/>,27339,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Exc thigh/knee tum dep 5cm/>,27339,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Removal of kneecap bursa,27340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9737.23,,,,,,,fee schedule,3239.17,14371.12,
Removal of kneecap bursa,27340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7805.24,,,,,,,fee schedule,3239.17,14371.12,
Removal of kneecap bursa,27340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8526.52,,,,,,,fee schedule,3239.17,14371.12,
Removal of kneecap bursa,27340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8964.43,,,,,,,fee schedule,3239.17,14371.12,
Removal of kneecap bursa,27340,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Removal of kneecap bursa,27340,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of kneecap bursa,27340,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of kneecap bursa,27340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of kneecap bursa,27340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Removal of kneecap bursa,27340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of kneecap bursa,27340,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of knee cyst,27345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,3239.17,14371.12,
Removal of knee cyst,27345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,3239.17,14371.12,
Removal of knee cyst,27345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,3239.17,14371.12,
Removal of knee cyst,27345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,3239.17,14371.12,
Removal of knee cyst,27345,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Removal of knee cyst,27345,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of knee cyst,27345,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of knee cyst,27345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of knee cyst,27345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Removal of knee cyst,27345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of knee cyst,27345,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Remove knee cyst,27347,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,3239.17,14371.12,
Remove knee cyst,27347,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,3239.17,14371.12,
Remove knee cyst,27347,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,3239.17,14371.12,
Remove knee cyst,27347,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,3239.17,14371.12,
Remove knee cyst,27347,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Remove knee cyst,27347,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Remove knee cyst,27347,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Remove knee cyst,27347,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Remove knee cyst,27347,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Remove knee cyst,27347,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Remove knee cyst,27347,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of kneecap,27350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,5839.66,31870.39,
Removal of kneecap,27350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,5839.66,31870.39,
Removal of kneecap,27350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,5839.66,31870.39,
Removal of kneecap,27350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,5839.66,31870.39,
Removal of kneecap,27350,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5839.66,31870.39,APC 378
Removal of kneecap,27350,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5839.66,31870.39,APC
Removal of kneecap,27350,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5839.66,31870.39,APC
Removal of kneecap,27350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5839.66,31870.39,APC
Removal of kneecap,27350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5839.66,31870.39,Radiology
Removal of kneecap,27350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5839.66,31870.39,APC
Removal of kneecap,27350,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5839.66,31870.39,APC
Remove femur lesion,27355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,3239.17,14371.12,
Remove femur lesion,27355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,3239.17,14371.12,
Remove femur lesion,27355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,3239.17,14371.12,
Remove femur lesion,27355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,3239.17,14371.12,
Remove femur lesion,27355,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Remove femur lesion,27355,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Remove femur lesion,27355,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Remove femur lesion,27355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Remove femur lesion,27355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Remove femur lesion,27355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Remove femur lesion,27355,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Remove femur lesion/graft,27356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,5839.66,56389.43,
Remove femur lesion/graft,27356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,5839.66,56389.43,
Remove femur lesion/graft,27356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,5839.66,56389.43,
Remove femur lesion/graft,27356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,5839.66,56389.43,
Remove femur lesion/graft,27356,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,5839.66,56389.43,APC 378
Remove femur lesion/graft,27356,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,5839.66,56389.43,APC
Remove femur lesion/graft,27356,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,5839.66,56389.43,APC
Remove femur lesion/graft,27356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,5839.66,56389.43,APC
Remove femur lesion/graft,27356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,5839.66,56389.43,Radiology
Remove femur lesion/graft,27356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,5839.66,56389.43,APC
Remove femur lesion/graft,27356,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,5839.66,56389.43,APC
Remove femur lesion/graft,27357,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,5839.66,31870.39,
Remove femur lesion/graft,27357,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,5839.66,31870.39,
Remove femur lesion/graft,27357,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,5839.66,31870.39,
Remove femur lesion/graft,27357,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,5839.66,31870.39,
Remove femur lesion/graft,27357,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5839.66,31870.39,APC 378
Remove femur lesion/graft,27357,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5839.66,31870.39,APC
Remove femur lesion/graft,27357,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5839.66,31870.39,APC
Remove femur lesion/graft,27357,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5839.66,31870.39,APC
Remove femur lesion/graft,27357,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5839.66,31870.39,Radiology
Remove femur lesion/graft,27357,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5839.66,31870.39,APC
Remove femur lesion/graft,27357,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5839.66,31870.39,APC
Remove femur lesion/fixation,27358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,5839.66,7285.12,
Remove femur lesion/fixation,27358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,5839.66,7285.12,
Remove femur lesion/fixation,27358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,5839.66,7285.12,
Remove femur lesion/fixation,27358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,5839.66,7285.12,
Partial removal leg bone(s),27360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5041.18,,,,,,,fee schedule,3239.17,14371.12,
Partial removal leg bone(s),27360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4040.94,,,,,,,fee schedule,3239.17,14371.12,
Partial removal leg bone(s),27360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4414.36,,,,,,,fee schedule,3239.17,14371.12,
Partial removal leg bone(s),27360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4641.08,,,,,,,fee schedule,3239.17,14371.12,
Partial removal leg bone(s),27360,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Partial removal leg bone(s),27360,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Partial removal leg bone(s),27360,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Partial removal leg bone(s),27360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Partial removal leg bone(s),27360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Partial removal leg bone(s),27360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Partial removal leg bone(s),27360,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Resect thigh/knee tum 5 cm/>,27364,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6177.24,,,,,,,fee schedule,2875.57,12757.95,
Resect thigh/knee tum 5 cm/>,27364,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4951.6,,,,,,,fee schedule,2875.57,12757.95,
Resect thigh/knee tum 5 cm/>,27364,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5409.17,,,,,,,fee schedule,2875.57,12757.95,
Resect thigh/knee tum 5 cm/>,27364,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5686.98,,,,,,,fee schedule,2875.57,12757.95,
Resect thigh/knee tum 5 cm/>,27364,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Resect thigh/knee tum 5 cm/>,27364,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Resect thigh/knee tum 5 cm/>,27364,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Resect thigh/knee tum 5 cm/>,27364,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Resect thigh/knee tum 5 cm/>,27364,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Resect thigh/knee tum 5 cm/>,27364,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Resect thigh/knee tum 5 cm/>,27364,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Resect femur/knee tumor,27365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,3239.17,23681.51,
Resect femur/knee tumor,27365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,3239.17,23681.51,
Resect femur/knee tumor,27365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,3239.17,23681.51,
Resect femur/knee tumor,27365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,3239.17,23681.51,
Resect femur/knee tumor,27365,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,23681.51,APC 378
Resect femur/knee tumor,27365,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,23681.51,APC
Resect femur/knee tumor,27365,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,23681.51,APC
Resect femur/knee tumor,27365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,23681.51,APC
Resect femur/knee tumor,27365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,23681.51,Radiology
Resect femur/knee tumor,27365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,23681.51,APC
Resect femur/knee tumor,27365,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,23681.51,APC
Njx cntrst kne arthg/ct/mri,27369,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,158.46,,,,,,,fee schedule,127.02,158.46,
Njx cntrst kne arthg/ct/mri,27369,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,127.02,,,,,,,fee schedule,127.02,158.46,
Njx cntrst kne arthg/ct/mri,27369,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,138.76,,,,,,,fee schedule,127.02,158.46,
Njx cntrst kne arthg/ct/mri,27369,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,145.88,,,,,,,fee schedule,127.02,158.46,
Removal of foreign body,27372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5268.49,,,,,,,fee schedule,2875.57,12757.95,
Removal of foreign body,27372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4223.15,,,,,,,fee schedule,2875.57,12757.95,
Removal of foreign body,27372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4613.41,,,,,,,fee schedule,2875.57,12757.95,
Removal of foreign body,27372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4850.35,,,,,,,fee schedule,2875.57,12757.95,
Removal of foreign body,27372,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Removal of foreign body,27372,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Removal of foreign body,27372,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Removal of foreign body,27372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Removal of foreign body,27372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Removal of foreign body,27372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Removal of foreign body,27372,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Repair of kneecap tendon,27380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,4254.97,31870.39,
Repair of kneecap tendon,27380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,4254.97,31870.39,
Repair of kneecap tendon,27380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,4254.97,31870.39,
Repair of kneecap tendon,27380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,4254.97,31870.39,
Repair of kneecap tendon,27380,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,4254.97,31870.39,APC 378
Repair of kneecap tendon,27380,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,4254.97,31870.39,APC
Repair of kneecap tendon,27380,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,4254.97,31870.39,APC
Repair of kneecap tendon,27380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,4254.97,31870.39,APC
Repair of kneecap tendon,27380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,4254.97,31870.39,Radiology
Repair of kneecap tendon,27380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,4254.97,31870.39,APC
Repair of kneecap tendon,27380,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,4254.97,31870.39,APC
Repair/graft kneecap tendon,27381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,4254.97,31870.39,
Repair/graft kneecap tendon,27381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,4254.97,31870.39,
Repair/graft kneecap tendon,27381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,4254.97,31870.39,
Repair/graft kneecap tendon,27381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,4254.97,31870.39,
Repair/graft kneecap tendon,27381,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,4254.97,31870.39,APC 378
Repair/graft kneecap tendon,27381,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,4254.97,31870.39,APC
Repair/graft kneecap tendon,27381,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,4254.97,31870.39,APC
Repair/graft kneecap tendon,27381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,4254.97,31870.39,APC
Repair/graft kneecap tendon,27381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,4254.97,31870.39,Radiology
Repair/graft kneecap tendon,27381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,4254.97,31870.39,APC
Repair/graft kneecap tendon,27381,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,4254.97,31870.39,APC
Repair of thigh muscle,27385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10466.49,,,,,,,fee schedule,7183.42,31870.39,
Repair of thigh muscle,27385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8389.81,,,,,,,fee schedule,7183.42,31870.39,
Repair of thigh muscle,27385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9165.1,,,,,,,fee schedule,7183.42,31870.39,
Repair of thigh muscle,27385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9635.82,,,,,,,fee schedule,7183.42,31870.39,
Repair of thigh muscle,27385,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Repair of thigh muscle,27385,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Repair of thigh muscle,27385,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Repair of thigh muscle,27385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Repair of thigh muscle,27385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Repair of thigh muscle,27385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Repair of thigh muscle,27385,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Repair/graft of thigh muscle,27386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,4254.97,31870.39,
Repair/graft of thigh muscle,27386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,4254.97,31870.39,
Repair/graft of thigh muscle,27386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,4254.97,31870.39,
Repair/graft of thigh muscle,27386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,4254.97,31870.39,
Repair/graft of thigh muscle,27386,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,4254.97,31870.39,APC 378
Repair/graft of thigh muscle,27386,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,4254.97,31870.39,APC
Repair/graft of thigh muscle,27386,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,4254.97,31870.39,APC
Repair/graft of thigh muscle,27386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,4254.97,31870.39,APC
Repair/graft of thigh muscle,27386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,4254.97,31870.39,Radiology
Repair/graft of thigh muscle,27386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,4254.97,31870.39,APC
Repair/graft of thigh muscle,27386,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,4254.97,31870.39,APC
Incision of thigh tendon,27390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,3239.17,14371.12,
Incision of thigh tendon,27390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,3239.17,14371.12,
Incision of thigh tendon,27390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,3239.17,14371.12,
Incision of thigh tendon,27390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,3239.17,14371.12,
Incision of thigh tendon,27390,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Incision of thigh tendon,27390,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Incision of thigh tendon,27390,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Incision of thigh tendon,27390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Incision of thigh tendon,27390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Incision of thigh tendon,27390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Incision of thigh tendon,27390,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Incision of thigh tendons,27391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,3239.17,14371.12,
Incision of thigh tendons,27391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,3239.17,14371.12,
Incision of thigh tendons,27391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,3239.17,14371.12,
Incision of thigh tendons,27391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,3239.17,14371.12,
Incision of thigh tendons,27391,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Incision of thigh tendons,27391,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Incision of thigh tendons,27391,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Incision of thigh tendons,27391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Incision of thigh tendons,27391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Incision of thigh tendons,27391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Incision of thigh tendons,27391,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Incision of thigh tendons,27392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,3239.17,14371.12,
Incision of thigh tendons,27392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,3239.17,14371.12,
Incision of thigh tendons,27392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,3239.17,14371.12,
Incision of thigh tendons,27392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,3239.17,14371.12,
Incision of thigh tendons,27392,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Incision of thigh tendons,27392,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Incision of thigh tendons,27392,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Incision of thigh tendons,27392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Incision of thigh tendons,27392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Incision of thigh tendons,27392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Incision of thigh tendons,27392,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Lengthening of thigh tendon,27393,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,5839.66,31870.39,
Lengthening of thigh tendon,27393,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,5839.66,31870.39,
Lengthening of thigh tendon,27393,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,5839.66,31870.39,
Lengthening of thigh tendon,27393,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,5839.66,31870.39,
Lengthening of thigh tendon,27393,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5839.66,31870.39,APC 378
Lengthening of thigh tendon,27393,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5839.66,31870.39,APC
Lengthening of thigh tendon,27393,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5839.66,31870.39,APC
Lengthening of thigh tendon,27393,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5839.66,31870.39,APC
Lengthening of thigh tendon,27393,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5839.66,31870.39,Radiology
Lengthening of thigh tendon,27393,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5839.66,31870.39,APC
Lengthening of thigh tendon,27393,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5839.66,31870.39,APC
Lengthening of thigh tendons,27394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,5839.66,31870.39,
Lengthening of thigh tendons,27394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,5839.66,31870.39,
Lengthening of thigh tendons,27394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,5839.66,31870.39,
Lengthening of thigh tendons,27394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,5839.66,31870.39,
Lengthening of thigh tendons,27394,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5839.66,31870.39,APC 378
Lengthening of thigh tendons,27394,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5839.66,31870.39,APC
Lengthening of thigh tendons,27394,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5839.66,31870.39,APC
Lengthening of thigh tendons,27394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5839.66,31870.39,APC
Lengthening of thigh tendons,27394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5839.66,31870.39,Radiology
Lengthening of thigh tendons,27394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5839.66,31870.39,APC
Lengthening of thigh tendons,27394,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5839.66,31870.39,APC
Lengthening of thigh tendons,27395,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10728.02,,,,,,,fee schedule,3239.17,14371.12,
Lengthening of thigh tendons,27395,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8599.44,,,,,,,fee schedule,3239.17,14371.12,
Lengthening of thigh tendons,27395,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9394.11,,,,,,,fee schedule,3239.17,14371.12,
Lengthening of thigh tendons,27395,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9876.59,,,,,,,fee schedule,3239.17,14371.12,
Lengthening of thigh tendons,27395,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Lengthening of thigh tendons,27395,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Lengthening of thigh tendons,27395,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Lengthening of thigh tendons,27395,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Lengthening of thigh tendons,27395,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Lengthening of thigh tendons,27395,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Lengthening of thigh tendons,27395,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Transplant of thigh tendon,27396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,5839.66,31870.39,
Transplant of thigh tendon,27396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,5839.66,31870.39,
Transplant of thigh tendon,27396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,5839.66,31870.39,
Transplant of thigh tendon,27396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,5839.66,31870.39,
Transplant of thigh tendon,27396,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5839.66,31870.39,APC 378
Transplant of thigh tendon,27396,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5839.66,31870.39,APC
Transplant of thigh tendon,27396,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5839.66,31870.39,APC
Transplant of thigh tendon,27396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5839.66,31870.39,APC
Transplant of thigh tendon,27396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5839.66,31870.39,Radiology
Transplant of thigh tendon,27396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5839.66,31870.39,APC
Transplant of thigh tendon,27396,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5839.66,31870.39,APC
Transplants of thigh tendons,27397,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10728.02,,,,,,,fee schedule,7183.42,31870.39,
Transplants of thigh tendons,27397,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8599.44,,,,,,,fee schedule,7183.42,31870.39,
Transplants of thigh tendons,27397,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9394.11,,,,,,,fee schedule,7183.42,31870.39,
Transplants of thigh tendons,27397,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9876.59,,,,,,,fee schedule,7183.42,31870.39,
Transplants of thigh tendons,27397,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Transplants of thigh tendons,27397,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Transplants of thigh tendons,27397,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Transplants of thigh tendons,27397,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Transplants of thigh tendons,27397,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Transplants of thigh tendons,27397,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Transplants of thigh tendons,27397,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Revise thigh muscles/tendons,27400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10728.02,,,,,,,fee schedule,7183.42,31870.39,
Revise thigh muscles/tendons,27400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8599.44,,,,,,,fee schedule,7183.42,31870.39,
Revise thigh muscles/tendons,27400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9394.11,,,,,,,fee schedule,7183.42,31870.39,
Revise thigh muscles/tendons,27400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9876.59,,,,,,,fee schedule,7183.42,31870.39,
Revise thigh muscles/tendons,27400,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Revise thigh muscles/tendons,27400,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Revise thigh muscles/tendons,27400,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Revise thigh muscles/tendons,27400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Revise thigh muscles/tendons,27400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Revise thigh muscles/tendons,27400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Revise thigh muscles/tendons,27400,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Repair of knee cartilage,27403,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,5839.66,31870.39,
Repair of knee cartilage,27403,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,5839.66,31870.39,
Repair of knee cartilage,27403,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,5839.66,31870.39,
Repair of knee cartilage,27403,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,5839.66,31870.39,
Repair of knee cartilage,27403,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5839.66,31870.39,APC 378
Repair of knee cartilage,27403,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5839.66,31870.39,APC
Repair of knee cartilage,27403,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5839.66,31870.39,APC
Repair of knee cartilage,27403,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5839.66,31870.39,APC
Repair of knee cartilage,27403,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5839.66,31870.39,Radiology
Repair of knee cartilage,27403,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5839.66,31870.39,APC
Repair of knee cartilage,27403,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5839.66,31870.39,APC
Repair of knee ligament,27405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10728.02,,,,,,,fee schedule,7183.42,31870.39,
Repair of knee ligament,27405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8599.44,,,,,,,fee schedule,7183.42,31870.39,
Repair of knee ligament,27405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9394.11,,,,,,,fee schedule,7183.42,31870.39,
Repair of knee ligament,27405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9876.59,,,,,,,fee schedule,7183.42,31870.39,
Repair of knee ligament,27405,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Repair of knee ligament,27405,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Repair of knee ligament,27405,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Repair of knee ligament,27405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Repair of knee ligament,27405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Repair of knee ligament,27405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Repair of knee ligament,27405,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Repair of knee ligament,27407,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19822.36,,,,,,,fee schedule,7183.42,31870.39,
Repair of knee ligament,27407,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15889.35,,,,,,,fee schedule,7183.42,31870.39,
Repair of knee ligament,27407,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17357.67,,,,,,,fee schedule,7183.42,31870.39,
Repair of knee ligament,27407,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18249.15,,,,,,,fee schedule,7183.42,31870.39,
Repair of knee ligament,27407,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Repair of knee ligament,27407,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Repair of knee ligament,27407,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Repair of knee ligament,27407,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Repair of knee ligament,27407,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Repair of knee ligament,27407,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Repair of knee ligament,27407,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Repair of knee ligaments,27409,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5570.79,,,,,,,fee schedule,4465.47,31870.39,
Repair of knee ligaments,27409,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4465.47,,,,,,,fee schedule,4465.47,31870.39,
Repair of knee ligaments,27409,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4878.12,,,,,,,fee schedule,4465.47,31870.39,
Repair of knee ligaments,27409,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5128.66,,,,,,,fee schedule,4465.47,31870.39,
Repair of knee ligaments,27409,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,4465.47,31870.39,APC 378
Repair of knee ligaments,27409,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,4465.47,31870.39,APC
Repair of knee ligaments,27409,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,4465.47,31870.39,APC
Repair of knee ligaments,27409,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,4465.47,31870.39,APC
Repair of knee ligaments,27409,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,4465.47,31870.39,Radiology
Repair of knee ligaments,27409,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,4465.47,31870.39,APC
Repair of knee ligaments,27409,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,4465.47,31870.39,APC
Autochondrocyte implant knee,27412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11407.36,,,,,,,fee schedule,7183.42,31870.39,
Autochondrocyte implant knee,27412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9143.99,,,,,,,fee schedule,7183.42,31870.39,
Autochondrocyte implant knee,27412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9988.98,,,,,,,fee schedule,7183.42,31870.39,
Autochondrocyte implant knee,27412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10502.01,,,,,,,fee schedule,7183.42,31870.39,
Autochondrocyte implant knee,27412,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Autochondrocyte implant knee,27412,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Autochondrocyte implant knee,27412,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Autochondrocyte implant knee,27412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Autochondrocyte implant knee,27412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Autochondrocyte implant knee,27412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Autochondrocyte implant knee,27412,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Osteochondral knee allograft,27415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10673.46,,,,,,,fee schedule,8555.71,56389.43,
Osteochondral knee allograft,27415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8555.71,,,,,,,fee schedule,8555.71,56389.43,
Osteochondral knee allograft,27415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9346.34,,,,,,,fee schedule,8555.71,56389.43,
Osteochondral knee allograft,27415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9826.36,,,,,,,fee schedule,8555.71,56389.43,
Osteochondral knee allograft,27415,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,8555.71,56389.43,APC 378
Osteochondral knee allograft,27415,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,8555.71,56389.43,APC
Osteochondral knee allograft,27415,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,8555.71,56389.43,APC
Osteochondral knee allograft,27415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,8555.71,56389.43,APC
Osteochondral knee allograft,27415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,8555.71,56389.43,Radiology
Osteochondral knee allograft,27415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,8555.71,56389.43,APC
Osteochondral knee allograft,27415,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,8555.71,56389.43,APC
Osteochondral knee autograft,27416,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10728.02,,,,,,,fee schedule,7183.42,31870.39,
Osteochondral knee autograft,27416,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8599.44,,,,,,,fee schedule,7183.42,31870.39,
Osteochondral knee autograft,27416,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9394.11,,,,,,,fee schedule,7183.42,31870.39,
Osteochondral knee autograft,27416,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9876.59,,,,,,,fee schedule,7183.42,31870.39,
Osteochondral knee autograft,27416,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Osteochondral knee autograft,27416,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Osteochondral knee autograft,27416,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Osteochondral knee autograft,27416,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Osteochondral knee autograft,27416,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Osteochondral knee autograft,27416,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Osteochondral knee autograft,27416,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Repair degenerated kneecap,27418,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3766.57,,,,,,,fee schedule,3019.23,31870.39,
Repair degenerated kneecap,27418,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3019.23,,,,,,,fee schedule,3019.23,31870.39,
Repair degenerated kneecap,27418,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3298.24,,,,,,,fee schedule,3019.23,31870.39,
Repair degenerated kneecap,27418,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3467.63,,,,,,,fee schedule,3019.23,31870.39,
Repair degenerated kneecap,27418,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,3019.23,31870.39,APC 378
Repair degenerated kneecap,27418,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,3019.23,31870.39,APC
Repair degenerated kneecap,27418,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,3019.23,31870.39,APC
Repair degenerated kneecap,27418,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,3019.23,31870.39,APC
Repair degenerated kneecap,27418,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,3019.23,31870.39,Radiology
Repair degenerated kneecap,27418,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,3019.23,31870.39,APC
Repair degenerated kneecap,27418,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,3019.23,31870.39,APC
Revision of unstable kneecap,27420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11141.58,,,,,,,fee schedule,7183.42,31870.39,
Revision of unstable kneecap,27420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8930.95,,,,,,,fee schedule,7183.42,31870.39,
Revision of unstable kneecap,27420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9756.25,,,,,,,fee schedule,7183.42,31870.39,
Revision of unstable kneecap,27420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10257.32,,,,,,,fee schedule,7183.42,31870.39,
Revision of unstable kneecap,27420,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Revision of unstable kneecap,27420,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Revision of unstable kneecap,27420,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Revision of unstable kneecap,27420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Revision of unstable kneecap,27420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Revision of unstable kneecap,27420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Revision of unstable kneecap,27420,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Revision of unstable kneecap,27422,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4737.13,,,,,,,fee schedule,3797.22,31870.39,
Revision of unstable kneecap,27422,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3797.22,,,,,,,fee schedule,3797.22,31870.39,
Revision of unstable kneecap,27422,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4148.12,,,,,,,fee schedule,3797.22,31870.39,
Revision of unstable kneecap,27422,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4361.17,,,,,,,fee schedule,3797.22,31870.39,
Revision of unstable kneecap,27422,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,3797.22,31870.39,APC 378
Revision of unstable kneecap,27422,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,3797.22,31870.39,APC
Revision of unstable kneecap,27422,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,3797.22,31870.39,APC
Revision of unstable kneecap,27422,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,3797.22,31870.39,APC
Revision of unstable kneecap,27422,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,3797.22,31870.39,Radiology
Revision of unstable kneecap,27422,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,3797.22,31870.39,APC
Revision of unstable kneecap,27422,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,3797.22,31870.39,APC
Revision/removal of kneecap,27424,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10728.02,,,,,,,fee schedule,7183.42,31870.39,
Revision/removal of kneecap,27424,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8599.44,,,,,,,fee schedule,7183.42,31870.39,
Revision/removal of kneecap,27424,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9394.11,,,,,,,fee schedule,7183.42,31870.39,
Revision/removal of kneecap,27424,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9876.59,,,,,,,fee schedule,7183.42,31870.39,
Revision/removal of kneecap,27424,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Revision/removal of kneecap,27424,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Revision/removal of kneecap,27424,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Revision/removal of kneecap,27424,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Revision/removal of kneecap,27424,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Revision/removal of kneecap,27424,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Revision/removal of kneecap,27424,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Lat retinacular release open,27425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5696.21,,,,,,,fee schedule,3239.17,14371.12,
Lat retinacular release open,27425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4566.01,,,,,,,fee schedule,3239.17,14371.12,
Lat retinacular release open,27425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4987.95,,,,,,,fee schedule,3239.17,14371.12,
Lat retinacular release open,27425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5244.13,,,,,,,fee schedule,3239.17,14371.12,
Lat retinacular release open,27425,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Lat retinacular release open,27425,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Lat retinacular release open,27425,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Lat retinacular release open,27425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Lat retinacular release open,27425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Lat retinacular release open,27425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Lat retinacular release open,27425,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Reconstruction knee,27427,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6534.92,,,,,,,fee schedule,5238.31,31870.39,
Reconstruction knee,27427,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5238.31,,,,,,,fee schedule,5238.31,31870.39,
Reconstruction knee,27427,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5722.38,,,,,,,fee schedule,5238.31,31870.39,
Reconstruction knee,27427,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6016.28,,,,,,,fee schedule,5238.31,31870.39,
Reconstruction knee,27427,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5238.31,31870.39,APC 378
Reconstruction knee,27427,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5238.31,31870.39,APC
Reconstruction knee,27427,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5238.31,31870.39,APC
Reconstruction knee,27427,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5238.31,31870.39,APC
Reconstruction knee,27427,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5238.31,31870.39,Radiology
Reconstruction knee,27427,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5238.31,31870.39,APC
Reconstruction knee,27427,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5238.31,31870.39,APC
Reconstruction knee,27428,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5715.88,,,,,,,fee schedule,4581.78,56389.43,
Reconstruction knee,27428,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4581.78,,,,,,,fee schedule,4581.78,56389.43,
Reconstruction knee,27428,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5005.18,,,,,,,fee schedule,4581.78,56389.43,
Reconstruction knee,27428,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5262.24,,,,,,,fee schedule,4581.78,56389.43,
Reconstruction knee,27428,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,4581.78,56389.43,APC 378
Reconstruction knee,27428,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,4581.78,56389.43,APC
Reconstruction knee,27428,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,4581.78,56389.43,APC
Reconstruction knee,27428,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,4581.78,56389.43,APC
Reconstruction knee,27428,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,4581.78,56389.43,Radiology
Reconstruction knee,27428,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,4581.78,56389.43,APC
Reconstruction knee,27428,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,4581.78,56389.43,APC
Reconstruction knee,27429,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5570.79,,,,,,,fee schedule,4465.47,56389.43,
Reconstruction knee,27429,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4465.47,,,,,,,fee schedule,4465.47,56389.43,
Reconstruction knee,27429,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4878.12,,,,,,,fee schedule,4465.47,56389.43,
Reconstruction knee,27429,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5128.66,,,,,,,fee schedule,4465.47,56389.43,
Reconstruction knee,27429,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,4465.47,56389.43,APC 378
Reconstruction knee,27429,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,4465.47,56389.43,APC
Reconstruction knee,27429,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,4465.47,56389.43,APC
Reconstruction knee,27429,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,4465.47,56389.43,APC
Reconstruction knee,27429,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,4465.47,56389.43,Radiology
Reconstruction knee,27429,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,4465.47,56389.43,APC
Reconstruction knee,27429,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,4465.47,56389.43,APC
Revision of thigh muscles,27430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10728.02,,,,,,,fee schedule,7183.42,31870.39,
Revision of thigh muscles,27430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8599.44,,,,,,,fee schedule,7183.42,31870.39,
Revision of thigh muscles,27430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9394.11,,,,,,,fee schedule,7183.42,31870.39,
Revision of thigh muscles,27430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9876.59,,,,,,,fee schedule,7183.42,31870.39,
Revision of thigh muscles,27430,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Revision of thigh muscles,27430,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Revision of thigh muscles,27430,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Revision of thigh muscles,27430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Revision of thigh muscles,27430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Revision of thigh muscles,27430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Revision of thigh muscles,27430,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Incision of knee joint,27435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10728.02,,,,,,,fee schedule,3239.17,14371.12,
Incision of knee joint,27435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8599.44,,,,,,,fee schedule,3239.17,14371.12,
Incision of knee joint,27435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9394.11,,,,,,,fee schedule,3239.17,14371.12,
Incision of knee joint,27435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9876.59,,,,,,,fee schedule,3239.17,14371.12,
Incision of knee joint,27435,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Incision of knee joint,27435,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Incision of knee joint,27435,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Incision of knee joint,27435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Incision of knee joint,27435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Incision of knee joint,27435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Incision of knee joint,27435,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Revise kneecap,27437,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8960.75,,,,,,,fee schedule,7182.83,31870.39,
Revise kneecap,27437,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7182.83,,,,,,,fee schedule,7182.83,31870.39,
Revise kneecap,27437,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7846.59,,,,,,,fee schedule,7182.83,31870.39,
Revise kneecap,27437,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8249.58,,,,,,,fee schedule,7182.83,31870.39,
Revise kneecap,27437,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7182.83,31870.39,APC 378
Revise kneecap,27437,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7182.83,31870.39,APC
Revise kneecap,27437,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7182.83,31870.39,APC
Revise kneecap,27437,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7182.83,31870.39,APC
Revise kneecap,27437,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7182.83,31870.39,Radiology
Revise kneecap,27437,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7182.83,31870.39,APC
Revise kneecap,27437,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7182.83,31870.39,APC
Revise kneecap with implant,27438,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12700.27,,,,,,,fee schedule,10180.38,56389.43,
Revise kneecap with implant,27438,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10180.38,,,,,,,fee schedule,10180.38,56389.43,
Revise kneecap with implant,27438,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11121.14,,,,,,,fee schedule,10180.38,56389.43,
Revise kneecap with implant,27438,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11692.31,,,,,,,fee schedule,10180.38,56389.43,
Revise kneecap with implant,27438,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,10180.38,56389.43,APC 378
Revise kneecap with implant,27438,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,10180.38,56389.43,APC
Revise kneecap with implant,27438,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,10180.38,56389.43,APC
Revise kneecap with implant,27438,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,10180.38,56389.43,APC
Revise kneecap with implant,27438,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,10180.38,56389.43,Radiology
Revise kneecap with implant,27438,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,10180.38,56389.43,APC
Revise kneecap with implant,27438,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,10180.38,56389.43,APC
Revision of knee joint,27440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8960.75,,,,,,,fee schedule,7182.83,56389.43,
Revision of knee joint,27440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7182.83,,,,,,,fee schedule,7182.83,56389.43,
Revision of knee joint,27440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7846.59,,,,,,,fee schedule,7182.83,56389.43,
Revision of knee joint,27440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8249.58,,,,,,,fee schedule,7182.83,56389.43,
Revision of knee joint,27440,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,7182.83,56389.43,APC 378
Revision of knee joint,27440,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,7182.83,56389.43,APC
Revision of knee joint,27440,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,7182.83,56389.43,APC
Revision of knee joint,27440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,7182.83,56389.43,APC
Revision of knee joint,27440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,7182.83,56389.43,Radiology
Revision of knee joint,27440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,7182.83,56389.43,APC
Revision of knee joint,27440,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,7182.83,56389.43,APC
Revision of knee joint,27441,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8960.75,,,,,,,fee schedule,7182.83,56389.43,
Revision of knee joint,27441,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7182.83,,,,,,,fee schedule,7182.83,56389.43,
Revision of knee joint,27441,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7846.59,,,,,,,fee schedule,7182.83,56389.43,
Revision of knee joint,27441,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8249.58,,,,,,,fee schedule,7182.83,56389.43,
Revision of knee joint,27441,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,7182.83,56389.43,APC 378
Revision of knee joint,27441,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,7182.83,56389.43,APC
Revision of knee joint,27441,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,7182.83,56389.43,APC
Revision of knee joint,27441,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,7182.83,56389.43,APC
Revision of knee joint,27441,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,7182.83,56389.43,Radiology
Revision of knee joint,27441,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,7182.83,56389.43,APC
Revision of knee joint,27441,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,7182.83,56389.43,APC
Revision of knee joint,27442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8960.75,,,,,,,fee schedule,7182.83,56389.43,
Revision of knee joint,27442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7182.83,,,,,,,fee schedule,7182.83,56389.43,
Revision of knee joint,27442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7846.59,,,,,,,fee schedule,7182.83,56389.43,
Revision of knee joint,27442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8249.58,,,,,,,fee schedule,7182.83,56389.43,
Revision of knee joint,27442,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,7182.83,56389.43,APC 378
Revision of knee joint,27442,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,7182.83,56389.43,APC
Revision of knee joint,27442,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,7182.83,56389.43,APC
Revision of knee joint,27442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,7182.83,56389.43,APC
Revision of knee joint,27442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,7182.83,56389.43,Radiology
Revision of knee joint,27442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,7182.83,56389.43,APC
Revision of knee joint,27442,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,7182.83,56389.43,APC
Revision of knee joint,27443,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8960.75,,,,,,,fee schedule,7182.83,56389.43,
Revision of knee joint,27443,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7182.83,,,,,,,fee schedule,7182.83,56389.43,
Revision of knee joint,27443,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7846.59,,,,,,,fee schedule,7182.83,56389.43,
Revision of knee joint,27443,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8249.58,,,,,,,fee schedule,7182.83,56389.43,
Revision of knee joint,27443,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,7182.83,56389.43,APC 378
Revision of knee joint,27443,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,7182.83,56389.43,APC
Revision of knee joint,27443,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,7182.83,56389.43,APC
Revision of knee joint,27443,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,7182.83,56389.43,APC
Revision of knee joint,27443,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,7182.83,56389.43,Radiology
Revision of knee joint,27443,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,7182.83,56389.43,APC
Revision of knee joint,27443,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,7182.83,56389.43,APC
Revision of knee joint,27445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46549.79,,,,,,,fee schedule,37313.72,46549.79,
Revision of knee joint,27445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37313.72,,,,,,,fee schedule,37313.72,46549.79,
Revision of knee joint,27445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40761.86,,,,,,,fee schedule,37313.72,46549.79,
Revision of knee joint,27445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42855.36,,,,,,,fee schedule,37313.72,46549.79,
Revision of knee joint,27446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22316.74,,,,,,,fee schedule,12709.88,56389.43,
Revision of knee joint,27446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17888.82,,,,,,,fee schedule,12709.88,56389.43,
Revision of knee joint,27446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19541.91,,,,,,,fee schedule,12709.88,56389.43,
Revision of knee joint,27446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20545.57,,,,,,,fee schedule,12709.88,56389.43,
Revision of knee joint,27446,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,12709.88,56389.43,APC 378
Revision of knee joint,27446,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,12709.88,56389.43,APC
Revision of knee joint,27446,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,12709.88,56389.43,APC
Revision of knee joint,27446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,12709.88,56389.43,APC
Revision of knee joint,27446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,12709.88,56389.43,Radiology
Revision of knee joint,27446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,12709.88,56389.43,APC
Revision of knee joint,27446,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,12709.88,56389.43,APC
Total knee arthroplasty,27447,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10850.91,,,,,,,fee schedule,8697.95,56389.43,
Total knee arthroplasty,27447,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8697.95,,,,,,,fee schedule,8697.95,56389.43,
Total knee arthroplasty,27447,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9501.72,,,,,,,fee schedule,8697.95,56389.43,
Total knee arthroplasty,27447,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9989.72,,,,,,,fee schedule,8697.95,56389.43,
Total knee arthroplasty,27447,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,8697.95,56389.43,APC 378
Total knee arthroplasty,27447,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,8697.95,56389.43,APC
Total knee arthroplasty,27447,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,8697.95,56389.43,APC
Total knee arthroplasty,27447,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,8697.95,56389.43,APC
Total knee arthroplasty,27447,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,8697.95,56389.43,Radiology
Total knee arthroplasty,27447,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,8697.95,56389.43,APC
Total knee arthroplasty,27447,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,8697.95,56389.43,APC
Incision of thigh,27448,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Incision of thigh,27448,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Incision of thigh,27448,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Incision of thigh,27448,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Incision of thigh,27448,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Incision of thigh,27448,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Incision of thigh,27448,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Incision of thigh,27448,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Incision of thigh,27448,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Incision of thigh,27448,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Incision of thigh,27448,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Incision of thigh,27450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Incision of thigh,27450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Incision of thigh,27450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Incision of thigh,27450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Incision of thigh,27450,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Incision of thigh,27450,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Incision of thigh,27450,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Incision of thigh,27450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Incision of thigh,27450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Incision of thigh,27450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Incision of thigh,27450,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Realignment of thigh bone,27454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Realignment of thigh bone,27454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Realignment of thigh bone,27454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Realignment of thigh bone,27454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Realignment of thigh bone,27454,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Realignment of thigh bone,27454,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Realignment of thigh bone,27454,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Realignment of thigh bone,27454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Realignment of thigh bone,27454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Realignment of thigh bone,27454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Realignment of thigh bone,27454,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Realignment of knee,27455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Realignment of knee,27455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Realignment of knee,27455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Realignment of knee,27455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Realignment of knee,27455,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Realignment of knee,27455,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Realignment of knee,27455,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Realignment of knee,27455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Realignment of knee,27455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Realignment of knee,27455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Realignment of knee,27455,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Realignment of knee,27457,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Realignment of knee,27457,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Realignment of knee,27457,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Realignment of knee,27457,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Realignment of knee,27457,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Realignment of knee,27457,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Realignment of knee,27457,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Realignment of knee,27457,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Realignment of knee,27457,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Realignment of knee,27457,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Realignment of knee,27457,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Osteot femur imed lngth dev,27458,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Osteot femur imed lngth dev,27458,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Osteot femur imed lngth dev,27458,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Osteot femur imed lngth dev,27458,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Osteot femur imed lngth dev,27458,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Osteot femur imed lngth dev,27458,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Osteot femur imed lngth dev,27458,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Shortening of thigh bone,27465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Shortening of thigh bone,27465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Shortening of thigh bone,27465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Shortening of thigh bone,27465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Shortening of thigh bone,27465,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Shortening of thigh bone,27465,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Shortening of thigh bone,27465,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Shortening of thigh bone,27465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Shortening of thigh bone,27465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Shortening of thigh bone,27465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Shortening of thigh bone,27465,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Lengthening of thigh bone,27466,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Lengthening of thigh bone,27466,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Lengthening of thigh bone,27466,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Lengthening of thigh bone,27466,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Lengthening of thigh bone,27466,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Lengthening of thigh bone,27466,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Lengthening of thigh bone,27466,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Lengthening of thigh bone,27466,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Lengthening of thigh bone,27466,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Lengthening of thigh bone,27466,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Lengthening of thigh bone,27466,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Shorten/lengthen thighs,27468,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,18982.8,23681.51,
Shorten/lengthen thighs,27468,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,18982.8,23681.51,
Shorten/lengthen thighs,27468,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,18982.8,23681.51,
Shorten/lengthen thighs,27468,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,18982.8,23681.51,
Repair of thigh,27470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Repair of thigh,27470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Repair of thigh,27470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Repair of thigh,27470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Repair of thigh,27470,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Repair of thigh,27470,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Repair of thigh,27470,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Repair of thigh,27470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Repair of thigh,27470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Repair of thigh,27470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Repair of thigh,27470,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Repair/graft of thigh,27472,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Repair/graft of thigh,27472,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Repair/graft of thigh,27472,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Repair/graft of thigh,27472,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Repair/graft of thigh,27472,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Repair/graft of thigh,27472,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Repair/graft of thigh,27472,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Repair/graft of thigh,27472,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Repair/graft of thigh,27472,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Repair/graft of thigh,27472,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Repair/graft of thigh,27472,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Surgery to stop leg growth,27475,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,5839.66,31870.39,
Surgery to stop leg growth,27475,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,5839.66,31870.39,
Surgery to stop leg growth,27475,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,5839.66,31870.39,
Surgery to stop leg growth,27475,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,5839.66,31870.39,
Surgery to stop leg growth,27475,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5839.66,31870.39,APC 378
Surgery to stop leg growth,27475,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5839.66,31870.39,APC
Surgery to stop leg growth,27475,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5839.66,31870.39,APC
Surgery to stop leg growth,27475,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5839.66,31870.39,APC
Surgery to stop leg growth,27475,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5839.66,31870.39,Radiology
Surgery to stop leg growth,27475,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5839.66,31870.39,APC
Surgery to stop leg growth,27475,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5839.66,31870.39,APC
Surgery to stop leg growth,27477,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9216.93,,,,,,,fee schedule,7183.42,31870.39,
Surgery to stop leg growth,27477,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7388.17,,,,,,,fee schedule,7183.42,31870.39,
Surgery to stop leg growth,27477,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8070.91,,,,,,,fee schedule,7183.42,31870.39,
Surgery to stop leg growth,27477,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8485.42,,,,,,,fee schedule,7183.42,31870.39,
Surgery to stop leg growth,27477,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Surgery to stop leg growth,27477,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Surgery to stop leg growth,27477,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Surgery to stop leg growth,27477,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Surgery to stop leg growth,27477,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Surgery to stop leg growth,27477,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Surgery to stop leg growth,27477,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Surgery to stop leg growth,27479,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19737.53,,,,,,,fee schedule,7183.42,31870.39,
Surgery to stop leg growth,27479,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15821.36,,,,,,,fee schedule,7183.42,31870.39,
Surgery to stop leg growth,27479,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17283.4,,,,,,,fee schedule,7183.42,31870.39,
Surgery to stop leg growth,27479,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18171.06,,,,,,,fee schedule,7183.42,31870.39,
Surgery to stop leg growth,27479,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Surgery to stop leg growth,27479,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Surgery to stop leg growth,27479,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Surgery to stop leg growth,27479,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Surgery to stop leg growth,27479,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Surgery to stop leg growth,27479,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Surgery to stop leg growth,27479,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Surgery to stop leg growth,27485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9216.93,,,,,,,fee schedule,7183.42,31870.39,
Surgery to stop leg growth,27485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7388.17,,,,,,,fee schedule,7183.42,31870.39,
Surgery to stop leg growth,27485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8070.91,,,,,,,fee schedule,7183.42,31870.39,
Surgery to stop leg growth,27485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8485.42,,,,,,,fee schedule,7183.42,31870.39,
Surgery to stop leg growth,27485,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Surgery to stop leg growth,27485,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Surgery to stop leg growth,27485,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Surgery to stop leg growth,27485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Surgery to stop leg growth,27485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Surgery to stop leg growth,27485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Surgery to stop leg growth,27485,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Revise/replace knee joint,27486,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46549.79,,,,,,,fee schedule,12709.88,56389.43,
Revise/replace knee joint,27486,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37313.72,,,,,,,fee schedule,12709.88,56389.43,
Revise/replace knee joint,27486,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40761.86,,,,,,,fee schedule,12709.88,56389.43,
Revise/replace knee joint,27486,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42855.36,,,,,,,fee schedule,12709.88,56389.43,
Revise/replace knee joint,27486,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,12709.88,56389.43,APC 378
Revise/replace knee joint,27486,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,12709.88,56389.43,APC
Revise/replace knee joint,27486,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,12709.88,56389.43,APC
Revise/replace knee joint,27486,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,12709.88,56389.43,APC
Revise/replace knee joint,27486,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,12709.88,56389.43,Radiology
Revise/replace knee joint,27486,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,12709.88,56389.43,APC
Revise/replace knee joint,27486,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,12709.88,56389.43,APC
Revise/replace knee joint,27487,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46549.79,,,,,,,fee schedule,17357.91,77011.17,
Revise/replace knee joint,27487,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37313.72,,,,,,,fee schedule,17357.91,77011.17,
Revise/replace knee joint,27487,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40761.86,,,,,,,fee schedule,17357.91,77011.17,
Revise/replace knee joint,27487,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42855.36,,,,,,,fee schedule,17357.91,77011.17,
Revise/replace knee joint,27487,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,77011.17,,,,,,,fee schedule,17357.91,77011.17,APC 378
Revise/replace knee joint,27487,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18225.81,,,,,,,fee schedule,17357.91,77011.17,APC
Revise/replace knee joint,27487,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18052.23,,,,,,,fee schedule,17357.91,77011.17,APC
Revise/replace knee joint,27487,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17357.91,,,,,,,fee schedule,17357.91,77011.17,APC
Revise/replace knee joint,27487,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26557.6,,,,,,,fee schedule,17357.91,77011.17,Radiology
Revise/replace knee joint,27487,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24301.07,,,,,,,fee schedule,17357.91,77011.17,APC
Revise/replace knee joint,27487,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30376.34,,,,,,,fee schedule,17357.91,77011.17,APC
Removal of knee prosthesis,27488,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,12709.88,56389.43,
Removal of knee prosthesis,27488,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,12709.88,56389.43,
Removal of knee prosthesis,27488,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,12709.88,56389.43,
Removal of knee prosthesis,27488,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,12709.88,56389.43,
Removal of knee prosthesis,27488,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,12709.88,56389.43,APC 378
Removal of knee prosthesis,27488,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,12709.88,56389.43,APC
Removal of knee prosthesis,27488,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,12709.88,56389.43,APC
Removal of knee prosthesis,27488,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,12709.88,56389.43,APC
Removal of knee prosthesis,27488,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,12709.88,56389.43,Radiology
Removal of knee prosthesis,27488,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,12709.88,56389.43,APC
Removal of knee prosthesis,27488,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,12709.88,56389.43,APC
Reinforce thigh,27495,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Reinforce thigh,27495,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Reinforce thigh,27495,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Reinforce thigh,27495,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Reinforce thigh,27495,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Reinforce thigh,27495,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Reinforce thigh,27495,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Reinforce thigh,27495,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Reinforce thigh,27495,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Reinforce thigh,27495,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Reinforce thigh,27495,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Decompression of thigh/knee,27496,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,3239.17,14371.12,
Decompression of thigh/knee,27496,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,3239.17,14371.12,
Decompression of thigh/knee,27496,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,3239.17,14371.12,
Decompression of thigh/knee,27496,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,3239.17,14371.12,
Decompression of thigh/knee,27496,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Decompression of thigh/knee,27496,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Decompression of thigh/knee,27496,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Decompression of thigh/knee,27496,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Decompression of thigh/knee,27496,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Decompression of thigh/knee,27496,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Decompression of thigh/knee,27496,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Decompression of thigh/knee,27497,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,3239.17,14371.12,
Decompression of thigh/knee,27497,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,3239.17,14371.12,
Decompression of thigh/knee,27497,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,3239.17,14371.12,
Decompression of thigh/knee,27497,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,3239.17,14371.12,
Decompression of thigh/knee,27497,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Decompression of thigh/knee,27497,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Decompression of thigh/knee,27497,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Decompression of thigh/knee,27497,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Decompression of thigh/knee,27497,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Decompression of thigh/knee,27497,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Decompression of thigh/knee,27497,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Decompression of thigh/knee,27498,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,1591.86,7062.54,
Decompression of thigh/knee,27498,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,1591.86,7062.54,
Decompression of thigh/knee,27498,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,1591.86,7062.54,
Decompression of thigh/knee,27498,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,1591.86,7062.54,
Decompression of thigh/knee,27498,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Decompression of thigh/knee,27498,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Decompression of thigh/knee,27498,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Decompression of thigh/knee,27498,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Decompression of thigh/knee,27498,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Decompression of thigh/knee,27498,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Decompression of thigh/knee,27498,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Decompression of thigh/knee,27499,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,4254.97,31870.39,
Decompression of thigh/knee,27499,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,4254.97,31870.39,
Decompression of thigh/knee,27499,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,4254.97,31870.39,
Decompression of thigh/knee,27499,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,4254.97,31870.39,
Decompression of thigh/knee,27499,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,4254.97,31870.39,APC 378
Decompression of thigh/knee,27499,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,4254.97,31870.39,APC
Decompression of thigh/knee,27499,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,4254.97,31870.39,APC
Decompression of thigh/knee,27499,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,4254.97,31870.39,APC
Decompression of thigh/knee,27499,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,4254.97,31870.39,Radiology
Decompression of thigh/knee,27499,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,4254.97,31870.39,APC
Decompression of thigh/knee,27499,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,4254.97,31870.39,APC
Treatment of thigh fracture,27500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,244.19,1083.4,
Treatment of thigh fracture,27500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,244.19,1083.4,
Treatment of thigh fracture,27500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,244.19,1083.4,
Treatment of thigh fracture,27500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,244.19,1083.4,
Treatment of thigh fracture,27500,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treatment of thigh fracture,27500,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treatment of thigh fracture,27500,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treatment of thigh fracture,27500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treatment of thigh fracture,27500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treatment of thigh fracture,27500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treatment of thigh fracture,27500,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treatment of thigh fracture,27501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,244.19,1083.4,
Treatment of thigh fracture,27501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,244.19,1083.4,
Treatment of thigh fracture,27501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,244.19,1083.4,
Treatment of thigh fracture,27501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,244.19,1083.4,
Treatment of thigh fracture,27501,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treatment of thigh fracture,27501,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treatment of thigh fracture,27501,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treatment of thigh fracture,27501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treatment of thigh fracture,27501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treatment of thigh fracture,27501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treatment of thigh fracture,27501,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treatment of thigh fracture,27502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,353.72,7062.54,
Treatment of thigh fracture,27502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,353.72,7062.54,
Treatment of thigh fracture,27502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,353.72,7062.54,
Treatment of thigh fracture,27502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,353.72,7062.54,
Treatment of thigh fracture,27502,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,353.72,7062.54,APC 378
Treatment of thigh fracture,27502,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,353.72,7062.54,APC
Treatment of thigh fracture,27502,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,353.72,7062.54,APC
Treatment of thigh fracture,27502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,353.72,7062.54,APC
Treatment of thigh fracture,27502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,353.72,7062.54,Radiology
Treatment of thigh fracture,27502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,353.72,7062.54,APC
Treatment of thigh fracture,27502,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,353.72,7062.54,APC
Treatment of thigh fracture,27503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,353.72,7062.54,
Treatment of thigh fracture,27503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,353.72,7062.54,
Treatment of thigh fracture,27503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,353.72,7062.54,
Treatment of thigh fracture,27503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,353.72,7062.54,
Treatment of thigh fracture,27503,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,353.72,7062.54,APC 378
Treatment of thigh fracture,27503,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,353.72,7062.54,APC
Treatment of thigh fracture,27503,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,353.72,7062.54,APC
Treatment of thigh fracture,27503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,353.72,7062.54,APC
Treatment of thigh fracture,27503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,353.72,7062.54,Radiology
Treatment of thigh fracture,27503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,353.72,7062.54,APC
Treatment of thigh fracture,27503,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,353.72,7062.54,APC
Treatment of thigh fracture,27506,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Treatment of thigh fracture,27506,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Treatment of thigh fracture,27506,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Treatment of thigh fracture,27506,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Treatment of thigh fracture,27506,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Treatment of thigh fracture,27506,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Treatment of thigh fracture,27506,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Treatment of thigh fracture,27506,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Treatment of thigh fracture,27506,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Treatment of thigh fracture,27506,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Treatment of thigh fracture,27506,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Treatment of thigh fracture,27507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Treatment of thigh fracture,27507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Treatment of thigh fracture,27507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Treatment of thigh fracture,27507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Treatment of thigh fracture,27507,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Treatment of thigh fracture,27507,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Treatment of thigh fracture,27507,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Treatment of thigh fracture,27507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Treatment of thigh fracture,27507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Treatment of thigh fracture,27507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Treatment of thigh fracture,27507,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Treatment of thigh fracture,27508,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,244.19,1083.4,
Treatment of thigh fracture,27508,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,244.19,1083.4,
Treatment of thigh fracture,27508,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,244.19,1083.4,
Treatment of thigh fracture,27508,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,244.19,1083.4,
Treatment of thigh fracture,27508,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treatment of thigh fracture,27508,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treatment of thigh fracture,27508,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treatment of thigh fracture,27508,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treatment of thigh fracture,27508,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treatment of thigh fracture,27508,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treatment of thigh fracture,27508,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treatment of thigh fracture,27509,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6528.66,,,,,,,fee schedule,5233.29,31870.39,
Treatment of thigh fracture,27509,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5233.29,,,,,,,fee schedule,5233.29,31870.39,
Treatment of thigh fracture,27509,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5716.9,,,,,,,fee schedule,5233.29,31870.39,
Treatment of thigh fracture,27509,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6010.52,,,,,,,fee schedule,5233.29,31870.39,
Treatment of thigh fracture,27509,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5233.29,31870.39,APC 378
Treatment of thigh fracture,27509,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5233.29,31870.39,APC
Treatment of thigh fracture,27509,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5233.29,31870.39,APC
Treatment of thigh fracture,27509,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5233.29,31870.39,APC
Treatment of thigh fracture,27509,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5233.29,31870.39,Radiology
Treatment of thigh fracture,27509,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5233.29,31870.39,APC
Treatment of thigh fracture,27509,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5233.29,31870.39,APC
Treatment of thigh fracture,27510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,353.72,7062.54,
Treatment of thigh fracture,27510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,353.72,7062.54,
Treatment of thigh fracture,27510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,353.72,7062.54,
Treatment of thigh fracture,27510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,353.72,7062.54,
Treatment of thigh fracture,27510,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,353.72,7062.54,APC 378
Treatment of thigh fracture,27510,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,353.72,7062.54,APC
Treatment of thigh fracture,27510,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,353.72,7062.54,APC
Treatment of thigh fracture,27510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,353.72,7062.54,APC
Treatment of thigh fracture,27510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,353.72,7062.54,Radiology
Treatment of thigh fracture,27510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,353.72,7062.54,APC
Treatment of thigh fracture,27510,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,353.72,7062.54,APC
Treatment of thigh fracture,27511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,12709.88,56389.43,
Treatment of thigh fracture,27511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,12709.88,56389.43,
Treatment of thigh fracture,27511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,12709.88,56389.43,
Treatment of thigh fracture,27511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,12709.88,56389.43,
Treatment of thigh fracture,27511,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,12709.88,56389.43,APC 378
Treatment of thigh fracture,27511,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,12709.88,56389.43,APC
Treatment of thigh fracture,27511,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,12709.88,56389.43,APC
Treatment of thigh fracture,27511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,12709.88,56389.43,APC
Treatment of thigh fracture,27511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,12709.88,56389.43,Radiology
Treatment of thigh fracture,27511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,12709.88,56389.43,APC
Treatment of thigh fracture,27511,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,12709.88,56389.43,APC
Treatment of thigh fracture,27513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,12709.88,56389.43,
Treatment of thigh fracture,27513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,12709.88,56389.43,
Treatment of thigh fracture,27513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,12709.88,56389.43,
Treatment of thigh fracture,27513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,12709.88,56389.43,
Treatment of thigh fracture,27513,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,12709.88,56389.43,APC 378
Treatment of thigh fracture,27513,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,12709.88,56389.43,APC
Treatment of thigh fracture,27513,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,12709.88,56389.43,APC
Treatment of thigh fracture,27513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,12709.88,56389.43,APC
Treatment of thigh fracture,27513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,12709.88,56389.43,Radiology
Treatment of thigh fracture,27513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,12709.88,56389.43,APC
Treatment of thigh fracture,27513,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,12709.88,56389.43,APC
Treatment of thigh fracture,27514,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,12709.88,56389.43,
Treatment of thigh fracture,27514,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,12709.88,56389.43,
Treatment of thigh fracture,27514,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,12709.88,56389.43,
Treatment of thigh fracture,27514,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,12709.88,56389.43,
Treatment of thigh fracture,27514,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,12709.88,56389.43,APC 378
Treatment of thigh fracture,27514,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,12709.88,56389.43,APC
Treatment of thigh fracture,27514,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,12709.88,56389.43,APC
Treatment of thigh fracture,27514,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,12709.88,56389.43,APC
Treatment of thigh fracture,27514,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,12709.88,56389.43,Radiology
Treatment of thigh fracture,27514,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,12709.88,56389.43,APC
Treatment of thigh fracture,27514,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,12709.88,56389.43,APC
Treat thigh fx growth plate,27516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,244.19,1083.4,
Treat thigh fx growth plate,27516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,244.19,1083.4,
Treat thigh fx growth plate,27516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,244.19,1083.4,
Treat thigh fx growth plate,27516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,244.19,1083.4,
Treat thigh fx growth plate,27516,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treat thigh fx growth plate,27516,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treat thigh fx growth plate,27516,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treat thigh fx growth plate,27516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treat thigh fx growth plate,27516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treat thigh fx growth plate,27516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treat thigh fx growth plate,27516,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treat thigh fx growth plate,27517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,353.72,7062.54,
Treat thigh fx growth plate,27517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,353.72,7062.54,
Treat thigh fx growth plate,27517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,353.72,7062.54,
Treat thigh fx growth plate,27517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,353.72,7062.54,
Treat thigh fx growth plate,27517,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,353.72,7062.54,APC 378
Treat thigh fx growth plate,27517,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,353.72,7062.54,APC
Treat thigh fx growth plate,27517,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,353.72,7062.54,APC
Treat thigh fx growth plate,27517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,353.72,7062.54,APC
Treat thigh fx growth plate,27517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,353.72,7062.54,Radiology
Treat thigh fx growth plate,27517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,353.72,7062.54,APC
Treat thigh fx growth plate,27517,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,353.72,7062.54,APC
Treat thigh fx growth plate,27519,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Treat thigh fx growth plate,27519,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Treat thigh fx growth plate,27519,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Treat thigh fx growth plate,27519,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Treat thigh fx growth plate,27519,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Treat thigh fx growth plate,27519,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Treat thigh fx growth plate,27519,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Treat thigh fx growth plate,27519,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Treat thigh fx growth plate,27519,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Treat thigh fx growth plate,27519,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Treat thigh fx growth plate,27519,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Treat kneecap fracture,27520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,244.19,1083.4,
Treat kneecap fracture,27520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,244.19,1083.4,
Treat kneecap fracture,27520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,244.19,1083.4,
Treat kneecap fracture,27520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,244.19,1083.4,
Treat kneecap fracture,27520,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treat kneecap fracture,27520,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treat kneecap fracture,27520,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treat kneecap fracture,27520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treat kneecap fracture,27520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treat kneecap fracture,27520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treat kneecap fracture,27520,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treat kneecap fracture,27524,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11141.58,,,,,,,fee schedule,7183.42,31870.39,
Treat kneecap fracture,27524,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8930.95,,,,,,,fee schedule,7183.42,31870.39,
Treat kneecap fracture,27524,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9756.25,,,,,,,fee schedule,7183.42,31870.39,
Treat kneecap fracture,27524,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10257.32,,,,,,,fee schedule,7183.42,31870.39,
Treat kneecap fracture,27524,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Treat kneecap fracture,27524,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Treat kneecap fracture,27524,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Treat kneecap fracture,27524,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Treat kneecap fracture,27524,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Treat kneecap fracture,27524,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Treat kneecap fracture,27524,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Treat knee fracture,27530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,244.19,1083.4,
Treat knee fracture,27530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,244.19,1083.4,
Treat knee fracture,27530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,244.19,1083.4,
Treat knee fracture,27530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,244.19,1083.4,
Treat knee fracture,27530,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treat knee fracture,27530,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treat knee fracture,27530,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treat knee fracture,27530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treat knee fracture,27530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treat knee fracture,27530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treat knee fracture,27530,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treat knee fracture,27532,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,353.72,14371.12,
Treat knee fracture,27532,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,353.72,14371.12,
Treat knee fracture,27532,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,353.72,14371.12,
Treat knee fracture,27532,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,353.72,14371.12,
Treat knee fracture,27532,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,353.72,14371.12,APC 378
Treat knee fracture,27532,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,353.72,14371.12,APC
Treat knee fracture,27532,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,353.72,14371.12,APC
Treat knee fracture,27532,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,353.72,14371.12,APC
Treat knee fracture,27532,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,353.72,14371.12,Radiology
Treat knee fracture,27532,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,353.72,14371.12,APC
Treat knee fracture,27532,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,353.72,14371.12,APC
Treat knee fracture,27535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12311.86,,,,,,,fee schedule,7183.42,31870.39,
Treat knee fracture,27535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9869.03,,,,,,,fee schedule,7183.42,31870.39,
Treat knee fracture,27535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10781.02,,,,,,,fee schedule,7183.42,31870.39,
Treat knee fracture,27535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11334.73,,,,,,,fee schedule,7183.42,31870.39,
Treat knee fracture,27535,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Treat knee fracture,27535,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Treat knee fracture,27535,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Treat knee fracture,27535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Treat knee fracture,27535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Treat knee fracture,27535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Treat knee fracture,27535,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Treat knee fracture,27536,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Treat knee fracture,27536,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Treat knee fracture,27536,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Treat knee fracture,27536,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Treat knee fracture,27536,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Treat knee fracture,27536,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Treat knee fracture,27536,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Treat knee fracture,27536,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Treat knee fracture,27536,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Treat knee fracture,27536,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Treat knee fracture,27536,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Treat knee fracture(s),27538,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,244.19,1083.4,
Treat knee fracture(s),27538,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,244.19,1083.4,
Treat knee fracture(s),27538,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,244.19,1083.4,
Treat knee fracture(s),27538,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,244.19,1083.4,
Treat knee fracture(s),27538,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treat knee fracture(s),27538,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treat knee fracture(s),27538,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treat knee fracture(s),27538,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treat knee fracture(s),27538,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treat knee fracture(s),27538,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treat knee fracture(s),27538,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treat knee fracture,27540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Treat knee fracture,27540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Treat knee fracture,27540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Treat knee fracture,27540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Treat knee fracture,27540,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Treat knee fracture,27540,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Treat knee fracture,27540,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Treat knee fracture,27540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Treat knee fracture,27540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Treat knee fracture,27540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Treat knee fracture,27540,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Treat knee dislocation,27550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,240.02,,,,,,,fee schedule,192.39,1083.4,
Treat knee dislocation,27550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,192.39,,,,,,,fee schedule,192.39,1083.4,
Treat knee dislocation,27550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,210.17,,,,,,,fee schedule,192.39,1083.4,
Treat knee dislocation,27550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,220.97,,,,,,,fee schedule,192.39,1083.4,
Treat knee dislocation,27550,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,192.39,1083.4,APC 378
Treat knee dislocation,27550,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,192.39,1083.4,APC
Treat knee dislocation,27550,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,192.39,1083.4,APC
Treat knee dislocation,27550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,192.39,1083.4,APC
Treat knee dislocation,27550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,192.39,1083.4,Radiology
Treat knee dislocation,27550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,192.39,1083.4,APC
Treat knee dislocation,27550,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,192.39,1083.4,APC
Treat knee dislocation,27552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3685.16,,,,,,,fee schedule,1591.86,7062.54,
Treat knee dislocation,27552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2953.98,,,,,,,fee schedule,1591.86,7062.54,
Treat knee dislocation,27552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3226.95,,,,,,,fee schedule,1591.86,7062.54,
Treat knee dislocation,27552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3392.69,,,,,,,fee schedule,1591.86,7062.54,
Treat knee dislocation,27552,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Treat knee dislocation,27552,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Treat knee dislocation,27552,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Treat knee dislocation,27552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Treat knee dislocation,27552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Treat knee dislocation,27552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Treat knee dislocation,27552,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Treat knee dislocation,27556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Treat knee dislocation,27556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Treat knee dislocation,27556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Treat knee dislocation,27556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Treat knee dislocation,27556,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Treat knee dislocation,27556,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Treat knee dislocation,27556,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Treat knee dislocation,27556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Treat knee dislocation,27556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Treat knee dislocation,27556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Treat knee dislocation,27556,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Treat knee dislocation,27557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Treat knee dislocation,27557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Treat knee dislocation,27557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Treat knee dislocation,27557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Treat knee dislocation,27557,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Treat knee dislocation,27557,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Treat knee dislocation,27557,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Treat knee dislocation,27557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Treat knee dislocation,27557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Treat knee dislocation,27557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Treat knee dislocation,27557,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Treat knee dislocation,27558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Treat knee dislocation,27558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Treat knee dislocation,27558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Treat knee dislocation,27558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Treat knee dislocation,27558,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Treat knee dislocation,27558,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Treat knee dislocation,27558,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Treat knee dislocation,27558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Treat knee dislocation,27558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Treat knee dislocation,27558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Treat knee dislocation,27558,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Treat kneecap dislocation,27560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,613.32,,,,,,,fee schedule,244.19,1083.4,
Treat kneecap dislocation,27560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,491.63,,,,,,,fee schedule,244.19,1083.4,
Treat kneecap dislocation,27560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,537.06,,,,,,,fee schedule,244.19,1083.4,
Treat kneecap dislocation,27560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,564.64,,,,,,,fee schedule,244.19,1083.4,
Treat kneecap dislocation,27560,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treat kneecap dislocation,27560,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treat kneecap dislocation,27560,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treat kneecap dislocation,27560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treat kneecap dislocation,27560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treat kneecap dislocation,27560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treat kneecap dislocation,27560,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treat kneecap dislocation,27562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3685.16,,,,,,,fee schedule,244.19,3685.16,
Treat kneecap dislocation,27562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2953.98,,,,,,,fee schedule,244.19,3685.16,
Treat kneecap dislocation,27562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3226.95,,,,,,,fee schedule,244.19,3685.16,
Treat kneecap dislocation,27562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3392.69,,,,,,,fee schedule,244.19,3685.16,
Treat kneecap dislocation,27562,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,3685.16,APC 378
Treat kneecap dislocation,27562,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,3685.16,APC
Treat kneecap dislocation,27562,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,3685.16,APC
Treat kneecap dislocation,27562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,3685.16,APC
Treat kneecap dislocation,27562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,3685.16,Radiology
Treat kneecap dislocation,27562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,3685.16,APC
Treat kneecap dislocation,27562,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,3685.16,APC
Treat kneecap dislocation,27566,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10259.79,,,,,,,fee schedule,7183.42,31870.39,
Treat kneecap dislocation,27566,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8224.12,,,,,,,fee schedule,7183.42,31870.39,
Treat kneecap dislocation,27566,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8984.1,,,,,,,fee schedule,7183.42,31870.39,
Treat kneecap dislocation,27566,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9445.52,,,,,,,fee schedule,7183.42,31870.39,
Treat kneecap dislocation,27566,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Treat kneecap dislocation,27566,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Treat kneecap dislocation,27566,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Treat kneecap dislocation,27566,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Treat kneecap dislocation,27566,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Treat kneecap dislocation,27566,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Treat kneecap dislocation,27566,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Fixation of knee joint,27570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2385.27,,,,,,,fee schedule,1591.86,7062.54,
Fixation of knee joint,27570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1912.01,,,,,,,fee schedule,1591.86,7062.54,
Fixation of knee joint,27570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2088.69,,,,,,,fee schedule,1591.86,7062.54,
Fixation of knee joint,27570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2195.97,,,,,,,fee schedule,1591.86,7062.54,
Fixation of knee joint,27570,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Fixation of knee joint,27570,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Fixation of knee joint,27570,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Fixation of knee joint,27570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Fixation of knee joint,27570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Fixation of knee joint,27570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Fixation of knee joint,27570,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Fusion of knee,27580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46549.79,,,,,,,fee schedule,12709.88,56389.43,
Fusion of knee,27580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37313.72,,,,,,,fee schedule,12709.88,56389.43,
Fusion of knee,27580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40761.86,,,,,,,fee schedule,12709.88,56389.43,
Fusion of knee,27580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42855.36,,,,,,,fee schedule,12709.88,56389.43,
Fusion of knee,27580,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,12709.88,56389.43,APC 378
Fusion of knee,27580,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,12709.88,56389.43,APC
Fusion of knee,27580,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,12709.88,56389.43,APC
Fusion of knee,27580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,12709.88,56389.43,APC
Fusion of knee,27580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,12709.88,56389.43,Radiology
Fusion of knee,27580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,12709.88,56389.43,APC
Fusion of knee,27580,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,12709.88,56389.43,APC
Amputate leg at thigh,27590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59981.53,,,,,,,fee schedule,3239.17,59981.53,
Amputate leg at thigh,27590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48080.43,,,,,,,fee schedule,3239.17,59981.53,
Amputate leg at thigh,27590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52523.51,,,,,,,fee schedule,3239.17,59981.53,
Amputate leg at thigh,27590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55221.09,,,,,,,fee schedule,3239.17,59981.53,
Amputate leg at thigh,27590,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,59981.53,APC 378
Amputate leg at thigh,27590,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,59981.53,APC
Amputate leg at thigh,27590,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,59981.53,APC
Amputate leg at thigh,27590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,59981.53,APC
Amputate leg at thigh,27590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,59981.53,Radiology
Amputate leg at thigh,27590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,59981.53,APC
Amputate leg at thigh,27590,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,59981.53,APC
Amputate leg at thigh,27591,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59981.53,,,,,,,fee schedule,3239.17,59981.53,
Amputate leg at thigh,27591,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48080.43,,,,,,,fee schedule,3239.17,59981.53,
Amputate leg at thigh,27591,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52523.51,,,,,,,fee schedule,3239.17,59981.53,
Amputate leg at thigh,27591,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55221.09,,,,,,,fee schedule,3239.17,59981.53,
Amputate leg at thigh,27591,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,59981.53,APC 378
Amputate leg at thigh,27591,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,59981.53,APC
Amputate leg at thigh,27591,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,59981.53,APC
Amputate leg at thigh,27591,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,59981.53,APC
Amputate leg at thigh,27591,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,59981.53,Radiology
Amputate leg at thigh,27591,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,59981.53,APC
Amputate leg at thigh,27591,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,59981.53,APC
Amputate leg at thigh,27592,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59981.53,,,,,,,fee schedule,3239.17,59981.53,
Amputate leg at thigh,27592,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48080.43,,,,,,,fee schedule,3239.17,59981.53,
Amputate leg at thigh,27592,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52523.51,,,,,,,fee schedule,3239.17,59981.53,
Amputate leg at thigh,27592,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55221.09,,,,,,,fee schedule,3239.17,59981.53,
Amputate leg at thigh,27592,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,59981.53,APC 378
Amputate leg at thigh,27592,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,59981.53,APC
Amputate leg at thigh,27592,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,59981.53,APC
Amputate leg at thigh,27592,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,59981.53,APC
Amputate leg at thigh,27592,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,59981.53,Radiology
Amputate leg at thigh,27592,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,59981.53,APC
Amputate leg at thigh,27592,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,59981.53,APC
Amputation follow-up surgery,27594,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,3239.17,14371.12,
Amputation follow-up surgery,27594,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,3239.17,14371.12,
Amputation follow-up surgery,27594,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,3239.17,14371.12,
Amputation follow-up surgery,27594,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,3239.17,14371.12,
Amputation follow-up surgery,27594,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Amputation follow-up surgery,27594,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Amputation follow-up surgery,27594,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Amputation follow-up surgery,27594,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Amputation follow-up surgery,27594,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Amputation follow-up surgery,27594,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Amputation follow-up surgery,27594,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Amputation follow-up surgery,27596,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,3239.17,23681.51,
Amputation follow-up surgery,27596,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,3239.17,23681.51,
Amputation follow-up surgery,27596,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,3239.17,23681.51,
Amputation follow-up surgery,27596,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,3239.17,23681.51,
Amputation follow-up surgery,27596,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,23681.51,APC 378
Amputation follow-up surgery,27596,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,23681.51,APC
Amputation follow-up surgery,27596,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,23681.51,APC
Amputation follow-up surgery,27596,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,23681.51,APC
Amputation follow-up surgery,27596,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,23681.51,Radiology
Amputation follow-up surgery,27596,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,23681.51,APC
Amputation follow-up surgery,27596,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,23681.51,APC
Amputate lower leg at knee,27598,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46549.79,,,,,,,fee schedule,3239.17,46549.79,
Amputate lower leg at knee,27598,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37313.72,,,,,,,fee schedule,3239.17,46549.79,
Amputate lower leg at knee,27598,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40761.86,,,,,,,fee schedule,3239.17,46549.79,
Amputate lower leg at knee,27598,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42855.36,,,,,,,fee schedule,3239.17,46549.79,
Amputate lower leg at knee,27598,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,46549.79,APC 378
Amputate lower leg at knee,27598,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,46549.79,APC
Amputate lower leg at knee,27598,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,46549.79,APC
Amputate lower leg at knee,27598,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,46549.79,APC
Amputate lower leg at knee,27598,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,46549.79,Radiology
Amputate lower leg at knee,27598,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,46549.79,APC
Amputate lower leg at knee,27598,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,46549.79,APC
Leg surgery procedure,27599,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9269.11,,,,,,,fee schedule,244.19,9269.11,
Leg surgery procedure,27599,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7430,,,,,,,fee schedule,244.19,9269.11,
Leg surgery procedure,27599,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8116.61,,,,,,,fee schedule,244.19,9269.11,
Leg surgery procedure,27599,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8533.47,,,,,,,fee schedule,244.19,9269.11,
Leg surgery procedure,27599,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,9269.11,APC 378
Leg surgery procedure,27599,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,9269.11,APC
Leg surgery procedure,27599,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,9269.11,APC
Leg surgery procedure,27599,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,9269.11,APC
Leg surgery procedure,27599,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,9269.11,Radiology
Leg surgery procedure,27599,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,9269.11,APC
Leg surgery procedure,27599,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,9269.11,APC
Decompression of lower leg,27600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10205.34,,,,,,,fee schedule,3239.17,14371.12,
Decompression of lower leg,27600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8180.47,,,,,,,fee schedule,3239.17,14371.12,
Decompression of lower leg,27600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8936.43,,,,,,,fee schedule,3239.17,14371.12,
Decompression of lower leg,27600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9395.4,,,,,,,fee schedule,3239.17,14371.12,
Decompression of lower leg,27600,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Decompression of lower leg,27600,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Decompression of lower leg,27600,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Decompression of lower leg,27600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Decompression of lower leg,27600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Decompression of lower leg,27600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Decompression of lower leg,27600,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Decompression of lower leg,27601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,3239.17,14371.12,
Decompression of lower leg,27601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,3239.17,14371.12,
Decompression of lower leg,27601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,3239.17,14371.12,
Decompression of lower leg,27601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,3239.17,14371.12,
Decompression of lower leg,27601,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Decompression of lower leg,27601,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Decompression of lower leg,27601,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Decompression of lower leg,27601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Decompression of lower leg,27601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Decompression of lower leg,27601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Decompression of lower leg,27601,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Decompression of lower leg,27602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11609.69,,,,,,,fee schedule,3239.17,14371.12,
Decompression of lower leg,27602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9306.18,,,,,,,fee schedule,3239.17,14371.12,
Decompression of lower leg,27602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10166.16,,,,,,,fee schedule,3239.17,14371.12,
Decompression of lower leg,27602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10688.29,,,,,,,fee schedule,3239.17,14371.12,
Decompression of lower leg,27602,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Decompression of lower leg,27602,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Decompression of lower leg,27602,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Decompression of lower leg,27602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Decompression of lower leg,27602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Decompression of lower leg,27602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Decompression of lower leg,27602,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Drain lower leg lesion,27603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4572.14,,,,,,,fee schedule,2875.57,12757.95,
Drain lower leg lesion,27603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3664.97,,,,,,,fee schedule,2875.57,12757.95,
Drain lower leg lesion,27603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4003.64,,,,,,,fee schedule,2875.57,12757.95,
Drain lower leg lesion,27603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4209.27,,,,,,,fee schedule,2875.57,12757.95,
Drain lower leg lesion,27603,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Drain lower leg lesion,27603,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Drain lower leg lesion,27603,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Drain lower leg lesion,27603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Drain lower leg lesion,27603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Drain lower leg lesion,27603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Drain lower leg lesion,27603,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Drain lower leg bursa,27604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,3239.17,14371.12,
Drain lower leg bursa,27604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,3239.17,14371.12,
Drain lower leg bursa,27604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,3239.17,14371.12,
Drain lower leg bursa,27604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,3239.17,14371.12,
Drain lower leg bursa,27604,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Drain lower leg bursa,27604,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Drain lower leg bursa,27604,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Drain lower leg bursa,27604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Drain lower leg bursa,27604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Drain lower leg bursa,27604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Drain lower leg bursa,27604,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Incision of achilles tendon,27605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5198.26,,,,,,,fee schedule,1591.86,7062.54,
Incision of achilles tendon,27605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4166.86,,,,,,,fee schedule,1591.86,7062.54,
Incision of achilles tendon,27605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4551.91,,,,,,,fee schedule,1591.86,7062.54,
Incision of achilles tendon,27605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4785.7,,,,,,,fee schedule,1591.86,7062.54,
Incision of achilles tendon,27605,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Incision of achilles tendon,27605,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Incision of achilles tendon,27605,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Incision of achilles tendon,27605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Incision of achilles tendon,27605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Incision of achilles tendon,27605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Incision of achilles tendon,27605,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Incision of achilles tendon,27606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3245.74,,,,,,,fee schedule,2601.74,14371.12,
Incision of achilles tendon,27606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2601.74,,,,,,,fee schedule,2601.74,14371.12,
Incision of achilles tendon,27606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2842.17,,,,,,,fee schedule,2601.74,14371.12,
Incision of achilles tendon,27606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2988.14,,,,,,,fee schedule,2601.74,14371.12,
Incision of achilles tendon,27606,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,2601.74,14371.12,APC 378
Incision of achilles tendon,27606,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,2601.74,14371.12,APC
Incision of achilles tendon,27606,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,2601.74,14371.12,APC
Incision of achilles tendon,27606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,2601.74,14371.12,APC
Incision of achilles tendon,27606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,2601.74,14371.12,Radiology
Incision of achilles tendon,27606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,2601.74,14371.12,APC
Incision of achilles tendon,27606,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,2601.74,14371.12,APC
Treat lower leg bone lesion,27607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,3239.17,14371.12,
Treat lower leg bone lesion,27607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,3239.17,14371.12,
Treat lower leg bone lesion,27607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,3239.17,14371.12,
Treat lower leg bone lesion,27607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,3239.17,14371.12,
Treat lower leg bone lesion,27607,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Treat lower leg bone lesion,27607,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Treat lower leg bone lesion,27607,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Treat lower leg bone lesion,27607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Treat lower leg bone lesion,27607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Treat lower leg bone lesion,27607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Treat lower leg bone lesion,27607,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Explore/treat ankle joint,27610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,3239.17,14371.12,
Explore/treat ankle joint,27610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,3239.17,14371.12,
Explore/treat ankle joint,27610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,3239.17,14371.12,
Explore/treat ankle joint,27610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,3239.17,14371.12,
Explore/treat ankle joint,27610,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Explore/treat ankle joint,27610,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Explore/treat ankle joint,27610,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Explore/treat ankle joint,27610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Explore/treat ankle joint,27610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Explore/treat ankle joint,27610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Explore/treat ankle joint,27610,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Exploration of ankle joint,27612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,3239.17,14371.12,
Exploration of ankle joint,27612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,3239.17,14371.12,
Exploration of ankle joint,27612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,3239.17,14371.12,
Exploration of ankle joint,27612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,3239.17,14371.12,
Exploration of ankle joint,27612,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Exploration of ankle joint,27612,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Exploration of ankle joint,27612,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Exploration of ankle joint,27612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Exploration of ankle joint,27612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Exploration of ankle joint,27612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Exploration of ankle joint,27612,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Biopsy lower leg soft tissue,27613,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2167.57,,,,,,,fee schedule,1635.03,7254.06,
Biopsy lower leg soft tissue,27613,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1737.49,,,,,,,fee schedule,1635.03,7254.06,
Biopsy lower leg soft tissue,27613,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1898.05,,,,,,,fee schedule,1635.03,7254.06,
Biopsy lower leg soft tissue,27613,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1995.54,,,,,,,fee schedule,1635.03,7254.06,
Biopsy lower leg soft tissue,27613,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,7254.06,APC 378
Biopsy lower leg soft tissue,27613,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,7254.06,APC
Biopsy lower leg soft tissue,27613,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,7254.06,APC
Biopsy lower leg soft tissue,27613,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,7254.06,APC
Biopsy lower leg soft tissue,27613,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,7254.06,Radiology
Biopsy lower leg soft tissue,27613,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,7254.06,APC
Biopsy lower leg soft tissue,27613,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,7254.06,APC
Biopsy lower leg soft tissue,27614,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5268.49,,,,,,,fee schedule,2875.57,12757.95,
Biopsy lower leg soft tissue,27614,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4223.15,,,,,,,fee schedule,2875.57,12757.95,
Biopsy lower leg soft tissue,27614,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4613.41,,,,,,,fee schedule,2875.57,12757.95,
Biopsy lower leg soft tissue,27614,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4850.35,,,,,,,fee schedule,2875.57,12757.95,
Biopsy lower leg soft tissue,27614,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Biopsy lower leg soft tissue,27614,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Biopsy lower leg soft tissue,27614,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Biopsy lower leg soft tissue,27614,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Biopsy lower leg soft tissue,27614,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Biopsy lower leg soft tissue,27614,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Biopsy lower leg soft tissue,27614,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Resect leg/ankle tum < 5 cm,27615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,2875.57,12757.95,
Resect leg/ankle tum < 5 cm,27615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,2875.57,12757.95,
Resect leg/ankle tum < 5 cm,27615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,2875.57,12757.95,
Resect leg/ankle tum < 5 cm,27615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,2875.57,12757.95,
Resect leg/ankle tum < 5 cm,27615,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Resect leg/ankle tum < 5 cm,27615,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Resect leg/ankle tum < 5 cm,27615,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Resect leg/ankle tum < 5 cm,27615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Resect leg/ankle tum < 5 cm,27615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Resect leg/ankle tum < 5 cm,27615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Resect leg/ankle tum < 5 cm,27615,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Resect leg/ankle tum 5 cm/>,27616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6177.24,,,,,,,fee schedule,2875.57,12757.95,
Resect leg/ankle tum 5 cm/>,27616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4951.6,,,,,,,fee schedule,2875.57,12757.95,
Resect leg/ankle tum 5 cm/>,27616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5409.17,,,,,,,fee schedule,2875.57,12757.95,
Resect leg/ankle tum 5 cm/>,27616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5686.98,,,,,,,fee schedule,2875.57,12757.95,
Resect leg/ankle tum 5 cm/>,27616,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Resect leg/ankle tum 5 cm/>,27616,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Resect leg/ankle tum 5 cm/>,27616,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Resect leg/ankle tum 5 cm/>,27616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Resect leg/ankle tum 5 cm/>,27616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Resect leg/ankle tum 5 cm/>,27616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Resect leg/ankle tum 5 cm/>,27616,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Exc leg/ankle tum < 3 cm,27618,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6721.57,,,,,,,fee schedule,1635.03,7254.06,
Exc leg/ankle tum < 3 cm,27618,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5387.93,,,,,,,fee schedule,1635.03,7254.06,
Exc leg/ankle tum < 3 cm,27618,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5885.82,,,,,,,fee schedule,1635.03,7254.06,
Exc leg/ankle tum < 3 cm,27618,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6188.11,,,,,,,fee schedule,1635.03,7254.06,
Exc leg/ankle tum < 3 cm,27618,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,7254.06,APC 378
Exc leg/ankle tum < 3 cm,27618,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,7254.06,APC
Exc leg/ankle tum < 3 cm,27618,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,7254.06,APC
Exc leg/ankle tum < 3 cm,27618,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,7254.06,APC
Exc leg/ankle tum < 3 cm,27618,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,7254.06,Radiology
Exc leg/ankle tum < 3 cm,27618,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,7254.06,APC
Exc leg/ankle tum < 3 cm,27618,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,7254.06,APC
Exc leg/ankle tum deep <5 cm,27619,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5268.49,,,,,,,fee schedule,2875.57,12757.95,
Exc leg/ankle tum deep <5 cm,27619,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4223.15,,,,,,,fee schedule,2875.57,12757.95,
Exc leg/ankle tum deep <5 cm,27619,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4613.41,,,,,,,fee schedule,2875.57,12757.95,
Exc leg/ankle tum deep <5 cm,27619,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4850.35,,,,,,,fee schedule,2875.57,12757.95,
Exc leg/ankle tum deep <5 cm,27619,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Exc leg/ankle tum deep <5 cm,27619,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Exc leg/ankle tum deep <5 cm,27619,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Exc leg/ankle tum deep <5 cm,27619,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Exc leg/ankle tum deep <5 cm,27619,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Exc leg/ankle tum deep <5 cm,27619,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Exc leg/ankle tum deep <5 cm,27619,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Explore/treat ankle joint,27620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,3239.17,14371.12,
Explore/treat ankle joint,27620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,3239.17,14371.12,
Explore/treat ankle joint,27620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,3239.17,14371.12,
Explore/treat ankle joint,27620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,3239.17,14371.12,
Explore/treat ankle joint,27620,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Explore/treat ankle joint,27620,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Explore/treat ankle joint,27620,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Explore/treat ankle joint,27620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Explore/treat ankle joint,27620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Explore/treat ankle joint,27620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Explore/treat ankle joint,27620,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Remove ankle joint lining,27625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5506.86,,,,,,,fee schedule,3239.17,14371.12,
Remove ankle joint lining,27625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4414.23,,,,,,,fee schedule,3239.17,14371.12,
Remove ankle joint lining,27625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4822.14,,,,,,,fee schedule,3239.17,14371.12,
Remove ankle joint lining,27625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5069.8,,,,,,,fee schedule,3239.17,14371.12,
Remove ankle joint lining,27625,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Remove ankle joint lining,27625,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Remove ankle joint lining,27625,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Remove ankle joint lining,27625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Remove ankle joint lining,27625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Remove ankle joint lining,27625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Remove ankle joint lining,27625,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Remove ankle joint lining,27626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,3239.17,14371.12,
Remove ankle joint lining,27626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,3239.17,14371.12,
Remove ankle joint lining,27626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,3239.17,14371.12,
Remove ankle joint lining,27626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,3239.17,14371.12,
Remove ankle joint lining,27626,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Remove ankle joint lining,27626,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Remove ankle joint lining,27626,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Remove ankle joint lining,27626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Remove ankle joint lining,27626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Remove ankle joint lining,27626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Remove ankle joint lining,27626,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of tendon lesion,27630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2552.61,,,,,,,fee schedule,2046.14,14371.12,
Removal of tendon lesion,27630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2046.14,,,,,,,fee schedule,2046.14,14371.12,
Removal of tendon lesion,27630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2235.23,,,,,,,fee schedule,2046.14,14371.12,
Removal of tendon lesion,27630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2350.03,,,,,,,fee schedule,2046.14,14371.12,
Removal of tendon lesion,27630,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,2046.14,14371.12,APC 378
Removal of tendon lesion,27630,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,2046.14,14371.12,APC
Removal of tendon lesion,27630,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,2046.14,14371.12,APC
Removal of tendon lesion,27630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,2046.14,14371.12,APC
Removal of tendon lesion,27630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,2046.14,14371.12,Radiology
Removal of tendon lesion,27630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,2046.14,14371.12,APC
Removal of tendon lesion,27630,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,2046.14,14371.12,APC
Exc leg/ankle les sc 3 cm/>,27632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3307.78,,,,,,,fee schedule,2651.47,12757.95,
Exc leg/ankle les sc 3 cm/>,27632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2651.47,,,,,,,fee schedule,2651.47,12757.95,
Exc leg/ankle les sc 3 cm/>,27632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2896.49,,,,,,,fee schedule,2651.47,12757.95,
Exc leg/ankle les sc 3 cm/>,27632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3045.26,,,,,,,fee schedule,2651.47,12757.95,
Exc leg/ankle les sc 3 cm/>,27632,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2651.47,12757.95,APC 378
Exc leg/ankle les sc 3 cm/>,27632,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2651.47,12757.95,APC
Exc leg/ankle les sc 3 cm/>,27632,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2651.47,12757.95,APC
Exc leg/ankle les sc 3 cm/>,27632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2651.47,12757.95,APC
Exc leg/ankle les sc 3 cm/>,27632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2651.47,12757.95,Radiology
Exc leg/ankle les sc 3 cm/>,27632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2651.47,12757.95,APC
Exc leg/ankle les sc 3 cm/>,27632,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2651.47,12757.95,APC
Exc leg/ankle tum dep 5 cm/>,27634,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6177.24,,,,,,,fee schedule,2875.57,12757.95,
Exc leg/ankle tum dep 5 cm/>,27634,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4951.6,,,,,,,fee schedule,2875.57,12757.95,
Exc leg/ankle tum dep 5 cm/>,27634,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5409.17,,,,,,,fee schedule,2875.57,12757.95,
Exc leg/ankle tum dep 5 cm/>,27634,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5686.98,,,,,,,fee schedule,2875.57,12757.95,
Exc leg/ankle tum dep 5 cm/>,27634,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Exc leg/ankle tum dep 5 cm/>,27634,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Exc leg/ankle tum dep 5 cm/>,27634,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Exc leg/ankle tum dep 5 cm/>,27634,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Exc leg/ankle tum dep 5 cm/>,27634,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Exc leg/ankle tum dep 5 cm/>,27634,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Exc leg/ankle tum dep 5 cm/>,27634,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Remove lower leg bone lesion,27635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5841.87,,,,,,,fee schedule,3239.17,14371.12,
Remove lower leg bone lesion,27635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4682.77,,,,,,,fee schedule,3239.17,14371.12,
Remove lower leg bone lesion,27635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5115.5,,,,,,,fee schedule,3239.17,14371.12,
Remove lower leg bone lesion,27635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5378.23,,,,,,,fee schedule,3239.17,14371.12,
Remove lower leg bone lesion,27635,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Remove lower leg bone lesion,27635,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Remove lower leg bone lesion,27635,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Remove lower leg bone lesion,27635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Remove lower leg bone lesion,27635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Remove lower leg bone lesion,27635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Remove lower leg bone lesion,27635,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Remove/graft leg bone lesion,27637,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,5839.66,31870.39,
Remove/graft leg bone lesion,27637,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,5839.66,31870.39,
Remove/graft leg bone lesion,27637,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,5839.66,31870.39,
Remove/graft leg bone lesion,27637,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,5839.66,31870.39,
Remove/graft leg bone lesion,27637,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5839.66,31870.39,APC 378
Remove/graft leg bone lesion,27637,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5839.66,31870.39,APC
Remove/graft leg bone lesion,27637,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5839.66,31870.39,APC
Remove/graft leg bone lesion,27637,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5839.66,31870.39,APC
Remove/graft leg bone lesion,27637,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5839.66,31870.39,Radiology
Remove/graft leg bone lesion,27637,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5839.66,31870.39,APC
Remove/graft leg bone lesion,27637,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5839.66,31870.39,APC
Remove/graft leg bone lesion,27638,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,5839.66,31870.39,
Remove/graft leg bone lesion,27638,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,5839.66,31870.39,
Remove/graft leg bone lesion,27638,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,5839.66,31870.39,
Remove/graft leg bone lesion,27638,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,5839.66,31870.39,
Remove/graft leg bone lesion,27638,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5839.66,31870.39,APC 378
Remove/graft leg bone lesion,27638,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5839.66,31870.39,APC
Remove/graft leg bone lesion,27638,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5839.66,31870.39,APC
Remove/graft leg bone lesion,27638,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5839.66,31870.39,APC
Remove/graft leg bone lesion,27638,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5839.66,31870.39,Radiology
Remove/graft leg bone lesion,27638,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5839.66,31870.39,APC
Remove/graft leg bone lesion,27638,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5839.66,31870.39,APC
Partial removal of tibia,27640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3176.77,,,,,,,fee schedule,2546.46,14371.12,
Partial removal of tibia,27640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2546.46,,,,,,,fee schedule,2546.46,14371.12,
Partial removal of tibia,27640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2781.77,,,,,,,fee schedule,2546.46,14371.12,
Partial removal of tibia,27640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2924.64,,,,,,,fee schedule,2546.46,14371.12,
Partial removal of tibia,27640,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,2546.46,14371.12,APC 378
Partial removal of tibia,27640,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,2546.46,14371.12,APC
Partial removal of tibia,27640,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,2546.46,14371.12,APC
Partial removal of tibia,27640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,2546.46,14371.12,APC
Partial removal of tibia,27640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,2546.46,14371.12,Radiology
Partial removal of tibia,27640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,2546.46,14371.12,APC
Partial removal of tibia,27640,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,2546.46,14371.12,APC
Partial removal of fibula,27641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,3239.17,14371.12,
Partial removal of fibula,27641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,3239.17,14371.12,
Partial removal of fibula,27641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,3239.17,14371.12,
Partial removal of fibula,27641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,3239.17,14371.12,
Partial removal of fibula,27641,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Partial removal of fibula,27641,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Partial removal of fibula,27641,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Partial removal of fibula,27641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Partial removal of fibula,27641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Partial removal of fibula,27641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Partial removal of fibula,27641,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Resect tibia tumor,27645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,3239.17,23681.51,
Resect tibia tumor,27645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,3239.17,23681.51,
Resect tibia tumor,27645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,3239.17,23681.51,
Resect tibia tumor,27645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,3239.17,23681.51,
Resect tibia tumor,27645,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,23681.51,APC 378
Resect tibia tumor,27645,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,23681.51,APC
Resect tibia tumor,27645,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,23681.51,APC
Resect tibia tumor,27645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,23681.51,APC
Resect tibia tumor,27645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,23681.51,Radiology
Resect tibia tumor,27645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,23681.51,APC
Resect tibia tumor,27645,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,23681.51,APC
Resect fibula tumor,27646,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,3239.17,23681.51,
Resect fibula tumor,27646,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,3239.17,23681.51,
Resect fibula tumor,27646,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,3239.17,23681.51,
Resect fibula tumor,27646,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,3239.17,23681.51,
Resect fibula tumor,27646,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,23681.51,APC 378
Resect fibula tumor,27646,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,23681.51,APC
Resect fibula tumor,27646,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,23681.51,APC
Resect fibula tumor,27646,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,23681.51,APC
Resect fibula tumor,27646,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,23681.51,Radiology
Resect fibula tumor,27646,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,23681.51,APC
Resect fibula tumor,27646,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,23681.51,APC
Resect talus/calcaneus tum,27647,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10728.02,,,,,,,fee schedule,3239.17,14371.12,
Resect talus/calcaneus tum,27647,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8599.44,,,,,,,fee schedule,3239.17,14371.12,
Resect talus/calcaneus tum,27647,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9394.11,,,,,,,fee schedule,3239.17,14371.12,
Resect talus/calcaneus tum,27647,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9876.59,,,,,,,fee schedule,3239.17,14371.12,
Resect talus/calcaneus tum,27647,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Resect talus/calcaneus tum,27647,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Resect talus/calcaneus tum,27647,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Resect talus/calcaneus tum,27647,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Resect talus/calcaneus tum,27647,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Resect talus/calcaneus tum,27647,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Resect talus/calcaneus tum,27647,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Repair achilles tendon,27650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8653.78,,,,,,,fee schedule,6936.76,31870.39,
Repair achilles tendon,27650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6936.76,,,,,,,fee schedule,6936.76,31870.39,
Repair achilles tendon,27650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7577.78,,,,,,,fee schedule,6936.76,31870.39,
Repair achilles tendon,27650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7966.98,,,,,,,fee schedule,6936.76,31870.39,
Repair achilles tendon,27650,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,6936.76,31870.39,APC 378
Repair achilles tendon,27650,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,6936.76,31870.39,APC
Repair achilles tendon,27650,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,6936.76,31870.39,APC
Repair achilles tendon,27650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,6936.76,31870.39,APC
Repair achilles tendon,27650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,6936.76,31870.39,Radiology
Repair achilles tendon,27650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,6936.76,31870.39,APC
Repair achilles tendon,27650,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,6936.76,31870.39,APC
Repair/graft achilles tendon,27652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10205.34,,,,,,,fee schedule,7183.42,31870.39,
Repair/graft achilles tendon,27652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8180.47,,,,,,,fee schedule,7183.42,31870.39,
Repair/graft achilles tendon,27652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8936.43,,,,,,,fee schedule,7183.42,31870.39,
Repair/graft achilles tendon,27652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9395.4,,,,,,,fee schedule,7183.42,31870.39,
Repair/graft achilles tendon,27652,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Repair/graft achilles tendon,27652,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Repair/graft achilles tendon,27652,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Repair/graft achilles tendon,27652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Repair/graft achilles tendon,27652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Repair/graft achilles tendon,27652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Repair/graft achilles tendon,27652,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Repair of achilles tendon,27654,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5570.79,,,,,,,fee schedule,4465.47,31870.39,
Repair of achilles tendon,27654,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4465.47,,,,,,,fee schedule,4465.47,31870.39,
Repair of achilles tendon,27654,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4878.12,,,,,,,fee schedule,4465.47,31870.39,
Repair of achilles tendon,27654,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5128.66,,,,,,,fee schedule,4465.47,31870.39,
Repair of achilles tendon,27654,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,4465.47,31870.39,APC 378
Repair of achilles tendon,27654,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,4465.47,31870.39,APC
Repair of achilles tendon,27654,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,4465.47,31870.39,APC
Repair of achilles tendon,27654,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,4465.47,31870.39,APC
Repair of achilles tendon,27654,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,4465.47,31870.39,Radiology
Repair of achilles tendon,27654,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,4465.47,31870.39,APC
Repair of achilles tendon,27654,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,4465.47,31870.39,APC
Repair leg fascia defect,27656,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,3239.17,14371.12,
Repair leg fascia defect,27656,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,3239.17,14371.12,
Repair leg fascia defect,27656,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,3239.17,14371.12,
Repair leg fascia defect,27656,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,3239.17,14371.12,
Repair leg fascia defect,27656,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Repair leg fascia defect,27656,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Repair leg fascia defect,27656,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Repair leg fascia defect,27656,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Repair leg fascia defect,27656,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Repair leg fascia defect,27656,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Repair leg fascia defect,27656,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Repair of leg tendon each,27658,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4465.79,,,,,,,fee schedule,3239.17,14371.12,
Repair of leg tendon each,27658,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3579.72,,,,,,,fee schedule,3239.17,14371.12,
Repair of leg tendon each,27658,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3910.52,,,,,,,fee schedule,3239.17,14371.12,
Repair of leg tendon each,27658,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4111.36,,,,,,,fee schedule,3239.17,14371.12,
Repair of leg tendon each,27658,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Repair of leg tendon each,27658,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Repair of leg tendon each,27658,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Repair of leg tendon each,27658,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Repair of leg tendon each,27658,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Repair of leg tendon each,27658,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Repair of leg tendon each,27658,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Repair of leg tendon each,27659,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,4254.97,31870.39,
Repair of leg tendon each,27659,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,4254.97,31870.39,
Repair of leg tendon each,27659,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,4254.97,31870.39,
Repair of leg tendon each,27659,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,4254.97,31870.39,
Repair of leg tendon each,27659,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,4254.97,31870.39,APC 378
Repair of leg tendon each,27659,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,4254.97,31870.39,APC
Repair of leg tendon each,27659,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,4254.97,31870.39,APC
Repair of leg tendon each,27659,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,4254.97,31870.39,APC
Repair of leg tendon each,27659,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,4254.97,31870.39,Radiology
Repair of leg tendon each,27659,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,4254.97,31870.39,APC
Repair of leg tendon each,27659,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,4254.97,31870.39,APC
Repair of leg tendon each,27664,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,4254.97,31870.39,
Repair of leg tendon each,27664,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,4254.97,31870.39,
Repair of leg tendon each,27664,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,4254.97,31870.39,
Repair of leg tendon each,27664,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,4254.97,31870.39,
Repair of leg tendon each,27664,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,4254.97,31870.39,APC 378
Repair of leg tendon each,27664,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,4254.97,31870.39,APC
Repair of leg tendon each,27664,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,4254.97,31870.39,APC
Repair of leg tendon each,27664,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,4254.97,31870.39,APC
Repair of leg tendon each,27664,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,4254.97,31870.39,Radiology
Repair of leg tendon each,27664,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,4254.97,31870.39,APC
Repair of leg tendon each,27664,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,4254.97,31870.39,APC
Repair of leg tendon each,27665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3360.79,,,,,,,fee schedule,2693.96,31870.39,
Repair of leg tendon each,27665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2693.96,,,,,,,fee schedule,2693.96,31870.39,
Repair of leg tendon each,27665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2942.91,,,,,,,fee schedule,2693.96,31870.39,
Repair of leg tendon each,27665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3094.06,,,,,,,fee schedule,2693.96,31870.39,
Repair of leg tendon each,27665,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,2693.96,31870.39,APC 378
Repair of leg tendon each,27665,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,2693.96,31870.39,APC
Repair of leg tendon each,27665,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,2693.96,31870.39,APC
Repair of leg tendon each,27665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,2693.96,31870.39,APC
Repair of leg tendon each,27665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,2693.96,31870.39,Radiology
Repair of leg tendon each,27665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,2693.96,31870.39,APC
Repair of leg tendon each,27665,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,2693.96,31870.39,APC
Repair lower leg tendons,27675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,3239.17,14371.12,
Repair lower leg tendons,27675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,3239.17,14371.12,
Repair lower leg tendons,27675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,3239.17,14371.12,
Repair lower leg tendons,27675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,3239.17,14371.12,
Repair lower leg tendons,27675,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Repair lower leg tendons,27675,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Repair lower leg tendons,27675,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Repair lower leg tendons,27675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Repair lower leg tendons,27675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Repair lower leg tendons,27675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Repair lower leg tendons,27675,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Repair lower leg tendons,27676,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5233.25,,,,,,,fee schedule,4194.9,31870.39,
Repair lower leg tendons,27676,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4194.9,,,,,,,fee schedule,4194.9,31870.39,
Repair lower leg tendons,27676,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4582.55,,,,,,,fee schedule,4194.9,31870.39,
Repair lower leg tendons,27676,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4817.91,,,,,,,fee schedule,4194.9,31870.39,
Repair lower leg tendons,27676,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,4194.9,31870.39,APC 378
Repair lower leg tendons,27676,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,4194.9,31870.39,APC
Repair lower leg tendons,27676,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,4194.9,31870.39,APC
Repair lower leg tendons,27676,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,4194.9,31870.39,APC
Repair lower leg tendons,27676,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,4194.9,31870.39,Radiology
Repair lower leg tendons,27676,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,4194.9,31870.39,APC
Repair lower leg tendons,27676,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,4194.9,31870.39,APC
Release of lower leg tendon,27680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5102.67,,,,,,,fee schedule,3239.17,14371.12,
Release of lower leg tendon,27680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4090.24,,,,,,,fee schedule,3239.17,14371.12,
Release of lower leg tendon,27680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4468.21,,,,,,,fee schedule,3239.17,14371.12,
Release of lower leg tendon,27680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4697.7,,,,,,,fee schedule,3239.17,14371.12,
Release of lower leg tendon,27680,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Release of lower leg tendon,27680,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Release of lower leg tendon,27680,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Release of lower leg tendon,27680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Release of lower leg tendon,27680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Release of lower leg tendon,27680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Release of lower leg tendon,27680,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Release of lower leg tendons,27681,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,3239.17,14371.12,
Release of lower leg tendons,27681,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,3239.17,14371.12,
Release of lower leg tendons,27681,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,3239.17,14371.12,
Release of lower leg tendons,27681,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,3239.17,14371.12,
Release of lower leg tendons,27681,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Release of lower leg tendons,27681,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Release of lower leg tendons,27681,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Release of lower leg tendons,27681,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Release of lower leg tendons,27681,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Release of lower leg tendons,27681,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Release of lower leg tendons,27681,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Revision of lower leg tendon,27685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3925.17,,,,,,,fee schedule,3146.37,14371.12,
Revision of lower leg tendon,27685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3146.37,,,,,,,fee schedule,3146.37,14371.12,
Revision of lower leg tendon,27685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3437.12,,,,,,,fee schedule,3146.37,14371.12,
Revision of lower leg tendon,27685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3613.65,,,,,,,fee schedule,3146.37,14371.12,
Revision of lower leg tendon,27685,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3146.37,14371.12,APC 378
Revision of lower leg tendon,27685,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3146.37,14371.12,APC
Revision of lower leg tendon,27685,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3146.37,14371.12,APC
Revision of lower leg tendon,27685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3146.37,14371.12,APC
Revision of lower leg tendon,27685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3146.37,14371.12,Radiology
Revision of lower leg tendon,27685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3146.37,14371.12,APC
Revision of lower leg tendon,27685,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3146.37,14371.12,APC
Revise lower leg tendons,27686,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,3239.17,14371.12,
Revise lower leg tendons,27686,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,3239.17,14371.12,
Revise lower leg tendons,27686,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,3239.17,14371.12,
Revise lower leg tendons,27686,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,3239.17,14371.12,
Revise lower leg tendons,27686,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Revise lower leg tendons,27686,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Revise lower leg tendons,27686,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Revise lower leg tendons,27686,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Revise lower leg tendons,27686,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Revise lower leg tendons,27686,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Revise lower leg tendons,27686,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Revision of calf tendon,27687,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3512.76,,,,,,,fee schedule,2815.78,14371.12,
Revision of calf tendon,27687,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2815.78,,,,,,,fee schedule,2815.78,14371.12,
Revision of calf tendon,27687,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3075.99,,,,,,,fee schedule,2815.78,14371.12,
Revision of calf tendon,27687,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3233.97,,,,,,,fee schedule,2815.78,14371.12,
Revision of calf tendon,27687,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,2815.78,14371.12,APC 378
Revision of calf tendon,27687,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,2815.78,14371.12,APC
Revision of calf tendon,27687,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,2815.78,14371.12,APC
Revision of calf tendon,27687,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,2815.78,14371.12,APC
Revision of calf tendon,27687,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,2815.78,14371.12,Radiology
Revision of calf tendon,27687,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,2815.78,14371.12,APC
Revision of calf tendon,27687,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,2815.78,14371.12,APC
Revise lower leg tendon,27690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5868.45,,,,,,,fee schedule,4704.08,31870.39,
Revise lower leg tendon,27690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4704.08,,,,,,,fee schedule,4704.08,31870.39,
Revise lower leg tendon,27690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5138.78,,,,,,,fee schedule,4704.08,31870.39,
Revise lower leg tendon,27690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5402.7,,,,,,,fee schedule,4704.08,31870.39,
Revise lower leg tendon,27690,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,4704.08,31870.39,APC 378
Revise lower leg tendon,27690,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,4704.08,31870.39,APC
Revise lower leg tendon,27690,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,4704.08,31870.39,APC
Revise lower leg tendon,27690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,4704.08,31870.39,APC
Revise lower leg tendon,27690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,4704.08,31870.39,Radiology
Revise lower leg tendon,27690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,4704.08,31870.39,APC
Revise lower leg tendon,27690,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,4704.08,31870.39,APC
Revise lower leg tendon,27691,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7249.79,,,,,,,fee schedule,5811.34,31870.39,
Revise lower leg tendon,27691,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5811.34,,,,,,,fee schedule,5811.34,31870.39,
Revise lower leg tendon,27691,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6348.36,,,,,,,fee schedule,5811.34,31870.39,
Revise lower leg tendon,27691,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6674.41,,,,,,,fee schedule,5811.34,31870.39,
Revise lower leg tendon,27691,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5811.34,31870.39,APC 378
Revise lower leg tendon,27691,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5811.34,31870.39,APC
Revise lower leg tendon,27691,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5811.34,31870.39,APC
Revise lower leg tendon,27691,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5811.34,31870.39,APC
Revise lower leg tendon,27691,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5811.34,31870.39,Radiology
Revise lower leg tendon,27691,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5811.34,31870.39,APC
Revise lower leg tendon,27691,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5811.34,31870.39,APC
Revise additional leg tendon,27692,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10728.02,,,,,,,fee schedule,8599.44,10728.02,
Revise additional leg tendon,27692,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8599.44,,,,,,,fee schedule,8599.44,10728.02,
Revise additional leg tendon,27692,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9394.11,,,,,,,fee schedule,8599.44,10728.02,
Revise additional leg tendon,27692,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9876.59,,,,,,,fee schedule,8599.44,10728.02,
Repair of ankle ligament,27695,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6066.67,,,,,,,fee schedule,4862.97,31870.39,
Repair of ankle ligament,27695,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4862.97,,,,,,,fee schedule,4862.97,31870.39,
Repair of ankle ligament,27695,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5312.35,,,,,,,fee schedule,4862.97,31870.39,
Repair of ankle ligament,27695,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5585.19,,,,,,,fee schedule,4862.97,31870.39,
Repair of ankle ligament,27695,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,4862.97,31870.39,APC 378
Repair of ankle ligament,27695,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,4862.97,31870.39,APC
Repair of ankle ligament,27695,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,4862.97,31870.39,APC
Repair of ankle ligament,27695,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,4862.97,31870.39,APC
Repair of ankle ligament,27695,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,4862.97,31870.39,Radiology
Repair of ankle ligament,27695,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,4862.97,31870.39,APC
Repair of ankle ligament,27695,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,4862.97,31870.39,APC
Repair of ankle ligaments,27696,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6263.21,,,,,,,fee schedule,5020.51,31870.39,
Repair of ankle ligaments,27696,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5020.51,,,,,,,fee schedule,5020.51,31870.39,
Repair of ankle ligaments,27696,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5484.45,,,,,,,fee schedule,5020.51,31870.39,
Repair of ankle ligaments,27696,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5766.13,,,,,,,fee schedule,5020.51,31870.39,
Repair of ankle ligaments,27696,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5020.51,31870.39,APC 378
Repair of ankle ligaments,27696,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5020.51,31870.39,APC
Repair of ankle ligaments,27696,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5020.51,31870.39,APC
Repair of ankle ligaments,27696,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5020.51,31870.39,APC
Repair of ankle ligaments,27696,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5020.51,31870.39,Radiology
Repair of ankle ligaments,27696,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5020.51,31870.39,APC
Repair of ankle ligaments,27696,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5020.51,31870.39,APC
Repair of ankle ligament,27698,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4873.79,,,,,,,fee schedule,3906.77,31870.39,
Repair of ankle ligament,27698,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3906.77,,,,,,,fee schedule,3906.77,31870.39,
Repair of ankle ligament,27698,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4267.79,,,,,,,fee schedule,3906.77,31870.39,
Repair of ankle ligament,27698,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4486.99,,,,,,,fee schedule,3906.77,31870.39,
Repair of ankle ligament,27698,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,3906.77,31870.39,APC 378
Repair of ankle ligament,27698,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,3906.77,31870.39,APC
Repair of ankle ligament,27698,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,3906.77,31870.39,APC
Repair of ankle ligament,27698,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,3906.77,31870.39,APC
Repair of ankle ligament,27698,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,3906.77,31870.39,Radiology
Repair of ankle ligament,27698,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,3906.77,31870.39,APC
Repair of ankle ligament,27698,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,3906.77,31870.39,APC
Revision of ankle joint,27700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8960.75,,,,,,,fee schedule,7182.83,31870.39,
Revision of ankle joint,27700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7182.83,,,,,,,fee schedule,7182.83,31870.39,
Revision of ankle joint,27700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7846.59,,,,,,,fee schedule,7182.83,31870.39,
Revision of ankle joint,27700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8249.58,,,,,,,fee schedule,7182.83,31870.39,
Revision of ankle joint,27700,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7182.83,31870.39,APC 378
Revision of ankle joint,27700,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7182.83,31870.39,APC
Revision of ankle joint,27700,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7182.83,31870.39,APC
Revision of ankle joint,27700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7182.83,31870.39,APC
Revision of ankle joint,27700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7182.83,31870.39,Radiology
Revision of ankle joint,27700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7182.83,31870.39,APC
Revision of ankle joint,27700,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7182.83,31870.39,APC
Reconstruct ankle joint,27702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46549.79,,,,,,,fee schedule,26861.8,119176.72,
Reconstruct ankle joint,27702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37313.72,,,,,,,fee schedule,26861.8,119176.72,
Reconstruct ankle joint,27702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40761.86,,,,,,,fee schedule,26861.8,119176.72,
Reconstruct ankle joint,27702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42855.36,,,,,,,fee schedule,26861.8,119176.72,
Reconstruct ankle joint,27702,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,119176.72,,,,,,,fee schedule,26861.8,119176.72,APC 378
Reconstruct ankle joint,27702,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,28204.89,,,,,,,fee schedule,26861.8,119176.72,APC
Reconstruct ankle joint,27702,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,27936.27,,,,,,,fee schedule,26861.8,119176.72,APC
Reconstruct ankle joint,27702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,26861.8,,,,,,,fee schedule,26861.8,119176.72,APC
Reconstruct ankle joint,27702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,41098.56,,,,,,,fee schedule,26861.8,119176.72,Radiology
Reconstruct ankle joint,27702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,37606.52,,,,,,,fee schedule,26861.8,119176.72,APC
Reconstruct ankle joint,27702,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,47008.15,,,,,,,fee schedule,26861.8,119176.72,APC
Reconstruction ankle joint,27703,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46549.79,,,,,,,fee schedule,17357.91,77011.17,
Reconstruction ankle joint,27703,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37313.72,,,,,,,fee schedule,17357.91,77011.17,
Reconstruction ankle joint,27703,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40761.86,,,,,,,fee schedule,17357.91,77011.17,
Reconstruction ankle joint,27703,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42855.36,,,,,,,fee schedule,17357.91,77011.17,
Reconstruction ankle joint,27703,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,77011.17,,,,,,,fee schedule,17357.91,77011.17,APC 378
Reconstruction ankle joint,27703,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18225.81,,,,,,,fee schedule,17357.91,77011.17,APC
Reconstruction ankle joint,27703,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18052.23,,,,,,,fee schedule,17357.91,77011.17,APC
Reconstruction ankle joint,27703,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17357.91,,,,,,,fee schedule,17357.91,77011.17,APC
Reconstruction ankle joint,27703,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26557.6,,,,,,,fee schedule,17357.91,77011.17,Radiology
Reconstruction ankle joint,27703,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24301.07,,,,,,,fee schedule,17357.91,77011.17,APC
Reconstruction ankle joint,27703,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30376.34,,,,,,,fee schedule,17357.91,77011.17,APC
Removal of ankle implant,27704,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,3239.17,14371.12,
Removal of ankle implant,27704,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,3239.17,14371.12,
Removal of ankle implant,27704,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,3239.17,14371.12,
Removal of ankle implant,27704,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,3239.17,14371.12,
Removal of ankle implant,27704,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Removal of ankle implant,27704,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of ankle implant,27704,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of ankle implant,27704,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of ankle implant,27704,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Removal of ankle implant,27704,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of ankle implant,27704,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Incision of tibia,27705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10728.02,,,,,,,fee schedule,7183.42,31870.39,
Incision of tibia,27705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8599.44,,,,,,,fee schedule,7183.42,31870.39,
Incision of tibia,27705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9394.11,,,,,,,fee schedule,7183.42,31870.39,
Incision of tibia,27705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9876.59,,,,,,,fee schedule,7183.42,31870.39,
Incision of tibia,27705,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Incision of tibia,27705,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Incision of tibia,27705,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Incision of tibia,27705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Incision of tibia,27705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Incision of tibia,27705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Incision of tibia,27705,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Incision of fibula,27707,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,3239.17,14371.12,
Incision of fibula,27707,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,3239.17,14371.12,
Incision of fibula,27707,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,3239.17,14371.12,
Incision of fibula,27707,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,3239.17,14371.12,
Incision of fibula,27707,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Incision of fibula,27707,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Incision of fibula,27707,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Incision of fibula,27707,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Incision of fibula,27707,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Incision of fibula,27707,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Incision of fibula,27707,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Incision of tibia & fibula,27709,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,5839.66,56389.43,
Incision of tibia & fibula,27709,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,5839.66,56389.43,
Incision of tibia & fibula,27709,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,5839.66,56389.43,
Incision of tibia & fibula,27709,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,5839.66,56389.43,
Incision of tibia & fibula,27709,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,5839.66,56389.43,APC 378
Incision of tibia & fibula,27709,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,5839.66,56389.43,APC
Incision of tibia & fibula,27709,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,5839.66,56389.43,APC
Incision of tibia & fibula,27709,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,5839.66,56389.43,APC
Incision of tibia & fibula,27709,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,5839.66,56389.43,Radiology
Incision of tibia & fibula,27709,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,5839.66,56389.43,APC
Incision of tibia & fibula,27709,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,5839.66,56389.43,APC
Realignment of lower leg,27712,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46549.79,,,,,,,fee schedule,12709.88,56389.43,
Realignment of lower leg,27712,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37313.72,,,,,,,fee schedule,12709.88,56389.43,
Realignment of lower leg,27712,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40761.86,,,,,,,fee schedule,12709.88,56389.43,
Realignment of lower leg,27712,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42855.36,,,,,,,fee schedule,12709.88,56389.43,
Realignment of lower leg,27712,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,12709.88,56389.43,APC 378
Realignment of lower leg,27712,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,12709.88,56389.43,APC
Realignment of lower leg,27712,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,12709.88,56389.43,APC
Realignment of lower leg,27712,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,12709.88,56389.43,APC
Realignment of lower leg,27712,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,12709.88,56389.43,Radiology
Realignment of lower leg,27712,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,12709.88,56389.43,APC
Realignment of lower leg,27712,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,12709.88,56389.43,APC
Osteot tibia imed lngth dev,27713,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Osteot tibia imed lngth dev,27713,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Osteot tibia imed lngth dev,27713,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Osteot tibia imed lngth dev,27713,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Osteot tibia imed lngth dev,27713,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Osteot tibia imed lngth dev,27713,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Osteot tibia imed lngth dev,27713,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Revision of lower leg,27715,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46549.79,,,,,,,fee schedule,12709.88,56389.43,
Revision of lower leg,27715,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37313.72,,,,,,,fee schedule,12709.88,56389.43,
Revision of lower leg,27715,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40761.86,,,,,,,fee schedule,12709.88,56389.43,
Revision of lower leg,27715,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42855.36,,,,,,,fee schedule,12709.88,56389.43,
Revision of lower leg,27715,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,12709.88,56389.43,APC 378
Revision of lower leg,27715,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,12709.88,56389.43,APC
Revision of lower leg,27715,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,12709.88,56389.43,APC
Revision of lower leg,27715,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,12709.88,56389.43,APC
Revision of lower leg,27715,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,12709.88,56389.43,Radiology
Revision of lower leg,27715,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,12709.88,56389.43,APC
Revision of lower leg,27715,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,12709.88,56389.43,APC
Repair of tibia,27720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10259.79,,,,,,,fee schedule,7183.42,31870.39,
Repair of tibia,27720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8224.12,,,,,,,fee schedule,7183.42,31870.39,
Repair of tibia,27720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8984.1,,,,,,,fee schedule,7183.42,31870.39,
Repair of tibia,27720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9445.52,,,,,,,fee schedule,7183.42,31870.39,
Repair of tibia,27720,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Repair of tibia,27720,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Repair of tibia,27720,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Repair of tibia,27720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Repair of tibia,27720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Repair of tibia,27720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Repair of tibia,27720,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Repair/graft of tibia,27722,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14780.67,,,,,,,fee schedule,7183.42,31870.39,
Repair/graft of tibia,27722,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11848,,,,,,,fee schedule,7183.42,31870.39,
Repair/graft of tibia,27722,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12942.86,,,,,,,fee schedule,7183.42,31870.39,
Repair/graft of tibia,27722,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13607.6,,,,,,,fee schedule,7183.42,31870.39,
Repair/graft of tibia,27722,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Repair/graft of tibia,27722,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Repair/graft of tibia,27722,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Repair/graft of tibia,27722,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Repair/graft of tibia,27722,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Repair/graft of tibia,27722,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Repair/graft of tibia,27722,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Repair/graft of tibia,27724,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Repair/graft of tibia,27724,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Repair/graft of tibia,27724,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Repair/graft of tibia,27724,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Repair/graft of tibia,27724,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Repair/graft of tibia,27724,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Repair/graft of tibia,27724,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Repair/graft of tibia,27724,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Repair/graft of tibia,27724,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Repair/graft of tibia,27724,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Repair/graft of tibia,27724,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Repair of lower leg,27725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Repair of lower leg,27725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Repair of lower leg,27725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Repair of lower leg,27725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Repair of lower leg,27725,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Repair of lower leg,27725,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Repair of lower leg,27725,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Repair of lower leg,27725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Repair of lower leg,27725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Repair of lower leg,27725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Repair of lower leg,27725,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Repair fibula nonunion,27726,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6528.66,,,,,,,fee schedule,5233.29,31870.39,
Repair fibula nonunion,27726,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5233.29,,,,,,,fee schedule,5233.29,31870.39,
Repair fibula nonunion,27726,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5716.9,,,,,,,fee schedule,5233.29,31870.39,
Repair fibula nonunion,27726,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6010.52,,,,,,,fee schedule,5233.29,31870.39,
Repair fibula nonunion,27726,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5233.29,31870.39,APC 378
Repair fibula nonunion,27726,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5233.29,31870.39,APC
Repair fibula nonunion,27726,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5233.29,31870.39,APC
Repair fibula nonunion,27726,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5233.29,31870.39,APC
Repair fibula nonunion,27726,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5233.29,31870.39,Radiology
Repair fibula nonunion,27726,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5233.29,31870.39,APC
Repair fibula nonunion,27726,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5233.29,31870.39,APC
Repair of lower leg,27727,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,3239.17,23681.51,
Repair of lower leg,27727,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,3239.17,23681.51,
Repair of lower leg,27727,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,3239.17,23681.51,
Repair of lower leg,27727,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,3239.17,23681.51,
Repair of lower leg,27727,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,23681.51,APC 378
Repair of lower leg,27727,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,23681.51,APC
Repair of lower leg,27727,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,23681.51,APC
Repair of lower leg,27727,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,23681.51,APC
Repair of lower leg,27727,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,23681.51,Radiology
Repair of lower leg,27727,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,23681.51,APC
Repair of lower leg,27727,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,23681.51,APC
Repair of tibia epiphysis,27730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,3239.17,14371.12,
Repair of tibia epiphysis,27730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,3239.17,14371.12,
Repair of tibia epiphysis,27730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,3239.17,14371.12,
Repair of tibia epiphysis,27730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,3239.17,14371.12,
Repair of tibia epiphysis,27730,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Repair of tibia epiphysis,27730,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Repair of tibia epiphysis,27730,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Repair of tibia epiphysis,27730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Repair of tibia epiphysis,27730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Repair of tibia epiphysis,27730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Repair of tibia epiphysis,27730,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Repair of fibula epiphysis,27732,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,3239.17,14371.12,
Repair of fibula epiphysis,27732,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,3239.17,14371.12,
Repair of fibula epiphysis,27732,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,3239.17,14371.12,
Repair of fibula epiphysis,27732,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,3239.17,14371.12,
Repair of fibula epiphysis,27732,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Repair of fibula epiphysis,27732,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Repair of fibula epiphysis,27732,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Repair of fibula epiphysis,27732,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Repair of fibula epiphysis,27732,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Repair of fibula epiphysis,27732,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Repair of fibula epiphysis,27732,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Repair lower leg epiphyses,27734,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,3239.17,14371.12,
Repair lower leg epiphyses,27734,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,3239.17,14371.12,
Repair lower leg epiphyses,27734,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,3239.17,14371.12,
Repair lower leg epiphyses,27734,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,3239.17,14371.12,
Repair lower leg epiphyses,27734,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Repair lower leg epiphyses,27734,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Repair lower leg epiphyses,27734,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Repair lower leg epiphyses,27734,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Repair lower leg epiphyses,27734,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Repair lower leg epiphyses,27734,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Repair lower leg epiphyses,27734,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Repair of leg epiphyses,27740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,3239.17,14371.12,
Repair of leg epiphyses,27740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,3239.17,14371.12,
Repair of leg epiphyses,27740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,3239.17,14371.12,
Repair of leg epiphyses,27740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,3239.17,14371.12,
Repair of leg epiphyses,27740,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Repair of leg epiphyses,27740,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Repair of leg epiphyses,27740,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Repair of leg epiphyses,27740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Repair of leg epiphyses,27740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Repair of leg epiphyses,27740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Repair of leg epiphyses,27740,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Repair of leg epiphyses,27742,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10728.02,,,,,,,fee schedule,3239.17,14371.12,
Repair of leg epiphyses,27742,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8599.44,,,,,,,fee schedule,3239.17,14371.12,
Repair of leg epiphyses,27742,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9394.11,,,,,,,fee schedule,3239.17,14371.12,
Repair of leg epiphyses,27742,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9876.59,,,,,,,fee schedule,3239.17,14371.12,
Repair of leg epiphyses,27742,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Repair of leg epiphyses,27742,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Repair of leg epiphyses,27742,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Repair of leg epiphyses,27742,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Repair of leg epiphyses,27742,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Repair of leg epiphyses,27742,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Repair of leg epiphyses,27742,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Reinforce tibia,27745,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19822.36,,,,,,,fee schedule,7183.42,31870.39,
Reinforce tibia,27745,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15889.35,,,,,,,fee schedule,7183.42,31870.39,
Reinforce tibia,27745,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17357.67,,,,,,,fee schedule,7183.42,31870.39,
Reinforce tibia,27745,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18249.15,,,,,,,fee schedule,7183.42,31870.39,
Reinforce tibia,27745,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Reinforce tibia,27745,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Reinforce tibia,27745,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Reinforce tibia,27745,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Reinforce tibia,27745,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Reinforce tibia,27745,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Reinforce tibia,27745,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Treatment of tibia fracture,27750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,244.19,1083.4,
Treatment of tibia fracture,27750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,244.19,1083.4,
Treatment of tibia fracture,27750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,244.19,1083.4,
Treatment of tibia fracture,27750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,244.19,1083.4,
Treatment of tibia fracture,27750,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treatment of tibia fracture,27750,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treatment of tibia fracture,27750,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treatment of tibia fracture,27750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treatment of tibia fracture,27750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treatment of tibia fracture,27750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treatment of tibia fracture,27750,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treatment of tibia fracture,27752,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1939.64,,,,,,,fee schedule,1554.79,7062.54,
Treatment of tibia fracture,27752,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1554.79,,,,,,,fee schedule,1554.79,7062.54,
Treatment of tibia fracture,27752,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1698.47,,,,,,,fee schedule,1554.79,7062.54,
Treatment of tibia fracture,27752,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1785.7,,,,,,,fee schedule,1554.79,7062.54,
Treatment of tibia fracture,27752,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1554.79,7062.54,APC 378
Treatment of tibia fracture,27752,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1554.79,7062.54,APC
Treatment of tibia fracture,27752,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1554.79,7062.54,APC
Treatment of tibia fracture,27752,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1554.79,7062.54,APC
Treatment of tibia fracture,27752,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1554.79,7062.54,Radiology
Treatment of tibia fracture,27752,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1554.79,7062.54,APC
Treatment of tibia fracture,27752,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1554.79,7062.54,APC
Treatment of tibia fracture,27756,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6528.66,,,,,,,fee schedule,5233.29,31870.39,
Treatment of tibia fracture,27756,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5233.29,,,,,,,fee schedule,5233.29,31870.39,
Treatment of tibia fracture,27756,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5716.9,,,,,,,fee schedule,5233.29,31870.39,
Treatment of tibia fracture,27756,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6010.52,,,,,,,fee schedule,5233.29,31870.39,
Treatment of tibia fracture,27756,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5233.29,31870.39,APC 378
Treatment of tibia fracture,27756,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5233.29,31870.39,APC
Treatment of tibia fracture,27756,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5233.29,31870.39,APC
Treatment of tibia fracture,27756,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5233.29,31870.39,APC
Treatment of tibia fracture,27756,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5233.29,31870.39,Radiology
Treatment of tibia fracture,27756,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5233.29,31870.39,APC
Treatment of tibia fracture,27756,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5233.29,31870.39,APC
Treatment of tibia fracture,27758,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10259.79,,,,,,,fee schedule,8224.12,56389.43,
Treatment of tibia fracture,27758,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8224.12,,,,,,,fee schedule,8224.12,56389.43,
Treatment of tibia fracture,27758,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8984.1,,,,,,,fee schedule,8224.12,56389.43,
Treatment of tibia fracture,27758,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9445.52,,,,,,,fee schedule,8224.12,56389.43,
Treatment of tibia fracture,27758,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,8224.12,56389.43,APC 378
Treatment of tibia fracture,27758,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,8224.12,56389.43,APC
Treatment of tibia fracture,27758,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,8224.12,56389.43,APC
Treatment of tibia fracture,27758,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,8224.12,56389.43,APC
Treatment of tibia fracture,27758,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,8224.12,56389.43,Radiology
Treatment of tibia fracture,27758,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,8224.12,56389.43,APC
Treatment of tibia fracture,27758,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,8224.12,56389.43,APC
Treatment of tibia fracture,27759,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12545.92,,,,,,,fee schedule,10056.65,56389.43,
Treatment of tibia fracture,27759,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10056.65,,,,,,,fee schedule,10056.65,56389.43,
Treatment of tibia fracture,27759,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10985.98,,,,,,,fee schedule,10056.65,56389.43,
Treatment of tibia fracture,27759,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11550.21,,,,,,,fee schedule,10056.65,56389.43,
Treatment of tibia fracture,27759,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,10056.65,56389.43,APC 378
Treatment of tibia fracture,27759,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,10056.65,56389.43,APC
Treatment of tibia fracture,27759,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,10056.65,56389.43,APC
Treatment of tibia fracture,27759,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,10056.65,56389.43,APC
Treatment of tibia fracture,27759,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,10056.65,56389.43,Radiology
Treatment of tibia fracture,27759,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,10056.65,56389.43,APC
Treatment of tibia fracture,27759,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,10056.65,56389.43,APC
Cltx medial ankle fx,27760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,244.19,1083.4,
Cltx medial ankle fx,27760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,244.19,1083.4,
Cltx medial ankle fx,27760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,244.19,1083.4,
Cltx medial ankle fx,27760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,244.19,1083.4,
Cltx medial ankle fx,27760,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Cltx medial ankle fx,27760,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Cltx medial ankle fx,27760,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Cltx medial ankle fx,27760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Cltx medial ankle fx,27760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Cltx medial ankle fx,27760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Cltx medial ankle fx,27760,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Cltx med ankle fx w/mnpj,27762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1763.02,,,,,,,fee schedule,1413.21,7062.54,
Cltx med ankle fx w/mnpj,27762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1413.21,,,,,,,fee schedule,1413.21,7062.54,
Cltx med ankle fx w/mnpj,27762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1543.81,,,,,,,fee schedule,1413.21,7062.54,
Cltx med ankle fx w/mnpj,27762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1623.1,,,,,,,fee schedule,1413.21,7062.54,
Cltx med ankle fx w/mnpj,27762,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1413.21,7062.54,APC 378
Cltx med ankle fx w/mnpj,27762,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1413.21,7062.54,APC
Cltx med ankle fx w/mnpj,27762,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1413.21,7062.54,APC
Cltx med ankle fx w/mnpj,27762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1413.21,7062.54,APC
Cltx med ankle fx w/mnpj,27762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1413.21,7062.54,Radiology
Cltx med ankle fx w/mnpj,27762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1413.21,7062.54,APC
Cltx med ankle fx w/mnpj,27762,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1413.21,7062.54,APC
Optx medial ankle fx,27766,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5580.9,,,,,,,fee schedule,4473.58,31870.39,
Optx medial ankle fx,27766,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4473.58,,,,,,,fee schedule,4473.58,31870.39,
Optx medial ankle fx,27766,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4886.98,,,,,,,fee schedule,4473.58,31870.39,
Optx medial ankle fx,27766,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5137.97,,,,,,,fee schedule,4473.58,31870.39,
Optx medial ankle fx,27766,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,4473.58,31870.39,APC 378
Optx medial ankle fx,27766,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,4473.58,31870.39,APC
Optx medial ankle fx,27766,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,4473.58,31870.39,APC
Optx medial ankle fx,27766,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,4473.58,31870.39,APC
Optx medial ankle fx,27766,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,4473.58,31870.39,Radiology
Optx medial ankle fx,27766,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,4473.58,31870.39,APC
Optx medial ankle fx,27766,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,4473.58,31870.39,APC
Cltx post ankle fx,27767,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,244.19,1083.4,
Cltx post ankle fx,27767,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,244.19,1083.4,
Cltx post ankle fx,27767,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,244.19,1083.4,
Cltx post ankle fx,27767,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,244.19,1083.4,
Cltx post ankle fx,27767,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Cltx post ankle fx,27767,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Cltx post ankle fx,27767,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Cltx post ankle fx,27767,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Cltx post ankle fx,27767,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Cltx post ankle fx,27767,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Cltx post ankle fx,27767,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Cltx post ankle fx w/mnpj,27768,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,353.72,7062.54,
Cltx post ankle fx w/mnpj,27768,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,353.72,7062.54,
Cltx post ankle fx w/mnpj,27768,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,353.72,7062.54,
Cltx post ankle fx w/mnpj,27768,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,353.72,7062.54,
Cltx post ankle fx w/mnpj,27768,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,353.72,7062.54,APC 378
Cltx post ankle fx w/mnpj,27768,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,353.72,7062.54,APC
Cltx post ankle fx w/mnpj,27768,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,353.72,7062.54,APC
Cltx post ankle fx w/mnpj,27768,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,353.72,7062.54,APC
Cltx post ankle fx w/mnpj,27768,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,353.72,7062.54,Radiology
Cltx post ankle fx w/mnpj,27768,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,353.72,7062.54,APC
Cltx post ankle fx w/mnpj,27768,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,353.72,7062.54,APC
Optx post ankle fx,27769,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10259.79,,,,,,,fee schedule,7183.42,31870.39,
Optx post ankle fx,27769,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8224.12,,,,,,,fee schedule,7183.42,31870.39,
Optx post ankle fx,27769,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8984.1,,,,,,,fee schedule,7183.42,31870.39,
Optx post ankle fx,27769,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9445.52,,,,,,,fee schedule,7183.42,31870.39,
Optx post ankle fx,27769,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Optx post ankle fx,27769,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Optx post ankle fx,27769,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Optx post ankle fx,27769,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Optx post ankle fx,27769,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Optx post ankle fx,27769,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Optx post ankle fx,27769,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Treatment of fibula fracture,27780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,244.19,1083.4,
Treatment of fibula fracture,27780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,244.19,1083.4,
Treatment of fibula fracture,27780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,244.19,1083.4,
Treatment of fibula fracture,27780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,244.19,1083.4,
Treatment of fibula fracture,27780,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treatment of fibula fracture,27780,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treatment of fibula fracture,27780,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treatment of fibula fracture,27780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treatment of fibula fracture,27780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treatment of fibula fracture,27780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treatment of fibula fracture,27780,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treatment of fibula fracture,27781,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4531.07,,,,,,,fee schedule,1591.86,7062.54,
Treatment of fibula fracture,27781,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3632.05,,,,,,,fee schedule,1591.86,7062.54,
Treatment of fibula fracture,27781,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3967.69,,,,,,,fee schedule,1591.86,7062.54,
Treatment of fibula fracture,27781,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4171.46,,,,,,,fee schedule,1591.86,7062.54,
Treatment of fibula fracture,27781,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Treatment of fibula fracture,27781,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Treatment of fibula fracture,27781,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Treatment of fibula fracture,27781,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Treatment of fibula fracture,27781,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Treatment of fibula fracture,27781,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Treatment of fibula fracture,27781,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Treatment of fibula fracture,27784,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6038.9,,,,,,,fee schedule,4840.71,31870.39,
Treatment of fibula fracture,27784,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4840.71,,,,,,,fee schedule,4840.71,31870.39,
Treatment of fibula fracture,27784,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5288.03,,,,,,,fee schedule,4840.71,31870.39,
Treatment of fibula fracture,27784,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5559.62,,,,,,,fee schedule,4840.71,31870.39,
Treatment of fibula fracture,27784,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,4840.71,31870.39,APC 378
Treatment of fibula fracture,27784,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,4840.71,31870.39,APC
Treatment of fibula fracture,27784,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,4840.71,31870.39,APC
Treatment of fibula fracture,27784,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,4840.71,31870.39,APC
Treatment of fibula fracture,27784,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,4840.71,31870.39,Radiology
Treatment of fibula fracture,27784,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,4840.71,31870.39,APC
Treatment of fibula fracture,27784,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,4840.71,31870.39,APC
Treatment of ankle fracture,27786,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,244.19,1083.4,
Treatment of ankle fracture,27786,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,244.19,1083.4,
Treatment of ankle fracture,27786,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,244.19,1083.4,
Treatment of ankle fracture,27786,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,244.19,1083.4,
Treatment of ankle fracture,27786,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treatment of ankle fracture,27786,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treatment of ankle fracture,27786,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treatment of ankle fracture,27786,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treatment of ankle fracture,27786,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treatment of ankle fracture,27786,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treatment of ankle fracture,27786,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treatment of ankle fracture,27788,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,280.65,,,,,,,fee schedule,224.97,1083.4,
Treatment of ankle fracture,27788,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,224.97,,,,,,,fee schedule,224.97,1083.4,
Treatment of ankle fracture,27788,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,245.76,,,,,,,fee schedule,224.97,1083.4,
Treatment of ankle fracture,27788,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,258.38,,,,,,,fee schedule,224.97,1083.4,
Treatment of ankle fracture,27788,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,224.97,1083.4,APC 378
Treatment of ankle fracture,27788,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,224.97,1083.4,APC
Treatment of ankle fracture,27788,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,224.97,1083.4,APC
Treatment of ankle fracture,27788,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,224.97,1083.4,APC
Treatment of ankle fracture,27788,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,224.97,1083.4,Radiology
Treatment of ankle fracture,27788,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,224.97,1083.4,APC
Treatment of ankle fracture,27788,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,224.97,1083.4,APC
Treatment of ankle fracture,27792,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8050.61,,,,,,,fee schedule,6453.26,31870.39,
Treatment of ankle fracture,27792,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6453.26,,,,,,,fee schedule,6453.26,31870.39,
Treatment of ankle fracture,27792,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7049.6,,,,,,,fee schedule,6453.26,31870.39,
Treatment of ankle fracture,27792,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7411.67,,,,,,,fee schedule,6453.26,31870.39,
Treatment of ankle fracture,27792,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,6453.26,31870.39,APC 378
Treatment of ankle fracture,27792,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,6453.26,31870.39,APC
Treatment of ankle fracture,27792,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,6453.26,31870.39,APC
Treatment of ankle fracture,27792,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,6453.26,31870.39,APC
Treatment of ankle fracture,27792,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,6453.26,31870.39,Radiology
Treatment of ankle fracture,27792,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,6453.26,31870.39,APC
Treatment of ankle fracture,27792,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,6453.26,31870.39,APC
Treatment of ankle fracture,27808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,244.19,1083.4,
Treatment of ankle fracture,27808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,244.19,1083.4,
Treatment of ankle fracture,27808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,244.19,1083.4,
Treatment of ankle fracture,27808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,244.19,1083.4,
Treatment of ankle fracture,27808,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treatment of ankle fracture,27808,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treatment of ankle fracture,27808,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treatment of ankle fracture,27808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treatment of ankle fracture,27808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treatment of ankle fracture,27808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treatment of ankle fracture,27808,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treatment of ankle fracture,27810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1045.67,,,,,,,fee schedule,838.2,7062.54,
Treatment of ankle fracture,27810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,838.2,,,,,,,fee schedule,838.2,7062.54,
Treatment of ankle fracture,27810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,915.66,,,,,,,fee schedule,838.2,7062.54,
Treatment of ankle fracture,27810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,962.68,,,,,,,fee schedule,838.2,7062.54,
Treatment of ankle fracture,27810,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,838.2,7062.54,APC 378
Treatment of ankle fracture,27810,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,838.2,7062.54,APC
Treatment of ankle fracture,27810,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,838.2,7062.54,APC
Treatment of ankle fracture,27810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,838.2,7062.54,APC
Treatment of ankle fracture,27810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,838.2,7062.54,Radiology
Treatment of ankle fracture,27810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,838.2,7062.54,APC
Treatment of ankle fracture,27810,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,838.2,7062.54,APC
Treatment of ankle fracture,27814,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7122.68,,,,,,,fee schedule,5709.45,31870.39,
Treatment of ankle fracture,27814,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5709.45,,,,,,,fee schedule,5709.45,31870.39,
Treatment of ankle fracture,27814,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6237.06,,,,,,,fee schedule,5709.45,31870.39,
Treatment of ankle fracture,27814,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6557.39,,,,,,,fee schedule,5709.45,31870.39,
Treatment of ankle fracture,27814,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5709.45,31870.39,APC 378
Treatment of ankle fracture,27814,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5709.45,31870.39,APC
Treatment of ankle fracture,27814,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5709.45,31870.39,APC
Treatment of ankle fracture,27814,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5709.45,31870.39,APC
Treatment of ankle fracture,27814,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5709.45,31870.39,Radiology
Treatment of ankle fracture,27814,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5709.45,31870.39,APC
Treatment of ankle fracture,27814,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5709.45,31870.39,APC
Treatment of ankle fracture,27816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,244.19,1083.4,
Treatment of ankle fracture,27816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,244.19,1083.4,
Treatment of ankle fracture,27816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,244.19,1083.4,
Treatment of ankle fracture,27816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,244.19,1083.4,
Treatment of ankle fracture,27816,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treatment of ankle fracture,27816,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treatment of ankle fracture,27816,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treatment of ankle fracture,27816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treatment of ankle fracture,27816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treatment of ankle fracture,27816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treatment of ankle fracture,27816,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treatment of ankle fracture,27818,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1045.67,,,,,,,fee schedule,838.2,7062.54,
Treatment of ankle fracture,27818,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,838.2,,,,,,,fee schedule,838.2,7062.54,
Treatment of ankle fracture,27818,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,915.66,,,,,,,fee schedule,838.2,7062.54,
Treatment of ankle fracture,27818,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,962.68,,,,,,,fee schedule,838.2,7062.54,
Treatment of ankle fracture,27818,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,838.2,7062.54,APC 378
Treatment of ankle fracture,27818,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,838.2,7062.54,APC
Treatment of ankle fracture,27818,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,838.2,7062.54,APC
Treatment of ankle fracture,27818,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,838.2,7062.54,APC
Treatment of ankle fracture,27818,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,838.2,7062.54,Radiology
Treatment of ankle fracture,27818,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,838.2,7062.54,APC
Treatment of ankle fracture,27818,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,838.2,7062.54,APC
Treatment of ankle fracture,27822,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4962.17,,,,,,,fee schedule,3977.61,31870.39,
Treatment of ankle fracture,27822,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3977.61,,,,,,,fee schedule,3977.61,31870.39,
Treatment of ankle fracture,27822,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4345.18,,,,,,,fee schedule,3977.61,31870.39,
Treatment of ankle fracture,27822,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4568.35,,,,,,,fee schedule,3977.61,31870.39,
Treatment of ankle fracture,27822,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,3977.61,31870.39,APC 378
Treatment of ankle fracture,27822,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,3977.61,31870.39,APC
Treatment of ankle fracture,27822,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,3977.61,31870.39,APC
Treatment of ankle fracture,27822,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,3977.61,31870.39,APC
Treatment of ankle fracture,27822,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,3977.61,31870.39,Radiology
Treatment of ankle fracture,27822,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,3977.61,31870.39,APC
Treatment of ankle fracture,27822,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,3977.61,31870.39,APC
Treatment of ankle fracture,27823,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6211.47,,,,,,,fee schedule,4979.03,31870.39,
Treatment of ankle fracture,27823,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4979.03,,,,,,,fee schedule,4979.03,31870.39,
Treatment of ankle fracture,27823,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5439.14,,,,,,,fee schedule,4979.03,31870.39,
Treatment of ankle fracture,27823,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5718.49,,,,,,,fee schedule,4979.03,31870.39,
Treatment of ankle fracture,27823,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,4979.03,31870.39,APC 378
Treatment of ankle fracture,27823,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,4979.03,31870.39,APC
Treatment of ankle fracture,27823,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,4979.03,31870.39,APC
Treatment of ankle fracture,27823,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,4979.03,31870.39,APC
Treatment of ankle fracture,27823,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,4979.03,31870.39,Radiology
Treatment of ankle fracture,27823,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,4979.03,31870.39,APC
Treatment of ankle fracture,27823,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,4979.03,31870.39,APC
Treat lower leg fracture,27824,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,244.19,1083.4,
Treat lower leg fracture,27824,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,244.19,1083.4,
Treat lower leg fracture,27824,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,244.19,1083.4,
Treat lower leg fracture,27824,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,244.19,1083.4,
Treat lower leg fracture,27824,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treat lower leg fracture,27824,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treat lower leg fracture,27824,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treat lower leg fracture,27824,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treat lower leg fracture,27824,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treat lower leg fracture,27824,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treat lower leg fracture,27824,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treat lower leg fracture,27825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,353.72,7062.54,
Treat lower leg fracture,27825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,353.72,7062.54,
Treat lower leg fracture,27825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,353.72,7062.54,
Treat lower leg fracture,27825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,353.72,7062.54,
Treat lower leg fracture,27825,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,353.72,7062.54,APC 378
Treat lower leg fracture,27825,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,353.72,7062.54,APC
Treat lower leg fracture,27825,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,353.72,7062.54,APC
Treat lower leg fracture,27825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,353.72,7062.54,APC
Treat lower leg fracture,27825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,353.72,7062.54,Radiology
Treat lower leg fracture,27825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,353.72,7062.54,APC
Treat lower leg fracture,27825,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,353.72,7062.54,APC
Treat lower leg fracture,27826,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10259.79,,,,,,,fee schedule,7183.42,31870.39,
Treat lower leg fracture,27826,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8224.12,,,,,,,fee schedule,7183.42,31870.39,
Treat lower leg fracture,27826,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8984.1,,,,,,,fee schedule,7183.42,31870.39,
Treat lower leg fracture,27826,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9445.52,,,,,,,fee schedule,7183.42,31870.39,
Treat lower leg fracture,27826,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Treat lower leg fracture,27826,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Treat lower leg fracture,27826,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Treat lower leg fracture,27826,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Treat lower leg fracture,27826,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Treat lower leg fracture,27826,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Treat lower leg fracture,27826,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Treat lower leg fracture,27827,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5841.87,,,,,,,fee schedule,4682.77,56389.43,
Treat lower leg fracture,27827,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4682.77,,,,,,,fee schedule,4682.77,56389.43,
Treat lower leg fracture,27827,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5115.5,,,,,,,fee schedule,4682.77,56389.43,
Treat lower leg fracture,27827,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5378.23,,,,,,,fee schedule,4682.77,56389.43,
Treat lower leg fracture,27827,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,4682.77,56389.43,APC 378
Treat lower leg fracture,27827,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,4682.77,56389.43,APC
Treat lower leg fracture,27827,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,4682.77,56389.43,APC
Treat lower leg fracture,27827,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,4682.77,56389.43,APC
Treat lower leg fracture,27827,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,4682.77,56389.43,Radiology
Treat lower leg fracture,27827,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,4682.77,56389.43,APC
Treat lower leg fracture,27827,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,4682.77,56389.43,APC
Treat lower leg fracture,27828,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6455.28,,,,,,,fee schedule,5174.47,56389.43,
Treat lower leg fracture,27828,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5174.47,,,,,,,fee schedule,5174.47,56389.43,
Treat lower leg fracture,27828,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5652.64,,,,,,,fee schedule,5174.47,56389.43,
Treat lower leg fracture,27828,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5942.95,,,,,,,fee schedule,5174.47,56389.43,
Treat lower leg fracture,27828,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,5174.47,56389.43,APC 378
Treat lower leg fracture,27828,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,5174.47,56389.43,APC
Treat lower leg fracture,27828,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,5174.47,56389.43,APC
Treat lower leg fracture,27828,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,5174.47,56389.43,APC
Treat lower leg fracture,27828,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,5174.47,56389.43,Radiology
Treat lower leg fracture,27828,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,5174.47,56389.43,APC
Treat lower leg fracture,27828,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,5174.47,56389.43,APC
Treat lower leg joint,27829,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5338.63,,,,,,,fee schedule,4279.38,31870.39,
Treat lower leg joint,27829,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4279.38,,,,,,,fee schedule,4279.38,31870.39,
Treat lower leg joint,27829,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4674.83,,,,,,,fee schedule,4279.38,31870.39,
Treat lower leg joint,27829,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4914.93,,,,,,,fee schedule,4279.38,31870.39,
Treat lower leg joint,27829,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,4279.38,31870.39,APC 378
Treat lower leg joint,27829,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,4279.38,31870.39,APC
Treat lower leg joint,27829,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,4279.38,31870.39,APC
Treat lower leg joint,27829,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,4279.38,31870.39,APC
Treat lower leg joint,27829,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,4279.38,31870.39,Radiology
Treat lower leg joint,27829,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,4279.38,31870.39,APC
Treat lower leg joint,27829,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,4279.38,31870.39,APC
Treat lower leg dislocation,27830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,244.19,1083.4,
Treat lower leg dislocation,27830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,244.19,1083.4,
Treat lower leg dislocation,27830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,244.19,1083.4,
Treat lower leg dislocation,27830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,244.19,1083.4,
Treat lower leg dislocation,27830,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treat lower leg dislocation,27830,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treat lower leg dislocation,27830,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treat lower leg dislocation,27830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treat lower leg dislocation,27830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treat lower leg dislocation,27830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treat lower leg dislocation,27830,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treat lower leg dislocation,27831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,353.72,14371.12,
Treat lower leg dislocation,27831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,353.72,14371.12,
Treat lower leg dislocation,27831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,353.72,14371.12,
Treat lower leg dislocation,27831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,353.72,14371.12,
Treat lower leg dislocation,27831,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,353.72,14371.12,APC 378
Treat lower leg dislocation,27831,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,353.72,14371.12,APC
Treat lower leg dislocation,27831,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,353.72,14371.12,APC
Treat lower leg dislocation,27831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,353.72,14371.12,APC
Treat lower leg dislocation,27831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,353.72,14371.12,Radiology
Treat lower leg dislocation,27831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,353.72,14371.12,APC
Treat lower leg dislocation,27831,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,353.72,14371.12,APC
Treat lower leg dislocation,27832,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10259.79,,,,,,,fee schedule,7183.42,31870.39,
Treat lower leg dislocation,27832,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8224.12,,,,,,,fee schedule,7183.42,31870.39,
Treat lower leg dislocation,27832,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8984.1,,,,,,,fee schedule,7183.42,31870.39,
Treat lower leg dislocation,27832,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9445.52,,,,,,,fee schedule,7183.42,31870.39,
Treat lower leg dislocation,27832,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Treat lower leg dislocation,27832,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Treat lower leg dislocation,27832,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Treat lower leg dislocation,27832,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Treat lower leg dislocation,27832,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Treat lower leg dislocation,27832,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Treat lower leg dislocation,27832,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Treat ankle dislocation,27840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,576.48,,,,,,,fee schedule,244.19,1083.4,
Treat ankle dislocation,27840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,462.1,,,,,,,fee schedule,244.19,1083.4,
Treat ankle dislocation,27840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,504.8,,,,,,,fee schedule,244.19,1083.4,
Treat ankle dislocation,27840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,530.72,,,,,,,fee schedule,244.19,1083.4,
Treat ankle dislocation,27840,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treat ankle dislocation,27840,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treat ankle dislocation,27840,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treat ankle dislocation,27840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treat ankle dislocation,27840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treat ankle dislocation,27840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treat ankle dislocation,27840,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treat ankle dislocation,27842,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1430.35,,,,,,,fee schedule,1146.55,7062.54,
Treat ankle dislocation,27842,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1146.55,,,,,,,fee schedule,1146.55,7062.54,
Treat ankle dislocation,27842,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1252.5,,,,,,,fee schedule,1146.55,7062.54,
Treat ankle dislocation,27842,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1316.83,,,,,,,fee schedule,1146.55,7062.54,
Treat ankle dislocation,27842,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1146.55,7062.54,APC 378
Treat ankle dislocation,27842,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1146.55,7062.54,APC
Treat ankle dislocation,27842,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1146.55,7062.54,APC
Treat ankle dislocation,27842,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1146.55,7062.54,APC
Treat ankle dislocation,27842,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1146.55,7062.54,Radiology
Treat ankle dislocation,27842,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1146.55,7062.54,APC
Treat ankle dislocation,27842,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1146.55,7062.54,APC
Treat ankle dislocation,27846,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10259.79,,,,,,,fee schedule,7183.42,31870.39,
Treat ankle dislocation,27846,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8224.12,,,,,,,fee schedule,7183.42,31870.39,
Treat ankle dislocation,27846,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8984.1,,,,,,,fee schedule,7183.42,31870.39,
Treat ankle dislocation,27846,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9445.52,,,,,,,fee schedule,7183.42,31870.39,
Treat ankle dislocation,27846,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Treat ankle dislocation,27846,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Treat ankle dislocation,27846,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Treat ankle dislocation,27846,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Treat ankle dislocation,27846,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Treat ankle dislocation,27846,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Treat ankle dislocation,27846,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Treat ankle dislocation,27848,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10259.79,,,,,,,fee schedule,7183.42,31870.39,
Treat ankle dislocation,27848,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8224.12,,,,,,,fee schedule,7183.42,31870.39,
Treat ankle dislocation,27848,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8984.1,,,,,,,fee schedule,7183.42,31870.39,
Treat ankle dislocation,27848,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9445.52,,,,,,,fee schedule,7183.42,31870.39,
Treat ankle dislocation,27848,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Treat ankle dislocation,27848,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Treat ankle dislocation,27848,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Treat ankle dislocation,27848,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Treat ankle dislocation,27848,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Treat ankle dislocation,27848,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Treat ankle dislocation,27848,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Fixation of ankle joint,27860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2762.1,,,,,,,fee schedule,2214.06,14371.12,
Fixation of ankle joint,27860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2214.06,,,,,,,fee schedule,2214.06,14371.12,
Fixation of ankle joint,27860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2418.66,,,,,,,fee schedule,2214.06,14371.12,
Fixation of ankle joint,27860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2542.88,,,,,,,fee schedule,2214.06,14371.12,
Fixation of ankle joint,27860,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,2214.06,14371.12,APC 378
Fixation of ankle joint,27860,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,2214.06,14371.12,APC
Fixation of ankle joint,27860,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,2214.06,14371.12,APC
Fixation of ankle joint,27860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,2214.06,14371.12,APC
Fixation of ankle joint,27860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,2214.06,14371.12,Radiology
Fixation of ankle joint,27860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,2214.06,14371.12,APC
Fixation of ankle joint,27860,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,2214.06,14371.12,APC
Fusion of ankle joint open,27870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4100.78,,,,,,,fee schedule,3287.13,56389.43,
Fusion of ankle joint open,27870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3287.13,,,,,,,fee schedule,3287.13,56389.43,
Fusion of ankle joint open,27870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3590.89,,,,,,,fee schedule,3287.13,56389.43,
Fusion of ankle joint open,27870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3775.32,,,,,,,fee schedule,3287.13,56389.43,
Fusion of ankle joint open,27870,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,3287.13,56389.43,APC 378
Fusion of ankle joint open,27870,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,3287.13,56389.43,APC
Fusion of ankle joint open,27870,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,3287.13,56389.43,APC
Fusion of ankle joint open,27870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,3287.13,56389.43,APC
Fusion of ankle joint open,27870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,3287.13,56389.43,Radiology
Fusion of ankle joint open,27870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,3287.13,56389.43,APC
Fusion of ankle joint open,27870,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,3287.13,56389.43,APC
Fusion of tibiofibular joint,27871,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5687.82,,,,,,,fee schedule,4559.28,56389.43,
Fusion of tibiofibular joint,27871,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4559.28,,,,,,,fee schedule,4559.28,56389.43,
Fusion of tibiofibular joint,27871,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4980.6,,,,,,,fee schedule,4559.28,56389.43,
Fusion of tibiofibular joint,27871,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5236.4,,,,,,,fee schedule,4559.28,56389.43,
Fusion of tibiofibular joint,27871,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,4559.28,56389.43,APC 378
Fusion of tibiofibular joint,27871,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,4559.28,56389.43,APC
Fusion of tibiofibular joint,27871,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,4559.28,56389.43,APC
Fusion of tibiofibular joint,27871,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,4559.28,56389.43,APC
Fusion of tibiofibular joint,27871,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,4559.28,56389.43,Radiology
Fusion of tibiofibular joint,27871,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,4559.28,56389.43,APC
Fusion of tibiofibular joint,27871,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,4559.28,56389.43,APC
Amputation of lower leg,27880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59981.53,,,,,,,fee schedule,7183.42,59981.53,
Amputation of lower leg,27880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48080.43,,,,,,,fee schedule,7183.42,59981.53,
Amputation of lower leg,27880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52523.51,,,,,,,fee schedule,7183.42,59981.53,
Amputation of lower leg,27880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55221.09,,,,,,,fee schedule,7183.42,59981.53,
Amputation of lower leg,27880,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,59981.53,APC 378
Amputation of lower leg,27880,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,59981.53,APC
Amputation of lower leg,27880,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,59981.53,APC
Amputation of lower leg,27880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,59981.53,APC
Amputation of lower leg,27880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,59981.53,Radiology
Amputation of lower leg,27880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,59981.53,APC
Amputation of lower leg,27880,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,59981.53,APC
Amputation of lower leg,27881,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,3239.17,23681.51,
Amputation of lower leg,27881,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,3239.17,23681.51,
Amputation of lower leg,27881,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,3239.17,23681.51,
Amputation of lower leg,27881,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,3239.17,23681.51,
Amputation of lower leg,27881,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,23681.51,APC 378
Amputation of lower leg,27881,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,23681.51,APC
Amputation of lower leg,27881,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,23681.51,APC
Amputation of lower leg,27881,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,23681.51,APC
Amputation of lower leg,27881,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,23681.51,Radiology
Amputation of lower leg,27881,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,23681.51,APC
Amputation of lower leg,27881,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,23681.51,APC
Amputation of lower leg,27882,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,3239.17,23681.51,
Amputation of lower leg,27882,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,3239.17,23681.51,
Amputation of lower leg,27882,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,3239.17,23681.51,
Amputation of lower leg,27882,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,3239.17,23681.51,
Amputation of lower leg,27882,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,23681.51,APC 378
Amputation of lower leg,27882,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,23681.51,APC
Amputation of lower leg,27882,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,23681.51,APC
Amputation of lower leg,27882,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,23681.51,APC
Amputation of lower leg,27882,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,23681.51,Radiology
Amputation of lower leg,27882,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,23681.51,APC
Amputation of lower leg,27882,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,23681.51,APC
Amputation follow-up surgery,27884,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,3239.17,14371.12,
Amputation follow-up surgery,27884,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,3239.17,14371.12,
Amputation follow-up surgery,27884,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,3239.17,14371.12,
Amputation follow-up surgery,27884,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,3239.17,14371.12,
Amputation follow-up surgery,27884,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Amputation follow-up surgery,27884,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Amputation follow-up surgery,27884,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Amputation follow-up surgery,27884,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Amputation follow-up surgery,27884,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Amputation follow-up surgery,27884,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Amputation follow-up surgery,27884,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Amputation follow-up surgery,27886,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,3239.17,23681.51,
Amputation follow-up surgery,27886,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,3239.17,23681.51,
Amputation follow-up surgery,27886,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,3239.17,23681.51,
Amputation follow-up surgery,27886,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,3239.17,23681.51,
Amputation follow-up surgery,27886,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,23681.51,APC 378
Amputation follow-up surgery,27886,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,23681.51,APC
Amputation follow-up surgery,27886,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,23681.51,APC
Amputation follow-up surgery,27886,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,23681.51,APC
Amputation follow-up surgery,27886,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,23681.51,Radiology
Amputation follow-up surgery,27886,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,23681.51,APC
Amputation follow-up surgery,27886,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,23681.51,APC
Amputation of foot at ankle,27888,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46549.79,,,,,,,fee schedule,3239.17,46549.79,
Amputation of foot at ankle,27888,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37313.72,,,,,,,fee schedule,3239.17,46549.79,
Amputation of foot at ankle,27888,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40761.86,,,,,,,fee schedule,3239.17,46549.79,
Amputation of foot at ankle,27888,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42855.36,,,,,,,fee schedule,3239.17,46549.79,
Amputation of foot at ankle,27888,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,46549.79,APC 378
Amputation of foot at ankle,27888,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,46549.79,APC
Amputation of foot at ankle,27888,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,46549.79,APC
Amputation of foot at ankle,27888,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,46549.79,APC
Amputation of foot at ankle,27888,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,46549.79,Radiology
Amputation of foot at ankle,27888,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,46549.79,APC
Amputation of foot at ankle,27888,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,46549.79,APC
Amputation of foot at ankle,27889,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,5839.66,31870.39,
Amputation of foot at ankle,27889,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,5839.66,31870.39,
Amputation of foot at ankle,27889,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,5839.66,31870.39,
Amputation of foot at ankle,27889,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,5839.66,31870.39,
Amputation of foot at ankle,27889,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5839.66,31870.39,APC 378
Amputation of foot at ankle,27889,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5839.66,31870.39,APC
Amputation of foot at ankle,27889,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5839.66,31870.39,APC
Amputation of foot at ankle,27889,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5839.66,31870.39,APC
Amputation of foot at ankle,27889,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5839.66,31870.39,Radiology
Amputation of foot at ankle,27889,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5839.66,31870.39,APC
Amputation of foot at ankle,27889,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5839.66,31870.39,APC
Decompression of leg,27892,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,3239.17,14371.12,
Decompression of leg,27892,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,3239.17,14371.12,
Decompression of leg,27892,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,3239.17,14371.12,
Decompression of leg,27892,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,3239.17,14371.12,
Decompression of leg,27892,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Decompression of leg,27892,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Decompression of leg,27892,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Decompression of leg,27892,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Decompression of leg,27892,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Decompression of leg,27892,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Decompression of leg,27892,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Decompression of leg,27893,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,4254.97,31870.39,
Decompression of leg,27893,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,4254.97,31870.39,
Decompression of leg,27893,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,4254.97,31870.39,
Decompression of leg,27893,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,4254.97,31870.39,
Decompression of leg,27893,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,4254.97,31870.39,APC 378
Decompression of leg,27893,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,4254.97,31870.39,APC
Decompression of leg,27893,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,4254.97,31870.39,APC
Decompression of leg,27893,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,4254.97,31870.39,APC
Decompression of leg,27893,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,4254.97,31870.39,Radiology
Decompression of leg,27893,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,4254.97,31870.39,APC
Decompression of leg,27893,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,4254.97,31870.39,APC
Decompression of leg,27894,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,3239.17,14371.12,
Decompression of leg,27894,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,3239.17,14371.12,
Decompression of leg,27894,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,3239.17,14371.12,
Decompression of leg,27894,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,3239.17,14371.12,
Decompression of leg,27894,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Decompression of leg,27894,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Decompression of leg,27894,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Decompression of leg,27894,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Decompression of leg,27894,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Decompression of leg,27894,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Decompression of leg,27894,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Leg/ankle surgery procedure,27899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,244.19,1083.4,
Leg/ankle surgery procedure,27899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,244.19,1083.4,
Leg/ankle surgery procedure,27899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,244.19,1083.4,
Leg/ankle surgery procedure,27899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,244.19,1083.4,
Leg/ankle surgery procedure,27899,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Leg/ankle surgery procedure,27899,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Leg/ankle surgery procedure,27899,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Leg/ankle surgery procedure,27899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Leg/ankle surgery procedure,27899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Leg/ankle surgery procedure,27899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Leg/ankle surgery procedure,27899,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Drainage of bursa of foot,28001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2884.93,,,,,,,fee schedule,1635.03,7254.06,
Drainage of bursa of foot,28001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2312.53,,,,,,,fee schedule,1635.03,7254.06,
Drainage of bursa of foot,28001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2526.23,,,,,,,fee schedule,1635.03,7254.06,
Drainage of bursa of foot,28001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2655.97,,,,,,,fee schedule,1635.03,7254.06,
Drainage of bursa of foot,28001,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,7254.06,APC 378
Drainage of bursa of foot,28001,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,7254.06,APC
Drainage of bursa of foot,28001,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,7254.06,APC
Drainage of bursa of foot,28001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,7254.06,APC
Drainage of bursa of foot,28001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,7254.06,Radiology
Drainage of bursa of foot,28001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,7254.06,APC
Drainage of bursa of foot,28001,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,7254.06,APC
Treatment of foot infection,28002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,1591.86,7062.54,
Treatment of foot infection,28002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,1591.86,7062.54,
Treatment of foot infection,28002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,1591.86,7062.54,
Treatment of foot infection,28002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,1591.86,7062.54,
Treatment of foot infection,28002,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Treatment of foot infection,28002,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Treatment of foot infection,28002,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Treatment of foot infection,28002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Treatment of foot infection,28002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Treatment of foot infection,28002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Treatment of foot infection,28002,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Treatment of foot infection,28003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308.18,,,,,,,fee schedule,3239.17,14371.12,
Treatment of foot infection,28003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4254.97,,,,,,,fee schedule,3239.17,14371.12,
Treatment of foot infection,28003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4648.17,,,,,,,fee schedule,3239.17,14371.12,
Treatment of foot infection,28003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4886.89,,,,,,,fee schedule,3239.17,14371.12,
Treatment of foot infection,28003,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Treatment of foot infection,28003,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Treatment of foot infection,28003,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Treatment of foot infection,28003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Treatment of foot infection,28003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Treatment of foot infection,28003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Treatment of foot infection,28003,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Treat foot bone lesion,28005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5198.26,,,,,,,fee schedule,3239.17,14371.12,
Treat foot bone lesion,28005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4166.86,,,,,,,fee schedule,3239.17,14371.12,
Treat foot bone lesion,28005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4551.91,,,,,,,fee schedule,3239.17,14371.12,
Treat foot bone lesion,28005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4785.7,,,,,,,fee schedule,3239.17,14371.12,
Treat foot bone lesion,28005,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Treat foot bone lesion,28005,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Treat foot bone lesion,28005,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Treat foot bone lesion,28005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Treat foot bone lesion,28005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Treat foot bone lesion,28005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Treat foot bone lesion,28005,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Incision of foot fascia,28008,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7189.69,,,,,,,fee schedule,3239.17,14371.12,
Incision of foot fascia,28008,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5763.16,,,,,,,fee schedule,3239.17,14371.12,
Incision of foot fascia,28008,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6295.73,,,,,,,fee schedule,3239.17,14371.12,
Incision of foot fascia,28008,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6619.08,,,,,,,fee schedule,3239.17,14371.12,
Incision of foot fascia,28008,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Incision of foot fascia,28008,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Incision of foot fascia,28008,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Incision of foot fascia,28008,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Incision of foot fascia,28008,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Incision of foot fascia,28008,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Incision of foot fascia,28008,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Incision of toe tendon,28010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3089.71,,,,,,,fee schedule,1591.86,7062.54,
Incision of toe tendon,28010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2476.67,,,,,,,fee schedule,1591.86,7062.54,
Incision of toe tendon,28010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2705.54,,,,,,,fee schedule,1591.86,7062.54,
Incision of toe tendon,28010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2844.49,,,,,,,fee schedule,1591.86,7062.54,
Incision of toe tendon,28010,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Incision of toe tendon,28010,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Incision of toe tendon,28010,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Incision of toe tendon,28010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Incision of toe tendon,28010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Incision of toe tendon,28010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Incision of toe tendon,28010,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Incision of toe tendons,28011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5198.26,,,,,,,fee schedule,1591.86,7062.54,
Incision of toe tendons,28011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4166.86,,,,,,,fee schedule,1591.86,7062.54,
Incision of toe tendons,28011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4551.91,,,,,,,fee schedule,1591.86,7062.54,
Incision of toe tendons,28011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4785.7,,,,,,,fee schedule,1591.86,7062.54,
Incision of toe tendons,28011,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Incision of toe tendons,28011,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Incision of toe tendons,28011,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Incision of toe tendons,28011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Incision of toe tendons,28011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Incision of toe tendons,28011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Incision of toe tendons,28011,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Exploration of foot joint,28020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5198.26,,,,,,,fee schedule,3239.17,14371.12,
Exploration of foot joint,28020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4166.86,,,,,,,fee schedule,3239.17,14371.12,
Exploration of foot joint,28020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4551.91,,,,,,,fee schedule,3239.17,14371.12,
Exploration of foot joint,28020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4785.7,,,,,,,fee schedule,3239.17,14371.12,
Exploration of foot joint,28020,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Exploration of foot joint,28020,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Exploration of foot joint,28020,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Exploration of foot joint,28020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Exploration of foot joint,28020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Exploration of foot joint,28020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Exploration of foot joint,28020,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Exploration of foot joint,28022,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5198.26,,,,,,,fee schedule,3239.17,14371.12,
Exploration of foot joint,28022,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4166.86,,,,,,,fee schedule,3239.17,14371.12,
Exploration of foot joint,28022,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4551.91,,,,,,,fee schedule,3239.17,14371.12,
Exploration of foot joint,28022,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4785.7,,,,,,,fee schedule,3239.17,14371.12,
Exploration of foot joint,28022,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Exploration of foot joint,28022,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Exploration of foot joint,28022,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Exploration of foot joint,28022,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Exploration of foot joint,28022,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Exploration of foot joint,28022,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Exploration of foot joint,28022,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Exploration of toe joint,28024,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5198.26,,,,,,,fee schedule,1591.86,7062.54,
Exploration of toe joint,28024,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4166.86,,,,,,,fee schedule,1591.86,7062.54,
Exploration of toe joint,28024,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4551.91,,,,,,,fee schedule,1591.86,7062.54,
Exploration of toe joint,28024,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4785.7,,,,,,,fee schedule,1591.86,7062.54,
Exploration of toe joint,28024,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Exploration of toe joint,28024,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Exploration of toe joint,28024,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Exploration of toe joint,28024,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Exploration of toe joint,28024,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Exploration of toe joint,28024,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Exploration of toe joint,28024,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Decompression of tibia nerve,28035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4505.27,,,,,,,fee schedule,1933.13,8576.66,
Decompression of tibia nerve,28035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3611.37,,,,,,,fee schedule,1933.13,8576.66,
Decompression of tibia nerve,28035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3945.09,,,,,,,fee schedule,1933.13,8576.66,
Decompression of tibia nerve,28035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4147.71,,,,,,,fee schedule,1933.13,8576.66,
Decompression of tibia nerve,28035,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8576.66,,,,,,,fee schedule,1933.13,8576.66,APC 378
Decompression of tibia nerve,28035,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2029.79,,,,,,,fee schedule,1933.13,8576.66,APC
Decompression of tibia nerve,28035,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2010.46,,,,,,,fee schedule,1933.13,8576.66,APC
Decompression of tibia nerve,28035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1933.13,,,,,,,fee schedule,1933.13,8576.66,APC
Decompression of tibia nerve,28035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2957.7,,,,,,,fee schedule,1933.13,8576.66,Radiology
Decompression of tibia nerve,28035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2706.39,,,,,,,fee schedule,1933.13,8576.66,APC
Decompression of tibia nerve,28035,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3382.99,,,,,,,fee schedule,1933.13,8576.66,APC
Exc foot/toe tum sc 1.5 cm/>,28039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5102.67,,,,,,,fee schedule,2875.57,12757.95,
Exc foot/toe tum sc 1.5 cm/>,28039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4090.24,,,,,,,fee schedule,2875.57,12757.95,
Exc foot/toe tum sc 1.5 cm/>,28039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4468.21,,,,,,,fee schedule,2875.57,12757.95,
Exc foot/toe tum sc 1.5 cm/>,28039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4697.7,,,,,,,fee schedule,2875.57,12757.95,
Exc foot/toe tum sc 1.5 cm/>,28039,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Exc foot/toe tum sc 1.5 cm/>,28039,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Exc foot/toe tum sc 1.5 cm/>,28039,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Exc foot/toe tum sc 1.5 cm/>,28039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Exc foot/toe tum sc 1.5 cm/>,28039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Exc foot/toe tum sc 1.5 cm/>,28039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Exc foot/toe tum sc 1.5 cm/>,28039,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Exc foot/toe tum dep 1.5cm/>,28041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6253.46,,,,,,,fee schedule,2875.57,12757.95,
Exc foot/toe tum dep 1.5cm/>,28041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5012.69,,,,,,,fee schedule,2875.57,12757.95,
Exc foot/toe tum dep 1.5cm/>,28041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5475.91,,,,,,,fee schedule,2875.57,12757.95,
Exc foot/toe tum dep 1.5cm/>,28041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5757.15,,,,,,,fee schedule,2875.57,12757.95,
Exc foot/toe tum dep 1.5cm/>,28041,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Exc foot/toe tum dep 1.5cm/>,28041,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Exc foot/toe tum dep 1.5cm/>,28041,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Exc foot/toe tum dep 1.5cm/>,28041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Exc foot/toe tum dep 1.5cm/>,28041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Exc foot/toe tum dep 1.5cm/>,28041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Exc foot/toe tum dep 1.5cm/>,28041,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Exc foot/toe tum sc < 1.5 cm,28043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3594.84,,,,,,,fee schedule,1635.03,7254.06,
Exc foot/toe tum sc < 1.5 cm,28043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2881.58,,,,,,,fee schedule,1635.03,7254.06,
Exc foot/toe tum sc < 1.5 cm,28043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3147.87,,,,,,,fee schedule,1635.03,7254.06,
Exc foot/toe tum sc < 1.5 cm,28043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3309.54,,,,,,,fee schedule,1635.03,7254.06,
Exc foot/toe tum sc < 1.5 cm,28043,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,7254.06,APC 378
Exc foot/toe tum sc < 1.5 cm,28043,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,7254.06,APC
Exc foot/toe tum sc < 1.5 cm,28043,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,7254.06,APC
Exc foot/toe tum sc < 1.5 cm,28043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,7254.06,APC
Exc foot/toe tum sc < 1.5 cm,28043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,7254.06,Radiology
Exc foot/toe tum sc < 1.5 cm,28043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,7254.06,APC
Exc foot/toe tum sc < 1.5 cm,28043,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,7254.06,APC
Exc foot/toe tum deep <1.5cm,28045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7189.69,,,,,,,fee schedule,2875.57,12757.95,
Exc foot/toe tum deep <1.5cm,28045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5763.16,,,,,,,fee schedule,2875.57,12757.95,
Exc foot/toe tum deep <1.5cm,28045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6295.73,,,,,,,fee schedule,2875.57,12757.95,
Exc foot/toe tum deep <1.5cm,28045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6619.08,,,,,,,fee schedule,2875.57,12757.95,
Exc foot/toe tum deep <1.5cm,28045,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Exc foot/toe tum deep <1.5cm,28045,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Exc foot/toe tum deep <1.5cm,28045,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Exc foot/toe tum deep <1.5cm,28045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Exc foot/toe tum deep <1.5cm,28045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Exc foot/toe tum deep <1.5cm,28045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Exc foot/toe tum deep <1.5cm,28045,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Resect foot/toe tumor < 3 cm,28046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5198.26,,,,,,,fee schedule,2875.57,12757.95,
Resect foot/toe tumor < 3 cm,28046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4166.86,,,,,,,fee schedule,2875.57,12757.95,
Resect foot/toe tumor < 3 cm,28046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4551.91,,,,,,,fee schedule,2875.57,12757.95,
Resect foot/toe tumor < 3 cm,28046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4785.7,,,,,,,fee schedule,2875.57,12757.95,
Resect foot/toe tumor < 3 cm,28046,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Resect foot/toe tumor < 3 cm,28046,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Resect foot/toe tumor < 3 cm,28046,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Resect foot/toe tumor < 3 cm,28046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Resect foot/toe tumor < 3 cm,28046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Resect foot/toe tumor < 3 cm,28046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Resect foot/toe tumor < 3 cm,28046,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Resect foot/toe tumor 3 cm/>,28047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1457.9,,,,,,,fee schedule,1168.63,12757.95,
Resect foot/toe tumor 3 cm/>,28047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1168.63,,,,,,,fee schedule,1168.63,12757.95,
Resect foot/toe tumor 3 cm/>,28047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1276.62,,,,,,,fee schedule,1168.63,12757.95,
Resect foot/toe tumor 3 cm/>,28047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1342.19,,,,,,,fee schedule,1168.63,12757.95,
Resect foot/toe tumor 3 cm/>,28047,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,1168.63,12757.95,APC 378
Resect foot/toe tumor 3 cm/>,28047,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,1168.63,12757.95,APC
Resect foot/toe tumor 3 cm/>,28047,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,1168.63,12757.95,APC
Resect foot/toe tumor 3 cm/>,28047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,1168.63,12757.95,APC
Resect foot/toe tumor 3 cm/>,28047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,1168.63,12757.95,Radiology
Resect foot/toe tumor 3 cm/>,28047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,1168.63,12757.95,APC
Resect foot/toe tumor 3 cm/>,28047,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,1168.63,12757.95,APC
Biopsy of foot joint lining,28050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5198.26,,,,,,,fee schedule,3239.17,14371.12,
Biopsy of foot joint lining,28050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4166.86,,,,,,,fee schedule,3239.17,14371.12,
Biopsy of foot joint lining,28050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4551.91,,,,,,,fee schedule,3239.17,14371.12,
Biopsy of foot joint lining,28050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4785.7,,,,,,,fee schedule,3239.17,14371.12,
Biopsy of foot joint lining,28050,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Biopsy of foot joint lining,28050,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Biopsy of foot joint lining,28050,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Biopsy of foot joint lining,28050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Biopsy of foot joint lining,28050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Biopsy of foot joint lining,28050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Biopsy of foot joint lining,28050,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Biopsy of foot joint lining,28052,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5198.26,,,,,,,fee schedule,3239.17,14371.12,
Biopsy of foot joint lining,28052,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4166.86,,,,,,,fee schedule,3239.17,14371.12,
Biopsy of foot joint lining,28052,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4551.91,,,,,,,fee schedule,3239.17,14371.12,
Biopsy of foot joint lining,28052,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4785.7,,,,,,,fee schedule,3239.17,14371.12,
Biopsy of foot joint lining,28052,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Biopsy of foot joint lining,28052,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Biopsy of foot joint lining,28052,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Biopsy of foot joint lining,28052,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Biopsy of foot joint lining,28052,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Biopsy of foot joint lining,28052,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Biopsy of foot joint lining,28052,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Biopsy of toe joint lining,28054,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5198.26,,,,,,,fee schedule,3239.17,14371.12,
Biopsy of toe joint lining,28054,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4166.86,,,,,,,fee schedule,3239.17,14371.12,
Biopsy of toe joint lining,28054,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4551.91,,,,,,,fee schedule,3239.17,14371.12,
Biopsy of toe joint lining,28054,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4785.7,,,,,,,fee schedule,3239.17,14371.12,
Biopsy of toe joint lining,28054,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Biopsy of toe joint lining,28054,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Biopsy of toe joint lining,28054,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Biopsy of toe joint lining,28054,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Biopsy of toe joint lining,28054,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Biopsy of toe joint lining,28054,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Biopsy of toe joint lining,28054,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Neurectomy foot,28055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4505.27,,,,,,,fee schedule,1933.13,8576.66,
Neurectomy foot,28055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3611.37,,,,,,,fee schedule,1933.13,8576.66,
Neurectomy foot,28055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3945.09,,,,,,,fee schedule,1933.13,8576.66,
Neurectomy foot,28055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4147.71,,,,,,,fee schedule,1933.13,8576.66,
Neurectomy foot,28055,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8576.66,,,,,,,fee schedule,1933.13,8576.66,APC 378
Neurectomy foot,28055,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2029.79,,,,,,,fee schedule,1933.13,8576.66,APC
Neurectomy foot,28055,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2010.46,,,,,,,fee schedule,1933.13,8576.66,APC
Neurectomy foot,28055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1933.13,,,,,,,fee schedule,1933.13,8576.66,APC
Neurectomy foot,28055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2957.7,,,,,,,fee schedule,1933.13,8576.66,Radiology
Neurectomy foot,28055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2706.39,,,,,,,fee schedule,1933.13,8576.66,APC
Neurectomy foot,28055,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3382.99,,,,,,,fee schedule,1933.13,8576.66,APC
Partial removal foot fascia,28060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5198.26,,,,,,,fee schedule,3239.17,14371.12,
Partial removal foot fascia,28060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4166.86,,,,,,,fee schedule,3239.17,14371.12,
Partial removal foot fascia,28060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4551.91,,,,,,,fee schedule,3239.17,14371.12,
Partial removal foot fascia,28060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4785.7,,,,,,,fee schedule,3239.17,14371.12,
Partial removal foot fascia,28060,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Partial removal foot fascia,28060,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Partial removal foot fascia,28060,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Partial removal foot fascia,28060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Partial removal foot fascia,28060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Partial removal foot fascia,28060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Partial removal foot fascia,28060,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of foot fascia,28062,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5198.26,,,,,,,fee schedule,3239.17,14371.12,
Removal of foot fascia,28062,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4166.86,,,,,,,fee schedule,3239.17,14371.12,
Removal of foot fascia,28062,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4551.91,,,,,,,fee schedule,3239.17,14371.12,
Removal of foot fascia,28062,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4785.7,,,,,,,fee schedule,3239.17,14371.12,
Removal of foot fascia,28062,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Removal of foot fascia,28062,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of foot fascia,28062,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of foot fascia,28062,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of foot fascia,28062,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Removal of foot fascia,28062,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of foot fascia,28062,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of foot joint lining,28070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5198.26,,,,,,,fee schedule,4166.86,31870.39,
Removal of foot joint lining,28070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4166.86,,,,,,,fee schedule,4166.86,31870.39,
Removal of foot joint lining,28070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4551.91,,,,,,,fee schedule,4166.86,31870.39,
Removal of foot joint lining,28070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4785.7,,,,,,,fee schedule,4166.86,31870.39,
Removal of foot joint lining,28070,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,4166.86,31870.39,APC 378
Removal of foot joint lining,28070,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,4166.86,31870.39,APC
Removal of foot joint lining,28070,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,4166.86,31870.39,APC
Removal of foot joint lining,28070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,4166.86,31870.39,APC
Removal of foot joint lining,28070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,4166.86,31870.39,Radiology
Removal of foot joint lining,28070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,4166.86,31870.39,APC
Removal of foot joint lining,28070,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,4166.86,31870.39,APC
Removal of foot joint lining,28072,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4466.25,,,,,,,fee schedule,3239.17,14371.12,
Removal of foot joint lining,28072,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3580.09,,,,,,,fee schedule,3239.17,14371.12,
Removal of foot joint lining,28072,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3910.92,,,,,,,fee schedule,3239.17,14371.12,
Removal of foot joint lining,28072,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4111.79,,,,,,,fee schedule,3239.17,14371.12,
Removal of foot joint lining,28072,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Removal of foot joint lining,28072,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of foot joint lining,28072,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of foot joint lining,28072,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of foot joint lining,28072,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Removal of foot joint lining,28072,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of foot joint lining,28072,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of foot lesion,28080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4487.27,,,,,,,fee schedule,1591.86,7062.54,
Removal of foot lesion,28080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3596.94,,,,,,,fee schedule,1591.86,7062.54,
Removal of foot lesion,28080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3929.33,,,,,,,fee schedule,1591.86,7062.54,
Removal of foot lesion,28080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4131.14,,,,,,,fee schedule,1591.86,7062.54,
Removal of foot lesion,28080,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Removal of foot lesion,28080,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Removal of foot lesion,28080,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Removal of foot lesion,28080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Removal of foot lesion,28080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Removal of foot lesion,28080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Removal of foot lesion,28080,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Excise foot tendon sheath,28086,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5198.26,,,,,,,fee schedule,3239.17,14371.12,
Excise foot tendon sheath,28086,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4166.86,,,,,,,fee schedule,3239.17,14371.12,
Excise foot tendon sheath,28086,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4551.91,,,,,,,fee schedule,3239.17,14371.12,
Excise foot tendon sheath,28086,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4785.7,,,,,,,fee schedule,3239.17,14371.12,
Excise foot tendon sheath,28086,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Excise foot tendon sheath,28086,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Excise foot tendon sheath,28086,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Excise foot tendon sheath,28086,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Excise foot tendon sheath,28086,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Excise foot tendon sheath,28086,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Excise foot tendon sheath,28086,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Excise foot tendon sheath,28088,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5198.26,,,,,,,fee schedule,3239.17,14371.12,
Excise foot tendon sheath,28088,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4166.86,,,,,,,fee schedule,3239.17,14371.12,
Excise foot tendon sheath,28088,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4551.91,,,,,,,fee schedule,3239.17,14371.12,
Excise foot tendon sheath,28088,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4785.7,,,,,,,fee schedule,3239.17,14371.12,
Excise foot tendon sheath,28088,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Excise foot tendon sheath,28088,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Excise foot tendon sheath,28088,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Excise foot tendon sheath,28088,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Excise foot tendon sheath,28088,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Excise foot tendon sheath,28088,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Excise foot tendon sheath,28088,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of foot lesion,28090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6721.57,,,,,,,fee schedule,1591.86,7062.54,
Removal of foot lesion,28090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5387.93,,,,,,,fee schedule,1591.86,7062.54,
Removal of foot lesion,28090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5885.82,,,,,,,fee schedule,1591.86,7062.54,
Removal of foot lesion,28090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6188.11,,,,,,,fee schedule,1591.86,7062.54,
Removal of foot lesion,28090,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Removal of foot lesion,28090,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Removal of foot lesion,28090,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Removal of foot lesion,28090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Removal of foot lesion,28090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Removal of foot lesion,28090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Removal of foot lesion,28090,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Removal of toe lesions,28092,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3360.79,,,,,,,fee schedule,1591.86,7062.54,
Removal of toe lesions,28092,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2693.96,,,,,,,fee schedule,1591.86,7062.54,
Removal of toe lesions,28092,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2942.91,,,,,,,fee schedule,1591.86,7062.54,
Removal of toe lesions,28092,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3094.06,,,,,,,fee schedule,1591.86,7062.54,
Removal of toe lesions,28092,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Removal of toe lesions,28092,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Removal of toe lesions,28092,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Removal of toe lesions,28092,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Removal of toe lesions,28092,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Removal of toe lesions,28092,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Removal of toe lesions,28092,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Removal of ankle/heel lesion,28100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5198.26,,,,,,,fee schedule,3239.17,14371.12,
Removal of ankle/heel lesion,28100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4166.86,,,,,,,fee schedule,3239.17,14371.12,
Removal of ankle/heel lesion,28100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4551.91,,,,,,,fee schedule,3239.17,14371.12,
Removal of ankle/heel lesion,28100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4785.7,,,,,,,fee schedule,3239.17,14371.12,
Removal of ankle/heel lesion,28100,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Removal of ankle/heel lesion,28100,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of ankle/heel lesion,28100,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of ankle/heel lesion,28100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of ankle/heel lesion,28100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Removal of ankle/heel lesion,28100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of ankle/heel lesion,28100,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Remove/graft foot lesion,28102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11048.37,,,,,,,fee schedule,7183.42,31870.39,
Remove/graft foot lesion,28102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8856.24,,,,,,,fee schedule,7183.42,31870.39,
Remove/graft foot lesion,28102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9674.63,,,,,,,fee schedule,7183.42,31870.39,
Remove/graft foot lesion,28102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10171.52,,,,,,,fee schedule,7183.42,31870.39,
Remove/graft foot lesion,28102,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Remove/graft foot lesion,28102,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Remove/graft foot lesion,28102,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Remove/graft foot lesion,28102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Remove/graft foot lesion,28102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Remove/graft foot lesion,28102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Remove/graft foot lesion,28102,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Remove/graft foot lesion,28103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11048.37,,,,,,,fee schedule,7183.42,31870.39,
Remove/graft foot lesion,28103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8856.24,,,,,,,fee schedule,7183.42,31870.39,
Remove/graft foot lesion,28103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9674.63,,,,,,,fee schedule,7183.42,31870.39,
Remove/graft foot lesion,28103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10171.52,,,,,,,fee schedule,7183.42,31870.39,
Remove/graft foot lesion,28103,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Remove/graft foot lesion,28103,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Remove/graft foot lesion,28103,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Remove/graft foot lesion,28103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Remove/graft foot lesion,28103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Remove/graft foot lesion,28103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Remove/graft foot lesion,28103,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Removal of foot lesion,28104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2785.39,,,,,,,fee schedule,2232.74,14371.12,
Removal of foot lesion,28104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2232.74,,,,,,,fee schedule,2232.74,14371.12,
Removal of foot lesion,28104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2439.06,,,,,,,fee schedule,2232.74,14371.12,
Removal of foot lesion,28104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2564.33,,,,,,,fee schedule,2232.74,14371.12,
Removal of foot lesion,28104,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,2232.74,14371.12,APC 378
Removal of foot lesion,28104,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,2232.74,14371.12,APC
Removal of foot lesion,28104,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,2232.74,14371.12,APC
Removal of foot lesion,28104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,2232.74,14371.12,APC
Removal of foot lesion,28104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,2232.74,14371.12,Radiology
Removal of foot lesion,28104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,2232.74,14371.12,APC
Removal of foot lesion,28104,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,2232.74,14371.12,APC
Remove/graft foot lesion,28106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11048.37,,,,,,,fee schedule,7183.42,31870.39,
Remove/graft foot lesion,28106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8856.24,,,,,,,fee schedule,7183.42,31870.39,
Remove/graft foot lesion,28106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9674.63,,,,,,,fee schedule,7183.42,31870.39,
Remove/graft foot lesion,28106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10171.52,,,,,,,fee schedule,7183.42,31870.39,
Remove/graft foot lesion,28106,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Remove/graft foot lesion,28106,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Remove/graft foot lesion,28106,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Remove/graft foot lesion,28106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Remove/graft foot lesion,28106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Remove/graft foot lesion,28106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Remove/graft foot lesion,28106,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Remove/graft foot lesion,28107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11048.37,,,,,,,fee schedule,7183.42,31870.39,
Remove/graft foot lesion,28107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8856.24,,,,,,,fee schedule,7183.42,31870.39,
Remove/graft foot lesion,28107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9674.63,,,,,,,fee schedule,7183.42,31870.39,
Remove/graft foot lesion,28107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10171.52,,,,,,,fee schedule,7183.42,31870.39,
Remove/graft foot lesion,28107,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Remove/graft foot lesion,28107,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Remove/graft foot lesion,28107,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Remove/graft foot lesion,28107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Remove/graft foot lesion,28107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Remove/graft foot lesion,28107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Remove/graft foot lesion,28107,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Removal of toe lesions,28108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4062.96,,,,,,,fee schedule,1591.86,7062.54,
Removal of toe lesions,28108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3256.82,,,,,,,fee schedule,1591.86,7062.54,
Removal of toe lesions,28108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3557.78,,,,,,,fee schedule,1591.86,7062.54,
Removal of toe lesions,28108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3740.5,,,,,,,fee schedule,1591.86,7062.54,
Removal of toe lesions,28108,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Removal of toe lesions,28108,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Removal of toe lesions,28108,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Removal of toe lesions,28108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Removal of toe lesions,28108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Removal of toe lesions,28108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Removal of toe lesions,28108,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Part removal of metatarsal,28110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3082.07,,,,,,,fee schedule,2470.54,14371.12,
Part removal of metatarsal,28110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2470.54,,,,,,,fee schedule,2470.54,14371.12,
Part removal of metatarsal,28110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2698.85,,,,,,,fee schedule,2470.54,14371.12,
Part removal of metatarsal,28110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2837.46,,,,,,,fee schedule,2470.54,14371.12,
Part removal of metatarsal,28110,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,2470.54,14371.12,APC 378
Part removal of metatarsal,28110,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,2470.54,14371.12,APC
Part removal of metatarsal,28110,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,2470.54,14371.12,APC
Part removal of metatarsal,28110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,2470.54,14371.12,APC
Part removal of metatarsal,28110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,2470.54,14371.12,Radiology
Part removal of metatarsal,28110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,2470.54,14371.12,APC
Part removal of metatarsal,28110,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,2470.54,14371.12,APC
Part removal of metatarsal,28111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5198.26,,,,,,,fee schedule,3239.17,14371.12,
Part removal of metatarsal,28111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4166.86,,,,,,,fee schedule,3239.17,14371.12,
Part removal of metatarsal,28111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4551.91,,,,,,,fee schedule,3239.17,14371.12,
Part removal of metatarsal,28111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4785.7,,,,,,,fee schedule,3239.17,14371.12,
Part removal of metatarsal,28111,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Part removal of metatarsal,28111,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Part removal of metatarsal,28111,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Part removal of metatarsal,28111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Part removal of metatarsal,28111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Part removal of metatarsal,28111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Part removal of metatarsal,28111,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Part removal of metatarsal,28112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5198.26,,,,,,,fee schedule,3239.17,14371.12,
Part removal of metatarsal,28112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4166.86,,,,,,,fee schedule,3239.17,14371.12,
Part removal of metatarsal,28112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4551.91,,,,,,,fee schedule,3239.17,14371.12,
Part removal of metatarsal,28112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4785.7,,,,,,,fee schedule,3239.17,14371.12,
Part removal of metatarsal,28112,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Part removal of metatarsal,28112,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Part removal of metatarsal,28112,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Part removal of metatarsal,28112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Part removal of metatarsal,28112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Part removal of metatarsal,28112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Part removal of metatarsal,28112,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Part removal of metatarsal,28113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9737.23,,,,,,,fee schedule,3239.17,14371.12,
Part removal of metatarsal,28113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7805.24,,,,,,,fee schedule,3239.17,14371.12,
Part removal of metatarsal,28113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8526.52,,,,,,,fee schedule,3239.17,14371.12,
Part removal of metatarsal,28113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8964.43,,,,,,,fee schedule,3239.17,14371.12,
Part removal of metatarsal,28113,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Part removal of metatarsal,28113,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Part removal of metatarsal,28113,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Part removal of metatarsal,28113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Part removal of metatarsal,28113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Part removal of metatarsal,28113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Part removal of metatarsal,28113,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of metatarsal heads,28114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5198.26,,,,,,,fee schedule,3239.17,14371.12,
Removal of metatarsal heads,28114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4166.86,,,,,,,fee schedule,3239.17,14371.12,
Removal of metatarsal heads,28114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4551.91,,,,,,,fee schedule,3239.17,14371.12,
Removal of metatarsal heads,28114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4785.7,,,,,,,fee schedule,3239.17,14371.12,
Removal of metatarsal heads,28114,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Removal of metatarsal heads,28114,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of metatarsal heads,28114,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of metatarsal heads,28114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of metatarsal heads,28114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Removal of metatarsal heads,28114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of metatarsal heads,28114,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Revision of foot,28116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7189.69,,,,,,,fee schedule,3239.17,14371.12,
Revision of foot,28116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5763.16,,,,,,,fee schedule,3239.17,14371.12,
Revision of foot,28116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6295.73,,,,,,,fee schedule,3239.17,14371.12,
Revision of foot,28116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6619.08,,,,,,,fee schedule,3239.17,14371.12,
Revision of foot,28116,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Revision of foot,28116,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Revision of foot,28116,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Revision of foot,28116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Revision of foot,28116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Revision of foot,28116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Revision of foot,28116,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of heel bone,28118,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4369.26,,,,,,,fee schedule,3239.17,14371.12,
Removal of heel bone,28118,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3502.34,,,,,,,fee schedule,3239.17,14371.12,
Removal of heel bone,28118,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3825.99,,,,,,,fee schedule,3239.17,14371.12,
Removal of heel bone,28118,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4022.49,,,,,,,fee schedule,3239.17,14371.12,
Removal of heel bone,28118,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Removal of heel bone,28118,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of heel bone,28118,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of heel bone,28118,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of heel bone,28118,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Removal of heel bone,28118,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of heel bone,28118,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of heel spur,28119,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6380.24,,,,,,,fee schedule,3239.17,14371.12,
Removal of heel spur,28119,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5114.32,,,,,,,fee schedule,3239.17,14371.12,
Removal of heel spur,28119,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5586.93,,,,,,,fee schedule,3239.17,14371.12,
Removal of heel spur,28119,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5873.87,,,,,,,fee schedule,3239.17,14371.12,
Removal of heel spur,28119,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Removal of heel spur,28119,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of heel spur,28119,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of heel spur,28119,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of heel spur,28119,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Removal of heel spur,28119,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of heel spur,28119,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Part removal of ankle/heel,28120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6038.9,,,,,,,fee schedule,3239.17,14371.12,
Part removal of ankle/heel,28120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4840.71,,,,,,,fee schedule,3239.17,14371.12,
Part removal of ankle/heel,28120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5288.03,,,,,,,fee schedule,3239.17,14371.12,
Part removal of ankle/heel,28120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5559.62,,,,,,,fee schedule,3239.17,14371.12,
Part removal of ankle/heel,28120,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Part removal of ankle/heel,28120,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Part removal of ankle/heel,28120,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Part removal of ankle/heel,28120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Part removal of ankle/heel,28120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Part removal of ankle/heel,28120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Part removal of ankle/heel,28120,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Partial removal of foot bone,28122,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6039.4,,,,,,,fee schedule,3239.17,14371.12,
Partial removal of foot bone,28122,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4841.11,,,,,,,fee schedule,3239.17,14371.12,
Partial removal of foot bone,28122,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5288.47,,,,,,,fee schedule,3239.17,14371.12,
Partial removal of foot bone,28122,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5560.08,,,,,,,fee schedule,3239.17,14371.12,
Partial removal of foot bone,28122,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Partial removal of foot bone,28122,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Partial removal of foot bone,28122,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Partial removal of foot bone,28122,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Partial removal of foot bone,28122,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Partial removal of foot bone,28122,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Partial removal of foot bone,28122,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Partial removal of toe,28124,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2084.5,,,,,,,fee schedule,1670.91,14371.12,
Partial removal of toe,28124,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1670.91,,,,,,,fee schedule,1670.91,14371.12,
Partial removal of toe,28124,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1825.32,,,,,,,fee schedule,1670.91,14371.12,
Partial removal of toe,28124,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1919.06,,,,,,,fee schedule,1670.91,14371.12,
Partial removal of toe,28124,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,1670.91,14371.12,APC 378
Partial removal of toe,28124,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,1670.91,14371.12,APC
Partial removal of toe,28124,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,1670.91,14371.12,APC
Partial removal of toe,28124,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,1670.91,14371.12,APC
Partial removal of toe,28124,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,1670.91,14371.12,Radiology
Partial removal of toe,28124,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,1670.91,14371.12,APC
Partial removal of toe,28124,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,1670.91,14371.12,APC
Partial removal of toe,28126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5198.26,,,,,,,fee schedule,3239.17,14371.12,
Partial removal of toe,28126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4166.86,,,,,,,fee schedule,3239.17,14371.12,
Partial removal of toe,28126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4551.91,,,,,,,fee schedule,3239.17,14371.12,
Partial removal of toe,28126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4785.7,,,,,,,fee schedule,3239.17,14371.12,
Partial removal of toe,28126,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Partial removal of toe,28126,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Partial removal of toe,28126,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Partial removal of toe,28126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Partial removal of toe,28126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Partial removal of toe,28126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Partial removal of toe,28126,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of ankle bone,28130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5198.26,,,,,,,fee schedule,4166.86,31870.39,
Removal of ankle bone,28130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4166.86,,,,,,,fee schedule,4166.86,31870.39,
Removal of ankle bone,28130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4551.91,,,,,,,fee schedule,4166.86,31870.39,
Removal of ankle bone,28130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4785.7,,,,,,,fee schedule,4166.86,31870.39,
Removal of ankle bone,28130,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,4166.86,31870.39,APC 378
Removal of ankle bone,28130,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,4166.86,31870.39,APC
Removal of ankle bone,28130,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,4166.86,31870.39,APC
Removal of ankle bone,28130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,4166.86,31870.39,APC
Removal of ankle bone,28130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,4166.86,31870.39,Radiology
Removal of ankle bone,28130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,4166.86,31870.39,APC
Removal of ankle bone,28130,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,4166.86,31870.39,APC
Removal of metatarsal,28140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5198.26,,,,,,,fee schedule,3239.17,14371.12,
Removal of metatarsal,28140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4166.86,,,,,,,fee schedule,3239.17,14371.12,
Removal of metatarsal,28140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4551.91,,,,,,,fee schedule,3239.17,14371.12,
Removal of metatarsal,28140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4785.7,,,,,,,fee schedule,3239.17,14371.12,
Removal of metatarsal,28140,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Removal of metatarsal,28140,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of metatarsal,28140,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of metatarsal,28140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of metatarsal,28140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Removal of metatarsal,28140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of metatarsal,28140,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of toe,28150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5198.26,,,,,,,fee schedule,3239.17,14371.12,
Removal of toe,28150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4166.86,,,,,,,fee schedule,3239.17,14371.12,
Removal of toe,28150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4551.91,,,,,,,fee schedule,3239.17,14371.12,
Removal of toe,28150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4785.7,,,,,,,fee schedule,3239.17,14371.12,
Removal of toe,28150,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Removal of toe,28150,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of toe,28150,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of toe,28150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of toe,28150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Removal of toe,28150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of toe,28150,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Partial removal of toe,28153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1999.68,,,,,,,fee schedule,1602.91,14371.12,
Partial removal of toe,28153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1602.91,,,,,,,fee schedule,1602.91,14371.12,
Partial removal of toe,28153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1751.04,,,,,,,fee schedule,1602.91,14371.12,
Partial removal of toe,28153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1840.97,,,,,,,fee schedule,1602.91,14371.12,
Partial removal of toe,28153,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,1602.91,14371.12,APC 378
Partial removal of toe,28153,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,1602.91,14371.12,APC
Partial removal of toe,28153,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,1602.91,14371.12,APC
Partial removal of toe,28153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,1602.91,14371.12,APC
Partial removal of toe,28153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,1602.91,14371.12,Radiology
Partial removal of toe,28153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,1602.91,14371.12,APC
Partial removal of toe,28153,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,1602.91,14371.12,APC
Partial removal of toe,28160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3360.79,,,,,,,fee schedule,2693.96,14371.12,
Partial removal of toe,28160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2693.96,,,,,,,fee schedule,2693.96,14371.12,
Partial removal of toe,28160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2942.91,,,,,,,fee schedule,2693.96,14371.12,
Partial removal of toe,28160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3094.06,,,,,,,fee schedule,2693.96,14371.12,
Partial removal of toe,28160,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,2693.96,14371.12,APC 378
Partial removal of toe,28160,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,2693.96,14371.12,APC
Partial removal of toe,28160,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,2693.96,14371.12,APC
Partial removal of toe,28160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,2693.96,14371.12,APC
Partial removal of toe,28160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,2693.96,14371.12,Radiology
Partial removal of toe,28160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,2693.96,14371.12,APC
Partial removal of toe,28160,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,2693.96,14371.12,APC
Resect tarsal tumor,28171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5198.26,,,,,,,fee schedule,3239.17,14371.12,
Resect tarsal tumor,28171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4166.86,,,,,,,fee schedule,3239.17,14371.12,
Resect tarsal tumor,28171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4551.91,,,,,,,fee schedule,3239.17,14371.12,
Resect tarsal tumor,28171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4785.7,,,,,,,fee schedule,3239.17,14371.12,
Resect tarsal tumor,28171,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Resect tarsal tumor,28171,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Resect tarsal tumor,28171,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Resect tarsal tumor,28171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Resect tarsal tumor,28171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Resect tarsal tumor,28171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Resect tarsal tumor,28171,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Resect metatarsal tumor,28173,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5198.26,,,,,,,fee schedule,3239.17,14371.12,
Resect metatarsal tumor,28173,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4166.86,,,,,,,fee schedule,3239.17,14371.12,
Resect metatarsal tumor,28173,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4551.91,,,,,,,fee schedule,3239.17,14371.12,
Resect metatarsal tumor,28173,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4785.7,,,,,,,fee schedule,3239.17,14371.12,
Resect metatarsal tumor,28173,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Resect metatarsal tumor,28173,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Resect metatarsal tumor,28173,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Resect metatarsal tumor,28173,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Resect metatarsal tumor,28173,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Resect metatarsal tumor,28173,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Resect metatarsal tumor,28173,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Resect phalanx of toe tumor,28175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5198.26,,,,,,,fee schedule,1591.86,7062.54,
Resect phalanx of toe tumor,28175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4166.86,,,,,,,fee schedule,1591.86,7062.54,
Resect phalanx of toe tumor,28175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4551.91,,,,,,,fee schedule,1591.86,7062.54,
Resect phalanx of toe tumor,28175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4785.7,,,,,,,fee schedule,1591.86,7062.54,
Resect phalanx of toe tumor,28175,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Resect phalanx of toe tumor,28175,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Resect phalanx of toe tumor,28175,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Resect phalanx of toe tumor,28175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Resect phalanx of toe tumor,28175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Resect phalanx of toe tumor,28175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Resect phalanx of toe tumor,28175,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Removal of foot foreign body,28190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4535.95,,,,,,,fee schedule,701.03,4535.95,
Removal of foot foreign body,28190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3635.96,,,,,,,fee schedule,701.03,4535.95,
Removal of foot foreign body,28190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3971.96,,,,,,,fee schedule,701.03,4535.95,
Removal of foot foreign body,28190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4175.95,,,,,,,fee schedule,701.03,4535.95,
Removal of foot foreign body,28190,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3110.22,,,,,,,fee schedule,701.03,4535.95,APC 378
Removal of foot foreign body,28190,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,736.08,,,,,,,fee schedule,701.03,4535.95,APC
Removal of foot foreign body,28190,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,729.07,,,,,,,fee schedule,701.03,4535.95,APC
Removal of foot foreign body,28190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,701.03,,,,,,,fee schedule,701.03,4535.95,APC
Removal of foot foreign body,28190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1072.57,,,,,,,fee schedule,701.03,4535.95,Radiology
Removal of foot foreign body,28190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,981.44,,,,,,,fee schedule,701.03,4535.95,APC
Removal of foot foreign body,28190,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1226.8,,,,,,,fee schedule,701.03,4535.95,APC
Removal of foot foreign body,28192,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6721.57,,,,,,,fee schedule,1635.03,7254.06,
Removal of foot foreign body,28192,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5387.93,,,,,,,fee schedule,1635.03,7254.06,
Removal of foot foreign body,28192,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5885.82,,,,,,,fee schedule,1635.03,7254.06,
Removal of foot foreign body,28192,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6188.11,,,,,,,fee schedule,1635.03,7254.06,
Removal of foot foreign body,28192,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,7254.06,APC 378
Removal of foot foreign body,28192,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,7254.06,APC
Removal of foot foreign body,28192,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,7254.06,APC
Removal of foot foreign body,28192,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,7254.06,APC
Removal of foot foreign body,28192,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,7254.06,Radiology
Removal of foot foreign body,28192,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,7254.06,APC
Removal of foot foreign body,28192,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,7254.06,APC
Removal of foot foreign body,28193,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2167.57,,,,,,,fee schedule,1635.03,7254.06,
Removal of foot foreign body,28193,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1737.49,,,,,,,fee schedule,1635.03,7254.06,
Removal of foot foreign body,28193,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1898.05,,,,,,,fee schedule,1635.03,7254.06,
Removal of foot foreign body,28193,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1995.54,,,,,,,fee schedule,1635.03,7254.06,
Removal of foot foreign body,28193,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,7254.06,APC 378
Removal of foot foreign body,28193,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,7254.06,APC
Removal of foot foreign body,28193,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,7254.06,APC
Removal of foot foreign body,28193,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,7254.06,APC
Removal of foot foreign body,28193,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,7254.06,Radiology
Removal of foot foreign body,28193,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,7254.06,APC
Removal of foot foreign body,28193,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,7254.06,APC
Repair of foot tendon,28200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6038.9,,,,,,,fee schedule,3239.17,14371.12,
Repair of foot tendon,28200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4840.71,,,,,,,fee schedule,3239.17,14371.12,
Repair of foot tendon,28200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5288.03,,,,,,,fee schedule,3239.17,14371.12,
Repair of foot tendon,28200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5559.62,,,,,,,fee schedule,3239.17,14371.12,
Repair of foot tendon,28200,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Repair of foot tendon,28200,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Repair of foot tendon,28200,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Repair of foot tendon,28200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Repair of foot tendon,28200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Repair of foot tendon,28200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Repair of foot tendon,28200,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Repair/graft of foot tendon,28202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5198.26,,,,,,,fee schedule,4166.86,31870.39,
Repair/graft of foot tendon,28202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4166.86,,,,,,,fee schedule,4166.86,31870.39,
Repair/graft of foot tendon,28202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4551.91,,,,,,,fee schedule,4166.86,31870.39,
Repair/graft of foot tendon,28202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4785.7,,,,,,,fee schedule,4166.86,31870.39,
Repair/graft of foot tendon,28202,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,4166.86,31870.39,APC 378
Repair/graft of foot tendon,28202,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,4166.86,31870.39,APC
Repair/graft of foot tendon,28202,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,4166.86,31870.39,APC
Repair/graft of foot tendon,28202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,4166.86,31870.39,APC
Repair/graft of foot tendon,28202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,4166.86,31870.39,Radiology
Repair/graft of foot tendon,28202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,4166.86,31870.39,APC
Repair/graft of foot tendon,28202,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,4166.86,31870.39,APC
Repair of foot tendon,28208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4056.27,,,,,,,fee schedule,3239.17,14371.12,
Repair of foot tendon,28208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3251.46,,,,,,,fee schedule,3239.17,14371.12,
Repair of foot tendon,28208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3551.92,,,,,,,fee schedule,3239.17,14371.12,
Repair of foot tendon,28208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3734.35,,,,,,,fee schedule,3239.17,14371.12,
Repair of foot tendon,28208,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Repair of foot tendon,28208,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Repair of foot tendon,28208,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Repair of foot tendon,28208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Repair of foot tendon,28208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Repair of foot tendon,28208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Repair of foot tendon,28208,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Repair/graft of foot tendon,28210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11048.37,,,,,,,fee schedule,7183.42,31870.39,
Repair/graft of foot tendon,28210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8856.24,,,,,,,fee schedule,7183.42,31870.39,
Repair/graft of foot tendon,28210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9674.63,,,,,,,fee schedule,7183.42,31870.39,
Repair/graft of foot tendon,28210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10171.52,,,,,,,fee schedule,7183.42,31870.39,
Repair/graft of foot tendon,28210,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Repair/graft of foot tendon,28210,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Repair/graft of foot tendon,28210,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Repair/graft of foot tendon,28210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Repair/graft of foot tendon,28210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Repair/graft of foot tendon,28210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Repair/graft of foot tendon,28210,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Release of foot tendon,28220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3360.79,,,,,,,fee schedule,1591.86,7062.54,
Release of foot tendon,28220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2693.96,,,,,,,fee schedule,1591.86,7062.54,
Release of foot tendon,28220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2942.91,,,,,,,fee schedule,1591.86,7062.54,
Release of foot tendon,28220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3094.06,,,,,,,fee schedule,1591.86,7062.54,
Release of foot tendon,28220,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Release of foot tendon,28220,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Release of foot tendon,28220,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Release of foot tendon,28220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Release of foot tendon,28220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Release of foot tendon,28220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Release of foot tendon,28220,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Release of foot tendons,28222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5198.26,,,,,,,fee schedule,3239.17,14371.12,
Release of foot tendons,28222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4166.86,,,,,,,fee schedule,3239.17,14371.12,
Release of foot tendons,28222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4551.91,,,,,,,fee schedule,3239.17,14371.12,
Release of foot tendons,28222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4785.7,,,,,,,fee schedule,3239.17,14371.12,
Release of foot tendons,28222,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Release of foot tendons,28222,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Release of foot tendons,28222,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Release of foot tendons,28222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Release of foot tendons,28222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Release of foot tendons,28222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Release of foot tendons,28222,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Release of foot tendon,28225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5198.26,,,,,,,fee schedule,3239.17,14371.12,
Release of foot tendon,28225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4166.86,,,,,,,fee schedule,3239.17,14371.12,
Release of foot tendon,28225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4551.91,,,,,,,fee schedule,3239.17,14371.12,
Release of foot tendon,28225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4785.7,,,,,,,fee schedule,3239.17,14371.12,
Release of foot tendon,28225,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Release of foot tendon,28225,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Release of foot tendon,28225,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Release of foot tendon,28225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Release of foot tendon,28225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Release of foot tendon,28225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Release of foot tendon,28225,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Release of foot tendons,28226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5198.26,,,,,,,fee schedule,3239.17,14371.12,
Release of foot tendons,28226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4166.86,,,,,,,fee schedule,3239.17,14371.12,
Release of foot tendons,28226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4551.91,,,,,,,fee schedule,3239.17,14371.12,
Release of foot tendons,28226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4785.7,,,,,,,fee schedule,3239.17,14371.12,
Release of foot tendons,28226,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Release of foot tendons,28226,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Release of foot tendons,28226,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Release of foot tendons,28226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Release of foot tendons,28226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Release of foot tendons,28226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Release of foot tendons,28226,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Incision of foot tendon(s),28230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5198.26,,,,,,,fee schedule,1591.86,7062.54,
Incision of foot tendon(s),28230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4166.86,,,,,,,fee schedule,1591.86,7062.54,
Incision of foot tendon(s),28230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4551.91,,,,,,,fee schedule,1591.86,7062.54,
Incision of foot tendon(s),28230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4785.7,,,,,,,fee schedule,1591.86,7062.54,
Incision of foot tendon(s),28230,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Incision of foot tendon(s),28230,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Incision of foot tendon(s),28230,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Incision of foot tendon(s),28230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Incision of foot tendon(s),28230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Incision of foot tendon(s),28230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Incision of foot tendon(s),28230,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Incision of toe tendon,28232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1622.88,,,,,,,fee schedule,1300.88,7062.54,
Incision of toe tendon,28232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1300.88,,,,,,,fee schedule,1300.88,7062.54,
Incision of toe tendon,28232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1421.09,,,,,,,fee schedule,1300.88,7062.54,
Incision of toe tendon,28232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1494.08,,,,,,,fee schedule,1300.88,7062.54,
Incision of toe tendon,28232,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1300.88,7062.54,APC 378
Incision of toe tendon,28232,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1300.88,7062.54,APC
Incision of toe tendon,28232,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1300.88,7062.54,APC
Incision of toe tendon,28232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1300.88,7062.54,APC
Incision of toe tendon,28232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1300.88,7062.54,Radiology
Incision of toe tendon,28232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1300.88,7062.54,APC
Incision of toe tendon,28232,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1300.88,7062.54,APC
Incision of foot tendon,28234,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2602.81,,,,,,,fee schedule,1591.86,7062.54,
Incision of foot tendon,28234,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2086.38,,,,,,,fee schedule,1591.86,7062.54,
Incision of foot tendon,28234,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2279.18,,,,,,,fee schedule,1591.86,7062.54,
Incision of foot tendon,28234,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2396.24,,,,,,,fee schedule,1591.86,7062.54,
Incision of foot tendon,28234,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Incision of foot tendon,28234,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Incision of foot tendon,28234,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Incision of foot tendon,28234,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Incision of foot tendon,28234,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Incision of foot tendon,28234,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Incision of foot tendon,28234,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Revision of foot tendon,28238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9293.68,,,,,,,fee schedule,7183.42,31870.39,
Revision of foot tendon,28238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7449.69,,,,,,,fee schedule,7183.42,31870.39,
Revision of foot tendon,28238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8138.11,,,,,,,fee schedule,7183.42,31870.39,
Revision of foot tendon,28238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8556.08,,,,,,,fee schedule,7183.42,31870.39,
Revision of foot tendon,28238,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Revision of foot tendon,28238,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Revision of foot tendon,28238,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Revision of foot tendon,28238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Revision of foot tendon,28238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Revision of foot tendon,28238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Revision of foot tendon,28238,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Release of big toe,28240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5198.26,,,,,,,fee schedule,3239.17,14371.12,
Release of big toe,28240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4166.86,,,,,,,fee schedule,3239.17,14371.12,
Release of big toe,28240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4551.91,,,,,,,fee schedule,3239.17,14371.12,
Release of big toe,28240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4785.7,,,,,,,fee schedule,3239.17,14371.12,
Release of big toe,28240,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Release of big toe,28240,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Release of big toe,28240,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Release of big toe,28240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Release of big toe,28240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Release of big toe,28240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Release of big toe,28240,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Revision of foot fascia,28250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3019.45,,,,,,,fee schedule,2420.35,14371.12,
Revision of foot fascia,28250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2420.35,,,,,,,fee schedule,2420.35,14371.12,
Revision of foot fascia,28250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2644.02,,,,,,,fee schedule,2420.35,14371.12,
Revision of foot fascia,28250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2779.81,,,,,,,fee schedule,2420.35,14371.12,
Revision of foot fascia,28250,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,2420.35,14371.12,APC 378
Revision of foot fascia,28250,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,2420.35,14371.12,APC
Revision of foot fascia,28250,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,2420.35,14371.12,APC
Revision of foot fascia,28250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,2420.35,14371.12,APC
Revision of foot fascia,28250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,2420.35,14371.12,Radiology
Revision of foot fascia,28250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,2420.35,14371.12,APC
Revision of foot fascia,28250,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,2420.35,14371.12,APC
Release of midfoot joint,28260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5198.26,,,,,,,fee schedule,3239.17,14371.12,
Release of midfoot joint,28260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4166.86,,,,,,,fee schedule,3239.17,14371.12,
Release of midfoot joint,28260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4551.91,,,,,,,fee schedule,3239.17,14371.12,
Release of midfoot joint,28260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4785.7,,,,,,,fee schedule,3239.17,14371.12,
Release of midfoot joint,28260,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Release of midfoot joint,28260,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Release of midfoot joint,28260,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Release of midfoot joint,28260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Release of midfoot joint,28260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Release of midfoot joint,28260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Release of midfoot joint,28260,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Revision of foot tendon,28261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5198.26,,,,,,,fee schedule,1591.86,7062.54,
Revision of foot tendon,28261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4166.86,,,,,,,fee schedule,1591.86,7062.54,
Revision of foot tendon,28261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4551.91,,,,,,,fee schedule,1591.86,7062.54,
Revision of foot tendon,28261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4785.7,,,,,,,fee schedule,1591.86,7062.54,
Revision of foot tendon,28261,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Revision of foot tendon,28261,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Revision of foot tendon,28261,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Revision of foot tendon,28261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Revision of foot tendon,28261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Revision of foot tendon,28261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Revision of foot tendon,28261,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Revision of foot and ankle,28262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5198.26,,,,,,,fee schedule,4166.86,31870.39,
Revision of foot and ankle,28262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4166.86,,,,,,,fee schedule,4166.86,31870.39,
Revision of foot and ankle,28262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4551.91,,,,,,,fee schedule,4166.86,31870.39,
Revision of foot and ankle,28262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4785.7,,,,,,,fee schedule,4166.86,31870.39,
Revision of foot and ankle,28262,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,4166.86,31870.39,APC 378
Revision of foot and ankle,28262,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,4166.86,31870.39,APC
Revision of foot and ankle,28262,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,4166.86,31870.39,APC
Revision of foot and ankle,28262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,4166.86,31870.39,APC
Revision of foot and ankle,28262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,4166.86,31870.39,Radiology
Revision of foot and ankle,28262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,4166.86,31870.39,APC
Revision of foot and ankle,28262,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,4166.86,31870.39,APC
Release of midfoot joint,28264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11048.37,,,,,,,fee schedule,1591.86,11048.37,
Release of midfoot joint,28264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8856.24,,,,,,,fee schedule,1591.86,11048.37,
Release of midfoot joint,28264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9674.63,,,,,,,fee schedule,1591.86,11048.37,
Release of midfoot joint,28264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10171.52,,,,,,,fee schedule,1591.86,11048.37,
Release of midfoot joint,28264,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,11048.37,APC 378
Release of midfoot joint,28264,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,11048.37,APC
Release of midfoot joint,28264,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,11048.37,APC
Release of midfoot joint,28264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,11048.37,APC
Release of midfoot joint,28264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,11048.37,Radiology
Release of midfoot joint,28264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,11048.37,APC
Release of midfoot joint,28264,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,11048.37,APC
Release of foot contracture,28270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2188.03,,,,,,,fee schedule,1753.89,14371.12,
Release of foot contracture,28270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1753.89,,,,,,,fee schedule,1753.89,14371.12,
Release of foot contracture,28270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1915.97,,,,,,,fee schedule,1753.89,14371.12,
Release of foot contracture,28270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2014.37,,,,,,,fee schedule,1753.89,14371.12,
Release of foot contracture,28270,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,1753.89,14371.12,APC 378
Release of foot contracture,28270,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,1753.89,14371.12,APC
Release of foot contracture,28270,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,1753.89,14371.12,APC
Release of foot contracture,28270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,1753.89,14371.12,APC
Release of foot contracture,28270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,1753.89,14371.12,Radiology
Release of foot contracture,28270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,1753.89,14371.12,APC
Release of foot contracture,28270,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,1753.89,14371.12,APC
Release of toe joint each,28272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1622.87,,,,,,,fee schedule,1300.87,7062.54,
Release of toe joint each,28272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1300.87,,,,,,,fee schedule,1300.87,7062.54,
Release of toe joint each,28272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1421.08,,,,,,,fee schedule,1300.87,7062.54,
Release of toe joint each,28272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1494.07,,,,,,,fee schedule,1300.87,7062.54,
Release of toe joint each,28272,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1300.87,7062.54,APC 378
Release of toe joint each,28272,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1300.87,7062.54,APC
Release of toe joint each,28272,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1300.87,7062.54,APC
Release of toe joint each,28272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1300.87,7062.54,APC
Release of toe joint each,28272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1300.87,7062.54,Radiology
Release of toe joint each,28272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1300.87,7062.54,APC
Release of toe joint each,28272,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1300.87,7062.54,APC
Fusion of toes,28280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1531.56,,,,,,,fee schedule,1227.68,14371.12,
Fusion of toes,28280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1227.68,,,,,,,fee schedule,1227.68,14371.12,
Fusion of toes,28280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1341.13,,,,,,,fee schedule,1227.68,14371.12,
Fusion of toes,28280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1410.01,,,,,,,fee schedule,1227.68,14371.12,
Fusion of toes,28280,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,1227.68,14371.12,APC 378
Fusion of toes,28280,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,1227.68,14371.12,APC
Fusion of toes,28280,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,1227.68,14371.12,APC
Fusion of toes,28280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,1227.68,14371.12,APC
Fusion of toes,28280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,1227.68,14371.12,Radiology
Fusion of toes,28280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,1227.68,14371.12,APC
Fusion of toes,28280,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,1227.68,14371.12,APC
Repair of hammertoe,28285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3082.71,,,,,,,fee schedule,2471.06,14371.12,
Repair of hammertoe,28285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2471.06,,,,,,,fee schedule,2471.06,14371.12,
Repair of hammertoe,28285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2699.41,,,,,,,fee schedule,2471.06,14371.12,
Repair of hammertoe,28285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2838.05,,,,,,,fee schedule,2471.06,14371.12,
Repair of hammertoe,28285,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,2471.06,14371.12,APC 378
Repair of hammertoe,28285,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,2471.06,14371.12,APC
Repair of hammertoe,28285,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,2471.06,14371.12,APC
Repair of hammertoe,28285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,2471.06,14371.12,APC
Repair of hammertoe,28285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,2471.06,14371.12,Radiology
Repair of hammertoe,28285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,2471.06,14371.12,APC
Repair of hammertoe,28285,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,2471.06,14371.12,APC
Repair of hammertoe,28286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2785.39,,,,,,,fee schedule,2232.74,14371.12,
Repair of hammertoe,28286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2232.74,,,,,,,fee schedule,2232.74,14371.12,
Repair of hammertoe,28286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2439.06,,,,,,,fee schedule,2232.74,14371.12,
Repair of hammertoe,28286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2564.33,,,,,,,fee schedule,2232.74,14371.12,
Repair of hammertoe,28286,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,2232.74,14371.12,APC 378
Repair of hammertoe,28286,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,2232.74,14371.12,APC
Repair of hammertoe,28286,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,2232.74,14371.12,APC
Repair of hammertoe,28286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,2232.74,14371.12,APC
Repair of hammertoe,28286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,2232.74,14371.12,Radiology
Repair of hammertoe,28286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,2232.74,14371.12,APC
Repair of hammertoe,28286,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,2232.74,14371.12,APC
Partial removal of foot bone,28288,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1990.01,,,,,,,fee schedule,1595.17,14371.12,
Partial removal of foot bone,28288,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1595.17,,,,,,,fee schedule,1595.17,14371.12,
Partial removal of foot bone,28288,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1742.58,,,,,,,fee schedule,1595.17,14371.12,
Partial removal of foot bone,28288,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1832.07,,,,,,,fee schedule,1595.17,14371.12,
Partial removal of foot bone,28288,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,1595.17,14371.12,APC 378
Partial removal of foot bone,28288,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,1595.17,14371.12,APC
Partial removal of foot bone,28288,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,1595.17,14371.12,APC
Partial removal of foot bone,28288,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,1595.17,14371.12,APC
Partial removal of foot bone,28288,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,1595.17,14371.12,Radiology
Partial removal of foot bone,28288,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,1595.17,14371.12,APC
Partial removal of foot bone,28288,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,1595.17,14371.12,APC
Corrj halux rigdus w/o implt,28289,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6731.32,,,,,,,fee schedule,3239.17,14371.12,
Corrj halux rigdus w/o implt,28289,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5395.74,,,,,,,fee schedule,3239.17,14371.12,
Corrj halux rigdus w/o implt,28289,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5894.36,,,,,,,fee schedule,3239.17,14371.12,
Corrj halux rigdus w/o implt,28289,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6197.09,,,,,,,fee schedule,3239.17,14371.12,
Corrj halux rigdus w/o implt,28289,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Corrj halux rigdus w/o implt,28289,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Corrj halux rigdus w/o implt,28289,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Corrj halux rigdus w/o implt,28289,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Corrj halux rigdus w/o implt,28289,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Corrj halux rigdus w/o implt,28289,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Corrj halux rigdus w/o implt,28289,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Corrj halux rigdus w/implt,28291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5968.27,,,,,,,fee schedule,4784.09,31870.39,
Corrj halux rigdus w/implt,28291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4784.09,,,,,,,fee schedule,4784.09,31870.39,
Corrj halux rigdus w/implt,28291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5226.18,,,,,,,fee schedule,4784.09,31870.39,
Corrj halux rigdus w/implt,28291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5494.59,,,,,,,fee schedule,4784.09,31870.39,
Corrj halux rigdus w/implt,28291,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,4784.09,31870.39,APC 378
Corrj halux rigdus w/implt,28291,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,4784.09,31870.39,APC
Corrj halux rigdus w/implt,28291,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,4784.09,31870.39,APC
Corrj halux rigdus w/implt,28291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,4784.09,31870.39,APC
Corrj halux rigdus w/implt,28291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,4784.09,31870.39,Radiology
Corrj halux rigdus w/implt,28291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,4784.09,31870.39,APC
Corrj halux rigdus w/implt,28291,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,4784.09,31870.39,APC
Correction hallux valgus,28292,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4646.31,,,,,,,fee schedule,3239.17,14371.12,
Correction hallux valgus,28292,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3724.42,,,,,,,fee schedule,3239.17,14371.12,
Correction hallux valgus,28292,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4068.59,,,,,,,fee schedule,3239.17,14371.12,
Correction hallux valgus,28292,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4277.56,,,,,,,fee schedule,3239.17,14371.12,
Correction hallux valgus,28292,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Correction hallux valgus,28292,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Correction hallux valgus,28292,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Correction hallux valgus,28292,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Correction hallux valgus,28292,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Correction hallux valgus,28292,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Correction hallux valgus,28292,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Correction hallux valgus,28295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9216.93,,,,,,,fee schedule,3239.17,14371.12,
Correction hallux valgus,28295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7388.17,,,,,,,fee schedule,3239.17,14371.12,
Correction hallux valgus,28295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8070.91,,,,,,,fee schedule,3239.17,14371.12,
Correction hallux valgus,28295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8485.42,,,,,,,fee schedule,3239.17,14371.12,
Correction hallux valgus,28295,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Correction hallux valgus,28295,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Correction hallux valgus,28295,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Correction hallux valgus,28295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Correction hallux valgus,28295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Correction hallux valgus,28295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Correction hallux valgus,28295,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Correction hallux valgus,28296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7184.96,,,,,,,fee schedule,3239.17,14371.12,
Correction hallux valgus,28296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5759.38,,,,,,,fee schedule,3239.17,14371.12,
Correction hallux valgus,28296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6291.59,,,,,,,fee schedule,3239.17,14371.12,
Correction hallux valgus,28296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6614.73,,,,,,,fee schedule,3239.17,14371.12,
Correction hallux valgus,28296,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Correction hallux valgus,28296,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Correction hallux valgus,28296,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Correction hallux valgus,28296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Correction hallux valgus,28296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Correction hallux valgus,28296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Correction hallux valgus,28296,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Correction hallux valgus,28297,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4181.97,,,,,,,fee schedule,3352.21,56389.43,
Correction hallux valgus,28297,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3352.21,,,,,,,fee schedule,3352.21,56389.43,
Correction hallux valgus,28297,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3661.99,,,,,,,fee schedule,3352.21,56389.43,
Correction hallux valgus,28297,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3850.07,,,,,,,fee schedule,3352.21,56389.43,
Correction hallux valgus,28297,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,3352.21,56389.43,APC 378
Correction hallux valgus,28297,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,3352.21,56389.43,APC
Correction hallux valgus,28297,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,3352.21,56389.43,APC
Correction hallux valgus,28297,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,3352.21,56389.43,APC
Correction hallux valgus,28297,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,3352.21,56389.43,Radiology
Correction hallux valgus,28297,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,3352.21,56389.43,APC
Correction hallux valgus,28297,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,3352.21,56389.43,APC
Correction hallux valgus,28298,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1509.73,,,,,,,fee schedule,1210.18,31870.39,
Correction hallux valgus,28298,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1210.18,,,,,,,fee schedule,1210.18,31870.39,
Correction hallux valgus,28298,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1322.01,,,,,,,fee schedule,1210.18,31870.39,
Correction hallux valgus,28298,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1389.91,,,,,,,fee schedule,1210.18,31870.39,
Correction hallux valgus,28298,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,1210.18,31870.39,APC 378
Correction hallux valgus,28298,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,1210.18,31870.39,APC
Correction hallux valgus,28298,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,1210.18,31870.39,APC
Correction hallux valgus,28298,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,1210.18,31870.39,APC
Correction hallux valgus,28298,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,1210.18,31870.39,Radiology
Correction hallux valgus,28298,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,1210.18,31870.39,APC
Correction hallux valgus,28298,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,1210.18,31870.39,APC
Correction hallux valgus,28299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3236.11,,,,,,,fee schedule,2594.02,31870.39,
Correction hallux valgus,28299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2594.02,,,,,,,fee schedule,2594.02,31870.39,
Correction hallux valgus,28299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2833.74,,,,,,,fee schedule,2594.02,31870.39,
Correction hallux valgus,28299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2979.27,,,,,,,fee schedule,2594.02,31870.39,
Correction hallux valgus,28299,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,2594.02,31870.39,APC 378
Correction hallux valgus,28299,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,2594.02,31870.39,APC
Correction hallux valgus,28299,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,2594.02,31870.39,APC
Correction hallux valgus,28299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,2594.02,31870.39,APC
Correction hallux valgus,28299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,2594.02,31870.39,Radiology
Correction hallux valgus,28299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,2594.02,31870.39,APC
Correction hallux valgus,28299,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,2594.02,31870.39,APC
Incision of heel bone,28300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5336.73,,,,,,,fee schedule,4277.86,31870.39,
Incision of heel bone,28300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4277.86,,,,,,,fee schedule,4277.86,31870.39,
Incision of heel bone,28300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4673.17,,,,,,,fee schedule,4277.86,31870.39,
Incision of heel bone,28300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4913.18,,,,,,,fee schedule,4277.86,31870.39,
Incision of heel bone,28300,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,4277.86,31870.39,APC 378
Incision of heel bone,28300,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,4277.86,31870.39,APC
Incision of heel bone,28300,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,4277.86,31870.39,APC
Incision of heel bone,28300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,4277.86,31870.39,APC
Incision of heel bone,28300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,4277.86,31870.39,Radiology
Incision of heel bone,28300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,4277.86,31870.39,APC
Incision of heel bone,28300,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,4277.86,31870.39,APC
Incision of ankle bone,28302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5198.26,,,,,,,fee schedule,4166.86,31870.39,
Incision of ankle bone,28302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4166.86,,,,,,,fee schedule,4166.86,31870.39,
Incision of ankle bone,28302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4551.91,,,,,,,fee schedule,4166.86,31870.39,
Incision of ankle bone,28302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4785.7,,,,,,,fee schedule,4166.86,31870.39,
Incision of ankle bone,28302,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,4166.86,31870.39,APC 378
Incision of ankle bone,28302,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,4166.86,31870.39,APC
Incision of ankle bone,28302,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,4166.86,31870.39,APC
Incision of ankle bone,28302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,4166.86,31870.39,APC
Incision of ankle bone,28302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,4166.86,31870.39,Radiology
Incision of ankle bone,28302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,4166.86,31870.39,APC
Incision of ankle bone,28302,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,4166.86,31870.39,APC
Incision of midfoot bones,28304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11048.37,,,,,,,fee schedule,7183.42,31870.39,
Incision of midfoot bones,28304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8856.24,,,,,,,fee schedule,7183.42,31870.39,
Incision of midfoot bones,28304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9674.63,,,,,,,fee schedule,7183.42,31870.39,
Incision of midfoot bones,28304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10171.52,,,,,,,fee schedule,7183.42,31870.39,
Incision of midfoot bones,28304,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Incision of midfoot bones,28304,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Incision of midfoot bones,28304,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Incision of midfoot bones,28304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Incision of midfoot bones,28304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Incision of midfoot bones,28304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Incision of midfoot bones,28304,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Incise/graft midfoot bones,28305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11048.37,,,,,,,fee schedule,7183.42,31870.39,
Incise/graft midfoot bones,28305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8856.24,,,,,,,fee schedule,7183.42,31870.39,
Incise/graft midfoot bones,28305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9674.63,,,,,,,fee schedule,7183.42,31870.39,
Incise/graft midfoot bones,28305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10171.52,,,,,,,fee schedule,7183.42,31870.39,
Incise/graft midfoot bones,28305,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Incise/graft midfoot bones,28305,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Incise/graft midfoot bones,28305,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Incise/graft midfoot bones,28305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Incise/graft midfoot bones,28305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Incise/graft midfoot bones,28305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Incise/graft midfoot bones,28305,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Incision of metatarsal,28306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6038.9,,,,,,,fee schedule,4840.71,31870.39,
Incision of metatarsal,28306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4840.71,,,,,,,fee schedule,4840.71,31870.39,
Incision of metatarsal,28306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5288.03,,,,,,,fee schedule,4840.71,31870.39,
Incision of metatarsal,28306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5559.62,,,,,,,fee schedule,4840.71,31870.39,
Incision of metatarsal,28306,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,4840.71,31870.39,APC 378
Incision of metatarsal,28306,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,4840.71,31870.39,APC
Incision of metatarsal,28306,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,4840.71,31870.39,APC
Incision of metatarsal,28306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,4840.71,31870.39,APC
Incision of metatarsal,28306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,4840.71,31870.39,Radiology
Incision of metatarsal,28306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,4840.71,31870.39,APC
Incision of metatarsal,28306,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,4840.71,31870.39,APC
Incision of metatarsal,28307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5198.26,,,,,,,fee schedule,4166.86,31870.39,
Incision of metatarsal,28307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4166.86,,,,,,,fee schedule,4166.86,31870.39,
Incision of metatarsal,28307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4551.91,,,,,,,fee schedule,4166.86,31870.39,
Incision of metatarsal,28307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4785.7,,,,,,,fee schedule,4166.86,31870.39,
Incision of metatarsal,28307,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,4166.86,31870.39,APC 378
Incision of metatarsal,28307,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,4166.86,31870.39,APC
Incision of metatarsal,28307,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,4166.86,31870.39,APC
Incision of metatarsal,28307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,4166.86,31870.39,APC
Incision of metatarsal,28307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,4166.86,31870.39,Radiology
Incision of metatarsal,28307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,4166.86,31870.39,APC
Incision of metatarsal,28307,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,4166.86,31870.39,APC
Incision of metatarsal,28308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3442.43,,,,,,,fee schedule,2759.41,14371.12,
Incision of metatarsal,28308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2759.41,,,,,,,fee schedule,2759.41,14371.12,
Incision of metatarsal,28308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3014.41,,,,,,,fee schedule,2759.41,14371.12,
Incision of metatarsal,28308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3169.23,,,,,,,fee schedule,2759.41,14371.12,
Incision of metatarsal,28308,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,2759.41,14371.12,APC 378
Incision of metatarsal,28308,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,2759.41,14371.12,APC
Incision of metatarsal,28308,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,2759.41,14371.12,APC
Incision of metatarsal,28308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,2759.41,14371.12,APC
Incision of metatarsal,28308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,2759.41,14371.12,Radiology
Incision of metatarsal,28308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,2759.41,14371.12,APC
Incision of metatarsal,28308,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,2759.41,14371.12,APC
Incision of metatarsals,28309,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11048.37,,,,,,,fee schedule,7183.42,31870.39,
Incision of metatarsals,28309,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8856.24,,,,,,,fee schedule,7183.42,31870.39,
Incision of metatarsals,28309,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9674.63,,,,,,,fee schedule,7183.42,31870.39,
Incision of metatarsals,28309,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10171.52,,,,,,,fee schedule,7183.42,31870.39,
Incision of metatarsals,28309,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Incision of metatarsals,28309,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Incision of metatarsals,28309,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Incision of metatarsals,28309,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Incision of metatarsals,28309,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Incision of metatarsals,28309,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Incision of metatarsals,28309,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Revision of big toe,28310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2785.27,,,,,,,fee schedule,2232.64,31870.39,
Revision of big toe,28310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2232.64,,,,,,,fee schedule,2232.64,31870.39,
Revision of big toe,28310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2438.96,,,,,,,fee schedule,2232.64,31870.39,
Revision of big toe,28310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2564.22,,,,,,,fee schedule,2232.64,31870.39,
Revision of big toe,28310,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,2232.64,31870.39,APC 378
Revision of big toe,28310,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,2232.64,31870.39,APC
Revision of big toe,28310,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,2232.64,31870.39,APC
Revision of big toe,28310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,2232.64,31870.39,APC
Revision of big toe,28310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,2232.64,31870.39,Radiology
Revision of big toe,28310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,2232.64,31870.39,APC
Revision of big toe,28310,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,2232.64,31870.39,APC
Revision of toe,28312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5198.26,,,,,,,fee schedule,3239.17,14371.12,
Revision of toe,28312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4166.86,,,,,,,fee schedule,3239.17,14371.12,
Revision of toe,28312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4551.91,,,,,,,fee schedule,3239.17,14371.12,
Revision of toe,28312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4785.7,,,,,,,fee schedule,3239.17,14371.12,
Revision of toe,28312,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Revision of toe,28312,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Revision of toe,28312,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Revision of toe,28312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Revision of toe,28312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Revision of toe,28312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Revision of toe,28312,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Repair deformity of toe,28313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3713.85,,,,,,,fee schedule,2976.98,14371.12,
Repair deformity of toe,28313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2976.98,,,,,,,fee schedule,2976.98,14371.12,
Repair deformity of toe,28313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3252.08,,,,,,,fee schedule,2976.98,14371.12,
Repair deformity of toe,28313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3419.1,,,,,,,fee schedule,2976.98,14371.12,
Repair deformity of toe,28313,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,2976.98,14371.12,APC 378
Repair deformity of toe,28313,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,2976.98,14371.12,APC
Repair deformity of toe,28313,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,2976.98,14371.12,APC
Repair deformity of toe,28313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,2976.98,14371.12,APC
Repair deformity of toe,28313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,2976.98,14371.12,Radiology
Repair deformity of toe,28313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,2976.98,14371.12,APC
Repair deformity of toe,28313,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,2976.98,14371.12,APC
Removal of sesamoid bone,28315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6253.46,,,,,,,fee schedule,3239.17,14371.12,
Removal of sesamoid bone,28315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5012.69,,,,,,,fee schedule,3239.17,14371.12,
Removal of sesamoid bone,28315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5475.91,,,,,,,fee schedule,3239.17,14371.12,
Removal of sesamoid bone,28315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5757.15,,,,,,,fee schedule,3239.17,14371.12,
Removal of sesamoid bone,28315,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Removal of sesamoid bone,28315,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of sesamoid bone,28315,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of sesamoid bone,28315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of sesamoid bone,28315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Removal of sesamoid bone,28315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Removal of sesamoid bone,28315,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Repair of foot bones,28320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11048.37,,,,,,,fee schedule,8856.24,56389.43,
Repair of foot bones,28320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8856.24,,,,,,,fee schedule,8856.24,56389.43,
Repair of foot bones,28320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9674.63,,,,,,,fee schedule,8856.24,56389.43,
Repair of foot bones,28320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10171.52,,,,,,,fee schedule,8856.24,56389.43,
Repair of foot bones,28320,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,8856.24,56389.43,APC 378
Repair of foot bones,28320,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,8856.24,56389.43,APC
Repair of foot bones,28320,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,8856.24,56389.43,APC
Repair of foot bones,28320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,8856.24,56389.43,APC
Repair of foot bones,28320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,8856.24,56389.43,Radiology
Repair of foot bones,28320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,8856.24,56389.43,APC
Repair of foot bones,28320,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,8856.24,56389.43,APC
Repair of metatarsals,28322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4999.19,,,,,,,fee schedule,4007.29,31870.39,
Repair of metatarsals,28322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4007.29,,,,,,,fee schedule,4007.29,31870.39,
Repair of metatarsals,28322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4377.6,,,,,,,fee schedule,4007.29,31870.39,
Repair of metatarsals,28322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4602.43,,,,,,,fee schedule,4007.29,31870.39,
Repair of metatarsals,28322,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,4007.29,31870.39,APC 378
Repair of metatarsals,28322,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,4007.29,31870.39,APC
Repair of metatarsals,28322,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,4007.29,31870.39,APC
Repair of metatarsals,28322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,4007.29,31870.39,APC
Repair of metatarsals,28322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,4007.29,31870.39,Radiology
Repair of metatarsals,28322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,4007.29,31870.39,APC
Repair of metatarsals,28322,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,4007.29,31870.39,APC
Resect enlarged toe tissue,28340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5198.26,,,,,,,fee schedule,3239.17,14371.12,
Resect enlarged toe tissue,28340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4166.86,,,,,,,fee schedule,3239.17,14371.12,
Resect enlarged toe tissue,28340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4551.91,,,,,,,fee schedule,3239.17,14371.12,
Resect enlarged toe tissue,28340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4785.7,,,,,,,fee schedule,3239.17,14371.12,
Resect enlarged toe tissue,28340,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Resect enlarged toe tissue,28340,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Resect enlarged toe tissue,28340,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Resect enlarged toe tissue,28340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Resect enlarged toe tissue,28340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Resect enlarged toe tissue,28340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Resect enlarged toe tissue,28340,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Resect enlarged toe,28341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5198.26,,,,,,,fee schedule,3239.17,14371.12,
Resect enlarged toe,28341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4166.86,,,,,,,fee schedule,3239.17,14371.12,
Resect enlarged toe,28341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4551.91,,,,,,,fee schedule,3239.17,14371.12,
Resect enlarged toe,28341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4785.7,,,,,,,fee schedule,3239.17,14371.12,
Resect enlarged toe,28341,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Resect enlarged toe,28341,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Resect enlarged toe,28341,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Resect enlarged toe,28341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Resect enlarged toe,28341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Resect enlarged toe,28341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Resect enlarged toe,28341,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Repair extra toe(s),28344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5198.26,,,,,,,fee schedule,3239.17,14371.12,
Repair extra toe(s),28344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4166.86,,,,,,,fee schedule,3239.17,14371.12,
Repair extra toe(s),28344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4551.91,,,,,,,fee schedule,3239.17,14371.12,
Repair extra toe(s),28344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4785.7,,,,,,,fee schedule,3239.17,14371.12,
Repair extra toe(s),28344,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Repair extra toe(s),28344,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Repair extra toe(s),28344,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Repair extra toe(s),28344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Repair extra toe(s),28344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Repair extra toe(s),28344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Repair extra toe(s),28344,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Repair webbed toe(s),28345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5198.26,,,,,,,fee schedule,1591.86,7062.54,
Repair webbed toe(s),28345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4166.86,,,,,,,fee schedule,1591.86,7062.54,
Repair webbed toe(s),28345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4551.91,,,,,,,fee schedule,1591.86,7062.54,
Repair webbed toe(s),28345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4785.7,,,,,,,fee schedule,1591.86,7062.54,
Repair webbed toe(s),28345,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Repair webbed toe(s),28345,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Repair webbed toe(s),28345,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Repair webbed toe(s),28345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Repair webbed toe(s),28345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Repair webbed toe(s),28345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Repair webbed toe(s),28345,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Reconstruct cleft foot,28360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11048.37,,,,,,,fee schedule,7183.42,31870.39,
Reconstruct cleft foot,28360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8856.24,,,,,,,fee schedule,7183.42,31870.39,
Reconstruct cleft foot,28360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9674.63,,,,,,,fee schedule,7183.42,31870.39,
Reconstruct cleft foot,28360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10171.52,,,,,,,fee schedule,7183.42,31870.39,
Reconstruct cleft foot,28360,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Reconstruct cleft foot,28360,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Reconstruct cleft foot,28360,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Reconstruct cleft foot,28360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Reconstruct cleft foot,28360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Reconstruct cleft foot,28360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Reconstruct cleft foot,28360,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Treatment of heel fracture,28400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,244.19,1083.4,
Treatment of heel fracture,28400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,244.19,1083.4,
Treatment of heel fracture,28400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,244.19,1083.4,
Treatment of heel fracture,28400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,244.19,1083.4,
Treatment of heel fracture,28400,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treatment of heel fracture,28400,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treatment of heel fracture,28400,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treatment of heel fracture,28400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treatment of heel fracture,28400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treatment of heel fracture,28400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treatment of heel fracture,28400,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treatment of heel fracture,28405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,244.19,1083.4,
Treatment of heel fracture,28405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,244.19,1083.4,
Treatment of heel fracture,28405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,244.19,1083.4,
Treatment of heel fracture,28405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,244.19,1083.4,
Treatment of heel fracture,28405,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treatment of heel fracture,28405,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treatment of heel fracture,28405,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treatment of heel fracture,28405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treatment of heel fracture,28405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treatment of heel fracture,28405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treatment of heel fracture,28405,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treatment of heel fracture,28406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6528.66,,,,,,,fee schedule,5233.29,31870.39,
Treatment of heel fracture,28406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5233.29,,,,,,,fee schedule,5233.29,31870.39,
Treatment of heel fracture,28406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5716.9,,,,,,,fee schedule,5233.29,31870.39,
Treatment of heel fracture,28406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6010.52,,,,,,,fee schedule,5233.29,31870.39,
Treatment of heel fracture,28406,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5233.29,31870.39,APC 378
Treatment of heel fracture,28406,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5233.29,31870.39,APC
Treatment of heel fracture,28406,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5233.29,31870.39,APC
Treatment of heel fracture,28406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5233.29,31870.39,APC
Treatment of heel fracture,28406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5233.29,31870.39,Radiology
Treatment of heel fracture,28406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5233.29,31870.39,APC
Treatment of heel fracture,28406,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5233.29,31870.39,APC
Treat heel fracture,28415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9737.23,,,,,,,fee schedule,7183.42,31870.39,
Treat heel fracture,28415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7805.24,,,,,,,fee schedule,7183.42,31870.39,
Treat heel fracture,28415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8526.52,,,,,,,fee schedule,7183.42,31870.39,
Treat heel fracture,28415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8964.43,,,,,,,fee schedule,7183.42,31870.39,
Treat heel fracture,28415,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Treat heel fracture,28415,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Treat heel fracture,28415,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Treat heel fracture,28415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Treat heel fracture,28415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Treat heel fracture,28415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Treat heel fracture,28415,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Treat/graft heel fracture,28420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10259.79,,,,,,,fee schedule,8224.12,56389.43,
Treat/graft heel fracture,28420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8224.12,,,,,,,fee schedule,8224.12,56389.43,
Treat/graft heel fracture,28420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8984.1,,,,,,,fee schedule,8224.12,56389.43,
Treat/graft heel fracture,28420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9445.52,,,,,,,fee schedule,8224.12,56389.43,
Treat/graft heel fracture,28420,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,8224.12,56389.43,APC 378
Treat/graft heel fracture,28420,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,8224.12,56389.43,APC
Treat/graft heel fracture,28420,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,8224.12,56389.43,APC
Treat/graft heel fracture,28420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,8224.12,56389.43,APC
Treat/graft heel fracture,28420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,8224.12,56389.43,Radiology
Treat/graft heel fracture,28420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,8224.12,56389.43,APC
Treat/graft heel fracture,28420,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,8224.12,56389.43,APC
Treatment of ankle fracture,28430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,244.19,1083.4,
Treatment of ankle fracture,28430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,244.19,1083.4,
Treatment of ankle fracture,28430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,244.19,1083.4,
Treatment of ankle fracture,28430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,244.19,1083.4,
Treatment of ankle fracture,28430,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treatment of ankle fracture,28430,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treatment of ankle fracture,28430,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treatment of ankle fracture,28430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treatment of ankle fracture,28430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treatment of ankle fracture,28430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treatment of ankle fracture,28430,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treatment of ankle fracture,28435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,353.72,7062.54,
Treatment of ankle fracture,28435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,353.72,7062.54,
Treatment of ankle fracture,28435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,353.72,7062.54,
Treatment of ankle fracture,28435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,353.72,7062.54,
Treatment of ankle fracture,28435,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,353.72,7062.54,APC 378
Treatment of ankle fracture,28435,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,353.72,7062.54,APC
Treatment of ankle fracture,28435,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,353.72,7062.54,APC
Treatment of ankle fracture,28435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,353.72,7062.54,APC
Treatment of ankle fracture,28435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,353.72,7062.54,Radiology
Treatment of ankle fracture,28435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,353.72,7062.54,APC
Treatment of ankle fracture,28435,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,353.72,7062.54,APC
Treatment of ankle fracture,28436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6528.66,,,,,,,fee schedule,5233.29,31870.39,
Treatment of ankle fracture,28436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5233.29,,,,,,,fee schedule,5233.29,31870.39,
Treatment of ankle fracture,28436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5716.9,,,,,,,fee schedule,5233.29,31870.39,
Treatment of ankle fracture,28436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6010.52,,,,,,,fee schedule,5233.29,31870.39,
Treatment of ankle fracture,28436,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5233.29,31870.39,APC 378
Treatment of ankle fracture,28436,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5233.29,31870.39,APC
Treatment of ankle fracture,28436,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5233.29,31870.39,APC
Treatment of ankle fracture,28436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5233.29,31870.39,APC
Treatment of ankle fracture,28436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5233.29,31870.39,Radiology
Treatment of ankle fracture,28436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5233.29,31870.39,APC
Treatment of ankle fracture,28436,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5233.29,31870.39,APC
Treat ankle fracture,28445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7657.8,,,,,,,fee schedule,6138.4,31870.39,
Treat ankle fracture,28445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6138.4,,,,,,,fee schedule,6138.4,31870.39,
Treat ankle fracture,28445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6705.64,,,,,,,fee schedule,6138.4,31870.39,
Treat ankle fracture,28445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7050.04,,,,,,,fee schedule,6138.4,31870.39,
Treat ankle fracture,28445,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,6138.4,31870.39,APC 378
Treat ankle fracture,28445,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,6138.4,31870.39,APC
Treat ankle fracture,28445,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,6138.4,31870.39,APC
Treat ankle fracture,28445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,6138.4,31870.39,APC
Treat ankle fracture,28445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,6138.4,31870.39,Radiology
Treat ankle fracture,28445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,6138.4,31870.39,APC
Treat ankle fracture,28445,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,6138.4,31870.39,APC
Osteochondral talus autogrft,28446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11048.37,,,,,,,fee schedule,7183.42,31870.39,
Osteochondral talus autogrft,28446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8856.24,,,,,,,fee schedule,7183.42,31870.39,
Osteochondral talus autogrft,28446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9674.63,,,,,,,fee schedule,7183.42,31870.39,
Osteochondral talus autogrft,28446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10171.52,,,,,,,fee schedule,7183.42,31870.39,
Osteochondral talus autogrft,28446,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Osteochondral talus autogrft,28446,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Osteochondral talus autogrft,28446,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Osteochondral talus autogrft,28446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Osteochondral talus autogrft,28446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Osteochondral talus autogrft,28446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Osteochondral talus autogrft,28446,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Treat midfoot fracture each,28450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,244.19,1083.4,
Treat midfoot fracture each,28450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,244.19,1083.4,
Treat midfoot fracture each,28450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,244.19,1083.4,
Treat midfoot fracture each,28450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,244.19,1083.4,
Treat midfoot fracture each,28450,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treat midfoot fracture each,28450,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treat midfoot fracture each,28450,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treat midfoot fracture each,28450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treat midfoot fracture each,28450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treat midfoot fracture each,28450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treat midfoot fracture each,28450,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treat midfoot fracture each,28455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,353.72,7062.54,
Treat midfoot fracture each,28455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,353.72,7062.54,
Treat midfoot fracture each,28455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,353.72,7062.54,
Treat midfoot fracture each,28455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,353.72,7062.54,
Treat midfoot fracture each,28455,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,353.72,7062.54,APC 378
Treat midfoot fracture each,28455,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,353.72,7062.54,APC
Treat midfoot fracture each,28455,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,353.72,7062.54,APC
Treat midfoot fracture each,28455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,353.72,7062.54,APC
Treat midfoot fracture each,28455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,353.72,7062.54,Radiology
Treat midfoot fracture each,28455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,353.72,7062.54,APC
Treat midfoot fracture each,28455,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,353.72,7062.54,APC
Treat midfoot fracture,28456,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6528.66,,,,,,,fee schedule,5233.29,31870.39,
Treat midfoot fracture,28456,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5233.29,,,,,,,fee schedule,5233.29,31870.39,
Treat midfoot fracture,28456,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5716.9,,,,,,,fee schedule,5233.29,31870.39,
Treat midfoot fracture,28456,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6010.52,,,,,,,fee schedule,5233.29,31870.39,
Treat midfoot fracture,28456,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5233.29,31870.39,APC 378
Treat midfoot fracture,28456,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5233.29,31870.39,APC
Treat midfoot fracture,28456,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5233.29,31870.39,APC
Treat midfoot fracture,28456,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5233.29,31870.39,APC
Treat midfoot fracture,28456,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5233.29,31870.39,Radiology
Treat midfoot fracture,28456,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5233.29,31870.39,APC
Treat midfoot fracture,28456,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5233.29,31870.39,APC
Treat midfoot fracture each,28465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4868.61,,,,,,,fee schedule,3902.62,31870.39,
Treat midfoot fracture each,28465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3902.62,,,,,,,fee schedule,3902.62,31870.39,
Treat midfoot fracture each,28465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4263.26,,,,,,,fee schedule,3902.62,31870.39,
Treat midfoot fracture each,28465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4482.22,,,,,,,fee schedule,3902.62,31870.39,
Treat midfoot fracture each,28465,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,3902.62,31870.39,APC 378
Treat midfoot fracture each,28465,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,3902.62,31870.39,APC
Treat midfoot fracture each,28465,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,3902.62,31870.39,APC
Treat midfoot fracture each,28465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,3902.62,31870.39,APC
Treat midfoot fracture each,28465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,3902.62,31870.39,Radiology
Treat midfoot fracture each,28465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,3902.62,31870.39,APC
Treat midfoot fracture each,28465,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,3902.62,31870.39,APC
Treat metatarsal fracture,28470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,244.19,1083.4,
Treat metatarsal fracture,28470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,244.19,1083.4,
Treat metatarsal fracture,28470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,244.19,1083.4,
Treat metatarsal fracture,28470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,244.19,1083.4,
Treat metatarsal fracture,28470,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treat metatarsal fracture,28470,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treat metatarsal fracture,28470,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treat metatarsal fracture,28470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treat metatarsal fracture,28470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treat metatarsal fracture,28470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treat metatarsal fracture,28470,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treat metatarsal fracture,28475,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,244.19,1083.4,
Treat metatarsal fracture,28475,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,244.19,1083.4,
Treat metatarsal fracture,28475,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,244.19,1083.4,
Treat metatarsal fracture,28475,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,244.19,1083.4,
Treat metatarsal fracture,28475,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treat metatarsal fracture,28475,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treat metatarsal fracture,28475,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treat metatarsal fracture,28475,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treat metatarsal fracture,28475,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treat metatarsal fracture,28475,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treat metatarsal fracture,28475,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treat metatarsal fracture,28476,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6528.66,,,,,,,fee schedule,3239.17,14371.12,
Treat metatarsal fracture,28476,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5233.29,,,,,,,fee schedule,3239.17,14371.12,
Treat metatarsal fracture,28476,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5716.9,,,,,,,fee schedule,3239.17,14371.12,
Treat metatarsal fracture,28476,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6010.52,,,,,,,fee schedule,3239.17,14371.12,
Treat metatarsal fracture,28476,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Treat metatarsal fracture,28476,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Treat metatarsal fracture,28476,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Treat metatarsal fracture,28476,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Treat metatarsal fracture,28476,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Treat metatarsal fracture,28476,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Treat metatarsal fracture,28476,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Treat metatarsal fracture,28485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4432.03,,,,,,,fee schedule,3552.66,31870.39,
Treat metatarsal fracture,28485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3552.66,,,,,,,fee schedule,3552.66,31870.39,
Treat metatarsal fracture,28485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3880.96,,,,,,,fee schedule,3552.66,31870.39,
Treat metatarsal fracture,28485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4080.28,,,,,,,fee schedule,3552.66,31870.39,
Treat metatarsal fracture,28485,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,3552.66,31870.39,APC 378
Treat metatarsal fracture,28485,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,3552.66,31870.39,APC
Treat metatarsal fracture,28485,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,3552.66,31870.39,APC
Treat metatarsal fracture,28485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,3552.66,31870.39,APC
Treat metatarsal fracture,28485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,3552.66,31870.39,Radiology
Treat metatarsal fracture,28485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,3552.66,31870.39,APC
Treat metatarsal fracture,28485,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,3552.66,31870.39,APC
Treat big toe fracture,28490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,244.19,1083.4,
Treat big toe fracture,28490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,244.19,1083.4,
Treat big toe fracture,28490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,244.19,1083.4,
Treat big toe fracture,28490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,244.19,1083.4,
Treat big toe fracture,28490,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treat big toe fracture,28490,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treat big toe fracture,28490,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treat big toe fracture,28490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treat big toe fracture,28490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treat big toe fracture,28490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treat big toe fracture,28490,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treat big toe fracture,28495,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,244.19,1083.4,
Treat big toe fracture,28495,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,244.19,1083.4,
Treat big toe fracture,28495,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,244.19,1083.4,
Treat big toe fracture,28495,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,244.19,1083.4,
Treat big toe fracture,28495,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treat big toe fracture,28495,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treat big toe fracture,28495,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treat big toe fracture,28495,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treat big toe fracture,28495,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treat big toe fracture,28495,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treat big toe fracture,28495,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treat big toe fracture,28496,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6528.66,,,,,,,fee schedule,3239.17,14371.12,
Treat big toe fracture,28496,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5233.29,,,,,,,fee schedule,3239.17,14371.12,
Treat big toe fracture,28496,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5716.9,,,,,,,fee schedule,3239.17,14371.12,
Treat big toe fracture,28496,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6010.52,,,,,,,fee schedule,3239.17,14371.12,
Treat big toe fracture,28496,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Treat big toe fracture,28496,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Treat big toe fracture,28496,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Treat big toe fracture,28496,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Treat big toe fracture,28496,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Treat big toe fracture,28496,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Treat big toe fracture,28496,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Treat big toe fracture,28505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7189.69,,,,,,,fee schedule,3239.17,14371.12,
Treat big toe fracture,28505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5763.16,,,,,,,fee schedule,3239.17,14371.12,
Treat big toe fracture,28505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6295.73,,,,,,,fee schedule,3239.17,14371.12,
Treat big toe fracture,28505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6619.08,,,,,,,fee schedule,3239.17,14371.12,
Treat big toe fracture,28505,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Treat big toe fracture,28505,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Treat big toe fracture,28505,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Treat big toe fracture,28505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Treat big toe fracture,28505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Treat big toe fracture,28505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Treat big toe fracture,28505,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Treatment of toe fracture,28510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,244.19,1083.4,
Treatment of toe fracture,28510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,244.19,1083.4,
Treatment of toe fracture,28510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,244.19,1083.4,
Treatment of toe fracture,28510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,244.19,1083.4,
Treatment of toe fracture,28510,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treatment of toe fracture,28510,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treatment of toe fracture,28510,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treatment of toe fracture,28510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treatment of toe fracture,28510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treatment of toe fracture,28510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treatment of toe fracture,28510,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treatment of toe fracture,28515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,300.16,,,,,,,fee schedule,240.6,1083.4,
Treatment of toe fracture,28515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,240.6,,,,,,,fee schedule,240.6,1083.4,
Treatment of toe fracture,28515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,262.84,,,,,,,fee schedule,240.6,1083.4,
Treatment of toe fracture,28515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,276.34,,,,,,,fee schedule,240.6,1083.4,
Treatment of toe fracture,28515,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,240.6,1083.4,APC 378
Treatment of toe fracture,28515,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,240.6,1083.4,APC
Treatment of toe fracture,28515,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,240.6,1083.4,APC
Treatment of toe fracture,28515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,240.6,1083.4,APC
Treatment of toe fracture,28515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,240.6,1083.4,Radiology
Treatment of toe fracture,28515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,240.6,1083.4,APC
Treatment of toe fracture,28515,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,240.6,1083.4,APC
Treat toe fracture,28525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6721.57,,,,,,,fee schedule,3239.17,14371.12,
Treat toe fracture,28525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5387.93,,,,,,,fee schedule,3239.17,14371.12,
Treat toe fracture,28525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5885.82,,,,,,,fee schedule,3239.17,14371.12,
Treat toe fracture,28525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6188.11,,,,,,,fee schedule,3239.17,14371.12,
Treat toe fracture,28525,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Treat toe fracture,28525,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Treat toe fracture,28525,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Treat toe fracture,28525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Treat toe fracture,28525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Treat toe fracture,28525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Treat toe fracture,28525,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Treat sesamoid bone fracture,28530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,244.19,1083.4,
Treat sesamoid bone fracture,28530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,244.19,1083.4,
Treat sesamoid bone fracture,28530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,244.19,1083.4,
Treat sesamoid bone fracture,28530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,244.19,1083.4,
Treat sesamoid bone fracture,28530,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treat sesamoid bone fracture,28530,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treat sesamoid bone fracture,28530,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treat sesamoid bone fracture,28530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treat sesamoid bone fracture,28530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treat sesamoid bone fracture,28530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treat sesamoid bone fracture,28530,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treat sesamoid bone fracture,28531,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6528.66,,,,,,,fee schedule,5233.29,31870.39,
Treat sesamoid bone fracture,28531,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5233.29,,,,,,,fee schedule,5233.29,31870.39,
Treat sesamoid bone fracture,28531,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5716.9,,,,,,,fee schedule,5233.29,31870.39,
Treat sesamoid bone fracture,28531,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6010.52,,,,,,,fee schedule,5233.29,31870.39,
Treat sesamoid bone fracture,28531,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5233.29,31870.39,APC 378
Treat sesamoid bone fracture,28531,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5233.29,31870.39,APC
Treat sesamoid bone fracture,28531,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5233.29,31870.39,APC
Treat sesamoid bone fracture,28531,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5233.29,31870.39,APC
Treat sesamoid bone fracture,28531,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5233.29,31870.39,Radiology
Treat sesamoid bone fracture,28531,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5233.29,31870.39,APC
Treat sesamoid bone fracture,28531,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5233.29,31870.39,APC
Treat foot dislocation,28540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,244.19,1083.4,
Treat foot dislocation,28540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,244.19,1083.4,
Treat foot dislocation,28540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,244.19,1083.4,
Treat foot dislocation,28540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,244.19,1083.4,
Treat foot dislocation,28540,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treat foot dislocation,28540,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treat foot dislocation,28540,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treat foot dislocation,28540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treat foot dislocation,28540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treat foot dislocation,28540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treat foot dislocation,28540,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treat foot dislocation,28545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6528.66,,,,,,,fee schedule,3239.17,14371.12,
Treat foot dislocation,28545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5233.29,,,,,,,fee schedule,3239.17,14371.12,
Treat foot dislocation,28545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5716.9,,,,,,,fee schedule,3239.17,14371.12,
Treat foot dislocation,28545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6010.52,,,,,,,fee schedule,3239.17,14371.12,
Treat foot dislocation,28545,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Treat foot dislocation,28545,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Treat foot dislocation,28545,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Treat foot dislocation,28545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Treat foot dislocation,28545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Treat foot dislocation,28545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Treat foot dislocation,28545,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Treat foot dislocation,28546,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6528.66,,,,,,,fee schedule,1591.86,7062.54,
Treat foot dislocation,28546,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5233.29,,,,,,,fee schedule,1591.86,7062.54,
Treat foot dislocation,28546,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5716.9,,,,,,,fee schedule,1591.86,7062.54,
Treat foot dislocation,28546,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6010.52,,,,,,,fee schedule,1591.86,7062.54,
Treat foot dislocation,28546,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Treat foot dislocation,28546,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Treat foot dislocation,28546,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Treat foot dislocation,28546,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Treat foot dislocation,28546,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Treat foot dislocation,28546,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Treat foot dislocation,28546,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Repair foot dislocation,28555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10259.79,,,,,,,fee schedule,7183.42,31870.39,
Repair foot dislocation,28555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8224.12,,,,,,,fee schedule,7183.42,31870.39,
Repair foot dislocation,28555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8984.1,,,,,,,fee schedule,7183.42,31870.39,
Repair foot dislocation,28555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9445.52,,,,,,,fee schedule,7183.42,31870.39,
Repair foot dislocation,28555,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Repair foot dislocation,28555,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Repair foot dislocation,28555,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Repair foot dislocation,28555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Repair foot dislocation,28555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Repair foot dislocation,28555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Repair foot dislocation,28555,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Treat foot dislocation,28570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,244.19,1083.4,
Treat foot dislocation,28570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,244.19,1083.4,
Treat foot dislocation,28570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,244.19,1083.4,
Treat foot dislocation,28570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,244.19,1083.4,
Treat foot dislocation,28570,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treat foot dislocation,28570,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treat foot dislocation,28570,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treat foot dislocation,28570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treat foot dislocation,28570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treat foot dislocation,28570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treat foot dislocation,28570,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treat foot dislocation,28575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,353.72,14371.12,
Treat foot dislocation,28575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,353.72,14371.12,
Treat foot dislocation,28575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,353.72,14371.12,
Treat foot dislocation,28575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,353.72,14371.12,
Treat foot dislocation,28575,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,353.72,14371.12,APC 378
Treat foot dislocation,28575,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,353.72,14371.12,APC
Treat foot dislocation,28575,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,353.72,14371.12,APC
Treat foot dislocation,28575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,353.72,14371.12,APC
Treat foot dislocation,28575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,353.72,14371.12,Radiology
Treat foot dislocation,28575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,353.72,14371.12,APC
Treat foot dislocation,28575,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,353.72,14371.12,APC
Treat foot dislocation,28576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6528.66,,,,,,,fee schedule,5233.29,31870.39,
Treat foot dislocation,28576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5233.29,,,,,,,fee schedule,5233.29,31870.39,
Treat foot dislocation,28576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5716.9,,,,,,,fee schedule,5233.29,31870.39,
Treat foot dislocation,28576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6010.52,,,,,,,fee schedule,5233.29,31870.39,
Treat foot dislocation,28576,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5233.29,31870.39,APC 378
Treat foot dislocation,28576,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5233.29,31870.39,APC
Treat foot dislocation,28576,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5233.29,31870.39,APC
Treat foot dislocation,28576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5233.29,31870.39,APC
Treat foot dislocation,28576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5233.29,31870.39,Radiology
Treat foot dislocation,28576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5233.29,31870.39,APC
Treat foot dislocation,28576,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5233.29,31870.39,APC
Repair foot dislocation,28585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6528.66,,,,,,,fee schedule,5233.29,31870.39,
Repair foot dislocation,28585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5233.29,,,,,,,fee schedule,5233.29,31870.39,
Repair foot dislocation,28585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5716.9,,,,,,,fee schedule,5233.29,31870.39,
Repair foot dislocation,28585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6010.52,,,,,,,fee schedule,5233.29,31870.39,
Repair foot dislocation,28585,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5233.29,31870.39,APC 378
Repair foot dislocation,28585,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5233.29,31870.39,APC
Repair foot dislocation,28585,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5233.29,31870.39,APC
Repair foot dislocation,28585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5233.29,31870.39,APC
Repair foot dislocation,28585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5233.29,31870.39,Radiology
Repair foot dislocation,28585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5233.29,31870.39,APC
Repair foot dislocation,28585,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5233.29,31870.39,APC
Treat foot dislocation,28600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,244.19,1083.4,
Treat foot dislocation,28600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,244.19,1083.4,
Treat foot dislocation,28600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,244.19,1083.4,
Treat foot dislocation,28600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,244.19,1083.4,
Treat foot dislocation,28600,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treat foot dislocation,28600,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treat foot dislocation,28600,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treat foot dislocation,28600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treat foot dislocation,28600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treat foot dislocation,28600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treat foot dislocation,28600,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treat foot dislocation,28605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,244.19,1083.4,
Treat foot dislocation,28605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,244.19,1083.4,
Treat foot dislocation,28605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,244.19,1083.4,
Treat foot dislocation,28605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,244.19,1083.4,
Treat foot dislocation,28605,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treat foot dislocation,28605,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treat foot dislocation,28605,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treat foot dislocation,28605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treat foot dislocation,28605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treat foot dislocation,28605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treat foot dislocation,28605,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treat foot dislocation,28606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2265.54,,,,,,,fee schedule,1816.03,14371.12,
Treat foot dislocation,28606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1816.03,,,,,,,fee schedule,1816.03,14371.12,
Treat foot dislocation,28606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1983.84,,,,,,,fee schedule,1816.03,14371.12,
Treat foot dislocation,28606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2085.73,,,,,,,fee schedule,1816.03,14371.12,
Treat foot dislocation,28606,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,1816.03,14371.12,APC 378
Treat foot dislocation,28606,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,1816.03,14371.12,APC
Treat foot dislocation,28606,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,1816.03,14371.12,APC
Treat foot dislocation,28606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,1816.03,14371.12,APC
Treat foot dislocation,28606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,1816.03,14371.12,Radiology
Treat foot dislocation,28606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,1816.03,14371.12,APC
Treat foot dislocation,28606,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,1816.03,14371.12,APC
Repair foot dislocation,28615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4056.27,,,,,,,fee schedule,3251.46,31870.39,
Repair foot dislocation,28615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3251.46,,,,,,,fee schedule,3251.46,31870.39,
Repair foot dislocation,28615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3551.92,,,,,,,fee schedule,3251.46,31870.39,
Repair foot dislocation,28615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3734.35,,,,,,,fee schedule,3251.46,31870.39,
Repair foot dislocation,28615,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,3251.46,31870.39,APC 378
Repair foot dislocation,28615,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,3251.46,31870.39,APC
Repair foot dislocation,28615,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,3251.46,31870.39,APC
Repair foot dislocation,28615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,3251.46,31870.39,APC
Repair foot dislocation,28615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,3251.46,31870.39,Radiology
Repair foot dislocation,28615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,3251.46,31870.39,APC
Repair foot dislocation,28615,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,3251.46,31870.39,APC
Treat toe dislocation,28630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,225.39,,,,,,,fee schedule,180.67,1083.4,
Treat toe dislocation,28630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,180.67,,,,,,,fee schedule,180.67,1083.4,
Treat toe dislocation,28630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,197.36,,,,,,,fee schedule,180.67,1083.4,
Treat toe dislocation,28630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,207.5,,,,,,,fee schedule,180.67,1083.4,
Treat toe dislocation,28630,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,180.67,1083.4,APC 378
Treat toe dislocation,28630,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,180.67,1083.4,APC
Treat toe dislocation,28630,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,180.67,1083.4,APC
Treat toe dislocation,28630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,180.67,1083.4,APC
Treat toe dislocation,28630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,180.67,1083.4,Radiology
Treat toe dislocation,28630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,180.67,1083.4,APC
Treat toe dislocation,28630,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,180.67,1083.4,APC
Treat toe dislocation,28635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3685.16,,,,,,,fee schedule,1591.86,7062.54,
Treat toe dislocation,28635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2953.98,,,,,,,fee schedule,1591.86,7062.54,
Treat toe dislocation,28635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3226.95,,,,,,,fee schedule,1591.86,7062.54,
Treat toe dislocation,28635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3392.69,,,,,,,fee schedule,1591.86,7062.54,
Treat toe dislocation,28635,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7062.54,APC 378
Treat toe dislocation,28635,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7062.54,APC
Treat toe dislocation,28635,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7062.54,APC
Treat toe dislocation,28635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7062.54,APC
Treat toe dislocation,28635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7062.54,Radiology
Treat toe dislocation,28635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7062.54,APC
Treat toe dislocation,28635,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7062.54,APC
Treat toe dislocation,28636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6528.66,,,,,,,fee schedule,3239.17,14371.12,
Treat toe dislocation,28636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5233.29,,,,,,,fee schedule,3239.17,14371.12,
Treat toe dislocation,28636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5716.9,,,,,,,fee schedule,3239.17,14371.12,
Treat toe dislocation,28636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6010.52,,,,,,,fee schedule,3239.17,14371.12,
Treat toe dislocation,28636,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Treat toe dislocation,28636,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Treat toe dislocation,28636,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Treat toe dislocation,28636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Treat toe dislocation,28636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Treat toe dislocation,28636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Treat toe dislocation,28636,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Repair toe dislocation,28645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4176.47,,,,,,,fee schedule,3239.17,14371.12,
Repair toe dislocation,28645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3347.8,,,,,,,fee schedule,3239.17,14371.12,
Repair toe dislocation,28645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3657.17,,,,,,,fee schedule,3239.17,14371.12,
Repair toe dislocation,28645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3845,,,,,,,fee schedule,3239.17,14371.12,
Repair toe dislocation,28645,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Repair toe dislocation,28645,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Repair toe dislocation,28645,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Repair toe dislocation,28645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Repair toe dislocation,28645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Repair toe dislocation,28645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Repair toe dislocation,28645,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Treat toe dislocation,28660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.28,,,,,,,fee schedule,244.19,1083.4,
Treat toe dislocation,28660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.72,,,,,,,fee schedule,244.19,1083.4,
Treat toe dislocation,28660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,244.19,1083.4,
Treat toe dislocation,28660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.26,,,,,,,fee schedule,244.19,1083.4,
Treat toe dislocation,28660,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,1083.4,APC 378
Treat toe dislocation,28660,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,1083.4,APC
Treat toe dislocation,28660,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,1083.4,APC
Treat toe dislocation,28660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,1083.4,APC
Treat toe dislocation,28660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,1083.4,Radiology
Treat toe dislocation,28660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,1083.4,APC
Treat toe dislocation,28660,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,1083.4,APC
Treat toe dislocation,28665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3685.16,,,,,,,fee schedule,276.89,3685.16,
Treat toe dislocation,28665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2953.98,,,,,,,fee schedule,276.89,3685.16,
Treat toe dislocation,28665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3226.95,,,,,,,fee schedule,276.89,3685.16,
Treat toe dislocation,28665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3392.69,,,,,,,fee schedule,276.89,3685.16,
Treat toe dislocation,28665,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1228.45,,,,,,,fee schedule,276.89,3685.16,APC 378
Treat toe dislocation,28665,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,290.73,,,,,,,fee schedule,276.89,3685.16,APC
Treat toe dislocation,28665,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,287.96,,,,,,,fee schedule,276.89,3685.16,APC
Treat toe dislocation,28665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,276.89,,,,,,,fee schedule,276.89,3685.16,APC
Treat toe dislocation,28665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,423.64,,,,,,,fee schedule,276.89,3685.16,Radiology
Treat toe dislocation,28665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,387.64,,,,,,,fee schedule,276.89,3685.16,APC
Treat toe dislocation,28665,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,484.55,,,,,,,fee schedule,276.89,3685.16,APC
Treat toe dislocation,28666,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6528.66,,,,,,,fee schedule,3239.17,14371.12,
Treat toe dislocation,28666,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5233.29,,,,,,,fee schedule,3239.17,14371.12,
Treat toe dislocation,28666,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5716.9,,,,,,,fee schedule,3239.17,14371.12,
Treat toe dislocation,28666,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6010.52,,,,,,,fee schedule,3239.17,14371.12,
Treat toe dislocation,28666,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Treat toe dislocation,28666,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Treat toe dislocation,28666,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Treat toe dislocation,28666,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Treat toe dislocation,28666,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Treat toe dislocation,28666,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Treat toe dislocation,28666,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Repair of toe dislocation,28675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6528.66,,,,,,,fee schedule,3239.17,14371.12,
Repair of toe dislocation,28675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5233.29,,,,,,,fee schedule,3239.17,14371.12,
Repair of toe dislocation,28675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5716.9,,,,,,,fee schedule,3239.17,14371.12,
Repair of toe dislocation,28675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6010.52,,,,,,,fee schedule,3239.17,14371.12,
Repair of toe dislocation,28675,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Repair of toe dislocation,28675,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Repair of toe dislocation,28675,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Repair of toe dislocation,28675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Repair of toe dislocation,28675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Repair of toe dislocation,28675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Repair of toe dislocation,28675,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Fusion of foot bones,28705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11048.37,,,,,,,fee schedule,8856.24,77011.17,
Fusion of foot bones,28705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8856.24,,,,,,,fee schedule,8856.24,77011.17,
Fusion of foot bones,28705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9674.63,,,,,,,fee schedule,8856.24,77011.17,
Fusion of foot bones,28705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10171.52,,,,,,,fee schedule,8856.24,77011.17,
Fusion of foot bones,28705,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,77011.17,,,,,,,fee schedule,8856.24,77011.17,APC 378
Fusion of foot bones,28705,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18225.81,,,,,,,fee schedule,8856.24,77011.17,APC
Fusion of foot bones,28705,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18052.23,,,,,,,fee schedule,8856.24,77011.17,APC
Fusion of foot bones,28705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17357.91,,,,,,,fee schedule,8856.24,77011.17,APC
Fusion of foot bones,28705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26557.6,,,,,,,fee schedule,8856.24,77011.17,Radiology
Fusion of foot bones,28705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24301.07,,,,,,,fee schedule,8856.24,77011.17,APC
Fusion of foot bones,28705,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30376.34,,,,,,,fee schedule,8856.24,77011.17,APC
Fusion of foot bones,28715,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19822.36,,,,,,,fee schedule,12709.88,56389.43,
Fusion of foot bones,28715,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15889.35,,,,,,,fee schedule,12709.88,56389.43,
Fusion of foot bones,28715,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17357.67,,,,,,,fee schedule,12709.88,56389.43,
Fusion of foot bones,28715,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18249.15,,,,,,,fee schedule,12709.88,56389.43,
Fusion of foot bones,28715,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,12709.88,56389.43,APC 378
Fusion of foot bones,28715,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,12709.88,56389.43,APC
Fusion of foot bones,28715,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,12709.88,56389.43,APC
Fusion of foot bones,28715,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,12709.88,56389.43,APC
Fusion of foot bones,28715,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,12709.88,56389.43,Radiology
Fusion of foot bones,28715,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,12709.88,56389.43,APC
Fusion of foot bones,28715,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,12709.88,56389.43,APC
Fusion of foot bones,28725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4999.19,,,,,,,fee schedule,4007.29,56389.43,
Fusion of foot bones,28725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4007.29,,,,,,,fee schedule,4007.29,56389.43,
Fusion of foot bones,28725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4377.6,,,,,,,fee schedule,4007.29,56389.43,
Fusion of foot bones,28725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4602.43,,,,,,,fee schedule,4007.29,56389.43,
Fusion of foot bones,28725,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,4007.29,56389.43,APC 378
Fusion of foot bones,28725,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,4007.29,56389.43,APC
Fusion of foot bones,28725,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,4007.29,56389.43,APC
Fusion of foot bones,28725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,4007.29,56389.43,APC
Fusion of foot bones,28725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,4007.29,56389.43,Radiology
Fusion of foot bones,28725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,4007.29,56389.43,APC
Fusion of foot bones,28725,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,4007.29,56389.43,APC
Fusion of foot bones,28730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5167.96,,,,,,,fee schedule,4142.57,56389.43,
Fusion of foot bones,28730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4142.57,,,,,,,fee schedule,4142.57,56389.43,
Fusion of foot bones,28730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4525.38,,,,,,,fee schedule,4142.57,56389.43,
Fusion of foot bones,28730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4757.8,,,,,,,fee schedule,4142.57,56389.43,
Fusion of foot bones,28730,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,4142.57,56389.43,APC 378
Fusion of foot bones,28730,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,4142.57,56389.43,APC
Fusion of foot bones,28730,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,4142.57,56389.43,APC
Fusion of foot bones,28730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,4142.57,56389.43,APC
Fusion of foot bones,28730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,4142.57,56389.43,Radiology
Fusion of foot bones,28730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,4142.57,56389.43,APC
Fusion of foot bones,28730,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,4142.57,56389.43,APC
Fusion of foot bones,28735,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11048.37,,,,,,,fee schedule,8856.24,56389.43,
Fusion of foot bones,28735,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8856.24,,,,,,,fee schedule,8856.24,56389.43,
Fusion of foot bones,28735,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9674.63,,,,,,,fee schedule,8856.24,56389.43,
Fusion of foot bones,28735,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10171.52,,,,,,,fee schedule,8856.24,56389.43,
Fusion of foot bones,28735,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,8856.24,56389.43,APC 378
Fusion of foot bones,28735,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,8856.24,56389.43,APC
Fusion of foot bones,28735,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,8856.24,56389.43,APC
Fusion of foot bones,28735,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,8856.24,56389.43,APC
Fusion of foot bones,28735,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,8856.24,56389.43,Radiology
Fusion of foot bones,28735,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,8856.24,56389.43,APC
Fusion of foot bones,28735,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,8856.24,56389.43,APC
Revision of foot bones,28737,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4297.02,,,,,,,fee schedule,3444.43,56389.43,
Revision of foot bones,28737,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3444.43,,,,,,,fee schedule,3444.43,56389.43,
Revision of foot bones,28737,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3762.73,,,,,,,fee schedule,3444.43,56389.43,
Revision of foot bones,28737,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3955.98,,,,,,,fee schedule,3444.43,56389.43,
Revision of foot bones,28737,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,3444.43,56389.43,APC 378
Revision of foot bones,28737,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,3444.43,56389.43,APC
Revision of foot bones,28737,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,3444.43,56389.43,APC
Revision of foot bones,28737,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,3444.43,56389.43,APC
Revision of foot bones,28737,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,3444.43,56389.43,Radiology
Revision of foot bones,28737,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,3444.43,56389.43,APC
Revision of foot bones,28737,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,3444.43,56389.43,APC
Fusion of foot bones,28740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5226.2,,,,,,,fee schedule,4189.26,31870.39,
Fusion of foot bones,28740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4189.26,,,,,,,fee schedule,4189.26,31870.39,
Fusion of foot bones,28740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4576.38,,,,,,,fee schedule,4189.26,31870.39,
Fusion of foot bones,28740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4811.42,,,,,,,fee schedule,4189.26,31870.39,
Fusion of foot bones,28740,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,4189.26,31870.39,APC 378
Fusion of foot bones,28740,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,4189.26,31870.39,APC
Fusion of foot bones,28740,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,4189.26,31870.39,APC
Fusion of foot bones,28740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,4189.26,31870.39,APC
Fusion of foot bones,28740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,4189.26,31870.39,Radiology
Fusion of foot bones,28740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,4189.26,31870.39,APC
Fusion of foot bones,28740,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,4189.26,31870.39,APC
Fusion of big toe joint,28750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6817.78,,,,,,,fee schedule,5465.05,31870.39,
Fusion of big toe joint,28750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5465.05,,,,,,,fee schedule,5465.05,31870.39,
Fusion of big toe joint,28750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5970.07,,,,,,,fee schedule,5465.05,31870.39,
Fusion of big toe joint,28750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6276.69,,,,,,,fee schedule,5465.05,31870.39,
Fusion of big toe joint,28750,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5465.05,31870.39,APC 378
Fusion of big toe joint,28750,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5465.05,31870.39,APC
Fusion of big toe joint,28750,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5465.05,31870.39,APC
Fusion of big toe joint,28750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5465.05,31870.39,APC
Fusion of big toe joint,28750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5465.05,31870.39,Radiology
Fusion of big toe joint,28750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5465.05,31870.39,APC
Fusion of big toe joint,28750,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5465.05,31870.39,APC
Fusion of big toe joint,28755,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5353.89,,,,,,,fee schedule,4291.61,31870.39,
Fusion of big toe joint,28755,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4291.61,,,,,,,fee schedule,4291.61,31870.39,
Fusion of big toe joint,28755,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4688.19,,,,,,,fee schedule,4291.61,31870.39,
Fusion of big toe joint,28755,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4928.98,,,,,,,fee schedule,4291.61,31870.39,
Fusion of big toe joint,28755,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,4291.61,31870.39,APC 378
Fusion of big toe joint,28755,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,4291.61,31870.39,APC
Fusion of big toe joint,28755,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,4291.61,31870.39,APC
Fusion of big toe joint,28755,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,4291.61,31870.39,APC
Fusion of big toe joint,28755,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,4291.61,31870.39,Radiology
Fusion of big toe joint,28755,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,4291.61,31870.39,APC
Fusion of big toe joint,28755,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,4291.61,31870.39,APC
Fusion of big toe joint,28760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7657.8,,,,,,,fee schedule,6138.4,31870.39,
Fusion of big toe joint,28760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6138.4,,,,,,,fee schedule,6138.4,31870.39,
Fusion of big toe joint,28760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6705.64,,,,,,,fee schedule,6138.4,31870.39,
Fusion of big toe joint,28760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7050.04,,,,,,,fee schedule,6138.4,31870.39,
Fusion of big toe joint,28760,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,6138.4,31870.39,APC 378
Fusion of big toe joint,28760,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,6138.4,31870.39,APC
Fusion of big toe joint,28760,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,6138.4,31870.39,APC
Fusion of big toe joint,28760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,6138.4,31870.39,APC
Fusion of big toe joint,28760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,6138.4,31870.39,Radiology
Fusion of big toe joint,28760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,6138.4,31870.39,APC
Fusion of big toe joint,28760,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,6138.4,31870.39,APC
Amputation of midfoot,28800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10698.91,,,,,,,fee schedule,3239.17,14371.12,
Amputation of midfoot,28800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8576.11,,,,,,,fee schedule,3239.17,14371.12,
Amputation of midfoot,28800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9368.62,,,,,,,fee schedule,3239.17,14371.12,
Amputation of midfoot,28800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9849.79,,,,,,,fee schedule,3239.17,14371.12,
Amputation of midfoot,28800,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Amputation of midfoot,28800,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Amputation of midfoot,28800,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Amputation of midfoot,28800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Amputation of midfoot,28800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Amputation of midfoot,28800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Amputation of midfoot,28800,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Amputation thru metatarsal,28805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9216.93,,,,,,,fee schedule,3239.17,14371.12,
Amputation thru metatarsal,28805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7388.17,,,,,,,fee schedule,3239.17,14371.12,
Amputation thru metatarsal,28805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8070.91,,,,,,,fee schedule,3239.17,14371.12,
Amputation thru metatarsal,28805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8485.42,,,,,,,fee schedule,3239.17,14371.12,
Amputation thru metatarsal,28805,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Amputation thru metatarsal,28805,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Amputation thru metatarsal,28805,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Amputation thru metatarsal,28805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Amputation thru metatarsal,28805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Amputation thru metatarsal,28805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Amputation thru metatarsal,28805,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Amputation toe & metatarsal,28810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3869.89,,,,,,,fee schedule,3102.06,14371.12,
Amputation toe & metatarsal,28810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3102.06,,,,,,,fee schedule,3102.06,14371.12,
Amputation toe & metatarsal,28810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3388.72,,,,,,,fee schedule,3102.06,14371.12,
Amputation toe & metatarsal,28810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3562.76,,,,,,,fee schedule,3102.06,14371.12,
Amputation toe & metatarsal,28810,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3102.06,14371.12,APC 378
Amputation toe & metatarsal,28810,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3102.06,14371.12,APC
Amputation toe & metatarsal,28810,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3102.06,14371.12,APC
Amputation toe & metatarsal,28810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3102.06,14371.12,APC
Amputation toe & metatarsal,28810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3102.06,14371.12,Radiology
Amputation toe & metatarsal,28810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3102.06,14371.12,APC
Amputation toe & metatarsal,28810,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3102.06,14371.12,APC
Amputation of toe,28820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6491.48,,,,,,,fee schedule,3239.17,14371.12,
Amputation of toe,28820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5203.49,,,,,,,fee schedule,3239.17,14371.12,
Amputation of toe,28820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5684.34,,,,,,,fee schedule,3239.17,14371.12,
Amputation of toe,28820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5976.29,,,,,,,fee schedule,3239.17,14371.12,
Amputation of toe,28820,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Amputation of toe,28820,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Amputation of toe,28820,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Amputation of toe,28820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Amputation of toe,28820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Amputation of toe,28820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Amputation of toe,28820,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Partial amputation of toe,28825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3245.74,,,,,,,fee schedule,2601.74,14371.12,
Partial amputation of toe,28825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2601.74,,,,,,,fee schedule,2601.74,14371.12,
Partial amputation of toe,28825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2842.17,,,,,,,fee schedule,2601.74,14371.12,
Partial amputation of toe,28825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2988.14,,,,,,,fee schedule,2601.74,14371.12,
Partial amputation of toe,28825,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,2601.74,14371.12,APC 378
Partial amputation of toe,28825,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,2601.74,14371.12,APC
Partial amputation of toe,28825,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,2601.74,14371.12,APC
Partial amputation of toe,28825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,2601.74,14371.12,APC
Partial amputation of toe,28825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,2601.74,14371.12,Radiology
Partial amputation of toe,28825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,2601.74,14371.12,APC
Partial amputation of toe,28825,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,2601.74,14371.12,APC
Hi enrgy eswt plantar fascia,28890,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7285.12,,,,,,,fee schedule,1591.86,7285.12,
Hi enrgy eswt plantar fascia,28890,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5839.66,,,,,,,fee schedule,1591.86,7285.12,
Hi enrgy eswt plantar fascia,28890,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6379.3,,,,,,,fee schedule,1591.86,7285.12,
Hi enrgy eswt plantar fascia,28890,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6706.93,,,,,,,fee schedule,1591.86,7285.12,
Hi enrgy eswt plantar fascia,28890,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7285.12,APC 378
Hi enrgy eswt plantar fascia,28890,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7285.12,APC
Hi enrgy eswt plantar fascia,28890,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7285.12,APC
Hi enrgy eswt plantar fascia,28890,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7285.12,APC
Hi enrgy eswt plantar fascia,28890,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7285.12,Radiology
Hi enrgy eswt plantar fascia,28890,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7285.12,APC
Hi enrgy eswt plantar fascia,28890,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7285.12,APC
Foot/toes surgery procedure,28899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2890.26,,,,,,,fee schedule,244.19,2890.26,
Foot/toes surgery procedure,28899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2316.79,,,,,,,fee schedule,244.19,2890.26,
Foot/toes surgery procedure,28899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2530.89,,,,,,,fee schedule,244.19,2890.26,
Foot/toes surgery procedure,28899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2660.87,,,,,,,fee schedule,244.19,2890.26,
Foot/toes surgery procedure,28899,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,2890.26,APC 378
Foot/toes surgery procedure,28899,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,2890.26,APC
Foot/toes surgery procedure,28899,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,2890.26,APC
Foot/toes surgery procedure,28899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,2890.26,APC
Foot/toes surgery procedure,28899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,2890.26,Radiology
Foot/toes surgery procedure,28899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,2890.26,APC
Foot/toes surgery procedure,28899,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,2890.26,APC
Application of body cast,29000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,272.8,,,,,,,fee schedule,218.68,1228.45,
Application of body cast,29000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,218.68,,,,,,,fee schedule,218.68,1228.45,
Application of body cast,29000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,238.88,,,,,,,fee schedule,218.68,1228.45,
Application of body cast,29000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,251.15,,,,,,,fee schedule,218.68,1228.45,
Application of body cast,29000,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1228.45,,,,,,,fee schedule,218.68,1228.45,APC 378
Application of body cast,29000,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,290.73,,,,,,,fee schedule,218.68,1228.45,APC
Application of body cast,29000,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,287.96,,,,,,,fee schedule,218.68,1228.45,APC
Application of body cast,29000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,276.89,,,,,,,fee schedule,218.68,1228.45,APC
Application of body cast,29000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,423.64,,,,,,,fee schedule,218.68,1228.45,Radiology
Application of body cast,29000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,387.64,,,,,,,fee schedule,218.68,1228.45,APC
Application of body cast,29000,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,484.55,,,,,,,fee schedule,218.68,1228.45,APC
Application of body cast,29010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,571.76,,,,,,,fee schedule,276.89,1228.45,
Application of body cast,29010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,458.32,,,,,,,fee schedule,276.89,1228.45,
Application of body cast,29010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,500.67,,,,,,,fee schedule,276.89,1228.45,
Application of body cast,29010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,526.38,,,,,,,fee schedule,276.89,1228.45,
Application of body cast,29010,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1228.45,,,,,,,fee schedule,276.89,1228.45,APC 378
Application of body cast,29010,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,290.73,,,,,,,fee schedule,276.89,1228.45,APC
Application of body cast,29010,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,287.96,,,,,,,fee schedule,276.89,1228.45,APC
Application of body cast,29010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,276.89,,,,,,,fee schedule,276.89,1228.45,APC
Application of body cast,29010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,423.64,,,,,,,fee schedule,276.89,1228.45,Radiology
Application of body cast,29010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,387.64,,,,,,,fee schedule,276.89,1228.45,APC
Application of body cast,29010,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,484.55,,,,,,,fee schedule,276.89,1228.45,APC
Application of body cast,29015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,571.76,,,,,,,fee schedule,276.89,1228.45,
Application of body cast,29015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,458.32,,,,,,,fee schedule,276.89,1228.45,
Application of body cast,29015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,500.67,,,,,,,fee schedule,276.89,1228.45,
Application of body cast,29015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,526.38,,,,,,,fee schedule,276.89,1228.45,
Application of body cast,29015,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1228.45,,,,,,,fee schedule,276.89,1228.45,APC 378
Application of body cast,29015,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,290.73,,,,,,,fee schedule,276.89,1228.45,APC
Application of body cast,29015,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,287.96,,,,,,,fee schedule,276.89,1228.45,APC
Application of body cast,29015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,276.89,,,,,,,fee schedule,276.89,1228.45,APC
Application of body cast,29015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,423.64,,,,,,,fee schedule,276.89,1228.45,Radiology
Application of body cast,29015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,387.64,,,,,,,fee schedule,276.89,1228.45,APC
Application of body cast,29015,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,484.55,,,,,,,fee schedule,276.89,1228.45,APC
Application of body cast,29035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,571.76,,,,,,,fee schedule,276.89,1228.45,
Application of body cast,29035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,458.32,,,,,,,fee schedule,276.89,1228.45,
Application of body cast,29035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,500.67,,,,,,,fee schedule,276.89,1228.45,
Application of body cast,29035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,526.38,,,,,,,fee schedule,276.89,1228.45,
Application of body cast,29035,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1228.45,,,,,,,fee schedule,276.89,1228.45,APC 378
Application of body cast,29035,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,290.73,,,,,,,fee schedule,276.89,1228.45,APC
Application of body cast,29035,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,287.96,,,,,,,fee schedule,276.89,1228.45,APC
Application of body cast,29035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,276.89,,,,,,,fee schedule,276.89,1228.45,APC
Application of body cast,29035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,423.64,,,,,,,fee schedule,276.89,1228.45,Radiology
Application of body cast,29035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,387.64,,,,,,,fee schedule,276.89,1228.45,APC
Application of body cast,29035,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,484.55,,,,,,,fee schedule,276.89,1228.45,APC
Application of body cast,29040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,272.8,,,,,,,fee schedule,218.68,1228.45,
Application of body cast,29040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,218.68,,,,,,,fee schedule,218.68,1228.45,
Application of body cast,29040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,238.88,,,,,,,fee schedule,218.68,1228.45,
Application of body cast,29040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,251.15,,,,,,,fee schedule,218.68,1228.45,
Application of body cast,29040,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1228.45,,,,,,,fee schedule,218.68,1228.45,APC 378
Application of body cast,29040,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,290.73,,,,,,,fee schedule,218.68,1228.45,APC
Application of body cast,29040,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,287.96,,,,,,,fee schedule,218.68,1228.45,APC
Application of body cast,29040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,276.89,,,,,,,fee schedule,218.68,1228.45,APC
Application of body cast,29040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,423.64,,,,,,,fee schedule,218.68,1228.45,Radiology
Application of body cast,29040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,387.64,,,,,,,fee schedule,218.68,1228.45,APC
Application of body cast,29040,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,484.55,,,,,,,fee schedule,218.68,1228.45,APC
Application of body cast,29044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,571.76,,,,,,,fee schedule,160.87,713.73,
Application of body cast,29044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,458.32,,,,,,,fee schedule,160.87,713.73,
Application of body cast,29044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,500.67,,,,,,,fee schedule,160.87,713.73,
Application of body cast,29044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,526.38,,,,,,,fee schedule,160.87,713.73,
Application of body cast,29044,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,713.73,,,,,,,fee schedule,160.87,713.73,APC 378
Application of body cast,29044,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,168.91,,,,,,,fee schedule,160.87,713.73,APC
Application of body cast,29044,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,167.3,,,,,,,fee schedule,160.87,713.73,APC
Application of body cast,29044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,160.87,,,,,,,fee schedule,160.87,713.73,APC
Application of body cast,29044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,246.13,,,,,,,fee schedule,160.87,713.73,Radiology
Application of body cast,29044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,225.22,,,,,,,fee schedule,160.87,713.73,APC
Application of body cast,29044,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,281.52,,,,,,,fee schedule,160.87,713.73,APC
Application of body cast,29046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,571.76,,,,,,,fee schedule,276.89,1228.45,
Application of body cast,29046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,458.32,,,,,,,fee schedule,276.89,1228.45,
Application of body cast,29046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,500.67,,,,,,,fee schedule,276.89,1228.45,
Application of body cast,29046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,526.38,,,,,,,fee schedule,276.89,1228.45,
Application of body cast,29046,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1228.45,,,,,,,fee schedule,276.89,1228.45,APC 378
Application of body cast,29046,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,290.73,,,,,,,fee schedule,276.89,1228.45,APC
Application of body cast,29046,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,287.96,,,,,,,fee schedule,276.89,1228.45,APC
Application of body cast,29046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,276.89,,,,,,,fee schedule,276.89,1228.45,APC
Application of body cast,29046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,423.64,,,,,,,fee schedule,276.89,1228.45,Radiology
Application of body cast,29046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,387.64,,,,,,,fee schedule,276.89,1228.45,APC
Application of body cast,29046,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,484.55,,,,,,,fee schedule,276.89,1228.45,APC
Application of figure eight,29049,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,272.8,,,,,,,fee schedule,218.68,1228.45,
Application of figure eight,29049,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,218.68,,,,,,,fee schedule,218.68,1228.45,
Application of figure eight,29049,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,238.88,,,,,,,fee schedule,218.68,1228.45,
Application of figure eight,29049,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,251.15,,,,,,,fee schedule,218.68,1228.45,
Application of figure eight,29049,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1228.45,,,,,,,fee schedule,218.68,1228.45,APC 378
Application of figure eight,29049,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,290.73,,,,,,,fee schedule,218.68,1228.45,APC
Application of figure eight,29049,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,287.96,,,,,,,fee schedule,218.68,1228.45,APC
Application of figure eight,29049,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,276.89,,,,,,,fee schedule,218.68,1228.45,APC
Application of figure eight,29049,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,423.64,,,,,,,fee schedule,218.68,1228.45,Radiology
Application of figure eight,29049,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,387.64,,,,,,,fee schedule,218.68,1228.45,APC
Application of figure eight,29049,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,484.55,,,,,,,fee schedule,218.68,1228.45,APC
Application of shoulder cast,29055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,571.76,,,,,,,fee schedule,276.89,1228.45,
Application of shoulder cast,29055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,458.32,,,,,,,fee schedule,276.89,1228.45,
Application of shoulder cast,29055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,500.67,,,,,,,fee schedule,276.89,1228.45,
Application of shoulder cast,29055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,526.38,,,,,,,fee schedule,276.89,1228.45,
Application of shoulder cast,29055,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1228.45,,,,,,,fee schedule,276.89,1228.45,APC 378
Application of shoulder cast,29055,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,290.73,,,,,,,fee schedule,276.89,1228.45,APC
Application of shoulder cast,29055,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,287.96,,,,,,,fee schedule,276.89,1228.45,APC
Application of shoulder cast,29055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,276.89,,,,,,,fee schedule,276.89,1228.45,APC
Application of shoulder cast,29055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,423.64,,,,,,,fee schedule,276.89,1228.45,Radiology
Application of shoulder cast,29055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,387.64,,,,,,,fee schedule,276.89,1228.45,APC
Application of shoulder cast,29055,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,484.55,,,,,,,fee schedule,276.89,1228.45,APC
Application of shoulder cast,29058,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,272.8,,,,,,,fee schedule,218.68,1228.45,
Application of shoulder cast,29058,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,218.68,,,,,,,fee schedule,218.68,1228.45,
Application of shoulder cast,29058,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,238.88,,,,,,,fee schedule,218.68,1228.45,
Application of shoulder cast,29058,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,251.15,,,,,,,fee schedule,218.68,1228.45,
Application of shoulder cast,29058,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1228.45,,,,,,,fee schedule,218.68,1228.45,APC 378
Application of shoulder cast,29058,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,290.73,,,,,,,fee schedule,218.68,1228.45,APC
Application of shoulder cast,29058,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,287.96,,,,,,,fee schedule,218.68,1228.45,APC
Application of shoulder cast,29058,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,276.89,,,,,,,fee schedule,218.68,1228.45,APC
Application of shoulder cast,29058,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,423.64,,,,,,,fee schedule,218.68,1228.45,Radiology
Application of shoulder cast,29058,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,387.64,,,,,,,fee schedule,218.68,1228.45,APC
Application of shoulder cast,29058,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,484.55,,,,,,,fee schedule,218.68,1228.45,APC
Application of long arm cast,29065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,297.99,,,,,,,fee schedule,238.87,1228.45,
Application of long arm cast,29065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,238.87,,,,,,,fee schedule,238.87,1228.45,
Application of long arm cast,29065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,260.94,,,,,,,fee schedule,238.87,1228.45,
Application of long arm cast,29065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,274.34,,,,,,,fee schedule,238.87,1228.45,
Application of long arm cast,29065,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1228.45,,,,,,,fee schedule,238.87,1228.45,APC 378
Application of long arm cast,29065,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,290.73,,,,,,,fee schedule,238.87,1228.45,APC
Application of long arm cast,29065,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,287.96,,,,,,,fee schedule,238.87,1228.45,APC
Application of long arm cast,29065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,276.89,,,,,,,fee schedule,238.87,1228.45,APC
Application of long arm cast,29065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,423.64,,,,,,,fee schedule,238.87,1228.45,Radiology
Application of long arm cast,29065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,387.64,,,,,,,fee schedule,238.87,1228.45,APC
Application of long arm cast,29065,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,484.55,,,,,,,fee schedule,238.87,1228.45,APC
Application of forearm cast,29075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,571.76,,,,,,,fee schedule,276.89,1228.45,
Application of forearm cast,29075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,458.32,,,,,,,fee schedule,276.89,1228.45,
Application of forearm cast,29075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,500.67,,,,,,,fee schedule,276.89,1228.45,
Application of forearm cast,29075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,526.38,,,,,,,fee schedule,276.89,1228.45,
Application of forearm cast,29075,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1228.45,,,,,,,fee schedule,276.89,1228.45,APC 378
Application of forearm cast,29075,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,290.73,,,,,,,fee schedule,276.89,1228.45,APC
Application of forearm cast,29075,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,287.96,,,,,,,fee schedule,276.89,1228.45,APC
Application of forearm cast,29075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,276.89,,,,,,,fee schedule,276.89,1228.45,APC
Application of forearm cast,29075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,423.64,,,,,,,fee schedule,276.89,1228.45,Radiology
Application of forearm cast,29075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,387.64,,,,,,,fee schedule,276.89,1228.45,APC
Application of forearm cast,29075,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,484.55,,,,,,,fee schedule,276.89,1228.45,APC
Apply hand/wrist cast,29085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,272.8,,,,,,,fee schedule,160.87,713.73,
Apply hand/wrist cast,29085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,218.68,,,,,,,fee schedule,160.87,713.73,
Apply hand/wrist cast,29085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,238.88,,,,,,,fee schedule,160.87,713.73,
Apply hand/wrist cast,29085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,251.15,,,,,,,fee schedule,160.87,713.73,
Apply hand/wrist cast,29085,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,713.73,,,,,,,fee schedule,160.87,713.73,APC 378
Apply hand/wrist cast,29085,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,168.91,,,,,,,fee schedule,160.87,713.73,APC
Apply hand/wrist cast,29085,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,167.3,,,,,,,fee schedule,160.87,713.73,APC
Apply hand/wrist cast,29085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,160.87,,,,,,,fee schedule,160.87,713.73,APC
Apply hand/wrist cast,29085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,246.13,,,,,,,fee schedule,160.87,713.73,Radiology
Apply hand/wrist cast,29085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,225.22,,,,,,,fee schedule,160.87,713.73,APC
Apply hand/wrist cast,29085,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,281.52,,,,,,,fee schedule,160.87,713.73,APC
Apply finger cast,29086,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,272.8,,,,,,,fee schedule,160.87,713.73,
Apply finger cast,29086,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,218.68,,,,,,,fee schedule,160.87,713.73,
Apply finger cast,29086,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,238.88,,,,,,,fee schedule,160.87,713.73,
Apply finger cast,29086,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,251.15,,,,,,,fee schedule,160.87,713.73,
Apply finger cast,29086,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,713.73,,,,,,,fee schedule,160.87,713.73,APC 378
Apply finger cast,29086,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,168.91,,,,,,,fee schedule,160.87,713.73,APC
Apply finger cast,29086,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,167.3,,,,,,,fee schedule,160.87,713.73,APC
Apply finger cast,29086,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,160.87,,,,,,,fee schedule,160.87,713.73,APC
Apply finger cast,29086,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,246.13,,,,,,,fee schedule,160.87,713.73,Radiology
Apply finger cast,29086,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,225.22,,,,,,,fee schedule,160.87,713.73,APC
Apply finger cast,29086,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,281.52,,,,,,,fee schedule,160.87,713.73,APC
Apply long arm splint,29105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,193.75,,,,,,,fee schedule,155.31,713.73,
Apply long arm splint,29105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,155.31,,,,,,,fee schedule,155.31,713.73,
Apply long arm splint,29105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,169.66,,,,,,,fee schedule,155.31,713.73,
Apply long arm splint,29105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,178.37,,,,,,,fee schedule,155.31,713.73,
Apply long arm splint,29105,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,713.73,,,,,,,fee schedule,155.31,713.73,APC 378
Apply long arm splint,29105,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,168.91,,,,,,,fee schedule,155.31,713.73,APC
Apply long arm splint,29105,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,167.3,,,,,,,fee schedule,155.31,713.73,APC
Apply long arm splint,29105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,160.87,,,,,,,fee schedule,155.31,713.73,APC
Apply long arm splint,29105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,246.13,,,,,,,fee schedule,155.31,713.73,Radiology
Apply long arm splint,29105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,225.22,,,,,,,fee schedule,155.31,713.73,APC
Apply long arm splint,29105,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,281.52,,,,,,,fee schedule,155.31,713.73,APC
Apply forearm splint,29125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,206.9,,,,,,,fee schedule,131.71,584.37,
Apply forearm splint,29125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,165.85,,,,,,,fee schedule,131.71,584.37,
Apply forearm splint,29125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,181.18,,,,,,,fee schedule,131.71,584.37,
Apply forearm splint,29125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,190.48,,,,,,,fee schedule,131.71,584.37,
Apply forearm splint,29125,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,131.71,584.37,APC 378
Apply forearm splint,29125,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,131.71,584.37,APC
Apply forearm splint,29125,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,131.71,584.37,APC
Apply forearm splint,29125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,131.71,584.37,APC
Apply forearm splint,29125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,131.71,584.37,Radiology
Apply forearm splint,29125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,131.71,584.37,APC
Apply forearm splint,29125,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,131.71,584.37,APC
Apply forearm splint,29126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,272.8,,,,,,,fee schedule,131.71,584.37,
Apply forearm splint,29126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,218.68,,,,,,,fee schedule,131.71,584.37,
Apply forearm splint,29126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,238.88,,,,,,,fee schedule,131.71,584.37,
Apply forearm splint,29126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,251.15,,,,,,,fee schedule,131.71,584.37,
Apply forearm splint,29126,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,131.71,584.37,APC 378
Apply forearm splint,29126,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,131.71,584.37,APC
Apply forearm splint,29126,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,131.71,584.37,APC
Apply forearm splint,29126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,131.71,584.37,APC
Apply forearm splint,29126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,131.71,584.37,Radiology
Apply forearm splint,29126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,131.71,584.37,APC
Apply forearm splint,29126,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,131.71,584.37,APC
Application of finger splint,29130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,158.21,,,,,,,fee schedule,126.82,584.37,
Application of finger splint,29130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,126.82,,,,,,,fee schedule,126.82,584.37,
Application of finger splint,29130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,138.53,,,,,,,fee schedule,126.82,584.37,
Application of finger splint,29130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,145.65,,,,,,,fee schedule,126.82,584.37,
Application of finger splint,29130,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,126.82,584.37,APC 378
Application of finger splint,29130,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,126.82,584.37,APC
Application of finger splint,29130,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,126.82,584.37,APC
Application of finger splint,29130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,126.82,584.37,APC
Application of finger splint,29130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,126.82,584.37,Radiology
Application of finger splint,29130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,126.82,584.37,APC
Application of finger splint,29130,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,126.82,584.37,APC
Application of finger splint,29131,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,272.8,,,,,,,fee schedule,58.4,272.8,
Application of finger splint,29131,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,218.68,,,,,,,fee schedule,58.4,272.8,
Application of finger splint,29131,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,238.88,,,,,,,fee schedule,58.4,272.8,
Application of finger splint,29131,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,251.15,,,,,,,fee schedule,58.4,272.8,
Application of finger splint,29131,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,58.4,272.8,APC 378
Application of finger splint,29131,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,58.4,272.8,APC
Application of finger splint,29131,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,58.4,272.8,APC
Application of finger splint,29131,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,58.4,272.8,APC
Application of finger splint,29131,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,58.4,272.8,Radiology
Application of finger splint,29131,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,58.4,272.8,APC
Application of finger splint,29131,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,58.4,272.8,APC
Strapping of chest,29200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,272.8,,,,,,,fee schedule,160.87,713.73,
Strapping of chest,29200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,218.68,,,,,,,fee schedule,160.87,713.73,
Strapping of chest,29200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,238.88,,,,,,,fee schedule,160.87,713.73,
Strapping of chest,29200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,251.15,,,,,,,fee schedule,160.87,713.73,
Strapping of chest,29200,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,713.73,,,,,,,fee schedule,160.87,713.73,APC 378
Strapping of chest,29200,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,168.91,,,,,,,fee schedule,160.87,713.73,APC
Strapping of chest,29200,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,167.3,,,,,,,fee schedule,160.87,713.73,APC
Strapping of chest,29200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,160.87,,,,,,,fee schedule,160.87,713.73,APC
Strapping of chest,29200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,246.13,,,,,,,fee schedule,160.87,713.73,Radiology
Strapping of chest,29200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,225.22,,,,,,,fee schedule,160.87,713.73,APC
Strapping of chest,29200,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,281.52,,,,,,,fee schedule,160.87,713.73,APC
Strapping of shoulder,29240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,272.8,,,,,,,fee schedule,131.71,584.37,
Strapping of shoulder,29240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,218.68,,,,,,,fee schedule,131.71,584.37,
Strapping of shoulder,29240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,238.88,,,,,,,fee schedule,131.71,584.37,
Strapping of shoulder,29240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,251.15,,,,,,,fee schedule,131.71,584.37,
Strapping of shoulder,29240,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,131.71,584.37,APC 378
Strapping of shoulder,29240,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,131.71,584.37,APC
Strapping of shoulder,29240,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,131.71,584.37,APC
Strapping of shoulder,29240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,131.71,584.37,APC
Strapping of shoulder,29240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,131.71,584.37,Radiology
Strapping of shoulder,29240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,131.71,584.37,APC
Strapping of shoulder,29240,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,131.71,584.37,APC
Strapping of elbow or wrist,29260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,272.8,,,,,,,fee schedule,58.4,272.8,
Strapping of elbow or wrist,29260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,218.68,,,,,,,fee schedule,58.4,272.8,
Strapping of elbow or wrist,29260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,238.88,,,,,,,fee schedule,58.4,272.8,
Strapping of elbow or wrist,29260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,251.15,,,,,,,fee schedule,58.4,272.8,
Strapping of elbow or wrist,29260,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,58.4,272.8,APC 378
Strapping of elbow or wrist,29260,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,58.4,272.8,APC
Strapping of elbow or wrist,29260,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,58.4,272.8,APC
Strapping of elbow or wrist,29260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,58.4,272.8,APC
Strapping of elbow or wrist,29260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,58.4,272.8,Radiology
Strapping of elbow or wrist,29260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,58.4,272.8,APC
Strapping of elbow or wrist,29260,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,58.4,272.8,APC
Strapping of hand or finger,29280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,272.8,,,,,,,fee schedule,58.4,272.8,
Strapping of hand or finger,29280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,218.68,,,,,,,fee schedule,58.4,272.8,
Strapping of hand or finger,29280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,238.88,,,,,,,fee schedule,58.4,272.8,
Strapping of hand or finger,29280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,251.15,,,,,,,fee schedule,58.4,272.8,
Strapping of hand or finger,29280,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,58.4,272.8,APC 378
Strapping of hand or finger,29280,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,58.4,272.8,APC
Strapping of hand or finger,29280,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,58.4,272.8,APC
Strapping of hand or finger,29280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,58.4,272.8,APC
Strapping of hand or finger,29280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,58.4,272.8,Radiology
Strapping of hand or finger,29280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,58.4,272.8,APC
Strapping of hand or finger,29280,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,58.4,272.8,APC
Application of hip cast,29305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,571.76,,,,,,,fee schedule,276.89,1228.45,
Application of hip cast,29305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,458.32,,,,,,,fee schedule,276.89,1228.45,
Application of hip cast,29305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,500.67,,,,,,,fee schedule,276.89,1228.45,
Application of hip cast,29305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,526.38,,,,,,,fee schedule,276.89,1228.45,
Application of hip cast,29305,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1228.45,,,,,,,fee schedule,276.89,1228.45,APC 378
Application of hip cast,29305,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,290.73,,,,,,,fee schedule,276.89,1228.45,APC
Application of hip cast,29305,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,287.96,,,,,,,fee schedule,276.89,1228.45,APC
Application of hip cast,29305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,276.89,,,,,,,fee schedule,276.89,1228.45,APC
Application of hip cast,29305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,423.64,,,,,,,fee schedule,276.89,1228.45,Radiology
Application of hip cast,29305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,387.64,,,,,,,fee schedule,276.89,1228.45,APC
Application of hip cast,29305,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,484.55,,,,,,,fee schedule,276.89,1228.45,APC
Application of hip casts,29325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,571.76,,,,,,,fee schedule,276.89,1228.45,
Application of hip casts,29325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,458.32,,,,,,,fee schedule,276.89,1228.45,
Application of hip casts,29325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,500.67,,,,,,,fee schedule,276.89,1228.45,
Application of hip casts,29325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,526.38,,,,,,,fee schedule,276.89,1228.45,
Application of hip casts,29325,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1228.45,,,,,,,fee schedule,276.89,1228.45,APC 378
Application of hip casts,29325,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,290.73,,,,,,,fee schedule,276.89,1228.45,APC
Application of hip casts,29325,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,287.96,,,,,,,fee schedule,276.89,1228.45,APC
Application of hip casts,29325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,276.89,,,,,,,fee schedule,276.89,1228.45,APC
Application of hip casts,29325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,423.64,,,,,,,fee schedule,276.89,1228.45,Radiology
Application of hip casts,29325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,387.64,,,,,,,fee schedule,276.89,1228.45,APC
Application of hip casts,29325,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,484.55,,,,,,,fee schedule,276.89,1228.45,APC
Application of long leg cast,29345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,571.76,,,,,,,fee schedule,276.89,1228.45,
Application of long leg cast,29345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,458.32,,,,,,,fee schedule,276.89,1228.45,
Application of long leg cast,29345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,500.67,,,,,,,fee schedule,276.89,1228.45,
Application of long leg cast,29345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,526.38,,,,,,,fee schedule,276.89,1228.45,
Application of long leg cast,29345,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1228.45,,,,,,,fee schedule,276.89,1228.45,APC 378
Application of long leg cast,29345,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,290.73,,,,,,,fee schedule,276.89,1228.45,APC
Application of long leg cast,29345,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,287.96,,,,,,,fee schedule,276.89,1228.45,APC
Application of long leg cast,29345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,276.89,,,,,,,fee schedule,276.89,1228.45,APC
Application of long leg cast,29345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,423.64,,,,,,,fee schedule,276.89,1228.45,Radiology
Application of long leg cast,29345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,387.64,,,,,,,fee schedule,276.89,1228.45,APC
Application of long leg cast,29345,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,484.55,,,,,,,fee schedule,276.89,1228.45,APC
Application of long leg cast,29355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,571.76,,,,,,,fee schedule,276.89,1228.45,
Application of long leg cast,29355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,458.32,,,,,,,fee schedule,276.89,1228.45,
Application of long leg cast,29355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,500.67,,,,,,,fee schedule,276.89,1228.45,
Application of long leg cast,29355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,526.38,,,,,,,fee schedule,276.89,1228.45,
Application of long leg cast,29355,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1228.45,,,,,,,fee schedule,276.89,1228.45,APC 378
Application of long leg cast,29355,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,290.73,,,,,,,fee schedule,276.89,1228.45,APC
Application of long leg cast,29355,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,287.96,,,,,,,fee schedule,276.89,1228.45,APC
Application of long leg cast,29355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,276.89,,,,,,,fee schedule,276.89,1228.45,APC
Application of long leg cast,29355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,423.64,,,,,,,fee schedule,276.89,1228.45,Radiology
Application of long leg cast,29355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,387.64,,,,,,,fee schedule,276.89,1228.45,APC
Application of long leg cast,29355,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,484.55,,,,,,,fee schedule,276.89,1228.45,APC
Apply long leg cast brace,29358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,571.76,,,,,,,fee schedule,276.89,1228.45,
Apply long leg cast brace,29358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,458.32,,,,,,,fee schedule,276.89,1228.45,
Apply long leg cast brace,29358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,500.67,,,,,,,fee schedule,276.89,1228.45,
Apply long leg cast brace,29358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,526.38,,,,,,,fee schedule,276.89,1228.45,
Apply long leg cast brace,29358,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1228.45,,,,,,,fee schedule,276.89,1228.45,APC 378
Apply long leg cast brace,29358,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,290.73,,,,,,,fee schedule,276.89,1228.45,APC
Apply long leg cast brace,29358,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,287.96,,,,,,,fee schedule,276.89,1228.45,APC
Apply long leg cast brace,29358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,276.89,,,,,,,fee schedule,276.89,1228.45,APC
Apply long leg cast brace,29358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,423.64,,,,,,,fee schedule,276.89,1228.45,Radiology
Apply long leg cast brace,29358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,387.64,,,,,,,fee schedule,276.89,1228.45,APC
Apply long leg cast brace,29358,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,484.55,,,,,,,fee schedule,276.89,1228.45,APC
Application of long leg cast,29365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,571.76,,,,,,,fee schedule,276.89,1228.45,
Application of long leg cast,29365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,458.32,,,,,,,fee schedule,276.89,1228.45,
Application of long leg cast,29365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,500.67,,,,,,,fee schedule,276.89,1228.45,
Application of long leg cast,29365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,526.38,,,,,,,fee schedule,276.89,1228.45,
Application of long leg cast,29365,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1228.45,,,,,,,fee schedule,276.89,1228.45,APC 378
Application of long leg cast,29365,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,290.73,,,,,,,fee schedule,276.89,1228.45,APC
Application of long leg cast,29365,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,287.96,,,,,,,fee schedule,276.89,1228.45,APC
Application of long leg cast,29365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,276.89,,,,,,,fee schedule,276.89,1228.45,APC
Application of long leg cast,29365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,423.64,,,,,,,fee schedule,276.89,1228.45,Radiology
Application of long leg cast,29365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,387.64,,,,,,,fee schedule,276.89,1228.45,APC
Application of long leg cast,29365,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,484.55,,,,,,,fee schedule,276.89,1228.45,APC
Apply short leg cast,29405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,452.94,,,,,,,fee schedule,276.89,1228.45,
Apply short leg cast,29405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,363.07,,,,,,,fee schedule,276.89,1228.45,
Apply short leg cast,29405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,396.63,,,,,,,fee schedule,276.89,1228.45,
Apply short leg cast,29405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,417,,,,,,,fee schedule,276.89,1228.45,
Apply short leg cast,29405,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1228.45,,,,,,,fee schedule,276.89,1228.45,APC 378
Apply short leg cast,29405,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,290.73,,,,,,,fee schedule,276.89,1228.45,APC
Apply short leg cast,29405,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,287.96,,,,,,,fee schedule,276.89,1228.45,APC
Apply short leg cast,29405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,276.89,,,,,,,fee schedule,276.89,1228.45,APC
Apply short leg cast,29405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,423.64,,,,,,,fee schedule,276.89,1228.45,Radiology
Apply short leg cast,29405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,387.64,,,,,,,fee schedule,276.89,1228.45,APC
Apply short leg cast,29405,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,484.55,,,,,,,fee schedule,276.89,1228.45,APC
Apply short leg cast,29425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,571.76,,,,,,,fee schedule,276.89,1228.45,
Apply short leg cast,29425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,458.32,,,,,,,fee schedule,276.89,1228.45,
Apply short leg cast,29425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,500.67,,,,,,,fee schedule,276.89,1228.45,
Apply short leg cast,29425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,526.38,,,,,,,fee schedule,276.89,1228.45,
Apply short leg cast,29425,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1228.45,,,,,,,fee schedule,276.89,1228.45,APC 378
Apply short leg cast,29425,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,290.73,,,,,,,fee schedule,276.89,1228.45,APC
Apply short leg cast,29425,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,287.96,,,,,,,fee schedule,276.89,1228.45,APC
Apply short leg cast,29425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,276.89,,,,,,,fee schedule,276.89,1228.45,APC
Apply short leg cast,29425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,423.64,,,,,,,fee schedule,276.89,1228.45,Radiology
Apply short leg cast,29425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,387.64,,,,,,,fee schedule,276.89,1228.45,APC
Apply short leg cast,29425,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,484.55,,,,,,,fee schedule,276.89,1228.45,APC
Apply short leg cast,29435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,571.76,,,,,,,fee schedule,276.89,1228.45,
Apply short leg cast,29435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,458.32,,,,,,,fee schedule,276.89,1228.45,
Apply short leg cast,29435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,500.67,,,,,,,fee schedule,276.89,1228.45,
Apply short leg cast,29435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,526.38,,,,,,,fee schedule,276.89,1228.45,
Apply short leg cast,29435,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1228.45,,,,,,,fee schedule,276.89,1228.45,APC 378
Apply short leg cast,29435,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,290.73,,,,,,,fee schedule,276.89,1228.45,APC
Apply short leg cast,29435,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,287.96,,,,,,,fee schedule,276.89,1228.45,APC
Apply short leg cast,29435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,276.89,,,,,,,fee schedule,276.89,1228.45,APC
Apply short leg cast,29435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,423.64,,,,,,,fee schedule,276.89,1228.45,Radiology
Apply short leg cast,29435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,387.64,,,,,,,fee schedule,276.89,1228.45,APC
Apply short leg cast,29435,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,484.55,,,,,,,fee schedule,276.89,1228.45,APC
Addition of walker to cast,29440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,272.8,,,,,,,fee schedule,160.87,713.73,
Addition of walker to cast,29440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,218.68,,,,,,,fee schedule,160.87,713.73,
Addition of walker to cast,29440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,238.88,,,,,,,fee schedule,160.87,713.73,
Addition of walker to cast,29440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,251.15,,,,,,,fee schedule,160.87,713.73,
Addition of walker to cast,29440,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,713.73,,,,,,,fee schedule,160.87,713.73,APC 378
Addition of walker to cast,29440,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,168.91,,,,,,,fee schedule,160.87,713.73,APC
Addition of walker to cast,29440,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,167.3,,,,,,,fee schedule,160.87,713.73,APC
Addition of walker to cast,29440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,160.87,,,,,,,fee schedule,160.87,713.73,APC
Addition of walker to cast,29440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,246.13,,,,,,,fee schedule,160.87,713.73,Radiology
Addition of walker to cast,29440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,225.22,,,,,,,fee schedule,160.87,713.73,APC
Addition of walker to cast,29440,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,281.52,,,,,,,fee schedule,160.87,713.73,APC
Apply rigid leg cast,29445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,646.91,,,,,,,fee schedule,276.89,1228.45,
Apply rigid leg cast,29445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,518.55,,,,,,,fee schedule,276.89,1228.45,
Apply rigid leg cast,29445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,566.47,,,,,,,fee schedule,276.89,1228.45,
Apply rigid leg cast,29445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,595.57,,,,,,,fee schedule,276.89,1228.45,
Apply rigid leg cast,29445,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1228.45,,,,,,,fee schedule,276.89,1228.45,APC 378
Apply rigid leg cast,29445,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,290.73,,,,,,,fee schedule,276.89,1228.45,APC
Apply rigid leg cast,29445,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,287.96,,,,,,,fee schedule,276.89,1228.45,APC
Apply rigid leg cast,29445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,276.89,,,,,,,fee schedule,276.89,1228.45,APC
Apply rigid leg cast,29445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,423.64,,,,,,,fee schedule,276.89,1228.45,Radiology
Apply rigid leg cast,29445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,387.64,,,,,,,fee schedule,276.89,1228.45,APC
Apply rigid leg cast,29445,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,484.55,,,,,,,fee schedule,276.89,1228.45,APC
Application of leg cast,29450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,272.8,,,,,,,fee schedule,160.87,713.73,
Application of leg cast,29450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,218.68,,,,,,,fee schedule,160.87,713.73,
Application of leg cast,29450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,238.88,,,,,,,fee schedule,160.87,713.73,
Application of leg cast,29450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,251.15,,,,,,,fee schedule,160.87,713.73,
Application of leg cast,29450,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,713.73,,,,,,,fee schedule,160.87,713.73,APC 378
Application of leg cast,29450,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,168.91,,,,,,,fee schedule,160.87,713.73,APC
Application of leg cast,29450,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,167.3,,,,,,,fee schedule,160.87,713.73,APC
Application of leg cast,29450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,160.87,,,,,,,fee schedule,160.87,713.73,APC
Application of leg cast,29450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,246.13,,,,,,,fee schedule,160.87,713.73,Radiology
Application of leg cast,29450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,225.22,,,,,,,fee schedule,160.87,713.73,APC
Application of leg cast,29450,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,281.52,,,,,,,fee schedule,160.87,713.73,APC
Application long leg splint,29505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,755.45,,,,,,,fee schedule,160.87,755.45,
Application long leg splint,29505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,605.56,,,,,,,fee schedule,160.87,755.45,
Application long leg splint,29505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,661.52,,,,,,,fee schedule,160.87,755.45,
Application long leg splint,29505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,695.49,,,,,,,fee schedule,160.87,755.45,
Application long leg splint,29505,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,713.73,,,,,,,fee schedule,160.87,755.45,APC 378
Application long leg splint,29505,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,168.91,,,,,,,fee schedule,160.87,755.45,APC
Application long leg splint,29505,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,167.3,,,,,,,fee schedule,160.87,755.45,APC
Application long leg splint,29505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,160.87,,,,,,,fee schedule,160.87,755.45,APC
Application long leg splint,29505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,246.13,,,,,,,fee schedule,160.87,755.45,Radiology
Application long leg splint,29505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,225.22,,,,,,,fee schedule,160.87,755.45,APC
Application long leg splint,29505,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,281.52,,,,,,,fee schedule,160.87,755.45,APC
Application lower leg splint,29515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,404.31,,,,,,,fee schedule,160.87,713.73,
Application lower leg splint,29515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,324.09,,,,,,,fee schedule,160.87,713.73,
Application lower leg splint,29515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,354.04,,,,,,,fee schedule,160.87,713.73,
Application lower leg splint,29515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,372.23,,,,,,,fee schedule,160.87,713.73,
Application lower leg splint,29515,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,713.73,,,,,,,fee schedule,160.87,713.73,APC 378
Application lower leg splint,29515,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,168.91,,,,,,,fee schedule,160.87,713.73,APC
Application lower leg splint,29515,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,167.3,,,,,,,fee schedule,160.87,713.73,APC
Application lower leg splint,29515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,160.87,,,,,,,fee schedule,160.87,713.73,APC
Application lower leg splint,29515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,246.13,,,,,,,fee schedule,160.87,713.73,Radiology
Application lower leg splint,29515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,225.22,,,,,,,fee schedule,160.87,713.73,APC
Application lower leg splint,29515,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,281.52,,,,,,,fee schedule,160.87,713.73,APC
Strapping of hip,29520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,272.8,,,,,,,fee schedule,131.71,584.37,
Strapping of hip,29520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,218.68,,,,,,,fee schedule,131.71,584.37,
Strapping of hip,29520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,238.88,,,,,,,fee schedule,131.71,584.37,
Strapping of hip,29520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,251.15,,,,,,,fee schedule,131.71,584.37,
Strapping of hip,29520,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,131.71,584.37,APC 378
Strapping of hip,29520,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,131.71,584.37,APC
Strapping of hip,29520,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,131.71,584.37,APC
Strapping of hip,29520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,131.71,584.37,APC
Strapping of hip,29520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,131.71,584.37,Radiology
Strapping of hip,29520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,131.71,584.37,APC
Strapping of hip,29520,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,131.71,584.37,APC
Strapping of knee,29530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,272.8,,,,,,,fee schedule,131.71,584.37,
Strapping of knee,29530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,218.68,,,,,,,fee schedule,131.71,584.37,
Strapping of knee,29530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,238.88,,,,,,,fee schedule,131.71,584.37,
Strapping of knee,29530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,251.15,,,,,,,fee schedule,131.71,584.37,
Strapping of knee,29530,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,131.71,584.37,APC 378
Strapping of knee,29530,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,131.71,584.37,APC
Strapping of knee,29530,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,131.71,584.37,APC
Strapping of knee,29530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,131.71,584.37,APC
Strapping of knee,29530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,131.71,584.37,Radiology
Strapping of knee,29530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,131.71,584.37,APC
Strapping of knee,29530,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,131.71,584.37,APC
Strapping of ankle and/or ft,29540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,272.8,,,,,,,fee schedule,160.87,713.73,
Strapping of ankle and/or ft,29540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,218.68,,,,,,,fee schedule,160.87,713.73,
Strapping of ankle and/or ft,29540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,238.88,,,,,,,fee schedule,160.87,713.73,
Strapping of ankle and/or ft,29540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,251.15,,,,,,,fee schedule,160.87,713.73,
Strapping of ankle and/or ft,29540,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,713.73,,,,,,,fee schedule,160.87,713.73,APC 378
Strapping of ankle and/or ft,29540,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,168.91,,,,,,,fee schedule,160.87,713.73,APC
Strapping of ankle and/or ft,29540,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,167.3,,,,,,,fee schedule,160.87,713.73,APC
Strapping of ankle and/or ft,29540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,160.87,,,,,,,fee schedule,160.87,713.73,APC
Strapping of ankle and/or ft,29540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,246.13,,,,,,,fee schedule,160.87,713.73,Radiology
Strapping of ankle and/or ft,29540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,225.22,,,,,,,fee schedule,160.87,713.73,APC
Strapping of ankle and/or ft,29540,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,281.52,,,,,,,fee schedule,160.87,713.73,APC
Strapping of toes,29550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,272.8,,,,,,,fee schedule,58.4,272.8,
Strapping of toes,29550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,218.68,,,,,,,fee schedule,58.4,272.8,
Strapping of toes,29550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,238.88,,,,,,,fee schedule,58.4,272.8,
Strapping of toes,29550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,251.15,,,,,,,fee schedule,58.4,272.8,
Strapping of toes,29550,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,58.4,272.8,APC 378
Strapping of toes,29550,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,58.4,272.8,APC
Strapping of toes,29550,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,58.4,272.8,APC
Strapping of toes,29550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,58.4,272.8,APC
Strapping of toes,29550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,58.4,272.8,Radiology
Strapping of toes,29550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,58.4,272.8,APC
Strapping of toes,29550,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,58.4,272.8,APC
Application of paste boot,29580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,272.8,,,,,,,fee schedule,160.87,713.73,
Application of paste boot,29580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,218.68,,,,,,,fee schedule,160.87,713.73,
Application of paste boot,29580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,238.88,,,,,,,fee schedule,160.87,713.73,
Application of paste boot,29580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,251.15,,,,,,,fee schedule,160.87,713.73,
Application of paste boot,29580,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,713.73,,,,,,,fee schedule,160.87,713.73,APC 378
Application of paste boot,29580,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,168.91,,,,,,,fee schedule,160.87,713.73,APC
Application of paste boot,29580,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,167.3,,,,,,,fee schedule,160.87,713.73,APC
Application of paste boot,29580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,160.87,,,,,,,fee schedule,160.87,713.73,APC
Application of paste boot,29580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,246.13,,,,,,,fee schedule,160.87,713.73,Radiology
Application of paste boot,29580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,225.22,,,,,,,fee schedule,160.87,713.73,APC
Application of paste boot,29580,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,281.52,,,,,,,fee schedule,160.87,713.73,APC
Apply multlay comprs lwr leg,29581,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,179.88,,,,,,,fee schedule,144.19,713.73,
Apply multlay comprs lwr leg,29581,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,144.19,,,,,,,fee schedule,144.19,713.73,
Apply multlay comprs lwr leg,29581,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,157.51,,,,,,,fee schedule,144.19,713.73,
Apply multlay comprs lwr leg,29581,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,165.6,,,,,,,fee schedule,144.19,713.73,
Apply multlay comprs lwr leg,29581,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,713.73,,,,,,,fee schedule,144.19,713.73,APC 378
Apply multlay comprs lwr leg,29581,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,168.91,,,,,,,fee schedule,144.19,713.73,APC
Apply multlay comprs lwr leg,29581,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,167.3,,,,,,,fee schedule,144.19,713.73,APC
Apply multlay comprs lwr leg,29581,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,160.87,,,,,,,fee schedule,144.19,713.73,APC
Apply multlay comprs lwr leg,29581,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,246.13,,,,,,,fee schedule,144.19,713.73,Radiology
Apply multlay comprs lwr leg,29581,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,225.22,,,,,,,fee schedule,144.19,713.73,APC
Apply multlay comprs lwr leg,29581,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,281.52,,,,,,,fee schedule,144.19,713.73,APC
Appl multlay comprs arm/hand,29584,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,203.86,,,,,,,fee schedule,160.87,713.73,
Appl multlay comprs arm/hand,29584,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,163.41,,,,,,,fee schedule,160.87,713.73,
Appl multlay comprs arm/hand,29584,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,178.51,,,,,,,fee schedule,160.87,713.73,
Appl multlay comprs arm/hand,29584,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,187.68,,,,,,,fee schedule,160.87,713.73,
Appl multlay comprs arm/hand,29584,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,713.73,,,,,,,fee schedule,160.87,713.73,APC 378
Appl multlay comprs arm/hand,29584,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,168.91,,,,,,,fee schedule,160.87,713.73,APC
Appl multlay comprs arm/hand,29584,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,167.3,,,,,,,fee schedule,160.87,713.73,APC
Appl multlay comprs arm/hand,29584,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,160.87,,,,,,,fee schedule,160.87,713.73,APC
Appl multlay comprs arm/hand,29584,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,246.13,,,,,,,fee schedule,160.87,713.73,Radiology
Appl multlay comprs arm/hand,29584,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,225.22,,,,,,,fee schedule,160.87,713.73,APC
Appl multlay comprs arm/hand,29584,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,281.52,,,,,,,fee schedule,160.87,713.73,APC
Removal/revision of cast,29700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,272.8,,,,,,,fee schedule,218.68,1228.45,
Removal/revision of cast,29700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,218.68,,,,,,,fee schedule,218.68,1228.45,
Removal/revision of cast,29700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,238.88,,,,,,,fee schedule,218.68,1228.45,
Removal/revision of cast,29700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,251.15,,,,,,,fee schedule,218.68,1228.45,
Removal/revision of cast,29700,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1228.45,,,,,,,fee schedule,218.68,1228.45,APC 378
Removal/revision of cast,29700,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,290.73,,,,,,,fee schedule,218.68,1228.45,APC
Removal/revision of cast,29700,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,287.96,,,,,,,fee schedule,218.68,1228.45,APC
Removal/revision of cast,29700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,276.89,,,,,,,fee schedule,218.68,1228.45,APC
Removal/revision of cast,29700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,423.64,,,,,,,fee schedule,218.68,1228.45,Radiology
Removal/revision of cast,29700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,387.64,,,,,,,fee schedule,218.68,1228.45,APC
Removal/revision of cast,29700,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,484.55,,,,,,,fee schedule,218.68,1228.45,APC
Removal/revision of cast,29705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,252.48,,,,,,,fee schedule,202.38,1228.45,
Removal/revision of cast,29705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,202.38,,,,,,,fee schedule,202.38,1228.45,
Removal/revision of cast,29705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,221.09,,,,,,,fee schedule,202.38,1228.45,
Removal/revision of cast,29705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,232.44,,,,,,,fee schedule,202.38,1228.45,
Removal/revision of cast,29705,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1228.45,,,,,,,fee schedule,202.38,1228.45,APC 378
Removal/revision of cast,29705,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,290.73,,,,,,,fee schedule,202.38,1228.45,APC
Removal/revision of cast,29705,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,287.96,,,,,,,fee schedule,202.38,1228.45,APC
Removal/revision of cast,29705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,276.89,,,,,,,fee schedule,202.38,1228.45,APC
Removal/revision of cast,29705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,423.64,,,,,,,fee schedule,202.38,1228.45,Radiology
Removal/revision of cast,29705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,387.64,,,,,,,fee schedule,202.38,1228.45,APC
Removal/revision of cast,29705,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,484.55,,,,,,,fee schedule,202.38,1228.45,APC
Removal/revision of cast,29710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,571.76,,,,,,,fee schedule,276.89,1228.45,
Removal/revision of cast,29710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,458.32,,,,,,,fee schedule,276.89,1228.45,
Removal/revision of cast,29710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,500.67,,,,,,,fee schedule,276.89,1228.45,
Removal/revision of cast,29710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,526.38,,,,,,,fee schedule,276.89,1228.45,
Removal/revision of cast,29710,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1228.45,,,,,,,fee schedule,276.89,1228.45,APC 378
Removal/revision of cast,29710,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,290.73,,,,,,,fee schedule,276.89,1228.45,APC
Removal/revision of cast,29710,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,287.96,,,,,,,fee schedule,276.89,1228.45,APC
Removal/revision of cast,29710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,276.89,,,,,,,fee schedule,276.89,1228.45,APC
Removal/revision of cast,29710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,423.64,,,,,,,fee schedule,276.89,1228.45,Radiology
Removal/revision of cast,29710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,387.64,,,,,,,fee schedule,276.89,1228.45,APC
Removal/revision of cast,29710,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,484.55,,,,,,,fee schedule,276.89,1228.45,APC
Repair of body cast,29720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,272.8,,,,,,,fee schedule,160.87,713.73,
Repair of body cast,29720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,218.68,,,,,,,fee schedule,160.87,713.73,
Repair of body cast,29720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,238.88,,,,,,,fee schedule,160.87,713.73,
Repair of body cast,29720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,251.15,,,,,,,fee schedule,160.87,713.73,
Repair of body cast,29720,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,713.73,,,,,,,fee schedule,160.87,713.73,APC 378
Repair of body cast,29720,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,168.91,,,,,,,fee schedule,160.87,713.73,APC
Repair of body cast,29720,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,167.3,,,,,,,fee schedule,160.87,713.73,APC
Repair of body cast,29720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,160.87,,,,,,,fee schedule,160.87,713.73,APC
Repair of body cast,29720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,246.13,,,,,,,fee schedule,160.87,713.73,Radiology
Repair of body cast,29720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,225.22,,,,,,,fee schedule,160.87,713.73,APC
Repair of body cast,29720,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,281.52,,,,,,,fee schedule,160.87,713.73,APC
Windowing of cast,29730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,272.8,,,,,,,fee schedule,160.87,713.73,
Windowing of cast,29730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,218.68,,,,,,,fee schedule,160.87,713.73,
Windowing of cast,29730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,238.88,,,,,,,fee schedule,160.87,713.73,
Windowing of cast,29730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,251.15,,,,,,,fee schedule,160.87,713.73,
Windowing of cast,29730,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,713.73,,,,,,,fee schedule,160.87,713.73,APC 378
Windowing of cast,29730,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,168.91,,,,,,,fee schedule,160.87,713.73,APC
Windowing of cast,29730,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,167.3,,,,,,,fee schedule,160.87,713.73,APC
Windowing of cast,29730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,160.87,,,,,,,fee schedule,160.87,713.73,APC
Windowing of cast,29730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,246.13,,,,,,,fee schedule,160.87,713.73,Radiology
Windowing of cast,29730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,225.22,,,,,,,fee schedule,160.87,713.73,APC
Windowing of cast,29730,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,281.52,,,,,,,fee schedule,160.87,713.73,APC
Wedging of cast,29740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,272.8,,,,,,,fee schedule,218.68,1228.45,
Wedging of cast,29740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,218.68,,,,,,,fee schedule,218.68,1228.45,
Wedging of cast,29740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,238.88,,,,,,,fee schedule,218.68,1228.45,
Wedging of cast,29740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,251.15,,,,,,,fee schedule,218.68,1228.45,
Wedging of cast,29740,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1228.45,,,,,,,fee schedule,218.68,1228.45,APC 378
Wedging of cast,29740,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,290.73,,,,,,,fee schedule,218.68,1228.45,APC
Wedging of cast,29740,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,287.96,,,,,,,fee schedule,218.68,1228.45,APC
Wedging of cast,29740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,276.89,,,,,,,fee schedule,218.68,1228.45,APC
Wedging of cast,29740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,423.64,,,,,,,fee schedule,218.68,1228.45,Radiology
Wedging of cast,29740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,387.64,,,,,,,fee schedule,218.68,1228.45,APC
Wedging of cast,29740,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,484.55,,,,,,,fee schedule,218.68,1228.45,APC
Wedging of clubfoot cast,29750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,272.8,,,,,,,fee schedule,218.68,1228.45,
Wedging of clubfoot cast,29750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,218.68,,,,,,,fee schedule,218.68,1228.45,
Wedging of clubfoot cast,29750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,238.88,,,,,,,fee schedule,218.68,1228.45,
Wedging of clubfoot cast,29750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,251.15,,,,,,,fee schedule,218.68,1228.45,
Wedging of clubfoot cast,29750,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1228.45,,,,,,,fee schedule,218.68,1228.45,APC 378
Wedging of clubfoot cast,29750,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,290.73,,,,,,,fee schedule,218.68,1228.45,APC
Wedging of clubfoot cast,29750,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,287.96,,,,,,,fee schedule,218.68,1228.45,APC
Wedging of clubfoot cast,29750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,276.89,,,,,,,fee schedule,218.68,1228.45,APC
Wedging of clubfoot cast,29750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,423.64,,,,,,,fee schedule,218.68,1228.45,Radiology
Wedging of clubfoot cast,29750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,387.64,,,,,,,fee schedule,218.68,1228.45,APC
Wedging of clubfoot cast,29750,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,484.55,,,,,,,fee schedule,218.68,1228.45,APC
Casting/strapping procedure,29799,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,272.8,,,,,,,fee schedule,160.87,713.73,
Casting/strapping procedure,29799,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,218.68,,,,,,,fee schedule,160.87,713.73,
Casting/strapping procedure,29799,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,238.88,,,,,,,fee schedule,160.87,713.73,
Casting/strapping procedure,29799,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,251.15,,,,,,,fee schedule,160.87,713.73,
Casting/strapping procedure,29799,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,713.73,,,,,,,fee schedule,160.87,713.73,APC 378
Casting/strapping procedure,29799,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,168.91,,,,,,,fee schedule,160.87,713.73,APC
Casting/strapping procedure,29799,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,167.3,,,,,,,fee schedule,160.87,713.73,APC
Casting/strapping procedure,29799,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,160.87,,,,,,,fee schedule,160.87,713.73,APC
Casting/strapping procedure,29799,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,246.13,,,,,,,fee schedule,160.87,713.73,Radiology
Casting/strapping procedure,29799,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,225.22,,,,,,,fee schedule,160.87,713.73,APC
Casting/strapping procedure,29799,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,281.52,,,,,,,fee schedule,160.87,713.73,APC
Jaw arthroscopy/surgery,29800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7182.83,,,,,,,fee schedule,3239.17,14371.12,
Jaw arthroscopy/surgery,29800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5757.67,,,,,,,fee schedule,3239.17,14371.12,
Jaw arthroscopy/surgery,29800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6289.73,,,,,,,fee schedule,3239.17,14371.12,
Jaw arthroscopy/surgery,29800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6612.77,,,,,,,fee schedule,3239.17,14371.12,
Jaw arthroscopy/surgery,29800,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Jaw arthroscopy/surgery,29800,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Jaw arthroscopy/surgery,29800,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Jaw arthroscopy/surgery,29800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Jaw arthroscopy/surgery,29800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Jaw arthroscopy/surgery,29800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Jaw arthroscopy/surgery,29800,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Jaw arthroscopy/surgery,29804,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7182.83,,,,,,,fee schedule,3239.17,14371.12,
Jaw arthroscopy/surgery,29804,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5757.67,,,,,,,fee schedule,3239.17,14371.12,
Jaw arthroscopy/surgery,29804,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6289.73,,,,,,,fee schedule,3239.17,14371.12,
Jaw arthroscopy/surgery,29804,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6612.77,,,,,,,fee schedule,3239.17,14371.12,
Jaw arthroscopy/surgery,29804,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Jaw arthroscopy/surgery,29804,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Jaw arthroscopy/surgery,29804,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Jaw arthroscopy/surgery,29804,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Jaw arthroscopy/surgery,29804,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Jaw arthroscopy/surgery,29804,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Jaw arthroscopy/surgery,29804,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Shoulder arthroscopy dx,29805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5336.73,,,,,,,fee schedule,3239.17,14371.12,
Shoulder arthroscopy dx,29805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4277.86,,,,,,,fee schedule,3239.17,14371.12,
Shoulder arthroscopy dx,29805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4673.17,,,,,,,fee schedule,3239.17,14371.12,
Shoulder arthroscopy dx,29805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4913.18,,,,,,,fee schedule,3239.17,14371.12,
Shoulder arthroscopy dx,29805,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Shoulder arthroscopy dx,29805,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Shoulder arthroscopy dx,29805,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Shoulder arthroscopy dx,29805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Shoulder arthroscopy dx,29805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Shoulder arthroscopy dx,29805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Shoulder arthroscopy dx,29805,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Shoulder arthroscopy/surgery,29806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8594.03,,,,,,,fee schedule,6888.87,31870.39,
Shoulder arthroscopy/surgery,29806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6888.87,,,,,,,fee schedule,6888.87,31870.39,
Shoulder arthroscopy/surgery,29806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7525.46,,,,,,,fee schedule,6888.87,31870.39,
Shoulder arthroscopy/surgery,29806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7911.97,,,,,,,fee schedule,6888.87,31870.39,
Shoulder arthroscopy/surgery,29806,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,6888.87,31870.39,APC 378
Shoulder arthroscopy/surgery,29806,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,6888.87,31870.39,APC
Shoulder arthroscopy/surgery,29806,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,6888.87,31870.39,APC
Shoulder arthroscopy/surgery,29806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,6888.87,31870.39,APC
Shoulder arthroscopy/surgery,29806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,6888.87,31870.39,Radiology
Shoulder arthroscopy/surgery,29806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,6888.87,31870.39,APC
Shoulder arthroscopy/surgery,29806,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,6888.87,31870.39,APC
Shoulder arthroscopy/surgery,29807,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7118.17,,,,,,,fee schedule,5705.83,31870.39,
Shoulder arthroscopy/surgery,29807,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5705.83,,,,,,,fee schedule,5705.83,31870.39,
Shoulder arthroscopy/surgery,29807,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6233.11,,,,,,,fee schedule,5705.83,31870.39,
Shoulder arthroscopy/surgery,29807,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6553.23,,,,,,,fee schedule,5705.83,31870.39,
Shoulder arthroscopy/surgery,29807,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5705.83,31870.39,APC 378
Shoulder arthroscopy/surgery,29807,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5705.83,31870.39,APC
Shoulder arthroscopy/surgery,29807,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5705.83,31870.39,APC
Shoulder arthroscopy/surgery,29807,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5705.83,31870.39,APC
Shoulder arthroscopy/surgery,29807,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5705.83,31870.39,Radiology
Shoulder arthroscopy/surgery,29807,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5705.83,31870.39,APC
Shoulder arthroscopy/surgery,29807,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5705.83,31870.39,APC
Shoulder arthroscopy/surgery,29819,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3828.9,,,,,,,fee schedule,3069.2,14371.12,
Shoulder arthroscopy/surgery,29819,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3069.2,,,,,,,fee schedule,3069.2,14371.12,
Shoulder arthroscopy/surgery,29819,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3352.82,,,,,,,fee schedule,3069.2,14371.12,
Shoulder arthroscopy/surgery,29819,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3525.02,,,,,,,fee schedule,3069.2,14371.12,
Shoulder arthroscopy/surgery,29819,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3069.2,14371.12,APC 378
Shoulder arthroscopy/surgery,29819,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3069.2,14371.12,APC
Shoulder arthroscopy/surgery,29819,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3069.2,14371.12,APC
Shoulder arthroscopy/surgery,29819,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3069.2,14371.12,APC
Shoulder arthroscopy/surgery,29819,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3069.2,14371.12,Radiology
Shoulder arthroscopy/surgery,29819,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3069.2,14371.12,APC
Shoulder arthroscopy/surgery,29819,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3069.2,14371.12,APC
Shoulder arthroscopy/surgery,29820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11407.36,,,,,,,fee schedule,7183.42,31870.39,
Shoulder arthroscopy/surgery,29820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9143.99,,,,,,,fee schedule,7183.42,31870.39,
Shoulder arthroscopy/surgery,29820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9988.98,,,,,,,fee schedule,7183.42,31870.39,
Shoulder arthroscopy/surgery,29820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10502.01,,,,,,,fee schedule,7183.42,31870.39,
Shoulder arthroscopy/surgery,29820,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Shoulder arthroscopy/surgery,29820,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Shoulder arthroscopy/surgery,29820,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Shoulder arthroscopy/surgery,29820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Shoulder arthroscopy/surgery,29820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Shoulder arthroscopy/surgery,29820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Shoulder arthroscopy/surgery,29820,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Shoulder arthroscopy/surgery,29821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11407.36,,,,,,,fee schedule,3239.17,14371.12,
Shoulder arthroscopy/surgery,29821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9143.99,,,,,,,fee schedule,3239.17,14371.12,
Shoulder arthroscopy/surgery,29821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9988.98,,,,,,,fee schedule,3239.17,14371.12,
Shoulder arthroscopy/surgery,29821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10502.01,,,,,,,fee schedule,3239.17,14371.12,
Shoulder arthroscopy/surgery,29821,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Shoulder arthroscopy/surgery,29821,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Shoulder arthroscopy/surgery,29821,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Shoulder arthroscopy/surgery,29821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Shoulder arthroscopy/surgery,29821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Shoulder arthroscopy/surgery,29821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Shoulder arthroscopy/surgery,29821,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Shoulder arthroscopy/surgery,29822,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4390.7,,,,,,,fee schedule,3239.17,14371.12,
Shoulder arthroscopy/surgery,29822,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3519.53,,,,,,,fee schedule,3239.17,14371.12,
Shoulder arthroscopy/surgery,29822,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3844.77,,,,,,,fee schedule,3239.17,14371.12,
Shoulder arthroscopy/surgery,29822,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4042.24,,,,,,,fee schedule,3239.17,14371.12,
Shoulder arthroscopy/surgery,29822,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Shoulder arthroscopy/surgery,29822,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Shoulder arthroscopy/surgery,29822,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Shoulder arthroscopy/surgery,29822,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Shoulder arthroscopy/surgery,29822,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Shoulder arthroscopy/surgery,29822,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Shoulder arthroscopy/surgery,29822,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Shoulder arthroscopy/surgery,29823,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4889.49,,,,,,,fee schedule,3239.17,14371.12,
Shoulder arthroscopy/surgery,29823,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3919.35,,,,,,,fee schedule,3239.17,14371.12,
Shoulder arthroscopy/surgery,29823,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4281.54,,,,,,,fee schedule,3239.17,14371.12,
Shoulder arthroscopy/surgery,29823,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4501.44,,,,,,,fee schedule,3239.17,14371.12,
Shoulder arthroscopy/surgery,29823,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Shoulder arthroscopy/surgery,29823,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Shoulder arthroscopy/surgery,29823,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Shoulder arthroscopy/surgery,29823,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Shoulder arthroscopy/surgery,29823,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Shoulder arthroscopy/surgery,29823,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Shoulder arthroscopy/surgery,29823,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Shoulder arthroscopy/surgery,29824,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4155.74,,,,,,,fee schedule,3239.17,14371.12,
Shoulder arthroscopy/surgery,29824,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3331.19,,,,,,,fee schedule,3239.17,14371.12,
Shoulder arthroscopy/surgery,29824,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3639.02,,,,,,,fee schedule,3239.17,14371.12,
Shoulder arthroscopy/surgery,29824,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3825.92,,,,,,,fee schedule,3239.17,14371.12,
Shoulder arthroscopy/surgery,29824,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Shoulder arthroscopy/surgery,29824,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Shoulder arthroscopy/surgery,29824,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Shoulder arthroscopy/surgery,29824,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Shoulder arthroscopy/surgery,29824,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Shoulder arthroscopy/surgery,29824,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Shoulder arthroscopy/surgery,29824,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Shoulder arthroscopy/surgery,29825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11141.58,,,,,,,fee schedule,3239.17,14371.12,
Shoulder arthroscopy/surgery,29825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8930.95,,,,,,,fee schedule,3239.17,14371.12,
Shoulder arthroscopy/surgery,29825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9756.25,,,,,,,fee schedule,3239.17,14371.12,
Shoulder arthroscopy/surgery,29825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10257.32,,,,,,,fee schedule,3239.17,14371.12,
Shoulder arthroscopy/surgery,29825,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Shoulder arthroscopy/surgery,29825,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Shoulder arthroscopy/surgery,29825,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Shoulder arthroscopy/surgery,29825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Shoulder arthroscopy/surgery,29825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Shoulder arthroscopy/surgery,29825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Shoulder arthroscopy/surgery,29825,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Shoulder arthroscopy/surgery,29826,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4745.91,,,,,,,fee schedule,3804.26,4745.91,
Shoulder arthroscopy/surgery,29826,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3804.26,,,,,,,fee schedule,3804.26,4745.91,
Shoulder arthroscopy/surgery,29826,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4155.81,,,,,,,fee schedule,3804.26,4745.91,
Shoulder arthroscopy/surgery,29826,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4369.25,,,,,,,fee schedule,3804.26,4745.91,
Arthroscop rotator cuff repr,29827,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4775.4,,,,,,,fee schedule,3827.9,31870.39,
Arthroscop rotator cuff repr,29827,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3827.9,,,,,,,fee schedule,3827.9,31870.39,
Arthroscop rotator cuff repr,29827,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4181.64,,,,,,,fee schedule,3827.9,31870.39,
Arthroscop rotator cuff repr,29827,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4396.4,,,,,,,fee schedule,3827.9,31870.39,
Arthroscop rotator cuff repr,29827,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,3827.9,31870.39,APC 378
Arthroscop rotator cuff repr,29827,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,3827.9,31870.39,APC
Arthroscop rotator cuff repr,29827,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,3827.9,31870.39,APC
Arthroscop rotator cuff repr,29827,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,3827.9,31870.39,APC
Arthroscop rotator cuff repr,29827,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,3827.9,31870.39,Radiology
Arthroscop rotator cuff repr,29827,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,3827.9,31870.39,APC
Arthroscop rotator cuff repr,29827,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,3827.9,31870.39,APC
Arthroscopy biceps tenodesis,29828,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5724.88,,,,,,,fee schedule,4588.99,31870.39,
Arthroscopy biceps tenodesis,29828,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4588.99,,,,,,,fee schedule,4588.99,31870.39,
Arthroscopy biceps tenodesis,29828,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5013.06,,,,,,,fee schedule,4588.99,31870.39,
Arthroscopy biceps tenodesis,29828,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5270.53,,,,,,,fee schedule,4588.99,31870.39,
Arthroscopy biceps tenodesis,29828,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,4588.99,31870.39,APC 378
Arthroscopy biceps tenodesis,29828,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,4588.99,31870.39,APC
Arthroscopy biceps tenodesis,29828,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,4588.99,31870.39,APC
Arthroscopy biceps tenodesis,29828,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,4588.99,31870.39,APC
Arthroscopy biceps tenodesis,29828,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,4588.99,31870.39,Radiology
Arthroscopy biceps tenodesis,29828,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,4588.99,31870.39,APC
Arthroscopy biceps tenodesis,29828,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,4588.99,31870.39,APC
Elbow arthroscopy,29830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7182.83,,,,,,,fee schedule,3239.17,14371.12,
Elbow arthroscopy,29830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5757.67,,,,,,,fee schedule,3239.17,14371.12,
Elbow arthroscopy,29830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6289.73,,,,,,,fee schedule,3239.17,14371.12,
Elbow arthroscopy,29830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6612.77,,,,,,,fee schedule,3239.17,14371.12,
Elbow arthroscopy,29830,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Elbow arthroscopy,29830,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Elbow arthroscopy,29830,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Elbow arthroscopy,29830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Elbow arthroscopy,29830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Elbow arthroscopy,29830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Elbow arthroscopy,29830,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Elbow arthroscopy/surgery,29834,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7182.83,,,,,,,fee schedule,3239.17,14371.12,
Elbow arthroscopy/surgery,29834,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5757.67,,,,,,,fee schedule,3239.17,14371.12,
Elbow arthroscopy/surgery,29834,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6289.73,,,,,,,fee schedule,3239.17,14371.12,
Elbow arthroscopy/surgery,29834,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6612.77,,,,,,,fee schedule,3239.17,14371.12,
Elbow arthroscopy/surgery,29834,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Elbow arthroscopy/surgery,29834,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Elbow arthroscopy/surgery,29834,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Elbow arthroscopy/surgery,29834,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Elbow arthroscopy/surgery,29834,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Elbow arthroscopy/surgery,29834,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Elbow arthroscopy/surgery,29834,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Elbow arthroscopy/surgery,29835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7182.83,,,,,,,fee schedule,3239.17,14371.12,
Elbow arthroscopy/surgery,29835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5757.67,,,,,,,fee schedule,3239.17,14371.12,
Elbow arthroscopy/surgery,29835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6289.73,,,,,,,fee schedule,3239.17,14371.12,
Elbow arthroscopy/surgery,29835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6612.77,,,,,,,fee schedule,3239.17,14371.12,
Elbow arthroscopy/surgery,29835,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Elbow arthroscopy/surgery,29835,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Elbow arthroscopy/surgery,29835,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Elbow arthroscopy/surgery,29835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Elbow arthroscopy/surgery,29835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Elbow arthroscopy/surgery,29835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Elbow arthroscopy/surgery,29835,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Elbow arthroscopy/surgery,29836,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7182.83,,,,,,,fee schedule,5757.67,31870.39,
Elbow arthroscopy/surgery,29836,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5757.67,,,,,,,fee schedule,5757.67,31870.39,
Elbow arthroscopy/surgery,29836,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6289.73,,,,,,,fee schedule,5757.67,31870.39,
Elbow arthroscopy/surgery,29836,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6612.77,,,,,,,fee schedule,5757.67,31870.39,
Elbow arthroscopy/surgery,29836,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5757.67,31870.39,APC 378
Elbow arthroscopy/surgery,29836,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5757.67,31870.39,APC
Elbow arthroscopy/surgery,29836,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5757.67,31870.39,APC
Elbow arthroscopy/surgery,29836,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5757.67,31870.39,APC
Elbow arthroscopy/surgery,29836,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5757.67,31870.39,Radiology
Elbow arthroscopy/surgery,29836,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5757.67,31870.39,APC
Elbow arthroscopy/surgery,29836,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5757.67,31870.39,APC
Elbow arthroscopy/surgery,29837,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7182.83,,,,,,,fee schedule,3239.17,14371.12,
Elbow arthroscopy/surgery,29837,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5757.67,,,,,,,fee schedule,3239.17,14371.12,
Elbow arthroscopy/surgery,29837,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6289.73,,,,,,,fee schedule,3239.17,14371.12,
Elbow arthroscopy/surgery,29837,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6612.77,,,,,,,fee schedule,3239.17,14371.12,
Elbow arthroscopy/surgery,29837,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Elbow arthroscopy/surgery,29837,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Elbow arthroscopy/surgery,29837,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Elbow arthroscopy/surgery,29837,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Elbow arthroscopy/surgery,29837,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Elbow arthroscopy/surgery,29837,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Elbow arthroscopy/surgery,29837,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Elbow arthroscopy/surgery,29838,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7182.83,,,,,,,fee schedule,3239.17,14371.12,
Elbow arthroscopy/surgery,29838,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5757.67,,,,,,,fee schedule,3239.17,14371.12,
Elbow arthroscopy/surgery,29838,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6289.73,,,,,,,fee schedule,3239.17,14371.12,
Elbow arthroscopy/surgery,29838,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6612.77,,,,,,,fee schedule,3239.17,14371.12,
Elbow arthroscopy/surgery,29838,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Elbow arthroscopy/surgery,29838,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Elbow arthroscopy/surgery,29838,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Elbow arthroscopy/surgery,29838,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Elbow arthroscopy/surgery,29838,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Elbow arthroscopy/surgery,29838,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Elbow arthroscopy/surgery,29838,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Wrist arthroscopy,29840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3869.89,,,,,,,fee schedule,3102.06,14371.12,
Wrist arthroscopy,29840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3102.06,,,,,,,fee schedule,3102.06,14371.12,
Wrist arthroscopy,29840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3388.72,,,,,,,fee schedule,3102.06,14371.12,
Wrist arthroscopy,29840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3562.76,,,,,,,fee schedule,3102.06,14371.12,
Wrist arthroscopy,29840,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3102.06,14371.12,APC 378
Wrist arthroscopy,29840,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3102.06,14371.12,APC
Wrist arthroscopy,29840,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3102.06,14371.12,APC
Wrist arthroscopy,29840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3102.06,14371.12,APC
Wrist arthroscopy,29840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3102.06,14371.12,Radiology
Wrist arthroscopy,29840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3102.06,14371.12,APC
Wrist arthroscopy,29840,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3102.06,14371.12,APC
Wrist arthroscopy/surgery,29843,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7182.83,,,,,,,fee schedule,3239.17,14371.12,
Wrist arthroscopy/surgery,29843,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5757.67,,,,,,,fee schedule,3239.17,14371.12,
Wrist arthroscopy/surgery,29843,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6289.73,,,,,,,fee schedule,3239.17,14371.12,
Wrist arthroscopy/surgery,29843,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6612.77,,,,,,,fee schedule,3239.17,14371.12,
Wrist arthroscopy/surgery,29843,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Wrist arthroscopy/surgery,29843,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Wrist arthroscopy/surgery,29843,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Wrist arthroscopy/surgery,29843,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Wrist arthroscopy/surgery,29843,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Wrist arthroscopy/surgery,29843,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Wrist arthroscopy/surgery,29843,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Wrist arthroscopy/surgery,29844,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7182.83,,,,,,,fee schedule,3239.17,14371.12,
Wrist arthroscopy/surgery,29844,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5757.67,,,,,,,fee schedule,3239.17,14371.12,
Wrist arthroscopy/surgery,29844,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6289.73,,,,,,,fee schedule,3239.17,14371.12,
Wrist arthroscopy/surgery,29844,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6612.77,,,,,,,fee schedule,3239.17,14371.12,
Wrist arthroscopy/surgery,29844,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Wrist arthroscopy/surgery,29844,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Wrist arthroscopy/surgery,29844,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Wrist arthroscopy/surgery,29844,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Wrist arthroscopy/surgery,29844,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Wrist arthroscopy/surgery,29844,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Wrist arthroscopy/surgery,29844,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Wrist arthroscopy/surgery,29845,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7182.83,,,,,,,fee schedule,3239.17,14371.12,
Wrist arthroscopy/surgery,29845,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5757.67,,,,,,,fee schedule,3239.17,14371.12,
Wrist arthroscopy/surgery,29845,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6289.73,,,,,,,fee schedule,3239.17,14371.12,
Wrist arthroscopy/surgery,29845,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6612.77,,,,,,,fee schedule,3239.17,14371.12,
Wrist arthroscopy/surgery,29845,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Wrist arthroscopy/surgery,29845,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Wrist arthroscopy/surgery,29845,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Wrist arthroscopy/surgery,29845,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Wrist arthroscopy/surgery,29845,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Wrist arthroscopy/surgery,29845,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Wrist arthroscopy/surgery,29845,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Wrist arthroscopy/surgery,29846,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5102.67,,,,,,,fee schedule,3239.17,14371.12,
Wrist arthroscopy/surgery,29846,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4090.24,,,,,,,fee schedule,3239.17,14371.12,
Wrist arthroscopy/surgery,29846,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4468.21,,,,,,,fee schedule,3239.17,14371.12,
Wrist arthroscopy/surgery,29846,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4697.7,,,,,,,fee schedule,3239.17,14371.12,
Wrist arthroscopy/surgery,29846,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Wrist arthroscopy/surgery,29846,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Wrist arthroscopy/surgery,29846,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Wrist arthroscopy/surgery,29846,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Wrist arthroscopy/surgery,29846,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Wrist arthroscopy/surgery,29846,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Wrist arthroscopy/surgery,29846,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Wrist arthroscopy/surgery,29847,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11407.36,,,,,,,fee schedule,7183.42,31870.39,
Wrist arthroscopy/surgery,29847,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9143.99,,,,,,,fee schedule,7183.42,31870.39,
Wrist arthroscopy/surgery,29847,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9988.98,,,,,,,fee schedule,7183.42,31870.39,
Wrist arthroscopy/surgery,29847,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10502.01,,,,,,,fee schedule,7183.42,31870.39,
Wrist arthroscopy/surgery,29847,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Wrist arthroscopy/surgery,29847,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Wrist arthroscopy/surgery,29847,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Wrist arthroscopy/surgery,29847,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Wrist arthroscopy/surgery,29847,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Wrist arthroscopy/surgery,29847,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Wrist arthroscopy/surgery,29847,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Wrist endoscopy/surgery,29848,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7182.83,,,,,,,fee schedule,1591.86,7182.83,
Wrist endoscopy/surgery,29848,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5757.67,,,,,,,fee schedule,1591.86,7182.83,
Wrist endoscopy/surgery,29848,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6289.73,,,,,,,fee schedule,1591.86,7182.83,
Wrist endoscopy/surgery,29848,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6612.77,,,,,,,fee schedule,1591.86,7182.83,
Wrist endoscopy/surgery,29848,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7182.83,APC 378
Wrist endoscopy/surgery,29848,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7182.83,APC
Wrist endoscopy/surgery,29848,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7182.83,APC
Wrist endoscopy/surgery,29848,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7182.83,APC
Wrist endoscopy/surgery,29848,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7182.83,Radiology
Wrist endoscopy/surgery,29848,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7182.83,APC
Wrist endoscopy/surgery,29848,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7182.83,APC
Knee arthroscopy/surgery,29850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7182.83,,,,,,,fee schedule,1591.86,7182.83,
Knee arthroscopy/surgery,29850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5757.67,,,,,,,fee schedule,1591.86,7182.83,
Knee arthroscopy/surgery,29850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6289.73,,,,,,,fee schedule,1591.86,7182.83,
Knee arthroscopy/surgery,29850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6612.77,,,,,,,fee schedule,1591.86,7182.83,
Knee arthroscopy/surgery,29850,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7182.83,APC 378
Knee arthroscopy/surgery,29850,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7182.83,APC
Knee arthroscopy/surgery,29850,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7182.83,APC
Knee arthroscopy/surgery,29850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7182.83,APC
Knee arthroscopy/surgery,29850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7182.83,Radiology
Knee arthroscopy/surgery,29850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7182.83,APC
Knee arthroscopy/surgery,29850,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7182.83,APC
Knee arthroscopy/surgery,29851,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11407.36,,,,,,,fee schedule,1591.86,11407.36,
Knee arthroscopy/surgery,29851,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9143.99,,,,,,,fee schedule,1591.86,11407.36,
Knee arthroscopy/surgery,29851,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9988.98,,,,,,,fee schedule,1591.86,11407.36,
Knee arthroscopy/surgery,29851,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10502.01,,,,,,,fee schedule,1591.86,11407.36,
Knee arthroscopy/surgery,29851,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,11407.36,APC 378
Knee arthroscopy/surgery,29851,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,11407.36,APC
Knee arthroscopy/surgery,29851,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,11407.36,APC
Knee arthroscopy/surgery,29851,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,11407.36,APC
Knee arthroscopy/surgery,29851,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,11407.36,Radiology
Knee arthroscopy/surgery,29851,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,11407.36,APC
Knee arthroscopy/surgery,29851,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,11407.36,APC
Tibial arthroscopy/surgery,29855,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11407.36,,,,,,,fee schedule,7183.42,31870.39,
Tibial arthroscopy/surgery,29855,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9143.99,,,,,,,fee schedule,7183.42,31870.39,
Tibial arthroscopy/surgery,29855,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9988.98,,,,,,,fee schedule,7183.42,31870.39,
Tibial arthroscopy/surgery,29855,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10502.01,,,,,,,fee schedule,7183.42,31870.39,
Tibial arthroscopy/surgery,29855,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Tibial arthroscopy/surgery,29855,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Tibial arthroscopy/surgery,29855,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Tibial arthroscopy/surgery,29855,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Tibial arthroscopy/surgery,29855,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Tibial arthroscopy/surgery,29855,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Tibial arthroscopy/surgery,29855,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Tibial arthroscopy/surgery,29856,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11407.36,,,,,,,fee schedule,9143.99,56389.43,
Tibial arthroscopy/surgery,29856,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9143.99,,,,,,,fee schedule,9143.99,56389.43,
Tibial arthroscopy/surgery,29856,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9988.98,,,,,,,fee schedule,9143.99,56389.43,
Tibial arthroscopy/surgery,29856,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10502.01,,,,,,,fee schedule,9143.99,56389.43,
Tibial arthroscopy/surgery,29856,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,9143.99,56389.43,APC 378
Tibial arthroscopy/surgery,29856,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,9143.99,56389.43,APC
Tibial arthroscopy/surgery,29856,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,9143.99,56389.43,APC
Tibial arthroscopy/surgery,29856,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,9143.99,56389.43,APC
Tibial arthroscopy/surgery,29856,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,9143.99,56389.43,Radiology
Tibial arthroscopy/surgery,29856,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,9143.99,56389.43,APC
Tibial arthroscopy/surgery,29856,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,9143.99,56389.43,APC
Hip arthroscopy dx,29860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11407.36,,,,,,,fee schedule,7183.42,31870.39,
Hip arthroscopy dx,29860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9143.99,,,,,,,fee schedule,7183.42,31870.39,
Hip arthroscopy dx,29860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9988.98,,,,,,,fee schedule,7183.42,31870.39,
Hip arthroscopy dx,29860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10502.01,,,,,,,fee schedule,7183.42,31870.39,
Hip arthroscopy dx,29860,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Hip arthroscopy dx,29860,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Hip arthroscopy dx,29860,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Hip arthroscopy dx,29860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Hip arthroscopy dx,29860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Hip arthroscopy dx,29860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Hip arthroscopy dx,29860,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Hip arthro w/fb removal,29861,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11407.36,,,,,,,fee schedule,7183.42,31870.39,
Hip arthro w/fb removal,29861,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9143.99,,,,,,,fee schedule,7183.42,31870.39,
Hip arthro w/fb removal,29861,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9988.98,,,,,,,fee schedule,7183.42,31870.39,
Hip arthro w/fb removal,29861,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10502.01,,,,,,,fee schedule,7183.42,31870.39,
Hip arthro w/fb removal,29861,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Hip arthro w/fb removal,29861,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Hip arthro w/fb removal,29861,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Hip arthro w/fb removal,29861,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Hip arthro w/fb removal,29861,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Hip arthro w/fb removal,29861,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Hip arthro w/fb removal,29861,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Hip arthr0 w/debridement,29862,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11407.36,,,,,,,fee schedule,7183.42,31870.39,
Hip arthr0 w/debridement,29862,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9143.99,,,,,,,fee schedule,7183.42,31870.39,
Hip arthr0 w/debridement,29862,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9988.98,,,,,,,fee schedule,7183.42,31870.39,
Hip arthr0 w/debridement,29862,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10502.01,,,,,,,fee schedule,7183.42,31870.39,
Hip arthr0 w/debridement,29862,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Hip arthr0 w/debridement,29862,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Hip arthr0 w/debridement,29862,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Hip arthr0 w/debridement,29862,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Hip arthr0 w/debridement,29862,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Hip arthr0 w/debridement,29862,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Hip arthr0 w/debridement,29862,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Hip arthr0 w/synovectomy,29863,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4765.13,,,,,,,fee schedule,3239.17,14371.12,
Hip arthr0 w/synovectomy,29863,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3819.67,,,,,,,fee schedule,3239.17,14371.12,
Hip arthr0 w/synovectomy,29863,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4172.64,,,,,,,fee schedule,3239.17,14371.12,
Hip arthr0 w/synovectomy,29863,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4386.95,,,,,,,fee schedule,3239.17,14371.12,
Hip arthr0 w/synovectomy,29863,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Hip arthr0 w/synovectomy,29863,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Hip arthr0 w/synovectomy,29863,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Hip arthr0 w/synovectomy,29863,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Hip arthr0 w/synovectomy,29863,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Hip arthr0 w/synovectomy,29863,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Hip arthr0 w/synovectomy,29863,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Autgrft implnt knee w/scope,29866,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4025.94,,,,,,,fee schedule,3227.14,31870.39,
Autgrft implnt knee w/scope,29866,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3227.14,,,,,,,fee schedule,3227.14,31870.39,
Autgrft implnt knee w/scope,29866,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3525.36,,,,,,,fee schedule,3227.14,31870.39,
Autgrft implnt knee w/scope,29866,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3706.42,,,,,,,fee schedule,3227.14,31870.39,
Autgrft implnt knee w/scope,29866,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,3227.14,31870.39,APC 378
Autgrft implnt knee w/scope,29866,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,3227.14,31870.39,APC
Autgrft implnt knee w/scope,29866,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,3227.14,31870.39,APC
Autgrft implnt knee w/scope,29866,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,3227.14,31870.39,APC
Autgrft implnt knee w/scope,29866,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,3227.14,31870.39,Radiology
Autgrft implnt knee w/scope,29866,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,3227.14,31870.39,APC
Autgrft implnt knee w/scope,29866,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,3227.14,31870.39,APC
Allgrft implnt knee w/scope,29867,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7714.33,,,,,,,fee schedule,6183.71,56389.43,
Allgrft implnt knee w/scope,29867,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6183.71,,,,,,,fee schedule,6183.71,56389.43,
Allgrft implnt knee w/scope,29867,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6755.14,,,,,,,fee schedule,6183.71,56389.43,
Allgrft implnt knee w/scope,29867,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7102.08,,,,,,,fee schedule,6183.71,56389.43,
Allgrft implnt knee w/scope,29867,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,6183.71,56389.43,APC 378
Allgrft implnt knee w/scope,29867,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,6183.71,56389.43,APC
Allgrft implnt knee w/scope,29867,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,6183.71,56389.43,APC
Allgrft implnt knee w/scope,29867,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,6183.71,56389.43,APC
Allgrft implnt knee w/scope,29867,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,6183.71,56389.43,Radiology
Allgrft implnt knee w/scope,29867,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,6183.71,56389.43,APC
Allgrft implnt knee w/scope,29867,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,6183.71,56389.43,APC
Meniscal trnspl knee w/scpe,29868,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11407.36,,,,,,,fee schedule,7183.42,31870.39,
Meniscal trnspl knee w/scpe,29868,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9143.99,,,,,,,fee schedule,7183.42,31870.39,
Meniscal trnspl knee w/scpe,29868,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9988.98,,,,,,,fee schedule,7183.42,31870.39,
Meniscal trnspl knee w/scpe,29868,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10502.01,,,,,,,fee schedule,7183.42,31870.39,
Meniscal trnspl knee w/scpe,29868,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Meniscal trnspl knee w/scpe,29868,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Meniscal trnspl knee w/scpe,29868,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Meniscal trnspl knee w/scpe,29868,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Meniscal trnspl knee w/scpe,29868,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Meniscal trnspl knee w/scpe,29868,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Meniscal trnspl knee w/scpe,29868,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Knee arthroscopy dx,29870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7536.98,,,,,,,fee schedule,3239.17,14371.12,
Knee arthroscopy dx,29870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6041.55,,,,,,,fee schedule,3239.17,14371.12,
Knee arthroscopy dx,29870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6599.84,,,,,,,fee schedule,3239.17,14371.12,
Knee arthroscopy dx,29870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6938.81,,,,,,,fee schedule,3239.17,14371.12,
Knee arthroscopy dx,29870,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Knee arthroscopy dx,29870,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Knee arthroscopy dx,29870,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Knee arthroscopy dx,29870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Knee arthroscopy dx,29870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Knee arthroscopy dx,29870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Knee arthroscopy dx,29870,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Knee arthroscopy/drainage,29871,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7182.83,,,,,,,fee schedule,3239.17,14371.12,
Knee arthroscopy/drainage,29871,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5757.67,,,,,,,fee schedule,3239.17,14371.12,
Knee arthroscopy/drainage,29871,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6289.73,,,,,,,fee schedule,3239.17,14371.12,
Knee arthroscopy/drainage,29871,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6612.77,,,,,,,fee schedule,3239.17,14371.12,
Knee arthroscopy/drainage,29871,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Knee arthroscopy/drainage,29871,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Knee arthroscopy/drainage,29871,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Knee arthroscopy/drainage,29871,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Knee arthroscopy/drainage,29871,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Knee arthroscopy/drainage,29871,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Knee arthroscopy/drainage,29871,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Knee arthroscopy/surgery,29873,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7368.21,,,,,,,fee schedule,3239.17,14371.12,
Knee arthroscopy/surgery,29873,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5906.26,,,,,,,fee schedule,3239.17,14371.12,
Knee arthroscopy/surgery,29873,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6452.06,,,,,,,fee schedule,3239.17,14371.12,
Knee arthroscopy/surgery,29873,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6783.43,,,,,,,fee schedule,3239.17,14371.12,
Knee arthroscopy/surgery,29873,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Knee arthroscopy/surgery,29873,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Knee arthroscopy/surgery,29873,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Knee arthroscopy/surgery,29873,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Knee arthroscopy/surgery,29873,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Knee arthroscopy/surgery,29873,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Knee arthroscopy/surgery,29873,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Knee arthroscopy/surgery,29874,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11609.69,,,,,,,fee schedule,3239.17,14371.12,
Knee arthroscopy/surgery,29874,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9306.18,,,,,,,fee schedule,3239.17,14371.12,
Knee arthroscopy/surgery,29874,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10166.16,,,,,,,fee schedule,3239.17,14371.12,
Knee arthroscopy/surgery,29874,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10688.29,,,,,,,fee schedule,3239.17,14371.12,
Knee arthroscopy/surgery,29874,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Knee arthroscopy/surgery,29874,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Knee arthroscopy/surgery,29874,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Knee arthroscopy/surgery,29874,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Knee arthroscopy/surgery,29874,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Knee arthroscopy/surgery,29874,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Knee arthroscopy/surgery,29874,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Knee arthroscopy/surgery,29875,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9269.11,,,,,,,fee schedule,3239.17,14371.12,
Knee arthroscopy/surgery,29875,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7430,,,,,,,fee schedule,3239.17,14371.12,
Knee arthroscopy/surgery,29875,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8116.61,,,,,,,fee schedule,3239.17,14371.12,
Knee arthroscopy/surgery,29875,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8533.47,,,,,,,fee schedule,3239.17,14371.12,
Knee arthroscopy/surgery,29875,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Knee arthroscopy/surgery,29875,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Knee arthroscopy/surgery,29875,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Knee arthroscopy/surgery,29875,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Knee arthroscopy/surgery,29875,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Knee arthroscopy/surgery,29875,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Knee arthroscopy/surgery,29875,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Knee arthroscopy/surgery,29876,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7182.83,,,,,,,fee schedule,3239.17,14371.12,
Knee arthroscopy/surgery,29876,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5757.67,,,,,,,fee schedule,3239.17,14371.12,
Knee arthroscopy/surgery,29876,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6289.73,,,,,,,fee schedule,3239.17,14371.12,
Knee arthroscopy/surgery,29876,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6612.77,,,,,,,fee schedule,3239.17,14371.12,
Knee arthroscopy/surgery,29876,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Knee arthroscopy/surgery,29876,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Knee arthroscopy/surgery,29876,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Knee arthroscopy/surgery,29876,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Knee arthroscopy/surgery,29876,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Knee arthroscopy/surgery,29876,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Knee arthroscopy/surgery,29876,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Knee arthroscopy/surgery,29877,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8487.2,,,,,,,fee schedule,3239.17,14371.12,
Knee arthroscopy/surgery,29877,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6803.24,,,,,,,fee schedule,3239.17,14371.12,
Knee arthroscopy/surgery,29877,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7431.92,,,,,,,fee schedule,3239.17,14371.12,
Knee arthroscopy/surgery,29877,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7813.62,,,,,,,fee schedule,3239.17,14371.12,
Knee arthroscopy/surgery,29877,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Knee arthroscopy/surgery,29877,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Knee arthroscopy/surgery,29877,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Knee arthroscopy/surgery,29877,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Knee arthroscopy/surgery,29877,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Knee arthroscopy/surgery,29877,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Knee arthroscopy/surgery,29877,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Knee arthroscopy/surgery,29879,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9289.83,,,,,,,fee schedule,3239.17,14371.12,
Knee arthroscopy/surgery,29879,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7446.61,,,,,,,fee schedule,3239.17,14371.12,
Knee arthroscopy/surgery,29879,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8134.74,,,,,,,fee schedule,3239.17,14371.12,
Knee arthroscopy/surgery,29879,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8552.54,,,,,,,fee schedule,3239.17,14371.12,
Knee arthroscopy/surgery,29879,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Knee arthroscopy/surgery,29879,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Knee arthroscopy/surgery,29879,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Knee arthroscopy/surgery,29879,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Knee arthroscopy/surgery,29879,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Knee arthroscopy/surgery,29879,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Knee arthroscopy/surgery,29879,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Knee arthroscopy/surgery,29880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8417.51,,,,,,,fee schedule,3239.17,14371.12,
Knee arthroscopy/surgery,29880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6747.37,,,,,,,fee schedule,3239.17,14371.12,
Knee arthroscopy/surgery,29880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7370.89,,,,,,,fee schedule,3239.17,14371.12,
Knee arthroscopy/surgery,29880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7749.45,,,,,,,fee schedule,3239.17,14371.12,
Knee arthroscopy/surgery,29880,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Knee arthroscopy/surgery,29880,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Knee arthroscopy/surgery,29880,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Knee arthroscopy/surgery,29880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Knee arthroscopy/surgery,29880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Knee arthroscopy/surgery,29880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Knee arthroscopy/surgery,29880,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Knee arthroscopy/surgery,29881,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9228.38,,,,,,,fee schedule,3239.17,14371.12,
Knee arthroscopy/surgery,29881,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7397.35,,,,,,,fee schedule,3239.17,14371.12,
Knee arthroscopy/surgery,29881,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8080.93,,,,,,,fee schedule,3239.17,14371.12,
Knee arthroscopy/surgery,29881,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8495.97,,,,,,,fee schedule,3239.17,14371.12,
Knee arthroscopy/surgery,29881,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Knee arthroscopy/surgery,29881,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Knee arthroscopy/surgery,29881,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Knee arthroscopy/surgery,29881,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Knee arthroscopy/surgery,29881,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Knee arthroscopy/surgery,29881,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Knee arthroscopy/surgery,29881,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Knee arthroscopy/surgery,29882,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7771,,,,,,,fee schedule,3239.17,14371.12,
Knee arthroscopy/surgery,29882,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6229.14,,,,,,,fee schedule,3239.17,14371.12,
Knee arthroscopy/surgery,29882,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6804.77,,,,,,,fee schedule,3239.17,14371.12,
Knee arthroscopy/surgery,29882,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7154.25,,,,,,,fee schedule,3239.17,14371.12,
Knee arthroscopy/surgery,29882,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Knee arthroscopy/surgery,29882,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Knee arthroscopy/surgery,29882,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Knee arthroscopy/surgery,29882,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Knee arthroscopy/surgery,29882,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Knee arthroscopy/surgery,29882,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Knee arthroscopy/surgery,29882,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Knee arthroscopy/surgery,29883,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6046.67,,,,,,,fee schedule,3239.17,14371.12,
Knee arthroscopy/surgery,29883,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4846.93,,,,,,,fee schedule,3239.17,14371.12,
Knee arthroscopy/surgery,29883,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5294.83,,,,,,,fee schedule,3239.17,14371.12,
Knee arthroscopy/surgery,29883,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5566.77,,,,,,,fee schedule,3239.17,14371.12,
Knee arthroscopy/surgery,29883,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Knee arthroscopy/surgery,29883,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Knee arthroscopy/surgery,29883,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Knee arthroscopy/surgery,29883,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Knee arthroscopy/surgery,29883,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Knee arthroscopy/surgery,29883,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Knee arthroscopy/surgery,29883,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Knee arthroscopy/surgery,29884,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7182.83,,,,,,,fee schedule,3239.17,14371.12,
Knee arthroscopy/surgery,29884,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5757.67,,,,,,,fee schedule,3239.17,14371.12,
Knee arthroscopy/surgery,29884,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6289.73,,,,,,,fee schedule,3239.17,14371.12,
Knee arthroscopy/surgery,29884,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6612.77,,,,,,,fee schedule,3239.17,14371.12,
Knee arthroscopy/surgery,29884,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Knee arthroscopy/surgery,29884,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Knee arthroscopy/surgery,29884,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Knee arthroscopy/surgery,29884,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Knee arthroscopy/surgery,29884,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Knee arthroscopy/surgery,29884,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Knee arthroscopy/surgery,29884,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Knee arthroscopy/surgery,29885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11407.36,,,,,,,fee schedule,7183.42,31870.39,
Knee arthroscopy/surgery,29885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9143.99,,,,,,,fee schedule,7183.42,31870.39,
Knee arthroscopy/surgery,29885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9988.98,,,,,,,fee schedule,7183.42,31870.39,
Knee arthroscopy/surgery,29885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10502.01,,,,,,,fee schedule,7183.42,31870.39,
Knee arthroscopy/surgery,29885,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Knee arthroscopy/surgery,29885,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Knee arthroscopy/surgery,29885,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Knee arthroscopy/surgery,29885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Knee arthroscopy/surgery,29885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Knee arthroscopy/surgery,29885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Knee arthroscopy/surgery,29885,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Knee arthroscopy/surgery,29886,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9737.23,,,,,,,fee schedule,3239.17,14371.12,
Knee arthroscopy/surgery,29886,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7805.24,,,,,,,fee schedule,3239.17,14371.12,
Knee arthroscopy/surgery,29886,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8526.52,,,,,,,fee schedule,3239.17,14371.12,
Knee arthroscopy/surgery,29886,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8964.43,,,,,,,fee schedule,3239.17,14371.12,
Knee arthroscopy/surgery,29886,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Knee arthroscopy/surgery,29886,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Knee arthroscopy/surgery,29886,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Knee arthroscopy/surgery,29886,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Knee arthroscopy/surgery,29886,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Knee arthroscopy/surgery,29886,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Knee arthroscopy/surgery,29886,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Knee arthroscopy/surgery,29887,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7182.83,,,,,,,fee schedule,5757.67,31870.39,
Knee arthroscopy/surgery,29887,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5757.67,,,,,,,fee schedule,5757.67,31870.39,
Knee arthroscopy/surgery,29887,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6289.73,,,,,,,fee schedule,5757.67,31870.39,
Knee arthroscopy/surgery,29887,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6612.77,,,,,,,fee schedule,5757.67,31870.39,
Knee arthroscopy/surgery,29887,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5757.67,31870.39,APC 378
Knee arthroscopy/surgery,29887,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5757.67,31870.39,APC
Knee arthroscopy/surgery,29887,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5757.67,31870.39,APC
Knee arthroscopy/surgery,29887,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5757.67,31870.39,APC
Knee arthroscopy/surgery,29887,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5757.67,31870.39,Radiology
Knee arthroscopy/surgery,29887,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5757.67,31870.39,APC
Knee arthroscopy/surgery,29887,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5757.67,31870.39,APC
Knee arthroscopy/surgery,29888,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7769.41,,,,,,,fee schedule,6227.86,31870.39,
Knee arthroscopy/surgery,29888,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6227.86,,,,,,,fee schedule,6227.86,31870.39,
Knee arthroscopy/surgery,29888,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6803.37,,,,,,,fee schedule,6227.86,31870.39,
Knee arthroscopy/surgery,29888,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7152.79,,,,,,,fee schedule,6227.86,31870.39,
Knee arthroscopy/surgery,29888,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,6227.86,31870.39,APC 378
Knee arthroscopy/surgery,29888,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,6227.86,31870.39,APC
Knee arthroscopy/surgery,29888,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,6227.86,31870.39,APC
Knee arthroscopy/surgery,29888,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,6227.86,31870.39,APC
Knee arthroscopy/surgery,29888,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,6227.86,31870.39,Radiology
Knee arthroscopy/surgery,29888,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,6227.86,31870.39,APC
Knee arthroscopy/surgery,29888,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,6227.86,31870.39,APC
Knee arthroscopy/surgery,29889,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7209.19,,,,,,,fee schedule,5778.8,56389.43,
Knee arthroscopy/surgery,29889,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5778.8,,,,,,,fee schedule,5778.8,56389.43,
Knee arthroscopy/surgery,29889,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6312.81,,,,,,,fee schedule,5778.8,56389.43,
Knee arthroscopy/surgery,29889,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6637.03,,,,,,,fee schedule,5778.8,56389.43,
Knee arthroscopy/surgery,29889,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,5778.8,56389.43,APC 378
Knee arthroscopy/surgery,29889,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,5778.8,56389.43,APC
Knee arthroscopy/surgery,29889,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,5778.8,56389.43,APC
Knee arthroscopy/surgery,29889,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,5778.8,56389.43,APC
Knee arthroscopy/surgery,29889,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,5778.8,56389.43,Radiology
Knee arthroscopy/surgery,29889,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,5778.8,56389.43,APC
Knee arthroscopy/surgery,29889,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,5778.8,56389.43,APC
Ankle arthroscopy/surgery,29891,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6221.22,,,,,,,fee schedule,3239.17,14371.12,
Ankle arthroscopy/surgery,29891,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4986.85,,,,,,,fee schedule,3239.17,14371.12,
Ankle arthroscopy/surgery,29891,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5447.68,,,,,,,fee schedule,3239.17,14371.12,
Ankle arthroscopy/surgery,29891,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5727.47,,,,,,,fee schedule,3239.17,14371.12,
Ankle arthroscopy/surgery,29891,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Ankle arthroscopy/surgery,29891,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Ankle arthroscopy/surgery,29891,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Ankle arthroscopy/surgery,29891,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Ankle arthroscopy/surgery,29891,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Ankle arthroscopy/surgery,29891,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Ankle arthroscopy/surgery,29891,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Ankle arthroscopy/surgery,29892,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3713.85,,,,,,,fee schedule,2976.98,31870.39,
Ankle arthroscopy/surgery,29892,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2976.98,,,,,,,fee schedule,2976.98,31870.39,
Ankle arthroscopy/surgery,29892,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3252.08,,,,,,,fee schedule,2976.98,31870.39,
Ankle arthroscopy/surgery,29892,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3419.1,,,,,,,fee schedule,2976.98,31870.39,
Ankle arthroscopy/surgery,29892,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,2976.98,31870.39,APC 378
Ankle arthroscopy/surgery,29892,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,2976.98,31870.39,APC
Ankle arthroscopy/surgery,29892,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,2976.98,31870.39,APC
Ankle arthroscopy/surgery,29892,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,2976.98,31870.39,APC
Ankle arthroscopy/surgery,29892,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,2976.98,31870.39,Radiology
Ankle arthroscopy/surgery,29892,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,2976.98,31870.39,APC
Ankle arthroscopy/surgery,29892,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,2976.98,31870.39,APC
Scope plantar fasciotomy,29893,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5553.33,,,,,,,fee schedule,3239.17,14371.12,
Scope plantar fasciotomy,29893,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4451.48,,,,,,,fee schedule,3239.17,14371.12,
Scope plantar fasciotomy,29893,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4862.84,,,,,,,fee schedule,3239.17,14371.12,
Scope plantar fasciotomy,29893,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5112.59,,,,,,,fee schedule,3239.17,14371.12,
Scope plantar fasciotomy,29893,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Scope plantar fasciotomy,29893,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Scope plantar fasciotomy,29893,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Scope plantar fasciotomy,29893,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Scope plantar fasciotomy,29893,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Scope plantar fasciotomy,29893,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Scope plantar fasciotomy,29893,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Ankle arthroscopy/surgery,29894,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7182.83,,,,,,,fee schedule,3239.17,14371.12,
Ankle arthroscopy/surgery,29894,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5757.67,,,,,,,fee schedule,3239.17,14371.12,
Ankle arthroscopy/surgery,29894,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6289.73,,,,,,,fee schedule,3239.17,14371.12,
Ankle arthroscopy/surgery,29894,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6612.77,,,,,,,fee schedule,3239.17,14371.12,
Ankle arthroscopy/surgery,29894,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Ankle arthroscopy/surgery,29894,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Ankle arthroscopy/surgery,29894,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Ankle arthroscopy/surgery,29894,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Ankle arthroscopy/surgery,29894,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Ankle arthroscopy/surgery,29894,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Ankle arthroscopy/surgery,29894,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Ankle arthroscopy/surgery,29895,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5921.87,,,,,,,fee schedule,3239.17,14371.12,
Ankle arthroscopy/surgery,29895,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4746.9,,,,,,,fee schedule,3239.17,14371.12,
Ankle arthroscopy/surgery,29895,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5185.56,,,,,,,fee schedule,3239.17,14371.12,
Ankle arthroscopy/surgery,29895,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5451.88,,,,,,,fee schedule,3239.17,14371.12,
Ankle arthroscopy/surgery,29895,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Ankle arthroscopy/surgery,29895,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Ankle arthroscopy/surgery,29895,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Ankle arthroscopy/surgery,29895,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Ankle arthroscopy/surgery,29895,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Ankle arthroscopy/surgery,29895,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Ankle arthroscopy/surgery,29895,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Ankle arthroscopy/surgery,29897,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5453.76,,,,,,,fee schedule,3239.17,14371.12,
Ankle arthroscopy/surgery,29897,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4371.66,,,,,,,fee schedule,3239.17,14371.12,
Ankle arthroscopy/surgery,29897,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4775.65,,,,,,,fee schedule,3239.17,14371.12,
Ankle arthroscopy/surgery,29897,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5020.92,,,,,,,fee schedule,3239.17,14371.12,
Ankle arthroscopy/surgery,29897,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Ankle arthroscopy/surgery,29897,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Ankle arthroscopy/surgery,29897,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Ankle arthroscopy/surgery,29897,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Ankle arthroscopy/surgery,29897,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Ankle arthroscopy/surgery,29897,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Ankle arthroscopy/surgery,29897,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Ankle arthroscopy/surgery,29898,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6134.78,,,,,,,fee schedule,3239.17,14371.12,
Ankle arthroscopy/surgery,29898,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4917.56,,,,,,,fee schedule,3239.17,14371.12,
Ankle arthroscopy/surgery,29898,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5371.99,,,,,,,fee schedule,3239.17,14371.12,
Ankle arthroscopy/surgery,29898,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5647.89,,,,,,,fee schedule,3239.17,14371.12,
Ankle arthroscopy/surgery,29898,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Ankle arthroscopy/surgery,29898,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Ankle arthroscopy/surgery,29898,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Ankle arthroscopy/surgery,29898,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Ankle arthroscopy/surgery,29898,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Ankle arthroscopy/surgery,29898,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Ankle arthroscopy/surgery,29898,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Ankle arthroscopy/surgery,29899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6507.02,,,,,,,fee schedule,5215.94,31870.39,
Ankle arthroscopy/surgery,29899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5215.94,,,,,,,fee schedule,5215.94,31870.39,
Ankle arthroscopy/surgery,29899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5697.94,,,,,,,fee schedule,5215.94,31870.39,
Ankle arthroscopy/surgery,29899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5990.59,,,,,,,fee schedule,5215.94,31870.39,
Ankle arthroscopy/surgery,29899,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5215.94,31870.39,APC 378
Ankle arthroscopy/surgery,29899,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5215.94,31870.39,APC
Ankle arthroscopy/surgery,29899,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5215.94,31870.39,APC
Ankle arthroscopy/surgery,29899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5215.94,31870.39,APC
Ankle arthroscopy/surgery,29899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5215.94,31870.39,Radiology
Ankle arthroscopy/surgery,29899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5215.94,31870.39,APC
Ankle arthroscopy/surgery,29899,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5215.94,31870.39,APC
Mcp joint arthroscopy dx,29900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7182.83,,,,,,,fee schedule,3239.17,14371.12,
Mcp joint arthroscopy dx,29900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5757.67,,,,,,,fee schedule,3239.17,14371.12,
Mcp joint arthroscopy dx,29900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6289.73,,,,,,,fee schedule,3239.17,14371.12,
Mcp joint arthroscopy dx,29900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6612.77,,,,,,,fee schedule,3239.17,14371.12,
Mcp joint arthroscopy dx,29900,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Mcp joint arthroscopy dx,29900,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Mcp joint arthroscopy dx,29900,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Mcp joint arthroscopy dx,29900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Mcp joint arthroscopy dx,29900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Mcp joint arthroscopy dx,29900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Mcp joint arthroscopy dx,29900,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Mcp joint arthroscopy surg,29901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7182.83,,,,,,,fee schedule,3239.17,14371.12,
Mcp joint arthroscopy surg,29901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5757.67,,,,,,,fee schedule,3239.17,14371.12,
Mcp joint arthroscopy surg,29901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6289.73,,,,,,,fee schedule,3239.17,14371.12,
Mcp joint arthroscopy surg,29901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6612.77,,,,,,,fee schedule,3239.17,14371.12,
Mcp joint arthroscopy surg,29901,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Mcp joint arthroscopy surg,29901,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Mcp joint arthroscopy surg,29901,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Mcp joint arthroscopy surg,29901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Mcp joint arthroscopy surg,29901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Mcp joint arthroscopy surg,29901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Mcp joint arthroscopy surg,29901,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Mcp joint arthroscopy surg,29902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7182.83,,,,,,,fee schedule,1591.86,7182.83,
Mcp joint arthroscopy surg,29902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5757.67,,,,,,,fee schedule,1591.86,7182.83,
Mcp joint arthroscopy surg,29902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6289.73,,,,,,,fee schedule,1591.86,7182.83,
Mcp joint arthroscopy surg,29902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6612.77,,,,,,,fee schedule,1591.86,7182.83,
Mcp joint arthroscopy surg,29902,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7062.54,,,,,,,fee schedule,1591.86,7182.83,APC 378
Mcp joint arthroscopy surg,29902,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1671.45,,,,,,,fee schedule,1591.86,7182.83,APC
Mcp joint arthroscopy surg,29902,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1655.53,,,,,,,fee schedule,1591.86,7182.83,APC
Mcp joint arthroscopy surg,29902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1591.86,,,,,,,fee schedule,1591.86,7182.83,APC
Mcp joint arthroscopy surg,29902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2435.55,,,,,,,fee schedule,1591.86,7182.83,Radiology
Mcp joint arthroscopy surg,29902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2228.6,,,,,,,fee schedule,1591.86,7182.83,APC
Mcp joint arthroscopy surg,29902,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2785.75,,,,,,,fee schedule,1591.86,7182.83,APC
Subtalar arthro w/fb rmvl,29904,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7182.83,,,,,,,fee schedule,3239.17,14371.12,
Subtalar arthro w/fb rmvl,29904,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5757.67,,,,,,,fee schedule,3239.17,14371.12,
Subtalar arthro w/fb rmvl,29904,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6289.73,,,,,,,fee schedule,3239.17,14371.12,
Subtalar arthro w/fb rmvl,29904,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6612.77,,,,,,,fee schedule,3239.17,14371.12,
Subtalar arthro w/fb rmvl,29904,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Subtalar arthro w/fb rmvl,29904,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Subtalar arthro w/fb rmvl,29904,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Subtalar arthro w/fb rmvl,29904,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Subtalar arthro w/fb rmvl,29904,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Subtalar arthro w/fb rmvl,29904,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Subtalar arthro w/fb rmvl,29904,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Subtalar arthro w/exc,29905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7182.83,,,,,,,fee schedule,5757.67,31870.39,
Subtalar arthro w/exc,29905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5757.67,,,,,,,fee schedule,5757.67,31870.39,
Subtalar arthro w/exc,29905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6289.73,,,,,,,fee schedule,5757.67,31870.39,
Subtalar arthro w/exc,29905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6612.77,,,,,,,fee schedule,5757.67,31870.39,
Subtalar arthro w/exc,29905,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5757.67,31870.39,APC 378
Subtalar arthro w/exc,29905,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5757.67,31870.39,APC
Subtalar arthro w/exc,29905,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5757.67,31870.39,APC
Subtalar arthro w/exc,29905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5757.67,31870.39,APC
Subtalar arthro w/exc,29905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5757.67,31870.39,Radiology
Subtalar arthro w/exc,29905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5757.67,31870.39,APC
Subtalar arthro w/exc,29905,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5757.67,31870.39,APC
Subtalar arthro w/deb,29906,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7182.83,,,,,,,fee schedule,3239.17,14371.12,
Subtalar arthro w/deb,29906,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5757.67,,,,,,,fee schedule,3239.17,14371.12,
Subtalar arthro w/deb,29906,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6289.73,,,,,,,fee schedule,3239.17,14371.12,
Subtalar arthro w/deb,29906,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6612.77,,,,,,,fee schedule,3239.17,14371.12,
Subtalar arthro w/deb,29906,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Subtalar arthro w/deb,29906,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Subtalar arthro w/deb,29906,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Subtalar arthro w/deb,29906,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Subtalar arthro w/deb,29906,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Subtalar arthro w/deb,29906,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Subtalar arthro w/deb,29906,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Subtalar arthro w/fusion,29907,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11407.36,,,,,,,fee schedule,9143.99,56389.43,
Subtalar arthro w/fusion,29907,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9143.99,,,,,,,fee schedule,9143.99,56389.43,
Subtalar arthro w/fusion,29907,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9988.98,,,,,,,fee schedule,9143.99,56389.43,
Subtalar arthro w/fusion,29907,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10502.01,,,,,,,fee schedule,9143.99,56389.43,
Subtalar arthro w/fusion,29907,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,9143.99,56389.43,APC 378
Subtalar arthro w/fusion,29907,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,9143.99,56389.43,APC
Subtalar arthro w/fusion,29907,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,9143.99,56389.43,APC
Subtalar arthro w/fusion,29907,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,9143.99,56389.43,APC
Subtalar arthro w/fusion,29907,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,9143.99,56389.43,Radiology
Subtalar arthro w/fusion,29907,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,9143.99,56389.43,APC
Subtalar arthro w/fusion,29907,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,9143.99,56389.43,APC
Hip arthro w/femoroplasty,29914,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6403.53,,,,,,,fee schedule,5132.99,31870.39,
Hip arthro w/femoroplasty,29914,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5132.99,,,,,,,fee schedule,5132.99,31870.39,
Hip arthro w/femoroplasty,29914,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5607.33,,,,,,,fee schedule,5132.99,31870.39,
Hip arthro w/femoroplasty,29914,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5895.32,,,,,,,fee schedule,5132.99,31870.39,
Hip arthro w/femoroplasty,29914,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5132.99,31870.39,APC 378
Hip arthro w/femoroplasty,29914,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5132.99,31870.39,APC
Hip arthro w/femoroplasty,29914,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5132.99,31870.39,APC
Hip arthro w/femoroplasty,29914,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5132.99,31870.39,APC
Hip arthro w/femoroplasty,29914,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5132.99,31870.39,Radiology
Hip arthro w/femoroplasty,29914,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5132.99,31870.39,APC
Hip arthro w/femoroplasty,29914,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5132.99,31870.39,APC
Hip arthro acetabuloplasty,29915,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12612.16,,,,,,,fee schedule,7183.42,31870.39,
Hip arthro acetabuloplasty,29915,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10109.75,,,,,,,fee schedule,7183.42,31870.39,
Hip arthro acetabuloplasty,29915,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11043.98,,,,,,,fee schedule,7183.42,31870.39,
Hip arthro acetabuloplasty,29915,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11611.19,,,,,,,fee schedule,7183.42,31870.39,
Hip arthro acetabuloplasty,29915,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Hip arthro acetabuloplasty,29915,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Hip arthro acetabuloplasty,29915,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Hip arthro acetabuloplasty,29915,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Hip arthro acetabuloplasty,29915,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Hip arthro acetabuloplasty,29915,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Hip arthro acetabuloplasty,29915,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Hip arthro w/labral repair,29916,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6403.53,,,,,,,fee schedule,5132.99,31870.39,
Hip arthro w/labral repair,29916,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5132.99,,,,,,,fee schedule,5132.99,31870.39,
Hip arthro w/labral repair,29916,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5607.33,,,,,,,fee schedule,5132.99,31870.39,
Hip arthro w/labral repair,29916,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5895.32,,,,,,,fee schedule,5132.99,31870.39,
Hip arthro w/labral repair,29916,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,5132.99,31870.39,APC 378
Hip arthro w/labral repair,29916,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,5132.99,31870.39,APC
Hip arthro w/labral repair,29916,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,5132.99,31870.39,APC
Hip arthro w/labral repair,29916,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,5132.99,31870.39,APC
Hip arthro w/labral repair,29916,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,5132.99,31870.39,Radiology
Hip arthro w/labral repair,29916,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,5132.99,31870.39,APC
Hip arthro w/labral repair,29916,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,5132.99,31870.39,APC
Arthroscopy of joint,29999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5167.96,,,,,,,fee schedule,244.19,5167.96,
Arthroscopy of joint,29999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4142.57,,,,,,,fee schedule,244.19,5167.96,
Arthroscopy of joint,29999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4525.38,,,,,,,fee schedule,244.19,5167.96,
Arthroscopy of joint,29999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4757.8,,,,,,,fee schedule,244.19,5167.96,
Arthroscopy of joint,29999,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1083.4,,,,,,,fee schedule,244.19,5167.96,APC 378
Arthroscopy of joint,29999,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.4,,,,,,,fee schedule,244.19,5167.96,APC
Arthroscopy of joint,29999,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.96,,,,,,,fee schedule,244.19,5167.96,APC
Arthroscopy of joint,29999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,244.19,,,,,,,fee schedule,244.19,5167.96,APC
Arthroscopy of joint,29999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.61,,,,,,,fee schedule,244.19,5167.96,Radiology
Arthroscopy of joint,29999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.87,,,,,,,fee schedule,244.19,5167.96,APC
Arthroscopy of joint,29999,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.34,,,,,,,fee schedule,244.19,5167.96,APC
Drainage of nose lesion,30000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,624,,,,,,,fee schedule,234.47,1040.28,
Drainage of nose lesion,30000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,500.19,,,,,,,fee schedule,234.47,1040.28,
Drainage of nose lesion,30000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,546.41,,,,,,,fee schedule,234.47,1040.28,
Drainage of nose lesion,30000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,574.48,,,,,,,fee schedule,234.47,1040.28,
Drainage of nose lesion,30000,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1040.28,,,,,,,fee schedule,234.47,1040.28,APC 378
Drainage of nose lesion,30000,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,246.2,,,,,,,fee schedule,234.47,1040.28,APC
Drainage of nose lesion,30000,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,243.85,,,,,,,fee schedule,234.47,1040.28,APC
Drainage of nose lesion,30000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,234.47,,,,,,,fee schedule,234.47,1040.28,APC
Drainage of nose lesion,30000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,358.74,,,,,,,fee schedule,234.47,1040.28,Radiology
Drainage of nose lesion,30000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,328.26,,,,,,,fee schedule,234.47,1040.28,APC
Drainage of nose lesion,30000,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,410.33,,,,,,,fee schedule,234.47,1040.28,APC
Drainage of nose lesion,30020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,624,,,,,,,fee schedule,500.19,2368.81,
Drainage of nose lesion,30020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,500.19,,,,,,,fee schedule,500.19,2368.81,
Drainage of nose lesion,30020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,546.41,,,,,,,fee schedule,500.19,2368.81,
Drainage of nose lesion,30020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,574.48,,,,,,,fee schedule,500.19,2368.81,
Drainage of nose lesion,30020,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2368.81,,,,,,,fee schedule,500.19,2368.81,APC 378
Drainage of nose lesion,30020,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,560.61,,,,,,,fee schedule,500.19,2368.81,APC
Drainage of nose lesion,30020,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,555.27,,,,,,,fee schedule,500.19,2368.81,APC
Drainage of nose lesion,30020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,533.92,,,,,,,fee schedule,500.19,2368.81,APC
Drainage of nose lesion,30020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,816.89,,,,,,,fee schedule,500.19,2368.81,Radiology
Drainage of nose lesion,30020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,747.48,,,,,,,fee schedule,500.19,2368.81,APC
Drainage of nose lesion,30020,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,934.36,,,,,,,fee schedule,500.19,2368.81,APC
Intranasal biopsy,30100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1858.66,,,,,,,fee schedule,1489.88,6814.79,
Intranasal biopsy,30100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1489.88,,,,,,,fee schedule,1489.88,6814.79,
Intranasal biopsy,30100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1627.56,,,,,,,fee schedule,1489.88,6814.79,
Intranasal biopsy,30100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1711.15,,,,,,,fee schedule,1489.88,6814.79,
Intranasal biopsy,30100,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1489.88,6814.79,APC 378
Intranasal biopsy,30100,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1489.88,6814.79,APC
Intranasal biopsy,30100,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1489.88,6814.79,APC
Intranasal biopsy,30100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1489.88,6814.79,APC
Intranasal biopsy,30100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1489.88,6814.79,Radiology
Intranasal biopsy,30100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1489.88,6814.79,APC
Intranasal biopsy,30100,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1489.88,6814.79,APC
Removal of nose polyp(s),30110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4075.29,,,,,,,fee schedule,1536.02,6814.79,
Removal of nose polyp(s),30110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3266.7,,,,,,,fee schedule,1536.02,6814.79,
Removal of nose polyp(s),30110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3568.58,,,,,,,fee schedule,1536.02,6814.79,
Removal of nose polyp(s),30110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3751.86,,,,,,,fee schedule,1536.02,6814.79,
Removal of nose polyp(s),30110,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1536.02,6814.79,APC 378
Removal of nose polyp(s),30110,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1536.02,6814.79,APC
Removal of nose polyp(s),30110,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1536.02,6814.79,APC
Removal of nose polyp(s),30110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1536.02,6814.79,APC
Removal of nose polyp(s),30110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1536.02,6814.79,Radiology
Removal of nose polyp(s),30110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1536.02,6814.79,APC
Removal of nose polyp(s),30110,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1536.02,6814.79,APC
Removal of nose polyp(s),30115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4075.29,,,,,,,fee schedule,3266.7,14562,
Removal of nose polyp(s),30115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3266.7,,,,,,,fee schedule,3266.7,14562,
Removal of nose polyp(s),30115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3568.58,,,,,,,fee schedule,3266.7,14562,
Removal of nose polyp(s),30115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3751.86,,,,,,,fee schedule,3266.7,14562,
Removal of nose polyp(s),30115,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3266.7,14562,APC 378
Removal of nose polyp(s),30115,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3266.7,14562,APC
Removal of nose polyp(s),30115,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3266.7,14562,APC
Removal of nose polyp(s),30115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3266.7,14562,APC
Removal of nose polyp(s),30115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3266.7,14562,Radiology
Removal of nose polyp(s),30115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3266.7,14562,APC
Removal of nose polyp(s),30115,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3266.7,14562,APC
Removal of intranasal lesion,30117,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5336.73,,,,,,,fee schedule,3282.2,14562,
Removal of intranasal lesion,30117,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4277.86,,,,,,,fee schedule,3282.2,14562,
Removal of intranasal lesion,30117,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4673.17,,,,,,,fee schedule,3282.2,14562,
Removal of intranasal lesion,30117,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4913.18,,,,,,,fee schedule,3282.2,14562,
Removal of intranasal lesion,30117,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Removal of intranasal lesion,30117,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Removal of intranasal lesion,30117,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Removal of intranasal lesion,30117,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Removal of intranasal lesion,30117,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Removal of intranasal lesion,30117,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Removal of intranasal lesion,30117,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Removal of intranasal lesion,30118,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9269.11,,,,,,,fee schedule,3282.2,14562,
Removal of intranasal lesion,30118,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7430,,,,,,,fee schedule,3282.2,14562,
Removal of intranasal lesion,30118,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8116.61,,,,,,,fee schedule,3282.2,14562,
Removal of intranasal lesion,30118,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8533.47,,,,,,,fee schedule,3282.2,14562,
Removal of intranasal lesion,30118,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Removal of intranasal lesion,30118,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Removal of intranasal lesion,30118,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Removal of intranasal lesion,30118,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Removal of intranasal lesion,30118,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Removal of intranasal lesion,30118,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Removal of intranasal lesion,30118,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Revision of nose,30120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4075.29,,,,,,,fee schedule,3266.7,14562,
Revision of nose,30120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3266.7,,,,,,,fee schedule,3266.7,14562,
Revision of nose,30120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3568.58,,,,,,,fee schedule,3266.7,14562,
Revision of nose,30120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3751.86,,,,,,,fee schedule,3266.7,14562,
Revision of nose,30120,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3266.7,14562,APC 378
Revision of nose,30120,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3266.7,14562,APC
Revision of nose,30120,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3266.7,14562,APC
Revision of nose,30120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3266.7,14562,APC
Revision of nose,30120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3266.7,14562,Radiology
Revision of nose,30120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3266.7,14562,APC
Revision of nose,30120,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3266.7,14562,APC
Removal of nose lesion,30124,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1858.66,,,,,,,fee schedule,1489.88,6814.79,
Removal of nose lesion,30124,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1489.88,,,,,,,fee schedule,1489.88,6814.79,
Removal of nose lesion,30124,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1627.56,,,,,,,fee schedule,1489.88,6814.79,
Removal of nose lesion,30124,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1711.15,,,,,,,fee schedule,1489.88,6814.79,
Removal of nose lesion,30124,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1489.88,6814.79,APC 378
Removal of nose lesion,30124,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1489.88,6814.79,APC
Removal of nose lesion,30124,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1489.88,6814.79,APC
Removal of nose lesion,30124,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1489.88,6814.79,APC
Removal of nose lesion,30124,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1489.88,6814.79,Radiology
Removal of nose lesion,30124,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1489.88,6814.79,APC
Removal of nose lesion,30124,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1489.88,6814.79,APC
Removal of nose lesion,30125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Removal of nose lesion,30125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Removal of nose lesion,30125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Removal of nose lesion,30125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Removal of nose lesion,30125,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Removal of nose lesion,30125,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of nose lesion,30125,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of nose lesion,30125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of nose lesion,30125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Removal of nose lesion,30125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of nose lesion,30125,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Excise inferior turbinate,30130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4868.61,,,,,,,fee schedule,3282.2,14562,
Excise inferior turbinate,30130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3902.62,,,,,,,fee schedule,3282.2,14562,
Excise inferior turbinate,30130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4263.26,,,,,,,fee schedule,3282.2,14562,
Excise inferior turbinate,30130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4482.22,,,,,,,fee schedule,3282.2,14562,
Excise inferior turbinate,30130,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Excise inferior turbinate,30130,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Excise inferior turbinate,30130,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Excise inferior turbinate,30130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Excise inferior turbinate,30130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Excise inferior turbinate,30130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Excise inferior turbinate,30130,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Resect inferior turbinate,30140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3916.07,,,,,,,fee schedule,3139.07,14562,
Resect inferior turbinate,30140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3139.07,,,,,,,fee schedule,3139.07,14562,
Resect inferior turbinate,30140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3429.15,,,,,,,fee schedule,3139.07,14562,
Resect inferior turbinate,30140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3605.27,,,,,,,fee schedule,3139.07,14562,
Resect inferior turbinate,30140,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3139.07,14562,APC 378
Resect inferior turbinate,30140,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3139.07,14562,APC
Resect inferior turbinate,30140,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3139.07,14562,APC
Resect inferior turbinate,30140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3139.07,14562,APC
Resect inferior turbinate,30140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3139.07,14562,Radiology
Resect inferior turbinate,30140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3139.07,14562,APC
Resect inferior turbinate,30140,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3139.07,14562,APC
Partial removal of nose,30150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Partial removal of nose,30150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Partial removal of nose,30150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Partial removal of nose,30150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Partial removal of nose,30150,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Partial removal of nose,30150,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Partial removal of nose,30150,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Partial removal of nose,30150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Partial removal of nose,30150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Partial removal of nose,30150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Partial removal of nose,30150,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of nose,30160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Removal of nose,30160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Removal of nose,30160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Removal of nose,30160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Removal of nose,30160,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Removal of nose,30160,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of nose,30160,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of nose,30160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of nose,30160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Removal of nose,30160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of nose,30160,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Injection treatment of nose,30200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1858.66,,,,,,,fee schedule,533.92,2368.81,
Injection treatment of nose,30200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1489.88,,,,,,,fee schedule,533.92,2368.81,
Injection treatment of nose,30200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1627.56,,,,,,,fee schedule,533.92,2368.81,
Injection treatment of nose,30200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1711.15,,,,,,,fee schedule,533.92,2368.81,
Injection treatment of nose,30200,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2368.81,,,,,,,fee schedule,533.92,2368.81,APC 378
Injection treatment of nose,30200,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,560.61,,,,,,,fee schedule,533.92,2368.81,APC
Injection treatment of nose,30200,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,555.27,,,,,,,fee schedule,533.92,2368.81,APC
Injection treatment of nose,30200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,533.92,,,,,,,fee schedule,533.92,2368.81,APC
Injection treatment of nose,30200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,816.89,,,,,,,fee schedule,533.92,2368.81,Radiology
Injection treatment of nose,30200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,747.48,,,,,,,fee schedule,533.92,2368.81,APC
Injection treatment of nose,30200,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,934.36,,,,,,,fee schedule,533.92,2368.81,APC
Nasal sinus therapy,30210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1858.66,,,,,,,fee schedule,1489.88,6814.79,
Nasal sinus therapy,30210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1489.88,,,,,,,fee schedule,1489.88,6814.79,
Nasal sinus therapy,30210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1627.56,,,,,,,fee schedule,1489.88,6814.79,
Nasal sinus therapy,30210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1711.15,,,,,,,fee schedule,1489.88,6814.79,
Nasal sinus therapy,30210,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1489.88,6814.79,APC 378
Nasal sinus therapy,30210,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1489.88,6814.79,APC
Nasal sinus therapy,30210,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1489.88,6814.79,APC
Nasal sinus therapy,30210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1489.88,6814.79,APC
Nasal sinus therapy,30210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1489.88,6814.79,Radiology
Nasal sinus therapy,30210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1489.88,6814.79,APC
Nasal sinus therapy,30210,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1489.88,6814.79,APC
Insert nasal septal button,30220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1858.66,,,,,,,fee schedule,1489.88,6814.79,
Insert nasal septal button,30220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1489.88,,,,,,,fee schedule,1489.88,6814.79,
Insert nasal septal button,30220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1627.56,,,,,,,fee schedule,1489.88,6814.79,
Insert nasal septal button,30220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1711.15,,,,,,,fee schedule,1489.88,6814.79,
Insert nasal septal button,30220,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1489.88,6814.79,APC 378
Insert nasal septal button,30220,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1489.88,6814.79,APC
Insert nasal septal button,30220,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1489.88,6814.79,APC
Insert nasal septal button,30220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1489.88,6814.79,APC
Insert nasal septal button,30220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1489.88,6814.79,Radiology
Insert nasal septal button,30220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1489.88,6814.79,APC
Insert nasal septal button,30220,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1489.88,6814.79,APC
Remove nasal foreign body,30300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,280.65,,,,,,,fee schedule,131.71,584.37,
Remove nasal foreign body,30300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,224.97,,,,,,,fee schedule,131.71,584.37,
Remove nasal foreign body,30300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,245.76,,,,,,,fee schedule,131.71,584.37,
Remove nasal foreign body,30300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,258.38,,,,,,,fee schedule,131.71,584.37,
Remove nasal foreign body,30300,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,131.71,584.37,APC 378
Remove nasal foreign body,30300,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,131.71,584.37,APC
Remove nasal foreign body,30300,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,131.71,584.37,APC
Remove nasal foreign body,30300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,131.71,584.37,APC
Remove nasal foreign body,30300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,131.71,584.37,Radiology
Remove nasal foreign body,30300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,131.71,584.37,APC
Remove nasal foreign body,30300,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,131.71,584.37,APC
Remove nasal foreign body,30310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4075.29,,,,,,,fee schedule,3266.7,14562,
Remove nasal foreign body,30310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3266.7,,,,,,,fee schedule,3266.7,14562,
Remove nasal foreign body,30310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3568.58,,,,,,,fee schedule,3266.7,14562,
Remove nasal foreign body,30310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3751.86,,,,,,,fee schedule,3266.7,14562,
Remove nasal foreign body,30310,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3266.7,14562,APC 378
Remove nasal foreign body,30310,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3266.7,14562,APC
Remove nasal foreign body,30310,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3266.7,14562,APC
Remove nasal foreign body,30310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3266.7,14562,APC
Remove nasal foreign body,30310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3266.7,14562,Radiology
Remove nasal foreign body,30310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3266.7,14562,APC
Remove nasal foreign body,30310,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3266.7,14562,APC
Remove nasal foreign body,30320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4075.29,,,,,,,fee schedule,1536.02,6814.79,
Remove nasal foreign body,30320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3266.7,,,,,,,fee schedule,1536.02,6814.79,
Remove nasal foreign body,30320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3568.58,,,,,,,fee schedule,1536.02,6814.79,
Remove nasal foreign body,30320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3751.86,,,,,,,fee schedule,1536.02,6814.79,
Remove nasal foreign body,30320,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1536.02,6814.79,APC 378
Remove nasal foreign body,30320,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1536.02,6814.79,APC
Remove nasal foreign body,30320,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1536.02,6814.79,APC
Remove nasal foreign body,30320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1536.02,6814.79,APC
Remove nasal foreign body,30320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1536.02,6814.79,Radiology
Remove nasal foreign body,30320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1536.02,6814.79,APC
Remove nasal foreign body,30320,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1536.02,6814.79,APC
Reconstruction of nose,30400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3916.13,,,,,,,fee schedule,3139.12,26000.79,
Reconstruction of nose,30400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3139.12,,,,,,,fee schedule,3139.12,26000.79,
Reconstruction of nose,30400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3429.2,,,,,,,fee schedule,3139.12,26000.79,
Reconstruction of nose,30400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3605.33,,,,,,,fee schedule,3139.12,26000.79,
Reconstruction of nose,30400,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,3139.12,26000.79,APC 378
Reconstruction of nose,30400,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,3139.12,26000.79,APC
Reconstruction of nose,30400,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,3139.12,26000.79,APC
Reconstruction of nose,30400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,3139.12,26000.79,APC
Reconstruction of nose,30400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,3139.12,26000.79,Radiology
Reconstruction of nose,30400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,3139.12,26000.79,APC
Reconstruction of nose,30400,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,3139.12,26000.79,APC
Reconstruction of nose,30410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Reconstruction of nose,30410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Reconstruction of nose,30410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Reconstruction of nose,30410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Reconstruction of nose,30410,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Reconstruction of nose,30410,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruction of nose,30410,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruction of nose,30410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruction of nose,30410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Reconstruction of nose,30410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruction of nose,30410,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruction of nose,30420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5988.2,,,,,,,fee schedule,4800.06,26000.79,
Reconstruction of nose,30420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4800.06,,,,,,,fee schedule,4800.06,26000.79,
Reconstruction of nose,30420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5243.64,,,,,,,fee schedule,4800.06,26000.79,
Reconstruction of nose,30420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5512.95,,,,,,,fee schedule,4800.06,26000.79,
Reconstruction of nose,30420,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,4800.06,26000.79,APC 378
Reconstruction of nose,30420,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,4800.06,26000.79,APC
Reconstruction of nose,30420,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,4800.06,26000.79,APC
Reconstruction of nose,30420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,4800.06,26000.79,APC
Reconstruction of nose,30420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,4800.06,26000.79,Radiology
Reconstruction of nose,30420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,4800.06,26000.79,APC
Reconstruction of nose,30420,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,4800.06,26000.79,APC
Revision of nose,30430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5983.93,,,,,,,fee schedule,4796.64,26000.79,
Revision of nose,30430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4796.64,,,,,,,fee schedule,4796.64,26000.79,
Revision of nose,30430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5239.9,,,,,,,fee schedule,4796.64,26000.79,
Revision of nose,30430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.01,,,,,,,fee schedule,4796.64,26000.79,
Revision of nose,30430,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,4796.64,26000.79,APC 378
Revision of nose,30430,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,4796.64,26000.79,APC
Revision of nose,30430,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,4796.64,26000.79,APC
Revision of nose,30430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,4796.64,26000.79,APC
Revision of nose,30430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,4796.64,26000.79,Radiology
Revision of nose,30430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,4796.64,26000.79,APC
Revision of nose,30430,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,4796.64,26000.79,APC
Revision of nose,30435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Revision of nose,30435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Revision of nose,30435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Revision of nose,30435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Revision of nose,30435,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Revision of nose,30435,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Revision of nose,30435,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Revision of nose,30435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Revision of nose,30435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Revision of nose,30435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Revision of nose,30435,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Revision of nose,30450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Revision of nose,30450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Revision of nose,30450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Revision of nose,30450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Revision of nose,30450,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Revision of nose,30450,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Revision of nose,30450,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Revision of nose,30450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Revision of nose,30450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Revision of nose,30450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Revision of nose,30450,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Revision of nose,30460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4999.19,,,,,,,fee schedule,4007.29,26000.79,
Revision of nose,30460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4007.29,,,,,,,fee schedule,4007.29,26000.79,
Revision of nose,30460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4377.6,,,,,,,fee schedule,4007.29,26000.79,
Revision of nose,30460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4602.43,,,,,,,fee schedule,4007.29,26000.79,
Revision of nose,30460,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,4007.29,26000.79,APC 378
Revision of nose,30460,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,4007.29,26000.79,APC
Revision of nose,30460,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,4007.29,26000.79,APC
Revision of nose,30460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,4007.29,26000.79,APC
Revision of nose,30460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,4007.29,26000.79,Radiology
Revision of nose,30460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,4007.29,26000.79,APC
Revision of nose,30460,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,4007.29,26000.79,APC
Revision of nose,30462,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7911.36,,,,,,,fee schedule,5860.44,26000.79,
Revision of nose,30462,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6341.65,,,,,,,fee schedule,5860.44,26000.79,
Revision of nose,30462,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6927.68,,,,,,,fee schedule,5860.44,26000.79,
Revision of nose,30462,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7283.48,,,,,,,fee schedule,5860.44,26000.79,
Revision of nose,30462,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Revision of nose,30462,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Revision of nose,30462,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Revision of nose,30462,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Revision of nose,30462,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Revision of nose,30462,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Revision of nose,30462,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Repair Nasal Stenosis,30465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3436.86,,,,,,,fee schedule,2754.95,26000.79,
Repair Nasal Stenosis,30465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2754.95,,,,,,,fee schedule,2754.95,26000.79,
Repair Nasal Stenosis,30465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3009.53,,,,,,,fee schedule,2754.95,26000.79,
Repair Nasal Stenosis,30465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3164.1,,,,,,,fee schedule,2754.95,26000.79,
Repair Nasal Stenosis,30465,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,2754.95,26000.79,APC 378
Repair Nasal Stenosis,30465,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,2754.95,26000.79,APC
Repair Nasal Stenosis,30465,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,2754.95,26000.79,APC
Repair Nasal Stenosis,30465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,2754.95,26000.79,APC
Repair Nasal Stenosis,30465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,2754.95,26000.79,Radiology
Repair Nasal Stenosis,30465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,2754.95,26000.79,APC
Repair Nasal Stenosis,30465,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,2754.95,26000.79,APC
Rpr nsl vlv collapse w/implt,30468,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19225.27,,,,,,,fee schedule,5860.44,26000.79,
Rpr nsl vlv collapse w/implt,30468,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15410.73,,,,,,,fee schedule,5860.44,26000.79,
Rpr nsl vlv collapse w/implt,30468,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16834.83,,,,,,,fee schedule,5860.44,26000.79,
Rpr nsl vlv collapse w/implt,30468,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17699.45,,,,,,,fee schedule,5860.44,26000.79,
Rpr nsl vlv collapse w/implt,30468,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Rpr nsl vlv collapse w/implt,30468,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Rpr nsl vlv collapse w/implt,30468,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Rpr nsl vlv collapse w/implt,30468,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Rpr nsl vlv collapse w/implt,30468,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Rpr nsl vlv collapse w/implt,30468,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Rpr nsl vlv collapse w/implt,30468,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Rpr nsl vlv collapse w/rmdlg,30469,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20183.95,,,,,,,fee schedule,5860.44,26000.79,
Rpr nsl vlv collapse w/rmdlg,30469,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16179.2,,,,,,,fee schedule,5860.44,26000.79,
Rpr nsl vlv collapse w/rmdlg,30469,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17674.31,,,,,,,fee schedule,5860.44,26000.79,
Rpr nsl vlv collapse w/rmdlg,30469,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18582.05,,,,,,,fee schedule,5860.44,26000.79,
Rpr nsl vlv collapse w/rmdlg,30469,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Rpr nsl vlv collapse w/rmdlg,30469,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Rpr nsl vlv collapse w/rmdlg,30469,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Rpr nsl vlv collapse w/rmdlg,30469,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Rpr nsl vlv collapse w/rmdlg,30469,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Rpr nsl vlv collapse w/rmdlg,30469,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Rpr nsl vlv collapse w/rmdlg,30469,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Repair of nasal septum,30520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3777.37,,,,,,,fee schedule,3027.89,14562,
Repair of nasal septum,30520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3027.89,,,,,,,fee schedule,3027.89,14562,
Repair of nasal septum,30520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3307.69,,,,,,,fee schedule,3027.89,14562,
Repair of nasal septum,30520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3477.58,,,,,,,fee schedule,3027.89,14562,
Repair of nasal septum,30520,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3027.89,14562,APC 378
Repair of nasal septum,30520,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3027.89,14562,APC
Repair of nasal septum,30520,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3027.89,14562,APC
Repair of nasal septum,30520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3027.89,14562,APC
Repair of nasal septum,30520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3027.89,14562,Radiology
Repair of nasal septum,30520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3027.89,14562,APC
Repair of nasal septum,30520,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3027.89,14562,APC
Repair nasal defect,30540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Repair nasal defect,30540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Repair nasal defect,30540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Repair nasal defect,30540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Repair nasal defect,30540,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Repair nasal defect,30540,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Repair nasal defect,30540,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Repair nasal defect,30540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Repair nasal defect,30540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Repair nasal defect,30540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Repair nasal defect,30540,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Repair nasal defect,30545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Repair nasal defect,30545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Repair nasal defect,30545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Repair nasal defect,30545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Repair nasal defect,30545,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Repair nasal defect,30545,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Repair nasal defect,30545,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Repair nasal defect,30545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Repair nasal defect,30545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Repair nasal defect,30545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Repair nasal defect,30545,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Release of nasal adhesions,30560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3126.73,,,,,,,fee schedule,533.92,3126.73,
Release of nasal adhesions,30560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2506.35,,,,,,,fee schedule,533.92,3126.73,
Release of nasal adhesions,30560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2737.95,,,,,,,fee schedule,533.92,3126.73,
Release of nasal adhesions,30560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2878.57,,,,,,,fee schedule,533.92,3126.73,
Release of nasal adhesions,30560,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2368.81,,,,,,,fee schedule,533.92,3126.73,APC 378
Release of nasal adhesions,30560,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,560.61,,,,,,,fee schedule,533.92,3126.73,APC
Release of nasal adhesions,30560,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,555.27,,,,,,,fee schedule,533.92,3126.73,APC
Release of nasal adhesions,30560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,533.92,,,,,,,fee schedule,533.92,3126.73,APC
Release of nasal adhesions,30560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,816.89,,,,,,,fee schedule,533.92,3126.73,Radiology
Release of nasal adhesions,30560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,747.48,,,,,,,fee schedule,533.92,3126.73,APC
Release of nasal adhesions,30560,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,934.36,,,,,,,fee schedule,533.92,3126.73,APC
Repair upper jaw fistula,30580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Repair upper jaw fistula,30580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Repair upper jaw fistula,30580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Repair upper jaw fistula,30580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Repair upper jaw fistula,30580,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Repair upper jaw fistula,30580,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Repair upper jaw fistula,30580,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Repair upper jaw fistula,30580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Repair upper jaw fistula,30580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Repair upper jaw fistula,30580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Repair upper jaw fistula,30580,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Repair mouth/nose fistula,30600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Repair mouth/nose fistula,30600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Repair mouth/nose fistula,30600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Repair mouth/nose fistula,30600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Repair mouth/nose fistula,30600,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Repair mouth/nose fistula,30600,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Repair mouth/nose fistula,30600,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Repair mouth/nose fistula,30600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Repair mouth/nose fistula,30600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Repair mouth/nose fistula,30600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Repair mouth/nose fistula,30600,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Intranasal reconstruction,30620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Intranasal reconstruction,30620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Intranasal reconstruction,30620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Intranasal reconstruction,30620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Intranasal reconstruction,30620,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Intranasal reconstruction,30620,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Intranasal reconstruction,30620,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Intranasal reconstruction,30620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Intranasal reconstruction,30620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Intranasal reconstruction,30620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Intranasal reconstruction,30620,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Repair nasal septum defect,30630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3358.06,,,,,,,fee schedule,2691.78,14562,
Repair nasal septum defect,30630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2691.78,,,,,,,fee schedule,2691.78,14562,
Repair nasal septum defect,30630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2940.52,,,,,,,fee schedule,2691.78,14562,
Repair nasal septum defect,30630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3091.54,,,,,,,fee schedule,2691.78,14562,
Repair nasal septum defect,30630,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,2691.78,14562,APC 378
Repair nasal septum defect,30630,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,2691.78,14562,APC
Repair nasal septum defect,30630,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,2691.78,14562,APC
Repair nasal septum defect,30630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,2691.78,14562,APC
Repair nasal septum defect,30630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,2691.78,14562,Radiology
Repair nasal septum defect,30630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,2691.78,14562,APC
Repair nasal septum defect,30630,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,2691.78,14562,APC
Ablate inf turbinate superf,30801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5678.06,,,,,,,fee schedule,1536.02,6814.79,
Ablate inf turbinate superf,30801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4551.46,,,,,,,fee schedule,1536.02,6814.79,
Ablate inf turbinate superf,30801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4972.06,,,,,,,fee schedule,1536.02,6814.79,
Ablate inf turbinate superf,30801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5227.42,,,,,,,fee schedule,1536.02,6814.79,
Ablate inf turbinate superf,30801,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1536.02,6814.79,APC 378
Ablate inf turbinate superf,30801,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1536.02,6814.79,APC
Ablate inf turbinate superf,30801,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1536.02,6814.79,APC
Ablate inf turbinate superf,30801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1536.02,6814.79,APC
Ablate inf turbinate superf,30801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1536.02,6814.79,Radiology
Ablate inf turbinate superf,30801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1536.02,6814.79,APC
Ablate inf turbinate superf,30801,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1536.02,6814.79,APC
Ablate inf turbinate submuc,30802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4110.6,,,,,,,fee schedule,1536.02,6814.79,
Ablate inf turbinate submuc,30802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3295,,,,,,,fee schedule,1536.02,6814.79,
Ablate inf turbinate submuc,30802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3599.49,,,,,,,fee schedule,1536.02,6814.79,
Ablate inf turbinate submuc,30802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3784.36,,,,,,,fee schedule,1536.02,6814.79,
Ablate inf turbinate submuc,30802,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1536.02,6814.79,APC 378
Ablate inf turbinate submuc,30802,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1536.02,6814.79,APC
Ablate inf turbinate submuc,30802,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1536.02,6814.79,APC
Ablate inf turbinate submuc,30802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1536.02,6814.79,APC
Ablate inf turbinate submuc,30802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1536.02,6814.79,Radiology
Ablate inf turbinate submuc,30802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1536.02,6814.79,APC
Ablate inf turbinate submuc,30802,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1536.02,6814.79,APC
Control of nosebleed,30901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,231.89,,,,,,,fee schedule,131.71,584.37,
Control of nosebleed,30901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,185.88,,,,,,,fee schedule,131.71,584.37,
Control of nosebleed,30901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,203.06,,,,,,,fee schedule,131.71,584.37,
Control of nosebleed,30901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,213.49,,,,,,,fee schedule,131.71,584.37,
Control of nosebleed,30901,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,131.71,584.37,APC 378
Control of nosebleed,30901,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,131.71,584.37,APC
Control of nosebleed,30901,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,131.71,584.37,APC
Control of nosebleed,30901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,131.71,584.37,APC
Control of nosebleed,30901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,131.71,584.37,Radiology
Control of nosebleed,30901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,131.71,584.37,APC
Control of nosebleed,30901,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,131.71,584.37,APC
Control of nosebleed,30903,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,279.57,,,,,,,fee schedule,131.71,584.37,
Control of nosebleed,30903,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,224.1,,,,,,,fee schedule,131.71,584.37,
Control of nosebleed,30903,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,244.81,,,,,,,fee schedule,131.71,584.37,
Control of nosebleed,30903,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,257.38,,,,,,,fee schedule,131.71,584.37,
Control of nosebleed,30903,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,131.71,584.37,APC 378
Control of nosebleed,30903,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,131.71,584.37,APC
Control of nosebleed,30903,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,131.71,584.37,APC
Control of nosebleed,30903,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,131.71,584.37,APC
Control of nosebleed,30903,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,131.71,584.37,Radiology
Control of nosebleed,30903,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,131.71,584.37,APC
Control of nosebleed,30903,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,131.71,584.37,APC
Control of nosebleed,30905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,366.26,,,,,,,fee schedule,131.71,584.37,
Control of nosebleed,30905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,293.59,,,,,,,fee schedule,131.71,584.37,
Control of nosebleed,30905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,320.72,,,,,,,fee schedule,131.71,584.37,
Control of nosebleed,30905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,337.19,,,,,,,fee schedule,131.71,584.37,
Control of nosebleed,30905,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,131.71,584.37,APC 378
Control of nosebleed,30905,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,131.71,584.37,APC
Control of nosebleed,30905,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,131.71,584.37,APC
Control of nosebleed,30905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,131.71,584.37,APC
Control of nosebleed,30905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,131.71,584.37,Radiology
Control of nosebleed,30905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,131.71,584.37,APC
Control of nosebleed,30905,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,131.71,584.37,APC
Repeat control of nosebleed,30906,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,280.78,,,,,,,fee schedule,225.07,1040.28,
Repeat control of nosebleed,30906,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,225.07,,,,,,,fee schedule,225.07,1040.28,
Repeat control of nosebleed,30906,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,245.87,,,,,,,fee schedule,225.07,1040.28,
Repeat control of nosebleed,30906,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,258.49,,,,,,,fee schedule,225.07,1040.28,
Repeat control of nosebleed,30906,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1040.28,,,,,,,fee schedule,225.07,1040.28,APC 378
Repeat control of nosebleed,30906,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,246.2,,,,,,,fee schedule,225.07,1040.28,APC
Repeat control of nosebleed,30906,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,243.85,,,,,,,fee schedule,225.07,1040.28,APC
Repeat control of nosebleed,30906,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,234.47,,,,,,,fee schedule,225.07,1040.28,APC
Repeat control of nosebleed,30906,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,358.74,,,,,,,fee schedule,225.07,1040.28,Radiology
Repeat control of nosebleed,30906,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,328.26,,,,,,,fee schedule,225.07,1040.28,APC
Repeat control of nosebleed,30906,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,410.33,,,,,,,fee schedule,225.07,1040.28,APC
Ligation nasal sinus artery,30915,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6449.28,,,,,,,fee schedule,3125.8,13868.13,
Ligation nasal sinus artery,30915,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5169.66,,,,,,,fee schedule,3125.8,13868.13,
Ligation nasal sinus artery,30915,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5647.39,,,,,,,fee schedule,3125.8,13868.13,
Ligation nasal sinus artery,30915,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5937.44,,,,,,,fee schedule,3125.8,13868.13,
Ligation nasal sinus artery,30915,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Ligation nasal sinus artery,30915,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Ligation nasal sinus artery,30915,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Ligation nasal sinus artery,30915,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Ligation nasal sinus artery,30915,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Ligation nasal sinus artery,30915,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Ligation nasal sinus artery,30915,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Ligation upper jaw artery,30920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6449.28,,,,,,,fee schedule,3125.8,13868.13,
Ligation upper jaw artery,30920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5169.66,,,,,,,fee schedule,3125.8,13868.13,
Ligation upper jaw artery,30920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5647.39,,,,,,,fee schedule,3125.8,13868.13,
Ligation upper jaw artery,30920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5937.44,,,,,,,fee schedule,3125.8,13868.13,
Ligation upper jaw artery,30920,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Ligation upper jaw artery,30920,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Ligation upper jaw artery,30920,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Ligation upper jaw artery,30920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Ligation upper jaw artery,30920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Ligation upper jaw artery,30920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Ligation upper jaw artery,30920,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Ther fx nasal inf turbinate,30930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4962.24,,,,,,,fee schedule,3282.2,14562,
Ther fx nasal inf turbinate,30930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3977.67,,,,,,,fee schedule,3282.2,14562,
Ther fx nasal inf turbinate,30930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4345.24,,,,,,,fee schedule,3282.2,14562,
Ther fx nasal inf turbinate,30930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4568.41,,,,,,,fee schedule,3282.2,14562,
Ther fx nasal inf turbinate,30930,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Ther fx nasal inf turbinate,30930,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Ther fx nasal inf turbinate,30930,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Ther fx nasal inf turbinate,30930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Ther fx nasal inf turbinate,30930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Ther fx nasal inf turbinate,30930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Ther fx nasal inf turbinate,30930,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Nasal surgery procedure,30999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3019.45,,,,,,,fee schedule,234.47,3019.45,
Nasal surgery procedure,30999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2420.35,,,,,,,fee schedule,234.47,3019.45,
Nasal surgery procedure,30999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2644.02,,,,,,,fee schedule,234.47,3019.45,
Nasal surgery procedure,30999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2779.81,,,,,,,fee schedule,234.47,3019.45,
Nasal surgery procedure,30999,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1040.28,,,,,,,fee schedule,234.47,3019.45,APC 378
Nasal surgery procedure,30999,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,246.2,,,,,,,fee schedule,234.47,3019.45,APC
Nasal surgery procedure,30999,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,243.85,,,,,,,fee schedule,234.47,3019.45,APC
Nasal surgery procedure,30999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,234.47,,,,,,,fee schedule,234.47,3019.45,APC
Nasal surgery procedure,30999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,358.74,,,,,,,fee schedule,234.47,3019.45,Radiology
Nasal surgery procedure,30999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,328.26,,,,,,,fee schedule,234.47,3019.45,APC
Nasal surgery procedure,30999,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,410.33,,,,,,,fee schedule,234.47,3019.45,APC
Irrigation maxillary sinus,31000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,624,,,,,,,fee schedule,234.47,1040.28,
Irrigation maxillary sinus,31000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,500.19,,,,,,,fee schedule,234.47,1040.28,
Irrigation maxillary sinus,31000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,546.41,,,,,,,fee schedule,234.47,1040.28,
Irrigation maxillary sinus,31000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,574.48,,,,,,,fee schedule,234.47,1040.28,
Irrigation maxillary sinus,31000,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1040.28,,,,,,,fee schedule,234.47,1040.28,APC 378
Irrigation maxillary sinus,31000,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,246.2,,,,,,,fee schedule,234.47,1040.28,APC
Irrigation maxillary sinus,31000,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,243.85,,,,,,,fee schedule,234.47,1040.28,APC
Irrigation maxillary sinus,31000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,234.47,,,,,,,fee schedule,234.47,1040.28,APC
Irrigation maxillary sinus,31000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,358.74,,,,,,,fee schedule,234.47,1040.28,Radiology
Irrigation maxillary sinus,31000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,328.26,,,,,,,fee schedule,234.47,1040.28,APC
Irrigation maxillary sinus,31000,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,410.33,,,,,,,fee schedule,234.47,1040.28,APC
Irrigation sphenoid sinus,31002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1858.66,,,,,,,fee schedule,1489.88,6814.79,
Irrigation sphenoid sinus,31002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1489.88,,,,,,,fee schedule,1489.88,6814.79,
Irrigation sphenoid sinus,31002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1627.56,,,,,,,fee schedule,1489.88,6814.79,
Irrigation sphenoid sinus,31002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1711.15,,,,,,,fee schedule,1489.88,6814.79,
Irrigation sphenoid sinus,31002,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1489.88,6814.79,APC 378
Irrigation sphenoid sinus,31002,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1489.88,6814.79,APC
Irrigation sphenoid sinus,31002,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1489.88,6814.79,APC
Irrigation sphenoid sinus,31002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1489.88,6814.79,APC
Irrigation sphenoid sinus,31002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1489.88,6814.79,Radiology
Irrigation sphenoid sinus,31002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1489.88,6814.79,APC
Irrigation sphenoid sinus,31002,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1489.88,6814.79,APC
Exploration maxillary sinus,31020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5983.93,,,,,,,fee schedule,3282.2,14562,
Exploration maxillary sinus,31020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4796.64,,,,,,,fee schedule,3282.2,14562,
Exploration maxillary sinus,31020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5239.9,,,,,,,fee schedule,3282.2,14562,
Exploration maxillary sinus,31020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.01,,,,,,,fee schedule,3282.2,14562,
Exploration maxillary sinus,31020,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Exploration maxillary sinus,31020,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Exploration maxillary sinus,31020,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Exploration maxillary sinus,31020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Exploration maxillary sinus,31020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Exploration maxillary sinus,31020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Exploration maxillary sinus,31020,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Exploration maxillary sinus,31030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Exploration maxillary sinus,31030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Exploration maxillary sinus,31030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Exploration maxillary sinus,31030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Exploration maxillary sinus,31030,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Exploration maxillary sinus,31030,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Exploration maxillary sinus,31030,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Exploration maxillary sinus,31030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Exploration maxillary sinus,31030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Exploration maxillary sinus,31030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Exploration maxillary sinus,31030,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Explore sinus remove polyps,31032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Explore sinus remove polyps,31032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Explore sinus remove polyps,31032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Explore sinus remove polyps,31032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Explore sinus remove polyps,31032,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Explore sinus remove polyps,31032,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Explore sinus remove polyps,31032,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Explore sinus remove polyps,31032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Explore sinus remove polyps,31032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Explore sinus remove polyps,31032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Explore sinus remove polyps,31032,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Exploration behind upper jaw,31040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5983.93,,,,,,,fee schedule,4796.64,26000.79,
Exploration behind upper jaw,31040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4796.64,,,,,,,fee schedule,4796.64,26000.79,
Exploration behind upper jaw,31040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5239.9,,,,,,,fee schedule,4796.64,26000.79,
Exploration behind upper jaw,31040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.01,,,,,,,fee schedule,4796.64,26000.79,
Exploration behind upper jaw,31040,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,4796.64,26000.79,APC 378
Exploration behind upper jaw,31040,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,4796.64,26000.79,APC
Exploration behind upper jaw,31040,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,4796.64,26000.79,APC
Exploration behind upper jaw,31040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,4796.64,26000.79,APC
Exploration behind upper jaw,31040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,4796.64,26000.79,Radiology
Exploration behind upper jaw,31040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,4796.64,26000.79,APC
Exploration behind upper jaw,31040,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,4796.64,26000.79,APC
Exploration sphenoid sinus,31050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Exploration sphenoid sinus,31050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Exploration sphenoid sinus,31050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Exploration sphenoid sinus,31050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Exploration sphenoid sinus,31050,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Exploration sphenoid sinus,31050,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Exploration sphenoid sinus,31050,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Exploration sphenoid sinus,31050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Exploration sphenoid sinus,31050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Exploration sphenoid sinus,31050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Exploration sphenoid sinus,31050,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Sphenoid sinus surgery,31051,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Sphenoid sinus surgery,31051,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Sphenoid sinus surgery,31051,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Sphenoid sinus surgery,31051,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Sphenoid sinus surgery,31051,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Sphenoid sinus surgery,31051,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Sphenoid sinus surgery,31051,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Sphenoid sinus surgery,31051,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Sphenoid sinus surgery,31051,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Sphenoid sinus surgery,31051,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Sphenoid sinus surgery,31051,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Exploration of frontal sinus,31070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5983.93,,,,,,,fee schedule,4796.64,26000.79,
Exploration of frontal sinus,31070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4796.64,,,,,,,fee schedule,4796.64,26000.79,
Exploration of frontal sinus,31070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5239.9,,,,,,,fee schedule,4796.64,26000.79,
Exploration of frontal sinus,31070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.01,,,,,,,fee schedule,4796.64,26000.79,
Exploration of frontal sinus,31070,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,4796.64,26000.79,APC 378
Exploration of frontal sinus,31070,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,4796.64,26000.79,APC
Exploration of frontal sinus,31070,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,4796.64,26000.79,APC
Exploration of frontal sinus,31070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,4796.64,26000.79,APC
Exploration of frontal sinus,31070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,4796.64,26000.79,Radiology
Exploration of frontal sinus,31070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,4796.64,26000.79,APC
Exploration of frontal sinus,31070,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,4796.64,26000.79,APC
Exploration of frontal sinus,31075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Exploration of frontal sinus,31075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Exploration of frontal sinus,31075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Exploration of frontal sinus,31075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Exploration of frontal sinus,31075,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Exploration of frontal sinus,31075,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Exploration of frontal sinus,31075,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Exploration of frontal sinus,31075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Exploration of frontal sinus,31075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Exploration of frontal sinus,31075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Exploration of frontal sinus,31075,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of frontal sinus,31080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Removal of frontal sinus,31080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Removal of frontal sinus,31080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Removal of frontal sinus,31080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Removal of frontal sinus,31080,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Removal of frontal sinus,31080,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of frontal sinus,31080,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of frontal sinus,31080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of frontal sinus,31080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Removal of frontal sinus,31080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of frontal sinus,31080,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of frontal sinus,31081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Removal of frontal sinus,31081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Removal of frontal sinus,31081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Removal of frontal sinus,31081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Removal of frontal sinus,31081,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Removal of frontal sinus,31081,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of frontal sinus,31081,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of frontal sinus,31081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of frontal sinus,31081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Removal of frontal sinus,31081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of frontal sinus,31081,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of frontal sinus,31084,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Removal of frontal sinus,31084,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Removal of frontal sinus,31084,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Removal of frontal sinus,31084,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Removal of frontal sinus,31084,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Removal of frontal sinus,31084,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of frontal sinus,31084,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of frontal sinus,31084,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of frontal sinus,31084,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Removal of frontal sinus,31084,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of frontal sinus,31084,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of frontal sinus,31085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Removal of frontal sinus,31085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Removal of frontal sinus,31085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Removal of frontal sinus,31085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Removal of frontal sinus,31085,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Removal of frontal sinus,31085,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of frontal sinus,31085,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of frontal sinus,31085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of frontal sinus,31085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Removal of frontal sinus,31085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of frontal sinus,31085,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of frontal sinus,31086,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Removal of frontal sinus,31086,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Removal of frontal sinus,31086,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Removal of frontal sinus,31086,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Removal of frontal sinus,31086,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Removal of frontal sinus,31086,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of frontal sinus,31086,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of frontal sinus,31086,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of frontal sinus,31086,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Removal of frontal sinus,31086,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of frontal sinus,31086,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of frontal sinus,31087,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Removal of frontal sinus,31087,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Removal of frontal sinus,31087,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Removal of frontal sinus,31087,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Removal of frontal sinus,31087,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Removal of frontal sinus,31087,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of frontal sinus,31087,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of frontal sinus,31087,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of frontal sinus,31087,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Removal of frontal sinus,31087,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of frontal sinus,31087,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Exploration of sinuses,31090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Exploration of sinuses,31090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Exploration of sinuses,31090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Exploration of sinuses,31090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Exploration of sinuses,31090,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Exploration of sinuses,31090,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Exploration of sinuses,31090,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Exploration of sinuses,31090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Exploration of sinuses,31090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Exploration of sinuses,31090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Exploration of sinuses,31090,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of ethmoid sinus,31200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Removal of ethmoid sinus,31200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Removal of ethmoid sinus,31200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Removal of ethmoid sinus,31200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Removal of ethmoid sinus,31200,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Removal of ethmoid sinus,31200,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of ethmoid sinus,31200,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of ethmoid sinus,31200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of ethmoid sinus,31200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Removal of ethmoid sinus,31200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of ethmoid sinus,31200,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of ethmoid sinus,31201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,1536.02,9952.44,
Removal of ethmoid sinus,31201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,1536.02,9952.44,
Removal of ethmoid sinus,31201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,1536.02,9952.44,
Removal of ethmoid sinus,31201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,1536.02,9952.44,
Removal of ethmoid sinus,31201,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1536.02,9952.44,APC 378
Removal of ethmoid sinus,31201,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1536.02,9952.44,APC
Removal of ethmoid sinus,31201,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1536.02,9952.44,APC
Removal of ethmoid sinus,31201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1536.02,9952.44,APC
Removal of ethmoid sinus,31201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1536.02,9952.44,Radiology
Removal of ethmoid sinus,31201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1536.02,9952.44,APC
Removal of ethmoid sinus,31201,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1536.02,9952.44,APC
Removal of ethmoid sinus,31205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,3282.2,14562,
Removal of ethmoid sinus,31205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,3282.2,14562,
Removal of ethmoid sinus,31205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,3282.2,14562,
Removal of ethmoid sinus,31205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,3282.2,14562,
Removal of ethmoid sinus,31205,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Removal of ethmoid sinus,31205,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Removal of ethmoid sinus,31205,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Removal of ethmoid sinus,31205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Removal of ethmoid sinus,31205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Removal of ethmoid sinus,31205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Removal of ethmoid sinus,31205,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Nasal endoscopy dx,31231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2888.59,,,,,,,fee schedule,197.6,2888.59,
Nasal endoscopy dx,31231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2315.45,,,,,,,fee schedule,197.6,2888.59,
Nasal endoscopy dx,31231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2529.42,,,,,,,fee schedule,197.6,2888.59,
Nasal endoscopy dx,31231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2659.33,,,,,,,fee schedule,197.6,2888.59,
Nasal endoscopy dx,31231,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,876.7,,,,,,,fee schedule,197.6,2888.59,APC 378
Nasal endoscopy dx,31231,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,207.48,,,,,,,fee schedule,197.6,2888.59,APC
Nasal endoscopy dx,31231,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,205.51,,,,,,,fee schedule,197.6,2888.59,APC
Nasal endoscopy dx,31231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,197.6,,,,,,,fee schedule,197.6,2888.59,APC
Nasal endoscopy dx,31231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,302.33,,,,,,,fee schedule,197.6,2888.59,Radiology
Nasal endoscopy dx,31231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,276.65,,,,,,,fee schedule,197.6,2888.59,APC
Nasal endoscopy dx,31231,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,345.81,,,,,,,fee schedule,197.6,2888.59,APC
Nasal/sinus endoscopy dx,31233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,402.19,,,,,,,fee schedule,322.39,1717.85,
Nasal/sinus endoscopy dx,31233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,322.39,,,,,,,fee schedule,322.39,1717.85,
Nasal/sinus endoscopy dx,31233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,352.18,,,,,,,fee schedule,322.39,1717.85,
Nasal/sinus endoscopy dx,31233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,370.27,,,,,,,fee schedule,322.39,1717.85,
Nasal/sinus endoscopy dx,31233,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1717.85,,,,,,,fee schedule,322.39,1717.85,APC 378
Nasal/sinus endoscopy dx,31233,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,406.55,,,,,,,fee schedule,322.39,1717.85,APC
Nasal/sinus endoscopy dx,31233,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,402.68,,,,,,,fee schedule,322.39,1717.85,APC
Nasal/sinus endoscopy dx,31233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,387.19,,,,,,,fee schedule,322.39,1717.85,APC
Nasal/sinus endoscopy dx,31233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,592.41,,,,,,,fee schedule,322.39,1717.85,Radiology
Nasal/sinus endoscopy dx,31233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,542.07,,,,,,,fee schedule,322.39,1717.85,APC
Nasal/sinus endoscopy dx,31233,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,677.59,,,,,,,fee schedule,322.39,1717.85,APC
Nasal/sinus endoscopy dx,31235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4246.79,,,,,,,fee schedule,1762.04,7817.58,
Nasal/sinus endoscopy dx,31235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3404.17,,,,,,,fee schedule,1762.04,7817.58,
Nasal/sinus endoscopy dx,31235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3718.75,,,,,,,fee schedule,1762.04,7817.58,
Nasal/sinus endoscopy dx,31235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3909.75,,,,,,,fee schedule,1762.04,7817.58,
Nasal/sinus endoscopy dx,31235,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7817.58,,,,,,,fee schedule,1762.04,7817.58,APC 378
Nasal/sinus endoscopy dx,31235,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1850.14,,,,,,,fee schedule,1762.04,7817.58,APC
Nasal/sinus endoscopy dx,31235,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1832.52,,,,,,,fee schedule,1762.04,7817.58,APC
Nasal/sinus endoscopy dx,31235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1762.04,,,,,,,fee schedule,1762.04,7817.58,APC
Nasal/sinus endoscopy dx,31235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2695.92,,,,,,,fee schedule,1762.04,7817.58,Radiology
Nasal/sinus endoscopy dx,31235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2466.86,,,,,,,fee schedule,1762.04,7817.58,APC
Nasal/sinus endoscopy dx,31235,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3083.57,,,,,,,fee schedule,1762.04,7817.58,APC
Nasal/sinus endoscopy surg,31237,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3293.36,,,,,,,fee schedule,1762.04,7817.58,
Nasal/sinus endoscopy surg,31237,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2639.91,,,,,,,fee schedule,1762.04,7817.58,
Nasal/sinus endoscopy surg,31237,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2883.87,,,,,,,fee schedule,1762.04,7817.58,
Nasal/sinus endoscopy surg,31237,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3031.98,,,,,,,fee schedule,1762.04,7817.58,
Nasal/sinus endoscopy surg,31237,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7817.58,,,,,,,fee schedule,1762.04,7817.58,APC 378
Nasal/sinus endoscopy surg,31237,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1850.14,,,,,,,fee schedule,1762.04,7817.58,APC
Nasal/sinus endoscopy surg,31237,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1832.52,,,,,,,fee schedule,1762.04,7817.58,APC
Nasal/sinus endoscopy surg,31237,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1762.04,,,,,,,fee schedule,1762.04,7817.58,APC
Nasal/sinus endoscopy surg,31237,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2695.92,,,,,,,fee schedule,1762.04,7817.58,Radiology
Nasal/sinus endoscopy surg,31237,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2466.86,,,,,,,fee schedule,1762.04,7817.58,APC
Nasal/sinus endoscopy surg,31237,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3083.57,,,,,,,fee schedule,1762.04,7817.58,APC
Nasal/sinus endoscopy surg,31238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9737.23,,,,,,,fee schedule,1762.04,9737.23,
Nasal/sinus endoscopy surg,31238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7805.24,,,,,,,fee schedule,1762.04,9737.23,
Nasal/sinus endoscopy surg,31238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8526.52,,,,,,,fee schedule,1762.04,9737.23,
Nasal/sinus endoscopy surg,31238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8964.43,,,,,,,fee schedule,1762.04,9737.23,
Nasal/sinus endoscopy surg,31238,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7817.58,,,,,,,fee schedule,1762.04,9737.23,APC 378
Nasal/sinus endoscopy surg,31238,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1850.14,,,,,,,fee schedule,1762.04,9737.23,APC
Nasal/sinus endoscopy surg,31238,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1832.52,,,,,,,fee schedule,1762.04,9737.23,APC
Nasal/sinus endoscopy surg,31238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1762.04,,,,,,,fee schedule,1762.04,9737.23,APC
Nasal/sinus endoscopy surg,31238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2695.92,,,,,,,fee schedule,1762.04,9737.23,Radiology
Nasal/sinus endoscopy surg,31238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2466.86,,,,,,,fee schedule,1762.04,9737.23,APC
Nasal/sinus endoscopy surg,31238,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3083.57,,,,,,,fee schedule,1762.04,9737.23,APC
Nasal/sinus endoscopy surg,31239,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5670.11,,,,,,,fee schedule,3690.94,16375.46,
Nasal/sinus endoscopy surg,31239,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4545.09,,,,,,,fee schedule,3690.94,16375.46,
Nasal/sinus endoscopy surg,31239,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4965.1,,,,,,,fee schedule,3690.94,16375.46,
Nasal/sinus endoscopy surg,31239,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5220.1,,,,,,,fee schedule,3690.94,16375.46,
Nasal/sinus endoscopy surg,31239,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16375.46,,,,,,,fee schedule,3690.94,16375.46,APC 378
Nasal/sinus endoscopy surg,31239,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3875.49,,,,,,,fee schedule,3690.94,16375.46,APC
Nasal/sinus endoscopy surg,31239,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3838.58,,,,,,,fee schedule,3690.94,16375.46,APC
Nasal/sinus endoscopy surg,31239,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3690.94,,,,,,,fee schedule,3690.94,16375.46,APC
Nasal/sinus endoscopy surg,31239,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5647.14,,,,,,,fee schedule,3690.94,16375.46,Radiology
Nasal/sinus endoscopy surg,31239,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5167.32,,,,,,,fee schedule,3690.94,16375.46,APC
Nasal/sinus endoscopy surg,31239,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6459.15,,,,,,,fee schedule,3690.94,16375.46,APC
Nasal/sinus endoscopy surg,31240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3275.84,,,,,,,fee schedule,1762.04,7817.58,
Nasal/sinus endoscopy surg,31240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2625.87,,,,,,,fee schedule,1762.04,7817.58,
Nasal/sinus endoscopy surg,31240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2868.53,,,,,,,fee schedule,1762.04,7817.58,
Nasal/sinus endoscopy surg,31240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3015.85,,,,,,,fee schedule,1762.04,7817.58,
Nasal/sinus endoscopy surg,31240,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7817.58,,,,,,,fee schedule,1762.04,7817.58,APC 378
Nasal/sinus endoscopy surg,31240,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1850.14,,,,,,,fee schedule,1762.04,7817.58,APC
Nasal/sinus endoscopy surg,31240,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1832.52,,,,,,,fee schedule,1762.04,7817.58,APC
Nasal/sinus endoscopy surg,31240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1762.04,,,,,,,fee schedule,1762.04,7817.58,APC
Nasal/sinus endoscopy surg,31240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2695.92,,,,,,,fee schedule,1762.04,7817.58,Radiology
Nasal/sinus endoscopy surg,31240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2466.86,,,,,,,fee schedule,1762.04,7817.58,APC
Nasal/sinus endoscopy surg,31240,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3083.57,,,,,,,fee schedule,1762.04,7817.58,APC
Nsl/sins ndsc w/artery lig,31241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5175.92,,,,,,,fee schedule,1762.04,7817.58,
Nsl/sins ndsc w/artery lig,31241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4148.95,,,,,,,fee schedule,1762.04,7817.58,
Nsl/sins ndsc w/artery lig,31241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4532.35,,,,,,,fee schedule,1762.04,7817.58,
Nsl/sins ndsc w/artery lig,31241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4765.13,,,,,,,fee schedule,1762.04,7817.58,
Nsl/sins ndsc w/artery lig,31241,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7817.58,,,,,,,fee schedule,1762.04,7817.58,APC 378
Nsl/sins ndsc w/artery lig,31241,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1850.14,,,,,,,fee schedule,1762.04,7817.58,APC
Nsl/sins ndsc w/artery lig,31241,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1832.52,,,,,,,fee schedule,1762.04,7817.58,APC
Nsl/sins ndsc w/artery lig,31241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1762.04,,,,,,,fee schedule,1762.04,7817.58,APC
Nsl/sins ndsc w/artery lig,31241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2695.92,,,,,,,fee schedule,1762.04,7817.58,Radiology
Nsl/sins ndsc w/artery lig,31241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2466.86,,,,,,,fee schedule,1762.04,7817.58,APC
Nsl/sins ndsc w/artery lig,31241,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3083.57,,,,,,,fee schedule,1762.04,7817.58,APC
Nsl/sinus ndsc rf abltj pnn,31242,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21113.23,,,,,,,fee schedule,5860.44,26000.79,
Nsl/sinus ndsc rf abltj pnn,31242,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16924.1,,,,,,,fee schedule,5860.44,26000.79,
Nsl/sinus ndsc rf abltj pnn,31242,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18488.04,,,,,,,fee schedule,5860.44,26000.79,
Nsl/sinus ndsc rf abltj pnn,31242,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19437.57,,,,,,,fee schedule,5860.44,26000.79,
Nsl/sinus ndsc rf abltj pnn,31242,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Nsl/sinus ndsc rf abltj pnn,31242,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Nsl/sinus ndsc rf abltj pnn,31242,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Nsl/sinus ndsc rf abltj pnn,31242,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Nsl/sinus ndsc rf abltj pnn,31242,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Nsl/sinus ndsc rf abltj pnn,31242,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Nsl/sinus ndsc rf abltj pnn,31242,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Nsl/sinus ndsc cryoabltj pnn,31243,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21113.23,,,,,,,fee schedule,5860.44,26000.79,
Nsl/sinus ndsc cryoabltj pnn,31243,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16924.1,,,,,,,fee schedule,5860.44,26000.79,
Nsl/sinus ndsc cryoabltj pnn,31243,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18488.04,,,,,,,fee schedule,5860.44,26000.79,
Nsl/sinus ndsc cryoabltj pnn,31243,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19437.57,,,,,,,fee schedule,5860.44,26000.79,
Nsl/sinus ndsc cryoabltj pnn,31243,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Nsl/sinus ndsc cryoabltj pnn,31243,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Nsl/sinus ndsc cryoabltj pnn,31243,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Nsl/sinus ndsc cryoabltj pnn,31243,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Nsl/sinus ndsc cryoabltj pnn,31243,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Nsl/sinus ndsc cryoabltj pnn,31243,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Nsl/sinus ndsc cryoabltj pnn,31243,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Nsl/sins ndsc total,31253,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19457.81,,,,,,,fee schedule,6986.66,30997.43,
Nsl/sins ndsc total,31253,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15597.14,,,,,,,fee schedule,6986.66,30997.43,
Nsl/sins ndsc total,31253,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17038.46,,,,,,,fee schedule,6986.66,30997.43,
Nsl/sins ndsc total,31253,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17913.54,,,,,,,fee schedule,6986.66,30997.43,
Nsl/sins ndsc total,31253,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,30997.43,,,,,,,fee schedule,6986.66,30997.43,APC 378
Nsl/sins ndsc total,31253,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7335.99,,,,,,,fee schedule,6986.66,30997.43,APC
Nsl/sins ndsc total,31253,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7266.12,,,,,,,fee schedule,6986.66,30997.43,APC
Nsl/sins ndsc total,31253,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6986.66,,,,,,,fee schedule,6986.66,30997.43,APC
Nsl/sins ndsc total,31253,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10689.58,,,,,,,fee schedule,6986.66,30997.43,Radiology
Nsl/sins ndsc total,31253,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9781.32,,,,,,,fee schedule,6986.66,30997.43,APC
Nsl/sins ndsc total,31253,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12226.65,,,,,,,fee schedule,6986.66,30997.43,APC
Revision of ethmoid sinus,31254,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3392.55,,,,,,,fee schedule,2719.43,30997.43,
Revision of ethmoid sinus,31254,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2719.43,,,,,,,fee schedule,2719.43,30997.43,
Revision of ethmoid sinus,31254,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2970.73,,,,,,,fee schedule,2719.43,30997.43,
Revision of ethmoid sinus,31254,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3123.3,,,,,,,fee schedule,2719.43,30997.43,
Revision of ethmoid sinus,31254,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,30997.43,,,,,,,fee schedule,2719.43,30997.43,APC 378
Revision of ethmoid sinus,31254,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7335.99,,,,,,,fee schedule,2719.43,30997.43,APC
Revision of ethmoid sinus,31254,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7266.12,,,,,,,fee schedule,2719.43,30997.43,APC
Revision of ethmoid sinus,31254,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6986.66,,,,,,,fee schedule,2719.43,30997.43,APC
Revision of ethmoid sinus,31254,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10689.58,,,,,,,fee schedule,2719.43,30997.43,Radiology
Revision of ethmoid sinus,31254,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9781.32,,,,,,,fee schedule,2719.43,30997.43,APC
Revision of ethmoid sinus,31254,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12226.65,,,,,,,fee schedule,2719.43,30997.43,APC
Removal of ethmoid sinus,31255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2453.6,,,,,,,fee schedule,1966.77,30997.43,
Removal of ethmoid sinus,31255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1966.77,,,,,,,fee schedule,1966.77,30997.43,
Removal of ethmoid sinus,31255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2148.52,,,,,,,fee schedule,1966.77,30997.43,
Removal of ethmoid sinus,31255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2258.87,,,,,,,fee schedule,1966.77,30997.43,
Removal of ethmoid sinus,31255,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,30997.43,,,,,,,fee schedule,1966.77,30997.43,APC 378
Removal of ethmoid sinus,31255,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7335.99,,,,,,,fee schedule,1966.77,30997.43,APC
Removal of ethmoid sinus,31255,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7266.12,,,,,,,fee schedule,1966.77,30997.43,APC
Removal of ethmoid sinus,31255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6986.66,,,,,,,fee schedule,1966.77,30997.43,APC
Removal of ethmoid sinus,31255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10689.58,,,,,,,fee schedule,1966.77,30997.43,Radiology
Removal of ethmoid sinus,31255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9781.32,,,,,,,fee schedule,1966.77,30997.43,APC
Removal of ethmoid sinus,31255,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12226.65,,,,,,,fee schedule,1966.77,30997.43,APC
Exploration maxillary sinus,31256,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2930.87,,,,,,,fee schedule,2349.35,16375.46,
Exploration maxillary sinus,31256,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2349.35,,,,,,,fee schedule,2349.35,16375.46,
Exploration maxillary sinus,31256,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2566.45,,,,,,,fee schedule,2349.35,16375.46,
Exploration maxillary sinus,31256,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2698.26,,,,,,,fee schedule,2349.35,16375.46,
Exploration maxillary sinus,31256,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16375.46,,,,,,,fee schedule,2349.35,16375.46,APC 378
Exploration maxillary sinus,31256,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3875.49,,,,,,,fee schedule,2349.35,16375.46,APC
Exploration maxillary sinus,31256,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3838.58,,,,,,,fee schedule,2349.35,16375.46,APC
Exploration maxillary sinus,31256,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3690.94,,,,,,,fee schedule,2349.35,16375.46,APC
Exploration maxillary sinus,31256,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5647.14,,,,,,,fee schedule,2349.35,16375.46,Radiology
Exploration maxillary sinus,31256,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5167.32,,,,,,,fee schedule,2349.35,16375.46,APC
Exploration maxillary sinus,31256,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6459.15,,,,,,,fee schedule,2349.35,16375.46,APC
Nsl/sins ndsc tot w/sphendt,31257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19457.81,,,,,,,fee schedule,6986.66,30997.43,
Nsl/sins ndsc tot w/sphendt,31257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15597.14,,,,,,,fee schedule,6986.66,30997.43,
Nsl/sins ndsc tot w/sphendt,31257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17038.46,,,,,,,fee schedule,6986.66,30997.43,
Nsl/sins ndsc tot w/sphendt,31257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17913.54,,,,,,,fee schedule,6986.66,30997.43,
Nsl/sins ndsc tot w/sphendt,31257,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,30997.43,,,,,,,fee schedule,6986.66,30997.43,APC 378
Nsl/sins ndsc tot w/sphendt,31257,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7335.99,,,,,,,fee schedule,6986.66,30997.43,APC
Nsl/sins ndsc tot w/sphendt,31257,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7266.12,,,,,,,fee schedule,6986.66,30997.43,APC
Nsl/sins ndsc tot w/sphendt,31257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6986.66,,,,,,,fee schedule,6986.66,30997.43,APC
Nsl/sins ndsc tot w/sphendt,31257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10689.58,,,,,,,fee schedule,6986.66,30997.43,Radiology
Nsl/sins ndsc tot w/sphendt,31257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9781.32,,,,,,,fee schedule,6986.66,30997.43,APC
Nsl/sins ndsc tot w/sphendt,31257,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12226.65,,,,,,,fee schedule,6986.66,30997.43,APC
Nsl/sins ndsc sphn tiss rmvl,31259,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19457.81,,,,,,,fee schedule,6986.66,30997.43,
Nsl/sins ndsc sphn tiss rmvl,31259,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15597.14,,,,,,,fee schedule,6986.66,30997.43,
Nsl/sins ndsc sphn tiss rmvl,31259,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17038.46,,,,,,,fee schedule,6986.66,30997.43,
Nsl/sins ndsc sphn tiss rmvl,31259,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17913.54,,,,,,,fee schedule,6986.66,30997.43,
Nsl/sins ndsc sphn tiss rmvl,31259,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,30997.43,,,,,,,fee schedule,6986.66,30997.43,APC 378
Nsl/sins ndsc sphn tiss rmvl,31259,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7335.99,,,,,,,fee schedule,6986.66,30997.43,APC
Nsl/sins ndsc sphn tiss rmvl,31259,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7266.12,,,,,,,fee schedule,6986.66,30997.43,APC
Nsl/sins ndsc sphn tiss rmvl,31259,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6986.66,,,,,,,fee schedule,6986.66,30997.43,APC
Nsl/sins ndsc sphn tiss rmvl,31259,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10689.58,,,,,,,fee schedule,6986.66,30997.43,Radiology
Nsl/sins ndsc sphn tiss rmvl,31259,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9781.32,,,,,,,fee schedule,6986.66,30997.43,APC
Nsl/sins ndsc sphn tiss rmvl,31259,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12226.65,,,,,,,fee schedule,6986.66,30997.43,APC
Endoscopy maxillary sinus,31267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2658.52,,,,,,,fee schedule,2131.03,30997.43,
Endoscopy maxillary sinus,31267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2131.03,,,,,,,fee schedule,2131.03,30997.43,
Endoscopy maxillary sinus,31267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2327.96,,,,,,,fee schedule,2131.03,30997.43,
Endoscopy maxillary sinus,31267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2447.52,,,,,,,fee schedule,2131.03,30997.43,
Endoscopy maxillary sinus,31267,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,30997.43,,,,,,,fee schedule,2131.03,30997.43,APC 378
Endoscopy maxillary sinus,31267,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7335.99,,,,,,,fee schedule,2131.03,30997.43,APC
Endoscopy maxillary sinus,31267,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7266.12,,,,,,,fee schedule,2131.03,30997.43,APC
Endoscopy maxillary sinus,31267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6986.66,,,,,,,fee schedule,2131.03,30997.43,APC
Endoscopy maxillary sinus,31267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10689.58,,,,,,,fee schedule,2131.03,30997.43,Radiology
Endoscopy maxillary sinus,31267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9781.32,,,,,,,fee schedule,2131.03,30997.43,APC
Endoscopy maxillary sinus,31267,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12226.65,,,,,,,fee schedule,2131.03,30997.43,APC
Sinus endoscopy surgical,31276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2498.52,,,,,,,fee schedule,2002.78,30997.43,
Sinus endoscopy surgical,31276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2002.78,,,,,,,fee schedule,2002.78,30997.43,
Sinus endoscopy surgical,31276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2187.86,,,,,,,fee schedule,2002.78,30997.43,
Sinus endoscopy surgical,31276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2300.23,,,,,,,fee schedule,2002.78,30997.43,
Sinus endoscopy surgical,31276,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,30997.43,,,,,,,fee schedule,2002.78,30997.43,APC 378
Sinus endoscopy surgical,31276,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7335.99,,,,,,,fee schedule,2002.78,30997.43,APC
Sinus endoscopy surgical,31276,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7266.12,,,,,,,fee schedule,2002.78,30997.43,APC
Sinus endoscopy surgical,31276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6986.66,,,,,,,fee schedule,2002.78,30997.43,APC
Sinus endoscopy surgical,31276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10689.58,,,,,,,fee schedule,2002.78,30997.43,Radiology
Sinus endoscopy surgical,31276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9781.32,,,,,,,fee schedule,2002.78,30997.43,APC
Sinus endoscopy surgical,31276,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12226.65,,,,,,,fee schedule,2002.78,30997.43,APC
Nasal/sinus endoscopy surg,31287,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2444.73,,,,,,,fee schedule,1959.66,30997.43,
Nasal/sinus endoscopy surg,31287,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1959.66,,,,,,,fee schedule,1959.66,30997.43,
Nasal/sinus endoscopy surg,31287,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2140.75,,,,,,,fee schedule,1959.66,30997.43,
Nasal/sinus endoscopy surg,31287,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2250.7,,,,,,,fee schedule,1959.66,30997.43,
Nasal/sinus endoscopy surg,31287,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,30997.43,,,,,,,fee schedule,1959.66,30997.43,APC 378
Nasal/sinus endoscopy surg,31287,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7335.99,,,,,,,fee schedule,1959.66,30997.43,APC
Nasal/sinus endoscopy surg,31287,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7266.12,,,,,,,fee schedule,1959.66,30997.43,APC
Nasal/sinus endoscopy surg,31287,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6986.66,,,,,,,fee schedule,1959.66,30997.43,APC
Nasal/sinus endoscopy surg,31287,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10689.58,,,,,,,fee schedule,1959.66,30997.43,Radiology
Nasal/sinus endoscopy surg,31287,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9781.32,,,,,,,fee schedule,1959.66,30997.43,APC
Nasal/sinus endoscopy surg,31287,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12226.65,,,,,,,fee schedule,1959.66,30997.43,APC
Nasal/sinus endoscopy surg,31288,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2180.16,,,,,,,fee schedule,1747.59,30997.43,
Nasal/sinus endoscopy surg,31288,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1747.59,,,,,,,fee schedule,1747.59,30997.43,
Nasal/sinus endoscopy surg,31288,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1909.08,,,,,,,fee schedule,1747.59,30997.43,
Nasal/sinus endoscopy surg,31288,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2007.13,,,,,,,fee schedule,1747.59,30997.43,
Nasal/sinus endoscopy surg,31288,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,30997.43,,,,,,,fee schedule,1747.59,30997.43,APC 378
Nasal/sinus endoscopy surg,31288,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7335.99,,,,,,,fee schedule,1747.59,30997.43,APC
Nasal/sinus endoscopy surg,31288,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7266.12,,,,,,,fee schedule,1747.59,30997.43,APC
Nasal/sinus endoscopy surg,31288,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6986.66,,,,,,,fee schedule,1747.59,30997.43,APC
Nasal/sinus endoscopy surg,31288,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10689.58,,,,,,,fee schedule,1747.59,30997.43,Radiology
Nasal/sinus endoscopy surg,31288,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9781.32,,,,,,,fee schedule,1747.59,30997.43,APC
Nasal/sinus endoscopy surg,31288,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12226.65,,,,,,,fee schedule,1747.59,30997.43,APC
Nasal/sinus endoscopy surg,31292,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5670.11,,,,,,,fee schedule,4545.09,30997.43,
Nasal/sinus endoscopy surg,31292,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4545.09,,,,,,,fee schedule,4545.09,30997.43,
Nasal/sinus endoscopy surg,31292,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4965.1,,,,,,,fee schedule,4545.09,30997.43,
Nasal/sinus endoscopy surg,31292,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5220.1,,,,,,,fee schedule,4545.09,30997.43,
Nasal/sinus endoscopy surg,31292,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,30997.43,,,,,,,fee schedule,4545.09,30997.43,APC 378
Nasal/sinus endoscopy surg,31292,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7335.99,,,,,,,fee schedule,4545.09,30997.43,APC
Nasal/sinus endoscopy surg,31292,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7266.12,,,,,,,fee schedule,4545.09,30997.43,APC
Nasal/sinus endoscopy surg,31292,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6986.66,,,,,,,fee schedule,4545.09,30997.43,APC
Nasal/sinus endoscopy surg,31292,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10689.58,,,,,,,fee schedule,4545.09,30997.43,Radiology
Nasal/sinus endoscopy surg,31292,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9781.32,,,,,,,fee schedule,4545.09,30997.43,APC
Nasal/sinus endoscopy surg,31292,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12226.65,,,,,,,fee schedule,4545.09,30997.43,APC
Nasal/sinus endoscopy surg,31293,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5670.11,,,,,,,fee schedule,4545.09,30997.43,
Nasal/sinus endoscopy surg,31293,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4545.09,,,,,,,fee schedule,4545.09,30997.43,
Nasal/sinus endoscopy surg,31293,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4965.1,,,,,,,fee schedule,4545.09,30997.43,
Nasal/sinus endoscopy surg,31293,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5220.1,,,,,,,fee schedule,4545.09,30997.43,
Nasal/sinus endoscopy surg,31293,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,30997.43,,,,,,,fee schedule,4545.09,30997.43,APC 378
Nasal/sinus endoscopy surg,31293,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7335.99,,,,,,,fee schedule,4545.09,30997.43,APC
Nasal/sinus endoscopy surg,31293,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7266.12,,,,,,,fee schedule,4545.09,30997.43,APC
Nasal/sinus endoscopy surg,31293,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6986.66,,,,,,,fee schedule,4545.09,30997.43,APC
Nasal/sinus endoscopy surg,31293,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10689.58,,,,,,,fee schedule,4545.09,30997.43,Radiology
Nasal/sinus endoscopy surg,31293,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9781.32,,,,,,,fee schedule,4545.09,30997.43,APC
Nasal/sinus endoscopy surg,31293,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12226.65,,,,,,,fee schedule,4545.09,30997.43,APC
Nasal/sinus endoscopy surg,31294,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5670.11,,,,,,,fee schedule,4545.09,30997.43,
Nasal/sinus endoscopy surg,31294,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4545.09,,,,,,,fee schedule,4545.09,30997.43,
Nasal/sinus endoscopy surg,31294,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4965.1,,,,,,,fee schedule,4545.09,30997.43,
Nasal/sinus endoscopy surg,31294,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5220.1,,,,,,,fee schedule,4545.09,30997.43,
Nasal/sinus endoscopy surg,31294,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,30997.43,,,,,,,fee schedule,4545.09,30997.43,APC 378
Nasal/sinus endoscopy surg,31294,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7335.99,,,,,,,fee schedule,4545.09,30997.43,APC
Nasal/sinus endoscopy surg,31294,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7266.12,,,,,,,fee schedule,4545.09,30997.43,APC
Nasal/sinus endoscopy surg,31294,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6986.66,,,,,,,fee schedule,4545.09,30997.43,APC
Nasal/sinus endoscopy surg,31294,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10689.58,,,,,,,fee schedule,4545.09,30997.43,Radiology
Nasal/sinus endoscopy surg,31294,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9781.32,,,,,,,fee schedule,4545.09,30997.43,APC
Nasal/sinus endoscopy surg,31294,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12226.65,,,,,,,fee schedule,4545.09,30997.43,APC
Sinus endo w/balloon dil,31295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8056.92,,,,,,,fee schedule,6458.32,30997.43,
Sinus endo w/balloon dil,31295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6458.32,,,,,,,fee schedule,6458.32,30997.43,
Sinus endo w/balloon dil,31295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7055.13,,,,,,,fee schedule,6458.32,30997.43,
Sinus endo w/balloon dil,31295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7417.48,,,,,,,fee schedule,6458.32,30997.43,
Sinus endo w/balloon dil,31295,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,30997.43,,,,,,,fee schedule,6458.32,30997.43,APC 378
Sinus endo w/balloon dil,31295,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7335.99,,,,,,,fee schedule,6458.32,30997.43,APC
Sinus endo w/balloon dil,31295,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7266.12,,,,,,,fee schedule,6458.32,30997.43,APC
Sinus endo w/balloon dil,31295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6986.66,,,,,,,fee schedule,6458.32,30997.43,APC
Sinus endo w/balloon dil,31295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10689.58,,,,,,,fee schedule,6458.32,30997.43,Radiology
Sinus endo w/balloon dil,31295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9781.32,,,,,,,fee schedule,6458.32,30997.43,APC
Sinus endo w/balloon dil,31295,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12226.65,,,,,,,fee schedule,6458.32,30997.43,APC
Sinus endo w/balloon dil,31296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1971.06,,,,,,,fee schedule,1579.97,30997.43,
Sinus endo w/balloon dil,31296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1579.97,,,,,,,fee schedule,1579.97,30997.43,
Sinus endo w/balloon dil,31296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1725.98,,,,,,,fee schedule,1579.97,30997.43,
Sinus endo w/balloon dil,31296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1814.62,,,,,,,fee schedule,1579.97,30997.43,
Sinus endo w/balloon dil,31296,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,30997.43,,,,,,,fee schedule,1579.97,30997.43,APC 378
Sinus endo w/balloon dil,31296,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7335.99,,,,,,,fee schedule,1579.97,30997.43,APC
Sinus endo w/balloon dil,31296,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7266.12,,,,,,,fee schedule,1579.97,30997.43,APC
Sinus endo w/balloon dil,31296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6986.66,,,,,,,fee schedule,1579.97,30997.43,APC
Sinus endo w/balloon dil,31296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10689.58,,,,,,,fee schedule,1579.97,30997.43,Radiology
Sinus endo w/balloon dil,31296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9781.32,,,,,,,fee schedule,1579.97,30997.43,APC
Sinus endo w/balloon dil,31296,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12226.65,,,,,,,fee schedule,1579.97,30997.43,APC
Sinus endo w/balloon dil,31297,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2836.86,,,,,,,fee schedule,2273.99,30997.43,
Sinus endo w/balloon dil,31297,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2273.99,,,,,,,fee schedule,2273.99,30997.43,
Sinus endo w/balloon dil,31297,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2484.13,,,,,,,fee schedule,2273.99,30997.43,
Sinus endo w/balloon dil,31297,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2611.72,,,,,,,fee schedule,2273.99,30997.43,
Sinus endo w/balloon dil,31297,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,30997.43,,,,,,,fee schedule,2273.99,30997.43,APC 378
Sinus endo w/balloon dil,31297,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7335.99,,,,,,,fee schedule,2273.99,30997.43,APC
Sinus endo w/balloon dil,31297,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7266.12,,,,,,,fee schedule,2273.99,30997.43,APC
Sinus endo w/balloon dil,31297,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6986.66,,,,,,,fee schedule,2273.99,30997.43,APC
Sinus endo w/balloon dil,31297,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10689.58,,,,,,,fee schedule,2273.99,30997.43,Radiology
Sinus endo w/balloon dil,31297,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9781.32,,,,,,,fee schedule,2273.99,30997.43,APC
Sinus endo w/balloon dil,31297,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12226.65,,,,,,,fee schedule,2273.99,30997.43,APC
Nsl/sins ndsc w/sins dilat,31298,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19457.81,,,,,,,fee schedule,6986.66,30997.43,
Nsl/sins ndsc w/sins dilat,31298,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15597.14,,,,,,,fee schedule,6986.66,30997.43,
Nsl/sins ndsc w/sins dilat,31298,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17038.46,,,,,,,fee schedule,6986.66,30997.43,
Nsl/sins ndsc w/sins dilat,31298,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17913.54,,,,,,,fee schedule,6986.66,30997.43,
Nsl/sins ndsc w/sins dilat,31298,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,30997.43,,,,,,,fee schedule,6986.66,30997.43,APC 378
Nsl/sins ndsc w/sins dilat,31298,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7335.99,,,,,,,fee schedule,6986.66,30997.43,APC
Nsl/sins ndsc w/sins dilat,31298,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7266.12,,,,,,,fee schedule,6986.66,30997.43,APC
Nsl/sins ndsc w/sins dilat,31298,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6986.66,,,,,,,fee schedule,6986.66,30997.43,APC
Nsl/sins ndsc w/sins dilat,31298,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10689.58,,,,,,,fee schedule,6986.66,30997.43,Radiology
Nsl/sins ndsc w/sins dilat,31298,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9781.32,,,,,,,fee schedule,6986.66,30997.43,APC
Nsl/sins ndsc w/sins dilat,31298,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12226.65,,,,,,,fee schedule,6986.66,30997.43,APC
Sinus surgery procedure,31299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,624,,,,,,,fee schedule,234.47,1040.28,
Sinus surgery procedure,31299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,500.19,,,,,,,fee schedule,234.47,1040.28,
Sinus surgery procedure,31299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,546.41,,,,,,,fee schedule,234.47,1040.28,
Sinus surgery procedure,31299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,574.48,,,,,,,fee schedule,234.47,1040.28,
Sinus surgery procedure,31299,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1040.28,,,,,,,fee schedule,234.47,1040.28,APC 378
Sinus surgery procedure,31299,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,246.2,,,,,,,fee schedule,234.47,1040.28,APC
Sinus surgery procedure,31299,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,243.85,,,,,,,fee schedule,234.47,1040.28,APC
Sinus surgery procedure,31299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,234.47,,,,,,,fee schedule,234.47,1040.28,APC
Sinus surgery procedure,31299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,358.74,,,,,,,fee schedule,234.47,1040.28,Radiology
Sinus surgery procedure,31299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,328.26,,,,,,,fee schedule,234.47,1040.28,APC
Sinus surgery procedure,31299,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,410.33,,,,,,,fee schedule,234.47,1040.28,APC
Removal of larynx lesion,31300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5983.93,,,,,,,fee schedule,3282.2,14562,
Removal of larynx lesion,31300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4796.64,,,,,,,fee schedule,3282.2,14562,
Removal of larynx lesion,31300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5239.9,,,,,,,fee schedule,3282.2,14562,
Removal of larynx lesion,31300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.01,,,,,,,fee schedule,3282.2,14562,
Removal of larynx lesion,31300,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Removal of larynx lesion,31300,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Removal of larynx lesion,31300,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Removal of larynx lesion,31300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Removal of larynx lesion,31300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Removal of larynx lesion,31300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Removal of larynx lesion,31300,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Revision of larynx,31400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Revision of larynx,31400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Revision of larynx,31400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Revision of larynx,31400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Revision of larynx,31400,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Revision of larynx,31400,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Revision of larynx,31400,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Revision of larynx,31400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Revision of larynx,31400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Revision of larynx,31400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Revision of larynx,31400,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of epiglottis,31420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Removal of epiglottis,31420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Removal of epiglottis,31420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Removal of epiglottis,31420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Removal of epiglottis,31420,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Removal of epiglottis,31420,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of epiglottis,31420,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of epiglottis,31420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of epiglottis,31420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Removal of epiglottis,31420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of epiglottis,31420,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Insert emergency airway,31500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,490.33,,,,,,,fee schedule,234.47,1040.28,
Insert emergency airway,31500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,393.04,,,,,,,fee schedule,234.47,1040.28,
Insert emergency airway,31500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,429.36,,,,,,,fee schedule,234.47,1040.28,
Insert emergency airway,31500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,451.41,,,,,,,fee schedule,234.47,1040.28,
Insert emergency airway,31500,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1040.28,,,,,,,fee schedule,234.47,1040.28,APC 378
Insert emergency airway,31500,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,246.2,,,,,,,fee schedule,234.47,1040.28,APC
Insert emergency airway,31500,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,243.85,,,,,,,fee schedule,234.47,1040.28,APC
Insert emergency airway,31500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,234.47,,,,,,,fee schedule,234.47,1040.28,APC
Insert emergency airway,31500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,358.74,,,,,,,fee schedule,234.47,1040.28,Radiology
Insert emergency airway,31500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,328.26,,,,,,,fee schedule,234.47,1040.28,APC
Insert emergency airway,31500,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,410.33,,,,,,,fee schedule,234.47,1040.28,APC
Change of windpipe airway,31502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,333.51,,,,,,,fee schedule,234.47,1040.28,
Change of windpipe airway,31502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,267.34,,,,,,,fee schedule,234.47,1040.28,
Change of windpipe airway,31502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,292.04,,,,,,,fee schedule,234.47,1040.28,
Change of windpipe airway,31502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,307.04,,,,,,,fee schedule,234.47,1040.28,
Change of windpipe airway,31502,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1040.28,,,,,,,fee schedule,234.47,1040.28,APC 378
Change of windpipe airway,31502,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,246.2,,,,,,,fee schedule,234.47,1040.28,APC
Change of windpipe airway,31502,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,243.85,,,,,,,fee schedule,234.47,1040.28,APC
Change of windpipe airway,31502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,234.47,,,,,,,fee schedule,234.47,1040.28,APC
Change of windpipe airway,31502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,358.74,,,,,,,fee schedule,234.47,1040.28,Radiology
Change of windpipe airway,31502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,328.26,,,,,,,fee schedule,234.47,1040.28,APC
Change of windpipe airway,31502,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,410.33,,,,,,,fee schedule,234.47,1040.28,APC
Diagnostic laryngoscopy,31505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,205.25,,,,,,,fee schedule,164.53,876.7,
Diagnostic laryngoscopy,31505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,164.53,,,,,,,fee schedule,164.53,876.7,
Diagnostic laryngoscopy,31505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,179.73,,,,,,,fee schedule,164.53,876.7,
Diagnostic laryngoscopy,31505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,188.96,,,,,,,fee schedule,164.53,876.7,
Diagnostic laryngoscopy,31505,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,876.7,,,,,,,fee schedule,164.53,876.7,APC 378
Diagnostic laryngoscopy,31505,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,207.48,,,,,,,fee schedule,164.53,876.7,APC
Diagnostic laryngoscopy,31505,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,205.51,,,,,,,fee schedule,164.53,876.7,APC
Diagnostic laryngoscopy,31505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,197.6,,,,,,,fee schedule,164.53,876.7,APC
Diagnostic laryngoscopy,31505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,302.33,,,,,,,fee schedule,164.53,876.7,Radiology
Diagnostic laryngoscopy,31505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,276.65,,,,,,,fee schedule,164.53,876.7,APC
Diagnostic laryngoscopy,31505,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,345.81,,,,,,,fee schedule,164.53,876.7,APC
Laryngoscopy with biopsy,31510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4246.79,,,,,,,fee schedule,3404.17,16375.46,
Laryngoscopy with biopsy,31510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3404.17,,,,,,,fee schedule,3404.17,16375.46,
Laryngoscopy with biopsy,31510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3718.75,,,,,,,fee schedule,3404.17,16375.46,
Laryngoscopy with biopsy,31510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3909.75,,,,,,,fee schedule,3404.17,16375.46,
Laryngoscopy with biopsy,31510,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16375.46,,,,,,,fee schedule,3404.17,16375.46,APC 378
Laryngoscopy with biopsy,31510,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3875.49,,,,,,,fee schedule,3404.17,16375.46,APC
Laryngoscopy with biopsy,31510,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3838.58,,,,,,,fee schedule,3404.17,16375.46,APC
Laryngoscopy with biopsy,31510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3690.94,,,,,,,fee schedule,3404.17,16375.46,APC
Laryngoscopy with biopsy,31510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5647.14,,,,,,,fee schedule,3404.17,16375.46,Radiology
Laryngoscopy with biopsy,31510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5167.32,,,,,,,fee schedule,3404.17,16375.46,APC
Laryngoscopy with biopsy,31510,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6459.15,,,,,,,fee schedule,3404.17,16375.46,APC
Remove foreign body larynx,31511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,402.19,,,,,,,fee schedule,197.6,876.7,
Remove foreign body larynx,31511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,322.39,,,,,,,fee schedule,197.6,876.7,
Remove foreign body larynx,31511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,352.18,,,,,,,fee schedule,197.6,876.7,
Remove foreign body larynx,31511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,370.27,,,,,,,fee schedule,197.6,876.7,
Remove foreign body larynx,31511,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,876.7,,,,,,,fee schedule,197.6,876.7,APC 378
Remove foreign body larynx,31511,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,207.48,,,,,,,fee schedule,197.6,876.7,APC
Remove foreign body larynx,31511,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,205.51,,,,,,,fee schedule,197.6,876.7,APC
Remove foreign body larynx,31511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,197.6,,,,,,,fee schedule,197.6,876.7,APC
Remove foreign body larynx,31511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,302.33,,,,,,,fee schedule,197.6,876.7,Radiology
Remove foreign body larynx,31511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,276.65,,,,,,,fee schedule,197.6,876.7,APC
Remove foreign body larynx,31511,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,345.81,,,,,,,fee schedule,197.6,876.7,APC
Removal of larynx lesion,31512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4246.79,,,,,,,fee schedule,3404.17,16375.46,
Removal of larynx lesion,31512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3404.17,,,,,,,fee schedule,3404.17,16375.46,
Removal of larynx lesion,31512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3718.75,,,,,,,fee schedule,3404.17,16375.46,
Removal of larynx lesion,31512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3909.75,,,,,,,fee schedule,3404.17,16375.46,
Removal of larynx lesion,31512,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16375.46,,,,,,,fee schedule,3404.17,16375.46,APC 378
Removal of larynx lesion,31512,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3875.49,,,,,,,fee schedule,3404.17,16375.46,APC
Removal of larynx lesion,31512,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3838.58,,,,,,,fee schedule,3404.17,16375.46,APC
Removal of larynx lesion,31512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3690.94,,,,,,,fee schedule,3404.17,16375.46,APC
Removal of larynx lesion,31512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5647.14,,,,,,,fee schedule,3404.17,16375.46,Radiology
Removal of larynx lesion,31512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5167.32,,,,,,,fee schedule,3404.17,16375.46,APC
Removal of larynx lesion,31512,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6459.15,,,,,,,fee schedule,3404.17,16375.46,APC
Injection into vocal cord,31513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,402.19,,,,,,,fee schedule,322.39,1717.85,
Injection into vocal cord,31513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,322.39,,,,,,,fee schedule,322.39,1717.85,
Injection into vocal cord,31513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,352.18,,,,,,,fee schedule,322.39,1717.85,
Injection into vocal cord,31513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,370.27,,,,,,,fee schedule,322.39,1717.85,
Injection into vocal cord,31513,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1717.85,,,,,,,fee schedule,322.39,1717.85,APC 378
Injection into vocal cord,31513,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,406.55,,,,,,,fee schedule,322.39,1717.85,APC
Injection into vocal cord,31513,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,402.68,,,,,,,fee schedule,322.39,1717.85,APC
Injection into vocal cord,31513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,387.19,,,,,,,fee schedule,322.39,1717.85,APC
Injection into vocal cord,31513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,592.41,,,,,,,fee schedule,322.39,1717.85,Radiology
Injection into vocal cord,31513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,542.07,,,,,,,fee schedule,322.39,1717.85,APC
Injection into vocal cord,31513,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,677.59,,,,,,,fee schedule,322.39,1717.85,APC
Laryngoscopy for aspiration,31515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4246.79,,,,,,,fee schedule,387.19,4246.79,
Laryngoscopy for aspiration,31515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3404.17,,,,,,,fee schedule,387.19,4246.79,
Laryngoscopy for aspiration,31515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3718.75,,,,,,,fee schedule,387.19,4246.79,
Laryngoscopy for aspiration,31515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3909.75,,,,,,,fee schedule,387.19,4246.79,
Laryngoscopy for aspiration,31515,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1717.85,,,,,,,fee schedule,387.19,4246.79,APC 378
Laryngoscopy for aspiration,31515,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,406.55,,,,,,,fee schedule,387.19,4246.79,APC
Laryngoscopy for aspiration,31515,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,402.68,,,,,,,fee schedule,387.19,4246.79,APC
Laryngoscopy for aspiration,31515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,387.19,,,,,,,fee schedule,387.19,4246.79,APC
Laryngoscopy for aspiration,31515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,592.41,,,,,,,fee schedule,387.19,4246.79,Radiology
Laryngoscopy for aspiration,31515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,542.07,,,,,,,fee schedule,387.19,4246.79,APC
Laryngoscopy for aspiration,31515,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,677.59,,,,,,,fee schedule,387.19,4246.79,APC
Dx laryngoscopy newborn,31520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,402.19,,,,,,,fee schedule,322.39,1717.85,
Dx laryngoscopy newborn,31520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,322.39,,,,,,,fee schedule,322.39,1717.85,
Dx laryngoscopy newborn,31520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,352.18,,,,,,,fee schedule,322.39,1717.85,
Dx laryngoscopy newborn,31520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,370.27,,,,,,,fee schedule,322.39,1717.85,
Dx laryngoscopy newborn,31520,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1717.85,,,,,,,fee schedule,322.39,1717.85,APC 378
Dx laryngoscopy newborn,31520,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,406.55,,,,,,,fee schedule,322.39,1717.85,APC
Dx laryngoscopy newborn,31520,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,402.68,,,,,,,fee schedule,322.39,1717.85,APC
Dx laryngoscopy newborn,31520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,387.19,,,,,,,fee schedule,322.39,1717.85,APC
Dx laryngoscopy newborn,31520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,592.41,,,,,,,fee schedule,322.39,1717.85,Radiology
Dx laryngoscopy newborn,31520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,542.07,,,,,,,fee schedule,322.39,1717.85,APC
Dx laryngoscopy newborn,31520,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,677.59,,,,,,,fee schedule,322.39,1717.85,APC
Dx laryngoscopy excl nb,31525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5785.34,,,,,,,fee schedule,1762.04,7817.58,
Dx laryngoscopy excl nb,31525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4637.46,,,,,,,fee schedule,1762.04,7817.58,
Dx laryngoscopy excl nb,31525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5066,,,,,,,fee schedule,1762.04,7817.58,
Dx laryngoscopy excl nb,31525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5326.19,,,,,,,fee schedule,1762.04,7817.58,
Dx laryngoscopy excl nb,31525,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7817.58,,,,,,,fee schedule,1762.04,7817.58,APC 378
Dx laryngoscopy excl nb,31525,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1850.14,,,,,,,fee schedule,1762.04,7817.58,APC
Dx laryngoscopy excl nb,31525,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1832.52,,,,,,,fee schedule,1762.04,7817.58,APC
Dx laryngoscopy excl nb,31525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1762.04,,,,,,,fee schedule,1762.04,7817.58,APC
Dx laryngoscopy excl nb,31525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2695.92,,,,,,,fee schedule,1762.04,7817.58,Radiology
Dx laryngoscopy excl nb,31525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2466.86,,,,,,,fee schedule,1762.04,7817.58,APC
Dx laryngoscopy excl nb,31525,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3083.57,,,,,,,fee schedule,1762.04,7817.58,APC
Dx laryngoscopy w/oper scope,31526,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4494.05,,,,,,,fee schedule,1762.04,7817.58,
Dx laryngoscopy w/oper scope,31526,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3602.37,,,,,,,fee schedule,1762.04,7817.58,
Dx laryngoscopy w/oper scope,31526,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3935.26,,,,,,,fee schedule,1762.04,7817.58,
Dx laryngoscopy w/oper scope,31526,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4137.38,,,,,,,fee schedule,1762.04,7817.58,
Dx laryngoscopy w/oper scope,31526,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7817.58,,,,,,,fee schedule,1762.04,7817.58,APC 378
Dx laryngoscopy w/oper scope,31526,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1850.14,,,,,,,fee schedule,1762.04,7817.58,APC
Dx laryngoscopy w/oper scope,31526,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1832.52,,,,,,,fee schedule,1762.04,7817.58,APC
Dx laryngoscopy w/oper scope,31526,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1762.04,,,,,,,fee schedule,1762.04,7817.58,APC
Dx laryngoscopy w/oper scope,31526,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2695.92,,,,,,,fee schedule,1762.04,7817.58,Radiology
Dx laryngoscopy w/oper scope,31526,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2466.86,,,,,,,fee schedule,1762.04,7817.58,APC
Dx laryngoscopy w/oper scope,31526,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3083.57,,,,,,,fee schedule,1762.04,7817.58,APC
Laryngoscopy for treatment,31527,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5670.11,,,,,,,fee schedule,3690.94,16375.46,
Laryngoscopy for treatment,31527,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4545.09,,,,,,,fee schedule,3690.94,16375.46,
Laryngoscopy for treatment,31527,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4965.1,,,,,,,fee schedule,3690.94,16375.46,
Laryngoscopy for treatment,31527,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5220.1,,,,,,,fee schedule,3690.94,16375.46,
Laryngoscopy for treatment,31527,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16375.46,,,,,,,fee schedule,3690.94,16375.46,APC 378
Laryngoscopy for treatment,31527,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3875.49,,,,,,,fee schedule,3690.94,16375.46,APC
Laryngoscopy for treatment,31527,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3838.58,,,,,,,fee schedule,3690.94,16375.46,APC
Laryngoscopy for treatment,31527,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3690.94,,,,,,,fee schedule,3690.94,16375.46,APC
Laryngoscopy for treatment,31527,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5647.14,,,,,,,fee schedule,3690.94,16375.46,Radiology
Laryngoscopy for treatment,31527,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5167.32,,,,,,,fee schedule,3690.94,16375.46,APC
Laryngoscopy for treatment,31527,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6459.15,,,,,,,fee schedule,3690.94,16375.46,APC
Laryngoscopy and dilation,31528,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5977.41,,,,,,,fee schedule,3690.94,16375.46,
Laryngoscopy and dilation,31528,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4791.41,,,,,,,fee schedule,3690.94,16375.46,
Laryngoscopy and dilation,31528,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5234.19,,,,,,,fee schedule,3690.94,16375.46,
Laryngoscopy and dilation,31528,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5503.01,,,,,,,fee schedule,3690.94,16375.46,
Laryngoscopy and dilation,31528,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16375.46,,,,,,,fee schedule,3690.94,16375.46,APC 378
Laryngoscopy and dilation,31528,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3875.49,,,,,,,fee schedule,3690.94,16375.46,APC
Laryngoscopy and dilation,31528,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3838.58,,,,,,,fee schedule,3690.94,16375.46,APC
Laryngoscopy and dilation,31528,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3690.94,,,,,,,fee schedule,3690.94,16375.46,APC
Laryngoscopy and dilation,31528,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5647.14,,,,,,,fee schedule,3690.94,16375.46,Radiology
Laryngoscopy and dilation,31528,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5167.32,,,,,,,fee schedule,3690.94,16375.46,APC
Laryngoscopy and dilation,31528,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6459.15,,,,,,,fee schedule,3690.94,16375.46,APC
Laryngoscopy and dilation,31529,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4246.79,,,,,,,fee schedule,3404.17,16375.46,
Laryngoscopy and dilation,31529,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3404.17,,,,,,,fee schedule,3404.17,16375.46,
Laryngoscopy and dilation,31529,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3718.75,,,,,,,fee schedule,3404.17,16375.46,
Laryngoscopy and dilation,31529,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3909.75,,,,,,,fee schedule,3404.17,16375.46,
Laryngoscopy and dilation,31529,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16375.46,,,,,,,fee schedule,3404.17,16375.46,APC 378
Laryngoscopy and dilation,31529,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3875.49,,,,,,,fee schedule,3404.17,16375.46,APC
Laryngoscopy and dilation,31529,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3838.58,,,,,,,fee schedule,3404.17,16375.46,APC
Laryngoscopy and dilation,31529,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3690.94,,,,,,,fee schedule,3404.17,16375.46,APC
Laryngoscopy and dilation,31529,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5647.14,,,,,,,fee schedule,3404.17,16375.46,Radiology
Laryngoscopy and dilation,31529,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5167.32,,,,,,,fee schedule,3404.17,16375.46,APC
Laryngoscopy and dilation,31529,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6459.15,,,,,,,fee schedule,3404.17,16375.46,APC
Laryngoscopy w/fb removal,31530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5670.11,,,,,,,fee schedule,1762.04,7817.58,
Laryngoscopy w/fb removal,31530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4545.09,,,,,,,fee schedule,1762.04,7817.58,
Laryngoscopy w/fb removal,31530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4965.1,,,,,,,fee schedule,1762.04,7817.58,
Laryngoscopy w/fb removal,31530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5220.1,,,,,,,fee schedule,1762.04,7817.58,
Laryngoscopy w/fb removal,31530,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7817.58,,,,,,,fee schedule,1762.04,7817.58,APC 378
Laryngoscopy w/fb removal,31530,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1850.14,,,,,,,fee schedule,1762.04,7817.58,APC
Laryngoscopy w/fb removal,31530,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1832.52,,,,,,,fee schedule,1762.04,7817.58,APC
Laryngoscopy w/fb removal,31530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1762.04,,,,,,,fee schedule,1762.04,7817.58,APC
Laryngoscopy w/fb removal,31530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2695.92,,,,,,,fee schedule,1762.04,7817.58,Radiology
Laryngoscopy w/fb removal,31530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2466.86,,,,,,,fee schedule,1762.04,7817.58,APC
Laryngoscopy w/fb removal,31530,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3083.57,,,,,,,fee schedule,1762.04,7817.58,APC
Laryngoscopy w/fb & op scope,31531,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5670.11,,,,,,,fee schedule,3690.94,16375.46,
Laryngoscopy w/fb & op scope,31531,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4545.09,,,,,,,fee schedule,3690.94,16375.46,
Laryngoscopy w/fb & op scope,31531,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4965.1,,,,,,,fee schedule,3690.94,16375.46,
Laryngoscopy w/fb & op scope,31531,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5220.1,,,,,,,fee schedule,3690.94,16375.46,
Laryngoscopy w/fb & op scope,31531,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16375.46,,,,,,,fee schedule,3690.94,16375.46,APC 378
Laryngoscopy w/fb & op scope,31531,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3875.49,,,,,,,fee schedule,3690.94,16375.46,APC
Laryngoscopy w/fb & op scope,31531,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3838.58,,,,,,,fee schedule,3690.94,16375.46,APC
Laryngoscopy w/fb & op scope,31531,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3690.94,,,,,,,fee schedule,3690.94,16375.46,APC
Laryngoscopy w/fb & op scope,31531,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5647.14,,,,,,,fee schedule,3690.94,16375.46,Radiology
Laryngoscopy w/fb & op scope,31531,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5167.32,,,,,,,fee schedule,3690.94,16375.46,APC
Laryngoscopy w/fb & op scope,31531,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6459.15,,,,,,,fee schedule,3690.94,16375.46,APC
Laryngoscopy w/biopsy,31535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4793.13,,,,,,,fee schedule,3690.94,16375.46,
Laryngoscopy w/biopsy,31535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3842.11,,,,,,,fee schedule,3690.94,16375.46,
Laryngoscopy w/biopsy,31535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4197.16,,,,,,,fee schedule,3690.94,16375.46,
Laryngoscopy w/biopsy,31535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4412.72,,,,,,,fee schedule,3690.94,16375.46,
Laryngoscopy w/biopsy,31535,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16375.46,,,,,,,fee schedule,3690.94,16375.46,APC 378
Laryngoscopy w/biopsy,31535,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3875.49,,,,,,,fee schedule,3690.94,16375.46,APC
Laryngoscopy w/biopsy,31535,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3838.58,,,,,,,fee schedule,3690.94,16375.46,APC
Laryngoscopy w/biopsy,31535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3690.94,,,,,,,fee schedule,3690.94,16375.46,APC
Laryngoscopy w/biopsy,31535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5647.14,,,,,,,fee schedule,3690.94,16375.46,Radiology
Laryngoscopy w/biopsy,31535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5167.32,,,,,,,fee schedule,3690.94,16375.46,APC
Laryngoscopy w/biopsy,31535,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6459.15,,,,,,,fee schedule,3690.94,16375.46,APC
Laryngoscopy w/bx & op scope,31536,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6290.98,,,,,,,fee schedule,3690.94,16375.46,
Laryngoscopy w/bx & op scope,31536,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5042.77,,,,,,,fee schedule,3690.94,16375.46,
Laryngoscopy w/bx & op scope,31536,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5508.76,,,,,,,fee schedule,3690.94,16375.46,
Laryngoscopy w/bx & op scope,31536,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5791.69,,,,,,,fee schedule,3690.94,16375.46,
Laryngoscopy w/bx & op scope,31536,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16375.46,,,,,,,fee schedule,3690.94,16375.46,APC 378
Laryngoscopy w/bx & op scope,31536,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3875.49,,,,,,,fee schedule,3690.94,16375.46,APC
Laryngoscopy w/bx & op scope,31536,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3838.58,,,,,,,fee schedule,3690.94,16375.46,APC
Laryngoscopy w/bx & op scope,31536,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3690.94,,,,,,,fee schedule,3690.94,16375.46,APC
Laryngoscopy w/bx & op scope,31536,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5647.14,,,,,,,fee schedule,3690.94,16375.46,Radiology
Laryngoscopy w/bx & op scope,31536,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5167.32,,,,,,,fee schedule,3690.94,16375.46,APC
Laryngoscopy w/bx & op scope,31536,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6459.15,,,,,,,fee schedule,3690.94,16375.46,APC
Laryngoscopy w/exc of tumor,31540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5336.73,,,,,,,fee schedule,3690.94,16375.46,
Laryngoscopy w/exc of tumor,31540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4277.86,,,,,,,fee schedule,3690.94,16375.46,
Laryngoscopy w/exc of tumor,31540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4673.17,,,,,,,fee schedule,3690.94,16375.46,
Laryngoscopy w/exc of tumor,31540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4913.18,,,,,,,fee schedule,3690.94,16375.46,
Laryngoscopy w/exc of tumor,31540,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16375.46,,,,,,,fee schedule,3690.94,16375.46,APC 378
Laryngoscopy w/exc of tumor,31540,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3875.49,,,,,,,fee schedule,3690.94,16375.46,APC
Laryngoscopy w/exc of tumor,31540,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3838.58,,,,,,,fee schedule,3690.94,16375.46,APC
Laryngoscopy w/exc of tumor,31540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3690.94,,,,,,,fee schedule,3690.94,16375.46,APC
Laryngoscopy w/exc of tumor,31540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5647.14,,,,,,,fee schedule,3690.94,16375.46,Radiology
Laryngoscopy w/exc of tumor,31540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5167.32,,,,,,,fee schedule,3690.94,16375.46,APC
Laryngoscopy w/exc of tumor,31540,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6459.15,,,,,,,fee schedule,3690.94,16375.46,APC
Larynscop w/tumr exc + scope,31541,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7657.8,,,,,,,fee schedule,3690.94,16375.46,
Larynscop w/tumr exc + scope,31541,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6138.4,,,,,,,fee schedule,3690.94,16375.46,
Larynscop w/tumr exc + scope,31541,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6705.64,,,,,,,fee schedule,3690.94,16375.46,
Larynscop w/tumr exc + scope,31541,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7050.04,,,,,,,fee schedule,3690.94,16375.46,
Larynscop w/tumr exc + scope,31541,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16375.46,,,,,,,fee schedule,3690.94,16375.46,APC 378
Larynscop w/tumr exc + scope,31541,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3875.49,,,,,,,fee schedule,3690.94,16375.46,APC
Larynscop w/tumr exc + scope,31541,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3838.58,,,,,,,fee schedule,3690.94,16375.46,APC
Larynscop w/tumr exc + scope,31541,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3690.94,,,,,,,fee schedule,3690.94,16375.46,APC
Larynscop w/tumr exc + scope,31541,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5647.14,,,,,,,fee schedule,3690.94,16375.46,Radiology
Larynscop w/tumr exc + scope,31541,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5167.32,,,,,,,fee schedule,3690.94,16375.46,APC
Larynscop w/tumr exc + scope,31541,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6459.15,,,,,,,fee schedule,3690.94,16375.46,APC
Remove vc lesion w/scope,31545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5670.11,,,,,,,fee schedule,3690.94,16375.46,
Remove vc lesion w/scope,31545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4545.09,,,,,,,fee schedule,3690.94,16375.46,
Remove vc lesion w/scope,31545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4965.1,,,,,,,fee schedule,3690.94,16375.46,
Remove vc lesion w/scope,31545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5220.1,,,,,,,fee schedule,3690.94,16375.46,
Remove vc lesion w/scope,31545,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16375.46,,,,,,,fee schedule,3690.94,16375.46,APC 378
Remove vc lesion w/scope,31545,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3875.49,,,,,,,fee schedule,3690.94,16375.46,APC
Remove vc lesion w/scope,31545,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3838.58,,,,,,,fee schedule,3690.94,16375.46,APC
Remove vc lesion w/scope,31545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3690.94,,,,,,,fee schedule,3690.94,16375.46,APC
Remove vc lesion w/scope,31545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5647.14,,,,,,,fee schedule,3690.94,16375.46,Radiology
Remove vc lesion w/scope,31545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5167.32,,,,,,,fee schedule,3690.94,16375.46,APC
Remove vc lesion w/scope,31545,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6459.15,,,,,,,fee schedule,3690.94,16375.46,APC
Remove vc lesion scope/graft,31546,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5670.11,,,,,,,fee schedule,4545.09,30997.43,
Remove vc lesion scope/graft,31546,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4545.09,,,,,,,fee schedule,4545.09,30997.43,
Remove vc lesion scope/graft,31546,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4965.1,,,,,,,fee schedule,4545.09,30997.43,
Remove vc lesion scope/graft,31546,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5220.1,,,,,,,fee schedule,4545.09,30997.43,
Remove vc lesion scope/graft,31546,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,30997.43,,,,,,,fee schedule,4545.09,30997.43,APC 378
Remove vc lesion scope/graft,31546,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7335.99,,,,,,,fee schedule,4545.09,30997.43,APC
Remove vc lesion scope/graft,31546,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7266.12,,,,,,,fee schedule,4545.09,30997.43,APC
Remove vc lesion scope/graft,31546,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6986.66,,,,,,,fee schedule,4545.09,30997.43,APC
Remove vc lesion scope/graft,31546,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10689.58,,,,,,,fee schedule,4545.09,30997.43,Radiology
Remove vc lesion scope/graft,31546,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9781.32,,,,,,,fee schedule,4545.09,30997.43,APC
Remove vc lesion scope/graft,31546,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12226.65,,,,,,,fee schedule,4545.09,30997.43,APC
Laryngoplasty laryngeal sten,31551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15614.95,,,,,,,fee schedule,5860.44,26000.79,
Laryngoplasty laryngeal sten,31551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12516.75,,,,,,,fee schedule,5860.44,26000.79,
Laryngoplasty laryngeal sten,31551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13673.41,,,,,,,fee schedule,5860.44,26000.79,
Laryngoplasty laryngeal sten,31551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14375.67,,,,,,,fee schedule,5860.44,26000.79,
Laryngoplasty laryngeal sten,31551,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Laryngoplasty laryngeal sten,31551,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Laryngoplasty laryngeal sten,31551,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Laryngoplasty laryngeal sten,31551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Laryngoplasty laryngeal sten,31551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Laryngoplasty laryngeal sten,31551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Laryngoplasty laryngeal sten,31551,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Laryngoplasty laryngeal sten,31552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15614.95,,,,,,,fee schedule,5860.44,26000.79,
Laryngoplasty laryngeal sten,31552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12516.75,,,,,,,fee schedule,5860.44,26000.79,
Laryngoplasty laryngeal sten,31552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13673.41,,,,,,,fee schedule,5860.44,26000.79,
Laryngoplasty laryngeal sten,31552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14375.67,,,,,,,fee schedule,5860.44,26000.79,
Laryngoplasty laryngeal sten,31552,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Laryngoplasty laryngeal sten,31552,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Laryngoplasty laryngeal sten,31552,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Laryngoplasty laryngeal sten,31552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Laryngoplasty laryngeal sten,31552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Laryngoplasty laryngeal sten,31552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Laryngoplasty laryngeal sten,31552,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Laryngoplasty laryngeal sten,31553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15614.95,,,,,,,fee schedule,5860.44,26000.79,
Laryngoplasty laryngeal sten,31553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12516.75,,,,,,,fee schedule,5860.44,26000.79,
Laryngoplasty laryngeal sten,31553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13673.41,,,,,,,fee schedule,5860.44,26000.79,
Laryngoplasty laryngeal sten,31553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14375.67,,,,,,,fee schedule,5860.44,26000.79,
Laryngoplasty laryngeal sten,31553,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Laryngoplasty laryngeal sten,31553,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Laryngoplasty laryngeal sten,31553,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Laryngoplasty laryngeal sten,31553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Laryngoplasty laryngeal sten,31553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Laryngoplasty laryngeal sten,31553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Laryngoplasty laryngeal sten,31553,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Laryngoplasty laryngeal sten,31554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15614.95,,,,,,,fee schedule,5860.44,26000.79,
Laryngoplasty laryngeal sten,31554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12516.75,,,,,,,fee schedule,5860.44,26000.79,
Laryngoplasty laryngeal sten,31554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13673.41,,,,,,,fee schedule,5860.44,26000.79,
Laryngoplasty laryngeal sten,31554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14375.67,,,,,,,fee schedule,5860.44,26000.79,
Laryngoplasty laryngeal sten,31554,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Laryngoplasty laryngeal sten,31554,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Laryngoplasty laryngeal sten,31554,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Laryngoplasty laryngeal sten,31554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Laryngoplasty laryngeal sten,31554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Laryngoplasty laryngeal sten,31554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Laryngoplasty laryngeal sten,31554,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Laryngoscop w/arytenoidectom,31560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5670.11,,,,,,,fee schedule,4545.09,30997.43,
Laryngoscop w/arytenoidectom,31560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4545.09,,,,,,,fee schedule,4545.09,30997.43,
Laryngoscop w/arytenoidectom,31560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4965.1,,,,,,,fee schedule,4545.09,30997.43,
Laryngoscop w/arytenoidectom,31560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5220.1,,,,,,,fee schedule,4545.09,30997.43,
Laryngoscop w/arytenoidectom,31560,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,30997.43,,,,,,,fee schedule,4545.09,30997.43,APC 378
Laryngoscop w/arytenoidectom,31560,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7335.99,,,,,,,fee schedule,4545.09,30997.43,APC
Laryngoscop w/arytenoidectom,31560,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7266.12,,,,,,,fee schedule,4545.09,30997.43,APC
Laryngoscop w/arytenoidectom,31560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6986.66,,,,,,,fee schedule,4545.09,30997.43,APC
Laryngoscop w/arytenoidectom,31560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10689.58,,,,,,,fee schedule,4545.09,30997.43,Radiology
Laryngoscop w/arytenoidectom,31560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9781.32,,,,,,,fee schedule,4545.09,30997.43,APC
Laryngoscop w/arytenoidectom,31560,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12226.65,,,,,,,fee schedule,4545.09,30997.43,APC
Larynscop remve cart + scop,31561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5670.11,,,,,,,fee schedule,4545.09,30997.43,
Larynscop remve cart + scop,31561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4545.09,,,,,,,fee schedule,4545.09,30997.43,
Larynscop remve cart + scop,31561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4965.1,,,,,,,fee schedule,4545.09,30997.43,
Larynscop remve cart + scop,31561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5220.1,,,,,,,fee schedule,4545.09,30997.43,
Larynscop remve cart + scop,31561,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,30997.43,,,,,,,fee schedule,4545.09,30997.43,APC 378
Larynscop remve cart + scop,31561,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7335.99,,,,,,,fee schedule,4545.09,30997.43,APC
Larynscop remve cart + scop,31561,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7266.12,,,,,,,fee schedule,4545.09,30997.43,APC
Larynscop remve cart + scop,31561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6986.66,,,,,,,fee schedule,4545.09,30997.43,APC
Larynscop remve cart + scop,31561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10689.58,,,,,,,fee schedule,4545.09,30997.43,Radiology
Larynscop remve cart + scop,31561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9781.32,,,,,,,fee schedule,4545.09,30997.43,APC
Larynscop remve cart + scop,31561,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12226.65,,,,,,,fee schedule,4545.09,30997.43,APC
Laryngoscope w/vc inj,31570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4246.79,,,,,,,fee schedule,3404.17,16375.46,
Laryngoscope w/vc inj,31570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3404.17,,,,,,,fee schedule,3404.17,16375.46,
Laryngoscope w/vc inj,31570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3718.75,,,,,,,fee schedule,3404.17,16375.46,
Laryngoscope w/vc inj,31570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3909.75,,,,,,,fee schedule,3404.17,16375.46,
Laryngoscope w/vc inj,31570,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16375.46,,,,,,,fee schedule,3404.17,16375.46,APC 378
Laryngoscope w/vc inj,31570,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3875.49,,,,,,,fee schedule,3404.17,16375.46,APC
Laryngoscope w/vc inj,31570,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3838.58,,,,,,,fee schedule,3404.17,16375.46,APC
Laryngoscope w/vc inj,31570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3690.94,,,,,,,fee schedule,3404.17,16375.46,APC
Laryngoscope w/vc inj,31570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5647.14,,,,,,,fee schedule,3404.17,16375.46,Radiology
Laryngoscope w/vc inj,31570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5167.32,,,,,,,fee schedule,3404.17,16375.46,APC
Laryngoscope w/vc inj,31570,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6459.15,,,,,,,fee schedule,3404.17,16375.46,APC
Laryngoscop w/vc inj + scope,31571,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5670.11,,,,,,,fee schedule,3690.94,16375.46,
Laryngoscop w/vc inj + scope,31571,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4545.09,,,,,,,fee schedule,3690.94,16375.46,
Laryngoscop w/vc inj + scope,31571,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4965.1,,,,,,,fee schedule,3690.94,16375.46,
Laryngoscop w/vc inj + scope,31571,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5220.1,,,,,,,fee schedule,3690.94,16375.46,
Laryngoscop w/vc inj + scope,31571,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16375.46,,,,,,,fee schedule,3690.94,16375.46,APC 378
Laryngoscop w/vc inj + scope,31571,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3875.49,,,,,,,fee schedule,3690.94,16375.46,APC
Laryngoscop w/vc inj + scope,31571,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3838.58,,,,,,,fee schedule,3690.94,16375.46,APC
Laryngoscop w/vc inj + scope,31571,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3690.94,,,,,,,fee schedule,3690.94,16375.46,APC
Laryngoscop w/vc inj + scope,31571,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5647.14,,,,,,,fee schedule,3690.94,16375.46,Radiology
Laryngoscop w/vc inj + scope,31571,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5167.32,,,,,,,fee schedule,3690.94,16375.46,APC
Laryngoscop w/vc inj + scope,31571,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6459.15,,,,,,,fee schedule,3690.94,16375.46,APC
Largsc w/laser dstrj les,31572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9190.05,,,,,,,fee schedule,3690.94,16375.46,
Largsc w/laser dstrj les,31572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7366.63,,,,,,,fee schedule,3690.94,16375.46,
Largsc w/laser dstrj les,31572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8047.37,,,,,,,fee schedule,3690.94,16375.46,
Largsc w/laser dstrj les,31572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8460.68,,,,,,,fee schedule,3690.94,16375.46,
Largsc w/laser dstrj les,31572,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16375.46,,,,,,,fee schedule,3690.94,16375.46,APC 378
Largsc w/laser dstrj les,31572,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3875.49,,,,,,,fee schedule,3690.94,16375.46,APC
Largsc w/laser dstrj les,31572,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3838.58,,,,,,,fee schedule,3690.94,16375.46,APC
Largsc w/laser dstrj les,31572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3690.94,,,,,,,fee schedule,3690.94,16375.46,APC
Largsc w/laser dstrj les,31572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5647.14,,,,,,,fee schedule,3690.94,16375.46,Radiology
Largsc w/laser dstrj les,31572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5167.32,,,,,,,fee schedule,3690.94,16375.46,APC
Largsc w/laser dstrj les,31572,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6459.15,,,,,,,fee schedule,3690.94,16375.46,APC
Largsc w/ther injection,31573,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4799.81,,,,,,,fee schedule,1762.04,7817.58,
Largsc w/ther injection,31573,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3847.46,,,,,,,fee schedule,1762.04,7817.58,
Largsc w/ther injection,31573,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4203,,,,,,,fee schedule,1762.04,7817.58,
Largsc w/ther injection,31573,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4418.87,,,,,,,fee schedule,1762.04,7817.58,
Largsc w/ther injection,31573,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7817.58,,,,,,,fee schedule,1762.04,7817.58,APC 378
Largsc w/ther injection,31573,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1850.14,,,,,,,fee schedule,1762.04,7817.58,APC
Largsc w/ther injection,31573,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1832.52,,,,,,,fee schedule,1762.04,7817.58,APC
Largsc w/ther injection,31573,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1762.04,,,,,,,fee schedule,1762.04,7817.58,APC
Largsc w/ther injection,31573,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2695.92,,,,,,,fee schedule,1762.04,7817.58,Radiology
Largsc w/ther injection,31573,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2466.86,,,,,,,fee schedule,1762.04,7817.58,APC
Largsc w/ther injection,31573,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3083.57,,,,,,,fee schedule,1762.04,7817.58,APC
Largsc w/njx augmentation,31574,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4799.81,,,,,,,fee schedule,1762.04,7817.58,
Largsc w/njx augmentation,31574,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3847.46,,,,,,,fee schedule,1762.04,7817.58,
Largsc w/njx augmentation,31574,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4203,,,,,,,fee schedule,1762.04,7817.58,
Largsc w/njx augmentation,31574,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4418.87,,,,,,,fee schedule,1762.04,7817.58,
Largsc w/njx augmentation,31574,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7817.58,,,,,,,fee schedule,1762.04,7817.58,APC 378
Largsc w/njx augmentation,31574,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1850.14,,,,,,,fee schedule,1762.04,7817.58,APC
Largsc w/njx augmentation,31574,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1832.52,,,,,,,fee schedule,1762.04,7817.58,APC
Largsc w/njx augmentation,31574,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1762.04,,,,,,,fee schedule,1762.04,7817.58,APC
Largsc w/njx augmentation,31574,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2695.92,,,,,,,fee schedule,1762.04,7817.58,Radiology
Largsc w/njx augmentation,31574,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2466.86,,,,,,,fee schedule,1762.04,7817.58,APC
Largsc w/njx augmentation,31574,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3083.57,,,,,,,fee schedule,1762.04,7817.58,APC
Diagnostic laryngoscopy,31575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,483.29,,,,,,,fee schedule,197.6,876.7,
Diagnostic laryngoscopy,31575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,387.4,,,,,,,fee schedule,197.6,876.7,
Diagnostic laryngoscopy,31575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,423.19,,,,,,,fee schedule,197.6,876.7,
Diagnostic laryngoscopy,31575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,444.93,,,,,,,fee schedule,197.6,876.7,
Diagnostic laryngoscopy,31575,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,876.7,,,,,,,fee schedule,197.6,876.7,APC 378
Diagnostic laryngoscopy,31575,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,207.48,,,,,,,fee schedule,197.6,876.7,APC
Diagnostic laryngoscopy,31575,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,205.51,,,,,,,fee schedule,197.6,876.7,APC
Diagnostic laryngoscopy,31575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,197.6,,,,,,,fee schedule,197.6,876.7,APC
Diagnostic laryngoscopy,31575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,302.33,,,,,,,fee schedule,197.6,876.7,Radiology
Diagnostic laryngoscopy,31575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,276.65,,,,,,,fee schedule,197.6,876.7,APC
Diagnostic laryngoscopy,31575,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,345.81,,,,,,,fee schedule,197.6,876.7,APC
Laryngoscopy with biopsy,31576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5670.11,,,,,,,fee schedule,1762.04,7817.58,
Laryngoscopy with biopsy,31576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4545.09,,,,,,,fee schedule,1762.04,7817.58,
Laryngoscopy with biopsy,31576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4965.1,,,,,,,fee schedule,1762.04,7817.58,
Laryngoscopy with biopsy,31576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5220.1,,,,,,,fee schedule,1762.04,7817.58,
Laryngoscopy with biopsy,31576,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7817.58,,,,,,,fee schedule,1762.04,7817.58,APC 378
Laryngoscopy with biopsy,31576,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1850.14,,,,,,,fee schedule,1762.04,7817.58,APC
Laryngoscopy with biopsy,31576,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1832.52,,,,,,,fee schedule,1762.04,7817.58,APC
Laryngoscopy with biopsy,31576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1762.04,,,,,,,fee schedule,1762.04,7817.58,APC
Laryngoscopy with biopsy,31576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2695.92,,,,,,,fee schedule,1762.04,7817.58,Radiology
Laryngoscopy with biopsy,31576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2466.86,,,,,,,fee schedule,1762.04,7817.58,APC
Laryngoscopy with biopsy,31576,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3083.57,,,,,,,fee schedule,1762.04,7817.58,APC
Largsc w/rmvl foreign bdy(s),31577,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,996.79,,,,,,,fee schedule,387.19,1717.85,
Largsc w/rmvl foreign bdy(s),31577,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,799.01,,,,,,,fee schedule,387.19,1717.85,
Largsc w/rmvl foreign bdy(s),31577,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,872.85,,,,,,,fee schedule,387.19,1717.85,
Largsc w/rmvl foreign bdy(s),31577,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,917.68,,,,,,,fee schedule,387.19,1717.85,
Largsc w/rmvl foreign bdy(s),31577,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1717.85,,,,,,,fee schedule,387.19,1717.85,APC 378
Largsc w/rmvl foreign bdy(s),31577,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,406.55,,,,,,,fee schedule,387.19,1717.85,APC
Largsc w/rmvl foreign bdy(s),31577,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,402.68,,,,,,,fee schedule,387.19,1717.85,APC
Largsc w/rmvl foreign bdy(s),31577,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,387.19,,,,,,,fee schedule,387.19,1717.85,APC
Largsc w/rmvl foreign bdy(s),31577,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,592.41,,,,,,,fee schedule,387.19,1717.85,Radiology
Largsc w/rmvl foreign bdy(s),31577,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,542.07,,,,,,,fee schedule,387.19,1717.85,APC
Largsc w/rmvl foreign bdy(s),31577,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,677.59,,,,,,,fee schedule,387.19,1717.85,APC
Largsc w/removal lesion,31578,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5670.11,,,,,,,fee schedule,3690.94,16375.46,
Largsc w/removal lesion,31578,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4545.09,,,,,,,fee schedule,3690.94,16375.46,
Largsc w/removal lesion,31578,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4965.1,,,,,,,fee schedule,3690.94,16375.46,
Largsc w/removal lesion,31578,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5220.1,,,,,,,fee schedule,3690.94,16375.46,
Largsc w/removal lesion,31578,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16375.46,,,,,,,fee schedule,3690.94,16375.46,APC 378
Largsc w/removal lesion,31578,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3875.49,,,,,,,fee schedule,3690.94,16375.46,APC
Largsc w/removal lesion,31578,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3838.58,,,,,,,fee schedule,3690.94,16375.46,APC
Largsc w/removal lesion,31578,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3690.94,,,,,,,fee schedule,3690.94,16375.46,APC
Largsc w/removal lesion,31578,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5647.14,,,,,,,fee schedule,3690.94,16375.46,Radiology
Largsc w/removal lesion,31578,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5167.32,,,,,,,fee schedule,3690.94,16375.46,APC
Largsc w/removal lesion,31578,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6459.15,,,,,,,fee schedule,3690.94,16375.46,APC
Laryngoscopy telescopic,31579,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,996.79,,,,,,,fee schedule,387.19,1717.85,
Laryngoscopy telescopic,31579,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,799.01,,,,,,,fee schedule,387.19,1717.85,
Laryngoscopy telescopic,31579,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,872.85,,,,,,,fee schedule,387.19,1717.85,
Laryngoscopy telescopic,31579,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,917.68,,,,,,,fee schedule,387.19,1717.85,
Laryngoscopy telescopic,31579,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1717.85,,,,,,,fee schedule,387.19,1717.85,APC 378
Laryngoscopy telescopic,31579,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,406.55,,,,,,,fee schedule,387.19,1717.85,APC
Laryngoscopy telescopic,31579,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,402.68,,,,,,,fee schedule,387.19,1717.85,APC
Laryngoscopy telescopic,31579,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,387.19,,,,,,,fee schedule,387.19,1717.85,APC
Laryngoscopy telescopic,31579,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,592.41,,,,,,,fee schedule,387.19,1717.85,Radiology
Laryngoscopy telescopic,31579,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,542.07,,,,,,,fee schedule,387.19,1717.85,APC
Laryngoscopy telescopic,31579,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,677.59,,,,,,,fee schedule,387.19,1717.85,APC
Laryngoplasty laryngeal web,31580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Laryngoplasty laryngeal web,31580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Laryngoplasty laryngeal web,31580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Laryngoplasty laryngeal web,31580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Laryngoplasty laryngeal web,31580,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Laryngoplasty laryngeal web,31580,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Laryngoplasty laryngeal web,31580,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Laryngoplasty laryngeal web,31580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Laryngoplasty laryngeal web,31580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Laryngoplasty laryngeal web,31580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Laryngoplasty laryngeal web,31580,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Laryngoplasty fx rdctj fixj,31584,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15614.95,,,,,,,fee schedule,5860.44,26000.79,
Laryngoplasty fx rdctj fixj,31584,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12516.75,,,,,,,fee schedule,5860.44,26000.79,
Laryngoplasty fx rdctj fixj,31584,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13673.41,,,,,,,fee schedule,5860.44,26000.79,
Laryngoplasty fx rdctj fixj,31584,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14375.67,,,,,,,fee schedule,5860.44,26000.79,
Laryngoplasty fx rdctj fixj,31584,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Laryngoplasty fx rdctj fixj,31584,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Laryngoplasty fx rdctj fixj,31584,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Laryngoplasty fx rdctj fixj,31584,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Laryngoplasty fx rdctj fixj,31584,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Laryngoplasty fx rdctj fixj,31584,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Laryngoplasty fx rdctj fixj,31584,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Laryngoplasty cricoid split,31587,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15614.95,,,,,,,fee schedule,5860.44,26000.79,
Laryngoplasty cricoid split,31587,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12516.75,,,,,,,fee schedule,5860.44,26000.79,
Laryngoplasty cricoid split,31587,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13673.41,,,,,,,fee schedule,5860.44,26000.79,
Laryngoplasty cricoid split,31587,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14375.67,,,,,,,fee schedule,5860.44,26000.79,
Laryngoplasty cricoid split,31587,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Laryngoplasty cricoid split,31587,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Laryngoplasty cricoid split,31587,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Laryngoplasty cricoid split,31587,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Laryngoplasty cricoid split,31587,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Laryngoplasty cricoid split,31587,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Laryngoplasty cricoid split,31587,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Reinnervate larynx,31590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Reinnervate larynx,31590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Reinnervate larynx,31590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Reinnervate larynx,31590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Reinnervate larynx,31590,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Reinnervate larynx,31590,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Reinnervate larynx,31590,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Reinnervate larynx,31590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Reinnervate larynx,31590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Reinnervate larynx,31590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Reinnervate larynx,31590,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Laryngoplasty medialization,31591,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15614.95,,,,,,,fee schedule,5860.44,26000.79,
Laryngoplasty medialization,31591,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12516.75,,,,,,,fee schedule,5860.44,26000.79,
Laryngoplasty medialization,31591,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13673.41,,,,,,,fee schedule,5860.44,26000.79,
Laryngoplasty medialization,31591,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14375.67,,,,,,,fee schedule,5860.44,26000.79,
Laryngoplasty medialization,31591,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Laryngoplasty medialization,31591,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Laryngoplasty medialization,31591,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Laryngoplasty medialization,31591,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Laryngoplasty medialization,31591,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Laryngoplasty medialization,31591,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Laryngoplasty medialization,31591,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Cricotracheal resection,31592,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15614.95,,,,,,,fee schedule,5860.44,26000.79,
Cricotracheal resection,31592,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12516.75,,,,,,,fee schedule,5860.44,26000.79,
Cricotracheal resection,31592,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13673.41,,,,,,,fee schedule,5860.44,26000.79,
Cricotracheal resection,31592,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14375.67,,,,,,,fee schedule,5860.44,26000.79,
Cricotracheal resection,31592,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Cricotracheal resection,31592,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Cricotracheal resection,31592,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Cricotracheal resection,31592,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Cricotracheal resection,31592,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Cricotracheal resection,31592,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Cricotracheal resection,31592,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Larynx surgery procedure,31599,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3828.9,,,,,,,fee schedule,234.47,3828.9,
Larynx surgery procedure,31599,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3069.2,,,,,,,fee schedule,234.47,3828.9,
Larynx surgery procedure,31599,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3352.82,,,,,,,fee schedule,234.47,3828.9,
Larynx surgery procedure,31599,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3525.02,,,,,,,fee schedule,234.47,3828.9,
Larynx surgery procedure,31599,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1040.28,,,,,,,fee schedule,234.47,3828.9,APC 378
Larynx surgery procedure,31599,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,246.2,,,,,,,fee schedule,234.47,3828.9,APC
Larynx surgery procedure,31599,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,243.85,,,,,,,fee schedule,234.47,3828.9,APC
Larynx surgery procedure,31599,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,234.47,,,,,,,fee schedule,234.47,3828.9,APC
Larynx surgery procedure,31599,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,358.74,,,,,,,fee schedule,234.47,3828.9,Radiology
Larynx surgery procedure,31599,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,328.26,,,,,,,fee schedule,234.47,3828.9,APC
Larynx surgery procedure,31599,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,410.33,,,,,,,fee schedule,234.47,3828.9,APC
Incision of windpipe,31600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5983.93,,,,,,,fee schedule,3282.2,14562,
Incision of windpipe,31600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4796.64,,,,,,,fee schedule,3282.2,14562,
Incision of windpipe,31600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5239.9,,,,,,,fee schedule,3282.2,14562,
Incision of windpipe,31600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.01,,,,,,,fee schedule,3282.2,14562,
Incision of windpipe,31600,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Incision of windpipe,31600,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Incision of windpipe,31600,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Incision of windpipe,31600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Incision of windpipe,31600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Incision of windpipe,31600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Incision of windpipe,31600,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Incision of windpipe,31601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5983.93,,,,,,,fee schedule,4796.64,26000.79,
Incision of windpipe,31601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4796.64,,,,,,,fee schedule,4796.64,26000.79,
Incision of windpipe,31601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5239.9,,,,,,,fee schedule,4796.64,26000.79,
Incision of windpipe,31601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.01,,,,,,,fee schedule,4796.64,26000.79,
Incision of windpipe,31601,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,4796.64,26000.79,APC 378
Incision of windpipe,31601,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,4796.64,26000.79,APC
Incision of windpipe,31601,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,4796.64,26000.79,APC
Incision of windpipe,31601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,4796.64,26000.79,APC
Incision of windpipe,31601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,4796.64,26000.79,Radiology
Incision of windpipe,31601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,4796.64,26000.79,APC
Incision of windpipe,31601,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,4796.64,26000.79,APC
Incision of windpipe,31603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1858.66,,,,,,,fee schedule,1489.88,6814.79,
Incision of windpipe,31603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1489.88,,,,,,,fee schedule,1489.88,6814.79,
Incision of windpipe,31603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1627.56,,,,,,,fee schedule,1489.88,6814.79,
Incision of windpipe,31603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1711.15,,,,,,,fee schedule,1489.88,6814.79,
Incision of windpipe,31603,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1489.88,6814.79,APC 378
Incision of windpipe,31603,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1489.88,6814.79,APC
Incision of windpipe,31603,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1489.88,6814.79,APC
Incision of windpipe,31603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1489.88,6814.79,APC
Incision of windpipe,31603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1489.88,6814.79,Radiology
Incision of windpipe,31603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1489.88,6814.79,APC
Incision of windpipe,31603,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1489.88,6814.79,APC
Incision of windpipe,31605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1858.66,,,,,,,fee schedule,234.47,1858.66,
Incision of windpipe,31605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1489.88,,,,,,,fee schedule,234.47,1858.66,
Incision of windpipe,31605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1627.56,,,,,,,fee schedule,234.47,1858.66,
Incision of windpipe,31605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1711.15,,,,,,,fee schedule,234.47,1858.66,
Incision of windpipe,31605,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1040.28,,,,,,,fee schedule,234.47,1858.66,APC 378
Incision of windpipe,31605,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,246.2,,,,,,,fee schedule,234.47,1858.66,APC
Incision of windpipe,31605,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,243.85,,,,,,,fee schedule,234.47,1858.66,APC
Incision of windpipe,31605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,234.47,,,,,,,fee schedule,234.47,1858.66,APC
Incision of windpipe,31605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,358.74,,,,,,,fee schedule,234.47,1858.66,Radiology
Incision of windpipe,31605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,328.26,,,,,,,fee schedule,234.47,1858.66,APC
Incision of windpipe,31605,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,410.33,,,,,,,fee schedule,234.47,1858.66,APC
Incision of windpipe,31610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5983.93,,,,,,,fee schedule,4796.64,26000.79,
Incision of windpipe,31610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4796.64,,,,,,,fee schedule,4796.64,26000.79,
Incision of windpipe,31610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5239.9,,,,,,,fee schedule,4796.64,26000.79,
Incision of windpipe,31610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.01,,,,,,,fee schedule,4796.64,26000.79,
Incision of windpipe,31610,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,4796.64,26000.79,APC 378
Incision of windpipe,31610,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,4796.64,26000.79,APC
Incision of windpipe,31610,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,4796.64,26000.79,APC
Incision of windpipe,31610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,4796.64,26000.79,APC
Incision of windpipe,31610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,4796.64,26000.79,Radiology
Incision of windpipe,31610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,4796.64,26000.79,APC
Incision of windpipe,31610,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,4796.64,26000.79,APC
Surgery/speech prosthesis,31611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5983.93,,,,,,,fee schedule,3282.2,14562,
Surgery/speech prosthesis,31611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4796.64,,,,,,,fee schedule,3282.2,14562,
Surgery/speech prosthesis,31611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5239.9,,,,,,,fee schedule,3282.2,14562,
Surgery/speech prosthesis,31611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.01,,,,,,,fee schedule,3282.2,14562,
Surgery/speech prosthesis,31611,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Surgery/speech prosthesis,31611,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Surgery/speech prosthesis,31611,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Surgery/speech prosthesis,31611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Surgery/speech prosthesis,31611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Surgery/speech prosthesis,31611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Surgery/speech prosthesis,31611,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Puncture/clear windpipe,31612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5983.93,,,,,,,fee schedule,3282.2,14562,
Puncture/clear windpipe,31612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4796.64,,,,,,,fee schedule,3282.2,14562,
Puncture/clear windpipe,31612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5239.9,,,,,,,fee schedule,3282.2,14562,
Puncture/clear windpipe,31612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.01,,,,,,,fee schedule,3282.2,14562,
Puncture/clear windpipe,31612,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Puncture/clear windpipe,31612,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Puncture/clear windpipe,31612,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Puncture/clear windpipe,31612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Puncture/clear windpipe,31612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Puncture/clear windpipe,31612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Puncture/clear windpipe,31612,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Repair windpipe opening,31613,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5983.93,,,,,,,fee schedule,3282.2,14562,
Repair windpipe opening,31613,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4796.64,,,,,,,fee schedule,3282.2,14562,
Repair windpipe opening,31613,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5239.9,,,,,,,fee schedule,3282.2,14562,
Repair windpipe opening,31613,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.01,,,,,,,fee schedule,3282.2,14562,
Repair windpipe opening,31613,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Repair windpipe opening,31613,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Repair windpipe opening,31613,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Repair windpipe opening,31613,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Repair windpipe opening,31613,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Repair windpipe opening,31613,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Repair windpipe opening,31613,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Repair windpipe opening,31614,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Repair windpipe opening,31614,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Repair windpipe opening,31614,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Repair windpipe opening,31614,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Repair windpipe opening,31614,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Repair windpipe opening,31614,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Repair windpipe opening,31614,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Repair windpipe opening,31614,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Repair windpipe opening,31614,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Repair windpipe opening,31614,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Repair windpipe opening,31614,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Visualization of windpipe,31615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2485.12,,,,,,,fee schedule,533.92,2485.12,
Visualization of windpipe,31615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1992.04,,,,,,,fee schedule,533.92,2485.12,
Visualization of windpipe,31615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2176.13,,,,,,,fee schedule,533.92,2485.12,
Visualization of windpipe,31615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2287.89,,,,,,,fee schedule,533.92,2485.12,
Visualization of windpipe,31615,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2368.81,,,,,,,fee schedule,533.92,2485.12,APC 378
Visualization of windpipe,31615,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,560.61,,,,,,,fee schedule,533.92,2485.12,APC
Visualization of windpipe,31615,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,555.27,,,,,,,fee schedule,533.92,2485.12,APC
Visualization of windpipe,31615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,533.92,,,,,,,fee schedule,533.92,2485.12,APC
Visualization of windpipe,31615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,816.89,,,,,,,fee schedule,533.92,2485.12,Radiology
Visualization of windpipe,31615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,747.48,,,,,,,fee schedule,533.92,2485.12,APC
Visualization of windpipe,31615,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,934.36,,,,,,,fee schedule,533.92,2485.12,APC
Dx bronchoscope/wash,31622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1413.01,,,,,,,fee schedule,1132.65,7817.58,
Dx bronchoscope/wash,31622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1132.65,,,,,,,fee schedule,1132.65,7817.58,
Dx bronchoscope/wash,31622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1237.32,,,,,,,fee schedule,1132.65,7817.58,
Dx bronchoscope/wash,31622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1300.87,,,,,,,fee schedule,1132.65,7817.58,
Dx bronchoscope/wash,31622,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7817.58,,,,,,,fee schedule,1132.65,7817.58,APC 378
Dx bronchoscope/wash,31622,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1850.14,,,,,,,fee schedule,1132.65,7817.58,APC
Dx bronchoscope/wash,31622,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1832.52,,,,,,,fee schedule,1132.65,7817.58,APC
Dx bronchoscope/wash,31622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1762.04,,,,,,,fee schedule,1132.65,7817.58,APC
Dx bronchoscope/wash,31622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2695.92,,,,,,,fee schedule,1132.65,7817.58,Radiology
Dx bronchoscope/wash,31622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2466.86,,,,,,,fee schedule,1132.65,7817.58,APC
Dx bronchoscope/wash,31622,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3083.57,,,,,,,fee schedule,1132.65,7817.58,APC
Dx bronchoscope/brush,31623,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,956.94,,,,,,,fee schedule,767.07,7817.58,
Dx bronchoscope/brush,31623,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,767.07,,,,,,,fee schedule,767.07,7817.58,
Dx bronchoscope/brush,31623,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,837.96,,,,,,,fee schedule,767.07,7817.58,
Dx bronchoscope/brush,31623,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,880.99,,,,,,,fee schedule,767.07,7817.58,
Dx bronchoscope/brush,31623,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7817.58,,,,,,,fee schedule,767.07,7817.58,APC 378
Dx bronchoscope/brush,31623,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1850.14,,,,,,,fee schedule,767.07,7817.58,APC
Dx bronchoscope/brush,31623,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1832.52,,,,,,,fee schedule,767.07,7817.58,APC
Dx bronchoscope/brush,31623,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1762.04,,,,,,,fee schedule,767.07,7817.58,APC
Dx bronchoscope/brush,31623,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2695.92,,,,,,,fee schedule,767.07,7817.58,Radiology
Dx bronchoscope/brush,31623,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2466.86,,,,,,,fee schedule,767.07,7817.58,APC
Dx bronchoscope/brush,31623,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3083.57,,,,,,,fee schedule,767.07,7817.58,APC
Dx bronchoscope/lavage,31624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1015,,,,,,,fee schedule,813.61,7817.58,
Dx bronchoscope/lavage,31624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,813.61,,,,,,,fee schedule,813.61,7817.58,
Dx bronchoscope/lavage,31624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,888.8,,,,,,,fee schedule,813.61,7817.58,
Dx bronchoscope/lavage,31624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,934.45,,,,,,,fee schedule,813.61,7817.58,
Dx bronchoscope/lavage,31624,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7817.58,,,,,,,fee schedule,813.61,7817.58,APC 378
Dx bronchoscope/lavage,31624,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1850.14,,,,,,,fee schedule,813.61,7817.58,APC
Dx bronchoscope/lavage,31624,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1832.52,,,,,,,fee schedule,813.61,7817.58,APC
Dx bronchoscope/lavage,31624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1762.04,,,,,,,fee schedule,813.61,7817.58,APC
Dx bronchoscope/lavage,31624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2695.92,,,,,,,fee schedule,813.61,7817.58,Radiology
Dx bronchoscope/lavage,31624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2466.86,,,,,,,fee schedule,813.61,7817.58,APC
Dx bronchoscope/lavage,31624,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3083.57,,,,,,,fee schedule,813.61,7817.58,APC
Bronchoscopy w/biopsy(s),31625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1230.34,,,,,,,fee schedule,986.22,7817.58,
Bronchoscopy w/biopsy(s),31625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,986.22,,,,,,,fee schedule,986.22,7817.58,
Bronchoscopy w/biopsy(s),31625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1077.36,,,,,,,fee schedule,986.22,7817.58,
Bronchoscopy w/biopsy(s),31625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1132.69,,,,,,,fee schedule,986.22,7817.58,
Bronchoscopy w/biopsy(s),31625,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7817.58,,,,,,,fee schedule,986.22,7817.58,APC 378
Bronchoscopy w/biopsy(s),31625,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1850.14,,,,,,,fee schedule,986.22,7817.58,APC
Bronchoscopy w/biopsy(s),31625,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1832.52,,,,,,,fee schedule,986.22,7817.58,APC
Bronchoscopy w/biopsy(s),31625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1762.04,,,,,,,fee schedule,986.22,7817.58,APC
Bronchoscopy w/biopsy(s),31625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2695.92,,,,,,,fee schedule,986.22,7817.58,Radiology
Bronchoscopy w/biopsy(s),31625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2466.86,,,,,,,fee schedule,986.22,7817.58,APC
Bronchoscopy w/biopsy(s),31625,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3083.57,,,,,,,fee schedule,986.22,7817.58,APC
Bronchoscopy w/markers,31626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2739.14,,,,,,,fee schedule,2195.66,30997.43,
Bronchoscopy w/markers,31626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2195.66,,,,,,,fee schedule,2195.66,30997.43,
Bronchoscopy w/markers,31626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2398.56,,,,,,,fee schedule,2195.66,30997.43,
Bronchoscopy w/markers,31626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2521.75,,,,,,,fee schedule,2195.66,30997.43,
Bronchoscopy w/markers,31626,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,30997.43,,,,,,,fee schedule,2195.66,30997.43,APC 378
Bronchoscopy w/markers,31626,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7335.99,,,,,,,fee schedule,2195.66,30997.43,APC
Bronchoscopy w/markers,31626,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7266.12,,,,,,,fee schedule,2195.66,30997.43,APC
Bronchoscopy w/markers,31626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6986.66,,,,,,,fee schedule,2195.66,30997.43,APC
Bronchoscopy w/markers,31626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10689.58,,,,,,,fee schedule,2195.66,30997.43,Radiology
Bronchoscopy w/markers,31626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9781.32,,,,,,,fee schedule,2195.66,30997.43,APC
Bronchoscopy w/markers,31626,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12226.65,,,,,,,fee schedule,2195.66,30997.43,APC
Bronchoscopy/lung bx each,31628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1816.83,,,,,,,fee schedule,1456.35,16375.46,
Bronchoscopy/lung bx each,31628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1456.35,,,,,,,fee schedule,1456.35,16375.46,
Bronchoscopy/lung bx each,31628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1590.93,,,,,,,fee schedule,1456.35,16375.46,
Bronchoscopy/lung bx each,31628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1672.64,,,,,,,fee schedule,1456.35,16375.46,
Bronchoscopy/lung bx each,31628,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16375.46,,,,,,,fee schedule,1456.35,16375.46,APC 378
Bronchoscopy/lung bx each,31628,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3875.49,,,,,,,fee schedule,1456.35,16375.46,APC
Bronchoscopy/lung bx each,31628,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3838.58,,,,,,,fee schedule,1456.35,16375.46,APC
Bronchoscopy/lung bx each,31628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3690.94,,,,,,,fee schedule,1456.35,16375.46,APC
Bronchoscopy/lung bx each,31628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5647.14,,,,,,,fee schedule,1456.35,16375.46,Radiology
Bronchoscopy/lung bx each,31628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5167.32,,,,,,,fee schedule,1456.35,16375.46,APC
Bronchoscopy/lung bx each,31628,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6459.15,,,,,,,fee schedule,1456.35,16375.46,APC
Bronchoscopy/needle bx each,31629,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6402.99,,,,,,,fee schedule,3690.94,16375.46,
Bronchoscopy/needle bx each,31629,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5132.56,,,,,,,fee schedule,3690.94,16375.46,
Bronchoscopy/needle bx each,31629,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5606.85,,,,,,,fee schedule,3690.94,16375.46,
Bronchoscopy/needle bx each,31629,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5894.82,,,,,,,fee schedule,3690.94,16375.46,
Bronchoscopy/needle bx each,31629,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16375.46,,,,,,,fee schedule,3690.94,16375.46,APC 378
Bronchoscopy/needle bx each,31629,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3875.49,,,,,,,fee schedule,3690.94,16375.46,APC
Bronchoscopy/needle bx each,31629,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3838.58,,,,,,,fee schedule,3690.94,16375.46,APC
Bronchoscopy/needle bx each,31629,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3690.94,,,,,,,fee schedule,3690.94,16375.46,APC
Bronchoscopy/needle bx each,31629,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5647.14,,,,,,,fee schedule,3690.94,16375.46,Radiology
Bronchoscopy/needle bx each,31629,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5167.32,,,,,,,fee schedule,3690.94,16375.46,APC
Bronchoscopy/needle bx each,31629,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6459.15,,,,,,,fee schedule,3690.94,16375.46,APC
Bronchoscopy dilate/fx repr,31630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6006.12,,,,,,,fee schedule,3690.94,16375.46,
Bronchoscopy dilate/fx repr,31630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4814.43,,,,,,,fee schedule,3690.94,16375.46,
Bronchoscopy dilate/fx repr,31630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5259.33,,,,,,,fee schedule,3690.94,16375.46,
Bronchoscopy dilate/fx repr,31630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5529.44,,,,,,,fee schedule,3690.94,16375.46,
Bronchoscopy dilate/fx repr,31630,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16375.46,,,,,,,fee schedule,3690.94,16375.46,APC 378
Bronchoscopy dilate/fx repr,31630,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3875.49,,,,,,,fee schedule,3690.94,16375.46,APC
Bronchoscopy dilate/fx repr,31630,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3838.58,,,,,,,fee schedule,3690.94,16375.46,APC
Bronchoscopy dilate/fx repr,31630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3690.94,,,,,,,fee schedule,3690.94,16375.46,APC
Bronchoscopy dilate/fx repr,31630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5647.14,,,,,,,fee schedule,3690.94,16375.46,Radiology
Bronchoscopy dilate/fx repr,31630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5167.32,,,,,,,fee schedule,3690.94,16375.46,APC
Bronchoscopy dilate/fx repr,31630,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6459.15,,,,,,,fee schedule,3690.94,16375.46,APC
Bronchoscopy dilate w/stent,31631,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6006.12,,,,,,,fee schedule,4814.43,30997.43,
Bronchoscopy dilate w/stent,31631,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4814.43,,,,,,,fee schedule,4814.43,30997.43,
Bronchoscopy dilate w/stent,31631,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5259.33,,,,,,,fee schedule,4814.43,30997.43,
Bronchoscopy dilate w/stent,31631,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5529.44,,,,,,,fee schedule,4814.43,30997.43,
Bronchoscopy dilate w/stent,31631,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,30997.43,,,,,,,fee schedule,4814.43,30997.43,APC 378
Bronchoscopy dilate w/stent,31631,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7335.99,,,,,,,fee schedule,4814.43,30997.43,APC
Bronchoscopy dilate w/stent,31631,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7266.12,,,,,,,fee schedule,4814.43,30997.43,APC
Bronchoscopy dilate w/stent,31631,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6986.66,,,,,,,fee schedule,4814.43,30997.43,APC
Bronchoscopy dilate w/stent,31631,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10689.58,,,,,,,fee schedule,4814.43,30997.43,Radiology
Bronchoscopy dilate w/stent,31631,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9781.32,,,,,,,fee schedule,4814.43,30997.43,APC
Bronchoscopy dilate w/stent,31631,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12226.65,,,,,,,fee schedule,4814.43,30997.43,APC
Bronchoscopy/lung bx addl,31632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1225.91,,,,,,,fee schedule,982.67,1225.91,
Bronchoscopy/lung bx addl,31632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,982.67,,,,,,,fee schedule,982.67,1225.91,
Bronchoscopy/lung bx addl,31632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1073.48,,,,,,,fee schedule,982.67,1225.91,
Bronchoscopy/lung bx addl,31632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1128.61,,,,,,,fee schedule,982.67,1225.91,
Bronchoscopy/needle bx addl,31633,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2485.12,,,,,,,fee schedule,1992.04,2485.12,
Bronchoscopy/needle bx addl,31633,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1992.04,,,,,,,fee schedule,1992.04,2485.12,
Bronchoscopy/needle bx addl,31633,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2176.13,,,,,,,fee schedule,1992.04,2485.12,
Bronchoscopy/needle bx addl,31633,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2287.89,,,,,,,fee schedule,1992.04,2485.12,
Bronch w/balloon occlusion,31634,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2733.85,,,,,,,fee schedule,2191.42,30997.43,
Bronch w/balloon occlusion,31634,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2191.42,,,,,,,fee schedule,2191.42,30997.43,
Bronch w/balloon occlusion,31634,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2393.92,,,,,,,fee schedule,2191.42,30997.43,
Bronch w/balloon occlusion,31634,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2516.88,,,,,,,fee schedule,2191.42,30997.43,
Bronch w/balloon occlusion,31634,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,30997.43,,,,,,,fee schedule,2191.42,30997.43,APC 378
Bronch w/balloon occlusion,31634,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7335.99,,,,,,,fee schedule,2191.42,30997.43,APC
Bronch w/balloon occlusion,31634,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7266.12,,,,,,,fee schedule,2191.42,30997.43,APC
Bronch w/balloon occlusion,31634,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6986.66,,,,,,,fee schedule,2191.42,30997.43,APC
Bronch w/balloon occlusion,31634,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10689.58,,,,,,,fee schedule,2191.42,30997.43,Radiology
Bronch w/balloon occlusion,31634,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9781.32,,,,,,,fee schedule,2191.42,30997.43,APC
Bronch w/balloon occlusion,31634,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12226.65,,,,,,,fee schedule,2191.42,30997.43,APC
Bronchoscopy w/fb removal,31635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2485.12,,,,,,,fee schedule,1762.04,7817.58,
Bronchoscopy w/fb removal,31635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1992.04,,,,,,,fee schedule,1762.04,7817.58,
Bronchoscopy w/fb removal,31635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2176.13,,,,,,,fee schedule,1762.04,7817.58,
Bronchoscopy w/fb removal,31635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2287.89,,,,,,,fee schedule,1762.04,7817.58,
Bronchoscopy w/fb removal,31635,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7817.58,,,,,,,fee schedule,1762.04,7817.58,APC 378
Bronchoscopy w/fb removal,31635,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1850.14,,,,,,,fee schedule,1762.04,7817.58,APC
Bronchoscopy w/fb removal,31635,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1832.52,,,,,,,fee schedule,1762.04,7817.58,APC
Bronchoscopy w/fb removal,31635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1762.04,,,,,,,fee schedule,1762.04,7817.58,APC
Bronchoscopy w/fb removal,31635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2695.92,,,,,,,fee schedule,1762.04,7817.58,Radiology
Bronchoscopy w/fb removal,31635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2466.86,,,,,,,fee schedule,1762.04,7817.58,APC
Bronchoscopy w/fb removal,31635,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3083.57,,,,,,,fee schedule,1762.04,7817.58,APC
Bronchoscopy bronch stents,31636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6006.12,,,,,,,fee schedule,4814.43,30997.43,
Bronchoscopy bronch stents,31636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4814.43,,,,,,,fee schedule,4814.43,30997.43,
Bronchoscopy bronch stents,31636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5259.33,,,,,,,fee schedule,4814.43,30997.43,
Bronchoscopy bronch stents,31636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5529.44,,,,,,,fee schedule,4814.43,30997.43,
Bronchoscopy bronch stents,31636,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,30997.43,,,,,,,fee schedule,4814.43,30997.43,APC 378
Bronchoscopy bronch stents,31636,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7335.99,,,,,,,fee schedule,4814.43,30997.43,APC
Bronchoscopy bronch stents,31636,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7266.12,,,,,,,fee schedule,4814.43,30997.43,APC
Bronchoscopy bronch stents,31636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6986.66,,,,,,,fee schedule,4814.43,30997.43,APC
Bronchoscopy bronch stents,31636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10689.58,,,,,,,fee schedule,4814.43,30997.43,Radiology
Bronchoscopy bronch stents,31636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9781.32,,,,,,,fee schedule,4814.43,30997.43,APC
Bronchoscopy bronch stents,31636,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12226.65,,,,,,,fee schedule,4814.43,30997.43,APC
Bronchoscopy stent add-on,31637,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2485.12,,,,,,,fee schedule,1992.04,2485.12,
Bronchoscopy stent add-on,31637,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1992.04,,,,,,,fee schedule,1992.04,2485.12,
Bronchoscopy stent add-on,31637,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2176.13,,,,,,,fee schedule,1992.04,2485.12,
Bronchoscopy stent add-on,31637,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2287.89,,,,,,,fee schedule,1992.04,2485.12,
Bronchoscopy revise stent,31638,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6006.12,,,,,,,fee schedule,4814.43,30997.43,
Bronchoscopy revise stent,31638,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4814.43,,,,,,,fee schedule,4814.43,30997.43,
Bronchoscopy revise stent,31638,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5259.33,,,,,,,fee schedule,4814.43,30997.43,
Bronchoscopy revise stent,31638,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5529.44,,,,,,,fee schedule,4814.43,30997.43,
Bronchoscopy revise stent,31638,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,30997.43,,,,,,,fee schedule,4814.43,30997.43,APC 378
Bronchoscopy revise stent,31638,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7335.99,,,,,,,fee schedule,4814.43,30997.43,APC
Bronchoscopy revise stent,31638,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7266.12,,,,,,,fee schedule,4814.43,30997.43,APC
Bronchoscopy revise stent,31638,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6986.66,,,,,,,fee schedule,4814.43,30997.43,APC
Bronchoscopy revise stent,31638,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10689.58,,,,,,,fee schedule,4814.43,30997.43,Radiology
Bronchoscopy revise stent,31638,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9781.32,,,,,,,fee schedule,4814.43,30997.43,APC
Bronchoscopy revise stent,31638,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12226.65,,,,,,,fee schedule,4814.43,30997.43,APC
Bronchoscopy w/tumor excise,31640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6006.12,,,,,,,fee schedule,3690.94,16375.46,
Bronchoscopy w/tumor excise,31640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4814.43,,,,,,,fee schedule,3690.94,16375.46,
Bronchoscopy w/tumor excise,31640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5259.33,,,,,,,fee schedule,3690.94,16375.46,
Bronchoscopy w/tumor excise,31640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5529.44,,,,,,,fee schedule,3690.94,16375.46,
Bronchoscopy w/tumor excise,31640,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16375.46,,,,,,,fee schedule,3690.94,16375.46,APC 378
Bronchoscopy w/tumor excise,31640,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3875.49,,,,,,,fee schedule,3690.94,16375.46,APC
Bronchoscopy w/tumor excise,31640,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3838.58,,,,,,,fee schedule,3690.94,16375.46,APC
Bronchoscopy w/tumor excise,31640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3690.94,,,,,,,fee schedule,3690.94,16375.46,APC
Bronchoscopy w/tumor excise,31640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5647.14,,,,,,,fee schedule,3690.94,16375.46,Radiology
Bronchoscopy w/tumor excise,31640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5167.32,,,,,,,fee schedule,3690.94,16375.46,APC
Bronchoscopy w/tumor excise,31640,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6459.15,,,,,,,fee schedule,3690.94,16375.46,APC
Bronchoscopy treat blockage,31641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6006.12,,,,,,,fee schedule,3690.94,16375.46,
Bronchoscopy treat blockage,31641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4814.43,,,,,,,fee schedule,3690.94,16375.46,
Bronchoscopy treat blockage,31641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5259.33,,,,,,,fee schedule,3690.94,16375.46,
Bronchoscopy treat blockage,31641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5529.44,,,,,,,fee schedule,3690.94,16375.46,
Bronchoscopy treat blockage,31641,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16375.46,,,,,,,fee schedule,3690.94,16375.46,APC 378
Bronchoscopy treat blockage,31641,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3875.49,,,,,,,fee schedule,3690.94,16375.46,APC
Bronchoscopy treat blockage,31641,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3838.58,,,,,,,fee schedule,3690.94,16375.46,APC
Bronchoscopy treat blockage,31641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3690.94,,,,,,,fee schedule,3690.94,16375.46,APC
Bronchoscopy treat blockage,31641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5647.14,,,,,,,fee schedule,3690.94,16375.46,Radiology
Bronchoscopy treat blockage,31641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5167.32,,,,,,,fee schedule,3690.94,16375.46,APC
Bronchoscopy treat blockage,31641,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6459.15,,,,,,,fee schedule,3690.94,16375.46,APC
Diag bronchoscope/catheter,31643,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2485.12,,,,,,,fee schedule,1762.04,7817.58,
Diag bronchoscope/catheter,31643,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1992.04,,,,,,,fee schedule,1762.04,7817.58,
Diag bronchoscope/catheter,31643,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2176.13,,,,,,,fee schedule,1762.04,7817.58,
Diag bronchoscope/catheter,31643,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2287.89,,,,,,,fee schedule,1762.04,7817.58,
Diag bronchoscope/catheter,31643,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7817.58,,,,,,,fee schedule,1762.04,7817.58,APC 378
Diag bronchoscope/catheter,31643,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1850.14,,,,,,,fee schedule,1762.04,7817.58,APC
Diag bronchoscope/catheter,31643,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1832.52,,,,,,,fee schedule,1762.04,7817.58,APC
Diag bronchoscope/catheter,31643,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1762.04,,,,,,,fee schedule,1762.04,7817.58,APC
Diag bronchoscope/catheter,31643,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2695.92,,,,,,,fee schedule,1762.04,7817.58,Radiology
Diag bronchoscope/catheter,31643,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2466.86,,,,,,,fee schedule,1762.04,7817.58,APC
Diag bronchoscope/catheter,31643,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3083.57,,,,,,,fee schedule,1762.04,7817.58,APC
Bronchoscopy clear airways,31645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2769.31,,,,,,,fee schedule,1762.04,7817.58,
Bronchoscopy clear airways,31645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2219.85,,,,,,,fee schedule,1762.04,7817.58,
Bronchoscopy clear airways,31645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2424.98,,,,,,,fee schedule,1762.04,7817.58,
Bronchoscopy clear airways,31645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2549.53,,,,,,,fee schedule,1762.04,7817.58,
Bronchoscopy clear airways,31645,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7817.58,,,,,,,fee schedule,1762.04,7817.58,APC 378
Bronchoscopy clear airways,31645,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1850.14,,,,,,,fee schedule,1762.04,7817.58,APC
Bronchoscopy clear airways,31645,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1832.52,,,,,,,fee schedule,1762.04,7817.58,APC
Bronchoscopy clear airways,31645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1762.04,,,,,,,fee schedule,1762.04,7817.58,APC
Bronchoscopy clear airways,31645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2695.92,,,,,,,fee schedule,1762.04,7817.58,Radiology
Bronchoscopy clear airways,31645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2466.86,,,,,,,fee schedule,1762.04,7817.58,APC
Bronchoscopy clear airways,31645,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3083.57,,,,,,,fee schedule,1762.04,7817.58,APC
Bronchoscopy reclear airway,31646,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2485.12,,,,,,,fee schedule,387.19,2485.12,
Bronchoscopy reclear airway,31646,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1992.04,,,,,,,fee schedule,387.19,2485.12,
Bronchoscopy reclear airway,31646,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2176.13,,,,,,,fee schedule,387.19,2485.12,
Bronchoscopy reclear airway,31646,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2287.89,,,,,,,fee schedule,387.19,2485.12,
Bronchoscopy reclear airway,31646,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1717.85,,,,,,,fee schedule,387.19,2485.12,APC 378
Bronchoscopy reclear airway,31646,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,406.55,,,,,,,fee schedule,387.19,2485.12,APC
Bronchoscopy reclear airway,31646,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,402.68,,,,,,,fee schedule,387.19,2485.12,APC
Bronchoscopy reclear airway,31646,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,387.19,,,,,,,fee schedule,387.19,2485.12,APC
Bronchoscopy reclear airway,31646,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,592.41,,,,,,,fee schedule,387.19,2485.12,Radiology
Bronchoscopy reclear airway,31646,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,542.07,,,,,,,fee schedule,387.19,2485.12,APC
Bronchoscopy reclear airway,31646,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,677.59,,,,,,,fee schedule,387.19,2485.12,APC
Bronchial valve init insert,31647,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5942.92,,,,,,,fee schedule,4763.77,30997.43,
Bronchial valve init insert,31647,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4763.77,,,,,,,fee schedule,4763.77,30997.43,
Bronchial valve init insert,31647,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5203.98,,,,,,,fee schedule,4763.77,30997.43,
Bronchial valve init insert,31647,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5471.26,,,,,,,fee schedule,4763.77,30997.43,
Bronchial valve init insert,31647,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,30997.43,,,,,,,fee schedule,4763.77,30997.43,APC 378
Bronchial valve init insert,31647,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7335.99,,,,,,,fee schedule,4763.77,30997.43,APC
Bronchial valve init insert,31647,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7266.12,,,,,,,fee schedule,4763.77,30997.43,APC
Bronchial valve init insert,31647,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6986.66,,,,,,,fee schedule,4763.77,30997.43,APC
Bronchial valve init insert,31647,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10689.58,,,,,,,fee schedule,4763.77,30997.43,Radiology
Bronchial valve init insert,31647,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9781.32,,,,,,,fee schedule,4763.77,30997.43,APC
Bronchial valve init insert,31647,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12226.65,,,,,,,fee schedule,4763.77,30997.43,APC
Bronchial valve remov init,31648,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5942.92,,,,,,,fee schedule,3690.94,16375.46,
Bronchial valve remov init,31648,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4763.77,,,,,,,fee schedule,3690.94,16375.46,
Bronchial valve remov init,31648,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5203.98,,,,,,,fee schedule,3690.94,16375.46,
Bronchial valve remov init,31648,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5471.26,,,,,,,fee schedule,3690.94,16375.46,
Bronchial valve remov init,31648,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16375.46,,,,,,,fee schedule,3690.94,16375.46,APC 378
Bronchial valve remov init,31648,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3875.49,,,,,,,fee schedule,3690.94,16375.46,APC
Bronchial valve remov init,31648,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3838.58,,,,,,,fee schedule,3690.94,16375.46,APC
Bronchial valve remov init,31648,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3690.94,,,,,,,fee schedule,3690.94,16375.46,APC
Bronchial valve remov init,31648,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5647.14,,,,,,,fee schedule,3690.94,16375.46,Radiology
Bronchial valve remov init,31648,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5167.32,,,,,,,fee schedule,3690.94,16375.46,APC
Bronchial valve remov init,31648,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6459.15,,,,,,,fee schedule,3690.94,16375.46,APC
Bronchial valve remov addl,31649,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2887.47,,,,,,,fee schedule,1762.04,7817.58,
Bronchial valve remov addl,31649,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2314.56,,,,,,,fee schedule,1762.04,7817.58,
Bronchial valve remov addl,31649,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2528.44,,,,,,,fee schedule,1762.04,7817.58,
Bronchial valve remov addl,31649,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2658.3,,,,,,,fee schedule,1762.04,7817.58,
Bronchial valve remov addl,31649,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7817.58,,,,,,,fee schedule,1762.04,7817.58,APC 378
Bronchial valve remov addl,31649,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1850.14,,,,,,,fee schedule,1762.04,7817.58,APC
Bronchial valve remov addl,31649,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1832.52,,,,,,,fee schedule,1762.04,7817.58,APC
Bronchial valve remov addl,31649,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1762.04,,,,,,,fee schedule,1762.04,7817.58,APC
Bronchial valve remov addl,31649,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2695.92,,,,,,,fee schedule,1762.04,7817.58,Radiology
Bronchial valve remov addl,31649,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2466.86,,,,,,,fee schedule,1762.04,7817.58,APC
Bronchial valve remov addl,31649,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3083.57,,,,,,,fee schedule,1762.04,7817.58,APC
Bronchial valve addl insert,31651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5942.92,,,,,,,fee schedule,4763.77,5942.92,
Bronchial valve addl insert,31651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4763.77,,,,,,,fee schedule,4763.77,5942.92,
Bronchial valve addl insert,31651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5203.98,,,,,,,fee schedule,4763.77,5942.92,
Bronchial valve addl insert,31651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5471.26,,,,,,,fee schedule,4763.77,5942.92,
Bronch ebus samplng 1/2 node,31652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1816.85,,,,,,,fee schedule,1456.36,16375.46,
Bronch ebus samplng 1/2 node,31652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1456.36,,,,,,,fee schedule,1456.36,16375.46,
Bronch ebus samplng 1/2 node,31652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1590.95,,,,,,,fee schedule,1456.36,16375.46,
Bronch ebus samplng 1/2 node,31652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1672.66,,,,,,,fee schedule,1456.36,16375.46,
Bronch ebus samplng 1/2 node,31652,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16375.46,,,,,,,fee schedule,1456.36,16375.46,APC 378
Bronch ebus samplng 1/2 node,31652,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3875.49,,,,,,,fee schedule,1456.36,16375.46,APC
Bronch ebus samplng 1/2 node,31652,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3838.58,,,,,,,fee schedule,1456.36,16375.46,APC
Bronch ebus samplng 1/2 node,31652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3690.94,,,,,,,fee schedule,1456.36,16375.46,APC
Bronch ebus samplng 1/2 node,31652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5647.14,,,,,,,fee schedule,1456.36,16375.46,Radiology
Bronch ebus samplng 1/2 node,31652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5167.32,,,,,,,fee schedule,1456.36,16375.46,APC
Bronch ebus samplng 1/2 node,31652,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6459.15,,,,,,,fee schedule,1456.36,16375.46,APC
Bronch ebus samplng 3/> node,31653,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2196.83,,,,,,,fee schedule,1760.95,16375.46,
Bronch ebus samplng 3/> node,31653,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1760.95,,,,,,,fee schedule,1760.95,16375.46,
Bronch ebus samplng 3/> node,31653,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1923.68,,,,,,,fee schedule,1760.95,16375.46,
Bronch ebus samplng 3/> node,31653,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2022.47,,,,,,,fee schedule,1760.95,16375.46,
Bronch ebus samplng 3/> node,31653,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16375.46,,,,,,,fee schedule,1760.95,16375.46,APC 378
Bronch ebus samplng 3/> node,31653,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3875.49,,,,,,,fee schedule,1760.95,16375.46,APC
Bronch ebus samplng 3/> node,31653,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3838.58,,,,,,,fee schedule,1760.95,16375.46,APC
Bronch ebus samplng 3/> node,31653,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3690.94,,,,,,,fee schedule,1760.95,16375.46,APC
Bronch ebus samplng 3/> node,31653,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5647.14,,,,,,,fee schedule,1760.95,16375.46,Radiology
Bronch ebus samplng 3/> node,31653,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5167.32,,,,,,,fee schedule,1760.95,16375.46,APC
Bronch ebus samplng 3/> node,31653,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6459.15,,,,,,,fee schedule,1760.95,16375.46,APC
Bronch ebus ivntj perph les,31654,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,262.14,,,,,,,fee schedule,210.13,262.14,
Bronch ebus ivntj perph les,31654,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,210.13,,,,,,,fee schedule,210.13,262.14,
Bronch ebus ivntj perph les,31654,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,229.55,,,,,,,fee schedule,210.13,262.14,
Bronch ebus ivntj perph les,31654,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,241.34,,,,,,,fee schedule,210.13,262.14,
Bronch thermoplsty 1 lobe,31660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5942.92,,,,,,,fee schedule,4763.77,30997.43,
Bronch thermoplsty 1 lobe,31660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4763.77,,,,,,,fee schedule,4763.77,30997.43,
Bronch thermoplsty 1 lobe,31660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5203.98,,,,,,,fee schedule,4763.77,30997.43,
Bronch thermoplsty 1 lobe,31660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5471.26,,,,,,,fee schedule,4763.77,30997.43,
Bronch thermoplsty 1 lobe,31660,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,30997.43,,,,,,,fee schedule,4763.77,30997.43,APC 378
Bronch thermoplsty 1 lobe,31660,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7335.99,,,,,,,fee schedule,4763.77,30997.43,APC
Bronch thermoplsty 1 lobe,31660,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7266.12,,,,,,,fee schedule,4763.77,30997.43,APC
Bronch thermoplsty 1 lobe,31660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6986.66,,,,,,,fee schedule,4763.77,30997.43,APC
Bronch thermoplsty 1 lobe,31660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10689.58,,,,,,,fee schedule,4763.77,30997.43,Radiology
Bronch thermoplsty 1 lobe,31660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9781.32,,,,,,,fee schedule,4763.77,30997.43,APC
Bronch thermoplsty 1 lobe,31660,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12226.65,,,,,,,fee schedule,4763.77,30997.43,APC
Bronch thermoplsty 2/> lobes,31661,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5942.92,,,,,,,fee schedule,4763.77,30997.43,
Bronch thermoplsty 2/> lobes,31661,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4763.77,,,,,,,fee schedule,4763.77,30997.43,
Bronch thermoplsty 2/> lobes,31661,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5203.98,,,,,,,fee schedule,4763.77,30997.43,
Bronch thermoplsty 2/> lobes,31661,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5471.26,,,,,,,fee schedule,4763.77,30997.43,
Bronch thermoplsty 2/> lobes,31661,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,30997.43,,,,,,,fee schedule,4763.77,30997.43,APC 378
Bronch thermoplsty 2/> lobes,31661,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7335.99,,,,,,,fee schedule,4763.77,30997.43,APC
Bronch thermoplsty 2/> lobes,31661,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7266.12,,,,,,,fee schedule,4763.77,30997.43,APC
Bronch thermoplsty 2/> lobes,31661,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6986.66,,,,,,,fee schedule,4763.77,30997.43,APC
Bronch thermoplsty 2/> lobes,31661,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10689.58,,,,,,,fee schedule,4763.77,30997.43,Radiology
Bronch thermoplsty 2/> lobes,31661,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9781.32,,,,,,,fee schedule,4763.77,30997.43,APC
Bronch thermoplsty 2/> lobes,31661,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12226.65,,,,,,,fee schedule,4763.77,30997.43,APC
Bronchial brush biopsy,31717,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,996.79,,,,,,,fee schedule,387.19,1717.85,
Bronchial brush biopsy,31717,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,799.01,,,,,,,fee schedule,387.19,1717.85,
Bronchial brush biopsy,31717,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,872.85,,,,,,,fee schedule,387.19,1717.85,
Bronchial brush biopsy,31717,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,917.68,,,,,,,fee schedule,387.19,1717.85,
Bronchial brush biopsy,31717,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1717.85,,,,,,,fee schedule,387.19,1717.85,APC 378
Bronchial brush biopsy,31717,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,406.55,,,,,,,fee schedule,387.19,1717.85,APC
Bronchial brush biopsy,31717,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,402.68,,,,,,,fee schedule,387.19,1717.85,APC
Bronchial brush biopsy,31717,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,387.19,,,,,,,fee schedule,387.19,1717.85,APC
Bronchial brush biopsy,31717,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,592.41,,,,,,,fee schedule,387.19,1717.85,Radiology
Bronchial brush biopsy,31717,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,542.07,,,,,,,fee schedule,387.19,1717.85,APC
Bronchial brush biopsy,31717,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,677.59,,,,,,,fee schedule,387.19,1717.85,APC
Clearance of airways,31720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,185.3,,,,,,,fee schedule,148.53,961.78,
Clearance of airways,31720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,148.53,,,,,,,fee schedule,148.53,961.78,
Clearance of airways,31720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,162.26,,,,,,,fee schedule,148.53,961.78,
Clearance of airways,31720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,170.59,,,,,,,fee schedule,148.53,961.78,
Clearance of airways,31720,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,961.78,,,,,,,fee schedule,148.53,961.78,APC 378
Clearance of airways,31720,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,227.62,,,,,,,fee schedule,148.53,961.78,APC
Clearance of airways,31720,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,225.45,,,,,,,fee schedule,148.53,961.78,APC
Clearance of airways,31720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,216.78,,,,,,,fee schedule,148.53,961.78,APC
Clearance of airways,31720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,331.67,,,,,,,fee schedule,148.53,961.78,Radiology
Clearance of airways,31720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.49,,,,,,,fee schedule,148.53,961.78,APC
Clearance of airways,31720,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,379.37,,,,,,,fee schedule,148.53,961.78,APC
Clearance of airways,31725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,385.76,,,,,,,fee schedule,309.22,385.76,
Clearance of airways,31725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,309.22,,,,,,,fee schedule,309.22,385.76,
Clearance of airways,31725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,337.8,,,,,,,fee schedule,309.22,385.76,
Clearance of airways,31725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,355.15,,,,,,,fee schedule,309.22,385.76,
Intro windpipe wire/tube,31730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,996.79,,,,,,,fee schedule,799.01,7817.58,
Intro windpipe wire/tube,31730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,799.01,,,,,,,fee schedule,799.01,7817.58,
Intro windpipe wire/tube,31730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,872.85,,,,,,,fee schedule,799.01,7817.58,
Intro windpipe wire/tube,31730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,917.68,,,,,,,fee schedule,799.01,7817.58,
Intro windpipe wire/tube,31730,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7817.58,,,,,,,fee schedule,799.01,7817.58,APC 378
Intro windpipe wire/tube,31730,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1850.14,,,,,,,fee schedule,799.01,7817.58,APC
Intro windpipe wire/tube,31730,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1832.52,,,,,,,fee schedule,799.01,7817.58,APC
Intro windpipe wire/tube,31730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1762.04,,,,,,,fee schedule,799.01,7817.58,APC
Intro windpipe wire/tube,31730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2695.92,,,,,,,fee schedule,799.01,7817.58,Radiology
Intro windpipe wire/tube,31730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2466.86,,,,,,,fee schedule,799.01,7817.58,APC
Intro windpipe wire/tube,31730,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3083.57,,,,,,,fee schedule,799.01,7817.58,APC
Repair of windpipe,31750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Repair of windpipe,31750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Repair of windpipe,31750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Repair of windpipe,31750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Repair of windpipe,31750,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Repair of windpipe,31750,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Repair of windpipe,31750,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Repair of windpipe,31750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Repair of windpipe,31750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Repair of windpipe,31750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Repair of windpipe,31750,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Repair of windpipe,31755,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Repair of windpipe,31755,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Repair of windpipe,31755,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Repair of windpipe,31755,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Repair of windpipe,31755,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Repair of windpipe,31755,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Repair of windpipe,31755,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Repair of windpipe,31755,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Repair of windpipe,31755,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Repair of windpipe,31755,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Repair of windpipe,31755,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Remove windpipe lesion,31785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5983.93,,,,,,,fee schedule,4796.64,26000.79,
Remove windpipe lesion,31785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4796.64,,,,,,,fee schedule,4796.64,26000.79,
Remove windpipe lesion,31785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5239.9,,,,,,,fee schedule,4796.64,26000.79,
Remove windpipe lesion,31785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.01,,,,,,,fee schedule,4796.64,26000.79,
Remove windpipe lesion,31785,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,4796.64,26000.79,APC 378
Remove windpipe lesion,31785,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,4796.64,26000.79,APC
Remove windpipe lesion,31785,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,4796.64,26000.79,APC
Remove windpipe lesion,31785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,4796.64,26000.79,APC
Remove windpipe lesion,31785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,4796.64,26000.79,Radiology
Remove windpipe lesion,31785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,4796.64,26000.79,APC
Remove windpipe lesion,31785,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,4796.64,26000.79,APC
Closure of windpipe lesion,31820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4075.29,,,,,,,fee schedule,3266.7,14562,
Closure of windpipe lesion,31820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3266.7,,,,,,,fee schedule,3266.7,14562,
Closure of windpipe lesion,31820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3568.58,,,,,,,fee schedule,3266.7,14562,
Closure of windpipe lesion,31820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3751.86,,,,,,,fee schedule,3266.7,14562,
Closure of windpipe lesion,31820,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3266.7,14562,APC 378
Closure of windpipe lesion,31820,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3266.7,14562,APC
Closure of windpipe lesion,31820,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3266.7,14562,APC
Closure of windpipe lesion,31820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3266.7,14562,APC
Closure of windpipe lesion,31820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3266.7,14562,Radiology
Closure of windpipe lesion,31820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3266.7,14562,APC
Closure of windpipe lesion,31820,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3266.7,14562,APC
Repair of windpipe defect,31825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5983.93,,,,,,,fee schedule,3282.2,14562,
Repair of windpipe defect,31825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4796.64,,,,,,,fee schedule,3282.2,14562,
Repair of windpipe defect,31825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5239.9,,,,,,,fee schedule,3282.2,14562,
Repair of windpipe defect,31825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.01,,,,,,,fee schedule,3282.2,14562,
Repair of windpipe defect,31825,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Repair of windpipe defect,31825,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Repair of windpipe defect,31825,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Repair of windpipe defect,31825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Repair of windpipe defect,31825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Repair of windpipe defect,31825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Repair of windpipe defect,31825,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Revise windpipe scar,31830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5983.93,,,,,,,fee schedule,3282.2,14562,
Revise windpipe scar,31830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4796.64,,,,,,,fee schedule,3282.2,14562,
Revise windpipe scar,31830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5239.9,,,,,,,fee schedule,3282.2,14562,
Revise windpipe scar,31830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.01,,,,,,,fee schedule,3282.2,14562,
Revise windpipe scar,31830,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Revise windpipe scar,31830,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Revise windpipe scar,31830,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Revise windpipe scar,31830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Revise windpipe scar,31830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Revise windpipe scar,31830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Revise windpipe scar,31830,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Airways surgical procedure,31899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2485.12,,,,,,,fee schedule,197.6,2485.12,
Airways surgical procedure,31899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1992.04,,,,,,,fee schedule,197.6,2485.12,
Airways surgical procedure,31899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2176.13,,,,,,,fee schedule,197.6,2485.12,
Airways surgical procedure,31899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2287.89,,,,,,,fee schedule,197.6,2485.12,
Airways surgical procedure,31899,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,876.7,,,,,,,fee schedule,197.6,2485.12,APC 378
Airways surgical procedure,31899,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,207.48,,,,,,,fee schedule,197.6,2485.12,APC
Airways surgical procedure,31899,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,205.51,,,,,,,fee schedule,197.6,2485.12,APC
Airways surgical procedure,31899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,197.6,,,,,,,fee schedule,197.6,2485.12,APC
Airways surgical procedure,31899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,302.33,,,,,,,fee schedule,197.6,2485.12,Radiology
Airways surgical procedure,31899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,276.65,,,,,,,fee schedule,197.6,2485.12,APC
Airways surgical procedure,31899,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,345.81,,,,,,,fee schedule,197.6,2485.12,APC
Open wedge/bx lung infiltr,32096,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3041.2,,,,,,,fee schedule,2437.79,3041.2,
Open wedge/bx lung infiltr,32096,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2437.79,,,,,,,fee schedule,2437.79,3041.2,
Open wedge/bx lung infiltr,32096,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2663.06,,,,,,,fee schedule,2437.79,3041.2,
Open wedge/bx lung infiltr,32096,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2799.83,,,,,,,fee schedule,2437.79,3041.2,
Open wedge/bx lung nodule,32097,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3041.2,,,,,,,fee schedule,2437.79,3041.2,
Open wedge/bx lung nodule,32097,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2437.79,,,,,,,fee schedule,2437.79,3041.2,
Open wedge/bx lung nodule,32097,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2663.06,,,,,,,fee schedule,2437.79,3041.2,
Open wedge/bx lung nodule,32097,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2799.83,,,,,,,fee schedule,2437.79,3041.2,
Open biopsy of lung pleura,32098,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2942.77,,,,,,,fee schedule,2358.89,2942.77,
Open biopsy of lung pleura,32098,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2358.89,,,,,,,fee schedule,2358.89,2942.77,
Open biopsy of lung pleura,32098,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2576.87,,,,,,,fee schedule,2358.89,2942.77,
Open biopsy of lung pleura,32098,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2709.21,,,,,,,fee schedule,2358.89,2942.77,
Needle biopsy chest lining,32400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1353.42,,,,,,,fee schedule,1084.88,7254.06,
Needle biopsy chest lining,32400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1084.88,,,,,,,fee schedule,1084.88,7254.06,
Needle biopsy chest lining,32400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1185.13,,,,,,,fee schedule,1084.88,7254.06,
Needle biopsy chest lining,32400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1246,,,,,,,fee schedule,1084.88,7254.06,
Needle biopsy chest lining,32400,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1084.88,7254.06,APC 378
Needle biopsy chest lining,32400,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1084.88,7254.06,APC
Needle biopsy chest lining,32400,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1084.88,7254.06,APC
Needle biopsy chest lining,32400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1084.88,7254.06,APC
Needle biopsy chest lining,32400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1084.88,7254.06,Radiology
Needle biopsy chest lining,32400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1084.88,7254.06,APC
Needle biopsy chest lining,32400,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1084.88,7254.06,APC
Core ndl bx lng/med perq,32408,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5318.46,,,,,,,fee schedule,1635.03,7254.06,
Core ndl bx lng/med perq,32408,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4263.21,,,,,,,fee schedule,1635.03,7254.06,
Core ndl bx lng/med perq,32408,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4657.17,,,,,,,fee schedule,1635.03,7254.06,
Core ndl bx lng/med perq,32408,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4896.36,,,,,,,fee schedule,1635.03,7254.06,
Core ndl bx lng/med perq,32408,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,7254.06,APC 378
Core ndl bx lng/med perq,32408,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,7254.06,APC
Core ndl bx lng/med perq,32408,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,7254.06,APC
Core ndl bx lng/med perq,32408,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,7254.06,APC
Core ndl bx lng/med perq,32408,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,7254.06,Radiology
Core ndl bx lng/med perq,32408,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,7254.06,APC
Core ndl bx lng/med perq,32408,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,7254.06,APC
Wedge resect of lung initial,32505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3589.9,,,,,,,fee schedule,2877.62,3589.9,
Wedge resect of lung initial,32505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2877.62,,,,,,,fee schedule,2877.62,3589.9,
Wedge resect of lung initial,32505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3143.54,,,,,,,fee schedule,2877.62,3589.9,
Wedge resect of lung initial,32505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3304.99,,,,,,,fee schedule,2877.62,3589.9,
Wedge resect of lung add-on,32506,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,620.56,,,,,,,fee schedule,497.44,620.56,
Wedge resect of lung add-on,32506,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,497.44,,,,,,,fee schedule,497.44,620.56,
Wedge resect of lung add-on,32506,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,543.4,,,,,,,fee schedule,497.44,620.56,
Wedge resect of lung add-on,32506,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,571.31,,,,,,,fee schedule,497.44,620.56,
Wedge resect of lung diag,32507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,620.56,,,,,,,fee schedule,497.44,620.56,
Wedge resect of lung diag,32507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,497.44,,,,,,,fee schedule,497.44,620.56,
Wedge resect of lung diag,32507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,543.4,,,,,,,fee schedule,497.44,620.56,
Wedge resect of lung diag,32507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,571.31,,,,,,,fee schedule,497.44,620.56,
Insert pleural cath,32550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3002.29,,,,,,,fee schedule,2406.6,15725.66,
Insert pleural cath,32550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2406.6,,,,,,,fee schedule,2406.6,15725.66,
Insert pleural cath,32550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2628.99,,,,,,,fee schedule,2406.6,15725.66,
Insert pleural cath,32550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2764.02,,,,,,,fee schedule,2406.6,15725.66,
Insert pleural cath,32550,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15725.66,,,,,,,fee schedule,2406.6,15725.66,APC 378
Insert pleural cath,32550,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3721.7,,,,,,,fee schedule,2406.6,15725.66,APC
Insert pleural cath,32550,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3686.26,,,,,,,fee schedule,2406.6,15725.66,APC
Insert pleural cath,32550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3544.48,,,,,,,fee schedule,2406.6,15725.66,APC
Insert pleural cath,32550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5423.05,,,,,,,fee schedule,2406.6,15725.66,Radiology
Insert pleural cath,32550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4962.27,,,,,,,fee schedule,2406.6,15725.66,APC
Insert pleural cath,32550,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6202.84,,,,,,,fee schedule,2406.6,15725.66,APC
Insertion of chest tube,32551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,824.98,,,,,,,fee schedule,661.29,6913.93,
Insertion of chest tube,32551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,661.29,,,,,,,fee schedule,661.29,6913.93,
Insertion of chest tube,32551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,722.4,,,,,,,fee schedule,661.29,6913.93,
Insertion of chest tube,32551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,759.51,,,,,,,fee schedule,661.29,6913.93,
Insertion of chest tube,32551,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6913.93,,,,,,,fee schedule,661.29,6913.93,APC 378
Insertion of chest tube,32551,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1636.28,,,,,,,fee schedule,661.29,6913.93,APC
Insertion of chest tube,32551,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1620.7,,,,,,,fee schedule,661.29,6913.93,APC
Insertion of chest tube,32551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1558.36,,,,,,,fee schedule,661.29,6913.93,APC
Insertion of chest tube,32551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2384.29,,,,,,,fee schedule,661.29,6913.93,Radiology
Insertion of chest tube,32551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2181.71,,,,,,,fee schedule,661.29,6913.93,APC
Insertion of chest tube,32551,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2727.13,,,,,,,fee schedule,661.29,6913.93,APC
Remove lung catheter,32552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,623.07,,,,,,,fee schedule,499.45,2755.21,
Remove lung catheter,32552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,499.45,,,,,,,fee schedule,499.45,2755.21,
Remove lung catheter,32552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,545.6,,,,,,,fee schedule,499.45,2755.21,
Remove lung catheter,32552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,573.62,,,,,,,fee schedule,499.45,2755.21,
Remove lung catheter,32552,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2755.21,,,,,,,fee schedule,499.45,2755.21,APC 378
Remove lung catheter,32552,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,652.06,,,,,,,fee schedule,499.45,2755.21,APC
Remove lung catheter,32552,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,645.85,,,,,,,fee schedule,499.45,2755.21,APC
Remove lung catheter,32552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,621.01,,,,,,,fee schedule,499.45,2755.21,APC
Remove lung catheter,32552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,950.14,,,,,,,fee schedule,499.45,2755.21,Radiology
Remove lung catheter,32552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,869.41,,,,,,,fee schedule,499.45,2755.21,APC
Remove lung catheter,32552,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1086.77,,,,,,,fee schedule,499.45,2755.21,APC
Ins mark thor for rt perq,32553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3633.64,,,,,,,fee schedule,1370.24,6079.31,
Ins mark thor for rt perq,32553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2912.68,,,,,,,fee schedule,1370.24,6079.31,
Ins mark thor for rt perq,32553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3181.84,,,,,,,fee schedule,1370.24,6079.31,
Ins mark thor for rt perq,32553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3345.25,,,,,,,fee schedule,1370.24,6079.31,
Ins mark thor for rt perq,32553,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6079.31,,,,,,,fee schedule,1370.24,6079.31,APC 378
Ins mark thor for rt perq,32553,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1438.76,,,,,,,fee schedule,1370.24,6079.31,APC
Ins mark thor for rt perq,32553,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1425.05,,,,,,,fee schedule,1370.24,6079.31,APC
Ins mark thor for rt perq,32553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1370.24,,,,,,,fee schedule,1370.24,6079.31,APC
Ins mark thor for rt perq,32553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2096.47,,,,,,,fee schedule,1370.24,6079.31,Radiology
Ins mark thor for rt perq,32553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1918.34,,,,,,,fee schedule,1370.24,6079.31,APC
Ins mark thor for rt perq,32553,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2397.93,,,,,,,fee schedule,1370.24,6079.31,APC
Aspirate pleura w/o imaging,32554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1558.83,,,,,,,fee schedule,621.01,2755.21,
Aspirate pleura w/o imaging,32554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1249.54,,,,,,,fee schedule,621.01,2755.21,
Aspirate pleura w/o imaging,32554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1365.01,,,,,,,fee schedule,621.01,2755.21,
Aspirate pleura w/o imaging,32554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1435.12,,,,,,,fee schedule,621.01,2755.21,
Aspirate pleura w/o imaging,32554,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2755.21,,,,,,,fee schedule,621.01,2755.21,APC 378
Aspirate pleura w/o imaging,32554,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,652.06,,,,,,,fee schedule,621.01,2755.21,APC
Aspirate pleura w/o imaging,32554,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,645.85,,,,,,,fee schedule,621.01,2755.21,APC
Aspirate pleura w/o imaging,32554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,621.01,,,,,,,fee schedule,621.01,2755.21,APC
Aspirate pleura w/o imaging,32554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,950.14,,,,,,,fee schedule,621.01,2755.21,Radiology
Aspirate pleura w/o imaging,32554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,869.41,,,,,,,fee schedule,621.01,2755.21,APC
Aspirate pleura w/o imaging,32554,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1086.77,,,,,,,fee schedule,621.01,2755.21,APC
Aspirate pleura w/ imaging,32555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1578.81,,,,,,,fee schedule,621.01,2755.21,
Aspirate pleura w/ imaging,32555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1265.55,,,,,,,fee schedule,621.01,2755.21,
Aspirate pleura w/ imaging,32555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1382.5,,,,,,,fee schedule,621.01,2755.21,
Aspirate pleura w/ imaging,32555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1453.5,,,,,,,fee schedule,621.01,2755.21,
Aspirate pleura w/ imaging,32555,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2755.21,,,,,,,fee schedule,621.01,2755.21,APC 378
Aspirate pleura w/ imaging,32555,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,652.06,,,,,,,fee schedule,621.01,2755.21,APC
Aspirate pleura w/ imaging,32555,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,645.85,,,,,,,fee schedule,621.01,2755.21,APC
Aspirate pleura w/ imaging,32555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,621.01,,,,,,,fee schedule,621.01,2755.21,APC
Aspirate pleura w/ imaging,32555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,950.14,,,,,,,fee schedule,621.01,2755.21,Radiology
Aspirate pleura w/ imaging,32555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,869.41,,,,,,,fee schedule,621.01,2755.21,APC
Aspirate pleura w/ imaging,32555,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1086.77,,,,,,,fee schedule,621.01,2755.21,APC
Insert cath pleura w/o image,32556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1558.83,,,,,,,fee schedule,1249.54,8428.13,
Insert cath pleura w/o image,32556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1249.54,,,,,,,fee schedule,1249.54,8428.13,
Insert cath pleura w/o image,32556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1365.01,,,,,,,fee schedule,1249.54,8428.13,
Insert cath pleura w/o image,32556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1435.12,,,,,,,fee schedule,1249.54,8428.13,
Insert cath pleura w/o image,32556,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8428.13,,,,,,,fee schedule,1249.54,8428.13,APC 378
Insert cath pleura w/o image,32556,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1994.64,,,,,,,fee schedule,1249.54,8428.13,APC
Insert cath pleura w/o image,32556,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1975.64,,,,,,,fee schedule,1249.54,8428.13,APC
Insert cath pleura w/o image,32556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1899.66,,,,,,,fee schedule,1249.54,8428.13,APC
Insert cath pleura w/o image,32556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2906.47,,,,,,,fee schedule,1249.54,8428.13,Radiology
Insert cath pleura w/o image,32556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2659.52,,,,,,,fee schedule,1249.54,8428.13,APC
Insert cath pleura w/o image,32556,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3324.4,,,,,,,fee schedule,1249.54,8428.13,APC
Insert cath pleura w/ image,32557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1558.83,,,,,,,fee schedule,1249.54,6913.93,
Insert cath pleura w/ image,32557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1249.54,,,,,,,fee schedule,1249.54,6913.93,
Insert cath pleura w/ image,32557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1365.01,,,,,,,fee schedule,1249.54,6913.93,
Insert cath pleura w/ image,32557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1435.12,,,,,,,fee schedule,1249.54,6913.93,
Insert cath pleura w/ image,32557,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6913.93,,,,,,,fee schedule,1249.54,6913.93,APC 378
Insert cath pleura w/ image,32557,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1636.28,,,,,,,fee schedule,1249.54,6913.93,APC
Insert cath pleura w/ image,32557,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1620.7,,,,,,,fee schedule,1249.54,6913.93,APC
Insert cath pleura w/ image,32557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1558.36,,,,,,,fee schedule,1249.54,6913.93,APC
Insert cath pleura w/ image,32557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2384.29,,,,,,,fee schedule,1249.54,6913.93,Radiology
Insert cath pleura w/ image,32557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2181.71,,,,,,,fee schedule,1249.54,6913.93,APC
Insert cath pleura w/ image,32557,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2727.13,,,,,,,fee schedule,1249.54,6913.93,APC
Treat pleurodesis w/agent,32560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1298.39,,,,,,,fee schedule,621.01,2755.21,
Treat pleurodesis w/agent,32560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1040.77,,,,,,,fee schedule,621.01,2755.21,
Treat pleurodesis w/agent,32560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1136.95,,,,,,,fee schedule,621.01,2755.21,
Treat pleurodesis w/agent,32560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1195.35,,,,,,,fee schedule,621.01,2755.21,
Treat pleurodesis w/agent,32560,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2755.21,,,,,,,fee schedule,621.01,2755.21,APC 378
Treat pleurodesis w/agent,32560,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,652.06,,,,,,,fee schedule,621.01,2755.21,APC
Treat pleurodesis w/agent,32560,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,645.85,,,,,,,fee schedule,621.01,2755.21,APC
Treat pleurodesis w/agent,32560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,621.01,,,,,,,fee schedule,621.01,2755.21,APC
Treat pleurodesis w/agent,32560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,950.14,,,,,,,fee schedule,621.01,2755.21,Radiology
Treat pleurodesis w/agent,32560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,869.41,,,,,,,fee schedule,621.01,2755.21,APC
Treat pleurodesis w/agent,32560,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1086.77,,,,,,,fee schedule,621.01,2755.21,APC
Lyse chest fibrin init day,32561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1466.41,,,,,,,fee schedule,621.01,2755.21,
Lyse chest fibrin init day,32561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1175.46,,,,,,,fee schedule,621.01,2755.21,
Lyse chest fibrin init day,32561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1284.08,,,,,,,fee schedule,621.01,2755.21,
Lyse chest fibrin init day,32561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1350.03,,,,,,,fee schedule,621.01,2755.21,
Lyse chest fibrin init day,32561,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2755.21,,,,,,,fee schedule,621.01,2755.21,APC 378
Lyse chest fibrin init day,32561,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,652.06,,,,,,,fee schedule,621.01,2755.21,APC
Lyse chest fibrin init day,32561,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,645.85,,,,,,,fee schedule,621.01,2755.21,APC
Lyse chest fibrin init day,32561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,621.01,,,,,,,fee schedule,621.01,2755.21,APC
Lyse chest fibrin init day,32561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,950.14,,,,,,,fee schedule,621.01,2755.21,Radiology
Lyse chest fibrin init day,32561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,869.41,,,,,,,fee schedule,621.01,2755.21,APC
Lyse chest fibrin init day,32561,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1086.77,,,,,,,fee schedule,621.01,2755.21,APC
Lyse chest fibrin subq day,32562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1504.21,,,,,,,fee schedule,621.01,2755.21,
Lyse chest fibrin subq day,32562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1205.76,,,,,,,fee schedule,621.01,2755.21,
Lyse chest fibrin subq day,32562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1317.18,,,,,,,fee schedule,621.01,2755.21,
Lyse chest fibrin subq day,32562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1384.83,,,,,,,fee schedule,621.01,2755.21,
Lyse chest fibrin subq day,32562,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2755.21,,,,,,,fee schedule,621.01,2755.21,APC 378
Lyse chest fibrin subq day,32562,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,652.06,,,,,,,fee schedule,621.01,2755.21,APC
Lyse chest fibrin subq day,32562,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,645.85,,,,,,,fee schedule,621.01,2755.21,APC
Lyse chest fibrin subq day,32562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,621.01,,,,,,,fee schedule,621.01,2755.21,APC
Lyse chest fibrin subq day,32562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,950.14,,,,,,,fee schedule,621.01,2755.21,Radiology
Lyse chest fibrin subq day,32562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,869.41,,,,,,,fee schedule,621.01,2755.21,APC
Lyse chest fibrin subq day,32562,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1086.77,,,,,,,fee schedule,621.01,2755.21,APC
Thoracoscopy diagnostic,32601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8127.83,,,,,,,fee schedule,5984.88,26552.87,
Thoracoscopy diagnostic,32601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6515.17,,,,,,,fee schedule,5984.88,26552.87,
Thoracoscopy diagnostic,32601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7117.23,,,,,,,fee schedule,5984.88,26552.87,
Thoracoscopy diagnostic,32601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7482.77,,,,,,,fee schedule,5984.88,26552.87,
Thoracoscopy diagnostic,32601,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,5984.88,26552.87,APC 378
Thoracoscopy diagnostic,32601,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,5984.88,26552.87,APC
Thoracoscopy diagnostic,32601,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,5984.88,26552.87,APC
Thoracoscopy diagnostic,32601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,5984.88,26552.87,APC
Thoracoscopy diagnostic,32601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,5984.88,26552.87,Radiology
Thoracoscopy diagnostic,32601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,5984.88,26552.87,APC
Thoracoscopy diagnostic,32601,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,5984.88,26552.87,APC
Thoracoscopy wbx sac,32604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8127.83,,,,,,,fee schedule,6515.17,46687.84,
Thoracoscopy wbx sac,32604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6515.17,,,,,,,fee schedule,6515.17,46687.84,
Thoracoscopy wbx sac,32604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7117.23,,,,,,,fee schedule,6515.17,46687.84,
Thoracoscopy wbx sac,32604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7482.77,,,,,,,fee schedule,6515.17,46687.84,
Thoracoscopy wbx sac,32604,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46687.84,,,,,,,fee schedule,6515.17,46687.84,APC 378
Thoracoscopy wbx sac,32604,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11049.35,,,,,,,fee schedule,6515.17,46687.84,APC
Thoracoscopy wbx sac,32604,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10944.12,,,,,,,fee schedule,6515.17,46687.84,APC
Thoracoscopy wbx sac,32604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10523.19,,,,,,,fee schedule,6515.17,46687.84,APC
Thoracoscopy wbx sac,32604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16100.48,,,,,,,fee schedule,6515.17,46687.84,Radiology
Thoracoscopy wbx sac,32604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14732.47,,,,,,,fee schedule,6515.17,46687.84,APC
Thoracoscopy wbx sac,32604,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18415.58,,,,,,,fee schedule,6515.17,46687.84,APC
Thoracoscopy w/bx med space,32606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8127.83,,,,,,,fee schedule,5984.88,26552.87,
Thoracoscopy w/bx med space,32606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6515.17,,,,,,,fee schedule,5984.88,26552.87,
Thoracoscopy w/bx med space,32606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7117.23,,,,,,,fee schedule,5984.88,26552.87,
Thoracoscopy w/bx med space,32606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7482.77,,,,,,,fee schedule,5984.88,26552.87,
Thoracoscopy w/bx med space,32606,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,5984.88,26552.87,APC 378
Thoracoscopy w/bx med space,32606,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,5984.88,26552.87,APC
Thoracoscopy w/bx med space,32606,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,5984.88,26552.87,APC
Thoracoscopy w/bx med space,32606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,5984.88,26552.87,APC
Thoracoscopy w/bx med space,32606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,5984.88,26552.87,Radiology
Thoracoscopy w/bx med space,32606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,5984.88,26552.87,APC
Thoracoscopy w/bx med space,32606,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,5984.88,26552.87,APC
Thoracoscopy w/bx infiltrate,32607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9694.76,,,,,,,fee schedule,7771.19,46687.84,
Thoracoscopy w/bx infiltrate,32607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7771.19,,,,,,,fee schedule,7771.19,46687.84,
Thoracoscopy w/bx infiltrate,32607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8489.32,,,,,,,fee schedule,7771.19,46687.84,
Thoracoscopy w/bx infiltrate,32607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8925.33,,,,,,,fee schedule,7771.19,46687.84,
Thoracoscopy w/bx infiltrate,32607,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46687.84,,,,,,,fee schedule,7771.19,46687.84,APC 378
Thoracoscopy w/bx infiltrate,32607,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11049.35,,,,,,,fee schedule,7771.19,46687.84,APC
Thoracoscopy w/bx infiltrate,32607,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10944.12,,,,,,,fee schedule,7771.19,46687.84,APC
Thoracoscopy w/bx infiltrate,32607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10523.19,,,,,,,fee schedule,7771.19,46687.84,APC
Thoracoscopy w/bx infiltrate,32607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16100.48,,,,,,,fee schedule,7771.19,46687.84,Radiology
Thoracoscopy w/bx infiltrate,32607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14732.47,,,,,,,fee schedule,7771.19,46687.84,APC
Thoracoscopy w/bx infiltrate,32607,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18415.58,,,,,,,fee schedule,7771.19,46687.84,APC
Thoracoscopy w/bx nodule,32608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9694.76,,,,,,,fee schedule,7771.19,46687.84,
Thoracoscopy w/bx nodule,32608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7771.19,,,,,,,fee schedule,7771.19,46687.84,
Thoracoscopy w/bx nodule,32608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8489.32,,,,,,,fee schedule,7771.19,46687.84,
Thoracoscopy w/bx nodule,32608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8925.33,,,,,,,fee schedule,7771.19,46687.84,
Thoracoscopy w/bx nodule,32608,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46687.84,,,,,,,fee schedule,7771.19,46687.84,APC 378
Thoracoscopy w/bx nodule,32608,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11049.35,,,,,,,fee schedule,7771.19,46687.84,APC
Thoracoscopy w/bx nodule,32608,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10944.12,,,,,,,fee schedule,7771.19,46687.84,APC
Thoracoscopy w/bx nodule,32608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10523.19,,,,,,,fee schedule,7771.19,46687.84,APC
Thoracoscopy w/bx nodule,32608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16100.48,,,,,,,fee schedule,7771.19,46687.84,Radiology
Thoracoscopy w/bx nodule,32608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14732.47,,,,,,,fee schedule,7771.19,46687.84,APC
Thoracoscopy w/bx nodule,32608,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18415.58,,,,,,,fee schedule,7771.19,46687.84,APC
Thoracoscopy w/bx pleura,32609,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9694.76,,,,,,,fee schedule,5984.88,26552.87,
Thoracoscopy w/bx pleura,32609,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7771.19,,,,,,,fee schedule,5984.88,26552.87,
Thoracoscopy w/bx pleura,32609,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8489.32,,,,,,,fee schedule,5984.88,26552.87,
Thoracoscopy w/bx pleura,32609,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8925.33,,,,,,,fee schedule,5984.88,26552.87,
Thoracoscopy w/bx pleura,32609,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,5984.88,26552.87,APC 378
Thoracoscopy w/bx pleura,32609,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,5984.88,26552.87,APC
Thoracoscopy w/bx pleura,32609,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,5984.88,26552.87,APC
Thoracoscopy w/bx pleura,32609,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,5984.88,26552.87,APC
Thoracoscopy w/bx pleura,32609,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,5984.88,26552.87,Radiology
Thoracoscopy w/bx pleura,32609,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,5984.88,26552.87,APC
Thoracoscopy w/bx pleura,32609,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,5984.88,26552.87,APC
Thoracoscopy w/wedge resect,32666,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3340.84,,,,,,,fee schedule,2677.97,3340.84,
Thoracoscopy w/wedge resect,32666,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2677.97,,,,,,,fee schedule,2677.97,3340.84,
Thoracoscopy w/wedge resect,32666,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2925.44,,,,,,,fee schedule,2677.97,3340.84,
Thoracoscopy w/wedge resect,32666,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3075.69,,,,,,,fee schedule,2677.97,3340.84,
Thoracoscopy w/w resect addl,32667,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,620.56,,,,,,,fee schedule,497.44,620.56,
Thoracoscopy w/w resect addl,32667,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,497.44,,,,,,,fee schedule,497.44,620.56,
Thoracoscopy w/w resect addl,32667,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,543.4,,,,,,,fee schedule,497.44,620.56,
Thoracoscopy w/w resect addl,32667,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,571.31,,,,,,,fee schedule,497.44,620.56,
Thoracoscopy w/w resect diag,32668,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,623.13,,,,,,,fee schedule,499.5,623.13,
Thoracoscopy w/w resect diag,32668,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,499.5,,,,,,,fee schedule,499.5,623.13,
Thoracoscopy w/w resect diag,32668,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,545.65,,,,,,,fee schedule,499.5,623.13,
Thoracoscopy w/w resect diag,32668,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,573.68,,,,,,,fee schedule,499.5,623.13,
Thoracoscopy remove segment,32669,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5045.81,,,,,,,fee schedule,4044.66,5045.81,
Thoracoscopy remove segment,32669,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4044.66,,,,,,,fee schedule,4044.66,5045.81,
Thoracoscopy remove segment,32669,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4418.42,,,,,,,fee schedule,4044.66,5045.81,
Thoracoscopy remove segment,32669,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4645.35,,,,,,,fee schedule,4044.66,5045.81,
Thoracoscopy bilobectomy,32670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6021.8,,,,,,,fee schedule,4827,6021.8,
Thoracoscopy bilobectomy,32670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4827,,,,,,,fee schedule,4827,6021.8,
Thoracoscopy bilobectomy,32670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5273.06,,,,,,,fee schedule,4827,6021.8,
Thoracoscopy bilobectomy,32670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5543.88,,,,,,,fee schedule,4827,6021.8,
Thoracoscopy pneumonectomy,32671,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6679.94,,,,,,,fee schedule,5354.56,6679.94,
Thoracoscopy pneumonectomy,32671,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5354.56,,,,,,,fee schedule,5354.56,6679.94,
Thoracoscopy pneumonectomy,32671,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5849.37,,,,,,,fee schedule,5354.56,6679.94,
Thoracoscopy pneumonectomy,32671,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6149.79,,,,,,,fee schedule,5354.56,6679.94,
Thoracoscopy for lvrs,32672,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5713.32,,,,,,,fee schedule,4579.72,5713.32,
Thoracoscopy for lvrs,32672,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4579.72,,,,,,,fee schedule,4579.72,5713.32,
Thoracoscopy for lvrs,32672,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5002.93,,,,,,,fee schedule,4579.72,5713.32,
Thoracoscopy for lvrs,32672,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5259.88,,,,,,,fee schedule,4579.72,5713.32,
Thoracoscopy w/thymus resect,32673,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4493.82,,,,,,,fee schedule,3602.19,4493.82,
Thoracoscopy w/thymus resect,32673,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3602.19,,,,,,,fee schedule,3602.19,4493.82,
Thoracoscopy w/thymus resect,32673,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3935.06,,,,,,,fee schedule,3602.19,4493.82,
Thoracoscopy w/thymus resect,32673,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4137.16,,,,,,,fee schedule,3602.19,4493.82,
Thoracoscopy lymph node exc,32674,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,810.81,,,,,,,fee schedule,649.94,810.81,
Thoracoscopy lymph node exc,32674,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,649.94,,,,,,,fee schedule,649.94,810.81,
Thoracoscopy lymph node exc,32674,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,710,,,,,,,fee schedule,649.94,810.81,
Thoracoscopy lymph node exc,32674,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,746.46,,,,,,,fee schedule,649.94,810.81,
Thorax stereo rad targetw/tx,32701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,827.71,,,,,,,fee schedule,663.48,827.71,
Thorax stereo rad targetw/tx,32701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,663.48,,,,,,,fee schedule,663.48,827.71,
Thorax stereo rad targetw/tx,32701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,724.79,,,,,,,fee schedule,663.48,827.71,
Thorax stereo rad targetw/tx,32701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,762.02,,,,,,,fee schedule,663.48,827.71,
Therapeutic pneumothorax,32960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1298.39,,,,,,,fee schedule,621.01,2755.21,
Therapeutic pneumothorax,32960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1040.77,,,,,,,fee schedule,621.01,2755.21,
Therapeutic pneumothorax,32960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1136.95,,,,,,,fee schedule,621.01,2755.21,
Therapeutic pneumothorax,32960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1195.35,,,,,,,fee schedule,621.01,2755.21,
Therapeutic pneumothorax,32960,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2755.21,,,,,,,fee schedule,621.01,2755.21,APC 378
Therapeutic pneumothorax,32960,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,652.06,,,,,,,fee schedule,621.01,2755.21,APC
Therapeutic pneumothorax,32960,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,645.85,,,,,,,fee schedule,621.01,2755.21,APC
Therapeutic pneumothorax,32960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,621.01,,,,,,,fee schedule,621.01,2755.21,APC
Therapeutic pneumothorax,32960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,950.14,,,,,,,fee schedule,621.01,2755.21,Radiology
Therapeutic pneumothorax,32960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,869.41,,,,,,,fee schedule,621.01,2755.21,APC
Therapeutic pneumothorax,32960,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1086.77,,,,,,,fee schedule,621.01,2755.21,APC
Ablate pulm tumor perq crybl,32994,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17372.31,,,,,,,fee schedule,10523.19,46687.84,
Ablate pulm tumor perq crybl,32994,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13925.43,,,,,,,fee schedule,10523.19,46687.84,
Ablate pulm tumor perq crybl,32994,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15212.26,,,,,,,fee schedule,10523.19,46687.84,
Ablate pulm tumor perq crybl,32994,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15993.56,,,,,,,fee schedule,10523.19,46687.84,
Ablate pulm tumor perq crybl,32994,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46687.84,,,,,,,fee schedule,10523.19,46687.84,APC 378
Ablate pulm tumor perq crybl,32994,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11049.35,,,,,,,fee schedule,10523.19,46687.84,APC
Ablate pulm tumor perq crybl,32994,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10944.12,,,,,,,fee schedule,10523.19,46687.84,APC
Ablate pulm tumor perq crybl,32994,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10523.19,,,,,,,fee schedule,10523.19,46687.84,APC
Ablate pulm tumor perq crybl,32994,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16100.48,,,,,,,fee schedule,10523.19,46687.84,Radiology
Ablate pulm tumor perq crybl,32994,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14732.47,,,,,,,fee schedule,10523.19,46687.84,APC
Ablate pulm tumor perq crybl,32994,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18415.58,,,,,,,fee schedule,10523.19,46687.84,APC
Perq rf ablate tx pul tumor,32998,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10731.23,,,,,,,fee schedule,5984.88,26552.87,
Perq rf ablate tx pul tumor,32998,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8602.02,,,,,,,fee schedule,5984.88,26552.87,
Perq rf ablate tx pul tumor,32998,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9396.92,,,,,,,fee schedule,5984.88,26552.87,
Perq rf ablate tx pul tumor,32998,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9879.55,,,,,,,fee schedule,5984.88,26552.87,
Perq rf ablate tx pul tumor,32998,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,5984.88,26552.87,APC 378
Perq rf ablate tx pul tumor,32998,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,5984.88,26552.87,APC
Perq rf ablate tx pul tumor,32998,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,5984.88,26552.87,APC
Perq rf ablate tx pul tumor,32998,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,5984.88,26552.87,APC
Perq rf ablate tx pul tumor,32998,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,5984.88,26552.87,Radiology
Perq rf ablate tx pul tumor,32998,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,5984.88,26552.87,APC
Perq rf ablate tx pul tumor,32998,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,5984.88,26552.87,APC
Chest surgery procedure,32999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1298.39,,,,,,,fee schedule,621.01,2755.21,
Chest surgery procedure,32999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1040.77,,,,,,,fee schedule,621.01,2755.21,
Chest surgery procedure,32999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1136.95,,,,,,,fee schedule,621.01,2755.21,
Chest surgery procedure,32999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1195.35,,,,,,,fee schedule,621.01,2755.21,
Chest surgery procedure,32999,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2755.21,,,,,,,fee schedule,621.01,2755.21,APC 378
Chest surgery procedure,32999,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,652.06,,,,,,,fee schedule,621.01,2755.21,APC
Chest surgery procedure,32999,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,645.85,,,,,,,fee schedule,621.01,2755.21,APC
Chest surgery procedure,32999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,621.01,,,,,,,fee schedule,621.01,2755.21,APC
Chest surgery procedure,32999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,950.14,,,,,,,fee schedule,621.01,2755.21,Radiology
Chest surgery procedure,32999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,869.41,,,,,,,fee schedule,621.01,2755.21,APC
Chest surgery procedure,32999,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1086.77,,,,,,,fee schedule,621.01,2755.21,APC
Pericardiocentesis w/imaging,33016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6165.67,,,,,,,fee schedule,1558.36,6913.93,
Pericardiocentesis w/imaging,33016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4942.32,,,,,,,fee schedule,1558.36,6913.93,
Pericardiocentesis w/imaging,33016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5399.04,,,,,,,fee schedule,1558.36,6913.93,
Pericardiocentesis w/imaging,33016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5676.33,,,,,,,fee schedule,1558.36,6913.93,
Pericardiocentesis w/imaging,33016,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6913.93,,,,,,,fee schedule,1558.36,6913.93,APC 378
Pericardiocentesis w/imaging,33016,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1636.28,,,,,,,fee schedule,1558.36,6913.93,APC
Pericardiocentesis w/imaging,33016,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1620.7,,,,,,,fee schedule,1558.36,6913.93,APC
Pericardiocentesis w/imaging,33016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1558.36,,,,,,,fee schedule,1558.36,6913.93,APC
Pericardiocentesis w/imaging,33016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2384.29,,,,,,,fee schedule,1558.36,6913.93,Radiology
Pericardiocentesis w/imaging,33016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2181.71,,,,,,,fee schedule,1558.36,6913.93,APC
Pericardiocentesis w/imaging,33016,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2727.13,,,,,,,fee schedule,1558.36,6913.93,APC
Prcrd drg 6yr+ w/o cgen car,33017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,967.87,,,,,,,fee schedule,775.83,967.87,
Prcrd drg 6yr+ w/o cgen car,33017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,775.83,,,,,,,fee schedule,775.83,967.87,
Prcrd drg 6yr+ w/o cgen car,33017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,847.53,,,,,,,fee schedule,775.83,967.87,
Prcrd drg 6yr+ w/o cgen car,33017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,891.05,,,,,,,fee schedule,775.83,967.87,
Prcrd drg 0-5yr or w/anomly,33018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1100.02,,,,,,,fee schedule,881.76,1100.02,
Prcrd drg 0-5yr or w/anomly,33018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,881.76,,,,,,,fee schedule,881.76,1100.02,
Prcrd drg 0-5yr or w/anomly,33018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,963.24,,,,,,,fee schedule,881.76,1100.02,
Prcrd drg 0-5yr or w/anomly,33018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1012.71,,,,,,,fee schedule,881.76,1100.02,
Perq prcrd drg insj cath ct,33019,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,894.84,,,,,,,fee schedule,717.29,894.84,
Perq prcrd drg insj cath ct,33019,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,717.29,,,,,,,fee schedule,717.29,894.84,
Perq prcrd drg insj cath ct,33019,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,783.58,,,,,,,fee schedule,717.29,894.84,
Perq prcrd drg insj cath ct,33019,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,823.82,,,,,,,fee schedule,717.29,894.84,
Insert heart pm atrial,33206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11810.16,,,,,,,fee schedule,9466.87,45906.74,
Insert heart pm atrial,33206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9466.87,,,,,,,fee schedule,9466.87,45906.74,
Insert heart pm atrial,33206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10341.7,,,,,,,fee schedule,9466.87,45906.74,
Insert heart pm atrial,33206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10872.84,,,,,,,fee schedule,9466.87,45906.74,
Insert heart pm atrial,33206,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,45906.74,,,,,,,fee schedule,9466.87,45906.74,APC 378
Insert heart pm atrial,33206,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10864.49,,,,,,,fee schedule,9466.87,45906.74,APC
Insert heart pm atrial,33206,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10761.02,,,,,,,fee schedule,9466.87,45906.74,APC
Insert heart pm atrial,33206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10347.14,,,,,,,fee schedule,9466.87,45906.74,APC
Insert heart pm atrial,33206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15831.12,,,,,,,fee schedule,9466.87,45906.74,Radiology
Insert heart pm atrial,33206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14485.99,,,,,,,fee schedule,9466.87,45906.74,APC
Insert heart pm atrial,33206,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18107.49,,,,,,,fee schedule,9466.87,45906.74,APC
Insert heart pm ventricular,33207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30361.04,,,,,,,fee schedule,10347.14,45906.74,
Insert heart pm ventricular,33207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24337.02,,,,,,,fee schedule,10347.14,45906.74,
Insert heart pm ventricular,33207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26585.99,,,,,,,fee schedule,10347.14,45906.74,
Insert heart pm ventricular,33207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27951.43,,,,,,,fee schedule,10347.14,45906.74,
Insert heart pm ventricular,33207,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,45906.74,,,,,,,fee schedule,10347.14,45906.74,APC 378
Insert heart pm ventricular,33207,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10864.49,,,,,,,fee schedule,10347.14,45906.74,APC
Insert heart pm ventricular,33207,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10761.02,,,,,,,fee schedule,10347.14,45906.74,APC
Insert heart pm ventricular,33207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10347.14,,,,,,,fee schedule,10347.14,45906.74,APC
Insert heart pm ventricular,33207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15831.12,,,,,,,fee schedule,10347.14,45906.74,Radiology
Insert heart pm ventricular,33207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14485.99,,,,,,,fee schedule,10347.14,45906.74,APC
Insert heart pm ventricular,33207,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18107.49,,,,,,,fee schedule,10347.14,45906.74,APC
Insrt heart pm atrial & vent,33208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18555.57,,,,,,,fee schedule,10347.14,45906.74,
Insrt heart pm atrial & vent,33208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14873.91,,,,,,,fee schedule,10347.14,45906.74,
Insrt heart pm atrial & vent,33208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16248.39,,,,,,,fee schedule,10347.14,45906.74,
Insrt heart pm atrial & vent,33208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17082.9,,,,,,,fee schedule,10347.14,45906.74,
Insrt heart pm atrial & vent,33208,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,45906.74,,,,,,,fee schedule,10347.14,45906.74,APC 378
Insrt heart pm atrial & vent,33208,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10864.49,,,,,,,fee schedule,10347.14,45906.74,APC
Insrt heart pm atrial & vent,33208,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10761.02,,,,,,,fee schedule,10347.14,45906.74,APC
Insrt heart pm atrial & vent,33208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10347.14,,,,,,,fee schedule,10347.14,45906.74,APC
Insrt heart pm atrial & vent,33208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15831.12,,,,,,,fee schedule,10347.14,45906.74,Radiology
Insrt heart pm atrial & vent,33208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14485.99,,,,,,,fee schedule,10347.14,45906.74,APC
Insrt heart pm atrial & vent,33208,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18107.49,,,,,,,fee schedule,10347.14,45906.74,APC
Insert electrd/pm cath sngl,33210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17350.92,,,,,,,fee schedule,8192.37,36346.76,
Insert electrd/pm cath sngl,33210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13908.28,,,,,,,fee schedule,8192.37,36346.76,
Insert electrd/pm cath sngl,33210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15193.53,,,,,,,fee schedule,8192.37,36346.76,
Insert electrd/pm cath sngl,33210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15973.86,,,,,,,fee schedule,8192.37,36346.76,
Insert electrd/pm cath sngl,33210,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,36346.76,,,,,,,fee schedule,8192.37,36346.76,APC 378
Insert electrd/pm cath sngl,33210,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8601.99,,,,,,,fee schedule,8192.37,36346.76,APC
Insert electrd/pm cath sngl,33210,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8520.06,,,,,,,fee schedule,8192.37,36346.76,APC
Insert electrd/pm cath sngl,33210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8192.37,,,,,,,fee schedule,8192.37,36346.76,APC
Insert electrd/pm cath sngl,33210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12534.32,,,,,,,fee schedule,8192.37,36346.76,Radiology
Insert electrd/pm cath sngl,33210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11469.31,,,,,,,fee schedule,8192.37,36346.76,APC
Insert electrd/pm cath sngl,33210,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14336.64,,,,,,,fee schedule,8192.37,36346.76,APC
Insert card electrodes dual,33211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17350.92,,,,,,,fee schedule,8192.37,36346.76,
Insert card electrodes dual,33211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13908.28,,,,,,,fee schedule,8192.37,36346.76,
Insert card electrodes dual,33211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15193.53,,,,,,,fee schedule,8192.37,36346.76,
Insert card electrodes dual,33211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15973.86,,,,,,,fee schedule,8192.37,36346.76,
Insert card electrodes dual,33211,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,36346.76,,,,,,,fee schedule,8192.37,36346.76,APC 378
Insert card electrodes dual,33211,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8601.99,,,,,,,fee schedule,8192.37,36346.76,APC
Insert card electrodes dual,33211,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8520.06,,,,,,,fee schedule,8192.37,36346.76,APC
Insert card electrodes dual,33211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8192.37,,,,,,,fee schedule,8192.37,36346.76,APC
Insert card electrodes dual,33211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12534.32,,,,,,,fee schedule,8192.37,36346.76,Radiology
Insert card electrodes dual,33211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11469.31,,,,,,,fee schedule,8192.37,36346.76,APC
Insert card electrodes dual,33211,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14336.64,,,,,,,fee schedule,8192.37,36346.76,APC
Insert pulse gen sngl lead,33212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,25165.69,,,,,,,fee schedule,8192.37,36346.76,
Insert pulse gen sngl lead,33212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20172.5,,,,,,,fee schedule,8192.37,36346.76,
Insert pulse gen sngl lead,33212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22036.62,,,,,,,fee schedule,8192.37,36346.76,
Insert pulse gen sngl lead,33212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23168.41,,,,,,,fee schedule,8192.37,36346.76,
Insert pulse gen sngl lead,33212,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,36346.76,,,,,,,fee schedule,8192.37,36346.76,APC 378
Insert pulse gen sngl lead,33212,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8601.99,,,,,,,fee schedule,8192.37,36346.76,APC
Insert pulse gen sngl lead,33212,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8520.06,,,,,,,fee schedule,8192.37,36346.76,APC
Insert pulse gen sngl lead,33212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8192.37,,,,,,,fee schedule,8192.37,36346.76,APC
Insert pulse gen sngl lead,33212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12534.32,,,,,,,fee schedule,8192.37,36346.76,Radiology
Insert pulse gen sngl lead,33212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11469.31,,,,,,,fee schedule,8192.37,36346.76,APC
Insert pulse gen sngl lead,33212,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14336.64,,,,,,,fee schedule,8192.37,36346.76,APC
Insert pulse gen dual leads,33213,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27274.89,,,,,,,fee schedule,10347.14,45906.74,
Insert pulse gen dual leads,33213,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21863.21,,,,,,,fee schedule,10347.14,45906.74,
Insert pulse gen dual leads,33213,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23883.57,,,,,,,fee schedule,10347.14,45906.74,
Insert pulse gen dual leads,33213,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,25110.22,,,,,,,fee schedule,10347.14,45906.74,
Insert pulse gen dual leads,33213,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,45906.74,,,,,,,fee schedule,10347.14,45906.74,APC 378
Insert pulse gen dual leads,33213,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10864.49,,,,,,,fee schedule,10347.14,45906.74,APC
Insert pulse gen dual leads,33213,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10761.02,,,,,,,fee schedule,10347.14,45906.74,APC
Insert pulse gen dual leads,33213,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10347.14,,,,,,,fee schedule,10347.14,45906.74,APC
Insert pulse gen dual leads,33213,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15831.12,,,,,,,fee schedule,10347.14,45906.74,Radiology
Insert pulse gen dual leads,33213,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14485.99,,,,,,,fee schedule,10347.14,45906.74,APC
Insert pulse gen dual leads,33213,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18107.49,,,,,,,fee schedule,10347.14,45906.74,APC
Upgrade of pacemaker system,33214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,34948.44,,,,,,,fee schedule,10347.14,45906.74,
Upgrade of pacemaker system,33214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28014.23,,,,,,,fee schedule,10347.14,45906.74,
Upgrade of pacemaker system,33214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,30603,,,,,,,fee schedule,10347.14,45906.74,
Upgrade of pacemaker system,33214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,32174.76,,,,,,,fee schedule,10347.14,45906.74,
Upgrade of pacemaker system,33214,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,45906.74,,,,,,,fee schedule,10347.14,45906.74,APC 378
Upgrade of pacemaker system,33214,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10864.49,,,,,,,fee schedule,10347.14,45906.74,APC
Upgrade of pacemaker system,33214,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10761.02,,,,,,,fee schedule,10347.14,45906.74,APC
Upgrade of pacemaker system,33214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10347.14,,,,,,,fee schedule,10347.14,45906.74,APC
Upgrade of pacemaker system,33214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15831.12,,,,,,,fee schedule,10347.14,45906.74,Radiology
Upgrade of pacemaker system,33214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14485.99,,,,,,,fee schedule,10347.14,45906.74,APC
Upgrade of pacemaker system,33214,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18107.49,,,,,,,fee schedule,10347.14,45906.74,APC
Reposition pacing-defib lead,33215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2411.01,,,,,,,fee schedule,1932.64,13868.13,
Reposition pacing-defib lead,33215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1932.64,,,,,,,fee schedule,1932.64,13868.13,
Reposition pacing-defib lead,33215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2111.23,,,,,,,fee schedule,1932.64,13868.13,
Reposition pacing-defib lead,33215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2219.66,,,,,,,fee schedule,1932.64,13868.13,
Reposition pacing-defib lead,33215,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,1932.64,13868.13,APC 378
Reposition pacing-defib lead,33215,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,1932.64,13868.13,APC
Reposition pacing-defib lead,33215,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,1932.64,13868.13,APC
Reposition pacing-defib lead,33215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,1932.64,13868.13,APC
Reposition pacing-defib lead,33215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,1932.64,13868.13,Radiology
Reposition pacing-defib lead,33215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,1932.64,13868.13,APC
Reposition pacing-defib lead,33215,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,1932.64,13868.13,APC
Insert 1 electrode pm-defib,33216,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7045.57,,,,,,,fee schedule,5647.64,36346.76,
Insert 1 electrode pm-defib,33216,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5647.64,,,,,,,fee schedule,5647.64,36346.76,
Insert 1 electrode pm-defib,33216,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6169.53,,,,,,,fee schedule,5647.64,36346.76,
Insert 1 electrode pm-defib,33216,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6486.4,,,,,,,fee schedule,5647.64,36346.76,
Insert 1 electrode pm-defib,33216,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,36346.76,,,,,,,fee schedule,5647.64,36346.76,APC 378
Insert 1 electrode pm-defib,33216,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8601.99,,,,,,,fee schedule,5647.64,36346.76,APC
Insert 1 electrode pm-defib,33216,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8520.06,,,,,,,fee schedule,5647.64,36346.76,APC
Insert 1 electrode pm-defib,33216,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8192.37,,,,,,,fee schedule,5647.64,36346.76,APC
Insert 1 electrode pm-defib,33216,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12534.32,,,,,,,fee schedule,5647.64,36346.76,Radiology
Insert 1 electrode pm-defib,33216,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11469.31,,,,,,,fee schedule,5647.64,36346.76,APC
Insert 1 electrode pm-defib,33216,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14336.64,,,,,,,fee schedule,5647.64,36346.76,APC
Insert 2 electrode pm-defib,33217,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17350.92,,,,,,,fee schedule,8192.37,36346.76,
Insert 2 electrode pm-defib,33217,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13908.28,,,,,,,fee schedule,8192.37,36346.76,
Insert 2 electrode pm-defib,33217,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15193.53,,,,,,,fee schedule,8192.37,36346.76,
Insert 2 electrode pm-defib,33217,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15973.86,,,,,,,fee schedule,8192.37,36346.76,
Insert 2 electrode pm-defib,33217,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,36346.76,,,,,,,fee schedule,8192.37,36346.76,APC 378
Insert 2 electrode pm-defib,33217,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8601.99,,,,,,,fee schedule,8192.37,36346.76,APC
Insert 2 electrode pm-defib,33217,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8520.06,,,,,,,fee schedule,8192.37,36346.76,APC
Insert 2 electrode pm-defib,33217,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8192.37,,,,,,,fee schedule,8192.37,36346.76,APC
Insert 2 electrode pm-defib,33217,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12534.32,,,,,,,fee schedule,8192.37,36346.76,Radiology
Insert 2 electrode pm-defib,33217,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11469.31,,,,,,,fee schedule,8192.37,36346.76,APC
Insert 2 electrode pm-defib,33217,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14336.64,,,,,,,fee schedule,8192.37,36346.76,APC
Repair lead pace-defib one,33218,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5984.84,,,,,,,fee schedule,3699.47,16413.29,
Repair lead pace-defib one,33218,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4797.37,,,,,,,fee schedule,3699.47,16413.29,
Repair lead pace-defib one,33218,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5240.69,,,,,,,fee schedule,3699.47,16413.29,
Repair lead pace-defib one,33218,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.85,,,,,,,fee schedule,3699.47,16413.29,
Repair lead pace-defib one,33218,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16413.29,,,,,,,fee schedule,3699.47,16413.29,APC 378
Repair lead pace-defib one,33218,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3884.44,,,,,,,fee schedule,3699.47,16413.29,APC
Repair lead pace-defib one,33218,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3847.45,,,,,,,fee schedule,3699.47,16413.29,APC
Repair lead pace-defib one,33218,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3699.47,,,,,,,fee schedule,3699.47,16413.29,APC
Repair lead pace-defib one,33218,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5660.19,,,,,,,fee schedule,3699.47,16413.29,Radiology
Repair lead pace-defib one,33218,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5179.26,,,,,,,fee schedule,3699.47,16413.29,APC
Repair lead pace-defib one,33218,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6474.07,,,,,,,fee schedule,3699.47,16413.29,APC
Repair lead pace-defib dual,33220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5984.84,,,,,,,fee schedule,3699.47,16413.29,
Repair lead pace-defib dual,33220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4797.37,,,,,,,fee schedule,3699.47,16413.29,
Repair lead pace-defib dual,33220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5240.69,,,,,,,fee schedule,3699.47,16413.29,
Repair lead pace-defib dual,33220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.85,,,,,,,fee schedule,3699.47,16413.29,
Repair lead pace-defib dual,33220,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16413.29,,,,,,,fee schedule,3699.47,16413.29,APC 378
Repair lead pace-defib dual,33220,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3884.44,,,,,,,fee schedule,3699.47,16413.29,APC
Repair lead pace-defib dual,33220,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3847.45,,,,,,,fee schedule,3699.47,16413.29,APC
Repair lead pace-defib dual,33220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3699.47,,,,,,,fee schedule,3699.47,16413.29,APC
Repair lead pace-defib dual,33220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5660.19,,,,,,,fee schedule,3699.47,16413.29,Radiology
Repair lead pace-defib dual,33220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5179.26,,,,,,,fee schedule,3699.47,16413.29,APC
Repair lead pace-defib dual,33220,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6474.07,,,,,,,fee schedule,3699.47,16413.29,APC
Insert pulse gen mult leads,33221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1336.61,,,,,,,fee schedule,1071.41,84600.26,
Insert pulse gen mult leads,33221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1071.41,,,,,,,fee schedule,1071.41,84600.26,
Insert pulse gen mult leads,33221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1170.42,,,,,,,fee schedule,1071.41,84600.26,
Insert pulse gen mult leads,33221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1230.53,,,,,,,fee schedule,1071.41,84600.26,
Insert pulse gen mult leads,33221,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,84600.26,,,,,,,fee schedule,1071.41,84600.26,APC 378
Insert pulse gen mult leads,33221,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20021.87,,,,,,,fee schedule,1071.41,84600.26,APC
Insert pulse gen mult leads,33221,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,19831.19,,,,,,,fee schedule,1071.41,84600.26,APC
Insert pulse gen mult leads,33221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,19068.45,,,,,,,fee schedule,1071.41,84600.26,APC
Insert pulse gen mult leads,33221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29174.73,,,,,,,fee schedule,1071.41,84600.26,Radiology
Insert pulse gen mult leads,33221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26695.83,,,,,,,fee schedule,1071.41,84600.26,APC
Insert pulse gen mult leads,33221,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,33369.79,,,,,,,fee schedule,1071.41,84600.26,APC
Relocation pocket pacemaker,33222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3755.05,,,,,,,fee schedule,2042.58,9062.24,
Relocation pocket pacemaker,33222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3010,,,,,,,fee schedule,2042.58,9062.24,
Relocation pocket pacemaker,33222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3288.15,,,,,,,fee schedule,2042.58,9062.24,
Relocation pocket pacemaker,33222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3457.03,,,,,,,fee schedule,2042.58,9062.24,
Relocation pocket pacemaker,33222,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,2042.58,9062.24,APC 378
Relocation pocket pacemaker,33222,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,2042.58,9062.24,APC
Relocation pocket pacemaker,33222,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,2042.58,9062.24,APC
Relocation pocket pacemaker,33222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,2042.58,9062.24,APC
Relocation pocket pacemaker,33222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,2042.58,9062.24,Radiology
Relocation pocket pacemaker,33222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,2042.58,9062.24,APC
Relocation pocket pacemaker,33222,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,2042.58,9062.24,APC
Relocate pocket for defib,33223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2608.23,,,,,,,fee schedule,2042.58,9062.24,
Relocate pocket for defib,33223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2090.72,,,,,,,fee schedule,2042.58,9062.24,
Relocate pocket for defib,33223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2283.92,,,,,,,fee schedule,2042.58,9062.24,
Relocate pocket for defib,33223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2401.22,,,,,,,fee schedule,2042.58,9062.24,
Relocate pocket for defib,33223,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,2042.58,9062.24,APC 378
Relocate pocket for defib,33223,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,2042.58,9062.24,APC
Relocate pocket for defib,33223,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,2042.58,9062.24,APC
Relocate pocket for defib,33223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,2042.58,9062.24,APC
Relocate pocket for defib,33223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,2042.58,9062.24,Radiology
Relocate pocket for defib,33223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,2042.58,9062.24,APC
Relocate pocket for defib,33223,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,2042.58,9062.24,APC
Insert pacing lead & connect,33224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37348.44,,,,,,,fee schedule,10347.14,45906.74,
Insert pacing lead & connect,33224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29938.04,,,,,,,fee schedule,10347.14,45906.74,
Insert pacing lead & connect,33224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32704.59,,,,,,,fee schedule,10347.14,45906.74,
Insert pacing lead & connect,33224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,34384.28,,,,,,,fee schedule,10347.14,45906.74,
Insert pacing lead & connect,33224,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,45906.74,,,,,,,fee schedule,10347.14,45906.74,APC 378
Insert pacing lead & connect,33224,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10864.49,,,,,,,fee schedule,10347.14,45906.74,APC
Insert pacing lead & connect,33224,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10761.02,,,,,,,fee schedule,10347.14,45906.74,APC
Insert pacing lead & connect,33224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10347.14,,,,,,,fee schedule,10347.14,45906.74,APC
Insert pacing lead & connect,33224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15831.12,,,,,,,fee schedule,10347.14,45906.74,Radiology
Insert pacing lead & connect,33224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14485.99,,,,,,,fee schedule,10347.14,45906.74,APC
Insert pacing lead & connect,33224,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18107.49,,,,,,,fee schedule,10347.14,45906.74,APC
L ventric pacing lead add-on,33225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37348.44,,,,,,,fee schedule,29938.04,37348.44,
L ventric pacing lead add-on,33225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29938.04,,,,,,,fee schedule,29938.04,37348.44,
L ventric pacing lead add-on,33225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32704.59,,,,,,,fee schedule,29938.04,37348.44,
L ventric pacing lead add-on,33225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,34384.28,,,,,,,fee schedule,29938.04,37348.44,
Reposition l ventric lead,33226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5984.84,,,,,,,fee schedule,3125.8,13868.13,
Reposition l ventric lead,33226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4797.37,,,,,,,fee schedule,3125.8,13868.13,
Reposition l ventric lead,33226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5240.69,,,,,,,fee schedule,3125.8,13868.13,
Reposition l ventric lead,33226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.85,,,,,,,fee schedule,3125.8,13868.13,
Reposition l ventric lead,33226,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Reposition l ventric lead,33226,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Reposition l ventric lead,33226,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Reposition l ventric lead,33226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Reposition l ventric lead,33226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Reposition l ventric lead,33226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Reposition l ventric lead,33226,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Remove&replace pm gen singl,33227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24994.72,,,,,,,fee schedule,8192.37,36346.76,
Remove&replace pm gen singl,33227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20035.45,,,,,,,fee schedule,8192.37,36346.76,
Remove&replace pm gen singl,33227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21886.91,,,,,,,fee schedule,8192.37,36346.76,
Remove&replace pm gen singl,33227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23011.01,,,,,,,fee schedule,8192.37,36346.76,
Remove&replace pm gen singl,33227,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,36346.76,,,,,,,fee schedule,8192.37,36346.76,APC 378
Remove&replace pm gen singl,33227,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8601.99,,,,,,,fee schedule,8192.37,36346.76,APC
Remove&replace pm gen singl,33227,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8520.06,,,,,,,fee schedule,8192.37,36346.76,APC
Remove&replace pm gen singl,33227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8192.37,,,,,,,fee schedule,8192.37,36346.76,APC
Remove&replace pm gen singl,33227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12534.32,,,,,,,fee schedule,8192.37,36346.76,Radiology
Remove&replace pm gen singl,33227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11469.31,,,,,,,fee schedule,8192.37,36346.76,APC
Remove&replace pm gen singl,33227,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14336.64,,,,,,,fee schedule,8192.37,36346.76,APC
Remv&replc pm gen dual lead,33228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19343.34,,,,,,,fee schedule,10347.14,45906.74,
Remv&replc pm gen dual lead,33228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15505.38,,,,,,,fee schedule,10347.14,45906.74,
Remv&replc pm gen dual lead,33228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16938.22,,,,,,,fee schedule,10347.14,45906.74,
Remv&replc pm gen dual lead,33228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17808.16,,,,,,,fee schedule,10347.14,45906.74,
Remv&replc pm gen dual lead,33228,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,45906.74,,,,,,,fee schedule,10347.14,45906.74,APC 378
Remv&replc pm gen dual lead,33228,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10864.49,,,,,,,fee schedule,10347.14,45906.74,APC
Remv&replc pm gen dual lead,33228,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10761.02,,,,,,,fee schedule,10347.14,45906.74,APC
Remv&replc pm gen dual lead,33228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10347.14,,,,,,,fee schedule,10347.14,45906.74,APC
Remv&replc pm gen dual lead,33228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15831.12,,,,,,,fee schedule,10347.14,45906.74,Radiology
Remv&replc pm gen dual lead,33228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14485.99,,,,,,,fee schedule,10347.14,45906.74,APC
Remv&replc pm gen dual lead,33228,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18107.49,,,,,,,fee schedule,10347.14,45906.74,APC
Remv&replc pm gen mult leads,33229,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17584.66,,,,,,,fee schedule,14095.64,84600.26,
Remv&replc pm gen mult leads,33229,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14095.64,,,,,,,fee schedule,14095.64,84600.26,
Remv&replc pm gen mult leads,33229,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15398.21,,,,,,,fee schedule,14095.64,84600.26,
Remv&replc pm gen mult leads,33229,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16189.05,,,,,,,fee schedule,14095.64,84600.26,
Remv&replc pm gen mult leads,33229,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,84600.26,,,,,,,fee schedule,14095.64,84600.26,APC 378
Remv&replc pm gen mult leads,33229,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20021.87,,,,,,,fee schedule,14095.64,84600.26,APC
Remv&replc pm gen mult leads,33229,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,19831.19,,,,,,,fee schedule,14095.64,84600.26,APC
Remv&replc pm gen mult leads,33229,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,19068.45,,,,,,,fee schedule,14095.64,84600.26,APC
Remv&replc pm gen mult leads,33229,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29174.73,,,,,,,fee schedule,14095.64,84600.26,Radiology
Remv&replc pm gen mult leads,33229,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26695.83,,,,,,,fee schedule,14095.64,84600.26,APC
Remv&replc pm gen mult leads,33229,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,33369.79,,,,,,,fee schedule,14095.64,84600.26,APC
Insrt pulse gen w/dual leads,33230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,85095.51,,,,,,,fee schedule,22020.42,97697.15,
Insrt pulse gen w/dual leads,33230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,68211.48,,,,,,,fee schedule,22020.42,97697.15,
Insrt pulse gen w/dual leads,33230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,74514.85,,,,,,,fee schedule,22020.42,97697.15,
Insrt pulse gen w/dual leads,33230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,78341.9,,,,,,,fee schedule,22020.42,97697.15,
Insrt pulse gen w/dual leads,33230,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,97697.15,,,,,,,fee schedule,22020.42,97697.15,APC 378
Insrt pulse gen w/dual leads,33230,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,23121.44,,,,,,,fee schedule,22020.42,97697.15,APC
Insrt pulse gen w/dual leads,33230,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,22901.24,,,,,,,fee schedule,22020.42,97697.15,APC
Insrt pulse gen w/dual leads,33230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,22020.42,,,,,,,fee schedule,22020.42,97697.15,APC
Insrt pulse gen w/dual leads,33230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,33691.24,,,,,,,fee schedule,22020.42,97697.15,Radiology
Insrt pulse gen w/dual leads,33230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,30828.59,,,,,,,fee schedule,22020.42,97697.15,APC
Insrt pulse gen w/dual leads,33230,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,38535.73,,,,,,,fee schedule,22020.42,97697.15,APC
Insrt pulse gen w/mult leads,33231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45152.53,,,,,,,fee schedule,31073.96,137864.64,
Insrt pulse gen w/mult leads,33231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36193.69,,,,,,,fee schedule,31073.96,137864.64,
Insrt pulse gen w/mult leads,33231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39538.33,,,,,,,fee schedule,31073.96,137864.64,
Insrt pulse gen w/mult leads,33231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41568.99,,,,,,,fee schedule,31073.96,137864.64,
Insrt pulse gen w/mult leads,33231,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,137864.64,,,,,,,fee schedule,31073.96,137864.64,APC 378
Insrt pulse gen w/mult leads,33231,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,32627.66,,,,,,,fee schedule,31073.96,137864.64,APC
Insrt pulse gen w/mult leads,33231,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,32316.92,,,,,,,fee schedule,31073.96,137864.64,APC
Insrt pulse gen w/mult leads,33231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,31073.96,,,,,,,fee schedule,31073.96,137864.64,APC
Insrt pulse gen w/mult leads,33231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,47543.16,,,,,,,fee schedule,31073.96,137864.64,Radiology
Insrt pulse gen w/mult leads,33231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43503.54,,,,,,,fee schedule,31073.96,137864.64,APC
Insrt pulse gen w/mult leads,33231,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,54379.43,,,,,,,fee schedule,31073.96,137864.64,APC
Removal of pm generator,33233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9590.94,,,,,,,fee schedule,7687.98,36346.76,
Removal of pm generator,33233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7687.98,,,,,,,fee schedule,7687.98,36346.76,
Removal of pm generator,33233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8398.42,,,,,,,fee schedule,7687.98,36346.76,
Removal of pm generator,33233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8829.76,,,,,,,fee schedule,7687.98,36346.76,
Removal of pm generator,33233,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,36346.76,,,,,,,fee schedule,7687.98,36346.76,APC 378
Removal of pm generator,33233,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8601.99,,,,,,,fee schedule,7687.98,36346.76,APC
Removal of pm generator,33233,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8520.06,,,,,,,fee schedule,7687.98,36346.76,APC
Removal of pm generator,33233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8192.37,,,,,,,fee schedule,7687.98,36346.76,APC
Removal of pm generator,33233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12534.32,,,,,,,fee schedule,7687.98,36346.76,Radiology
Removal of pm generator,33233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11469.31,,,,,,,fee schedule,7687.98,36346.76,APC
Removal of pm generator,33233,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14336.64,,,,,,,fee schedule,7687.98,36346.76,APC
Removal of pacemaker system,33234,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17369.02,,,,,,,fee schedule,3699.47,17369.02,
Removal of pacemaker system,33234,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13922.79,,,,,,,fee schedule,3699.47,17369.02,
Removal of pacemaker system,33234,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15209.38,,,,,,,fee schedule,3699.47,17369.02,
Removal of pacemaker system,33234,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15990.53,,,,,,,fee schedule,3699.47,17369.02,
Removal of pacemaker system,33234,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16413.29,,,,,,,fee schedule,3699.47,17369.02,APC 378
Removal of pacemaker system,33234,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3884.44,,,,,,,fee schedule,3699.47,17369.02,APC
Removal of pacemaker system,33234,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3847.45,,,,,,,fee schedule,3699.47,17369.02,APC
Removal of pacemaker system,33234,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3699.47,,,,,,,fee schedule,3699.47,17369.02,APC
Removal of pacemaker system,33234,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5660.19,,,,,,,fee schedule,3699.47,17369.02,Radiology
Removal of pacemaker system,33234,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5179.26,,,,,,,fee schedule,3699.47,17369.02,APC
Removal of pacemaker system,33234,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6474.07,,,,,,,fee schedule,3699.47,17369.02,APC
Removal pacemaker electrode,33235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5984.84,,,,,,,fee schedule,3699.47,16413.29,
Removal pacemaker electrode,33235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4797.37,,,,,,,fee schedule,3699.47,16413.29,
Removal pacemaker electrode,33235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5240.69,,,,,,,fee schedule,3699.47,16413.29,
Removal pacemaker electrode,33235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.85,,,,,,,fee schedule,3699.47,16413.29,
Removal pacemaker electrode,33235,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16413.29,,,,,,,fee schedule,3699.47,16413.29,APC 378
Removal pacemaker electrode,33235,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3884.44,,,,,,,fee schedule,3699.47,16413.29,APC
Removal pacemaker electrode,33235,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3847.45,,,,,,,fee schedule,3699.47,16413.29,APC
Removal pacemaker electrode,33235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3699.47,,,,,,,fee schedule,3699.47,16413.29,APC
Removal pacemaker electrode,33235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5660.19,,,,,,,fee schedule,3699.47,16413.29,Radiology
Removal pacemaker electrode,33235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5179.26,,,,,,,fee schedule,3699.47,16413.29,APC
Removal pacemaker electrode,33235,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6474.07,,,,,,,fee schedule,3699.47,16413.29,APC
Insrt pulse gen w/singl lead,33240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83310.63,,,,,,,fee schedule,22020.42,97697.15,
Insrt pulse gen w/singl lead,33240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66780.75,,,,,,,fee schedule,22020.42,97697.15,
Insrt pulse gen w/singl lead,33240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,72951.9,,,,,,,fee schedule,22020.42,97697.15,
Insrt pulse gen w/singl lead,33240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,76698.68,,,,,,,fee schedule,22020.42,97697.15,
Insrt pulse gen w/singl lead,33240,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,97697.15,,,,,,,fee schedule,22020.42,97697.15,APC 378
Insrt pulse gen w/singl lead,33240,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,23121.44,,,,,,,fee schedule,22020.42,97697.15,APC
Insrt pulse gen w/singl lead,33240,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,22901.24,,,,,,,fee schedule,22020.42,97697.15,APC
Insrt pulse gen w/singl lead,33240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,22020.42,,,,,,,fee schedule,22020.42,97697.15,APC
Insrt pulse gen w/singl lead,33240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,33691.24,,,,,,,fee schedule,22020.42,97697.15,Radiology
Insrt pulse gen w/singl lead,33240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,30828.59,,,,,,,fee schedule,22020.42,97697.15,APC
Insrt pulse gen w/singl lead,33240,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,38535.73,,,,,,,fee schedule,22020.42,97697.15,APC
Remove pulse generator,33241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5116.76,,,,,,,fee schedule,3699.47,16413.29,
Remove pulse generator,33241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4101.53,,,,,,,fee schedule,3699.47,16413.29,
Remove pulse generator,33241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4480.55,,,,,,,fee schedule,3699.47,16413.29,
Remove pulse generator,33241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4710.67,,,,,,,fee schedule,3699.47,16413.29,
Remove pulse generator,33241,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16413.29,,,,,,,fee schedule,3699.47,16413.29,APC 378
Remove pulse generator,33241,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3884.44,,,,,,,fee schedule,3699.47,16413.29,APC
Remove pulse generator,33241,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3847.45,,,,,,,fee schedule,3699.47,16413.29,APC
Remove pulse generator,33241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3699.47,,,,,,,fee schedule,3699.47,16413.29,APC
Remove pulse generator,33241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5660.19,,,,,,,fee schedule,3699.47,16413.29,Radiology
Remove pulse generator,33241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5179.26,,,,,,,fee schedule,3699.47,16413.29,APC
Remove pulse generator,33241,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6474.07,,,,,,,fee schedule,3699.47,16413.29,APC
Remove elctrd transvenously,33244,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8354.56,,,,,,,fee schedule,3699.47,16413.29,
Remove elctrd transvenously,33244,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6696.91,,,,,,,fee schedule,3699.47,16413.29,
Remove elctrd transvenously,33244,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7315.76,,,,,,,fee schedule,3699.47,16413.29,
Remove elctrd transvenously,33244,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7691.5,,,,,,,fee schedule,3699.47,16413.29,
Remove elctrd transvenously,33244,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16413.29,,,,,,,fee schedule,3699.47,16413.29,APC 378
Remove elctrd transvenously,33244,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3884.44,,,,,,,fee schedule,3699.47,16413.29,APC
Remove elctrd transvenously,33244,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3847.45,,,,,,,fee schedule,3699.47,16413.29,APC
Remove elctrd transvenously,33244,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3699.47,,,,,,,fee schedule,3699.47,16413.29,APC
Remove elctrd transvenously,33244,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5660.19,,,,,,,fee schedule,3699.47,16413.29,Radiology
Remove elctrd transvenously,33244,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5179.26,,,,,,,fee schedule,3699.47,16413.29,APC
Remove elctrd transvenously,33244,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6474.07,,,,,,,fee schedule,3699.47,16413.29,APC
Insj/rplcmt defib w/lead(s),33249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46153.77,,,,,,,fee schedule,31073.96,137864.64,
Insj/rplcmt defib w/lead(s),33249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36996.28,,,,,,,fee schedule,31073.96,137864.64,
Insj/rplcmt defib w/lead(s),33249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40415.08,,,,,,,fee schedule,31073.96,137864.64,
Insj/rplcmt defib w/lead(s),33249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42490.78,,,,,,,fee schedule,31073.96,137864.64,
Insj/rplcmt defib w/lead(s),33249,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,137864.64,,,,,,,fee schedule,31073.96,137864.64,APC 378
Insj/rplcmt defib w/lead(s),33249,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,32627.66,,,,,,,fee schedule,31073.96,137864.64,APC
Insj/rplcmt defib w/lead(s),33249,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,32316.92,,,,,,,fee schedule,31073.96,137864.64,APC
Insj/rplcmt defib w/lead(s),33249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,31073.96,,,,,,,fee schedule,31073.96,137864.64,APC
Insj/rplcmt defib w/lead(s),33249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,47543.16,,,,,,,fee schedule,31073.96,137864.64,Radiology
Insj/rplcmt defib w/lead(s),33249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43503.54,,,,,,,fee schedule,31073.96,137864.64,APC
Insj/rplcmt defib w/lead(s),33249,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,54379.43,,,,,,,fee schedule,31073.96,137864.64,APC
Rmvl& replc pulse gen 1 lead,33262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30510.93,,,,,,,fee schedule,22020.42,97697.15,
Rmvl& replc pulse gen 1 lead,33262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24457.17,,,,,,,fee schedule,22020.42,97697.15,
Rmvl& replc pulse gen 1 lead,33262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26717.24,,,,,,,fee schedule,22020.42,97697.15,
Rmvl& replc pulse gen 1 lead,33262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,28089.42,,,,,,,fee schedule,22020.42,97697.15,
Rmvl& replc pulse gen 1 lead,33262,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,97697.15,,,,,,,fee schedule,22020.42,97697.15,APC 378
Rmvl& replc pulse gen 1 lead,33262,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,23121.44,,,,,,,fee schedule,22020.42,97697.15,APC
Rmvl& replc pulse gen 1 lead,33262,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,22901.24,,,,,,,fee schedule,22020.42,97697.15,APC
Rmvl& replc pulse gen 1 lead,33262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,22020.42,,,,,,,fee schedule,22020.42,97697.15,APC
Rmvl& replc pulse gen 1 lead,33262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,33691.24,,,,,,,fee schedule,22020.42,97697.15,Radiology
Rmvl& replc pulse gen 1 lead,33262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,30828.59,,,,,,,fee schedule,22020.42,97697.15,APC
Rmvl& replc pulse gen 1 lead,33262,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,38535.73,,,,,,,fee schedule,22020.42,97697.15,APC
Rmvl & rplcmt dfb gen 2 lead,33263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33562.34,,,,,,,fee schedule,22020.42,97697.15,
Rmvl & rplcmt dfb gen 2 lead,33263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26903.15,,,,,,,fee schedule,22020.42,97697.15,
Rmvl & rplcmt dfb gen 2 lead,33263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29389.25,,,,,,,fee schedule,22020.42,97697.15,
Rmvl & rplcmt dfb gen 2 lead,33263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30898.66,,,,,,,fee schedule,22020.42,97697.15,
Rmvl & rplcmt dfb gen 2 lead,33263,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,97697.15,,,,,,,fee schedule,22020.42,97697.15,APC 378
Rmvl & rplcmt dfb gen 2 lead,33263,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,23121.44,,,,,,,fee schedule,22020.42,97697.15,APC
Rmvl & rplcmt dfb gen 2 lead,33263,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,22901.24,,,,,,,fee schedule,22020.42,97697.15,APC
Rmvl & rplcmt dfb gen 2 lead,33263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,22020.42,,,,,,,fee schedule,22020.42,97697.15,APC
Rmvl & rplcmt dfb gen 2 lead,33263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,33691.24,,,,,,,fee schedule,22020.42,97697.15,Radiology
Rmvl & rplcmt dfb gen 2 lead,33263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,30828.59,,,,,,,fee schedule,22020.42,97697.15,APC
Rmvl & rplcmt dfb gen 2 lead,33263,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,38535.73,,,,,,,fee schedule,22020.42,97697.15,APC
Rmvl & rplcmt dfb gen mlt ld,33264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45135.19,,,,,,,fee schedule,31073.96,137864.64,
Rmvl & rplcmt dfb gen mlt ld,33264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36179.8,,,,,,,fee schedule,31073.96,137864.64,
Rmvl & rplcmt dfb gen mlt ld,33264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39523.14,,,,,,,fee schedule,31073.96,137864.64,
Rmvl & rplcmt dfb gen mlt ld,33264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41553.03,,,,,,,fee schedule,31073.96,137864.64,
Rmvl & rplcmt dfb gen mlt ld,33264,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,137864.64,,,,,,,fee schedule,31073.96,137864.64,APC 378
Rmvl & rplcmt dfb gen mlt ld,33264,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,32627.66,,,,,,,fee schedule,31073.96,137864.64,APC
Rmvl & rplcmt dfb gen mlt ld,33264,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,32316.92,,,,,,,fee schedule,31073.96,137864.64,APC
Rmvl & rplcmt dfb gen mlt ld,33264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,31073.96,,,,,,,fee schedule,31073.96,137864.64,APC
Rmvl & rplcmt dfb gen mlt ld,33264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,47543.16,,,,,,,fee schedule,31073.96,137864.64,Radiology
Rmvl & rplcmt dfb gen mlt ld,33264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43503.54,,,,,,,fee schedule,31073.96,137864.64,APC
Rmvl & rplcmt dfb gen mlt ld,33264,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,54379.43,,,,,,,fee schedule,31073.96,137864.64,APC
Ins/rep subq defibrillator,33270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,116493.7,,,,,,,fee schedule,31073.96,137864.64,
Ins/rep subq defibrillator,33270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,93379.87,,,,,,,fee schedule,31073.96,137864.64,
Ins/rep subq defibrillator,33270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,102009.04,,,,,,,fee schedule,31073.96,137864.64,
Ins/rep subq defibrillator,33270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,107248.17,,,,,,,fee schedule,31073.96,137864.64,
Ins/rep subq defibrillator,33270,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,137864.64,,,,,,,fee schedule,31073.96,137864.64,APC 378
Ins/rep subq defibrillator,33270,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,32627.66,,,,,,,fee schedule,31073.96,137864.64,APC
Ins/rep subq defibrillator,33270,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,32316.92,,,,,,,fee schedule,31073.96,137864.64,APC
Ins/rep subq defibrillator,33270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,31073.96,,,,,,,fee schedule,31073.96,137864.64,APC
Ins/rep subq defibrillator,33270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,47543.16,,,,,,,fee schedule,31073.96,137864.64,Radiology
Ins/rep subq defibrillator,33270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43503.54,,,,,,,fee schedule,31073.96,137864.64,APC
Ins/rep subq defibrillator,33270,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,54379.43,,,,,,,fee schedule,31073.96,137864.64,APC
Insj subq impltbl dfb elctrd,33271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24741.39,,,,,,,fee schedule,8192.37,36346.76,
Insj subq impltbl dfb elctrd,33271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19832.38,,,,,,,fee schedule,8192.37,36346.76,
Insj subq impltbl dfb elctrd,33271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21665.08,,,,,,,fee schedule,8192.37,36346.76,
Insj subq impltbl dfb elctrd,33271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22777.78,,,,,,,fee schedule,8192.37,36346.76,
Insj subq impltbl dfb elctrd,33271,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,36346.76,,,,,,,fee schedule,8192.37,36346.76,APC 378
Insj subq impltbl dfb elctrd,33271,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8601.99,,,,,,,fee schedule,8192.37,36346.76,APC
Insj subq impltbl dfb elctrd,33271,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8520.06,,,,,,,fee schedule,8192.37,36346.76,APC
Insj subq impltbl dfb elctrd,33271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8192.37,,,,,,,fee schedule,8192.37,36346.76,APC
Insj subq impltbl dfb elctrd,33271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12534.32,,,,,,,fee schedule,8192.37,36346.76,Radiology
Insj subq impltbl dfb elctrd,33271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11469.31,,,,,,,fee schedule,8192.37,36346.76,APC
Insj subq impltbl dfb elctrd,33271,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14336.64,,,,,,,fee schedule,8192.37,36346.76,APC
Rmvl of subq defibrillator,33272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8872.57,,,,,,,fee schedule,3699.47,16413.29,
Rmvl of subq defibrillator,33272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7112.14,,,,,,,fee schedule,3699.47,16413.29,
Rmvl of subq defibrillator,33272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7769.36,,,,,,,fee schedule,3699.47,16413.29,
Rmvl of subq defibrillator,33272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8168.4,,,,,,,fee schedule,3699.47,16413.29,
Rmvl of subq defibrillator,33272,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16413.29,,,,,,,fee schedule,3699.47,16413.29,APC 378
Rmvl of subq defibrillator,33272,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3884.44,,,,,,,fee schedule,3699.47,16413.29,APC
Rmvl of subq defibrillator,33272,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3847.45,,,,,,,fee schedule,3699.47,16413.29,APC
Rmvl of subq defibrillator,33272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3699.47,,,,,,,fee schedule,3699.47,16413.29,APC
Rmvl of subq defibrillator,33272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5660.19,,,,,,,fee schedule,3699.47,16413.29,Radiology
Rmvl of subq defibrillator,33272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5179.26,,,,,,,fee schedule,3699.47,16413.29,APC
Rmvl of subq defibrillator,33272,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6474.07,,,,,,,fee schedule,3699.47,16413.29,APC
Repos prev impltbl subq dfb,33273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8872.57,,,,,,,fee schedule,3699.47,16413.29,
Repos prev impltbl subq dfb,33273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7112.14,,,,,,,fee schedule,3699.47,16413.29,
Repos prev impltbl subq dfb,33273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7769.36,,,,,,,fee schedule,3699.47,16413.29,
Repos prev impltbl subq dfb,33273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8168.4,,,,,,,fee schedule,3699.47,16413.29,
Repos prev impltbl subq dfb,33273,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16413.29,,,,,,,fee schedule,3699.47,16413.29,APC 378
Repos prev impltbl subq dfb,33273,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3884.44,,,,,,,fee schedule,3699.47,16413.29,APC
Repos prev impltbl subq dfb,33273,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3847.45,,,,,,,fee schedule,3699.47,16413.29,APC
Repos prev impltbl subq dfb,33273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3699.47,,,,,,,fee schedule,3699.47,16413.29,APC
Repos prev impltbl subq dfb,33273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5660.19,,,,,,,fee schedule,3699.47,16413.29,Radiology
Repos prev impltbl subq dfb,33273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5179.26,,,,,,,fee schedule,3699.47,16413.29,APC
Repos prev impltbl subq dfb,33273,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6474.07,,,,,,,fee schedule,3699.47,16413.29,APC
Tcat insj/rpl perm ldls pm,33274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,58040.01,,,,,,,fee schedule,19068.45,84600.26,
Tcat insj/rpl perm ldls pm,33274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46524.14,,,,,,,fee schedule,19068.45,84600.26,
Tcat insj/rpl perm ldls pm,33274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,50823.4,,,,,,,fee schedule,19068.45,84600.26,
Tcat insj/rpl perm ldls pm,33274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,53433.66,,,,,,,fee schedule,19068.45,84600.26,
Tcat insj/rpl perm ldls pm,33274,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,84600.26,,,,,,,fee schedule,19068.45,84600.26,APC 378
Tcat insj/rpl perm ldls pm,33274,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20021.87,,,,,,,fee schedule,19068.45,84600.26,APC
Tcat insj/rpl perm ldls pm,33274,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,19831.19,,,,,,,fee schedule,19068.45,84600.26,APC
Tcat insj/rpl perm ldls pm,33274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,19068.45,,,,,,,fee schedule,19068.45,84600.26,APC
Tcat insj/rpl perm ldls pm,33274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29174.73,,,,,,,fee schedule,19068.45,84600.26,Radiology
Tcat insj/rpl perm ldls pm,33274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26695.83,,,,,,,fee schedule,19068.45,84600.26,APC
Tcat insj/rpl perm ldls pm,33274,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,33369.79,,,,,,,fee schedule,19068.45,84600.26,APC
Tcat rmvl perm ldls pm,33275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9984.95,,,,,,,fee schedule,3125.8,13868.13,
Tcat rmvl perm ldls pm,33275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8003.81,,,,,,,fee schedule,3125.8,13868.13,
Tcat rmvl perm ldls pm,33275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8743.43,,,,,,,fee schedule,3125.8,13868.13,
Tcat rmvl perm ldls pm,33275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9192.49,,,,,,,fee schedule,3125.8,13868.13,
Tcat rmvl perm ldls pm,33275,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Tcat rmvl perm ldls pm,33275,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Tcat rmvl perm ldls pm,33275,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Tcat rmvl perm ldls pm,33275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Tcat rmvl perm ldls pm,33275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Tcat rmvl perm ldls pm,33275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Tcat rmvl perm ldls pm,33275,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Insj phrnc nrv stim sys,33276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,170101.89,,,,,,,fee schedule,43604.58,193458.78,
Insj phrnc nrv stim sys,33276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,136351.52,,,,,,,fee schedule,43604.58,193458.78,
Insj phrnc nrv stim sys,33276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,148951.66,,,,,,,fee schedule,43604.58,193458.78,
Insj phrnc nrv stim sys,33276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,156601.74,,,,,,,fee schedule,43604.58,193458.78,
Insj phrnc nrv stim sys,33276,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,193458.78,,,,,,,fee schedule,43604.58,193458.78,APC 378
Insj phrnc nrv stim sys,33276,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,45784.81,,,,,,,fee schedule,43604.58,193458.78,APC
Insj phrnc nrv stim sys,33276,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,45348.77,,,,,,,fee schedule,43604.58,193458.78,APC
Insj phrnc nrv stim sys,33276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,43604.58,,,,,,,fee schedule,43604.58,193458.78,APC
Insj phrnc nrv stim sys,33276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,66715.01,,,,,,,fee schedule,43604.58,193458.78,Radiology
Insj phrnc nrv stim sys,33276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,61046.42,,,,,,,fee schedule,43604.58,193458.78,APC
Insj phrnc nrv stim sys,33276,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,76308.02,,,,,,,fee schedule,43604.58,193458.78,APC
Rmvl phrnc nrv stim sys,33278,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12267.12,,,,,,,fee schedule,3461.03,15355.43,
Rmvl phrnc nrv stim sys,33278,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9833.17,,,,,,,fee schedule,3461.03,15355.43,
Rmvl phrnc nrv stim sys,33278,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10741.84,,,,,,,fee schedule,3461.03,15355.43,
Rmvl phrnc nrv stim sys,33278,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11293.54,,,,,,,fee schedule,3461.03,15355.43,
Rmvl phrnc nrv stim sys,33278,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15355.43,,,,,,,fee schedule,3461.03,15355.43,APC 378
Rmvl phrnc nrv stim sys,33278,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3634.08,,,,,,,fee schedule,3461.03,15355.43,APC
Rmvl phrnc nrv stim sys,33278,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3599.47,,,,,,,fee schedule,3461.03,15355.43,APC
Rmvl phrnc nrv stim sys,33278,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3461.03,,,,,,,fee schedule,3461.03,15355.43,APC
Rmvl phrnc nrv stim sys,33278,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5295.38,,,,,,,fee schedule,3461.03,15355.43,Radiology
Rmvl phrnc nrv stim sys,33278,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4845.44,,,,,,,fee schedule,3461.03,15355.43,APC
Rmvl phrnc nrv stim sys,33278,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6056.81,,,,,,,fee schedule,3461.03,15355.43,APC
Rmvl phrnc nrv stim transvns,33279,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12267.12,,,,,,,fee schedule,3461.03,15355.43,
Rmvl phrnc nrv stim transvns,33279,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9833.17,,,,,,,fee schedule,3461.03,15355.43,
Rmvl phrnc nrv stim transvns,33279,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10741.84,,,,,,,fee schedule,3461.03,15355.43,
Rmvl phrnc nrv stim transvns,33279,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11293.54,,,,,,,fee schedule,3461.03,15355.43,
Rmvl phrnc nrv stim transvns,33279,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15355.43,,,,,,,fee schedule,3461.03,15355.43,APC 378
Rmvl phrnc nrv stim transvns,33279,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3634.08,,,,,,,fee schedule,3461.03,15355.43,APC
Rmvl phrnc nrv stim transvns,33279,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3599.47,,,,,,,fee schedule,3461.03,15355.43,APC
Rmvl phrnc nrv stim transvns,33279,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3461.03,,,,,,,fee schedule,3461.03,15355.43,APC
Rmvl phrnc nrv stim transvns,33279,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5295.38,,,,,,,fee schedule,3461.03,15355.43,Radiology
Rmvl phrnc nrv stim transvns,33279,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4845.44,,,,,,,fee schedule,3461.03,15355.43,APC
Rmvl phrnc nrv stim transvns,33279,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6056.81,,,,,,,fee schedule,3461.03,15355.43,APC
Rmvl phrnc nrv stim pg only,33280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12267.12,,,,,,,fee schedule,3461.03,15355.43,
Rmvl phrnc nrv stim pg only,33280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9833.17,,,,,,,fee schedule,3461.03,15355.43,
Rmvl phrnc nrv stim pg only,33280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10741.84,,,,,,,fee schedule,3461.03,15355.43,
Rmvl phrnc nrv stim pg only,33280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11293.54,,,,,,,fee schedule,3461.03,15355.43,
Rmvl phrnc nrv stim pg only,33280,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15355.43,,,,,,,fee schedule,3461.03,15355.43,APC 378
Rmvl phrnc nrv stim pg only,33280,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3634.08,,,,,,,fee schedule,3461.03,15355.43,APC
Rmvl phrnc nrv stim pg only,33280,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3599.47,,,,,,,fee schedule,3461.03,15355.43,APC
Rmvl phrnc nrv stim pg only,33280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3461.03,,,,,,,fee schedule,3461.03,15355.43,APC
Rmvl phrnc nrv stim pg only,33280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5295.38,,,,,,,fee schedule,3461.03,15355.43,Radiology
Rmvl phrnc nrv stim pg only,33280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4845.44,,,,,,,fee schedule,3461.03,15355.43,APC
Rmvl phrnc nrv stim pg only,33280,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6056.81,,,,,,,fee schedule,3461.03,15355.43,APC
Reposg phrnc nrv stim trnsvn,33281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12267.12,,,,,,,fee schedule,3461.03,15355.43,
Reposg phrnc nrv stim trnsvn,33281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9833.17,,,,,,,fee schedule,3461.03,15355.43,
Reposg phrnc nrv stim trnsvn,33281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10741.84,,,,,,,fee schedule,3461.03,15355.43,
Reposg phrnc nrv stim trnsvn,33281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11293.54,,,,,,,fee schedule,3461.03,15355.43,
Reposg phrnc nrv stim trnsvn,33281,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15355.43,,,,,,,fee schedule,3461.03,15355.43,APC 378
Reposg phrnc nrv stim trnsvn,33281,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3634.08,,,,,,,fee schedule,3461.03,15355.43,APC
Reposg phrnc nrv stim trnsvn,33281,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3599.47,,,,,,,fee schedule,3461.03,15355.43,APC
Reposg phrnc nrv stim trnsvn,33281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3461.03,,,,,,,fee schedule,3461.03,15355.43,APC
Reposg phrnc nrv stim trnsvn,33281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5295.38,,,,,,,fee schedule,3461.03,15355.43,Radiology
Reposg phrnc nrv stim trnsvn,33281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4845.44,,,,,,,fee schedule,3461.03,15355.43,APC
Reposg phrnc nrv stim trnsvn,33281,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6056.81,,,,,,,fee schedule,3461.03,15355.43,APC
Insj subq car rhythm mntr,33285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27987.54,,,,,,,fee schedule,8192.37,36346.76,
Insj subq car rhythm mntr,33285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22434.45,,,,,,,fee schedule,8192.37,36346.76,
Insj subq car rhythm mntr,33285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24507.6,,,,,,,fee schedule,8192.37,36346.76,
Insj subq car rhythm mntr,33285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,25766.3,,,,,,,fee schedule,8192.37,36346.76,
Insj subq car rhythm mntr,33285,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,36346.76,,,,,,,fee schedule,8192.37,36346.76,APC 378
Insj subq car rhythm mntr,33285,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8601.99,,,,,,,fee schedule,8192.37,36346.76,APC
Insj subq car rhythm mntr,33285,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8520.06,,,,,,,fee schedule,8192.37,36346.76,APC
Insj subq car rhythm mntr,33285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8192.37,,,,,,,fee schedule,8192.37,36346.76,APC
Insj subq car rhythm mntr,33285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12534.32,,,,,,,fee schedule,8192.37,36346.76,Radiology
Insj subq car rhythm mntr,33285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11469.31,,,,,,,fee schedule,8192.37,36346.76,APC
Insj subq car rhythm mntr,33285,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14336.64,,,,,,,fee schedule,8192.37,36346.76,APC
Rmvl subq car rhythm mntr,33286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2189.91,,,,,,,fee schedule,701.03,3110.22,
Rmvl subq car rhythm mntr,33286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1755.4,,,,,,,fee schedule,701.03,3110.22,
Rmvl subq car rhythm mntr,33286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1917.62,,,,,,,fee schedule,701.03,3110.22,
Rmvl subq car rhythm mntr,33286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2016.1,,,,,,,fee schedule,701.03,3110.22,
Rmvl subq car rhythm mntr,33286,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3110.22,,,,,,,fee schedule,701.03,3110.22,APC 378
Rmvl subq car rhythm mntr,33286,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,736.08,,,,,,,fee schedule,701.03,3110.22,APC
Rmvl subq car rhythm mntr,33286,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,729.07,,,,,,,fee schedule,701.03,3110.22,APC
Rmvl subq car rhythm mntr,33286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,701.03,,,,,,,fee schedule,701.03,3110.22,APC
Rmvl subq car rhythm mntr,33286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1072.57,,,,,,,fee schedule,701.03,3110.22,Radiology
Rmvl subq car rhythm mntr,33286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,981.44,,,,,,,fee schedule,701.03,3110.22,APC
Rmvl subq car rhythm mntr,33286,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1226.8,,,,,,,fee schedule,701.03,3110.22,APC
Rmv&rplcmt phrnc nrv stim pg,33287,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,111952.52,,,,,,,fee schedule,30548.12,135531.68,
Rmv&rplcmt phrnc nrv stim pg,33287,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,89739.72,,,,,,,fee schedule,30548.12,135531.68,
Rmv&rplcmt phrnc nrv stim pg,33287,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,98032.5,,,,,,,fee schedule,30548.12,135531.68,
Rmv&rplcmt phrnc nrv stim pg,33287,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,103067.4,,,,,,,fee schedule,30548.12,135531.68,
Rmv&rplcmt phrnc nrv stim pg,33287,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,135531.68,,,,,,,fee schedule,30548.12,135531.68,APC 378
Rmv&rplcmt phrnc nrv stim pg,33287,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,32075.53,,,,,,,fee schedule,30548.12,135531.68,APC
Rmv&rplcmt phrnc nrv stim pg,33287,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,31770.05,,,,,,,fee schedule,30548.12,135531.68,APC
Rmv&rplcmt phrnc nrv stim pg,33287,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,30548.12,,,,,,,fee schedule,30548.12,135531.68,APC
Rmv&rplcmt phrnc nrv stim pg,33287,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,46738.63,,,,,,,fee schedule,30548.12,135531.68,Radiology
Rmv&rplcmt phrnc nrv stim pg,33287,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,42767.37,,,,,,,fee schedule,30548.12,135531.68,APC
Rmv&rplcmt phrnc nrv stim pg,33287,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,53459.21,,,,,,,fee schedule,30548.12,135531.68,APC
Rmv&rplcmt phrnc nrv stim ld,33288,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,49111.5,,,,,,,fee schedule,11030.91,49111.5,
Rmv&rplcmt phrnc nrv stim ld,33288,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39367.15,,,,,,,fee schedule,11030.91,49111.5,
Rmv&rplcmt phrnc nrv stim ld,33288,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,43005.04,,,,,,,fee schedule,11030.91,49111.5,
Rmv&rplcmt phrnc nrv stim ld,33288,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45213.76,,,,,,,fee schedule,11030.91,49111.5,
Rmv&rplcmt phrnc nrv stim ld,33288,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,48940.4,,,,,,,fee schedule,11030.91,49111.5,APC 378
Rmv&rplcmt phrnc nrv stim ld,33288,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11582.45,,,,,,,fee schedule,11030.91,49111.5,APC
Rmv&rplcmt phrnc nrv stim ld,33288,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11472.14,,,,,,,fee schedule,11030.91,49111.5,APC
Rmv&rplcmt phrnc nrv stim ld,33288,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11030.91,,,,,,,fee schedule,11030.91,49111.5,APC
Rmv&rplcmt phrnc nrv stim ld,33288,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16877.29,,,,,,,fee schedule,11030.91,49111.5,Radiology
Rmv&rplcmt phrnc nrv stim ld,33288,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15443.27,,,,,,,fee schedule,11030.91,49111.5,APC
Rmv&rplcmt phrnc nrv stim ld,33288,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19304.09,,,,,,,fee schedule,11030.91,49111.5,APC
Tcat impl wrls p-art prs snr,33289,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,110907.96,,,,,,,fee schedule,28395.59,125981.63,
Tcat impl wrls p-art prs snr,33289,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,88902.41,,,,,,,fee schedule,28395.59,125981.63,
Tcat impl wrls p-art prs snr,33289,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,97117.82,,,,,,,fee schedule,28395.59,125981.63,
Tcat impl wrls p-art prs snr,33289,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,102105.74,,,,,,,fee schedule,28395.59,125981.63,
Tcat impl wrls p-art prs snr,33289,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,125981.63,,,,,,,fee schedule,28395.59,125981.63,APC 378
Tcat impl wrls p-art prs snr,33289,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,29815.37,,,,,,,fee schedule,28395.59,125981.63,APC
Tcat impl wrls p-art prs snr,33289,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,29531.41,,,,,,,fee schedule,28395.59,125981.63,APC
Tcat impl wrls p-art prs snr,33289,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,28395.59,,,,,,,fee schedule,28395.59,125981.63,APC
Tcat impl wrls p-art prs snr,33289,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43445.25,,,,,,,fee schedule,28395.59,125981.63,Radiology
Tcat impl wrls p-art prs snr,33289,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,39753.83,,,,,,,fee schedule,28395.59,125981.63,APC
Tcat impl wrls p-art prs snr,33289,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,49692.28,,,,,,,fee schedule,28395.59,125981.63,APC
Perq clsr tcat l atr apndge,33340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3168.61,,,,,,,fee schedule,2539.92,3168.61,
Perq clsr tcat l atr apndge,33340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2539.92,,,,,,,fee schedule,2539.92,3168.61,
Perq clsr tcat l atr apndge,33340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2774.63,,,,,,,fee schedule,2539.92,3168.61,
Perq clsr tcat l atr apndge,33340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2917.13,,,,,,,fee schedule,2539.92,3168.61,
Replace aortic valve perq,33361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5012.62,,,,,,,fee schedule,4018.05,5012.62,
Replace aortic valve perq,33361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4018.05,,,,,,,fee schedule,4018.05,5012.62,
Replace aortic valve perq,33361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4389.36,,,,,,,fee schedule,4018.05,5012.62,
Replace aortic valve perq,33361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4614.79,,,,,,,fee schedule,4018.05,5012.62,
Replace aortic valve open,33362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5484.55,,,,,,,fee schedule,4396.35,5484.55,
Replace aortic valve open,33362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4396.35,,,,,,,fee schedule,4396.35,5484.55,
Replace aortic valve open,33362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4802.61,,,,,,,fee schedule,4396.35,5484.55,
Replace aortic valve open,33362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5049.27,,,,,,,fee schedule,4396.35,5484.55,
Replace aortic valve open,33363,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5678.85,,,,,,,fee schedule,4552.09,5678.85,
Replace aortic valve open,33363,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4552.09,,,,,,,fee schedule,4552.09,5678.85,
Replace aortic valve open,33363,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4972.75,,,,,,,fee schedule,4552.09,5678.85,
Replace aortic valve open,33363,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5228.14,,,,,,,fee schedule,4552.09,5678.85,
Replace aortic valve open,33364,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6037.87,,,,,,,fee schedule,4839.88,6037.87,
Replace aortic valve open,33364,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4839.88,,,,,,,fee schedule,4839.88,6037.87,
Replace aortic valve open,33364,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5287.13,,,,,,,fee schedule,4839.88,6037.87,
Replace aortic valve open,33364,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5558.67,,,,,,,fee schedule,4839.88,6037.87,
Replace aortic valve open,33365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6629.82,,,,,,,fee schedule,5314.38,6629.82,
Replace aortic valve open,33365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5314.38,,,,,,,fee schedule,5314.38,6629.82,
Replace aortic valve open,33365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5805.48,,,,,,,fee schedule,5314.38,6629.82,
Replace aortic valve open,33365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6103.64,,,,,,,fee schedule,5314.38,6629.82,
Trcath replace aortic valve,33366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7630.69,,,,,,,fee schedule,6116.66,7630.69,
Trcath replace aortic valve,33366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6116.66,,,,,,,fee schedule,6116.66,7630.69,
Trcath replace aortic valve,33366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6681.9,,,,,,,fee schedule,6116.66,7630.69,
Trcath replace aortic valve,33366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7025.08,,,,,,,fee schedule,6116.66,7630.69,
Replace aortic valve w/byp,33367,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2331.39,,,,,,,fee schedule,1868.81,2331.39,
Replace aortic valve w/byp,33367,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1868.81,,,,,,,fee schedule,1868.81,2331.39,
Replace aortic valve w/byp,33367,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2041.51,,,,,,,fee schedule,1868.81,2331.39,
Replace aortic valve w/byp,33367,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2146.36,,,,,,,fee schedule,1868.81,2331.39,
Replace aortic valve w/byp,33368,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2825.47,,,,,,,fee schedule,2264.86,2825.47,
Replace aortic valve w/byp,33368,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2264.86,,,,,,,fee schedule,2264.86,2825.47,
Replace aortic valve w/byp,33368,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2474.16,,,,,,,fee schedule,2264.86,2825.47,
Replace aortic valve w/byp,33368,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2601.23,,,,,,,fee schedule,2264.86,2825.47,
Replace aortic valve w/byp,33369,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3730.22,,,,,,,fee schedule,2990.09,3730.22,
Replace aortic valve w/byp,33369,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2990.09,,,,,,,fee schedule,2990.09,3730.22,
Replace aortic valve w/byp,33369,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3266.41,,,,,,,fee schedule,2990.09,3730.22,
Replace aortic valve w/byp,33369,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3434.17,,,,,,,fee schedule,2990.09,3730.22,
Valvuloplasty aortic valve,33390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7572.02,,,,,,,fee schedule,6069.63,7572.02,
Valvuloplasty aortic valve,33390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6069.63,,,,,,,fee schedule,6069.63,7572.02,
Valvuloplasty aortic valve,33390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6630.52,,,,,,,fee schedule,6069.63,7572.02,
Valvuloplasty aortic valve,33390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6971.06,,,,,,,fee schedule,6069.63,7572.02,
Valvuloplasty aortic valve,33391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8972.59,,,,,,,fee schedule,7192.32,8972.59,
Valvuloplasty aortic valve,33391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7192.32,,,,,,,fee schedule,7192.32,8972.59,
Valvuloplasty aortic valve,33391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7856.95,,,,,,,fee schedule,7192.32,8972.59,
Valvuloplasty aortic valve,33391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8260.48,,,,,,,fee schedule,7192.32,8972.59,
Repair tcat mitral valve,33418,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7291.39,,,,,,,fee schedule,5844.69,7291.39,
Repair tcat mitral valve,33418,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5844.69,,,,,,,fee schedule,5844.69,7291.39,
Repair tcat mitral valve,33418,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6384.79,,,,,,,fee schedule,5844.69,7291.39,
Repair tcat mitral valve,33418,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6712.71,,,,,,,fee schedule,5844.69,7291.39,
Repair tcat mitral valve,33419,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1719.56,,,,,,,fee schedule,1378.38,1719.56,
Repair tcat mitral valve,33419,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1378.38,,,,,,,fee schedule,1378.38,1719.56,
Repair tcat mitral valve,33419,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1505.75,,,,,,,fee schedule,1378.38,1719.56,
Repair tcat mitral valve,33419,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1583.09,,,,,,,fee schedule,1378.38,1719.56,
Rplcmt a-valve tlcj autol pv,33440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13631.74,,,,,,,fee schedule,10927.03,13631.74,
Rplcmt a-valve tlcj autol pv,33440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10927.03,,,,,,,fee schedule,10927.03,13631.74,
Rplcmt a-valve tlcj autol pv,33440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11936.79,,,,,,,fee schedule,10927.03,13631.74,
Rplcmt a-valve tlcj autol pv,33440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12549.85,,,,,,,fee schedule,10927.03,13631.74,
Implant tcat pulm vlv perq,33477,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5070.08,,,,,,,fee schedule,4064.11,5070.08,
Implant tcat pulm vlv perq,33477,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4064.11,,,,,,,fee schedule,4064.11,5070.08,
Implant tcat pulm vlv perq,33477,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4439.67,,,,,,,fee schedule,4064.11,5070.08,
Implant tcat pulm vlv perq,33477,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4667.69,,,,,,,fee schedule,4064.11,5070.08,
Apply r&l pulm art bands,33620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5523.15,,,,,,,fee schedule,4427.28,5523.15,
Apply r&l pulm art bands,33620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4427.28,,,,,,,fee schedule,4427.28,5523.15,
Apply r&l pulm art bands,33620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4836.41,,,,,,,fee schedule,4427.28,5523.15,
Apply r&l pulm art bands,33620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5084.8,,,,,,,fee schedule,4427.28,5523.15,
Transthor cath for stent,33621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3282.74,,,,,,,fee schedule,2631.4,3282.74,
Transthor cath for stent,33621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2631.4,,,,,,,fee schedule,2631.4,3282.74,
Transthor cath for stent,33621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2874.57,,,,,,,fee schedule,2631.4,3282.74,
Transthor cath for stent,33621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3022.21,,,,,,,fee schedule,2631.4,3282.74,
Redo compl cardiac anomaly,33622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12916.45,,,,,,,fee schedule,10353.66,12916.45,
Redo compl cardiac anomaly,33622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10353.66,,,,,,,fee schedule,10353.66,12916.45,
Redo compl cardiac anomaly,33622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11310.44,,,,,,,fee schedule,10353.66,12916.45,
Redo compl cardiac anomaly,33622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11891.33,,,,,,,fee schedule,10353.66,12916.45,
As-aort grf f/aortic dsj,33858,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13505.83,,,,,,,fee schedule,10826.1,13505.83,
As-aort grf f/aortic dsj,33858,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10826.1,,,,,,,fee schedule,10826.1,13505.83,
As-aort grf f/aortic dsj,33858,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11826.53,,,,,,,fee schedule,10826.1,13505.83,
As-aort grf f/aortic dsj,33858,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12433.94,,,,,,,fee schedule,10826.1,13505.83,
As-aort grf f/ds oth/thn dsj,33859,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9685.76,,,,,,,fee schedule,7763.98,9685.76,
As-aort grf f/ds oth/thn dsj,33859,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7763.98,,,,,,,fee schedule,7763.98,9685.76,
As-aort grf f/ds oth/thn dsj,33859,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8481.44,,,,,,,fee schedule,7763.98,9685.76,
As-aort grf f/ds oth/thn dsj,33859,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8917.05,,,,,,,fee schedule,7763.98,9685.76,
Aortic hemiarch graft,33866,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3677.71,,,,,,,fee schedule,2948.01,3677.71,
Aortic hemiarch graft,33866,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2948.01,,,,,,,fee schedule,2948.01,3677.71,
Aortic hemiarch graft,33866,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3220.43,,,,,,,fee schedule,2948.01,3677.71,
Aortic hemiarch graft,33866,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3385.83,,,,,,,fee schedule,2948.01,3677.71,
Transvrs a-arch grf hypthrm,33871,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12989.37,,,,,,,fee schedule,10412.11,12989.37,
Transvrs a-arch grf hypthrm,33871,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10412.11,,,,,,,fee schedule,10412.11,12989.37,
Transvrs a-arch grf hypthrm,33871,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11374.29,,,,,,,fee schedule,10412.11,12989.37,
Transvrs a-arch grf hypthrm,33871,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11958.46,,,,,,,fee schedule,10412.11,12989.37,
Perq p-art revsc 1 nm nt uni,33900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,40125.87,,,,,,,fee schedule,11428.37,50703.82,
Perq p-art revsc 1 nm nt uni,33900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32164.39,,,,,,,fee schedule,11428.37,50703.82,
Perq p-art revsc 1 nm nt uni,33900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35136.68,,,,,,,fee schedule,11428.37,50703.82,
Perq p-art revsc 1 nm nt uni,33900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,36941.28,,,,,,,fee schedule,11428.37,50703.82,
Perq p-art revsc 1 nm nt uni,33900,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,50703.82,,,,,,,fee schedule,11428.37,50703.82,APC 378
Perq p-art revsc 1 nm nt uni,33900,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11999.79,,,,,,,fee schedule,11428.37,50703.82,APC
Perq p-art revsc 1 nm nt uni,33900,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11885.51,,,,,,,fee schedule,11428.37,50703.82,APC
Perq p-art revsc 1 nm nt uni,33900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11428.37,,,,,,,fee schedule,11428.37,50703.82,APC
Perq p-art revsc 1 nm nt uni,33900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17485.41,,,,,,,fee schedule,11428.37,50703.82,Radiology
Perq p-art revsc 1 nm nt uni,33900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15999.72,,,,,,,fee schedule,11428.37,50703.82,APC
Perq p-art revsc 1 nm nt uni,33900,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19999.65,,,,,,,fee schedule,11428.37,50703.82,APC
Perq p-art revsc 1 nm nt bi,33901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,40125.87,,,,,,,fee schedule,11428.37,50703.82,
Perq p-art revsc 1 nm nt bi,33901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32164.39,,,,,,,fee schedule,11428.37,50703.82,
Perq p-art revsc 1 nm nt bi,33901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35136.68,,,,,,,fee schedule,11428.37,50703.82,
Perq p-art revsc 1 nm nt bi,33901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,36941.28,,,,,,,fee schedule,11428.37,50703.82,
Perq p-art revsc 1 nm nt bi,33901,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,50703.82,,,,,,,fee schedule,11428.37,50703.82,APC 378
Perq p-art revsc 1 nm nt bi,33901,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11999.79,,,,,,,fee schedule,11428.37,50703.82,APC
Perq p-art revsc 1 nm nt bi,33901,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11885.51,,,,,,,fee schedule,11428.37,50703.82,APC
Perq p-art revsc 1 nm nt bi,33901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11428.37,,,,,,,fee schedule,11428.37,50703.82,APC
Perq p-art revsc 1 nm nt bi,33901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17485.41,,,,,,,fee schedule,11428.37,50703.82,Radiology
Perq p-art revsc 1 nm nt bi,33901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15999.72,,,,,,,fee schedule,11428.37,50703.82,APC
Perq p-art revsc 1 nm nt bi,33901,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19999.65,,,,,,,fee schedule,11428.37,50703.82,APC
Perq p-art revsc 1 abnor uni,33902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,64931.33,,,,,,,fee schedule,18147.73,80515.32,
Perq p-art revsc 1 abnor uni,33902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52048.13,,,,,,,fee schedule,18147.73,80515.32,
Perq p-art revsc 1 abnor uni,33902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56857.86,,,,,,,fee schedule,18147.73,80515.32,
Perq p-art revsc 1 abnor uni,33902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59778.05,,,,,,,fee schedule,18147.73,80515.32,
Perq p-art revsc 1 abnor uni,33902,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,80515.32,,,,,,,fee schedule,18147.73,80515.32,APC 378
Perq p-art revsc 1 abnor uni,33902,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19055.11,,,,,,,fee schedule,18147.73,80515.32,APC
Perq p-art revsc 1 abnor uni,33902,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18873.64,,,,,,,fee schedule,18147.73,80515.32,APC
Perq p-art revsc 1 abnor uni,33902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18147.73,,,,,,,fee schedule,18147.73,80515.32,APC
Perq p-art revsc 1 abnor uni,33902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27766.02,,,,,,,fee schedule,18147.73,80515.32,Radiology
Perq p-art revsc 1 abnor uni,33902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25406.82,,,,,,,fee schedule,18147.73,80515.32,APC
Perq p-art revsc 1 abnor uni,33902,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31758.52,,,,,,,fee schedule,18147.73,80515.32,APC
Perq p-art revsc 1 abnor bi,33903,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,40125.87,,,,,,,fee schedule,11428.37,50703.82,
Perq p-art revsc 1 abnor bi,33903,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32164.39,,,,,,,fee schedule,11428.37,50703.82,
Perq p-art revsc 1 abnor bi,33903,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35136.68,,,,,,,fee schedule,11428.37,50703.82,
Perq p-art revsc 1 abnor bi,33903,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,36941.28,,,,,,,fee schedule,11428.37,50703.82,
Perq p-art revsc 1 abnor bi,33903,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,50703.82,,,,,,,fee schedule,11428.37,50703.82,APC 378
Perq p-art revsc 1 abnor bi,33903,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11999.79,,,,,,,fee schedule,11428.37,50703.82,APC
Perq p-art revsc 1 abnor bi,33903,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11885.51,,,,,,,fee schedule,11428.37,50703.82,APC
Perq p-art revsc 1 abnor bi,33903,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11428.37,,,,,,,fee schedule,11428.37,50703.82,APC
Perq p-art revsc 1 abnor bi,33903,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17485.41,,,,,,,fee schedule,11428.37,50703.82,Radiology
Perq p-art revsc 1 abnor bi,33903,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15999.72,,,,,,,fee schedule,11428.37,50703.82,APC
Perq p-art revsc 1 abnor bi,33903,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19999.65,,,,,,,fee schedule,11428.37,50703.82,APC
Impltj tot rplcmt hrt sys,33927,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10179.88,,,,,,,fee schedule,8160.06,10179.88,
Impltj tot rplcmt hrt sys,33927,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8160.06,,,,,,,fee schedule,8160.06,10179.88,
Impltj tot rplcmt hrt sys,33927,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8914.13,,,,,,,fee schedule,8160.06,10179.88,
Impltj tot rplcmt hrt sys,33927,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9371.95,,,,,,,fee schedule,8160.06,10179.88,
Rmvl & rplcmt tot hrt sys,33928,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9683.11,,,,,,,fee schedule,7761.86,9683.11,
Rmvl & rplcmt tot hrt sys,33928,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7761.86,,,,,,,fee schedule,7761.86,9683.11,
Rmvl & rplcmt tot hrt sys,33928,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8479.13,,,,,,,fee schedule,7761.86,9683.11,
Rmvl & rplcmt tot hrt sys,33928,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8914.61,,,,,,,fee schedule,7761.86,9683.11,
Rmvl rplcmt hrt sys f/trnspl,33929,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6233.18,,,,,,,fee schedule,4996.44,6233.18,
Rmvl rplcmt hrt sys f/trnspl,33929,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4996.44,,,,,,,fee schedule,4996.44,6233.18,
Rmvl rplcmt hrt sys f/trnspl,33929,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5458.16,,,,,,,fee schedule,4996.44,6233.18,
Rmvl rplcmt hrt sys f/trnspl,33929,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5738.49,,,,,,,fee schedule,4996.44,6233.18,
Ecmo/ecls initiation venous,33946,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1219.24,,,,,,,fee schedule,977.33,1219.24,
Ecmo/ecls initiation venous,33946,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,977.33,,,,,,,fee schedule,977.33,1219.24,
Ecmo/ecls initiation venous,33946,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1067.64,,,,,,,fee schedule,977.33,1219.24,
Ecmo/ecls initiation venous,33946,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1122.47,,,,,,,fee schedule,977.33,1219.24,
Ecmo/ecls initiation artery,33947,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1346.81,,,,,,,fee schedule,1079.59,1346.81,
Ecmo/ecls initiation artery,33947,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1079.59,,,,,,,fee schedule,1079.59,1346.81,
Ecmo/ecls initiation artery,33947,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1179.35,,,,,,,fee schedule,1079.59,1346.81,
Ecmo/ecls initiation artery,33947,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1239.92,,,,,,,fee schedule,1079.59,1346.81,
Ecmo/ecls daily mgmt-venous,33948,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,961.1,,,,,,,fee schedule,770.41,961.1,
Ecmo/ecls daily mgmt-venous,33948,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,770.41,,,,,,,fee schedule,770.41,961.1,
Ecmo/ecls daily mgmt-venous,33948,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,841.6,,,,,,,fee schedule,770.41,961.1,
Ecmo/ecls daily mgmt-venous,33948,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,884.82,,,,,,,fee schedule,770.41,961.1,
Ecmo/ecls daily mgmt artery,33949,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,935.44,,,,,,,fee schedule,749.83,935.44,
Ecmo/ecls daily mgmt artery,33949,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,749.83,,,,,,,fee schedule,749.83,935.44,
Ecmo/ecls daily mgmt artery,33949,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,819.13,,,,,,,fee schedule,749.83,935.44,
Ecmo/ecls daily mgmt artery,33949,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,861.2,,,,,,,fee schedule,749.83,935.44,
Ecmo/ecls insj prph cannula,33951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1755.58,,,,,,,fee schedule,1407.25,1755.58,
Ecmo/ecls insj prph cannula,33951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1407.25,,,,,,,fee schedule,1407.25,1755.58,
Ecmo/ecls insj prph cannula,33951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1537.3,,,,,,,fee schedule,1407.25,1755.58,
Ecmo/ecls insj prph cannula,33951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1616.25,,,,,,,fee schedule,1407.25,1755.58,
Ecmo/ecls insj prph cannula,33952,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1708.56,,,,,,,fee schedule,1369.56,1708.56,
Ecmo/ecls insj prph cannula,33952,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1369.56,,,,,,,fee schedule,1369.56,1708.56,
Ecmo/ecls insj prph cannula,33952,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1496.12,,,,,,,fee schedule,1369.56,1708.56,
Ecmo/ecls insj prph cannula,33952,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1572.96,,,,,,,fee schedule,1369.56,1708.56,
Ecmo/ecls insj prph cannula,33953,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1958,,,,,,,fee schedule,1569.51,1958,
Ecmo/ecls insj prph cannula,33953,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1569.51,,,,,,,fee schedule,1569.51,1958,
Ecmo/ecls insj prph cannula,33953,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1714.55,,,,,,,fee schedule,1569.51,1958,
Ecmo/ecls insj prph cannula,33953,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1802.61,,,,,,,fee schedule,1569.51,1958,
Ecmo/ecls insj prph cannula,33954,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1909.2,,,,,,,fee schedule,1530.39,1909.2,
Ecmo/ecls insj prph cannula,33954,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1530.39,,,,,,,fee schedule,1530.39,1909.2,
Ecmo/ecls insj prph cannula,33954,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1671.81,,,,,,,fee schedule,1530.39,1909.2,
Ecmo/ecls insj prph cannula,33954,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1757.68,,,,,,,fee schedule,1530.39,1909.2,
Ecmo/ecls insj ctr cannula,33955,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3526.29,,,,,,,fee schedule,2826.63,3526.29,
Ecmo/ecls insj ctr cannula,33955,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2826.63,,,,,,,fee schedule,2826.63,3526.29,
Ecmo/ecls insj ctr cannula,33955,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3087.83,,,,,,,fee schedule,2826.63,3526.29,
Ecmo/ecls insj ctr cannula,33955,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3246.42,,,,,,,fee schedule,2826.63,3526.29,
Ecmo/ecls insj ctr cannula,33956,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3352.41,,,,,,,fee schedule,2687.25,3352.41,
Ecmo/ecls insj ctr cannula,33956,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2687.25,,,,,,,fee schedule,2687.25,3352.41,
Ecmo/ecls insj ctr cannula,33956,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2935.57,,,,,,,fee schedule,2687.25,3352.41,
Ecmo/ecls insj ctr cannula,33956,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3086.34,,,,,,,fee schedule,2687.25,3352.41,
Ecmo/ecls repos perph cnula,33957,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,782.23,,,,,,,fee schedule,627.03,782.23,
Ecmo/ecls repos perph cnula,33957,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,627.03,,,,,,,fee schedule,627.03,782.23,
Ecmo/ecls repos perph cnula,33957,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,684.97,,,,,,,fee schedule,627.03,782.23,
Ecmo/ecls repos perph cnula,33957,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,720.15,,,,,,,fee schedule,627.03,782.23,
Ecmo/ecls repos perph cnula,33958,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,758.65,,,,,,,fee schedule,608.12,758.65,
Ecmo/ecls repos perph cnula,33958,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,608.12,,,,,,,fee schedule,608.12,758.65,
Ecmo/ecls repos perph cnula,33958,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,664.32,,,,,,,fee schedule,608.12,758.65,
Ecmo/ecls repos perph cnula,33958,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,698.44,,,,,,,fee schedule,608.12,758.65,
Ecmo/ecls repos perph cnula,33959,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,994.03,,,,,,,fee schedule,796.8,994.03,
Ecmo/ecls repos perph cnula,33959,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,796.8,,,,,,,fee schedule,796.8,994.03,
Ecmo/ecls repos perph cnula,33959,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,870.43,,,,,,,fee schedule,796.8,994.03,
Ecmo/ecls repos perph cnula,33959,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,915.14,,,,,,,fee schedule,796.8,994.03,
Ecmo/ecls repos perph cnula,33962,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,938.12,,,,,,,fee schedule,751.99,938.12,
Ecmo/ecls repos perph cnula,33962,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,751.99,,,,,,,fee schedule,751.99,938.12,
Ecmo/ecls repos perph cnula,33962,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,821.48,,,,,,,fee schedule,751.99,938.12,
Ecmo/ecls repos perph cnula,33962,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,863.67,,,,,,,fee schedule,751.99,938.12,
Ecmo/ecls repos perph cnula,33963,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1986.54,,,,,,,fee schedule,1592.39,1986.54,
Ecmo/ecls repos perph cnula,33963,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1592.39,,,,,,,fee schedule,1592.39,1986.54,
Ecmo/ecls repos perph cnula,33963,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1739.54,,,,,,,fee schedule,1592.39,1986.54,
Ecmo/ecls repos perph cnula,33963,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1828.88,,,,,,,fee schedule,1592.39,1986.54,
Ecmo/ecls repos perph cnula,33964,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2040.07,,,,,,,fee schedule,1635.29,2040.07,
Ecmo/ecls repos perph cnula,33964,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1635.29,,,,,,,fee schedule,1635.29,2040.07,
Ecmo/ecls repos perph cnula,33964,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1786.41,,,,,,,fee schedule,1635.29,2040.07,
Ecmo/ecls repos perph cnula,33964,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1878.16,,,,,,,fee schedule,1635.29,2040.07,
Ecmo/ecls rmvl perph cannula,33965,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,782.23,,,,,,,fee schedule,627.03,782.23,
Ecmo/ecls rmvl perph cannula,33965,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,627.03,,,,,,,fee schedule,627.03,782.23,
Ecmo/ecls rmvl perph cannula,33965,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,684.97,,,,,,,fee schedule,627.03,782.23,
Ecmo/ecls rmvl perph cannula,33965,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,720.15,,,,,,,fee schedule,627.03,782.23,
Ecmo/ecls rmvl prph cannula,33966,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,945,,,,,,,fee schedule,757.5,945,
Ecmo/ecls rmvl prph cannula,33966,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,757.5,,,,,,,fee schedule,757.5,945,
Ecmo/ecls rmvl prph cannula,33966,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,827.5,,,,,,,fee schedule,757.5,945,
Ecmo/ecls rmvl prph cannula,33966,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,870,,,,,,,fee schedule,757.5,945,
Ecmo/ecls rmvl perph cannula,33969,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1151.8,,,,,,,fee schedule,923.27,1151.8,
Ecmo/ecls rmvl perph cannula,33969,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,923.27,,,,,,,fee schedule,923.27,1151.8,
Ecmo/ecls rmvl perph cannula,33969,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1008.59,,,,,,,fee schedule,923.27,1151.8,
Ecmo/ecls rmvl perph cannula,33969,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1060.39,,,,,,,fee schedule,923.27,1151.8,
Ecmo/ecls rmvl prph cannula,33984,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1136.53,,,,,,,fee schedule,911.03,1136.53,
Ecmo/ecls rmvl prph cannula,33984,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,911.03,,,,,,,fee schedule,911.03,1136.53,
Ecmo/ecls rmvl prph cannula,33984,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,995.22,,,,,,,fee schedule,911.03,1136.53,
Ecmo/ecls rmvl prph cannula,33984,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1046.33,,,,,,,fee schedule,911.03,1136.53,
Ecmo/ecls rmvl ctr cannula,33985,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2171.38,,,,,,,fee schedule,1740.55,2171.38,
Ecmo/ecls rmvl ctr cannula,33985,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1740.55,,,,,,,fee schedule,1740.55,2171.38,
Ecmo/ecls rmvl ctr cannula,33985,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1901.4,,,,,,,fee schedule,1740.55,2171.38,
Ecmo/ecls rmvl ctr cannula,33985,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1999.05,,,,,,,fee schedule,1740.55,2171.38,
Ecmo/ecls rmvl ctr cannula,33986,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2074.2,,,,,,,fee schedule,1662.65,2074.2,
Ecmo/ecls rmvl ctr cannula,33986,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1662.65,,,,,,,fee schedule,1662.65,2074.2,
Ecmo/ecls rmvl ctr cannula,33986,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1816.3,,,,,,,fee schedule,1662.65,2074.2,
Ecmo/ecls rmvl ctr cannula,33986,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1909.58,,,,,,,fee schedule,1662.65,2074.2,
Artery expos/graft artery,33987,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,832.28,,,,,,,fee schedule,667.15,832.28,
Artery expos/graft artery,33987,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,667.15,,,,,,,fee schedule,667.15,832.28,
Artery expos/graft artery,33987,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,728.8,,,,,,,fee schedule,667.15,832.28,
Artery expos/graft artery,33987,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,766.23,,,,,,,fee schedule,667.15,832.28,
Insertion of left heart vent,33988,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3092.72,,,,,,,fee schedule,2479.09,3092.72,
Insertion of left heart vent,33988,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2479.09,,,,,,,fee schedule,2479.09,3092.72,
Insertion of left heart vent,33988,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2708.18,,,,,,,fee schedule,2479.09,3092.72,
Insertion of left heart vent,33988,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2847.27,,,,,,,fee schedule,2479.09,3092.72,
Removal of left heart vent,33989,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1965.68,,,,,,,fee schedule,1575.66,1965.68,
Removal of left heart vent,33989,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1575.66,,,,,,,fee schedule,1575.66,1965.68,
Removal of left heart vent,33989,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1721.27,,,,,,,fee schedule,1575.66,1965.68,
Removal of left heart vent,33989,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1809.67,,,,,,,fee schedule,1575.66,1965.68,
Insert vad artery access,33990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1630.2,,,,,,,fee schedule,1306.75,1630.2,
Insert vad artery access,33990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1306.75,,,,,,,fee schedule,1306.75,1630.2,
Insert vad artery access,33990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1427.5,,,,,,,fee schedule,1306.75,1630.2,
Insert vad artery access,33990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1500.82,,,,,,,fee schedule,1306.75,1630.2,
Insert vad art&vein access,33991,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2375.39,,,,,,,fee schedule,1904.08,2375.39,
Insert vad art&vein access,33991,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1904.08,,,,,,,fee schedule,1904.08,2375.39,
Insert vad art&vein access,33991,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2080.04,,,,,,,fee schedule,1904.08,2375.39,
Insert vad art&vein access,33991,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2186.87,,,,,,,fee schedule,1904.08,2375.39,
Remove vad different session,33992,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,776.98,,,,,,,fee schedule,622.82,776.98,
Remove vad different session,33992,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,622.82,,,,,,,fee schedule,622.82,776.98,
Remove vad different session,33992,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,680.37,,,,,,,fee schedule,622.82,776.98,
Remove vad different session,33992,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,715.31,,,,,,,fee schedule,622.82,776.98,
Reposition vad diff session,33993,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,682.18,,,,,,,fee schedule,546.82,682.18,
Reposition vad diff session,33993,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,546.82,,,,,,,fee schedule,546.82,682.18,
Reposition vad diff session,33993,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,597.36,,,,,,,fee schedule,546.82,682.18,
Reposition vad diff session,33993,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,628.04,,,,,,,fee schedule,546.82,682.18,
Cardiac surgery procedure,33999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1298.39,,,,,,,fee schedule,621.01,2755.21,
Cardiac surgery procedure,33999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1040.77,,,,,,,fee schedule,621.01,2755.21,
Cardiac surgery procedure,33999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1136.95,,,,,,,fee schedule,621.01,2755.21,
Cardiac surgery procedure,33999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1195.35,,,,,,,fee schedule,621.01,2755.21,
Cardiac surgery procedure,33999,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2755.21,,,,,,,fee schedule,621.01,2755.21,APC 378
Cardiac surgery procedure,33999,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,652.06,,,,,,,fee schedule,621.01,2755.21,APC
Cardiac surgery procedure,33999,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,645.85,,,,,,,fee schedule,621.01,2755.21,APC
Cardiac surgery procedure,33999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,621.01,,,,,,,fee schedule,621.01,2755.21,APC
Cardiac surgery procedure,33999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,950.14,,,,,,,fee schedule,621.01,2755.21,Radiology
Cardiac surgery procedure,33999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,869.41,,,,,,,fee schedule,621.01,2755.21,APC
Cardiac surgery procedure,33999,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1086.77,,,,,,,fee schedule,621.01,2755.21,APC
Removal of artery clot,34101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9675.33,,,,,,,fee schedule,5508.66,24440.06,
Removal of artery clot,34101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7755.62,,,,,,,fee schedule,5508.66,24440.06,
Removal of artery clot,34101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8472.31,,,,,,,fee schedule,5508.66,24440.06,
Removal of artery clot,34101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8907.44,,,,,,,fee schedule,5508.66,24440.06,
Removal of artery clot,34101,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24440.06,,,,,,,fee schedule,5508.66,24440.06,APC 378
Removal of artery clot,34101,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5784.09,,,,,,,fee schedule,5508.66,24440.06,APC
Removal of artery clot,34101,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5729.01,,,,,,,fee schedule,5508.66,24440.06,APC
Removal of artery clot,34101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5508.66,,,,,,,fee schedule,5508.66,24440.06,APC
Removal of artery clot,34101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8428.25,,,,,,,fee schedule,5508.66,24440.06,Radiology
Removal of artery clot,34101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7712.13,,,,,,,fee schedule,5508.66,24440.06,APC
Removal of artery clot,34101,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9640.16,,,,,,,fee schedule,5508.66,24440.06,APC
Removal of arm artery clot,34111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9675.33,,,,,,,fee schedule,5508.66,24440.06,
Removal of arm artery clot,34111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7755.62,,,,,,,fee schedule,5508.66,24440.06,
Removal of arm artery clot,34111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8472.31,,,,,,,fee schedule,5508.66,24440.06,
Removal of arm artery clot,34111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8907.44,,,,,,,fee schedule,5508.66,24440.06,
Removal of arm artery clot,34111,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24440.06,,,,,,,fee schedule,5508.66,24440.06,APC 378
Removal of arm artery clot,34111,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5784.09,,,,,,,fee schedule,5508.66,24440.06,APC
Removal of arm artery clot,34111,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5729.01,,,,,,,fee schedule,5508.66,24440.06,APC
Removal of arm artery clot,34111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5508.66,,,,,,,fee schedule,5508.66,24440.06,APC
Removal of arm artery clot,34111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8428.25,,,,,,,fee schedule,5508.66,24440.06,Radiology
Removal of arm artery clot,34111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7712.13,,,,,,,fee schedule,5508.66,24440.06,APC
Removal of arm artery clot,34111,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9640.16,,,,,,,fee schedule,5508.66,24440.06,APC
Removal of artery clot,34201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9675.33,,,,,,,fee schedule,5508.66,24440.06,
Removal of artery clot,34201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7755.62,,,,,,,fee schedule,5508.66,24440.06,
Removal of artery clot,34201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8472.31,,,,,,,fee schedule,5508.66,24440.06,
Removal of artery clot,34201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8907.44,,,,,,,fee schedule,5508.66,24440.06,
Removal of artery clot,34201,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24440.06,,,,,,,fee schedule,5508.66,24440.06,APC 378
Removal of artery clot,34201,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5784.09,,,,,,,fee schedule,5508.66,24440.06,APC
Removal of artery clot,34201,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5729.01,,,,,,,fee schedule,5508.66,24440.06,APC
Removal of artery clot,34201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5508.66,,,,,,,fee schedule,5508.66,24440.06,APC
Removal of artery clot,34201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8428.25,,,,,,,fee schedule,5508.66,24440.06,Radiology
Removal of artery clot,34201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7712.13,,,,,,,fee schedule,5508.66,24440.06,APC
Removal of artery clot,34201,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9640.16,,,,,,,fee schedule,5508.66,24440.06,APC
Removal of leg artery clot,34203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9675.33,,,,,,,fee schedule,5508.66,24440.06,
Removal of leg artery clot,34203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7755.62,,,,,,,fee schedule,5508.66,24440.06,
Removal of leg artery clot,34203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8472.31,,,,,,,fee schedule,5508.66,24440.06,
Removal of leg artery clot,34203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8907.44,,,,,,,fee schedule,5508.66,24440.06,
Removal of leg artery clot,34203,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24440.06,,,,,,,fee schedule,5508.66,24440.06,APC 378
Removal of leg artery clot,34203,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5784.09,,,,,,,fee schedule,5508.66,24440.06,APC
Removal of leg artery clot,34203,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5729.01,,,,,,,fee schedule,5508.66,24440.06,APC
Removal of leg artery clot,34203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5508.66,,,,,,,fee schedule,5508.66,24440.06,APC
Removal of leg artery clot,34203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8428.25,,,,,,,fee schedule,5508.66,24440.06,Radiology
Removal of leg artery clot,34203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7712.13,,,,,,,fee schedule,5508.66,24440.06,APC
Removal of leg artery clot,34203,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9640.16,,,,,,,fee schedule,5508.66,24440.06,APC
Removal of vein clot,34421,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9675.33,,,,,,,fee schedule,3125.8,13868.13,
Removal of vein clot,34421,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7755.62,,,,,,,fee schedule,3125.8,13868.13,
Removal of vein clot,34421,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8472.31,,,,,,,fee schedule,3125.8,13868.13,
Removal of vein clot,34421,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8907.44,,,,,,,fee schedule,3125.8,13868.13,
Removal of vein clot,34421,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Removal of vein clot,34421,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Removal of vein clot,34421,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Removal of vein clot,34421,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Removal of vein clot,34421,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Removal of vein clot,34421,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Removal of vein clot,34421,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Removal of vein clot,34471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9675.33,,,,,,,fee schedule,621.01,9675.33,
Removal of vein clot,34471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7755.62,,,,,,,fee schedule,621.01,9675.33,
Removal of vein clot,34471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8472.31,,,,,,,fee schedule,621.01,9675.33,
Removal of vein clot,34471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8907.44,,,,,,,fee schedule,621.01,9675.33,
Removal of vein clot,34471,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2755.21,,,,,,,fee schedule,621.01,9675.33,APC 378
Removal of vein clot,34471,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,652.06,,,,,,,fee schedule,621.01,9675.33,APC
Removal of vein clot,34471,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,645.85,,,,,,,fee schedule,621.01,9675.33,APC
Removal of vein clot,34471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,621.01,,,,,,,fee schedule,621.01,9675.33,APC
Removal of vein clot,34471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,950.14,,,,,,,fee schedule,621.01,9675.33,Radiology
Removal of vein clot,34471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,869.41,,,,,,,fee schedule,621.01,9675.33,APC
Removal of vein clot,34471,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1086.77,,,,,,,fee schedule,621.01,9675.33,APC
Removal of vein clot,34490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9675.33,,,,,,,fee schedule,3125.8,13868.13,
Removal of vein clot,34490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7755.62,,,,,,,fee schedule,3125.8,13868.13,
Removal of vein clot,34490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8472.31,,,,,,,fee schedule,3125.8,13868.13,
Removal of vein clot,34490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8907.44,,,,,,,fee schedule,3125.8,13868.13,
Removal of vein clot,34490,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Removal of vein clot,34490,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Removal of vein clot,34490,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Removal of vein clot,34490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Removal of vein clot,34490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Removal of vein clot,34490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Removal of vein clot,34490,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Repair valve femoral vein,34501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9675.33,,,,,,,fee schedule,5508.66,24440.06,
Repair valve femoral vein,34501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7755.62,,,,,,,fee schedule,5508.66,24440.06,
Repair valve femoral vein,34501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8472.31,,,,,,,fee schedule,5508.66,24440.06,
Repair valve femoral vein,34501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8907.44,,,,,,,fee schedule,5508.66,24440.06,
Repair valve femoral vein,34501,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24440.06,,,,,,,fee schedule,5508.66,24440.06,APC 378
Repair valve femoral vein,34501,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5784.09,,,,,,,fee schedule,5508.66,24440.06,APC
Repair valve femoral vein,34501,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5729.01,,,,,,,fee schedule,5508.66,24440.06,APC
Repair valve femoral vein,34501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5508.66,,,,,,,fee schedule,5508.66,24440.06,APC
Repair valve femoral vein,34501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8428.25,,,,,,,fee schedule,5508.66,24440.06,Radiology
Repair valve femoral vein,34501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7712.13,,,,,,,fee schedule,5508.66,24440.06,APC
Repair valve femoral vein,34501,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9640.16,,,,,,,fee schedule,5508.66,24440.06,APC
Transposition of vein valve,34510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9675.33,,,,,,,fee schedule,5508.66,24440.06,
Transposition of vein valve,34510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7755.62,,,,,,,fee schedule,5508.66,24440.06,
Transposition of vein valve,34510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8472.31,,,,,,,fee schedule,5508.66,24440.06,
Transposition of vein valve,34510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8907.44,,,,,,,fee schedule,5508.66,24440.06,
Transposition of vein valve,34510,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24440.06,,,,,,,fee schedule,5508.66,24440.06,APC 378
Transposition of vein valve,34510,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5784.09,,,,,,,fee schedule,5508.66,24440.06,APC
Transposition of vein valve,34510,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5729.01,,,,,,,fee schedule,5508.66,24440.06,APC
Transposition of vein valve,34510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5508.66,,,,,,,fee schedule,5508.66,24440.06,APC
Transposition of vein valve,34510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8428.25,,,,,,,fee schedule,5508.66,24440.06,Radiology
Transposition of vein valve,34510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7712.13,,,,,,,fee schedule,5508.66,24440.06,APC
Transposition of vein valve,34510,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9640.16,,,,,,,fee schedule,5508.66,24440.06,APC
Cross-over vein graft,34520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9675.33,,,,,,,fee schedule,5508.66,24440.06,
Cross-over vein graft,34520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7755.62,,,,,,,fee schedule,5508.66,24440.06,
Cross-over vein graft,34520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8472.31,,,,,,,fee schedule,5508.66,24440.06,
Cross-over vein graft,34520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8907.44,,,,,,,fee schedule,5508.66,24440.06,
Cross-over vein graft,34520,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24440.06,,,,,,,fee schedule,5508.66,24440.06,APC 378
Cross-over vein graft,34520,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5784.09,,,,,,,fee schedule,5508.66,24440.06,APC
Cross-over vein graft,34520,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5729.01,,,,,,,fee schedule,5508.66,24440.06,APC
Cross-over vein graft,34520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5508.66,,,,,,,fee schedule,5508.66,24440.06,APC
Cross-over vein graft,34520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8428.25,,,,,,,fee schedule,5508.66,24440.06,Radiology
Cross-over vein graft,34520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7712.13,,,,,,,fee schedule,5508.66,24440.06,APC
Cross-over vein graft,34520,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9640.16,,,,,,,fee schedule,5508.66,24440.06,APC
Leg vein fusion,34530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9675.33,,,,,,,fee schedule,3125.8,13868.13,
Leg vein fusion,34530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7755.62,,,,,,,fee schedule,3125.8,13868.13,
Leg vein fusion,34530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8472.31,,,,,,,fee schedule,3125.8,13868.13,
Leg vein fusion,34530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8907.44,,,,,,,fee schedule,3125.8,13868.13,
Leg vein fusion,34530,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Leg vein fusion,34530,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Leg vein fusion,34530,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Leg vein fusion,34530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Leg vein fusion,34530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Leg vein fusion,34530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Leg vein fusion,34530,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Evasc rpr a-ao ndgft,34701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4966.62,,,,,,,fee schedule,3981.18,4966.62,
Evasc rpr a-ao ndgft,34701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3981.18,,,,,,,fee schedule,3981.18,4966.62,
Evasc rpr a-ao ndgft,34701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4349.08,,,,,,,fee schedule,3981.18,4966.62,
Evasc rpr a-ao ndgft,34701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4572.44,,,,,,,fee schedule,3981.18,4966.62,
Evasc rpr a-ao ndgft rpt,34702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7427.66,,,,,,,fee schedule,5953.92,7427.66,
Evasc rpr a-ao ndgft rpt,34702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5953.92,,,,,,,fee schedule,5953.92,7427.66,
Evasc rpr a-ao ndgft rpt,34702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6504.12,,,,,,,fee schedule,5953.92,7427.66,
Evasc rpr a-ao ndgft rpt,34702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6838.17,,,,,,,fee schedule,5953.92,7427.66,
Evasc rpr a-unilac ndgft,34703,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5485.35,,,,,,,fee schedule,4396.98,5485.35,
Evasc rpr a-unilac ndgft,34703,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4396.98,,,,,,,fee schedule,4396.98,5485.35,
Evasc rpr a-unilac ndgft,34703,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4803.31,,,,,,,fee schedule,4396.98,5485.35,
Evasc rpr a-unilac ndgft,34703,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5050,,,,,,,fee schedule,4396.98,5485.35,
Evasc rpr a-unilac ndgft rpt,34704,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9158.22,,,,,,,fee schedule,7341.11,9158.22,
Evasc rpr a-unilac ndgft rpt,34704,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7341.11,,,,,,,fee schedule,7341.11,9158.22,
Evasc rpr a-unilac ndgft rpt,34704,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8019.5,,,,,,,fee schedule,7341.11,9158.22,
Evasc rpr a-unilac ndgft rpt,34704,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8431.38,,,,,,,fee schedule,7341.11,9158.22,
Evac rpr a-biiliac ndgft,34705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6123.3,,,,,,,fee schedule,4908.36,6123.3,
Evac rpr a-biiliac ndgft,34705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4908.36,,,,,,,fee schedule,4908.36,6123.3,
Evac rpr a-biiliac ndgft,34705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5361.94,,,,,,,fee schedule,4908.36,6123.3,
Evac rpr a-biiliac ndgft,34705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5637.32,,,,,,,fee schedule,4908.36,6123.3,
Evasc rpr a-biiliac rpt,34706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9242.48,,,,,,,fee schedule,7408.65,9242.48,
Evasc rpr a-biiliac rpt,34706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7408.65,,,,,,,fee schedule,7408.65,9242.48,
Evasc rpr a-biiliac rpt,34706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8093.28,,,,,,,fee schedule,7408.65,9242.48,
Evasc rpr a-biiliac rpt,34706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8508.95,,,,,,,fee schedule,7408.65,9242.48,
Evasc rpr ilio-iliac ndgft,34707,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4636.17,,,,,,,fee schedule,3716.3,4636.17,
Evasc rpr ilio-iliac ndgft,34707,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3716.3,,,,,,,fee schedule,3716.3,4636.17,
Evasc rpr ilio-iliac ndgft,34707,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4059.72,,,,,,,fee schedule,3716.3,4636.17,
Evasc rpr ilio-iliac ndgft,34707,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4268.22,,,,,,,fee schedule,3716.3,4636.17,
Evasc rpr ilio-iliac rpt,34708,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7413.9,,,,,,,fee schedule,5942.89,7413.9,
Evasc rpr ilio-iliac rpt,34708,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5942.89,,,,,,,fee schedule,5942.89,7413.9,
Evasc rpr ilio-iliac rpt,34708,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6492.07,,,,,,,fee schedule,5942.89,7413.9,
Evasc rpr ilio-iliac rpt,34708,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6825.5,,,,,,,fee schedule,5942.89,7413.9,
Plmt xtn prosth evasc rpr,34709,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1300.74,,,,,,,fee schedule,1042.65,1300.74,
Plmt xtn prosth evasc rpr,34709,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1042.65,,,,,,,fee schedule,1042.65,1300.74,
Plmt xtn prosth evasc rpr,34709,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1139,,,,,,,fee schedule,1042.65,1300.74,
Plmt xtn prosth evasc rpr,34709,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1197.5,,,,,,,fee schedule,1042.65,1300.74,
Dlyd plmt xtn prosth 1st vsl,34710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3193.84,,,,,,,fee schedule,2560.14,3193.84,
Dlyd plmt xtn prosth 1st vsl,34710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2560.14,,,,,,,fee schedule,2560.14,3193.84,
Dlyd plmt xtn prosth 1st vsl,34710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2796.72,,,,,,,fee schedule,2560.14,3193.84,
Dlyd plmt xtn prosth 1st vsl,34710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2940.36,,,,,,,fee schedule,2560.14,3193.84,
Dlyd plmt xtn prosth ea addl,34711,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1198.6,,,,,,,fee schedule,960.78,1198.6,
Dlyd plmt xtn prosth ea addl,34711,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,960.78,,,,,,,fee schedule,960.78,1198.6,
Dlyd plmt xtn prosth ea addl,34711,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1049.57,,,,,,,fee schedule,960.78,1198.6,
Dlyd plmt xtn prosth ea addl,34711,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1103.47,,,,,,,fee schedule,960.78,1198.6,
Tcat dlvr enhncd fixj dev,34712,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2623.06,,,,,,,fee schedule,2102.61,2623.06,
Tcat dlvr enhncd fixj dev,34712,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2102.61,,,,,,,fee schedule,2102.61,2623.06,
Tcat dlvr enhncd fixj dev,34712,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2296.91,,,,,,,fee schedule,2102.61,2623.06,
Tcat dlvr enhncd fixj dev,34712,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2414.88,,,,,,,fee schedule,2102.61,2623.06,
Perq access & clsr fem art,34713,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,500.43,,,,,,,fee schedule,401.14,500.43,
Perq access & clsr fem art,34713,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,401.14,,,,,,,fee schedule,401.14,500.43,
Perq access & clsr fem art,34713,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,438.21,,,,,,,fee schedule,401.14,500.43,
Perq access & clsr fem art,34713,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,460.72,,,,,,,fee schedule,401.14,500.43,
Opn fem art expos cndt crtj,34714,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1082.93,,,,,,,fee schedule,868.06,1082.93,
Opn fem art expos cndt crtj,34714,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,868.06,,,,,,,fee schedule,868.06,1082.93,
Opn fem art expos cndt crtj,34714,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,948.28,,,,,,,fee schedule,868.06,1082.93,
Opn fem art expos cndt crtj,34714,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,996.99,,,,,,,fee schedule,868.06,1082.93,
Opn ax/subcla art expos,34715,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1204.76,,,,,,,fee schedule,965.72,1204.76,
Opn ax/subcla art expos,34715,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,965.72,,,,,,,fee schedule,965.72,1204.76,
Opn ax/subcla art expos,34715,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1054.96,,,,,,,fee schedule,965.72,1204.76,
Opn ax/subcla art expos,34715,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1109.15,,,,,,,fee schedule,965.72,1204.76,
Opn ax/subcla art expos cndt,34716,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1484.71,,,,,,,fee schedule,1190.12,1484.71,
Opn ax/subcla art expos cndt,34716,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1190.12,,,,,,,fee schedule,1190.12,1484.71,
Opn ax/subcla art expos cndt,34716,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1300.1,,,,,,,fee schedule,1190.12,1484.71,
Opn ax/subcla art expos cndt,34716,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1366.87,,,,,,,fee schedule,1190.12,1484.71,
Evasc rpr a-iliac ndgft,34717,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1788.36,,,,,,,fee schedule,1433.52,1788.36,
Evasc rpr a-iliac ndgft,34717,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1433.52,,,,,,,fee schedule,1433.52,1788.36,
Evasc rpr a-iliac ndgft,34717,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1565.99,,,,,,,fee schedule,1433.52,1788.36,
Evasc rpr a-iliac ndgft,34717,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1646.42,,,,,,,fee schedule,1433.52,1788.36,
Evasc rpr n/a a-iliac ndgft,34718,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4964.84,,,,,,,fee schedule,3979.75,4964.84,
Evasc rpr n/a a-iliac ndgft,34718,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3979.75,,,,,,,fee schedule,3979.75,4964.84,
Evasc rpr n/a a-iliac ndgft,34718,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4347.52,,,,,,,fee schedule,3979.75,4964.84,
Evasc rpr n/a a-iliac ndgft,34718,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4570.81,,,,,,,fee schedule,3979.75,4964.84,
Repair defect of artery,35011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10099.52,,,,,,,fee schedule,5508.66,24440.06,
Repair defect of artery,35011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8095.64,,,,,,,fee schedule,5508.66,24440.06,
Repair defect of artery,35011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8843.76,,,,,,,fee schedule,5508.66,24440.06,
Repair defect of artery,35011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9297.97,,,,,,,fee schedule,5508.66,24440.06,
Repair defect of artery,35011,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24440.06,,,,,,,fee schedule,5508.66,24440.06,APC 378
Repair defect of artery,35011,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5784.09,,,,,,,fee schedule,5508.66,24440.06,APC
Repair defect of artery,35011,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5729.01,,,,,,,fee schedule,5508.66,24440.06,APC
Repair defect of artery,35011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5508.66,,,,,,,fee schedule,5508.66,24440.06,APC
Repair defect of artery,35011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8428.25,,,,,,,fee schedule,5508.66,24440.06,Radiology
Repair defect of artery,35011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7712.13,,,,,,,fee schedule,5508.66,24440.06,APC
Repair defect of artery,35011,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9640.16,,,,,,,fee schedule,5508.66,24440.06,APC
Repair defect of arm artery,35045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14833.78,,,,,,,fee schedule,5508.66,24440.06,
Repair defect of arm artery,35045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11890.57,,,,,,,fee schedule,5508.66,24440.06,
Repair defect of arm artery,35045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12989.37,,,,,,,fee schedule,5508.66,24440.06,
Repair defect of arm artery,35045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13656.49,,,,,,,fee schedule,5508.66,24440.06,
Repair defect of arm artery,35045,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24440.06,,,,,,,fee schedule,5508.66,24440.06,APC 378
Repair defect of arm artery,35045,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5784.09,,,,,,,fee schedule,5508.66,24440.06,APC
Repair defect of arm artery,35045,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5729.01,,,,,,,fee schedule,5508.66,24440.06,APC
Repair defect of arm artery,35045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5508.66,,,,,,,fee schedule,5508.66,24440.06,APC
Repair defect of arm artery,35045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8428.25,,,,,,,fee schedule,5508.66,24440.06,Radiology
Repair defect of arm artery,35045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7712.13,,,,,,,fee schedule,5508.66,24440.06,APC
Repair defect of arm artery,35045,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9640.16,,,,,,,fee schedule,5508.66,24440.06,APC
Repair blood vessel lesion,35180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7519.55,,,,,,,fee schedule,1558.36,7519.55,
Repair blood vessel lesion,35180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6027.58,,,,,,,fee schedule,1558.36,7519.55,
Repair blood vessel lesion,35180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6584.58,,,,,,,fee schedule,1558.36,7519.55,
Repair blood vessel lesion,35180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6922.76,,,,,,,fee schedule,1558.36,7519.55,
Repair blood vessel lesion,35180,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6913.93,,,,,,,fee schedule,1558.36,7519.55,APC 378
Repair blood vessel lesion,35180,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1636.28,,,,,,,fee schedule,1558.36,7519.55,APC
Repair blood vessel lesion,35180,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1620.7,,,,,,,fee schedule,1558.36,7519.55,APC
Repair blood vessel lesion,35180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1558.36,,,,,,,fee schedule,1558.36,7519.55,APC
Repair blood vessel lesion,35180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2384.29,,,,,,,fee schedule,1558.36,7519.55,Radiology
Repair blood vessel lesion,35180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2181.71,,,,,,,fee schedule,1558.36,7519.55,APC
Repair blood vessel lesion,35180,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2727.13,,,,,,,fee schedule,1558.36,7519.55,APC
Repair blood vessel lesion,35184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7519.55,,,,,,,fee schedule,3125.8,13868.13,
Repair blood vessel lesion,35184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6027.58,,,,,,,fee schedule,3125.8,13868.13,
Repair blood vessel lesion,35184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6584.58,,,,,,,fee schedule,3125.8,13868.13,
Repair blood vessel lesion,35184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6922.76,,,,,,,fee schedule,3125.8,13868.13,
Repair blood vessel lesion,35184,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Repair blood vessel lesion,35184,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Repair blood vessel lesion,35184,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Repair blood vessel lesion,35184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Repair blood vessel lesion,35184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Repair blood vessel lesion,35184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Repair blood vessel lesion,35184,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Repair blood vessel lesion,35188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9675.33,,,,,,,fee schedule,5508.66,24440.06,
Repair blood vessel lesion,35188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7755.62,,,,,,,fee schedule,5508.66,24440.06,
Repair blood vessel lesion,35188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8472.31,,,,,,,fee schedule,5508.66,24440.06,
Repair blood vessel lesion,35188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8907.44,,,,,,,fee schedule,5508.66,24440.06,
Repair blood vessel lesion,35188,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24440.06,,,,,,,fee schedule,5508.66,24440.06,APC 378
Repair blood vessel lesion,35188,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5784.09,,,,,,,fee schedule,5508.66,24440.06,APC
Repair blood vessel lesion,35188,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5729.01,,,,,,,fee schedule,5508.66,24440.06,APC
Repair blood vessel lesion,35188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5508.66,,,,,,,fee schedule,5508.66,24440.06,APC
Repair blood vessel lesion,35188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8428.25,,,,,,,fee schedule,5508.66,24440.06,Radiology
Repair blood vessel lesion,35188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7712.13,,,,,,,fee schedule,5508.66,24440.06,APC
Repair blood vessel lesion,35188,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9640.16,,,,,,,fee schedule,5508.66,24440.06,APC
Repair blood vessel lesion,35190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7519.55,,,,,,,fee schedule,5508.66,24440.06,
Repair blood vessel lesion,35190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6027.58,,,,,,,fee schedule,5508.66,24440.06,
Repair blood vessel lesion,35190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6584.58,,,,,,,fee schedule,5508.66,24440.06,
Repair blood vessel lesion,35190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6922.76,,,,,,,fee schedule,5508.66,24440.06,
Repair blood vessel lesion,35190,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24440.06,,,,,,,fee schedule,5508.66,24440.06,APC 378
Repair blood vessel lesion,35190,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5784.09,,,,,,,fee schedule,5508.66,24440.06,APC
Repair blood vessel lesion,35190,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5729.01,,,,,,,fee schedule,5508.66,24440.06,APC
Repair blood vessel lesion,35190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5508.66,,,,,,,fee schedule,5508.66,24440.06,APC
Repair blood vessel lesion,35190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8428.25,,,,,,,fee schedule,5508.66,24440.06,Radiology
Repair blood vessel lesion,35190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7712.13,,,,,,,fee schedule,5508.66,24440.06,APC
Repair blood vessel lesion,35190,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9640.16,,,,,,,fee schedule,5508.66,24440.06,APC
Repair blood vessel lesion,35201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7519.55,,,,,,,fee schedule,5508.66,24440.06,
Repair blood vessel lesion,35201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6027.58,,,,,,,fee schedule,5508.66,24440.06,
Repair blood vessel lesion,35201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6584.58,,,,,,,fee schedule,5508.66,24440.06,
Repair blood vessel lesion,35201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6922.76,,,,,,,fee schedule,5508.66,24440.06,
Repair blood vessel lesion,35201,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24440.06,,,,,,,fee schedule,5508.66,24440.06,APC 378
Repair blood vessel lesion,35201,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5784.09,,,,,,,fee schedule,5508.66,24440.06,APC
Repair blood vessel lesion,35201,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5729.01,,,,,,,fee schedule,5508.66,24440.06,APC
Repair blood vessel lesion,35201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5508.66,,,,,,,fee schedule,5508.66,24440.06,APC
Repair blood vessel lesion,35201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8428.25,,,,,,,fee schedule,5508.66,24440.06,Radiology
Repair blood vessel lesion,35201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7712.13,,,,,,,fee schedule,5508.66,24440.06,APC
Repair blood vessel lesion,35201,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9640.16,,,,,,,fee schedule,5508.66,24440.06,APC
Repair blood vessel lesion,35206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4297.02,,,,,,,fee schedule,3125.8,13868.13,
Repair blood vessel lesion,35206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3444.43,,,,,,,fee schedule,3125.8,13868.13,
Repair blood vessel lesion,35206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3762.73,,,,,,,fee schedule,3125.8,13868.13,
Repair blood vessel lesion,35206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3955.98,,,,,,,fee schedule,3125.8,13868.13,
Repair blood vessel lesion,35206,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Repair blood vessel lesion,35206,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Repair blood vessel lesion,35206,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Repair blood vessel lesion,35206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Repair blood vessel lesion,35206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Repair blood vessel lesion,35206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Repair blood vessel lesion,35206,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Repair blood vessel lesion,35207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9675.33,,,,,,,fee schedule,3125.8,13868.13,
Repair blood vessel lesion,35207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7755.62,,,,,,,fee schedule,3125.8,13868.13,
Repair blood vessel lesion,35207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8472.31,,,,,,,fee schedule,3125.8,13868.13,
Repair blood vessel lesion,35207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8907.44,,,,,,,fee schedule,3125.8,13868.13,
Repair blood vessel lesion,35207,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Repair blood vessel lesion,35207,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Repair blood vessel lesion,35207,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Repair blood vessel lesion,35207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Repair blood vessel lesion,35207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Repair blood vessel lesion,35207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Repair blood vessel lesion,35207,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Repair blood vessel lesion,35226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7519.55,,,,,,,fee schedule,701.03,7519.55,
Repair blood vessel lesion,35226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6027.58,,,,,,,fee schedule,701.03,7519.55,
Repair blood vessel lesion,35226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6584.58,,,,,,,fee schedule,701.03,7519.55,
Repair blood vessel lesion,35226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6922.76,,,,,,,fee schedule,701.03,7519.55,
Repair blood vessel lesion,35226,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3110.22,,,,,,,fee schedule,701.03,7519.55,APC 378
Repair blood vessel lesion,35226,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,736.08,,,,,,,fee schedule,701.03,7519.55,APC
Repair blood vessel lesion,35226,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,729.07,,,,,,,fee schedule,701.03,7519.55,APC
Repair blood vessel lesion,35226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,701.03,,,,,,,fee schedule,701.03,7519.55,APC
Repair blood vessel lesion,35226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1072.57,,,,,,,fee schedule,701.03,7519.55,Radiology
Repair blood vessel lesion,35226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,981.44,,,,,,,fee schedule,701.03,7519.55,APC
Repair blood vessel lesion,35226,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1226.8,,,,,,,fee schedule,701.03,7519.55,APC
Repair blood vessel lesion,35231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7519.55,,,,,,,fee schedule,3125.8,13868.13,
Repair blood vessel lesion,35231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6027.58,,,,,,,fee schedule,3125.8,13868.13,
Repair blood vessel lesion,35231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6584.58,,,,,,,fee schedule,3125.8,13868.13,
Repair blood vessel lesion,35231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6922.76,,,,,,,fee schedule,3125.8,13868.13,
Repair blood vessel lesion,35231,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Repair blood vessel lesion,35231,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Repair blood vessel lesion,35231,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Repair blood vessel lesion,35231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Repair blood vessel lesion,35231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Repair blood vessel lesion,35231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Repair blood vessel lesion,35231,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Repair blood vessel lesion,35236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7519.55,,,,,,,fee schedule,5508.66,24440.06,
Repair blood vessel lesion,35236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6027.58,,,,,,,fee schedule,5508.66,24440.06,
Repair blood vessel lesion,35236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6584.58,,,,,,,fee schedule,5508.66,24440.06,
Repair blood vessel lesion,35236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6922.76,,,,,,,fee schedule,5508.66,24440.06,
Repair blood vessel lesion,35236,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24440.06,,,,,,,fee schedule,5508.66,24440.06,APC 378
Repair blood vessel lesion,35236,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5784.09,,,,,,,fee schedule,5508.66,24440.06,APC
Repair blood vessel lesion,35236,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5729.01,,,,,,,fee schedule,5508.66,24440.06,APC
Repair blood vessel lesion,35236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5508.66,,,,,,,fee schedule,5508.66,24440.06,APC
Repair blood vessel lesion,35236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8428.25,,,,,,,fee schedule,5508.66,24440.06,Radiology
Repair blood vessel lesion,35236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7712.13,,,,,,,fee schedule,5508.66,24440.06,APC
Repair blood vessel lesion,35236,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9640.16,,,,,,,fee schedule,5508.66,24440.06,APC
Repair blood vessel lesion,35256,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7519.55,,,,,,,fee schedule,5508.66,24440.06,
Repair blood vessel lesion,35256,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6027.58,,,,,,,fee schedule,5508.66,24440.06,
Repair blood vessel lesion,35256,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6584.58,,,,,,,fee schedule,5508.66,24440.06,
Repair blood vessel lesion,35256,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6922.76,,,,,,,fee schedule,5508.66,24440.06,
Repair blood vessel lesion,35256,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24440.06,,,,,,,fee schedule,5508.66,24440.06,APC 378
Repair blood vessel lesion,35256,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5784.09,,,,,,,fee schedule,5508.66,24440.06,APC
Repair blood vessel lesion,35256,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5729.01,,,,,,,fee schedule,5508.66,24440.06,APC
Repair blood vessel lesion,35256,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5508.66,,,,,,,fee schedule,5508.66,24440.06,APC
Repair blood vessel lesion,35256,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8428.25,,,,,,,fee schedule,5508.66,24440.06,Radiology
Repair blood vessel lesion,35256,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7712.13,,,,,,,fee schedule,5508.66,24440.06,APC
Repair blood vessel lesion,35256,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9640.16,,,,,,,fee schedule,5508.66,24440.06,APC
Repair blood vessel lesion,35261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10099.52,,,,,,,fee schedule,3125.8,13868.13,
Repair blood vessel lesion,35261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8095.64,,,,,,,fee schedule,3125.8,13868.13,
Repair blood vessel lesion,35261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8843.76,,,,,,,fee schedule,3125.8,13868.13,
Repair blood vessel lesion,35261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9297.97,,,,,,,fee schedule,3125.8,13868.13,
Repair blood vessel lesion,35261,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Repair blood vessel lesion,35261,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Repair blood vessel lesion,35261,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Repair blood vessel lesion,35261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Repair blood vessel lesion,35261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Repair blood vessel lesion,35261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Repair blood vessel lesion,35261,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Repair blood vessel lesion,35266,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10099.52,,,,,,,fee schedule,5508.66,24440.06,
Repair blood vessel lesion,35266,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8095.64,,,,,,,fee schedule,5508.66,24440.06,
Repair blood vessel lesion,35266,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8843.76,,,,,,,fee schedule,5508.66,24440.06,
Repair blood vessel lesion,35266,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9297.97,,,,,,,fee schedule,5508.66,24440.06,
Repair blood vessel lesion,35266,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24440.06,,,,,,,fee schedule,5508.66,24440.06,APC 378
Repair blood vessel lesion,35266,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5784.09,,,,,,,fee schedule,5508.66,24440.06,APC
Repair blood vessel lesion,35266,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5729.01,,,,,,,fee schedule,5508.66,24440.06,APC
Repair blood vessel lesion,35266,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5508.66,,,,,,,fee schedule,5508.66,24440.06,APC
Repair blood vessel lesion,35266,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8428.25,,,,,,,fee schedule,5508.66,24440.06,Radiology
Repair blood vessel lesion,35266,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7712.13,,,,,,,fee schedule,5508.66,24440.06,APC
Repair blood vessel lesion,35266,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9640.16,,,,,,,fee schedule,5508.66,24440.06,APC
Repair blood vessel lesion,35286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10099.52,,,,,,,fee schedule,5508.66,24440.06,
Repair blood vessel lesion,35286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8095.64,,,,,,,fee schedule,5508.66,24440.06,
Repair blood vessel lesion,35286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8843.76,,,,,,,fee schedule,5508.66,24440.06,
Repair blood vessel lesion,35286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9297.97,,,,,,,fee schedule,5508.66,24440.06,
Repair blood vessel lesion,35286,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24440.06,,,,,,,fee schedule,5508.66,24440.06,APC 378
Repair blood vessel lesion,35286,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5784.09,,,,,,,fee schedule,5508.66,24440.06,APC
Repair blood vessel lesion,35286,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5729.01,,,,,,,fee schedule,5508.66,24440.06,APC
Repair blood vessel lesion,35286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5508.66,,,,,,,fee schedule,5508.66,24440.06,APC
Repair blood vessel lesion,35286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8428.25,,,,,,,fee schedule,5508.66,24440.06,Radiology
Repair blood vessel lesion,35286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7712.13,,,,,,,fee schedule,5508.66,24440.06,APC
Repair blood vessel lesion,35286,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9640.16,,,,,,,fee schedule,5508.66,24440.06,APC
Rechanneling of artery,35321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7519.55,,,,,,,fee schedule,5508.66,24440.06,
Rechanneling of artery,35321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6027.58,,,,,,,fee schedule,5508.66,24440.06,
Rechanneling of artery,35321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6584.58,,,,,,,fee schedule,5508.66,24440.06,
Rechanneling of artery,35321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6922.76,,,,,,,fee schedule,5508.66,24440.06,
Rechanneling of artery,35321,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24440.06,,,,,,,fee schedule,5508.66,24440.06,APC 378
Rechanneling of artery,35321,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5784.09,,,,,,,fee schedule,5508.66,24440.06,APC
Rechanneling of artery,35321,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5729.01,,,,,,,fee schedule,5508.66,24440.06,APC
Rechanneling of artery,35321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5508.66,,,,,,,fee schedule,5508.66,24440.06,APC
Rechanneling of artery,35321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8428.25,,,,,,,fee schedule,5508.66,24440.06,Radiology
Rechanneling of artery,35321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7712.13,,,,,,,fee schedule,5508.66,24440.06,APC
Rechanneling of artery,35321,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9640.16,,,,,,,fee schedule,5508.66,24440.06,APC
Rechanneling of artery,35372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18032,,,,,,,fee schedule,5508.66,24440.06,
Rechanneling of artery,35372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14454.22,,,,,,,fee schedule,5508.66,24440.06,
Rechanneling of artery,35372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15789.92,,,,,,,fee schedule,5508.66,24440.06,
Rechanneling of artery,35372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16600.89,,,,,,,fee schedule,5508.66,24440.06,
Rechanneling of artery,35372,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24440.06,,,,,,,fee schedule,5508.66,24440.06,APC 378
Rechanneling of artery,35372,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5784.09,,,,,,,fee schedule,5508.66,24440.06,APC
Rechanneling of artery,35372,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5729.01,,,,,,,fee schedule,5508.66,24440.06,APC
Rechanneling of artery,35372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5508.66,,,,,,,fee schedule,5508.66,24440.06,APC
Rechanneling of artery,35372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8428.25,,,,,,,fee schedule,5508.66,24440.06,Radiology
Rechanneling of artery,35372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7712.13,,,,,,,fee schedule,5508.66,24440.06,APC
Rechanneling of artery,35372,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9640.16,,,,,,,fee schedule,5508.66,24440.06,APC
Harvest vein for bypass,35500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3658.17,,,,,,,fee schedule,2932.34,3658.17,
Harvest vein for bypass,35500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2932.34,,,,,,,fee schedule,2932.34,3658.17,
Harvest vein for bypass,35500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3203.32,,,,,,,fee schedule,2932.34,3658.17,
Harvest vein for bypass,35500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3367.84,,,,,,,fee schedule,2932.34,3658.17,
Art byp grft hepatorenal,35535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7609.82,,,,,,,fee schedule,6099.94,7609.82,
Art byp grft hepatorenal,35535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6099.94,,,,,,,fee schedule,6099.94,7609.82,
Art byp grft hepatorenal,35535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6663.63,,,,,,,fee schedule,6099.94,7609.82,
Art byp grft hepatorenal,35535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7005.87,,,,,,,fee schedule,6099.94,7609.82,
Art byp tibial-tib/peroneal,35570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5866.48,,,,,,,fee schedule,4702.5,5866.48,
Art byp tibial-tib/peroneal,35570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4702.5,,,,,,,fee schedule,4702.5,5866.48,
Art byp tibial-tib/peroneal,35570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5137.05,,,,,,,fee schedule,4702.5,5866.48,
Art byp tibial-tib/peroneal,35570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5400.89,,,,,,,fee schedule,4702.5,5866.48,
Art byp ilio-celiac,35632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7224.26,,,,,,,fee schedule,5790.88,7224.26,
Art byp ilio-celiac,35632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5790.88,,,,,,,fee schedule,5790.88,7224.26,
Art byp ilio-celiac,35632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6326.01,,,,,,,fee schedule,5790.88,7224.26,
Art byp ilio-celiac,35632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6650.91,,,,,,,fee schedule,5790.88,7224.26,
Art byp ilio-mesenteric,35633,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7803.73,,,,,,,fee schedule,6255.37,7803.73,
Art byp ilio-mesenteric,35633,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6255.37,,,,,,,fee schedule,6255.37,7803.73,
Art byp ilio-mesenteric,35633,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6833.43,,,,,,,fee schedule,6255.37,7803.73,
Art byp ilio-mesenteric,35633,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7184.39,,,,,,,fee schedule,6255.37,7803.73,
Art byp iliorenal,35634,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7069.66,,,,,,,fee schedule,5666.95,7069.66,
Art byp iliorenal,35634,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5666.95,,,,,,,fee schedule,5666.95,7069.66,
Art byp iliorenal,35634,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6190.63,,,,,,,fee schedule,5666.95,7069.66,
Art byp iliorenal,35634,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6508.57,,,,,,,fee schedule,5666.95,7069.66,
Bypass graft patency/patch,35685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7519.55,,,,,,,fee schedule,6027.58,7519.55,
Bypass graft patency/patch,35685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6027.58,,,,,,,fee schedule,6027.58,7519.55,
Bypass graft patency/patch,35685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6584.58,,,,,,,fee schedule,6027.58,7519.55,
Bypass graft patency/patch,35685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6922.76,,,,,,,fee schedule,6027.58,7519.55,
Bypass graft/av fist patency,35686,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7519.55,,,,,,,fee schedule,6027.58,7519.55,
Bypass graft/av fist patency,35686,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6027.58,,,,,,,fee schedule,6027.58,7519.55,
Bypass graft/av fist patency,35686,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6584.58,,,,,,,fee schedule,6027.58,7519.55,
Bypass graft/av fist patency,35686,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6922.76,,,,,,,fee schedule,6027.58,7519.55,
Expl n/flwd surg uxtr art,35702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1616.9,,,,,,,fee schedule,1296.08,1616.9,
Expl n/flwd surg uxtr art,35702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1296.08,,,,,,,fee schedule,1296.08,1616.9,
Expl n/flwd surg uxtr art,35702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1415.85,,,,,,,fee schedule,1296.08,1616.9,
Expl n/flwd surg uxtr art,35702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1488.57,,,,,,,fee schedule,1296.08,1616.9,
Expl n/flwd surg lxtr art,35703,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1649.55,,,,,,,fee schedule,1322.26,1649.55,
Expl n/flwd surg lxtr art,35703,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1322.26,,,,,,,fee schedule,1322.26,1649.55,
Expl n/flwd surg lxtr art,35703,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1444.45,,,,,,,fee schedule,1322.26,1649.55,
Expl n/flwd surg lxtr art,35703,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1518.64,,,,,,,fee schedule,1322.26,1649.55,
Explore neck vessels,35800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18032,,,,,,,fee schedule,5508.66,24440.06,
Explore neck vessels,35800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14454.22,,,,,,,fee schedule,5508.66,24440.06,
Explore neck vessels,35800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15789.92,,,,,,,fee schedule,5508.66,24440.06,
Explore neck vessels,35800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16600.89,,,,,,,fee schedule,5508.66,24440.06,
Explore neck vessels,35800,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24440.06,,,,,,,fee schedule,5508.66,24440.06,APC 378
Explore neck vessels,35800,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5784.09,,,,,,,fee schedule,5508.66,24440.06,APC
Explore neck vessels,35800,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5729.01,,,,,,,fee schedule,5508.66,24440.06,APC
Explore neck vessels,35800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5508.66,,,,,,,fee schedule,5508.66,24440.06,APC
Explore neck vessels,35800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8428.25,,,,,,,fee schedule,5508.66,24440.06,Radiology
Explore neck vessels,35800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7712.13,,,,,,,fee schedule,5508.66,24440.06,APC
Explore neck vessels,35800,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9640.16,,,,,,,fee schedule,5508.66,24440.06,APC
Explore limb vessels,35860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7519.55,,,,,,,fee schedule,3125.8,13868.13,
Explore limb vessels,35860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6027.58,,,,,,,fee schedule,3125.8,13868.13,
Explore limb vessels,35860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6584.58,,,,,,,fee schedule,3125.8,13868.13,
Explore limb vessels,35860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6922.76,,,,,,,fee schedule,3125.8,13868.13,
Explore limb vessels,35860,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Explore limb vessels,35860,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Explore limb vessels,35860,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Explore limb vessels,35860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Explore limb vessels,35860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Explore limb vessels,35860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Explore limb vessels,35860,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Removal of clot in graft,35875,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9675.33,,,,,,,fee schedule,5508.66,24440.06,
Removal of clot in graft,35875,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7755.62,,,,,,,fee schedule,5508.66,24440.06,
Removal of clot in graft,35875,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8472.31,,,,,,,fee schedule,5508.66,24440.06,
Removal of clot in graft,35875,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8907.44,,,,,,,fee schedule,5508.66,24440.06,
Removal of clot in graft,35875,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24440.06,,,,,,,fee schedule,5508.66,24440.06,APC 378
Removal of clot in graft,35875,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5784.09,,,,,,,fee schedule,5508.66,24440.06,APC
Removal of clot in graft,35875,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5729.01,,,,,,,fee schedule,5508.66,24440.06,APC
Removal of clot in graft,35875,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5508.66,,,,,,,fee schedule,5508.66,24440.06,APC
Removal of clot in graft,35875,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8428.25,,,,,,,fee schedule,5508.66,24440.06,Radiology
Removal of clot in graft,35875,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7712.13,,,,,,,fee schedule,5508.66,24440.06,APC
Removal of clot in graft,35875,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9640.16,,,,,,,fee schedule,5508.66,24440.06,APC
Removal of clot in graft,35876,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9675.33,,,,,,,fee schedule,5508.66,24440.06,
Removal of clot in graft,35876,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7755.62,,,,,,,fee schedule,5508.66,24440.06,
Removal of clot in graft,35876,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8472.31,,,,,,,fee schedule,5508.66,24440.06,
Removal of clot in graft,35876,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8907.44,,,,,,,fee schedule,5508.66,24440.06,
Removal of clot in graft,35876,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24440.06,,,,,,,fee schedule,5508.66,24440.06,APC 378
Removal of clot in graft,35876,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5784.09,,,,,,,fee schedule,5508.66,24440.06,APC
Removal of clot in graft,35876,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5729.01,,,,,,,fee schedule,5508.66,24440.06,APC
Removal of clot in graft,35876,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5508.66,,,,,,,fee schedule,5508.66,24440.06,APC
Removal of clot in graft,35876,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8428.25,,,,,,,fee schedule,5508.66,24440.06,Radiology
Removal of clot in graft,35876,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7712.13,,,,,,,fee schedule,5508.66,24440.06,APC
Removal of clot in graft,35876,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9640.16,,,,,,,fee schedule,5508.66,24440.06,APC
Revise graft w/vein,35879,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9675.33,,,,,,,fee schedule,5508.66,24440.06,
Revise graft w/vein,35879,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7755.62,,,,,,,fee schedule,5508.66,24440.06,
Revise graft w/vein,35879,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8472.31,,,,,,,fee schedule,5508.66,24440.06,
Revise graft w/vein,35879,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8907.44,,,,,,,fee schedule,5508.66,24440.06,
Revise graft w/vein,35879,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24440.06,,,,,,,fee schedule,5508.66,24440.06,APC 378
Revise graft w/vein,35879,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5784.09,,,,,,,fee schedule,5508.66,24440.06,APC
Revise graft w/vein,35879,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5729.01,,,,,,,fee schedule,5508.66,24440.06,APC
Revise graft w/vein,35879,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5508.66,,,,,,,fee schedule,5508.66,24440.06,APC
Revise graft w/vein,35879,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8428.25,,,,,,,fee schedule,5508.66,24440.06,Radiology
Revise graft w/vein,35879,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7712.13,,,,,,,fee schedule,5508.66,24440.06,APC
Revise graft w/vein,35879,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9640.16,,,,,,,fee schedule,5508.66,24440.06,APC
Revise graft w/vein,35881,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9675.33,,,,,,,fee schedule,5508.66,24440.06,
Revise graft w/vein,35881,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7755.62,,,,,,,fee schedule,5508.66,24440.06,
Revise graft w/vein,35881,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8472.31,,,,,,,fee schedule,5508.66,24440.06,
Revise graft w/vein,35881,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8907.44,,,,,,,fee schedule,5508.66,24440.06,
Revise graft w/vein,35881,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24440.06,,,,,,,fee schedule,5508.66,24440.06,APC 378
Revise graft w/vein,35881,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5784.09,,,,,,,fee schedule,5508.66,24440.06,APC
Revise graft w/vein,35881,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5729.01,,,,,,,fee schedule,5508.66,24440.06,APC
Revise graft w/vein,35881,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5508.66,,,,,,,fee schedule,5508.66,24440.06,APC
Revise graft w/vein,35881,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8428.25,,,,,,,fee schedule,5508.66,24440.06,Radiology
Revise graft w/vein,35881,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7712.13,,,,,,,fee schedule,5508.66,24440.06,APC
Revise graft w/vein,35881,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9640.16,,,,,,,fee schedule,5508.66,24440.06,APC
Revise Graft w/Nonauto Graft,35883,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9675.33,,,,,,,fee schedule,5508.66,24440.06,
Revise Graft w/Nonauto Graft,35883,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7755.62,,,,,,,fee schedule,5508.66,24440.06,
Revise Graft w/Nonauto Graft,35883,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8472.31,,,,,,,fee schedule,5508.66,24440.06,
Revise Graft w/Nonauto Graft,35883,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8907.44,,,,,,,fee schedule,5508.66,24440.06,
Revise Graft w/Nonauto Graft,35883,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24440.06,,,,,,,fee schedule,5508.66,24440.06,APC 378
Revise Graft w/Nonauto Graft,35883,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5784.09,,,,,,,fee schedule,5508.66,24440.06,APC
Revise Graft w/Nonauto Graft,35883,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5729.01,,,,,,,fee schedule,5508.66,24440.06,APC
Revise Graft w/Nonauto Graft,35883,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5508.66,,,,,,,fee schedule,5508.66,24440.06,APC
Revise Graft w/Nonauto Graft,35883,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8428.25,,,,,,,fee schedule,5508.66,24440.06,Radiology
Revise Graft w/Nonauto Graft,35883,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7712.13,,,,,,,fee schedule,5508.66,24440.06,APC
Revise Graft w/Nonauto Graft,35883,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9640.16,,,,,,,fee schedule,5508.66,24440.06,APC
Revise graft w/vein,35884,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9675.33,,,,,,,fee schedule,5508.66,24440.06,
Revise graft w/vein,35884,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7755.62,,,,,,,fee schedule,5508.66,24440.06,
Revise graft w/vein,35884,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8472.31,,,,,,,fee schedule,5508.66,24440.06,
Revise graft w/vein,35884,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8907.44,,,,,,,fee schedule,5508.66,24440.06,
Revise graft w/vein,35884,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24440.06,,,,,,,fee schedule,5508.66,24440.06,APC 378
Revise graft w/vein,35884,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5784.09,,,,,,,fee schedule,5508.66,24440.06,APC
Revise graft w/vein,35884,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5729.01,,,,,,,fee schedule,5508.66,24440.06,APC
Revise graft w/vein,35884,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5508.66,,,,,,,fee schedule,5508.66,24440.06,APC
Revise graft w/vein,35884,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8428.25,,,,,,,fee schedule,5508.66,24440.06,Radiology
Revise graft w/vein,35884,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7712.13,,,,,,,fee schedule,5508.66,24440.06,APC
Revise graft w/vein,35884,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9640.16,,,,,,,fee schedule,5508.66,24440.06,APC
Excision graft extremity,35903,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7411.52,,,,,,,fee schedule,3125.8,13868.13,
Excision graft extremity,35903,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5940.98,,,,,,,fee schedule,3125.8,13868.13,
Excision graft extremity,35903,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6489.98,,,,,,,fee schedule,3125.8,13868.13,
Excision graft extremity,35903,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6823.31,,,,,,,fee schedule,3125.8,13868.13,
Excision graft extremity,35903,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Excision graft extremity,35903,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Excision graft extremity,35903,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Excision graft extremity,35903,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Excision graft extremity,35903,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Excision graft extremity,35903,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Excision graft extremity,35903,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Pseudoaneurysm injection trt,36002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,593.8,,,,,,,fee schedule,475.98,2755.21,
Pseudoaneurysm injection trt,36002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,475.98,,,,,,,fee schedule,475.98,2755.21,
Pseudoaneurysm injection trt,36002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,519.97,,,,,,,fee schedule,475.98,2755.21,
Pseudoaneurysm injection trt,36002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,546.67,,,,,,,fee schedule,475.98,2755.21,
Pseudoaneurysm injection trt,36002,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2755.21,,,,,,,fee schedule,475.98,2755.21,APC 378
Pseudoaneurysm injection trt,36002,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,652.06,,,,,,,fee schedule,475.98,2755.21,APC
Pseudoaneurysm injection trt,36002,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,645.85,,,,,,,fee schedule,475.98,2755.21,APC
Pseudoaneurysm injection trt,36002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,621.01,,,,,,,fee schedule,475.98,2755.21,APC
Pseudoaneurysm injection trt,36002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,950.14,,,,,,,fee schedule,475.98,2755.21,Radiology
Pseudoaneurysm injection trt,36002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,869.41,,,,,,,fee schedule,475.98,2755.21,APC
Pseudoaneurysm injection trt,36002,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1086.77,,,,,,,fee schedule,475.98,2755.21,APC
Place cath thoracic aorta,36221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3065.5,,,,,,,fee schedule,2457.27,13868.13,
Place cath thoracic aorta,36221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2457.27,,,,,,,fee schedule,2457.27,13868.13,
Place cath thoracic aorta,36221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2684.34,,,,,,,fee schedule,2457.27,13868.13,
Place cath thoracic aorta,36221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2822.21,,,,,,,fee schedule,2457.27,13868.13,
Place cath thoracic aorta,36221,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,2457.27,13868.13,APC 378
Place cath thoracic aorta,36221,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,2457.27,13868.13,APC
Place cath thoracic aorta,36221,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,2457.27,13868.13,APC
Place cath thoracic aorta,36221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,2457.27,13868.13,APC
Place cath thoracic aorta,36221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,2457.27,13868.13,Radiology
Place cath thoracic aorta,36221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,2457.27,13868.13,APC
Place cath thoracic aorta,36221,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,2457.27,13868.13,APC
Place cath carotid/inom art,36222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3065.5,,,,,,,fee schedule,2457.27,13868.13,
Place cath carotid/inom art,36222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2457.27,,,,,,,fee schedule,2457.27,13868.13,
Place cath carotid/inom art,36222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2684.34,,,,,,,fee schedule,2457.27,13868.13,
Place cath carotid/inom art,36222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2822.21,,,,,,,fee schedule,2457.27,13868.13,
Place cath carotid/inom art,36222,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,2457.27,13868.13,APC 378
Place cath carotid/inom art,36222,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,2457.27,13868.13,APC
Place cath carotid/inom art,36222,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,2457.27,13868.13,APC
Place cath carotid/inom art,36222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,2457.27,13868.13,APC
Place cath carotid/inom art,36222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,2457.27,13868.13,Radiology
Place cath carotid/inom art,36222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,2457.27,13868.13,APC
Place cath carotid/inom art,36222,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,2457.27,13868.13,APC
Place cath carotid/inom art,36223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3065.5,,,,,,,fee schedule,2457.27,24440.06,
Place cath carotid/inom art,36223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2457.27,,,,,,,fee schedule,2457.27,24440.06,
Place cath carotid/inom art,36223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2684.34,,,,,,,fee schedule,2457.27,24440.06,
Place cath carotid/inom art,36223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2822.21,,,,,,,fee schedule,2457.27,24440.06,
Place cath carotid/inom art,36223,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24440.06,,,,,,,fee schedule,2457.27,24440.06,APC 378
Place cath carotid/inom art,36223,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5784.09,,,,,,,fee schedule,2457.27,24440.06,APC
Place cath carotid/inom art,36223,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5729.01,,,,,,,fee schedule,2457.27,24440.06,APC
Place cath carotid/inom art,36223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5508.66,,,,,,,fee schedule,2457.27,24440.06,APC
Place cath carotid/inom art,36223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8428.25,,,,,,,fee schedule,2457.27,24440.06,Radiology
Place cath carotid/inom art,36223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7712.13,,,,,,,fee schedule,2457.27,24440.06,APC
Place cath carotid/inom art,36223,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9640.16,,,,,,,fee schedule,2457.27,24440.06,APC
Place cath carotd art,36224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13722.91,,,,,,,fee schedule,5508.66,24440.06,
Place cath carotd art,36224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11000.11,,,,,,,fee schedule,5508.66,24440.06,
Place cath carotd art,36224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12016.62,,,,,,,fee schedule,5508.66,24440.06,
Place cath carotd art,36224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12633.79,,,,,,,fee schedule,5508.66,24440.06,
Place cath carotd art,36224,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24440.06,,,,,,,fee schedule,5508.66,24440.06,APC 378
Place cath carotd art,36224,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5784.09,,,,,,,fee schedule,5508.66,24440.06,APC
Place cath carotd art,36224,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5729.01,,,,,,,fee schedule,5508.66,24440.06,APC
Place cath carotd art,36224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5508.66,,,,,,,fee schedule,5508.66,24440.06,APC
Place cath carotd art,36224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8428.25,,,,,,,fee schedule,5508.66,24440.06,Radiology
Place cath carotd art,36224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7712.13,,,,,,,fee schedule,5508.66,24440.06,APC
Place cath carotd art,36224,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9640.16,,,,,,,fee schedule,5508.66,24440.06,APC
Place cath subclavian art,36225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3383.92,,,,,,,fee schedule,2712.51,13868.13,
Place cath subclavian art,36225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2712.51,,,,,,,fee schedule,2712.51,13868.13,
Place cath subclavian art,36225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2963.17,,,,,,,fee schedule,2712.51,13868.13,
Place cath subclavian art,36225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3115.36,,,,,,,fee schedule,2712.51,13868.13,
Place cath subclavian art,36225,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,2712.51,13868.13,APC 378
Place cath subclavian art,36225,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,2712.51,13868.13,APC
Place cath subclavian art,36225,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,2712.51,13868.13,APC
Place cath subclavian art,36225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,2712.51,13868.13,APC
Place cath subclavian art,36225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,2712.51,13868.13,Radiology
Place cath subclavian art,36225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,2712.51,13868.13,APC
Place cath subclavian art,36225,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,2712.51,13868.13,APC
Place cath vertebral art,36226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13722.91,,,,,,,fee schedule,5508.66,24440.06,
Place cath vertebral art,36226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11000.11,,,,,,,fee schedule,5508.66,24440.06,
Place cath vertebral art,36226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12016.62,,,,,,,fee schedule,5508.66,24440.06,
Place cath vertebral art,36226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12633.79,,,,,,,fee schedule,5508.66,24440.06,
Place cath vertebral art,36226,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24440.06,,,,,,,fee schedule,5508.66,24440.06,APC 378
Place cath vertebral art,36226,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5784.09,,,,,,,fee schedule,5508.66,24440.06,APC
Place cath vertebral art,36226,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5729.01,,,,,,,fee schedule,5508.66,24440.06,APC
Place cath vertebral art,36226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5508.66,,,,,,,fee schedule,5508.66,24440.06,APC
Place cath vertebral art,36226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8428.25,,,,,,,fee schedule,5508.66,24440.06,Radiology
Place cath vertebral art,36226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7712.13,,,,,,,fee schedule,5508.66,24440.06,APC
Place cath vertebral art,36226,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9640.16,,,,,,,fee schedule,5508.66,24440.06,APC
Place cath xtrnl carotid,36227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,405.33,,,,,,,fee schedule,324.91,405.33,
Place cath xtrnl carotid,36227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,324.91,,,,,,,fee schedule,324.91,405.33,
Place cath xtrnl carotid,36227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,354.93,,,,,,,fee schedule,324.91,405.33,
Place cath xtrnl carotid,36227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,373.16,,,,,,,fee schedule,324.91,405.33,
Place cath intracranial art,36228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,825.7,,,,,,,fee schedule,661.87,825.7,
Place cath intracranial art,36228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,661.87,,,,,,,fee schedule,661.87,825.7,
Place cath intracranial art,36228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,723.04,,,,,,,fee schedule,661.87,825.7,
Place cath intracranial art,36228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,760.17,,,,,,,fee schedule,661.87,825.7,
Ins cath ren art 1st unilat,36251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8390.92,,,,,,,fee schedule,3125.8,13868.13,
Ins cath ren art 1st unilat,36251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6726.05,,,,,,,fee schedule,3125.8,13868.13,
Ins cath ren art 1st unilat,36251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7347.6,,,,,,,fee schedule,3125.8,13868.13,
Ins cath ren art 1st unilat,36251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7724.97,,,,,,,fee schedule,3125.8,13868.13,
Ins cath ren art 1st unilat,36251,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Ins cath ren art 1st unilat,36251,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Ins cath ren art 1st unilat,36251,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Ins cath ren art 1st unilat,36251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Ins cath ren art 1st unilat,36251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Ins cath ren art 1st unilat,36251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Ins cath ren art 1st unilat,36251,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Ins cath ren art 1st bilat,36252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9142.33,,,,,,,fee schedule,3125.8,13868.13,
Ins cath ren art 1st bilat,36252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7328.38,,,,,,,fee schedule,3125.8,13868.13,
Ins cath ren art 1st bilat,36252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8005.59,,,,,,,fee schedule,3125.8,13868.13,
Ins cath ren art 1st bilat,36252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8416.75,,,,,,,fee schedule,3125.8,13868.13,
Ins cath ren art 1st bilat,36252,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Ins cath ren art 1st bilat,36252,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Ins cath ren art 1st bilat,36252,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Ins cath ren art 1st bilat,36252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Ins cath ren art 1st bilat,36252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Ins cath ren art 1st bilat,36252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Ins cath ren art 1st bilat,36252,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Ins cath ren art 2nd+ unilat,36253,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8390.92,,,,,,,fee schedule,5508.66,24440.06,
Ins cath ren art 2nd+ unilat,36253,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6726.05,,,,,,,fee schedule,5508.66,24440.06,
Ins cath ren art 2nd+ unilat,36253,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7347.6,,,,,,,fee schedule,5508.66,24440.06,
Ins cath ren art 2nd+ unilat,36253,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7724.97,,,,,,,fee schedule,5508.66,24440.06,
Ins cath ren art 2nd+ unilat,36253,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24440.06,,,,,,,fee schedule,5508.66,24440.06,APC 378
Ins cath ren art 2nd+ unilat,36253,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5784.09,,,,,,,fee schedule,5508.66,24440.06,APC
Ins cath ren art 2nd+ unilat,36253,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5729.01,,,,,,,fee schedule,5508.66,24440.06,APC
Ins cath ren art 2nd+ unilat,36253,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5508.66,,,,,,,fee schedule,5508.66,24440.06,APC
Ins cath ren art 2nd+ unilat,36253,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8428.25,,,,,,,fee schedule,5508.66,24440.06,Radiology
Ins cath ren art 2nd+ unilat,36253,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7712.13,,,,,,,fee schedule,5508.66,24440.06,APC
Ins cath ren art 2nd+ unilat,36253,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9640.16,,,,,,,fee schedule,5508.66,24440.06,APC
Ins cath ren art 2nd+ bilat,36254,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8390.92,,,,,,,fee schedule,3125.8,13868.13,
Ins cath ren art 2nd+ bilat,36254,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6726.05,,,,,,,fee schedule,3125.8,13868.13,
Ins cath ren art 2nd+ bilat,36254,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7347.6,,,,,,,fee schedule,3125.8,13868.13,
Ins cath ren art 2nd+ bilat,36254,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7724.97,,,,,,,fee schedule,3125.8,13868.13,
Ins cath ren art 2nd+ bilat,36254,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Ins cath ren art 2nd+ bilat,36254,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Ins cath ren art 2nd+ bilat,36254,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Ins cath ren art 2nd+ bilat,36254,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Ins cath ren art 2nd+ bilat,36254,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Ins cath ren art 2nd+ bilat,36254,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Ins cath ren art 2nd+ bilat,36254,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Insertion of infusion pump,36260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7206.31,,,,,,,fee schedule,5508.66,24440.06,
Insertion of infusion pump,36260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5776.48,,,,,,,fee schedule,5508.66,24440.06,
Insertion of infusion pump,36260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6310.28,,,,,,,fee schedule,5508.66,24440.06,
Insertion of infusion pump,36260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6634.38,,,,,,,fee schedule,5508.66,24440.06,
Insertion of infusion pump,36260,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24440.06,,,,,,,fee schedule,5508.66,24440.06,APC 378
Insertion of infusion pump,36260,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5784.09,,,,,,,fee schedule,5508.66,24440.06,APC
Insertion of infusion pump,36260,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5729.01,,,,,,,fee schedule,5508.66,24440.06,APC
Insertion of infusion pump,36260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5508.66,,,,,,,fee schedule,5508.66,24440.06,APC
Insertion of infusion pump,36260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8428.25,,,,,,,fee schedule,5508.66,24440.06,Radiology
Insertion of infusion pump,36260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7712.13,,,,,,,fee schedule,5508.66,24440.06,APC
Insertion of infusion pump,36260,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9640.16,,,,,,,fee schedule,5508.66,24440.06,APC
Revision of infusion pump,36261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5984.84,,,,,,,fee schedule,3699.47,16413.29,
Revision of infusion pump,36261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4797.37,,,,,,,fee schedule,3699.47,16413.29,
Revision of infusion pump,36261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5240.69,,,,,,,fee schedule,3699.47,16413.29,
Revision of infusion pump,36261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.85,,,,,,,fee schedule,3699.47,16413.29,
Revision of infusion pump,36261,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16413.29,,,,,,,fee schedule,3699.47,16413.29,APC 378
Revision of infusion pump,36261,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3884.44,,,,,,,fee schedule,3699.47,16413.29,APC
Revision of infusion pump,36261,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3847.45,,,,,,,fee schedule,3699.47,16413.29,APC
Revision of infusion pump,36261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3699.47,,,,,,,fee schedule,3699.47,16413.29,APC
Revision of infusion pump,36261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5660.19,,,,,,,fee schedule,3699.47,16413.29,Radiology
Revision of infusion pump,36261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5179.26,,,,,,,fee schedule,3699.47,16413.29,APC
Revision of infusion pump,36261,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6474.07,,,,,,,fee schedule,3699.47,16413.29,APC
Removal of infusion pump,36262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5984.84,,,,,,,fee schedule,3699.47,16413.29,
Removal of infusion pump,36262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4797.37,,,,,,,fee schedule,3699.47,16413.29,
Removal of infusion pump,36262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5240.69,,,,,,,fee schedule,3699.47,16413.29,
Removal of infusion pump,36262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.85,,,,,,,fee schedule,3699.47,16413.29,
Removal of infusion pump,36262,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16413.29,,,,,,,fee schedule,3699.47,16413.29,APC 378
Removal of infusion pump,36262,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3884.44,,,,,,,fee schedule,3699.47,16413.29,APC
Removal of infusion pump,36262,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3847.45,,,,,,,fee schedule,3699.47,16413.29,APC
Removal of infusion pump,36262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3699.47,,,,,,,fee schedule,3699.47,16413.29,APC
Removal of infusion pump,36262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5660.19,,,,,,,fee schedule,3699.47,16413.29,Radiology
Removal of infusion pump,36262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5179.26,,,,,,,fee schedule,3699.47,16413.29,APC
Removal of infusion pump,36262,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6474.07,,,,,,,fee schedule,3699.47,16413.29,APC
Routine venipuncture,36415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45.97,,,,,,,fee schedule,8.41,45.97,
Routine venipuncture,36415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36.85,,,,,,,fee schedule,8.41,45.97,
Routine venipuncture,36415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40.25,,,,,,,fee schedule,8.41,45.97,
Routine venipuncture,36415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42.32,,,,,,,fee schedule,8.41,45.97,
Routine venipuncture,36415,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.41,,,,,,,fee schedule,8.41,45.97,Laboratory
Routine venipuncture,36415,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.81,,,,,,,fee schedule,8.41,45.97,APC
Routine venipuncture,36415,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9.71,,,,,,,fee schedule,8.41,45.97,APC
Routine venipuncture,36415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9.34,,,,,,,fee schedule,8.41,45.97,APC
Routine venipuncture,36415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.29,,,,,,,fee schedule,8.41,45.97,Radiology
Routine venipuncture,36415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.08,,,,,,,fee schedule,8.41,45.97,APC
Routine venipuncture,36415,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16.34,,,,,,,fee schedule,8.41,45.97,APC
Vein access cutdown < 1 yr,36420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,53.49,,,,,,,fee schedule,42.87,584.37,
Vein access cutdown < 1 yr,36420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.87,,,,,,,fee schedule,42.87,584.37,
Vein access cutdown < 1 yr,36420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.84,,,,,,,fee schedule,42.87,584.37,
Vein access cutdown < 1 yr,36420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,49.24,,,,,,,fee schedule,42.87,584.37,
Vein access cutdown < 1 yr,36420,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,42.87,584.37,APC 378
Vein access cutdown < 1 yr,36420,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,42.87,584.37,APC
Vein access cutdown < 1 yr,36420,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,42.87,584.37,APC
Vein access cutdown < 1 yr,36420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,42.87,584.37,APC
Vein access cutdown < 1 yr,36420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,42.87,584.37,Radiology
Vein access cutdown < 1 yr,36420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,42.87,584.37,APC
Vein access cutdown < 1 yr,36420,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,42.87,584.37,APC
Vein access cutdown > 1 yr,36425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,53.49,,,,,,,fee schedule,42.87,1962.08,
Vein access cutdown > 1 yr,36425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.87,,,,,,,fee schedule,42.87,1962.08,
Vein access cutdown > 1 yr,36425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.84,,,,,,,fee schedule,42.87,1962.08,
Vein access cutdown > 1 yr,36425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,49.24,,,,,,,fee schedule,42.87,1962.08,
Vein access cutdown > 1 yr,36425,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1962.08,,,,,,,fee schedule,42.87,1962.08,APC 378
Vein access cutdown > 1 yr,36425,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,464.35,,,,,,,fee schedule,42.87,1962.08,APC
Vein access cutdown > 1 yr,36425,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,459.93,,,,,,,fee schedule,42.87,1962.08,APC
Vein access cutdown > 1 yr,36425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,442.24,,,,,,,fee schedule,42.87,1962.08,APC
Vein access cutdown > 1 yr,36425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,676.63,,,,,,,fee schedule,42.87,1962.08,Radiology
Vein access cutdown > 1 yr,36425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,619.14,,,,,,,fee schedule,42.87,1962.08,APC
Vein access cutdown > 1 yr,36425,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,773.92,,,,,,,fee schedule,42.87,1962.08,APC
Blood transfusion service,36430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1272.42,,,,,,,fee schedule,436.75,1937.7,
Blood transfusion service,36430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1019.96,,,,,,,fee schedule,436.75,1937.7,
Blood transfusion service,36430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1114.21,,,,,,,fee schedule,436.75,1937.7,
Blood transfusion service,36430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1171.44,,,,,,,fee schedule,436.75,1937.7,
Blood transfusion service,36430,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1937.7,,,,,,,fee schedule,436.75,1937.7,APC 378
Blood transfusion service,36430,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,458.59,,,,,,,fee schedule,436.75,1937.7,APC
Blood transfusion service,36430,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,454.22,,,,,,,fee schedule,436.75,1937.7,APC
Blood transfusion service,36430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,436.75,,,,,,,fee schedule,436.75,1937.7,APC
Blood transfusion service,36430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,668.22,,,,,,,fee schedule,436.75,1937.7,Radiology
Blood transfusion service,36430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,611.45,,,,,,,fee schedule,436.75,1937.7,APC
Blood transfusion service,36430,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,764.31,,,,,,,fee schedule,436.75,1937.7,APC
Bl push transfuse 2 yr/<,36440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,847.74,,,,,,,fee schedule,436.75,1937.7,
Bl push transfuse 2 yr/<,36440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,679.54,,,,,,,fee schedule,436.75,1937.7,
Bl push transfuse 2 yr/<,36440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,742.33,,,,,,,fee schedule,436.75,1937.7,
Bl push transfuse 2 yr/<,36440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,780.46,,,,,,,fee schedule,436.75,1937.7,
Bl push transfuse 2 yr/<,36440,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1937.7,,,,,,,fee schedule,436.75,1937.7,APC 378
Bl push transfuse 2 yr/<,36440,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,458.59,,,,,,,fee schedule,436.75,1937.7,APC
Bl push transfuse 2 yr/<,36440,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,454.22,,,,,,,fee schedule,436.75,1937.7,APC
Bl push transfuse 2 yr/<,36440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,436.75,,,,,,,fee schedule,436.75,1937.7,APC
Bl push transfuse 2 yr/<,36440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,668.22,,,,,,,fee schedule,436.75,1937.7,Radiology
Bl push transfuse 2 yr/<,36440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,611.45,,,,,,,fee schedule,436.75,1937.7,APC
Bl push transfuse 2 yr/<,36440,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,764.31,,,,,,,fee schedule,436.75,1937.7,APC
Bl exchange/transfuse nb,36450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,847.74,,,,,,,fee schedule,436.75,1937.7,
Bl exchange/transfuse nb,36450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,679.54,,,,,,,fee schedule,436.75,1937.7,
Bl exchange/transfuse nb,36450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,742.33,,,,,,,fee schedule,436.75,1937.7,
Bl exchange/transfuse nb,36450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,780.46,,,,,,,fee schedule,436.75,1937.7,
Bl exchange/transfuse nb,36450,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1937.7,,,,,,,fee schedule,436.75,1937.7,APC 378
Bl exchange/transfuse nb,36450,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,458.59,,,,,,,fee schedule,436.75,1937.7,APC
Bl exchange/transfuse nb,36450,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,454.22,,,,,,,fee schedule,436.75,1937.7,APC
Bl exchange/transfuse nb,36450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,436.75,,,,,,,fee schedule,436.75,1937.7,APC
Bl exchange/transfuse nb,36450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,668.22,,,,,,,fee schedule,436.75,1937.7,Radiology
Bl exchange/transfuse nb,36450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,611.45,,,,,,,fee schedule,436.75,1937.7,APC
Bl exchange/transfuse nb,36450,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,764.31,,,,,,,fee schedule,436.75,1937.7,APC
Bl exchange/transfuse non-nb,36455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,847.74,,,,,,,fee schedule,436.75,1937.7,
Bl exchange/transfuse non-nb,36455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,679.54,,,,,,,fee schedule,436.75,1937.7,
Bl exchange/transfuse non-nb,36455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,742.33,,,,,,,fee schedule,436.75,1937.7,
Bl exchange/transfuse non-nb,36455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,780.46,,,,,,,fee schedule,436.75,1937.7,
Bl exchange/transfuse non-nb,36455,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1937.7,,,,,,,fee schedule,436.75,1937.7,APC 378
Bl exchange/transfuse non-nb,36455,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,458.59,,,,,,,fee schedule,436.75,1937.7,APC
Bl exchange/transfuse non-nb,36455,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,454.22,,,,,,,fee schedule,436.75,1937.7,APC
Bl exchange/transfuse non-nb,36455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,436.75,,,,,,,fee schedule,436.75,1937.7,APC
Bl exchange/transfuse non-nb,36455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,668.22,,,,,,,fee schedule,436.75,1937.7,Radiology
Bl exchange/transfuse non-nb,36455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,611.45,,,,,,,fee schedule,436.75,1937.7,APC
Bl exchange/transfuse non-nb,36455,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,764.31,,,,,,,fee schedule,436.75,1937.7,APC
Prtl exchange transfuse nb,36456,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1340.16,,,,,,,fee schedule,436.75,1937.7,
Prtl exchange transfuse nb,36456,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1074.26,,,,,,,fee schedule,436.75,1937.7,
Prtl exchange transfuse nb,36456,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1173.53,,,,,,,fee schedule,436.75,1937.7,
Prtl exchange transfuse nb,36456,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1233.8,,,,,,,fee schedule,436.75,1937.7,
Prtl exchange transfuse nb,36456,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1937.7,,,,,,,fee schedule,436.75,1937.7,APC 378
Prtl exchange transfuse nb,36456,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,458.59,,,,,,,fee schedule,436.75,1937.7,APC
Prtl exchange transfuse nb,36456,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,454.22,,,,,,,fee schedule,436.75,1937.7,APC
Prtl exchange transfuse nb,36456,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,436.75,,,,,,,fee schedule,436.75,1937.7,APC
Prtl exchange transfuse nb,36456,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,668.22,,,,,,,fee schedule,436.75,1937.7,Radiology
Prtl exchange transfuse nb,36456,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,611.45,,,,,,,fee schedule,436.75,1937.7,APC
Prtl exchange transfuse nb,36456,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,764.31,,,,,,,fee schedule,436.75,1937.7,APC
Transfusion service fetal,36460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,847.74,,,,,,,fee schedule,436.75,1937.7,
Transfusion service fetal,36460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,679.54,,,,,,,fee schedule,436.75,1937.7,
Transfusion service fetal,36460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,742.33,,,,,,,fee schedule,436.75,1937.7,
Transfusion service fetal,36460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,780.46,,,,,,,fee schedule,436.75,1937.7,
Transfusion service fetal,36460,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1937.7,,,,,,,fee schedule,436.75,1937.7,APC 378
Transfusion service fetal,36460,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,458.59,,,,,,,fee schedule,436.75,1937.7,APC
Transfusion service fetal,36460,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,454.22,,,,,,,fee schedule,436.75,1937.7,APC
Transfusion service fetal,36460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,436.75,,,,,,,fee schedule,436.75,1937.7,APC
Transfusion service fetal,36460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,668.22,,,,,,,fee schedule,436.75,1937.7,Radiology
Transfusion service fetal,36460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,611.45,,,,,,,fee schedule,436.75,1937.7,APC
Transfusion service fetal,36460,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,764.31,,,,,,,fee schedule,436.75,1937.7,APC
Njx noncmpnd sclrsnt 1 vein,36465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5855.07,,,,,,,fee schedule,2042.58,9062.24,
Njx noncmpnd sclrsnt 1 vein,36465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4693.35,,,,,,,fee schedule,2042.58,9062.24,
Njx noncmpnd sclrsnt 1 vein,36465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5127.06,,,,,,,fee schedule,2042.58,9062.24,
Njx noncmpnd sclrsnt 1 vein,36465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5390.38,,,,,,,fee schedule,2042.58,9062.24,
Njx noncmpnd sclrsnt 1 vein,36465,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,2042.58,9062.24,APC 378
Njx noncmpnd sclrsnt 1 vein,36465,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,2042.58,9062.24,APC
Njx noncmpnd sclrsnt 1 vein,36465,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,2042.58,9062.24,APC
Njx noncmpnd sclrsnt 1 vein,36465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,2042.58,9062.24,APC
Njx noncmpnd sclrsnt 1 vein,36465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,2042.58,9062.24,Radiology
Njx noncmpnd sclrsnt 1 vein,36465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,2042.58,9062.24,APC
Njx noncmpnd sclrsnt 1 vein,36465,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,2042.58,9062.24,APC
Njx noncmpnd sclrsnt mlt vn,36466,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5855.07,,,,,,,fee schedule,2042.58,9062.24,
Njx noncmpnd sclrsnt mlt vn,36466,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4693.35,,,,,,,fee schedule,2042.58,9062.24,
Njx noncmpnd sclrsnt mlt vn,36466,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5127.06,,,,,,,fee schedule,2042.58,9062.24,
Njx noncmpnd sclrsnt mlt vn,36466,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5390.38,,,,,,,fee schedule,2042.58,9062.24,
Njx noncmpnd sclrsnt mlt vn,36466,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,2042.58,9062.24,APC 378
Njx noncmpnd sclrsnt mlt vn,36466,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,2042.58,9062.24,APC
Njx noncmpnd sclrsnt mlt vn,36466,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,2042.58,9062.24,APC
Njx noncmpnd sclrsnt mlt vn,36466,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,2042.58,9062.24,APC
Njx noncmpnd sclrsnt mlt vn,36466,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,2042.58,9062.24,Radiology
Njx noncmpnd sclrsnt mlt vn,36466,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,2042.58,9062.24,APC
Njx noncmpnd sclrsnt mlt vn,36466,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,2042.58,9062.24,APC
Injection(s) spider veins,36468,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,197.92,,,,,,,fee schedule,158.65,1785.48,
Injection(s) spider veins,36468,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,158.65,,,,,,,fee schedule,158.65,1785.48,
Injection(s) spider veins,36468,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,173.31,,,,,,,fee schedule,158.65,1785.48,
Injection(s) spider veins,36468,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,182.21,,,,,,,fee schedule,158.65,1785.48,
Injection(s) spider veins,36468,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1785.48,,,,,,,fee schedule,158.65,1785.48,APC 378
Injection(s) spider veins,36468,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,422.56,,,,,,,fee schedule,158.65,1785.48,APC
Injection(s) spider veins,36468,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,418.53,,,,,,,fee schedule,158.65,1785.48,APC
Injection(s) spider veins,36468,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,402.44,,,,,,,fee schedule,158.65,1785.48,APC
Injection(s) spider veins,36468,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,615.73,,,,,,,fee schedule,158.65,1785.48,Radiology
Injection(s) spider veins,36468,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,563.41,,,,,,,fee schedule,158.65,1785.48,APC
Injection(s) spider veins,36468,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,704.26,,,,,,,fee schedule,158.65,1785.48,APC
Injection therapy of vein,36470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,197.92,,,,,,,fee schedule,158.65,1785.48,
Injection therapy of vein,36470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,158.65,,,,,,,fee schedule,158.65,1785.48,
Injection therapy of vein,36470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,173.31,,,,,,,fee schedule,158.65,1785.48,
Injection therapy of vein,36470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,182.21,,,,,,,fee schedule,158.65,1785.48,
Injection therapy of vein,36470,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1785.48,,,,,,,fee schedule,158.65,1785.48,APC 378
Injection therapy of vein,36470,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,422.56,,,,,,,fee schedule,158.65,1785.48,APC
Injection therapy of vein,36470,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,418.53,,,,,,,fee schedule,158.65,1785.48,APC
Injection therapy of vein,36470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,402.44,,,,,,,fee schedule,158.65,1785.48,APC
Injection therapy of vein,36470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,615.73,,,,,,,fee schedule,158.65,1785.48,Radiology
Injection therapy of vein,36470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,563.41,,,,,,,fee schedule,158.65,1785.48,APC
Injection therapy of vein,36470,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,704.26,,,,,,,fee schedule,158.65,1785.48,APC
Injection therapy of veins,36471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,197.92,,,,,,,fee schedule,158.65,1785.48,
Injection therapy of veins,36471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,158.65,,,,,,,fee schedule,158.65,1785.48,
Injection therapy of veins,36471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,173.31,,,,,,,fee schedule,158.65,1785.48,
Injection therapy of veins,36471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,182.21,,,,,,,fee schedule,158.65,1785.48,
Injection therapy of veins,36471,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1785.48,,,,,,,fee schedule,158.65,1785.48,APC 378
Injection therapy of veins,36471,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,422.56,,,,,,,fee schedule,158.65,1785.48,APC
Injection therapy of veins,36471,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,418.53,,,,,,,fee schedule,158.65,1785.48,APC
Injection therapy of veins,36471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,402.44,,,,,,,fee schedule,158.65,1785.48,APC
Injection therapy of veins,36471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,615.73,,,,,,,fee schedule,158.65,1785.48,Radiology
Injection therapy of veins,36471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,563.41,,,,,,,fee schedule,158.65,1785.48,APC
Injection therapy of veins,36471,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,704.26,,,,,,,fee schedule,158.65,1785.48,APC
Endovenous mchnchem 1st vein,36473,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8923.07,,,,,,,fee schedule,3125.8,13868.13,
Endovenous mchnchem 1st vein,36473,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7152.62,,,,,,,fee schedule,3125.8,13868.13,
Endovenous mchnchem 1st vein,36473,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7813.59,,,,,,,fee schedule,3125.8,13868.13,
Endovenous mchnchem 1st vein,36473,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8214.89,,,,,,,fee schedule,3125.8,13868.13,
Endovenous mchnchem 1st vein,36473,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Endovenous mchnchem 1st vein,36473,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Endovenous mchnchem 1st vein,36473,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Endovenous mchnchem 1st vein,36473,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Endovenous mchnchem 1st vein,36473,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Endovenous mchnchem 1st vein,36473,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Endovenous mchnchem 1st vein,36473,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Endovenous mchnchem add-on,36474,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,343.04,,,,,,,fee schedule,274.98,343.04,
Endovenous mchnchem add-on,36474,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,274.98,,,,,,,fee schedule,274.98,343.04,
Endovenous mchnchem add-on,36474,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,300.39,,,,,,,fee schedule,274.98,343.04,
Endovenous mchnchem add-on,36474,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,315.82,,,,,,,fee schedule,274.98,343.04,
Endovenous rf 1st vein,36475,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6968.45,,,,,,,fee schedule,3125.8,13868.13,
Endovenous rf 1st vein,36475,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5585.82,,,,,,,fee schedule,3125.8,13868.13,
Endovenous rf 1st vein,36475,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6102,,,,,,,fee schedule,3125.8,13868.13,
Endovenous rf 1st vein,36475,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6415.4,,,,,,,fee schedule,3125.8,13868.13,
Endovenous rf 1st vein,36475,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Endovenous rf 1st vein,36475,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Endovenous rf 1st vein,36475,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Endovenous rf 1st vein,36475,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Endovenous rf 1st vein,36475,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Endovenous rf 1st vein,36475,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Endovenous rf 1st vein,36475,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Endovenous rf vein add-on,36476,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4531.07,,,,,,,fee schedule,3632.05,4531.07,
Endovenous rf vein add-on,36476,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3632.05,,,,,,,fee schedule,3632.05,4531.07,
Endovenous rf vein add-on,36476,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3967.69,,,,,,,fee schedule,3632.05,4531.07,
Endovenous rf vein add-on,36476,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4171.46,,,,,,,fee schedule,3632.05,4531.07,
Endovenous laser 1st vein,36478,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6449.28,,,,,,,fee schedule,3125.8,13868.13,
Endovenous laser 1st vein,36478,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5169.66,,,,,,,fee schedule,3125.8,13868.13,
Endovenous laser 1st vein,36478,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5647.39,,,,,,,fee schedule,3125.8,13868.13,
Endovenous laser 1st vein,36478,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5937.44,,,,,,,fee schedule,3125.8,13868.13,
Endovenous laser 1st vein,36478,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Endovenous laser 1st vein,36478,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Endovenous laser 1st vein,36478,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Endovenous laser 1st vein,36478,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Endovenous laser 1st vein,36478,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Endovenous laser 1st vein,36478,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Endovenous laser 1st vein,36478,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Endovenous laser vein addon,36479,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6449.28,,,,,,,fee schedule,5169.66,6449.28,
Endovenous laser vein addon,36479,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5169.66,,,,,,,fee schedule,5169.66,6449.28,
Endovenous laser vein addon,36479,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5647.39,,,,,,,fee schedule,5169.66,6449.28,
Endovenous laser vein addon,36479,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5937.44,,,,,,,fee schedule,5169.66,6449.28,
Endoven ther chem adhes 1st,36482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16543.25,,,,,,,fee schedule,5508.66,24440.06,
Endoven ther chem adhes 1st,36482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13260.86,,,,,,,fee schedule,5508.66,24440.06,
Endoven ther chem adhes 1st,36482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14486.28,,,,,,,fee schedule,5508.66,24440.06,
Endoven ther chem adhes 1st,36482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15230.29,,,,,,,fee schedule,5508.66,24440.06,
Endoven ther chem adhes 1st,36482,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24440.06,,,,,,,fee schedule,5508.66,24440.06,APC 378
Endoven ther chem adhes 1st,36482,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5784.09,,,,,,,fee schedule,5508.66,24440.06,APC
Endoven ther chem adhes 1st,36482,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5729.01,,,,,,,fee schedule,5508.66,24440.06,APC
Endoven ther chem adhes 1st,36482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5508.66,,,,,,,fee schedule,5508.66,24440.06,APC
Endoven ther chem adhes 1st,36482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8428.25,,,,,,,fee schedule,5508.66,24440.06,Radiology
Endoven ther chem adhes 1st,36482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7712.13,,,,,,,fee schedule,5508.66,24440.06,APC
Endoven ther chem adhes 1st,36482,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9640.16,,,,,,,fee schedule,5508.66,24440.06,APC
Endoven ther chem adhes sbsq,36483,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,357.97,,,,,,,fee schedule,286.94,357.97,
Endoven ther chem adhes sbsq,36483,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,286.94,,,,,,,fee schedule,286.94,357.97,
Endoven ther chem adhes sbsq,36483,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,313.46,,,,,,,fee schedule,286.94,357.97,
Endoven ther chem adhes sbsq,36483,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,329.56,,,,,,,fee schedule,286.94,357.97,
Apheresis wbc,36511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2871.55,,,,,,,fee schedule,1541.8,6840.45,
Apheresis wbc,36511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2301.8,,,,,,,fee schedule,1541.8,6840.45,
Apheresis wbc,36511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2514.51,,,,,,,fee schedule,1541.8,6840.45,
Apheresis wbc,36511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2643.65,,,,,,,fee schedule,1541.8,6840.45,
Apheresis wbc,36511,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6840.45,,,,,,,fee schedule,1541.8,6840.45,APC 378
Apheresis wbc,36511,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1618.89,,,,,,,fee schedule,1541.8,6840.45,APC
Apheresis wbc,36511,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1603.47,,,,,,,fee schedule,1541.8,6840.45,APC
Apheresis wbc,36511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1541.8,,,,,,,fee schedule,1541.8,6840.45,APC
Apheresis wbc,36511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2358.96,,,,,,,fee schedule,1541.8,6840.45,Radiology
Apheresis wbc,36511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2158.52,,,,,,,fee schedule,1541.8,6840.45,APC
Apheresis wbc,36511,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2698.15,,,,,,,fee schedule,1541.8,6840.45,APC
Apheresis rbc,36512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2871.55,,,,,,,fee schedule,1541.8,6840.45,
Apheresis rbc,36512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2301.8,,,,,,,fee schedule,1541.8,6840.45,
Apheresis rbc,36512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2514.51,,,,,,,fee schedule,1541.8,6840.45,
Apheresis rbc,36512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2643.65,,,,,,,fee schedule,1541.8,6840.45,
Apheresis rbc,36512,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6840.45,,,,,,,fee schedule,1541.8,6840.45,APC 378
Apheresis rbc,36512,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1618.89,,,,,,,fee schedule,1541.8,6840.45,APC
Apheresis rbc,36512,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1603.47,,,,,,,fee schedule,1541.8,6840.45,APC
Apheresis rbc,36512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1541.8,,,,,,,fee schedule,1541.8,6840.45,APC
Apheresis rbc,36512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2358.96,,,,,,,fee schedule,1541.8,6840.45,Radiology
Apheresis rbc,36512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2158.52,,,,,,,fee schedule,1541.8,6840.45,APC
Apheresis rbc,36512,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2698.15,,,,,,,fee schedule,1541.8,6840.45,APC
Apheresis platelets,36513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2871.55,,,,,,,fee schedule,436.75,2871.55,
Apheresis platelets,36513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2301.8,,,,,,,fee schedule,436.75,2871.55,
Apheresis platelets,36513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2514.51,,,,,,,fee schedule,436.75,2871.55,
Apheresis platelets,36513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2643.65,,,,,,,fee schedule,436.75,2871.55,
Apheresis platelets,36513,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1937.7,,,,,,,fee schedule,436.75,2871.55,APC 378
Apheresis platelets,36513,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,458.59,,,,,,,fee schedule,436.75,2871.55,APC
Apheresis platelets,36513,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,454.22,,,,,,,fee schedule,436.75,2871.55,APC
Apheresis platelets,36513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,436.75,,,,,,,fee schedule,436.75,2871.55,APC
Apheresis platelets,36513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,668.22,,,,,,,fee schedule,436.75,2871.55,Radiology
Apheresis platelets,36513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,611.45,,,,,,,fee schedule,436.75,2871.55,APC
Apheresis platelets,36513,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,764.31,,,,,,,fee schedule,436.75,2871.55,APC
Apheresis plasma,36514,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3158.69,,,,,,,fee schedule,1541.8,6840.45,
Apheresis plasma,36514,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2531.97,,,,,,,fee schedule,1541.8,6840.45,
Apheresis plasma,36514,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2765.95,,,,,,,fee schedule,1541.8,6840.45,
Apheresis plasma,36514,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2908,,,,,,,fee schedule,1541.8,6840.45,
Apheresis plasma,36514,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6840.45,,,,,,,fee schedule,1541.8,6840.45,APC 378
Apheresis plasma,36514,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1618.89,,,,,,,fee schedule,1541.8,6840.45,APC
Apheresis plasma,36514,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1603.47,,,,,,,fee schedule,1541.8,6840.45,APC
Apheresis plasma,36514,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1541.8,,,,,,,fee schedule,1541.8,6840.45,APC
Apheresis plasma,36514,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2358.96,,,,,,,fee schedule,1541.8,6840.45,Radiology
Apheresis plasma,36514,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2158.52,,,,,,,fee schedule,1541.8,6840.45,APC
Apheresis plasma,36514,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2698.15,,,,,,,fee schedule,1541.8,6840.45,APC
Apheresis selective,36516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7637.87,,,,,,,fee schedule,4311.81,19130.02,
Apheresis selective,36516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6122.42,,,,,,,fee schedule,4311.81,19130.02,
Apheresis selective,36516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6688.19,,,,,,,fee schedule,4311.81,19130.02,
Apheresis selective,36516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7031.69,,,,,,,fee schedule,4311.81,19130.02,
Apheresis selective,36516,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19130.02,,,,,,,fee schedule,4311.81,19130.02,APC 378
Apheresis selective,36516,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4527.4,,,,,,,fee schedule,4311.81,19130.02,APC
Apheresis selective,36516,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4484.28,,,,,,,fee schedule,4311.81,19130.02,APC
Apheresis selective,36516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4311.81,,,,,,,fee schedule,4311.81,19130.02,APC
Apheresis selective,36516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6597.06,,,,,,,fee schedule,4311.81,19130.02,Radiology
Apheresis selective,36516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6036.53,,,,,,,fee schedule,4311.81,19130.02,APC
Apheresis selective,36516,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7545.66,,,,,,,fee schedule,4311.81,19130.02,APC
Photopheresis,36522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6075.75,,,,,,,fee schedule,4311.81,19130.02,
Photopheresis,36522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4870.24,,,,,,,fee schedule,4311.81,19130.02,
Photopheresis,36522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5320.3,,,,,,,fee schedule,4311.81,19130.02,
Photopheresis,36522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5593.54,,,,,,,fee schedule,4311.81,19130.02,
Photopheresis,36522,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19130.02,,,,,,,fee schedule,4311.81,19130.02,APC 378
Photopheresis,36522,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4527.4,,,,,,,fee schedule,4311.81,19130.02,APC
Photopheresis,36522,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4484.28,,,,,,,fee schedule,4311.81,19130.02,APC
Photopheresis,36522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4311.81,,,,,,,fee schedule,4311.81,19130.02,APC
Photopheresis,36522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6597.06,,,,,,,fee schedule,4311.81,19130.02,Radiology
Photopheresis,36522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6036.53,,,,,,,fee schedule,4311.81,19130.02,APC
Photopheresis,36522,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7545.66,,,,,,,fee schedule,4311.81,19130.02,APC
Insert non-tunnel cv cath,36555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2722.66,,,,,,,fee schedule,2182.45,13868.13,
Insert non-tunnel cv cath,36555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2182.45,,,,,,,fee schedule,2182.45,13868.13,
Insert non-tunnel cv cath,36555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2384.13,,,,,,,fee schedule,2182.45,13868.13,
Insert non-tunnel cv cath,36555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2506.57,,,,,,,fee schedule,2182.45,13868.13,
Insert non-tunnel cv cath,36555,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,2182.45,13868.13,APC 378
Insert non-tunnel cv cath,36555,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,2182.45,13868.13,APC
Insert non-tunnel cv cath,36555,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,2182.45,13868.13,APC
Insert non-tunnel cv cath,36555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,2182.45,13868.13,APC
Insert non-tunnel cv cath,36555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,2182.45,13868.13,Radiology
Insert non-tunnel cv cath,36555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,2182.45,13868.13,APC
Insert non-tunnel cv cath,36555,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,2182.45,13868.13,APC
Insert non-tunnel cv cath,36556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1143.35,,,,,,,fee schedule,916.5,13868.13,
Insert non-tunnel cv cath,36556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,916.5,,,,,,,fee schedule,916.5,13868.13,
Insert non-tunnel cv cath,36556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1001.19,,,,,,,fee schedule,916.5,13868.13,
Insert non-tunnel cv cath,36556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1052.61,,,,,,,fee schedule,916.5,13868.13,
Insert non-tunnel cv cath,36556,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,916.5,13868.13,APC 378
Insert non-tunnel cv cath,36556,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,916.5,13868.13,APC
Insert non-tunnel cv cath,36556,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,916.5,13868.13,APC
Insert non-tunnel cv cath,36556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,916.5,13868.13,APC
Insert non-tunnel cv cath,36556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,916.5,13868.13,Radiology
Insert non-tunnel cv cath,36556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,916.5,13868.13,APC
Insert non-tunnel cv cath,36556,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,916.5,13868.13,APC
Insert tunneled cv cath,36557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6016.47,,,,,,,fee schedule,4822.73,24440.06,
Insert tunneled cv cath,36557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4822.73,,,,,,,fee schedule,4822.73,24440.06,
Insert tunneled cv cath,36557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5268.39,,,,,,,fee schedule,4822.73,24440.06,
Insert tunneled cv cath,36557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5538.98,,,,,,,fee schedule,4822.73,24440.06,
Insert tunneled cv cath,36557,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24440.06,,,,,,,fee schedule,4822.73,24440.06,APC 378
Insert tunneled cv cath,36557,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5784.09,,,,,,,fee schedule,4822.73,24440.06,APC
Insert tunneled cv cath,36557,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5729.01,,,,,,,fee schedule,4822.73,24440.06,APC
Insert tunneled cv cath,36557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5508.66,,,,,,,fee schedule,4822.73,24440.06,APC
Insert tunneled cv cath,36557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8428.25,,,,,,,fee schedule,4822.73,24440.06,Radiology
Insert tunneled cv cath,36557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7712.13,,,,,,,fee schedule,4822.73,24440.06,APC
Insert tunneled cv cath,36557,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9640.16,,,,,,,fee schedule,4822.73,24440.06,APC
Insert tunneled cv cath,36558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3137.02,,,,,,,fee schedule,2514.6,13868.13,
Insert tunneled cv cath,36558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2514.6,,,,,,,fee schedule,2514.6,13868.13,
Insert tunneled cv cath,36558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2746.97,,,,,,,fee schedule,2514.6,13868.13,
Insert tunneled cv cath,36558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2888.05,,,,,,,fee schedule,2514.6,13868.13,
Insert tunneled cv cath,36558,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,2514.6,13868.13,APC 378
Insert tunneled cv cath,36558,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,2514.6,13868.13,APC
Insert tunneled cv cath,36558,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,2514.6,13868.13,APC
Insert tunneled cv cath,36558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,2514.6,13868.13,APC
Insert tunneled cv cath,36558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,2514.6,13868.13,Radiology
Insert tunneled cv cath,36558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,2514.6,13868.13,APC
Insert tunneled cv cath,36558,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,2514.6,13868.13,APC
Insert tunneled cv cath,36560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4660.56,,,,,,,fee schedule,3125.8,13868.13,
Insert tunneled cv cath,36560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3735.85,,,,,,,fee schedule,3125.8,13868.13,
Insert tunneled cv cath,36560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4081.08,,,,,,,fee schedule,3125.8,13868.13,
Insert tunneled cv cath,36560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4290.68,,,,,,,fee schedule,3125.8,13868.13,
Insert tunneled cv cath,36560,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Insert tunneled cv cath,36560,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Insert tunneled cv cath,36560,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Insert tunneled cv cath,36560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Insert tunneled cv cath,36560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Insert tunneled cv cath,36560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Insert tunneled cv cath,36560,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Insert tunneled cv cath,36561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5126.51,,,,,,,fee schedule,3125.8,13868.13,
Insert tunneled cv cath,36561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4109.35,,,,,,,fee schedule,3125.8,13868.13,
Insert tunneled cv cath,36561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4489.09,,,,,,,fee schedule,3125.8,13868.13,
Insert tunneled cv cath,36561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4719.65,,,,,,,fee schedule,3125.8,13868.13,
Insert tunneled cv cath,36561,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Insert tunneled cv cath,36561,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Insert tunneled cv cath,36561,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Insert tunneled cv cath,36561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Insert tunneled cv cath,36561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Insert tunneled cv cath,36561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Insert tunneled cv cath,36561,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Insert tunneled cv cath,36563,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7206.31,,,,,,,fee schedule,5508.66,24440.06,
Insert tunneled cv cath,36563,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5776.48,,,,,,,fee schedule,5508.66,24440.06,
Insert tunneled cv cath,36563,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6310.28,,,,,,,fee schedule,5508.66,24440.06,
Insert tunneled cv cath,36563,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6634.38,,,,,,,fee schedule,5508.66,24440.06,
Insert tunneled cv cath,36563,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24440.06,,,,,,,fee schedule,5508.66,24440.06,APC 378
Insert tunneled cv cath,36563,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5784.09,,,,,,,fee schedule,5508.66,24440.06,APC
Insert tunneled cv cath,36563,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5729.01,,,,,,,fee schedule,5508.66,24440.06,APC
Insert tunneled cv cath,36563,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5508.66,,,,,,,fee schedule,5508.66,24440.06,APC
Insert tunneled cv cath,36563,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8428.25,,,,,,,fee schedule,5508.66,24440.06,Radiology
Insert tunneled cv cath,36563,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7712.13,,,,,,,fee schedule,5508.66,24440.06,APC
Insert tunneled cv cath,36563,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9640.16,,,,,,,fee schedule,5508.66,24440.06,APC
Insert tunneled cv cath,36565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7206.31,,,,,,,fee schedule,3125.8,13868.13,
Insert tunneled cv cath,36565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5776.48,,,,,,,fee schedule,3125.8,13868.13,
Insert tunneled cv cath,36565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6310.28,,,,,,,fee schedule,3125.8,13868.13,
Insert tunneled cv cath,36565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6634.38,,,,,,,fee schedule,3125.8,13868.13,
Insert tunneled cv cath,36565,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Insert tunneled cv cath,36565,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Insert tunneled cv cath,36565,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Insert tunneled cv cath,36565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Insert tunneled cv cath,36565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Insert tunneled cv cath,36565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Insert tunneled cv cath,36565,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Insert tunneled cv cath,36566,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20402.32,,,,,,,fee schedule,5508.66,24440.06,
Insert tunneled cv cath,36566,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16354.24,,,,,,,fee schedule,5508.66,24440.06,
Insert tunneled cv cath,36566,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17865.53,,,,,,,fee schedule,5508.66,24440.06,
Insert tunneled cv cath,36566,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18783.09,,,,,,,fee schedule,5508.66,24440.06,
Insert tunneled cv cath,36566,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24440.06,,,,,,,fee schedule,5508.66,24440.06,APC 378
Insert tunneled cv cath,36566,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5784.09,,,,,,,fee schedule,5508.66,24440.06,APC
Insert tunneled cv cath,36566,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5729.01,,,,,,,fee schedule,5508.66,24440.06,APC
Insert tunneled cv cath,36566,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5508.66,,,,,,,fee schedule,5508.66,24440.06,APC
Insert tunneled cv cath,36566,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8428.25,,,,,,,fee schedule,5508.66,24440.06,Radiology
Insert tunneled cv cath,36566,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7712.13,,,,,,,fee schedule,5508.66,24440.06,APC
Insert tunneled cv cath,36566,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9640.16,,,,,,,fee schedule,5508.66,24440.06,APC
Insert picc cath,36568,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2722.66,,,,,,,fee schedule,1558.36,6913.93,
Insert picc cath,36568,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2182.45,,,,,,,fee schedule,1558.36,6913.93,
Insert picc cath,36568,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2384.13,,,,,,,fee schedule,1558.36,6913.93,
Insert picc cath,36568,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2506.57,,,,,,,fee schedule,1558.36,6913.93,
Insert picc cath,36568,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6913.93,,,,,,,fee schedule,1558.36,6913.93,APC 378
Insert picc cath,36568,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1636.28,,,,,,,fee schedule,1558.36,6913.93,APC
Insert picc cath,36568,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1620.7,,,,,,,fee schedule,1558.36,6913.93,APC
Insert picc cath,36568,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1558.36,,,,,,,fee schedule,1558.36,6913.93,APC
Insert picc cath,36568,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2384.29,,,,,,,fee schedule,1558.36,6913.93,Radiology
Insert picc cath,36568,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2181.71,,,,,,,fee schedule,1558.36,6913.93,APC
Insert picc cath,36568,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2727.13,,,,,,,fee schedule,1558.36,6913.93,APC
Insert picc cath,36569,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1144.28,,,,,,,fee schedule,917.24,6913.93,
Insert picc cath,36569,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,917.24,,,,,,,fee schedule,917.24,6913.93,
Insert picc cath,36569,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1002,,,,,,,fee schedule,917.24,6913.93,
Insert picc cath,36569,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1053.47,,,,,,,fee schedule,917.24,6913.93,
Insert picc cath,36569,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6913.93,,,,,,,fee schedule,917.24,6913.93,APC 378
Insert picc cath,36569,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1636.28,,,,,,,fee schedule,917.24,6913.93,APC
Insert picc cath,36569,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1620.7,,,,,,,fee schedule,917.24,6913.93,APC
Insert picc cath,36569,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1558.36,,,,,,,fee schedule,917.24,6913.93,APC
Insert picc cath,36569,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2384.29,,,,,,,fee schedule,917.24,6913.93,Radiology
Insert picc cath,36569,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2181.71,,,,,,,fee schedule,917.24,6913.93,APC
Insert picc cath,36569,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2727.13,,,,,,,fee schedule,917.24,6913.93,APC
Insert picvad cath,36570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6016.47,,,,,,,fee schedule,3125.8,13868.13,
Insert picvad cath,36570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4822.73,,,,,,,fee schedule,3125.8,13868.13,
Insert picvad cath,36570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5268.39,,,,,,,fee schedule,3125.8,13868.13,
Insert picvad cath,36570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5538.98,,,,,,,fee schedule,3125.8,13868.13,
Insert picvad cath,36570,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Insert picvad cath,36570,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Insert picvad cath,36570,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Insert picvad cath,36570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Insert picvad cath,36570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Insert picvad cath,36570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Insert picvad cath,36570,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Insert picvad cath,36571,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6016.47,,,,,,,fee schedule,3125.8,13868.13,
Insert picvad cath,36571,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4822.73,,,,,,,fee schedule,3125.8,13868.13,
Insert picvad cath,36571,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5268.39,,,,,,,fee schedule,3125.8,13868.13,
Insert picvad cath,36571,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5538.98,,,,,,,fee schedule,3125.8,13868.13,
Insert picvad cath,36571,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Insert picvad cath,36571,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Insert picvad cath,36571,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Insert picvad cath,36571,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Insert picvad cath,36571,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Insert picvad cath,36571,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Insert picvad cath,36571,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Insj picc rs&i <5 yr,36572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2343.64,,,,,,,fee schedule,621.01,2755.21,
Insj picc rs&i <5 yr,36572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1878.63,,,,,,,fee schedule,621.01,2755.21,
Insj picc rs&i <5 yr,36572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2052.23,,,,,,,fee schedule,621.01,2755.21,
Insj picc rs&i <5 yr,36572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2157.63,,,,,,,fee schedule,621.01,2755.21,
Insj picc rs&i <5 yr,36572,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2755.21,,,,,,,fee schedule,621.01,2755.21,APC 378
Insj picc rs&i <5 yr,36572,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,652.06,,,,,,,fee schedule,621.01,2755.21,APC
Insj picc rs&i <5 yr,36572,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,645.85,,,,,,,fee schedule,621.01,2755.21,APC
Insj picc rs&i <5 yr,36572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,621.01,,,,,,,fee schedule,621.01,2755.21,APC
Insj picc rs&i <5 yr,36572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,950.14,,,,,,,fee schedule,621.01,2755.21,Radiology
Insj picc rs&i <5 yr,36572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,869.41,,,,,,,fee schedule,621.01,2755.21,APC
Insj picc rs&i <5 yr,36572,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1086.77,,,,,,,fee schedule,621.01,2755.21,APC
Insj picc rs&i 5 yr+,36573,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4133.92,,,,,,,fee schedule,1558.36,6913.93,
Insj picc rs&i 5 yr+,36573,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3313.7,,,,,,,fee schedule,1558.36,6913.93,
Insj picc rs&i 5 yr+,36573,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3619.92,,,,,,,fee schedule,1558.36,6913.93,
Insj picc rs&i 5 yr+,36573,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3805.83,,,,,,,fee schedule,1558.36,6913.93,
Insj picc rs&i 5 yr+,36573,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6913.93,,,,,,,fee schedule,1558.36,6913.93,APC 378
Insj picc rs&i 5 yr+,36573,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1636.28,,,,,,,fee schedule,1558.36,6913.93,APC
Insj picc rs&i 5 yr+,36573,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1620.7,,,,,,,fee schedule,1558.36,6913.93,APC
Insj picc rs&i 5 yr+,36573,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1558.36,,,,,,,fee schedule,1558.36,6913.93,APC
Insj picc rs&i 5 yr+,36573,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2384.29,,,,,,,fee schedule,1558.36,6913.93,Radiology
Insj picc rs&i 5 yr+,36573,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2181.71,,,,,,,fee schedule,1558.36,6913.93,APC
Insj picc rs&i 5 yr+,36573,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2727.13,,,,,,,fee schedule,1558.36,6913.93,APC
Repair tunneled cv cath,36575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1412.96,,,,,,,fee schedule,621.01,2755.21,
Repair tunneled cv cath,36575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1132.61,,,,,,,fee schedule,621.01,2755.21,
Repair tunneled cv cath,36575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1237.28,,,,,,,fee schedule,621.01,2755.21,
Repair tunneled cv cath,36575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1300.82,,,,,,,fee schedule,621.01,2755.21,
Repair tunneled cv cath,36575,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2755.21,,,,,,,fee schedule,621.01,2755.21,APC 378
Repair tunneled cv cath,36575,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,652.06,,,,,,,fee schedule,621.01,2755.21,APC
Repair tunneled cv cath,36575,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,645.85,,,,,,,fee schedule,621.01,2755.21,APC
Repair tunneled cv cath,36575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,621.01,,,,,,,fee schedule,621.01,2755.21,APC
Repair tunneled cv cath,36575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,950.14,,,,,,,fee schedule,621.01,2755.21,Radiology
Repair tunneled cv cath,36575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,869.41,,,,,,,fee schedule,621.01,2755.21,APC
Repair tunneled cv cath,36575,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1086.77,,,,,,,fee schedule,621.01,2755.21,APC
Repair tunneled cv cath,36576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1199.55,,,,,,,fee schedule,961.54,6913.93,
Repair tunneled cv cath,36576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,961.54,,,,,,,fee schedule,961.54,6913.93,
Repair tunneled cv cath,36576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1050.4,,,,,,,fee schedule,961.54,6913.93,
Repair tunneled cv cath,36576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1104.34,,,,,,,fee schedule,961.54,6913.93,
Repair tunneled cv cath,36576,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6913.93,,,,,,,fee schedule,961.54,6913.93,APC 378
Repair tunneled cv cath,36576,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1636.28,,,,,,,fee schedule,961.54,6913.93,APC
Repair tunneled cv cath,36576,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1620.7,,,,,,,fee schedule,961.54,6913.93,APC
Repair tunneled cv cath,36576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1558.36,,,,,,,fee schedule,961.54,6913.93,APC
Repair tunneled cv cath,36576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2384.29,,,,,,,fee schedule,961.54,6913.93,Radiology
Repair tunneled cv cath,36576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2181.71,,,,,,,fee schedule,961.54,6913.93,APC
Repair tunneled cv cath,36576,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2727.13,,,,,,,fee schedule,961.54,6913.93,APC
Replace tunneled cv cath,36578,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6016.47,,,,,,,fee schedule,3125.8,13868.13,
Replace tunneled cv cath,36578,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4822.73,,,,,,,fee schedule,3125.8,13868.13,
Replace tunneled cv cath,36578,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5268.39,,,,,,,fee schedule,3125.8,13868.13,
Replace tunneled cv cath,36578,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5538.98,,,,,,,fee schedule,3125.8,13868.13,
Replace tunneled cv cath,36578,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Replace tunneled cv cath,36578,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Replace tunneled cv cath,36578,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Replace tunneled cv cath,36578,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Replace tunneled cv cath,36578,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Replace tunneled cv cath,36578,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Replace tunneled cv cath,36578,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Replace cvad cath,36580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2722.66,,,,,,,fee schedule,1558.36,6913.93,
Replace cvad cath,36580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2182.45,,,,,,,fee schedule,1558.36,6913.93,
Replace cvad cath,36580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2384.13,,,,,,,fee schedule,1558.36,6913.93,
Replace cvad cath,36580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2506.57,,,,,,,fee schedule,1558.36,6913.93,
Replace cvad cath,36580,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6913.93,,,,,,,fee schedule,1558.36,6913.93,APC 378
Replace cvad cath,36580,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1636.28,,,,,,,fee schedule,1558.36,6913.93,APC
Replace cvad cath,36580,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1620.7,,,,,,,fee schedule,1558.36,6913.93,APC
Replace cvad cath,36580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1558.36,,,,,,,fee schedule,1558.36,6913.93,APC
Replace cvad cath,36580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2384.29,,,,,,,fee schedule,1558.36,6913.93,Radiology
Replace cvad cath,36580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2181.71,,,,,,,fee schedule,1558.36,6913.93,APC
Replace cvad cath,36580,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2727.13,,,,,,,fee schedule,1558.36,6913.93,APC
Replace tunneled cv cath,36581,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6016.47,,,,,,,fee schedule,3125.8,13868.13,
Replace tunneled cv cath,36581,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4822.73,,,,,,,fee schedule,3125.8,13868.13,
Replace tunneled cv cath,36581,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5268.39,,,,,,,fee schedule,3125.8,13868.13,
Replace tunneled cv cath,36581,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5538.98,,,,,,,fee schedule,3125.8,13868.13,
Replace tunneled cv cath,36581,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Replace tunneled cv cath,36581,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Replace tunneled cv cath,36581,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Replace tunneled cv cath,36581,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Replace tunneled cv cath,36581,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Replace tunneled cv cath,36581,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Replace tunneled cv cath,36581,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Replace tunneled cv cath,36582,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7206.31,,,,,,,fee schedule,3125.8,13868.13,
Replace tunneled cv cath,36582,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5776.48,,,,,,,fee schedule,3125.8,13868.13,
Replace tunneled cv cath,36582,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6310.28,,,,,,,fee schedule,3125.8,13868.13,
Replace tunneled cv cath,36582,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6634.38,,,,,,,fee schedule,3125.8,13868.13,
Replace tunneled cv cath,36582,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Replace tunneled cv cath,36582,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Replace tunneled cv cath,36582,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Replace tunneled cv cath,36582,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Replace tunneled cv cath,36582,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Replace tunneled cv cath,36582,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Replace tunneled cv cath,36582,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Replace tunneled cv cath,36583,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7206.31,,,,,,,fee schedule,5508.66,24440.06,
Replace tunneled cv cath,36583,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5776.48,,,,,,,fee schedule,5508.66,24440.06,
Replace tunneled cv cath,36583,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6310.28,,,,,,,fee schedule,5508.66,24440.06,
Replace tunneled cv cath,36583,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6634.38,,,,,,,fee schedule,5508.66,24440.06,
Replace tunneled cv cath,36583,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24440.06,,,,,,,fee schedule,5508.66,24440.06,APC 378
Replace tunneled cv cath,36583,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5784.09,,,,,,,fee schedule,5508.66,24440.06,APC
Replace tunneled cv cath,36583,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5729.01,,,,,,,fee schedule,5508.66,24440.06,APC
Replace tunneled cv cath,36583,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5508.66,,,,,,,fee schedule,5508.66,24440.06,APC
Replace tunneled cv cath,36583,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8428.25,,,,,,,fee schedule,5508.66,24440.06,Radiology
Replace tunneled cv cath,36583,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7712.13,,,,,,,fee schedule,5508.66,24440.06,APC
Replace tunneled cv cath,36583,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9640.16,,,,,,,fee schedule,5508.66,24440.06,APC
Replace picc cath,36584,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2722.66,,,,,,,fee schedule,1558.36,6913.93,
Replace picc cath,36584,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2182.45,,,,,,,fee schedule,1558.36,6913.93,
Replace picc cath,36584,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2384.13,,,,,,,fee schedule,1558.36,6913.93,
Replace picc cath,36584,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2506.57,,,,,,,fee schedule,1558.36,6913.93,
Replace picc cath,36584,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6913.93,,,,,,,fee schedule,1558.36,6913.93,APC 378
Replace picc cath,36584,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1636.28,,,,,,,fee schedule,1558.36,6913.93,APC
Replace picc cath,36584,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1620.7,,,,,,,fee schedule,1558.36,6913.93,APC
Replace picc cath,36584,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1558.36,,,,,,,fee schedule,1558.36,6913.93,APC
Replace picc cath,36584,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2384.29,,,,,,,fee schedule,1558.36,6913.93,Radiology
Replace picc cath,36584,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2181.71,,,,,,,fee schedule,1558.36,6913.93,APC
Replace picc cath,36584,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2727.13,,,,,,,fee schedule,1558.36,6913.93,APC
Replace picvad cath,36585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6016.47,,,,,,,fee schedule,3125.8,13868.13,
Replace picvad cath,36585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4822.73,,,,,,,fee schedule,3125.8,13868.13,
Replace picvad cath,36585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5268.39,,,,,,,fee schedule,3125.8,13868.13,
Replace picvad cath,36585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5538.98,,,,,,,fee schedule,3125.8,13868.13,
Replace picvad cath,36585,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Replace picvad cath,36585,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Replace picvad cath,36585,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Replace picvad cath,36585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Replace picvad cath,36585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Replace picvad cath,36585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Replace picvad cath,36585,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Removal tunneled cv cath,36589,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,863.63,,,,,,,fee schedule,621.01,2755.21,
Removal tunneled cv cath,36589,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,692.27,,,,,,,fee schedule,621.01,2755.21,
Removal tunneled cv cath,36589,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,756.25,,,,,,,fee schedule,621.01,2755.21,
Removal tunneled cv cath,36589,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,795.09,,,,,,,fee schedule,621.01,2755.21,
Removal tunneled cv cath,36589,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2755.21,,,,,,,fee schedule,621.01,2755.21,APC 378
Removal tunneled cv cath,36589,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,652.06,,,,,,,fee schedule,621.01,2755.21,APC
Removal tunneled cv cath,36589,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,645.85,,,,,,,fee schedule,621.01,2755.21,APC
Removal tunneled cv cath,36589,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,621.01,,,,,,,fee schedule,621.01,2755.21,APC
Removal tunneled cv cath,36589,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,950.14,,,,,,,fee schedule,621.01,2755.21,Radiology
Removal tunneled cv cath,36589,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,869.41,,,,,,,fee schedule,621.01,2755.21,APC
Removal tunneled cv cath,36589,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1086.77,,,,,,,fee schedule,621.01,2755.21,APC
Removal tunneled cv cath,36590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1632.72,,,,,,,fee schedule,1308.77,6913.93,
Removal tunneled cv cath,36590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1308.77,,,,,,,fee schedule,1308.77,6913.93,
Removal tunneled cv cath,36590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1429.71,,,,,,,fee schedule,1308.77,6913.93,
Removal tunneled cv cath,36590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1503.14,,,,,,,fee schedule,1308.77,6913.93,
Removal tunneled cv cath,36590,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6913.93,,,,,,,fee schedule,1308.77,6913.93,APC 378
Removal tunneled cv cath,36590,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1636.28,,,,,,,fee schedule,1308.77,6913.93,APC
Removal tunneled cv cath,36590,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1620.7,,,,,,,fee schedule,1308.77,6913.93,APC
Removal tunneled cv cath,36590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1558.36,,,,,,,fee schedule,1308.77,6913.93,APC
Removal tunneled cv cath,36590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2384.29,,,,,,,fee schedule,1308.77,6913.93,Radiology
Removal tunneled cv cath,36590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2181.71,,,,,,,fee schedule,1308.77,6913.93,APC
Removal tunneled cv cath,36590,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2727.13,,,,,,,fee schedule,1308.77,6913.93,APC
Draw blood off venous device,36591,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,276.01,,,,,,,fee schedule,131.71,584.37,
Draw blood off venous device,36591,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,221.24,,,,,,,fee schedule,131.71,584.37,
Draw blood off venous device,36591,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,241.69,,,,,,,fee schedule,131.71,584.37,
Draw blood off venous device,36591,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,254.1,,,,,,,fee schedule,131.71,584.37,
Draw blood off venous device,36591,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,131.71,584.37,APC 378
Draw blood off venous device,36591,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,131.71,584.37,APC
Draw blood off venous device,36591,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,131.71,584.37,APC
Draw blood off venous device,36591,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,131.71,584.37,APC
Draw blood off venous device,36591,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,131.71,584.37,Radiology
Draw blood off venous device,36591,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,131.71,584.37,APC
Draw blood off venous device,36591,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,131.71,584.37,APC
Collect blood from picc,36592,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,276.32,,,,,,,fee schedule,131.71,584.37,
Collect blood from picc,36592,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,221.49,,,,,,,fee schedule,131.71,584.37,
Collect blood from picc,36592,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,241.96,,,,,,,fee schedule,131.71,584.37,
Collect blood from picc,36592,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,254.39,,,,,,,fee schedule,131.71,584.37,
Collect blood from picc,36592,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,131.71,584.37,APC 378
Collect blood from picc,36592,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,131.71,584.37,APC
Collect blood from picc,36592,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,131.71,584.37,APC
Collect blood from picc,36592,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,131.71,584.37,APC
Collect blood from picc,36592,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,131.71,584.37,Radiology
Collect blood from picc,36592,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,131.71,584.37,APC
Collect blood from picc,36592,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,131.71,584.37,APC
Declot vascular device,36593,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,937.84,,,,,,,fee schedule,326.99,1450.75,
Declot vascular device,36593,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,751.76,,,,,,,fee schedule,326.99,1450.75,
Declot vascular device,36593,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,821.23,,,,,,,fee schedule,326.99,1450.75,
Declot vascular device,36593,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,863.41,,,,,,,fee schedule,326.99,1450.75,
Declot vascular device,36593,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1450.75,,,,,,,fee schedule,326.99,1450.75,APC 378
Declot vascular device,36593,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,343.34,,,,,,,fee schedule,326.99,1450.75,APC
Declot vascular device,36593,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,340.07,,,,,,,fee schedule,326.99,1450.75,APC
Declot vascular device,36593,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,326.99,,,,,,,fee schedule,326.99,1450.75,APC
Declot vascular device,36593,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,500.3,,,,,,,fee schedule,326.99,1450.75,Radiology
Declot vascular device,36593,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,457.79,,,,,,,fee schedule,326.99,1450.75,APC
Declot vascular device,36593,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,572.24,,,,,,,fee schedule,326.99,1450.75,APC
Mech remov tunneled cv cath,36595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3383.92,,,,,,,fee schedule,2712.51,13868.13,
Mech remov tunneled cv cath,36595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2712.51,,,,,,,fee schedule,2712.51,13868.13,
Mech remov tunneled cv cath,36595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2963.17,,,,,,,fee schedule,2712.51,13868.13,
Mech remov tunneled cv cath,36595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3115.36,,,,,,,fee schedule,2712.51,13868.13,
Mech remov tunneled cv cath,36595,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,2712.51,13868.13,APC 378
Mech remov tunneled cv cath,36595,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,2712.51,13868.13,APC
Mech remov tunneled cv cath,36595,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,2712.51,13868.13,APC
Mech remov tunneled cv cath,36595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,2712.51,13868.13,APC
Mech remov tunneled cv cath,36595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,2712.51,13868.13,Radiology
Mech remov tunneled cv cath,36595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,2712.51,13868.13,APC
Mech remov tunneled cv cath,36595,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,2712.51,13868.13,APC
Mech remov tunneled cv cath,36596,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2722.66,,,,,,,fee schedule,1558.36,6913.93,
Mech remov tunneled cv cath,36596,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2182.45,,,,,,,fee schedule,1558.36,6913.93,
Mech remov tunneled cv cath,36596,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2384.13,,,,,,,fee schedule,1558.36,6913.93,
Mech remov tunneled cv cath,36596,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2506.57,,,,,,,fee schedule,1558.36,6913.93,
Mech remov tunneled cv cath,36596,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6913.93,,,,,,,fee schedule,1558.36,6913.93,APC 378
Mech remov tunneled cv cath,36596,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1636.28,,,,,,,fee schedule,1558.36,6913.93,APC
Mech remov tunneled cv cath,36596,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1620.7,,,,,,,fee schedule,1558.36,6913.93,APC
Mech remov tunneled cv cath,36596,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1558.36,,,,,,,fee schedule,1558.36,6913.93,APC
Mech remov tunneled cv cath,36596,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2384.29,,,,,,,fee schedule,1558.36,6913.93,Radiology
Mech remov tunneled cv cath,36596,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2181.71,,,,,,,fee schedule,1558.36,6913.93,APC
Mech remov tunneled cv cath,36596,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2727.13,,,,,,,fee schedule,1558.36,6913.93,APC
Reposition venous catheter,36597,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2722.66,,,,,,,fee schedule,1558.36,6913.93,
Reposition venous catheter,36597,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2182.45,,,,,,,fee schedule,1558.36,6913.93,
Reposition venous catheter,36597,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2384.13,,,,,,,fee schedule,1558.36,6913.93,
Reposition venous catheter,36597,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2506.57,,,,,,,fee schedule,1558.36,6913.93,
Reposition venous catheter,36597,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6913.93,,,,,,,fee schedule,1558.36,6913.93,APC 378
Reposition venous catheter,36597,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1636.28,,,,,,,fee schedule,1558.36,6913.93,APC
Reposition venous catheter,36597,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1620.7,,,,,,,fee schedule,1558.36,6913.93,APC
Reposition venous catheter,36597,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1558.36,,,,,,,fee schedule,1558.36,6913.93,APC
Reposition venous catheter,36597,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2384.29,,,,,,,fee schedule,1558.36,6913.93,Radiology
Reposition venous catheter,36597,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2181.71,,,,,,,fee schedule,1558.36,6913.93,APC
Reposition venous catheter,36597,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2727.13,,,,,,,fee schedule,1558.36,6913.93,APC
Inj w/fluor eval cv device,36598,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,308.83,,,,,,,fee schedule,210.57,934.22,
Inj w/fluor eval cv device,36598,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,247.55,,,,,,,fee schedule,210.57,934.22,
Inj w/fluor eval cv device,36598,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,270.43,,,,,,,fee schedule,210.57,934.22,
Inj w/fluor eval cv device,36598,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,284.32,,,,,,,fee schedule,210.57,934.22,
Inj w/fluor eval cv device,36598,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,934.22,,,,,,,fee schedule,210.57,934.22,APC 378
Inj w/fluor eval cv device,36598,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,221.1,,,,,,,fee schedule,210.57,934.22,APC
Inj w/fluor eval cv device,36598,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,218.99,,,,,,,fee schedule,210.57,934.22,APC
Inj w/fluor eval cv device,36598,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,210.57,,,,,,,fee schedule,210.57,934.22,APC
Inj w/fluor eval cv device,36598,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,322.17,,,,,,,fee schedule,210.57,934.22,Radiology
Inj w/fluor eval cv device,36598,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,294.8,,,,,,,fee schedule,210.57,934.22,APC
Inj w/fluor eval cv device,36598,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,368.5,,,,,,,fee schedule,210.57,934.22,APC
Withdrawal of arterial blood,36600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,237.85,,,,,,,fee schedule,131.71,584.37,
Withdrawal of arterial blood,36600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,190.66,,,,,,,fee schedule,131.71,584.37,
Withdrawal of arterial blood,36600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,208.28,,,,,,,fee schedule,131.71,584.37,
Withdrawal of arterial blood,36600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,218.97,,,,,,,fee schedule,131.71,584.37,
Withdrawal of arterial blood,36600,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,131.71,584.37,APC 378
Withdrawal of arterial blood,36600,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,131.71,584.37,APC
Withdrawal of arterial blood,36600,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,131.71,584.37,APC
Withdrawal of arterial blood,36600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,131.71,584.37,APC
Withdrawal of arterial blood,36600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,131.71,584.37,Radiology
Withdrawal of arterial blood,36600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,131.71,584.37,APC
Withdrawal of arterial blood,36600,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,131.71,584.37,APC
Insertion catheter artery,36640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7206.31,,,,,,,fee schedule,3125.8,13868.13,
Insertion catheter artery,36640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5776.48,,,,,,,fee schedule,3125.8,13868.13,
Insertion catheter artery,36640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6310.28,,,,,,,fee schedule,3125.8,13868.13,
Insertion catheter artery,36640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6634.38,,,,,,,fee schedule,3125.8,13868.13,
Insertion catheter artery,36640,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Insertion catheter artery,36640,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Insertion catheter artery,36640,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Insertion catheter artery,36640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Insertion catheter artery,36640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Insertion catheter artery,36640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Insertion catheter artery,36640,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Insert needle bone cavity,36680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,267.65,,,,,,,fee schedule,214.54,1962.08,
Insert needle bone cavity,36680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,214.54,,,,,,,fee schedule,214.54,1962.08,
Insert needle bone cavity,36680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,234.37,,,,,,,fee schedule,214.54,1962.08,
Insert needle bone cavity,36680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,246.41,,,,,,,fee schedule,214.54,1962.08,
Insert needle bone cavity,36680,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1962.08,,,,,,,fee schedule,214.54,1962.08,APC 378
Insert needle bone cavity,36680,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,464.35,,,,,,,fee schedule,214.54,1962.08,APC
Insert needle bone cavity,36680,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,459.93,,,,,,,fee schedule,214.54,1962.08,APC
Insert needle bone cavity,36680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,442.24,,,,,,,fee schedule,214.54,1962.08,APC
Insert needle bone cavity,36680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,676.63,,,,,,,fee schedule,214.54,1962.08,Radiology
Insert needle bone cavity,36680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,619.14,,,,,,,fee schedule,214.54,1962.08,APC
Insert needle bone cavity,36680,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,773.92,,,,,,,fee schedule,214.54,1962.08,APC
Insertion of cannula,36800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7411.52,,,,,,,fee schedule,5508.66,24440.06,
Insertion of cannula,36800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5940.98,,,,,,,fee schedule,5508.66,24440.06,
Insertion of cannula,36800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6489.98,,,,,,,fee schedule,5508.66,24440.06,
Insertion of cannula,36800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6823.31,,,,,,,fee schedule,5508.66,24440.06,
Insertion of cannula,36800,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24440.06,,,,,,,fee schedule,5508.66,24440.06,APC 378
Insertion of cannula,36800,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5784.09,,,,,,,fee schedule,5508.66,24440.06,APC
Insertion of cannula,36800,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5729.01,,,,,,,fee schedule,5508.66,24440.06,APC
Insertion of cannula,36800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5508.66,,,,,,,fee schedule,5508.66,24440.06,APC
Insertion of cannula,36800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8428.25,,,,,,,fee schedule,5508.66,24440.06,Radiology
Insertion of cannula,36800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7712.13,,,,,,,fee schedule,5508.66,24440.06,APC
Insertion of cannula,36800,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9640.16,,,,,,,fee schedule,5508.66,24440.06,APC
Insertion of cannula,36810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7411.52,,,,,,,fee schedule,3125.8,13868.13,
Insertion of cannula,36810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5940.98,,,,,,,fee schedule,3125.8,13868.13,
Insertion of cannula,36810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6489.98,,,,,,,fee schedule,3125.8,13868.13,
Insertion of cannula,36810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6823.31,,,,,,,fee schedule,3125.8,13868.13,
Insertion of cannula,36810,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Insertion of cannula,36810,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Insertion of cannula,36810,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Insertion of cannula,36810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Insertion of cannula,36810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Insertion of cannula,36810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Insertion of cannula,36810,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Insertion of cannula,36815,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7411.52,,,,,,,fee schedule,5508.66,24440.06,
Insertion of cannula,36815,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5940.98,,,,,,,fee schedule,5508.66,24440.06,
Insertion of cannula,36815,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6489.98,,,,,,,fee schedule,5508.66,24440.06,
Insertion of cannula,36815,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6823.31,,,,,,,fee schedule,5508.66,24440.06,
Insertion of cannula,36815,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24440.06,,,,,,,fee schedule,5508.66,24440.06,APC 378
Insertion of cannula,36815,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5784.09,,,,,,,fee schedule,5508.66,24440.06,APC
Insertion of cannula,36815,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5729.01,,,,,,,fee schedule,5508.66,24440.06,APC
Insertion of cannula,36815,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5508.66,,,,,,,fee schedule,5508.66,24440.06,APC
Insertion of cannula,36815,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8428.25,,,,,,,fee schedule,5508.66,24440.06,Radiology
Insertion of cannula,36815,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7712.13,,,,,,,fee schedule,5508.66,24440.06,APC
Insertion of cannula,36815,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9640.16,,,,,,,fee schedule,5508.66,24440.06,APC
Av fuse uppr arm cephalic,36818,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10673.46,,,,,,,fee schedule,5508.66,24440.06,
Av fuse uppr arm cephalic,36818,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8555.71,,,,,,,fee schedule,5508.66,24440.06,
Av fuse uppr arm cephalic,36818,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9346.34,,,,,,,fee schedule,5508.66,24440.06,
Av fuse uppr arm cephalic,36818,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9826.36,,,,,,,fee schedule,5508.66,24440.06,
Av fuse uppr arm cephalic,36818,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24440.06,,,,,,,fee schedule,5508.66,24440.06,APC 378
Av fuse uppr arm cephalic,36818,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5784.09,,,,,,,fee schedule,5508.66,24440.06,APC
Av fuse uppr arm cephalic,36818,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5729.01,,,,,,,fee schedule,5508.66,24440.06,APC
Av fuse uppr arm cephalic,36818,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5508.66,,,,,,,fee schedule,5508.66,24440.06,APC
Av fuse uppr arm cephalic,36818,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8428.25,,,,,,,fee schedule,5508.66,24440.06,Radiology
Av fuse uppr arm cephalic,36818,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7712.13,,,,,,,fee schedule,5508.66,24440.06,APC
Av fuse uppr arm cephalic,36818,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9640.16,,,,,,,fee schedule,5508.66,24440.06,APC
Av fuse uppr arm basilic,36819,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10205.34,,,,,,,fee schedule,5508.66,24440.06,
Av fuse uppr arm basilic,36819,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8180.47,,,,,,,fee schedule,5508.66,24440.06,
Av fuse uppr arm basilic,36819,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8936.43,,,,,,,fee schedule,5508.66,24440.06,
Av fuse uppr arm basilic,36819,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9395.4,,,,,,,fee schedule,5508.66,24440.06,
Av fuse uppr arm basilic,36819,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24440.06,,,,,,,fee schedule,5508.66,24440.06,APC 378
Av fuse uppr arm basilic,36819,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5784.09,,,,,,,fee schedule,5508.66,24440.06,APC
Av fuse uppr arm basilic,36819,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5729.01,,,,,,,fee schedule,5508.66,24440.06,APC
Av fuse uppr arm basilic,36819,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5508.66,,,,,,,fee schedule,5508.66,24440.06,APC
Av fuse uppr arm basilic,36819,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8428.25,,,,,,,fee schedule,5508.66,24440.06,Radiology
Av fuse uppr arm basilic,36819,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7712.13,,,,,,,fee schedule,5508.66,24440.06,APC
Av fuse uppr arm basilic,36819,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9640.16,,,,,,,fee schedule,5508.66,24440.06,APC
Av fusion/forearm vein,36820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9675.33,,,,,,,fee schedule,5508.66,24440.06,
Av fusion/forearm vein,36820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7755.62,,,,,,,fee schedule,5508.66,24440.06,
Av fusion/forearm vein,36820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8472.31,,,,,,,fee schedule,5508.66,24440.06,
Av fusion/forearm vein,36820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8907.44,,,,,,,fee schedule,5508.66,24440.06,
Av fusion/forearm vein,36820,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24440.06,,,,,,,fee schedule,5508.66,24440.06,APC 378
Av fusion/forearm vein,36820,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5784.09,,,,,,,fee schedule,5508.66,24440.06,APC
Av fusion/forearm vein,36820,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5729.01,,,,,,,fee schedule,5508.66,24440.06,APC
Av fusion/forearm vein,36820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5508.66,,,,,,,fee schedule,5508.66,24440.06,APC
Av fusion/forearm vein,36820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8428.25,,,,,,,fee schedule,5508.66,24440.06,Radiology
Av fusion/forearm vein,36820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7712.13,,,,,,,fee schedule,5508.66,24440.06,APC
Av fusion/forearm vein,36820,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9640.16,,,,,,,fee schedule,5508.66,24440.06,APC
Av fusion direct any site,36821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11141.58,,,,,,,fee schedule,3125.8,13868.13,
Av fusion direct any site,36821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8930.95,,,,,,,fee schedule,3125.8,13868.13,
Av fusion direct any site,36821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9756.25,,,,,,,fee schedule,3125.8,13868.13,
Av fusion direct any site,36821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10257.32,,,,,,,fee schedule,3125.8,13868.13,
Av fusion direct any site,36821,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Av fusion direct any site,36821,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Av fusion direct any site,36821,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Av fusion direct any site,36821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Av fusion direct any site,36821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Av fusion direct any site,36821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Av fusion direct any site,36821,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Artery-vein autograft,36825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9675.33,,,,,,,fee schedule,5508.66,24440.06,
Artery-vein autograft,36825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7755.62,,,,,,,fee schedule,5508.66,24440.06,
Artery-vein autograft,36825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8472.31,,,,,,,fee schedule,5508.66,24440.06,
Artery-vein autograft,36825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8907.44,,,,,,,fee schedule,5508.66,24440.06,
Artery-vein autograft,36825,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24440.06,,,,,,,fee schedule,5508.66,24440.06,APC 378
Artery-vein autograft,36825,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5784.09,,,,,,,fee schedule,5508.66,24440.06,APC
Artery-vein autograft,36825,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5729.01,,,,,,,fee schedule,5508.66,24440.06,APC
Artery-vein autograft,36825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5508.66,,,,,,,fee schedule,5508.66,24440.06,APC
Artery-vein autograft,36825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8428.25,,,,,,,fee schedule,5508.66,24440.06,Radiology
Artery-vein autograft,36825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7712.13,,,,,,,fee schedule,5508.66,24440.06,APC
Artery-vein autograft,36825,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9640.16,,,,,,,fee schedule,5508.66,24440.06,APC
Artery-vein nonautograft,36830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9675.33,,,,,,,fee schedule,5508.66,24440.06,
Artery-vein nonautograft,36830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7755.62,,,,,,,fee schedule,5508.66,24440.06,
Artery-vein nonautograft,36830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8472.31,,,,,,,fee schedule,5508.66,24440.06,
Artery-vein nonautograft,36830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8907.44,,,,,,,fee schedule,5508.66,24440.06,
Artery-vein nonautograft,36830,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24440.06,,,,,,,fee schedule,5508.66,24440.06,APC 378
Artery-vein nonautograft,36830,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5784.09,,,,,,,fee schedule,5508.66,24440.06,APC
Artery-vein nonautograft,36830,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5729.01,,,,,,,fee schedule,5508.66,24440.06,APC
Artery-vein nonautograft,36830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5508.66,,,,,,,fee schedule,5508.66,24440.06,APC
Artery-vein nonautograft,36830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8428.25,,,,,,,fee schedule,5508.66,24440.06,Radiology
Artery-vein nonautograft,36830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7712.13,,,,,,,fee schedule,5508.66,24440.06,APC
Artery-vein nonautograft,36830,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9640.16,,,,,,,fee schedule,5508.66,24440.06,APC
Open thrombect av fistula,36831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9675.33,,,,,,,fee schedule,5508.66,24440.06,
Open thrombect av fistula,36831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7755.62,,,,,,,fee schedule,5508.66,24440.06,
Open thrombect av fistula,36831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8472.31,,,,,,,fee schedule,5508.66,24440.06,
Open thrombect av fistula,36831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8907.44,,,,,,,fee schedule,5508.66,24440.06,
Open thrombect av fistula,36831,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24440.06,,,,,,,fee schedule,5508.66,24440.06,APC 378
Open thrombect av fistula,36831,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5784.09,,,,,,,fee schedule,5508.66,24440.06,APC
Open thrombect av fistula,36831,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5729.01,,,,,,,fee schedule,5508.66,24440.06,APC
Open thrombect av fistula,36831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5508.66,,,,,,,fee schedule,5508.66,24440.06,APC
Open thrombect av fistula,36831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8428.25,,,,,,,fee schedule,5508.66,24440.06,Radiology
Open thrombect av fistula,36831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7712.13,,,,,,,fee schedule,5508.66,24440.06,APC
Open thrombect av fistula,36831,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9640.16,,,,,,,fee schedule,5508.66,24440.06,APC
Av fistula revision open,36832,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9971.29,,,,,,,fee schedule,5508.66,24440.06,
Av fistula revision open,36832,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7992.86,,,,,,,fee schedule,5508.66,24440.06,
Av fistula revision open,36832,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8731.47,,,,,,,fee schedule,5508.66,24440.06,
Av fistula revision open,36832,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9179.92,,,,,,,fee schedule,5508.66,24440.06,
Av fistula revision open,36832,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24440.06,,,,,,,fee schedule,5508.66,24440.06,APC 378
Av fistula revision open,36832,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5784.09,,,,,,,fee schedule,5508.66,24440.06,APC
Av fistula revision open,36832,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5729.01,,,,,,,fee schedule,5508.66,24440.06,APC
Av fistula revision open,36832,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5508.66,,,,,,,fee schedule,5508.66,24440.06,APC
Av fistula revision open,36832,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8428.25,,,,,,,fee schedule,5508.66,24440.06,Radiology
Av fistula revision open,36832,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7712.13,,,,,,,fee schedule,5508.66,24440.06,APC
Av fistula revision open,36832,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9640.16,,,,,,,fee schedule,5508.66,24440.06,APC
Av fistula revision,36833,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9675.33,,,,,,,fee schedule,5508.66,24440.06,
Av fistula revision,36833,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7755.62,,,,,,,fee schedule,5508.66,24440.06,
Av fistula revision,36833,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8472.31,,,,,,,fee schedule,5508.66,24440.06,
Av fistula revision,36833,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8907.44,,,,,,,fee schedule,5508.66,24440.06,
Av fistula revision,36833,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24440.06,,,,,,,fee schedule,5508.66,24440.06,APC 378
Av fistula revision,36833,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5784.09,,,,,,,fee schedule,5508.66,24440.06,APC
Av fistula revision,36833,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5729.01,,,,,,,fee schedule,5508.66,24440.06,APC
Av fistula revision,36833,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5508.66,,,,,,,fee schedule,5508.66,24440.06,APC
Av fistula revision,36833,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8428.25,,,,,,,fee schedule,5508.66,24440.06,Radiology
Av fistula revision,36833,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7712.13,,,,,,,fee schedule,5508.66,24440.06,APC
Av fistula revision,36833,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9640.16,,,,,,,fee schedule,5508.66,24440.06,APC
Artery to vein shunt,36835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7411.52,,,,,,,fee schedule,3125.8,13868.13,
Artery to vein shunt,36835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5940.98,,,,,,,fee schedule,3125.8,13868.13,
Artery to vein shunt,36835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6489.98,,,,,,,fee schedule,3125.8,13868.13,
Artery to vein shunt,36835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6823.31,,,,,,,fee schedule,3125.8,13868.13,
Artery to vein shunt,36835,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Artery to vein shunt,36835,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Artery to vein shunt,36835,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Artery to vein shunt,36835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Artery to vein shunt,36835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Artery to vein shunt,36835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Artery to vein shunt,36835,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Prq av fstl crtj uxtr 1 acs,36836,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,64931.33,,,,,,,fee schedule,18147.73,80515.32,
Prq av fstl crtj uxtr 1 acs,36836,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52048.13,,,,,,,fee schedule,18147.73,80515.32,
Prq av fstl crtj uxtr 1 acs,36836,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56857.86,,,,,,,fee schedule,18147.73,80515.32,
Prq av fstl crtj uxtr 1 acs,36836,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59778.05,,,,,,,fee schedule,18147.73,80515.32,
Prq av fstl crtj uxtr 1 acs,36836,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,80515.32,,,,,,,fee schedule,18147.73,80515.32,APC 378
Prq av fstl crtj uxtr 1 acs,36836,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19055.11,,,,,,,fee schedule,18147.73,80515.32,APC
Prq av fstl crtj uxtr 1 acs,36836,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18873.64,,,,,,,fee schedule,18147.73,80515.32,APC
Prq av fstl crtj uxtr 1 acs,36836,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18147.73,,,,,,,fee schedule,18147.73,80515.32,APC
Prq av fstl crtj uxtr 1 acs,36836,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27766.02,,,,,,,fee schedule,18147.73,80515.32,Radiology
Prq av fstl crtj uxtr 1 acs,36836,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25406.82,,,,,,,fee schedule,18147.73,80515.32,APC
Prq av fstl crtj uxtr 1 acs,36836,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31758.52,,,,,,,fee schedule,18147.73,80515.32,APC
Prq av fstl crt uxtr sep acs,36837,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,64931.33,,,,,,,fee schedule,18147.73,80515.32,
Prq av fstl crt uxtr sep acs,36837,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52048.13,,,,,,,fee schedule,18147.73,80515.32,
Prq av fstl crt uxtr sep acs,36837,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56857.86,,,,,,,fee schedule,18147.73,80515.32,
Prq av fstl crt uxtr sep acs,36837,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59778.05,,,,,,,fee schedule,18147.73,80515.32,
Prq av fstl crt uxtr sep acs,36837,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,80515.32,,,,,,,fee schedule,18147.73,80515.32,APC 378
Prq av fstl crt uxtr sep acs,36837,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19055.11,,,,,,,fee schedule,18147.73,80515.32,APC
Prq av fstl crt uxtr sep acs,36837,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18873.64,,,,,,,fee schedule,18147.73,80515.32,APC
Prq av fstl crt uxtr sep acs,36837,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18147.73,,,,,,,fee schedule,18147.73,80515.32,APC
Prq av fstl crt uxtr sep acs,36837,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27766.02,,,,,,,fee schedule,18147.73,80515.32,Radiology
Prq av fstl crt uxtr sep acs,36837,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25406.82,,,,,,,fee schedule,18147.73,80515.32,APC
Prq av fstl crt uxtr sep acs,36837,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31758.52,,,,,,,fee schedule,18147.73,80515.32,APC
Dist revas ligation hemo,36838,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9675.33,,,,,,,fee schedule,5508.66,24440.06,
Dist revas ligation hemo,36838,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7755.62,,,,,,,fee schedule,5508.66,24440.06,
Dist revas ligation hemo,36838,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8472.31,,,,,,,fee schedule,5508.66,24440.06,
Dist revas ligation hemo,36838,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8907.44,,,,,,,fee schedule,5508.66,24440.06,
Dist revas ligation hemo,36838,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24440.06,,,,,,,fee schedule,5508.66,24440.06,APC 378
Dist revas ligation hemo,36838,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5784.09,,,,,,,fee schedule,5508.66,24440.06,APC
Dist revas ligation hemo,36838,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5729.01,,,,,,,fee schedule,5508.66,24440.06,APC
Dist revas ligation hemo,36838,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5508.66,,,,,,,fee schedule,5508.66,24440.06,APC
Dist revas ligation hemo,36838,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8428.25,,,,,,,fee schedule,5508.66,24440.06,Radiology
Dist revas ligation hemo,36838,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7712.13,,,,,,,fee schedule,5508.66,24440.06,APC
Dist revas ligation hemo,36838,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9640.16,,,,,,,fee schedule,5508.66,24440.06,APC
External cannula declotting,36860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,619.54,,,,,,,fee schedule,496.62,6913.93,
External cannula declotting,36860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,496.62,,,,,,,fee schedule,496.62,6913.93,
External cannula declotting,36860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,542.51,,,,,,,fee schedule,496.62,6913.93,
External cannula declotting,36860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,570.37,,,,,,,fee schedule,496.62,6913.93,
External cannula declotting,36860,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6913.93,,,,,,,fee schedule,496.62,6913.93,APC 378
External cannula declotting,36860,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1636.28,,,,,,,fee schedule,496.62,6913.93,APC
External cannula declotting,36860,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1620.7,,,,,,,fee schedule,496.62,6913.93,APC
External cannula declotting,36860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1558.36,,,,,,,fee schedule,496.62,6913.93,APC
External cannula declotting,36860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2384.29,,,,,,,fee schedule,496.62,6913.93,Radiology
External cannula declotting,36860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2181.71,,,,,,,fee schedule,496.62,6913.93,APC
External cannula declotting,36860,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2727.13,,,,,,,fee schedule,496.62,6913.93,APC
Cannula declotting,36861,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7411.52,,,,,,,fee schedule,5508.66,24440.06,
Cannula declotting,36861,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5940.98,,,,,,,fee schedule,5508.66,24440.06,
Cannula declotting,36861,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6489.98,,,,,,,fee schedule,5508.66,24440.06,
Cannula declotting,36861,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6823.31,,,,,,,fee schedule,5508.66,24440.06,
Cannula declotting,36861,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24440.06,,,,,,,fee schedule,5508.66,24440.06,APC 378
Cannula declotting,36861,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5784.09,,,,,,,fee schedule,5508.66,24440.06,APC
Cannula declotting,36861,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5729.01,,,,,,,fee schedule,5508.66,24440.06,APC
Cannula declotting,36861,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5508.66,,,,,,,fee schedule,5508.66,24440.06,APC
Cannula declotting,36861,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8428.25,,,,,,,fee schedule,5508.66,24440.06,Radiology
Cannula declotting,36861,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7712.13,,,,,,,fee schedule,5508.66,24440.06,APC
Cannula declotting,36861,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9640.16,,,,,,,fee schedule,5508.66,24440.06,APC
Intro cath dialysis circuit,36901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2586.01,,,,,,,fee schedule,1558.36,6913.93,
Intro cath dialysis circuit,36901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2072.91,,,,,,,fee schedule,1558.36,6913.93,
Intro cath dialysis circuit,36901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2264.47,,,,,,,fee schedule,1558.36,6913.93,
Intro cath dialysis circuit,36901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2380.77,,,,,,,fee schedule,1558.36,6913.93,
Intro cath dialysis circuit,36901,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6913.93,,,,,,,fee schedule,1558.36,6913.93,APC 378
Intro cath dialysis circuit,36901,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1636.28,,,,,,,fee schedule,1558.36,6913.93,APC
Intro cath dialysis circuit,36901,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1620.7,,,,,,,fee schedule,1558.36,6913.93,APC
Intro cath dialysis circuit,36901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1558.36,,,,,,,fee schedule,1558.36,6913.93,APC
Intro cath dialysis circuit,36901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2384.29,,,,,,,fee schedule,1558.36,6913.93,Radiology
Intro cath dialysis circuit,36901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2181.71,,,,,,,fee schedule,1558.36,6913.93,APC
Intro cath dialysis circuit,36901,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2727.13,,,,,,,fee schedule,1558.36,6913.93,APC
Intro cath dialysis circuit,36902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10673.46,,,,,,,fee schedule,5634.46,24998.21,
Intro cath dialysis circuit,36902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8555.71,,,,,,,fee schedule,5634.46,24998.21,
Intro cath dialysis circuit,36902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9346.34,,,,,,,fee schedule,5634.46,24998.21,
Intro cath dialysis circuit,36902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9826.36,,,,,,,fee schedule,5634.46,24998.21,
Intro cath dialysis circuit,36902,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24998.21,,,,,,,fee schedule,5634.46,24998.21,APC 378
Intro cath dialysis circuit,36902,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5916.19,,,,,,,fee schedule,5634.46,24998.21,APC
Intro cath dialysis circuit,36902,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5859.84,,,,,,,fee schedule,5634.46,24998.21,APC
Intro cath dialysis circuit,36902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5634.46,,,,,,,fee schedule,5634.46,24998.21,APC
Intro cath dialysis circuit,36902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8620.73,,,,,,,fee schedule,5634.46,24998.21,Radiology
Intro cath dialysis circuit,36902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7888.25,,,,,,,fee schedule,5634.46,24998.21,APC
Intro cath dialysis circuit,36902,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9860.31,,,,,,,fee schedule,5634.46,24998.21,APC
Intro cath dialysis circuit,36903,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,36864.19,,,,,,,fee schedule,11428.37,50703.82,
Intro cath dialysis circuit,36903,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29549.86,,,,,,,fee schedule,11428.37,50703.82,
Intro cath dialysis circuit,36903,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32280.54,,,,,,,fee schedule,11428.37,50703.82,
Intro cath dialysis circuit,36903,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33938.46,,,,,,,fee schedule,11428.37,50703.82,
Intro cath dialysis circuit,36903,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,50703.82,,,,,,,fee schedule,11428.37,50703.82,APC 378
Intro cath dialysis circuit,36903,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11999.79,,,,,,,fee schedule,11428.37,50703.82,APC
Intro cath dialysis circuit,36903,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11885.51,,,,,,,fee schedule,11428.37,50703.82,APC
Intro cath dialysis circuit,36903,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11428.37,,,,,,,fee schedule,11428.37,50703.82,APC
Intro cath dialysis circuit,36903,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17485.41,,,,,,,fee schedule,11428.37,50703.82,Radiology
Intro cath dialysis circuit,36903,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15999.72,,,,,,,fee schedule,11428.37,50703.82,APC
Intro cath dialysis circuit,36903,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19999.65,,,,,,,fee schedule,11428.37,50703.82,APC
Thrmbc/nfs dialysis circuit,36904,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18239.26,,,,,,,fee schedule,5634.46,24998.21,
Thrmbc/nfs dialysis circuit,36904,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14620.36,,,,,,,fee schedule,5634.46,24998.21,
Thrmbc/nfs dialysis circuit,36904,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15971.41,,,,,,,fee schedule,5634.46,24998.21,
Thrmbc/nfs dialysis circuit,36904,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16791.7,,,,,,,fee schedule,5634.46,24998.21,
Thrmbc/nfs dialysis circuit,36904,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24998.21,,,,,,,fee schedule,5634.46,24998.21,APC 378
Thrmbc/nfs dialysis circuit,36904,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5916.19,,,,,,,fee schedule,5634.46,24998.21,APC
Thrmbc/nfs dialysis circuit,36904,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5859.84,,,,,,,fee schedule,5634.46,24998.21,APC
Thrmbc/nfs dialysis circuit,36904,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5634.46,,,,,,,fee schedule,5634.46,24998.21,APC
Thrmbc/nfs dialysis circuit,36904,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8620.73,,,,,,,fee schedule,5634.46,24998.21,Radiology
Thrmbc/nfs dialysis circuit,36904,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7888.25,,,,,,,fee schedule,5634.46,24998.21,APC
Thrmbc/nfs dialysis circuit,36904,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9860.31,,,,,,,fee schedule,5634.46,24998.21,APC
Thrmbc/nfs dialysis circuit,36905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,36864.19,,,,,,,fee schedule,11428.37,50703.82,
Thrmbc/nfs dialysis circuit,36905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29549.86,,,,,,,fee schedule,11428.37,50703.82,
Thrmbc/nfs dialysis circuit,36905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32280.54,,,,,,,fee schedule,11428.37,50703.82,
Thrmbc/nfs dialysis circuit,36905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33938.46,,,,,,,fee schedule,11428.37,50703.82,
Thrmbc/nfs dialysis circuit,36905,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,50703.82,,,,,,,fee schedule,11428.37,50703.82,APC 378
Thrmbc/nfs dialysis circuit,36905,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11999.79,,,,,,,fee schedule,11428.37,50703.82,APC
Thrmbc/nfs dialysis circuit,36905,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11885.51,,,,,,,fee schedule,11428.37,50703.82,APC
Thrmbc/nfs dialysis circuit,36905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11428.37,,,,,,,fee schedule,11428.37,50703.82,APC
Thrmbc/nfs dialysis circuit,36905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17485.41,,,,,,,fee schedule,11428.37,50703.82,Radiology
Thrmbc/nfs dialysis circuit,36905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15999.72,,,,,,,fee schedule,11428.37,50703.82,APC
Thrmbc/nfs dialysis circuit,36905,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19999.65,,,,,,,fee schedule,11428.37,50703.82,APC
Thrmbc/nfs dialysis circuit,36906,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55876.49,,,,,,,fee schedule,18147.73,80515.32,
Thrmbc/nfs dialysis circuit,36906,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,44789.88,,,,,,,fee schedule,18147.73,80515.32,
Thrmbc/nfs dialysis circuit,36906,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48928.88,,,,,,,fee schedule,18147.73,80515.32,
Thrmbc/nfs dialysis circuit,36906,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,51441.85,,,,,,,fee schedule,18147.73,80515.32,
Thrmbc/nfs dialysis circuit,36906,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,80515.32,,,,,,,fee schedule,18147.73,80515.32,APC 378
Thrmbc/nfs dialysis circuit,36906,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19055.11,,,,,,,fee schedule,18147.73,80515.32,APC
Thrmbc/nfs dialysis circuit,36906,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18873.64,,,,,,,fee schedule,18147.73,80515.32,APC
Thrmbc/nfs dialysis circuit,36906,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18147.73,,,,,,,fee schedule,18147.73,80515.32,APC
Thrmbc/nfs dialysis circuit,36906,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27766.02,,,,,,,fee schedule,18147.73,80515.32,Radiology
Thrmbc/nfs dialysis circuit,36906,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25406.82,,,,,,,fee schedule,18147.73,80515.32,APC
Thrmbc/nfs dialysis circuit,36906,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31758.52,,,,,,,fee schedule,18147.73,80515.32,APC
Balo angiop ctr dialysis seg,36907,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,493.26,,,,,,,fee schedule,395.39,493.26,
Balo angiop ctr dialysis seg,36907,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,395.39,,,,,,,fee schedule,395.39,493.26,
Balo angiop ctr dialysis seg,36907,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,431.93,,,,,,,fee schedule,395.39,493.26,
Balo angiop ctr dialysis seg,36907,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,454.11,,,,,,,fee schedule,395.39,493.26,
Stent plmt ctr dialysis seg,36908,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,739.57,,,,,,,fee schedule,592.83,739.57,
Stent plmt ctr dialysis seg,36908,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,592.83,,,,,,,fee schedule,592.83,739.57,
Stent plmt ctr dialysis seg,36908,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,647.61,,,,,,,fee schedule,592.83,739.57,
Stent plmt ctr dialysis seg,36908,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,680.87,,,,,,,fee schedule,592.83,739.57,
Dialysis circuit embolj,36909,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,701.62,,,,,,,fee schedule,562.41,701.62,
Dialysis circuit embolj,36909,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,562.41,,,,,,,fee schedule,562.41,701.62,
Dialysis circuit embolj,36909,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,614.38,,,,,,,fee schedule,562.41,701.62,
Dialysis circuit embolj,36909,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,645.93,,,,,,,fee schedule,562.41,701.62,
Insert hepatic shunt (tips),37182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6693.94,,,,,,,fee schedule,5365.77,80515.32,
Insert hepatic shunt (tips),37182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5365.77,,,,,,,fee schedule,5365.77,80515.32,
Insert hepatic shunt (tips),37182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5861.62,,,,,,,fee schedule,5365.77,80515.32,
Insert hepatic shunt (tips),37182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6162.67,,,,,,,fee schedule,5365.77,80515.32,
Insert hepatic shunt (tips),37182,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,80515.32,,,,,,,fee schedule,5365.77,80515.32,APC 378
Insert hepatic shunt (tips),37182,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19055.11,,,,,,,fee schedule,5365.77,80515.32,APC
Insert hepatic shunt (tips),37182,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18873.64,,,,,,,fee schedule,5365.77,80515.32,APC
Insert hepatic shunt (tips),37182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18147.73,,,,,,,fee schedule,5365.77,80515.32,APC
Insert hepatic shunt (tips),37182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27766.02,,,,,,,fee schedule,5365.77,80515.32,Radiology
Insert hepatic shunt (tips),37182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25406.82,,,,,,,fee schedule,5365.77,80515.32,APC
Insert hepatic shunt (tips),37182,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31758.52,,,,,,,fee schedule,5365.77,80515.32,APC
Remove hepatic shunt (tips),37183,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22096.59,,,,,,,fee schedule,5634.46,24998.21,
Remove hepatic shunt (tips),37183,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17712.35,,,,,,,fee schedule,5634.46,24998.21,
Remove hepatic shunt (tips),37183,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19349.13,,,,,,,fee schedule,5634.46,24998.21,
Remove hepatic shunt (tips),37183,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20342.9,,,,,,,fee schedule,5634.46,24998.21,
Remove hepatic shunt (tips),37183,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24998.21,,,,,,,fee schedule,5634.46,24998.21,APC 378
Remove hepatic shunt (tips),37183,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5916.19,,,,,,,fee schedule,5634.46,24998.21,APC
Remove hepatic shunt (tips),37183,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5859.84,,,,,,,fee schedule,5634.46,24998.21,APC
Remove hepatic shunt (tips),37183,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5634.46,,,,,,,fee schedule,5634.46,24998.21,APC
Remove hepatic shunt (tips),37183,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8620.73,,,,,,,fee schedule,5634.46,24998.21,Radiology
Remove hepatic shunt (tips),37183,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7888.25,,,,,,,fee schedule,5634.46,24998.21,APC
Remove hepatic shunt (tips),37183,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9860.31,,,,,,,fee schedule,5634.46,24998.21,APC
Prim art m-thrmbc 1st vsl,37184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4181.97,,,,,,,fee schedule,3352.21,80515.32,
Prim art m-thrmbc 1st vsl,37184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3352.21,,,,,,,fee schedule,3352.21,80515.32,
Prim art m-thrmbc 1st vsl,37184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3661.99,,,,,,,fee schedule,3352.21,80515.32,
Prim art m-thrmbc 1st vsl,37184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3850.07,,,,,,,fee schedule,3352.21,80515.32,
Prim art m-thrmbc 1st vsl,37184,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,80515.32,,,,,,,fee schedule,3352.21,80515.32,APC 378
Prim art m-thrmbc 1st vsl,37184,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19055.11,,,,,,,fee schedule,3352.21,80515.32,APC
Prim art m-thrmbc 1st vsl,37184,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18873.64,,,,,,,fee schedule,3352.21,80515.32,APC
Prim art m-thrmbc 1st vsl,37184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18147.73,,,,,,,fee schedule,3352.21,80515.32,APC
Prim art m-thrmbc 1st vsl,37184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27766.02,,,,,,,fee schedule,3352.21,80515.32,Radiology
Prim art m-thrmbc 1st vsl,37184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25406.82,,,,,,,fee schedule,3352.21,80515.32,APC
Prim art m-thrmbc 1st vsl,37184,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31758.52,,,,,,,fee schedule,3352.21,80515.32,APC
Prim art m-thrmbc sbsq vsl,37185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9675.33,,,,,,,fee schedule,7755.62,9675.33,
Prim art m-thrmbc sbsq vsl,37185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7755.62,,,,,,,fee schedule,7755.62,9675.33,
Prim art m-thrmbc sbsq vsl,37185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8472.31,,,,,,,fee schedule,7755.62,9675.33,
Prim art m-thrmbc sbsq vsl,37185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8907.44,,,,,,,fee schedule,7755.62,9675.33,
Sec art thrombectomy add-on,37186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9675.33,,,,,,,fee schedule,7755.62,9675.33,
Sec art thrombectomy add-on,37186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7755.62,,,,,,,fee schedule,7755.62,9675.33,
Sec art thrombectomy add-on,37186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8472.31,,,,,,,fee schedule,7755.62,9675.33,
Sec art thrombectomy add-on,37186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8907.44,,,,,,,fee schedule,7755.62,9675.33,
Venous mech thrombectomy,37187,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13860.33,,,,,,,fee schedule,11110.26,50703.82,
Venous mech thrombectomy,37187,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11110.26,,,,,,,fee schedule,11110.26,50703.82,
Venous mech thrombectomy,37187,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12136.95,,,,,,,fee schedule,11110.26,50703.82,
Venous mech thrombectomy,37187,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12760.3,,,,,,,fee schedule,11110.26,50703.82,
Venous mech thrombectomy,37187,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,50703.82,,,,,,,fee schedule,11110.26,50703.82,APC 378
Venous mech thrombectomy,37187,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11999.79,,,,,,,fee schedule,11110.26,50703.82,APC
Venous mech thrombectomy,37187,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11885.51,,,,,,,fee schedule,11110.26,50703.82,APC
Venous mech thrombectomy,37187,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11428.37,,,,,,,fee schedule,11110.26,50703.82,APC
Venous mech thrombectomy,37187,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17485.41,,,,,,,fee schedule,11110.26,50703.82,Radiology
Venous mech thrombectomy,37187,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15999.72,,,,,,,fee schedule,11110.26,50703.82,APC
Venous mech thrombectomy,37187,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19999.65,,,,,,,fee schedule,11110.26,50703.82,APC
Venous m-thrombectomy add-on,37188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3383.92,,,,,,,fee schedule,2712.51,13868.13,
Venous m-thrombectomy add-on,37188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2712.51,,,,,,,fee schedule,2712.51,13868.13,
Venous m-thrombectomy add-on,37188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2963.17,,,,,,,fee schedule,2712.51,13868.13,
Venous m-thrombectomy add-on,37188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3115.36,,,,,,,fee schedule,2712.51,13868.13,
Venous m-thrombectomy add-on,37188,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,2712.51,13868.13,APC 378
Venous m-thrombectomy add-on,37188,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,2712.51,13868.13,APC
Venous m-thrombectomy add-on,37188,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,2712.51,13868.13,APC
Venous m-thrombectomy add-on,37188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,2712.51,13868.13,APC
Venous m-thrombectomy add-on,37188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,2712.51,13868.13,Radiology
Venous m-thrombectomy add-on,37188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,2712.51,13868.13,APC
Venous m-thrombectomy add-on,37188,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,2712.51,13868.13,APC
Ins endovas vena cava filtr,37191,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6499.43,,,,,,,fee schedule,5209.86,24440.06,
Ins endovas vena cava filtr,37191,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5209.86,,,,,,,fee schedule,5209.86,24440.06,
Ins endovas vena cava filtr,37191,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5691.3,,,,,,,fee schedule,5209.86,24440.06,
Ins endovas vena cava filtr,37191,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5983.6,,,,,,,fee schedule,5209.86,24440.06,
Ins endovas vena cava filtr,37191,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24440.06,,,,,,,fee schedule,5209.86,24440.06,APC 378
Ins endovas vena cava filtr,37191,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5784.09,,,,,,,fee schedule,5209.86,24440.06,APC
Ins endovas vena cava filtr,37191,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5729.01,,,,,,,fee schedule,5209.86,24440.06,APC
Ins endovas vena cava filtr,37191,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5508.66,,,,,,,fee schedule,5209.86,24440.06,APC
Ins endovas vena cava filtr,37191,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8428.25,,,,,,,fee schedule,5209.86,24440.06,Radiology
Ins endovas vena cava filtr,37191,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7712.13,,,,,,,fee schedule,5209.86,24440.06,APC
Ins endovas vena cava filtr,37191,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9640.16,,,,,,,fee schedule,5209.86,24440.06,APC
Redo endovas vena cava filtr,37192,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8421.84,,,,,,,fee schedule,3125.8,13868.13,
Redo endovas vena cava filtr,37192,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6750.84,,,,,,,fee schedule,3125.8,13868.13,
Redo endovas vena cava filtr,37192,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7374.68,,,,,,,fee schedule,3125.8,13868.13,
Redo endovas vena cava filtr,37192,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7753.44,,,,,,,fee schedule,3125.8,13868.13,
Redo endovas vena cava filtr,37192,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Redo endovas vena cava filtr,37192,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Redo endovas vena cava filtr,37192,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Redo endovas vena cava filtr,37192,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Redo endovas vena cava filtr,37192,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Redo endovas vena cava filtr,37192,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Redo endovas vena cava filtr,37192,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Rem endovas vena cava filter,37193,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11824.24,,,,,,,fee schedule,3125.8,13868.13,
Rem endovas vena cava filter,37193,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9478.16,,,,,,,fee schedule,3125.8,13868.13,
Rem endovas vena cava filter,37193,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10354.03,,,,,,,fee schedule,3125.8,13868.13,
Rem endovas vena cava filter,37193,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10885.81,,,,,,,fee schedule,3125.8,13868.13,
Rem endovas vena cava filter,37193,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Rem endovas vena cava filter,37193,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Rem endovas vena cava filter,37193,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Rem endovas vena cava filter,37193,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Rem endovas vena cava filter,37193,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Rem endovas vena cava filter,37193,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Rem endovas vena cava filter,37193,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Thrombolytic therapy stroke,37195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,619.54,,,,,,,fee schedule,326.99,1450.75,
Thrombolytic therapy stroke,37195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,496.62,,,,,,,fee schedule,326.99,1450.75,
Thrombolytic therapy stroke,37195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,542.51,,,,,,,fee schedule,326.99,1450.75,
Thrombolytic therapy stroke,37195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,570.37,,,,,,,fee schedule,326.99,1450.75,
Thrombolytic therapy stroke,37195,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1450.75,,,,,,,fee schedule,326.99,1450.75,APC 378
Thrombolytic therapy stroke,37195,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,343.34,,,,,,,fee schedule,326.99,1450.75,APC
Thrombolytic therapy stroke,37195,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,340.07,,,,,,,fee schedule,326.99,1450.75,APC
Thrombolytic therapy stroke,37195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,326.99,,,,,,,fee schedule,326.99,1450.75,APC
Thrombolytic therapy stroke,37195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,500.3,,,,,,,fee schedule,326.99,1450.75,Radiology
Thrombolytic therapy stroke,37195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,457.79,,,,,,,fee schedule,326.99,1450.75,APC
Thrombolytic therapy stroke,37195,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,572.24,,,,,,,fee schedule,326.99,1450.75,APC
Remove intrvas foreign body,37197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8421.84,,,,,,,fee schedule,3125.8,13868.13,
Remove intrvas foreign body,37197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6750.84,,,,,,,fee schedule,3125.8,13868.13,
Remove intrvas foreign body,37197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7374.68,,,,,,,fee schedule,3125.8,13868.13,
Remove intrvas foreign body,37197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7753.44,,,,,,,fee schedule,3125.8,13868.13,
Remove intrvas foreign body,37197,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Remove intrvas foreign body,37197,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Remove intrvas foreign body,37197,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Remove intrvas foreign body,37197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Remove intrvas foreign body,37197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Remove intrvas foreign body,37197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Remove intrvas foreign body,37197,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Transcatheter biopsy,37200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3794.77,,,,,,,fee schedule,3041.84,24440.06,
Transcatheter biopsy,37200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3041.84,,,,,,,fee schedule,3041.84,24440.06,
Transcatheter biopsy,37200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3322.93,,,,,,,fee schedule,3041.84,24440.06,
Transcatheter biopsy,37200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3493.6,,,,,,,fee schedule,3041.84,24440.06,
Transcatheter biopsy,37200,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24440.06,,,,,,,fee schedule,3041.84,24440.06,APC 378
Transcatheter biopsy,37200,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5784.09,,,,,,,fee schedule,3041.84,24440.06,APC
Transcatheter biopsy,37200,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5729.01,,,,,,,fee schedule,3041.84,24440.06,APC
Transcatheter biopsy,37200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5508.66,,,,,,,fee schedule,3041.84,24440.06,APC
Transcatheter biopsy,37200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8428.25,,,,,,,fee schedule,3041.84,24440.06,Radiology
Transcatheter biopsy,37200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7712.13,,,,,,,fee schedule,3041.84,24440.06,APC
Transcatheter biopsy,37200,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9640.16,,,,,,,fee schedule,3041.84,24440.06,APC
Thrombolytic art therapy,37211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2971.38,,,,,,,fee schedule,2381.82,24440.06,
Thrombolytic art therapy,37211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2381.82,,,,,,,fee schedule,2381.82,24440.06,
Thrombolytic art therapy,37211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2601.92,,,,,,,fee schedule,2381.82,24440.06,
Thrombolytic art therapy,37211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2735.56,,,,,,,fee schedule,2381.82,24440.06,
Thrombolytic art therapy,37211,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24440.06,,,,,,,fee schedule,2381.82,24440.06,APC 378
Thrombolytic art therapy,37211,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5784.09,,,,,,,fee schedule,2381.82,24440.06,APC
Thrombolytic art therapy,37211,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5729.01,,,,,,,fee schedule,2381.82,24440.06,APC
Thrombolytic art therapy,37211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5508.66,,,,,,,fee schedule,2381.82,24440.06,APC
Thrombolytic art therapy,37211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8428.25,,,,,,,fee schedule,2381.82,24440.06,Radiology
Thrombolytic art therapy,37211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7712.13,,,,,,,fee schedule,2381.82,24440.06,APC
Thrombolytic art therapy,37211,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9640.16,,,,,,,fee schedule,2381.82,24440.06,APC
Thrombolytic venous therapy,37212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2971.38,,,,,,,fee schedule,2381.82,13868.13,
Thrombolytic venous therapy,37212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2381.82,,,,,,,fee schedule,2381.82,13868.13,
Thrombolytic venous therapy,37212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2601.92,,,,,,,fee schedule,2381.82,13868.13,
Thrombolytic venous therapy,37212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2735.56,,,,,,,fee schedule,2381.82,13868.13,
Thrombolytic venous therapy,37212,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,2381.82,13868.13,APC 378
Thrombolytic venous therapy,37212,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,2381.82,13868.13,APC
Thrombolytic venous therapy,37212,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,2381.82,13868.13,APC
Thrombolytic venous therapy,37212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,2381.82,13868.13,APC
Thrombolytic venous therapy,37212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,2381.82,13868.13,Radiology
Thrombolytic venous therapy,37212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,2381.82,13868.13,APC
Thrombolytic venous therapy,37212,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,2381.82,13868.13,APC
Thromblytic art/ven therapy,37213,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6630.5,,,,,,,fee schedule,3125.8,13868.13,
Thromblytic art/ven therapy,37213,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5314.92,,,,,,,fee schedule,3125.8,13868.13,
Thromblytic art/ven therapy,37213,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5806.07,,,,,,,fee schedule,3125.8,13868.13,
Thromblytic art/ven therapy,37213,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6104.27,,,,,,,fee schedule,3125.8,13868.13,
Thromblytic art/ven therapy,37213,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Thromblytic art/ven therapy,37213,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Thromblytic art/ven therapy,37213,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Thromblytic art/ven therapy,37213,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Thromblytic art/ven therapy,37213,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Thromblytic art/ven therapy,37213,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Thromblytic art/ven therapy,37213,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Cessj therapy cath removal,37214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6630.5,,,,,,,fee schedule,3125.8,13868.13,
Cessj therapy cath removal,37214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5314.92,,,,,,,fee schedule,3125.8,13868.13,
Cessj therapy cath removal,37214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5806.07,,,,,,,fee schedule,3125.8,13868.13,
Cessj therapy cath removal,37214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6104.27,,,,,,,fee schedule,3125.8,13868.13,
Cessj therapy cath removal,37214,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Cessj therapy cath removal,37214,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Cessj therapy cath removal,37214,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Cessj therapy cath removal,37214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Cessj therapy cath removal,37214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Cessj therapy cath removal,37214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Cessj therapy cath removal,37214,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Stent placemt retro carotid,37217,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4474.39,,,,,,,fee schedule,3586.61,4474.39,
Stent placemt retro carotid,37217,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3586.61,,,,,,,fee schedule,3586.61,4474.39,
Stent placemt retro carotid,37217,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3918.05,,,,,,,fee schedule,3586.61,4474.39,
Stent placemt retro carotid,37217,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4119.28,,,,,,,fee schedule,3586.61,4474.39,
Stent placemt ante carotid,37218,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3254.66,,,,,,,fee schedule,2608.89,3254.66,
Stent placemt ante carotid,37218,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2608.89,,,,,,,fee schedule,2608.89,3254.66,
Stent placemt ante carotid,37218,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2849.98,,,,,,,fee schedule,2608.89,3254.66,
Stent placemt ante carotid,37218,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2996.35,,,,,,,fee schedule,2608.89,3254.66,
Iliac revasc,37220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3017.9,,,,,,,fee schedule,2419.11,3017.9,
Iliac revasc,37220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2419.11,,,,,,,fee schedule,2419.11,3017.9,
Iliac revasc,37220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2642.66,,,,,,,fee schedule,2419.11,3017.9,
Iliac revasc,37220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2778.38,,,,,,,fee schedule,2419.11,3017.9,
Iliac revasc w/stent,37221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9477.71,,,,,,,fee schedule,7597.21,9477.71,
Iliac revasc w/stent,37221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7597.21,,,,,,,fee schedule,7597.21,9477.71,
Iliac revasc w/stent,37221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8299.26,,,,,,,fee schedule,7597.21,9477.71,
Iliac revasc w/stent,37221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8725.51,,,,,,,fee schedule,7597.21,9477.71,
Iliac revasc add-on,37222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5804.85,,,,,,,fee schedule,4653.09,5804.85,
Iliac revasc add-on,37222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4653.09,,,,,,,fee schedule,4653.09,5804.85,
Iliac revasc add-on,37222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5083.08,,,,,,,fee schedule,4653.09,5804.85,
Iliac revasc add-on,37222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5344.14,,,,,,,fee schedule,4653.09,5804.85,
Iliac revasc w/stent add-on,37223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8349.68,,,,,,,fee schedule,6693,8349.68,
Iliac revasc w/stent add-on,37223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6693,,,,,,,fee schedule,6693,8349.68,
Iliac revasc w/stent add-on,37223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7311.49,,,,,,,fee schedule,6693,8349.68,
Iliac revasc w/stent add-on,37223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7687.01,,,,,,,fee schedule,6693,8349.68,
Fem/popl revas w/tla,37224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4836.34,,,,,,,fee schedule,3876.75,4836.34,
Fem/popl revas w/tla,37224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3876.75,,,,,,,fee schedule,3876.75,4836.34,
Fem/popl revas w/tla,37224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4234.99,,,,,,,fee schedule,3876.75,4836.34,
Fem/popl revas w/tla,37224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4452.5,,,,,,,fee schedule,3876.75,4836.34,
Fem/popl revas w/ather,37225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12026.88,,,,,,,fee schedule,9640.59,12026.88,
Fem/popl revas w/ather,37225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9640.59,,,,,,,fee schedule,9640.59,12026.88,
Fem/popl revas w/ather,37225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10531.47,,,,,,,fee schedule,9640.59,12026.88,
Fem/popl revas w/ather,37225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11072.36,,,,,,,fee schedule,9640.59,12026.88,
Fem/popl revasc w/stent,37226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11677.96,,,,,,,fee schedule,9360.9,11677.96,
Fem/popl revasc w/stent,37226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9360.9,,,,,,,fee schedule,9360.9,11677.96,
Fem/popl revasc w/stent,37226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10225.94,,,,,,,fee schedule,9360.9,11677.96,
Fem/popl revasc w/stent,37226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10751.14,,,,,,,fee schedule,9360.9,11677.96,
Fem/popl revasc stnt & ather,37227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13014.04,,,,,,,fee schedule,10431.89,13014.04,
Fem/popl revasc stnt & ather,37227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10431.89,,,,,,,fee schedule,10431.89,13014.04,
Fem/popl revasc stnt & ather,37227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11395.89,,,,,,,fee schedule,10431.89,13014.04,
Fem/popl revasc stnt & ather,37227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11981.18,,,,,,,fee schedule,10431.89,13014.04,
Tib/per revasc w/tla,37228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5042.86,,,,,,,fee schedule,4042.29,5042.86,
Tib/per revasc w/tla,37228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4042.29,,,,,,,fee schedule,4042.29,5042.86,
Tib/per revasc w/tla,37228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4415.84,,,,,,,fee schedule,4042.29,5042.86,
Tib/per revasc w/tla,37228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4642.63,,,,,,,fee schedule,4042.29,5042.86,
Tib/per revasc w/ather,37229,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30335.07,,,,,,,fee schedule,24316.2,30335.07,
Tib/per revasc w/ather,37229,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24316.2,,,,,,,fee schedule,24316.2,30335.07,
Tib/per revasc w/ather,37229,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26563.25,,,,,,,fee schedule,24316.2,30335.07,
Tib/per revasc w/ather,37229,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27927.52,,,,,,,fee schedule,24316.2,30335.07,
Tib/per revasc w/stent,37230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21752.19,,,,,,,fee schedule,17436.28,21752.19,
Tib/per revasc w/stent,37230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17436.28,,,,,,,fee schedule,17436.28,21752.19,
Tib/per revasc w/stent,37230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19047.55,,,,,,,fee schedule,17436.28,21752.19,
Tib/per revasc w/stent,37230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20025.82,,,,,,,fee schedule,17436.28,21752.19,
Tib/per revasc stent & ather,37231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,52537.12,,,,,,,fee schedule,42113.09,52537.12,
Tib/per revasc stent & ather,37231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42113.09,,,,,,,fee schedule,42113.09,52537.12,
Tib/per revasc stent & ather,37231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46004.73,,,,,,,fee schedule,42113.09,52537.12,
Tib/per revasc stent & ather,37231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,48367.51,,,,,,,fee schedule,42113.09,52537.12,
Tib/per revasc add-on,37232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2090.98,,,,,,,fee schedule,1676.11,2090.98,
Tib/per revasc add-on,37232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1676.11,,,,,,,fee schedule,1676.11,2090.98,
Tib/per revasc add-on,37232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1830.99,,,,,,,fee schedule,1676.11,2090.98,
Tib/per revasc add-on,37232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1925.03,,,,,,,fee schedule,1676.11,2090.98,
Tibper revasc w/ather add-on,37233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30335.45,,,,,,,fee schedule,24316.51,30335.45,
Tibper revasc w/ather add-on,37233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24316.51,,,,,,,fee schedule,24316.51,30335.45,
Tibper revasc w/ather add-on,37233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26563.58,,,,,,,fee schedule,24316.51,30335.45,
Tibper revasc w/ather add-on,37233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27927.87,,,,,,,fee schedule,24316.51,30335.45,
Revsc opn/prq tib/pero stent,37234,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14289.08,,,,,,,fee schedule,11453.95,14289.08,
Revsc opn/prq tib/pero stent,37234,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11453.95,,,,,,,fee schedule,11453.95,14289.08,
Revsc opn/prq tib/pero stent,37234,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12512.4,,,,,,,fee schedule,11453.95,14289.08,
Revsc opn/prq tib/pero stent,37234,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13155.03,,,,,,,fee schedule,11453.95,14289.08,
Tib/per revasc stnt & ather,37235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14289.08,,,,,,,fee schedule,11453.95,14289.08,
Tib/per revasc stnt & ather,37235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11453.95,,,,,,,fee schedule,11453.95,14289.08,
Tib/per revasc stnt & ather,37235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12512.4,,,,,,,fee schedule,11453.95,14289.08,
Tib/per revasc stnt & ather,37235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13155.03,,,,,,,fee schedule,11453.95,14289.08,
Open/perq place stent 1st,37236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12301.03,,,,,,,fee schedule,9860.35,50703.82,
Open/perq place stent 1st,37236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9860.35,,,,,,,fee schedule,9860.35,50703.82,
Open/perq place stent 1st,37236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10771.53,,,,,,,fee schedule,9860.35,50703.82,
Open/perq place stent 1st,37236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11324.76,,,,,,,fee schedule,9860.35,50703.82,
Open/perq place stent 1st,37236,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,50703.82,,,,,,,fee schedule,9860.35,50703.82,APC 378
Open/perq place stent 1st,37236,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11999.79,,,,,,,fee schedule,9860.35,50703.82,APC
Open/perq place stent 1st,37236,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11885.51,,,,,,,fee schedule,9860.35,50703.82,APC
Open/perq place stent 1st,37236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11428.37,,,,,,,fee schedule,9860.35,50703.82,APC
Open/perq place stent 1st,37236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17485.41,,,,,,,fee schedule,9860.35,50703.82,Radiology
Open/perq place stent 1st,37236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15999.72,,,,,,,fee schedule,9860.35,50703.82,APC
Open/perq place stent 1st,37236,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19999.65,,,,,,,fee schedule,9860.35,50703.82,APC
Open/perq place stent ea add,37237,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,864.07,,,,,,,fee schedule,692.63,864.07,
Open/perq place stent ea add,37237,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,692.63,,,,,,,fee schedule,692.63,864.07,
Open/perq place stent ea add,37237,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,756.63,,,,,,,fee schedule,692.63,864.07,
Open/perq place stent ea add,37237,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,795.49,,,,,,,fee schedule,692.63,864.07,
Open/perq place stent same,37238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12301.03,,,,,,,fee schedule,9860.35,50703.82,
Open/perq place stent same,37238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9860.35,,,,,,,fee schedule,9860.35,50703.82,
Open/perq place stent same,37238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10771.53,,,,,,,fee schedule,9860.35,50703.82,
Open/perq place stent same,37238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11324.76,,,,,,,fee schedule,9860.35,50703.82,
Open/perq place stent same,37238,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,50703.82,,,,,,,fee schedule,9860.35,50703.82,APC 378
Open/perq place stent same,37238,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11999.79,,,,,,,fee schedule,9860.35,50703.82,APC
Open/perq place stent same,37238,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11885.51,,,,,,,fee schedule,9860.35,50703.82,APC
Open/perq place stent same,37238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11428.37,,,,,,,fee schedule,9860.35,50703.82,APC
Open/perq place stent same,37238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17485.41,,,,,,,fee schedule,9860.35,50703.82,Radiology
Open/perq place stent same,37238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15999.72,,,,,,,fee schedule,9860.35,50703.82,APC
Open/perq place stent same,37238,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19999.65,,,,,,,fee schedule,9860.35,50703.82,APC
Open/perq place stent ea add,37239,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,603.67,,,,,,,fee schedule,483.89,603.67,
Open/perq place stent ea add,37239,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,483.89,,,,,,,fee schedule,483.89,603.67,
Open/perq place stent ea add,37239,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,528.61,,,,,,,fee schedule,483.89,603.67,
Open/perq place stent ea add,37239,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,555.76,,,,,,,fee schedule,483.89,603.67,
Vasc embolize/occlude venous,37241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,36393.31,,,,,,,fee schedule,11428.37,50703.82,
Vasc embolize/occlude venous,37241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29172.42,,,,,,,fee schedule,11428.37,50703.82,
Vasc embolize/occlude venous,37241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31868.22,,,,,,,fee schedule,11428.37,50703.82,
Vasc embolize/occlude venous,37241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33504.95,,,,,,,fee schedule,11428.37,50703.82,
Vasc embolize/occlude venous,37241,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,50703.82,,,,,,,fee schedule,11428.37,50703.82,APC 378
Vasc embolize/occlude venous,37241,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11999.79,,,,,,,fee schedule,11428.37,50703.82,APC
Vasc embolize/occlude venous,37241,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11885.51,,,,,,,fee schedule,11428.37,50703.82,APC
Vasc embolize/occlude venous,37241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11428.37,,,,,,,fee schedule,11428.37,50703.82,APC
Vasc embolize/occlude venous,37241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17485.41,,,,,,,fee schedule,11428.37,50703.82,Radiology
Vasc embolize/occlude venous,37241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15999.72,,,,,,,fee schedule,11428.37,50703.82,APC
Vasc embolize/occlude venous,37241,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19999.65,,,,,,,fee schedule,11428.37,50703.82,APC
Vasc embolize/occlude artery,37242,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13120.23,,,,,,,fee schedule,10517.01,80515.32,
Vasc embolize/occlude artery,37242,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10517.01,,,,,,,fee schedule,10517.01,80515.32,
Vasc embolize/occlude artery,37242,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11488.88,,,,,,,fee schedule,10517.01,80515.32,
Vasc embolize/occlude artery,37242,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12078.94,,,,,,,fee schedule,10517.01,80515.32,
Vasc embolize/occlude artery,37242,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,80515.32,,,,,,,fee schedule,10517.01,80515.32,APC 378
Vasc embolize/occlude artery,37242,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19055.11,,,,,,,fee schedule,10517.01,80515.32,APC
Vasc embolize/occlude artery,37242,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18873.64,,,,,,,fee schedule,10517.01,80515.32,APC
Vasc embolize/occlude artery,37242,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18147.73,,,,,,,fee schedule,10517.01,80515.32,APC
Vasc embolize/occlude artery,37242,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27766.02,,,,,,,fee schedule,10517.01,80515.32,Radiology
Vasc embolize/occlude artery,37242,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25406.82,,,,,,,fee schedule,10517.01,80515.32,APC
Vasc embolize/occlude artery,37242,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31758.52,,,,,,,fee schedule,10517.01,80515.32,APC
Vasc embolize/occlude organ,37243,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12324.87,,,,,,,fee schedule,9879.46,50703.82,
Vasc embolize/occlude organ,37243,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9879.46,,,,,,,fee schedule,9879.46,50703.82,
Vasc embolize/occlude organ,37243,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10792.41,,,,,,,fee schedule,9879.46,50703.82,
Vasc embolize/occlude organ,37243,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11346.7,,,,,,,fee schedule,9879.46,50703.82,
Vasc embolize/occlude organ,37243,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,50703.82,,,,,,,fee schedule,9879.46,50703.82,APC 378
Vasc embolize/occlude organ,37243,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11999.79,,,,,,,fee schedule,9879.46,50703.82,APC
Vasc embolize/occlude organ,37243,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11885.51,,,,,,,fee schedule,9879.46,50703.82,APC
Vasc embolize/occlude organ,37243,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11428.37,,,,,,,fee schedule,9879.46,50703.82,APC
Vasc embolize/occlude organ,37243,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17485.41,,,,,,,fee schedule,9879.46,50703.82,Radiology
Vasc embolize/occlude organ,37243,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15999.72,,,,,,,fee schedule,9879.46,50703.82,APC
Vasc embolize/occlude organ,37243,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19999.65,,,,,,,fee schedule,9879.46,50703.82,APC
Vasc embolize/occlude bleed,37244,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,36393.31,,,,,,,fee schedule,11428.37,50703.82,
Vasc embolize/occlude bleed,37244,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29172.42,,,,,,,fee schedule,11428.37,50703.82,
Vasc embolize/occlude bleed,37244,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31868.22,,,,,,,fee schedule,11428.37,50703.82,
Vasc embolize/occlude bleed,37244,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33504.95,,,,,,,fee schedule,11428.37,50703.82,
Vasc embolize/occlude bleed,37244,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,50703.82,,,,,,,fee schedule,11428.37,50703.82,APC 378
Vasc embolize/occlude bleed,37244,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11999.79,,,,,,,fee schedule,11428.37,50703.82,APC
Vasc embolize/occlude bleed,37244,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11885.51,,,,,,,fee schedule,11428.37,50703.82,APC
Vasc embolize/occlude bleed,37244,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11428.37,,,,,,,fee schedule,11428.37,50703.82,APC
Vasc embolize/occlude bleed,37244,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17485.41,,,,,,,fee schedule,11428.37,50703.82,Radiology
Vasc embolize/occlude bleed,37244,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15999.72,,,,,,,fee schedule,11428.37,50703.82,APC
Vasc embolize/occlude bleed,37244,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19999.65,,,,,,,fee schedule,11428.37,50703.82,APC
Trluml balo angiop 1st art,37246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18239.26,,,,,,,fee schedule,5634.46,24998.21,
Trluml balo angiop 1st art,37246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14620.36,,,,,,,fee schedule,5634.46,24998.21,
Trluml balo angiop 1st art,37246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15971.41,,,,,,,fee schedule,5634.46,24998.21,
Trluml balo angiop 1st art,37246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16791.7,,,,,,,fee schedule,5634.46,24998.21,
Trluml balo angiop 1st art,37246,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24998.21,,,,,,,fee schedule,5634.46,24998.21,APC 378
Trluml balo angiop 1st art,37246,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5916.19,,,,,,,fee schedule,5634.46,24998.21,APC
Trluml balo angiop 1st art,37246,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5859.84,,,,,,,fee schedule,5634.46,24998.21,APC
Trluml balo angiop 1st art,37246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5634.46,,,,,,,fee schedule,5634.46,24998.21,APC
Trluml balo angiop 1st art,37246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8620.73,,,,,,,fee schedule,5634.46,24998.21,Radiology
Trluml balo angiop 1st art,37246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7888.25,,,,,,,fee schedule,5634.46,24998.21,APC
Trluml balo angiop 1st art,37246,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9860.31,,,,,,,fee schedule,5634.46,24998.21,APC
Trluml balo angiop addl art,37247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,697.61,,,,,,,fee schedule,559.2,697.61,
Trluml balo angiop addl art,37247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,559.2,,,,,,,fee schedule,559.2,697.61,
Trluml balo angiop addl art,37247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,610.87,,,,,,,fee schedule,559.2,697.61,
Trluml balo angiop addl art,37247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,642.25,,,,,,,fee schedule,559.2,697.61,
Trluml balo angiop 1st vein,37248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3383.92,,,,,,,fee schedule,2712.51,24998.21,
Trluml balo angiop 1st vein,37248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2712.51,,,,,,,fee schedule,2712.51,24998.21,
Trluml balo angiop 1st vein,37248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2963.17,,,,,,,fee schedule,2712.51,24998.21,
Trluml balo angiop 1st vein,37248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3115.36,,,,,,,fee schedule,2712.51,24998.21,
Trluml balo angiop 1st vein,37248,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24998.21,,,,,,,fee schedule,2712.51,24998.21,APC 378
Trluml balo angiop 1st vein,37248,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5916.19,,,,,,,fee schedule,2712.51,24998.21,APC
Trluml balo angiop 1st vein,37248,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5859.84,,,,,,,fee schedule,2712.51,24998.21,APC
Trluml balo angiop 1st vein,37248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5634.46,,,,,,,fee schedule,2712.51,24998.21,APC
Trluml balo angiop 1st vein,37248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8620.73,,,,,,,fee schedule,2712.51,24998.21,Radiology
Trluml balo angiop 1st vein,37248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7888.25,,,,,,,fee schedule,2712.51,24998.21,APC
Trluml balo angiop 1st vein,37248,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9860.31,,,,,,,fee schedule,2712.51,24998.21,APC
Trluml balo angiop addl vein,37249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,593.54,,,,,,,fee schedule,475.78,593.54,
Trluml balo angiop addl vein,37249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,475.78,,,,,,,fee schedule,475.78,593.54,
Trluml balo angiop addl vein,37249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,519.74,,,,,,,fee schedule,475.78,593.54,
Trluml balo angiop addl vein,37249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,546.44,,,,,,,fee schedule,475.78,593.54,
Intrvasc us noncoronary 1st,37252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,368.66,,,,,,,fee schedule,295.52,368.66,
Intrvasc us noncoronary 1st,37252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,295.52,,,,,,,fee schedule,295.52,368.66,
Intrvasc us noncoronary 1st,37252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,322.82,,,,,,,fee schedule,295.52,368.66,
Intrvasc us noncoronary 1st,37252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,339.4,,,,,,,fee schedule,295.52,368.66,
Intrvasc us noncoronary addl,37253,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,295.26,,,,,,,fee schedule,236.67,295.26,
Intrvasc us noncoronary addl,37253,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,236.67,,,,,,,fee schedule,236.67,295.26,
Intrvasc us noncoronary addl,37253,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,258.54,,,,,,,fee schedule,236.67,295.26,
Intrvasc us noncoronary addl,37253,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,271.82,,,,,,,fee schedule,236.67,295.26,
Revsc evasc ivt angio sf 1st,37254,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24998.21,,,,,,,fee schedule,5634.46,24998.21,APC 378
Revsc evasc ivt angio sf 1st,37254,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5916.19,,,,,,,fee schedule,5634.46,24998.21,APC
Revsc evasc ivt angio sf 1st,37254,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5859.84,,,,,,,fee schedule,5634.46,24998.21,APC
Revsc evasc ivt angio sf 1st,37254,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5634.46,,,,,,,fee schedule,5634.46,24998.21,APC
Revsc evasc ivt angio sf 1st,37254,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8620.73,,,,,,,fee schedule,5634.46,24998.21,Radiology
Revsc evasc ivt angio sf 1st,37254,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7888.25,,,,,,,fee schedule,5634.46,24998.21,APC
Revsc evasc ivt angio sf 1st,37254,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9860.31,,,,,,,fee schedule,5634.46,24998.21,APC
Revsc evasc ivt angio cplx 1,37256,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24998.21,,,,,,,fee schedule,5634.46,24998.21,APC 378
Revsc evasc ivt angio cplx 1,37256,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5916.19,,,,,,,fee schedule,5634.46,24998.21,APC
Revsc evasc ivt angio cplx 1,37256,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5859.84,,,,,,,fee schedule,5634.46,24998.21,APC
Revsc evasc ivt angio cplx 1,37256,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5634.46,,,,,,,fee schedule,5634.46,24998.21,APC
Revsc evasc ivt angio cplx 1,37256,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8620.73,,,,,,,fee schedule,5634.46,24998.21,Radiology
Revsc evasc ivt angio cplx 1,37256,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7888.25,,,,,,,fee schedule,5634.46,24998.21,APC
Revsc evasc ivt angio cplx 1,37256,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9860.31,,,,,,,fee schedule,5634.46,24998.21,APC
Revsc evasc ivt stent sf 1st,37258,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,50703.82,,,,,,,fee schedule,11428.37,50703.82,APC 378
Revsc evasc ivt stent sf 1st,37258,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11999.79,,,,,,,fee schedule,11428.37,50703.82,APC
Revsc evasc ivt stent sf 1st,37258,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11885.51,,,,,,,fee schedule,11428.37,50703.82,APC
Revsc evasc ivt stent sf 1st,37258,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11428.37,,,,,,,fee schedule,11428.37,50703.82,APC
Revsc evasc ivt stent sf 1st,37258,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17485.41,,,,,,,fee schedule,11428.37,50703.82,Radiology
Revsc evasc ivt stent sf 1st,37258,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15999.72,,,,,,,fee schedule,11428.37,50703.82,APC
Revsc evasc ivt stent sf 1st,37258,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19999.65,,,,,,,fee schedule,11428.37,50703.82,APC
Revsc evasc ivt st cplx 1st,37260,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,50703.82,,,,,,,fee schedule,11428.37,50703.82,APC 378
Revsc evasc ivt st cplx 1st,37260,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11999.79,,,,,,,fee schedule,11428.37,50703.82,APC
Revsc evasc ivt st cplx 1st,37260,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11885.51,,,,,,,fee schedule,11428.37,50703.82,APC
Revsc evasc ivt st cplx 1st,37260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11428.37,,,,,,,fee schedule,11428.37,50703.82,APC
Revsc evasc ivt st cplx 1st,37260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17485.41,,,,,,,fee schedule,11428.37,50703.82,Radiology
Revsc evasc ivt st cplx 1st,37260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15999.72,,,,,,,fee schedule,11428.37,50703.82,APC
Revsc evasc ivt st cplx 1st,37260,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19999.65,,,,,,,fee schedule,11428.37,50703.82,APC
Revsc evasc fpvt angio sf 1,37263,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24998.21,,,,,,,fee schedule,5634.46,24998.21,APC 378
Revsc evasc fpvt angio sf 1,37263,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5916.19,,,,,,,fee schedule,5634.46,24998.21,APC
Revsc evasc fpvt angio sf 1,37263,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5859.84,,,,,,,fee schedule,5634.46,24998.21,APC
Revsc evasc fpvt angio sf 1,37263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5634.46,,,,,,,fee schedule,5634.46,24998.21,APC
Revsc evasc fpvt angio sf 1,37263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8620.73,,,,,,,fee schedule,5634.46,24998.21,Radiology
Revsc evasc fpvt angio sf 1,37263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7888.25,,,,,,,fee schedule,5634.46,24998.21,APC
Revsc evasc fpvt angio sf 1,37263,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9860.31,,,,,,,fee schedule,5634.46,24998.21,APC
Revsc evsc fpvt angio cplx 1,37265,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24998.21,,,,,,,fee schedule,5634.46,24998.21,APC 378
Revsc evsc fpvt angio cplx 1,37265,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5916.19,,,,,,,fee schedule,5634.46,24998.21,APC
Revsc evsc fpvt angio cplx 1,37265,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5859.84,,,,,,,fee schedule,5634.46,24998.21,APC
Revsc evsc fpvt angio cplx 1,37265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5634.46,,,,,,,fee schedule,5634.46,24998.21,APC
Revsc evsc fpvt angio cplx 1,37265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8620.73,,,,,,,fee schedule,5634.46,24998.21,Radiology
Revsc evsc fpvt angio cplx 1,37265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7888.25,,,,,,,fee schedule,5634.46,24998.21,APC
Revsc evsc fpvt angio cplx 1,37265,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9860.31,,,,,,,fee schedule,5634.46,24998.21,APC
Revsc evsc fpvt stent sf 1st,37267,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,50703.82,,,,,,,fee schedule,11428.37,50703.82,APC 378
Revsc evsc fpvt stent sf 1st,37267,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11999.79,,,,,,,fee schedule,11428.37,50703.82,APC
Revsc evsc fpvt stent sf 1st,37267,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11885.51,,,,,,,fee schedule,11428.37,50703.82,APC
Revsc evsc fpvt stent sf 1st,37267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11428.37,,,,,,,fee schedule,11428.37,50703.82,APC
Revsc evsc fpvt stent sf 1st,37267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17485.41,,,,,,,fee schedule,11428.37,50703.82,Radiology
Revsc evsc fpvt stent sf 1st,37267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15999.72,,,,,,,fee schedule,11428.37,50703.82,APC
Revsc evsc fpvt stent sf 1st,37267,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19999.65,,,,,,,fee schedule,11428.37,50703.82,APC
Revsc evasc fpvt st cplx 1st,37269,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,50703.82,,,,,,,fee schedule,11428.37,50703.82,APC 378
Revsc evasc fpvt st cplx 1st,37269,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11999.79,,,,,,,fee schedule,11428.37,50703.82,APC
Revsc evasc fpvt st cplx 1st,37269,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11885.51,,,,,,,fee schedule,11428.37,50703.82,APC
Revsc evasc fpvt st cplx 1st,37269,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11428.37,,,,,,,fee schedule,11428.37,50703.82,APC
Revsc evasc fpvt st cplx 1st,37269,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17485.41,,,,,,,fee schedule,11428.37,50703.82,Radiology
Revsc evasc fpvt st cplx 1st,37269,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15999.72,,,,,,,fee schedule,11428.37,50703.82,APC
Revsc evasc fpvt st cplx 1st,37269,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19999.65,,,,,,,fee schedule,11428.37,50703.82,APC
Revsc evsc fpvt athrc sf 1st,37271,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,80515.32,,,,,,,fee schedule,18147.73,80515.32,APC 378
Revsc evsc fpvt athrc sf 1st,37271,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19055.11,,,,,,,fee schedule,18147.73,80515.32,APC
Revsc evsc fpvt athrc sf 1st,37271,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18873.64,,,,,,,fee schedule,18147.73,80515.32,APC
Revsc evsc fpvt athrc sf 1st,37271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18147.73,,,,,,,fee schedule,18147.73,80515.32,APC
Revsc evsc fpvt athrc sf 1st,37271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27766.02,,,,,,,fee schedule,18147.73,80515.32,Radiology
Revsc evsc fpvt athrc sf 1st,37271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25406.82,,,,,,,fee schedule,18147.73,80515.32,APC
Revsc evsc fpvt athrc sf 1st,37271,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31758.52,,,,,,,fee schedule,18147.73,80515.32,APC
Revsc evsc fpvt athrc cplx 1,37273,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,80515.32,,,,,,,fee schedule,18147.73,80515.32,APC 378
Revsc evsc fpvt athrc cplx 1,37273,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19055.11,,,,,,,fee schedule,18147.73,80515.32,APC
Revsc evsc fpvt athrc cplx 1,37273,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18873.64,,,,,,,fee schedule,18147.73,80515.32,APC
Revsc evsc fpvt athrc cplx 1,37273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18147.73,,,,,,,fee schedule,18147.73,80515.32,APC
Revsc evsc fpvt athrc cplx 1,37273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27766.02,,,,,,,fee schedule,18147.73,80515.32,Radiology
Revsc evsc fpvt athrc cplx 1,37273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25406.82,,,,,,,fee schedule,18147.73,80515.32,APC
Revsc evsc fpvt athrc cplx 1,37273,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31758.52,,,,,,,fee schedule,18147.73,80515.32,APC
Rvsc evsc fpvt st athrc sf 1,37275,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,80515.32,,,,,,,fee schedule,18147.73,80515.32,APC 378
Rvsc evsc fpvt st athrc sf 1,37275,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19055.11,,,,,,,fee schedule,18147.73,80515.32,APC
Rvsc evsc fpvt st athrc sf 1,37275,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18873.64,,,,,,,fee schedule,18147.73,80515.32,APC
Rvsc evsc fpvt st athrc sf 1,37275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18147.73,,,,,,,fee schedule,18147.73,80515.32,APC
Rvsc evsc fpvt st athrc sf 1,37275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27766.02,,,,,,,fee schedule,18147.73,80515.32,Radiology
Rvsc evsc fpvt st athrc sf 1,37275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25406.82,,,,,,,fee schedule,18147.73,80515.32,APC
Rvsc evsc fpvt st athrc sf 1,37275,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31758.52,,,,,,,fee schedule,18147.73,80515.32,APC
Rvsc evsc fpvt st athr cpx 1,37277,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,80515.32,,,,,,,fee schedule,18147.73,80515.32,APC 378
Rvsc evsc fpvt st athr cpx 1,37277,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19055.11,,,,,,,fee schedule,18147.73,80515.32,APC
Rvsc evsc fpvt st athr cpx 1,37277,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18873.64,,,,,,,fee schedule,18147.73,80515.32,APC
Rvsc evsc fpvt st athr cpx 1,37277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18147.73,,,,,,,fee schedule,18147.73,80515.32,APC
Rvsc evsc fpvt st athr cpx 1,37277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27766.02,,,,,,,fee schedule,18147.73,80515.32,Radiology
Rvsc evsc fpvt st athr cpx 1,37277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25406.82,,,,,,,fee schedule,18147.73,80515.32,APC
Rvsc evsc fpvt st athr cpx 1,37277,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31758.52,,,,,,,fee schedule,18147.73,80515.32,APC
Revsc evsc tpvt angio sf 1st,37280,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,50703.82,,,,,,,fee schedule,11428.37,50703.82,APC 378
Revsc evsc tpvt angio sf 1st,37280,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11999.79,,,,,,,fee schedule,11428.37,50703.82,APC
Revsc evsc tpvt angio sf 1st,37280,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11885.51,,,,,,,fee schedule,11428.37,50703.82,APC
Revsc evsc tpvt angio sf 1st,37280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11428.37,,,,,,,fee schedule,11428.37,50703.82,APC
Revsc evsc tpvt angio sf 1st,37280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17485.41,,,,,,,fee schedule,11428.37,50703.82,Radiology
Revsc evsc tpvt angio sf 1st,37280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15999.72,,,,,,,fee schedule,11428.37,50703.82,APC
Revsc evsc tpvt angio sf 1st,37280,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19999.65,,,,,,,fee schedule,11428.37,50703.82,APC
Rvsc evsc tpvt angio cplx 1,37282,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,50703.82,,,,,,,fee schedule,11428.37,50703.82,APC 378
Rvsc evsc tpvt angio cplx 1,37282,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11999.79,,,,,,,fee schedule,11428.37,50703.82,APC
Rvsc evsc tpvt angio cplx 1,37282,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11885.51,,,,,,,fee schedule,11428.37,50703.82,APC
Rvsc evsc tpvt angio cplx 1,37282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11428.37,,,,,,,fee schedule,11428.37,50703.82,APC
Rvsc evsc tpvt angio cplx 1,37282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17485.41,,,,,,,fee schedule,11428.37,50703.82,Radiology
Rvsc evsc tpvt angio cplx 1,37282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15999.72,,,,,,,fee schedule,11428.37,50703.82,APC
Rvsc evsc tpvt angio cplx 1,37282,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19999.65,,,,,,,fee schedule,11428.37,50703.82,APC
Revsc evasc tpvt st sf 1st,37284,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,80515.32,,,,,,,fee schedule,18147.73,80515.32,APC 378
Revsc evasc tpvt st sf 1st,37284,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19055.11,,,,,,,fee schedule,18147.73,80515.32,APC
Revsc evasc tpvt st sf 1st,37284,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18873.64,,,,,,,fee schedule,18147.73,80515.32,APC
Revsc evasc tpvt st sf 1st,37284,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18147.73,,,,,,,fee schedule,18147.73,80515.32,APC
Revsc evasc tpvt st sf 1st,37284,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27766.02,,,,,,,fee schedule,18147.73,80515.32,Radiology
Revsc evasc tpvt st sf 1st,37284,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25406.82,,,,,,,fee schedule,18147.73,80515.32,APC
Revsc evasc tpvt st sf 1st,37284,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31758.52,,,,,,,fee schedule,18147.73,80515.32,APC
Revsc evasc tpvt st cplx 1st,37286,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,80515.32,,,,,,,fee schedule,18147.73,80515.32,APC 378
Revsc evasc tpvt st cplx 1st,37286,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19055.11,,,,,,,fee schedule,18147.73,80515.32,APC
Revsc evasc tpvt st cplx 1st,37286,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18873.64,,,,,,,fee schedule,18147.73,80515.32,APC
Revsc evasc tpvt st cplx 1st,37286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18147.73,,,,,,,fee schedule,18147.73,80515.32,APC
Revsc evasc tpvt st cplx 1st,37286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27766.02,,,,,,,fee schedule,18147.73,80515.32,Radiology
Revsc evasc tpvt st cplx 1st,37286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25406.82,,,,,,,fee schedule,18147.73,80515.32,APC
Revsc evasc tpvt st cplx 1st,37286,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31758.52,,,,,,,fee schedule,18147.73,80515.32,APC
Revsc evsc tpvt athrc sf 1st,37288,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,80515.32,,,,,,,fee schedule,18147.73,80515.32,APC 378
Revsc evsc tpvt athrc sf 1st,37288,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19055.11,,,,,,,fee schedule,18147.73,80515.32,APC
Revsc evsc tpvt athrc sf 1st,37288,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18873.64,,,,,,,fee schedule,18147.73,80515.32,APC
Revsc evsc tpvt athrc sf 1st,37288,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18147.73,,,,,,,fee schedule,18147.73,80515.32,APC
Revsc evsc tpvt athrc sf 1st,37288,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27766.02,,,,,,,fee schedule,18147.73,80515.32,Radiology
Revsc evsc tpvt athrc sf 1st,37288,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25406.82,,,,,,,fee schedule,18147.73,80515.32,APC
Revsc evsc tpvt athrc sf 1st,37288,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31758.52,,,,,,,fee schedule,18147.73,80515.32,APC
Revsc evsc tpvt athrc cplx 1,37290,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,80515.32,,,,,,,fee schedule,18147.73,80515.32,APC 378
Revsc evsc tpvt athrc cplx 1,37290,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19055.11,,,,,,,fee schedule,18147.73,80515.32,APC
Revsc evsc tpvt athrc cplx 1,37290,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18873.64,,,,,,,fee schedule,18147.73,80515.32,APC
Revsc evsc tpvt athrc cplx 1,37290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18147.73,,,,,,,fee schedule,18147.73,80515.32,APC
Revsc evsc tpvt athrc cplx 1,37290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27766.02,,,,,,,fee schedule,18147.73,80515.32,Radiology
Revsc evsc tpvt athrc cplx 1,37290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25406.82,,,,,,,fee schedule,18147.73,80515.32,APC
Revsc evsc tpvt athrc cplx 1,37290,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31758.52,,,,,,,fee schedule,18147.73,80515.32,APC
Rvsc evsc tpvt st athrc sf 1,37292,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,80515.32,,,,,,,fee schedule,18147.73,80515.32,APC 378
Rvsc evsc tpvt st athrc sf 1,37292,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19055.11,,,,,,,fee schedule,18147.73,80515.32,APC
Rvsc evsc tpvt st athrc sf 1,37292,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18873.64,,,,,,,fee schedule,18147.73,80515.32,APC
Rvsc evsc tpvt st athrc sf 1,37292,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18147.73,,,,,,,fee schedule,18147.73,80515.32,APC
Rvsc evsc tpvt st athrc sf 1,37292,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27766.02,,,,,,,fee schedule,18147.73,80515.32,Radiology
Rvsc evsc tpvt st athrc sf 1,37292,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25406.82,,,,,,,fee schedule,18147.73,80515.32,APC
Rvsc evsc tpvt st athrc sf 1,37292,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31758.52,,,,,,,fee schedule,18147.73,80515.32,APC
Rvsc evsc tpvt st athr cpx 1,37294,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,80515.32,,,,,,,fee schedule,18147.73,80515.32,APC 378
Rvsc evsc tpvt st athr cpx 1,37294,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19055.11,,,,,,,fee schedule,18147.73,80515.32,APC
Rvsc evsc tpvt st athr cpx 1,37294,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18873.64,,,,,,,fee schedule,18147.73,80515.32,APC
Rvsc evsc tpvt st athr cpx 1,37294,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18147.73,,,,,,,fee schedule,18147.73,80515.32,APC
Rvsc evsc tpvt st athr cpx 1,37294,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27766.02,,,,,,,fee schedule,18147.73,80515.32,Radiology
Rvsc evsc tpvt st athr cpx 1,37294,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25406.82,,,,,,,fee schedule,18147.73,80515.32,APC
Rvsc evsc tpvt st athr cpx 1,37294,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31758.52,,,,,,,fee schedule,18147.73,80515.32,APC
Revsc evasc imvt angio sf 1,37296,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,50703.82,,,,,,,fee schedule,11428.37,50703.82,APC 378
Revsc evasc imvt angio sf 1,37296,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11999.79,,,,,,,fee schedule,11428.37,50703.82,APC
Revsc evasc imvt angio sf 1,37296,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11885.51,,,,,,,fee schedule,11428.37,50703.82,APC
Revsc evasc imvt angio sf 1,37296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11428.37,,,,,,,fee schedule,11428.37,50703.82,APC
Revsc evasc imvt angio sf 1,37296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17485.41,,,,,,,fee schedule,11428.37,50703.82,Radiology
Revsc evasc imvt angio sf 1,37296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15999.72,,,,,,,fee schedule,11428.37,50703.82,APC
Revsc evasc imvt angio sf 1,37296,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19999.65,,,,,,,fee schedule,11428.37,50703.82,APC
Revsc evsc imvt angio cplx 1,37298,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,50703.82,,,,,,,fee schedule,11428.37,50703.82,APC 378
Revsc evsc imvt angio cplx 1,37298,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11999.79,,,,,,,fee schedule,11428.37,50703.82,APC
Revsc evsc imvt angio cplx 1,37298,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11885.51,,,,,,,fee schedule,11428.37,50703.82,APC
Revsc evsc imvt angio cplx 1,37298,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11428.37,,,,,,,fee schedule,11428.37,50703.82,APC
Revsc evsc imvt angio cplx 1,37298,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17485.41,,,,,,,fee schedule,11428.37,50703.82,Radiology
Revsc evsc imvt angio cplx 1,37298,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15999.72,,,,,,,fee schedule,11428.37,50703.82,APC
Revsc evsc imvt angio cplx 1,37298,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19999.65,,,,,,,fee schedule,11428.37,50703.82,APC
Endoscopy ligate perf veins,37500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10634.77,,,,,,,fee schedule,8524.69,10634.77,
Endoscopy ligate perf veins,37500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8524.69,,,,,,,fee schedule,8524.69,10634.77,
Endoscopy ligate perf veins,37500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9312.45,,,,,,,fee schedule,8524.69,10634.77,
Endoscopy ligate perf veins,37500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9790.74,,,,,,,fee schedule,8524.69,10634.77,
Vascular endoscopy procedure,37501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6449.28,,,,,,,fee schedule,621.01,6449.28,
Vascular endoscopy procedure,37501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5169.66,,,,,,,fee schedule,621.01,6449.28,
Vascular endoscopy procedure,37501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5647.39,,,,,,,fee schedule,621.01,6449.28,
Vascular endoscopy procedure,37501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5937.44,,,,,,,fee schedule,621.01,6449.28,
Vascular endoscopy procedure,37501,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2755.21,,,,,,,fee schedule,621.01,6449.28,APC 378
Vascular endoscopy procedure,37501,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,652.06,,,,,,,fee schedule,621.01,6449.28,APC
Vascular endoscopy procedure,37501,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,645.85,,,,,,,fee schedule,621.01,6449.28,APC
Vascular endoscopy procedure,37501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,621.01,,,,,,,fee schedule,621.01,6449.28,APC
Vascular endoscopy procedure,37501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,950.14,,,,,,,fee schedule,621.01,6449.28,Radiology
Vascular endoscopy procedure,37501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,869.41,,,,,,,fee schedule,621.01,6449.28,APC
Vascular endoscopy procedure,37501,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1086.77,,,,,,,fee schedule,621.01,6449.28,APC
Ligation of neck vein,37565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7519.55,,,,,,,fee schedule,3125.8,13868.13,
Ligation of neck vein,37565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6027.58,,,,,,,fee schedule,3125.8,13868.13,
Ligation of neck vein,37565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6584.58,,,,,,,fee schedule,3125.8,13868.13,
Ligation of neck vein,37565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6922.76,,,,,,,fee schedule,3125.8,13868.13,
Ligation of neck vein,37565,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Ligation of neck vein,37565,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Ligation of neck vein,37565,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Ligation of neck vein,37565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Ligation of neck vein,37565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Ligation of neck vein,37565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Ligation of neck vein,37565,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Ligation of neck artery,37600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7519.55,,,,,,,fee schedule,3125.8,13868.13,
Ligation of neck artery,37600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6027.58,,,,,,,fee schedule,3125.8,13868.13,
Ligation of neck artery,37600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6584.58,,,,,,,fee schedule,3125.8,13868.13,
Ligation of neck artery,37600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6922.76,,,,,,,fee schedule,3125.8,13868.13,
Ligation of neck artery,37600,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Ligation of neck artery,37600,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Ligation of neck artery,37600,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Ligation of neck artery,37600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Ligation of neck artery,37600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Ligation of neck artery,37600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Ligation of neck artery,37600,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Ligation of neck artery,37605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10634.77,,,,,,,fee schedule,3125.8,13868.13,
Ligation of neck artery,37605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8524.69,,,,,,,fee schedule,3125.8,13868.13,
Ligation of neck artery,37605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9312.45,,,,,,,fee schedule,3125.8,13868.13,
Ligation of neck artery,37605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9790.74,,,,,,,fee schedule,3125.8,13868.13,
Ligation of neck artery,37605,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Ligation of neck artery,37605,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Ligation of neck artery,37605,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Ligation of neck artery,37605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Ligation of neck artery,37605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Ligation of neck artery,37605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Ligation of neck artery,37605,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Ligation of neck artery,37606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6449.28,,,,,,,fee schedule,3125.8,13868.13,
Ligation of neck artery,37606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5169.66,,,,,,,fee schedule,3125.8,13868.13,
Ligation of neck artery,37606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5647.39,,,,,,,fee schedule,3125.8,13868.13,
Ligation of neck artery,37606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5937.44,,,,,,,fee schedule,3125.8,13868.13,
Ligation of neck artery,37606,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Ligation of neck artery,37606,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Ligation of neck artery,37606,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Ligation of neck artery,37606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Ligation of neck artery,37606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Ligation of neck artery,37606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Ligation of neck artery,37606,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Ligation of a-v fistula,37607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6449.28,,,,,,,fee schedule,3125.8,13868.13,
Ligation of a-v fistula,37607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5169.66,,,,,,,fee schedule,3125.8,13868.13,
Ligation of a-v fistula,37607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5647.39,,,,,,,fee schedule,3125.8,13868.13,
Ligation of a-v fistula,37607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5937.44,,,,,,,fee schedule,3125.8,13868.13,
Ligation of a-v fistula,37607,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Ligation of a-v fistula,37607,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Ligation of a-v fistula,37607,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Ligation of a-v fistula,37607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Ligation of a-v fistula,37607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Ligation of a-v fistula,37607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Ligation of a-v fistula,37607,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Temporal artery procedure,37609,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7891.86,,,,,,,fee schedule,1635.03,7891.86,
Temporal artery procedure,37609,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6326.01,,,,,,,fee schedule,1635.03,7891.86,
Temporal artery procedure,37609,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6910.6,,,,,,,fee schedule,1635.03,7891.86,
Temporal artery procedure,37609,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7265.52,,,,,,,fee schedule,1635.03,7891.86,
Temporal artery procedure,37609,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,7891.86,APC 378
Temporal artery procedure,37609,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,7891.86,APC
Temporal artery procedure,37609,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,7891.86,APC
Temporal artery procedure,37609,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,7891.86,APC
Temporal artery procedure,37609,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,7891.86,Radiology
Temporal artery procedure,37609,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,7891.86,APC
Temporal artery procedure,37609,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,7891.86,APC
Ligation of neck artery,37615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6449.28,,,,,,,fee schedule,3125.8,13868.13,
Ligation of neck artery,37615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5169.66,,,,,,,fee schedule,3125.8,13868.13,
Ligation of neck artery,37615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5647.39,,,,,,,fee schedule,3125.8,13868.13,
Ligation of neck artery,37615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5937.44,,,,,,,fee schedule,3125.8,13868.13,
Ligation of neck artery,37615,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Ligation of neck artery,37615,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Ligation of neck artery,37615,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Ligation of neck artery,37615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Ligation of neck artery,37615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Ligation of neck artery,37615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Ligation of neck artery,37615,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Ligation of abdomen artery,37617,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10817.07,,,,,,,fee schedule,5508.66,24440.06,
Ligation of abdomen artery,37617,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8670.83,,,,,,,fee schedule,5508.66,24440.06,
Ligation of abdomen artery,37617,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9472.09,,,,,,,fee schedule,5508.66,24440.06,
Ligation of abdomen artery,37617,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9958.58,,,,,,,fee schedule,5508.66,24440.06,
Ligation of abdomen artery,37617,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24440.06,,,,,,,fee schedule,5508.66,24440.06,APC 378
Ligation of abdomen artery,37617,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5784.09,,,,,,,fee schedule,5508.66,24440.06,APC
Ligation of abdomen artery,37617,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5729.01,,,,,,,fee schedule,5508.66,24440.06,APC
Ligation of abdomen artery,37617,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5508.66,,,,,,,fee schedule,5508.66,24440.06,APC
Ligation of abdomen artery,37617,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8428.25,,,,,,,fee schedule,5508.66,24440.06,Radiology
Ligation of abdomen artery,37617,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7712.13,,,,,,,fee schedule,5508.66,24440.06,APC
Ligation of abdomen artery,37617,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9640.16,,,,,,,fee schedule,5508.66,24440.06,APC
Ligation of inf vena cava,37619,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11433.18,,,,,,,fee schedule,5508.66,24440.06,
Ligation of inf vena cava,37619,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9164.69,,,,,,,fee schedule,5508.66,24440.06,
Ligation of inf vena cava,37619,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10011.59,,,,,,,fee schedule,5508.66,24440.06,
Ligation of inf vena cava,37619,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10525.78,,,,,,,fee schedule,5508.66,24440.06,
Ligation of inf vena cava,37619,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24440.06,,,,,,,fee schedule,5508.66,24440.06,APC 378
Ligation of inf vena cava,37619,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5784.09,,,,,,,fee schedule,5508.66,24440.06,APC
Ligation of inf vena cava,37619,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5729.01,,,,,,,fee schedule,5508.66,24440.06,APC
Ligation of inf vena cava,37619,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5508.66,,,,,,,fee schedule,5508.66,24440.06,APC
Ligation of inf vena cava,37619,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8428.25,,,,,,,fee schedule,5508.66,24440.06,Radiology
Ligation of inf vena cava,37619,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7712.13,,,,,,,fee schedule,5508.66,24440.06,APC
Ligation of inf vena cava,37619,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9640.16,,,,,,,fee schedule,5508.66,24440.06,APC
Revision of major vein,37650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6449.28,,,,,,,fee schedule,3125.8,13868.13,
Revision of major vein,37650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5169.66,,,,,,,fee schedule,3125.8,13868.13,
Revision of major vein,37650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5647.39,,,,,,,fee schedule,3125.8,13868.13,
Revision of major vein,37650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5937.44,,,,,,,fee schedule,3125.8,13868.13,
Revision of major vein,37650,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Revision of major vein,37650,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Revision of major vein,37650,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Revision of major vein,37650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Revision of major vein,37650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Revision of major vein,37650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Revision of major vein,37650,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Revise leg vein,37700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6449.28,,,,,,,fee schedule,3125.8,13868.13,
Revise leg vein,37700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5169.66,,,,,,,fee schedule,3125.8,13868.13,
Revise leg vein,37700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5647.39,,,,,,,fee schedule,3125.8,13868.13,
Revise leg vein,37700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5937.44,,,,,,,fee schedule,3125.8,13868.13,
Revise leg vein,37700,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Revise leg vein,37700,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Revise leg vein,37700,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Revise leg vein,37700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Revise leg vein,37700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Revise leg vein,37700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Revise leg vein,37700,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Ligate/strip short leg vein,37718,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6449.28,,,,,,,fee schedule,3125.8,13868.13,
Ligate/strip short leg vein,37718,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5169.66,,,,,,,fee schedule,3125.8,13868.13,
Ligate/strip short leg vein,37718,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5647.39,,,,,,,fee schedule,3125.8,13868.13,
Ligate/strip short leg vein,37718,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5937.44,,,,,,,fee schedule,3125.8,13868.13,
Ligate/strip short leg vein,37718,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Ligate/strip short leg vein,37718,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Ligate/strip short leg vein,37718,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Ligate/strip short leg vein,37718,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Ligate/strip short leg vein,37718,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Ligate/strip short leg vein,37718,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Ligate/strip short leg vein,37718,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Ligate/strip long leg vein,37722,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10634.77,,,,,,,fee schedule,3125.8,13868.13,
Ligate/strip long leg vein,37722,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8524.69,,,,,,,fee schedule,3125.8,13868.13,
Ligate/strip long leg vein,37722,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9312.45,,,,,,,fee schedule,3125.8,13868.13,
Ligate/strip long leg vein,37722,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9790.74,,,,,,,fee schedule,3125.8,13868.13,
Ligate/strip long leg vein,37722,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Ligate/strip long leg vein,37722,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Ligate/strip long leg vein,37722,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Ligate/strip long leg vein,37722,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Ligate/strip long leg vein,37722,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Ligate/strip long leg vein,37722,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Ligate/strip long leg vein,37722,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Removal of leg veins/lesion,37735,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10634.77,,,,,,,fee schedule,3125.8,13868.13,
Removal of leg veins/lesion,37735,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8524.69,,,,,,,fee schedule,3125.8,13868.13,
Removal of leg veins/lesion,37735,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9312.45,,,,,,,fee schedule,3125.8,13868.13,
Removal of leg veins/lesion,37735,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9790.74,,,,,,,fee schedule,3125.8,13868.13,
Removal of leg veins/lesion,37735,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Removal of leg veins/lesion,37735,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Removal of leg veins/lesion,37735,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Removal of leg veins/lesion,37735,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Removal of leg veins/lesion,37735,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Removal of leg veins/lesion,37735,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Removal of leg veins/lesion,37735,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Ligate leg veins radical,37760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6449.28,,,,,,,fee schedule,3125.8,13868.13,
Ligate leg veins radical,37760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5169.66,,,,,,,fee schedule,3125.8,13868.13,
Ligate leg veins radical,37760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5647.39,,,,,,,fee schedule,3125.8,13868.13,
Ligate leg veins radical,37760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5937.44,,,,,,,fee schedule,3125.8,13868.13,
Ligate leg veins radical,37760,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Ligate leg veins radical,37760,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Ligate leg veins radical,37760,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Ligate leg veins radical,37760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Ligate leg veins radical,37760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Ligate leg veins radical,37760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Ligate leg veins radical,37760,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Ligate leg veins open,37761,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7018.02,,,,,,,fee schedule,3125.8,13868.13,
Ligate leg veins open,37761,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5625.56,,,,,,,fee schedule,3125.8,13868.13,
Ligate leg veins open,37761,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6145.41,,,,,,,fee schedule,3125.8,13868.13,
Ligate leg veins open,37761,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6461.04,,,,,,,fee schedule,3125.8,13868.13,
Ligate leg veins open,37761,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Ligate leg veins open,37761,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Ligate leg veins open,37761,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Ligate leg veins open,37761,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Ligate leg veins open,37761,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Ligate leg veins open,37761,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Ligate leg veins open,37761,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Stab phleb veins xtr 10-20,37765,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4531.07,,,,,,,fee schedule,3125.8,13868.13,
Stab phleb veins xtr 10-20,37765,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3632.05,,,,,,,fee schedule,3125.8,13868.13,
Stab phleb veins xtr 10-20,37765,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3967.69,,,,,,,fee schedule,3125.8,13868.13,
Stab phleb veins xtr 10-20,37765,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4171.46,,,,,,,fee schedule,3125.8,13868.13,
Stab phleb veins xtr 10-20,37765,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Stab phleb veins xtr 10-20,37765,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Stab phleb veins xtr 10-20,37765,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Stab phleb veins xtr 10-20,37765,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Stab phleb veins xtr 10-20,37765,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Stab phleb veins xtr 10-20,37765,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Stab phleb veins xtr 10-20,37765,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Phleb veins - extrem 20+,37766,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8594.03,,,,,,,fee schedule,3125.8,13868.13,
Phleb veins - extrem 20+,37766,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6888.87,,,,,,,fee schedule,3125.8,13868.13,
Phleb veins - extrem 20+,37766,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7525.46,,,,,,,fee schedule,3125.8,13868.13,
Phleb veins - extrem 20+,37766,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7911.97,,,,,,,fee schedule,3125.8,13868.13,
Phleb veins - extrem 20+,37766,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Phleb veins - extrem 20+,37766,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Phleb veins - extrem 20+,37766,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Phleb veins - extrem 20+,37766,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Phleb veins - extrem 20+,37766,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Phleb veins - extrem 20+,37766,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Phleb veins - extrem 20+,37766,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Revision of leg vein,37780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6449.28,,,,,,,fee schedule,3125.8,13868.13,
Revision of leg vein,37780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5169.66,,,,,,,fee schedule,3125.8,13868.13,
Revision of leg vein,37780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5647.39,,,,,,,fee schedule,3125.8,13868.13,
Revision of leg vein,37780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5937.44,,,,,,,fee schedule,3125.8,13868.13,
Revision of leg vein,37780,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Revision of leg vein,37780,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Revision of leg vein,37780,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Revision of leg vein,37780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Revision of leg vein,37780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Revision of leg vein,37780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Revision of leg vein,37780,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Ligate/divide/excise vein,37785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6449.28,,,,,,,fee schedule,3125.8,13868.13,
Ligate/divide/excise vein,37785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5169.66,,,,,,,fee schedule,3125.8,13868.13,
Ligate/divide/excise vein,37785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5647.39,,,,,,,fee schedule,3125.8,13868.13,
Ligate/divide/excise vein,37785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5937.44,,,,,,,fee schedule,3125.8,13868.13,
Ligate/divide/excise vein,37785,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Ligate/divide/excise vein,37785,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Ligate/divide/excise vein,37785,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Ligate/divide/excise vein,37785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Ligate/divide/excise vein,37785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Ligate/divide/excise vein,37785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Ligate/divide/excise vein,37785,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Penile venous occlusion,37790,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8468.26,,,,,,,fee schedule,3489.62,15482.25,
Penile venous occlusion,37790,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6788.05,,,,,,,fee schedule,3489.62,15482.25,
Penile venous occlusion,37790,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7415.33,,,,,,,fee schedule,3489.62,15482.25,
Penile venous occlusion,37790,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7796.17,,,,,,,fee schedule,3489.62,15482.25,
Penile venous occlusion,37790,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Penile venous occlusion,37790,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Penile venous occlusion,37790,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Penile venous occlusion,37790,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Penile venous occlusion,37790,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Penile venous occlusion,37790,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Penile venous occlusion,37790,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Vascular surgery procedure,37799,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3828.9,,,,,,,fee schedule,621.01,3828.9,
Vascular surgery procedure,37799,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3069.2,,,,,,,fee schedule,621.01,3828.9,
Vascular surgery procedure,37799,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3352.82,,,,,,,fee schedule,621.01,3828.9,
Vascular surgery procedure,37799,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3525.02,,,,,,,fee schedule,621.01,3828.9,
Vascular surgery procedure,37799,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2755.21,,,,,,,fee schedule,621.01,3828.9,APC 378
Vascular surgery procedure,37799,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,652.06,,,,,,,fee schedule,621.01,3828.9,APC
Vascular surgery procedure,37799,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,645.85,,,,,,,fee schedule,621.01,3828.9,APC
Vascular surgery procedure,37799,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,621.01,,,,,,,fee schedule,621.01,3828.9,APC
Vascular surgery procedure,37799,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,950.14,,,,,,,fee schedule,621.01,3828.9,Radiology
Vascular surgery procedure,37799,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,869.41,,,,,,,fee schedule,621.01,3828.9,APC
Vascular surgery procedure,37799,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1086.77,,,,,,,fee schedule,621.01,3828.9,APC
Laparoscopy splenectomy,38120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11141.58,,,,,,,fee schedule,8930.95,46687.84,
Laparoscopy splenectomy,38120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8930.95,,,,,,,fee schedule,8930.95,46687.84,
Laparoscopy splenectomy,38120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9756.25,,,,,,,fee schedule,8930.95,46687.84,
Laparoscopy splenectomy,38120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10257.32,,,,,,,fee schedule,8930.95,46687.84,
Laparoscopy splenectomy,38120,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46687.84,,,,,,,fee schedule,8930.95,46687.84,APC 378
Laparoscopy splenectomy,38120,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11049.35,,,,,,,fee schedule,8930.95,46687.84,APC
Laparoscopy splenectomy,38120,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10944.12,,,,,,,fee schedule,8930.95,46687.84,APC
Laparoscopy splenectomy,38120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10523.19,,,,,,,fee schedule,8930.95,46687.84,APC
Laparoscopy splenectomy,38120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16100.48,,,,,,,fee schedule,8930.95,46687.84,Radiology
Laparoscopy splenectomy,38120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14732.47,,,,,,,fee schedule,8930.95,46687.84,APC
Laparoscopy splenectomy,38120,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18415.58,,,,,,,fee schedule,8930.95,46687.84,APC
Laparoscope proc spleen,38129,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8584.34,,,,,,,fee schedule,5984.88,26552.87,
Laparoscope proc spleen,38129,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6881.1,,,,,,,fee schedule,5984.88,26552.87,
Laparoscope proc spleen,38129,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7516.98,,,,,,,fee schedule,5984.88,26552.87,
Laparoscope proc spleen,38129,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7903.05,,,,,,,fee schedule,5984.88,26552.87,
Laparoscope proc spleen,38129,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,5984.88,26552.87,APC 378
Laparoscope proc spleen,38129,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscope proc spleen,38129,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscope proc spleen,38129,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscope proc spleen,38129,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,5984.88,26552.87,Radiology
Laparoscope proc spleen,38129,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscope proc spleen,38129,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,5984.88,26552.87,APC
Harvest allogeneic stem cell,38205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2871.55,,,,,,,fee schedule,2301.8,2871.55,
Harvest allogeneic stem cell,38205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2301.8,,,,,,,fee schedule,2301.8,2871.55,
Harvest allogeneic stem cell,38205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2514.51,,,,,,,fee schedule,2301.8,2871.55,
Harvest allogeneic stem cell,38205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2643.65,,,,,,,fee schedule,2301.8,2871.55,
Harvest auto stem cells,38206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2871.55,,,,,,,fee schedule,1541.8,6840.45,
Harvest auto stem cells,38206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2301.8,,,,,,,fee schedule,1541.8,6840.45,
Harvest auto stem cells,38206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2514.51,,,,,,,fee schedule,1541.8,6840.45,
Harvest auto stem cells,38206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2643.65,,,,,,,fee schedule,1541.8,6840.45,
Harvest auto stem cells,38206,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6840.45,,,,,,,fee schedule,1541.8,6840.45,APC 378
Harvest auto stem cells,38206,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1618.89,,,,,,,fee schedule,1541.8,6840.45,APC
Harvest auto stem cells,38206,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1603.47,,,,,,,fee schedule,1541.8,6840.45,APC
Harvest auto stem cells,38206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1541.8,,,,,,,fee schedule,1541.8,6840.45,APC
Harvest auto stem cells,38206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2358.96,,,,,,,fee schedule,1541.8,6840.45,Radiology
Harvest auto stem cells,38206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2158.52,,,,,,,fee schedule,1541.8,6840.45,APC
Harvest auto stem cells,38206,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2698.15,,,,,,,fee schedule,1541.8,6840.45,APC
Cryopreserve stem cells,38207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2198.62,,,,,,,fee schedule,436.75,2198.62,
Cryopreserve stem cells,38207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1762.39,,,,,,,fee schedule,436.75,2198.62,
Cryopreserve stem cells,38207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1925.25,,,,,,,fee schedule,436.75,2198.62,
Cryopreserve stem cells,38207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2024.13,,,,,,,fee schedule,436.75,2198.62,
Cryopreserve stem cells,38207,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1937.7,,,,,,,fee schedule,436.75,2198.62,APC 378
Cryopreserve stem cells,38207,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,458.59,,,,,,,fee schedule,436.75,2198.62,APC
Cryopreserve stem cells,38207,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,454.22,,,,,,,fee schedule,436.75,2198.62,APC
Cryopreserve stem cells,38207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,436.75,,,,,,,fee schedule,436.75,2198.62,APC
Cryopreserve stem cells,38207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,668.22,,,,,,,fee schedule,436.75,2198.62,Radiology
Cryopreserve stem cells,38207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,611.45,,,,,,,fee schedule,436.75,2198.62,APC
Cryopreserve stem cells,38207,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,764.31,,,,,,,fee schedule,436.75,2198.62,APC
Thaw preserved stem cells,38208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,847.74,,,,,,,fee schedule,436.75,1937.7,
Thaw preserved stem cells,38208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,679.54,,,,,,,fee schedule,436.75,1937.7,
Thaw preserved stem cells,38208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,742.33,,,,,,,fee schedule,436.75,1937.7,
Thaw preserved stem cells,38208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,780.46,,,,,,,fee schedule,436.75,1937.7,
Thaw preserved stem cells,38208,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1937.7,,,,,,,fee schedule,436.75,1937.7,APC 378
Thaw preserved stem cells,38208,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,458.59,,,,,,,fee schedule,436.75,1937.7,APC
Thaw preserved stem cells,38208,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,454.22,,,,,,,fee schedule,436.75,1937.7,APC
Thaw preserved stem cells,38208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,436.75,,,,,,,fee schedule,436.75,1937.7,APC
Thaw preserved stem cells,38208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,668.22,,,,,,,fee schedule,436.75,1937.7,Radiology
Thaw preserved stem cells,38208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,611.45,,,,,,,fee schedule,436.75,1937.7,APC
Thaw preserved stem cells,38208,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,764.31,,,,,,,fee schedule,436.75,1937.7,APC
Wash harvest stem cells,38209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,847.74,,,,,,,fee schedule,436.75,1937.7,
Wash harvest stem cells,38209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,679.54,,,,,,,fee schedule,436.75,1937.7,
Wash harvest stem cells,38209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,742.33,,,,,,,fee schedule,436.75,1937.7,
Wash harvest stem cells,38209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,780.46,,,,,,,fee schedule,436.75,1937.7,
Wash harvest stem cells,38209,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1937.7,,,,,,,fee schedule,436.75,1937.7,APC 378
Wash harvest stem cells,38209,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,458.59,,,,,,,fee schedule,436.75,1937.7,APC
Wash harvest stem cells,38209,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,454.22,,,,,,,fee schedule,436.75,1937.7,APC
Wash harvest stem cells,38209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,436.75,,,,,,,fee schedule,436.75,1937.7,APC
Wash harvest stem cells,38209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,668.22,,,,,,,fee schedule,436.75,1937.7,Radiology
Wash harvest stem cells,38209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,611.45,,,,,,,fee schedule,436.75,1937.7,APC
Wash harvest stem cells,38209,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,764.31,,,,,,,fee schedule,436.75,1937.7,APC
T-cell depletion of harvest,38210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1420.6,,,,,,,fee schedule,436.75,1937.7,
T-cell depletion of harvest,38210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1138.73,,,,,,,fee schedule,436.75,1937.7,
T-cell depletion of harvest,38210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1243.96,,,,,,,fee schedule,436.75,1937.7,
T-cell depletion of harvest,38210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1307.85,,,,,,,fee schedule,436.75,1937.7,
T-cell depletion of harvest,38210,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1937.7,,,,,,,fee schedule,436.75,1937.7,APC 378
T-cell depletion of harvest,38210,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,458.59,,,,,,,fee schedule,436.75,1937.7,APC
T-cell depletion of harvest,38210,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,454.22,,,,,,,fee schedule,436.75,1937.7,APC
T-cell depletion of harvest,38210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,436.75,,,,,,,fee schedule,436.75,1937.7,APC
T-cell depletion of harvest,38210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,668.22,,,,,,,fee schedule,436.75,1937.7,Radiology
T-cell depletion of harvest,38210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,611.45,,,,,,,fee schedule,436.75,1937.7,APC
T-cell depletion of harvest,38210,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,764.31,,,,,,,fee schedule,436.75,1937.7,APC
Tumor cell deplete of harvst,38211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1420.6,,,,,,,fee schedule,436.75,1937.7,
Tumor cell deplete of harvst,38211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1138.73,,,,,,,fee schedule,436.75,1937.7,
Tumor cell deplete of harvst,38211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1243.96,,,,,,,fee schedule,436.75,1937.7,
Tumor cell deplete of harvst,38211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1307.85,,,,,,,fee schedule,436.75,1937.7,
Tumor cell deplete of harvst,38211,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1937.7,,,,,,,fee schedule,436.75,1937.7,APC 378
Tumor cell deplete of harvst,38211,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,458.59,,,,,,,fee schedule,436.75,1937.7,APC
Tumor cell deplete of harvst,38211,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,454.22,,,,,,,fee schedule,436.75,1937.7,APC
Tumor cell deplete of harvst,38211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,436.75,,,,,,,fee schedule,436.75,1937.7,APC
Tumor cell deplete of harvst,38211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,668.22,,,,,,,fee schedule,436.75,1937.7,Radiology
Tumor cell deplete of harvst,38211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,611.45,,,,,,,fee schedule,436.75,1937.7,APC
Tumor cell deplete of harvst,38211,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,764.31,,,,,,,fee schedule,436.75,1937.7,APC
Rbc depletion of harvest,38212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1420.6,,,,,,,fee schedule,436.75,1937.7,
Rbc depletion of harvest,38212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1138.73,,,,,,,fee schedule,436.75,1937.7,
Rbc depletion of harvest,38212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1243.96,,,,,,,fee schedule,436.75,1937.7,
Rbc depletion of harvest,38212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1307.85,,,,,,,fee schedule,436.75,1937.7,
Rbc depletion of harvest,38212,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1937.7,,,,,,,fee schedule,436.75,1937.7,APC 378
Rbc depletion of harvest,38212,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,458.59,,,,,,,fee schedule,436.75,1937.7,APC
Rbc depletion of harvest,38212,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,454.22,,,,,,,fee schedule,436.75,1937.7,APC
Rbc depletion of harvest,38212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,436.75,,,,,,,fee schedule,436.75,1937.7,APC
Rbc depletion of harvest,38212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,668.22,,,,,,,fee schedule,436.75,1937.7,Radiology
Rbc depletion of harvest,38212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,611.45,,,,,,,fee schedule,436.75,1937.7,APC
Rbc depletion of harvest,38212,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,764.31,,,,,,,fee schedule,436.75,1937.7,APC
Platelet deplete of harvest,38213,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1420.6,,,,,,,fee schedule,436.75,1937.7,
Platelet deplete of harvest,38213,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1138.73,,,,,,,fee schedule,436.75,1937.7,
Platelet deplete of harvest,38213,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1243.96,,,,,,,fee schedule,436.75,1937.7,
Platelet deplete of harvest,38213,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1307.85,,,,,,,fee schedule,436.75,1937.7,
Platelet deplete of harvest,38213,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1937.7,,,,,,,fee schedule,436.75,1937.7,APC 378
Platelet deplete of harvest,38213,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,458.59,,,,,,,fee schedule,436.75,1937.7,APC
Platelet deplete of harvest,38213,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,454.22,,,,,,,fee schedule,436.75,1937.7,APC
Platelet deplete of harvest,38213,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,436.75,,,,,,,fee schedule,436.75,1937.7,APC
Platelet deplete of harvest,38213,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,668.22,,,,,,,fee schedule,436.75,1937.7,Radiology
Platelet deplete of harvest,38213,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,611.45,,,,,,,fee schedule,436.75,1937.7,APC
Platelet deplete of harvest,38213,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,764.31,,,,,,,fee schedule,436.75,1937.7,APC
Volume deplete of harvest,38214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1420.6,,,,,,,fee schedule,436.75,1937.7,
Volume deplete of harvest,38214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1138.73,,,,,,,fee schedule,436.75,1937.7,
Volume deplete of harvest,38214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1243.96,,,,,,,fee schedule,436.75,1937.7,
Volume deplete of harvest,38214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1307.85,,,,,,,fee schedule,436.75,1937.7,
Volume deplete of harvest,38214,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1937.7,,,,,,,fee schedule,436.75,1937.7,APC 378
Volume deplete of harvest,38214,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,458.59,,,,,,,fee schedule,436.75,1937.7,APC
Volume deplete of harvest,38214,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,454.22,,,,,,,fee schedule,436.75,1937.7,APC
Volume deplete of harvest,38214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,436.75,,,,,,,fee schedule,436.75,1937.7,APC
Volume deplete of harvest,38214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,668.22,,,,,,,fee schedule,436.75,1937.7,Radiology
Volume deplete of harvest,38214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,611.45,,,,,,,fee schedule,436.75,1937.7,APC
Volume deplete of harvest,38214,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,764.31,,,,,,,fee schedule,436.75,1937.7,APC
Harvest stem cell concentrte,38215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1420.6,,,,,,,fee schedule,436.75,1937.7,
Harvest stem cell concentrte,38215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1138.73,,,,,,,fee schedule,436.75,1937.7,
Harvest stem cell concentrte,38215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1243.96,,,,,,,fee schedule,436.75,1937.7,
Harvest stem cell concentrte,38215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1307.85,,,,,,,fee schedule,436.75,1937.7,
Harvest stem cell concentrte,38215,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1937.7,,,,,,,fee schedule,436.75,1937.7,APC 378
Harvest stem cell concentrte,38215,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,458.59,,,,,,,fee schedule,436.75,1937.7,APC
Harvest stem cell concentrte,38215,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,454.22,,,,,,,fee schedule,436.75,1937.7,APC
Harvest stem cell concentrte,38215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,436.75,,,,,,,fee schedule,436.75,1937.7,APC
Harvest stem cell concentrte,38215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,668.22,,,,,,,fee schedule,436.75,1937.7,Radiology
Harvest stem cell concentrte,38215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,611.45,,,,,,,fee schedule,436.75,1937.7,APC
Harvest stem cell concentrte,38215,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,764.31,,,,,,,fee schedule,436.75,1937.7,APC
Bone marrow aspiration,38220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1411.03,,,,,,,fee schedule,1131.06,7254.06,
Bone marrow aspiration,38220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1131.06,,,,,,,fee schedule,1131.06,7254.06,
Bone marrow aspiration,38220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1235.58,,,,,,,fee schedule,1131.06,7254.06,
Bone marrow aspiration,38220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1299.04,,,,,,,fee schedule,1131.06,7254.06,
Bone marrow aspiration,38220,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1131.06,7254.06,APC 378
Bone marrow aspiration,38220,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1131.06,7254.06,APC
Bone marrow aspiration,38220,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1131.06,7254.06,APC
Bone marrow aspiration,38220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1131.06,7254.06,APC
Bone marrow aspiration,38220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1131.06,7254.06,Radiology
Bone marrow aspiration,38220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1131.06,7254.06,APC
Bone marrow aspiration,38220,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1131.06,7254.06,APC
Bone marrow biopsy,38221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1159.45,,,,,,,fee schedule,929.4,7254.06,
Bone marrow biopsy,38221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,929.4,,,,,,,fee schedule,929.4,7254.06,
Bone marrow biopsy,38221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1015.29,,,,,,,fee schedule,929.4,7254.06,
Bone marrow biopsy,38221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1067.43,,,,,,,fee schedule,929.4,7254.06,
Bone marrow biopsy,38221,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,929.4,7254.06,APC 378
Bone marrow biopsy,38221,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,929.4,7254.06,APC
Bone marrow biopsy,38221,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,929.4,7254.06,APC
Bone marrow biopsy,38221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,929.4,7254.06,APC
Bone marrow biopsy,38221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,929.4,7254.06,Radiology
Bone marrow biopsy,38221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,929.4,7254.06,APC
Bone marrow biopsy,38221,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,929.4,7254.06,APC
Dx bone marrow bx & aspir,38222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5199.39,,,,,,,fee schedule,2875.57,12757.95,
Dx bone marrow bx & aspir,38222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4167.77,,,,,,,fee schedule,2875.57,12757.95,
Dx bone marrow bx & aspir,38222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4552.91,,,,,,,fee schedule,2875.57,12757.95,
Dx bone marrow bx & aspir,38222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4786.74,,,,,,,fee schedule,2875.57,12757.95,
Dx bone marrow bx & aspir,38222,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Dx bone marrow bx & aspir,38222,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Dx bone marrow bx & aspir,38222,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Dx bone marrow bx & aspir,38222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Dx bone marrow bx & aspir,38222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Dx bone marrow bx & aspir,38222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Dx bone marrow bx & aspir,38222,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Car-t admn autologous,38228,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1450.75,,,,,,,fee schedule,326.99,1450.75,APC 378
Car-t admn autologous,38228,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,343.34,,,,,,,fee schedule,326.99,1450.75,APC
Car-t admn autologous,38228,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,340.07,,,,,,,fee schedule,326.99,1450.75,APC
Car-t admn autologous,38228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,326.99,,,,,,,fee schedule,326.99,1450.75,APC
Car-t admn autologous,38228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,500.3,,,,,,,fee schedule,326.99,1450.75,Radiology
Car-t admn autologous,38228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,457.79,,,,,,,fee schedule,326.99,1450.75,APC
Car-t admn autologous,38228,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,572.24,,,,,,,fee schedule,326.99,1450.75,APC
Bone marrow harvest allogen,38230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7637.87,,,,,,,fee schedule,1541.8,7637.87,
Bone marrow harvest allogen,38230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6122.42,,,,,,,fee schedule,1541.8,7637.87,
Bone marrow harvest allogen,38230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6688.19,,,,,,,fee schedule,1541.8,7637.87,
Bone marrow harvest allogen,38230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7031.69,,,,,,,fee schedule,1541.8,7637.87,
Bone marrow harvest allogen,38230,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6840.45,,,,,,,fee schedule,1541.8,7637.87,APC 378
Bone marrow harvest allogen,38230,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1618.89,,,,,,,fee schedule,1541.8,7637.87,APC
Bone marrow harvest allogen,38230,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1603.47,,,,,,,fee schedule,1541.8,7637.87,APC
Bone marrow harvest allogen,38230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1541.8,,,,,,,fee schedule,1541.8,7637.87,APC
Bone marrow harvest allogen,38230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2358.96,,,,,,,fee schedule,1541.8,7637.87,Radiology
Bone marrow harvest allogen,38230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2158.52,,,,,,,fee schedule,1541.8,7637.87,APC
Bone marrow harvest allogen,38230,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2698.15,,,,,,,fee schedule,1541.8,7637.87,APC
Bone marrow harvest autolog,38232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10919.29,,,,,,,fee schedule,4311.81,19130.02,
Bone marrow harvest autolog,38232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8752.76,,,,,,,fee schedule,4311.81,19130.02,
Bone marrow harvest autolog,38232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9561.6,,,,,,,fee schedule,4311.81,19130.02,
Bone marrow harvest autolog,38232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10052.68,,,,,,,fee schedule,4311.81,19130.02,
Bone marrow harvest autolog,38232,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19130.02,,,,,,,fee schedule,4311.81,19130.02,APC 378
Bone marrow harvest autolog,38232,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4527.4,,,,,,,fee schedule,4311.81,19130.02,APC
Bone marrow harvest autolog,38232,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4484.28,,,,,,,fee schedule,4311.81,19130.02,APC
Bone marrow harvest autolog,38232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4311.81,,,,,,,fee schedule,4311.81,19130.02,APC
Bone marrow harvest autolog,38232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6597.06,,,,,,,fee schedule,4311.81,19130.02,Radiology
Bone marrow harvest autolog,38232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6036.53,,,,,,,fee schedule,4311.81,19130.02,APC
Bone marrow harvest autolog,38232,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7545.66,,,,,,,fee schedule,4311.81,19130.02,APC
Transplt allo hct/donor,38240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7637.87,,,,,,,fee schedule,6122.42,276271.21,
Transplt allo hct/donor,38240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6122.42,,,,,,,fee schedule,6122.42,276271.21,
Transplt allo hct/donor,38240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6688.19,,,,,,,fee schedule,6122.42,276271.21,
Transplt allo hct/donor,38240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7031.69,,,,,,,fee schedule,6122.42,276271.21,
Transplt allo hct/donor,38240,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,276271.21,,,,,,,fee schedule,6122.42,276271.21,APC 378
Transplt allo hct/donor,38240,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,65383.57,,,,,,,fee schedule,6122.42,276271.21,APC
Transplt allo hct/donor,38240,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,64760.87,,,,,,,fee schedule,6122.42,276271.21,APC
Transplt allo hct/donor,38240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,62270.07,,,,,,,fee schedule,6122.42,276271.21,APC
Transplt allo hct/donor,38240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,95273.2,,,,,,,fee schedule,6122.42,276271.21,Radiology
Transplt allo hct/donor,38240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,87178.09,,,,,,,fee schedule,6122.42,276271.21,APC
Transplt allo hct/donor,38240,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,108972.61,,,,,,,fee schedule,6122.42,276271.21,APC
Transplt autol hct/donor,38241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7637.87,,,,,,,fee schedule,1541.8,7637.87,
Transplt autol hct/donor,38241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6122.42,,,,,,,fee schedule,1541.8,7637.87,
Transplt autol hct/donor,38241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6688.19,,,,,,,fee schedule,1541.8,7637.87,
Transplt autol hct/donor,38241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7031.69,,,,,,,fee schedule,1541.8,7637.87,
Transplt autol hct/donor,38241,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6840.45,,,,,,,fee schedule,1541.8,7637.87,APC 378
Transplt autol hct/donor,38241,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1618.89,,,,,,,fee schedule,1541.8,7637.87,APC
Transplt autol hct/donor,38241,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1603.47,,,,,,,fee schedule,1541.8,7637.87,APC
Transplt autol hct/donor,38241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1541.8,,,,,,,fee schedule,1541.8,7637.87,APC
Transplt autol hct/donor,38241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2358.96,,,,,,,fee schedule,1541.8,7637.87,Radiology
Transplt autol hct/donor,38241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2158.52,,,,,,,fee schedule,1541.8,7637.87,APC
Transplt autol hct/donor,38241,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2698.15,,,,,,,fee schedule,1541.8,7637.87,APC
Transplt allo lymphocytes,38242,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2871.55,,,,,,,fee schedule,1541.8,6840.45,
Transplt allo lymphocytes,38242,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2301.8,,,,,,,fee schedule,1541.8,6840.45,
Transplt allo lymphocytes,38242,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2514.51,,,,,,,fee schedule,1541.8,6840.45,
Transplt allo lymphocytes,38242,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2643.65,,,,,,,fee schedule,1541.8,6840.45,
Transplt allo lymphocytes,38242,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6840.45,,,,,,,fee schedule,1541.8,6840.45,APC 378
Transplt allo lymphocytes,38242,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1618.89,,,,,,,fee schedule,1541.8,6840.45,APC
Transplt allo lymphocytes,38242,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1603.47,,,,,,,fee schedule,1541.8,6840.45,APC
Transplt allo lymphocytes,38242,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1541.8,,,,,,,fee schedule,1541.8,6840.45,APC
Transplt allo lymphocytes,38242,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2358.96,,,,,,,fee schedule,1541.8,6840.45,Radiology
Transplt allo lymphocytes,38242,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2158.52,,,,,,,fee schedule,1541.8,6840.45,APC
Transplt allo lymphocytes,38242,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2698.15,,,,,,,fee schedule,1541.8,6840.45,APC
Transplj hematopoietic boost,38243,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3593.46,,,,,,,fee schedule,1541.8,6840.45,
Transplj hematopoietic boost,38243,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2880.47,,,,,,,fee schedule,1541.8,6840.45,
Transplj hematopoietic boost,38243,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3146.65,,,,,,,fee schedule,1541.8,6840.45,
Transplj hematopoietic boost,38243,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3308.26,,,,,,,fee schedule,1541.8,6840.45,
Transplj hematopoietic boost,38243,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6840.45,,,,,,,fee schedule,1541.8,6840.45,APC 378
Transplj hematopoietic boost,38243,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1618.89,,,,,,,fee schedule,1541.8,6840.45,APC
Transplj hematopoietic boost,38243,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1603.47,,,,,,,fee schedule,1541.8,6840.45,APC
Transplj hematopoietic boost,38243,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1541.8,,,,,,,fee schedule,1541.8,6840.45,APC
Transplj hematopoietic boost,38243,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2358.96,,,,,,,fee schedule,1541.8,6840.45,Radiology
Transplj hematopoietic boost,38243,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2158.52,,,,,,,fee schedule,1541.8,6840.45,APC
Transplj hematopoietic boost,38243,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2698.15,,,,,,,fee schedule,1541.8,6840.45,APC
Drainage lymph node lesion,38300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2884.93,,,,,,,fee schedule,2312.53,12757.95,
Drainage lymph node lesion,38300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2312.53,,,,,,,fee schedule,2312.53,12757.95,
Drainage lymph node lesion,38300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2526.23,,,,,,,fee schedule,2312.53,12757.95,
Drainage lymph node lesion,38300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2655.97,,,,,,,fee schedule,2312.53,12757.95,
Drainage lymph node lesion,38300,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2312.53,12757.95,APC 378
Drainage lymph node lesion,38300,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2312.53,12757.95,APC
Drainage lymph node lesion,38300,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2312.53,12757.95,APC
Drainage lymph node lesion,38300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2312.53,12757.95,APC
Drainage lymph node lesion,38300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2312.53,12757.95,Radiology
Drainage lymph node lesion,38300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2312.53,12757.95,APC
Drainage lymph node lesion,38300,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2312.53,12757.95,APC
Drainage lymph node lesion,38305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4572.14,,,,,,,fee schedule,2875.57,12757.95,
Drainage lymph node lesion,38305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3664.97,,,,,,,fee schedule,2875.57,12757.95,
Drainage lymph node lesion,38305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4003.64,,,,,,,fee schedule,2875.57,12757.95,
Drainage lymph node lesion,38305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4209.27,,,,,,,fee schedule,2875.57,12757.95,
Drainage lymph node lesion,38305,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Drainage lymph node lesion,38305,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Drainage lymph node lesion,38305,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Drainage lymph node lesion,38305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Drainage lymph node lesion,38305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Drainage lymph node lesion,38305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Drainage lymph node lesion,38305,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Incision of lymph channels,38308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5729.84,,,,,,,fee schedule,3876.15,17197.18,
Incision of lymph channels,38308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4592.96,,,,,,,fee schedule,3876.15,17197.18,
Incision of lymph channels,38308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5017.4,,,,,,,fee schedule,3876.15,17197.18,
Incision of lymph channels,38308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5275.09,,,,,,,fee schedule,3876.15,17197.18,
Incision of lymph channels,38308,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17197.18,,,,,,,fee schedule,3876.15,17197.18,APC 378
Incision of lymph channels,38308,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4069.96,,,,,,,fee schedule,3876.15,17197.18,APC
Incision of lymph channels,38308,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4031.2,,,,,,,fee schedule,3876.15,17197.18,APC
Incision of lymph channels,38308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3876.15,,,,,,,fee schedule,3876.15,17197.18,APC
Incision of lymph channels,38308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5930.51,,,,,,,fee schedule,3876.15,17197.18,Radiology
Incision of lymph channels,38308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5426.61,,,,,,,fee schedule,3876.15,17197.18,APC
Incision of lymph channels,38308,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6783.27,,,,,,,fee schedule,3876.15,17197.18,APC
Biopsy/removal lymph nodes,38500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5272.52,,,,,,,fee schedule,3876.15,17197.18,
Biopsy/removal lymph nodes,38500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4226.38,,,,,,,fee schedule,3876.15,17197.18,
Biopsy/removal lymph nodes,38500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4616.94,,,,,,,fee schedule,3876.15,17197.18,
Biopsy/removal lymph nodes,38500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4854.06,,,,,,,fee schedule,3876.15,17197.18,
Biopsy/removal lymph nodes,38500,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17197.18,,,,,,,fee schedule,3876.15,17197.18,APC 378
Biopsy/removal lymph nodes,38500,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4069.96,,,,,,,fee schedule,3876.15,17197.18,APC
Biopsy/removal lymph nodes,38500,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4031.2,,,,,,,fee schedule,3876.15,17197.18,APC
Biopsy/removal lymph nodes,38500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3876.15,,,,,,,fee schedule,3876.15,17197.18,APC
Biopsy/removal lymph nodes,38500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5930.51,,,,,,,fee schedule,3876.15,17197.18,Radiology
Biopsy/removal lymph nodes,38500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5426.61,,,,,,,fee schedule,3876.15,17197.18,APC
Biopsy/removal lymph nodes,38500,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6783.27,,,,,,,fee schedule,3876.15,17197.18,APC
Needle biopsy lymph nodes,38505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1476.95,,,,,,,fee schedule,1183.9,7254.06,
Needle biopsy lymph nodes,38505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1183.9,,,,,,,fee schedule,1183.9,7254.06,
Needle biopsy lymph nodes,38505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1293.31,,,,,,,fee schedule,1183.9,7254.06,
Needle biopsy lymph nodes,38505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1359.73,,,,,,,fee schedule,1183.9,7254.06,
Needle biopsy lymph nodes,38505,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1183.9,7254.06,APC 378
Needle biopsy lymph nodes,38505,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1183.9,7254.06,APC
Needle biopsy lymph nodes,38505,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1183.9,7254.06,APC
Needle biopsy lymph nodes,38505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1183.9,7254.06,APC
Needle biopsy lymph nodes,38505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1183.9,7254.06,Radiology
Needle biopsy lymph nodes,38505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1183.9,7254.06,APC
Needle biopsy lymph nodes,38505,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1183.9,7254.06,APC
Biopsy/removal lymph nodes,38510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5451.77,,,,,,,fee schedule,3876.15,17197.18,
Biopsy/removal lymph nodes,38510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4370.07,,,,,,,fee schedule,3876.15,17197.18,
Biopsy/removal lymph nodes,38510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4773.91,,,,,,,fee schedule,3876.15,17197.18,
Biopsy/removal lymph nodes,38510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5019.09,,,,,,,fee schedule,3876.15,17197.18,
Biopsy/removal lymph nodes,38510,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17197.18,,,,,,,fee schedule,3876.15,17197.18,APC 378
Biopsy/removal lymph nodes,38510,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4069.96,,,,,,,fee schedule,3876.15,17197.18,APC
Biopsy/removal lymph nodes,38510,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4031.2,,,,,,,fee schedule,3876.15,17197.18,APC
Biopsy/removal lymph nodes,38510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3876.15,,,,,,,fee schedule,3876.15,17197.18,APC
Biopsy/removal lymph nodes,38510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5930.51,,,,,,,fee schedule,3876.15,17197.18,Radiology
Biopsy/removal lymph nodes,38510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5426.61,,,,,,,fee schedule,3876.15,17197.18,APC
Biopsy/removal lymph nodes,38510,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6783.27,,,,,,,fee schedule,3876.15,17197.18,APC
Biopsy/removal lymph nodes,38520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5729.84,,,,,,,fee schedule,3876.15,17197.18,
Biopsy/removal lymph nodes,38520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4592.96,,,,,,,fee schedule,3876.15,17197.18,
Biopsy/removal lymph nodes,38520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5017.4,,,,,,,fee schedule,3876.15,17197.18,
Biopsy/removal lymph nodes,38520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5275.09,,,,,,,fee schedule,3876.15,17197.18,
Biopsy/removal lymph nodes,38520,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17197.18,,,,,,,fee schedule,3876.15,17197.18,APC 378
Biopsy/removal lymph nodes,38520,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4069.96,,,,,,,fee schedule,3876.15,17197.18,APC
Biopsy/removal lymph nodes,38520,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4031.2,,,,,,,fee schedule,3876.15,17197.18,APC
Biopsy/removal lymph nodes,38520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3876.15,,,,,,,fee schedule,3876.15,17197.18,APC
Biopsy/removal lymph nodes,38520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5930.51,,,,,,,fee schedule,3876.15,17197.18,Radiology
Biopsy/removal lymph nodes,38520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5426.61,,,,,,,fee schedule,3876.15,17197.18,APC
Biopsy/removal lymph nodes,38520,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6783.27,,,,,,,fee schedule,3876.15,17197.18,APC
Biopsy/removal lymph nodes,38525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3871.59,,,,,,,fee schedule,3103.42,17197.18,
Biopsy/removal lymph nodes,38525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3103.42,,,,,,,fee schedule,3103.42,17197.18,
Biopsy/removal lymph nodes,38525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3390.2,,,,,,,fee schedule,3103.42,17197.18,
Biopsy/removal lymph nodes,38525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3564.32,,,,,,,fee schedule,3103.42,17197.18,
Biopsy/removal lymph nodes,38525,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17197.18,,,,,,,fee schedule,3103.42,17197.18,APC 378
Biopsy/removal lymph nodes,38525,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4069.96,,,,,,,fee schedule,3103.42,17197.18,APC
Biopsy/removal lymph nodes,38525,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4031.2,,,,,,,fee schedule,3103.42,17197.18,APC
Biopsy/removal lymph nodes,38525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3876.15,,,,,,,fee schedule,3103.42,17197.18,APC
Biopsy/removal lymph nodes,38525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5930.51,,,,,,,fee schedule,3103.42,17197.18,Radiology
Biopsy/removal lymph nodes,38525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5426.61,,,,,,,fee schedule,3103.42,17197.18,APC
Biopsy/removal lymph nodes,38525,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6783.27,,,,,,,fee schedule,3103.42,17197.18,APC
Biopsy/removal lymph nodes,38530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5110.44,,,,,,,fee schedule,3876.15,17197.18,
Biopsy/removal lymph nodes,38530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4096.46,,,,,,,fee schedule,3876.15,17197.18,
Biopsy/removal lymph nodes,38530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4475.01,,,,,,,fee schedule,3876.15,17197.18,
Biopsy/removal lymph nodes,38530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4704.85,,,,,,,fee schedule,3876.15,17197.18,
Biopsy/removal lymph nodes,38530,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17197.18,,,,,,,fee schedule,3876.15,17197.18,APC 378
Biopsy/removal lymph nodes,38530,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4069.96,,,,,,,fee schedule,3876.15,17197.18,APC
Biopsy/removal lymph nodes,38530,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4031.2,,,,,,,fee schedule,3876.15,17197.18,APC
Biopsy/removal lymph nodes,38530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3876.15,,,,,,,fee schedule,3876.15,17197.18,APC
Biopsy/removal lymph nodes,38530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5930.51,,,,,,,fee schedule,3876.15,17197.18,Radiology
Biopsy/removal lymph nodes,38530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5426.61,,,,,,,fee schedule,3876.15,17197.18,APC
Biopsy/removal lymph nodes,38530,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6783.27,,,,,,,fee schedule,3876.15,17197.18,APC
Open bx/exc inguinofem nodes,38531,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10644.52,,,,,,,fee schedule,3876.15,17197.18,
Open bx/exc inguinofem nodes,38531,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8532.51,,,,,,,fee schedule,3876.15,17197.18,
Open bx/exc inguinofem nodes,38531,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9320.99,,,,,,,fee schedule,3876.15,17197.18,
Open bx/exc inguinofem nodes,38531,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9799.71,,,,,,,fee schedule,3876.15,17197.18,
Open bx/exc inguinofem nodes,38531,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17197.18,,,,,,,fee schedule,3876.15,17197.18,APC 378
Open bx/exc inguinofem nodes,38531,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4069.96,,,,,,,fee schedule,3876.15,17197.18,APC
Open bx/exc inguinofem nodes,38531,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4031.2,,,,,,,fee schedule,3876.15,17197.18,APC
Open bx/exc inguinofem nodes,38531,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3876.15,,,,,,,fee schedule,3876.15,17197.18,APC
Open bx/exc inguinofem nodes,38531,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5930.51,,,,,,,fee schedule,3876.15,17197.18,Radiology
Open bx/exc inguinofem nodes,38531,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5426.61,,,,,,,fee schedule,3876.15,17197.18,APC
Open bx/exc inguinofem nodes,38531,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6783.27,,,,,,,fee schedule,3876.15,17197.18,APC
Explore deep node(s) neck,38542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11062.17,,,,,,,fee schedule,5984.88,26552.87,
Explore deep node(s) neck,38542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8867.3,,,,,,,fee schedule,5984.88,26552.87,
Explore deep node(s) neck,38542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9686.72,,,,,,,fee schedule,5984.88,26552.87,
Explore deep node(s) neck,38542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10184.22,,,,,,,fee schedule,5984.88,26552.87,
Explore deep node(s) neck,38542,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,5984.88,26552.87,APC 378
Explore deep node(s) neck,38542,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,5984.88,26552.87,APC
Explore deep node(s) neck,38542,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,5984.88,26552.87,APC
Explore deep node(s) neck,38542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,5984.88,26552.87,APC
Explore deep node(s) neck,38542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,5984.88,26552.87,Radiology
Explore deep node(s) neck,38542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,5984.88,26552.87,APC
Explore deep node(s) neck,38542,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,5984.88,26552.87,APC
Removal neck/armpit lesion,38550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5729.84,,,,,,,fee schedule,3876.15,17197.18,
Removal neck/armpit lesion,38550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4592.96,,,,,,,fee schedule,3876.15,17197.18,
Removal neck/armpit lesion,38550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5017.4,,,,,,,fee schedule,3876.15,17197.18,
Removal neck/armpit lesion,38550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5275.09,,,,,,,fee schedule,3876.15,17197.18,
Removal neck/armpit lesion,38550,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17197.18,,,,,,,fee schedule,3876.15,17197.18,APC 378
Removal neck/armpit lesion,38550,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4069.96,,,,,,,fee schedule,3876.15,17197.18,APC
Removal neck/armpit lesion,38550,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4031.2,,,,,,,fee schedule,3876.15,17197.18,APC
Removal neck/armpit lesion,38550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3876.15,,,,,,,fee schedule,3876.15,17197.18,APC
Removal neck/armpit lesion,38550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5930.51,,,,,,,fee schedule,3876.15,17197.18,Radiology
Removal neck/armpit lesion,38550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5426.61,,,,,,,fee schedule,3876.15,17197.18,APC
Removal neck/armpit lesion,38550,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6783.27,,,,,,,fee schedule,3876.15,17197.18,APC
Removal neck/armpit lesion,38555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5729.84,,,,,,,fee schedule,4592.96,29164.62,
Removal neck/armpit lesion,38555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4592.96,,,,,,,fee schedule,4592.96,29164.62,
Removal neck/armpit lesion,38555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5017.4,,,,,,,fee schedule,4592.96,29164.62,
Removal neck/armpit lesion,38555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5275.09,,,,,,,fee schedule,4592.96,29164.62,
Removal neck/armpit lesion,38555,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,29164.62,,,,,,,fee schedule,4592.96,29164.62,APC 378
Removal neck/armpit lesion,38555,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6902.23,,,,,,,fee schedule,4592.96,29164.62,APC
Removal neck/armpit lesion,38555,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6836.49,,,,,,,fee schedule,4592.96,29164.62,APC
Removal neck/armpit lesion,38555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6573.55,,,,,,,fee schedule,4592.96,29164.62,APC
Removal neck/armpit lesion,38555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10057.53,,,,,,,fee schedule,4592.96,29164.62,Radiology
Removal neck/armpit lesion,38555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9202.97,,,,,,,fee schedule,4592.96,29164.62,APC
Removal neck/armpit lesion,38555,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11503.71,,,,,,,fee schedule,4592.96,29164.62,APC
Removal pelvic lymph nodes,38562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33670.95,,,,,,,fee schedule,8091.39,35898.76,
Removal pelvic lymph nodes,38562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26990.21,,,,,,,fee schedule,8091.39,35898.76,
Removal pelvic lymph nodes,38562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29484.35,,,,,,,fee schedule,8091.39,35898.76,
Removal pelvic lymph nodes,38562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30998.66,,,,,,,fee schedule,8091.39,35898.76,
Removal pelvic lymph nodes,38562,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,35898.76,,,,,,,fee schedule,8091.39,35898.76,APC 378
Removal pelvic lymph nodes,38562,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8495.96,,,,,,,fee schedule,8091.39,35898.76,APC
Removal pelvic lymph nodes,38562,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8415.05,,,,,,,fee schedule,8091.39,35898.76,APC
Removal pelvic lymph nodes,38562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8091.39,,,,,,,fee schedule,8091.39,35898.76,APC
Removal pelvic lymph nodes,38562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12379.83,,,,,,,fee schedule,8091.39,35898.76,Radiology
Removal pelvic lymph nodes,38562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11327.95,,,,,,,fee schedule,8091.39,35898.76,APC
Removal pelvic lymph nodes,38562,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14159.93,,,,,,,fee schedule,8091.39,35898.76,APC
Laparoscopy lymph node biop,38570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11363.59,,,,,,,fee schedule,5984.88,26552.87,
Laparoscopy lymph node biop,38570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9108.91,,,,,,,fee schedule,5984.88,26552.87,
Laparoscopy lymph node biop,38570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9950.65,,,,,,,fee schedule,5984.88,26552.87,
Laparoscopy lymph node biop,38570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10461.72,,,,,,,fee schedule,5984.88,26552.87,
Laparoscopy lymph node biop,38570,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,5984.88,26552.87,APC 378
Laparoscopy lymph node biop,38570,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscopy lymph node biop,38570,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscopy lymph node biop,38570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscopy lymph node biop,38570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,5984.88,26552.87,Radiology
Laparoscopy lymph node biop,38570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscopy lymph node biop,38570,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscopy lymphadenectomy,38571,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7735.46,,,,,,,fee schedule,6200.65,46687.84,
Laparoscopy lymphadenectomy,38571,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6200.65,,,,,,,fee schedule,6200.65,46687.84,
Laparoscopy lymphadenectomy,38571,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6773.64,,,,,,,fee schedule,6200.65,46687.84,
Laparoscopy lymphadenectomy,38571,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7121.53,,,,,,,fee schedule,6200.65,46687.84,
Laparoscopy lymphadenectomy,38571,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46687.84,,,,,,,fee schedule,6200.65,46687.84,APC 378
Laparoscopy lymphadenectomy,38571,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11049.35,,,,,,,fee schedule,6200.65,46687.84,APC
Laparoscopy lymphadenectomy,38571,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10944.12,,,,,,,fee schedule,6200.65,46687.84,APC
Laparoscopy lymphadenectomy,38571,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10523.19,,,,,,,fee schedule,6200.65,46687.84,APC
Laparoscopy lymphadenectomy,38571,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16100.48,,,,,,,fee schedule,6200.65,46687.84,Radiology
Laparoscopy lymphadenectomy,38571,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14732.47,,,,,,,fee schedule,6200.65,46687.84,APC
Laparoscopy lymphadenectomy,38571,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18415.58,,,,,,,fee schedule,6200.65,46687.84,APC
Laparoscopy lymphadenectomy,38572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5566.45,,,,,,,fee schedule,4462,46687.84,
Laparoscopy lymphadenectomy,38572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4462,,,,,,,fee schedule,4462,46687.84,
Laparoscopy lymphadenectomy,38572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4874.33,,,,,,,fee schedule,4462,46687.84,
Laparoscopy lymphadenectomy,38572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5124.67,,,,,,,fee schedule,4462,46687.84,
Laparoscopy lymphadenectomy,38572,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46687.84,,,,,,,fee schedule,4462,46687.84,APC 378
Laparoscopy lymphadenectomy,38572,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11049.35,,,,,,,fee schedule,4462,46687.84,APC
Laparoscopy lymphadenectomy,38572,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10944.12,,,,,,,fee schedule,4462,46687.84,APC
Laparoscopy lymphadenectomy,38572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10523.19,,,,,,,fee schedule,4462,46687.84,APC
Laparoscopy lymphadenectomy,38572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16100.48,,,,,,,fee schedule,4462,46687.84,Radiology
Laparoscopy lymphadenectomy,38572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14732.47,,,,,,,fee schedule,4462,46687.84,APC
Laparoscopy lymphadenectomy,38572,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18415.58,,,,,,,fee schedule,4462,46687.84,APC
Laps pelvic lymphadec,38573,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,29263.36,,,,,,,fee schedule,10523.19,46687.84,
Laps pelvic lymphadec,38573,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23457.14,,,,,,,fee schedule,10523.19,46687.84,
Laps pelvic lymphadec,38573,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,25624.8,,,,,,,fee schedule,10523.19,46687.84,
Laps pelvic lymphadec,38573,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26940.87,,,,,,,fee schedule,10523.19,46687.84,
Laps pelvic lymphadec,38573,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46687.84,,,,,,,fee schedule,10523.19,46687.84,APC 378
Laps pelvic lymphadec,38573,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11049.35,,,,,,,fee schedule,10523.19,46687.84,APC
Laps pelvic lymphadec,38573,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10944.12,,,,,,,fee schedule,10523.19,46687.84,APC
Laps pelvic lymphadec,38573,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10523.19,,,,,,,fee schedule,10523.19,46687.84,APC
Laps pelvic lymphadec,38573,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16100.48,,,,,,,fee schedule,10523.19,46687.84,Radiology
Laps pelvic lymphadec,38573,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14732.47,,,,,,,fee schedule,10523.19,46687.84,APC
Laps pelvic lymphadec,38573,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18415.58,,,,,,,fee schedule,10523.19,46687.84,APC
Laparoscope proc lymphatic,38589,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8584.34,,,,,,,fee schedule,5984.88,26552.87,
Laparoscope proc lymphatic,38589,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6881.1,,,,,,,fee schedule,5984.88,26552.87,
Laparoscope proc lymphatic,38589,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7516.98,,,,,,,fee schedule,5984.88,26552.87,
Laparoscope proc lymphatic,38589,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7903.05,,,,,,,fee schedule,5984.88,26552.87,
Laparoscope proc lymphatic,38589,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,5984.88,26552.87,APC 378
Laparoscope proc lymphatic,38589,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscope proc lymphatic,38589,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscope proc lymphatic,38589,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscope proc lymphatic,38589,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,5984.88,26552.87,Radiology
Laparoscope proc lymphatic,38589,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscope proc lymphatic,38589,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,5984.88,26552.87,APC
Removal of lymph nodes neck,38700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10073.42,,,,,,,fee schedule,6573.55,29164.62,
Removal of lymph nodes neck,38700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8074.72,,,,,,,fee schedule,6573.55,29164.62,
Removal of lymph nodes neck,38700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8820.9,,,,,,,fee schedule,6573.55,29164.62,
Removal of lymph nodes neck,38700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9273.94,,,,,,,fee schedule,6573.55,29164.62,
Removal of lymph nodes neck,38700,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,29164.62,,,,,,,fee schedule,6573.55,29164.62,APC 378
Removal of lymph nodes neck,38700,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6902.23,,,,,,,fee schedule,6573.55,29164.62,APC
Removal of lymph nodes neck,38700,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6836.49,,,,,,,fee schedule,6573.55,29164.62,APC
Removal of lymph nodes neck,38700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6573.55,,,,,,,fee schedule,6573.55,29164.62,APC
Removal of lymph nodes neck,38700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10057.53,,,,,,,fee schedule,6573.55,29164.62,Radiology
Removal of lymph nodes neck,38700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9202.97,,,,,,,fee schedule,6573.55,29164.62,APC
Removal of lymph nodes neck,38700,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11503.71,,,,,,,fee schedule,6573.55,29164.62,APC
Removal of lymph nodes neck,38720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14211.41,,,,,,,fee schedule,6573.55,29164.62,
Removal of lymph nodes neck,38720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11391.69,,,,,,,fee schedule,6573.55,29164.62,
Removal of lymph nodes neck,38720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12444.39,,,,,,,fee schedule,6573.55,29164.62,
Removal of lymph nodes neck,38720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13083.52,,,,,,,fee schedule,6573.55,29164.62,
Removal of lymph nodes neck,38720,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,29164.62,,,,,,,fee schedule,6573.55,29164.62,APC 378
Removal of lymph nodes neck,38720,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6902.23,,,,,,,fee schedule,6573.55,29164.62,APC
Removal of lymph nodes neck,38720,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6836.49,,,,,,,fee schedule,6573.55,29164.62,APC
Removal of lymph nodes neck,38720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6573.55,,,,,,,fee schedule,6573.55,29164.62,APC
Removal of lymph nodes neck,38720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10057.53,,,,,,,fee schedule,6573.55,29164.62,Radiology
Removal of lymph nodes neck,38720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9202.97,,,,,,,fee schedule,6573.55,29164.62,APC
Removal of lymph nodes neck,38720,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11503.71,,,,,,,fee schedule,6573.55,29164.62,APC
Removal of lymph nodes neck,38724,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7401.61,,,,,,,fee schedule,5933.04,7401.61,
Removal of lymph nodes neck,38724,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5933.04,,,,,,,fee schedule,5933.04,7401.61,
Removal of lymph nodes neck,38724,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6481.3,,,,,,,fee schedule,5933.04,7401.61,
Removal of lymph nodes neck,38724,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6814.18,,,,,,,fee schedule,5933.04,7401.61,
Remove armpit lymph nodes,38740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2481.08,,,,,,,fee schedule,1988.8,26552.87,
Remove armpit lymph nodes,38740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1988.8,,,,,,,fee schedule,1988.8,26552.87,
Remove armpit lymph nodes,38740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2172.58,,,,,,,fee schedule,1988.8,26552.87,
Remove armpit lymph nodes,38740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2284.16,,,,,,,fee schedule,1988.8,26552.87,
Remove armpit lymph nodes,38740,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,1988.8,26552.87,APC 378
Remove armpit lymph nodes,38740,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,1988.8,26552.87,APC
Remove armpit lymph nodes,38740,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,1988.8,26552.87,APC
Remove armpit lymph nodes,38740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,1988.8,26552.87,APC
Remove armpit lymph nodes,38740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,1988.8,26552.87,Radiology
Remove armpit lymph nodes,38740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,1988.8,26552.87,APC
Remove armpit lymph nodes,38740,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,1988.8,26552.87,APC
Remove armpit lymph nodes,38745,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3955.68,,,,,,,fee schedule,3170.82,26552.87,
Remove armpit lymph nodes,38745,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3170.82,,,,,,,fee schedule,3170.82,26552.87,
Remove armpit lymph nodes,38745,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3463.84,,,,,,,fee schedule,3170.82,26552.87,
Remove armpit lymph nodes,38745,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3641.74,,,,,,,fee schedule,3170.82,26552.87,
Remove armpit lymph nodes,38745,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,3170.82,26552.87,APC 378
Remove armpit lymph nodes,38745,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,3170.82,26552.87,APC
Remove armpit lymph nodes,38745,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,3170.82,26552.87,APC
Remove armpit lymph nodes,38745,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,3170.82,26552.87,APC
Remove armpit lymph nodes,38745,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,3170.82,26552.87,Radiology
Remove armpit lymph nodes,38745,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,3170.82,26552.87,APC
Remove armpit lymph nodes,38745,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,3170.82,26552.87,APC
Remove groin lymph nodes,38760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3828.9,,,,,,,fee schedule,3069.2,29164.62,
Remove groin lymph nodes,38760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3069.2,,,,,,,fee schedule,3069.2,29164.62,
Remove groin lymph nodes,38760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3352.82,,,,,,,fee schedule,3069.2,29164.62,
Remove groin lymph nodes,38760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3525.02,,,,,,,fee schedule,3069.2,29164.62,
Remove groin lymph nodes,38760,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,29164.62,,,,,,,fee schedule,3069.2,29164.62,APC 378
Remove groin lymph nodes,38760,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6902.23,,,,,,,fee schedule,3069.2,29164.62,APC
Remove groin lymph nodes,38760,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6836.49,,,,,,,fee schedule,3069.2,29164.62,APC
Remove groin lymph nodes,38760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6573.55,,,,,,,fee schedule,3069.2,29164.62,APC
Remove groin lymph nodes,38760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10057.53,,,,,,,fee schedule,3069.2,29164.62,Radiology
Remove groin lymph nodes,38760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9202.97,,,,,,,fee schedule,3069.2,29164.62,APC
Remove groin lymph nodes,38760,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11503.71,,,,,,,fee schedule,3069.2,29164.62,APC
Ra tracer id of sentinl node,38792,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1203.05,,,,,,,fee schedule,395.76,1755.86,
Ra tracer id of sentinl node,38792,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,964.35,,,,,,,fee schedule,395.76,1755.86,
Ra tracer id of sentinl node,38792,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1053.47,,,,,,,fee schedule,395.76,1755.86,
Ra tracer id of sentinl node,38792,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1107.57,,,,,,,fee schedule,395.76,1755.86,
Ra tracer id of sentinl node,38792,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755.86,,,,,,,fee schedule,395.76,1755.86,APC 378
Ra tracer id of sentinl node,38792,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,415.55,,,,,,,fee schedule,395.76,1755.86,APC
Ra tracer id of sentinl node,38792,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,411.59,,,,,,,fee schedule,395.76,1755.86,APC
Ra tracer id of sentinl node,38792,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,395.76,,,,,,,fee schedule,395.76,1755.86,APC
Ra tracer id of sentinl node,38792,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,605.51,,,,,,,fee schedule,395.76,1755.86,Radiology
Ra tracer id of sentinl node,38792,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,554.06,,,,,,,fee schedule,395.76,1755.86,APC
Ra tracer id of sentinl node,38792,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,692.58,,,,,,,fee schedule,395.76,1755.86,APC
Blood/lymph system procedure,38999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7657.8,,,,,,,fee schedule,436.75,7657.8,
Blood/lymph system procedure,38999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6138.4,,,,,,,fee schedule,436.75,7657.8,
Blood/lymph system procedure,38999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6705.64,,,,,,,fee schedule,436.75,7657.8,
Blood/lymph system procedure,38999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7050.04,,,,,,,fee schedule,436.75,7657.8,
Blood/lymph system procedure,38999,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1937.7,,,,,,,fee schedule,436.75,7657.8,APC 378
Blood/lymph system procedure,38999,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,458.59,,,,,,,fee schedule,436.75,7657.8,APC
Blood/lymph system procedure,38999,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,454.22,,,,,,,fee schedule,436.75,7657.8,APC
Blood/lymph system procedure,38999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,436.75,,,,,,,fee schedule,436.75,7657.8,APC
Blood/lymph system procedure,38999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,668.22,,,,,,,fee schedule,436.75,7657.8,Radiology
Blood/lymph system procedure,38999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,611.45,,,,,,,fee schedule,436.75,7657.8,APC
Blood/lymph system procedure,38999,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,764.31,,,,,,,fee schedule,436.75,7657.8,APC
Mediastinoscpy w/medstnl bx,39401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11918.04,,,,,,,fee schedule,5984.88,26552.87,
Mediastinoscpy w/medstnl bx,39401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9553.35,,,,,,,fee schedule,5984.88,26552.87,
Mediastinoscpy w/medstnl bx,39401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10436.17,,,,,,,fee schedule,5984.88,26552.87,
Mediastinoscpy w/medstnl bx,39401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10972.16,,,,,,,fee schedule,5984.88,26552.87,
Mediastinoscpy w/medstnl bx,39401,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,5984.88,26552.87,APC 378
Mediastinoscpy w/medstnl bx,39401,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,5984.88,26552.87,APC
Mediastinoscpy w/medstnl bx,39401,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,5984.88,26552.87,APC
Mediastinoscpy w/medstnl bx,39401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,5984.88,26552.87,APC
Mediastinoscpy w/medstnl bx,39401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,5984.88,26552.87,Radiology
Mediastinoscpy w/medstnl bx,39401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,5984.88,26552.87,APC
Mediastinoscpy w/medstnl bx,39401,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,5984.88,26552.87,APC
Mediastinoscpy w/lmph nod bx,39402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10101.86,,,,,,,fee schedule,5984.88,26552.87,
Mediastinoscpy w/lmph nod bx,39402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8097.52,,,,,,,fee schedule,5984.88,26552.87,
Mediastinoscpy w/lmph nod bx,39402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8845.81,,,,,,,fee schedule,5984.88,26552.87,
Mediastinoscpy w/lmph nod bx,39402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9300.13,,,,,,,fee schedule,5984.88,26552.87,
Mediastinoscpy w/lmph nod bx,39402,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,5984.88,26552.87,APC 378
Mediastinoscpy w/lmph nod bx,39402,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,5984.88,26552.87,APC
Mediastinoscpy w/lmph nod bx,39402,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,5984.88,26552.87,APC
Mediastinoscpy w/lmph nod bx,39402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,5984.88,26552.87,APC
Mediastinoscpy w/lmph nod bx,39402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,5984.88,26552.87,Radiology
Mediastinoscpy w/lmph nod bx,39402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,5984.88,26552.87,APC
Mediastinoscpy w/lmph nod bx,39402,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,5984.88,26552.87,APC
Biopsy of lip,40490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,624,,,,,,,fee schedule,234.47,1040.28,
Biopsy of lip,40490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,500.19,,,,,,,fee schedule,234.47,1040.28,
Biopsy of lip,40490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,546.41,,,,,,,fee schedule,234.47,1040.28,
Biopsy of lip,40490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,574.48,,,,,,,fee schedule,234.47,1040.28,
Biopsy of lip,40490,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1040.28,,,,,,,fee schedule,234.47,1040.28,APC 378
Biopsy of lip,40490,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,246.2,,,,,,,fee schedule,234.47,1040.28,APC
Biopsy of lip,40490,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,243.85,,,,,,,fee schedule,234.47,1040.28,APC
Biopsy of lip,40490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,234.47,,,,,,,fee schedule,234.47,1040.28,APC
Biopsy of lip,40490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,358.74,,,,,,,fee schedule,234.47,1040.28,Radiology
Biopsy of lip,40490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,328.26,,,,,,,fee schedule,234.47,1040.28,APC
Biopsy of lip,40490,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,410.33,,,,,,,fee schedule,234.47,1040.28,APC
Partial excision of lip,40500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4075.29,,,,,,,fee schedule,3266.7,14562,
Partial excision of lip,40500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3266.7,,,,,,,fee schedule,3266.7,14562,
Partial excision of lip,40500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3568.58,,,,,,,fee schedule,3266.7,14562,
Partial excision of lip,40500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3751.86,,,,,,,fee schedule,3266.7,14562,
Partial excision of lip,40500,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3266.7,14562,APC 378
Partial excision of lip,40500,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3266.7,14562,APC
Partial excision of lip,40500,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3266.7,14562,APC
Partial excision of lip,40500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3266.7,14562,APC
Partial excision of lip,40500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3266.7,14562,Radiology
Partial excision of lip,40500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3266.7,14562,APC
Partial excision of lip,40500,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3266.7,14562,APC
Partial excision of lip,40510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4999.19,,,,,,,fee schedule,3282.2,14562,
Partial excision of lip,40510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4007.29,,,,,,,fee schedule,3282.2,14562,
Partial excision of lip,40510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4377.6,,,,,,,fee schedule,3282.2,14562,
Partial excision of lip,40510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4602.43,,,,,,,fee schedule,3282.2,14562,
Partial excision of lip,40510,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Partial excision of lip,40510,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Partial excision of lip,40510,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Partial excision of lip,40510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Partial excision of lip,40510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Partial excision of lip,40510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Partial excision of lip,40510,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Partial excision of lip,40520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4075.29,,,,,,,fee schedule,3266.7,14562,
Partial excision of lip,40520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3266.7,,,,,,,fee schedule,3266.7,14562,
Partial excision of lip,40520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3568.58,,,,,,,fee schedule,3266.7,14562,
Partial excision of lip,40520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3751.86,,,,,,,fee schedule,3266.7,14562,
Partial excision of lip,40520,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3266.7,14562,APC 378
Partial excision of lip,40520,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3266.7,14562,APC
Partial excision of lip,40520,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3266.7,14562,APC
Partial excision of lip,40520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3266.7,14562,APC
Partial excision of lip,40520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3266.7,14562,Radiology
Partial excision of lip,40520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3266.7,14562,APC
Partial excision of lip,40520,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3266.7,14562,APC
Reconstruct lip with flap,40525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5983.93,,,,,,,fee schedule,3282.2,14562,
Reconstruct lip with flap,40525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4796.64,,,,,,,fee schedule,3282.2,14562,
Reconstruct lip with flap,40525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5239.9,,,,,,,fee schedule,3282.2,14562,
Reconstruct lip with flap,40525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.01,,,,,,,fee schedule,3282.2,14562,
Reconstruct lip with flap,40525,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Reconstruct lip with flap,40525,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Reconstruct lip with flap,40525,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Reconstruct lip with flap,40525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Reconstruct lip with flap,40525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Reconstruct lip with flap,40525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Reconstruct lip with flap,40525,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Reconstruct lip with flap,40527,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5983.93,,,,,,,fee schedule,4796.64,26000.79,
Reconstruct lip with flap,40527,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4796.64,,,,,,,fee schedule,4796.64,26000.79,
Reconstruct lip with flap,40527,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5239.9,,,,,,,fee schedule,4796.64,26000.79,
Reconstruct lip with flap,40527,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.01,,,,,,,fee schedule,4796.64,26000.79,
Reconstruct lip with flap,40527,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,4796.64,26000.79,APC 378
Reconstruct lip with flap,40527,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,4796.64,26000.79,APC
Reconstruct lip with flap,40527,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,4796.64,26000.79,APC
Reconstruct lip with flap,40527,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,4796.64,26000.79,APC
Reconstruct lip with flap,40527,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,4796.64,26000.79,Radiology
Reconstruct lip with flap,40527,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,4796.64,26000.79,APC
Reconstruct lip with flap,40527,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,4796.64,26000.79,APC
Partial removal of lip,40530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5983.93,,,,,,,fee schedule,3282.2,14562,
Partial removal of lip,40530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4796.64,,,,,,,fee schedule,3282.2,14562,
Partial removal of lip,40530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5239.9,,,,,,,fee schedule,3282.2,14562,
Partial removal of lip,40530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.01,,,,,,,fee schedule,3282.2,14562,
Partial removal of lip,40530,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Partial removal of lip,40530,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Partial removal of lip,40530,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Partial removal of lip,40530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Partial removal of lip,40530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Partial removal of lip,40530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Partial removal of lip,40530,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Repair lip,40650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,797.17,,,,,,,fee schedule,533.92,2368.81,
Repair lip,40650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,639,,,,,,,fee schedule,533.92,2368.81,
Repair lip,40650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,698.05,,,,,,,fee schedule,533.92,2368.81,
Repair lip,40650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,733.9,,,,,,,fee schedule,533.92,2368.81,
Repair lip,40650,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2368.81,,,,,,,fee schedule,533.92,2368.81,APC 378
Repair lip,40650,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,560.61,,,,,,,fee schedule,533.92,2368.81,APC
Repair lip,40650,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,555.27,,,,,,,fee schedule,533.92,2368.81,APC
Repair lip,40650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,533.92,,,,,,,fee schedule,533.92,2368.81,APC
Repair lip,40650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,816.89,,,,,,,fee schedule,533.92,2368.81,Radiology
Repair lip,40650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,747.48,,,,,,,fee schedule,533.92,2368.81,APC
Repair lip,40650,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,934.36,,,,,,,fee schedule,533.92,2368.81,APC
Repair lip,40652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1858.66,,,,,,,fee schedule,533.92,2368.81,
Repair lip,40652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1489.88,,,,,,,fee schedule,533.92,2368.81,
Repair lip,40652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1627.56,,,,,,,fee schedule,533.92,2368.81,
Repair lip,40652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1711.15,,,,,,,fee schedule,533.92,2368.81,
Repair lip,40652,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2368.81,,,,,,,fee schedule,533.92,2368.81,APC 378
Repair lip,40652,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,560.61,,,,,,,fee schedule,533.92,2368.81,APC
Repair lip,40652,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,555.27,,,,,,,fee schedule,533.92,2368.81,APC
Repair lip,40652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,533.92,,,,,,,fee schedule,533.92,2368.81,APC
Repair lip,40652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,816.89,,,,,,,fee schedule,533.92,2368.81,Radiology
Repair lip,40652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,747.48,,,,,,,fee schedule,533.92,2368.81,APC
Repair lip,40652,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,934.36,,,,,,,fee schedule,533.92,2368.81,APC
Repair lip,40654,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9269.11,,,,,,,fee schedule,1536.02,9269.11,
Repair lip,40654,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7430,,,,,,,fee schedule,1536.02,9269.11,
Repair lip,40654,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8116.61,,,,,,,fee schedule,1536.02,9269.11,
Repair lip,40654,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8533.47,,,,,,,fee schedule,1536.02,9269.11,
Repair lip,40654,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1536.02,9269.11,APC 378
Repair lip,40654,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1536.02,9269.11,APC
Repair lip,40654,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1536.02,9269.11,APC
Repair lip,40654,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1536.02,9269.11,APC
Repair lip,40654,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1536.02,9269.11,Radiology
Repair lip,40654,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1536.02,9269.11,APC
Repair lip,40654,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1536.02,9269.11,APC
Repair cleft lip/nasal,40700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Repair cleft lip/nasal,40700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Repair cleft lip/nasal,40700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Repair cleft lip/nasal,40700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Repair cleft lip/nasal,40700,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Repair cleft lip/nasal,40700,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Repair cleft lip/nasal,40700,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Repair cleft lip/nasal,40700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Repair cleft lip/nasal,40700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Repair cleft lip/nasal,40700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Repair cleft lip/nasal,40700,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Repair cleft lip/nasal,40701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Repair cleft lip/nasal,40701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Repair cleft lip/nasal,40701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Repair cleft lip/nasal,40701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Repair cleft lip/nasal,40701,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Repair cleft lip/nasal,40701,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Repair cleft lip/nasal,40701,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Repair cleft lip/nasal,40701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Repair cleft lip/nasal,40701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Repair cleft lip/nasal,40701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Repair cleft lip/nasal,40701,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Repair cleft lip/nasal,40702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Repair cleft lip/nasal,40702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Repair cleft lip/nasal,40702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Repair cleft lip/nasal,40702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Repair cleft lip/nasal,40702,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Repair cleft lip/nasal,40702,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Repair cleft lip/nasal,40702,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Repair cleft lip/nasal,40702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Repair cleft lip/nasal,40702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Repair cleft lip/nasal,40702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Repair cleft lip/nasal,40702,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Repair cleft lip/nasal,40720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9971.29,,,,,,,fee schedule,3282.2,14562,
Repair cleft lip/nasal,40720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7992.86,,,,,,,fee schedule,3282.2,14562,
Repair cleft lip/nasal,40720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8731.47,,,,,,,fee schedule,3282.2,14562,
Repair cleft lip/nasal,40720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9179.92,,,,,,,fee schedule,3282.2,14562,
Repair cleft lip/nasal,40720,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Repair cleft lip/nasal,40720,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Repair cleft lip/nasal,40720,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Repair cleft lip/nasal,40720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Repair cleft lip/nasal,40720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Repair cleft lip/nasal,40720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Repair cleft lip/nasal,40720,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Repair cleft lip/nasal,40761,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Repair cleft lip/nasal,40761,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Repair cleft lip/nasal,40761,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Repair cleft lip/nasal,40761,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Repair cleft lip/nasal,40761,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Repair cleft lip/nasal,40761,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Repair cleft lip/nasal,40761,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Repair cleft lip/nasal,40761,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Repair cleft lip/nasal,40761,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Repair cleft lip/nasal,40761,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Repair cleft lip/nasal,40761,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Lip surgery procedure,40799,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,624,,,,,,,fee schedule,234.47,1040.28,
Lip surgery procedure,40799,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,500.19,,,,,,,fee schedule,234.47,1040.28,
Lip surgery procedure,40799,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,546.41,,,,,,,fee schedule,234.47,1040.28,
Lip surgery procedure,40799,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,574.48,,,,,,,fee schedule,234.47,1040.28,
Lip surgery procedure,40799,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1040.28,,,,,,,fee schedule,234.47,1040.28,APC 378
Lip surgery procedure,40799,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,246.2,,,,,,,fee schedule,234.47,1040.28,APC
Lip surgery procedure,40799,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,243.85,,,,,,,fee schedule,234.47,1040.28,APC
Lip surgery procedure,40799,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,234.47,,,,,,,fee schedule,234.47,1040.28,APC
Lip surgery procedure,40799,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,358.74,,,,,,,fee schedule,234.47,1040.28,Radiology
Lip surgery procedure,40799,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,328.26,,,,,,,fee schedule,234.47,1040.28,APC
Lip surgery procedure,40799,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,410.33,,,,,,,fee schedule,234.47,1040.28,APC
Drainage of mouth lesion,40800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3360.79,,,,,,,fee schedule,701.03,3360.79,
Drainage of mouth lesion,40800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2693.96,,,,,,,fee schedule,701.03,3360.79,
Drainage of mouth lesion,40800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2942.91,,,,,,,fee schedule,701.03,3360.79,
Drainage of mouth lesion,40800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3094.06,,,,,,,fee schedule,701.03,3360.79,
Drainage of mouth lesion,40800,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3110.22,,,,,,,fee schedule,701.03,3360.79,APC 378
Drainage of mouth lesion,40800,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,736.08,,,,,,,fee schedule,701.03,3360.79,APC
Drainage of mouth lesion,40800,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,729.07,,,,,,,fee schedule,701.03,3360.79,APC
Drainage of mouth lesion,40800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,701.03,,,,,,,fee schedule,701.03,3360.79,APC
Drainage of mouth lesion,40800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1072.57,,,,,,,fee schedule,701.03,3360.79,Radiology
Drainage of mouth lesion,40800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,981.44,,,,,,,fee schedule,701.03,3360.79,APC
Drainage of mouth lesion,40800,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1226.8,,,,,,,fee schedule,701.03,3360.79,APC
Drainage of mouth lesion,40801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1858.66,,,,,,,fee schedule,533.92,2368.81,
Drainage of mouth lesion,40801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1489.88,,,,,,,fee schedule,533.92,2368.81,
Drainage of mouth lesion,40801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1627.56,,,,,,,fee schedule,533.92,2368.81,
Drainage of mouth lesion,40801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1711.15,,,,,,,fee schedule,533.92,2368.81,
Drainage of mouth lesion,40801,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2368.81,,,,,,,fee schedule,533.92,2368.81,APC 378
Drainage of mouth lesion,40801,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,560.61,,,,,,,fee schedule,533.92,2368.81,APC
Drainage of mouth lesion,40801,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,555.27,,,,,,,fee schedule,533.92,2368.81,APC
Drainage of mouth lesion,40801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,533.92,,,,,,,fee schedule,533.92,2368.81,APC
Drainage of mouth lesion,40801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,816.89,,,,,,,fee schedule,533.92,2368.81,Radiology
Drainage of mouth lesion,40801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,747.48,,,,,,,fee schedule,533.92,2368.81,APC
Drainage of mouth lesion,40801,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,934.36,,,,,,,fee schedule,533.92,2368.81,APC
Removal foreign body mouth,40804,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,157.47,,,,,,,fee schedule,126.23,3983.62,
Removal foreign body mouth,40804,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,126.23,,,,,,,fee schedule,126.23,3983.62,
Removal foreign body mouth,40804,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,137.89,,,,,,,fee schedule,126.23,3983.62,
Removal foreign body mouth,40804,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,144.98,,,,,,,fee schedule,126.23,3983.62,
Removal foreign body mouth,40804,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3983.62,,,,,,,fee schedule,126.23,3983.62,APC 378
Removal foreign body mouth,40804,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,942.78,,,,,,,fee schedule,126.23,3983.62,APC
Removal foreign body mouth,40804,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,933.8,,,,,,,fee schedule,126.23,3983.62,APC
Removal foreign body mouth,40804,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,897.89,,,,,,,fee schedule,126.23,3983.62,APC
Removal foreign body mouth,40804,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1373.77,,,,,,,fee schedule,126.23,3983.62,Radiology
Removal foreign body mouth,40804,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1257.04,,,,,,,fee schedule,126.23,3983.62,APC
Removal foreign body mouth,40804,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1571.3,,,,,,,fee schedule,126.23,3983.62,APC
Removal foreign body mouth,40805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1858.66,,,,,,,fee schedule,533.92,2368.81,
Removal foreign body mouth,40805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1489.88,,,,,,,fee schedule,533.92,2368.81,
Removal foreign body mouth,40805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1627.56,,,,,,,fee schedule,533.92,2368.81,
Removal foreign body mouth,40805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1711.15,,,,,,,fee schedule,533.92,2368.81,
Removal foreign body mouth,40805,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2368.81,,,,,,,fee schedule,533.92,2368.81,APC 378
Removal foreign body mouth,40805,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,560.61,,,,,,,fee schedule,533.92,2368.81,APC
Removal foreign body mouth,40805,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,555.27,,,,,,,fee schedule,533.92,2368.81,APC
Removal foreign body mouth,40805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,533.92,,,,,,,fee schedule,533.92,2368.81,APC
Removal foreign body mouth,40805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,816.89,,,,,,,fee schedule,533.92,2368.81,Radiology
Removal foreign body mouth,40805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,747.48,,,,,,,fee schedule,533.92,2368.81,APC
Removal foreign body mouth,40805,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,934.36,,,,,,,fee schedule,533.92,2368.81,APC
Incision of lip fold,40806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,624,,,,,,,fee schedule,500.19,2368.81,
Incision of lip fold,40806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,500.19,,,,,,,fee schedule,500.19,2368.81,
Incision of lip fold,40806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,546.41,,,,,,,fee schedule,500.19,2368.81,
Incision of lip fold,40806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,574.48,,,,,,,fee schedule,500.19,2368.81,
Incision of lip fold,40806,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2368.81,,,,,,,fee schedule,500.19,2368.81,APC 378
Incision of lip fold,40806,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,560.61,,,,,,,fee schedule,500.19,2368.81,APC
Incision of lip fold,40806,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,555.27,,,,,,,fee schedule,500.19,2368.81,APC
Incision of lip fold,40806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,533.92,,,,,,,fee schedule,500.19,2368.81,APC
Incision of lip fold,40806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,816.89,,,,,,,fee schedule,500.19,2368.81,Radiology
Incision of lip fold,40806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,747.48,,,,,,,fee schedule,500.19,2368.81,APC
Incision of lip fold,40806,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,934.36,,,,,,,fee schedule,500.19,2368.81,APC
Biopsy of mouth lesion,40808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,624,,,,,,,fee schedule,500.19,2368.81,
Biopsy of mouth lesion,40808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,500.19,,,,,,,fee schedule,500.19,2368.81,
Biopsy of mouth lesion,40808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,546.41,,,,,,,fee schedule,500.19,2368.81,
Biopsy of mouth lesion,40808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,574.48,,,,,,,fee schedule,500.19,2368.81,
Biopsy of mouth lesion,40808,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2368.81,,,,,,,fee schedule,500.19,2368.81,APC 378
Biopsy of mouth lesion,40808,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,560.61,,,,,,,fee schedule,500.19,2368.81,APC
Biopsy of mouth lesion,40808,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,555.27,,,,,,,fee schedule,500.19,2368.81,APC
Biopsy of mouth lesion,40808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,533.92,,,,,,,fee schedule,500.19,2368.81,APC
Biopsy of mouth lesion,40808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,816.89,,,,,,,fee schedule,500.19,2368.81,Radiology
Biopsy of mouth lesion,40808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,747.48,,,,,,,fee schedule,500.19,2368.81,APC
Biopsy of mouth lesion,40808,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,934.36,,,,,,,fee schedule,500.19,2368.81,APC
Excision of mouth lesion,40810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6253.46,,,,,,,fee schedule,3282.2,14562,
Excision of mouth lesion,40810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5012.69,,,,,,,fee schedule,3282.2,14562,
Excision of mouth lesion,40810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5475.91,,,,,,,fee schedule,3282.2,14562,
Excision of mouth lesion,40810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5757.15,,,,,,,fee schedule,3282.2,14562,
Excision of mouth lesion,40810,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Excision of mouth lesion,40810,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Excision of mouth lesion,40810,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Excision of mouth lesion,40810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Excision of mouth lesion,40810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Excision of mouth lesion,40810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Excision of mouth lesion,40810,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Excise/repair mouth lesion,40812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4075.29,,,,,,,fee schedule,1536.02,6814.79,
Excise/repair mouth lesion,40812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3266.7,,,,,,,fee schedule,1536.02,6814.79,
Excise/repair mouth lesion,40812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3568.58,,,,,,,fee schedule,1536.02,6814.79,
Excise/repair mouth lesion,40812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3751.86,,,,,,,fee schedule,1536.02,6814.79,
Excise/repair mouth lesion,40812,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1536.02,6814.79,APC 378
Excise/repair mouth lesion,40812,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1536.02,6814.79,APC
Excise/repair mouth lesion,40812,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1536.02,6814.79,APC
Excise/repair mouth lesion,40812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1536.02,6814.79,APC
Excise/repair mouth lesion,40812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1536.02,6814.79,Radiology
Excise/repair mouth lesion,40812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1536.02,6814.79,APC
Excise/repair mouth lesion,40812,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1536.02,6814.79,APC
Excise/repair mouth lesion,40814,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4075.29,,,,,,,fee schedule,3266.7,14562,
Excise/repair mouth lesion,40814,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3266.7,,,,,,,fee schedule,3266.7,14562,
Excise/repair mouth lesion,40814,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3568.58,,,,,,,fee schedule,3266.7,14562,
Excise/repair mouth lesion,40814,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3751.86,,,,,,,fee schedule,3266.7,14562,
Excise/repair mouth lesion,40814,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3266.7,14562,APC 378
Excise/repair mouth lesion,40814,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3266.7,14562,APC
Excise/repair mouth lesion,40814,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3266.7,14562,APC
Excise/repair mouth lesion,40814,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3266.7,14562,APC
Excise/repair mouth lesion,40814,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3266.7,14562,Radiology
Excise/repair mouth lesion,40814,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3266.7,14562,APC
Excise/repair mouth lesion,40814,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3266.7,14562,APC
Excision of mouth lesion,40816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5983.93,,,,,,,fee schedule,3282.2,14562,
Excision of mouth lesion,40816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4796.64,,,,,,,fee schedule,3282.2,14562,
Excision of mouth lesion,40816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5239.9,,,,,,,fee schedule,3282.2,14562,
Excision of mouth lesion,40816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.01,,,,,,,fee schedule,3282.2,14562,
Excision of mouth lesion,40816,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Excision of mouth lesion,40816,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Excision of mouth lesion,40816,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Excision of mouth lesion,40816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Excision of mouth lesion,40816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Excision of mouth lesion,40816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Excision of mouth lesion,40816,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Excise oral mucosa for graft,40818,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,624,,,,,,,fee schedule,500.19,2368.81,
Excise oral mucosa for graft,40818,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,500.19,,,,,,,fee schedule,500.19,2368.81,
Excise oral mucosa for graft,40818,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,546.41,,,,,,,fee schedule,500.19,2368.81,
Excise oral mucosa for graft,40818,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,574.48,,,,,,,fee schedule,500.19,2368.81,
Excise oral mucosa for graft,40818,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2368.81,,,,,,,fee schedule,500.19,2368.81,APC 378
Excise oral mucosa for graft,40818,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,560.61,,,,,,,fee schedule,500.19,2368.81,APC
Excise oral mucosa for graft,40818,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,555.27,,,,,,,fee schedule,500.19,2368.81,APC
Excise oral mucosa for graft,40818,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,533.92,,,,,,,fee schedule,500.19,2368.81,APC
Excise oral mucosa for graft,40818,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,816.89,,,,,,,fee schedule,500.19,2368.81,Radiology
Excise oral mucosa for graft,40818,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,747.48,,,,,,,fee schedule,500.19,2368.81,APC
Excise oral mucosa for graft,40818,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,934.36,,,,,,,fee schedule,500.19,2368.81,APC
Excise lip or cheek fold,40819,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,319.94,,,,,,,fee schedule,256.46,6814.79,
Excise lip or cheek fold,40819,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,256.46,,,,,,,fee schedule,256.46,6814.79,
Excise lip or cheek fold,40819,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,280.16,,,,,,,fee schedule,256.46,6814.79,
Excise lip or cheek fold,40819,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,294.55,,,,,,,fee schedule,256.46,6814.79,
Excise lip or cheek fold,40819,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,256.46,6814.79,APC 378
Excise lip or cheek fold,40819,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,256.46,6814.79,APC
Excise lip or cheek fold,40819,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,256.46,6814.79,APC
Excise lip or cheek fold,40819,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,256.46,6814.79,APC
Excise lip or cheek fold,40819,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,256.46,6814.79,Radiology
Excise lip or cheek fold,40819,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,256.46,6814.79,APC
Excise lip or cheek fold,40819,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,256.46,6814.79,APC
Treatment of mouth lesion,40820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4075.29,,,,,,,fee schedule,3266.7,14562,
Treatment of mouth lesion,40820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3266.7,,,,,,,fee schedule,3266.7,14562,
Treatment of mouth lesion,40820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3568.58,,,,,,,fee schedule,3266.7,14562,
Treatment of mouth lesion,40820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3751.86,,,,,,,fee schedule,3266.7,14562,
Treatment of mouth lesion,40820,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3266.7,14562,APC 378
Treatment of mouth lesion,40820,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3266.7,14562,APC
Treatment of mouth lesion,40820,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3266.7,14562,APC
Treatment of mouth lesion,40820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3266.7,14562,APC
Treatment of mouth lesion,40820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3266.7,14562,Radiology
Treatment of mouth lesion,40820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3266.7,14562,APC
Treatment of mouth lesion,40820,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3266.7,14562,APC
Repair mouth laceration,40830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,624,,,,,,,fee schedule,234.47,1040.28,
Repair mouth laceration,40830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,500.19,,,,,,,fee schedule,234.47,1040.28,
Repair mouth laceration,40830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,546.41,,,,,,,fee schedule,234.47,1040.28,
Repair mouth laceration,40830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,574.48,,,,,,,fee schedule,234.47,1040.28,
Repair mouth laceration,40830,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1040.28,,,,,,,fee schedule,234.47,1040.28,APC 378
Repair mouth laceration,40830,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,246.2,,,,,,,fee schedule,234.47,1040.28,APC
Repair mouth laceration,40830,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,243.85,,,,,,,fee schedule,234.47,1040.28,APC
Repair mouth laceration,40830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,234.47,,,,,,,fee schedule,234.47,1040.28,APC
Repair mouth laceration,40830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,358.74,,,,,,,fee schedule,234.47,1040.28,Radiology
Repair mouth laceration,40830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,328.26,,,,,,,fee schedule,234.47,1040.28,APC
Repair mouth laceration,40830,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,410.33,,,,,,,fee schedule,234.47,1040.28,APC
Repair mouth laceration,40831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1858.66,,,,,,,fee schedule,533.92,2368.81,
Repair mouth laceration,40831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1489.88,,,,,,,fee schedule,533.92,2368.81,
Repair mouth laceration,40831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1627.56,,,,,,,fee schedule,533.92,2368.81,
Repair mouth laceration,40831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1711.15,,,,,,,fee schedule,533.92,2368.81,
Repair mouth laceration,40831,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2368.81,,,,,,,fee schedule,533.92,2368.81,APC 378
Repair mouth laceration,40831,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,560.61,,,,,,,fee schedule,533.92,2368.81,APC
Repair mouth laceration,40831,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,555.27,,,,,,,fee schedule,533.92,2368.81,APC
Repair mouth laceration,40831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,533.92,,,,,,,fee schedule,533.92,2368.81,APC
Repair mouth laceration,40831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,816.89,,,,,,,fee schedule,533.92,2368.81,Radiology
Repair mouth laceration,40831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,747.48,,,,,,,fee schedule,533.92,2368.81,APC
Repair mouth laceration,40831,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,934.36,,,,,,,fee schedule,533.92,2368.81,APC
Reconstruction of mouth,40840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5983.93,,,,,,,fee schedule,4796.64,26000.79,
Reconstruction of mouth,40840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4796.64,,,,,,,fee schedule,4796.64,26000.79,
Reconstruction of mouth,40840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5239.9,,,,,,,fee schedule,4796.64,26000.79,
Reconstruction of mouth,40840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.01,,,,,,,fee schedule,4796.64,26000.79,
Reconstruction of mouth,40840,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,4796.64,26000.79,APC 378
Reconstruction of mouth,40840,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,4796.64,26000.79,APC
Reconstruction of mouth,40840,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,4796.64,26000.79,APC
Reconstruction of mouth,40840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,4796.64,26000.79,APC
Reconstruction of mouth,40840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,4796.64,26000.79,Radiology
Reconstruction of mouth,40840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,4796.64,26000.79,APC
Reconstruction of mouth,40840,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,4796.64,26000.79,APC
Reconstruction of mouth,40842,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5983.93,,,,,,,fee schedule,4796.64,26000.79,
Reconstruction of mouth,40842,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4796.64,,,,,,,fee schedule,4796.64,26000.79,
Reconstruction of mouth,40842,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5239.9,,,,,,,fee schedule,4796.64,26000.79,
Reconstruction of mouth,40842,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.01,,,,,,,fee schedule,4796.64,26000.79,
Reconstruction of mouth,40842,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,4796.64,26000.79,APC 378
Reconstruction of mouth,40842,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,4796.64,26000.79,APC
Reconstruction of mouth,40842,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,4796.64,26000.79,APC
Reconstruction of mouth,40842,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,4796.64,26000.79,APC
Reconstruction of mouth,40842,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,4796.64,26000.79,Radiology
Reconstruction of mouth,40842,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,4796.64,26000.79,APC
Reconstruction of mouth,40842,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,4796.64,26000.79,APC
Reconstruction of mouth,40843,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5983.93,,,,,,,fee schedule,4796.64,26000.79,
Reconstruction of mouth,40843,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4796.64,,,,,,,fee schedule,4796.64,26000.79,
Reconstruction of mouth,40843,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5239.9,,,,,,,fee schedule,4796.64,26000.79,
Reconstruction of mouth,40843,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.01,,,,,,,fee schedule,4796.64,26000.79,
Reconstruction of mouth,40843,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,4796.64,26000.79,APC 378
Reconstruction of mouth,40843,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,4796.64,26000.79,APC
Reconstruction of mouth,40843,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,4796.64,26000.79,APC
Reconstruction of mouth,40843,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,4796.64,26000.79,APC
Reconstruction of mouth,40843,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,4796.64,26000.79,Radiology
Reconstruction of mouth,40843,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,4796.64,26000.79,APC
Reconstruction of mouth,40843,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,4796.64,26000.79,APC
Reconstruction of mouth,40844,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Reconstruction of mouth,40844,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Reconstruction of mouth,40844,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Reconstruction of mouth,40844,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Reconstruction of mouth,40844,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Reconstruction of mouth,40844,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruction of mouth,40844,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruction of mouth,40844,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruction of mouth,40844,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Reconstruction of mouth,40844,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruction of mouth,40844,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruction of mouth,40845,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Reconstruction of mouth,40845,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Reconstruction of mouth,40845,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Reconstruction of mouth,40845,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Reconstruction of mouth,40845,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Reconstruction of mouth,40845,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruction of mouth,40845,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruction of mouth,40845,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruction of mouth,40845,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Reconstruction of mouth,40845,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruction of mouth,40845,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Mouth surgery procedure,40899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,624,,,,,,,fee schedule,234.47,1040.28,
Mouth surgery procedure,40899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,500.19,,,,,,,fee schedule,234.47,1040.28,
Mouth surgery procedure,40899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,546.41,,,,,,,fee schedule,234.47,1040.28,
Mouth surgery procedure,40899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,574.48,,,,,,,fee schedule,234.47,1040.28,
Mouth surgery procedure,40899,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1040.28,,,,,,,fee schedule,234.47,1040.28,APC 378
Mouth surgery procedure,40899,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,246.2,,,,,,,fee schedule,234.47,1040.28,APC
Mouth surgery procedure,40899,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,243.85,,,,,,,fee schedule,234.47,1040.28,APC
Mouth surgery procedure,40899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,234.47,,,,,,,fee schedule,234.47,1040.28,APC
Mouth surgery procedure,40899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,358.74,,,,,,,fee schedule,234.47,1040.28,Radiology
Mouth surgery procedure,40899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,328.26,,,,,,,fee schedule,234.47,1040.28,APC
Mouth surgery procedure,40899,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,410.33,,,,,,,fee schedule,234.47,1040.28,APC
Drainage of mouth lesion,41000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4075.29,,,,,,,fee schedule,533.92,4075.29,
Drainage of mouth lesion,41000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3266.7,,,,,,,fee schedule,533.92,4075.29,
Drainage of mouth lesion,41000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3568.58,,,,,,,fee schedule,533.92,4075.29,
Drainage of mouth lesion,41000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3751.86,,,,,,,fee schedule,533.92,4075.29,
Drainage of mouth lesion,41000,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2368.81,,,,,,,fee schedule,533.92,4075.29,APC 378
Drainage of mouth lesion,41000,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,560.61,,,,,,,fee schedule,533.92,4075.29,APC
Drainage of mouth lesion,41000,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,555.27,,,,,,,fee schedule,533.92,4075.29,APC
Drainage of mouth lesion,41000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,533.92,,,,,,,fee schedule,533.92,4075.29,APC
Drainage of mouth lesion,41000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,816.89,,,,,,,fee schedule,533.92,4075.29,Radiology
Drainage of mouth lesion,41000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,747.48,,,,,,,fee schedule,533.92,4075.29,APC
Drainage of mouth lesion,41000,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,934.36,,,,,,,fee schedule,533.92,4075.29,APC
Drainage of mouth lesion,41005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,624,,,,,,,fee schedule,234.47,1040.28,
Drainage of mouth lesion,41005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,500.19,,,,,,,fee schedule,234.47,1040.28,
Drainage of mouth lesion,41005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,546.41,,,,,,,fee schedule,234.47,1040.28,
Drainage of mouth lesion,41005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,574.48,,,,,,,fee schedule,234.47,1040.28,
Drainage of mouth lesion,41005,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1040.28,,,,,,,fee schedule,234.47,1040.28,APC 378
Drainage of mouth lesion,41005,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,246.2,,,,,,,fee schedule,234.47,1040.28,APC
Drainage of mouth lesion,41005,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,243.85,,,,,,,fee schedule,234.47,1040.28,APC
Drainage of mouth lesion,41005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,234.47,,,,,,,fee schedule,234.47,1040.28,APC
Drainage of mouth lesion,41005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,358.74,,,,,,,fee schedule,234.47,1040.28,Radiology
Drainage of mouth lesion,41005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,328.26,,,,,,,fee schedule,234.47,1040.28,APC
Drainage of mouth lesion,41005,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,410.33,,,,,,,fee schedule,234.47,1040.28,APC
Drainage of mouth lesion,41006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5983.93,,,,,,,fee schedule,1536.02,6814.79,
Drainage of mouth lesion,41006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4796.64,,,,,,,fee schedule,1536.02,6814.79,
Drainage of mouth lesion,41006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5239.9,,,,,,,fee schedule,1536.02,6814.79,
Drainage of mouth lesion,41006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.01,,,,,,,fee schedule,1536.02,6814.79,
Drainage of mouth lesion,41006,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1536.02,6814.79,APC 378
Drainage of mouth lesion,41006,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1536.02,6814.79,APC
Drainage of mouth lesion,41006,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1536.02,6814.79,APC
Drainage of mouth lesion,41006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1536.02,6814.79,APC
Drainage of mouth lesion,41006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1536.02,6814.79,Radiology
Drainage of mouth lesion,41006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1536.02,6814.79,APC
Drainage of mouth lesion,41006,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1536.02,6814.79,APC
Drainage of mouth lesion,41007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4075.29,,,,,,,fee schedule,1536.02,6814.79,
Drainage of mouth lesion,41007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3266.7,,,,,,,fee schedule,1536.02,6814.79,
Drainage of mouth lesion,41007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3568.58,,,,,,,fee schedule,1536.02,6814.79,
Drainage of mouth lesion,41007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3751.86,,,,,,,fee schedule,1536.02,6814.79,
Drainage of mouth lesion,41007,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1536.02,6814.79,APC 378
Drainage of mouth lesion,41007,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1536.02,6814.79,APC
Drainage of mouth lesion,41007,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1536.02,6814.79,APC
Drainage of mouth lesion,41007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1536.02,6814.79,APC
Drainage of mouth lesion,41007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1536.02,6814.79,Radiology
Drainage of mouth lesion,41007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1536.02,6814.79,APC
Drainage of mouth lesion,41007,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1536.02,6814.79,APC
Drainage of mouth lesion,41008,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4075.29,,,,,,,fee schedule,3266.7,14562,
Drainage of mouth lesion,41008,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3266.7,,,,,,,fee schedule,3266.7,14562,
Drainage of mouth lesion,41008,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3568.58,,,,,,,fee schedule,3266.7,14562,
Drainage of mouth lesion,41008,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3751.86,,,,,,,fee schedule,3266.7,14562,
Drainage of mouth lesion,41008,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3266.7,14562,APC 378
Drainage of mouth lesion,41008,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3266.7,14562,APC
Drainage of mouth lesion,41008,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3266.7,14562,APC
Drainage of mouth lesion,41008,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3266.7,14562,APC
Drainage of mouth lesion,41008,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3266.7,14562,Radiology
Drainage of mouth lesion,41008,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3266.7,14562,APC
Drainage of mouth lesion,41008,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3266.7,14562,APC
Drainage of mouth lesion,41009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,624,,,,,,,fee schedule,500.19,2368.81,
Drainage of mouth lesion,41009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,500.19,,,,,,,fee schedule,500.19,2368.81,
Drainage of mouth lesion,41009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,546.41,,,,,,,fee schedule,500.19,2368.81,
Drainage of mouth lesion,41009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,574.48,,,,,,,fee schedule,500.19,2368.81,
Drainage of mouth lesion,41009,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2368.81,,,,,,,fee schedule,500.19,2368.81,APC 378
Drainage of mouth lesion,41009,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,560.61,,,,,,,fee schedule,500.19,2368.81,APC
Drainage of mouth lesion,41009,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,555.27,,,,,,,fee schedule,500.19,2368.81,APC
Drainage of mouth lesion,41009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,533.92,,,,,,,fee schedule,500.19,2368.81,APC
Drainage of mouth lesion,41009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,816.89,,,,,,,fee schedule,500.19,2368.81,Radiology
Drainage of mouth lesion,41009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,747.48,,,,,,,fee schedule,500.19,2368.81,APC
Drainage of mouth lesion,41009,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,934.36,,,,,,,fee schedule,500.19,2368.81,APC
Incision of tongue fold,41010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5785.34,,,,,,,fee schedule,1536.02,6814.79,
Incision of tongue fold,41010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4637.46,,,,,,,fee schedule,1536.02,6814.79,
Incision of tongue fold,41010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5066,,,,,,,fee schedule,1536.02,6814.79,
Incision of tongue fold,41010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5326.19,,,,,,,fee schedule,1536.02,6814.79,
Incision of tongue fold,41010,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1536.02,6814.79,APC 378
Incision of tongue fold,41010,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1536.02,6814.79,APC
Incision of tongue fold,41010,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1536.02,6814.79,APC
Incision of tongue fold,41010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1536.02,6814.79,APC
Incision of tongue fold,41010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1536.02,6814.79,Radiology
Incision of tongue fold,41010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1536.02,6814.79,APC
Incision of tongue fold,41010,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1536.02,6814.79,APC
Drainage of mouth lesion,41015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3360.79,,,,,,,fee schedule,533.92,3360.79,
Drainage of mouth lesion,41015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2693.96,,,,,,,fee schedule,533.92,3360.79,
Drainage of mouth lesion,41015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2942.91,,,,,,,fee schedule,533.92,3360.79,
Drainage of mouth lesion,41015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3094.06,,,,,,,fee schedule,533.92,3360.79,
Drainage of mouth lesion,41015,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2368.81,,,,,,,fee schedule,533.92,3360.79,APC 378
Drainage of mouth lesion,41015,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,560.61,,,,,,,fee schedule,533.92,3360.79,APC
Drainage of mouth lesion,41015,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,555.27,,,,,,,fee schedule,533.92,3360.79,APC
Drainage of mouth lesion,41015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,533.92,,,,,,,fee schedule,533.92,3360.79,APC
Drainage of mouth lesion,41015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,816.89,,,,,,,fee schedule,533.92,3360.79,Radiology
Drainage of mouth lesion,41015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,747.48,,,,,,,fee schedule,533.92,3360.79,APC
Drainage of mouth lesion,41015,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,934.36,,,,,,,fee schedule,533.92,3360.79,APC
Drainage of mouth lesion,41016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1858.66,,,,,,,fee schedule,1489.88,26000.79,
Drainage of mouth lesion,41016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1489.88,,,,,,,fee schedule,1489.88,26000.79,
Drainage of mouth lesion,41016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1627.56,,,,,,,fee schedule,1489.88,26000.79,
Drainage of mouth lesion,41016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1711.15,,,,,,,fee schedule,1489.88,26000.79,
Drainage of mouth lesion,41016,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,1489.88,26000.79,APC 378
Drainage of mouth lesion,41016,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,1489.88,26000.79,APC
Drainage of mouth lesion,41016,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,1489.88,26000.79,APC
Drainage of mouth lesion,41016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,1489.88,26000.79,APC
Drainage of mouth lesion,41016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,1489.88,26000.79,Radiology
Drainage of mouth lesion,41016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,1489.88,26000.79,APC
Drainage of mouth lesion,41016,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,1489.88,26000.79,APC
Drainage of mouth lesion,41017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1858.66,,,,,,,fee schedule,1489.88,14562,
Drainage of mouth lesion,41017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1489.88,,,,,,,fee schedule,1489.88,14562,
Drainage of mouth lesion,41017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1627.56,,,,,,,fee schedule,1489.88,14562,
Drainage of mouth lesion,41017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1711.15,,,,,,,fee schedule,1489.88,14562,
Drainage of mouth lesion,41017,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,1489.88,14562,APC 378
Drainage of mouth lesion,41017,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,1489.88,14562,APC
Drainage of mouth lesion,41017,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,1489.88,14562,APC
Drainage of mouth lesion,41017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,1489.88,14562,APC
Drainage of mouth lesion,41017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,1489.88,14562,Radiology
Drainage of mouth lesion,41017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,1489.88,14562,APC
Drainage of mouth lesion,41017,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,1489.88,14562,APC
Drainage of mouth lesion,41018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1858.66,,,,,,,fee schedule,1489.88,6814.79,
Drainage of mouth lesion,41018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1489.88,,,,,,,fee schedule,1489.88,6814.79,
Drainage of mouth lesion,41018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1627.56,,,,,,,fee schedule,1489.88,6814.79,
Drainage of mouth lesion,41018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1711.15,,,,,,,fee schedule,1489.88,6814.79,
Drainage of mouth lesion,41018,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1489.88,6814.79,APC 378
Drainage of mouth lesion,41018,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1489.88,6814.79,APC
Drainage of mouth lesion,41018,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1489.88,6814.79,APC
Drainage of mouth lesion,41018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1489.88,6814.79,APC
Drainage of mouth lesion,41018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1489.88,6814.79,Radiology
Drainage of mouth lesion,41018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1489.88,6814.79,APC
Drainage of mouth lesion,41018,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1489.88,6814.79,APC
Place needles h&n for rt,41019,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5983.93,,,,,,,fee schedule,4796.64,26000.79,
Place needles h&n for rt,41019,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4796.64,,,,,,,fee schedule,4796.64,26000.79,
Place needles h&n for rt,41019,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5239.9,,,,,,,fee schedule,4796.64,26000.79,
Place needles h&n for rt,41019,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.01,,,,,,,fee schedule,4796.64,26000.79,
Place needles h&n for rt,41019,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,4796.64,26000.79,APC 378
Place needles h&n for rt,41019,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,4796.64,26000.79,APC
Place needles h&n for rt,41019,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,4796.64,26000.79,APC
Place needles h&n for rt,41019,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,4796.64,26000.79,APC
Place needles h&n for rt,41019,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,4796.64,26000.79,Radiology
Place needles h&n for rt,41019,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,4796.64,26000.79,APC
Place needles h&n for rt,41019,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,4796.64,26000.79,APC
Biopsy of tongue,41100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1858.66,,,,,,,fee schedule,533.92,2368.81,
Biopsy of tongue,41100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1489.88,,,,,,,fee schedule,533.92,2368.81,
Biopsy of tongue,41100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1627.56,,,,,,,fee schedule,533.92,2368.81,
Biopsy of tongue,41100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1711.15,,,,,,,fee schedule,533.92,2368.81,
Biopsy of tongue,41100,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2368.81,,,,,,,fee schedule,533.92,2368.81,APC 378
Biopsy of tongue,41100,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,560.61,,,,,,,fee schedule,533.92,2368.81,APC
Biopsy of tongue,41100,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,555.27,,,,,,,fee schedule,533.92,2368.81,APC
Biopsy of tongue,41100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,533.92,,,,,,,fee schedule,533.92,2368.81,APC
Biopsy of tongue,41100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,816.89,,,,,,,fee schedule,533.92,2368.81,Radiology
Biopsy of tongue,41100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,747.48,,,,,,,fee schedule,533.92,2368.81,APC
Biopsy of tongue,41100,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,934.36,,,,,,,fee schedule,533.92,2368.81,APC
Biopsy of tongue,41105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4075.29,,,,,,,fee schedule,3266.7,14562,
Biopsy of tongue,41105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3266.7,,,,,,,fee schedule,3266.7,14562,
Biopsy of tongue,41105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3568.58,,,,,,,fee schedule,3266.7,14562,
Biopsy of tongue,41105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3751.86,,,,,,,fee schedule,3266.7,14562,
Biopsy of tongue,41105,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3266.7,14562,APC 378
Biopsy of tongue,41105,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3266.7,14562,APC
Biopsy of tongue,41105,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3266.7,14562,APC
Biopsy of tongue,41105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3266.7,14562,APC
Biopsy of tongue,41105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3266.7,14562,Radiology
Biopsy of tongue,41105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3266.7,14562,APC
Biopsy of tongue,41105,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3266.7,14562,APC
Biopsy of floor of mouth,41108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1858.66,,,,,,,fee schedule,1489.88,7254.06,
Biopsy of floor of mouth,41108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1489.88,,,,,,,fee schedule,1489.88,7254.06,
Biopsy of floor of mouth,41108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1627.56,,,,,,,fee schedule,1489.88,7254.06,
Biopsy of floor of mouth,41108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1711.15,,,,,,,fee schedule,1489.88,7254.06,
Biopsy of floor of mouth,41108,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1489.88,7254.06,APC 378
Biopsy of floor of mouth,41108,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1489.88,7254.06,APC
Biopsy of floor of mouth,41108,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1489.88,7254.06,APC
Biopsy of floor of mouth,41108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1489.88,7254.06,APC
Biopsy of floor of mouth,41108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1489.88,7254.06,Radiology
Biopsy of floor of mouth,41108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1489.88,7254.06,APC
Biopsy of floor of mouth,41108,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1489.88,7254.06,APC
Excision of tongue lesion,41110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4075.29,,,,,,,fee schedule,3266.7,14562,
Excision of tongue lesion,41110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3266.7,,,,,,,fee schedule,3266.7,14562,
Excision of tongue lesion,41110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3568.58,,,,,,,fee schedule,3266.7,14562,
Excision of tongue lesion,41110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3751.86,,,,,,,fee schedule,3266.7,14562,
Excision of tongue lesion,41110,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3266.7,14562,APC 378
Excision of tongue lesion,41110,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3266.7,14562,APC
Excision of tongue lesion,41110,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3266.7,14562,APC
Excision of tongue lesion,41110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3266.7,14562,APC
Excision of tongue lesion,41110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3266.7,14562,Radiology
Excision of tongue lesion,41110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3266.7,14562,APC
Excision of tongue lesion,41110,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3266.7,14562,APC
Excision of tongue lesion,41112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4200.98,,,,,,,fee schedule,3282.2,14562,
Excision of tongue lesion,41112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3367.45,,,,,,,fee schedule,3282.2,14562,
Excision of tongue lesion,41112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3678.64,,,,,,,fee schedule,3282.2,14562,
Excision of tongue lesion,41112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3867.57,,,,,,,fee schedule,3282.2,14562,
Excision of tongue lesion,41112,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Excision of tongue lesion,41112,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Excision of tongue lesion,41112,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Excision of tongue lesion,41112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Excision of tongue lesion,41112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Excision of tongue lesion,41112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Excision of tongue lesion,41112,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Excision of tongue lesion,41113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4075.29,,,,,,,fee schedule,3266.7,14562,
Excision of tongue lesion,41113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3266.7,,,,,,,fee schedule,3266.7,14562,
Excision of tongue lesion,41113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3568.58,,,,,,,fee schedule,3266.7,14562,
Excision of tongue lesion,41113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3751.86,,,,,,,fee schedule,3266.7,14562,
Excision of tongue lesion,41113,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3266.7,14562,APC 378
Excision of tongue lesion,41113,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3266.7,14562,APC
Excision of tongue lesion,41113,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3266.7,14562,APC
Excision of tongue lesion,41113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3266.7,14562,APC
Excision of tongue lesion,41113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3266.7,14562,Radiology
Excision of tongue lesion,41113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3266.7,14562,APC
Excision of tongue lesion,41113,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3266.7,14562,APC
Excision of tongue lesion,41114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5983.93,,,,,,,fee schedule,3282.2,14562,
Excision of tongue lesion,41114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4796.64,,,,,,,fee schedule,3282.2,14562,
Excision of tongue lesion,41114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5239.9,,,,,,,fee schedule,3282.2,14562,
Excision of tongue lesion,41114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.01,,,,,,,fee schedule,3282.2,14562,
Excision of tongue lesion,41114,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Excision of tongue lesion,41114,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Excision of tongue lesion,41114,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Excision of tongue lesion,41114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Excision of tongue lesion,41114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Excision of tongue lesion,41114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Excision of tongue lesion,41114,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Excision of tongue fold,41115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1858.66,,,,,,,fee schedule,1489.88,6814.79,
Excision of tongue fold,41115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1489.88,,,,,,,fee schedule,1489.88,6814.79,
Excision of tongue fold,41115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1627.56,,,,,,,fee schedule,1489.88,6814.79,
Excision of tongue fold,41115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1711.15,,,,,,,fee schedule,1489.88,6814.79,
Excision of tongue fold,41115,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1489.88,6814.79,APC 378
Excision of tongue fold,41115,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1489.88,6814.79,APC
Excision of tongue fold,41115,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1489.88,6814.79,APC
Excision of tongue fold,41115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1489.88,6814.79,APC
Excision of tongue fold,41115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1489.88,6814.79,Radiology
Excision of tongue fold,41115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1489.88,6814.79,APC
Excision of tongue fold,41115,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1489.88,6814.79,APC
Excision of mouth lesion,41116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4075.29,,,,,,,fee schedule,3266.7,14562,
Excision of mouth lesion,41116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3266.7,,,,,,,fee schedule,3266.7,14562,
Excision of mouth lesion,41116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3568.58,,,,,,,fee schedule,3266.7,14562,
Excision of mouth lesion,41116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3751.86,,,,,,,fee schedule,3266.7,14562,
Excision of mouth lesion,41116,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3266.7,14562,APC 378
Excision of mouth lesion,41116,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3266.7,14562,APC
Excision of mouth lesion,41116,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3266.7,14562,APC
Excision of mouth lesion,41116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3266.7,14562,APC
Excision of mouth lesion,41116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3266.7,14562,Radiology
Excision of mouth lesion,41116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3266.7,14562,APC
Excision of mouth lesion,41116,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3266.7,14562,APC
Partial removal of tongue,41120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6253.46,,,,,,,fee schedule,5012.69,26000.79,
Partial removal of tongue,41120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5012.69,,,,,,,fee schedule,5012.69,26000.79,
Partial removal of tongue,41120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5475.91,,,,,,,fee schedule,5012.69,26000.79,
Partial removal of tongue,41120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5757.15,,,,,,,fee schedule,5012.69,26000.79,
Partial removal of tongue,41120,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5012.69,26000.79,APC 378
Partial removal of tongue,41120,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5012.69,26000.79,APC
Partial removal of tongue,41120,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5012.69,26000.79,APC
Partial removal of tongue,41120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5012.69,26000.79,APC
Partial removal of tongue,41120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5012.69,26000.79,Radiology
Partial removal of tongue,41120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5012.69,26000.79,APC
Partial removal of tongue,41120,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5012.69,26000.79,APC
Repair tongue laceration,41250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,386.85,,,,,,,fee schedule,310.09,1962.08,
Repair tongue laceration,41250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,310.09,,,,,,,fee schedule,310.09,1962.08,
Repair tongue laceration,41250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,338.75,,,,,,,fee schedule,310.09,1962.08,
Repair tongue laceration,41250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,356.14,,,,,,,fee schedule,310.09,1962.08,
Repair tongue laceration,41250,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1962.08,,,,,,,fee schedule,310.09,1962.08,APC 378
Repair tongue laceration,41250,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,464.35,,,,,,,fee schedule,310.09,1962.08,APC
Repair tongue laceration,41250,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,459.93,,,,,,,fee schedule,310.09,1962.08,APC
Repair tongue laceration,41250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,442.24,,,,,,,fee schedule,310.09,1962.08,APC
Repair tongue laceration,41250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,676.63,,,,,,,fee schedule,310.09,1962.08,Radiology
Repair tongue laceration,41250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,619.14,,,,,,,fee schedule,310.09,1962.08,APC
Repair tongue laceration,41250,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,773.92,,,,,,,fee schedule,310.09,1962.08,APC
Repair tongue laceration,41251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,624,,,,,,,fee schedule,234.47,1040.28,
Repair tongue laceration,41251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,500.19,,,,,,,fee schedule,234.47,1040.28,
Repair tongue laceration,41251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,546.41,,,,,,,fee schedule,234.47,1040.28,
Repair tongue laceration,41251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,574.48,,,,,,,fee schedule,234.47,1040.28,
Repair tongue laceration,41251,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1040.28,,,,,,,fee schedule,234.47,1040.28,APC 378
Repair tongue laceration,41251,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,246.2,,,,,,,fee schedule,234.47,1040.28,APC
Repair tongue laceration,41251,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,243.85,,,,,,,fee schedule,234.47,1040.28,APC
Repair tongue laceration,41251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,234.47,,,,,,,fee schedule,234.47,1040.28,APC
Repair tongue laceration,41251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,358.74,,,,,,,fee schedule,234.47,1040.28,Radiology
Repair tongue laceration,41251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,328.26,,,,,,,fee schedule,234.47,1040.28,APC
Repair tongue laceration,41251,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,410.33,,,,,,,fee schedule,234.47,1040.28,APC
Repair tongue laceration,41252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1858.66,,,,,,,fee schedule,234.47,1858.66,
Repair tongue laceration,41252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1489.88,,,,,,,fee schedule,234.47,1858.66,
Repair tongue laceration,41252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1627.56,,,,,,,fee schedule,234.47,1858.66,
Repair tongue laceration,41252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1711.15,,,,,,,fee schedule,234.47,1858.66,
Repair tongue laceration,41252,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1040.28,,,,,,,fee schedule,234.47,1858.66,APC 378
Repair tongue laceration,41252,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,246.2,,,,,,,fee schedule,234.47,1858.66,APC
Repair tongue laceration,41252,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,243.85,,,,,,,fee schedule,234.47,1858.66,APC
Repair tongue laceration,41252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,234.47,,,,,,,fee schedule,234.47,1858.66,APC
Repair tongue laceration,41252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,358.74,,,,,,,fee schedule,234.47,1858.66,Radiology
Repair tongue laceration,41252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,328.26,,,,,,,fee schedule,234.47,1858.66,APC
Repair tongue laceration,41252,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,410.33,,,,,,,fee schedule,234.47,1858.66,APC
Tongue to lip surgery,41510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4075.29,,,,,,,fee schedule,3266.7,14562,
Tongue to lip surgery,41510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3266.7,,,,,,,fee schedule,3266.7,14562,
Tongue to lip surgery,41510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3568.58,,,,,,,fee schedule,3266.7,14562,
Tongue to lip surgery,41510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3751.86,,,,,,,fee schedule,3266.7,14562,
Tongue to lip surgery,41510,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3266.7,14562,APC 378
Tongue to lip surgery,41510,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3266.7,14562,APC
Tongue to lip surgery,41510,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3266.7,14562,APC
Tongue to lip surgery,41510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3266.7,14562,APC
Tongue to lip surgery,41510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3266.7,14562,Radiology
Tongue to lip surgery,41510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3266.7,14562,APC
Tongue to lip surgery,41510,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3266.7,14562,APC
Tongue suspension,41512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2013.98,,,,,,,fee schedule,1614.38,26000.79,
Tongue suspension,41512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1614.38,,,,,,,fee schedule,1614.38,26000.79,
Tongue suspension,41512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1763.57,,,,,,,fee schedule,1614.38,26000.79,
Tongue suspension,41512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1854.14,,,,,,,fee schedule,1614.38,26000.79,
Tongue suspension,41512,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,1614.38,26000.79,APC 378
Tongue suspension,41512,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,1614.38,26000.79,APC
Tongue suspension,41512,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,1614.38,26000.79,APC
Tongue suspension,41512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,1614.38,26000.79,APC
Tongue suspension,41512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,1614.38,26000.79,Radiology
Tongue suspension,41512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,1614.38,26000.79,APC
Tongue suspension,41512,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,1614.38,26000.79,APC
Reconstruction tongue fold,41520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1858.66,,,,,,,fee schedule,1489.88,14562,
Reconstruction tongue fold,41520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1489.88,,,,,,,fee schedule,1489.88,14562,
Reconstruction tongue fold,41520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1627.56,,,,,,,fee schedule,1489.88,14562,
Reconstruction tongue fold,41520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1711.15,,,,,,,fee schedule,1489.88,14562,
Reconstruction tongue fold,41520,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,1489.88,14562,APC 378
Reconstruction tongue fold,41520,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,1489.88,14562,APC
Reconstruction tongue fold,41520,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,1489.88,14562,APC
Reconstruction tongue fold,41520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,1489.88,14562,APC
Reconstruction tongue fold,41520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,1489.88,14562,Radiology
Reconstruction tongue fold,41520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,1489.88,14562,APC
Reconstruction tongue fold,41520,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,1489.88,14562,APC
Tongue base vol reduction,41530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1680.39,,,,,,,fee schedule,1346.98,14562,
Tongue base vol reduction,41530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1346.98,,,,,,,fee schedule,1346.98,14562,
Tongue base vol reduction,41530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1471.45,,,,,,,fee schedule,1346.98,14562,
Tongue base vol reduction,41530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1547.03,,,,,,,fee schedule,1346.98,14562,
Tongue base vol reduction,41530,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,1346.98,14562,APC 378
Tongue base vol reduction,41530,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,1346.98,14562,APC
Tongue base vol reduction,41530,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,1346.98,14562,APC
Tongue base vol reduction,41530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,1346.98,14562,APC
Tongue base vol reduction,41530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,1346.98,14562,Radiology
Tongue base vol reduction,41530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,1346.98,14562,APC
Tongue base vol reduction,41530,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,1346.98,14562,APC
Tongue and mouth surgery,41599,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4047.11,,,,,,,fee schedule,234.47,4047.11,
Tongue and mouth surgery,41599,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3244.11,,,,,,,fee schedule,234.47,4047.11,
Tongue and mouth surgery,41599,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3543.9,,,,,,,fee schedule,234.47,4047.11,
Tongue and mouth surgery,41599,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3725.91,,,,,,,fee schedule,234.47,4047.11,
Tongue and mouth surgery,41599,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1040.28,,,,,,,fee schedule,234.47,4047.11,APC 378
Tongue and mouth surgery,41599,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,246.2,,,,,,,fee schedule,234.47,4047.11,APC
Tongue and mouth surgery,41599,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,243.85,,,,,,,fee schedule,234.47,4047.11,APC
Tongue and mouth surgery,41599,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,234.47,,,,,,,fee schedule,234.47,4047.11,APC
Tongue and mouth surgery,41599,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,358.74,,,,,,,fee schedule,234.47,4047.11,Radiology
Tongue and mouth surgery,41599,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,328.26,,,,,,,fee schedule,234.47,4047.11,APC
Tongue and mouth surgery,41599,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,410.33,,,,,,,fee schedule,234.47,4047.11,APC
Drainage of gum lesion,41800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,248.14,,,,,,,fee schedule,131.71,584.37,
Drainage of gum lesion,41800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,198.91,,,,,,,fee schedule,131.71,584.37,
Drainage of gum lesion,41800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,217.29,,,,,,,fee schedule,131.71,584.37,
Drainage of gum lesion,41800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,228.45,,,,,,,fee schedule,131.71,584.37,
Drainage of gum lesion,41800,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,131.71,584.37,APC 378
Drainage of gum lesion,41800,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,131.71,584.37,APC
Drainage of gum lesion,41800,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,131.71,584.37,APC
Drainage of gum lesion,41800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,131.71,584.37,APC
Drainage of gum lesion,41800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,131.71,584.37,Radiology
Drainage of gum lesion,41800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,131.71,584.37,APC
Drainage of gum lesion,41800,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,131.71,584.37,APC
Removal foreign body gum,41805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5983.93,,,,,,,fee schedule,1536.02,6814.79,
Removal foreign body gum,41805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4796.64,,,,,,,fee schedule,1536.02,6814.79,
Removal foreign body gum,41805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5239.9,,,,,,,fee schedule,1536.02,6814.79,
Removal foreign body gum,41805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.01,,,,,,,fee schedule,1536.02,6814.79,
Removal foreign body gum,41805,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1536.02,6814.79,APC 378
Removal foreign body gum,41805,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1536.02,6814.79,APC
Removal foreign body gum,41805,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1536.02,6814.79,APC
Removal foreign body gum,41805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1536.02,6814.79,APC
Removal foreign body gum,41805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1536.02,6814.79,Radiology
Removal foreign body gum,41805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1536.02,6814.79,APC
Removal foreign body gum,41805,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1536.02,6814.79,APC
Removal foreign body jawbone,41806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4075.29,,,,,,,fee schedule,1536.02,6814.79,
Removal foreign body jawbone,41806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3266.7,,,,,,,fee schedule,1536.02,6814.79,
Removal foreign body jawbone,41806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3568.58,,,,,,,fee schedule,1536.02,6814.79,
Removal foreign body jawbone,41806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3751.86,,,,,,,fee schedule,1536.02,6814.79,
Removal foreign body jawbone,41806,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1536.02,6814.79,APC 378
Removal foreign body jawbone,41806,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1536.02,6814.79,APC
Removal foreign body jawbone,41806,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1536.02,6814.79,APC
Removal foreign body jawbone,41806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1536.02,6814.79,APC
Removal foreign body jawbone,41806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1536.02,6814.79,Radiology
Removal foreign body jawbone,41806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1536.02,6814.79,APC
Removal foreign body jawbone,41806,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1536.02,6814.79,APC
Excision gum each quadrant,41820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1858.66,,,,,,,fee schedule,1489.88,14562,
Excision gum each quadrant,41820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1489.88,,,,,,,fee schedule,1489.88,14562,
Excision gum each quadrant,41820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1627.56,,,,,,,fee schedule,1489.88,14562,
Excision gum each quadrant,41820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1711.15,,,,,,,fee schedule,1489.88,14562,
Excision gum each quadrant,41820,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,1489.88,14562,APC 378
Excision gum each quadrant,41820,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,1489.88,14562,APC
Excision gum each quadrant,41820,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,1489.88,14562,APC
Excision gum each quadrant,41820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,1489.88,14562,APC
Excision gum each quadrant,41820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,1489.88,14562,Radiology
Excision gum each quadrant,41820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,1489.88,14562,APC
Excision gum each quadrant,41820,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,1489.88,14562,APC
Excision of gum flap,41821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1858.66,,,,,,,fee schedule,1489.88,6814.79,
Excision of gum flap,41821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1489.88,,,,,,,fee schedule,1489.88,6814.79,
Excision of gum flap,41821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1627.56,,,,,,,fee schedule,1489.88,6814.79,
Excision of gum flap,41821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1711.15,,,,,,,fee schedule,1489.88,6814.79,
Excision of gum flap,41821,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1489.88,6814.79,APC 378
Excision of gum flap,41821,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1489.88,6814.79,APC
Excision of gum flap,41821,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1489.88,6814.79,APC
Excision of gum flap,41821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1489.88,6814.79,APC
Excision of gum flap,41821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1489.88,6814.79,Radiology
Excision of gum flap,41821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1489.88,6814.79,APC
Excision of gum flap,41821,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1489.88,6814.79,APC
Excision of gum lesion,41822,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4075.29,,,,,,,fee schedule,1536.02,6814.79,
Excision of gum lesion,41822,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3266.7,,,,,,,fee schedule,1536.02,6814.79,
Excision of gum lesion,41822,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3568.58,,,,,,,fee schedule,1536.02,6814.79,
Excision of gum lesion,41822,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3751.86,,,,,,,fee schedule,1536.02,6814.79,
Excision of gum lesion,41822,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1536.02,6814.79,APC 378
Excision of gum lesion,41822,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1536.02,6814.79,APC
Excision of gum lesion,41822,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1536.02,6814.79,APC
Excision of gum lesion,41822,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1536.02,6814.79,APC
Excision of gum lesion,41822,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1536.02,6814.79,Radiology
Excision of gum lesion,41822,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1536.02,6814.79,APC
Excision of gum lesion,41822,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1536.02,6814.79,APC
Excision of gum lesion,41823,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5983.93,,,,,,,fee schedule,4796.64,26000.79,
Excision of gum lesion,41823,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4796.64,,,,,,,fee schedule,4796.64,26000.79,
Excision of gum lesion,41823,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5239.9,,,,,,,fee schedule,4796.64,26000.79,
Excision of gum lesion,41823,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.01,,,,,,,fee schedule,4796.64,26000.79,
Excision of gum lesion,41823,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,4796.64,26000.79,APC 378
Excision of gum lesion,41823,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,4796.64,26000.79,APC
Excision of gum lesion,41823,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,4796.64,26000.79,APC
Excision of gum lesion,41823,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,4796.64,26000.79,APC
Excision of gum lesion,41823,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,4796.64,26000.79,Radiology
Excision of gum lesion,41823,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,4796.64,26000.79,APC
Excision of gum lesion,41823,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,4796.64,26000.79,APC
Excision of gum lesion,41825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4075.29,,,,,,,fee schedule,3266.7,14562,
Excision of gum lesion,41825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3266.7,,,,,,,fee schedule,3266.7,14562,
Excision of gum lesion,41825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3568.58,,,,,,,fee schedule,3266.7,14562,
Excision of gum lesion,41825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3751.86,,,,,,,fee schedule,3266.7,14562,
Excision of gum lesion,41825,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3266.7,14562,APC 378
Excision of gum lesion,41825,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3266.7,14562,APC
Excision of gum lesion,41825,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3266.7,14562,APC
Excision of gum lesion,41825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3266.7,14562,APC
Excision of gum lesion,41825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3266.7,14562,Radiology
Excision of gum lesion,41825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3266.7,14562,APC
Excision of gum lesion,41825,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3266.7,14562,APC
Excision of gum lesion,41826,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4075.29,,,,,,,fee schedule,3266.7,14562,
Excision of gum lesion,41826,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3266.7,,,,,,,fee schedule,3266.7,14562,
Excision of gum lesion,41826,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3568.58,,,,,,,fee schedule,3266.7,14562,
Excision of gum lesion,41826,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3751.86,,,,,,,fee schedule,3266.7,14562,
Excision of gum lesion,41826,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3266.7,14562,APC 378
Excision of gum lesion,41826,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3266.7,14562,APC
Excision of gum lesion,41826,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3266.7,14562,APC
Excision of gum lesion,41826,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3266.7,14562,APC
Excision of gum lesion,41826,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3266.7,14562,Radiology
Excision of gum lesion,41826,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3266.7,14562,APC
Excision of gum lesion,41826,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3266.7,14562,APC
Excision of gum lesion,41827,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5983.93,,,,,,,fee schedule,4796.64,26000.79,
Excision of gum lesion,41827,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4796.64,,,,,,,fee schedule,4796.64,26000.79,
Excision of gum lesion,41827,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5239.9,,,,,,,fee schedule,4796.64,26000.79,
Excision of gum lesion,41827,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.01,,,,,,,fee schedule,4796.64,26000.79,
Excision of gum lesion,41827,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,4796.64,26000.79,APC 378
Excision of gum lesion,41827,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,4796.64,26000.79,APC
Excision of gum lesion,41827,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,4796.64,26000.79,APC
Excision of gum lesion,41827,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,4796.64,26000.79,APC
Excision of gum lesion,41827,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,4796.64,26000.79,Radiology
Excision of gum lesion,41827,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,4796.64,26000.79,APC
Excision of gum lesion,41827,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,4796.64,26000.79,APC
Excision of gum lesion,41828,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4075.29,,,,,,,fee schedule,1536.02,6814.79,
Excision of gum lesion,41828,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3266.7,,,,,,,fee schedule,1536.02,6814.79,
Excision of gum lesion,41828,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3568.58,,,,,,,fee schedule,1536.02,6814.79,
Excision of gum lesion,41828,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3751.86,,,,,,,fee schedule,1536.02,6814.79,
Excision of gum lesion,41828,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1536.02,6814.79,APC 378
Excision of gum lesion,41828,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1536.02,6814.79,APC
Excision of gum lesion,41828,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1536.02,6814.79,APC
Excision of gum lesion,41828,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1536.02,6814.79,APC
Excision of gum lesion,41828,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1536.02,6814.79,Radiology
Excision of gum lesion,41828,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1536.02,6814.79,APC
Excision of gum lesion,41828,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1536.02,6814.79,APC
Removal of gum tissue,41830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4075.29,,,,,,,fee schedule,3266.7,14562,
Removal of gum tissue,41830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3266.7,,,,,,,fee schedule,3266.7,14562,
Removal of gum tissue,41830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3568.58,,,,,,,fee schedule,3266.7,14562,
Removal of gum tissue,41830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3751.86,,,,,,,fee schedule,3266.7,14562,
Removal of gum tissue,41830,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3266.7,14562,APC 378
Removal of gum tissue,41830,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3266.7,14562,APC
Removal of gum tissue,41830,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3266.7,14562,APC
Removal of gum tissue,41830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3266.7,14562,APC
Removal of gum tissue,41830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3266.7,14562,Radiology
Removal of gum tissue,41830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3266.7,14562,APC
Removal of gum tissue,41830,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3266.7,14562,APC
Treatment of gum lesion,41850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4075.29,,,,,,,fee schedule,1536.02,6814.79,
Treatment of gum lesion,41850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3266.7,,,,,,,fee schedule,1536.02,6814.79,
Treatment of gum lesion,41850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3568.58,,,,,,,fee schedule,1536.02,6814.79,
Treatment of gum lesion,41850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3751.86,,,,,,,fee schedule,1536.02,6814.79,
Treatment of gum lesion,41850,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1536.02,6814.79,APC 378
Treatment of gum lesion,41850,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1536.02,6814.79,APC
Treatment of gum lesion,41850,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1536.02,6814.79,APC
Treatment of gum lesion,41850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1536.02,6814.79,APC
Treatment of gum lesion,41850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1536.02,6814.79,Radiology
Treatment of gum lesion,41850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1536.02,6814.79,APC
Treatment of gum lesion,41850,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1536.02,6814.79,APC
Gum graft,41870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5983.93,,,,,,,fee schedule,1536.02,6814.79,
Gum graft,41870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4796.64,,,,,,,fee schedule,1536.02,6814.79,
Gum graft,41870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5239.9,,,,,,,fee schedule,1536.02,6814.79,
Gum graft,41870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.01,,,,,,,fee schedule,1536.02,6814.79,
Gum graft,41870,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1536.02,6814.79,APC 378
Gum graft,41870,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1536.02,6814.79,APC
Gum graft,41870,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1536.02,6814.79,APC
Gum graft,41870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1536.02,6814.79,APC
Gum graft,41870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1536.02,6814.79,Radiology
Gum graft,41870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1536.02,6814.79,APC
Gum graft,41870,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1536.02,6814.79,APC
Repair gum,41872,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4075.29,,,,,,,fee schedule,3266.7,14562,
Repair gum,41872,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3266.7,,,,,,,fee schedule,3266.7,14562,
Repair gum,41872,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3568.58,,,,,,,fee schedule,3266.7,14562,
Repair gum,41872,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3751.86,,,,,,,fee schedule,3266.7,14562,
Repair gum,41872,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3266.7,14562,APC 378
Repair gum,41872,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3266.7,14562,APC
Repair gum,41872,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3266.7,14562,APC
Repair gum,41872,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3266.7,14562,APC
Repair gum,41872,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3266.7,14562,Radiology
Repair gum,41872,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3266.7,14562,APC
Repair gum,41872,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3266.7,14562,APC
Repair tooth socket,41874,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5983.93,,,,,,,fee schedule,3282.2,14562,
Repair tooth socket,41874,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4796.64,,,,,,,fee schedule,3282.2,14562,
Repair tooth socket,41874,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5239.9,,,,,,,fee schedule,3282.2,14562,
Repair tooth socket,41874,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.01,,,,,,,fee schedule,3282.2,14562,
Repair tooth socket,41874,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Repair tooth socket,41874,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Repair tooth socket,41874,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Repair tooth socket,41874,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Repair tooth socket,41874,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Repair tooth socket,41874,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Repair tooth socket,41874,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Dental surgery procedure,41899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6413.83,,,,,,,fee schedule,234.47,6413.83,
Dental surgery procedure,41899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5141.24,,,,,,,fee schedule,234.47,6413.83,
Dental surgery procedure,41899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5616.34,,,,,,,fee schedule,234.47,6413.83,
Dental surgery procedure,41899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5904.79,,,,,,,fee schedule,234.47,6413.83,
Dental surgery procedure,41899,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1040.28,,,,,,,fee schedule,234.47,6413.83,APC 378
Dental surgery procedure,41899,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,246.2,,,,,,,fee schedule,234.47,6413.83,APC
Dental surgery procedure,41899,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,243.85,,,,,,,fee schedule,234.47,6413.83,APC
Dental surgery procedure,41899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,234.47,,,,,,,fee schedule,234.47,6413.83,APC
Dental surgery procedure,41899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,358.74,,,,,,,fee schedule,234.47,6413.83,Radiology
Dental surgery procedure,41899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,328.26,,,,,,,fee schedule,234.47,6413.83,APC
Dental surgery procedure,41899,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,410.33,,,,,,,fee schedule,234.47,6413.83,APC
Drainage mouth roof lesion,42000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,624,,,,,,,fee schedule,234.47,1040.28,
Drainage mouth roof lesion,42000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,500.19,,,,,,,fee schedule,234.47,1040.28,
Drainage mouth roof lesion,42000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,546.41,,,,,,,fee schedule,234.47,1040.28,
Drainage mouth roof lesion,42000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,574.48,,,,,,,fee schedule,234.47,1040.28,
Drainage mouth roof lesion,42000,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1040.28,,,,,,,fee schedule,234.47,1040.28,APC 378
Drainage mouth roof lesion,42000,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,246.2,,,,,,,fee schedule,234.47,1040.28,APC
Drainage mouth roof lesion,42000,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,243.85,,,,,,,fee schedule,234.47,1040.28,APC
Drainage mouth roof lesion,42000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,234.47,,,,,,,fee schedule,234.47,1040.28,APC
Drainage mouth roof lesion,42000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,358.74,,,,,,,fee schedule,234.47,1040.28,Radiology
Drainage mouth roof lesion,42000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,328.26,,,,,,,fee schedule,234.47,1040.28,APC
Drainage mouth roof lesion,42000,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,410.33,,,,,,,fee schedule,234.47,1040.28,APC
Biopsy roof of mouth,42100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1858.66,,,,,,,fee schedule,1489.88,6814.79,
Biopsy roof of mouth,42100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1489.88,,,,,,,fee schedule,1489.88,6814.79,
Biopsy roof of mouth,42100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1627.56,,,,,,,fee schedule,1489.88,6814.79,
Biopsy roof of mouth,42100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1711.15,,,,,,,fee schedule,1489.88,6814.79,
Biopsy roof of mouth,42100,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1489.88,6814.79,APC 378
Biopsy roof of mouth,42100,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1489.88,6814.79,APC
Biopsy roof of mouth,42100,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1489.88,6814.79,APC
Biopsy roof of mouth,42100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1489.88,6814.79,APC
Biopsy roof of mouth,42100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1489.88,6814.79,Radiology
Biopsy roof of mouth,42100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1489.88,6814.79,APC
Biopsy roof of mouth,42100,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1489.88,6814.79,APC
Excision lesion mouth roof,42104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6253.46,,,,,,,fee schedule,3282.2,14562,
Excision lesion mouth roof,42104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5012.69,,,,,,,fee schedule,3282.2,14562,
Excision lesion mouth roof,42104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5475.91,,,,,,,fee schedule,3282.2,14562,
Excision lesion mouth roof,42104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5757.15,,,,,,,fee schedule,3282.2,14562,
Excision lesion mouth roof,42104,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Excision lesion mouth roof,42104,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Excision lesion mouth roof,42104,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Excision lesion mouth roof,42104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Excision lesion mouth roof,42104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Excision lesion mouth roof,42104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Excision lesion mouth roof,42104,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Excision lesion mouth roof,42106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6721.57,,,,,,,fee schedule,3282.2,14562,
Excision lesion mouth roof,42106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5387.93,,,,,,,fee schedule,3282.2,14562,
Excision lesion mouth roof,42106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5885.82,,,,,,,fee schedule,3282.2,14562,
Excision lesion mouth roof,42106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6188.11,,,,,,,fee schedule,3282.2,14562,
Excision lesion mouth roof,42106,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Excision lesion mouth roof,42106,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Excision lesion mouth roof,42106,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Excision lesion mouth roof,42106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Excision lesion mouth roof,42106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Excision lesion mouth roof,42106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Excision lesion mouth roof,42106,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Excision lesion mouth roof,42107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5983.93,,,,,,,fee schedule,4796.64,26000.79,
Excision lesion mouth roof,42107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4796.64,,,,,,,fee schedule,4796.64,26000.79,
Excision lesion mouth roof,42107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5239.9,,,,,,,fee schedule,4796.64,26000.79,
Excision lesion mouth roof,42107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.01,,,,,,,fee schedule,4796.64,26000.79,
Excision lesion mouth roof,42107,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,4796.64,26000.79,APC 378
Excision lesion mouth roof,42107,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,4796.64,26000.79,APC
Excision lesion mouth roof,42107,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,4796.64,26000.79,APC
Excision lesion mouth roof,42107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,4796.64,26000.79,APC
Excision lesion mouth roof,42107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,4796.64,26000.79,Radiology
Excision lesion mouth roof,42107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,4796.64,26000.79,APC
Excision lesion mouth roof,42107,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,4796.64,26000.79,APC
Remove palate/lesion,42120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Remove palate/lesion,42120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Remove palate/lesion,42120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Remove palate/lesion,42120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Remove palate/lesion,42120,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Remove palate/lesion,42120,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Remove palate/lesion,42120,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Remove palate/lesion,42120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Remove palate/lesion,42120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Remove palate/lesion,42120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Remove palate/lesion,42120,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Excision of uvula,42140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3194.75,,,,,,,fee schedule,2560.87,14562,
Excision of uvula,42140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2560.87,,,,,,,fee schedule,2560.87,14562,
Excision of uvula,42140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2797.52,,,,,,,fee schedule,2560.87,14562,
Excision of uvula,42140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2941.19,,,,,,,fee schedule,2560.87,14562,
Excision of uvula,42140,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,2560.87,14562,APC 378
Excision of uvula,42140,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,2560.87,14562,APC
Excision of uvula,42140,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,2560.87,14562,APC
Excision of uvula,42140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,2560.87,14562,APC
Excision of uvula,42140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,2560.87,14562,Radiology
Excision of uvula,42140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,2560.87,14562,APC
Excision of uvula,42140,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,2560.87,14562,APC
Repair palate pharynx/uvula,42145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6721.57,,,,,,,fee schedule,5387.93,26000.79,
Repair palate pharynx/uvula,42145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5387.93,,,,,,,fee schedule,5387.93,26000.79,
Repair palate pharynx/uvula,42145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5885.82,,,,,,,fee schedule,5387.93,26000.79,
Repair palate pharynx/uvula,42145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6188.11,,,,,,,fee schedule,5387.93,26000.79,
Repair palate pharynx/uvula,42145,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5387.93,26000.79,APC 378
Repair palate pharynx/uvula,42145,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5387.93,26000.79,APC
Repair palate pharynx/uvula,42145,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5387.93,26000.79,APC
Repair palate pharynx/uvula,42145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5387.93,26000.79,APC
Repair palate pharynx/uvula,42145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5387.93,26000.79,Radiology
Repair palate pharynx/uvula,42145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5387.93,26000.79,APC
Repair palate pharynx/uvula,42145,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5387.93,26000.79,APC
Treatment mouth roof lesion,42160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4075.29,,,,,,,fee schedule,3266.7,14562,
Treatment mouth roof lesion,42160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3266.7,,,,,,,fee schedule,3266.7,14562,
Treatment mouth roof lesion,42160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3568.58,,,,,,,fee schedule,3266.7,14562,
Treatment mouth roof lesion,42160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3751.86,,,,,,,fee schedule,3266.7,14562,
Treatment mouth roof lesion,42160,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3266.7,14562,APC 378
Treatment mouth roof lesion,42160,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3266.7,14562,APC
Treatment mouth roof lesion,42160,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3266.7,14562,APC
Treatment mouth roof lesion,42160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3266.7,14562,APC
Treatment mouth roof lesion,42160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3266.7,14562,Radiology
Treatment mouth roof lesion,42160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3266.7,14562,APC
Treatment mouth roof lesion,42160,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3266.7,14562,APC
Repair palate,42180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,624,,,,,,,fee schedule,500.19,2368.81,
Repair palate,42180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,500.19,,,,,,,fee schedule,500.19,2368.81,
Repair palate,42180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,546.41,,,,,,,fee schedule,500.19,2368.81,
Repair palate,42180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,574.48,,,,,,,fee schedule,500.19,2368.81,
Repair palate,42180,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2368.81,,,,,,,fee schedule,500.19,2368.81,APC 378
Repair palate,42180,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,560.61,,,,,,,fee schedule,500.19,2368.81,APC
Repair palate,42180,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,555.27,,,,,,,fee schedule,500.19,2368.81,APC
Repair palate,42180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,533.92,,,,,,,fee schedule,500.19,2368.81,APC
Repair palate,42180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,816.89,,,,,,,fee schedule,500.19,2368.81,Radiology
Repair palate,42180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,747.48,,,,,,,fee schedule,500.19,2368.81,APC
Repair palate,42180,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,934.36,,,,,,,fee schedule,500.19,2368.81,APC
Repair palate,42182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Repair palate,42182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Repair palate,42182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Repair palate,42182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Repair palate,42182,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Repair palate,42182,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Repair palate,42182,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Repair palate,42182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Repair palate,42182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Repair palate,42182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Repair palate,42182,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruct cleft palate,42200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6272.96,,,,,,,fee schedule,5028.33,26000.79,
Reconstruct cleft palate,42200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5028.33,,,,,,,fee schedule,5028.33,26000.79,
Reconstruct cleft palate,42200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5492.99,,,,,,,fee schedule,5028.33,26000.79,
Reconstruct cleft palate,42200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5775.11,,,,,,,fee schedule,5028.33,26000.79,
Reconstruct cleft palate,42200,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5028.33,26000.79,APC 378
Reconstruct cleft palate,42200,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5028.33,26000.79,APC
Reconstruct cleft palate,42200,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5028.33,26000.79,APC
Reconstruct cleft palate,42200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5028.33,26000.79,APC
Reconstruct cleft palate,42200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5028.33,26000.79,Radiology
Reconstruct cleft palate,42200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5028.33,26000.79,APC
Reconstruct cleft palate,42200,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5028.33,26000.79,APC
Reconstruct cleft palate,42205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,3282.2,14562,
Reconstruct cleft palate,42205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,3282.2,14562,
Reconstruct cleft palate,42205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,3282.2,14562,
Reconstruct cleft palate,42205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,3282.2,14562,
Reconstruct cleft palate,42205,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Reconstruct cleft palate,42205,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Reconstruct cleft palate,42205,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Reconstruct cleft palate,42205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Reconstruct cleft palate,42205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Reconstruct cleft palate,42205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Reconstruct cleft palate,42205,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Reconstruct cleft palate,42210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Reconstruct cleft palate,42210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Reconstruct cleft palate,42210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Reconstruct cleft palate,42210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Reconstruct cleft palate,42210,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Reconstruct cleft palate,42210,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruct cleft palate,42210,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruct cleft palate,42210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruct cleft palate,42210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Reconstruct cleft palate,42210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruct cleft palate,42210,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruct cleft palate,42215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12545.92,,,,,,,fee schedule,5860.44,26000.79,
Reconstruct cleft palate,42215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10056.65,,,,,,,fee schedule,5860.44,26000.79,
Reconstruct cleft palate,42215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10985.98,,,,,,,fee schedule,5860.44,26000.79,
Reconstruct cleft palate,42215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11550.21,,,,,,,fee schedule,5860.44,26000.79,
Reconstruct cleft palate,42215,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Reconstruct cleft palate,42215,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruct cleft palate,42215,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruct cleft palate,42215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruct cleft palate,42215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Reconstruct cleft palate,42215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruct cleft palate,42215,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruct cleft palate,42220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Reconstruct cleft palate,42220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Reconstruct cleft palate,42220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Reconstruct cleft palate,42220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Reconstruct cleft palate,42220,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Reconstruct cleft palate,42220,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruct cleft palate,42220,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruct cleft palate,42220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruct cleft palate,42220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Reconstruct cleft palate,42220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruct cleft palate,42220,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruct cleft palate,42225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Reconstruct cleft palate,42225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Reconstruct cleft palate,42225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Reconstruct cleft palate,42225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Reconstruct cleft palate,42225,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Reconstruct cleft palate,42225,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruct cleft palate,42225,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruct cleft palate,42225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruct cleft palate,42225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Reconstruct cleft palate,42225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruct cleft palate,42225,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Lengthening of palate,42226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Lengthening of palate,42226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Lengthening of palate,42226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Lengthening of palate,42226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Lengthening of palate,42226,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Lengthening of palate,42226,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Lengthening of palate,42226,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Lengthening of palate,42226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Lengthening of palate,42226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Lengthening of palate,42226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Lengthening of palate,42226,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Lengthening of palate,42227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Lengthening of palate,42227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Lengthening of palate,42227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Lengthening of palate,42227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Lengthening of palate,42227,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Lengthening of palate,42227,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Lengthening of palate,42227,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Lengthening of palate,42227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Lengthening of palate,42227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Lengthening of palate,42227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Lengthening of palate,42227,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Repair palate,42235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4075.29,,,,,,,fee schedule,3266.7,26000.79,
Repair palate,42235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3266.7,,,,,,,fee schedule,3266.7,26000.79,
Repair palate,42235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3568.58,,,,,,,fee schedule,3266.7,26000.79,
Repair palate,42235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3751.86,,,,,,,fee schedule,3266.7,26000.79,
Repair palate,42235,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,3266.7,26000.79,APC 378
Repair palate,42235,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,3266.7,26000.79,APC
Repair palate,42235,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,3266.7,26000.79,APC
Repair palate,42235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,3266.7,26000.79,APC
Repair palate,42235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,3266.7,26000.79,Radiology
Repair palate,42235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,3266.7,26000.79,APC
Repair palate,42235,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,3266.7,26000.79,APC
Repair nose to lip fistula,42260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5983.93,,,,,,,fee schedule,4796.64,26000.79,
Repair nose to lip fistula,42260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4796.64,,,,,,,fee schedule,4796.64,26000.79,
Repair nose to lip fistula,42260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5239.9,,,,,,,fee schedule,4796.64,26000.79,
Repair nose to lip fistula,42260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.01,,,,,,,fee schedule,4796.64,26000.79,
Repair nose to lip fistula,42260,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,4796.64,26000.79,APC 378
Repair nose to lip fistula,42260,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,4796.64,26000.79,APC
Repair nose to lip fistula,42260,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,4796.64,26000.79,APC
Repair nose to lip fistula,42260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,4796.64,26000.79,APC
Repair nose to lip fistula,42260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,4796.64,26000.79,Radiology
Repair nose to lip fistula,42260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,4796.64,26000.79,APC
Repair nose to lip fistula,42260,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,4796.64,26000.79,APC
Preparation palate mold,42280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,624,,,,,,,fee schedule,500.19,2368.81,
Preparation palate mold,42280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,500.19,,,,,,,fee schedule,500.19,2368.81,
Preparation palate mold,42280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,546.41,,,,,,,fee schedule,500.19,2368.81,
Preparation palate mold,42280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,574.48,,,,,,,fee schedule,500.19,2368.81,
Preparation palate mold,42280,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2368.81,,,,,,,fee schedule,500.19,2368.81,APC 378
Preparation palate mold,42280,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,560.61,,,,,,,fee schedule,500.19,2368.81,APC
Preparation palate mold,42280,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,555.27,,,,,,,fee schedule,500.19,2368.81,APC
Preparation palate mold,42280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,533.92,,,,,,,fee schedule,500.19,2368.81,APC
Preparation palate mold,42280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,816.89,,,,,,,fee schedule,500.19,2368.81,Radiology
Preparation palate mold,42280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,747.48,,,,,,,fee schedule,500.19,2368.81,APC
Preparation palate mold,42280,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,934.36,,,,,,,fee schedule,500.19,2368.81,APC
Insertion palate prosthesis,42281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4075.29,,,,,,,fee schedule,3266.7,26000.79,
Insertion palate prosthesis,42281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3266.7,,,,,,,fee schedule,3266.7,26000.79,
Insertion palate prosthesis,42281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3568.58,,,,,,,fee schedule,3266.7,26000.79,
Insertion palate prosthesis,42281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3751.86,,,,,,,fee schedule,3266.7,26000.79,
Insertion palate prosthesis,42281,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,3266.7,26000.79,APC 378
Insertion palate prosthesis,42281,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,3266.7,26000.79,APC
Insertion palate prosthesis,42281,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,3266.7,26000.79,APC
Insertion palate prosthesis,42281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,3266.7,26000.79,APC
Insertion palate prosthesis,42281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,3266.7,26000.79,Radiology
Insertion palate prosthesis,42281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,3266.7,26000.79,APC
Insertion palate prosthesis,42281,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,3266.7,26000.79,APC
Palate/uvula surgery,42299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,624,,,,,,,fee schedule,234.47,1040.28,
Palate/uvula surgery,42299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,500.19,,,,,,,fee schedule,234.47,1040.28,
Palate/uvula surgery,42299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,546.41,,,,,,,fee schedule,234.47,1040.28,
Palate/uvula surgery,42299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,574.48,,,,,,,fee schedule,234.47,1040.28,
Palate/uvula surgery,42299,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1040.28,,,,,,,fee schedule,234.47,1040.28,APC 378
Palate/uvula surgery,42299,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,246.2,,,,,,,fee schedule,234.47,1040.28,APC
Palate/uvula surgery,42299,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,243.85,,,,,,,fee schedule,234.47,1040.28,APC
Palate/uvula surgery,42299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,234.47,,,,,,,fee schedule,234.47,1040.28,APC
Palate/uvula surgery,42299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,358.74,,,,,,,fee schedule,234.47,1040.28,Radiology
Palate/uvula surgery,42299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,328.26,,,,,,,fee schedule,234.47,1040.28,APC
Palate/uvula surgery,42299,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,410.33,,,,,,,fee schedule,234.47,1040.28,APC
Drainage of salivary gland,42300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4075.29,,,,,,,fee schedule,1536.02,6814.79,
Drainage of salivary gland,42300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3266.7,,,,,,,fee schedule,1536.02,6814.79,
Drainage of salivary gland,42300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3568.58,,,,,,,fee schedule,1536.02,6814.79,
Drainage of salivary gland,42300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3751.86,,,,,,,fee schedule,1536.02,6814.79,
Drainage of salivary gland,42300,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1536.02,6814.79,APC 378
Drainage of salivary gland,42300,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1536.02,6814.79,APC
Drainage of salivary gland,42300,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1536.02,6814.79,APC
Drainage of salivary gland,42300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1536.02,6814.79,APC
Drainage of salivary gland,42300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1536.02,6814.79,Radiology
Drainage of salivary gland,42300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1536.02,6814.79,APC
Drainage of salivary gland,42300,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1536.02,6814.79,APC
Drainage of salivary gland,42305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4075.29,,,,,,,fee schedule,3266.7,14562,
Drainage of salivary gland,42305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3266.7,,,,,,,fee schedule,3266.7,14562,
Drainage of salivary gland,42305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3568.58,,,,,,,fee schedule,3266.7,14562,
Drainage of salivary gland,42305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3751.86,,,,,,,fee schedule,3266.7,14562,
Drainage of salivary gland,42305,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3266.7,14562,APC 378
Drainage of salivary gland,42305,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3266.7,14562,APC
Drainage of salivary gland,42305,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3266.7,14562,APC
Drainage of salivary gland,42305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3266.7,14562,APC
Drainage of salivary gland,42305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3266.7,14562,Radiology
Drainage of salivary gland,42305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3266.7,14562,APC
Drainage of salivary gland,42305,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3266.7,14562,APC
Drainage of salivary gland,42310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5570.79,,,,,,,fee schedule,533.92,5570.79,
Drainage of salivary gland,42310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4465.47,,,,,,,fee schedule,533.92,5570.79,
Drainage of salivary gland,42310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4878.12,,,,,,,fee schedule,533.92,5570.79,
Drainage of salivary gland,42310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5128.66,,,,,,,fee schedule,533.92,5570.79,
Drainage of salivary gland,42310,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2368.81,,,,,,,fee schedule,533.92,5570.79,APC 378
Drainage of salivary gland,42310,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,560.61,,,,,,,fee schedule,533.92,5570.79,APC
Drainage of salivary gland,42310,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,555.27,,,,,,,fee schedule,533.92,5570.79,APC
Drainage of salivary gland,42310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,533.92,,,,,,,fee schedule,533.92,5570.79,APC
Drainage of salivary gland,42310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,816.89,,,,,,,fee schedule,533.92,5570.79,Radiology
Drainage of salivary gland,42310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,747.48,,,,,,,fee schedule,533.92,5570.79,APC
Drainage of salivary gland,42310,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,934.36,,,,,,,fee schedule,533.92,5570.79,APC
Drainage of salivary gland,42320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,624,,,,,,,fee schedule,500.19,2368.81,
Drainage of salivary gland,42320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,500.19,,,,,,,fee schedule,500.19,2368.81,
Drainage of salivary gland,42320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,546.41,,,,,,,fee schedule,500.19,2368.81,
Drainage of salivary gland,42320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,574.48,,,,,,,fee schedule,500.19,2368.81,
Drainage of salivary gland,42320,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2368.81,,,,,,,fee schedule,500.19,2368.81,APC 378
Drainage of salivary gland,42320,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,560.61,,,,,,,fee schedule,500.19,2368.81,APC
Drainage of salivary gland,42320,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,555.27,,,,,,,fee schedule,500.19,2368.81,APC
Drainage of salivary gland,42320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,533.92,,,,,,,fee schedule,500.19,2368.81,APC
Drainage of salivary gland,42320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,816.89,,,,,,,fee schedule,500.19,2368.81,Radiology
Drainage of salivary gland,42320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,747.48,,,,,,,fee schedule,500.19,2368.81,APC
Drainage of salivary gland,42320,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,934.36,,,,,,,fee schedule,500.19,2368.81,APC
Removal of salivary stone,42330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4075.29,,,,,,,fee schedule,3266.7,14562,
Removal of salivary stone,42330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3266.7,,,,,,,fee schedule,3266.7,14562,
Removal of salivary stone,42330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3568.58,,,,,,,fee schedule,3266.7,14562,
Removal of salivary stone,42330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3751.86,,,,,,,fee schedule,3266.7,14562,
Removal of salivary stone,42330,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3266.7,14562,APC 378
Removal of salivary stone,42330,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3266.7,14562,APC
Removal of salivary stone,42330,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3266.7,14562,APC
Removal of salivary stone,42330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3266.7,14562,APC
Removal of salivary stone,42330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3266.7,14562,Radiology
Removal of salivary stone,42330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3266.7,14562,APC
Removal of salivary stone,42330,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3266.7,14562,APC
Removal of salivary stone,42335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4075.29,,,,,,,fee schedule,3266.7,14562,
Removal of salivary stone,42335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3266.7,,,,,,,fee schedule,3266.7,14562,
Removal of salivary stone,42335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3568.58,,,,,,,fee schedule,3266.7,14562,
Removal of salivary stone,42335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3751.86,,,,,,,fee schedule,3266.7,14562,
Removal of salivary stone,42335,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3266.7,14562,APC 378
Removal of salivary stone,42335,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3266.7,14562,APC
Removal of salivary stone,42335,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3266.7,14562,APC
Removal of salivary stone,42335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3266.7,14562,APC
Removal of salivary stone,42335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3266.7,14562,Radiology
Removal of salivary stone,42335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3266.7,14562,APC
Removal of salivary stone,42335,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3266.7,14562,APC
Removal of salivary stone,42340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4075.29,,,,,,,fee schedule,3266.7,14562,
Removal of salivary stone,42340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3266.7,,,,,,,fee schedule,3266.7,14562,
Removal of salivary stone,42340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3568.58,,,,,,,fee schedule,3266.7,14562,
Removal of salivary stone,42340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3751.86,,,,,,,fee schedule,3266.7,14562,
Removal of salivary stone,42340,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3266.7,14562,APC 378
Removal of salivary stone,42340,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3266.7,14562,APC
Removal of salivary stone,42340,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3266.7,14562,APC
Removal of salivary stone,42340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3266.7,14562,APC
Removal of salivary stone,42340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3266.7,14562,Radiology
Removal of salivary stone,42340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3266.7,14562,APC
Removal of salivary stone,42340,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3266.7,14562,APC
Biopsy of salivary gland,42400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1775.66,,,,,,,fee schedule,701.03,3110.22,
Biopsy of salivary gland,42400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1423.34,,,,,,,fee schedule,701.03,3110.22,
Biopsy of salivary gland,42400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1554.87,,,,,,,fee schedule,701.03,3110.22,
Biopsy of salivary gland,42400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1634.73,,,,,,,fee schedule,701.03,3110.22,
Biopsy of salivary gland,42400,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3110.22,,,,,,,fee schedule,701.03,3110.22,APC 378
Biopsy of salivary gland,42400,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,736.08,,,,,,,fee schedule,701.03,3110.22,APC
Biopsy of salivary gland,42400,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,729.07,,,,,,,fee schedule,701.03,3110.22,APC
Biopsy of salivary gland,42400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,701.03,,,,,,,fee schedule,701.03,3110.22,APC
Biopsy of salivary gland,42400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1072.57,,,,,,,fee schedule,701.03,3110.22,Radiology
Biopsy of salivary gland,42400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,981.44,,,,,,,fee schedule,701.03,3110.22,APC
Biopsy of salivary gland,42400,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1226.8,,,,,,,fee schedule,701.03,3110.22,APC
Biopsy of salivary gland,42405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4075.29,,,,,,,fee schedule,1536.02,6814.79,
Biopsy of salivary gland,42405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3266.7,,,,,,,fee schedule,1536.02,6814.79,
Biopsy of salivary gland,42405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3568.58,,,,,,,fee schedule,1536.02,6814.79,
Biopsy of salivary gland,42405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3751.86,,,,,,,fee schedule,1536.02,6814.79,
Biopsy of salivary gland,42405,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1536.02,6814.79,APC 378
Biopsy of salivary gland,42405,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1536.02,6814.79,APC
Biopsy of salivary gland,42405,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1536.02,6814.79,APC
Biopsy of salivary gland,42405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1536.02,6814.79,APC
Biopsy of salivary gland,42405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1536.02,6814.79,Radiology
Biopsy of salivary gland,42405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1536.02,6814.79,APC
Biopsy of salivary gland,42405,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1536.02,6814.79,APC
Excision of salivary cyst,42408,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4075.29,,,,,,,fee schedule,3266.7,14562,
Excision of salivary cyst,42408,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3266.7,,,,,,,fee schedule,3266.7,14562,
Excision of salivary cyst,42408,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3568.58,,,,,,,fee schedule,3266.7,14562,
Excision of salivary cyst,42408,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3751.86,,,,,,,fee schedule,3266.7,14562,
Excision of salivary cyst,42408,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3266.7,14562,APC 378
Excision of salivary cyst,42408,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3266.7,14562,APC
Excision of salivary cyst,42408,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3266.7,14562,APC
Excision of salivary cyst,42408,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3266.7,14562,APC
Excision of salivary cyst,42408,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3266.7,14562,Radiology
Excision of salivary cyst,42408,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3266.7,14562,APC
Excision of salivary cyst,42408,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3266.7,14562,APC
Drainage of salivary cyst,42409,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4075.29,,,,,,,fee schedule,3266.7,14562,
Drainage of salivary cyst,42409,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3266.7,,,,,,,fee schedule,3266.7,14562,
Drainage of salivary cyst,42409,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3568.58,,,,,,,fee schedule,3266.7,14562,
Drainage of salivary cyst,42409,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3751.86,,,,,,,fee schedule,3266.7,14562,
Drainage of salivary cyst,42409,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3266.7,14562,APC 378
Drainage of salivary cyst,42409,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3266.7,14562,APC
Drainage of salivary cyst,42409,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3266.7,14562,APC
Drainage of salivary cyst,42409,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3266.7,14562,APC
Drainage of salivary cyst,42409,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3266.7,14562,Radiology
Drainage of salivary cyst,42409,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3266.7,14562,APC
Drainage of salivary cyst,42409,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3266.7,14562,APC
Excise parotid gland/lesion,42410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11632.99,,,,,,,fee schedule,5860.44,26000.79,
Excise parotid gland/lesion,42410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9324.86,,,,,,,fee schedule,5860.44,26000.79,
Excise parotid gland/lesion,42410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10186.56,,,,,,,fee schedule,5860.44,26000.79,
Excise parotid gland/lesion,42410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10709.73,,,,,,,fee schedule,5860.44,26000.79,
Excise parotid gland/lesion,42410,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Excise parotid gland/lesion,42410,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Excise parotid gland/lesion,42410,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Excise parotid gland/lesion,42410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Excise parotid gland/lesion,42410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Excise parotid gland/lesion,42410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Excise parotid gland/lesion,42410,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Excise parotid gland/lesion,42415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14184.32,,,,,,,fee schedule,5860.44,26000.79,
Excise parotid gland/lesion,42415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11369.97,,,,,,,fee schedule,5860.44,26000.79,
Excise parotid gland/lesion,42415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12420.66,,,,,,,fee schedule,5860.44,26000.79,
Excise parotid gland/lesion,42415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13058.58,,,,,,,fee schedule,5860.44,26000.79,
Excise parotid gland/lesion,42415,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Excise parotid gland/lesion,42415,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Excise parotid gland/lesion,42415,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Excise parotid gland/lesion,42415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Excise parotid gland/lesion,42415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Excise parotid gland/lesion,42415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Excise parotid gland/lesion,42415,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Excise parotid gland/lesion,42420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17695.19,,,,,,,fee schedule,5860.44,26000.79,
Excise parotid gland/lesion,42420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14184.24,,,,,,,fee schedule,5860.44,26000.79,
Excise parotid gland/lesion,42420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15494.99,,,,,,,fee schedule,5860.44,26000.79,
Excise parotid gland/lesion,42420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16290.81,,,,,,,fee schedule,5860.44,26000.79,
Excise parotid gland/lesion,42420,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Excise parotid gland/lesion,42420,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Excise parotid gland/lesion,42420,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Excise parotid gland/lesion,42420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Excise parotid gland/lesion,42420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Excise parotid gland/lesion,42420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Excise parotid gland/lesion,42420,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Excise parotid gland/lesion,42425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Excise parotid gland/lesion,42425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Excise parotid gland/lesion,42425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Excise parotid gland/lesion,42425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Excise parotid gland/lesion,42425,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Excise parotid gland/lesion,42425,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Excise parotid gland/lesion,42425,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Excise parotid gland/lesion,42425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Excise parotid gland/lesion,42425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Excise parotid gland/lesion,42425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Excise parotid gland/lesion,42425,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Excise submaxillary gland,42440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13423.23,,,,,,,fee schedule,5860.44,26000.79,
Excise submaxillary gland,42440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10759.89,,,,,,,fee schedule,5860.44,26000.79,
Excise submaxillary gland,42440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11754.2,,,,,,,fee schedule,5860.44,26000.79,
Excise submaxillary gland,42440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12357.89,,,,,,,fee schedule,5860.44,26000.79,
Excise submaxillary gland,42440,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Excise submaxillary gland,42440,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Excise submaxillary gland,42440,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Excise submaxillary gland,42440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Excise submaxillary gland,42440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Excise submaxillary gland,42440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Excise submaxillary gland,42440,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Excise sublingual gland,42450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5983.93,,,,,,,fee schedule,4796.64,26000.79,
Excise sublingual gland,42450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4796.64,,,,,,,fee schedule,4796.64,26000.79,
Excise sublingual gland,42450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5239.9,,,,,,,fee schedule,4796.64,26000.79,
Excise sublingual gland,42450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.01,,,,,,,fee schedule,4796.64,26000.79,
Excise sublingual gland,42450,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,4796.64,26000.79,APC 378
Excise sublingual gland,42450,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,4796.64,26000.79,APC
Excise sublingual gland,42450,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,4796.64,26000.79,APC
Excise sublingual gland,42450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,4796.64,26000.79,APC
Excise sublingual gland,42450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,4796.64,26000.79,Radiology
Excise sublingual gland,42450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,4796.64,26000.79,APC
Excise sublingual gland,42450,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,4796.64,26000.79,APC
Repair salivary duct,42500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5983.93,,,,,,,fee schedule,4796.64,26000.79,
Repair salivary duct,42500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4796.64,,,,,,,fee schedule,4796.64,26000.79,
Repair salivary duct,42500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5239.9,,,,,,,fee schedule,4796.64,26000.79,
Repair salivary duct,42500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.01,,,,,,,fee schedule,4796.64,26000.79,
Repair salivary duct,42500,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,4796.64,26000.79,APC 378
Repair salivary duct,42500,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,4796.64,26000.79,APC
Repair salivary duct,42500,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,4796.64,26000.79,APC
Repair salivary duct,42500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,4796.64,26000.79,APC
Repair salivary duct,42500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,4796.64,26000.79,Radiology
Repair salivary duct,42500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,4796.64,26000.79,APC
Repair salivary duct,42500,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,4796.64,26000.79,APC
Repair salivary duct,42505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Repair salivary duct,42505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Repair salivary duct,42505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Repair salivary duct,42505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Repair salivary duct,42505,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Repair salivary duct,42505,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Repair salivary duct,42505,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Repair salivary duct,42505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Repair salivary duct,42505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Repair salivary duct,42505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Repair salivary duct,42505,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Parotid duct diversion,42507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Parotid duct diversion,42507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Parotid duct diversion,42507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Parotid duct diversion,42507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Parotid duct diversion,42507,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Parotid duct diversion,42507,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Parotid duct diversion,42507,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Parotid duct diversion,42507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Parotid duct diversion,42507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Parotid duct diversion,42507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Parotid duct diversion,42507,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Parotid duct diversion,42509,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Parotid duct diversion,42509,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Parotid duct diversion,42509,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Parotid duct diversion,42509,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Parotid duct diversion,42509,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Parotid duct diversion,42509,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Parotid duct diversion,42509,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Parotid duct diversion,42509,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Parotid duct diversion,42509,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Parotid duct diversion,42509,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Parotid duct diversion,42509,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Parotid duct diversion,42510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,3282.2,14562,
Parotid duct diversion,42510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,3282.2,14562,
Parotid duct diversion,42510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,3282.2,14562,
Parotid duct diversion,42510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,3282.2,14562,
Parotid duct diversion,42510,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Parotid duct diversion,42510,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Parotid duct diversion,42510,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Parotid duct diversion,42510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Parotid duct diversion,42510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Parotid duct diversion,42510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Parotid duct diversion,42510,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Closure of salivary fistula,42600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4075.29,,,,,,,fee schedule,3266.7,14562,
Closure of salivary fistula,42600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3266.7,,,,,,,fee schedule,3266.7,14562,
Closure of salivary fistula,42600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3568.58,,,,,,,fee schedule,3266.7,14562,
Closure of salivary fistula,42600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3751.86,,,,,,,fee schedule,3266.7,14562,
Closure of salivary fistula,42600,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3266.7,14562,APC 378
Closure of salivary fistula,42600,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3266.7,14562,APC
Closure of salivary fistula,42600,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3266.7,14562,APC
Closure of salivary fistula,42600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3266.7,14562,APC
Closure of salivary fistula,42600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3266.7,14562,Radiology
Closure of salivary fistula,42600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3266.7,14562,APC
Closure of salivary fistula,42600,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3266.7,14562,APC
Dilation of salivary duct,42650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1858.66,,,,,,,fee schedule,1489.88,6814.79,
Dilation of salivary duct,42650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1489.88,,,,,,,fee schedule,1489.88,6814.79,
Dilation of salivary duct,42650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1627.56,,,,,,,fee schedule,1489.88,6814.79,
Dilation of salivary duct,42650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1711.15,,,,,,,fee schedule,1489.88,6814.79,
Dilation of salivary duct,42650,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1489.88,6814.79,APC 378
Dilation of salivary duct,42650,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1489.88,6814.79,APC
Dilation of salivary duct,42650,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1489.88,6814.79,APC
Dilation of salivary duct,42650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1489.88,6814.79,APC
Dilation of salivary duct,42650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1489.88,6814.79,Radiology
Dilation of salivary duct,42650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1489.88,6814.79,APC
Dilation of salivary duct,42650,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1489.88,6814.79,APC
Dilation of salivary duct,42660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,624,,,,,,,fee schedule,500.19,2368.81,
Dilation of salivary duct,42660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,500.19,,,,,,,fee schedule,500.19,2368.81,
Dilation of salivary duct,42660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,546.41,,,,,,,fee schedule,500.19,2368.81,
Dilation of salivary duct,42660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,574.48,,,,,,,fee schedule,500.19,2368.81,
Dilation of salivary duct,42660,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2368.81,,,,,,,fee schedule,500.19,2368.81,APC 378
Dilation of salivary duct,42660,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,560.61,,,,,,,fee schedule,500.19,2368.81,APC
Dilation of salivary duct,42660,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,555.27,,,,,,,fee schedule,500.19,2368.81,APC
Dilation of salivary duct,42660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,533.92,,,,,,,fee schedule,500.19,2368.81,APC
Dilation of salivary duct,42660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,816.89,,,,,,,fee schedule,500.19,2368.81,Radiology
Dilation of salivary duct,42660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,747.48,,,,,,,fee schedule,500.19,2368.81,APC
Dilation of salivary duct,42660,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,934.36,,,,,,,fee schedule,500.19,2368.81,APC
Ligation of salivary duct,42665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5983.93,,,,,,,fee schedule,3282.2,14562,
Ligation of salivary duct,42665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4796.64,,,,,,,fee schedule,3282.2,14562,
Ligation of salivary duct,42665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5239.9,,,,,,,fee schedule,3282.2,14562,
Ligation of salivary duct,42665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.01,,,,,,,fee schedule,3282.2,14562,
Ligation of salivary duct,42665,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Ligation of salivary duct,42665,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Ligation of salivary duct,42665,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Ligation of salivary duct,42665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Ligation of salivary duct,42665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Ligation of salivary duct,42665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Ligation of salivary duct,42665,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Salivary surgery procedure,42699,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,624,,,,,,,fee schedule,234.47,1040.28,
Salivary surgery procedure,42699,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,500.19,,,,,,,fee schedule,234.47,1040.28,
Salivary surgery procedure,42699,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,546.41,,,,,,,fee schedule,234.47,1040.28,
Salivary surgery procedure,42699,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,574.48,,,,,,,fee schedule,234.47,1040.28,
Salivary surgery procedure,42699,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1040.28,,,,,,,fee schedule,234.47,1040.28,APC 378
Salivary surgery procedure,42699,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,246.2,,,,,,,fee schedule,234.47,1040.28,APC
Salivary surgery procedure,42699,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,243.85,,,,,,,fee schedule,234.47,1040.28,APC
Salivary surgery procedure,42699,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,234.47,,,,,,,fee schedule,234.47,1040.28,APC
Salivary surgery procedure,42699,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,358.74,,,,,,,fee schedule,234.47,1040.28,Radiology
Salivary surgery procedure,42699,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,328.26,,,,,,,fee schedule,234.47,1040.28,APC
Salivary surgery procedure,42699,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,410.33,,,,,,,fee schedule,234.47,1040.28,APC
Drainage of tonsil abscess,42700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,538.55,,,,,,,fee schedule,234.47,1040.28,
Drainage of tonsil abscess,42700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,431.69,,,,,,,fee schedule,234.47,1040.28,
Drainage of tonsil abscess,42700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,471.59,,,,,,,fee schedule,234.47,1040.28,
Drainage of tonsil abscess,42700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,495.81,,,,,,,fee schedule,234.47,1040.28,
Drainage of tonsil abscess,42700,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1040.28,,,,,,,fee schedule,234.47,1040.28,APC 378
Drainage of tonsil abscess,42700,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,246.2,,,,,,,fee schedule,234.47,1040.28,APC
Drainage of tonsil abscess,42700,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,243.85,,,,,,,fee schedule,234.47,1040.28,APC
Drainage of tonsil abscess,42700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,234.47,,,,,,,fee schedule,234.47,1040.28,APC
Drainage of tonsil abscess,42700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,358.74,,,,,,,fee schedule,234.47,1040.28,Radiology
Drainage of tonsil abscess,42700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,328.26,,,,,,,fee schedule,234.47,1040.28,APC
Drainage of tonsil abscess,42700,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,410.33,,,,,,,fee schedule,234.47,1040.28,APC
Drainage of throat abscess,42720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4075.29,,,,,,,fee schedule,3266.7,14562,
Drainage of throat abscess,42720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3266.7,,,,,,,fee schedule,3266.7,14562,
Drainage of throat abscess,42720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3568.58,,,,,,,fee schedule,3266.7,14562,
Drainage of throat abscess,42720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3751.86,,,,,,,fee schedule,3266.7,14562,
Drainage of throat abscess,42720,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3266.7,14562,APC 378
Drainage of throat abscess,42720,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3266.7,14562,APC
Drainage of throat abscess,42720,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3266.7,14562,APC
Drainage of throat abscess,42720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3266.7,14562,APC
Drainage of throat abscess,42720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3266.7,14562,Radiology
Drainage of throat abscess,42720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3266.7,14562,APC
Drainage of throat abscess,42720,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3266.7,14562,APC
Drainage of throat abscess,42725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Drainage of throat abscess,42725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Drainage of throat abscess,42725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Drainage of throat abscess,42725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Drainage of throat abscess,42725,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Drainage of throat abscess,42725,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Drainage of throat abscess,42725,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Drainage of throat abscess,42725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Drainage of throat abscess,42725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Drainage of throat abscess,42725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Drainage of throat abscess,42725,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Biopsy of throat,42800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2169,,,,,,,fee schedule,1536.02,6814.79,
Biopsy of throat,42800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1738.64,,,,,,,fee schedule,1536.02,6814.79,
Biopsy of throat,42800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1899.31,,,,,,,fee schedule,1536.02,6814.79,
Biopsy of throat,42800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1996.86,,,,,,,fee schedule,1536.02,6814.79,
Biopsy of throat,42800,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1536.02,6814.79,APC 378
Biopsy of throat,42800,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1536.02,6814.79,APC
Biopsy of throat,42800,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1536.02,6814.79,APC
Biopsy of throat,42800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1536.02,6814.79,APC
Biopsy of throat,42800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1536.02,6814.79,Radiology
Biopsy of throat,42800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1536.02,6814.79,APC
Biopsy of throat,42800,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1536.02,6814.79,APC
Biopsy of upper nose/throat,42804,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3713.85,,,,,,,fee schedule,2976.98,14562,
Biopsy of upper nose/throat,42804,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2976.98,,,,,,,fee schedule,2976.98,14562,
Biopsy of upper nose/throat,42804,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3252.08,,,,,,,fee schedule,2976.98,14562,
Biopsy of upper nose/throat,42804,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3419.1,,,,,,,fee schedule,2976.98,14562,
Biopsy of upper nose/throat,42804,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,2976.98,14562,APC 378
Biopsy of upper nose/throat,42804,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,2976.98,14562,APC
Biopsy of upper nose/throat,42804,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,2976.98,14562,APC
Biopsy of upper nose/throat,42804,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,2976.98,14562,APC
Biopsy of upper nose/throat,42804,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,2976.98,14562,Radiology
Biopsy of upper nose/throat,42804,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,2976.98,14562,APC
Biopsy of upper nose/throat,42804,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,2976.98,14562,APC
Biopsy of upper nose/throat,42806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7389.78,,,,,,,fee schedule,3282.2,14562,
Biopsy of upper nose/throat,42806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5923.56,,,,,,,fee schedule,3282.2,14562,
Biopsy of upper nose/throat,42806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6470.95,,,,,,,fee schedule,3282.2,14562,
Biopsy of upper nose/throat,42806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6803.29,,,,,,,fee schedule,3282.2,14562,
Biopsy of upper nose/throat,42806,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Biopsy of upper nose/throat,42806,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Biopsy of upper nose/throat,42806,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Biopsy of upper nose/throat,42806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Biopsy of upper nose/throat,42806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Biopsy of upper nose/throat,42806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Biopsy of upper nose/throat,42806,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Excise pharynx lesion,42808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4075.29,,,,,,,fee schedule,3266.7,14562,
Excise pharynx lesion,42808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3266.7,,,,,,,fee schedule,3266.7,14562,
Excise pharynx lesion,42808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3568.58,,,,,,,fee schedule,3266.7,14562,
Excise pharynx lesion,42808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3751.86,,,,,,,fee schedule,3266.7,14562,
Excise pharynx lesion,42808,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3266.7,14562,APC 378
Excise pharynx lesion,42808,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3266.7,14562,APC
Excise pharynx lesion,42808,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3266.7,14562,APC
Excise pharynx lesion,42808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3266.7,14562,APC
Excise pharynx lesion,42808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3266.7,14562,Radiology
Excise pharynx lesion,42808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3266.7,14562,APC
Excise pharynx lesion,42808,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3266.7,14562,APC
Remove pharynx foreign body,42809,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,157.47,,,,,,,fee schedule,126.23,1962.08,
Remove pharynx foreign body,42809,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,126.23,,,,,,,fee schedule,126.23,1962.08,
Remove pharynx foreign body,42809,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,137.89,,,,,,,fee schedule,126.23,1962.08,
Remove pharynx foreign body,42809,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,144.98,,,,,,,fee schedule,126.23,1962.08,
Remove pharynx foreign body,42809,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1962.08,,,,,,,fee schedule,126.23,1962.08,APC 378
Remove pharynx foreign body,42809,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,464.35,,,,,,,fee schedule,126.23,1962.08,APC
Remove pharynx foreign body,42809,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,459.93,,,,,,,fee schedule,126.23,1962.08,APC
Remove pharynx foreign body,42809,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,442.24,,,,,,,fee schedule,126.23,1962.08,APC
Remove pharynx foreign body,42809,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,676.63,,,,,,,fee schedule,126.23,1962.08,Radiology
Remove pharynx foreign body,42809,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,619.14,,,,,,,fee schedule,126.23,1962.08,APC
Remove pharynx foreign body,42809,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,773.92,,,,,,,fee schedule,126.23,1962.08,APC
Excision of neck cyst,42810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5983.93,,,,,,,fee schedule,3282.2,14562,
Excision of neck cyst,42810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4796.64,,,,,,,fee schedule,3282.2,14562,
Excision of neck cyst,42810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5239.9,,,,,,,fee schedule,3282.2,14562,
Excision of neck cyst,42810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.01,,,,,,,fee schedule,3282.2,14562,
Excision of neck cyst,42810,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Excision of neck cyst,42810,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Excision of neck cyst,42810,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Excision of neck cyst,42810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Excision of neck cyst,42810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Excision of neck cyst,42810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Excision of neck cyst,42810,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Excision of neck cyst,42815,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8125.92,,,,,,,fee schedule,5860.44,26000.79,
Excision of neck cyst,42815,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6513.63,,,,,,,fee schedule,5860.44,26000.79,
Excision of neck cyst,42815,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7115.55,,,,,,,fee schedule,5860.44,26000.79,
Excision of neck cyst,42815,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7481,,,,,,,fee schedule,5860.44,26000.79,
Excision of neck cyst,42815,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Excision of neck cyst,42815,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Excision of neck cyst,42815,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Excision of neck cyst,42815,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Excision of neck cyst,42815,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Excision of neck cyst,42815,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Excision of neck cyst,42815,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Remove tonsils and adenoids,42820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8869.95,,,,,,,fee schedule,5860.44,26000.79,
Remove tonsils and adenoids,42820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7110.04,,,,,,,fee schedule,5860.44,26000.79,
Remove tonsils and adenoids,42820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7767.07,,,,,,,fee schedule,5860.44,26000.79,
Remove tonsils and adenoids,42820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8165.99,,,,,,,fee schedule,5860.44,26000.79,
Remove tonsils and adenoids,42820,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Remove tonsils and adenoids,42820,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Remove tonsils and adenoids,42820,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Remove tonsils and adenoids,42820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Remove tonsils and adenoids,42820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Remove tonsils and adenoids,42820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Remove tonsils and adenoids,42820,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Remove tonsils and adenoids,42821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7532.1,,,,,,,fee schedule,3282.2,14562,
Remove tonsils and adenoids,42821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6037.64,,,,,,,fee schedule,3282.2,14562,
Remove tonsils and adenoids,42821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6595.57,,,,,,,fee schedule,3282.2,14562,
Remove tonsils and adenoids,42821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6934.32,,,,,,,fee schedule,3282.2,14562,
Remove tonsils and adenoids,42821,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Remove tonsils and adenoids,42821,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Remove tonsils and adenoids,42821,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Remove tonsils and adenoids,42821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Remove tonsils and adenoids,42821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Remove tonsils and adenoids,42821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Remove tonsils and adenoids,42821,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Removal of tonsils,42825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8463.46,,,,,,,fee schedule,5860.44,26000.79,
Removal of tonsils,42825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6784.2,,,,,,,fee schedule,5860.44,26000.79,
Removal of tonsils,42825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7411.12,,,,,,,fee schedule,5860.44,26000.79,
Removal of tonsils,42825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7791.75,,,,,,,fee schedule,5860.44,26000.79,
Removal of tonsils,42825,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Removal of tonsils,42825,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of tonsils,42825,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of tonsils,42825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of tonsils,42825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Removal of tonsils,42825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of tonsils,42825,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of tonsils,42826,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6514.2,,,,,,,fee schedule,3282.2,14562,
Removal of tonsils,42826,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5221.7,,,,,,,fee schedule,3282.2,14562,
Removal of tonsils,42826,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5704.23,,,,,,,fee schedule,3282.2,14562,
Removal of tonsils,42826,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5997.2,,,,,,,fee schedule,3282.2,14562,
Removal of tonsils,42826,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Removal of tonsils,42826,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Removal of tonsils,42826,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Removal of tonsils,42826,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Removal of tonsils,42826,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Removal of tonsils,42826,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Removal of tonsils,42826,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Removal of adenoids,42830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4205.86,,,,,,,fee schedule,3282.2,14562,
Removal of adenoids,42830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3371.36,,,,,,,fee schedule,3282.2,14562,
Removal of adenoids,42830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3682.91,,,,,,,fee schedule,3282.2,14562,
Removal of adenoids,42830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3872.06,,,,,,,fee schedule,3282.2,14562,
Removal of adenoids,42830,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Removal of adenoids,42830,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Removal of adenoids,42830,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Removal of adenoids,42830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Removal of adenoids,42830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Removal of adenoids,42830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Removal of adenoids,42830,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Removal of adenoids,42831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2964.61,,,,,,,fee schedule,2376.4,14562,
Removal of adenoids,42831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2376.4,,,,,,,fee schedule,2376.4,14562,
Removal of adenoids,42831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2596,,,,,,,fee schedule,2376.4,14562,
Removal of adenoids,42831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2729.33,,,,,,,fee schedule,2376.4,14562,
Removal of adenoids,42831,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,2376.4,14562,APC 378
Removal of adenoids,42831,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,2376.4,14562,APC
Removal of adenoids,42831,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,2376.4,14562,APC
Removal of adenoids,42831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,2376.4,14562,APC
Removal of adenoids,42831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,2376.4,14562,Radiology
Removal of adenoids,42831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,2376.4,14562,APC
Removal of adenoids,42831,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,2376.4,14562,APC
Removal of adenoids,42835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5554.45,,,,,,,fee schedule,3282.2,14562,
Removal of adenoids,42835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4452.37,,,,,,,fee schedule,3282.2,14562,
Removal of adenoids,42835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4863.81,,,,,,,fee schedule,3282.2,14562,
Removal of adenoids,42835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5113.62,,,,,,,fee schedule,3282.2,14562,
Removal of adenoids,42835,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Removal of adenoids,42835,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Removal of adenoids,42835,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Removal of adenoids,42835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Removal of adenoids,42835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Removal of adenoids,42835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Removal of adenoids,42835,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Removal of adenoids,42836,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5554.45,,,,,,,fee schedule,3282.2,14562,
Removal of adenoids,42836,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4452.37,,,,,,,fee schedule,3282.2,14562,
Removal of adenoids,42836,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4863.81,,,,,,,fee schedule,3282.2,14562,
Removal of adenoids,42836,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5113.62,,,,,,,fee schedule,3282.2,14562,
Removal of adenoids,42836,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Removal of adenoids,42836,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Removal of adenoids,42836,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Removal of adenoids,42836,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Removal of adenoids,42836,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Removal of adenoids,42836,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Removal of adenoids,42836,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Extensive surgery of throat,42842,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5983.93,,,,,,,fee schedule,4796.64,26000.79,
Extensive surgery of throat,42842,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4796.64,,,,,,,fee schedule,4796.64,26000.79,
Extensive surgery of throat,42842,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5239.9,,,,,,,fee schedule,4796.64,26000.79,
Extensive surgery of throat,42842,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.01,,,,,,,fee schedule,4796.64,26000.79,
Extensive surgery of throat,42842,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,4796.64,26000.79,APC 378
Extensive surgery of throat,42842,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,4796.64,26000.79,APC
Extensive surgery of throat,42842,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,4796.64,26000.79,APC
Extensive surgery of throat,42842,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,4796.64,26000.79,APC
Extensive surgery of throat,42842,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,4796.64,26000.79,Radiology
Extensive surgery of throat,42842,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,4796.64,26000.79,APC
Extensive surgery of throat,42842,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,4796.64,26000.79,APC
Extensive surgery of throat,42844,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Extensive surgery of throat,42844,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Extensive surgery of throat,42844,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Extensive surgery of throat,42844,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Extensive surgery of throat,42844,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Extensive surgery of throat,42844,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Extensive surgery of throat,42844,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Extensive surgery of throat,42844,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Extensive surgery of throat,42844,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Extensive surgery of throat,42844,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Extensive surgery of throat,42844,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Excision of tonsil tags,42860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5554.45,,,,,,,fee schedule,3282.2,14562,
Excision of tonsil tags,42860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4452.37,,,,,,,fee schedule,3282.2,14562,
Excision of tonsil tags,42860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4863.81,,,,,,,fee schedule,3282.2,14562,
Excision of tonsil tags,42860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5113.62,,,,,,,fee schedule,3282.2,14562,
Excision of tonsil tags,42860,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Excision of tonsil tags,42860,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Excision of tonsil tags,42860,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Excision of tonsil tags,42860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Excision of tonsil tags,42860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Excision of tonsil tags,42860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Excision of tonsil tags,42860,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Excision of lingual tonsil,42870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5554.45,,,,,,,fee schedule,4452.37,26000.79,
Excision of lingual tonsil,42870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4452.37,,,,,,,fee schedule,4452.37,26000.79,
Excision of lingual tonsil,42870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4863.81,,,,,,,fee schedule,4452.37,26000.79,
Excision of lingual tonsil,42870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5113.62,,,,,,,fee schedule,4452.37,26000.79,
Excision of lingual tonsil,42870,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,4452.37,26000.79,APC 378
Excision of lingual tonsil,42870,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,4452.37,26000.79,APC
Excision of lingual tonsil,42870,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,4452.37,26000.79,APC
Excision of lingual tonsil,42870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,4452.37,26000.79,APC
Excision of lingual tonsil,42870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,4452.37,26000.79,Radiology
Excision of lingual tonsil,42870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,4452.37,26000.79,APC
Excision of lingual tonsil,42870,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,4452.37,26000.79,APC
Partial removal of pharynx,42890,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Partial removal of pharynx,42890,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Partial removal of pharynx,42890,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Partial removal of pharynx,42890,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Partial removal of pharynx,42890,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Partial removal of pharynx,42890,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Partial removal of pharynx,42890,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Partial removal of pharynx,42890,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Partial removal of pharynx,42890,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Partial removal of pharynx,42890,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Partial removal of pharynx,42890,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Revision of pharyngeal walls,42892,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Revision of pharyngeal walls,42892,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Revision of pharyngeal walls,42892,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Revision of pharyngeal walls,42892,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Revision of pharyngeal walls,42892,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Revision of pharyngeal walls,42892,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Revision of pharyngeal walls,42892,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Revision of pharyngeal walls,42892,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Revision of pharyngeal walls,42892,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Revision of pharyngeal walls,42892,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Revision of pharyngeal walls,42892,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Repair throat wound,42900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1858.66,,,,,,,fee schedule,1489.88,6814.79,
Repair throat wound,42900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1489.88,,,,,,,fee schedule,1489.88,6814.79,
Repair throat wound,42900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1627.56,,,,,,,fee schedule,1489.88,6814.79,
Repair throat wound,42900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1711.15,,,,,,,fee schedule,1489.88,6814.79,
Repair throat wound,42900,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1489.88,6814.79,APC 378
Repair throat wound,42900,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1489.88,6814.79,APC
Repair throat wound,42900,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1489.88,6814.79,APC
Repair throat wound,42900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1489.88,6814.79,APC
Repair throat wound,42900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1489.88,6814.79,Radiology
Repair throat wound,42900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1489.88,6814.79,APC
Repair throat wound,42900,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1489.88,6814.79,APC
Reconstruction of throat,42950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9737.23,,,,,,,fee schedule,5860.44,26000.79,
Reconstruction of throat,42950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7805.24,,,,,,,fee schedule,5860.44,26000.79,
Reconstruction of throat,42950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8526.52,,,,,,,fee schedule,5860.44,26000.79,
Reconstruction of throat,42950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8964.43,,,,,,,fee schedule,5860.44,26000.79,
Reconstruction of throat,42950,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Reconstruction of throat,42950,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruction of throat,42950,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruction of throat,42950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruction of throat,42950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Reconstruction of throat,42950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Reconstruction of throat,42950,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Surgical opening of throat,42955,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5983.93,,,,,,,fee schedule,1536.02,6814.79,
Surgical opening of throat,42955,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4796.64,,,,,,,fee schedule,1536.02,6814.79,
Surgical opening of throat,42955,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5239.9,,,,,,,fee schedule,1536.02,6814.79,
Surgical opening of throat,42955,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.01,,,,,,,fee schedule,1536.02,6814.79,
Surgical opening of throat,42955,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1536.02,6814.79,APC 378
Surgical opening of throat,42955,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1536.02,6814.79,APC
Surgical opening of throat,42955,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1536.02,6814.79,APC
Surgical opening of throat,42955,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1536.02,6814.79,APC
Surgical opening of throat,42955,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1536.02,6814.79,Radiology
Surgical opening of throat,42955,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1536.02,6814.79,APC
Surgical opening of throat,42955,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1536.02,6814.79,APC
Control throat bleeding,42960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6370.48,,,,,,,fee schedule,533.92,6370.48,
Control throat bleeding,42960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5106.5,,,,,,,fee schedule,533.92,6370.48,
Control throat bleeding,42960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5578.39,,,,,,,fee schedule,533.92,6370.48,
Control throat bleeding,42960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5864.89,,,,,,,fee schedule,533.92,6370.48,
Control throat bleeding,42960,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2368.81,,,,,,,fee schedule,533.92,6370.48,APC 378
Control throat bleeding,42960,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,560.61,,,,,,,fee schedule,533.92,6370.48,APC
Control throat bleeding,42960,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,555.27,,,,,,,fee schedule,533.92,6370.48,APC
Control throat bleeding,42960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,533.92,,,,,,,fee schedule,533.92,6370.48,APC
Control throat bleeding,42960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,816.89,,,,,,,fee schedule,533.92,6370.48,Radiology
Control throat bleeding,42960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,747.48,,,,,,,fee schedule,533.92,6370.48,APC
Control throat bleeding,42960,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,934.36,,,,,,,fee schedule,533.92,6370.48,APC
Control throat bleeding,42962,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6253.46,,,,,,,fee schedule,3282.2,14562,
Control throat bleeding,42962,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5012.69,,,,,,,fee schedule,3282.2,14562,
Control throat bleeding,42962,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5475.91,,,,,,,fee schedule,3282.2,14562,
Control throat bleeding,42962,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5757.15,,,,,,,fee schedule,3282.2,14562,
Control throat bleeding,42962,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Control throat bleeding,42962,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Control throat bleeding,42962,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Control throat bleeding,42962,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Control throat bleeding,42962,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Control throat bleeding,42962,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Control throat bleeding,42962,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Control nose/throat bleeding,42970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,280.78,,,,,,,fee schedule,225.07,1040.28,
Control nose/throat bleeding,42970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,225.07,,,,,,,fee schedule,225.07,1040.28,
Control nose/throat bleeding,42970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,245.87,,,,,,,fee schedule,225.07,1040.28,
Control nose/throat bleeding,42970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,258.49,,,,,,,fee schedule,225.07,1040.28,
Control nose/throat bleeding,42970,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1040.28,,,,,,,fee schedule,225.07,1040.28,APC 378
Control nose/throat bleeding,42970,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,246.2,,,,,,,fee schedule,225.07,1040.28,APC
Control nose/throat bleeding,42970,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,243.85,,,,,,,fee schedule,225.07,1040.28,APC
Control nose/throat bleeding,42970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,234.47,,,,,,,fee schedule,225.07,1040.28,APC
Control nose/throat bleeding,42970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,358.74,,,,,,,fee schedule,225.07,1040.28,Radiology
Control nose/throat bleeding,42970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,328.26,,,,,,,fee schedule,225.07,1040.28,APC
Control nose/throat bleeding,42970,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,410.33,,,,,,,fee schedule,225.07,1040.28,APC
Control nose/throat bleeding,42972,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4075.29,,,,,,,fee schedule,3266.7,14562,
Control nose/throat bleeding,42972,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3266.7,,,,,,,fee schedule,3266.7,14562,
Control nose/throat bleeding,42972,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3568.58,,,,,,,fee schedule,3266.7,14562,
Control nose/throat bleeding,42972,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3751.86,,,,,,,fee schedule,3266.7,14562,
Control nose/throat bleeding,42972,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3266.7,14562,APC 378
Control nose/throat bleeding,42972,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3266.7,14562,APC
Control nose/throat bleeding,42972,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3266.7,14562,APC
Control nose/throat bleeding,42972,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3266.7,14562,APC
Control nose/throat bleeding,42972,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3266.7,14562,Radiology
Control nose/throat bleeding,42972,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3266.7,14562,APC
Control nose/throat bleeding,42972,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3266.7,14562,APC
Dise eval slp do brth flx dx,42975,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,635.49,,,,,,,fee schedule,509.4,7817.58,
Dise eval slp do brth flx dx,42975,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,509.4,,,,,,,fee schedule,509.4,7817.58,
Dise eval slp do brth flx dx,42975,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,556.48,,,,,,,fee schedule,509.4,7817.58,
Dise eval slp do brth flx dx,42975,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,585.06,,,,,,,fee schedule,509.4,7817.58,
Dise eval slp do brth flx dx,42975,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7817.58,,,,,,,fee schedule,509.4,7817.58,APC 378
Dise eval slp do brth flx dx,42975,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1850.14,,,,,,,fee schedule,509.4,7817.58,APC
Dise eval slp do brth flx dx,42975,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1832.52,,,,,,,fee schedule,509.4,7817.58,APC
Dise eval slp do brth flx dx,42975,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1762.04,,,,,,,fee schedule,509.4,7817.58,APC
Dise eval slp do brth flx dx,42975,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2695.92,,,,,,,fee schedule,509.4,7817.58,Radiology
Dise eval slp do brth flx dx,42975,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2466.86,,,,,,,fee schedule,509.4,7817.58,APC
Dise eval slp do brth flx dx,42975,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3083.57,,,,,,,fee schedule,509.4,7817.58,APC
Throat surgery procedure,42999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10205.34,,,,,,,fee schedule,234.47,10205.34,
Throat surgery procedure,42999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8180.47,,,,,,,fee schedule,234.47,10205.34,
Throat surgery procedure,42999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8936.43,,,,,,,fee schedule,234.47,10205.34,
Throat surgery procedure,42999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9395.4,,,,,,,fee schedule,234.47,10205.34,
Throat surgery procedure,42999,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1040.28,,,,,,,fee schedule,234.47,10205.34,APC 378
Throat surgery procedure,42999,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,246.2,,,,,,,fee schedule,234.47,10205.34,APC
Throat surgery procedure,42999,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,243.85,,,,,,,fee schedule,234.47,10205.34,APC
Throat surgery procedure,42999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,234.47,,,,,,,fee schedule,234.47,10205.34,APC
Throat surgery procedure,42999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,358.74,,,,,,,fee schedule,234.47,10205.34,Radiology
Throat surgery procedure,42999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,328.26,,,,,,,fee schedule,234.47,10205.34,APC
Throat surgery procedure,42999,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,410.33,,,,,,,fee schedule,234.47,10205.34,APC
Incision of esophagus,43020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1858.66,,,,,,,fee schedule,1489.88,6814.79,
Incision of esophagus,43020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1489.88,,,,,,,fee schedule,1489.88,6814.79,
Incision of esophagus,43020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1627.56,,,,,,,fee schedule,1489.88,6814.79,
Incision of esophagus,43020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1711.15,,,,,,,fee schedule,1489.88,6814.79,
Incision of esophagus,43020,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1489.88,6814.79,APC 378
Incision of esophagus,43020,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1489.88,6814.79,APC
Incision of esophagus,43020,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1489.88,6814.79,APC
Incision of esophagus,43020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1489.88,6814.79,APC
Incision of esophagus,43020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1489.88,6814.79,Radiology
Incision of esophagus,43020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1489.88,6814.79,APC
Incision of esophagus,43020,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1489.88,6814.79,APC
Throat muscle surgery,43030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4075.29,,,,,,,fee schedule,3266.7,26000.79,
Throat muscle surgery,43030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3266.7,,,,,,,fee schedule,3266.7,26000.79,
Throat muscle surgery,43030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3568.58,,,,,,,fee schedule,3266.7,26000.79,
Throat muscle surgery,43030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3751.86,,,,,,,fee schedule,3266.7,26000.79,
Throat muscle surgery,43030,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,3266.7,26000.79,APC 378
Throat muscle surgery,43030,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,3266.7,26000.79,APC
Throat muscle surgery,43030,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,3266.7,26000.79,APC
Throat muscle surgery,43030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,3266.7,26000.79,APC
Throat muscle surgery,43030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,3266.7,26000.79,Radiology
Throat muscle surgery,43030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,3266.7,26000.79,APC
Throat muscle surgery,43030,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,3266.7,26000.79,APC
Removal of esophagus pouch,43130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Removal of esophagus pouch,43130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Removal of esophagus pouch,43130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Removal of esophagus pouch,43130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Removal of esophagus pouch,43130,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Removal of esophagus pouch,43130,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of esophagus pouch,43130,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of esophagus pouch,43130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of esophagus pouch,43130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Removal of esophagus pouch,43130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of esophagus pouch,43130,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Esophagoscopy rigid trnso,43180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7657.8,,,,,,,fee schedule,5860.44,26000.79,
Esophagoscopy rigid trnso,43180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6138.4,,,,,,,fee schedule,5860.44,26000.79,
Esophagoscopy rigid trnso,43180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6705.64,,,,,,,fee schedule,5860.44,26000.79,
Esophagoscopy rigid trnso,43180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7050.04,,,,,,,fee schedule,5860.44,26000.79,
Esophagoscopy rigid trnso,43180,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Esophagoscopy rigid trnso,43180,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Esophagoscopy rigid trnso,43180,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Esophagoscopy rigid trnso,43180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Esophagoscopy rigid trnso,43180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Esophagoscopy rigid trnso,43180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Esophagoscopy rigid trnso,43180,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Esophagoscopy rigid trnso dx,43191,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2818.37,,,,,,,fee schedule,1899.66,8428.13,
Esophagoscopy rigid trnso dx,43191,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2259.17,,,,,,,fee schedule,1899.66,8428.13,
Esophagoscopy rigid trnso dx,43191,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2467.94,,,,,,,fee schedule,1899.66,8428.13,
Esophagoscopy rigid trnso dx,43191,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2594.69,,,,,,,fee schedule,1899.66,8428.13,
Esophagoscopy rigid trnso dx,43191,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8428.13,,,,,,,fee schedule,1899.66,8428.13,APC 378
Esophagoscopy rigid trnso dx,43191,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1994.64,,,,,,,fee schedule,1899.66,8428.13,APC
Esophagoscopy rigid trnso dx,43191,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1975.64,,,,,,,fee schedule,1899.66,8428.13,APC
Esophagoscopy rigid trnso dx,43191,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1899.66,,,,,,,fee schedule,1899.66,8428.13,APC
Esophagoscopy rigid trnso dx,43191,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2906.47,,,,,,,fee schedule,1899.66,8428.13,Radiology
Esophagoscopy rigid trnso dx,43191,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2659.52,,,,,,,fee schedule,1899.66,8428.13,APC
Esophagoscopy rigid trnso dx,43191,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3324.4,,,,,,,fee schedule,1899.66,8428.13,APC
Esophagoscp rig trnso inject,43192,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4025.17,,,,,,,fee schedule,1899.66,8428.13,
Esophagoscp rig trnso inject,43192,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3226.53,,,,,,,fee schedule,1899.66,8428.13,
Esophagoscp rig trnso inject,43192,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3524.69,,,,,,,fee schedule,1899.66,8428.13,
Esophagoscp rig trnso inject,43192,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3705.71,,,,,,,fee schedule,1899.66,8428.13,
Esophagoscp rig trnso inject,43192,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8428.13,,,,,,,fee schedule,1899.66,8428.13,APC 378
Esophagoscp rig trnso inject,43192,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1994.64,,,,,,,fee schedule,1899.66,8428.13,APC
Esophagoscp rig trnso inject,43192,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1975.64,,,,,,,fee schedule,1899.66,8428.13,APC
Esophagoscp rig trnso inject,43192,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1899.66,,,,,,,fee schedule,1899.66,8428.13,APC
Esophagoscp rig trnso inject,43192,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2906.47,,,,,,,fee schedule,1899.66,8428.13,Radiology
Esophagoscp rig trnso inject,43192,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2659.52,,,,,,,fee schedule,1899.66,8428.13,APC
Esophagoscp rig trnso inject,43192,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3324.4,,,,,,,fee schedule,1899.66,8428.13,APC
Esophagoscp rig trnso biopsy,43193,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4025.17,,,,,,,fee schedule,1899.66,8428.13,
Esophagoscp rig trnso biopsy,43193,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3226.53,,,,,,,fee schedule,1899.66,8428.13,
Esophagoscp rig trnso biopsy,43193,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3524.69,,,,,,,fee schedule,1899.66,8428.13,
Esophagoscp rig trnso biopsy,43193,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3705.71,,,,,,,fee schedule,1899.66,8428.13,
Esophagoscp rig trnso biopsy,43193,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8428.13,,,,,,,fee schedule,1899.66,8428.13,APC 378
Esophagoscp rig trnso biopsy,43193,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1994.64,,,,,,,fee schedule,1899.66,8428.13,APC
Esophagoscp rig trnso biopsy,43193,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1975.64,,,,,,,fee schedule,1899.66,8428.13,APC
Esophagoscp rig trnso biopsy,43193,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1899.66,,,,,,,fee schedule,1899.66,8428.13,APC
Esophagoscp rig trnso biopsy,43193,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2906.47,,,,,,,fee schedule,1899.66,8428.13,Radiology
Esophagoscp rig trnso biopsy,43193,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2659.52,,,,,,,fee schedule,1899.66,8428.13,APC
Esophagoscp rig trnso biopsy,43193,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3324.4,,,,,,,fee schedule,1899.66,8428.13,APC
Esophagoscp rig trnso rem fb,43194,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7657.8,,,,,,,fee schedule,1899.66,8428.13,
Esophagoscp rig trnso rem fb,43194,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6138.4,,,,,,,fee schedule,1899.66,8428.13,
Esophagoscp rig trnso rem fb,43194,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6705.64,,,,,,,fee schedule,1899.66,8428.13,
Esophagoscp rig trnso rem fb,43194,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7050.04,,,,,,,fee schedule,1899.66,8428.13,
Esophagoscp rig trnso rem fb,43194,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8428.13,,,,,,,fee schedule,1899.66,8428.13,APC 378
Esophagoscp rig trnso rem fb,43194,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1994.64,,,,,,,fee schedule,1899.66,8428.13,APC
Esophagoscp rig trnso rem fb,43194,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1975.64,,,,,,,fee schedule,1899.66,8428.13,APC
Esophagoscp rig trnso rem fb,43194,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1899.66,,,,,,,fee schedule,1899.66,8428.13,APC
Esophagoscp rig trnso rem fb,43194,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2906.47,,,,,,,fee schedule,1899.66,8428.13,Radiology
Esophagoscp rig trnso rem fb,43194,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2659.52,,,,,,,fee schedule,1899.66,8428.13,APC
Esophagoscp rig trnso rem fb,43194,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3324.4,,,,,,,fee schedule,1899.66,8428.13,APC
Esophagoscopy rigid balloon,43195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4025.17,,,,,,,fee schedule,3226.53,16933.82,
Esophagoscopy rigid balloon,43195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3226.53,,,,,,,fee schedule,3226.53,16933.82,
Esophagoscopy rigid balloon,43195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3524.69,,,,,,,fee schedule,3226.53,16933.82,
Esophagoscopy rigid balloon,43195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3705.71,,,,,,,fee schedule,3226.53,16933.82,
Esophagoscopy rigid balloon,43195,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16933.82,,,,,,,fee schedule,3226.53,16933.82,APC 378
Esophagoscopy rigid balloon,43195,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4007.63,,,,,,,fee schedule,3226.53,16933.82,APC
Esophagoscopy rigid balloon,43195,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3969.46,,,,,,,fee schedule,3226.53,16933.82,APC
Esophagoscopy rigid balloon,43195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3816.79,,,,,,,fee schedule,3226.53,16933.82,APC
Esophagoscopy rigid balloon,43195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5839.69,,,,,,,fee schedule,3226.53,16933.82,Radiology
Esophagoscopy rigid balloon,43195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5343.51,,,,,,,fee schedule,3226.53,16933.82,APC
Esophagoscopy rigid balloon,43195,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6679.39,,,,,,,fee schedule,3226.53,16933.82,APC
Esophagoscp guide wire dilat,43196,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4025.17,,,,,,,fee schedule,1899.66,8428.13,
Esophagoscp guide wire dilat,43196,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3226.53,,,,,,,fee schedule,1899.66,8428.13,
Esophagoscp guide wire dilat,43196,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3524.69,,,,,,,fee schedule,1899.66,8428.13,
Esophagoscp guide wire dilat,43196,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3705.71,,,,,,,fee schedule,1899.66,8428.13,
Esophagoscp guide wire dilat,43196,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8428.13,,,,,,,fee schedule,1899.66,8428.13,APC 378
Esophagoscp guide wire dilat,43196,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1994.64,,,,,,,fee schedule,1899.66,8428.13,APC
Esophagoscp guide wire dilat,43196,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1975.64,,,,,,,fee schedule,1899.66,8428.13,APC
Esophagoscp guide wire dilat,43196,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1899.66,,,,,,,fee schedule,1899.66,8428.13,APC
Esophagoscp guide wire dilat,43196,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2906.47,,,,,,,fee schedule,1899.66,8428.13,Radiology
Esophagoscp guide wire dilat,43196,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2659.52,,,,,,,fee schedule,1899.66,8428.13,APC
Esophagoscp guide wire dilat,43196,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3324.4,,,,,,,fee schedule,1899.66,8428.13,APC
Esophagoscopy flex dx brush,43197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2818.37,,,,,,,fee schedule,897.89,3983.62,
Esophagoscopy flex dx brush,43197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2259.17,,,,,,,fee schedule,897.89,3983.62,
Esophagoscopy flex dx brush,43197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2467.94,,,,,,,fee schedule,897.89,3983.62,
Esophagoscopy flex dx brush,43197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2594.69,,,,,,,fee schedule,897.89,3983.62,
Esophagoscopy flex dx brush,43197,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3983.62,,,,,,,fee schedule,897.89,3983.62,APC 378
Esophagoscopy flex dx brush,43197,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,942.78,,,,,,,fee schedule,897.89,3983.62,APC
Esophagoscopy flex dx brush,43197,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,933.8,,,,,,,fee schedule,897.89,3983.62,APC
Esophagoscopy flex dx brush,43197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,897.89,,,,,,,fee schedule,897.89,3983.62,APC
Esophagoscopy flex dx brush,43197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1373.77,,,,,,,fee schedule,897.89,3983.62,Radiology
Esophagoscopy flex dx brush,43197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1257.04,,,,,,,fee schedule,897.89,3983.62,APC
Esophagoscopy flex dx brush,43197,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1571.3,,,,,,,fee schedule,897.89,3983.62,APC
Esophagosc flex trnsn biopsy,43198,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2818.37,,,,,,,fee schedule,897.89,3983.62,
Esophagosc flex trnsn biopsy,43198,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2259.17,,,,,,,fee schedule,897.89,3983.62,
Esophagosc flex trnsn biopsy,43198,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2467.94,,,,,,,fee schedule,897.89,3983.62,
Esophagosc flex trnsn biopsy,43198,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2594.69,,,,,,,fee schedule,897.89,3983.62,
Esophagosc flex trnsn biopsy,43198,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3983.62,,,,,,,fee schedule,897.89,3983.62,APC 378
Esophagosc flex trnsn biopsy,43198,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,942.78,,,,,,,fee schedule,897.89,3983.62,APC
Esophagosc flex trnsn biopsy,43198,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,933.8,,,,,,,fee schedule,897.89,3983.62,APC
Esophagosc flex trnsn biopsy,43198,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,897.89,,,,,,,fee schedule,897.89,3983.62,APC
Esophagosc flex trnsn biopsy,43198,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1373.77,,,,,,,fee schedule,897.89,3983.62,Radiology
Esophagosc flex trnsn biopsy,43198,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1257.04,,,,,,,fee schedule,897.89,3983.62,APC
Esophagosc flex trnsn biopsy,43198,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1571.3,,,,,,,fee schedule,897.89,3983.62,APC
Esophagoscopy flexible brush,43200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2795.69,,,,,,,fee schedule,897.89,3983.62,
Esophagoscopy flexible brush,43200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2240.99,,,,,,,fee schedule,897.89,3983.62,
Esophagoscopy flexible brush,43200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2448.08,,,,,,,fee schedule,897.89,3983.62,
Esophagoscopy flexible brush,43200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2573.81,,,,,,,fee schedule,897.89,3983.62,
Esophagoscopy flexible brush,43200,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3983.62,,,,,,,fee schedule,897.89,3983.62,APC 378
Esophagoscopy flexible brush,43200,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,942.78,,,,,,,fee schedule,897.89,3983.62,APC
Esophagoscopy flexible brush,43200,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,933.8,,,,,,,fee schedule,897.89,3983.62,APC
Esophagoscopy flexible brush,43200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,897.89,,,,,,,fee schedule,897.89,3983.62,APC
Esophagoscopy flexible brush,43200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1373.77,,,,,,,fee schedule,897.89,3983.62,Radiology
Esophagoscopy flexible brush,43200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1257.04,,,,,,,fee schedule,897.89,3983.62,APC
Esophagoscopy flexible brush,43200,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1571.3,,,,,,,fee schedule,897.89,3983.62,APC
Esoph scope w/submucous inj,43201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2122.13,,,,,,,fee schedule,1701.07,8428.13,
Esoph scope w/submucous inj,43201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1701.07,,,,,,,fee schedule,1701.07,8428.13,
Esoph scope w/submucous inj,43201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1858.27,,,,,,,fee schedule,1701.07,8428.13,
Esoph scope w/submucous inj,43201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1953.71,,,,,,,fee schedule,1701.07,8428.13,
Esoph scope w/submucous inj,43201,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8428.13,,,,,,,fee schedule,1701.07,8428.13,APC 378
Esoph scope w/submucous inj,43201,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1994.64,,,,,,,fee schedule,1701.07,8428.13,APC
Esoph scope w/submucous inj,43201,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1975.64,,,,,,,fee schedule,1701.07,8428.13,APC
Esoph scope w/submucous inj,43201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1899.66,,,,,,,fee schedule,1701.07,8428.13,APC
Esoph scope w/submucous inj,43201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2906.47,,,,,,,fee schedule,1701.07,8428.13,Radiology
Esoph scope w/submucous inj,43201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2659.52,,,,,,,fee schedule,1701.07,8428.13,APC
Esoph scope w/submucous inj,43201,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3324.4,,,,,,,fee schedule,1701.07,8428.13,APC
Esophagoscopy flex biopsy,43202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2122.13,,,,,,,fee schedule,1701.07,8428.13,
Esophagoscopy flex biopsy,43202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1701.07,,,,,,,fee schedule,1701.07,8428.13,
Esophagoscopy flex biopsy,43202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1858.27,,,,,,,fee schedule,1701.07,8428.13,
Esophagoscopy flex biopsy,43202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1953.71,,,,,,,fee schedule,1701.07,8428.13,
Esophagoscopy flex biopsy,43202,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8428.13,,,,,,,fee schedule,1701.07,8428.13,APC 378
Esophagoscopy flex biopsy,43202,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1994.64,,,,,,,fee schedule,1701.07,8428.13,APC
Esophagoscopy flex biopsy,43202,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1975.64,,,,,,,fee schedule,1701.07,8428.13,APC
Esophagoscopy flex biopsy,43202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1899.66,,,,,,,fee schedule,1701.07,8428.13,APC
Esophagoscopy flex biopsy,43202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2906.47,,,,,,,fee schedule,1701.07,8428.13,Radiology
Esophagoscopy flex biopsy,43202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2659.52,,,,,,,fee schedule,1701.07,8428.13,APC
Esophagoscopy flex biopsy,43202,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3324.4,,,,,,,fee schedule,1701.07,8428.13,APC
Esoph scope w/sclerosis inj,43204,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2122.13,,,,,,,fee schedule,1701.07,8428.13,
Esoph scope w/sclerosis inj,43204,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1701.07,,,,,,,fee schedule,1701.07,8428.13,
Esoph scope w/sclerosis inj,43204,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1858.27,,,,,,,fee schedule,1701.07,8428.13,
Esoph scope w/sclerosis inj,43204,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1953.71,,,,,,,fee schedule,1701.07,8428.13,
Esoph scope w/sclerosis inj,43204,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8428.13,,,,,,,fee schedule,1701.07,8428.13,APC 378
Esoph scope w/sclerosis inj,43204,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1994.64,,,,,,,fee schedule,1701.07,8428.13,APC
Esoph scope w/sclerosis inj,43204,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1975.64,,,,,,,fee schedule,1701.07,8428.13,APC
Esoph scope w/sclerosis inj,43204,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1899.66,,,,,,,fee schedule,1701.07,8428.13,APC
Esoph scope w/sclerosis inj,43204,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2906.47,,,,,,,fee schedule,1701.07,8428.13,Radiology
Esoph scope w/sclerosis inj,43204,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2659.52,,,,,,,fee schedule,1701.07,8428.13,APC
Esoph scope w/sclerosis inj,43204,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3324.4,,,,,,,fee schedule,1701.07,8428.13,APC
Esophagus endoscopy/ligation,43205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2122.13,,,,,,,fee schedule,1701.07,8428.13,
Esophagus endoscopy/ligation,43205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1701.07,,,,,,,fee schedule,1701.07,8428.13,
Esophagus endoscopy/ligation,43205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1858.27,,,,,,,fee schedule,1701.07,8428.13,
Esophagus endoscopy/ligation,43205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1953.71,,,,,,,fee schedule,1701.07,8428.13,
Esophagus endoscopy/ligation,43205,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8428.13,,,,,,,fee schedule,1701.07,8428.13,APC 378
Esophagus endoscopy/ligation,43205,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1994.64,,,,,,,fee schedule,1701.07,8428.13,APC
Esophagus endoscopy/ligation,43205,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1975.64,,,,,,,fee schedule,1701.07,8428.13,APC
Esophagus endoscopy/ligation,43205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1899.66,,,,,,,fee schedule,1701.07,8428.13,APC
Esophagus endoscopy/ligation,43205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2906.47,,,,,,,fee schedule,1701.07,8428.13,Radiology
Esophagus endoscopy/ligation,43205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2659.52,,,,,,,fee schedule,1701.07,8428.13,APC
Esophagus endoscopy/ligation,43205,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3324.4,,,,,,,fee schedule,1701.07,8428.13,APC
Esoph optical endomicroscopy,43206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3503.23,,,,,,,fee schedule,1899.66,8428.13,
Esoph optical endomicroscopy,43206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2808.14,,,,,,,fee schedule,1899.66,8428.13,
Esoph optical endomicroscopy,43206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3067.64,,,,,,,fee schedule,1899.66,8428.13,
Esoph optical endomicroscopy,43206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3225.19,,,,,,,fee schedule,1899.66,8428.13,
Esoph optical endomicroscopy,43206,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8428.13,,,,,,,fee schedule,1899.66,8428.13,APC 378
Esoph optical endomicroscopy,43206,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1994.64,,,,,,,fee schedule,1899.66,8428.13,APC
Esoph optical endomicroscopy,43206,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1975.64,,,,,,,fee schedule,1899.66,8428.13,APC
Esoph optical endomicroscopy,43206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1899.66,,,,,,,fee schedule,1899.66,8428.13,APC
Esoph optical endomicroscopy,43206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2906.47,,,,,,,fee schedule,1899.66,8428.13,Radiology
Esoph optical endomicroscopy,43206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2659.52,,,,,,,fee schedule,1899.66,8428.13,APC
Esoph optical endomicroscopy,43206,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3324.4,,,,,,,fee schedule,1899.66,8428.13,APC
Egd esophagogastrc fndoplsty,43210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13659.29,,,,,,,fee schedule,10523.19,46687.84,
Egd esophagogastrc fndoplsty,43210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10949.12,,,,,,,fee schedule,10523.19,46687.84,
Egd esophagogastrc fndoplsty,43210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11960.92,,,,,,,fee schedule,10523.19,46687.84,
Egd esophagogastrc fndoplsty,43210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12575.22,,,,,,,fee schedule,10523.19,46687.84,
Egd esophagogastrc fndoplsty,43210,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46687.84,,,,,,,fee schedule,10523.19,46687.84,APC 378
Egd esophagogastrc fndoplsty,43210,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11049.35,,,,,,,fee schedule,10523.19,46687.84,APC
Egd esophagogastrc fndoplsty,43210,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10944.12,,,,,,,fee schedule,10523.19,46687.84,APC
Egd esophagogastrc fndoplsty,43210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10523.19,,,,,,,fee schedule,10523.19,46687.84,APC
Egd esophagogastrc fndoplsty,43210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16100.48,,,,,,,fee schedule,10523.19,46687.84,Radiology
Egd esophagogastrc fndoplsty,43210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14732.47,,,,,,,fee schedule,10523.19,46687.84,APC
Egd esophagogastrc fndoplsty,43210,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18415.58,,,,,,,fee schedule,10523.19,46687.84,APC
Esophagoscop mucosal resect,43211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4025.17,,,,,,,fee schedule,1899.66,8428.13,
Esophagoscop mucosal resect,43211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3226.53,,,,,,,fee schedule,1899.66,8428.13,
Esophagoscop mucosal resect,43211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3524.69,,,,,,,fee schedule,1899.66,8428.13,
Esophagoscop mucosal resect,43211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3705.71,,,,,,,fee schedule,1899.66,8428.13,
Esophagoscop mucosal resect,43211,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8428.13,,,,,,,fee schedule,1899.66,8428.13,APC 378
Esophagoscop mucosal resect,43211,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1994.64,,,,,,,fee schedule,1899.66,8428.13,APC
Esophagoscop mucosal resect,43211,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1975.64,,,,,,,fee schedule,1899.66,8428.13,APC
Esophagoscop mucosal resect,43211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1899.66,,,,,,,fee schedule,1899.66,8428.13,APC
Esophagoscop mucosal resect,43211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2906.47,,,,,,,fee schedule,1899.66,8428.13,Radiology
Esophagoscop mucosal resect,43211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2659.52,,,,,,,fee schedule,1899.66,8428.13,APC
Esophagoscop mucosal resect,43211,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3324.4,,,,,,,fee schedule,1899.66,8428.13,APC
Esophagoscop stent placement,43212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12001.76,,,,,,,fee schedule,6009.99,26664.3,
Esophagoscop stent placement,43212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9620.46,,,,,,,fee schedule,6009.99,26664.3,
Esophagoscop stent placement,43212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10509.48,,,,,,,fee schedule,6009.99,26664.3,
Esophagoscop stent placement,43212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11049.24,,,,,,,fee schedule,6009.99,26664.3,
Esophagoscop stent placement,43212,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26664.3,,,,,,,fee schedule,6009.99,26664.3,APC 378
Esophagoscop stent placement,43212,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6310.49,,,,,,,fee schedule,6009.99,26664.3,APC
Esophagoscop stent placement,43212,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6250.39,,,,,,,fee schedule,6009.99,26664.3,APC
Esophagoscop stent placement,43212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6009.99,,,,,,,fee schedule,6009.99,26664.3,APC
Esophagoscop stent placement,43212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9195.29,,,,,,,fee schedule,6009.99,26664.3,Radiology
Esophagoscop stent placement,43212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8413.99,,,,,,,fee schedule,6009.99,26664.3,APC
Esophagoscop stent placement,43212,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10517.49,,,,,,,fee schedule,6009.99,26664.3,APC
Esophagoscopy retro balloon,43213,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4025.17,,,,,,,fee schedule,1899.66,8428.13,
Esophagoscopy retro balloon,43213,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3226.53,,,,,,,fee schedule,1899.66,8428.13,
Esophagoscopy retro balloon,43213,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3524.69,,,,,,,fee schedule,1899.66,8428.13,
Esophagoscopy retro balloon,43213,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3705.71,,,,,,,fee schedule,1899.66,8428.13,
Esophagoscopy retro balloon,43213,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8428.13,,,,,,,fee schedule,1899.66,8428.13,APC 378
Esophagoscopy retro balloon,43213,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1994.64,,,,,,,fee schedule,1899.66,8428.13,APC
Esophagoscopy retro balloon,43213,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1975.64,,,,,,,fee schedule,1899.66,8428.13,APC
Esophagoscopy retro balloon,43213,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1899.66,,,,,,,fee schedule,1899.66,8428.13,APC
Esophagoscopy retro balloon,43213,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2906.47,,,,,,,fee schedule,1899.66,8428.13,Radiology
Esophagoscopy retro balloon,43213,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2659.52,,,,,,,fee schedule,1899.66,8428.13,APC
Esophagoscopy retro balloon,43213,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3324.4,,,,,,,fee schedule,1899.66,8428.13,APC
Esophagosc dilate balloon 30,43214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4025.17,,,,,,,fee schedule,1899.66,8428.13,
Esophagosc dilate balloon 30,43214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3226.53,,,,,,,fee schedule,1899.66,8428.13,
Esophagosc dilate balloon 30,43214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3524.69,,,,,,,fee schedule,1899.66,8428.13,
Esophagosc dilate balloon 30,43214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3705.71,,,,,,,fee schedule,1899.66,8428.13,
Esophagosc dilate balloon 30,43214,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8428.13,,,,,,,fee schedule,1899.66,8428.13,APC 378
Esophagosc dilate balloon 30,43214,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1994.64,,,,,,,fee schedule,1899.66,8428.13,APC
Esophagosc dilate balloon 30,43214,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1975.64,,,,,,,fee schedule,1899.66,8428.13,APC
Esophagosc dilate balloon 30,43214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1899.66,,,,,,,fee schedule,1899.66,8428.13,APC
Esophagosc dilate balloon 30,43214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2906.47,,,,,,,fee schedule,1899.66,8428.13,Radiology
Esophagosc dilate balloon 30,43214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2659.52,,,,,,,fee schedule,1899.66,8428.13,APC
Esophagosc dilate balloon 30,43214,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3324.4,,,,,,,fee schedule,1899.66,8428.13,APC
Esophagoscopy flex remove fb,43215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2122.13,,,,,,,fee schedule,1701.07,8428.13,
Esophagoscopy flex remove fb,43215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1701.07,,,,,,,fee schedule,1701.07,8428.13,
Esophagoscopy flex remove fb,43215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1858.27,,,,,,,fee schedule,1701.07,8428.13,
Esophagoscopy flex remove fb,43215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1953.71,,,,,,,fee schedule,1701.07,8428.13,
Esophagoscopy flex remove fb,43215,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8428.13,,,,,,,fee schedule,1701.07,8428.13,APC 378
Esophagoscopy flex remove fb,43215,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1994.64,,,,,,,fee schedule,1701.07,8428.13,APC
Esophagoscopy flex remove fb,43215,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1975.64,,,,,,,fee schedule,1701.07,8428.13,APC
Esophagoscopy flex remove fb,43215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1899.66,,,,,,,fee schedule,1701.07,8428.13,APC
Esophagoscopy flex remove fb,43215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2906.47,,,,,,,fee schedule,1701.07,8428.13,Radiology
Esophagoscopy flex remove fb,43215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2659.52,,,,,,,fee schedule,1701.07,8428.13,APC
Esophagoscopy flex remove fb,43215,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3324.4,,,,,,,fee schedule,1701.07,8428.13,APC
Esophagoscopy lesion removal,43216,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2122.13,,,,,,,fee schedule,1701.07,8428.13,
Esophagoscopy lesion removal,43216,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1701.07,,,,,,,fee schedule,1701.07,8428.13,
Esophagoscopy lesion removal,43216,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1858.27,,,,,,,fee schedule,1701.07,8428.13,
Esophagoscopy lesion removal,43216,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1953.71,,,,,,,fee schedule,1701.07,8428.13,
Esophagoscopy lesion removal,43216,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8428.13,,,,,,,fee schedule,1701.07,8428.13,APC 378
Esophagoscopy lesion removal,43216,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1994.64,,,,,,,fee schedule,1701.07,8428.13,APC
Esophagoscopy lesion removal,43216,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1975.64,,,,,,,fee schedule,1701.07,8428.13,APC
Esophagoscopy lesion removal,43216,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1899.66,,,,,,,fee schedule,1701.07,8428.13,APC
Esophagoscopy lesion removal,43216,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2906.47,,,,,,,fee schedule,1701.07,8428.13,Radiology
Esophagoscopy lesion removal,43216,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2659.52,,,,,,,fee schedule,1701.07,8428.13,APC
Esophagoscopy lesion removal,43216,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3324.4,,,,,,,fee schedule,1701.07,8428.13,APC
Esophagoscopy snare les remv,43217,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2122.13,,,,,,,fee schedule,1701.07,8428.13,
Esophagoscopy snare les remv,43217,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1701.07,,,,,,,fee schedule,1701.07,8428.13,
Esophagoscopy snare les remv,43217,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1858.27,,,,,,,fee schedule,1701.07,8428.13,
Esophagoscopy snare les remv,43217,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1953.71,,,,,,,fee schedule,1701.07,8428.13,
Esophagoscopy snare les remv,43217,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8428.13,,,,,,,fee schedule,1701.07,8428.13,APC 378
Esophagoscopy snare les remv,43217,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1994.64,,,,,,,fee schedule,1701.07,8428.13,APC
Esophagoscopy snare les remv,43217,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1975.64,,,,,,,fee schedule,1701.07,8428.13,APC
Esophagoscopy snare les remv,43217,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1899.66,,,,,,,fee schedule,1701.07,8428.13,APC
Esophagoscopy snare les remv,43217,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2906.47,,,,,,,fee schedule,1701.07,8428.13,Radiology
Esophagoscopy snare les remv,43217,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2659.52,,,,,,,fee schedule,1701.07,8428.13,APC
Esophagoscopy snare les remv,43217,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3324.4,,,,,,,fee schedule,1701.07,8428.13,APC
Esophagoscopy balloon <30mm,43220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3019.99,,,,,,,fee schedule,1899.66,8428.13,
Esophagoscopy balloon <30mm,43220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2420.79,,,,,,,fee schedule,1899.66,8428.13,
Esophagoscopy balloon <30mm,43220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2644.49,,,,,,,fee schedule,1899.66,8428.13,
Esophagoscopy balloon <30mm,43220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2780.31,,,,,,,fee schedule,1899.66,8428.13,
Esophagoscopy balloon <30mm,43220,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8428.13,,,,,,,fee schedule,1899.66,8428.13,APC 378
Esophagoscopy balloon <30mm,43220,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1994.64,,,,,,,fee schedule,1899.66,8428.13,APC
Esophagoscopy balloon <30mm,43220,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1975.64,,,,,,,fee schedule,1899.66,8428.13,APC
Esophagoscopy balloon <30mm,43220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1899.66,,,,,,,fee schedule,1899.66,8428.13,APC
Esophagoscopy balloon <30mm,43220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2906.47,,,,,,,fee schedule,1899.66,8428.13,Radiology
Esophagoscopy balloon <30mm,43220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2659.52,,,,,,,fee schedule,1899.66,8428.13,APC
Esophagoscopy balloon <30mm,43220,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3324.4,,,,,,,fee schedule,1899.66,8428.13,APC
Esoph endoscopy dilation,43226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2122.13,,,,,,,fee schedule,1701.07,8428.13,
Esoph endoscopy dilation,43226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1701.07,,,,,,,fee schedule,1701.07,8428.13,
Esoph endoscopy dilation,43226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1858.27,,,,,,,fee schedule,1701.07,8428.13,
Esoph endoscopy dilation,43226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1953.71,,,,,,,fee schedule,1701.07,8428.13,
Esoph endoscopy dilation,43226,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8428.13,,,,,,,fee schedule,1701.07,8428.13,APC 378
Esoph endoscopy dilation,43226,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1994.64,,,,,,,fee schedule,1701.07,8428.13,APC
Esoph endoscopy dilation,43226,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1975.64,,,,,,,fee schedule,1701.07,8428.13,APC
Esoph endoscopy dilation,43226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1899.66,,,,,,,fee schedule,1701.07,8428.13,APC
Esoph endoscopy dilation,43226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2906.47,,,,,,,fee schedule,1701.07,8428.13,Radiology
Esoph endoscopy dilation,43226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2659.52,,,,,,,fee schedule,1701.07,8428.13,APC
Esoph endoscopy dilation,43226,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3324.4,,,,,,,fee schedule,1701.07,8428.13,APC
Esophagoscopy control bleed,43227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2122.13,,,,,,,fee schedule,1701.07,8428.13,
Esophagoscopy control bleed,43227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1701.07,,,,,,,fee schedule,1701.07,8428.13,
Esophagoscopy control bleed,43227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1858.27,,,,,,,fee schedule,1701.07,8428.13,
Esophagoscopy control bleed,43227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1953.71,,,,,,,fee schedule,1701.07,8428.13,
Esophagoscopy control bleed,43227,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8428.13,,,,,,,fee schedule,1701.07,8428.13,APC 378
Esophagoscopy control bleed,43227,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1994.64,,,,,,,fee schedule,1701.07,8428.13,APC
Esophagoscopy control bleed,43227,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1975.64,,,,,,,fee schedule,1701.07,8428.13,APC
Esophagoscopy control bleed,43227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1899.66,,,,,,,fee schedule,1701.07,8428.13,APC
Esophagoscopy control bleed,43227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2906.47,,,,,,,fee schedule,1701.07,8428.13,Radiology
Esophagoscopy control bleed,43227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2659.52,,,,,,,fee schedule,1701.07,8428.13,APC
Esophagoscopy control bleed,43227,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3324.4,,,,,,,fee schedule,1701.07,8428.13,APC
Esophagoscopy lesion ablate,43229,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3858.34,,,,,,,fee schedule,3092.8,16933.82,
Esophagoscopy lesion ablate,43229,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3092.8,,,,,,,fee schedule,3092.8,16933.82,
Esophagoscopy lesion ablate,43229,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3378.6,,,,,,,fee schedule,3092.8,16933.82,
Esophagoscopy lesion ablate,43229,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3552.12,,,,,,,fee schedule,3092.8,16933.82,
Esophagoscopy lesion ablate,43229,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16933.82,,,,,,,fee schedule,3092.8,16933.82,APC 378
Esophagoscopy lesion ablate,43229,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4007.63,,,,,,,fee schedule,3092.8,16933.82,APC
Esophagoscopy lesion ablate,43229,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3969.46,,,,,,,fee schedule,3092.8,16933.82,APC
Esophagoscopy lesion ablate,43229,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3816.79,,,,,,,fee schedule,3092.8,16933.82,APC
Esophagoscopy lesion ablate,43229,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5839.69,,,,,,,fee schedule,3092.8,16933.82,Radiology
Esophagoscopy lesion ablate,43229,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5343.51,,,,,,,fee schedule,3092.8,16933.82,APC
Esophagoscopy lesion ablate,43229,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6679.39,,,,,,,fee schedule,3092.8,16933.82,APC
Esophagoscop ultrasound exam,43231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2122.13,,,,,,,fee schedule,1701.07,8428.13,
Esophagoscop ultrasound exam,43231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1701.07,,,,,,,fee schedule,1701.07,8428.13,
Esophagoscop ultrasound exam,43231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1858.27,,,,,,,fee schedule,1701.07,8428.13,
Esophagoscop ultrasound exam,43231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1953.71,,,,,,,fee schedule,1701.07,8428.13,
Esophagoscop ultrasound exam,43231,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8428.13,,,,,,,fee schedule,1701.07,8428.13,APC 378
Esophagoscop ultrasound exam,43231,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1994.64,,,,,,,fee schedule,1701.07,8428.13,APC
Esophagoscop ultrasound exam,43231,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1975.64,,,,,,,fee schedule,1701.07,8428.13,APC
Esophagoscop ultrasound exam,43231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1899.66,,,,,,,fee schedule,1701.07,8428.13,APC
Esophagoscop ultrasound exam,43231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2906.47,,,,,,,fee schedule,1701.07,8428.13,Radiology
Esophagoscop ultrasound exam,43231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2659.52,,,,,,,fee schedule,1701.07,8428.13,APC
Esophagoscop ultrasound exam,43231,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3324.4,,,,,,,fee schedule,1701.07,8428.13,APC
Esophagoscopy w/us needle bx,43232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2122.13,,,,,,,fee schedule,1701.07,8428.13,
Esophagoscopy w/us needle bx,43232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1701.07,,,,,,,fee schedule,1701.07,8428.13,
Esophagoscopy w/us needle bx,43232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1858.27,,,,,,,fee schedule,1701.07,8428.13,
Esophagoscopy w/us needle bx,43232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1953.71,,,,,,,fee schedule,1701.07,8428.13,
Esophagoscopy w/us needle bx,43232,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8428.13,,,,,,,fee schedule,1701.07,8428.13,APC 378
Esophagoscopy w/us needle bx,43232,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1994.64,,,,,,,fee schedule,1701.07,8428.13,APC
Esophagoscopy w/us needle bx,43232,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1975.64,,,,,,,fee schedule,1701.07,8428.13,APC
Esophagoscopy w/us needle bx,43232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1899.66,,,,,,,fee schedule,1701.07,8428.13,APC
Esophagoscopy w/us needle bx,43232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2906.47,,,,,,,fee schedule,1701.07,8428.13,Radiology
Esophagoscopy w/us needle bx,43232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2659.52,,,,,,,fee schedule,1701.07,8428.13,APC
Esophagoscopy w/us needle bx,43232,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3324.4,,,,,,,fee schedule,1701.07,8428.13,APC
Egd balloon dil esoph30 mm/>,43233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1573.39,,,,,,,fee schedule,1261.21,8428.13,
Egd balloon dil esoph30 mm/>,43233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1261.21,,,,,,,fee schedule,1261.21,8428.13,
Egd balloon dil esoph30 mm/>,43233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1377.75,,,,,,,fee schedule,1261.21,8428.13,
Egd balloon dil esoph30 mm/>,43233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1448.52,,,,,,,fee schedule,1261.21,8428.13,
Egd balloon dil esoph30 mm/>,43233,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8428.13,,,,,,,fee schedule,1261.21,8428.13,APC 378
Egd balloon dil esoph30 mm/>,43233,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1994.64,,,,,,,fee schedule,1261.21,8428.13,APC
Egd balloon dil esoph30 mm/>,43233,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1975.64,,,,,,,fee schedule,1261.21,8428.13,APC
Egd balloon dil esoph30 mm/>,43233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1899.66,,,,,,,fee schedule,1261.21,8428.13,APC
Egd balloon dil esoph30 mm/>,43233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2906.47,,,,,,,fee schedule,1261.21,8428.13,Radiology
Egd balloon dil esoph30 mm/>,43233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2659.52,,,,,,,fee schedule,1261.21,8428.13,APC
Egd balloon dil esoph30 mm/>,43233,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3324.4,,,,,,,fee schedule,1261.21,8428.13,APC
Egd diagnostic brush wash,43235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2530.03,,,,,,,fee schedule,897.89,3983.62,
Egd diagnostic brush wash,43235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2028.04,,,,,,,fee schedule,897.89,3983.62,
Egd diagnostic brush wash,43235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2215.45,,,,,,,fee schedule,897.89,3983.62,
Egd diagnostic brush wash,43235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2329.23,,,,,,,fee schedule,897.89,3983.62,
Egd diagnostic brush wash,43235,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3983.62,,,,,,,fee schedule,897.89,3983.62,APC 378
Egd diagnostic brush wash,43235,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,942.78,,,,,,,fee schedule,897.89,3983.62,APC
Egd diagnostic brush wash,43235,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,933.8,,,,,,,fee schedule,897.89,3983.62,APC
Egd diagnostic brush wash,43235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,897.89,,,,,,,fee schedule,897.89,3983.62,APC
Egd diagnostic brush wash,43235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1373.77,,,,,,,fee schedule,897.89,3983.62,Radiology
Egd diagnostic brush wash,43235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1257.04,,,,,,,fee schedule,897.89,3983.62,APC
Egd diagnostic brush wash,43235,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1571.3,,,,,,,fee schedule,897.89,3983.62,APC
Uppr gi scope w/submuc inj,43236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1539.12,,,,,,,fee schedule,897.89,3983.62,
Uppr gi scope w/submuc inj,43236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1233.74,,,,,,,fee schedule,897.89,3983.62,
Uppr gi scope w/submuc inj,43236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1347.75,,,,,,,fee schedule,897.89,3983.62,
Uppr gi scope w/submuc inj,43236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1416.97,,,,,,,fee schedule,897.89,3983.62,
Uppr gi scope w/submuc inj,43236,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3983.62,,,,,,,fee schedule,897.89,3983.62,APC 378
Uppr gi scope w/submuc inj,43236,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,942.78,,,,,,,fee schedule,897.89,3983.62,APC
Uppr gi scope w/submuc inj,43236,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,933.8,,,,,,,fee schedule,897.89,3983.62,APC
Uppr gi scope w/submuc inj,43236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,897.89,,,,,,,fee schedule,897.89,3983.62,APC
Uppr gi scope w/submuc inj,43236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1373.77,,,,,,,fee schedule,897.89,3983.62,Radiology
Uppr gi scope w/submuc inj,43236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1257.04,,,,,,,fee schedule,897.89,3983.62,APC
Uppr gi scope w/submuc inj,43236,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1571.3,,,,,,,fee schedule,897.89,3983.62,APC
Endoscopic us exam esoph,43237,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2119.32,,,,,,,fee schedule,1698.82,8428.13,
Endoscopic us exam esoph,43237,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1698.82,,,,,,,fee schedule,1698.82,8428.13,
Endoscopic us exam esoph,43237,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1855.8,,,,,,,fee schedule,1698.82,8428.13,
Endoscopic us exam esoph,43237,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1951.12,,,,,,,fee schedule,1698.82,8428.13,
Endoscopic us exam esoph,43237,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8428.13,,,,,,,fee schedule,1698.82,8428.13,APC 378
Endoscopic us exam esoph,43237,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1994.64,,,,,,,fee schedule,1698.82,8428.13,APC
Endoscopic us exam esoph,43237,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1975.64,,,,,,,fee schedule,1698.82,8428.13,APC
Endoscopic us exam esoph,43237,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1899.66,,,,,,,fee schedule,1698.82,8428.13,APC
Endoscopic us exam esoph,43237,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2906.47,,,,,,,fee schedule,1698.82,8428.13,Radiology
Endoscopic us exam esoph,43237,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2659.52,,,,,,,fee schedule,1698.82,8428.13,APC
Endoscopic us exam esoph,43237,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3324.4,,,,,,,fee schedule,1698.82,8428.13,APC
Egd us fine needle bx/aspir,43238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1098.99,,,,,,,fee schedule,880.93,8428.13,
Egd us fine needle bx/aspir,43238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,880.93,,,,,,,fee schedule,880.93,8428.13,
Egd us fine needle bx/aspir,43238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,962.34,,,,,,,fee schedule,880.93,8428.13,
Egd us fine needle bx/aspir,43238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1011.77,,,,,,,fee schedule,880.93,8428.13,
Egd us fine needle bx/aspir,43238,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8428.13,,,,,,,fee schedule,880.93,8428.13,APC 378
Egd us fine needle bx/aspir,43238,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1994.64,,,,,,,fee schedule,880.93,8428.13,APC
Egd us fine needle bx/aspir,43238,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1975.64,,,,,,,fee schedule,880.93,8428.13,APC
Egd us fine needle bx/aspir,43238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1899.66,,,,,,,fee schedule,880.93,8428.13,APC
Egd us fine needle bx/aspir,43238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2906.47,,,,,,,fee schedule,880.93,8428.13,Radiology
Egd us fine needle bx/aspir,43238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2659.52,,,,,,,fee schedule,880.93,8428.13,APC
Egd us fine needle bx/aspir,43238,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3324.4,,,,,,,fee schedule,880.93,8428.13,APC
Egd biopsy single/multiple,43239,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2611.82,,,,,,,fee schedule,897.89,3983.62,
Egd biopsy single/multiple,43239,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2093.6,,,,,,,fee schedule,897.89,3983.62,
Egd biopsy single/multiple,43239,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2287.07,,,,,,,fee schedule,897.89,3983.62,
Egd biopsy single/multiple,43239,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2404.54,,,,,,,fee schedule,897.89,3983.62,
Egd biopsy single/multiple,43239,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3983.62,,,,,,,fee schedule,897.89,3983.62,APC 378
Egd biopsy single/multiple,43239,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,942.78,,,,,,,fee schedule,897.89,3983.62,APC
Egd biopsy single/multiple,43239,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,933.8,,,,,,,fee schedule,897.89,3983.62,APC
Egd biopsy single/multiple,43239,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,897.89,,,,,,,fee schedule,897.89,3983.62,APC
Egd biopsy single/multiple,43239,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1373.77,,,,,,,fee schedule,897.89,3983.62,Radiology
Egd biopsy single/multiple,43239,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1257.04,,,,,,,fee schedule,897.89,3983.62,APC
Egd biopsy single/multiple,43239,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1571.3,,,,,,,fee schedule,897.89,3983.62,APC
Egd w/transmural drain cyst,43240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2122.13,,,,,,,fee schedule,1701.07,26664.3,
Egd w/transmural drain cyst,43240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1701.07,,,,,,,fee schedule,1701.07,26664.3,
Egd w/transmural drain cyst,43240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1858.27,,,,,,,fee schedule,1701.07,26664.3,
Egd w/transmural drain cyst,43240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1953.71,,,,,,,fee schedule,1701.07,26664.3,
Egd w/transmural drain cyst,43240,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26664.3,,,,,,,fee schedule,1701.07,26664.3,APC 378
Egd w/transmural drain cyst,43240,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6310.49,,,,,,,fee schedule,1701.07,26664.3,APC
Egd w/transmural drain cyst,43240,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6250.39,,,,,,,fee schedule,1701.07,26664.3,APC
Egd w/transmural drain cyst,43240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6009.99,,,,,,,fee schedule,1701.07,26664.3,APC
Egd w/transmural drain cyst,43240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9195.29,,,,,,,fee schedule,1701.07,26664.3,Radiology
Egd w/transmural drain cyst,43240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8413.99,,,,,,,fee schedule,1701.07,26664.3,APC
Egd w/transmural drain cyst,43240,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10517.49,,,,,,,fee schedule,1701.07,26664.3,APC
Egd tube/cath insertion,43241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2122.13,,,,,,,fee schedule,1701.07,8428.13,
Egd tube/cath insertion,43241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1701.07,,,,,,,fee schedule,1701.07,8428.13,
Egd tube/cath insertion,43241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1858.27,,,,,,,fee schedule,1701.07,8428.13,
Egd tube/cath insertion,43241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1953.71,,,,,,,fee schedule,1701.07,8428.13,
Egd tube/cath insertion,43241,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8428.13,,,,,,,fee schedule,1701.07,8428.13,APC 378
Egd tube/cath insertion,43241,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1994.64,,,,,,,fee schedule,1701.07,8428.13,APC
Egd tube/cath insertion,43241,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1975.64,,,,,,,fee schedule,1701.07,8428.13,APC
Egd tube/cath insertion,43241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1899.66,,,,,,,fee schedule,1701.07,8428.13,APC
Egd tube/cath insertion,43241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2906.47,,,,,,,fee schedule,1701.07,8428.13,Radiology
Egd tube/cath insertion,43241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2659.52,,,,,,,fee schedule,1701.07,8428.13,APC
Egd tube/cath insertion,43241,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3324.4,,,,,,,fee schedule,1701.07,8428.13,APC
Egd us fine needle bx/aspir,43242,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2616.89,,,,,,,fee schedule,1899.66,8428.13,
Egd us fine needle bx/aspir,43242,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2097.67,,,,,,,fee schedule,1899.66,8428.13,
Egd us fine needle bx/aspir,43242,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2291.51,,,,,,,fee schedule,1899.66,8428.13,
Egd us fine needle bx/aspir,43242,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2409.2,,,,,,,fee schedule,1899.66,8428.13,
Egd us fine needle bx/aspir,43242,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8428.13,,,,,,,fee schedule,1899.66,8428.13,APC 378
Egd us fine needle bx/aspir,43242,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1994.64,,,,,,,fee schedule,1899.66,8428.13,APC
Egd us fine needle bx/aspir,43242,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1975.64,,,,,,,fee schedule,1899.66,8428.13,APC
Egd us fine needle bx/aspir,43242,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1899.66,,,,,,,fee schedule,1899.66,8428.13,APC
Egd us fine needle bx/aspir,43242,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2906.47,,,,,,,fee schedule,1899.66,8428.13,Radiology
Egd us fine needle bx/aspir,43242,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2659.52,,,,,,,fee schedule,1899.66,8428.13,APC
Egd us fine needle bx/aspir,43242,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3324.4,,,,,,,fee schedule,1899.66,8428.13,APC
Egd injection varices,43243,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2122.13,,,,,,,fee schedule,1701.07,8428.13,
Egd injection varices,43243,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1701.07,,,,,,,fee schedule,1701.07,8428.13,
Egd injection varices,43243,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1858.27,,,,,,,fee schedule,1701.07,8428.13,
Egd injection varices,43243,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1953.71,,,,,,,fee schedule,1701.07,8428.13,
Egd injection varices,43243,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8428.13,,,,,,,fee schedule,1701.07,8428.13,APC 378
Egd injection varices,43243,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1994.64,,,,,,,fee schedule,1701.07,8428.13,APC
Egd injection varices,43243,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1975.64,,,,,,,fee schedule,1701.07,8428.13,APC
Egd injection varices,43243,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1899.66,,,,,,,fee schedule,1701.07,8428.13,APC
Egd injection varices,43243,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2906.47,,,,,,,fee schedule,1701.07,8428.13,Radiology
Egd injection varices,43243,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2659.52,,,,,,,fee schedule,1701.07,8428.13,APC
Egd injection varices,43243,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3324.4,,,,,,,fee schedule,1701.07,8428.13,APC
Egd varices ligation,43244,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2940.38,,,,,,,fee schedule,1899.66,8428.13,
Egd varices ligation,43244,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2356.97,,,,,,,fee schedule,1899.66,8428.13,
Egd varices ligation,43244,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2574.78,,,,,,,fee schedule,1899.66,8428.13,
Egd varices ligation,43244,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2707.02,,,,,,,fee schedule,1899.66,8428.13,
Egd varices ligation,43244,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8428.13,,,,,,,fee schedule,1899.66,8428.13,APC 378
Egd varices ligation,43244,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1994.64,,,,,,,fee schedule,1899.66,8428.13,APC
Egd varices ligation,43244,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1975.64,,,,,,,fee schedule,1899.66,8428.13,APC
Egd varices ligation,43244,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1899.66,,,,,,,fee schedule,1899.66,8428.13,APC
Egd varices ligation,43244,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2906.47,,,,,,,fee schedule,1899.66,8428.13,Radiology
Egd varices ligation,43244,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2659.52,,,,,,,fee schedule,1899.66,8428.13,APC
Egd varices ligation,43244,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3324.4,,,,,,,fee schedule,1899.66,8428.13,APC
Egd dilate stricture,43245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2122.13,,,,,,,fee schedule,1701.07,8428.13,
Egd dilate stricture,43245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1701.07,,,,,,,fee schedule,1701.07,8428.13,
Egd dilate stricture,43245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1858.27,,,,,,,fee schedule,1701.07,8428.13,
Egd dilate stricture,43245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1953.71,,,,,,,fee schedule,1701.07,8428.13,
Egd dilate stricture,43245,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8428.13,,,,,,,fee schedule,1701.07,8428.13,APC 378
Egd dilate stricture,43245,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1994.64,,,,,,,fee schedule,1701.07,8428.13,APC
Egd dilate stricture,43245,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1975.64,,,,,,,fee schedule,1701.07,8428.13,APC
Egd dilate stricture,43245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1899.66,,,,,,,fee schedule,1701.07,8428.13,APC
Egd dilate stricture,43245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2906.47,,,,,,,fee schedule,1701.07,8428.13,Radiology
Egd dilate stricture,43245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2659.52,,,,,,,fee schedule,1701.07,8428.13,APC
Egd dilate stricture,43245,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3324.4,,,,,,,fee schedule,1701.07,8428.13,APC
Egd place gastrostomy tube,43246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4794.39,,,,,,,fee schedule,1899.66,8428.13,
Egd place gastrostomy tube,43246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3843.12,,,,,,,fee schedule,1899.66,8428.13,
Egd place gastrostomy tube,43246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4198.26,,,,,,,fee schedule,1899.66,8428.13,
Egd place gastrostomy tube,43246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4413.88,,,,,,,fee schedule,1899.66,8428.13,
Egd place gastrostomy tube,43246,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8428.13,,,,,,,fee schedule,1899.66,8428.13,APC 378
Egd place gastrostomy tube,43246,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1994.64,,,,,,,fee schedule,1899.66,8428.13,APC
Egd place gastrostomy tube,43246,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1975.64,,,,,,,fee schedule,1899.66,8428.13,APC
Egd place gastrostomy tube,43246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1899.66,,,,,,,fee schedule,1899.66,8428.13,APC
Egd place gastrostomy tube,43246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2906.47,,,,,,,fee schedule,1899.66,8428.13,Radiology
Egd place gastrostomy tube,43246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2659.52,,,,,,,fee schedule,1899.66,8428.13,APC
Egd place gastrostomy tube,43246,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3324.4,,,,,,,fee schedule,1899.66,8428.13,APC
Egd remove foreign body,43247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1948.85,,,,,,,fee schedule,897.89,3983.62,
Egd remove foreign body,43247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1562.18,,,,,,,fee schedule,897.89,3983.62,
Egd remove foreign body,43247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1706.54,,,,,,,fee schedule,897.89,3983.62,
Egd remove foreign body,43247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1794.18,,,,,,,fee schedule,897.89,3983.62,
Egd remove foreign body,43247,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3983.62,,,,,,,fee schedule,897.89,3983.62,APC 378
Egd remove foreign body,43247,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,942.78,,,,,,,fee schedule,897.89,3983.62,APC
Egd remove foreign body,43247,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,933.8,,,,,,,fee schedule,897.89,3983.62,APC
Egd remove foreign body,43247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,897.89,,,,,,,fee schedule,897.89,3983.62,APC
Egd remove foreign body,43247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1373.77,,,,,,,fee schedule,897.89,3983.62,Radiology
Egd remove foreign body,43247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1257.04,,,,,,,fee schedule,897.89,3983.62,APC
Egd remove foreign body,43247,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1571.3,,,,,,,fee schedule,897.89,3983.62,APC
Egd guide wire insertion,43248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2093.81,,,,,,,fee schedule,897.89,3983.62,
Egd guide wire insertion,43248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1678.37,,,,,,,fee schedule,897.89,3983.62,
Egd guide wire insertion,43248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1833.47,,,,,,,fee schedule,897.89,3983.62,
Egd guide wire insertion,43248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1927.64,,,,,,,fee schedule,897.89,3983.62,
Egd guide wire insertion,43248,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3983.62,,,,,,,fee schedule,897.89,3983.62,APC 378
Egd guide wire insertion,43248,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,942.78,,,,,,,fee schedule,897.89,3983.62,APC
Egd guide wire insertion,43248,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,933.8,,,,,,,fee schedule,897.89,3983.62,APC
Egd guide wire insertion,43248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,897.89,,,,,,,fee schedule,897.89,3983.62,APC
Egd guide wire insertion,43248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1373.77,,,,,,,fee schedule,897.89,3983.62,Radiology
Egd guide wire insertion,43248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1257.04,,,,,,,fee schedule,897.89,3983.62,APC
Egd guide wire insertion,43248,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1571.3,,,,,,,fee schedule,897.89,3983.62,APC
Esoph egd dilation <30 mm,43249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1818.03,,,,,,,fee schedule,1457.31,8428.13,
Esoph egd dilation <30 mm,43249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1457.31,,,,,,,fee schedule,1457.31,8428.13,
Esoph egd dilation <30 mm,43249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1591.97,,,,,,,fee schedule,1457.31,8428.13,
Esoph egd dilation <30 mm,43249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1673.74,,,,,,,fee schedule,1457.31,8428.13,
Esoph egd dilation <30 mm,43249,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8428.13,,,,,,,fee schedule,1457.31,8428.13,APC 378
Esoph egd dilation <30 mm,43249,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1994.64,,,,,,,fee schedule,1457.31,8428.13,APC
Esoph egd dilation <30 mm,43249,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1975.64,,,,,,,fee schedule,1457.31,8428.13,APC
Esoph egd dilation <30 mm,43249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1899.66,,,,,,,fee schedule,1457.31,8428.13,APC
Esoph egd dilation <30 mm,43249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2906.47,,,,,,,fee schedule,1457.31,8428.13,Radiology
Esoph egd dilation <30 mm,43249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2659.52,,,,,,,fee schedule,1457.31,8428.13,APC
Esoph egd dilation <30 mm,43249,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3324.4,,,,,,,fee schedule,1457.31,8428.13,APC
Egd cautery tumor polyp,43250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1077.91,,,,,,,fee schedule,864.04,8428.13,
Egd cautery tumor polyp,43250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,864.04,,,,,,,fee schedule,864.04,8428.13,
Egd cautery tumor polyp,43250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,943.89,,,,,,,fee schedule,864.04,8428.13,
Egd cautery tumor polyp,43250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,992.36,,,,,,,fee schedule,864.04,8428.13,
Egd cautery tumor polyp,43250,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8428.13,,,,,,,fee schedule,864.04,8428.13,APC 378
Egd cautery tumor polyp,43250,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1994.64,,,,,,,fee schedule,864.04,8428.13,APC
Egd cautery tumor polyp,43250,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1975.64,,,,,,,fee schedule,864.04,8428.13,APC
Egd cautery tumor polyp,43250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1899.66,,,,,,,fee schedule,864.04,8428.13,APC
Egd cautery tumor polyp,43250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2906.47,,,,,,,fee schedule,864.04,8428.13,Radiology
Egd cautery tumor polyp,43250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2659.52,,,,,,,fee schedule,864.04,8428.13,APC
Egd cautery tumor polyp,43250,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3324.4,,,,,,,fee schedule,864.04,8428.13,APC
Egd remove lesion snare,43251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1735.55,,,,,,,fee schedule,1391.19,8428.13,
Egd remove lesion snare,43251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1391.19,,,,,,,fee schedule,1391.19,8428.13,
Egd remove lesion snare,43251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1519.75,,,,,,,fee schedule,1391.19,8428.13,
Egd remove lesion snare,43251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1597.81,,,,,,,fee schedule,1391.19,8428.13,
Egd remove lesion snare,43251,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8428.13,,,,,,,fee schedule,1391.19,8428.13,APC 378
Egd remove lesion snare,43251,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1994.64,,,,,,,fee schedule,1391.19,8428.13,APC
Egd remove lesion snare,43251,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1975.64,,,,,,,fee schedule,1391.19,8428.13,APC
Egd remove lesion snare,43251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1899.66,,,,,,,fee schedule,1391.19,8428.13,APC
Egd remove lesion snare,43251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2906.47,,,,,,,fee schedule,1391.19,8428.13,Radiology
Egd remove lesion snare,43251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2659.52,,,,,,,fee schedule,1391.19,8428.13,APC
Egd remove lesion snare,43251,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3324.4,,,,,,,fee schedule,1391.19,8428.13,APC
Egd optical endomicroscopy,43252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3503.23,,,,,,,fee schedule,1899.66,8428.13,
Egd optical endomicroscopy,43252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2808.14,,,,,,,fee schedule,1899.66,8428.13,
Egd optical endomicroscopy,43252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3067.64,,,,,,,fee schedule,1899.66,8428.13,
Egd optical endomicroscopy,43252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3225.19,,,,,,,fee schedule,1899.66,8428.13,
Egd optical endomicroscopy,43252,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8428.13,,,,,,,fee schedule,1899.66,8428.13,APC 378
Egd optical endomicroscopy,43252,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1994.64,,,,,,,fee schedule,1899.66,8428.13,APC
Egd optical endomicroscopy,43252,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1975.64,,,,,,,fee schedule,1899.66,8428.13,APC
Egd optical endomicroscopy,43252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1899.66,,,,,,,fee schedule,1899.66,8428.13,APC
Egd optical endomicroscopy,43252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2906.47,,,,,,,fee schedule,1899.66,8428.13,Radiology
Egd optical endomicroscopy,43252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2659.52,,,,,,,fee schedule,1899.66,8428.13,APC
Egd optical endomicroscopy,43252,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3324.4,,,,,,,fee schedule,1899.66,8428.13,APC
Egd us transmural injxn/mark,43253,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4025.17,,,,,,,fee schedule,1899.66,8428.13,
Egd us transmural injxn/mark,43253,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3226.53,,,,,,,fee schedule,1899.66,8428.13,
Egd us transmural injxn/mark,43253,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3524.69,,,,,,,fee schedule,1899.66,8428.13,
Egd us transmural injxn/mark,43253,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3705.71,,,,,,,fee schedule,1899.66,8428.13,
Egd us transmural injxn/mark,43253,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8428.13,,,,,,,fee schedule,1899.66,8428.13,APC 378
Egd us transmural injxn/mark,43253,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1994.64,,,,,,,fee schedule,1899.66,8428.13,APC
Egd us transmural injxn/mark,43253,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1975.64,,,,,,,fee schedule,1899.66,8428.13,APC
Egd us transmural injxn/mark,43253,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1899.66,,,,,,,fee schedule,1899.66,8428.13,APC
Egd us transmural injxn/mark,43253,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2906.47,,,,,,,fee schedule,1899.66,8428.13,Radiology
Egd us transmural injxn/mark,43253,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2659.52,,,,,,,fee schedule,1899.66,8428.13,APC
Egd us transmural injxn/mark,43253,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3324.4,,,,,,,fee schedule,1899.66,8428.13,APC
Egd endo mucosal resection,43254,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4025.17,,,,,,,fee schedule,1899.66,8428.13,
Egd endo mucosal resection,43254,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3226.53,,,,,,,fee schedule,1899.66,8428.13,
Egd endo mucosal resection,43254,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3524.69,,,,,,,fee schedule,1899.66,8428.13,
Egd endo mucosal resection,43254,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3705.71,,,,,,,fee schedule,1899.66,8428.13,
Egd endo mucosal resection,43254,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8428.13,,,,,,,fee schedule,1899.66,8428.13,APC 378
Egd endo mucosal resection,43254,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1994.64,,,,,,,fee schedule,1899.66,8428.13,APC
Egd endo mucosal resection,43254,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1975.64,,,,,,,fee schedule,1899.66,8428.13,APC
Egd endo mucosal resection,43254,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1899.66,,,,,,,fee schedule,1899.66,8428.13,APC
Egd endo mucosal resection,43254,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2906.47,,,,,,,fee schedule,1899.66,8428.13,Radiology
Egd endo mucosal resection,43254,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2659.52,,,,,,,fee schedule,1899.66,8428.13,APC
Egd endo mucosal resection,43254,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3324.4,,,,,,,fee schedule,1899.66,8428.13,APC
Egd control bleeding any,43255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1719.67,,,,,,,fee schedule,1378.47,8428.13,
Egd control bleeding any,43255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1378.47,,,,,,,fee schedule,1378.47,8428.13,
Egd control bleeding any,43255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1505.85,,,,,,,fee schedule,1378.47,8428.13,
Egd control bleeding any,43255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1583.19,,,,,,,fee schedule,1378.47,8428.13,
Egd control bleeding any,43255,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8428.13,,,,,,,fee schedule,1378.47,8428.13,APC 378
Egd control bleeding any,43255,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1994.64,,,,,,,fee schedule,1378.47,8428.13,APC
Egd control bleeding any,43255,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1975.64,,,,,,,fee schedule,1378.47,8428.13,APC
Egd control bleeding any,43255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1899.66,,,,,,,fee schedule,1378.47,8428.13,APC
Egd control bleeding any,43255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2906.47,,,,,,,fee schedule,1378.47,8428.13,Radiology
Egd control bleeding any,43255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2659.52,,,,,,,fee schedule,1378.47,8428.13,APC
Egd control bleeding any,43255,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3324.4,,,,,,,fee schedule,1378.47,8428.13,APC
Egd w/thrml txmnt gerd,43257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6320.05,,,,,,,fee schedule,3816.79,16933.82,
Egd w/thrml txmnt gerd,43257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5066.07,,,,,,,fee schedule,3816.79,16933.82,
Egd w/thrml txmnt gerd,43257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5534.22,,,,,,,fee schedule,3816.79,16933.82,
Egd w/thrml txmnt gerd,43257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5818.46,,,,,,,fee schedule,3816.79,16933.82,
Egd w/thrml txmnt gerd,43257,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16933.82,,,,,,,fee schedule,3816.79,16933.82,APC 378
Egd w/thrml txmnt gerd,43257,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4007.63,,,,,,,fee schedule,3816.79,16933.82,APC
Egd w/thrml txmnt gerd,43257,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3969.46,,,,,,,fee schedule,3816.79,16933.82,APC
Egd w/thrml txmnt gerd,43257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3816.79,,,,,,,fee schedule,3816.79,16933.82,APC
Egd w/thrml txmnt gerd,43257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5839.69,,,,,,,fee schedule,3816.79,16933.82,Radiology
Egd w/thrml txmnt gerd,43257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5343.51,,,,,,,fee schedule,3816.79,16933.82,APC
Egd w/thrml txmnt gerd,43257,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6679.39,,,,,,,fee schedule,3816.79,16933.82,APC
Egd us exam duodenum/jejunum,43259,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1244.19,,,,,,,fee schedule,997.33,8428.13,
Egd us exam duodenum/jejunum,43259,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,997.33,,,,,,,fee schedule,997.33,8428.13,
Egd us exam duodenum/jejunum,43259,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1089.49,,,,,,,fee schedule,997.33,8428.13,
Egd us exam duodenum/jejunum,43259,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1145.44,,,,,,,fee schedule,997.33,8428.13,
Egd us exam duodenum/jejunum,43259,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8428.13,,,,,,,fee schedule,997.33,8428.13,APC 378
Egd us exam duodenum/jejunum,43259,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1994.64,,,,,,,fee schedule,997.33,8428.13,APC
Egd us exam duodenum/jejunum,43259,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1975.64,,,,,,,fee schedule,997.33,8428.13,APC
Egd us exam duodenum/jejunum,43259,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1899.66,,,,,,,fee schedule,997.33,8428.13,APC
Egd us exam duodenum/jejunum,43259,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2906.47,,,,,,,fee schedule,997.33,8428.13,Radiology
Egd us exam duodenum/jejunum,43259,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2659.52,,,,,,,fee schedule,997.33,8428.13,APC
Egd us exam duodenum/jejunum,43259,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3324.4,,,,,,,fee schedule,997.33,8428.13,APC
Ercp w/specimen collection,43260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3910.71,,,,,,,fee schedule,3134.78,16933.82,
Ercp w/specimen collection,43260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3134.78,,,,,,,fee schedule,3134.78,16933.82,
Ercp w/specimen collection,43260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3424.46,,,,,,,fee schedule,3134.78,16933.82,
Ercp w/specimen collection,43260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3600.34,,,,,,,fee schedule,3134.78,16933.82,
Ercp w/specimen collection,43260,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16933.82,,,,,,,fee schedule,3134.78,16933.82,APC 378
Ercp w/specimen collection,43260,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4007.63,,,,,,,fee schedule,3134.78,16933.82,APC
Ercp w/specimen collection,43260,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3969.46,,,,,,,fee schedule,3134.78,16933.82,APC
Ercp w/specimen collection,43260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3816.79,,,,,,,fee schedule,3134.78,16933.82,APC
Ercp w/specimen collection,43260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5839.69,,,,,,,fee schedule,3134.78,16933.82,Radiology
Ercp w/specimen collection,43260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5343.51,,,,,,,fee schedule,3134.78,16933.82,APC
Ercp w/specimen collection,43260,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6679.39,,,,,,,fee schedule,3134.78,16933.82,APC
Endo cholangiopancreatograph,43261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2234.38,,,,,,,fee schedule,1791.05,16933.82,
Endo cholangiopancreatograph,43261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1791.05,,,,,,,fee schedule,1791.05,16933.82,
Endo cholangiopancreatograph,43261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1956.56,,,,,,,fee schedule,1791.05,16933.82,
Endo cholangiopancreatograph,43261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2057.05,,,,,,,fee schedule,1791.05,16933.82,
Endo cholangiopancreatograph,43261,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16933.82,,,,,,,fee schedule,1791.05,16933.82,APC 378
Endo cholangiopancreatograph,43261,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4007.63,,,,,,,fee schedule,1791.05,16933.82,APC
Endo cholangiopancreatograph,43261,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3969.46,,,,,,,fee schedule,1791.05,16933.82,APC
Endo cholangiopancreatograph,43261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3816.79,,,,,,,fee schedule,1791.05,16933.82,APC
Endo cholangiopancreatograph,43261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5839.69,,,,,,,fee schedule,1791.05,16933.82,Radiology
Endo cholangiopancreatograph,43261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5343.51,,,,,,,fee schedule,1791.05,16933.82,APC
Endo cholangiopancreatograph,43261,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6679.39,,,,,,,fee schedule,1791.05,16933.82,APC
Endo cholangiopancreatograph,43262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2345.64,,,,,,,fee schedule,1880.23,16933.82,
Endo cholangiopancreatograph,43262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1880.23,,,,,,,fee schedule,1880.23,16933.82,
Endo cholangiopancreatograph,43262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2053.98,,,,,,,fee schedule,1880.23,16933.82,
Endo cholangiopancreatograph,43262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2159.47,,,,,,,fee schedule,1880.23,16933.82,
Endo cholangiopancreatograph,43262,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16933.82,,,,,,,fee schedule,1880.23,16933.82,APC 378
Endo cholangiopancreatograph,43262,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4007.63,,,,,,,fee schedule,1880.23,16933.82,APC
Endo cholangiopancreatograph,43262,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3969.46,,,,,,,fee schedule,1880.23,16933.82,APC
Endo cholangiopancreatograph,43262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3816.79,,,,,,,fee schedule,1880.23,16933.82,APC
Endo cholangiopancreatograph,43262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5839.69,,,,,,,fee schedule,1880.23,16933.82,Radiology
Endo cholangiopancreatograph,43262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5343.51,,,,,,,fee schedule,1880.23,16933.82,APC
Endo cholangiopancreatograph,43262,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6679.39,,,,,,,fee schedule,1880.23,16933.82,APC
Ercp sphincter pressure meas,43263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5228.84,,,,,,,fee schedule,1899.66,8428.13,
Ercp sphincter pressure meas,43263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4191.37,,,,,,,fee schedule,1899.66,8428.13,
Ercp sphincter pressure meas,43263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4578.69,,,,,,,fee schedule,1899.66,8428.13,
Ercp sphincter pressure meas,43263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4813.85,,,,,,,fee schedule,1899.66,8428.13,
Ercp sphincter pressure meas,43263,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8428.13,,,,,,,fee schedule,1899.66,8428.13,APC 378
Ercp sphincter pressure meas,43263,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1994.64,,,,,,,fee schedule,1899.66,8428.13,APC
Ercp sphincter pressure meas,43263,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1975.64,,,,,,,fee schedule,1899.66,8428.13,APC
Ercp sphincter pressure meas,43263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1899.66,,,,,,,fee schedule,1899.66,8428.13,APC
Ercp sphincter pressure meas,43263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2906.47,,,,,,,fee schedule,1899.66,8428.13,Radiology
Ercp sphincter pressure meas,43263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2659.52,,,,,,,fee schedule,1899.66,8428.13,APC
Ercp sphincter pressure meas,43263,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3324.4,,,,,,,fee schedule,1899.66,8428.13,APC
Ercp remove duct calculi,43264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2345.63,,,,,,,fee schedule,1880.22,16933.82,
Ercp remove duct calculi,43264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1880.22,,,,,,,fee schedule,1880.22,16933.82,
Ercp remove duct calculi,43264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2053.97,,,,,,,fee schedule,1880.22,16933.82,
Ercp remove duct calculi,43264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2159.46,,,,,,,fee schedule,1880.22,16933.82,
Ercp remove duct calculi,43264,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16933.82,,,,,,,fee schedule,1880.22,16933.82,APC 378
Ercp remove duct calculi,43264,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4007.63,,,,,,,fee schedule,1880.22,16933.82,APC
Ercp remove duct calculi,43264,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3969.46,,,,,,,fee schedule,1880.22,16933.82,APC
Ercp remove duct calculi,43264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3816.79,,,,,,,fee schedule,1880.22,16933.82,APC
Ercp remove duct calculi,43264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5839.69,,,,,,,fee schedule,1880.22,16933.82,Radiology
Ercp remove duct calculi,43264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5343.51,,,,,,,fee schedule,1880.22,16933.82,APC
Ercp remove duct calculi,43264,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6679.39,,,,,,,fee schedule,1880.22,16933.82,APC
Ercp lithotripsy calculi,43265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5228.84,,,,,,,fee schedule,4191.37,26664.3,
Ercp lithotripsy calculi,43265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4191.37,,,,,,,fee schedule,4191.37,26664.3,
Ercp lithotripsy calculi,43265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4578.69,,,,,,,fee schedule,4191.37,26664.3,
Ercp lithotripsy calculi,43265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4813.85,,,,,,,fee schedule,4191.37,26664.3,
Ercp lithotripsy calculi,43265,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26664.3,,,,,,,fee schedule,4191.37,26664.3,APC 378
Ercp lithotripsy calculi,43265,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6310.49,,,,,,,fee schedule,4191.37,26664.3,APC
Ercp lithotripsy calculi,43265,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6250.39,,,,,,,fee schedule,4191.37,26664.3,APC
Ercp lithotripsy calculi,43265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6009.99,,,,,,,fee schedule,4191.37,26664.3,APC
Ercp lithotripsy calculi,43265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9195.29,,,,,,,fee schedule,4191.37,26664.3,Radiology
Ercp lithotripsy calculi,43265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8413.99,,,,,,,fee schedule,4191.37,26664.3,APC
Ercp lithotripsy calculi,43265,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10517.49,,,,,,,fee schedule,4191.37,26664.3,APC
Egd endoscopic stent place,43266,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12001.76,,,,,,,fee schedule,6009.99,26664.3,
Egd endoscopic stent place,43266,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9620.46,,,,,,,fee schedule,6009.99,26664.3,
Egd endoscopic stent place,43266,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10509.48,,,,,,,fee schedule,6009.99,26664.3,
Egd endoscopic stent place,43266,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11049.24,,,,,,,fee schedule,6009.99,26664.3,
Egd endoscopic stent place,43266,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26664.3,,,,,,,fee schedule,6009.99,26664.3,APC 378
Egd endoscopic stent place,43266,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6310.49,,,,,,,fee schedule,6009.99,26664.3,APC
Egd endoscopic stent place,43266,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6250.39,,,,,,,fee schedule,6009.99,26664.3,APC
Egd endoscopic stent place,43266,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6009.99,,,,,,,fee schedule,6009.99,26664.3,APC
Egd endoscopic stent place,43266,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9195.29,,,,,,,fee schedule,6009.99,26664.3,Radiology
Egd endoscopic stent place,43266,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8413.99,,,,,,,fee schedule,6009.99,26664.3,APC
Egd endoscopic stent place,43266,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10517.49,,,,,,,fee schedule,6009.99,26664.3,APC
Egd lesion ablation,43270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2770.77,,,,,,,fee schedule,1899.66,8428.13,
Egd lesion ablation,43270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2221.01,,,,,,,fee schedule,1899.66,8428.13,
Egd lesion ablation,43270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2426.25,,,,,,,fee schedule,1899.66,8428.13,
Egd lesion ablation,43270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2550.86,,,,,,,fee schedule,1899.66,8428.13,
Egd lesion ablation,43270,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8428.13,,,,,,,fee schedule,1899.66,8428.13,APC 378
Egd lesion ablation,43270,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1994.64,,,,,,,fee schedule,1899.66,8428.13,APC
Egd lesion ablation,43270,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1975.64,,,,,,,fee schedule,1899.66,8428.13,APC
Egd lesion ablation,43270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1899.66,,,,,,,fee schedule,1899.66,8428.13,APC
Egd lesion ablation,43270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2906.47,,,,,,,fee schedule,1899.66,8428.13,Radiology
Egd lesion ablation,43270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2659.52,,,,,,,fee schedule,1899.66,8428.13,APC
Egd lesion ablation,43270,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3324.4,,,,,,,fee schedule,1899.66,8428.13,APC
Endoscopic pancreatoscopy,43273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2295.78,,,,,,,fee schedule,1840.27,2295.78,
Endoscopic pancreatoscopy,43273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1840.27,,,,,,,fee schedule,1840.27,2295.78,
Endoscopic pancreatoscopy,43273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2010.33,,,,,,,fee schedule,1840.27,2295.78,
Endoscopic pancreatoscopy,43273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2113.58,,,,,,,fee schedule,1840.27,2295.78,
Ercp duct stent placement,43274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2234.38,,,,,,,fee schedule,1791.05,26664.3,
Ercp duct stent placement,43274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1791.05,,,,,,,fee schedule,1791.05,26664.3,
Ercp duct stent placement,43274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1956.56,,,,,,,fee schedule,1791.05,26664.3,
Ercp duct stent placement,43274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2057.05,,,,,,,fee schedule,1791.05,26664.3,
Ercp duct stent placement,43274,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26664.3,,,,,,,fee schedule,1791.05,26664.3,APC 378
Ercp duct stent placement,43274,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6310.49,,,,,,,fee schedule,1791.05,26664.3,APC
Ercp duct stent placement,43274,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6250.39,,,,,,,fee schedule,1791.05,26664.3,APC
Ercp duct stent placement,43274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6009.99,,,,,,,fee schedule,1791.05,26664.3,APC
Ercp duct stent placement,43274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9195.29,,,,,,,fee schedule,1791.05,26664.3,Radiology
Ercp duct stent placement,43274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8413.99,,,,,,,fee schedule,1791.05,26664.3,APC
Ercp duct stent placement,43274,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10517.49,,,,,,,fee schedule,1791.05,26664.3,APC
Ercp remove forgn body duct,43275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7382.57,,,,,,,fee schedule,1899.66,8428.13,
Ercp remove forgn body duct,43275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5917.77,,,,,,,fee schedule,1899.66,8428.13,
Ercp remove forgn body duct,43275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6464.63,,,,,,,fee schedule,1899.66,8428.13,
Ercp remove forgn body duct,43275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6796.65,,,,,,,fee schedule,1899.66,8428.13,
Ercp remove forgn body duct,43275,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8428.13,,,,,,,fee schedule,1899.66,8428.13,APC 378
Ercp remove forgn body duct,43275,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1994.64,,,,,,,fee schedule,1899.66,8428.13,APC
Ercp remove forgn body duct,43275,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1975.64,,,,,,,fee schedule,1899.66,8428.13,APC
Ercp remove forgn body duct,43275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1899.66,,,,,,,fee schedule,1899.66,8428.13,APC
Ercp remove forgn body duct,43275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2906.47,,,,,,,fee schedule,1899.66,8428.13,Radiology
Ercp remove forgn body duct,43275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2659.52,,,,,,,fee schedule,1899.66,8428.13,APC
Ercp remove forgn body duct,43275,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3324.4,,,,,,,fee schedule,1899.66,8428.13,APC
Ercp stent exchange w/dilate,43276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12001.76,,,,,,,fee schedule,6009.99,26664.3,
Ercp stent exchange w/dilate,43276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9620.46,,,,,,,fee schedule,6009.99,26664.3,
Ercp stent exchange w/dilate,43276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10509.48,,,,,,,fee schedule,6009.99,26664.3,
Ercp stent exchange w/dilate,43276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11049.24,,,,,,,fee schedule,6009.99,26664.3,
Ercp stent exchange w/dilate,43276,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26664.3,,,,,,,fee schedule,6009.99,26664.3,APC 378
Ercp stent exchange w/dilate,43276,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6310.49,,,,,,,fee schedule,6009.99,26664.3,APC
Ercp stent exchange w/dilate,43276,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6250.39,,,,,,,fee schedule,6009.99,26664.3,APC
Ercp stent exchange w/dilate,43276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6009.99,,,,,,,fee schedule,6009.99,26664.3,APC
Ercp stent exchange w/dilate,43276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9195.29,,,,,,,fee schedule,6009.99,26664.3,Radiology
Ercp stent exchange w/dilate,43276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8413.99,,,,,,,fee schedule,6009.99,26664.3,APC
Ercp stent exchange w/dilate,43276,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10517.49,,,,,,,fee schedule,6009.99,26664.3,APC
Ercp ea duct/ampulla dilate,43277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2234.38,,,,,,,fee schedule,1791.05,16933.82,
Ercp ea duct/ampulla dilate,43277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1791.05,,,,,,,fee schedule,1791.05,16933.82,
Ercp ea duct/ampulla dilate,43277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1956.56,,,,,,,fee schedule,1791.05,16933.82,
Ercp ea duct/ampulla dilate,43277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2057.05,,,,,,,fee schedule,1791.05,16933.82,
Ercp ea duct/ampulla dilate,43277,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16933.82,,,,,,,fee schedule,1791.05,16933.82,APC 378
Ercp ea duct/ampulla dilate,43277,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4007.63,,,,,,,fee schedule,1791.05,16933.82,APC
Ercp ea duct/ampulla dilate,43277,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3969.46,,,,,,,fee schedule,1791.05,16933.82,APC
Ercp ea duct/ampulla dilate,43277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3816.79,,,,,,,fee schedule,1791.05,16933.82,APC
Ercp ea duct/ampulla dilate,43277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5839.69,,,,,,,fee schedule,1791.05,16933.82,Radiology
Ercp ea duct/ampulla dilate,43277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5343.51,,,,,,,fee schedule,1791.05,16933.82,APC
Ercp ea duct/ampulla dilate,43277,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6679.39,,,,,,,fee schedule,1791.05,16933.82,APC
Ercp lesion ablate w/dilate,43278,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7382.57,,,,,,,fee schedule,3816.79,16933.82,
Ercp lesion ablate w/dilate,43278,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5917.77,,,,,,,fee schedule,3816.79,16933.82,
Ercp lesion ablate w/dilate,43278,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6464.63,,,,,,,fee schedule,3816.79,16933.82,
Ercp lesion ablate w/dilate,43278,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6796.65,,,,,,,fee schedule,3816.79,16933.82,
Ercp lesion ablate w/dilate,43278,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16933.82,,,,,,,fee schedule,3816.79,16933.82,APC 378
Ercp lesion ablate w/dilate,43278,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4007.63,,,,,,,fee schedule,3816.79,16933.82,APC
Ercp lesion ablate w/dilate,43278,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3969.46,,,,,,,fee schedule,3816.79,16933.82,APC
Ercp lesion ablate w/dilate,43278,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3816.79,,,,,,,fee schedule,3816.79,16933.82,APC
Ercp lesion ablate w/dilate,43278,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5839.69,,,,,,,fee schedule,3816.79,16933.82,Radiology
Ercp lesion ablate w/dilate,43278,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5343.51,,,,,,,fee schedule,3816.79,16933.82,APC
Ercp lesion ablate w/dilate,43278,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6679.39,,,,,,,fee schedule,3816.79,16933.82,APC
Lap myotomy heller,43279,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10472.38,,,,,,,fee schedule,8394.52,10472.38,
Lap myotomy heller,43279,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8394.52,,,,,,,fee schedule,8394.52,10472.38,
Lap myotomy heller,43279,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9170.26,,,,,,,fee schedule,8394.52,10472.38,
Lap myotomy heller,43279,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9641.24,,,,,,,fee schedule,8394.52,10472.38,
Laparoscopy fundoplasty,43280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11717.83,,,,,,,fee schedule,9392.87,46687.84,
Laparoscopy fundoplasty,43280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9392.87,,,,,,,fee schedule,9392.87,46687.84,
Laparoscopy fundoplasty,43280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10260.85,,,,,,,fee schedule,9392.87,46687.84,
Laparoscopy fundoplasty,43280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10787.85,,,,,,,fee schedule,9392.87,46687.84,
Laparoscopy fundoplasty,43280,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46687.84,,,,,,,fee schedule,9392.87,46687.84,APC 378
Laparoscopy fundoplasty,43280,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11049.35,,,,,,,fee schedule,9392.87,46687.84,APC
Laparoscopy fundoplasty,43280,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10944.12,,,,,,,fee schedule,9392.87,46687.84,APC
Laparoscopy fundoplasty,43280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10523.19,,,,,,,fee schedule,9392.87,46687.84,APC
Laparoscopy fundoplasty,43280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16100.48,,,,,,,fee schedule,9392.87,46687.84,Radiology
Laparoscopy fundoplasty,43280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14732.47,,,,,,,fee schedule,9392.87,46687.84,APC
Laparoscopy fundoplasty,43280,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18415.58,,,,,,,fee schedule,9392.87,46687.84,APC
Lap paraesophag hern repair,43281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15207.78,,,,,,,fee schedule,10523.19,46687.84,
Lap paraesophag hern repair,43281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12190.37,,,,,,,fee schedule,10523.19,46687.84,
Lap paraesophag hern repair,43281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13316.87,,,,,,,fee schedule,10523.19,46687.84,
Lap paraesophag hern repair,43281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14000.82,,,,,,,fee schedule,10523.19,46687.84,
Lap paraesophag hern repair,43281,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46687.84,,,,,,,fee schedule,10523.19,46687.84,APC 378
Lap paraesophag hern repair,43281,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11049.35,,,,,,,fee schedule,10523.19,46687.84,APC
Lap paraesophag hern repair,43281,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10944.12,,,,,,,fee schedule,10523.19,46687.84,APC
Lap paraesophag hern repair,43281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10523.19,,,,,,,fee schedule,10523.19,46687.84,APC
Lap paraesophag hern repair,43281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16100.48,,,,,,,fee schedule,10523.19,46687.84,Radiology
Lap paraesophag hern repair,43281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14732.47,,,,,,,fee schedule,10523.19,46687.84,APC
Lap paraesophag hern repair,43281,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18415.58,,,,,,,fee schedule,10523.19,46687.84,APC
Lap paraesoph her rpr w/mesh,43282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14229.92,,,,,,,fee schedule,10523.19,46687.84,
Lap paraesoph her rpr w/mesh,43282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11406.53,,,,,,,fee schedule,10523.19,46687.84,
Lap paraesoph her rpr w/mesh,43282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12460.59,,,,,,,fee schedule,10523.19,46687.84,
Lap paraesoph her rpr w/mesh,43282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13100.56,,,,,,,fee schedule,10523.19,46687.84,
Lap paraesoph her rpr w/mesh,43282,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46687.84,,,,,,,fee schedule,10523.19,46687.84,APC 378
Lap paraesoph her rpr w/mesh,43282,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11049.35,,,,,,,fee schedule,10523.19,46687.84,APC
Lap paraesoph her rpr w/mesh,43282,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10944.12,,,,,,,fee schedule,10523.19,46687.84,APC
Lap paraesoph her rpr w/mesh,43282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10523.19,,,,,,,fee schedule,10523.19,46687.84,APC
Lap paraesoph her rpr w/mesh,43282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16100.48,,,,,,,fee schedule,10523.19,46687.84,Radiology
Lap paraesoph her rpr w/mesh,43282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14732.47,,,,,,,fee schedule,10523.19,46687.84,APC
Lap paraesoph her rpr w/mesh,43282,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18415.58,,,,,,,fee schedule,10523.19,46687.84,APC
Lap esoph lengthening,43283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6272.96,,,,,,,fee schedule,5028.33,6272.96,
Lap esoph lengthening,43283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5028.33,,,,,,,fee schedule,5028.33,6272.96,
Lap esoph lengthening,43283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5492.99,,,,,,,fee schedule,5028.33,6272.96,
Lap esoph lengthening,43283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5775.11,,,,,,,fee schedule,5028.33,6272.96,
Laps esophgl sphnctr agmntj,43284,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26346,,,,,,,fee schedule,10523.19,46687.84,
Laps esophgl sphnctr agmntj,43284,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21118.62,,,,,,,fee schedule,10523.19,46687.84,
Laps esophgl sphnctr agmntj,43284,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23070.17,,,,,,,fee schedule,10523.19,46687.84,
Laps esophgl sphnctr agmntj,43284,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24255.04,,,,,,,fee schedule,10523.19,46687.84,
Laps esophgl sphnctr agmntj,43284,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46687.84,,,,,,,fee schedule,10523.19,46687.84,APC 378
Laps esophgl sphnctr agmntj,43284,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11049.35,,,,,,,fee schedule,10523.19,46687.84,APC
Laps esophgl sphnctr agmntj,43284,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10944.12,,,,,,,fee schedule,10523.19,46687.84,APC
Laps esophgl sphnctr agmntj,43284,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10523.19,,,,,,,fee schedule,10523.19,46687.84,APC
Laps esophgl sphnctr agmntj,43284,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16100.48,,,,,,,fee schedule,10523.19,46687.84,Radiology
Laps esophgl sphnctr agmntj,43284,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14732.47,,,,,,,fee schedule,10523.19,46687.84,APC
Laps esophgl sphnctr agmntj,43284,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18415.58,,,,,,,fee schedule,10523.19,46687.84,APC
Rmvl esophgl sphnctr dev,43285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15872.71,,,,,,,fee schedule,5984.88,26552.87,
Rmvl esophgl sphnctr dev,43285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12723.36,,,,,,,fee schedule,5984.88,26552.87,
Rmvl esophgl sphnctr dev,43285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13899.12,,,,,,,fee schedule,5984.88,26552.87,
Rmvl esophgl sphnctr dev,43285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14612.97,,,,,,,fee schedule,5984.88,26552.87,
Rmvl esophgl sphnctr dev,43285,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,5984.88,26552.87,APC 378
Rmvl esophgl sphnctr dev,43285,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,5984.88,26552.87,APC
Rmvl esophgl sphnctr dev,43285,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,5984.88,26552.87,APC
Rmvl esophgl sphnctr dev,43285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,5984.88,26552.87,APC
Rmvl esophgl sphnctr dev,43285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,5984.88,26552.87,Radiology
Rmvl esophgl sphnctr dev,43285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,5984.88,26552.87,APC
Rmvl esophgl sphnctr dev,43285,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,5984.88,26552.87,APC
Esphg tot w/laps moblj,43286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12543.44,,,,,,,fee schedule,10054.66,12543.44,
Esphg tot w/laps moblj,43286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10054.66,,,,,,,fee schedule,10054.66,12543.44,
Esphg tot w/laps moblj,43286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10983.8,,,,,,,fee schedule,10054.66,12543.44,
Esphg tot w/laps moblj,43286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11547.93,,,,,,,fee schedule,10054.66,12543.44,
Esphg dstl 2/3 w/laps moblj,43287,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14255.02,,,,,,,fee schedule,11426.65,14255.02,
Esphg dstl 2/3 w/laps moblj,43287,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11426.65,,,,,,,fee schedule,11426.65,14255.02,
Esphg dstl 2/3 w/laps moblj,43287,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12482.57,,,,,,,fee schedule,11426.65,14255.02,
Esphg dstl 2/3 w/laps moblj,43287,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13123.67,,,,,,,fee schedule,11426.65,14255.02,
Esphg thrsc moblj,43288,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14955.99,,,,,,,fee schedule,11988.53,14955.99,
Esphg thrsc moblj,43288,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11988.53,,,,,,,fee schedule,11988.53,14955.99,
Esphg thrsc moblj,43288,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13096.38,,,,,,,fee schedule,11988.53,14955.99,
Esphg thrsc moblj,43288,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13769,,,,,,,fee schedule,11988.53,14955.99,
Laparoscope proc esoph,43289,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8584.34,,,,,,,fee schedule,5984.88,26552.87,
Laparoscope proc esoph,43289,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6881.1,,,,,,,fee schedule,5984.88,26552.87,
Laparoscope proc esoph,43289,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7516.98,,,,,,,fee schedule,5984.88,26552.87,
Laparoscope proc esoph,43289,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7903.05,,,,,,,fee schedule,5984.88,26552.87,
Laparoscope proc esoph,43289,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,5984.88,26552.87,APC 378
Laparoscope proc esoph,43289,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscope proc esoph,43289,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscope proc esoph,43289,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscope proc esoph,43289,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,5984.88,26552.87,Radiology
Laparoscope proc esoph,43289,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscope proc esoph,43289,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,5984.88,26552.87,APC
Egd flx trnsorl dplmnt balo,43290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6583.21,,,,,,,fee schedule,1899.66,8428.13,
Egd flx trnsorl dplmnt balo,43290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5277.02,,,,,,,fee schedule,1899.66,8428.13,
Egd flx trnsorl dplmnt balo,43290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5764.66,,,,,,,fee schedule,1899.66,8428.13,
Egd flx trnsorl dplmnt balo,43290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6060.73,,,,,,,fee schedule,1899.66,8428.13,
Egd flx trnsorl dplmnt balo,43290,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8428.13,,,,,,,fee schedule,1899.66,8428.13,APC 378
Egd flx trnsorl dplmnt balo,43290,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1994.64,,,,,,,fee schedule,1899.66,8428.13,APC
Egd flx trnsorl dplmnt balo,43290,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1975.64,,,,,,,fee schedule,1899.66,8428.13,APC
Egd flx trnsorl dplmnt balo,43290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1899.66,,,,,,,fee schedule,1899.66,8428.13,APC
Egd flx trnsorl dplmnt balo,43290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2906.47,,,,,,,fee schedule,1899.66,8428.13,Radiology
Egd flx trnsorl dplmnt balo,43290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2659.52,,,,,,,fee schedule,1899.66,8428.13,APC
Egd flx trnsorl dplmnt balo,43290,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3324.4,,,,,,,fee schedule,1899.66,8428.13,APC
Egd flx trnsorl rmvl balo,43291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3120.43,,,,,,,fee schedule,897.89,3983.62,
Egd flx trnsorl rmvl balo,43291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2501.3,,,,,,,fee schedule,897.89,3983.62,
Egd flx trnsorl rmvl balo,43291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2732.44,,,,,,,fee schedule,897.89,3983.62,
Egd flx trnsorl rmvl balo,43291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2872.77,,,,,,,fee schedule,897.89,3983.62,
Egd flx trnsorl rmvl balo,43291,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3983.62,,,,,,,fee schedule,897.89,3983.62,APC 378
Egd flx trnsorl rmvl balo,43291,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,942.78,,,,,,,fee schedule,897.89,3983.62,APC
Egd flx trnsorl rmvl balo,43291,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,933.8,,,,,,,fee schedule,897.89,3983.62,APC
Egd flx trnsorl rmvl balo,43291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,897.89,,,,,,,fee schedule,897.89,3983.62,APC
Egd flx trnsorl rmvl balo,43291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1373.77,,,,,,,fee schedule,897.89,3983.62,Radiology
Egd flx trnsorl rmvl balo,43291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1257.04,,,,,,,fee schedule,897.89,3983.62,APC
Egd flx trnsorl rmvl balo,43291,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1571.3,,,,,,,fee schedule,897.89,3983.62,APC
Esoph fundoplasty lap,43327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3018.78,,,,,,,fee schedule,2419.82,3018.78,
Esoph fundoplasty lap,43327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2419.82,,,,,,,fee schedule,2419.82,3018.78,
Esoph fundoplasty lap,43327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2643.43,,,,,,,fee schedule,2419.82,3018.78,
Esoph fundoplasty lap,43327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2779.2,,,,,,,fee schedule,2419.82,3018.78,
Esoph fundoplasty thor,43328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4330.03,,,,,,,fee schedule,3470.9,4330.03,
Esoph fundoplasty thor,43328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3470.9,,,,,,,fee schedule,3470.9,4330.03,
Esoph fundoplasty thor,43328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3791.64,,,,,,,fee schedule,3470.9,4330.03,
Esoph fundoplasty thor,43328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3986.37,,,,,,,fee schedule,3470.9,4330.03,
Transab esoph hiat hern rpr,43332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4305.61,,,,,,,fee schedule,3451.32,4305.61,
Transab esoph hiat hern rpr,43332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3451.32,,,,,,,fee schedule,3451.32,4305.61,
Transab esoph hiat hern rpr,43332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3770.26,,,,,,,fee schedule,3451.32,4305.61,
Transab esoph hiat hern rpr,43332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3963.89,,,,,,,fee schedule,3451.32,4305.61,
Transab esoph hiat hern rpr,43333,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4681.57,,,,,,,fee schedule,3752.69,4681.57,
Transab esoph hiat hern rpr,43333,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3752.69,,,,,,,fee schedule,3752.69,4681.57,
Transab esoph hiat hern rpr,43333,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4099.47,,,,,,,fee schedule,3752.69,4681.57,
Transab esoph hiat hern rpr,43333,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4310.01,,,,,,,fee schedule,3752.69,4681.57,
Transthor diaphrag hern rpr,43334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4652.65,,,,,,,fee schedule,3729.51,4652.65,
Transthor diaphrag hern rpr,43334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3729.51,,,,,,,fee schedule,3729.51,4652.65,
Transthor diaphrag hern rpr,43334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4074.15,,,,,,,fee schedule,3729.51,4652.65,
Transthor diaphrag hern rpr,43334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4283.39,,,,,,,fee schedule,3729.51,4652.65,
Transthor diaphrag hern rpr,43335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4963.93,,,,,,,fee schedule,3979.03,4963.93,
Transthor diaphrag hern rpr,43335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3979.03,,,,,,,fee schedule,3979.03,4963.93,
Transthor diaphrag hern rpr,43335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4346.73,,,,,,,fee schedule,3979.03,4963.93,
Transthor diaphrag hern rpr,43335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4569.97,,,,,,,fee schedule,3979.03,4963.93,
Thorabd diaphr hern repair,43336,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5659.79,,,,,,,fee schedule,4536.82,5659.79,
Thorabd diaphr hern repair,43336,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4536.82,,,,,,,fee schedule,4536.82,5659.79,
Thorabd diaphr hern repair,43336,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4956.06,,,,,,,fee schedule,4536.82,5659.79,
Thorabd diaphr hern repair,43336,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5210.6,,,,,,,fee schedule,4536.82,5659.79,
Thorabd diaphr hern repair,43337,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6095.17,,,,,,,fee schedule,4885.81,6095.17,
Thorabd diaphr hern repair,43337,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4885.81,,,,,,,fee schedule,4885.81,6095.17,
Thorabd diaphr hern repair,43337,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5337.31,,,,,,,fee schedule,4885.81,6095.17,
Thorabd diaphr hern repair,43337,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5611.43,,,,,,,fee schedule,4885.81,6095.17,
Esoph lengthening,43338,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,434.32,,,,,,,fee schedule,348.15,434.32,
Esoph lengthening,43338,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,348.15,,,,,,,fee schedule,348.15,434.32,
Esoph lengthening,43338,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,380.32,,,,,,,fee schedule,348.15,434.32,
Esoph lengthening,43338,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,399.85,,,,,,,fee schedule,348.15,434.32,
Repair esophagus opening,43420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8216.55,,,,,,,fee schedule,3282.2,14562,
Repair esophagus opening,43420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6586.28,,,,,,,fee schedule,3282.2,14562,
Repair esophagus opening,43420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7194.91,,,,,,,fee schedule,3282.2,14562,
Repair esophagus opening,43420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7564.44,,,,,,,fee schedule,3282.2,14562,
Repair esophagus opening,43420,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Repair esophagus opening,43420,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Repair esophagus opening,43420,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Repair esophagus opening,43420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Repair esophagus opening,43420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Repair esophagus opening,43420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Repair esophagus opening,43420,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Dilate esophagus 1/mult pass,43450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1628.72,,,,,,,fee schedule,897.89,3983.62,
Dilate esophagus 1/mult pass,43450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1305.56,,,,,,,fee schedule,897.89,3983.62,
Dilate esophagus 1/mult pass,43450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1426.21,,,,,,,fee schedule,897.89,3983.62,
Dilate esophagus 1/mult pass,43450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1499.46,,,,,,,fee schedule,897.89,3983.62,
Dilate esophagus 1/mult pass,43450,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3983.62,,,,,,,fee schedule,897.89,3983.62,APC 378
Dilate esophagus 1/mult pass,43450,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,942.78,,,,,,,fee schedule,897.89,3983.62,APC
Dilate esophagus 1/mult pass,43450,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,933.8,,,,,,,fee schedule,897.89,3983.62,APC
Dilate esophagus 1/mult pass,43450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,897.89,,,,,,,fee schedule,897.89,3983.62,APC
Dilate esophagus 1/mult pass,43450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1373.77,,,,,,,fee schedule,897.89,3983.62,Radiology
Dilate esophagus 1/mult pass,43450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1257.04,,,,,,,fee schedule,897.89,3983.62,APC
Dilate esophagus 1/mult pass,43450,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1571.3,,,,,,,fee schedule,897.89,3983.62,APC
Dilate esophagus,43453,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1989.12,,,,,,,fee schedule,1594.45,8428.13,
Dilate esophagus,43453,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1594.45,,,,,,,fee schedule,1594.45,8428.13,
Dilate esophagus,43453,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1741.8,,,,,,,fee schedule,1594.45,8428.13,
Dilate esophagus,43453,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1831.25,,,,,,,fee schedule,1594.45,8428.13,
Dilate esophagus,43453,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8428.13,,,,,,,fee schedule,1594.45,8428.13,APC 378
Dilate esophagus,43453,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1994.64,,,,,,,fee schedule,1594.45,8428.13,APC
Dilate esophagus,43453,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1975.64,,,,,,,fee schedule,1594.45,8428.13,APC
Dilate esophagus,43453,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1899.66,,,,,,,fee schedule,1594.45,8428.13,APC
Dilate esophagus,43453,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2906.47,,,,,,,fee schedule,1594.45,8428.13,Radiology
Dilate esophagus,43453,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2659.52,,,,,,,fee schedule,1594.45,8428.13,APC
Dilate esophagus,43453,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3324.4,,,,,,,fee schedule,1594.45,8428.13,APC
Transorl lwr esophgl myotomy,43497,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11853.7,,,,,,,fee schedule,6009.99,26664.3,
Transorl lwr esophgl myotomy,43497,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9501.78,,,,,,,fee schedule,6009.99,26664.3,
Transorl lwr esophgl myotomy,43497,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10379.83,,,,,,,fee schedule,6009.99,26664.3,
Transorl lwr esophgl myotomy,43497,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10912.93,,,,,,,fee schedule,6009.99,26664.3,
Transorl lwr esophgl myotomy,43497,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26664.3,,,,,,,fee schedule,6009.99,26664.3,APC 378
Transorl lwr esophgl myotomy,43497,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6310.49,,,,,,,fee schedule,6009.99,26664.3,APC
Transorl lwr esophgl myotomy,43497,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6250.39,,,,,,,fee schedule,6009.99,26664.3,APC
Transorl lwr esophgl myotomy,43497,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6009.99,,,,,,,fee schedule,6009.99,26664.3,APC
Transorl lwr esophgl myotomy,43497,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9195.29,,,,,,,fee schedule,6009.99,26664.3,Radiology
Transorl lwr esophgl myotomy,43497,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8413.99,,,,,,,fee schedule,6009.99,26664.3,APC
Transorl lwr esophgl myotomy,43497,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10517.49,,,,,,,fee schedule,6009.99,26664.3,APC
Esophagus surgery procedure,43499,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1573.39,,,,,,,fee schedule,897.89,3983.62,
Esophagus surgery procedure,43499,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1261.21,,,,,,,fee schedule,897.89,3983.62,
Esophagus surgery procedure,43499,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1377.75,,,,,,,fee schedule,897.89,3983.62,
Esophagus surgery procedure,43499,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1448.52,,,,,,,fee schedule,897.89,3983.62,
Esophagus surgery procedure,43499,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3983.62,,,,,,,fee schedule,897.89,3983.62,APC 378
Esophagus surgery procedure,43499,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,942.78,,,,,,,fee schedule,897.89,3983.62,APC
Esophagus surgery procedure,43499,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,933.8,,,,,,,fee schedule,897.89,3983.62,APC
Esophagus surgery procedure,43499,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,897.89,,,,,,,fee schedule,897.89,3983.62,APC
Esophagus surgery procedure,43499,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1373.77,,,,,,,fee schedule,897.89,3983.62,Radiology
Esophagus surgery procedure,43499,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1257.04,,,,,,,fee schedule,897.89,3983.62,APC
Esophagus surgery procedure,43499,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1571.3,,,,,,,fee schedule,897.89,3983.62,APC
Surgical opening of stomach,43510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2122.13,,,,,,,fee schedule,897.89,3983.62,
Surgical opening of stomach,43510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1701.07,,,,,,,fee schedule,897.89,3983.62,
Surgical opening of stomach,43510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1858.27,,,,,,,fee schedule,897.89,3983.62,
Surgical opening of stomach,43510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1953.71,,,,,,,fee schedule,897.89,3983.62,
Surgical opening of stomach,43510,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3983.62,,,,,,,fee schedule,897.89,3983.62,APC 378
Surgical opening of stomach,43510,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,942.78,,,,,,,fee schedule,897.89,3983.62,APC
Surgical opening of stomach,43510,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,933.8,,,,,,,fee schedule,897.89,3983.62,APC
Surgical opening of stomach,43510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,897.89,,,,,,,fee schedule,897.89,3983.62,APC
Surgical opening of stomach,43510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1373.77,,,,,,,fee schedule,897.89,3983.62,Radiology
Surgical opening of stomach,43510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1257.04,,,,,,,fee schedule,897.89,3983.62,APC
Surgical opening of stomach,43510,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1571.3,,,,,,,fee schedule,897.89,3983.62,APC
Lap impl electrode antrum,43647,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20679.74,,,,,,,fee schedule,11030.91,48940.4,
Lap impl electrode antrum,43647,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16576.61,,,,,,,fee schedule,11030.91,48940.4,
Lap impl electrode antrum,43647,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18108.45,,,,,,,fee schedule,11030.91,48940.4,
Lap impl electrode antrum,43647,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19038.49,,,,,,,fee schedule,11030.91,48940.4,
Lap impl electrode antrum,43647,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,48940.4,,,,,,,fee schedule,11030.91,48940.4,APC 378
Lap impl electrode antrum,43647,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11582.45,,,,,,,fee schedule,11030.91,48940.4,APC
Lap impl electrode antrum,43647,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11472.14,,,,,,,fee schedule,11030.91,48940.4,APC
Lap impl electrode antrum,43647,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11030.91,,,,,,,fee schedule,11030.91,48940.4,APC
Lap impl electrode antrum,43647,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16877.29,,,,,,,fee schedule,11030.91,48940.4,Radiology
Lap impl electrode antrum,43647,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15443.27,,,,,,,fee schedule,11030.91,48940.4,APC
Lap impl electrode antrum,43647,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19304.09,,,,,,,fee schedule,11030.91,48940.4,APC
Lap revise/remv eltrd antrum,43648,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8584.34,,,,,,,fee schedule,6881.1,46687.84,
Lap revise/remv eltrd antrum,43648,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6881.1,,,,,,,fee schedule,6881.1,46687.84,
Lap revise/remv eltrd antrum,43648,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7516.98,,,,,,,fee schedule,6881.1,46687.84,
Lap revise/remv eltrd antrum,43648,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7903.05,,,,,,,fee schedule,6881.1,46687.84,
Lap revise/remv eltrd antrum,43648,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46687.84,,,,,,,fee schedule,6881.1,46687.84,APC 378
Lap revise/remv eltrd antrum,43648,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11049.35,,,,,,,fee schedule,6881.1,46687.84,APC
Lap revise/remv eltrd antrum,43648,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10944.12,,,,,,,fee schedule,6881.1,46687.84,APC
Lap revise/remv eltrd antrum,43648,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10523.19,,,,,,,fee schedule,6881.1,46687.84,APC
Lap revise/remv eltrd antrum,43648,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16100.48,,,,,,,fee schedule,6881.1,46687.84,Radiology
Lap revise/remv eltrd antrum,43648,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14732.47,,,,,,,fee schedule,6881.1,46687.84,APC
Lap revise/remv eltrd antrum,43648,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18415.58,,,,,,,fee schedule,6881.1,46687.84,APC
Laparoscopy vagus nerve,43651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17386.71,,,,,,,fee schedule,5984.88,26552.87,
Laparoscopy vagus nerve,43651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13936.97,,,,,,,fee schedule,5984.88,26552.87,
Laparoscopy vagus nerve,43651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15224.87,,,,,,,fee schedule,5984.88,26552.87,
Laparoscopy vagus nerve,43651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16006.82,,,,,,,fee schedule,5984.88,26552.87,
Laparoscopy vagus nerve,43651,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,5984.88,26552.87,APC 378
Laparoscopy vagus nerve,43651,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscopy vagus nerve,43651,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscopy vagus nerve,43651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscopy vagus nerve,43651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,5984.88,26552.87,Radiology
Laparoscopy vagus nerve,43651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscopy vagus nerve,43651,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscopy vagus nerve,43652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17386.71,,,,,,,fee schedule,5984.88,26552.87,
Laparoscopy vagus nerve,43652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13936.97,,,,,,,fee schedule,5984.88,26552.87,
Laparoscopy vagus nerve,43652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15224.87,,,,,,,fee schedule,5984.88,26552.87,
Laparoscopy vagus nerve,43652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16006.82,,,,,,,fee schedule,5984.88,26552.87,
Laparoscopy vagus nerve,43652,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,5984.88,26552.87,APC 378
Laparoscopy vagus nerve,43652,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscopy vagus nerve,43652,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscopy vagus nerve,43652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscopy vagus nerve,43652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,5984.88,26552.87,Radiology
Laparoscopy vagus nerve,43652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscopy vagus nerve,43652,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscopy gastrostomy,43653,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7189.69,,,,,,,fee schedule,5763.16,26552.87,
Laparoscopy gastrostomy,43653,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5763.16,,,,,,,fee schedule,5763.16,26552.87,
Laparoscopy gastrostomy,43653,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6295.73,,,,,,,fee schedule,5763.16,26552.87,
Laparoscopy gastrostomy,43653,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6619.08,,,,,,,fee schedule,5763.16,26552.87,
Laparoscopy gastrostomy,43653,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,5763.16,26552.87,APC 378
Laparoscopy gastrostomy,43653,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,5763.16,26552.87,APC
Laparoscopy gastrostomy,43653,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,5763.16,26552.87,APC
Laparoscopy gastrostomy,43653,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,5763.16,26552.87,APC
Laparoscopy gastrostomy,43653,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,5763.16,26552.87,Radiology
Laparoscopy gastrostomy,43653,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,5763.16,26552.87,APC
Laparoscopy gastrostomy,43653,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,5763.16,26552.87,APC
Laparoscope proc stom,43659,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8584.34,,,,,,,fee schedule,5984.88,26552.87,
Laparoscope proc stom,43659,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6881.1,,,,,,,fee schedule,5984.88,26552.87,
Laparoscope proc stom,43659,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7516.98,,,,,,,fee schedule,5984.88,26552.87,
Laparoscope proc stom,43659,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7903.05,,,,,,,fee schedule,5984.88,26552.87,
Laparoscope proc stom,43659,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,5984.88,26552.87,APC 378
Laparoscope proc stom,43659,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscope proc stom,43659,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscope proc stom,43659,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscope proc stom,43659,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,5984.88,26552.87,Radiology
Laparoscope proc stom,43659,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscope proc stom,43659,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,5984.88,26552.87,APC
Nasal/orogastric w/tube plmt,43752,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,331.2,,,,,,,fee schedule,265.49,1962.08,
Nasal/orogastric w/tube plmt,43752,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,265.49,,,,,,,fee schedule,265.49,1962.08,
Nasal/orogastric w/tube plmt,43752,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,290.02,,,,,,,fee schedule,265.49,1962.08,
Nasal/orogastric w/tube plmt,43752,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,304.92,,,,,,,fee schedule,265.49,1962.08,
Nasal/orogastric w/tube plmt,43752,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1962.08,,,,,,,fee schedule,265.49,1962.08,APC 378
Nasal/orogastric w/tube plmt,43752,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,464.35,,,,,,,fee schedule,265.49,1962.08,APC
Nasal/orogastric w/tube plmt,43752,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,459.93,,,,,,,fee schedule,265.49,1962.08,APC
Nasal/orogastric w/tube plmt,43752,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,442.24,,,,,,,fee schedule,265.49,1962.08,APC
Nasal/orogastric w/tube plmt,43752,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,676.63,,,,,,,fee schedule,265.49,1962.08,Radiology
Nasal/orogastric w/tube plmt,43752,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,619.14,,,,,,,fee schedule,265.49,1962.08,APC
Nasal/orogastric w/tube plmt,43752,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,773.92,,,,,,,fee schedule,265.49,1962.08,APC
Tx gastro intub w/asp,43753,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,146.29,,,,,,,fee schedule,117.26,948.37,
Tx gastro intub w/asp,43753,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,117.26,,,,,,,fee schedule,117.26,948.37,
Tx gastro intub w/asp,43753,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,128.1,,,,,,,fee schedule,117.26,948.37,
Tx gastro intub w/asp,43753,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,134.68,,,,,,,fee schedule,117.26,948.37,
Tx gastro intub w/asp,43753,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,117.26,948.37,APC 378
Tx gastro intub w/asp,43753,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,117.26,948.37,APC
Tx gastro intub w/asp,43753,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,117.26,948.37,APC
Tx gastro intub w/asp,43753,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,117.26,948.37,APC
Tx gastro intub w/asp,43753,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,117.26,948.37,Radiology
Tx gastro intub w/asp,43753,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,117.26,948.37,APC
Tx gastro intub w/asp,43753,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,117.26,948.37,APC
Dx gastr intub w/asp spec,43754,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,174.75,,,,,,,fee schedule,140.08,948.37,
Dx gastr intub w/asp spec,43754,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,140.08,,,,,,,fee schedule,140.08,948.37,
Dx gastr intub w/asp spec,43754,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,153.02,,,,,,,fee schedule,140.08,948.37,
Dx gastr intub w/asp spec,43754,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,160.88,,,,,,,fee schedule,140.08,948.37,
Dx gastr intub w/asp spec,43754,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,140.08,948.37,APC 378
Dx gastr intub w/asp spec,43754,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,140.08,948.37,APC
Dx gastr intub w/asp spec,43754,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,140.08,948.37,APC
Dx gastr intub w/asp spec,43754,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,140.08,948.37,APC
Dx gastr intub w/asp spec,43754,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,140.08,948.37,Radiology
Dx gastr intub w/asp spec,43754,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,140.08,948.37,APC
Dx gastr intub w/asp spec,43754,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,140.08,948.37,APC
Dx gastr intub w/asp specs,43755,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,250.43,,,,,,,fee schedule,127.38,565.15,
Dx gastr intub w/asp specs,43755,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,200.74,,,,,,,fee schedule,127.38,565.15,
Dx gastr intub w/asp specs,43755,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,219.29,,,,,,,fee schedule,127.38,565.15,
Dx gastr intub w/asp specs,43755,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,230.55,,,,,,,fee schedule,127.38,565.15,
Dx gastr intub w/asp specs,43755,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,565.15,,,,,,,fee schedule,127.38,565.15,APC 378
Dx gastr intub w/asp specs,43755,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,133.75,,,,,,,fee schedule,127.38,565.15,APC
Dx gastr intub w/asp specs,43755,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,132.48,,,,,,,fee schedule,127.38,565.15,APC
Dx gastr intub w/asp specs,43755,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,127.38,,,,,,,fee schedule,127.38,565.15,APC
Dx gastr intub w/asp specs,43755,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,194.89,,,,,,,fee schedule,127.38,565.15,Radiology
Dx gastr intub w/asp specs,43755,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,178.33,,,,,,,fee schedule,127.38,565.15,APC
Dx gastr intub w/asp specs,43755,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,222.92,,,,,,,fee schedule,127.38,565.15,APC
Dx duod intub w/asp spec,43756,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,315.63,,,,,,,fee schedule,253.01,3983.62,
Dx duod intub w/asp spec,43756,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,253.01,,,,,,,fee schedule,253.01,3983.62,
Dx duod intub w/asp spec,43756,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,276.39,,,,,,,fee schedule,253.01,3983.62,
Dx duod intub w/asp spec,43756,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,290.58,,,,,,,fee schedule,253.01,3983.62,
Dx duod intub w/asp spec,43756,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3983.62,,,,,,,fee schedule,253.01,3983.62,APC 378
Dx duod intub w/asp spec,43756,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,942.78,,,,,,,fee schedule,253.01,3983.62,APC
Dx duod intub w/asp spec,43756,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,933.8,,,,,,,fee schedule,253.01,3983.62,APC
Dx duod intub w/asp spec,43756,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,897.89,,,,,,,fee schedule,253.01,3983.62,APC
Dx duod intub w/asp spec,43756,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1373.77,,,,,,,fee schedule,253.01,3983.62,Radiology
Dx duod intub w/asp spec,43756,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1257.04,,,,,,,fee schedule,253.01,3983.62,APC
Dx duod intub w/asp spec,43756,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1571.3,,,,,,,fee schedule,253.01,3983.62,APC
Dx duod intub w/asp specs,43757,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,315.63,,,,,,,fee schedule,253.01,3983.62,
Dx duod intub w/asp specs,43757,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,253.01,,,,,,,fee schedule,253.01,3983.62,
Dx duod intub w/asp specs,43757,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,276.39,,,,,,,fee schedule,253.01,3983.62,
Dx duod intub w/asp specs,43757,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,290.58,,,,,,,fee schedule,253.01,3983.62,
Dx duod intub w/asp specs,43757,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3983.62,,,,,,,fee schedule,253.01,3983.62,APC 378
Dx duod intub w/asp specs,43757,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,942.78,,,,,,,fee schedule,253.01,3983.62,APC
Dx duod intub w/asp specs,43757,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,933.8,,,,,,,fee schedule,253.01,3983.62,APC
Dx duod intub w/asp specs,43757,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,897.89,,,,,,,fee schedule,253.01,3983.62,APC
Dx duod intub w/asp specs,43757,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1373.77,,,,,,,fee schedule,253.01,3983.62,Radiology
Dx duod intub w/asp specs,43757,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1257.04,,,,,,,fee schedule,253.01,3983.62,APC
Dx duod intub w/asp specs,43757,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1571.3,,,,,,,fee schedule,253.01,3983.62,APC
Reposition gastrostomy tube,43761,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2122.13,,,,,,,fee schedule,247.34,2122.13,
Reposition gastrostomy tube,43761,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1701.07,,,,,,,fee schedule,247.34,2122.13,
Reposition gastrostomy tube,43761,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1858.27,,,,,,,fee schedule,247.34,2122.13,
Reposition gastrostomy tube,43761,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1953.71,,,,,,,fee schedule,247.34,2122.13,
Reposition gastrostomy tube,43761,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1097.37,,,,,,,fee schedule,247.34,2122.13,APC 378
Reposition gastrostomy tube,43761,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,259.71,,,,,,,fee schedule,247.34,2122.13,APC
Reposition gastrostomy tube,43761,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,257.24,,,,,,,fee schedule,247.34,2122.13,APC
Reposition gastrostomy tube,43761,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,247.34,,,,,,,fee schedule,247.34,2122.13,APC
Reposition gastrostomy tube,43761,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,378.43,,,,,,,fee schedule,247.34,2122.13,Radiology
Reposition gastrostomy tube,43761,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,346.28,,,,,,,fee schedule,247.34,2122.13,APC
Reposition gastrostomy tube,43761,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,432.85,,,,,,,fee schedule,247.34,2122.13,APC
Rplc gtube no revj trc,43762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,874.77,,,,,,,fee schedule,247.34,1097.37,
Rplc gtube no revj trc,43762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,701.2,,,,,,,fee schedule,247.34,1097.37,
Rplc gtube no revj trc,43762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,766,,,,,,,fee schedule,247.34,1097.37,
Rplc gtube no revj trc,43762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,805.34,,,,,,,fee schedule,247.34,1097.37,
Rplc gtube no revj trc,43762,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1097.37,,,,,,,fee schedule,247.34,1097.37,APC 378
Rplc gtube no revj trc,43762,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,259.71,,,,,,,fee schedule,247.34,1097.37,APC
Rplc gtube no revj trc,43762,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,257.24,,,,,,,fee schedule,247.34,1097.37,APC
Rplc gtube no revj trc,43762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,247.34,,,,,,,fee schedule,247.34,1097.37,APC
Rplc gtube no revj trc,43762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,378.43,,,,,,,fee schedule,247.34,1097.37,Radiology
Rplc gtube no revj trc,43762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,346.28,,,,,,,fee schedule,247.34,1097.37,APC
Rplc gtube no revj trc,43762,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,432.85,,,,,,,fee schedule,247.34,1097.37,APC
Rplc gtube  revj gstrst trc,43763,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,874.77,,,,,,,fee schedule,247.34,1097.37,
Rplc gtube  revj gstrst trc,43763,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,701.2,,,,,,,fee schedule,247.34,1097.37,
Rplc gtube  revj gstrst trc,43763,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,766,,,,,,,fee schedule,247.34,1097.37,
Rplc gtube  revj gstrst trc,43763,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,805.34,,,,,,,fee schedule,247.34,1097.37,
Rplc gtube  revj gstrst trc,43763,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1097.37,,,,,,,fee schedule,247.34,1097.37,APC 378
Rplc gtube  revj gstrst trc,43763,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,259.71,,,,,,,fee schedule,247.34,1097.37,APC
Rplc gtube  revj gstrst trc,43763,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,257.24,,,,,,,fee schedule,247.34,1097.37,APC
Rplc gtube  revj gstrst trc,43763,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,247.34,,,,,,,fee schedule,247.34,1097.37,APC
Rplc gtube  revj gstrst trc,43763,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,378.43,,,,,,,fee schedule,247.34,1097.37,Radiology
Rplc gtube  revj gstrst trc,43763,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,346.28,,,,,,,fee schedule,247.34,1097.37,APC
Rplc gtube  revj gstrst trc,43763,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,432.85,,,,,,,fee schedule,247.34,1097.37,APC
Lap place gastr adj device,43770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26346,,,,,,,fee schedule,10523.19,46687.84,
Lap place gastr adj device,43770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21118.62,,,,,,,fee schedule,10523.19,46687.84,
Lap place gastr adj device,43770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23070.17,,,,,,,fee schedule,10523.19,46687.84,
Lap place gastr adj device,43770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24255.04,,,,,,,fee schedule,10523.19,46687.84,
Lap place gastr adj device,43770,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46687.84,,,,,,,fee schedule,10523.19,46687.84,APC 378
Lap place gastr adj device,43770,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11049.35,,,,,,,fee schedule,10523.19,46687.84,APC
Lap place gastr adj device,43770,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10944.12,,,,,,,fee schedule,10523.19,46687.84,APC
Lap place gastr adj device,43770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10523.19,,,,,,,fee schedule,10523.19,46687.84,APC
Lap place gastr adj device,43770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16100.48,,,,,,,fee schedule,10523.19,46687.84,Radiology
Lap place gastr adj device,43770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14732.47,,,,,,,fee schedule,10523.19,46687.84,APC
Lap place gastr adj device,43770,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18415.58,,,,,,,fee schedule,10523.19,46687.84,APC
Lap rmvl gastr adj device,43772,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7711.58,,,,,,,fee schedule,3816.79,16933.82,
Lap rmvl gastr adj device,43772,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6181.5,,,,,,,fee schedule,3816.79,16933.82,
Lap rmvl gastr adj device,43772,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6752.73,,,,,,,fee schedule,3816.79,16933.82,
Lap rmvl gastr adj device,43772,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7099.55,,,,,,,fee schedule,3816.79,16933.82,
Lap rmvl gastr adj device,43772,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16933.82,,,,,,,fee schedule,3816.79,16933.82,APC 378
Lap rmvl gastr adj device,43772,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4007.63,,,,,,,fee schedule,3816.79,16933.82,APC
Lap rmvl gastr adj device,43772,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3969.46,,,,,,,fee schedule,3816.79,16933.82,APC
Lap rmvl gastr adj device,43772,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3816.79,,,,,,,fee schedule,3816.79,16933.82,APC
Lap rmvl gastr adj device,43772,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5839.69,,,,,,,fee schedule,3816.79,16933.82,Radiology
Lap rmvl gastr adj device,43772,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5343.51,,,,,,,fee schedule,3816.79,16933.82,APC
Lap rmvl gastr adj device,43772,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6679.39,,,,,,,fee schedule,3816.79,16933.82,APC
Lap replace gastr adj device,43773,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10343.82,,,,,,,fee schedule,5984.88,26552.87,
Lap replace gastr adj device,43773,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8291.47,,,,,,,fee schedule,5984.88,26552.87,
Lap replace gastr adj device,43773,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9057.68,,,,,,,fee schedule,5984.88,26552.87,
Lap replace gastr adj device,43773,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9522.88,,,,,,,fee schedule,5984.88,26552.87,
Lap replace gastr adj device,43773,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,5984.88,26552.87,APC 378
Lap replace gastr adj device,43773,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,5984.88,26552.87,APC
Lap replace gastr adj device,43773,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,5984.88,26552.87,APC
Lap replace gastr adj device,43773,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,5984.88,26552.87,APC
Lap replace gastr adj device,43773,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,5984.88,26552.87,Radiology
Lap replace gastr adj device,43773,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,5984.88,26552.87,APC
Lap replace gastr adj device,43773,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,5984.88,26552.87,APC
Lap rmvl gastr adj all parts,43774,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7824.07,,,,,,,fee schedule,3816.79,16933.82,
Lap rmvl gastr adj all parts,43774,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6271.68,,,,,,,fee schedule,3816.79,16933.82,
Lap rmvl gastr adj all parts,43774,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6851.24,,,,,,,fee schedule,3816.79,16933.82,
Lap rmvl gastr adj all parts,43774,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7203.11,,,,,,,fee schedule,3816.79,16933.82,
Lap rmvl gastr adj all parts,43774,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16933.82,,,,,,,fee schedule,3816.79,16933.82,APC 378
Lap rmvl gastr adj all parts,43774,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4007.63,,,,,,,fee schedule,3816.79,16933.82,APC
Lap rmvl gastr adj all parts,43774,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3969.46,,,,,,,fee schedule,3816.79,16933.82,APC
Lap rmvl gastr adj all parts,43774,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3816.79,,,,,,,fee schedule,3816.79,16933.82,APC
Lap rmvl gastr adj all parts,43774,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5839.69,,,,,,,fee schedule,3816.79,16933.82,Radiology
Lap rmvl gastr adj all parts,43774,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5343.51,,,,,,,fee schedule,3816.79,16933.82,APC
Lap rmvl gastr adj all parts,43774,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6679.39,,,,,,,fee schedule,3816.79,16933.82,APC
Place gastrostomy tube,43830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6320.05,,,,,,,fee schedule,1899.66,8428.13,
Place gastrostomy tube,43830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5066.07,,,,,,,fee schedule,1899.66,8428.13,
Place gastrostomy tube,43830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5534.22,,,,,,,fee schedule,1899.66,8428.13,
Place gastrostomy tube,43830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5818.46,,,,,,,fee schedule,1899.66,8428.13,
Place gastrostomy tube,43830,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8428.13,,,,,,,fee schedule,1899.66,8428.13,APC 378
Place gastrostomy tube,43830,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1994.64,,,,,,,fee schedule,1899.66,8428.13,APC
Place gastrostomy tube,43830,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1975.64,,,,,,,fee schedule,1899.66,8428.13,APC
Place gastrostomy tube,43830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1899.66,,,,,,,fee schedule,1899.66,8428.13,APC
Place gastrostomy tube,43830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2906.47,,,,,,,fee schedule,1899.66,8428.13,Radiology
Place gastrostomy tube,43830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2659.52,,,,,,,fee schedule,1899.66,8428.13,APC
Place gastrostomy tube,43830,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3324.4,,,,,,,fee schedule,1899.66,8428.13,APC
Place gastrostomy tube,43831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2122.13,,,,,,,fee schedule,897.89,3983.62,
Place gastrostomy tube,43831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1701.07,,,,,,,fee schedule,897.89,3983.62,
Place gastrostomy tube,43831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1858.27,,,,,,,fee schedule,897.89,3983.62,
Place gastrostomy tube,43831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1953.71,,,,,,,fee schedule,897.89,3983.62,
Place gastrostomy tube,43831,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3983.62,,,,,,,fee schedule,897.89,3983.62,APC 378
Place gastrostomy tube,43831,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,942.78,,,,,,,fee schedule,897.89,3983.62,APC
Place gastrostomy tube,43831,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,933.8,,,,,,,fee schedule,897.89,3983.62,APC
Place gastrostomy tube,43831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,897.89,,,,,,,fee schedule,897.89,3983.62,APC
Place gastrostomy tube,43831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1373.77,,,,,,,fee schedule,897.89,3983.62,Radiology
Place gastrostomy tube,43831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1257.04,,,,,,,fee schedule,897.89,3983.62,APC
Place gastrostomy tube,43831,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1571.3,,,,,,,fee schedule,897.89,3983.62,APC
Repair of stomach lesion,43840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19007.81,,,,,,,fee schedule,3816.79,19007.81,
Repair of stomach lesion,43840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15236.42,,,,,,,fee schedule,3816.79,19007.81,
Repair of stomach lesion,43840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16644.4,,,,,,,fee schedule,3816.79,19007.81,
Repair of stomach lesion,43840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17499.25,,,,,,,fee schedule,3816.79,19007.81,
Repair of stomach lesion,43840,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16933.82,,,,,,,fee schedule,3816.79,19007.81,APC 378
Repair of stomach lesion,43840,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4007.63,,,,,,,fee schedule,3816.79,19007.81,APC
Repair of stomach lesion,43840,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3969.46,,,,,,,fee schedule,3816.79,19007.81,APC
Repair of stomach lesion,43840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3816.79,,,,,,,fee schedule,3816.79,19007.81,APC
Repair of stomach lesion,43840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5839.69,,,,,,,fee schedule,3816.79,19007.81,Radiology
Repair of stomach lesion,43840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5343.51,,,,,,,fee schedule,3816.79,19007.81,APC
Repair of stomach lesion,43840,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6679.39,,,,,,,fee schedule,3816.79,19007.81,APC
Repair stomach opening,43870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2122.13,,,,,,,fee schedule,1701.07,16933.82,
Repair stomach opening,43870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1701.07,,,,,,,fee schedule,1701.07,16933.82,
Repair stomach opening,43870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1858.27,,,,,,,fee schedule,1701.07,16933.82,
Repair stomach opening,43870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1953.71,,,,,,,fee schedule,1701.07,16933.82,
Repair stomach opening,43870,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16933.82,,,,,,,fee schedule,1701.07,16933.82,APC 378
Repair stomach opening,43870,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4007.63,,,,,,,fee schedule,1701.07,16933.82,APC
Repair stomach opening,43870,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3969.46,,,,,,,fee schedule,1701.07,16933.82,APC
Repair stomach opening,43870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3816.79,,,,,,,fee schedule,1701.07,16933.82,APC
Repair stomach opening,43870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5839.69,,,,,,,fee schedule,1701.07,16933.82,Radiology
Repair stomach opening,43870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5343.51,,,,,,,fee schedule,1701.07,16933.82,APC
Repair stomach opening,43870,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6679.39,,,,,,,fee schedule,1701.07,16933.82,APC
Revise gastric port open,43886,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5043.16,,,,,,,fee schedule,3508.17,15564.58,
Revise gastric port open,43886,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4042.54,,,,,,,fee schedule,3508.17,15564.58,
Revise gastric port open,43886,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4416.1,,,,,,,fee schedule,3508.17,15564.58,
Revise gastric port open,43886,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4642.91,,,,,,,fee schedule,3508.17,15564.58,
Revise gastric port open,43886,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15564.58,,,,,,,fee schedule,3508.17,15564.58,APC 378
Revise gastric port open,43886,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3683.58,,,,,,,fee schedule,3508.17,15564.58,APC
Revise gastric port open,43886,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3648.5,,,,,,,fee schedule,3508.17,15564.58,APC
Revise gastric port open,43886,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3508.17,,,,,,,fee schedule,3508.17,15564.58,APC
Revise gastric port open,43886,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5367.5,,,,,,,fee schedule,3508.17,15564.58,Radiology
Revise gastric port open,43886,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4911.44,,,,,,,fee schedule,3508.17,15564.58,APC
Revise gastric port open,43886,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6139.3,,,,,,,fee schedule,3508.17,15564.58,APC
Remove gastric port open,43887,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1129.65,,,,,,,fee schedule,905.52,9062.24,
Remove gastric port open,43887,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,905.52,,,,,,,fee schedule,905.52,9062.24,
Remove gastric port open,43887,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,989.19,,,,,,,fee schedule,905.52,9062.24,
Remove gastric port open,43887,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1040,,,,,,,fee schedule,905.52,9062.24,
Remove gastric port open,43887,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,905.52,9062.24,APC 378
Remove gastric port open,43887,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,905.52,9062.24,APC
Remove gastric port open,43887,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,905.52,9062.24,APC
Remove gastric port open,43887,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,905.52,9062.24,APC
Remove gastric port open,43887,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,905.52,9062.24,Radiology
Remove gastric port open,43887,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,905.52,9062.24,APC
Remove gastric port open,43887,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,905.52,9062.24,APC
Change gastric port open,43888,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5043.16,,,,,,,fee schedule,3508.17,15564.58,
Change gastric port open,43888,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4042.54,,,,,,,fee schedule,3508.17,15564.58,
Change gastric port open,43888,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4416.1,,,,,,,fee schedule,3508.17,15564.58,
Change gastric port open,43888,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4642.91,,,,,,,fee schedule,3508.17,15564.58,
Change gastric port open,43888,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15564.58,,,,,,,fee schedule,3508.17,15564.58,APC 378
Change gastric port open,43888,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3683.58,,,,,,,fee schedule,3508.17,15564.58,APC
Change gastric port open,43888,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3648.5,,,,,,,fee schedule,3508.17,15564.58,APC
Change gastric port open,43888,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3508.17,,,,,,,fee schedule,3508.17,15564.58,APC
Change gastric port open,43888,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5367.5,,,,,,,fee schedule,3508.17,15564.58,Radiology
Change gastric port open,43888,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4911.44,,,,,,,fee schedule,3508.17,15564.58,APC
Change gastric port open,43888,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6139.3,,,,,,,fee schedule,3508.17,15564.58,APC
Gstr rstcv px trnsorl esg,43889,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46687.84,,,,,,,fee schedule,10523.19,46687.84,APC 378
Gstr rstcv px trnsorl esg,43889,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11049.35,,,,,,,fee schedule,10523.19,46687.84,APC
Gstr rstcv px trnsorl esg,43889,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10944.12,,,,,,,fee schedule,10523.19,46687.84,APC
Gstr rstcv px trnsorl esg,43889,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10523.19,,,,,,,fee schedule,10523.19,46687.84,APC
Gstr rstcv px trnsorl esg,43889,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16100.48,,,,,,,fee schedule,10523.19,46687.84,Radiology
Gstr rstcv px trnsorl esg,43889,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14732.47,,,,,,,fee schedule,10523.19,46687.84,APC
Gstr rstcv px trnsorl esg,43889,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18415.58,,,,,,,fee schedule,10523.19,46687.84,APC
Stomach surgery procedure,43999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2122.13,,,,,,,fee schedule,897.89,3983.62,
Stomach surgery procedure,43999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1701.07,,,,,,,fee schedule,897.89,3983.62,
Stomach surgery procedure,43999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1858.27,,,,,,,fee schedule,897.89,3983.62,
Stomach surgery procedure,43999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1953.71,,,,,,,fee schedule,897.89,3983.62,
Stomach surgery procedure,43999,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3983.62,,,,,,,fee schedule,897.89,3983.62,APC 378
Stomach surgery procedure,43999,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,942.78,,,,,,,fee schedule,897.89,3983.62,APC
Stomach surgery procedure,43999,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,933.8,,,,,,,fee schedule,897.89,3983.62,APC
Stomach surgery procedure,43999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,897.89,,,,,,,fee schedule,897.89,3983.62,APC
Stomach surgery procedure,43999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1373.77,,,,,,,fee schedule,897.89,3983.62,Radiology
Stomach surgery procedure,43999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1257.04,,,,,,,fee schedule,897.89,3983.62,APC
Stomach surgery procedure,43999,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1571.3,,,,,,,fee schedule,897.89,3983.62,APC
Biopsy of bowel,44100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2122.13,,,,,,,fee schedule,897.89,3983.62,
Biopsy of bowel,44100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1701.07,,,,,,,fee schedule,897.89,3983.62,
Biopsy of bowel,44100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1858.27,,,,,,,fee schedule,897.89,3983.62,
Biopsy of bowel,44100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1953.71,,,,,,,fee schedule,897.89,3983.62,
Biopsy of bowel,44100,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3983.62,,,,,,,fee schedule,897.89,3983.62,APC 378
Biopsy of bowel,44100,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,942.78,,,,,,,fee schedule,897.89,3983.62,APC
Biopsy of bowel,44100,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,933.8,,,,,,,fee schedule,897.89,3983.62,APC
Biopsy of bowel,44100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,897.89,,,,,,,fee schedule,897.89,3983.62,APC
Biopsy of bowel,44100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1373.77,,,,,,,fee schedule,897.89,3983.62,Radiology
Biopsy of bowel,44100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1257.04,,,,,,,fee schedule,897.89,3983.62,APC
Biopsy of bowel,44100,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1571.3,,,,,,,fee schedule,897.89,3983.62,APC
Lap enterolysis,44180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3594.84,,,,,,,fee schedule,2881.58,26552.87,
Lap enterolysis,44180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2881.58,,,,,,,fee schedule,2881.58,26552.87,
Lap enterolysis,44180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3147.87,,,,,,,fee schedule,2881.58,26552.87,
Lap enterolysis,44180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3309.54,,,,,,,fee schedule,2881.58,26552.87,
Lap enterolysis,44180,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,2881.58,26552.87,APC 378
Lap enterolysis,44180,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,2881.58,26552.87,APC
Lap enterolysis,44180,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,2881.58,26552.87,APC
Lap enterolysis,44180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,2881.58,26552.87,APC
Lap enterolysis,44180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,2881.58,26552.87,Radiology
Lap enterolysis,44180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,2881.58,26552.87,APC
Lap enterolysis,44180,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,2881.58,26552.87,APC
Lap jejunostomy,44186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11363.59,,,,,,,fee schedule,5984.88,26552.87,
Lap jejunostomy,44186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9108.91,,,,,,,fee schedule,5984.88,26552.87,
Lap jejunostomy,44186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9950.65,,,,,,,fee schedule,5984.88,26552.87,
Lap jejunostomy,44186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10461.72,,,,,,,fee schedule,5984.88,26552.87,
Lap jejunostomy,44186,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,5984.88,26552.87,APC 378
Lap jejunostomy,44186,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,5984.88,26552.87,APC
Lap jejunostomy,44186,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,5984.88,26552.87,APC
Lap jejunostomy,44186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,5984.88,26552.87,APC
Lap jejunostomy,44186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,5984.88,26552.87,Radiology
Lap jejunostomy,44186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,5984.88,26552.87,APC
Lap jejunostomy,44186,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,5984.88,26552.87,APC
Lap part colectomy w/stoma,44206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17386.71,,,,,,,fee schedule,13936.97,17386.71,
Lap part colectomy w/stoma,44206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13936.97,,,,,,,fee schedule,13936.97,17386.71,
Lap part colectomy w/stoma,44206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15224.87,,,,,,,fee schedule,13936.97,17386.71,
Lap part colectomy w/stoma,44206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16006.82,,,,,,,fee schedule,13936.97,17386.71,
L colectomy/coloproctostomy,44207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17386.71,,,,,,,fee schedule,13936.97,17386.71,
L colectomy/coloproctostomy,44207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13936.97,,,,,,,fee schedule,13936.97,17386.71,
L colectomy/coloproctostomy,44207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15224.87,,,,,,,fee schedule,13936.97,17386.71,
L colectomy/coloproctostomy,44207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16006.82,,,,,,,fee schedule,13936.97,17386.71,
L colectomy/coloproctostomy,44208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17386.71,,,,,,,fee schedule,13936.97,17386.71,
L colectomy/coloproctostomy,44208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13936.97,,,,,,,fee schedule,13936.97,17386.71,
L colectomy/coloproctostomy,44208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15224.87,,,,,,,fee schedule,13936.97,17386.71,
L colectomy/coloproctostomy,44208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16006.82,,,,,,,fee schedule,13936.97,17386.71,
Lap mobil splenic fl add-on,44213,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8584.34,,,,,,,fee schedule,6881.1,8584.34,
Lap mobil splenic fl add-on,44213,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6881.1,,,,,,,fee schedule,6881.1,8584.34,
Lap mobil splenic fl add-on,44213,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7516.98,,,,,,,fee schedule,6881.1,8584.34,
Lap mobil splenic fl add-on,44213,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7903.05,,,,,,,fee schedule,6881.1,8584.34,
Laparoscope proc intestine,44238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8584.34,,,,,,,fee schedule,5984.88,26552.87,
Laparoscope proc intestine,44238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6881.1,,,,,,,fee schedule,5984.88,26552.87,
Laparoscope proc intestine,44238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7516.98,,,,,,,fee schedule,5984.88,26552.87,
Laparoscope proc intestine,44238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7903.05,,,,,,,fee schedule,5984.88,26552.87,
Laparoscope proc intestine,44238,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,5984.88,26552.87,APC 378
Laparoscope proc intestine,44238,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscope proc intestine,44238,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscope proc intestine,44238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscope proc intestine,44238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,5984.88,26552.87,Radiology
Laparoscope proc intestine,44238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscope proc intestine,44238,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,5984.88,26552.87,APC
Open bowel to skin,44300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6142.58,,,,,,,fee schedule,1899.66,8428.13,
Open bowel to skin,44300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4923.81,,,,,,,fee schedule,1899.66,8428.13,
Open bowel to skin,44300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5378.82,,,,,,,fee schedule,1899.66,8428.13,
Open bowel to skin,44300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5655.07,,,,,,,fee schedule,1899.66,8428.13,
Open bowel to skin,44300,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8428.13,,,,,,,fee schedule,1899.66,8428.13,APC 378
Open bowel to skin,44300,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1994.64,,,,,,,fee schedule,1899.66,8428.13,APC
Open bowel to skin,44300,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1975.64,,,,,,,fee schedule,1899.66,8428.13,APC
Open bowel to skin,44300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1899.66,,,,,,,fee schedule,1899.66,8428.13,APC
Open bowel to skin,44300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2906.47,,,,,,,fee schedule,1899.66,8428.13,Radiology
Open bowel to skin,44300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2659.52,,,,,,,fee schedule,1899.66,8428.13,APC
Open bowel to skin,44300,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3324.4,,,,,,,fee schedule,1899.66,8428.13,APC
Revision of ileostomy,44312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5043.16,,,,,,,fee schedule,3508.17,15564.58,
Revision of ileostomy,44312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4042.54,,,,,,,fee schedule,3508.17,15564.58,
Revision of ileostomy,44312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4416.1,,,,,,,fee schedule,3508.17,15564.58,
Revision of ileostomy,44312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4642.91,,,,,,,fee schedule,3508.17,15564.58,
Revision of ileostomy,44312,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15564.58,,,,,,,fee schedule,3508.17,15564.58,APC 378
Revision of ileostomy,44312,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3683.58,,,,,,,fee schedule,3508.17,15564.58,APC
Revision of ileostomy,44312,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3648.5,,,,,,,fee schedule,3508.17,15564.58,APC
Revision of ileostomy,44312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3508.17,,,,,,,fee schedule,3508.17,15564.58,APC
Revision of ileostomy,44312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5367.5,,,,,,,fee schedule,3508.17,15564.58,Radiology
Revision of ileostomy,44312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4911.44,,,,,,,fee schedule,3508.17,15564.58,APC
Revision of ileostomy,44312,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6139.3,,,,,,,fee schedule,3508.17,15564.58,APC
Revision of ileostomy,44314,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13313.73,,,,,,,fee schedule,3508.17,15564.58,
Revision of ileostomy,44314,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10672.11,,,,,,,fee schedule,3508.17,15564.58,
Revision of ileostomy,44314,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11658.32,,,,,,,fee schedule,3508.17,15564.58,
Revision of ileostomy,44314,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12257.08,,,,,,,fee schedule,3508.17,15564.58,
Revision of ileostomy,44314,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15564.58,,,,,,,fee schedule,3508.17,15564.58,APC 378
Revision of ileostomy,44314,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3683.58,,,,,,,fee schedule,3508.17,15564.58,APC
Revision of ileostomy,44314,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3648.5,,,,,,,fee schedule,3508.17,15564.58,APC
Revision of ileostomy,44314,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3508.17,,,,,,,fee schedule,3508.17,15564.58,APC
Revision of ileostomy,44314,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5367.5,,,,,,,fee schedule,3508.17,15564.58,Radiology
Revision of ileostomy,44314,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4911.44,,,,,,,fee schedule,3508.17,15564.58,APC
Revision of ileostomy,44314,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6139.3,,,,,,,fee schedule,3508.17,15564.58,APC
Revision of colostomy,44340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5043.16,,,,,,,fee schedule,3508.17,15564.58,
Revision of colostomy,44340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4042.54,,,,,,,fee schedule,3508.17,15564.58,
Revision of colostomy,44340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4416.1,,,,,,,fee schedule,3508.17,15564.58,
Revision of colostomy,44340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4642.91,,,,,,,fee schedule,3508.17,15564.58,
Revision of colostomy,44340,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15564.58,,,,,,,fee schedule,3508.17,15564.58,APC 378
Revision of colostomy,44340,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3683.58,,,,,,,fee schedule,3508.17,15564.58,APC
Revision of colostomy,44340,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3648.5,,,,,,,fee schedule,3508.17,15564.58,APC
Revision of colostomy,44340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3508.17,,,,,,,fee schedule,3508.17,15564.58,APC
Revision of colostomy,44340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5367.5,,,,,,,fee schedule,3508.17,15564.58,Radiology
Revision of colostomy,44340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4911.44,,,,,,,fee schedule,3508.17,15564.58,APC
Revision of colostomy,44340,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6139.3,,,,,,,fee schedule,3508.17,15564.58,APC
Revision of colostomy,44345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12033.29,,,,,,,fee schedule,3508.17,15564.58,
Revision of colostomy,44345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9645.73,,,,,,,fee schedule,3508.17,15564.58,
Revision of colostomy,44345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10537.09,,,,,,,fee schedule,3508.17,15564.58,
Revision of colostomy,44345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11078.27,,,,,,,fee schedule,3508.17,15564.58,
Revision of colostomy,44345,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15564.58,,,,,,,fee schedule,3508.17,15564.58,APC 378
Revision of colostomy,44345,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3683.58,,,,,,,fee schedule,3508.17,15564.58,APC
Revision of colostomy,44345,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3648.5,,,,,,,fee schedule,3508.17,15564.58,APC
Revision of colostomy,44345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3508.17,,,,,,,fee schedule,3508.17,15564.58,APC
Revision of colostomy,44345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5367.5,,,,,,,fee schedule,3508.17,15564.58,Radiology
Revision of colostomy,44345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4911.44,,,,,,,fee schedule,3508.17,15564.58,APC
Revision of colostomy,44345,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6139.3,,,,,,,fee schedule,3508.17,15564.58,APC
Revision of colostomy,44346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12033.29,,,,,,,fee schedule,3508.17,15564.58,
Revision of colostomy,44346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9645.73,,,,,,,fee schedule,3508.17,15564.58,
Revision of colostomy,44346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10537.09,,,,,,,fee schedule,3508.17,15564.58,
Revision of colostomy,44346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11078.27,,,,,,,fee schedule,3508.17,15564.58,
Revision of colostomy,44346,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15564.58,,,,,,,fee schedule,3508.17,15564.58,APC 378
Revision of colostomy,44346,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3683.58,,,,,,,fee schedule,3508.17,15564.58,APC
Revision of colostomy,44346,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3648.5,,,,,,,fee schedule,3508.17,15564.58,APC
Revision of colostomy,44346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3508.17,,,,,,,fee schedule,3508.17,15564.58,APC
Revision of colostomy,44346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5367.5,,,,,,,fee schedule,3508.17,15564.58,Radiology
Revision of colostomy,44346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4911.44,,,,,,,fee schedule,3508.17,15564.58,APC
Revision of colostomy,44346,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6139.3,,,,,,,fee schedule,3508.17,15564.58,APC
Small bowel endoscopy,44360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2378.22,,,,,,,fee schedule,1899.66,8428.13,
Small bowel endoscopy,44360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1906.35,,,,,,,fee schedule,1899.66,8428.13,
Small bowel endoscopy,44360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2082.52,,,,,,,fee schedule,1899.66,8428.13,
Small bowel endoscopy,44360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2189.48,,,,,,,fee schedule,1899.66,8428.13,
Small bowel endoscopy,44360,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8428.13,,,,,,,fee schedule,1899.66,8428.13,APC 378
Small bowel endoscopy,44360,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1994.64,,,,,,,fee schedule,1899.66,8428.13,APC
Small bowel endoscopy,44360,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1975.64,,,,,,,fee schedule,1899.66,8428.13,APC
Small bowel endoscopy,44360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1899.66,,,,,,,fee schedule,1899.66,8428.13,APC
Small bowel endoscopy,44360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2906.47,,,,,,,fee schedule,1899.66,8428.13,Radiology
Small bowel endoscopy,44360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2659.52,,,,,,,fee schedule,1899.66,8428.13,APC
Small bowel endoscopy,44360,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3324.4,,,,,,,fee schedule,1899.66,8428.13,APC
Small bowel endoscopy/biopsy,44361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2378.22,,,,,,,fee schedule,1899.66,8428.13,
Small bowel endoscopy/biopsy,44361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1906.35,,,,,,,fee schedule,1899.66,8428.13,
Small bowel endoscopy/biopsy,44361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2082.52,,,,,,,fee schedule,1899.66,8428.13,
Small bowel endoscopy/biopsy,44361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2189.48,,,,,,,fee schedule,1899.66,8428.13,
Small bowel endoscopy/biopsy,44361,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8428.13,,,,,,,fee schedule,1899.66,8428.13,APC 378
Small bowel endoscopy/biopsy,44361,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1994.64,,,,,,,fee schedule,1899.66,8428.13,APC
Small bowel endoscopy/biopsy,44361,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1975.64,,,,,,,fee schedule,1899.66,8428.13,APC
Small bowel endoscopy/biopsy,44361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1899.66,,,,,,,fee schedule,1899.66,8428.13,APC
Small bowel endoscopy/biopsy,44361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2906.47,,,,,,,fee schedule,1899.66,8428.13,Radiology
Small bowel endoscopy/biopsy,44361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2659.52,,,,,,,fee schedule,1899.66,8428.13,APC
Small bowel endoscopy/biopsy,44361,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3324.4,,,,,,,fee schedule,1899.66,8428.13,APC
Small bowel endoscopy,44363,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2378.22,,,,,,,fee schedule,1899.66,8428.13,
Small bowel endoscopy,44363,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1906.35,,,,,,,fee schedule,1899.66,8428.13,
Small bowel endoscopy,44363,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2082.52,,,,,,,fee schedule,1899.66,8428.13,
Small bowel endoscopy,44363,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2189.48,,,,,,,fee schedule,1899.66,8428.13,
Small bowel endoscopy,44363,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8428.13,,,,,,,fee schedule,1899.66,8428.13,APC 378
Small bowel endoscopy,44363,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1994.64,,,,,,,fee schedule,1899.66,8428.13,APC
Small bowel endoscopy,44363,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1975.64,,,,,,,fee schedule,1899.66,8428.13,APC
Small bowel endoscopy,44363,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1899.66,,,,,,,fee schedule,1899.66,8428.13,APC
Small bowel endoscopy,44363,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2906.47,,,,,,,fee schedule,1899.66,8428.13,Radiology
Small bowel endoscopy,44363,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2659.52,,,,,,,fee schedule,1899.66,8428.13,APC
Small bowel endoscopy,44363,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3324.4,,,,,,,fee schedule,1899.66,8428.13,APC
Small bowel endoscopy,44364,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2378.22,,,,,,,fee schedule,1899.66,8428.13,
Small bowel endoscopy,44364,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1906.35,,,,,,,fee schedule,1899.66,8428.13,
Small bowel endoscopy,44364,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2082.52,,,,,,,fee schedule,1899.66,8428.13,
Small bowel endoscopy,44364,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2189.48,,,,,,,fee schedule,1899.66,8428.13,
Small bowel endoscopy,44364,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8428.13,,,,,,,fee schedule,1899.66,8428.13,APC 378
Small bowel endoscopy,44364,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1994.64,,,,,,,fee schedule,1899.66,8428.13,APC
Small bowel endoscopy,44364,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1975.64,,,,,,,fee schedule,1899.66,8428.13,APC
Small bowel endoscopy,44364,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1899.66,,,,,,,fee schedule,1899.66,8428.13,APC
Small bowel endoscopy,44364,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2906.47,,,,,,,fee schedule,1899.66,8428.13,Radiology
Small bowel endoscopy,44364,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2659.52,,,,,,,fee schedule,1899.66,8428.13,APC
Small bowel endoscopy,44364,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3324.4,,,,,,,fee schedule,1899.66,8428.13,APC
Small bowel endoscopy,44365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2378.22,,,,,,,fee schedule,1899.66,8428.13,
Small bowel endoscopy,44365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1906.35,,,,,,,fee schedule,1899.66,8428.13,
Small bowel endoscopy,44365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2082.52,,,,,,,fee schedule,1899.66,8428.13,
Small bowel endoscopy,44365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2189.48,,,,,,,fee schedule,1899.66,8428.13,
Small bowel endoscopy,44365,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8428.13,,,,,,,fee schedule,1899.66,8428.13,APC 378
Small bowel endoscopy,44365,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1994.64,,,,,,,fee schedule,1899.66,8428.13,APC
Small bowel endoscopy,44365,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1975.64,,,,,,,fee schedule,1899.66,8428.13,APC
Small bowel endoscopy,44365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1899.66,,,,,,,fee schedule,1899.66,8428.13,APC
Small bowel endoscopy,44365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2906.47,,,,,,,fee schedule,1899.66,8428.13,Radiology
Small bowel endoscopy,44365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2659.52,,,,,,,fee schedule,1899.66,8428.13,APC
Small bowel endoscopy,44365,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3324.4,,,,,,,fee schedule,1899.66,8428.13,APC
Small bowel endoscopy,44366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2378.22,,,,,,,fee schedule,1899.66,8428.13,
Small bowel endoscopy,44366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1906.35,,,,,,,fee schedule,1899.66,8428.13,
Small bowel endoscopy,44366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2082.52,,,,,,,fee schedule,1899.66,8428.13,
Small bowel endoscopy,44366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2189.48,,,,,,,fee schedule,1899.66,8428.13,
Small bowel endoscopy,44366,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8428.13,,,,,,,fee schedule,1899.66,8428.13,APC 378
Small bowel endoscopy,44366,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1994.64,,,,,,,fee schedule,1899.66,8428.13,APC
Small bowel endoscopy,44366,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1975.64,,,,,,,fee schedule,1899.66,8428.13,APC
Small bowel endoscopy,44366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1899.66,,,,,,,fee schedule,1899.66,8428.13,APC
Small bowel endoscopy,44366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2906.47,,,,,,,fee schedule,1899.66,8428.13,Radiology
Small bowel endoscopy,44366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2659.52,,,,,,,fee schedule,1899.66,8428.13,APC
Small bowel endoscopy,44366,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3324.4,,,,,,,fee schedule,1899.66,8428.13,APC
Small bowel endoscopy,44369,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2378.22,,,,,,,fee schedule,1899.66,8428.13,
Small bowel endoscopy,44369,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1906.35,,,,,,,fee schedule,1899.66,8428.13,
Small bowel endoscopy,44369,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2082.52,,,,,,,fee schedule,1899.66,8428.13,
Small bowel endoscopy,44369,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2189.48,,,,,,,fee schedule,1899.66,8428.13,
Small bowel endoscopy,44369,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8428.13,,,,,,,fee schedule,1899.66,8428.13,APC 378
Small bowel endoscopy,44369,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1994.64,,,,,,,fee schedule,1899.66,8428.13,APC
Small bowel endoscopy,44369,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1975.64,,,,,,,fee schedule,1899.66,8428.13,APC
Small bowel endoscopy,44369,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1899.66,,,,,,,fee schedule,1899.66,8428.13,APC
Small bowel endoscopy,44369,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2906.47,,,,,,,fee schedule,1899.66,8428.13,Radiology
Small bowel endoscopy,44369,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2659.52,,,,,,,fee schedule,1899.66,8428.13,APC
Small bowel endoscopy,44369,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3324.4,,,,,,,fee schedule,1899.66,8428.13,APC
Small Bowel Endoscopy/Stent,44370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6234.77,,,,,,,fee schedule,4997.71,26664.3,
Small Bowel Endoscopy/Stent,44370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4997.71,,,,,,,fee schedule,4997.71,26664.3,
Small Bowel Endoscopy/Stent,44370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5459.55,,,,,,,fee schedule,4997.71,26664.3,
Small Bowel Endoscopy/Stent,44370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5739.95,,,,,,,fee schedule,4997.71,26664.3,
Small Bowel Endoscopy/Stent,44370,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26664.3,,,,,,,fee schedule,4997.71,26664.3,APC 378
Small Bowel Endoscopy/Stent,44370,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6310.49,,,,,,,fee schedule,4997.71,26664.3,APC
Small Bowel Endoscopy/Stent,44370,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6250.39,,,,,,,fee schedule,4997.71,26664.3,APC
Small Bowel Endoscopy/Stent,44370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6009.99,,,,,,,fee schedule,4997.71,26664.3,APC
Small Bowel Endoscopy/Stent,44370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9195.29,,,,,,,fee schedule,4997.71,26664.3,Radiology
Small Bowel Endoscopy/Stent,44370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8413.99,,,,,,,fee schedule,4997.71,26664.3,APC
Small Bowel Endoscopy/Stent,44370,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10517.49,,,,,,,fee schedule,4997.71,26664.3,APC
Small bowel endoscopy,44372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2378.22,,,,,,,fee schedule,1899.66,8428.13,
Small bowel endoscopy,44372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1906.35,,,,,,,fee schedule,1899.66,8428.13,
Small bowel endoscopy,44372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2082.52,,,,,,,fee schedule,1899.66,8428.13,
Small bowel endoscopy,44372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2189.48,,,,,,,fee schedule,1899.66,8428.13,
Small bowel endoscopy,44372,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8428.13,,,,,,,fee schedule,1899.66,8428.13,APC 378
Small bowel endoscopy,44372,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1994.64,,,,,,,fee schedule,1899.66,8428.13,APC
Small bowel endoscopy,44372,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1975.64,,,,,,,fee schedule,1899.66,8428.13,APC
Small bowel endoscopy,44372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1899.66,,,,,,,fee schedule,1899.66,8428.13,APC
Small bowel endoscopy,44372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2906.47,,,,,,,fee schedule,1899.66,8428.13,Radiology
Small bowel endoscopy,44372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2659.52,,,,,,,fee schedule,1899.66,8428.13,APC
Small bowel endoscopy,44372,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3324.4,,,,,,,fee schedule,1899.66,8428.13,APC
Small bowel endoscopy,44373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2378.22,,,,,,,fee schedule,1899.66,8428.13,
Small bowel endoscopy,44373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1906.35,,,,,,,fee schedule,1899.66,8428.13,
Small bowel endoscopy,44373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2082.52,,,,,,,fee schedule,1899.66,8428.13,
Small bowel endoscopy,44373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2189.48,,,,,,,fee schedule,1899.66,8428.13,
Small bowel endoscopy,44373,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8428.13,,,,,,,fee schedule,1899.66,8428.13,APC 378
Small bowel endoscopy,44373,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1994.64,,,,,,,fee schedule,1899.66,8428.13,APC
Small bowel endoscopy,44373,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1975.64,,,,,,,fee schedule,1899.66,8428.13,APC
Small bowel endoscopy,44373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1899.66,,,,,,,fee schedule,1899.66,8428.13,APC
Small bowel endoscopy,44373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2906.47,,,,,,,fee schedule,1899.66,8428.13,Radiology
Small bowel endoscopy,44373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2659.52,,,,,,,fee schedule,1899.66,8428.13,APC
Small bowel endoscopy,44373,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3324.4,,,,,,,fee schedule,1899.66,8428.13,APC
Small bowel endoscopy,44376,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3306.61,,,,,,,fee schedule,1899.66,8428.13,
Small bowel endoscopy,44376,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2650.53,,,,,,,fee schedule,1899.66,8428.13,
Small bowel endoscopy,44376,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2895.47,,,,,,,fee schedule,1899.66,8428.13,
Small bowel endoscopy,44376,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3044.18,,,,,,,fee schedule,1899.66,8428.13,
Small bowel endoscopy,44376,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8428.13,,,,,,,fee schedule,1899.66,8428.13,APC 378
Small bowel endoscopy,44376,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1994.64,,,,,,,fee schedule,1899.66,8428.13,APC
Small bowel endoscopy,44376,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1975.64,,,,,,,fee schedule,1899.66,8428.13,APC
Small bowel endoscopy,44376,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1899.66,,,,,,,fee schedule,1899.66,8428.13,APC
Small bowel endoscopy,44376,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2906.47,,,,,,,fee schedule,1899.66,8428.13,Radiology
Small bowel endoscopy,44376,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2659.52,,,,,,,fee schedule,1899.66,8428.13,APC
Small bowel endoscopy,44376,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3324.4,,,,,,,fee schedule,1899.66,8428.13,APC
Small bowel endoscopy/biopsy,44377,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1939.28,,,,,,,fee schedule,1554.5,8428.13,
Small bowel endoscopy/biopsy,44377,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1554.5,,,,,,,fee schedule,1554.5,8428.13,
Small bowel endoscopy/biopsy,44377,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1698.15,,,,,,,fee schedule,1554.5,8428.13,
Small bowel endoscopy/biopsy,44377,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1785.36,,,,,,,fee schedule,1554.5,8428.13,
Small bowel endoscopy/biopsy,44377,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8428.13,,,,,,,fee schedule,1554.5,8428.13,APC 378
Small bowel endoscopy/biopsy,44377,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1994.64,,,,,,,fee schedule,1554.5,8428.13,APC
Small bowel endoscopy/biopsy,44377,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1975.64,,,,,,,fee schedule,1554.5,8428.13,APC
Small bowel endoscopy/biopsy,44377,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1899.66,,,,,,,fee schedule,1554.5,8428.13,APC
Small bowel endoscopy/biopsy,44377,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2906.47,,,,,,,fee schedule,1554.5,8428.13,Radiology
Small bowel endoscopy/biopsy,44377,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2659.52,,,,,,,fee schedule,1554.5,8428.13,APC
Small bowel endoscopy/biopsy,44377,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3324.4,,,,,,,fee schedule,1554.5,8428.13,APC
Small bowel endoscopy,44378,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2378.22,,,,,,,fee schedule,1899.66,8428.13,
Small bowel endoscopy,44378,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1906.35,,,,,,,fee schedule,1899.66,8428.13,
Small bowel endoscopy,44378,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2082.52,,,,,,,fee schedule,1899.66,8428.13,
Small bowel endoscopy,44378,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2189.48,,,,,,,fee schedule,1899.66,8428.13,
Small bowel endoscopy,44378,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8428.13,,,,,,,fee schedule,1899.66,8428.13,APC 378
Small bowel endoscopy,44378,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1994.64,,,,,,,fee schedule,1899.66,8428.13,APC
Small bowel endoscopy,44378,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1975.64,,,,,,,fee schedule,1899.66,8428.13,APC
Small bowel endoscopy,44378,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1899.66,,,,,,,fee schedule,1899.66,8428.13,APC
Small bowel endoscopy,44378,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2906.47,,,,,,,fee schedule,1899.66,8428.13,Radiology
Small bowel endoscopy,44378,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2659.52,,,,,,,fee schedule,1899.66,8428.13,APC
Small bowel endoscopy,44378,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3324.4,,,,,,,fee schedule,1899.66,8428.13,APC
S Bowel Endoscope W/Stent,44379,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6234.77,,,,,,,fee schedule,4997.71,26664.3,
S Bowel Endoscope W/Stent,44379,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4997.71,,,,,,,fee schedule,4997.71,26664.3,
S Bowel Endoscope W/Stent,44379,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5459.55,,,,,,,fee schedule,4997.71,26664.3,
S Bowel Endoscope W/Stent,44379,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5739.95,,,,,,,fee schedule,4997.71,26664.3,
S Bowel Endoscope W/Stent,44379,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26664.3,,,,,,,fee schedule,4997.71,26664.3,APC 378
S Bowel Endoscope W/Stent,44379,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6310.49,,,,,,,fee schedule,4997.71,26664.3,APC
S Bowel Endoscope W/Stent,44379,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6250.39,,,,,,,fee schedule,4997.71,26664.3,APC
S Bowel Endoscope W/Stent,44379,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6009.99,,,,,,,fee schedule,4997.71,26664.3,APC
S Bowel Endoscope W/Stent,44379,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9195.29,,,,,,,fee schedule,4997.71,26664.3,Radiology
S Bowel Endoscope W/Stent,44379,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8413.99,,,,,,,fee schedule,4997.71,26664.3,APC
S Bowel Endoscope W/Stent,44379,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10517.49,,,,,,,fee schedule,4997.71,26664.3,APC
Small bowel endoscopy br/wa,44380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2378.22,,,,,,,fee schedule,897.89,3983.62,
Small bowel endoscopy br/wa,44380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1906.35,,,,,,,fee schedule,897.89,3983.62,
Small bowel endoscopy br/wa,44380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2082.52,,,,,,,fee schedule,897.89,3983.62,
Small bowel endoscopy br/wa,44380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2189.48,,,,,,,fee schedule,897.89,3983.62,
Small bowel endoscopy br/wa,44380,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3983.62,,,,,,,fee schedule,897.89,3983.62,APC 378
Small bowel endoscopy br/wa,44380,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,942.78,,,,,,,fee schedule,897.89,3983.62,APC
Small bowel endoscopy br/wa,44380,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,933.8,,,,,,,fee schedule,897.89,3983.62,APC
Small bowel endoscopy br/wa,44380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,897.89,,,,,,,fee schedule,897.89,3983.62,APC
Small bowel endoscopy br/wa,44380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1373.77,,,,,,,fee schedule,897.89,3983.62,Radiology
Small bowel endoscopy br/wa,44380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1257.04,,,,,,,fee schedule,897.89,3983.62,APC
Small bowel endoscopy br/wa,44380,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1571.3,,,,,,,fee schedule,897.89,3983.62,APC
Small bowel endoscopy br/wa,44381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3222.19,,,,,,,fee schedule,1899.66,8428.13,
Small bowel endoscopy br/wa,44381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2582.86,,,,,,,fee schedule,1899.66,8428.13,
Small bowel endoscopy br/wa,44381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2821.54,,,,,,,fee schedule,1899.66,8428.13,
Small bowel endoscopy br/wa,44381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2966.46,,,,,,,fee schedule,1899.66,8428.13,
Small bowel endoscopy br/wa,44381,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8428.13,,,,,,,fee schedule,1899.66,8428.13,APC 378
Small bowel endoscopy br/wa,44381,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1994.64,,,,,,,fee schedule,1899.66,8428.13,APC
Small bowel endoscopy br/wa,44381,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1975.64,,,,,,,fee schedule,1899.66,8428.13,APC
Small bowel endoscopy br/wa,44381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1899.66,,,,,,,fee schedule,1899.66,8428.13,APC
Small bowel endoscopy br/wa,44381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2906.47,,,,,,,fee schedule,1899.66,8428.13,Radiology
Small bowel endoscopy br/wa,44381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2659.52,,,,,,,fee schedule,1899.66,8428.13,APC
Small bowel endoscopy br/wa,44381,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3324.4,,,,,,,fee schedule,1899.66,8428.13,APC
Small bowel endoscopy,44382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1939.28,,,,,,,fee schedule,897.89,3983.62,
Small bowel endoscopy,44382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1554.5,,,,,,,fee schedule,897.89,3983.62,
Small bowel endoscopy,44382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1698.15,,,,,,,fee schedule,897.89,3983.62,
Small bowel endoscopy,44382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1785.36,,,,,,,fee schedule,897.89,3983.62,
Small bowel endoscopy,44382,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3983.62,,,,,,,fee schedule,897.89,3983.62,APC 378
Small bowel endoscopy,44382,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,942.78,,,,,,,fee schedule,897.89,3983.62,APC
Small bowel endoscopy,44382,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,933.8,,,,,,,fee schedule,897.89,3983.62,APC
Small bowel endoscopy,44382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,897.89,,,,,,,fee schedule,897.89,3983.62,APC
Small bowel endoscopy,44382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1373.77,,,,,,,fee schedule,897.89,3983.62,Radiology
Small bowel endoscopy,44382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1257.04,,,,,,,fee schedule,897.89,3983.62,APC
Small bowel endoscopy,44382,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1571.3,,,,,,,fee schedule,897.89,3983.62,APC
Small bowel endoscopy,44384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3222.19,,,,,,,fee schedule,1899.66,8428.13,
Small bowel endoscopy,44384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2582.86,,,,,,,fee schedule,1899.66,8428.13,
Small bowel endoscopy,44384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2821.54,,,,,,,fee schedule,1899.66,8428.13,
Small bowel endoscopy,44384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2966.46,,,,,,,fee schedule,1899.66,8428.13,
Small bowel endoscopy,44384,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8428.13,,,,,,,fee schedule,1899.66,8428.13,APC 378
Small bowel endoscopy,44384,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1994.64,,,,,,,fee schedule,1899.66,8428.13,APC
Small bowel endoscopy,44384,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1975.64,,,,,,,fee schedule,1899.66,8428.13,APC
Small bowel endoscopy,44384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1899.66,,,,,,,fee schedule,1899.66,8428.13,APC
Small bowel endoscopy,44384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2906.47,,,,,,,fee schedule,1899.66,8428.13,Radiology
Small bowel endoscopy,44384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2659.52,,,,,,,fee schedule,1899.66,8428.13,APC
Small bowel endoscopy,44384,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3324.4,,,,,,,fee schedule,1899.66,8428.13,APC
Endoscopy of bowel pouch,44385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2208.39,,,,,,,fee schedule,920.63,4084.51,
Endoscopy of bowel pouch,44385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1770.22,,,,,,,fee schedule,920.63,4084.51,
Endoscopy of bowel pouch,44385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1933.8,,,,,,,fee schedule,920.63,4084.51,
Endoscopy of bowel pouch,44385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2033.12,,,,,,,fee schedule,920.63,4084.51,
Endoscopy of bowel pouch,44385,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4084.51,,,,,,,fee schedule,920.63,4084.51,APC 378
Endoscopy of bowel pouch,44385,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,966.66,,,,,,,fee schedule,920.63,4084.51,APC
Endoscopy of bowel pouch,44385,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,957.45,,,,,,,fee schedule,920.63,4084.51,APC
Endoscopy of bowel pouch,44385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,920.63,,,,,,,fee schedule,920.63,4084.51,APC
Endoscopy of bowel pouch,44385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1408.56,,,,,,,fee schedule,920.63,4084.51,Radiology
Endoscopy of bowel pouch,44385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1288.88,,,,,,,fee schedule,920.63,4084.51,APC
Endoscopy of bowel pouch,44385,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1611.1,,,,,,,fee schedule,920.63,4084.51,APC
Endoscopy bowel pouch/biop,44386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2557.3,,,,,,,fee schedule,920.63,4084.51,
Endoscopy bowel pouch/biop,44386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2049.9,,,,,,,fee schedule,920.63,4084.51,
Endoscopy bowel pouch/biop,44386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2239.33,,,,,,,fee schedule,920.63,4084.51,
Endoscopy bowel pouch/biop,44386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2354.34,,,,,,,fee schedule,920.63,4084.51,
Endoscopy bowel pouch/biop,44386,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4084.51,,,,,,,fee schedule,920.63,4084.51,APC 378
Endoscopy bowel pouch/biop,44386,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,966.66,,,,,,,fee schedule,920.63,4084.51,APC
Endoscopy bowel pouch/biop,44386,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,957.45,,,,,,,fee schedule,920.63,4084.51,APC
Endoscopy bowel pouch/biop,44386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,920.63,,,,,,,fee schedule,920.63,4084.51,APC
Endoscopy bowel pouch/biop,44386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1408.56,,,,,,,fee schedule,920.63,4084.51,Radiology
Endoscopy bowel pouch/biop,44386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1288.88,,,,,,,fee schedule,920.63,4084.51,APC
Endoscopy bowel pouch/biop,44386,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1611.1,,,,,,,fee schedule,920.63,4084.51,APC
Colonoscopy thru stoma spx,44388,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2330.1,,,,,,,fee schedule,920.63,4084.51,
Colonoscopy thru stoma spx,44388,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1867.78,,,,,,,fee schedule,920.63,4084.51,
Colonoscopy thru stoma spx,44388,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2040.38,,,,,,,fee schedule,920.63,4084.51,
Colonoscopy thru stoma spx,44388,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2145.17,,,,,,,fee schedule,920.63,4084.51,
Colonoscopy thru stoma spx,44388,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4084.51,,,,,,,fee schedule,920.63,4084.51,APC 378
Colonoscopy thru stoma spx,44388,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,966.66,,,,,,,fee schedule,920.63,4084.51,APC
Colonoscopy thru stoma spx,44388,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,957.45,,,,,,,fee schedule,920.63,4084.51,APC
Colonoscopy thru stoma spx,44388,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,920.63,,,,,,,fee schedule,920.63,4084.51,APC
Colonoscopy thru stoma spx,44388,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1408.56,,,,,,,fee schedule,920.63,4084.51,Radiology
Colonoscopy thru stoma spx,44388,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1288.88,,,,,,,fee schedule,920.63,4084.51,APC
Colonoscopy thru stoma spx,44388,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1611.1,,,,,,,fee schedule,920.63,4084.51,APC
Colonoscopy with biopsy,44389,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2208.39,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy with biopsy,44389,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1770.22,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy with biopsy,44389,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1933.8,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy with biopsy,44389,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2033.12,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy with biopsy,44389,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5255.83,,,,,,,fee schedule,1184.64,5255.83,APC 378
Colonoscopy with biopsy,44389,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1243.87,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy with biopsy,44389,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1232.02,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy with biopsy,44389,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1184.64,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy with biopsy,44389,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1812.49,,,,,,,fee schedule,1184.64,5255.83,Radiology
Colonoscopy with biopsy,44389,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1658.49,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy with biopsy,44389,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2073.11,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy for foreign body,44390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2208.39,,,,,,,fee schedule,920.63,4084.51,
Colonoscopy for foreign body,44390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1770.22,,,,,,,fee schedule,920.63,4084.51,
Colonoscopy for foreign body,44390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1933.8,,,,,,,fee schedule,920.63,4084.51,
Colonoscopy for foreign body,44390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2033.12,,,,,,,fee schedule,920.63,4084.51,
Colonoscopy for foreign body,44390,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4084.51,,,,,,,fee schedule,920.63,4084.51,APC 378
Colonoscopy for foreign body,44390,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,966.66,,,,,,,fee schedule,920.63,4084.51,APC
Colonoscopy for foreign body,44390,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,957.45,,,,,,,fee schedule,920.63,4084.51,APC
Colonoscopy for foreign body,44390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,920.63,,,,,,,fee schedule,920.63,4084.51,APC
Colonoscopy for foreign body,44390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1408.56,,,,,,,fee schedule,920.63,4084.51,Radiology
Colonoscopy for foreign body,44390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1288.88,,,,,,,fee schedule,920.63,4084.51,APC
Colonoscopy for foreign body,44390,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1611.1,,,,,,,fee schedule,920.63,4084.51,APC
Colonoscopy for bleeding,44391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2208.39,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy for bleeding,44391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1770.22,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy for bleeding,44391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1933.8,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy for bleeding,44391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2033.12,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy for bleeding,44391,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5255.83,,,,,,,fee schedule,1184.64,5255.83,APC 378
Colonoscopy for bleeding,44391,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1243.87,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy for bleeding,44391,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1232.02,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy for bleeding,44391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1184.64,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy for bleeding,44391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1812.49,,,,,,,fee schedule,1184.64,5255.83,Radiology
Colonoscopy for bleeding,44391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1658.49,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy for bleeding,44391,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2073.11,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy & polypectomy,44392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1596.14,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy & polypectomy,44392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1279.45,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy & polypectomy,44392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1397.68,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy & polypectomy,44392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1469.46,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy & polypectomy,44392,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5255.83,,,,,,,fee schedule,1184.64,5255.83,APC 378
Colonoscopy & polypectomy,44392,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1243.87,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy & polypectomy,44392,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1232.02,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy & polypectomy,44392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1184.64,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy & polypectomy,44392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1812.49,,,,,,,fee schedule,1184.64,5255.83,Radiology
Colonoscopy & polypectomy,44392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1658.49,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy & polypectomy,44392,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2073.11,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/snare,44394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1596.14,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy w/snare,44394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1279.45,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy w/snare,44394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1397.68,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy w/snare,44394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1469.46,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy w/snare,44394,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5255.83,,,,,,,fee schedule,1184.64,5255.83,APC 378
Colonoscopy w/snare,44394,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1243.87,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/snare,44394,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1232.02,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/snare,44394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1184.64,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/snare,44394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1812.49,,,,,,,fee schedule,1184.64,5255.83,Radiology
Colonoscopy w/snare,44394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1658.49,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/snare,44394,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2073.11,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy with ablation,44401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2985.67,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy with ablation,44401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2393.28,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy with ablation,44401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2614.44,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy with ablation,44401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2748.71,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy with ablation,44401,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5255.83,,,,,,,fee schedule,1184.64,5255.83,APC 378
Colonoscopy with ablation,44401,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1243.87,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy with ablation,44401,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1232.02,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy with ablation,44401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1184.64,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy with ablation,44401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1812.49,,,,,,,fee schedule,1184.64,5255.83,Radiology
Colonoscopy with ablation,44401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1658.49,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy with ablation,44401,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2073.11,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/stent plcmt,44402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2985.67,,,,,,,fee schedule,2393.28,26664.3,
Colonoscopy w/stent plcmt,44402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2393.28,,,,,,,fee schedule,2393.28,26664.3,
Colonoscopy w/stent plcmt,44402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2614.44,,,,,,,fee schedule,2393.28,26664.3,
Colonoscopy w/stent plcmt,44402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2748.71,,,,,,,fee schedule,2393.28,26664.3,
Colonoscopy w/stent plcmt,44402,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26664.3,,,,,,,fee schedule,2393.28,26664.3,APC 378
Colonoscopy w/stent plcmt,44402,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6310.49,,,,,,,fee schedule,2393.28,26664.3,APC
Colonoscopy w/stent plcmt,44402,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6250.39,,,,,,,fee schedule,2393.28,26664.3,APC
Colonoscopy w/stent plcmt,44402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6009.99,,,,,,,fee schedule,2393.28,26664.3,APC
Colonoscopy w/stent plcmt,44402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9195.29,,,,,,,fee schedule,2393.28,26664.3,Radiology
Colonoscopy w/stent plcmt,44402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8413.99,,,,,,,fee schedule,2393.28,26664.3,APC
Colonoscopy w/stent plcmt,44402,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10517.49,,,,,,,fee schedule,2393.28,26664.3,APC
Colonoscopy w/resection,44403,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2985.67,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy w/resection,44403,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2393.28,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy w/resection,44403,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2614.44,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy w/resection,44403,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2748.71,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy w/resection,44403,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5255.83,,,,,,,fee schedule,1184.64,5255.83,APC 378
Colonoscopy w/resection,44403,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1243.87,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/resection,44403,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1232.02,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/resection,44403,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1184.64,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/resection,44403,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1812.49,,,,,,,fee schedule,1184.64,5255.83,Radiology
Colonoscopy w/resection,44403,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1658.49,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/resection,44403,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2073.11,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/injection,44404,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2985.67,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy w/injection,44404,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2393.28,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy w/injection,44404,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2614.44,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy w/injection,44404,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2748.71,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy w/injection,44404,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5255.83,,,,,,,fee schedule,1184.64,5255.83,APC 378
Colonoscopy w/injection,44404,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1243.87,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/injection,44404,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1232.02,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/injection,44404,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1184.64,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/injection,44404,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1812.49,,,,,,,fee schedule,1184.64,5255.83,Radiology
Colonoscopy w/injection,44404,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1658.49,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/injection,44404,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2073.11,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/dilation,44405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1784.15,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy w/dilation,44405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1430.15,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy w/dilation,44405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1562.31,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy w/dilation,44405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1642.55,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy w/dilation,44405,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5255.83,,,,,,,fee schedule,1184.64,5255.83,APC 378
Colonoscopy w/dilation,44405,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1243.87,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/dilation,44405,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1232.02,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/dilation,44405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1184.64,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/dilation,44405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1812.49,,,,,,,fee schedule,1184.64,5255.83,Radiology
Colonoscopy w/dilation,44405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1658.49,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/dilation,44405,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2073.11,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/ultrasound,44406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2985.67,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy w/ultrasound,44406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2393.28,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy w/ultrasound,44406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2614.44,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy w/ultrasound,44406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2748.71,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy w/ultrasound,44406,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5255.83,,,,,,,fee schedule,1184.64,5255.83,APC 378
Colonoscopy w/ultrasound,44406,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1243.87,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/ultrasound,44406,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1232.02,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/ultrasound,44406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1184.64,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/ultrasound,44406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1812.49,,,,,,,fee schedule,1184.64,5255.83,Radiology
Colonoscopy w/ultrasound,44406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1658.49,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/ultrasound,44406,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2073.11,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/ndl aspir/bx,44407,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2985.67,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy w/ndl aspir/bx,44407,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2393.28,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy w/ndl aspir/bx,44407,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2614.44,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy w/ndl aspir/bx,44407,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2748.71,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy w/ndl aspir/bx,44407,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5255.83,,,,,,,fee schedule,1184.64,5255.83,APC 378
Colonoscopy w/ndl aspir/bx,44407,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1243.87,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/ndl aspir/bx,44407,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1232.02,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/ndl aspir/bx,44407,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1184.64,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/ndl aspir/bx,44407,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1812.49,,,,,,,fee schedule,1184.64,5255.83,Radiology
Colonoscopy w/ndl aspir/bx,44407,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1658.49,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/ndl aspir/bx,44407,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2073.11,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/decompression,44408,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2985.67,,,,,,,fee schedule,920.63,4084.51,
Colonoscopy w/decompression,44408,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2393.28,,,,,,,fee schedule,920.63,4084.51,
Colonoscopy w/decompression,44408,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2614.44,,,,,,,fee schedule,920.63,4084.51,
Colonoscopy w/decompression,44408,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2748.71,,,,,,,fee schedule,920.63,4084.51,
Colonoscopy w/decompression,44408,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4084.51,,,,,,,fee schedule,920.63,4084.51,APC 378
Colonoscopy w/decompression,44408,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,966.66,,,,,,,fee schedule,920.63,4084.51,APC
Colonoscopy w/decompression,44408,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,957.45,,,,,,,fee schedule,920.63,4084.51,APC
Colonoscopy w/decompression,44408,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,920.63,,,,,,,fee schedule,920.63,4084.51,APC
Colonoscopy w/decompression,44408,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1408.56,,,,,,,fee schedule,920.63,4084.51,Radiology
Colonoscopy w/decompression,44408,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1288.88,,,,,,,fee schedule,920.63,4084.51,APC
Colonoscopy w/decompression,44408,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1611.1,,,,,,,fee schedule,920.63,4084.51,APC
Intro gastrointestinal tube,44500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,808.2,,,,,,,fee schedule,647.84,3983.62,
Intro gastrointestinal tube,44500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,647.84,,,,,,,fee schedule,647.84,3983.62,
Intro gastrointestinal tube,44500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,707.71,,,,,,,fee schedule,647.84,3983.62,
Intro gastrointestinal tube,44500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,744.06,,,,,,,fee schedule,647.84,3983.62,
Intro gastrointestinal tube,44500,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3983.62,,,,,,,fee schedule,647.84,3983.62,APC 378
Intro gastrointestinal tube,44500,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,942.78,,,,,,,fee schedule,647.84,3983.62,APC
Intro gastrointestinal tube,44500,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,933.8,,,,,,,fee schedule,647.84,3983.62,APC
Intro gastrointestinal tube,44500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,897.89,,,,,,,fee schedule,647.84,3983.62,APC
Intro gastrointestinal tube,44500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1373.77,,,,,,,fee schedule,647.84,3983.62,Radiology
Intro gastrointestinal tube,44500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1257.04,,,,,,,fee schedule,647.84,3983.62,APC
Intro gastrointestinal tube,44500,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1571.3,,,,,,,fee schedule,647.84,3983.62,APC
Suture small intestine,44602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11645.39,,,,,,,fee schedule,3816.79,16933.82,
Suture small intestine,44602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9334.79,,,,,,,fee schedule,3816.79,16933.82,
Suture small intestine,44602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10197.41,,,,,,,fee schedule,3816.79,16933.82,
Suture small intestine,44602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10721.15,,,,,,,fee schedule,3816.79,16933.82,
Suture small intestine,44602,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16933.82,,,,,,,fee schedule,3816.79,16933.82,APC 378
Suture small intestine,44602,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4007.63,,,,,,,fee schedule,3816.79,16933.82,APC
Suture small intestine,44602,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3969.46,,,,,,,fee schedule,3816.79,16933.82,APC
Suture small intestine,44602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3816.79,,,,,,,fee schedule,3816.79,16933.82,APC
Suture small intestine,44602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5839.69,,,,,,,fee schedule,3816.79,16933.82,Radiology
Suture small intestine,44602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5343.51,,,,,,,fee schedule,3816.79,16933.82,APC
Suture small intestine,44602,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6679.39,,,,,,,fee schedule,3816.79,16933.82,APC
Unlisted px small intestine,44799,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6412.77,,,,,,,fee schedule,897.89,6412.77,
Unlisted px small intestine,44799,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5140.4,,,,,,,fee schedule,897.89,6412.77,
Unlisted px small intestine,44799,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5615.42,,,,,,,fee schedule,897.89,6412.77,
Unlisted px small intestine,44799,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5903.82,,,,,,,fee schedule,897.89,6412.77,
Unlisted px small intestine,44799,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3983.62,,,,,,,fee schedule,897.89,6412.77,APC 378
Unlisted px small intestine,44799,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,942.78,,,,,,,fee schedule,897.89,6412.77,APC
Unlisted px small intestine,44799,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,933.8,,,,,,,fee schedule,897.89,6412.77,APC
Unlisted px small intestine,44799,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,897.89,,,,,,,fee schedule,897.89,6412.77,APC
Unlisted px small intestine,44799,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1373.77,,,,,,,fee schedule,897.89,6412.77,Radiology
Unlisted px small intestine,44799,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1257.04,,,,,,,fee schedule,897.89,6412.77,APC
Unlisted px small intestine,44799,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1571.3,,,,,,,fee schedule,897.89,6412.77,APC
Appendectomy,44950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9737.23,,,,,,,fee schedule,6408.87,28434,
Appendectomy,44950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7805.24,,,,,,,fee schedule,6408.87,28434,
Appendectomy,44950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8526.52,,,,,,,fee schedule,6408.87,28434,
Appendectomy,44950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8964.43,,,,,,,fee schedule,6408.87,28434,
Appendectomy,44950,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,28434,,,,,,,fee schedule,6408.87,28434,APC 378
Appendectomy,44950,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6729.32,,,,,,,fee schedule,6408.87,28434,APC
Appendectomy,44950,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6665.23,,,,,,,fee schedule,6408.87,28434,APC
Appendectomy,44950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6408.87,,,,,,,fee schedule,6408.87,28434,APC
Appendectomy,44950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9805.57,,,,,,,fee schedule,6408.87,28434,Radiology
Appendectomy,44950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8972.42,,,,,,,fee schedule,6408.87,28434,APC
Appendectomy,44950,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11215.53,,,,,,,fee schedule,6408.87,28434,APC
Laparoscopy appendectomy,44970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9408.04,,,,,,,fee schedule,5984.88,26552.87,
Laparoscopy appendectomy,44970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7541.37,,,,,,,fee schedule,5984.88,26552.87,
Laparoscopy appendectomy,44970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8238.26,,,,,,,fee schedule,5984.88,26552.87,
Laparoscopy appendectomy,44970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8661.37,,,,,,,fee schedule,5984.88,26552.87,
Laparoscopy appendectomy,44970,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,5984.88,26552.87,APC 378
Laparoscopy appendectomy,44970,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscopy appendectomy,44970,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscopy appendectomy,44970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscopy appendectomy,44970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,5984.88,26552.87,Radiology
Laparoscopy appendectomy,44970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscopy appendectomy,44970,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscope proc app,44979,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5102.67,,,,,,,fee schedule,4090.24,26552.87,
Laparoscope proc app,44979,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4090.24,,,,,,,fee schedule,4090.24,26552.87,
Laparoscope proc app,44979,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4468.21,,,,,,,fee schedule,4090.24,26552.87,
Laparoscope proc app,44979,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4697.7,,,,,,,fee schedule,4090.24,26552.87,
Laparoscope proc app,44979,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,4090.24,26552.87,APC 378
Laparoscope proc app,44979,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,4090.24,26552.87,APC
Laparoscope proc app,44979,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,4090.24,26552.87,APC
Laparoscope proc app,44979,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,4090.24,26552.87,APC
Laparoscope proc app,44979,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,4090.24,26552.87,Radiology
Laparoscope proc app,44979,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,4090.24,26552.87,APC
Laparoscope proc app,44979,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,4090.24,26552.87,APC
Drainage of pelvic abscess,45000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2723.68,,,,,,,fee schedule,1184.64,5255.83,
Drainage of pelvic abscess,45000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2183.27,,,,,,,fee schedule,1184.64,5255.83,
Drainage of pelvic abscess,45000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2385.02,,,,,,,fee schedule,1184.64,5255.83,
Drainage of pelvic abscess,45000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2507.51,,,,,,,fee schedule,1184.64,5255.83,
Drainage of pelvic abscess,45000,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5255.83,,,,,,,fee schedule,1184.64,5255.83,APC 378
Drainage of pelvic abscess,45000,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1243.87,,,,,,,fee schedule,1184.64,5255.83,APC
Drainage of pelvic abscess,45000,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1232.02,,,,,,,fee schedule,1184.64,5255.83,APC
Drainage of pelvic abscess,45000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1184.64,,,,,,,fee schedule,1184.64,5255.83,APC
Drainage of pelvic abscess,45000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1812.49,,,,,,,fee schedule,1184.64,5255.83,Radiology
Drainage of pelvic abscess,45000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1658.49,,,,,,,fee schedule,1184.64,5255.83,APC
Drainage of pelvic abscess,45000,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2073.11,,,,,,,fee schedule,1184.64,5255.83,APC
Drainage of rectal abscess,45005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2723.68,,,,,,,fee schedule,1184.64,5255.83,
Drainage of rectal abscess,45005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2183.27,,,,,,,fee schedule,1184.64,5255.83,
Drainage of rectal abscess,45005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2385.02,,,,,,,fee schedule,1184.64,5255.83,
Drainage of rectal abscess,45005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2507.51,,,,,,,fee schedule,1184.64,5255.83,
Drainage of rectal abscess,45005,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5255.83,,,,,,,fee schedule,1184.64,5255.83,APC 378
Drainage of rectal abscess,45005,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1243.87,,,,,,,fee schedule,1184.64,5255.83,APC
Drainage of rectal abscess,45005,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1232.02,,,,,,,fee schedule,1184.64,5255.83,APC
Drainage of rectal abscess,45005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1184.64,,,,,,,fee schedule,1184.64,5255.83,APC
Drainage of rectal abscess,45005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1812.49,,,,,,,fee schedule,1184.64,5255.83,Radiology
Drainage of rectal abscess,45005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1658.49,,,,,,,fee schedule,1184.64,5255.83,APC
Drainage of rectal abscess,45005,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2073.11,,,,,,,fee schedule,1184.64,5255.83,APC
Drainage of rectal abscess,45020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2723.68,,,,,,,fee schedule,2183.27,12191.12,
Drainage of rectal abscess,45020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2183.27,,,,,,,fee schedule,2183.27,12191.12,
Drainage of rectal abscess,45020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2385.02,,,,,,,fee schedule,2183.27,12191.12,
Drainage of rectal abscess,45020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2507.51,,,,,,,fee schedule,2183.27,12191.12,
Drainage of rectal abscess,45020,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12191.12,,,,,,,fee schedule,2183.27,12191.12,APC 378
Drainage of rectal abscess,45020,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2885.2,,,,,,,fee schedule,2183.27,12191.12,APC
Drainage of rectal abscess,45020,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2857.73,,,,,,,fee schedule,2183.27,12191.12,APC
Drainage of rectal abscess,45020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2747.81,,,,,,,fee schedule,2183.27,12191.12,APC
Drainage of rectal abscess,45020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4204.16,,,,,,,fee schedule,2183.27,12191.12,Radiology
Drainage of rectal abscess,45020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3846.94,,,,,,,fee schedule,2183.27,12191.12,APC
Drainage of rectal abscess,45020,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4808.67,,,,,,,fee schedule,2183.27,12191.12,APC
Biopsy of rectum,45100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,448.61,,,,,,,fee schedule,359.6,12191.12,
Biopsy of rectum,45100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,359.6,,,,,,,fee schedule,359.6,12191.12,
Biopsy of rectum,45100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,392.83,,,,,,,fee schedule,359.6,12191.12,
Biopsy of rectum,45100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,413.01,,,,,,,fee schedule,359.6,12191.12,
Biopsy of rectum,45100,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12191.12,,,,,,,fee schedule,359.6,12191.12,APC 378
Biopsy of rectum,45100,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2885.2,,,,,,,fee schedule,359.6,12191.12,APC
Biopsy of rectum,45100,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2857.73,,,,,,,fee schedule,359.6,12191.12,APC
Biopsy of rectum,45100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2747.81,,,,,,,fee schedule,359.6,12191.12,APC
Biopsy of rectum,45100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4204.16,,,,,,,fee schedule,359.6,12191.12,Radiology
Biopsy of rectum,45100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3846.94,,,,,,,fee schedule,359.6,12191.12,APC
Biopsy of rectum,45100,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4808.67,,,,,,,fee schedule,359.6,12191.12,APC
Removal of anorectal lesion,45108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5676.62,,,,,,,fee schedule,2747.81,12191.12,
Removal of anorectal lesion,45108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4550.3,,,,,,,fee schedule,2747.81,12191.12,
Removal of anorectal lesion,45108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4970.79,,,,,,,fee schedule,2747.81,12191.12,
Removal of anorectal lesion,45108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5226.09,,,,,,,fee schedule,2747.81,12191.12,
Removal of anorectal lesion,45108,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12191.12,,,,,,,fee schedule,2747.81,12191.12,APC 378
Removal of anorectal lesion,45108,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2885.2,,,,,,,fee schedule,2747.81,12191.12,APC
Removal of anorectal lesion,45108,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2857.73,,,,,,,fee schedule,2747.81,12191.12,APC
Removal of anorectal lesion,45108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2747.81,,,,,,,fee schedule,2747.81,12191.12,APC
Removal of anorectal lesion,45108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4204.16,,,,,,,fee schedule,2747.81,12191.12,Radiology
Removal of anorectal lesion,45108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3846.94,,,,,,,fee schedule,2747.81,12191.12,APC
Removal of anorectal lesion,45108,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4808.67,,,,,,,fee schedule,2747.81,12191.12,APC
Excision of rectal stricture,45150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5676.62,,,,,,,fee schedule,1184.64,5676.62,
Excision of rectal stricture,45150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4550.3,,,,,,,fee schedule,1184.64,5676.62,
Excision of rectal stricture,45150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4970.79,,,,,,,fee schedule,1184.64,5676.62,
Excision of rectal stricture,45150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5226.09,,,,,,,fee schedule,1184.64,5676.62,
Excision of rectal stricture,45150,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5255.83,,,,,,,fee schedule,1184.64,5676.62,APC 378
Excision of rectal stricture,45150,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1243.87,,,,,,,fee schedule,1184.64,5676.62,APC
Excision of rectal stricture,45150,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1232.02,,,,,,,fee schedule,1184.64,5676.62,APC
Excision of rectal stricture,45150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1184.64,,,,,,,fee schedule,1184.64,5676.62,APC
Excision of rectal stricture,45150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1812.49,,,,,,,fee schedule,1184.64,5676.62,Radiology
Excision of rectal stricture,45150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1658.49,,,,,,,fee schedule,1184.64,5676.62,APC
Excision of rectal stricture,45150,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2073.11,,,,,,,fee schedule,1184.64,5676.62,APC
Excision of rectal lesion,45160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5676.62,,,,,,,fee schedule,2747.81,12191.12,
Excision of rectal lesion,45160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4550.3,,,,,,,fee schedule,2747.81,12191.12,
Excision of rectal lesion,45160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4970.79,,,,,,,fee schedule,2747.81,12191.12,
Excision of rectal lesion,45160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5226.09,,,,,,,fee schedule,2747.81,12191.12,
Excision of rectal lesion,45160,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12191.12,,,,,,,fee schedule,2747.81,12191.12,APC 378
Excision of rectal lesion,45160,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2885.2,,,,,,,fee schedule,2747.81,12191.12,APC
Excision of rectal lesion,45160,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2857.73,,,,,,,fee schedule,2747.81,12191.12,APC
Excision of rectal lesion,45160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2747.81,,,,,,,fee schedule,2747.81,12191.12,APC
Excision of rectal lesion,45160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4204.16,,,,,,,fee schedule,2747.81,12191.12,Radiology
Excision of rectal lesion,45160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3846.94,,,,,,,fee schedule,2747.81,12191.12,APC
Excision of rectal lesion,45160,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4808.67,,,,,,,fee schedule,2747.81,12191.12,APC
Exc rect tum transanal part,45171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7189.69,,,,,,,fee schedule,2747.81,12191.12,
Exc rect tum transanal part,45171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5763.16,,,,,,,fee schedule,2747.81,12191.12,
Exc rect tum transanal part,45171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6295.73,,,,,,,fee schedule,2747.81,12191.12,
Exc rect tum transanal part,45171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6619.08,,,,,,,fee schedule,2747.81,12191.12,
Exc rect tum transanal part,45171,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12191.12,,,,,,,fee schedule,2747.81,12191.12,APC 378
Exc rect tum transanal part,45171,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2885.2,,,,,,,fee schedule,2747.81,12191.12,APC
Exc rect tum transanal part,45171,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2857.73,,,,,,,fee schedule,2747.81,12191.12,APC
Exc rect tum transanal part,45171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2747.81,,,,,,,fee schedule,2747.81,12191.12,APC
Exc rect tum transanal part,45171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4204.16,,,,,,,fee schedule,2747.81,12191.12,Radiology
Exc rect tum transanal part,45171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3846.94,,,,,,,fee schedule,2747.81,12191.12,APC
Exc rect tum transanal part,45171,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4808.67,,,,,,,fee schedule,2747.81,12191.12,APC
Exc rect tum transanal full,45172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8499.71,,,,,,,fee schedule,2747.81,12191.12,
Exc rect tum transanal full,45172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6813.26,,,,,,,fee schedule,2747.81,12191.12,
Exc rect tum transanal full,45172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7442.87,,,,,,,fee schedule,2747.81,12191.12,
Exc rect tum transanal full,45172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7825.13,,,,,,,fee schedule,2747.81,12191.12,
Exc rect tum transanal full,45172,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12191.12,,,,,,,fee schedule,2747.81,12191.12,APC 378
Exc rect tum transanal full,45172,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2885.2,,,,,,,fee schedule,2747.81,12191.12,APC
Exc rect tum transanal full,45172,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2857.73,,,,,,,fee schedule,2747.81,12191.12,APC
Exc rect tum transanal full,45172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2747.81,,,,,,,fee schedule,2747.81,12191.12,APC
Exc rect tum transanal full,45172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4204.16,,,,,,,fee schedule,2747.81,12191.12,Radiology
Exc rect tum transanal full,45172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3846.94,,,,,,,fee schedule,2747.81,12191.12,APC
Exc rect tum transanal full,45172,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4808.67,,,,,,,fee schedule,2747.81,12191.12,APC
Destruction rectal tumor,45190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5676.62,,,,,,,fee schedule,2747.81,12191.12,
Destruction rectal tumor,45190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4550.3,,,,,,,fee schedule,2747.81,12191.12,
Destruction rectal tumor,45190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4970.79,,,,,,,fee schedule,2747.81,12191.12,
Destruction rectal tumor,45190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5226.09,,,,,,,fee schedule,2747.81,12191.12,
Destruction rectal tumor,45190,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12191.12,,,,,,,fee schedule,2747.81,12191.12,APC 378
Destruction rectal tumor,45190,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2885.2,,,,,,,fee schedule,2747.81,12191.12,APC
Destruction rectal tumor,45190,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2857.73,,,,,,,fee schedule,2747.81,12191.12,APC
Destruction rectal tumor,45190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2747.81,,,,,,,fee schedule,2747.81,12191.12,APC
Destruction rectal tumor,45190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4204.16,,,,,,,fee schedule,2747.81,12191.12,Radiology
Destruction rectal tumor,45190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3846.94,,,,,,,fee schedule,2747.81,12191.12,APC
Destruction rectal tumor,45190,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4808.67,,,,,,,fee schedule,2747.81,12191.12,APC
Proctosigmoidoscopy dx,45300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4116.6,,,,,,,fee schedule,920.63,4116.6,
Proctosigmoidoscopy dx,45300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3299.81,,,,,,,fee schedule,920.63,4116.6,
Proctosigmoidoscopy dx,45300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3604.74,,,,,,,fee schedule,920.63,4116.6,
Proctosigmoidoscopy dx,45300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3789.88,,,,,,,fee schedule,920.63,4116.6,
Proctosigmoidoscopy dx,45300,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4084.51,,,,,,,fee schedule,920.63,4116.6,APC 378
Proctosigmoidoscopy dx,45300,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,966.66,,,,,,,fee schedule,920.63,4116.6,APC
Proctosigmoidoscopy dx,45300,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,957.45,,,,,,,fee schedule,920.63,4116.6,APC
Proctosigmoidoscopy dx,45300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,920.63,,,,,,,fee schedule,920.63,4116.6,APC
Proctosigmoidoscopy dx,45300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1408.56,,,,,,,fee schedule,920.63,4116.6,Radiology
Proctosigmoidoscopy dx,45300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1288.88,,,,,,,fee schedule,920.63,4116.6,APC
Proctosigmoidoscopy dx,45300,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1611.1,,,,,,,fee schedule,920.63,4116.6,APC
Proctosigmoidoscopy dilate,45303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2172.1,,,,,,,fee schedule,1184.64,5255.83,
Proctosigmoidoscopy dilate,45303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1741.13,,,,,,,fee schedule,1184.64,5255.83,
Proctosigmoidoscopy dilate,45303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1902.03,,,,,,,fee schedule,1184.64,5255.83,
Proctosigmoidoscopy dilate,45303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1999.71,,,,,,,fee schedule,1184.64,5255.83,
Proctosigmoidoscopy dilate,45303,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5255.83,,,,,,,fee schedule,1184.64,5255.83,APC 378
Proctosigmoidoscopy dilate,45303,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1243.87,,,,,,,fee schedule,1184.64,5255.83,APC
Proctosigmoidoscopy dilate,45303,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1232.02,,,,,,,fee schedule,1184.64,5255.83,APC
Proctosigmoidoscopy dilate,45303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1184.64,,,,,,,fee schedule,1184.64,5255.83,APC
Proctosigmoidoscopy dilate,45303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1812.49,,,,,,,fee schedule,1184.64,5255.83,Radiology
Proctosigmoidoscopy dilate,45303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1658.49,,,,,,,fee schedule,1184.64,5255.83,APC
Proctosigmoidoscopy dilate,45303,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2073.11,,,,,,,fee schedule,1184.64,5255.83,APC
Proctosigmoidoscopy w/bx,45305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1955.82,,,,,,,fee schedule,1184.64,5255.83,
Proctosigmoidoscopy w/bx,45305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1567.76,,,,,,,fee schedule,1184.64,5255.83,
Proctosigmoidoscopy w/bx,45305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1712.63,,,,,,,fee schedule,1184.64,5255.83,
Proctosigmoidoscopy w/bx,45305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1800.59,,,,,,,fee schedule,1184.64,5255.83,
Proctosigmoidoscopy w/bx,45305,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5255.83,,,,,,,fee schedule,1184.64,5255.83,APC 378
Proctosigmoidoscopy w/bx,45305,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1243.87,,,,,,,fee schedule,1184.64,5255.83,APC
Proctosigmoidoscopy w/bx,45305,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1232.02,,,,,,,fee schedule,1184.64,5255.83,APC
Proctosigmoidoscopy w/bx,45305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1184.64,,,,,,,fee schedule,1184.64,5255.83,APC
Proctosigmoidoscopy w/bx,45305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1812.49,,,,,,,fee schedule,1184.64,5255.83,Radiology
Proctosigmoidoscopy w/bx,45305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1658.49,,,,,,,fee schedule,1184.64,5255.83,APC
Proctosigmoidoscopy w/bx,45305,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2073.11,,,,,,,fee schedule,1184.64,5255.83,APC
Proctosigmoidoscopy fb,45307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5356.71,,,,,,,fee schedule,2747.81,12191.12,
Proctosigmoidoscopy fb,45307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4293.87,,,,,,,fee schedule,2747.81,12191.12,
Proctosigmoidoscopy fb,45307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4690.67,,,,,,,fee schedule,2747.81,12191.12,
Proctosigmoidoscopy fb,45307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4931.58,,,,,,,fee schedule,2747.81,12191.12,
Proctosigmoidoscopy fb,45307,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12191.12,,,,,,,fee schedule,2747.81,12191.12,APC 378
Proctosigmoidoscopy fb,45307,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2885.2,,,,,,,fee schedule,2747.81,12191.12,APC
Proctosigmoidoscopy fb,45307,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2857.73,,,,,,,fee schedule,2747.81,12191.12,APC
Proctosigmoidoscopy fb,45307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2747.81,,,,,,,fee schedule,2747.81,12191.12,APC
Proctosigmoidoscopy fb,45307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4204.16,,,,,,,fee schedule,2747.81,12191.12,Radiology
Proctosigmoidoscopy fb,45307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3846.94,,,,,,,fee schedule,2747.81,12191.12,APC
Proctosigmoidoscopy fb,45307,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4808.67,,,,,,,fee schedule,2747.81,12191.12,APC
Proctosigmoidoscopy removal,45308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2172.1,,,,,,,fee schedule,1741.13,12191.12,
Proctosigmoidoscopy removal,45308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1741.13,,,,,,,fee schedule,1741.13,12191.12,
Proctosigmoidoscopy removal,45308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1902.03,,,,,,,fee schedule,1741.13,12191.12,
Proctosigmoidoscopy removal,45308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1999.71,,,,,,,fee schedule,1741.13,12191.12,
Proctosigmoidoscopy removal,45308,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12191.12,,,,,,,fee schedule,1741.13,12191.12,APC 378
Proctosigmoidoscopy removal,45308,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2885.2,,,,,,,fee schedule,1741.13,12191.12,APC
Proctosigmoidoscopy removal,45308,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2857.73,,,,,,,fee schedule,1741.13,12191.12,APC
Proctosigmoidoscopy removal,45308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2747.81,,,,,,,fee schedule,1741.13,12191.12,APC
Proctosigmoidoscopy removal,45308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4204.16,,,,,,,fee schedule,1741.13,12191.12,Radiology
Proctosigmoidoscopy removal,45308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3846.94,,,,,,,fee schedule,1741.13,12191.12,APC
Proctosigmoidoscopy removal,45308,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4808.67,,,,,,,fee schedule,1741.13,12191.12,APC
Proctosigmoidoscopy removal,45309,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2172.1,,,,,,,fee schedule,1184.64,5255.83,
Proctosigmoidoscopy removal,45309,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1741.13,,,,,,,fee schedule,1184.64,5255.83,
Proctosigmoidoscopy removal,45309,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1902.03,,,,,,,fee schedule,1184.64,5255.83,
Proctosigmoidoscopy removal,45309,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1999.71,,,,,,,fee schedule,1184.64,5255.83,
Proctosigmoidoscopy removal,45309,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5255.83,,,,,,,fee schedule,1184.64,5255.83,APC 378
Proctosigmoidoscopy removal,45309,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1243.87,,,,,,,fee schedule,1184.64,5255.83,APC
Proctosigmoidoscopy removal,45309,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1232.02,,,,,,,fee schedule,1184.64,5255.83,APC
Proctosigmoidoscopy removal,45309,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1184.64,,,,,,,fee schedule,1184.64,5255.83,APC
Proctosigmoidoscopy removal,45309,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1812.49,,,,,,,fee schedule,1184.64,5255.83,Radiology
Proctosigmoidoscopy removal,45309,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1658.49,,,,,,,fee schedule,1184.64,5255.83,APC
Proctosigmoidoscopy removal,45309,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2073.11,,,,,,,fee schedule,1184.64,5255.83,APC
Proctosigmoidoscopy removal,45315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2172.1,,,,,,,fee schedule,1184.64,5255.83,
Proctosigmoidoscopy removal,45315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1741.13,,,,,,,fee schedule,1184.64,5255.83,
Proctosigmoidoscopy removal,45315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1902.03,,,,,,,fee schedule,1184.64,5255.83,
Proctosigmoidoscopy removal,45315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1999.71,,,,,,,fee schedule,1184.64,5255.83,
Proctosigmoidoscopy removal,45315,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5255.83,,,,,,,fee schedule,1184.64,5255.83,APC 378
Proctosigmoidoscopy removal,45315,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1243.87,,,,,,,fee schedule,1184.64,5255.83,APC
Proctosigmoidoscopy removal,45315,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1232.02,,,,,,,fee schedule,1184.64,5255.83,APC
Proctosigmoidoscopy removal,45315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1184.64,,,,,,,fee schedule,1184.64,5255.83,APC
Proctosigmoidoscopy removal,45315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1812.49,,,,,,,fee schedule,1184.64,5255.83,Radiology
Proctosigmoidoscopy removal,45315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1658.49,,,,,,,fee schedule,1184.64,5255.83,APC
Proctosigmoidoscopy removal,45315,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2073.11,,,,,,,fee schedule,1184.64,5255.83,APC
Proctosigmoidoscopy bleed,45317,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2172.1,,,,,,,fee schedule,1184.64,5255.83,
Proctosigmoidoscopy bleed,45317,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1741.13,,,,,,,fee schedule,1184.64,5255.83,
Proctosigmoidoscopy bleed,45317,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1902.03,,,,,,,fee schedule,1184.64,5255.83,
Proctosigmoidoscopy bleed,45317,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1999.71,,,,,,,fee schedule,1184.64,5255.83,
Proctosigmoidoscopy bleed,45317,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5255.83,,,,,,,fee schedule,1184.64,5255.83,APC 378
Proctosigmoidoscopy bleed,45317,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1243.87,,,,,,,fee schedule,1184.64,5255.83,APC
Proctosigmoidoscopy bleed,45317,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1232.02,,,,,,,fee schedule,1184.64,5255.83,APC
Proctosigmoidoscopy bleed,45317,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1184.64,,,,,,,fee schedule,1184.64,5255.83,APC
Proctosigmoidoscopy bleed,45317,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1812.49,,,,,,,fee schedule,1184.64,5255.83,Radiology
Proctosigmoidoscopy bleed,45317,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1658.49,,,,,,,fee schedule,1184.64,5255.83,APC
Proctosigmoidoscopy bleed,45317,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2073.11,,,,,,,fee schedule,1184.64,5255.83,APC
Proctosigmoidoscopy ablate,45320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5356.71,,,,,,,fee schedule,2747.81,12191.12,
Proctosigmoidoscopy ablate,45320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4293.87,,,,,,,fee schedule,2747.81,12191.12,
Proctosigmoidoscopy ablate,45320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4690.67,,,,,,,fee schedule,2747.81,12191.12,
Proctosigmoidoscopy ablate,45320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4931.58,,,,,,,fee schedule,2747.81,12191.12,
Proctosigmoidoscopy ablate,45320,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12191.12,,,,,,,fee schedule,2747.81,12191.12,APC 378
Proctosigmoidoscopy ablate,45320,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2885.2,,,,,,,fee schedule,2747.81,12191.12,APC
Proctosigmoidoscopy ablate,45320,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2857.73,,,,,,,fee schedule,2747.81,12191.12,APC
Proctosigmoidoscopy ablate,45320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2747.81,,,,,,,fee schedule,2747.81,12191.12,APC
Proctosigmoidoscopy ablate,45320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4204.16,,,,,,,fee schedule,2747.81,12191.12,Radiology
Proctosigmoidoscopy ablate,45320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3846.94,,,,,,,fee schedule,2747.81,12191.12,APC
Proctosigmoidoscopy ablate,45320,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4808.67,,,,,,,fee schedule,2747.81,12191.12,APC
Proctosigmoidoscopy volvul,45321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5356.71,,,,,,,fee schedule,2747.81,12191.12,
Proctosigmoidoscopy volvul,45321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4293.87,,,,,,,fee schedule,2747.81,12191.12,
Proctosigmoidoscopy volvul,45321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4690.67,,,,,,,fee schedule,2747.81,12191.12,
Proctosigmoidoscopy volvul,45321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4931.58,,,,,,,fee schedule,2747.81,12191.12,
Proctosigmoidoscopy volvul,45321,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12191.12,,,,,,,fee schedule,2747.81,12191.12,APC 378
Proctosigmoidoscopy volvul,45321,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2885.2,,,,,,,fee schedule,2747.81,12191.12,APC
Proctosigmoidoscopy volvul,45321,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2857.73,,,,,,,fee schedule,2747.81,12191.12,APC
Proctosigmoidoscopy volvul,45321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2747.81,,,,,,,fee schedule,2747.81,12191.12,APC
Proctosigmoidoscopy volvul,45321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4204.16,,,,,,,fee schedule,2747.81,12191.12,Radiology
Proctosigmoidoscopy volvul,45321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3846.94,,,,,,,fee schedule,2747.81,12191.12,APC
Proctosigmoidoscopy volvul,45321,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4808.67,,,,,,,fee schedule,2747.81,12191.12,APC
Proctosigmoidoscopy W/Stent,45327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6234.77,,,,,,,fee schedule,4997.71,26664.3,
Proctosigmoidoscopy W/Stent,45327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4997.71,,,,,,,fee schedule,4997.71,26664.3,
Proctosigmoidoscopy W/Stent,45327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5459.55,,,,,,,fee schedule,4997.71,26664.3,
Proctosigmoidoscopy W/Stent,45327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5739.95,,,,,,,fee schedule,4997.71,26664.3,
Proctosigmoidoscopy W/Stent,45327,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26664.3,,,,,,,fee schedule,4997.71,26664.3,APC 378
Proctosigmoidoscopy W/Stent,45327,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6310.49,,,,,,,fee schedule,4997.71,26664.3,APC
Proctosigmoidoscopy W/Stent,45327,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6250.39,,,,,,,fee schedule,4997.71,26664.3,APC
Proctosigmoidoscopy W/Stent,45327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6009.99,,,,,,,fee schedule,4997.71,26664.3,APC
Proctosigmoidoscopy W/Stent,45327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9195.29,,,,,,,fee schedule,4997.71,26664.3,Radiology
Proctosigmoidoscopy W/Stent,45327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8413.99,,,,,,,fee schedule,4997.71,26664.3,APC
Proctosigmoidoscopy W/Stent,45327,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10517.49,,,,,,,fee schedule,4997.71,26664.3,APC
Diagnostic sigmoidoscopy,45330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2703.47,,,,,,,fee schedule,920.63,4084.51,
Diagnostic sigmoidoscopy,45330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2167.06,,,,,,,fee schedule,920.63,4084.51,
Diagnostic sigmoidoscopy,45330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2367.32,,,,,,,fee schedule,920.63,4084.51,
Diagnostic sigmoidoscopy,45330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2488.91,,,,,,,fee schedule,920.63,4084.51,
Diagnostic sigmoidoscopy,45330,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4084.51,,,,,,,fee schedule,920.63,4084.51,APC 378
Diagnostic sigmoidoscopy,45330,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,966.66,,,,,,,fee schedule,920.63,4084.51,APC
Diagnostic sigmoidoscopy,45330,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,957.45,,,,,,,fee schedule,920.63,4084.51,APC
Diagnostic sigmoidoscopy,45330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,920.63,,,,,,,fee schedule,920.63,4084.51,APC
Diagnostic sigmoidoscopy,45330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1408.56,,,,,,,fee schedule,920.63,4084.51,Radiology
Diagnostic sigmoidoscopy,45330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1288.88,,,,,,,fee schedule,920.63,4084.51,APC
Diagnostic sigmoidoscopy,45330,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1611.1,,,,,,,fee schedule,920.63,4084.51,APC
Sigmoidoscopy and biopsy,45331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2648.1,,,,,,,fee schedule,920.63,4084.51,
Sigmoidoscopy and biopsy,45331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2122.68,,,,,,,fee schedule,920.63,4084.51,
Sigmoidoscopy and biopsy,45331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2318.84,,,,,,,fee schedule,920.63,4084.51,
Sigmoidoscopy and biopsy,45331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2437.93,,,,,,,fee schedule,920.63,4084.51,
Sigmoidoscopy and biopsy,45331,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4084.51,,,,,,,fee schedule,920.63,4084.51,APC 378
Sigmoidoscopy and biopsy,45331,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,966.66,,,,,,,fee schedule,920.63,4084.51,APC
Sigmoidoscopy and biopsy,45331,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,957.45,,,,,,,fee schedule,920.63,4084.51,APC
Sigmoidoscopy and biopsy,45331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,920.63,,,,,,,fee schedule,920.63,4084.51,APC
Sigmoidoscopy and biopsy,45331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1408.56,,,,,,,fee schedule,920.63,4084.51,Radiology
Sigmoidoscopy and biopsy,45331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1288.88,,,,,,,fee schedule,920.63,4084.51,APC
Sigmoidoscopy and biopsy,45331,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1611.1,,,,,,,fee schedule,920.63,4084.51,APC
Sigmoidoscopy w/fb removal,45332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1272.12,,,,,,,fee schedule,1019.72,5255.83,
Sigmoidoscopy w/fb removal,45332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1019.72,,,,,,,fee schedule,1019.72,5255.83,
Sigmoidoscopy w/fb removal,45332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1113.95,,,,,,,fee schedule,1019.72,5255.83,
Sigmoidoscopy w/fb removal,45332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1171.16,,,,,,,fee schedule,1019.72,5255.83,
Sigmoidoscopy w/fb removal,45332,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5255.83,,,,,,,fee schedule,1019.72,5255.83,APC 378
Sigmoidoscopy w/fb removal,45332,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1243.87,,,,,,,fee schedule,1019.72,5255.83,APC
Sigmoidoscopy w/fb removal,45332,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1232.02,,,,,,,fee schedule,1019.72,5255.83,APC
Sigmoidoscopy w/fb removal,45332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1184.64,,,,,,,fee schedule,1019.72,5255.83,APC
Sigmoidoscopy w/fb removal,45332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1812.49,,,,,,,fee schedule,1019.72,5255.83,Radiology
Sigmoidoscopy w/fb removal,45332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1658.49,,,,,,,fee schedule,1019.72,5255.83,APC
Sigmoidoscopy w/fb removal,45332,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2073.11,,,,,,,fee schedule,1019.72,5255.83,APC
Sigmoidoscopy & polypectomy,45333,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1314.95,,,,,,,fee schedule,920.63,4084.51,
Sigmoidoscopy & polypectomy,45333,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1054.05,,,,,,,fee schedule,920.63,4084.51,
Sigmoidoscopy & polypectomy,45333,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1151.45,,,,,,,fee schedule,920.63,4084.51,
Sigmoidoscopy & polypectomy,45333,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1210.59,,,,,,,fee schedule,920.63,4084.51,
Sigmoidoscopy & polypectomy,45333,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4084.51,,,,,,,fee schedule,920.63,4084.51,APC 378
Sigmoidoscopy & polypectomy,45333,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,966.66,,,,,,,fee schedule,920.63,4084.51,APC
Sigmoidoscopy & polypectomy,45333,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,957.45,,,,,,,fee schedule,920.63,4084.51,APC
Sigmoidoscopy & polypectomy,45333,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,920.63,,,,,,,fee schedule,920.63,4084.51,APC
Sigmoidoscopy & polypectomy,45333,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1408.56,,,,,,,fee schedule,920.63,4084.51,Radiology
Sigmoidoscopy & polypectomy,45333,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1288.88,,,,,,,fee schedule,920.63,4084.51,APC
Sigmoidoscopy & polypectomy,45333,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1611.1,,,,,,,fee schedule,920.63,4084.51,APC
Sigmoidoscopy for bleeding,45334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2629.9,,,,,,,fee schedule,1184.64,5255.83,
Sigmoidoscopy for bleeding,45334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2108.09,,,,,,,fee schedule,1184.64,5255.83,
Sigmoidoscopy for bleeding,45334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2302.9,,,,,,,fee schedule,1184.64,5255.83,
Sigmoidoscopy for bleeding,45334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2421.18,,,,,,,fee schedule,1184.64,5255.83,
Sigmoidoscopy for bleeding,45334,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5255.83,,,,,,,fee schedule,1184.64,5255.83,APC 378
Sigmoidoscopy for bleeding,45334,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1243.87,,,,,,,fee schedule,1184.64,5255.83,APC
Sigmoidoscopy for bleeding,45334,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1232.02,,,,,,,fee schedule,1184.64,5255.83,APC
Sigmoidoscopy for bleeding,45334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1184.64,,,,,,,fee schedule,1184.64,5255.83,APC
Sigmoidoscopy for bleeding,45334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1812.49,,,,,,,fee schedule,1184.64,5255.83,Radiology
Sigmoidoscopy for bleeding,45334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1658.49,,,,,,,fee schedule,1184.64,5255.83,APC
Sigmoidoscopy for bleeding,45334,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2073.11,,,,,,,fee schedule,1184.64,5255.83,APC
Sigmoidoscopy w/submuc inj,45335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1930.43,,,,,,,fee schedule,920.63,4084.51,
Sigmoidoscopy w/submuc inj,45335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1547.41,,,,,,,fee schedule,920.63,4084.51,
Sigmoidoscopy w/submuc inj,45335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1690.41,,,,,,,fee schedule,920.63,4084.51,
Sigmoidoscopy w/submuc inj,45335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1777.22,,,,,,,fee schedule,920.63,4084.51,
Sigmoidoscopy w/submuc inj,45335,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4084.51,,,,,,,fee schedule,920.63,4084.51,APC 378
Sigmoidoscopy w/submuc inj,45335,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,966.66,,,,,,,fee schedule,920.63,4084.51,APC
Sigmoidoscopy w/submuc inj,45335,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,957.45,,,,,,,fee schedule,920.63,4084.51,APC
Sigmoidoscopy w/submuc inj,45335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,920.63,,,,,,,fee schedule,920.63,4084.51,APC
Sigmoidoscopy w/submuc inj,45335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1408.56,,,,,,,fee schedule,920.63,4084.51,Radiology
Sigmoidoscopy w/submuc inj,45335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1288.88,,,,,,,fee schedule,920.63,4084.51,APC
Sigmoidoscopy w/submuc inj,45335,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1611.1,,,,,,,fee schedule,920.63,4084.51,APC
Sigmoidoscopy & decompress,45337,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1272.12,,,,,,,fee schedule,920.63,4084.51,
Sigmoidoscopy & decompress,45337,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1019.72,,,,,,,fee schedule,920.63,4084.51,
Sigmoidoscopy & decompress,45337,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1113.95,,,,,,,fee schedule,920.63,4084.51,
Sigmoidoscopy & decompress,45337,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1171.16,,,,,,,fee schedule,920.63,4084.51,
Sigmoidoscopy & decompress,45337,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4084.51,,,,,,,fee schedule,920.63,4084.51,APC 378
Sigmoidoscopy & decompress,45337,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,966.66,,,,,,,fee schedule,920.63,4084.51,APC
Sigmoidoscopy & decompress,45337,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,957.45,,,,,,,fee schedule,920.63,4084.51,APC
Sigmoidoscopy & decompress,45337,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,920.63,,,,,,,fee schedule,920.63,4084.51,APC
Sigmoidoscopy & decompress,45337,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1408.56,,,,,,,fee schedule,920.63,4084.51,Radiology
Sigmoidoscopy & decompress,45337,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1288.88,,,,,,,fee schedule,920.63,4084.51,APC
Sigmoidoscopy & decompress,45337,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1611.1,,,,,,,fee schedule,920.63,4084.51,APC
Sigmoidoscopy w/tumr remove,45338,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2009.61,,,,,,,fee schedule,1184.64,5255.83,
Sigmoidoscopy w/tumr remove,45338,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1610.88,,,,,,,fee schedule,1184.64,5255.83,
Sigmoidoscopy w/tumr remove,45338,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1759.74,,,,,,,fee schedule,1184.64,5255.83,
Sigmoidoscopy w/tumr remove,45338,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1850.12,,,,,,,fee schedule,1184.64,5255.83,
Sigmoidoscopy w/tumr remove,45338,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5255.83,,,,,,,fee schedule,1184.64,5255.83,APC 378
Sigmoidoscopy w/tumr remove,45338,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1243.87,,,,,,,fee schedule,1184.64,5255.83,APC
Sigmoidoscopy w/tumr remove,45338,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1232.02,,,,,,,fee schedule,1184.64,5255.83,APC
Sigmoidoscopy w/tumr remove,45338,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1184.64,,,,,,,fee schedule,1184.64,5255.83,APC
Sigmoidoscopy w/tumr remove,45338,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1812.49,,,,,,,fee schedule,1184.64,5255.83,Radiology
Sigmoidoscopy w/tumr remove,45338,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1658.49,,,,,,,fee schedule,1184.64,5255.83,APC
Sigmoidoscopy w/tumr remove,45338,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2073.11,,,,,,,fee schedule,1184.64,5255.83,APC
Sig w/tndsc balloon dilation,45340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1502.95,,,,,,,fee schedule,1184.64,5255.83,
Sig w/tndsc balloon dilation,45340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1204.75,,,,,,,fee schedule,1184.64,5255.83,
Sig w/tndsc balloon dilation,45340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1316.08,,,,,,,fee schedule,1184.64,5255.83,
Sig w/tndsc balloon dilation,45340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1383.67,,,,,,,fee schedule,1184.64,5255.83,
Sig w/tndsc balloon dilation,45340,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5255.83,,,,,,,fee schedule,1184.64,5255.83,APC 378
Sig w/tndsc balloon dilation,45340,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1243.87,,,,,,,fee schedule,1184.64,5255.83,APC
Sig w/tndsc balloon dilation,45340,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1232.02,,,,,,,fee schedule,1184.64,5255.83,APC
Sig w/tndsc balloon dilation,45340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1184.64,,,,,,,fee schedule,1184.64,5255.83,APC
Sig w/tndsc balloon dilation,45340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1812.49,,,,,,,fee schedule,1184.64,5255.83,Radiology
Sig w/tndsc balloon dilation,45340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1658.49,,,,,,,fee schedule,1184.64,5255.83,APC
Sig w/tndsc balloon dilation,45340,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2073.11,,,,,,,fee schedule,1184.64,5255.83,APC
Sigmoidoscopy W/Ultrasound,45341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1574.47,,,,,,,fee schedule,920.63,4084.51,
Sigmoidoscopy W/Ultrasound,45341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1262.08,,,,,,,fee schedule,920.63,4084.51,
Sigmoidoscopy W/Ultrasound,45341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1378.7,,,,,,,fee schedule,920.63,4084.51,
Sigmoidoscopy W/Ultrasound,45341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1449.51,,,,,,,fee schedule,920.63,4084.51,
Sigmoidoscopy W/Ultrasound,45341,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4084.51,,,,,,,fee schedule,920.63,4084.51,APC 378
Sigmoidoscopy W/Ultrasound,45341,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,966.66,,,,,,,fee schedule,920.63,4084.51,APC
Sigmoidoscopy W/Ultrasound,45341,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,957.45,,,,,,,fee schedule,920.63,4084.51,APC
Sigmoidoscopy W/Ultrasound,45341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,920.63,,,,,,,fee schedule,920.63,4084.51,APC
Sigmoidoscopy W/Ultrasound,45341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1408.56,,,,,,,fee schedule,920.63,4084.51,Radiology
Sigmoidoscopy W/Ultrasound,45341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1288.88,,,,,,,fee schedule,920.63,4084.51,APC
Sigmoidoscopy W/Ultrasound,45341,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1611.1,,,,,,,fee schedule,920.63,4084.51,APC
Sigmoidoscopy W/Us Guide Bx,45342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2172.1,,,,,,,fee schedule,1184.64,5255.83,
Sigmoidoscopy W/Us Guide Bx,45342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1741.13,,,,,,,fee schedule,1184.64,5255.83,
Sigmoidoscopy W/Us Guide Bx,45342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1902.03,,,,,,,fee schedule,1184.64,5255.83,
Sigmoidoscopy W/Us Guide Bx,45342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1999.71,,,,,,,fee schedule,1184.64,5255.83,
Sigmoidoscopy W/Us Guide Bx,45342,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5255.83,,,,,,,fee schedule,1184.64,5255.83,APC 378
Sigmoidoscopy W/Us Guide Bx,45342,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1243.87,,,,,,,fee schedule,1184.64,5255.83,APC
Sigmoidoscopy W/Us Guide Bx,45342,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1232.02,,,,,,,fee schedule,1184.64,5255.83,APC
Sigmoidoscopy W/Us Guide Bx,45342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1184.64,,,,,,,fee schedule,1184.64,5255.83,APC
Sigmoidoscopy W/Us Guide Bx,45342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1812.49,,,,,,,fee schedule,1184.64,5255.83,Radiology
Sigmoidoscopy W/Us Guide Bx,45342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1658.49,,,,,,,fee schedule,1184.64,5255.83,APC
Sigmoidoscopy W/Us Guide Bx,45342,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2073.11,,,,,,,fee schedule,1184.64,5255.83,APC
Sigmoidoscopy w/ablation,45346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1972.42,,,,,,,fee schedule,1184.64,5255.83,
Sigmoidoscopy w/ablation,45346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1581.07,,,,,,,fee schedule,1184.64,5255.83,
Sigmoidoscopy w/ablation,45346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1727.17,,,,,,,fee schedule,1184.64,5255.83,
Sigmoidoscopy w/ablation,45346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1815.88,,,,,,,fee schedule,1184.64,5255.83,
Sigmoidoscopy w/ablation,45346,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5255.83,,,,,,,fee schedule,1184.64,5255.83,APC 378
Sigmoidoscopy w/ablation,45346,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1243.87,,,,,,,fee schedule,1184.64,5255.83,APC
Sigmoidoscopy w/ablation,45346,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1232.02,,,,,,,fee schedule,1184.64,5255.83,APC
Sigmoidoscopy w/ablation,45346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1184.64,,,,,,,fee schedule,1184.64,5255.83,APC
Sigmoidoscopy w/ablation,45346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1812.49,,,,,,,fee schedule,1184.64,5255.83,Radiology
Sigmoidoscopy w/ablation,45346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1658.49,,,,,,,fee schedule,1184.64,5255.83,APC
Sigmoidoscopy w/ablation,45346,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2073.11,,,,,,,fee schedule,1184.64,5255.83,APC
Sigmoidoscopy w/plcmt stent,45347,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3127.65,,,,,,,fee schedule,2507.08,26664.3,
Sigmoidoscopy w/plcmt stent,45347,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2507.08,,,,,,,fee schedule,2507.08,26664.3,
Sigmoidoscopy w/plcmt stent,45347,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2738.76,,,,,,,fee schedule,2507.08,26664.3,
Sigmoidoscopy w/plcmt stent,45347,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2879.42,,,,,,,fee schedule,2507.08,26664.3,
Sigmoidoscopy w/plcmt stent,45347,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26664.3,,,,,,,fee schedule,2507.08,26664.3,APC 378
Sigmoidoscopy w/plcmt stent,45347,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6310.49,,,,,,,fee schedule,2507.08,26664.3,APC
Sigmoidoscopy w/plcmt stent,45347,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6250.39,,,,,,,fee schedule,2507.08,26664.3,APC
Sigmoidoscopy w/plcmt stent,45347,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6009.99,,,,,,,fee schedule,2507.08,26664.3,APC
Sigmoidoscopy w/plcmt stent,45347,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9195.29,,,,,,,fee schedule,2507.08,26664.3,Radiology
Sigmoidoscopy w/plcmt stent,45347,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8413.99,,,,,,,fee schedule,2507.08,26664.3,APC
Sigmoidoscopy w/plcmt stent,45347,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10517.49,,,,,,,fee schedule,2507.08,26664.3,APC
Sigmoidoscopy w/resection,45349,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,634.62,,,,,,,fee schedule,508.7,12191.12,
Sigmoidoscopy w/resection,45349,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,508.7,,,,,,,fee schedule,508.7,12191.12,
Sigmoidoscopy w/resection,45349,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,555.71,,,,,,,fee schedule,508.7,12191.12,
Sigmoidoscopy w/resection,45349,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,584.25,,,,,,,fee schedule,508.7,12191.12,
Sigmoidoscopy w/resection,45349,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12191.12,,,,,,,fee schedule,508.7,12191.12,APC 378
Sigmoidoscopy w/resection,45349,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2885.2,,,,,,,fee schedule,508.7,12191.12,APC
Sigmoidoscopy w/resection,45349,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2857.73,,,,,,,fee schedule,508.7,12191.12,APC
Sigmoidoscopy w/resection,45349,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2747.81,,,,,,,fee schedule,508.7,12191.12,APC
Sigmoidoscopy w/resection,45349,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4204.16,,,,,,,fee schedule,508.7,12191.12,Radiology
Sigmoidoscopy w/resection,45349,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3846.94,,,,,,,fee schedule,508.7,12191.12,APC
Sigmoidoscopy w/resection,45349,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4808.67,,,,,,,fee schedule,508.7,12191.12,APC
Sgmdsc w/band ligation,45350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2258.22,,,,,,,fee schedule,1184.64,5255.83,
Sgmdsc w/band ligation,45350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1810.16,,,,,,,fee schedule,1184.64,5255.83,
Sgmdsc w/band ligation,45350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1977.44,,,,,,,fee schedule,1184.64,5255.83,
Sgmdsc w/band ligation,45350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2079,,,,,,,fee schedule,1184.64,5255.83,
Sgmdsc w/band ligation,45350,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5255.83,,,,,,,fee schedule,1184.64,5255.83,APC 378
Sgmdsc w/band ligation,45350,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1243.87,,,,,,,fee schedule,1184.64,5255.83,APC
Sgmdsc w/band ligation,45350,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1232.02,,,,,,,fee schedule,1184.64,5255.83,APC
Sgmdsc w/band ligation,45350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1184.64,,,,,,,fee schedule,1184.64,5255.83,APC
Sgmdsc w/band ligation,45350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1812.49,,,,,,,fee schedule,1184.64,5255.83,Radiology
Sgmdsc w/band ligation,45350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1658.49,,,,,,,fee schedule,1184.64,5255.83,APC
Sgmdsc w/band ligation,45350,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2073.11,,,,,,,fee schedule,1184.64,5255.83,APC
Diagnostic colonoscopy,45378,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,215.65,,,,,,,fee schedule,172.86,4084.51,
Diagnostic colonoscopy,45378,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2851.53,,,,,,,fee schedule,172.86,4084.51,
Diagnostic colonoscopy,45378,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,172.86,,,,,,,fee schedule,172.86,4084.51,
Diagnostic colonoscopy,45378,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2285.75,,,,,,,fee schedule,172.86,4084.51,
Diagnostic colonoscopy,45378,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,188.84,,,,,,,fee schedule,172.86,4084.51,
Diagnostic colonoscopy,45378,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2496.97,,,,,,,fee schedule,172.86,4084.51,
Diagnostic colonoscopy,45378,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,198.53,,,,,,,fee schedule,172.86,4084.51,
Diagnostic colonoscopy,45378,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2625.22,,,,,,,fee schedule,172.86,4084.51,
Diagnostic colonoscopy,45378,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4084.51,,,,,,,fee schedule,172.86,4084.51,APC 378
Diagnostic colonoscopy,45378,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,966.66,,,,,,,fee schedule,172.86,4084.51,APC
Diagnostic colonoscopy,45378,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,957.45,,,,,,,fee schedule,172.86,4084.51,APC
Diagnostic colonoscopy,45378,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,920.63,,,,,,,fee schedule,172.86,4084.51,APC
Diagnostic colonoscopy,45378,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1408.56,,,,,,,fee schedule,172.86,4084.51,Radiology
Diagnostic colonoscopy,45378,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1288.88,,,,,,,fee schedule,172.86,4084.51,APC
Diagnostic colonoscopy,45378,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1611.1,,,,,,,fee schedule,172.86,4084.51,APC
Colonoscopy w/fb removal,45379,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2208.39,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy w/fb removal,45379,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1770.22,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy w/fb removal,45379,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1933.8,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy w/fb removal,45379,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2033.12,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy w/fb removal,45379,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5255.83,,,,,,,fee schedule,1184.64,5255.83,APC 378
Colonoscopy w/fb removal,45379,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1243.87,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/fb removal,45379,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1232.02,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/fb removal,45379,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1184.64,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/fb removal,45379,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1812.49,,,,,,,fee schedule,1184.64,5255.83,Radiology
Colonoscopy w/fb removal,45379,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1658.49,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/fb removal,45379,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2073.11,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy and biopsy,45380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2836.41,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy and biopsy,45380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2273.63,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy and biopsy,45380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2483.74,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy and biopsy,45380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2611.3,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy and biopsy,45380,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5255.83,,,,,,,fee schedule,1184.64,5255.83,APC 378
Colonoscopy and biopsy,45380,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1243.87,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy and biopsy,45380,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1232.02,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy and biopsy,45380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1184.64,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy and biopsy,45380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1812.49,,,,,,,fee schedule,1184.64,5255.83,Radiology
Colonoscopy and biopsy,45380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1658.49,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy and biopsy,45380,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2073.11,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy submucous njx,45381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1746.32,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy submucous njx,45381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1399.83,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy submucous njx,45381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1529.18,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy submucous njx,45381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1607.72,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy submucous njx,45381,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5255.83,,,,,,,fee schedule,1184.64,5255.83,APC 378
Colonoscopy submucous njx,45381,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1243.87,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy submucous njx,45381,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1232.02,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy submucous njx,45381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1184.64,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy submucous njx,45381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1812.49,,,,,,,fee schedule,1184.64,5255.83,Radiology
Colonoscopy submucous njx,45381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1658.49,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy submucous njx,45381,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2073.11,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/control bleed,45382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1499.97,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy w/control bleed,45382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1202.36,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy w/control bleed,45382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1313.47,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy w/control bleed,45382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1380.93,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy w/control bleed,45382,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5255.83,,,,,,,fee schedule,1184.64,5255.83,APC 378
Colonoscopy w/control bleed,45382,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1243.87,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/control bleed,45382,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1232.02,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/control bleed,45382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1184.64,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/control bleed,45382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1812.49,,,,,,,fee schedule,1184.64,5255.83,Radiology
Colonoscopy w/control bleed,45382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1658.49,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/control bleed,45382,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2073.11,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/lesion removal,45384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2149.73,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy w/lesion removal,45384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1723.19,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy w/lesion removal,45384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1882.43,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy w/lesion removal,45384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1979.11,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy w/lesion removal,45384,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5255.83,,,,,,,fee schedule,1184.64,5255.83,APC 378
Colonoscopy w/lesion removal,45384,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1243.87,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/lesion removal,45384,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1232.02,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/lesion removal,45384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1184.64,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/lesion removal,45384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1812.49,,,,,,,fee schedule,1184.64,5255.83,Radiology
Colonoscopy w/lesion removal,45384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1658.49,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/lesion removal,45384,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2073.11,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/lesion removal,45385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2172.67,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy w/lesion removal,45385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1741.58,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy w/lesion removal,45385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1902.52,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy w/lesion removal,45385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2000.23,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy w/lesion removal,45385,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5255.83,,,,,,,fee schedule,1184.64,5255.83,APC 378
Colonoscopy w/lesion removal,45385,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1243.87,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/lesion removal,45385,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1232.02,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/lesion removal,45385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1184.64,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/lesion removal,45385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1812.49,,,,,,,fee schedule,1184.64,5255.83,Radiology
Colonoscopy w/lesion removal,45385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1658.49,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/lesion removal,45385,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2073.11,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/balloon dilat,45386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1640.57,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy w/balloon dilat,45386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1315.06,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy w/balloon dilat,45386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1436.58,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy w/balloon dilat,45386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1510.37,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy w/balloon dilat,45386,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5255.83,,,,,,,fee schedule,1184.64,5255.83,APC 378
Colonoscopy w/balloon dilat,45386,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1243.87,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/balloon dilat,45386,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1232.02,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/balloon dilat,45386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1184.64,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/balloon dilat,45386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1812.49,,,,,,,fee schedule,1184.64,5255.83,Radiology
Colonoscopy w/balloon dilat,45386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1658.49,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/balloon dilat,45386,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2073.11,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/ablation,45388,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2086.65,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy w/ablation,45388,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1672.63,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy w/ablation,45388,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1827.19,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy w/ablation,45388,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1921.04,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy w/ablation,45388,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5255.83,,,,,,,fee schedule,1184.64,5255.83,APC 378
Colonoscopy w/ablation,45388,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1243.87,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/ablation,45388,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1232.02,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/ablation,45388,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1184.64,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/ablation,45388,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1812.49,,,,,,,fee schedule,1184.64,5255.83,Radiology
Colonoscopy w/ablation,45388,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1658.49,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/ablation,45388,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2073.11,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/stent plcmt,45389,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2985.67,,,,,,,fee schedule,2393.28,26664.3,
Colonoscopy w/stent plcmt,45389,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2393.28,,,,,,,fee schedule,2393.28,26664.3,
Colonoscopy w/stent plcmt,45389,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2614.44,,,,,,,fee schedule,2393.28,26664.3,
Colonoscopy w/stent plcmt,45389,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2748.71,,,,,,,fee schedule,2393.28,26664.3,
Colonoscopy w/stent plcmt,45389,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26664.3,,,,,,,fee schedule,2393.28,26664.3,APC 378
Colonoscopy w/stent plcmt,45389,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6310.49,,,,,,,fee schedule,2393.28,26664.3,APC
Colonoscopy w/stent plcmt,45389,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6250.39,,,,,,,fee schedule,2393.28,26664.3,APC
Colonoscopy w/stent plcmt,45389,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6009.99,,,,,,,fee schedule,2393.28,26664.3,APC
Colonoscopy w/stent plcmt,45389,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9195.29,,,,,,,fee schedule,2393.28,26664.3,Radiology
Colonoscopy w/stent plcmt,45389,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8413.99,,,,,,,fee schedule,2393.28,26664.3,APC
Colonoscopy w/stent plcmt,45389,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10517.49,,,,,,,fee schedule,2393.28,26664.3,APC
Colonoscopy w/resection,45390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2220.52,,,,,,,fee schedule,1779.94,12191.12,
Colonoscopy w/resection,45390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1779.94,,,,,,,fee schedule,1779.94,12191.12,
Colonoscopy w/resection,45390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1944.43,,,,,,,fee schedule,1779.94,12191.12,
Colonoscopy w/resection,45390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2044.29,,,,,,,fee schedule,1779.94,12191.12,
Colonoscopy w/resection,45390,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12191.12,,,,,,,fee schedule,1779.94,12191.12,APC 378
Colonoscopy w/resection,45390,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2885.2,,,,,,,fee schedule,1779.94,12191.12,APC
Colonoscopy w/resection,45390,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2857.73,,,,,,,fee schedule,1779.94,12191.12,APC
Colonoscopy w/resection,45390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2747.81,,,,,,,fee schedule,1779.94,12191.12,APC
Colonoscopy w/resection,45390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4204.16,,,,,,,fee schedule,1779.94,12191.12,Radiology
Colonoscopy w/resection,45390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3846.94,,,,,,,fee schedule,1779.94,12191.12,APC
Colonoscopy w/resection,45390,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4808.67,,,,,,,fee schedule,1779.94,12191.12,APC
Colonoscopy w/endoscope us,45391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2208.39,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy w/endoscope us,45391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1770.22,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy w/endoscope us,45391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1933.8,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy w/endoscope us,45391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2033.12,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy w/endoscope us,45391,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5255.83,,,,,,,fee schedule,1184.64,5255.83,APC 378
Colonoscopy w/endoscope us,45391,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1243.87,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/endoscope us,45391,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1232.02,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/endoscope us,45391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1184.64,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/endoscope us,45391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1812.49,,,,,,,fee schedule,1184.64,5255.83,Radiology
Colonoscopy w/endoscope us,45391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1658.49,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/endoscope us,45391,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2073.11,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/endoscopic fnb,45392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2208.39,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy w/endoscopic fnb,45392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1770.22,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy w/endoscopic fnb,45392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1933.8,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy w/endoscopic fnb,45392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2033.12,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy w/endoscopic fnb,45392,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5255.83,,,,,,,fee schedule,1184.64,5255.83,APC 378
Colonoscopy w/endoscopic fnb,45392,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1243.87,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/endoscopic fnb,45392,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1232.02,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/endoscopic fnb,45392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1184.64,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/endoscopic fnb,45392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1812.49,,,,,,,fee schedule,1184.64,5255.83,Radiology
Colonoscopy w/endoscopic fnb,45392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1658.49,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/endoscopic fnb,45392,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2073.11,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/decompression,45393,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2985.67,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy w/decompression,45393,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2393.28,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy w/decompression,45393,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2614.44,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy w/decompression,45393,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2748.71,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy w/decompression,45393,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5255.83,,,,,,,fee schedule,1184.64,5255.83,APC 378
Colonoscopy w/decompression,45393,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1243.87,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/decompression,45393,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1232.02,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/decompression,45393,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1184.64,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/decompression,45393,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1812.49,,,,,,,fee schedule,1184.64,5255.83,Radiology
Colonoscopy w/decompression,45393,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1658.49,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/decompression,45393,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2073.11,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/band ligation,45398,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3481.88,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy w/band ligation,45398,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2791.03,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy w/band ligation,45398,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3048.95,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy w/band ligation,45398,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3205.54,,,,,,,fee schedule,1184.64,5255.83,
Colonoscopy w/band ligation,45398,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5255.83,,,,,,,fee schedule,1184.64,5255.83,APC 378
Colonoscopy w/band ligation,45398,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1243.87,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/band ligation,45398,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1232.02,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/band ligation,45398,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1184.64,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/band ligation,45398,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1812.49,,,,,,,fee schedule,1184.64,5255.83,Radiology
Colonoscopy w/band ligation,45398,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1658.49,,,,,,,fee schedule,1184.64,5255.83,APC
Colonoscopy w/band ligation,45398,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2073.11,,,,,,,fee schedule,1184.64,5255.83,APC
Unlisted procedure colon,45399,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2985.67,,,,,,,fee schedule,920.63,4084.51,
Unlisted procedure colon,45399,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2393.28,,,,,,,fee schedule,920.63,4084.51,
Unlisted procedure colon,45399,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2614.44,,,,,,,fee schedule,920.63,4084.51,
Unlisted procedure colon,45399,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2748.71,,,,,,,fee schedule,920.63,4084.51,
Unlisted procedure colon,45399,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4084.51,,,,,,,fee schedule,920.63,4084.51,APC 378
Unlisted procedure colon,45399,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,966.66,,,,,,,fee schedule,920.63,4084.51,APC
Unlisted procedure colon,45399,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,957.45,,,,,,,fee schedule,920.63,4084.51,APC
Unlisted procedure colon,45399,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,920.63,,,,,,,fee schedule,920.63,4084.51,APC
Unlisted procedure colon,45399,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1408.56,,,,,,,fee schedule,920.63,4084.51,Radiology
Unlisted procedure colon,45399,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1288.88,,,,,,,fee schedule,920.63,4084.51,APC
Unlisted procedure colon,45399,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1611.1,,,,,,,fee schedule,920.63,4084.51,APC
Laparoscope proc rectum,45499,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8584.34,,,,,,,fee schedule,5984.88,26552.87,
Laparoscope proc rectum,45499,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6881.1,,,,,,,fee schedule,5984.88,26552.87,
Laparoscope proc rectum,45499,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7516.98,,,,,,,fee schedule,5984.88,26552.87,
Laparoscope proc rectum,45499,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7903.05,,,,,,,fee schedule,5984.88,26552.87,
Laparoscope proc rectum,45499,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,5984.88,26552.87,APC 378
Laparoscope proc rectum,45499,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscope proc rectum,45499,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscope proc rectum,45499,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscope proc rectum,45499,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,5984.88,26552.87,Radiology
Laparoscope proc rectum,45499,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscope proc rectum,45499,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,5984.88,26552.87,APC
Repair of rectum,45500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5676.62,,,,,,,fee schedule,2747.81,12191.12,
Repair of rectum,45500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4550.3,,,,,,,fee schedule,2747.81,12191.12,
Repair of rectum,45500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4970.79,,,,,,,fee schedule,2747.81,12191.12,
Repair of rectum,45500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5226.09,,,,,,,fee schedule,2747.81,12191.12,
Repair of rectum,45500,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12191.12,,,,,,,fee schedule,2747.81,12191.12,APC 378
Repair of rectum,45500,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2885.2,,,,,,,fee schedule,2747.81,12191.12,APC
Repair of rectum,45500,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2857.73,,,,,,,fee schedule,2747.81,12191.12,APC
Repair of rectum,45500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2747.81,,,,,,,fee schedule,2747.81,12191.12,APC
Repair of rectum,45500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4204.16,,,,,,,fee schedule,2747.81,12191.12,Radiology
Repair of rectum,45500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3846.94,,,,,,,fee schedule,2747.81,12191.12,APC
Repair of rectum,45500,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4808.67,,,,,,,fee schedule,2747.81,12191.12,APC
Repair of rectum,45505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7527.34,,,,,,,fee schedule,2747.81,12191.12,
Repair of rectum,45505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6033.82,,,,,,,fee schedule,2747.81,12191.12,
Repair of rectum,45505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6591.4,,,,,,,fee schedule,2747.81,12191.12,
Repair of rectum,45505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6929.93,,,,,,,fee schedule,2747.81,12191.12,
Repair of rectum,45505,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12191.12,,,,,,,fee schedule,2747.81,12191.12,APC 378
Repair of rectum,45505,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2885.2,,,,,,,fee schedule,2747.81,12191.12,APC
Repair of rectum,45505,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2857.73,,,,,,,fee schedule,2747.81,12191.12,APC
Repair of rectum,45505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2747.81,,,,,,,fee schedule,2747.81,12191.12,APC
Repair of rectum,45505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4204.16,,,,,,,fee schedule,2747.81,12191.12,Radiology
Repair of rectum,45505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3846.94,,,,,,,fee schedule,2747.81,12191.12,APC
Repair of rectum,45505,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4808.67,,,,,,,fee schedule,2747.81,12191.12,APC
Treatment of rectal prolapse,45520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,197.92,,,,,,,fee schedule,158.65,4084.51,
Treatment of rectal prolapse,45520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,158.65,,,,,,,fee schedule,158.65,4084.51,
Treatment of rectal prolapse,45520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,173.31,,,,,,,fee schedule,158.65,4084.51,
Treatment of rectal prolapse,45520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,182.21,,,,,,,fee schedule,158.65,4084.51,
Treatment of rectal prolapse,45520,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4084.51,,,,,,,fee schedule,158.65,4084.51,APC 378
Treatment of rectal prolapse,45520,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,966.66,,,,,,,fee schedule,158.65,4084.51,APC
Treatment of rectal prolapse,45520,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,957.45,,,,,,,fee schedule,158.65,4084.51,APC
Treatment of rectal prolapse,45520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,920.63,,,,,,,fee schedule,158.65,4084.51,APC
Treatment of rectal prolapse,45520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1408.56,,,,,,,fee schedule,158.65,4084.51,Radiology
Treatment of rectal prolapse,45520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1288.88,,,,,,,fee schedule,158.65,4084.51,APC
Treatment of rectal prolapse,45520,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1611.1,,,,,,,fee schedule,158.65,4084.51,APC
Correct rectal prolapse,45541,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7527.34,,,,,,,fee schedule,2747.81,12191.12,
Correct rectal prolapse,45541,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6033.82,,,,,,,fee schedule,2747.81,12191.12,
Correct rectal prolapse,45541,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6591.4,,,,,,,fee schedule,2747.81,12191.12,
Correct rectal prolapse,45541,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6929.93,,,,,,,fee schedule,2747.81,12191.12,
Correct rectal prolapse,45541,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12191.12,,,,,,,fee schedule,2747.81,12191.12,APC 378
Correct rectal prolapse,45541,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2885.2,,,,,,,fee schedule,2747.81,12191.12,APC
Correct rectal prolapse,45541,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2857.73,,,,,,,fee schedule,2747.81,12191.12,APC
Correct rectal prolapse,45541,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2747.81,,,,,,,fee schedule,2747.81,12191.12,APC
Correct rectal prolapse,45541,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4204.16,,,,,,,fee schedule,2747.81,12191.12,Radiology
Correct rectal prolapse,45541,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3846.94,,,,,,,fee schedule,2747.81,12191.12,APC
Correct rectal prolapse,45541,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4808.67,,,,,,,fee schedule,2747.81,12191.12,APC
Repair of rectocele,45560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7527.34,,,,,,,fee schedule,2747.81,12191.12,
Repair of rectocele,45560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6033.82,,,,,,,fee schedule,2747.81,12191.12,
Repair of rectocele,45560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6591.4,,,,,,,fee schedule,2747.81,12191.12,
Repair of rectocele,45560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6929.93,,,,,,,fee schedule,2747.81,12191.12,
Repair of rectocele,45560,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12191.12,,,,,,,fee schedule,2747.81,12191.12,APC 378
Repair of rectocele,45560,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2885.2,,,,,,,fee schedule,2747.81,12191.12,APC
Repair of rectocele,45560,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2857.73,,,,,,,fee schedule,2747.81,12191.12,APC
Repair of rectocele,45560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2747.81,,,,,,,fee schedule,2747.81,12191.12,APC
Repair of rectocele,45560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4204.16,,,,,,,fee schedule,2747.81,12191.12,Radiology
Repair of rectocele,45560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3846.94,,,,,,,fee schedule,2747.81,12191.12,APC
Repair of rectocele,45560,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4808.67,,,,,,,fee schedule,2747.81,12191.12,APC
Reduction of rectal prolapse,45900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1196.33,,,,,,,fee schedule,920.63,4084.51,
Reduction of rectal prolapse,45900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,958.96,,,,,,,fee schedule,920.63,4084.51,
Reduction of rectal prolapse,45900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1047.58,,,,,,,fee schedule,920.63,4084.51,
Reduction of rectal prolapse,45900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1101.39,,,,,,,fee schedule,920.63,4084.51,
Reduction of rectal prolapse,45900,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4084.51,,,,,,,fee schedule,920.63,4084.51,APC 378
Reduction of rectal prolapse,45900,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,966.66,,,,,,,fee schedule,920.63,4084.51,APC
Reduction of rectal prolapse,45900,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,957.45,,,,,,,fee schedule,920.63,4084.51,APC
Reduction of rectal prolapse,45900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,920.63,,,,,,,fee schedule,920.63,4084.51,APC
Reduction of rectal prolapse,45900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1408.56,,,,,,,fee schedule,920.63,4084.51,Radiology
Reduction of rectal prolapse,45900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1288.88,,,,,,,fee schedule,920.63,4084.51,APC
Reduction of rectal prolapse,45900,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1611.1,,,,,,,fee schedule,920.63,4084.51,APC
Dilation of anal sphincter,45905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5676.62,,,,,,,fee schedule,1184.64,5676.62,
Dilation of anal sphincter,45905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4550.3,,,,,,,fee schedule,1184.64,5676.62,
Dilation of anal sphincter,45905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4970.79,,,,,,,fee schedule,1184.64,5676.62,
Dilation of anal sphincter,45905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5226.09,,,,,,,fee schedule,1184.64,5676.62,
Dilation of anal sphincter,45905,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5255.83,,,,,,,fee schedule,1184.64,5676.62,APC 378
Dilation of anal sphincter,45905,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1243.87,,,,,,,fee schedule,1184.64,5676.62,APC
Dilation of anal sphincter,45905,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1232.02,,,,,,,fee schedule,1184.64,5676.62,APC
Dilation of anal sphincter,45905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1184.64,,,,,,,fee schedule,1184.64,5676.62,APC
Dilation of anal sphincter,45905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1812.49,,,,,,,fee schedule,1184.64,5676.62,Radiology
Dilation of anal sphincter,45905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1658.49,,,,,,,fee schedule,1184.64,5676.62,APC
Dilation of anal sphincter,45905,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2073.11,,,,,,,fee schedule,1184.64,5676.62,APC
Dilation of rectal narrowing,45910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5676.62,,,,,,,fee schedule,1184.64,5676.62,
Dilation of rectal narrowing,45910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4550.3,,,,,,,fee schedule,1184.64,5676.62,
Dilation of rectal narrowing,45910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4970.79,,,,,,,fee schedule,1184.64,5676.62,
Dilation of rectal narrowing,45910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5226.09,,,,,,,fee schedule,1184.64,5676.62,
Dilation of rectal narrowing,45910,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5255.83,,,,,,,fee schedule,1184.64,5676.62,APC 378
Dilation of rectal narrowing,45910,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1243.87,,,,,,,fee schedule,1184.64,5676.62,APC
Dilation of rectal narrowing,45910,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1232.02,,,,,,,fee schedule,1184.64,5676.62,APC
Dilation of rectal narrowing,45910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1184.64,,,,,,,fee schedule,1184.64,5676.62,APC
Dilation of rectal narrowing,45910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1812.49,,,,,,,fee schedule,1184.64,5676.62,Radiology
Dilation of rectal narrowing,45910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1658.49,,,,,,,fee schedule,1184.64,5676.62,APC
Dilation of rectal narrowing,45910,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2073.11,,,,,,,fee schedule,1184.64,5676.62,APC
Remove rectal obstruction,45915,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3648.48,,,,,,,fee schedule,1184.64,5255.83,
Remove rectal obstruction,45915,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2924.58,,,,,,,fee schedule,1184.64,5255.83,
Remove rectal obstruction,45915,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3194.83,,,,,,,fee schedule,1184.64,5255.83,
Remove rectal obstruction,45915,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3358.92,,,,,,,fee schedule,1184.64,5255.83,
Remove rectal obstruction,45915,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5255.83,,,,,,,fee schedule,1184.64,5255.83,APC 378
Remove rectal obstruction,45915,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1243.87,,,,,,,fee schedule,1184.64,5255.83,APC
Remove rectal obstruction,45915,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1232.02,,,,,,,fee schedule,1184.64,5255.83,APC
Remove rectal obstruction,45915,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1184.64,,,,,,,fee schedule,1184.64,5255.83,APC
Remove rectal obstruction,45915,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1812.49,,,,,,,fee schedule,1184.64,5255.83,Radiology
Remove rectal obstruction,45915,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1658.49,,,,,,,fee schedule,1184.64,5255.83,APC
Remove rectal obstruction,45915,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2073.11,,,,,,,fee schedule,1184.64,5255.83,APC
Surg dx exam anorectal,45990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4516.81,,,,,,,fee schedule,2747.81,12191.12,
Surg dx exam anorectal,45990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3620.61,,,,,,,fee schedule,2747.81,12191.12,
Surg dx exam anorectal,45990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3955.19,,,,,,,fee schedule,2747.81,12191.12,
Surg dx exam anorectal,45990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4158.33,,,,,,,fee schedule,2747.81,12191.12,
Surg dx exam anorectal,45990,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12191.12,,,,,,,fee schedule,2747.81,12191.12,APC 378
Surg dx exam anorectal,45990,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2885.2,,,,,,,fee schedule,2747.81,12191.12,APC
Surg dx exam anorectal,45990,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2857.73,,,,,,,fee schedule,2747.81,12191.12,APC
Surg dx exam anorectal,45990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2747.81,,,,,,,fee schedule,2747.81,12191.12,APC
Surg dx exam anorectal,45990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4204.16,,,,,,,fee schedule,2747.81,12191.12,Radiology
Surg dx exam anorectal,45990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3846.94,,,,,,,fee schedule,2747.81,12191.12,APC
Surg dx exam anorectal,45990,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4808.67,,,,,,,fee schedule,2747.81,12191.12,APC
Rectum surgery procedure,45999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1196.33,,,,,,,fee schedule,920.63,4084.51,
Rectum surgery procedure,45999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,958.96,,,,,,,fee schedule,920.63,4084.51,
Rectum surgery procedure,45999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1047.58,,,,,,,fee schedule,920.63,4084.51,
Rectum surgery procedure,45999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1101.39,,,,,,,fee schedule,920.63,4084.51,
Rectum surgery procedure,45999,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4084.51,,,,,,,fee schedule,920.63,4084.51,APC 378
Rectum surgery procedure,45999,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,966.66,,,,,,,fee schedule,920.63,4084.51,APC
Rectum surgery procedure,45999,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,957.45,,,,,,,fee schedule,920.63,4084.51,APC
Rectum surgery procedure,45999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,920.63,,,,,,,fee schedule,920.63,4084.51,APC
Rectum surgery procedure,45999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1408.56,,,,,,,fee schedule,920.63,4084.51,Radiology
Rectum surgery procedure,45999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1288.88,,,,,,,fee schedule,920.63,4084.51,APC
Rectum surgery procedure,45999,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1611.1,,,,,,,fee schedule,920.63,4084.51,APC
Placement of seton,46020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6721.57,,,,,,,fee schedule,2747.81,12191.12,
Placement of seton,46020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5387.93,,,,,,,fee schedule,2747.81,12191.12,
Placement of seton,46020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5885.82,,,,,,,fee schedule,2747.81,12191.12,
Placement of seton,46020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6188.11,,,,,,,fee schedule,2747.81,12191.12,
Placement of seton,46020,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12191.12,,,,,,,fee schedule,2747.81,12191.12,APC 378
Placement of seton,46020,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2885.2,,,,,,,fee schedule,2747.81,12191.12,APC
Placement of seton,46020,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2857.73,,,,,,,fee schedule,2747.81,12191.12,APC
Placement of seton,46020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2747.81,,,,,,,fee schedule,2747.81,12191.12,APC
Placement of seton,46020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4204.16,,,,,,,fee schedule,2747.81,12191.12,Radiology
Placement of seton,46020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3846.94,,,,,,,fee schedule,2747.81,12191.12,APC
Placement of seton,46020,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4808.67,,,,,,,fee schedule,2747.81,12191.12,APC
Removal of rectal marker,46030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6253.46,,,,,,,fee schedule,1184.64,6253.46,
Removal of rectal marker,46030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5012.69,,,,,,,fee schedule,1184.64,6253.46,
Removal of rectal marker,46030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5475.91,,,,,,,fee schedule,1184.64,6253.46,
Removal of rectal marker,46030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5757.15,,,,,,,fee schedule,1184.64,6253.46,
Removal of rectal marker,46030,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5255.83,,,,,,,fee schedule,1184.64,6253.46,APC 378
Removal of rectal marker,46030,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1243.87,,,,,,,fee schedule,1184.64,6253.46,APC
Removal of rectal marker,46030,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1232.02,,,,,,,fee schedule,1184.64,6253.46,APC
Removal of rectal marker,46030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1184.64,,,,,,,fee schedule,1184.64,6253.46,APC
Removal of rectal marker,46030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1812.49,,,,,,,fee schedule,1184.64,6253.46,Radiology
Removal of rectal marker,46030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1658.49,,,,,,,fee schedule,1184.64,6253.46,APC
Removal of rectal marker,46030,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2073.11,,,,,,,fee schedule,1184.64,6253.46,APC
Incision of rectal abscess,46040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6253.46,,,,,,,fee schedule,1184.64,6253.46,
Incision of rectal abscess,46040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5012.69,,,,,,,fee schedule,1184.64,6253.46,
Incision of rectal abscess,46040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5475.91,,,,,,,fee schedule,1184.64,6253.46,
Incision of rectal abscess,46040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5757.15,,,,,,,fee schedule,1184.64,6253.46,
Incision of rectal abscess,46040,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5255.83,,,,,,,fee schedule,1184.64,6253.46,APC 378
Incision of rectal abscess,46040,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1243.87,,,,,,,fee schedule,1184.64,6253.46,APC
Incision of rectal abscess,46040,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1232.02,,,,,,,fee schedule,1184.64,6253.46,APC
Incision of rectal abscess,46040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1184.64,,,,,,,fee schedule,1184.64,6253.46,APC
Incision of rectal abscess,46040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1812.49,,,,,,,fee schedule,1184.64,6253.46,Radiology
Incision of rectal abscess,46040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1658.49,,,,,,,fee schedule,1184.64,6253.46,APC
Incision of rectal abscess,46040,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2073.11,,,,,,,fee schedule,1184.64,6253.46,APC
Incision of rectal abscess,46045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5676.62,,,,,,,fee schedule,2747.81,12191.12,
Incision of rectal abscess,46045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4550.3,,,,,,,fee schedule,2747.81,12191.12,
Incision of rectal abscess,46045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4970.79,,,,,,,fee schedule,2747.81,12191.12,
Incision of rectal abscess,46045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5226.09,,,,,,,fee schedule,2747.81,12191.12,
Incision of rectal abscess,46045,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12191.12,,,,,,,fee schedule,2747.81,12191.12,APC 378
Incision of rectal abscess,46045,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2885.2,,,,,,,fee schedule,2747.81,12191.12,APC
Incision of rectal abscess,46045,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2857.73,,,,,,,fee schedule,2747.81,12191.12,APC
Incision of rectal abscess,46045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2747.81,,,,,,,fee schedule,2747.81,12191.12,APC
Incision of rectal abscess,46045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4204.16,,,,,,,fee schedule,2747.81,12191.12,Radiology
Incision of rectal abscess,46045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3846.94,,,,,,,fee schedule,2747.81,12191.12,APC
Incision of rectal abscess,46045,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4808.67,,,,,,,fee schedule,2747.81,12191.12,APC
Incision of anal abscess,46050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2502.15,,,,,,,fee schedule,920.63,4084.51,
Incision of anal abscess,46050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2005.69,,,,,,,fee schedule,920.63,4084.51,
Incision of anal abscess,46050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2191.04,,,,,,,fee schedule,920.63,4084.51,
Incision of anal abscess,46050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2303.57,,,,,,,fee schedule,920.63,4084.51,
Incision of anal abscess,46050,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4084.51,,,,,,,fee schedule,920.63,4084.51,APC 378
Incision of anal abscess,46050,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,966.66,,,,,,,fee schedule,920.63,4084.51,APC
Incision of anal abscess,46050,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,957.45,,,,,,,fee schedule,920.63,4084.51,APC
Incision of anal abscess,46050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,920.63,,,,,,,fee schedule,920.63,4084.51,APC
Incision of anal abscess,46050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1408.56,,,,,,,fee schedule,920.63,4084.51,Radiology
Incision of anal abscess,46050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1288.88,,,,,,,fee schedule,920.63,4084.51,APC
Incision of anal abscess,46050,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1611.1,,,,,,,fee schedule,920.63,4084.51,APC
Incision of rectal abscess,46060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5676.62,,,,,,,fee schedule,2747.81,12191.12,
Incision of rectal abscess,46060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4550.3,,,,,,,fee schedule,2747.81,12191.12,
Incision of rectal abscess,46060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4970.79,,,,,,,fee schedule,2747.81,12191.12,
Incision of rectal abscess,46060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5226.09,,,,,,,fee schedule,2747.81,12191.12,
Incision of rectal abscess,46060,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12191.12,,,,,,,fee schedule,2747.81,12191.12,APC 378
Incision of rectal abscess,46060,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2885.2,,,,,,,fee schedule,2747.81,12191.12,APC
Incision of rectal abscess,46060,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2857.73,,,,,,,fee schedule,2747.81,12191.12,APC
Incision of rectal abscess,46060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2747.81,,,,,,,fee schedule,2747.81,12191.12,APC
Incision of rectal abscess,46060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4204.16,,,,,,,fee schedule,2747.81,12191.12,Radiology
Incision of rectal abscess,46060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3846.94,,,,,,,fee schedule,2747.81,12191.12,APC
Incision of rectal abscess,46060,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4808.67,,,,,,,fee schedule,2747.81,12191.12,APC
Incision of anal septum,46070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2723.68,,,,,,,fee schedule,2183.27,12191.12,
Incision of anal septum,46070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2183.27,,,,,,,fee schedule,2183.27,12191.12,
Incision of anal septum,46070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2385.02,,,,,,,fee schedule,2183.27,12191.12,
Incision of anal septum,46070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2507.51,,,,,,,fee schedule,2183.27,12191.12,
Incision of anal septum,46070,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12191.12,,,,,,,fee schedule,2183.27,12191.12,APC 378
Incision of anal septum,46070,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2885.2,,,,,,,fee schedule,2183.27,12191.12,APC
Incision of anal septum,46070,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2857.73,,,,,,,fee schedule,2183.27,12191.12,APC
Incision of anal septum,46070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2747.81,,,,,,,fee schedule,2183.27,12191.12,APC
Incision of anal septum,46070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4204.16,,,,,,,fee schedule,2183.27,12191.12,Radiology
Incision of anal septum,46070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3846.94,,,,,,,fee schedule,2183.27,12191.12,APC
Incision of anal septum,46070,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4808.67,,,,,,,fee schedule,2183.27,12191.12,APC
Incision of anal sphincter,46080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5676.62,,,,,,,fee schedule,2747.81,12191.12,
Incision of anal sphincter,46080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4550.3,,,,,,,fee schedule,2747.81,12191.12,
Incision of anal sphincter,46080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4970.79,,,,,,,fee schedule,2747.81,12191.12,
Incision of anal sphincter,46080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5226.09,,,,,,,fee schedule,2747.81,12191.12,
Incision of anal sphincter,46080,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12191.12,,,,,,,fee schedule,2747.81,12191.12,APC 378
Incision of anal sphincter,46080,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2885.2,,,,,,,fee schedule,2747.81,12191.12,APC
Incision of anal sphincter,46080,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2857.73,,,,,,,fee schedule,2747.81,12191.12,APC
Incision of anal sphincter,46080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2747.81,,,,,,,fee schedule,2747.81,12191.12,APC
Incision of anal sphincter,46080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4204.16,,,,,,,fee schedule,2747.81,12191.12,Radiology
Incision of anal sphincter,46080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3846.94,,,,,,,fee schedule,2747.81,12191.12,APC
Incision of anal sphincter,46080,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4808.67,,,,,,,fee schedule,2747.81,12191.12,APC
Incise external hemorrhoid,46083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1675.52,,,,,,,fee schedule,247.34,1675.52,
Incise external hemorrhoid,46083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1343.07,,,,,,,fee schedule,247.34,1675.52,
Incise external hemorrhoid,46083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1467.19,,,,,,,fee schedule,247.34,1675.52,
Incise external hemorrhoid,46083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1542.54,,,,,,,fee schedule,247.34,1675.52,
Incise external hemorrhoid,46083,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1097.37,,,,,,,fee schedule,247.34,1675.52,APC 378
Incise external hemorrhoid,46083,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,259.71,,,,,,,fee schedule,247.34,1675.52,APC
Incise external hemorrhoid,46083,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,257.24,,,,,,,fee schedule,247.34,1675.52,APC
Incise external hemorrhoid,46083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,247.34,,,,,,,fee schedule,247.34,1675.52,APC
Incise external hemorrhoid,46083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,378.43,,,,,,,fee schedule,247.34,1675.52,Radiology
Incise external hemorrhoid,46083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,346.28,,,,,,,fee schedule,247.34,1675.52,APC
Incise external hemorrhoid,46083,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,432.85,,,,,,,fee schedule,247.34,1675.52,APC
Removal of anal fissure,46200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5676.62,,,,,,,fee schedule,2747.81,12191.12,
Removal of anal fissure,46200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4550.3,,,,,,,fee schedule,2747.81,12191.12,
Removal of anal fissure,46200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4970.79,,,,,,,fee schedule,2747.81,12191.12,
Removal of anal fissure,46200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5226.09,,,,,,,fee schedule,2747.81,12191.12,
Removal of anal fissure,46200,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12191.12,,,,,,,fee schedule,2747.81,12191.12,APC 378
Removal of anal fissure,46200,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2885.2,,,,,,,fee schedule,2747.81,12191.12,APC
Removal of anal fissure,46200,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2857.73,,,,,,,fee schedule,2747.81,12191.12,APC
Removal of anal fissure,46200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2747.81,,,,,,,fee schedule,2747.81,12191.12,APC
Removal of anal fissure,46200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4204.16,,,,,,,fee schedule,2747.81,12191.12,Radiology
Removal of anal fissure,46200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3846.94,,,,,,,fee schedule,2747.81,12191.12,APC
Removal of anal fissure,46200,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4808.67,,,,,,,fee schedule,2747.81,12191.12,APC
Excise anal ext tag/papilla,46220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5676.62,,,,,,,fee schedule,1184.64,5676.62,
Excise anal ext tag/papilla,46220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4550.3,,,,,,,fee schedule,1184.64,5676.62,
Excise anal ext tag/papilla,46220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4970.79,,,,,,,fee schedule,1184.64,5676.62,
Excise anal ext tag/papilla,46220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5226.09,,,,,,,fee schedule,1184.64,5676.62,
Excise anal ext tag/papilla,46220,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5255.83,,,,,,,fee schedule,1184.64,5676.62,APC 378
Excise anal ext tag/papilla,46220,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1243.87,,,,,,,fee schedule,1184.64,5676.62,APC
Excise anal ext tag/papilla,46220,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1232.02,,,,,,,fee schedule,1184.64,5676.62,APC
Excise anal ext tag/papilla,46220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1184.64,,,,,,,fee schedule,1184.64,5676.62,APC
Excise anal ext tag/papilla,46220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1812.49,,,,,,,fee schedule,1184.64,5676.62,Radiology
Excise anal ext tag/papilla,46220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1658.49,,,,,,,fee schedule,1184.64,5676.62,APC
Excise anal ext tag/papilla,46220,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2073.11,,,,,,,fee schedule,1184.64,5676.62,APC
Ligation of hemorrhoid(s),46221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1196.33,,,,,,,fee schedule,920.63,4084.51,
Ligation of hemorrhoid(s),46221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,958.96,,,,,,,fee schedule,920.63,4084.51,
Ligation of hemorrhoid(s),46221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1047.58,,,,,,,fee schedule,920.63,4084.51,
Ligation of hemorrhoid(s),46221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1101.39,,,,,,,fee schedule,920.63,4084.51,
Ligation of hemorrhoid(s),46221,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4084.51,,,,,,,fee schedule,920.63,4084.51,APC 378
Ligation of hemorrhoid(s),46221,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,966.66,,,,,,,fee schedule,920.63,4084.51,APC
Ligation of hemorrhoid(s),46221,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,957.45,,,,,,,fee schedule,920.63,4084.51,APC
Ligation of hemorrhoid(s),46221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,920.63,,,,,,,fee schedule,920.63,4084.51,APC
Ligation of hemorrhoid(s),46221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1408.56,,,,,,,fee schedule,920.63,4084.51,Radiology
Ligation of hemorrhoid(s),46221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1288.88,,,,,,,fee schedule,920.63,4084.51,APC
Ligation of hemorrhoid(s),46221,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1611.1,,,,,,,fee schedule,920.63,4084.51,APC
Removal of anal tags,46230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6253.46,,,,,,,fee schedule,2747.81,12191.12,
Removal of anal tags,46230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5012.69,,,,,,,fee schedule,2747.81,12191.12,
Removal of anal tags,46230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5475.91,,,,,,,fee schedule,2747.81,12191.12,
Removal of anal tags,46230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5757.15,,,,,,,fee schedule,2747.81,12191.12,
Removal of anal tags,46230,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12191.12,,,,,,,fee schedule,2747.81,12191.12,APC 378
Removal of anal tags,46230,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2885.2,,,,,,,fee schedule,2747.81,12191.12,APC
Removal of anal tags,46230,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2857.73,,,,,,,fee schedule,2747.81,12191.12,APC
Removal of anal tags,46230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2747.81,,,,,,,fee schedule,2747.81,12191.12,APC
Removal of anal tags,46230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4204.16,,,,,,,fee schedule,2747.81,12191.12,Radiology
Removal of anal tags,46230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3846.94,,,,,,,fee schedule,2747.81,12191.12,APC
Removal of anal tags,46230,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4808.67,,,,,,,fee schedule,2747.81,12191.12,APC
Remove ext hem groups 2+,46250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6253.46,,,,,,,fee schedule,2747.81,12191.12,
Remove ext hem groups 2+,46250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5012.69,,,,,,,fee schedule,2747.81,12191.12,
Remove ext hem groups 2+,46250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5475.91,,,,,,,fee schedule,2747.81,12191.12,
Remove ext hem groups 2+,46250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5757.15,,,,,,,fee schedule,2747.81,12191.12,
Remove ext hem groups 2+,46250,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12191.12,,,,,,,fee schedule,2747.81,12191.12,APC 378
Remove ext hem groups 2+,46250,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2885.2,,,,,,,fee schedule,2747.81,12191.12,APC
Remove ext hem groups 2+,46250,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2857.73,,,,,,,fee schedule,2747.81,12191.12,APC
Remove ext hem groups 2+,46250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2747.81,,,,,,,fee schedule,2747.81,12191.12,APC
Remove ext hem groups 2+,46250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4204.16,,,,,,,fee schedule,2747.81,12191.12,Radiology
Remove ext hem groups 2+,46250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3846.94,,,,,,,fee schedule,2747.81,12191.12,APC
Remove ext hem groups 2+,46250,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4808.67,,,,,,,fee schedule,2747.81,12191.12,APC
Remove int/ext hem 1 group,46255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3685.82,,,,,,,fee schedule,2747.81,12191.12,
Remove int/ext hem 1 group,46255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2954.51,,,,,,,fee schedule,2747.81,12191.12,
Remove int/ext hem 1 group,46255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3227.53,,,,,,,fee schedule,2747.81,12191.12,
Remove int/ext hem 1 group,46255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3393.3,,,,,,,fee schedule,2747.81,12191.12,
Remove int/ext hem 1 group,46255,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12191.12,,,,,,,fee schedule,2747.81,12191.12,APC 378
Remove int/ext hem 1 group,46255,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2885.2,,,,,,,fee schedule,2747.81,12191.12,APC
Remove int/ext hem 1 group,46255,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2857.73,,,,,,,fee schedule,2747.81,12191.12,APC
Remove int/ext hem 1 group,46255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2747.81,,,,,,,fee schedule,2747.81,12191.12,APC
Remove int/ext hem 1 group,46255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4204.16,,,,,,,fee schedule,2747.81,12191.12,Radiology
Remove int/ext hem 1 group,46255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3846.94,,,,,,,fee schedule,2747.81,12191.12,APC
Remove int/ext hem 1 group,46255,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4808.67,,,,,,,fee schedule,2747.81,12191.12,APC
Remove in/ex hem grp & fiss,46257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7189.69,,,,,,,fee schedule,2747.81,12191.12,
Remove in/ex hem grp & fiss,46257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5763.16,,,,,,,fee schedule,2747.81,12191.12,
Remove in/ex hem grp & fiss,46257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6295.73,,,,,,,fee schedule,2747.81,12191.12,
Remove in/ex hem grp & fiss,46257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6619.08,,,,,,,fee schedule,2747.81,12191.12,
Remove in/ex hem grp & fiss,46257,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12191.12,,,,,,,fee schedule,2747.81,12191.12,APC 378
Remove in/ex hem grp & fiss,46257,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2885.2,,,,,,,fee schedule,2747.81,12191.12,APC
Remove in/ex hem grp & fiss,46257,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2857.73,,,,,,,fee schedule,2747.81,12191.12,APC
Remove in/ex hem grp & fiss,46257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2747.81,,,,,,,fee schedule,2747.81,12191.12,APC
Remove in/ex hem grp & fiss,46257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4204.16,,,,,,,fee schedule,2747.81,12191.12,Radiology
Remove in/ex hem grp & fiss,46257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3846.94,,,,,,,fee schedule,2747.81,12191.12,APC
Remove in/ex hem grp & fiss,46257,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4808.67,,,,,,,fee schedule,2747.81,12191.12,APC
Remove in/ex hem grp w/fistu,46258,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5676.62,,,,,,,fee schedule,2747.81,12191.12,
Remove in/ex hem grp w/fistu,46258,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4550.3,,,,,,,fee schedule,2747.81,12191.12,
Remove in/ex hem grp w/fistu,46258,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4970.79,,,,,,,fee schedule,2747.81,12191.12,
Remove in/ex hem grp w/fistu,46258,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5226.09,,,,,,,fee schedule,2747.81,12191.12,
Remove in/ex hem grp w/fistu,46258,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12191.12,,,,,,,fee schedule,2747.81,12191.12,APC 378
Remove in/ex hem grp w/fistu,46258,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2885.2,,,,,,,fee schedule,2747.81,12191.12,APC
Remove in/ex hem grp w/fistu,46258,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2857.73,,,,,,,fee schedule,2747.81,12191.12,APC
Remove in/ex hem grp w/fistu,46258,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2747.81,,,,,,,fee schedule,2747.81,12191.12,APC
Remove in/ex hem grp w/fistu,46258,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4204.16,,,,,,,fee schedule,2747.81,12191.12,Radiology
Remove in/ex hem grp w/fistu,46258,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3846.94,,,,,,,fee schedule,2747.81,12191.12,APC
Remove in/ex hem grp w/fistu,46258,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4808.67,,,,,,,fee schedule,2747.81,12191.12,APC
Remove in/ex hem groups 2+,46260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6721.57,,,,,,,fee schedule,2747.81,12191.12,
Remove in/ex hem groups 2+,46260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5387.93,,,,,,,fee schedule,2747.81,12191.12,
Remove in/ex hem groups 2+,46260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5885.82,,,,,,,fee schedule,2747.81,12191.12,
Remove in/ex hem groups 2+,46260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6188.11,,,,,,,fee schedule,2747.81,12191.12,
Remove in/ex hem groups 2+,46260,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12191.12,,,,,,,fee schedule,2747.81,12191.12,APC 378
Remove in/ex hem groups 2+,46260,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2885.2,,,,,,,fee schedule,2747.81,12191.12,APC
Remove in/ex hem groups 2+,46260,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2857.73,,,,,,,fee schedule,2747.81,12191.12,APC
Remove in/ex hem groups 2+,46260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2747.81,,,,,,,fee schedule,2747.81,12191.12,APC
Remove in/ex hem groups 2+,46260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4204.16,,,,,,,fee schedule,2747.81,12191.12,Radiology
Remove in/ex hem groups 2+,46260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3846.94,,,,,,,fee schedule,2747.81,12191.12,APC
Remove in/ex hem groups 2+,46260,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4808.67,,,,,,,fee schedule,2747.81,12191.12,APC
Remove in/ex hem grps & fiss,46261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5676.62,,,,,,,fee schedule,2747.81,12191.12,
Remove in/ex hem grps & fiss,46261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4550.3,,,,,,,fee schedule,2747.81,12191.12,
Remove in/ex hem grps & fiss,46261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4970.79,,,,,,,fee schedule,2747.81,12191.12,
Remove in/ex hem grps & fiss,46261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5226.09,,,,,,,fee schedule,2747.81,12191.12,
Remove in/ex hem grps & fiss,46261,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12191.12,,,,,,,fee schedule,2747.81,12191.12,APC 378
Remove in/ex hem grps & fiss,46261,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2885.2,,,,,,,fee schedule,2747.81,12191.12,APC
Remove in/ex hem grps & fiss,46261,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2857.73,,,,,,,fee schedule,2747.81,12191.12,APC
Remove in/ex hem grps & fiss,46261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2747.81,,,,,,,fee schedule,2747.81,12191.12,APC
Remove in/ex hem grps & fiss,46261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4204.16,,,,,,,fee schedule,2747.81,12191.12,Radiology
Remove in/ex hem grps & fiss,46261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3846.94,,,,,,,fee schedule,2747.81,12191.12,APC
Remove in/ex hem grps & fiss,46261,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4808.67,,,,,,,fee schedule,2747.81,12191.12,APC
Remove in/ex hem grps w/fist,46262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4116.6,,,,,,,fee schedule,2747.81,12191.12,
Remove in/ex hem grps w/fist,46262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3299.81,,,,,,,fee schedule,2747.81,12191.12,
Remove in/ex hem grps w/fist,46262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3604.74,,,,,,,fee schedule,2747.81,12191.12,
Remove in/ex hem grps w/fist,46262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3789.88,,,,,,,fee schedule,2747.81,12191.12,
Remove in/ex hem grps w/fist,46262,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12191.12,,,,,,,fee schedule,2747.81,12191.12,APC 378
Remove in/ex hem grps w/fist,46262,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2885.2,,,,,,,fee schedule,2747.81,12191.12,APC
Remove in/ex hem grps w/fist,46262,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2857.73,,,,,,,fee schedule,2747.81,12191.12,APC
Remove in/ex hem grps w/fist,46262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2747.81,,,,,,,fee schedule,2747.81,12191.12,APC
Remove in/ex hem grps w/fist,46262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4204.16,,,,,,,fee schedule,2747.81,12191.12,Radiology
Remove in/ex hem grps w/fist,46262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3846.94,,,,,,,fee schedule,2747.81,12191.12,APC
Remove in/ex hem grps w/fist,46262,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4808.67,,,,,,,fee schedule,2747.81,12191.12,APC
Remove anal fist subq,46270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6200.58,,,,,,,fee schedule,2747.81,12191.12,
Remove anal fist subq,46270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4970.3,,,,,,,fee schedule,2747.81,12191.12,
Remove anal fist subq,46270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5429.6,,,,,,,fee schedule,2747.81,12191.12,
Remove anal fist subq,46270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5708.47,,,,,,,fee schedule,2747.81,12191.12,
Remove anal fist subq,46270,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12191.12,,,,,,,fee schedule,2747.81,12191.12,APC 378
Remove anal fist subq,46270,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2885.2,,,,,,,fee schedule,2747.81,12191.12,APC
Remove anal fist subq,46270,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2857.73,,,,,,,fee schedule,2747.81,12191.12,APC
Remove anal fist subq,46270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2747.81,,,,,,,fee schedule,2747.81,12191.12,APC
Remove anal fist subq,46270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4204.16,,,,,,,fee schedule,2747.81,12191.12,Radiology
Remove anal fist subq,46270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3846.94,,,,,,,fee schedule,2747.81,12191.12,APC
Remove anal fist subq,46270,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4808.67,,,,,,,fee schedule,2747.81,12191.12,APC
Remove anal fist inter,46275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6721.57,,,,,,,fee schedule,2747.81,12191.12,
Remove anal fist inter,46275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5387.93,,,,,,,fee schedule,2747.81,12191.12,
Remove anal fist inter,46275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5885.82,,,,,,,fee schedule,2747.81,12191.12,
Remove anal fist inter,46275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6188.11,,,,,,,fee schedule,2747.81,12191.12,
Remove anal fist inter,46275,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12191.12,,,,,,,fee schedule,2747.81,12191.12,APC 378
Remove anal fist inter,46275,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2885.2,,,,,,,fee schedule,2747.81,12191.12,APC
Remove anal fist inter,46275,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2857.73,,,,,,,fee schedule,2747.81,12191.12,APC
Remove anal fist inter,46275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2747.81,,,,,,,fee schedule,2747.81,12191.12,APC
Remove anal fist inter,46275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4204.16,,,,,,,fee schedule,2747.81,12191.12,Radiology
Remove anal fist inter,46275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3846.94,,,,,,,fee schedule,2747.81,12191.12,APC
Remove anal fist inter,46275,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4808.67,,,,,,,fee schedule,2747.81,12191.12,APC
Remove anal fist complex,46280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5676.62,,,,,,,fee schedule,2747.81,12191.12,
Remove anal fist complex,46280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4550.3,,,,,,,fee schedule,2747.81,12191.12,
Remove anal fist complex,46280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4970.79,,,,,,,fee schedule,2747.81,12191.12,
Remove anal fist complex,46280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5226.09,,,,,,,fee schedule,2747.81,12191.12,
Remove anal fist complex,46280,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12191.12,,,,,,,fee schedule,2747.81,12191.12,APC 378
Remove anal fist complex,46280,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2885.2,,,,,,,fee schedule,2747.81,12191.12,APC
Remove anal fist complex,46280,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2857.73,,,,,,,fee schedule,2747.81,12191.12,APC
Remove anal fist complex,46280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2747.81,,,,,,,fee schedule,2747.81,12191.12,APC
Remove anal fist complex,46280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4204.16,,,,,,,fee schedule,2747.81,12191.12,Radiology
Remove anal fist complex,46280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3846.94,,,,,,,fee schedule,2747.81,12191.12,APC
Remove anal fist complex,46280,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4808.67,,,,,,,fee schedule,2747.81,12191.12,APC
Remove anal fist 2 stage,46285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5676.62,,,,,,,fee schedule,2747.81,12191.12,
Remove anal fist 2 stage,46285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4550.3,,,,,,,fee schedule,2747.81,12191.12,
Remove anal fist 2 stage,46285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4970.79,,,,,,,fee schedule,2747.81,12191.12,
Remove anal fist 2 stage,46285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5226.09,,,,,,,fee schedule,2747.81,12191.12,
Remove anal fist 2 stage,46285,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12191.12,,,,,,,fee schedule,2747.81,12191.12,APC 378
Remove anal fist 2 stage,46285,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2885.2,,,,,,,fee schedule,2747.81,12191.12,APC
Remove anal fist 2 stage,46285,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2857.73,,,,,,,fee schedule,2747.81,12191.12,APC
Remove anal fist 2 stage,46285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2747.81,,,,,,,fee schedule,2747.81,12191.12,APC
Remove anal fist 2 stage,46285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4204.16,,,,,,,fee schedule,2747.81,12191.12,Radiology
Remove anal fist 2 stage,46285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3846.94,,,,,,,fee schedule,2747.81,12191.12,APC
Remove anal fist 2 stage,46285,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4808.67,,,,,,,fee schedule,2747.81,12191.12,APC
Repair anal fistula,46288,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5676.62,,,,,,,fee schedule,2747.81,12191.12,
Repair anal fistula,46288,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4550.3,,,,,,,fee schedule,2747.81,12191.12,
Repair anal fistula,46288,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4970.79,,,,,,,fee schedule,2747.81,12191.12,
Repair anal fistula,46288,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5226.09,,,,,,,fee schedule,2747.81,12191.12,
Repair anal fistula,46288,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12191.12,,,,,,,fee schedule,2747.81,12191.12,APC 378
Repair anal fistula,46288,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2885.2,,,,,,,fee schedule,2747.81,12191.12,APC
Repair anal fistula,46288,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2857.73,,,,,,,fee schedule,2747.81,12191.12,APC
Repair anal fistula,46288,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2747.81,,,,,,,fee schedule,2747.81,12191.12,APC
Repair anal fistula,46288,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4204.16,,,,,,,fee schedule,2747.81,12191.12,Radiology
Repair anal fistula,46288,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3846.94,,,,,,,fee schedule,2747.81,12191.12,APC
Repair anal fistula,46288,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4808.67,,,,,,,fee schedule,2747.81,12191.12,APC
Removal of hemorrhoid clot,46320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5676.62,,,,,,,fee schedule,1184.64,5676.62,
Removal of hemorrhoid clot,46320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4550.3,,,,,,,fee schedule,1184.64,5676.62,
Removal of hemorrhoid clot,46320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4970.79,,,,,,,fee schedule,1184.64,5676.62,
Removal of hemorrhoid clot,46320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5226.09,,,,,,,fee schedule,1184.64,5676.62,
Removal of hemorrhoid clot,46320,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5255.83,,,,,,,fee schedule,1184.64,5676.62,APC 378
Removal of hemorrhoid clot,46320,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1243.87,,,,,,,fee schedule,1184.64,5676.62,APC
Removal of hemorrhoid clot,46320,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1232.02,,,,,,,fee schedule,1184.64,5676.62,APC
Removal of hemorrhoid clot,46320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1184.64,,,,,,,fee schedule,1184.64,5676.62,APC
Removal of hemorrhoid clot,46320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1812.49,,,,,,,fee schedule,1184.64,5676.62,Radiology
Removal of hemorrhoid clot,46320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1658.49,,,,,,,fee schedule,1184.64,5676.62,APC
Removal of hemorrhoid clot,46320,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2073.11,,,,,,,fee schedule,1184.64,5676.62,APC
Injection into hemorrhoid(s),46500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2723.68,,,,,,,fee schedule,920.63,4084.51,
Injection into hemorrhoid(s),46500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2183.27,,,,,,,fee schedule,920.63,4084.51,
Injection into hemorrhoid(s),46500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2385.02,,,,,,,fee schedule,920.63,4084.51,
Injection into hemorrhoid(s),46500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2507.51,,,,,,,fee schedule,920.63,4084.51,
Injection into hemorrhoid(s),46500,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4084.51,,,,,,,fee schedule,920.63,4084.51,APC 378
Injection into hemorrhoid(s),46500,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,966.66,,,,,,,fee schedule,920.63,4084.51,APC
Injection into hemorrhoid(s),46500,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,957.45,,,,,,,fee schedule,920.63,4084.51,APC
Injection into hemorrhoid(s),46500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,920.63,,,,,,,fee schedule,920.63,4084.51,APC
Injection into hemorrhoid(s),46500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1408.56,,,,,,,fee schedule,920.63,4084.51,Radiology
Injection into hemorrhoid(s),46500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1288.88,,,,,,,fee schedule,920.63,4084.51,APC
Injection into hemorrhoid(s),46500,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1611.1,,,,,,,fee schedule,920.63,4084.51,APC
Chemodenervation anal musc,46505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1196.33,,,,,,,fee schedule,958.96,5255.83,
Chemodenervation anal musc,46505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,958.96,,,,,,,fee schedule,958.96,5255.83,
Chemodenervation anal musc,46505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1047.58,,,,,,,fee schedule,958.96,5255.83,
Chemodenervation anal musc,46505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1101.39,,,,,,,fee schedule,958.96,5255.83,
Chemodenervation anal musc,46505,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5255.83,,,,,,,fee schedule,958.96,5255.83,APC 378
Chemodenervation anal musc,46505,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1243.87,,,,,,,fee schedule,958.96,5255.83,APC
Chemodenervation anal musc,46505,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1232.02,,,,,,,fee schedule,958.96,5255.83,APC
Chemodenervation anal musc,46505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1184.64,,,,,,,fee schedule,958.96,5255.83,APC
Chemodenervation anal musc,46505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1812.49,,,,,,,fee schedule,958.96,5255.83,Radiology
Chemodenervation anal musc,46505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1658.49,,,,,,,fee schedule,958.96,5255.83,APC
Chemodenervation anal musc,46505,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2073.11,,,,,,,fee schedule,958.96,5255.83,APC
Diagnostic anoscopy spx,46600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,192.88,,,,,,,fee schedule,131.71,584.37,
Diagnostic anoscopy spx,46600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,154.61,,,,,,,fee schedule,131.71,584.37,
Diagnostic anoscopy spx,46600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,168.9,,,,,,,fee schedule,131.71,584.37,
Diagnostic anoscopy spx,46600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,177.57,,,,,,,fee schedule,131.71,584.37,
Diagnostic anoscopy spx,46600,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,131.71,584.37,APC 378
Diagnostic anoscopy spx,46600,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,131.71,584.37,APC
Diagnostic anoscopy spx,46600,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,131.71,584.37,APC
Diagnostic anoscopy spx,46600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,131.71,584.37,APC
Diagnostic anoscopy spx,46600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,131.71,584.37,Radiology
Diagnostic anoscopy spx,46600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,131.71,584.37,APC
Diagnostic anoscopy spx,46600,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,131.71,584.37,APC
Diagnostic anoscopy,46601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,498.02,,,,,,,fee schedule,399.2,1962.08,
Diagnostic anoscopy,46601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,399.2,,,,,,,fee schedule,399.2,1962.08,
Diagnostic anoscopy,46601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,436.09,,,,,,,fee schedule,399.2,1962.08,
Diagnostic anoscopy,46601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,458.49,,,,,,,fee schedule,399.2,1962.08,
Diagnostic anoscopy,46601,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1962.08,,,,,,,fee schedule,399.2,1962.08,APC 378
Diagnostic anoscopy,46601,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,464.35,,,,,,,fee schedule,399.2,1962.08,APC
Diagnostic anoscopy,46601,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,459.93,,,,,,,fee schedule,399.2,1962.08,APC
Diagnostic anoscopy,46601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,442.24,,,,,,,fee schedule,399.2,1962.08,APC
Diagnostic anoscopy,46601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,676.63,,,,,,,fee schedule,399.2,1962.08,Radiology
Diagnostic anoscopy,46601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,619.14,,,,,,,fee schedule,399.2,1962.08,APC
Diagnostic anoscopy,46601,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,773.92,,,,,,,fee schedule,399.2,1962.08,APC
Anoscopy and dilation,46604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2172.1,,,,,,,fee schedule,1184.64,5255.83,
Anoscopy and dilation,46604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1741.13,,,,,,,fee schedule,1184.64,5255.83,
Anoscopy and dilation,46604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1902.03,,,,,,,fee schedule,1184.64,5255.83,
Anoscopy and dilation,46604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1999.71,,,,,,,fee schedule,1184.64,5255.83,
Anoscopy and dilation,46604,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5255.83,,,,,,,fee schedule,1184.64,5255.83,APC 378
Anoscopy and dilation,46604,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1243.87,,,,,,,fee schedule,1184.64,5255.83,APC
Anoscopy and dilation,46604,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1232.02,,,,,,,fee schedule,1184.64,5255.83,APC
Anoscopy and dilation,46604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1184.64,,,,,,,fee schedule,1184.64,5255.83,APC
Anoscopy and dilation,46604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1812.49,,,,,,,fee schedule,1184.64,5255.83,Radiology
Anoscopy and dilation,46604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1658.49,,,,,,,fee schedule,1184.64,5255.83,APC
Anoscopy and dilation,46604,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2073.11,,,,,,,fee schedule,1184.64,5255.83,APC
Anoscopy and biopsy,46606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2088.81,,,,,,,fee schedule,1184.64,5255.83,
Anoscopy and biopsy,46606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1674.37,,,,,,,fee schedule,1184.64,5255.83,
Anoscopy and biopsy,46606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1829.09,,,,,,,fee schedule,1184.64,5255.83,
Anoscopy and biopsy,46606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1923.03,,,,,,,fee schedule,1184.64,5255.83,
Anoscopy and biopsy,46606,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5255.83,,,,,,,fee schedule,1184.64,5255.83,APC 378
Anoscopy and biopsy,46606,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1243.87,,,,,,,fee schedule,1184.64,5255.83,APC
Anoscopy and biopsy,46606,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1232.02,,,,,,,fee schedule,1184.64,5255.83,APC
Anoscopy and biopsy,46606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1184.64,,,,,,,fee schedule,1184.64,5255.83,APC
Anoscopy and biopsy,46606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1812.49,,,,,,,fee schedule,1184.64,5255.83,Radiology
Anoscopy and biopsy,46606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1658.49,,,,,,,fee schedule,1184.64,5255.83,APC
Anoscopy and biopsy,46606,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2073.11,,,,,,,fee schedule,1184.64,5255.83,APC
Diagnostic anoscopy & biopsy,46607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3127.65,,,,,,,fee schedule,1184.64,5255.83,
Diagnostic anoscopy & biopsy,46607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2507.08,,,,,,,fee schedule,1184.64,5255.83,
Diagnostic anoscopy & biopsy,46607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2738.76,,,,,,,fee schedule,1184.64,5255.83,
Diagnostic anoscopy & biopsy,46607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2879.42,,,,,,,fee schedule,1184.64,5255.83,
Diagnostic anoscopy & biopsy,46607,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5255.83,,,,,,,fee schedule,1184.64,5255.83,APC 378
Diagnostic anoscopy & biopsy,46607,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1243.87,,,,,,,fee schedule,1184.64,5255.83,APC
Diagnostic anoscopy & biopsy,46607,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1232.02,,,,,,,fee schedule,1184.64,5255.83,APC
Diagnostic anoscopy & biopsy,46607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1184.64,,,,,,,fee schedule,1184.64,5255.83,APC
Diagnostic anoscopy & biopsy,46607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1812.49,,,,,,,fee schedule,1184.64,5255.83,Radiology
Diagnostic anoscopy & biopsy,46607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1658.49,,,,,,,fee schedule,1184.64,5255.83,APC
Diagnostic anoscopy & biopsy,46607,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2073.11,,,,,,,fee schedule,1184.64,5255.83,APC
Anoscopy remove for body,46608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2172.1,,,,,,,fee schedule,920.63,4084.51,
Anoscopy remove for body,46608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1741.13,,,,,,,fee schedule,920.63,4084.51,
Anoscopy remove for body,46608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1902.03,,,,,,,fee schedule,920.63,4084.51,
Anoscopy remove for body,46608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1999.71,,,,,,,fee schedule,920.63,4084.51,
Anoscopy remove for body,46608,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4084.51,,,,,,,fee schedule,920.63,4084.51,APC 378
Anoscopy remove for body,46608,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,966.66,,,,,,,fee schedule,920.63,4084.51,APC
Anoscopy remove for body,46608,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,957.45,,,,,,,fee schedule,920.63,4084.51,APC
Anoscopy remove for body,46608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,920.63,,,,,,,fee schedule,920.63,4084.51,APC
Anoscopy remove for body,46608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1408.56,,,,,,,fee schedule,920.63,4084.51,Radiology
Anoscopy remove for body,46608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1288.88,,,,,,,fee schedule,920.63,4084.51,APC
Anoscopy remove for body,46608,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1611.1,,,,,,,fee schedule,920.63,4084.51,APC
Anoscopy remove lesion,46610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6253.46,,,,,,,fee schedule,2747.81,12191.12,
Anoscopy remove lesion,46610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5012.69,,,,,,,fee schedule,2747.81,12191.12,
Anoscopy remove lesion,46610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5475.91,,,,,,,fee schedule,2747.81,12191.12,
Anoscopy remove lesion,46610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5757.15,,,,,,,fee schedule,2747.81,12191.12,
Anoscopy remove lesion,46610,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12191.12,,,,,,,fee schedule,2747.81,12191.12,APC 378
Anoscopy remove lesion,46610,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2885.2,,,,,,,fee schedule,2747.81,12191.12,APC
Anoscopy remove lesion,46610,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2857.73,,,,,,,fee schedule,2747.81,12191.12,APC
Anoscopy remove lesion,46610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2747.81,,,,,,,fee schedule,2747.81,12191.12,APC
Anoscopy remove lesion,46610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4204.16,,,,,,,fee schedule,2747.81,12191.12,Radiology
Anoscopy remove lesion,46610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3846.94,,,,,,,fee schedule,2747.81,12191.12,APC
Anoscopy remove lesion,46610,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4808.67,,,,,,,fee schedule,2747.81,12191.12,APC
Anoscopy,46611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2172.1,,,,,,,fee schedule,920.63,4084.51,
Anoscopy,46611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1741.13,,,,,,,fee schedule,920.63,4084.51,
Anoscopy,46611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1902.03,,,,,,,fee schedule,920.63,4084.51,
Anoscopy,46611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1999.71,,,,,,,fee schedule,920.63,4084.51,
Anoscopy,46611,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4084.51,,,,,,,fee schedule,920.63,4084.51,APC 378
Anoscopy,46611,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,966.66,,,,,,,fee schedule,920.63,4084.51,APC
Anoscopy,46611,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,957.45,,,,,,,fee schedule,920.63,4084.51,APC
Anoscopy,46611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,920.63,,,,,,,fee schedule,920.63,4084.51,APC
Anoscopy,46611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1408.56,,,,,,,fee schedule,920.63,4084.51,Radiology
Anoscopy,46611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1288.88,,,,,,,fee schedule,920.63,4084.51,APC
Anoscopy,46611,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1611.1,,,,,,,fee schedule,920.63,4084.51,APC
Anoscopy remove lesions,46612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5356.71,,,,,,,fee schedule,2747.81,12191.12,
Anoscopy remove lesions,46612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4293.87,,,,,,,fee schedule,2747.81,12191.12,
Anoscopy remove lesions,46612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4690.67,,,,,,,fee schedule,2747.81,12191.12,
Anoscopy remove lesions,46612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4931.58,,,,,,,fee schedule,2747.81,12191.12,
Anoscopy remove lesions,46612,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12191.12,,,,,,,fee schedule,2747.81,12191.12,APC 378
Anoscopy remove lesions,46612,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2885.2,,,,,,,fee schedule,2747.81,12191.12,APC
Anoscopy remove lesions,46612,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2857.73,,,,,,,fee schedule,2747.81,12191.12,APC
Anoscopy remove lesions,46612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2747.81,,,,,,,fee schedule,2747.81,12191.12,APC
Anoscopy remove lesions,46612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4204.16,,,,,,,fee schedule,2747.81,12191.12,Radiology
Anoscopy remove lesions,46612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3846.94,,,,,,,fee schedule,2747.81,12191.12,APC
Anoscopy remove lesions,46612,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4808.67,,,,,,,fee schedule,2747.81,12191.12,APC
Anoscopy control bleeding,46614,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1272.12,,,,,,,fee schedule,1019.72,5255.83,
Anoscopy control bleeding,46614,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1019.72,,,,,,,fee schedule,1019.72,5255.83,
Anoscopy control bleeding,46614,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1113.95,,,,,,,fee schedule,1019.72,5255.83,
Anoscopy control bleeding,46614,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1171.16,,,,,,,fee schedule,1019.72,5255.83,
Anoscopy control bleeding,46614,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5255.83,,,,,,,fee schedule,1019.72,5255.83,APC 378
Anoscopy control bleeding,46614,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1243.87,,,,,,,fee schedule,1019.72,5255.83,APC
Anoscopy control bleeding,46614,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1232.02,,,,,,,fee schedule,1019.72,5255.83,APC
Anoscopy control bleeding,46614,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1184.64,,,,,,,fee schedule,1019.72,5255.83,APC
Anoscopy control bleeding,46614,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1812.49,,,,,,,fee schedule,1019.72,5255.83,Radiology
Anoscopy control bleeding,46614,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1658.49,,,,,,,fee schedule,1019.72,5255.83,APC
Anoscopy control bleeding,46614,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2073.11,,,,,,,fee schedule,1019.72,5255.83,APC
Anoscopy,46615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2396.58,,,,,,,fee schedule,1921.07,12191.12,
Anoscopy,46615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1921.07,,,,,,,fee schedule,1921.07,12191.12,
Anoscopy,46615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2098.59,,,,,,,fee schedule,1921.07,12191.12,
Anoscopy,46615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2206.37,,,,,,,fee schedule,1921.07,12191.12,
Anoscopy,46615,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12191.12,,,,,,,fee schedule,1921.07,12191.12,APC 378
Anoscopy,46615,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2885.2,,,,,,,fee schedule,1921.07,12191.12,APC
Anoscopy,46615,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2857.73,,,,,,,fee schedule,1921.07,12191.12,APC
Anoscopy,46615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2747.81,,,,,,,fee schedule,1921.07,12191.12,APC
Anoscopy,46615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4204.16,,,,,,,fee schedule,1921.07,12191.12,Radiology
Anoscopy,46615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3846.94,,,,,,,fee schedule,1921.07,12191.12,APC
Anoscopy,46615,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4808.67,,,,,,,fee schedule,1921.07,12191.12,APC
Repair of anal stricture,46700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7657.8,,,,,,,fee schedule,2747.81,12191.12,
Repair of anal stricture,46700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6138.4,,,,,,,fee schedule,2747.81,12191.12,
Repair of anal stricture,46700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6705.64,,,,,,,fee schedule,2747.81,12191.12,
Repair of anal stricture,46700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7050.04,,,,,,,fee schedule,2747.81,12191.12,
Repair of anal stricture,46700,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12191.12,,,,,,,fee schedule,2747.81,12191.12,APC 378
Repair of anal stricture,46700,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2885.2,,,,,,,fee schedule,2747.81,12191.12,APC
Repair of anal stricture,46700,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2857.73,,,,,,,fee schedule,2747.81,12191.12,APC
Repair of anal stricture,46700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2747.81,,,,,,,fee schedule,2747.81,12191.12,APC
Repair of anal stricture,46700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4204.16,,,,,,,fee schedule,2747.81,12191.12,Radiology
Repair of anal stricture,46700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3846.94,,,,,,,fee schedule,2747.81,12191.12,APC
Repair of anal stricture,46700,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4808.67,,,,,,,fee schedule,2747.81,12191.12,APC
Repr of anal fistula w/glue,46706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7527.34,,,,,,,fee schedule,2747.81,12191.12,
Repr of anal fistula w/glue,46706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6033.82,,,,,,,fee schedule,2747.81,12191.12,
Repr of anal fistula w/glue,46706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6591.4,,,,,,,fee schedule,2747.81,12191.12,
Repr of anal fistula w/glue,46706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6929.93,,,,,,,fee schedule,2747.81,12191.12,
Repr of anal fistula w/glue,46706,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12191.12,,,,,,,fee schedule,2747.81,12191.12,APC 378
Repr of anal fistula w/glue,46706,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2885.2,,,,,,,fee schedule,2747.81,12191.12,APC
Repr of anal fistula w/glue,46706,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2857.73,,,,,,,fee schedule,2747.81,12191.12,APC
Repr of anal fistula w/glue,46706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2747.81,,,,,,,fee schedule,2747.81,12191.12,APC
Repr of anal fistula w/glue,46706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4204.16,,,,,,,fee schedule,2747.81,12191.12,Radiology
Repr of anal fistula w/glue,46706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3846.94,,,,,,,fee schedule,2747.81,12191.12,APC
Repr of anal fistula w/glue,46706,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4808.67,,,,,,,fee schedule,2747.81,12191.12,APC
Repair anorectal fist w/plug,46707,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3633.64,,,,,,,fee schedule,2747.81,12191.12,
Repair anorectal fist w/plug,46707,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2912.68,,,,,,,fee schedule,2747.81,12191.12,
Repair anorectal fist w/plug,46707,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3181.84,,,,,,,fee schedule,2747.81,12191.12,
Repair anorectal fist w/plug,46707,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3345.25,,,,,,,fee schedule,2747.81,12191.12,
Repair anorectal fist w/plug,46707,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12191.12,,,,,,,fee schedule,2747.81,12191.12,APC 378
Repair anorectal fist w/plug,46707,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2885.2,,,,,,,fee schedule,2747.81,12191.12,APC
Repair anorectal fist w/plug,46707,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2857.73,,,,,,,fee schedule,2747.81,12191.12,APC
Repair anorectal fist w/plug,46707,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2747.81,,,,,,,fee schedule,2747.81,12191.12,APC
Repair anorectal fist w/plug,46707,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4204.16,,,,,,,fee schedule,2747.81,12191.12,Radiology
Repair anorectal fist w/plug,46707,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3846.94,,,,,,,fee schedule,2747.81,12191.12,APC
Repair anorectal fist w/plug,46707,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4808.67,,,,,,,fee schedule,2747.81,12191.12,APC
Repair of anal sphincter,46750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7189.69,,,,,,,fee schedule,2747.81,12191.12,
Repair of anal sphincter,46750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5763.16,,,,,,,fee schedule,2747.81,12191.12,
Repair of anal sphincter,46750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6295.73,,,,,,,fee schedule,2747.81,12191.12,
Repair of anal sphincter,46750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6619.08,,,,,,,fee schedule,2747.81,12191.12,
Repair of anal sphincter,46750,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12191.12,,,,,,,fee schedule,2747.81,12191.12,APC 378
Repair of anal sphincter,46750,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2885.2,,,,,,,fee schedule,2747.81,12191.12,APC
Repair of anal sphincter,46750,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2857.73,,,,,,,fee schedule,2747.81,12191.12,APC
Repair of anal sphincter,46750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2747.81,,,,,,,fee schedule,2747.81,12191.12,APC
Repair of anal sphincter,46750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4204.16,,,,,,,fee schedule,2747.81,12191.12,Radiology
Repair of anal sphincter,46750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3846.94,,,,,,,fee schedule,2747.81,12191.12,APC
Repair of anal sphincter,46750,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4808.67,,,,,,,fee schedule,2747.81,12191.12,APC
Reconstruction of anus,46753,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5676.62,,,,,,,fee schedule,2747.81,12191.12,
Reconstruction of anus,46753,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4550.3,,,,,,,fee schedule,2747.81,12191.12,
Reconstruction of anus,46753,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4970.79,,,,,,,fee schedule,2747.81,12191.12,
Reconstruction of anus,46753,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5226.09,,,,,,,fee schedule,2747.81,12191.12,
Reconstruction of anus,46753,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12191.12,,,,,,,fee schedule,2747.81,12191.12,APC 378
Reconstruction of anus,46753,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2885.2,,,,,,,fee schedule,2747.81,12191.12,APC
Reconstruction of anus,46753,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2857.73,,,,,,,fee schedule,2747.81,12191.12,APC
Reconstruction of anus,46753,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2747.81,,,,,,,fee schedule,2747.81,12191.12,APC
Reconstruction of anus,46753,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4204.16,,,,,,,fee schedule,2747.81,12191.12,Radiology
Reconstruction of anus,46753,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3846.94,,,,,,,fee schedule,2747.81,12191.12,APC
Reconstruction of anus,46753,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4808.67,,,,,,,fee schedule,2747.81,12191.12,APC
Removal of suture from anus,46754,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5676.62,,,,,,,fee schedule,2747.81,12191.12,
Removal of suture from anus,46754,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4550.3,,,,,,,fee schedule,2747.81,12191.12,
Removal of suture from anus,46754,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4970.79,,,,,,,fee schedule,2747.81,12191.12,
Removal of suture from anus,46754,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5226.09,,,,,,,fee schedule,2747.81,12191.12,
Removal of suture from anus,46754,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12191.12,,,,,,,fee schedule,2747.81,12191.12,APC 378
Removal of suture from anus,46754,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2885.2,,,,,,,fee schedule,2747.81,12191.12,APC
Removal of suture from anus,46754,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2857.73,,,,,,,fee schedule,2747.81,12191.12,APC
Removal of suture from anus,46754,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2747.81,,,,,,,fee schedule,2747.81,12191.12,APC
Removal of suture from anus,46754,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4204.16,,,,,,,fee schedule,2747.81,12191.12,Radiology
Removal of suture from anus,46754,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3846.94,,,,,,,fee schedule,2747.81,12191.12,APC
Removal of suture from anus,46754,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4808.67,,,,,,,fee schedule,2747.81,12191.12,APC
Repair of anal sphincter,46760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7527.34,,,,,,,fee schedule,2747.81,12191.12,
Repair of anal sphincter,46760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6033.82,,,,,,,fee schedule,2747.81,12191.12,
Repair of anal sphincter,46760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6591.4,,,,,,,fee schedule,2747.81,12191.12,
Repair of anal sphincter,46760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6929.93,,,,,,,fee schedule,2747.81,12191.12,
Repair of anal sphincter,46760,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12191.12,,,,,,,fee schedule,2747.81,12191.12,APC 378
Repair of anal sphincter,46760,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2885.2,,,,,,,fee schedule,2747.81,12191.12,APC
Repair of anal sphincter,46760,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2857.73,,,,,,,fee schedule,2747.81,12191.12,APC
Repair of anal sphincter,46760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2747.81,,,,,,,fee schedule,2747.81,12191.12,APC
Repair of anal sphincter,46760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4204.16,,,,,,,fee schedule,2747.81,12191.12,Radiology
Repair of anal sphincter,46760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3846.94,,,,,,,fee schedule,2747.81,12191.12,APC
Repair of anal sphincter,46760,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4808.67,,,,,,,fee schedule,2747.81,12191.12,APC
Repair of anal sphincter,46761,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7527.34,,,,,,,fee schedule,2747.81,12191.12,
Repair of anal sphincter,46761,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6033.82,,,,,,,fee schedule,2747.81,12191.12,
Repair of anal sphincter,46761,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6591.4,,,,,,,fee schedule,2747.81,12191.12,
Repair of anal sphincter,46761,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6929.93,,,,,,,fee schedule,2747.81,12191.12,
Repair of anal sphincter,46761,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12191.12,,,,,,,fee schedule,2747.81,12191.12,APC 378
Repair of anal sphincter,46761,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2885.2,,,,,,,fee schedule,2747.81,12191.12,APC
Repair of anal sphincter,46761,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2857.73,,,,,,,fee schedule,2747.81,12191.12,APC
Repair of anal sphincter,46761,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2747.81,,,,,,,fee schedule,2747.81,12191.12,APC
Repair of anal sphincter,46761,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4204.16,,,,,,,fee schedule,2747.81,12191.12,Radiology
Repair of anal sphincter,46761,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3846.94,,,,,,,fee schedule,2747.81,12191.12,APC
Repair of anal sphincter,46761,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4808.67,,,,,,,fee schedule,2747.81,12191.12,APC
Destruction anal lesion(s),46900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,663.96,,,,,,,fee schedule,402.44,1785.48,
Destruction anal lesion(s),46900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,532.22,,,,,,,fee schedule,402.44,1785.48,
Destruction anal lesion(s),46900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,581.4,,,,,,,fee schedule,402.44,1785.48,
Destruction anal lesion(s),46900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,611.26,,,,,,,fee schedule,402.44,1785.48,
Destruction anal lesion(s),46900,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1785.48,,,,,,,fee schedule,402.44,1785.48,APC 378
Destruction anal lesion(s),46900,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,422.56,,,,,,,fee schedule,402.44,1785.48,APC
Destruction anal lesion(s),46900,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,418.53,,,,,,,fee schedule,402.44,1785.48,APC
Destruction anal lesion(s),46900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,402.44,,,,,,,fee schedule,402.44,1785.48,APC
Destruction anal lesion(s),46900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,615.73,,,,,,,fee schedule,402.44,1785.48,Radiology
Destruction anal lesion(s),46900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,563.41,,,,,,,fee schedule,402.44,1785.48,APC
Destruction anal lesion(s),46900,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,704.26,,,,,,,fee schedule,402.44,1785.48,APC
Destruction anal lesion(s),46910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4967.56,,,,,,,fee schedule,2042.58,9062.24,
Destruction anal lesion(s),46910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3981.94,,,,,,,fee schedule,2042.58,9062.24,
Destruction anal lesion(s),46910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4349.9,,,,,,,fee schedule,2042.58,9062.24,
Destruction anal lesion(s),46910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4573.31,,,,,,,fee schedule,2042.58,9062.24,
Destruction anal lesion(s),46910,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,2042.58,9062.24,APC 378
Destruction anal lesion(s),46910,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,2042.58,9062.24,APC
Destruction anal lesion(s),46910,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,2042.58,9062.24,APC
Destruction anal lesion(s),46910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,2042.58,9062.24,APC
Destruction anal lesion(s),46910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,2042.58,9062.24,Radiology
Destruction anal lesion(s),46910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,2042.58,9062.24,APC
Destruction anal lesion(s),46910,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,2042.58,9062.24,APC
Cryosurgery anal lesion(s),46916,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,364.24,,,,,,,fee schedule,198.62,881.22,
Cryosurgery anal lesion(s),46916,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,291.97,,,,,,,fee schedule,198.62,881.22,
Cryosurgery anal lesion(s),46916,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,318.95,,,,,,,fee schedule,198.62,881.22,
Cryosurgery anal lesion(s),46916,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,335.33,,,,,,,fee schedule,198.62,881.22,
Cryosurgery anal lesion(s),46916,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,881.22,,,,,,,fee schedule,198.62,881.22,APC 378
Cryosurgery anal lesion(s),46916,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.55,,,,,,,fee schedule,198.62,881.22,APC
Cryosurgery anal lesion(s),46916,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,206.57,,,,,,,fee schedule,198.62,881.22,APC
Cryosurgery anal lesion(s),46916,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.62,,,,,,,fee schedule,198.62,881.22,APC
Cryosurgery anal lesion(s),46916,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.89,,,,,,,fee schedule,198.62,881.22,Radiology
Cryosurgery anal lesion(s),46916,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,278.07,,,,,,,fee schedule,198.62,881.22,APC
Cryosurgery anal lesion(s),46916,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,347.59,,,,,,,fee schedule,198.62,881.22,APC
Laser surgery anal lesions,46917,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9737.23,,,,,,,fee schedule,2747.81,12191.12,
Laser surgery anal lesions,46917,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7805.24,,,,,,,fee schedule,2747.81,12191.12,
Laser surgery anal lesions,46917,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8526.52,,,,,,,fee schedule,2747.81,12191.12,
Laser surgery anal lesions,46917,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8964.43,,,,,,,fee schedule,2747.81,12191.12,
Laser surgery anal lesions,46917,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12191.12,,,,,,,fee schedule,2747.81,12191.12,APC 378
Laser surgery anal lesions,46917,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2885.2,,,,,,,fee schedule,2747.81,12191.12,APC
Laser surgery anal lesions,46917,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2857.73,,,,,,,fee schedule,2747.81,12191.12,APC
Laser surgery anal lesions,46917,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2747.81,,,,,,,fee schedule,2747.81,12191.12,APC
Laser surgery anal lesions,46917,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4204.16,,,,,,,fee schedule,2747.81,12191.12,Radiology
Laser surgery anal lesions,46917,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3846.94,,,,,,,fee schedule,2747.81,12191.12,APC
Laser surgery anal lesions,46917,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4808.67,,,,,,,fee schedule,2747.81,12191.12,APC
Excision of anal lesion(s),46922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3360.79,,,,,,,fee schedule,2693.96,12191.12,
Excision of anal lesion(s),46922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2693.96,,,,,,,fee schedule,2693.96,12191.12,
Excision of anal lesion(s),46922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2942.91,,,,,,,fee schedule,2693.96,12191.12,
Excision of anal lesion(s),46922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3094.06,,,,,,,fee schedule,2693.96,12191.12,
Excision of anal lesion(s),46922,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12191.12,,,,,,,fee schedule,2693.96,12191.12,APC 378
Excision of anal lesion(s),46922,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2885.2,,,,,,,fee schedule,2693.96,12191.12,APC
Excision of anal lesion(s),46922,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2857.73,,,,,,,fee schedule,2693.96,12191.12,APC
Excision of anal lesion(s),46922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2747.81,,,,,,,fee schedule,2693.96,12191.12,APC
Excision of anal lesion(s),46922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4204.16,,,,,,,fee schedule,2693.96,12191.12,Radiology
Excision of anal lesion(s),46922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3846.94,,,,,,,fee schedule,2693.96,12191.12,APC
Excision of anal lesion(s),46922,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4808.67,,,,,,,fee schedule,2693.96,12191.12,APC
Destruction anal lesion(s),46924,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4967.56,,,,,,,fee schedule,2747.81,12191.12,
Destruction anal lesion(s),46924,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3981.94,,,,,,,fee schedule,2747.81,12191.12,
Destruction anal lesion(s),46924,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4349.9,,,,,,,fee schedule,2747.81,12191.12,
Destruction anal lesion(s),46924,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4573.31,,,,,,,fee schedule,2747.81,12191.12,
Destruction anal lesion(s),46924,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12191.12,,,,,,,fee schedule,2747.81,12191.12,APC 378
Destruction anal lesion(s),46924,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2885.2,,,,,,,fee schedule,2747.81,12191.12,APC
Destruction anal lesion(s),46924,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2857.73,,,,,,,fee schedule,2747.81,12191.12,APC
Destruction anal lesion(s),46924,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2747.81,,,,,,,fee schedule,2747.81,12191.12,APC
Destruction anal lesion(s),46924,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4204.16,,,,,,,fee schedule,2747.81,12191.12,Radiology
Destruction anal lesion(s),46924,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3846.94,,,,,,,fee schedule,2747.81,12191.12,APC
Destruction anal lesion(s),46924,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4808.67,,,,,,,fee schedule,2747.81,12191.12,APC
Destroy internal hemorrhoids,46930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6721.57,,,,,,,fee schedule,1184.64,6721.57,
Destroy internal hemorrhoids,46930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5387.93,,,,,,,fee schedule,1184.64,6721.57,
Destroy internal hemorrhoids,46930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5885.82,,,,,,,fee schedule,1184.64,6721.57,
Destroy internal hemorrhoids,46930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6188.11,,,,,,,fee schedule,1184.64,6721.57,
Destroy internal hemorrhoids,46930,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5255.83,,,,,,,fee schedule,1184.64,6721.57,APC 378
Destroy internal hemorrhoids,46930,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1243.87,,,,,,,fee schedule,1184.64,6721.57,APC
Destroy internal hemorrhoids,46930,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1232.02,,,,,,,fee schedule,1184.64,6721.57,APC
Destroy internal hemorrhoids,46930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1184.64,,,,,,,fee schedule,1184.64,6721.57,APC
Destroy internal hemorrhoids,46930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1812.49,,,,,,,fee schedule,1184.64,6721.57,Radiology
Destroy internal hemorrhoids,46930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1658.49,,,,,,,fee schedule,1184.64,6721.57,APC
Destroy internal hemorrhoids,46930,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2073.11,,,,,,,fee schedule,1184.64,6721.57,APC
Treatment of anal fissure,46940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4116.6,,,,,,,fee schedule,2747.81,12191.12,
Treatment of anal fissure,46940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3299.81,,,,,,,fee schedule,2747.81,12191.12,
Treatment of anal fissure,46940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3604.74,,,,,,,fee schedule,2747.81,12191.12,
Treatment of anal fissure,46940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3789.88,,,,,,,fee schedule,2747.81,12191.12,
Treatment of anal fissure,46940,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12191.12,,,,,,,fee schedule,2747.81,12191.12,APC 378
Treatment of anal fissure,46940,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2885.2,,,,,,,fee schedule,2747.81,12191.12,APC
Treatment of anal fissure,46940,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2857.73,,,,,,,fee schedule,2747.81,12191.12,APC
Treatment of anal fissure,46940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2747.81,,,,,,,fee schedule,2747.81,12191.12,APC
Treatment of anal fissure,46940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4204.16,,,,,,,fee schedule,2747.81,12191.12,Radiology
Treatment of anal fissure,46940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3846.94,,,,,,,fee schedule,2747.81,12191.12,APC
Treatment of anal fissure,46940,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4808.67,,,,,,,fee schedule,2747.81,12191.12,APC
Treatment of anal fissure,46942,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1196.33,,,,,,,fee schedule,920.63,4084.51,
Treatment of anal fissure,46942,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,958.96,,,,,,,fee schedule,920.63,4084.51,
Treatment of anal fissure,46942,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1047.58,,,,,,,fee schedule,920.63,4084.51,
Treatment of anal fissure,46942,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1101.39,,,,,,,fee schedule,920.63,4084.51,
Treatment of anal fissure,46942,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4084.51,,,,,,,fee schedule,920.63,4084.51,APC 378
Treatment of anal fissure,46942,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,966.66,,,,,,,fee schedule,920.63,4084.51,APC
Treatment of anal fissure,46942,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,957.45,,,,,,,fee schedule,920.63,4084.51,APC
Treatment of anal fissure,46942,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,920.63,,,,,,,fee schedule,920.63,4084.51,APC
Treatment of anal fissure,46942,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1408.56,,,,,,,fee schedule,920.63,4084.51,Radiology
Treatment of anal fissure,46942,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1288.88,,,,,,,fee schedule,920.63,4084.51,APC
Treatment of anal fissure,46942,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1611.1,,,,,,,fee schedule,920.63,4084.51,APC
Remove by ligat int hem grp,46945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2723.68,,,,,,,fee schedule,2183.27,12191.12,
Remove by ligat int hem grp,46945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2183.27,,,,,,,fee schedule,2183.27,12191.12,
Remove by ligat int hem grp,46945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2385.02,,,,,,,fee schedule,2183.27,12191.12,
Remove by ligat int hem grp,46945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2507.51,,,,,,,fee schedule,2183.27,12191.12,
Remove by ligat int hem grp,46945,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12191.12,,,,,,,fee schedule,2183.27,12191.12,APC 378
Remove by ligat int hem grp,46945,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2885.2,,,,,,,fee schedule,2183.27,12191.12,APC
Remove by ligat int hem grp,46945,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2857.73,,,,,,,fee schedule,2183.27,12191.12,APC
Remove by ligat int hem grp,46945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2747.81,,,,,,,fee schedule,2183.27,12191.12,APC
Remove by ligat int hem grp,46945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4204.16,,,,,,,fee schedule,2183.27,12191.12,Radiology
Remove by ligat int hem grp,46945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3846.94,,,,,,,fee schedule,2183.27,12191.12,APC
Remove by ligat int hem grp,46945,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4808.67,,,,,,,fee schedule,2183.27,12191.12,APC
Remove by ligat int hem grps,46946,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7189.69,,,,,,,fee schedule,2747.81,12191.12,
Remove by ligat int hem grps,46946,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5763.16,,,,,,,fee schedule,2747.81,12191.12,
Remove by ligat int hem grps,46946,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6295.73,,,,,,,fee schedule,2747.81,12191.12,
Remove by ligat int hem grps,46946,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6619.08,,,,,,,fee schedule,2747.81,12191.12,
Remove by ligat int hem grps,46946,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12191.12,,,,,,,fee schedule,2747.81,12191.12,APC 378
Remove by ligat int hem grps,46946,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2885.2,,,,,,,fee schedule,2747.81,12191.12,APC
Remove by ligat int hem grps,46946,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2857.73,,,,,,,fee schedule,2747.81,12191.12,APC
Remove by ligat int hem grps,46946,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2747.81,,,,,,,fee schedule,2747.81,12191.12,APC
Remove by ligat int hem grps,46946,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4204.16,,,,,,,fee schedule,2747.81,12191.12,Radiology
Remove by ligat int hem grps,46946,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3846.94,,,,,,,fee schedule,2747.81,12191.12,APC
Remove by ligat int hem grps,46946,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4808.67,,,,,,,fee schedule,2747.81,12191.12,APC
Hemorrhoidopexy by stapling,46947,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5041.18,,,,,,,fee schedule,2747.81,12191.12,
Hemorrhoidopexy by stapling,46947,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4040.94,,,,,,,fee schedule,2747.81,12191.12,
Hemorrhoidopexy by stapling,46947,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4414.36,,,,,,,fee schedule,2747.81,12191.12,
Hemorrhoidopexy by stapling,46947,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4641.08,,,,,,,fee schedule,2747.81,12191.12,
Hemorrhoidopexy by stapling,46947,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12191.12,,,,,,,fee schedule,2747.81,12191.12,APC 378
Hemorrhoidopexy by stapling,46947,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2885.2,,,,,,,fee schedule,2747.81,12191.12,APC
Hemorrhoidopexy by stapling,46947,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2857.73,,,,,,,fee schedule,2747.81,12191.12,APC
Hemorrhoidopexy by stapling,46947,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2747.81,,,,,,,fee schedule,2747.81,12191.12,APC
Hemorrhoidopexy by stapling,46947,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4204.16,,,,,,,fee schedule,2747.81,12191.12,Radiology
Hemorrhoidopexy by stapling,46947,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3846.94,,,,,,,fee schedule,2747.81,12191.12,APC
Hemorrhoidopexy by stapling,46947,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4808.67,,,,,,,fee schedule,2747.81,12191.12,APC
Int hrhc tranal dartlzj 2+,46948,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8861,,,,,,,fee schedule,2747.81,12191.12,
Int hrhc tranal dartlzj 2+,46948,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7102.87,,,,,,,fee schedule,2747.81,12191.12,
Int hrhc tranal dartlzj 2+,46948,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7759.24,,,,,,,fee schedule,2747.81,12191.12,
Int hrhc tranal dartlzj 2+,46948,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8157.75,,,,,,,fee schedule,2747.81,12191.12,
Int hrhc tranal dartlzj 2+,46948,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12191.12,,,,,,,fee schedule,2747.81,12191.12,APC 378
Int hrhc tranal dartlzj 2+,46948,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2885.2,,,,,,,fee schedule,2747.81,12191.12,APC
Int hrhc tranal dartlzj 2+,46948,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2857.73,,,,,,,fee schedule,2747.81,12191.12,APC
Int hrhc tranal dartlzj 2+,46948,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2747.81,,,,,,,fee schedule,2747.81,12191.12,APC
Int hrhc tranal dartlzj 2+,46948,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4204.16,,,,,,,fee schedule,2747.81,12191.12,Radiology
Int hrhc tranal dartlzj 2+,46948,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3846.94,,,,,,,fee schedule,2747.81,12191.12,APC
Int hrhc tranal dartlzj 2+,46948,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4808.67,,,,,,,fee schedule,2747.81,12191.12,APC
Anus surgery procedure,46999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2425.1,,,,,,,fee schedule,920.63,4084.51,
Anus surgery procedure,46999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1943.93,,,,,,,fee schedule,920.63,4084.51,
Anus surgery procedure,46999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2123.56,,,,,,,fee schedule,920.63,4084.51,
Anus surgery procedure,46999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2232.63,,,,,,,fee schedule,920.63,4084.51,
Anus surgery procedure,46999,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4084.51,,,,,,,fee schedule,920.63,4084.51,APC 378
Anus surgery procedure,46999,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,966.66,,,,,,,fee schedule,920.63,4084.51,APC
Anus surgery procedure,46999,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,957.45,,,,,,,fee schedule,920.63,4084.51,APC
Anus surgery procedure,46999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,920.63,,,,,,,fee schedule,920.63,4084.51,APC
Anus surgery procedure,46999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1408.56,,,,,,,fee schedule,920.63,4084.51,Radiology
Anus surgery procedure,46999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1288.88,,,,,,,fee schedule,920.63,4084.51,APC
Anus surgery procedure,46999,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1611.1,,,,,,,fee schedule,920.63,4084.51,APC
Needle biopsy of liver,47000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1624.24,,,,,,,fee schedule,1301.97,7254.06,
Needle biopsy of liver,47000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1301.97,,,,,,,fee schedule,1301.97,7254.06,
Needle biopsy of liver,47000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1422.28,,,,,,,fee schedule,1301.97,7254.06,
Needle biopsy of liver,47000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1495.33,,,,,,,fee schedule,1301.97,7254.06,
Needle biopsy of liver,47000,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1301.97,7254.06,APC 378
Needle biopsy of liver,47000,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1301.97,7254.06,APC
Needle biopsy of liver,47000,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1301.97,7254.06,APC
Needle biopsy of liver,47000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1301.97,7254.06,APC
Needle biopsy of liver,47000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1301.97,7254.06,Radiology
Needle biopsy of liver,47000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1301.97,7254.06,APC
Needle biopsy of liver,47000,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1301.97,7254.06,APC
Laparo ablate liver tumor rf,47370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17386.71,,,,,,,fee schedule,10523.19,46687.84,
Laparo ablate liver tumor rf,47370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13936.97,,,,,,,fee schedule,10523.19,46687.84,
Laparo ablate liver tumor rf,47370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15224.87,,,,,,,fee schedule,10523.19,46687.84,
Laparo ablate liver tumor rf,47370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16006.82,,,,,,,fee schedule,10523.19,46687.84,
Laparo ablate liver tumor rf,47370,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46687.84,,,,,,,fee schedule,10523.19,46687.84,APC 378
Laparo ablate liver tumor rf,47370,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11049.35,,,,,,,fee schedule,10523.19,46687.84,APC
Laparo ablate liver tumor rf,47370,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10944.12,,,,,,,fee schedule,10523.19,46687.84,APC
Laparo ablate liver tumor rf,47370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10523.19,,,,,,,fee schedule,10523.19,46687.84,APC
Laparo ablate liver tumor rf,47370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16100.48,,,,,,,fee schedule,10523.19,46687.84,Radiology
Laparo ablate liver tumor rf,47370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14732.47,,,,,,,fee schedule,10523.19,46687.84,APC
Laparo ablate liver tumor rf,47370,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18415.58,,,,,,,fee schedule,10523.19,46687.84,APC
Laparo ablate liver cryosurg,47371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11363.59,,,,,,,fee schedule,9108.91,46687.84,
Laparo ablate liver cryosurg,47371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9108.91,,,,,,,fee schedule,9108.91,46687.84,
Laparo ablate liver cryosurg,47371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9950.65,,,,,,,fee schedule,9108.91,46687.84,
Laparo ablate liver cryosurg,47371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10461.72,,,,,,,fee schedule,9108.91,46687.84,
Laparo ablate liver cryosurg,47371,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46687.84,,,,,,,fee schedule,9108.91,46687.84,APC 378
Laparo ablate liver cryosurg,47371,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11049.35,,,,,,,fee schedule,9108.91,46687.84,APC
Laparo ablate liver cryosurg,47371,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10944.12,,,,,,,fee schedule,9108.91,46687.84,APC
Laparo ablate liver cryosurg,47371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10523.19,,,,,,,fee schedule,9108.91,46687.84,APC
Laparo ablate liver cryosurg,47371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16100.48,,,,,,,fee schedule,9108.91,46687.84,Radiology
Laparo ablate liver cryosurg,47371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14732.47,,,,,,,fee schedule,9108.91,46687.84,APC
Laparo ablate liver cryosurg,47371,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18415.58,,,,,,,fee schedule,9108.91,46687.84,APC
Laparoscope procedure liver,47379,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7101.37,,,,,,,fee schedule,5692.37,26552.87,
Laparoscope procedure liver,47379,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5692.37,,,,,,,fee schedule,5692.37,26552.87,
Laparoscope procedure liver,47379,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6218.4,,,,,,,fee schedule,5692.37,26552.87,
Laparoscope procedure liver,47379,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6537.77,,,,,,,fee schedule,5692.37,26552.87,
Laparoscope procedure liver,47379,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,5692.37,26552.87,APC 378
Laparoscope procedure liver,47379,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,5692.37,26552.87,APC
Laparoscope procedure liver,47379,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,5692.37,26552.87,APC
Laparoscope procedure liver,47379,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,5692.37,26552.87,APC
Laparoscope procedure liver,47379,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,5692.37,26552.87,Radiology
Laparoscope procedure liver,47379,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,5692.37,26552.87,APC
Laparoscope procedure liver,47379,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,5692.37,26552.87,APC
Percut ablate liver rf,47382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10731.23,,,,,,,fee schedule,5984.88,26552.87,
Percut ablate liver rf,47382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8602.02,,,,,,,fee schedule,5984.88,26552.87,
Percut ablate liver rf,47382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9396.92,,,,,,,fee schedule,5984.88,26552.87,
Percut ablate liver rf,47382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9879.55,,,,,,,fee schedule,5984.88,26552.87,
Percut ablate liver rf,47382,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,5984.88,26552.87,APC 378
Percut ablate liver rf,47382,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,5984.88,26552.87,APC
Percut ablate liver rf,47382,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,5984.88,26552.87,APC
Percut ablate liver rf,47382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,5984.88,26552.87,APC
Percut ablate liver rf,47382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,5984.88,26552.87,Radiology
Percut ablate liver rf,47382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,5984.88,26552.87,APC
Percut ablate liver rf,47382,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,5984.88,26552.87,APC
Perq abltj lvr cryoablation,47383,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15482.46,,,,,,,fee schedule,10523.19,46687.84,
Perq abltj lvr cryoablation,47383,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12410.55,,,,,,,fee schedule,10523.19,46687.84,
Perq abltj lvr cryoablation,47383,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13557.4,,,,,,,fee schedule,10523.19,46687.84,
Perq abltj lvr cryoablation,47383,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14253.7,,,,,,,fee schedule,10523.19,46687.84,
Perq abltj lvr cryoablation,47383,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46687.84,,,,,,,fee schedule,10523.19,46687.84,APC 378
Perq abltj lvr cryoablation,47383,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11049.35,,,,,,,fee schedule,10523.19,46687.84,APC
Perq abltj lvr cryoablation,47383,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10944.12,,,,,,,fee schedule,10523.19,46687.84,APC
Perq abltj lvr cryoablation,47383,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10523.19,,,,,,,fee schedule,10523.19,46687.84,APC
Perq abltj lvr cryoablation,47383,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16100.48,,,,,,,fee schedule,10523.19,46687.84,Radiology
Perq abltj lvr cryoablation,47383,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14732.47,,,,,,,fee schedule,10523.19,46687.84,APC
Perq abltj lvr cryoablation,47383,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18415.58,,,,,,,fee schedule,10523.19,46687.84,APC
Abltj ire liver 1+ tum perq,47384,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46687.84,,,,,,,fee schedule,10523.19,46687.84,APC 378
Abltj ire liver 1+ tum perq,47384,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11049.35,,,,,,,fee schedule,10523.19,46687.84,APC
Abltj ire liver 1+ tum perq,47384,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10944.12,,,,,,,fee schedule,10523.19,46687.84,APC
Abltj ire liver 1+ tum perq,47384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10523.19,,,,,,,fee schedule,10523.19,46687.84,APC
Abltj ire liver 1+ tum perq,47384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16100.48,,,,,,,fee schedule,10523.19,46687.84,Radiology
Abltj ire liver 1+ tum perq,47384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14732.47,,,,,,,fee schedule,10523.19,46687.84,APC
Abltj ire liver 1+ tum perq,47384,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18415.58,,,,,,,fee schedule,10523.19,46687.84,APC
Liver surgery procedure,47399,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1079.91,,,,,,,fee schedule,701.03,3110.22,
Liver surgery procedure,47399,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,865.64,,,,,,,fee schedule,701.03,3110.22,
Liver surgery procedure,47399,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,945.63,,,,,,,fee schedule,701.03,3110.22,
Liver surgery procedure,47399,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,994.2,,,,,,,fee schedule,701.03,3110.22,
Liver surgery procedure,47399,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3110.22,,,,,,,fee schedule,701.03,3110.22,APC 378
Liver surgery procedure,47399,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,736.08,,,,,,,fee schedule,701.03,3110.22,APC
Liver surgery procedure,47399,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,729.07,,,,,,,fee schedule,701.03,3110.22,APC
Liver surgery procedure,47399,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,701.03,,,,,,,fee schedule,701.03,3110.22,APC
Liver surgery procedure,47399,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1072.57,,,,,,,fee schedule,701.03,3110.22,Radiology
Liver surgery procedure,47399,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,981.44,,,,,,,fee schedule,701.03,3110.22,APC
Liver surgery procedure,47399,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1226.8,,,,,,,fee schedule,701.03,3110.22,APC
Incision of gallbladder,47490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7159.92,,,,,,,fee schedule,3544.48,15725.66,
Incision of gallbladder,47490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5739.3,,,,,,,fee schedule,3544.48,15725.66,
Incision of gallbladder,47490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6269.67,,,,,,,fee schedule,3544.48,15725.66,
Incision of gallbladder,47490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6591.68,,,,,,,fee schedule,3544.48,15725.66,
Incision of gallbladder,47490,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15725.66,,,,,,,fee schedule,3544.48,15725.66,APC 378
Incision of gallbladder,47490,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3721.7,,,,,,,fee schedule,3544.48,15725.66,APC
Incision of gallbladder,47490,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3686.26,,,,,,,fee schedule,3544.48,15725.66,APC
Incision of gallbladder,47490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3544.48,,,,,,,fee schedule,3544.48,15725.66,APC
Incision of gallbladder,47490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5423.05,,,,,,,fee schedule,3544.48,15725.66,Radiology
Incision of gallbladder,47490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4962.27,,,,,,,fee schedule,3544.48,15725.66,APC
Incision of gallbladder,47490,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6202.84,,,,,,,fee schedule,3544.48,15725.66,APC
Injection for cholangiogram,47531,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,614.4,,,,,,,fee schedule,492.5,15725.66,
Injection for cholangiogram,47531,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,492.5,,,,,,,fee schedule,492.5,15725.66,
Injection for cholangiogram,47531,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,538.01,,,,,,,fee schedule,492.5,15725.66,
Injection for cholangiogram,47531,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,565.64,,,,,,,fee schedule,492.5,15725.66,
Injection for cholangiogram,47531,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15725.66,,,,,,,fee schedule,492.5,15725.66,APC 378
Injection for cholangiogram,47531,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3721.7,,,,,,,fee schedule,492.5,15725.66,APC
Injection for cholangiogram,47531,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3686.26,,,,,,,fee schedule,492.5,15725.66,APC
Injection for cholangiogram,47531,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3544.48,,,,,,,fee schedule,492.5,15725.66,APC
Injection for cholangiogram,47531,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5423.05,,,,,,,fee schedule,492.5,15725.66,Radiology
Injection for cholangiogram,47531,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4962.27,,,,,,,fee schedule,492.5,15725.66,APC
Injection for cholangiogram,47531,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6202.84,,,,,,,fee schedule,492.5,15725.66,APC
Injection for cholangiogram,47532,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8229.48,,,,,,,fee schedule,3544.48,15725.66,
Injection for cholangiogram,47532,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6596.64,,,,,,,fee schedule,3544.48,15725.66,
Injection for cholangiogram,47532,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7206.23,,,,,,,fee schedule,3544.48,15725.66,
Injection for cholangiogram,47532,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7576.34,,,,,,,fee schedule,3544.48,15725.66,
Injection for cholangiogram,47532,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15725.66,,,,,,,fee schedule,3544.48,15725.66,APC 378
Injection for cholangiogram,47532,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3721.7,,,,,,,fee schedule,3544.48,15725.66,APC
Injection for cholangiogram,47532,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3686.26,,,,,,,fee schedule,3544.48,15725.66,APC
Injection for cholangiogram,47532,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3544.48,,,,,,,fee schedule,3544.48,15725.66,APC
Injection for cholangiogram,47532,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5423.05,,,,,,,fee schedule,3544.48,15725.66,Radiology
Injection for cholangiogram,47532,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4962.27,,,,,,,fee schedule,3544.48,15725.66,APC
Injection for cholangiogram,47532,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6202.84,,,,,,,fee schedule,3544.48,15725.66,APC
Plmt biliary drainage cath,47533,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8229.48,,,,,,,fee schedule,3544.48,15725.66,
Plmt biliary drainage cath,47533,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6596.64,,,,,,,fee schedule,3544.48,15725.66,
Plmt biliary drainage cath,47533,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7206.23,,,,,,,fee schedule,3544.48,15725.66,
Plmt biliary drainage cath,47533,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7576.34,,,,,,,fee schedule,3544.48,15725.66,
Plmt biliary drainage cath,47533,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15725.66,,,,,,,fee schedule,3544.48,15725.66,APC 378
Plmt biliary drainage cath,47533,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3721.7,,,,,,,fee schedule,3544.48,15725.66,APC
Plmt biliary drainage cath,47533,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3686.26,,,,,,,fee schedule,3544.48,15725.66,APC
Plmt biliary drainage cath,47533,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3544.48,,,,,,,fee schedule,3544.48,15725.66,APC
Plmt biliary drainage cath,47533,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5423.05,,,,,,,fee schedule,3544.48,15725.66,Radiology
Plmt biliary drainage cath,47533,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4962.27,,,,,,,fee schedule,3544.48,15725.66,APC
Plmt biliary drainage cath,47533,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6202.84,,,,,,,fee schedule,3544.48,15725.66,APC
Plmt biliary drainage cath,47534,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8229.48,,,,,,,fee schedule,3544.48,15725.66,
Plmt biliary drainage cath,47534,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6596.64,,,,,,,fee schedule,3544.48,15725.66,
Plmt biliary drainage cath,47534,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7206.23,,,,,,,fee schedule,3544.48,15725.66,
Plmt biliary drainage cath,47534,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7576.34,,,,,,,fee schedule,3544.48,15725.66,
Plmt biliary drainage cath,47534,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15725.66,,,,,,,fee schedule,3544.48,15725.66,APC 378
Plmt biliary drainage cath,47534,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3721.7,,,,,,,fee schedule,3544.48,15725.66,APC
Plmt biliary drainage cath,47534,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3686.26,,,,,,,fee schedule,3544.48,15725.66,APC
Plmt biliary drainage cath,47534,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3544.48,,,,,,,fee schedule,3544.48,15725.66,APC
Plmt biliary drainage cath,47534,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5423.05,,,,,,,fee schedule,3544.48,15725.66,Radiology
Plmt biliary drainage cath,47534,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4962.27,,,,,,,fee schedule,3544.48,15725.66,APC
Plmt biliary drainage cath,47534,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6202.84,,,,,,,fee schedule,3544.48,15725.66,APC
Conversion ext bil drg cath,47535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8229.48,,,,,,,fee schedule,3544.48,15725.66,
Conversion ext bil drg cath,47535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6596.64,,,,,,,fee schedule,3544.48,15725.66,
Conversion ext bil drg cath,47535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7206.23,,,,,,,fee schedule,3544.48,15725.66,
Conversion ext bil drg cath,47535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7576.34,,,,,,,fee schedule,3544.48,15725.66,
Conversion ext bil drg cath,47535,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15725.66,,,,,,,fee schedule,3544.48,15725.66,APC 378
Conversion ext bil drg cath,47535,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3721.7,,,,,,,fee schedule,3544.48,15725.66,APC
Conversion ext bil drg cath,47535,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3686.26,,,,,,,fee schedule,3544.48,15725.66,APC
Conversion ext bil drg cath,47535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3544.48,,,,,,,fee schedule,3544.48,15725.66,APC
Conversion ext bil drg cath,47535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5423.05,,,,,,,fee schedule,3544.48,15725.66,Radiology
Conversion ext bil drg cath,47535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4962.27,,,,,,,fee schedule,3544.48,15725.66,APC
Conversion ext bil drg cath,47535,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6202.84,,,,,,,fee schedule,3544.48,15725.66,APC
Exchange biliary drg cath,47536,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3122.94,,,,,,,fee schedule,2503.31,15725.66,
Exchange biliary drg cath,47536,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2503.31,,,,,,,fee schedule,2503.31,15725.66,
Exchange biliary drg cath,47536,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2734.63,,,,,,,fee schedule,2503.31,15725.66,
Exchange biliary drg cath,47536,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2875.08,,,,,,,fee schedule,2503.31,15725.66,
Exchange biliary drg cath,47536,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15725.66,,,,,,,fee schedule,2503.31,15725.66,APC 378
Exchange biliary drg cath,47536,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3721.7,,,,,,,fee schedule,2503.31,15725.66,APC
Exchange biliary drg cath,47536,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3686.26,,,,,,,fee schedule,2503.31,15725.66,APC
Exchange biliary drg cath,47536,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3544.48,,,,,,,fee schedule,2503.31,15725.66,APC
Exchange biliary drg cath,47536,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5423.05,,,,,,,fee schedule,2503.31,15725.66,Radiology
Exchange biliary drg cath,47536,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4962.27,,,,,,,fee schedule,2503.31,15725.66,APC
Exchange biliary drg cath,47536,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6202.84,,,,,,,fee schedule,2503.31,15725.66,APC
Removal biliary drg cath,47537,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1825.1,,,,,,,fee schedule,897.89,3983.62,
Removal biliary drg cath,47537,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1462.97,,,,,,,fee schedule,897.89,3983.62,
Removal biliary drg cath,47537,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1598.17,,,,,,,fee schedule,897.89,3983.62,
Removal biliary drg cath,47537,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1680.25,,,,,,,fee schedule,897.89,3983.62,
Removal biliary drg cath,47537,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3983.62,,,,,,,fee schedule,897.89,3983.62,APC 378
Removal biliary drg cath,47537,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,942.78,,,,,,,fee schedule,897.89,3983.62,APC
Removal biliary drg cath,47537,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,933.8,,,,,,,fee schedule,897.89,3983.62,APC
Removal biliary drg cath,47537,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,897.89,,,,,,,fee schedule,897.89,3983.62,APC
Removal biliary drg cath,47537,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1373.77,,,,,,,fee schedule,897.89,3983.62,Radiology
Removal biliary drg cath,47537,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1257.04,,,,,,,fee schedule,897.89,3983.62,APC
Removal biliary drg cath,47537,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1571.3,,,,,,,fee schedule,897.89,3983.62,APC
Perq plmt bile duct stent,47538,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15566.91,,,,,,,fee schedule,5984.88,26552.87,
Perq plmt bile duct stent,47538,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12478.24,,,,,,,fee schedule,5984.88,26552.87,
Perq plmt bile duct stent,47538,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13631.34,,,,,,,fee schedule,5984.88,26552.87,
Perq plmt bile duct stent,47538,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14331.44,,,,,,,fee schedule,5984.88,26552.87,
Perq plmt bile duct stent,47538,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,5984.88,26552.87,APC 378
Perq plmt bile duct stent,47538,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,5984.88,26552.87,APC
Perq plmt bile duct stent,47538,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,5984.88,26552.87,APC
Perq plmt bile duct stent,47538,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,5984.88,26552.87,APC
Perq plmt bile duct stent,47538,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,5984.88,26552.87,Radiology
Perq plmt bile duct stent,47538,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,5984.88,26552.87,APC
Perq plmt bile duct stent,47538,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,5984.88,26552.87,APC
Perq plmt bile duct stent,47539,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15566.91,,,,,,,fee schedule,5984.88,26552.87,
Perq plmt bile duct stent,47539,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12478.24,,,,,,,fee schedule,5984.88,26552.87,
Perq plmt bile duct stent,47539,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13631.34,,,,,,,fee schedule,5984.88,26552.87,
Perq plmt bile duct stent,47539,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14331.44,,,,,,,fee schedule,5984.88,26552.87,
Perq plmt bile duct stent,47539,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,5984.88,26552.87,APC 378
Perq plmt bile duct stent,47539,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,5984.88,26552.87,APC
Perq plmt bile duct stent,47539,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,5984.88,26552.87,APC
Perq plmt bile duct stent,47539,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,5984.88,26552.87,APC
Perq plmt bile duct stent,47539,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,5984.88,26552.87,Radiology
Perq plmt bile duct stent,47539,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,5984.88,26552.87,APC
Perq plmt bile duct stent,47539,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,5984.88,26552.87,APC
Perq plmt bile duct stent,47540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15566.91,,,,,,,fee schedule,5984.88,26552.87,
Perq plmt bile duct stent,47540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12478.24,,,,,,,fee schedule,5984.88,26552.87,
Perq plmt bile duct stent,47540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13631.34,,,,,,,fee schedule,5984.88,26552.87,
Perq plmt bile duct stent,47540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14331.44,,,,,,,fee schedule,5984.88,26552.87,
Perq plmt bile duct stent,47540,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,5984.88,26552.87,APC 378
Perq plmt bile duct stent,47540,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,5984.88,26552.87,APC
Perq plmt bile duct stent,47540,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,5984.88,26552.87,APC
Perq plmt bile duct stent,47540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,5984.88,26552.87,APC
Perq plmt bile duct stent,47540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,5984.88,26552.87,Radiology
Perq plmt bile duct stent,47540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,5984.88,26552.87,APC
Perq plmt bile duct stent,47540,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,5984.88,26552.87,APC
Plmt access bil tree sm bwl,47541,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8229.48,,,,,,,fee schedule,6408.87,28434,
Plmt access bil tree sm bwl,47541,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6596.64,,,,,,,fee schedule,6408.87,28434,
Plmt access bil tree sm bwl,47541,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7206.23,,,,,,,fee schedule,6408.87,28434,
Plmt access bil tree sm bwl,47541,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7576.34,,,,,,,fee schedule,6408.87,28434,
Plmt access bil tree sm bwl,47541,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,28434,,,,,,,fee schedule,6408.87,28434,APC 378
Plmt access bil tree sm bwl,47541,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6729.32,,,,,,,fee schedule,6408.87,28434,APC
Plmt access bil tree sm bwl,47541,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6665.23,,,,,,,fee schedule,6408.87,28434,APC
Plmt access bil tree sm bwl,47541,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6408.87,,,,,,,fee schedule,6408.87,28434,APC
Plmt access bil tree sm bwl,47541,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9805.57,,,,,,,fee schedule,6408.87,28434,Radiology
Plmt access bil tree sm bwl,47541,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8972.42,,,,,,,fee schedule,6408.87,28434,APC
Plmt access bil tree sm bwl,47541,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11215.53,,,,,,,fee schedule,6408.87,28434,APC
Dilate biliary duct/ampulla,47542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,529.31,,,,,,,fee schedule,424.29,529.31,
Dilate biliary duct/ampulla,47542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,424.29,,,,,,,fee schedule,424.29,529.31,
Dilate biliary duct/ampulla,47542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,463.5,,,,,,,fee schedule,424.29,529.31,
Dilate biliary duct/ampulla,47542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,487.3,,,,,,,fee schedule,424.29,529.31,
Endoluminal bx biliary tree,47543,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,664.52,,,,,,,fee schedule,532.67,664.52,
Endoluminal bx biliary tree,47543,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,532.67,,,,,,,fee schedule,532.67,664.52,
Endoluminal bx biliary tree,47543,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,581.9,,,,,,,fee schedule,532.67,664.52,
Endoluminal bx biliary tree,47543,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,611.78,,,,,,,fee schedule,532.67,664.52,
Removal duct glbldr calculi,47544,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,842.41,,,,,,,fee schedule,675.27,842.41,
Removal duct glbldr calculi,47544,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,675.27,,,,,,,fee schedule,675.27,842.41,
Removal duct glbldr calculi,47544,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,737.67,,,,,,,fee schedule,675.27,842.41,
Removal duct glbldr calculi,47544,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,775.55,,,,,,,fee schedule,675.27,842.41,
Biliary endo perq dx w/speci,47552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7159.92,,,,,,,fee schedule,5739.3,28434,
Biliary endo perq dx w/speci,47552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5739.3,,,,,,,fee schedule,5739.3,28434,
Biliary endo perq dx w/speci,47552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6269.67,,,,,,,fee schedule,5739.3,28434,
Biliary endo perq dx w/speci,47552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6591.68,,,,,,,fee schedule,5739.3,28434,
Biliary endo perq dx w/speci,47552,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,28434,,,,,,,fee schedule,5739.3,28434,APC 378
Biliary endo perq dx w/speci,47552,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6729.32,,,,,,,fee schedule,5739.3,28434,APC
Biliary endo perq dx w/speci,47552,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6665.23,,,,,,,fee schedule,5739.3,28434,APC
Biliary endo perq dx w/speci,47552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6408.87,,,,,,,fee schedule,5739.3,28434,APC
Biliary endo perq dx w/speci,47552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9805.57,,,,,,,fee schedule,5739.3,28434,Radiology
Biliary endo perq dx w/speci,47552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8972.42,,,,,,,fee schedule,5739.3,28434,APC
Biliary endo perq dx w/speci,47552,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11215.53,,,,,,,fee schedule,5739.3,28434,APC
Biliary endoscopy thru skin,47553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7159.92,,,,,,,fee schedule,5739.3,28434,
Biliary endoscopy thru skin,47553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5739.3,,,,,,,fee schedule,5739.3,28434,
Biliary endoscopy thru skin,47553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6269.67,,,,,,,fee schedule,5739.3,28434,
Biliary endoscopy thru skin,47553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6591.68,,,,,,,fee schedule,5739.3,28434,
Biliary endoscopy thru skin,47553,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,28434,,,,,,,fee schedule,5739.3,28434,APC 378
Biliary endoscopy thru skin,47553,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6729.32,,,,,,,fee schedule,5739.3,28434,APC
Biliary endoscopy thru skin,47553,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6665.23,,,,,,,fee schedule,5739.3,28434,APC
Biliary endoscopy thru skin,47553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6408.87,,,,,,,fee schedule,5739.3,28434,APC
Biliary endoscopy thru skin,47553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9805.57,,,,,,,fee schedule,5739.3,28434,Radiology
Biliary endoscopy thru skin,47553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8972.42,,,,,,,fee schedule,5739.3,28434,APC
Biliary endoscopy thru skin,47553,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11215.53,,,,,,,fee schedule,5739.3,28434,APC
Biliary endoscopy thru skin,47554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7159.92,,,,,,,fee schedule,5739.3,46687.84,
Biliary endoscopy thru skin,47554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5739.3,,,,,,,fee schedule,5739.3,46687.84,
Biliary endoscopy thru skin,47554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6269.67,,,,,,,fee schedule,5739.3,46687.84,
Biliary endoscopy thru skin,47554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6591.68,,,,,,,fee schedule,5739.3,46687.84,
Biliary endoscopy thru skin,47554,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46687.84,,,,,,,fee schedule,5739.3,46687.84,APC 378
Biliary endoscopy thru skin,47554,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11049.35,,,,,,,fee schedule,5739.3,46687.84,APC
Biliary endoscopy thru skin,47554,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10944.12,,,,,,,fee schedule,5739.3,46687.84,APC
Biliary endoscopy thru skin,47554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10523.19,,,,,,,fee schedule,5739.3,46687.84,APC
Biliary endoscopy thru skin,47554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16100.48,,,,,,,fee schedule,5739.3,46687.84,Radiology
Biliary endoscopy thru skin,47554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14732.47,,,,,,,fee schedule,5739.3,46687.84,APC
Biliary endoscopy thru skin,47554,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18415.58,,,,,,,fee schedule,5739.3,46687.84,APC
Biliary endoscopy thru skin,47555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7159.92,,,,,,,fee schedule,5739.3,28434,
Biliary endoscopy thru skin,47555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5739.3,,,,,,,fee schedule,5739.3,28434,
Biliary endoscopy thru skin,47555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6269.67,,,,,,,fee schedule,5739.3,28434,
Biliary endoscopy thru skin,47555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6591.68,,,,,,,fee schedule,5739.3,28434,
Biliary endoscopy thru skin,47555,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,28434,,,,,,,fee schedule,5739.3,28434,APC 378
Biliary endoscopy thru skin,47555,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6729.32,,,,,,,fee schedule,5739.3,28434,APC
Biliary endoscopy thru skin,47555,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6665.23,,,,,,,fee schedule,5739.3,28434,APC
Biliary endoscopy thru skin,47555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6408.87,,,,,,,fee schedule,5739.3,28434,APC
Biliary endoscopy thru skin,47555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9805.57,,,,,,,fee schedule,5739.3,28434,Radiology
Biliary endoscopy thru skin,47555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8972.42,,,,,,,fee schedule,5739.3,28434,APC
Biliary endoscopy thru skin,47555,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11215.53,,,,,,,fee schedule,5739.3,28434,APC
Biliary endoscopy thru skin,47556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7159.92,,,,,,,fee schedule,5739.3,46687.84,
Biliary endoscopy thru skin,47556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5739.3,,,,,,,fee schedule,5739.3,46687.84,
Biliary endoscopy thru skin,47556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6269.67,,,,,,,fee schedule,5739.3,46687.84,
Biliary endoscopy thru skin,47556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6591.68,,,,,,,fee schedule,5739.3,46687.84,
Biliary endoscopy thru skin,47556,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46687.84,,,,,,,fee schedule,5739.3,46687.84,APC 378
Biliary endoscopy thru skin,47556,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11049.35,,,,,,,fee schedule,5739.3,46687.84,APC
Biliary endoscopy thru skin,47556,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10944.12,,,,,,,fee schedule,5739.3,46687.84,APC
Biliary endoscopy thru skin,47556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10523.19,,,,,,,fee schedule,5739.3,46687.84,APC
Biliary endoscopy thru skin,47556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16100.48,,,,,,,fee schedule,5739.3,46687.84,Radiology
Biliary endoscopy thru skin,47556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14732.47,,,,,,,fee schedule,5739.3,46687.84,APC
Biliary endoscopy thru skin,47556,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18415.58,,,,,,,fee schedule,5739.3,46687.84,APC
Laparoscopic cholecystectomy,47562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14146.85,,,,,,,fee schedule,5984.88,26552.87,
Laparoscopic cholecystectomy,47562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11339.94,,,,,,,fee schedule,5984.88,26552.87,
Laparoscopic cholecystectomy,47562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12387.85,,,,,,,fee schedule,5984.88,26552.87,
Laparoscopic cholecystectomy,47562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13024.08,,,,,,,fee schedule,5984.88,26552.87,
Laparoscopic cholecystectomy,47562,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,5984.88,26552.87,APC 378
Laparoscopic cholecystectomy,47562,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscopic cholecystectomy,47562,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscopic cholecystectomy,47562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscopic cholecystectomy,47562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,5984.88,26552.87,Radiology
Laparoscopic cholecystectomy,47562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscopic cholecystectomy,47562,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,5984.88,26552.87,APC
Laparo cholecystectomy/graph,47563,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13716.59,,,,,,,fee schedule,5984.88,26552.87,
Laparo cholecystectomy/graph,47563,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10995.04,,,,,,,fee schedule,5984.88,26552.87,
Laparo cholecystectomy/graph,47563,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12011.09,,,,,,,fee schedule,5984.88,26552.87,
Laparo cholecystectomy/graph,47563,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12627.97,,,,,,,fee schedule,5984.88,26552.87,
Laparo cholecystectomy/graph,47563,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,5984.88,26552.87,APC 378
Laparo cholecystectomy/graph,47563,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,5984.88,26552.87,APC
Laparo cholecystectomy/graph,47563,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,5984.88,26552.87,APC
Laparo cholecystectomy/graph,47563,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,5984.88,26552.87,APC
Laparo cholecystectomy/graph,47563,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,5984.88,26552.87,Radiology
Laparo cholecystectomy/graph,47563,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,5984.88,26552.87,APC
Laparo cholecystectomy/graph,47563,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,5984.88,26552.87,APC
Laparo cholecystectomy/explr,47564,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11363.59,,,,,,,fee schedule,9108.91,46687.84,
Laparo cholecystectomy/explr,47564,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9108.91,,,,,,,fee schedule,9108.91,46687.84,
Laparo cholecystectomy/explr,47564,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9950.65,,,,,,,fee schedule,9108.91,46687.84,
Laparo cholecystectomy/explr,47564,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10461.72,,,,,,,fee schedule,9108.91,46687.84,
Laparo cholecystectomy/explr,47564,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46687.84,,,,,,,fee schedule,9108.91,46687.84,APC 378
Laparo cholecystectomy/explr,47564,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11049.35,,,,,,,fee schedule,9108.91,46687.84,APC
Laparo cholecystectomy/explr,47564,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10944.12,,,,,,,fee schedule,9108.91,46687.84,APC
Laparo cholecystectomy/explr,47564,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10523.19,,,,,,,fee schedule,9108.91,46687.84,APC
Laparo cholecystectomy/explr,47564,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16100.48,,,,,,,fee schedule,9108.91,46687.84,Radiology
Laparo cholecystectomy/explr,47564,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14732.47,,,,,,,fee schedule,9108.91,46687.84,APC
Laparo cholecystectomy/explr,47564,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18415.58,,,,,,,fee schedule,9108.91,46687.84,APC
Laparoscope proc biliary,47579,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8584.34,,,,,,,fee schedule,5984.88,26552.87,
Laparoscope proc biliary,47579,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6881.1,,,,,,,fee schedule,5984.88,26552.87,
Laparoscope proc biliary,47579,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7516.98,,,,,,,fee schedule,5984.88,26552.87,
Laparoscope proc biliary,47579,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7903.05,,,,,,,fee schedule,5984.88,26552.87,
Laparoscope proc biliary,47579,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,5984.88,26552.87,APC 378
Laparoscope proc biliary,47579,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscope proc biliary,47579,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscope proc biliary,47579,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscope proc biliary,47579,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,5984.88,26552.87,Radiology
Laparoscope proc biliary,47579,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscope proc biliary,47579,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,5984.88,26552.87,APC
Bile tract surgery procedure,47999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7159.92,,,,,,,fee schedule,897.89,7159.92,
Bile tract surgery procedure,47999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5739.3,,,,,,,fee schedule,897.89,7159.92,
Bile tract surgery procedure,47999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6269.67,,,,,,,fee schedule,897.89,7159.92,
Bile tract surgery procedure,47999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6591.68,,,,,,,fee schedule,897.89,7159.92,
Bile tract surgery procedure,47999,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3983.62,,,,,,,fee schedule,897.89,7159.92,APC 378
Bile tract surgery procedure,47999,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,942.78,,,,,,,fee schedule,897.89,7159.92,APC
Bile tract surgery procedure,47999,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,933.8,,,,,,,fee schedule,897.89,7159.92,APC
Bile tract surgery procedure,47999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,897.89,,,,,,,fee schedule,897.89,7159.92,APC
Bile tract surgery procedure,47999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1373.77,,,,,,,fee schedule,897.89,7159.92,Radiology
Bile tract surgery procedure,47999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1257.04,,,,,,,fee schedule,897.89,7159.92,APC
Bile tract surgery procedure,47999,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1571.3,,,,,,,fee schedule,897.89,7159.92,APC
Needle biopsy pancreas,48102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2329.88,,,,,,,fee schedule,1635.03,7254.06,
Needle biopsy pancreas,48102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1867.6,,,,,,,fee schedule,1635.03,7254.06,
Needle biopsy pancreas,48102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2040.18,,,,,,,fee schedule,1635.03,7254.06,
Needle biopsy pancreas,48102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2144.97,,,,,,,fee schedule,1635.03,7254.06,
Needle biopsy pancreas,48102,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,7254.06,APC 378
Needle biopsy pancreas,48102,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,7254.06,APC
Needle biopsy pancreas,48102,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,7254.06,APC
Needle biopsy pancreas,48102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,7254.06,APC
Needle biopsy pancreas,48102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,7254.06,Radiology
Needle biopsy pancreas,48102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,7254.06,APC
Needle biopsy pancreas,48102,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,7254.06,APC
Pancreas surgery procedure,48999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1079.91,,,,,,,fee schedule,701.03,3110.22,
Pancreas surgery procedure,48999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,865.64,,,,,,,fee schedule,701.03,3110.22,
Pancreas surgery procedure,48999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,945.63,,,,,,,fee schedule,701.03,3110.22,
Pancreas surgery procedure,48999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,994.2,,,,,,,fee schedule,701.03,3110.22,
Pancreas surgery procedure,48999,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3110.22,,,,,,,fee schedule,701.03,3110.22,APC 378
Pancreas surgery procedure,48999,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,736.08,,,,,,,fee schedule,701.03,3110.22,APC
Pancreas surgery procedure,48999,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,729.07,,,,,,,fee schedule,701.03,3110.22,APC
Pancreas surgery procedure,48999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,701.03,,,,,,,fee schedule,701.03,3110.22,APC
Pancreas surgery procedure,48999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1072.57,,,,,,,fee schedule,701.03,3110.22,Radiology
Pancreas surgery procedure,48999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,981.44,,,,,,,fee schedule,701.03,3110.22,APC
Pancreas surgery procedure,48999,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1226.8,,,,,,,fee schedule,701.03,3110.22,APC
Exploration of abdomen,49000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10205.34,,,,,,,fee schedule,8180.47,10205.34,
Exploration of abdomen,49000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8180.47,,,,,,,fee schedule,8180.47,10205.34,
Exploration of abdomen,49000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8936.43,,,,,,,fee schedule,8180.47,10205.34,
Exploration of abdomen,49000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9395.4,,,,,,,fee schedule,8180.47,10205.34,
Exploration behind abdomen,49010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12033.29,,,,,,,fee schedule,6408.87,28434,
Exploration behind abdomen,49010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9645.73,,,,,,,fee schedule,6408.87,28434,
Exploration behind abdomen,49010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10537.09,,,,,,,fee schedule,6408.87,28434,
Exploration behind abdomen,49010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11078.27,,,,,,,fee schedule,6408.87,28434,
Exploration behind abdomen,49010,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,28434,,,,,,,fee schedule,6408.87,28434,APC 378
Exploration behind abdomen,49010,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6729.32,,,,,,,fee schedule,6408.87,28434,APC
Exploration behind abdomen,49010,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6665.23,,,,,,,fee schedule,6408.87,28434,APC
Exploration behind abdomen,49010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6408.87,,,,,,,fee schedule,6408.87,28434,APC
Exploration behind abdomen,49010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9805.57,,,,,,,fee schedule,6408.87,28434,Radiology
Exploration behind abdomen,49010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8972.42,,,,,,,fee schedule,6408.87,28434,APC
Exploration behind abdomen,49010,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11215.53,,,,,,,fee schedule,6408.87,28434,APC
Prpertl pel pack hemrrg trma,49013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1726.1,,,,,,,fee schedule,1383.62,1726.1,
Prpertl pel pack hemrrg trma,49013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1383.62,,,,,,,fee schedule,1383.62,1726.1,
Prpertl pel pack hemrrg trma,49013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1511.48,,,,,,,fee schedule,1383.62,1726.1,
Prpertl pel pack hemrrg trma,49013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1589.11,,,,,,,fee schedule,1383.62,1726.1,
Reexploration pelvic wound,49014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1424.46,,,,,,,fee schedule,1141.83,1424.46,
Reexploration pelvic wound,49014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1141.83,,,,,,,fee schedule,1141.83,1424.46,
Reexploration pelvic wound,49014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1247.34,,,,,,,fee schedule,1141.83,1424.46,
Reexploration pelvic wound,49014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1311.4,,,,,,,fee schedule,1141.83,1424.46,
Abd paracentesis,49082,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,601.4,,,,,,,fee schedule,482.07,3983.62,
Abd paracentesis,49082,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,482.07,,,,,,,fee schedule,482.07,3983.62,
Abd paracentesis,49082,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,526.62,,,,,,,fee schedule,482.07,3983.62,
Abd paracentesis,49082,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,553.67,,,,,,,fee schedule,482.07,3983.62,
Abd paracentesis,49082,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3983.62,,,,,,,fee schedule,482.07,3983.62,APC 378
Abd paracentesis,49082,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,942.78,,,,,,,fee schedule,482.07,3983.62,APC
Abd paracentesis,49082,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,933.8,,,,,,,fee schedule,482.07,3983.62,APC
Abd paracentesis,49082,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,897.89,,,,,,,fee schedule,482.07,3983.62,APC
Abd paracentesis,49082,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1373.77,,,,,,,fee schedule,482.07,3983.62,Radiology
Abd paracentesis,49082,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1257.04,,,,,,,fee schedule,482.07,3983.62,APC
Abd paracentesis,49082,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1571.3,,,,,,,fee schedule,482.07,3983.62,APC
Abd paracentesis w/imaging,49083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1766.27,,,,,,,fee schedule,897.89,3983.62,
Abd paracentesis w/imaging,49083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1415.82,,,,,,,fee schedule,897.89,3983.62,
Abd paracentesis w/imaging,49083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1546.65,,,,,,,fee schedule,897.89,3983.62,
Abd paracentesis w/imaging,49083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1626.09,,,,,,,fee schedule,897.89,3983.62,
Abd paracentesis w/imaging,49083,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3983.62,,,,,,,fee schedule,897.89,3983.62,APC 378
Abd paracentesis w/imaging,49083,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,942.78,,,,,,,fee schedule,897.89,3983.62,APC
Abd paracentesis w/imaging,49083,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,933.8,,,,,,,fee schedule,897.89,3983.62,APC
Abd paracentesis w/imaging,49083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,897.89,,,,,,,fee schedule,897.89,3983.62,APC
Abd paracentesis w/imaging,49083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1373.77,,,,,,,fee schedule,897.89,3983.62,Radiology
Abd paracentesis w/imaging,49083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1257.04,,,,,,,fee schedule,897.89,3983.62,APC
Abd paracentesis w/imaging,49083,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1571.3,,,,,,,fee schedule,897.89,3983.62,APC
Peritoneal lavage,49084,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1558.83,,,,,,,fee schedule,897.89,3983.62,
Peritoneal lavage,49084,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1249.54,,,,,,,fee schedule,897.89,3983.62,
Peritoneal lavage,49084,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1365.01,,,,,,,fee schedule,897.89,3983.62,
Peritoneal lavage,49084,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1435.12,,,,,,,fee schedule,897.89,3983.62,
Peritoneal lavage,49084,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3983.62,,,,,,,fee schedule,897.89,3983.62,APC 378
Peritoneal lavage,49084,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,942.78,,,,,,,fee schedule,897.89,3983.62,APC
Peritoneal lavage,49084,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,933.8,,,,,,,fee schedule,897.89,3983.62,APC
Peritoneal lavage,49084,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,897.89,,,,,,,fee schedule,897.89,3983.62,APC
Peritoneal lavage,49084,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1373.77,,,,,,,fee schedule,897.89,3983.62,Radiology
Peritoneal lavage,49084,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1257.04,,,,,,,fee schedule,897.89,3983.62,APC
Peritoneal lavage,49084,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1571.3,,,,,,,fee schedule,897.89,3983.62,APC
Biopsy abdominal mass,49180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1294.9,,,,,,,fee schedule,1037.98,7254.06,
Biopsy abdominal mass,49180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1037.98,,,,,,,fee schedule,1037.98,7254.06,
Biopsy abdominal mass,49180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1133.9,,,,,,,fee schedule,1037.98,7254.06,
Biopsy abdominal mass,49180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1192.13,,,,,,,fee schedule,1037.98,7254.06,
Biopsy abdominal mass,49180,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1037.98,7254.06,APC 378
Biopsy abdominal mass,49180,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1037.98,7254.06,APC
Biopsy abdominal mass,49180,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1037.98,7254.06,APC
Biopsy abdominal mass,49180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1037.98,7254.06,APC
Biopsy abdominal mass,49180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1037.98,7254.06,Radiology
Biopsy abdominal mass,49180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1037.98,7254.06,APC
Biopsy abdominal mass,49180,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1037.98,7254.06,APC
Sclerotx fluid collection,49185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3560.68,,,,,,,fee schedule,1635.03,7254.06,
Sclerotx fluid collection,49185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2854.2,,,,,,,fee schedule,1635.03,7254.06,
Sclerotx fluid collection,49185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3117.95,,,,,,,fee schedule,1635.03,7254.06,
Sclerotx fluid collection,49185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3278.09,,,,,,,fee schedule,1635.03,7254.06,
Sclerotx fluid collection,49185,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,7254.06,APC 378
Sclerotx fluid collection,49185,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,7254.06,APC
Sclerotx fluid collection,49185,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,7254.06,APC
Sclerotx fluid collection,49185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,7254.06,APC
Sclerotx fluid collection,49185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,7254.06,Radiology
Sclerotx fluid collection,49185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,7254.06,APC
Sclerotx fluid collection,49185,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,7254.06,APC
Excision of umbilicus,49250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6721.57,,,,,,,fee schedule,3544.48,15725.66,
Excision of umbilicus,49250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5387.93,,,,,,,fee schedule,3544.48,15725.66,
Excision of umbilicus,49250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5885.82,,,,,,,fee schedule,3544.48,15725.66,
Excision of umbilicus,49250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6188.11,,,,,,,fee schedule,3544.48,15725.66,
Excision of umbilicus,49250,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15725.66,,,,,,,fee schedule,3544.48,15725.66,APC 378
Excision of umbilicus,49250,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3721.7,,,,,,,fee schedule,3544.48,15725.66,APC
Excision of umbilicus,49250,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3686.26,,,,,,,fee schedule,3544.48,15725.66,APC
Excision of umbilicus,49250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3544.48,,,,,,,fee schedule,3544.48,15725.66,APC
Excision of umbilicus,49250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5423.05,,,,,,,fee schedule,3544.48,15725.66,Radiology
Excision of umbilicus,49250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4962.27,,,,,,,fee schedule,3544.48,15725.66,APC
Excision of umbilicus,49250,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6202.84,,,,,,,fee schedule,3544.48,15725.66,APC
Removal of omentum,49255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3034.71,,,,,,,fee schedule,2432.58,28434,
Removal of omentum,49255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2432.58,,,,,,,fee schedule,2432.58,28434,
Removal of omentum,49255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2657.38,,,,,,,fee schedule,2432.58,28434,
Removal of omentum,49255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2793.86,,,,,,,fee schedule,2432.58,28434,
Removal of omentum,49255,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,28434,,,,,,,fee schedule,2432.58,28434,APC 378
Removal of omentum,49255,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6729.32,,,,,,,fee schedule,2432.58,28434,APC
Removal of omentum,49255,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6665.23,,,,,,,fee schedule,2432.58,28434,APC
Removal of omentum,49255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6408.87,,,,,,,fee schedule,2432.58,28434,APC
Removal of omentum,49255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9805.57,,,,,,,fee schedule,2432.58,28434,Radiology
Removal of omentum,49255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8972.42,,,,,,,fee schedule,2432.58,28434,APC
Removal of omentum,49255,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11215.53,,,,,,,fee schedule,2432.58,28434,APC
Diag laparo separate proc,49320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5646.55,,,,,,,fee schedule,4526.2,26552.87,
Diag laparo separate proc,49320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4526.2,,,,,,,fee schedule,4526.2,26552.87,
Diag laparo separate proc,49320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4944.47,,,,,,,fee schedule,4526.2,26552.87,
Diag laparo separate proc,49320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5198.41,,,,,,,fee schedule,4526.2,26552.87,
Diag laparo separate proc,49320,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,4526.2,26552.87,APC 378
Diag laparo separate proc,49320,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,4526.2,26552.87,APC
Diag laparo separate proc,49320,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,4526.2,26552.87,APC
Diag laparo separate proc,49320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,4526.2,26552.87,APC
Diag laparo separate proc,49320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,4526.2,26552.87,Radiology
Diag laparo separate proc,49320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,4526.2,26552.87,APC
Diag laparo separate proc,49320,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,4526.2,26552.87,APC
Laparoscopy biopsy,49321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4388.46,,,,,,,fee schedule,3517.73,26552.87,
Laparoscopy biopsy,49321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3517.73,,,,,,,fee schedule,3517.73,26552.87,
Laparoscopy biopsy,49321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3842.81,,,,,,,fee schedule,3517.73,26552.87,
Laparoscopy biopsy,49321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4040.17,,,,,,,fee schedule,3517.73,26552.87,
Laparoscopy biopsy,49321,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,3517.73,26552.87,APC 378
Laparoscopy biopsy,49321,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,3517.73,26552.87,APC
Laparoscopy biopsy,49321,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,3517.73,26552.87,APC
Laparoscopy biopsy,49321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,3517.73,26552.87,APC
Laparoscopy biopsy,49321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,3517.73,26552.87,Radiology
Laparoscopy biopsy,49321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,3517.73,26552.87,APC
Laparoscopy biopsy,49321,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,3517.73,26552.87,APC
Laparoscopy aspiration,49322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6146.18,,,,,,,fee schedule,4926.7,26552.87,
Laparoscopy aspiration,49322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4926.7,,,,,,,fee schedule,4926.7,26552.87,
Laparoscopy aspiration,49322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5381.97,,,,,,,fee schedule,4926.7,26552.87,
Laparoscopy aspiration,49322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5658.39,,,,,,,fee schedule,4926.7,26552.87,
Laparoscopy aspiration,49322,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,4926.7,26552.87,APC 378
Laparoscopy aspiration,49322,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,4926.7,26552.87,APC
Laparoscopy aspiration,49322,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,4926.7,26552.87,APC
Laparoscopy aspiration,49322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,4926.7,26552.87,APC
Laparoscopy aspiration,49322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,4926.7,26552.87,Radiology
Laparoscopy aspiration,49322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,4926.7,26552.87,APC
Laparoscopy aspiration,49322,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,4926.7,26552.87,APC
Laparo drain lymphocele,49323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8584.34,,,,,,,fee schedule,5984.88,26552.87,
Laparo drain lymphocele,49323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6881.1,,,,,,,fee schedule,5984.88,26552.87,
Laparo drain lymphocele,49323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7516.98,,,,,,,fee schedule,5984.88,26552.87,
Laparo drain lymphocele,49323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7903.05,,,,,,,fee schedule,5984.88,26552.87,
Laparo drain lymphocele,49323,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,5984.88,26552.87,APC 378
Laparo drain lymphocele,49323,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,5984.88,26552.87,APC
Laparo drain lymphocele,49323,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,5984.88,26552.87,APC
Laparo drain lymphocele,49323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,5984.88,26552.87,APC
Laparo drain lymphocele,49323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,5984.88,26552.87,Radiology
Laparo drain lymphocele,49323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,5984.88,26552.87,APC
Laparo drain lymphocele,49323,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,5984.88,26552.87,APC
Lap insert tunnel ip cath,49324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8584.34,,,,,,,fee schedule,5984.88,26552.87,
Lap insert tunnel ip cath,49324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6881.1,,,,,,,fee schedule,5984.88,26552.87,
Lap insert tunnel ip cath,49324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7516.98,,,,,,,fee schedule,5984.88,26552.87,
Lap insert tunnel ip cath,49324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7903.05,,,,,,,fee schedule,5984.88,26552.87,
Lap insert tunnel ip cath,49324,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,5984.88,26552.87,APC 378
Lap insert tunnel ip cath,49324,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,5984.88,26552.87,APC
Lap insert tunnel ip cath,49324,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,5984.88,26552.87,APC
Lap insert tunnel ip cath,49324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,5984.88,26552.87,APC
Lap insert tunnel ip cath,49324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,5984.88,26552.87,Radiology
Lap insert tunnel ip cath,49324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,5984.88,26552.87,APC
Lap insert tunnel ip cath,49324,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,5984.88,26552.87,APC
Lap Revision Perm IP Cath,49325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7657.8,,,,,,,fee schedule,5984.88,26552.87,
Lap Revision Perm IP Cath,49325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6138.4,,,,,,,fee schedule,5984.88,26552.87,
Lap Revision Perm IP Cath,49325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6705.64,,,,,,,fee schedule,5984.88,26552.87,
Lap Revision Perm IP Cath,49325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7050.04,,,,,,,fee schedule,5984.88,26552.87,
Lap Revision Perm IP Cath,49325,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,5984.88,26552.87,APC 378
Lap Revision Perm IP Cath,49325,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,5984.88,26552.87,APC
Lap Revision Perm IP Cath,49325,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,5984.88,26552.87,APC
Lap Revision Perm IP Cath,49325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,5984.88,26552.87,APC
Lap Revision Perm IP Cath,49325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,5984.88,26552.87,Radiology
Lap Revision Perm IP Cath,49325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,5984.88,26552.87,APC
Lap Revision Perm IP Cath,49325,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,5984.88,26552.87,APC
Lap w/Omentopexy Add-on,49326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8584.34,,,,,,,fee schedule,6881.1,8584.34,
Lap w/Omentopexy Add-on,49326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6881.1,,,,,,,fee schedule,6881.1,8584.34,
Lap w/Omentopexy Add-on,49326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7516.98,,,,,,,fee schedule,6881.1,8584.34,
Lap w/Omentopexy Add-on,49326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7903.05,,,,,,,fee schedule,6881.1,8584.34,
Lap ins device for rt,49327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10062.93,,,,,,,fee schedule,8066.31,10062.93,
Lap ins device for rt,49327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8066.31,,,,,,,fee schedule,8066.31,10062.93,
Lap ins device for rt,49327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8811.72,,,,,,,fee schedule,8066.31,10062.93,
Lap ins device for rt,49327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9264.28,,,,,,,fee schedule,8066.31,10062.93,
Laparo proc abdm/per/oment,49329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5254.36,,,,,,,fee schedule,4211.83,26552.87,
Laparo proc abdm/per/oment,49329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4211.83,,,,,,,fee schedule,4211.83,26552.87,
Laparo proc abdm/per/oment,49329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4601.04,,,,,,,fee schedule,4211.83,26552.87,
Laparo proc abdm/per/oment,49329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4837.35,,,,,,,fee schedule,4211.83,26552.87,
Laparo proc abdm/per/oment,49329,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,4211.83,26552.87,APC 378
Laparo proc abdm/per/oment,49329,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,4211.83,26552.87,APC
Laparo proc abdm/per/oment,49329,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,4211.83,26552.87,APC
Laparo proc abdm/per/oment,49329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,4211.83,26552.87,APC
Laparo proc abdm/per/oment,49329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,4211.83,26552.87,Radiology
Laparo proc abdm/per/oment,49329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,4211.83,26552.87,APC
Laparo proc abdm/per/oment,49329,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,4211.83,26552.87,APC
Remove foreign body adbomen,49402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7189.69,,,,,,,fee schedule,3544.48,15725.66,
Remove foreign body adbomen,49402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5763.16,,,,,,,fee schedule,3544.48,15725.66,
Remove foreign body adbomen,49402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6295.73,,,,,,,fee schedule,3544.48,15725.66,
Remove foreign body adbomen,49402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6619.08,,,,,,,fee schedule,3544.48,15725.66,
Remove foreign body adbomen,49402,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15725.66,,,,,,,fee schedule,3544.48,15725.66,APC 378
Remove foreign body adbomen,49402,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3721.7,,,,,,,fee schedule,3544.48,15725.66,APC
Remove foreign body adbomen,49402,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3686.26,,,,,,,fee schedule,3544.48,15725.66,APC
Remove foreign body adbomen,49402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3544.48,,,,,,,fee schedule,3544.48,15725.66,APC
Remove foreign body adbomen,49402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5423.05,,,,,,,fee schedule,3544.48,15725.66,Radiology
Remove foreign body adbomen,49402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4962.27,,,,,,,fee schedule,3544.48,15725.66,APC
Remove foreign body adbomen,49402,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6202.84,,,,,,,fee schedule,3544.48,15725.66,APC
Image cath fluid colxn visc,49405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1815.03,,,,,,,fee schedule,1454.91,7254.06,
Image cath fluid colxn visc,49405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1454.91,,,,,,,fee schedule,1454.91,7254.06,
Image cath fluid colxn visc,49405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1589.35,,,,,,,fee schedule,1454.91,7254.06,
Image cath fluid colxn visc,49405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1670.98,,,,,,,fee schedule,1454.91,7254.06,
Image cath fluid colxn visc,49405,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1454.91,7254.06,APC 378
Image cath fluid colxn visc,49405,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1454.91,7254.06,APC
Image cath fluid colxn visc,49405,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1454.91,7254.06,APC
Image cath fluid colxn visc,49405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1454.91,7254.06,APC
Image cath fluid colxn visc,49405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1454.91,7254.06,Radiology
Image cath fluid colxn visc,49405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1454.91,7254.06,APC
Image cath fluid colxn visc,49405,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1454.91,7254.06,APC
Image cath fluid peri/retro,49406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1650.32,,,,,,,fee schedule,1322.88,7254.06,
Image cath fluid peri/retro,49406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1322.88,,,,,,,fee schedule,1322.88,7254.06,
Image cath fluid peri/retro,49406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1445.12,,,,,,,fee schedule,1322.88,7254.06,
Image cath fluid peri/retro,49406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1519.34,,,,,,,fee schedule,1322.88,7254.06,
Image cath fluid peri/retro,49406,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1322.88,7254.06,APC 378
Image cath fluid peri/retro,49406,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1322.88,7254.06,APC
Image cath fluid peri/retro,49406,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1322.88,7254.06,APC
Image cath fluid peri/retro,49406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1322.88,7254.06,APC
Image cath fluid peri/retro,49406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1322.88,7254.06,Radiology
Image cath fluid peri/retro,49406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1322.88,7254.06,APC
Image cath fluid peri/retro,49406,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1322.88,7254.06,APC
Image cath fluid trns/vgnl,49407,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1541.96,,,,,,,fee schedule,1236.02,7254.06,
Image cath fluid trns/vgnl,49407,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1236.02,,,,,,,fee schedule,1236.02,7254.06,
Image cath fluid trns/vgnl,49407,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1350.24,,,,,,,fee schedule,1236.02,7254.06,
Image cath fluid trns/vgnl,49407,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1419.58,,,,,,,fee schedule,1236.02,7254.06,
Image cath fluid trns/vgnl,49407,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1236.02,7254.06,APC 378
Image cath fluid trns/vgnl,49407,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1236.02,7254.06,APC
Image cath fluid trns/vgnl,49407,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1236.02,7254.06,APC
Image cath fluid trns/vgnl,49407,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1236.02,7254.06,APC
Image cath fluid trns/vgnl,49407,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1236.02,7254.06,Radiology
Image cath fluid trns/vgnl,49407,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1236.02,7254.06,APC
Image cath fluid trns/vgnl,49407,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1236.02,7254.06,APC
Ins mark abd/pel for rt perq,49411,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3633.64,,,,,,,fee schedule,1370.24,6079.31,
Ins mark abd/pel for rt perq,49411,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2912.68,,,,,,,fee schedule,1370.24,6079.31,
Ins mark abd/pel for rt perq,49411,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3181.84,,,,,,,fee schedule,1370.24,6079.31,
Ins mark abd/pel for rt perq,49411,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3345.25,,,,,,,fee schedule,1370.24,6079.31,
Ins mark abd/pel for rt perq,49411,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6079.31,,,,,,,fee schedule,1370.24,6079.31,APC 378
Ins mark abd/pel for rt perq,49411,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1438.76,,,,,,,fee schedule,1370.24,6079.31,APC
Ins mark abd/pel for rt perq,49411,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1425.05,,,,,,,fee schedule,1370.24,6079.31,APC
Ins mark abd/pel for rt perq,49411,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1370.24,,,,,,,fee schedule,1370.24,6079.31,APC
Ins mark abd/pel for rt perq,49411,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2096.47,,,,,,,fee schedule,1370.24,6079.31,Radiology
Ins mark abd/pel for rt perq,49411,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1918.34,,,,,,,fee schedule,1370.24,6079.31,APC
Ins mark abd/pel for rt perq,49411,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2397.93,,,,,,,fee schedule,1370.24,6079.31,APC
Ins device for rt guide open,49412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,300.89,,,,,,,fee schedule,241.19,300.89,
Ins device for rt guide open,49412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,241.19,,,,,,,fee schedule,241.19,300.89,
Ins device for rt guide open,49412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,263.48,,,,,,,fee schedule,241.19,300.89,
Ins device for rt guide open,49412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,277.01,,,,,,,fee schedule,241.19,300.89,
Insert tun ip cath perc,49418,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2988.03,,,,,,,fee schedule,2395.16,15725.66,
Insert tun ip cath perc,49418,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2395.16,,,,,,,fee schedule,2395.16,15725.66,
Insert tun ip cath perc,49418,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2616.5,,,,,,,fee schedule,2395.16,15725.66,
Insert tun ip cath perc,49418,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2750.88,,,,,,,fee schedule,2395.16,15725.66,
Insert tun ip cath perc,49418,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15725.66,,,,,,,fee schedule,2395.16,15725.66,APC 378
Insert tun ip cath perc,49418,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3721.7,,,,,,,fee schedule,2395.16,15725.66,APC
Insert tun ip cath perc,49418,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3686.26,,,,,,,fee schedule,2395.16,15725.66,APC
Insert tun ip cath perc,49418,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3544.48,,,,,,,fee schedule,2395.16,15725.66,APC
Insert tun ip cath perc,49418,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5423.05,,,,,,,fee schedule,2395.16,15725.66,Radiology
Insert tun ip cath perc,49418,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4962.27,,,,,,,fee schedule,2395.16,15725.66,APC
Insert tun ip cath perc,49418,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6202.84,,,,,,,fee schedule,2395.16,15725.66,APC
Insert tun ip cath w/port,49419,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7411.52,,,,,,,fee schedule,5508.66,24440.06,
Insert tun ip cath w/port,49419,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5940.98,,,,,,,fee schedule,5508.66,24440.06,
Insert tun ip cath w/port,49419,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6489.98,,,,,,,fee schedule,5508.66,24440.06,
Insert tun ip cath w/port,49419,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6823.31,,,,,,,fee schedule,5508.66,24440.06,
Insert tun ip cath w/port,49419,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24440.06,,,,,,,fee schedule,5508.66,24440.06,APC 378
Insert tun ip cath w/port,49419,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5784.09,,,,,,,fee schedule,5508.66,24440.06,APC
Insert tun ip cath w/port,49419,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5729.01,,,,,,,fee schedule,5508.66,24440.06,APC
Insert tun ip cath w/port,49419,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5508.66,,,,,,,fee schedule,5508.66,24440.06,APC
Insert tun ip cath w/port,49419,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8428.25,,,,,,,fee schedule,5508.66,24440.06,Radiology
Insert tun ip cath w/port,49419,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7712.13,,,,,,,fee schedule,5508.66,24440.06,APC
Insert tun ip cath w/port,49419,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9640.16,,,,,,,fee schedule,5508.66,24440.06,APC
Ins tun ip cath for dial opn,49421,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7664.37,,,,,,,fee schedule,3544.48,15725.66,
Ins tun ip cath for dial opn,49421,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6143.66,,,,,,,fee schedule,3544.48,15725.66,
Ins tun ip cath for dial opn,49421,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6711.39,,,,,,,fee schedule,3544.48,15725.66,
Ins tun ip cath for dial opn,49421,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7056.08,,,,,,,fee schedule,3544.48,15725.66,
Ins tun ip cath for dial opn,49421,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15725.66,,,,,,,fee schedule,3544.48,15725.66,APC 378
Ins tun ip cath for dial opn,49421,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3721.7,,,,,,,fee schedule,3544.48,15725.66,APC
Ins tun ip cath for dial opn,49421,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3686.26,,,,,,,fee schedule,3544.48,15725.66,APC
Ins tun ip cath for dial opn,49421,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3544.48,,,,,,,fee schedule,3544.48,15725.66,APC
Ins tun ip cath for dial opn,49421,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5423.05,,,,,,,fee schedule,3544.48,15725.66,Radiology
Ins tun ip cath for dial opn,49421,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4962.27,,,,,,,fee schedule,3544.48,15725.66,APC
Ins tun ip cath for dial opn,49421,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6202.84,,,,,,,fee schedule,3544.48,15725.66,APC
Remove tunneled ip cath,49422,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3536.33,,,,,,,fee schedule,2834.68,13868.13,
Remove tunneled ip cath,49422,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2834.68,,,,,,,fee schedule,2834.68,13868.13,
Remove tunneled ip cath,49422,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3096.63,,,,,,,fee schedule,2834.68,13868.13,
Remove tunneled ip cath,49422,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3255.67,,,,,,,fee schedule,2834.68,13868.13,
Remove tunneled ip cath,49422,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,2834.68,13868.13,APC 378
Remove tunneled ip cath,49422,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,2834.68,13868.13,APC
Remove tunneled ip cath,49422,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,2834.68,13868.13,APC
Remove tunneled ip cath,49422,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,2834.68,13868.13,APC
Remove tunneled ip cath,49422,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,2834.68,13868.13,Radiology
Remove tunneled ip cath,49422,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,2834.68,13868.13,APC
Remove tunneled ip cath,49422,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,2834.68,13868.13,APC
Exchange drainage catheter,49423,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1655.74,,,,,,,fee schedule,1327.22,8428.13,
Exchange drainage catheter,49423,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1327.22,,,,,,,fee schedule,1327.22,8428.13,
Exchange drainage catheter,49423,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1449.87,,,,,,,fee schedule,1327.22,8428.13,
Exchange drainage catheter,49423,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1524.33,,,,,,,fee schedule,1327.22,8428.13,
Exchange drainage catheter,49423,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8428.13,,,,,,,fee schedule,1327.22,8428.13,APC 378
Exchange drainage catheter,49423,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1994.64,,,,,,,fee schedule,1327.22,8428.13,APC
Exchange drainage catheter,49423,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1975.64,,,,,,,fee schedule,1327.22,8428.13,APC
Exchange drainage catheter,49423,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1899.66,,,,,,,fee schedule,1327.22,8428.13,APC
Exchange drainage catheter,49423,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2906.47,,,,,,,fee schedule,1327.22,8428.13,Radiology
Exchange drainage catheter,49423,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2659.52,,,,,,,fee schedule,1327.22,8428.13,APC
Exchange drainage catheter,49423,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3324.4,,,,,,,fee schedule,1327.22,8428.13,APC
Revise abdomen-venous shunt,49426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6412.77,,,,,,,fee schedule,3544.48,15725.66,
Revise abdomen-venous shunt,49426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5140.4,,,,,,,fee schedule,3544.48,15725.66,
Revise abdomen-venous shunt,49426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5615.42,,,,,,,fee schedule,3544.48,15725.66,
Revise abdomen-venous shunt,49426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5903.82,,,,,,,fee schedule,3544.48,15725.66,
Revise abdomen-venous shunt,49426,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15725.66,,,,,,,fee schedule,3544.48,15725.66,APC 378
Revise abdomen-venous shunt,49426,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3721.7,,,,,,,fee schedule,3544.48,15725.66,APC
Revise abdomen-venous shunt,49426,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3686.26,,,,,,,fee schedule,3544.48,15725.66,APC
Revise abdomen-venous shunt,49426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3544.48,,,,,,,fee schedule,3544.48,15725.66,APC
Revise abdomen-venous shunt,49426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5423.05,,,,,,,fee schedule,3544.48,15725.66,Radiology
Revise abdomen-venous shunt,49426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4962.27,,,,,,,fee schedule,3544.48,15725.66,APC
Revise abdomen-venous shunt,49426,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6202.84,,,,,,,fee schedule,3544.48,15725.66,APC
Removal of shunt,49429,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5984.84,,,,,,,fee schedule,3125.8,13868.13,
Removal of shunt,49429,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4797.37,,,,,,,fee schedule,3125.8,13868.13,
Removal of shunt,49429,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5240.69,,,,,,,fee schedule,3125.8,13868.13,
Removal of shunt,49429,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.85,,,,,,,fee schedule,3125.8,13868.13,
Removal of shunt,49429,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Removal of shunt,49429,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Removal of shunt,49429,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Removal of shunt,49429,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Removal of shunt,49429,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Removal of shunt,49429,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Removal of shunt,49429,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Insert Subq Exten to IP Cath,49435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3832.09,,,,,,,fee schedule,3071.75,3832.09,
Insert Subq Exten to IP Cath,49435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3071.75,,,,,,,fee schedule,3071.75,3832.09,
Insert Subq Exten to IP Cath,49435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3355.61,,,,,,,fee schedule,3071.75,3832.09,
Insert Subq Exten to IP Cath,49435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3527.95,,,,,,,fee schedule,3071.75,3832.09,
Embedded IP Cath Exit-Site,49436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3832.09,,,,,,,fee schedule,1899.66,8428.13,
Embedded IP Cath Exit-Site,49436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3071.75,,,,,,,fee schedule,1899.66,8428.13,
Embedded IP Cath Exit-Site,49436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3355.61,,,,,,,fee schedule,1899.66,8428.13,
Embedded IP Cath Exit-Site,49436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3527.95,,,,,,,fee schedule,1899.66,8428.13,
Embedded IP Cath Exit-Site,49436,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8428.13,,,,,,,fee schedule,1899.66,8428.13,APC 378
Embedded IP Cath Exit-Site,49436,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1994.64,,,,,,,fee schedule,1899.66,8428.13,APC
Embedded IP Cath Exit-Site,49436,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1975.64,,,,,,,fee schedule,1899.66,8428.13,APC
Embedded IP Cath Exit-Site,49436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1899.66,,,,,,,fee schedule,1899.66,8428.13,APC
Embedded IP Cath Exit-Site,49436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2906.47,,,,,,,fee schedule,1899.66,8428.13,Radiology
Embedded IP Cath Exit-Site,49436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2659.52,,,,,,,fee schedule,1899.66,8428.13,APC
Embedded IP Cath Exit-Site,49436,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3324.4,,,,,,,fee schedule,1899.66,8428.13,APC
Place gastrostomy tube perc,49440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3244.3,,,,,,,fee schedule,1899.66,8428.13,
Place gastrostomy tube perc,49440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2600.59,,,,,,,fee schedule,1899.66,8428.13,
Place gastrostomy tube perc,49440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2840.91,,,,,,,fee schedule,1899.66,8428.13,
Place gastrostomy tube perc,49440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2986.81,,,,,,,fee schedule,1899.66,8428.13,
Place gastrostomy tube perc,49440,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8428.13,,,,,,,fee schedule,1899.66,8428.13,APC 378
Place gastrostomy tube perc,49440,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1994.64,,,,,,,fee schedule,1899.66,8428.13,APC
Place gastrostomy tube perc,49440,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1975.64,,,,,,,fee schedule,1899.66,8428.13,APC
Place gastrostomy tube perc,49440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1899.66,,,,,,,fee schedule,1899.66,8428.13,APC
Place gastrostomy tube perc,49440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2906.47,,,,,,,fee schedule,1899.66,8428.13,Radiology
Place gastrostomy tube perc,49440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2659.52,,,,,,,fee schedule,1899.66,8428.13,APC
Place gastrostomy tube perc,49440,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3324.4,,,,,,,fee schedule,1899.66,8428.13,APC
Place duod/jej tube perc,49441,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2122.13,,,,,,,fee schedule,1701.07,8428.13,
Place duod/jej tube perc,49441,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1701.07,,,,,,,fee schedule,1701.07,8428.13,
Place duod/jej tube perc,49441,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1858.27,,,,,,,fee schedule,1701.07,8428.13,
Place duod/jej tube perc,49441,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1953.71,,,,,,,fee schedule,1701.07,8428.13,
Place duod/jej tube perc,49441,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8428.13,,,,,,,fee schedule,1701.07,8428.13,APC 378
Place duod/jej tube perc,49441,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1994.64,,,,,,,fee schedule,1701.07,8428.13,APC
Place duod/jej tube perc,49441,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1975.64,,,,,,,fee schedule,1701.07,8428.13,APC
Place duod/jej tube perc,49441,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1899.66,,,,,,,fee schedule,1701.07,8428.13,APC
Place duod/jej tube perc,49441,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2906.47,,,,,,,fee schedule,1701.07,8428.13,Radiology
Place duod/jej tube perc,49441,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2659.52,,,,,,,fee schedule,1701.07,8428.13,APC
Place duod/jej tube perc,49441,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3324.4,,,,,,,fee schedule,1701.07,8428.13,APC
Place cecostomy tube perc,49442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2723.68,,,,,,,fee schedule,1184.64,5255.83,
Place cecostomy tube perc,49442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2183.27,,,,,,,fee schedule,1184.64,5255.83,
Place cecostomy tube perc,49442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2385.02,,,,,,,fee schedule,1184.64,5255.83,
Place cecostomy tube perc,49442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2507.51,,,,,,,fee schedule,1184.64,5255.83,
Place cecostomy tube perc,49442,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5255.83,,,,,,,fee schedule,1184.64,5255.83,APC 378
Place cecostomy tube perc,49442,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1243.87,,,,,,,fee schedule,1184.64,5255.83,APC
Place cecostomy tube perc,49442,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1232.02,,,,,,,fee schedule,1184.64,5255.83,APC
Place cecostomy tube perc,49442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1184.64,,,,,,,fee schedule,1184.64,5255.83,APC
Place cecostomy tube perc,49442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1812.49,,,,,,,fee schedule,1184.64,5255.83,Radiology
Place cecostomy tube perc,49442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1658.49,,,,,,,fee schedule,1184.64,5255.83,APC
Place cecostomy tube perc,49442,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2073.11,,,,,,,fee schedule,1184.64,5255.83,APC
Change g-tube to g-j perc,49446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2122.13,,,,,,,fee schedule,1701.07,8428.13,
Change g-tube to g-j perc,49446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1701.07,,,,,,,fee schedule,1701.07,8428.13,
Change g-tube to g-j perc,49446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1858.27,,,,,,,fee schedule,1701.07,8428.13,
Change g-tube to g-j perc,49446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1953.71,,,,,,,fee schedule,1701.07,8428.13,
Change g-tube to g-j perc,49446,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8428.13,,,,,,,fee schedule,1701.07,8428.13,APC 378
Change g-tube to g-j perc,49446,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1994.64,,,,,,,fee schedule,1701.07,8428.13,APC
Change g-tube to g-j perc,49446,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1975.64,,,,,,,fee schedule,1701.07,8428.13,APC
Change g-tube to g-j perc,49446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1899.66,,,,,,,fee schedule,1701.07,8428.13,APC
Change g-tube to g-j perc,49446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2906.47,,,,,,,fee schedule,1701.07,8428.13,Radiology
Change g-tube to g-j perc,49446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2659.52,,,,,,,fee schedule,1701.07,8428.13,APC
Change g-tube to g-j perc,49446,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3324.4,,,,,,,fee schedule,1701.07,8428.13,APC
Replace g/c tube perc,49450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,615.48,,,,,,,fee schedule,493.36,3983.62,
Replace g/c tube perc,49450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,493.36,,,,,,,fee schedule,493.36,3983.62,
Replace g/c tube perc,49450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,538.96,,,,,,,fee schedule,493.36,3983.62,
Replace g/c tube perc,49450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,566.64,,,,,,,fee schedule,493.36,3983.62,
Replace g/c tube perc,49450,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3983.62,,,,,,,fee schedule,493.36,3983.62,APC 378
Replace g/c tube perc,49450,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,942.78,,,,,,,fee schedule,493.36,3983.62,APC
Replace g/c tube perc,49450,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,933.8,,,,,,,fee schedule,493.36,3983.62,APC
Replace g/c tube perc,49450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,897.89,,,,,,,fee schedule,493.36,3983.62,APC
Replace g/c tube perc,49450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1373.77,,,,,,,fee schedule,493.36,3983.62,Radiology
Replace g/c tube perc,49450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1257.04,,,,,,,fee schedule,493.36,3983.62,APC
Replace g/c tube perc,49450,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1571.3,,,,,,,fee schedule,493.36,3983.62,APC
Replace duod/jej tube perc,49451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,584.06,,,,,,,fee schedule,468.18,3983.62,
Replace duod/jej tube perc,49451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,468.18,,,,,,,fee schedule,468.18,3983.62,
Replace duod/jej tube perc,49451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,511.44,,,,,,,fee schedule,468.18,3983.62,
Replace duod/jej tube perc,49451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,537.71,,,,,,,fee schedule,468.18,3983.62,
Replace duod/jej tube perc,49451,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3983.62,,,,,,,fee schedule,468.18,3983.62,APC 378
Replace duod/jej tube perc,49451,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,942.78,,,,,,,fee schedule,468.18,3983.62,APC
Replace duod/jej tube perc,49451,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,933.8,,,,,,,fee schedule,468.18,3983.62,APC
Replace duod/jej tube perc,49451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,897.89,,,,,,,fee schedule,468.18,3983.62,APC
Replace duod/jej tube perc,49451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1373.77,,,,,,,fee schedule,468.18,3983.62,Radiology
Replace duod/jej tube perc,49451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1257.04,,,,,,,fee schedule,468.18,3983.62,APC
Replace duod/jej tube perc,49451,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1571.3,,,,,,,fee schedule,468.18,3983.62,APC
Replace g-j tube perc,49452,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,808.2,,,,,,,fee schedule,647.84,3983.62,
Replace g-j tube perc,49452,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,647.84,,,,,,,fee schedule,647.84,3983.62,
Replace g-j tube perc,49452,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,707.71,,,,,,,fee schedule,647.84,3983.62,
Replace g-j tube perc,49452,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,744.06,,,,,,,fee schedule,647.84,3983.62,
Replace g-j tube perc,49452,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3983.62,,,,,,,fee schedule,647.84,3983.62,APC 378
Replace g-j tube perc,49452,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,942.78,,,,,,,fee schedule,647.84,3983.62,APC
Replace g-j tube perc,49452,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,933.8,,,,,,,fee schedule,647.84,3983.62,APC
Replace g-j tube perc,49452,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,897.89,,,,,,,fee schedule,647.84,3983.62,APC
Replace g-j tube perc,49452,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1373.77,,,,,,,fee schedule,647.84,3983.62,Radiology
Replace g-j tube perc,49452,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1257.04,,,,,,,fee schedule,647.84,3983.62,APC
Replace g-j tube perc,49452,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1571.3,,,,,,,fee schedule,647.84,3983.62,APC
Fix g/colon tube w/device,49460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,808.2,,,,,,,fee schedule,647.84,3983.62,
Fix g/colon tube w/device,49460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,647.84,,,,,,,fee schedule,647.84,3983.62,
Fix g/colon tube w/device,49460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,707.71,,,,,,,fee schedule,647.84,3983.62,
Fix g/colon tube w/device,49460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,744.06,,,,,,,fee schedule,647.84,3983.62,
Fix g/colon tube w/device,49460,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3983.62,,,,,,,fee schedule,647.84,3983.62,APC 378
Fix g/colon tube w/device,49460,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,942.78,,,,,,,fee schedule,647.84,3983.62,APC
Fix g/colon tube w/device,49460,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,933.8,,,,,,,fee schedule,647.84,3983.62,APC
Fix g/colon tube w/device,49460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,897.89,,,,,,,fee schedule,647.84,3983.62,APC
Fix g/colon tube w/device,49460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1373.77,,,,,,,fee schedule,647.84,3983.62,Radiology
Fix g/colon tube w/device,49460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1257.04,,,,,,,fee schedule,647.84,3983.62,APC
Fix g/colon tube w/device,49460,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1571.3,,,,,,,fee schedule,647.84,3983.62,APC
Fluoro exam of g/colon tube,49465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,196.13,,,,,,,fee schedule,157.22,1047.98,
Fluoro exam of g/colon tube,49465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,157.22,,,,,,,fee schedule,157.22,1047.98,
Fluoro exam of g/colon tube,49465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,171.74,,,,,,,fee schedule,157.22,1047.98,
Fluoro exam of g/colon tube,49465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,180.57,,,,,,,fee schedule,157.22,1047.98,
Fluoro exam of g/colon tube,49465,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,157.22,1047.98,APC 378
Fluoro exam of g/colon tube,49465,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,157.22,1047.98,APC
Fluoro exam of g/colon tube,49465,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,157.22,1047.98,APC
Fluoro exam of g/colon tube,49465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,157.22,1047.98,APC
Fluoro exam of g/colon tube,49465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,157.22,1047.98,Radiology
Fluoro exam of g/colon tube,49465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,157.22,1047.98,APC
Fluoro exam of g/colon tube,49465,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,157.22,1047.98,APC
Rpr hern preemie reduc,49491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7656.69,,,,,,,fee schedule,5984.88,26552.87,
Rpr hern preemie reduc,49491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6137.51,,,,,,,fee schedule,5984.88,26552.87,
Rpr hern preemie reduc,49491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6704.67,,,,,,,fee schedule,5984.88,26552.87,
Rpr hern preemie reduc,49491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7049.02,,,,,,,fee schedule,5984.88,26552.87,
Rpr hern preemie reduc,49491,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,5984.88,26552.87,APC 378
Rpr hern preemie reduc,49491,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,5984.88,26552.87,APC
Rpr hern preemie reduc,49491,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,5984.88,26552.87,APC
Rpr hern preemie reduc,49491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,5984.88,26552.87,APC
Rpr hern preemie reduc,49491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,5984.88,26552.87,Radiology
Rpr hern preemie reduc,49491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,5984.88,26552.87,APC
Rpr hern preemie reduc,49491,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,5984.88,26552.87,APC
Rpr ing hern premie blocked,49492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7656.69,,,,,,,fee schedule,3544.48,15725.66,
Rpr ing hern premie blocked,49492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6137.51,,,,,,,fee schedule,3544.48,15725.66,
Rpr ing hern premie blocked,49492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6704.67,,,,,,,fee schedule,3544.48,15725.66,
Rpr ing hern premie blocked,49492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7049.02,,,,,,,fee schedule,3544.48,15725.66,
Rpr ing hern premie blocked,49492,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15725.66,,,,,,,fee schedule,3544.48,15725.66,APC 378
Rpr ing hern premie blocked,49492,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3721.7,,,,,,,fee schedule,3544.48,15725.66,APC
Rpr ing hern premie blocked,49492,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3686.26,,,,,,,fee schedule,3544.48,15725.66,APC
Rpr ing hern premie blocked,49492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3544.48,,,,,,,fee schedule,3544.48,15725.66,APC
Rpr ing hern premie blocked,49492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5423.05,,,,,,,fee schedule,3544.48,15725.66,Radiology
Rpr ing hern premie blocked,49492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4962.27,,,,,,,fee schedule,3544.48,15725.66,APC
Rpr ing hern premie blocked,49492,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6202.84,,,,,,,fee schedule,3544.48,15725.66,APC
Rpr ing hernia baby reduc,49495,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7030.67,,,,,,,fee schedule,3544.48,15725.66,
Rpr ing hernia baby reduc,49495,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5635.69,,,,,,,fee schedule,3544.48,15725.66,
Rpr ing hernia baby reduc,49495,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6156.48,,,,,,,fee schedule,3544.48,15725.66,
Rpr ing hernia baby reduc,49495,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6472.68,,,,,,,fee schedule,3544.48,15725.66,
Rpr ing hernia baby reduc,49495,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15725.66,,,,,,,fee schedule,3544.48,15725.66,APC 378
Rpr ing hernia baby reduc,49495,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3721.7,,,,,,,fee schedule,3544.48,15725.66,APC
Rpr ing hernia baby reduc,49495,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3686.26,,,,,,,fee schedule,3544.48,15725.66,APC
Rpr ing hernia baby reduc,49495,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3544.48,,,,,,,fee schedule,3544.48,15725.66,APC
Rpr ing hernia baby reduc,49495,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5423.05,,,,,,,fee schedule,3544.48,15725.66,Radiology
Rpr ing hernia baby reduc,49495,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4962.27,,,,,,,fee schedule,3544.48,15725.66,APC
Rpr ing hernia baby reduc,49495,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6202.84,,,,,,,fee schedule,3544.48,15725.66,APC
Rpr ing hernia baby blocked,49496,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7656.69,,,,,,,fee schedule,3544.48,15725.66,
Rpr ing hernia baby blocked,49496,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6137.51,,,,,,,fee schedule,3544.48,15725.66,
Rpr ing hernia baby blocked,49496,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6704.67,,,,,,,fee schedule,3544.48,15725.66,
Rpr ing hernia baby blocked,49496,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7049.02,,,,,,,fee schedule,3544.48,15725.66,
Rpr ing hernia baby blocked,49496,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15725.66,,,,,,,fee schedule,3544.48,15725.66,APC 378
Rpr ing hernia baby blocked,49496,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3721.7,,,,,,,fee schedule,3544.48,15725.66,APC
Rpr ing hernia baby blocked,49496,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3686.26,,,,,,,fee schedule,3544.48,15725.66,APC
Rpr ing hernia baby blocked,49496,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3544.48,,,,,,,fee schedule,3544.48,15725.66,APC
Rpr ing hernia baby blocked,49496,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5423.05,,,,,,,fee schedule,3544.48,15725.66,Radiology
Rpr ing hernia baby blocked,49496,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4962.27,,,,,,,fee schedule,3544.48,15725.66,APC
Rpr ing hernia baby blocked,49496,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6202.84,,,,,,,fee schedule,3544.48,15725.66,APC
Rpr ing hernia init reduce,49500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5570.79,,,,,,,fee schedule,4465.47,28434,
Rpr ing hernia init reduce,49500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4465.47,,,,,,,fee schedule,4465.47,28434,
Rpr ing hernia init reduce,49500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4878.12,,,,,,,fee schedule,4465.47,28434,
Rpr ing hernia init reduce,49500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5128.66,,,,,,,fee schedule,4465.47,28434,
Rpr ing hernia init reduce,49500,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,28434,,,,,,,fee schedule,4465.47,28434,APC 378
Rpr ing hernia init reduce,49500,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6729.32,,,,,,,fee schedule,4465.47,28434,APC
Rpr ing hernia init reduce,49500,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6665.23,,,,,,,fee schedule,4465.47,28434,APC
Rpr ing hernia init reduce,49500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6408.87,,,,,,,fee schedule,4465.47,28434,APC
Rpr ing hernia init reduce,49500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9805.57,,,,,,,fee schedule,4465.47,28434,Radiology
Rpr ing hernia init reduce,49500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8972.42,,,,,,,fee schedule,4465.47,28434,APC
Rpr ing hernia init reduce,49500,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11215.53,,,,,,,fee schedule,4465.47,28434,APC
Rpr ing hernia init blocked,49501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7656.69,,,,,,,fee schedule,3544.48,15725.66,
Rpr ing hernia init blocked,49501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6137.51,,,,,,,fee schedule,3544.48,15725.66,
Rpr ing hernia init blocked,49501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6704.67,,,,,,,fee schedule,3544.48,15725.66,
Rpr ing hernia init blocked,49501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7049.02,,,,,,,fee schedule,3544.48,15725.66,
Rpr ing hernia init blocked,49501,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15725.66,,,,,,,fee schedule,3544.48,15725.66,APC 378
Rpr ing hernia init blocked,49501,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3721.7,,,,,,,fee schedule,3544.48,15725.66,APC
Rpr ing hernia init blocked,49501,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3686.26,,,,,,,fee schedule,3544.48,15725.66,APC
Rpr ing hernia init blocked,49501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3544.48,,,,,,,fee schedule,3544.48,15725.66,APC
Rpr ing hernia init blocked,49501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5423.05,,,,,,,fee schedule,3544.48,15725.66,Radiology
Rpr ing hernia init blocked,49501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4962.27,,,,,,,fee schedule,3544.48,15725.66,APC
Rpr ing hernia init blocked,49501,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6202.84,,,,,,,fee schedule,3544.48,15725.66,APC
Prp i/hern init reduc >5 yr,49505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6972,,,,,,,fee schedule,3544.48,15725.66,
Prp i/hern init reduc >5 yr,49505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5588.66,,,,,,,fee schedule,3544.48,15725.66,
Prp i/hern init reduc >5 yr,49505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6105.11,,,,,,,fee schedule,3544.48,15725.66,
Prp i/hern init reduc >5 yr,49505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6418.66,,,,,,,fee schedule,3544.48,15725.66,
Prp i/hern init reduc >5 yr,49505,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15725.66,,,,,,,fee schedule,3544.48,15725.66,APC 378
Prp i/hern init reduc >5 yr,49505,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3721.7,,,,,,,fee schedule,3544.48,15725.66,APC
Prp i/hern init reduc >5 yr,49505,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3686.26,,,,,,,fee schedule,3544.48,15725.66,APC
Prp i/hern init reduc >5 yr,49505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3544.48,,,,,,,fee schedule,3544.48,15725.66,APC
Prp i/hern init reduc >5 yr,49505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5423.05,,,,,,,fee schedule,3544.48,15725.66,Radiology
Prp i/hern init reduc >5 yr,49505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4962.27,,,,,,,fee schedule,3544.48,15725.66,APC
Prp i/hern init reduc >5 yr,49505,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6202.84,,,,,,,fee schedule,3544.48,15725.66,APC
Prp i/hern init block >5 yr,49507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6789.52,,,,,,,fee schedule,3544.48,15725.66,
Prp i/hern init block >5 yr,49507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5442.39,,,,,,,fee schedule,3544.48,15725.66,
Prp i/hern init block >5 yr,49507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5945.32,,,,,,,fee schedule,3544.48,15725.66,
Prp i/hern init block >5 yr,49507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6250.66,,,,,,,fee schedule,3544.48,15725.66,
Prp i/hern init block >5 yr,49507,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15725.66,,,,,,,fee schedule,3544.48,15725.66,APC 378
Prp i/hern init block >5 yr,49507,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3721.7,,,,,,,fee schedule,3544.48,15725.66,APC
Prp i/hern init block >5 yr,49507,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3686.26,,,,,,,fee schedule,3544.48,15725.66,APC
Prp i/hern init block >5 yr,49507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3544.48,,,,,,,fee schedule,3544.48,15725.66,APC
Prp i/hern init block >5 yr,49507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5423.05,,,,,,,fee schedule,3544.48,15725.66,Radiology
Prp i/hern init block >5 yr,49507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4962.27,,,,,,,fee schedule,3544.48,15725.66,APC
Prp i/hern init block >5 yr,49507,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6202.84,,,,,,,fee schedule,3544.48,15725.66,APC
Rerepair ing hernia reduce,49520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6537.54,,,,,,,fee schedule,3544.48,15725.66,
Rerepair ing hernia reduce,49520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5240.41,,,,,,,fee schedule,3544.48,15725.66,
Rerepair ing hernia reduce,49520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5724.67,,,,,,,fee schedule,3544.48,15725.66,
Rerepair ing hernia reduce,49520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6018.69,,,,,,,fee schedule,3544.48,15725.66,
Rerepair ing hernia reduce,49520,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15725.66,,,,,,,fee schedule,3544.48,15725.66,APC 378
Rerepair ing hernia reduce,49520,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3721.7,,,,,,,fee schedule,3544.48,15725.66,APC
Rerepair ing hernia reduce,49520,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3686.26,,,,,,,fee schedule,3544.48,15725.66,APC
Rerepair ing hernia reduce,49520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3544.48,,,,,,,fee schedule,3544.48,15725.66,APC
Rerepair ing hernia reduce,49520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5423.05,,,,,,,fee schedule,3544.48,15725.66,Radiology
Rerepair ing hernia reduce,49520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4962.27,,,,,,,fee schedule,3544.48,15725.66,APC
Rerepair ing hernia reduce,49520,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6202.84,,,,,,,fee schedule,3544.48,15725.66,APC
Rerepair ing hernia blocked,49521,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10205.34,,,,,,,fee schedule,6408.87,28434,
Rerepair ing hernia blocked,49521,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8180.47,,,,,,,fee schedule,6408.87,28434,
Rerepair ing hernia blocked,49521,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8936.43,,,,,,,fee schedule,6408.87,28434,
Rerepair ing hernia blocked,49521,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9395.4,,,,,,,fee schedule,6408.87,28434,
Rerepair ing hernia blocked,49521,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,28434,,,,,,,fee schedule,6408.87,28434,APC 378
Rerepair ing hernia blocked,49521,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6729.32,,,,,,,fee schedule,6408.87,28434,APC
Rerepair ing hernia blocked,49521,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6665.23,,,,,,,fee schedule,6408.87,28434,APC
Rerepair ing hernia blocked,49521,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6408.87,,,,,,,fee schedule,6408.87,28434,APC
Rerepair ing hernia blocked,49521,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9805.57,,,,,,,fee schedule,6408.87,28434,Radiology
Rerepair ing hernia blocked,49521,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8972.42,,,,,,,fee schedule,6408.87,28434,APC
Rerepair ing hernia blocked,49521,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11215.53,,,,,,,fee schedule,6408.87,28434,APC
Repair ing hernia sliding,49525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7656.69,,,,,,,fee schedule,3544.48,15725.66,
Repair ing hernia sliding,49525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6137.51,,,,,,,fee schedule,3544.48,15725.66,
Repair ing hernia sliding,49525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6704.67,,,,,,,fee schedule,3544.48,15725.66,
Repair ing hernia sliding,49525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7049.02,,,,,,,fee schedule,3544.48,15725.66,
Repair ing hernia sliding,49525,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15725.66,,,,,,,fee schedule,3544.48,15725.66,APC 378
Repair ing hernia sliding,49525,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3721.7,,,,,,,fee schedule,3544.48,15725.66,APC
Repair ing hernia sliding,49525,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3686.26,,,,,,,fee schedule,3544.48,15725.66,APC
Repair ing hernia sliding,49525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3544.48,,,,,,,fee schedule,3544.48,15725.66,APC
Repair ing hernia sliding,49525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5423.05,,,,,,,fee schedule,3544.48,15725.66,Radiology
Repair ing hernia sliding,49525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4962.27,,,,,,,fee schedule,3544.48,15725.66,APC
Repair ing hernia sliding,49525,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6202.84,,,,,,,fee schedule,3544.48,15725.66,APC
Repair lumbar hernia,49540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7656.69,,,,,,,fee schedule,5984.88,26552.87,
Repair lumbar hernia,49540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6137.51,,,,,,,fee schedule,5984.88,26552.87,
Repair lumbar hernia,49540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6704.67,,,,,,,fee schedule,5984.88,26552.87,
Repair lumbar hernia,49540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7049.02,,,,,,,fee schedule,5984.88,26552.87,
Repair lumbar hernia,49540,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,5984.88,26552.87,APC 378
Repair lumbar hernia,49540,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,5984.88,26552.87,APC
Repair lumbar hernia,49540,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,5984.88,26552.87,APC
Repair lumbar hernia,49540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,5984.88,26552.87,APC
Repair lumbar hernia,49540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,5984.88,26552.87,Radiology
Repair lumbar hernia,49540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,5984.88,26552.87,APC
Repair lumbar hernia,49540,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,5984.88,26552.87,APC
Rpr rem hernia init reduce,49550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7656.69,,,,,,,fee schedule,3544.48,15725.66,
Rpr rem hernia init reduce,49550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6137.51,,,,,,,fee schedule,3544.48,15725.66,
Rpr rem hernia init reduce,49550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6704.67,,,,,,,fee schedule,3544.48,15725.66,
Rpr rem hernia init reduce,49550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7049.02,,,,,,,fee schedule,3544.48,15725.66,
Rpr rem hernia init reduce,49550,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15725.66,,,,,,,fee schedule,3544.48,15725.66,APC 378
Rpr rem hernia init reduce,49550,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3721.7,,,,,,,fee schedule,3544.48,15725.66,APC
Rpr rem hernia init reduce,49550,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3686.26,,,,,,,fee schedule,3544.48,15725.66,APC
Rpr rem hernia init reduce,49550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3544.48,,,,,,,fee schedule,3544.48,15725.66,APC
Rpr rem hernia init reduce,49550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5423.05,,,,,,,fee schedule,3544.48,15725.66,Radiology
Rpr rem hernia init reduce,49550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4962.27,,,,,,,fee schedule,3544.48,15725.66,APC
Rpr rem hernia init reduce,49550,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6202.84,,,,,,,fee schedule,3544.48,15725.66,APC
Rpr fem hernia init blocked,49553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2031.48,,,,,,,fee schedule,1628.41,15725.66,
Rpr fem hernia init blocked,49553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1628.41,,,,,,,fee schedule,1628.41,15725.66,
Rpr fem hernia init blocked,49553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1778.89,,,,,,,fee schedule,1628.41,15725.66,
Rpr fem hernia init blocked,49553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1870.25,,,,,,,fee schedule,1628.41,15725.66,
Rpr fem hernia init blocked,49553,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15725.66,,,,,,,fee schedule,1628.41,15725.66,APC 378
Rpr fem hernia init blocked,49553,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3721.7,,,,,,,fee schedule,1628.41,15725.66,APC
Rpr fem hernia init blocked,49553,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3686.26,,,,,,,fee schedule,1628.41,15725.66,APC
Rpr fem hernia init blocked,49553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3544.48,,,,,,,fee schedule,1628.41,15725.66,APC
Rpr fem hernia init blocked,49553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5423.05,,,,,,,fee schedule,1628.41,15725.66,Radiology
Rpr fem hernia init blocked,49553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4962.27,,,,,,,fee schedule,1628.41,15725.66,APC
Rpr fem hernia init blocked,49553,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6202.84,,,,,,,fee schedule,1628.41,15725.66,APC
Rerepair fem hernia reduce,49555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7656.69,,,,,,,fee schedule,3544.48,15725.66,
Rerepair fem hernia reduce,49555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6137.51,,,,,,,fee schedule,3544.48,15725.66,
Rerepair fem hernia reduce,49555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6704.67,,,,,,,fee schedule,3544.48,15725.66,
Rerepair fem hernia reduce,49555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7049.02,,,,,,,fee schedule,3544.48,15725.66,
Rerepair fem hernia reduce,49555,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15725.66,,,,,,,fee schedule,3544.48,15725.66,APC 378
Rerepair fem hernia reduce,49555,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3721.7,,,,,,,fee schedule,3544.48,15725.66,APC
Rerepair fem hernia reduce,49555,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3686.26,,,,,,,fee schedule,3544.48,15725.66,APC
Rerepair fem hernia reduce,49555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3544.48,,,,,,,fee schedule,3544.48,15725.66,APC
Rerepair fem hernia reduce,49555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5423.05,,,,,,,fee schedule,3544.48,15725.66,Radiology
Rerepair fem hernia reduce,49555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4962.27,,,,,,,fee schedule,3544.48,15725.66,APC
Rerepair fem hernia reduce,49555,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6202.84,,,,,,,fee schedule,3544.48,15725.66,APC
Rerepair fem hernia blocked,49557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7656.69,,,,,,,fee schedule,3544.48,15725.66,
Rerepair fem hernia blocked,49557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6137.51,,,,,,,fee schedule,3544.48,15725.66,
Rerepair fem hernia blocked,49557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6704.67,,,,,,,fee schedule,3544.48,15725.66,
Rerepair fem hernia blocked,49557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7049.02,,,,,,,fee schedule,3544.48,15725.66,
Rerepair fem hernia blocked,49557,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15725.66,,,,,,,fee schedule,3544.48,15725.66,APC 378
Rerepair fem hernia blocked,49557,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3721.7,,,,,,,fee schedule,3544.48,15725.66,APC
Rerepair fem hernia blocked,49557,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3686.26,,,,,,,fee schedule,3544.48,15725.66,APC
Rerepair fem hernia blocked,49557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3544.48,,,,,,,fee schedule,3544.48,15725.66,APC
Rerepair fem hernia blocked,49557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5423.05,,,,,,,fee schedule,3544.48,15725.66,Radiology
Rerepair fem hernia blocked,49557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4962.27,,,,,,,fee schedule,3544.48,15725.66,APC
Rerepair fem hernia blocked,49557,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6202.84,,,,,,,fee schedule,3544.48,15725.66,APC
Rpr aa hrn 1st < 3 cm rdc,49591,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13388.5,,,,,,,fee schedule,3544.48,15725.66,
Rpr aa hrn 1st < 3 cm rdc,49591,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10732.05,,,,,,,fee schedule,3544.48,15725.66,
Rpr aa hrn 1st < 3 cm rdc,49591,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11723.79,,,,,,,fee schedule,3544.48,15725.66,
Rpr aa hrn 1st < 3 cm rdc,49591,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12325.92,,,,,,,fee schedule,3544.48,15725.66,
Rpr aa hrn 1st < 3 cm rdc,49591,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15725.66,,,,,,,fee schedule,3544.48,15725.66,APC 378
Rpr aa hrn 1st < 3 cm rdc,49591,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3721.7,,,,,,,fee schedule,3544.48,15725.66,APC
Rpr aa hrn 1st < 3 cm rdc,49591,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3686.26,,,,,,,fee schedule,3544.48,15725.66,APC
Rpr aa hrn 1st < 3 cm rdc,49591,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3544.48,,,,,,,fee schedule,3544.48,15725.66,APC
Rpr aa hrn 1st < 3 cm rdc,49591,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5423.05,,,,,,,fee schedule,3544.48,15725.66,Radiology
Rpr aa hrn 1st < 3 cm rdc,49591,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4962.27,,,,,,,fee schedule,3544.48,15725.66,APC
Rpr aa hrn 1st < 3 cm rdc,49591,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6202.84,,,,,,,fee schedule,3544.48,15725.66,APC
Rpr aa hrn 1st < 3 ncr/strn,49592,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19701.93,,,,,,,fee schedule,5984.88,26552.87,
Rpr aa hrn 1st < 3 ncr/strn,49592,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15792.81,,,,,,,fee schedule,5984.88,26552.87,
Rpr aa hrn 1st < 3 ncr/strn,49592,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17252.22,,,,,,,fee schedule,5984.88,26552.87,
Rpr aa hrn 1st < 3 ncr/strn,49592,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18138.28,,,,,,,fee schedule,5984.88,26552.87,
Rpr aa hrn 1st < 3 ncr/strn,49592,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,5984.88,26552.87,APC 378
Rpr aa hrn 1st < 3 ncr/strn,49592,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,5984.88,26552.87,APC
Rpr aa hrn 1st < 3 ncr/strn,49592,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,5984.88,26552.87,APC
Rpr aa hrn 1st < 3 ncr/strn,49592,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,5984.88,26552.87,APC
Rpr aa hrn 1st < 3 ncr/strn,49592,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,5984.88,26552.87,Radiology
Rpr aa hrn 1st < 3 ncr/strn,49592,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,5984.88,26552.87,APC
Rpr aa hrn 1st < 3 ncr/strn,49592,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,5984.88,26552.87,APC
Rpr aa hrn 1st 3-10 rdc,49593,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13388.5,,,,,,,fee schedule,6408.87,28434,
Rpr aa hrn 1st 3-10 rdc,49593,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10732.05,,,,,,,fee schedule,6408.87,28434,
Rpr aa hrn 1st 3-10 rdc,49593,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11723.79,,,,,,,fee schedule,6408.87,28434,
Rpr aa hrn 1st 3-10 rdc,49593,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12325.92,,,,,,,fee schedule,6408.87,28434,
Rpr aa hrn 1st 3-10 rdc,49593,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,28434,,,,,,,fee schedule,6408.87,28434,APC 378
Rpr aa hrn 1st 3-10 rdc,49593,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6729.32,,,,,,,fee schedule,6408.87,28434,APC
Rpr aa hrn 1st 3-10 rdc,49593,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6665.23,,,,,,,fee schedule,6408.87,28434,APC
Rpr aa hrn 1st 3-10 rdc,49593,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6408.87,,,,,,,fee schedule,6408.87,28434,APC
Rpr aa hrn 1st 3-10 rdc,49593,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9805.57,,,,,,,fee schedule,6408.87,28434,Radiology
Rpr aa hrn 1st 3-10 rdc,49593,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8972.42,,,,,,,fee schedule,6408.87,28434,APC
Rpr aa hrn 1st 3-10 rdc,49593,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11215.53,,,,,,,fee schedule,6408.87,28434,APC
Rpr aa hrn 1st 3-10 ncr/strn,49594,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19701.93,,,,,,,fee schedule,5984.88,26552.87,
Rpr aa hrn 1st 3-10 ncr/strn,49594,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15792.81,,,,,,,fee schedule,5984.88,26552.87,
Rpr aa hrn 1st 3-10 ncr/strn,49594,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17252.22,,,,,,,fee schedule,5984.88,26552.87,
Rpr aa hrn 1st 3-10 ncr/strn,49594,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18138.28,,,,,,,fee schedule,5984.88,26552.87,
Rpr aa hrn 1st 3-10 ncr/strn,49594,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,5984.88,26552.87,APC 378
Rpr aa hrn 1st 3-10 ncr/strn,49594,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,5984.88,26552.87,APC
Rpr aa hrn 1st 3-10 ncr/strn,49594,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,5984.88,26552.87,APC
Rpr aa hrn 1st 3-10 ncr/strn,49594,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,5984.88,26552.87,APC
Rpr aa hrn 1st 3-10 ncr/strn,49594,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,5984.88,26552.87,Radiology
Rpr aa hrn 1st 3-10 ncr/strn,49594,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,5984.88,26552.87,APC
Rpr aa hrn 1st 3-10 ncr/strn,49594,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,5984.88,26552.87,APC
Rpr aa hrn 1st > 10 rdc,49595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13388.5,,,,,,,fee schedule,6408.87,28434,
Rpr aa hrn 1st > 10 rdc,49595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10732.05,,,,,,,fee schedule,6408.87,28434,
Rpr aa hrn 1st > 10 rdc,49595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11723.79,,,,,,,fee schedule,6408.87,28434,
Rpr aa hrn 1st > 10 rdc,49595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12325.92,,,,,,,fee schedule,6408.87,28434,
Rpr aa hrn 1st > 10 rdc,49595,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,28434,,,,,,,fee schedule,6408.87,28434,APC 378
Rpr aa hrn 1st > 10 rdc,49595,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6729.32,,,,,,,fee schedule,6408.87,28434,APC
Rpr aa hrn 1st > 10 rdc,49595,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6665.23,,,,,,,fee schedule,6408.87,28434,APC
Rpr aa hrn 1st > 10 rdc,49595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6408.87,,,,,,,fee schedule,6408.87,28434,APC
Rpr aa hrn 1st > 10 rdc,49595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9805.57,,,,,,,fee schedule,6408.87,28434,Radiology
Rpr aa hrn 1st > 10 rdc,49595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8972.42,,,,,,,fee schedule,6408.87,28434,APC
Rpr aa hrn 1st > 10 rdc,49595,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11215.53,,,,,,,fee schedule,6408.87,28434,APC
Repair umbilical lesion,49600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7656.69,,,,,,,fee schedule,3544.48,15725.66,
Repair umbilical lesion,49600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6137.51,,,,,,,fee schedule,3544.48,15725.66,
Repair umbilical lesion,49600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6704.67,,,,,,,fee schedule,3544.48,15725.66,
Repair umbilical lesion,49600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7049.02,,,,,,,fee schedule,3544.48,15725.66,
Repair umbilical lesion,49600,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15725.66,,,,,,,fee schedule,3544.48,15725.66,APC 378
Repair umbilical lesion,49600,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3721.7,,,,,,,fee schedule,3544.48,15725.66,APC
Repair umbilical lesion,49600,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3686.26,,,,,,,fee schedule,3544.48,15725.66,APC
Repair umbilical lesion,49600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3544.48,,,,,,,fee schedule,3544.48,15725.66,APC
Repair umbilical lesion,49600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5423.05,,,,,,,fee schedule,3544.48,15725.66,Radiology
Repair umbilical lesion,49600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4962.27,,,,,,,fee schedule,3544.48,15725.66,APC
Repair umbilical lesion,49600,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6202.84,,,,,,,fee schedule,3544.48,15725.66,APC
Rpr aa hrn rcr < 3 rdc,49613,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13388.5,,,,,,,fee schedule,3544.48,15725.66,
Rpr aa hrn rcr < 3 rdc,49613,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10732.05,,,,,,,fee schedule,3544.48,15725.66,
Rpr aa hrn rcr < 3 rdc,49613,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11723.79,,,,,,,fee schedule,3544.48,15725.66,
Rpr aa hrn rcr < 3 rdc,49613,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12325.92,,,,,,,fee schedule,3544.48,15725.66,
Rpr aa hrn rcr < 3 rdc,49613,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15725.66,,,,,,,fee schedule,3544.48,15725.66,APC 378
Rpr aa hrn rcr < 3 rdc,49613,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3721.7,,,,,,,fee schedule,3544.48,15725.66,APC
Rpr aa hrn rcr < 3 rdc,49613,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3686.26,,,,,,,fee schedule,3544.48,15725.66,APC
Rpr aa hrn rcr < 3 rdc,49613,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3544.48,,,,,,,fee schedule,3544.48,15725.66,APC
Rpr aa hrn rcr < 3 rdc,49613,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5423.05,,,,,,,fee schedule,3544.48,15725.66,Radiology
Rpr aa hrn rcr < 3 rdc,49613,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4962.27,,,,,,,fee schedule,3544.48,15725.66,APC
Rpr aa hrn rcr < 3 rdc,49613,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6202.84,,,,,,,fee schedule,3544.48,15725.66,APC
Rpr aa hrn rcr < 3 ncr/strn,49614,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19701.93,,,,,,,fee schedule,5984.88,26552.87,
Rpr aa hrn rcr < 3 ncr/strn,49614,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15792.81,,,,,,,fee schedule,5984.88,26552.87,
Rpr aa hrn rcr < 3 ncr/strn,49614,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17252.22,,,,,,,fee schedule,5984.88,26552.87,
Rpr aa hrn rcr < 3 ncr/strn,49614,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18138.28,,,,,,,fee schedule,5984.88,26552.87,
Rpr aa hrn rcr < 3 ncr/strn,49614,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,5984.88,26552.87,APC 378
Rpr aa hrn rcr < 3 ncr/strn,49614,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,5984.88,26552.87,APC
Rpr aa hrn rcr < 3 ncr/strn,49614,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,5984.88,26552.87,APC
Rpr aa hrn rcr < 3 ncr/strn,49614,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,5984.88,26552.87,APC
Rpr aa hrn rcr < 3 ncr/strn,49614,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,5984.88,26552.87,Radiology
Rpr aa hrn rcr < 3 ncr/strn,49614,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,5984.88,26552.87,APC
Rpr aa hrn rcr < 3 ncr/strn,49614,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,5984.88,26552.87,APC
Rpr aa hrn rcr 3-10 rdc,49615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13388.5,,,,,,,fee schedule,6408.87,28434,
Rpr aa hrn rcr 3-10 rdc,49615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10732.05,,,,,,,fee schedule,6408.87,28434,
Rpr aa hrn rcr 3-10 rdc,49615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11723.79,,,,,,,fee schedule,6408.87,28434,
Rpr aa hrn rcr 3-10 rdc,49615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12325.92,,,,,,,fee schedule,6408.87,28434,
Rpr aa hrn rcr 3-10 rdc,49615,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,28434,,,,,,,fee schedule,6408.87,28434,APC 378
Rpr aa hrn rcr 3-10 rdc,49615,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6729.32,,,,,,,fee schedule,6408.87,28434,APC
Rpr aa hrn rcr 3-10 rdc,49615,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6665.23,,,,,,,fee schedule,6408.87,28434,APC
Rpr aa hrn rcr 3-10 rdc,49615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6408.87,,,,,,,fee schedule,6408.87,28434,APC
Rpr aa hrn rcr 3-10 rdc,49615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9805.57,,,,,,,fee schedule,6408.87,28434,Radiology
Rpr aa hrn rcr 3-10 rdc,49615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8972.42,,,,,,,fee schedule,6408.87,28434,APC
Rpr aa hrn rcr 3-10 rdc,49615,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11215.53,,,,,,,fee schedule,6408.87,28434,APC
Lap ing hernia repair init,49650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7278.68,,,,,,,fee schedule,5834.49,26552.87,
Lap ing hernia repair init,49650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5834.49,,,,,,,fee schedule,5834.49,26552.87,
Lap ing hernia repair init,49650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6373.66,,,,,,,fee schedule,5834.49,26552.87,
Lap ing hernia repair init,49650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6701,,,,,,,fee schedule,5834.49,26552.87,
Lap ing hernia repair init,49650,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,5834.49,26552.87,APC 378
Lap ing hernia repair init,49650,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,5834.49,26552.87,APC
Lap ing hernia repair init,49650,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,5834.49,26552.87,APC
Lap ing hernia repair init,49650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,5834.49,26552.87,APC
Lap ing hernia repair init,49650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,5834.49,26552.87,Radiology
Lap ing hernia repair init,49650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,5834.49,26552.87,APC
Lap ing hernia repair init,49650,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,5834.49,26552.87,APC
Lap ing hernia repair recur,49651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9045.99,,,,,,,fee schedule,5984.88,26552.87,
Lap ing hernia repair recur,49651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7251.15,,,,,,,fee schedule,5984.88,26552.87,
Lap ing hernia repair recur,49651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7921.23,,,,,,,fee schedule,5984.88,26552.87,
Lap ing hernia repair recur,49651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8328.06,,,,,,,fee schedule,5984.88,26552.87,
Lap ing hernia repair recur,49651,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,5984.88,26552.87,APC 378
Lap ing hernia repair recur,49651,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,5984.88,26552.87,APC
Lap ing hernia repair recur,49651,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,5984.88,26552.87,APC
Lap ing hernia repair recur,49651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,5984.88,26552.87,APC
Lap ing hernia repair recur,49651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,5984.88,26552.87,Radiology
Lap ing hernia repair recur,49651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,5984.88,26552.87,APC
Lap ing hernia repair recur,49651,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,5984.88,26552.87,APC
Laparo proc hernia repair,49659,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8584.34,,,,,,,fee schedule,5984.88,26552.87,
Laparo proc hernia repair,49659,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6881.1,,,,,,,fee schedule,5984.88,26552.87,
Laparo proc hernia repair,49659,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7516.98,,,,,,,fee schedule,5984.88,26552.87,
Laparo proc hernia repair,49659,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7903.05,,,,,,,fee schedule,5984.88,26552.87,
Laparo proc hernia repair,49659,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,5984.88,26552.87,APC 378
Laparo proc hernia repair,49659,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,5984.88,26552.87,APC
Laparo proc hernia repair,49659,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,5984.88,26552.87,APC
Laparo proc hernia repair,49659,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,5984.88,26552.87,APC
Laparo proc hernia repair,49659,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,5984.88,26552.87,Radiology
Laparo proc hernia repair,49659,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,5984.88,26552.87,APC
Laparo proc hernia repair,49659,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,5984.88,26552.87,APC
Abdomen surgery procedure,49999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4531.07,,,,,,,fee schedule,897.89,4531.07,
Abdomen surgery procedure,49999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3632.05,,,,,,,fee schedule,897.89,4531.07,
Abdomen surgery procedure,49999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3967.69,,,,,,,fee schedule,897.89,4531.07,
Abdomen surgery procedure,49999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4171.46,,,,,,,fee schedule,897.89,4531.07,
Abdomen surgery procedure,49999,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3983.62,,,,,,,fee schedule,897.89,4531.07,APC 378
Abdomen surgery procedure,49999,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,942.78,,,,,,,fee schedule,897.89,4531.07,APC
Abdomen surgery procedure,49999,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,933.8,,,,,,,fee schedule,897.89,4531.07,APC
Abdomen surgery procedure,49999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,897.89,,,,,,,fee schedule,897.89,4531.07,APC
Abdomen surgery procedure,49999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1373.77,,,,,,,fee schedule,897.89,4531.07,Radiology
Abdomen surgery procedure,49999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1257.04,,,,,,,fee schedule,897.89,4531.07,APC
Abdomen surgery procedure,49999,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1571.3,,,,,,,fee schedule,897.89,4531.07,APC
Renal abscess open drain,50020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6183.21,,,,,,,fee schedule,2069.41,9181.28,
Renal abscess open drain,50020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4956.38,,,,,,,fee schedule,2069.41,9181.28,
Renal abscess open drain,50020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5414.4,,,,,,,fee schedule,2069.41,9181.28,
Renal abscess open drain,50020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5692.48,,,,,,,fee schedule,2069.41,9181.28,
Renal abscess open drain,50020,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9181.28,,,,,,,fee schedule,2069.41,9181.28,APC 378
Renal abscess open drain,50020,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2172.88,,,,,,,fee schedule,2069.41,9181.28,APC
Renal abscess open drain,50020,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2152.19,,,,,,,fee schedule,2069.41,9181.28,APC
Renal abscess open drain,50020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2069.41,,,,,,,fee schedule,2069.41,9181.28,APC
Renal abscess open drain,50020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3166.2,,,,,,,fee schedule,2069.41,9181.28,Radiology
Renal abscess open drain,50020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2897.18,,,,,,,fee schedule,2069.41,9181.28,APC
Renal abscess open drain,50020,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3621.47,,,,,,,fee schedule,2069.41,9181.28,APC
Removal of kidney stone,50080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11281.86,,,,,,,fee schedule,9043.4,41578.13,
Removal of kidney stone,50080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9043.4,,,,,,,fee schedule,9043.4,41578.13,
Removal of kidney stone,50080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9879.09,,,,,,,fee schedule,9043.4,41578.13,
Removal of kidney stone,50080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10386.48,,,,,,,fee schedule,9043.4,41578.13,
Removal of kidney stone,50080,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,41578.13,,,,,,,fee schedule,9043.4,41578.13,APC 378
Removal of kidney stone,50080,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9840.06,,,,,,,fee schedule,9043.4,41578.13,APC
Removal of kidney stone,50080,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9746.35,,,,,,,fee schedule,9043.4,41578.13,APC
Removal of kidney stone,50080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9371.49,,,,,,,fee schedule,9043.4,41578.13,APC
Removal of kidney stone,50080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14338.38,,,,,,,fee schedule,9043.4,41578.13,Radiology
Removal of kidney stone,50080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13120.09,,,,,,,fee schedule,9043.4,41578.13,APC
Removal of kidney stone,50080,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16400.11,,,,,,,fee schedule,9043.4,41578.13,APC
Removal of kidney stone,50081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6342.49,,,,,,,fee schedule,5084.06,41578.13,
Removal of kidney stone,50081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5084.06,,,,,,,fee schedule,5084.06,41578.13,
Removal of kidney stone,50081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5553.87,,,,,,,fee schedule,5084.06,41578.13,
Removal of kidney stone,50081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5839.12,,,,,,,fee schedule,5084.06,41578.13,
Removal of kidney stone,50081,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,41578.13,,,,,,,fee schedule,5084.06,41578.13,APC 378
Removal of kidney stone,50081,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9840.06,,,,,,,fee schedule,5084.06,41578.13,APC
Removal of kidney stone,50081,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9746.35,,,,,,,fee schedule,5084.06,41578.13,APC
Removal of kidney stone,50081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9371.49,,,,,,,fee schedule,5084.06,41578.13,APC
Removal of kidney stone,50081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14338.38,,,,,,,fee schedule,5084.06,41578.13,Radiology
Removal of kidney stone,50081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13120.09,,,,,,,fee schedule,5084.06,41578.13,APC
Removal of kidney stone,50081,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16400.11,,,,,,,fee schedule,5084.06,41578.13,APC
Renal biopsy perq,50200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1673.67,,,,,,,fee schedule,1341.6,7254.06,
Renal biopsy perq,50200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1341.6,,,,,,,fee schedule,1341.6,7254.06,
Renal biopsy perq,50200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1465.57,,,,,,,fee schedule,1341.6,7254.06,
Renal biopsy perq,50200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1540.84,,,,,,,fee schedule,1341.6,7254.06,
Renal biopsy perq,50200,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1341.6,7254.06,APC 378
Renal biopsy perq,50200,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1341.6,7254.06,APC
Renal biopsy perq,50200,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1341.6,7254.06,APC
Renal biopsy perq,50200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1341.6,7254.06,APC
Renal biopsy perq,50200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1341.6,7254.06,Radiology
Renal biopsy perq,50200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1341.6,7254.06,APC
Renal biopsy perq,50200,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1341.6,7254.06,APC
Change ureter stent percut,50382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6183.21,,,,,,,fee schedule,2069.41,9181.28,
Change ureter stent percut,50382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4956.38,,,,,,,fee schedule,2069.41,9181.28,
Change ureter stent percut,50382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5414.4,,,,,,,fee schedule,2069.41,9181.28,
Change ureter stent percut,50382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5692.48,,,,,,,fee schedule,2069.41,9181.28,
Change ureter stent percut,50382,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9181.28,,,,,,,fee schedule,2069.41,9181.28,APC 378
Change ureter stent percut,50382,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2172.88,,,,,,,fee schedule,2069.41,9181.28,APC
Change ureter stent percut,50382,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2152.19,,,,,,,fee schedule,2069.41,9181.28,APC
Change ureter stent percut,50382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2069.41,,,,,,,fee schedule,2069.41,9181.28,APC
Change ureter stent percut,50382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3166.2,,,,,,,fee schedule,2069.41,9181.28,Radiology
Change ureter stent percut,50382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2897.18,,,,,,,fee schedule,2069.41,9181.28,APC
Change ureter stent percut,50382,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3621.47,,,,,,,fee schedule,2069.41,9181.28,APC
Remove ureter stent percut,50384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4477.9,,,,,,,fee schedule,2069.41,9181.28,
Remove ureter stent percut,50384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3589.43,,,,,,,fee schedule,2069.41,9181.28,
Remove ureter stent percut,50384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3921.13,,,,,,,fee schedule,2069.41,9181.28,
Remove ureter stent percut,50384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4122.51,,,,,,,fee schedule,2069.41,9181.28,
Remove ureter stent percut,50384,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9181.28,,,,,,,fee schedule,2069.41,9181.28,APC 378
Remove ureter stent percut,50384,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2172.88,,,,,,,fee schedule,2069.41,9181.28,APC
Remove ureter stent percut,50384,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2152.19,,,,,,,fee schedule,2069.41,9181.28,APC
Remove ureter stent percut,50384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2069.41,,,,,,,fee schedule,2069.41,9181.28,APC
Remove ureter stent percut,50384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3166.2,,,,,,,fee schedule,2069.41,9181.28,Radiology
Remove ureter stent percut,50384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2897.18,,,,,,,fee schedule,2069.41,9181.28,APC
Remove ureter stent percut,50384,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3621.47,,,,,,,fee schedule,2069.41,9181.28,APC
Change stent via transureth,50385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4477.9,,,,,,,fee schedule,2069.41,9181.28,
Change stent via transureth,50385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3589.43,,,,,,,fee schedule,2069.41,9181.28,
Change stent via transureth,50385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3921.13,,,,,,,fee schedule,2069.41,9181.28,
Change stent via transureth,50385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4122.51,,,,,,,fee schedule,2069.41,9181.28,
Change stent via transureth,50385,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9181.28,,,,,,,fee schedule,2069.41,9181.28,APC 378
Change stent via transureth,50385,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2172.88,,,,,,,fee schedule,2069.41,9181.28,APC
Change stent via transureth,50385,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2152.19,,,,,,,fee schedule,2069.41,9181.28,APC
Change stent via transureth,50385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2069.41,,,,,,,fee schedule,2069.41,9181.28,APC
Change stent via transureth,50385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3166.2,,,,,,,fee schedule,2069.41,9181.28,Radiology
Change stent via transureth,50385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2897.18,,,,,,,fee schedule,2069.41,9181.28,APC
Change stent via transureth,50385,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3621.47,,,,,,,fee schedule,2069.41,9181.28,APC
Remove stent via transureth,50386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1490.87,,,,,,,fee schedule,1195.06,9181.28,
Remove stent via transureth,50386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1195.06,,,,,,,fee schedule,1195.06,9181.28,
Remove stent via transureth,50386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1305.5,,,,,,,fee schedule,1195.06,9181.28,
Remove stent via transureth,50386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1372.55,,,,,,,fee schedule,1195.06,9181.28,
Remove stent via transureth,50386,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9181.28,,,,,,,fee schedule,1195.06,9181.28,APC 378
Remove stent via transureth,50386,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2172.88,,,,,,,fee schedule,1195.06,9181.28,APC
Remove stent via transureth,50386,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2152.19,,,,,,,fee schedule,1195.06,9181.28,APC
Remove stent via transureth,50386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2069.41,,,,,,,fee schedule,1195.06,9181.28,APC
Remove stent via transureth,50386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3166.2,,,,,,,fee schedule,1195.06,9181.28,Radiology
Remove stent via transureth,50386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2897.18,,,,,,,fee schedule,1195.06,9181.28,APC
Remove stent via transureth,50386,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3621.47,,,,,,,fee schedule,1195.06,9181.28,APC
Change nephroureteral cath,50387,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3832.09,,,,,,,fee schedule,2069.41,9181.28,
Change nephroureteral cath,50387,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3071.75,,,,,,,fee schedule,2069.41,9181.28,
Change nephroureteral cath,50387,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3355.61,,,,,,,fee schedule,2069.41,9181.28,
Change nephroureteral cath,50387,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3527.95,,,,,,,fee schedule,2069.41,9181.28,
Change nephroureteral cath,50387,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9181.28,,,,,,,fee schedule,2069.41,9181.28,APC 378
Change nephroureteral cath,50387,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2172.88,,,,,,,fee schedule,2069.41,9181.28,APC
Change nephroureteral cath,50387,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2152.19,,,,,,,fee schedule,2069.41,9181.28,APC
Change nephroureteral cath,50387,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2069.41,,,,,,,fee schedule,2069.41,9181.28,APC
Change nephroureteral cath,50387,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3166.2,,,,,,,fee schedule,2069.41,9181.28,Radiology
Change nephroureteral cath,50387,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2897.18,,,,,,,fee schedule,2069.41,9181.28,APC
Change nephroureteral cath,50387,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3621.47,,,,,,,fee schedule,2069.41,9181.28,APC
Remove renal tube w/fluoro,50389,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2529.66,,,,,,,fee schedule,690.3,3062.63,
Remove renal tube w/fluoro,50389,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2027.75,,,,,,,fee schedule,690.3,3062.63,
Remove renal tube w/fluoro,50389,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2215.13,,,,,,,fee schedule,690.3,3062.63,
Remove renal tube w/fluoro,50389,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2328.9,,,,,,,fee schedule,690.3,3062.63,
Remove renal tube w/fluoro,50389,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3062.63,,,,,,,fee schedule,690.3,3062.63,APC 378
Remove renal tube w/fluoro,50389,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,724.82,,,,,,,fee schedule,690.3,3062.63,APC
Remove renal tube w/fluoro,50389,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,717.91,,,,,,,fee schedule,690.3,3062.63,APC
Remove renal tube w/fluoro,50389,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,690.3,,,,,,,fee schedule,690.3,3062.63,APC
Remove renal tube w/fluoro,50389,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1056.16,,,,,,,fee schedule,690.3,3062.63,Radiology
Remove renal tube w/fluoro,50389,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,966.42,,,,,,,fee schedule,690.3,3062.63,APC
Remove renal tube w/fluoro,50389,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1208.03,,,,,,,fee schedule,690.3,3062.63,APC
Drainage of kidney lesion,50390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2329.88,,,,,,,fee schedule,701.03,3110.22,
Drainage of kidney lesion,50390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1867.6,,,,,,,fee schedule,701.03,3110.22,
Drainage of kidney lesion,50390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2040.18,,,,,,,fee schedule,701.03,3110.22,
Drainage of kidney lesion,50390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2144.97,,,,,,,fee schedule,701.03,3110.22,
Drainage of kidney lesion,50390,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3110.22,,,,,,,fee schedule,701.03,3110.22,APC 378
Drainage of kidney lesion,50390,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,736.08,,,,,,,fee schedule,701.03,3110.22,APC
Drainage of kidney lesion,50390,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,729.07,,,,,,,fee schedule,701.03,3110.22,APC
Drainage of kidney lesion,50390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,701.03,,,,,,,fee schedule,701.03,3110.22,APC
Drainage of kidney lesion,50390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1072.57,,,,,,,fee schedule,701.03,3110.22,Radiology
Drainage of kidney lesion,50390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,981.44,,,,,,,fee schedule,701.03,3110.22,APC
Drainage of kidney lesion,50390,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1226.8,,,,,,,fee schedule,701.03,3110.22,APC
Instll rx agnt into rnal tub,50391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,258.44,,,,,,,fee schedule,207.16,1097.37,
Instll rx agnt into rnal tub,50391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,207.16,,,,,,,fee schedule,207.16,1097.37,
Instll rx agnt into rnal tub,50391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,226.3,,,,,,,fee schedule,207.16,1097.37,
Instll rx agnt into rnal tub,50391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,237.93,,,,,,,fee schedule,207.16,1097.37,
Instll rx agnt into rnal tub,50391,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1097.37,,,,,,,fee schedule,207.16,1097.37,APC 378
Instll rx agnt into rnal tub,50391,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,259.71,,,,,,,fee schedule,207.16,1097.37,APC
Instll rx agnt into rnal tub,50391,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,257.24,,,,,,,fee schedule,207.16,1097.37,APC
Instll rx agnt into rnal tub,50391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,247.34,,,,,,,fee schedule,207.16,1097.37,APC
Instll rx agnt into rnal tub,50391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,378.43,,,,,,,fee schedule,207.16,1097.37,Radiology
Instll rx agnt into rnal tub,50391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,346.28,,,,,,,fee schedule,207.16,1097.37,APC
Instll rx agnt into rnal tub,50391,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,432.85,,,,,,,fee schedule,207.16,1097.37,APC
Measure kidney pressure,50396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,501.08,,,,,,,fee schedule,401.66,3062.63,
Measure kidney pressure,50396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,401.66,,,,,,,fee schedule,401.66,3062.63,
Measure kidney pressure,50396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,438.77,,,,,,,fee schedule,401.66,3062.63,
Measure kidney pressure,50396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,461.31,,,,,,,fee schedule,401.66,3062.63,
Measure kidney pressure,50396,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3062.63,,,,,,,fee schedule,401.66,3062.63,APC 378
Measure kidney pressure,50396,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,724.82,,,,,,,fee schedule,401.66,3062.63,APC
Measure kidney pressure,50396,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,717.91,,,,,,,fee schedule,401.66,3062.63,APC
Measure kidney pressure,50396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,690.3,,,,,,,fee schedule,401.66,3062.63,APC
Measure kidney pressure,50396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1056.16,,,,,,,fee schedule,401.66,3062.63,Radiology
Measure kidney pressure,50396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,966.42,,,,,,,fee schedule,401.66,3062.63,APC
Measure kidney pressure,50396,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1208.03,,,,,,,fee schedule,401.66,3062.63,APC
Njx px nfrosgrm &/urtrgrm,50430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1982.53,,,,,,,fee schedule,690.3,3062.63,
Njx px nfrosgrm &/urtrgrm,50430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1589.17,,,,,,,fee schedule,690.3,3062.63,
Njx px nfrosgrm &/urtrgrm,50430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1736.03,,,,,,,fee schedule,690.3,3062.63,
Njx px nfrosgrm &/urtrgrm,50430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1825.19,,,,,,,fee schedule,690.3,3062.63,
Njx px nfrosgrm &/urtrgrm,50430,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3062.63,,,,,,,fee schedule,690.3,3062.63,APC 378
Njx px nfrosgrm &/urtrgrm,50430,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,724.82,,,,,,,fee schedule,690.3,3062.63,APC
Njx px nfrosgrm &/urtrgrm,50430,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,717.91,,,,,,,fee schedule,690.3,3062.63,APC
Njx px nfrosgrm &/urtrgrm,50430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,690.3,,,,,,,fee schedule,690.3,3062.63,APC
Njx px nfrosgrm &/urtrgrm,50430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1056.16,,,,,,,fee schedule,690.3,3062.63,Radiology
Njx px nfrosgrm &/urtrgrm,50430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,966.42,,,,,,,fee schedule,690.3,3062.63,APC
Njx px nfrosgrm &/urtrgrm,50430,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1208.03,,,,,,,fee schedule,690.3,3062.63,APC
Njx px nfrosgrm &/urtrgrm,50431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,926.48,,,,,,,fee schedule,690.3,3062.63,
Njx px nfrosgrm &/urtrgrm,50431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,742.65,,,,,,,fee schedule,690.3,3062.63,
Njx px nfrosgrm &/urtrgrm,50431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,811.28,,,,,,,fee schedule,690.3,3062.63,
Njx px nfrosgrm &/urtrgrm,50431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,852.95,,,,,,,fee schedule,690.3,3062.63,
Njx px nfrosgrm &/urtrgrm,50431,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3062.63,,,,,,,fee schedule,690.3,3062.63,APC 378
Njx px nfrosgrm &/urtrgrm,50431,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,724.82,,,,,,,fee schedule,690.3,3062.63,APC
Njx px nfrosgrm &/urtrgrm,50431,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,717.91,,,,,,,fee schedule,690.3,3062.63,APC
Njx px nfrosgrm &/urtrgrm,50431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,690.3,,,,,,,fee schedule,690.3,3062.63,APC
Njx px nfrosgrm &/urtrgrm,50431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1056.16,,,,,,,fee schedule,690.3,3062.63,Radiology
Njx px nfrosgrm &/urtrgrm,50431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,966.42,,,,,,,fee schedule,690.3,3062.63,APC
Njx px nfrosgrm &/urtrgrm,50431,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1208.03,,,,,,,fee schedule,690.3,3062.63,APC
Plmt nephrostomy catheter,50432,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6016.15,,,,,,,fee schedule,2069.41,9181.28,
Plmt nephrostomy catheter,50432,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4822.47,,,,,,,fee schedule,2069.41,9181.28,
Plmt nephrostomy catheter,50432,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5268.11,,,,,,,fee schedule,2069.41,9181.28,
Plmt nephrostomy catheter,50432,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5538.68,,,,,,,fee schedule,2069.41,9181.28,
Plmt nephrostomy catheter,50432,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9181.28,,,,,,,fee schedule,2069.41,9181.28,APC 378
Plmt nephrostomy catheter,50432,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2172.88,,,,,,,fee schedule,2069.41,9181.28,APC
Plmt nephrostomy catheter,50432,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2152.19,,,,,,,fee schedule,2069.41,9181.28,APC
Plmt nephrostomy catheter,50432,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2069.41,,,,,,,fee schedule,2069.41,9181.28,APC
Plmt nephrostomy catheter,50432,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3166.2,,,,,,,fee schedule,2069.41,9181.28,Radiology
Plmt nephrostomy catheter,50432,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2897.18,,,,,,,fee schedule,2069.41,9181.28,APC
Plmt nephrostomy catheter,50432,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3621.47,,,,,,,fee schedule,2069.41,9181.28,APC
Plmt nephroureteral catheter,50433,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7804.09,,,,,,,fee schedule,3489.62,15482.25,
Plmt nephroureteral catheter,50433,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6255.66,,,,,,,fee schedule,3489.62,15482.25,
Plmt nephroureteral catheter,50433,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6833.74,,,,,,,fee schedule,3489.62,15482.25,
Plmt nephroureteral catheter,50433,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7184.72,,,,,,,fee schedule,3489.62,15482.25,
Plmt nephroureteral catheter,50433,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Plmt nephroureteral catheter,50433,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Plmt nephroureteral catheter,50433,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Plmt nephroureteral catheter,50433,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Plmt nephroureteral catheter,50433,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Plmt nephroureteral catheter,50433,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Plmt nephroureteral catheter,50433,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Convert nephrostomy catheter,50434,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3360.79,,,,,,,fee schedule,2069.41,9181.28,
Convert nephrostomy catheter,50434,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2693.96,,,,,,,fee schedule,2069.41,9181.28,
Convert nephrostomy catheter,50434,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2942.91,,,,,,,fee schedule,2069.41,9181.28,
Convert nephrostomy catheter,50434,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3094.06,,,,,,,fee schedule,2069.41,9181.28,
Convert nephrostomy catheter,50434,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9181.28,,,,,,,fee schedule,2069.41,9181.28,APC 378
Convert nephrostomy catheter,50434,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2172.88,,,,,,,fee schedule,2069.41,9181.28,APC
Convert nephrostomy catheter,50434,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2152.19,,,,,,,fee schedule,2069.41,9181.28,APC
Convert nephrostomy catheter,50434,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2069.41,,,,,,,fee schedule,2069.41,9181.28,APC
Convert nephrostomy catheter,50434,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3166.2,,,,,,,fee schedule,2069.41,9181.28,Radiology
Convert nephrostomy catheter,50434,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2897.18,,,,,,,fee schedule,2069.41,9181.28,APC
Convert nephrostomy catheter,50434,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3621.47,,,,,,,fee schedule,2069.41,9181.28,APC
Exchange nephrostomy cath,50435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2647.23,,,,,,,fee schedule,2069.41,9181.28,
Exchange nephrostomy cath,50435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2121.99,,,,,,,fee schedule,2069.41,9181.28,
Exchange nephrostomy cath,50435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2318.08,,,,,,,fee schedule,2069.41,9181.28,
Exchange nephrostomy cath,50435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2437.14,,,,,,,fee schedule,2069.41,9181.28,
Exchange nephrostomy cath,50435,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9181.28,,,,,,,fee schedule,2069.41,9181.28,APC 378
Exchange nephrostomy cath,50435,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2172.88,,,,,,,fee schedule,2069.41,9181.28,APC
Exchange nephrostomy cath,50435,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2152.19,,,,,,,fee schedule,2069.41,9181.28,APC
Exchange nephrostomy cath,50435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2069.41,,,,,,,fee schedule,2069.41,9181.28,APC
Exchange nephrostomy cath,50435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3166.2,,,,,,,fee schedule,2069.41,9181.28,Radiology
Exchange nephrostomy cath,50435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2897.18,,,,,,,fee schedule,2069.41,9181.28,APC
Exchange nephrostomy cath,50435,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3621.47,,,,,,,fee schedule,2069.41,9181.28,APC
Dilat xst trc ndurlgc px,50436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6576.26,,,,,,,fee schedule,3489.62,15482.25,
Dilat xst trc ndurlgc px,50436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5271.44,,,,,,,fee schedule,3489.62,15482.25,
Dilat xst trc ndurlgc px,50436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5758.57,,,,,,,fee schedule,3489.62,15482.25,
Dilat xst trc ndurlgc px,50436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6054.33,,,,,,,fee schedule,3489.62,15482.25,
Dilat xst trc ndurlgc px,50436,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Dilat xst trc ndurlgc px,50436,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Dilat xst trc ndurlgc px,50436,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Dilat xst trc ndurlgc px,50436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Dilat xst trc ndurlgc px,50436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Dilat xst trc ndurlgc px,50436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Dilat xst trc ndurlgc px,50436,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Dilat xst trc new access rcs,50437,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11063.53,,,,,,,fee schedule,3489.62,15482.25,
Dilat xst trc new access rcs,50437,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8868.39,,,,,,,fee schedule,3489.62,15482.25,
Dilat xst trc new access rcs,50437,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9687.91,,,,,,,fee schedule,3489.62,15482.25,
Dilat xst trc new access rcs,50437,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10185.47,,,,,,,fee schedule,3489.62,15482.25,
Dilat xst trc new access rcs,50437,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Dilat xst trc new access rcs,50437,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Dilat xst trc new access rcs,50437,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Dilat xst trc new access rcs,50437,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Dilat xst trc new access rcs,50437,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Dilat xst trc new access rcs,50437,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Dilat xst trc new access rcs,50437,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Laparo ablate renal cyst,50541,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8584.34,,,,,,,fee schedule,6881.1,46687.84,
Laparo ablate renal cyst,50541,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6881.1,,,,,,,fee schedule,6881.1,46687.84,
Laparo ablate renal cyst,50541,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7516.98,,,,,,,fee schedule,6881.1,46687.84,
Laparo ablate renal cyst,50541,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7903.05,,,,,,,fee schedule,6881.1,46687.84,
Laparo ablate renal cyst,50541,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46687.84,,,,,,,fee schedule,6881.1,46687.84,APC 378
Laparo ablate renal cyst,50541,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11049.35,,,,,,,fee schedule,6881.1,46687.84,APC
Laparo ablate renal cyst,50541,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10944.12,,,,,,,fee schedule,6881.1,46687.84,APC
Laparo ablate renal cyst,50541,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10523.19,,,,,,,fee schedule,6881.1,46687.84,APC
Laparo ablate renal cyst,50541,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16100.48,,,,,,,fee schedule,6881.1,46687.84,Radiology
Laparo ablate renal cyst,50541,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14732.47,,,,,,,fee schedule,6881.1,46687.84,APC
Laparo ablate renal cyst,50541,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18415.58,,,,,,,fee schedule,6881.1,46687.84,APC
Laparo ablate renal mass,50542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17386.71,,,,,,,fee schedule,10523.19,46687.84,
Laparo ablate renal mass,50542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13936.97,,,,,,,fee schedule,10523.19,46687.84,
Laparo ablate renal mass,50542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15224.87,,,,,,,fee schedule,10523.19,46687.84,
Laparo ablate renal mass,50542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16006.82,,,,,,,fee schedule,10523.19,46687.84,
Laparo ablate renal mass,50542,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46687.84,,,,,,,fee schedule,10523.19,46687.84,APC 378
Laparo ablate renal mass,50542,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11049.35,,,,,,,fee schedule,10523.19,46687.84,APC
Laparo ablate renal mass,50542,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10944.12,,,,,,,fee schedule,10523.19,46687.84,APC
Laparo ablate renal mass,50542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10523.19,,,,,,,fee schedule,10523.19,46687.84,APC
Laparo ablate renal mass,50542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16100.48,,,,,,,fee schedule,10523.19,46687.84,Radiology
Laparo ablate renal mass,50542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14732.47,,,,,,,fee schedule,10523.19,46687.84,APC
Laparo ablate renal mass,50542,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18415.58,,,,,,,fee schedule,10523.19,46687.84,APC
Laparo partial nephrectomy,50543,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17869.65,,,,,,,fee schedule,10523.19,46687.84,
Laparo partial nephrectomy,50543,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14324.08,,,,,,,fee schedule,10523.19,46687.84,
Laparo partial nephrectomy,50543,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15647.76,,,,,,,fee schedule,10523.19,46687.84,
Laparo partial nephrectomy,50543,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16451.42,,,,,,,fee schedule,10523.19,46687.84,
Laparo partial nephrectomy,50543,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46687.84,,,,,,,fee schedule,10523.19,46687.84,APC 378
Laparo partial nephrectomy,50543,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11049.35,,,,,,,fee schedule,10523.19,46687.84,APC
Laparo partial nephrectomy,50543,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10944.12,,,,,,,fee schedule,10523.19,46687.84,APC
Laparo partial nephrectomy,50543,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10523.19,,,,,,,fee schedule,10523.19,46687.84,APC
Laparo partial nephrectomy,50543,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16100.48,,,,,,,fee schedule,10523.19,46687.84,Radiology
Laparo partial nephrectomy,50543,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14732.47,,,,,,,fee schedule,10523.19,46687.84,APC
Laparo partial nephrectomy,50543,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18415.58,,,,,,,fee schedule,10523.19,46687.84,APC
Laparoscopy pyeloplasty,50544,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10236.41,,,,,,,fee schedule,8205.37,46687.84,
Laparoscopy pyeloplasty,50544,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8205.37,,,,,,,fee schedule,8205.37,46687.84,
Laparoscopy pyeloplasty,50544,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8963.63,,,,,,,fee schedule,8205.37,46687.84,
Laparoscopy pyeloplasty,50544,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9423.99,,,,,,,fee schedule,8205.37,46687.84,
Laparoscopy pyeloplasty,50544,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46687.84,,,,,,,fee schedule,8205.37,46687.84,APC 378
Laparoscopy pyeloplasty,50544,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11049.35,,,,,,,fee schedule,8205.37,46687.84,APC
Laparoscopy pyeloplasty,50544,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10944.12,,,,,,,fee schedule,8205.37,46687.84,APC
Laparoscopy pyeloplasty,50544,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10523.19,,,,,,,fee schedule,8205.37,46687.84,APC
Laparoscopy pyeloplasty,50544,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16100.48,,,,,,,fee schedule,8205.37,46687.84,Radiology
Laparoscopy pyeloplasty,50544,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14732.47,,,,,,,fee schedule,8205.37,46687.84,APC
Laparoscopy pyeloplasty,50544,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18415.58,,,,,,,fee schedule,8205.37,46687.84,APC
Laparoscope proc renal,50549,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8584.34,,,,,,,fee schedule,5984.88,26552.87,
Laparoscope proc renal,50549,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6881.1,,,,,,,fee schedule,5984.88,26552.87,
Laparoscope proc renal,50549,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7516.98,,,,,,,fee schedule,5984.88,26552.87,
Laparoscope proc renal,50549,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7903.05,,,,,,,fee schedule,5984.88,26552.87,
Laparoscope proc renal,50549,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,5984.88,26552.87,APC 378
Laparoscope proc renal,50549,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscope proc renal,50549,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscope proc renal,50549,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscope proc renal,50549,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,5984.88,26552.87,Radiology
Laparoscope proc renal,50549,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscope proc renal,50549,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,5984.88,26552.87,APC
Kidney endoscopy,50551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1490.87,,,,,,,fee schedule,1195.06,23549.82,
Kidney endoscopy,50551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1195.06,,,,,,,fee schedule,1195.06,23549.82,
Kidney endoscopy,50551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1305.5,,,,,,,fee schedule,1195.06,23549.82,
Kidney endoscopy,50551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1372.55,,,,,,,fee schedule,1195.06,23549.82,
Kidney endoscopy,50551,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23549.82,,,,,,,fee schedule,1195.06,23549.82,APC 378
Kidney endoscopy,50551,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5573.4,,,,,,,fee schedule,1195.06,23549.82,APC
Kidney endoscopy,50551,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5520.32,,,,,,,fee schedule,1195.06,23549.82,APC
Kidney endoscopy,50551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5308,,,,,,,fee schedule,1195.06,23549.82,APC
Kidney endoscopy,50551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8121.25,,,,,,,fee schedule,1195.06,23549.82,Radiology
Kidney endoscopy,50551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7431.21,,,,,,,fee schedule,1195.06,23549.82,APC
Kidney endoscopy,50551,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9289.01,,,,,,,fee schedule,1195.06,23549.82,APC
Kidney endoscopy,50553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6183.21,,,,,,,fee schedule,4956.38,23549.82,
Kidney endoscopy,50553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4956.38,,,,,,,fee schedule,4956.38,23549.82,
Kidney endoscopy,50553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5414.4,,,,,,,fee schedule,4956.38,23549.82,
Kidney endoscopy,50553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5692.48,,,,,,,fee schedule,4956.38,23549.82,
Kidney endoscopy,50553,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23549.82,,,,,,,fee schedule,4956.38,23549.82,APC 378
Kidney endoscopy,50553,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5573.4,,,,,,,fee schedule,4956.38,23549.82,APC
Kidney endoscopy,50553,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5520.32,,,,,,,fee schedule,4956.38,23549.82,APC
Kidney endoscopy,50553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5308,,,,,,,fee schedule,4956.38,23549.82,APC
Kidney endoscopy,50553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8121.25,,,,,,,fee schedule,4956.38,23549.82,Radiology
Kidney endoscopy,50553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7431.21,,,,,,,fee schedule,4956.38,23549.82,APC
Kidney endoscopy,50553,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9289.01,,,,,,,fee schedule,4956.38,23549.82,APC
Kidney endoscopy & biopsy,50555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1490.87,,,,,,,fee schedule,1195.06,41578.13,
Kidney endoscopy & biopsy,50555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1195.06,,,,,,,fee schedule,1195.06,41578.13,
Kidney endoscopy & biopsy,50555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1305.5,,,,,,,fee schedule,1195.06,41578.13,
Kidney endoscopy & biopsy,50555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1372.55,,,,,,,fee schedule,1195.06,41578.13,
Kidney endoscopy & biopsy,50555,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,41578.13,,,,,,,fee schedule,1195.06,41578.13,APC 378
Kidney endoscopy & biopsy,50555,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9840.06,,,,,,,fee schedule,1195.06,41578.13,APC
Kidney endoscopy & biopsy,50555,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9746.35,,,,,,,fee schedule,1195.06,41578.13,APC
Kidney endoscopy & biopsy,50555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9371.49,,,,,,,fee schedule,1195.06,41578.13,APC
Kidney endoscopy & biopsy,50555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14338.38,,,,,,,fee schedule,1195.06,41578.13,Radiology
Kidney endoscopy & biopsy,50555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13120.09,,,,,,,fee schedule,1195.06,41578.13,APC
Kidney endoscopy & biopsy,50555,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16400.11,,,,,,,fee schedule,1195.06,41578.13,APC
Kidney endoscopy & treatment,50557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6183.21,,,,,,,fee schedule,4956.38,41578.13,
Kidney endoscopy & treatment,50557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4956.38,,,,,,,fee schedule,4956.38,41578.13,
Kidney endoscopy & treatment,50557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5414.4,,,,,,,fee schedule,4956.38,41578.13,
Kidney endoscopy & treatment,50557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5692.48,,,,,,,fee schedule,4956.38,41578.13,
Kidney endoscopy & treatment,50557,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,41578.13,,,,,,,fee schedule,4956.38,41578.13,APC 378
Kidney endoscopy & treatment,50557,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9840.06,,,,,,,fee schedule,4956.38,41578.13,APC
Kidney endoscopy & treatment,50557,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9746.35,,,,,,,fee schedule,4956.38,41578.13,APC
Kidney endoscopy & treatment,50557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9371.49,,,,,,,fee schedule,4956.38,41578.13,APC
Kidney endoscopy & treatment,50557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14338.38,,,,,,,fee schedule,4956.38,41578.13,Radiology
Kidney endoscopy & treatment,50557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13120.09,,,,,,,fee schedule,4956.38,41578.13,APC
Kidney endoscopy & treatment,50557,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16400.11,,,,,,,fee schedule,4956.38,41578.13,APC
Kidney endoscopy & treatment,50561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6183.21,,,,,,,fee schedule,4956.38,23549.82,
Kidney endoscopy & treatment,50561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4956.38,,,,,,,fee schedule,4956.38,23549.82,
Kidney endoscopy & treatment,50561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5414.4,,,,,,,fee schedule,4956.38,23549.82,
Kidney endoscopy & treatment,50561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5692.48,,,,,,,fee schedule,4956.38,23549.82,
Kidney endoscopy & treatment,50561,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23549.82,,,,,,,fee schedule,4956.38,23549.82,APC 378
Kidney endoscopy & treatment,50561,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5573.4,,,,,,,fee schedule,4956.38,23549.82,APC
Kidney endoscopy & treatment,50561,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5520.32,,,,,,,fee schedule,4956.38,23549.82,APC
Kidney endoscopy & treatment,50561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5308,,,,,,,fee schedule,4956.38,23549.82,APC
Kidney endoscopy & treatment,50561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8121.25,,,,,,,fee schedule,4956.38,23549.82,Radiology
Kidney endoscopy & treatment,50561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7431.21,,,,,,,fee schedule,4956.38,23549.82,APC
Kidney endoscopy & treatment,50561,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9289.01,,,,,,,fee schedule,4956.38,23549.82,APC
Renal scope w/tumor resect,50562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1490.87,,,,,,,fee schedule,1195.06,41578.13,
Renal scope w/tumor resect,50562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1195.06,,,,,,,fee schedule,1195.06,41578.13,
Renal scope w/tumor resect,50562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1305.5,,,,,,,fee schedule,1195.06,41578.13,
Renal scope w/tumor resect,50562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1372.55,,,,,,,fee schedule,1195.06,41578.13,
Renal scope w/tumor resect,50562,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,41578.13,,,,,,,fee schedule,1195.06,41578.13,APC 378
Renal scope w/tumor resect,50562,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9840.06,,,,,,,fee schedule,1195.06,41578.13,APC
Renal scope w/tumor resect,50562,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9746.35,,,,,,,fee schedule,1195.06,41578.13,APC
Renal scope w/tumor resect,50562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9371.49,,,,,,,fee schedule,1195.06,41578.13,APC
Renal scope w/tumor resect,50562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14338.38,,,,,,,fee schedule,1195.06,41578.13,Radiology
Renal scope w/tumor resect,50562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13120.09,,,,,,,fee schedule,1195.06,41578.13,APC
Renal scope w/tumor resect,50562,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16400.11,,,,,,,fee schedule,1195.06,41578.13,APC
Kidney endoscopy,50570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1490.87,,,,,,,fee schedule,1195.06,15482.25,
Kidney endoscopy,50570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1195.06,,,,,,,fee schedule,1195.06,15482.25,
Kidney endoscopy,50570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1305.5,,,,,,,fee schedule,1195.06,15482.25,
Kidney endoscopy,50570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1372.55,,,,,,,fee schedule,1195.06,15482.25,
Kidney endoscopy,50570,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,1195.06,15482.25,APC 378
Kidney endoscopy,50570,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,1195.06,15482.25,APC
Kidney endoscopy,50570,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,1195.06,15482.25,APC
Kidney endoscopy,50570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,1195.06,15482.25,APC
Kidney endoscopy,50570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,1195.06,15482.25,Radiology
Kidney endoscopy,50570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,1195.06,15482.25,APC
Kidney endoscopy,50570,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,1195.06,15482.25,APC
Kidney endoscopy,50572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1490.87,,,,,,,fee schedule,690.3,3062.63,
Kidney endoscopy,50572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1195.06,,,,,,,fee schedule,690.3,3062.63,
Kidney endoscopy,50572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1305.5,,,,,,,fee schedule,690.3,3062.63,
Kidney endoscopy,50572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1372.55,,,,,,,fee schedule,690.3,3062.63,
Kidney endoscopy,50572,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3062.63,,,,,,,fee schedule,690.3,3062.63,APC 378
Kidney endoscopy,50572,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,724.82,,,,,,,fee schedule,690.3,3062.63,APC
Kidney endoscopy,50572,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,717.91,,,,,,,fee schedule,690.3,3062.63,APC
Kidney endoscopy,50572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,690.3,,,,,,,fee schedule,690.3,3062.63,APC
Kidney endoscopy,50572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1056.16,,,,,,,fee schedule,690.3,3062.63,Radiology
Kidney endoscopy,50572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,966.42,,,,,,,fee schedule,690.3,3062.63,APC
Kidney endoscopy,50572,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1208.03,,,,,,,fee schedule,690.3,3062.63,APC
Kidney endoscopy & biopsy,50574,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1490.87,,,,,,,fee schedule,1195.06,15482.25,
Kidney endoscopy & biopsy,50574,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1195.06,,,,,,,fee schedule,1195.06,15482.25,
Kidney endoscopy & biopsy,50574,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1305.5,,,,,,,fee schedule,1195.06,15482.25,
Kidney endoscopy & biopsy,50574,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1372.55,,,,,,,fee schedule,1195.06,15482.25,
Kidney endoscopy & biopsy,50574,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,1195.06,15482.25,APC 378
Kidney endoscopy & biopsy,50574,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,1195.06,15482.25,APC
Kidney endoscopy & biopsy,50574,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,1195.06,15482.25,APC
Kidney endoscopy & biopsy,50574,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,1195.06,15482.25,APC
Kidney endoscopy & biopsy,50574,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,1195.06,15482.25,Radiology
Kidney endoscopy & biopsy,50574,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,1195.06,15482.25,APC
Kidney endoscopy & biopsy,50574,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,1195.06,15482.25,APC
Kidney endoscopy,50575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9004,,,,,,,fee schedule,5308,23549.82,
Kidney endoscopy,50575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7217.49,,,,,,,fee schedule,5308,23549.82,
Kidney endoscopy,50575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7884.45,,,,,,,fee schedule,5308,23549.82,
Kidney endoscopy,50575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8289.39,,,,,,,fee schedule,5308,23549.82,
Kidney endoscopy,50575,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23549.82,,,,,,,fee schedule,5308,23549.82,APC 378
Kidney endoscopy,50575,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5573.4,,,,,,,fee schedule,5308,23549.82,APC
Kidney endoscopy,50575,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5520.32,,,,,,,fee schedule,5308,23549.82,APC
Kidney endoscopy,50575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5308,,,,,,,fee schedule,5308,23549.82,APC
Kidney endoscopy,50575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8121.25,,,,,,,fee schedule,5308,23549.82,Radiology
Kidney endoscopy,50575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7431.21,,,,,,,fee schedule,5308,23549.82,APC
Kidney endoscopy,50575,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9289.01,,,,,,,fee schedule,5308,23549.82,APC
Kidney endoscopy & treatment,50576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4477.9,,,,,,,fee schedule,3589.43,41578.13,
Kidney endoscopy & treatment,50576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3589.43,,,,,,,fee schedule,3589.43,41578.13,
Kidney endoscopy & treatment,50576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3921.13,,,,,,,fee schedule,3589.43,41578.13,
Kidney endoscopy & treatment,50576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4122.51,,,,,,,fee schedule,3589.43,41578.13,
Kidney endoscopy & treatment,50576,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,41578.13,,,,,,,fee schedule,3589.43,41578.13,APC 378
Kidney endoscopy & treatment,50576,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9840.06,,,,,,,fee schedule,3589.43,41578.13,APC
Kidney endoscopy & treatment,50576,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9746.35,,,,,,,fee schedule,3589.43,41578.13,APC
Kidney endoscopy & treatment,50576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9371.49,,,,,,,fee schedule,3589.43,41578.13,APC
Kidney endoscopy & treatment,50576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14338.38,,,,,,,fee schedule,3589.43,41578.13,Radiology
Kidney endoscopy & treatment,50576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13120.09,,,,,,,fee schedule,3589.43,41578.13,APC
Kidney endoscopy & treatment,50576,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16400.11,,,,,,,fee schedule,3589.43,41578.13,APC
Kidney endoscopy & treatment,50580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4477.9,,,,,,,fee schedule,3589.43,23549.82,
Kidney endoscopy & treatment,50580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3589.43,,,,,,,fee schedule,3589.43,23549.82,
Kidney endoscopy & treatment,50580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3921.13,,,,,,,fee schedule,3589.43,23549.82,
Kidney endoscopy & treatment,50580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4122.51,,,,,,,fee schedule,3589.43,23549.82,
Kidney endoscopy & treatment,50580,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23549.82,,,,,,,fee schedule,3589.43,23549.82,APC 378
Kidney endoscopy & treatment,50580,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5573.4,,,,,,,fee schedule,3589.43,23549.82,APC
Kidney endoscopy & treatment,50580,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5520.32,,,,,,,fee schedule,3589.43,23549.82,APC
Kidney endoscopy & treatment,50580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5308,,,,,,,fee schedule,3589.43,23549.82,APC
Kidney endoscopy & treatment,50580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8121.25,,,,,,,fee schedule,3589.43,23549.82,Radiology
Kidney endoscopy & treatment,50580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7431.21,,,,,,,fee schedule,3589.43,23549.82,APC
Kidney endoscopy & treatment,50580,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9289.01,,,,,,,fee schedule,3589.43,23549.82,APC
Fragmenting of kidney stone,50590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9146.19,,,,,,,fee schedule,3489.62,15482.25,
Fragmenting of kidney stone,50590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7331.47,,,,,,,fee schedule,3489.62,15482.25,
Fragmenting of kidney stone,50590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8008.96,,,,,,,fee schedule,3489.62,15482.25,
Fragmenting of kidney stone,50590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8420.3,,,,,,,fee schedule,3489.62,15482.25,
Fragmenting of kidney stone,50590,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Fragmenting of kidney stone,50590,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Fragmenting of kidney stone,50590,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Fragmenting of kidney stone,50590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Fragmenting of kidney stone,50590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Fragmenting of kidney stone,50590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Fragmenting of kidney stone,50590,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Perc rf ablate renal tumor,50592,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10731.23,,,,,,,fee schedule,5984.88,26552.87,
Perc rf ablate renal tumor,50592,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8602.02,,,,,,,fee schedule,5984.88,26552.87,
Perc rf ablate renal tumor,50592,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9396.92,,,,,,,fee schedule,5984.88,26552.87,
Perc rf ablate renal tumor,50592,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9879.55,,,,,,,fee schedule,5984.88,26552.87,
Perc rf ablate renal tumor,50592,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,5984.88,26552.87,APC 378
Perc rf ablate renal tumor,50592,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,5984.88,26552.87,APC
Perc rf ablate renal tumor,50592,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,5984.88,26552.87,APC
Perc rf ablate renal tumor,50592,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,5984.88,26552.87,APC
Perc rf ablate renal tumor,50592,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,5984.88,26552.87,Radiology
Perc rf ablate renal tumor,50592,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,5984.88,26552.87,APC
Perc rf ablate renal tumor,50592,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,5984.88,26552.87,APC
Perc cryo ablate renal tum,50593,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4701.74,,,,,,,fee schedule,3768.86,46687.84,
Perc cryo ablate renal tum,50593,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3768.86,,,,,,,fee schedule,3768.86,46687.84,
Perc cryo ablate renal tum,50593,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4117.13,,,,,,,fee schedule,3768.86,46687.84,
Perc cryo ablate renal tum,50593,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4328.59,,,,,,,fee schedule,3768.86,46687.84,
Perc cryo ablate renal tum,50593,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46687.84,,,,,,,fee schedule,3768.86,46687.84,APC 378
Perc cryo ablate renal tum,50593,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11049.35,,,,,,,fee schedule,3768.86,46687.84,APC
Perc cryo ablate renal tum,50593,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10944.12,,,,,,,fee schedule,3768.86,46687.84,APC
Perc cryo ablate renal tum,50593,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10523.19,,,,,,,fee schedule,3768.86,46687.84,APC
Perc cryo ablate renal tum,50593,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16100.48,,,,,,,fee schedule,3768.86,46687.84,Radiology
Perc cryo ablate renal tum,50593,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14732.47,,,,,,,fee schedule,3768.86,46687.84,APC
Perc cryo ablate renal tum,50593,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18415.58,,,,,,,fee schedule,3768.86,46687.84,APC
Endoluminal bx urtr rnl plvs,50606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,613.27,,,,,,,fee schedule,491.59,613.27,
Endoluminal bx urtr rnl plvs,50606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,491.59,,,,,,,fee schedule,491.59,613.27,
Endoluminal bx urtr rnl plvs,50606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,537.01,,,,,,,fee schedule,491.59,613.27,
Endoluminal bx urtr rnl plvs,50606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,564.6,,,,,,,fee schedule,491.59,613.27,
Measure ureter pressure,50686,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,258.44,,,,,,,fee schedule,127.38,565.15,
Measure ureter pressure,50686,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,207.16,,,,,,,fee schedule,127.38,565.15,
Measure ureter pressure,50686,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,226.3,,,,,,,fee schedule,127.38,565.15,
Measure ureter pressure,50686,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,237.93,,,,,,,fee schedule,127.38,565.15,
Measure ureter pressure,50686,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,565.15,,,,,,,fee schedule,127.38,565.15,APC 378
Measure ureter pressure,50686,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,133.75,,,,,,,fee schedule,127.38,565.15,APC
Measure ureter pressure,50686,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,132.48,,,,,,,fee schedule,127.38,565.15,APC
Measure ureter pressure,50686,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,127.38,,,,,,,fee schedule,127.38,565.15,APC
Measure ureter pressure,50686,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,194.89,,,,,,,fee schedule,127.38,565.15,Radiology
Measure ureter pressure,50686,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,178.33,,,,,,,fee schedule,127.38,565.15,APC
Measure ureter pressure,50686,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,222.92,,,,,,,fee schedule,127.38,565.15,APC
Change of ureter tube/stent,50688,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3832.09,,,,,,,fee schedule,2069.41,9181.28,
Change of ureter tube/stent,50688,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3071.75,,,,,,,fee schedule,2069.41,9181.28,
Change of ureter tube/stent,50688,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3355.61,,,,,,,fee schedule,2069.41,9181.28,
Change of ureter tube/stent,50688,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3527.95,,,,,,,fee schedule,2069.41,9181.28,
Change of ureter tube/stent,50688,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9181.28,,,,,,,fee schedule,2069.41,9181.28,APC 378
Change of ureter tube/stent,50688,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2172.88,,,,,,,fee schedule,2069.41,9181.28,APC
Change of ureter tube/stent,50688,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2152.19,,,,,,,fee schedule,2069.41,9181.28,APC
Change of ureter tube/stent,50688,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2069.41,,,,,,,fee schedule,2069.41,9181.28,APC
Change of ureter tube/stent,50688,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3166.2,,,,,,,fee schedule,2069.41,9181.28,Radiology
Change of ureter tube/stent,50688,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2897.18,,,,,,,fee schedule,2069.41,9181.28,APC
Change of ureter tube/stent,50688,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3621.47,,,,,,,fee schedule,2069.41,9181.28,APC
Plmt ureteral stent prq,50693,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8480.39,,,,,,,fee schedule,3489.62,15482.25,
Plmt ureteral stent prq,50693,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6797.77,,,,,,,fee schedule,3489.62,15482.25,
Plmt ureteral stent prq,50693,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7425.95,,,,,,,fee schedule,3489.62,15482.25,
Plmt ureteral stent prq,50693,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7807.35,,,,,,,fee schedule,3489.62,15482.25,
Plmt ureteral stent prq,50693,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Plmt ureteral stent prq,50693,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Plmt ureteral stent prq,50693,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Plmt ureteral stent prq,50693,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Plmt ureteral stent prq,50693,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Plmt ureteral stent prq,50693,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Plmt ureteral stent prq,50693,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Plmt ureteral stent prq,50694,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8480.39,,,,,,,fee schedule,3489.62,15482.25,
Plmt ureteral stent prq,50694,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6797.77,,,,,,,fee schedule,3489.62,15482.25,
Plmt ureteral stent prq,50694,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7425.95,,,,,,,fee schedule,3489.62,15482.25,
Plmt ureteral stent prq,50694,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7807.35,,,,,,,fee schedule,3489.62,15482.25,
Plmt ureteral stent prq,50694,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Plmt ureteral stent prq,50694,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Plmt ureteral stent prq,50694,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Plmt ureteral stent prq,50694,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Plmt ureteral stent prq,50694,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Plmt ureteral stent prq,50694,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Plmt ureteral stent prq,50694,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Plmt ureteral stent prq,50695,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8480.39,,,,,,,fee schedule,3489.62,15482.25,
Plmt ureteral stent prq,50695,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6797.77,,,,,,,fee schedule,3489.62,15482.25,
Plmt ureteral stent prq,50695,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7425.95,,,,,,,fee schedule,3489.62,15482.25,
Plmt ureteral stent prq,50695,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7807.35,,,,,,,fee schedule,3489.62,15482.25,
Plmt ureteral stent prq,50695,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Plmt ureteral stent prq,50695,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Plmt ureteral stent prq,50695,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Plmt ureteral stent prq,50695,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Plmt ureteral stent prq,50695,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Plmt ureteral stent prq,50695,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Plmt ureteral stent prq,50695,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Ureteral embolization/occl,50705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,785.94,,,,,,,fee schedule,630,785.94,
Ureteral embolization/occl,50705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,630,,,,,,,fee schedule,630,785.94,
Ureteral embolization/occl,50705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,688.22,,,,,,,fee schedule,630,785.94,
Ureteral embolization/occl,50705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,723.56,,,,,,,fee schedule,630,785.94,
Balloon dilate urtrl strix,50706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,728.82,,,,,,,fee schedule,584.21,728.82,
Balloon dilate urtrl strix,50706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,584.21,,,,,,,fee schedule,584.21,728.82,
Balloon dilate urtrl strix,50706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,638.2,,,,,,,fee schedule,584.21,728.82,
Balloon dilate urtrl strix,50706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,670.98,,,,,,,fee schedule,584.21,728.82,
Revise ureter,50727,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9610.88,,,,,,,fee schedule,3489.62,15482.25,
Revise ureter,50727,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7703.96,,,,,,,fee schedule,3489.62,15482.25,
Revise ureter,50727,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8415.87,,,,,,,fee schedule,3489.62,15482.25,
Revise ureter,50727,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8848.11,,,,,,,fee schedule,3489.62,15482.25,
Revise ureter,50727,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Revise ureter,50727,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Revise ureter,50727,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Revise ureter,50727,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Revise ureter,50727,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Revise ureter,50727,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Revise ureter,50727,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Laparoscopy ureterolithotomy,50945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11363.59,,,,,,,fee schedule,5984.88,26552.87,
Laparoscopy ureterolithotomy,50945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9108.91,,,,,,,fee schedule,5984.88,26552.87,
Laparoscopy ureterolithotomy,50945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9950.65,,,,,,,fee schedule,5984.88,26552.87,
Laparoscopy ureterolithotomy,50945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10461.72,,,,,,,fee schedule,5984.88,26552.87,
Laparoscopy ureterolithotomy,50945,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,5984.88,26552.87,APC 378
Laparoscopy ureterolithotomy,50945,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscopy ureterolithotomy,50945,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscopy ureterolithotomy,50945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscopy ureterolithotomy,50945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,5984.88,26552.87,Radiology
Laparoscopy ureterolithotomy,50945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscopy ureterolithotomy,50945,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,5984.88,26552.87,APC
Laparo New Ureter/Bladder,50947,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11363.59,,,,,,,fee schedule,9108.91,46687.84,
Laparo New Ureter/Bladder,50947,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9108.91,,,,,,,fee schedule,9108.91,46687.84,
Laparo New Ureter/Bladder,50947,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9950.65,,,,,,,fee schedule,9108.91,46687.84,
Laparo New Ureter/Bladder,50947,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10461.72,,,,,,,fee schedule,9108.91,46687.84,
Laparo New Ureter/Bladder,50947,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46687.84,,,,,,,fee schedule,9108.91,46687.84,APC 378
Laparo New Ureter/Bladder,50947,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11049.35,,,,,,,fee schedule,9108.91,46687.84,APC
Laparo New Ureter/Bladder,50947,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10944.12,,,,,,,fee schedule,9108.91,46687.84,APC
Laparo New Ureter/Bladder,50947,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10523.19,,,,,,,fee schedule,9108.91,46687.84,APC
Laparo New Ureter/Bladder,50947,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16100.48,,,,,,,fee schedule,9108.91,46687.84,Radiology
Laparo New Ureter/Bladder,50947,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14732.47,,,,,,,fee schedule,9108.91,46687.84,APC
Laparo New Ureter/Bladder,50947,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18415.58,,,,,,,fee schedule,9108.91,46687.84,APC
Laparo New Ureter/Bladder,50948,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11363.59,,,,,,,fee schedule,9108.91,46687.84,
Laparo New Ureter/Bladder,50948,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9108.91,,,,,,,fee schedule,9108.91,46687.84,
Laparo New Ureter/Bladder,50948,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9950.65,,,,,,,fee schedule,9108.91,46687.84,
Laparo New Ureter/Bladder,50948,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10461.72,,,,,,,fee schedule,9108.91,46687.84,
Laparo New Ureter/Bladder,50948,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46687.84,,,,,,,fee schedule,9108.91,46687.84,APC 378
Laparo New Ureter/Bladder,50948,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11049.35,,,,,,,fee schedule,9108.91,46687.84,APC
Laparo New Ureter/Bladder,50948,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10944.12,,,,,,,fee schedule,9108.91,46687.84,APC
Laparo New Ureter/Bladder,50948,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10523.19,,,,,,,fee schedule,9108.91,46687.84,APC
Laparo New Ureter/Bladder,50948,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16100.48,,,,,,,fee schedule,9108.91,46687.84,Radiology
Laparo New Ureter/Bladder,50948,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14732.47,,,,,,,fee schedule,9108.91,46687.84,APC
Laparo New Ureter/Bladder,50948,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18415.58,,,,,,,fee schedule,9108.91,46687.84,APC
Laparoscope proc ureter,50949,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8584.34,,,,,,,fee schedule,5984.88,26552.87,
Laparoscope proc ureter,50949,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6881.1,,,,,,,fee schedule,5984.88,26552.87,
Laparoscope proc ureter,50949,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7516.98,,,,,,,fee schedule,5984.88,26552.87,
Laparoscope proc ureter,50949,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7903.05,,,,,,,fee schedule,5984.88,26552.87,
Laparoscope proc ureter,50949,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,5984.88,26552.87,APC 378
Laparoscope proc ureter,50949,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscope proc ureter,50949,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscope proc ureter,50949,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscope proc ureter,50949,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,5984.88,26552.87,Radiology
Laparoscope proc ureter,50949,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscope proc ureter,50949,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,5984.88,26552.87,APC
Endoscopy of ureter,50951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1490.87,,,,,,,fee schedule,1195.06,15482.25,
Endoscopy of ureter,50951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1195.06,,,,,,,fee schedule,1195.06,15482.25,
Endoscopy of ureter,50951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1305.5,,,,,,,fee schedule,1195.06,15482.25,
Endoscopy of ureter,50951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1372.55,,,,,,,fee schedule,1195.06,15482.25,
Endoscopy of ureter,50951,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,1195.06,15482.25,APC 378
Endoscopy of ureter,50951,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,1195.06,15482.25,APC
Endoscopy of ureter,50951,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,1195.06,15482.25,APC
Endoscopy of ureter,50951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,1195.06,15482.25,APC
Endoscopy of ureter,50951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,1195.06,15482.25,Radiology
Endoscopy of ureter,50951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,1195.06,15482.25,APC
Endoscopy of ureter,50951,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,1195.06,15482.25,APC
Endoscopy of ureter,50953,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1490.87,,,,,,,fee schedule,1195.06,15482.25,
Endoscopy of ureter,50953,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1195.06,,,,,,,fee schedule,1195.06,15482.25,
Endoscopy of ureter,50953,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1305.5,,,,,,,fee schedule,1195.06,15482.25,
Endoscopy of ureter,50953,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1372.55,,,,,,,fee schedule,1195.06,15482.25,
Endoscopy of ureter,50953,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,1195.06,15482.25,APC 378
Endoscopy of ureter,50953,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,1195.06,15482.25,APC
Endoscopy of ureter,50953,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,1195.06,15482.25,APC
Endoscopy of ureter,50953,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,1195.06,15482.25,APC
Endoscopy of ureter,50953,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,1195.06,15482.25,Radiology
Endoscopy of ureter,50953,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,1195.06,15482.25,APC
Endoscopy of ureter,50953,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,1195.06,15482.25,APC
Ureter endoscopy & biopsy,50955,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6183.21,,,,,,,fee schedule,4956.38,23549.82,
Ureter endoscopy & biopsy,50955,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4956.38,,,,,,,fee schedule,4956.38,23549.82,
Ureter endoscopy & biopsy,50955,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5414.4,,,,,,,fee schedule,4956.38,23549.82,
Ureter endoscopy & biopsy,50955,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5692.48,,,,,,,fee schedule,4956.38,23549.82,
Ureter endoscopy & biopsy,50955,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23549.82,,,,,,,fee schedule,4956.38,23549.82,APC 378
Ureter endoscopy & biopsy,50955,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5573.4,,,,,,,fee schedule,4956.38,23549.82,APC
Ureter endoscopy & biopsy,50955,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5520.32,,,,,,,fee schedule,4956.38,23549.82,APC
Ureter endoscopy & biopsy,50955,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5308,,,,,,,fee schedule,4956.38,23549.82,APC
Ureter endoscopy & biopsy,50955,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8121.25,,,,,,,fee schedule,4956.38,23549.82,Radiology
Ureter endoscopy & biopsy,50955,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7431.21,,,,,,,fee schedule,4956.38,23549.82,APC
Ureter endoscopy & biopsy,50955,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9289.01,,,,,,,fee schedule,4956.38,23549.82,APC
Ureter endoscopy & treatment,50957,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6183.21,,,,,,,fee schedule,4956.38,23549.82,
Ureter endoscopy & treatment,50957,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4956.38,,,,,,,fee schedule,4956.38,23549.82,
Ureter endoscopy & treatment,50957,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5414.4,,,,,,,fee schedule,4956.38,23549.82,
Ureter endoscopy & treatment,50957,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5692.48,,,,,,,fee schedule,4956.38,23549.82,
Ureter endoscopy & treatment,50957,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23549.82,,,,,,,fee schedule,4956.38,23549.82,APC 378
Ureter endoscopy & treatment,50957,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5573.4,,,,,,,fee schedule,4956.38,23549.82,APC
Ureter endoscopy & treatment,50957,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5520.32,,,,,,,fee schedule,4956.38,23549.82,APC
Ureter endoscopy & treatment,50957,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5308,,,,,,,fee schedule,4956.38,23549.82,APC
Ureter endoscopy & treatment,50957,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8121.25,,,,,,,fee schedule,4956.38,23549.82,Radiology
Ureter endoscopy & treatment,50957,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7431.21,,,,,,,fee schedule,4956.38,23549.82,APC
Ureter endoscopy & treatment,50957,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9289.01,,,,,,,fee schedule,4956.38,23549.82,APC
Ureter endoscopy & treatment,50961,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6183.21,,,,,,,fee schedule,4956.38,23549.82,
Ureter endoscopy & treatment,50961,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4956.38,,,,,,,fee schedule,4956.38,23549.82,
Ureter endoscopy & treatment,50961,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5414.4,,,,,,,fee schedule,4956.38,23549.82,
Ureter endoscopy & treatment,50961,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5692.48,,,,,,,fee schedule,4956.38,23549.82,
Ureter endoscopy & treatment,50961,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23549.82,,,,,,,fee schedule,4956.38,23549.82,APC 378
Ureter endoscopy & treatment,50961,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5573.4,,,,,,,fee schedule,4956.38,23549.82,APC
Ureter endoscopy & treatment,50961,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5520.32,,,,,,,fee schedule,4956.38,23549.82,APC
Ureter endoscopy & treatment,50961,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5308,,,,,,,fee schedule,4956.38,23549.82,APC
Ureter endoscopy & treatment,50961,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8121.25,,,,,,,fee schedule,4956.38,23549.82,Radiology
Ureter endoscopy & treatment,50961,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7431.21,,,,,,,fee schedule,4956.38,23549.82,APC
Ureter endoscopy & treatment,50961,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9289.01,,,,,,,fee schedule,4956.38,23549.82,APC
Ureter endoscopy,50970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1490.87,,,,,,,fee schedule,1195.06,15482.25,
Ureter endoscopy,50970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1195.06,,,,,,,fee schedule,1195.06,15482.25,
Ureter endoscopy,50970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1305.5,,,,,,,fee schedule,1195.06,15482.25,
Ureter endoscopy,50970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1372.55,,,,,,,fee schedule,1195.06,15482.25,
Ureter endoscopy,50970,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,1195.06,15482.25,APC 378
Ureter endoscopy,50970,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,1195.06,15482.25,APC
Ureter endoscopy,50970,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,1195.06,15482.25,APC
Ureter endoscopy,50970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,1195.06,15482.25,APC
Ureter endoscopy,50970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,1195.06,15482.25,Radiology
Ureter endoscopy,50970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,1195.06,15482.25,APC
Ureter endoscopy,50970,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,1195.06,15482.25,APC
Ureter endoscopy & catheter,50972,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1490.87,,,,,,,fee schedule,1195.06,15482.25,
Ureter endoscopy & catheter,50972,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1195.06,,,,,,,fee schedule,1195.06,15482.25,
Ureter endoscopy & catheter,50972,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1305.5,,,,,,,fee schedule,1195.06,15482.25,
Ureter endoscopy & catheter,50972,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1372.55,,,,,,,fee schedule,1195.06,15482.25,
Ureter endoscopy & catheter,50972,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,1195.06,15482.25,APC 378
Ureter endoscopy & catheter,50972,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,1195.06,15482.25,APC
Ureter endoscopy & catheter,50972,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,1195.06,15482.25,APC
Ureter endoscopy & catheter,50972,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,1195.06,15482.25,APC
Ureter endoscopy & catheter,50972,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,1195.06,15482.25,Radiology
Ureter endoscopy & catheter,50972,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,1195.06,15482.25,APC
Ureter endoscopy & catheter,50972,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,1195.06,15482.25,APC
Ureter endoscopy & biopsy,50974,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4477.9,,,,,,,fee schedule,3589.43,23549.82,
Ureter endoscopy & biopsy,50974,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3589.43,,,,,,,fee schedule,3589.43,23549.82,
Ureter endoscopy & biopsy,50974,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3921.13,,,,,,,fee schedule,3589.43,23549.82,
Ureter endoscopy & biopsy,50974,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4122.51,,,,,,,fee schedule,3589.43,23549.82,
Ureter endoscopy & biopsy,50974,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23549.82,,,,,,,fee schedule,3589.43,23549.82,APC 378
Ureter endoscopy & biopsy,50974,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5573.4,,,,,,,fee schedule,3589.43,23549.82,APC
Ureter endoscopy & biopsy,50974,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5520.32,,,,,,,fee schedule,3589.43,23549.82,APC
Ureter endoscopy & biopsy,50974,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5308,,,,,,,fee schedule,3589.43,23549.82,APC
Ureter endoscopy & biopsy,50974,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8121.25,,,,,,,fee schedule,3589.43,23549.82,Radiology
Ureter endoscopy & biopsy,50974,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7431.21,,,,,,,fee schedule,3589.43,23549.82,APC
Ureter endoscopy & biopsy,50974,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9289.01,,,,,,,fee schedule,3589.43,23549.82,APC
Ureter endoscopy & treatment,50976,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4477.9,,,,,,,fee schedule,3589.43,23549.82,
Ureter endoscopy & treatment,50976,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3589.43,,,,,,,fee schedule,3589.43,23549.82,
Ureter endoscopy & treatment,50976,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3921.13,,,,,,,fee schedule,3589.43,23549.82,
Ureter endoscopy & treatment,50976,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4122.51,,,,,,,fee schedule,3589.43,23549.82,
Ureter endoscopy & treatment,50976,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23549.82,,,,,,,fee schedule,3589.43,23549.82,APC 378
Ureter endoscopy & treatment,50976,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5573.4,,,,,,,fee schedule,3589.43,23549.82,APC
Ureter endoscopy & treatment,50976,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5520.32,,,,,,,fee schedule,3589.43,23549.82,APC
Ureter endoscopy & treatment,50976,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5308,,,,,,,fee schedule,3589.43,23549.82,APC
Ureter endoscopy & treatment,50976,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8121.25,,,,,,,fee schedule,3589.43,23549.82,Radiology
Ureter endoscopy & treatment,50976,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7431.21,,,,,,,fee schedule,3589.43,23549.82,APC
Ureter endoscopy & treatment,50976,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9289.01,,,,,,,fee schedule,3589.43,23549.82,APC
Ureter endoscopy & treatment,50980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6183.21,,,,,,,fee schedule,4956.38,23549.82,
Ureter endoscopy & treatment,50980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4956.38,,,,,,,fee schedule,4956.38,23549.82,
Ureter endoscopy & treatment,50980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5414.4,,,,,,,fee schedule,4956.38,23549.82,
Ureter endoscopy & treatment,50980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5692.48,,,,,,,fee schedule,4956.38,23549.82,
Ureter endoscopy & treatment,50980,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23549.82,,,,,,,fee schedule,4956.38,23549.82,APC 378
Ureter endoscopy & treatment,50980,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5573.4,,,,,,,fee schedule,4956.38,23549.82,APC
Ureter endoscopy & treatment,50980,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5520.32,,,,,,,fee schedule,4956.38,23549.82,APC
Ureter endoscopy & treatment,50980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5308,,,,,,,fee schedule,4956.38,23549.82,APC
Ureter endoscopy & treatment,50980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8121.25,,,,,,,fee schedule,4956.38,23549.82,Radiology
Ureter endoscopy & treatment,50980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7431.21,,,,,,,fee schedule,4956.38,23549.82,APC
Ureter endoscopy & treatment,50980,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9289.01,,,,,,,fee schedule,4956.38,23549.82,APC
Incise & treat bladder,51020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6183.21,,,,,,,fee schedule,3489.62,15482.25,
Incise & treat bladder,51020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4956.38,,,,,,,fee schedule,3489.62,15482.25,
Incise & treat bladder,51020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5414.4,,,,,,,fee schedule,3489.62,15482.25,
Incise & treat bladder,51020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5692.48,,,,,,,fee schedule,3489.62,15482.25,
Incise & treat bladder,51020,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Incise & treat bladder,51020,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Incise & treat bladder,51020,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Incise & treat bladder,51020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Incise & treat bladder,51020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Incise & treat bladder,51020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Incise & treat bladder,51020,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Incise & treat bladder,51030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6183.21,,,,,,,fee schedule,4956.38,6183.21,
Incise & treat bladder,51030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4956.38,,,,,,,fee schedule,4956.38,6183.21,
Incise & treat bladder,51030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5414.4,,,,,,,fee schedule,4956.38,6183.21,
Incise & treat bladder,51030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5692.48,,,,,,,fee schedule,4956.38,6183.21,
Incise & drain bladder,51040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6183.21,,,,,,,fee schedule,2069.41,9181.28,
Incise & drain bladder,51040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4956.38,,,,,,,fee schedule,2069.41,9181.28,
Incise & drain bladder,51040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5414.4,,,,,,,fee schedule,2069.41,9181.28,
Incise & drain bladder,51040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5692.48,,,,,,,fee schedule,2069.41,9181.28,
Incise & drain bladder,51040,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9181.28,,,,,,,fee schedule,2069.41,9181.28,APC 378
Incise & drain bladder,51040,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2172.88,,,,,,,fee schedule,2069.41,9181.28,APC
Incise & drain bladder,51040,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2152.19,,,,,,,fee schedule,2069.41,9181.28,APC
Incise & drain bladder,51040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2069.41,,,,,,,fee schedule,2069.41,9181.28,APC
Incise & drain bladder,51040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3166.2,,,,,,,fee schedule,2069.41,9181.28,Radiology
Incise & drain bladder,51040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2897.18,,,,,,,fee schedule,2069.41,9181.28,APC
Incise & drain bladder,51040,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3621.47,,,,,,,fee schedule,2069.41,9181.28,APC
Incise bladder/drain ureter,51045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1490.87,,,,,,,fee schedule,1195.06,9181.28,
Incise bladder/drain ureter,51045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1195.06,,,,,,,fee schedule,1195.06,9181.28,
Incise bladder/drain ureter,51045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1305.5,,,,,,,fee schedule,1195.06,9181.28,
Incise bladder/drain ureter,51045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1372.55,,,,,,,fee schedule,1195.06,9181.28,
Incise bladder/drain ureter,51045,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9181.28,,,,,,,fee schedule,1195.06,9181.28,APC 378
Incise bladder/drain ureter,51045,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2172.88,,,,,,,fee schedule,1195.06,9181.28,APC
Incise bladder/drain ureter,51045,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2152.19,,,,,,,fee schedule,1195.06,9181.28,APC
Incise bladder/drain ureter,51045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2069.41,,,,,,,fee schedule,1195.06,9181.28,APC
Incise bladder/drain ureter,51045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3166.2,,,,,,,fee schedule,1195.06,9181.28,Radiology
Incise bladder/drain ureter,51045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2897.18,,,,,,,fee schedule,1195.06,9181.28,APC
Incise bladder/drain ureter,51045,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3621.47,,,,,,,fee schedule,1195.06,9181.28,APC
Removal of bladder stone,51050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6183.21,,,,,,,fee schedule,4956.38,23549.82,
Removal of bladder stone,51050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4956.38,,,,,,,fee schedule,4956.38,23549.82,
Removal of bladder stone,51050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5414.4,,,,,,,fee schedule,4956.38,23549.82,
Removal of bladder stone,51050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5692.48,,,,,,,fee schedule,4956.38,23549.82,
Removal of bladder stone,51050,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23549.82,,,,,,,fee schedule,4956.38,23549.82,APC 378
Removal of bladder stone,51050,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5573.4,,,,,,,fee schedule,4956.38,23549.82,APC
Removal of bladder stone,51050,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5520.32,,,,,,,fee schedule,4956.38,23549.82,APC
Removal of bladder stone,51050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5308,,,,,,,fee schedule,4956.38,23549.82,APC
Removal of bladder stone,51050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8121.25,,,,,,,fee schedule,4956.38,23549.82,Radiology
Removal of bladder stone,51050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7431.21,,,,,,,fee schedule,4956.38,23549.82,APC
Removal of bladder stone,51050,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9289.01,,,,,,,fee schedule,4956.38,23549.82,APC
Removal of ureter stone,51060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6216.81,,,,,,,fee schedule,2069.41,9181.28,
Removal of ureter stone,51060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4983.32,,,,,,,fee schedule,2069.41,9181.28,
Removal of ureter stone,51060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5443.82,,,,,,,fee schedule,2069.41,9181.28,
Removal of ureter stone,51060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5723.42,,,,,,,fee schedule,2069.41,9181.28,
Removal of ureter stone,51060,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9181.28,,,,,,,fee schedule,2069.41,9181.28,APC 378
Removal of ureter stone,51060,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2172.88,,,,,,,fee schedule,2069.41,9181.28,APC
Removal of ureter stone,51060,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2152.19,,,,,,,fee schedule,2069.41,9181.28,APC
Removal of ureter stone,51060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2069.41,,,,,,,fee schedule,2069.41,9181.28,APC
Removal of ureter stone,51060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3166.2,,,,,,,fee schedule,2069.41,9181.28,Radiology
Removal of ureter stone,51060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2897.18,,,,,,,fee schedule,2069.41,9181.28,APC
Removal of ureter stone,51060,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3621.47,,,,,,,fee schedule,2069.41,9181.28,APC
Remove ureter calculus,51065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6183.21,,,,,,,fee schedule,3489.62,15482.25,
Remove ureter calculus,51065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4956.38,,,,,,,fee schedule,3489.62,15482.25,
Remove ureter calculus,51065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5414.4,,,,,,,fee schedule,3489.62,15482.25,
Remove ureter calculus,51065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5692.48,,,,,,,fee schedule,3489.62,15482.25,
Remove ureter calculus,51065,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Remove ureter calculus,51065,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Remove ureter calculus,51065,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Remove ureter calculus,51065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Remove ureter calculus,51065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Remove ureter calculus,51065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Remove ureter calculus,51065,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Drainage of bladder abscess,51080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4572.14,,,,,,,fee schedule,2875.57,12757.95,
Drainage of bladder abscess,51080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3664.97,,,,,,,fee schedule,2875.57,12757.95,
Drainage of bladder abscess,51080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4003.64,,,,,,,fee schedule,2875.57,12757.95,
Drainage of bladder abscess,51080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4209.27,,,,,,,fee schedule,2875.57,12757.95,
Drainage of bladder abscess,51080,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Drainage of bladder abscess,51080,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Drainage of bladder abscess,51080,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Drainage of bladder abscess,51080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Drainage of bladder abscess,51080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Drainage of bladder abscess,51080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Drainage of bladder abscess,51080,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Drain bladder by needle,51100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,501.08,,,,,,,fee schedule,247.34,1097.37,
Drain bladder by needle,51100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,401.66,,,,,,,fee schedule,247.34,1097.37,
Drain bladder by needle,51100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,438.77,,,,,,,fee schedule,247.34,1097.37,
Drain bladder by needle,51100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,461.31,,,,,,,fee schedule,247.34,1097.37,
Drain bladder by needle,51100,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1097.37,,,,,,,fee schedule,247.34,1097.37,APC 378
Drain bladder by needle,51100,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,259.71,,,,,,,fee schedule,247.34,1097.37,APC
Drain bladder by needle,51100,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,257.24,,,,,,,fee schedule,247.34,1097.37,APC
Drain bladder by needle,51100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,247.34,,,,,,,fee schedule,247.34,1097.37,APC
Drain bladder by needle,51100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,378.43,,,,,,,fee schedule,247.34,1097.37,Radiology
Drain bladder by needle,51100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,346.28,,,,,,,fee schedule,247.34,1097.37,APC
Drain bladder by needle,51100,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,432.85,,,,,,,fee schedule,247.34,1097.37,APC
Drain bladder by trocar/cath,51101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,258.44,,,,,,,fee schedule,207.16,3771.72,
Drain bladder by trocar/cath,51101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,207.16,,,,,,,fee schedule,207.16,3771.72,
Drain bladder by trocar/cath,51101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,226.3,,,,,,,fee schedule,207.16,3771.72,
Drain bladder by trocar/cath,51101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,237.93,,,,,,,fee schedule,207.16,3771.72,
Drain bladder by trocar/cath,51101,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3771.72,,,,,,,fee schedule,207.16,3771.72,APC 378
Drain bladder by trocar/cath,51101,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,892.63,,,,,,,fee schedule,207.16,3771.72,APC
Drain bladder by trocar/cath,51101,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,884.13,,,,,,,fee schedule,207.16,3771.72,APC
Drain bladder by trocar/cath,51101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,850.12,,,,,,,fee schedule,207.16,3771.72,APC
Drain bladder by trocar/cath,51101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1300.69,,,,,,,fee schedule,207.16,3771.72,Radiology
Drain bladder by trocar/cath,51101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1190.17,,,,,,,fee schedule,207.16,3771.72,APC
Drain bladder by trocar/cath,51101,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1487.72,,,,,,,fee schedule,207.16,3771.72,APC
Drain bl w/cath insertion,51102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2537.79,,,,,,,fee schedule,2034.26,9181.28,
Drain bl w/cath insertion,51102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2034.26,,,,,,,fee schedule,2034.26,9181.28,
Drain bl w/cath insertion,51102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2222.25,,,,,,,fee schedule,2034.26,9181.28,
Drain bl w/cath insertion,51102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2336.38,,,,,,,fee schedule,2034.26,9181.28,
Drain bl w/cath insertion,51102,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9181.28,,,,,,,fee schedule,2034.26,9181.28,APC 378
Drain bl w/cath insertion,51102,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2172.88,,,,,,,fee schedule,2034.26,9181.28,APC
Drain bl w/cath insertion,51102,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2152.19,,,,,,,fee schedule,2034.26,9181.28,APC
Drain bl w/cath insertion,51102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2069.41,,,,,,,fee schedule,2034.26,9181.28,APC
Drain bl w/cath insertion,51102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3166.2,,,,,,,fee schedule,2034.26,9181.28,Radiology
Drain bl w/cath insertion,51102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2897.18,,,,,,,fee schedule,2034.26,9181.28,APC
Drain bl w/cath insertion,51102,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3621.47,,,,,,,fee schedule,2034.26,9181.28,APC
Removal of bladder cyst,51500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10466.49,,,,,,,fee schedule,5984.88,26552.87,
Removal of bladder cyst,51500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8389.81,,,,,,,fee schedule,5984.88,26552.87,
Removal of bladder cyst,51500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9165.1,,,,,,,fee schedule,5984.88,26552.87,
Removal of bladder cyst,51500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9635.82,,,,,,,fee schedule,5984.88,26552.87,
Removal of bladder cyst,51500,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,5984.88,26552.87,APC 378
Removal of bladder cyst,51500,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,5984.88,26552.87,APC
Removal of bladder cyst,51500,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,5984.88,26552.87,APC
Removal of bladder cyst,51500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,5984.88,26552.87,APC
Removal of bladder cyst,51500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,5984.88,26552.87,Radiology
Removal of bladder cyst,51500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,5984.88,26552.87,APC
Removal of bladder cyst,51500,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,5984.88,26552.87,APC
Removal of bladder lesion,51520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6183.21,,,,,,,fee schedule,3489.62,15482.25,
Removal of bladder lesion,51520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4956.38,,,,,,,fee schedule,3489.62,15482.25,
Removal of bladder lesion,51520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5414.4,,,,,,,fee schedule,3489.62,15482.25,
Removal of bladder lesion,51520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5692.48,,,,,,,fee schedule,3489.62,15482.25,
Removal of bladder lesion,51520,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Removal of bladder lesion,51520,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Removal of bladder lesion,51520,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Removal of bladder lesion,51520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Removal of bladder lesion,51520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Removal of bladder lesion,51520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Removal of bladder lesion,51520,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Repair of ureter lesion,51535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6183.21,,,,,,,fee schedule,3489.62,15482.25,
Repair of ureter lesion,51535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4956.38,,,,,,,fee schedule,3489.62,15482.25,
Repair of ureter lesion,51535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5414.4,,,,,,,fee schedule,3489.62,15482.25,
Repair of ureter lesion,51535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5692.48,,,,,,,fee schedule,3489.62,15482.25,
Repair of ureter lesion,51535,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Repair of ureter lesion,51535,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Repair of ureter lesion,51535,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Repair of ureter lesion,51535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Repair of ureter lesion,51535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Repair of ureter lesion,51535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Repair of ureter lesion,51535,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Irrigation of bladder,51700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,284.99,,,,,,,fee schedule,228.44,1097.37,
Irrigation of bladder,51700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,228.44,,,,,,,fee schedule,228.44,1097.37,
Irrigation of bladder,51700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,249.55,,,,,,,fee schedule,228.44,1097.37,
Irrigation of bladder,51700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,262.37,,,,,,,fee schedule,228.44,1097.37,
Irrigation of bladder,51700,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1097.37,,,,,,,fee schedule,228.44,1097.37,APC 378
Irrigation of bladder,51700,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,259.71,,,,,,,fee schedule,228.44,1097.37,APC
Irrigation of bladder,51700,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,257.24,,,,,,,fee schedule,228.44,1097.37,APC
Irrigation of bladder,51700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,247.34,,,,,,,fee schedule,228.44,1097.37,APC
Irrigation of bladder,51700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,378.43,,,,,,,fee schedule,228.44,1097.37,Radiology
Irrigation of bladder,51700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,346.28,,,,,,,fee schedule,228.44,1097.37,APC
Irrigation of bladder,51700,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,432.85,,,,,,,fee schedule,228.44,1097.37,APC
Insert bladder catheter,51701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,241.55,,,,,,,fee schedule,131.71,584.37,
Insert bladder catheter,51701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,193.62,,,,,,,fee schedule,131.71,584.37,
Insert bladder catheter,51701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,211.51,,,,,,,fee schedule,131.71,584.37,
Insert bladder catheter,51701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,222.38,,,,,,,fee schedule,131.71,584.37,
Insert bladder catheter,51701,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,131.71,584.37,APC 378
Insert bladder catheter,51701,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,131.71,584.37,APC
Insert bladder catheter,51701,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,131.71,584.37,APC
Insert bladder catheter,51701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,131.71,584.37,APC
Insert bladder catheter,51701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,131.71,584.37,Radiology
Insert bladder catheter,51701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,131.71,584.37,APC
Insert bladder catheter,51701,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,131.71,584.37,APC
Insert temp bladder cath,51702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,197.1,,,,,,,fee schedule,131.71,584.37,
Insert temp bladder cath,51702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,157.99,,,,,,,fee schedule,131.71,584.37,
Insert temp bladder cath,51702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,172.59,,,,,,,fee schedule,131.71,584.37,
Insert temp bladder cath,51702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,181.45,,,,,,,fee schedule,131.71,584.37,
Insert temp bladder cath,51702,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,131.71,584.37,APC 378
Insert temp bladder cath,51702,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,131.71,584.37,APC
Insert temp bladder cath,51702,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,131.71,584.37,APC
Insert temp bladder cath,51702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,131.71,584.37,APC
Insert temp bladder cath,51702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,131.71,584.37,Radiology
Insert temp bladder cath,51702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,131.71,584.37,APC
Insert temp bladder cath,51702,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,131.71,584.37,APC
Insert bladder cath complex,51703,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,258.44,,,,,,,fee schedule,127.38,565.15,
Insert bladder cath complex,51703,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,207.16,,,,,,,fee schedule,127.38,565.15,
Insert bladder cath complex,51703,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,226.3,,,,,,,fee schedule,127.38,565.15,
Insert bladder cath complex,51703,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,237.93,,,,,,,fee schedule,127.38,565.15,
Insert bladder cath complex,51703,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,565.15,,,,,,,fee schedule,127.38,565.15,APC 378
Insert bladder cath complex,51703,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,133.75,,,,,,,fee schedule,127.38,565.15,APC
Insert bladder cath complex,51703,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,132.48,,,,,,,fee schedule,127.38,565.15,APC
Insert bladder cath complex,51703,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,127.38,,,,,,,fee schedule,127.38,565.15,APC
Insert bladder cath complex,51703,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,194.89,,,,,,,fee schedule,127.38,565.15,Radiology
Insert bladder cath complex,51703,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,178.33,,,,,,,fee schedule,127.38,565.15,APC
Insert bladder cath complex,51703,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,222.92,,,,,,,fee schedule,127.38,565.15,APC
Change of bladder tube,51705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,501.08,,,,,,,fee schedule,247.34,1097.37,
Change of bladder tube,51705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,401.66,,,,,,,fee schedule,247.34,1097.37,
Change of bladder tube,51705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,438.77,,,,,,,fee schedule,247.34,1097.37,
Change of bladder tube,51705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,461.31,,,,,,,fee schedule,247.34,1097.37,
Change of bladder tube,51705,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1097.37,,,,,,,fee schedule,247.34,1097.37,APC 378
Change of bladder tube,51705,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,259.71,,,,,,,fee schedule,247.34,1097.37,APC
Change of bladder tube,51705,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,257.24,,,,,,,fee schedule,247.34,1097.37,APC
Change of bladder tube,51705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,247.34,,,,,,,fee schedule,247.34,1097.37,APC
Change of bladder tube,51705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,378.43,,,,,,,fee schedule,247.34,1097.37,Radiology
Change of bladder tube,51705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,346.28,,,,,,,fee schedule,247.34,1097.37,APC
Change of bladder tube,51705,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,432.85,,,,,,,fee schedule,247.34,1097.37,APC
Change of bladder tube,51710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1426.02,,,,,,,fee schedule,690.3,3062.63,
Change of bladder tube,51710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1143.08,,,,,,,fee schedule,690.3,3062.63,
Change of bladder tube,51710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1248.71,,,,,,,fee schedule,690.3,3062.63,
Change of bladder tube,51710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1312.84,,,,,,,fee schedule,690.3,3062.63,
Change of bladder tube,51710,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3062.63,,,,,,,fee schedule,690.3,3062.63,APC 378
Change of bladder tube,51710,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,724.82,,,,,,,fee schedule,690.3,3062.63,APC
Change of bladder tube,51710,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,717.91,,,,,,,fee schedule,690.3,3062.63,APC
Change of bladder tube,51710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,690.3,,,,,,,fee schedule,690.3,3062.63,APC
Change of bladder tube,51710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1056.16,,,,,,,fee schedule,690.3,3062.63,Radiology
Change of bladder tube,51710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,966.42,,,,,,,fee schedule,690.3,3062.63,APC
Change of bladder tube,51710,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1208.03,,,,,,,fee schedule,690.3,3062.63,APC
Endoscopic injection/implant,51715,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5785.34,,,,,,,fee schedule,3489.62,15482.25,
Endoscopic injection/implant,51715,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4637.46,,,,,,,fee schedule,3489.62,15482.25,
Endoscopic injection/implant,51715,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5066,,,,,,,fee schedule,3489.62,15482.25,
Endoscopic injection/implant,51715,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5326.19,,,,,,,fee schedule,3489.62,15482.25,
Endoscopic injection/implant,51715,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Endoscopic injection/implant,51715,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Endoscopic injection/implant,51715,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Endoscopic injection/implant,51715,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Endoscopic injection/implant,51715,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Endoscopic injection/implant,51715,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Endoscopic injection/implant,51715,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Treatment of bladder lesion,51720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3126.73,,,,,,,fee schedule,690.3,3126.73,
Treatment of bladder lesion,51720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2506.35,,,,,,,fee schedule,690.3,3126.73,
Treatment of bladder lesion,51720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2737.95,,,,,,,fee schedule,690.3,3126.73,
Treatment of bladder lesion,51720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2878.57,,,,,,,fee schedule,690.3,3126.73,
Treatment of bladder lesion,51720,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3062.63,,,,,,,fee schedule,690.3,3126.73,APC 378
Treatment of bladder lesion,51720,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,724.82,,,,,,,fee schedule,690.3,3126.73,APC
Treatment of bladder lesion,51720,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,717.91,,,,,,,fee schedule,690.3,3126.73,APC
Treatment of bladder lesion,51720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,690.3,,,,,,,fee schedule,690.3,3126.73,APC
Treatment of bladder lesion,51720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1056.16,,,,,,,fee schedule,690.3,3126.73,Radiology
Treatment of bladder lesion,51720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,966.42,,,,,,,fee schedule,690.3,3126.73,APC
Treatment of bladder lesion,51720,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1208.03,,,,,,,fee schedule,690.3,3126.73,APC
Simple cystometrogram,51725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,487.7,,,,,,,fee schedule,247.34,1097.37,
Simple cystometrogram,51725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,390.93,,,,,,,fee schedule,247.34,1097.37,
Simple cystometrogram,51725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,427.06,,,,,,,fee schedule,247.34,1097.37,
Simple cystometrogram,51725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,448.99,,,,,,,fee schedule,247.34,1097.37,
Simple cystometrogram,51725,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1097.37,,,,,,,fee schedule,247.34,1097.37,APC 378
Simple cystometrogram,51725,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,259.71,,,,,,,fee schedule,247.34,1097.37,APC
Simple cystometrogram,51725,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,257.24,,,,,,,fee schedule,247.34,1097.37,APC
Simple cystometrogram,51725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,247.34,,,,,,,fee schedule,247.34,1097.37,APC
Simple cystometrogram,51725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,378.43,,,,,,,fee schedule,247.34,1097.37,Radiology
Simple cystometrogram,51725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,346.28,,,,,,,fee schedule,247.34,1097.37,APC
Simple cystometrogram,51725,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,432.85,,,,,,,fee schedule,247.34,1097.37,APC
Complex cystometrogram,51726,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,792.51,,,,,,,fee schedule,247.34,1097.37,
Complex cystometrogram,51726,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,635.27,,,,,,,fee schedule,247.34,1097.37,
Complex cystometrogram,51726,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,693.97,,,,,,,fee schedule,247.34,1097.37,
Complex cystometrogram,51726,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,729.62,,,,,,,fee schedule,247.34,1097.37,
Complex cystometrogram,51726,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1097.37,,,,,,,fee schedule,247.34,1097.37,APC 378
Complex cystometrogram,51726,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,259.71,,,,,,,fee schedule,247.34,1097.37,APC
Complex cystometrogram,51726,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,257.24,,,,,,,fee schedule,247.34,1097.37,APC
Complex cystometrogram,51726,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,247.34,,,,,,,fee schedule,247.34,1097.37,APC
Complex cystometrogram,51726,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,378.43,,,,,,,fee schedule,247.34,1097.37,Radiology
Complex cystometrogram,51726,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,346.28,,,,,,,fee schedule,247.34,1097.37,APC
Complex cystometrogram,51726,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,432.85,,,,,,,fee schedule,247.34,1097.37,APC
Cystometrogram w/up,51727,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,798,,,,,,,fee schedule,639.66,3062.63,
Cystometrogram w/up,51727,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,639.66,,,,,,,fee schedule,639.66,3062.63,
Cystometrogram w/up,51727,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,698.77,,,,,,,fee schedule,639.66,3062.63,
Cystometrogram w/up,51727,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,734.66,,,,,,,fee schedule,639.66,3062.63,
Cystometrogram w/up,51727,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3062.63,,,,,,,fee schedule,639.66,3062.63,APC 378
Cystometrogram w/up,51727,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,724.82,,,,,,,fee schedule,639.66,3062.63,APC
Cystometrogram w/up,51727,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,717.91,,,,,,,fee schedule,639.66,3062.63,APC
Cystometrogram w/up,51727,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,690.3,,,,,,,fee schedule,639.66,3062.63,APC
Cystometrogram w/up,51727,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1056.16,,,,,,,fee schedule,639.66,3062.63,Radiology
Cystometrogram w/up,51727,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,966.42,,,,,,,fee schedule,639.66,3062.63,APC
Cystometrogram w/up,51727,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1208.03,,,,,,,fee schedule,639.66,3062.63,APC
Cystometrogram w/vp,51728,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,798,,,,,,,fee schedule,639.66,3062.63,
Cystometrogram w/vp,51728,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,639.66,,,,,,,fee schedule,639.66,3062.63,
Cystometrogram w/vp,51728,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,698.77,,,,,,,fee schedule,639.66,3062.63,
Cystometrogram w/vp,51728,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,734.66,,,,,,,fee schedule,639.66,3062.63,
Cystometrogram w/vp,51728,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3062.63,,,,,,,fee schedule,639.66,3062.63,APC 378
Cystometrogram w/vp,51728,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,724.82,,,,,,,fee schedule,639.66,3062.63,APC
Cystometrogram w/vp,51728,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,717.91,,,,,,,fee schedule,639.66,3062.63,APC
Cystometrogram w/vp,51728,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,690.3,,,,,,,fee schedule,639.66,3062.63,APC
Cystometrogram w/vp,51728,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1056.16,,,,,,,fee schedule,639.66,3062.63,Radiology
Cystometrogram w/vp,51728,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,966.42,,,,,,,fee schedule,639.66,3062.63,APC
Cystometrogram w/vp,51728,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1208.03,,,,,,,fee schedule,639.66,3062.63,APC
Cystometrogram w/vp&up,51729,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,798,,,,,,,fee schedule,639.66,3062.63,
Cystometrogram w/vp&up,51729,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,639.66,,,,,,,fee schedule,639.66,3062.63,
Cystometrogram w/vp&up,51729,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,698.77,,,,,,,fee schedule,639.66,3062.63,
Cystometrogram w/vp&up,51729,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,734.66,,,,,,,fee schedule,639.66,3062.63,
Cystometrogram w/vp&up,51729,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3062.63,,,,,,,fee schedule,639.66,3062.63,APC 378
Cystometrogram w/vp&up,51729,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,724.82,,,,,,,fee schedule,639.66,3062.63,APC
Cystometrogram w/vp&up,51729,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,717.91,,,,,,,fee schedule,639.66,3062.63,APC
Cystometrogram w/vp&up,51729,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,690.3,,,,,,,fee schedule,639.66,3062.63,APC
Cystometrogram w/vp&up,51729,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1056.16,,,,,,,fee schedule,639.66,3062.63,Radiology
Cystometrogram w/vp&up,51729,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,966.42,,,,,,,fee schedule,639.66,3062.63,APC
Cystometrogram w/vp&up,51729,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1208.03,,,,,,,fee schedule,639.66,3062.63,APC
Urine flow measurement,51736,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,75.52,,,,,,,fee schedule,60.54,584.37,
Urine flow measurement,51736,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,60.54,,,,,,,fee schedule,60.54,584.37,
Urine flow measurement,51736,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66.13,,,,,,,fee schedule,60.54,584.37,
Urine flow measurement,51736,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,69.53,,,,,,,fee schedule,60.54,584.37,
Urine flow measurement,51736,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,60.54,584.37,APC 378
Urine flow measurement,51736,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,60.54,584.37,APC
Urine flow measurement,51736,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,60.54,584.37,APC
Urine flow measurement,51736,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,60.54,584.37,APC
Urine flow measurement,51736,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,60.54,584.37,Radiology
Urine flow measurement,51736,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,60.54,584.37,APC
Urine flow measurement,51736,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,60.54,584.37,APC
Electro-uroflowmetry first,51741,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,89.13,,,,,,,fee schedule,71.45,948.37,
Electro-uroflowmetry first,51741,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,71.45,,,,,,,fee schedule,71.45,948.37,
Electro-uroflowmetry first,51741,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,78.05,,,,,,,fee schedule,71.45,948.37,
Electro-uroflowmetry first,51741,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,82.06,,,,,,,fee schedule,71.45,948.37,
Electro-uroflowmetry first,51741,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,71.45,948.37,APC 378
Electro-uroflowmetry first,51741,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,71.45,948.37,APC
Electro-uroflowmetry first,51741,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,71.45,948.37,APC
Electro-uroflowmetry first,51741,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,71.45,948.37,APC
Electro-uroflowmetry first,51741,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,71.45,948.37,Radiology
Electro-uroflowmetry first,51741,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,71.45,948.37,APC
Electro-uroflowmetry first,51741,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,71.45,948.37,APC
Anal/urinary muscle study,51784,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,423.36,,,,,,,fee schedule,127.38,565.15,
Anal/urinary muscle study,51784,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,339.36,,,,,,,fee schedule,127.38,565.15,
Anal/urinary muscle study,51784,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,370.72,,,,,,,fee schedule,127.38,565.15,
Anal/urinary muscle study,51784,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,389.76,,,,,,,fee schedule,127.38,565.15,
Anal/urinary muscle study,51784,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,565.15,,,,,,,fee schedule,127.38,565.15,APC 378
Anal/urinary muscle study,51784,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,133.75,,,,,,,fee schedule,127.38,565.15,APC
Anal/urinary muscle study,51784,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,132.48,,,,,,,fee schedule,127.38,565.15,APC
Anal/urinary muscle study,51784,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,127.38,,,,,,,fee schedule,127.38,565.15,APC
Anal/urinary muscle study,51784,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,194.89,,,,,,,fee schedule,127.38,565.15,Radiology
Anal/urinary muscle study,51784,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,178.33,,,,,,,fee schedule,127.38,565.15,APC
Anal/urinary muscle study,51784,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,222.92,,,,,,,fee schedule,127.38,565.15,APC
Anal/urinary muscle study,51785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,481.61,,,,,,,fee schedule,247.34,1097.37,
Anal/urinary muscle study,51785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.05,,,,,,,fee schedule,247.34,1097.37,
Anal/urinary muscle study,51785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,421.73,,,,,,,fee schedule,247.34,1097.37,
Anal/urinary muscle study,51785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,443.39,,,,,,,fee schedule,247.34,1097.37,
Anal/urinary muscle study,51785,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1097.37,,,,,,,fee schedule,247.34,1097.37,APC 378
Anal/urinary muscle study,51785,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,259.71,,,,,,,fee schedule,247.34,1097.37,APC
Anal/urinary muscle study,51785,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,257.24,,,,,,,fee schedule,247.34,1097.37,APC
Anal/urinary muscle study,51785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,247.34,,,,,,,fee schedule,247.34,1097.37,APC
Anal/urinary muscle study,51785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,378.43,,,,,,,fee schedule,247.34,1097.37,Radiology
Anal/urinary muscle study,51785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,346.28,,,,,,,fee schedule,247.34,1097.37,APC
Anal/urinary muscle study,51785,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,432.85,,,,,,,fee schedule,247.34,1097.37,APC
Urinary reflex study,51792,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,599.39,,,,,,,fee schedule,58.4,599.39,
Urinary reflex study,51792,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,480.47,,,,,,,fee schedule,58.4,599.39,
Urinary reflex study,51792,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,524.87,,,,,,,fee schedule,58.4,599.39,
Urinary reflex study,51792,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,551.82,,,,,,,fee schedule,58.4,599.39,
Urinary reflex study,51792,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,58.4,599.39,APC 378
Urinary reflex study,51792,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,58.4,599.39,APC
Urinary reflex study,51792,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,58.4,599.39,APC
Urinary reflex study,51792,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,58.4,599.39,APC
Urinary reflex study,51792,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,58.4,599.39,Radiology
Urinary reflex study,51792,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,58.4,599.39,APC
Urinary reflex study,51792,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,58.4,599.39,APC
Intraabdominal pressure test,51797,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,358.12,,,,,,,fee schedule,287.06,358.12,
Intraabdominal pressure test,51797,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,287.06,,,,,,,fee schedule,287.06,358.12,
Intraabdominal pressure test,51797,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,313.59,,,,,,,fee schedule,287.06,358.12,
Intraabdominal pressure test,51797,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,329.7,,,,,,,fee schedule,287.06,358.12,
Us urine capacity measure,51798,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,215.64,,,,,,,fee schedule,58.4,259.1,
Us urine capacity measure,51798,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,172.85,,,,,,,fee schedule,58.4,259.1,
Us urine capacity measure,51798,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,188.82,,,,,,,fee schedule,58.4,259.1,
Us urine capacity measure,51798,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,198.52,,,,,,,fee schedule,58.4,259.1,
Us urine capacity measure,51798,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,58.4,259.1,APC 378
Us urine capacity measure,51798,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,58.4,259.1,APC
Us urine capacity measure,51798,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,58.4,259.1,APC
Us urine capacity measure,51798,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,58.4,259.1,APC
Us urine capacity measure,51798,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,58.4,259.1,Radiology
Us urine capacity measure,51798,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,58.4,259.1,APC
Us urine capacity measure,51798,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,58.4,259.1,APC
Attach bladder/urethra,51840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5174.78,,,,,,,fee schedule,4148.03,21971.51,
Attach bladder/urethra,51840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4148.03,,,,,,,fee schedule,4148.03,21971.51,
Attach bladder/urethra,51840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4531.35,,,,,,,fee schedule,4148.03,21971.51,
Attach bladder/urethra,51840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4764.08,,,,,,,fee schedule,4148.03,21971.51,
Attach bladder/urethra,51840,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21971.51,,,,,,,fee schedule,4148.03,21971.51,APC 378
Attach bladder/urethra,51840,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5199.88,,,,,,,fee schedule,4148.03,21971.51,APC
Attach bladder/urethra,51840,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5150.35,,,,,,,fee schedule,4148.03,21971.51,APC
Attach bladder/urethra,51840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4952.26,,,,,,,fee schedule,4148.03,21971.51,APC
Attach bladder/urethra,51840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7576.96,,,,,,,fee schedule,4148.03,21971.51,Radiology
Attach bladder/urethra,51840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6933.17,,,,,,,fee schedule,4148.03,21971.51,APC
Attach bladder/urethra,51840,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8666.46,,,,,,,fee schedule,4148.03,21971.51,APC
Repair bladder neck,51845,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14405.01,,,,,,,fee schedule,4952.26,21971.51,
Repair bladder neck,51845,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11546.88,,,,,,,fee schedule,4952.26,21971.51,
Repair bladder neck,51845,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12613.91,,,,,,,fee schedule,4952.26,21971.51,
Repair bladder neck,51845,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13261.76,,,,,,,fee schedule,4952.26,21971.51,
Repair bladder neck,51845,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21971.51,,,,,,,fee schedule,4952.26,21971.51,APC 378
Repair bladder neck,51845,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5199.88,,,,,,,fee schedule,4952.26,21971.51,APC
Repair bladder neck,51845,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5150.35,,,,,,,fee schedule,4952.26,21971.51,APC
Repair bladder neck,51845,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4952.26,,,,,,,fee schedule,4952.26,21971.51,APC
Repair bladder neck,51845,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7576.96,,,,,,,fee schedule,4952.26,21971.51,Radiology
Repair bladder neck,51845,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6933.17,,,,,,,fee schedule,4952.26,21971.51,APC
Repair bladder neck,51845,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8666.46,,,,,,,fee schedule,4952.26,21971.51,APC
Repair of bladder wound,51860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13169.56,,,,,,,fee schedule,9371.49,41578.13,
Repair of bladder wound,51860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10556.55,,,,,,,fee schedule,9371.49,41578.13,
Repair of bladder wound,51860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11532.07,,,,,,,fee schedule,9371.49,41578.13,
Repair of bladder wound,51860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12124.35,,,,,,,fee schedule,9371.49,41578.13,
Repair of bladder wound,51860,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,41578.13,,,,,,,fee schedule,9371.49,41578.13,APC 378
Repair of bladder wound,51860,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9840.06,,,,,,,fee schedule,9371.49,41578.13,APC
Repair of bladder wound,51860,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9746.35,,,,,,,fee schedule,9371.49,41578.13,APC
Repair of bladder wound,51860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9371.49,,,,,,,fee schedule,9371.49,41578.13,APC
Repair of bladder wound,51860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14338.38,,,,,,,fee schedule,9371.49,41578.13,Radiology
Repair of bladder wound,51860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13120.09,,,,,,,fee schedule,9371.49,41578.13,APC
Repair of bladder wound,51860,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16400.11,,,,,,,fee schedule,9371.49,41578.13,APC
Repair of bladder opening,51880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6183.21,,,,,,,fee schedule,3489.62,15482.25,
Repair of bladder opening,51880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4956.38,,,,,,,fee schedule,3489.62,15482.25,
Repair of bladder opening,51880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5414.4,,,,,,,fee schedule,3489.62,15482.25,
Repair of bladder opening,51880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5692.48,,,,,,,fee schedule,3489.62,15482.25,
Repair of bladder opening,51880,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Repair of bladder opening,51880,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Repair of bladder opening,51880,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Repair of bladder opening,51880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Repair of bladder opening,51880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Repair of bladder opening,51880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Repair of bladder opening,51880,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Laparo urethral suspension,51990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5566.45,,,,,,,fee schedule,4462,26552.87,
Laparo urethral suspension,51990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4462,,,,,,,fee schedule,4462,26552.87,
Laparo urethral suspension,51990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4874.33,,,,,,,fee schedule,4462,26552.87,
Laparo urethral suspension,51990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5124.67,,,,,,,fee schedule,4462,26552.87,
Laparo urethral suspension,51990,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,4462,26552.87,APC 378
Laparo urethral suspension,51990,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,4462,26552.87,APC
Laparo urethral suspension,51990,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,4462,26552.87,APC
Laparo urethral suspension,51990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,4462,26552.87,APC
Laparo urethral suspension,51990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,4462,26552.87,Radiology
Laparo urethral suspension,51990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,4462,26552.87,APC
Laparo urethral suspension,51990,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,4462,26552.87,APC
Laparo sling operation,51992,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4531.07,,,,,,,fee schedule,3632.05,26552.87,
Laparo sling operation,51992,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3632.05,,,,,,,fee schedule,3632.05,26552.87,
Laparo sling operation,51992,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3967.69,,,,,,,fee schedule,3632.05,26552.87,
Laparo sling operation,51992,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4171.46,,,,,,,fee schedule,3632.05,26552.87,
Laparo sling operation,51992,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,3632.05,26552.87,APC 378
Laparo sling operation,51992,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,3632.05,26552.87,APC
Laparo sling operation,51992,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,3632.05,26552.87,APC
Laparo sling operation,51992,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,3632.05,26552.87,APC
Laparo sling operation,51992,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,3632.05,26552.87,Radiology
Laparo sling operation,51992,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,3632.05,26552.87,APC
Laparo sling operation,51992,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,3632.05,26552.87,APC
Laparoscope proc bla,51999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8584.34,,,,,,,fee schedule,5984.88,26552.87,
Laparoscope proc bla,51999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6881.1,,,,,,,fee schedule,5984.88,26552.87,
Laparoscope proc bla,51999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7516.98,,,,,,,fee schedule,5984.88,26552.87,
Laparoscope proc bla,51999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7903.05,,,,,,,fee schedule,5984.88,26552.87,
Laparoscope proc bla,51999,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,5984.88,26552.87,APC 378
Laparoscope proc bla,51999,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscope proc bla,51999,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscope proc bla,51999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscope proc bla,51999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,5984.88,26552.87,Radiology
Laparoscope proc bla,51999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscope proc bla,51999,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,5984.88,26552.87,APC
Cystoscopy,52000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5762.58,,,,,,,fee schedule,690.3,5762.58,
Cystoscopy,52000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4619.21,,,,,,,fee schedule,690.3,5762.58,
Cystoscopy,52000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5046.07,,,,,,,fee schedule,690.3,5762.58,
Cystoscopy,52000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5305.24,,,,,,,fee schedule,690.3,5762.58,
Cystoscopy,52000,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3062.63,,,,,,,fee schedule,690.3,5762.58,APC 378
Cystoscopy,52000,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,724.82,,,,,,,fee schedule,690.3,5762.58,APC
Cystoscopy,52000,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,717.91,,,,,,,fee schedule,690.3,5762.58,APC
Cystoscopy,52000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,690.3,,,,,,,fee schedule,690.3,5762.58,APC
Cystoscopy,52000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1056.16,,,,,,,fee schedule,690.3,5762.58,Radiology
Cystoscopy,52000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,966.42,,,,,,,fee schedule,690.3,5762.58,APC
Cystoscopy,52000,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1208.03,,,,,,,fee schedule,690.3,5762.58,APC
Cystoscopy removal of clots,52001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7189.69,,,,,,,fee schedule,3489.62,15482.25,
Cystoscopy removal of clots,52001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5763.16,,,,,,,fee schedule,3489.62,15482.25,
Cystoscopy removal of clots,52001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6295.73,,,,,,,fee schedule,3489.62,15482.25,
Cystoscopy removal of clots,52001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6619.08,,,,,,,fee schedule,3489.62,15482.25,
Cystoscopy removal of clots,52001,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Cystoscopy removal of clots,52001,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Cystoscopy removal of clots,52001,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Cystoscopy removal of clots,52001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Cystoscopy removal of clots,52001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Cystoscopy removal of clots,52001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Cystoscopy removal of clots,52001,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Cystoscopy & ureter catheter,52005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4794.32,,,,,,,fee schedule,2069.41,9181.28,
Cystoscopy & ureter catheter,52005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3843.07,,,,,,,fee schedule,2069.41,9181.28,
Cystoscopy & ureter catheter,52005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4198.2,,,,,,,fee schedule,2069.41,9181.28,
Cystoscopy & ureter catheter,52005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4413.82,,,,,,,fee schedule,2069.41,9181.28,
Cystoscopy & ureter catheter,52005,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9181.28,,,,,,,fee schedule,2069.41,9181.28,APC 378
Cystoscopy & ureter catheter,52005,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2172.88,,,,,,,fee schedule,2069.41,9181.28,APC
Cystoscopy & ureter catheter,52005,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2152.19,,,,,,,fee schedule,2069.41,9181.28,APC
Cystoscopy & ureter catheter,52005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2069.41,,,,,,,fee schedule,2069.41,9181.28,APC
Cystoscopy & ureter catheter,52005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3166.2,,,,,,,fee schedule,2069.41,9181.28,Radiology
Cystoscopy & ureter catheter,52005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2897.18,,,,,,,fee schedule,2069.41,9181.28,APC
Cystoscopy & ureter catheter,52005,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3621.47,,,,,,,fee schedule,2069.41,9181.28,APC
Cystoscopy and biopsy,52007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6183.21,,,,,,,fee schedule,3489.62,15482.25,
Cystoscopy and biopsy,52007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4956.38,,,,,,,fee schedule,3489.62,15482.25,
Cystoscopy and biopsy,52007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5414.4,,,,,,,fee schedule,3489.62,15482.25,
Cystoscopy and biopsy,52007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5692.48,,,,,,,fee schedule,3489.62,15482.25,
Cystoscopy and biopsy,52007,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Cystoscopy and biopsy,52007,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Cystoscopy and biopsy,52007,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Cystoscopy and biopsy,52007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Cystoscopy and biopsy,52007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Cystoscopy and biopsy,52007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Cystoscopy and biopsy,52007,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Cystoscopy & duct catheter,52010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1490.87,,,,,,,fee schedule,690.3,3062.63,
Cystoscopy & duct catheter,52010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1195.06,,,,,,,fee schedule,690.3,3062.63,
Cystoscopy & duct catheter,52010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1305.5,,,,,,,fee schedule,690.3,3062.63,
Cystoscopy & duct catheter,52010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1372.55,,,,,,,fee schedule,690.3,3062.63,
Cystoscopy & duct catheter,52010,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3062.63,,,,,,,fee schedule,690.3,3062.63,APC 378
Cystoscopy & duct catheter,52010,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,724.82,,,,,,,fee schedule,690.3,3062.63,APC
Cystoscopy & duct catheter,52010,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,717.91,,,,,,,fee schedule,690.3,3062.63,APC
Cystoscopy & duct catheter,52010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,690.3,,,,,,,fee schedule,690.3,3062.63,APC
Cystoscopy & duct catheter,52010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1056.16,,,,,,,fee schedule,690.3,3062.63,Radiology
Cystoscopy & duct catheter,52010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,966.42,,,,,,,fee schedule,690.3,3062.63,APC
Cystoscopy & duct catheter,52010,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1208.03,,,,,,,fee schedule,690.3,3062.63,APC
Cystoscopy w/biopsy(s),52204,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5177.78,,,,,,,fee schedule,2069.41,9181.28,
Cystoscopy w/biopsy(s),52204,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4150.44,,,,,,,fee schedule,2069.41,9181.28,
Cystoscopy w/biopsy(s),52204,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4533.98,,,,,,,fee schedule,2069.41,9181.28,
Cystoscopy w/biopsy(s),52204,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4766.84,,,,,,,fee schedule,2069.41,9181.28,
Cystoscopy w/biopsy(s),52204,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9181.28,,,,,,,fee schedule,2069.41,9181.28,APC 378
Cystoscopy w/biopsy(s),52204,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2172.88,,,,,,,fee schedule,2069.41,9181.28,APC
Cystoscopy w/biopsy(s),52204,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2152.19,,,,,,,fee schedule,2069.41,9181.28,APC
Cystoscopy w/biopsy(s),52204,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2069.41,,,,,,,fee schedule,2069.41,9181.28,APC
Cystoscopy w/biopsy(s),52204,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3166.2,,,,,,,fee schedule,2069.41,9181.28,Radiology
Cystoscopy w/biopsy(s),52204,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2897.18,,,,,,,fee schedule,2069.41,9181.28,APC
Cystoscopy w/biopsy(s),52204,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3621.47,,,,,,,fee schedule,2069.41,9181.28,APC
Cystoscopy and treatment,52214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6183.21,,,,,,,fee schedule,3489.62,15482.25,
Cystoscopy and treatment,52214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4956.38,,,,,,,fee schedule,3489.62,15482.25,
Cystoscopy and treatment,52214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5414.4,,,,,,,fee schedule,3489.62,15482.25,
Cystoscopy and treatment,52214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5692.48,,,,,,,fee schedule,3489.62,15482.25,
Cystoscopy and treatment,52214,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Cystoscopy and treatment,52214,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Cystoscopy and treatment,52214,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Cystoscopy and treatment,52214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Cystoscopy and treatment,52214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Cystoscopy and treatment,52214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Cystoscopy and treatment,52214,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Cystoscopy and treatment,52224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6721.57,,,,,,,fee schedule,3489.62,15482.25,
Cystoscopy and treatment,52224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5387.93,,,,,,,fee schedule,3489.62,15482.25,
Cystoscopy and treatment,52224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5885.82,,,,,,,fee schedule,3489.62,15482.25,
Cystoscopy and treatment,52224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6188.11,,,,,,,fee schedule,3489.62,15482.25,
Cystoscopy and treatment,52224,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Cystoscopy and treatment,52224,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Cystoscopy and treatment,52224,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Cystoscopy and treatment,52224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Cystoscopy and treatment,52224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Cystoscopy and treatment,52224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Cystoscopy and treatment,52224,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Cystoscopy and treatment,52234,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5330.45,,,,,,,fee schedule,3489.62,15482.25,
Cystoscopy and treatment,52234,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4272.82,,,,,,,fee schedule,3489.62,15482.25,
Cystoscopy and treatment,52234,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4667.66,,,,,,,fee schedule,3489.62,15482.25,
Cystoscopy and treatment,52234,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4907.39,,,,,,,fee schedule,3489.62,15482.25,
Cystoscopy and treatment,52234,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Cystoscopy and treatment,52234,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Cystoscopy and treatment,52234,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Cystoscopy and treatment,52234,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Cystoscopy and treatment,52234,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Cystoscopy and treatment,52234,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Cystoscopy and treatment,52234,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Cystoscopy and treatment,52235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4929.51,,,,,,,fee schedule,3489.62,15482.25,
Cystoscopy and treatment,52235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3951.44,,,,,,,fee schedule,3489.62,15482.25,
Cystoscopy and treatment,52235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4316.58,,,,,,,fee schedule,3489.62,15482.25,
Cystoscopy and treatment,52235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4538.28,,,,,,,fee schedule,3489.62,15482.25,
Cystoscopy and treatment,52235,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Cystoscopy and treatment,52235,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Cystoscopy and treatment,52235,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Cystoscopy and treatment,52235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Cystoscopy and treatment,52235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Cystoscopy and treatment,52235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Cystoscopy and treatment,52235,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Cystoscopy and treatment,52240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6955.63,,,,,,,fee schedule,5308,23549.82,
Cystoscopy and treatment,52240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5575.54,,,,,,,fee schedule,5308,23549.82,
Cystoscopy and treatment,52240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6090.78,,,,,,,fee schedule,5308,23549.82,
Cystoscopy and treatment,52240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6403.59,,,,,,,fee schedule,5308,23549.82,
Cystoscopy and treatment,52240,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23549.82,,,,,,,fee schedule,5308,23549.82,APC 378
Cystoscopy and treatment,52240,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5573.4,,,,,,,fee schedule,5308,23549.82,APC
Cystoscopy and treatment,52240,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5520.32,,,,,,,fee schedule,5308,23549.82,APC
Cystoscopy and treatment,52240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5308,,,,,,,fee schedule,5308,23549.82,APC
Cystoscopy and treatment,52240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8121.25,,,,,,,fee schedule,5308,23549.82,Radiology
Cystoscopy and treatment,52240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7431.21,,,,,,,fee schedule,5308,23549.82,APC
Cystoscopy and treatment,52240,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9289.01,,,,,,,fee schedule,5308,23549.82,APC
Cystoscopy and radiotracer,52250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6183.21,,,,,,,fee schedule,3489.62,15482.25,
Cystoscopy and radiotracer,52250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4956.38,,,,,,,fee schedule,3489.62,15482.25,
Cystoscopy and radiotracer,52250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5414.4,,,,,,,fee schedule,3489.62,15482.25,
Cystoscopy and radiotracer,52250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5692.48,,,,,,,fee schedule,3489.62,15482.25,
Cystoscopy and radiotracer,52250,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Cystoscopy and radiotracer,52250,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Cystoscopy and radiotracer,52250,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Cystoscopy and radiotracer,52250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Cystoscopy and radiotracer,52250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Cystoscopy and radiotracer,52250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Cystoscopy and radiotracer,52250,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Cystoscopy and treatment,52260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4742.38,,,,,,,fee schedule,2069.41,9181.28,
Cystoscopy and treatment,52260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3801.43,,,,,,,fee schedule,2069.41,9181.28,
Cystoscopy and treatment,52260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4152.71,,,,,,,fee schedule,2069.41,9181.28,
Cystoscopy and treatment,52260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4366,,,,,,,fee schedule,2069.41,9181.28,
Cystoscopy and treatment,52260,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9181.28,,,,,,,fee schedule,2069.41,9181.28,APC 378
Cystoscopy and treatment,52260,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2172.88,,,,,,,fee schedule,2069.41,9181.28,APC
Cystoscopy and treatment,52260,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2152.19,,,,,,,fee schedule,2069.41,9181.28,APC
Cystoscopy and treatment,52260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2069.41,,,,,,,fee schedule,2069.41,9181.28,APC
Cystoscopy and treatment,52260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3166.2,,,,,,,fee schedule,2069.41,9181.28,Radiology
Cystoscopy and treatment,52260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2897.18,,,,,,,fee schedule,2069.41,9181.28,APC
Cystoscopy and treatment,52260,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3621.47,,,,,,,fee schedule,2069.41,9181.28,APC
Cystoscopy and treatment,52265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1490.87,,,,,,,fee schedule,1195.06,9181.28,
Cystoscopy and treatment,52265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1195.06,,,,,,,fee schedule,1195.06,9181.28,
Cystoscopy and treatment,52265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1305.5,,,,,,,fee schedule,1195.06,9181.28,
Cystoscopy and treatment,52265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1372.55,,,,,,,fee schedule,1195.06,9181.28,
Cystoscopy and treatment,52265,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9181.28,,,,,,,fee schedule,1195.06,9181.28,APC 378
Cystoscopy and treatment,52265,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2172.88,,,,,,,fee schedule,1195.06,9181.28,APC
Cystoscopy and treatment,52265,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2152.19,,,,,,,fee schedule,1195.06,9181.28,APC
Cystoscopy and treatment,52265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2069.41,,,,,,,fee schedule,1195.06,9181.28,APC
Cystoscopy and treatment,52265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3166.2,,,,,,,fee schedule,1195.06,9181.28,Radiology
Cystoscopy and treatment,52265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2897.18,,,,,,,fee schedule,1195.06,9181.28,APC
Cystoscopy and treatment,52265,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3621.47,,,,,,,fee schedule,1195.06,9181.28,APC
Cystoscopy & revise urethra,52270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4477.9,,,,,,,fee schedule,2069.41,9181.28,
Cystoscopy & revise urethra,52270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3589.43,,,,,,,fee schedule,2069.41,9181.28,
Cystoscopy & revise urethra,52270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3921.13,,,,,,,fee schedule,2069.41,9181.28,
Cystoscopy & revise urethra,52270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4122.51,,,,,,,fee schedule,2069.41,9181.28,
Cystoscopy & revise urethra,52270,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9181.28,,,,,,,fee schedule,2069.41,9181.28,APC 378
Cystoscopy & revise urethra,52270,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2172.88,,,,,,,fee schedule,2069.41,9181.28,APC
Cystoscopy & revise urethra,52270,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2152.19,,,,,,,fee schedule,2069.41,9181.28,APC
Cystoscopy & revise urethra,52270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2069.41,,,,,,,fee schedule,2069.41,9181.28,APC
Cystoscopy & revise urethra,52270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3166.2,,,,,,,fee schedule,2069.41,9181.28,Radiology
Cystoscopy & revise urethra,52270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2897.18,,,,,,,fee schedule,2069.41,9181.28,APC
Cystoscopy & revise urethra,52270,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3621.47,,,,,,,fee schedule,2069.41,9181.28,APC
Cystoscopy & revise urethra,52275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5785.34,,,,,,,fee schedule,2069.41,9181.28,
Cystoscopy & revise urethra,52275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4637.46,,,,,,,fee schedule,2069.41,9181.28,
Cystoscopy & revise urethra,52275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5066,,,,,,,fee schedule,2069.41,9181.28,
Cystoscopy & revise urethra,52275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5326.19,,,,,,,fee schedule,2069.41,9181.28,
Cystoscopy & revise urethra,52275,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9181.28,,,,,,,fee schedule,2069.41,9181.28,APC 378
Cystoscopy & revise urethra,52275,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2172.88,,,,,,,fee schedule,2069.41,9181.28,APC
Cystoscopy & revise urethra,52275,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2152.19,,,,,,,fee schedule,2069.41,9181.28,APC
Cystoscopy & revise urethra,52275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2069.41,,,,,,,fee schedule,2069.41,9181.28,APC
Cystoscopy & revise urethra,52275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3166.2,,,,,,,fee schedule,2069.41,9181.28,Radiology
Cystoscopy & revise urethra,52275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2897.18,,,,,,,fee schedule,2069.41,9181.28,APC
Cystoscopy & revise urethra,52275,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3621.47,,,,,,,fee schedule,2069.41,9181.28,APC
Cystoscopy and treatment,52276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5530.29,,,,,,,fee schedule,2069.41,9181.28,
Cystoscopy and treatment,52276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4433.01,,,,,,,fee schedule,2069.41,9181.28,
Cystoscopy and treatment,52276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4842.66,,,,,,,fee schedule,2069.41,9181.28,
Cystoscopy and treatment,52276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5091.38,,,,,,,fee schedule,2069.41,9181.28,
Cystoscopy and treatment,52276,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9181.28,,,,,,,fee schedule,2069.41,9181.28,APC 378
Cystoscopy and treatment,52276,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2172.88,,,,,,,fee schedule,2069.41,9181.28,APC
Cystoscopy and treatment,52276,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2152.19,,,,,,,fee schedule,2069.41,9181.28,APC
Cystoscopy and treatment,52276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2069.41,,,,,,,fee schedule,2069.41,9181.28,APC
Cystoscopy and treatment,52276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3166.2,,,,,,,fee schedule,2069.41,9181.28,Radiology
Cystoscopy and treatment,52276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2897.18,,,,,,,fee schedule,2069.41,9181.28,APC
Cystoscopy and treatment,52276,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3621.47,,,,,,,fee schedule,2069.41,9181.28,APC
Cystoscopy and treatment,52277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6183.21,,,,,,,fee schedule,3489.62,15482.25,
Cystoscopy and treatment,52277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4956.38,,,,,,,fee schedule,3489.62,15482.25,
Cystoscopy and treatment,52277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5414.4,,,,,,,fee schedule,3489.62,15482.25,
Cystoscopy and treatment,52277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5692.48,,,,,,,fee schedule,3489.62,15482.25,
Cystoscopy and treatment,52277,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Cystoscopy and treatment,52277,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Cystoscopy and treatment,52277,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Cystoscopy and treatment,52277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Cystoscopy and treatment,52277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Cystoscopy and treatment,52277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Cystoscopy and treatment,52277,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Cystoscopy and treatment,52281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5941.38,,,,,,,fee schedule,2069.41,9181.28,
Cystoscopy and treatment,52281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4762.53,,,,,,,fee schedule,2069.41,9181.28,
Cystoscopy and treatment,52281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5202.64,,,,,,,fee schedule,2069.41,9181.28,
Cystoscopy and treatment,52281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5469.84,,,,,,,fee schedule,2069.41,9181.28,
Cystoscopy and treatment,52281,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9181.28,,,,,,,fee schedule,2069.41,9181.28,APC 378
Cystoscopy and treatment,52281,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2172.88,,,,,,,fee schedule,2069.41,9181.28,APC
Cystoscopy and treatment,52281,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2152.19,,,,,,,fee schedule,2069.41,9181.28,APC
Cystoscopy and treatment,52281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2069.41,,,,,,,fee schedule,2069.41,9181.28,APC
Cystoscopy and treatment,52281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3166.2,,,,,,,fee schedule,2069.41,9181.28,Radiology
Cystoscopy and treatment,52281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2897.18,,,,,,,fee schedule,2069.41,9181.28,APC
Cystoscopy and treatment,52281,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3621.47,,,,,,,fee schedule,2069.41,9181.28,APC
Cystoscopy implant stent,52282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3126.73,,,,,,,fee schedule,2506.35,15482.25,
Cystoscopy implant stent,52282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2506.35,,,,,,,fee schedule,2506.35,15482.25,
Cystoscopy implant stent,52282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2737.95,,,,,,,fee schedule,2506.35,15482.25,
Cystoscopy implant stent,52282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2878.57,,,,,,,fee schedule,2506.35,15482.25,
Cystoscopy implant stent,52282,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,2506.35,15482.25,APC 378
Cystoscopy implant stent,52282,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,2506.35,15482.25,APC
Cystoscopy implant stent,52282,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,2506.35,15482.25,APC
Cystoscopy implant stent,52282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,2506.35,15482.25,APC
Cystoscopy implant stent,52282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,2506.35,15482.25,Radiology
Cystoscopy implant stent,52282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,2506.35,15482.25,APC
Cystoscopy implant stent,52282,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,2506.35,15482.25,APC
Cystoscopy and treatment,52283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3830.53,,,,,,,fee schedule,2069.41,9181.28,
Cystoscopy and treatment,52283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3070.5,,,,,,,fee schedule,2069.41,9181.28,
Cystoscopy and treatment,52283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3354.24,,,,,,,fee schedule,2069.41,9181.28,
Cystoscopy and treatment,52283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3526.52,,,,,,,fee schedule,2069.41,9181.28,
Cystoscopy and treatment,52283,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9181.28,,,,,,,fee schedule,2069.41,9181.28,APC 378
Cystoscopy and treatment,52283,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2172.88,,,,,,,fee schedule,2069.41,9181.28,APC
Cystoscopy and treatment,52283,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2152.19,,,,,,,fee schedule,2069.41,9181.28,APC
Cystoscopy and treatment,52283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2069.41,,,,,,,fee schedule,2069.41,9181.28,APC
Cystoscopy and treatment,52283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3166.2,,,,,,,fee schedule,2069.41,9181.28,Radiology
Cystoscopy and treatment,52283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2897.18,,,,,,,fee schedule,2069.41,9181.28,APC
Cystoscopy and treatment,52283,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3621.47,,,,,,,fee schedule,2069.41,9181.28,APC
Cysto rx balo cath urtl strx,52284,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18655.09,,,,,,,fee schedule,5308,23549.82,
Cysto rx balo cath urtl strx,52284,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14953.69,,,,,,,fee schedule,5308,23549.82,
Cysto rx balo cath urtl strx,52284,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16335.55,,,,,,,fee schedule,5308,23549.82,
Cysto rx balo cath urtl strx,52284,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17174.53,,,,,,,fee schedule,5308,23549.82,
Cysto rx balo cath urtl strx,52284,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23549.82,,,,,,,fee schedule,5308,23549.82,APC 378
Cysto rx balo cath urtl strx,52284,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5573.4,,,,,,,fee schedule,5308,23549.82,APC
Cysto rx balo cath urtl strx,52284,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5520.32,,,,,,,fee schedule,5308,23549.82,APC
Cysto rx balo cath urtl strx,52284,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5308,,,,,,,fee schedule,5308,23549.82,APC
Cysto rx balo cath urtl strx,52284,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8121.25,,,,,,,fee schedule,5308,23549.82,Radiology
Cysto rx balo cath urtl strx,52284,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7431.21,,,,,,,fee schedule,5308,23549.82,APC
Cysto rx balo cath urtl strx,52284,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9289.01,,,,,,,fee schedule,5308,23549.82,APC
Cystoscopy and treatment,52285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4477.9,,,,,,,fee schedule,690.3,4477.9,
Cystoscopy and treatment,52285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3589.43,,,,,,,fee schedule,690.3,4477.9,
Cystoscopy and treatment,52285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3921.13,,,,,,,fee schedule,690.3,4477.9,
Cystoscopy and treatment,52285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4122.51,,,,,,,fee schedule,690.3,4477.9,
Cystoscopy and treatment,52285,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3062.63,,,,,,,fee schedule,690.3,4477.9,APC 378
Cystoscopy and treatment,52285,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,724.82,,,,,,,fee schedule,690.3,4477.9,APC
Cystoscopy and treatment,52285,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,717.91,,,,,,,fee schedule,690.3,4477.9,APC
Cystoscopy and treatment,52285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,690.3,,,,,,,fee schedule,690.3,4477.9,APC
Cystoscopy and treatment,52285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1056.16,,,,,,,fee schedule,690.3,4477.9,Radiology
Cystoscopy and treatment,52285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,966.42,,,,,,,fee schedule,690.3,4477.9,APC
Cystoscopy and treatment,52285,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1208.03,,,,,,,fee schedule,690.3,4477.9,APC
Cystoscopy chemodenervation,52287,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4276.2,,,,,,,fee schedule,2069.41,9181.28,
Cystoscopy chemodenervation,52287,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3427.75,,,,,,,fee schedule,2069.41,9181.28,
Cystoscopy chemodenervation,52287,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3744.5,,,,,,,fee schedule,2069.41,9181.28,
Cystoscopy chemodenervation,52287,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3936.82,,,,,,,fee schedule,2069.41,9181.28,
Cystoscopy chemodenervation,52287,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9181.28,,,,,,,fee schedule,2069.41,9181.28,APC 378
Cystoscopy chemodenervation,52287,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2172.88,,,,,,,fee schedule,2069.41,9181.28,APC
Cystoscopy chemodenervation,52287,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2152.19,,,,,,,fee schedule,2069.41,9181.28,APC
Cystoscopy chemodenervation,52287,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2069.41,,,,,,,fee schedule,2069.41,9181.28,APC
Cystoscopy chemodenervation,52287,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3166.2,,,,,,,fee schedule,2069.41,9181.28,Radiology
Cystoscopy chemodenervation,52287,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2897.18,,,,,,,fee schedule,2069.41,9181.28,APC
Cystoscopy chemodenervation,52287,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3621.47,,,,,,,fee schedule,2069.41,9181.28,APC
Cystoscopy and treatment,52290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4477.9,,,,,,,fee schedule,2069.41,9181.28,
Cystoscopy and treatment,52290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3589.43,,,,,,,fee schedule,2069.41,9181.28,
Cystoscopy and treatment,52290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3921.13,,,,,,,fee schedule,2069.41,9181.28,
Cystoscopy and treatment,52290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4122.51,,,,,,,fee schedule,2069.41,9181.28,
Cystoscopy and treatment,52290,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9181.28,,,,,,,fee schedule,2069.41,9181.28,APC 378
Cystoscopy and treatment,52290,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2172.88,,,,,,,fee schedule,2069.41,9181.28,APC
Cystoscopy and treatment,52290,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2152.19,,,,,,,fee schedule,2069.41,9181.28,APC
Cystoscopy and treatment,52290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2069.41,,,,,,,fee schedule,2069.41,9181.28,APC
Cystoscopy and treatment,52290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3166.2,,,,,,,fee schedule,2069.41,9181.28,Radiology
Cystoscopy and treatment,52290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2897.18,,,,,,,fee schedule,2069.41,9181.28,APC
Cystoscopy and treatment,52290,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3621.47,,,,,,,fee schedule,2069.41,9181.28,APC
Cystoscopy and treatment,52300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6183.21,,,,,,,fee schedule,3489.62,15482.25,
Cystoscopy and treatment,52300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4956.38,,,,,,,fee schedule,3489.62,15482.25,
Cystoscopy and treatment,52300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5414.4,,,,,,,fee schedule,3489.62,15482.25,
Cystoscopy and treatment,52300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5692.48,,,,,,,fee schedule,3489.62,15482.25,
Cystoscopy and treatment,52300,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Cystoscopy and treatment,52300,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Cystoscopy and treatment,52300,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Cystoscopy and treatment,52300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Cystoscopy and treatment,52300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Cystoscopy and treatment,52300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Cystoscopy and treatment,52300,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Cystoscopy and treatment,52301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5785.34,,,,,,,fee schedule,3489.62,15482.25,
Cystoscopy and treatment,52301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4637.46,,,,,,,fee schedule,3489.62,15482.25,
Cystoscopy and treatment,52301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5066,,,,,,,fee schedule,3489.62,15482.25,
Cystoscopy and treatment,52301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5326.19,,,,,,,fee schedule,3489.62,15482.25,
Cystoscopy and treatment,52301,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Cystoscopy and treatment,52301,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Cystoscopy and treatment,52301,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Cystoscopy and treatment,52301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Cystoscopy and treatment,52301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Cystoscopy and treatment,52301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Cystoscopy and treatment,52301,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Cystoscopy and treatment,52305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6183.21,,,,,,,fee schedule,4956.38,23549.82,
Cystoscopy and treatment,52305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4956.38,,,,,,,fee schedule,4956.38,23549.82,
Cystoscopy and treatment,52305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5414.4,,,,,,,fee schedule,4956.38,23549.82,
Cystoscopy and treatment,52305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5692.48,,,,,,,fee schedule,4956.38,23549.82,
Cystoscopy and treatment,52305,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23549.82,,,,,,,fee schedule,4956.38,23549.82,APC 378
Cystoscopy and treatment,52305,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5573.4,,,,,,,fee schedule,4956.38,23549.82,APC
Cystoscopy and treatment,52305,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5520.32,,,,,,,fee schedule,4956.38,23549.82,APC
Cystoscopy and treatment,52305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5308,,,,,,,fee schedule,4956.38,23549.82,APC
Cystoscopy and treatment,52305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8121.25,,,,,,,fee schedule,4956.38,23549.82,Radiology
Cystoscopy and treatment,52305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7431.21,,,,,,,fee schedule,4956.38,23549.82,APC
Cystoscopy and treatment,52305,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9289.01,,,,,,,fee schedule,4956.38,23549.82,APC
Cystoscopy and treatment,52310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5561.04,,,,,,,fee schedule,2069.41,9181.28,
Cystoscopy and treatment,52310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4457.66,,,,,,,fee schedule,2069.41,9181.28,
Cystoscopy and treatment,52310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4869.58,,,,,,,fee schedule,2069.41,9181.28,
Cystoscopy and treatment,52310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5119.68,,,,,,,fee schedule,2069.41,9181.28,
Cystoscopy and treatment,52310,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9181.28,,,,,,,fee schedule,2069.41,9181.28,APC 378
Cystoscopy and treatment,52310,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2172.88,,,,,,,fee schedule,2069.41,9181.28,APC
Cystoscopy and treatment,52310,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2152.19,,,,,,,fee schedule,2069.41,9181.28,APC
Cystoscopy and treatment,52310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2069.41,,,,,,,fee schedule,2069.41,9181.28,APC
Cystoscopy and treatment,52310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3166.2,,,,,,,fee schedule,2069.41,9181.28,Radiology
Cystoscopy and treatment,52310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2897.18,,,,,,,fee schedule,2069.41,9181.28,APC
Cystoscopy and treatment,52310,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3621.47,,,,,,,fee schedule,2069.41,9181.28,APC
Cystoscopy and treatment,52315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4214.48,,,,,,,fee schedule,2069.41,9181.28,
Cystoscopy and treatment,52315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3378.27,,,,,,,fee schedule,2069.41,9181.28,
Cystoscopy and treatment,52315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3690.46,,,,,,,fee schedule,2069.41,9181.28,
Cystoscopy and treatment,52315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3880,,,,,,,fee schedule,2069.41,9181.28,
Cystoscopy and treatment,52315,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9181.28,,,,,,,fee schedule,2069.41,9181.28,APC 378
Cystoscopy and treatment,52315,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2172.88,,,,,,,fee schedule,2069.41,9181.28,APC
Cystoscopy and treatment,52315,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2152.19,,,,,,,fee schedule,2069.41,9181.28,APC
Cystoscopy and treatment,52315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2069.41,,,,,,,fee schedule,2069.41,9181.28,APC
Cystoscopy and treatment,52315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3166.2,,,,,,,fee schedule,2069.41,9181.28,Radiology
Cystoscopy and treatment,52315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2897.18,,,,,,,fee schedule,2069.41,9181.28,APC
Cystoscopy and treatment,52315,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3621.47,,,,,,,fee schedule,2069.41,9181.28,APC
Remove bladder stone,52317,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6069.42,,,,,,,fee schedule,3489.62,15482.25,
Remove bladder stone,52317,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4865.17,,,,,,,fee schedule,3489.62,15482.25,
Remove bladder stone,52317,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5314.76,,,,,,,fee schedule,3489.62,15482.25,
Remove bladder stone,52317,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5587.72,,,,,,,fee schedule,3489.62,15482.25,
Remove bladder stone,52317,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Remove bladder stone,52317,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Remove bladder stone,52317,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Remove bladder stone,52317,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Remove bladder stone,52317,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Remove bladder stone,52317,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Remove bladder stone,52317,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Remove bladder stone,52318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8125.92,,,,,,,fee schedule,3489.62,15482.25,
Remove bladder stone,52318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6513.63,,,,,,,fee schedule,3489.62,15482.25,
Remove bladder stone,52318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7115.55,,,,,,,fee schedule,3489.62,15482.25,
Remove bladder stone,52318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7481,,,,,,,fee schedule,3489.62,15482.25,
Remove bladder stone,52318,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Remove bladder stone,52318,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Remove bladder stone,52318,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Remove bladder stone,52318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Remove bladder stone,52318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Remove bladder stone,52318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Remove bladder stone,52318,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Cystoscopy and treatment,52320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4297.02,,,,,,,fee schedule,3444.43,15482.25,
Cystoscopy and treatment,52320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3444.43,,,,,,,fee schedule,3444.43,15482.25,
Cystoscopy and treatment,52320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3762.73,,,,,,,fee schedule,3444.43,15482.25,
Cystoscopy and treatment,52320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3955.98,,,,,,,fee schedule,3444.43,15482.25,
Cystoscopy and treatment,52320,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3444.43,15482.25,APC 378
Cystoscopy and treatment,52320,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3444.43,15482.25,APC
Cystoscopy and treatment,52320,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3444.43,15482.25,APC
Cystoscopy and treatment,52320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3444.43,15482.25,APC
Cystoscopy and treatment,52320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3444.43,15482.25,Radiology
Cystoscopy and treatment,52320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3444.43,15482.25,APC
Cystoscopy and treatment,52320,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3444.43,15482.25,APC
Cystoscopy stone removal,52325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6183.21,,,,,,,fee schedule,4956.38,23549.82,
Cystoscopy stone removal,52325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4956.38,,,,,,,fee schedule,4956.38,23549.82,
Cystoscopy stone removal,52325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5414.4,,,,,,,fee schedule,4956.38,23549.82,
Cystoscopy stone removal,52325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5692.48,,,,,,,fee schedule,4956.38,23549.82,
Cystoscopy stone removal,52325,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23549.82,,,,,,,fee schedule,4956.38,23549.82,APC 378
Cystoscopy stone removal,52325,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5573.4,,,,,,,fee schedule,4956.38,23549.82,APC
Cystoscopy stone removal,52325,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5520.32,,,,,,,fee schedule,4956.38,23549.82,APC
Cystoscopy stone removal,52325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5308,,,,,,,fee schedule,4956.38,23549.82,APC
Cystoscopy stone removal,52325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8121.25,,,,,,,fee schedule,4956.38,23549.82,Radiology
Cystoscopy stone removal,52325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7431.21,,,,,,,fee schedule,4956.38,23549.82,APC
Cystoscopy stone removal,52325,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9289.01,,,,,,,fee schedule,4956.38,23549.82,APC
Cystoscopy inject material,52327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6183.21,,,,,,,fee schedule,4956.38,23549.82,
Cystoscopy inject material,52327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4956.38,,,,,,,fee schedule,4956.38,23549.82,
Cystoscopy inject material,52327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5414.4,,,,,,,fee schedule,4956.38,23549.82,
Cystoscopy inject material,52327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5692.48,,,,,,,fee schedule,4956.38,23549.82,
Cystoscopy inject material,52327,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23549.82,,,,,,,fee schedule,4956.38,23549.82,APC 378
Cystoscopy inject material,52327,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5573.4,,,,,,,fee schedule,4956.38,23549.82,APC
Cystoscopy inject material,52327,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5520.32,,,,,,,fee schedule,4956.38,23549.82,APC
Cystoscopy inject material,52327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5308,,,,,,,fee schedule,4956.38,23549.82,APC
Cystoscopy inject material,52327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8121.25,,,,,,,fee schedule,4956.38,23549.82,Radiology
Cystoscopy inject material,52327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7431.21,,,,,,,fee schedule,4956.38,23549.82,APC
Cystoscopy inject material,52327,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9289.01,,,,,,,fee schedule,4956.38,23549.82,APC
Cystoscopy and treatment,52330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6183.21,,,,,,,fee schedule,3489.62,15482.25,
Cystoscopy and treatment,52330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4956.38,,,,,,,fee schedule,3489.62,15482.25,
Cystoscopy and treatment,52330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5414.4,,,,,,,fee schedule,3489.62,15482.25,
Cystoscopy and treatment,52330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5692.48,,,,,,,fee schedule,3489.62,15482.25,
Cystoscopy and treatment,52330,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Cystoscopy and treatment,52330,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Cystoscopy and treatment,52330,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Cystoscopy and treatment,52330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Cystoscopy and treatment,52330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Cystoscopy and treatment,52330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Cystoscopy and treatment,52330,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Cystoscopy and treatment,52332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4508.29,,,,,,,fee schedule,3489.62,15482.25,
Cystoscopy and treatment,52332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3613.79,,,,,,,fee schedule,3489.62,15482.25,
Cystoscopy and treatment,52332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3947.73,,,,,,,fee schedule,3489.62,15482.25,
Cystoscopy and treatment,52332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4150.49,,,,,,,fee schedule,3489.62,15482.25,
Cystoscopy and treatment,52332,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Cystoscopy and treatment,52332,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Cystoscopy and treatment,52332,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Cystoscopy and treatment,52332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Cystoscopy and treatment,52332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Cystoscopy and treatment,52332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Cystoscopy and treatment,52332,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Create passage to kidney,52334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6183.21,,,,,,,fee schedule,3489.62,15482.25,
Create passage to kidney,52334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4956.38,,,,,,,fee schedule,3489.62,15482.25,
Create passage to kidney,52334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5414.4,,,,,,,fee schedule,3489.62,15482.25,
Create passage to kidney,52334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5692.48,,,,,,,fee schedule,3489.62,15482.25,
Create passage to kidney,52334,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Create passage to kidney,52334,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Create passage to kidney,52334,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Create passage to kidney,52334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Create passage to kidney,52334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Create passage to kidney,52334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Create passage to kidney,52334,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Cysto W/Ureter Stricture Tx,52341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3302.27,,,,,,,fee schedule,2647.06,15482.25,
Cysto W/Ureter Stricture Tx,52341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2647.06,,,,,,,fee schedule,2647.06,15482.25,
Cysto W/Ureter Stricture Tx,52341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2891.67,,,,,,,fee schedule,2647.06,15482.25,
Cysto W/Ureter Stricture Tx,52341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3040.19,,,,,,,fee schedule,2647.06,15482.25,
Cysto W/Ureter Stricture Tx,52341,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,2647.06,15482.25,APC 378
Cysto W/Ureter Stricture Tx,52341,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,2647.06,15482.25,APC
Cysto W/Ureter Stricture Tx,52341,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,2647.06,15482.25,APC
Cysto W/Ureter Stricture Tx,52341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,2647.06,15482.25,APC
Cysto W/Ureter Stricture Tx,52341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,2647.06,15482.25,Radiology
Cysto W/Ureter Stricture Tx,52341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,2647.06,15482.25,APC
Cysto W/Ureter Stricture Tx,52341,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,2647.06,15482.25,APC
Cysto W/Up Stricture Tx,52342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6183.21,,,,,,,fee schedule,3489.62,15482.25,
Cysto W/Up Stricture Tx,52342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4956.38,,,,,,,fee schedule,3489.62,15482.25,
Cysto W/Up Stricture Tx,52342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5414.4,,,,,,,fee schedule,3489.62,15482.25,
Cysto W/Up Stricture Tx,52342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5692.48,,,,,,,fee schedule,3489.62,15482.25,
Cysto W/Up Stricture Tx,52342,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Cysto W/Up Stricture Tx,52342,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Cysto W/Up Stricture Tx,52342,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Cysto W/Up Stricture Tx,52342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Cysto W/Up Stricture Tx,52342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Cysto W/Up Stricture Tx,52342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Cysto W/Up Stricture Tx,52342,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Cysto W/Renal Stricture Tx,52343,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6183.21,,,,,,,fee schedule,3489.62,15482.25,
Cysto W/Renal Stricture Tx,52343,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4956.38,,,,,,,fee schedule,3489.62,15482.25,
Cysto W/Renal Stricture Tx,52343,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5414.4,,,,,,,fee schedule,3489.62,15482.25,
Cysto W/Renal Stricture Tx,52343,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5692.48,,,,,,,fee schedule,3489.62,15482.25,
Cysto W/Renal Stricture Tx,52343,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Cysto W/Renal Stricture Tx,52343,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Cysto W/Renal Stricture Tx,52343,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Cysto W/Renal Stricture Tx,52343,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Cysto W/Renal Stricture Tx,52343,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Cysto W/Renal Stricture Tx,52343,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Cysto W/Renal Stricture Tx,52343,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Cysto/uretero stricture tx,52344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3061.21,,,,,,,fee schedule,2453.83,15482.25,
Cysto/uretero stricture tx,52344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2453.83,,,,,,,fee schedule,2453.83,15482.25,
Cysto/uretero stricture tx,52344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2680.59,,,,,,,fee schedule,2453.83,15482.25,
Cysto/uretero stricture tx,52344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2818.26,,,,,,,fee schedule,2453.83,15482.25,
Cysto/uretero stricture tx,52344,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,2453.83,15482.25,APC 378
Cysto/uretero stricture tx,52344,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,2453.83,15482.25,APC
Cysto/uretero stricture tx,52344,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,2453.83,15482.25,APC
Cysto/uretero stricture tx,52344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,2453.83,15482.25,APC
Cysto/uretero stricture tx,52344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,2453.83,15482.25,Radiology
Cysto/uretero stricture tx,52344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,2453.83,15482.25,APC
Cysto/uretero stricture tx,52344,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,2453.83,15482.25,APC
Cysto/Uretero W/Up Stricture,52345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4062.96,,,,,,,fee schedule,3256.82,15482.25,
Cysto/Uretero W/Up Stricture,52345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3256.82,,,,,,,fee schedule,3256.82,15482.25,
Cysto/Uretero W/Up Stricture,52345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3557.78,,,,,,,fee schedule,3256.82,15482.25,
Cysto/Uretero W/Up Stricture,52345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3740.5,,,,,,,fee schedule,3256.82,15482.25,
Cysto/Uretero W/Up Stricture,52345,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3256.82,15482.25,APC 378
Cysto/Uretero W/Up Stricture,52345,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3256.82,15482.25,APC
Cysto/Uretero W/Up Stricture,52345,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3256.82,15482.25,APC
Cysto/Uretero W/Up Stricture,52345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3256.82,15482.25,APC
Cysto/Uretero W/Up Stricture,52345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3256.82,15482.25,Radiology
Cysto/Uretero W/Up Stricture,52345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3256.82,15482.25,APC
Cysto/Uretero W/Up Stricture,52345,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3256.82,15482.25,APC
Cystouretero W/Renal Strict,52346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6183.21,,,,,,,fee schedule,4956.38,23549.82,
Cystouretero W/Renal Strict,52346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4956.38,,,,,,,fee schedule,4956.38,23549.82,
Cystouretero W/Renal Strict,52346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5414.4,,,,,,,fee schedule,4956.38,23549.82,
Cystouretero W/Renal Strict,52346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5692.48,,,,,,,fee schedule,4956.38,23549.82,
Cystouretero W/Renal Strict,52346,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23549.82,,,,,,,fee schedule,4956.38,23549.82,APC 378
Cystouretero W/Renal Strict,52346,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5573.4,,,,,,,fee schedule,4956.38,23549.82,APC
Cystouretero W/Renal Strict,52346,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5520.32,,,,,,,fee schedule,4956.38,23549.82,APC
Cystouretero W/Renal Strict,52346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5308,,,,,,,fee schedule,4956.38,23549.82,APC
Cystouretero W/Renal Strict,52346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8121.25,,,,,,,fee schedule,4956.38,23549.82,Radiology
Cystouretero W/Renal Strict,52346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7431.21,,,,,,,fee schedule,4956.38,23549.82,APC
Cystouretero W/Renal Strict,52346,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9289.01,,,,,,,fee schedule,4956.38,23549.82,APC
Cystouretero & or pyeloscope,52351,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5487.68,,,,,,,fee schedule,3489.62,15482.25,
Cystouretero & or pyeloscope,52351,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4398.85,,,,,,,fee schedule,3489.62,15482.25,
Cystouretero & or pyeloscope,52351,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4805.35,,,,,,,fee schedule,3489.62,15482.25,
Cystouretero & or pyeloscope,52351,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5052.15,,,,,,,fee schedule,3489.62,15482.25,
Cystouretero & or pyeloscope,52351,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Cystouretero & or pyeloscope,52351,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Cystouretero & or pyeloscope,52351,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Cystouretero & or pyeloscope,52351,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Cystouretero & or pyeloscope,52351,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Cystouretero & or pyeloscope,52351,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Cystouretero & or pyeloscope,52351,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Cystouretero w/stone remove,52352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2761.64,,,,,,,fee schedule,2213.7,15482.25,
Cystouretero w/stone remove,52352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2213.7,,,,,,,fee schedule,2213.7,15482.25,
Cystouretero w/stone remove,52352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2418.26,,,,,,,fee schedule,2213.7,15482.25,
Cystouretero w/stone remove,52352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2542.46,,,,,,,fee schedule,2213.7,15482.25,
Cystouretero w/stone remove,52352,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,2213.7,15482.25,APC 378
Cystouretero w/stone remove,52352,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,2213.7,15482.25,APC
Cystouretero w/stone remove,52352,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,2213.7,15482.25,APC
Cystouretero w/stone remove,52352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,2213.7,15482.25,APC
Cystouretero w/stone remove,52352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,2213.7,15482.25,Radiology
Cystouretero w/stone remove,52352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,2213.7,15482.25,APC
Cystouretero w/stone remove,52352,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,2213.7,15482.25,APC
Cystouretero W/Lithotripsy,52353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8931.57,,,,,,,fee schedule,5308,23549.82,
Cystouretero W/Lithotripsy,52353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7159.44,,,,,,,fee schedule,5308,23549.82,
Cystouretero W/Lithotripsy,52353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7821.03,,,,,,,fee schedule,5308,23549.82,
Cystouretero W/Lithotripsy,52353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8222.72,,,,,,,fee schedule,5308,23549.82,
Cystouretero W/Lithotripsy,52353,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23549.82,,,,,,,fee schedule,5308,23549.82,APC 378
Cystouretero W/Lithotripsy,52353,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5573.4,,,,,,,fee schedule,5308,23549.82,APC
Cystouretero W/Lithotripsy,52353,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5520.32,,,,,,,fee schedule,5308,23549.82,APC
Cystouretero W/Lithotripsy,52353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5308,,,,,,,fee schedule,5308,23549.82,APC
Cystouretero W/Lithotripsy,52353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8121.25,,,,,,,fee schedule,5308,23549.82,Radiology
Cystouretero W/Lithotripsy,52353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7431.21,,,,,,,fee schedule,5308,23549.82,APC
Cystouretero W/Lithotripsy,52353,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9289.01,,,,,,,fee schedule,5308,23549.82,APC
Cystouretero W/Biopsy,52354,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5275.24,,,,,,,fee schedule,4228.56,23549.82,
Cystouretero W/Biopsy,52354,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4228.56,,,,,,,fee schedule,4228.56,23549.82,
Cystouretero W/Biopsy,52354,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4619.32,,,,,,,fee schedule,4228.56,23549.82,
Cystouretero W/Biopsy,52354,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4856.57,,,,,,,fee schedule,4228.56,23549.82,
Cystouretero W/Biopsy,52354,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23549.82,,,,,,,fee schedule,4228.56,23549.82,APC 378
Cystouretero W/Biopsy,52354,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5573.4,,,,,,,fee schedule,4228.56,23549.82,APC
Cystouretero W/Biopsy,52354,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5520.32,,,,,,,fee schedule,4228.56,23549.82,APC
Cystouretero W/Biopsy,52354,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5308,,,,,,,fee schedule,4228.56,23549.82,APC
Cystouretero W/Biopsy,52354,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8121.25,,,,,,,fee schedule,4228.56,23549.82,Radiology
Cystouretero W/Biopsy,52354,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7431.21,,,,,,,fee schedule,4228.56,23549.82,APC
Cystouretero W/Biopsy,52354,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9289.01,,,,,,,fee schedule,4228.56,23549.82,APC
Cystouretero W/Excise Tumor,52355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6183.21,,,,,,,fee schedule,4956.38,23549.82,
Cystouretero W/Excise Tumor,52355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4956.38,,,,,,,fee schedule,4956.38,23549.82,
Cystouretero W/Excise Tumor,52355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5414.4,,,,,,,fee schedule,4956.38,23549.82,
Cystouretero W/Excise Tumor,52355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5692.48,,,,,,,fee schedule,4956.38,23549.82,
Cystouretero W/Excise Tumor,52355,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23549.82,,,,,,,fee schedule,4956.38,23549.82,APC 378
Cystouretero W/Excise Tumor,52355,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5573.4,,,,,,,fee schedule,4956.38,23549.82,APC
Cystouretero W/Excise Tumor,52355,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5520.32,,,,,,,fee schedule,4956.38,23549.82,APC
Cystouretero W/Excise Tumor,52355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5308,,,,,,,fee schedule,4956.38,23549.82,APC
Cystouretero W/Excise Tumor,52355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8121.25,,,,,,,fee schedule,4956.38,23549.82,Radiology
Cystouretero W/Excise Tumor,52355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7431.21,,,,,,,fee schedule,4956.38,23549.82,APC
Cystouretero W/Excise Tumor,52355,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9289.01,,,,,,,fee schedule,4956.38,23549.82,APC
Cysto/uretero w/lithotripsy,52356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6777.62,,,,,,,fee schedule,5308,23549.82,
Cysto/uretero w/lithotripsy,52356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5432.85,,,,,,,fee schedule,5308,23549.82,
Cysto/uretero w/lithotripsy,52356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5934.9,,,,,,,fee schedule,5308,23549.82,
Cysto/uretero w/lithotripsy,52356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6239.71,,,,,,,fee schedule,5308,23549.82,
Cysto/uretero w/lithotripsy,52356,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23549.82,,,,,,,fee schedule,5308,23549.82,APC 378
Cysto/uretero w/lithotripsy,52356,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5573.4,,,,,,,fee schedule,5308,23549.82,APC
Cysto/uretero w/lithotripsy,52356,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5520.32,,,,,,,fee schedule,5308,23549.82,APC
Cysto/uretero w/lithotripsy,52356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5308,,,,,,,fee schedule,5308,23549.82,APC
Cysto/uretero w/lithotripsy,52356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8121.25,,,,,,,fee schedule,5308,23549.82,Radiology
Cysto/uretero w/lithotripsy,52356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7431.21,,,,,,,fee schedule,5308,23549.82,APC
Cysto/uretero w/lithotripsy,52356,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9289.01,,,,,,,fee schedule,5308,23549.82,APC
Cystouretero W/Congen Repr,52400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6183.21,,,,,,,fee schedule,3489.62,15482.25,
Cystouretero W/Congen Repr,52400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4956.38,,,,,,,fee schedule,3489.62,15482.25,
Cystouretero W/Congen Repr,52400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5414.4,,,,,,,fee schedule,3489.62,15482.25,
Cystouretero W/Congen Repr,52400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5692.48,,,,,,,fee schedule,3489.62,15482.25,
Cystouretero W/Congen Repr,52400,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Cystouretero W/Congen Repr,52400,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Cystouretero W/Congen Repr,52400,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Cystouretero W/Congen Repr,52400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Cystouretero W/Congen Repr,52400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Cystouretero W/Congen Repr,52400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Cystouretero W/Congen Repr,52400,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Cystourethro cut ejacul duct,52402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6183.21,,,,,,,fee schedule,3489.62,15482.25,
Cystourethro cut ejacul duct,52402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4956.38,,,,,,,fee schedule,3489.62,15482.25,
Cystourethro cut ejacul duct,52402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5414.4,,,,,,,fee schedule,3489.62,15482.25,
Cystourethro cut ejacul duct,52402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5692.48,,,,,,,fee schedule,3489.62,15482.25,
Cystourethro cut ejacul duct,52402,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Cystourethro cut ejacul duct,52402,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Cystourethro cut ejacul duct,52402,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Cystourethro cut ejacul duct,52402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Cystourethro cut ejacul duct,52402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Cystourethro cut ejacul duct,52402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Cystourethro cut ejacul duct,52402,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Cystourethro w/implant,52441,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,878.59,,,,,,,fee schedule,704.26,878.59,
Cystourethro w/implant,52441,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,704.26,,,,,,,fee schedule,704.26,878.59,
Cystourethro w/implant,52441,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,769.34,,,,,,,fee schedule,704.26,878.59,
Cystourethro w/implant,52441,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,808.86,,,,,,,fee schedule,704.26,878.59,
Cystourethro w/addl implant,52442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,235.08,,,,,,,fee schedule,188.44,235.08,
Cystourethro w/addl implant,52442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,188.44,,,,,,,fee schedule,188.44,235.08,
Cystourethro w/addl implant,52442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,205.85,,,,,,,fee schedule,188.44,235.08,
Cystourethro w/addl implant,52442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,216.42,,,,,,,fee schedule,188.44,235.08,
Cysto 1st trurl prst8 comis,52443,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,41578.13,,,,,,,fee schedule,9371.49,41578.13,APC 378
Cysto 1st trurl prst8 comis,52443,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9840.06,,,,,,,fee schedule,9371.49,41578.13,APC
Cysto 1st trurl prst8 comis,52443,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9746.35,,,,,,,fee schedule,9371.49,41578.13,APC
Cysto 1st trurl prst8 comis,52443,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9371.49,,,,,,,fee schedule,9371.49,41578.13,APC
Cysto 1st trurl prst8 comis,52443,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14338.38,,,,,,,fee schedule,9371.49,41578.13,Radiology
Cysto 1st trurl prst8 comis,52443,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13120.09,,,,,,,fee schedule,9371.49,41578.13,APC
Cysto 1st trurl prst8 comis,52443,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16400.11,,,,,,,fee schedule,9371.49,41578.13,APC
Incision of prostate,52450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6183.21,,,,,,,fee schedule,3489.62,15482.25,
Incision of prostate,52450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4956.38,,,,,,,fee schedule,3489.62,15482.25,
Incision of prostate,52450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5414.4,,,,,,,fee schedule,3489.62,15482.25,
Incision of prostate,52450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5692.48,,,,,,,fee schedule,3489.62,15482.25,
Incision of prostate,52450,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Incision of prostate,52450,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Incision of prostate,52450,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Incision of prostate,52450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Incision of prostate,52450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Incision of prostate,52450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Incision of prostate,52450,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Revision of bladder neck,52500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6253.46,,,,,,,fee schedule,3489.62,15482.25,
Revision of bladder neck,52500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5012.69,,,,,,,fee schedule,3489.62,15482.25,
Revision of bladder neck,52500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5475.91,,,,,,,fee schedule,3489.62,15482.25,
Revision of bladder neck,52500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5757.15,,,,,,,fee schedule,3489.62,15482.25,
Revision of bladder neck,52500,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Revision of bladder neck,52500,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Revision of bladder neck,52500,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Revision of bladder neck,52500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Revision of bladder neck,52500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Revision of bladder neck,52500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Revision of bladder neck,52500,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Trurl rbtc wtrjt rescj prst8,52597,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,41578.13,,,,,,,fee schedule,9371.49,41578.13,APC 378
Trurl rbtc wtrjt rescj prst8,52597,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9840.06,,,,,,,fee schedule,9371.49,41578.13,APC
Trurl rbtc wtrjt rescj prst8,52597,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9746.35,,,,,,,fee schedule,9371.49,41578.13,APC
Trurl rbtc wtrjt rescj prst8,52597,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9371.49,,,,,,,fee schedule,9371.49,41578.13,APC
Trurl rbtc wtrjt rescj prst8,52597,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14338.38,,,,,,,fee schedule,9371.49,41578.13,Radiology
Trurl rbtc wtrjt rescj prst8,52597,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13120.09,,,,,,,fee schedule,9371.49,41578.13,APC
Trurl rbtc wtrjt rescj prst8,52597,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16400.11,,,,,,,fee schedule,9371.49,41578.13,APC
Prostatectomy (TURP),52601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7657.8,,,,,,,fee schedule,5308,23549.82,
Prostatectomy (TURP),52601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6138.4,,,,,,,fee schedule,5308,23549.82,
Prostatectomy (TURP),52601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6705.64,,,,,,,fee schedule,5308,23549.82,
Prostatectomy (TURP),52601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7050.04,,,,,,,fee schedule,5308,23549.82,
Prostatectomy (TURP),52601,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23549.82,,,,,,,fee schedule,5308,23549.82,APC 378
Prostatectomy (TURP),52601,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5573.4,,,,,,,fee schedule,5308,23549.82,APC
Prostatectomy (TURP),52601,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5520.32,,,,,,,fee schedule,5308,23549.82,APC
Prostatectomy (TURP),52601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5308,,,,,,,fee schedule,5308,23549.82,APC
Prostatectomy (TURP),52601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8121.25,,,,,,,fee schedule,5308,23549.82,Radiology
Prostatectomy (TURP),52601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7431.21,,,,,,,fee schedule,5308,23549.82,APC
Prostatectomy (TURP),52601,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9289.01,,,,,,,fee schedule,5308,23549.82,APC
Remove prostate regrowth,52630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7657.8,,,,,,,fee schedule,5308,23549.82,
Remove prostate regrowth,52630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6138.4,,,,,,,fee schedule,5308,23549.82,
Remove prostate regrowth,52630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6705.64,,,,,,,fee schedule,5308,23549.82,
Remove prostate regrowth,52630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7050.04,,,,,,,fee schedule,5308,23549.82,
Remove prostate regrowth,52630,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23549.82,,,,,,,fee schedule,5308,23549.82,APC 378
Remove prostate regrowth,52630,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5573.4,,,,,,,fee schedule,5308,23549.82,APC
Remove prostate regrowth,52630,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5520.32,,,,,,,fee schedule,5308,23549.82,APC
Remove prostate regrowth,52630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5308,,,,,,,fee schedule,5308,23549.82,APC
Remove prostate regrowth,52630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8121.25,,,,,,,fee schedule,5308,23549.82,Radiology
Remove prostate regrowth,52630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7431.21,,,,,,,fee schedule,5308,23549.82,APC
Remove prostate regrowth,52630,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9289.01,,,,,,,fee schedule,5308,23549.82,APC
Relieve bladder contracture,52640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6183.21,,,,,,,fee schedule,3489.62,15482.25,
Relieve bladder contracture,52640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4956.38,,,,,,,fee schedule,3489.62,15482.25,
Relieve bladder contracture,52640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5414.4,,,,,,,fee schedule,3489.62,15482.25,
Relieve bladder contracture,52640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5692.48,,,,,,,fee schedule,3489.62,15482.25,
Relieve bladder contracture,52640,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Relieve bladder contracture,52640,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Relieve bladder contracture,52640,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Relieve bladder contracture,52640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Relieve bladder contracture,52640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Relieve bladder contracture,52640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Relieve bladder contracture,52640,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Laser surgery of prostate,52647,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11281.86,,,,,,,fee schedule,9043.4,11281.86,
Laser surgery of prostate,52647,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9043.4,,,,,,,fee schedule,9043.4,11281.86,
Laser surgery of prostate,52647,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9879.09,,,,,,,fee schedule,9043.4,11281.86,
Laser surgery of prostate,52647,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10386.48,,,,,,,fee schedule,9043.4,11281.86,
Laser surgery of prostate,52648,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7306.71,,,,,,,fee schedule,5308,23549.82,
Laser surgery of prostate,52648,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5856.97,,,,,,,fee schedule,5308,23549.82,
Laser surgery of prostate,52648,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6398.21,,,,,,,fee schedule,5308,23549.82,
Laser surgery of prostate,52648,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6726.82,,,,,,,fee schedule,5308,23549.82,
Laser surgery of prostate,52648,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23549.82,,,,,,,fee schedule,5308,23549.82,APC 378
Laser surgery of prostate,52648,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5573.4,,,,,,,fee schedule,5308,23549.82,APC
Laser surgery of prostate,52648,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5520.32,,,,,,,fee schedule,5308,23549.82,APC
Laser surgery of prostate,52648,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5308,,,,,,,fee schedule,5308,23549.82,APC
Laser surgery of prostate,52648,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8121.25,,,,,,,fee schedule,5308,23549.82,Radiology
Laser surgery of prostate,52648,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7431.21,,,,,,,fee schedule,5308,23549.82,APC
Laser surgery of prostate,52648,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9289.01,,,,,,,fee schedule,5308,23549.82,APC
Prostate laser enucleation,52649,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11281.86,,,,,,,fee schedule,5308,23549.82,
Prostate laser enucleation,52649,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9043.4,,,,,,,fee schedule,5308,23549.82,
Prostate laser enucleation,52649,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9879.09,,,,,,,fee schedule,5308,23549.82,
Prostate laser enucleation,52649,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10386.48,,,,,,,fee schedule,5308,23549.82,
Prostate laser enucleation,52649,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23549.82,,,,,,,fee schedule,5308,23549.82,APC 378
Prostate laser enucleation,52649,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5573.4,,,,,,,fee schedule,5308,23549.82,APC
Prostate laser enucleation,52649,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5520.32,,,,,,,fee schedule,5308,23549.82,APC
Prostate laser enucleation,52649,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5308,,,,,,,fee schedule,5308,23549.82,APC
Prostate laser enucleation,52649,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8121.25,,,,,,,fee schedule,5308,23549.82,Radiology
Prostate laser enucleation,52649,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7431.21,,,,,,,fee schedule,5308,23549.82,APC
Prostate laser enucleation,52649,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9289.01,,,,,,,fee schedule,5308,23549.82,APC
Drainage of prostate abscess,52700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6183.21,,,,,,,fee schedule,3489.62,15482.25,
Drainage of prostate abscess,52700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4956.38,,,,,,,fee schedule,3489.62,15482.25,
Drainage of prostate abscess,52700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5414.4,,,,,,,fee schedule,3489.62,15482.25,
Drainage of prostate abscess,52700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5692.48,,,,,,,fee schedule,3489.62,15482.25,
Drainage of prostate abscess,52700,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Drainage of prostate abscess,52700,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Drainage of prostate abscess,52700,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Drainage of prostate abscess,52700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Drainage of prostate abscess,52700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Drainage of prostate abscess,52700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Drainage of prostate abscess,52700,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Incision of urethra,53000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4779.47,,,,,,,fee schedule,2069.41,9181.28,
Incision of urethra,53000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3831.16,,,,,,,fee schedule,2069.41,9181.28,
Incision of urethra,53000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4185.2,,,,,,,fee schedule,2069.41,9181.28,
Incision of urethra,53000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4400.15,,,,,,,fee schedule,2069.41,9181.28,
Incision of urethra,53000,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9181.28,,,,,,,fee schedule,2069.41,9181.28,APC 378
Incision of urethra,53000,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2172.88,,,,,,,fee schedule,2069.41,9181.28,APC
Incision of urethra,53000,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2152.19,,,,,,,fee schedule,2069.41,9181.28,APC
Incision of urethra,53000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2069.41,,,,,,,fee schedule,2069.41,9181.28,APC
Incision of urethra,53000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3166.2,,,,,,,fee schedule,2069.41,9181.28,Radiology
Incision of urethra,53000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2897.18,,,,,,,fee schedule,2069.41,9181.28,APC
Incision of urethra,53000,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3621.47,,,,,,,fee schedule,2069.41,9181.28,APC
Incision of urethra,53010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4779.47,,,,,,,fee schedule,3831.16,23549.82,
Incision of urethra,53010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3831.16,,,,,,,fee schedule,3831.16,23549.82,
Incision of urethra,53010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4185.2,,,,,,,fee schedule,3831.16,23549.82,
Incision of urethra,53010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4400.15,,,,,,,fee schedule,3831.16,23549.82,
Incision of urethra,53010,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23549.82,,,,,,,fee schedule,3831.16,23549.82,APC 378
Incision of urethra,53010,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5573.4,,,,,,,fee schedule,3831.16,23549.82,APC
Incision of urethra,53010,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5520.32,,,,,,,fee schedule,3831.16,23549.82,APC
Incision of urethra,53010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5308,,,,,,,fee schedule,3831.16,23549.82,APC
Incision of urethra,53010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8121.25,,,,,,,fee schedule,3831.16,23549.82,Radiology
Incision of urethra,53010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7431.21,,,,,,,fee schedule,3831.16,23549.82,APC
Incision of urethra,53010,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9289.01,,,,,,,fee schedule,3831.16,23549.82,APC
Incision of urethra,53020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5785.34,,,,,,,fee schedule,2069.41,9181.28,
Incision of urethra,53020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4637.46,,,,,,,fee schedule,2069.41,9181.28,
Incision of urethra,53020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5066,,,,,,,fee schedule,2069.41,9181.28,
Incision of urethra,53020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5326.19,,,,,,,fee schedule,2069.41,9181.28,
Incision of urethra,53020,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9181.28,,,,,,,fee schedule,2069.41,9181.28,APC 378
Incision of urethra,53020,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2172.88,,,,,,,fee schedule,2069.41,9181.28,APC
Incision of urethra,53020,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2152.19,,,,,,,fee schedule,2069.41,9181.28,APC
Incision of urethra,53020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2069.41,,,,,,,fee schedule,2069.41,9181.28,APC
Incision of urethra,53020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3166.2,,,,,,,fee schedule,2069.41,9181.28,Radiology
Incision of urethra,53020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2897.18,,,,,,,fee schedule,2069.41,9181.28,APC
Incision of urethra,53020,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3621.47,,,,,,,fee schedule,2069.41,9181.28,APC
Incision of urethra,53025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4779.47,,,,,,,fee schedule,2069.41,9181.28,
Incision of urethra,53025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3831.16,,,,,,,fee schedule,2069.41,9181.28,
Incision of urethra,53025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4185.2,,,,,,,fee schedule,2069.41,9181.28,
Incision of urethra,53025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4400.15,,,,,,,fee schedule,2069.41,9181.28,
Incision of urethra,53025,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9181.28,,,,,,,fee schedule,2069.41,9181.28,APC 378
Incision of urethra,53025,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2172.88,,,,,,,fee schedule,2069.41,9181.28,APC
Incision of urethra,53025,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2152.19,,,,,,,fee schedule,2069.41,9181.28,APC
Incision of urethra,53025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2069.41,,,,,,,fee schedule,2069.41,9181.28,APC
Incision of urethra,53025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3166.2,,,,,,,fee schedule,2069.41,9181.28,Radiology
Incision of urethra,53025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2897.18,,,,,,,fee schedule,2069.41,9181.28,APC
Incision of urethra,53025,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3621.47,,,,,,,fee schedule,2069.41,9181.28,APC
Drainage of urethra abscess,53040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4779.47,,,,,,,fee schedule,3489.62,15482.25,
Drainage of urethra abscess,53040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3831.16,,,,,,,fee schedule,3489.62,15482.25,
Drainage of urethra abscess,53040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4185.2,,,,,,,fee schedule,3489.62,15482.25,
Drainage of urethra abscess,53040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4400.15,,,,,,,fee schedule,3489.62,15482.25,
Drainage of urethra abscess,53040,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Drainage of urethra abscess,53040,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Drainage of urethra abscess,53040,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Drainage of urethra abscess,53040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Drainage of urethra abscess,53040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Drainage of urethra abscess,53040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Drainage of urethra abscess,53040,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Drainage of urethra abscess,53060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4779.47,,,,,,,fee schedule,2069.41,9181.28,
Drainage of urethra abscess,53060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3831.16,,,,,,,fee schedule,2069.41,9181.28,
Drainage of urethra abscess,53060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4185.2,,,,,,,fee schedule,2069.41,9181.28,
Drainage of urethra abscess,53060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4400.15,,,,,,,fee schedule,2069.41,9181.28,
Drainage of urethra abscess,53060,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9181.28,,,,,,,fee schedule,2069.41,9181.28,APC 378
Drainage of urethra abscess,53060,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2172.88,,,,,,,fee schedule,2069.41,9181.28,APC
Drainage of urethra abscess,53060,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2152.19,,,,,,,fee schedule,2069.41,9181.28,APC
Drainage of urethra abscess,53060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2069.41,,,,,,,fee schedule,2069.41,9181.28,APC
Drainage of urethra abscess,53060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3166.2,,,,,,,fee schedule,2069.41,9181.28,Radiology
Drainage of urethra abscess,53060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2897.18,,,,,,,fee schedule,2069.41,9181.28,APC
Drainage of urethra abscess,53060,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3621.47,,,,,,,fee schedule,2069.41,9181.28,APC
Drainage of urinary leakage,53080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4779.47,,,,,,,fee schedule,690.3,4779.47,
Drainage of urinary leakage,53080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3831.16,,,,,,,fee schedule,690.3,4779.47,
Drainage of urinary leakage,53080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4185.2,,,,,,,fee schedule,690.3,4779.47,
Drainage of urinary leakage,53080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4400.15,,,,,,,fee schedule,690.3,4779.47,
Drainage of urinary leakage,53080,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3062.63,,,,,,,fee schedule,690.3,4779.47,APC 378
Drainage of urinary leakage,53080,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,724.82,,,,,,,fee schedule,690.3,4779.47,APC
Drainage of urinary leakage,53080,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,717.91,,,,,,,fee schedule,690.3,4779.47,APC
Drainage of urinary leakage,53080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,690.3,,,,,,,fee schedule,690.3,4779.47,APC
Drainage of urinary leakage,53080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1056.16,,,,,,,fee schedule,690.3,4779.47,Radiology
Drainage of urinary leakage,53080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,966.42,,,,,,,fee schedule,690.3,4779.47,APC
Drainage of urinary leakage,53080,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1208.03,,,,,,,fee schedule,690.3,4779.47,APC
Drainage of urinary leakage,53085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4779.47,,,,,,,fee schedule,2069.41,9181.28,
Drainage of urinary leakage,53085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3831.16,,,,,,,fee schedule,2069.41,9181.28,
Drainage of urinary leakage,53085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4185.2,,,,,,,fee schedule,2069.41,9181.28,
Drainage of urinary leakage,53085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4400.15,,,,,,,fee schedule,2069.41,9181.28,
Drainage of urinary leakage,53085,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9181.28,,,,,,,fee schedule,2069.41,9181.28,APC 378
Drainage of urinary leakage,53085,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2172.88,,,,,,,fee schedule,2069.41,9181.28,APC
Drainage of urinary leakage,53085,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2152.19,,,,,,,fee schedule,2069.41,9181.28,APC
Drainage of urinary leakage,53085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2069.41,,,,,,,fee schedule,2069.41,9181.28,APC
Drainage of urinary leakage,53085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3166.2,,,,,,,fee schedule,2069.41,9181.28,Radiology
Drainage of urinary leakage,53085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2897.18,,,,,,,fee schedule,2069.41,9181.28,APC
Drainage of urinary leakage,53085,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3621.47,,,,,,,fee schedule,2069.41,9181.28,APC
Biopsy of urethra,53200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4779.47,,,,,,,fee schedule,2069.41,9181.28,
Biopsy of urethra,53200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3831.16,,,,,,,fee schedule,2069.41,9181.28,
Biopsy of urethra,53200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4185.2,,,,,,,fee schedule,2069.41,9181.28,
Biopsy of urethra,53200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4400.15,,,,,,,fee schedule,2069.41,9181.28,
Biopsy of urethra,53200,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9181.28,,,,,,,fee schedule,2069.41,9181.28,APC 378
Biopsy of urethra,53200,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2172.88,,,,,,,fee schedule,2069.41,9181.28,APC
Biopsy of urethra,53200,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2152.19,,,,,,,fee schedule,2069.41,9181.28,APC
Biopsy of urethra,53200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2069.41,,,,,,,fee schedule,2069.41,9181.28,APC
Biopsy of urethra,53200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3166.2,,,,,,,fee schedule,2069.41,9181.28,Radiology
Biopsy of urethra,53200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2897.18,,,,,,,fee schedule,2069.41,9181.28,APC
Biopsy of urethra,53200,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3621.47,,,,,,,fee schedule,2069.41,9181.28,APC
Removal of urethra,53210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3828.9,,,,,,,fee schedule,3069.2,15482.25,
Removal of urethra,53210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3069.2,,,,,,,fee schedule,3069.2,15482.25,
Removal of urethra,53210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3352.82,,,,,,,fee schedule,3069.2,15482.25,
Removal of urethra,53210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3525.02,,,,,,,fee schedule,3069.2,15482.25,
Removal of urethra,53210,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3069.2,15482.25,APC 378
Removal of urethra,53210,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3069.2,15482.25,APC
Removal of urethra,53210,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3069.2,15482.25,APC
Removal of urethra,53210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3069.2,15482.25,APC
Removal of urethra,53210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3069.2,15482.25,Radiology
Removal of urethra,53210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3069.2,15482.25,APC
Removal of urethra,53210,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3069.2,15482.25,APC
Removal of urethra,53215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4779.47,,,,,,,fee schedule,3831.16,23549.82,
Removal of urethra,53215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3831.16,,,,,,,fee schedule,3831.16,23549.82,
Removal of urethra,53215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4185.2,,,,,,,fee schedule,3831.16,23549.82,
Removal of urethra,53215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4400.15,,,,,,,fee schedule,3831.16,23549.82,
Removal of urethra,53215,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23549.82,,,,,,,fee schedule,3831.16,23549.82,APC 378
Removal of urethra,53215,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5573.4,,,,,,,fee schedule,3831.16,23549.82,APC
Removal of urethra,53215,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5520.32,,,,,,,fee schedule,3831.16,23549.82,APC
Removal of urethra,53215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5308,,,,,,,fee schedule,3831.16,23549.82,APC
Removal of urethra,53215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8121.25,,,,,,,fee schedule,3831.16,23549.82,Radiology
Removal of urethra,53215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7431.21,,,,,,,fee schedule,3831.16,23549.82,APC
Removal of urethra,53215,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9289.01,,,,,,,fee schedule,3831.16,23549.82,APC
Treatment of urethra lesion,53220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7433.94,,,,,,,fee schedule,3489.62,15482.25,
Treatment of urethra lesion,53220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5958.95,,,,,,,fee schedule,3489.62,15482.25,
Treatment of urethra lesion,53220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6509.61,,,,,,,fee schedule,3489.62,15482.25,
Treatment of urethra lesion,53220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6843.94,,,,,,,fee schedule,3489.62,15482.25,
Treatment of urethra lesion,53220,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Treatment of urethra lesion,53220,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Treatment of urethra lesion,53220,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Treatment of urethra lesion,53220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Treatment of urethra lesion,53220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Treatment of urethra lesion,53220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Treatment of urethra lesion,53220,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Removal of urethra lesion,53230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5233.25,,,,,,,fee schedule,4194.9,23549.82,
Removal of urethra lesion,53230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4194.9,,,,,,,fee schedule,4194.9,23549.82,
Removal of urethra lesion,53230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4582.55,,,,,,,fee schedule,4194.9,23549.82,
Removal of urethra lesion,53230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4817.91,,,,,,,fee schedule,4194.9,23549.82,
Removal of urethra lesion,53230,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23549.82,,,,,,,fee schedule,4194.9,23549.82,APC 378
Removal of urethra lesion,53230,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5573.4,,,,,,,fee schedule,4194.9,23549.82,APC
Removal of urethra lesion,53230,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5520.32,,,,,,,fee schedule,4194.9,23549.82,APC
Removal of urethra lesion,53230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5308,,,,,,,fee schedule,4194.9,23549.82,APC
Removal of urethra lesion,53230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8121.25,,,,,,,fee schedule,4194.9,23549.82,Radiology
Removal of urethra lesion,53230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7431.21,,,,,,,fee schedule,4194.9,23549.82,APC
Removal of urethra lesion,53230,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9289.01,,,,,,,fee schedule,4194.9,23549.82,APC
Removal of urethra lesion,53235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4779.47,,,,,,,fee schedule,3831.16,23549.82,
Removal of urethra lesion,53235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3831.16,,,,,,,fee schedule,3831.16,23549.82,
Removal of urethra lesion,53235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4185.2,,,,,,,fee schedule,3831.16,23549.82,
Removal of urethra lesion,53235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4400.15,,,,,,,fee schedule,3831.16,23549.82,
Removal of urethra lesion,53235,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23549.82,,,,,,,fee schedule,3831.16,23549.82,APC 378
Removal of urethra lesion,53235,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5573.4,,,,,,,fee schedule,3831.16,23549.82,APC
Removal of urethra lesion,53235,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5520.32,,,,,,,fee schedule,3831.16,23549.82,APC
Removal of urethra lesion,53235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5308,,,,,,,fee schedule,3831.16,23549.82,APC
Removal of urethra lesion,53235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8121.25,,,,,,,fee schedule,3831.16,23549.82,Radiology
Removal of urethra lesion,53235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7431.21,,,,,,,fee schedule,3831.16,23549.82,APC
Removal of urethra lesion,53235,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9289.01,,,,,,,fee schedule,3831.16,23549.82,APC
Surgery for urethra pouch,53240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7433.94,,,,,,,fee schedule,3489.62,15482.25,
Surgery for urethra pouch,53240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5958.95,,,,,,,fee schedule,3489.62,15482.25,
Surgery for urethra pouch,53240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6509.61,,,,,,,fee schedule,3489.62,15482.25,
Surgery for urethra pouch,53240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6843.94,,,,,,,fee schedule,3489.62,15482.25,
Surgery for urethra pouch,53240,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Surgery for urethra pouch,53240,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Surgery for urethra pouch,53240,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Surgery for urethra pouch,53240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Surgery for urethra pouch,53240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Surgery for urethra pouch,53240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Surgery for urethra pouch,53240,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Removal of urethra gland,53250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4779.47,,,,,,,fee schedule,3489.62,15482.25,
Removal of urethra gland,53250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3831.16,,,,,,,fee schedule,3489.62,15482.25,
Removal of urethra gland,53250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4185.2,,,,,,,fee schedule,3489.62,15482.25,
Removal of urethra gland,53250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4400.15,,,,,,,fee schedule,3489.62,15482.25,
Removal of urethra gland,53250,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Removal of urethra gland,53250,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Removal of urethra gland,53250,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Removal of urethra gland,53250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Removal of urethra gland,53250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Removal of urethra gland,53250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Removal of urethra gland,53250,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Treatment of urethra lesion,53260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4779.47,,,,,,,fee schedule,3489.62,15482.25,
Treatment of urethra lesion,53260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3831.16,,,,,,,fee schedule,3489.62,15482.25,
Treatment of urethra lesion,53260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4185.2,,,,,,,fee schedule,3489.62,15482.25,
Treatment of urethra lesion,53260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4400.15,,,,,,,fee schedule,3489.62,15482.25,
Treatment of urethra lesion,53260,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Treatment of urethra lesion,53260,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Treatment of urethra lesion,53260,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Treatment of urethra lesion,53260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Treatment of urethra lesion,53260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Treatment of urethra lesion,53260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Treatment of urethra lesion,53260,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Treatment of urethra lesion,53265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4779.47,,,,,,,fee schedule,2069.41,9181.28,
Treatment of urethra lesion,53265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3831.16,,,,,,,fee schedule,2069.41,9181.28,
Treatment of urethra lesion,53265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4185.2,,,,,,,fee schedule,2069.41,9181.28,
Treatment of urethra lesion,53265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4400.15,,,,,,,fee schedule,2069.41,9181.28,
Treatment of urethra lesion,53265,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9181.28,,,,,,,fee schedule,2069.41,9181.28,APC 378
Treatment of urethra lesion,53265,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2172.88,,,,,,,fee schedule,2069.41,9181.28,APC
Treatment of urethra lesion,53265,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2152.19,,,,,,,fee schedule,2069.41,9181.28,APC
Treatment of urethra lesion,53265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2069.41,,,,,,,fee schedule,2069.41,9181.28,APC
Treatment of urethra lesion,53265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3166.2,,,,,,,fee schedule,2069.41,9181.28,Radiology
Treatment of urethra lesion,53265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2897.18,,,,,,,fee schedule,2069.41,9181.28,APC
Treatment of urethra lesion,53265,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3621.47,,,,,,,fee schedule,2069.41,9181.28,APC
Removal of urethra gland,53270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6253.46,,,,,,,fee schedule,3489.62,15482.25,
Removal of urethra gland,53270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5012.69,,,,,,,fee schedule,3489.62,15482.25,
Removal of urethra gland,53270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5475.91,,,,,,,fee schedule,3489.62,15482.25,
Removal of urethra gland,53270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5757.15,,,,,,,fee schedule,3489.62,15482.25,
Removal of urethra gland,53270,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Removal of urethra gland,53270,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Removal of urethra gland,53270,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Removal of urethra gland,53270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Removal of urethra gland,53270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Removal of urethra gland,53270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Removal of urethra gland,53270,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Repair of urethra defect,53275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4779.47,,,,,,,fee schedule,3489.62,15482.25,
Repair of urethra defect,53275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3831.16,,,,,,,fee schedule,3489.62,15482.25,
Repair of urethra defect,53275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4185.2,,,,,,,fee schedule,3489.62,15482.25,
Repair of urethra defect,53275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4400.15,,,,,,,fee schedule,3489.62,15482.25,
Repair of urethra defect,53275,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Repair of urethra defect,53275,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Repair of urethra defect,53275,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Repair of urethra defect,53275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Repair of urethra defect,53275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Repair of urethra defect,53275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Repair of urethra defect,53275,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Revise urethra stage 1,53400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7433.94,,,,,,,fee schedule,5308,23549.82,
Revise urethra stage 1,53400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5958.95,,,,,,,fee schedule,5308,23549.82,
Revise urethra stage 1,53400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6509.61,,,,,,,fee schedule,5308,23549.82,
Revise urethra stage 1,53400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6843.94,,,,,,,fee schedule,5308,23549.82,
Revise urethra stage 1,53400,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23549.82,,,,,,,fee schedule,5308,23549.82,APC 378
Revise urethra stage 1,53400,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5573.4,,,,,,,fee schedule,5308,23549.82,APC
Revise urethra stage 1,53400,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5520.32,,,,,,,fee schedule,5308,23549.82,APC
Revise urethra stage 1,53400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5308,,,,,,,fee schedule,5308,23549.82,APC
Revise urethra stage 1,53400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8121.25,,,,,,,fee schedule,5308,23549.82,Radiology
Revise urethra stage 1,53400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7431.21,,,,,,,fee schedule,5308,23549.82,APC
Revise urethra stage 1,53400,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9289.01,,,,,,,fee schedule,5308,23549.82,APC
Revise urethra stage 2,53405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7433.94,,,,,,,fee schedule,5308,23549.82,
Revise urethra stage 2,53405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5958.95,,,,,,,fee schedule,5308,23549.82,
Revise urethra stage 2,53405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6509.61,,,,,,,fee schedule,5308,23549.82,
Revise urethra stage 2,53405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6843.94,,,,,,,fee schedule,5308,23549.82,
Revise urethra stage 2,53405,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23549.82,,,,,,,fee schedule,5308,23549.82,APC 378
Revise urethra stage 2,53405,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5573.4,,,,,,,fee schedule,5308,23549.82,APC
Revise urethra stage 2,53405,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5520.32,,,,,,,fee schedule,5308,23549.82,APC
Revise urethra stage 2,53405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5308,,,,,,,fee schedule,5308,23549.82,APC
Revise urethra stage 2,53405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8121.25,,,,,,,fee schedule,5308,23549.82,Radiology
Revise urethra stage 2,53405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7431.21,,,,,,,fee schedule,5308,23549.82,APC
Revise urethra stage 2,53405,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9289.01,,,,,,,fee schedule,5308,23549.82,APC
Reconstruction of urethra,53410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11402.72,,,,,,,fee schedule,5308,23549.82,
Reconstruction of urethra,53410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9140.28,,,,,,,fee schedule,5308,23549.82,
Reconstruction of urethra,53410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9984.92,,,,,,,fee schedule,5308,23549.82,
Reconstruction of urethra,53410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10497.74,,,,,,,fee schedule,5308,23549.82,
Reconstruction of urethra,53410,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23549.82,,,,,,,fee schedule,5308,23549.82,APC 378
Reconstruction of urethra,53410,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5573.4,,,,,,,fee schedule,5308,23549.82,APC
Reconstruction of urethra,53410,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5520.32,,,,,,,fee schedule,5308,23549.82,APC
Reconstruction of urethra,53410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5308,,,,,,,fee schedule,5308,23549.82,APC
Reconstruction of urethra,53410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8121.25,,,,,,,fee schedule,5308,23549.82,Radiology
Reconstruction of urethra,53410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7431.21,,,,,,,fee schedule,5308,23549.82,APC
Reconstruction of urethra,53410,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9289.01,,,,,,,fee schedule,5308,23549.82,APC
Reconstruct urethra stage 1,53420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7433.94,,,,,,,fee schedule,5308,23549.82,
Reconstruct urethra stage 1,53420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5958.95,,,,,,,fee schedule,5308,23549.82,
Reconstruct urethra stage 1,53420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6509.61,,,,,,,fee schedule,5308,23549.82,
Reconstruct urethra stage 1,53420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6843.94,,,,,,,fee schedule,5308,23549.82,
Reconstruct urethra stage 1,53420,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23549.82,,,,,,,fee schedule,5308,23549.82,APC 378
Reconstruct urethra stage 1,53420,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5573.4,,,,,,,fee schedule,5308,23549.82,APC
Reconstruct urethra stage 1,53420,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5520.32,,,,,,,fee schedule,5308,23549.82,APC
Reconstruct urethra stage 1,53420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5308,,,,,,,fee schedule,5308,23549.82,APC
Reconstruct urethra stage 1,53420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8121.25,,,,,,,fee schedule,5308,23549.82,Radiology
Reconstruct urethra stage 1,53420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7431.21,,,,,,,fee schedule,5308,23549.82,APC
Reconstruct urethra stage 1,53420,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9289.01,,,,,,,fee schedule,5308,23549.82,APC
Reconstruct urethra stage 2,53425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7433.94,,,,,,,fee schedule,5308,23549.82,
Reconstruct urethra stage 2,53425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5958.95,,,,,,,fee schedule,5308,23549.82,
Reconstruct urethra stage 2,53425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6509.61,,,,,,,fee schedule,5308,23549.82,
Reconstruct urethra stage 2,53425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6843.94,,,,,,,fee schedule,5308,23549.82,
Reconstruct urethra stage 2,53425,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23549.82,,,,,,,fee schedule,5308,23549.82,APC 378
Reconstruct urethra stage 2,53425,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5573.4,,,,,,,fee schedule,5308,23549.82,APC
Reconstruct urethra stage 2,53425,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5520.32,,,,,,,fee schedule,5308,23549.82,APC
Reconstruct urethra stage 2,53425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5308,,,,,,,fee schedule,5308,23549.82,APC
Reconstruct urethra stage 2,53425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8121.25,,,,,,,fee schedule,5308,23549.82,Radiology
Reconstruct urethra stage 2,53425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7431.21,,,,,,,fee schedule,5308,23549.82,APC
Reconstruct urethra stage 2,53425,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9289.01,,,,,,,fee schedule,5308,23549.82,APC
Reconstruction of urethra,53430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7433.94,,,,,,,fee schedule,5308,23549.82,
Reconstruction of urethra,53430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5958.95,,,,,,,fee schedule,5308,23549.82,
Reconstruction of urethra,53430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6509.61,,,,,,,fee schedule,5308,23549.82,
Reconstruction of urethra,53430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6843.94,,,,,,,fee schedule,5308,23549.82,
Reconstruction of urethra,53430,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23549.82,,,,,,,fee schedule,5308,23549.82,APC 378
Reconstruction of urethra,53430,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5573.4,,,,,,,fee schedule,5308,23549.82,APC
Reconstruction of urethra,53430,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5520.32,,,,,,,fee schedule,5308,23549.82,APC
Reconstruction of urethra,53430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5308,,,,,,,fee schedule,5308,23549.82,APC
Reconstruction of urethra,53430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8121.25,,,,,,,fee schedule,5308,23549.82,Radiology
Reconstruction of urethra,53430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7431.21,,,,,,,fee schedule,5308,23549.82,APC
Reconstruction of urethra,53430,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9289.01,,,,,,,fee schedule,5308,23549.82,APC
Reconstruct urethra/bladder,53431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7433.94,,,,,,,fee schedule,5308,23549.82,
Reconstruct urethra/bladder,53431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5958.95,,,,,,,fee schedule,5308,23549.82,
Reconstruct urethra/bladder,53431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6509.61,,,,,,,fee schedule,5308,23549.82,
Reconstruct urethra/bladder,53431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6843.94,,,,,,,fee schedule,5308,23549.82,
Reconstruct urethra/bladder,53431,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23549.82,,,,,,,fee schedule,5308,23549.82,APC 378
Reconstruct urethra/bladder,53431,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5573.4,,,,,,,fee schedule,5308,23549.82,APC
Reconstruct urethra/bladder,53431,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5520.32,,,,,,,fee schedule,5308,23549.82,APC
Reconstruct urethra/bladder,53431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5308,,,,,,,fee schedule,5308,23549.82,APC
Reconstruct urethra/bladder,53431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8121.25,,,,,,,fee schedule,5308,23549.82,Radiology
Reconstruct urethra/bladder,53431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7431.21,,,,,,,fee schedule,5308,23549.82,APC
Reconstruct urethra/bladder,53431,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9289.01,,,,,,,fee schedule,5308,23549.82,APC
Male sling procedure,53440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20873.61,,,,,,,fee schedule,13061.09,57947.66,
Male sling procedure,53440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16732.02,,,,,,,fee schedule,13061.09,57947.66,
Male sling procedure,53440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18278.22,,,,,,,fee schedule,13061.09,57947.66,
Male sling procedure,53440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19216.98,,,,,,,fee schedule,13061.09,57947.66,
Male sling procedure,53440,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,57947.66,,,,,,,fee schedule,13061.09,57947.66,APC 378
Male sling procedure,53440,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13714.15,,,,,,,fee schedule,13061.09,57947.66,APC
Male sling procedure,53440,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13583.54,,,,,,,fee schedule,13061.09,57947.66,APC
Male sling procedure,53440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13061.09,,,,,,,fee schedule,13061.09,57947.66,APC
Male sling procedure,53440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19983.47,,,,,,,fee schedule,13061.09,57947.66,Radiology
Male sling procedure,53440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18285.53,,,,,,,fee schedule,13061.09,57947.66,APC
Male sling procedure,53440,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22856.92,,,,,,,fee schedule,13061.09,57947.66,APC
Remove/revise male sling,53442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7433.94,,,,,,,fee schedule,5308,23549.82,
Remove/revise male sling,53442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5958.95,,,,,,,fee schedule,5308,23549.82,
Remove/revise male sling,53442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6509.61,,,,,,,fee schedule,5308,23549.82,
Remove/revise male sling,53442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6843.94,,,,,,,fee schedule,5308,23549.82,
Remove/revise male sling,53442,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23549.82,,,,,,,fee schedule,5308,23549.82,APC 378
Remove/revise male sling,53442,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5573.4,,,,,,,fee schedule,5308,23549.82,APC
Remove/revise male sling,53442,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5520.32,,,,,,,fee schedule,5308,23549.82,APC
Remove/revise male sling,53442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5308,,,,,,,fee schedule,5308,23549.82,APC
Remove/revise male sling,53442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8121.25,,,,,,,fee schedule,5308,23549.82,Radiology
Remove/revise male sling,53442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7431.21,,,,,,,fee schedule,5308,23549.82,APC
Remove/revise male sling,53442,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9289.01,,,,,,,fee schedule,5308,23549.82,APC
Insert tandem cuff,53444,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20873.61,,,,,,,fee schedule,16732.02,91032.27,
Insert tandem cuff,53444,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16732.02,,,,,,,fee schedule,16732.02,91032.27,
Insert tandem cuff,53444,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18278.22,,,,,,,fee schedule,16732.02,91032.27,
Insert tandem cuff,53444,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19216.98,,,,,,,fee schedule,16732.02,91032.27,
Insert tandem cuff,53444,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,91032.27,,,,,,,fee schedule,16732.02,91032.27,APC 378
Insert tandem cuff,53444,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21544.1,,,,,,,fee schedule,16732.02,91032.27,APC
Insert tandem cuff,53444,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,21338.92,,,,,,,fee schedule,16732.02,91032.27,APC
Insert tandem cuff,53444,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,20518.19,,,,,,,fee schedule,16732.02,91032.27,APC
Insert tandem cuff,53444,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,31392.83,,,,,,,fee schedule,16732.02,91032.27,Radiology
Insert tandem cuff,53444,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28725.47,,,,,,,fee schedule,16732.02,91032.27,APC
Insert tandem cuff,53444,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,35906.83,,,,,,,fee schedule,16732.02,91032.27,APC
Insert uro/ves nck sphincter,53445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,35969.91,,,,,,,fee schedule,20518.19,91032.27,
Insert uro/ves nck sphincter,53445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28833.03,,,,,,,fee schedule,20518.19,91032.27,
Insert uro/ves nck sphincter,53445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31497.46,,,,,,,fee schedule,20518.19,91032.27,
Insert uro/ves nck sphincter,53445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33115.16,,,,,,,fee schedule,20518.19,91032.27,
Insert uro/ves nck sphincter,53445,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,91032.27,,,,,,,fee schedule,20518.19,91032.27,APC 378
Insert uro/ves nck sphincter,53445,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21544.1,,,,,,,fee schedule,20518.19,91032.27,APC
Insert uro/ves nck sphincter,53445,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,21338.92,,,,,,,fee schedule,20518.19,91032.27,APC
Insert uro/ves nck sphincter,53445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,20518.19,,,,,,,fee schedule,20518.19,91032.27,APC
Insert uro/ves nck sphincter,53445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,31392.83,,,,,,,fee schedule,20518.19,91032.27,Radiology
Insert uro/ves nck sphincter,53445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28725.47,,,,,,,fee schedule,20518.19,91032.27,APC
Insert uro/ves nck sphincter,53445,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,35906.83,,,,,,,fee schedule,20518.19,91032.27,APC
Remove uro sphincter,53446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7433.94,,,,,,,fee schedule,5308,23549.82,
Remove uro sphincter,53446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5958.95,,,,,,,fee schedule,5308,23549.82,
Remove uro sphincter,53446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6509.61,,,,,,,fee schedule,5308,23549.82,
Remove uro sphincter,53446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6843.94,,,,,,,fee schedule,5308,23549.82,
Remove uro sphincter,53446,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23549.82,,,,,,,fee schedule,5308,23549.82,APC 378
Remove uro sphincter,53446,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5573.4,,,,,,,fee schedule,5308,23549.82,APC
Remove uro sphincter,53446,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5520.32,,,,,,,fee schedule,5308,23549.82,APC
Remove uro sphincter,53446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5308,,,,,,,fee schedule,5308,23549.82,APC
Remove uro sphincter,53446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8121.25,,,,,,,fee schedule,5308,23549.82,Radiology
Remove uro sphincter,53446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7431.21,,,,,,,fee schedule,5308,23549.82,APC
Remove uro sphincter,53446,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9289.01,,,,,,,fee schedule,5308,23549.82,APC
Remove/replace ur sphincter,53447,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,35969.91,,,,,,,fee schedule,20518.19,91032.27,
Remove/replace ur sphincter,53447,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28833.03,,,,,,,fee schedule,20518.19,91032.27,
Remove/replace ur sphincter,53447,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31497.46,,,,,,,fee schedule,20518.19,91032.27,
Remove/replace ur sphincter,53447,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33115.16,,,,,,,fee schedule,20518.19,91032.27,
Remove/replace ur sphincter,53447,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,91032.27,,,,,,,fee schedule,20518.19,91032.27,APC 378
Remove/replace ur sphincter,53447,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21544.1,,,,,,,fee schedule,20518.19,91032.27,APC
Remove/replace ur sphincter,53447,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,21338.92,,,,,,,fee schedule,20518.19,91032.27,APC
Remove/replace ur sphincter,53447,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,20518.19,,,,,,,fee schedule,20518.19,91032.27,APC
Remove/replace ur sphincter,53447,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,31392.83,,,,,,,fee schedule,20518.19,91032.27,Radiology
Remove/replace ur sphincter,53447,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28725.47,,,,,,,fee schedule,20518.19,91032.27,APC
Remove/replace ur sphincter,53447,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,35906.83,,,,,,,fee schedule,20518.19,91032.27,APC
Repair uro sphincter,53449,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7433.94,,,,,,,fee schedule,5958.95,41578.13,
Repair uro sphincter,53449,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5958.95,,,,,,,fee schedule,5958.95,41578.13,
Repair uro sphincter,53449,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6509.61,,,,,,,fee schedule,5958.95,41578.13,
Repair uro sphincter,53449,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6843.94,,,,,,,fee schedule,5958.95,41578.13,
Repair uro sphincter,53449,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,41578.13,,,,,,,fee schedule,5958.95,41578.13,APC 378
Repair uro sphincter,53449,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9840.06,,,,,,,fee schedule,5958.95,41578.13,APC
Repair uro sphincter,53449,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9746.35,,,,,,,fee schedule,5958.95,41578.13,APC
Repair uro sphincter,53449,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9371.49,,,,,,,fee schedule,5958.95,41578.13,APC
Repair uro sphincter,53449,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14338.38,,,,,,,fee schedule,5958.95,41578.13,Radiology
Repair uro sphincter,53449,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13120.09,,,,,,,fee schedule,5958.95,41578.13,APC
Repair uro sphincter,53449,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16400.11,,,,,,,fee schedule,5958.95,41578.13,APC
Revision of urethra,53450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7433.94,,,,,,,fee schedule,3489.62,15482.25,
Revision of urethra,53450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5958.95,,,,,,,fee schedule,3489.62,15482.25,
Revision of urethra,53450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6509.61,,,,,,,fee schedule,3489.62,15482.25,
Revision of urethra,53450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6843.94,,,,,,,fee schedule,3489.62,15482.25,
Revision of urethra,53450,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Revision of urethra,53450,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Revision of urethra,53450,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Revision of urethra,53450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Revision of urethra,53450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Revision of urethra,53450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Revision of urethra,53450,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Tprnl balo cntnc dev bi,53451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,44339.25,,,,,,,fee schedule,13061.09,57947.66,
Tprnl balo cntnc dev bi,53451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35541.78,,,,,,,fee schedule,13061.09,57947.66,
Tprnl balo cntnc dev bi,53451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38826.17,,,,,,,fee schedule,13061.09,57947.66,
Tprnl balo cntnc dev bi,53451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,40820.26,,,,,,,fee schedule,13061.09,57947.66,
Tprnl balo cntnc dev bi,53451,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,57947.66,,,,,,,fee schedule,13061.09,57947.66,APC 378
Tprnl balo cntnc dev bi,53451,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13714.15,,,,,,,fee schedule,13061.09,57947.66,APC
Tprnl balo cntnc dev bi,53451,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13583.54,,,,,,,fee schedule,13061.09,57947.66,APC
Tprnl balo cntnc dev bi,53451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13061.09,,,,,,,fee schedule,13061.09,57947.66,APC
Tprnl balo cntnc dev bi,53451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19983.47,,,,,,,fee schedule,13061.09,57947.66,Radiology
Tprnl balo cntnc dev bi,53451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18285.53,,,,,,,fee schedule,13061.09,57947.66,APC
Tprnl balo cntnc dev bi,53451,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22856.92,,,,,,,fee schedule,13061.09,57947.66,APC
Tprnl balo cntnc dev uni,53452,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17032.26,,,,,,,fee schedule,9371.49,41578.13,
Tprnl balo cntnc dev uni,53452,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13652.85,,,,,,,fee schedule,9371.49,41578.13,
Tprnl balo cntnc dev uni,53452,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14914.5,,,,,,,fee schedule,9371.49,41578.13,
Tprnl balo cntnc dev uni,53452,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15680.5,,,,,,,fee schedule,9371.49,41578.13,
Tprnl balo cntnc dev uni,53452,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,41578.13,,,,,,,fee schedule,9371.49,41578.13,APC 378
Tprnl balo cntnc dev uni,53452,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9840.06,,,,,,,fee schedule,9371.49,41578.13,APC
Tprnl balo cntnc dev uni,53452,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9746.35,,,,,,,fee schedule,9371.49,41578.13,APC
Tprnl balo cntnc dev uni,53452,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9371.49,,,,,,,fee schedule,9371.49,41578.13,APC
Tprnl balo cntnc dev uni,53452,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14338.38,,,,,,,fee schedule,9371.49,41578.13,Radiology
Tprnl balo cntnc dev uni,53452,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13120.09,,,,,,,fee schedule,9371.49,41578.13,APC
Tprnl balo cntnc dev uni,53452,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16400.11,,,,,,,fee schedule,9371.49,41578.13,APC
Tprnl balo cntnc dev rmvl ea,53453,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11869.35,,,,,,,fee schedule,3489.62,15482.25,
Tprnl balo cntnc dev rmvl ea,53453,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9514.32,,,,,,,fee schedule,3489.62,15482.25,
Tprnl balo cntnc dev rmvl ea,53453,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10393.53,,,,,,,fee schedule,3489.62,15482.25,
Tprnl balo cntnc dev rmvl ea,53453,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10927.34,,,,,,,fee schedule,3489.62,15482.25,
Tprnl balo cntnc dev rmvl ea,53453,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Tprnl balo cntnc dev rmvl ea,53453,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Tprnl balo cntnc dev rmvl ea,53453,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Tprnl balo cntnc dev rmvl ea,53453,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Tprnl balo cntnc dev rmvl ea,53453,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Tprnl balo cntnc dev rmvl ea,53453,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Tprnl balo cntnc dev rmvl ea,53453,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Tprnl balo cntnc dev adjmt,53454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1027.29,,,,,,,fee schedule,247.34,1097.37,
Tprnl balo cntnc dev adjmt,53454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,823.46,,,,,,,fee schedule,247.34,1097.37,
Tprnl balo cntnc dev adjmt,53454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,899.56,,,,,,,fee schedule,247.34,1097.37,
Tprnl balo cntnc dev adjmt,53454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,945.76,,,,,,,fee schedule,247.34,1097.37,
Tprnl balo cntnc dev adjmt,53454,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1097.37,,,,,,,fee schedule,247.34,1097.37,APC 378
Tprnl balo cntnc dev adjmt,53454,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,259.71,,,,,,,fee schedule,247.34,1097.37,APC
Tprnl balo cntnc dev adjmt,53454,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,257.24,,,,,,,fee schedule,247.34,1097.37,APC
Tprnl balo cntnc dev adjmt,53454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,247.34,,,,,,,fee schedule,247.34,1097.37,APC
Tprnl balo cntnc dev adjmt,53454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,378.43,,,,,,,fee schedule,247.34,1097.37,Radiology
Tprnl balo cntnc dev adjmt,53454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,346.28,,,,,,,fee schedule,247.34,1097.37,APC
Tprnl balo cntnc dev adjmt,53454,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,432.85,,,,,,,fee schedule,247.34,1097.37,APC
Revision of urethra,53460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4779.47,,,,,,,fee schedule,3489.62,15482.25,
Revision of urethra,53460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3831.16,,,,,,,fee schedule,3489.62,15482.25,
Revision of urethra,53460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4185.2,,,,,,,fee schedule,3489.62,15482.25,
Revision of urethra,53460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4400.15,,,,,,,fee schedule,3489.62,15482.25,
Revision of urethra,53460,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Revision of urethra,53460,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Revision of urethra,53460,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Revision of urethra,53460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Revision of urethra,53460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Revision of urethra,53460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Revision of urethra,53460,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Urethrlys transvag w/ scope,53500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7433.94,,,,,,,fee schedule,3489.62,15482.25,
Urethrlys transvag w/ scope,53500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5958.95,,,,,,,fee schedule,3489.62,15482.25,
Urethrlys transvag w/ scope,53500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6509.61,,,,,,,fee schedule,3489.62,15482.25,
Urethrlys transvag w/ scope,53500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6843.94,,,,,,,fee schedule,3489.62,15482.25,
Urethrlys transvag w/ scope,53500,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Urethrlys transvag w/ scope,53500,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Urethrlys transvag w/ scope,53500,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Urethrlys transvag w/ scope,53500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Urethrlys transvag w/ scope,53500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Urethrlys transvag w/ scope,53500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Urethrlys transvag w/ scope,53500,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Repair of urethra injury,53502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3594.84,,,,,,,fee schedule,2881.58,15482.25,
Repair of urethra injury,53502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2881.58,,,,,,,fee schedule,2881.58,15482.25,
Repair of urethra injury,53502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3147.87,,,,,,,fee schedule,2881.58,15482.25,
Repair of urethra injury,53502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3309.54,,,,,,,fee schedule,2881.58,15482.25,
Repair of urethra injury,53502,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,2881.58,15482.25,APC 378
Repair of urethra injury,53502,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,2881.58,15482.25,APC
Repair of urethra injury,53502,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,2881.58,15482.25,APC
Repair of urethra injury,53502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,2881.58,15482.25,APC
Repair of urethra injury,53502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,2881.58,15482.25,Radiology
Repair of urethra injury,53502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,2881.58,15482.25,APC
Repair of urethra injury,53502,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,2881.58,15482.25,APC
Repair of urethra injury,53505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7433.94,,,,,,,fee schedule,5308,23549.82,
Repair of urethra injury,53505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5958.95,,,,,,,fee schedule,5308,23549.82,
Repair of urethra injury,53505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6509.61,,,,,,,fee schedule,5308,23549.82,
Repair of urethra injury,53505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6843.94,,,,,,,fee schedule,5308,23549.82,
Repair of urethra injury,53505,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23549.82,,,,,,,fee schedule,5308,23549.82,APC 378
Repair of urethra injury,53505,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5573.4,,,,,,,fee schedule,5308,23549.82,APC
Repair of urethra injury,53505,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5520.32,,,,,,,fee schedule,5308,23549.82,APC
Repair of urethra injury,53505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5308,,,,,,,fee schedule,5308,23549.82,APC
Repair of urethra injury,53505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8121.25,,,,,,,fee schedule,5308,23549.82,Radiology
Repair of urethra injury,53505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7431.21,,,,,,,fee schedule,5308,23549.82,APC
Repair of urethra injury,53505,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9289.01,,,,,,,fee schedule,5308,23549.82,APC
Repair of urethra injury,53510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4779.47,,,,,,,fee schedule,3831.16,23549.82,
Repair of urethra injury,53510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3831.16,,,,,,,fee schedule,3831.16,23549.82,
Repair of urethra injury,53510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4185.2,,,,,,,fee schedule,3831.16,23549.82,
Repair of urethra injury,53510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4400.15,,,,,,,fee schedule,3831.16,23549.82,
Repair of urethra injury,53510,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23549.82,,,,,,,fee schedule,3831.16,23549.82,APC 378
Repair of urethra injury,53510,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5573.4,,,,,,,fee schedule,3831.16,23549.82,APC
Repair of urethra injury,53510,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5520.32,,,,,,,fee schedule,3831.16,23549.82,APC
Repair of urethra injury,53510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5308,,,,,,,fee schedule,3831.16,23549.82,APC
Repair of urethra injury,53510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8121.25,,,,,,,fee schedule,3831.16,23549.82,Radiology
Repair of urethra injury,53510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7431.21,,,,,,,fee schedule,3831.16,23549.82,APC
Repair of urethra injury,53510,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9289.01,,,,,,,fee schedule,3831.16,23549.82,APC
Repair of urethra injury,53515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7433.94,,,,,,,fee schedule,5308,23549.82,
Repair of urethra injury,53515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5958.95,,,,,,,fee schedule,5308,23549.82,
Repair of urethra injury,53515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6509.61,,,,,,,fee schedule,5308,23549.82,
Repair of urethra injury,53515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6843.94,,,,,,,fee schedule,5308,23549.82,
Repair of urethra injury,53515,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23549.82,,,,,,,fee schedule,5308,23549.82,APC 378
Repair of urethra injury,53515,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5573.4,,,,,,,fee schedule,5308,23549.82,APC
Repair of urethra injury,53515,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5520.32,,,,,,,fee schedule,5308,23549.82,APC
Repair of urethra injury,53515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5308,,,,,,,fee schedule,5308,23549.82,APC
Repair of urethra injury,53515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8121.25,,,,,,,fee schedule,5308,23549.82,Radiology
Repair of urethra injury,53515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7431.21,,,,,,,fee schedule,5308,23549.82,APC
Repair of urethra injury,53515,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9289.01,,,,,,,fee schedule,5308,23549.82,APC
Repair of urethra defect,53520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7433.94,,,,,,,fee schedule,5308,23549.82,
Repair of urethra defect,53520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5958.95,,,,,,,fee schedule,5308,23549.82,
Repair of urethra defect,53520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6509.61,,,,,,,fee schedule,5308,23549.82,
Repair of urethra defect,53520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6843.94,,,,,,,fee schedule,5308,23549.82,
Repair of urethra defect,53520,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23549.82,,,,,,,fee schedule,5308,23549.82,APC 378
Repair of urethra defect,53520,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5573.4,,,,,,,fee schedule,5308,23549.82,APC
Repair of urethra defect,53520,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5520.32,,,,,,,fee schedule,5308,23549.82,APC
Repair of urethra defect,53520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5308,,,,,,,fee schedule,5308,23549.82,APC
Repair of urethra defect,53520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8121.25,,,,,,,fee schedule,5308,23549.82,Radiology
Repair of urethra defect,53520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7431.21,,,,,,,fee schedule,5308,23549.82,APC
Repair of urethra defect,53520,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9289.01,,,,,,,fee schedule,5308,23549.82,APC
Dilate urethra stricture,53600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,760.42,,,,,,,fee schedule,247.34,1097.37,
Dilate urethra stricture,53600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,609.55,,,,,,,fee schedule,247.34,1097.37,
Dilate urethra stricture,53600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,665.87,,,,,,,fee schedule,247.34,1097.37,
Dilate urethra stricture,53600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,700.07,,,,,,,fee schedule,247.34,1097.37,
Dilate urethra stricture,53600,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1097.37,,,,,,,fee schedule,247.34,1097.37,APC 378
Dilate urethra stricture,53600,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,259.71,,,,,,,fee schedule,247.34,1097.37,APC
Dilate urethra stricture,53600,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,257.24,,,,,,,fee schedule,247.34,1097.37,APC
Dilate urethra stricture,53600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,247.34,,,,,,,fee schedule,247.34,1097.37,APC
Dilate urethra stricture,53600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,378.43,,,,,,,fee schedule,247.34,1097.37,Radiology
Dilate urethra stricture,53600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,346.28,,,,,,,fee schedule,247.34,1097.37,APC
Dilate urethra stricture,53600,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,432.85,,,,,,,fee schedule,247.34,1097.37,APC
Dilate urethra stricture,53601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,258.44,,,,,,,fee schedule,131.71,584.37,
Dilate urethra stricture,53601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,207.16,,,,,,,fee schedule,131.71,584.37,
Dilate urethra stricture,53601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,226.3,,,,,,,fee schedule,131.71,584.37,
Dilate urethra stricture,53601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,237.93,,,,,,,fee schedule,131.71,584.37,
Dilate urethra stricture,53601,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,131.71,584.37,APC 378
Dilate urethra stricture,53601,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,131.71,584.37,APC
Dilate urethra stricture,53601,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,131.71,584.37,APC
Dilate urethra stricture,53601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,131.71,584.37,APC
Dilate urethra stricture,53601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,131.71,584.37,Radiology
Dilate urethra stricture,53601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,131.71,584.37,APC
Dilate urethra stricture,53601,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,131.71,584.37,APC
Dilate urethra stricture,53605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4477.9,,,,,,,fee schedule,3489.62,15482.25,
Dilate urethra stricture,53605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3589.43,,,,,,,fee schedule,3489.62,15482.25,
Dilate urethra stricture,53605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3921.13,,,,,,,fee schedule,3489.62,15482.25,
Dilate urethra stricture,53605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4122.51,,,,,,,fee schedule,3489.62,15482.25,
Dilate urethra stricture,53605,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Dilate urethra stricture,53605,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Dilate urethra stricture,53605,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Dilate urethra stricture,53605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Dilate urethra stricture,53605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Dilate urethra stricture,53605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Dilate urethra stricture,53605,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Dilate urethra stricture,53620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4827.14,,,,,,,fee schedule,690.3,4827.14,
Dilate urethra stricture,53620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3869.37,,,,,,,fee schedule,690.3,4827.14,
Dilate urethra stricture,53620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4226.94,,,,,,,fee schedule,690.3,4827.14,
Dilate urethra stricture,53620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4444.03,,,,,,,fee schedule,690.3,4827.14,
Dilate urethra stricture,53620,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3062.63,,,,,,,fee schedule,690.3,4827.14,APC 378
Dilate urethra stricture,53620,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,724.82,,,,,,,fee schedule,690.3,4827.14,APC
Dilate urethra stricture,53620,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,717.91,,,,,,,fee schedule,690.3,4827.14,APC
Dilate urethra stricture,53620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,690.3,,,,,,,fee schedule,690.3,4827.14,APC
Dilate urethra stricture,53620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1056.16,,,,,,,fee schedule,690.3,4827.14,Radiology
Dilate urethra stricture,53620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,966.42,,,,,,,fee schedule,690.3,4827.14,APC
Dilate urethra stricture,53620,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1208.03,,,,,,,fee schedule,690.3,4827.14,APC
Dilate urethra stricture,53621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,501.08,,,,,,,fee schedule,247.34,1097.37,
Dilate urethra stricture,53621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,401.66,,,,,,,fee schedule,247.34,1097.37,
Dilate urethra stricture,53621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,438.77,,,,,,,fee schedule,247.34,1097.37,
Dilate urethra stricture,53621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,461.31,,,,,,,fee schedule,247.34,1097.37,
Dilate urethra stricture,53621,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1097.37,,,,,,,fee schedule,247.34,1097.37,APC 378
Dilate urethra stricture,53621,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,259.71,,,,,,,fee schedule,247.34,1097.37,APC
Dilate urethra stricture,53621,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,257.24,,,,,,,fee schedule,247.34,1097.37,APC
Dilate urethra stricture,53621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,247.34,,,,,,,fee schedule,247.34,1097.37,APC
Dilate urethra stricture,53621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,378.43,,,,,,,fee schedule,247.34,1097.37,Radiology
Dilate urethra stricture,53621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,346.28,,,,,,,fee schedule,247.34,1097.37,APC
Dilate urethra stricture,53621,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,432.85,,,,,,,fee schedule,247.34,1097.37,APC
Dilation of urethra,53660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,258.44,,,,,,,fee schedule,127.38,565.15,
Dilation of urethra,53660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,207.16,,,,,,,fee schedule,127.38,565.15,
Dilation of urethra,53660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,226.3,,,,,,,fee schedule,127.38,565.15,
Dilation of urethra,53660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,237.93,,,,,,,fee schedule,127.38,565.15,
Dilation of urethra,53660,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,565.15,,,,,,,fee schedule,127.38,565.15,APC 378
Dilation of urethra,53660,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,133.75,,,,,,,fee schedule,127.38,565.15,APC
Dilation of urethra,53660,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,132.48,,,,,,,fee schedule,127.38,565.15,APC
Dilation of urethra,53660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,127.38,,,,,,,fee schedule,127.38,565.15,APC
Dilation of urethra,53660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,194.89,,,,,,,fee schedule,127.38,565.15,Radiology
Dilation of urethra,53660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,178.33,,,,,,,fee schedule,127.38,565.15,APC
Dilation of urethra,53660,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,222.92,,,,,,,fee schedule,127.38,565.15,APC
Dilation of urethra,53661,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,258.44,,,,,,,fee schedule,131.71,584.37,
Dilation of urethra,53661,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,207.16,,,,,,,fee schedule,131.71,584.37,
Dilation of urethra,53661,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,226.3,,,,,,,fee schedule,131.71,584.37,
Dilation of urethra,53661,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,237.93,,,,,,,fee schedule,131.71,584.37,
Dilation of urethra,53661,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,131.71,584.37,APC 378
Dilation of urethra,53661,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,131.71,584.37,APC
Dilation of urethra,53661,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,131.71,584.37,APC
Dilation of urethra,53661,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,131.71,584.37,APC
Dilation of urethra,53661,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,131.71,584.37,Radiology
Dilation of urethra,53661,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,131.71,584.37,APC
Dilation of urethra,53661,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,131.71,584.37,APC
Dilation of urethra,53665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4779.47,,,,,,,fee schedule,2069.41,9181.28,
Dilation of urethra,53665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3831.16,,,,,,,fee schedule,2069.41,9181.28,
Dilation of urethra,53665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4185.2,,,,,,,fee schedule,2069.41,9181.28,
Dilation of urethra,53665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4400.15,,,,,,,fee schedule,2069.41,9181.28,
Dilation of urethra,53665,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9181.28,,,,,,,fee schedule,2069.41,9181.28,APC 378
Dilation of urethra,53665,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2172.88,,,,,,,fee schedule,2069.41,9181.28,APC
Dilation of urethra,53665,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2152.19,,,,,,,fee schedule,2069.41,9181.28,APC
Dilation of urethra,53665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2069.41,,,,,,,fee schedule,2069.41,9181.28,APC
Dilation of urethra,53665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3166.2,,,,,,,fee schedule,2069.41,9181.28,Radiology
Dilation of urethra,53665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2897.18,,,,,,,fee schedule,2069.41,9181.28,APC
Dilation of urethra,53665,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3621.47,,,,,,,fee schedule,2069.41,9181.28,APC
Prostatic microwave thermotx,53850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11281.86,,,,,,,fee schedule,3489.62,15482.25,
Prostatic microwave thermotx,53850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9043.4,,,,,,,fee schedule,3489.62,15482.25,
Prostatic microwave thermotx,53850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9879.09,,,,,,,fee schedule,3489.62,15482.25,
Prostatic microwave thermotx,53850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10386.48,,,,,,,fee schedule,3489.62,15482.25,
Prostatic microwave thermotx,53850,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Prostatic microwave thermotx,53850,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Prostatic microwave thermotx,53850,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Prostatic microwave thermotx,53850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Prostatic microwave thermotx,53850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Prostatic microwave thermotx,53850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Prostatic microwave thermotx,53850,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Prostatic rf thermotx,53852,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11281.86,,,,,,,fee schedule,3489.62,15482.25,
Prostatic rf thermotx,53852,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9043.4,,,,,,,fee schedule,3489.62,15482.25,
Prostatic rf thermotx,53852,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9879.09,,,,,,,fee schedule,3489.62,15482.25,
Prostatic rf thermotx,53852,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10386.48,,,,,,,fee schedule,3489.62,15482.25,
Prostatic rf thermotx,53852,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Prostatic rf thermotx,53852,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Prostatic rf thermotx,53852,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Prostatic rf thermotx,53852,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Prostatic rf thermotx,53852,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Prostatic rf thermotx,53852,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Prostatic rf thermotx,53852,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Trurl dstrj prst8 tiss rf wv,53854,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6576.26,,,,,,,fee schedule,3489.62,15482.25,
Trurl dstrj prst8 tiss rf wv,53854,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5271.44,,,,,,,fee schedule,3489.62,15482.25,
Trurl dstrj prst8 tiss rf wv,53854,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5758.57,,,,,,,fee schedule,3489.62,15482.25,
Trurl dstrj prst8 tiss rf wv,53854,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6054.33,,,,,,,fee schedule,3489.62,15482.25,
Trurl dstrj prst8 tiss rf wv,53854,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Trurl dstrj prst8 tiss rf wv,53854,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Trurl dstrj prst8 tiss rf wv,53854,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Trurl dstrj prst8 tiss rf wv,53854,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Trurl dstrj prst8 tiss rf wv,53854,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Trurl dstrj prst8 tiss rf wv,53854,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Trurl dstrj prst8 tiss rf wv,53854,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Insert prost urethral stent,53855,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3360.79,,,,,,,fee schedule,2069.41,9181.28,
Insert prost urethral stent,53855,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2693.96,,,,,,,fee schedule,2069.41,9181.28,
Insert prost urethral stent,53855,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2942.91,,,,,,,fee schedule,2069.41,9181.28,
Insert prost urethral stent,53855,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3094.06,,,,,,,fee schedule,2069.41,9181.28,
Insert prost urethral stent,53855,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9181.28,,,,,,,fee schedule,2069.41,9181.28,APC 378
Insert prost urethral stent,53855,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2172.88,,,,,,,fee schedule,2069.41,9181.28,APC
Insert prost urethral stent,53855,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2152.19,,,,,,,fee schedule,2069.41,9181.28,APC
Insert prost urethral stent,53855,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2069.41,,,,,,,fee schedule,2069.41,9181.28,APC
Insert prost urethral stent,53855,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3166.2,,,,,,,fee schedule,2069.41,9181.28,Radiology
Insert prost urethral stent,53855,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2897.18,,,,,,,fee schedule,2069.41,9181.28,APC
Insert prost urethral stent,53855,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3621.47,,,,,,,fee schedule,2069.41,9181.28,APC
Transurethral rf treatment,53860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5230.08,,,,,,,fee schedule,2069.41,9181.28,
Transurethral rf treatment,53860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4192.37,,,,,,,fee schedule,2069.41,9181.28,
Transurethral rf treatment,53860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4579.78,,,,,,,fee schedule,2069.41,9181.28,
Transurethral rf treatment,53860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4815,,,,,,,fee schedule,2069.41,9181.28,
Transurethral rf treatment,53860,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9181.28,,,,,,,fee schedule,2069.41,9181.28,APC 378
Transurethral rf treatment,53860,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2172.88,,,,,,,fee schedule,2069.41,9181.28,APC
Transurethral rf treatment,53860,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2152.19,,,,,,,fee schedule,2069.41,9181.28,APC
Transurethral rf treatment,53860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2069.41,,,,,,,fee schedule,2069.41,9181.28,APC
Transurethral rf treatment,53860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3166.2,,,,,,,fee schedule,2069.41,9181.28,Radiology
Transurethral rf treatment,53860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2897.18,,,,,,,fee schedule,2069.41,9181.28,APC
Transurethral rf treatment,53860,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3621.47,,,,,,,fee schedule,2069.41,9181.28,APC
Cysto insj dev ischmc rmdlg,53865,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,41578.13,,,,,,,fee schedule,9371.49,41578.13,APC 378
Cysto insj dev ischmc rmdlg,53865,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9840.06,,,,,,,fee schedule,9371.49,41578.13,APC
Cysto insj dev ischmc rmdlg,53865,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9746.35,,,,,,,fee schedule,9371.49,41578.13,APC
Cysto insj dev ischmc rmdlg,53865,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9371.49,,,,,,,fee schedule,9371.49,41578.13,APC
Cysto insj dev ischmc rmdlg,53865,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14338.38,,,,,,,fee schedule,9371.49,41578.13,Radiology
Cysto insj dev ischmc rmdlg,53865,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13120.09,,,,,,,fee schedule,9371.49,41578.13,APC
Cysto insj dev ischmc rmdlg,53865,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16400.11,,,,,,,fee schedule,9371.49,41578.13,APC
Cathj rmvl dev ischmc rmdlg,53866,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1097.37,,,,,,,fee schedule,247.34,1097.37,APC 378
Cathj rmvl dev ischmc rmdlg,53866,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,259.71,,,,,,,fee schedule,247.34,1097.37,APC
Cathj rmvl dev ischmc rmdlg,53866,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,257.24,,,,,,,fee schedule,247.34,1097.37,APC
Cathj rmvl dev ischmc rmdlg,53866,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,247.34,,,,,,,fee schedule,247.34,1097.37,APC
Cathj rmvl dev ischmc rmdlg,53866,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,378.43,,,,,,,fee schedule,247.34,1097.37,Radiology
Cathj rmvl dev ischmc rmdlg,53866,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,346.28,,,,,,,fee schedule,247.34,1097.37,APC
Cathj rmvl dev ischmc rmdlg,53866,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,432.85,,,,,,,fee schedule,247.34,1097.37,APC
Urology surgery procedure,53899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2708.65,,,,,,,fee schedule,247.34,2708.65,
Urology surgery procedure,53899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2171.22,,,,,,,fee schedule,247.34,2708.65,
Urology surgery procedure,53899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2371.86,,,,,,,fee schedule,247.34,2708.65,
Urology surgery procedure,53899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2493.68,,,,,,,fee schedule,247.34,2708.65,
Urology surgery procedure,53899,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1097.37,,,,,,,fee schedule,247.34,2708.65,APC 378
Urology surgery procedure,53899,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,259.71,,,,,,,fee schedule,247.34,2708.65,APC
Urology surgery procedure,53899,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,257.24,,,,,,,fee schedule,247.34,2708.65,APC
Urology surgery procedure,53899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,247.34,,,,,,,fee schedule,247.34,2708.65,APC
Urology surgery procedure,53899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,378.43,,,,,,,fee schedule,247.34,2708.65,Radiology
Urology surgery procedure,53899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,346.28,,,,,,,fee schedule,247.34,2708.65,APC
Urology surgery procedure,53899,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,432.85,,,,,,,fee schedule,247.34,2708.65,APC
Slitting of prepuce,54000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4779.47,,,,,,,fee schedule,3489.62,15482.25,
Slitting of prepuce,54000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3831.16,,,,,,,fee schedule,3489.62,15482.25,
Slitting of prepuce,54000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4185.2,,,,,,,fee schedule,3489.62,15482.25,
Slitting of prepuce,54000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4400.15,,,,,,,fee schedule,3489.62,15482.25,
Slitting of prepuce,54000,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Slitting of prepuce,54000,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Slitting of prepuce,54000,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Slitting of prepuce,54000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Slitting of prepuce,54000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Slitting of prepuce,54000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Slitting of prepuce,54000,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Slitting of prepuce,54001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4779.47,,,,,,,fee schedule,2069.41,9181.28,
Slitting of prepuce,54001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3831.16,,,,,,,fee schedule,2069.41,9181.28,
Slitting of prepuce,54001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4185.2,,,,,,,fee schedule,2069.41,9181.28,
Slitting of prepuce,54001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4400.15,,,,,,,fee schedule,2069.41,9181.28,
Slitting of prepuce,54001,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9181.28,,,,,,,fee schedule,2069.41,9181.28,APC 378
Slitting of prepuce,54001,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2172.88,,,,,,,fee schedule,2069.41,9181.28,APC
Slitting of prepuce,54001,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2152.19,,,,,,,fee schedule,2069.41,9181.28,APC
Slitting of prepuce,54001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2069.41,,,,,,,fee schedule,2069.41,9181.28,APC
Slitting of prepuce,54001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3166.2,,,,,,,fee schedule,2069.41,9181.28,Radiology
Slitting of prepuce,54001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2897.18,,,,,,,fee schedule,2069.41,9181.28,APC
Slitting of prepuce,54001,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3621.47,,,,,,,fee schedule,2069.41,9181.28,APC
Drain penis lesion,54015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4572.14,,,,,,,fee schedule,1635.03,7254.06,
Drain penis lesion,54015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3664.97,,,,,,,fee schedule,1635.03,7254.06,
Drain penis lesion,54015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4003.64,,,,,,,fee schedule,1635.03,7254.06,
Drain penis lesion,54015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4209.27,,,,,,,fee schedule,1635.03,7254.06,
Drain penis lesion,54015,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,7254.06,APC 378
Drain penis lesion,54015,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,7254.06,APC
Drain penis lesion,54015,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,7254.06,APC
Drain penis lesion,54015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,7254.06,APC
Drain penis lesion,54015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,7254.06,Radiology
Drain penis lesion,54015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,7254.06,APC
Drain penis lesion,54015,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,7254.06,APC
Destruction penis lesion(s),54050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,364.24,,,,,,,fee schedule,291.97,1785.48,
Destruction penis lesion(s),54050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,291.97,,,,,,,fee schedule,291.97,1785.48,
Destruction penis lesion(s),54050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,318.95,,,,,,,fee schedule,291.97,1785.48,
Destruction penis lesion(s),54050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,335.33,,,,,,,fee schedule,291.97,1785.48,
Destruction penis lesion(s),54050,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1785.48,,,,,,,fee schedule,291.97,1785.48,APC 378
Destruction penis lesion(s),54050,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,422.56,,,,,,,fee schedule,291.97,1785.48,APC
Destruction penis lesion(s),54050,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,418.53,,,,,,,fee schedule,291.97,1785.48,APC
Destruction penis lesion(s),54050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,402.44,,,,,,,fee schedule,291.97,1785.48,APC
Destruction penis lesion(s),54050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,615.73,,,,,,,fee schedule,291.97,1785.48,Radiology
Destruction penis lesion(s),54050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,563.41,,,,,,,fee schedule,291.97,1785.48,APC
Destruction penis lesion(s),54050,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,704.26,,,,,,,fee schedule,291.97,1785.48,APC
Destruction penis lesion(s),54055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4967.56,,,,,,,fee schedule,2042.58,9062.24,
Destruction penis lesion(s),54055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3981.94,,,,,,,fee schedule,2042.58,9062.24,
Destruction penis lesion(s),54055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4349.9,,,,,,,fee schedule,2042.58,9062.24,
Destruction penis lesion(s),54055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4573.31,,,,,,,fee schedule,2042.58,9062.24,
Destruction penis lesion(s),54055,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,2042.58,9062.24,APC 378
Destruction penis lesion(s),54055,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,2042.58,9062.24,APC
Destruction penis lesion(s),54055,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,2042.58,9062.24,APC
Destruction penis lesion(s),54055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,2042.58,9062.24,APC
Destruction penis lesion(s),54055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,2042.58,9062.24,Radiology
Destruction penis lesion(s),54055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,2042.58,9062.24,APC
Destruction penis lesion(s),54055,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,2042.58,9062.24,APC
Cryosurgery penis lesion(s),54056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,197.92,,,,,,,fee schedule,158.65,881.22,
Cryosurgery penis lesion(s),54056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,158.65,,,,,,,fee schedule,158.65,881.22,
Cryosurgery penis lesion(s),54056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,173.31,,,,,,,fee schedule,158.65,881.22,
Cryosurgery penis lesion(s),54056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,182.21,,,,,,,fee schedule,158.65,881.22,
Cryosurgery penis lesion(s),54056,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,881.22,,,,,,,fee schedule,158.65,881.22,APC 378
Cryosurgery penis lesion(s),54056,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.55,,,,,,,fee schedule,158.65,881.22,APC
Cryosurgery penis lesion(s),54056,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,206.57,,,,,,,fee schedule,158.65,881.22,APC
Cryosurgery penis lesion(s),54056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.62,,,,,,,fee schedule,158.65,881.22,APC
Cryosurgery penis lesion(s),54056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.89,,,,,,,fee schedule,158.65,881.22,Radiology
Cryosurgery penis lesion(s),54056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,278.07,,,,,,,fee schedule,158.65,881.22,APC
Cryosurgery penis lesion(s),54056,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,347.59,,,,,,,fee schedule,158.65,881.22,APC
Laser surg penis lesion(s),54057,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4967.56,,,,,,,fee schedule,2042.58,9062.24,
Laser surg penis lesion(s),54057,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3981.94,,,,,,,fee schedule,2042.58,9062.24,
Laser surg penis lesion(s),54057,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4349.9,,,,,,,fee schedule,2042.58,9062.24,
Laser surg penis lesion(s),54057,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4573.31,,,,,,,fee schedule,2042.58,9062.24,
Laser surg penis lesion(s),54057,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,2042.58,9062.24,APC 378
Laser surg penis lesion(s),54057,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,2042.58,9062.24,APC
Laser surg penis lesion(s),54057,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,2042.58,9062.24,APC
Laser surg penis lesion(s),54057,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,2042.58,9062.24,APC
Laser surg penis lesion(s),54057,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,2042.58,9062.24,Radiology
Laser surg penis lesion(s),54057,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,2042.58,9062.24,APC
Laser surg penis lesion(s),54057,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,2042.58,9062.24,APC
Excision of penis lesion(s),54060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4967.56,,,,,,,fee schedule,2042.58,9062.24,
Excision of penis lesion(s),54060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3981.94,,,,,,,fee schedule,2042.58,9062.24,
Excision of penis lesion(s),54060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4349.9,,,,,,,fee schedule,2042.58,9062.24,
Excision of penis lesion(s),54060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4573.31,,,,,,,fee schedule,2042.58,9062.24,
Excision of penis lesion(s),54060,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,2042.58,9062.24,APC 378
Excision of penis lesion(s),54060,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,2042.58,9062.24,APC
Excision of penis lesion(s),54060,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,2042.58,9062.24,APC
Excision of penis lesion(s),54060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,2042.58,9062.24,APC
Excision of penis lesion(s),54060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,2042.58,9062.24,Radiology
Excision of penis lesion(s),54060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,2042.58,9062.24,APC
Excision of penis lesion(s),54060,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,2042.58,9062.24,APC
Destruction penis lesion(s),54065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4967.56,,,,,,,fee schedule,2042.58,9062.24,
Destruction penis lesion(s),54065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3981.94,,,,,,,fee schedule,2042.58,9062.24,
Destruction penis lesion(s),54065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4349.9,,,,,,,fee schedule,2042.58,9062.24,
Destruction penis lesion(s),54065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4573.31,,,,,,,fee schedule,2042.58,9062.24,
Destruction penis lesion(s),54065,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,2042.58,9062.24,APC 378
Destruction penis lesion(s),54065,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,2042.58,9062.24,APC
Destruction penis lesion(s),54065,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,2042.58,9062.24,APC
Destruction penis lesion(s),54065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,2042.58,9062.24,APC
Destruction penis lesion(s),54065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,2042.58,9062.24,Radiology
Destruction penis lesion(s),54065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,2042.58,9062.24,APC
Destruction penis lesion(s),54065,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,2042.58,9062.24,APC
Biopsy of penis,54100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4018.18,,,,,,,fee schedule,1635.03,7254.06,
Biopsy of penis,54100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3220.92,,,,,,,fee schedule,1635.03,7254.06,
Biopsy of penis,54100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3518.56,,,,,,,fee schedule,1635.03,7254.06,
Biopsy of penis,54100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3699.27,,,,,,,fee schedule,1635.03,7254.06,
Biopsy of penis,54100,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,7254.06,APC 378
Biopsy of penis,54100,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,7254.06,APC
Biopsy of penis,54100,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,7254.06,APC
Biopsy of penis,54100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,7254.06,APC
Biopsy of penis,54100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,7254.06,Radiology
Biopsy of penis,54100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,7254.06,APC
Biopsy of penis,54100,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,7254.06,APC
Biopsy of penis,54105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5268.49,,,,,,,fee schedule,2875.57,12757.95,
Biopsy of penis,54105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4223.15,,,,,,,fee schedule,2875.57,12757.95,
Biopsy of penis,54105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4613.41,,,,,,,fee schedule,2875.57,12757.95,
Biopsy of penis,54105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4850.35,,,,,,,fee schedule,2875.57,12757.95,
Biopsy of penis,54105,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Biopsy of penis,54105,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Biopsy of penis,54105,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Biopsy of penis,54105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Biopsy of penis,54105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Biopsy of penis,54105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Biopsy of penis,54105,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Treatment of penis lesion,54110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8468.26,,,,,,,fee schedule,3489.62,15482.25,
Treatment of penis lesion,54110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6788.05,,,,,,,fee schedule,3489.62,15482.25,
Treatment of penis lesion,54110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7415.33,,,,,,,fee schedule,3489.62,15482.25,
Treatment of penis lesion,54110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7796.17,,,,,,,fee schedule,3489.62,15482.25,
Treatment of penis lesion,54110,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Treatment of penis lesion,54110,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Treatment of penis lesion,54110,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Treatment of penis lesion,54110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Treatment of penis lesion,54110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Treatment of penis lesion,54110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Treatment of penis lesion,54110,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Treat penis lesion graft,54111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8468.26,,,,,,,fee schedule,5308,23549.82,
Treat penis lesion graft,54111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6788.05,,,,,,,fee schedule,5308,23549.82,
Treat penis lesion graft,54111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7415.33,,,,,,,fee schedule,5308,23549.82,
Treat penis lesion graft,54111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7796.17,,,,,,,fee schedule,5308,23549.82,
Treat penis lesion graft,54111,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23549.82,,,,,,,fee schedule,5308,23549.82,APC 378
Treat penis lesion graft,54111,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5573.4,,,,,,,fee schedule,5308,23549.82,APC
Treat penis lesion graft,54111,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5520.32,,,,,,,fee schedule,5308,23549.82,APC
Treat penis lesion graft,54111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5308,,,,,,,fee schedule,5308,23549.82,APC
Treat penis lesion graft,54111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8121.25,,,,,,,fee schedule,5308,23549.82,Radiology
Treat penis lesion graft,54111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7431.21,,,,,,,fee schedule,5308,23549.82,APC
Treat penis lesion graft,54111,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9289.01,,,,,,,fee schedule,5308,23549.82,APC
Treat penis lesion graft,54112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8468.26,,,,,,,fee schedule,6788.05,41578.13,
Treat penis lesion graft,54112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6788.05,,,,,,,fee schedule,6788.05,41578.13,
Treat penis lesion graft,54112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7415.33,,,,,,,fee schedule,6788.05,41578.13,
Treat penis lesion graft,54112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7796.17,,,,,,,fee schedule,6788.05,41578.13,
Treat penis lesion graft,54112,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,41578.13,,,,,,,fee schedule,6788.05,41578.13,APC 378
Treat penis lesion graft,54112,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9840.06,,,,,,,fee schedule,6788.05,41578.13,APC
Treat penis lesion graft,54112,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9746.35,,,,,,,fee schedule,6788.05,41578.13,APC
Treat penis lesion graft,54112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9371.49,,,,,,,fee schedule,6788.05,41578.13,APC
Treat penis lesion graft,54112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14338.38,,,,,,,fee schedule,6788.05,41578.13,Radiology
Treat penis lesion graft,54112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13120.09,,,,,,,fee schedule,6788.05,41578.13,APC
Treat penis lesion graft,54112,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16400.11,,,,,,,fee schedule,6788.05,41578.13,APC
Treatment of penis lesion,54115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4572.14,,,,,,,fee schedule,2875.57,12757.95,
Treatment of penis lesion,54115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3664.97,,,,,,,fee schedule,2875.57,12757.95,
Treatment of penis lesion,54115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4003.64,,,,,,,fee schedule,2875.57,12757.95,
Treatment of penis lesion,54115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4209.27,,,,,,,fee schedule,2875.57,12757.95,
Treatment of penis lesion,54115,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Treatment of penis lesion,54115,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Treatment of penis lesion,54115,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Treatment of penis lesion,54115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Treatment of penis lesion,54115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Treatment of penis lesion,54115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Treatment of penis lesion,54115,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Partial removal of penis,54120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8468.26,,,,,,,fee schedule,3489.62,15482.25,
Partial removal of penis,54120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6788.05,,,,,,,fee schedule,3489.62,15482.25,
Partial removal of penis,54120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7415.33,,,,,,,fee schedule,3489.62,15482.25,
Partial removal of penis,54120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7796.17,,,,,,,fee schedule,3489.62,15482.25,
Partial removal of penis,54120,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Partial removal of penis,54120,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Partial removal of penis,54120,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Partial removal of penis,54120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Partial removal of penis,54120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Partial removal of penis,54120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Partial removal of penis,54120,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Circumcision w/regionl block,54150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6721.57,,,,,,,fee schedule,2069.41,9181.28,
Circumcision w/regionl block,54150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5387.93,,,,,,,fee schedule,2069.41,9181.28,
Circumcision w/regionl block,54150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5885.82,,,,,,,fee schedule,2069.41,9181.28,
Circumcision w/regionl block,54150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6188.11,,,,,,,fee schedule,2069.41,9181.28,
Circumcision w/regionl block,54150,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9181.28,,,,,,,fee schedule,2069.41,9181.28,APC 378
Circumcision w/regionl block,54150,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2172.88,,,,,,,fee schedule,2069.41,9181.28,APC
Circumcision w/regionl block,54150,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2152.19,,,,,,,fee schedule,2069.41,9181.28,APC
Circumcision w/regionl block,54150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2069.41,,,,,,,fee schedule,2069.41,9181.28,APC
Circumcision w/regionl block,54150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3166.2,,,,,,,fee schedule,2069.41,9181.28,Radiology
Circumcision w/regionl block,54150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2897.18,,,,,,,fee schedule,2069.41,9181.28,APC
Circumcision w/regionl block,54150,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3621.47,,,,,,,fee schedule,2069.41,9181.28,APC
Circumcision neonate,54160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5571.76,,,,,,,fee schedule,690.3,5571.76,
Circumcision neonate,54160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4466.25,,,,,,,fee schedule,690.3,5571.76,
Circumcision neonate,54160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4878.97,,,,,,,fee schedule,690.3,5571.76,
Circumcision neonate,54160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5129.55,,,,,,,fee schedule,690.3,5571.76,
Circumcision neonate,54160,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3062.63,,,,,,,fee schedule,690.3,5571.76,APC 378
Circumcision neonate,54160,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,724.82,,,,,,,fee schedule,690.3,5571.76,APC
Circumcision neonate,54160,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,717.91,,,,,,,fee schedule,690.3,5571.76,APC
Circumcision neonate,54160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,690.3,,,,,,,fee schedule,690.3,5571.76,APC
Circumcision neonate,54160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1056.16,,,,,,,fee schedule,690.3,5571.76,Radiology
Circumcision neonate,54160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,966.42,,,,,,,fee schedule,690.3,5571.76,APC
Circumcision neonate,54160,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1208.03,,,,,,,fee schedule,690.3,5571.76,APC
Circum 28 days or older,54161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6981.63,,,,,,,fee schedule,2069.41,9181.28,
Circum 28 days or older,54161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5596.39,,,,,,,fee schedule,2069.41,9181.28,
Circum 28 days or older,54161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6113.55,,,,,,,fee schedule,2069.41,9181.28,
Circum 28 days or older,54161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6427.54,,,,,,,fee schedule,2069.41,9181.28,
Circum 28 days or older,54161,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9181.28,,,,,,,fee schedule,2069.41,9181.28,APC 378
Circum 28 days or older,54161,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2172.88,,,,,,,fee schedule,2069.41,9181.28,APC
Circum 28 days or older,54161,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2152.19,,,,,,,fee schedule,2069.41,9181.28,APC
Circum 28 days or older,54161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2069.41,,,,,,,fee schedule,2069.41,9181.28,APC
Circum 28 days or older,54161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3166.2,,,,,,,fee schedule,2069.41,9181.28,Radiology
Circum 28 days or older,54161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2897.18,,,,,,,fee schedule,2069.41,9181.28,APC
Circum 28 days or older,54161,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3621.47,,,,,,,fee schedule,2069.41,9181.28,APC
Lysis penil circumic lesion,54162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6253.46,,,,,,,fee schedule,2069.41,9181.28,
Lysis penil circumic lesion,54162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5012.69,,,,,,,fee schedule,2069.41,9181.28,
Lysis penil circumic lesion,54162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5475.91,,,,,,,fee schedule,2069.41,9181.28,
Lysis penil circumic lesion,54162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5757.15,,,,,,,fee schedule,2069.41,9181.28,
Lysis penil circumic lesion,54162,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9181.28,,,,,,,fee schedule,2069.41,9181.28,APC 378
Lysis penil circumic lesion,54162,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2172.88,,,,,,,fee schedule,2069.41,9181.28,APC
Lysis penil circumic lesion,54162,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2152.19,,,,,,,fee schedule,2069.41,9181.28,APC
Lysis penil circumic lesion,54162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2069.41,,,,,,,fee schedule,2069.41,9181.28,APC
Lysis penil circumic lesion,54162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3166.2,,,,,,,fee schedule,2069.41,9181.28,Radiology
Lysis penil circumic lesion,54162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2897.18,,,,,,,fee schedule,2069.41,9181.28,APC
Lysis penil circumic lesion,54162,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3621.47,,,,,,,fee schedule,2069.41,9181.28,APC
Repair of circumcision,54163,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6604.54,,,,,,,fee schedule,2069.41,9181.28,
Repair of circumcision,54163,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5294.12,,,,,,,fee schedule,2069.41,9181.28,
Repair of circumcision,54163,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5783.34,,,,,,,fee schedule,2069.41,9181.28,
Repair of circumcision,54163,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6080.37,,,,,,,fee schedule,2069.41,9181.28,
Repair of circumcision,54163,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9181.28,,,,,,,fee schedule,2069.41,9181.28,APC 378
Repair of circumcision,54163,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2172.88,,,,,,,fee schedule,2069.41,9181.28,APC
Repair of circumcision,54163,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2152.19,,,,,,,fee schedule,2069.41,9181.28,APC
Repair of circumcision,54163,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2069.41,,,,,,,fee schedule,2069.41,9181.28,APC
Repair of circumcision,54163,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3166.2,,,,,,,fee schedule,2069.41,9181.28,Radiology
Repair of circumcision,54163,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2897.18,,,,,,,fee schedule,2069.41,9181.28,APC
Repair of circumcision,54163,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3621.47,,,,,,,fee schedule,2069.41,9181.28,APC
Frenulotomy of penis,54164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3594.84,,,,,,,fee schedule,2069.41,9181.28,
Frenulotomy of penis,54164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2881.58,,,,,,,fee schedule,2069.41,9181.28,
Frenulotomy of penis,54164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3147.87,,,,,,,fee schedule,2069.41,9181.28,
Frenulotomy of penis,54164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3309.54,,,,,,,fee schedule,2069.41,9181.28,
Frenulotomy of penis,54164,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9181.28,,,,,,,fee schedule,2069.41,9181.28,APC 378
Frenulotomy of penis,54164,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2172.88,,,,,,,fee schedule,2069.41,9181.28,APC
Frenulotomy of penis,54164,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2152.19,,,,,,,fee schedule,2069.41,9181.28,APC
Frenulotomy of penis,54164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2069.41,,,,,,,fee schedule,2069.41,9181.28,APC
Frenulotomy of penis,54164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3166.2,,,,,,,fee schedule,2069.41,9181.28,Radiology
Frenulotomy of penis,54164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2897.18,,,,,,,fee schedule,2069.41,9181.28,APC
Frenulotomy of penis,54164,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3621.47,,,,,,,fee schedule,2069.41,9181.28,APC
Treatment of penis lesion,54200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,501.08,,,,,,,fee schedule,247.34,1097.37,
Treatment of penis lesion,54200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,401.66,,,,,,,fee schedule,247.34,1097.37,
Treatment of penis lesion,54200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,438.77,,,,,,,fee schedule,247.34,1097.37,
Treatment of penis lesion,54200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,461.31,,,,,,,fee schedule,247.34,1097.37,
Treatment of penis lesion,54200,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1097.37,,,,,,,fee schedule,247.34,1097.37,APC 378
Treatment of penis lesion,54200,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,259.71,,,,,,,fee schedule,247.34,1097.37,APC
Treatment of penis lesion,54200,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,257.24,,,,,,,fee schedule,247.34,1097.37,APC
Treatment of penis lesion,54200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,247.34,,,,,,,fee schedule,247.34,1097.37,APC
Treatment of penis lesion,54200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,378.43,,,,,,,fee schedule,247.34,1097.37,Radiology
Treatment of penis lesion,54200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,346.28,,,,,,,fee schedule,247.34,1097.37,APC
Treatment of penis lesion,54200,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,432.85,,,,,,,fee schedule,247.34,1097.37,APC
Treatment of penis lesion,54205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9530.26,,,,,,,fee schedule,5308,23549.82,
Treatment of penis lesion,54205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7639.34,,,,,,,fee schedule,5308,23549.82,
Treatment of penis lesion,54205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8345.28,,,,,,,fee schedule,5308,23549.82,
Treatment of penis lesion,54205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8773.89,,,,,,,fee schedule,5308,23549.82,
Treatment of penis lesion,54205,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23549.82,,,,,,,fee schedule,5308,23549.82,APC 378
Treatment of penis lesion,54205,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5573.4,,,,,,,fee schedule,5308,23549.82,APC
Treatment of penis lesion,54205,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5520.32,,,,,,,fee schedule,5308,23549.82,APC
Treatment of penis lesion,54205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5308,,,,,,,fee schedule,5308,23549.82,APC
Treatment of penis lesion,54205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8121.25,,,,,,,fee schedule,5308,23549.82,Radiology
Treatment of penis lesion,54205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7431.21,,,,,,,fee schedule,5308,23549.82,APC
Treatment of penis lesion,54205,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9289.01,,,,,,,fee schedule,5308,23549.82,APC
Treatment of penis lesion,54220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4297.02,,,,,,,fee schedule,247.34,4297.02,
Treatment of penis lesion,54220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3444.43,,,,,,,fee schedule,247.34,4297.02,
Treatment of penis lesion,54220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3762.73,,,,,,,fee schedule,247.34,4297.02,
Treatment of penis lesion,54220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3955.98,,,,,,,fee schedule,247.34,4297.02,
Treatment of penis lesion,54220,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1097.37,,,,,,,fee schedule,247.34,4297.02,APC 378
Treatment of penis lesion,54220,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,259.71,,,,,,,fee schedule,247.34,4297.02,APC
Treatment of penis lesion,54220,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,257.24,,,,,,,fee schedule,247.34,4297.02,APC
Treatment of penis lesion,54220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,247.34,,,,,,,fee schedule,247.34,4297.02,APC
Treatment of penis lesion,54220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,378.43,,,,,,,fee schedule,247.34,4297.02,Radiology
Treatment of penis lesion,54220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,346.28,,,,,,,fee schedule,247.34,4297.02,APC
Treatment of penis lesion,54220,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,432.85,,,,,,,fee schedule,247.34,4297.02,APC
Dynamic cavernosometry,54231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4827.14,,,,,,,fee schedule,247.34,4827.14,
Dynamic cavernosometry,54231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3869.37,,,,,,,fee schedule,247.34,4827.14,
Dynamic cavernosometry,54231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4226.94,,,,,,,fee schedule,247.34,4827.14,
Dynamic cavernosometry,54231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4444.03,,,,,,,fee schedule,247.34,4827.14,
Dynamic cavernosometry,54231,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1097.37,,,,,,,fee schedule,247.34,4827.14,APC 378
Dynamic cavernosometry,54231,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,259.71,,,,,,,fee schedule,247.34,4827.14,APC
Dynamic cavernosometry,54231,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,257.24,,,,,,,fee schedule,247.34,4827.14,APC
Dynamic cavernosometry,54231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,247.34,,,,,,,fee schedule,247.34,4827.14,APC
Dynamic cavernosometry,54231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,378.43,,,,,,,fee schedule,247.34,4827.14,Radiology
Dynamic cavernosometry,54231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,346.28,,,,,,,fee schedule,247.34,4827.14,APC
Dynamic cavernosometry,54231,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,432.85,,,,,,,fee schedule,247.34,4827.14,APC
Penile injection,54235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,501.08,,,,,,,fee schedule,247.34,1097.37,
Penile injection,54235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,401.66,,,,,,,fee schedule,247.34,1097.37,
Penile injection,54235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,438.77,,,,,,,fee schedule,247.34,1097.37,
Penile injection,54235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,461.31,,,,,,,fee schedule,247.34,1097.37,
Penile injection,54235,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1097.37,,,,,,,fee schedule,247.34,1097.37,APC 378
Penile injection,54235,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,259.71,,,,,,,fee schedule,247.34,1097.37,APC
Penile injection,54235,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,257.24,,,,,,,fee schedule,247.34,1097.37,APC
Penile injection,54235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,247.34,,,,,,,fee schedule,247.34,1097.37,APC
Penile injection,54235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,378.43,,,,,,,fee schedule,247.34,1097.37,Radiology
Penile injection,54235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,346.28,,,,,,,fee schedule,247.34,1097.37,APC
Penile injection,54235,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,432.85,,,,,,,fee schedule,247.34,1097.37,APC
Penis study,54240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,121.79,,,,,,,fee schedule,97.63,948.37,
Penis study,54240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,97.63,,,,,,,fee schedule,97.63,948.37,
Penis study,54240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,106.65,,,,,,,fee schedule,97.63,948.37,
Penis study,54240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,112.13,,,,,,,fee schedule,97.63,948.37,
Penis study,54240,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,97.63,948.37,APC 378
Penis study,54240,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,97.63,948.37,APC
Penis study,54240,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,97.63,948.37,APC
Penis study,54240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,97.63,948.37,APC
Penis study,54240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,97.63,948.37,Radiology
Penis study,54240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,97.63,948.37,APC
Penis study,54240,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,97.63,948.37,APC
Penis study,54250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,43.02,,,,,,,fee schedule,34.48,1097.37,
Penis study,54250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,34.48,,,,,,,fee schedule,34.48,1097.37,
Penis study,54250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37.67,,,,,,,fee schedule,34.48,1097.37,
Penis study,54250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,39.6,,,,,,,fee schedule,34.48,1097.37,
Penis study,54250,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1097.37,,,,,,,fee schedule,34.48,1097.37,APC 378
Penis study,54250,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,259.71,,,,,,,fee schedule,34.48,1097.37,APC
Penis study,54250,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,257.24,,,,,,,fee schedule,34.48,1097.37,APC
Penis study,54250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,247.34,,,,,,,fee schedule,34.48,1097.37,APC
Penis study,54250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,378.43,,,,,,,fee schedule,34.48,1097.37,Radiology
Penis study,54250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,346.28,,,,,,,fee schedule,34.48,1097.37,APC
Penis study,54250,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,432.85,,,,,,,fee schedule,34.48,1097.37,APC
Revision of penis,54300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9062.15,,,,,,,fee schedule,3489.62,15482.25,
Revision of penis,54300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7264.1,,,,,,,fee schedule,3489.62,15482.25,
Revision of penis,54300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7935.37,,,,,,,fee schedule,3489.62,15482.25,
Revision of penis,54300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8342.93,,,,,,,fee schedule,3489.62,15482.25,
Revision of penis,54300,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Revision of penis,54300,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Revision of penis,54300,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Revision of penis,54300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Revision of penis,54300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Revision of penis,54300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Revision of penis,54300,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Revision of penis,54304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8125.92,,,,,,,fee schedule,3489.62,15482.25,
Revision of penis,54304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6513.63,,,,,,,fee schedule,3489.62,15482.25,
Revision of penis,54304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7115.55,,,,,,,fee schedule,3489.62,15482.25,
Revision of penis,54304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7481,,,,,,,fee schedule,3489.62,15482.25,
Revision of penis,54304,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Revision of penis,54304,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Revision of penis,54304,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Revision of penis,54304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Revision of penis,54304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Revision of penis,54304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Revision of penis,54304,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Reconstruction of urethra,54308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8468.26,,,,,,,fee schedule,5308,23549.82,
Reconstruction of urethra,54308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6788.05,,,,,,,fee schedule,5308,23549.82,
Reconstruction of urethra,54308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7415.33,,,,,,,fee schedule,5308,23549.82,
Reconstruction of urethra,54308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7796.17,,,,,,,fee schedule,5308,23549.82,
Reconstruction of urethra,54308,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23549.82,,,,,,,fee schedule,5308,23549.82,APC 378
Reconstruction of urethra,54308,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5573.4,,,,,,,fee schedule,5308,23549.82,APC
Reconstruction of urethra,54308,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5520.32,,,,,,,fee schedule,5308,23549.82,APC
Reconstruction of urethra,54308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5308,,,,,,,fee schedule,5308,23549.82,APC
Reconstruction of urethra,54308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8121.25,,,,,,,fee schedule,5308,23549.82,Radiology
Reconstruction of urethra,54308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7431.21,,,,,,,fee schedule,5308,23549.82,APC
Reconstruction of urethra,54308,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9289.01,,,,,,,fee schedule,5308,23549.82,APC
Reconstruction of urethra,54312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8468.26,,,,,,,fee schedule,3489.62,15482.25,
Reconstruction of urethra,54312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6788.05,,,,,,,fee schedule,3489.62,15482.25,
Reconstruction of urethra,54312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7415.33,,,,,,,fee schedule,3489.62,15482.25,
Reconstruction of urethra,54312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7796.17,,,,,,,fee schedule,3489.62,15482.25,
Reconstruction of urethra,54312,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Reconstruction of urethra,54312,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Reconstruction of urethra,54312,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Reconstruction of urethra,54312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Reconstruction of urethra,54312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Reconstruction of urethra,54312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Reconstruction of urethra,54312,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Reconstruction of urethra,54316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8468.26,,,,,,,fee schedule,6788.05,41578.13,
Reconstruction of urethra,54316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6788.05,,,,,,,fee schedule,6788.05,41578.13,
Reconstruction of urethra,54316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7415.33,,,,,,,fee schedule,6788.05,41578.13,
Reconstruction of urethra,54316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7796.17,,,,,,,fee schedule,6788.05,41578.13,
Reconstruction of urethra,54316,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,41578.13,,,,,,,fee schedule,6788.05,41578.13,APC 378
Reconstruction of urethra,54316,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9840.06,,,,,,,fee schedule,6788.05,41578.13,APC
Reconstruction of urethra,54316,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9746.35,,,,,,,fee schedule,6788.05,41578.13,APC
Reconstruction of urethra,54316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9371.49,,,,,,,fee schedule,6788.05,41578.13,APC
Reconstruction of urethra,54316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14338.38,,,,,,,fee schedule,6788.05,41578.13,Radiology
Reconstruction of urethra,54316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13120.09,,,,,,,fee schedule,6788.05,41578.13,APC
Reconstruction of urethra,54316,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16400.11,,,,,,,fee schedule,6788.05,41578.13,APC
Reconstruction of urethra,54318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8468.26,,,,,,,fee schedule,3489.62,15482.25,
Reconstruction of urethra,54318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6788.05,,,,,,,fee schedule,3489.62,15482.25,
Reconstruction of urethra,54318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7415.33,,,,,,,fee schedule,3489.62,15482.25,
Reconstruction of urethra,54318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7796.17,,,,,,,fee schedule,3489.62,15482.25,
Reconstruction of urethra,54318,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Reconstruction of urethra,54318,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Reconstruction of urethra,54318,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Reconstruction of urethra,54318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Reconstruction of urethra,54318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Reconstruction of urethra,54318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Reconstruction of urethra,54318,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Reconstruction of urethra,54322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7657.8,,,,,,,fee schedule,3489.62,15482.25,
Reconstruction of urethra,54322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6138.4,,,,,,,fee schedule,3489.62,15482.25,
Reconstruction of urethra,54322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6705.64,,,,,,,fee schedule,3489.62,15482.25,
Reconstruction of urethra,54322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7050.04,,,,,,,fee schedule,3489.62,15482.25,
Reconstruction of urethra,54322,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Reconstruction of urethra,54322,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Reconstruction of urethra,54322,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Reconstruction of urethra,54322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Reconstruction of urethra,54322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Reconstruction of urethra,54322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Reconstruction of urethra,54322,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Reconstruction of urethra,54324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8468.26,,,,,,,fee schedule,3489.62,15482.25,
Reconstruction of urethra,54324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6788.05,,,,,,,fee schedule,3489.62,15482.25,
Reconstruction of urethra,54324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7415.33,,,,,,,fee schedule,3489.62,15482.25,
Reconstruction of urethra,54324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7796.17,,,,,,,fee schedule,3489.62,15482.25,
Reconstruction of urethra,54324,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Reconstruction of urethra,54324,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Reconstruction of urethra,54324,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Reconstruction of urethra,54324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Reconstruction of urethra,54324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Reconstruction of urethra,54324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Reconstruction of urethra,54324,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Reconstruction of urethra,54326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8468.26,,,,,,,fee schedule,3489.62,15482.25,
Reconstruction of urethra,54326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6788.05,,,,,,,fee schedule,3489.62,15482.25,
Reconstruction of urethra,54326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7415.33,,,,,,,fee schedule,3489.62,15482.25,
Reconstruction of urethra,54326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7796.17,,,,,,,fee schedule,3489.62,15482.25,
Reconstruction of urethra,54326,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Reconstruction of urethra,54326,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Reconstruction of urethra,54326,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Reconstruction of urethra,54326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Reconstruction of urethra,54326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Reconstruction of urethra,54326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Reconstruction of urethra,54326,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Revise penis/urethra,54328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8468.26,,,,,,,fee schedule,3489.62,15482.25,
Revise penis/urethra,54328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6788.05,,,,,,,fee schedule,3489.62,15482.25,
Revise penis/urethra,54328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7415.33,,,,,,,fee schedule,3489.62,15482.25,
Revise penis/urethra,54328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7796.17,,,,,,,fee schedule,3489.62,15482.25,
Revise penis/urethra,54328,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Revise penis/urethra,54328,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Revise penis/urethra,54328,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Revise penis/urethra,54328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Revise penis/urethra,54328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Revise penis/urethra,54328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Revise penis/urethra,54328,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Revise penis/urethra,54332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9764.32,,,,,,,fee schedule,3489.62,15482.25,
Revise penis/urethra,54332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7826.95,,,,,,,fee schedule,3489.62,15482.25,
Revise penis/urethra,54332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8550.24,,,,,,,fee schedule,3489.62,15482.25,
Revise penis/urethra,54332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8989.37,,,,,,,fee schedule,3489.62,15482.25,
Revise penis/urethra,54332,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Revise penis/urethra,54332,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Revise penis/urethra,54332,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Revise penis/urethra,54332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Revise penis/urethra,54332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Revise penis/urethra,54332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Revise penis/urethra,54332,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Revise penis/urethra,54336,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9610.88,,,,,,,fee schedule,3489.62,15482.25,
Revise penis/urethra,54336,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7703.96,,,,,,,fee schedule,3489.62,15482.25,
Revise penis/urethra,54336,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8415.87,,,,,,,fee schedule,3489.62,15482.25,
Revise penis/urethra,54336,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8848.11,,,,,,,fee schedule,3489.62,15482.25,
Revise penis/urethra,54336,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Revise penis/urethra,54336,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Revise penis/urethra,54336,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Revise penis/urethra,54336,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Revise penis/urethra,54336,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Revise penis/urethra,54336,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Revise penis/urethra,54336,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Secondary urethral surgery,54340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8125.92,,,,,,,fee schedule,3489.62,15482.25,
Secondary urethral surgery,54340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6513.63,,,,,,,fee schedule,3489.62,15482.25,
Secondary urethral surgery,54340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7115.55,,,,,,,fee schedule,3489.62,15482.25,
Secondary urethral surgery,54340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7481,,,,,,,fee schedule,3489.62,15482.25,
Secondary urethral surgery,54340,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Secondary urethral surgery,54340,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Secondary urethral surgery,54340,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Secondary urethral surgery,54340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Secondary urethral surgery,54340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Secondary urethral surgery,54340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Secondary urethral surgery,54340,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Secondary urethral surgery,54344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8468.26,,,,,,,fee schedule,6788.05,41578.13,
Secondary urethral surgery,54344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6788.05,,,,,,,fee schedule,6788.05,41578.13,
Secondary urethral surgery,54344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7415.33,,,,,,,fee schedule,6788.05,41578.13,
Secondary urethral surgery,54344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7796.17,,,,,,,fee schedule,6788.05,41578.13,
Secondary urethral surgery,54344,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,41578.13,,,,,,,fee schedule,6788.05,41578.13,APC 378
Secondary urethral surgery,54344,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9840.06,,,,,,,fee schedule,6788.05,41578.13,APC
Secondary urethral surgery,54344,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9746.35,,,,,,,fee schedule,6788.05,41578.13,APC
Secondary urethral surgery,54344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9371.49,,,,,,,fee schedule,6788.05,41578.13,APC
Secondary urethral surgery,54344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14338.38,,,,,,,fee schedule,6788.05,41578.13,Radiology
Secondary urethral surgery,54344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13120.09,,,,,,,fee schedule,6788.05,41578.13,APC
Secondary urethral surgery,54344,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16400.11,,,,,,,fee schedule,6788.05,41578.13,APC
Secondary urethral surgery,54348,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8468.26,,,,,,,fee schedule,5308,23549.82,
Secondary urethral surgery,54348,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6788.05,,,,,,,fee schedule,5308,23549.82,
Secondary urethral surgery,54348,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7415.33,,,,,,,fee schedule,5308,23549.82,
Secondary urethral surgery,54348,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7796.17,,,,,,,fee schedule,5308,23549.82,
Secondary urethral surgery,54348,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23549.82,,,,,,,fee schedule,5308,23549.82,APC 378
Secondary urethral surgery,54348,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5573.4,,,,,,,fee schedule,5308,23549.82,APC
Secondary urethral surgery,54348,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5520.32,,,,,,,fee schedule,5308,23549.82,APC
Secondary urethral surgery,54348,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5308,,,,,,,fee schedule,5308,23549.82,APC
Secondary urethral surgery,54348,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8121.25,,,,,,,fee schedule,5308,23549.82,Radiology
Secondary urethral surgery,54348,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7431.21,,,,,,,fee schedule,5308,23549.82,APC
Secondary urethral surgery,54348,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9289.01,,,,,,,fee schedule,5308,23549.82,APC
Reconstruct urethra/penis,54352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8468.26,,,,,,,fee schedule,5308,23549.82,
Reconstruct urethra/penis,54352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6788.05,,,,,,,fee schedule,5308,23549.82,
Reconstruct urethra/penis,54352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7415.33,,,,,,,fee schedule,5308,23549.82,
Reconstruct urethra/penis,54352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7796.17,,,,,,,fee schedule,5308,23549.82,
Reconstruct urethra/penis,54352,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23549.82,,,,,,,fee schedule,5308,23549.82,APC 378
Reconstruct urethra/penis,54352,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5573.4,,,,,,,fee schedule,5308,23549.82,APC
Reconstruct urethra/penis,54352,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5520.32,,,,,,,fee schedule,5308,23549.82,APC
Reconstruct urethra/penis,54352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5308,,,,,,,fee schedule,5308,23549.82,APC
Reconstruct urethra/penis,54352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8121.25,,,,,,,fee schedule,5308,23549.82,Radiology
Reconstruct urethra/penis,54352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7431.21,,,,,,,fee schedule,5308,23549.82,APC
Reconstruct urethra/penis,54352,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9289.01,,,,,,,fee schedule,5308,23549.82,APC
Penis plastic surgery,54360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8828.09,,,,,,,fee schedule,3489.62,15482.25,
Penis plastic surgery,54360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7076.48,,,,,,,fee schedule,3489.62,15482.25,
Penis plastic surgery,54360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7730.42,,,,,,,fee schedule,3489.62,15482.25,
Penis plastic surgery,54360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8127.45,,,,,,,fee schedule,3489.62,15482.25,
Penis plastic surgery,54360,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Penis plastic surgery,54360,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Penis plastic surgery,54360,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Penis plastic surgery,54360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Penis plastic surgery,54360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Penis plastic surgery,54360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Penis plastic surgery,54360,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Repair penis,54380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8468.26,,,,,,,fee schedule,2069.41,9181.28,
Repair penis,54380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6788.05,,,,,,,fee schedule,2069.41,9181.28,
Repair penis,54380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7415.33,,,,,,,fee schedule,2069.41,9181.28,
Repair penis,54380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7796.17,,,,,,,fee schedule,2069.41,9181.28,
Repair penis,54380,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9181.28,,,,,,,fee schedule,2069.41,9181.28,APC 378
Repair penis,54380,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2172.88,,,,,,,fee schedule,2069.41,9181.28,APC
Repair penis,54380,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2152.19,,,,,,,fee schedule,2069.41,9181.28,APC
Repair penis,54380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2069.41,,,,,,,fee schedule,2069.41,9181.28,APC
Repair penis,54380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3166.2,,,,,,,fee schedule,2069.41,9181.28,Radiology
Repair penis,54380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2897.18,,,,,,,fee schedule,2069.41,9181.28,APC
Repair penis,54380,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3621.47,,,,,,,fee schedule,2069.41,9181.28,APC
Repair penis,54385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8468.26,,,,,,,fee schedule,2069.41,9181.28,
Repair penis,54385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6788.05,,,,,,,fee schedule,2069.41,9181.28,
Repair penis,54385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7415.33,,,,,,,fee schedule,2069.41,9181.28,
Repair penis,54385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7796.17,,,,,,,fee schedule,2069.41,9181.28,
Repair penis,54385,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9181.28,,,,,,,fee schedule,2069.41,9181.28,APC 378
Repair penis,54385,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2172.88,,,,,,,fee schedule,2069.41,9181.28,APC
Repair penis,54385,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2152.19,,,,,,,fee schedule,2069.41,9181.28,APC
Repair penis,54385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2069.41,,,,,,,fee schedule,2069.41,9181.28,APC
Repair penis,54385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3166.2,,,,,,,fee schedule,2069.41,9181.28,Radiology
Repair penis,54385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2897.18,,,,,,,fee schedule,2069.41,9181.28,APC
Repair penis,54385,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3621.47,,,,,,,fee schedule,2069.41,9181.28,APC
Insert semi-rigid prosthesis,54400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20873.61,,,,,,,fee schedule,13061.09,57947.66,
Insert semi-rigid prosthesis,54400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16732.02,,,,,,,fee schedule,13061.09,57947.66,
Insert semi-rigid prosthesis,54400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18278.22,,,,,,,fee schedule,13061.09,57947.66,
Insert semi-rigid prosthesis,54400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19216.98,,,,,,,fee schedule,13061.09,57947.66,
Insert semi-rigid prosthesis,54400,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,57947.66,,,,,,,fee schedule,13061.09,57947.66,APC 378
Insert semi-rigid prosthesis,54400,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13714.15,,,,,,,fee schedule,13061.09,57947.66,APC
Insert semi-rigid prosthesis,54400,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13583.54,,,,,,,fee schedule,13061.09,57947.66,APC
Insert semi-rigid prosthesis,54400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13061.09,,,,,,,fee schedule,13061.09,57947.66,APC
Insert semi-rigid prosthesis,54400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19983.47,,,,,,,fee schedule,13061.09,57947.66,Radiology
Insert semi-rigid prosthesis,54400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18285.53,,,,,,,fee schedule,13061.09,57947.66,APC
Insert semi-rigid prosthesis,54400,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22856.92,,,,,,,fee schedule,13061.09,57947.66,APC
Insert self-contd prosthesis,54401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,35969.91,,,,,,,fee schedule,20518.19,91032.27,
Insert self-contd prosthesis,54401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28833.03,,,,,,,fee schedule,20518.19,91032.27,
Insert self-contd prosthesis,54401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31497.46,,,,,,,fee schedule,20518.19,91032.27,
Insert self-contd prosthesis,54401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33115.16,,,,,,,fee schedule,20518.19,91032.27,
Insert self-contd prosthesis,54401,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,91032.27,,,,,,,fee schedule,20518.19,91032.27,APC 378
Insert self-contd prosthesis,54401,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21544.1,,,,,,,fee schedule,20518.19,91032.27,APC
Insert self-contd prosthesis,54401,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,21338.92,,,,,,,fee schedule,20518.19,91032.27,APC
Insert self-contd prosthesis,54401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,20518.19,,,,,,,fee schedule,20518.19,91032.27,APC
Insert self-contd prosthesis,54401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,31392.83,,,,,,,fee schedule,20518.19,91032.27,Radiology
Insert self-contd prosthesis,54401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28725.47,,,,,,,fee schedule,20518.19,91032.27,APC
Insert self-contd prosthesis,54401,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,35906.83,,,,,,,fee schedule,20518.19,91032.27,APC
Insert multi-comp penis pros,54405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,35969.91,,,,,,,fee schedule,20518.19,91032.27,
Insert multi-comp penis pros,54405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28833.03,,,,,,,fee schedule,20518.19,91032.27,
Insert multi-comp penis pros,54405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31497.46,,,,,,,fee schedule,20518.19,91032.27,
Insert multi-comp penis pros,54405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33115.16,,,,,,,fee schedule,20518.19,91032.27,
Insert multi-comp penis pros,54405,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,91032.27,,,,,,,fee schedule,20518.19,91032.27,APC 378
Insert multi-comp penis pros,54405,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21544.1,,,,,,,fee schedule,20518.19,91032.27,APC
Insert multi-comp penis pros,54405,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,21338.92,,,,,,,fee schedule,20518.19,91032.27,APC
Insert multi-comp penis pros,54405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,20518.19,,,,,,,fee schedule,20518.19,91032.27,APC
Insert multi-comp penis pros,54405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,31392.83,,,,,,,fee schedule,20518.19,91032.27,Radiology
Insert multi-comp penis pros,54405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28725.47,,,,,,,fee schedule,20518.19,91032.27,APC
Insert multi-comp penis pros,54405,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,35906.83,,,,,,,fee schedule,20518.19,91032.27,APC
Remove muti-comp penis pros,54406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8468.26,,,,,,,fee schedule,3489.62,15482.25,
Remove muti-comp penis pros,54406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6788.05,,,,,,,fee schedule,3489.62,15482.25,
Remove muti-comp penis pros,54406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7415.33,,,,,,,fee schedule,3489.62,15482.25,
Remove muti-comp penis pros,54406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7796.17,,,,,,,fee schedule,3489.62,15482.25,
Remove muti-comp penis pros,54406,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Remove muti-comp penis pros,54406,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Remove muti-comp penis pros,54406,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Remove muti-comp penis pros,54406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Remove muti-comp penis pros,54406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Remove muti-comp penis pros,54406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Remove muti-comp penis pros,54406,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Repair multi-comp penis pros,54408,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8468.26,,,,,,,fee schedule,5308,23549.82,
Repair multi-comp penis pros,54408,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6788.05,,,,,,,fee schedule,5308,23549.82,
Repair multi-comp penis pros,54408,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7415.33,,,,,,,fee schedule,5308,23549.82,
Repair multi-comp penis pros,54408,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7796.17,,,,,,,fee schedule,5308,23549.82,
Repair multi-comp penis pros,54408,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23549.82,,,,,,,fee schedule,5308,23549.82,APC 378
Repair multi-comp penis pros,54408,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5573.4,,,,,,,fee schedule,5308,23549.82,APC
Repair multi-comp penis pros,54408,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5520.32,,,,,,,fee schedule,5308,23549.82,APC
Repair multi-comp penis pros,54408,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5308,,,,,,,fee schedule,5308,23549.82,APC
Repair multi-comp penis pros,54408,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8121.25,,,,,,,fee schedule,5308,23549.82,Radiology
Repair multi-comp penis pros,54408,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7431.21,,,,,,,fee schedule,5308,23549.82,APC
Repair multi-comp penis pros,54408,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9289.01,,,,,,,fee schedule,5308,23549.82,APC
Remove/replace penis prosth,54410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10813.79,,,,,,,fee schedule,8668.19,91032.27,
Remove/replace penis prosth,54410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8668.19,,,,,,,fee schedule,8668.19,91032.27,
Remove/replace penis prosth,54410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9469.21,,,,,,,fee schedule,8668.19,91032.27,
Remove/replace penis prosth,54410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9955.55,,,,,,,fee schedule,8668.19,91032.27,
Remove/replace penis prosth,54410,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,91032.27,,,,,,,fee schedule,8668.19,91032.27,APC 378
Remove/replace penis prosth,54410,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21544.1,,,,,,,fee schedule,8668.19,91032.27,APC
Remove/replace penis prosth,54410,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,21338.92,,,,,,,fee schedule,8668.19,91032.27,APC
Remove/replace penis prosth,54410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,20518.19,,,,,,,fee schedule,8668.19,91032.27,APC
Remove/replace penis prosth,54410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,31392.83,,,,,,,fee schedule,8668.19,91032.27,Radiology
Remove/replace penis prosth,54410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28725.47,,,,,,,fee schedule,8668.19,91032.27,APC
Remove/replace penis prosth,54410,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,35906.83,,,,,,,fee schedule,8668.19,91032.27,APC
Remov/replc penis pros comp,54411,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,54294.45,,,,,,,fee schedule,20518.19,91032.27,
Remov/replc penis pros comp,54411,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,43521.74,,,,,,,fee schedule,20518.19,91032.27,
Remov/replc penis pros comp,54411,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,47543.55,,,,,,,fee schedule,20518.19,91032.27,
Remov/replc penis pros comp,54411,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,49985.36,,,,,,,fee schedule,20518.19,91032.27,
Remov/replc penis pros comp,54411,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,91032.27,,,,,,,fee schedule,20518.19,91032.27,APC 378
Remov/replc penis pros comp,54411,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21544.1,,,,,,,fee schedule,20518.19,91032.27,APC
Remov/replc penis pros comp,54411,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,21338.92,,,,,,,fee schedule,20518.19,91032.27,APC
Remov/replc penis pros comp,54411,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,20518.19,,,,,,,fee schedule,20518.19,91032.27,APC
Remov/replc penis pros comp,54411,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,31392.83,,,,,,,fee schedule,20518.19,91032.27,Radiology
Remov/replc penis pros comp,54411,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28725.47,,,,,,,fee schedule,20518.19,91032.27,APC
Remov/replc penis pros comp,54411,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,35906.83,,,,,,,fee schedule,20518.19,91032.27,APC
Remove self-contd penis pros,54415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8468.26,,,,,,,fee schedule,3489.62,15482.25,
Remove self-contd penis pros,54415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6788.05,,,,,,,fee schedule,3489.62,15482.25,
Remove self-contd penis pros,54415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7415.33,,,,,,,fee schedule,3489.62,15482.25,
Remove self-contd penis pros,54415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7796.17,,,,,,,fee schedule,3489.62,15482.25,
Remove self-contd penis pros,54415,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Remove self-contd penis pros,54415,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Remove self-contd penis pros,54415,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Remove self-contd penis pros,54415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Remove self-contd penis pros,54415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Remove self-contd penis pros,54415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Remove self-contd penis pros,54415,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Remv/repl penis contain pros,54416,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,35969.91,,,,,,,fee schedule,20518.19,91032.27,
Remv/repl penis contain pros,54416,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28833.03,,,,,,,fee schedule,20518.19,91032.27,
Remv/repl penis contain pros,54416,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31497.46,,,,,,,fee schedule,20518.19,91032.27,
Remv/repl penis contain pros,54416,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33115.16,,,,,,,fee schedule,20518.19,91032.27,
Remv/repl penis contain pros,54416,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,91032.27,,,,,,,fee schedule,20518.19,91032.27,APC 378
Remv/repl penis contain pros,54416,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21544.1,,,,,,,fee schedule,20518.19,91032.27,APC
Remv/repl penis contain pros,54416,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,21338.92,,,,,,,fee schedule,20518.19,91032.27,APC
Remv/repl penis contain pros,54416,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,20518.19,,,,,,,fee schedule,20518.19,91032.27,APC
Remv/repl penis contain pros,54416,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,31392.83,,,,,,,fee schedule,20518.19,91032.27,Radiology
Remv/repl penis contain pros,54416,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28725.47,,,,,,,fee schedule,20518.19,91032.27,APC
Remv/repl penis contain pros,54416,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,35906.83,,,,,,,fee schedule,20518.19,91032.27,APC
Remv/replc penis pros compl,54417,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,54294.45,,,,,,,fee schedule,20518.19,91032.27,
Remv/replc penis pros compl,54417,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,43521.74,,,,,,,fee schedule,20518.19,91032.27,
Remv/replc penis pros compl,54417,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,47543.55,,,,,,,fee schedule,20518.19,91032.27,
Remv/replc penis pros compl,54417,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,49985.36,,,,,,,fee schedule,20518.19,91032.27,
Remv/replc penis pros compl,54417,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,91032.27,,,,,,,fee schedule,20518.19,91032.27,APC 378
Remv/replc penis pros compl,54417,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21544.1,,,,,,,fee schedule,20518.19,91032.27,APC
Remv/replc penis pros compl,54417,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,21338.92,,,,,,,fee schedule,20518.19,91032.27,APC
Remv/replc penis pros compl,54417,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,20518.19,,,,,,,fee schedule,20518.19,91032.27,APC
Remv/replc penis pros compl,54417,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,31392.83,,,,,,,fee schedule,20518.19,91032.27,Radiology
Remv/replc penis pros compl,54417,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28725.47,,,,,,,fee schedule,20518.19,91032.27,APC
Remv/replc penis pros compl,54417,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,35906.83,,,,,,,fee schedule,20518.19,91032.27,APC
Revision of penis,54420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8468.26,,,,,,,fee schedule,3489.62,15482.25,
Revision of penis,54420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6788.05,,,,,,,fee schedule,3489.62,15482.25,
Revision of penis,54420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7415.33,,,,,,,fee schedule,3489.62,15482.25,
Revision of penis,54420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7796.17,,,,,,,fee schedule,3489.62,15482.25,
Revision of penis,54420,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Revision of penis,54420,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Revision of penis,54420,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Revision of penis,54420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Revision of penis,54420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Revision of penis,54420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Revision of penis,54420,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Revision of penis,54435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8468.26,,,,,,,fee schedule,3489.62,15482.25,
Revision of penis,54435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6788.05,,,,,,,fee schedule,3489.62,15482.25,
Revision of penis,54435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7415.33,,,,,,,fee schedule,3489.62,15482.25,
Revision of penis,54435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7796.17,,,,,,,fee schedule,3489.62,15482.25,
Revision of penis,54435,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Revision of penis,54435,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Revision of penis,54435,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Revision of penis,54435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Revision of penis,54435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Revision of penis,54435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Revision of penis,54435,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Repair corporeal tear,54437,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4297.02,,,,,,,fee schedule,3444.43,15482.25,
Repair corporeal tear,54437,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3444.43,,,,,,,fee schedule,3444.43,15482.25,
Repair corporeal tear,54437,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3762.73,,,,,,,fee schedule,3444.43,15482.25,
Repair corporeal tear,54437,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3955.98,,,,,,,fee schedule,3444.43,15482.25,
Repair corporeal tear,54437,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3444.43,15482.25,APC 378
Repair corporeal tear,54437,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3444.43,15482.25,APC
Repair corporeal tear,54437,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3444.43,15482.25,APC
Repair corporeal tear,54437,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3444.43,15482.25,APC
Repair corporeal tear,54437,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3444.43,15482.25,Radiology
Repair corporeal tear,54437,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3444.43,15482.25,APC
Repair corporeal tear,54437,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3444.43,15482.25,APC
Replantation of penis,54438,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5287.5,,,,,,,fee schedule,4238.39,5287.5,
Replantation of penis,54438,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4238.39,,,,,,,fee schedule,4238.39,5287.5,
Replantation of penis,54438,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4630.06,,,,,,,fee schedule,4238.39,5287.5,
Replantation of penis,54438,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4867.86,,,,,,,fee schedule,4238.39,5287.5,
Repair of penis,54440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7189.69,,,,,,,fee schedule,3489.62,15482.25,
Repair of penis,54440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5763.16,,,,,,,fee schedule,3489.62,15482.25,
Repair of penis,54440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6295.73,,,,,,,fee schedule,3489.62,15482.25,
Repair of penis,54440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6619.08,,,,,,,fee schedule,3489.62,15482.25,
Repair of penis,54440,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Repair of penis,54440,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Repair of penis,54440,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Repair of penis,54440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Repair of penis,54440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Repair of penis,54440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Repair of penis,54440,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Preputial stretching,54450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5785.34,,,,,,,fee schedule,247.34,5785.34,
Preputial stretching,54450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4637.46,,,,,,,fee schedule,247.34,5785.34,
Preputial stretching,54450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5066,,,,,,,fee schedule,247.34,5785.34,
Preputial stretching,54450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5326.19,,,,,,,fee schedule,247.34,5785.34,
Preputial stretching,54450,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1097.37,,,,,,,fee schedule,247.34,5785.34,APC 378
Preputial stretching,54450,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,259.71,,,,,,,fee schedule,247.34,5785.34,APC
Preputial stretching,54450,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,257.24,,,,,,,fee schedule,247.34,5785.34,APC
Preputial stretching,54450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,247.34,,,,,,,fee schedule,247.34,5785.34,APC
Preputial stretching,54450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,378.43,,,,,,,fee schedule,247.34,5785.34,Radiology
Preputial stretching,54450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,346.28,,,,,,,fee schedule,247.34,5785.34,APC
Preputial stretching,54450,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,432.85,,,,,,,fee schedule,247.34,5785.34,APC
Biopsy of testis,54500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3388.35,,,,,,,fee schedule,2716.06,12757.95,
Biopsy of testis,54500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2716.06,,,,,,,fee schedule,2716.06,12757.95,
Biopsy of testis,54500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2967.05,,,,,,,fee schedule,2716.06,12757.95,
Biopsy of testis,54500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3119.44,,,,,,,fee schedule,2716.06,12757.95,
Biopsy of testis,54500,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2716.06,12757.95,APC 378
Biopsy of testis,54500,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2716.06,12757.95,APC
Biopsy of testis,54500,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2716.06,12757.95,APC
Biopsy of testis,54500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2716.06,12757.95,APC
Biopsy of testis,54500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2716.06,12757.95,Radiology
Biopsy of testis,54500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2716.06,12757.95,APC
Biopsy of testis,54500,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2716.06,12757.95,APC
Biopsy of testis,54505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5571.76,,,,,,,fee schedule,3489.62,15482.25,
Biopsy of testis,54505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4466.25,,,,,,,fee schedule,3489.62,15482.25,
Biopsy of testis,54505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4878.97,,,,,,,fee schedule,3489.62,15482.25,
Biopsy of testis,54505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5129.55,,,,,,,fee schedule,3489.62,15482.25,
Biopsy of testis,54505,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Biopsy of testis,54505,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Biopsy of testis,54505,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Biopsy of testis,54505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Biopsy of testis,54505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Biopsy of testis,54505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Biopsy of testis,54505,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Excise Lesion Testis,54512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5571.76,,,,,,,fee schedule,3489.62,15482.25,
Excise Lesion Testis,54512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4466.25,,,,,,,fee schedule,3489.62,15482.25,
Excise Lesion Testis,54512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4878.97,,,,,,,fee schedule,3489.62,15482.25,
Excise Lesion Testis,54512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5129.55,,,,,,,fee schedule,3489.62,15482.25,
Excise Lesion Testis,54512,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Excise Lesion Testis,54512,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Excise Lesion Testis,54512,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Excise Lesion Testis,54512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Excise Lesion Testis,54512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Excise Lesion Testis,54512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Excise Lesion Testis,54512,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Removal of testis,54520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5553.92,,,,,,,fee schedule,3489.62,15482.25,
Removal of testis,54520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4451.96,,,,,,,fee schedule,3489.62,15482.25,
Removal of testis,54520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4863.36,,,,,,,fee schedule,3489.62,15482.25,
Removal of testis,54520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5113.14,,,,,,,fee schedule,3489.62,15482.25,
Removal of testis,54520,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Removal of testis,54520,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Removal of testis,54520,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Removal of testis,54520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Removal of testis,54520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Removal of testis,54520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Removal of testis,54520,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Orchiectomy partial,54522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5571.76,,,,,,,fee schedule,3489.62,15482.25,
Orchiectomy partial,54522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4466.25,,,,,,,fee schedule,3489.62,15482.25,
Orchiectomy partial,54522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4878.97,,,,,,,fee schedule,3489.62,15482.25,
Orchiectomy partial,54522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5129.55,,,,,,,fee schedule,3489.62,15482.25,
Orchiectomy partial,54522,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Orchiectomy partial,54522,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Orchiectomy partial,54522,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Orchiectomy partial,54522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Orchiectomy partial,54522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Orchiectomy partial,54522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Orchiectomy partial,54522,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Removal of testis,54530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7189.69,,,,,,,fee schedule,3544.48,15725.66,
Removal of testis,54530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5763.16,,,,,,,fee schedule,3544.48,15725.66,
Removal of testis,54530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6295.73,,,,,,,fee schedule,3544.48,15725.66,
Removal of testis,54530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6619.08,,,,,,,fee schedule,3544.48,15725.66,
Removal of testis,54530,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15725.66,,,,,,,fee schedule,3544.48,15725.66,APC 378
Removal of testis,54530,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3721.7,,,,,,,fee schedule,3544.48,15725.66,APC
Removal of testis,54530,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3686.26,,,,,,,fee schedule,3544.48,15725.66,APC
Removal of testis,54530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3544.48,,,,,,,fee schedule,3544.48,15725.66,APC
Removal of testis,54530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5423.05,,,,,,,fee schedule,3544.48,15725.66,Radiology
Removal of testis,54530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4962.27,,,,,,,fee schedule,3544.48,15725.66,APC
Removal of testis,54530,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6202.84,,,,,,,fee schedule,3544.48,15725.66,APC
Extensive testis surgery,54535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13169.56,,,,,,,fee schedule,3489.62,15482.25,
Extensive testis surgery,54535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10556.55,,,,,,,fee schedule,3489.62,15482.25,
Extensive testis surgery,54535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11532.07,,,,,,,fee schedule,3489.62,15482.25,
Extensive testis surgery,54535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12124.35,,,,,,,fee schedule,3489.62,15482.25,
Extensive testis surgery,54535,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Extensive testis surgery,54535,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Extensive testis surgery,54535,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Extensive testis surgery,54535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Extensive testis surgery,54535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Extensive testis surgery,54535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Extensive testis surgery,54535,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Exploration for testis,54550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7656.69,,,,,,,fee schedule,3544.48,15725.66,
Exploration for testis,54550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6137.51,,,,,,,fee schedule,3544.48,15725.66,
Exploration for testis,54550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6704.67,,,,,,,fee schedule,3544.48,15725.66,
Exploration for testis,54550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7049.02,,,,,,,fee schedule,3544.48,15725.66,
Exploration for testis,54550,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15725.66,,,,,,,fee schedule,3544.48,15725.66,APC 378
Exploration for testis,54550,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3721.7,,,,,,,fee schedule,3544.48,15725.66,APC
Exploration for testis,54550,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3686.26,,,,,,,fee schedule,3544.48,15725.66,APC
Exploration for testis,54550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3544.48,,,,,,,fee schedule,3544.48,15725.66,APC
Exploration for testis,54550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5423.05,,,,,,,fee schedule,3544.48,15725.66,Radiology
Exploration for testis,54550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4962.27,,,,,,,fee schedule,3544.48,15725.66,APC
Exploration for testis,54550,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6202.84,,,,,,,fee schedule,3544.48,15725.66,APC
Exploration for testis,54560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5571.76,,,,,,,fee schedule,2069.41,9181.28,
Exploration for testis,54560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4466.25,,,,,,,fee schedule,2069.41,9181.28,
Exploration for testis,54560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4878.97,,,,,,,fee schedule,2069.41,9181.28,
Exploration for testis,54560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5129.55,,,,,,,fee schedule,2069.41,9181.28,
Exploration for testis,54560,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9181.28,,,,,,,fee schedule,2069.41,9181.28,APC 378
Exploration for testis,54560,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2172.88,,,,,,,fee schedule,2069.41,9181.28,APC
Exploration for testis,54560,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2152.19,,,,,,,fee schedule,2069.41,9181.28,APC
Exploration for testis,54560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2069.41,,,,,,,fee schedule,2069.41,9181.28,APC
Exploration for testis,54560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3166.2,,,,,,,fee schedule,2069.41,9181.28,Radiology
Exploration for testis,54560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2897.18,,,,,,,fee schedule,2069.41,9181.28,APC
Exploration for testis,54560,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3621.47,,,,,,,fee schedule,2069.41,9181.28,APC
Reduce testis torsion,54600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7189.69,,,,,,,fee schedule,3489.62,15482.25,
Reduce testis torsion,54600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5763.16,,,,,,,fee schedule,3489.62,15482.25,
Reduce testis torsion,54600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6295.73,,,,,,,fee schedule,3489.62,15482.25,
Reduce testis torsion,54600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6619.08,,,,,,,fee schedule,3489.62,15482.25,
Reduce testis torsion,54600,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Reduce testis torsion,54600,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Reduce testis torsion,54600,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Reduce testis torsion,54600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Reduce testis torsion,54600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Reduce testis torsion,54600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Reduce testis torsion,54600,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Suspension of testis,54620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5571.76,,,,,,,fee schedule,3489.62,15482.25,
Suspension of testis,54620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4466.25,,,,,,,fee schedule,3489.62,15482.25,
Suspension of testis,54620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4878.97,,,,,,,fee schedule,3489.62,15482.25,
Suspension of testis,54620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5129.55,,,,,,,fee schedule,3489.62,15482.25,
Suspension of testis,54620,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Suspension of testis,54620,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Suspension of testis,54620,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Suspension of testis,54620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Suspension of testis,54620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Suspension of testis,54620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Suspension of testis,54620,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Suspension of testis,54640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5687.82,,,,,,,fee schedule,3544.48,15725.66,
Suspension of testis,54640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4559.28,,,,,,,fee schedule,3544.48,15725.66,
Suspension of testis,54640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4980.6,,,,,,,fee schedule,3544.48,15725.66,
Suspension of testis,54640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5236.4,,,,,,,fee schedule,3544.48,15725.66,
Suspension of testis,54640,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15725.66,,,,,,,fee schedule,3544.48,15725.66,APC 378
Suspension of testis,54640,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3721.7,,,,,,,fee schedule,3544.48,15725.66,APC
Suspension of testis,54640,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3686.26,,,,,,,fee schedule,3544.48,15725.66,APC
Suspension of testis,54640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3544.48,,,,,,,fee schedule,3544.48,15725.66,APC
Suspension of testis,54640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5423.05,,,,,,,fee schedule,3544.48,15725.66,Radiology
Suspension of testis,54640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4962.27,,,,,,,fee schedule,3544.48,15725.66,APC
Suspension of testis,54640,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6202.84,,,,,,,fee schedule,3544.48,15725.66,APC
Orchiopexy (Fowler-Stephens),54650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10821.16,,,,,,,fee schedule,3544.48,15725.66,
Orchiopexy (Fowler-Stephens),54650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8674.1,,,,,,,fee schedule,3544.48,15725.66,
Orchiopexy (Fowler-Stephens),54650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9475.67,,,,,,,fee schedule,3544.48,15725.66,
Orchiopexy (Fowler-Stephens),54650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9962.34,,,,,,,fee schedule,3544.48,15725.66,
Orchiopexy (Fowler-Stephens),54650,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15725.66,,,,,,,fee schedule,3544.48,15725.66,APC 378
Orchiopexy (Fowler-Stephens),54650,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3721.7,,,,,,,fee schedule,3544.48,15725.66,APC
Orchiopexy (Fowler-Stephens),54650,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3686.26,,,,,,,fee schedule,3544.48,15725.66,APC
Orchiopexy (Fowler-Stephens),54650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3544.48,,,,,,,fee schedule,3544.48,15725.66,APC
Orchiopexy (Fowler-Stephens),54650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5423.05,,,,,,,fee schedule,3544.48,15725.66,Radiology
Orchiopexy (Fowler-Stephens),54650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4962.27,,,,,,,fee schedule,3544.48,15725.66,APC
Orchiopexy (Fowler-Stephens),54650,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6202.84,,,,,,,fee schedule,3544.48,15725.66,APC
Revision of testis,54660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5571.76,,,,,,,fee schedule,4466.25,23549.82,
Revision of testis,54660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4466.25,,,,,,,fee schedule,4466.25,23549.82,
Revision of testis,54660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4878.97,,,,,,,fee schedule,4466.25,23549.82,
Revision of testis,54660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5129.55,,,,,,,fee schedule,4466.25,23549.82,
Revision of testis,54660,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23549.82,,,,,,,fee schedule,4466.25,23549.82,APC 378
Revision of testis,54660,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5573.4,,,,,,,fee schedule,4466.25,23549.82,APC
Revision of testis,54660,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5520.32,,,,,,,fee schedule,4466.25,23549.82,APC
Revision of testis,54660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5308,,,,,,,fee schedule,4466.25,23549.82,APC
Revision of testis,54660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8121.25,,,,,,,fee schedule,4466.25,23549.82,Radiology
Revision of testis,54660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7431.21,,,,,,,fee schedule,4466.25,23549.82,APC
Revision of testis,54660,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9289.01,,,,,,,fee schedule,4466.25,23549.82,APC
Repair testis injury,54670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5571.76,,,,,,,fee schedule,3489.62,15482.25,
Repair testis injury,54670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4466.25,,,,,,,fee schedule,3489.62,15482.25,
Repair testis injury,54670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4878.97,,,,,,,fee schedule,3489.62,15482.25,
Repair testis injury,54670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5129.55,,,,,,,fee schedule,3489.62,15482.25,
Repair testis injury,54670,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Repair testis injury,54670,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Repair testis injury,54670,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Repair testis injury,54670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Repair testis injury,54670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Repair testis injury,54670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Repair testis injury,54670,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Relocation of testis(es),54680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5571.76,,,,,,,fee schedule,3489.62,15482.25,
Relocation of testis(es),54680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4466.25,,,,,,,fee schedule,3489.62,15482.25,
Relocation of testis(es),54680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4878.97,,,,,,,fee schedule,3489.62,15482.25,
Relocation of testis(es),54680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5129.55,,,,,,,fee schedule,3489.62,15482.25,
Relocation of testis(es),54680,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Relocation of testis(es),54680,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Relocation of testis(es),54680,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Relocation of testis(es),54680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Relocation of testis(es),54680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Relocation of testis(es),54680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Relocation of testis(es),54680,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Laparoscopy orchiectomy,54690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11363.59,,,,,,,fee schedule,5984.88,26552.87,
Laparoscopy orchiectomy,54690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9108.91,,,,,,,fee schedule,5984.88,26552.87,
Laparoscopy orchiectomy,54690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9950.65,,,,,,,fee schedule,5984.88,26552.87,
Laparoscopy orchiectomy,54690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10461.72,,,,,,,fee schedule,5984.88,26552.87,
Laparoscopy orchiectomy,54690,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,5984.88,26552.87,APC 378
Laparoscopy orchiectomy,54690,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscopy orchiectomy,54690,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscopy orchiectomy,54690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscopy orchiectomy,54690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,5984.88,26552.87,Radiology
Laparoscopy orchiectomy,54690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscopy orchiectomy,54690,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscopy orchiopexy,54692,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17386.71,,,,,,,fee schedule,5984.88,26552.87,
Laparoscopy orchiopexy,54692,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13936.97,,,,,,,fee schedule,5984.88,26552.87,
Laparoscopy orchiopexy,54692,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15224.87,,,,,,,fee schedule,5984.88,26552.87,
Laparoscopy orchiopexy,54692,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16006.82,,,,,,,fee schedule,5984.88,26552.87,
Laparoscopy orchiopexy,54692,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,5984.88,26552.87,APC 378
Laparoscopy orchiopexy,54692,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscopy orchiopexy,54692,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscopy orchiopexy,54692,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscopy orchiopexy,54692,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,5984.88,26552.87,Radiology
Laparoscopy orchiopexy,54692,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscopy orchiopexy,54692,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscope proc testis,54699,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8584.34,,,,,,,fee schedule,5984.88,26552.87,
Laparoscope proc testis,54699,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6881.1,,,,,,,fee schedule,5984.88,26552.87,
Laparoscope proc testis,54699,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7516.98,,,,,,,fee schedule,5984.88,26552.87,
Laparoscope proc testis,54699,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7903.05,,,,,,,fee schedule,5984.88,26552.87,
Laparoscope proc testis,54699,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,5984.88,26552.87,APC 378
Laparoscope proc testis,54699,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscope proc testis,54699,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscope proc testis,54699,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscope proc testis,54699,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,5984.88,26552.87,Radiology
Laparoscope proc testis,54699,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscope proc testis,54699,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,5984.88,26552.87,APC
Drainage of scrotum,54700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7189.69,,,,,,,fee schedule,2069.41,9181.28,
Drainage of scrotum,54700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5763.16,,,,,,,fee schedule,2069.41,9181.28,
Drainage of scrotum,54700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6295.73,,,,,,,fee schedule,2069.41,9181.28,
Drainage of scrotum,54700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6619.08,,,,,,,fee schedule,2069.41,9181.28,
Drainage of scrotum,54700,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9181.28,,,,,,,fee schedule,2069.41,9181.28,APC 378
Drainage of scrotum,54700,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2172.88,,,,,,,fee schedule,2069.41,9181.28,APC
Drainage of scrotum,54700,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2152.19,,,,,,,fee schedule,2069.41,9181.28,APC
Drainage of scrotum,54700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2069.41,,,,,,,fee schedule,2069.41,9181.28,APC
Drainage of scrotum,54700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3166.2,,,,,,,fee schedule,2069.41,9181.28,Radiology
Drainage of scrotum,54700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2897.18,,,,,,,fee schedule,2069.41,9181.28,APC
Drainage of scrotum,54700,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3621.47,,,,,,,fee schedule,2069.41,9181.28,APC
Biopsy of epididymis,54800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1079.91,,,,,,,fee schedule,865.64,7254.06,
Biopsy of epididymis,54800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,865.64,,,,,,,fee schedule,865.64,7254.06,
Biopsy of epididymis,54800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,945.63,,,,,,,fee schedule,865.64,7254.06,
Biopsy of epididymis,54800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,994.2,,,,,,,fee schedule,865.64,7254.06,
Biopsy of epididymis,54800,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,865.64,7254.06,APC 378
Biopsy of epididymis,54800,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,865.64,7254.06,APC
Biopsy of epididymis,54800,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,865.64,7254.06,APC
Biopsy of epididymis,54800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,865.64,7254.06,APC
Biopsy of epididymis,54800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,865.64,7254.06,Radiology
Biopsy of epididymis,54800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,865.64,7254.06,APC
Biopsy of epididymis,54800,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,865.64,7254.06,APC
Remove epididymis lesion,54830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9062.15,,,,,,,fee schedule,3489.62,15482.25,
Remove epididymis lesion,54830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7264.1,,,,,,,fee schedule,3489.62,15482.25,
Remove epididymis lesion,54830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7935.37,,,,,,,fee schedule,3489.62,15482.25,
Remove epididymis lesion,54830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8342.93,,,,,,,fee schedule,3489.62,15482.25,
Remove epididymis lesion,54830,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Remove epididymis lesion,54830,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Remove epididymis lesion,54830,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Remove epididymis lesion,54830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Remove epididymis lesion,54830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Remove epididymis lesion,54830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Remove epididymis lesion,54830,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Remove epididymis lesion,54840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4793.12,,,,,,,fee schedule,2069.41,9181.28,
Remove epididymis lesion,54840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3842.11,,,,,,,fee schedule,2069.41,9181.28,
Remove epididymis lesion,54840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4197.15,,,,,,,fee schedule,2069.41,9181.28,
Remove epididymis lesion,54840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4412.72,,,,,,,fee schedule,2069.41,9181.28,
Remove epididymis lesion,54840,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9181.28,,,,,,,fee schedule,2069.41,9181.28,APC 378
Remove epididymis lesion,54840,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2172.88,,,,,,,fee schedule,2069.41,9181.28,APC
Remove epididymis lesion,54840,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2152.19,,,,,,,fee schedule,2069.41,9181.28,APC
Remove epididymis lesion,54840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2069.41,,,,,,,fee schedule,2069.41,9181.28,APC
Remove epididymis lesion,54840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3166.2,,,,,,,fee schedule,2069.41,9181.28,Radiology
Remove epididymis lesion,54840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2897.18,,,,,,,fee schedule,2069.41,9181.28,APC
Remove epididymis lesion,54840,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3621.47,,,,,,,fee schedule,2069.41,9181.28,APC
Removal of epididymis,54860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4062.96,,,,,,,fee schedule,3256.82,15482.25,
Removal of epididymis,54860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3256.82,,,,,,,fee schedule,3256.82,15482.25,
Removal of epididymis,54860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3557.78,,,,,,,fee schedule,3256.82,15482.25,
Removal of epididymis,54860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3740.5,,,,,,,fee schedule,3256.82,15482.25,
Removal of epididymis,54860,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3256.82,15482.25,APC 378
Removal of epididymis,54860,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3256.82,15482.25,APC
Removal of epididymis,54860,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3256.82,15482.25,APC
Removal of epididymis,54860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3256.82,15482.25,APC
Removal of epididymis,54860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3256.82,15482.25,Radiology
Removal of epididymis,54860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3256.82,15482.25,APC
Removal of epididymis,54860,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3256.82,15482.25,APC
Removal of epididymis,54861,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5571.76,,,,,,,fee schedule,3489.62,15482.25,
Removal of epididymis,54861,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4466.25,,,,,,,fee schedule,3489.62,15482.25,
Removal of epididymis,54861,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4878.97,,,,,,,fee schedule,3489.62,15482.25,
Removal of epididymis,54861,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5129.55,,,,,,,fee schedule,3489.62,15482.25,
Removal of epididymis,54861,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Removal of epididymis,54861,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Removal of epididymis,54861,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Removal of epididymis,54861,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Removal of epididymis,54861,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Removal of epididymis,54861,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Removal of epididymis,54861,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Explore Epididymis,54865,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5571.76,,,,,,,fee schedule,3489.62,15482.25,
Explore Epididymis,54865,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4466.25,,,,,,,fee schedule,3489.62,15482.25,
Explore Epididymis,54865,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4878.97,,,,,,,fee schedule,3489.62,15482.25,
Explore Epididymis,54865,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5129.55,,,,,,,fee schedule,3489.62,15482.25,
Explore Epididymis,54865,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Explore Epididymis,54865,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Explore Epididymis,54865,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Explore Epididymis,54865,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Explore Epididymis,54865,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Explore Epididymis,54865,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Explore Epididymis,54865,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Fusion of spermatic ducts,54900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5571.76,,,,,,,fee schedule,2069.41,9181.28,
Fusion of spermatic ducts,54900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4466.25,,,,,,,fee schedule,2069.41,9181.28,
Fusion of spermatic ducts,54900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4878.97,,,,,,,fee schedule,2069.41,9181.28,
Fusion of spermatic ducts,54900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5129.55,,,,,,,fee schedule,2069.41,9181.28,
Fusion of spermatic ducts,54900,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9181.28,,,,,,,fee schedule,2069.41,9181.28,APC 378
Fusion of spermatic ducts,54900,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2172.88,,,,,,,fee schedule,2069.41,9181.28,APC
Fusion of spermatic ducts,54900,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2152.19,,,,,,,fee schedule,2069.41,9181.28,APC
Fusion of spermatic ducts,54900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2069.41,,,,,,,fee schedule,2069.41,9181.28,APC
Fusion of spermatic ducts,54900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3166.2,,,,,,,fee schedule,2069.41,9181.28,Radiology
Fusion of spermatic ducts,54900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2897.18,,,,,,,fee schedule,2069.41,9181.28,APC
Fusion of spermatic ducts,54900,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3621.47,,,,,,,fee schedule,2069.41,9181.28,APC
Fusion of spermatic ducts,54901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5571.76,,,,,,,fee schedule,3489.62,15482.25,
Fusion of spermatic ducts,54901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4466.25,,,,,,,fee schedule,3489.62,15482.25,
Fusion of spermatic ducts,54901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4878.97,,,,,,,fee schedule,3489.62,15482.25,
Fusion of spermatic ducts,54901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5129.55,,,,,,,fee schedule,3489.62,15482.25,
Fusion of spermatic ducts,54901,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Fusion of spermatic ducts,54901,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Fusion of spermatic ducts,54901,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Fusion of spermatic ducts,54901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Fusion of spermatic ducts,54901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Fusion of spermatic ducts,54901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Fusion of spermatic ducts,54901,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Drainage of hydrocele,55000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1079.91,,,,,,,fee schedule,701.03,3110.22,
Drainage of hydrocele,55000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,865.64,,,,,,,fee schedule,701.03,3110.22,
Drainage of hydrocele,55000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,945.63,,,,,,,fee schedule,701.03,3110.22,
Drainage of hydrocele,55000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,994.2,,,,,,,fee schedule,701.03,3110.22,
Drainage of hydrocele,55000,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3110.22,,,,,,,fee schedule,701.03,3110.22,APC 378
Drainage of hydrocele,55000,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,736.08,,,,,,,fee schedule,701.03,3110.22,APC
Drainage of hydrocele,55000,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,729.07,,,,,,,fee schedule,701.03,3110.22,APC
Drainage of hydrocele,55000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,701.03,,,,,,,fee schedule,701.03,3110.22,APC
Drainage of hydrocele,55000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1072.57,,,,,,,fee schedule,701.03,3110.22,Radiology
Drainage of hydrocele,55000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,981.44,,,,,,,fee schedule,701.03,3110.22,APC
Drainage of hydrocele,55000,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1226.8,,,,,,,fee schedule,701.03,3110.22,APC
Removal of hydrocele,55040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7423.74,,,,,,,fee schedule,3544.48,15725.66,
Removal of hydrocele,55040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5950.78,,,,,,,fee schedule,3544.48,15725.66,
Removal of hydrocele,55040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6500.69,,,,,,,fee schedule,3544.48,15725.66,
Removal of hydrocele,55040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6834.56,,,,,,,fee schedule,3544.48,15725.66,
Removal of hydrocele,55040,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15725.66,,,,,,,fee schedule,3544.48,15725.66,APC 378
Removal of hydrocele,55040,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3721.7,,,,,,,fee schedule,3544.48,15725.66,APC
Removal of hydrocele,55040,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3686.26,,,,,,,fee schedule,3544.48,15725.66,APC
Removal of hydrocele,55040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3544.48,,,,,,,fee schedule,3544.48,15725.66,APC
Removal of hydrocele,55040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5423.05,,,,,,,fee schedule,3544.48,15725.66,Radiology
Removal of hydrocele,55040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4962.27,,,,,,,fee schedule,3544.48,15725.66,APC
Removal of hydrocele,55040,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6202.84,,,,,,,fee schedule,3544.48,15725.66,APC
Removal of hydroceles,55041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7189.69,,,,,,,fee schedule,3544.48,15725.66,
Removal of hydroceles,55041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5763.16,,,,,,,fee schedule,3544.48,15725.66,
Removal of hydroceles,55041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6295.73,,,,,,,fee schedule,3544.48,15725.66,
Removal of hydroceles,55041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6619.08,,,,,,,fee schedule,3544.48,15725.66,
Removal of hydroceles,55041,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15725.66,,,,,,,fee schedule,3544.48,15725.66,APC 378
Removal of hydroceles,55041,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3721.7,,,,,,,fee schedule,3544.48,15725.66,APC
Removal of hydroceles,55041,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3686.26,,,,,,,fee schedule,3544.48,15725.66,APC
Removal of hydroceles,55041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3544.48,,,,,,,fee schedule,3544.48,15725.66,APC
Removal of hydroceles,55041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5423.05,,,,,,,fee schedule,3544.48,15725.66,Radiology
Removal of hydroceles,55041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4962.27,,,,,,,fee schedule,3544.48,15725.66,APC
Removal of hydroceles,55041,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6202.84,,,,,,,fee schedule,3544.48,15725.66,APC
Repair of hydrocele,55060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3594.84,,,,,,,fee schedule,2881.58,15482.25,
Repair of hydrocele,55060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2881.58,,,,,,,fee schedule,2881.58,15482.25,
Repair of hydrocele,55060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3147.87,,,,,,,fee schedule,2881.58,15482.25,
Repair of hydrocele,55060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3309.54,,,,,,,fee schedule,2881.58,15482.25,
Repair of hydrocele,55060,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,2881.58,15482.25,APC 378
Repair of hydrocele,55060,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,2881.58,15482.25,APC
Repair of hydrocele,55060,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,2881.58,15482.25,APC
Repair of hydrocele,55060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,2881.58,15482.25,APC
Repair of hydrocele,55060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,2881.58,15482.25,Radiology
Repair of hydrocele,55060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,2881.58,15482.25,APC
Repair of hydrocele,55060,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,2881.58,15482.25,APC
Drainage of scrotum abscess,55100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2884.93,,,,,,,fee schedule,1635.03,7254.06,
Drainage of scrotum abscess,55100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2312.53,,,,,,,fee schedule,1635.03,7254.06,
Drainage of scrotum abscess,55100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2526.23,,,,,,,fee schedule,1635.03,7254.06,
Drainage of scrotum abscess,55100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2655.97,,,,,,,fee schedule,1635.03,7254.06,
Drainage of scrotum abscess,55100,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,7254.06,APC 378
Drainage of scrotum abscess,55100,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,7254.06,APC
Drainage of scrotum abscess,55100,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,7254.06,APC
Drainage of scrotum abscess,55100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,7254.06,APC
Drainage of scrotum abscess,55100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,7254.06,Radiology
Drainage of scrotum abscess,55100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,7254.06,APC
Drainage of scrotum abscess,55100,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,7254.06,APC
Explore scrotum,55110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5571.76,,,,,,,fee schedule,3489.62,15482.25,
Explore scrotum,55110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4466.25,,,,,,,fee schedule,3489.62,15482.25,
Explore scrotum,55110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4878.97,,,,,,,fee schedule,3489.62,15482.25,
Explore scrotum,55110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5129.55,,,,,,,fee schedule,3489.62,15482.25,
Explore scrotum,55110,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Explore scrotum,55110,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Explore scrotum,55110,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Explore scrotum,55110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Explore scrotum,55110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Explore scrotum,55110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Explore scrotum,55110,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Removal of scrotum lesion,55120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5571.76,,,,,,,fee schedule,2069.41,9181.28,
Removal of scrotum lesion,55120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4466.25,,,,,,,fee schedule,2069.41,9181.28,
Removal of scrotum lesion,55120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4878.97,,,,,,,fee schedule,2069.41,9181.28,
Removal of scrotum lesion,55120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5129.55,,,,,,,fee schedule,2069.41,9181.28,
Removal of scrotum lesion,55120,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9181.28,,,,,,,fee schedule,2069.41,9181.28,APC 378
Removal of scrotum lesion,55120,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2172.88,,,,,,,fee schedule,2069.41,9181.28,APC
Removal of scrotum lesion,55120,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2152.19,,,,,,,fee schedule,2069.41,9181.28,APC
Removal of scrotum lesion,55120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2069.41,,,,,,,fee schedule,2069.41,9181.28,APC
Removal of scrotum lesion,55120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3166.2,,,,,,,fee schedule,2069.41,9181.28,Radiology
Removal of scrotum lesion,55120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2897.18,,,,,,,fee schedule,2069.41,9181.28,APC
Removal of scrotum lesion,55120,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3621.47,,,,,,,fee schedule,2069.41,9181.28,APC
Removal of scrotum,55150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5571.76,,,,,,,fee schedule,3489.62,15482.25,
Removal of scrotum,55150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4466.25,,,,,,,fee schedule,3489.62,15482.25,
Removal of scrotum,55150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4878.97,,,,,,,fee schedule,3489.62,15482.25,
Removal of scrotum,55150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5129.55,,,,,,,fee schedule,3489.62,15482.25,
Removal of scrotum,55150,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Removal of scrotum,55150,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Removal of scrotum,55150,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Removal of scrotum,55150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Removal of scrotum,55150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Removal of scrotum,55150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Removal of scrotum,55150,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Revision of scrotum,55175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6038.9,,,,,,,fee schedule,3489.62,15482.25,
Revision of scrotum,55175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4840.71,,,,,,,fee schedule,3489.62,15482.25,
Revision of scrotum,55175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5288.03,,,,,,,fee schedule,3489.62,15482.25,
Revision of scrotum,55175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5559.62,,,,,,,fee schedule,3489.62,15482.25,
Revision of scrotum,55175,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Revision of scrotum,55175,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Revision of scrotum,55175,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Revision of scrotum,55175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Revision of scrotum,55175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Revision of scrotum,55175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Revision of scrotum,55175,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Revision of scrotum,55180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5571.76,,,,,,,fee schedule,4466.25,23549.82,
Revision of scrotum,55180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4466.25,,,,,,,fee schedule,4466.25,23549.82,
Revision of scrotum,55180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4878.97,,,,,,,fee schedule,4466.25,23549.82,
Revision of scrotum,55180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5129.55,,,,,,,fee schedule,4466.25,23549.82,
Revision of scrotum,55180,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23549.82,,,,,,,fee schedule,4466.25,23549.82,APC 378
Revision of scrotum,55180,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5573.4,,,,,,,fee schedule,4466.25,23549.82,APC
Revision of scrotum,55180,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5520.32,,,,,,,fee schedule,4466.25,23549.82,APC
Revision of scrotum,55180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5308,,,,,,,fee schedule,4466.25,23549.82,APC
Revision of scrotum,55180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8121.25,,,,,,,fee schedule,4466.25,23549.82,Radiology
Revision of scrotum,55180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7431.21,,,,,,,fee schedule,4466.25,23549.82,APC
Revision of scrotum,55180,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9289.01,,,,,,,fee schedule,4466.25,23549.82,APC
Incision of sperm duct,55200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5571.76,,,,,,,fee schedule,3489.62,15482.25,
Incision of sperm duct,55200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4466.25,,,,,,,fee schedule,3489.62,15482.25,
Incision of sperm duct,55200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4878.97,,,,,,,fee schedule,3489.62,15482.25,
Incision of sperm duct,55200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5129.55,,,,,,,fee schedule,3489.62,15482.25,
Incision of sperm duct,55200,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Incision of sperm duct,55200,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Incision of sperm duct,55200,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Incision of sperm duct,55200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Incision of sperm duct,55200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Incision of sperm duct,55200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Incision of sperm duct,55200,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Removal of sperm duct(s),55250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3058.19,,,,,,,fee schedule,2069.41,9181.28,
Removal of sperm duct(s),55250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2451.41,,,,,,,fee schedule,2069.41,9181.28,
Removal of sperm duct(s),55250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2677.94,,,,,,,fee schedule,2069.41,9181.28,
Removal of sperm duct(s),55250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2815.48,,,,,,,fee schedule,2069.41,9181.28,
Removal of sperm duct(s),55250,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9181.28,,,,,,,fee schedule,2069.41,9181.28,APC 378
Removal of sperm duct(s),55250,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2172.88,,,,,,,fee schedule,2069.41,9181.28,APC
Removal of sperm duct(s),55250,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2152.19,,,,,,,fee schedule,2069.41,9181.28,APC
Removal of sperm duct(s),55250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2069.41,,,,,,,fee schedule,2069.41,9181.28,APC
Removal of sperm duct(s),55250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3166.2,,,,,,,fee schedule,2069.41,9181.28,Radiology
Removal of sperm duct(s),55250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2897.18,,,,,,,fee schedule,2069.41,9181.28,APC
Removal of sperm duct(s),55250,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3621.47,,,,,,,fee schedule,2069.41,9181.28,APC
Repair of sperm duct,55400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5571.76,,,,,,,fee schedule,3489.62,15482.25,
Repair of sperm duct,55400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4466.25,,,,,,,fee schedule,3489.62,15482.25,
Repair of sperm duct,55400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4878.97,,,,,,,fee schedule,3489.62,15482.25,
Repair of sperm duct,55400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5129.55,,,,,,,fee schedule,3489.62,15482.25,
Repair of sperm duct,55400,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Repair of sperm duct,55400,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Repair of sperm duct,55400,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Repair of sperm duct,55400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Repair of sperm duct,55400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Repair of sperm duct,55400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Repair of sperm duct,55400,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Removal of hydrocele,55500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3828.9,,,,,,,fee schedule,3069.2,15482.25,
Removal of hydrocele,55500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3069.2,,,,,,,fee schedule,3069.2,15482.25,
Removal of hydrocele,55500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3352.82,,,,,,,fee schedule,3069.2,15482.25,
Removal of hydrocele,55500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3525.02,,,,,,,fee schedule,3069.2,15482.25,
Removal of hydrocele,55500,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3069.2,15482.25,APC 378
Removal of hydrocele,55500,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3069.2,15482.25,APC
Removal of hydrocele,55500,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3069.2,15482.25,APC
Removal of hydrocele,55500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3069.2,15482.25,APC
Removal of hydrocele,55500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3069.2,15482.25,Radiology
Removal of hydrocele,55500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3069.2,15482.25,APC
Removal of hydrocele,55500,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3069.2,15482.25,APC
Removal of sperm cord lesion,55520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3718.87,,,,,,,fee schedule,2981,15482.25,
Removal of sperm cord lesion,55520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2981,,,,,,,fee schedule,2981,15482.25,
Removal of sperm cord lesion,55520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3256.47,,,,,,,fee schedule,2981,15482.25,
Removal of sperm cord lesion,55520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3423.72,,,,,,,fee schedule,2981,15482.25,
Removal of sperm cord lesion,55520,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,2981,15482.25,APC 378
Removal of sperm cord lesion,55520,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,2981,15482.25,APC
Removal of sperm cord lesion,55520,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,2981,15482.25,APC
Removal of sperm cord lesion,55520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,2981,15482.25,APC
Removal of sperm cord lesion,55520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,2981,15482.25,Radiology
Removal of sperm cord lesion,55520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,2981,15482.25,APC
Removal of sperm cord lesion,55520,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,2981,15482.25,APC
Revise spermatic cord veins,55530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7891.86,,,,,,,fee schedule,3489.62,15482.25,
Revise spermatic cord veins,55530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6326.01,,,,,,,fee schedule,3489.62,15482.25,
Revise spermatic cord veins,55530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6910.6,,,,,,,fee schedule,3489.62,15482.25,
Revise spermatic cord veins,55530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7265.52,,,,,,,fee schedule,3489.62,15482.25,
Revise spermatic cord veins,55530,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Revise spermatic cord veins,55530,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Revise spermatic cord veins,55530,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Revise spermatic cord veins,55530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Revise spermatic cord veins,55530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Revise spermatic cord veins,55530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Revise spermatic cord veins,55530,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Revise spermatic cord veins,55535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7189.69,,,,,,,fee schedule,5763.16,28434,
Revise spermatic cord veins,55535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5763.16,,,,,,,fee schedule,5763.16,28434,
Revise spermatic cord veins,55535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6295.73,,,,,,,fee schedule,5763.16,28434,
Revise spermatic cord veins,55535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6619.08,,,,,,,fee schedule,5763.16,28434,
Revise spermatic cord veins,55535,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,28434,,,,,,,fee schedule,5763.16,28434,APC 378
Revise spermatic cord veins,55535,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6729.32,,,,,,,fee schedule,5763.16,28434,APC
Revise spermatic cord veins,55535,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6665.23,,,,,,,fee schedule,5763.16,28434,APC
Revise spermatic cord veins,55535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6408.87,,,,,,,fee schedule,5763.16,28434,APC
Revise spermatic cord veins,55535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9805.57,,,,,,,fee schedule,5763.16,28434,Radiology
Revise spermatic cord veins,55535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8972.42,,,,,,,fee schedule,5763.16,28434,APC
Revise spermatic cord veins,55535,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11215.53,,,,,,,fee schedule,5763.16,28434,APC
Revise hernia & sperm veins,55540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6721.57,,,,,,,fee schedule,3544.48,15725.66,
Revise hernia & sperm veins,55540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5387.93,,,,,,,fee schedule,3544.48,15725.66,
Revise hernia & sperm veins,55540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5885.82,,,,,,,fee schedule,3544.48,15725.66,
Revise hernia & sperm veins,55540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6188.11,,,,,,,fee schedule,3544.48,15725.66,
Revise hernia & sperm veins,55540,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15725.66,,,,,,,fee schedule,3544.48,15725.66,APC 378
Revise hernia & sperm veins,55540,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3721.7,,,,,,,fee schedule,3544.48,15725.66,APC
Revise hernia & sperm veins,55540,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3686.26,,,,,,,fee schedule,3544.48,15725.66,APC
Revise hernia & sperm veins,55540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3544.48,,,,,,,fee schedule,3544.48,15725.66,APC
Revise hernia & sperm veins,55540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5423.05,,,,,,,fee schedule,3544.48,15725.66,Radiology
Revise hernia & sperm veins,55540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4962.27,,,,,,,fee schedule,3544.48,15725.66,APC
Revise hernia & sperm veins,55540,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6202.84,,,,,,,fee schedule,3544.48,15725.66,APC
Laparo ligate spermatic vein,55550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11363.59,,,,,,,fee schedule,5984.88,26552.87,
Laparo ligate spermatic vein,55550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9108.91,,,,,,,fee schedule,5984.88,26552.87,
Laparo ligate spermatic vein,55550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9950.65,,,,,,,fee schedule,5984.88,26552.87,
Laparo ligate spermatic vein,55550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10461.72,,,,,,,fee schedule,5984.88,26552.87,
Laparo ligate spermatic vein,55550,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,5984.88,26552.87,APC 378
Laparo ligate spermatic vein,55550,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,5984.88,26552.87,APC
Laparo ligate spermatic vein,55550,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,5984.88,26552.87,APC
Laparo ligate spermatic vein,55550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,5984.88,26552.87,APC
Laparo ligate spermatic vein,55550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,5984.88,26552.87,Radiology
Laparo ligate spermatic vein,55550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,5984.88,26552.87,APC
Laparo ligate spermatic vein,55550,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,5984.88,26552.87,APC
Laparo proc spermatic cord,55559,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8584.34,,,,,,,fee schedule,5984.88,26552.87,
Laparo proc spermatic cord,55559,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6881.1,,,,,,,fee schedule,5984.88,26552.87,
Laparo proc spermatic cord,55559,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7516.98,,,,,,,fee schedule,5984.88,26552.87,
Laparo proc spermatic cord,55559,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7903.05,,,,,,,fee schedule,5984.88,26552.87,
Laparo proc spermatic cord,55559,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,5984.88,26552.87,APC 378
Laparo proc spermatic cord,55559,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,5984.88,26552.87,APC
Laparo proc spermatic cord,55559,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,5984.88,26552.87,APC
Laparo proc spermatic cord,55559,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,5984.88,26552.87,APC
Laparo proc spermatic cord,55559,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,5984.88,26552.87,Radiology
Laparo proc spermatic cord,55559,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,5984.88,26552.87,APC
Laparo proc spermatic cord,55559,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,5984.88,26552.87,APC
Incise sperm duct pouch,55600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5571.76,,,,,,,fee schedule,2069.41,9181.28,
Incise sperm duct pouch,55600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4466.25,,,,,,,fee schedule,2069.41,9181.28,
Incise sperm duct pouch,55600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4878.97,,,,,,,fee schedule,2069.41,9181.28,
Incise sperm duct pouch,55600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5129.55,,,,,,,fee schedule,2069.41,9181.28,
Incise sperm duct pouch,55600,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9181.28,,,,,,,fee schedule,2069.41,9181.28,APC 378
Incise sperm duct pouch,55600,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2172.88,,,,,,,fee schedule,2069.41,9181.28,APC
Incise sperm duct pouch,55600,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2152.19,,,,,,,fee schedule,2069.41,9181.28,APC
Incise sperm duct pouch,55600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2069.41,,,,,,,fee schedule,2069.41,9181.28,APC
Incise sperm duct pouch,55600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3166.2,,,,,,,fee schedule,2069.41,9181.28,Radiology
Incise sperm duct pouch,55600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2897.18,,,,,,,fee schedule,2069.41,9181.28,APC
Incise sperm duct pouch,55600,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3621.47,,,,,,,fee schedule,2069.41,9181.28,APC
Remove sperm pouch lesion,55680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5571.76,,,,,,,fee schedule,3489.62,15482.25,
Remove sperm pouch lesion,55680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4466.25,,,,,,,fee schedule,3489.62,15482.25,
Remove sperm pouch lesion,55680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4878.97,,,,,,,fee schedule,3489.62,15482.25,
Remove sperm pouch lesion,55680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5129.55,,,,,,,fee schedule,3489.62,15482.25,
Remove sperm pouch lesion,55680,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Remove sperm pouch lesion,55680,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Remove sperm pouch lesion,55680,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Remove sperm pouch lesion,55680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Remove sperm pouch lesion,55680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Remove sperm pouch lesion,55680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Remove sperm pouch lesion,55680,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Biopsy of prostate,55700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2058.3,,,,,,,fee schedule,1649.91,2058.3,
Biopsy of prostate,55700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1649.91,,,,,,,fee schedule,1649.91,2058.3,
Biopsy of prostate,55700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1802.37,,,,,,,fee schedule,1649.91,2058.3,
Biopsy of prostate,55700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1894.94,,,,,,,fee schedule,1649.91,2058.3,
Biopsy of prostate,55705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2753.77,,,,,,,fee schedule,2207.39,15482.25,
Biopsy of prostate,55705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2207.39,,,,,,,fee schedule,2207.39,15482.25,
Biopsy of prostate,55705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2411.37,,,,,,,fee schedule,2207.39,15482.25,
Biopsy of prostate,55705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2535.21,,,,,,,fee schedule,2207.39,15482.25,
Biopsy of prostate,55705,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,2207.39,15482.25,APC 378
Biopsy of prostate,55705,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,2207.39,15482.25,APC
Biopsy of prostate,55705,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,2207.39,15482.25,APC
Biopsy of prostate,55705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,2207.39,15482.25,APC
Biopsy of prostate,55705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,2207.39,15482.25,Radiology
Biopsy of prostate,55705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,2207.39,15482.25,APC
Biopsy of prostate,55705,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,2207.39,15482.25,APC
Prostate saturation sampling,55706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1429.37,,,,,,,fee schedule,1145.76,15482.25,
Prostate saturation sampling,55706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1145.76,,,,,,,fee schedule,1145.76,15482.25,
Prostate saturation sampling,55706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1251.64,,,,,,,fee schedule,1145.76,15482.25,
Prostate saturation sampling,55706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1315.93,,,,,,,fee schedule,1145.76,15482.25,
Prostate saturation sampling,55706,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,1145.76,15482.25,APC 378
Prostate saturation sampling,55706,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,1145.76,15482.25,APC
Prostate saturation sampling,55706,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,1145.76,15482.25,APC
Prostate saturation sampling,55706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,1145.76,15482.25,APC
Prostate saturation sampling,55706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,1145.76,15482.25,Radiology
Prostate saturation sampling,55706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,1145.76,15482.25,APC
Prostate saturation sampling,55706,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,1145.76,15482.25,APC
Bx prst8 trct us guided,55707,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Bx prst8 trct us guided,55707,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Bx prst8 trct us guided,55707,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Bx prst8 trct us guided,55707,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Bx prst8 trct us guided,55707,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Bx prst8 trct us guided,55707,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Bx prst8 trct us guided,55707,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Bx prst8 trct us w/mri fus 1,55708,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Bx prst8 trct us w/mri fus 1,55708,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Bx prst8 trct us w/mri fus 1,55708,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Bx prst8 trct us w/mri fus 1,55708,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Bx prst8 trct us w/mri fus 1,55708,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Bx prst8 trct us w/mri fus 1,55708,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Bx prst8 trct us w/mri fus 1,55708,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Bx prst8 tprnl us guided,55709,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Bx prst8 tprnl us guided,55709,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Bx prst8 tprnl us guided,55709,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Bx prst8 tprnl us guided,55709,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Bx prst8 tprnl us guided,55709,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Bx prst8 tprnl us guided,55709,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Bx prst8 tprnl us guided,55709,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Bx prst8 tprn us w/mri fus 1,55710,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Bx prst8 tprn us w/mri fus 1,55710,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Bx prst8 tprn us w/mri fus 1,55710,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Bx prst8 tprn us w/mri fus 1,55710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Bx prst8 tprn us w/mri fus 1,55710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Bx prst8 tprn us w/mri fus 1,55710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Bx prst8 tprn us w/mri fus 1,55710,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Bx prst8 trct mri-us 1st,55711,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Bx prst8 trct mri-us 1st,55711,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Bx prst8 trct mri-us 1st,55711,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Bx prst8 trct mri-us 1st,55711,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Bx prst8 trct mri-us 1st,55711,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Bx prst8 trct mri-us 1st,55711,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Bx prst8 trct mri-us 1st,55711,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Bx prst8 tprnl mri-us 1st,55712,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Bx prst8 tprnl mri-us 1st,55712,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Bx prst8 tprnl mri-us 1st,55712,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Bx prst8 tprnl mri-us 1st,55712,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Bx prst8 tprnl mri-us 1st,55712,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Bx prst8 tprnl mri-us 1st,55712,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Bx prst8 tprnl mri-us 1st,55712,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Bx prst8 in-bore ct/mri bx 1,55713,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23549.82,,,,,,,fee schedule,5308,23549.82,APC 378
Bx prst8 in-bore ct/mri bx 1,55713,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5573.4,,,,,,,fee schedule,5308,23549.82,APC
Bx prst8 in-bore ct/mri bx 1,55713,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5520.32,,,,,,,fee schedule,5308,23549.82,APC
Bx prst8 in-bore ct/mri bx 1,55713,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5308,,,,,,,fee schedule,5308,23549.82,APC
Bx prst8 in-bore ct/mri bx 1,55713,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8121.25,,,,,,,fee schedule,5308,23549.82,Radiology
Bx prst8 in-bore ct/mri bx 1,55713,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7431.21,,,,,,,fee schedule,5308,23549.82,APC
Bx prst8 in-bore ct/mri bx 1,55713,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9289.01,,,,,,,fee schedule,5308,23549.82,APC
Bx prst8 in-bore ct/mri 1,55714,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23549.82,,,,,,,fee schedule,5308,23549.82,APC 378
Bx prst8 in-bore ct/mri 1,55714,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5573.4,,,,,,,fee schedule,5308,23549.82,APC
Bx prst8 in-bore ct/mri 1,55714,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5520.32,,,,,,,fee schedule,5308,23549.82,APC
Bx prst8 in-bore ct/mri 1,55714,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5308,,,,,,,fee schedule,5308,23549.82,APC
Bx prst8 in-bore ct/mri 1,55714,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8121.25,,,,,,,fee schedule,5308,23549.82,Radiology
Bx prst8 in-bore ct/mri 1,55714,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7431.21,,,,,,,fee schedule,5308,23549.82,APC
Bx prst8 in-bore ct/mri 1,55714,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9289.01,,,,,,,fee schedule,5308,23549.82,APC
Drainage of prostate abscess,55720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6183.21,,,,,,,fee schedule,3489.62,15482.25,
Drainage of prostate abscess,55720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4956.38,,,,,,,fee schedule,3489.62,15482.25,
Drainage of prostate abscess,55720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5414.4,,,,,,,fee schedule,3489.62,15482.25,
Drainage of prostate abscess,55720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5692.48,,,,,,,fee schedule,3489.62,15482.25,
Drainage of prostate abscess,55720,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Drainage of prostate abscess,55720,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Drainage of prostate abscess,55720,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Drainage of prostate abscess,55720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Drainage of prostate abscess,55720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Drainage of prostate abscess,55720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Drainage of prostate abscess,55720,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Drainage of prostate abscess,55725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6183.21,,,,,,,fee schedule,3489.62,15482.25,
Drainage of prostate abscess,55725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4956.38,,,,,,,fee schedule,3489.62,15482.25,
Drainage of prostate abscess,55725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5414.4,,,,,,,fee schedule,3489.62,15482.25,
Drainage of prostate abscess,55725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5692.48,,,,,,,fee schedule,3489.62,15482.25,
Drainage of prostate abscess,55725,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Drainage of prostate abscess,55725,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Drainage of prostate abscess,55725,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Drainage of prostate abscess,55725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Drainage of prostate abscess,55725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Drainage of prostate abscess,55725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Drainage of prostate abscess,55725,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
Surgical exposure prostate,55860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4827.14,,,,,,,fee schedule,3869.37,23549.82,
Surgical exposure prostate,55860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3869.37,,,,,,,fee schedule,3869.37,23549.82,
Surgical exposure prostate,55860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4226.94,,,,,,,fee schedule,3869.37,23549.82,
Surgical exposure prostate,55860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4444.03,,,,,,,fee schedule,3869.37,23549.82,
Surgical exposure prostate,55860,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23549.82,,,,,,,fee schedule,3869.37,23549.82,APC 378
Surgical exposure prostate,55860,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5573.4,,,,,,,fee schedule,3869.37,23549.82,APC
Surgical exposure prostate,55860,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5520.32,,,,,,,fee schedule,3869.37,23549.82,APC
Surgical exposure prostate,55860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5308,,,,,,,fee schedule,3869.37,23549.82,APC
Surgical exposure prostate,55860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8121.25,,,,,,,fee schedule,3869.37,23549.82,Radiology
Surgical exposure prostate,55860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7431.21,,,,,,,fee schedule,3869.37,23549.82,APC
Surgical exposure prostate,55860,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9289.01,,,,,,,fee schedule,3869.37,23549.82,APC
Laparo radical prostatectomy,55866,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7911.36,,,,,,,fee schedule,6341.65,46687.84,
Laparo radical prostatectomy,55866,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6341.65,,,,,,,fee schedule,6341.65,46687.84,
Laparo radical prostatectomy,55866,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6927.68,,,,,,,fee schedule,6341.65,46687.84,
Laparo radical prostatectomy,55866,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7283.48,,,,,,,fee schedule,6341.65,46687.84,
Laparo radical prostatectomy,55866,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46687.84,,,,,,,fee schedule,6341.65,46687.84,APC 378
Laparo radical prostatectomy,55866,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11049.35,,,,,,,fee schedule,6341.65,46687.84,APC
Laparo radical prostatectomy,55866,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10944.12,,,,,,,fee schedule,6341.65,46687.84,APC
Laparo radical prostatectomy,55866,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10523.19,,,,,,,fee schedule,6341.65,46687.84,APC
Laparo radical prostatectomy,55866,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16100.48,,,,,,,fee schedule,6341.65,46687.84,Radiology
Laparo radical prostatectomy,55866,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14732.47,,,,,,,fee schedule,6341.65,46687.84,APC
Laparo radical prostatectomy,55866,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18415.58,,,,,,,fee schedule,6341.65,46687.84,APC
Laps surg prst8ect smpl stot,55867,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,34349.99,,,,,,,fee schedule,10523.19,46687.84,
Laps surg prst8ect smpl stot,55867,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,27534.52,,,,,,,fee schedule,10523.19,46687.84,
Laps surg prst8ect smpl stot,55867,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,30078.96,,,,,,,fee schedule,10523.19,46687.84,
Laps surg prst8ect smpl stot,55867,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,31623.8,,,,,,,fee schedule,10523.19,46687.84,
Laps surg prst8ect smpl stot,55867,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46687.84,,,,,,,fee schedule,10523.19,46687.84,APC 378
Laps surg prst8ect smpl stot,55867,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11049.35,,,,,,,fee schedule,10523.19,46687.84,APC
Laps surg prst8ect smpl stot,55867,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10944.12,,,,,,,fee schedule,10523.19,46687.84,APC
Laps surg prst8ect smpl stot,55867,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10523.19,,,,,,,fee schedule,10523.19,46687.84,APC
Laps surg prst8ect smpl stot,55867,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16100.48,,,,,,,fee schedule,10523.19,46687.84,Radiology
Laps surg prst8ect smpl stot,55867,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14732.47,,,,,,,fee schedule,10523.19,46687.84,APC
Laps surg prst8ect smpl stot,55867,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18415.58,,,,,,,fee schedule,10523.19,46687.84,APC
Lap srg prst8ct lymph nod bx,55868,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46687.84,,,,,,,fee schedule,10523.19,46687.84,APC 378
Lap srg prst8ct lymph nod bx,55868,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11049.35,,,,,,,fee schedule,10523.19,46687.84,APC
Lap srg prst8ct lymph nod bx,55868,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10944.12,,,,,,,fee schedule,10523.19,46687.84,APC
Lap srg prst8ct lymph nod bx,55868,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10523.19,,,,,,,fee schedule,10523.19,46687.84,APC
Lap srg prst8ct lymph nod bx,55868,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16100.48,,,,,,,fee schedule,10523.19,46687.84,Radiology
Lap srg prst8ct lymph nod bx,55868,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14732.47,,,,,,,fee schedule,10523.19,46687.84,APC
Lap srg prst8ct lymph nod bx,55868,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18415.58,,,,,,,fee schedule,10523.19,46687.84,APC
Lap srg prst8ct bi pl lmphad,55869,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46687.84,,,,,,,fee schedule,10523.19,46687.84,APC 378
Lap srg prst8ct bi pl lmphad,55869,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11049.35,,,,,,,fee schedule,10523.19,46687.84,APC
Lap srg prst8ct bi pl lmphad,55869,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10944.12,,,,,,,fee schedule,10523.19,46687.84,APC
Lap srg prst8ct bi pl lmphad,55869,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10523.19,,,,,,,fee schedule,10523.19,46687.84,APC
Lap srg prst8ct bi pl lmphad,55869,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16100.48,,,,,,,fee schedule,10523.19,46687.84,Radiology
Lap srg prst8ct bi pl lmphad,55869,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14732.47,,,,,,,fee schedule,10523.19,46687.84,APC
Lap srg prst8ct bi pl lmphad,55869,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18415.58,,,,,,,fee schedule,10523.19,46687.84,APC
Electroejaculation,55870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,688.41,,,,,,,fee schedule,551.82,4045.39,
Electroejaculation,55870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,551.82,,,,,,,fee schedule,551.82,4045.39,
Electroejaculation,55870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,602.82,,,,,,,fee schedule,551.82,4045.39,
Electroejaculation,55870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,633.78,,,,,,,fee schedule,551.82,4045.39,
Electroejaculation,55870,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4045.39,,,,,,,fee schedule,551.82,4045.39,APC 378
Electroejaculation,55870,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,957.4,,,,,,,fee schedule,551.82,4045.39,APC
Electroejaculation,55870,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,948.28,,,,,,,fee schedule,551.82,4045.39,APC
Electroejaculation,55870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,911.81,,,,,,,fee schedule,551.82,4045.39,APC
Electroejaculation,55870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1395.07,,,,,,,fee schedule,551.82,4045.39,Radiology
Electroejaculation,55870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1276.53,,,,,,,fee schedule,551.82,4045.39,APC
Electroejaculation,55870,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1595.67,,,,,,,fee schedule,551.82,4045.39,APC
Cryoablate Prostate,55873,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30626.2,,,,,,,fee schedule,9371.49,41578.13,
Cryoablate Prostate,55873,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24549.58,,,,,,,fee schedule,9371.49,41578.13,
Cryoablate Prostate,55873,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26818.18,,,,,,,fee schedule,9371.49,41578.13,
Cryoablate Prostate,55873,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,28195.55,,,,,,,fee schedule,9371.49,41578.13,
Cryoablate Prostate,55873,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,41578.13,,,,,,,fee schedule,9371.49,41578.13,APC 378
Cryoablate Prostate,55873,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9840.06,,,,,,,fee schedule,9371.49,41578.13,APC
Cryoablate Prostate,55873,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9746.35,,,,,,,fee schedule,9371.49,41578.13,APC
Cryoablate Prostate,55873,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9371.49,,,,,,,fee schedule,9371.49,41578.13,APC
Cryoablate Prostate,55873,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14338.38,,,,,,,fee schedule,9371.49,41578.13,Radiology
Cryoablate Prostate,55873,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13120.09,,,,,,,fee schedule,9371.49,41578.13,APC
Cryoablate Prostate,55873,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16400.11,,,,,,,fee schedule,9371.49,41578.13,APC
Tprnl plmt biodegrdabl matrl,55874,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15197.64,,,,,,,fee schedule,5308,23549.82,
Tprnl plmt biodegrdabl matrl,55874,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12182.24,,,,,,,fee schedule,5308,23549.82,
Tprnl plmt biodegrdabl matrl,55874,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13307.99,,,,,,,fee schedule,5308,23549.82,
Tprnl plmt biodegrdabl matrl,55874,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13991.48,,,,,,,fee schedule,5308,23549.82,
Tprnl plmt biodegrdabl matrl,55874,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23549.82,,,,,,,fee schedule,5308,23549.82,APC 378
Tprnl plmt biodegrdabl matrl,55874,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5573.4,,,,,,,fee schedule,5308,23549.82,APC
Tprnl plmt biodegrdabl matrl,55874,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5520.32,,,,,,,fee schedule,5308,23549.82,APC
Tprnl plmt biodegrdabl matrl,55874,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5308,,,,,,,fee schedule,5308,23549.82,APC
Tprnl plmt biodegrdabl matrl,55874,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8121.25,,,,,,,fee schedule,5308,23549.82,Radiology
Tprnl plmt biodegrdabl matrl,55874,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7431.21,,,,,,,fee schedule,5308,23549.82,APC
Tprnl plmt biodegrdabl matrl,55874,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9289.01,,,,,,,fee schedule,5308,23549.82,APC
Transperi needle place pros,55875,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9004,,,,,,,fee schedule,5308,23549.82,
Transperi needle place pros,55875,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7217.49,,,,,,,fee schedule,5308,23549.82,
Transperi needle place pros,55875,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7884.45,,,,,,,fee schedule,5308,23549.82,
Transperi needle place pros,55875,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8289.39,,,,,,,fee schedule,5308,23549.82,
Transperi needle place pros,55875,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23549.82,,,,,,,fee schedule,5308,23549.82,APC 378
Transperi needle place pros,55875,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5573.4,,,,,,,fee schedule,5308,23549.82,APC
Transperi needle place pros,55875,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5520.32,,,,,,,fee schedule,5308,23549.82,APC
Transperi needle place pros,55875,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5308,,,,,,,fee schedule,5308,23549.82,APC
Transperi needle place pros,55875,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8121.25,,,,,,,fee schedule,5308,23549.82,Radiology
Transperi needle place pros,55875,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7431.21,,,,,,,fee schedule,5308,23549.82,APC
Transperi needle place pros,55875,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9289.01,,,,,,,fee schedule,5308,23549.82,APC
Place rt device/marker pros,55876,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1387.01,,,,,,,fee schedule,1111.81,6079.31,
Place rt device/marker pros,55876,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1111.81,,,,,,,fee schedule,1111.81,6079.31,
Place rt device/marker pros,55876,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1214.55,,,,,,,fee schedule,1111.81,6079.31,
Place rt device/marker pros,55876,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1276.93,,,,,,,fee schedule,1111.81,6079.31,
Place rt device/marker pros,55876,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6079.31,,,,,,,fee schedule,1111.81,6079.31,APC 378
Place rt device/marker pros,55876,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1438.76,,,,,,,fee schedule,1111.81,6079.31,APC
Place rt device/marker pros,55876,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1425.05,,,,,,,fee schedule,1111.81,6079.31,APC
Place rt device/marker pros,55876,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1370.24,,,,,,,fee schedule,1111.81,6079.31,APC
Place rt device/marker pros,55876,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2096.47,,,,,,,fee schedule,1111.81,6079.31,Radiology
Place rt device/marker pros,55876,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1918.34,,,,,,,fee schedule,1111.81,6079.31,APC
Place rt device/marker pros,55876,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2397.93,,,,,,,fee schedule,1111.81,6079.31,APC
Abltj ire prst8 1+ tum perq,55877,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46687.84,,,,,,,fee schedule,10523.19,46687.84,APC 378
Abltj ire prst8 1+ tum perq,55877,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11049.35,,,,,,,fee schedule,10523.19,46687.84,APC
Abltj ire prst8 1+ tum perq,55877,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10944.12,,,,,,,fee schedule,10523.19,46687.84,APC
Abltj ire prst8 1+ tum perq,55877,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10523.19,,,,,,,fee schedule,10523.19,46687.84,APC
Abltj ire prst8 1+ tum perq,55877,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16100.48,,,,,,,fee schedule,10523.19,46687.84,Radiology
Abltj ire prst8 1+ tum perq,55877,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14732.47,,,,,,,fee schedule,10523.19,46687.84,APC
Abltj ire prst8 1+ tum perq,55877,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18415.58,,,,,,,fee schedule,10523.19,46687.84,APC
Abltj mal prst8 tiss hifu,55880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16684.54,,,,,,,fee schedule,9371.49,41578.13,
Abltj mal prst8 tiss hifu,55880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13374.12,,,,,,,fee schedule,9371.49,41578.13,
Abltj mal prst8 tiss hifu,55880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14610.01,,,,,,,fee schedule,9371.49,41578.13,
Abltj mal prst8 tiss hifu,55880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15360.37,,,,,,,fee schedule,9371.49,41578.13,
Abltj mal prst8 tiss hifu,55880,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,41578.13,,,,,,,fee schedule,9371.49,41578.13,APC 378
Abltj mal prst8 tiss hifu,55880,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9840.06,,,,,,,fee schedule,9371.49,41578.13,APC
Abltj mal prst8 tiss hifu,55880,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9746.35,,,,,,,fee schedule,9371.49,41578.13,APC
Abltj mal prst8 tiss hifu,55880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9371.49,,,,,,,fee schedule,9371.49,41578.13,APC
Abltj mal prst8 tiss hifu,55880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14338.38,,,,,,,fee schedule,9371.49,41578.13,Radiology
Abltj mal prst8 tiss hifu,55880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13120.09,,,,,,,fee schedule,9371.49,41578.13,APC
Abltj mal prst8 tiss hifu,55880,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16400.11,,,,,,,fee schedule,9371.49,41578.13,APC
Genital surgery procedure,55899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3360.79,,,,,,,fee schedule,247.34,3360.79,
Genital surgery procedure,55899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2693.96,,,,,,,fee schedule,247.34,3360.79,
Genital surgery procedure,55899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2942.91,,,,,,,fee schedule,247.34,3360.79,
Genital surgery procedure,55899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3094.06,,,,,,,fee schedule,247.34,3360.79,
Genital surgery procedure,55899,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1097.37,,,,,,,fee schedule,247.34,3360.79,APC 378
Genital surgery procedure,55899,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,259.71,,,,,,,fee schedule,247.34,3360.79,APC
Genital surgery procedure,55899,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,257.24,,,,,,,fee schedule,247.34,3360.79,APC
Genital surgery procedure,55899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,247.34,,,,,,,fee schedule,247.34,3360.79,APC
Genital surgery procedure,55899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,378.43,,,,,,,fee schedule,247.34,3360.79,Radiology
Genital surgery procedure,55899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,346.28,,,,,,,fee schedule,247.34,3360.79,APC
Genital surgery procedure,55899,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,432.85,,,,,,,fee schedule,247.34,3360.79,APC
Place needles pelvic for rt,55920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6412.77,,,,,,,fee schedule,4952.26,21971.51,
Place needles pelvic for rt,55920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5140.4,,,,,,,fee schedule,4952.26,21971.51,
Place needles pelvic for rt,55920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5615.42,,,,,,,fee schedule,4952.26,21971.51,
Place needles pelvic for rt,55920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5903.82,,,,,,,fee schedule,4952.26,21971.51,
Place needles pelvic for rt,55920,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21971.51,,,,,,,fee schedule,4952.26,21971.51,APC 378
Place needles pelvic for rt,55920,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5199.88,,,,,,,fee schedule,4952.26,21971.51,APC
Place needles pelvic for rt,55920,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5150.35,,,,,,,fee schedule,4952.26,21971.51,APC
Place needles pelvic for rt,55920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4952.26,,,,,,,fee schedule,4952.26,21971.51,APC
Place needles pelvic for rt,55920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7576.96,,,,,,,fee schedule,4952.26,21971.51,Radiology
Place needles pelvic for rt,55920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6933.17,,,,,,,fee schedule,4952.26,21971.51,APC
Place needles pelvic for rt,55920,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8666.46,,,,,,,fee schedule,4952.26,21971.51,APC
Sex transformation m to f,55970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7883.08,,,,,,,fee schedule,4952.26,21971.51,
Sex transformation m to f,55970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6318.97,,,,,,,fee schedule,4952.26,21971.51,
Sex transformation m to f,55970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6902.91,,,,,,,fee schedule,4952.26,21971.51,
Sex transformation m to f,55970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7257.44,,,,,,,fee schedule,4952.26,21971.51,
Sex transformation m to f,55970,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21971.51,,,,,,,fee schedule,4952.26,21971.51,APC 378
Sex transformation m to f,55970,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5199.88,,,,,,,fee schedule,4952.26,21971.51,APC
Sex transformation m to f,55970,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5150.35,,,,,,,fee schedule,4952.26,21971.51,APC
Sex transformation m to f,55970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4952.26,,,,,,,fee schedule,4952.26,21971.51,APC
Sex transformation m to f,55970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7576.96,,,,,,,fee schedule,4952.26,21971.51,Radiology
Sex transformation m to f,55970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6933.17,,,,,,,fee schedule,4952.26,21971.51,APC
Sex transformation m to f,55970,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8666.46,,,,,,,fee schedule,4952.26,21971.51,APC
Sex transformation f to m,55980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9610.88,,,,,,,fee schedule,3489.62,15482.25,
Sex transformation f to m,55980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7703.96,,,,,,,fee schedule,3489.62,15482.25,
Sex transformation f to m,55980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8415.87,,,,,,,fee schedule,3489.62,15482.25,
Sex transformation f to m,55980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8848.11,,,,,,,fee schedule,3489.62,15482.25,
Sex transformation f to m,55980,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15482.25,,,,,,,fee schedule,3489.62,15482.25,APC 378
Sex transformation f to m,55980,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3664.1,,,,,,,fee schedule,3489.62,15482.25,APC
Sex transformation f to m,55980,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3629.2,,,,,,,fee schedule,3489.62,15482.25,APC
Sex transformation f to m,55980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3489.62,,,,,,,fee schedule,3489.62,15482.25,APC
Sex transformation f to m,55980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5339.11,,,,,,,fee schedule,3489.62,15482.25,Radiology
Sex transformation f to m,55980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4885.46,,,,,,,fee schedule,3489.62,15482.25,APC
Sex transformation f to m,55980,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6106.83,,,,,,,fee schedule,3489.62,15482.25,APC
I & D of vulva/perineum,56405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,279.57,,,,,,,fee schedule,224.1,1338.42,
I & D of vulva/perineum,56405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,224.1,,,,,,,fee schedule,224.1,1338.42,
I & D of vulva/perineum,56405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,244.81,,,,,,,fee schedule,224.1,1338.42,
I & D of vulva/perineum,56405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,257.38,,,,,,,fee schedule,224.1,1338.42,
I & D of vulva/perineum,56405,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1338.42,,,,,,,fee schedule,224.1,1338.42,APC 378
I & D of vulva/perineum,56405,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,316.76,,,,,,,fee schedule,224.1,1338.42,APC
I & D of vulva/perineum,56405,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,313.74,,,,,,,fee schedule,224.1,1338.42,APC
I & D of vulva/perineum,56405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,301.67,,,,,,,fee schedule,224.1,1338.42,APC
I & D of vulva/perineum,56405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,461.56,,,,,,,fee schedule,224.1,1338.42,Radiology
I & D of vulva/perineum,56405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,422.34,,,,,,,fee schedule,224.1,1338.42,APC
I & D of vulva/perineum,56405,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,527.93,,,,,,,fee schedule,224.1,1338.42,APC
Drainage of gland abscess,56420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,326.16,,,,,,,fee schedule,200.14,887.97,
Drainage of gland abscess,56420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,261.45,,,,,,,fee schedule,200.14,887.97,
Drainage of gland abscess,56420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,285.61,,,,,,,fee schedule,200.14,887.97,
Drainage of gland abscess,56420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,300.28,,,,,,,fee schedule,200.14,887.97,
Drainage of gland abscess,56420,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,887.97,,,,,,,fee schedule,200.14,887.97,APC 378
Drainage of gland abscess,56420,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,210.15,,,,,,,fee schedule,200.14,887.97,APC
Drainage of gland abscess,56420,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,208.15,,,,,,,fee schedule,200.14,887.97,APC
Drainage of gland abscess,56420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,200.14,,,,,,,fee schedule,200.14,887.97,APC
Drainage of gland abscess,56420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,306.22,,,,,,,fee schedule,200.14,887.97,Radiology
Drainage of gland abscess,56420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,280.2,,,,,,,fee schedule,200.14,887.97,APC
Drainage of gland abscess,56420,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,350.25,,,,,,,fee schedule,200.14,887.97,APC
Surgery for vulva lesion,56440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6721.57,,,,,,,fee schedule,3204.65,14217.94,
Surgery for vulva lesion,56440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5387.93,,,,,,,fee schedule,3204.65,14217.94,
Surgery for vulva lesion,56440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5885.82,,,,,,,fee schedule,3204.65,14217.94,
Surgery for vulva lesion,56440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6188.11,,,,,,,fee schedule,3204.65,14217.94,
Surgery for vulva lesion,56440,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14217.94,,,,,,,fee schedule,3204.65,14217.94,APC 378
Surgery for vulva lesion,56440,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3364.88,,,,,,,fee schedule,3204.65,14217.94,APC
Surgery for vulva lesion,56440,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3332.84,,,,,,,fee schedule,3204.65,14217.94,APC
Surgery for vulva lesion,56440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3204.65,,,,,,,fee schedule,3204.65,14217.94,APC
Surgery for vulva lesion,56440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4903.11,,,,,,,fee schedule,3204.65,14217.94,Radiology
Surgery for vulva lesion,56440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4486.51,,,,,,,fee schedule,3204.65,14217.94,APC
Surgery for vulva lesion,56440,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5608.14,,,,,,,fee schedule,3204.65,14217.94,APC
Lysis of labial lesion(s),56441,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4747,,,,,,,fee schedule,3204.65,14217.94,
Lysis of labial lesion(s),56441,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3805.13,,,,,,,fee schedule,3204.65,14217.94,
Lysis of labial lesion(s),56441,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4156.76,,,,,,,fee schedule,3204.65,14217.94,
Lysis of labial lesion(s),56441,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4370.25,,,,,,,fee schedule,3204.65,14217.94,
Lysis of labial lesion(s),56441,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14217.94,,,,,,,fee schedule,3204.65,14217.94,APC 378
Lysis of labial lesion(s),56441,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3364.88,,,,,,,fee schedule,3204.65,14217.94,APC
Lysis of labial lesion(s),56441,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3332.84,,,,,,,fee schedule,3204.65,14217.94,APC
Lysis of labial lesion(s),56441,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3204.65,,,,,,,fee schedule,3204.65,14217.94,APC
Lysis of labial lesion(s),56441,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4903.11,,,,,,,fee schedule,3204.65,14217.94,Radiology
Lysis of labial lesion(s),56441,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4486.51,,,,,,,fee schedule,3204.65,14217.94,APC
Lysis of labial lesion(s),56441,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5608.14,,,,,,,fee schedule,3204.65,14217.94,APC
Hymenotomy,56442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6253.46,,,,,,,fee schedule,3204.65,14217.94,
Hymenotomy,56442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5012.69,,,,,,,fee schedule,3204.65,14217.94,
Hymenotomy,56442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5475.91,,,,,,,fee schedule,3204.65,14217.94,
Hymenotomy,56442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5757.15,,,,,,,fee schedule,3204.65,14217.94,
Hymenotomy,56442,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14217.94,,,,,,,fee schedule,3204.65,14217.94,APC 378
Hymenotomy,56442,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3364.88,,,,,,,fee schedule,3204.65,14217.94,APC
Hymenotomy,56442,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3332.84,,,,,,,fee schedule,3204.65,14217.94,APC
Hymenotomy,56442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3204.65,,,,,,,fee schedule,3204.65,14217.94,APC
Hymenotomy,56442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4903.11,,,,,,,fee schedule,3204.65,14217.94,Radiology
Hymenotomy,56442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4486.51,,,,,,,fee schedule,3204.65,14217.94,APC
Hymenotomy,56442,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5608.14,,,,,,,fee schedule,3204.65,14217.94,APC
Destroy vulva lesions sim,56501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2396.55,,,,,,,fee schedule,1921.05,9062.24,
Destroy vulva lesions sim,56501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1921.05,,,,,,,fee schedule,1921.05,9062.24,
Destroy vulva lesions sim,56501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2098.57,,,,,,,fee schedule,1921.05,9062.24,
Destroy vulva lesions sim,56501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2206.35,,,,,,,fee schedule,1921.05,9062.24,
Destroy vulva lesions sim,56501,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,1921.05,9062.24,APC 378
Destroy vulva lesions sim,56501,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,1921.05,9062.24,APC
Destroy vulva lesions sim,56501,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,1921.05,9062.24,APC
Destroy vulva lesions sim,56501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,1921.05,9062.24,APC
Destroy vulva lesions sim,56501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,1921.05,9062.24,Radiology
Destroy vulva lesions sim,56501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,1921.05,9062.24,APC
Destroy vulva lesions sim,56501,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,1921.05,9062.24,APC
Destroy vulva lesion/s compl,56515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3126.73,,,,,,,fee schedule,2042.58,9062.24,
Destroy vulva lesion/s compl,56515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2506.35,,,,,,,fee schedule,2042.58,9062.24,
Destroy vulva lesion/s compl,56515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2737.95,,,,,,,fee schedule,2042.58,9062.24,
Destroy vulva lesion/s compl,56515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2878.57,,,,,,,fee schedule,2042.58,9062.24,
Destroy vulva lesion/s compl,56515,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,2042.58,9062.24,APC 378
Destroy vulva lesion/s compl,56515,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,2042.58,9062.24,APC
Destroy vulva lesion/s compl,56515,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,2042.58,9062.24,APC
Destroy vulva lesion/s compl,56515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,2042.58,9062.24,APC
Destroy vulva lesion/s compl,56515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,2042.58,9062.24,Radiology
Destroy vulva lesion/s compl,56515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,2042.58,9062.24,APC
Destroy vulva lesion/s compl,56515,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,2042.58,9062.24,APC
Biopsy of vulva/perineum,56605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3578.17,,,,,,,fee schedule,911.81,4045.39,
Biopsy of vulva/perineum,56605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2868.21,,,,,,,fee schedule,911.81,4045.39,
Biopsy of vulva/perineum,56605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3133.26,,,,,,,fee schedule,911.81,4045.39,
Biopsy of vulva/perineum,56605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3294.18,,,,,,,fee schedule,911.81,4045.39,
Biopsy of vulva/perineum,56605,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4045.39,,,,,,,fee schedule,911.81,4045.39,APC 378
Biopsy of vulva/perineum,56605,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,957.4,,,,,,,fee schedule,911.81,4045.39,APC
Biopsy of vulva/perineum,56605,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,948.28,,,,,,,fee schedule,911.81,4045.39,APC
Biopsy of vulva/perineum,56605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,911.81,,,,,,,fee schedule,911.81,4045.39,APC
Biopsy of vulva/perineum,56605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1395.07,,,,,,,fee schedule,911.81,4045.39,Radiology
Biopsy of vulva/perineum,56605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1276.53,,,,,,,fee schedule,911.81,4045.39,APC
Biopsy of vulva/perineum,56605,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1595.67,,,,,,,fee schedule,911.81,4045.39,APC
Biopsy of vulva/perineum,56606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,625.35,,,,,,,fee schedule,501.27,625.35,
Biopsy of vulva/perineum,56606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,501.27,,,,,,,fee schedule,501.27,625.35,
Biopsy of vulva/perineum,56606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,547.59,,,,,,,fee schedule,501.27,625.35,
Biopsy of vulva/perineum,56606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,575.71,,,,,,,fee schedule,501.27,625.35,
Partial removal of vulva,56620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6290.98,,,,,,,fee schedule,3204.65,14217.94,
Partial removal of vulva,56620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5042.77,,,,,,,fee schedule,3204.65,14217.94,
Partial removal of vulva,56620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5508.76,,,,,,,fee schedule,3204.65,14217.94,
Partial removal of vulva,56620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5791.69,,,,,,,fee schedule,3204.65,14217.94,
Partial removal of vulva,56620,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14217.94,,,,,,,fee schedule,3204.65,14217.94,APC 378
Partial removal of vulva,56620,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3364.88,,,,,,,fee schedule,3204.65,14217.94,APC
Partial removal of vulva,56620,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3332.84,,,,,,,fee schedule,3204.65,14217.94,APC
Partial removal of vulva,56620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3204.65,,,,,,,fee schedule,3204.65,14217.94,APC
Partial removal of vulva,56620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4903.11,,,,,,,fee schedule,3204.65,14217.94,Radiology
Partial removal of vulva,56620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4486.51,,,,,,,fee schedule,3204.65,14217.94,APC
Partial removal of vulva,56620,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5608.14,,,,,,,fee schedule,3204.65,14217.94,APC
Complete removal of vulva,56625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4747,,,,,,,fee schedule,3204.65,14217.94,
Complete removal of vulva,56625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3805.13,,,,,,,fee schedule,3204.65,14217.94,
Complete removal of vulva,56625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4156.76,,,,,,,fee schedule,3204.65,14217.94,
Complete removal of vulva,56625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4370.25,,,,,,,fee schedule,3204.65,14217.94,
Complete removal of vulva,56625,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14217.94,,,,,,,fee schedule,3204.65,14217.94,APC 378
Complete removal of vulva,56625,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3364.88,,,,,,,fee schedule,3204.65,14217.94,APC
Complete removal of vulva,56625,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3332.84,,,,,,,fee schedule,3204.65,14217.94,APC
Complete removal of vulva,56625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3204.65,,,,,,,fee schedule,3204.65,14217.94,APC
Complete removal of vulva,56625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4903.11,,,,,,,fee schedule,3204.65,14217.94,Radiology
Complete removal of vulva,56625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4486.51,,,,,,,fee schedule,3204.65,14217.94,APC
Complete removal of vulva,56625,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5608.14,,,,,,,fee schedule,3204.65,14217.94,APC
Extensive vulva surgery,56630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16668.06,,,,,,,fee schedule,4952.26,21971.51,
Extensive vulva surgery,56630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13360.91,,,,,,,fee schedule,4952.26,21971.51,
Extensive vulva surgery,56630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14595.58,,,,,,,fee schedule,4952.26,21971.51,
Extensive vulva surgery,56630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15345.2,,,,,,,fee schedule,4952.26,21971.51,
Extensive vulva surgery,56630,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21971.51,,,,,,,fee schedule,4952.26,21971.51,APC 378
Extensive vulva surgery,56630,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5199.88,,,,,,,fee schedule,4952.26,21971.51,APC
Extensive vulva surgery,56630,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5150.35,,,,,,,fee schedule,4952.26,21971.51,APC
Extensive vulva surgery,56630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4952.26,,,,,,,fee schedule,4952.26,21971.51,APC
Extensive vulva surgery,56630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7576.96,,,,,,,fee schedule,4952.26,21971.51,Radiology
Extensive vulva surgery,56630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6933.17,,,,,,,fee schedule,4952.26,21971.51,APC
Extensive vulva surgery,56630,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8666.46,,,,,,,fee schedule,4952.26,21971.51,APC
Partial removal of hymen,56700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6253.46,,,,,,,fee schedule,3204.65,14217.94,
Partial removal of hymen,56700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5012.69,,,,,,,fee schedule,3204.65,14217.94,
Partial removal of hymen,56700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5475.91,,,,,,,fee schedule,3204.65,14217.94,
Partial removal of hymen,56700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5757.15,,,,,,,fee schedule,3204.65,14217.94,
Partial removal of hymen,56700,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14217.94,,,,,,,fee schedule,3204.65,14217.94,APC 378
Partial removal of hymen,56700,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3364.88,,,,,,,fee schedule,3204.65,14217.94,APC
Partial removal of hymen,56700,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3332.84,,,,,,,fee schedule,3204.65,14217.94,APC
Partial removal of hymen,56700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3204.65,,,,,,,fee schedule,3204.65,14217.94,APC
Partial removal of hymen,56700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4903.11,,,,,,,fee schedule,3204.65,14217.94,Radiology
Partial removal of hymen,56700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4486.51,,,,,,,fee schedule,3204.65,14217.94,APC
Partial removal of hymen,56700,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5608.14,,,,,,,fee schedule,3204.65,14217.94,APC
Remove vagina gland lesion,56740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5275.24,,,,,,,fee schedule,3204.65,14217.94,
Remove vagina gland lesion,56740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4228.56,,,,,,,fee schedule,3204.65,14217.94,
Remove vagina gland lesion,56740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4619.32,,,,,,,fee schedule,3204.65,14217.94,
Remove vagina gland lesion,56740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4856.57,,,,,,,fee schedule,3204.65,14217.94,
Remove vagina gland lesion,56740,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14217.94,,,,,,,fee schedule,3204.65,14217.94,APC 378
Remove vagina gland lesion,56740,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3364.88,,,,,,,fee schedule,3204.65,14217.94,APC
Remove vagina gland lesion,56740,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3332.84,,,,,,,fee schedule,3204.65,14217.94,APC
Remove vagina gland lesion,56740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3204.65,,,,,,,fee schedule,3204.65,14217.94,APC
Remove vagina gland lesion,56740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4903.11,,,,,,,fee schedule,3204.65,14217.94,Radiology
Remove vagina gland lesion,56740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4486.51,,,,,,,fee schedule,3204.65,14217.94,APC
Remove vagina gland lesion,56740,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5608.14,,,,,,,fee schedule,3204.65,14217.94,APC
Repair of vagina,56800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4747,,,,,,,fee schedule,3204.65,14217.94,
Repair of vagina,56800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3805.13,,,,,,,fee schedule,3204.65,14217.94,
Repair of vagina,56800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4156.76,,,,,,,fee schedule,3204.65,14217.94,
Repair of vagina,56800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4370.25,,,,,,,fee schedule,3204.65,14217.94,
Repair of vagina,56800,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14217.94,,,,,,,fee schedule,3204.65,14217.94,APC 378
Repair of vagina,56800,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3364.88,,,,,,,fee schedule,3204.65,14217.94,APC
Repair of vagina,56800,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3332.84,,,,,,,fee schedule,3204.65,14217.94,APC
Repair of vagina,56800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3204.65,,,,,,,fee schedule,3204.65,14217.94,APC
Repair of vagina,56800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4903.11,,,,,,,fee schedule,3204.65,14217.94,Radiology
Repair of vagina,56800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4486.51,,,,,,,fee schedule,3204.65,14217.94,APC
Repair of vagina,56800,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5608.14,,,,,,,fee schedule,3204.65,14217.94,APC
Repair clitoris,56805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4747,,,,,,,fee schedule,3204.65,14217.94,
Repair clitoris,56805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3805.13,,,,,,,fee schedule,3204.65,14217.94,
Repair clitoris,56805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4156.76,,,,,,,fee schedule,3204.65,14217.94,
Repair clitoris,56805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4370.25,,,,,,,fee schedule,3204.65,14217.94,
Repair clitoris,56805,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14217.94,,,,,,,fee schedule,3204.65,14217.94,APC 378
Repair clitoris,56805,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3364.88,,,,,,,fee schedule,3204.65,14217.94,APC
Repair clitoris,56805,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3332.84,,,,,,,fee schedule,3204.65,14217.94,APC
Repair clitoris,56805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3204.65,,,,,,,fee schedule,3204.65,14217.94,APC
Repair clitoris,56805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4903.11,,,,,,,fee schedule,3204.65,14217.94,Radiology
Repair clitoris,56805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4486.51,,,,,,,fee schedule,3204.65,14217.94,APC
Repair clitoris,56805,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5608.14,,,,,,,fee schedule,3204.65,14217.94,APC
Repair of perineum,56810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4747,,,,,,,fee schedule,3204.65,14217.94,
Repair of perineum,56810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3805.13,,,,,,,fee schedule,3204.65,14217.94,
Repair of perineum,56810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4156.76,,,,,,,fee schedule,3204.65,14217.94,
Repair of perineum,56810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4370.25,,,,,,,fee schedule,3204.65,14217.94,
Repair of perineum,56810,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14217.94,,,,,,,fee schedule,3204.65,14217.94,APC 378
Repair of perineum,56810,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3364.88,,,,,,,fee schedule,3204.65,14217.94,APC
Repair of perineum,56810,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3332.84,,,,,,,fee schedule,3204.65,14217.94,APC
Repair of perineum,56810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3204.65,,,,,,,fee schedule,3204.65,14217.94,APC
Repair of perineum,56810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4903.11,,,,,,,fee schedule,3204.65,14217.94,Radiology
Repair of perineum,56810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4486.51,,,,,,,fee schedule,3204.65,14217.94,APC
Repair of perineum,56810,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5608.14,,,,,,,fee schedule,3204.65,14217.94,APC
Exam of vulva w/scope,56820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,337.4,,,,,,,fee schedule,200.14,887.97,
Exam of vulva w/scope,56820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,270.46,,,,,,,fee schedule,200.14,887.97,
Exam of vulva w/scope,56820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,295.45,,,,,,,fee schedule,200.14,887.97,
Exam of vulva w/scope,56820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,310.62,,,,,,,fee schedule,200.14,887.97,
Exam of vulva w/scope,56820,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,887.97,,,,,,,fee schedule,200.14,887.97,APC 378
Exam of vulva w/scope,56820,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,210.15,,,,,,,fee schedule,200.14,887.97,APC
Exam of vulva w/scope,56820,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,208.15,,,,,,,fee schedule,200.14,887.97,APC
Exam of vulva w/scope,56820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,200.14,,,,,,,fee schedule,200.14,887.97,APC
Exam of vulva w/scope,56820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,306.22,,,,,,,fee schedule,200.14,887.97,Radiology
Exam of vulva w/scope,56820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,280.2,,,,,,,fee schedule,200.14,887.97,APC
Exam of vulva w/scope,56820,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,350.25,,,,,,,fee schedule,200.14,887.97,APC
Exam/biopsy of vulva w/scope,56821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3126.73,,,,,,,fee schedule,301.67,3126.73,
Exam/biopsy of vulva w/scope,56821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2506.35,,,,,,,fee schedule,301.67,3126.73,
Exam/biopsy of vulva w/scope,56821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2737.95,,,,,,,fee schedule,301.67,3126.73,
Exam/biopsy of vulva w/scope,56821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2878.57,,,,,,,fee schedule,301.67,3126.73,
Exam/biopsy of vulva w/scope,56821,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1338.42,,,,,,,fee schedule,301.67,3126.73,APC 378
Exam/biopsy of vulva w/scope,56821,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,316.76,,,,,,,fee schedule,301.67,3126.73,APC
Exam/biopsy of vulva w/scope,56821,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,313.74,,,,,,,fee schedule,301.67,3126.73,APC
Exam/biopsy of vulva w/scope,56821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,301.67,,,,,,,fee schedule,301.67,3126.73,APC
Exam/biopsy of vulva w/scope,56821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,461.56,,,,,,,fee schedule,301.67,3126.73,Radiology
Exam/biopsy of vulva w/scope,56821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,422.34,,,,,,,fee schedule,301.67,3126.73,APC
Exam/biopsy of vulva w/scope,56821,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,527.93,,,,,,,fee schedule,301.67,3126.73,APC
Exploration of vagina,57000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4747,,,,,,,fee schedule,3204.65,14217.94,
Exploration of vagina,57000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3805.13,,,,,,,fee schedule,3204.65,14217.94,
Exploration of vagina,57000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4156.76,,,,,,,fee schedule,3204.65,14217.94,
Exploration of vagina,57000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4370.25,,,,,,,fee schedule,3204.65,14217.94,
Exploration of vagina,57000,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14217.94,,,,,,,fee schedule,3204.65,14217.94,APC 378
Exploration of vagina,57000,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3364.88,,,,,,,fee schedule,3204.65,14217.94,APC
Exploration of vagina,57000,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3332.84,,,,,,,fee schedule,3204.65,14217.94,APC
Exploration of vagina,57000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3204.65,,,,,,,fee schedule,3204.65,14217.94,APC
Exploration of vagina,57000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4903.11,,,,,,,fee schedule,3204.65,14217.94,Radiology
Exploration of vagina,57000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4486.51,,,,,,,fee schedule,3204.65,14217.94,APC
Exploration of vagina,57000,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5608.14,,,,,,,fee schedule,3204.65,14217.94,APC
Drainage of pelvic abscess,57010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4747,,,,,,,fee schedule,3204.65,14217.94,
Drainage of pelvic abscess,57010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3805.13,,,,,,,fee schedule,3204.65,14217.94,
Drainage of pelvic abscess,57010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4156.76,,,,,,,fee schedule,3204.65,14217.94,
Drainage of pelvic abscess,57010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4370.25,,,,,,,fee schedule,3204.65,14217.94,
Drainage of pelvic abscess,57010,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14217.94,,,,,,,fee schedule,3204.65,14217.94,APC 378
Drainage of pelvic abscess,57010,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3364.88,,,,,,,fee schedule,3204.65,14217.94,APC
Drainage of pelvic abscess,57010,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3332.84,,,,,,,fee schedule,3204.65,14217.94,APC
Drainage of pelvic abscess,57010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3204.65,,,,,,,fee schedule,3204.65,14217.94,APC
Drainage of pelvic abscess,57010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4903.11,,,,,,,fee schedule,3204.65,14217.94,Radiology
Drainage of pelvic abscess,57010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4486.51,,,,,,,fee schedule,3204.65,14217.94,APC
Drainage of pelvic abscess,57010,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5608.14,,,,,,,fee schedule,3204.65,14217.94,APC
Drainage of pelvic fluid,57020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1516.99,,,,,,,fee schedule,1216,21971.51,
Drainage of pelvic fluid,57020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1216,,,,,,,fee schedule,1216,21971.51,
Drainage of pelvic fluid,57020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1328.37,,,,,,,fee schedule,1216,21971.51,
Drainage of pelvic fluid,57020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1396.59,,,,,,,fee schedule,1216,21971.51,
Drainage of pelvic fluid,57020,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21971.51,,,,,,,fee schedule,1216,21971.51,APC 378
Drainage of pelvic fluid,57020,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5199.88,,,,,,,fee schedule,1216,21971.51,APC
Drainage of pelvic fluid,57020,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5150.35,,,,,,,fee schedule,1216,21971.51,APC
Drainage of pelvic fluid,57020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4952.26,,,,,,,fee schedule,1216,21971.51,APC
Drainage of pelvic fluid,57020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7576.96,,,,,,,fee schedule,1216,21971.51,Radiology
Drainage of pelvic fluid,57020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6933.17,,,,,,,fee schedule,1216,21971.51,APC
Drainage of pelvic fluid,57020,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8666.46,,,,,,,fee schedule,1216,21971.51,APC
I & d vaginal hematoma pp,57022,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2884.93,,,,,,,fee schedule,2312.53,12757.95,
I & d vaginal hematoma pp,57022,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2312.53,,,,,,,fee schedule,2312.53,12757.95,
I & d vaginal hematoma pp,57022,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2526.23,,,,,,,fee schedule,2312.53,12757.95,
I & d vaginal hematoma pp,57022,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2655.97,,,,,,,fee schedule,2312.53,12757.95,
I & d vaginal hematoma pp,57022,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2312.53,12757.95,APC 378
I & d vaginal hematoma pp,57022,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2312.53,12757.95,APC
I & d vaginal hematoma pp,57022,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2312.53,12757.95,APC
I & d vaginal hematoma pp,57022,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2312.53,12757.95,APC
I & d vaginal hematoma pp,57022,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2312.53,12757.95,Radiology
I & d vaginal hematoma pp,57022,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2312.53,12757.95,APC
I & d vaginal hematoma pp,57022,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2312.53,12757.95,APC
I & d vag hematoma non-ob,57023,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4572.14,,,,,,,fee schedule,2875.57,12757.95,
I & d vag hematoma non-ob,57023,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3664.97,,,,,,,fee schedule,2875.57,12757.95,
I & d vag hematoma non-ob,57023,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4003.64,,,,,,,fee schedule,2875.57,12757.95,
I & d vag hematoma non-ob,57023,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4209.27,,,,,,,fee schedule,2875.57,12757.95,
I & d vag hematoma non-ob,57023,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
I & d vag hematoma non-ob,57023,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
I & d vag hematoma non-ob,57023,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
I & d vag hematoma non-ob,57023,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
I & d vag hematoma non-ob,57023,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
I & d vag hematoma non-ob,57023,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
I & d vag hematoma non-ob,57023,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Destroy vag lesions simple,57061,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2396.55,,,,,,,fee schedule,1921.05,14217.94,
Destroy vag lesions simple,57061,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1921.05,,,,,,,fee schedule,1921.05,14217.94,
Destroy vag lesions simple,57061,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2098.57,,,,,,,fee schedule,1921.05,14217.94,
Destroy vag lesions simple,57061,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2206.35,,,,,,,fee schedule,1921.05,14217.94,
Destroy vag lesions simple,57061,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14217.94,,,,,,,fee schedule,1921.05,14217.94,APC 378
Destroy vag lesions simple,57061,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3364.88,,,,,,,fee schedule,1921.05,14217.94,APC
Destroy vag lesions simple,57061,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3332.84,,,,,,,fee schedule,1921.05,14217.94,APC
Destroy vag lesions simple,57061,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3204.65,,,,,,,fee schedule,1921.05,14217.94,APC
Destroy vag lesions simple,57061,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4903.11,,,,,,,fee schedule,1921.05,14217.94,Radiology
Destroy vag lesions simple,57061,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4486.51,,,,,,,fee schedule,1921.05,14217.94,APC
Destroy vag lesions simple,57061,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5608.14,,,,,,,fee schedule,1921.05,14217.94,APC
Destroy vag lesions complex,57065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4747,,,,,,,fee schedule,3204.65,14217.94,
Destroy vag lesions complex,57065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3805.13,,,,,,,fee schedule,3204.65,14217.94,
Destroy vag lesions complex,57065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4156.76,,,,,,,fee schedule,3204.65,14217.94,
Destroy vag lesions complex,57065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4370.25,,,,,,,fee schedule,3204.65,14217.94,
Destroy vag lesions complex,57065,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14217.94,,,,,,,fee schedule,3204.65,14217.94,APC 378
Destroy vag lesions complex,57065,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3364.88,,,,,,,fee schedule,3204.65,14217.94,APC
Destroy vag lesions complex,57065,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3332.84,,,,,,,fee schedule,3204.65,14217.94,APC
Destroy vag lesions complex,57065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3204.65,,,,,,,fee schedule,3204.65,14217.94,APC
Destroy vag lesions complex,57065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4903.11,,,,,,,fee schedule,3204.65,14217.94,Radiology
Destroy vag lesions complex,57065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4486.51,,,,,,,fee schedule,3204.65,14217.94,APC
Destroy vag lesions complex,57065,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5608.14,,,,,,,fee schedule,3204.65,14217.94,APC
Biopsy of vagina,57100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1516.99,,,,,,,fee schedule,911.81,4045.39,
Biopsy of vagina,57100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1216,,,,,,,fee schedule,911.81,4045.39,
Biopsy of vagina,57100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1328.37,,,,,,,fee schedule,911.81,4045.39,
Biopsy of vagina,57100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1396.59,,,,,,,fee schedule,911.81,4045.39,
Biopsy of vagina,57100,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4045.39,,,,,,,fee schedule,911.81,4045.39,APC 378
Biopsy of vagina,57100,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,957.4,,,,,,,fee schedule,911.81,4045.39,APC
Biopsy of vagina,57100,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,948.28,,,,,,,fee schedule,911.81,4045.39,APC
Biopsy of vagina,57100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,911.81,,,,,,,fee schedule,911.81,4045.39,APC
Biopsy of vagina,57100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1395.07,,,,,,,fee schedule,911.81,4045.39,Radiology
Biopsy of vagina,57100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1276.53,,,,,,,fee schedule,911.81,4045.39,APC
Biopsy of vagina,57100,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1595.67,,,,,,,fee schedule,911.81,4045.39,APC
Biopsy of vagina,57105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4747,,,,,,,fee schedule,3204.65,14217.94,
Biopsy of vagina,57105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3805.13,,,,,,,fee schedule,3204.65,14217.94,
Biopsy of vagina,57105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4156.76,,,,,,,fee schedule,3204.65,14217.94,
Biopsy of vagina,57105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4370.25,,,,,,,fee schedule,3204.65,14217.94,
Biopsy of vagina,57105,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14217.94,,,,,,,fee schedule,3204.65,14217.94,APC 378
Biopsy of vagina,57105,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3364.88,,,,,,,fee schedule,3204.65,14217.94,APC
Biopsy of vagina,57105,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3332.84,,,,,,,fee schedule,3204.65,14217.94,APC
Biopsy of vagina,57105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3204.65,,,,,,,fee schedule,3204.65,14217.94,APC
Biopsy of vagina,57105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4903.11,,,,,,,fee schedule,3204.65,14217.94,Radiology
Biopsy of vagina,57105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4486.51,,,,,,,fee schedule,3204.65,14217.94,APC
Biopsy of vagina,57105,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5608.14,,,,,,,fee schedule,3204.65,14217.94,APC
Remove vagina wall partial,57106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5785.34,,,,,,,fee schedule,3204.65,14217.94,
Remove vagina wall partial,57106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4637.46,,,,,,,fee schedule,3204.65,14217.94,
Remove vagina wall partial,57106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5066,,,,,,,fee schedule,3204.65,14217.94,
Remove vagina wall partial,57106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5326.19,,,,,,,fee schedule,3204.65,14217.94,
Remove vagina wall partial,57106,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14217.94,,,,,,,fee schedule,3204.65,14217.94,APC 378
Remove vagina wall partial,57106,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3364.88,,,,,,,fee schedule,3204.65,14217.94,APC
Remove vagina wall partial,57106,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3332.84,,,,,,,fee schedule,3204.65,14217.94,APC
Remove vagina wall partial,57106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3204.65,,,,,,,fee schedule,3204.65,14217.94,APC
Remove vagina wall partial,57106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4903.11,,,,,,,fee schedule,3204.65,14217.94,Radiology
Remove vagina wall partial,57106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4486.51,,,,,,,fee schedule,3204.65,14217.94,APC
Remove vagina wall partial,57106,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5608.14,,,,,,,fee schedule,3204.65,14217.94,APC
Remove vagina tissue part,57107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8092.19,,,,,,,fee schedule,3204.65,14217.94,
Remove vagina tissue part,57107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6486.59,,,,,,,fee schedule,3204.65,14217.94,
Remove vagina tissue part,57107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7086.01,,,,,,,fee schedule,3204.65,14217.94,
Remove vagina tissue part,57107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7449.95,,,,,,,fee schedule,3204.65,14217.94,
Remove vagina tissue part,57107,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14217.94,,,,,,,fee schedule,3204.65,14217.94,APC 378
Remove vagina tissue part,57107,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3364.88,,,,,,,fee schedule,3204.65,14217.94,APC
Remove vagina tissue part,57107,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3332.84,,,,,,,fee schedule,3204.65,14217.94,APC
Remove vagina tissue part,57107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3204.65,,,,,,,fee schedule,3204.65,14217.94,APC
Remove vagina tissue part,57107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4903.11,,,,,,,fee schedule,3204.65,14217.94,Radiology
Remove vagina tissue part,57107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4486.51,,,,,,,fee schedule,3204.65,14217.94,APC
Remove vagina tissue part,57107,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5608.14,,,,,,,fee schedule,3204.65,14217.94,APC
Vaginectomy partial w/nodes,57109,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8092.19,,,,,,,fee schedule,3204.65,14217.94,
Vaginectomy partial w/nodes,57109,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6486.59,,,,,,,fee schedule,3204.65,14217.94,
Vaginectomy partial w/nodes,57109,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7086.01,,,,,,,fee schedule,3204.65,14217.94,
Vaginectomy partial w/nodes,57109,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7449.95,,,,,,,fee schedule,3204.65,14217.94,
Vaginectomy partial w/nodes,57109,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14217.94,,,,,,,fee schedule,3204.65,14217.94,APC 378
Vaginectomy partial w/nodes,57109,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3364.88,,,,,,,fee schedule,3204.65,14217.94,APC
Vaginectomy partial w/nodes,57109,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3332.84,,,,,,,fee schedule,3204.65,14217.94,APC
Vaginectomy partial w/nodes,57109,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3204.65,,,,,,,fee schedule,3204.65,14217.94,APC
Vaginectomy partial w/nodes,57109,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4903.11,,,,,,,fee schedule,3204.65,14217.94,Radiology
Vaginectomy partial w/nodes,57109,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4486.51,,,,,,,fee schedule,3204.65,14217.94,APC
Vaginectomy partial w/nodes,57109,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5608.14,,,,,,,fee schedule,3204.65,14217.94,APC
Closure of vagina,57120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2850.68,,,,,,,fee schedule,2285.07,21971.51,
Closure of vagina,57120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2285.07,,,,,,,fee schedule,2285.07,21971.51,
Closure of vagina,57120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2496.23,,,,,,,fee schedule,2285.07,21971.51,
Closure of vagina,57120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2624.44,,,,,,,fee schedule,2285.07,21971.51,
Closure of vagina,57120,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21971.51,,,,,,,fee schedule,2285.07,21971.51,APC 378
Closure of vagina,57120,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5199.88,,,,,,,fee schedule,2285.07,21971.51,APC
Closure of vagina,57120,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5150.35,,,,,,,fee schedule,2285.07,21971.51,APC
Closure of vagina,57120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4952.26,,,,,,,fee schedule,2285.07,21971.51,APC
Closure of vagina,57120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7576.96,,,,,,,fee schedule,2285.07,21971.51,Radiology
Closure of vagina,57120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6933.17,,,,,,,fee schedule,2285.07,21971.51,APC
Closure of vagina,57120,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8666.46,,,,,,,fee schedule,2285.07,21971.51,APC
Remove vagina lesion,57130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4747,,,,,,,fee schedule,3204.65,14217.94,
Remove vagina lesion,57130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3805.13,,,,,,,fee schedule,3204.65,14217.94,
Remove vagina lesion,57130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4156.76,,,,,,,fee schedule,3204.65,14217.94,
Remove vagina lesion,57130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4370.25,,,,,,,fee schedule,3204.65,14217.94,
Remove vagina lesion,57130,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14217.94,,,,,,,fee schedule,3204.65,14217.94,APC 378
Remove vagina lesion,57130,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3364.88,,,,,,,fee schedule,3204.65,14217.94,APC
Remove vagina lesion,57130,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3332.84,,,,,,,fee schedule,3204.65,14217.94,APC
Remove vagina lesion,57130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3204.65,,,,,,,fee schedule,3204.65,14217.94,APC
Remove vagina lesion,57130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4903.11,,,,,,,fee schedule,3204.65,14217.94,Radiology
Remove vagina lesion,57130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4486.51,,,,,,,fee schedule,3204.65,14217.94,APC
Remove vagina lesion,57130,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5608.14,,,,,,,fee schedule,3204.65,14217.94,APC
Remove vagina lesion,57135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6721.57,,,,,,,fee schedule,3204.65,14217.94,
Remove vagina lesion,57135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5387.93,,,,,,,fee schedule,3204.65,14217.94,
Remove vagina lesion,57135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5885.82,,,,,,,fee schedule,3204.65,14217.94,
Remove vagina lesion,57135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6188.11,,,,,,,fee schedule,3204.65,14217.94,
Remove vagina lesion,57135,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14217.94,,,,,,,fee schedule,3204.65,14217.94,APC 378
Remove vagina lesion,57135,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3364.88,,,,,,,fee schedule,3204.65,14217.94,APC
Remove vagina lesion,57135,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3332.84,,,,,,,fee schedule,3204.65,14217.94,APC
Remove vagina lesion,57135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3204.65,,,,,,,fee schedule,3204.65,14217.94,APC
Remove vagina lesion,57135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4903.11,,,,,,,fee schedule,3204.65,14217.94,Radiology
Remove vagina lesion,57135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4486.51,,,,,,,fee schedule,3204.65,14217.94,APC
Remove vagina lesion,57135,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5608.14,,,,,,,fee schedule,3204.65,14217.94,APC
Treat vagina infection,57150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,337.4,,,,,,,fee schedule,58.4,337.4,
Treat vagina infection,57150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,270.46,,,,,,,fee schedule,58.4,337.4,
Treat vagina infection,57150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,295.45,,,,,,,fee schedule,58.4,337.4,
Treat vagina infection,57150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,310.62,,,,,,,fee schedule,58.4,337.4,
Treat vagina infection,57150,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,58.4,337.4,APC 378
Treat vagina infection,57150,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,58.4,337.4,APC
Treat vagina infection,57150,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,58.4,337.4,APC
Treat vagina infection,57150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,58.4,337.4,APC
Treat vagina infection,57150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,58.4,337.4,Radiology
Treat vagina infection,57150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,58.4,337.4,APC
Treat vagina infection,57150,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,58.4,337.4,APC
Insert uteri tandem/ovoids,57155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5679.33,,,,,,,fee schedule,4552.48,21971.51,
Insert uteri tandem/ovoids,57155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4552.48,,,,,,,fee schedule,4552.48,21971.51,
Insert uteri tandem/ovoids,57155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4973.17,,,,,,,fee schedule,4552.48,21971.51,
Insert uteri tandem/ovoids,57155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5228.59,,,,,,,fee schedule,4552.48,21971.51,
Insert uteri tandem/ovoids,57155,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21971.51,,,,,,,fee schedule,4552.48,21971.51,APC 378
Insert uteri tandem/ovoids,57155,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5199.88,,,,,,,fee schedule,4552.48,21971.51,APC
Insert uteri tandem/ovoids,57155,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5150.35,,,,,,,fee schedule,4552.48,21971.51,APC
Insert uteri tandem/ovoids,57155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4952.26,,,,,,,fee schedule,4552.48,21971.51,APC
Insert uteri tandem/ovoids,57155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7576.96,,,,,,,fee schedule,4552.48,21971.51,Radiology
Insert uteri tandem/ovoids,57155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6933.17,,,,,,,fee schedule,4552.48,21971.51,APC
Insert uteri tandem/ovoids,57155,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8666.46,,,,,,,fee schedule,4552.48,21971.51,APC
Ins vag brachytx device,57156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1001.25,,,,,,,fee schedule,301.67,1338.42,
Ins vag brachytx device,57156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,802.59,,,,,,,fee schedule,301.67,1338.42,
Ins vag brachytx device,57156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,876.75,,,,,,,fee schedule,301.67,1338.42,
Ins vag brachytx device,57156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,921.78,,,,,,,fee schedule,301.67,1338.42,
Ins vag brachytx device,57156,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1338.42,,,,,,,fee schedule,301.67,1338.42,APC 378
Ins vag brachytx device,57156,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,316.76,,,,,,,fee schedule,301.67,1338.42,APC
Ins vag brachytx device,57156,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,313.74,,,,,,,fee schedule,301.67,1338.42,APC
Ins vag brachytx device,57156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,301.67,,,,,,,fee schedule,301.67,1338.42,APC
Ins vag brachytx device,57156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,461.56,,,,,,,fee schedule,301.67,1338.42,Radiology
Ins vag brachytx device,57156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,422.34,,,,,,,fee schedule,301.67,1338.42,APC
Ins vag brachytx device,57156,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,527.93,,,,,,,fee schedule,301.67,1338.42,APC
Insert pessary/other device,57160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,337.4,,,,,,,fee schedule,200.14,887.97,
Insert pessary/other device,57160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,270.46,,,,,,,fee schedule,200.14,887.97,
Insert pessary/other device,57160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,295.45,,,,,,,fee schedule,200.14,887.97,
Insert pessary/other device,57160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,310.62,,,,,,,fee schedule,200.14,887.97,
Insert pessary/other device,57160,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,887.97,,,,,,,fee schedule,200.14,887.97,APC 378
Insert pessary/other device,57160,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,210.15,,,,,,,fee schedule,200.14,887.97,APC
Insert pessary/other device,57160,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,208.15,,,,,,,fee schedule,200.14,887.97,APC
Insert pessary/other device,57160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,200.14,,,,,,,fee schedule,200.14,887.97,APC
Insert pessary/other device,57160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,306.22,,,,,,,fee schedule,200.14,887.97,Radiology
Insert pessary/other device,57160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,280.2,,,,,,,fee schedule,200.14,887.97,APC
Insert pessary/other device,57160,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,350.25,,,,,,,fee schedule,200.14,887.97,APC
Fitting of diaphragm/cap,57170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,32.7,,,,,,,fee schedule,26.21,887.97,
Fitting of diaphragm/cap,57170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26.21,,,,,,,fee schedule,26.21,887.97,
Fitting of diaphragm/cap,57170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28.63,,,,,,,fee schedule,26.21,887.97,
Fitting of diaphragm/cap,57170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30.1,,,,,,,fee schedule,26.21,887.97,
Fitting of diaphragm/cap,57170,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,887.97,,,,,,,fee schedule,26.21,887.97,APC 378
Fitting of diaphragm/cap,57170,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,210.15,,,,,,,fee schedule,26.21,887.97,APC
Fitting of diaphragm/cap,57170,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,208.15,,,,,,,fee schedule,26.21,887.97,APC
Fitting of diaphragm/cap,57170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,200.14,,,,,,,fee schedule,26.21,887.97,APC
Fitting of diaphragm/cap,57170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,306.22,,,,,,,fee schedule,26.21,887.97,Radiology
Fitting of diaphragm/cap,57170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,280.2,,,,,,,fee schedule,26.21,887.97,APC
Fitting of diaphragm/cap,57170,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,350.25,,,,,,,fee schedule,26.21,887.97,APC
Treat vaginal bleeding,57180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,337.4,,,,,,,fee schedule,200.14,887.97,
Treat vaginal bleeding,57180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,270.46,,,,,,,fee schedule,200.14,887.97,
Treat vaginal bleeding,57180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,295.45,,,,,,,fee schedule,200.14,887.97,
Treat vaginal bleeding,57180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,310.62,,,,,,,fee schedule,200.14,887.97,
Treat vaginal bleeding,57180,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,887.97,,,,,,,fee schedule,200.14,887.97,APC 378
Treat vaginal bleeding,57180,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,210.15,,,,,,,fee schedule,200.14,887.97,APC
Treat vaginal bleeding,57180,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,208.15,,,,,,,fee schedule,200.14,887.97,APC
Treat vaginal bleeding,57180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,200.14,,,,,,,fee schedule,200.14,887.97,APC
Treat vaginal bleeding,57180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,306.22,,,,,,,fee schedule,200.14,887.97,Radiology
Treat vaginal bleeding,57180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,280.2,,,,,,,fee schedule,200.14,887.97,APC
Treat vaginal bleeding,57180,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,350.25,,,,,,,fee schedule,200.14,887.97,APC
Repair of vagina,57200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5523.29,,,,,,,fee schedule,3204.65,14217.94,
Repair of vagina,57200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4427.4,,,,,,,fee schedule,3204.65,14217.94,
Repair of vagina,57200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4836.53,,,,,,,fee schedule,3204.65,14217.94,
Repair of vagina,57200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5084.93,,,,,,,fee schedule,3204.65,14217.94,
Repair of vagina,57200,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14217.94,,,,,,,fee schedule,3204.65,14217.94,APC 378
Repair of vagina,57200,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3364.88,,,,,,,fee schedule,3204.65,14217.94,APC
Repair of vagina,57200,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3332.84,,,,,,,fee schedule,3204.65,14217.94,APC
Repair of vagina,57200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3204.65,,,,,,,fee schedule,3204.65,14217.94,APC
Repair of vagina,57200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4903.11,,,,,,,fee schedule,3204.65,14217.94,Radiology
Repair of vagina,57200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4486.51,,,,,,,fee schedule,3204.65,14217.94,APC
Repair of vagina,57200,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5608.14,,,,,,,fee schedule,3204.65,14217.94,APC
Repair vagina/perineum,57210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8115.62,,,,,,,fee schedule,3204.65,14217.94,
Repair vagina/perineum,57210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6505.38,,,,,,,fee schedule,3204.65,14217.94,
Repair vagina/perineum,57210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7106.54,,,,,,,fee schedule,3204.65,14217.94,
Repair vagina/perineum,57210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7471.53,,,,,,,fee schedule,3204.65,14217.94,
Repair vagina/perineum,57210,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14217.94,,,,,,,fee schedule,3204.65,14217.94,APC 378
Repair vagina/perineum,57210,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3364.88,,,,,,,fee schedule,3204.65,14217.94,APC
Repair vagina/perineum,57210,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3332.84,,,,,,,fee schedule,3204.65,14217.94,APC
Repair vagina/perineum,57210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3204.65,,,,,,,fee schedule,3204.65,14217.94,APC
Repair vagina/perineum,57210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4903.11,,,,,,,fee schedule,3204.65,14217.94,Radiology
Repair vagina/perineum,57210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4486.51,,,,,,,fee schedule,3204.65,14217.94,APC
Repair vagina/perineum,57210,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5608.14,,,,,,,fee schedule,3204.65,14217.94,APC
Revision of urethra,57220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10659.34,,,,,,,fee schedule,4952.26,21971.51,
Revision of urethra,57220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8544.39,,,,,,,fee schedule,4952.26,21971.51,
Revision of urethra,57220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9333.97,,,,,,,fee schedule,4952.26,21971.51,
Revision of urethra,57220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9813.36,,,,,,,fee schedule,4952.26,21971.51,
Revision of urethra,57220,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21971.51,,,,,,,fee schedule,4952.26,21971.51,APC 378
Revision of urethra,57220,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5199.88,,,,,,,fee schedule,4952.26,21971.51,APC
Revision of urethra,57220,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5150.35,,,,,,,fee schedule,4952.26,21971.51,APC
Revision of urethra,57220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4952.26,,,,,,,fee schedule,4952.26,21971.51,APC
Revision of urethra,57220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7576.96,,,,,,,fee schedule,4952.26,21971.51,Radiology
Revision of urethra,57220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6933.17,,,,,,,fee schedule,4952.26,21971.51,APC
Revision of urethra,57220,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8666.46,,,,,,,fee schedule,4952.26,21971.51,APC
Repair of urethral lesion,57230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8092.19,,,,,,,fee schedule,3204.65,14217.94,
Repair of urethral lesion,57230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6486.59,,,,,,,fee schedule,3204.65,14217.94,
Repair of urethral lesion,57230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7086.01,,,,,,,fee schedule,3204.65,14217.94,
Repair of urethral lesion,57230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7449.95,,,,,,,fee schedule,3204.65,14217.94,
Repair of urethral lesion,57230,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14217.94,,,,,,,fee schedule,3204.65,14217.94,APC 378
Repair of urethral lesion,57230,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3364.88,,,,,,,fee schedule,3204.65,14217.94,APC
Repair of urethral lesion,57230,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3332.84,,,,,,,fee schedule,3204.65,14217.94,APC
Repair of urethral lesion,57230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3204.65,,,,,,,fee schedule,3204.65,14217.94,APC
Repair of urethral lesion,57230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4903.11,,,,,,,fee schedule,3204.65,14217.94,Radiology
Repair of urethral lesion,57230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4486.51,,,,,,,fee schedule,3204.65,14217.94,APC
Repair of urethral lesion,57230,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5608.14,,,,,,,fee schedule,3204.65,14217.94,APC
Repair bladder & vagina,57240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5626.32,,,,,,,fee schedule,4509.99,21971.51,
Repair bladder & vagina,57240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4509.99,,,,,,,fee schedule,4509.99,21971.51,
Repair bladder & vagina,57240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4926.75,,,,,,,fee schedule,4509.99,21971.51,
Repair bladder & vagina,57240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5179.79,,,,,,,fee schedule,4509.99,21971.51,
Repair bladder & vagina,57240,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21971.51,,,,,,,fee schedule,4509.99,21971.51,APC 378
Repair bladder & vagina,57240,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5199.88,,,,,,,fee schedule,4509.99,21971.51,APC
Repair bladder & vagina,57240,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5150.35,,,,,,,fee schedule,4509.99,21971.51,APC
Repair bladder & vagina,57240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4952.26,,,,,,,fee schedule,4509.99,21971.51,APC
Repair bladder & vagina,57240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7576.96,,,,,,,fee schedule,4509.99,21971.51,Radiology
Repair bladder & vagina,57240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6933.17,,,,,,,fee schedule,4509.99,21971.51,APC
Repair bladder & vagina,57240,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8666.46,,,,,,,fee schedule,4509.99,21971.51,APC
Repair rectum & vagina,57250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6858.95,,,,,,,fee schedule,4952.26,21971.51,
Repair rectum & vagina,57250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5498.05,,,,,,,fee schedule,4952.26,21971.51,
Repair rectum & vagina,57250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6006.12,,,,,,,fee schedule,4952.26,21971.51,
Repair rectum & vagina,57250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6314.59,,,,,,,fee schedule,4952.26,21971.51,
Repair rectum & vagina,57250,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21971.51,,,,,,,fee schedule,4952.26,21971.51,APC 378
Repair rectum & vagina,57250,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5199.88,,,,,,,fee schedule,4952.26,21971.51,APC
Repair rectum & vagina,57250,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5150.35,,,,,,,fee schedule,4952.26,21971.51,APC
Repair rectum & vagina,57250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4952.26,,,,,,,fee schedule,4952.26,21971.51,APC
Repair rectum & vagina,57250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7576.96,,,,,,,fee schedule,4952.26,21971.51,Radiology
Repair rectum & vagina,57250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6933.17,,,,,,,fee schedule,4952.26,21971.51,APC
Repair rectum & vagina,57250,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8666.46,,,,,,,fee schedule,4952.26,21971.51,APC
Repair of vagina,57260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4383.47,,,,,,,fee schedule,3513.74,21971.51,
Repair of vagina,57260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3513.74,,,,,,,fee schedule,3513.74,21971.51,
Repair of vagina,57260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3838.44,,,,,,,fee schedule,3513.74,21971.51,
Repair of vagina,57260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4035.58,,,,,,,fee schedule,3513.74,21971.51,
Repair of vagina,57260,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21971.51,,,,,,,fee schedule,3513.74,21971.51,APC 378
Repair of vagina,57260,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5199.88,,,,,,,fee schedule,3513.74,21971.51,APC
Repair of vagina,57260,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5150.35,,,,,,,fee schedule,3513.74,21971.51,APC
Repair of vagina,57260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4952.26,,,,,,,fee schedule,3513.74,21971.51,APC
Repair of vagina,57260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7576.96,,,,,,,fee schedule,3513.74,21971.51,Radiology
Repair of vagina,57260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6933.17,,,,,,,fee schedule,3513.74,21971.51,APC
Repair of vagina,57260,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8666.46,,,,,,,fee schedule,3513.74,21971.51,APC
Extensive repair of vagina,57265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5701.36,,,,,,,fee schedule,4570.14,21971.51,
Extensive repair of vagina,57265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4570.14,,,,,,,fee schedule,4570.14,21971.51,
Extensive repair of vagina,57265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4992.46,,,,,,,fee schedule,4570.14,21971.51,
Extensive repair of vagina,57265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5248.87,,,,,,,fee schedule,4570.14,21971.51,
Extensive repair of vagina,57265,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21971.51,,,,,,,fee schedule,4570.14,21971.51,APC 378
Extensive repair of vagina,57265,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5199.88,,,,,,,fee schedule,4570.14,21971.51,APC
Extensive repair of vagina,57265,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5150.35,,,,,,,fee schedule,4570.14,21971.51,APC
Extensive repair of vagina,57265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4952.26,,,,,,,fee schedule,4570.14,21971.51,APC
Extensive repair of vagina,57265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7576.96,,,,,,,fee schedule,4570.14,21971.51,Radiology
Extensive repair of vagina,57265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6933.17,,,,,,,fee schedule,4570.14,21971.51,APC
Extensive repair of vagina,57265,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8666.46,,,,,,,fee schedule,4570.14,21971.51,APC
Insert mesh/pelvic flr addon,57267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3111.54,,,,,,,fee schedule,2494.17,3111.54,
Insert mesh/pelvic flr addon,57267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2494.17,,,,,,,fee schedule,2494.17,3111.54,
Insert mesh/pelvic flr addon,57267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2724.65,,,,,,,fee schedule,2494.17,3111.54,
Insert mesh/pelvic flr addon,57267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2864.59,,,,,,,fee schedule,2494.17,3111.54,
Repair of bowel bulge,57268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4096.82,,,,,,,fee schedule,3283.96,21971.51,
Repair of bowel bulge,57268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3283.96,,,,,,,fee schedule,3283.96,21971.51,
Repair of bowel bulge,57268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3587.43,,,,,,,fee schedule,3283.96,21971.51,
Repair of bowel bulge,57268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3771.68,,,,,,,fee schedule,3283.96,21971.51,
Repair of bowel bulge,57268,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21971.51,,,,,,,fee schedule,3283.96,21971.51,APC 378
Repair of bowel bulge,57268,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5199.88,,,,,,,fee schedule,3283.96,21971.51,APC
Repair of bowel bulge,57268,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5150.35,,,,,,,fee schedule,3283.96,21971.51,APC
Repair of bowel bulge,57268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4952.26,,,,,,,fee schedule,3283.96,21971.51,APC
Repair of bowel bulge,57268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7576.96,,,,,,,fee schedule,3283.96,21971.51,Radiology
Repair of bowel bulge,57268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6933.17,,,,,,,fee schedule,3283.96,21971.51,APC
Repair of bowel bulge,57268,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8666.46,,,,,,,fee schedule,3283.96,21971.51,APC
Colpopexy extraperitoneal,57282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5632.55,,,,,,,fee schedule,4514.98,32569.71,
Colpopexy extraperitoneal,57282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4514.98,,,,,,,fee schedule,4514.98,32569.71,
Colpopexy extraperitoneal,57282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4932.21,,,,,,,fee schedule,4514.98,32569.71,
Colpopexy extraperitoneal,57282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5185.52,,,,,,,fee schedule,4514.98,32569.71,
Colpopexy extraperitoneal,57282,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,32569.71,,,,,,,fee schedule,4514.98,32569.71,APC 378
Colpopexy extraperitoneal,57282,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7708.09,,,,,,,fee schedule,4514.98,32569.71,APC
Colpopexy extraperitoneal,57282,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7634.68,,,,,,,fee schedule,4514.98,32569.71,APC
Colpopexy extraperitoneal,57282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7341.04,,,,,,,fee schedule,4514.98,32569.71,APC
Colpopexy extraperitoneal,57282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11231.79,,,,,,,fee schedule,4514.98,32569.71,Radiology
Colpopexy extraperitoneal,57282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10277.46,,,,,,,fee schedule,4514.98,32569.71,APC
Colpopexy extraperitoneal,57282,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12846.82,,,,,,,fee schedule,4514.98,32569.71,APC
Colpopexy intraperitoneal,57283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3800.9,,,,,,,fee schedule,3046.75,32569.71,
Colpopexy intraperitoneal,57283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3046.75,,,,,,,fee schedule,3046.75,32569.71,
Colpopexy intraperitoneal,57283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3328.3,,,,,,,fee schedule,3046.75,32569.71,
Colpopexy intraperitoneal,57283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3499.24,,,,,,,fee schedule,3046.75,32569.71,
Colpopexy intraperitoneal,57283,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,32569.71,,,,,,,fee schedule,3046.75,32569.71,APC 378
Colpopexy intraperitoneal,57283,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7708.09,,,,,,,fee schedule,3046.75,32569.71,APC
Colpopexy intraperitoneal,57283,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7634.68,,,,,,,fee schedule,3046.75,32569.71,APC
Colpopexy intraperitoneal,57283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7341.04,,,,,,,fee schedule,3046.75,32569.71,APC
Colpopexy intraperitoneal,57283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11231.79,,,,,,,fee schedule,3046.75,32569.71,Radiology
Colpopexy intraperitoneal,57283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10277.46,,,,,,,fee schedule,3046.75,32569.71,APC
Colpopexy intraperitoneal,57283,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12846.82,,,,,,,fee schedule,3046.75,32569.71,APC
Repair paravag defect open,57284,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10659.34,,,,,,,fee schedule,4952.26,21971.51,
Repair paravag defect open,57284,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8544.39,,,,,,,fee schedule,4952.26,21971.51,
Repair paravag defect open,57284,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9333.97,,,,,,,fee schedule,4952.26,21971.51,
Repair paravag defect open,57284,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9813.36,,,,,,,fee schedule,4952.26,21971.51,
Repair paravag defect open,57284,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21971.51,,,,,,,fee schedule,4952.26,21971.51,APC 378
Repair paravag defect open,57284,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5199.88,,,,,,,fee schedule,4952.26,21971.51,APC
Repair paravag defect open,57284,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5150.35,,,,,,,fee schedule,4952.26,21971.51,APC
Repair paravag defect open,57284,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4952.26,,,,,,,fee schedule,4952.26,21971.51,APC
Repair paravag defect open,57284,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7576.96,,,,,,,fee schedule,4952.26,21971.51,Radiology
Repair paravag defect open,57284,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6933.17,,,,,,,fee schedule,4952.26,21971.51,APC
Repair paravag defect open,57284,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8666.46,,,,,,,fee schedule,4952.26,21971.51,APC
Repair paravag defect vag,57285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6346.65,,,,,,,fee schedule,5087.39,32569.71,
Repair paravag defect vag,57285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5087.39,,,,,,,fee schedule,5087.39,32569.71,
Repair paravag defect vag,57285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5557.51,,,,,,,fee schedule,5087.39,32569.71,
Repair paravag defect vag,57285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5842.94,,,,,,,fee schedule,5087.39,32569.71,
Repair paravag defect vag,57285,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,32569.71,,,,,,,fee schedule,5087.39,32569.71,APC 378
Repair paravag defect vag,57285,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7708.09,,,,,,,fee schedule,5087.39,32569.71,APC
Repair paravag defect vag,57285,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7634.68,,,,,,,fee schedule,5087.39,32569.71,APC
Repair paravag defect vag,57285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7341.04,,,,,,,fee schedule,5087.39,32569.71,APC
Repair paravag defect vag,57285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11231.79,,,,,,,fee schedule,5087.39,32569.71,Radiology
Repair paravag defect vag,57285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10277.46,,,,,,,fee schedule,5087.39,32569.71,APC
Repair paravag defect vag,57285,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12846.82,,,,,,,fee schedule,5087.39,32569.71,APC
Revise/Remove Sling Repair,57287,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6955.63,,,,,,,fee schedule,3204.65,14217.94,
Revise/Remove Sling Repair,57287,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5575.54,,,,,,,fee schedule,3204.65,14217.94,
Revise/Remove Sling Repair,57287,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6090.78,,,,,,,fee schedule,3204.65,14217.94,
Revise/Remove Sling Repair,57287,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6403.59,,,,,,,fee schedule,3204.65,14217.94,
Revise/Remove Sling Repair,57287,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14217.94,,,,,,,fee schedule,3204.65,14217.94,APC 378
Revise/Remove Sling Repair,57287,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3364.88,,,,,,,fee schedule,3204.65,14217.94,APC
Revise/Remove Sling Repair,57287,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3332.84,,,,,,,fee schedule,3204.65,14217.94,APC
Revise/Remove Sling Repair,57287,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3204.65,,,,,,,fee schedule,3204.65,14217.94,APC
Revise/Remove Sling Repair,57287,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4903.11,,,,,,,fee schedule,3204.65,14217.94,Radiology
Revise/Remove Sling Repair,57287,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4486.51,,,,,,,fee schedule,3204.65,14217.94,APC
Revise/Remove Sling Repair,57287,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5608.14,,,,,,,fee schedule,3204.65,14217.94,APC
Repair bladder defect,57288,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5786.26,,,,,,,fee schedule,4638.19,21971.51,
Repair bladder defect,57288,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4638.19,,,,,,,fee schedule,4638.19,21971.51,
Repair bladder defect,57288,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5066.8,,,,,,,fee schedule,4638.19,21971.51,
Repair bladder defect,57288,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5327.03,,,,,,,fee schedule,4638.19,21971.51,
Repair bladder defect,57288,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21971.51,,,,,,,fee schedule,4638.19,21971.51,APC 378
Repair bladder defect,57288,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5199.88,,,,,,,fee schedule,4638.19,21971.51,APC
Repair bladder defect,57288,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5150.35,,,,,,,fee schedule,4638.19,21971.51,APC
Repair bladder defect,57288,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4952.26,,,,,,,fee schedule,4638.19,21971.51,APC
Repair bladder defect,57288,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7576.96,,,,,,,fee schedule,4638.19,21971.51,Radiology
Repair bladder defect,57288,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6933.17,,,,,,,fee schedule,4638.19,21971.51,APC
Repair bladder defect,57288,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8666.46,,,,,,,fee schedule,4638.19,21971.51,APC
Repair bladder & vagina,57289,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8092.19,,,,,,,fee schedule,6486.59,32569.71,
Repair bladder & vagina,57289,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6486.59,,,,,,,fee schedule,6486.59,32569.71,
Repair bladder & vagina,57289,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7086.01,,,,,,,fee schedule,6486.59,32569.71,
Repair bladder & vagina,57289,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7449.95,,,,,,,fee schedule,6486.59,32569.71,
Repair bladder & vagina,57289,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,32569.71,,,,,,,fee schedule,6486.59,32569.71,APC 378
Repair bladder & vagina,57289,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7708.09,,,,,,,fee schedule,6486.59,32569.71,APC
Repair bladder & vagina,57289,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7634.68,,,,,,,fee schedule,6486.59,32569.71,APC
Repair bladder & vagina,57289,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7341.04,,,,,,,fee schedule,6486.59,32569.71,APC
Repair bladder & vagina,57289,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11231.79,,,,,,,fee schedule,6486.59,32569.71,Radiology
Repair bladder & vagina,57289,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10277.46,,,,,,,fee schedule,6486.59,32569.71,APC
Repair bladder & vagina,57289,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12846.82,,,,,,,fee schedule,6486.59,32569.71,APC
Construction of vagina,57291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8092.19,,,,,,,fee schedule,4952.26,21971.51,
Construction of vagina,57291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6486.59,,,,,,,fee schedule,4952.26,21971.51,
Construction of vagina,57291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7086.01,,,,,,,fee schedule,4952.26,21971.51,
Construction of vagina,57291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7449.95,,,,,,,fee schedule,4952.26,21971.51,
Construction of vagina,57291,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21971.51,,,,,,,fee schedule,4952.26,21971.51,APC 378
Construction of vagina,57291,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5199.88,,,,,,,fee schedule,4952.26,21971.51,APC
Construction of vagina,57291,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5150.35,,,,,,,fee schedule,4952.26,21971.51,APC
Construction of vagina,57291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4952.26,,,,,,,fee schedule,4952.26,21971.51,APC
Construction of vagina,57291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7576.96,,,,,,,fee schedule,4952.26,21971.51,Radiology
Construction of vagina,57291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6933.17,,,,,,,fee schedule,4952.26,21971.51,APC
Construction of vagina,57291,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8666.46,,,,,,,fee schedule,4952.26,21971.51,APC
Construct vagina with graft,57292,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8092.19,,,,,,,fee schedule,4952.26,21971.51,
Construct vagina with graft,57292,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6486.59,,,,,,,fee schedule,4952.26,21971.51,
Construct vagina with graft,57292,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7086.01,,,,,,,fee schedule,4952.26,21971.51,
Construct vagina with graft,57292,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7449.95,,,,,,,fee schedule,4952.26,21971.51,
Construct vagina with graft,57292,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21971.51,,,,,,,fee schedule,4952.26,21971.51,APC 378
Construct vagina with graft,57292,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5199.88,,,,,,,fee schedule,4952.26,21971.51,APC
Construct vagina with graft,57292,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5150.35,,,,,,,fee schedule,4952.26,21971.51,APC
Construct vagina with graft,57292,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4952.26,,,,,,,fee schedule,4952.26,21971.51,APC
Construct vagina with graft,57292,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7576.96,,,,,,,fee schedule,4952.26,21971.51,Radiology
Construct vagina with graft,57292,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6933.17,,,,,,,fee schedule,4952.26,21971.51,APC
Construct vagina with graft,57292,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8666.46,,,,,,,fee schedule,4952.26,21971.51,APC
Revise vag graft via vagina,57295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5041.18,,,,,,,fee schedule,3204.65,14217.94,
Revise vag graft via vagina,57295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4040.94,,,,,,,fee schedule,3204.65,14217.94,
Revise vag graft via vagina,57295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4414.36,,,,,,,fee schedule,3204.65,14217.94,
Revise vag graft via vagina,57295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4641.08,,,,,,,fee schedule,3204.65,14217.94,
Revise vag graft via vagina,57295,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14217.94,,,,,,,fee schedule,3204.65,14217.94,APC 378
Revise vag graft via vagina,57295,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3364.88,,,,,,,fee schedule,3204.65,14217.94,APC
Revise vag graft via vagina,57295,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3332.84,,,,,,,fee schedule,3204.65,14217.94,APC
Revise vag graft via vagina,57295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3204.65,,,,,,,fee schedule,3204.65,14217.94,APC
Revise vag graft via vagina,57295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4903.11,,,,,,,fee schedule,3204.65,14217.94,Radiology
Revise vag graft via vagina,57295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4486.51,,,,,,,fee schedule,3204.65,14217.94,APC
Revise vag graft via vagina,57295,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5608.14,,,,,,,fee schedule,3204.65,14217.94,APC
Repair rectum-vagina fistula,57300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8092.19,,,,,,,fee schedule,3204.65,14217.94,
Repair rectum-vagina fistula,57300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6486.59,,,,,,,fee schedule,3204.65,14217.94,
Repair rectum-vagina fistula,57300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7086.01,,,,,,,fee schedule,3204.65,14217.94,
Repair rectum-vagina fistula,57300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7449.95,,,,,,,fee schedule,3204.65,14217.94,
Repair rectum-vagina fistula,57300,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14217.94,,,,,,,fee schedule,3204.65,14217.94,APC 378
Repair rectum-vagina fistula,57300,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3364.88,,,,,,,fee schedule,3204.65,14217.94,APC
Repair rectum-vagina fistula,57300,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3332.84,,,,,,,fee schedule,3204.65,14217.94,APC
Repair rectum-vagina fistula,57300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3204.65,,,,,,,fee schedule,3204.65,14217.94,APC
Repair rectum-vagina fistula,57300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4903.11,,,,,,,fee schedule,3204.65,14217.94,Radiology
Repair rectum-vagina fistula,57300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4486.51,,,,,,,fee schedule,3204.65,14217.94,APC
Repair rectum-vagina fistula,57300,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5608.14,,,,,,,fee schedule,3204.65,14217.94,APC
Repair urethrovaginal lesion,57310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10659.34,,,,,,,fee schedule,7341.04,32569.71,
Repair urethrovaginal lesion,57310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8544.39,,,,,,,fee schedule,7341.04,32569.71,
Repair urethrovaginal lesion,57310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9333.97,,,,,,,fee schedule,7341.04,32569.71,
Repair urethrovaginal lesion,57310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9813.36,,,,,,,fee schedule,7341.04,32569.71,
Repair urethrovaginal lesion,57310,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,32569.71,,,,,,,fee schedule,7341.04,32569.71,APC 378
Repair urethrovaginal lesion,57310,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7708.09,,,,,,,fee schedule,7341.04,32569.71,APC
Repair urethrovaginal lesion,57310,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7634.68,,,,,,,fee schedule,7341.04,32569.71,APC
Repair urethrovaginal lesion,57310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7341.04,,,,,,,fee schedule,7341.04,32569.71,APC
Repair urethrovaginal lesion,57310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11231.79,,,,,,,fee schedule,7341.04,32569.71,Radiology
Repair urethrovaginal lesion,57310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10277.46,,,,,,,fee schedule,7341.04,32569.71,APC
Repair urethrovaginal lesion,57310,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12846.82,,,,,,,fee schedule,7341.04,32569.71,APC
Repair bladder-vagina lesion,57320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8092.19,,,,,,,fee schedule,4952.26,21971.51,
Repair bladder-vagina lesion,57320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6486.59,,,,,,,fee schedule,4952.26,21971.51,
Repair bladder-vagina lesion,57320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7086.01,,,,,,,fee schedule,4952.26,21971.51,
Repair bladder-vagina lesion,57320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7449.95,,,,,,,fee schedule,4952.26,21971.51,
Repair bladder-vagina lesion,57320,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21971.51,,,,,,,fee schedule,4952.26,21971.51,APC 378
Repair bladder-vagina lesion,57320,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5199.88,,,,,,,fee schedule,4952.26,21971.51,APC
Repair bladder-vagina lesion,57320,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5150.35,,,,,,,fee schedule,4952.26,21971.51,APC
Repair bladder-vagina lesion,57320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4952.26,,,,,,,fee schedule,4952.26,21971.51,APC
Repair bladder-vagina lesion,57320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7576.96,,,,,,,fee schedule,4952.26,21971.51,Radiology
Repair bladder-vagina lesion,57320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6933.17,,,,,,,fee schedule,4952.26,21971.51,APC
Repair bladder-vagina lesion,57320,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8666.46,,,,,,,fee schedule,4952.26,21971.51,APC
Repair bladder-vagina lesion,57330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8092.19,,,,,,,fee schedule,6486.59,32569.71,
Repair bladder-vagina lesion,57330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6486.59,,,,,,,fee schedule,6486.59,32569.71,
Repair bladder-vagina lesion,57330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7086.01,,,,,,,fee schedule,6486.59,32569.71,
Repair bladder-vagina lesion,57330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7449.95,,,,,,,fee schedule,6486.59,32569.71,
Repair bladder-vagina lesion,57330,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,32569.71,,,,,,,fee schedule,6486.59,32569.71,APC 378
Repair bladder-vagina lesion,57330,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7708.09,,,,,,,fee schedule,6486.59,32569.71,APC
Repair bladder-vagina lesion,57330,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7634.68,,,,,,,fee schedule,6486.59,32569.71,APC
Repair bladder-vagina lesion,57330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7341.04,,,,,,,fee schedule,6486.59,32569.71,APC
Repair bladder-vagina lesion,57330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11231.79,,,,,,,fee schedule,6486.59,32569.71,Radiology
Repair bladder-vagina lesion,57330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10277.46,,,,,,,fee schedule,6486.59,32569.71,APC
Repair bladder-vagina lesion,57330,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12846.82,,,,,,,fee schedule,6486.59,32569.71,APC
Repair vagina,57335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8092.19,,,,,,,fee schedule,4952.26,21971.51,
Repair vagina,57335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6486.59,,,,,,,fee schedule,4952.26,21971.51,
Repair vagina,57335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7086.01,,,,,,,fee schedule,4952.26,21971.51,
Repair vagina,57335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7449.95,,,,,,,fee schedule,4952.26,21971.51,
Repair vagina,57335,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21971.51,,,,,,,fee schedule,4952.26,21971.51,APC 378
Repair vagina,57335,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5199.88,,,,,,,fee schedule,4952.26,21971.51,APC
Repair vagina,57335,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5150.35,,,,,,,fee schedule,4952.26,21971.51,APC
Repair vagina,57335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4952.26,,,,,,,fee schedule,4952.26,21971.51,APC
Repair vagina,57335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7576.96,,,,,,,fee schedule,4952.26,21971.51,Radiology
Repair vagina,57335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6933.17,,,,,,,fee schedule,4952.26,21971.51,APC
Repair vagina,57335,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8666.46,,,,,,,fee schedule,4952.26,21971.51,APC
Dilation of vagina,57400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4747,,,,,,,fee schedule,3204.65,14217.94,
Dilation of vagina,57400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3805.13,,,,,,,fee schedule,3204.65,14217.94,
Dilation of vagina,57400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4156.76,,,,,,,fee schedule,3204.65,14217.94,
Dilation of vagina,57400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4370.25,,,,,,,fee schedule,3204.65,14217.94,
Dilation of vagina,57400,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14217.94,,,,,,,fee schedule,3204.65,14217.94,APC 378
Dilation of vagina,57400,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3364.88,,,,,,,fee schedule,3204.65,14217.94,APC
Dilation of vagina,57400,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3332.84,,,,,,,fee schedule,3204.65,14217.94,APC
Dilation of vagina,57400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3204.65,,,,,,,fee schedule,3204.65,14217.94,APC
Dilation of vagina,57400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4903.11,,,,,,,fee schedule,3204.65,14217.94,Radiology
Dilation of vagina,57400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4486.51,,,,,,,fee schedule,3204.65,14217.94,APC
Dilation of vagina,57400,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5608.14,,,,,,,fee schedule,3204.65,14217.94,APC
Pelvic examination,57410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6253.46,,,,,,,fee schedule,3204.65,14217.94,
Pelvic examination,57410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5012.69,,,,,,,fee schedule,3204.65,14217.94,
Pelvic examination,57410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5475.91,,,,,,,fee schedule,3204.65,14217.94,
Pelvic examination,57410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5757.15,,,,,,,fee schedule,3204.65,14217.94,
Pelvic examination,57410,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14217.94,,,,,,,fee schedule,3204.65,14217.94,APC 378
Pelvic examination,57410,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3364.88,,,,,,,fee schedule,3204.65,14217.94,APC
Pelvic examination,57410,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3332.84,,,,,,,fee schedule,3204.65,14217.94,APC
Pelvic examination,57410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3204.65,,,,,,,fee schedule,3204.65,14217.94,APC
Pelvic examination,57410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4903.11,,,,,,,fee schedule,3204.65,14217.94,Radiology
Pelvic examination,57410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4486.51,,,,,,,fee schedule,3204.65,14217.94,APC
Pelvic examination,57410,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5608.14,,,,,,,fee schedule,3204.65,14217.94,APC
Remove vaginal foreign body,57415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4747,,,,,,,fee schedule,3204.65,14217.94,
Remove vaginal foreign body,57415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3805.13,,,,,,,fee schedule,3204.65,14217.94,
Remove vaginal foreign body,57415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4156.76,,,,,,,fee schedule,3204.65,14217.94,
Remove vaginal foreign body,57415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4370.25,,,,,,,fee schedule,3204.65,14217.94,
Remove vaginal foreign body,57415,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14217.94,,,,,,,fee schedule,3204.65,14217.94,APC 378
Remove vaginal foreign body,57415,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3364.88,,,,,,,fee schedule,3204.65,14217.94,APC
Remove vaginal foreign body,57415,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3332.84,,,,,,,fee schedule,3204.65,14217.94,APC
Remove vaginal foreign body,57415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3204.65,,,,,,,fee schedule,3204.65,14217.94,APC
Remove vaginal foreign body,57415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4903.11,,,,,,,fee schedule,3204.65,14217.94,Radiology
Remove vaginal foreign body,57415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4486.51,,,,,,,fee schedule,3204.65,14217.94,APC
Remove vaginal foreign body,57415,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5608.14,,,,,,,fee schedule,3204.65,14217.94,APC
Exam of vagina w/scope,57420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3594.84,,,,,,,fee schedule,301.67,3594.84,
Exam of vagina w/scope,57420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2881.58,,,,,,,fee schedule,301.67,3594.84,
Exam of vagina w/scope,57420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3147.87,,,,,,,fee schedule,301.67,3594.84,
Exam of vagina w/scope,57420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3309.54,,,,,,,fee schedule,301.67,3594.84,
Exam of vagina w/scope,57420,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1338.42,,,,,,,fee schedule,301.67,3594.84,APC 378
Exam of vagina w/scope,57420,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,316.76,,,,,,,fee schedule,301.67,3594.84,APC
Exam of vagina w/scope,57420,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,313.74,,,,,,,fee schedule,301.67,3594.84,APC
Exam of vagina w/scope,57420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,301.67,,,,,,,fee schedule,301.67,3594.84,APC
Exam of vagina w/scope,57420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,461.56,,,,,,,fee schedule,301.67,3594.84,Radiology
Exam of vagina w/scope,57420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,422.34,,,,,,,fee schedule,301.67,3594.84,APC
Exam of vagina w/scope,57420,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,527.93,,,,,,,fee schedule,301.67,3594.84,APC
Exam/biopsy of vag w/scope,57421,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,688.41,,,,,,,fee schedule,551.82,4045.39,
Exam/biopsy of vag w/scope,57421,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,551.82,,,,,,,fee schedule,551.82,4045.39,
Exam/biopsy of vag w/scope,57421,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,602.82,,,,,,,fee schedule,551.82,4045.39,
Exam/biopsy of vag w/scope,57421,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,633.78,,,,,,,fee schedule,551.82,4045.39,
Exam/biopsy of vag w/scope,57421,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4045.39,,,,,,,fee schedule,551.82,4045.39,APC 378
Exam/biopsy of vag w/scope,57421,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,957.4,,,,,,,fee schedule,551.82,4045.39,APC
Exam/biopsy of vag w/scope,57421,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,948.28,,,,,,,fee schedule,551.82,4045.39,APC
Exam/biopsy of vag w/scope,57421,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,911.81,,,,,,,fee schedule,551.82,4045.39,APC
Exam/biopsy of vag w/scope,57421,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1395.07,,,,,,,fee schedule,551.82,4045.39,Radiology
Exam/biopsy of vag w/scope,57421,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1276.53,,,,,,,fee schedule,551.82,4045.39,APC
Exam/biopsy of vag w/scope,57421,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1595.67,,,,,,,fee schedule,551.82,4045.39,APC
Repair paravag defect lap,57423,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10659.34,,,,,,,fee schedule,8544.39,46687.84,
Repair paravag defect lap,57423,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8544.39,,,,,,,fee schedule,8544.39,46687.84,
Repair paravag defect lap,57423,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9333.97,,,,,,,fee schedule,8544.39,46687.84,
Repair paravag defect lap,57423,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9813.36,,,,,,,fee schedule,8544.39,46687.84,
Repair paravag defect lap,57423,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46687.84,,,,,,,fee schedule,8544.39,46687.84,APC 378
Repair paravag defect lap,57423,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11049.35,,,,,,,fee schedule,8544.39,46687.84,APC
Repair paravag defect lap,57423,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10944.12,,,,,,,fee schedule,8544.39,46687.84,APC
Repair paravag defect lap,57423,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10523.19,,,,,,,fee schedule,8544.39,46687.84,APC
Repair paravag defect lap,57423,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16100.48,,,,,,,fee schedule,8544.39,46687.84,Radiology
Repair paravag defect lap,57423,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14732.47,,,,,,,fee schedule,8544.39,46687.84,APC
Repair paravag defect lap,57423,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18415.58,,,,,,,fee schedule,8544.39,46687.84,APC
Laparoscopy surg colpopexy,57425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6107.2,,,,,,,fee schedule,4895.45,46687.84,
Laparoscopy surg colpopexy,57425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4895.45,,,,,,,fee schedule,4895.45,46687.84,
Laparoscopy surg colpopexy,57425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5347.84,,,,,,,fee schedule,4895.45,46687.84,
Laparoscopy surg colpopexy,57425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5622.5,,,,,,,fee schedule,4895.45,46687.84,
Laparoscopy surg colpopexy,57425,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46687.84,,,,,,,fee schedule,4895.45,46687.84,APC 378
Laparoscopy surg colpopexy,57425,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11049.35,,,,,,,fee schedule,4895.45,46687.84,APC
Laparoscopy surg colpopexy,57425,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10944.12,,,,,,,fee schedule,4895.45,46687.84,APC
Laparoscopy surg colpopexy,57425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10523.19,,,,,,,fee schedule,4895.45,46687.84,APC
Laparoscopy surg colpopexy,57425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16100.48,,,,,,,fee schedule,4895.45,46687.84,Radiology
Laparoscopy surg colpopexy,57425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14732.47,,,,,,,fee schedule,4895.45,46687.84,APC
Laparoscopy surg colpopexy,57425,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18415.58,,,,,,,fee schedule,4895.45,46687.84,APC
Revise prosth vag graft lap,57426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5294.34,,,,,,,fee schedule,4243.88,32569.71,
Revise prosth vag graft lap,57426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4243.88,,,,,,,fee schedule,4243.88,32569.71,
Revise prosth vag graft lap,57426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4636.05,,,,,,,fee schedule,4243.88,32569.71,
Revise prosth vag graft lap,57426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4874.16,,,,,,,fee schedule,4243.88,32569.71,
Revise prosth vag graft lap,57426,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,32569.71,,,,,,,fee schedule,4243.88,32569.71,APC 378
Revise prosth vag graft lap,57426,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7708.09,,,,,,,fee schedule,4243.88,32569.71,APC
Revise prosth vag graft lap,57426,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7634.68,,,,,,,fee schedule,4243.88,32569.71,APC
Revise prosth vag graft lap,57426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7341.04,,,,,,,fee schedule,4243.88,32569.71,APC
Revise prosth vag graft lap,57426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11231.79,,,,,,,fee schedule,4243.88,32569.71,Radiology
Revise prosth vag graft lap,57426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10277.46,,,,,,,fee schedule,4243.88,32569.71,APC
Revise prosth vag graft lap,57426,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12846.82,,,,,,,fee schedule,4243.88,32569.71,APC
Exam of cervix w/scope,57452,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,688.41,,,,,,,fee schedule,200.14,887.97,
Exam of cervix w/scope,57452,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,551.82,,,,,,,fee schedule,200.14,887.97,
Exam of cervix w/scope,57452,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,602.82,,,,,,,fee schedule,200.14,887.97,
Exam of cervix w/scope,57452,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,633.78,,,,,,,fee schedule,200.14,887.97,
Exam of cervix w/scope,57452,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,887.97,,,,,,,fee schedule,200.14,887.97,APC 378
Exam of cervix w/scope,57452,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,210.15,,,,,,,fee schedule,200.14,887.97,APC
Exam of cervix w/scope,57452,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,208.15,,,,,,,fee schedule,200.14,887.97,APC
Exam of cervix w/scope,57452,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,200.14,,,,,,,fee schedule,200.14,887.97,APC
Exam of cervix w/scope,57452,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,306.22,,,,,,,fee schedule,200.14,887.97,Radiology
Exam of cervix w/scope,57452,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,280.2,,,,,,,fee schedule,200.14,887.97,APC
Exam of cervix w/scope,57452,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,350.25,,,,,,,fee schedule,200.14,887.97,APC
Bx/curett of cervix w/scope,57454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4062.96,,,,,,,fee schedule,301.67,4062.96,
Bx/curett of cervix w/scope,57454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3256.82,,,,,,,fee schedule,301.67,4062.96,
Bx/curett of cervix w/scope,57454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3557.78,,,,,,,fee schedule,301.67,4062.96,
Bx/curett of cervix w/scope,57454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3740.5,,,,,,,fee schedule,301.67,4062.96,
Bx/curett of cervix w/scope,57454,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1338.42,,,,,,,fee schedule,301.67,4062.96,APC 378
Bx/curett of cervix w/scope,57454,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,316.76,,,,,,,fee schedule,301.67,4062.96,APC
Bx/curett of cervix w/scope,57454,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,313.74,,,,,,,fee schedule,301.67,4062.96,APC
Bx/curett of cervix w/scope,57454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,301.67,,,,,,,fee schedule,301.67,4062.96,APC
Bx/curett of cervix w/scope,57454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,461.56,,,,,,,fee schedule,301.67,4062.96,Radiology
Bx/curett of cervix w/scope,57454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,422.34,,,,,,,fee schedule,301.67,4062.96,APC
Bx/curett of cervix w/scope,57454,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,527.93,,,,,,,fee schedule,301.67,4062.96,APC
Biopsy of cervix w/scope,57455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3594.84,,,,,,,fee schedule,301.67,3594.84,
Biopsy of cervix w/scope,57455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2881.58,,,,,,,fee schedule,301.67,3594.84,
Biopsy of cervix w/scope,57455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3147.87,,,,,,,fee schedule,301.67,3594.84,
Biopsy of cervix w/scope,57455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3309.54,,,,,,,fee schedule,301.67,3594.84,
Biopsy of cervix w/scope,57455,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1338.42,,,,,,,fee schedule,301.67,3594.84,APC 378
Biopsy of cervix w/scope,57455,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,316.76,,,,,,,fee schedule,301.67,3594.84,APC
Biopsy of cervix w/scope,57455,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,313.74,,,,,,,fee schedule,301.67,3594.84,APC
Biopsy of cervix w/scope,57455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,301.67,,,,,,,fee schedule,301.67,3594.84,APC
Biopsy of cervix w/scope,57455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,461.56,,,,,,,fee schedule,301.67,3594.84,Radiology
Biopsy of cervix w/scope,57455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,422.34,,,,,,,fee schedule,301.67,3594.84,APC
Biopsy of cervix w/scope,57455,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,527.93,,,,,,,fee schedule,301.67,3594.84,APC
Endocerv curettage w/scope,57456,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4062.96,,,,,,,fee schedule,301.67,4062.96,
Endocerv curettage w/scope,57456,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3256.82,,,,,,,fee schedule,301.67,4062.96,
Endocerv curettage w/scope,57456,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3557.78,,,,,,,fee schedule,301.67,4062.96,
Endocerv curettage w/scope,57456,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3740.5,,,,,,,fee schedule,301.67,4062.96,
Endocerv curettage w/scope,57456,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1338.42,,,,,,,fee schedule,301.67,4062.96,APC 378
Endocerv curettage w/scope,57456,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,316.76,,,,,,,fee schedule,301.67,4062.96,APC
Endocerv curettage w/scope,57456,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,313.74,,,,,,,fee schedule,301.67,4062.96,APC
Endocerv curettage w/scope,57456,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,301.67,,,,,,,fee schedule,301.67,4062.96,APC
Endocerv curettage w/scope,57456,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,461.56,,,,,,,fee schedule,301.67,4062.96,Radiology
Endocerv curettage w/scope,57456,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,422.34,,,,,,,fee schedule,301.67,4062.96,APC
Endocerv curettage w/scope,57456,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,527.93,,,,,,,fee schedule,301.67,4062.96,APC
Bx of cervix w/scope leep,57460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4747,,,,,,,fee schedule,3204.65,14217.94,
Bx of cervix w/scope leep,57460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3805.13,,,,,,,fee schedule,3204.65,14217.94,
Bx of cervix w/scope leep,57460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4156.76,,,,,,,fee schedule,3204.65,14217.94,
Bx of cervix w/scope leep,57460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4370.25,,,,,,,fee schedule,3204.65,14217.94,
Bx of cervix w/scope leep,57460,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14217.94,,,,,,,fee schedule,3204.65,14217.94,APC 378
Bx of cervix w/scope leep,57460,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3364.88,,,,,,,fee schedule,3204.65,14217.94,APC
Bx of cervix w/scope leep,57460,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3332.84,,,,,,,fee schedule,3204.65,14217.94,APC
Bx of cervix w/scope leep,57460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3204.65,,,,,,,fee schedule,3204.65,14217.94,APC
Bx of cervix w/scope leep,57460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4903.11,,,,,,,fee schedule,3204.65,14217.94,Radiology
Bx of cervix w/scope leep,57460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4486.51,,,,,,,fee schedule,3204.65,14217.94,APC
Bx of cervix w/scope leep,57460,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5608.14,,,,,,,fee schedule,3204.65,14217.94,APC
Conz of cervix w/scope leep,57461,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4741.91,,,,,,,fee schedule,3204.65,14217.94,
Conz of cervix w/scope leep,57461,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3801.05,,,,,,,fee schedule,3204.65,14217.94,
Conz of cervix w/scope leep,57461,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4152.3,,,,,,,fee schedule,3204.65,14217.94,
Conz of cervix w/scope leep,57461,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4365.56,,,,,,,fee schedule,3204.65,14217.94,
Conz of cervix w/scope leep,57461,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14217.94,,,,,,,fee schedule,3204.65,14217.94,APC 378
Conz of cervix w/scope leep,57461,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3364.88,,,,,,,fee schedule,3204.65,14217.94,APC
Conz of cervix w/scope leep,57461,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3332.84,,,,,,,fee schedule,3204.65,14217.94,APC
Conz of cervix w/scope leep,57461,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3204.65,,,,,,,fee schedule,3204.65,14217.94,APC
Conz of cervix w/scope leep,57461,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4903.11,,,,,,,fee schedule,3204.65,14217.94,Radiology
Conz of cervix w/scope leep,57461,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4486.51,,,,,,,fee schedule,3204.65,14217.94,APC
Conz of cervix w/scope leep,57461,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5608.14,,,,,,,fee schedule,3204.65,14217.94,APC
Biopsy of cervix,57500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1516.99,,,,,,,fee schedule,911.81,4045.39,
Biopsy of cervix,57500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1216,,,,,,,fee schedule,911.81,4045.39,
Biopsy of cervix,57500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1328.37,,,,,,,fee schedule,911.81,4045.39,
Biopsy of cervix,57500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1396.59,,,,,,,fee schedule,911.81,4045.39,
Biopsy of cervix,57500,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4045.39,,,,,,,fee schedule,911.81,4045.39,APC 378
Biopsy of cervix,57500,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,957.4,,,,,,,fee schedule,911.81,4045.39,APC
Biopsy of cervix,57500,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,948.28,,,,,,,fee schedule,911.81,4045.39,APC
Biopsy of cervix,57500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,911.81,,,,,,,fee schedule,911.81,4045.39,APC
Biopsy of cervix,57500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1395.07,,,,,,,fee schedule,911.81,4045.39,Radiology
Biopsy of cervix,57500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1276.53,,,,,,,fee schedule,911.81,4045.39,APC
Biopsy of cervix,57500,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1595.67,,,,,,,fee schedule,911.81,4045.39,APC
Endocervical curettage,57505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3126.73,,,,,,,fee schedule,911.81,4045.39,
Endocervical curettage,57505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2506.35,,,,,,,fee schedule,911.81,4045.39,
Endocervical curettage,57505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2737.95,,,,,,,fee schedule,911.81,4045.39,
Endocervical curettage,57505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2878.57,,,,,,,fee schedule,911.81,4045.39,
Endocervical curettage,57505,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4045.39,,,,,,,fee schedule,911.81,4045.39,APC 378
Endocervical curettage,57505,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,957.4,,,,,,,fee schedule,911.81,4045.39,APC
Endocervical curettage,57505,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,948.28,,,,,,,fee schedule,911.81,4045.39,APC
Endocervical curettage,57505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,911.81,,,,,,,fee schedule,911.81,4045.39,APC
Endocervical curettage,57505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1395.07,,,,,,,fee schedule,911.81,4045.39,Radiology
Endocervical curettage,57505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1276.53,,,,,,,fee schedule,911.81,4045.39,APC
Endocervical curettage,57505,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1595.67,,,,,,,fee schedule,911.81,4045.39,APC
Cauterization of cervix,57510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6253.46,,,,,,,fee schedule,3204.65,14217.94,
Cauterization of cervix,57510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5012.69,,,,,,,fee schedule,3204.65,14217.94,
Cauterization of cervix,57510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5475.91,,,,,,,fee schedule,3204.65,14217.94,
Cauterization of cervix,57510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5757.15,,,,,,,fee schedule,3204.65,14217.94,
Cauterization of cervix,57510,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14217.94,,,,,,,fee schedule,3204.65,14217.94,APC 378
Cauterization of cervix,57510,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3364.88,,,,,,,fee schedule,3204.65,14217.94,APC
Cauterization of cervix,57510,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3332.84,,,,,,,fee schedule,3204.65,14217.94,APC
Cauterization of cervix,57510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3204.65,,,,,,,fee schedule,3204.65,14217.94,APC
Cauterization of cervix,57510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4903.11,,,,,,,fee schedule,3204.65,14217.94,Radiology
Cauterization of cervix,57510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4486.51,,,,,,,fee schedule,3204.65,14217.94,APC
Cauterization of cervix,57510,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5608.14,,,,,,,fee schedule,3204.65,14217.94,APC
Cryocautery of cervix,57511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,337.4,,,,,,,fee schedule,270.46,1338.42,
Cryocautery of cervix,57511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,270.46,,,,,,,fee schedule,270.46,1338.42,
Cryocautery of cervix,57511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,295.45,,,,,,,fee schedule,270.46,1338.42,
Cryocautery of cervix,57511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,310.62,,,,,,,fee schedule,270.46,1338.42,
Cryocautery of cervix,57511,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1338.42,,,,,,,fee schedule,270.46,1338.42,APC 378
Cryocautery of cervix,57511,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,316.76,,,,,,,fee schedule,270.46,1338.42,APC
Cryocautery of cervix,57511,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,313.74,,,,,,,fee schedule,270.46,1338.42,APC
Cryocautery of cervix,57511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,301.67,,,,,,,fee schedule,270.46,1338.42,APC
Cryocautery of cervix,57511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,461.56,,,,,,,fee schedule,270.46,1338.42,Radiology
Cryocautery of cervix,57511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,422.34,,,,,,,fee schedule,270.46,1338.42,APC
Cryocautery of cervix,57511,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,527.93,,,,,,,fee schedule,270.46,1338.42,APC
Laser surgery of cervix,57513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4747,,,,,,,fee schedule,3204.65,14217.94,
Laser surgery of cervix,57513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3805.13,,,,,,,fee schedule,3204.65,14217.94,
Laser surgery of cervix,57513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4156.76,,,,,,,fee schedule,3204.65,14217.94,
Laser surgery of cervix,57513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4370.25,,,,,,,fee schedule,3204.65,14217.94,
Laser surgery of cervix,57513,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14217.94,,,,,,,fee schedule,3204.65,14217.94,APC 378
Laser surgery of cervix,57513,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3364.88,,,,,,,fee schedule,3204.65,14217.94,APC
Laser surgery of cervix,57513,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3332.84,,,,,,,fee schedule,3204.65,14217.94,APC
Laser surgery of cervix,57513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3204.65,,,,,,,fee schedule,3204.65,14217.94,APC
Laser surgery of cervix,57513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4903.11,,,,,,,fee schedule,3204.65,14217.94,Radiology
Laser surgery of cervix,57513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4486.51,,,,,,,fee schedule,3204.65,14217.94,APC
Laser surgery of cervix,57513,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5608.14,,,,,,,fee schedule,3204.65,14217.94,APC
Conization of cervix,57520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6409.49,,,,,,,fee schedule,3204.65,14217.94,
Conization of cervix,57520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5137.77,,,,,,,fee schedule,3204.65,14217.94,
Conization of cervix,57520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5612.55,,,,,,,fee schedule,3204.65,14217.94,
Conization of cervix,57520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5900.8,,,,,,,fee schedule,3204.65,14217.94,
Conization of cervix,57520,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14217.94,,,,,,,fee schedule,3204.65,14217.94,APC 378
Conization of cervix,57520,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3364.88,,,,,,,fee schedule,3204.65,14217.94,APC
Conization of cervix,57520,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3332.84,,,,,,,fee schedule,3204.65,14217.94,APC
Conization of cervix,57520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3204.65,,,,,,,fee schedule,3204.65,14217.94,APC
Conization of cervix,57520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4903.11,,,,,,,fee schedule,3204.65,14217.94,Radiology
Conization of cervix,57520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4486.51,,,,,,,fee schedule,3204.65,14217.94,APC
Conization of cervix,57520,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5608.14,,,,,,,fee schedule,3204.65,14217.94,APC
Conization of cervix,57522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6253.46,,,,,,,fee schedule,3204.65,14217.94,
Conization of cervix,57522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5012.69,,,,,,,fee schedule,3204.65,14217.94,
Conization of cervix,57522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5475.91,,,,,,,fee schedule,3204.65,14217.94,
Conization of cervix,57522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5757.15,,,,,,,fee schedule,3204.65,14217.94,
Conization of cervix,57522,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14217.94,,,,,,,fee schedule,3204.65,14217.94,APC 378
Conization of cervix,57522,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3364.88,,,,,,,fee schedule,3204.65,14217.94,APC
Conization of cervix,57522,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3332.84,,,,,,,fee schedule,3204.65,14217.94,APC
Conization of cervix,57522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3204.65,,,,,,,fee schedule,3204.65,14217.94,APC
Conization of cervix,57522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4903.11,,,,,,,fee schedule,3204.65,14217.94,Radiology
Conization of cervix,57522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4486.51,,,,,,,fee schedule,3204.65,14217.94,APC
Conization of cervix,57522,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5608.14,,,,,,,fee schedule,3204.65,14217.94,APC
Removal of cervix,57530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7743.31,,,,,,,fee schedule,4952.26,21971.51,
Removal of cervix,57530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6206.94,,,,,,,fee schedule,4952.26,21971.51,
Removal of cervix,57530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6780.52,,,,,,,fee schedule,4952.26,21971.51,
Removal of cervix,57530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7128.76,,,,,,,fee schedule,4952.26,21971.51,
Removal of cervix,57530,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21971.51,,,,,,,fee schedule,4952.26,21971.51,APC 378
Removal of cervix,57530,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5199.88,,,,,,,fee schedule,4952.26,21971.51,APC
Removal of cervix,57530,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5150.35,,,,,,,fee schedule,4952.26,21971.51,APC
Removal of cervix,57530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4952.26,,,,,,,fee schedule,4952.26,21971.51,APC
Removal of cervix,57530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7576.96,,,,,,,fee schedule,4952.26,21971.51,Radiology
Removal of cervix,57530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6933.17,,,,,,,fee schedule,4952.26,21971.51,APC
Removal of cervix,57530,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8666.46,,,,,,,fee schedule,4952.26,21971.51,APC
Removal of residual cervix,57550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8092.19,,,,,,,fee schedule,4952.26,21971.51,
Removal of residual cervix,57550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6486.59,,,,,,,fee schedule,4952.26,21971.51,
Removal of residual cervix,57550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7086.01,,,,,,,fee schedule,4952.26,21971.51,
Removal of residual cervix,57550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7449.95,,,,,,,fee schedule,4952.26,21971.51,
Removal of residual cervix,57550,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21971.51,,,,,,,fee schedule,4952.26,21971.51,APC 378
Removal of residual cervix,57550,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5199.88,,,,,,,fee schedule,4952.26,21971.51,APC
Removal of residual cervix,57550,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5150.35,,,,,,,fee schedule,4952.26,21971.51,APC
Removal of residual cervix,57550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4952.26,,,,,,,fee schedule,4952.26,21971.51,APC
Removal of residual cervix,57550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7576.96,,,,,,,fee schedule,4952.26,21971.51,Radiology
Removal of residual cervix,57550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6933.17,,,,,,,fee schedule,4952.26,21971.51,APC
Removal of residual cervix,57550,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8666.46,,,,,,,fee schedule,4952.26,21971.51,APC
Remove cervix/repair vagina,57555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8092.19,,,,,,,fee schedule,4952.26,21971.51,
Remove cervix/repair vagina,57555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6486.59,,,,,,,fee schedule,4952.26,21971.51,
Remove cervix/repair vagina,57555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7086.01,,,,,,,fee schedule,4952.26,21971.51,
Remove cervix/repair vagina,57555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7449.95,,,,,,,fee schedule,4952.26,21971.51,
Remove cervix/repair vagina,57555,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21971.51,,,,,,,fee schedule,4952.26,21971.51,APC 378
Remove cervix/repair vagina,57555,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5199.88,,,,,,,fee schedule,4952.26,21971.51,APC
Remove cervix/repair vagina,57555,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5150.35,,,,,,,fee schedule,4952.26,21971.51,APC
Remove cervix/repair vagina,57555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4952.26,,,,,,,fee schedule,4952.26,21971.51,APC
Remove cervix/repair vagina,57555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7576.96,,,,,,,fee schedule,4952.26,21971.51,Radiology
Remove cervix/repair vagina,57555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6933.17,,,,,,,fee schedule,4952.26,21971.51,APC
Remove cervix/repair vagina,57555,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8666.46,,,,,,,fee schedule,4952.26,21971.51,APC
Remove cervix repair bowel,57556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10659.34,,,,,,,fee schedule,4952.26,21971.51,
Remove cervix repair bowel,57556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8544.39,,,,,,,fee schedule,4952.26,21971.51,
Remove cervix repair bowel,57556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9333.97,,,,,,,fee schedule,4952.26,21971.51,
Remove cervix repair bowel,57556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9813.36,,,,,,,fee schedule,4952.26,21971.51,
Remove cervix repair bowel,57556,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21971.51,,,,,,,fee schedule,4952.26,21971.51,APC 378
Remove cervix repair bowel,57556,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5199.88,,,,,,,fee schedule,4952.26,21971.51,APC
Remove cervix repair bowel,57556,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5150.35,,,,,,,fee schedule,4952.26,21971.51,APC
Remove cervix repair bowel,57556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4952.26,,,,,,,fee schedule,4952.26,21971.51,APC
Remove cervix repair bowel,57556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7576.96,,,,,,,fee schedule,4952.26,21971.51,Radiology
Remove cervix repair bowel,57556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6933.17,,,,,,,fee schedule,4952.26,21971.51,APC
Remove cervix repair bowel,57556,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8666.46,,,,,,,fee schedule,4952.26,21971.51,APC
D&C oF Cervical Stump,57558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4747,,,,,,,fee schedule,3204.65,14217.94,
D&C oF Cervical Stump,57558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3805.13,,,,,,,fee schedule,3204.65,14217.94,
D&C oF Cervical Stump,57558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4156.76,,,,,,,fee schedule,3204.65,14217.94,
D&C oF Cervical Stump,57558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4370.25,,,,,,,fee schedule,3204.65,14217.94,
D&C oF Cervical Stump,57558,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14217.94,,,,,,,fee schedule,3204.65,14217.94,APC 378
D&C oF Cervical Stump,57558,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3364.88,,,,,,,fee schedule,3204.65,14217.94,APC
D&C oF Cervical Stump,57558,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3332.84,,,,,,,fee schedule,3204.65,14217.94,APC
D&C oF Cervical Stump,57558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3204.65,,,,,,,fee schedule,3204.65,14217.94,APC
D&C oF Cervical Stump,57558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4903.11,,,,,,,fee schedule,3204.65,14217.94,Radiology
D&C oF Cervical Stump,57558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4486.51,,,,,,,fee schedule,3204.65,14217.94,APC
D&C oF Cervical Stump,57558,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5608.14,,,,,,,fee schedule,3204.65,14217.94,APC
Revision of cervix,57700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4747,,,,,,,fee schedule,3204.65,14217.94,
Revision of cervix,57700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3805.13,,,,,,,fee schedule,3204.65,14217.94,
Revision of cervix,57700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4156.76,,,,,,,fee schedule,3204.65,14217.94,
Revision of cervix,57700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4370.25,,,,,,,fee schedule,3204.65,14217.94,
Revision of cervix,57700,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14217.94,,,,,,,fee schedule,3204.65,14217.94,APC 378
Revision of cervix,57700,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3364.88,,,,,,,fee schedule,3204.65,14217.94,APC
Revision of cervix,57700,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3332.84,,,,,,,fee schedule,3204.65,14217.94,APC
Revision of cervix,57700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3204.65,,,,,,,fee schedule,3204.65,14217.94,APC
Revision of cervix,57700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4903.11,,,,,,,fee schedule,3204.65,14217.94,Radiology
Revision of cervix,57700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4486.51,,,,,,,fee schedule,3204.65,14217.94,APC
Revision of cervix,57700,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5608.14,,,,,,,fee schedule,3204.65,14217.94,APC
Revision of cervix,57720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4747,,,,,,,fee schedule,3204.65,14217.94,
Revision of cervix,57720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3805.13,,,,,,,fee schedule,3204.65,14217.94,
Revision of cervix,57720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4156.76,,,,,,,fee schedule,3204.65,14217.94,
Revision of cervix,57720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4370.25,,,,,,,fee schedule,3204.65,14217.94,
Revision of cervix,57720,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14217.94,,,,,,,fee schedule,3204.65,14217.94,APC 378
Revision of cervix,57720,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3364.88,,,,,,,fee schedule,3204.65,14217.94,APC
Revision of cervix,57720,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3332.84,,,,,,,fee schedule,3204.65,14217.94,APC
Revision of cervix,57720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3204.65,,,,,,,fee schedule,3204.65,14217.94,APC
Revision of cervix,57720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4903.11,,,,,,,fee schedule,3204.65,14217.94,Radiology
Revision of cervix,57720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4486.51,,,,,,,fee schedule,3204.65,14217.94,APC
Revision of cervix,57720,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5608.14,,,,,,,fee schedule,3204.65,14217.94,APC
Dilation of cervical canal,57800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4747,,,,,,,fee schedule,3204.65,14217.94,
Dilation of cervical canal,57800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3805.13,,,,,,,fee schedule,3204.65,14217.94,
Dilation of cervical canal,57800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4156.76,,,,,,,fee schedule,3204.65,14217.94,
Dilation of cervical canal,57800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4370.25,,,,,,,fee schedule,3204.65,14217.94,
Dilation of cervical canal,57800,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14217.94,,,,,,,fee schedule,3204.65,14217.94,APC 378
Dilation of cervical canal,57800,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3364.88,,,,,,,fee schedule,3204.65,14217.94,APC
Dilation of cervical canal,57800,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3332.84,,,,,,,fee schedule,3204.65,14217.94,APC
Dilation of cervical canal,57800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3204.65,,,,,,,fee schedule,3204.65,14217.94,APC
Dilation of cervical canal,57800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4903.11,,,,,,,fee schedule,3204.65,14217.94,Radiology
Dilation of cervical canal,57800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4486.51,,,,,,,fee schedule,3204.65,14217.94,APC
Dilation of cervical canal,57800,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5608.14,,,,,,,fee schedule,3204.65,14217.94,APC
Biopsy of uterus lining,58100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2396.55,,,,,,,fee schedule,200.14,2396.55,
Biopsy of uterus lining,58100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1921.05,,,,,,,fee schedule,200.14,2396.55,
Biopsy of uterus lining,58100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2098.57,,,,,,,fee schedule,200.14,2396.55,
Biopsy of uterus lining,58100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2206.35,,,,,,,fee schedule,200.14,2396.55,
Biopsy of uterus lining,58100,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,887.97,,,,,,,fee schedule,200.14,2396.55,APC 378
Biopsy of uterus lining,58100,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,210.15,,,,,,,fee schedule,200.14,2396.55,APC
Biopsy of uterus lining,58100,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,208.15,,,,,,,fee schedule,200.14,2396.55,APC
Biopsy of uterus lining,58100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,200.14,,,,,,,fee schedule,200.14,2396.55,APC
Biopsy of uterus lining,58100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,306.22,,,,,,,fee schedule,200.14,2396.55,Radiology
Biopsy of uterus lining,58100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,280.2,,,,,,,fee schedule,200.14,2396.55,APC
Biopsy of uterus lining,58100,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,350.25,,,,,,,fee schedule,200.14,2396.55,APC
Dilation and curettage,58120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5237.72,,,,,,,fee schedule,3204.65,14217.94,
Dilation and curettage,58120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4198.49,,,,,,,fee schedule,3204.65,14217.94,
Dilation and curettage,58120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4586.47,,,,,,,fee schedule,3204.65,14217.94,
Dilation and curettage,58120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4822.02,,,,,,,fee schedule,3204.65,14217.94,
Dilation and curettage,58120,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14217.94,,,,,,,fee schedule,3204.65,14217.94,APC 378
Dilation and curettage,58120,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3364.88,,,,,,,fee schedule,3204.65,14217.94,APC
Dilation and curettage,58120,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3332.84,,,,,,,fee schedule,3204.65,14217.94,APC
Dilation and curettage,58120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3204.65,,,,,,,fee schedule,3204.65,14217.94,APC
Dilation and curettage,58120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4903.11,,,,,,,fee schedule,3204.65,14217.94,Radiology
Dilation and curettage,58120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4486.51,,,,,,,fee schedule,3204.65,14217.94,APC
Dilation and curettage,58120,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5608.14,,,,,,,fee schedule,3204.65,14217.94,APC
Myomectomy vag method,58145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8092.19,,,,,,,fee schedule,3204.65,14217.94,
Myomectomy vag method,58145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6486.59,,,,,,,fee schedule,3204.65,14217.94,
Myomectomy vag method,58145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7086.01,,,,,,,fee schedule,3204.65,14217.94,
Myomectomy vag method,58145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7449.95,,,,,,,fee schedule,3204.65,14217.94,
Myomectomy vag method,58145,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14217.94,,,,,,,fee schedule,3204.65,14217.94,APC 378
Myomectomy vag method,58145,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3364.88,,,,,,,fee schedule,3204.65,14217.94,APC
Myomectomy vag method,58145,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3332.84,,,,,,,fee schedule,3204.65,14217.94,APC
Myomectomy vag method,58145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3204.65,,,,,,,fee schedule,3204.65,14217.94,APC
Myomectomy vag method,58145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4903.11,,,,,,,fee schedule,3204.65,14217.94,Radiology
Myomectomy vag method,58145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4486.51,,,,,,,fee schedule,3204.65,14217.94,APC
Myomectomy vag method,58145,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5608.14,,,,,,,fee schedule,3204.65,14217.94,APC
Total hysterectomy,58150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10798.89,,,,,,,fee schedule,8656.25,10798.89,
Total hysterectomy,58150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8656.25,,,,,,,fee schedule,8656.25,10798.89,
Total hysterectomy,58150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9456.17,,,,,,,fee schedule,8656.25,10798.89,
Total hysterectomy,58150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9941.83,,,,,,,fee schedule,8656.25,10798.89,
Vaginal hysterectomy,58260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7579.32,,,,,,,fee schedule,4952.26,21971.51,
Vaginal hysterectomy,58260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6075.48,,,,,,,fee schedule,4952.26,21971.51,
Vaginal hysterectomy,58260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6636.92,,,,,,,fee schedule,4952.26,21971.51,
Vaginal hysterectomy,58260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6977.78,,,,,,,fee schedule,4952.26,21971.51,
Vaginal hysterectomy,58260,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21971.51,,,,,,,fee schedule,4952.26,21971.51,APC 378
Vaginal hysterectomy,58260,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5199.88,,,,,,,fee schedule,4952.26,21971.51,APC
Vaginal hysterectomy,58260,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5150.35,,,,,,,fee schedule,4952.26,21971.51,APC
Vaginal hysterectomy,58260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4952.26,,,,,,,fee schedule,4952.26,21971.51,APC
Vaginal hysterectomy,58260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7576.96,,,,,,,fee schedule,4952.26,21971.51,Radiology
Vaginal hysterectomy,58260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6933.17,,,,,,,fee schedule,4952.26,21971.51,APC
Vaginal hysterectomy,58260,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8666.46,,,,,,,fee schedule,4952.26,21971.51,APC
Vag hyst including t/o,58262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5502.64,,,,,,,fee schedule,4410.84,21971.51,
Vag hyst including t/o,58262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4410.84,,,,,,,fee schedule,4410.84,21971.51,
Vag hyst including t/o,58262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4818.45,,,,,,,fee schedule,4410.84,21971.51,
Vag hyst including t/o,58262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5065.92,,,,,,,fee schedule,4410.84,21971.51,
Vag hyst including t/o,58262,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21971.51,,,,,,,fee schedule,4410.84,21971.51,APC 378
Vag hyst including t/o,58262,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5199.88,,,,,,,fee schedule,4410.84,21971.51,APC
Vag hyst including t/o,58262,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5150.35,,,,,,,fee schedule,4410.84,21971.51,APC
Vag hyst including t/o,58262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4952.26,,,,,,,fee schedule,4410.84,21971.51,APC
Vag hyst including t/o,58262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7576.96,,,,,,,fee schedule,4410.84,21971.51,Radiology
Vag hyst including t/o,58262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6933.17,,,,,,,fee schedule,4410.84,21971.51,APC
Vag hyst including t/o,58262,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8666.46,,,,,,,fee schedule,4410.84,21971.51,APC
Vag hyst w/t/o & vag repair,58263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6211.47,,,,,,,fee schedule,4952.26,21971.51,
Vag hyst w/t/o & vag repair,58263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4979.03,,,,,,,fee schedule,4952.26,21971.51,
Vag hyst w/t/o & vag repair,58263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5439.14,,,,,,,fee schedule,4952.26,21971.51,
Vag hyst w/t/o & vag repair,58263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5718.49,,,,,,,fee schedule,4952.26,21971.51,
Vag hyst w/t/o & vag repair,58263,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21971.51,,,,,,,fee schedule,4952.26,21971.51,APC 378
Vag hyst w/t/o & vag repair,58263,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5199.88,,,,,,,fee schedule,4952.26,21971.51,APC
Vag hyst w/t/o & vag repair,58263,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5150.35,,,,,,,fee schedule,4952.26,21971.51,APC
Vag hyst w/t/o & vag repair,58263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4952.26,,,,,,,fee schedule,4952.26,21971.51,APC
Vag hyst w/t/o & vag repair,58263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7576.96,,,,,,,fee schedule,4952.26,21971.51,Radiology
Vag hyst w/t/o & vag repair,58263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6933.17,,,,,,,fee schedule,4952.26,21971.51,APC
Vag hyst w/t/o & vag repair,58263,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8666.46,,,,,,,fee schedule,4952.26,21971.51,APC
Vag hyst w/enterocele repair,58270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4751.14,,,,,,,fee schedule,3808.45,21971.51,
Vag hyst w/enterocele repair,58270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3808.45,,,,,,,fee schedule,3808.45,21971.51,
Vag hyst w/enterocele repair,58270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4160.39,,,,,,,fee schedule,3808.45,21971.51,
Vag hyst w/enterocele repair,58270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4374.07,,,,,,,fee schedule,3808.45,21971.51,
Vag hyst w/enterocele repair,58270,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21971.51,,,,,,,fee schedule,3808.45,21971.51,APC 378
Vag hyst w/enterocele repair,58270,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5199.88,,,,,,,fee schedule,3808.45,21971.51,APC
Vag hyst w/enterocele repair,58270,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5150.35,,,,,,,fee schedule,3808.45,21971.51,APC
Vag hyst w/enterocele repair,58270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4952.26,,,,,,,fee schedule,3808.45,21971.51,APC
Vag hyst w/enterocele repair,58270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7576.96,,,,,,,fee schedule,3808.45,21971.51,Radiology
Vag hyst w/enterocele repair,58270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6933.17,,,,,,,fee schedule,3808.45,21971.51,APC
Vag hyst w/enterocele repair,58270,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8666.46,,,,,,,fee schedule,3808.45,21971.51,APC
Vag hyst complex,58290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4765.13,,,,,,,fee schedule,3819.67,32569.71,
Vag hyst complex,58290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3819.67,,,,,,,fee schedule,3819.67,32569.71,
Vag hyst complex,58290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4172.64,,,,,,,fee schedule,3819.67,32569.71,
Vag hyst complex,58290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4386.95,,,,,,,fee schedule,3819.67,32569.71,
Vag hyst complex,58290,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,32569.71,,,,,,,fee schedule,3819.67,32569.71,APC 378
Vag hyst complex,58290,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7708.09,,,,,,,fee schedule,3819.67,32569.71,APC
Vag hyst complex,58290,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7634.68,,,,,,,fee schedule,3819.67,32569.71,APC
Vag hyst complex,58290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7341.04,,,,,,,fee schedule,3819.67,32569.71,APC
Vag hyst complex,58290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11231.79,,,,,,,fee schedule,3819.67,32569.71,Radiology
Vag hyst complex,58290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10277.46,,,,,,,fee schedule,3819.67,32569.71,APC
Vag hyst complex,58290,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12846.82,,,,,,,fee schedule,3819.67,32569.71,APC
Vag hyst incl t/o complex,58291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8594.03,,,,,,,fee schedule,4952.26,21971.51,
Vag hyst incl t/o complex,58291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6888.87,,,,,,,fee schedule,4952.26,21971.51,
Vag hyst incl t/o complex,58291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7525.46,,,,,,,fee schedule,4952.26,21971.51,
Vag hyst incl t/o complex,58291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7911.97,,,,,,,fee schedule,4952.26,21971.51,
Vag hyst incl t/o complex,58291,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21971.51,,,,,,,fee schedule,4952.26,21971.51,APC 378
Vag hyst incl t/o complex,58291,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5199.88,,,,,,,fee schedule,4952.26,21971.51,APC
Vag hyst incl t/o complex,58291,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5150.35,,,,,,,fee schedule,4952.26,21971.51,APC
Vag hyst incl t/o complex,58291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4952.26,,,,,,,fee schedule,4952.26,21971.51,APC
Vag hyst incl t/o complex,58291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7576.96,,,,,,,fee schedule,4952.26,21971.51,Radiology
Vag hyst incl t/o complex,58291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6933.17,,,,,,,fee schedule,4952.26,21971.51,APC
Vag hyst incl t/o complex,58291,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8666.46,,,,,,,fee schedule,4952.26,21971.51,APC
Vag hyst t/o & repair compl,58292,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12338.95,,,,,,,fee schedule,7341.04,32569.71,
Vag hyst t/o & repair compl,58292,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9890.75,,,,,,,fee schedule,7341.04,32569.71,
Vag hyst t/o & repair compl,58292,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10804.74,,,,,,,fee schedule,7341.04,32569.71,
Vag hyst t/o & repair compl,58292,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11359.67,,,,,,,fee schedule,7341.04,32569.71,
Vag hyst t/o & repair compl,58292,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,32569.71,,,,,,,fee schedule,7341.04,32569.71,APC 378
Vag hyst t/o & repair compl,58292,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7708.09,,,,,,,fee schedule,7341.04,32569.71,APC
Vag hyst t/o & repair compl,58292,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7634.68,,,,,,,fee schedule,7341.04,32569.71,APC
Vag hyst t/o & repair compl,58292,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7341.04,,,,,,,fee schedule,7341.04,32569.71,APC
Vag hyst t/o & repair compl,58292,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11231.79,,,,,,,fee schedule,7341.04,32569.71,Radiology
Vag hyst t/o & repair compl,58292,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10277.46,,,,,,,fee schedule,7341.04,32569.71,APC
Vag hyst t/o & repair compl,58292,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12846.82,,,,,,,fee schedule,7341.04,32569.71,APC
Vag hyst w/enterocele compl,58294,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10659.34,,,,,,,fee schedule,4952.26,21971.51,
Vag hyst w/enterocele compl,58294,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8544.39,,,,,,,fee schedule,4952.26,21971.51,
Vag hyst w/enterocele compl,58294,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9333.97,,,,,,,fee schedule,4952.26,21971.51,
Vag hyst w/enterocele compl,58294,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9813.36,,,,,,,fee schedule,4952.26,21971.51,
Vag hyst w/enterocele compl,58294,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21971.51,,,,,,,fee schedule,4952.26,21971.51,APC 378
Vag hyst w/enterocele compl,58294,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5199.88,,,,,,,fee schedule,4952.26,21971.51,APC
Vag hyst w/enterocele compl,58294,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5150.35,,,,,,,fee schedule,4952.26,21971.51,APC
Vag hyst w/enterocele compl,58294,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4952.26,,,,,,,fee schedule,4952.26,21971.51,APC
Vag hyst w/enterocele compl,58294,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7576.96,,,,,,,fee schedule,4952.26,21971.51,Radiology
Vag hyst w/enterocele compl,58294,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6933.17,,,,,,,fee schedule,4952.26,21971.51,APC
Vag hyst w/enterocele compl,58294,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8666.46,,,,,,,fee schedule,4952.26,21971.51,APC
Insert intrauterine device,58300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3360.79,,,,,,,fee schedule,2693.96,3360.79,
Insert intrauterine device,58300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2693.96,,,,,,,fee schedule,2693.96,3360.79,
Insert intrauterine device,58300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2942.91,,,,,,,fee schedule,2693.96,3360.79,
Insert intrauterine device,58300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3094.06,,,,,,,fee schedule,2693.96,3360.79,
Remove intrauterine device,58301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3965.98,,,,,,,fee schedule,301.67,3965.98,
Remove intrauterine device,58301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3179.08,,,,,,,fee schedule,301.67,3965.98,
Remove intrauterine device,58301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3472.85,,,,,,,fee schedule,301.67,3965.98,
Remove intrauterine device,58301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3651.22,,,,,,,fee schedule,301.67,3965.98,
Remove intrauterine device,58301,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1338.42,,,,,,,fee schedule,301.67,3965.98,APC 378
Remove intrauterine device,58301,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,316.76,,,,,,,fee schedule,301.67,3965.98,APC
Remove intrauterine device,58301,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,313.74,,,,,,,fee schedule,301.67,3965.98,APC
Remove intrauterine device,58301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,301.67,,,,,,,fee schedule,301.67,3965.98,APC
Remove intrauterine device,58301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,461.56,,,,,,,fee schedule,301.67,3965.98,Radiology
Remove intrauterine device,58301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,422.34,,,,,,,fee schedule,301.67,3965.98,APC
Remove intrauterine device,58301,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,527.93,,,,,,,fee schedule,301.67,3965.98,APC
Artificial insemination,58321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,688.41,,,,,,,fee schedule,301.67,1338.42,
Artificial insemination,58321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,551.82,,,,,,,fee schedule,301.67,1338.42,
Artificial insemination,58321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,602.82,,,,,,,fee schedule,301.67,1338.42,
Artificial insemination,58321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,633.78,,,,,,,fee schedule,301.67,1338.42,
Artificial insemination,58321,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1338.42,,,,,,,fee schedule,301.67,1338.42,APC 378
Artificial insemination,58321,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,316.76,,,,,,,fee schedule,301.67,1338.42,APC
Artificial insemination,58321,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,313.74,,,,,,,fee schedule,301.67,1338.42,APC
Artificial insemination,58321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,301.67,,,,,,,fee schedule,301.67,1338.42,APC
Artificial insemination,58321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,461.56,,,,,,,fee schedule,301.67,1338.42,Radiology
Artificial insemination,58321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,422.34,,,,,,,fee schedule,301.67,1338.42,APC
Artificial insemination,58321,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,527.93,,,,,,,fee schedule,301.67,1338.42,APC
Artificial insemination,58322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,688.41,,,,,,,fee schedule,200.14,887.97,
Artificial insemination,58322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,551.82,,,,,,,fee schedule,200.14,887.97,
Artificial insemination,58322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,602.82,,,,,,,fee schedule,200.14,887.97,
Artificial insemination,58322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,633.78,,,,,,,fee schedule,200.14,887.97,
Artificial insemination,58322,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,887.97,,,,,,,fee schedule,200.14,887.97,APC 378
Artificial insemination,58322,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,210.15,,,,,,,fee schedule,200.14,887.97,APC
Artificial insemination,58322,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,208.15,,,,,,,fee schedule,200.14,887.97,APC
Artificial insemination,58322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,200.14,,,,,,,fee schedule,200.14,887.97,APC
Artificial insemination,58322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,306.22,,,,,,,fee schedule,200.14,887.97,Radiology
Artificial insemination,58322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,280.2,,,,,,,fee schedule,200.14,887.97,APC
Artificial insemination,58322,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,350.25,,,,,,,fee schedule,200.14,887.97,APC
Sperm washing,58323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,688.41,,,,,,,fee schedule,200.14,887.97,
Sperm washing,58323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,551.82,,,,,,,fee schedule,200.14,887.97,
Sperm washing,58323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,602.82,,,,,,,fee schedule,200.14,887.97,
Sperm washing,58323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,633.78,,,,,,,fee schedule,200.14,887.97,
Sperm washing,58323,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,887.97,,,,,,,fee schedule,200.14,887.97,APC 378
Sperm washing,58323,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,210.15,,,,,,,fee schedule,200.14,887.97,APC
Sperm washing,58323,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,208.15,,,,,,,fee schedule,200.14,887.97,APC
Sperm washing,58323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,200.14,,,,,,,fee schedule,200.14,887.97,APC
Sperm washing,58323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,306.22,,,,,,,fee schedule,200.14,887.97,Radiology
Sperm washing,58323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,280.2,,,,,,,fee schedule,200.14,887.97,APC
Sperm washing,58323,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,350.25,,,,,,,fee schedule,200.14,887.97,APC
Reopen fallopian tube,58345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4747,,,,,,,fee schedule,3204.65,14217.94,
Reopen fallopian tube,58345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3805.13,,,,,,,fee schedule,3204.65,14217.94,
Reopen fallopian tube,58345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4156.76,,,,,,,fee schedule,3204.65,14217.94,
Reopen fallopian tube,58345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4370.25,,,,,,,fee schedule,3204.65,14217.94,
Reopen fallopian tube,58345,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14217.94,,,,,,,fee schedule,3204.65,14217.94,APC 378
Reopen fallopian tube,58345,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3364.88,,,,,,,fee schedule,3204.65,14217.94,APC
Reopen fallopian tube,58345,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3332.84,,,,,,,fee schedule,3204.65,14217.94,APC
Reopen fallopian tube,58345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3204.65,,,,,,,fee schedule,3204.65,14217.94,APC
Reopen fallopian tube,58345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4903.11,,,,,,,fee schedule,3204.65,14217.94,Radiology
Reopen fallopian tube,58345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4486.51,,,,,,,fee schedule,3204.65,14217.94,APC
Reopen fallopian tube,58345,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5608.14,,,,,,,fee schedule,3204.65,14217.94,APC
Insert heyman uteri capsule,58346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4747,,,,,,,fee schedule,3805.13,21971.51,
Insert heyman uteri capsule,58346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3805.13,,,,,,,fee schedule,3805.13,21971.51,
Insert heyman uteri capsule,58346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4156.76,,,,,,,fee schedule,3805.13,21971.51,
Insert heyman uteri capsule,58346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4370.25,,,,,,,fee schedule,3805.13,21971.51,
Insert heyman uteri capsule,58346,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21971.51,,,,,,,fee schedule,3805.13,21971.51,APC 378
Insert heyman uteri capsule,58346,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5199.88,,,,,,,fee schedule,3805.13,21971.51,APC
Insert heyman uteri capsule,58346,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5150.35,,,,,,,fee schedule,3805.13,21971.51,APC
Insert heyman uteri capsule,58346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4952.26,,,,,,,fee schedule,3805.13,21971.51,APC
Insert heyman uteri capsule,58346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7576.96,,,,,,,fee schedule,3805.13,21971.51,Radiology
Insert heyman uteri capsule,58346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6933.17,,,,,,,fee schedule,3805.13,21971.51,APC
Insert heyman uteri capsule,58346,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8666.46,,,,,,,fee schedule,3805.13,21971.51,APC
Reopen fallopian tube,58350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3059.22,,,,,,,fee schedule,2452.23,21971.51,
Reopen fallopian tube,58350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2452.23,,,,,,,fee schedule,2452.23,21971.51,
Reopen fallopian tube,58350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2678.84,,,,,,,fee schedule,2452.23,21971.51,
Reopen fallopian tube,58350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2816.42,,,,,,,fee schedule,2452.23,21971.51,
Reopen fallopian tube,58350,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21971.51,,,,,,,fee schedule,2452.23,21971.51,APC 378
Reopen fallopian tube,58350,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5199.88,,,,,,,fee schedule,2452.23,21971.51,APC
Reopen fallopian tube,58350,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5150.35,,,,,,,fee schedule,2452.23,21971.51,APC
Reopen fallopian tube,58350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4952.26,,,,,,,fee schedule,2452.23,21971.51,APC
Reopen fallopian tube,58350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7576.96,,,,,,,fee schedule,2452.23,21971.51,Radiology
Reopen fallopian tube,58350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6933.17,,,,,,,fee schedule,2452.23,21971.51,APC
Reopen fallopian tube,58350,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8666.46,,,,,,,fee schedule,2452.23,21971.51,APC
Endometr ablate thermal,58353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4549.74,,,,,,,fee schedule,3647.01,21971.51,
Endometr ablate thermal,58353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3647.01,,,,,,,fee schedule,3647.01,21971.51,
Endometr ablate thermal,58353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3984.03,,,,,,,fee schedule,3647.01,21971.51,
Endometr ablate thermal,58353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4188.65,,,,,,,fee schedule,3647.01,21971.51,
Endometr ablate thermal,58353,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21971.51,,,,,,,fee schedule,3647.01,21971.51,APC 378
Endometr ablate thermal,58353,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5199.88,,,,,,,fee schedule,3647.01,21971.51,APC
Endometr ablate thermal,58353,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5150.35,,,,,,,fee schedule,3647.01,21971.51,APC
Endometr ablate thermal,58353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4952.26,,,,,,,fee schedule,3647.01,21971.51,APC
Endometr ablate thermal,58353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7576.96,,,,,,,fee schedule,3647.01,21971.51,Radiology
Endometr ablate thermal,58353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6933.17,,,,,,,fee schedule,3647.01,21971.51,APC
Endometr ablate thermal,58353,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8666.46,,,,,,,fee schedule,3647.01,21971.51,APC
Endometrial cryoablation,58356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10659.34,,,,,,,fee schedule,4952.26,21971.51,
Endometrial cryoablation,58356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8544.39,,,,,,,fee schedule,4952.26,21971.51,
Endometrial cryoablation,58356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9333.97,,,,,,,fee schedule,4952.26,21971.51,
Endometrial cryoablation,58356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9813.36,,,,,,,fee schedule,4952.26,21971.51,
Endometrial cryoablation,58356,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21971.51,,,,,,,fee schedule,4952.26,21971.51,APC 378
Endometrial cryoablation,58356,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5199.88,,,,,,,fee schedule,4952.26,21971.51,APC
Endometrial cryoablation,58356,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5150.35,,,,,,,fee schedule,4952.26,21971.51,APC
Endometrial cryoablation,58356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4952.26,,,,,,,fee schedule,4952.26,21971.51,APC
Endometrial cryoablation,58356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7576.96,,,,,,,fee schedule,4952.26,21971.51,Radiology
Endometrial cryoablation,58356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6933.17,,,,,,,fee schedule,4952.26,21971.51,APC
Endometrial cryoablation,58356,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8666.46,,,,,,,fee schedule,4952.26,21971.51,APC
Lsh uterus 250 g or less,58541,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11363.59,,,,,,,fee schedule,9108.91,46687.84,
Lsh uterus 250 g or less,58541,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9108.91,,,,,,,fee schedule,9108.91,46687.84,
Lsh uterus 250 g or less,58541,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9950.65,,,,,,,fee schedule,9108.91,46687.84,
Lsh uterus 250 g or less,58541,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10461.72,,,,,,,fee schedule,9108.91,46687.84,
Lsh uterus 250 g or less,58541,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46687.84,,,,,,,fee schedule,9108.91,46687.84,APC 378
Lsh uterus 250 g or less,58541,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11049.35,,,,,,,fee schedule,9108.91,46687.84,APC
Lsh uterus 250 g or less,58541,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10944.12,,,,,,,fee schedule,9108.91,46687.84,APC
Lsh uterus 250 g or less,58541,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10523.19,,,,,,,fee schedule,9108.91,46687.84,APC
Lsh uterus 250 g or less,58541,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16100.48,,,,,,,fee schedule,9108.91,46687.84,Radiology
Lsh uterus 250 g or less,58541,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14732.47,,,,,,,fee schedule,9108.91,46687.84,APC
Lsh uterus 250 g or less,58541,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18415.58,,,,,,,fee schedule,9108.91,46687.84,APC
Lsh w/t/o ut 250 g or less,58542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8594.03,,,,,,,fee schedule,6888.87,46687.84,
Lsh w/t/o ut 250 g or less,58542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6888.87,,,,,,,fee schedule,6888.87,46687.84,
Lsh w/t/o ut 250 g or less,58542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7525.46,,,,,,,fee schedule,6888.87,46687.84,
Lsh w/t/o ut 250 g or less,58542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7911.97,,,,,,,fee schedule,6888.87,46687.84,
Lsh w/t/o ut 250 g or less,58542,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46687.84,,,,,,,fee schedule,6888.87,46687.84,APC 378
Lsh w/t/o ut 250 g or less,58542,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11049.35,,,,,,,fee schedule,6888.87,46687.84,APC
Lsh w/t/o ut 250 g or less,58542,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10944.12,,,,,,,fee schedule,6888.87,46687.84,APC
Lsh w/t/o ut 250 g or less,58542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10523.19,,,,,,,fee schedule,6888.87,46687.84,APC
Lsh w/t/o ut 250 g or less,58542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16100.48,,,,,,,fee schedule,6888.87,46687.84,Radiology
Lsh w/t/o ut 250 g or less,58542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14732.47,,,,,,,fee schedule,6888.87,46687.84,APC
Lsh w/t/o ut 250 g or less,58542,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18415.58,,,,,,,fee schedule,6888.87,46687.84,APC
LSH Uterus Above 250 g,58543,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11363.59,,,,,,,fee schedule,9108.91,46687.84,
LSH Uterus Above 250 g,58543,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9108.91,,,,,,,fee schedule,9108.91,46687.84,
LSH Uterus Above 250 g,58543,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9950.65,,,,,,,fee schedule,9108.91,46687.84,
LSH Uterus Above 250 g,58543,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10461.72,,,,,,,fee schedule,9108.91,46687.84,
LSH Uterus Above 250 g,58543,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46687.84,,,,,,,fee schedule,9108.91,46687.84,APC 378
LSH Uterus Above 250 g,58543,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11049.35,,,,,,,fee schedule,9108.91,46687.84,APC
LSH Uterus Above 250 g,58543,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10944.12,,,,,,,fee schedule,9108.91,46687.84,APC
LSH Uterus Above 250 g,58543,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10523.19,,,,,,,fee schedule,9108.91,46687.84,APC
LSH Uterus Above 250 g,58543,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16100.48,,,,,,,fee schedule,9108.91,46687.84,Radiology
LSH Uterus Above 250 g,58543,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14732.47,,,,,,,fee schedule,9108.91,46687.84,APC
LSH Uterus Above 250 g,58543,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18415.58,,,,,,,fee schedule,9108.91,46687.84,APC
LSH w/t/o Uterus Above 250 g,58544,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11363.59,,,,,,,fee schedule,9108.91,46687.84,
LSH w/t/o Uterus Above 250 g,58544,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9108.91,,,,,,,fee schedule,9108.91,46687.84,
LSH w/t/o Uterus Above 250 g,58544,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9950.65,,,,,,,fee schedule,9108.91,46687.84,
LSH w/t/o Uterus Above 250 g,58544,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10461.72,,,,,,,fee schedule,9108.91,46687.84,
LSH w/t/o Uterus Above 250 g,58544,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46687.84,,,,,,,fee schedule,9108.91,46687.84,APC 378
LSH w/t/o Uterus Above 250 g,58544,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11049.35,,,,,,,fee schedule,9108.91,46687.84,APC
LSH w/t/o Uterus Above 250 g,58544,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10944.12,,,,,,,fee schedule,9108.91,46687.84,APC
LSH w/t/o Uterus Above 250 g,58544,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10523.19,,,,,,,fee schedule,9108.91,46687.84,APC
LSH w/t/o Uterus Above 250 g,58544,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16100.48,,,,,,,fee schedule,9108.91,46687.84,Radiology
LSH w/t/o Uterus Above 250 g,58544,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14732.47,,,,,,,fee schedule,9108.91,46687.84,APC
LSH w/t/o Uterus Above 250 g,58544,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18415.58,,,,,,,fee schedule,9108.91,46687.84,APC
Laparoscopic myomectomy,58545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4062.96,,,,,,,fee schedule,3256.82,26552.87,
Laparoscopic myomectomy,58545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3256.82,,,,,,,fee schedule,3256.82,26552.87,
Laparoscopic myomectomy,58545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3557.78,,,,,,,fee schedule,3256.82,26552.87,
Laparoscopic myomectomy,58545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3740.5,,,,,,,fee schedule,3256.82,26552.87,
Laparoscopic myomectomy,58545,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,3256.82,26552.87,APC 378
Laparoscopic myomectomy,58545,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,3256.82,26552.87,APC
Laparoscopic myomectomy,58545,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,3256.82,26552.87,APC
Laparoscopic myomectomy,58545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,3256.82,26552.87,APC
Laparoscopic myomectomy,58545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,3256.82,26552.87,Radiology
Laparoscopic myomectomy,58545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,3256.82,26552.87,APC
Laparoscopic myomectomy,58545,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,3256.82,26552.87,APC
Laparo-myomectomy complex,58546,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11363.59,,,,,,,fee schedule,9108.91,46687.84,
Laparo-myomectomy complex,58546,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9108.91,,,,,,,fee schedule,9108.91,46687.84,
Laparo-myomectomy complex,58546,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9950.65,,,,,,,fee schedule,9108.91,46687.84,
Laparo-myomectomy complex,58546,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10461.72,,,,,,,fee schedule,9108.91,46687.84,
Laparo-myomectomy complex,58546,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46687.84,,,,,,,fee schedule,9108.91,46687.84,APC 378
Laparo-myomectomy complex,58546,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11049.35,,,,,,,fee schedule,9108.91,46687.84,APC
Laparo-myomectomy complex,58546,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10944.12,,,,,,,fee schedule,9108.91,46687.84,APC
Laparo-myomectomy complex,58546,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10523.19,,,,,,,fee schedule,9108.91,46687.84,APC
Laparo-myomectomy complex,58546,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16100.48,,,,,,,fee schedule,9108.91,46687.84,Radiology
Laparo-myomectomy complex,58546,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14732.47,,,,,,,fee schedule,9108.91,46687.84,APC
Laparo-myomectomy complex,58546,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18415.58,,,,,,,fee schedule,9108.91,46687.84,APC
Lap Radical Hyst,58548,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12173.43,,,,,,,fee schedule,9758.07,12173.43,
Lap Radical Hyst,58548,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9758.07,,,,,,,fee schedule,9758.07,12173.43,
Lap Radical Hyst,58548,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10659.81,,,,,,,fee schedule,9758.07,12173.43,
Lap Radical Hyst,58548,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11207.29,,,,,,,fee schedule,9758.07,12173.43,
Laparo-asst vag hysterectomy,58550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9433.96,,,,,,,fee schedule,5984.88,26552.87,
Laparo-asst vag hysterectomy,58550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7562.14,,,,,,,fee schedule,5984.88,26552.87,
Laparo-asst vag hysterectomy,58550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8260.95,,,,,,,fee schedule,5984.88,26552.87,
Laparo-asst vag hysterectomy,58550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8685.23,,,,,,,fee schedule,5984.88,26552.87,
Laparo-asst vag hysterectomy,58550,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,5984.88,26552.87,APC 378
Laparo-asst vag hysterectomy,58550,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,5984.88,26552.87,APC
Laparo-asst vag hysterectomy,58550,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,5984.88,26552.87,APC
Laparo-asst vag hysterectomy,58550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,5984.88,26552.87,APC
Laparo-asst vag hysterectomy,58550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,5984.88,26552.87,Radiology
Laparo-asst vag hysterectomy,58550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,5984.88,26552.87,APC
Laparo-asst vag hysterectomy,58550,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,5984.88,26552.87,APC
Laparo-vag hyst incl t/o,58552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9055.83,,,,,,,fee schedule,7259.03,46687.84,
Laparo-vag hyst incl t/o,58552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7259.03,,,,,,,fee schedule,7259.03,46687.84,
Laparo-vag hyst incl t/o,58552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7929.84,,,,,,,fee schedule,7259.03,46687.84,
Laparo-vag hyst incl t/o,58552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8337.11,,,,,,,fee schedule,7259.03,46687.84,
Laparo-vag hyst incl t/o,58552,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46687.84,,,,,,,fee schedule,7259.03,46687.84,APC 378
Laparo-vag hyst incl t/o,58552,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11049.35,,,,,,,fee schedule,7259.03,46687.84,APC
Laparo-vag hyst incl t/o,58552,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10944.12,,,,,,,fee schedule,7259.03,46687.84,APC
Laparo-vag hyst incl t/o,58552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10523.19,,,,,,,fee schedule,7259.03,46687.84,APC
Laparo-vag hyst incl t/o,58552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16100.48,,,,,,,fee schedule,7259.03,46687.84,Radiology
Laparo-vag hyst incl t/o,58552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14732.47,,,,,,,fee schedule,7259.03,46687.84,APC
Laparo-vag hyst incl t/o,58552,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18415.58,,,,,,,fee schedule,7259.03,46687.84,APC
Laparo-vag hyst complex,58553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11363.59,,,,,,,fee schedule,9108.91,46687.84,
Laparo-vag hyst complex,58553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9108.91,,,,,,,fee schedule,9108.91,46687.84,
Laparo-vag hyst complex,58553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9950.65,,,,,,,fee schedule,9108.91,46687.84,
Laparo-vag hyst complex,58553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10461.72,,,,,,,fee schedule,9108.91,46687.84,
Laparo-vag hyst complex,58553,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46687.84,,,,,,,fee schedule,9108.91,46687.84,APC 378
Laparo-vag hyst complex,58553,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11049.35,,,,,,,fee schedule,9108.91,46687.84,APC
Laparo-vag hyst complex,58553,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10944.12,,,,,,,fee schedule,9108.91,46687.84,APC
Laparo-vag hyst complex,58553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10523.19,,,,,,,fee schedule,9108.91,46687.84,APC
Laparo-vag hyst complex,58553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16100.48,,,,,,,fee schedule,9108.91,46687.84,Radiology
Laparo-vag hyst complex,58553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14732.47,,,,,,,fee schedule,9108.91,46687.84,APC
Laparo-vag hyst complex,58553,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18415.58,,,,,,,fee schedule,9108.91,46687.84,APC
Laparo-vag hyst w/t/o compl,58554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8065.17,,,,,,,fee schedule,6464.94,46687.84,
Laparo-vag hyst w/t/o compl,58554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6464.94,,,,,,,fee schedule,6464.94,46687.84,
Laparo-vag hyst w/t/o compl,58554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7062.36,,,,,,,fee schedule,6464.94,46687.84,
Laparo-vag hyst w/t/o compl,58554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7425.07,,,,,,,fee schedule,6464.94,46687.84,
Laparo-vag hyst w/t/o compl,58554,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46687.84,,,,,,,fee schedule,6464.94,46687.84,APC 378
Laparo-vag hyst w/t/o compl,58554,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11049.35,,,,,,,fee schedule,6464.94,46687.84,APC
Laparo-vag hyst w/t/o compl,58554,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10944.12,,,,,,,fee schedule,6464.94,46687.84,APC
Laparo-vag hyst w/t/o compl,58554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10523.19,,,,,,,fee schedule,6464.94,46687.84,APC
Laparo-vag hyst w/t/o compl,58554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16100.48,,,,,,,fee schedule,6464.94,46687.84,Radiology
Laparo-vag hyst w/t/o compl,58554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14732.47,,,,,,,fee schedule,6464.94,46687.84,APC
Laparo-vag hyst w/t/o compl,58554,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18415.58,,,,,,,fee schedule,6464.94,46687.84,APC
Hysteroscopy dx sep proc,58555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5679.33,,,,,,,fee schedule,3204.65,14217.94,
Hysteroscopy dx sep proc,58555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4552.48,,,,,,,fee schedule,3204.65,14217.94,
Hysteroscopy dx sep proc,58555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4973.17,,,,,,,fee schedule,3204.65,14217.94,
Hysteroscopy dx sep proc,58555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5228.59,,,,,,,fee schedule,3204.65,14217.94,
Hysteroscopy dx sep proc,58555,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14217.94,,,,,,,fee schedule,3204.65,14217.94,APC 378
Hysteroscopy dx sep proc,58555,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3364.88,,,,,,,fee schedule,3204.65,14217.94,APC
Hysteroscopy dx sep proc,58555,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3332.84,,,,,,,fee schedule,3204.65,14217.94,APC
Hysteroscopy dx sep proc,58555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3204.65,,,,,,,fee schedule,3204.65,14217.94,APC
Hysteroscopy dx sep proc,58555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4903.11,,,,,,,fee schedule,3204.65,14217.94,Radiology
Hysteroscopy dx sep proc,58555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4486.51,,,,,,,fee schedule,3204.65,14217.94,APC
Hysteroscopy dx sep proc,58555,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5608.14,,,,,,,fee schedule,3204.65,14217.94,APC
Hysteroscopy biopsy,58558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5715.01,,,,,,,fee schedule,3204.65,14217.94,
Hysteroscopy biopsy,58558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4581.08,,,,,,,fee schedule,3204.65,14217.94,
Hysteroscopy biopsy,58558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5004.42,,,,,,,fee schedule,3204.65,14217.94,
Hysteroscopy biopsy,58558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5261.44,,,,,,,fee schedule,3204.65,14217.94,
Hysteroscopy biopsy,58558,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14217.94,,,,,,,fee schedule,3204.65,14217.94,APC 378
Hysteroscopy biopsy,58558,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3364.88,,,,,,,fee schedule,3204.65,14217.94,APC
Hysteroscopy biopsy,58558,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3332.84,,,,,,,fee schedule,3204.65,14217.94,APC
Hysteroscopy biopsy,58558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3204.65,,,,,,,fee schedule,3204.65,14217.94,APC
Hysteroscopy biopsy,58558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4903.11,,,,,,,fee schedule,3204.65,14217.94,Radiology
Hysteroscopy biopsy,58558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4486.51,,,,,,,fee schedule,3204.65,14217.94,APC
Hysteroscopy biopsy,58558,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5608.14,,,,,,,fee schedule,3204.65,14217.94,APC
Hysteroscopy lysis,58559,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2552.59,,,,,,,fee schedule,2046.13,21971.51,
Hysteroscopy lysis,58559,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2046.13,,,,,,,fee schedule,2046.13,21971.51,
Hysteroscopy lysis,58559,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2235.21,,,,,,,fee schedule,2046.13,21971.51,
Hysteroscopy lysis,58559,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2350.01,,,,,,,fee schedule,2046.13,21971.51,
Hysteroscopy lysis,58559,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21971.51,,,,,,,fee schedule,2046.13,21971.51,APC 378
Hysteroscopy lysis,58559,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5199.88,,,,,,,fee schedule,2046.13,21971.51,APC
Hysteroscopy lysis,58559,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5150.35,,,,,,,fee schedule,2046.13,21971.51,APC
Hysteroscopy lysis,58559,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4952.26,,,,,,,fee schedule,2046.13,21971.51,APC
Hysteroscopy lysis,58559,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7576.96,,,,,,,fee schedule,2046.13,21971.51,Radiology
Hysteroscopy lysis,58559,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6933.17,,,,,,,fee schedule,2046.13,21971.51,APC
Hysteroscopy lysis,58559,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8666.46,,,,,,,fee schedule,2046.13,21971.51,APC
Hysteroscopy resect septum,58560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5523.29,,,,,,,fee schedule,4427.4,21971.51,
Hysteroscopy resect septum,58560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4427.4,,,,,,,fee schedule,4427.4,21971.51,
Hysteroscopy resect septum,58560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4836.53,,,,,,,fee schedule,4427.4,21971.51,
Hysteroscopy resect septum,58560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5084.93,,,,,,,fee schedule,4427.4,21971.51,
Hysteroscopy resect septum,58560,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21971.51,,,,,,,fee schedule,4427.4,21971.51,APC 378
Hysteroscopy resect septum,58560,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5199.88,,,,,,,fee schedule,4427.4,21971.51,APC
Hysteroscopy resect septum,58560,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5150.35,,,,,,,fee schedule,4427.4,21971.51,APC
Hysteroscopy resect septum,58560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4952.26,,,,,,,fee schedule,4427.4,21971.51,APC
Hysteroscopy resect septum,58560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7576.96,,,,,,,fee schedule,4427.4,21971.51,Radiology
Hysteroscopy resect septum,58560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6933.17,,,,,,,fee schedule,4427.4,21971.51,APC
Hysteroscopy resect septum,58560,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8666.46,,,,,,,fee schedule,4427.4,21971.51,APC
Hysteroscopy remove myoma,58561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6062.28,,,,,,,fee schedule,4859.44,21971.51,
Hysteroscopy remove myoma,58561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4859.44,,,,,,,fee schedule,4859.44,21971.51,
Hysteroscopy remove myoma,58561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5308.5,,,,,,,fee schedule,4859.44,21971.51,
Hysteroscopy remove myoma,58561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5581.14,,,,,,,fee schedule,4859.44,21971.51,
Hysteroscopy remove myoma,58561,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21971.51,,,,,,,fee schedule,4859.44,21971.51,APC 378
Hysteroscopy remove myoma,58561,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5199.88,,,,,,,fee schedule,4859.44,21971.51,APC
Hysteroscopy remove myoma,58561,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5150.35,,,,,,,fee schedule,4859.44,21971.51,APC
Hysteroscopy remove myoma,58561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4952.26,,,,,,,fee schedule,4859.44,21971.51,APC
Hysteroscopy remove myoma,58561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7576.96,,,,,,,fee schedule,4859.44,21971.51,Radiology
Hysteroscopy remove myoma,58561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6933.17,,,,,,,fee schedule,4859.44,21971.51,APC
Hysteroscopy remove myoma,58561,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8666.46,,,,,,,fee schedule,4859.44,21971.51,APC
Hysteroscopy remove fb,58562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6097.42,,,,,,,fee schedule,3204.65,14217.94,
Hysteroscopy remove fb,58562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4887.61,,,,,,,fee schedule,3204.65,14217.94,
Hysteroscopy remove fb,58562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5339.27,,,,,,,fee schedule,3204.65,14217.94,
Hysteroscopy remove fb,58562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5613.5,,,,,,,fee schedule,3204.65,14217.94,
Hysteroscopy remove fb,58562,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14217.94,,,,,,,fee schedule,3204.65,14217.94,APC 378
Hysteroscopy remove fb,58562,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3364.88,,,,,,,fee schedule,3204.65,14217.94,APC
Hysteroscopy remove fb,58562,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3332.84,,,,,,,fee schedule,3204.65,14217.94,APC
Hysteroscopy remove fb,58562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3204.65,,,,,,,fee schedule,3204.65,14217.94,APC
Hysteroscopy remove fb,58562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4903.11,,,,,,,fee schedule,3204.65,14217.94,Radiology
Hysteroscopy remove fb,58562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4486.51,,,,,,,fee schedule,3204.65,14217.94,APC
Hysteroscopy remove fb,58562,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5608.14,,,,,,,fee schedule,3204.65,14217.94,APC
Hysteroscopy ablation,58563,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5983.37,,,,,,,fee schedule,4796.19,21971.51,
Hysteroscopy ablation,58563,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4796.19,,,,,,,fee schedule,4796.19,21971.51,
Hysteroscopy ablation,58563,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5239.41,,,,,,,fee schedule,4796.19,21971.51,
Hysteroscopy ablation,58563,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5508.5,,,,,,,fee schedule,4796.19,21971.51,
Hysteroscopy ablation,58563,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21971.51,,,,,,,fee schedule,4796.19,21971.51,APC 378
Hysteroscopy ablation,58563,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5199.88,,,,,,,fee schedule,4796.19,21971.51,APC
Hysteroscopy ablation,58563,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5150.35,,,,,,,fee schedule,4796.19,21971.51,APC
Hysteroscopy ablation,58563,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4952.26,,,,,,,fee schedule,4796.19,21971.51,APC
Hysteroscopy ablation,58563,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7576.96,,,,,,,fee schedule,4796.19,21971.51,Radiology
Hysteroscopy ablation,58563,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6933.17,,,,,,,fee schedule,4796.19,21971.51,APC
Hysteroscopy ablation,58563,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8666.46,,,,,,,fee schedule,4796.19,21971.51,APC
Hysteroscopy sterilization,58565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6721.57,,,,,,,fee schedule,4952.26,21971.51,
Hysteroscopy sterilization,58565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5387.93,,,,,,,fee schedule,4952.26,21971.51,
Hysteroscopy sterilization,58565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5885.82,,,,,,,fee schedule,4952.26,21971.51,
Hysteroscopy sterilization,58565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6188.11,,,,,,,fee schedule,4952.26,21971.51,
Hysteroscopy sterilization,58565,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21971.51,,,,,,,fee schedule,4952.26,21971.51,APC 378
Hysteroscopy sterilization,58565,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5199.88,,,,,,,fee schedule,4952.26,21971.51,APC
Hysteroscopy sterilization,58565,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5150.35,,,,,,,fee schedule,4952.26,21971.51,APC
Hysteroscopy sterilization,58565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4952.26,,,,,,,fee schedule,4952.26,21971.51,APC
Hysteroscopy sterilization,58565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7576.96,,,,,,,fee schedule,4952.26,21971.51,Radiology
Hysteroscopy sterilization,58565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6933.17,,,,,,,fee schedule,4952.26,21971.51,APC
Hysteroscopy sterilization,58565,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8666.46,,,,,,,fee schedule,4952.26,21971.51,APC
Tlh uterus 250 g or less,58570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10976.87,,,,,,,fee schedule,8798.92,46687.84,
Tlh uterus 250 g or less,58570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8798.92,,,,,,,fee schedule,8798.92,46687.84,
Tlh uterus 250 g or less,58570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9612.02,,,,,,,fee schedule,8798.92,46687.84,
Tlh uterus 250 g or less,58570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10105.69,,,,,,,fee schedule,8798.92,46687.84,
Tlh uterus 250 g or less,58570,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46687.84,,,,,,,fee schedule,8798.92,46687.84,APC 378
Tlh uterus 250 g or less,58570,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11049.35,,,,,,,fee schedule,8798.92,46687.84,APC
Tlh uterus 250 g or less,58570,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10944.12,,,,,,,fee schedule,8798.92,46687.84,APC
Tlh uterus 250 g or less,58570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10523.19,,,,,,,fee schedule,8798.92,46687.84,APC
Tlh uterus 250 g or less,58570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16100.48,,,,,,,fee schedule,8798.92,46687.84,Radiology
Tlh uterus 250 g or less,58570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14732.47,,,,,,,fee schedule,8798.92,46687.84,APC
Tlh uterus 250 g or less,58570,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18415.58,,,,,,,fee schedule,8798.92,46687.84,APC
Tlh w/t/o 250 g or less,58571,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11092.03,,,,,,,fee schedule,8891.23,46687.84,
Tlh w/t/o 250 g or less,58571,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8891.23,,,,,,,fee schedule,8891.23,46687.84,
Tlh w/t/o 250 g or less,58571,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9712.87,,,,,,,fee schedule,8891.23,46687.84,
Tlh w/t/o 250 g or less,58571,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10211.71,,,,,,,fee schedule,8891.23,46687.84,
Tlh w/t/o 250 g or less,58571,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46687.84,,,,,,,fee schedule,8891.23,46687.84,APC 378
Tlh w/t/o 250 g or less,58571,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11049.35,,,,,,,fee schedule,8891.23,46687.84,APC
Tlh w/t/o 250 g or less,58571,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10944.12,,,,,,,fee schedule,8891.23,46687.84,APC
Tlh w/t/o 250 g or less,58571,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10523.19,,,,,,,fee schedule,8891.23,46687.84,APC
Tlh w/t/o 250 g or less,58571,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16100.48,,,,,,,fee schedule,8891.23,46687.84,Radiology
Tlh w/t/o 250 g or less,58571,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14732.47,,,,,,,fee schedule,8891.23,46687.84,APC
Tlh w/t/o 250 g or less,58571,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18415.58,,,,,,,fee schedule,8891.23,46687.84,APC
Tlh uterus over 250 g,58572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11363.59,,,,,,,fee schedule,9108.91,46687.84,
Tlh uterus over 250 g,58572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9108.91,,,,,,,fee schedule,9108.91,46687.84,
Tlh uterus over 250 g,58572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9950.65,,,,,,,fee schedule,9108.91,46687.84,
Tlh uterus over 250 g,58572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10461.72,,,,,,,fee schedule,9108.91,46687.84,
Tlh uterus over 250 g,58572,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46687.84,,,,,,,fee schedule,9108.91,46687.84,APC 378
Tlh uterus over 250 g,58572,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11049.35,,,,,,,fee schedule,9108.91,46687.84,APC
Tlh uterus over 250 g,58572,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10944.12,,,,,,,fee schedule,9108.91,46687.84,APC
Tlh uterus over 250 g,58572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10523.19,,,,,,,fee schedule,9108.91,46687.84,APC
Tlh uterus over 250 g,58572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16100.48,,,,,,,fee schedule,9108.91,46687.84,Radiology
Tlh uterus over 250 g,58572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14732.47,,,,,,,fee schedule,9108.91,46687.84,APC
Tlh uterus over 250 g,58572,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18415.58,,,,,,,fee schedule,9108.91,46687.84,APC
Tlh w/t/o uterus over 250 g,58573,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11133.68,,,,,,,fee schedule,8924.62,46687.84,
Tlh w/t/o uterus over 250 g,58573,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8924.62,,,,,,,fee schedule,8924.62,46687.84,
Tlh w/t/o uterus over 250 g,58573,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9749.33,,,,,,,fee schedule,8924.62,46687.84,
Tlh w/t/o uterus over 250 g,58573,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10250.05,,,,,,,fee schedule,8924.62,46687.84,
Tlh w/t/o uterus over 250 g,58573,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46687.84,,,,,,,fee schedule,8924.62,46687.84,APC 378
Tlh w/t/o uterus over 250 g,58573,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11049.35,,,,,,,fee schedule,8924.62,46687.84,APC
Tlh w/t/o uterus over 250 g,58573,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10944.12,,,,,,,fee schedule,8924.62,46687.84,APC
Tlh w/t/o uterus over 250 g,58573,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10523.19,,,,,,,fee schedule,8924.62,46687.84,APC
Tlh w/t/o uterus over 250 g,58573,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16100.48,,,,,,,fee schedule,8924.62,46687.84,Radiology
Tlh w/t/o uterus over 250 g,58573,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14732.47,,,,,,,fee schedule,8924.62,46687.84,APC
Tlh w/t/o uterus over 250 g,58573,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18415.58,,,,,,,fee schedule,8924.62,46687.84,APC
Laps tot hyst resj mal,58575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7374.29,,,,,,,fee schedule,5911.14,7374.29,
Laps tot hyst resj mal,58575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5911.14,,,,,,,fee schedule,5911.14,7374.29,
Laps tot hyst resj mal,58575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6457.38,,,,,,,fee schedule,5911.14,7374.29,
Laps tot hyst resj mal,58575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6789.03,,,,,,,fee schedule,5911.14,7374.29,
Laparo proc uterus,58578,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3956.96,,,,,,,fee schedule,3171.85,26552.87,
Laparo proc uterus,58578,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3171.85,,,,,,,fee schedule,3171.85,26552.87,
Laparo proc uterus,58578,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3464.96,,,,,,,fee schedule,3171.85,26552.87,
Laparo proc uterus,58578,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3642.92,,,,,,,fee schedule,3171.85,26552.87,
Laparo proc uterus,58578,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,3171.85,26552.87,APC 378
Laparo proc uterus,58578,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,3171.85,26552.87,APC
Laparo proc uterus,58578,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,3171.85,26552.87,APC
Laparo proc uterus,58578,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,3171.85,26552.87,APC
Laparo proc uterus,58578,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,3171.85,26552.87,Radiology
Laparo proc uterus,58578,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,3171.85,26552.87,APC
Laparo proc uterus,58578,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,3171.85,26552.87,APC
Hysteroscope procedure,58579,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6272.96,,,,,,,fee schedule,200.14,6272.96,
Hysteroscope procedure,58579,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5028.33,,,,,,,fee schedule,200.14,6272.96,
Hysteroscope procedure,58579,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5492.99,,,,,,,fee schedule,200.14,6272.96,
Hysteroscope procedure,58579,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5775.11,,,,,,,fee schedule,200.14,6272.96,
Hysteroscope procedure,58579,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,887.97,,,,,,,fee schedule,200.14,6272.96,APC 378
Hysteroscope procedure,58579,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,210.15,,,,,,,fee schedule,200.14,6272.96,APC
Hysteroscope procedure,58579,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,208.15,,,,,,,fee schedule,200.14,6272.96,APC
Hysteroscope procedure,58579,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,200.14,,,,,,,fee schedule,200.14,6272.96,APC
Hysteroscope procedure,58579,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,306.22,,,,,,,fee schedule,200.14,6272.96,Radiology
Hysteroscope procedure,58579,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,280.2,,,,,,,fee schedule,200.14,6272.96,APC
Hysteroscope procedure,58579,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,350.25,,,,,,,fee schedule,200.14,6272.96,APC
Transcrv abltj utrn fibrd rf,58580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27243.52,,,,,,,fee schedule,7341.04,32569.71,
Transcrv abltj utrn fibrd rf,58580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21838.06,,,,,,,fee schedule,7341.04,32569.71,
Transcrv abltj utrn fibrd rf,58580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23856.1,,,,,,,fee schedule,7341.04,32569.71,
Transcrv abltj utrn fibrd rf,58580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,25081.33,,,,,,,fee schedule,7341.04,32569.71,
Transcrv abltj utrn fibrd rf,58580,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,32569.71,,,,,,,fee schedule,7341.04,32569.71,APC 378
Transcrv abltj utrn fibrd rf,58580,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7708.09,,,,,,,fee schedule,7341.04,32569.71,APC
Transcrv abltj utrn fibrd rf,58580,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7634.68,,,,,,,fee schedule,7341.04,32569.71,APC
Transcrv abltj utrn fibrd rf,58580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7341.04,,,,,,,fee schedule,7341.04,32569.71,APC
Transcrv abltj utrn fibrd rf,58580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11231.79,,,,,,,fee schedule,7341.04,32569.71,Radiology
Transcrv abltj utrn fibrd rf,58580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10277.46,,,,,,,fee schedule,7341.04,32569.71,APC
Transcrv abltj utrn fibrd rf,58580,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12846.82,,,,,,,fee schedule,7341.04,32569.71,APC
Division of fallopian tube,58600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3828.9,,,,,,,fee schedule,3069.2,14217.94,
Division of fallopian tube,58600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3069.2,,,,,,,fee schedule,3069.2,14217.94,
Division of fallopian tube,58600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3352.82,,,,,,,fee schedule,3069.2,14217.94,
Division of fallopian tube,58600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3525.02,,,,,,,fee schedule,3069.2,14217.94,
Division of fallopian tube,58600,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14217.94,,,,,,,fee schedule,3069.2,14217.94,APC 378
Division of fallopian tube,58600,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3364.88,,,,,,,fee schedule,3069.2,14217.94,APC
Division of fallopian tube,58600,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3332.84,,,,,,,fee schedule,3069.2,14217.94,APC
Division of fallopian tube,58600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3204.65,,,,,,,fee schedule,3069.2,14217.94,APC
Division of fallopian tube,58600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4903.11,,,,,,,fee schedule,3069.2,14217.94,Radiology
Division of fallopian tube,58600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4486.51,,,,,,,fee schedule,3069.2,14217.94,APC
Division of fallopian tube,58600,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5608.14,,,,,,,fee schedule,3069.2,14217.94,APC
Occlude fallopian tube(s),58615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4747,,,,,,,fee schedule,3204.65,14217.94,
Occlude fallopian tube(s),58615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3805.13,,,,,,,fee schedule,3204.65,14217.94,
Occlude fallopian tube(s),58615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4156.76,,,,,,,fee schedule,3204.65,14217.94,
Occlude fallopian tube(s),58615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4370.25,,,,,,,fee schedule,3204.65,14217.94,
Occlude fallopian tube(s),58615,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14217.94,,,,,,,fee schedule,3204.65,14217.94,APC 378
Occlude fallopian tube(s),58615,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3364.88,,,,,,,fee schedule,3204.65,14217.94,APC
Occlude fallopian tube(s),58615,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3332.84,,,,,,,fee schedule,3204.65,14217.94,APC
Occlude fallopian tube(s),58615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3204.65,,,,,,,fee schedule,3204.65,14217.94,APC
Occlude fallopian tube(s),58615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4903.11,,,,,,,fee schedule,3204.65,14217.94,Radiology
Occlude fallopian tube(s),58615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4486.51,,,,,,,fee schedule,3204.65,14217.94,APC
Occlude fallopian tube(s),58615,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5608.14,,,,,,,fee schedule,3204.65,14217.94,APC
Laparoscopy lysis,58660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7501.76,,,,,,,fee schedule,5984.88,26552.87,
Laparoscopy lysis,58660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6013.32,,,,,,,fee schedule,5984.88,26552.87,
Laparoscopy lysis,58660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6569,,,,,,,fee schedule,5984.88,26552.87,
Laparoscopy lysis,58660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6906.38,,,,,,,fee schedule,5984.88,26552.87,
Laparoscopy lysis,58660,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,5984.88,26552.87,APC 378
Laparoscopy lysis,58660,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscopy lysis,58660,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscopy lysis,58660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscopy lysis,58660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,5984.88,26552.87,Radiology
Laparoscopy lysis,58660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscopy lysis,58660,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscopy remove adnexa,58661,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6211.62,,,,,,,fee schedule,4979.16,26552.87,
Laparoscopy remove adnexa,58661,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4979.16,,,,,,,fee schedule,4979.16,26552.87,
Laparoscopy remove adnexa,58661,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5439.28,,,,,,,fee schedule,4979.16,26552.87,
Laparoscopy remove adnexa,58661,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5718.64,,,,,,,fee schedule,4979.16,26552.87,
Laparoscopy remove adnexa,58661,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,4979.16,26552.87,APC 378
Laparoscopy remove adnexa,58661,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,4979.16,26552.87,APC
Laparoscopy remove adnexa,58661,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,4979.16,26552.87,APC
Laparoscopy remove adnexa,58661,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,4979.16,26552.87,APC
Laparoscopy remove adnexa,58661,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,4979.16,26552.87,Radiology
Laparoscopy remove adnexa,58661,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,4979.16,26552.87,APC
Laparoscopy remove adnexa,58661,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,4979.16,26552.87,APC
Laparoscopy excise lesions,58662,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6358.72,,,,,,,fee schedule,5097.07,26552.87,
Laparoscopy excise lesions,58662,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5097.07,,,,,,,fee schedule,5097.07,26552.87,
Laparoscopy excise lesions,58662,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5568.09,,,,,,,fee schedule,5097.07,26552.87,
Laparoscopy excise lesions,58662,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5854.06,,,,,,,fee schedule,5097.07,26552.87,
Laparoscopy excise lesions,58662,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,5097.07,26552.87,APC 378
Laparoscopy excise lesions,58662,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,5097.07,26552.87,APC
Laparoscopy excise lesions,58662,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,5097.07,26552.87,APC
Laparoscopy excise lesions,58662,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,5097.07,26552.87,APC
Laparoscopy excise lesions,58662,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,5097.07,26552.87,Radiology
Laparoscopy excise lesions,58662,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,5097.07,26552.87,APC
Laparoscopy excise lesions,58662,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,5097.07,26552.87,APC
Laparoscopy tubal cautery,58670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5496.58,,,,,,,fee schedule,4405.99,26552.87,
Laparoscopy tubal cautery,58670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4405.99,,,,,,,fee schedule,4405.99,26552.87,
Laparoscopy tubal cautery,58670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4813.14,,,,,,,fee schedule,4405.99,26552.87,
Laparoscopy tubal cautery,58670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5060.34,,,,,,,fee schedule,4405.99,26552.87,
Laparoscopy tubal cautery,58670,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,4405.99,26552.87,APC 378
Laparoscopy tubal cautery,58670,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,4405.99,26552.87,APC
Laparoscopy tubal cautery,58670,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,4405.99,26552.87,APC
Laparoscopy tubal cautery,58670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,4405.99,26552.87,APC
Laparoscopy tubal cautery,58670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,4405.99,26552.87,Radiology
Laparoscopy tubal cautery,58670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,4405.99,26552.87,APC
Laparoscopy tubal cautery,58670,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,4405.99,26552.87,APC
Laparoscopy tubal block,58671,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5762.14,,,,,,,fee schedule,4618.86,26552.87,
Laparoscopy tubal block,58671,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4618.86,,,,,,,fee schedule,4618.86,26552.87,
Laparoscopy tubal block,58671,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5045.69,,,,,,,fee schedule,4618.86,26552.87,
Laparoscopy tubal block,58671,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5304.83,,,,,,,fee schedule,4618.86,26552.87,
Laparoscopy tubal block,58671,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,4618.86,26552.87,APC 378
Laparoscopy tubal block,58671,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,4618.86,26552.87,APC
Laparoscopy tubal block,58671,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,4618.86,26552.87,APC
Laparoscopy tubal block,58671,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,4618.86,26552.87,APC
Laparoscopy tubal block,58671,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,4618.86,26552.87,Radiology
Laparoscopy tubal block,58671,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,4618.86,26552.87,APC
Laparoscopy tubal block,58671,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,4618.86,26552.87,APC
Laparoscopy fimbrioplasty,58672,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11363.59,,,,,,,fee schedule,5984.88,26552.87,
Laparoscopy fimbrioplasty,58672,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9108.91,,,,,,,fee schedule,5984.88,26552.87,
Laparoscopy fimbrioplasty,58672,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9950.65,,,,,,,fee schedule,5984.88,26552.87,
Laparoscopy fimbrioplasty,58672,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10461.72,,,,,,,fee schedule,5984.88,26552.87,
Laparoscopy fimbrioplasty,58672,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,5984.88,26552.87,APC 378
Laparoscopy fimbrioplasty,58672,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscopy fimbrioplasty,58672,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscopy fimbrioplasty,58672,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscopy fimbrioplasty,58672,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,5984.88,26552.87,Radiology
Laparoscopy fimbrioplasty,58672,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscopy fimbrioplasty,58672,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,5984.88,26552.87,APC
Laparoscopy salpingostomy,58673,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.29,,,,,,,fee schedule,4416.18,46687.84,
Laparoscopy salpingostomy,58673,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4416.18,,,,,,,fee schedule,4416.18,46687.84,
Laparoscopy salpingostomy,58673,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4824.28,,,,,,,fee schedule,4416.18,46687.84,
Laparoscopy salpingostomy,58673,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5072.05,,,,,,,fee schedule,4416.18,46687.84,
Laparoscopy salpingostomy,58673,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46687.84,,,,,,,fee schedule,4416.18,46687.84,APC 378
Laparoscopy salpingostomy,58673,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11049.35,,,,,,,fee schedule,4416.18,46687.84,APC
Laparoscopy salpingostomy,58673,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10944.12,,,,,,,fee schedule,4416.18,46687.84,APC
Laparoscopy salpingostomy,58673,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10523.19,,,,,,,fee schedule,4416.18,46687.84,APC
Laparoscopy salpingostomy,58673,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16100.48,,,,,,,fee schedule,4416.18,46687.84,Radiology
Laparoscopy salpingostomy,58673,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14732.47,,,,,,,fee schedule,4416.18,46687.84,APC
Laparoscopy salpingostomy,58673,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18415.58,,,,,,,fee schedule,4416.18,46687.84,APC
Laps abltj uterine fibroids,58674,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26346,,,,,,,fee schedule,10523.19,46687.84,
Laps abltj uterine fibroids,58674,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21118.62,,,,,,,fee schedule,10523.19,46687.84,
Laps abltj uterine fibroids,58674,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23070.17,,,,,,,fee schedule,10523.19,46687.84,
Laps abltj uterine fibroids,58674,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24255.04,,,,,,,fee schedule,10523.19,46687.84,
Laps abltj uterine fibroids,58674,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46687.84,,,,,,,fee schedule,10523.19,46687.84,APC 378
Laps abltj uterine fibroids,58674,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11049.35,,,,,,,fee schedule,10523.19,46687.84,APC
Laps abltj uterine fibroids,58674,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10944.12,,,,,,,fee schedule,10523.19,46687.84,APC
Laps abltj uterine fibroids,58674,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10523.19,,,,,,,fee schedule,10523.19,46687.84,APC
Laps abltj uterine fibroids,58674,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16100.48,,,,,,,fee schedule,10523.19,46687.84,Radiology
Laps abltj uterine fibroids,58674,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14732.47,,,,,,,fee schedule,10523.19,46687.84,APC
Laps abltj uterine fibroids,58674,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18415.58,,,,,,,fee schedule,10523.19,46687.84,APC
Laparo proc oviduct-ovary,58679,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8584.34,,,,,,,fee schedule,5984.88,26552.87,
Laparo proc oviduct-ovary,58679,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6881.1,,,,,,,fee schedule,5984.88,26552.87,
Laparo proc oviduct-ovary,58679,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7516.98,,,,,,,fee schedule,5984.88,26552.87,
Laparo proc oviduct-ovary,58679,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7903.05,,,,,,,fee schedule,5984.88,26552.87,
Laparo proc oviduct-ovary,58679,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,5984.88,26552.87,APC 378
Laparo proc oviduct-ovary,58679,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,5984.88,26552.87,APC
Laparo proc oviduct-ovary,58679,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,5984.88,26552.87,APC
Laparo proc oviduct-ovary,58679,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,5984.88,26552.87,APC
Laparo proc oviduct-ovary,58679,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,5984.88,26552.87,Radiology
Laparo proc oviduct-ovary,58679,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,5984.88,26552.87,APC
Laparo proc oviduct-ovary,58679,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,5984.88,26552.87,APC
Removal of fallopian tube,58700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4531.07,,,,,,,fee schedule,3632.05,4531.07,
Removal of fallopian tube,58700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3632.05,,,,,,,fee schedule,3632.05,4531.07,
Removal of fallopian tube,58700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3967.69,,,,,,,fee schedule,3632.05,4531.07,
Removal of fallopian tube,58700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4171.46,,,,,,,fee schedule,3632.05,4531.07,
Create new tubal opening,58770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8092.19,,,,,,,fee schedule,3204.65,14217.94,
Create new tubal opening,58770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6486.59,,,,,,,fee schedule,3204.65,14217.94,
Create new tubal opening,58770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7086.01,,,,,,,fee schedule,3204.65,14217.94,
Create new tubal opening,58770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7449.95,,,,,,,fee schedule,3204.65,14217.94,
Create new tubal opening,58770,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14217.94,,,,,,,fee schedule,3204.65,14217.94,APC 378
Create new tubal opening,58770,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3364.88,,,,,,,fee schedule,3204.65,14217.94,APC
Create new tubal opening,58770,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3332.84,,,,,,,fee schedule,3204.65,14217.94,APC
Create new tubal opening,58770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3204.65,,,,,,,fee schedule,3204.65,14217.94,APC
Create new tubal opening,58770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4903.11,,,,,,,fee schedule,3204.65,14217.94,Radiology
Create new tubal opening,58770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4486.51,,,,,,,fee schedule,3204.65,14217.94,APC
Create new tubal opening,58770,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5608.14,,,,,,,fee schedule,3204.65,14217.94,APC
Drainage of ovarian cyst(s),58800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4747,,,,,,,fee schedule,3204.65,14217.94,
Drainage of ovarian cyst(s),58800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3805.13,,,,,,,fee schedule,3204.65,14217.94,
Drainage of ovarian cyst(s),58800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4156.76,,,,,,,fee schedule,3204.65,14217.94,
Drainage of ovarian cyst(s),58800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4370.25,,,,,,,fee schedule,3204.65,14217.94,
Drainage of ovarian cyst(s),58800,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14217.94,,,,,,,fee schedule,3204.65,14217.94,APC 378
Drainage of ovarian cyst(s),58800,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3364.88,,,,,,,fee schedule,3204.65,14217.94,APC
Drainage of ovarian cyst(s),58800,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3332.84,,,,,,,fee schedule,3204.65,14217.94,APC
Drainage of ovarian cyst(s),58800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3204.65,,,,,,,fee schedule,3204.65,14217.94,APC
Drainage of ovarian cyst(s),58800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4903.11,,,,,,,fee schedule,3204.65,14217.94,Radiology
Drainage of ovarian cyst(s),58800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4486.51,,,,,,,fee schedule,3204.65,14217.94,APC
Drainage of ovarian cyst(s),58800,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5608.14,,,,,,,fee schedule,3204.65,14217.94,APC
Drainage of ovarian cyst(s),58805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8092.19,,,,,,,fee schedule,3204.65,14217.94,
Drainage of ovarian cyst(s),58805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6486.59,,,,,,,fee schedule,3204.65,14217.94,
Drainage of ovarian cyst(s),58805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7086.01,,,,,,,fee schedule,3204.65,14217.94,
Drainage of ovarian cyst(s),58805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7449.95,,,,,,,fee schedule,3204.65,14217.94,
Drainage of ovarian cyst(s),58805,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14217.94,,,,,,,fee schedule,3204.65,14217.94,APC 378
Drainage of ovarian cyst(s),58805,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3364.88,,,,,,,fee schedule,3204.65,14217.94,APC
Drainage of ovarian cyst(s),58805,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3332.84,,,,,,,fee schedule,3204.65,14217.94,APC
Drainage of ovarian cyst(s),58805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3204.65,,,,,,,fee schedule,3204.65,14217.94,APC
Drainage of ovarian cyst(s),58805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4903.11,,,,,,,fee schedule,3204.65,14217.94,Radiology
Drainage of ovarian cyst(s),58805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4486.51,,,,,,,fee schedule,3204.65,14217.94,APC
Drainage of ovarian cyst(s),58805,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5608.14,,,,,,,fee schedule,3204.65,14217.94,APC
Drain ovary abscess open,58820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8092.19,,,,,,,fee schedule,3204.65,14217.94,
Drain ovary abscess open,58820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6486.59,,,,,,,fee schedule,3204.65,14217.94,
Drain ovary abscess open,58820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7086.01,,,,,,,fee schedule,3204.65,14217.94,
Drain ovary abscess open,58820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7449.95,,,,,,,fee schedule,3204.65,14217.94,
Drain ovary abscess open,58820,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14217.94,,,,,,,fee schedule,3204.65,14217.94,APC 378
Drain ovary abscess open,58820,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3364.88,,,,,,,fee schedule,3204.65,14217.94,APC
Drain ovary abscess open,58820,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3332.84,,,,,,,fee schedule,3204.65,14217.94,APC
Drain ovary abscess open,58820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3204.65,,,,,,,fee schedule,3204.65,14217.94,APC
Drain ovary abscess open,58820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4903.11,,,,,,,fee schedule,3204.65,14217.94,Radiology
Drain ovary abscess open,58820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4486.51,,,,,,,fee schedule,3204.65,14217.94,APC
Drain ovary abscess open,58820,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5608.14,,,,,,,fee schedule,3204.65,14217.94,APC
Biopsy of ovary(s),58900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4747,,,,,,,fee schedule,3204.65,14217.94,
Biopsy of ovary(s),58900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3805.13,,,,,,,fee schedule,3204.65,14217.94,
Biopsy of ovary(s),58900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4156.76,,,,,,,fee schedule,3204.65,14217.94,
Biopsy of ovary(s),58900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4370.25,,,,,,,fee schedule,3204.65,14217.94,
Biopsy of ovary(s),58900,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14217.94,,,,,,,fee schedule,3204.65,14217.94,APC 378
Biopsy of ovary(s),58900,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3364.88,,,,,,,fee schedule,3204.65,14217.94,APC
Biopsy of ovary(s),58900,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3332.84,,,,,,,fee schedule,3204.65,14217.94,APC
Biopsy of ovary(s),58900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3204.65,,,,,,,fee schedule,3204.65,14217.94,APC
Biopsy of ovary(s),58900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4903.11,,,,,,,fee schedule,3204.65,14217.94,Radiology
Biopsy of ovary(s),58900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4486.51,,,,,,,fee schedule,3204.65,14217.94,APC
Biopsy of ovary(s),58900,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5608.14,,,,,,,fee schedule,3204.65,14217.94,APC
Partial removal of ovary(s),58920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8092.19,,,,,,,fee schedule,6486.59,32569.71,
Partial removal of ovary(s),58920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6486.59,,,,,,,fee schedule,6486.59,32569.71,
Partial removal of ovary(s),58920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7086.01,,,,,,,fee schedule,6486.59,32569.71,
Partial removal of ovary(s),58920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7449.95,,,,,,,fee schedule,6486.59,32569.71,
Partial removal of ovary(s),58920,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,32569.71,,,,,,,fee schedule,6486.59,32569.71,APC 378
Partial removal of ovary(s),58920,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7708.09,,,,,,,fee schedule,6486.59,32569.71,APC
Partial removal of ovary(s),58920,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7634.68,,,,,,,fee schedule,6486.59,32569.71,APC
Partial removal of ovary(s),58920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7341.04,,,,,,,fee schedule,6486.59,32569.71,APC
Partial removal of ovary(s),58920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11231.79,,,,,,,fee schedule,6486.59,32569.71,Radiology
Partial removal of ovary(s),58920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10277.46,,,,,,,fee schedule,6486.59,32569.71,APC
Partial removal of ovary(s),58920,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12846.82,,,,,,,fee schedule,6486.59,32569.71,APC
Removal of ovarian cyst(s),58925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4619.66,,,,,,,fee schedule,3703.06,21971.51,
Removal of ovarian cyst(s),58925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3703.06,,,,,,,fee schedule,3703.06,21971.51,
Removal of ovarian cyst(s),58925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4045.26,,,,,,,fee schedule,3703.06,21971.51,
Removal of ovarian cyst(s),58925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4253.02,,,,,,,fee schedule,3703.06,21971.51,
Removal of ovarian cyst(s),58925,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21971.51,,,,,,,fee schedule,3703.06,21971.51,APC 378
Removal of ovarian cyst(s),58925,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5199.88,,,,,,,fee schedule,3703.06,21971.51,APC
Removal of ovarian cyst(s),58925,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5150.35,,,,,,,fee schedule,3703.06,21971.51,APC
Removal of ovarian cyst(s),58925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4952.26,,,,,,,fee schedule,3703.06,21971.51,APC
Removal of ovarian cyst(s),58925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7576.96,,,,,,,fee schedule,3703.06,21971.51,Radiology
Removal of ovarian cyst(s),58925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6933.17,,,,,,,fee schedule,3703.06,21971.51,APC
Removal of ovarian cyst(s),58925,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8666.46,,,,,,,fee schedule,3703.06,21971.51,APC
Retrieval of oocyte,58970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,688.41,,,,,,,fee schedule,551.82,4045.39,
Retrieval of oocyte,58970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,551.82,,,,,,,fee schedule,551.82,4045.39,
Retrieval of oocyte,58970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,602.82,,,,,,,fee schedule,551.82,4045.39,
Retrieval of oocyte,58970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,633.78,,,,,,,fee schedule,551.82,4045.39,
Retrieval of oocyte,58970,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4045.39,,,,,,,fee schedule,551.82,4045.39,APC 378
Retrieval of oocyte,58970,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,957.4,,,,,,,fee schedule,551.82,4045.39,APC
Retrieval of oocyte,58970,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,948.28,,,,,,,fee schedule,551.82,4045.39,APC
Retrieval of oocyte,58970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,911.81,,,,,,,fee schedule,551.82,4045.39,APC
Retrieval of oocyte,58970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1395.07,,,,,,,fee schedule,551.82,4045.39,Radiology
Retrieval of oocyte,58970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1276.53,,,,,,,fee schedule,551.82,4045.39,APC
Retrieval of oocyte,58970,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1595.67,,,,,,,fee schedule,551.82,4045.39,APC
Transfer of embryo,58974,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,688.41,,,,,,,fee schedule,551.82,4045.39,
Transfer of embryo,58974,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,551.82,,,,,,,fee schedule,551.82,4045.39,
Transfer of embryo,58974,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,602.82,,,,,,,fee schedule,551.82,4045.39,
Transfer of embryo,58974,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,633.78,,,,,,,fee schedule,551.82,4045.39,
Transfer of embryo,58974,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4045.39,,,,,,,fee schedule,551.82,4045.39,APC 378
Transfer of embryo,58974,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,957.4,,,,,,,fee schedule,551.82,4045.39,APC
Transfer of embryo,58974,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,948.28,,,,,,,fee schedule,551.82,4045.39,APC
Transfer of embryo,58974,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,911.81,,,,,,,fee schedule,551.82,4045.39,APC
Transfer of embryo,58974,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1395.07,,,,,,,fee schedule,551.82,4045.39,Radiology
Transfer of embryo,58974,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1276.53,,,,,,,fee schedule,551.82,4045.39,APC
Transfer of embryo,58974,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1595.67,,,,,,,fee schedule,551.82,4045.39,APC
Transfer of embryo,58976,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,688.41,,,,,,,fee schedule,301.67,1338.42,
Transfer of embryo,58976,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,551.82,,,,,,,fee schedule,301.67,1338.42,
Transfer of embryo,58976,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,602.82,,,,,,,fee schedule,301.67,1338.42,
Transfer of embryo,58976,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,633.78,,,,,,,fee schedule,301.67,1338.42,
Transfer of embryo,58976,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1338.42,,,,,,,fee schedule,301.67,1338.42,APC 378
Transfer of embryo,58976,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,316.76,,,,,,,fee schedule,301.67,1338.42,APC
Transfer of embryo,58976,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,313.74,,,,,,,fee schedule,301.67,1338.42,APC
Transfer of embryo,58976,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,301.67,,,,,,,fee schedule,301.67,1338.42,APC
Transfer of embryo,58976,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,461.56,,,,,,,fee schedule,301.67,1338.42,Radiology
Transfer of embryo,58976,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,422.34,,,,,,,fee schedule,301.67,1338.42,APC
Transfer of embryo,58976,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,527.93,,,,,,,fee schedule,301.67,1338.42,APC
Genital surgery procedure,58999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7615.6,,,,,,,fee schedule,200.14,7615.6,
Genital surgery procedure,58999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6104.57,,,,,,,fee schedule,200.14,7615.6,
Genital surgery procedure,58999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6668.69,,,,,,,fee schedule,200.14,7615.6,
Genital surgery procedure,58999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7011.19,,,,,,,fee schedule,200.14,7615.6,
Genital surgery procedure,58999,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,887.97,,,,,,,fee schedule,200.14,7615.6,APC 378
Genital surgery procedure,58999,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,210.15,,,,,,,fee schedule,200.14,7615.6,APC
Genital surgery procedure,58999,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,208.15,,,,,,,fee schedule,200.14,7615.6,APC
Genital surgery procedure,58999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,200.14,,,,,,,fee schedule,200.14,7615.6,APC
Genital surgery procedure,58999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,306.22,,,,,,,fee schedule,200.14,7615.6,Radiology
Genital surgery procedure,58999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,280.2,,,,,,,fee schedule,200.14,7615.6,APC
Genital surgery procedure,58999,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,350.25,,,,,,,fee schedule,200.14,7615.6,APC
Amniocentesis diagnostic,59000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,688.41,,,,,,,fee schedule,551.82,4045.39,
Amniocentesis diagnostic,59000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,551.82,,,,,,,fee schedule,551.82,4045.39,
Amniocentesis diagnostic,59000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,602.82,,,,,,,fee schedule,551.82,4045.39,
Amniocentesis diagnostic,59000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,633.78,,,,,,,fee schedule,551.82,4045.39,
Amniocentesis diagnostic,59000,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4045.39,,,,,,,fee schedule,551.82,4045.39,APC 378
Amniocentesis diagnostic,59000,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,957.4,,,,,,,fee schedule,551.82,4045.39,APC
Amniocentesis diagnostic,59000,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,948.28,,,,,,,fee schedule,551.82,4045.39,APC
Amniocentesis diagnostic,59000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,911.81,,,,,,,fee schedule,551.82,4045.39,APC
Amniocentesis diagnostic,59000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1395.07,,,,,,,fee schedule,551.82,4045.39,Radiology
Amniocentesis diagnostic,59000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1276.53,,,,,,,fee schedule,551.82,4045.39,APC
Amniocentesis diagnostic,59000,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1595.67,,,,,,,fee schedule,551.82,4045.39,APC
Amniocentesis therapeutic,59001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1516.99,,,,,,,fee schedule,301.67,1516.99,
Amniocentesis therapeutic,59001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1216,,,,,,,fee schedule,301.67,1516.99,
Amniocentesis therapeutic,59001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1328.37,,,,,,,fee schedule,301.67,1516.99,
Amniocentesis therapeutic,59001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1396.59,,,,,,,fee schedule,301.67,1516.99,
Amniocentesis therapeutic,59001,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1338.42,,,,,,,fee schedule,301.67,1516.99,APC 378
Amniocentesis therapeutic,59001,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,316.76,,,,,,,fee schedule,301.67,1516.99,APC
Amniocentesis therapeutic,59001,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,313.74,,,,,,,fee schedule,301.67,1516.99,APC
Amniocentesis therapeutic,59001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,301.67,,,,,,,fee schedule,301.67,1516.99,APC
Amniocentesis therapeutic,59001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,461.56,,,,,,,fee schedule,301.67,1516.99,Radiology
Amniocentesis therapeutic,59001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,422.34,,,,,,,fee schedule,301.67,1516.99,APC
Amniocentesis therapeutic,59001,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,527.93,,,,,,,fee schedule,301.67,1516.99,APC
Fetal cord puncture prenatal,59012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,688.41,,,,,,,fee schedule,301.67,1338.42,
Fetal cord puncture prenatal,59012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,551.82,,,,,,,fee schedule,301.67,1338.42,
Fetal cord puncture prenatal,59012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,602.82,,,,,,,fee schedule,301.67,1338.42,
Fetal cord puncture prenatal,59012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,633.78,,,,,,,fee schedule,301.67,1338.42,
Fetal cord puncture prenatal,59012,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1338.42,,,,,,,fee schedule,301.67,1338.42,APC 378
Fetal cord puncture prenatal,59012,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,316.76,,,,,,,fee schedule,301.67,1338.42,APC
Fetal cord puncture prenatal,59012,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,313.74,,,,,,,fee schedule,301.67,1338.42,APC
Fetal cord puncture prenatal,59012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,301.67,,,,,,,fee schedule,301.67,1338.42,APC
Fetal cord puncture prenatal,59012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,461.56,,,,,,,fee schedule,301.67,1338.42,Radiology
Fetal cord puncture prenatal,59012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,422.34,,,,,,,fee schedule,301.67,1338.42,APC
Fetal cord puncture prenatal,59012,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,527.93,,,,,,,fee schedule,301.67,1338.42,APC
Chorion biopsy,59015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,688.41,,,,,,,fee schedule,551.82,4045.39,
Chorion biopsy,59015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,551.82,,,,,,,fee schedule,551.82,4045.39,
Chorion biopsy,59015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,602.82,,,,,,,fee schedule,551.82,4045.39,
Chorion biopsy,59015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,633.78,,,,,,,fee schedule,551.82,4045.39,
Chorion biopsy,59015,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4045.39,,,,,,,fee schedule,551.82,4045.39,APC 378
Chorion biopsy,59015,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,957.4,,,,,,,fee schedule,551.82,4045.39,APC
Chorion biopsy,59015,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,948.28,,,,,,,fee schedule,551.82,4045.39,APC
Chorion biopsy,59015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,911.81,,,,,,,fee schedule,551.82,4045.39,APC
Chorion biopsy,59015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1395.07,,,,,,,fee schedule,551.82,4045.39,Radiology
Chorion biopsy,59015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1276.53,,,,,,,fee schedule,551.82,4045.39,APC
Chorion biopsy,59015,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1595.67,,,,,,,fee schedule,551.82,4045.39,APC
Fetal contract stress test,59020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,109.58,,,,,,,fee schedule,87.84,887.97,
Fetal contract stress test,59020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,87.84,,,,,,,fee schedule,87.84,887.97,
Fetal contract stress test,59020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,95.96,,,,,,,fee schedule,87.84,887.97,
Fetal contract stress test,59020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,100.89,,,,,,,fee schedule,87.84,887.97,
Fetal contract stress test,59020,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,887.97,,,,,,,fee schedule,87.84,887.97,APC 378
Fetal contract stress test,59020,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,210.15,,,,,,,fee schedule,87.84,887.97,APC
Fetal contract stress test,59020,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,208.15,,,,,,,fee schedule,87.84,887.97,APC
Fetal contract stress test,59020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,200.14,,,,,,,fee schedule,87.84,887.97,APC
Fetal contract stress test,59020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,306.22,,,,,,,fee schedule,87.84,887.97,Radiology
Fetal contract stress test,59020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,280.2,,,,,,,fee schedule,87.84,887.97,APC
Fetal contract stress test,59020,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,350.25,,,,,,,fee schedule,87.84,887.97,APC
Fetal non-stress test,59025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,52.73,,,,,,,fee schedule,42.27,887.97,
Fetal non-stress test,59025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.27,,,,,,,fee schedule,42.27,887.97,
Fetal non-stress test,59025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.17,,,,,,,fee schedule,42.27,887.97,
Fetal non-stress test,59025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,48.55,,,,,,,fee schedule,42.27,887.97,
Fetal non-stress test,59025,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,887.97,,,,,,,fee schedule,42.27,887.97,APC 378
Fetal non-stress test,59025,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,210.15,,,,,,,fee schedule,42.27,887.97,APC
Fetal non-stress test,59025,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,208.15,,,,,,,fee schedule,42.27,887.97,APC
Fetal non-stress test,59025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,200.14,,,,,,,fee schedule,42.27,887.97,APC
Fetal non-stress test,59025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,306.22,,,,,,,fee schedule,42.27,887.97,Radiology
Fetal non-stress test,59025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,280.2,,,,,,,fee schedule,42.27,887.97,APC
Fetal non-stress test,59025,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,350.25,,,,,,,fee schedule,42.27,887.97,APC
Fetal scalp blood sample,59030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,688.41,,,,,,,fee schedule,301.67,1338.42,
Fetal scalp blood sample,59030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,551.82,,,,,,,fee schedule,301.67,1338.42,
Fetal scalp blood sample,59030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,602.82,,,,,,,fee schedule,301.67,1338.42,
Fetal scalp blood sample,59030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,633.78,,,,,,,fee schedule,301.67,1338.42,
Fetal scalp blood sample,59030,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1338.42,,,,,,,fee schedule,301.67,1338.42,APC 378
Fetal scalp blood sample,59030,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,316.76,,,,,,,fee schedule,301.67,1338.42,APC
Fetal scalp blood sample,59030,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,313.74,,,,,,,fee schedule,301.67,1338.42,APC
Fetal scalp blood sample,59030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,301.67,,,,,,,fee schedule,301.67,1338.42,APC
Fetal scalp blood sample,59030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,461.56,,,,,,,fee schedule,301.67,1338.42,Radiology
Fetal scalp blood sample,59030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,422.34,,,,,,,fee schedule,301.67,1338.42,APC
Fetal scalp blood sample,59030,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,527.93,,,,,,,fee schedule,301.67,1338.42,APC
Fetal monitor/interpret only,59051,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,154.19,,,,,,,fee schedule,123.59,154.19,
Fetal monitor/interpret only,59051,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,123.59,,,,,,,fee schedule,123.59,154.19,
Fetal monitor/interpret only,59051,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,135.01,,,,,,,fee schedule,123.59,154.19,
Fetal monitor/interpret only,59051,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,141.95,,,,,,,fee schedule,123.59,154.19,
Transabdom amnioinfus w/us,59070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,688.41,,,,,,,fee schedule,301.67,1338.42,
Transabdom amnioinfus w/us,59070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,551.82,,,,,,,fee schedule,301.67,1338.42,
Transabdom amnioinfus w/us,59070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,602.82,,,,,,,fee schedule,301.67,1338.42,
Transabdom amnioinfus w/us,59070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,633.78,,,,,,,fee schedule,301.67,1338.42,
Transabdom amnioinfus w/us,59070,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1338.42,,,,,,,fee schedule,301.67,1338.42,APC 378
Transabdom amnioinfus w/us,59070,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,316.76,,,,,,,fee schedule,301.67,1338.42,APC
Transabdom amnioinfus w/us,59070,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,313.74,,,,,,,fee schedule,301.67,1338.42,APC
Transabdom amnioinfus w/us,59070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,301.67,,,,,,,fee schedule,301.67,1338.42,APC
Transabdom amnioinfus w/us,59070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,461.56,,,,,,,fee schedule,301.67,1338.42,Radiology
Transabdom amnioinfus w/us,59070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,422.34,,,,,,,fee schedule,301.67,1338.42,APC
Transabdom amnioinfus w/us,59070,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,527.93,,,,,,,fee schedule,301.67,1338.42,APC
Umbilical cord occlud w/us,59072,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,688.41,,,,,,,fee schedule,301.67,1338.42,
Umbilical cord occlud w/us,59072,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,551.82,,,,,,,fee schedule,301.67,1338.42,
Umbilical cord occlud w/us,59072,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,602.82,,,,,,,fee schedule,301.67,1338.42,
Umbilical cord occlud w/us,59072,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,633.78,,,,,,,fee schedule,301.67,1338.42,
Umbilical cord occlud w/us,59072,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1338.42,,,,,,,fee schedule,301.67,1338.42,APC 378
Umbilical cord occlud w/us,59072,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,316.76,,,,,,,fee schedule,301.67,1338.42,APC
Umbilical cord occlud w/us,59072,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,313.74,,,,,,,fee schedule,301.67,1338.42,APC
Umbilical cord occlud w/us,59072,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,301.67,,,,,,,fee schedule,301.67,1338.42,APC
Umbilical cord occlud w/us,59072,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,461.56,,,,,,,fee schedule,301.67,1338.42,Radiology
Umbilical cord occlud w/us,59072,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,422.34,,,,,,,fee schedule,301.67,1338.42,APC
Umbilical cord occlud w/us,59072,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,527.93,,,,,,,fee schedule,301.67,1338.42,APC
Fetal fluid drainage w/us,59074,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,688.41,,,,,,,fee schedule,301.67,1338.42,
Fetal fluid drainage w/us,59074,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,551.82,,,,,,,fee schedule,301.67,1338.42,
Fetal fluid drainage w/us,59074,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,602.82,,,,,,,fee schedule,301.67,1338.42,
Fetal fluid drainage w/us,59074,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,633.78,,,,,,,fee schedule,301.67,1338.42,
Fetal fluid drainage w/us,59074,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1338.42,,,,,,,fee schedule,301.67,1338.42,APC 378
Fetal fluid drainage w/us,59074,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,316.76,,,,,,,fee schedule,301.67,1338.42,APC
Fetal fluid drainage w/us,59074,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,313.74,,,,,,,fee schedule,301.67,1338.42,APC
Fetal fluid drainage w/us,59074,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,301.67,,,,,,,fee schedule,301.67,1338.42,APC
Fetal fluid drainage w/us,59074,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,461.56,,,,,,,fee schedule,301.67,1338.42,Radiology
Fetal fluid drainage w/us,59074,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,422.34,,,,,,,fee schedule,301.67,1338.42,APC
Fetal fluid drainage w/us,59074,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,527.93,,,,,,,fee schedule,301.67,1338.42,APC
Fetal shunt placement w/us,59076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,688.41,,,,,,,fee schedule,301.67,1338.42,
Fetal shunt placement w/us,59076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,551.82,,,,,,,fee schedule,301.67,1338.42,
Fetal shunt placement w/us,59076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,602.82,,,,,,,fee schedule,301.67,1338.42,
Fetal shunt placement w/us,59076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,633.78,,,,,,,fee schedule,301.67,1338.42,
Fetal shunt placement w/us,59076,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1338.42,,,,,,,fee schedule,301.67,1338.42,APC 378
Fetal shunt placement w/us,59076,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,316.76,,,,,,,fee schedule,301.67,1338.42,APC
Fetal shunt placement w/us,59076,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,313.74,,,,,,,fee schedule,301.67,1338.42,APC
Fetal shunt placement w/us,59076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,301.67,,,,,,,fee schedule,301.67,1338.42,APC
Fetal shunt placement w/us,59076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,461.56,,,,,,,fee schedule,301.67,1338.42,Radiology
Fetal shunt placement w/us,59076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,422.34,,,,,,,fee schedule,301.67,1338.42,APC
Fetal shunt placement w/us,59076,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,527.93,,,,,,,fee schedule,301.67,1338.42,APC
Remove uterus lesion,59100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8092.19,,,,,,,fee schedule,4952.26,21971.51,
Remove uterus lesion,59100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6486.59,,,,,,,fee schedule,4952.26,21971.51,
Remove uterus lesion,59100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7086.01,,,,,,,fee schedule,4952.26,21971.51,
Remove uterus lesion,59100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7449.95,,,,,,,fee schedule,4952.26,21971.51,
Remove uterus lesion,59100,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21971.51,,,,,,,fee schedule,4952.26,21971.51,APC 378
Remove uterus lesion,59100,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5199.88,,,,,,,fee schedule,4952.26,21971.51,APC
Remove uterus lesion,59100,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5150.35,,,,,,,fee schedule,4952.26,21971.51,APC
Remove uterus lesion,59100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4952.26,,,,,,,fee schedule,4952.26,21971.51,APC
Remove uterus lesion,59100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7576.96,,,,,,,fee schedule,4952.26,21971.51,Radiology
Remove uterus lesion,59100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6933.17,,,,,,,fee schedule,4952.26,21971.51,APC
Remove uterus lesion,59100,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8666.46,,,,,,,fee schedule,4952.26,21971.51,APC
Treat ectopic pregnancy,59150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8594.03,,,,,,,fee schedule,5984.88,26552.87,
Treat ectopic pregnancy,59150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6888.87,,,,,,,fee schedule,5984.88,26552.87,
Treat ectopic pregnancy,59150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7525.46,,,,,,,fee schedule,5984.88,26552.87,
Treat ectopic pregnancy,59150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7911.97,,,,,,,fee schedule,5984.88,26552.87,
Treat ectopic pregnancy,59150,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,5984.88,26552.87,APC 378
Treat ectopic pregnancy,59150,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,5984.88,26552.87,APC
Treat ectopic pregnancy,59150,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,5984.88,26552.87,APC
Treat ectopic pregnancy,59150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,5984.88,26552.87,APC
Treat ectopic pregnancy,59150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,5984.88,26552.87,Radiology
Treat ectopic pregnancy,59150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,5984.88,26552.87,APC
Treat ectopic pregnancy,59150,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,5984.88,26552.87,APC
Treat ectopic pregnancy,59151,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8906.11,,,,,,,fee schedule,5984.88,26552.87,
Treat ectopic pregnancy,59151,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7139.02,,,,,,,fee schedule,5984.88,26552.87,
Treat ectopic pregnancy,59151,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7798.74,,,,,,,fee schedule,5984.88,26552.87,
Treat ectopic pregnancy,59151,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8199.27,,,,,,,fee schedule,5984.88,26552.87,
Treat ectopic pregnancy,59151,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,5984.88,26552.87,APC 378
Treat ectopic pregnancy,59151,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,5984.88,26552.87,APC
Treat ectopic pregnancy,59151,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,5984.88,26552.87,APC
Treat ectopic pregnancy,59151,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,5984.88,26552.87,APC
Treat ectopic pregnancy,59151,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,5984.88,26552.87,Radiology
Treat ectopic pregnancy,59151,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,5984.88,26552.87,APC
Treat ectopic pregnancy,59151,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,5984.88,26552.87,APC
D & c after delivery,59160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6253.46,,,,,,,fee schedule,3204.65,14217.94,
D & c after delivery,59160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5012.69,,,,,,,fee schedule,3204.65,14217.94,
D & c after delivery,59160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5475.91,,,,,,,fee schedule,3204.65,14217.94,
D & c after delivery,59160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5757.15,,,,,,,fee schedule,3204.65,14217.94,
D & c after delivery,59160,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14217.94,,,,,,,fee schedule,3204.65,14217.94,APC 378
D & c after delivery,59160,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3364.88,,,,,,,fee schedule,3204.65,14217.94,APC
D & c after delivery,59160,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3332.84,,,,,,,fee schedule,3204.65,14217.94,APC
D & c after delivery,59160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3204.65,,,,,,,fee schedule,3204.65,14217.94,APC
D & c after delivery,59160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4903.11,,,,,,,fee schedule,3204.65,14217.94,Radiology
D & c after delivery,59160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4486.51,,,,,,,fee schedule,3204.65,14217.94,APC
D & c after delivery,59160,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5608.14,,,,,,,fee schedule,3204.65,14217.94,APC
Insert cervical dilator,59200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,688.41,,,,,,,fee schedule,301.67,1338.42,
Insert cervical dilator,59200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,551.82,,,,,,,fee schedule,301.67,1338.42,
Insert cervical dilator,59200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,602.82,,,,,,,fee schedule,301.67,1338.42,
Insert cervical dilator,59200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,633.78,,,,,,,fee schedule,301.67,1338.42,
Insert cervical dilator,59200,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1338.42,,,,,,,fee schedule,301.67,1338.42,APC 378
Insert cervical dilator,59200,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,316.76,,,,,,,fee schedule,301.67,1338.42,APC
Insert cervical dilator,59200,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,313.74,,,,,,,fee schedule,301.67,1338.42,APC
Insert cervical dilator,59200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,301.67,,,,,,,fee schedule,301.67,1338.42,APC
Insert cervical dilator,59200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,461.56,,,,,,,fee schedule,301.67,1338.42,Radiology
Insert cervical dilator,59200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,422.34,,,,,,,fee schedule,301.67,1338.42,APC
Insert cervical dilator,59200,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,527.93,,,,,,,fee schedule,301.67,1338.42,APC
Episiotomy or vaginal repair,59300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4747,,,,,,,fee schedule,3204.65,14217.94,
Episiotomy or vaginal repair,59300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3805.13,,,,,,,fee schedule,3204.65,14217.94,
Episiotomy or vaginal repair,59300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4156.76,,,,,,,fee schedule,3204.65,14217.94,
Episiotomy or vaginal repair,59300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4370.25,,,,,,,fee schedule,3204.65,14217.94,
Episiotomy or vaginal repair,59300,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14217.94,,,,,,,fee schedule,3204.65,14217.94,APC 378
Episiotomy or vaginal repair,59300,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3364.88,,,,,,,fee schedule,3204.65,14217.94,APC
Episiotomy or vaginal repair,59300,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3332.84,,,,,,,fee schedule,3204.65,14217.94,APC
Episiotomy or vaginal repair,59300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3204.65,,,,,,,fee schedule,3204.65,14217.94,APC
Episiotomy or vaginal repair,59300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4903.11,,,,,,,fee schedule,3204.65,14217.94,Radiology
Episiotomy or vaginal repair,59300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4486.51,,,,,,,fee schedule,3204.65,14217.94,APC
Episiotomy or vaginal repair,59300,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5608.14,,,,,,,fee schedule,3204.65,14217.94,APC
Revision of cervix,59320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6019.4,,,,,,,fee schedule,3204.65,14217.94,
Revision of cervix,59320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4825.07,,,,,,,fee schedule,3204.65,14217.94,
Revision of cervix,59320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5270.95,,,,,,,fee schedule,3204.65,14217.94,
Revision of cervix,59320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5541.67,,,,,,,fee schedule,3204.65,14217.94,
Revision of cervix,59320,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14217.94,,,,,,,fee schedule,3204.65,14217.94,APC 378
Revision of cervix,59320,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3364.88,,,,,,,fee schedule,3204.65,14217.94,APC
Revision of cervix,59320,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3332.84,,,,,,,fee schedule,3204.65,14217.94,APC
Revision of cervix,59320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3204.65,,,,,,,fee schedule,3204.65,14217.94,APC
Revision of cervix,59320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4903.11,,,,,,,fee schedule,3204.65,14217.94,Radiology
Revision of cervix,59320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4486.51,,,,,,,fee schedule,3204.65,14217.94,APC
Revision of cervix,59320,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5608.14,,,,,,,fee schedule,3204.65,14217.94,APC
Obstetrical care,59400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6260.32,,,,,,,fee schedule,5018.2,6260.32,
Obstetrical care,59400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5018.2,,,,,,,fee schedule,5018.2,6260.32,
Obstetrical care,59400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5481.92,,,,,,,fee schedule,5018.2,6260.32,
Obstetrical care,59400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5763.47,,,,,,,fee schedule,5018.2,6260.32,
Obstetrical care,59409,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4747,,,,,,,fee schedule,3204.65,14217.94,
Obstetrical care,59409,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3805.13,,,,,,,fee schedule,3204.65,14217.94,
Obstetrical care,59409,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4156.76,,,,,,,fee schedule,3204.65,14217.94,
Obstetrical care,59409,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4370.25,,,,,,,fee schedule,3204.65,14217.94,
Obstetrical care,59409,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14217.94,,,,,,,fee schedule,3204.65,14217.94,APC 378
Obstetrical care,59409,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3364.88,,,,,,,fee schedule,3204.65,14217.94,APC
Obstetrical care,59409,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3332.84,,,,,,,fee schedule,3204.65,14217.94,APC
Obstetrical care,59409,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3204.65,,,,,,,fee schedule,3204.65,14217.94,APC
Obstetrical care,59409,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4903.11,,,,,,,fee schedule,3204.65,14217.94,Radiology
Obstetrical care,59409,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4486.51,,,,,,,fee schedule,3204.65,14217.94,APC
Obstetrical care,59409,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5608.14,,,,,,,fee schedule,3204.65,14217.94,APC
Obstetrical care,59410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3276.62,,,,,,,fee schedule,2626.49,3276.62,
Obstetrical care,59410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2626.49,,,,,,,fee schedule,2626.49,3276.62,
Obstetrical care,59410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2869.21,,,,,,,fee schedule,2626.49,3276.62,
Obstetrical care,59410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3016.57,,,,,,,fee schedule,2626.49,3276.62,
Antepartum manipulation,59412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2705.75,,,,,,,fee schedule,2168.89,14217.94,
Antepartum manipulation,59412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2168.89,,,,,,,fee schedule,2168.89,14217.94,
Antepartum manipulation,59412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2369.32,,,,,,,fee schedule,2168.89,14217.94,
Antepartum manipulation,59412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2491.01,,,,,,,fee schedule,2168.89,14217.94,
Antepartum manipulation,59412,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14217.94,,,,,,,fee schedule,2168.89,14217.94,APC 378
Antepartum manipulation,59412,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3364.88,,,,,,,fee schedule,2168.89,14217.94,APC
Antepartum manipulation,59412,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3332.84,,,,,,,fee schedule,2168.89,14217.94,APC
Antepartum manipulation,59412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3204.65,,,,,,,fee schedule,2168.89,14217.94,APC
Antepartum manipulation,59412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4903.11,,,,,,,fee schedule,2168.89,14217.94,Radiology
Antepartum manipulation,59412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4486.51,,,,,,,fee schedule,2168.89,14217.94,APC
Antepartum manipulation,59412,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5608.14,,,,,,,fee schedule,2168.89,14217.94,APC
Deliver placenta,59414,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4747,,,,,,,fee schedule,3204.65,14217.94,
Deliver placenta,59414,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3805.13,,,,,,,fee schedule,3204.65,14217.94,
Deliver placenta,59414,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4156.76,,,,,,,fee schedule,3204.65,14217.94,
Deliver placenta,59414,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4370.25,,,,,,,fee schedule,3204.65,14217.94,
Deliver placenta,59414,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14217.94,,,,,,,fee schedule,3204.65,14217.94,APC 378
Deliver placenta,59414,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3364.88,,,,,,,fee schedule,3204.65,14217.94,APC
Deliver placenta,59414,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3332.84,,,,,,,fee schedule,3204.65,14217.94,APC
Deliver placenta,59414,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3204.65,,,,,,,fee schedule,3204.65,14217.94,APC
Deliver placenta,59414,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4903.11,,,,,,,fee schedule,3204.65,14217.94,Radiology
Deliver placenta,59414,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4486.51,,,,,,,fee schedule,3204.65,14217.94,APC
Deliver placenta,59414,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5608.14,,,,,,,fee schedule,3204.65,14217.94,APC
Antepartum care only,59425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1239.16,,,,,,,fee schedule,993.29,1239.16,
Antepartum care only,59425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,993.29,,,,,,,fee schedule,993.29,1239.16,
Antepartum care only,59425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1085.08,,,,,,,fee schedule,993.29,1239.16,
Antepartum care only,59425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1140.81,,,,,,,fee schedule,993.29,1239.16,
Antepartum care only,59426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2190.43,,,,,,,fee schedule,1755.82,2190.43,
Antepartum care only,59426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1755.82,,,,,,,fee schedule,1755.82,2190.43,
Antepartum care only,59426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1918.08,,,,,,,fee schedule,1755.82,2190.43,
Antepartum care only,59426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2016.59,,,,,,,fee schedule,1755.82,2190.43,
Care after delivery,59430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,460.93,,,,,,,fee schedule,369.48,460.93,
Care after delivery,59430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,369.48,,,,,,,fee schedule,369.48,460.93,
Care after delivery,59430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,403.62,,,,,,,fee schedule,369.48,460.93,
Care after delivery,59430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,424.35,,,,,,,fee schedule,369.48,460.93,
Cesarean delivery,59510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7090.41,,,,,,,fee schedule,5683.58,7090.41,
Cesarean delivery,59510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5683.58,,,,,,,fee schedule,5683.58,7090.41,
Cesarean delivery,59510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6208.8,,,,,,,fee schedule,5683.58,7090.41,
Cesarean delivery,59510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6527.68,,,,,,,fee schedule,5683.58,7090.41,
Cesarean delivery,59515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3936.45,,,,,,,fee schedule,3155.41,3936.45,
Cesarean delivery,59515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3155.41,,,,,,,fee schedule,3155.41,3936.45,
Cesarean delivery,59515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3447,,,,,,,fee schedule,3155.41,3936.45,
Cesarean delivery,59515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3624.04,,,,,,,fee schedule,3155.41,3936.45,
Vbac delivery,59610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6597.65,,,,,,,fee schedule,5288.59,6597.65,
Vbac delivery,59610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5288.59,,,,,,,fee schedule,5288.59,6597.65,
Vbac delivery,59610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5777.31,,,,,,,fee schedule,5288.59,6597.65,
Vbac delivery,59610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6074.03,,,,,,,fee schedule,5288.59,6597.65,
Vbac delivery only,59612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4747,,,,,,,fee schedule,3204.65,14217.94,
Vbac delivery only,59612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3805.13,,,,,,,fee schedule,3204.65,14217.94,
Vbac delivery only,59612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4156.76,,,,,,,fee schedule,3204.65,14217.94,
Vbac delivery only,59612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4370.25,,,,,,,fee schedule,3204.65,14217.94,
Vbac delivery only,59612,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14217.94,,,,,,,fee schedule,3204.65,14217.94,APC 378
Vbac delivery only,59612,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3364.88,,,,,,,fee schedule,3204.65,14217.94,APC
Vbac delivery only,59612,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3332.84,,,,,,,fee schedule,3204.65,14217.94,APC
Vbac delivery only,59612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3204.65,,,,,,,fee schedule,3204.65,14217.94,APC
Vbac delivery only,59612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4903.11,,,,,,,fee schedule,3204.65,14217.94,Radiology
Vbac delivery only,59612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4486.51,,,,,,,fee schedule,3204.65,14217.94,APC
Vbac delivery only,59612,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5608.14,,,,,,,fee schedule,3204.65,14217.94,APC
Vbac care after delivery,59614,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3549.16,,,,,,,fee schedule,2844.96,3549.16,
Vbac care after delivery,59614,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2844.96,,,,,,,fee schedule,2844.96,3549.16,
Vbac care after delivery,59614,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3107.86,,,,,,,fee schedule,2844.96,3549.16,
Vbac care after delivery,59614,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3267.48,,,,,,,fee schedule,2844.96,3549.16,
Attempted vbac delivery,59618,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7423.01,,,,,,,fee schedule,5950.19,7423.01,
Attempted vbac delivery,59618,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5950.19,,,,,,,fee schedule,5950.19,7423.01,
Attempted vbac delivery,59618,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6500.05,,,,,,,fee schedule,5950.19,7423.01,
Attempted vbac delivery,59618,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6833.88,,,,,,,fee schedule,5950.19,7423.01,
Attempted vbac after care,59622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4268.15,,,,,,,fee schedule,3421.29,4268.15,
Attempted vbac after care,59622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3421.29,,,,,,,fee schedule,3421.29,4268.15,
Attempted vbac after care,59622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3737.45,,,,,,,fee schedule,3421.29,4268.15,
Attempted vbac after care,59622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3929.41,,,,,,,fee schedule,3421.29,4268.15,
Treatment of miscarriage,59812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6440.7,,,,,,,fee schedule,3204.65,14217.94,
Treatment of miscarriage,59812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5162.78,,,,,,,fee schedule,3204.65,14217.94,
Treatment of miscarriage,59812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5639.87,,,,,,,fee schedule,3204.65,14217.94,
Treatment of miscarriage,59812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5929.53,,,,,,,fee schedule,3204.65,14217.94,
Treatment of miscarriage,59812,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14217.94,,,,,,,fee schedule,3204.65,14217.94,APC 378
Treatment of miscarriage,59812,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3364.88,,,,,,,fee schedule,3204.65,14217.94,APC
Treatment of miscarriage,59812,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3332.84,,,,,,,fee schedule,3204.65,14217.94,APC
Treatment of miscarriage,59812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3204.65,,,,,,,fee schedule,3204.65,14217.94,APC
Treatment of miscarriage,59812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4903.11,,,,,,,fee schedule,3204.65,14217.94,Radiology
Treatment of miscarriage,59812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4486.51,,,,,,,fee schedule,3204.65,14217.94,APC
Treatment of miscarriage,59812,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5608.14,,,,,,,fee schedule,3204.65,14217.94,APC
Care of miscarriage,59820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6487.51,,,,,,,fee schedule,3204.65,14217.94,
Care of miscarriage,59820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5200.31,,,,,,,fee schedule,3204.65,14217.94,
Care of miscarriage,59820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5680.86,,,,,,,fee schedule,3204.65,14217.94,
Care of miscarriage,59820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5972.63,,,,,,,fee schedule,3204.65,14217.94,
Care of miscarriage,59820,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14217.94,,,,,,,fee schedule,3204.65,14217.94,APC 378
Care of miscarriage,59820,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3364.88,,,,,,,fee schedule,3204.65,14217.94,APC
Care of miscarriage,59820,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3332.84,,,,,,,fee schedule,3204.65,14217.94,APC
Care of miscarriage,59820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3204.65,,,,,,,fee schedule,3204.65,14217.94,APC
Care of miscarriage,59820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4903.11,,,,,,,fee schedule,3204.65,14217.94,Radiology
Care of miscarriage,59820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4486.51,,,,,,,fee schedule,3204.65,14217.94,APC
Care of miscarriage,59820,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5608.14,,,,,,,fee schedule,3204.65,14217.94,APC
Treatment of miscarriage,59821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4747,,,,,,,fee schedule,3204.65,14217.94,
Treatment of miscarriage,59821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3805.13,,,,,,,fee schedule,3204.65,14217.94,
Treatment of miscarriage,59821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4156.76,,,,,,,fee schedule,3204.65,14217.94,
Treatment of miscarriage,59821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4370.25,,,,,,,fee schedule,3204.65,14217.94,
Treatment of miscarriage,59821,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14217.94,,,,,,,fee schedule,3204.65,14217.94,APC 378
Treatment of miscarriage,59821,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3364.88,,,,,,,fee schedule,3204.65,14217.94,APC
Treatment of miscarriage,59821,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3332.84,,,,,,,fee schedule,3204.65,14217.94,APC
Treatment of miscarriage,59821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3204.65,,,,,,,fee schedule,3204.65,14217.94,APC
Treatment of miscarriage,59821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4903.11,,,,,,,fee schedule,3204.65,14217.94,Radiology
Treatment of miscarriage,59821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4486.51,,,,,,,fee schedule,3204.65,14217.94,APC
Treatment of miscarriage,59821,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5608.14,,,,,,,fee schedule,3204.65,14217.94,APC
Abortion,59840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4747,,,,,,,fee schedule,3204.65,14217.94,
Abortion,59840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3805.13,,,,,,,fee schedule,3204.65,14217.94,
Abortion,59840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4156.76,,,,,,,fee schedule,3204.65,14217.94,
Abortion,59840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4370.25,,,,,,,fee schedule,3204.65,14217.94,
Abortion,59840,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14217.94,,,,,,,fee schedule,3204.65,14217.94,APC 378
Abortion,59840,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3364.88,,,,,,,fee schedule,3204.65,14217.94,APC
Abortion,59840,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3332.84,,,,,,,fee schedule,3204.65,14217.94,APC
Abortion,59840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3204.65,,,,,,,fee schedule,3204.65,14217.94,APC
Abortion,59840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4903.11,,,,,,,fee schedule,3204.65,14217.94,Radiology
Abortion,59840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4486.51,,,,,,,fee schedule,3204.65,14217.94,APC
Abortion,59840,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5608.14,,,,,,,fee schedule,3204.65,14217.94,APC
Abortion,59841,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4747,,,,,,,fee schedule,3204.65,14217.94,
Abortion,59841,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3805.13,,,,,,,fee schedule,3204.65,14217.94,
Abortion,59841,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4156.76,,,,,,,fee schedule,3204.65,14217.94,
Abortion,59841,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4370.25,,,,,,,fee schedule,3204.65,14217.94,
Abortion,59841,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14217.94,,,,,,,fee schedule,3204.65,14217.94,APC 378
Abortion,59841,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3364.88,,,,,,,fee schedule,3204.65,14217.94,APC
Abortion,59841,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3332.84,,,,,,,fee schedule,3204.65,14217.94,APC
Abortion,59841,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3204.65,,,,,,,fee schedule,3204.65,14217.94,APC
Abortion,59841,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4903.11,,,,,,,fee schedule,3204.65,14217.94,Radiology
Abortion,59841,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4486.51,,,,,,,fee schedule,3204.65,14217.94,APC
Abortion,59841,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5608.14,,,,,,,fee schedule,3204.65,14217.94,APC
Abortion (mpr),59866,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,688.41,,,,,,,fee schedule,301.67,1338.42,
Abortion (mpr),59866,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,551.82,,,,,,,fee schedule,301.67,1338.42,
Abortion (mpr),59866,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,602.82,,,,,,,fee schedule,301.67,1338.42,
Abortion (mpr),59866,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,633.78,,,,,,,fee schedule,301.67,1338.42,
Abortion (mpr),59866,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1338.42,,,,,,,fee schedule,301.67,1338.42,APC 378
Abortion (mpr),59866,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,316.76,,,,,,,fee schedule,301.67,1338.42,APC
Abortion (mpr),59866,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,313.74,,,,,,,fee schedule,301.67,1338.42,APC
Abortion (mpr),59866,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,301.67,,,,,,,fee schedule,301.67,1338.42,APC
Abortion (mpr),59866,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,461.56,,,,,,,fee schedule,301.67,1338.42,Radiology
Abortion (mpr),59866,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,422.34,,,,,,,fee schedule,301.67,1338.42,APC
Abortion (mpr),59866,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,527.93,,,,,,,fee schedule,301.67,1338.42,APC
Evacuate mole of uterus,59870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4747,,,,,,,fee schedule,3204.65,14217.94,
Evacuate mole of uterus,59870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3805.13,,,,,,,fee schedule,3204.65,14217.94,
Evacuate mole of uterus,59870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4156.76,,,,,,,fee schedule,3204.65,14217.94,
Evacuate mole of uterus,59870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4370.25,,,,,,,fee schedule,3204.65,14217.94,
Evacuate mole of uterus,59870,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14217.94,,,,,,,fee schedule,3204.65,14217.94,APC 378
Evacuate mole of uterus,59870,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3364.88,,,,,,,fee schedule,3204.65,14217.94,APC
Evacuate mole of uterus,59870,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3332.84,,,,,,,fee schedule,3204.65,14217.94,APC
Evacuate mole of uterus,59870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3204.65,,,,,,,fee schedule,3204.65,14217.94,APC
Evacuate mole of uterus,59870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4903.11,,,,,,,fee schedule,3204.65,14217.94,Radiology
Evacuate mole of uterus,59870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4486.51,,,,,,,fee schedule,3204.65,14217.94,APC
Evacuate mole of uterus,59870,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5608.14,,,,,,,fee schedule,3204.65,14217.94,APC
Remove cerclage suture,59871,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4747,,,,,,,fee schedule,3204.65,14217.94,
Remove cerclage suture,59871,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3805.13,,,,,,,fee schedule,3204.65,14217.94,
Remove cerclage suture,59871,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4156.76,,,,,,,fee schedule,3204.65,14217.94,
Remove cerclage suture,59871,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4370.25,,,,,,,fee schedule,3204.65,14217.94,
Remove cerclage suture,59871,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14217.94,,,,,,,fee schedule,3204.65,14217.94,APC 378
Remove cerclage suture,59871,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3364.88,,,,,,,fee schedule,3204.65,14217.94,APC
Remove cerclage suture,59871,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3332.84,,,,,,,fee schedule,3204.65,14217.94,APC
Remove cerclage suture,59871,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3204.65,,,,,,,fee schedule,3204.65,14217.94,APC
Remove cerclage suture,59871,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4903.11,,,,,,,fee schedule,3204.65,14217.94,Radiology
Remove cerclage suture,59871,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4486.51,,,,,,,fee schedule,3204.65,14217.94,APC
Remove cerclage suture,59871,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5608.14,,,,,,,fee schedule,3204.65,14217.94,APC
Fetal invas px w/us,59897,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,688.41,,,,,,,fee schedule,200.14,887.97,
Fetal invas px w/us,59897,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,551.82,,,,,,,fee schedule,200.14,887.97,
Fetal invas px w/us,59897,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,602.82,,,,,,,fee schedule,200.14,887.97,
Fetal invas px w/us,59897,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,633.78,,,,,,,fee schedule,200.14,887.97,
Fetal invas px w/us,59897,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,887.97,,,,,,,fee schedule,200.14,887.97,APC 378
Fetal invas px w/us,59897,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,210.15,,,,,,,fee schedule,200.14,887.97,APC
Fetal invas px w/us,59897,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,208.15,,,,,,,fee schedule,200.14,887.97,APC
Fetal invas px w/us,59897,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,200.14,,,,,,,fee schedule,200.14,887.97,APC
Fetal invas px w/us,59897,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,306.22,,,,,,,fee schedule,200.14,887.97,Radiology
Fetal invas px w/us,59897,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,280.2,,,,,,,fee schedule,200.14,887.97,APC
Fetal invas px w/us,59897,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,350.25,,,,,,,fee schedule,200.14,887.97,APC
Laparo proc ob care/deliver,59898,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8584.34,,,,,,,fee schedule,5984.88,26552.87,
Laparo proc ob care/deliver,59898,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6881.1,,,,,,,fee schedule,5984.88,26552.87,
Laparo proc ob care/deliver,59898,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7516.98,,,,,,,fee schedule,5984.88,26552.87,
Laparo proc ob care/deliver,59898,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7903.05,,,,,,,fee schedule,5984.88,26552.87,
Laparo proc ob care/deliver,59898,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,5984.88,26552.87,APC 378
Laparo proc ob care/deliver,59898,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,5984.88,26552.87,APC
Laparo proc ob care/deliver,59898,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,5984.88,26552.87,APC
Laparo proc ob care/deliver,59898,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,5984.88,26552.87,APC
Laparo proc ob care/deliver,59898,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,5984.88,26552.87,Radiology
Laparo proc ob care/deliver,59898,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,5984.88,26552.87,APC
Laparo proc ob care/deliver,59898,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,5984.88,26552.87,APC
Maternity care procedure,59899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,32.7,,,,,,,fee schedule,26.21,887.97,
Maternity care procedure,59899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26.21,,,,,,,fee schedule,26.21,887.97,
Maternity care procedure,59899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28.63,,,,,,,fee schedule,26.21,887.97,
Maternity care procedure,59899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30.1,,,,,,,fee schedule,26.21,887.97,
Maternity care procedure,59899,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,887.97,,,,,,,fee schedule,26.21,887.97,APC 378
Maternity care procedure,59899,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,210.15,,,,,,,fee schedule,26.21,887.97,APC
Maternity care procedure,59899,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,208.15,,,,,,,fee schedule,26.21,887.97,APC
Maternity care procedure,59899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,200.14,,,,,,,fee schedule,26.21,887.97,APC
Maternity care procedure,59899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,306.22,,,,,,,fee schedule,26.21,887.97,Radiology
Maternity care procedure,59899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,280.2,,,,,,,fee schedule,26.21,887.97,APC
Maternity care procedure,59899,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,350.25,,,,,,,fee schedule,26.21,887.97,APC
Drain thyroid/tongue cyst,60000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1858.66,,,,,,,fee schedule,1489.88,6814.79,
Drain thyroid/tongue cyst,60000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1489.88,,,,,,,fee schedule,1489.88,6814.79,
Drain thyroid/tongue cyst,60000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1627.56,,,,,,,fee schedule,1489.88,6814.79,
Drain thyroid/tongue cyst,60000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1711.15,,,,,,,fee schedule,1489.88,6814.79,
Drain thyroid/tongue cyst,60000,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1489.88,6814.79,APC 378
Drain thyroid/tongue cyst,60000,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1489.88,6814.79,APC
Drain thyroid/tongue cyst,60000,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1489.88,6814.79,APC
Drain thyroid/tongue cyst,60000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1489.88,6814.79,APC
Drain thyroid/tongue cyst,60000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1489.88,6814.79,Radiology
Drain thyroid/tongue cyst,60000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1489.88,6814.79,APC
Drain thyroid/tongue cyst,60000,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1489.88,6814.79,APC
Biopsy of thyroid,60100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1079.91,,,,,,,fee schedule,701.03,3110.22,
Biopsy of thyroid,60100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,865.64,,,,,,,fee schedule,701.03,3110.22,
Biopsy of thyroid,60100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,945.63,,,,,,,fee schedule,701.03,3110.22,
Biopsy of thyroid,60100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,994.2,,,,,,,fee schedule,701.03,3110.22,
Biopsy of thyroid,60100,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3110.22,,,,,,,fee schedule,701.03,3110.22,APC 378
Biopsy of thyroid,60100,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,736.08,,,,,,,fee schedule,701.03,3110.22,APC
Biopsy of thyroid,60100,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,729.07,,,,,,,fee schedule,701.03,3110.22,APC
Biopsy of thyroid,60100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,701.03,,,,,,,fee schedule,701.03,3110.22,APC
Biopsy of thyroid,60100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1072.57,,,,,,,fee schedule,701.03,3110.22,Radiology
Biopsy of thyroid,60100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,981.44,,,,,,,fee schedule,701.03,3110.22,APC
Biopsy of thyroid,60100,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1226.8,,,,,,,fee schedule,701.03,3110.22,APC
Remove thyroid lesion,60200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5804.85,,,,,,,fee schedule,4653.09,26552.87,
Remove thyroid lesion,60200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4653.09,,,,,,,fee schedule,4653.09,26552.87,
Remove thyroid lesion,60200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5083.08,,,,,,,fee schedule,4653.09,26552.87,
Remove thyroid lesion,60200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5344.14,,,,,,,fee schedule,4653.09,26552.87,
Remove thyroid lesion,60200,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,4653.09,26552.87,APC 378
Remove thyroid lesion,60200,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,4653.09,26552.87,APC
Remove thyroid lesion,60200,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,4653.09,26552.87,APC
Remove thyroid lesion,60200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,4653.09,26552.87,APC
Remove thyroid lesion,60200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,4653.09,26552.87,Radiology
Remove thyroid lesion,60200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,4653.09,26552.87,APC
Remove thyroid lesion,60200,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,4653.09,26552.87,APC
Partial thyroid excision,60210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12077.81,,,,,,,fee schedule,5984.88,26552.87,
Partial thyroid excision,60210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9681.42,,,,,,,fee schedule,5984.88,26552.87,
Partial thyroid excision,60210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10576.07,,,,,,,fee schedule,5984.88,26552.87,
Partial thyroid excision,60210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11119.25,,,,,,,fee schedule,5984.88,26552.87,
Partial thyroid excision,60210,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,5984.88,26552.87,APC 378
Partial thyroid excision,60210,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,5984.88,26552.87,APC
Partial thyroid excision,60210,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,5984.88,26552.87,APC
Partial thyroid excision,60210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,5984.88,26552.87,APC
Partial thyroid excision,60210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,5984.88,26552.87,Radiology
Partial thyroid excision,60210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,5984.88,26552.87,APC
Partial thyroid excision,60210,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,5984.88,26552.87,APC
Partial thyroid excision,60212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11062.17,,,,,,,fee schedule,5984.88,26552.87,
Partial thyroid excision,60212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8867.3,,,,,,,fee schedule,5984.88,26552.87,
Partial thyroid excision,60212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9686.72,,,,,,,fee schedule,5984.88,26552.87,
Partial thyroid excision,60212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10184.22,,,,,,,fee schedule,5984.88,26552.87,
Partial thyroid excision,60212,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,5984.88,26552.87,APC 378
Partial thyroid excision,60212,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,5984.88,26552.87,APC
Partial thyroid excision,60212,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,5984.88,26552.87,APC
Partial thyroid excision,60212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,5984.88,26552.87,APC
Partial thyroid excision,60212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,5984.88,26552.87,Radiology
Partial thyroid excision,60212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,5984.88,26552.87,APC
Partial thyroid excision,60212,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,5984.88,26552.87,APC
Partial removal of thyroid,60220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11375.63,,,,,,,fee schedule,5984.88,26552.87,
Partial removal of thyroid,60220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9118.56,,,,,,,fee schedule,5984.88,26552.87,
Partial removal of thyroid,60220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9961.2,,,,,,,fee schedule,5984.88,26552.87,
Partial removal of thyroid,60220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10472.8,,,,,,,fee schedule,5984.88,26552.87,
Partial removal of thyroid,60220,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,5984.88,26552.87,APC 378
Partial removal of thyroid,60220,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,5984.88,26552.87,APC
Partial removal of thyroid,60220,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,5984.88,26552.87,APC
Partial removal of thyroid,60220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,5984.88,26552.87,APC
Partial removal of thyroid,60220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,5984.88,26552.87,Radiology
Partial removal of thyroid,60220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,5984.88,26552.87,APC
Partial removal of thyroid,60220,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,5984.88,26552.87,APC
Partial removal of thyroid,60225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11270.25,,,,,,,fee schedule,5984.88,26552.87,
Partial removal of thyroid,60225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9034.09,,,,,,,fee schedule,5984.88,26552.87,
Partial removal of thyroid,60225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9868.92,,,,,,,fee schedule,5984.88,26552.87,
Partial removal of thyroid,60225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10375.79,,,,,,,fee schedule,5984.88,26552.87,
Partial removal of thyroid,60225,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,5984.88,26552.87,APC 378
Partial removal of thyroid,60225,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,5984.88,26552.87,APC
Partial removal of thyroid,60225,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,5984.88,26552.87,APC
Partial removal of thyroid,60225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,5984.88,26552.87,APC
Partial removal of thyroid,60225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,5984.88,26552.87,Radiology
Partial removal of thyroid,60225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,5984.88,26552.87,APC
Partial removal of thyroid,60225,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,5984.88,26552.87,APC
Removal of thyroid,60240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10688.99,,,,,,,fee schedule,5984.88,26552.87,
Removal of thyroid,60240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8568.16,,,,,,,fee schedule,5984.88,26552.87,
Removal of thyroid,60240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9359.94,,,,,,,fee schedule,5984.88,26552.87,
Removal of thyroid,60240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9840.66,,,,,,,fee schedule,5984.88,26552.87,
Removal of thyroid,60240,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,5984.88,26552.87,APC 378
Removal of thyroid,60240,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,5984.88,26552.87,APC
Removal of thyroid,60240,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,5984.88,26552.87,APC
Removal of thyroid,60240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,5984.88,26552.87,APC
Removal of thyroid,60240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,5984.88,26552.87,Radiology
Removal of thyroid,60240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,5984.88,26552.87,APC
Removal of thyroid,60240,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,5984.88,26552.87,APC
Removal of thyroid,60252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6686.44,,,,,,,fee schedule,5359.77,26000.79,
Removal of thyroid,60252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5359.77,,,,,,,fee schedule,5359.77,26000.79,
Removal of thyroid,60252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5855.06,,,,,,,fee schedule,5359.77,26000.79,
Removal of thyroid,60252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6155.77,,,,,,,fee schedule,5359.77,26000.79,
Removal of thyroid,60252,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5359.77,26000.79,APC 378
Removal of thyroid,60252,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5359.77,26000.79,APC
Removal of thyroid,60252,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5359.77,26000.79,APC
Removal of thyroid,60252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5359.77,26000.79,APC
Removal of thyroid,60252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5359.77,26000.79,Radiology
Removal of thyroid,60252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5359.77,26000.79,APC
Removal of thyroid,60252,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5359.77,26000.79,APC
Extensive thyroid surgery,60254,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13224.61,,,,,,,fee schedule,10600.68,13224.61,
Extensive thyroid surgery,60254,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10600.68,,,,,,,fee schedule,10600.68,13224.61,
Extensive thyroid surgery,60254,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11580.28,,,,,,,fee schedule,10600.68,13224.61,
Extensive thyroid surgery,60254,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12175.04,,,,,,,fee schedule,10600.68,13224.61,
Repeat thyroid surgery,60260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7443.25,,,,,,,fee schedule,5860.44,26000.79,
Repeat thyroid surgery,60260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5966.41,,,,,,,fee schedule,5860.44,26000.79,
Repeat thyroid surgery,60260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6517.77,,,,,,,fee schedule,5860.44,26000.79,
Repeat thyroid surgery,60260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6852.51,,,,,,,fee schedule,5860.44,26000.79,
Repeat thyroid surgery,60260,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Repeat thyroid surgery,60260,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Repeat thyroid surgery,60260,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Repeat thyroid surgery,60260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Repeat thyroid surgery,60260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Repeat thyroid surgery,60260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Repeat thyroid surgery,60260,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of thyroid,60271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9994.58,,,,,,,fee schedule,5860.44,26000.79,
Removal of thyroid,60271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8011.53,,,,,,,fee schedule,5860.44,26000.79,
Removal of thyroid,60271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8751.87,,,,,,,fee schedule,5860.44,26000.79,
Removal of thyroid,60271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9201.36,,,,,,,fee schedule,5860.44,26000.79,
Removal of thyroid,60271,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Removal of thyroid,60271,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of thyroid,60271,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of thyroid,60271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of thyroid,60271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Removal of thyroid,60271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of thyroid,60271,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Remove thyroid duct lesion,60280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8359.97,,,,,,,fee schedule,5984.88,26552.87,
Remove thyroid duct lesion,60280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6701.25,,,,,,,fee schedule,5984.88,26552.87,
Remove thyroid duct lesion,60280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7320.51,,,,,,,fee schedule,5984.88,26552.87,
Remove thyroid duct lesion,60280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7696.48,,,,,,,fee schedule,5984.88,26552.87,
Remove thyroid duct lesion,60280,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,5984.88,26552.87,APC 378
Remove thyroid duct lesion,60280,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,5984.88,26552.87,APC
Remove thyroid duct lesion,60280,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,5984.88,26552.87,APC
Remove thyroid duct lesion,60280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,5984.88,26552.87,APC
Remove thyroid duct lesion,60280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,5984.88,26552.87,Radiology
Remove thyroid duct lesion,60280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,5984.88,26552.87,APC
Remove thyroid duct lesion,60280,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,5984.88,26552.87,APC
Remove thyroid duct lesion,60281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11062.17,,,,,,,fee schedule,5984.88,26552.87,
Remove thyroid duct lesion,60281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8867.3,,,,,,,fee schedule,5984.88,26552.87,
Remove thyroid duct lesion,60281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9686.72,,,,,,,fee schedule,5984.88,26552.87,
Remove thyroid duct lesion,60281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10184.22,,,,,,,fee schedule,5984.88,26552.87,
Remove thyroid duct lesion,60281,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,5984.88,26552.87,APC 378
Remove thyroid duct lesion,60281,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,5984.88,26552.87,APC
Remove thyroid duct lesion,60281,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,5984.88,26552.87,APC
Remove thyroid duct lesion,60281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,5984.88,26552.87,APC
Remove thyroid duct lesion,60281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,5984.88,26552.87,Radiology
Remove thyroid duct lesion,60281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,5984.88,26552.87,APC
Remove thyroid duct lesion,60281,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,5984.88,26552.87,APC
Aspir/inj thyroid cyst,60300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1079.91,,,,,,,fee schedule,701.03,3110.22,
Aspir/inj thyroid cyst,60300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,865.64,,,,,,,fee schedule,701.03,3110.22,
Aspir/inj thyroid cyst,60300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,945.63,,,,,,,fee schedule,701.03,3110.22,
Aspir/inj thyroid cyst,60300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,994.2,,,,,,,fee schedule,701.03,3110.22,
Aspir/inj thyroid cyst,60300,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3110.22,,,,,,,fee schedule,701.03,3110.22,APC 378
Aspir/inj thyroid cyst,60300,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,736.08,,,,,,,fee schedule,701.03,3110.22,APC
Aspir/inj thyroid cyst,60300,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,729.07,,,,,,,fee schedule,701.03,3110.22,APC
Aspir/inj thyroid cyst,60300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,701.03,,,,,,,fee schedule,701.03,3110.22,APC
Aspir/inj thyroid cyst,60300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1072.57,,,,,,,fee schedule,701.03,3110.22,Radiology
Aspir/inj thyroid cyst,60300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,981.44,,,,,,,fee schedule,701.03,3110.22,APC
Aspir/inj thyroid cyst,60300,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1226.8,,,,,,,fee schedule,701.03,3110.22,APC
Explore parathyroid glands,60500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12858,,,,,,,fee schedule,5860.44,26000.79,
Explore parathyroid glands,60500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10306.81,,,,,,,fee schedule,5860.44,26000.79,
Explore parathyroid glands,60500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11259.25,,,,,,,fee schedule,5860.44,26000.79,
Explore parathyroid glands,60500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11837.52,,,,,,,fee schedule,5860.44,26000.79,
Explore parathyroid glands,60500,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Explore parathyroid glands,60500,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Explore parathyroid glands,60500,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Explore parathyroid glands,60500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Explore parathyroid glands,60500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Explore parathyroid glands,60500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Explore parathyroid glands,60500,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Re-explore parathyroids,60502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11609.69,,,,,,,fee schedule,5860.44,26000.79,
Re-explore parathyroids,60502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9306.18,,,,,,,fee schedule,5860.44,26000.79,
Re-explore parathyroids,60502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10166.16,,,,,,,fee schedule,5860.44,26000.79,
Re-explore parathyroids,60502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10688.29,,,,,,,fee schedule,5860.44,26000.79,
Re-explore parathyroids,60502,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Re-explore parathyroids,60502,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Re-explore parathyroids,60502,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Re-explore parathyroids,60502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Re-explore parathyroids,60502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Re-explore parathyroids,60502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Re-explore parathyroids,60502,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Autotransplant parathyroid,60512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6369.69,,,,,,,fee schedule,5105.86,6369.69,
Autotransplant parathyroid,60512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5105.86,,,,,,,fee schedule,5105.86,6369.69,
Autotransplant parathyroid,60512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5577.69,,,,,,,fee schedule,5105.86,6369.69,
Autotransplant parathyroid,60512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5864.16,,,,,,,fee schedule,5105.86,6369.69,
Removal of thymus gland,60520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13482.15,,,,,,,fee schedule,5860.44,26000.79,
Removal of thymus gland,60520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10807.12,,,,,,,fee schedule,5860.44,26000.79,
Removal of thymus gland,60520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11805.8,,,,,,,fee schedule,5860.44,26000.79,
Removal of thymus gland,60520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12412.14,,,,,,,fee schedule,5860.44,26000.79,
Removal of thymus gland,60520,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Removal of thymus gland,60520,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of thymus gland,60520,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of thymus gland,60520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of thymus gland,60520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Removal of thymus gland,60520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Removal of thymus gland,60520,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Laparo proc endocrine,60659,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8584.34,,,,,,,fee schedule,5984.88,26552.87,
Laparo proc endocrine,60659,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6881.1,,,,,,,fee schedule,5984.88,26552.87,
Laparo proc endocrine,60659,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7516.98,,,,,,,fee schedule,5984.88,26552.87,
Laparo proc endocrine,60659,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7903.05,,,,,,,fee schedule,5984.88,26552.87,
Laparo proc endocrine,60659,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,5984.88,26552.87,APC 378
Laparo proc endocrine,60659,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,5984.88,26552.87,APC
Laparo proc endocrine,60659,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,5984.88,26552.87,APC
Laparo proc endocrine,60659,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,5984.88,26552.87,APC
Laparo proc endocrine,60659,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,5984.88,26552.87,Radiology
Laparo proc endocrine,60659,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,5984.88,26552.87,APC
Laparo proc endocrine,60659,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,5984.88,26552.87,APC
Abltj 1/+thyr ndul 1lobe prq,60660,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,7254.06,APC 378
Abltj 1/+thyr ndul 1lobe prq,60660,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,7254.06,APC
Abltj 1/+thyr ndul 1lobe prq,60660,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,7254.06,APC
Abltj 1/+thyr ndul 1lobe prq,60660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,7254.06,APC
Abltj 1/+thyr ndul 1lobe prq,60660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,7254.06,Radiology
Abltj 1/+thyr ndul 1lobe prq,60660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,7254.06,APC
Abltj 1/+thyr ndul 1lobe prq,60660,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,7254.06,APC
Endocrine surgery procedure,60699,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11062.17,,,,,,,fee schedule,5984.88,26552.87,
Endocrine surgery procedure,60699,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8867.3,,,,,,,fee schedule,5984.88,26552.87,
Endocrine surgery procedure,60699,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9686.72,,,,,,,fee schedule,5984.88,26552.87,
Endocrine surgery procedure,60699,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10184.22,,,,,,,fee schedule,5984.88,26552.87,
Endocrine surgery procedure,60699,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26552.87,,,,,,,fee schedule,5984.88,26552.87,APC 378
Endocrine surgery procedure,60699,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6284.12,,,,,,,fee schedule,5984.88,26552.87,APC
Endocrine surgery procedure,60699,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6224.27,,,,,,,fee schedule,5984.88,26552.87,APC
Endocrine surgery procedure,60699,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5984.88,,,,,,,fee schedule,5984.88,26552.87,APC
Endocrine surgery procedure,60699,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9156.86,,,,,,,fee schedule,5984.88,26552.87,Radiology
Endocrine surgery procedure,60699,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8378.83,,,,,,,fee schedule,5984.88,26552.87,APC
Endocrine surgery procedure,60699,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10473.53,,,,,,,fee schedule,5984.88,26552.87,APC
Remove cranial cavity fluid,61000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2127.95,,,,,,,fee schedule,698.8,3100.34,
Remove cranial cavity fluid,61000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1705.74,,,,,,,fee schedule,698.8,3100.34,
Remove cranial cavity fluid,61000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1863.36,,,,,,,fee schedule,698.8,3100.34,
Remove cranial cavity fluid,61000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1959.07,,,,,,,fee schedule,698.8,3100.34,
Remove cranial cavity fluid,61000,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3100.34,,,,,,,fee schedule,698.8,3100.34,APC 378
Remove cranial cavity fluid,61000,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,733.74,,,,,,,fee schedule,698.8,3100.34,APC
Remove cranial cavity fluid,61000,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,726.75,,,,,,,fee schedule,698.8,3100.34,APC
Remove cranial cavity fluid,61000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,698.8,,,,,,,fee schedule,698.8,3100.34,APC
Remove cranial cavity fluid,61000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1069.16,,,,,,,fee schedule,698.8,3100.34,Radiology
Remove cranial cavity fluid,61000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,978.32,,,,,,,fee schedule,698.8,3100.34,APC
Remove cranial cavity fluid,61000,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1222.9,,,,,,,fee schedule,698.8,3100.34,APC
Remove cranial cavity fluid,61001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2127.95,,,,,,,fee schedule,698.8,3100.34,
Remove cranial cavity fluid,61001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1705.74,,,,,,,fee schedule,698.8,3100.34,
Remove cranial cavity fluid,61001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1863.36,,,,,,,fee schedule,698.8,3100.34,
Remove cranial cavity fluid,61001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1959.07,,,,,,,fee schedule,698.8,3100.34,
Remove cranial cavity fluid,61001,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3100.34,,,,,,,fee schedule,698.8,3100.34,APC 378
Remove cranial cavity fluid,61001,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,733.74,,,,,,,fee schedule,698.8,3100.34,APC
Remove cranial cavity fluid,61001,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,726.75,,,,,,,fee schedule,698.8,3100.34,APC
Remove cranial cavity fluid,61001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,698.8,,,,,,,fee schedule,698.8,3100.34,APC
Remove cranial cavity fluid,61001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1069.16,,,,,,,fee schedule,698.8,3100.34,Radiology
Remove cranial cavity fluid,61001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,978.32,,,,,,,fee schedule,698.8,3100.34,APC
Remove cranial cavity fluid,61001,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1222.9,,,,,,,fee schedule,698.8,3100.34,APC
Remove brain cavity fluid,61020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2127.95,,,,,,,fee schedule,875.6,3884.74,
Remove brain cavity fluid,61020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1705.74,,,,,,,fee schedule,875.6,3884.74,
Remove brain cavity fluid,61020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1863.36,,,,,,,fee schedule,875.6,3884.74,
Remove brain cavity fluid,61020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1959.07,,,,,,,fee schedule,875.6,3884.74,
Remove brain cavity fluid,61020,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3884.74,,,,,,,fee schedule,875.6,3884.74,APC 378
Remove brain cavity fluid,61020,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,919.38,,,,,,,fee schedule,875.6,3884.74,APC
Remove brain cavity fluid,61020,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,910.62,,,,,,,fee schedule,875.6,3884.74,APC
Remove brain cavity fluid,61020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,875.6,,,,,,,fee schedule,875.6,3884.74,APC
Remove brain cavity fluid,61020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1339.67,,,,,,,fee schedule,875.6,3884.74,Radiology
Remove brain cavity fluid,61020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1225.84,,,,,,,fee schedule,875.6,3884.74,APC
Remove brain cavity fluid,61020,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1532.3,,,,,,,fee schedule,875.6,3884.74,APC
Injection into brain canal,61026,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2127.95,,,,,,,fee schedule,698.8,3100.34,
Injection into brain canal,61026,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1705.74,,,,,,,fee schedule,698.8,3100.34,
Injection into brain canal,61026,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1863.36,,,,,,,fee schedule,698.8,3100.34,
Injection into brain canal,61026,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1959.07,,,,,,,fee schedule,698.8,3100.34,
Injection into brain canal,61026,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3100.34,,,,,,,fee schedule,698.8,3100.34,APC 378
Injection into brain canal,61026,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,733.74,,,,,,,fee schedule,698.8,3100.34,APC
Injection into brain canal,61026,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,726.75,,,,,,,fee schedule,698.8,3100.34,APC
Injection into brain canal,61026,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,698.8,,,,,,,fee schedule,698.8,3100.34,APC
Injection into brain canal,61026,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1069.16,,,,,,,fee schedule,698.8,3100.34,Radiology
Injection into brain canal,61026,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,978.32,,,,,,,fee schedule,698.8,3100.34,APC
Injection into brain canal,61026,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1222.9,,,,,,,fee schedule,698.8,3100.34,APC
Remove brain canal fluid,61050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2127.95,,,,,,,fee schedule,303.87,2127.95,
Remove brain canal fluid,61050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1705.74,,,,,,,fee schedule,303.87,2127.95,
Remove brain canal fluid,61050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1863.36,,,,,,,fee schedule,303.87,2127.95,
Remove brain canal fluid,61050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1959.07,,,,,,,fee schedule,303.87,2127.95,
Remove brain canal fluid,61050,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1348.18,,,,,,,fee schedule,303.87,2127.95,APC 378
Remove brain canal fluid,61050,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,319.07,,,,,,,fee schedule,303.87,2127.95,APC
Remove brain canal fluid,61050,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,316.03,,,,,,,fee schedule,303.87,2127.95,APC
Remove brain canal fluid,61050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,303.87,,,,,,,fee schedule,303.87,2127.95,APC
Remove brain canal fluid,61050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,464.92,,,,,,,fee schedule,303.87,2127.95,Radiology
Remove brain canal fluid,61050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,425.42,,,,,,,fee schedule,303.87,2127.95,APC
Remove brain canal fluid,61050,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,531.78,,,,,,,fee schedule,303.87,2127.95,APC
Injection into brain canal,61055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2127.95,,,,,,,fee schedule,303.87,2127.95,
Injection into brain canal,61055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1705.74,,,,,,,fee schedule,303.87,2127.95,
Injection into brain canal,61055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1863.36,,,,,,,fee schedule,303.87,2127.95,
Injection into brain canal,61055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1959.07,,,,,,,fee schedule,303.87,2127.95,
Injection into brain canal,61055,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1348.18,,,,,,,fee schedule,303.87,2127.95,APC 378
Injection into brain canal,61055,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,319.07,,,,,,,fee schedule,303.87,2127.95,APC
Injection into brain canal,61055,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,316.03,,,,,,,fee schedule,303.87,2127.95,APC
Injection into brain canal,61055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,303.87,,,,,,,fee schedule,303.87,2127.95,APC
Injection into brain canal,61055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,464.92,,,,,,,fee schedule,303.87,2127.95,Radiology
Injection into brain canal,61055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,425.42,,,,,,,fee schedule,303.87,2127.95,APC
Injection into brain canal,61055,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,531.78,,,,,,,fee schedule,303.87,2127.95,APC
Brain canal shunt procedure,61070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,808.2,,,,,,,fee schedule,647.84,3100.34,
Brain canal shunt procedure,61070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,647.84,,,,,,,fee schedule,647.84,3100.34,
Brain canal shunt procedure,61070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,707.71,,,,,,,fee schedule,647.84,3100.34,
Brain canal shunt procedure,61070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,744.06,,,,,,,fee schedule,647.84,3100.34,
Brain canal shunt procedure,61070,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3100.34,,,,,,,fee schedule,647.84,3100.34,APC 378
Brain canal shunt procedure,61070,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,733.74,,,,,,,fee schedule,647.84,3100.34,APC
Brain canal shunt procedure,61070,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,726.75,,,,,,,fee schedule,647.84,3100.34,APC
Brain canal shunt procedure,61070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,698.8,,,,,,,fee schedule,647.84,3100.34,APC
Brain canal shunt procedure,61070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1069.16,,,,,,,fee schedule,647.84,3100.34,Radiology
Brain canal shunt procedure,61070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,978.32,,,,,,,fee schedule,647.84,3100.34,APC
Brain canal shunt procedure,61070,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1222.9,,,,,,,fee schedule,647.84,3100.34,APC
Insert brain-fluid device,61215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9053.78,,,,,,,fee schedule,7257.4,38544.86,
Insert brain-fluid device,61215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7257.4,,,,,,,fee schedule,7257.4,38544.86,
Insert brain-fluid device,61215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7928.05,,,,,,,fee schedule,7257.4,38544.86,
Insert brain-fluid device,61215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8335.23,,,,,,,fee schedule,7257.4,38544.86,
Insert brain-fluid device,61215,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,38544.86,,,,,,,fee schedule,7257.4,38544.86,APC 378
Insert brain-fluid device,61215,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9122.2,,,,,,,fee schedule,7257.4,38544.86,APC
Insert brain-fluid device,61215,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9035.32,,,,,,,fee schedule,7257.4,38544.86,APC
Insert brain-fluid device,61215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8687.81,,,,,,,fee schedule,7257.4,38544.86,APC
Insert brain-fluid device,61215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13292.34,,,,,,,fee schedule,7257.4,38544.86,Radiology
Insert brain-fluid device,61215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12162.93,,,,,,,fee schedule,7257.4,38544.86,APC
Insert brain-fluid device,61215,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15203.66,,,,,,,fee schedule,7257.4,38544.86,APC
Decompress eye socket,61330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,3282.2,14562,
Decompress eye socket,61330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,3282.2,14562,
Decompress eye socket,61330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,3282.2,14562,
Decompress eye socket,61330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,3282.2,14562,
Decompress eye socket,61330,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Decompress eye socket,61330,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Decompress eye socket,61330,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Decompress eye socket,61330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Decompress eye socket,61330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Decompress eye socket,61330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Decompress eye socket,61330,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Endovasc tempory vessel occl,61623,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21841.26,,,,,,,fee schedule,11428.37,50703.82,
Endovasc tempory vessel occl,61623,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17507.67,,,,,,,fee schedule,11428.37,50703.82,
Endovasc tempory vessel occl,61623,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19125.54,,,,,,,fee schedule,11428.37,50703.82,
Endovasc tempory vessel occl,61623,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20107.82,,,,,,,fee schedule,11428.37,50703.82,
Endovasc tempory vessel occl,61623,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,50703.82,,,,,,,fee schedule,11428.37,50703.82,APC 378
Endovasc tempory vessel occl,61623,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11999.79,,,,,,,fee schedule,11428.37,50703.82,APC
Endovasc tempory vessel occl,61623,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11885.51,,,,,,,fee schedule,11428.37,50703.82,APC
Endovasc tempory vessel occl,61623,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11428.37,,,,,,,fee schedule,11428.37,50703.82,APC
Endovasc tempory vessel occl,61623,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17485.41,,,,,,,fee schedule,11428.37,50703.82,Radiology
Endovasc tempory vessel occl,61623,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15999.72,,,,,,,fee schedule,11428.37,50703.82,APC
Endovasc tempory vessel occl,61623,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19999.65,,,,,,,fee schedule,11428.37,50703.82,APC
Transcath occlusion cns,61624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60721.92,,,,,,,fee schedule,18147.73,80515.32,
Transcath occlusion cns,61624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48673.92,,,,,,,fee schedule,18147.73,80515.32,
Transcath occlusion cns,61624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53171.84,,,,,,,fee schedule,18147.73,80515.32,
Transcath occlusion cns,61624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55902.72,,,,,,,fee schedule,18147.73,80515.32,
Transcath occlusion cns,61624,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,80515.32,,,,,,,fee schedule,18147.73,80515.32,APC 378
Transcath occlusion cns,61624,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19055.11,,,,,,,fee schedule,18147.73,80515.32,APC
Transcath occlusion cns,61624,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18873.64,,,,,,,fee schedule,18147.73,80515.32,APC
Transcath occlusion cns,61624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18147.73,,,,,,,fee schedule,18147.73,80515.32,APC
Transcath occlusion cns,61624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27766.02,,,,,,,fee schedule,18147.73,80515.32,Radiology
Transcath occlusion cns,61624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25406.82,,,,,,,fee schedule,18147.73,80515.32,APC
Transcath occlusion cns,61624,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31758.52,,,,,,,fee schedule,18147.73,80515.32,APC
Transcath occlusion non-cns,61626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21841.26,,,,,,,fee schedule,11428.37,50703.82,
Transcath occlusion non-cns,61626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17507.67,,,,,,,fee schedule,11428.37,50703.82,
Transcath occlusion non-cns,61626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19125.54,,,,,,,fee schedule,11428.37,50703.82,
Transcath occlusion non-cns,61626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20107.82,,,,,,,fee schedule,11428.37,50703.82,
Transcath occlusion non-cns,61626,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,50703.82,,,,,,,fee schedule,11428.37,50703.82,APC 378
Transcath occlusion non-cns,61626,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11999.79,,,,,,,fee schedule,11428.37,50703.82,APC
Transcath occlusion non-cns,61626,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11885.51,,,,,,,fee schedule,11428.37,50703.82,APC
Transcath occlusion non-cns,61626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11428.37,,,,,,,fee schedule,11428.37,50703.82,APC
Transcath occlusion non-cns,61626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17485.41,,,,,,,fee schedule,11428.37,50703.82,Radiology
Transcath occlusion non-cns,61626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15999.72,,,,,,,fee schedule,11428.37,50703.82,APC
Transcath occlusion non-cns,61626,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19999.65,,,,,,,fee schedule,11428.37,50703.82,APC
Perq art m-thrombect &/nfs,61645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3074.99,,,,,,,fee schedule,2464.87,3074.99,
Perq art m-thrombect &/nfs,61645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2464.87,,,,,,,fee schedule,2464.87,3074.99,
Perq art m-thrombect &/nfs,61645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2692.65,,,,,,,fee schedule,2464.87,3074.99,
Perq art m-thrombect &/nfs,61645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2830.95,,,,,,,fee schedule,2464.87,3074.99,
Evasc prlng admn rx agnt 1st,61650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2043.28,,,,,,,fee schedule,1637.87,2043.28,
Evasc prlng admn rx agnt 1st,61650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1637.87,,,,,,,fee schedule,1637.87,2043.28,
Evasc prlng admn rx agnt 1st,61650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1789.22,,,,,,,fee schedule,1637.87,2043.28,
Evasc prlng admn rx agnt 1st,61650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1881.11,,,,,,,fee schedule,1637.87,2043.28,
Evasc prlng admn rx agnt add,61651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,867.81,,,,,,,fee schedule,695.63,867.81,
Evasc prlng admn rx agnt add,61651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,695.63,,,,,,,fee schedule,695.63,867.81,
Evasc prlng admn rx agnt add,61651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,759.91,,,,,,,fee schedule,695.63,867.81,
Evasc prlng admn rx agnt add,61651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,798.94,,,,,,,fee schedule,695.63,867.81,
Incise skull/brain surgery,61720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8303.53,,,,,,,fee schedule,6656,38544.86,
Incise skull/brain surgery,61720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6656,,,,,,,fee schedule,6656,38544.86,
Incise skull/brain surgery,61720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7271.08,,,,,,,fee schedule,6656,38544.86,
Incise skull/brain surgery,61720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7644.52,,,,,,,fee schedule,6656,38544.86,
Incise skull/brain surgery,61720,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,38544.86,,,,,,,fee schedule,6656,38544.86,APC 378
Incise skull/brain surgery,61720,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9122.2,,,,,,,fee schedule,6656,38544.86,APC
Incise skull/brain surgery,61720,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9035.32,,,,,,,fee schedule,6656,38544.86,APC
Incise skull/brain surgery,61720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8687.81,,,,,,,fee schedule,6656,38544.86,APC
Incise skull/brain surgery,61720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13292.34,,,,,,,fee schedule,6656,38544.86,Radiology
Incise skull/brain surgery,61720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12162.93,,,,,,,fee schedule,6656,38544.86,APC
Incise skull/brain surgery,61720,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15203.66,,,,,,,fee schedule,6656,38544.86,APC
Incise skull for treatment,61770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8303.53,,,,,,,fee schedule,3381.88,15004.24,
Incise skull for treatment,61770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6656,,,,,,,fee schedule,3381.88,15004.24,
Incise skull for treatment,61770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7271.08,,,,,,,fee schedule,3381.88,15004.24,
Incise skull for treatment,61770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7644.52,,,,,,,fee schedule,3381.88,15004.24,
Incise skull for treatment,61770,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15004.24,,,,,,,fee schedule,3381.88,15004.24,APC 378
Incise skull for treatment,61770,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3550.97,,,,,,,fee schedule,3381.88,15004.24,APC
Incise skull for treatment,61770,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3517.15,,,,,,,fee schedule,3381.88,15004.24,APC
Incise skull for treatment,61770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3381.88,,,,,,,fee schedule,3381.88,15004.24,APC
Incise skull for treatment,61770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5174.27,,,,,,,fee schedule,3381.88,15004.24,Radiology
Incise skull for treatment,61770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4734.63,,,,,,,fee schedule,3381.88,15004.24,APC
Incise skull for treatment,61770,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5918.28,,,,,,,fee schedule,3381.88,15004.24,APC
Treat trigeminal nerve,61790,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4505.27,,,,,,,fee schedule,1933.13,8576.66,
Treat trigeminal nerve,61790,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3611.37,,,,,,,fee schedule,1933.13,8576.66,
Treat trigeminal nerve,61790,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3945.09,,,,,,,fee schedule,1933.13,8576.66,
Treat trigeminal nerve,61790,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4147.71,,,,,,,fee schedule,1933.13,8576.66,
Treat trigeminal nerve,61790,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8576.66,,,,,,,fee schedule,1933.13,8576.66,APC 378
Treat trigeminal nerve,61790,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2029.79,,,,,,,fee schedule,1933.13,8576.66,APC
Treat trigeminal nerve,61790,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2010.46,,,,,,,fee schedule,1933.13,8576.66,APC
Treat trigeminal nerve,61790,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1933.13,,,,,,,fee schedule,1933.13,8576.66,APC
Treat trigeminal nerve,61790,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2957.7,,,,,,,fee schedule,1933.13,8576.66,Radiology
Treat trigeminal nerve,61790,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2706.39,,,,,,,fee schedule,1933.13,8576.66,APC
Treat trigeminal nerve,61790,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3382.99,,,,,,,fee schedule,1933.13,8576.66,APC
Treat trigeminal tract,61791,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3615.8,,,,,,,fee schedule,1933.13,8576.66,
Treat trigeminal tract,61791,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2898.38,,,,,,,fee schedule,1933.13,8576.66,
Treat trigeminal tract,61791,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3166.21,,,,,,,fee schedule,1933.13,8576.66,
Treat trigeminal tract,61791,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3328.83,,,,,,,fee schedule,1933.13,8576.66,
Treat trigeminal tract,61791,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8576.66,,,,,,,fee schedule,1933.13,8576.66,APC 378
Treat trigeminal tract,61791,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2029.79,,,,,,,fee schedule,1933.13,8576.66,APC
Treat trigeminal tract,61791,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2010.46,,,,,,,fee schedule,1933.13,8576.66,APC
Treat trigeminal tract,61791,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1933.13,,,,,,,fee schedule,1933.13,8576.66,APC
Treat trigeminal tract,61791,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2957.7,,,,,,,fee schedule,1933.13,8576.66,Radiology
Treat trigeminal tract,61791,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2706.39,,,,,,,fee schedule,1933.13,8576.66,APC
Treat trigeminal tract,61791,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3382.99,,,,,,,fee schedule,1933.13,8576.66,APC
Srs cranial lesion simple,61796,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2696.65,,,,,,,fee schedule,2161.6,2696.65,
Srs cranial lesion simple,61796,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2161.6,,,,,,,fee schedule,2161.6,2696.65,
Srs cranial lesion simple,61796,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2361.35,,,,,,,fee schedule,2161.6,2696.65,
Srs cranial lesion simple,61796,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2482.63,,,,,,,fee schedule,2161.6,2696.65,
Srs cran les simple addl,61797,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,744.62,,,,,,,fee schedule,596.88,744.62,
Srs cran les simple addl,61797,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,596.88,,,,,,,fee schedule,596.88,744.62,
Srs cran les simple addl,61797,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,652.04,,,,,,,fee schedule,596.88,744.62,
Srs cran les simple addl,61797,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,685.53,,,,,,,fee schedule,596.88,744.62,
Srs cranial lesion complex,61798,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2696.65,,,,,,,fee schedule,2161.6,2696.65,
Srs cranial lesion complex,61798,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2161.6,,,,,,,fee schedule,2161.6,2696.65,
Srs cranial lesion complex,61798,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2361.35,,,,,,,fee schedule,2161.6,2696.65,
Srs cranial lesion complex,61798,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2482.63,,,,,,,fee schedule,2161.6,2696.65,
Srs cran les complex addl,61799,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1029.63,,,,,,,fee schedule,825.34,1029.63,
Srs cran les complex addl,61799,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,825.34,,,,,,,fee schedule,825.34,1029.63,
Srs cran les complex addl,61799,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,901.61,,,,,,,fee schedule,825.34,1029.63,
Srs cran les complex addl,61799,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,947.92,,,,,,,fee schedule,825.34,1029.63,
Apply srs headframe add-on,61800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,526.59,,,,,,,fee schedule,422.11,526.59,
Apply srs headframe add-on,61800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,422.11,,,,,,,fee schedule,422.11,526.59,
Apply srs headframe add-on,61800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,461.12,,,,,,,fee schedule,422.11,526.59,
Apply srs headframe add-on,61800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,484.8,,,,,,,fee schedule,422.11,526.59,
Revise/remove neuroelectrode,61880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5608.8,,,,,,,fee schedule,3461.03,15355.43,
Revise/remove neuroelectrode,61880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4495.94,,,,,,,fee schedule,3461.03,15355.43,
Revise/remove neuroelectrode,61880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4911.41,,,,,,,fee schedule,3461.03,15355.43,
Revise/remove neuroelectrode,61880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5163.66,,,,,,,fee schedule,3461.03,15355.43,
Revise/remove neuroelectrode,61880,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15355.43,,,,,,,fee schedule,3461.03,15355.43,APC 378
Revise/remove neuroelectrode,61880,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3634.08,,,,,,,fee schedule,3461.03,15355.43,APC
Revise/remove neuroelectrode,61880,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3599.47,,,,,,,fee schedule,3461.03,15355.43,APC
Revise/remove neuroelectrode,61880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3461.03,,,,,,,fee schedule,3461.03,15355.43,APC
Revise/remove neuroelectrode,61880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5295.38,,,,,,,fee schedule,3461.03,15355.43,Radiology
Revise/remove neuroelectrode,61880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4845.44,,,,,,,fee schedule,3461.03,15355.43,APC
Revise/remove neuroelectrode,61880,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6056.81,,,,,,,fee schedule,3461.03,15355.43,APC
Insrt/redo neurostim 1 array,61885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4765.13,,,,,,,fee schedule,3819.67,135531.68,
Insrt/redo neurostim 1 array,61885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3819.67,,,,,,,fee schedule,3819.67,135531.68,
Insrt/redo neurostim 1 array,61885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4172.64,,,,,,,fee schedule,3819.67,135531.68,
Insrt/redo neurostim 1 array,61885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4386.95,,,,,,,fee schedule,3819.67,135531.68,
Insrt/redo neurostim 1 array,61885,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,135531.68,,,,,,,fee schedule,3819.67,135531.68,APC 378
Insrt/redo neurostim 1 array,61885,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,32075.53,,,,,,,fee schedule,3819.67,135531.68,APC
Insrt/redo neurostim 1 array,61885,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,31770.05,,,,,,,fee schedule,3819.67,135531.68,APC
Insrt/redo neurostim 1 array,61885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,30548.12,,,,,,,fee schedule,3819.67,135531.68,APC
Insrt/redo neurostim 1 array,61885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,46738.63,,,,,,,fee schedule,3819.67,135531.68,Radiology
Insrt/redo neurostim 1 array,61885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,42767.37,,,,,,,fee schedule,3819.67,135531.68,APC
Insrt/redo neurostim 1 array,61885,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,53459.21,,,,,,,fee schedule,3819.67,135531.68,APC
Implant neurostim arrays,61886,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10205.34,,,,,,,fee schedule,8180.47,135531.68,
Implant neurostim arrays,61886,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8180.47,,,,,,,fee schedule,8180.47,135531.68,
Implant neurostim arrays,61886,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8936.43,,,,,,,fee schedule,8180.47,135531.68,
Implant neurostim arrays,61886,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9395.4,,,,,,,fee schedule,8180.47,135531.68,
Implant neurostim arrays,61886,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,135531.68,,,,,,,fee schedule,8180.47,135531.68,APC 378
Implant neurostim arrays,61886,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,32075.53,,,,,,,fee schedule,8180.47,135531.68,APC
Implant neurostim arrays,61886,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,31770.05,,,,,,,fee schedule,8180.47,135531.68,APC
Implant neurostim arrays,61886,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,30548.12,,,,,,,fee schedule,8180.47,135531.68,APC
Implant neurostim arrays,61886,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,46738.63,,,,,,,fee schedule,8180.47,135531.68,Radiology
Implant neurostim arrays,61886,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,42767.37,,,,,,,fee schedule,8180.47,135531.68,APC
Implant neurostim arrays,61886,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,53459.21,,,,,,,fee schedule,8180.47,135531.68,APC
Revise/remove neuroreceiver,61888,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8589.52,,,,,,,fee schedule,6885.25,48940.4,
Revise/remove neuroreceiver,61888,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6885.25,,,,,,,fee schedule,6885.25,48940.4,
Revise/remove neuroreceiver,61888,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7521.51,,,,,,,fee schedule,6885.25,48940.4,
Revise/remove neuroreceiver,61888,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7907.81,,,,,,,fee schedule,6885.25,48940.4,
Revise/remove neuroreceiver,61888,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,48940.4,,,,,,,fee schedule,6885.25,48940.4,APC 378
Revise/remove neuroreceiver,61888,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11582.45,,,,,,,fee schedule,6885.25,48940.4,APC
Revise/remove neuroreceiver,61888,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11472.14,,,,,,,fee schedule,6885.25,48940.4,APC
Revise/remove neuroreceiver,61888,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11030.91,,,,,,,fee schedule,6885.25,48940.4,APC
Revise/remove neuroreceiver,61888,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16877.29,,,,,,,fee schedule,6885.25,48940.4,Radiology
Revise/remove neuroreceiver,61888,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15443.27,,,,,,,fee schedule,6885.25,48940.4,APC
Revise/remove neuroreceiver,61888,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19304.09,,,,,,,fee schedule,6885.25,48940.4,APC
Rev/rplcmt sk-mnt crnl nstm,61891,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,78867.89,,,,,,,fee schedule,30548.12,135531.68,
Rev/rplcmt sk-mnt crnl nstm,61891,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,63219.5,,,,,,,fee schedule,30548.12,135531.68,
Rev/rplcmt sk-mnt crnl nstm,61891,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,69061.56,,,,,,,fee schedule,30548.12,135531.68,
Rev/rplcmt sk-mnt crnl nstm,61891,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,72608.53,,,,,,,fee schedule,30548.12,135531.68,
Rev/rplcmt sk-mnt crnl nstm,61891,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,135531.68,,,,,,,fee schedule,30548.12,135531.68,APC 378
Rev/rplcmt sk-mnt crnl nstm,61891,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,32075.53,,,,,,,fee schedule,30548.12,135531.68,APC
Rev/rplcmt sk-mnt crnl nstm,61891,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,31770.05,,,,,,,fee schedule,30548.12,135531.68,APC
Rev/rplcmt sk-mnt crnl nstm,61891,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,30548.12,,,,,,,fee schedule,30548.12,135531.68,APC
Rev/rplcmt sk-mnt crnl nstm,61891,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,46738.63,,,,,,,fee schedule,30548.12,135531.68,Radiology
Rev/rplcmt sk-mnt crnl nstm,61891,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,42767.37,,,,,,,fee schedule,30548.12,135531.68,APC
Rev/rplcmt sk-mnt crnl nstm,61891,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,53459.21,,,,,,,fee schedule,30548.12,135531.68,APC
Rmv sk-mnt crnl nstm pg/rcvr,61892,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11669.77,,,,,,,fee schedule,3239.17,14371.12,
Rmv sk-mnt crnl nstm pg/rcvr,61892,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9354.34,,,,,,,fee schedule,3239.17,14371.12,
Rmv sk-mnt crnl nstm pg/rcvr,61892,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10218.76,,,,,,,fee schedule,3239.17,14371.12,
Rmv sk-mnt crnl nstm pg/rcvr,61892,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10743.6,,,,,,,fee schedule,3239.17,14371.12,
Rmv sk-mnt crnl nstm pg/rcvr,61892,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Rmv sk-mnt crnl nstm pg/rcvr,61892,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Rmv sk-mnt crnl nstm pg/rcvr,61892,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Rmv sk-mnt crnl nstm pg/rcvr,61892,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Rmv sk-mnt crnl nstm pg/rcvr,61892,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Rmv sk-mnt crnl nstm pg/rcvr,61892,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Rmv sk-mnt crnl nstm pg/rcvr,61892,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Treat skull fracture,62000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5983.93,,,,,,,fee schedule,3282.2,14562,
Treat skull fracture,62000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4796.64,,,,,,,fee schedule,3282.2,14562,
Treat skull fracture,62000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5239.9,,,,,,,fee schedule,3282.2,14562,
Treat skull fracture,62000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.01,,,,,,,fee schedule,3282.2,14562,
Treat skull fracture,62000,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Treat skull fracture,62000,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Treat skull fracture,62000,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Treat skull fracture,62000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Treat skull fracture,62000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Treat skull fracture,62000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Treat skull fracture,62000,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Replace/irrigate catheter,62194,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2127.95,,,,,,,fee schedule,1705.74,8576.66,
Replace/irrigate catheter,62194,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1705.74,,,,,,,fee schedule,1705.74,8576.66,
Replace/irrigate catheter,62194,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1863.36,,,,,,,fee schedule,1705.74,8576.66,
Replace/irrigate catheter,62194,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1959.07,,,,,,,fee schedule,1705.74,8576.66,
Replace/irrigate catheter,62194,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8576.66,,,,,,,fee schedule,1705.74,8576.66,APC 378
Replace/irrigate catheter,62194,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2029.79,,,,,,,fee schedule,1705.74,8576.66,APC
Replace/irrigate catheter,62194,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2010.46,,,,,,,fee schedule,1705.74,8576.66,APC
Replace/irrigate catheter,62194,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1933.13,,,,,,,fee schedule,1705.74,8576.66,APC
Replace/irrigate catheter,62194,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2957.7,,,,,,,fee schedule,1705.74,8576.66,Radiology
Replace/irrigate catheter,62194,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2706.39,,,,,,,fee schedule,1705.74,8576.66,APC
Replace/irrigate catheter,62194,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3382.99,,,,,,,fee schedule,1705.74,8576.66,APC
Replace/irrigate catheter,62225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3832.09,,,,,,,fee schedule,3071.75,15004.24,
Replace/irrigate catheter,62225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3071.75,,,,,,,fee schedule,3071.75,15004.24,
Replace/irrigate catheter,62225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3355.61,,,,,,,fee schedule,3071.75,15004.24,
Replace/irrigate catheter,62225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3527.95,,,,,,,fee schedule,3071.75,15004.24,
Replace/irrigate catheter,62225,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15004.24,,,,,,,fee schedule,3071.75,15004.24,APC 378
Replace/irrigate catheter,62225,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3550.97,,,,,,,fee schedule,3071.75,15004.24,APC
Replace/irrigate catheter,62225,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3517.15,,,,,,,fee schedule,3071.75,15004.24,APC
Replace/irrigate catheter,62225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3381.88,,,,,,,fee schedule,3071.75,15004.24,APC
Replace/irrigate catheter,62225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5174.27,,,,,,,fee schedule,3071.75,15004.24,Radiology
Replace/irrigate catheter,62225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4734.63,,,,,,,fee schedule,3071.75,15004.24,APC
Replace/irrigate catheter,62225,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5918.28,,,,,,,fee schedule,3071.75,15004.24,APC
Replace/revise brain shunt,62230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9053.78,,,,,,,fee schedule,7257.4,38544.86,
Replace/revise brain shunt,62230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7257.4,,,,,,,fee schedule,7257.4,38544.86,
Replace/revise brain shunt,62230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7928.05,,,,,,,fee schedule,7257.4,38544.86,
Replace/revise brain shunt,62230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8335.23,,,,,,,fee schedule,7257.4,38544.86,
Replace/revise brain shunt,62230,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,38544.86,,,,,,,fee schedule,7257.4,38544.86,APC 378
Replace/revise brain shunt,62230,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9122.2,,,,,,,fee schedule,7257.4,38544.86,APC
Replace/revise brain shunt,62230,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9035.32,,,,,,,fee schedule,7257.4,38544.86,APC
Replace/revise brain shunt,62230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8687.81,,,,,,,fee schedule,7257.4,38544.86,APC
Replace/revise brain shunt,62230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13292.34,,,,,,,fee schedule,7257.4,38544.86,Radiology
Replace/revise brain shunt,62230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12162.93,,,,,,,fee schedule,7257.4,38544.86,APC
Replace/revise brain shunt,62230,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15203.66,,,,,,,fee schedule,7257.4,38544.86,APC
Csf Shunt Reprogram,62252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,165.56,,,,,,,fee schedule,132.71,1348.99,
Csf Shunt Reprogram,62252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,132.71,,,,,,,fee schedule,132.71,1348.99,
Csf Shunt Reprogram,62252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,144.98,,,,,,,fee schedule,132.71,1348.99,
Csf Shunt Reprogram,62252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,152.42,,,,,,,fee schedule,132.71,1348.99,
Csf Shunt Reprogram,62252,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1348.99,,,,,,,fee schedule,132.71,1348.99,APC 378
Csf Shunt Reprogram,62252,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,319.26,,,,,,,fee schedule,132.71,1348.99,APC
Csf Shunt Reprogram,62252,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,316.22,,,,,,,fee schedule,132.71,1348.99,APC
Csf Shunt Reprogram,62252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,304.06,,,,,,,fee schedule,132.71,1348.99,APC
Csf Shunt Reprogram,62252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,465.21,,,,,,,fee schedule,132.71,1348.99,Radiology
Csf Shunt Reprogram,62252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,425.68,,,,,,,fee schedule,132.71,1348.99,APC
Csf Shunt Reprogram,62252,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,532.1,,,,,,,fee schedule,132.71,1348.99,APC
Epidural lysis mult sessions,62263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3615.8,,,,,,,fee schedule,875.6,3884.74,
Epidural lysis mult sessions,62263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2898.38,,,,,,,fee schedule,875.6,3884.74,
Epidural lysis mult sessions,62263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3166.21,,,,,,,fee schedule,875.6,3884.74,
Epidural lysis mult sessions,62263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3328.83,,,,,,,fee schedule,875.6,3884.74,
Epidural lysis mult sessions,62263,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3884.74,,,,,,,fee schedule,875.6,3884.74,APC 378
Epidural lysis mult sessions,62263,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,919.38,,,,,,,fee schedule,875.6,3884.74,APC
Epidural lysis mult sessions,62263,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,910.62,,,,,,,fee schedule,875.6,3884.74,APC
Epidural lysis mult sessions,62263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,875.6,,,,,,,fee schedule,875.6,3884.74,APC
Epidural lysis mult sessions,62263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1339.67,,,,,,,fee schedule,875.6,3884.74,Radiology
Epidural lysis mult sessions,62263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1225.84,,,,,,,fee schedule,875.6,3884.74,APC
Epidural lysis mult sessions,62263,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1532.3,,,,,,,fee schedule,875.6,3884.74,APC
Epidural lysis on single day,62264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3615.8,,,,,,,fee schedule,875.6,3884.74,
Epidural lysis on single day,62264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2898.38,,,,,,,fee schedule,875.6,3884.74,
Epidural lysis on single day,62264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3166.21,,,,,,,fee schedule,875.6,3884.74,
Epidural lysis on single day,62264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3328.83,,,,,,,fee schedule,875.6,3884.74,
Epidural lysis on single day,62264,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3884.74,,,,,,,fee schedule,875.6,3884.74,APC 378
Epidural lysis on single day,62264,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,919.38,,,,,,,fee schedule,875.6,3884.74,APC
Epidural lysis on single day,62264,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,910.62,,,,,,,fee schedule,875.6,3884.74,APC
Epidural lysis on single day,62264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,875.6,,,,,,,fee schedule,875.6,3884.74,APC
Epidural lysis on single day,62264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1339.67,,,,,,,fee schedule,875.6,3884.74,Radiology
Epidural lysis on single day,62264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1225.84,,,,,,,fee schedule,875.6,3884.74,APC
Epidural lysis on single day,62264,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1532.3,,,,,,,fee schedule,875.6,3884.74,APC
Interdiscal perq aspir dx,62267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,582.91,,,,,,,fee schedule,467.26,3110.22,
Interdiscal perq aspir dx,62267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,467.26,,,,,,,fee schedule,467.26,3110.22,
Interdiscal perq aspir dx,62267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,510.44,,,,,,,fee schedule,467.26,3110.22,
Interdiscal perq aspir dx,62267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,536.65,,,,,,,fee schedule,467.26,3110.22,
Interdiscal perq aspir dx,62267,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3110.22,,,,,,,fee schedule,467.26,3110.22,APC 378
Interdiscal perq aspir dx,62267,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,736.08,,,,,,,fee schedule,467.26,3110.22,APC
Interdiscal perq aspir dx,62267,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,729.07,,,,,,,fee schedule,467.26,3110.22,APC
Interdiscal perq aspir dx,62267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,701.03,,,,,,,fee schedule,467.26,3110.22,APC
Interdiscal perq aspir dx,62267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1072.57,,,,,,,fee schedule,467.26,3110.22,Radiology
Interdiscal perq aspir dx,62267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,981.44,,,,,,,fee schedule,467.26,3110.22,APC
Interdiscal perq aspir dx,62267,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1226.8,,,,,,,fee schedule,467.26,3110.22,APC
Drain spinal cord cyst,62268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2127.95,,,,,,,fee schedule,875.6,3884.74,
Drain spinal cord cyst,62268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1705.74,,,,,,,fee schedule,875.6,3884.74,
Drain spinal cord cyst,62268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1863.36,,,,,,,fee schedule,875.6,3884.74,
Drain spinal cord cyst,62268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1959.07,,,,,,,fee schedule,875.6,3884.74,
Drain spinal cord cyst,62268,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3884.74,,,,,,,fee schedule,875.6,3884.74,APC 378
Drain spinal cord cyst,62268,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,919.38,,,,,,,fee schedule,875.6,3884.74,APC
Drain spinal cord cyst,62268,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,910.62,,,,,,,fee schedule,875.6,3884.74,APC
Drain spinal cord cyst,62268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,875.6,,,,,,,fee schedule,875.6,3884.74,APC
Drain spinal cord cyst,62268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1339.67,,,,,,,fee schedule,875.6,3884.74,Radiology
Drain spinal cord cyst,62268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1225.84,,,,,,,fee schedule,875.6,3884.74,APC
Drain spinal cord cyst,62268,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1532.3,,,,,,,fee schedule,875.6,3884.74,APC
Needle biopsy spinal cord,62269,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2329.88,,,,,,,fee schedule,1635.03,7254.06,
Needle biopsy spinal cord,62269,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1867.6,,,,,,,fee schedule,1635.03,7254.06,
Needle biopsy spinal cord,62269,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2040.18,,,,,,,fee schedule,1635.03,7254.06,
Needle biopsy spinal cord,62269,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2144.97,,,,,,,fee schedule,1635.03,7254.06,
Needle biopsy spinal cord,62269,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,7254.06,APC 378
Needle biopsy spinal cord,62269,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,7254.06,APC
Needle biopsy spinal cord,62269,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,7254.06,APC
Needle biopsy spinal cord,62269,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,7254.06,APC
Needle biopsy spinal cord,62269,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,7254.06,Radiology
Needle biopsy spinal cord,62269,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,7254.06,APC
Needle biopsy spinal cord,62269,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,7254.06,APC
Spinal fluid tap diagnostic,62270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,619.98,,,,,,,fee schedule,496.97,3100.34,
Spinal fluid tap diagnostic,62270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,496.97,,,,,,,fee schedule,496.97,3100.34,
Spinal fluid tap diagnostic,62270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,542.89,,,,,,,fee schedule,496.97,3100.34,
Spinal fluid tap diagnostic,62270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,570.77,,,,,,,fee schedule,496.97,3100.34,
Spinal fluid tap diagnostic,62270,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3100.34,,,,,,,fee schedule,496.97,3100.34,APC 378
Spinal fluid tap diagnostic,62270,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,733.74,,,,,,,fee schedule,496.97,3100.34,APC
Spinal fluid tap diagnostic,62270,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,726.75,,,,,,,fee schedule,496.97,3100.34,APC
Spinal fluid tap diagnostic,62270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,698.8,,,,,,,fee schedule,496.97,3100.34,APC
Spinal fluid tap diagnostic,62270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1069.16,,,,,,,fee schedule,496.97,3100.34,Radiology
Spinal fluid tap diagnostic,62270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,978.32,,,,,,,fee schedule,496.97,3100.34,APC
Spinal fluid tap diagnostic,62270,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1222.9,,,,,,,fee schedule,496.97,3100.34,APC
Drain cerebro spinal fluid,62272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1022.38,,,,,,,fee schedule,698.8,3100.34,
Drain cerebro spinal fluid,62272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,819.52,,,,,,,fee schedule,698.8,3100.34,
Drain cerebro spinal fluid,62272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,895.26,,,,,,,fee schedule,698.8,3100.34,
Drain cerebro spinal fluid,62272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,941.24,,,,,,,fee schedule,698.8,3100.34,
Drain cerebro spinal fluid,62272,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3100.34,,,,,,,fee schedule,698.8,3100.34,APC 378
Drain cerebro spinal fluid,62272,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,733.74,,,,,,,fee schedule,698.8,3100.34,APC
Drain cerebro spinal fluid,62272,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,726.75,,,,,,,fee schedule,698.8,3100.34,APC
Drain cerebro spinal fluid,62272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,698.8,,,,,,,fee schedule,698.8,3100.34,APC
Drain cerebro spinal fluid,62272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1069.16,,,,,,,fee schedule,698.8,3100.34,Radiology
Drain cerebro spinal fluid,62272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,978.32,,,,,,,fee schedule,698.8,3100.34,APC
Drain cerebro spinal fluid,62272,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1222.9,,,,,,,fee schedule,698.8,3100.34,APC
Inject epidural patch,62273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1622.15,,,,,,,fee schedule,698.8,3100.34,
Inject epidural patch,62273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1300.29,,,,,,,fee schedule,698.8,3100.34,
Inject epidural patch,62273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1420.45,,,,,,,fee schedule,698.8,3100.34,
Inject epidural patch,62273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1493.41,,,,,,,fee schedule,698.8,3100.34,
Inject epidural patch,62273,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3100.34,,,,,,,fee schedule,698.8,3100.34,APC 378
Inject epidural patch,62273,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,733.74,,,,,,,fee schedule,698.8,3100.34,APC
Inject epidural patch,62273,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,726.75,,,,,,,fee schedule,698.8,3100.34,APC
Inject epidural patch,62273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,698.8,,,,,,,fee schedule,698.8,3100.34,APC
Inject epidural patch,62273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1069.16,,,,,,,fee schedule,698.8,3100.34,Radiology
Inject epidural patch,62273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,978.32,,,,,,,fee schedule,698.8,3100.34,APC
Inject epidural patch,62273,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1222.9,,,,,,,fee schedule,698.8,3100.34,APC
Treat spinal cord lesion,62280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1760.69,,,,,,,fee schedule,875.6,3884.74,
Treat spinal cord lesion,62280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1411.34,,,,,,,fee schedule,875.6,3884.74,
Treat spinal cord lesion,62280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1541.76,,,,,,,fee schedule,875.6,3884.74,
Treat spinal cord lesion,62280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1620.95,,,,,,,fee schedule,875.6,3884.74,
Treat spinal cord lesion,62280,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3884.74,,,,,,,fee schedule,875.6,3884.74,APC 378
Treat spinal cord lesion,62280,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,919.38,,,,,,,fee schedule,875.6,3884.74,APC
Treat spinal cord lesion,62280,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,910.62,,,,,,,fee schedule,875.6,3884.74,APC
Treat spinal cord lesion,62280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,875.6,,,,,,,fee schedule,875.6,3884.74,APC
Treat spinal cord lesion,62280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1339.67,,,,,,,fee schedule,875.6,3884.74,Radiology
Treat spinal cord lesion,62280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1225.84,,,,,,,fee schedule,875.6,3884.74,APC
Treat spinal cord lesion,62280,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1532.3,,,,,,,fee schedule,875.6,3884.74,APC
Treat spinal cord lesion,62281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1760.69,,,,,,,fee schedule,875.6,3884.74,
Treat spinal cord lesion,62281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1411.34,,,,,,,fee schedule,875.6,3884.74,
Treat spinal cord lesion,62281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1541.76,,,,,,,fee schedule,875.6,3884.74,
Treat spinal cord lesion,62281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1620.95,,,,,,,fee schedule,875.6,3884.74,
Treat spinal cord lesion,62281,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3884.74,,,,,,,fee schedule,875.6,3884.74,APC 378
Treat spinal cord lesion,62281,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,919.38,,,,,,,fee schedule,875.6,3884.74,APC
Treat spinal cord lesion,62281,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,910.62,,,,,,,fee schedule,875.6,3884.74,APC
Treat spinal cord lesion,62281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,875.6,,,,,,,fee schedule,875.6,3884.74,APC
Treat spinal cord lesion,62281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1339.67,,,,,,,fee schedule,875.6,3884.74,Radiology
Treat spinal cord lesion,62281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1225.84,,,,,,,fee schedule,875.6,3884.74,APC
Treat spinal cord lesion,62281,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1532.3,,,,,,,fee schedule,875.6,3884.74,APC
Treat spinal canal lesion,62282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1760.69,,,,,,,fee schedule,875.6,3884.74,
Treat spinal canal lesion,62282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1411.34,,,,,,,fee schedule,875.6,3884.74,
Treat spinal canal lesion,62282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1541.76,,,,,,,fee schedule,875.6,3884.74,
Treat spinal canal lesion,62282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1620.95,,,,,,,fee schedule,875.6,3884.74,
Treat spinal canal lesion,62282,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3884.74,,,,,,,fee schedule,875.6,3884.74,APC 378
Treat spinal canal lesion,62282,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,919.38,,,,,,,fee schedule,875.6,3884.74,APC
Treat spinal canal lesion,62282,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,910.62,,,,,,,fee schedule,875.6,3884.74,APC
Treat spinal canal lesion,62282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,875.6,,,,,,,fee schedule,875.6,3884.74,APC
Treat spinal canal lesion,62282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1339.67,,,,,,,fee schedule,875.6,3884.74,Radiology
Treat spinal canal lesion,62282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1225.84,,,,,,,fee schedule,875.6,3884.74,APC
Treat spinal canal lesion,62282,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1532.3,,,,,,,fee schedule,875.6,3884.74,APC
Percutaneous diskectomy,62287,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8303.53,,,,,,,fee schedule,1933.13,8576.66,
Percutaneous diskectomy,62287,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6656,,,,,,,fee schedule,1933.13,8576.66,
Percutaneous diskectomy,62287,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7271.08,,,,,,,fee schedule,1933.13,8576.66,
Percutaneous diskectomy,62287,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7644.52,,,,,,,fee schedule,1933.13,8576.66,
Percutaneous diskectomy,62287,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8576.66,,,,,,,fee schedule,1933.13,8576.66,APC 378
Percutaneous diskectomy,62287,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2029.79,,,,,,,fee schedule,1933.13,8576.66,APC
Percutaneous diskectomy,62287,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2010.46,,,,,,,fee schedule,1933.13,8576.66,APC
Percutaneous diskectomy,62287,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1933.13,,,,,,,fee schedule,1933.13,8576.66,APC
Percutaneous diskectomy,62287,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2957.7,,,,,,,fee schedule,1933.13,8576.66,Radiology
Percutaneous diskectomy,62287,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2706.39,,,,,,,fee schedule,1933.13,8576.66,APC
Percutaneous diskectomy,62287,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3382.99,,,,,,,fee schedule,1933.13,8576.66,APC
Injection into disk lesion,62292,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2127.95,,,,,,,fee schedule,1705.74,8576.66,
Injection into disk lesion,62292,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1705.74,,,,,,,fee schedule,1705.74,8576.66,
Injection into disk lesion,62292,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1863.36,,,,,,,fee schedule,1705.74,8576.66,
Injection into disk lesion,62292,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1959.07,,,,,,,fee schedule,1705.74,8576.66,
Injection into disk lesion,62292,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8576.66,,,,,,,fee schedule,1705.74,8576.66,APC 378
Injection into disk lesion,62292,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2029.79,,,,,,,fee schedule,1705.74,8576.66,APC
Injection into disk lesion,62292,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2010.46,,,,,,,fee schedule,1705.74,8576.66,APC
Injection into disk lesion,62292,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1933.13,,,,,,,fee schedule,1705.74,8576.66,APC
Injection into disk lesion,62292,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2957.7,,,,,,,fee schedule,1705.74,8576.66,Radiology
Injection into disk lesion,62292,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2706.39,,,,,,,fee schedule,1705.74,8576.66,APC
Injection into disk lesion,62292,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3382.99,,,,,,,fee schedule,1705.74,8576.66,APC
Injection into spinal artery,62294,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2127.95,,,,,,,fee schedule,875.6,3884.74,
Injection into spinal artery,62294,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1705.74,,,,,,,fee schedule,875.6,3884.74,
Injection into spinal artery,62294,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1863.36,,,,,,,fee schedule,875.6,3884.74,
Injection into spinal artery,62294,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1959.07,,,,,,,fee schedule,875.6,3884.74,
Injection into spinal artery,62294,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3884.74,,,,,,,fee schedule,875.6,3884.74,APC 378
Injection into spinal artery,62294,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,919.38,,,,,,,fee schedule,875.6,3884.74,APC
Injection into spinal artery,62294,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,910.62,,,,,,,fee schedule,875.6,3884.74,APC
Injection into spinal artery,62294,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,875.6,,,,,,,fee schedule,875.6,3884.74,APC
Injection into spinal artery,62294,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1339.67,,,,,,,fee schedule,875.6,3884.74,Radiology
Injection into spinal artery,62294,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1225.84,,,,,,,fee schedule,875.6,3884.74,APC
Injection into spinal artery,62294,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1532.3,,,,,,,fee schedule,875.6,3884.74,APC
Myelography lumbar injection,62302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2321.98,,,,,,,fee schedule,776.06,3443.1,
Myelography lumbar injection,62302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1861.27,,,,,,,fee schedule,776.06,3443.1,
Myelography lumbar injection,62302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2033.27,,,,,,,fee schedule,776.06,3443.1,
Myelography lumbar injection,62302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2137.69,,,,,,,fee schedule,776.06,3443.1,
Myelography lumbar injection,62302,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3443.1,,,,,,,fee schedule,776.06,3443.1,APC 378
Myelography lumbar injection,62302,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,814.86,,,,,,,fee schedule,776.06,3443.1,APC
Myelography lumbar injection,62302,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,807.1,,,,,,,fee schedule,776.06,3443.1,APC
Myelography lumbar injection,62302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,776.06,,,,,,,fee schedule,776.06,3443.1,APC
Myelography lumbar injection,62302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1187.37,,,,,,,fee schedule,776.06,3443.1,Radiology
Myelography lumbar injection,62302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1086.48,,,,,,,fee schedule,776.06,3443.1,APC
Myelography lumbar injection,62302,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1358.1,,,,,,,fee schedule,776.06,3443.1,APC
Myelography lumbar injection,62303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2321.98,,,,,,,fee schedule,776.06,3443.1,
Myelography lumbar injection,62303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1861.27,,,,,,,fee schedule,776.06,3443.1,
Myelography lumbar injection,62303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2033.27,,,,,,,fee schedule,776.06,3443.1,
Myelography lumbar injection,62303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2137.69,,,,,,,fee schedule,776.06,3443.1,
Myelography lumbar injection,62303,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3443.1,,,,,,,fee schedule,776.06,3443.1,APC 378
Myelography lumbar injection,62303,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,814.86,,,,,,,fee schedule,776.06,3443.1,APC
Myelography lumbar injection,62303,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,807.1,,,,,,,fee schedule,776.06,3443.1,APC
Myelography lumbar injection,62303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,776.06,,,,,,,fee schedule,776.06,3443.1,APC
Myelography lumbar injection,62303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1187.37,,,,,,,fee schedule,776.06,3443.1,Radiology
Myelography lumbar injection,62303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1086.48,,,,,,,fee schedule,776.06,3443.1,APC
Myelography lumbar injection,62303,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1358.1,,,,,,,fee schedule,776.06,3443.1,APC
Myelography lumbar injection,62304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,901.56,,,,,,,fee schedule,722.68,3443.1,
Myelography lumbar injection,62304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,722.68,,,,,,,fee schedule,722.68,3443.1,
Myelography lumbar injection,62304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,789.46,,,,,,,fee schedule,722.68,3443.1,
Myelography lumbar injection,62304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,830,,,,,,,fee schedule,722.68,3443.1,
Myelography lumbar injection,62304,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3443.1,,,,,,,fee schedule,722.68,3443.1,APC 378
Myelography lumbar injection,62304,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,814.86,,,,,,,fee schedule,722.68,3443.1,APC
Myelography lumbar injection,62304,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,807.1,,,,,,,fee schedule,722.68,3443.1,APC
Myelography lumbar injection,62304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,776.06,,,,,,,fee schedule,722.68,3443.1,APC
Myelography lumbar injection,62304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1187.37,,,,,,,fee schedule,722.68,3443.1,Radiology
Myelography lumbar injection,62304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1086.48,,,,,,,fee schedule,722.68,3443.1,APC
Myelography lumbar injection,62304,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1358.1,,,,,,,fee schedule,722.68,3443.1,APC
Myelography lumbar injection,62305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2321.98,,,,,,,fee schedule,776.06,3443.1,
Myelography lumbar injection,62305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1861.27,,,,,,,fee schedule,776.06,3443.1,
Myelography lumbar injection,62305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2033.27,,,,,,,fee schedule,776.06,3443.1,
Myelography lumbar injection,62305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2137.69,,,,,,,fee schedule,776.06,3443.1,
Myelography lumbar injection,62305,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3443.1,,,,,,,fee schedule,776.06,3443.1,APC 378
Myelography lumbar injection,62305,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,814.86,,,,,,,fee schedule,776.06,3443.1,APC
Myelography lumbar injection,62305,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,807.1,,,,,,,fee schedule,776.06,3443.1,APC
Myelography lumbar injection,62305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,776.06,,,,,,,fee schedule,776.06,3443.1,APC
Myelography lumbar injection,62305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1187.37,,,,,,,fee schedule,776.06,3443.1,Radiology
Myelography lumbar injection,62305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1086.48,,,,,,,fee schedule,776.06,3443.1,APC
Myelography lumbar injection,62305,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1358.1,,,,,,,fee schedule,776.06,3443.1,APC
Njx interlaminar crv/thrc,62320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1917.18,,,,,,,fee schedule,698.8,3100.34,
Njx interlaminar crv/thrc,62320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1536.79,,,,,,,fee schedule,698.8,3100.34,
Njx interlaminar crv/thrc,62320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1678.8,,,,,,,fee schedule,698.8,3100.34,
Njx interlaminar crv/thrc,62320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1765.02,,,,,,,fee schedule,698.8,3100.34,
Njx interlaminar crv/thrc,62320,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3100.34,,,,,,,fee schedule,698.8,3100.34,APC 378
Njx interlaminar crv/thrc,62320,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,733.74,,,,,,,fee schedule,698.8,3100.34,APC
Njx interlaminar crv/thrc,62320,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,726.75,,,,,,,fee schedule,698.8,3100.34,APC
Njx interlaminar crv/thrc,62320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,698.8,,,,,,,fee schedule,698.8,3100.34,APC
Njx interlaminar crv/thrc,62320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1069.16,,,,,,,fee schedule,698.8,3100.34,Radiology
Njx interlaminar crv/thrc,62320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,978.32,,,,,,,fee schedule,698.8,3100.34,APC
Njx interlaminar crv/thrc,62320,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1222.9,,,,,,,fee schedule,698.8,3100.34,APC
Njx interlaminar crv/thrc,62321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1622.15,,,,,,,fee schedule,698.8,3100.34,
Njx interlaminar crv/thrc,62321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1300.29,,,,,,,fee schedule,698.8,3100.34,
Njx interlaminar crv/thrc,62321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1420.45,,,,,,,fee schedule,698.8,3100.34,
Njx interlaminar crv/thrc,62321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1493.41,,,,,,,fee schedule,698.8,3100.34,
Njx interlaminar crv/thrc,62321,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3100.34,,,,,,,fee schedule,698.8,3100.34,APC 378
Njx interlaminar crv/thrc,62321,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,733.74,,,,,,,fee schedule,698.8,3100.34,APC
Njx interlaminar crv/thrc,62321,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,726.75,,,,,,,fee schedule,698.8,3100.34,APC
Njx interlaminar crv/thrc,62321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,698.8,,,,,,,fee schedule,698.8,3100.34,APC
Njx interlaminar crv/thrc,62321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1069.16,,,,,,,fee schedule,698.8,3100.34,Radiology
Njx interlaminar crv/thrc,62321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,978.32,,,,,,,fee schedule,698.8,3100.34,APC
Njx interlaminar crv/thrc,62321,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1222.9,,,,,,,fee schedule,698.8,3100.34,APC
Njx interlaminar lmbr/sac,62322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1413.01,,,,,,,fee schedule,875.6,3884.74,
Njx interlaminar lmbr/sac,62322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1132.65,,,,,,,fee schedule,875.6,3884.74,
Njx interlaminar lmbr/sac,62322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1237.32,,,,,,,fee schedule,875.6,3884.74,
Njx interlaminar lmbr/sac,62322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1300.87,,,,,,,fee schedule,875.6,3884.74,
Njx interlaminar lmbr/sac,62322,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3884.74,,,,,,,fee schedule,875.6,3884.74,APC 378
Njx interlaminar lmbr/sac,62322,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,919.38,,,,,,,fee schedule,875.6,3884.74,APC
Njx interlaminar lmbr/sac,62322,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,910.62,,,,,,,fee schedule,875.6,3884.74,APC
Njx interlaminar lmbr/sac,62322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,875.6,,,,,,,fee schedule,875.6,3884.74,APC
Njx interlaminar lmbr/sac,62322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1339.67,,,,,,,fee schedule,875.6,3884.74,Radiology
Njx interlaminar lmbr/sac,62322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1225.84,,,,,,,fee schedule,875.6,3884.74,APC
Njx interlaminar lmbr/sac,62322,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1532.3,,,,,,,fee schedule,875.6,3884.74,APC
Njx interlaminar lmbr/sac,62323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1413.01,,,,,,,fee schedule,698.8,3100.34,
Njx interlaminar lmbr/sac,62323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1132.65,,,,,,,fee schedule,698.8,3100.34,
Njx interlaminar lmbr/sac,62323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1237.32,,,,,,,fee schedule,698.8,3100.34,
Njx interlaminar lmbr/sac,62323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1300.87,,,,,,,fee schedule,698.8,3100.34,
Njx interlaminar lmbr/sac,62323,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3100.34,,,,,,,fee schedule,698.8,3100.34,APC 378
Njx interlaminar lmbr/sac,62323,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,733.74,,,,,,,fee schedule,698.8,3100.34,APC
Njx interlaminar lmbr/sac,62323,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,726.75,,,,,,,fee schedule,698.8,3100.34,APC
Njx interlaminar lmbr/sac,62323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,698.8,,,,,,,fee schedule,698.8,3100.34,APC
Njx interlaminar lmbr/sac,62323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1069.16,,,,,,,fee schedule,698.8,3100.34,Radiology
Njx interlaminar lmbr/sac,62323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,978.32,,,,,,,fee schedule,698.8,3100.34,APC
Njx interlaminar lmbr/sac,62323,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1222.9,,,,,,,fee schedule,698.8,3100.34,APC
Njx interlaminar crv/thrc,62324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2415.16,,,,,,,fee schedule,875.6,3884.74,
Njx interlaminar crv/thrc,62324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1935.96,,,,,,,fee schedule,875.6,3884.74,
Njx interlaminar crv/thrc,62324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2114.86,,,,,,,fee schedule,875.6,3884.74,
Njx interlaminar crv/thrc,62324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2223.48,,,,,,,fee schedule,875.6,3884.74,
Njx interlaminar crv/thrc,62324,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3884.74,,,,,,,fee schedule,875.6,3884.74,APC 378
Njx interlaminar crv/thrc,62324,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,919.38,,,,,,,fee schedule,875.6,3884.74,APC
Njx interlaminar crv/thrc,62324,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,910.62,,,,,,,fee schedule,875.6,3884.74,APC
Njx interlaminar crv/thrc,62324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,875.6,,,,,,,fee schedule,875.6,3884.74,APC
Njx interlaminar crv/thrc,62324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1339.67,,,,,,,fee schedule,875.6,3884.74,Radiology
Njx interlaminar crv/thrc,62324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1225.84,,,,,,,fee schedule,875.6,3884.74,APC
Njx interlaminar crv/thrc,62324,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1532.3,,,,,,,fee schedule,875.6,3884.74,APC
Njx interlaminar crv/thrc,62325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2415.16,,,,,,,fee schedule,875.6,3884.74,
Njx interlaminar crv/thrc,62325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1935.96,,,,,,,fee schedule,875.6,3884.74,
Njx interlaminar crv/thrc,62325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2114.86,,,,,,,fee schedule,875.6,3884.74,
Njx interlaminar crv/thrc,62325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2223.48,,,,,,,fee schedule,875.6,3884.74,
Njx interlaminar crv/thrc,62325,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3884.74,,,,,,,fee schedule,875.6,3884.74,APC 378
Njx interlaminar crv/thrc,62325,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,919.38,,,,,,,fee schedule,875.6,3884.74,APC
Njx interlaminar crv/thrc,62325,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,910.62,,,,,,,fee schedule,875.6,3884.74,APC
Njx interlaminar crv/thrc,62325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,875.6,,,,,,,fee schedule,875.6,3884.74,APC
Njx interlaminar crv/thrc,62325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1339.67,,,,,,,fee schedule,875.6,3884.74,Radiology
Njx interlaminar crv/thrc,62325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1225.84,,,,,,,fee schedule,875.6,3884.74,APC
Njx interlaminar crv/thrc,62325,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1532.3,,,,,,,fee schedule,875.6,3884.74,APC
Njx interlaminar lmbr/sac,62326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2415.16,,,,,,,fee schedule,875.6,3884.74,
Njx interlaminar lmbr/sac,62326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1935.96,,,,,,,fee schedule,875.6,3884.74,
Njx interlaminar lmbr/sac,62326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2114.86,,,,,,,fee schedule,875.6,3884.74,
Njx interlaminar lmbr/sac,62326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2223.48,,,,,,,fee schedule,875.6,3884.74,
Njx interlaminar lmbr/sac,62326,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3884.74,,,,,,,fee schedule,875.6,3884.74,APC 378
Njx interlaminar lmbr/sac,62326,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,919.38,,,,,,,fee schedule,875.6,3884.74,APC
Njx interlaminar lmbr/sac,62326,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,910.62,,,,,,,fee schedule,875.6,3884.74,APC
Njx interlaminar lmbr/sac,62326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,875.6,,,,,,,fee schedule,875.6,3884.74,APC
Njx interlaminar lmbr/sac,62326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1339.67,,,,,,,fee schedule,875.6,3884.74,Radiology
Njx interlaminar lmbr/sac,62326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1225.84,,,,,,,fee schedule,875.6,3884.74,APC
Njx interlaminar lmbr/sac,62326,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1532.3,,,,,,,fee schedule,875.6,3884.74,APC
Njx interlaminar lmbr/sac,62327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2415.16,,,,,,,fee schedule,875.6,3884.74,
Njx interlaminar lmbr/sac,62327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1935.96,,,,,,,fee schedule,875.6,3884.74,
Njx interlaminar lmbr/sac,62327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2114.86,,,,,,,fee schedule,875.6,3884.74,
Njx interlaminar lmbr/sac,62327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2223.48,,,,,,,fee schedule,875.6,3884.74,
Njx interlaminar lmbr/sac,62327,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3884.74,,,,,,,fee schedule,875.6,3884.74,APC 378
Njx interlaminar lmbr/sac,62327,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,919.38,,,,,,,fee schedule,875.6,3884.74,APC
Njx interlaminar lmbr/sac,62327,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,910.62,,,,,,,fee schedule,875.6,3884.74,APC
Njx interlaminar lmbr/sac,62327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,875.6,,,,,,,fee schedule,875.6,3884.74,APC
Njx interlaminar lmbr/sac,62327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1339.67,,,,,,,fee schedule,875.6,3884.74,Radiology
Njx interlaminar lmbr/sac,62327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1225.84,,,,,,,fee schedule,875.6,3884.74,APC
Njx interlaminar lmbr/sac,62327,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1532.3,,,,,,,fee schedule,875.6,3884.74,APC
Dx lmbr spi pnxr w/fluor/ct,62328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2362.69,,,,,,,fee schedule,698.8,3100.34,
Dx lmbr spi pnxr w/fluor/ct,62328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1893.9,,,,,,,fee schedule,698.8,3100.34,
Dx lmbr spi pnxr w/fluor/ct,62328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2068.92,,,,,,,fee schedule,698.8,3100.34,
Dx lmbr spi pnxr w/fluor/ct,62328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2175.17,,,,,,,fee schedule,698.8,3100.34,
Dx lmbr spi pnxr w/fluor/ct,62328,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3100.34,,,,,,,fee schedule,698.8,3100.34,APC 378
Dx lmbr spi pnxr w/fluor/ct,62328,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,733.74,,,,,,,fee schedule,698.8,3100.34,APC
Dx lmbr spi pnxr w/fluor/ct,62328,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,726.75,,,,,,,fee schedule,698.8,3100.34,APC
Dx lmbr spi pnxr w/fluor/ct,62328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,698.8,,,,,,,fee schedule,698.8,3100.34,APC
Dx lmbr spi pnxr w/fluor/ct,62328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1069.16,,,,,,,fee schedule,698.8,3100.34,Radiology
Dx lmbr spi pnxr w/fluor/ct,62328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,978.32,,,,,,,fee schedule,698.8,3100.34,APC
Dx lmbr spi pnxr w/fluor/ct,62328,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1222.9,,,,,,,fee schedule,698.8,3100.34,APC
Ther spi pnxr csf fluor/ct,62329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2362.69,,,,,,,fee schedule,698.8,3100.34,
Ther spi pnxr csf fluor/ct,62329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1893.9,,,,,,,fee schedule,698.8,3100.34,
Ther spi pnxr csf fluor/ct,62329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2068.92,,,,,,,fee schedule,698.8,3100.34,
Ther spi pnxr csf fluor/ct,62329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2175.17,,,,,,,fee schedule,698.8,3100.34,
Ther spi pnxr csf fluor/ct,62329,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3100.34,,,,,,,fee schedule,698.8,3100.34,APC 378
Ther spi pnxr csf fluor/ct,62329,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,733.74,,,,,,,fee schedule,698.8,3100.34,APC
Ther spi pnxr csf fluor/ct,62329,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,726.75,,,,,,,fee schedule,698.8,3100.34,APC
Ther spi pnxr csf fluor/ct,62329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,698.8,,,,,,,fee schedule,698.8,3100.34,APC
Ther spi pnxr csf fluor/ct,62329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1069.16,,,,,,,fee schedule,698.8,3100.34,Radiology
Ther spi pnxr csf fluor/ct,62329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,978.32,,,,,,,fee schedule,698.8,3100.34,APC
Ther spi pnxr csf fluor/ct,62329,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1222.9,,,,,,,fee schedule,698.8,3100.34,APC
Dcmprn prq rmv lig flv 1lmbr,62330,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Dcmprn prq rmv lig flv 1lmbr,62330,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Dcmprn prq rmv lig flv 1lmbr,62330,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Dcmprn prq rmv lig flv 1lmbr,62330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Dcmprn prq rmv lig flv 1lmbr,62330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Dcmprn prq rmv lig flv 1lmbr,62330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Dcmprn prq rmv lig flv 1lmbr,62330,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Implant spinal canal cath,62350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9053.78,,,,,,,fee schedule,7257.4,38544.86,
Implant spinal canal cath,62350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7257.4,,,,,,,fee schedule,7257.4,38544.86,
Implant spinal canal cath,62350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7928.05,,,,,,,fee schedule,7257.4,38544.86,
Implant spinal canal cath,62350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8335.23,,,,,,,fee schedule,7257.4,38544.86,
Implant spinal canal cath,62350,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,38544.86,,,,,,,fee schedule,7257.4,38544.86,APC 378
Implant spinal canal cath,62350,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9122.2,,,,,,,fee schedule,7257.4,38544.86,APC
Implant spinal canal cath,62350,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9035.32,,,,,,,fee schedule,7257.4,38544.86,APC
Implant spinal canal cath,62350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8687.81,,,,,,,fee schedule,7257.4,38544.86,APC
Implant spinal canal cath,62350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13292.34,,,,,,,fee schedule,7257.4,38544.86,Radiology
Implant spinal canal cath,62350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12162.93,,,,,,,fee schedule,7257.4,38544.86,APC
Implant spinal canal cath,62350,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15203.66,,,,,,,fee schedule,7257.4,38544.86,APC
Implant spinal canal cath,62351,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11673.24,,,,,,,fee schedule,7183.42,31870.39,
Implant spinal canal cath,62351,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9357.12,,,,,,,fee schedule,7183.42,31870.39,
Implant spinal canal cath,62351,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10221.81,,,,,,,fee schedule,7183.42,31870.39,
Implant spinal canal cath,62351,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10746.8,,,,,,,fee schedule,7183.42,31870.39,
Implant spinal canal cath,62351,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Implant spinal canal cath,62351,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Implant spinal canal cath,62351,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Implant spinal canal cath,62351,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Implant spinal canal cath,62351,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Implant spinal canal cath,62351,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Implant spinal canal cath,62351,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Remove spinal canal catheter,62355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3615.8,,,,,,,fee schedule,1933.13,8576.66,
Remove spinal canal catheter,62355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2898.38,,,,,,,fee schedule,1933.13,8576.66,
Remove spinal canal catheter,62355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3166.21,,,,,,,fee schedule,1933.13,8576.66,
Remove spinal canal catheter,62355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3328.83,,,,,,,fee schedule,1933.13,8576.66,
Remove spinal canal catheter,62355,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8576.66,,,,,,,fee schedule,1933.13,8576.66,APC 378
Remove spinal canal catheter,62355,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2029.79,,,,,,,fee schedule,1933.13,8576.66,APC
Remove spinal canal catheter,62355,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2010.46,,,,,,,fee schedule,1933.13,8576.66,APC
Remove spinal canal catheter,62355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1933.13,,,,,,,fee schedule,1933.13,8576.66,APC
Remove spinal canal catheter,62355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2957.7,,,,,,,fee schedule,1933.13,8576.66,Radiology
Remove spinal canal catheter,62355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2706.39,,,,,,,fee schedule,1933.13,8576.66,APC
Remove spinal canal catheter,62355,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3382.99,,,,,,,fee schedule,1933.13,8576.66,APC
Insert spine infusion device,62360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9053.78,,,,,,,fee schedule,7257.4,79163.49,
Insert spine infusion device,62360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7257.4,,,,,,,fee schedule,7257.4,79163.49,
Insert spine infusion device,62360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7928.05,,,,,,,fee schedule,7257.4,79163.49,
Insert spine infusion device,62360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8335.23,,,,,,,fee schedule,7257.4,79163.49,
Insert spine infusion device,62360,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,79163.49,,,,,,,fee schedule,7257.4,79163.49,APC 378
Insert spine infusion device,62360,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18735.18,,,,,,,fee schedule,7257.4,79163.49,APC
Insert spine infusion device,62360,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18556.75,,,,,,,fee schedule,7257.4,79163.49,APC
Insert spine infusion device,62360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17843.03,,,,,,,fee schedule,7257.4,79163.49,APC
Insert spine infusion device,62360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27299.84,,,,,,,fee schedule,7257.4,79163.49,Radiology
Insert spine infusion device,62360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24980.24,,,,,,,fee schedule,7257.4,79163.49,APC
Insert spine infusion device,62360,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31225.3,,,,,,,fee schedule,7257.4,79163.49,APC
Implant spine infusion pump,62361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45895.1,,,,,,,fee schedule,17843.03,79163.49,
Implant spine infusion pump,62361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36788.93,,,,,,,fee schedule,17843.03,79163.49,
Implant spine infusion pump,62361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40188.56,,,,,,,fee schedule,17843.03,79163.49,
Implant spine infusion pump,62361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42252.63,,,,,,,fee schedule,17843.03,79163.49,
Implant spine infusion pump,62361,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,79163.49,,,,,,,fee schedule,17843.03,79163.49,APC 378
Implant spine infusion pump,62361,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18735.18,,,,,,,fee schedule,17843.03,79163.49,APC
Implant spine infusion pump,62361,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18556.75,,,,,,,fee schedule,17843.03,79163.49,APC
Implant spine infusion pump,62361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17843.03,,,,,,,fee schedule,17843.03,79163.49,APC
Implant spine infusion pump,62361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27299.84,,,,,,,fee schedule,17843.03,79163.49,Radiology
Implant spine infusion pump,62361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24980.24,,,,,,,fee schedule,17843.03,79163.49,APC
Implant spine infusion pump,62361,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31225.3,,,,,,,fee schedule,17843.03,79163.49,APC
Implant spine infusion pump,62362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45895.1,,,,,,,fee schedule,17843.03,79163.49,
Implant spine infusion pump,62362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36788.93,,,,,,,fee schedule,17843.03,79163.49,
Implant spine infusion pump,62362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40188.56,,,,,,,fee schedule,17843.03,79163.49,
Implant spine infusion pump,62362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42252.63,,,,,,,fee schedule,17843.03,79163.49,
Implant spine infusion pump,62362,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,79163.49,,,,,,,fee schedule,17843.03,79163.49,APC 378
Implant spine infusion pump,62362,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18735.18,,,,,,,fee schedule,17843.03,79163.49,APC
Implant spine infusion pump,62362,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18556.75,,,,,,,fee schedule,17843.03,79163.49,APC
Implant spine infusion pump,62362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17843.03,,,,,,,fee schedule,17843.03,79163.49,APC
Implant spine infusion pump,62362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27299.84,,,,,,,fee schedule,17843.03,79163.49,Radiology
Implant spine infusion pump,62362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24980.24,,,,,,,fee schedule,17843.03,79163.49,APC
Implant spine infusion pump,62362,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31225.3,,,,,,,fee schedule,17843.03,79163.49,APC
Remove spine infusion device,62365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8303.53,,,,,,,fee schedule,3381.88,15004.24,
Remove spine infusion device,62365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6656,,,,,,,fee schedule,3381.88,15004.24,
Remove spine infusion device,62365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7271.08,,,,,,,fee schedule,3381.88,15004.24,
Remove spine infusion device,62365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7644.52,,,,,,,fee schedule,3381.88,15004.24,
Remove spine infusion device,62365,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15004.24,,,,,,,fee schedule,3381.88,15004.24,APC 378
Remove spine infusion device,62365,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3550.97,,,,,,,fee schedule,3381.88,15004.24,APC
Remove spine infusion device,62365,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3517.15,,,,,,,fee schedule,3381.88,15004.24,APC
Remove spine infusion device,62365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3381.88,,,,,,,fee schedule,3381.88,15004.24,APC
Remove spine infusion device,62365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5174.27,,,,,,,fee schedule,3381.88,15004.24,Radiology
Remove spine infusion device,62365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4734.63,,,,,,,fee schedule,3381.88,15004.24,APC
Remove spine infusion device,62365,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5918.28,,,,,,,fee schedule,3381.88,15004.24,APC
Analyze spine infus pump,62367,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,580.72,,,,,,,fee schedule,304.06,1348.99,
Analyze spine infus pump,62367,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,465.5,,,,,,,fee schedule,304.06,1348.99,
Analyze spine infus pump,62367,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,508.52,,,,,,,fee schedule,304.06,1348.99,
Analyze spine infus pump,62367,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,534.63,,,,,,,fee schedule,304.06,1348.99,
Analyze spine infus pump,62367,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1348.99,,,,,,,fee schedule,304.06,1348.99,APC 378
Analyze spine infus pump,62367,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,319.26,,,,,,,fee schedule,304.06,1348.99,APC
Analyze spine infus pump,62367,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,316.22,,,,,,,fee schedule,304.06,1348.99,APC
Analyze spine infus pump,62367,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,304.06,,,,,,,fee schedule,304.06,1348.99,APC
Analyze spine infus pump,62367,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,465.21,,,,,,,fee schedule,304.06,1348.99,Radiology
Analyze spine infus pump,62367,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,425.68,,,,,,,fee schedule,304.06,1348.99,APC
Analyze spine infus pump,62367,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,532.1,,,,,,,fee schedule,304.06,1348.99,APC
Analyze sp inf pump w/reprog,62368,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,580.72,,,,,,,fee schedule,304.06,1348.99,
Analyze sp inf pump w/reprog,62368,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,465.5,,,,,,,fee schedule,304.06,1348.99,
Analyze sp inf pump w/reprog,62368,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,508.52,,,,,,,fee schedule,304.06,1348.99,
Analyze sp inf pump w/reprog,62368,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,534.63,,,,,,,fee schedule,304.06,1348.99,
Analyze sp inf pump w/reprog,62368,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1348.99,,,,,,,fee schedule,304.06,1348.99,APC 378
Analyze sp inf pump w/reprog,62368,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,319.26,,,,,,,fee schedule,304.06,1348.99,APC
Analyze sp inf pump w/reprog,62368,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,316.22,,,,,,,fee schedule,304.06,1348.99,APC
Analyze sp inf pump w/reprog,62368,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,304.06,,,,,,,fee schedule,304.06,1348.99,APC
Analyze sp inf pump w/reprog,62368,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,465.21,,,,,,,fee schedule,304.06,1348.99,Radiology
Analyze sp inf pump w/reprog,62368,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,425.68,,,,,,,fee schedule,304.06,1348.99,APC
Analyze sp inf pump w/reprog,62368,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,532.1,,,,,,,fee schedule,304.06,1348.99,APC
Anal sp inf pmp w/reprg&fill,62369,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,724.55,,,,,,,fee schedule,304.06,1348.99,
Anal sp inf pmp w/reprg&fill,62369,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,580.79,,,,,,,fee schedule,304.06,1348.99,
Anal sp inf pmp w/reprg&fill,62369,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,634.46,,,,,,,fee schedule,304.06,1348.99,
Anal sp inf pmp w/reprg&fill,62369,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,667.05,,,,,,,fee schedule,304.06,1348.99,
Anal sp inf pmp w/reprg&fill,62369,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1348.99,,,,,,,fee schedule,304.06,1348.99,APC 378
Anal sp inf pmp w/reprg&fill,62369,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,319.26,,,,,,,fee schedule,304.06,1348.99,APC
Anal sp inf pmp w/reprg&fill,62369,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,316.22,,,,,,,fee schedule,304.06,1348.99,APC
Anal sp inf pmp w/reprg&fill,62369,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,304.06,,,,,,,fee schedule,304.06,1348.99,APC
Anal sp inf pmp w/reprg&fill,62369,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,465.21,,,,,,,fee schedule,304.06,1348.99,Radiology
Anal sp inf pmp w/reprg&fill,62369,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,425.68,,,,,,,fee schedule,304.06,1348.99,APC
Anal sp inf pmp w/reprg&fill,62369,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,532.1,,,,,,,fee schedule,304.06,1348.99,APC
Anl sp inf pmp w/mdreprg&fil,62370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,773.69,,,,,,,fee schedule,304.06,1348.99,
Anl sp inf pmp w/mdreprg&fil,62370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,620.18,,,,,,,fee schedule,304.06,1348.99,
Anl sp inf pmp w/mdreprg&fil,62370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,677.49,,,,,,,fee schedule,304.06,1348.99,
Anl sp inf pmp w/mdreprg&fil,62370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,712.29,,,,,,,fee schedule,304.06,1348.99,
Anl sp inf pmp w/mdreprg&fil,62370,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1348.99,,,,,,,fee schedule,304.06,1348.99,APC 378
Anl sp inf pmp w/mdreprg&fil,62370,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,319.26,,,,,,,fee schedule,304.06,1348.99,APC
Anl sp inf pmp w/mdreprg&fil,62370,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,316.22,,,,,,,fee schedule,304.06,1348.99,APC
Anl sp inf pmp w/mdreprg&fil,62370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,304.06,,,,,,,fee schedule,304.06,1348.99,APC
Anl sp inf pmp w/mdreprg&fil,62370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,465.21,,,,,,,fee schedule,304.06,1348.99,Radiology
Anl sp inf pmp w/mdreprg&fil,62370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,425.68,,,,,,,fee schedule,304.06,1348.99,APC
Anl sp inf pmp w/mdreprg&fil,62370,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,532.1,,,,,,,fee schedule,304.06,1348.99,APC
Ndsc dcmprn 1 ntrspc lumbar,62380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19737.53,,,,,,,fee schedule,7183.42,31870.39,
Ndsc dcmprn 1 ntrspc lumbar,62380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15821.36,,,,,,,fee schedule,7183.42,31870.39,
Ndsc dcmprn 1 ntrspc lumbar,62380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17283.4,,,,,,,fee schedule,7183.42,31870.39,
Ndsc dcmprn 1 ntrspc lumbar,62380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18171.06,,,,,,,fee schedule,7183.42,31870.39,
Ndsc dcmprn 1 ntrspc lumbar,62380,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Ndsc dcmprn 1 ntrspc lumbar,62380,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Ndsc dcmprn 1 ntrspc lumbar,62380,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Ndsc dcmprn 1 ntrspc lumbar,62380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Ndsc dcmprn 1 ntrspc lumbar,62380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Ndsc dcmprn 1 ntrspc lumbar,62380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Ndsc dcmprn 1 ntrspc lumbar,62380,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Remove spine lamina 1/2 crvl,63001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11673.24,,,,,,,fee schedule,7183.42,31870.39,
Remove spine lamina 1/2 crvl,63001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9357.12,,,,,,,fee schedule,7183.42,31870.39,
Remove spine lamina 1/2 crvl,63001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10221.81,,,,,,,fee schedule,7183.42,31870.39,
Remove spine lamina 1/2 crvl,63001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10746.8,,,,,,,fee schedule,7183.42,31870.39,
Remove spine lamina 1/2 crvl,63001,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Remove spine lamina 1/2 crvl,63001,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Remove spine lamina 1/2 crvl,63001,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Remove spine lamina 1/2 crvl,63001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Remove spine lamina 1/2 crvl,63001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Remove spine lamina 1/2 crvl,63001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Remove spine lamina 1/2 crvl,63001,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Remove spine lamina 1/2 thrc,63003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11673.24,,,,,,,fee schedule,7183.42,31870.39,
Remove spine lamina 1/2 thrc,63003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9357.12,,,,,,,fee schedule,7183.42,31870.39,
Remove spine lamina 1/2 thrc,63003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10221.81,,,,,,,fee schedule,7183.42,31870.39,
Remove spine lamina 1/2 thrc,63003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10746.8,,,,,,,fee schedule,7183.42,31870.39,
Remove spine lamina 1/2 thrc,63003,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Remove spine lamina 1/2 thrc,63003,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Remove spine lamina 1/2 thrc,63003,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Remove spine lamina 1/2 thrc,63003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Remove spine lamina 1/2 thrc,63003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Remove spine lamina 1/2 thrc,63003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Remove spine lamina 1/2 thrc,63003,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Remove spine lamina 1/2 lmbr,63005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10673.46,,,,,,,fee schedule,7183.42,31870.39,
Remove spine lamina 1/2 lmbr,63005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8555.71,,,,,,,fee schedule,7183.42,31870.39,
Remove spine lamina 1/2 lmbr,63005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9346.34,,,,,,,fee schedule,7183.42,31870.39,
Remove spine lamina 1/2 lmbr,63005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9826.36,,,,,,,fee schedule,7183.42,31870.39,
Remove spine lamina 1/2 lmbr,63005,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Remove spine lamina 1/2 lmbr,63005,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Remove spine lamina 1/2 lmbr,63005,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Remove spine lamina 1/2 lmbr,63005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Remove spine lamina 1/2 lmbr,63005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Remove spine lamina 1/2 lmbr,63005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Remove spine lamina 1/2 lmbr,63005,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Remove spine lamina 1/2 scrl,63011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11673.24,,,,,,,fee schedule,7183.42,31870.39,
Remove spine lamina 1/2 scrl,63011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9357.12,,,,,,,fee schedule,7183.42,31870.39,
Remove spine lamina 1/2 scrl,63011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10221.81,,,,,,,fee schedule,7183.42,31870.39,
Remove spine lamina 1/2 scrl,63011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10746.8,,,,,,,fee schedule,7183.42,31870.39,
Remove spine lamina 1/2 scrl,63011,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Remove spine lamina 1/2 scrl,63011,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Remove spine lamina 1/2 scrl,63011,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Remove spine lamina 1/2 scrl,63011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Remove spine lamina 1/2 scrl,63011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Remove spine lamina 1/2 scrl,63011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Remove spine lamina 1/2 scrl,63011,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Remove lamina/facets lumbar,63012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11673.24,,,,,,,fee schedule,7183.42,31870.39,
Remove lamina/facets lumbar,63012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9357.12,,,,,,,fee schedule,7183.42,31870.39,
Remove lamina/facets lumbar,63012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10221.81,,,,,,,fee schedule,7183.42,31870.39,
Remove lamina/facets lumbar,63012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10746.8,,,,,,,fee schedule,7183.42,31870.39,
Remove lamina/facets lumbar,63012,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Remove lamina/facets lumbar,63012,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Remove lamina/facets lumbar,63012,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Remove lamina/facets lumbar,63012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Remove lamina/facets lumbar,63012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Remove lamina/facets lumbar,63012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Remove lamina/facets lumbar,63012,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Remove spine lamina >2 crvcl,63015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11673.24,,,,,,,fee schedule,7183.42,31870.39,
Remove spine lamina >2 crvcl,63015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9357.12,,,,,,,fee schedule,7183.42,31870.39,
Remove spine lamina >2 crvcl,63015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10221.81,,,,,,,fee schedule,7183.42,31870.39,
Remove spine lamina >2 crvcl,63015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10746.8,,,,,,,fee schedule,7183.42,31870.39,
Remove spine lamina >2 crvcl,63015,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Remove spine lamina >2 crvcl,63015,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Remove spine lamina >2 crvcl,63015,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Remove spine lamina >2 crvcl,63015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Remove spine lamina >2 crvcl,63015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Remove spine lamina >2 crvcl,63015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Remove spine lamina >2 crvcl,63015,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Remove spine lamina >2 thrc,63016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11673.24,,,,,,,fee schedule,7183.42,31870.39,
Remove spine lamina >2 thrc,63016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9357.12,,,,,,,fee schedule,7183.42,31870.39,
Remove spine lamina >2 thrc,63016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10221.81,,,,,,,fee schedule,7183.42,31870.39,
Remove spine lamina >2 thrc,63016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10746.8,,,,,,,fee schedule,7183.42,31870.39,
Remove spine lamina >2 thrc,63016,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Remove spine lamina >2 thrc,63016,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Remove spine lamina >2 thrc,63016,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Remove spine lamina >2 thrc,63016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Remove spine lamina >2 thrc,63016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Remove spine lamina >2 thrc,63016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Remove spine lamina >2 thrc,63016,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Remove spine lamina >2 lmbr,63017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11673.24,,,,,,,fee schedule,7183.42,31870.39,
Remove spine lamina >2 lmbr,63017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9357.12,,,,,,,fee schedule,7183.42,31870.39,
Remove spine lamina >2 lmbr,63017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10221.81,,,,,,,fee schedule,7183.42,31870.39,
Remove spine lamina >2 lmbr,63017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10746.8,,,,,,,fee schedule,7183.42,31870.39,
Remove spine lamina >2 lmbr,63017,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Remove spine lamina >2 lmbr,63017,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Remove spine lamina >2 lmbr,63017,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Remove spine lamina >2 lmbr,63017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Remove spine lamina >2 lmbr,63017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Remove spine lamina >2 lmbr,63017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Remove spine lamina >2 lmbr,63017,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Neck spine disk surgery,63020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11673.24,,,,,,,fee schedule,7183.42,31870.39,
Neck spine disk surgery,63020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9357.12,,,,,,,fee schedule,7183.42,31870.39,
Neck spine disk surgery,63020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10221.81,,,,,,,fee schedule,7183.42,31870.39,
Neck spine disk surgery,63020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10746.8,,,,,,,fee schedule,7183.42,31870.39,
Neck spine disk surgery,63020,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Neck spine disk surgery,63020,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Neck spine disk surgery,63020,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Neck spine disk surgery,63020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Neck spine disk surgery,63020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Neck spine disk surgery,63020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Neck spine disk surgery,63020,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Low back disk surgery,63030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11328.82,,,,,,,fee schedule,7183.42,31870.39,
Low back disk surgery,63030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9081.04,,,,,,,fee schedule,7183.42,31870.39,
Low back disk surgery,63030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9920.21,,,,,,,fee schedule,7183.42,31870.39,
Low back disk surgery,63030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10429.71,,,,,,,fee schedule,7183.42,31870.39,
Low back disk surgery,63030,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Low back disk surgery,63030,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Low back disk surgery,63030,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Low back disk surgery,63030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Low back disk surgery,63030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Low back disk surgery,63030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Low back disk surgery,63030,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Spinal disk surgery add-on,63035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3791.88,,,,,,,fee schedule,3039.52,3791.88,
Spinal disk surgery add-on,63035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3039.52,,,,,,,fee schedule,3039.52,3791.88,
Spinal disk surgery add-on,63035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3320.4,,,,,,,fee schedule,3039.52,3791.88,
Spinal disk surgery add-on,63035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3490.93,,,,,,,fee schedule,3039.52,3791.88,
Laminotomy single cervical,63040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11673.24,,,,,,,fee schedule,7183.42,31870.39,
Laminotomy single cervical,63040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9357.12,,,,,,,fee schedule,7183.42,31870.39,
Laminotomy single cervical,63040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10221.81,,,,,,,fee schedule,7183.42,31870.39,
Laminotomy single cervical,63040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10746.8,,,,,,,fee schedule,7183.42,31870.39,
Laminotomy single cervical,63040,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Laminotomy single cervical,63040,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Laminotomy single cervical,63040,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Laminotomy single cervical,63040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Laminotomy single cervical,63040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Laminotomy single cervical,63040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Laminotomy single cervical,63040,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Laminotomy single lumbar,63042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11921.77,,,,,,,fee schedule,7183.42,31870.39,
Laminotomy single lumbar,63042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9556.34,,,,,,,fee schedule,7183.42,31870.39,
Laminotomy single lumbar,63042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10439.43,,,,,,,fee schedule,7183.42,31870.39,
Laminotomy single lumbar,63042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10975.6,,,,,,,fee schedule,7183.42,31870.39,
Laminotomy single lumbar,63042,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Laminotomy single lumbar,63042,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Laminotomy single lumbar,63042,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Laminotomy single lumbar,63042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Laminotomy single lumbar,63042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Laminotomy single lumbar,63042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Laminotomy single lumbar,63042,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Remove spine lamina 1 crvl,63045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11141.58,,,,,,,fee schedule,7183.42,31870.39,
Remove spine lamina 1 crvl,63045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8930.95,,,,,,,fee schedule,7183.42,31870.39,
Remove spine lamina 1 crvl,63045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9756.25,,,,,,,fee schedule,7183.42,31870.39,
Remove spine lamina 1 crvl,63045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10257.32,,,,,,,fee schedule,7183.42,31870.39,
Remove spine lamina 1 crvl,63045,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Remove spine lamina 1 crvl,63045,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Remove spine lamina 1 crvl,63045,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Remove spine lamina 1 crvl,63045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Remove spine lamina 1 crvl,63045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Remove spine lamina 1 crvl,63045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Remove spine lamina 1 crvl,63045,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Remove spine lamina 1 thrc,63046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11673.24,,,,,,,fee schedule,7183.42,31870.39,
Remove spine lamina 1 thrc,63046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9357.12,,,,,,,fee schedule,7183.42,31870.39,
Remove spine lamina 1 thrc,63046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10221.81,,,,,,,fee schedule,7183.42,31870.39,
Remove spine lamina 1 thrc,63046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10746.8,,,,,,,fee schedule,7183.42,31870.39,
Remove spine lamina 1 thrc,63046,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Remove spine lamina 1 thrc,63046,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Remove spine lamina 1 thrc,63046,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Remove spine lamina 1 thrc,63046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Remove spine lamina 1 thrc,63046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Remove spine lamina 1 thrc,63046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Remove spine lamina 1 thrc,63046,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Remove spine lamina 1 lmbr,63047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10746.99,,,,,,,fee schedule,7183.42,31870.39,
Remove spine lamina 1 lmbr,63047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8614.65,,,,,,,fee schedule,7183.42,31870.39,
Remove spine lamina 1 lmbr,63047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9410.72,,,,,,,fee schedule,7183.42,31870.39,
Remove spine lamina 1 lmbr,63047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9894.05,,,,,,,fee schedule,7183.42,31870.39,
Remove spine lamina 1 lmbr,63047,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Remove spine lamina 1 lmbr,63047,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Remove spine lamina 1 lmbr,63047,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Remove spine lamina 1 lmbr,63047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Remove spine lamina 1 lmbr,63047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Remove spine lamina 1 lmbr,63047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Remove spine lamina 1 lmbr,63047,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Remove spinal lamina add-on,63048,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6038.9,,,,,,,fee schedule,4840.71,6038.9,
Remove spinal lamina add-on,63048,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4840.71,,,,,,,fee schedule,4840.71,6038.9,
Remove spinal lamina add-on,63048,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5288.03,,,,,,,fee schedule,4840.71,6038.9,
Remove spinal lamina add-on,63048,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5559.62,,,,,,,fee schedule,4840.71,6038.9,
Decompress spinal cord thrc,63055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11673.24,,,,,,,fee schedule,7183.42,31870.39,
Decompress spinal cord thrc,63055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9357.12,,,,,,,fee schedule,7183.42,31870.39,
Decompress spinal cord thrc,63055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10221.81,,,,,,,fee schedule,7183.42,31870.39,
Decompress spinal cord thrc,63055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10746.8,,,,,,,fee schedule,7183.42,31870.39,
Decompress spinal cord thrc,63055,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Decompress spinal cord thrc,63055,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Decompress spinal cord thrc,63055,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Decompress spinal cord thrc,63055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Decompress spinal cord thrc,63055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Decompress spinal cord thrc,63055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Decompress spinal cord thrc,63055,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Decompress spinal cord lmbr,63056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12077.81,,,,,,,fee schedule,7183.42,31870.39,
Decompress spinal cord lmbr,63056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9681.42,,,,,,,fee schedule,7183.42,31870.39,
Decompress spinal cord lmbr,63056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10576.07,,,,,,,fee schedule,7183.42,31870.39,
Decompress spinal cord lmbr,63056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11119.25,,,,,,,fee schedule,7183.42,31870.39,
Decompress spinal cord lmbr,63056,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Decompress spinal cord lmbr,63056,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Decompress spinal cord lmbr,63056,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Decompress spinal cord lmbr,63056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Decompress spinal cord lmbr,63056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Decompress spinal cord lmbr,63056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Decompress spinal cord lmbr,63056,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Decompress spine cord add-on,63057,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11673.24,,,,,,,fee schedule,9357.12,11673.24,
Decompress spine cord add-on,63057,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9357.12,,,,,,,fee schedule,9357.12,11673.24,
Decompress spine cord add-on,63057,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10221.81,,,,,,,fee schedule,9357.12,11673.24,
Decompress spine cord add-on,63057,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10746.8,,,,,,,fee schedule,9357.12,11673.24,
Decompress spinal cord thrc,63064,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11673.24,,,,,,,fee schedule,7183.42,31870.39,
Decompress spinal cord thrc,63064,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9357.12,,,,,,,fee schedule,7183.42,31870.39,
Decompress spinal cord thrc,63064,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10221.81,,,,,,,fee schedule,7183.42,31870.39,
Decompress spinal cord thrc,63064,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10746.8,,,,,,,fee schedule,7183.42,31870.39,
Decompress spinal cord thrc,63064,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Decompress spinal cord thrc,63064,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Decompress spinal cord thrc,63064,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Decompress spinal cord thrc,63064,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Decompress spinal cord thrc,63064,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Decompress spinal cord thrc,63064,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Decompress spinal cord thrc,63064,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Decompress spine cord add-on,63066,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11673.24,,,,,,,fee schedule,9357.12,11673.24,
Decompress spine cord add-on,63066,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9357.12,,,,,,,fee schedule,9357.12,11673.24,
Decompress spine cord add-on,63066,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10221.81,,,,,,,fee schedule,9357.12,11673.24,
Decompress spine cord add-on,63066,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10746.8,,,,,,,fee schedule,9357.12,11673.24,
Neck spine disk surgery,63075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4025.93,,,,,,,fee schedule,3227.14,31870.39,
Neck spine disk surgery,63075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3227.14,,,,,,,fee schedule,3227.14,31870.39,
Neck spine disk surgery,63075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3525.35,,,,,,,fee schedule,3227.14,31870.39,
Neck spine disk surgery,63075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3706.41,,,,,,,fee schedule,3227.14,31870.39,
Neck spine disk surgery,63075,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,3227.14,31870.39,APC 378
Neck spine disk surgery,63075,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,3227.14,31870.39,APC
Neck spine disk surgery,63075,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,3227.14,31870.39,APC
Neck spine disk surgery,63075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,3227.14,31870.39,APC
Neck spine disk surgery,63075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,3227.14,31870.39,Radiology
Neck spine disk surgery,63075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,3227.14,31870.39,APC
Neck spine disk surgery,63075,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,3227.14,31870.39,APC
Excise intraspinl lesion crv,63265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Excise intraspinl lesion crv,63265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Excise intraspinl lesion crv,63265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Excise intraspinl lesion crv,63265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Excise intraspinl lesion crv,63265,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Excise intraspinl lesion crv,63265,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Excise intraspinl lesion crv,63265,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Excise intraspinl lesion crv,63265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Excise intraspinl lesion crv,63265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Excise intraspinl lesion crv,63265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Excise intraspinl lesion crv,63265,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Excise intrspinl lesion thrc,63266,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Excise intrspinl lesion thrc,63266,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Excise intrspinl lesion thrc,63266,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Excise intrspinl lesion thrc,63266,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Excise intrspinl lesion thrc,63266,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Excise intrspinl lesion thrc,63266,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Excise intrspinl lesion thrc,63266,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Excise intrspinl lesion thrc,63266,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Excise intrspinl lesion thrc,63266,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Excise intrspinl lesion thrc,63266,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Excise intrspinl lesion thrc,63266,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Excise intrspinl lesion lmbr,63267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8122.12,,,,,,,fee schedule,6510.59,31870.39,
Excise intrspinl lesion lmbr,63267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6510.59,,,,,,,fee schedule,6510.59,31870.39,
Excise intrspinl lesion lmbr,63267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7112.23,,,,,,,fee schedule,6510.59,31870.39,
Excise intrspinl lesion lmbr,63267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7477.51,,,,,,,fee schedule,6510.59,31870.39,
Excise intrspinl lesion lmbr,63267,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,6510.59,31870.39,APC 378
Excise intrspinl lesion lmbr,63267,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,6510.59,31870.39,APC
Excise intrspinl lesion lmbr,63267,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,6510.59,31870.39,APC
Excise intrspinl lesion lmbr,63267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,6510.59,31870.39,APC
Excise intrspinl lesion lmbr,63267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,6510.59,31870.39,Radiology
Excise intrspinl lesion lmbr,63267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,6510.59,31870.39,APC
Excise intrspinl lesion lmbr,63267,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,6510.59,31870.39,APC
Excise intrspinl lesion scrl,63268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23681.51,,,,,,,fee schedule,7183.42,31870.39,
Excise intrspinl lesion scrl,63268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18982.8,,,,,,,fee schedule,7183.42,31870.39,
Excise intrspinl lesion scrl,63268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20736.98,,,,,,,fee schedule,7183.42,31870.39,
Excise intrspinl lesion scrl,63268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21802.03,,,,,,,fee schedule,7183.42,31870.39,
Excise intrspinl lesion scrl,63268,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Excise intrspinl lesion scrl,63268,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Excise intrspinl lesion scrl,63268,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Excise intrspinl lesion scrl,63268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Excise intrspinl lesion scrl,63268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Excise intrspinl lesion scrl,63268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Excise intrspinl lesion scrl,63268,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Remove spinal cord lesion,63600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4505.27,,,,,,,fee schedule,1933.13,8576.66,
Remove spinal cord lesion,63600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3611.37,,,,,,,fee schedule,1933.13,8576.66,
Remove spinal cord lesion,63600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3945.09,,,,,,,fee schedule,1933.13,8576.66,
Remove spinal cord lesion,63600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4147.71,,,,,,,fee schedule,1933.13,8576.66,
Remove spinal cord lesion,63600,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8576.66,,,,,,,fee schedule,1933.13,8576.66,APC 378
Remove spinal cord lesion,63600,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2029.79,,,,,,,fee schedule,1933.13,8576.66,APC
Remove spinal cord lesion,63600,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2010.46,,,,,,,fee schedule,1933.13,8576.66,APC
Remove spinal cord lesion,63600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1933.13,,,,,,,fee schedule,1933.13,8576.66,APC
Remove spinal cord lesion,63600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2957.7,,,,,,,fee schedule,1933.13,8576.66,Radiology
Remove spinal cord lesion,63600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2706.39,,,,,,,fee schedule,1933.13,8576.66,APC
Remove spinal cord lesion,63600,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3382.99,,,,,,,fee schedule,1933.13,8576.66,APC
Stimulation of spinal cord,63610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4505.27,,,,,,,fee schedule,1933.13,8576.66,
Stimulation of spinal cord,63610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3611.37,,,,,,,fee schedule,1933.13,8576.66,
Stimulation of spinal cord,63610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3945.09,,,,,,,fee schedule,1933.13,8576.66,
Stimulation of spinal cord,63610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4147.71,,,,,,,fee schedule,1933.13,8576.66,
Stimulation of spinal cord,63610,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8576.66,,,,,,,fee schedule,1933.13,8576.66,APC 378
Stimulation of spinal cord,63610,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2029.79,,,,,,,fee schedule,1933.13,8576.66,APC
Stimulation of spinal cord,63610,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2010.46,,,,,,,fee schedule,1933.13,8576.66,APC
Stimulation of spinal cord,63610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1933.13,,,,,,,fee schedule,1933.13,8576.66,APC
Stimulation of spinal cord,63610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2957.7,,,,,,,fee schedule,1933.13,8576.66,Radiology
Stimulation of spinal cord,63610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2706.39,,,,,,,fee schedule,1933.13,8576.66,APC
Stimulation of spinal cord,63610,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3382.99,,,,,,,fee schedule,1933.13,8576.66,APC
Srs spinal lesion,63620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2696.65,,,,,,,fee schedule,2161.6,2696.65,
Srs spinal lesion,63620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2161.6,,,,,,,fee schedule,2161.6,2696.65,
Srs spinal lesion,63620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2361.35,,,,,,,fee schedule,2161.6,2696.65,
Srs spinal lesion,63620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2482.63,,,,,,,fee schedule,2161.6,2696.65,
Srs spinal lesion addl,63621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,856.21,,,,,,,fee schedule,686.33,856.21,
Srs spinal lesion addl,63621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,686.33,,,,,,,fee schedule,686.33,856.21,
Srs spinal lesion addl,63621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,749.75,,,,,,,fee schedule,686.33,856.21,
Srs spinal lesion addl,63621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,788.25,,,,,,,fee schedule,686.33,856.21,
Implant neuroelectrodes,63650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9296.2,,,,,,,fee schedule,6309.06,27991.15,
Implant neuroelectrodes,63650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7451.72,,,,,,,fee schedule,6309.06,27991.15,
Implant neuroelectrodes,63650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8140.33,,,,,,,fee schedule,6309.06,27991.15,
Implant neuroelectrodes,63650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8558.41,,,,,,,fee schedule,6309.06,27991.15,
Implant neuroelectrodes,63650,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,27991.15,,,,,,,fee schedule,6309.06,27991.15,APC 378
Implant neuroelectrodes,63650,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6624.51,,,,,,,fee schedule,6309.06,27991.15,APC
Implant neuroelectrodes,63650,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6561.42,,,,,,,fee schedule,6309.06,27991.15,APC
Implant neuroelectrodes,63650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6309.06,,,,,,,fee schedule,6309.06,27991.15,APC
Implant neuroelectrodes,63650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9652.86,,,,,,,fee schedule,6309.06,27991.15,Radiology
Implant neuroelectrodes,63650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8832.68,,,,,,,fee schedule,6309.06,27991.15,APC
Implant neuroelectrodes,63650,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11040.85,,,,,,,fee schedule,6309.06,27991.15,APC
Implant neuroelectrodes,63655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2265.54,,,,,,,fee schedule,1816.03,85208.23,
Implant neuroelectrodes,63655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1816.03,,,,,,,fee schedule,1816.03,85208.23,
Implant neuroelectrodes,63655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1983.84,,,,,,,fee schedule,1816.03,85208.23,
Implant neuroelectrodes,63655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2085.73,,,,,,,fee schedule,1816.03,85208.23,
Implant neuroelectrodes,63655,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,85208.23,,,,,,,fee schedule,1816.03,85208.23,APC 378
Implant neuroelectrodes,63655,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20165.76,,,,,,,fee schedule,1816.03,85208.23,APC
Implant neuroelectrodes,63655,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,19973.7,,,,,,,fee schedule,1816.03,85208.23,APC
Implant neuroelectrodes,63655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,19205.48,,,,,,,fee schedule,1816.03,85208.23,APC
Implant neuroelectrodes,63655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29384.39,,,,,,,fee schedule,1816.03,85208.23,Radiology
Implant neuroelectrodes,63655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26887.68,,,,,,,fee schedule,1816.03,85208.23,APC
Implant neuroelectrodes,63655,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,33609.6,,,,,,,fee schedule,1816.03,85208.23,APC
Remove spine eltrd perq aray,63661,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5186.84,,,,,,,fee schedule,1933.13,8576.66,
Remove spine eltrd perq aray,63661,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4157.71,,,,,,,fee schedule,1933.13,8576.66,
Remove spine eltrd perq aray,63661,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4541.92,,,,,,,fee schedule,1933.13,8576.66,
Remove spine eltrd perq aray,63661,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4775.19,,,,,,,fee schedule,1933.13,8576.66,
Remove spine eltrd perq aray,63661,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8576.66,,,,,,,fee schedule,1933.13,8576.66,APC 378
Remove spine eltrd perq aray,63661,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2029.79,,,,,,,fee schedule,1933.13,8576.66,APC
Remove spine eltrd perq aray,63661,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2010.46,,,,,,,fee schedule,1933.13,8576.66,APC
Remove spine eltrd perq aray,63661,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1933.13,,,,,,,fee schedule,1933.13,8576.66,APC
Remove spine eltrd perq aray,63661,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2957.7,,,,,,,fee schedule,1933.13,8576.66,Radiology
Remove spine eltrd perq aray,63661,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2706.39,,,,,,,fee schedule,1933.13,8576.66,APC
Remove spine eltrd perq aray,63661,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3382.99,,,,,,,fee schedule,1933.13,8576.66,APC
Remove spine eltrd plate,63662,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5186.84,,,,,,,fee schedule,3461.03,15355.43,
Remove spine eltrd plate,63662,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4157.71,,,,,,,fee schedule,3461.03,15355.43,
Remove spine eltrd plate,63662,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4541.92,,,,,,,fee schedule,3461.03,15355.43,
Remove spine eltrd plate,63662,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4775.19,,,,,,,fee schedule,3461.03,15355.43,
Remove spine eltrd plate,63662,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15355.43,,,,,,,fee schedule,3461.03,15355.43,APC 378
Remove spine eltrd plate,63662,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3634.08,,,,,,,fee schedule,3461.03,15355.43,APC
Remove spine eltrd plate,63662,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3599.47,,,,,,,fee schedule,3461.03,15355.43,APC
Remove spine eltrd plate,63662,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3461.03,,,,,,,fee schedule,3461.03,15355.43,APC
Remove spine eltrd plate,63662,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5295.38,,,,,,,fee schedule,3461.03,15355.43,Radiology
Remove spine eltrd plate,63662,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4845.44,,,,,,,fee schedule,3461.03,15355.43,APC
Remove spine eltrd plate,63662,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6056.81,,,,,,,fee schedule,3461.03,15355.43,APC
Revise spine eltrd perq aray,63663,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5186.84,,,,,,,fee schedule,4157.71,27991.15,
Revise spine eltrd perq aray,63663,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4157.71,,,,,,,fee schedule,4157.71,27991.15,
Revise spine eltrd perq aray,63663,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4541.92,,,,,,,fee schedule,4157.71,27991.15,
Revise spine eltrd perq aray,63663,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4775.19,,,,,,,fee schedule,4157.71,27991.15,
Revise spine eltrd perq aray,63663,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,27991.15,,,,,,,fee schedule,4157.71,27991.15,APC 378
Revise spine eltrd perq aray,63663,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6624.51,,,,,,,fee schedule,4157.71,27991.15,APC
Revise spine eltrd perq aray,63663,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6561.42,,,,,,,fee schedule,4157.71,27991.15,APC
Revise spine eltrd perq aray,63663,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6309.06,,,,,,,fee schedule,4157.71,27991.15,APC
Revise spine eltrd perq aray,63663,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9652.86,,,,,,,fee schedule,4157.71,27991.15,Radiology
Revise spine eltrd perq aray,63663,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8832.68,,,,,,,fee schedule,4157.71,27991.15,APC
Revise spine eltrd perq aray,63663,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11040.85,,,,,,,fee schedule,4157.71,27991.15,APC
Revise spine eltrd plate,63664,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5186.84,,,,,,,fee schedule,4157.71,48940.4,
Revise spine eltrd plate,63664,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4157.71,,,,,,,fee schedule,4157.71,48940.4,
Revise spine eltrd plate,63664,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4541.92,,,,,,,fee schedule,4157.71,48940.4,
Revise spine eltrd plate,63664,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4775.19,,,,,,,fee schedule,4157.71,48940.4,
Revise spine eltrd plate,63664,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,48940.4,,,,,,,fee schedule,4157.71,48940.4,APC 378
Revise spine eltrd plate,63664,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11582.45,,,,,,,fee schedule,4157.71,48940.4,APC
Revise spine eltrd plate,63664,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11472.14,,,,,,,fee schedule,4157.71,48940.4,APC
Revise spine eltrd plate,63664,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11030.91,,,,,,,fee schedule,4157.71,48940.4,APC
Revise spine eltrd plate,63664,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16877.29,,,,,,,fee schedule,4157.71,48940.4,Radiology
Revise spine eltrd plate,63664,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15443.27,,,,,,,fee schedule,4157.71,48940.4,APC
Revise spine eltrd plate,63664,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19304.09,,,,,,,fee schedule,4157.71,48940.4,APC
Insrt/redo spine n generator,63685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4531.07,,,,,,,fee schedule,3632.05,135531.68,
Insrt/redo spine n generator,63685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3632.05,,,,,,,fee schedule,3632.05,135531.68,
Insrt/redo spine n generator,63685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3967.69,,,,,,,fee schedule,3632.05,135531.68,
Insrt/redo spine n generator,63685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4171.46,,,,,,,fee schedule,3632.05,135531.68,
Insrt/redo spine n generator,63685,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,135531.68,,,,,,,fee schedule,3632.05,135531.68,APC 378
Insrt/redo spine n generator,63685,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,32075.53,,,,,,,fee schedule,3632.05,135531.68,APC
Insrt/redo spine n generator,63685,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,31770.05,,,,,,,fee schedule,3632.05,135531.68,APC
Insrt/redo spine n generator,63685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,30548.12,,,,,,,fee schedule,3632.05,135531.68,APC
Insrt/redo spine n generator,63685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,46738.63,,,,,,,fee schedule,3632.05,135531.68,Radiology
Insrt/redo spine n generator,63685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,42767.37,,,,,,,fee schedule,3632.05,135531.68,APC
Insrt/redo spine n generator,63685,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,53459.21,,,,,,,fee schedule,3632.05,135531.68,APC
Revise/remove neuroreceiver,63688,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8589.52,,,,,,,fee schedule,3461.03,15355.43,
Revise/remove neuroreceiver,63688,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6885.25,,,,,,,fee schedule,3461.03,15355.43,
Revise/remove neuroreceiver,63688,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7521.51,,,,,,,fee schedule,3461.03,15355.43,
Revise/remove neuroreceiver,63688,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7907.81,,,,,,,fee schedule,3461.03,15355.43,
Revise/remove neuroreceiver,63688,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15355.43,,,,,,,fee schedule,3461.03,15355.43,APC 378
Revise/remove neuroreceiver,63688,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3634.08,,,,,,,fee schedule,3461.03,15355.43,APC
Revise/remove neuroreceiver,63688,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3599.47,,,,,,,fee schedule,3461.03,15355.43,APC
Revise/remove neuroreceiver,63688,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3461.03,,,,,,,fee schedule,3461.03,15355.43,APC
Revise/remove neuroreceiver,63688,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5295.38,,,,,,,fee schedule,3461.03,15355.43,Radiology
Revise/remove neuroreceiver,63688,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4845.44,,,,,,,fee schedule,3461.03,15355.43,APC
Revise/remove neuroreceiver,63688,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6056.81,,,,,,,fee schedule,3461.03,15355.43,APC
Install spinal shunt,63741,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9053.78,,,,,,,fee schedule,7257.4,38544.86,
Install spinal shunt,63741,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7257.4,,,,,,,fee schedule,7257.4,38544.86,
Install spinal shunt,63741,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7928.05,,,,,,,fee schedule,7257.4,38544.86,
Install spinal shunt,63741,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8335.23,,,,,,,fee schedule,7257.4,38544.86,
Install spinal shunt,63741,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,38544.86,,,,,,,fee schedule,7257.4,38544.86,APC 378
Install spinal shunt,63741,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9122.2,,,,,,,fee schedule,7257.4,38544.86,APC
Install spinal shunt,63741,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9035.32,,,,,,,fee schedule,7257.4,38544.86,APC
Install spinal shunt,63741,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8687.81,,,,,,,fee schedule,7257.4,38544.86,APC
Install spinal shunt,63741,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13292.34,,,,,,,fee schedule,7257.4,38544.86,Radiology
Install spinal shunt,63741,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12162.93,,,,,,,fee schedule,7257.4,38544.86,APC
Install spinal shunt,63741,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15203.66,,,,,,,fee schedule,7257.4,38544.86,APC
Revision of spinal shunt,63744,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9053.78,,,,,,,fee schedule,3381.88,15004.24,
Revision of spinal shunt,63744,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7257.4,,,,,,,fee schedule,3381.88,15004.24,
Revision of spinal shunt,63744,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7928.05,,,,,,,fee schedule,3381.88,15004.24,
Revision of spinal shunt,63744,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8335.23,,,,,,,fee schedule,3381.88,15004.24,
Revision of spinal shunt,63744,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15004.24,,,,,,,fee schedule,3381.88,15004.24,APC 378
Revision of spinal shunt,63744,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3550.97,,,,,,,fee schedule,3381.88,15004.24,APC
Revision of spinal shunt,63744,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3517.15,,,,,,,fee schedule,3381.88,15004.24,APC
Revision of spinal shunt,63744,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3381.88,,,,,,,fee schedule,3381.88,15004.24,APC
Revision of spinal shunt,63744,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5174.27,,,,,,,fee schedule,3381.88,15004.24,Radiology
Revision of spinal shunt,63744,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4734.63,,,,,,,fee schedule,3381.88,15004.24,APC
Revision of spinal shunt,63744,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5918.28,,,,,,,fee schedule,3381.88,15004.24,APC
Removal of spinal shunt,63746,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1412.96,,,,,,,fee schedule,1132.61,8576.66,
Removal of spinal shunt,63746,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1132.61,,,,,,,fee schedule,1132.61,8576.66,
Removal of spinal shunt,63746,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1237.28,,,,,,,fee schedule,1132.61,8576.66,
Removal of spinal shunt,63746,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1300.82,,,,,,,fee schedule,1132.61,8576.66,
Removal of spinal shunt,63746,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8576.66,,,,,,,fee schedule,1132.61,8576.66,APC 378
Removal of spinal shunt,63746,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2029.79,,,,,,,fee schedule,1132.61,8576.66,APC
Removal of spinal shunt,63746,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2010.46,,,,,,,fee schedule,1132.61,8576.66,APC
Removal of spinal shunt,63746,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1933.13,,,,,,,fee schedule,1132.61,8576.66,APC
Removal of spinal shunt,63746,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2957.7,,,,,,,fee schedule,1132.61,8576.66,Radiology
Removal of spinal shunt,63746,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2706.39,,,,,,,fee schedule,1132.61,8576.66,APC
Removal of spinal shunt,63746,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3382.99,,,,,,,fee schedule,1132.61,8576.66,APC
N block inj trigeminal,64400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,753.1,,,,,,,fee schedule,303.87,1348.18,
N block inj trigeminal,64400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,603.68,,,,,,,fee schedule,303.87,1348.18,
N block inj trigeminal,64400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,659.46,,,,,,,fee schedule,303.87,1348.18,
N block inj trigeminal,64400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,693.33,,,,,,,fee schedule,303.87,1348.18,
N block inj trigeminal,64400,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1348.18,,,,,,,fee schedule,303.87,1348.18,APC 378
N block inj trigeminal,64400,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,319.07,,,,,,,fee schedule,303.87,1348.18,APC
N block inj trigeminal,64400,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,316.03,,,,,,,fee schedule,303.87,1348.18,APC
N block inj trigeminal,64400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,303.87,,,,,,,fee schedule,303.87,1348.18,APC
N block inj trigeminal,64400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,464.92,,,,,,,fee schedule,303.87,1348.18,Radiology
N block inj trigeminal,64400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,425.42,,,,,,,fee schedule,303.87,1348.18,APC
N block inj trigeminal,64400,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,531.78,,,,,,,fee schedule,303.87,1348.18,APC
N block inj occipital,64405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,719.24,,,,,,,fee schedule,303.87,1348.18,
N block inj occipital,64405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,576.53,,,,,,,fee schedule,303.87,1348.18,
N block inj occipital,64405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,629.81,,,,,,,fee schedule,303.87,1348.18,
N block inj occipital,64405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,662.16,,,,,,,fee schedule,303.87,1348.18,
N block inj occipital,64405,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1348.18,,,,,,,fee schedule,303.87,1348.18,APC 378
N block inj occipital,64405,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,319.07,,,,,,,fee schedule,303.87,1348.18,APC
N block inj occipital,64405,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,316.03,,,,,,,fee schedule,303.87,1348.18,APC
N block inj occipital,64405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,303.87,,,,,,,fee schedule,303.87,1348.18,APC
N block inj occipital,64405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,464.92,,,,,,,fee schedule,303.87,1348.18,Radiology
N block inj occipital,64405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,425.42,,,,,,,fee schedule,303.87,1348.18,APC
N block inj occipital,64405,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,531.78,,,,,,,fee schedule,303.87,1348.18,APC
N block inj vagus,64408,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1022.38,,,,,,,fee schedule,303.87,1348.18,
N block inj vagus,64408,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,819.52,,,,,,,fee schedule,303.87,1348.18,
N block inj vagus,64408,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,895.26,,,,,,,fee schedule,303.87,1348.18,
N block inj vagus,64408,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,941.24,,,,,,,fee schedule,303.87,1348.18,
N block inj vagus,64408,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1348.18,,,,,,,fee schedule,303.87,1348.18,APC 378
N block inj vagus,64408,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,319.07,,,,,,,fee schedule,303.87,1348.18,APC
N block inj vagus,64408,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,316.03,,,,,,,fee schedule,303.87,1348.18,APC
N block inj vagus,64408,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,303.87,,,,,,,fee schedule,303.87,1348.18,APC
N block inj vagus,64408,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,464.92,,,,,,,fee schedule,303.87,1348.18,Radiology
N block inj vagus,64408,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,425.42,,,,,,,fee schedule,303.87,1348.18,APC
N block inj vagus,64408,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,531.78,,,,,,,fee schedule,303.87,1348.18,APC
N block inj brachial plexus,64415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2903.05,,,,,,,fee schedule,875.6,3884.74,
N block inj brachial plexus,64415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2327.05,,,,,,,fee schedule,875.6,3884.74,
N block inj brachial plexus,64415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2542.09,,,,,,,fee schedule,875.6,3884.74,
N block inj brachial plexus,64415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2672.65,,,,,,,fee schedule,875.6,3884.74,
N block inj brachial plexus,64415,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3884.74,,,,,,,fee schedule,875.6,3884.74,APC 378
N block inj brachial plexus,64415,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,919.38,,,,,,,fee schedule,875.6,3884.74,APC
N block inj brachial plexus,64415,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,910.62,,,,,,,fee schedule,875.6,3884.74,APC
N block inj brachial plexus,64415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,875.6,,,,,,,fee schedule,875.6,3884.74,APC
N block inj brachial plexus,64415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1339.67,,,,,,,fee schedule,875.6,3884.74,Radiology
N block inj brachial plexus,64415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1225.84,,,,,,,fee schedule,875.6,3884.74,APC
N block inj brachial plexus,64415,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1532.3,,,,,,,fee schedule,875.6,3884.74,APC
N block cont infuse b plex,64416,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1760.69,,,,,,,fee schedule,875.6,3884.74,
N block cont infuse b plex,64416,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1411.34,,,,,,,fee schedule,875.6,3884.74,
N block cont infuse b plex,64416,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1541.76,,,,,,,fee schedule,875.6,3884.74,
N block cont infuse b plex,64416,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1620.95,,,,,,,fee schedule,875.6,3884.74,
N block cont infuse b plex,64416,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3884.74,,,,,,,fee schedule,875.6,3884.74,APC 378
N block cont infuse b plex,64416,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,919.38,,,,,,,fee schedule,875.6,3884.74,APC
N block cont infuse b plex,64416,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,910.62,,,,,,,fee schedule,875.6,3884.74,APC
N block cont infuse b plex,64416,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,875.6,,,,,,,fee schedule,875.6,3884.74,APC
N block cont infuse b plex,64416,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1339.67,,,,,,,fee schedule,875.6,3884.74,Radiology
N block cont infuse b plex,64416,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1225.84,,,,,,,fee schedule,875.6,3884.74,APC
N block cont infuse b plex,64416,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1532.3,,,,,,,fee schedule,875.6,3884.74,APC
N block inj axillary,64417,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1022.38,,,,,,,fee schedule,819.52,3884.74,
N block inj axillary,64417,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,819.52,,,,,,,fee schedule,819.52,3884.74,
N block inj axillary,64417,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,895.26,,,,,,,fee schedule,819.52,3884.74,
N block inj axillary,64417,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,941.24,,,,,,,fee schedule,819.52,3884.74,
N block inj axillary,64417,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3884.74,,,,,,,fee schedule,819.52,3884.74,APC 378
N block inj axillary,64417,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,919.38,,,,,,,fee schedule,819.52,3884.74,APC
N block inj axillary,64417,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,910.62,,,,,,,fee schedule,819.52,3884.74,APC
N block inj axillary,64417,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,875.6,,,,,,,fee schedule,819.52,3884.74,APC
N block inj axillary,64417,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1339.67,,,,,,,fee schedule,819.52,3884.74,Radiology
N block inj axillary,64417,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1225.84,,,,,,,fee schedule,819.52,3884.74,APC
N block inj axillary,64417,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1532.3,,,,,,,fee schedule,819.52,3884.74,APC
N block inj suprascapular,64418,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1022.38,,,,,,,fee schedule,698.8,3100.34,
N block inj suprascapular,64418,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,819.52,,,,,,,fee schedule,698.8,3100.34,
N block inj suprascapular,64418,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,895.26,,,,,,,fee schedule,698.8,3100.34,
N block inj suprascapular,64418,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,941.24,,,,,,,fee schedule,698.8,3100.34,
N block inj suprascapular,64418,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3100.34,,,,,,,fee schedule,698.8,3100.34,APC 378
N block inj suprascapular,64418,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,733.74,,,,,,,fee schedule,698.8,3100.34,APC
N block inj suprascapular,64418,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,726.75,,,,,,,fee schedule,698.8,3100.34,APC
N block inj suprascapular,64418,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,698.8,,,,,,,fee schedule,698.8,3100.34,APC
N block inj suprascapular,64418,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1069.16,,,,,,,fee schedule,698.8,3100.34,Radiology
N block inj suprascapular,64418,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,978.32,,,,,,,fee schedule,698.8,3100.34,APC
N block inj suprascapular,64418,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1222.9,,,,,,,fee schedule,698.8,3100.34,APC
N block inj intercost sng,64420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,697.84,,,,,,,fee schedule,559.38,3100.34,
N block inj intercost sng,64420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,559.38,,,,,,,fee schedule,559.38,3100.34,
N block inj intercost sng,64420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,611.07,,,,,,,fee schedule,559.38,3100.34,
N block inj intercost sng,64420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,642.45,,,,,,,fee schedule,559.38,3100.34,
N block inj intercost sng,64420,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3100.34,,,,,,,fee schedule,559.38,3100.34,APC 378
N block inj intercost sng,64420,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,733.74,,,,,,,fee schedule,559.38,3100.34,APC
N block inj intercost sng,64420,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,726.75,,,,,,,fee schedule,559.38,3100.34,APC
N block inj intercost sng,64420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,698.8,,,,,,,fee schedule,559.38,3100.34,APC
N block inj intercost sng,64420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1069.16,,,,,,,fee schedule,559.38,3100.34,Radiology
N block inj intercost sng,64420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,978.32,,,,,,,fee schedule,559.38,3100.34,APC
N block inj intercost sng,64420,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1222.9,,,,,,,fee schedule,559.38,3100.34,APC
N block inj intercost mlt,64421,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1022.38,,,,,,,fee schedule,819.52,3884.74,
N block inj intercost mlt,64421,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,819.52,,,,,,,fee schedule,819.52,3884.74,
N block inj intercost mlt,64421,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,895.26,,,,,,,fee schedule,819.52,3884.74,
N block inj intercost mlt,64421,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,941.24,,,,,,,fee schedule,819.52,3884.74,
N block inj intercost mlt,64421,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3884.74,,,,,,,fee schedule,819.52,3884.74,APC 378
N block inj intercost mlt,64421,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,919.38,,,,,,,fee schedule,819.52,3884.74,APC
N block inj intercost mlt,64421,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,910.62,,,,,,,fee schedule,819.52,3884.74,APC
N block inj intercost mlt,64421,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,875.6,,,,,,,fee schedule,819.52,3884.74,APC
N block inj intercost mlt,64421,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1339.67,,,,,,,fee schedule,819.52,3884.74,Radiology
N block inj intercost mlt,64421,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1225.84,,,,,,,fee schedule,819.52,3884.74,APC
N block inj intercost mlt,64421,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1532.3,,,,,,,fee schedule,819.52,3884.74,APC
N block inj ilio-ing/hypogi,64425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1022.38,,,,,,,fee schedule,698.8,3100.34,
N block inj ilio-ing/hypogi,64425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,819.52,,,,,,,fee schedule,698.8,3100.34,
N block inj ilio-ing/hypogi,64425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,895.26,,,,,,,fee schedule,698.8,3100.34,
N block inj ilio-ing/hypogi,64425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,941.24,,,,,,,fee schedule,698.8,3100.34,
N block inj ilio-ing/hypogi,64425,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3100.34,,,,,,,fee schedule,698.8,3100.34,APC 378
N block inj ilio-ing/hypogi,64425,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,733.74,,,,,,,fee schedule,698.8,3100.34,APC
N block inj ilio-ing/hypogi,64425,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,726.75,,,,,,,fee schedule,698.8,3100.34,APC
N block inj ilio-ing/hypogi,64425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,698.8,,,,,,,fee schedule,698.8,3100.34,APC
N block inj ilio-ing/hypogi,64425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1069.16,,,,,,,fee schedule,698.8,3100.34,Radiology
N block inj ilio-ing/hypogi,64425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,978.32,,,,,,,fee schedule,698.8,3100.34,APC
N block inj ilio-ing/hypogi,64425,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1222.9,,,,,,,fee schedule,698.8,3100.34,APC
N block inj pudendal,64430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1760.69,,,,,,,fee schedule,875.6,3884.74,
N block inj pudendal,64430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1411.34,,,,,,,fee schedule,875.6,3884.74,
N block inj pudendal,64430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1541.76,,,,,,,fee schedule,875.6,3884.74,
N block inj pudendal,64430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1620.95,,,,,,,fee schedule,875.6,3884.74,
N block inj pudendal,64430,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3884.74,,,,,,,fee schedule,875.6,3884.74,APC 378
N block inj pudendal,64430,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,919.38,,,,,,,fee schedule,875.6,3884.74,APC
N block inj pudendal,64430,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,910.62,,,,,,,fee schedule,875.6,3884.74,APC
N block inj pudendal,64430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,875.6,,,,,,,fee schedule,875.6,3884.74,APC
N block inj pudendal,64430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1339.67,,,,,,,fee schedule,875.6,3884.74,Radiology
N block inj pudendal,64430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1225.84,,,,,,,fee schedule,875.6,3884.74,APC
N block inj pudendal,64430,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1532.3,,,,,,,fee schedule,875.6,3884.74,APC
N block inj paracervical,64435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1022.38,,,,,,,fee schedule,698.8,3100.34,
N block inj paracervical,64435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,819.52,,,,,,,fee schedule,698.8,3100.34,
N block inj paracervical,64435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,895.26,,,,,,,fee schedule,698.8,3100.34,
N block inj paracervical,64435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,941.24,,,,,,,fee schedule,698.8,3100.34,
N block inj paracervical,64435,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3100.34,,,,,,,fee schedule,698.8,3100.34,APC 378
N block inj paracervical,64435,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,733.74,,,,,,,fee schedule,698.8,3100.34,APC
N block inj paracervical,64435,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,726.75,,,,,,,fee schedule,698.8,3100.34,APC
N block inj paracervical,64435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,698.8,,,,,,,fee schedule,698.8,3100.34,APC
N block inj paracervical,64435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1069.16,,,,,,,fee schedule,698.8,3100.34,Radiology
N block inj paracervical,64435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,978.32,,,,,,,fee schedule,698.8,3100.34,APC
N block inj paracervical,64435,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1222.9,,,,,,,fee schedule,698.8,3100.34,APC
N block inj sciatic sng,64445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4297.02,,,,,,,fee schedule,698.8,4297.02,
N block inj sciatic sng,64445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3444.43,,,,,,,fee schedule,698.8,4297.02,
N block inj sciatic sng,64445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3762.73,,,,,,,fee schedule,698.8,4297.02,
N block inj sciatic sng,64445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3955.98,,,,,,,fee schedule,698.8,4297.02,
N block inj sciatic sng,64445,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3100.34,,,,,,,fee schedule,698.8,4297.02,APC 378
N block inj sciatic sng,64445,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,733.74,,,,,,,fee schedule,698.8,4297.02,APC
N block inj sciatic sng,64445,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,726.75,,,,,,,fee schedule,698.8,4297.02,APC
N block inj sciatic sng,64445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,698.8,,,,,,,fee schedule,698.8,4297.02,APC
N block inj sciatic sng,64445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1069.16,,,,,,,fee schedule,698.8,4297.02,Radiology
N block inj sciatic sng,64445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,978.32,,,,,,,fee schedule,698.8,4297.02,APC
N block inj sciatic sng,64445,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1222.9,,,,,,,fee schedule,698.8,4297.02,APC
N blk inj sciatic cont inf,64446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3615.8,,,,,,,fee schedule,875.6,3884.74,
N blk inj sciatic cont inf,64446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2898.38,,,,,,,fee schedule,875.6,3884.74,
N blk inj sciatic cont inf,64446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3166.21,,,,,,,fee schedule,875.6,3884.74,
N blk inj sciatic cont inf,64446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3328.83,,,,,,,fee schedule,875.6,3884.74,
N blk inj sciatic cont inf,64446,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3884.74,,,,,,,fee schedule,875.6,3884.74,APC 378
N blk inj sciatic cont inf,64446,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,919.38,,,,,,,fee schedule,875.6,3884.74,APC
N blk inj sciatic cont inf,64446,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,910.62,,,,,,,fee schedule,875.6,3884.74,APC
N blk inj sciatic cont inf,64446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,875.6,,,,,,,fee schedule,875.6,3884.74,APC
N blk inj sciatic cont inf,64446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1339.67,,,,,,,fee schedule,875.6,3884.74,Radiology
N blk inj sciatic cont inf,64446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1225.84,,,,,,,fee schedule,875.6,3884.74,APC
N blk inj sciatic cont inf,64446,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1532.3,,,,,,,fee schedule,875.6,3884.74,APC
N block inj fem single,64447,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5804.85,,,,,,,fee schedule,698.8,5804.85,
N block inj fem single,64447,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4653.09,,,,,,,fee schedule,698.8,5804.85,
N block inj fem single,64447,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5083.08,,,,,,,fee schedule,698.8,5804.85,
N block inj fem single,64447,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5344.14,,,,,,,fee schedule,698.8,5804.85,
N block inj fem single,64447,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3100.34,,,,,,,fee schedule,698.8,5804.85,APC 378
N block inj fem single,64447,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,733.74,,,,,,,fee schedule,698.8,5804.85,APC
N block inj fem single,64447,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,726.75,,,,,,,fee schedule,698.8,5804.85,APC
N block inj fem single,64447,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,698.8,,,,,,,fee schedule,698.8,5804.85,APC
N block inj fem single,64447,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1069.16,,,,,,,fee schedule,698.8,5804.85,Radiology
N block inj fem single,64447,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,978.32,,,,,,,fee schedule,698.8,5804.85,APC
N block inj fem single,64447,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1222.9,,,,,,,fee schedule,698.8,5804.85,APC
N block inj fem cont inf,64448,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1022.38,,,,,,,fee schedule,819.52,3884.74,
N block inj fem cont inf,64448,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,819.52,,,,,,,fee schedule,819.52,3884.74,
N block inj fem cont inf,64448,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,895.26,,,,,,,fee schedule,819.52,3884.74,
N block inj fem cont inf,64448,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,941.24,,,,,,,fee schedule,819.52,3884.74,
N block inj fem cont inf,64448,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3884.74,,,,,,,fee schedule,819.52,3884.74,APC 378
N block inj fem cont inf,64448,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,919.38,,,,,,,fee schedule,819.52,3884.74,APC
N block inj fem cont inf,64448,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,910.62,,,,,,,fee schedule,819.52,3884.74,APC
N block inj fem cont inf,64448,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,875.6,,,,,,,fee schedule,819.52,3884.74,APC
N block inj fem cont inf,64448,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1339.67,,,,,,,fee schedule,819.52,3884.74,Radiology
N block inj fem cont inf,64448,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1225.84,,,,,,,fee schedule,819.52,3884.74,APC
N block inj fem cont inf,64448,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1532.3,,,,,,,fee schedule,819.52,3884.74,APC
N block inj lumbar plexus,64449,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1760.69,,,,,,,fee schedule,875.6,3884.74,
N block inj lumbar plexus,64449,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1411.34,,,,,,,fee schedule,875.6,3884.74,
N block inj lumbar plexus,64449,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1541.76,,,,,,,fee schedule,875.6,3884.74,
N block inj lumbar plexus,64449,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1620.95,,,,,,,fee schedule,875.6,3884.74,
N block inj lumbar plexus,64449,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3884.74,,,,,,,fee schedule,875.6,3884.74,APC 378
N block inj lumbar plexus,64449,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,919.38,,,,,,,fee schedule,875.6,3884.74,APC
N block inj lumbar plexus,64449,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,910.62,,,,,,,fee schedule,875.6,3884.74,APC
N block inj lumbar plexus,64449,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,875.6,,,,,,,fee schedule,875.6,3884.74,APC
N block inj lumbar plexus,64449,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1339.67,,,,,,,fee schedule,875.6,3884.74,Radiology
N block inj lumbar plexus,64449,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1225.84,,,,,,,fee schedule,875.6,3884.74,APC
N block inj lumbar plexus,64449,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1532.3,,,,,,,fee schedule,875.6,3884.74,APC
N block other peripheral,64450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,864.71,,,,,,,fee schedule,693.14,3100.34,
N block other peripheral,64450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,693.14,,,,,,,fee schedule,693.14,3100.34,
N block other peripheral,64450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,757.2,,,,,,,fee schedule,693.14,3100.34,
N block other peripheral,64450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,796.08,,,,,,,fee schedule,693.14,3100.34,
N block other peripheral,64450,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3100.34,,,,,,,fee schedule,693.14,3100.34,APC 378
N block other peripheral,64450,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,733.74,,,,,,,fee schedule,693.14,3100.34,APC
N block other peripheral,64450,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,726.75,,,,,,,fee schedule,693.14,3100.34,APC
N block other peripheral,64450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,698.8,,,,,,,fee schedule,693.14,3100.34,APC
N block other peripheral,64450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1069.16,,,,,,,fee schedule,693.14,3100.34,Radiology
N block other peripheral,64450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,978.32,,,,,,,fee schedule,693.14,3100.34,APC
N block other peripheral,64450,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1222.9,,,,,,,fee schedule,693.14,3100.34,APC
Njx aa&/strd nrv nrvtg si jt,64451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2362.69,,,,,,,fee schedule,698.8,3100.34,
Njx aa&/strd nrv nrvtg si jt,64451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1893.9,,,,,,,fee schedule,698.8,3100.34,
Njx aa&/strd nrv nrvtg si jt,64451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2068.92,,,,,,,fee schedule,698.8,3100.34,
Njx aa&/strd nrv nrvtg si jt,64451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2175.17,,,,,,,fee schedule,698.8,3100.34,
Njx aa&/strd nrv nrvtg si jt,64451,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3100.34,,,,,,,fee schedule,698.8,3100.34,APC 378
Njx aa&/strd nrv nrvtg si jt,64451,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,733.74,,,,,,,fee schedule,698.8,3100.34,APC
Njx aa&/strd nrv nrvtg si jt,64451,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,726.75,,,,,,,fee schedule,698.8,3100.34,APC
Njx aa&/strd nrv nrvtg si jt,64451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,698.8,,,,,,,fee schedule,698.8,3100.34,APC
Njx aa&/strd nrv nrvtg si jt,64451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1069.16,,,,,,,fee schedule,698.8,3100.34,Radiology
Njx aa&/strd nrv nrvtg si jt,64451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,978.32,,,,,,,fee schedule,698.8,3100.34,APC
Njx aa&/strd nrv nrvtg si jt,64451,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1222.9,,,,,,,fee schedule,698.8,3100.34,APC
Njx aa&/strd gnclr nrv brnch,64454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2362.69,,,,,,,fee schedule,698.8,3100.34,
Njx aa&/strd gnclr nrv brnch,64454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1893.9,,,,,,,fee schedule,698.8,3100.34,
Njx aa&/strd gnclr nrv brnch,64454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2068.92,,,,,,,fee schedule,698.8,3100.34,
Njx aa&/strd gnclr nrv brnch,64454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2175.17,,,,,,,fee schedule,698.8,3100.34,
Njx aa&/strd gnclr nrv brnch,64454,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3100.34,,,,,,,fee schedule,698.8,3100.34,APC 378
Njx aa&/strd gnclr nrv brnch,64454,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,733.74,,,,,,,fee schedule,698.8,3100.34,APC
Njx aa&/strd gnclr nrv brnch,64454,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,726.75,,,,,,,fee schedule,698.8,3100.34,APC
Njx aa&/strd gnclr nrv brnch,64454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,698.8,,,,,,,fee schedule,698.8,3100.34,APC
Njx aa&/strd gnclr nrv brnch,64454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1069.16,,,,,,,fee schedule,698.8,3100.34,Radiology
Njx aa&/strd gnclr nrv brnch,64454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,978.32,,,,,,,fee schedule,698.8,3100.34,APC
Njx aa&/strd gnclr nrv brnch,64454,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1222.9,,,,,,,fee schedule,698.8,3100.34,APC
N block inj plantar digit,64455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5336.73,,,,,,,fee schedule,303.87,5336.73,
N block inj plantar digit,64455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4277.86,,,,,,,fee schedule,303.87,5336.73,
N block inj plantar digit,64455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4673.17,,,,,,,fee schedule,303.87,5336.73,
N block inj plantar digit,64455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4913.18,,,,,,,fee schedule,303.87,5336.73,
N block inj plantar digit,64455,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1348.18,,,,,,,fee schedule,303.87,5336.73,APC 378
N block inj plantar digit,64455,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,319.07,,,,,,,fee schedule,303.87,5336.73,APC
N block inj plantar digit,64455,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,316.03,,,,,,,fee schedule,303.87,5336.73,APC
N block inj plantar digit,64455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,303.87,,,,,,,fee schedule,303.87,5336.73,APC
N block inj plantar digit,64455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,464.92,,,,,,,fee schedule,303.87,5336.73,Radiology
N block inj plantar digit,64455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,425.42,,,,,,,fee schedule,303.87,5336.73,APC
N block inj plantar digit,64455,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,531.78,,,,,,,fee schedule,303.87,5336.73,APC
Pvb thoracic single inj site,64461,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2211.94,,,,,,,fee schedule,698.8,3100.34,
Pvb thoracic single inj site,64461,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1773.07,,,,,,,fee schedule,698.8,3100.34,
Pvb thoracic single inj site,64461,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1936.91,,,,,,,fee schedule,698.8,3100.34,
Pvb thoracic single inj site,64461,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2036.39,,,,,,,fee schedule,698.8,3100.34,
Pvb thoracic single inj site,64461,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3100.34,,,,,,,fee schedule,698.8,3100.34,APC 378
Pvb thoracic single inj site,64461,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,733.74,,,,,,,fee schedule,698.8,3100.34,APC
Pvb thoracic single inj site,64461,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,726.75,,,,,,,fee schedule,698.8,3100.34,APC
Pvb thoracic single inj site,64461,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,698.8,,,,,,,fee schedule,698.8,3100.34,APC
Pvb thoracic single inj site,64461,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1069.16,,,,,,,fee schedule,698.8,3100.34,Radiology
Pvb thoracic single inj site,64461,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,978.32,,,,,,,fee schedule,698.8,3100.34,APC
Pvb thoracic single inj site,64461,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1222.9,,,,,,,fee schedule,698.8,3100.34,APC
Pvb thoracic 2nd+ inj site,64462,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,210.62,,,,,,,fee schedule,168.83,210.62,
Pvb thoracic 2nd+ inj site,64462,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,168.83,,,,,,,fee schedule,168.83,210.62,
Pvb thoracic 2nd+ inj site,64462,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,184.43,,,,,,,fee schedule,168.83,210.62,
Pvb thoracic 2nd+ inj site,64462,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,193.91,,,,,,,fee schedule,168.83,210.62,
Pvb thoracic cont infusion,64463,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2211.94,,,,,,,fee schedule,698.8,3100.34,
Pvb thoracic cont infusion,64463,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1773.07,,,,,,,fee schedule,698.8,3100.34,
Pvb thoracic cont infusion,64463,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1936.91,,,,,,,fee schedule,698.8,3100.34,
Pvb thoracic cont infusion,64463,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2036.39,,,,,,,fee schedule,698.8,3100.34,
Pvb thoracic cont infusion,64463,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3100.34,,,,,,,fee schedule,698.8,3100.34,APC 378
Pvb thoracic cont infusion,64463,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,733.74,,,,,,,fee schedule,698.8,3100.34,APC
Pvb thoracic cont infusion,64463,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,726.75,,,,,,,fee schedule,698.8,3100.34,APC
Pvb thoracic cont infusion,64463,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,698.8,,,,,,,fee schedule,698.8,3100.34,APC
Pvb thoracic cont infusion,64463,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1069.16,,,,,,,fee schedule,698.8,3100.34,Radiology
Pvb thoracic cont infusion,64463,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,978.32,,,,,,,fee schedule,698.8,3100.34,APC
Pvb thoracic cont infusion,64463,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1222.9,,,,,,,fee schedule,698.8,3100.34,APC
Inj foramen epidural c/t,64479,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2331.37,,,,,,,fee schedule,875.6,3884.74,
Inj foramen epidural c/t,64479,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1868.79,,,,,,,fee schedule,875.6,3884.74,
Inj foramen epidural c/t,64479,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2041.49,,,,,,,fee schedule,875.6,3884.74,
Inj foramen epidural c/t,64479,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2146.34,,,,,,,fee schedule,875.6,3884.74,
Inj foramen epidural c/t,64479,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3884.74,,,,,,,fee schedule,875.6,3884.74,APC 378
Inj foramen epidural c/t,64479,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,919.38,,,,,,,fee schedule,875.6,3884.74,APC
Inj foramen epidural c/t,64479,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,910.62,,,,,,,fee schedule,875.6,3884.74,APC
Inj foramen epidural c/t,64479,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,875.6,,,,,,,fee schedule,875.6,3884.74,APC
Inj foramen epidural c/t,64479,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1339.67,,,,,,,fee schedule,875.6,3884.74,Radiology
Inj foramen epidural c/t,64479,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1225.84,,,,,,,fee schedule,875.6,3884.74,APC
Inj foramen epidural c/t,64479,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1532.3,,,,,,,fee schedule,875.6,3884.74,APC
Inj foramen epidural add-on,64480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1022.38,,,,,,,fee schedule,819.52,1022.38,
Inj foramen epidural add-on,64480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,819.52,,,,,,,fee schedule,819.52,1022.38,
Inj foramen epidural add-on,64480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,895.26,,,,,,,fee schedule,819.52,1022.38,
Inj foramen epidural add-on,64480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,941.24,,,,,,,fee schedule,819.52,1022.38,
Inj foramen epidural l/s,64483,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1921.95,,,,,,,fee schedule,875.6,3884.74,
Inj foramen epidural l/s,64483,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1540.61,,,,,,,fee schedule,875.6,3884.74,
Inj foramen epidural l/s,64483,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1682.97,,,,,,,fee schedule,875.6,3884.74,
Inj foramen epidural l/s,64483,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1769.41,,,,,,,fee schedule,875.6,3884.74,
Inj foramen epidural l/s,64483,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3884.74,,,,,,,fee schedule,875.6,3884.74,APC 378
Inj foramen epidural l/s,64483,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,919.38,,,,,,,fee schedule,875.6,3884.74,APC
Inj foramen epidural l/s,64483,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,910.62,,,,,,,fee schedule,875.6,3884.74,APC
Inj foramen epidural l/s,64483,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,875.6,,,,,,,fee schedule,875.6,3884.74,APC
Inj foramen epidural l/s,64483,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1339.67,,,,,,,fee schedule,875.6,3884.74,Radiology
Inj foramen epidural l/s,64483,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1225.84,,,,,,,fee schedule,875.6,3884.74,APC
Inj foramen epidural l/s,64483,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1532.3,,,,,,,fee schedule,875.6,3884.74,APC
Inj foramen epidural add-on,64484,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1251.96,,,,,,,fee schedule,1003.56,1251.96,
Inj foramen epidural add-on,64484,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1003.56,,,,,,,fee schedule,1003.56,1251.96,
Inj foramen epidural add-on,64484,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1096.3,,,,,,,fee schedule,1003.56,1251.96,
Inj foramen epidural add-on,64484,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1152.6,,,,,,,fee schedule,1003.56,1251.96,
Tap block unil by injection,64486,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,242,,,,,,,fee schedule,193.98,242,
Tap block unil by injection,64486,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,193.98,,,,,,,fee schedule,193.98,242,
Tap block unil by injection,64486,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,211.91,,,,,,,fee schedule,193.98,242,
Tap block unil by injection,64486,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,222.79,,,,,,,fee schedule,193.98,242,
Tap block uni by infusion,64487,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,278.13,,,,,,,fee schedule,222.95,278.13,
Tap block uni by infusion,64487,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,222.95,,,,,,,fee schedule,222.95,278.13,
Tap block uni by infusion,64487,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,243.55,,,,,,,fee schedule,222.95,278.13,
Tap block uni by infusion,64487,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,256.06,,,,,,,fee schedule,222.95,278.13,
Tap block bi injection,64488,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,303.38,,,,,,,fee schedule,243.19,303.38,
Tap block bi injection,64488,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,243.19,,,,,,,fee schedule,243.19,303.38,
Tap block bi injection,64488,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,265.66,,,,,,,fee schedule,243.19,303.38,
Tap block bi injection,64488,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,279.3,,,,,,,fee schedule,243.19,303.38,
Tap block bi by infusion,64489,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,341.33,,,,,,,fee schedule,273.61,341.33,
Tap block bi by infusion,64489,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,273.61,,,,,,,fee schedule,273.61,341.33,
Tap block bi by infusion,64489,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,298.89,,,,,,,fee schedule,273.61,341.33,
Tap block bi by infusion,64489,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,314.24,,,,,,,fee schedule,273.61,341.33,
Inj paravert f jnt c/t 1 lev,64490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1988.18,,,,,,,fee schedule,875.6,3884.74,
Inj paravert f jnt c/t 1 lev,64490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1593.7,,,,,,,fee schedule,875.6,3884.74,
Inj paravert f jnt c/t 1 lev,64490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1740.97,,,,,,,fee schedule,875.6,3884.74,
Inj paravert f jnt c/t 1 lev,64490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1830.39,,,,,,,fee schedule,875.6,3884.74,
Inj paravert f jnt c/t 1 lev,64490,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3884.74,,,,,,,fee schedule,875.6,3884.74,APC 378
Inj paravert f jnt c/t 1 lev,64490,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,919.38,,,,,,,fee schedule,875.6,3884.74,APC
Inj paravert f jnt c/t 1 lev,64490,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,910.62,,,,,,,fee schedule,875.6,3884.74,APC
Inj paravert f jnt c/t 1 lev,64490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,875.6,,,,,,,fee schedule,875.6,3884.74,APC
Inj paravert f jnt c/t 1 lev,64490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1339.67,,,,,,,fee schedule,875.6,3884.74,Radiology
Inj paravert f jnt c/t 1 lev,64490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1225.84,,,,,,,fee schedule,875.6,3884.74,APC
Inj paravert f jnt c/t 1 lev,64490,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1532.3,,,,,,,fee schedule,875.6,3884.74,APC
Inj paravert f jnt c/t 2 lev,64491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1005.56,,,,,,,fee schedule,806.05,1005.56,
Inj paravert f jnt c/t 2 lev,64491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,806.05,,,,,,,fee schedule,806.05,1005.56,
Inj paravert f jnt c/t 2 lev,64491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,880.53,,,,,,,fee schedule,806.05,1005.56,
Inj paravert f jnt c/t 2 lev,64491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,925.76,,,,,,,fee schedule,806.05,1005.56,
Inj paravert f jnt c/t 3 lev,64492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,926.97,,,,,,,fee schedule,743.05,926.97,
Inj paravert f jnt c/t 3 lev,64492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,743.05,,,,,,,fee schedule,743.05,926.97,
Inj paravert f jnt c/t 3 lev,64492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,811.72,,,,,,,fee schedule,743.05,926.97,
Inj paravert f jnt c/t 3 lev,64492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,853.4,,,,,,,fee schedule,743.05,926.97,
Inj paravert f jnt l/s 1 lev,64493,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1602.58,,,,,,,fee schedule,875.6,3884.74,
Inj paravert f jnt l/s 1 lev,64493,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1284.61,,,,,,,fee schedule,875.6,3884.74,
Inj paravert f jnt l/s 1 lev,64493,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1403.32,,,,,,,fee schedule,875.6,3884.74,
Inj paravert f jnt l/s 1 lev,64493,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1475.39,,,,,,,fee schedule,875.6,3884.74,
Inj paravert f jnt l/s 1 lev,64493,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3884.74,,,,,,,fee schedule,875.6,3884.74,APC 378
Inj paravert f jnt l/s 1 lev,64493,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,919.38,,,,,,,fee schedule,875.6,3884.74,APC
Inj paravert f jnt l/s 1 lev,64493,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,910.62,,,,,,,fee schedule,875.6,3884.74,APC
Inj paravert f jnt l/s 1 lev,64493,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,875.6,,,,,,,fee schedule,875.6,3884.74,APC
Inj paravert f jnt l/s 1 lev,64493,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1339.67,,,,,,,fee schedule,875.6,3884.74,Radiology
Inj paravert f jnt l/s 1 lev,64493,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1225.84,,,,,,,fee schedule,875.6,3884.74,APC
Inj paravert f jnt l/s 1 lev,64493,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1532.3,,,,,,,fee schedule,875.6,3884.74,APC
Inj paravert f jnt l/s 2 lev,64494,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,807.64,,,,,,,fee schedule,647.4,807.64,
Inj paravert f jnt l/s 2 lev,64494,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,647.4,,,,,,,fee schedule,647.4,807.64,
Inj paravert f jnt l/s 2 lev,64494,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,707.22,,,,,,,fee schedule,647.4,807.64,
Inj paravert f jnt l/s 2 lev,64494,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,743.54,,,,,,,fee schedule,647.4,807.64,
Inj paravert f jnt l/s 3 lev,64495,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,746.59,,,,,,,fee schedule,598.45,746.59,
Inj paravert f jnt l/s 3 lev,64495,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,598.45,,,,,,,fee schedule,598.45,746.59,
Inj paravert f jnt l/s 3 lev,64495,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,653.76,,,,,,,fee schedule,598.45,746.59,
Inj paravert f jnt l/s 3 lev,64495,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,687.33,,,,,,,fee schedule,598.45,746.59,
N block spenopalatine gangl,64505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,579.32,,,,,,,fee schedule,303.87,1348.18,
N block spenopalatine gangl,64505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,464.38,,,,,,,fee schedule,303.87,1348.18,
N block spenopalatine gangl,64505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,507.29,,,,,,,fee schedule,303.87,1348.18,
N block spenopalatine gangl,64505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,533.34,,,,,,,fee schedule,303.87,1348.18,
N block spenopalatine gangl,64505,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1348.18,,,,,,,fee schedule,303.87,1348.18,APC 378
N block spenopalatine gangl,64505,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,319.07,,,,,,,fee schedule,303.87,1348.18,APC
N block spenopalatine gangl,64505,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,316.03,,,,,,,fee schedule,303.87,1348.18,APC
N block spenopalatine gangl,64505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,303.87,,,,,,,fee schedule,303.87,1348.18,APC
N block spenopalatine gangl,64505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,464.92,,,,,,,fee schedule,303.87,1348.18,Radiology
N block spenopalatine gangl,64505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,425.42,,,,,,,fee schedule,303.87,1348.18,APC
N block spenopalatine gangl,64505,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,531.78,,,,,,,fee schedule,303.87,1348.18,APC
N block stellate ganglion,64510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1324.16,,,,,,,fee schedule,875.6,3884.74,
N block stellate ganglion,64510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1061.43,,,,,,,fee schedule,875.6,3884.74,
N block stellate ganglion,64510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1159.52,,,,,,,fee schedule,875.6,3884.74,
N block stellate ganglion,64510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1219.07,,,,,,,fee schedule,875.6,3884.74,
N block stellate ganglion,64510,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3884.74,,,,,,,fee schedule,875.6,3884.74,APC 378
N block stellate ganglion,64510,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,919.38,,,,,,,fee schedule,875.6,3884.74,APC
N block stellate ganglion,64510,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,910.62,,,,,,,fee schedule,875.6,3884.74,APC
N block stellate ganglion,64510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,875.6,,,,,,,fee schedule,875.6,3884.74,APC
N block stellate ganglion,64510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1339.67,,,,,,,fee schedule,875.6,3884.74,Radiology
N block stellate ganglion,64510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1225.84,,,,,,,fee schedule,875.6,3884.74,APC
N block stellate ganglion,64510,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1532.3,,,,,,,fee schedule,875.6,3884.74,APC
N block inj hypogas plxs,64517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1760.69,,,,,,,fee schedule,875.6,3884.74,
N block inj hypogas plxs,64517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1411.34,,,,,,,fee schedule,875.6,3884.74,
N block inj hypogas plxs,64517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1541.76,,,,,,,fee schedule,875.6,3884.74,
N block inj hypogas plxs,64517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1620.95,,,,,,,fee schedule,875.6,3884.74,
N block inj hypogas plxs,64517,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3884.74,,,,,,,fee schedule,875.6,3884.74,APC 378
N block inj hypogas plxs,64517,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,919.38,,,,,,,fee schedule,875.6,3884.74,APC
N block inj hypogas plxs,64517,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,910.62,,,,,,,fee schedule,875.6,3884.74,APC
N block inj hypogas plxs,64517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,875.6,,,,,,,fee schedule,875.6,3884.74,APC
N block inj hypogas plxs,64517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1339.67,,,,,,,fee schedule,875.6,3884.74,Radiology
N block inj hypogas plxs,64517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1225.84,,,,,,,fee schedule,875.6,3884.74,APC
N block inj hypogas plxs,64517,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1532.3,,,,,,,fee schedule,875.6,3884.74,APC
N block lumbar/thoracic,64520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1760.69,,,,,,,fee schedule,875.6,3884.74,
N block lumbar/thoracic,64520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1411.34,,,,,,,fee schedule,875.6,3884.74,
N block lumbar/thoracic,64520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1541.76,,,,,,,fee schedule,875.6,3884.74,
N block lumbar/thoracic,64520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1620.95,,,,,,,fee schedule,875.6,3884.74,
N block lumbar/thoracic,64520,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3884.74,,,,,,,fee schedule,875.6,3884.74,APC 378
N block lumbar/thoracic,64520,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,919.38,,,,,,,fee schedule,875.6,3884.74,APC
N block lumbar/thoracic,64520,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,910.62,,,,,,,fee schedule,875.6,3884.74,APC
N block lumbar/thoracic,64520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,875.6,,,,,,,fee schedule,875.6,3884.74,APC
N block lumbar/thoracic,64520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1339.67,,,,,,,fee schedule,875.6,3884.74,Radiology
N block lumbar/thoracic,64520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1225.84,,,,,,,fee schedule,875.6,3884.74,APC
N block lumbar/thoracic,64520,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1532.3,,,,,,,fee schedule,875.6,3884.74,APC
N block inj celiac pelus,64530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1760.69,,,,,,,fee schedule,875.6,3884.74,
N block inj celiac pelus,64530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1411.34,,,,,,,fee schedule,875.6,3884.74,
N block inj celiac pelus,64530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1541.76,,,,,,,fee schedule,875.6,3884.74,
N block inj celiac pelus,64530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1620.95,,,,,,,fee schedule,875.6,3884.74,
N block inj celiac pelus,64530,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3884.74,,,,,,,fee schedule,875.6,3884.74,APC 378
N block inj celiac pelus,64530,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,919.38,,,,,,,fee schedule,875.6,3884.74,APC
N block inj celiac pelus,64530,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,910.62,,,,,,,fee schedule,875.6,3884.74,APC
N block inj celiac pelus,64530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,875.6,,,,,,,fee schedule,875.6,3884.74,APC
N block inj celiac pelus,64530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1339.67,,,,,,,fee schedule,875.6,3884.74,Radiology
N block inj celiac pelus,64530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1225.84,,,,,,,fee schedule,875.6,3884.74,APC
N block inj celiac pelus,64530,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1532.3,,,,,,,fee schedule,875.6,3884.74,APC
Implant neuroelectrodes,64553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4765.13,,,,,,,fee schedule,3819.67,48940.4,
Implant neuroelectrodes,64553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3819.67,,,,,,,fee schedule,3819.67,48940.4,
Implant neuroelectrodes,64553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4172.64,,,,,,,fee schedule,3819.67,48940.4,
Implant neuroelectrodes,64553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4386.95,,,,,,,fee schedule,3819.67,48940.4,
Implant neuroelectrodes,64553,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,48940.4,,,,,,,fee schedule,3819.67,48940.4,APC 378
Implant neuroelectrodes,64553,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11582.45,,,,,,,fee schedule,3819.67,48940.4,APC
Implant neuroelectrodes,64553,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11472.14,,,,,,,fee schedule,3819.67,48940.4,APC
Implant neuroelectrodes,64553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11030.91,,,,,,,fee schedule,3819.67,48940.4,APC
Implant neuroelectrodes,64553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16877.29,,,,,,,fee schedule,3819.67,48940.4,Radiology
Implant neuroelectrodes,64553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15443.27,,,,,,,fee schedule,3819.67,48940.4,APC
Implant neuroelectrodes,64553,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19304.09,,,,,,,fee schedule,3819.67,48940.4,APC
Implant neuroelectrodes,64555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15919.55,,,,,,,fee schedule,6309.06,27991.15,
Implant neuroelectrodes,64555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12760.91,,,,,,,fee schedule,6309.06,27991.15,
Implant neuroelectrodes,64555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13940.13,,,,,,,fee schedule,6309.06,27991.15,
Implant neuroelectrodes,64555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14656.09,,,,,,,fee schedule,6309.06,27991.15,
Implant neuroelectrodes,64555,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,27991.15,,,,,,,fee schedule,6309.06,27991.15,APC 378
Implant neuroelectrodes,64555,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6624.51,,,,,,,fee schedule,6309.06,27991.15,APC
Implant neuroelectrodes,64555,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6561.42,,,,,,,fee schedule,6309.06,27991.15,APC
Implant neuroelectrodes,64555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6309.06,,,,,,,fee schedule,6309.06,27991.15,APC
Implant neuroelectrodes,64555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9652.86,,,,,,,fee schedule,6309.06,27991.15,Radiology
Implant neuroelectrodes,64555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8832.68,,,,,,,fee schedule,6309.06,27991.15,APC
Implant neuroelectrodes,64555,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11040.85,,,,,,,fee schedule,6309.06,27991.15,APC
Implant neuroelectrodes,64561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7888.07,,,,,,,fee schedule,6309.06,27991.15,
Implant neuroelectrodes,64561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6322.97,,,,,,,fee schedule,6309.06,27991.15,
Implant neuroelectrodes,64561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6907.27,,,,,,,fee schedule,6309.06,27991.15,
Implant neuroelectrodes,64561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7262.03,,,,,,,fee schedule,6309.06,27991.15,
Implant neuroelectrodes,64561,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,27991.15,,,,,,,fee schedule,6309.06,27991.15,APC 378
Implant neuroelectrodes,64561,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6624.51,,,,,,,fee schedule,6309.06,27991.15,APC
Implant neuroelectrodes,64561,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6561.42,,,,,,,fee schedule,6309.06,27991.15,APC
Implant neuroelectrodes,64561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6309.06,,,,,,,fee schedule,6309.06,27991.15,APC
Implant neuroelectrodes,64561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9652.86,,,,,,,fee schedule,6309.06,27991.15,Radiology
Implant neuroelectrodes,64561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8832.68,,,,,,,fee schedule,6309.06,27991.15,APC
Implant neuroelectrodes,64561,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11040.85,,,,,,,fee schedule,6309.06,27991.15,APC
Neuroeltrd stim post tibial,64566,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,694.69,,,,,,,fee schedule,303.87,1348.18,
Neuroeltrd stim post tibial,64566,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,556.85,,,,,,,fee schedule,303.87,1348.18,
Neuroeltrd stim post tibial,64566,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,608.31,,,,,,,fee schedule,303.87,1348.18,
Neuroeltrd stim post tibial,64566,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,639.55,,,,,,,fee schedule,303.87,1348.18,
Neuroeltrd stim post tibial,64566,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1348.18,,,,,,,fee schedule,303.87,1348.18,APC 378
Neuroeltrd stim post tibial,64566,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,319.07,,,,,,,fee schedule,303.87,1348.18,APC
Neuroeltrd stim post tibial,64566,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,316.03,,,,,,,fee schedule,303.87,1348.18,APC
Neuroeltrd stim post tibial,64566,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,303.87,,,,,,,fee schedule,303.87,1348.18,APC
Neuroeltrd stim post tibial,64566,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,464.92,,,,,,,fee schedule,303.87,1348.18,Radiology
Neuroeltrd stim post tibial,64566,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,425.42,,,,,,,fee schedule,303.87,1348.18,APC
Neuroeltrd stim post tibial,64566,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,531.78,,,,,,,fee schedule,303.87,1348.18,APC
Perq elec nrv field stimj cn,64567,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3983.62,,,,,,,fee schedule,897.89,3983.62,APC 378
Perq elec nrv field stimj cn,64567,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,942.78,,,,,,,fee schedule,897.89,3983.62,APC
Perq elec nrv field stimj cn,64567,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,933.8,,,,,,,fee schedule,897.89,3983.62,APC
Perq elec nrv field stimj cn,64567,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,897.89,,,,,,,fee schedule,897.89,3983.62,APC
Perq elec nrv field stimj cn,64567,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1373.77,,,,,,,fee schedule,897.89,3983.62,Radiology
Perq elec nrv field stimj cn,64567,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1257.04,,,,,,,fee schedule,897.89,3983.62,APC
Perq elec nrv field stimj cn,64567,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1571.3,,,,,,,fee schedule,897.89,3983.62,APC
Inc for vagus n elect impl,64568,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,86200.71,,,,,,,fee schedule,43604.58,193458.78,
Inc for vagus n elect impl,64568,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,69097.39,,,,,,,fee schedule,43604.58,193458.78,
Inc for vagus n elect impl,64568,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,75482.63,,,,,,,fee schedule,43604.58,193458.78,
Inc for vagus n elect impl,64568,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,79359.38,,,,,,,fee schedule,43604.58,193458.78,
Inc for vagus n elect impl,64568,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,193458.78,,,,,,,fee schedule,43604.58,193458.78,APC 378
Inc for vagus n elect impl,64568,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,45784.81,,,,,,,fee schedule,43604.58,193458.78,APC
Inc for vagus n elect impl,64568,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,45348.77,,,,,,,fee schedule,43604.58,193458.78,APC
Inc for vagus n elect impl,64568,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,43604.58,,,,,,,fee schedule,43604.58,193458.78,APC
Inc for vagus n elect impl,64568,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,66715.01,,,,,,,fee schedule,43604.58,193458.78,Radiology
Inc for vagus n elect impl,64568,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,61046.42,,,,,,,fee schedule,43604.58,193458.78,APC
Inc for vagus n elect impl,64568,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,76308.02,,,,,,,fee schedule,43604.58,193458.78,APC
Revise/repl vagus n eltrd,64569,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5655.45,,,,,,,fee schedule,4533.33,48940.4,
Revise/repl vagus n eltrd,64569,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4533.33,,,,,,,fee schedule,4533.33,48940.4,
Revise/repl vagus n eltrd,64569,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4952.26,,,,,,,fee schedule,4533.33,48940.4,
Revise/repl vagus n eltrd,64569,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5206.6,,,,,,,fee schedule,4533.33,48940.4,
Revise/repl vagus n eltrd,64569,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,48940.4,,,,,,,fee schedule,4533.33,48940.4,APC 378
Revise/repl vagus n eltrd,64569,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11582.45,,,,,,,fee schedule,4533.33,48940.4,APC
Revise/repl vagus n eltrd,64569,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11472.14,,,,,,,fee schedule,4533.33,48940.4,APC
Revise/repl vagus n eltrd,64569,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11030.91,,,,,,,fee schedule,4533.33,48940.4,APC
Revise/repl vagus n eltrd,64569,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16877.29,,,,,,,fee schedule,4533.33,48940.4,Radiology
Revise/repl vagus n eltrd,64569,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15443.27,,,,,,,fee schedule,4533.33,48940.4,APC
Revise/repl vagus n eltrd,64569,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19304.09,,,,,,,fee schedule,4533.33,48940.4,APC
Remove vagus n eltrd,64570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9704.51,,,,,,,fee schedule,3381.88,15004.24,
Remove vagus n eltrd,64570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7779.01,,,,,,,fee schedule,3381.88,15004.24,
Remove vagus n eltrd,64570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8497.86,,,,,,,fee schedule,3381.88,15004.24,
Remove vagus n eltrd,64570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8934.31,,,,,,,fee schedule,3381.88,15004.24,
Remove vagus n eltrd,64570,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15004.24,,,,,,,fee schedule,3381.88,15004.24,APC 378
Remove vagus n eltrd,64570,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3550.97,,,,,,,fee schedule,3381.88,15004.24,APC
Remove vagus n eltrd,64570,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3517.15,,,,,,,fee schedule,3381.88,15004.24,APC
Remove vagus n eltrd,64570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3381.88,,,,,,,fee schedule,3381.88,15004.24,APC
Remove vagus n eltrd,64570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5174.27,,,,,,,fee schedule,3381.88,15004.24,Radiology
Remove vagus n eltrd,64570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4734.63,,,,,,,fee schedule,3381.88,15004.24,APC
Remove vagus n eltrd,64570,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5918.28,,,,,,,fee schedule,3381.88,15004.24,APC
Implant neuroelectrodes,64575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20679.74,,,,,,,fee schedule,11030.91,48940.4,
Implant neuroelectrodes,64575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16576.61,,,,,,,fee schedule,11030.91,48940.4,
Implant neuroelectrodes,64575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18108.45,,,,,,,fee schedule,11030.91,48940.4,
Implant neuroelectrodes,64575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19038.49,,,,,,,fee schedule,11030.91,48940.4,
Implant neuroelectrodes,64575,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,48940.4,,,,,,,fee schedule,11030.91,48940.4,APC 378
Implant neuroelectrodes,64575,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11582.45,,,,,,,fee schedule,11030.91,48940.4,APC
Implant neuroelectrodes,64575,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11472.14,,,,,,,fee schedule,11030.91,48940.4,APC
Implant neuroelectrodes,64575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11030.91,,,,,,,fee schedule,11030.91,48940.4,APC
Implant neuroelectrodes,64575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16877.29,,,,,,,fee schedule,11030.91,48940.4,Radiology
Implant neuroelectrodes,64575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15443.27,,,,,,,fee schedule,11030.91,48940.4,APC
Implant neuroelectrodes,64575,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19304.09,,,,,,,fee schedule,11030.91,48940.4,APC
Implant neuroelectrodes,64580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20679.74,,,,,,,fee schedule,16576.61,85208.23,
Implant neuroelectrodes,64580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16576.61,,,,,,,fee schedule,16576.61,85208.23,
Implant neuroelectrodes,64580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18108.45,,,,,,,fee schedule,16576.61,85208.23,
Implant neuroelectrodes,64580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19038.49,,,,,,,fee schedule,16576.61,85208.23,
Implant neuroelectrodes,64580,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,85208.23,,,,,,,fee schedule,16576.61,85208.23,APC 378
Implant neuroelectrodes,64580,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20165.76,,,,,,,fee schedule,16576.61,85208.23,APC
Implant neuroelectrodes,64580,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,19973.7,,,,,,,fee schedule,16576.61,85208.23,APC
Implant neuroelectrodes,64580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,19205.48,,,,,,,fee schedule,16576.61,85208.23,APC
Implant neuroelectrodes,64580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29384.39,,,,,,,fee schedule,16576.61,85208.23,Radiology
Implant neuroelectrodes,64580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26887.68,,,,,,,fee schedule,16576.61,85208.23,APC
Implant neuroelectrodes,64580,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,33609.6,,,,,,,fee schedule,16576.61,85208.23,APC
Implant neuroelectrodes,64581,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5102.67,,,,,,,fee schedule,4090.24,27991.15,
Implant neuroelectrodes,64581,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4090.24,,,,,,,fee schedule,4090.24,27991.15,
Implant neuroelectrodes,64581,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4468.21,,,,,,,fee schedule,4090.24,27991.15,
Implant neuroelectrodes,64581,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4697.7,,,,,,,fee schedule,4090.24,27991.15,
Implant neuroelectrodes,64581,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,27991.15,,,,,,,fee schedule,4090.24,27991.15,APC 378
Implant neuroelectrodes,64581,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6624.51,,,,,,,fee schedule,4090.24,27991.15,APC
Implant neuroelectrodes,64581,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6561.42,,,,,,,fee schedule,4090.24,27991.15,APC
Implant neuroelectrodes,64581,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6309.06,,,,,,,fee schedule,4090.24,27991.15,APC
Implant neuroelectrodes,64581,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9652.86,,,,,,,fee schedule,4090.24,27991.15,Radiology
Implant neuroelectrodes,64581,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8832.68,,,,,,,fee schedule,4090.24,27991.15,APC
Implant neuroelectrodes,64581,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11040.85,,,,,,,fee schedule,4090.24,27991.15,APC
Opn mpltj hpglsl nstm ary pg,64582,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,113639.95,,,,,,,fee schedule,30548.12,135531.68,
Opn mpltj hpglsl nstm ary pg,64582,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,91092.34,,,,,,,fee schedule,30548.12,135531.68,
Opn mpltj hpglsl nstm ary pg,64582,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,99510.12,,,,,,,fee schedule,30548.12,135531.68,
Opn mpltj hpglsl nstm ary pg,64582,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,104620.91,,,,,,,fee schedule,30548.12,135531.68,
Opn mpltj hpglsl nstm ary pg,64582,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,135531.68,,,,,,,fee schedule,30548.12,135531.68,APC 378
Opn mpltj hpglsl nstm ary pg,64582,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,32075.53,,,,,,,fee schedule,30548.12,135531.68,APC
Opn mpltj hpglsl nstm ary pg,64582,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,31770.05,,,,,,,fee schedule,30548.12,135531.68,APC
Opn mpltj hpglsl nstm ary pg,64582,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,30548.12,,,,,,,fee schedule,30548.12,135531.68,APC
Opn mpltj hpglsl nstm ary pg,64582,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,46738.63,,,,,,,fee schedule,30548.12,135531.68,Radiology
Opn mpltj hpglsl nstm ary pg,64582,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,42767.37,,,,,,,fee schedule,30548.12,135531.68,APC
Opn mpltj hpglsl nstm ary pg,64582,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,53459.21,,,,,,,fee schedule,30548.12,135531.68,APC
Rev/rplct hpglsl nstm ary pg,64583,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,43407.18,,,,,,,fee schedule,11030.91,48940.4,
Rev/rplct hpglsl nstm ary pg,64583,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,34794.64,,,,,,,fee schedule,11030.91,48940.4,
Rev/rplct hpglsl nstm ary pg,64583,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38009.99,,,,,,,fee schedule,11030.91,48940.4,
Rev/rplct hpglsl nstm ary pg,64583,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,39962.16,,,,,,,fee schedule,11030.91,48940.4,
Rev/rplct hpglsl nstm ary pg,64583,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,48940.4,,,,,,,fee schedule,11030.91,48940.4,APC 378
Rev/rplct hpglsl nstm ary pg,64583,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11582.45,,,,,,,fee schedule,11030.91,48940.4,APC
Rev/rplct hpglsl nstm ary pg,64583,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11472.14,,,,,,,fee schedule,11030.91,48940.4,APC
Rev/rplct hpglsl nstm ary pg,64583,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11030.91,,,,,,,fee schedule,11030.91,48940.4,APC
Rev/rplct hpglsl nstm ary pg,64583,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16877.29,,,,,,,fee schedule,11030.91,48940.4,Radiology
Rev/rplct hpglsl nstm ary pg,64583,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15443.27,,,,,,,fee schedule,11030.91,48940.4,APC
Rev/rplct hpglsl nstm ary pg,64583,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19304.09,,,,,,,fee schedule,11030.91,48940.4,APC
Rmvl hpglsl nstim ary pg,64584,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22014.53,,,,,,,fee schedule,3381.88,22014.53,
Rmvl hpglsl nstim ary pg,64584,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17646.57,,,,,,,fee schedule,3381.88,22014.53,
Rmvl hpglsl nstim ary pg,64584,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19277.27,,,,,,,fee schedule,3381.88,22014.53,
Rmvl hpglsl nstim ary pg,64584,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20267.35,,,,,,,fee schedule,3381.88,22014.53,
Rmvl hpglsl nstim ary pg,64584,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15004.24,,,,,,,fee schedule,3381.88,22014.53,APC 378
Rmvl hpglsl nstim ary pg,64584,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3550.97,,,,,,,fee schedule,3381.88,22014.53,APC
Rmvl hpglsl nstim ary pg,64584,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3517.15,,,,,,,fee schedule,3381.88,22014.53,APC
Rmvl hpglsl nstim ary pg,64584,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3381.88,,,,,,,fee schedule,3381.88,22014.53,APC
Rmvl hpglsl nstim ary pg,64584,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5174.27,,,,,,,fee schedule,3381.88,22014.53,Radiology
Rmvl hpglsl nstim ary pg,64584,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4734.63,,,,,,,fee schedule,3381.88,22014.53,APC
Rmvl hpglsl nstim ary pg,64584,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5918.28,,,,,,,fee schedule,3381.88,22014.53,APC
Revise/remove neuroelectrode,64585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5570.79,,,,,,,fee schedule,3461.03,15355.43,
Revise/remove neuroelectrode,64585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4465.47,,,,,,,fee schedule,3461.03,15355.43,
Revise/remove neuroelectrode,64585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4878.12,,,,,,,fee schedule,3461.03,15355.43,
Revise/remove neuroelectrode,64585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5128.66,,,,,,,fee schedule,3461.03,15355.43,
Revise/remove neuroelectrode,64585,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15355.43,,,,,,,fee schedule,3461.03,15355.43,APC 378
Revise/remove neuroelectrode,64585,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3634.08,,,,,,,fee schedule,3461.03,15355.43,APC
Revise/remove neuroelectrode,64585,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3599.47,,,,,,,fee schedule,3461.03,15355.43,APC
Revise/remove neuroelectrode,64585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3461.03,,,,,,,fee schedule,3461.03,15355.43,APC
Revise/remove neuroelectrode,64585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5295.38,,,,,,,fee schedule,3461.03,15355.43,Radiology
Revise/remove neuroelectrode,64585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4845.44,,,,,,,fee schedule,3461.03,15355.43,APC
Revise/remove neuroelectrode,64585,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6056.81,,,,,,,fee schedule,3461.03,15355.43,APC
Insrt/redo pn/gastr stimul,64590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7536.98,,,,,,,fee schedule,6041.55,85208.23,
Insrt/redo pn/gastr stimul,64590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6041.55,,,,,,,fee schedule,6041.55,85208.23,
Insrt/redo pn/gastr stimul,64590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6599.84,,,,,,,fee schedule,6041.55,85208.23,
Insrt/redo pn/gastr stimul,64590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6938.81,,,,,,,fee schedule,6041.55,85208.23,
Insrt/redo pn/gastr stimul,64590,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,85208.23,,,,,,,fee schedule,6041.55,85208.23,APC 378
Insrt/redo pn/gastr stimul,64590,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20165.76,,,,,,,fee schedule,6041.55,85208.23,APC
Insrt/redo pn/gastr stimul,64590,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,19973.7,,,,,,,fee schedule,6041.55,85208.23,APC
Insrt/redo pn/gastr stimul,64590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,19205.48,,,,,,,fee schedule,6041.55,85208.23,APC
Insrt/redo pn/gastr stimul,64590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29384.39,,,,,,,fee schedule,6041.55,85208.23,Radiology
Insrt/redo pn/gastr stimul,64590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26887.68,,,,,,,fee schedule,6041.55,85208.23,APC
Insrt/redo pn/gastr stimul,64590,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,33609.6,,,,,,,fee schedule,6041.55,85208.23,APC
Revise/rmv pn/gastr stimul,64595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8589.52,,,,,,,fee schedule,3461.03,15355.43,
Revise/rmv pn/gastr stimul,64595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6885.25,,,,,,,fee schedule,3461.03,15355.43,
Revise/rmv pn/gastr stimul,64595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7521.51,,,,,,,fee schedule,3461.03,15355.43,
Revise/rmv pn/gastr stimul,64595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7907.81,,,,,,,fee schedule,3461.03,15355.43,
Revise/rmv pn/gastr stimul,64595,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15355.43,,,,,,,fee schedule,3461.03,15355.43,APC 378
Revise/rmv pn/gastr stimul,64595,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3634.08,,,,,,,fee schedule,3461.03,15355.43,APC
Revise/rmv pn/gastr stimul,64595,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3599.47,,,,,,,fee schedule,3461.03,15355.43,APC
Revise/rmv pn/gastr stimul,64595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3461.03,,,,,,,fee schedule,3461.03,15355.43,APC
Revise/rmv pn/gastr stimul,64595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5295.38,,,,,,,fee schedule,3461.03,15355.43,Radiology
Revise/rmv pn/gastr stimul,64595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4845.44,,,,,,,fee schedule,3461.03,15355.43,APC
Revise/rmv pn/gastr stimul,64595,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6056.81,,,,,,,fee schedule,3461.03,15355.43,APC
Ins/rplcmt prq eltrd ra pn 1,64596,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,49111.5,,,,,,,fee schedule,11030.91,49111.5,
Ins/rplcmt prq eltrd ra pn 1,64596,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39367.15,,,,,,,fee schedule,11030.91,49111.5,
Ins/rplcmt prq eltrd ra pn 1,64596,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,43005.04,,,,,,,fee schedule,11030.91,49111.5,
Ins/rplcmt prq eltrd ra pn 1,64596,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45213.76,,,,,,,fee schedule,11030.91,49111.5,
Ins/rplcmt prq eltrd ra pn 1,64596,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,48940.4,,,,,,,fee schedule,11030.91,49111.5,APC 378
Ins/rplcmt prq eltrd ra pn 1,64596,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11582.45,,,,,,,fee schedule,11030.91,49111.5,APC
Ins/rplcmt prq eltrd ra pn 1,64596,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11472.14,,,,,,,fee schedule,11030.91,49111.5,APC
Ins/rplcmt prq eltrd ra pn 1,64596,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11030.91,,,,,,,fee schedule,11030.91,49111.5,APC
Ins/rplcmt prq eltrd ra pn 1,64596,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16877.29,,,,,,,fee schedule,11030.91,49111.5,Radiology
Ins/rplcmt prq eltrd ra pn 1,64596,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15443.27,,,,,,,fee schedule,11030.91,49111.5,APC
Ins/rplcmt prq eltrd ra pn 1,64596,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19304.09,,,,,,,fee schedule,11030.91,49111.5,APC
Revj/rmvl nea pn w/int nstim,64598,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12267.12,,,,,,,fee schedule,3461.03,15355.43,
Revj/rmvl nea pn w/int nstim,64598,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9833.17,,,,,,,fee schedule,3461.03,15355.43,
Revj/rmvl nea pn w/int nstim,64598,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10741.84,,,,,,,fee schedule,3461.03,15355.43,
Revj/rmvl nea pn w/int nstim,64598,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11293.54,,,,,,,fee schedule,3461.03,15355.43,
Revj/rmvl nea pn w/int nstim,64598,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15355.43,,,,,,,fee schedule,3461.03,15355.43,APC 378
Revj/rmvl nea pn w/int nstim,64598,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3634.08,,,,,,,fee schedule,3461.03,15355.43,APC
Revj/rmvl nea pn w/int nstim,64598,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3599.47,,,,,,,fee schedule,3461.03,15355.43,APC
Revj/rmvl nea pn w/int nstim,64598,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3461.03,,,,,,,fee schedule,3461.03,15355.43,APC
Revj/rmvl nea pn w/int nstim,64598,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5295.38,,,,,,,fee schedule,3461.03,15355.43,Radiology
Revj/rmvl nea pn w/int nstim,64598,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4845.44,,,,,,,fee schedule,3461.03,15355.43,APC
Revj/rmvl nea pn w/int nstim,64598,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6056.81,,,,,,,fee schedule,3461.03,15355.43,APC
Injection treatment of nerve,64600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3615.8,,,,,,,fee schedule,875.6,3884.74,
Injection treatment of nerve,64600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2898.38,,,,,,,fee schedule,875.6,3884.74,
Injection treatment of nerve,64600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3166.21,,,,,,,fee schedule,875.6,3884.74,
Injection treatment of nerve,64600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3328.83,,,,,,,fee schedule,875.6,3884.74,
Injection treatment of nerve,64600,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3884.74,,,,,,,fee schedule,875.6,3884.74,APC 378
Injection treatment of nerve,64600,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,919.38,,,,,,,fee schedule,875.6,3884.74,APC
Injection treatment of nerve,64600,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,910.62,,,,,,,fee schedule,875.6,3884.74,APC
Injection treatment of nerve,64600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,875.6,,,,,,,fee schedule,875.6,3884.74,APC
Injection treatment of nerve,64600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1339.67,,,,,,,fee schedule,875.6,3884.74,Radiology
Injection treatment of nerve,64600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1225.84,,,,,,,fee schedule,875.6,3884.74,APC
Injection treatment of nerve,64600,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1532.3,,,,,,,fee schedule,875.6,3884.74,APC
Injection treatment of nerve,64605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3615.8,,,,,,,fee schedule,1933.13,8576.66,
Injection treatment of nerve,64605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2898.38,,,,,,,fee schedule,1933.13,8576.66,
Injection treatment of nerve,64605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3166.21,,,,,,,fee schedule,1933.13,8576.66,
Injection treatment of nerve,64605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3328.83,,,,,,,fee schedule,1933.13,8576.66,
Injection treatment of nerve,64605,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8576.66,,,,,,,fee schedule,1933.13,8576.66,APC 378
Injection treatment of nerve,64605,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2029.79,,,,,,,fee schedule,1933.13,8576.66,APC
Injection treatment of nerve,64605,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2010.46,,,,,,,fee schedule,1933.13,8576.66,APC
Injection treatment of nerve,64605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1933.13,,,,,,,fee schedule,1933.13,8576.66,APC
Injection treatment of nerve,64605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2957.7,,,,,,,fee schedule,1933.13,8576.66,Radiology
Injection treatment of nerve,64605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2706.39,,,,,,,fee schedule,1933.13,8576.66,APC
Injection treatment of nerve,64605,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3382.99,,,,,,,fee schedule,1933.13,8576.66,APC
Injection treatment of nerve,64610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3615.8,,,,,,,fee schedule,1933.13,8576.66,
Injection treatment of nerve,64610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2898.38,,,,,,,fee schedule,1933.13,8576.66,
Injection treatment of nerve,64610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3166.21,,,,,,,fee schedule,1933.13,8576.66,
Injection treatment of nerve,64610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3328.83,,,,,,,fee schedule,1933.13,8576.66,
Injection treatment of nerve,64610,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8576.66,,,,,,,fee schedule,1933.13,8576.66,APC 378
Injection treatment of nerve,64610,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2029.79,,,,,,,fee schedule,1933.13,8576.66,APC
Injection treatment of nerve,64610,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2010.46,,,,,,,fee schedule,1933.13,8576.66,APC
Injection treatment of nerve,64610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1933.13,,,,,,,fee schedule,1933.13,8576.66,APC
Injection treatment of nerve,64610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2957.7,,,,,,,fee schedule,1933.13,8576.66,Radiology
Injection treatment of nerve,64610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2706.39,,,,,,,fee schedule,1933.13,8576.66,APC
Injection treatment of nerve,64610,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3382.99,,,,,,,fee schedule,1933.13,8576.66,APC
Chemodenerv saliv glands,64611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,694.69,,,,,,,fee schedule,303.87,1348.18,
Chemodenerv saliv glands,64611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,556.85,,,,,,,fee schedule,303.87,1348.18,
Chemodenerv saliv glands,64611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,608.31,,,,,,,fee schedule,303.87,1348.18,
Chemodenerv saliv glands,64611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,639.55,,,,,,,fee schedule,303.87,1348.18,
Chemodenerv saliv glands,64611,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1348.18,,,,,,,fee schedule,303.87,1348.18,APC 378
Chemodenerv saliv glands,64611,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,319.07,,,,,,,fee schedule,303.87,1348.18,APC
Chemodenerv saliv glands,64611,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,316.03,,,,,,,fee schedule,303.87,1348.18,APC
Chemodenerv saliv glands,64611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,303.87,,,,,,,fee schedule,303.87,1348.18,APC
Chemodenerv saliv glands,64611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,464.92,,,,,,,fee schedule,303.87,1348.18,Radiology
Chemodenerv saliv glands,64611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,425.42,,,,,,,fee schedule,303.87,1348.18,APC
Chemodenerv saliv glands,64611,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,531.78,,,,,,,fee schedule,303.87,1348.18,APC
Destroy nerve face muscle,64612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,579.32,,,,,,,fee schedule,303.87,1348.18,
Destroy nerve face muscle,64612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,464.38,,,,,,,fee schedule,303.87,1348.18,
Destroy nerve face muscle,64612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,507.29,,,,,,,fee schedule,303.87,1348.18,
Destroy nerve face muscle,64612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,533.34,,,,,,,fee schedule,303.87,1348.18,
Destroy nerve face muscle,64612,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1348.18,,,,,,,fee schedule,303.87,1348.18,APC 378
Destroy nerve face muscle,64612,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,319.07,,,,,,,fee schedule,303.87,1348.18,APC
Destroy nerve face muscle,64612,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,316.03,,,,,,,fee schedule,303.87,1348.18,APC
Destroy nerve face muscle,64612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,303.87,,,,,,,fee schedule,303.87,1348.18,APC
Destroy nerve face muscle,64612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,464.92,,,,,,,fee schedule,303.87,1348.18,Radiology
Destroy nerve face muscle,64612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,425.42,,,,,,,fee schedule,303.87,1348.18,APC
Destroy nerve face muscle,64612,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,531.78,,,,,,,fee schedule,303.87,1348.18,APC
Chemodenerv musc migraine,64615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,690.27,,,,,,,fee schedule,303.87,1348.18,
Chemodenerv musc migraine,64615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,553.31,,,,,,,fee schedule,303.87,1348.18,
Chemodenerv musc migraine,64615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,604.44,,,,,,,fee schedule,303.87,1348.18,
Chemodenerv musc migraine,64615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,635.48,,,,,,,fee schedule,303.87,1348.18,
Chemodenerv musc migraine,64615,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1348.18,,,,,,,fee schedule,303.87,1348.18,APC 378
Chemodenerv musc migraine,64615,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,319.07,,,,,,,fee schedule,303.87,1348.18,APC
Chemodenerv musc migraine,64615,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,316.03,,,,,,,fee schedule,303.87,1348.18,APC
Chemodenerv musc migraine,64615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,303.87,,,,,,,fee schedule,303.87,1348.18,APC
Chemodenerv musc migraine,64615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,464.92,,,,,,,fee schedule,303.87,1348.18,Radiology
Chemodenerv musc migraine,64615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,425.42,,,,,,,fee schedule,303.87,1348.18,APC
Chemodenerv musc migraine,64615,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,531.78,,,,,,,fee schedule,303.87,1348.18,APC
Chemodenerv musc neck dyston,64616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1409.03,,,,,,,fee schedule,303.87,1409.03,
Chemodenerv musc neck dyston,64616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1129.46,,,,,,,fee schedule,303.87,1409.03,
Chemodenerv musc neck dyston,64616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1233.84,,,,,,,fee schedule,303.87,1409.03,
Chemodenerv musc neck dyston,64616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1297.2,,,,,,,fee schedule,303.87,1409.03,
Chemodenerv musc neck dyston,64616,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1348.18,,,,,,,fee schedule,303.87,1409.03,APC 378
Chemodenerv musc neck dyston,64616,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,319.07,,,,,,,fee schedule,303.87,1409.03,APC
Chemodenerv musc neck dyston,64616,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,316.03,,,,,,,fee schedule,303.87,1409.03,APC
Chemodenerv musc neck dyston,64616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,303.87,,,,,,,fee schedule,303.87,1409.03,APC
Chemodenerv musc neck dyston,64616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,464.92,,,,,,,fee schedule,303.87,1409.03,Radiology
Chemodenerv musc neck dyston,64616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,425.42,,,,,,,fee schedule,303.87,1409.03,APC
Chemodenerv musc neck dyston,64616,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,531.78,,,,,,,fee schedule,303.87,1409.03,APC
Chemodener muscle larynx emg,64617,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3360.79,,,,,,,fee schedule,698.8,3360.79,
Chemodener muscle larynx emg,64617,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2693.96,,,,,,,fee schedule,698.8,3360.79,
Chemodener muscle larynx emg,64617,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2942.91,,,,,,,fee schedule,698.8,3360.79,
Chemodener muscle larynx emg,64617,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3094.06,,,,,,,fee schedule,698.8,3360.79,
Chemodener muscle larynx emg,64617,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3100.34,,,,,,,fee schedule,698.8,3360.79,APC 378
Chemodener muscle larynx emg,64617,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,733.74,,,,,,,fee schedule,698.8,3360.79,APC
Chemodener muscle larynx emg,64617,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,726.75,,,,,,,fee schedule,698.8,3360.79,APC
Chemodener muscle larynx emg,64617,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,698.8,,,,,,,fee schedule,698.8,3360.79,APC
Chemodener muscle larynx emg,64617,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1069.16,,,,,,,fee schedule,698.8,3360.79,Radiology
Chemodener muscle larynx emg,64617,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,978.32,,,,,,,fee schedule,698.8,3360.79,APC
Chemodener muscle larynx emg,64617,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1222.9,,,,,,,fee schedule,698.8,3360.79,APC
Injection treatment of nerve,64620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1760.69,,,,,,,fee schedule,875.6,3884.74,
Injection treatment of nerve,64620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1411.34,,,,,,,fee schedule,875.6,3884.74,
Injection treatment of nerve,64620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1541.76,,,,,,,fee schedule,875.6,3884.74,
Injection treatment of nerve,64620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1620.95,,,,,,,fee schedule,875.6,3884.74,
Injection treatment of nerve,64620,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3884.74,,,,,,,fee schedule,875.6,3884.74,APC 378
Injection treatment of nerve,64620,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,919.38,,,,,,,fee schedule,875.6,3884.74,APC
Injection treatment of nerve,64620,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,910.62,,,,,,,fee schedule,875.6,3884.74,APC
Injection treatment of nerve,64620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,875.6,,,,,,,fee schedule,875.6,3884.74,APC
Injection treatment of nerve,64620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1339.67,,,,,,,fee schedule,875.6,3884.74,Radiology
Injection treatment of nerve,64620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1225.84,,,,,,,fee schedule,875.6,3884.74,APC
Injection treatment of nerve,64620,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1532.3,,,,,,,fee schedule,875.6,3884.74,APC
Dstrj nulyt agt gnclr nrv,64624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6499.14,,,,,,,fee schedule,1933.13,8576.66,
Dstrj nulyt agt gnclr nrv,64624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5209.63,,,,,,,fee schedule,1933.13,8576.66,
Dstrj nulyt agt gnclr nrv,64624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5691.05,,,,,,,fee schedule,1933.13,8576.66,
Dstrj nulyt agt gnclr nrv,64624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5983.34,,,,,,,fee schedule,1933.13,8576.66,
Dstrj nulyt agt gnclr nrv,64624,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8576.66,,,,,,,fee schedule,1933.13,8576.66,APC 378
Dstrj nulyt agt gnclr nrv,64624,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2029.79,,,,,,,fee schedule,1933.13,8576.66,APC
Dstrj nulyt agt gnclr nrv,64624,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2010.46,,,,,,,fee schedule,1933.13,8576.66,APC
Dstrj nulyt agt gnclr nrv,64624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1933.13,,,,,,,fee schedule,1933.13,8576.66,APC
Dstrj nulyt agt gnclr nrv,64624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2957.7,,,,,,,fee schedule,1933.13,8576.66,Radiology
Dstrj nulyt agt gnclr nrv,64624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2706.39,,,,,,,fee schedule,1933.13,8576.66,APC
Dstrj nulyt agt gnclr nrv,64624,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3382.99,,,,,,,fee schedule,1933.13,8576.66,APC
Rf abltj nrv nrvtg si jt,64625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6499.14,,,,,,,fee schedule,1933.13,8576.66,
Rf abltj nrv nrvtg si jt,64625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5209.63,,,,,,,fee schedule,1933.13,8576.66,
Rf abltj nrv nrvtg si jt,64625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5691.05,,,,,,,fee schedule,1933.13,8576.66,
Rf abltj nrv nrvtg si jt,64625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5983.34,,,,,,,fee schedule,1933.13,8576.66,
Rf abltj nrv nrvtg si jt,64625,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8576.66,,,,,,,fee schedule,1933.13,8576.66,APC 378
Rf abltj nrv nrvtg si jt,64625,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2029.79,,,,,,,fee schedule,1933.13,8576.66,APC
Rf abltj nrv nrvtg si jt,64625,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2010.46,,,,,,,fee schedule,1933.13,8576.66,APC
Rf abltj nrv nrvtg si jt,64625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1933.13,,,,,,,fee schedule,1933.13,8576.66,APC
Rf abltj nrv nrvtg si jt,64625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2957.7,,,,,,,fee schedule,1933.13,8576.66,Radiology
Rf abltj nrv nrvtg si jt,64625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2706.39,,,,,,,fee schedule,1933.13,8576.66,APC
Rf abltj nrv nrvtg si jt,64625,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3382.99,,,,,,,fee schedule,1933.13,8576.66,APC
Trml dstrj ios bvn 1st 2 l/s,64628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,47602.64,,,,,,,fee schedule,12709.88,56389.43,
Trml dstrj ios bvn 1st 2 l/s,64628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38157.67,,,,,,,fee schedule,12709.88,56389.43,
Trml dstrj ios bvn 1st 2 l/s,64628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,41683.79,,,,,,,fee schedule,12709.88,56389.43,
Trml dstrj ios bvn 1st 2 l/s,64628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,43824.65,,,,,,,fee schedule,12709.88,56389.43,
Trml dstrj ios bvn 1st 2 l/s,64628,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,12709.88,56389.43,APC 378
Trml dstrj ios bvn 1st 2 l/s,64628,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,12709.88,56389.43,APC
Trml dstrj ios bvn 1st 2 l/s,64628,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,12709.88,56389.43,APC
Trml dstrj ios bvn 1st 2 l/s,64628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,12709.88,56389.43,APC
Trml dstrj ios bvn 1st 2 l/s,64628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,12709.88,56389.43,Radiology
Trml dstrj ios bvn 1st 2 l/s,64628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,12709.88,56389.43,APC
Trml dstrj ios bvn 1st 2 l/s,64628,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,12709.88,56389.43,APC
Injection treatment of nerve,64630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1760.69,,,,,,,fee schedule,875.6,3884.74,
Injection treatment of nerve,64630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1411.34,,,,,,,fee schedule,875.6,3884.74,
Injection treatment of nerve,64630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1541.76,,,,,,,fee schedule,875.6,3884.74,
Injection treatment of nerve,64630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1620.95,,,,,,,fee schedule,875.6,3884.74,
Injection treatment of nerve,64630,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3884.74,,,,,,,fee schedule,875.6,3884.74,APC 378
Injection treatment of nerve,64630,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,919.38,,,,,,,fee schedule,875.6,3884.74,APC
Injection treatment of nerve,64630,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,910.62,,,,,,,fee schedule,875.6,3884.74,APC
Injection treatment of nerve,64630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,875.6,,,,,,,fee schedule,875.6,3884.74,APC
Injection treatment of nerve,64630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1339.67,,,,,,,fee schedule,875.6,3884.74,Radiology
Injection treatment of nerve,64630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1225.84,,,,,,,fee schedule,875.6,3884.74,APC
Injection treatment of nerve,64630,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1532.3,,,,,,,fee schedule,875.6,3884.74,APC
N block inj common digit,64632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,247.51,,,,,,,fee schedule,198.4,1348.18,
N block inj common digit,64632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,198.4,,,,,,,fee schedule,198.4,1348.18,
N block inj common digit,64632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,216.74,,,,,,,fee schedule,198.4,1348.18,
N block inj common digit,64632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,227.87,,,,,,,fee schedule,198.4,1348.18,
N block inj common digit,64632,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1348.18,,,,,,,fee schedule,198.4,1348.18,APC 378
N block inj common digit,64632,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,319.07,,,,,,,fee schedule,198.4,1348.18,APC
N block inj common digit,64632,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,316.03,,,,,,,fee schedule,198.4,1348.18,APC
N block inj common digit,64632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,303.87,,,,,,,fee schedule,198.4,1348.18,APC
N block inj common digit,64632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,464.92,,,,,,,fee schedule,198.4,1348.18,Radiology
N block inj common digit,64632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,425.42,,,,,,,fee schedule,198.4,1348.18,APC
N block inj common digit,64632,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,531.78,,,,,,,fee schedule,198.4,1348.18,APC
Destroy cerv/thor facet jnt,64633,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2571.38,,,,,,,fee schedule,1933.13,8576.66,
Destroy cerv/thor facet jnt,64633,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2061.19,,,,,,,fee schedule,1933.13,8576.66,
Destroy cerv/thor facet jnt,64633,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2251.66,,,,,,,fee schedule,1933.13,8576.66,
Destroy cerv/thor facet jnt,64633,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2367.3,,,,,,,fee schedule,1933.13,8576.66,
Destroy cerv/thor facet jnt,64633,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8576.66,,,,,,,fee schedule,1933.13,8576.66,APC 378
Destroy cerv/thor facet jnt,64633,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2029.79,,,,,,,fee schedule,1933.13,8576.66,APC
Destroy cerv/thor facet jnt,64633,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2010.46,,,,,,,fee schedule,1933.13,8576.66,APC
Destroy cerv/thor facet jnt,64633,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1933.13,,,,,,,fee schedule,1933.13,8576.66,APC
Destroy cerv/thor facet jnt,64633,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2957.7,,,,,,,fee schedule,1933.13,8576.66,Radiology
Destroy cerv/thor facet jnt,64633,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2706.39,,,,,,,fee schedule,1933.13,8576.66,APC
Destroy cerv/thor facet jnt,64633,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3382.99,,,,,,,fee schedule,1933.13,8576.66,APC
Destroy c/th facet jnt addl,64634,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1291.65,,,,,,,fee schedule,1035.37,1291.65,
Destroy c/th facet jnt addl,64634,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1035.37,,,,,,,fee schedule,1035.37,1291.65,
Destroy c/th facet jnt addl,64634,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1131.05,,,,,,,fee schedule,1035.37,1291.65,
Destroy c/th facet jnt addl,64634,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1189.14,,,,,,,fee schedule,1035.37,1291.65,
Destroy lumb/sac facet jnt,64635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3158.4,,,,,,,fee schedule,1933.13,8576.66,
Destroy lumb/sac facet jnt,64635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2531.73,,,,,,,fee schedule,1933.13,8576.66,
Destroy lumb/sac facet jnt,64635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2765.69,,,,,,,fee schedule,1933.13,8576.66,
Destroy lumb/sac facet jnt,64635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2907.73,,,,,,,fee schedule,1933.13,8576.66,
Destroy lumb/sac facet jnt,64635,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8576.66,,,,,,,fee schedule,1933.13,8576.66,APC 378
Destroy lumb/sac facet jnt,64635,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2029.79,,,,,,,fee schedule,1933.13,8576.66,APC
Destroy lumb/sac facet jnt,64635,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2010.46,,,,,,,fee schedule,1933.13,8576.66,APC
Destroy lumb/sac facet jnt,64635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1933.13,,,,,,,fee schedule,1933.13,8576.66,APC
Destroy lumb/sac facet jnt,64635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2957.7,,,,,,,fee schedule,1933.13,8576.66,Radiology
Destroy lumb/sac facet jnt,64635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2706.39,,,,,,,fee schedule,1933.13,8576.66,APC
Destroy lumb/sac facet jnt,64635,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3382.99,,,,,,,fee schedule,1933.13,8576.66,APC
Destroy l/s facet jnt addl,64636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1475.6,,,,,,,fee schedule,1182.82,1475.6,
Destroy l/s facet jnt addl,64636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1182.82,,,,,,,fee schedule,1182.82,1475.6,
Destroy l/s facet jnt addl,64636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1292.13,,,,,,,fee schedule,1182.82,1475.6,
Destroy l/s facet jnt addl,64636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1358.49,,,,,,,fee schedule,1182.82,1475.6,
Injection treatment of nerve,64640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1026.71,,,,,,,fee schedule,823,3884.74,
Injection treatment of nerve,64640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,823,,,,,,,fee schedule,823,3884.74,
Injection treatment of nerve,64640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,899.05,,,,,,,fee schedule,823,3884.74,
Injection treatment of nerve,64640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,945.23,,,,,,,fee schedule,823,3884.74,
Injection treatment of nerve,64640,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3884.74,,,,,,,fee schedule,823,3884.74,APC 378
Injection treatment of nerve,64640,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,919.38,,,,,,,fee schedule,823,3884.74,APC
Injection treatment of nerve,64640,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,910.62,,,,,,,fee schedule,823,3884.74,APC
Injection treatment of nerve,64640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,875.6,,,,,,,fee schedule,823,3884.74,APC
Injection treatment of nerve,64640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1339.67,,,,,,,fee schedule,823,3884.74,Radiology
Injection treatment of nerve,64640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1225.84,,,,,,,fee schedule,823,3884.74,APC
Injection treatment of nerve,64640,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1532.3,,,,,,,fee schedule,823,3884.74,APC
Chemodenerv 1 extremity 1-4,64642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1409.03,,,,,,,fee schedule,698.8,3100.34,
Chemodenerv 1 extremity 1-4,64642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1129.46,,,,,,,fee schedule,698.8,3100.34,
Chemodenerv 1 extremity 1-4,64642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1233.84,,,,,,,fee schedule,698.8,3100.34,
Chemodenerv 1 extremity 1-4,64642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1297.2,,,,,,,fee schedule,698.8,3100.34,
Chemodenerv 1 extremity 1-4,64642,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3100.34,,,,,,,fee schedule,698.8,3100.34,APC 378
Chemodenerv 1 extremity 1-4,64642,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,733.74,,,,,,,fee schedule,698.8,3100.34,APC
Chemodenerv 1 extremity 1-4,64642,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,726.75,,,,,,,fee schedule,698.8,3100.34,APC
Chemodenerv 1 extremity 1-4,64642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,698.8,,,,,,,fee schedule,698.8,3100.34,APC
Chemodenerv 1 extremity 1-4,64642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1069.16,,,,,,,fee schedule,698.8,3100.34,Radiology
Chemodenerv 1 extremity 1-4,64642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,978.32,,,,,,,fee schedule,698.8,3100.34,APC
Chemodenerv 1 extremity 1-4,64642,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1222.9,,,,,,,fee schedule,698.8,3100.34,APC
Chemodenerv 1 extrem 1-4 ea,64643,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,287.73,,,,,,,fee schedule,230.64,287.73,
Chemodenerv 1 extrem 1-4 ea,64643,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,230.64,,,,,,,fee schedule,230.64,287.73,
Chemodenerv 1 extrem 1-4 ea,64643,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,251.96,,,,,,,fee schedule,230.64,287.73,
Chemodenerv 1 extrem 1-4 ea,64643,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,264.9,,,,,,,fee schedule,230.64,287.73,
Chemodenerv 1 extrem 5/> mus,64644,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1409.03,,,,,,,fee schedule,698.8,3100.34,
Chemodenerv 1 extrem 5/> mus,64644,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1129.46,,,,,,,fee schedule,698.8,3100.34,
Chemodenerv 1 extrem 5/> mus,64644,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1233.84,,,,,,,fee schedule,698.8,3100.34,
Chemodenerv 1 extrem 5/> mus,64644,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1297.2,,,,,,,fee schedule,698.8,3100.34,
Chemodenerv 1 extrem 5/> mus,64644,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3100.34,,,,,,,fee schedule,698.8,3100.34,APC 378
Chemodenerv 1 extrem 5/> mus,64644,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,733.74,,,,,,,fee schedule,698.8,3100.34,APC
Chemodenerv 1 extrem 5/> mus,64644,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,726.75,,,,,,,fee schedule,698.8,3100.34,APC
Chemodenerv 1 extrem 5/> mus,64644,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,698.8,,,,,,,fee schedule,698.8,3100.34,APC
Chemodenerv 1 extrem 5/> mus,64644,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1069.16,,,,,,,fee schedule,698.8,3100.34,Radiology
Chemodenerv 1 extrem 5/> mus,64644,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,978.32,,,,,,,fee schedule,698.8,3100.34,APC
Chemodenerv 1 extrem 5/> mus,64644,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1222.9,,,,,,,fee schedule,698.8,3100.34,APC
Chemodenerv 1 extrem 5/> ea,64645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,325.34,,,,,,,fee schedule,260.79,325.34,
Chemodenerv 1 extrem 5/> ea,64645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,260.79,,,,,,,fee schedule,260.79,325.34,
Chemodenerv 1 extrem 5/> ea,64645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,284.89,,,,,,,fee schedule,260.79,325.34,
Chemodenerv 1 extrem 5/> ea,64645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,299.52,,,,,,,fee schedule,260.79,325.34,
Chemodenerv trunk musc 1-5,64646,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1409.03,,,,,,,fee schedule,698.8,3100.34,
Chemodenerv trunk musc 1-5,64646,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1129.46,,,,,,,fee schedule,698.8,3100.34,
Chemodenerv trunk musc 1-5,64646,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1233.84,,,,,,,fee schedule,698.8,3100.34,
Chemodenerv trunk musc 1-5,64646,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1297.2,,,,,,,fee schedule,698.8,3100.34,
Chemodenerv trunk musc 1-5,64646,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3100.34,,,,,,,fee schedule,698.8,3100.34,APC 378
Chemodenerv trunk musc 1-5,64646,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,733.74,,,,,,,fee schedule,698.8,3100.34,APC
Chemodenerv trunk musc 1-5,64646,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,726.75,,,,,,,fee schedule,698.8,3100.34,APC
Chemodenerv trunk musc 1-5,64646,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,698.8,,,,,,,fee schedule,698.8,3100.34,APC
Chemodenerv trunk musc 1-5,64646,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1069.16,,,,,,,fee schedule,698.8,3100.34,Radiology
Chemodenerv trunk musc 1-5,64646,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,978.32,,,,,,,fee schedule,698.8,3100.34,APC
Chemodenerv trunk musc 1-5,64646,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1222.9,,,,,,,fee schedule,698.8,3100.34,APC
Chemodenerv trunk musc 6/>,64647,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1409.03,,,,,,,fee schedule,698.8,3100.34,
Chemodenerv trunk musc 6/>,64647,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1129.46,,,,,,,fee schedule,698.8,3100.34,
Chemodenerv trunk musc 6/>,64647,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1233.84,,,,,,,fee schedule,698.8,3100.34,
Chemodenerv trunk musc 6/>,64647,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1297.2,,,,,,,fee schedule,698.8,3100.34,
Chemodenerv trunk musc 6/>,64647,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3100.34,,,,,,,fee schedule,698.8,3100.34,APC 378
Chemodenerv trunk musc 6/>,64647,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,733.74,,,,,,,fee schedule,698.8,3100.34,APC
Chemodenerv trunk musc 6/>,64647,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,726.75,,,,,,,fee schedule,698.8,3100.34,APC
Chemodenerv trunk musc 6/>,64647,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,698.8,,,,,,,fee schedule,698.8,3100.34,APC
Chemodenerv trunk musc 6/>,64647,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1069.16,,,,,,,fee schedule,698.8,3100.34,Radiology
Chemodenerv trunk musc 6/>,64647,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,978.32,,,,,,,fee schedule,698.8,3100.34,APC
Chemodenerv trunk musc 6/>,64647,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1222.9,,,,,,,fee schedule,698.8,3100.34,APC
Chemodenerv eccrine glands,64650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,579.32,,,,,,,fee schedule,303.87,1348.18,
Chemodenerv eccrine glands,64650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,464.38,,,,,,,fee schedule,303.87,1348.18,
Chemodenerv eccrine glands,64650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,507.29,,,,,,,fee schedule,303.87,1348.18,
Chemodenerv eccrine glands,64650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,533.34,,,,,,,fee schedule,303.87,1348.18,
Chemodenerv eccrine glands,64650,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1348.18,,,,,,,fee schedule,303.87,1348.18,APC 378
Chemodenerv eccrine glands,64650,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,319.07,,,,,,,fee schedule,303.87,1348.18,APC
Chemodenerv eccrine glands,64650,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,316.03,,,,,,,fee schedule,303.87,1348.18,APC
Chemodenerv eccrine glands,64650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,303.87,,,,,,,fee schedule,303.87,1348.18,APC
Chemodenerv eccrine glands,64650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,464.92,,,,,,,fee schedule,303.87,1348.18,Radiology
Chemodenerv eccrine glands,64650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,425.42,,,,,,,fee schedule,303.87,1348.18,APC
Chemodenerv eccrine glands,64650,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,531.78,,,,,,,fee schedule,303.87,1348.18,APC
Chemodenerv eccrine glands,64653,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,579.32,,,,,,,fee schedule,303.87,1348.18,
Chemodenerv eccrine glands,64653,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,464.38,,,,,,,fee schedule,303.87,1348.18,
Chemodenerv eccrine glands,64653,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,507.29,,,,,,,fee schedule,303.87,1348.18,
Chemodenerv eccrine glands,64653,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,533.34,,,,,,,fee schedule,303.87,1348.18,
Chemodenerv eccrine glands,64653,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1348.18,,,,,,,fee schedule,303.87,1348.18,APC 378
Chemodenerv eccrine glands,64653,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,319.07,,,,,,,fee schedule,303.87,1348.18,APC
Chemodenerv eccrine glands,64653,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,316.03,,,,,,,fee schedule,303.87,1348.18,APC
Chemodenerv eccrine glands,64653,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,303.87,,,,,,,fee schedule,303.87,1348.18,APC
Chemodenerv eccrine glands,64653,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,464.92,,,,,,,fee schedule,303.87,1348.18,Radiology
Chemodenerv eccrine glands,64653,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,425.42,,,,,,,fee schedule,303.87,1348.18,APC
Chemodenerv eccrine glands,64653,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,531.78,,,,,,,fee schedule,303.87,1348.18,APC
Revj/rplcmt bat mod sys lead,64655,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15355.43,,,,,,,fee schedule,3461.03,15355.43,APC 378
Revj/rplcmt bat mod sys lead,64655,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3634.08,,,,,,,fee schedule,3461.03,15355.43,APC
Revj/rplcmt bat mod sys lead,64655,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3599.47,,,,,,,fee schedule,3461.03,15355.43,APC
Revj/rplcmt bat mod sys lead,64655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3461.03,,,,,,,fee schedule,3461.03,15355.43,APC
Revj/rplcmt bat mod sys lead,64655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5295.38,,,,,,,fee schedule,3461.03,15355.43,Radiology
Revj/rplcmt bat mod sys lead,64655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4845.44,,,,,,,fee schedule,3461.03,15355.43,APC
Revj/rplcmt bat mod sys lead,64655,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6056.81,,,,,,,fee schedule,3461.03,15355.43,APC
Revj/rplcmt bat mod sys pg,64656,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,135531.68,,,,,,,fee schedule,30548.12,135531.68,APC 378
Revj/rplcmt bat mod sys pg,64656,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,32075.53,,,,,,,fee schedule,30548.12,135531.68,APC
Revj/rplcmt bat mod sys pg,64656,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,31770.05,,,,,,,fee schedule,30548.12,135531.68,APC
Revj/rplcmt bat mod sys pg,64656,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,30548.12,,,,,,,fee schedule,30548.12,135531.68,APC
Revj/rplcmt bat mod sys pg,64656,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,46738.63,,,,,,,fee schedule,30548.12,135531.68,Radiology
Revj/rplcmt bat mod sys pg,64656,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,42767.37,,,,,,,fee schedule,30548.12,135531.68,APC
Revj/rplcmt bat mod sys pg,64656,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,53459.21,,,,,,,fee schedule,30548.12,135531.68,APC
Rmvl bat modul sys lead only,64658,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15355.43,,,,,,,fee schedule,3461.03,15355.43,APC 378
Rmvl bat modul sys lead only,64658,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3634.08,,,,,,,fee schedule,3461.03,15355.43,APC
Rmvl bat modul sys lead only,64658,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3599.47,,,,,,,fee schedule,3461.03,15355.43,APC
Rmvl bat modul sys lead only,64658,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3461.03,,,,,,,fee schedule,3461.03,15355.43,APC
Rmvl bat modul sys lead only,64658,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5295.38,,,,,,,fee schedule,3461.03,15355.43,Radiology
Rmvl bat modul sys lead only,64658,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4845.44,,,,,,,fee schedule,3461.03,15355.43,APC
Rmvl bat modul sys lead only,64658,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6056.81,,,,,,,fee schedule,3461.03,15355.43,APC
Rmvl bat modulj sys pg only,64659,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15355.43,,,,,,,fee schedule,3461.03,15355.43,APC 378
Rmvl bat modulj sys pg only,64659,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3634.08,,,,,,,fee schedule,3461.03,15355.43,APC
Rmvl bat modulj sys pg only,64659,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3599.47,,,,,,,fee schedule,3461.03,15355.43,APC
Rmvl bat modulj sys pg only,64659,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3461.03,,,,,,,fee schedule,3461.03,15355.43,APC
Rmvl bat modulj sys pg only,64659,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5295.38,,,,,,,fee schedule,3461.03,15355.43,Radiology
Rmvl bat modulj sys pg only,64659,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4845.44,,,,,,,fee schedule,3461.03,15355.43,APC
Rmvl bat modulj sys pg only,64659,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6056.81,,,,,,,fee schedule,3461.03,15355.43,APC
Injection treatment of nerve,64680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3615.8,,,,,,,fee schedule,875.6,3884.74,
Injection treatment of nerve,64680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2898.38,,,,,,,fee schedule,875.6,3884.74,
Injection treatment of nerve,64680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3166.21,,,,,,,fee schedule,875.6,3884.74,
Injection treatment of nerve,64680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3328.83,,,,,,,fee schedule,875.6,3884.74,
Injection treatment of nerve,64680,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3884.74,,,,,,,fee schedule,875.6,3884.74,APC 378
Injection treatment of nerve,64680,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,919.38,,,,,,,fee schedule,875.6,3884.74,APC
Injection treatment of nerve,64680,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,910.62,,,,,,,fee schedule,875.6,3884.74,APC
Injection treatment of nerve,64680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,875.6,,,,,,,fee schedule,875.6,3884.74,APC
Injection treatment of nerve,64680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1339.67,,,,,,,fee schedule,875.6,3884.74,Radiology
Injection treatment of nerve,64680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1225.84,,,,,,,fee schedule,875.6,3884.74,APC
Injection treatment of nerve,64680,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1532.3,,,,,,,fee schedule,875.6,3884.74,APC
Injection treatment of nerve,64681,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3615.8,,,,,,,fee schedule,875.6,3884.74,
Injection treatment of nerve,64681,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2898.38,,,,,,,fee schedule,875.6,3884.74,
Injection treatment of nerve,64681,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3166.21,,,,,,,fee schedule,875.6,3884.74,
Injection treatment of nerve,64681,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3328.83,,,,,,,fee schedule,875.6,3884.74,
Injection treatment of nerve,64681,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3884.74,,,,,,,fee schedule,875.6,3884.74,APC 378
Injection treatment of nerve,64681,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,919.38,,,,,,,fee schedule,875.6,3884.74,APC
Injection treatment of nerve,64681,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,910.62,,,,,,,fee schedule,875.6,3884.74,APC
Injection treatment of nerve,64681,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,875.6,,,,,,,fee schedule,875.6,3884.74,APC
Injection treatment of nerve,64681,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1339.67,,,,,,,fee schedule,875.6,3884.74,Radiology
Injection treatment of nerve,64681,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1225.84,,,,,,,fee schedule,875.6,3884.74,APC
Injection treatment of nerve,64681,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1532.3,,,,,,,fee schedule,875.6,3884.74,APC
Revise finger/toe nerve,64702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3245.74,,,,,,,fee schedule,1933.13,8576.66,
Revise finger/toe nerve,64702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2601.74,,,,,,,fee schedule,1933.13,8576.66,
Revise finger/toe nerve,64702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2842.17,,,,,,,fee schedule,1933.13,8576.66,
Revise finger/toe nerve,64702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2988.14,,,,,,,fee schedule,1933.13,8576.66,
Revise finger/toe nerve,64702,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8576.66,,,,,,,fee schedule,1933.13,8576.66,APC 378
Revise finger/toe nerve,64702,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2029.79,,,,,,,fee schedule,1933.13,8576.66,APC
Revise finger/toe nerve,64702,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2010.46,,,,,,,fee schedule,1933.13,8576.66,APC
Revise finger/toe nerve,64702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1933.13,,,,,,,fee schedule,1933.13,8576.66,APC
Revise finger/toe nerve,64702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2957.7,,,,,,,fee schedule,1933.13,8576.66,Radiology
Revise finger/toe nerve,64702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2706.39,,,,,,,fee schedule,1933.13,8576.66,APC
Revise finger/toe nerve,64702,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3382.99,,,,,,,fee schedule,1933.13,8576.66,APC
Revise hand/foot nerve,64704,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3051.96,,,,,,,fee schedule,1933.13,8576.66,
Revise hand/foot nerve,64704,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2446.41,,,,,,,fee schedule,1933.13,8576.66,
Revise hand/foot nerve,64704,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2672.48,,,,,,,fee schedule,1933.13,8576.66,
Revise hand/foot nerve,64704,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2809.74,,,,,,,fee schedule,1933.13,8576.66,
Revise hand/foot nerve,64704,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8576.66,,,,,,,fee schedule,1933.13,8576.66,APC 378
Revise hand/foot nerve,64704,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2029.79,,,,,,,fee schedule,1933.13,8576.66,APC
Revise hand/foot nerve,64704,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2010.46,,,,,,,fee schedule,1933.13,8576.66,APC
Revise hand/foot nerve,64704,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1933.13,,,,,,,fee schedule,1933.13,8576.66,APC
Revise hand/foot nerve,64704,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2957.7,,,,,,,fee schedule,1933.13,8576.66,Radiology
Revise hand/foot nerve,64704,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2706.39,,,,,,,fee schedule,1933.13,8576.66,APC
Revise hand/foot nerve,64704,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3382.99,,,,,,,fee schedule,1933.13,8576.66,APC
Revise arm/leg nerve,64708,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4505.27,,,,,,,fee schedule,1933.13,8576.66,
Revise arm/leg nerve,64708,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3611.37,,,,,,,fee schedule,1933.13,8576.66,
Revise arm/leg nerve,64708,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3945.09,,,,,,,fee schedule,1933.13,8576.66,
Revise arm/leg nerve,64708,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4147.71,,,,,,,fee schedule,1933.13,8576.66,
Revise arm/leg nerve,64708,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8576.66,,,,,,,fee schedule,1933.13,8576.66,APC 378
Revise arm/leg nerve,64708,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2029.79,,,,,,,fee schedule,1933.13,8576.66,APC
Revise arm/leg nerve,64708,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2010.46,,,,,,,fee schedule,1933.13,8576.66,APC
Revise arm/leg nerve,64708,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1933.13,,,,,,,fee schedule,1933.13,8576.66,APC
Revise arm/leg nerve,64708,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2957.7,,,,,,,fee schedule,1933.13,8576.66,Radiology
Revise arm/leg nerve,64708,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2706.39,,,,,,,fee schedule,1933.13,8576.66,APC
Revise arm/leg nerve,64708,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3382.99,,,,,,,fee schedule,1933.13,8576.66,APC
Revision of sciatic nerve,64712,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4505.27,,,,,,,fee schedule,1933.13,8576.66,
Revision of sciatic nerve,64712,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3611.37,,,,,,,fee schedule,1933.13,8576.66,
Revision of sciatic nerve,64712,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3945.09,,,,,,,fee schedule,1933.13,8576.66,
Revision of sciatic nerve,64712,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4147.71,,,,,,,fee schedule,1933.13,8576.66,
Revision of sciatic nerve,64712,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8576.66,,,,,,,fee schedule,1933.13,8576.66,APC 378
Revision of sciatic nerve,64712,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2029.79,,,,,,,fee schedule,1933.13,8576.66,APC
Revision of sciatic nerve,64712,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2010.46,,,,,,,fee schedule,1933.13,8576.66,APC
Revision of sciatic nerve,64712,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1933.13,,,,,,,fee schedule,1933.13,8576.66,APC
Revision of sciatic nerve,64712,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2957.7,,,,,,,fee schedule,1933.13,8576.66,Radiology
Revision of sciatic nerve,64712,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2706.39,,,,,,,fee schedule,1933.13,8576.66,APC
Revision of sciatic nerve,64712,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3382.99,,,,,,,fee schedule,1933.13,8576.66,APC
Revision of arm nerve(s),64713,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4505.27,,,,,,,fee schedule,1933.13,8576.66,
Revision of arm nerve(s),64713,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3611.37,,,,,,,fee schedule,1933.13,8576.66,
Revision of arm nerve(s),64713,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3945.09,,,,,,,fee schedule,1933.13,8576.66,
Revision of arm nerve(s),64713,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4147.71,,,,,,,fee schedule,1933.13,8576.66,
Revision of arm nerve(s),64713,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8576.66,,,,,,,fee schedule,1933.13,8576.66,APC 378
Revision of arm nerve(s),64713,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2029.79,,,,,,,fee schedule,1933.13,8576.66,APC
Revision of arm nerve(s),64713,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2010.46,,,,,,,fee schedule,1933.13,8576.66,APC
Revision of arm nerve(s),64713,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1933.13,,,,,,,fee schedule,1933.13,8576.66,APC
Revision of arm nerve(s),64713,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2957.7,,,,,,,fee schedule,1933.13,8576.66,Radiology
Revision of arm nerve(s),64713,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2706.39,,,,,,,fee schedule,1933.13,8576.66,APC
Revision of arm nerve(s),64713,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3382.99,,,,,,,fee schedule,1933.13,8576.66,APC
Revise low back nerve(s),64714,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4505.27,,,,,,,fee schedule,1933.13,8576.66,
Revise low back nerve(s),64714,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3611.37,,,,,,,fee schedule,1933.13,8576.66,
Revise low back nerve(s),64714,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3945.09,,,,,,,fee schedule,1933.13,8576.66,
Revise low back nerve(s),64714,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4147.71,,,,,,,fee schedule,1933.13,8576.66,
Revise low back nerve(s),64714,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8576.66,,,,,,,fee schedule,1933.13,8576.66,APC 378
Revise low back nerve(s),64714,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2029.79,,,,,,,fee schedule,1933.13,8576.66,APC
Revise low back nerve(s),64714,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2010.46,,,,,,,fee schedule,1933.13,8576.66,APC
Revise low back nerve(s),64714,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1933.13,,,,,,,fee schedule,1933.13,8576.66,APC
Revise low back nerve(s),64714,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2957.7,,,,,,,fee schedule,1933.13,8576.66,Radiology
Revise low back nerve(s),64714,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2706.39,,,,,,,fee schedule,1933.13,8576.66,APC
Revise low back nerve(s),64714,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3382.99,,,,,,,fee schedule,1933.13,8576.66,APC
Revision of cranial nerve,64716,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4505.27,,,,,,,fee schedule,1933.13,8576.66,
Revision of cranial nerve,64716,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3611.37,,,,,,,fee schedule,1933.13,8576.66,
Revision of cranial nerve,64716,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3945.09,,,,,,,fee schedule,1933.13,8576.66,
Revision of cranial nerve,64716,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4147.71,,,,,,,fee schedule,1933.13,8576.66,
Revision of cranial nerve,64716,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8576.66,,,,,,,fee schedule,1933.13,8576.66,APC 378
Revision of cranial nerve,64716,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2029.79,,,,,,,fee schedule,1933.13,8576.66,APC
Revision of cranial nerve,64716,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2010.46,,,,,,,fee schedule,1933.13,8576.66,APC
Revision of cranial nerve,64716,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1933.13,,,,,,,fee schedule,1933.13,8576.66,APC
Revision of cranial nerve,64716,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2957.7,,,,,,,fee schedule,1933.13,8576.66,Radiology
Revision of cranial nerve,64716,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2706.39,,,,,,,fee schedule,1933.13,8576.66,APC
Revision of cranial nerve,64716,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3382.99,,,,,,,fee schedule,1933.13,8576.66,APC
Revise ulnar nerve at elbow,64718,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8666.11,,,,,,,fee schedule,1933.13,8666.11,
Revise ulnar nerve at elbow,64718,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6946.65,,,,,,,fee schedule,1933.13,8666.11,
Revise ulnar nerve at elbow,64718,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7588.58,,,,,,,fee schedule,1933.13,8666.11,
Revise ulnar nerve at elbow,64718,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7978.33,,,,,,,fee schedule,1933.13,8666.11,
Revise ulnar nerve at elbow,64718,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8576.66,,,,,,,fee schedule,1933.13,8666.11,APC 378
Revise ulnar nerve at elbow,64718,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2029.79,,,,,,,fee schedule,1933.13,8666.11,APC
Revise ulnar nerve at elbow,64718,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2010.46,,,,,,,fee schedule,1933.13,8666.11,APC
Revise ulnar nerve at elbow,64718,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1933.13,,,,,,,fee schedule,1933.13,8666.11,APC
Revise ulnar nerve at elbow,64718,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2957.7,,,,,,,fee schedule,1933.13,8666.11,Radiology
Revise ulnar nerve at elbow,64718,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2706.39,,,,,,,fee schedule,1933.13,8666.11,APC
Revise ulnar nerve at elbow,64718,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3382.99,,,,,,,fee schedule,1933.13,8666.11,APC
Revise ulnar nerve at wrist,64719,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3557.82,,,,,,,fee schedule,1933.13,8576.66,
Revise ulnar nerve at wrist,64719,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2851.9,,,,,,,fee schedule,1933.13,8576.66,
Revise ulnar nerve at wrist,64719,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3115.44,,,,,,,fee schedule,1933.13,8576.66,
Revise ulnar nerve at wrist,64719,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3275.45,,,,,,,fee schedule,1933.13,8576.66,
Revise ulnar nerve at wrist,64719,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8576.66,,,,,,,fee schedule,1933.13,8576.66,APC 378
Revise ulnar nerve at wrist,64719,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2029.79,,,,,,,fee schedule,1933.13,8576.66,APC
Revise ulnar nerve at wrist,64719,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2010.46,,,,,,,fee schedule,1933.13,8576.66,APC
Revise ulnar nerve at wrist,64719,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1933.13,,,,,,,fee schedule,1933.13,8576.66,APC
Revise ulnar nerve at wrist,64719,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2957.7,,,,,,,fee schedule,1933.13,8576.66,Radiology
Revise ulnar nerve at wrist,64719,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2706.39,,,,,,,fee schedule,1933.13,8576.66,APC
Revise ulnar nerve at wrist,64719,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3382.99,,,,,,,fee schedule,1933.13,8576.66,APC
Carpal tunnel surgery,64721,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8553.91,,,,,,,fee schedule,1933.13,8576.66,
Carpal tunnel surgery,64721,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6856.7,,,,,,,fee schedule,1933.13,8576.66,
Carpal tunnel surgery,64721,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7490.33,,,,,,,fee schedule,1933.13,8576.66,
Carpal tunnel surgery,64721,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7875.03,,,,,,,fee schedule,1933.13,8576.66,
Carpal tunnel surgery,64721,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8576.66,,,,,,,fee schedule,1933.13,8576.66,APC 378
Carpal tunnel surgery,64721,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2029.79,,,,,,,fee schedule,1933.13,8576.66,APC
Carpal tunnel surgery,64721,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2010.46,,,,,,,fee schedule,1933.13,8576.66,APC
Carpal tunnel surgery,64721,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1933.13,,,,,,,fee schedule,1933.13,8576.66,APC
Carpal tunnel surgery,64721,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2957.7,,,,,,,fee schedule,1933.13,8576.66,Radiology
Carpal tunnel surgery,64721,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2706.39,,,,,,,fee schedule,1933.13,8576.66,APC
Carpal tunnel surgery,64721,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3382.99,,,,,,,fee schedule,1933.13,8576.66,APC
Relieve pressure on nerve(s),64722,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4505.27,,,,,,,fee schedule,1933.13,8576.66,
Relieve pressure on nerve(s),64722,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3611.37,,,,,,,fee schedule,1933.13,8576.66,
Relieve pressure on nerve(s),64722,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3945.09,,,,,,,fee schedule,1933.13,8576.66,
Relieve pressure on nerve(s),64722,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4147.71,,,,,,,fee schedule,1933.13,8576.66,
Relieve pressure on nerve(s),64722,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8576.66,,,,,,,fee schedule,1933.13,8576.66,APC 378
Relieve pressure on nerve(s),64722,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2029.79,,,,,,,fee schedule,1933.13,8576.66,APC
Relieve pressure on nerve(s),64722,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2010.46,,,,,,,fee schedule,1933.13,8576.66,APC
Relieve pressure on nerve(s),64722,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1933.13,,,,,,,fee schedule,1933.13,8576.66,APC
Relieve pressure on nerve(s),64722,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2957.7,,,,,,,fee schedule,1933.13,8576.66,Radiology
Relieve pressure on nerve(s),64722,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2706.39,,,,,,,fee schedule,1933.13,8576.66,APC
Relieve pressure on nerve(s),64722,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3382.99,,,,,,,fee schedule,1933.13,8576.66,APC
Release foot/toe nerve,64726,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4505.27,,,,,,,fee schedule,1933.13,8576.66,
Release foot/toe nerve,64726,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3611.37,,,,,,,fee schedule,1933.13,8576.66,
Release foot/toe nerve,64726,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3945.09,,,,,,,fee schedule,1933.13,8576.66,
Release foot/toe nerve,64726,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4147.71,,,,,,,fee schedule,1933.13,8576.66,
Release foot/toe nerve,64726,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8576.66,,,,,,,fee schedule,1933.13,8576.66,APC 378
Release foot/toe nerve,64726,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2029.79,,,,,,,fee schedule,1933.13,8576.66,APC
Release foot/toe nerve,64726,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2010.46,,,,,,,fee schedule,1933.13,8576.66,APC
Release foot/toe nerve,64726,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1933.13,,,,,,,fee schedule,1933.13,8576.66,APC
Release foot/toe nerve,64726,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2957.7,,,,,,,fee schedule,1933.13,8576.66,Radiology
Release foot/toe nerve,64726,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2706.39,,,,,,,fee schedule,1933.13,8576.66,APC
Release foot/toe nerve,64726,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3382.99,,,,,,,fee schedule,1933.13,8576.66,APC
Internal nerve revision,64727,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4505.27,,,,,,,fee schedule,3611.37,4505.27,
Internal nerve revision,64727,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3611.37,,,,,,,fee schedule,3611.37,4505.27,
Internal nerve revision,64727,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3945.09,,,,,,,fee schedule,3611.37,4505.27,
Internal nerve revision,64727,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4147.71,,,,,,,fee schedule,3611.37,4505.27,
Dcmprn median nrv carpl tunl,64728,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8576.66,,,,,,,fee schedule,1933.13,8576.66,APC 378
Dcmprn median nrv carpl tunl,64728,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2029.79,,,,,,,fee schedule,1933.13,8576.66,APC
Dcmprn median nrv carpl tunl,64728,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2010.46,,,,,,,fee schedule,1933.13,8576.66,APC
Dcmprn median nrv carpl tunl,64728,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1933.13,,,,,,,fee schedule,1933.13,8576.66,APC
Dcmprn median nrv carpl tunl,64728,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2957.7,,,,,,,fee schedule,1933.13,8576.66,Radiology
Dcmprn median nrv carpl tunl,64728,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2706.39,,,,,,,fee schedule,1933.13,8576.66,APC
Dcmprn median nrv carpl tunl,64728,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3382.99,,,,,,,fee schedule,1933.13,8576.66,APC
Incision of brow nerve,64732,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4505.27,,,,,,,fee schedule,1933.13,8576.66,
Incision of brow nerve,64732,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3611.37,,,,,,,fee schedule,1933.13,8576.66,
Incision of brow nerve,64732,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3945.09,,,,,,,fee schedule,1933.13,8576.66,
Incision of brow nerve,64732,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4147.71,,,,,,,fee schedule,1933.13,8576.66,
Incision of brow nerve,64732,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8576.66,,,,,,,fee schedule,1933.13,8576.66,APC 378
Incision of brow nerve,64732,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2029.79,,,,,,,fee schedule,1933.13,8576.66,APC
Incision of brow nerve,64732,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2010.46,,,,,,,fee schedule,1933.13,8576.66,APC
Incision of brow nerve,64732,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1933.13,,,,,,,fee schedule,1933.13,8576.66,APC
Incision of brow nerve,64732,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2957.7,,,,,,,fee schedule,1933.13,8576.66,Radiology
Incision of brow nerve,64732,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2706.39,,,,,,,fee schedule,1933.13,8576.66,APC
Incision of brow nerve,64732,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3382.99,,,,,,,fee schedule,1933.13,8576.66,APC
Incision of cheek nerve,64734,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4505.27,,,,,,,fee schedule,1933.13,8576.66,
Incision of cheek nerve,64734,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3611.37,,,,,,,fee schedule,1933.13,8576.66,
Incision of cheek nerve,64734,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3945.09,,,,,,,fee schedule,1933.13,8576.66,
Incision of cheek nerve,64734,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4147.71,,,,,,,fee schedule,1933.13,8576.66,
Incision of cheek nerve,64734,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8576.66,,,,,,,fee schedule,1933.13,8576.66,APC 378
Incision of cheek nerve,64734,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2029.79,,,,,,,fee schedule,1933.13,8576.66,APC
Incision of cheek nerve,64734,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2010.46,,,,,,,fee schedule,1933.13,8576.66,APC
Incision of cheek nerve,64734,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1933.13,,,,,,,fee schedule,1933.13,8576.66,APC
Incision of cheek nerve,64734,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2957.7,,,,,,,fee schedule,1933.13,8576.66,Radiology
Incision of cheek nerve,64734,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2706.39,,,,,,,fee schedule,1933.13,8576.66,APC
Incision of cheek nerve,64734,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3382.99,,,,,,,fee schedule,1933.13,8576.66,APC
Incision of chin nerve,64736,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4505.27,,,,,,,fee schedule,1933.13,8576.66,
Incision of chin nerve,64736,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3611.37,,,,,,,fee schedule,1933.13,8576.66,
Incision of chin nerve,64736,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3945.09,,,,,,,fee schedule,1933.13,8576.66,
Incision of chin nerve,64736,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4147.71,,,,,,,fee schedule,1933.13,8576.66,
Incision of chin nerve,64736,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8576.66,,,,,,,fee schedule,1933.13,8576.66,APC 378
Incision of chin nerve,64736,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2029.79,,,,,,,fee schedule,1933.13,8576.66,APC
Incision of chin nerve,64736,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2010.46,,,,,,,fee schedule,1933.13,8576.66,APC
Incision of chin nerve,64736,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1933.13,,,,,,,fee schedule,1933.13,8576.66,APC
Incision of chin nerve,64736,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2957.7,,,,,,,fee schedule,1933.13,8576.66,Radiology
Incision of chin nerve,64736,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2706.39,,,,,,,fee schedule,1933.13,8576.66,APC
Incision of chin nerve,64736,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3382.99,,,,,,,fee schedule,1933.13,8576.66,APC
Incision of jaw nerve,64738,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4505.27,,,,,,,fee schedule,1933.13,8576.66,
Incision of jaw nerve,64738,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3611.37,,,,,,,fee schedule,1933.13,8576.66,
Incision of jaw nerve,64738,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3945.09,,,,,,,fee schedule,1933.13,8576.66,
Incision of jaw nerve,64738,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4147.71,,,,,,,fee schedule,1933.13,8576.66,
Incision of jaw nerve,64738,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8576.66,,,,,,,fee schedule,1933.13,8576.66,APC 378
Incision of jaw nerve,64738,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2029.79,,,,,,,fee schedule,1933.13,8576.66,APC
Incision of jaw nerve,64738,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2010.46,,,,,,,fee schedule,1933.13,8576.66,APC
Incision of jaw nerve,64738,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1933.13,,,,,,,fee schedule,1933.13,8576.66,APC
Incision of jaw nerve,64738,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2957.7,,,,,,,fee schedule,1933.13,8576.66,Radiology
Incision of jaw nerve,64738,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2706.39,,,,,,,fee schedule,1933.13,8576.66,APC
Incision of jaw nerve,64738,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3382.99,,,,,,,fee schedule,1933.13,8576.66,APC
Incision of tongue nerve,64740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4505.27,,,,,,,fee schedule,1933.13,8576.66,
Incision of tongue nerve,64740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3611.37,,,,,,,fee schedule,1933.13,8576.66,
Incision of tongue nerve,64740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3945.09,,,,,,,fee schedule,1933.13,8576.66,
Incision of tongue nerve,64740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4147.71,,,,,,,fee schedule,1933.13,8576.66,
Incision of tongue nerve,64740,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8576.66,,,,,,,fee schedule,1933.13,8576.66,APC 378
Incision of tongue nerve,64740,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2029.79,,,,,,,fee schedule,1933.13,8576.66,APC
Incision of tongue nerve,64740,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2010.46,,,,,,,fee schedule,1933.13,8576.66,APC
Incision of tongue nerve,64740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1933.13,,,,,,,fee schedule,1933.13,8576.66,APC
Incision of tongue nerve,64740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2957.7,,,,,,,fee schedule,1933.13,8576.66,Radiology
Incision of tongue nerve,64740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2706.39,,,,,,,fee schedule,1933.13,8576.66,APC
Incision of tongue nerve,64740,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3382.99,,,,,,,fee schedule,1933.13,8576.66,APC
Incision of facial nerve,64742,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4505.27,,,,,,,fee schedule,1933.13,8576.66,
Incision of facial nerve,64742,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3611.37,,,,,,,fee schedule,1933.13,8576.66,
Incision of facial nerve,64742,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3945.09,,,,,,,fee schedule,1933.13,8576.66,
Incision of facial nerve,64742,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4147.71,,,,,,,fee schedule,1933.13,8576.66,
Incision of facial nerve,64742,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8576.66,,,,,,,fee schedule,1933.13,8576.66,APC 378
Incision of facial nerve,64742,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2029.79,,,,,,,fee schedule,1933.13,8576.66,APC
Incision of facial nerve,64742,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2010.46,,,,,,,fee schedule,1933.13,8576.66,APC
Incision of facial nerve,64742,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1933.13,,,,,,,fee schedule,1933.13,8576.66,APC
Incision of facial nerve,64742,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2957.7,,,,,,,fee schedule,1933.13,8576.66,Radiology
Incision of facial nerve,64742,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2706.39,,,,,,,fee schedule,1933.13,8576.66,APC
Incision of facial nerve,64742,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3382.99,,,,,,,fee schedule,1933.13,8576.66,APC
Incise nerve back of head,64744,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4505.27,,,,,,,fee schedule,1933.13,8576.66,
Incise nerve back of head,64744,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3611.37,,,,,,,fee schedule,1933.13,8576.66,
Incise nerve back of head,64744,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3945.09,,,,,,,fee schedule,1933.13,8576.66,
Incise nerve back of head,64744,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4147.71,,,,,,,fee schedule,1933.13,8576.66,
Incise nerve back of head,64744,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8576.66,,,,,,,fee schedule,1933.13,8576.66,APC 378
Incise nerve back of head,64744,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2029.79,,,,,,,fee schedule,1933.13,8576.66,APC
Incise nerve back of head,64744,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2010.46,,,,,,,fee schedule,1933.13,8576.66,APC
Incise nerve back of head,64744,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1933.13,,,,,,,fee schedule,1933.13,8576.66,APC
Incise nerve back of head,64744,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2957.7,,,,,,,fee schedule,1933.13,8576.66,Radiology
Incise nerve back of head,64744,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2706.39,,,,,,,fee schedule,1933.13,8576.66,APC
Incise nerve back of head,64744,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3382.99,,,,,,,fee schedule,1933.13,8576.66,APC
Incise diaphragm nerve,64746,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4505.27,,,,,,,fee schedule,1933.13,8576.66,
Incise diaphragm nerve,64746,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3611.37,,,,,,,fee schedule,1933.13,8576.66,
Incise diaphragm nerve,64746,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3945.09,,,,,,,fee schedule,1933.13,8576.66,
Incise diaphragm nerve,64746,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4147.71,,,,,,,fee schedule,1933.13,8576.66,
Incise diaphragm nerve,64746,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8576.66,,,,,,,fee schedule,1933.13,8576.66,APC 378
Incise diaphragm nerve,64746,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2029.79,,,,,,,fee schedule,1933.13,8576.66,APC
Incise diaphragm nerve,64746,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2010.46,,,,,,,fee schedule,1933.13,8576.66,APC
Incise diaphragm nerve,64746,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1933.13,,,,,,,fee schedule,1933.13,8576.66,APC
Incise diaphragm nerve,64746,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2957.7,,,,,,,fee schedule,1933.13,8576.66,Radiology
Incise diaphragm nerve,64746,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2706.39,,,,,,,fee schedule,1933.13,8576.66,APC
Incise diaphragm nerve,64746,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3382.99,,,,,,,fee schedule,1933.13,8576.66,APC
Incise hip/thigh nerve,64763,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4505.27,,,,,,,fee schedule,1933.13,8576.66,
Incise hip/thigh nerve,64763,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3611.37,,,,,,,fee schedule,1933.13,8576.66,
Incise hip/thigh nerve,64763,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3945.09,,,,,,,fee schedule,1933.13,8576.66,
Incise hip/thigh nerve,64763,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4147.71,,,,,,,fee schedule,1933.13,8576.66,
Incise hip/thigh nerve,64763,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8576.66,,,,,,,fee schedule,1933.13,8576.66,APC 378
Incise hip/thigh nerve,64763,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2029.79,,,,,,,fee schedule,1933.13,8576.66,APC
Incise hip/thigh nerve,64763,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2010.46,,,,,,,fee schedule,1933.13,8576.66,APC
Incise hip/thigh nerve,64763,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1933.13,,,,,,,fee schedule,1933.13,8576.66,APC
Incise hip/thigh nerve,64763,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2957.7,,,,,,,fee schedule,1933.13,8576.66,Radiology
Incise hip/thigh nerve,64763,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2706.39,,,,,,,fee schedule,1933.13,8576.66,APC
Incise hip/thigh nerve,64763,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3382.99,,,,,,,fee schedule,1933.13,8576.66,APC
Incise hip/thigh nerve,64766,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8303.53,,,,,,,fee schedule,1933.13,8576.66,
Incise hip/thigh nerve,64766,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6656,,,,,,,fee schedule,1933.13,8576.66,
Incise hip/thigh nerve,64766,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7271.08,,,,,,,fee schedule,1933.13,8576.66,
Incise hip/thigh nerve,64766,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7644.52,,,,,,,fee schedule,1933.13,8576.66,
Incise hip/thigh nerve,64766,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8576.66,,,,,,,fee schedule,1933.13,8576.66,APC 378
Incise hip/thigh nerve,64766,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2029.79,,,,,,,fee schedule,1933.13,8576.66,APC
Incise hip/thigh nerve,64766,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2010.46,,,,,,,fee schedule,1933.13,8576.66,APC
Incise hip/thigh nerve,64766,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1933.13,,,,,,,fee schedule,1933.13,8576.66,APC
Incise hip/thigh nerve,64766,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2957.7,,,,,,,fee schedule,1933.13,8576.66,Radiology
Incise hip/thigh nerve,64766,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2706.39,,,,,,,fee schedule,1933.13,8576.66,APC
Incise hip/thigh nerve,64766,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3382.99,,,,,,,fee schedule,1933.13,8576.66,APC
Sever cranial nerve,64771,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4505.27,,,,,,,fee schedule,1933.13,8576.66,
Sever cranial nerve,64771,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3611.37,,,,,,,fee schedule,1933.13,8576.66,
Sever cranial nerve,64771,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3945.09,,,,,,,fee schedule,1933.13,8576.66,
Sever cranial nerve,64771,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4147.71,,,,,,,fee schedule,1933.13,8576.66,
Sever cranial nerve,64771,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8576.66,,,,,,,fee schedule,1933.13,8576.66,APC 378
Sever cranial nerve,64771,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2029.79,,,,,,,fee schedule,1933.13,8576.66,APC
Sever cranial nerve,64771,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2010.46,,,,,,,fee schedule,1933.13,8576.66,APC
Sever cranial nerve,64771,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1933.13,,,,,,,fee schedule,1933.13,8576.66,APC
Sever cranial nerve,64771,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2957.7,,,,,,,fee schedule,1933.13,8576.66,Radiology
Sever cranial nerve,64771,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2706.39,,,,,,,fee schedule,1933.13,8576.66,APC
Sever cranial nerve,64771,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3382.99,,,,,,,fee schedule,1933.13,8576.66,APC
Incision of spinal nerve,64772,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4505.27,,,,,,,fee schedule,1933.13,8576.66,
Incision of spinal nerve,64772,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3611.37,,,,,,,fee schedule,1933.13,8576.66,
Incision of spinal nerve,64772,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3945.09,,,,,,,fee schedule,1933.13,8576.66,
Incision of spinal nerve,64772,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4147.71,,,,,,,fee schedule,1933.13,8576.66,
Incision of spinal nerve,64772,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8576.66,,,,,,,fee schedule,1933.13,8576.66,APC 378
Incision of spinal nerve,64772,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2029.79,,,,,,,fee schedule,1933.13,8576.66,APC
Incision of spinal nerve,64772,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2010.46,,,,,,,fee schedule,1933.13,8576.66,APC
Incision of spinal nerve,64772,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1933.13,,,,,,,fee schedule,1933.13,8576.66,APC
Incision of spinal nerve,64772,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2957.7,,,,,,,fee schedule,1933.13,8576.66,Radiology
Incision of spinal nerve,64772,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2706.39,,,,,,,fee schedule,1933.13,8576.66,APC
Incision of spinal nerve,64772,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3382.99,,,,,,,fee schedule,1933.13,8576.66,APC
Remove skin nerve lesion,64774,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4505.27,,,,,,,fee schedule,1933.13,8576.66,
Remove skin nerve lesion,64774,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3611.37,,,,,,,fee schedule,1933.13,8576.66,
Remove skin nerve lesion,64774,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3945.09,,,,,,,fee schedule,1933.13,8576.66,
Remove skin nerve lesion,64774,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4147.71,,,,,,,fee schedule,1933.13,8576.66,
Remove skin nerve lesion,64774,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8576.66,,,,,,,fee schedule,1933.13,8576.66,APC 378
Remove skin nerve lesion,64774,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2029.79,,,,,,,fee schedule,1933.13,8576.66,APC
Remove skin nerve lesion,64774,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2010.46,,,,,,,fee schedule,1933.13,8576.66,APC
Remove skin nerve lesion,64774,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1933.13,,,,,,,fee schedule,1933.13,8576.66,APC
Remove skin nerve lesion,64774,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2957.7,,,,,,,fee schedule,1933.13,8576.66,Radiology
Remove skin nerve lesion,64774,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2706.39,,,,,,,fee schedule,1933.13,8576.66,APC
Remove skin nerve lesion,64774,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3382.99,,,,,,,fee schedule,1933.13,8576.66,APC
Remove digit nerve lesion,64776,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4505.27,,,,,,,fee schedule,1933.13,8576.66,
Remove digit nerve lesion,64776,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3611.37,,,,,,,fee schedule,1933.13,8576.66,
Remove digit nerve lesion,64776,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3945.09,,,,,,,fee schedule,1933.13,8576.66,
Remove digit nerve lesion,64776,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4147.71,,,,,,,fee schedule,1933.13,8576.66,
Remove digit nerve lesion,64776,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8576.66,,,,,,,fee schedule,1933.13,8576.66,APC 378
Remove digit nerve lesion,64776,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2029.79,,,,,,,fee schedule,1933.13,8576.66,APC
Remove digit nerve lesion,64776,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2010.46,,,,,,,fee schedule,1933.13,8576.66,APC
Remove digit nerve lesion,64776,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1933.13,,,,,,,fee schedule,1933.13,8576.66,APC
Remove digit nerve lesion,64776,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2957.7,,,,,,,fee schedule,1933.13,8576.66,Radiology
Remove digit nerve lesion,64776,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2706.39,,,,,,,fee schedule,1933.13,8576.66,APC
Remove digit nerve lesion,64776,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3382.99,,,,,,,fee schedule,1933.13,8576.66,APC
Digit nerve surgery add-on,64778,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4505.27,,,,,,,fee schedule,3611.37,4505.27,
Digit nerve surgery add-on,64778,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3611.37,,,,,,,fee schedule,3611.37,4505.27,
Digit nerve surgery add-on,64778,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3945.09,,,,,,,fee schedule,3611.37,4505.27,
Digit nerve surgery add-on,64778,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4147.71,,,,,,,fee schedule,3611.37,4505.27,
Remove limb nerve lesion,64782,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9269.11,,,,,,,fee schedule,1933.13,9269.11,
Remove limb nerve lesion,64782,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7430,,,,,,,fee schedule,1933.13,9269.11,
Remove limb nerve lesion,64782,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8116.61,,,,,,,fee schedule,1933.13,9269.11,
Remove limb nerve lesion,64782,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8533.47,,,,,,,fee schedule,1933.13,9269.11,
Remove limb nerve lesion,64782,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8576.66,,,,,,,fee schedule,1933.13,9269.11,APC 378
Remove limb nerve lesion,64782,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2029.79,,,,,,,fee schedule,1933.13,9269.11,APC
Remove limb nerve lesion,64782,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2010.46,,,,,,,fee schedule,1933.13,9269.11,APC
Remove limb nerve lesion,64782,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1933.13,,,,,,,fee schedule,1933.13,9269.11,APC
Remove limb nerve lesion,64782,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2957.7,,,,,,,fee schedule,1933.13,9269.11,Radiology
Remove limb nerve lesion,64782,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2706.39,,,,,,,fee schedule,1933.13,9269.11,APC
Remove limb nerve lesion,64782,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3382.99,,,,,,,fee schedule,1933.13,9269.11,APC
Limb nerve surgery add-on,64783,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4505.27,,,,,,,fee schedule,3611.37,4505.27,
Limb nerve surgery add-on,64783,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3611.37,,,,,,,fee schedule,3611.37,4505.27,
Limb nerve surgery add-on,64783,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3945.09,,,,,,,fee schedule,3611.37,4505.27,
Limb nerve surgery add-on,64783,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4147.71,,,,,,,fee schedule,3611.37,4505.27,
Remove nerve lesion,64784,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4505.27,,,,,,,fee schedule,1933.13,8576.66,
Remove nerve lesion,64784,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3611.37,,,,,,,fee schedule,1933.13,8576.66,
Remove nerve lesion,64784,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3945.09,,,,,,,fee schedule,1933.13,8576.66,
Remove nerve lesion,64784,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4147.71,,,,,,,fee schedule,1933.13,8576.66,
Remove nerve lesion,64784,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8576.66,,,,,,,fee schedule,1933.13,8576.66,APC 378
Remove nerve lesion,64784,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2029.79,,,,,,,fee schedule,1933.13,8576.66,APC
Remove nerve lesion,64784,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2010.46,,,,,,,fee schedule,1933.13,8576.66,APC
Remove nerve lesion,64784,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1933.13,,,,,,,fee schedule,1933.13,8576.66,APC
Remove nerve lesion,64784,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2957.7,,,,,,,fee schedule,1933.13,8576.66,Radiology
Remove nerve lesion,64784,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2706.39,,,,,,,fee schedule,1933.13,8576.66,APC
Remove nerve lesion,64784,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3382.99,,,,,,,fee schedule,1933.13,8576.66,APC
Remove sciatic nerve lesion,64786,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8303.53,,,,,,,fee schedule,3381.88,15004.24,
Remove sciatic nerve lesion,64786,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6656,,,,,,,fee schedule,3381.88,15004.24,
Remove sciatic nerve lesion,64786,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7271.08,,,,,,,fee schedule,3381.88,15004.24,
Remove sciatic nerve lesion,64786,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7644.52,,,,,,,fee schedule,3381.88,15004.24,
Remove sciatic nerve lesion,64786,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15004.24,,,,,,,fee schedule,3381.88,15004.24,APC 378
Remove sciatic nerve lesion,64786,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3550.97,,,,,,,fee schedule,3381.88,15004.24,APC
Remove sciatic nerve lesion,64786,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3517.15,,,,,,,fee schedule,3381.88,15004.24,APC
Remove sciatic nerve lesion,64786,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3381.88,,,,,,,fee schedule,3381.88,15004.24,APC
Remove sciatic nerve lesion,64786,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5174.27,,,,,,,fee schedule,3381.88,15004.24,Radiology
Remove sciatic nerve lesion,64786,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4734.63,,,,,,,fee schedule,3381.88,15004.24,APC
Remove sciatic nerve lesion,64786,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5918.28,,,,,,,fee schedule,3381.88,15004.24,APC
Implant nerve end,64787,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1276.3,,,,,,,fee schedule,1023.06,1276.3,
Implant nerve end,64787,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1023.06,,,,,,,fee schedule,1023.06,1276.3,
Implant nerve end,64787,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1117.6,,,,,,,fee schedule,1023.06,1276.3,
Implant nerve end,64787,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1175,,,,,,,fee schedule,1023.06,1276.3,
Remove skin nerve lesion,64788,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7677.31,,,,,,,fee schedule,1933.13,8576.66,
Remove skin nerve lesion,64788,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6154.03,,,,,,,fee schedule,1933.13,8576.66,
Remove skin nerve lesion,64788,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6722.72,,,,,,,fee schedule,1933.13,8576.66,
Remove skin nerve lesion,64788,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7068,,,,,,,fee schedule,1933.13,8576.66,
Remove skin nerve lesion,64788,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8576.66,,,,,,,fee schedule,1933.13,8576.66,APC 378
Remove skin nerve lesion,64788,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2029.79,,,,,,,fee schedule,1933.13,8576.66,APC
Remove skin nerve lesion,64788,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2010.46,,,,,,,fee schedule,1933.13,8576.66,APC
Remove skin nerve lesion,64788,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1933.13,,,,,,,fee schedule,1933.13,8576.66,APC
Remove skin nerve lesion,64788,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2957.7,,,,,,,fee schedule,1933.13,8576.66,Radiology
Remove skin nerve lesion,64788,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2706.39,,,,,,,fee schedule,1933.13,8576.66,APC
Remove skin nerve lesion,64788,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3382.99,,,,,,,fee schedule,1933.13,8576.66,APC
Removal of nerve lesion,64790,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4505.27,,,,,,,fee schedule,1933.13,8576.66,
Removal of nerve lesion,64790,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3611.37,,,,,,,fee schedule,1933.13,8576.66,
Removal of nerve lesion,64790,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3945.09,,,,,,,fee schedule,1933.13,8576.66,
Removal of nerve lesion,64790,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4147.71,,,,,,,fee schedule,1933.13,8576.66,
Removal of nerve lesion,64790,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8576.66,,,,,,,fee schedule,1933.13,8576.66,APC 378
Removal of nerve lesion,64790,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2029.79,,,,,,,fee schedule,1933.13,8576.66,APC
Removal of nerve lesion,64790,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2010.46,,,,,,,fee schedule,1933.13,8576.66,APC
Removal of nerve lesion,64790,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1933.13,,,,,,,fee schedule,1933.13,8576.66,APC
Removal of nerve lesion,64790,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2957.7,,,,,,,fee schedule,1933.13,8576.66,Radiology
Removal of nerve lesion,64790,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2706.39,,,,,,,fee schedule,1933.13,8576.66,APC
Removal of nerve lesion,64790,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3382.99,,,,,,,fee schedule,1933.13,8576.66,APC
Removal of nerve lesion,64792,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8303.53,,,,,,,fee schedule,3381.88,15004.24,
Removal of nerve lesion,64792,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6656,,,,,,,fee schedule,3381.88,15004.24,
Removal of nerve lesion,64792,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7271.08,,,,,,,fee schedule,3381.88,15004.24,
Removal of nerve lesion,64792,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7644.52,,,,,,,fee schedule,3381.88,15004.24,
Removal of nerve lesion,64792,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15004.24,,,,,,,fee schedule,3381.88,15004.24,APC 378
Removal of nerve lesion,64792,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3550.97,,,,,,,fee schedule,3381.88,15004.24,APC
Removal of nerve lesion,64792,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3517.15,,,,,,,fee schedule,3381.88,15004.24,APC
Removal of nerve lesion,64792,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3381.88,,,,,,,fee schedule,3381.88,15004.24,APC
Removal of nerve lesion,64792,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5174.27,,,,,,,fee schedule,3381.88,15004.24,Radiology
Removal of nerve lesion,64792,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4734.63,,,,,,,fee schedule,3381.88,15004.24,APC
Removal of nerve lesion,64792,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5918.28,,,,,,,fee schedule,3381.88,15004.24,APC
Biopsy of nerve,64795,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4505.27,,,,,,,fee schedule,1933.13,8576.66,
Biopsy of nerve,64795,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3611.37,,,,,,,fee schedule,1933.13,8576.66,
Biopsy of nerve,64795,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3945.09,,,,,,,fee schedule,1933.13,8576.66,
Biopsy of nerve,64795,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4147.71,,,,,,,fee schedule,1933.13,8576.66,
Biopsy of nerve,64795,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8576.66,,,,,,,fee schedule,1933.13,8576.66,APC 378
Biopsy of nerve,64795,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2029.79,,,,,,,fee schedule,1933.13,8576.66,APC
Biopsy of nerve,64795,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2010.46,,,,,,,fee schedule,1933.13,8576.66,APC
Biopsy of nerve,64795,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1933.13,,,,,,,fee schedule,1933.13,8576.66,APC
Biopsy of nerve,64795,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2957.7,,,,,,,fee schedule,1933.13,8576.66,Radiology
Biopsy of nerve,64795,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2706.39,,,,,,,fee schedule,1933.13,8576.66,APC
Biopsy of nerve,64795,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3382.99,,,,,,,fee schedule,1933.13,8576.66,APC
Sympathectomy cervical,64802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4505.27,,,,,,,fee schedule,1933.13,8576.66,
Sympathectomy cervical,64802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3611.37,,,,,,,fee schedule,1933.13,8576.66,
Sympathectomy cervical,64802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3945.09,,,,,,,fee schedule,1933.13,8576.66,
Sympathectomy cervical,64802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4147.71,,,,,,,fee schedule,1933.13,8576.66,
Sympathectomy cervical,64802,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8576.66,,,,,,,fee schedule,1933.13,8576.66,APC 378
Sympathectomy cervical,64802,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2029.79,,,,,,,fee schedule,1933.13,8576.66,APC
Sympathectomy cervical,64802,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2010.46,,,,,,,fee schedule,1933.13,8576.66,APC
Sympathectomy cervical,64802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1933.13,,,,,,,fee schedule,1933.13,8576.66,APC
Sympathectomy cervical,64802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2957.7,,,,,,,fee schedule,1933.13,8576.66,Radiology
Sympathectomy cervical,64802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2706.39,,,,,,,fee schedule,1933.13,8576.66,APC
Sympathectomy cervical,64802,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3382.99,,,,,,,fee schedule,1933.13,8576.66,APC
Remove sympathetic nerves,64804,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4505.27,,,,,,,fee schedule,1933.13,8576.66,
Remove sympathetic nerves,64804,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3611.37,,,,,,,fee schedule,1933.13,8576.66,
Remove sympathetic nerves,64804,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3945.09,,,,,,,fee schedule,1933.13,8576.66,
Remove sympathetic nerves,64804,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4147.71,,,,,,,fee schedule,1933.13,8576.66,
Remove sympathetic nerves,64804,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8576.66,,,,,,,fee schedule,1933.13,8576.66,APC 378
Remove sympathetic nerves,64804,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2029.79,,,,,,,fee schedule,1933.13,8576.66,APC
Remove sympathetic nerves,64804,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2010.46,,,,,,,fee schedule,1933.13,8576.66,APC
Remove sympathetic nerves,64804,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1933.13,,,,,,,fee schedule,1933.13,8576.66,APC
Remove sympathetic nerves,64804,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2957.7,,,,,,,fee schedule,1933.13,8576.66,Radiology
Remove sympathetic nerves,64804,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2706.39,,,,,,,fee schedule,1933.13,8576.66,APC
Remove sympathetic nerves,64804,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3382.99,,,,,,,fee schedule,1933.13,8576.66,APC
Sympathectomy digital artery,64820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4505.27,,,,,,,fee schedule,1933.13,8576.66,
Sympathectomy digital artery,64820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3611.37,,,,,,,fee schedule,1933.13,8576.66,
Sympathectomy digital artery,64820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3945.09,,,,,,,fee schedule,1933.13,8576.66,
Sympathectomy digital artery,64820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4147.71,,,,,,,fee schedule,1933.13,8576.66,
Sympathectomy digital artery,64820,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8576.66,,,,,,,fee schedule,1933.13,8576.66,APC 378
Sympathectomy digital artery,64820,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2029.79,,,,,,,fee schedule,1933.13,8576.66,APC
Sympathectomy digital artery,64820,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2010.46,,,,,,,fee schedule,1933.13,8576.66,APC
Sympathectomy digital artery,64820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1933.13,,,,,,,fee schedule,1933.13,8576.66,APC
Sympathectomy digital artery,64820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2957.7,,,,,,,fee schedule,1933.13,8576.66,Radiology
Sympathectomy digital artery,64820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2706.39,,,,,,,fee schedule,1933.13,8576.66,APC
Sympathectomy digital artery,64820,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3382.99,,,,,,,fee schedule,1933.13,8576.66,APC
Remove sympathetic nerves,64821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6566.46,,,,,,,fee schedule,3239.17,14371.12,
Remove sympathetic nerves,64821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5263.59,,,,,,,fee schedule,3239.17,14371.12,
Remove sympathetic nerves,64821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5750,,,,,,,fee schedule,3239.17,14371.12,
Remove sympathetic nerves,64821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6045.32,,,,,,,fee schedule,3239.17,14371.12,
Remove sympathetic nerves,64821,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Remove sympathetic nerves,64821,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Remove sympathetic nerves,64821,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Remove sympathetic nerves,64821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Remove sympathetic nerves,64821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Remove sympathetic nerves,64821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Remove sympathetic nerves,64821,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Remove sympathetic nerves,64822,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6566.46,,,,,,,fee schedule,3239.17,14371.12,
Remove sympathetic nerves,64822,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5263.59,,,,,,,fee schedule,3239.17,14371.12,
Remove sympathetic nerves,64822,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5750,,,,,,,fee schedule,3239.17,14371.12,
Remove sympathetic nerves,64822,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6045.32,,,,,,,fee schedule,3239.17,14371.12,
Remove sympathetic nerves,64822,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Remove sympathetic nerves,64822,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Remove sympathetic nerves,64822,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Remove sympathetic nerves,64822,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Remove sympathetic nerves,64822,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Remove sympathetic nerves,64822,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Remove sympathetic nerves,64822,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Sympathectomy supfc palmar,64823,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6566.46,,,,,,,fee schedule,3239.17,14371.12,
Sympathectomy supfc palmar,64823,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5263.59,,,,,,,fee schedule,3239.17,14371.12,
Sympathectomy supfc palmar,64823,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5750,,,,,,,fee schedule,3239.17,14371.12,
Sympathectomy supfc palmar,64823,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6045.32,,,,,,,fee schedule,3239.17,14371.12,
Sympathectomy supfc palmar,64823,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Sympathectomy supfc palmar,64823,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Sympathectomy supfc palmar,64823,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Sympathectomy supfc palmar,64823,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Sympathectomy supfc palmar,64823,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Sympathectomy supfc palmar,64823,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Sympathectomy supfc palmar,64823,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Repair of digit nerve,64831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3523.68,,,,,,,fee schedule,1933.13,8576.66,
Repair of digit nerve,64831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2824.54,,,,,,,fee schedule,1933.13,8576.66,
Repair of digit nerve,64831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3085.55,,,,,,,fee schedule,1933.13,8576.66,
Repair of digit nerve,64831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3244.03,,,,,,,fee schedule,1933.13,8576.66,
Repair of digit nerve,64831,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8576.66,,,,,,,fee schedule,1933.13,8576.66,APC 378
Repair of digit nerve,64831,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2029.79,,,,,,,fee schedule,1933.13,8576.66,APC
Repair of digit nerve,64831,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2010.46,,,,,,,fee schedule,1933.13,8576.66,APC
Repair of digit nerve,64831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1933.13,,,,,,,fee schedule,1933.13,8576.66,APC
Repair of digit nerve,64831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2957.7,,,,,,,fee schedule,1933.13,8576.66,Radiology
Repair of digit nerve,64831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2706.39,,,,,,,fee schedule,1933.13,8576.66,APC
Repair of digit nerve,64831,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3382.99,,,,,,,fee schedule,1933.13,8576.66,APC
Repair nerve add-on,64832,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3176.75,,,,,,,fee schedule,2546.44,3176.75,
Repair nerve add-on,64832,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2546.44,,,,,,,fee schedule,2546.44,3176.75,
Repair nerve add-on,64832,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2781.75,,,,,,,fee schedule,2546.44,3176.75,
Repair nerve add-on,64832,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2924.62,,,,,,,fee schedule,2546.44,3176.75,
Repair of hand or foot nerve,64834,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8303.53,,,,,,,fee schedule,3381.88,15004.24,
Repair of hand or foot nerve,64834,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6656,,,,,,,fee schedule,3381.88,15004.24,
Repair of hand or foot nerve,64834,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7271.08,,,,,,,fee schedule,3381.88,15004.24,
Repair of hand or foot nerve,64834,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7644.52,,,,,,,fee schedule,3381.88,15004.24,
Repair of hand or foot nerve,64834,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15004.24,,,,,,,fee schedule,3381.88,15004.24,APC 378
Repair of hand or foot nerve,64834,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3550.97,,,,,,,fee schedule,3381.88,15004.24,APC
Repair of hand or foot nerve,64834,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3517.15,,,,,,,fee schedule,3381.88,15004.24,APC
Repair of hand or foot nerve,64834,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3381.88,,,,,,,fee schedule,3381.88,15004.24,APC
Repair of hand or foot nerve,64834,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5174.27,,,,,,,fee schedule,3381.88,15004.24,Radiology
Repair of hand or foot nerve,64834,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4734.63,,,,,,,fee schedule,3381.88,15004.24,APC
Repair of hand or foot nerve,64834,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5918.28,,,,,,,fee schedule,3381.88,15004.24,APC
Repair of hand or foot nerve,64835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8303.53,,,,,,,fee schedule,3381.88,15004.24,
Repair of hand or foot nerve,64835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6656,,,,,,,fee schedule,3381.88,15004.24,
Repair of hand or foot nerve,64835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7271.08,,,,,,,fee schedule,3381.88,15004.24,
Repair of hand or foot nerve,64835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7644.52,,,,,,,fee schedule,3381.88,15004.24,
Repair of hand or foot nerve,64835,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15004.24,,,,,,,fee schedule,3381.88,15004.24,APC 378
Repair of hand or foot nerve,64835,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3550.97,,,,,,,fee schedule,3381.88,15004.24,APC
Repair of hand or foot nerve,64835,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3517.15,,,,,,,fee schedule,3381.88,15004.24,APC
Repair of hand or foot nerve,64835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3381.88,,,,,,,fee schedule,3381.88,15004.24,APC
Repair of hand or foot nerve,64835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5174.27,,,,,,,fee schedule,3381.88,15004.24,Radiology
Repair of hand or foot nerve,64835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4734.63,,,,,,,fee schedule,3381.88,15004.24,APC
Repair of hand or foot nerve,64835,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5918.28,,,,,,,fee schedule,3381.88,15004.24,APC
Repair of hand or foot nerve,64836,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8303.53,,,,,,,fee schedule,3381.88,15004.24,
Repair of hand or foot nerve,64836,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6656,,,,,,,fee schedule,3381.88,15004.24,
Repair of hand or foot nerve,64836,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7271.08,,,,,,,fee schedule,3381.88,15004.24,
Repair of hand or foot nerve,64836,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7644.52,,,,,,,fee schedule,3381.88,15004.24,
Repair of hand or foot nerve,64836,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15004.24,,,,,,,fee schedule,3381.88,15004.24,APC 378
Repair of hand or foot nerve,64836,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3550.97,,,,,,,fee schedule,3381.88,15004.24,APC
Repair of hand or foot nerve,64836,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3517.15,,,,,,,fee schedule,3381.88,15004.24,APC
Repair of hand or foot nerve,64836,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3381.88,,,,,,,fee schedule,3381.88,15004.24,APC
Repair of hand or foot nerve,64836,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5174.27,,,,,,,fee schedule,3381.88,15004.24,Radiology
Repair of hand or foot nerve,64836,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4734.63,,,,,,,fee schedule,3381.88,15004.24,APC
Repair of hand or foot nerve,64836,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5918.28,,,,,,,fee schedule,3381.88,15004.24,APC
Repair nerve add-on,64837,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8303.53,,,,,,,fee schedule,6656,8303.53,
Repair nerve add-on,64837,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6656,,,,,,,fee schedule,6656,8303.53,
Repair nerve add-on,64837,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7271.08,,,,,,,fee schedule,6656,8303.53,
Repair nerve add-on,64837,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7644.52,,,,,,,fee schedule,6656,8303.53,
Repair of leg nerve,64840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8303.53,,,,,,,fee schedule,6656,38544.86,
Repair of leg nerve,64840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6656,,,,,,,fee schedule,6656,38544.86,
Repair of leg nerve,64840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7271.08,,,,,,,fee schedule,6656,38544.86,
Repair of leg nerve,64840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7644.52,,,,,,,fee schedule,6656,38544.86,
Repair of leg nerve,64840,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,38544.86,,,,,,,fee schedule,6656,38544.86,APC 378
Repair of leg nerve,64840,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9122.2,,,,,,,fee schedule,6656,38544.86,APC
Repair of leg nerve,64840,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9035.32,,,,,,,fee schedule,6656,38544.86,APC
Repair of leg nerve,64840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8687.81,,,,,,,fee schedule,6656,38544.86,APC
Repair of leg nerve,64840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13292.34,,,,,,,fee schedule,6656,38544.86,Radiology
Repair of leg nerve,64840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12162.93,,,,,,,fee schedule,6656,38544.86,APC
Repair of leg nerve,64840,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15203.66,,,,,,,fee schedule,6656,38544.86,APC
Repair/transpose nerve,64856,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8303.53,,,,,,,fee schedule,6656,38544.86,
Repair/transpose nerve,64856,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6656,,,,,,,fee schedule,6656,38544.86,
Repair/transpose nerve,64856,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7271.08,,,,,,,fee schedule,6656,38544.86,
Repair/transpose nerve,64856,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7644.52,,,,,,,fee schedule,6656,38544.86,
Repair/transpose nerve,64856,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,38544.86,,,,,,,fee schedule,6656,38544.86,APC 378
Repair/transpose nerve,64856,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9122.2,,,,,,,fee schedule,6656,38544.86,APC
Repair/transpose nerve,64856,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9035.32,,,,,,,fee schedule,6656,38544.86,APC
Repair/transpose nerve,64856,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8687.81,,,,,,,fee schedule,6656,38544.86,APC
Repair/transpose nerve,64856,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13292.34,,,,,,,fee schedule,6656,38544.86,Radiology
Repair/transpose nerve,64856,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12162.93,,,,,,,fee schedule,6656,38544.86,APC
Repair/transpose nerve,64856,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15203.66,,,,,,,fee schedule,6656,38544.86,APC
Repair arm/leg nerve,64857,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8303.53,,,,,,,fee schedule,3381.88,15004.24,
Repair arm/leg nerve,64857,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6656,,,,,,,fee schedule,3381.88,15004.24,
Repair arm/leg nerve,64857,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7271.08,,,,,,,fee schedule,3381.88,15004.24,
Repair arm/leg nerve,64857,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7644.52,,,,,,,fee schedule,3381.88,15004.24,
Repair arm/leg nerve,64857,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15004.24,,,,,,,fee schedule,3381.88,15004.24,APC 378
Repair arm/leg nerve,64857,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3550.97,,,,,,,fee schedule,3381.88,15004.24,APC
Repair arm/leg nerve,64857,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3517.15,,,,,,,fee schedule,3381.88,15004.24,APC
Repair arm/leg nerve,64857,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3381.88,,,,,,,fee schedule,3381.88,15004.24,APC
Repair arm/leg nerve,64857,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5174.27,,,,,,,fee schedule,3381.88,15004.24,Radiology
Repair arm/leg nerve,64857,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4734.63,,,,,,,fee schedule,3381.88,15004.24,APC
Repair arm/leg nerve,64857,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5918.28,,,,,,,fee schedule,3381.88,15004.24,APC
Repair sciatic nerve,64858,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8303.53,,,,,,,fee schedule,1933.13,8576.66,
Repair sciatic nerve,64858,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6656,,,,,,,fee schedule,1933.13,8576.66,
Repair sciatic nerve,64858,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7271.08,,,,,,,fee schedule,1933.13,8576.66,
Repair sciatic nerve,64858,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7644.52,,,,,,,fee schedule,1933.13,8576.66,
Repair sciatic nerve,64858,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8576.66,,,,,,,fee schedule,1933.13,8576.66,APC 378
Repair sciatic nerve,64858,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2029.79,,,,,,,fee schedule,1933.13,8576.66,APC
Repair sciatic nerve,64858,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2010.46,,,,,,,fee schedule,1933.13,8576.66,APC
Repair sciatic nerve,64858,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1933.13,,,,,,,fee schedule,1933.13,8576.66,APC
Repair sciatic nerve,64858,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2957.7,,,,,,,fee schedule,1933.13,8576.66,Radiology
Repair sciatic nerve,64858,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2706.39,,,,,,,fee schedule,1933.13,8576.66,APC
Repair sciatic nerve,64858,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3382.99,,,,,,,fee schedule,1933.13,8576.66,APC
Nerve surgery,64859,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8303.53,,,,,,,fee schedule,6656,8303.53,
Nerve surgery,64859,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6656,,,,,,,fee schedule,6656,8303.53,
Nerve surgery,64859,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7271.08,,,,,,,fee schedule,6656,8303.53,
Nerve surgery,64859,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7644.52,,,,,,,fee schedule,6656,8303.53,
Repair of arm nerves,64861,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8303.53,,,,,,,fee schedule,1933.13,8576.66,
Repair of arm nerves,64861,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6656,,,,,,,fee schedule,1933.13,8576.66,
Repair of arm nerves,64861,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7271.08,,,,,,,fee schedule,1933.13,8576.66,
Repair of arm nerves,64861,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7644.52,,,,,,,fee schedule,1933.13,8576.66,
Repair of arm nerves,64861,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8576.66,,,,,,,fee schedule,1933.13,8576.66,APC 378
Repair of arm nerves,64861,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2029.79,,,,,,,fee schedule,1933.13,8576.66,APC
Repair of arm nerves,64861,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2010.46,,,,,,,fee schedule,1933.13,8576.66,APC
Repair of arm nerves,64861,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1933.13,,,,,,,fee schedule,1933.13,8576.66,APC
Repair of arm nerves,64861,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2957.7,,,,,,,fee schedule,1933.13,8576.66,Radiology
Repair of arm nerves,64861,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2706.39,,,,,,,fee schedule,1933.13,8576.66,APC
Repair of arm nerves,64861,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3382.99,,,,,,,fee schedule,1933.13,8576.66,APC
Repair of low back nerves,64862,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8303.53,,,,,,,fee schedule,3381.88,15004.24,
Repair of low back nerves,64862,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6656,,,,,,,fee schedule,3381.88,15004.24,
Repair of low back nerves,64862,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7271.08,,,,,,,fee schedule,3381.88,15004.24,
Repair of low back nerves,64862,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7644.52,,,,,,,fee schedule,3381.88,15004.24,
Repair of low back nerves,64862,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15004.24,,,,,,,fee schedule,3381.88,15004.24,APC 378
Repair of low back nerves,64862,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3550.97,,,,,,,fee schedule,3381.88,15004.24,APC
Repair of low back nerves,64862,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3517.15,,,,,,,fee schedule,3381.88,15004.24,APC
Repair of low back nerves,64862,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3381.88,,,,,,,fee schedule,3381.88,15004.24,APC
Repair of low back nerves,64862,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5174.27,,,,,,,fee schedule,3381.88,15004.24,Radiology
Repair of low back nerves,64862,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4734.63,,,,,,,fee schedule,3381.88,15004.24,APC
Repair of low back nerves,64862,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5918.28,,,,,,,fee schedule,3381.88,15004.24,APC
Repair of facial nerve,64864,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8303.53,,,,,,,fee schedule,6656,38544.86,
Repair of facial nerve,64864,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6656,,,,,,,fee schedule,6656,38544.86,
Repair of facial nerve,64864,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7271.08,,,,,,,fee schedule,6656,38544.86,
Repair of facial nerve,64864,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7644.52,,,,,,,fee schedule,6656,38544.86,
Repair of facial nerve,64864,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,38544.86,,,,,,,fee schedule,6656,38544.86,APC 378
Repair of facial nerve,64864,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9122.2,,,,,,,fee schedule,6656,38544.86,APC
Repair of facial nerve,64864,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9035.32,,,,,,,fee schedule,6656,38544.86,APC
Repair of facial nerve,64864,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8687.81,,,,,,,fee schedule,6656,38544.86,APC
Repair of facial nerve,64864,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13292.34,,,,,,,fee schedule,6656,38544.86,Radiology
Repair of facial nerve,64864,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12162.93,,,,,,,fee schedule,6656,38544.86,APC
Repair of facial nerve,64864,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15203.66,,,,,,,fee schedule,6656,38544.86,APC
Repair of facial nerve,64865,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8303.53,,,,,,,fee schedule,3381.88,15004.24,
Repair of facial nerve,64865,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6656,,,,,,,fee schedule,3381.88,15004.24,
Repair of facial nerve,64865,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7271.08,,,,,,,fee schedule,3381.88,15004.24,
Repair of facial nerve,64865,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7644.52,,,,,,,fee schedule,3381.88,15004.24,
Repair of facial nerve,64865,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15004.24,,,,,,,fee schedule,3381.88,15004.24,APC 378
Repair of facial nerve,64865,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3550.97,,,,,,,fee schedule,3381.88,15004.24,APC
Repair of facial nerve,64865,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3517.15,,,,,,,fee schedule,3381.88,15004.24,APC
Repair of facial nerve,64865,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3381.88,,,,,,,fee schedule,3381.88,15004.24,APC
Repair of facial nerve,64865,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5174.27,,,,,,,fee schedule,3381.88,15004.24,Radiology
Repair of facial nerve,64865,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4734.63,,,,,,,fee schedule,3381.88,15004.24,APC
Repair of facial nerve,64865,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5918.28,,,,,,,fee schedule,3381.88,15004.24,APC
Subsequent repair of nerve,64872,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8303.53,,,,,,,fee schedule,6656,8303.53,
Subsequent repair of nerve,64872,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6656,,,,,,,fee schedule,6656,8303.53,
Subsequent repair of nerve,64872,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7271.08,,,,,,,fee schedule,6656,8303.53,
Subsequent repair of nerve,64872,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7644.52,,,,,,,fee schedule,6656,8303.53,
Repair & revise nerve add-on,64874,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8303.53,,,,,,,fee schedule,6656,8303.53,
Repair & revise nerve add-on,64874,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6656,,,,,,,fee schedule,6656,8303.53,
Repair & revise nerve add-on,64874,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7271.08,,,,,,,fee schedule,6656,8303.53,
Repair & revise nerve add-on,64874,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7644.52,,,,,,,fee schedule,6656,8303.53,
Repair nerve/shorten bone,64876,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8303.53,,,,,,,fee schedule,6656,8303.53,
Repair nerve/shorten bone,64876,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6656,,,,,,,fee schedule,6656,8303.53,
Repair nerve/shorten bone,64876,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7271.08,,,,,,,fee schedule,6656,8303.53,
Repair nerve/shorten bone,64876,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7644.52,,,,,,,fee schedule,6656,8303.53,
Nerve graft head/neck <=4 cm,64885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8303.53,,,,,,,fee schedule,6656,38544.86,
Nerve graft head/neck <=4 cm,64885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6656,,,,,,,fee schedule,6656,38544.86,
Nerve graft head/neck <=4 cm,64885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7271.08,,,,,,,fee schedule,6656,38544.86,
Nerve graft head/neck <=4 cm,64885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7644.52,,,,,,,fee schedule,6656,38544.86,
Nerve graft head/neck <=4 cm,64885,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,38544.86,,,,,,,fee schedule,6656,38544.86,APC 378
Nerve graft head/neck <=4 cm,64885,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9122.2,,,,,,,fee schedule,6656,38544.86,APC
Nerve graft head/neck <=4 cm,64885,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9035.32,,,,,,,fee schedule,6656,38544.86,APC
Nerve graft head/neck <=4 cm,64885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8687.81,,,,,,,fee schedule,6656,38544.86,APC
Nerve graft head/neck <=4 cm,64885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13292.34,,,,,,,fee schedule,6656,38544.86,Radiology
Nerve graft head/neck <=4 cm,64885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12162.93,,,,,,,fee schedule,6656,38544.86,APC
Nerve graft head/neck <=4 cm,64885,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15203.66,,,,,,,fee schedule,6656,38544.86,APC
Nerve graft head/neck >4 cm,64886,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8303.53,,,,,,,fee schedule,6656,38544.86,
Nerve graft head/neck >4 cm,64886,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6656,,,,,,,fee schedule,6656,38544.86,
Nerve graft head/neck >4 cm,64886,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7271.08,,,,,,,fee schedule,6656,38544.86,
Nerve graft head/neck >4 cm,64886,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7644.52,,,,,,,fee schedule,6656,38544.86,
Nerve graft head/neck >4 cm,64886,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,38544.86,,,,,,,fee schedule,6656,38544.86,APC 378
Nerve graft head/neck >4 cm,64886,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9122.2,,,,,,,fee schedule,6656,38544.86,APC
Nerve graft head/neck >4 cm,64886,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9035.32,,,,,,,fee schedule,6656,38544.86,APC
Nerve graft head/neck >4 cm,64886,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8687.81,,,,,,,fee schedule,6656,38544.86,APC
Nerve graft head/neck >4 cm,64886,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13292.34,,,,,,,fee schedule,6656,38544.86,Radiology
Nerve graft head/neck >4 cm,64886,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12162.93,,,,,,,fee schedule,6656,38544.86,APC
Nerve graft head/neck >4 cm,64886,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15203.66,,,,,,,fee schedule,6656,38544.86,APC
Nerve graft hand/foot <=4 cm,64890,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8303.53,,,,,,,fee schedule,6656,38544.86,
Nerve graft hand/foot <=4 cm,64890,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6656,,,,,,,fee schedule,6656,38544.86,
Nerve graft hand/foot <=4 cm,64890,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7271.08,,,,,,,fee schedule,6656,38544.86,
Nerve graft hand/foot <=4 cm,64890,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7644.52,,,,,,,fee schedule,6656,38544.86,
Nerve graft hand/foot <=4 cm,64890,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,38544.86,,,,,,,fee schedule,6656,38544.86,APC 378
Nerve graft hand/foot <=4 cm,64890,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9122.2,,,,,,,fee schedule,6656,38544.86,APC
Nerve graft hand/foot <=4 cm,64890,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9035.32,,,,,,,fee schedule,6656,38544.86,APC
Nerve graft hand/foot <=4 cm,64890,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8687.81,,,,,,,fee schedule,6656,38544.86,APC
Nerve graft hand/foot <=4 cm,64890,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13292.34,,,,,,,fee schedule,6656,38544.86,Radiology
Nerve graft hand/foot <=4 cm,64890,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12162.93,,,,,,,fee schedule,6656,38544.86,APC
Nerve graft hand/foot <=4 cm,64890,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15203.66,,,,,,,fee schedule,6656,38544.86,APC
Nerve graft hand/foot >4 cm,64891,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8303.53,,,,,,,fee schedule,6656,38544.86,
Nerve graft hand/foot >4 cm,64891,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6656,,,,,,,fee schedule,6656,38544.86,
Nerve graft hand/foot >4 cm,64891,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7271.08,,,,,,,fee schedule,6656,38544.86,
Nerve graft hand/foot >4 cm,64891,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7644.52,,,,,,,fee schedule,6656,38544.86,
Nerve graft hand/foot >4 cm,64891,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,38544.86,,,,,,,fee schedule,6656,38544.86,APC 378
Nerve graft hand/foot >4 cm,64891,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9122.2,,,,,,,fee schedule,6656,38544.86,APC
Nerve graft hand/foot >4 cm,64891,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9035.32,,,,,,,fee schedule,6656,38544.86,APC
Nerve graft hand/foot >4 cm,64891,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8687.81,,,,,,,fee schedule,6656,38544.86,APC
Nerve graft hand/foot >4 cm,64891,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13292.34,,,,,,,fee schedule,6656,38544.86,Radiology
Nerve graft hand/foot >4 cm,64891,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12162.93,,,,,,,fee schedule,6656,38544.86,APC
Nerve graft hand/foot >4 cm,64891,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15203.66,,,,,,,fee schedule,6656,38544.86,APC
Nerve graft arm/leg <4 cm,64892,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8303.53,,,,,,,fee schedule,6656,38544.86,
Nerve graft arm/leg <4 cm,64892,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6656,,,,,,,fee schedule,6656,38544.86,
Nerve graft arm/leg <4 cm,64892,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7271.08,,,,,,,fee schedule,6656,38544.86,
Nerve graft arm/leg <4 cm,64892,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7644.52,,,,,,,fee schedule,6656,38544.86,
Nerve graft arm/leg <4 cm,64892,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,38544.86,,,,,,,fee schedule,6656,38544.86,APC 378
Nerve graft arm/leg <4 cm,64892,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9122.2,,,,,,,fee schedule,6656,38544.86,APC
Nerve graft arm/leg <4 cm,64892,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9035.32,,,,,,,fee schedule,6656,38544.86,APC
Nerve graft arm/leg <4 cm,64892,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8687.81,,,,,,,fee schedule,6656,38544.86,APC
Nerve graft arm/leg <4 cm,64892,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13292.34,,,,,,,fee schedule,6656,38544.86,Radiology
Nerve graft arm/leg <4 cm,64892,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12162.93,,,,,,,fee schedule,6656,38544.86,APC
Nerve graft arm/leg <4 cm,64892,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15203.66,,,,,,,fee schedule,6656,38544.86,APC
Nerve graft arm/leg >4 cm,64893,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8303.53,,,,,,,fee schedule,3381.88,15004.24,
Nerve graft arm/leg >4 cm,64893,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6656,,,,,,,fee schedule,3381.88,15004.24,
Nerve graft arm/leg >4 cm,64893,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7271.08,,,,,,,fee schedule,3381.88,15004.24,
Nerve graft arm/leg >4 cm,64893,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7644.52,,,,,,,fee schedule,3381.88,15004.24,
Nerve graft arm/leg >4 cm,64893,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15004.24,,,,,,,fee schedule,3381.88,15004.24,APC 378
Nerve graft arm/leg >4 cm,64893,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3550.97,,,,,,,fee schedule,3381.88,15004.24,APC
Nerve graft arm/leg >4 cm,64893,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3517.15,,,,,,,fee schedule,3381.88,15004.24,APC
Nerve graft arm/leg >4 cm,64893,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3381.88,,,,,,,fee schedule,3381.88,15004.24,APC
Nerve graft arm/leg >4 cm,64893,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5174.27,,,,,,,fee schedule,3381.88,15004.24,Radiology
Nerve graft arm/leg >4 cm,64893,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4734.63,,,,,,,fee schedule,3381.88,15004.24,APC
Nerve graft arm/leg >4 cm,64893,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5918.28,,,,,,,fee schedule,3381.88,15004.24,APC
Nerve graft hand/foot <=4 cm,64895,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8303.53,,,,,,,fee schedule,6656,38544.86,
Nerve graft hand/foot <=4 cm,64895,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6656,,,,,,,fee schedule,6656,38544.86,
Nerve graft hand/foot <=4 cm,64895,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7271.08,,,,,,,fee schedule,6656,38544.86,
Nerve graft hand/foot <=4 cm,64895,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7644.52,,,,,,,fee schedule,6656,38544.86,
Nerve graft hand/foot <=4 cm,64895,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,38544.86,,,,,,,fee schedule,6656,38544.86,APC 378
Nerve graft hand/foot <=4 cm,64895,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9122.2,,,,,,,fee schedule,6656,38544.86,APC
Nerve graft hand/foot <=4 cm,64895,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9035.32,,,,,,,fee schedule,6656,38544.86,APC
Nerve graft hand/foot <=4 cm,64895,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8687.81,,,,,,,fee schedule,6656,38544.86,APC
Nerve graft hand/foot <=4 cm,64895,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13292.34,,,,,,,fee schedule,6656,38544.86,Radiology
Nerve graft hand/foot <=4 cm,64895,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12162.93,,,,,,,fee schedule,6656,38544.86,APC
Nerve graft hand/foot <=4 cm,64895,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15203.66,,,,,,,fee schedule,6656,38544.86,APC
Nerve graft hand/foot >4 cm,64896,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8303.53,,,,,,,fee schedule,6656,38544.86,
Nerve graft hand/foot >4 cm,64896,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6656,,,,,,,fee schedule,6656,38544.86,
Nerve graft hand/foot >4 cm,64896,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7271.08,,,,,,,fee schedule,6656,38544.86,
Nerve graft hand/foot >4 cm,64896,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7644.52,,,,,,,fee schedule,6656,38544.86,
Nerve graft hand/foot >4 cm,64896,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,38544.86,,,,,,,fee schedule,6656,38544.86,APC 378
Nerve graft hand/foot >4 cm,64896,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9122.2,,,,,,,fee schedule,6656,38544.86,APC
Nerve graft hand/foot >4 cm,64896,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9035.32,,,,,,,fee schedule,6656,38544.86,APC
Nerve graft hand/foot >4 cm,64896,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8687.81,,,,,,,fee schedule,6656,38544.86,APC
Nerve graft hand/foot >4 cm,64896,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13292.34,,,,,,,fee schedule,6656,38544.86,Radiology
Nerve graft hand/foot >4 cm,64896,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12162.93,,,,,,,fee schedule,6656,38544.86,APC
Nerve graft hand/foot >4 cm,64896,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15203.66,,,,,,,fee schedule,6656,38544.86,APC
Nerve graft arm/leg <=4 cm,64897,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8303.53,,,,,,,fee schedule,6656,38544.86,
Nerve graft arm/leg <=4 cm,64897,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6656,,,,,,,fee schedule,6656,38544.86,
Nerve graft arm/leg <=4 cm,64897,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7271.08,,,,,,,fee schedule,6656,38544.86,
Nerve graft arm/leg <=4 cm,64897,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7644.52,,,,,,,fee schedule,6656,38544.86,
Nerve graft arm/leg <=4 cm,64897,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,38544.86,,,,,,,fee schedule,6656,38544.86,APC 378
Nerve graft arm/leg <=4 cm,64897,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9122.2,,,,,,,fee schedule,6656,38544.86,APC
Nerve graft arm/leg <=4 cm,64897,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9035.32,,,,,,,fee schedule,6656,38544.86,APC
Nerve graft arm/leg <=4 cm,64897,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8687.81,,,,,,,fee schedule,6656,38544.86,APC
Nerve graft arm/leg <=4 cm,64897,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13292.34,,,,,,,fee schedule,6656,38544.86,Radiology
Nerve graft arm/leg <=4 cm,64897,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12162.93,,,,,,,fee schedule,6656,38544.86,APC
Nerve graft arm/leg <=4 cm,64897,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15203.66,,,,,,,fee schedule,6656,38544.86,APC
Nerve graft arm/leg >4 cm,64898,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8303.53,,,,,,,fee schedule,6656,38544.86,
Nerve graft arm/leg >4 cm,64898,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6656,,,,,,,fee schedule,6656,38544.86,
Nerve graft arm/leg >4 cm,64898,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7271.08,,,,,,,fee schedule,6656,38544.86,
Nerve graft arm/leg >4 cm,64898,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7644.52,,,,,,,fee schedule,6656,38544.86,
Nerve graft arm/leg >4 cm,64898,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,38544.86,,,,,,,fee schedule,6656,38544.86,APC 378
Nerve graft arm/leg >4 cm,64898,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9122.2,,,,,,,fee schedule,6656,38544.86,APC
Nerve graft arm/leg >4 cm,64898,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9035.32,,,,,,,fee schedule,6656,38544.86,APC
Nerve graft arm/leg >4 cm,64898,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8687.81,,,,,,,fee schedule,6656,38544.86,APC
Nerve graft arm/leg >4 cm,64898,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13292.34,,,,,,,fee schedule,6656,38544.86,Radiology
Nerve graft arm/leg >4 cm,64898,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12162.93,,,,,,,fee schedule,6656,38544.86,APC
Nerve graft arm/leg >4 cm,64898,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15203.66,,,,,,,fee schedule,6656,38544.86,APC
Nerve graft add-on,64901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8303.53,,,,,,,fee schedule,6656,8303.53,
Nerve graft add-on,64901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6656,,,,,,,fee schedule,6656,8303.53,
Nerve graft add-on,64901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7271.08,,,,,,,fee schedule,6656,8303.53,
Nerve graft add-on,64901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7644.52,,,,,,,fee schedule,6656,8303.53,
Nerve graft add-on,64902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8303.53,,,,,,,fee schedule,6656,8303.53,
Nerve graft add-on,64902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6656,,,,,,,fee schedule,6656,8303.53,
Nerve graft add-on,64902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7271.08,,,,,,,fee schedule,6656,8303.53,
Nerve graft add-on,64902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7644.52,,,,,,,fee schedule,6656,8303.53,
Nerve pedicle transfer,64905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8303.53,,,,,,,fee schedule,6656,38544.86,
Nerve pedicle transfer,64905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6656,,,,,,,fee schedule,6656,38544.86,
Nerve pedicle transfer,64905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7271.08,,,,,,,fee schedule,6656,38544.86,
Nerve pedicle transfer,64905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7644.52,,,,,,,fee schedule,6656,38544.86,
Nerve pedicle transfer,64905,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,38544.86,,,,,,,fee schedule,6656,38544.86,APC 378
Nerve pedicle transfer,64905,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9122.2,,,,,,,fee schedule,6656,38544.86,APC
Nerve pedicle transfer,64905,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9035.32,,,,,,,fee schedule,6656,38544.86,APC
Nerve pedicle transfer,64905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8687.81,,,,,,,fee schedule,6656,38544.86,APC
Nerve pedicle transfer,64905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13292.34,,,,,,,fee schedule,6656,38544.86,Radiology
Nerve pedicle transfer,64905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12162.93,,,,,,,fee schedule,6656,38544.86,APC
Nerve pedicle transfer,64905,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15203.66,,,,,,,fee schedule,6656,38544.86,APC
Nerve pedicle transfer,64907,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8303.53,,,,,,,fee schedule,6656,38544.86,
Nerve pedicle transfer,64907,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6656,,,,,,,fee schedule,6656,38544.86,
Nerve pedicle transfer,64907,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7271.08,,,,,,,fee schedule,6656,38544.86,
Nerve pedicle transfer,64907,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7644.52,,,,,,,fee schedule,6656,38544.86,
Nerve pedicle transfer,64907,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,38544.86,,,,,,,fee schedule,6656,38544.86,APC 378
Nerve pedicle transfer,64907,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9122.2,,,,,,,fee schedule,6656,38544.86,APC
Nerve pedicle transfer,64907,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9035.32,,,,,,,fee schedule,6656,38544.86,APC
Nerve pedicle transfer,64907,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8687.81,,,,,,,fee schedule,6656,38544.86,APC
Nerve pedicle transfer,64907,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13292.34,,,,,,,fee schedule,6656,38544.86,Radiology
Nerve pedicle transfer,64907,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12162.93,,,,,,,fee schedule,6656,38544.86,APC
Nerve pedicle transfer,64907,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15203.66,,,,,,,fee schedule,6656,38544.86,APC
Nerve repair w/allograft,64910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4531.07,,,,,,,fee schedule,3632.05,38544.86,
Nerve repair w/allograft,64910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3632.05,,,,,,,fee schedule,3632.05,38544.86,
Nerve repair w/allograft,64910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3967.69,,,,,,,fee schedule,3632.05,38544.86,
Nerve repair w/allograft,64910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4171.46,,,,,,,fee schedule,3632.05,38544.86,
Nerve repair w/allograft,64910,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,38544.86,,,,,,,fee schedule,3632.05,38544.86,APC 378
Nerve repair w/allograft,64910,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9122.2,,,,,,,fee schedule,3632.05,38544.86,APC
Nerve repair w/allograft,64910,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9035.32,,,,,,,fee schedule,3632.05,38544.86,APC
Nerve repair w/allograft,64910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8687.81,,,,,,,fee schedule,3632.05,38544.86,APC
Nerve repair w/allograft,64910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13292.34,,,,,,,fee schedule,3632.05,38544.86,Radiology
Nerve repair w/allograft,64910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12162.93,,,,,,,fee schedule,3632.05,38544.86,APC
Nerve repair w/allograft,64910,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15203.66,,,,,,,fee schedule,3632.05,38544.86,APC
Neurorraphy w/vein autograft,64911,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4505.27,,,,,,,fee schedule,3611.37,38544.86,
Neurorraphy w/vein autograft,64911,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3611.37,,,,,,,fee schedule,3611.37,38544.86,
Neurorraphy w/vein autograft,64911,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3945.09,,,,,,,fee schedule,3611.37,38544.86,
Neurorraphy w/vein autograft,64911,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4147.71,,,,,,,fee schedule,3611.37,38544.86,
Neurorraphy w/vein autograft,64911,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,38544.86,,,,,,,fee schedule,3611.37,38544.86,APC 378
Neurorraphy w/vein autograft,64911,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9122.2,,,,,,,fee schedule,3611.37,38544.86,APC
Neurorraphy w/vein autograft,64911,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9035.32,,,,,,,fee schedule,3611.37,38544.86,APC
Neurorraphy w/vein autograft,64911,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8687.81,,,,,,,fee schedule,3611.37,38544.86,APC
Neurorraphy w/vein autograft,64911,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13292.34,,,,,,,fee schedule,3611.37,38544.86,Radiology
Neurorraphy w/vein autograft,64911,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12162.93,,,,,,,fee schedule,3611.37,38544.86,APC
Neurorraphy w/vein autograft,64911,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15203.66,,,,,,,fee schedule,3611.37,38544.86,APC
Nrv rpr w/nrv algrft 1st,64912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17259.71,,,,,,,fee schedule,8687.81,38544.86,
Nrv rpr w/nrv algrft 1st,64912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13835.16,,,,,,,fee schedule,8687.81,38544.86,
Nrv rpr w/nrv algrft 1st,64912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15113.66,,,,,,,fee schedule,8687.81,38544.86,
Nrv rpr w/nrv algrft 1st,64912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15889.89,,,,,,,fee schedule,8687.81,38544.86,
Nrv rpr w/nrv algrft 1st,64912,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,38544.86,,,,,,,fee schedule,8687.81,38544.86,APC 378
Nrv rpr w/nrv algrft 1st,64912,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9122.2,,,,,,,fee schedule,8687.81,38544.86,APC
Nrv rpr w/nrv algrft 1st,64912,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9035.32,,,,,,,fee schedule,8687.81,38544.86,APC
Nrv rpr w/nrv algrft 1st,64912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8687.81,,,,,,,fee schedule,8687.81,38544.86,APC
Nrv rpr w/nrv algrft 1st,64912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13292.34,,,,,,,fee schedule,8687.81,38544.86,Radiology
Nrv rpr w/nrv algrft 1st,64912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12162.93,,,,,,,fee schedule,8687.81,38544.86,APC
Nrv rpr w/nrv algrft 1st,64912,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15203.66,,,,,,,fee schedule,8687.81,38544.86,APC
Nrv rpr w/nrv algrft ea addl,64913,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,692.31,,,,,,,fee schedule,554.94,692.31,
Nrv rpr w/nrv algrft ea addl,64913,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,554.94,,,,,,,fee schedule,554.94,692.31,
Nrv rpr w/nrv algrft ea addl,64913,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,606.23,,,,,,,fee schedule,554.94,692.31,
Nrv rpr w/nrv algrft ea addl,64913,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,637.36,,,,,,,fee schedule,554.94,692.31,
Nervous system surgery,64999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3869.89,,,,,,,fee schedule,303.87,3869.89,
Nervous system surgery,64999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3102.06,,,,,,,fee schedule,303.87,3869.89,
Nervous system surgery,64999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3388.72,,,,,,,fee schedule,303.87,3869.89,
Nervous system surgery,64999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3562.76,,,,,,,fee schedule,303.87,3869.89,
Nervous system surgery,64999,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1348.18,,,,,,,fee schedule,303.87,3869.89,APC 378
Nervous system surgery,64999,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,319.07,,,,,,,fee schedule,303.87,3869.89,APC
Nervous system surgery,64999,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,316.03,,,,,,,fee schedule,303.87,3869.89,APC
Nervous system surgery,64999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,303.87,,,,,,,fee schedule,303.87,3869.89,APC
Nervous system surgery,64999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,464.92,,,,,,,fee schedule,303.87,3869.89,Radiology
Nervous system surgery,64999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,425.42,,,,,,,fee schedule,303.87,3869.89,APC
Nervous system surgery,64999,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,531.78,,,,,,,fee schedule,303.87,3869.89,APC
Revise eye,65091,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9415.04,,,,,,,fee schedule,3891.96,17267.29,
Revise eye,65091,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7546.97,,,,,,,fee schedule,3891.96,17267.29,
Revise eye,65091,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8244.38,,,,,,,fee schedule,3891.96,17267.29,
Revise eye,65091,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8667.81,,,,,,,fee schedule,3891.96,17267.29,
Revise eye,65091,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17267.29,,,,,,,fee schedule,3891.96,17267.29,APC 378
Revise eye,65091,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4086.55,,,,,,,fee schedule,3891.96,17267.29,APC
Revise eye,65091,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4047.63,,,,,,,fee schedule,3891.96,17267.29,APC
Revise eye,65091,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3891.96,,,,,,,fee schedule,3891.96,17267.29,APC
Revise eye,65091,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5954.69,,,,,,,fee schedule,3891.96,17267.29,Radiology
Revise eye,65091,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5448.74,,,,,,,fee schedule,3891.96,17267.29,APC
Revise eye,65091,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6810.92,,,,,,,fee schedule,3891.96,17267.29,APC
Revise eye with implant,65093,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9415.04,,,,,,,fee schedule,3891.96,17267.29,
Revise eye with implant,65093,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7546.97,,,,,,,fee schedule,3891.96,17267.29,
Revise eye with implant,65093,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8244.38,,,,,,,fee schedule,3891.96,17267.29,
Revise eye with implant,65093,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8667.81,,,,,,,fee schedule,3891.96,17267.29,
Revise eye with implant,65093,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17267.29,,,,,,,fee schedule,3891.96,17267.29,APC 378
Revise eye with implant,65093,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4086.55,,,,,,,fee schedule,3891.96,17267.29,APC
Revise eye with implant,65093,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4047.63,,,,,,,fee schedule,3891.96,17267.29,APC
Revise eye with implant,65093,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3891.96,,,,,,,fee schedule,3891.96,17267.29,APC
Revise eye with implant,65093,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5954.69,,,,,,,fee schedule,3891.96,17267.29,Radiology
Revise eye with implant,65093,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5448.74,,,,,,,fee schedule,3891.96,17267.29,APC
Revise eye with implant,65093,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6810.92,,,,,,,fee schedule,3891.96,17267.29,APC
Removal of eye,65101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9415.04,,,,,,,fee schedule,3891.96,17267.29,
Removal of eye,65101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7546.97,,,,,,,fee schedule,3891.96,17267.29,
Removal of eye,65101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8244.38,,,,,,,fee schedule,3891.96,17267.29,
Removal of eye,65101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8667.81,,,,,,,fee schedule,3891.96,17267.29,
Removal of eye,65101,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17267.29,,,,,,,fee schedule,3891.96,17267.29,APC 378
Removal of eye,65101,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4086.55,,,,,,,fee schedule,3891.96,17267.29,APC
Removal of eye,65101,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4047.63,,,,,,,fee schedule,3891.96,17267.29,APC
Removal of eye,65101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3891.96,,,,,,,fee schedule,3891.96,17267.29,APC
Removal of eye,65101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5954.69,,,,,,,fee schedule,3891.96,17267.29,Radiology
Removal of eye,65101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5448.74,,,,,,,fee schedule,3891.96,17267.29,APC
Removal of eye,65101,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6810.92,,,,,,,fee schedule,3891.96,17267.29,APC
Remove eye/insert implant,65103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9415.04,,,,,,,fee schedule,3891.96,17267.29,
Remove eye/insert implant,65103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7546.97,,,,,,,fee schedule,3891.96,17267.29,
Remove eye/insert implant,65103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8244.38,,,,,,,fee schedule,3891.96,17267.29,
Remove eye/insert implant,65103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8667.81,,,,,,,fee schedule,3891.96,17267.29,
Remove eye/insert implant,65103,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17267.29,,,,,,,fee schedule,3891.96,17267.29,APC 378
Remove eye/insert implant,65103,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4086.55,,,,,,,fee schedule,3891.96,17267.29,APC
Remove eye/insert implant,65103,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4047.63,,,,,,,fee schedule,3891.96,17267.29,APC
Remove eye/insert implant,65103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3891.96,,,,,,,fee schedule,3891.96,17267.29,APC
Remove eye/insert implant,65103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5954.69,,,,,,,fee schedule,3891.96,17267.29,Radiology
Remove eye/insert implant,65103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5448.74,,,,,,,fee schedule,3891.96,17267.29,APC
Remove eye/insert implant,65103,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6810.92,,,,,,,fee schedule,3891.96,17267.29,APC
Remove eye/attach implant,65105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9415.04,,,,,,,fee schedule,3891.96,17267.29,
Remove eye/attach implant,65105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7546.97,,,,,,,fee schedule,3891.96,17267.29,
Remove eye/attach implant,65105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8244.38,,,,,,,fee schedule,3891.96,17267.29,
Remove eye/attach implant,65105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8667.81,,,,,,,fee schedule,3891.96,17267.29,
Remove eye/attach implant,65105,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17267.29,,,,,,,fee schedule,3891.96,17267.29,APC 378
Remove eye/attach implant,65105,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4086.55,,,,,,,fee schedule,3891.96,17267.29,APC
Remove eye/attach implant,65105,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4047.63,,,,,,,fee schedule,3891.96,17267.29,APC
Remove eye/attach implant,65105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3891.96,,,,,,,fee schedule,3891.96,17267.29,APC
Remove eye/attach implant,65105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5954.69,,,,,,,fee schedule,3891.96,17267.29,Radiology
Remove eye/attach implant,65105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5448.74,,,,,,,fee schedule,3891.96,17267.29,APC
Remove eye/attach implant,65105,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6810.92,,,,,,,fee schedule,3891.96,17267.29,APC
Removal of eye,65110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9415.04,,,,,,,fee schedule,3891.96,17267.29,
Removal of eye,65110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7546.97,,,,,,,fee schedule,3891.96,17267.29,
Removal of eye,65110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8244.38,,,,,,,fee schedule,3891.96,17267.29,
Removal of eye,65110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8667.81,,,,,,,fee schedule,3891.96,17267.29,
Removal of eye,65110,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17267.29,,,,,,,fee schedule,3891.96,17267.29,APC 378
Removal of eye,65110,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4086.55,,,,,,,fee schedule,3891.96,17267.29,APC
Removal of eye,65110,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4047.63,,,,,,,fee schedule,3891.96,17267.29,APC
Removal of eye,65110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3891.96,,,,,,,fee schedule,3891.96,17267.29,APC
Removal of eye,65110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5954.69,,,,,,,fee schedule,3891.96,17267.29,Radiology
Removal of eye,65110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5448.74,,,,,,,fee schedule,3891.96,17267.29,APC
Removal of eye,65110,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6810.92,,,,,,,fee schedule,3891.96,17267.29,APC
Remove eye/revise socket,65112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9415.04,,,,,,,fee schedule,3891.96,17267.29,
Remove eye/revise socket,65112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7546.97,,,,,,,fee schedule,3891.96,17267.29,
Remove eye/revise socket,65112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8244.38,,,,,,,fee schedule,3891.96,17267.29,
Remove eye/revise socket,65112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8667.81,,,,,,,fee schedule,3891.96,17267.29,
Remove eye/revise socket,65112,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17267.29,,,,,,,fee schedule,3891.96,17267.29,APC 378
Remove eye/revise socket,65112,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4086.55,,,,,,,fee schedule,3891.96,17267.29,APC
Remove eye/revise socket,65112,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4047.63,,,,,,,fee schedule,3891.96,17267.29,APC
Remove eye/revise socket,65112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3891.96,,,,,,,fee schedule,3891.96,17267.29,APC
Remove eye/revise socket,65112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5954.69,,,,,,,fee schedule,3891.96,17267.29,Radiology
Remove eye/revise socket,65112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5448.74,,,,,,,fee schedule,3891.96,17267.29,APC
Remove eye/revise socket,65112,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6810.92,,,,,,,fee schedule,3891.96,17267.29,APC
Remove eye/revise socket,65114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9415.04,,,,,,,fee schedule,3891.96,17267.29,
Remove eye/revise socket,65114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7546.97,,,,,,,fee schedule,3891.96,17267.29,
Remove eye/revise socket,65114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8244.38,,,,,,,fee schedule,3891.96,17267.29,
Remove eye/revise socket,65114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8667.81,,,,,,,fee schedule,3891.96,17267.29,
Remove eye/revise socket,65114,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17267.29,,,,,,,fee schedule,3891.96,17267.29,APC 378
Remove eye/revise socket,65114,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4086.55,,,,,,,fee schedule,3891.96,17267.29,APC
Remove eye/revise socket,65114,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4047.63,,,,,,,fee schedule,3891.96,17267.29,APC
Remove eye/revise socket,65114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3891.96,,,,,,,fee schedule,3891.96,17267.29,APC
Remove eye/revise socket,65114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5954.69,,,,,,,fee schedule,3891.96,17267.29,Radiology
Remove eye/revise socket,65114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5448.74,,,,,,,fee schedule,3891.96,17267.29,APC
Remove eye/revise socket,65114,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6810.92,,,,,,,fee schedule,3891.96,17267.29,APC
Revise ocular implant,65125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4674.69,,,,,,,fee schedule,2353.63,10442.27,
Revise ocular implant,65125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3747.17,,,,,,,fee schedule,2353.63,10442.27,
Revise ocular implant,65125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4093.44,,,,,,,fee schedule,2353.63,10442.27,
Revise ocular implant,65125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4303.68,,,,,,,fee schedule,2353.63,10442.27,
Revise ocular implant,65125,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2353.63,10442.27,APC 378
Revise ocular implant,65125,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2353.63,10442.27,APC
Revise ocular implant,65125,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2353.63,10442.27,APC
Revise ocular implant,65125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2353.63,10442.27,APC
Revise ocular implant,65125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2353.63,10442.27,Radiology
Revise ocular implant,65125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2353.63,10442.27,APC
Revise ocular implant,65125,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2353.63,10442.27,APC
Insert ocular implant,65130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6066.6,,,,,,,fee schedule,3891.96,17267.29,
Insert ocular implant,65130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4862.91,,,,,,,fee schedule,3891.96,17267.29,
Insert ocular implant,65130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5312.29,,,,,,,fee schedule,3891.96,17267.29,
Insert ocular implant,65130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5585.12,,,,,,,fee schedule,3891.96,17267.29,
Insert ocular implant,65130,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17267.29,,,,,,,fee schedule,3891.96,17267.29,APC 378
Insert ocular implant,65130,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4086.55,,,,,,,fee schedule,3891.96,17267.29,APC
Insert ocular implant,65130,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4047.63,,,,,,,fee schedule,3891.96,17267.29,APC
Insert ocular implant,65130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3891.96,,,,,,,fee schedule,3891.96,17267.29,APC
Insert ocular implant,65130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5954.69,,,,,,,fee schedule,3891.96,17267.29,Radiology
Insert ocular implant,65130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5448.74,,,,,,,fee schedule,3891.96,17267.29,APC
Insert ocular implant,65130,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6810.92,,,,,,,fee schedule,3891.96,17267.29,APC
Insert ocular implant,65135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6066.6,,,,,,,fee schedule,3891.96,17267.29,
Insert ocular implant,65135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4862.91,,,,,,,fee schedule,3891.96,17267.29,
Insert ocular implant,65135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5312.29,,,,,,,fee schedule,3891.96,17267.29,
Insert ocular implant,65135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5585.12,,,,,,,fee schedule,3891.96,17267.29,
Insert ocular implant,65135,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17267.29,,,,,,,fee schedule,3891.96,17267.29,APC 378
Insert ocular implant,65135,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4086.55,,,,,,,fee schedule,3891.96,17267.29,APC
Insert ocular implant,65135,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4047.63,,,,,,,fee schedule,3891.96,17267.29,APC
Insert ocular implant,65135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3891.96,,,,,,,fee schedule,3891.96,17267.29,APC
Insert ocular implant,65135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5954.69,,,,,,,fee schedule,3891.96,17267.29,Radiology
Insert ocular implant,65135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5448.74,,,,,,,fee schedule,3891.96,17267.29,APC
Insert ocular implant,65135,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6810.92,,,,,,,fee schedule,3891.96,17267.29,APC
Attach ocular implant,65140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9415.04,,,,,,,fee schedule,3891.96,17267.29,
Attach ocular implant,65140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7546.97,,,,,,,fee schedule,3891.96,17267.29,
Attach ocular implant,65140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8244.38,,,,,,,fee schedule,3891.96,17267.29,
Attach ocular implant,65140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8667.81,,,,,,,fee schedule,3891.96,17267.29,
Attach ocular implant,65140,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17267.29,,,,,,,fee schedule,3891.96,17267.29,APC 378
Attach ocular implant,65140,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4086.55,,,,,,,fee schedule,3891.96,17267.29,APC
Attach ocular implant,65140,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4047.63,,,,,,,fee schedule,3891.96,17267.29,APC
Attach ocular implant,65140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3891.96,,,,,,,fee schedule,3891.96,17267.29,APC
Attach ocular implant,65140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5954.69,,,,,,,fee schedule,3891.96,17267.29,Radiology
Attach ocular implant,65140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5448.74,,,,,,,fee schedule,3891.96,17267.29,APC
Attach ocular implant,65140,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6810.92,,,,,,,fee schedule,3891.96,17267.29,APC
Revise ocular implant,65150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6066.6,,,,,,,fee schedule,3891.96,17267.29,
Revise ocular implant,65150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4862.91,,,,,,,fee schedule,3891.96,17267.29,
Revise ocular implant,65150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5312.29,,,,,,,fee schedule,3891.96,17267.29,
Revise ocular implant,65150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5585.12,,,,,,,fee schedule,3891.96,17267.29,
Revise ocular implant,65150,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17267.29,,,,,,,fee schedule,3891.96,17267.29,APC 378
Revise ocular implant,65150,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4086.55,,,,,,,fee schedule,3891.96,17267.29,APC
Revise ocular implant,65150,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4047.63,,,,,,,fee schedule,3891.96,17267.29,APC
Revise ocular implant,65150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3891.96,,,,,,,fee schedule,3891.96,17267.29,APC
Revise ocular implant,65150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5954.69,,,,,,,fee schedule,3891.96,17267.29,Radiology
Revise ocular implant,65150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5448.74,,,,,,,fee schedule,3891.96,17267.29,APC
Revise ocular implant,65150,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6810.92,,,,,,,fee schedule,3891.96,17267.29,APC
Reinsert ocular implant,65155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9415.04,,,,,,,fee schedule,3891.96,17267.29,
Reinsert ocular implant,65155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7546.97,,,,,,,fee schedule,3891.96,17267.29,
Reinsert ocular implant,65155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8244.38,,,,,,,fee schedule,3891.96,17267.29,
Reinsert ocular implant,65155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8667.81,,,,,,,fee schedule,3891.96,17267.29,
Reinsert ocular implant,65155,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17267.29,,,,,,,fee schedule,3891.96,17267.29,APC 378
Reinsert ocular implant,65155,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4086.55,,,,,,,fee schedule,3891.96,17267.29,APC
Reinsert ocular implant,65155,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4047.63,,,,,,,fee schedule,3891.96,17267.29,APC
Reinsert ocular implant,65155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3891.96,,,,,,,fee schedule,3891.96,17267.29,APC
Reinsert ocular implant,65155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5954.69,,,,,,,fee schedule,3891.96,17267.29,Radiology
Reinsert ocular implant,65155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5448.74,,,,,,,fee schedule,3891.96,17267.29,APC
Reinsert ocular implant,65155,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6810.92,,,,,,,fee schedule,3891.96,17267.29,APC
Removal of ocular implant,65175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4674.69,,,,,,,fee schedule,3747.17,17267.29,
Removal of ocular implant,65175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3747.17,,,,,,,fee schedule,3747.17,17267.29,
Removal of ocular implant,65175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4093.44,,,,,,,fee schedule,3747.17,17267.29,
Removal of ocular implant,65175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4303.68,,,,,,,fee schedule,3747.17,17267.29,
Removal of ocular implant,65175,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17267.29,,,,,,,fee schedule,3747.17,17267.29,APC 378
Removal of ocular implant,65175,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4086.55,,,,,,,fee schedule,3747.17,17267.29,APC
Removal of ocular implant,65175,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4047.63,,,,,,,fee schedule,3747.17,17267.29,APC
Removal of ocular implant,65175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3891.96,,,,,,,fee schedule,3747.17,17267.29,APC
Removal of ocular implant,65175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5954.69,,,,,,,fee schedule,3747.17,17267.29,Radiology
Removal of ocular implant,65175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5448.74,,,,,,,fee schedule,3747.17,17267.29,APC
Removal of ocular implant,65175,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6810.92,,,,,,,fee schedule,3747.17,17267.29,APC
Remove foreign body from eye,65205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,412.85,,,,,,,fee schedule,131.71,584.37,
Remove foreign body from eye,65205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,330.94,,,,,,,fee schedule,131.71,584.37,
Remove foreign body from eye,65205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,361.52,,,,,,,fee schedule,131.71,584.37,
Remove foreign body from eye,65205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,380.09,,,,,,,fee schedule,131.71,584.37,
Remove foreign body from eye,65205,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,131.71,584.37,APC 378
Remove foreign body from eye,65205,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,131.71,584.37,APC
Remove foreign body from eye,65205,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,131.71,584.37,APC
Remove foreign body from eye,65205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,131.71,584.37,APC
Remove foreign body from eye,65205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,131.71,584.37,Radiology
Remove foreign body from eye,65205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,131.71,584.37,APC
Remove foreign body from eye,65205,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,131.71,584.37,APC
Remove foreign body from eye,65210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,217.05,,,,,,,fee schedule,173.98,1962.08,
Remove foreign body from eye,65210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,173.98,,,,,,,fee schedule,173.98,1962.08,
Remove foreign body from eye,65210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,190.06,,,,,,,fee schedule,173.98,1962.08,
Remove foreign body from eye,65210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,199.82,,,,,,,fee schedule,173.98,1962.08,
Remove foreign body from eye,65210,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1962.08,,,,,,,fee schedule,173.98,1962.08,APC 378
Remove foreign body from eye,65210,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,464.35,,,,,,,fee schedule,173.98,1962.08,APC
Remove foreign body from eye,65210,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,459.93,,,,,,,fee schedule,173.98,1962.08,APC
Remove foreign body from eye,65210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,442.24,,,,,,,fee schedule,173.98,1962.08,APC
Remove foreign body from eye,65210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,676.63,,,,,,,fee schedule,173.98,1962.08,Radiology
Remove foreign body from eye,65210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,619.14,,,,,,,fee schedule,173.98,1962.08,APC
Remove foreign body from eye,65210,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,773.92,,,,,,,fee schedule,173.98,1962.08,APC
Remove foreign body from eye,65220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,419.9,,,,,,,fee schedule,336.58,1962.08,
Remove foreign body from eye,65220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,336.58,,,,,,,fee schedule,336.58,1962.08,
Remove foreign body from eye,65220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,367.69,,,,,,,fee schedule,336.58,1962.08,
Remove foreign body from eye,65220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,386.57,,,,,,,fee schedule,336.58,1962.08,
Remove foreign body from eye,65220,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1962.08,,,,,,,fee schedule,336.58,1962.08,APC 378
Remove foreign body from eye,65220,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,464.35,,,,,,,fee schedule,336.58,1962.08,APC
Remove foreign body from eye,65220,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,459.93,,,,,,,fee schedule,336.58,1962.08,APC
Remove foreign body from eye,65220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,442.24,,,,,,,fee schedule,336.58,1962.08,APC
Remove foreign body from eye,65220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,676.63,,,,,,,fee schedule,336.58,1962.08,Radiology
Remove foreign body from eye,65220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,619.14,,,,,,,fee schedule,336.58,1962.08,APC
Remove foreign body from eye,65220,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,773.92,,,,,,,fee schedule,336.58,1962.08,APC
Remove foreign body from eye,65222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,412.85,,,,,,,fee schedule,131.71,584.37,
Remove foreign body from eye,65222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,330.94,,,,,,,fee schedule,131.71,584.37,
Remove foreign body from eye,65222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,361.52,,,,,,,fee schedule,131.71,584.37,
Remove foreign body from eye,65222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,380.09,,,,,,,fee schedule,131.71,584.37,
Remove foreign body from eye,65222,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,131.71,584.37,APC 378
Remove foreign body from eye,65222,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,131.71,584.37,APC
Remove foreign body from eye,65222,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,131.71,584.37,APC
Remove foreign body from eye,65222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,131.71,584.37,APC
Remove foreign body from eye,65222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,131.71,584.37,Radiology
Remove foreign body from eye,65222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,131.71,584.37,APC
Remove foreign body from eye,65222,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,131.71,584.37,APC
Remove foreign body from eye,65235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4035.91,,,,,,,fee schedule,2284.67,10136.31,
Remove foreign body from eye,65235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3235.13,,,,,,,fee schedule,2284.67,10136.31,
Remove foreign body from eye,65235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3534.09,,,,,,,fee schedule,2284.67,10136.31,
Remove foreign body from eye,65235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3715.6,,,,,,,fee schedule,2284.67,10136.31,
Remove foreign body from eye,65235,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10136.31,,,,,,,fee schedule,2284.67,10136.31,APC 378
Remove foreign body from eye,65235,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2398.9,,,,,,,fee schedule,2284.67,10136.31,APC
Remove foreign body from eye,65235,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2376.06,,,,,,,fee schedule,2284.67,10136.31,APC
Remove foreign body from eye,65235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2284.67,,,,,,,fee schedule,2284.67,10136.31,APC
Remove foreign body from eye,65235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3495.55,,,,,,,fee schedule,2284.67,10136.31,Radiology
Remove foreign body from eye,65235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3198.54,,,,,,,fee schedule,2284.67,10136.31,APC
Remove foreign body from eye,65235,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3998.17,,,,,,,fee schedule,2284.67,10136.31,APC
Remove foreign body from eye,65260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4551.01,,,,,,,fee schedule,2284.67,10136.31,
Remove foreign body from eye,65260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3648.03,,,,,,,fee schedule,2284.67,10136.31,
Remove foreign body from eye,65260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3985.14,,,,,,,fee schedule,2284.67,10136.31,
Remove foreign body from eye,65260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4189.82,,,,,,,fee schedule,2284.67,10136.31,
Remove foreign body from eye,65260,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10136.31,,,,,,,fee schedule,2284.67,10136.31,APC 378
Remove foreign body from eye,65260,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2398.9,,,,,,,fee schedule,2284.67,10136.31,APC
Remove foreign body from eye,65260,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2376.06,,,,,,,fee schedule,2284.67,10136.31,APC
Remove foreign body from eye,65260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2284.67,,,,,,,fee schedule,2284.67,10136.31,APC
Remove foreign body from eye,65260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3495.55,,,,,,,fee schedule,2284.67,10136.31,Radiology
Remove foreign body from eye,65260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3198.54,,,,,,,fee schedule,2284.67,10136.31,APC
Remove foreign body from eye,65260,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3998.17,,,,,,,fee schedule,2284.67,10136.31,APC
Remove foreign body from eye,65265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6949.42,,,,,,,fee schedule,2284.67,10136.31,
Remove foreign body from eye,65265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5570.56,,,,,,,fee schedule,2284.67,10136.31,
Remove foreign body from eye,65265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6085.34,,,,,,,fee schedule,2284.67,10136.31,
Remove foreign body from eye,65265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6397.88,,,,,,,fee schedule,2284.67,10136.31,
Remove foreign body from eye,65265,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10136.31,,,,,,,fee schedule,2284.67,10136.31,APC 378
Remove foreign body from eye,65265,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2398.9,,,,,,,fee schedule,2284.67,10136.31,APC
Remove foreign body from eye,65265,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2376.06,,,,,,,fee schedule,2284.67,10136.31,APC
Remove foreign body from eye,65265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2284.67,,,,,,,fee schedule,2284.67,10136.31,APC
Remove foreign body from eye,65265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3495.55,,,,,,,fee schedule,2284.67,10136.31,Radiology
Remove foreign body from eye,65265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3198.54,,,,,,,fee schedule,2284.67,10136.31,APC
Remove foreign body from eye,65265,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3998.17,,,,,,,fee schedule,2284.67,10136.31,APC
Repair of eye wound,65270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4674.69,,,,,,,fee schedule,2353.63,10442.27,
Repair of eye wound,65270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3747.17,,,,,,,fee schedule,2353.63,10442.27,
Repair of eye wound,65270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4093.44,,,,,,,fee schedule,2353.63,10442.27,
Repair of eye wound,65270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4303.68,,,,,,,fee schedule,2353.63,10442.27,
Repair of eye wound,65270,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2353.63,10442.27,APC 378
Repair of eye wound,65270,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2353.63,10442.27,APC
Repair of eye wound,65270,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2353.63,10442.27,APC
Repair of eye wound,65270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2353.63,10442.27,APC
Repair of eye wound,65270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2353.63,10442.27,Radiology
Repair of eye wound,65270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2353.63,10442.27,APC
Repair of eye wound,65270,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2353.63,10442.27,APC
Repair of eye wound,65272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5784.12,,,,,,,fee schedule,2353.63,10442.27,
Repair of eye wound,65272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4636.48,,,,,,,fee schedule,2353.63,10442.27,
Repair of eye wound,65272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5064.93,,,,,,,fee schedule,2353.63,10442.27,
Repair of eye wound,65272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5325.06,,,,,,,fee schedule,2353.63,10442.27,
Repair of eye wound,65272,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2353.63,10442.27,APC 378
Repair of eye wound,65272,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2353.63,10442.27,APC
Repair of eye wound,65272,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2353.63,10442.27,APC
Repair of eye wound,65272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2353.63,10442.27,APC
Repair of eye wound,65272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2353.63,10442.27,Radiology
Repair of eye wound,65272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2353.63,10442.27,APC
Repair of eye wound,65272,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2353.63,10442.27,APC
Repair of eye wound,65275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5784.12,,,,,,,fee schedule,3891.96,17267.29,
Repair of eye wound,65275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4636.48,,,,,,,fee schedule,3891.96,17267.29,
Repair of eye wound,65275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5064.93,,,,,,,fee schedule,3891.96,17267.29,
Repair of eye wound,65275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5325.06,,,,,,,fee schedule,3891.96,17267.29,
Repair of eye wound,65275,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17267.29,,,,,,,fee schedule,3891.96,17267.29,APC 378
Repair of eye wound,65275,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4086.55,,,,,,,fee schedule,3891.96,17267.29,APC
Repair of eye wound,65275,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4047.63,,,,,,,fee schedule,3891.96,17267.29,APC
Repair of eye wound,65275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3891.96,,,,,,,fee schedule,3891.96,17267.29,APC
Repair of eye wound,65275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5954.69,,,,,,,fee schedule,3891.96,17267.29,Radiology
Repair of eye wound,65275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5448.74,,,,,,,fee schedule,3891.96,17267.29,APC
Repair of eye wound,65275,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6810.92,,,,,,,fee schedule,3891.96,17267.29,APC
Repair of eye wound,65280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4551.01,,,,,,,fee schedule,3648.03,23371.97,
Repair of eye wound,65280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3648.03,,,,,,,fee schedule,3648.03,23371.97,
Repair of eye wound,65280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3985.14,,,,,,,fee schedule,3648.03,23371.97,
Repair of eye wound,65280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4189.82,,,,,,,fee schedule,3648.03,23371.97,
Repair of eye wound,65280,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23371.97,,,,,,,fee schedule,3648.03,23371.97,APC 378
Repair of eye wound,65280,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5531.31,,,,,,,fee schedule,3648.03,23371.97,APC
Repair of eye wound,65280,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5478.63,,,,,,,fee schedule,3648.03,23371.97,APC
Repair of eye wound,65280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5267.92,,,,,,,fee schedule,3648.03,23371.97,APC
Repair of eye wound,65280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8059.91,,,,,,,fee schedule,3648.03,23371.97,Radiology
Repair of eye wound,65280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7375.09,,,,,,,fee schedule,3648.03,23371.97,APC
Repair of eye wound,65280,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9218.86,,,,,,,fee schedule,3648.03,23371.97,APC
Repair of eye wound,65285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12077.81,,,,,,,fee schedule,5267.92,23371.97,
Repair of eye wound,65285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9681.42,,,,,,,fee schedule,5267.92,23371.97,
Repair of eye wound,65285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10576.07,,,,,,,fee schedule,5267.92,23371.97,
Repair of eye wound,65285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11119.25,,,,,,,fee schedule,5267.92,23371.97,
Repair of eye wound,65285,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23371.97,,,,,,,fee schedule,5267.92,23371.97,APC 378
Repair of eye wound,65285,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5531.31,,,,,,,fee schedule,5267.92,23371.97,APC
Repair of eye wound,65285,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5478.63,,,,,,,fee schedule,5267.92,23371.97,APC
Repair of eye wound,65285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5267.92,,,,,,,fee schedule,5267.92,23371.97,APC
Repair of eye wound,65285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8059.91,,,,,,,fee schedule,5267.92,23371.97,Radiology
Repair of eye wound,65285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7375.09,,,,,,,fee schedule,5267.92,23371.97,APC
Repair of eye wound,65285,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9218.86,,,,,,,fee schedule,5267.92,23371.97,APC
Repair of eye wound,65286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1277.07,,,,,,,fee schedule,1023.69,10136.31,
Repair of eye wound,65286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1023.69,,,,,,,fee schedule,1023.69,10136.31,
Repair of eye wound,65286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1118.28,,,,,,,fee schedule,1023.69,10136.31,
Repair of eye wound,65286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1175.72,,,,,,,fee schedule,1023.69,10136.31,
Repair of eye wound,65286,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10136.31,,,,,,,fee schedule,1023.69,10136.31,APC 378
Repair of eye wound,65286,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2398.9,,,,,,,fee schedule,1023.69,10136.31,APC
Repair of eye wound,65286,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2376.06,,,,,,,fee schedule,1023.69,10136.31,APC
Repair of eye wound,65286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2284.67,,,,,,,fee schedule,1023.69,10136.31,APC
Repair of eye wound,65286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3495.55,,,,,,,fee schedule,1023.69,10136.31,Radiology
Repair of eye wound,65286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3198.54,,,,,,,fee schedule,1023.69,10136.31,APC
Repair of eye wound,65286,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3998.17,,,,,,,fee schedule,1023.69,10136.31,APC
Repair of eye socket wound,65290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6022.03,,,,,,,fee schedule,3891.96,17267.29,
Repair of eye socket wound,65290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4827.18,,,,,,,fee schedule,3891.96,17267.29,
Repair of eye socket wound,65290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5273.26,,,,,,,fee schedule,3891.96,17267.29,
Repair of eye socket wound,65290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5544.09,,,,,,,fee schedule,3891.96,17267.29,
Repair of eye socket wound,65290,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17267.29,,,,,,,fee schedule,3891.96,17267.29,APC 378
Repair of eye socket wound,65290,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4086.55,,,,,,,fee schedule,3891.96,17267.29,APC
Repair of eye socket wound,65290,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4047.63,,,,,,,fee schedule,3891.96,17267.29,APC
Repair of eye socket wound,65290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3891.96,,,,,,,fee schedule,3891.96,17267.29,APC
Repair of eye socket wound,65290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5954.69,,,,,,,fee schedule,3891.96,17267.29,Radiology
Repair of eye socket wound,65290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5448.74,,,,,,,fee schedule,3891.96,17267.29,APC
Repair of eye socket wound,65290,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6810.92,,,,,,,fee schedule,3891.96,17267.29,APC
Removal of eye lesion,65400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4035.91,,,,,,,fee schedule,986.88,4378.44,
Removal of eye lesion,65400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3235.13,,,,,,,fee schedule,986.88,4378.44,
Removal of eye lesion,65400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3534.09,,,,,,,fee schedule,986.88,4378.44,
Removal of eye lesion,65400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3715.6,,,,,,,fee schedule,986.88,4378.44,
Removal of eye lesion,65400,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4378.44,,,,,,,fee schedule,986.88,4378.44,APC 378
Removal of eye lesion,65400,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1036.22,,,,,,,fee schedule,986.88,4378.44,APC
Removal of eye lesion,65400,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1026.35,,,,,,,fee schedule,986.88,4378.44,APC
Removal of eye lesion,65400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,986.88,,,,,,,fee schedule,986.88,4378.44,APC
Removal of eye lesion,65400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1509.92,,,,,,,fee schedule,986.88,4378.44,Radiology
Removal of eye lesion,65400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1381.63,,,,,,,fee schedule,986.88,4378.44,APC
Removal of eye lesion,65400,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1727.03,,,,,,,fee schedule,986.88,4378.44,APC
Biopsy of cornea,65410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4035.91,,,,,,,fee schedule,2353.63,10442.27,
Biopsy of cornea,65410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3235.13,,,,,,,fee schedule,2353.63,10442.27,
Biopsy of cornea,65410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3534.09,,,,,,,fee schedule,2353.63,10442.27,
Biopsy of cornea,65410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3715.6,,,,,,,fee schedule,2353.63,10442.27,
Biopsy of cornea,65410,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2353.63,10442.27,APC 378
Biopsy of cornea,65410,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2353.63,10442.27,APC
Biopsy of cornea,65410,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2353.63,10442.27,APC
Biopsy of cornea,65410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2353.63,10442.27,APC
Biopsy of cornea,65410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2353.63,10442.27,Radiology
Biopsy of cornea,65410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2353.63,10442.27,APC
Biopsy of cornea,65410,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2353.63,10442.27,APC
Removal of eye lesion,65420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4035.91,,,,,,,fee schedule,2353.63,10442.27,
Removal of eye lesion,65420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3235.13,,,,,,,fee schedule,2353.63,10442.27,
Removal of eye lesion,65420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3534.09,,,,,,,fee schedule,2353.63,10442.27,
Removal of eye lesion,65420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3715.6,,,,,,,fee schedule,2353.63,10442.27,
Removal of eye lesion,65420,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2353.63,10442.27,APC 378
Removal of eye lesion,65420,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2353.63,10442.27,APC
Removal of eye lesion,65420,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2353.63,10442.27,APC
Removal of eye lesion,65420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2353.63,10442.27,APC
Removal of eye lesion,65420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2353.63,10442.27,Radiology
Removal of eye lesion,65420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2353.63,10442.27,APC
Removal of eye lesion,65420,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2353.63,10442.27,APC
Removal of eye lesion,65426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14358.78,,,,,,,fee schedule,2353.63,14358.78,
Removal of eye lesion,65426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11509.82,,,,,,,fee schedule,2353.63,14358.78,
Removal of eye lesion,65426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12573.43,,,,,,,fee schedule,2353.63,14358.78,
Removal of eye lesion,65426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13219.2,,,,,,,fee schedule,2353.63,14358.78,
Removal of eye lesion,65426,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2353.63,14358.78,APC 378
Removal of eye lesion,65426,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2353.63,14358.78,APC
Removal of eye lesion,65426,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2353.63,14358.78,APC
Removal of eye lesion,65426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2353.63,14358.78,APC
Removal of eye lesion,65426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2353.63,14358.78,Radiology
Removal of eye lesion,65426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2353.63,14358.78,APC
Removal of eye lesion,65426,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2353.63,14358.78,APC
Corneal smear,65430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,217.05,,,,,,,fee schedule,173.98,1962.08,
Corneal smear,65430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,173.98,,,,,,,fee schedule,173.98,1962.08,
Corneal smear,65430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,190.06,,,,,,,fee schedule,173.98,1962.08,
Corneal smear,65430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,199.82,,,,,,,fee schedule,173.98,1962.08,
Corneal smear,65430,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1962.08,,,,,,,fee schedule,173.98,1962.08,APC 378
Corneal smear,65430,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,464.35,,,,,,,fee schedule,173.98,1962.08,APC
Corneal smear,65430,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,459.93,,,,,,,fee schedule,173.98,1962.08,APC
Corneal smear,65430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,442.24,,,,,,,fee schedule,173.98,1962.08,APC
Corneal smear,65430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,676.63,,,,,,,fee schedule,173.98,1962.08,Radiology
Corneal smear,65430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,619.14,,,,,,,fee schedule,173.98,1962.08,APC
Corneal smear,65430,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,773.92,,,,,,,fee schedule,173.98,1962.08,APC
Curette/treat cornea,65435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1818.07,,,,,,,fee schedule,986.88,4378.44,
Curette/treat cornea,65435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1457.34,,,,,,,fee schedule,986.88,4378.44,
Curette/treat cornea,65435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1592.01,,,,,,,fee schedule,986.88,4378.44,
Curette/treat cornea,65435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1673.78,,,,,,,fee schedule,986.88,4378.44,
Curette/treat cornea,65435,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4378.44,,,,,,,fee schedule,986.88,4378.44,APC 378
Curette/treat cornea,65435,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1036.22,,,,,,,fee schedule,986.88,4378.44,APC
Curette/treat cornea,65435,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1026.35,,,,,,,fee schedule,986.88,4378.44,APC
Curette/treat cornea,65435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,986.88,,,,,,,fee schedule,986.88,4378.44,APC
Curette/treat cornea,65435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1509.92,,,,,,,fee schedule,986.88,4378.44,Radiology
Curette/treat cornea,65435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1381.63,,,,,,,fee schedule,986.88,4378.44,APC
Curette/treat cornea,65435,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1727.03,,,,,,,fee schedule,986.88,4378.44,APC
Curette/treat cornea,65436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4035.91,,,,,,,fee schedule,2353.63,10442.27,
Curette/treat cornea,65436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3235.13,,,,,,,fee schedule,2353.63,10442.27,
Curette/treat cornea,65436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3534.09,,,,,,,fee schedule,2353.63,10442.27,
Curette/treat cornea,65436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3715.6,,,,,,,fee schedule,2353.63,10442.27,
Curette/treat cornea,65436,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2353.63,10442.27,APC 378
Curette/treat cornea,65436,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2353.63,10442.27,APC
Curette/treat cornea,65436,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2353.63,10442.27,APC
Curette/treat cornea,65436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2353.63,10442.27,APC
Curette/treat cornea,65436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2353.63,10442.27,Radiology
Curette/treat cornea,65436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2353.63,10442.27,APC
Curette/treat cornea,65436,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2353.63,10442.27,APC
Treatment of corneal lesion,65450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,543.83,,,,,,,fee schedule,314.22,1394.09,
Treatment of corneal lesion,65450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,435.93,,,,,,,fee schedule,314.22,1394.09,
Treatment of corneal lesion,65450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,476.21,,,,,,,fee schedule,314.22,1394.09,
Treatment of corneal lesion,65450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,500.67,,,,,,,fee schedule,314.22,1394.09,
Treatment of corneal lesion,65450,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1394.09,,,,,,,fee schedule,314.22,1394.09,APC 378
Treatment of corneal lesion,65450,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,329.93,,,,,,,fee schedule,314.22,1394.09,APC
Treatment of corneal lesion,65450,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,326.79,,,,,,,fee schedule,314.22,1394.09,APC
Treatment of corneal lesion,65450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,314.22,,,,,,,fee schedule,314.22,1394.09,APC
Treatment of corneal lesion,65450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,480.76,,,,,,,fee schedule,314.22,1394.09,Radiology
Treatment of corneal lesion,65450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,439.91,,,,,,,fee schedule,314.22,1394.09,APC
Treatment of corneal lesion,65450,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,549.89,,,,,,,fee schedule,314.22,1394.09,APC
Revision of cornea,65600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4674.69,,,,,,,fee schedule,2353.63,10442.27,
Revision of cornea,65600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3747.17,,,,,,,fee schedule,2353.63,10442.27,
Revision of cornea,65600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4093.44,,,,,,,fee schedule,2353.63,10442.27,
Revision of cornea,65600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4303.68,,,,,,,fee schedule,2353.63,10442.27,
Revision of cornea,65600,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2353.63,10442.27,APC 378
Revision of cornea,65600,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2353.63,10442.27,APC
Revision of cornea,65600,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2353.63,10442.27,APC
Revision of cornea,65600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2353.63,10442.27,APC
Revision of cornea,65600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2353.63,10442.27,Radiology
Revision of cornea,65600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2353.63,10442.27,APC
Revision of cornea,65600,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2353.63,10442.27,APC
Corneal transplant,65710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9356.48,,,,,,,fee schedule,5267.92,23371.97,
Corneal transplant,65710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7500.04,,,,,,,fee schedule,5267.92,23371.97,
Corneal transplant,65710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8193.11,,,,,,,fee schedule,5267.92,23371.97,
Corneal transplant,65710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8613.9,,,,,,,fee schedule,5267.92,23371.97,
Corneal transplant,65710,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23371.97,,,,,,,fee schedule,5267.92,23371.97,APC 378
Corneal transplant,65710,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5531.31,,,,,,,fee schedule,5267.92,23371.97,APC
Corneal transplant,65710,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5478.63,,,,,,,fee schedule,5267.92,23371.97,APC
Corneal transplant,65710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5267.92,,,,,,,fee schedule,5267.92,23371.97,APC
Corneal transplant,65710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8059.91,,,,,,,fee schedule,5267.92,23371.97,Radiology
Corneal transplant,65710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7375.09,,,,,,,fee schedule,5267.92,23371.97,APC
Corneal transplant,65710,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9218.86,,,,,,,fee schedule,5267.92,23371.97,APC
Corneal transplant,65730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9356.48,,,,,,,fee schedule,4091.95,18154.62,
Corneal transplant,65730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7500.04,,,,,,,fee schedule,4091.95,18154.62,
Corneal transplant,65730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8193.11,,,,,,,fee schedule,4091.95,18154.62,
Corneal transplant,65730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8613.9,,,,,,,fee schedule,4091.95,18154.62,
Corneal transplant,65730,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18154.62,,,,,,,fee schedule,4091.95,18154.62,APC 378
Corneal transplant,65730,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4296.55,,,,,,,fee schedule,4091.95,18154.62,APC
Corneal transplant,65730,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4255.63,,,,,,,fee schedule,4091.95,18154.62,APC
Corneal transplant,65730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4091.95,,,,,,,fee schedule,4091.95,18154.62,APC
Corneal transplant,65730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6260.69,,,,,,,fee schedule,4091.95,18154.62,Radiology
Corneal transplant,65730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5728.74,,,,,,,fee schedule,4091.95,18154.62,APC
Corneal transplant,65730,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7160.92,,,,,,,fee schedule,4091.95,18154.62,APC
Corneal transplant,65750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9356.48,,,,,,,fee schedule,5267.92,23371.97,
Corneal transplant,65750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7500.04,,,,,,,fee schedule,5267.92,23371.97,
Corneal transplant,65750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8193.11,,,,,,,fee schedule,5267.92,23371.97,
Corneal transplant,65750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8613.9,,,,,,,fee schedule,5267.92,23371.97,
Corneal transplant,65750,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23371.97,,,,,,,fee schedule,5267.92,23371.97,APC 378
Corneal transplant,65750,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5531.31,,,,,,,fee schedule,5267.92,23371.97,APC
Corneal transplant,65750,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5478.63,,,,,,,fee schedule,5267.92,23371.97,APC
Corneal transplant,65750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5267.92,,,,,,,fee schedule,5267.92,23371.97,APC
Corneal transplant,65750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8059.91,,,,,,,fee schedule,5267.92,23371.97,Radiology
Corneal transplant,65750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7375.09,,,,,,,fee schedule,5267.92,23371.97,APC
Corneal transplant,65750,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9218.86,,,,,,,fee schedule,5267.92,23371.97,APC
Corneal transplant,65755,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9356.48,,,,,,,fee schedule,4091.95,18154.62,
Corneal transplant,65755,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7500.04,,,,,,,fee schedule,4091.95,18154.62,
Corneal transplant,65755,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8193.11,,,,,,,fee schedule,4091.95,18154.62,
Corneal transplant,65755,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8613.9,,,,,,,fee schedule,4091.95,18154.62,
Corneal transplant,65755,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18154.62,,,,,,,fee schedule,4091.95,18154.62,APC 378
Corneal transplant,65755,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4296.55,,,,,,,fee schedule,4091.95,18154.62,APC
Corneal transplant,65755,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4255.63,,,,,,,fee schedule,4091.95,18154.62,APC
Corneal transplant,65755,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4091.95,,,,,,,fee schedule,4091.95,18154.62,APC
Corneal transplant,65755,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6260.69,,,,,,,fee schedule,4091.95,18154.62,Radiology
Corneal transplant,65755,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5728.74,,,,,,,fee schedule,4091.95,18154.62,APC
Corneal transplant,65755,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7160.92,,,,,,,fee schedule,4091.95,18154.62,APC
Corneal trnspl endothelial,65756,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3604,,,,,,,fee schedule,2888.92,18154.62,
Corneal trnspl endothelial,65756,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2888.92,,,,,,,fee schedule,2888.92,18154.62,
Corneal trnspl endothelial,65756,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3155.89,,,,,,,fee schedule,2888.92,18154.62,
Corneal trnspl endothelial,65756,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3317.97,,,,,,,fee schedule,2888.92,18154.62,
Corneal trnspl endothelial,65756,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18154.62,,,,,,,fee schedule,2888.92,18154.62,APC 378
Corneal trnspl endothelial,65756,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4296.55,,,,,,,fee schedule,2888.92,18154.62,APC
Corneal trnspl endothelial,65756,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4255.63,,,,,,,fee schedule,2888.92,18154.62,APC
Corneal trnspl endothelial,65756,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4091.95,,,,,,,fee schedule,2888.92,18154.62,APC
Corneal trnspl endothelial,65756,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6260.69,,,,,,,fee schedule,2888.92,18154.62,Radiology
Corneal trnspl endothelial,65756,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5728.74,,,,,,,fee schedule,2888.92,18154.62,APC
Corneal trnspl endothelial,65756,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7160.92,,,,,,,fee schedule,2888.92,18154.62,APC
Revise cornea with implant,65770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21164.94,,,,,,,fee schedule,14360.57,63713.01,
Revise cornea with implant,65770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16965.55,,,,,,,fee schedule,14360.57,63713.01,
Revise cornea with implant,65770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18533.32,,,,,,,fee schedule,14360.57,63713.01,
Revise cornea with implant,65770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19485.18,,,,,,,fee schedule,14360.57,63713.01,
Revise cornea with implant,65770,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,63713.01,,,,,,,fee schedule,14360.57,63713.01,APC 378
Revise cornea with implant,65770,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15078.6,,,,,,,fee schedule,14360.57,63713.01,APC
Revise cornea with implant,65770,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,14935,,,,,,,fee schedule,14360.57,63713.01,APC
Revise cornea with implant,65770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14360.57,,,,,,,fee schedule,14360.57,63713.01,APC
Revise cornea with implant,65770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21971.68,,,,,,,fee schedule,14360.57,63713.01,Radiology
Revise cornea with implant,65770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20104.8,,,,,,,fee schedule,14360.57,63713.01,APC
Revise cornea with implant,65770,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,25131.01,,,,,,,fee schedule,14360.57,63713.01,APC
Correction of astigmatism,65772,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4035.91,,,,,,,fee schedule,986.88,4378.44,
Correction of astigmatism,65772,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3235.13,,,,,,,fee schedule,986.88,4378.44,
Correction of astigmatism,65772,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3534.09,,,,,,,fee schedule,986.88,4378.44,
Correction of astigmatism,65772,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3715.6,,,,,,,fee schedule,986.88,4378.44,
Correction of astigmatism,65772,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4378.44,,,,,,,fee schedule,986.88,4378.44,APC 378
Correction of astigmatism,65772,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1036.22,,,,,,,fee schedule,986.88,4378.44,APC
Correction of astigmatism,65772,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1026.35,,,,,,,fee schedule,986.88,4378.44,APC
Correction of astigmatism,65772,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,986.88,,,,,,,fee schedule,986.88,4378.44,APC
Correction of astigmatism,65772,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1509.92,,,,,,,fee schedule,986.88,4378.44,Radiology
Correction of astigmatism,65772,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1381.63,,,,,,,fee schedule,986.88,4378.44,APC
Correction of astigmatism,65772,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1727.03,,,,,,,fee schedule,986.88,4378.44,APC
Correction of astigmatism,65775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4035.91,,,,,,,fee schedule,2353.63,10442.27,
Correction of astigmatism,65775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3235.13,,,,,,,fee schedule,2353.63,10442.27,
Correction of astigmatism,65775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3534.09,,,,,,,fee schedule,2353.63,10442.27,
Correction of astigmatism,65775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3715.6,,,,,,,fee schedule,2353.63,10442.27,
Correction of astigmatism,65775,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2353.63,10442.27,APC 378
Correction of astigmatism,65775,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2353.63,10442.27,APC
Correction of astigmatism,65775,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2353.63,10442.27,APC
Correction of astigmatism,65775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2353.63,10442.27,APC
Correction of astigmatism,65775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2353.63,10442.27,Radiology
Correction of astigmatism,65775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2353.63,10442.27,APC
Correction of astigmatism,65775,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2353.63,10442.27,APC
Cover eye w/membrane,65778,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2114.72,,,,,,,fee schedule,986.88,4378.44,
Cover eye w/membrane,65778,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1695.13,,,,,,,fee schedule,986.88,4378.44,
Cover eye w/membrane,65778,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1851.78,,,,,,,fee schedule,986.88,4378.44,
Cover eye w/membrane,65778,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1946.89,,,,,,,fee schedule,986.88,4378.44,
Cover eye w/membrane,65778,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4378.44,,,,,,,fee schedule,986.88,4378.44,APC 378
Cover eye w/membrane,65778,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1036.22,,,,,,,fee schedule,986.88,4378.44,APC
Cover eye w/membrane,65778,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1026.35,,,,,,,fee schedule,986.88,4378.44,APC
Cover eye w/membrane,65778,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,986.88,,,,,,,fee schedule,986.88,4378.44,APC
Cover eye w/membrane,65778,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1509.92,,,,,,,fee schedule,986.88,4378.44,Radiology
Cover eye w/membrane,65778,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1381.63,,,,,,,fee schedule,986.88,4378.44,APC
Cover eye w/membrane,65778,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1727.03,,,,,,,fee schedule,986.88,4378.44,APC
Cover eye w/membrane suture,65779,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1961.52,,,,,,,fee schedule,1572.33,17267.29,
Cover eye w/membrane suture,65779,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1572.33,,,,,,,fee schedule,1572.33,17267.29,
Cover eye w/membrane suture,65779,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1717.63,,,,,,,fee schedule,1572.33,17267.29,
Cover eye w/membrane suture,65779,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1805.84,,,,,,,fee schedule,1572.33,17267.29,
Cover eye w/membrane suture,65779,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17267.29,,,,,,,fee schedule,1572.33,17267.29,APC 378
Cover eye w/membrane suture,65779,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4086.55,,,,,,,fee schedule,1572.33,17267.29,APC
Cover eye w/membrane suture,65779,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4047.63,,,,,,,fee schedule,1572.33,17267.29,APC
Cover eye w/membrane suture,65779,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3891.96,,,,,,,fee schedule,1572.33,17267.29,APC
Cover eye w/membrane suture,65779,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5954.69,,,,,,,fee schedule,1572.33,17267.29,Radiology
Cover eye w/membrane suture,65779,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5448.74,,,,,,,fee schedule,1572.33,17267.29,APC
Cover eye w/membrane suture,65779,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6810.92,,,,,,,fee schedule,1572.33,17267.29,APC
Ocular reconst transplant,65780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9356.48,,,,,,,fee schedule,3891.96,17267.29,
Ocular reconst transplant,65780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7500.04,,,,,,,fee schedule,3891.96,17267.29,
Ocular reconst transplant,65780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8193.11,,,,,,,fee schedule,3891.96,17267.29,
Ocular reconst transplant,65780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8613.9,,,,,,,fee schedule,3891.96,17267.29,
Ocular reconst transplant,65780,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17267.29,,,,,,,fee schedule,3891.96,17267.29,APC 378
Ocular reconst transplant,65780,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4086.55,,,,,,,fee schedule,3891.96,17267.29,APC
Ocular reconst transplant,65780,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4047.63,,,,,,,fee schedule,3891.96,17267.29,APC
Ocular reconst transplant,65780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3891.96,,,,,,,fee schedule,3891.96,17267.29,APC
Ocular reconst transplant,65780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5954.69,,,,,,,fee schedule,3891.96,17267.29,Radiology
Ocular reconst transplant,65780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5448.74,,,,,,,fee schedule,3891.96,17267.29,APC
Ocular reconst transplant,65780,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6810.92,,,,,,,fee schedule,3891.96,17267.29,APC
Ocular reconst transplant,65781,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9356.48,,,,,,,fee schedule,5267.92,23371.97,
Ocular reconst transplant,65781,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7500.04,,,,,,,fee schedule,5267.92,23371.97,
Ocular reconst transplant,65781,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8193.11,,,,,,,fee schedule,5267.92,23371.97,
Ocular reconst transplant,65781,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8613.9,,,,,,,fee schedule,5267.92,23371.97,
Ocular reconst transplant,65781,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23371.97,,,,,,,fee schedule,5267.92,23371.97,APC 378
Ocular reconst transplant,65781,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5531.31,,,,,,,fee schedule,5267.92,23371.97,APC
Ocular reconst transplant,65781,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5478.63,,,,,,,fee schedule,5267.92,23371.97,APC
Ocular reconst transplant,65781,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5267.92,,,,,,,fee schedule,5267.92,23371.97,APC
Ocular reconst transplant,65781,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8059.91,,,,,,,fee schedule,5267.92,23371.97,Radiology
Ocular reconst transplant,65781,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7375.09,,,,,,,fee schedule,5267.92,23371.97,APC
Ocular reconst transplant,65781,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9218.86,,,,,,,fee schedule,5267.92,23371.97,APC
Ocular reconst transplant,65782,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9356.48,,,,,,,fee schedule,3891.96,17267.29,
Ocular reconst transplant,65782,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7500.04,,,,,,,fee schedule,3891.96,17267.29,
Ocular reconst transplant,65782,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8193.11,,,,,,,fee schedule,3891.96,17267.29,
Ocular reconst transplant,65782,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8613.9,,,,,,,fee schedule,3891.96,17267.29,
Ocular reconst transplant,65782,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17267.29,,,,,,,fee schedule,3891.96,17267.29,APC 378
Ocular reconst transplant,65782,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4086.55,,,,,,,fee schedule,3891.96,17267.29,APC
Ocular reconst transplant,65782,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4047.63,,,,,,,fee schedule,3891.96,17267.29,APC
Ocular reconst transplant,65782,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3891.96,,,,,,,fee schedule,3891.96,17267.29,APC
Ocular reconst transplant,65782,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5954.69,,,,,,,fee schedule,3891.96,17267.29,Radiology
Ocular reconst transplant,65782,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5448.74,,,,,,,fee schedule,3891.96,17267.29,APC
Ocular reconst transplant,65782,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6810.92,,,,,,,fee schedule,3891.96,17267.29,APC
Impltj ntrstrml crnl rng seg,65785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12779.31,,,,,,,fee schedule,4091.95,18154.62,
Impltj ntrstrml crnl rng seg,65785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10243.73,,,,,,,fee schedule,4091.95,18154.62,
Impltj ntrstrml crnl rng seg,65785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11190.35,,,,,,,fee schedule,4091.95,18154.62,
Impltj ntrstrml crnl rng seg,65785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11765.08,,,,,,,fee schedule,4091.95,18154.62,
Impltj ntrstrml crnl rng seg,65785,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18154.62,,,,,,,fee schedule,4091.95,18154.62,APC 378
Impltj ntrstrml crnl rng seg,65785,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4296.55,,,,,,,fee schedule,4091.95,18154.62,APC
Impltj ntrstrml crnl rng seg,65785,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4255.63,,,,,,,fee schedule,4091.95,18154.62,APC
Impltj ntrstrml crnl rng seg,65785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4091.95,,,,,,,fee schedule,4091.95,18154.62,APC
Impltj ntrstrml crnl rng seg,65785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6260.69,,,,,,,fee schedule,4091.95,18154.62,Radiology
Impltj ntrstrml crnl rng seg,65785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5728.74,,,,,,,fee schedule,4091.95,18154.62,APC
Impltj ntrstrml crnl rng seg,65785,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7160.92,,,,,,,fee schedule,4091.95,18154.62,APC
Drainage of eye,65800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5785.34,,,,,,,fee schedule,2284.67,10136.31,
Drainage of eye,65800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4637.46,,,,,,,fee schedule,2284.67,10136.31,
Drainage of eye,65800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5066,,,,,,,fee schedule,2284.67,10136.31,
Drainage of eye,65800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5326.19,,,,,,,fee schedule,2284.67,10136.31,
Drainage of eye,65800,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10136.31,,,,,,,fee schedule,2284.67,10136.31,APC 378
Drainage of eye,65800,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2398.9,,,,,,,fee schedule,2284.67,10136.31,APC
Drainage of eye,65800,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2376.06,,,,,,,fee schedule,2284.67,10136.31,APC
Drainage of eye,65800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2284.67,,,,,,,fee schedule,2284.67,10136.31,APC
Drainage of eye,65800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3495.55,,,,,,,fee schedule,2284.67,10136.31,Radiology
Drainage of eye,65800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3198.54,,,,,,,fee schedule,2284.67,10136.31,APC
Drainage of eye,65800,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3998.17,,,,,,,fee schedule,2284.67,10136.31,APC
Drainage of eye,65810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5784.12,,,,,,,fee schedule,2284.67,10136.31,
Drainage of eye,65810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4636.48,,,,,,,fee schedule,2284.67,10136.31,
Drainage of eye,65810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5064.93,,,,,,,fee schedule,2284.67,10136.31,
Drainage of eye,65810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5325.06,,,,,,,fee schedule,2284.67,10136.31,
Drainage of eye,65810,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10136.31,,,,,,,fee schedule,2284.67,10136.31,APC 378
Drainage of eye,65810,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2398.9,,,,,,,fee schedule,2284.67,10136.31,APC
Drainage of eye,65810,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2376.06,,,,,,,fee schedule,2284.67,10136.31,APC
Drainage of eye,65810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2284.67,,,,,,,fee schedule,2284.67,10136.31,APC
Drainage of eye,65810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3495.55,,,,,,,fee schedule,2284.67,10136.31,Radiology
Drainage of eye,65810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3198.54,,,,,,,fee schedule,2284.67,10136.31,APC
Drainage of eye,65810,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3998.17,,,,,,,fee schedule,2284.67,10136.31,APC
Drainage of eye,65815,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5784.12,,,,,,,fee schedule,2284.67,10136.31,
Drainage of eye,65815,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4636.48,,,,,,,fee schedule,2284.67,10136.31,
Drainage of eye,65815,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5064.93,,,,,,,fee schedule,2284.67,10136.31,
Drainage of eye,65815,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5325.06,,,,,,,fee schedule,2284.67,10136.31,
Drainage of eye,65815,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10136.31,,,,,,,fee schedule,2284.67,10136.31,APC 378
Drainage of eye,65815,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2398.9,,,,,,,fee schedule,2284.67,10136.31,APC
Drainage of eye,65815,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2376.06,,,,,,,fee schedule,2284.67,10136.31,APC
Drainage of eye,65815,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2284.67,,,,,,,fee schedule,2284.67,10136.31,APC
Drainage of eye,65815,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3495.55,,,,,,,fee schedule,2284.67,10136.31,Radiology
Drainage of eye,65815,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3198.54,,,,,,,fee schedule,2284.67,10136.31,APC
Drainage of eye,65815,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3998.17,,,,,,,fee schedule,2284.67,10136.31,APC
Relieve inner eye pressure,65820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1277.07,,,,,,,fee schedule,1023.69,18154.62,
Relieve inner eye pressure,65820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1023.69,,,,,,,fee schedule,1023.69,18154.62,
Relieve inner eye pressure,65820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1118.28,,,,,,,fee schedule,1023.69,18154.62,
Relieve inner eye pressure,65820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1175.72,,,,,,,fee schedule,1023.69,18154.62,
Relieve inner eye pressure,65820,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18154.62,,,,,,,fee schedule,1023.69,18154.62,APC 378
Relieve inner eye pressure,65820,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4296.55,,,,,,,fee schedule,1023.69,18154.62,APC
Relieve inner eye pressure,65820,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4255.63,,,,,,,fee schedule,1023.69,18154.62,APC
Relieve inner eye pressure,65820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4091.95,,,,,,,fee schedule,1023.69,18154.62,APC
Relieve inner eye pressure,65820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6260.69,,,,,,,fee schedule,1023.69,18154.62,Radiology
Relieve inner eye pressure,65820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5728.74,,,,,,,fee schedule,1023.69,18154.62,APC
Relieve inner eye pressure,65820,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7160.92,,,,,,,fee schedule,1023.69,18154.62,APC
Incision of eye,65850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5784.12,,,,,,,fee schedule,2284.67,10136.31,
Incision of eye,65850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4636.48,,,,,,,fee schedule,2284.67,10136.31,
Incision of eye,65850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5064.93,,,,,,,fee schedule,2284.67,10136.31,
Incision of eye,65850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5325.06,,,,,,,fee schedule,2284.67,10136.31,
Incision of eye,65850,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10136.31,,,,,,,fee schedule,2284.67,10136.31,APC 378
Incision of eye,65850,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2398.9,,,,,,,fee schedule,2284.67,10136.31,APC
Incision of eye,65850,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2376.06,,,,,,,fee schedule,2284.67,10136.31,APC
Incision of eye,65850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2284.67,,,,,,,fee schedule,2284.67,10136.31,APC
Incision of eye,65850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3495.55,,,,,,,fee schedule,2284.67,10136.31,Radiology
Incision of eye,65850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3198.54,,,,,,,fee schedule,2284.67,10136.31,APC
Incision of eye,65850,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3998.17,,,,,,,fee schedule,2284.67,10136.31,APC
Trabeculoplasty laser surg,65855,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1297.83,,,,,,,fee schedule,544.48,2415.67,
Trabeculoplasty laser surg,65855,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1040.32,,,,,,,fee schedule,544.48,2415.67,
Trabeculoplasty laser surg,65855,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1136.46,,,,,,,fee schedule,544.48,2415.67,
Trabeculoplasty laser surg,65855,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1194.82,,,,,,,fee schedule,544.48,2415.67,
Trabeculoplasty laser surg,65855,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2415.67,,,,,,,fee schedule,544.48,2415.67,APC 378
Trabeculoplasty laser surg,65855,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,571.7,,,,,,,fee schedule,544.48,2415.67,APC
Trabeculoplasty laser surg,65855,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,566.26,,,,,,,fee schedule,544.48,2415.67,APC
Trabeculoplasty laser surg,65855,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,544.48,,,,,,,fee schedule,544.48,2415.67,APC
Trabeculoplasty laser surg,65855,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,833.05,,,,,,,fee schedule,544.48,2415.67,Radiology
Trabeculoplasty laser surg,65855,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,762.27,,,,,,,fee schedule,544.48,2415.67,APC
Trabeculoplasty laser surg,65855,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,952.84,,,,,,,fee schedule,544.48,2415.67,APC
Incise inner eye adhesions,65860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1297.83,,,,,,,fee schedule,544.48,2415.67,
Incise inner eye adhesions,65860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1040.32,,,,,,,fee schedule,544.48,2415.67,
Incise inner eye adhesions,65860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1136.46,,,,,,,fee schedule,544.48,2415.67,
Incise inner eye adhesions,65860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1194.82,,,,,,,fee schedule,544.48,2415.67,
Incise inner eye adhesions,65860,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2415.67,,,,,,,fee schedule,544.48,2415.67,APC 378
Incise inner eye adhesions,65860,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,571.7,,,,,,,fee schedule,544.48,2415.67,APC
Incise inner eye adhesions,65860,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,566.26,,,,,,,fee schedule,544.48,2415.67,APC
Incise inner eye adhesions,65860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,544.48,,,,,,,fee schedule,544.48,2415.67,APC
Incise inner eye adhesions,65860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,833.05,,,,,,,fee schedule,544.48,2415.67,Radiology
Incise inner eye adhesions,65860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,762.27,,,,,,,fee schedule,544.48,2415.67,APC
Incise inner eye adhesions,65860,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,952.84,,,,,,,fee schedule,544.48,2415.67,APC
Incise inner eye adhesions,65865,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4035.91,,,,,,,fee schedule,2284.67,10136.31,
Incise inner eye adhesions,65865,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3235.13,,,,,,,fee schedule,2284.67,10136.31,
Incise inner eye adhesions,65865,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3534.09,,,,,,,fee schedule,2284.67,10136.31,
Incise inner eye adhesions,65865,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3715.6,,,,,,,fee schedule,2284.67,10136.31,
Incise inner eye adhesions,65865,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10136.31,,,,,,,fee schedule,2284.67,10136.31,APC 378
Incise inner eye adhesions,65865,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2398.9,,,,,,,fee schedule,2284.67,10136.31,APC
Incise inner eye adhesions,65865,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2376.06,,,,,,,fee schedule,2284.67,10136.31,APC
Incise inner eye adhesions,65865,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2284.67,,,,,,,fee schedule,2284.67,10136.31,APC
Incise inner eye adhesions,65865,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3495.55,,,,,,,fee schedule,2284.67,10136.31,Radiology
Incise inner eye adhesions,65865,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3198.54,,,,,,,fee schedule,2284.67,10136.31,APC
Incise inner eye adhesions,65865,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3998.17,,,,,,,fee schedule,2284.67,10136.31,APC
Incise inner eye adhesions,65870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5784.12,,,,,,,fee schedule,2284.67,10136.31,
Incise inner eye adhesions,65870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4636.48,,,,,,,fee schedule,2284.67,10136.31,
Incise inner eye adhesions,65870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5064.93,,,,,,,fee schedule,2284.67,10136.31,
Incise inner eye adhesions,65870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5325.06,,,,,,,fee schedule,2284.67,10136.31,
Incise inner eye adhesions,65870,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10136.31,,,,,,,fee schedule,2284.67,10136.31,APC 378
Incise inner eye adhesions,65870,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2398.9,,,,,,,fee schedule,2284.67,10136.31,APC
Incise inner eye adhesions,65870,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2376.06,,,,,,,fee schedule,2284.67,10136.31,APC
Incise inner eye adhesions,65870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2284.67,,,,,,,fee schedule,2284.67,10136.31,APC
Incise inner eye adhesions,65870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3495.55,,,,,,,fee schedule,2284.67,10136.31,Radiology
Incise inner eye adhesions,65870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3198.54,,,,,,,fee schedule,2284.67,10136.31,APC
Incise inner eye adhesions,65870,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3998.17,,,,,,,fee schedule,2284.67,10136.31,APC
Incise inner eye adhesions,65875,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5784.12,,,,,,,fee schedule,2284.67,10136.31,
Incise inner eye adhesions,65875,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4636.48,,,,,,,fee schedule,2284.67,10136.31,
Incise inner eye adhesions,65875,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5064.93,,,,,,,fee schedule,2284.67,10136.31,
Incise inner eye adhesions,65875,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5325.06,,,,,,,fee schedule,2284.67,10136.31,
Incise inner eye adhesions,65875,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10136.31,,,,,,,fee schedule,2284.67,10136.31,APC 378
Incise inner eye adhesions,65875,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2398.9,,,,,,,fee schedule,2284.67,10136.31,APC
Incise inner eye adhesions,65875,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2376.06,,,,,,,fee schedule,2284.67,10136.31,APC
Incise inner eye adhesions,65875,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2284.67,,,,,,,fee schedule,2284.67,10136.31,APC
Incise inner eye adhesions,65875,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3495.55,,,,,,,fee schedule,2284.67,10136.31,Radiology
Incise inner eye adhesions,65875,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3198.54,,,,,,,fee schedule,2284.67,10136.31,APC
Incise inner eye adhesions,65875,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3998.17,,,,,,,fee schedule,2284.67,10136.31,APC
Incise inner eye adhesions,65880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4035.91,,,,,,,fee schedule,3235.13,18154.62,
Incise inner eye adhesions,65880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3235.13,,,,,,,fee schedule,3235.13,18154.62,
Incise inner eye adhesions,65880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3534.09,,,,,,,fee schedule,3235.13,18154.62,
Incise inner eye adhesions,65880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3715.6,,,,,,,fee schedule,3235.13,18154.62,
Incise inner eye adhesions,65880,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18154.62,,,,,,,fee schedule,3235.13,18154.62,APC 378
Incise inner eye adhesions,65880,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4296.55,,,,,,,fee schedule,3235.13,18154.62,APC
Incise inner eye adhesions,65880,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4255.63,,,,,,,fee schedule,3235.13,18154.62,APC
Incise inner eye adhesions,65880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4091.95,,,,,,,fee schedule,3235.13,18154.62,APC
Incise inner eye adhesions,65880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6260.69,,,,,,,fee schedule,3235.13,18154.62,Radiology
Incise inner eye adhesions,65880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5728.74,,,,,,,fee schedule,3235.13,18154.62,APC
Incise inner eye adhesions,65880,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7160.92,,,,,,,fee schedule,3235.13,18154.62,APC
Remove eye lesion,65900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4035.91,,,,,,,fee schedule,2284.67,10136.31,
Remove eye lesion,65900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3235.13,,,,,,,fee schedule,2284.67,10136.31,
Remove eye lesion,65900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3534.09,,,,,,,fee schedule,2284.67,10136.31,
Remove eye lesion,65900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3715.6,,,,,,,fee schedule,2284.67,10136.31,
Remove eye lesion,65900,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10136.31,,,,,,,fee schedule,2284.67,10136.31,APC 378
Remove eye lesion,65900,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2398.9,,,,,,,fee schedule,2284.67,10136.31,APC
Remove eye lesion,65900,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2376.06,,,,,,,fee schedule,2284.67,10136.31,APC
Remove eye lesion,65900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2284.67,,,,,,,fee schedule,2284.67,10136.31,APC
Remove eye lesion,65900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3495.55,,,,,,,fee schedule,2284.67,10136.31,Radiology
Remove eye lesion,65900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3198.54,,,,,,,fee schedule,2284.67,10136.31,APC
Remove eye lesion,65900,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3998.17,,,,,,,fee schedule,2284.67,10136.31,APC
Remove implant of eye,65920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5784.12,,,,,,,fee schedule,2284.67,10136.31,
Remove implant of eye,65920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4636.48,,,,,,,fee schedule,2284.67,10136.31,
Remove implant of eye,65920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5064.93,,,,,,,fee schedule,2284.67,10136.31,
Remove implant of eye,65920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5325.06,,,,,,,fee schedule,2284.67,10136.31,
Remove implant of eye,65920,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10136.31,,,,,,,fee schedule,2284.67,10136.31,APC 378
Remove implant of eye,65920,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2398.9,,,,,,,fee schedule,2284.67,10136.31,APC
Remove implant of eye,65920,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2376.06,,,,,,,fee schedule,2284.67,10136.31,APC
Remove implant of eye,65920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2284.67,,,,,,,fee schedule,2284.67,10136.31,APC
Remove implant of eye,65920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3495.55,,,,,,,fee schedule,2284.67,10136.31,Radiology
Remove implant of eye,65920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3198.54,,,,,,,fee schedule,2284.67,10136.31,APC
Remove implant of eye,65920,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3998.17,,,,,,,fee schedule,2284.67,10136.31,APC
Remove blood clot from eye,65930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5784.12,,,,,,,fee schedule,2284.67,10136.31,
Remove blood clot from eye,65930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4636.48,,,,,,,fee schedule,2284.67,10136.31,
Remove blood clot from eye,65930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5064.93,,,,,,,fee schedule,2284.67,10136.31,
Remove blood clot from eye,65930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5325.06,,,,,,,fee schedule,2284.67,10136.31,
Remove blood clot from eye,65930,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10136.31,,,,,,,fee schedule,2284.67,10136.31,APC 378
Remove blood clot from eye,65930,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2398.9,,,,,,,fee schedule,2284.67,10136.31,APC
Remove blood clot from eye,65930,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2376.06,,,,,,,fee schedule,2284.67,10136.31,APC
Remove blood clot from eye,65930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2284.67,,,,,,,fee schedule,2284.67,10136.31,APC
Remove blood clot from eye,65930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3495.55,,,,,,,fee schedule,2284.67,10136.31,Radiology
Remove blood clot from eye,65930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3198.54,,,,,,,fee schedule,2284.67,10136.31,APC
Remove blood clot from eye,65930,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3998.17,,,,,,,fee schedule,2284.67,10136.31,APC
Injection treatment of eye,66020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4035.91,,,,,,,fee schedule,2284.67,10136.31,
Injection treatment of eye,66020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3235.13,,,,,,,fee schedule,2284.67,10136.31,
Injection treatment of eye,66020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3534.09,,,,,,,fee schedule,2284.67,10136.31,
Injection treatment of eye,66020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3715.6,,,,,,,fee schedule,2284.67,10136.31,
Injection treatment of eye,66020,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10136.31,,,,,,,fee schedule,2284.67,10136.31,APC 378
Injection treatment of eye,66020,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2398.9,,,,,,,fee schedule,2284.67,10136.31,APC
Injection treatment of eye,66020,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2376.06,,,,,,,fee schedule,2284.67,10136.31,APC
Injection treatment of eye,66020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2284.67,,,,,,,fee schedule,2284.67,10136.31,APC
Injection treatment of eye,66020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3495.55,,,,,,,fee schedule,2284.67,10136.31,Radiology
Injection treatment of eye,66020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3198.54,,,,,,,fee schedule,2284.67,10136.31,APC
Injection treatment of eye,66020,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3998.17,,,,,,,fee schedule,2284.67,10136.31,APC
Injection treatment of eye,66030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5785.34,,,,,,,fee schedule,2284.67,10136.31,
Injection treatment of eye,66030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4637.46,,,,,,,fee schedule,2284.67,10136.31,
Injection treatment of eye,66030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5066,,,,,,,fee schedule,2284.67,10136.31,
Injection treatment of eye,66030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5326.19,,,,,,,fee schedule,2284.67,10136.31,
Injection treatment of eye,66030,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10136.31,,,,,,,fee schedule,2284.67,10136.31,APC 378
Injection treatment of eye,66030,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2398.9,,,,,,,fee schedule,2284.67,10136.31,APC
Injection treatment of eye,66030,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2376.06,,,,,,,fee schedule,2284.67,10136.31,APC
Injection treatment of eye,66030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2284.67,,,,,,,fee schedule,2284.67,10136.31,APC
Injection treatment of eye,66030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3495.55,,,,,,,fee schedule,2284.67,10136.31,Radiology
Injection treatment of eye,66030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3198.54,,,,,,,fee schedule,2284.67,10136.31,APC
Injection treatment of eye,66030,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3998.17,,,,,,,fee schedule,2284.67,10136.31,APC
Remove eye lesion,66130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5784.12,,,,,,,fee schedule,2353.63,10442.27,
Remove eye lesion,66130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4636.48,,,,,,,fee schedule,2353.63,10442.27,
Remove eye lesion,66130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5064.93,,,,,,,fee schedule,2353.63,10442.27,
Remove eye lesion,66130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5325.06,,,,,,,fee schedule,2353.63,10442.27,
Remove eye lesion,66130,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2353.63,10442.27,APC 378
Remove eye lesion,66130,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2353.63,10442.27,APC
Remove eye lesion,66130,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2353.63,10442.27,APC
Remove eye lesion,66130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2353.63,10442.27,APC
Remove eye lesion,66130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2353.63,10442.27,Radiology
Remove eye lesion,66130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2353.63,10442.27,APC
Remove eye lesion,66130,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2353.63,10442.27,APC
Glaucoma surgery,66150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5784.12,,,,,,,fee schedule,4091.95,18154.62,
Glaucoma surgery,66150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4636.48,,,,,,,fee schedule,4091.95,18154.62,
Glaucoma surgery,66150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5064.93,,,,,,,fee schedule,4091.95,18154.62,
Glaucoma surgery,66150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5325.06,,,,,,,fee schedule,4091.95,18154.62,
Glaucoma surgery,66150,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18154.62,,,,,,,fee schedule,4091.95,18154.62,APC 378
Glaucoma surgery,66150,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4296.55,,,,,,,fee schedule,4091.95,18154.62,APC
Glaucoma surgery,66150,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4255.63,,,,,,,fee schedule,4091.95,18154.62,APC
Glaucoma surgery,66150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4091.95,,,,,,,fee schedule,4091.95,18154.62,APC
Glaucoma surgery,66150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6260.69,,,,,,,fee schedule,4091.95,18154.62,Radiology
Glaucoma surgery,66150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5728.74,,,,,,,fee schedule,4091.95,18154.62,APC
Glaucoma surgery,66150,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7160.92,,,,,,,fee schedule,4091.95,18154.62,APC
Glaucoma surgery,66155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5784.12,,,,,,,fee schedule,4091.95,18154.62,
Glaucoma surgery,66155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4636.48,,,,,,,fee schedule,4091.95,18154.62,
Glaucoma surgery,66155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5064.93,,,,,,,fee schedule,4091.95,18154.62,
Glaucoma surgery,66155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5325.06,,,,,,,fee schedule,4091.95,18154.62,
Glaucoma surgery,66155,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18154.62,,,,,,,fee schedule,4091.95,18154.62,APC 378
Glaucoma surgery,66155,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4296.55,,,,,,,fee schedule,4091.95,18154.62,APC
Glaucoma surgery,66155,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4255.63,,,,,,,fee schedule,4091.95,18154.62,APC
Glaucoma surgery,66155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4091.95,,,,,,,fee schedule,4091.95,18154.62,APC
Glaucoma surgery,66155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6260.69,,,,,,,fee schedule,4091.95,18154.62,Radiology
Glaucoma surgery,66155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5728.74,,,,,,,fee schedule,4091.95,18154.62,APC
Glaucoma surgery,66155,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7160.92,,,,,,,fee schedule,4091.95,18154.62,APC
Glaucoma surgery,66160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5784.12,,,,,,,fee schedule,2284.67,10136.31,
Glaucoma surgery,66160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4636.48,,,,,,,fee schedule,2284.67,10136.31,
Glaucoma surgery,66160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5064.93,,,,,,,fee schedule,2284.67,10136.31,
Glaucoma surgery,66160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5325.06,,,,,,,fee schedule,2284.67,10136.31,
Glaucoma surgery,66160,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10136.31,,,,,,,fee schedule,2284.67,10136.31,APC 378
Glaucoma surgery,66160,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2398.9,,,,,,,fee schedule,2284.67,10136.31,APC
Glaucoma surgery,66160,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2376.06,,,,,,,fee schedule,2284.67,10136.31,APC
Glaucoma surgery,66160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2284.67,,,,,,,fee schedule,2284.67,10136.31,APC
Glaucoma surgery,66160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3495.55,,,,,,,fee schedule,2284.67,10136.31,Radiology
Glaucoma surgery,66160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3198.54,,,,,,,fee schedule,2284.67,10136.31,APC
Glaucoma surgery,66160,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3998.17,,,,,,,fee schedule,2284.67,10136.31,APC
Glaucoma surgery,66170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5784.12,,,,,,,fee schedule,2284.67,10136.31,
Glaucoma surgery,66170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4636.48,,,,,,,fee schedule,2284.67,10136.31,
Glaucoma surgery,66170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5064.93,,,,,,,fee schedule,2284.67,10136.31,
Glaucoma surgery,66170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5325.06,,,,,,,fee schedule,2284.67,10136.31,
Glaucoma surgery,66170,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10136.31,,,,,,,fee schedule,2284.67,10136.31,APC 378
Glaucoma surgery,66170,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2398.9,,,,,,,fee schedule,2284.67,10136.31,APC
Glaucoma surgery,66170,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2376.06,,,,,,,fee schedule,2284.67,10136.31,APC
Glaucoma surgery,66170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2284.67,,,,,,,fee schedule,2284.67,10136.31,APC
Glaucoma surgery,66170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3495.55,,,,,,,fee schedule,2284.67,10136.31,Radiology
Glaucoma surgery,66170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3198.54,,,,,,,fee schedule,2284.67,10136.31,APC
Glaucoma surgery,66170,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3998.17,,,,,,,fee schedule,2284.67,10136.31,APC
Incision of eye,66172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5784.12,,,,,,,fee schedule,2284.67,10136.31,
Incision of eye,66172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4636.48,,,,,,,fee schedule,2284.67,10136.31,
Incision of eye,66172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5064.93,,,,,,,fee schedule,2284.67,10136.31,
Incision of eye,66172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5325.06,,,,,,,fee schedule,2284.67,10136.31,
Incision of eye,66172,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10136.31,,,,,,,fee schedule,2284.67,10136.31,APC 378
Incision of eye,66172,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2398.9,,,,,,,fee schedule,2284.67,10136.31,APC
Incision of eye,66172,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2376.06,,,,,,,fee schedule,2284.67,10136.31,APC
Incision of eye,66172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2284.67,,,,,,,fee schedule,2284.67,10136.31,APC
Incision of eye,66172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3495.55,,,,,,,fee schedule,2284.67,10136.31,Radiology
Incision of eye,66172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3198.54,,,,,,,fee schedule,2284.67,10136.31,APC
Incision of eye,66172,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3998.17,,,,,,,fee schedule,2284.67,10136.31,APC
Translum dil eye canal,66174,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11257.26,,,,,,,fee schedule,4091.95,18154.62,
Translum dil eye canal,66174,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9023.67,,,,,,,fee schedule,4091.95,18154.62,
Translum dil eye canal,66174,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9857.54,,,,,,,fee schedule,4091.95,18154.62,
Translum dil eye canal,66174,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10363.82,,,,,,,fee schedule,4091.95,18154.62,
Translum dil eye canal,66174,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18154.62,,,,,,,fee schedule,4091.95,18154.62,APC 378
Translum dil eye canal,66174,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4296.55,,,,,,,fee schedule,4091.95,18154.62,APC
Translum dil eye canal,66174,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4255.63,,,,,,,fee schedule,4091.95,18154.62,APC
Translum dil eye canal,66174,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4091.95,,,,,,,fee schedule,4091.95,18154.62,APC
Translum dil eye canal,66174,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6260.69,,,,,,,fee schedule,4091.95,18154.62,Radiology
Translum dil eye canal,66174,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5728.74,,,,,,,fee schedule,4091.95,18154.62,APC
Translum dil eye canal,66174,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7160.92,,,,,,,fee schedule,4091.95,18154.62,APC
Trnslum dil eye canal w/stnt,66175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11257.26,,,,,,,fee schedule,5267.92,23371.97,
Trnslum dil eye canal w/stnt,66175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9023.67,,,,,,,fee schedule,5267.92,23371.97,
Trnslum dil eye canal w/stnt,66175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9857.54,,,,,,,fee schedule,5267.92,23371.97,
Trnslum dil eye canal w/stnt,66175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10363.82,,,,,,,fee schedule,5267.92,23371.97,
Trnslum dil eye canal w/stnt,66175,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23371.97,,,,,,,fee schedule,5267.92,23371.97,APC 378
Trnslum dil eye canal w/stnt,66175,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5531.31,,,,,,,fee schedule,5267.92,23371.97,APC
Trnslum dil eye canal w/stnt,66175,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5478.63,,,,,,,fee schedule,5267.92,23371.97,APC
Trnslum dil eye canal w/stnt,66175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5267.92,,,,,,,fee schedule,5267.92,23371.97,APC
Trnslum dil eye canal w/stnt,66175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8059.91,,,,,,,fee schedule,5267.92,23371.97,Radiology
Trnslum dil eye canal w/stnt,66175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7375.09,,,,,,,fee schedule,5267.92,23371.97,APC
Trnslum dil eye canal w/stnt,66175,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9218.86,,,,,,,fee schedule,5267.92,23371.97,APC
Aqueous shunt eye w/o graft,66179,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11803.28,,,,,,,fee schedule,5267.92,23371.97,
Aqueous shunt eye w/o graft,66179,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9461.36,,,,,,,fee schedule,5267.92,23371.97,
Aqueous shunt eye w/o graft,66179,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10335.67,,,,,,,fee schedule,5267.92,23371.97,
Aqueous shunt eye w/o graft,66179,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10866.51,,,,,,,fee schedule,5267.92,23371.97,
Aqueous shunt eye w/o graft,66179,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23371.97,,,,,,,fee schedule,5267.92,23371.97,APC 378
Aqueous shunt eye w/o graft,66179,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5531.31,,,,,,,fee schedule,5267.92,23371.97,APC
Aqueous shunt eye w/o graft,66179,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5478.63,,,,,,,fee schedule,5267.92,23371.97,APC
Aqueous shunt eye w/o graft,66179,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5267.92,,,,,,,fee schedule,5267.92,23371.97,APC
Aqueous shunt eye w/o graft,66179,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8059.91,,,,,,,fee schedule,5267.92,23371.97,Radiology
Aqueous shunt eye w/o graft,66179,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7375.09,,,,,,,fee schedule,5267.92,23371.97,APC
Aqueous shunt eye w/o graft,66179,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9218.86,,,,,,,fee schedule,5267.92,23371.97,APC
Aqueous shunt eye w/graft,66180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9910.67,,,,,,,fee schedule,5267.92,23371.97,
Aqueous shunt eye w/graft,66180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7944.27,,,,,,,fee schedule,5267.92,23371.97,
Aqueous shunt eye w/graft,66180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8678.39,,,,,,,fee schedule,5267.92,23371.97,
Aqueous shunt eye w/graft,66180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9124.11,,,,,,,fee schedule,5267.92,23371.97,
Aqueous shunt eye w/graft,66180,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23371.97,,,,,,,fee schedule,5267.92,23371.97,APC 378
Aqueous shunt eye w/graft,66180,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5531.31,,,,,,,fee schedule,5267.92,23371.97,APC
Aqueous shunt eye w/graft,66180,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5478.63,,,,,,,fee schedule,5267.92,23371.97,APC
Aqueous shunt eye w/graft,66180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5267.92,,,,,,,fee schedule,5267.92,23371.97,APC
Aqueous shunt eye w/graft,66180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8059.91,,,,,,,fee schedule,5267.92,23371.97,Radiology
Aqueous shunt eye w/graft,66180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7375.09,,,,,,,fee schedule,5267.92,23371.97,APC
Aqueous shunt eye w/graft,66180,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9218.86,,,,,,,fee schedule,5267.92,23371.97,APC
Insert ant drainage device,66183,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11803.28,,,,,,,fee schedule,4091.95,18154.62,
Insert ant drainage device,66183,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9461.36,,,,,,,fee schedule,4091.95,18154.62,
Insert ant drainage device,66183,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10335.67,,,,,,,fee schedule,4091.95,18154.62,
Insert ant drainage device,66183,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10866.51,,,,,,,fee schedule,4091.95,18154.62,
Insert ant drainage device,66183,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18154.62,,,,,,,fee schedule,4091.95,18154.62,APC 378
Insert ant drainage device,66183,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4296.55,,,,,,,fee schedule,4091.95,18154.62,APC
Insert ant drainage device,66183,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4255.63,,,,,,,fee schedule,4091.95,18154.62,APC
Insert ant drainage device,66183,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4091.95,,,,,,,fee schedule,4091.95,18154.62,APC
Insert ant drainage device,66183,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6260.69,,,,,,,fee schedule,4091.95,18154.62,Radiology
Insert ant drainage device,66183,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5728.74,,,,,,,fee schedule,4091.95,18154.62,APC
Insert ant drainage device,66183,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7160.92,,,,,,,fee schedule,4091.95,18154.62,APC
Revision of aqueous shunt,66184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6624.9,,,,,,,fee schedule,2284.67,10136.31,
Revision of aqueous shunt,66184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5310.44,,,,,,,fee schedule,2284.67,10136.31,
Revision of aqueous shunt,66184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5801.17,,,,,,,fee schedule,2284.67,10136.31,
Revision of aqueous shunt,66184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6099.12,,,,,,,fee schedule,2284.67,10136.31,
Revision of aqueous shunt,66184,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10136.31,,,,,,,fee schedule,2284.67,10136.31,APC 378
Revision of aqueous shunt,66184,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2398.9,,,,,,,fee schedule,2284.67,10136.31,APC
Revision of aqueous shunt,66184,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2376.06,,,,,,,fee schedule,2284.67,10136.31,APC
Revision of aqueous shunt,66184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2284.67,,,,,,,fee schedule,2284.67,10136.31,APC
Revision of aqueous shunt,66184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3495.55,,,,,,,fee schedule,2284.67,10136.31,Radiology
Revision of aqueous shunt,66184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3198.54,,,,,,,fee schedule,2284.67,10136.31,APC
Revision of aqueous shunt,66184,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3998.17,,,,,,,fee schedule,2284.67,10136.31,APC
Revise aqueous shunt eye,66185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9910.67,,,,,,,fee schedule,2284.67,10136.31,
Revise aqueous shunt eye,66185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7944.27,,,,,,,fee schedule,2284.67,10136.31,
Revise aqueous shunt eye,66185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8678.39,,,,,,,fee schedule,2284.67,10136.31,
Revise aqueous shunt eye,66185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9124.11,,,,,,,fee schedule,2284.67,10136.31,
Revise aqueous shunt eye,66185,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10136.31,,,,,,,fee schedule,2284.67,10136.31,APC 378
Revise aqueous shunt eye,66185,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2398.9,,,,,,,fee schedule,2284.67,10136.31,APC
Revise aqueous shunt eye,66185,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2376.06,,,,,,,fee schedule,2284.67,10136.31,APC
Revise aqueous shunt eye,66185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2284.67,,,,,,,fee schedule,2284.67,10136.31,APC
Revise aqueous shunt eye,66185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3495.55,,,,,,,fee schedule,2284.67,10136.31,Radiology
Revise aqueous shunt eye,66185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3198.54,,,,,,,fee schedule,2284.67,10136.31,APC
Revise aqueous shunt eye,66185,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3998.17,,,,,,,fee schedule,2284.67,10136.31,APC
Repair/graft eye lesion,66225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9910.67,,,,,,,fee schedule,5267.92,23371.97,
Repair/graft eye lesion,66225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7944.27,,,,,,,fee schedule,5267.92,23371.97,
Repair/graft eye lesion,66225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8678.39,,,,,,,fee schedule,5267.92,23371.97,
Repair/graft eye lesion,66225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9124.11,,,,,,,fee schedule,5267.92,23371.97,
Repair/graft eye lesion,66225,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23371.97,,,,,,,fee schedule,5267.92,23371.97,APC 378
Repair/graft eye lesion,66225,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5531.31,,,,,,,fee schedule,5267.92,23371.97,APC
Repair/graft eye lesion,66225,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5478.63,,,,,,,fee schedule,5267.92,23371.97,APC
Repair/graft eye lesion,66225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5267.92,,,,,,,fee schedule,5267.92,23371.97,APC
Repair/graft eye lesion,66225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8059.91,,,,,,,fee schedule,5267.92,23371.97,Radiology
Repair/graft eye lesion,66225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7375.09,,,,,,,fee schedule,5267.92,23371.97,APC
Repair/graft eye lesion,66225,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9218.86,,,,,,,fee schedule,5267.92,23371.97,APC
Follow-up surgery of eye,66250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4035.91,,,,,,,fee schedule,2353.63,10442.27,
Follow-up surgery of eye,66250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3235.13,,,,,,,fee schedule,2353.63,10442.27,
Follow-up surgery of eye,66250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3534.09,,,,,,,fee schedule,2353.63,10442.27,
Follow-up surgery of eye,66250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3715.6,,,,,,,fee schedule,2353.63,10442.27,
Follow-up surgery of eye,66250,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2353.63,10442.27,APC 378
Follow-up surgery of eye,66250,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2353.63,10442.27,APC
Follow-up surgery of eye,66250,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2353.63,10442.27,APC
Follow-up surgery of eye,66250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2353.63,10442.27,APC
Follow-up surgery of eye,66250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2353.63,10442.27,Radiology
Follow-up surgery of eye,66250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2353.63,10442.27,APC
Follow-up surgery of eye,66250,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2353.63,10442.27,APC
Incision of iris,66500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1277.07,,,,,,,fee schedule,1023.69,10136.31,
Incision of iris,66500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1023.69,,,,,,,fee schedule,1023.69,10136.31,
Incision of iris,66500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1118.28,,,,,,,fee schedule,1023.69,10136.31,
Incision of iris,66500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1175.72,,,,,,,fee schedule,1023.69,10136.31,
Incision of iris,66500,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10136.31,,,,,,,fee schedule,1023.69,10136.31,APC 378
Incision of iris,66500,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2398.9,,,,,,,fee schedule,1023.69,10136.31,APC
Incision of iris,66500,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2376.06,,,,,,,fee schedule,1023.69,10136.31,APC
Incision of iris,66500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2284.67,,,,,,,fee schedule,1023.69,10136.31,APC
Incision of iris,66500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3495.55,,,,,,,fee schedule,1023.69,10136.31,Radiology
Incision of iris,66500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3198.54,,,,,,,fee schedule,1023.69,10136.31,APC
Incision of iris,66500,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3998.17,,,,,,,fee schedule,1023.69,10136.31,APC
Incision of iris,66505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1277.07,,,,,,,fee schedule,1023.69,10136.31,
Incision of iris,66505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1023.69,,,,,,,fee schedule,1023.69,10136.31,
Incision of iris,66505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1118.28,,,,,,,fee schedule,1023.69,10136.31,
Incision of iris,66505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1175.72,,,,,,,fee schedule,1023.69,10136.31,
Incision of iris,66505,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10136.31,,,,,,,fee schedule,1023.69,10136.31,APC 378
Incision of iris,66505,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2398.9,,,,,,,fee schedule,1023.69,10136.31,APC
Incision of iris,66505,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2376.06,,,,,,,fee schedule,1023.69,10136.31,APC
Incision of iris,66505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2284.67,,,,,,,fee schedule,1023.69,10136.31,APC
Incision of iris,66505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3495.55,,,,,,,fee schedule,1023.69,10136.31,Radiology
Incision of iris,66505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3198.54,,,,,,,fee schedule,1023.69,10136.31,APC
Incision of iris,66505,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3998.17,,,,,,,fee schedule,1023.69,10136.31,APC
Remove iris and lesion,66600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5784.12,,,,,,,fee schedule,4091.95,18154.62,
Remove iris and lesion,66600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4636.48,,,,,,,fee schedule,4091.95,18154.62,
Remove iris and lesion,66600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5064.93,,,,,,,fee schedule,4091.95,18154.62,
Remove iris and lesion,66600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5325.06,,,,,,,fee schedule,4091.95,18154.62,
Remove iris and lesion,66600,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18154.62,,,,,,,fee schedule,4091.95,18154.62,APC 378
Remove iris and lesion,66600,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4296.55,,,,,,,fee schedule,4091.95,18154.62,APC
Remove iris and lesion,66600,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4255.63,,,,,,,fee schedule,4091.95,18154.62,APC
Remove iris and lesion,66600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4091.95,,,,,,,fee schedule,4091.95,18154.62,APC
Remove iris and lesion,66600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6260.69,,,,,,,fee schedule,4091.95,18154.62,Radiology
Remove iris and lesion,66600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5728.74,,,,,,,fee schedule,4091.95,18154.62,APC
Remove iris and lesion,66600,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7160.92,,,,,,,fee schedule,4091.95,18154.62,APC
Removal of iris,66605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5784.12,,,,,,,fee schedule,2284.67,10136.31,
Removal of iris,66605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4636.48,,,,,,,fee schedule,2284.67,10136.31,
Removal of iris,66605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5064.93,,,,,,,fee schedule,2284.67,10136.31,
Removal of iris,66605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5325.06,,,,,,,fee schedule,2284.67,10136.31,
Removal of iris,66605,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10136.31,,,,,,,fee schedule,2284.67,10136.31,APC 378
Removal of iris,66605,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2398.9,,,,,,,fee schedule,2284.67,10136.31,APC
Removal of iris,66605,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2376.06,,,,,,,fee schedule,2284.67,10136.31,APC
Removal of iris,66605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2284.67,,,,,,,fee schedule,2284.67,10136.31,APC
Removal of iris,66605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3495.55,,,,,,,fee schedule,2284.67,10136.31,Radiology
Removal of iris,66605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3198.54,,,,,,,fee schedule,2284.67,10136.31,APC
Removal of iris,66605,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3998.17,,,,,,,fee schedule,2284.67,10136.31,APC
Removal of iris,66625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1277.07,,,,,,,fee schedule,1023.69,10136.31,
Removal of iris,66625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1023.69,,,,,,,fee schedule,1023.69,10136.31,
Removal of iris,66625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1118.28,,,,,,,fee schedule,1023.69,10136.31,
Removal of iris,66625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1175.72,,,,,,,fee schedule,1023.69,10136.31,
Removal of iris,66625,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10136.31,,,,,,,fee schedule,1023.69,10136.31,APC 378
Removal of iris,66625,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2398.9,,,,,,,fee schedule,1023.69,10136.31,APC
Removal of iris,66625,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2376.06,,,,,,,fee schedule,1023.69,10136.31,APC
Removal of iris,66625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2284.67,,,,,,,fee schedule,1023.69,10136.31,APC
Removal of iris,66625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3495.55,,,,,,,fee schedule,1023.69,10136.31,Radiology
Removal of iris,66625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3198.54,,,,,,,fee schedule,1023.69,10136.31,APC
Removal of iris,66625,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3998.17,,,,,,,fee schedule,1023.69,10136.31,APC
Removal of iris,66630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5784.12,,,,,,,fee schedule,2284.67,10136.31,
Removal of iris,66630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4636.48,,,,,,,fee schedule,2284.67,10136.31,
Removal of iris,66630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5064.93,,,,,,,fee schedule,2284.67,10136.31,
Removal of iris,66630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5325.06,,,,,,,fee schedule,2284.67,10136.31,
Removal of iris,66630,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10136.31,,,,,,,fee schedule,2284.67,10136.31,APC 378
Removal of iris,66630,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2398.9,,,,,,,fee schedule,2284.67,10136.31,APC
Removal of iris,66630,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2376.06,,,,,,,fee schedule,2284.67,10136.31,APC
Removal of iris,66630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2284.67,,,,,,,fee schedule,2284.67,10136.31,APC
Removal of iris,66630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3495.55,,,,,,,fee schedule,2284.67,10136.31,Radiology
Removal of iris,66630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3198.54,,,,,,,fee schedule,2284.67,10136.31,APC
Removal of iris,66630,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3998.17,,,,,,,fee schedule,2284.67,10136.31,APC
Removal of iris,66635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5784.12,,,,,,,fee schedule,2284.67,10136.31,
Removal of iris,66635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4636.48,,,,,,,fee schedule,2284.67,10136.31,
Removal of iris,66635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5064.93,,,,,,,fee schedule,2284.67,10136.31,
Removal of iris,66635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5325.06,,,,,,,fee schedule,2284.67,10136.31,
Removal of iris,66635,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10136.31,,,,,,,fee schedule,2284.67,10136.31,APC 378
Removal of iris,66635,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2398.9,,,,,,,fee schedule,2284.67,10136.31,APC
Removal of iris,66635,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2376.06,,,,,,,fee schedule,2284.67,10136.31,APC
Removal of iris,66635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2284.67,,,,,,,fee schedule,2284.67,10136.31,APC
Removal of iris,66635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3495.55,,,,,,,fee schedule,2284.67,10136.31,Radiology
Removal of iris,66635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3198.54,,,,,,,fee schedule,2284.67,10136.31,APC
Removal of iris,66635,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3998.17,,,,,,,fee schedule,2284.67,10136.31,APC
Repair iris & ciliary body,66680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5784.12,,,,,,,fee schedule,2284.67,10136.31,
Repair iris & ciliary body,66680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4636.48,,,,,,,fee schedule,2284.67,10136.31,
Repair iris & ciliary body,66680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5064.93,,,,,,,fee schedule,2284.67,10136.31,
Repair iris & ciliary body,66680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5325.06,,,,,,,fee schedule,2284.67,10136.31,
Repair iris & ciliary body,66680,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10136.31,,,,,,,fee schedule,2284.67,10136.31,APC 378
Repair iris & ciliary body,66680,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2398.9,,,,,,,fee schedule,2284.67,10136.31,APC
Repair iris & ciliary body,66680,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2376.06,,,,,,,fee schedule,2284.67,10136.31,APC
Repair iris & ciliary body,66680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2284.67,,,,,,,fee schedule,2284.67,10136.31,APC
Repair iris & ciliary body,66680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3495.55,,,,,,,fee schedule,2284.67,10136.31,Radiology
Repair iris & ciliary body,66680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3198.54,,,,,,,fee schedule,2284.67,10136.31,APC
Repair iris & ciliary body,66680,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3998.17,,,,,,,fee schedule,2284.67,10136.31,APC
Repair iris & ciliary body,66682,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5784.12,,,,,,,fee schedule,2284.67,10136.31,
Repair iris & ciliary body,66682,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4636.48,,,,,,,fee schedule,2284.67,10136.31,
Repair iris & ciliary body,66682,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5064.93,,,,,,,fee schedule,2284.67,10136.31,
Repair iris & ciliary body,66682,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5325.06,,,,,,,fee schedule,2284.67,10136.31,
Repair iris & ciliary body,66682,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10136.31,,,,,,,fee schedule,2284.67,10136.31,APC 378
Repair iris & ciliary body,66682,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2398.9,,,,,,,fee schedule,2284.67,10136.31,APC
Repair iris & ciliary body,66682,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2376.06,,,,,,,fee schedule,2284.67,10136.31,APC
Repair iris & ciliary body,66682,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2284.67,,,,,,,fee schedule,2284.67,10136.31,APC
Repair iris & ciliary body,66682,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3495.55,,,,,,,fee schedule,2284.67,10136.31,Radiology
Repair iris & ciliary body,66682,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3198.54,,,,,,,fee schedule,2284.67,10136.31,APC
Repair iris & ciliary body,66682,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3998.17,,,,,,,fee schedule,2284.67,10136.31,APC
Destruction ciliary body,66700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4035.91,,,,,,,fee schedule,2284.67,10136.31,
Destruction ciliary body,66700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3235.13,,,,,,,fee schedule,2284.67,10136.31,
Destruction ciliary body,66700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3534.09,,,,,,,fee schedule,2284.67,10136.31,
Destruction ciliary body,66700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3715.6,,,,,,,fee schedule,2284.67,10136.31,
Destruction ciliary body,66700,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10136.31,,,,,,,fee schedule,2284.67,10136.31,APC 378
Destruction ciliary body,66700,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2398.9,,,,,,,fee schedule,2284.67,10136.31,APC
Destruction ciliary body,66700,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2376.06,,,,,,,fee schedule,2284.67,10136.31,APC
Destruction ciliary body,66700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2284.67,,,,,,,fee schedule,2284.67,10136.31,APC
Destruction ciliary body,66700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3495.55,,,,,,,fee schedule,2284.67,10136.31,Radiology
Destruction ciliary body,66700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3198.54,,,,,,,fee schedule,2284.67,10136.31,APC
Destruction ciliary body,66700,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3998.17,,,,,,,fee schedule,2284.67,10136.31,APC
Ciliary transsleral therapy,66710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4035.91,,,,,,,fee schedule,2353.63,10442.27,
Ciliary transsleral therapy,66710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3235.13,,,,,,,fee schedule,2353.63,10442.27,
Ciliary transsleral therapy,66710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3534.09,,,,,,,fee schedule,2353.63,10442.27,
Ciliary transsleral therapy,66710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3715.6,,,,,,,fee schedule,2353.63,10442.27,
Ciliary transsleral therapy,66710,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2353.63,10442.27,APC 378
Ciliary transsleral therapy,66710,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2353.63,10442.27,APC
Ciliary transsleral therapy,66710,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2353.63,10442.27,APC
Ciliary transsleral therapy,66710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2353.63,10442.27,APC
Ciliary transsleral therapy,66710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2353.63,10442.27,Radiology
Ciliary transsleral therapy,66710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2353.63,10442.27,APC
Ciliary transsleral therapy,66710,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2353.63,10442.27,APC
Ciliary endoscopic ablation,66711,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4035.91,,,,,,,fee schedule,2284.67,10136.31,
Ciliary endoscopic ablation,66711,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3235.13,,,,,,,fee schedule,2284.67,10136.31,
Ciliary endoscopic ablation,66711,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3534.09,,,,,,,fee schedule,2284.67,10136.31,
Ciliary endoscopic ablation,66711,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3715.6,,,,,,,fee schedule,2284.67,10136.31,
Ciliary endoscopic ablation,66711,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10136.31,,,,,,,fee schedule,2284.67,10136.31,APC 378
Ciliary endoscopic ablation,66711,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2398.9,,,,,,,fee schedule,2284.67,10136.31,APC
Ciliary endoscopic ablation,66711,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2376.06,,,,,,,fee schedule,2284.67,10136.31,APC
Ciliary endoscopic ablation,66711,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2284.67,,,,,,,fee schedule,2284.67,10136.31,APC
Ciliary endoscopic ablation,66711,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3495.55,,,,,,,fee schedule,2284.67,10136.31,Radiology
Ciliary endoscopic ablation,66711,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3198.54,,,,,,,fee schedule,2284.67,10136.31,APC
Ciliary endoscopic ablation,66711,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3998.17,,,,,,,fee schedule,2284.67,10136.31,APC
Destruction ciliary body,66720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4035.91,,,,,,,fee schedule,2353.63,10442.27,
Destruction ciliary body,66720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3235.13,,,,,,,fee schedule,2353.63,10442.27,
Destruction ciliary body,66720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3534.09,,,,,,,fee schedule,2353.63,10442.27,
Destruction ciliary body,66720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3715.6,,,,,,,fee schedule,2353.63,10442.27,
Destruction ciliary body,66720,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2353.63,10442.27,APC 378
Destruction ciliary body,66720,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2353.63,10442.27,APC
Destruction ciliary body,66720,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2353.63,10442.27,APC
Destruction ciliary body,66720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2353.63,10442.27,APC
Destruction ciliary body,66720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2353.63,10442.27,Radiology
Destruction ciliary body,66720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2353.63,10442.27,APC
Destruction ciliary body,66720,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2353.63,10442.27,APC
Destruction ciliary body,66740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5784.12,,,,,,,fee schedule,2353.63,10442.27,
Destruction ciliary body,66740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4636.48,,,,,,,fee schedule,2353.63,10442.27,
Destruction ciliary body,66740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5064.93,,,,,,,fee schedule,2353.63,10442.27,
Destruction ciliary body,66740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5325.06,,,,,,,fee schedule,2353.63,10442.27,
Destruction ciliary body,66740,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2353.63,10442.27,APC 378
Destruction ciliary body,66740,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2353.63,10442.27,APC
Destruction ciliary body,66740,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2353.63,10442.27,APC
Destruction ciliary body,66740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2353.63,10442.27,APC
Destruction ciliary body,66740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2353.63,10442.27,Radiology
Destruction ciliary body,66740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2353.63,10442.27,APC
Destruction ciliary body,66740,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2353.63,10442.27,APC
Revision of iris,66761,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1297.83,,,,,,,fee schedule,544.48,2415.67,
Revision of iris,66761,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1040.32,,,,,,,fee schedule,544.48,2415.67,
Revision of iris,66761,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1136.46,,,,,,,fee schedule,544.48,2415.67,
Revision of iris,66761,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1194.82,,,,,,,fee schedule,544.48,2415.67,
Revision of iris,66761,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2415.67,,,,,,,fee schedule,544.48,2415.67,APC 378
Revision of iris,66761,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,571.7,,,,,,,fee schedule,544.48,2415.67,APC
Revision of iris,66761,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,566.26,,,,,,,fee schedule,544.48,2415.67,APC
Revision of iris,66761,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,544.48,,,,,,,fee schedule,544.48,2415.67,APC
Revision of iris,66761,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,833.05,,,,,,,fee schedule,544.48,2415.67,Radiology
Revision of iris,66761,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,762.27,,,,,,,fee schedule,544.48,2415.67,APC
Revision of iris,66761,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,952.84,,,,,,,fee schedule,544.48,2415.67,APC
Revision of iris,66762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1297.83,,,,,,,fee schedule,544.48,2415.67,
Revision of iris,66762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1040.32,,,,,,,fee schedule,544.48,2415.67,
Revision of iris,66762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1136.46,,,,,,,fee schedule,544.48,2415.67,
Revision of iris,66762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1194.82,,,,,,,fee schedule,544.48,2415.67,
Revision of iris,66762,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2415.67,,,,,,,fee schedule,544.48,2415.67,APC 378
Revision of iris,66762,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,571.7,,,,,,,fee schedule,544.48,2415.67,APC
Revision of iris,66762,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,566.26,,,,,,,fee schedule,544.48,2415.67,APC
Revision of iris,66762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,544.48,,,,,,,fee schedule,544.48,2415.67,APC
Revision of iris,66762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,833.05,,,,,,,fee schedule,544.48,2415.67,Radiology
Revision of iris,66762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,762.27,,,,,,,fee schedule,544.48,2415.67,APC
Revision of iris,66762,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,952.84,,,,,,,fee schedule,544.48,2415.67,APC
Removal of inner eye lesion,66770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1297.83,,,,,,,fee schedule,544.48,2415.67,
Removal of inner eye lesion,66770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1040.32,,,,,,,fee schedule,544.48,2415.67,
Removal of inner eye lesion,66770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1136.46,,,,,,,fee schedule,544.48,2415.67,
Removal of inner eye lesion,66770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1194.82,,,,,,,fee schedule,544.48,2415.67,
Removal of inner eye lesion,66770,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2415.67,,,,,,,fee schedule,544.48,2415.67,APC 378
Removal of inner eye lesion,66770,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,571.7,,,,,,,fee schedule,544.48,2415.67,APC
Removal of inner eye lesion,66770,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,566.26,,,,,,,fee schedule,544.48,2415.67,APC
Removal of inner eye lesion,66770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,544.48,,,,,,,fee schedule,544.48,2415.67,APC
Removal of inner eye lesion,66770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,833.05,,,,,,,fee schedule,544.48,2415.67,Radiology
Removal of inner eye lesion,66770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,762.27,,,,,,,fee schedule,544.48,2415.67,APC
Removal of inner eye lesion,66770,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,952.84,,,,,,,fee schedule,544.48,2415.67,APC
Incision secondary cataract,66820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1277.07,,,,,,,fee schedule,1023.69,10136.31,
Incision secondary cataract,66820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1023.69,,,,,,,fee schedule,1023.69,10136.31,
Incision secondary cataract,66820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1118.28,,,,,,,fee schedule,1023.69,10136.31,
Incision secondary cataract,66820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1175.72,,,,,,,fee schedule,1023.69,10136.31,
Incision secondary cataract,66820,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10136.31,,,,,,,fee schedule,1023.69,10136.31,APC 378
Incision secondary cataract,66820,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2398.9,,,,,,,fee schedule,1023.69,10136.31,APC
Incision secondary cataract,66820,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2376.06,,,,,,,fee schedule,1023.69,10136.31,APC
Incision secondary cataract,66820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2284.67,,,,,,,fee schedule,1023.69,10136.31,APC
Incision secondary cataract,66820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3495.55,,,,,,,fee schedule,1023.69,10136.31,Radiology
Incision secondary cataract,66820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3198.54,,,,,,,fee schedule,1023.69,10136.31,APC
Incision secondary cataract,66820,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3998.17,,,,,,,fee schedule,1023.69,10136.31,APC
After cataract laser surgery,66821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1297.83,,,,,,,fee schedule,544.48,2415.67,
After cataract laser surgery,66821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1040.32,,,,,,,fee schedule,544.48,2415.67,
After cataract laser surgery,66821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1136.46,,,,,,,fee schedule,544.48,2415.67,
After cataract laser surgery,66821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1194.82,,,,,,,fee schedule,544.48,2415.67,
After cataract laser surgery,66821,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2415.67,,,,,,,fee schedule,544.48,2415.67,APC 378
After cataract laser surgery,66821,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,571.7,,,,,,,fee schedule,544.48,2415.67,APC
After cataract laser surgery,66821,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,566.26,,,,,,,fee schedule,544.48,2415.67,APC
After cataract laser surgery,66821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,544.48,,,,,,,fee schedule,544.48,2415.67,APC
After cataract laser surgery,66821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,833.05,,,,,,,fee schedule,544.48,2415.67,Radiology
After cataract laser surgery,66821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,762.27,,,,,,,fee schedule,544.48,2415.67,APC
After cataract laser surgery,66821,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,952.84,,,,,,,fee schedule,544.48,2415.67,APC
Reposition intraocular lens,66825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5784.12,,,,,,,fee schedule,2284.67,10136.31,
Reposition intraocular lens,66825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4636.48,,,,,,,fee schedule,2284.67,10136.31,
Reposition intraocular lens,66825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5064.93,,,,,,,fee schedule,2284.67,10136.31,
Reposition intraocular lens,66825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5325.06,,,,,,,fee schedule,2284.67,10136.31,
Reposition intraocular lens,66825,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10136.31,,,,,,,fee schedule,2284.67,10136.31,APC 378
Reposition intraocular lens,66825,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2398.9,,,,,,,fee schedule,2284.67,10136.31,APC
Reposition intraocular lens,66825,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2376.06,,,,,,,fee schedule,2284.67,10136.31,APC
Reposition intraocular lens,66825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2284.67,,,,,,,fee schedule,2284.67,10136.31,APC
Reposition intraocular lens,66825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3495.55,,,,,,,fee schedule,2284.67,10136.31,Radiology
Reposition intraocular lens,66825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3198.54,,,,,,,fee schedule,2284.67,10136.31,APC
Reposition intraocular lens,66825,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3998.17,,,,,,,fee schedule,2284.67,10136.31,APC
Removal of lens lesion,66830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1277.07,,,,,,,fee schedule,1023.69,10136.31,
Removal of lens lesion,66830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1023.69,,,,,,,fee schedule,1023.69,10136.31,
Removal of lens lesion,66830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1118.28,,,,,,,fee schedule,1023.69,10136.31,
Removal of lens lesion,66830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1175.72,,,,,,,fee schedule,1023.69,10136.31,
Removal of lens lesion,66830,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10136.31,,,,,,,fee schedule,1023.69,10136.31,APC 378
Removal of lens lesion,66830,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2398.9,,,,,,,fee schedule,1023.69,10136.31,APC
Removal of lens lesion,66830,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2376.06,,,,,,,fee schedule,1023.69,10136.31,APC
Removal of lens lesion,66830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2284.67,,,,,,,fee schedule,1023.69,10136.31,APC
Removal of lens lesion,66830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3495.55,,,,,,,fee schedule,1023.69,10136.31,Radiology
Removal of lens lesion,66830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3198.54,,,,,,,fee schedule,1023.69,10136.31,APC
Removal of lens lesion,66830,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3998.17,,,,,,,fee schedule,1023.69,10136.31,APC
Removal of lens material,66840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3722.92,,,,,,,fee schedule,2284.67,10136.31,
Removal of lens material,66840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2984.25,,,,,,,fee schedule,2284.67,10136.31,
Removal of lens material,66840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3260.02,,,,,,,fee schedule,2284.67,10136.31,
Removal of lens material,66840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3427.45,,,,,,,fee schedule,2284.67,10136.31,
Removal of lens material,66840,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10136.31,,,,,,,fee schedule,2284.67,10136.31,APC 378
Removal of lens material,66840,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2398.9,,,,,,,fee schedule,2284.67,10136.31,APC
Removal of lens material,66840,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2376.06,,,,,,,fee schedule,2284.67,10136.31,APC
Removal of lens material,66840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2284.67,,,,,,,fee schedule,2284.67,10136.31,APC
Removal of lens material,66840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3495.55,,,,,,,fee schedule,2284.67,10136.31,Radiology
Removal of lens material,66840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3198.54,,,,,,,fee schedule,2284.67,10136.31,APC
Removal of lens material,66840,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3998.17,,,,,,,fee schedule,2284.67,10136.31,APC
Removal of lens material,66850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7163.67,,,,,,,fee schedule,2284.67,10136.31,
Removal of lens material,66850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5742.3,,,,,,,fee schedule,2284.67,10136.31,
Removal of lens material,66850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6272.95,,,,,,,fee schedule,2284.67,10136.31,
Removal of lens material,66850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6595.12,,,,,,,fee schedule,2284.67,10136.31,
Removal of lens material,66850,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10136.31,,,,,,,fee schedule,2284.67,10136.31,APC 378
Removal of lens material,66850,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2398.9,,,,,,,fee schedule,2284.67,10136.31,APC
Removal of lens material,66850,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2376.06,,,,,,,fee schedule,2284.67,10136.31,APC
Removal of lens material,66850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2284.67,,,,,,,fee schedule,2284.67,10136.31,APC
Removal of lens material,66850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3495.55,,,,,,,fee schedule,2284.67,10136.31,Radiology
Removal of lens material,66850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3198.54,,,,,,,fee schedule,2284.67,10136.31,APC
Removal of lens material,66850,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3998.17,,,,,,,fee schedule,2284.67,10136.31,APC
Removal of lens material,66852,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7163.67,,,,,,,fee schedule,4091.95,18154.62,
Removal of lens material,66852,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5742.3,,,,,,,fee schedule,4091.95,18154.62,
Removal of lens material,66852,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6272.95,,,,,,,fee schedule,4091.95,18154.62,
Removal of lens material,66852,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6595.12,,,,,,,fee schedule,4091.95,18154.62,
Removal of lens material,66852,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18154.62,,,,,,,fee schedule,4091.95,18154.62,APC 378
Removal of lens material,66852,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4296.55,,,,,,,fee schedule,4091.95,18154.62,APC
Removal of lens material,66852,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4255.63,,,,,,,fee schedule,4091.95,18154.62,APC
Removal of lens material,66852,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4091.95,,,,,,,fee schedule,4091.95,18154.62,APC
Removal of lens material,66852,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6260.69,,,,,,,fee schedule,4091.95,18154.62,Radiology
Removal of lens material,66852,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5728.74,,,,,,,fee schedule,4091.95,18154.62,APC
Removal of lens material,66852,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7160.92,,,,,,,fee schedule,4091.95,18154.62,APC
Extraction of lens,66920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7163.67,,,,,,,fee schedule,2284.67,10136.31,
Extraction of lens,66920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5742.3,,,,,,,fee schedule,2284.67,10136.31,
Extraction of lens,66920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6272.95,,,,,,,fee schedule,2284.67,10136.31,
Extraction of lens,66920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6595.12,,,,,,,fee schedule,2284.67,10136.31,
Extraction of lens,66920,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10136.31,,,,,,,fee schedule,2284.67,10136.31,APC 378
Extraction of lens,66920,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2398.9,,,,,,,fee schedule,2284.67,10136.31,APC
Extraction of lens,66920,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2376.06,,,,,,,fee schedule,2284.67,10136.31,APC
Extraction of lens,66920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2284.67,,,,,,,fee schedule,2284.67,10136.31,APC
Extraction of lens,66920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3495.55,,,,,,,fee schedule,2284.67,10136.31,Radiology
Extraction of lens,66920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3198.54,,,,,,,fee schedule,2284.67,10136.31,APC
Extraction of lens,66920,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3998.17,,,,,,,fee schedule,2284.67,10136.31,APC
Extraction of lens,66930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7163.67,,,,,,,fee schedule,4091.95,18154.62,
Extraction of lens,66930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5742.3,,,,,,,fee schedule,4091.95,18154.62,
Extraction of lens,66930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6272.95,,,,,,,fee schedule,4091.95,18154.62,
Extraction of lens,66930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6595.12,,,,,,,fee schedule,4091.95,18154.62,
Extraction of lens,66930,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18154.62,,,,,,,fee schedule,4091.95,18154.62,APC 378
Extraction of lens,66930,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4296.55,,,,,,,fee schedule,4091.95,18154.62,APC
Extraction of lens,66930,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4255.63,,,,,,,fee schedule,4091.95,18154.62,APC
Extraction of lens,66930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4091.95,,,,,,,fee schedule,4091.95,18154.62,APC
Extraction of lens,66930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6260.69,,,,,,,fee schedule,4091.95,18154.62,Radiology
Extraction of lens,66930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5728.74,,,,,,,fee schedule,4091.95,18154.62,APC
Extraction of lens,66930,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7160.92,,,,,,,fee schedule,4091.95,18154.62,APC
Extraction of lens,66940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3722.92,,,,,,,fee schedule,2284.67,10136.31,
Extraction of lens,66940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2984.25,,,,,,,fee schedule,2284.67,10136.31,
Extraction of lens,66940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3260.02,,,,,,,fee schedule,2284.67,10136.31,
Extraction of lens,66940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3427.45,,,,,,,fee schedule,2284.67,10136.31,
Extraction of lens,66940,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10136.31,,,,,,,fee schedule,2284.67,10136.31,APC 378
Extraction of lens,66940,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2398.9,,,,,,,fee schedule,2284.67,10136.31,APC
Extraction of lens,66940,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2376.06,,,,,,,fee schedule,2284.67,10136.31,APC
Extraction of lens,66940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2284.67,,,,,,,fee schedule,2284.67,10136.31,APC
Extraction of lens,66940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3495.55,,,,,,,fee schedule,2284.67,10136.31,Radiology
Extraction of lens,66940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3198.54,,,,,,,fee schedule,2284.67,10136.31,APC
Extraction of lens,66940,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3998.17,,,,,,,fee schedule,2284.67,10136.31,APC
Cataract surgery complex,66982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5956.07,,,,,,,fee schedule,2284.67,10136.31,
Cataract surgery complex,66982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4774.31,,,,,,,fee schedule,2284.67,10136.31,
Cataract surgery complex,66982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5215.5,,,,,,,fee schedule,2284.67,10136.31,
Cataract surgery complex,66982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5483.37,,,,,,,fee schedule,2284.67,10136.31,
Cataract surgery complex,66982,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10136.31,,,,,,,fee schedule,2284.67,10136.31,APC 378
Cataract surgery complex,66982,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2398.9,,,,,,,fee schedule,2284.67,10136.31,APC
Cataract surgery complex,66982,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2376.06,,,,,,,fee schedule,2284.67,10136.31,APC
Cataract surgery complex,66982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2284.67,,,,,,,fee schedule,2284.67,10136.31,APC
Cataract surgery complex,66982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3495.55,,,,,,,fee schedule,2284.67,10136.31,Radiology
Cataract surgery complex,66982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3198.54,,,,,,,fee schedule,2284.67,10136.31,APC
Cataract surgery complex,66982,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3998.17,,,,,,,fee schedule,2284.67,10136.31,APC
Cataract surg w/iol 1 stage,66983,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5956.07,,,,,,,fee schedule,2284.67,10136.31,
Cataract surg w/iol 1 stage,66983,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4774.31,,,,,,,fee schedule,2284.67,10136.31,
Cataract surg w/iol 1 stage,66983,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5215.5,,,,,,,fee schedule,2284.67,10136.31,
Cataract surg w/iol 1 stage,66983,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5483.37,,,,,,,fee schedule,2284.67,10136.31,
Cataract surg w/iol 1 stage,66983,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10136.31,,,,,,,fee schedule,2284.67,10136.31,APC 378
Cataract surg w/iol 1 stage,66983,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2398.9,,,,,,,fee schedule,2284.67,10136.31,APC
Cataract surg w/iol 1 stage,66983,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2376.06,,,,,,,fee schedule,2284.67,10136.31,APC
Cataract surg w/iol 1 stage,66983,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2284.67,,,,,,,fee schedule,2284.67,10136.31,APC
Cataract surg w/iol 1 stage,66983,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3495.55,,,,,,,fee schedule,2284.67,10136.31,Radiology
Cataract surg w/iol 1 stage,66983,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3198.54,,,,,,,fee schedule,2284.67,10136.31,APC
Cataract surg w/iol 1 stage,66983,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3998.17,,,,,,,fee schedule,2284.67,10136.31,APC
Cataract surg w/iol 1 stage,66984,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9854.26,,,,,,,fee schedule,2284.67,10136.31,
Cataract surg w/iol 1 stage,66984,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7899.05,,,,,,,fee schedule,2284.67,10136.31,
Cataract surg w/iol 1 stage,66984,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8628.99,,,,,,,fee schedule,2284.67,10136.31,
Cataract surg w/iol 1 stage,66984,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9072.17,,,,,,,fee schedule,2284.67,10136.31,
Cataract surg w/iol 1 stage,66984,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10136.31,,,,,,,fee schedule,2284.67,10136.31,APC 378
Cataract surg w/iol 1 stage,66984,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2398.9,,,,,,,fee schedule,2284.67,10136.31,APC
Cataract surg w/iol 1 stage,66984,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2376.06,,,,,,,fee schedule,2284.67,10136.31,APC
Cataract surg w/iol 1 stage,66984,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2284.67,,,,,,,fee schedule,2284.67,10136.31,APC
Cataract surg w/iol 1 stage,66984,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3495.55,,,,,,,fee schedule,2284.67,10136.31,Radiology
Cataract surg w/iol 1 stage,66984,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3198.54,,,,,,,fee schedule,2284.67,10136.31,APC
Cataract surg w/iol 1 stage,66984,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3998.17,,,,,,,fee schedule,2284.67,10136.31,APC
Insert lens prosthesis,66985,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5956.07,,,,,,,fee schedule,2284.67,10136.31,
Insert lens prosthesis,66985,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4774.31,,,,,,,fee schedule,2284.67,10136.31,
Insert lens prosthesis,66985,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5215.5,,,,,,,fee schedule,2284.67,10136.31,
Insert lens prosthesis,66985,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5483.37,,,,,,,fee schedule,2284.67,10136.31,
Insert lens prosthesis,66985,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10136.31,,,,,,,fee schedule,2284.67,10136.31,APC 378
Insert lens prosthesis,66985,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2398.9,,,,,,,fee schedule,2284.67,10136.31,APC
Insert lens prosthesis,66985,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2376.06,,,,,,,fee schedule,2284.67,10136.31,APC
Insert lens prosthesis,66985,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2284.67,,,,,,,fee schedule,2284.67,10136.31,APC
Insert lens prosthesis,66985,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3495.55,,,,,,,fee schedule,2284.67,10136.31,Radiology
Insert lens prosthesis,66985,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3198.54,,,,,,,fee schedule,2284.67,10136.31,APC
Insert lens prosthesis,66985,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3998.17,,,,,,,fee schedule,2284.67,10136.31,APC
Exchange lens prosthesis,66986,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4531.07,,,,,,,fee schedule,2284.67,10136.31,
Exchange lens prosthesis,66986,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3632.05,,,,,,,fee schedule,2284.67,10136.31,
Exchange lens prosthesis,66986,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3967.69,,,,,,,fee schedule,2284.67,10136.31,
Exchange lens prosthesis,66986,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4171.46,,,,,,,fee schedule,2284.67,10136.31,
Exchange lens prosthesis,66986,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10136.31,,,,,,,fee schedule,2284.67,10136.31,APC 378
Exchange lens prosthesis,66986,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2398.9,,,,,,,fee schedule,2284.67,10136.31,APC
Exchange lens prosthesis,66986,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2376.06,,,,,,,fee schedule,2284.67,10136.31,APC
Exchange lens prosthesis,66986,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2284.67,,,,,,,fee schedule,2284.67,10136.31,APC
Exchange lens prosthesis,66986,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3495.55,,,,,,,fee schedule,2284.67,10136.31,Radiology
Exchange lens prosthesis,66986,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3198.54,,,,,,,fee schedule,2284.67,10136.31,APC
Exchange lens prosthesis,66986,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3998.17,,,,,,,fee schedule,2284.67,10136.31,APC
Xcapsl ctrc rmvl cplx w/ecp,66987,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14433.29,,,,,,,fee schedule,4091.95,18154.62,
Xcapsl ctrc rmvl cplx w/ecp,66987,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11569.54,,,,,,,fee schedule,4091.95,18154.62,
Xcapsl ctrc rmvl cplx w/ecp,66987,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12638.67,,,,,,,fee schedule,4091.95,18154.62,
Xcapsl ctrc rmvl cplx w/ecp,66987,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13287.79,,,,,,,fee schedule,4091.95,18154.62,
Xcapsl ctrc rmvl cplx w/ecp,66987,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18154.62,,,,,,,fee schedule,4091.95,18154.62,APC 378
Xcapsl ctrc rmvl cplx w/ecp,66987,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4296.55,,,,,,,fee schedule,4091.95,18154.62,APC
Xcapsl ctrc rmvl cplx w/ecp,66987,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4255.63,,,,,,,fee schedule,4091.95,18154.62,APC
Xcapsl ctrc rmvl cplx w/ecp,66987,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4091.95,,,,,,,fee schedule,4091.95,18154.62,APC
Xcapsl ctrc rmvl cplx w/ecp,66987,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6260.69,,,,,,,fee schedule,4091.95,18154.62,Radiology
Xcapsl ctrc rmvl cplx w/ecp,66987,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5728.74,,,,,,,fee schedule,4091.95,18154.62,APC
Xcapsl ctrc rmvl cplx w/ecp,66987,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7160.92,,,,,,,fee schedule,4091.95,18154.62,APC
Xcapsl ctrc rmvl w/ecp,66988,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14433.29,,,,,,,fee schedule,4091.95,18154.62,
Xcapsl ctrc rmvl w/ecp,66988,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11569.54,,,,,,,fee schedule,4091.95,18154.62,
Xcapsl ctrc rmvl w/ecp,66988,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12638.67,,,,,,,fee schedule,4091.95,18154.62,
Xcapsl ctrc rmvl w/ecp,66988,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13287.79,,,,,,,fee schedule,4091.95,18154.62,
Xcapsl ctrc rmvl w/ecp,66988,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18154.62,,,,,,,fee schedule,4091.95,18154.62,APC 378
Xcapsl ctrc rmvl w/ecp,66988,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4296.55,,,,,,,fee schedule,4091.95,18154.62,APC
Xcapsl ctrc rmvl w/ecp,66988,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4255.63,,,,,,,fee schedule,4091.95,18154.62,APC
Xcapsl ctrc rmvl w/ecp,66988,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4091.95,,,,,,,fee schedule,4091.95,18154.62,APC
Xcapsl ctrc rmvl w/ecp,66988,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6260.69,,,,,,,fee schedule,4091.95,18154.62,Radiology
Xcapsl ctrc rmvl w/ecp,66988,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5728.74,,,,,,,fee schedule,4091.95,18154.62,APC
Xcapsl ctrc rmvl w/ecp,66988,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7160.92,,,,,,,fee schedule,4091.95,18154.62,APC
Xcpsl ctrc rmvl cplx insj 1+,66989,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16066.89,,,,,,,fee schedule,5267.92,23371.97,
Xcpsl ctrc rmvl cplx insj 1+,66989,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12879.02,,,,,,,fee schedule,5267.92,23371.97,
Xcpsl ctrc rmvl cplx insj 1+,66989,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14069.16,,,,,,,fee schedule,5267.92,23371.97,
Xcpsl ctrc rmvl cplx insj 1+,66989,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14791.74,,,,,,,fee schedule,5267.92,23371.97,
Xcpsl ctrc rmvl cplx insj 1+,66989,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23371.97,,,,,,,fee schedule,5267.92,23371.97,APC 378
Xcpsl ctrc rmvl cplx insj 1+,66989,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5531.31,,,,,,,fee schedule,5267.92,23371.97,APC
Xcpsl ctrc rmvl cplx insj 1+,66989,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5478.63,,,,,,,fee schedule,5267.92,23371.97,APC
Xcpsl ctrc rmvl cplx insj 1+,66989,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5267.92,,,,,,,fee schedule,5267.92,23371.97,APC
Xcpsl ctrc rmvl cplx insj 1+,66989,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8059.91,,,,,,,fee schedule,5267.92,23371.97,Radiology
Xcpsl ctrc rmvl cplx insj 1+,66989,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7375.09,,,,,,,fee schedule,5267.92,23371.97,APC
Xcpsl ctrc rmvl cplx insj 1+,66989,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9218.86,,,,,,,fee schedule,5267.92,23371.97,APC
Xcapsl ctrc rmvl insj 1+,66991,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16066.89,,,,,,,fee schedule,5267.92,23371.97,
Xcapsl ctrc rmvl insj 1+,66991,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12879.02,,,,,,,fee schedule,5267.92,23371.97,
Xcapsl ctrc rmvl insj 1+,66991,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14069.16,,,,,,,fee schedule,5267.92,23371.97,
Xcapsl ctrc rmvl insj 1+,66991,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14791.74,,,,,,,fee schedule,5267.92,23371.97,
Xcapsl ctrc rmvl insj 1+,66991,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23371.97,,,,,,,fee schedule,5267.92,23371.97,APC 378
Xcapsl ctrc rmvl insj 1+,66991,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5531.31,,,,,,,fee schedule,5267.92,23371.97,APC
Xcapsl ctrc rmvl insj 1+,66991,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5478.63,,,,,,,fee schedule,5267.92,23371.97,APC
Xcapsl ctrc rmvl insj 1+,66991,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5267.92,,,,,,,fee schedule,5267.92,23371.97,APC
Xcapsl ctrc rmvl insj 1+,66991,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8059.91,,,,,,,fee schedule,5267.92,23371.97,Radiology
Xcapsl ctrc rmvl insj 1+,66991,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7375.09,,,,,,,fee schedule,5267.92,23371.97,APC
Xcapsl ctrc rmvl insj 1+,66991,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9218.86,,,,,,,fee schedule,5267.92,23371.97,APC
Eye surgery procedure,66999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4425.05,,,,,,,fee schedule,2284.67,10136.31,
Eye surgery procedure,66999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3547.07,,,,,,,fee schedule,2284.67,10136.31,
Eye surgery procedure,66999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3874.85,,,,,,,fee schedule,2284.67,10136.31,
Eye surgery procedure,66999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4073.86,,,,,,,fee schedule,2284.67,10136.31,
Eye surgery procedure,66999,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10136.31,,,,,,,fee schedule,2284.67,10136.31,APC 378
Eye surgery procedure,66999,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2398.9,,,,,,,fee schedule,2284.67,10136.31,APC
Eye surgery procedure,66999,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2376.06,,,,,,,fee schedule,2284.67,10136.31,APC
Eye surgery procedure,66999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2284.67,,,,,,,fee schedule,2284.67,10136.31,APC
Eye surgery procedure,66999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3495.55,,,,,,,fee schedule,2284.67,10136.31,Radiology
Eye surgery procedure,66999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3198.54,,,,,,,fee schedule,2284.67,10136.31,APC
Eye surgery procedure,66999,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3998.17,,,,,,,fee schedule,2284.67,10136.31,APC
Partial removal of eye fluid,67005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6949.42,,,,,,,fee schedule,2284.67,10136.31,
Partial removal of eye fluid,67005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5570.56,,,,,,,fee schedule,2284.67,10136.31,
Partial removal of eye fluid,67005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6085.34,,,,,,,fee schedule,2284.67,10136.31,
Partial removal of eye fluid,67005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6397.88,,,,,,,fee schedule,2284.67,10136.31,
Partial removal of eye fluid,67005,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10136.31,,,,,,,fee schedule,2284.67,10136.31,APC 378
Partial removal of eye fluid,67005,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2398.9,,,,,,,fee schedule,2284.67,10136.31,APC
Partial removal of eye fluid,67005,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2376.06,,,,,,,fee schedule,2284.67,10136.31,APC
Partial removal of eye fluid,67005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2284.67,,,,,,,fee schedule,2284.67,10136.31,APC
Partial removal of eye fluid,67005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3495.55,,,,,,,fee schedule,2284.67,10136.31,Radiology
Partial removal of eye fluid,67005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3198.54,,,,,,,fee schedule,2284.67,10136.31,APC
Partial removal of eye fluid,67005,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3998.17,,,,,,,fee schedule,2284.67,10136.31,APC
Partial removal of eye fluid,67010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4531.07,,,,,,,fee schedule,2284.67,10136.31,
Partial removal of eye fluid,67010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3632.05,,,,,,,fee schedule,2284.67,10136.31,
Partial removal of eye fluid,67010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3967.69,,,,,,,fee schedule,2284.67,10136.31,
Partial removal of eye fluid,67010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4171.46,,,,,,,fee schedule,2284.67,10136.31,
Partial removal of eye fluid,67010,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10136.31,,,,,,,fee schedule,2284.67,10136.31,APC 378
Partial removal of eye fluid,67010,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2398.9,,,,,,,fee schedule,2284.67,10136.31,APC
Partial removal of eye fluid,67010,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2376.06,,,,,,,fee schedule,2284.67,10136.31,APC
Partial removal of eye fluid,67010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2284.67,,,,,,,fee schedule,2284.67,10136.31,APC
Partial removal of eye fluid,67010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3495.55,,,,,,,fee schedule,2284.67,10136.31,Radiology
Partial removal of eye fluid,67010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3198.54,,,,,,,fee schedule,2284.67,10136.31,APC
Partial removal of eye fluid,67010,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3998.17,,,,,,,fee schedule,2284.67,10136.31,APC
Release of eye fluid,67015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2864.69,,,,,,,fee schedule,2284.67,10136.31,
Release of eye fluid,67015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2296.3,,,,,,,fee schedule,2284.67,10136.31,
Release of eye fluid,67015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2508.5,,,,,,,fee schedule,2284.67,10136.31,
Release of eye fluid,67015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2637.34,,,,,,,fee schedule,2284.67,10136.31,
Release of eye fluid,67015,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10136.31,,,,,,,fee schedule,2284.67,10136.31,APC 378
Release of eye fluid,67015,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2398.9,,,,,,,fee schedule,2284.67,10136.31,APC
Release of eye fluid,67015,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2376.06,,,,,,,fee schedule,2284.67,10136.31,APC
Release of eye fluid,67015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2284.67,,,,,,,fee schedule,2284.67,10136.31,APC
Release of eye fluid,67015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3495.55,,,,,,,fee schedule,2284.67,10136.31,Radiology
Release of eye fluid,67015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3198.54,,,,,,,fee schedule,2284.67,10136.31,APC
Release of eye fluid,67015,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3998.17,,,,,,,fee schedule,2284.67,10136.31,APC
Replace eye fluid,67025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2502.52,,,,,,,fee schedule,2005.99,10136.31,
Replace eye fluid,67025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2005.99,,,,,,,fee schedule,2005.99,10136.31,
Replace eye fluid,67025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2191.36,,,,,,,fee schedule,2005.99,10136.31,
Replace eye fluid,67025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2303.91,,,,,,,fee schedule,2005.99,10136.31,
Replace eye fluid,67025,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10136.31,,,,,,,fee schedule,2005.99,10136.31,APC 378
Replace eye fluid,67025,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2398.9,,,,,,,fee schedule,2005.99,10136.31,APC
Replace eye fluid,67025,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2376.06,,,,,,,fee schedule,2005.99,10136.31,APC
Replace eye fluid,67025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2284.67,,,,,,,fee schedule,2005.99,10136.31,APC
Replace eye fluid,67025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3495.55,,,,,,,fee schedule,2005.99,10136.31,Radiology
Replace eye fluid,67025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3198.54,,,,,,,fee schedule,2005.99,10136.31,APC
Replace eye fluid,67025,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3998.17,,,,,,,fee schedule,2005.99,10136.31,APC
Implant eye drug system,67027,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11141.58,,,,,,,fee schedule,8930.95,61283.49,
Implant eye drug system,67027,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8930.95,,,,,,,fee schedule,8930.95,61283.49,
Implant eye drug system,67027,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9756.25,,,,,,,fee schedule,8930.95,61283.49,
Implant eye drug system,67027,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10257.32,,,,,,,fee schedule,8930.95,61283.49,
Implant eye drug system,67027,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,61283.49,,,,,,,fee schedule,8930.95,61283.49,APC 378
Implant eye drug system,67027,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14503.62,,,,,,,fee schedule,8930.95,61283.49,APC
Implant eye drug system,67027,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,14365.49,,,,,,,fee schedule,8930.95,61283.49,APC
Implant eye drug system,67027,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13812.97,,,,,,,fee schedule,8930.95,61283.49,APC
Implant eye drug system,67027,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21133.85,,,,,,,fee schedule,8930.95,61283.49,Radiology
Implant eye drug system,67027,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19338.16,,,,,,,fee schedule,8930.95,61283.49,APC
Implant eye drug system,67027,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,24172.71,,,,,,,fee schedule,8930.95,61283.49,APC
Injection eye drug,67028,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4425.05,,,,,,,fee schedule,326.99,4425.05,
Injection eye drug,67028,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3547.07,,,,,,,fee schedule,326.99,4425.05,
Injection eye drug,67028,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3874.85,,,,,,,fee schedule,326.99,4425.05,
Injection eye drug,67028,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4073.86,,,,,,,fee schedule,326.99,4425.05,
Injection eye drug,67028,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1450.75,,,,,,,fee schedule,326.99,4425.05,APC 378
Injection eye drug,67028,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,343.34,,,,,,,fee schedule,326.99,4425.05,APC
Injection eye drug,67028,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,340.07,,,,,,,fee schedule,326.99,4425.05,APC
Injection eye drug,67028,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,326.99,,,,,,,fee schedule,326.99,4425.05,APC
Injection eye drug,67028,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,500.3,,,,,,,fee schedule,326.99,4425.05,Radiology
Injection eye drug,67028,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,457.79,,,,,,,fee schedule,326.99,4425.05,APC
Injection eye drug,67028,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,572.24,,,,,,,fee schedule,326.99,4425.05,APC
Incise inner eye strands,67030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4551.01,,,,,,,fee schedule,2284.67,10136.31,
Incise inner eye strands,67030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3648.03,,,,,,,fee schedule,2284.67,10136.31,
Incise inner eye strands,67030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3985.14,,,,,,,fee schedule,2284.67,10136.31,
Incise inner eye strands,67030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4189.82,,,,,,,fee schedule,2284.67,10136.31,
Incise inner eye strands,67030,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10136.31,,,,,,,fee schedule,2284.67,10136.31,APC 378
Incise inner eye strands,67030,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2398.9,,,,,,,fee schedule,2284.67,10136.31,APC
Incise inner eye strands,67030,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2376.06,,,,,,,fee schedule,2284.67,10136.31,APC
Incise inner eye strands,67030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2284.67,,,,,,,fee schedule,2284.67,10136.31,APC
Incise inner eye strands,67030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3495.55,,,,,,,fee schedule,2284.67,10136.31,Radiology
Incise inner eye strands,67030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3198.54,,,,,,,fee schedule,2284.67,10136.31,APC
Incise inner eye strands,67030,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3998.17,,,,,,,fee schedule,2284.67,10136.31,APC
Laser surgery eye strands,67031,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1297.83,,,,,,,fee schedule,544.48,2415.67,
Laser surgery eye strands,67031,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1040.32,,,,,,,fee schedule,544.48,2415.67,
Laser surgery eye strands,67031,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1136.46,,,,,,,fee schedule,544.48,2415.67,
Laser surgery eye strands,67031,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1194.82,,,,,,,fee schedule,544.48,2415.67,
Laser surgery eye strands,67031,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2415.67,,,,,,,fee schedule,544.48,2415.67,APC 378
Laser surgery eye strands,67031,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,571.7,,,,,,,fee schedule,544.48,2415.67,APC
Laser surgery eye strands,67031,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,566.26,,,,,,,fee schedule,544.48,2415.67,APC
Laser surgery eye strands,67031,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,544.48,,,,,,,fee schedule,544.48,2415.67,APC
Laser surgery eye strands,67031,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,833.05,,,,,,,fee schedule,544.48,2415.67,Radiology
Laser surgery eye strands,67031,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,762.27,,,,,,,fee schedule,544.48,2415.67,APC
Laser surgery eye strands,67031,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,952.84,,,,,,,fee schedule,544.48,2415.67,APC
Removal of inner eye fluid,67036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4991.85,,,,,,,fee schedule,4001.4,18154.62,
Removal of inner eye fluid,67036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4001.4,,,,,,,fee schedule,4001.4,18154.62,
Removal of inner eye fluid,67036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4371.17,,,,,,,fee schedule,4001.4,18154.62,
Removal of inner eye fluid,67036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4595.67,,,,,,,fee schedule,4001.4,18154.62,
Removal of inner eye fluid,67036,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18154.62,,,,,,,fee schedule,4001.4,18154.62,APC 378
Removal of inner eye fluid,67036,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4296.55,,,,,,,fee schedule,4001.4,18154.62,APC
Removal of inner eye fluid,67036,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4255.63,,,,,,,fee schedule,4001.4,18154.62,APC
Removal of inner eye fluid,67036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4091.95,,,,,,,fee schedule,4001.4,18154.62,APC
Removal of inner eye fluid,67036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6260.69,,,,,,,fee schedule,4001.4,18154.62,Radiology
Removal of inner eye fluid,67036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5728.74,,,,,,,fee schedule,4001.4,18154.62,APC
Removal of inner eye fluid,67036,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7160.92,,,,,,,fee schedule,4001.4,18154.62,APC
Laser treatment of retina,67039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5764.35,,,,,,,fee schedule,4091.95,18154.62,
Laser treatment of retina,67039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4620.63,,,,,,,fee schedule,4091.95,18154.62,
Laser treatment of retina,67039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5047.61,,,,,,,fee schedule,4091.95,18154.62,
Laser treatment of retina,67039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5306.86,,,,,,,fee schedule,4091.95,18154.62,
Laser treatment of retina,67039,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18154.62,,,,,,,fee schedule,4091.95,18154.62,APC 378
Laser treatment of retina,67039,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4296.55,,,,,,,fee schedule,4091.95,18154.62,APC
Laser treatment of retina,67039,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4255.63,,,,,,,fee schedule,4091.95,18154.62,APC
Laser treatment of retina,67039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4091.95,,,,,,,fee schedule,4091.95,18154.62,APC
Laser treatment of retina,67039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6260.69,,,,,,,fee schedule,4091.95,18154.62,Radiology
Laser treatment of retina,67039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5728.74,,,,,,,fee schedule,4091.95,18154.62,APC
Laser treatment of retina,67039,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7160.92,,,,,,,fee schedule,4091.95,18154.62,APC
Laser treatment of retina,67040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5757.35,,,,,,,fee schedule,4091.95,18154.62,
Laser treatment of retina,67040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4615.02,,,,,,,fee schedule,4091.95,18154.62,
Laser treatment of retina,67040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5041.49,,,,,,,fee schedule,4091.95,18154.62,
Laser treatment of retina,67040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5300.42,,,,,,,fee schedule,4091.95,18154.62,
Laser treatment of retina,67040,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18154.62,,,,,,,fee schedule,4091.95,18154.62,APC 378
Laser treatment of retina,67040,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4296.55,,,,,,,fee schedule,4091.95,18154.62,APC
Laser treatment of retina,67040,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4255.63,,,,,,,fee schedule,4091.95,18154.62,APC
Laser treatment of retina,67040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4091.95,,,,,,,fee schedule,4091.95,18154.62,APC
Laser treatment of retina,67040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6260.69,,,,,,,fee schedule,4091.95,18154.62,Radiology
Laser treatment of retina,67040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5728.74,,,,,,,fee schedule,4091.95,18154.62,APC
Laser treatment of retina,67040,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7160.92,,,,,,,fee schedule,4091.95,18154.62,APC
Vit for macular pucker,67041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7189.69,,,,,,,fee schedule,4091.95,18154.62,
Vit for macular pucker,67041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5763.16,,,,,,,fee schedule,4091.95,18154.62,
Vit for macular pucker,67041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6295.73,,,,,,,fee schedule,4091.95,18154.62,
Vit for macular pucker,67041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6619.08,,,,,,,fee schedule,4091.95,18154.62,
Vit for macular pucker,67041,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18154.62,,,,,,,fee schedule,4091.95,18154.62,APC 378
Vit for macular pucker,67041,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4296.55,,,,,,,fee schedule,4091.95,18154.62,APC
Vit for macular pucker,67041,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4255.63,,,,,,,fee schedule,4091.95,18154.62,APC
Vit for macular pucker,67041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4091.95,,,,,,,fee schedule,4091.95,18154.62,APC
Vit for macular pucker,67041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6260.69,,,,,,,fee schedule,4091.95,18154.62,Radiology
Vit for macular pucker,67041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5728.74,,,,,,,fee schedule,4091.95,18154.62,APC
Vit for macular pucker,67041,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7160.92,,,,,,,fee schedule,4091.95,18154.62,APC
Vit for macular hole,67042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5570.64,,,,,,,fee schedule,4091.95,18154.62,
Vit for macular hole,67042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4465.35,,,,,,,fee schedule,4091.95,18154.62,
Vit for macular hole,67042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4877.99,,,,,,,fee schedule,4091.95,18154.62,
Vit for macular hole,67042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5128.52,,,,,,,fee schedule,4091.95,18154.62,
Vit for macular hole,67042,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18154.62,,,,,,,fee schedule,4091.95,18154.62,APC 378
Vit for macular hole,67042,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4296.55,,,,,,,fee schedule,4091.95,18154.62,APC
Vit for macular hole,67042,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4255.63,,,,,,,fee schedule,4091.95,18154.62,APC
Vit for macular hole,67042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4091.95,,,,,,,fee schedule,4091.95,18154.62,APC
Vit for macular hole,67042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6260.69,,,,,,,fee schedule,4091.95,18154.62,Radiology
Vit for macular hole,67042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5728.74,,,,,,,fee schedule,4091.95,18154.62,APC
Vit for macular hole,67042,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7160.92,,,,,,,fee schedule,4091.95,18154.62,APC
Vit for membrane dissect,67043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5183.22,,,,,,,fee schedule,4091.95,18154.62,
Vit for membrane dissect,67043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4154.8,,,,,,,fee schedule,4091.95,18154.62,
Vit for membrane dissect,67043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4538.74,,,,,,,fee schedule,4091.95,18154.62,
Vit for membrane dissect,67043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4771.85,,,,,,,fee schedule,4091.95,18154.62,
Vit for membrane dissect,67043,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18154.62,,,,,,,fee schedule,4091.95,18154.62,APC 378
Vit for membrane dissect,67043,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4296.55,,,,,,,fee schedule,4091.95,18154.62,APC
Vit for membrane dissect,67043,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4255.63,,,,,,,fee schedule,4091.95,18154.62,APC
Vit for membrane dissect,67043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4091.95,,,,,,,fee schedule,4091.95,18154.62,APC
Vit for membrane dissect,67043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6260.69,,,,,,,fee schedule,4091.95,18154.62,Radiology
Vit for membrane dissect,67043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5728.74,,,,,,,fee schedule,4091.95,18154.62,APC
Vit for membrane dissect,67043,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7160.92,,,,,,,fee schedule,4091.95,18154.62,APC
Repair detached retina crtx,67101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4765.13,,,,,,,fee schedule,2284.67,10136.31,
Repair detached retina crtx,67101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3819.67,,,,,,,fee schedule,2284.67,10136.31,
Repair detached retina crtx,67101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4172.64,,,,,,,fee schedule,2284.67,10136.31,
Repair detached retina crtx,67101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4386.95,,,,,,,fee schedule,2284.67,10136.31,
Repair detached retina crtx,67101,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10136.31,,,,,,,fee schedule,2284.67,10136.31,APC 378
Repair detached retina crtx,67101,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2398.9,,,,,,,fee schedule,2284.67,10136.31,APC
Repair detached retina crtx,67101,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2376.06,,,,,,,fee schedule,2284.67,10136.31,APC
Repair detached retina crtx,67101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2284.67,,,,,,,fee schedule,2284.67,10136.31,APC
Repair detached retina crtx,67101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3495.55,,,,,,,fee schedule,2284.67,10136.31,Radiology
Repair detached retina crtx,67101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3198.54,,,,,,,fee schedule,2284.67,10136.31,APC
Repair detached retina crtx,67101,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3998.17,,,,,,,fee schedule,2284.67,10136.31,APC
Repair detached retina pc,67105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4727.61,,,,,,,fee schedule,544.48,4727.61,
Repair detached retina pc,67105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3789.59,,,,,,,fee schedule,544.48,4727.61,
Repair detached retina pc,67105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4139.79,,,,,,,fee schedule,544.48,4727.61,
Repair detached retina pc,67105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4352.4,,,,,,,fee schedule,544.48,4727.61,
Repair detached retina pc,67105,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2415.67,,,,,,,fee schedule,544.48,4727.61,APC 378
Repair detached retina pc,67105,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,571.7,,,,,,,fee schedule,544.48,4727.61,APC
Repair detached retina pc,67105,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,566.26,,,,,,,fee schedule,544.48,4727.61,APC
Repair detached retina pc,67105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,544.48,,,,,,,fee schedule,544.48,4727.61,APC
Repair detached retina pc,67105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,833.05,,,,,,,fee schedule,544.48,4727.61,Radiology
Repair detached retina pc,67105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,762.27,,,,,,,fee schedule,544.48,4727.61,APC
Repair detached retina pc,67105,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,952.84,,,,,,,fee schedule,544.48,4727.61,APC
Repair detached retina,67107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8594.03,,,,,,,fee schedule,4091.95,18154.62,
Repair detached retina,67107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6888.87,,,,,,,fee schedule,4091.95,18154.62,
Repair detached retina,67107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7525.46,,,,,,,fee schedule,4091.95,18154.62,
Repair detached retina,67107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7911.97,,,,,,,fee schedule,4091.95,18154.62,
Repair detached retina,67107,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18154.62,,,,,,,fee schedule,4091.95,18154.62,APC 378
Repair detached retina,67107,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4296.55,,,,,,,fee schedule,4091.95,18154.62,APC
Repair detached retina,67107,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4255.63,,,,,,,fee schedule,4091.95,18154.62,APC
Repair detached retina,67107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4091.95,,,,,,,fee schedule,4091.95,18154.62,APC
Repair detached retina,67107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6260.69,,,,,,,fee schedule,4091.95,18154.62,Radiology
Repair detached retina,67107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5728.74,,,,,,,fee schedule,4091.95,18154.62,APC
Repair detached retina,67107,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7160.92,,,,,,,fee schedule,4091.95,18154.62,APC
Repair detached retina,67108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6603.05,,,,,,,fee schedule,4091.95,18154.62,
Repair detached retina,67108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5292.92,,,,,,,fee schedule,4091.95,18154.62,
Repair detached retina,67108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5782.04,,,,,,,fee schedule,4091.95,18154.62,
Repair detached retina,67108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6079,,,,,,,fee schedule,4091.95,18154.62,
Repair detached retina,67108,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18154.62,,,,,,,fee schedule,4091.95,18154.62,APC 378
Repair detached retina,67108,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4296.55,,,,,,,fee schedule,4091.95,18154.62,APC
Repair detached retina,67108,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4255.63,,,,,,,fee schedule,4091.95,18154.62,APC
Repair detached retina,67108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4091.95,,,,,,,fee schedule,4091.95,18154.62,APC
Repair detached retina,67108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6260.69,,,,,,,fee schedule,4091.95,18154.62,Radiology
Repair detached retina,67108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5728.74,,,,,,,fee schedule,4091.95,18154.62,APC
Repair detached retina,67108,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7160.92,,,,,,,fee schedule,4091.95,18154.62,APC
Repair detached retina,67110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2396.55,,,,,,,fee schedule,1921.05,10136.31,
Repair detached retina,67110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1921.05,,,,,,,fee schedule,1921.05,10136.31,
Repair detached retina,67110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2098.57,,,,,,,fee schedule,1921.05,10136.31,
Repair detached retina,67110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2206.35,,,,,,,fee schedule,1921.05,10136.31,
Repair detached retina,67110,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10136.31,,,,,,,fee schedule,1921.05,10136.31,APC 378
Repair detached retina,67110,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2398.9,,,,,,,fee schedule,1921.05,10136.31,APC
Repair detached retina,67110,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2376.06,,,,,,,fee schedule,1921.05,10136.31,APC
Repair detached retina,67110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2284.67,,,,,,,fee schedule,1921.05,10136.31,APC
Repair detached retina,67110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3495.55,,,,,,,fee schedule,1921.05,10136.31,Radiology
Repair detached retina,67110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3198.54,,,,,,,fee schedule,1921.05,10136.31,APC
Repair detached retina,67110,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3998.17,,,,,,,fee schedule,1921.05,10136.31,APC
Repair retinal detach cplx,67113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7421.96,,,,,,,fee schedule,5267.92,23371.97,
Repair retinal detach cplx,67113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5949.35,,,,,,,fee schedule,5267.92,23371.97,
Repair retinal detach cplx,67113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6499.12,,,,,,,fee schedule,5267.92,23371.97,
Repair retinal detach cplx,67113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6832.91,,,,,,,fee schedule,5267.92,23371.97,
Repair retinal detach cplx,67113,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23371.97,,,,,,,fee schedule,5267.92,23371.97,APC 378
Repair retinal detach cplx,67113,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5531.31,,,,,,,fee schedule,5267.92,23371.97,APC
Repair retinal detach cplx,67113,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5478.63,,,,,,,fee schedule,5267.92,23371.97,APC
Repair retinal detach cplx,67113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5267.92,,,,,,,fee schedule,5267.92,23371.97,APC
Repair retinal detach cplx,67113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8059.91,,,,,,,fee schedule,5267.92,23371.97,Radiology
Repair retinal detach cplx,67113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7375.09,,,,,,,fee schedule,5267.92,23371.97,APC
Repair retinal detach cplx,67113,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9218.86,,,,,,,fee schedule,5267.92,23371.97,APC
Release encircling material,67115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4551.01,,,,,,,fee schedule,3648.03,18154.62,
Release encircling material,67115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3648.03,,,,,,,fee schedule,3648.03,18154.62,
Release encircling material,67115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3985.14,,,,,,,fee schedule,3648.03,18154.62,
Release encircling material,67115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4189.82,,,,,,,fee schedule,3648.03,18154.62,
Release encircling material,67115,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18154.62,,,,,,,fee schedule,3648.03,18154.62,APC 378
Release encircling material,67115,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4296.55,,,,,,,fee schedule,3648.03,18154.62,APC
Release encircling material,67115,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4255.63,,,,,,,fee schedule,3648.03,18154.62,APC
Release encircling material,67115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4091.95,,,,,,,fee schedule,3648.03,18154.62,APC
Release encircling material,67115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6260.69,,,,,,,fee schedule,3648.03,18154.62,Radiology
Release encircling material,67115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5728.74,,,,,,,fee schedule,3648.03,18154.62,APC
Release encircling material,67115,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7160.92,,,,,,,fee schedule,3648.03,18154.62,APC
Remove eye implant material,67120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4551.01,,,,,,,fee schedule,2284.67,10136.31,
Remove eye implant material,67120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3648.03,,,,,,,fee schedule,2284.67,10136.31,
Remove eye implant material,67120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3985.14,,,,,,,fee schedule,2284.67,10136.31,
Remove eye implant material,67120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4189.82,,,,,,,fee schedule,2284.67,10136.31,
Remove eye implant material,67120,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10136.31,,,,,,,fee schedule,2284.67,10136.31,APC 378
Remove eye implant material,67120,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2398.9,,,,,,,fee schedule,2284.67,10136.31,APC
Remove eye implant material,67120,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2376.06,,,,,,,fee schedule,2284.67,10136.31,APC
Remove eye implant material,67120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2284.67,,,,,,,fee schedule,2284.67,10136.31,APC
Remove eye implant material,67120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3495.55,,,,,,,fee schedule,2284.67,10136.31,Radiology
Remove eye implant material,67120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3198.54,,,,,,,fee schedule,2284.67,10136.31,APC
Remove eye implant material,67120,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3998.17,,,,,,,fee schedule,2284.67,10136.31,APC
Remove eye implant material,67121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6949.42,,,,,,,fee schedule,2284.67,10136.31,
Remove eye implant material,67121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5570.56,,,,,,,fee schedule,2284.67,10136.31,
Remove eye implant material,67121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6085.34,,,,,,,fee schedule,2284.67,10136.31,
Remove eye implant material,67121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6397.88,,,,,,,fee schedule,2284.67,10136.31,
Remove eye implant material,67121,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10136.31,,,,,,,fee schedule,2284.67,10136.31,APC 378
Remove eye implant material,67121,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2398.9,,,,,,,fee schedule,2284.67,10136.31,APC
Remove eye implant material,67121,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2376.06,,,,,,,fee schedule,2284.67,10136.31,APC
Remove eye implant material,67121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2284.67,,,,,,,fee schedule,2284.67,10136.31,APC
Remove eye implant material,67121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3495.55,,,,,,,fee schedule,2284.67,10136.31,Radiology
Remove eye implant material,67121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3198.54,,,,,,,fee schedule,2284.67,10136.31,APC
Remove eye implant material,67121,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3998.17,,,,,,,fee schedule,2284.67,10136.31,APC
Treatment of retina,67141,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1031.49,,,,,,,fee schedule,314.22,1394.09,
Treatment of retina,67141,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,826.83,,,,,,,fee schedule,314.22,1394.09,
Treatment of retina,67141,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,903.23,,,,,,,fee schedule,314.22,1394.09,
Treatment of retina,67141,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,949.62,,,,,,,fee schedule,314.22,1394.09,
Treatment of retina,67141,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1394.09,,,,,,,fee schedule,314.22,1394.09,APC 378
Treatment of retina,67141,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,329.93,,,,,,,fee schedule,314.22,1394.09,APC
Treatment of retina,67141,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,326.79,,,,,,,fee schedule,314.22,1394.09,APC
Treatment of retina,67141,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,314.22,,,,,,,fee schedule,314.22,1394.09,APC
Treatment of retina,67141,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,480.76,,,,,,,fee schedule,314.22,1394.09,Radiology
Treatment of retina,67141,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,439.91,,,,,,,fee schedule,314.22,1394.09,APC
Treatment of retina,67141,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,549.89,,,,,,,fee schedule,314.22,1394.09,APC
Treatment of retina,67145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2708.63,,,,,,,fee schedule,544.48,2708.63,
Treatment of retina,67145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2171.2,,,,,,,fee schedule,544.48,2708.63,
Treatment of retina,67145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2371.84,,,,,,,fee schedule,544.48,2708.63,
Treatment of retina,67145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2493.66,,,,,,,fee schedule,544.48,2708.63,
Treatment of retina,67145,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2415.67,,,,,,,fee schedule,544.48,2708.63,APC 378
Treatment of retina,67145,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,571.7,,,,,,,fee schedule,544.48,2708.63,APC
Treatment of retina,67145,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,566.26,,,,,,,fee schedule,544.48,2708.63,APC
Treatment of retina,67145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,544.48,,,,,,,fee schedule,544.48,2708.63,APC
Treatment of retina,67145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,833.05,,,,,,,fee schedule,544.48,2708.63,Radiology
Treatment of retina,67145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,762.27,,,,,,,fee schedule,544.48,2708.63,APC
Treatment of retina,67145,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,952.84,,,,,,,fee schedule,544.48,2708.63,APC
Treatment of retinal lesion,67208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4551.01,,,,,,,fee schedule,314.22,4551.01,
Treatment of retinal lesion,67208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3648.03,,,,,,,fee schedule,314.22,4551.01,
Treatment of retinal lesion,67208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3985.14,,,,,,,fee schedule,314.22,4551.01,
Treatment of retinal lesion,67208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4189.82,,,,,,,fee schedule,314.22,4551.01,
Treatment of retinal lesion,67208,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1394.09,,,,,,,fee schedule,314.22,4551.01,APC 378
Treatment of retinal lesion,67208,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,329.93,,,,,,,fee schedule,314.22,4551.01,APC
Treatment of retinal lesion,67208,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,326.79,,,,,,,fee schedule,314.22,4551.01,APC
Treatment of retinal lesion,67208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,314.22,,,,,,,fee schedule,314.22,4551.01,APC
Treatment of retinal lesion,67208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,480.76,,,,,,,fee schedule,314.22,4551.01,Radiology
Treatment of retinal lesion,67208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,439.91,,,,,,,fee schedule,314.22,4551.01,APC
Treatment of retinal lesion,67208,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,549.89,,,,,,,fee schedule,314.22,4551.01,APC
Treatment of retinal lesion,67210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1297.83,,,,,,,fee schedule,544.48,2415.67,
Treatment of retinal lesion,67210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1040.32,,,,,,,fee schedule,544.48,2415.67,
Treatment of retinal lesion,67210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1136.46,,,,,,,fee schedule,544.48,2415.67,
Treatment of retinal lesion,67210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1194.82,,,,,,,fee schedule,544.48,2415.67,
Treatment of retinal lesion,67210,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2415.67,,,,,,,fee schedule,544.48,2415.67,APC 378
Treatment of retinal lesion,67210,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,571.7,,,,,,,fee schedule,544.48,2415.67,APC
Treatment of retinal lesion,67210,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,566.26,,,,,,,fee schedule,544.48,2415.67,APC
Treatment of retinal lesion,67210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,544.48,,,,,,,fee schedule,544.48,2415.67,APC
Treatment of retinal lesion,67210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,833.05,,,,,,,fee schedule,544.48,2415.67,Radiology
Treatment of retinal lesion,67210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,762.27,,,,,,,fee schedule,544.48,2415.67,APC
Treatment of retinal lesion,67210,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,952.84,,,,,,,fee schedule,544.48,2415.67,APC
Treatment of retinal lesion,67218,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4551.01,,,,,,,fee schedule,3648.03,17267.29,
Treatment of retinal lesion,67218,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3648.03,,,,,,,fee schedule,3648.03,17267.29,
Treatment of retinal lesion,67218,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3985.14,,,,,,,fee schedule,3648.03,17267.29,
Treatment of retinal lesion,67218,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4189.82,,,,,,,fee schedule,3648.03,17267.29,
Treatment of retinal lesion,67218,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17267.29,,,,,,,fee schedule,3648.03,17267.29,APC 378
Treatment of retinal lesion,67218,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4086.55,,,,,,,fee schedule,3648.03,17267.29,APC
Treatment of retinal lesion,67218,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4047.63,,,,,,,fee schedule,3648.03,17267.29,APC
Treatment of retinal lesion,67218,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3891.96,,,,,,,fee schedule,3648.03,17267.29,APC
Treatment of retinal lesion,67218,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5954.69,,,,,,,fee schedule,3648.03,17267.29,Radiology
Treatment of retinal lesion,67218,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5448.74,,,,,,,fee schedule,3648.03,17267.29,APC
Treatment of retinal lesion,67218,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6810.92,,,,,,,fee schedule,3648.03,17267.29,APC
Treatment of choroid lesion,67220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1031.49,,,,,,,fee schedule,544.48,2415.67,
Treatment of choroid lesion,67220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,826.83,,,,,,,fee schedule,544.48,2415.67,
Treatment of choroid lesion,67220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,903.23,,,,,,,fee schedule,544.48,2415.67,
Treatment of choroid lesion,67220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,949.62,,,,,,,fee schedule,544.48,2415.67,
Treatment of choroid lesion,67220,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2415.67,,,,,,,fee schedule,544.48,2415.67,APC 378
Treatment of choroid lesion,67220,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,571.7,,,,,,,fee schedule,544.48,2415.67,APC
Treatment of choroid lesion,67220,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,566.26,,,,,,,fee schedule,544.48,2415.67,APC
Treatment of choroid lesion,67220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,544.48,,,,,,,fee schedule,544.48,2415.67,APC
Treatment of choroid lesion,67220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,833.05,,,,,,,fee schedule,544.48,2415.67,Radiology
Treatment of choroid lesion,67220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,762.27,,,,,,,fee schedule,544.48,2415.67,APC
Treatment of choroid lesion,67220,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,952.84,,,,,,,fee schedule,544.48,2415.67,APC
Ocular Photodynamic Ther,67221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1031.49,,,,,,,fee schedule,544.48,2415.67,
Ocular Photodynamic Ther,67221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,826.83,,,,,,,fee schedule,544.48,2415.67,
Ocular Photodynamic Ther,67221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,903.23,,,,,,,fee schedule,544.48,2415.67,
Ocular Photodynamic Ther,67221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,949.62,,,,,,,fee schedule,544.48,2415.67,
Ocular Photodynamic Ther,67221,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2415.67,,,,,,,fee schedule,544.48,2415.67,APC 378
Ocular Photodynamic Ther,67221,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,571.7,,,,,,,fee schedule,544.48,2415.67,APC
Ocular Photodynamic Ther,67221,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,566.26,,,,,,,fee schedule,544.48,2415.67,APC
Ocular Photodynamic Ther,67221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,544.48,,,,,,,fee schedule,544.48,2415.67,APC
Ocular Photodynamic Ther,67221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,833.05,,,,,,,fee schedule,544.48,2415.67,Radiology
Ocular Photodynamic Ther,67221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,762.27,,,,,,,fee schedule,544.48,2415.67,APC
Ocular Photodynamic Ther,67221,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,952.84,,,,,,,fee schedule,544.48,2415.67,APC
Eye photodynamic ther add-on,67225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1031.49,,,,,,,fee schedule,826.83,1031.49,
Eye photodynamic ther add-on,67225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,826.83,,,,,,,fee schedule,826.83,1031.49,
Eye photodynamic ther add-on,67225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,903.23,,,,,,,fee schedule,826.83,1031.49,
Eye photodynamic ther add-on,67225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,949.62,,,,,,,fee schedule,826.83,1031.49,
Dstrj extensive retinopathy,67227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2305.87,,,,,,,fee schedule,1848.36,17267.29,
Dstrj extensive retinopathy,67227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1848.36,,,,,,,fee schedule,1848.36,17267.29,
Dstrj extensive retinopathy,67227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2019.16,,,,,,,fee schedule,1848.36,17267.29,
Dstrj extensive retinopathy,67227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2122.87,,,,,,,fee schedule,1848.36,17267.29,
Dstrj extensive retinopathy,67227,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17267.29,,,,,,,fee schedule,1848.36,17267.29,APC 378
Dstrj extensive retinopathy,67227,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4086.55,,,,,,,fee schedule,1848.36,17267.29,APC
Dstrj extensive retinopathy,67227,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4047.63,,,,,,,fee schedule,1848.36,17267.29,APC
Dstrj extensive retinopathy,67227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3891.96,,,,,,,fee schedule,1848.36,17267.29,APC
Dstrj extensive retinopathy,67227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5954.69,,,,,,,fee schedule,1848.36,17267.29,Radiology
Dstrj extensive retinopathy,67227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5448.74,,,,,,,fee schedule,1848.36,17267.29,APC
Dstrj extensive retinopathy,67227,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6810.92,,,,,,,fee schedule,1848.36,17267.29,APC
Treatment x10sv retinopathy,67228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1297.83,,,,,,,fee schedule,544.48,2415.67,
Treatment x10sv retinopathy,67228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1040.32,,,,,,,fee schedule,544.48,2415.67,
Treatment x10sv retinopathy,67228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1136.46,,,,,,,fee schedule,544.48,2415.67,
Treatment x10sv retinopathy,67228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1194.82,,,,,,,fee schedule,544.48,2415.67,
Treatment x10sv retinopathy,67228,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2415.67,,,,,,,fee schedule,544.48,2415.67,APC 378
Treatment x10sv retinopathy,67228,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,571.7,,,,,,,fee schedule,544.48,2415.67,APC
Treatment x10sv retinopathy,67228,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,566.26,,,,,,,fee schedule,544.48,2415.67,APC
Treatment x10sv retinopathy,67228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,544.48,,,,,,,fee schedule,544.48,2415.67,APC
Treatment x10sv retinopathy,67228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,833.05,,,,,,,fee schedule,544.48,2415.67,Radiology
Treatment x10sv retinopathy,67228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,762.27,,,,,,,fee schedule,544.48,2415.67,APC
Treatment x10sv retinopathy,67228,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,952.84,,,,,,,fee schedule,544.48,2415.67,APC
Tr retinal les preterm inf,67229,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1297.83,,,,,,,fee schedule,544.48,2415.67,
Tr retinal les preterm inf,67229,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1040.32,,,,,,,fee schedule,544.48,2415.67,
Tr retinal les preterm inf,67229,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1136.46,,,,,,,fee schedule,544.48,2415.67,
Tr retinal les preterm inf,67229,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1194.82,,,,,,,fee schedule,544.48,2415.67,
Tr retinal les preterm inf,67229,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2415.67,,,,,,,fee schedule,544.48,2415.67,APC 378
Tr retinal les preterm inf,67229,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,571.7,,,,,,,fee schedule,544.48,2415.67,APC
Tr retinal les preterm inf,67229,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,566.26,,,,,,,fee schedule,544.48,2415.67,APC
Tr retinal les preterm inf,67229,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,544.48,,,,,,,fee schedule,544.48,2415.67,APC
Tr retinal les preterm inf,67229,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,833.05,,,,,,,fee schedule,544.48,2415.67,Radiology
Tr retinal les preterm inf,67229,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,762.27,,,,,,,fee schedule,544.48,2415.67,APC
Tr retinal les preterm inf,67229,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,952.84,,,,,,,fee schedule,544.48,2415.67,APC
Reinforce eye wall,67250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4674.69,,,,,,,fee schedule,2353.63,10442.27,
Reinforce eye wall,67250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3747.17,,,,,,,fee schedule,2353.63,10442.27,
Reinforce eye wall,67250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4093.44,,,,,,,fee schedule,2353.63,10442.27,
Reinforce eye wall,67250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4303.68,,,,,,,fee schedule,2353.63,10442.27,
Reinforce eye wall,67250,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2353.63,10442.27,APC 378
Reinforce eye wall,67250,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2353.63,10442.27,APC
Reinforce eye wall,67250,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2353.63,10442.27,APC
Reinforce eye wall,67250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2353.63,10442.27,APC
Reinforce eye wall,67250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2353.63,10442.27,Radiology
Reinforce eye wall,67250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2353.63,10442.27,APC
Reinforce eye wall,67250,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2353.63,10442.27,APC
Reinforce/graft eye wall,67255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6949.42,,,,,,,fee schedule,4091.95,18154.62,
Reinforce/graft eye wall,67255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5570.56,,,,,,,fee schedule,4091.95,18154.62,
Reinforce/graft eye wall,67255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6085.34,,,,,,,fee schedule,4091.95,18154.62,
Reinforce/graft eye wall,67255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6397.88,,,,,,,fee schedule,4091.95,18154.62,
Reinforce/graft eye wall,67255,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18154.62,,,,,,,fee schedule,4091.95,18154.62,APC 378
Reinforce/graft eye wall,67255,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4296.55,,,,,,,fee schedule,4091.95,18154.62,APC
Reinforce/graft eye wall,67255,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4255.63,,,,,,,fee schedule,4091.95,18154.62,APC
Reinforce/graft eye wall,67255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4091.95,,,,,,,fee schedule,4091.95,18154.62,APC
Reinforce/graft eye wall,67255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6260.69,,,,,,,fee schedule,4091.95,18154.62,Radiology
Reinforce/graft eye wall,67255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5728.74,,,,,,,fee schedule,4091.95,18154.62,APC
Reinforce/graft eye wall,67255,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7160.92,,,,,,,fee schedule,4091.95,18154.62,APC
Eye surgery procedure,67299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1031.49,,,,,,,fee schedule,826.83,10136.31,
Eye surgery procedure,67299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,826.83,,,,,,,fee schedule,826.83,10136.31,
Eye surgery procedure,67299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,903.23,,,,,,,fee schedule,826.83,10136.31,
Eye surgery procedure,67299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,949.62,,,,,,,fee schedule,826.83,10136.31,
Eye surgery procedure,67299,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10136.31,,,,,,,fee schedule,826.83,10136.31,APC 378
Eye surgery procedure,67299,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2398.9,,,,,,,fee schedule,826.83,10136.31,APC
Eye surgery procedure,67299,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2376.06,,,,,,,fee schedule,826.83,10136.31,APC
Eye surgery procedure,67299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2284.67,,,,,,,fee schedule,826.83,10136.31,APC
Eye surgery procedure,67299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3495.55,,,,,,,fee schedule,826.83,10136.31,Radiology
Eye surgery procedure,67299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3198.54,,,,,,,fee schedule,826.83,10136.31,APC
Eye surgery procedure,67299,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3998.17,,,,,,,fee schedule,826.83,10136.31,APC
Revise eye muscle,67311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5950.19,,,,,,,fee schedule,2353.63,10442.27,
Revise eye muscle,67311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4769.6,,,,,,,fee schedule,2353.63,10442.27,
Revise eye muscle,67311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5210.36,,,,,,,fee schedule,2353.63,10442.27,
Revise eye muscle,67311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5477.96,,,,,,,fee schedule,2353.63,10442.27,
Revise eye muscle,67311,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2353.63,10442.27,APC 378
Revise eye muscle,67311,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2353.63,10442.27,APC
Revise eye muscle,67311,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2353.63,10442.27,APC
Revise eye muscle,67311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2353.63,10442.27,APC
Revise eye muscle,67311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2353.63,10442.27,Radiology
Revise eye muscle,67311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2353.63,10442.27,APC
Revise eye muscle,67311,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2353.63,10442.27,APC
Revise two eye muscles,67312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3828.9,,,,,,,fee schedule,3069.2,17267.29,
Revise two eye muscles,67312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3069.2,,,,,,,fee schedule,3069.2,17267.29,
Revise two eye muscles,67312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3352.82,,,,,,,fee schedule,3069.2,17267.29,
Revise two eye muscles,67312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3525.02,,,,,,,fee schedule,3069.2,17267.29,
Revise two eye muscles,67312,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17267.29,,,,,,,fee schedule,3069.2,17267.29,APC 378
Revise two eye muscles,67312,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4086.55,,,,,,,fee schedule,3069.2,17267.29,APC
Revise two eye muscles,67312,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4047.63,,,,,,,fee schedule,3069.2,17267.29,APC
Revise two eye muscles,67312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3891.96,,,,,,,fee schedule,3069.2,17267.29,APC
Revise two eye muscles,67312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5954.69,,,,,,,fee schedule,3069.2,17267.29,Radiology
Revise two eye muscles,67312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5448.74,,,,,,,fee schedule,3069.2,17267.29,APC
Revise two eye muscles,67312,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6810.92,,,,,,,fee schedule,3069.2,17267.29,APC
Revise eye muscle,67314,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3828.9,,,,,,,fee schedule,2353.63,10442.27,
Revise eye muscle,67314,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3069.2,,,,,,,fee schedule,2353.63,10442.27,
Revise eye muscle,67314,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3352.82,,,,,,,fee schedule,2353.63,10442.27,
Revise eye muscle,67314,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3525.02,,,,,,,fee schedule,2353.63,10442.27,
Revise eye muscle,67314,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2353.63,10442.27,APC 378
Revise eye muscle,67314,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2353.63,10442.27,APC
Revise eye muscle,67314,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2353.63,10442.27,APC
Revise eye muscle,67314,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2353.63,10442.27,APC
Revise eye muscle,67314,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2353.63,10442.27,Radiology
Revise eye muscle,67314,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2353.63,10442.27,APC
Revise eye muscle,67314,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2353.63,10442.27,APC
Revise two eye muscles,67316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6253.46,,,,,,,fee schedule,2353.63,10442.27,
Revise two eye muscles,67316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5012.69,,,,,,,fee schedule,2353.63,10442.27,
Revise two eye muscles,67316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5475.91,,,,,,,fee schedule,2353.63,10442.27,
Revise two eye muscles,67316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5757.15,,,,,,,fee schedule,2353.63,10442.27,
Revise two eye muscles,67316,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2353.63,10442.27,APC 378
Revise two eye muscles,67316,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2353.63,10442.27,APC
Revise two eye muscles,67316,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2353.63,10442.27,APC
Revise two eye muscles,67316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2353.63,10442.27,APC
Revise two eye muscles,67316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2353.63,10442.27,Radiology
Revise two eye muscles,67316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2353.63,10442.27,APC
Revise two eye muscles,67316,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2353.63,10442.27,APC
Revise eye muscle(s),67318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6022.03,,,,,,,fee schedule,2353.63,10442.27,
Revise eye muscle(s),67318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4827.18,,,,,,,fee schedule,2353.63,10442.27,
Revise eye muscle(s),67318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5273.26,,,,,,,fee schedule,2353.63,10442.27,
Revise eye muscle(s),67318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5544.09,,,,,,,fee schedule,2353.63,10442.27,
Revise eye muscle(s),67318,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2353.63,10442.27,APC 378
Revise eye muscle(s),67318,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2353.63,10442.27,APC
Revise eye muscle(s),67318,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2353.63,10442.27,APC
Revise eye muscle(s),67318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2353.63,10442.27,APC
Revise eye muscle(s),67318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2353.63,10442.27,Radiology
Revise eye muscle(s),67318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2353.63,10442.27,APC
Revise eye muscle(s),67318,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2353.63,10442.27,APC
Revise eye muscle(s) add-on,67320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6022.03,,,,,,,fee schedule,4827.18,6022.03,
Revise eye muscle(s) add-on,67320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4827.18,,,,,,,fee schedule,4827.18,6022.03,
Revise eye muscle(s) add-on,67320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5273.26,,,,,,,fee schedule,4827.18,6022.03,
Revise eye muscle(s) add-on,67320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5544.09,,,,,,,fee schedule,4827.18,6022.03,
Eye surgery follow-up add-on,67331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6022.03,,,,,,,fee schedule,4827.18,6022.03,
Eye surgery follow-up add-on,67331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4827.18,,,,,,,fee schedule,4827.18,6022.03,
Eye surgery follow-up add-on,67331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5273.26,,,,,,,fee schedule,4827.18,6022.03,
Eye surgery follow-up add-on,67331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5544.09,,,,,,,fee schedule,4827.18,6022.03,
Rerevise eye muscles add-on,67332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6022.03,,,,,,,fee schedule,4827.18,6022.03,
Rerevise eye muscles add-on,67332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4827.18,,,,,,,fee schedule,4827.18,6022.03,
Rerevise eye muscles add-on,67332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5273.26,,,,,,,fee schedule,4827.18,6022.03,
Rerevise eye muscles add-on,67332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5544.09,,,,,,,fee schedule,4827.18,6022.03,
Revise eye muscle w/suture,67334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6022.03,,,,,,,fee schedule,4827.18,6022.03,
Revise eye muscle w/suture,67334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4827.18,,,,,,,fee schedule,4827.18,6022.03,
Revise eye muscle w/suture,67334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5273.26,,,,,,,fee schedule,4827.18,6022.03,
Revise eye muscle w/suture,67334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5544.09,,,,,,,fee schedule,4827.18,6022.03,
Eye suture during surgery,67335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2396.55,,,,,,,fee schedule,1921.05,2396.55,
Eye suture during surgery,67335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1921.05,,,,,,,fee schedule,1921.05,2396.55,
Eye suture during surgery,67335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2098.57,,,,,,,fee schedule,1921.05,2396.55,
Eye suture during surgery,67335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2206.35,,,,,,,fee schedule,1921.05,2396.55,
Revise eye muscle add-on,67340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6022.03,,,,,,,fee schedule,4827.18,6022.03,
Revise eye muscle add-on,67340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4827.18,,,,,,,fee schedule,4827.18,6022.03,
Revise eye muscle add-on,67340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5273.26,,,,,,,fee schedule,4827.18,6022.03,
Revise eye muscle add-on,67340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5544.09,,,,,,,fee schedule,4827.18,6022.03,
Release eye tissue,67343,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3828.9,,,,,,,fee schedule,2353.63,10442.27,
Release eye tissue,67343,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3069.2,,,,,,,fee schedule,2353.63,10442.27,
Release eye tissue,67343,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3352.82,,,,,,,fee schedule,2353.63,10442.27,
Release eye tissue,67343,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3525.02,,,,,,,fee schedule,2353.63,10442.27,
Release eye tissue,67343,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2353.63,10442.27,APC 378
Release eye tissue,67343,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2353.63,10442.27,APC
Release eye tissue,67343,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2353.63,10442.27,APC
Release eye tissue,67343,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2353.63,10442.27,APC
Release eye tissue,67343,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2353.63,10442.27,Radiology
Release eye tissue,67343,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2353.63,10442.27,APC
Release eye tissue,67343,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2353.63,10442.27,APC
Destroy nerve of eye muscle,67345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,724.32,,,,,,,fee schedule,314.22,1394.09,
Destroy nerve of eye muscle,67345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,580.61,,,,,,,fee schedule,314.22,1394.09,
Destroy nerve of eye muscle,67345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,634.26,,,,,,,fee schedule,314.22,1394.09,
Destroy nerve of eye muscle,67345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,666.84,,,,,,,fee schedule,314.22,1394.09,
Destroy nerve of eye muscle,67345,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1394.09,,,,,,,fee schedule,314.22,1394.09,APC 378
Destroy nerve of eye muscle,67345,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,329.93,,,,,,,fee schedule,314.22,1394.09,APC
Destroy nerve of eye muscle,67345,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,326.79,,,,,,,fee schedule,314.22,1394.09,APC
Destroy nerve of eye muscle,67345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,314.22,,,,,,,fee schedule,314.22,1394.09,APC
Destroy nerve of eye muscle,67345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,480.76,,,,,,,fee schedule,314.22,1394.09,Radiology
Destroy nerve of eye muscle,67345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,439.91,,,,,,,fee schedule,314.22,1394.09,APC
Destroy nerve of eye muscle,67345,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,549.89,,,,,,,fee schedule,314.22,1394.09,APC
Biopsy eye muscle,67346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3430.46,,,,,,,fee schedule,2749.82,17267.29,
Biopsy eye muscle,67346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2749.82,,,,,,,fee schedule,2749.82,17267.29,
Biopsy eye muscle,67346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3003.92,,,,,,,fee schedule,2749.82,17267.29,
Biopsy eye muscle,67346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3158.2,,,,,,,fee schedule,2749.82,17267.29,
Biopsy eye muscle,67346,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17267.29,,,,,,,fee schedule,2749.82,17267.29,APC 378
Biopsy eye muscle,67346,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4086.55,,,,,,,fee schedule,2749.82,17267.29,APC
Biopsy eye muscle,67346,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4047.63,,,,,,,fee schedule,2749.82,17267.29,APC
Biopsy eye muscle,67346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3891.96,,,,,,,fee schedule,2749.82,17267.29,APC
Biopsy eye muscle,67346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5954.69,,,,,,,fee schedule,2749.82,17267.29,Radiology
Biopsy eye muscle,67346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5448.74,,,,,,,fee schedule,2749.82,17267.29,APC
Biopsy eye muscle,67346,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6810.92,,,,,,,fee schedule,2749.82,17267.29,APC
Unlisted px extraocular musc,67399,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6022.03,,,,,,,fee schedule,314.22,6022.03,
Unlisted px extraocular musc,67399,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4827.18,,,,,,,fee schedule,314.22,6022.03,
Unlisted px extraocular musc,67399,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5273.26,,,,,,,fee schedule,314.22,6022.03,
Unlisted px extraocular musc,67399,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5544.09,,,,,,,fee schedule,314.22,6022.03,
Unlisted px extraocular musc,67399,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1394.09,,,,,,,fee schedule,314.22,6022.03,APC 378
Unlisted px extraocular musc,67399,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,329.93,,,,,,,fee schedule,314.22,6022.03,APC
Unlisted px extraocular musc,67399,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,326.79,,,,,,,fee schedule,314.22,6022.03,APC
Unlisted px extraocular musc,67399,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,314.22,,,,,,,fee schedule,314.22,6022.03,APC
Unlisted px extraocular musc,67399,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,480.76,,,,,,,fee schedule,314.22,6022.03,Radiology
Unlisted px extraocular musc,67399,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,439.91,,,,,,,fee schedule,314.22,6022.03,APC
Unlisted px extraocular musc,67399,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,549.89,,,,,,,fee schedule,314.22,6022.03,APC
Explore/biopsy eye socket,67400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6721.57,,,,,,,fee schedule,3891.96,17267.29,
Explore/biopsy eye socket,67400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5387.93,,,,,,,fee schedule,3891.96,17267.29,
Explore/biopsy eye socket,67400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5885.82,,,,,,,fee schedule,3891.96,17267.29,
Explore/biopsy eye socket,67400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6188.11,,,,,,,fee schedule,3891.96,17267.29,
Explore/biopsy eye socket,67400,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17267.29,,,,,,,fee schedule,3891.96,17267.29,APC 378
Explore/biopsy eye socket,67400,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4086.55,,,,,,,fee schedule,3891.96,17267.29,APC
Explore/biopsy eye socket,67400,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4047.63,,,,,,,fee schedule,3891.96,17267.29,APC
Explore/biopsy eye socket,67400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3891.96,,,,,,,fee schedule,3891.96,17267.29,APC
Explore/biopsy eye socket,67400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5954.69,,,,,,,fee schedule,3891.96,17267.29,Radiology
Explore/biopsy eye socket,67400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5448.74,,,,,,,fee schedule,3891.96,17267.29,APC
Explore/biopsy eye socket,67400,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6810.92,,,,,,,fee schedule,3891.96,17267.29,APC
Explore/drain eye socket,67405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6066.6,,,,,,,fee schedule,2353.63,10442.27,
Explore/drain eye socket,67405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4862.91,,,,,,,fee schedule,2353.63,10442.27,
Explore/drain eye socket,67405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5312.29,,,,,,,fee schedule,2353.63,10442.27,
Explore/drain eye socket,67405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5585.12,,,,,,,fee schedule,2353.63,10442.27,
Explore/drain eye socket,67405,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2353.63,10442.27,APC 378
Explore/drain eye socket,67405,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2353.63,10442.27,APC
Explore/drain eye socket,67405,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2353.63,10442.27,APC
Explore/drain eye socket,67405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2353.63,10442.27,APC
Explore/drain eye socket,67405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2353.63,10442.27,Radiology
Explore/drain eye socket,67405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2353.63,10442.27,APC
Explore/drain eye socket,67405,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2353.63,10442.27,APC
Explore/treat eye socket,67412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8125.92,,,,,,,fee schedule,2353.63,10442.27,
Explore/treat eye socket,67412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6513.63,,,,,,,fee schedule,2353.63,10442.27,
Explore/treat eye socket,67412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7115.55,,,,,,,fee schedule,2353.63,10442.27,
Explore/treat eye socket,67412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7481,,,,,,,fee schedule,2353.63,10442.27,
Explore/treat eye socket,67412,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2353.63,10442.27,APC 378
Explore/treat eye socket,67412,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2353.63,10442.27,APC
Explore/treat eye socket,67412,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2353.63,10442.27,APC
Explore/treat eye socket,67412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2353.63,10442.27,APC
Explore/treat eye socket,67412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2353.63,10442.27,Radiology
Explore/treat eye socket,67412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2353.63,10442.27,APC
Explore/treat eye socket,67412,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2353.63,10442.27,APC
Explore/treat eye socket,67413,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4494.05,,,,,,,fee schedule,2353.63,10442.27,
Explore/treat eye socket,67413,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3602.37,,,,,,,fee schedule,2353.63,10442.27,
Explore/treat eye socket,67413,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3935.26,,,,,,,fee schedule,2353.63,10442.27,
Explore/treat eye socket,67413,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4137.38,,,,,,,fee schedule,2353.63,10442.27,
Explore/treat eye socket,67413,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2353.63,10442.27,APC 378
Explore/treat eye socket,67413,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2353.63,10442.27,APC
Explore/treat eye socket,67413,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2353.63,10442.27,APC
Explore/treat eye socket,67413,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2353.63,10442.27,APC
Explore/treat eye socket,67413,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2353.63,10442.27,Radiology
Explore/treat eye socket,67413,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2353.63,10442.27,APC
Explore/treat eye socket,67413,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2353.63,10442.27,APC
Explr/decompress eye socket,67414,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9415.04,,,,,,,fee schedule,3891.96,17267.29,
Explr/decompress eye socket,67414,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7546.97,,,,,,,fee schedule,3891.96,17267.29,
Explr/decompress eye socket,67414,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8244.38,,,,,,,fee schedule,3891.96,17267.29,
Explr/decompress eye socket,67414,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8667.81,,,,,,,fee schedule,3891.96,17267.29,
Explr/decompress eye socket,67414,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17267.29,,,,,,,fee schedule,3891.96,17267.29,APC 378
Explr/decompress eye socket,67414,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4086.55,,,,,,,fee schedule,3891.96,17267.29,APC
Explr/decompress eye socket,67414,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4047.63,,,,,,,fee schedule,3891.96,17267.29,APC
Explr/decompress eye socket,67414,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3891.96,,,,,,,fee schedule,3891.96,17267.29,APC
Explr/decompress eye socket,67414,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5954.69,,,,,,,fee schedule,3891.96,17267.29,Radiology
Explr/decompress eye socket,67414,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5448.74,,,,,,,fee schedule,3891.96,17267.29,APC
Explr/decompress eye socket,67414,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6810.92,,,,,,,fee schedule,3891.96,17267.29,APC
Aspiration orbital contents,67415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4674.69,,,,,,,fee schedule,2353.63,10442.27,
Aspiration orbital contents,67415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3747.17,,,,,,,fee schedule,2353.63,10442.27,
Aspiration orbital contents,67415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4093.44,,,,,,,fee schedule,2353.63,10442.27,
Aspiration orbital contents,67415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4303.68,,,,,,,fee schedule,2353.63,10442.27,
Aspiration orbital contents,67415,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2353.63,10442.27,APC 378
Aspiration orbital contents,67415,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2353.63,10442.27,APC
Aspiration orbital contents,67415,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2353.63,10442.27,APC
Aspiration orbital contents,67415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2353.63,10442.27,APC
Aspiration orbital contents,67415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2353.63,10442.27,Radiology
Aspiration orbital contents,67415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2353.63,10442.27,APC
Aspiration orbital contents,67415,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2353.63,10442.27,APC
Explore/treat eye socket,67420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9415.04,,,,,,,fee schedule,3891.96,17267.29,
Explore/treat eye socket,67420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7546.97,,,,,,,fee schedule,3891.96,17267.29,
Explore/treat eye socket,67420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8244.38,,,,,,,fee schedule,3891.96,17267.29,
Explore/treat eye socket,67420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8667.81,,,,,,,fee schedule,3891.96,17267.29,
Explore/treat eye socket,67420,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17267.29,,,,,,,fee schedule,3891.96,17267.29,APC 378
Explore/treat eye socket,67420,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4086.55,,,,,,,fee schedule,3891.96,17267.29,APC
Explore/treat eye socket,67420,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4047.63,,,,,,,fee schedule,3891.96,17267.29,APC
Explore/treat eye socket,67420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3891.96,,,,,,,fee schedule,3891.96,17267.29,APC
Explore/treat eye socket,67420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5954.69,,,,,,,fee schedule,3891.96,17267.29,Radiology
Explore/treat eye socket,67420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5448.74,,,,,,,fee schedule,3891.96,17267.29,APC
Explore/treat eye socket,67420,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6810.92,,,,,,,fee schedule,3891.96,17267.29,APC
Explore/treat eye socket,67430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9415.04,,,,,,,fee schedule,3891.96,17267.29,
Explore/treat eye socket,67430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7546.97,,,,,,,fee schedule,3891.96,17267.29,
Explore/treat eye socket,67430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8244.38,,,,,,,fee schedule,3891.96,17267.29,
Explore/treat eye socket,67430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8667.81,,,,,,,fee schedule,3891.96,17267.29,
Explore/treat eye socket,67430,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17267.29,,,,,,,fee schedule,3891.96,17267.29,APC 378
Explore/treat eye socket,67430,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4086.55,,,,,,,fee schedule,3891.96,17267.29,APC
Explore/treat eye socket,67430,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4047.63,,,,,,,fee schedule,3891.96,17267.29,APC
Explore/treat eye socket,67430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3891.96,,,,,,,fee schedule,3891.96,17267.29,APC
Explore/treat eye socket,67430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5954.69,,,,,,,fee schedule,3891.96,17267.29,Radiology
Explore/treat eye socket,67430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5448.74,,,,,,,fee schedule,3891.96,17267.29,APC
Explore/treat eye socket,67430,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6810.92,,,,,,,fee schedule,3891.96,17267.29,APC
Explore/drain eye socket,67440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9415.04,,,,,,,fee schedule,3891.96,17267.29,
Explore/drain eye socket,67440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7546.97,,,,,,,fee schedule,3891.96,17267.29,
Explore/drain eye socket,67440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8244.38,,,,,,,fee schedule,3891.96,17267.29,
Explore/drain eye socket,67440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8667.81,,,,,,,fee schedule,3891.96,17267.29,
Explore/drain eye socket,67440,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17267.29,,,,,,,fee schedule,3891.96,17267.29,APC 378
Explore/drain eye socket,67440,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4086.55,,,,,,,fee schedule,3891.96,17267.29,APC
Explore/drain eye socket,67440,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4047.63,,,,,,,fee schedule,3891.96,17267.29,APC
Explore/drain eye socket,67440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3891.96,,,,,,,fee schedule,3891.96,17267.29,APC
Explore/drain eye socket,67440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5954.69,,,,,,,fee schedule,3891.96,17267.29,Radiology
Explore/drain eye socket,67440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5448.74,,,,,,,fee schedule,3891.96,17267.29,APC
Explore/drain eye socket,67440,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6810.92,,,,,,,fee schedule,3891.96,17267.29,APC
Explr/decompress eye socket,67445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8125.92,,,,,,,fee schedule,3891.96,17267.29,
Explr/decompress eye socket,67445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6513.63,,,,,,,fee schedule,3891.96,17267.29,
Explr/decompress eye socket,67445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7115.55,,,,,,,fee schedule,3891.96,17267.29,
Explr/decompress eye socket,67445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7481,,,,,,,fee schedule,3891.96,17267.29,
Explr/decompress eye socket,67445,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17267.29,,,,,,,fee schedule,3891.96,17267.29,APC 378
Explr/decompress eye socket,67445,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4086.55,,,,,,,fee schedule,3891.96,17267.29,APC
Explr/decompress eye socket,67445,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4047.63,,,,,,,fee schedule,3891.96,17267.29,APC
Explr/decompress eye socket,67445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3891.96,,,,,,,fee schedule,3891.96,17267.29,APC
Explr/decompress eye socket,67445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5954.69,,,,,,,fee schedule,3891.96,17267.29,Radiology
Explr/decompress eye socket,67445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5448.74,,,,,,,fee schedule,3891.96,17267.29,APC
Explr/decompress eye socket,67445,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6810.92,,,,,,,fee schedule,3891.96,17267.29,APC
Explore/biopsy eye socket,67450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9415.04,,,,,,,fee schedule,3891.96,17267.29,
Explore/biopsy eye socket,67450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7546.97,,,,,,,fee schedule,3891.96,17267.29,
Explore/biopsy eye socket,67450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8244.38,,,,,,,fee schedule,3891.96,17267.29,
Explore/biopsy eye socket,67450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8667.81,,,,,,,fee schedule,3891.96,17267.29,
Explore/biopsy eye socket,67450,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17267.29,,,,,,,fee schedule,3891.96,17267.29,APC 378
Explore/biopsy eye socket,67450,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4086.55,,,,,,,fee schedule,3891.96,17267.29,APC
Explore/biopsy eye socket,67450,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4047.63,,,,,,,fee schedule,3891.96,17267.29,APC
Explore/biopsy eye socket,67450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3891.96,,,,,,,fee schedule,3891.96,17267.29,APC
Explore/biopsy eye socket,67450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5954.69,,,,,,,fee schedule,3891.96,17267.29,Radiology
Explore/biopsy eye socket,67450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5448.74,,,,,,,fee schedule,3891.96,17267.29,APC
Explore/biopsy eye socket,67450,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6810.92,,,,,,,fee schedule,3891.96,17267.29,APC
Inject/treat eye socket,67500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,543.83,,,,,,,fee schedule,314.22,1394.09,
Inject/treat eye socket,67500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,435.93,,,,,,,fee schedule,314.22,1394.09,
Inject/treat eye socket,67500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,476.21,,,,,,,fee schedule,314.22,1394.09,
Inject/treat eye socket,67500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,500.67,,,,,,,fee schedule,314.22,1394.09,
Inject/treat eye socket,67500,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1394.09,,,,,,,fee schedule,314.22,1394.09,APC 378
Inject/treat eye socket,67500,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,329.93,,,,,,,fee schedule,314.22,1394.09,APC
Inject/treat eye socket,67500,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,326.79,,,,,,,fee schedule,314.22,1394.09,APC
Inject/treat eye socket,67500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,314.22,,,,,,,fee schedule,314.22,1394.09,APC
Inject/treat eye socket,67500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,480.76,,,,,,,fee schedule,314.22,1394.09,Radiology
Inject/treat eye socket,67500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,439.91,,,,,,,fee schedule,314.22,1394.09,APC
Inject/treat eye socket,67500,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,549.89,,,,,,,fee schedule,314.22,1394.09,APC
Inject/treat eye socket,67505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,724.32,,,,,,,fee schedule,314.22,1394.09,
Inject/treat eye socket,67505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,580.61,,,,,,,fee schedule,314.22,1394.09,
Inject/treat eye socket,67505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,634.26,,,,,,,fee schedule,314.22,1394.09,
Inject/treat eye socket,67505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,666.84,,,,,,,fee schedule,314.22,1394.09,
Inject/treat eye socket,67505,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1394.09,,,,,,,fee schedule,314.22,1394.09,APC 378
Inject/treat eye socket,67505,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,329.93,,,,,,,fee schedule,314.22,1394.09,APC
Inject/treat eye socket,67505,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,326.79,,,,,,,fee schedule,314.22,1394.09,APC
Inject/treat eye socket,67505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,314.22,,,,,,,fee schedule,314.22,1394.09,APC
Inject/treat eye socket,67505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,480.76,,,,,,,fee schedule,314.22,1394.09,Radiology
Inject/treat eye socket,67505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,439.91,,,,,,,fee schedule,314.22,1394.09,APC
Inject/treat eye socket,67505,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,549.89,,,,,,,fee schedule,314.22,1394.09,APC
Inject/treat eye socket,67515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,724.32,,,,,,,fee schedule,314.22,1394.09,
Inject/treat eye socket,67515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,580.61,,,,,,,fee schedule,314.22,1394.09,
Inject/treat eye socket,67515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,634.26,,,,,,,fee schedule,314.22,1394.09,
Inject/treat eye socket,67515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,666.84,,,,,,,fee schedule,314.22,1394.09,
Inject/treat eye socket,67515,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1394.09,,,,,,,fee schedule,314.22,1394.09,APC 378
Inject/treat eye socket,67515,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,329.93,,,,,,,fee schedule,314.22,1394.09,APC
Inject/treat eye socket,67515,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,326.79,,,,,,,fee schedule,314.22,1394.09,APC
Inject/treat eye socket,67515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,314.22,,,,,,,fee schedule,314.22,1394.09,APC
Inject/treat eye socket,67515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,480.76,,,,,,,fee schedule,314.22,1394.09,Radiology
Inject/treat eye socket,67515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,439.91,,,,,,,fee schedule,314.22,1394.09,APC
Inject/treat eye socket,67515,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,549.89,,,,,,,fee schedule,314.22,1394.09,APC
Sprchoroidal spc njx rx agt,67516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1221.02,,,,,,,fee schedule,326.99,1450.75,
Sprchoroidal spc njx rx agt,67516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,978.75,,,,,,,fee schedule,326.99,1450.75,
Sprchoroidal spc njx rx agt,67516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1069.2,,,,,,,fee schedule,326.99,1450.75,
Sprchoroidal spc njx rx agt,67516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1124.11,,,,,,,fee schedule,326.99,1450.75,
Sprchoroidal spc njx rx agt,67516,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1450.75,,,,,,,fee schedule,326.99,1450.75,APC 378
Sprchoroidal spc njx rx agt,67516,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,343.34,,,,,,,fee schedule,326.99,1450.75,APC
Sprchoroidal spc njx rx agt,67516,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,340.07,,,,,,,fee schedule,326.99,1450.75,APC
Sprchoroidal spc njx rx agt,67516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,326.99,,,,,,,fee schedule,326.99,1450.75,APC
Sprchoroidal spc njx rx agt,67516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,500.3,,,,,,,fee schedule,326.99,1450.75,Radiology
Sprchoroidal spc njx rx agt,67516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,457.79,,,,,,,fee schedule,326.99,1450.75,APC
Sprchoroidal spc njx rx agt,67516,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,572.24,,,,,,,fee schedule,326.99,1450.75,APC
Insert eye socket implant,67550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9415.04,,,,,,,fee schedule,3891.96,17267.29,
Insert eye socket implant,67550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7546.97,,,,,,,fee schedule,3891.96,17267.29,
Insert eye socket implant,67550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8244.38,,,,,,,fee schedule,3891.96,17267.29,
Insert eye socket implant,67550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8667.81,,,,,,,fee schedule,3891.96,17267.29,
Insert eye socket implant,67550,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17267.29,,,,,,,fee schedule,3891.96,17267.29,APC 378
Insert eye socket implant,67550,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4086.55,,,,,,,fee schedule,3891.96,17267.29,APC
Insert eye socket implant,67550,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4047.63,,,,,,,fee schedule,3891.96,17267.29,APC
Insert eye socket implant,67550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3891.96,,,,,,,fee schedule,3891.96,17267.29,APC
Insert eye socket implant,67550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5954.69,,,,,,,fee schedule,3891.96,17267.29,Radiology
Insert eye socket implant,67550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5448.74,,,,,,,fee schedule,3891.96,17267.29,APC
Insert eye socket implant,67550,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6810.92,,,,,,,fee schedule,3891.96,17267.29,APC
Revise eye socket implant,67560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6066.6,,,,,,,fee schedule,3891.96,17267.29,
Revise eye socket implant,67560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4862.91,,,,,,,fee schedule,3891.96,17267.29,
Revise eye socket implant,67560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5312.29,,,,,,,fee schedule,3891.96,17267.29,
Revise eye socket implant,67560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5585.12,,,,,,,fee schedule,3891.96,17267.29,
Revise eye socket implant,67560,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17267.29,,,,,,,fee schedule,3891.96,17267.29,APC 378
Revise eye socket implant,67560,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4086.55,,,,,,,fee schedule,3891.96,17267.29,APC
Revise eye socket implant,67560,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4047.63,,,,,,,fee schedule,3891.96,17267.29,APC
Revise eye socket implant,67560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3891.96,,,,,,,fee schedule,3891.96,17267.29,APC
Revise eye socket implant,67560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5954.69,,,,,,,fee schedule,3891.96,17267.29,Radiology
Revise eye socket implant,67560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5448.74,,,,,,,fee schedule,3891.96,17267.29,APC
Revise eye socket implant,67560,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6810.92,,,,,,,fee schedule,3891.96,17267.29,APC
Decompress optic nerve,67570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9415.04,,,,,,,fee schedule,3891.96,17267.29,
Decompress optic nerve,67570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7546.97,,,,,,,fee schedule,3891.96,17267.29,
Decompress optic nerve,67570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8244.38,,,,,,,fee schedule,3891.96,17267.29,
Decompress optic nerve,67570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8667.81,,,,,,,fee schedule,3891.96,17267.29,
Decompress optic nerve,67570,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17267.29,,,,,,,fee schedule,3891.96,17267.29,APC 378
Decompress optic nerve,67570,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4086.55,,,,,,,fee schedule,3891.96,17267.29,APC
Decompress optic nerve,67570,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4047.63,,,,,,,fee schedule,3891.96,17267.29,APC
Decompress optic nerve,67570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3891.96,,,,,,,fee schedule,3891.96,17267.29,APC
Decompress optic nerve,67570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5954.69,,,,,,,fee schedule,3891.96,17267.29,Radiology
Decompress optic nerve,67570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5448.74,,,,,,,fee schedule,3891.96,17267.29,APC
Decompress optic nerve,67570,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6810.92,,,,,,,fee schedule,3891.96,17267.29,APC
Orbit surgery procedure,67599,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,724.32,,,,,,,fee schedule,314.22,1394.09,
Orbit surgery procedure,67599,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,580.61,,,,,,,fee schedule,314.22,1394.09,
Orbit surgery procedure,67599,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,634.26,,,,,,,fee schedule,314.22,1394.09,
Orbit surgery procedure,67599,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,666.84,,,,,,,fee schedule,314.22,1394.09,
Orbit surgery procedure,67599,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1394.09,,,,,,,fee schedule,314.22,1394.09,APC 378
Orbit surgery procedure,67599,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,329.93,,,,,,,fee schedule,314.22,1394.09,APC
Orbit surgery procedure,67599,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,326.79,,,,,,,fee schedule,314.22,1394.09,APC
Orbit surgery procedure,67599,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,314.22,,,,,,,fee schedule,314.22,1394.09,APC
Orbit surgery procedure,67599,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,480.76,,,,,,,fee schedule,314.22,1394.09,Radiology
Orbit surgery procedure,67599,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,439.91,,,,,,,fee schedule,314.22,1394.09,APC
Orbit surgery procedure,67599,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,549.89,,,,,,,fee schedule,314.22,1394.09,APC
Drainage of eyelid abscess,67700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,724.32,,,,,,,fee schedule,314.22,1394.09,
Drainage of eyelid abscess,67700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,580.61,,,,,,,fee schedule,314.22,1394.09,
Drainage of eyelid abscess,67700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,634.26,,,,,,,fee schedule,314.22,1394.09,
Drainage of eyelid abscess,67700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,666.84,,,,,,,fee schedule,314.22,1394.09,
Drainage of eyelid abscess,67700,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1394.09,,,,,,,fee schedule,314.22,1394.09,APC 378
Drainage of eyelid abscess,67700,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,329.93,,,,,,,fee schedule,314.22,1394.09,APC
Drainage of eyelid abscess,67700,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,326.79,,,,,,,fee schedule,314.22,1394.09,APC
Drainage of eyelid abscess,67700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,314.22,,,,,,,fee schedule,314.22,1394.09,APC
Drainage of eyelid abscess,67700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,480.76,,,,,,,fee schedule,314.22,1394.09,Radiology
Drainage of eyelid abscess,67700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,439.91,,,,,,,fee schedule,314.22,1394.09,APC
Drainage of eyelid abscess,67700,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,549.89,,,,,,,fee schedule,314.22,1394.09,APC
Incision of eyelid,67710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1818.07,,,,,,,fee schedule,986.88,4378.44,
Incision of eyelid,67710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1457.34,,,,,,,fee schedule,986.88,4378.44,
Incision of eyelid,67710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1592.01,,,,,,,fee schedule,986.88,4378.44,
Incision of eyelid,67710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1673.78,,,,,,,fee schedule,986.88,4378.44,
Incision of eyelid,67710,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4378.44,,,,,,,fee schedule,986.88,4378.44,APC 378
Incision of eyelid,67710,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1036.22,,,,,,,fee schedule,986.88,4378.44,APC
Incision of eyelid,67710,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1026.35,,,,,,,fee schedule,986.88,4378.44,APC
Incision of eyelid,67710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,986.88,,,,,,,fee schedule,986.88,4378.44,APC
Incision of eyelid,67710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1509.92,,,,,,,fee schedule,986.88,4378.44,Radiology
Incision of eyelid,67710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1381.63,,,,,,,fee schedule,986.88,4378.44,APC
Incision of eyelid,67710,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1727.03,,,,,,,fee schedule,986.88,4378.44,APC
Incision of eyelid fold,67715,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4674.69,,,,,,,fee schedule,2353.63,10442.27,
Incision of eyelid fold,67715,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3747.17,,,,,,,fee schedule,2353.63,10442.27,
Incision of eyelid fold,67715,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4093.44,,,,,,,fee schedule,2353.63,10442.27,
Incision of eyelid fold,67715,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4303.68,,,,,,,fee schedule,2353.63,10442.27,
Incision of eyelid fold,67715,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2353.63,10442.27,APC 378
Incision of eyelid fold,67715,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2353.63,10442.27,APC
Incision of eyelid fold,67715,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2353.63,10442.27,APC
Incision of eyelid fold,67715,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2353.63,10442.27,APC
Incision of eyelid fold,67715,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2353.63,10442.27,Radiology
Incision of eyelid fold,67715,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2353.63,10442.27,APC
Incision of eyelid fold,67715,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2353.63,10442.27,APC
Remove eyelid lesion,67800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,724.32,,,,,,,fee schedule,314.22,1394.09,
Remove eyelid lesion,67800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,580.61,,,,,,,fee schedule,314.22,1394.09,
Remove eyelid lesion,67800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,634.26,,,,,,,fee schedule,314.22,1394.09,
Remove eyelid lesion,67800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,666.84,,,,,,,fee schedule,314.22,1394.09,
Remove eyelid lesion,67800,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1394.09,,,,,,,fee schedule,314.22,1394.09,APC 378
Remove eyelid lesion,67800,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,329.93,,,,,,,fee schedule,314.22,1394.09,APC
Remove eyelid lesion,67800,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,326.79,,,,,,,fee schedule,314.22,1394.09,APC
Remove eyelid lesion,67800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,314.22,,,,,,,fee schedule,314.22,1394.09,APC
Remove eyelid lesion,67800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,480.76,,,,,,,fee schedule,314.22,1394.09,Radiology
Remove eyelid lesion,67800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,439.91,,,,,,,fee schedule,314.22,1394.09,APC
Remove eyelid lesion,67800,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,549.89,,,,,,,fee schedule,314.22,1394.09,APC
Remove eyelid lesions,67801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1818.07,,,,,,,fee schedule,986.88,4378.44,
Remove eyelid lesions,67801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1457.34,,,,,,,fee schedule,986.88,4378.44,
Remove eyelid lesions,67801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1592.01,,,,,,,fee schedule,986.88,4378.44,
Remove eyelid lesions,67801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1673.78,,,,,,,fee schedule,986.88,4378.44,
Remove eyelid lesions,67801,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4378.44,,,,,,,fee schedule,986.88,4378.44,APC 378
Remove eyelid lesions,67801,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1036.22,,,,,,,fee schedule,986.88,4378.44,APC
Remove eyelid lesions,67801,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1026.35,,,,,,,fee schedule,986.88,4378.44,APC
Remove eyelid lesions,67801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,986.88,,,,,,,fee schedule,986.88,4378.44,APC
Remove eyelid lesions,67801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1509.92,,,,,,,fee schedule,986.88,4378.44,Radiology
Remove eyelid lesions,67801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1381.63,,,,,,,fee schedule,986.88,4378.44,APC
Remove eyelid lesions,67801,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1727.03,,,,,,,fee schedule,986.88,4378.44,APC
Remove eyelid lesions,67805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,724.32,,,,,,,fee schedule,314.22,1394.09,
Remove eyelid lesions,67805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,580.61,,,,,,,fee schedule,314.22,1394.09,
Remove eyelid lesions,67805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,634.26,,,,,,,fee schedule,314.22,1394.09,
Remove eyelid lesions,67805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,666.84,,,,,,,fee schedule,314.22,1394.09,
Remove eyelid lesions,67805,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1394.09,,,,,,,fee schedule,314.22,1394.09,APC 378
Remove eyelid lesions,67805,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,329.93,,,,,,,fee schedule,314.22,1394.09,APC
Remove eyelid lesions,67805,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,326.79,,,,,,,fee schedule,314.22,1394.09,APC
Remove eyelid lesions,67805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,314.22,,,,,,,fee schedule,314.22,1394.09,APC
Remove eyelid lesions,67805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,480.76,,,,,,,fee schedule,314.22,1394.09,Radiology
Remove eyelid lesions,67805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,439.91,,,,,,,fee schedule,314.22,1394.09,APC
Remove eyelid lesions,67805,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,549.89,,,,,,,fee schedule,314.22,1394.09,APC
Remove eyelid lesion(s),67808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6019.4,,,,,,,fee schedule,2353.63,10442.27,
Remove eyelid lesion(s),67808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4825.07,,,,,,,fee schedule,2353.63,10442.27,
Remove eyelid lesion(s),67808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5270.95,,,,,,,fee schedule,2353.63,10442.27,
Remove eyelid lesion(s),67808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5541.67,,,,,,,fee schedule,2353.63,10442.27,
Remove eyelid lesion(s),67808,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2353.63,10442.27,APC 378
Remove eyelid lesion(s),67808,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2353.63,10442.27,APC
Remove eyelid lesion(s),67808,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2353.63,10442.27,APC
Remove eyelid lesion(s),67808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2353.63,10442.27,APC
Remove eyelid lesion(s),67808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2353.63,10442.27,Radiology
Remove eyelid lesion(s),67808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2353.63,10442.27,APC
Remove eyelid lesion(s),67808,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2353.63,10442.27,APC
Biopsy eyelid & lid margin,67810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,724.32,,,,,,,fee schedule,314.22,1394.09,
Biopsy eyelid & lid margin,67810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,580.61,,,,,,,fee schedule,314.22,1394.09,
Biopsy eyelid & lid margin,67810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,634.26,,,,,,,fee schedule,314.22,1394.09,
Biopsy eyelid & lid margin,67810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,666.84,,,,,,,fee schedule,314.22,1394.09,
Biopsy eyelid & lid margin,67810,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1394.09,,,,,,,fee schedule,314.22,1394.09,APC 378
Biopsy eyelid & lid margin,67810,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,329.93,,,,,,,fee schedule,314.22,1394.09,APC
Biopsy eyelid & lid margin,67810,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,326.79,,,,,,,fee schedule,314.22,1394.09,APC
Biopsy eyelid & lid margin,67810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,314.22,,,,,,,fee schedule,314.22,1394.09,APC
Biopsy eyelid & lid margin,67810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,480.76,,,,,,,fee schedule,314.22,1394.09,Radiology
Biopsy eyelid & lid margin,67810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,439.91,,,,,,,fee schedule,314.22,1394.09,APC
Biopsy eyelid & lid margin,67810,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,549.89,,,,,,,fee schedule,314.22,1394.09,APC
Revise eyelashes,67820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,217.05,,,,,,,fee schedule,131.71,584.37,
Revise eyelashes,67820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,173.98,,,,,,,fee schedule,131.71,584.37,
Revise eyelashes,67820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,190.06,,,,,,,fee schedule,131.71,584.37,
Revise eyelashes,67820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,199.82,,,,,,,fee schedule,131.71,584.37,
Revise eyelashes,67820,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,131.71,584.37,APC 378
Revise eyelashes,67820,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,131.71,584.37,APC
Revise eyelashes,67820,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,131.71,584.37,APC
Revise eyelashes,67820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,131.71,584.37,APC
Revise eyelashes,67820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,131.71,584.37,Radiology
Revise eyelashes,67820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,131.71,584.37,APC
Revise eyelashes,67820,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,131.71,584.37,APC
Revise eyelashes,67825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,724.32,,,,,,,fee schedule,314.22,1394.09,
Revise eyelashes,67825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,580.61,,,,,,,fee schedule,314.22,1394.09,
Revise eyelashes,67825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,634.26,,,,,,,fee schedule,314.22,1394.09,
Revise eyelashes,67825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,666.84,,,,,,,fee schedule,314.22,1394.09,
Revise eyelashes,67825,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1394.09,,,,,,,fee schedule,314.22,1394.09,APC 378
Revise eyelashes,67825,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,329.93,,,,,,,fee schedule,314.22,1394.09,APC
Revise eyelashes,67825,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,326.79,,,,,,,fee schedule,314.22,1394.09,APC
Revise eyelashes,67825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,314.22,,,,,,,fee schedule,314.22,1394.09,APC
Revise eyelashes,67825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,480.76,,,,,,,fee schedule,314.22,1394.09,Radiology
Revise eyelashes,67825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,439.91,,,,,,,fee schedule,314.22,1394.09,APC
Revise eyelashes,67825,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,549.89,,,,,,,fee schedule,314.22,1394.09,APC
Revise eyelashes,67830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1818.07,,,,,,,fee schedule,986.88,4378.44,
Revise eyelashes,67830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1457.34,,,,,,,fee schedule,986.88,4378.44,
Revise eyelashes,67830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1592.01,,,,,,,fee schedule,986.88,4378.44,
Revise eyelashes,67830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1673.78,,,,,,,fee schedule,986.88,4378.44,
Revise eyelashes,67830,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4378.44,,,,,,,fee schedule,986.88,4378.44,APC 378
Revise eyelashes,67830,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1036.22,,,,,,,fee schedule,986.88,4378.44,APC
Revise eyelashes,67830,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1026.35,,,,,,,fee schedule,986.88,4378.44,APC
Revise eyelashes,67830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,986.88,,,,,,,fee schedule,986.88,4378.44,APC
Revise eyelashes,67830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1509.92,,,,,,,fee schedule,986.88,4378.44,Radiology
Revise eyelashes,67830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1381.63,,,,,,,fee schedule,986.88,4378.44,APC
Revise eyelashes,67830,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1727.03,,,,,,,fee schedule,986.88,4378.44,APC
Revise eyelashes,67835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4674.69,,,,,,,fee schedule,2353.63,10442.27,
Revise eyelashes,67835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3747.17,,,,,,,fee schedule,2353.63,10442.27,
Revise eyelashes,67835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4093.44,,,,,,,fee schedule,2353.63,10442.27,
Revise eyelashes,67835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4303.68,,,,,,,fee schedule,2353.63,10442.27,
Revise eyelashes,67835,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2353.63,10442.27,APC 378
Revise eyelashes,67835,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2353.63,10442.27,APC
Revise eyelashes,67835,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2353.63,10442.27,APC
Revise eyelashes,67835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2353.63,10442.27,APC
Revise eyelashes,67835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2353.63,10442.27,Radiology
Revise eyelashes,67835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2353.63,10442.27,APC
Revise eyelashes,67835,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2353.63,10442.27,APC
Remove eyelid lesion,67840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1818.07,,,,,,,fee schedule,986.88,4378.44,
Remove eyelid lesion,67840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1457.34,,,,,,,fee schedule,986.88,4378.44,
Remove eyelid lesion,67840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1592.01,,,,,,,fee schedule,986.88,4378.44,
Remove eyelid lesion,67840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1673.78,,,,,,,fee schedule,986.88,4378.44,
Remove eyelid lesion,67840,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4378.44,,,,,,,fee schedule,986.88,4378.44,APC 378
Remove eyelid lesion,67840,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1036.22,,,,,,,fee schedule,986.88,4378.44,APC
Remove eyelid lesion,67840,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1026.35,,,,,,,fee schedule,986.88,4378.44,APC
Remove eyelid lesion,67840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,986.88,,,,,,,fee schedule,986.88,4378.44,APC
Remove eyelid lesion,67840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1509.92,,,,,,,fee schedule,986.88,4378.44,Radiology
Remove eyelid lesion,67840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1381.63,,,,,,,fee schedule,986.88,4378.44,APC
Remove eyelid lesion,67840,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1727.03,,,,,,,fee schedule,986.88,4378.44,APC
Treat eyelid lesion,67850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1818.07,,,,,,,fee schedule,986.88,4378.44,
Treat eyelid lesion,67850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1457.34,,,,,,,fee schedule,986.88,4378.44,
Treat eyelid lesion,67850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1592.01,,,,,,,fee schedule,986.88,4378.44,
Treat eyelid lesion,67850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1673.78,,,,,,,fee schedule,986.88,4378.44,
Treat eyelid lesion,67850,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4378.44,,,,,,,fee schedule,986.88,4378.44,APC 378
Treat eyelid lesion,67850,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1036.22,,,,,,,fee schedule,986.88,4378.44,APC
Treat eyelid lesion,67850,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1026.35,,,,,,,fee schedule,986.88,4378.44,APC
Treat eyelid lesion,67850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,986.88,,,,,,,fee schedule,986.88,4378.44,APC
Treat eyelid lesion,67850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1509.92,,,,,,,fee schedule,986.88,4378.44,Radiology
Treat eyelid lesion,67850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1381.63,,,,,,,fee schedule,986.88,4378.44,APC
Treat eyelid lesion,67850,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1727.03,,,,,,,fee schedule,986.88,4378.44,APC
Closure of eyelid by suture,67875,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3360.79,,,,,,,fee schedule,986.88,4378.44,
Closure of eyelid by suture,67875,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2693.96,,,,,,,fee schedule,986.88,4378.44,
Closure of eyelid by suture,67875,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2942.91,,,,,,,fee schedule,986.88,4378.44,
Closure of eyelid by suture,67875,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3094.06,,,,,,,fee schedule,986.88,4378.44,
Closure of eyelid by suture,67875,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4378.44,,,,,,,fee schedule,986.88,4378.44,APC 378
Closure of eyelid by suture,67875,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1036.22,,,,,,,fee schedule,986.88,4378.44,APC
Closure of eyelid by suture,67875,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1026.35,,,,,,,fee schedule,986.88,4378.44,APC
Closure of eyelid by suture,67875,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,986.88,,,,,,,fee schedule,986.88,4378.44,APC
Closure of eyelid by suture,67875,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1509.92,,,,,,,fee schedule,986.88,4378.44,Radiology
Closure of eyelid by suture,67875,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1381.63,,,,,,,fee schedule,986.88,4378.44,APC
Closure of eyelid by suture,67875,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1727.03,,,,,,,fee schedule,986.88,4378.44,APC
Revision of eyelid,67880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4035.91,,,,,,,fee schedule,2353.63,10442.27,
Revision of eyelid,67880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3235.13,,,,,,,fee schedule,2353.63,10442.27,
Revision of eyelid,67880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3534.09,,,,,,,fee schedule,2353.63,10442.27,
Revision of eyelid,67880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3715.6,,,,,,,fee schedule,2353.63,10442.27,
Revision of eyelid,67880,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2353.63,10442.27,APC 378
Revision of eyelid,67880,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2353.63,10442.27,APC
Revision of eyelid,67880,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2353.63,10442.27,APC
Revision of eyelid,67880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2353.63,10442.27,APC
Revision of eyelid,67880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2353.63,10442.27,Radiology
Revision of eyelid,67880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2353.63,10442.27,APC
Revision of eyelid,67880,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2353.63,10442.27,APC
Revision of eyelid,67882,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4674.69,,,,,,,fee schedule,2353.63,10442.27,
Revision of eyelid,67882,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3747.17,,,,,,,fee schedule,2353.63,10442.27,
Revision of eyelid,67882,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4093.44,,,,,,,fee schedule,2353.63,10442.27,
Revision of eyelid,67882,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4303.68,,,,,,,fee schedule,2353.63,10442.27,
Revision of eyelid,67882,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2353.63,10442.27,APC 378
Revision of eyelid,67882,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2353.63,10442.27,APC
Revision of eyelid,67882,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2353.63,10442.27,APC
Revision of eyelid,67882,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2353.63,10442.27,APC
Revision of eyelid,67882,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2353.63,10442.27,Radiology
Revision of eyelid,67882,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2353.63,10442.27,APC
Revision of eyelid,67882,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2353.63,10442.27,APC
Repair brow defect,67900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4531.07,,,,,,,fee schedule,2353.63,10442.27,
Repair brow defect,67900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3632.05,,,,,,,fee schedule,2353.63,10442.27,
Repair brow defect,67900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3967.69,,,,,,,fee schedule,2353.63,10442.27,
Repair brow defect,67900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4171.46,,,,,,,fee schedule,2353.63,10442.27,
Repair brow defect,67900,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2353.63,10442.27,APC 378
Repair brow defect,67900,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2353.63,10442.27,APC
Repair brow defect,67900,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2353.63,10442.27,APC
Repair brow defect,67900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2353.63,10442.27,APC
Repair brow defect,67900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2353.63,10442.27,Radiology
Repair brow defect,67900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2353.63,10442.27,APC
Repair brow defect,67900,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2353.63,10442.27,APC
Repair eyelid defect,67901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4674.69,,,,,,,fee schedule,2353.63,10442.27,
Repair eyelid defect,67901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3747.17,,,,,,,fee schedule,2353.63,10442.27,
Repair eyelid defect,67901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4093.44,,,,,,,fee schedule,2353.63,10442.27,
Repair eyelid defect,67901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4303.68,,,,,,,fee schedule,2353.63,10442.27,
Repair eyelid defect,67901,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2353.63,10442.27,APC 378
Repair eyelid defect,67901,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2353.63,10442.27,APC
Repair eyelid defect,67901,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2353.63,10442.27,APC
Repair eyelid defect,67901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2353.63,10442.27,APC
Repair eyelid defect,67901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2353.63,10442.27,Radiology
Repair eyelid defect,67901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2353.63,10442.27,APC
Repair eyelid defect,67901,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2353.63,10442.27,APC
Repair eyelid defect,67902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4674.69,,,,,,,fee schedule,3747.17,17267.29,
Repair eyelid defect,67902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3747.17,,,,,,,fee schedule,3747.17,17267.29,
Repair eyelid defect,67902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4093.44,,,,,,,fee schedule,3747.17,17267.29,
Repair eyelid defect,67902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4303.68,,,,,,,fee schedule,3747.17,17267.29,
Repair eyelid defect,67902,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17267.29,,,,,,,fee schedule,3747.17,17267.29,APC 378
Repair eyelid defect,67902,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4086.55,,,,,,,fee schedule,3747.17,17267.29,APC
Repair eyelid defect,67902,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4047.63,,,,,,,fee schedule,3747.17,17267.29,APC
Repair eyelid defect,67902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3891.96,,,,,,,fee schedule,3747.17,17267.29,APC
Repair eyelid defect,67902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5954.69,,,,,,,fee schedule,3747.17,17267.29,Radiology
Repair eyelid defect,67902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5448.74,,,,,,,fee schedule,3747.17,17267.29,APC
Repair eyelid defect,67902,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6810.92,,,,,,,fee schedule,3747.17,17267.29,APC
Repair eyelid defect,67903,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4456.03,,,,,,,fee schedule,2353.63,10442.27,
Repair eyelid defect,67903,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3571.9,,,,,,,fee schedule,2353.63,10442.27,
Repair eyelid defect,67903,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3901.98,,,,,,,fee schedule,2353.63,10442.27,
Repair eyelid defect,67903,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4102.38,,,,,,,fee schedule,2353.63,10442.27,
Repair eyelid defect,67903,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2353.63,10442.27,APC 378
Repair eyelid defect,67903,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2353.63,10442.27,APC
Repair eyelid defect,67903,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2353.63,10442.27,APC
Repair eyelid defect,67903,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2353.63,10442.27,APC
Repair eyelid defect,67903,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2353.63,10442.27,Radiology
Repair eyelid defect,67903,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2353.63,10442.27,APC
Repair eyelid defect,67903,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2353.63,10442.27,APC
Repair eyelid defect,67904,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5523.29,,,,,,,fee schedule,2353.63,10442.27,
Repair eyelid defect,67904,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4427.4,,,,,,,fee schedule,2353.63,10442.27,
Repair eyelid defect,67904,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4836.53,,,,,,,fee schedule,2353.63,10442.27,
Repair eyelid defect,67904,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5084.93,,,,,,,fee schedule,2353.63,10442.27,
Repair eyelid defect,67904,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2353.63,10442.27,APC 378
Repair eyelid defect,67904,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2353.63,10442.27,APC
Repair eyelid defect,67904,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2353.63,10442.27,APC
Repair eyelid defect,67904,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2353.63,10442.27,APC
Repair eyelid defect,67904,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2353.63,10442.27,Radiology
Repair eyelid defect,67904,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2353.63,10442.27,APC
Repair eyelid defect,67904,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2353.63,10442.27,APC
Repair eyelid defect,67906,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4674.69,,,,,,,fee schedule,3747.17,17267.29,
Repair eyelid defect,67906,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3747.17,,,,,,,fee schedule,3747.17,17267.29,
Repair eyelid defect,67906,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4093.44,,,,,,,fee schedule,3747.17,17267.29,
Repair eyelid defect,67906,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4303.68,,,,,,,fee schedule,3747.17,17267.29,
Repair eyelid defect,67906,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17267.29,,,,,,,fee schedule,3747.17,17267.29,APC 378
Repair eyelid defect,67906,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4086.55,,,,,,,fee schedule,3747.17,17267.29,APC
Repair eyelid defect,67906,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4047.63,,,,,,,fee schedule,3747.17,17267.29,APC
Repair eyelid defect,67906,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3891.96,,,,,,,fee schedule,3747.17,17267.29,APC
Repair eyelid defect,67906,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5954.69,,,,,,,fee schedule,3747.17,17267.29,Radiology
Repair eyelid defect,67906,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5448.74,,,,,,,fee schedule,3747.17,17267.29,APC
Repair eyelid defect,67906,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6810.92,,,,,,,fee schedule,3747.17,17267.29,APC
Repair eyelid defect,67908,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4674.69,,,,,,,fee schedule,2353.63,10442.27,
Repair eyelid defect,67908,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3747.17,,,,,,,fee schedule,2353.63,10442.27,
Repair eyelid defect,67908,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4093.44,,,,,,,fee schedule,2353.63,10442.27,
Repair eyelid defect,67908,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4303.68,,,,,,,fee schedule,2353.63,10442.27,
Repair eyelid defect,67908,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2353.63,10442.27,APC 378
Repair eyelid defect,67908,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2353.63,10442.27,APC
Repair eyelid defect,67908,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2353.63,10442.27,APC
Repair eyelid defect,67908,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2353.63,10442.27,APC
Repair eyelid defect,67908,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2353.63,10442.27,Radiology
Repair eyelid defect,67908,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2353.63,10442.27,APC
Repair eyelid defect,67908,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2353.63,10442.27,APC
Revise eyelid defect,67909,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4674.69,,,,,,,fee schedule,2353.63,10442.27,
Revise eyelid defect,67909,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3747.17,,,,,,,fee schedule,2353.63,10442.27,
Revise eyelid defect,67909,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4093.44,,,,,,,fee schedule,2353.63,10442.27,
Revise eyelid defect,67909,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4303.68,,,,,,,fee schedule,2353.63,10442.27,
Revise eyelid defect,67909,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2353.63,10442.27,APC 378
Revise eyelid defect,67909,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2353.63,10442.27,APC
Revise eyelid defect,67909,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2353.63,10442.27,APC
Revise eyelid defect,67909,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2353.63,10442.27,APC
Revise eyelid defect,67909,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2353.63,10442.27,Radiology
Revise eyelid defect,67909,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2353.63,10442.27,APC
Revise eyelid defect,67909,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2353.63,10442.27,APC
Revise eyelid defect,67911,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5785.34,,,,,,,fee schedule,2353.63,10442.27,
Revise eyelid defect,67911,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4637.46,,,,,,,fee schedule,2353.63,10442.27,
Revise eyelid defect,67911,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5066,,,,,,,fee schedule,2353.63,10442.27,
Revise eyelid defect,67911,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5326.19,,,,,,,fee schedule,2353.63,10442.27,
Revise eyelid defect,67911,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2353.63,10442.27,APC 378
Revise eyelid defect,67911,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2353.63,10442.27,APC
Revise eyelid defect,67911,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2353.63,10442.27,APC
Revise eyelid defect,67911,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2353.63,10442.27,APC
Revise eyelid defect,67911,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2353.63,10442.27,Radiology
Revise eyelid defect,67911,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2353.63,10442.27,APC
Revise eyelid defect,67911,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2353.63,10442.27,APC
Correction eyelid w/implant,67912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4674.69,,,,,,,fee schedule,2353.63,10442.27,
Correction eyelid w/implant,67912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3747.17,,,,,,,fee schedule,2353.63,10442.27,
Correction eyelid w/implant,67912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4093.44,,,,,,,fee schedule,2353.63,10442.27,
Correction eyelid w/implant,67912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4303.68,,,,,,,fee schedule,2353.63,10442.27,
Correction eyelid w/implant,67912,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2353.63,10442.27,APC 378
Correction eyelid w/implant,67912,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2353.63,10442.27,APC
Correction eyelid w/implant,67912,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2353.63,10442.27,APC
Correction eyelid w/implant,67912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2353.63,10442.27,APC
Correction eyelid w/implant,67912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2353.63,10442.27,Radiology
Correction eyelid w/implant,67912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2353.63,10442.27,APC
Correction eyelid w/implant,67912,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2353.63,10442.27,APC
Repair eyelid defect,67914,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4674.69,,,,,,,fee schedule,2353.63,10442.27,
Repair eyelid defect,67914,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3747.17,,,,,,,fee schedule,2353.63,10442.27,
Repair eyelid defect,67914,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4093.44,,,,,,,fee schedule,2353.63,10442.27,
Repair eyelid defect,67914,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4303.68,,,,,,,fee schedule,2353.63,10442.27,
Repair eyelid defect,67914,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2353.63,10442.27,APC 378
Repair eyelid defect,67914,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2353.63,10442.27,APC
Repair eyelid defect,67914,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2353.63,10442.27,APC
Repair eyelid defect,67914,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2353.63,10442.27,APC
Repair eyelid defect,67914,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2353.63,10442.27,Radiology
Repair eyelid defect,67914,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2353.63,10442.27,APC
Repair eyelid defect,67914,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2353.63,10442.27,APC
Repair eyelid defect,67915,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4674.69,,,,,,,fee schedule,2353.63,10442.27,
Repair eyelid defect,67915,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3747.17,,,,,,,fee schedule,2353.63,10442.27,
Repair eyelid defect,67915,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4093.44,,,,,,,fee schedule,2353.63,10442.27,
Repair eyelid defect,67915,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4303.68,,,,,,,fee schedule,2353.63,10442.27,
Repair eyelid defect,67915,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2353.63,10442.27,APC 378
Repair eyelid defect,67915,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2353.63,10442.27,APC
Repair eyelid defect,67915,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2353.63,10442.27,APC
Repair eyelid defect,67915,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2353.63,10442.27,APC
Repair eyelid defect,67915,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2353.63,10442.27,Radiology
Repair eyelid defect,67915,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2353.63,10442.27,APC
Repair eyelid defect,67915,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2353.63,10442.27,APC
Repair eyelid defect,67916,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4674.69,,,,,,,fee schedule,2353.63,10442.27,
Repair eyelid defect,67916,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3747.17,,,,,,,fee schedule,2353.63,10442.27,
Repair eyelid defect,67916,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4093.44,,,,,,,fee schedule,2353.63,10442.27,
Repair eyelid defect,67916,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4303.68,,,,,,,fee schedule,2353.63,10442.27,
Repair eyelid defect,67916,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2353.63,10442.27,APC 378
Repair eyelid defect,67916,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2353.63,10442.27,APC
Repair eyelid defect,67916,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2353.63,10442.27,APC
Repair eyelid defect,67916,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2353.63,10442.27,APC
Repair eyelid defect,67916,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2353.63,10442.27,Radiology
Repair eyelid defect,67916,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2353.63,10442.27,APC
Repair eyelid defect,67916,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2353.63,10442.27,APC
Repair eyelid defect,67917,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4674.69,,,,,,,fee schedule,2353.63,10442.27,
Repair eyelid defect,67917,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3747.17,,,,,,,fee schedule,2353.63,10442.27,
Repair eyelid defect,67917,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4093.44,,,,,,,fee schedule,2353.63,10442.27,
Repair eyelid defect,67917,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4303.68,,,,,,,fee schedule,2353.63,10442.27,
Repair eyelid defect,67917,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2353.63,10442.27,APC 378
Repair eyelid defect,67917,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2353.63,10442.27,APC
Repair eyelid defect,67917,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2353.63,10442.27,APC
Repair eyelid defect,67917,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2353.63,10442.27,APC
Repair eyelid defect,67917,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2353.63,10442.27,Radiology
Repair eyelid defect,67917,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2353.63,10442.27,APC
Repair eyelid defect,67917,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2353.63,10442.27,APC
Repair eyelid defect,67921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4674.69,,,,,,,fee schedule,2353.63,10442.27,
Repair eyelid defect,67921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3747.17,,,,,,,fee schedule,2353.63,10442.27,
Repair eyelid defect,67921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4093.44,,,,,,,fee schedule,2353.63,10442.27,
Repair eyelid defect,67921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4303.68,,,,,,,fee schedule,2353.63,10442.27,
Repair eyelid defect,67921,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2353.63,10442.27,APC 378
Repair eyelid defect,67921,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2353.63,10442.27,APC
Repair eyelid defect,67921,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2353.63,10442.27,APC
Repair eyelid defect,67921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2353.63,10442.27,APC
Repair eyelid defect,67921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2353.63,10442.27,Radiology
Repair eyelid defect,67921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2353.63,10442.27,APC
Repair eyelid defect,67921,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2353.63,10442.27,APC
Repair eyelid defect,67922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4674.69,,,,,,,fee schedule,2353.63,10442.27,
Repair eyelid defect,67922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3747.17,,,,,,,fee schedule,2353.63,10442.27,
Repair eyelid defect,67922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4093.44,,,,,,,fee schedule,2353.63,10442.27,
Repair eyelid defect,67922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4303.68,,,,,,,fee schedule,2353.63,10442.27,
Repair eyelid defect,67922,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2353.63,10442.27,APC 378
Repair eyelid defect,67922,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2353.63,10442.27,APC
Repair eyelid defect,67922,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2353.63,10442.27,APC
Repair eyelid defect,67922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2353.63,10442.27,APC
Repair eyelid defect,67922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2353.63,10442.27,Radiology
Repair eyelid defect,67922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2353.63,10442.27,APC
Repair eyelid defect,67922,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2353.63,10442.27,APC
Repair eyelid defect,67923,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4674.69,,,,,,,fee schedule,2353.63,10442.27,
Repair eyelid defect,67923,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3747.17,,,,,,,fee schedule,2353.63,10442.27,
Repair eyelid defect,67923,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4093.44,,,,,,,fee schedule,2353.63,10442.27,
Repair eyelid defect,67923,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4303.68,,,,,,,fee schedule,2353.63,10442.27,
Repair eyelid defect,67923,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2353.63,10442.27,APC 378
Repair eyelid defect,67923,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2353.63,10442.27,APC
Repair eyelid defect,67923,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2353.63,10442.27,APC
Repair eyelid defect,67923,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2353.63,10442.27,APC
Repair eyelid defect,67923,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2353.63,10442.27,Radiology
Repair eyelid defect,67923,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2353.63,10442.27,APC
Repair eyelid defect,67923,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2353.63,10442.27,APC
Repair eyelid defect,67924,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4674.69,,,,,,,fee schedule,2353.63,10442.27,
Repair eyelid defect,67924,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3747.17,,,,,,,fee schedule,2353.63,10442.27,
Repair eyelid defect,67924,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4093.44,,,,,,,fee schedule,2353.63,10442.27,
Repair eyelid defect,67924,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4303.68,,,,,,,fee schedule,2353.63,10442.27,
Repair eyelid defect,67924,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2353.63,10442.27,APC 378
Repair eyelid defect,67924,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2353.63,10442.27,APC
Repair eyelid defect,67924,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2353.63,10442.27,APC
Repair eyelid defect,67924,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2353.63,10442.27,APC
Repair eyelid defect,67924,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2353.63,10442.27,Radiology
Repair eyelid defect,67924,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2353.63,10442.27,APC
Repair eyelid defect,67924,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2353.63,10442.27,APC
Repair eyelid wound,67930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4674.69,,,,,,,fee schedule,2353.63,10442.27,
Repair eyelid wound,67930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3747.17,,,,,,,fee schedule,2353.63,10442.27,
Repair eyelid wound,67930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4093.44,,,,,,,fee schedule,2353.63,10442.27,
Repair eyelid wound,67930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4303.68,,,,,,,fee schedule,2353.63,10442.27,
Repair eyelid wound,67930,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2353.63,10442.27,APC 378
Repair eyelid wound,67930,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2353.63,10442.27,APC
Repair eyelid wound,67930,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2353.63,10442.27,APC
Repair eyelid wound,67930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2353.63,10442.27,APC
Repair eyelid wound,67930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2353.63,10442.27,Radiology
Repair eyelid wound,67930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2353.63,10442.27,APC
Repair eyelid wound,67930,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2353.63,10442.27,APC
Repair eyelid wound,67935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4674.69,,,,,,,fee schedule,2353.63,10442.27,
Repair eyelid wound,67935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3747.17,,,,,,,fee schedule,2353.63,10442.27,
Repair eyelid wound,67935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4093.44,,,,,,,fee schedule,2353.63,10442.27,
Repair eyelid wound,67935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4303.68,,,,,,,fee schedule,2353.63,10442.27,
Repair eyelid wound,67935,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2353.63,10442.27,APC 378
Repair eyelid wound,67935,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2353.63,10442.27,APC
Repair eyelid wound,67935,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2353.63,10442.27,APC
Repair eyelid wound,67935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2353.63,10442.27,APC
Repair eyelid wound,67935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2353.63,10442.27,Radiology
Repair eyelid wound,67935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2353.63,10442.27,APC
Repair eyelid wound,67935,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2353.63,10442.27,APC
Remove eyelid foreign body,67938,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,543.83,,,,,,,fee schedule,314.22,1394.09,
Remove eyelid foreign body,67938,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,435.93,,,,,,,fee schedule,314.22,1394.09,
Remove eyelid foreign body,67938,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,476.21,,,,,,,fee schedule,314.22,1394.09,
Remove eyelid foreign body,67938,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,500.67,,,,,,,fee schedule,314.22,1394.09,
Remove eyelid foreign body,67938,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1394.09,,,,,,,fee schedule,314.22,1394.09,APC 378
Remove eyelid foreign body,67938,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,329.93,,,,,,,fee schedule,314.22,1394.09,APC
Remove eyelid foreign body,67938,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,326.79,,,,,,,fee schedule,314.22,1394.09,APC
Remove eyelid foreign body,67938,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,314.22,,,,,,,fee schedule,314.22,1394.09,APC
Remove eyelid foreign body,67938,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,480.76,,,,,,,fee schedule,314.22,1394.09,Radiology
Remove eyelid foreign body,67938,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,439.91,,,,,,,fee schedule,314.22,1394.09,APC
Remove eyelid foreign body,67938,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,549.89,,,,,,,fee schedule,314.22,1394.09,APC
Revision of eyelid,67950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2708.63,,,,,,,fee schedule,2171.2,10442.27,
Revision of eyelid,67950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2171.2,,,,,,,fee schedule,2171.2,10442.27,
Revision of eyelid,67950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2371.84,,,,,,,fee schedule,2171.2,10442.27,
Revision of eyelid,67950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2493.66,,,,,,,fee schedule,2171.2,10442.27,
Revision of eyelid,67950,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2171.2,10442.27,APC 378
Revision of eyelid,67950,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2171.2,10442.27,APC
Revision of eyelid,67950,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2171.2,10442.27,APC
Revision of eyelid,67950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2171.2,10442.27,APC
Revision of eyelid,67950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2171.2,10442.27,Radiology
Revision of eyelid,67950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2171.2,10442.27,APC
Revision of eyelid,67950,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2171.2,10442.27,APC
Revision of eyelid,67961,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4674.69,,,,,,,fee schedule,2353.63,10442.27,
Revision of eyelid,67961,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3747.17,,,,,,,fee schedule,2353.63,10442.27,
Revision of eyelid,67961,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4093.44,,,,,,,fee schedule,2353.63,10442.27,
Revision of eyelid,67961,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4303.68,,,,,,,fee schedule,2353.63,10442.27,
Revision of eyelid,67961,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2353.63,10442.27,APC 378
Revision of eyelid,67961,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2353.63,10442.27,APC
Revision of eyelid,67961,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2353.63,10442.27,APC
Revision of eyelid,67961,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2353.63,10442.27,APC
Revision of eyelid,67961,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2353.63,10442.27,Radiology
Revision of eyelid,67961,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2353.63,10442.27,APC
Revision of eyelid,67961,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2353.63,10442.27,APC
Revision of eyelid,67966,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6253.46,,,,,,,fee schedule,2353.63,10442.27,
Revision of eyelid,67966,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5012.69,,,,,,,fee schedule,2353.63,10442.27,
Revision of eyelid,67966,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5475.91,,,,,,,fee schedule,2353.63,10442.27,
Revision of eyelid,67966,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5757.15,,,,,,,fee schedule,2353.63,10442.27,
Revision of eyelid,67966,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2353.63,10442.27,APC 378
Revision of eyelid,67966,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2353.63,10442.27,APC
Revision of eyelid,67966,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2353.63,10442.27,APC
Revision of eyelid,67966,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2353.63,10442.27,APC
Revision of eyelid,67966,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2353.63,10442.27,Radiology
Revision of eyelid,67966,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2353.63,10442.27,APC
Revision of eyelid,67966,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2353.63,10442.27,APC
Reconstruction of eyelid,67971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6066.6,,,,,,,fee schedule,2353.63,10442.27,
Reconstruction of eyelid,67971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4862.91,,,,,,,fee schedule,2353.63,10442.27,
Reconstruction of eyelid,67971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5312.29,,,,,,,fee schedule,2353.63,10442.27,
Reconstruction of eyelid,67971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5585.12,,,,,,,fee schedule,2353.63,10442.27,
Reconstruction of eyelid,67971,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2353.63,10442.27,APC 378
Reconstruction of eyelid,67971,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2353.63,10442.27,APC
Reconstruction of eyelid,67971,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2353.63,10442.27,APC
Reconstruction of eyelid,67971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2353.63,10442.27,APC
Reconstruction of eyelid,67971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2353.63,10442.27,Radiology
Reconstruction of eyelid,67971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2353.63,10442.27,APC
Reconstruction of eyelid,67971,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2353.63,10442.27,APC
Reconstruction of eyelid,67973,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6066.6,,,,,,,fee schedule,2353.63,10442.27,
Reconstruction of eyelid,67973,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4862.91,,,,,,,fee schedule,2353.63,10442.27,
Reconstruction of eyelid,67973,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5312.29,,,,,,,fee schedule,2353.63,10442.27,
Reconstruction of eyelid,67973,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5585.12,,,,,,,fee schedule,2353.63,10442.27,
Reconstruction of eyelid,67973,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2353.63,10442.27,APC 378
Reconstruction of eyelid,67973,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2353.63,10442.27,APC
Reconstruction of eyelid,67973,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2353.63,10442.27,APC
Reconstruction of eyelid,67973,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2353.63,10442.27,APC
Reconstruction of eyelid,67973,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2353.63,10442.27,Radiology
Reconstruction of eyelid,67973,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2353.63,10442.27,APC
Reconstruction of eyelid,67973,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2353.63,10442.27,APC
Reconstruction of eyelid,67974,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6066.6,,,,,,,fee schedule,3891.96,17267.29,
Reconstruction of eyelid,67974,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4862.91,,,,,,,fee schedule,3891.96,17267.29,
Reconstruction of eyelid,67974,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5312.29,,,,,,,fee schedule,3891.96,17267.29,
Reconstruction of eyelid,67974,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5585.12,,,,,,,fee schedule,3891.96,17267.29,
Reconstruction of eyelid,67974,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17267.29,,,,,,,fee schedule,3891.96,17267.29,APC 378
Reconstruction of eyelid,67974,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4086.55,,,,,,,fee schedule,3891.96,17267.29,APC
Reconstruction of eyelid,67974,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4047.63,,,,,,,fee schedule,3891.96,17267.29,APC
Reconstruction of eyelid,67974,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3891.96,,,,,,,fee schedule,3891.96,17267.29,APC
Reconstruction of eyelid,67974,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5954.69,,,,,,,fee schedule,3891.96,17267.29,Radiology
Reconstruction of eyelid,67974,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5448.74,,,,,,,fee schedule,3891.96,17267.29,APC
Reconstruction of eyelid,67974,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6810.92,,,,,,,fee schedule,3891.96,17267.29,APC
Reconstruction of eyelid,67975,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4674.69,,,,,,,fee schedule,2353.63,10442.27,
Reconstruction of eyelid,67975,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3747.17,,,,,,,fee schedule,2353.63,10442.27,
Reconstruction of eyelid,67975,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4093.44,,,,,,,fee schedule,2353.63,10442.27,
Reconstruction of eyelid,67975,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4303.68,,,,,,,fee schedule,2353.63,10442.27,
Reconstruction of eyelid,67975,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2353.63,10442.27,APC 378
Reconstruction of eyelid,67975,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2353.63,10442.27,APC
Reconstruction of eyelid,67975,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2353.63,10442.27,APC
Reconstruction of eyelid,67975,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2353.63,10442.27,APC
Reconstruction of eyelid,67975,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2353.63,10442.27,Radiology
Reconstruction of eyelid,67975,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2353.63,10442.27,APC
Reconstruction of eyelid,67975,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2353.63,10442.27,APC
Revision of eyelid,67999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,724.32,,,,,,,fee schedule,314.22,1394.09,
Revision of eyelid,67999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,580.61,,,,,,,fee schedule,314.22,1394.09,
Revision of eyelid,67999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,634.26,,,,,,,fee schedule,314.22,1394.09,
Revision of eyelid,67999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,666.84,,,,,,,fee schedule,314.22,1394.09,
Revision of eyelid,67999,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1394.09,,,,,,,fee schedule,314.22,1394.09,APC 378
Revision of eyelid,67999,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,329.93,,,,,,,fee schedule,314.22,1394.09,APC
Revision of eyelid,67999,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,326.79,,,,,,,fee schedule,314.22,1394.09,APC
Revision of eyelid,67999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,314.22,,,,,,,fee schedule,314.22,1394.09,APC
Revision of eyelid,67999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,480.76,,,,,,,fee schedule,314.22,1394.09,Radiology
Revision of eyelid,67999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,439.91,,,,,,,fee schedule,314.22,1394.09,APC
Revision of eyelid,67999,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,549.89,,,,,,,fee schedule,314.22,1394.09,APC
Incise/drain eyelid lining,68020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4674.69,,,,,,,fee schedule,986.88,4674.69,
Incise/drain eyelid lining,68020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3747.17,,,,,,,fee schedule,986.88,4674.69,
Incise/drain eyelid lining,68020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4093.44,,,,,,,fee schedule,986.88,4674.69,
Incise/drain eyelid lining,68020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4303.68,,,,,,,fee schedule,986.88,4674.69,
Incise/drain eyelid lining,68020,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4378.44,,,,,,,fee schedule,986.88,4674.69,APC 378
Incise/drain eyelid lining,68020,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1036.22,,,,,,,fee schedule,986.88,4674.69,APC
Incise/drain eyelid lining,68020,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1026.35,,,,,,,fee schedule,986.88,4674.69,APC
Incise/drain eyelid lining,68020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,986.88,,,,,,,fee schedule,986.88,4674.69,APC
Incise/drain eyelid lining,68020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1509.92,,,,,,,fee schedule,986.88,4674.69,Radiology
Incise/drain eyelid lining,68020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1381.63,,,,,,,fee schedule,986.88,4674.69,APC
Incise/drain eyelid lining,68020,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1727.03,,,,,,,fee schedule,986.88,4674.69,APC
Treatment of eyelid lesions,68040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,217.05,,,,,,,fee schedule,173.98,1394.09,
Treatment of eyelid lesions,68040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,173.98,,,,,,,fee schedule,173.98,1394.09,
Treatment of eyelid lesions,68040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,190.06,,,,,,,fee schedule,173.98,1394.09,
Treatment of eyelid lesions,68040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,199.82,,,,,,,fee schedule,173.98,1394.09,
Treatment of eyelid lesions,68040,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1394.09,,,,,,,fee schedule,173.98,1394.09,APC 378
Treatment of eyelid lesions,68040,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,329.93,,,,,,,fee schedule,173.98,1394.09,APC
Treatment of eyelid lesions,68040,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,326.79,,,,,,,fee schedule,173.98,1394.09,APC
Treatment of eyelid lesions,68040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,314.22,,,,,,,fee schedule,173.98,1394.09,APC
Treatment of eyelid lesions,68040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,480.76,,,,,,,fee schedule,173.98,1394.09,Radiology
Treatment of eyelid lesions,68040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,439.91,,,,,,,fee schedule,173.98,1394.09,APC
Treatment of eyelid lesions,68040,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,549.89,,,,,,,fee schedule,173.98,1394.09,APC
Biopsy of eyelid lining,68100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6253.46,,,,,,,fee schedule,2353.63,10442.27,
Biopsy of eyelid lining,68100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5012.69,,,,,,,fee schedule,2353.63,10442.27,
Biopsy of eyelid lining,68100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5475.91,,,,,,,fee schedule,2353.63,10442.27,
Biopsy of eyelid lining,68100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5757.15,,,,,,,fee schedule,2353.63,10442.27,
Biopsy of eyelid lining,68100,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2353.63,10442.27,APC 378
Biopsy of eyelid lining,68100,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2353.63,10442.27,APC
Biopsy of eyelid lining,68100,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2353.63,10442.27,APC
Biopsy of eyelid lining,68100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2353.63,10442.27,APC
Biopsy of eyelid lining,68100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2353.63,10442.27,Radiology
Biopsy of eyelid lining,68100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2353.63,10442.27,APC
Biopsy of eyelid lining,68100,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2353.63,10442.27,APC
Remove eyelid lining lesion,68110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6253.46,,,,,,,fee schedule,2353.63,10442.27,
Remove eyelid lining lesion,68110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5012.69,,,,,,,fee schedule,2353.63,10442.27,
Remove eyelid lining lesion,68110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5475.91,,,,,,,fee schedule,2353.63,10442.27,
Remove eyelid lining lesion,68110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5757.15,,,,,,,fee schedule,2353.63,10442.27,
Remove eyelid lining lesion,68110,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2353.63,10442.27,APC 378
Remove eyelid lining lesion,68110,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2353.63,10442.27,APC
Remove eyelid lining lesion,68110,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2353.63,10442.27,APC
Remove eyelid lining lesion,68110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2353.63,10442.27,APC
Remove eyelid lining lesion,68110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2353.63,10442.27,Radiology
Remove eyelid lining lesion,68110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2353.63,10442.27,APC
Remove eyelid lining lesion,68110,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2353.63,10442.27,APC
Remove eyelid lining lesion,68115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4674.69,,,,,,,fee schedule,2353.63,10442.27,
Remove eyelid lining lesion,68115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3747.17,,,,,,,fee schedule,2353.63,10442.27,
Remove eyelid lining lesion,68115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4093.44,,,,,,,fee schedule,2353.63,10442.27,
Remove eyelid lining lesion,68115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4303.68,,,,,,,fee schedule,2353.63,10442.27,
Remove eyelid lining lesion,68115,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2353.63,10442.27,APC 378
Remove eyelid lining lesion,68115,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2353.63,10442.27,APC
Remove eyelid lining lesion,68115,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2353.63,10442.27,APC
Remove eyelid lining lesion,68115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2353.63,10442.27,APC
Remove eyelid lining lesion,68115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2353.63,10442.27,Radiology
Remove eyelid lining lesion,68115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2353.63,10442.27,APC
Remove eyelid lining lesion,68115,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2353.63,10442.27,APC
Remove eyelid lining lesion,68130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4035.91,,,,,,,fee schedule,2353.63,10442.27,
Remove eyelid lining lesion,68130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3235.13,,,,,,,fee schedule,2353.63,10442.27,
Remove eyelid lining lesion,68130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3534.09,,,,,,,fee schedule,2353.63,10442.27,
Remove eyelid lining lesion,68130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3715.6,,,,,,,fee schedule,2353.63,10442.27,
Remove eyelid lining lesion,68130,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2353.63,10442.27,APC 378
Remove eyelid lining lesion,68130,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2353.63,10442.27,APC
Remove eyelid lining lesion,68130,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2353.63,10442.27,APC
Remove eyelid lining lesion,68130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2353.63,10442.27,APC
Remove eyelid lining lesion,68130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2353.63,10442.27,Radiology
Remove eyelid lining lesion,68130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2353.63,10442.27,APC
Remove eyelid lining lesion,68130,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2353.63,10442.27,APC
Remove eyelid lining lesion,68135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1818.07,,,,,,,fee schedule,1457.34,10442.27,
Remove eyelid lining lesion,68135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1457.34,,,,,,,fee schedule,1457.34,10442.27,
Remove eyelid lining lesion,68135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1592.01,,,,,,,fee schedule,1457.34,10442.27,
Remove eyelid lining lesion,68135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1673.78,,,,,,,fee schedule,1457.34,10442.27,
Remove eyelid lining lesion,68135,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,1457.34,10442.27,APC 378
Remove eyelid lining lesion,68135,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,1457.34,10442.27,APC
Remove eyelid lining lesion,68135,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,1457.34,10442.27,APC
Remove eyelid lining lesion,68135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,1457.34,10442.27,APC
Remove eyelid lining lesion,68135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,1457.34,10442.27,Radiology
Remove eyelid lining lesion,68135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,1457.34,10442.27,APC
Remove eyelid lining lesion,68135,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,1457.34,10442.27,APC
Treat eyelid by injection,68200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,217.05,,,,,,,fee schedule,173.98,1962.08,
Treat eyelid by injection,68200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,173.98,,,,,,,fee schedule,173.98,1962.08,
Treat eyelid by injection,68200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,190.06,,,,,,,fee schedule,173.98,1962.08,
Treat eyelid by injection,68200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,199.82,,,,,,,fee schedule,173.98,1962.08,
Treat eyelid by injection,68200,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1962.08,,,,,,,fee schedule,173.98,1962.08,APC 378
Treat eyelid by injection,68200,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,464.35,,,,,,,fee schedule,173.98,1962.08,APC
Treat eyelid by injection,68200,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,459.93,,,,,,,fee schedule,173.98,1962.08,APC
Treat eyelid by injection,68200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,442.24,,,,,,,fee schedule,173.98,1962.08,APC
Treat eyelid by injection,68200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,676.63,,,,,,,fee schedule,173.98,1962.08,Radiology
Treat eyelid by injection,68200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,619.14,,,,,,,fee schedule,173.98,1962.08,APC
Treat eyelid by injection,68200,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,773.92,,,,,,,fee schedule,173.98,1962.08,APC
Revise/graft eyelid lining,68320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4674.69,,,,,,,fee schedule,2353.63,10442.27,
Revise/graft eyelid lining,68320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3747.17,,,,,,,fee schedule,2353.63,10442.27,
Revise/graft eyelid lining,68320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4093.44,,,,,,,fee schedule,2353.63,10442.27,
Revise/graft eyelid lining,68320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4303.68,,,,,,,fee schedule,2353.63,10442.27,
Revise/graft eyelid lining,68320,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2353.63,10442.27,APC 378
Revise/graft eyelid lining,68320,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2353.63,10442.27,APC
Revise/graft eyelid lining,68320,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2353.63,10442.27,APC
Revise/graft eyelid lining,68320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2353.63,10442.27,APC
Revise/graft eyelid lining,68320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2353.63,10442.27,Radiology
Revise/graft eyelid lining,68320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2353.63,10442.27,APC
Revise/graft eyelid lining,68320,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2353.63,10442.27,APC
Revise/graft eyelid lining,68325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3360.79,,,,,,,fee schedule,2693.96,17267.29,
Revise/graft eyelid lining,68325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2693.96,,,,,,,fee schedule,2693.96,17267.29,
Revise/graft eyelid lining,68325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2942.91,,,,,,,fee schedule,2693.96,17267.29,
Revise/graft eyelid lining,68325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3094.06,,,,,,,fee schedule,2693.96,17267.29,
Revise/graft eyelid lining,68325,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17267.29,,,,,,,fee schedule,2693.96,17267.29,APC 378
Revise/graft eyelid lining,68325,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4086.55,,,,,,,fee schedule,2693.96,17267.29,APC
Revise/graft eyelid lining,68325,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4047.63,,,,,,,fee schedule,2693.96,17267.29,APC
Revise/graft eyelid lining,68325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3891.96,,,,,,,fee schedule,2693.96,17267.29,APC
Revise/graft eyelid lining,68325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5954.69,,,,,,,fee schedule,2693.96,17267.29,Radiology
Revise/graft eyelid lining,68325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5448.74,,,,,,,fee schedule,2693.96,17267.29,APC
Revise/graft eyelid lining,68325,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6810.92,,,,,,,fee schedule,2693.96,17267.29,APC
Revise/graft eyelid lining,68326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6066.6,,,,,,,fee schedule,3891.96,17267.29,
Revise/graft eyelid lining,68326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4862.91,,,,,,,fee schedule,3891.96,17267.29,
Revise/graft eyelid lining,68326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5312.29,,,,,,,fee schedule,3891.96,17267.29,
Revise/graft eyelid lining,68326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5585.12,,,,,,,fee schedule,3891.96,17267.29,
Revise/graft eyelid lining,68326,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17267.29,,,,,,,fee schedule,3891.96,17267.29,APC 378
Revise/graft eyelid lining,68326,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4086.55,,,,,,,fee schedule,3891.96,17267.29,APC
Revise/graft eyelid lining,68326,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4047.63,,,,,,,fee schedule,3891.96,17267.29,APC
Revise/graft eyelid lining,68326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3891.96,,,,,,,fee schedule,3891.96,17267.29,APC
Revise/graft eyelid lining,68326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5954.69,,,,,,,fee schedule,3891.96,17267.29,Radiology
Revise/graft eyelid lining,68326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5448.74,,,,,,,fee schedule,3891.96,17267.29,APC
Revise/graft eyelid lining,68326,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6810.92,,,,,,,fee schedule,3891.96,17267.29,APC
Revise/graft eyelid lining,68328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6066.6,,,,,,,fee schedule,2353.63,10442.27,
Revise/graft eyelid lining,68328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4862.91,,,,,,,fee schedule,2353.63,10442.27,
Revise/graft eyelid lining,68328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5312.29,,,,,,,fee schedule,2353.63,10442.27,
Revise/graft eyelid lining,68328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5585.12,,,,,,,fee schedule,2353.63,10442.27,
Revise/graft eyelid lining,68328,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2353.63,10442.27,APC 378
Revise/graft eyelid lining,68328,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2353.63,10442.27,APC
Revise/graft eyelid lining,68328,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2353.63,10442.27,APC
Revise/graft eyelid lining,68328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2353.63,10442.27,APC
Revise/graft eyelid lining,68328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2353.63,10442.27,Radiology
Revise/graft eyelid lining,68328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2353.63,10442.27,APC
Revise/graft eyelid lining,68328,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2353.63,10442.27,APC
Revise eyelid lining,68330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5784.12,,,,,,,fee schedule,2284.67,10136.31,
Revise eyelid lining,68330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4636.48,,,,,,,fee schedule,2284.67,10136.31,
Revise eyelid lining,68330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5064.93,,,,,,,fee schedule,2284.67,10136.31,
Revise eyelid lining,68330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5325.06,,,,,,,fee schedule,2284.67,10136.31,
Revise eyelid lining,68330,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10136.31,,,,,,,fee schedule,2284.67,10136.31,APC 378
Revise eyelid lining,68330,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2398.9,,,,,,,fee schedule,2284.67,10136.31,APC
Revise eyelid lining,68330,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2376.06,,,,,,,fee schedule,2284.67,10136.31,APC
Revise eyelid lining,68330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2284.67,,,,,,,fee schedule,2284.67,10136.31,APC
Revise eyelid lining,68330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3495.55,,,,,,,fee schedule,2284.67,10136.31,Radiology
Revise eyelid lining,68330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3198.54,,,,,,,fee schedule,2284.67,10136.31,APC
Revise eyelid lining,68330,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3998.17,,,,,,,fee schedule,2284.67,10136.31,APC
Revise/graft eyelid lining,68335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6066.6,,,,,,,fee schedule,3891.96,17267.29,
Revise/graft eyelid lining,68335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4862.91,,,,,,,fee schedule,3891.96,17267.29,
Revise/graft eyelid lining,68335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5312.29,,,,,,,fee schedule,3891.96,17267.29,
Revise/graft eyelid lining,68335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5585.12,,,,,,,fee schedule,3891.96,17267.29,
Revise/graft eyelid lining,68335,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17267.29,,,,,,,fee schedule,3891.96,17267.29,APC 378
Revise/graft eyelid lining,68335,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4086.55,,,,,,,fee schedule,3891.96,17267.29,APC
Revise/graft eyelid lining,68335,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4047.63,,,,,,,fee schedule,3891.96,17267.29,APC
Revise/graft eyelid lining,68335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3891.96,,,,,,,fee schedule,3891.96,17267.29,APC
Revise/graft eyelid lining,68335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5954.69,,,,,,,fee schedule,3891.96,17267.29,Radiology
Revise/graft eyelid lining,68335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5448.74,,,,,,,fee schedule,3891.96,17267.29,APC
Revise/graft eyelid lining,68335,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6810.92,,,,,,,fee schedule,3891.96,17267.29,APC
Separate eyelid adhesions,68340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4674.69,,,,,,,fee schedule,2353.63,10442.27,
Separate eyelid adhesions,68340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3747.17,,,,,,,fee schedule,2353.63,10442.27,
Separate eyelid adhesions,68340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4093.44,,,,,,,fee schedule,2353.63,10442.27,
Separate eyelid adhesions,68340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4303.68,,,,,,,fee schedule,2353.63,10442.27,
Separate eyelid adhesions,68340,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2353.63,10442.27,APC 378
Separate eyelid adhesions,68340,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2353.63,10442.27,APC
Separate eyelid adhesions,68340,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2353.63,10442.27,APC
Separate eyelid adhesions,68340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2353.63,10442.27,APC
Separate eyelid adhesions,68340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2353.63,10442.27,Radiology
Separate eyelid adhesions,68340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2353.63,10442.27,APC
Separate eyelid adhesions,68340,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2353.63,10442.27,APC
Revise eyelid lining,68360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5784.12,,,,,,,fee schedule,3891.96,17267.29,
Revise eyelid lining,68360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4636.48,,,,,,,fee schedule,3891.96,17267.29,
Revise eyelid lining,68360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5064.93,,,,,,,fee schedule,3891.96,17267.29,
Revise eyelid lining,68360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5325.06,,,,,,,fee schedule,3891.96,17267.29,
Revise eyelid lining,68360,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17267.29,,,,,,,fee schedule,3891.96,17267.29,APC 378
Revise eyelid lining,68360,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4086.55,,,,,,,fee schedule,3891.96,17267.29,APC
Revise eyelid lining,68360,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4047.63,,,,,,,fee schedule,3891.96,17267.29,APC
Revise eyelid lining,68360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3891.96,,,,,,,fee schedule,3891.96,17267.29,APC
Revise eyelid lining,68360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5954.69,,,,,,,fee schedule,3891.96,17267.29,Radiology
Revise eyelid lining,68360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5448.74,,,,,,,fee schedule,3891.96,17267.29,APC
Revise eyelid lining,68360,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6810.92,,,,,,,fee schedule,3891.96,17267.29,APC
Revise eyelid lining,68362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5784.12,,,,,,,fee schedule,2353.63,10442.27,
Revise eyelid lining,68362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4636.48,,,,,,,fee schedule,2353.63,10442.27,
Revise eyelid lining,68362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5064.93,,,,,,,fee schedule,2353.63,10442.27,
Revise eyelid lining,68362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5325.06,,,,,,,fee schedule,2353.63,10442.27,
Revise eyelid lining,68362,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2353.63,10442.27,APC 378
Revise eyelid lining,68362,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2353.63,10442.27,APC
Revise eyelid lining,68362,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2353.63,10442.27,APC
Revise eyelid lining,68362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2353.63,10442.27,APC
Revise eyelid lining,68362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2353.63,10442.27,Radiology
Revise eyelid lining,68362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2353.63,10442.27,APC
Revise eyelid lining,68362,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2353.63,10442.27,APC
Harvest eye tissue alograft,68371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4035.91,,,,,,,fee schedule,2353.63,10442.27,
Harvest eye tissue alograft,68371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3235.13,,,,,,,fee schedule,2353.63,10442.27,
Harvest eye tissue alograft,68371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3534.09,,,,,,,fee schedule,2353.63,10442.27,
Harvest eye tissue alograft,68371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3715.6,,,,,,,fee schedule,2353.63,10442.27,
Harvest eye tissue alograft,68371,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2353.63,10442.27,APC 378
Harvest eye tissue alograft,68371,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2353.63,10442.27,APC
Harvest eye tissue alograft,68371,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2353.63,10442.27,APC
Harvest eye tissue alograft,68371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2353.63,10442.27,APC
Harvest eye tissue alograft,68371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2353.63,10442.27,Radiology
Harvest eye tissue alograft,68371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2353.63,10442.27,APC
Harvest eye tissue alograft,68371,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2353.63,10442.27,APC
Eyelid lining surgery,68399,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,724.32,,,,,,,fee schedule,314.22,1394.09,
Eyelid lining surgery,68399,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,580.61,,,,,,,fee schedule,314.22,1394.09,
Eyelid lining surgery,68399,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,634.26,,,,,,,fee schedule,314.22,1394.09,
Eyelid lining surgery,68399,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,666.84,,,,,,,fee schedule,314.22,1394.09,
Eyelid lining surgery,68399,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1394.09,,,,,,,fee schedule,314.22,1394.09,APC 378
Eyelid lining surgery,68399,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,329.93,,,,,,,fee schedule,314.22,1394.09,APC
Eyelid lining surgery,68399,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,326.79,,,,,,,fee schedule,314.22,1394.09,APC
Eyelid lining surgery,68399,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,314.22,,,,,,,fee schedule,314.22,1394.09,APC
Eyelid lining surgery,68399,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,480.76,,,,,,,fee schedule,314.22,1394.09,Radiology
Eyelid lining surgery,68399,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,439.91,,,,,,,fee schedule,314.22,1394.09,APC
Eyelid lining surgery,68399,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,549.89,,,,,,,fee schedule,314.22,1394.09,APC
Incise/drain tear gland,68400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,724.32,,,,,,,fee schedule,580.61,4378.44,
Incise/drain tear gland,68400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,580.61,,,,,,,fee schedule,580.61,4378.44,
Incise/drain tear gland,68400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,634.26,,,,,,,fee schedule,580.61,4378.44,
Incise/drain tear gland,68400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,666.84,,,,,,,fee schedule,580.61,4378.44,
Incise/drain tear gland,68400,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4378.44,,,,,,,fee schedule,580.61,4378.44,APC 378
Incise/drain tear gland,68400,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1036.22,,,,,,,fee schedule,580.61,4378.44,APC
Incise/drain tear gland,68400,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1026.35,,,,,,,fee schedule,580.61,4378.44,APC
Incise/drain tear gland,68400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,986.88,,,,,,,fee schedule,580.61,4378.44,APC
Incise/drain tear gland,68400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1509.92,,,,,,,fee schedule,580.61,4378.44,Radiology
Incise/drain tear gland,68400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1381.63,,,,,,,fee schedule,580.61,4378.44,APC
Incise/drain tear gland,68400,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1727.03,,,,,,,fee schedule,580.61,4378.44,APC
Incise/drain tear sac,68420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4674.69,,,,,,,fee schedule,2353.63,10442.27,
Incise/drain tear sac,68420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3747.17,,,,,,,fee schedule,2353.63,10442.27,
Incise/drain tear sac,68420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4093.44,,,,,,,fee schedule,2353.63,10442.27,
Incise/drain tear sac,68420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4303.68,,,,,,,fee schedule,2353.63,10442.27,
Incise/drain tear sac,68420,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2353.63,10442.27,APC 378
Incise/drain tear sac,68420,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2353.63,10442.27,APC
Incise/drain tear sac,68420,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2353.63,10442.27,APC
Incise/drain tear sac,68420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2353.63,10442.27,APC
Incise/drain tear sac,68420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2353.63,10442.27,Radiology
Incise/drain tear sac,68420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2353.63,10442.27,APC
Incise/drain tear sac,68420,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2353.63,10442.27,APC
Incise tear duct opening,68440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,724.32,,,,,,,fee schedule,314.22,1394.09,
Incise tear duct opening,68440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,580.61,,,,,,,fee schedule,314.22,1394.09,
Incise tear duct opening,68440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,634.26,,,,,,,fee schedule,314.22,1394.09,
Incise tear duct opening,68440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,666.84,,,,,,,fee schedule,314.22,1394.09,
Incise tear duct opening,68440,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1394.09,,,,,,,fee schedule,314.22,1394.09,APC 378
Incise tear duct opening,68440,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,329.93,,,,,,,fee schedule,314.22,1394.09,APC
Incise tear duct opening,68440,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,326.79,,,,,,,fee schedule,314.22,1394.09,APC
Incise tear duct opening,68440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,314.22,,,,,,,fee schedule,314.22,1394.09,APC
Incise tear duct opening,68440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,480.76,,,,,,,fee schedule,314.22,1394.09,Radiology
Incise tear duct opening,68440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,439.91,,,,,,,fee schedule,314.22,1394.09,APC
Incise tear duct opening,68440,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,549.89,,,,,,,fee schedule,314.22,1394.09,APC
Removal of tear gland,68500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6066.6,,,,,,,fee schedule,3891.96,17267.29,
Removal of tear gland,68500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4862.91,,,,,,,fee schedule,3891.96,17267.29,
Removal of tear gland,68500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5312.29,,,,,,,fee schedule,3891.96,17267.29,
Removal of tear gland,68500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5585.12,,,,,,,fee schedule,3891.96,17267.29,
Removal of tear gland,68500,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17267.29,,,,,,,fee schedule,3891.96,17267.29,APC 378
Removal of tear gland,68500,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4086.55,,,,,,,fee schedule,3891.96,17267.29,APC
Removal of tear gland,68500,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4047.63,,,,,,,fee schedule,3891.96,17267.29,APC
Removal of tear gland,68500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3891.96,,,,,,,fee schedule,3891.96,17267.29,APC
Removal of tear gland,68500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5954.69,,,,,,,fee schedule,3891.96,17267.29,Radiology
Removal of tear gland,68500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5448.74,,,,,,,fee schedule,3891.96,17267.29,APC
Removal of tear gland,68500,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6810.92,,,,,,,fee schedule,3891.96,17267.29,APC
Partial removal tear gland,68505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6066.6,,,,,,,fee schedule,3891.96,17267.29,
Partial removal tear gland,68505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4862.91,,,,,,,fee schedule,3891.96,17267.29,
Partial removal tear gland,68505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5312.29,,,,,,,fee schedule,3891.96,17267.29,
Partial removal tear gland,68505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5585.12,,,,,,,fee schedule,3891.96,17267.29,
Partial removal tear gland,68505,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17267.29,,,,,,,fee schedule,3891.96,17267.29,APC 378
Partial removal tear gland,68505,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4086.55,,,,,,,fee schedule,3891.96,17267.29,APC
Partial removal tear gland,68505,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4047.63,,,,,,,fee schedule,3891.96,17267.29,APC
Partial removal tear gland,68505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3891.96,,,,,,,fee schedule,3891.96,17267.29,APC
Partial removal tear gland,68505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5954.69,,,,,,,fee schedule,3891.96,17267.29,Radiology
Partial removal tear gland,68505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5448.74,,,,,,,fee schedule,3891.96,17267.29,APC
Partial removal tear gland,68505,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6810.92,,,,,,,fee schedule,3891.96,17267.29,APC
Biopsy of tear gland,68510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4674.69,,,,,,,fee schedule,2353.63,10442.27,
Biopsy of tear gland,68510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3747.17,,,,,,,fee schedule,2353.63,10442.27,
Biopsy of tear gland,68510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4093.44,,,,,,,fee schedule,2353.63,10442.27,
Biopsy of tear gland,68510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4303.68,,,,,,,fee schedule,2353.63,10442.27,
Biopsy of tear gland,68510,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2353.63,10442.27,APC 378
Biopsy of tear gland,68510,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2353.63,10442.27,APC
Biopsy of tear gland,68510,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2353.63,10442.27,APC
Biopsy of tear gland,68510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2353.63,10442.27,APC
Biopsy of tear gland,68510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2353.63,10442.27,Radiology
Biopsy of tear gland,68510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2353.63,10442.27,APC
Biopsy of tear gland,68510,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2353.63,10442.27,APC
Removal of tear sac,68520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6066.6,,,,,,,fee schedule,3891.96,17267.29,
Removal of tear sac,68520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4862.91,,,,,,,fee schedule,3891.96,17267.29,
Removal of tear sac,68520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5312.29,,,,,,,fee schedule,3891.96,17267.29,
Removal of tear sac,68520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5585.12,,,,,,,fee schedule,3891.96,17267.29,
Removal of tear sac,68520,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17267.29,,,,,,,fee schedule,3891.96,17267.29,APC 378
Removal of tear sac,68520,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4086.55,,,,,,,fee schedule,3891.96,17267.29,APC
Removal of tear sac,68520,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4047.63,,,,,,,fee schedule,3891.96,17267.29,APC
Removal of tear sac,68520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3891.96,,,,,,,fee schedule,3891.96,17267.29,APC
Removal of tear sac,68520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5954.69,,,,,,,fee schedule,3891.96,17267.29,Radiology
Removal of tear sac,68520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5448.74,,,,,,,fee schedule,3891.96,17267.29,APC
Removal of tear sac,68520,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6810.92,,,,,,,fee schedule,3891.96,17267.29,APC
Biopsy of tear sac,68525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4674.69,,,,,,,fee schedule,2353.63,10442.27,
Biopsy of tear sac,68525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3747.17,,,,,,,fee schedule,2353.63,10442.27,
Biopsy of tear sac,68525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4093.44,,,,,,,fee schedule,2353.63,10442.27,
Biopsy of tear sac,68525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4303.68,,,,,,,fee schedule,2353.63,10442.27,
Biopsy of tear sac,68525,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2353.63,10442.27,APC 378
Biopsy of tear sac,68525,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2353.63,10442.27,APC
Biopsy of tear sac,68525,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2353.63,10442.27,APC
Biopsy of tear sac,68525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2353.63,10442.27,APC
Biopsy of tear sac,68525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2353.63,10442.27,Radiology
Biopsy of tear sac,68525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2353.63,10442.27,APC
Biopsy of tear sac,68525,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2353.63,10442.27,APC
Clearance of tear duct,68530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4674.69,,,,,,,fee schedule,314.22,4674.69,
Clearance of tear duct,68530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3747.17,,,,,,,fee schedule,314.22,4674.69,
Clearance of tear duct,68530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4093.44,,,,,,,fee schedule,314.22,4674.69,
Clearance of tear duct,68530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4303.68,,,,,,,fee schedule,314.22,4674.69,
Clearance of tear duct,68530,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1394.09,,,,,,,fee schedule,314.22,4674.69,APC 378
Clearance of tear duct,68530,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,329.93,,,,,,,fee schedule,314.22,4674.69,APC
Clearance of tear duct,68530,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,326.79,,,,,,,fee schedule,314.22,4674.69,APC
Clearance of tear duct,68530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,314.22,,,,,,,fee schedule,314.22,4674.69,APC
Clearance of tear duct,68530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,480.76,,,,,,,fee schedule,314.22,4674.69,Radiology
Clearance of tear duct,68530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,439.91,,,,,,,fee schedule,314.22,4674.69,APC
Clearance of tear duct,68530,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,549.89,,,,,,,fee schedule,314.22,4674.69,APC
Remove tear gland lesion,68540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6066.6,,,,,,,fee schedule,2353.63,10442.27,
Remove tear gland lesion,68540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4862.91,,,,,,,fee schedule,2353.63,10442.27,
Remove tear gland lesion,68540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5312.29,,,,,,,fee schedule,2353.63,10442.27,
Remove tear gland lesion,68540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5585.12,,,,,,,fee schedule,2353.63,10442.27,
Remove tear gland lesion,68540,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2353.63,10442.27,APC 378
Remove tear gland lesion,68540,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2353.63,10442.27,APC
Remove tear gland lesion,68540,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2353.63,10442.27,APC
Remove tear gland lesion,68540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2353.63,10442.27,APC
Remove tear gland lesion,68540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2353.63,10442.27,Radiology
Remove tear gland lesion,68540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2353.63,10442.27,APC
Remove tear gland lesion,68540,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2353.63,10442.27,APC
Remove tear gland lesion,68550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6066.6,,,,,,,fee schedule,3891.96,17267.29,
Remove tear gland lesion,68550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4862.91,,,,,,,fee schedule,3891.96,17267.29,
Remove tear gland lesion,68550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5312.29,,,,,,,fee schedule,3891.96,17267.29,
Remove tear gland lesion,68550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5585.12,,,,,,,fee schedule,3891.96,17267.29,
Remove tear gland lesion,68550,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17267.29,,,,,,,fee schedule,3891.96,17267.29,APC 378
Remove tear gland lesion,68550,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4086.55,,,,,,,fee schedule,3891.96,17267.29,APC
Remove tear gland lesion,68550,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4047.63,,,,,,,fee schedule,3891.96,17267.29,APC
Remove tear gland lesion,68550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3891.96,,,,,,,fee schedule,3891.96,17267.29,APC
Remove tear gland lesion,68550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5954.69,,,,,,,fee schedule,3891.96,17267.29,Radiology
Remove tear gland lesion,68550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5448.74,,,,,,,fee schedule,3891.96,17267.29,APC
Remove tear gland lesion,68550,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6810.92,,,,,,,fee schedule,3891.96,17267.29,APC
Repair tear ducts,68700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6066.6,,,,,,,fee schedule,2353.63,10442.27,
Repair tear ducts,68700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4862.91,,,,,,,fee schedule,2353.63,10442.27,
Repair tear ducts,68700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5312.29,,,,,,,fee schedule,2353.63,10442.27,
Repair tear ducts,68700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5585.12,,,,,,,fee schedule,2353.63,10442.27,
Repair tear ducts,68700,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2353.63,10442.27,APC 378
Repair tear ducts,68700,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2353.63,10442.27,APC
Repair tear ducts,68700,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2353.63,10442.27,APC
Repair tear ducts,68700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2353.63,10442.27,APC
Repair tear ducts,68700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2353.63,10442.27,Radiology
Repair tear ducts,68700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2353.63,10442.27,APC
Repair tear ducts,68700,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2353.63,10442.27,APC
Revise tear duct opening,68705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,724.32,,,,,,,fee schedule,314.22,1394.09,
Revise tear duct opening,68705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,580.61,,,,,,,fee schedule,314.22,1394.09,
Revise tear duct opening,68705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,634.26,,,,,,,fee schedule,314.22,1394.09,
Revise tear duct opening,68705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,666.84,,,,,,,fee schedule,314.22,1394.09,
Revise tear duct opening,68705,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1394.09,,,,,,,fee schedule,314.22,1394.09,APC 378
Revise tear duct opening,68705,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,329.93,,,,,,,fee schedule,314.22,1394.09,APC
Revise tear duct opening,68705,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,326.79,,,,,,,fee schedule,314.22,1394.09,APC
Revise tear duct opening,68705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,314.22,,,,,,,fee schedule,314.22,1394.09,APC
Revise tear duct opening,68705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,480.76,,,,,,,fee schedule,314.22,1394.09,Radiology
Revise tear duct opening,68705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,439.91,,,,,,,fee schedule,314.22,1394.09,APC
Revise tear duct opening,68705,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,549.89,,,,,,,fee schedule,314.22,1394.09,APC
Create tear sac drain,68720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5275.24,,,,,,,fee schedule,3891.96,17267.29,
Create tear sac drain,68720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4228.56,,,,,,,fee schedule,3891.96,17267.29,
Create tear sac drain,68720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4619.32,,,,,,,fee schedule,3891.96,17267.29,
Create tear sac drain,68720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4856.57,,,,,,,fee schedule,3891.96,17267.29,
Create tear sac drain,68720,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17267.29,,,,,,,fee schedule,3891.96,17267.29,APC 378
Create tear sac drain,68720,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4086.55,,,,,,,fee schedule,3891.96,17267.29,APC
Create tear sac drain,68720,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4047.63,,,,,,,fee schedule,3891.96,17267.29,APC
Create tear sac drain,68720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3891.96,,,,,,,fee schedule,3891.96,17267.29,APC
Create tear sac drain,68720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5954.69,,,,,,,fee schedule,3891.96,17267.29,Radiology
Create tear sac drain,68720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5448.74,,,,,,,fee schedule,3891.96,17267.29,APC
Create tear sac drain,68720,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6810.92,,,,,,,fee schedule,3891.96,17267.29,APC
Create tear duct drain,68745,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6066.6,,,,,,,fee schedule,3891.96,17267.29,
Create tear duct drain,68745,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4862.91,,,,,,,fee schedule,3891.96,17267.29,
Create tear duct drain,68745,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5312.29,,,,,,,fee schedule,3891.96,17267.29,
Create tear duct drain,68745,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5585.12,,,,,,,fee schedule,3891.96,17267.29,
Create tear duct drain,68745,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17267.29,,,,,,,fee schedule,3891.96,17267.29,APC 378
Create tear duct drain,68745,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4086.55,,,,,,,fee schedule,3891.96,17267.29,APC
Create tear duct drain,68745,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4047.63,,,,,,,fee schedule,3891.96,17267.29,APC
Create tear duct drain,68745,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3891.96,,,,,,,fee schedule,3891.96,17267.29,APC
Create tear duct drain,68745,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5954.69,,,,,,,fee schedule,3891.96,17267.29,Radiology
Create tear duct drain,68745,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5448.74,,,,,,,fee schedule,3891.96,17267.29,APC
Create tear duct drain,68745,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6810.92,,,,,,,fee schedule,3891.96,17267.29,APC
Create tear duct drain,68750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6066.6,,,,,,,fee schedule,3891.96,17267.29,
Create tear duct drain,68750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4862.91,,,,,,,fee schedule,3891.96,17267.29,
Create tear duct drain,68750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5312.29,,,,,,,fee schedule,3891.96,17267.29,
Create tear duct drain,68750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5585.12,,,,,,,fee schedule,3891.96,17267.29,
Create tear duct drain,68750,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17267.29,,,,,,,fee schedule,3891.96,17267.29,APC 378
Create tear duct drain,68750,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4086.55,,,,,,,fee schedule,3891.96,17267.29,APC
Create tear duct drain,68750,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4047.63,,,,,,,fee schedule,3891.96,17267.29,APC
Create tear duct drain,68750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3891.96,,,,,,,fee schedule,3891.96,17267.29,APC
Create tear duct drain,68750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5954.69,,,,,,,fee schedule,3891.96,17267.29,Radiology
Create tear duct drain,68750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5448.74,,,,,,,fee schedule,3891.96,17267.29,APC
Create tear duct drain,68750,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6810.92,,,,,,,fee schedule,3891.96,17267.29,APC
Close tear duct opening,68760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,543.83,,,,,,,fee schedule,314.22,1394.09,
Close tear duct opening,68760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,435.93,,,,,,,fee schedule,314.22,1394.09,
Close tear duct opening,68760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,476.21,,,,,,,fee schedule,314.22,1394.09,
Close tear duct opening,68760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,500.67,,,,,,,fee schedule,314.22,1394.09,
Close tear duct opening,68760,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1394.09,,,,,,,fee schedule,314.22,1394.09,APC 378
Close tear duct opening,68760,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,329.93,,,,,,,fee schedule,314.22,1394.09,APC
Close tear duct opening,68760,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,326.79,,,,,,,fee schedule,314.22,1394.09,APC
Close tear duct opening,68760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,314.22,,,,,,,fee schedule,314.22,1394.09,APC
Close tear duct opening,68760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,480.76,,,,,,,fee schedule,314.22,1394.09,Radiology
Close tear duct opening,68760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,439.91,,,,,,,fee schedule,314.22,1394.09,APC
Close tear duct opening,68760,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,549.89,,,,,,,fee schedule,314.22,1394.09,APC
Close tear duct opening,68761,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,543.83,,,,,,,fee schedule,314.22,1394.09,
Close tear duct opening,68761,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,435.93,,,,,,,fee schedule,314.22,1394.09,
Close tear duct opening,68761,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,476.21,,,,,,,fee schedule,314.22,1394.09,
Close tear duct opening,68761,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,500.67,,,,,,,fee schedule,314.22,1394.09,
Close tear duct opening,68761,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1394.09,,,,,,,fee schedule,314.22,1394.09,APC 378
Close tear duct opening,68761,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,329.93,,,,,,,fee schedule,314.22,1394.09,APC
Close tear duct opening,68761,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,326.79,,,,,,,fee schedule,314.22,1394.09,APC
Close tear duct opening,68761,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,314.22,,,,,,,fee schedule,314.22,1394.09,APC
Close tear duct opening,68761,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,480.76,,,,,,,fee schedule,314.22,1394.09,Radiology
Close tear duct opening,68761,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,439.91,,,,,,,fee schedule,314.22,1394.09,APC
Close tear duct opening,68761,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,549.89,,,,,,,fee schedule,314.22,1394.09,APC
Close tear system fistula,68770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4674.69,,,,,,,fee schedule,2353.63,10442.27,
Close tear system fistula,68770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3747.17,,,,,,,fee schedule,2353.63,10442.27,
Close tear system fistula,68770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4093.44,,,,,,,fee schedule,2353.63,10442.27,
Close tear system fistula,68770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4303.68,,,,,,,fee schedule,2353.63,10442.27,
Close tear system fistula,68770,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2353.63,10442.27,APC 378
Close tear system fistula,68770,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2353.63,10442.27,APC
Close tear system fistula,68770,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2353.63,10442.27,APC
Close tear system fistula,68770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2353.63,10442.27,APC
Close tear system fistula,68770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2353.63,10442.27,Radiology
Close tear system fistula,68770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2353.63,10442.27,APC
Close tear system fistula,68770,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2353.63,10442.27,APC
Dilate tear duct opening,68801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,217.05,,,,,,,fee schedule,173.98,1962.08,
Dilate tear duct opening,68801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,173.98,,,,,,,fee schedule,173.98,1962.08,
Dilate tear duct opening,68801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,190.06,,,,,,,fee schedule,173.98,1962.08,
Dilate tear duct opening,68801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,199.82,,,,,,,fee schedule,173.98,1962.08,
Dilate tear duct opening,68801,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1962.08,,,,,,,fee schedule,173.98,1962.08,APC 378
Dilate tear duct opening,68801,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,464.35,,,,,,,fee schedule,173.98,1962.08,APC
Dilate tear duct opening,68801,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,459.93,,,,,,,fee schedule,173.98,1962.08,APC
Dilate tear duct opening,68801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,442.24,,,,,,,fee schedule,173.98,1962.08,APC
Dilate tear duct opening,68801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,676.63,,,,,,,fee schedule,173.98,1962.08,Radiology
Dilate tear duct opening,68801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,619.14,,,,,,,fee schedule,173.98,1962.08,APC
Dilate tear duct opening,68801,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,773.92,,,,,,,fee schedule,173.98,1962.08,APC
Probe nasolacrimal duct,68810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1824.24,,,,,,,fee schedule,314.22,1824.24,
Probe nasolacrimal duct,68810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1462.29,,,,,,,fee schedule,314.22,1824.24,
Probe nasolacrimal duct,68810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1597.42,,,,,,,fee schedule,314.22,1824.24,
Probe nasolacrimal duct,68810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1679.46,,,,,,,fee schedule,314.22,1824.24,
Probe nasolacrimal duct,68810,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1394.09,,,,,,,fee schedule,314.22,1824.24,APC 378
Probe nasolacrimal duct,68810,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,329.93,,,,,,,fee schedule,314.22,1824.24,APC
Probe nasolacrimal duct,68810,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,326.79,,,,,,,fee schedule,314.22,1824.24,APC
Probe nasolacrimal duct,68810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,314.22,,,,,,,fee schedule,314.22,1824.24,APC
Probe nasolacrimal duct,68810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,480.76,,,,,,,fee schedule,314.22,1824.24,Radiology
Probe nasolacrimal duct,68810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,439.91,,,,,,,fee schedule,314.22,1824.24,APC
Probe nasolacrimal duct,68810,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,549.89,,,,,,,fee schedule,314.22,1824.24,APC
Probe nasolacrimal duct,68811,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3504.63,,,,,,,fee schedule,2353.63,10442.27,
Probe nasolacrimal duct,68811,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2809.27,,,,,,,fee schedule,2353.63,10442.27,
Probe nasolacrimal duct,68811,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3068.87,,,,,,,fee schedule,2353.63,10442.27,
Probe nasolacrimal duct,68811,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3226.49,,,,,,,fee schedule,2353.63,10442.27,
Probe nasolacrimal duct,68811,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2353.63,10442.27,APC 378
Probe nasolacrimal duct,68811,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2353.63,10442.27,APC
Probe nasolacrimal duct,68811,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2353.63,10442.27,APC
Probe nasolacrimal duct,68811,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2353.63,10442.27,APC
Probe nasolacrimal duct,68811,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2353.63,10442.27,Radiology
Probe nasolacrimal duct,68811,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2353.63,10442.27,APC
Probe nasolacrimal duct,68811,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2353.63,10442.27,APC
Probe nasolacrimal duct,68815,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3360.79,,,,,,,fee schedule,2353.63,10442.27,
Probe nasolacrimal duct,68815,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2693.96,,,,,,,fee schedule,2353.63,10442.27,
Probe nasolacrimal duct,68815,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2942.91,,,,,,,fee schedule,2353.63,10442.27,
Probe nasolacrimal duct,68815,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3094.06,,,,,,,fee schedule,2353.63,10442.27,
Probe nasolacrimal duct,68815,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2353.63,10442.27,APC 378
Probe nasolacrimal duct,68815,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2353.63,10442.27,APC
Probe nasolacrimal duct,68815,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2353.63,10442.27,APC
Probe nasolacrimal duct,68815,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2353.63,10442.27,APC
Probe nasolacrimal duct,68815,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2353.63,10442.27,Radiology
Probe nasolacrimal duct,68815,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2353.63,10442.27,APC
Probe nasolacrimal duct,68815,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2353.63,10442.27,APC
Probe nl duct w/balloon,68816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4674.69,,,,,,,fee schedule,2353.63,10442.27,
Probe nl duct w/balloon,68816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3747.17,,,,,,,fee schedule,2353.63,10442.27,
Probe nl duct w/balloon,68816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4093.44,,,,,,,fee schedule,2353.63,10442.27,
Probe nl duct w/balloon,68816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4303.68,,,,,,,fee schedule,2353.63,10442.27,
Probe nl duct w/balloon,68816,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2353.63,10442.27,APC 378
Probe nl duct w/balloon,68816,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2353.63,10442.27,APC
Probe nl duct w/balloon,68816,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2353.63,10442.27,APC
Probe nl duct w/balloon,68816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2353.63,10442.27,APC
Probe nl duct w/balloon,68816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2353.63,10442.27,Radiology
Probe nl duct w/balloon,68816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2353.63,10442.27,APC
Probe nl duct w/balloon,68816,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2353.63,10442.27,APC
Explore/irrigate tear ducts,68840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,543.83,,,,,,,fee schedule,314.22,1394.09,
Explore/irrigate tear ducts,68840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,435.93,,,,,,,fee schedule,314.22,1394.09,
Explore/irrigate tear ducts,68840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,476.21,,,,,,,fee schedule,314.22,1394.09,
Explore/irrigate tear ducts,68840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,500.67,,,,,,,fee schedule,314.22,1394.09,
Explore/irrigate tear ducts,68840,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1394.09,,,,,,,fee schedule,314.22,1394.09,APC 378
Explore/irrigate tear ducts,68840,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,329.93,,,,,,,fee schedule,314.22,1394.09,APC
Explore/irrigate tear ducts,68840,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,326.79,,,,,,,fee schedule,314.22,1394.09,APC
Explore/irrigate tear ducts,68840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,314.22,,,,,,,fee schedule,314.22,1394.09,APC
Explore/irrigate tear ducts,68840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,480.76,,,,,,,fee schedule,314.22,1394.09,Radiology
Explore/irrigate tear ducts,68840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,439.91,,,,,,,fee schedule,314.22,1394.09,APC
Explore/irrigate tear ducts,68840,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,549.89,,,,,,,fee schedule,314.22,1394.09,APC
Insj rx elut implt lac canal,68841,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1230.92,,,,,,,fee schedule,986.69,10442.27,
Insj rx elut implt lac canal,68841,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,986.69,,,,,,,fee schedule,986.69,10442.27,
Insj rx elut implt lac canal,68841,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1077.87,,,,,,,fee schedule,986.69,10442.27,
Insj rx elut implt lac canal,68841,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1133.23,,,,,,,fee schedule,986.69,10442.27,
Insj rx elut implt lac canal,68841,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,986.69,10442.27,APC 378
Insj rx elut implt lac canal,68841,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,986.69,10442.27,APC
Insj rx elut implt lac canal,68841,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,986.69,10442.27,APC
Insj rx elut implt lac canal,68841,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,986.69,10442.27,APC
Insj rx elut implt lac canal,68841,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,986.69,10442.27,Radiology
Insj rx elut implt lac canal,68841,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,986.69,10442.27,APC
Insj rx elut implt lac canal,68841,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,986.69,10442.27,APC
Tear duct system surgery,68899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,724.32,,,,,,,fee schedule,314.22,1394.09,
Tear duct system surgery,68899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,580.61,,,,,,,fee schedule,314.22,1394.09,
Tear duct system surgery,68899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,634.26,,,,,,,fee schedule,314.22,1394.09,
Tear duct system surgery,68899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,666.84,,,,,,,fee schedule,314.22,1394.09,
Tear duct system surgery,68899,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1394.09,,,,,,,fee schedule,314.22,1394.09,APC 378
Tear duct system surgery,68899,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,329.93,,,,,,,fee schedule,314.22,1394.09,APC
Tear duct system surgery,68899,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,326.79,,,,,,,fee schedule,314.22,1394.09,APC
Tear duct system surgery,68899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,314.22,,,,,,,fee schedule,314.22,1394.09,APC
Tear duct system surgery,68899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,480.76,,,,,,,fee schedule,314.22,1394.09,Radiology
Tear duct system surgery,68899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,439.91,,,,,,,fee schedule,314.22,1394.09,APC
Tear duct system surgery,68899,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,549.89,,,,,,,fee schedule,314.22,1394.09,APC
Drain external ear lesion,69000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,228.64,,,,,,,fee schedule,183.27,3110.22,
Drain external ear lesion,69000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,183.27,,,,,,,fee schedule,183.27,3110.22,
Drain external ear lesion,69000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,200.21,,,,,,,fee schedule,183.27,3110.22,
Drain external ear lesion,69000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,210.49,,,,,,,fee schedule,183.27,3110.22,
Drain external ear lesion,69000,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3110.22,,,,,,,fee schedule,183.27,3110.22,APC 378
Drain external ear lesion,69000,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,736.08,,,,,,,fee schedule,183.27,3110.22,APC
Drain external ear lesion,69000,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,729.07,,,,,,,fee schedule,183.27,3110.22,APC
Drain external ear lesion,69000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,701.03,,,,,,,fee schedule,183.27,3110.22,APC
Drain external ear lesion,69000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1072.57,,,,,,,fee schedule,183.27,3110.22,Radiology
Drain external ear lesion,69000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,981.44,,,,,,,fee schedule,183.27,3110.22,APC
Drain external ear lesion,69000,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1226.8,,,,,,,fee schedule,183.27,3110.22,APC
Drain external ear lesion,69005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4572.14,,,,,,,fee schedule,1635.03,7254.06,
Drain external ear lesion,69005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3664.97,,,,,,,fee schedule,1635.03,7254.06,
Drain external ear lesion,69005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4003.64,,,,,,,fee schedule,1635.03,7254.06,
Drain external ear lesion,69005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4209.27,,,,,,,fee schedule,1635.03,7254.06,
Drain external ear lesion,69005,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,7254.06,APC 378
Drain external ear lesion,69005,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,7254.06,APC
Drain external ear lesion,69005,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,7254.06,APC
Drain external ear lesion,69005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,7254.06,APC
Drain external ear lesion,69005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,7254.06,Radiology
Drain external ear lesion,69005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,7254.06,APC
Drain external ear lesion,69005,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,7254.06,APC
Drain outer ear canal lesion,69020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,351.05,,,,,,,fee schedule,281.4,3110.22,
Drain outer ear canal lesion,69020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,281.4,,,,,,,fee schedule,281.4,3110.22,
Drain outer ear canal lesion,69020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,307.4,,,,,,,fee schedule,281.4,3110.22,
Drain outer ear canal lesion,69020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,323.19,,,,,,,fee schedule,281.4,3110.22,
Drain outer ear canal lesion,69020,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3110.22,,,,,,,fee schedule,281.4,3110.22,APC 378
Drain outer ear canal lesion,69020,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,736.08,,,,,,,fee schedule,281.4,3110.22,APC
Drain outer ear canal lesion,69020,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,729.07,,,,,,,fee schedule,281.4,3110.22,APC
Drain outer ear canal lesion,69020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,701.03,,,,,,,fee schedule,281.4,3110.22,APC
Drain outer ear canal lesion,69020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1072.57,,,,,,,fee schedule,281.4,3110.22,Radiology
Drain outer ear canal lesion,69020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,981.44,,,,,,,fee schedule,281.4,3110.22,APC
Drain outer ear canal lesion,69020,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1226.8,,,,,,,fee schedule,281.4,3110.22,APC
Biopsy of external ear,69100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,624,,,,,,,fee schedule,234.47,1040.28,
Biopsy of external ear,69100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,500.19,,,,,,,fee schedule,234.47,1040.28,
Biopsy of external ear,69100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,546.41,,,,,,,fee schedule,234.47,1040.28,
Biopsy of external ear,69100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,574.48,,,,,,,fee schedule,234.47,1040.28,
Biopsy of external ear,69100,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1040.28,,,,,,,fee schedule,234.47,1040.28,APC 378
Biopsy of external ear,69100,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,246.2,,,,,,,fee schedule,234.47,1040.28,APC
Biopsy of external ear,69100,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,243.85,,,,,,,fee schedule,234.47,1040.28,APC
Biopsy of external ear,69100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,234.47,,,,,,,fee schedule,234.47,1040.28,APC
Biopsy of external ear,69100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,358.74,,,,,,,fee schedule,234.47,1040.28,Radiology
Biopsy of external ear,69100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,328.26,,,,,,,fee schedule,234.47,1040.28,APC
Biopsy of external ear,69100,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,410.33,,,,,,,fee schedule,234.47,1040.28,APC
Biopsy of external ear canal,69105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4075.29,,,,,,,fee schedule,1536.02,6814.79,
Biopsy of external ear canal,69105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3266.7,,,,,,,fee schedule,1536.02,6814.79,
Biopsy of external ear canal,69105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3568.58,,,,,,,fee schedule,1536.02,6814.79,
Biopsy of external ear canal,69105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3751.86,,,,,,,fee schedule,1536.02,6814.79,
Biopsy of external ear canal,69105,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1536.02,6814.79,APC 378
Biopsy of external ear canal,69105,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1536.02,6814.79,APC
Biopsy of external ear canal,69105,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1536.02,6814.79,APC
Biopsy of external ear canal,69105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1536.02,6814.79,APC
Biopsy of external ear canal,69105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1536.02,6814.79,Radiology
Biopsy of external ear canal,69105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1536.02,6814.79,APC
Biopsy of external ear canal,69105,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1536.02,6814.79,APC
Remove external ear partial,69110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9062.15,,,,,,,fee schedule,2875.57,12757.95,
Remove external ear partial,69110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7264.1,,,,,,,fee schedule,2875.57,12757.95,
Remove external ear partial,69110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7935.37,,,,,,,fee schedule,2875.57,12757.95,
Remove external ear partial,69110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8342.93,,,,,,,fee schedule,2875.57,12757.95,
Remove external ear partial,69110,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Remove external ear partial,69110,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Remove external ear partial,69110,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Remove external ear partial,69110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Remove external ear partial,69110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Remove external ear partial,69110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Remove external ear partial,69110,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Removal of external ear,69120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5983.93,,,,,,,fee schedule,4796.64,26000.79,
Removal of external ear,69120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4796.64,,,,,,,fee schedule,4796.64,26000.79,
Removal of external ear,69120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5239.9,,,,,,,fee schedule,4796.64,26000.79,
Removal of external ear,69120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.01,,,,,,,fee schedule,4796.64,26000.79,
Removal of external ear,69120,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,4796.64,26000.79,APC 378
Removal of external ear,69120,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,4796.64,26000.79,APC
Removal of external ear,69120,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,4796.64,26000.79,APC
Removal of external ear,69120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,4796.64,26000.79,APC
Removal of external ear,69120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,4796.64,26000.79,Radiology
Removal of external ear,69120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,4796.64,26000.79,APC
Removal of external ear,69120,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,4796.64,26000.79,APC
Remove ear canal lesion(s),69140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5983.93,,,,,,,fee schedule,4796.64,26000.79,
Remove ear canal lesion(s),69140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4796.64,,,,,,,fee schedule,4796.64,26000.79,
Remove ear canal lesion(s),69140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5239.9,,,,,,,fee schedule,4796.64,26000.79,
Remove ear canal lesion(s),69140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.01,,,,,,,fee schedule,4796.64,26000.79,
Remove ear canal lesion(s),69140,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,4796.64,26000.79,APC 378
Remove ear canal lesion(s),69140,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,4796.64,26000.79,APC
Remove ear canal lesion(s),69140,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,4796.64,26000.79,APC
Remove ear canal lesion(s),69140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,4796.64,26000.79,APC
Remove ear canal lesion(s),69140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,4796.64,26000.79,Radiology
Remove ear canal lesion(s),69140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,4796.64,26000.79,APC
Remove ear canal lesion(s),69140,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,4796.64,26000.79,APC
Remove ear canal lesion(s),69145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4018.18,,,,,,,fee schedule,2875.57,12757.95,
Remove ear canal lesion(s),69145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3220.92,,,,,,,fee schedule,2875.57,12757.95,
Remove ear canal lesion(s),69145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3518.56,,,,,,,fee schedule,2875.57,12757.95,
Remove ear canal lesion(s),69145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3699.27,,,,,,,fee schedule,2875.57,12757.95,
Remove ear canal lesion(s),69145,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12757.95,,,,,,,fee schedule,2875.57,12757.95,APC 378
Remove ear canal lesion(s),69145,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3019.35,,,,,,,fee schedule,2875.57,12757.95,APC
Remove ear canal lesion(s),69145,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2990.6,,,,,,,fee schedule,2875.57,12757.95,APC
Remove ear canal lesion(s),69145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2875.57,,,,,,,fee schedule,2875.57,12757.95,APC
Remove ear canal lesion(s),69145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4399.63,,,,,,,fee schedule,2875.57,12757.95,Radiology
Remove ear canal lesion(s),69145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4025.8,,,,,,,fee schedule,2875.57,12757.95,APC
Remove ear canal lesion(s),69145,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5032.25,,,,,,,fee schedule,2875.57,12757.95,APC
Extensive ear canal surgery,69150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1858.66,,,,,,,fee schedule,1489.88,26000.79,
Extensive ear canal surgery,69150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1489.88,,,,,,,fee schedule,1489.88,26000.79,
Extensive ear canal surgery,69150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1627.56,,,,,,,fee schedule,1489.88,26000.79,
Extensive ear canal surgery,69150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1711.15,,,,,,,fee schedule,1489.88,26000.79,
Extensive ear canal surgery,69150,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,1489.88,26000.79,APC 378
Extensive ear canal surgery,69150,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,1489.88,26000.79,APC
Extensive ear canal surgery,69150,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,1489.88,26000.79,APC
Extensive ear canal surgery,69150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,1489.88,26000.79,APC
Extensive ear canal surgery,69150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,1489.88,26000.79,Radiology
Extensive ear canal surgery,69150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,1489.88,26000.79,APC
Extensive ear canal surgery,69150,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,1489.88,26000.79,APC
Clear outer ear canal,69200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,183.59,,,,,,,fee schedule,131.71,584.37,
Clear outer ear canal,69200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,147.17,,,,,,,fee schedule,131.71,584.37,
Clear outer ear canal,69200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,160.77,,,,,,,fee schedule,131.71,584.37,
Clear outer ear canal,69200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,169.02,,,,,,,fee schedule,131.71,584.37,
Clear outer ear canal,69200,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,131.71,584.37,APC 378
Clear outer ear canal,69200,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,131.71,584.37,APC
Clear outer ear canal,69200,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,131.71,584.37,APC
Clear outer ear canal,69200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,131.71,584.37,APC
Clear outer ear canal,69200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,131.71,584.37,Radiology
Clear outer ear canal,69200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,131.71,584.37,APC
Clear outer ear canal,69200,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,131.71,584.37,APC
Clear outer ear canal,69205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5785.34,,,,,,,fee schedule,1635.03,7254.06,
Clear outer ear canal,69205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4637.46,,,,,,,fee schedule,1635.03,7254.06,
Clear outer ear canal,69205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5066,,,,,,,fee schedule,1635.03,7254.06,
Clear outer ear canal,69205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5326.19,,,,,,,fee schedule,1635.03,7254.06,
Clear outer ear canal,69205,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7254.06,,,,,,,fee schedule,1635.03,7254.06,APC 378
Clear outer ear canal,69205,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1716.78,,,,,,,fee schedule,1635.03,7254.06,APC
Clear outer ear canal,69205,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1700.43,,,,,,,fee schedule,1635.03,7254.06,APC
Clear outer ear canal,69205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1635.03,,,,,,,fee schedule,1635.03,7254.06,APC
Clear outer ear canal,69205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2501.59,,,,,,,fee schedule,1635.03,7254.06,Radiology
Clear outer ear canal,69205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2289.04,,,,,,,fee schedule,1635.03,7254.06,APC
Clear outer ear canal,69205,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2861.3,,,,,,,fee schedule,1635.03,7254.06,APC
Remove impacted ear wax uni,69209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,73.68,,,,,,,fee schedule,58.4,259.1,
Remove impacted ear wax uni,69209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,59.06,,,,,,,fee schedule,58.4,259.1,
Remove impacted ear wax uni,69209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,64.52,,,,,,,fee schedule,58.4,259.1,
Remove impacted ear wax uni,69209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,67.84,,,,,,,fee schedule,58.4,259.1,
Remove impacted ear wax uni,69209,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,58.4,259.1,APC 378
Remove impacted ear wax uni,69209,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,58.4,259.1,APC
Remove impacted ear wax uni,69209,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,58.4,259.1,APC
Remove impacted ear wax uni,69209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,58.4,259.1,APC
Remove impacted ear wax uni,69209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,58.4,259.1,Radiology
Remove impacted ear wax uni,69209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,58.4,259.1,APC
Remove impacted ear wax uni,69209,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,58.4,259.1,APC
Remove impacted ear wax uni,69210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1669.67,,,,,,,fee schedule,58.4,1669.67,
Remove impacted ear wax uni,69210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1338.39,,,,,,,fee schedule,58.4,1669.67,
Remove impacted ear wax uni,69210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1462.07,,,,,,,fee schedule,58.4,1669.67,
Remove impacted ear wax uni,69210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1537.16,,,,,,,fee schedule,58.4,1669.67,
Remove impacted ear wax uni,69210,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,58.4,1669.67,APC 378
Remove impacted ear wax uni,69210,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,58.4,1669.67,APC
Remove impacted ear wax uni,69210,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,58.4,1669.67,APC
Remove impacted ear wax uni,69210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,58.4,1669.67,APC
Remove impacted ear wax uni,69210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,58.4,1669.67,Radiology
Remove impacted ear wax uni,69210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,58.4,1669.67,APC
Remove impacted ear wax uni,69210,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,58.4,1669.67,APC
Clean out mastoid cavity,69220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,197.92,,,,,,,fee schedule,158.65,881.22,
Clean out mastoid cavity,69220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,158.65,,,,,,,fee schedule,158.65,881.22,
Clean out mastoid cavity,69220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,173.31,,,,,,,fee schedule,158.65,881.22,
Clean out mastoid cavity,69220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,182.21,,,,,,,fee schedule,158.65,881.22,
Clean out mastoid cavity,69220,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,881.22,,,,,,,fee schedule,158.65,881.22,APC 378
Clean out mastoid cavity,69220,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.55,,,,,,,fee schedule,158.65,881.22,APC
Clean out mastoid cavity,69220,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,206.57,,,,,,,fee schedule,158.65,881.22,APC
Clean out mastoid cavity,69220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.62,,,,,,,fee schedule,158.65,881.22,APC
Clean out mastoid cavity,69220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.89,,,,,,,fee schedule,158.65,881.22,Radiology
Clean out mastoid cavity,69220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,278.07,,,,,,,fee schedule,158.65,881.22,APC
Clean out mastoid cavity,69220,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,347.59,,,,,,,fee schedule,158.65,881.22,APC
Clean out mastoid cavity,69222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4075.29,,,,,,,fee schedule,533.92,4075.29,
Clean out mastoid cavity,69222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3266.7,,,,,,,fee schedule,533.92,4075.29,
Clean out mastoid cavity,69222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3568.58,,,,,,,fee schedule,533.92,4075.29,
Clean out mastoid cavity,69222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3751.86,,,,,,,fee schedule,533.92,4075.29,
Clean out mastoid cavity,69222,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2368.81,,,,,,,fee schedule,533.92,4075.29,APC 378
Clean out mastoid cavity,69222,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,560.61,,,,,,,fee schedule,533.92,4075.29,APC
Clean out mastoid cavity,69222,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,555.27,,,,,,,fee schedule,533.92,4075.29,APC
Clean out mastoid cavity,69222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,533.92,,,,,,,fee schedule,533.92,4075.29,APC
Clean out mastoid cavity,69222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,816.89,,,,,,,fee schedule,533.92,4075.29,Radiology
Clean out mastoid cavity,69222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,747.48,,,,,,,fee schedule,533.92,4075.29,APC
Clean out mastoid cavity,69222,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,934.36,,,,,,,fee schedule,533.92,4075.29,APC
Revise external ear,69300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5983.93,,,,,,,fee schedule,3282.2,14562,
Revise external ear,69300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4796.64,,,,,,,fee schedule,3282.2,14562,
Revise external ear,69300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5239.9,,,,,,,fee schedule,3282.2,14562,
Revise external ear,69300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.01,,,,,,,fee schedule,3282.2,14562,
Revise external ear,69300,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Revise external ear,69300,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Revise external ear,69300,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Revise external ear,69300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Revise external ear,69300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Revise external ear,69300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Revise external ear,69300,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Rebuild outer ear canal,69310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Rebuild outer ear canal,69310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Rebuild outer ear canal,69310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Rebuild outer ear canal,69310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Rebuild outer ear canal,69310,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Rebuild outer ear canal,69310,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Rebuild outer ear canal,69310,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Rebuild outer ear canal,69310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Rebuild outer ear canal,69310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Rebuild outer ear canal,69310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Rebuild outer ear canal,69310,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Rebuild outer ear canal,69320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Rebuild outer ear canal,69320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Rebuild outer ear canal,69320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Rebuild outer ear canal,69320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Rebuild outer ear canal,69320,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Rebuild outer ear canal,69320,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Rebuild outer ear canal,69320,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Rebuild outer ear canal,69320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Rebuild outer ear canal,69320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Rebuild outer ear canal,69320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Rebuild outer ear canal,69320,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Outer ear surgery procedure,69399,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,624,,,,,,,fee schedule,234.47,1040.28,
Outer ear surgery procedure,69399,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,500.19,,,,,,,fee schedule,234.47,1040.28,
Outer ear surgery procedure,69399,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,546.41,,,,,,,fee schedule,234.47,1040.28,
Outer ear surgery procedure,69399,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,574.48,,,,,,,fee schedule,234.47,1040.28,
Outer ear surgery procedure,69399,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1040.28,,,,,,,fee schedule,234.47,1040.28,APC 378
Outer ear surgery procedure,69399,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,246.2,,,,,,,fee schedule,234.47,1040.28,APC
Outer ear surgery procedure,69399,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,243.85,,,,,,,fee schedule,234.47,1040.28,APC
Outer ear surgery procedure,69399,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,234.47,,,,,,,fee schedule,234.47,1040.28,APC
Outer ear surgery procedure,69399,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,358.74,,,,,,,fee schedule,234.47,1040.28,Radiology
Outer ear surgery procedure,69399,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,328.26,,,,,,,fee schedule,234.47,1040.28,APC
Outer ear surgery procedure,69399,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,410.33,,,,,,,fee schedule,234.47,1040.28,APC
Incision of eardrum,69420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,624,,,,,,,fee schedule,234.47,1040.28,
Incision of eardrum,69420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,500.19,,,,,,,fee schedule,234.47,1040.28,
Incision of eardrum,69420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,546.41,,,,,,,fee schedule,234.47,1040.28,
Incision of eardrum,69420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,574.48,,,,,,,fee schedule,234.47,1040.28,
Incision of eardrum,69420,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1040.28,,,,,,,fee schedule,234.47,1040.28,APC 378
Incision of eardrum,69420,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,246.2,,,,,,,fee schedule,234.47,1040.28,APC
Incision of eardrum,69420,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,243.85,,,,,,,fee schedule,234.47,1040.28,APC
Incision of eardrum,69420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,234.47,,,,,,,fee schedule,234.47,1040.28,APC
Incision of eardrum,69420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,358.74,,,,,,,fee schedule,234.47,1040.28,Radiology
Incision of eardrum,69420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,328.26,,,,,,,fee schedule,234.47,1040.28,APC
Incision of eardrum,69420,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,410.33,,,,,,,fee schedule,234.47,1040.28,APC
Incision of eardrum,69421,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7189.69,,,,,,,fee schedule,3282.2,14562,
Incision of eardrum,69421,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5763.16,,,,,,,fee schedule,3282.2,14562,
Incision of eardrum,69421,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6295.73,,,,,,,fee schedule,3282.2,14562,
Incision of eardrum,69421,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6619.08,,,,,,,fee schedule,3282.2,14562,
Incision of eardrum,69421,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Incision of eardrum,69421,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Incision of eardrum,69421,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Incision of eardrum,69421,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Incision of eardrum,69421,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Incision of eardrum,69421,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Incision of eardrum,69421,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Remove ventilating tube,69424,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1590.18,,,,,,,fee schedule,1274.67,14562,
Remove ventilating tube,69424,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1274.67,,,,,,,fee schedule,1274.67,14562,
Remove ventilating tube,69424,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1392.46,,,,,,,fee schedule,1274.67,14562,
Remove ventilating tube,69424,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1463.98,,,,,,,fee schedule,1274.67,14562,
Remove ventilating tube,69424,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,1274.67,14562,APC 378
Remove ventilating tube,69424,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,1274.67,14562,APC
Remove ventilating tube,69424,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,1274.67,14562,APC
Remove ventilating tube,69424,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,1274.67,14562,APC
Remove ventilating tube,69424,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,1274.67,14562,Radiology
Remove ventilating tube,69424,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,1274.67,14562,APC
Remove ventilating tube,69424,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,1274.67,14562,APC
Create eardrum opening,69433,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1590.18,,,,,,,fee schedule,533.92,2368.81,
Create eardrum opening,69433,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1274.67,,,,,,,fee schedule,533.92,2368.81,
Create eardrum opening,69433,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1392.46,,,,,,,fee schedule,533.92,2368.81,
Create eardrum opening,69433,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1463.98,,,,,,,fee schedule,533.92,2368.81,
Create eardrum opening,69433,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2368.81,,,,,,,fee schedule,533.92,2368.81,APC 378
Create eardrum opening,69433,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,560.61,,,,,,,fee schedule,533.92,2368.81,APC
Create eardrum opening,69433,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,555.27,,,,,,,fee schedule,533.92,2368.81,APC
Create eardrum opening,69433,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,533.92,,,,,,,fee schedule,533.92,2368.81,APC
Create eardrum opening,69433,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,816.89,,,,,,,fee schedule,533.92,2368.81,Radiology
Create eardrum opening,69433,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,747.48,,,,,,,fee schedule,533.92,2368.81,APC
Create eardrum opening,69433,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,934.36,,,,,,,fee schedule,533.92,2368.81,APC
Create eardrum opening,69436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3500.35,,,,,,,fee schedule,1536.02,6814.79,
Create eardrum opening,69436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2805.83,,,,,,,fee schedule,1536.02,6814.79,
Create eardrum opening,69436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3065.12,,,,,,,fee schedule,1536.02,6814.79,
Create eardrum opening,69436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3222.54,,,,,,,fee schedule,1536.02,6814.79,
Create eardrum opening,69436,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1536.02,6814.79,APC 378
Create eardrum opening,69436,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1536.02,6814.79,APC
Create eardrum opening,69436,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1536.02,6814.79,APC
Create eardrum opening,69436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1536.02,6814.79,APC
Create eardrum opening,69436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1536.02,6814.79,Radiology
Create eardrum opening,69436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1536.02,6814.79,APC
Create eardrum opening,69436,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1536.02,6814.79,APC
Exploration of middle ear,69440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5983.93,,,,,,,fee schedule,3282.2,14562,
Exploration of middle ear,69440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4796.64,,,,,,,fee schedule,3282.2,14562,
Exploration of middle ear,69440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5239.9,,,,,,,fee schedule,3282.2,14562,
Exploration of middle ear,69440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5509.01,,,,,,,fee schedule,3282.2,14562,
Exploration of middle ear,69440,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Exploration of middle ear,69440,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Exploration of middle ear,69440,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Exploration of middle ear,69440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Exploration of middle ear,69440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Exploration of middle ear,69440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Exploration of middle ear,69440,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Eardrum revision,69450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8125.92,,,,,,,fee schedule,3282.2,14562,
Eardrum revision,69450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6513.63,,,,,,,fee schedule,3282.2,14562,
Eardrum revision,69450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7115.55,,,,,,,fee schedule,3282.2,14562,
Eardrum revision,69450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7481,,,,,,,fee schedule,3282.2,14562,
Eardrum revision,69450,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Eardrum revision,69450,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Eardrum revision,69450,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Eardrum revision,69450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Eardrum revision,69450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Eardrum revision,69450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Eardrum revision,69450,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Mastoidectomy,69501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5233.25,,,,,,,fee schedule,4194.9,26000.79,
Mastoidectomy,69501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4194.9,,,,,,,fee schedule,4194.9,26000.79,
Mastoidectomy,69501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4582.55,,,,,,,fee schedule,4194.9,26000.79,
Mastoidectomy,69501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4817.91,,,,,,,fee schedule,4194.9,26000.79,
Mastoidectomy,69501,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,4194.9,26000.79,APC 378
Mastoidectomy,69501,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,4194.9,26000.79,APC
Mastoidectomy,69501,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,4194.9,26000.79,APC
Mastoidectomy,69501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,4194.9,26000.79,APC
Mastoidectomy,69501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,4194.9,26000.79,Radiology
Mastoidectomy,69501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,4194.9,26000.79,APC
Mastoidectomy,69501,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,4194.9,26000.79,APC
Mastoidectomy,69502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3828.9,,,,,,,fee schedule,3069.2,26000.79,
Mastoidectomy,69502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3069.2,,,,,,,fee schedule,3069.2,26000.79,
Mastoidectomy,69502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3352.82,,,,,,,fee schedule,3069.2,26000.79,
Mastoidectomy,69502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3525.02,,,,,,,fee schedule,3069.2,26000.79,
Mastoidectomy,69502,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,3069.2,26000.79,APC 378
Mastoidectomy,69502,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,3069.2,26000.79,APC
Mastoidectomy,69502,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,3069.2,26000.79,APC
Mastoidectomy,69502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,3069.2,26000.79,APC
Mastoidectomy,69502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,3069.2,26000.79,Radiology
Mastoidectomy,69502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,3069.2,26000.79,APC
Mastoidectomy,69502,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,3069.2,26000.79,APC
Remove mastoid structures,69505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Remove mastoid structures,69505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Remove mastoid structures,69505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Remove mastoid structures,69505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Remove mastoid structures,69505,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Remove mastoid structures,69505,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Remove mastoid structures,69505,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Remove mastoid structures,69505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Remove mastoid structures,69505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Remove mastoid structures,69505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Remove mastoid structures,69505,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Extensive mastoid surgery,69511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Extensive mastoid surgery,69511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Extensive mastoid surgery,69511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Extensive mastoid surgery,69511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Extensive mastoid surgery,69511,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Extensive mastoid surgery,69511,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Extensive mastoid surgery,69511,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Extensive mastoid surgery,69511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Extensive mastoid surgery,69511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Extensive mastoid surgery,69511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Extensive mastoid surgery,69511,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Extensive mastoid surgery,69530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Extensive mastoid surgery,69530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Extensive mastoid surgery,69530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Extensive mastoid surgery,69530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Extensive mastoid surgery,69530,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Extensive mastoid surgery,69530,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Extensive mastoid surgery,69530,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Extensive mastoid surgery,69530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Extensive mastoid surgery,69530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Extensive mastoid surgery,69530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Extensive mastoid surgery,69530,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Remove ear lesion,69540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4075.29,,,,,,,fee schedule,1536.02,6814.79,
Remove ear lesion,69540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3266.7,,,,,,,fee schedule,1536.02,6814.79,
Remove ear lesion,69540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3568.58,,,,,,,fee schedule,1536.02,6814.79,
Remove ear lesion,69540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3751.86,,,,,,,fee schedule,1536.02,6814.79,
Remove ear lesion,69540,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1536.02,6814.79,APC 378
Remove ear lesion,69540,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1536.02,6814.79,APC
Remove ear lesion,69540,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1536.02,6814.79,APC
Remove ear lesion,69540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1536.02,6814.79,APC
Remove ear lesion,69540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1536.02,6814.79,Radiology
Remove ear lesion,69540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1536.02,6814.79,APC
Remove ear lesion,69540,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1536.02,6814.79,APC
Remove ear lesion,69550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8613.54,,,,,,,fee schedule,5860.44,26000.79,
Remove ear lesion,69550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6904.5,,,,,,,fee schedule,5860.44,26000.79,
Remove ear lesion,69550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7542.54,,,,,,,fee schedule,5860.44,26000.79,
Remove ear lesion,69550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7929.92,,,,,,,fee schedule,5860.44,26000.79,
Remove ear lesion,69550,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Remove ear lesion,69550,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Remove ear lesion,69550,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Remove ear lesion,69550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Remove ear lesion,69550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Remove ear lesion,69550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Remove ear lesion,69550,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Remove ear lesion,69552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3828.9,,,,,,,fee schedule,3069.2,26000.79,
Remove ear lesion,69552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3069.2,,,,,,,fee schedule,3069.2,26000.79,
Remove ear lesion,69552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3352.82,,,,,,,fee schedule,3069.2,26000.79,
Remove ear lesion,69552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3525.02,,,,,,,fee schedule,3069.2,26000.79,
Remove ear lesion,69552,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,3069.2,26000.79,APC 378
Remove ear lesion,69552,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,3069.2,26000.79,APC
Remove ear lesion,69552,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,3069.2,26000.79,APC
Remove ear lesion,69552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,3069.2,26000.79,APC
Remove ear lesion,69552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,3069.2,26000.79,Radiology
Remove ear lesion,69552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,3069.2,26000.79,APC
Remove ear lesion,69552,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,3069.2,26000.79,APC
Mastoid surgery revision,69601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Mastoid surgery revision,69601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Mastoid surgery revision,69601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Mastoid surgery revision,69601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Mastoid surgery revision,69601,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Mastoid surgery revision,69601,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Mastoid surgery revision,69601,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Mastoid surgery revision,69601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Mastoid surgery revision,69601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Mastoid surgery revision,69601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Mastoid surgery revision,69601,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Mastoid surgery revision,69602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Mastoid surgery revision,69602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Mastoid surgery revision,69602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Mastoid surgery revision,69602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Mastoid surgery revision,69602,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Mastoid surgery revision,69602,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Mastoid surgery revision,69602,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Mastoid surgery revision,69602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Mastoid surgery revision,69602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Mastoid surgery revision,69602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Mastoid surgery revision,69602,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Mastoid surgery revision,69603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Mastoid surgery revision,69603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Mastoid surgery revision,69603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Mastoid surgery revision,69603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Mastoid surgery revision,69603,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Mastoid surgery revision,69603,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Mastoid surgery revision,69603,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Mastoid surgery revision,69603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Mastoid surgery revision,69603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Mastoid surgery revision,69603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Mastoid surgery revision,69603,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Mastoid surgery revision,69604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Mastoid surgery revision,69604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Mastoid surgery revision,69604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Mastoid surgery revision,69604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Mastoid surgery revision,69604,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Mastoid surgery revision,69604,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Mastoid surgery revision,69604,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Mastoid surgery revision,69604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Mastoid surgery revision,69604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Mastoid surgery revision,69604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Mastoid surgery revision,69604,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Repair of eardrum,69610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5073.05,,,,,,,fee schedule,1536.02,6814.79,
Repair of eardrum,69610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4066.5,,,,,,,fee schedule,1536.02,6814.79,
Repair of eardrum,69610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4442.28,,,,,,,fee schedule,1536.02,6814.79,
Repair of eardrum,69610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4670.43,,,,,,,fee schedule,1536.02,6814.79,
Repair of eardrum,69610,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1536.02,6814.79,APC 378
Repair of eardrum,69610,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1536.02,6814.79,APC
Repair of eardrum,69610,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1536.02,6814.79,APC
Repair of eardrum,69610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1536.02,6814.79,APC
Repair of eardrum,69610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1536.02,6814.79,Radiology
Repair of eardrum,69610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1536.02,6814.79,APC
Repair of eardrum,69610,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1536.02,6814.79,APC
Repair of eardrum,69620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4584.71,,,,,,,fee schedule,3282.2,14562,
Repair of eardrum,69620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3675.05,,,,,,,fee schedule,3282.2,14562,
Repair of eardrum,69620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4014.65,,,,,,,fee schedule,3282.2,14562,
Repair of eardrum,69620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4220.85,,,,,,,fee schedule,3282.2,14562,
Repair of eardrum,69620,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Repair of eardrum,69620,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Repair of eardrum,69620,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Repair of eardrum,69620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Repair of eardrum,69620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Repair of eardrum,69620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Repair of eardrum,69620,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Repair eardrum structures,69631,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4969.17,,,,,,,fee schedule,3983.23,26000.79,
Repair eardrum structures,69631,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3983.23,,,,,,,fee schedule,3983.23,26000.79,
Repair eardrum structures,69631,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4351.31,,,,,,,fee schedule,3983.23,26000.79,
Repair eardrum structures,69631,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4574.79,,,,,,,fee schedule,3983.23,26000.79,
Repair eardrum structures,69631,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,3983.23,26000.79,APC 378
Repair eardrum structures,69631,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,3983.23,26000.79,APC
Repair eardrum structures,69631,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,3983.23,26000.79,APC
Repair eardrum structures,69631,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,3983.23,26000.79,APC
Repair eardrum structures,69631,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,3983.23,26000.79,Radiology
Repair eardrum structures,69631,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,3983.23,26000.79,APC
Repair eardrum structures,69631,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,3983.23,26000.79,APC
Rebuild eardrum structures,69632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8125.92,,,,,,,fee schedule,5860.44,26000.79,
Rebuild eardrum structures,69632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6513.63,,,,,,,fee schedule,5860.44,26000.79,
Rebuild eardrum structures,69632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7115.55,,,,,,,fee schedule,5860.44,26000.79,
Rebuild eardrum structures,69632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7481,,,,,,,fee schedule,5860.44,26000.79,
Rebuild eardrum structures,69632,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Rebuild eardrum structures,69632,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Rebuild eardrum structures,69632,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Rebuild eardrum structures,69632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Rebuild eardrum structures,69632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Rebuild eardrum structures,69632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Rebuild eardrum structures,69632,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Rebuild eardrum structures,69633,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6848.35,,,,,,,fee schedule,5489.55,26000.79,
Rebuild eardrum structures,69633,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5489.55,,,,,,,fee schedule,5489.55,26000.79,
Rebuild eardrum structures,69633,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5996.84,,,,,,,fee schedule,5489.55,26000.79,
Rebuild eardrum structures,69633,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6304.83,,,,,,,fee schedule,5489.55,26000.79,
Rebuild eardrum structures,69633,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5489.55,26000.79,APC 378
Rebuild eardrum structures,69633,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5489.55,26000.79,APC
Rebuild eardrum structures,69633,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5489.55,26000.79,APC
Rebuild eardrum structures,69633,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5489.55,26000.79,APC
Rebuild eardrum structures,69633,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5489.55,26000.79,Radiology
Rebuild eardrum structures,69633,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5489.55,26000.79,APC
Rebuild eardrum structures,69633,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5489.55,26000.79,APC
Repair eardrum structures,69635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Repair eardrum structures,69635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Repair eardrum structures,69635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Repair eardrum structures,69635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Repair eardrum structures,69635,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Repair eardrum structures,69635,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Repair eardrum structures,69635,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Repair eardrum structures,69635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Repair eardrum structures,69635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Repair eardrum structures,69635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Repair eardrum structures,69635,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Rebuild eardrum structures,69636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Rebuild eardrum structures,69636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Rebuild eardrum structures,69636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Rebuild eardrum structures,69636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Rebuild eardrum structures,69636,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Rebuild eardrum structures,69636,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Rebuild eardrum structures,69636,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Rebuild eardrum structures,69636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Rebuild eardrum structures,69636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Rebuild eardrum structures,69636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Rebuild eardrum structures,69636,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Rebuild eardrum structures,69637,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Rebuild eardrum structures,69637,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Rebuild eardrum structures,69637,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Rebuild eardrum structures,69637,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Rebuild eardrum structures,69637,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Rebuild eardrum structures,69637,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Rebuild eardrum structures,69637,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Rebuild eardrum structures,69637,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Rebuild eardrum structures,69637,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Rebuild eardrum structures,69637,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Rebuild eardrum structures,69637,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Revise middle ear & mastoid,69641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4765.13,,,,,,,fee schedule,3819.67,26000.79,
Revise middle ear & mastoid,69641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3819.67,,,,,,,fee schedule,3819.67,26000.79,
Revise middle ear & mastoid,69641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4172.64,,,,,,,fee schedule,3819.67,26000.79,
Revise middle ear & mastoid,69641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4386.95,,,,,,,fee schedule,3819.67,26000.79,
Revise middle ear & mastoid,69641,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,3819.67,26000.79,APC 378
Revise middle ear & mastoid,69641,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,3819.67,26000.79,APC
Revise middle ear & mastoid,69641,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,3819.67,26000.79,APC
Revise middle ear & mastoid,69641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,3819.67,26000.79,APC
Revise middle ear & mastoid,69641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,3819.67,26000.79,Radiology
Revise middle ear & mastoid,69641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,3819.67,26000.79,APC
Revise middle ear & mastoid,69641,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,3819.67,26000.79,APC
Revise middle ear & mastoid,69642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11402.72,,,,,,,fee schedule,5860.44,26000.79,
Revise middle ear & mastoid,69642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9140.28,,,,,,,fee schedule,5860.44,26000.79,
Revise middle ear & mastoid,69642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9984.92,,,,,,,fee schedule,5860.44,26000.79,
Revise middle ear & mastoid,69642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10497.74,,,,,,,fee schedule,5860.44,26000.79,
Revise middle ear & mastoid,69642,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Revise middle ear & mastoid,69642,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Revise middle ear & mastoid,69642,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Revise middle ear & mastoid,69642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Revise middle ear & mastoid,69642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Revise middle ear & mastoid,69642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Revise middle ear & mastoid,69642,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Revise middle ear & mastoid,69643,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5467.3,,,,,,,fee schedule,4382.52,26000.79,
Revise middle ear & mastoid,69643,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4382.52,,,,,,,fee schedule,4382.52,26000.79,
Revise middle ear & mastoid,69643,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4787.51,,,,,,,fee schedule,4382.52,26000.79,
Revise middle ear & mastoid,69643,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5033.39,,,,,,,fee schedule,4382.52,26000.79,
Revise middle ear & mastoid,69643,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,4382.52,26000.79,APC 378
Revise middle ear & mastoid,69643,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,4382.52,26000.79,APC
Revise middle ear & mastoid,69643,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,4382.52,26000.79,APC
Revise middle ear & mastoid,69643,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,4382.52,26000.79,APC
Revise middle ear & mastoid,69643,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,4382.52,26000.79,Radiology
Revise middle ear & mastoid,69643,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,4382.52,26000.79,APC
Revise middle ear & mastoid,69643,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,4382.52,26000.79,APC
Revise middle ear & mastoid,69644,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8200.96,,,,,,,fee schedule,5860.44,26000.79,
Revise middle ear & mastoid,69644,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6573.78,,,,,,,fee schedule,5860.44,26000.79,
Revise middle ear & mastoid,69644,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7181.26,,,,,,,fee schedule,5860.44,26000.79,
Revise middle ear & mastoid,69644,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7550.09,,,,,,,fee schedule,5860.44,26000.79,
Revise middle ear & mastoid,69644,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Revise middle ear & mastoid,69644,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Revise middle ear & mastoid,69644,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Revise middle ear & mastoid,69644,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Revise middle ear & mastoid,69644,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Revise middle ear & mastoid,69644,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Revise middle ear & mastoid,69644,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Revise middle ear & mastoid,69645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14679.53,,,,,,,fee schedule,5860.44,26000.79,
Revise middle ear & mastoid,69645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11766.92,,,,,,,fee schedule,5860.44,26000.79,
Revise middle ear & mastoid,69645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12854.3,,,,,,,fee schedule,5860.44,26000.79,
Revise middle ear & mastoid,69645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13514.49,,,,,,,fee schedule,5860.44,26000.79,
Revise middle ear & mastoid,69645,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Revise middle ear & mastoid,69645,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Revise middle ear & mastoid,69645,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Revise middle ear & mastoid,69645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Revise middle ear & mastoid,69645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Revise middle ear & mastoid,69645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Revise middle ear & mastoid,69645,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Revise middle ear & mastoid,69646,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Revise middle ear & mastoid,69646,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Revise middle ear & mastoid,69646,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Revise middle ear & mastoid,69646,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Revise middle ear & mastoid,69646,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Revise middle ear & mastoid,69646,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Revise middle ear & mastoid,69646,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Revise middle ear & mastoid,69646,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Revise middle ear & mastoid,69646,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Revise middle ear & mastoid,69646,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Revise middle ear & mastoid,69646,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Release middle ear bone,69650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7657.8,,,,,,,fee schedule,3282.2,14562,
Release middle ear bone,69650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6138.4,,,,,,,fee schedule,3282.2,14562,
Release middle ear bone,69650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6705.64,,,,,,,fee schedule,3282.2,14562,
Release middle ear bone,69650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7050.04,,,,,,,fee schedule,3282.2,14562,
Release middle ear bone,69650,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Release middle ear bone,69650,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Release middle ear bone,69650,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Release middle ear bone,69650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Release middle ear bone,69650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Release middle ear bone,69650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Release middle ear bone,69650,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Revise middle ear bone,69660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11609.69,,,,,,,fee schedule,5860.44,26000.79,
Revise middle ear bone,69660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9306.18,,,,,,,fee schedule,5860.44,26000.79,
Revise middle ear bone,69660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10166.16,,,,,,,fee schedule,5860.44,26000.79,
Revise middle ear bone,69660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10688.29,,,,,,,fee schedule,5860.44,26000.79,
Revise middle ear bone,69660,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Revise middle ear bone,69660,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Revise middle ear bone,69660,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Revise middle ear bone,69660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Revise middle ear bone,69660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Revise middle ear bone,69660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Revise middle ear bone,69660,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Revise middle ear bone,69661,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8122.12,,,,,,,fee schedule,5860.44,26000.79,
Revise middle ear bone,69661,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6510.59,,,,,,,fee schedule,5860.44,26000.79,
Revise middle ear bone,69661,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7112.23,,,,,,,fee schedule,5860.44,26000.79,
Revise middle ear bone,69661,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7477.51,,,,,,,fee schedule,5860.44,26000.79,
Revise middle ear bone,69661,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Revise middle ear bone,69661,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Revise middle ear bone,69661,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Revise middle ear bone,69661,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Revise middle ear bone,69661,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Revise middle ear bone,69661,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Revise middle ear bone,69661,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Revise middle ear bone,69662,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3176.77,,,,,,,fee schedule,2546.46,26000.79,
Revise middle ear bone,69662,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2546.46,,,,,,,fee schedule,2546.46,26000.79,
Revise middle ear bone,69662,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2781.77,,,,,,,fee schedule,2546.46,26000.79,
Revise middle ear bone,69662,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2924.64,,,,,,,fee schedule,2546.46,26000.79,
Revise middle ear bone,69662,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,2546.46,26000.79,APC 378
Revise middle ear bone,69662,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,2546.46,26000.79,APC
Revise middle ear bone,69662,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,2546.46,26000.79,APC
Revise middle ear bone,69662,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,2546.46,26000.79,APC
Revise middle ear bone,69662,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,2546.46,26000.79,Radiology
Revise middle ear bone,69662,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,2546.46,26000.79,APC
Revise middle ear bone,69662,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,2546.46,26000.79,APC
Repair middle ear structures,69666,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,3282.2,14562,
Repair middle ear structures,69666,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,3282.2,14562,
Repair middle ear structures,69666,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,3282.2,14562,
Repair middle ear structures,69666,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,3282.2,14562,
Repair middle ear structures,69666,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Repair middle ear structures,69666,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Repair middle ear structures,69666,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Repair middle ear structures,69666,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Repair middle ear structures,69666,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Repair middle ear structures,69666,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Repair middle ear structures,69666,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Repair middle ear structures,69667,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,3282.2,14562,
Repair middle ear structures,69667,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,3282.2,14562,
Repair middle ear structures,69667,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,3282.2,14562,
Repair middle ear structures,69667,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,3282.2,14562,
Repair middle ear structures,69667,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Repair middle ear structures,69667,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Repair middle ear structures,69667,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Repair middle ear structures,69667,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Repair middle ear structures,69667,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Repair middle ear structures,69667,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Repair middle ear structures,69667,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Remove mastoid air cells,69670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Remove mastoid air cells,69670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Remove mastoid air cells,69670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Remove mastoid air cells,69670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Remove mastoid air cells,69670,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Remove mastoid air cells,69670,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Remove mastoid air cells,69670,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Remove mastoid air cells,69670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Remove mastoid air cells,69670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Remove mastoid air cells,69670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Remove mastoid air cells,69670,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Remove middle ear nerve,69676,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,3282.2,14562,
Remove middle ear nerve,69676,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,3282.2,14562,
Remove middle ear nerve,69676,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,3282.2,14562,
Remove middle ear nerve,69676,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,3282.2,14562,
Remove middle ear nerve,69676,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Remove middle ear nerve,69676,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Remove middle ear nerve,69676,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Remove middle ear nerve,69676,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Remove middle ear nerve,69676,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Remove middle ear nerve,69676,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Remove middle ear nerve,69676,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Close mastoid fistula,69700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,1536.02,9952.44,
Close mastoid fistula,69700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,1536.02,9952.44,
Close mastoid fistula,69700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,1536.02,9952.44,
Close mastoid fistula,69700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,1536.02,9952.44,
Close mastoid fistula,69700,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1536.02,9952.44,APC 378
Close mastoid fistula,69700,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1536.02,9952.44,APC
Close mastoid fistula,69700,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1536.02,9952.44,APC
Close mastoid fistula,69700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1536.02,9952.44,APC
Close mastoid fistula,69700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1536.02,9952.44,Radiology
Close mastoid fistula,69700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1536.02,9952.44,APC
Close mastoid fistula,69700,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1536.02,9952.44,APC
Nps surg dilat eust tube uni,69705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19225.27,,,,,,,fee schedule,5860.44,26000.79,
Nps surg dilat eust tube uni,69705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15410.73,,,,,,,fee schedule,5860.44,26000.79,
Nps surg dilat eust tube uni,69705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16834.83,,,,,,,fee schedule,5860.44,26000.79,
Nps surg dilat eust tube uni,69705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17699.45,,,,,,,fee schedule,5860.44,26000.79,
Nps surg dilat eust tube uni,69705,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Nps surg dilat eust tube uni,69705,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Nps surg dilat eust tube uni,69705,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Nps surg dilat eust tube uni,69705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Nps surg dilat eust tube uni,69705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Nps surg dilat eust tube uni,69705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Nps surg dilat eust tube uni,69705,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Nps surg dilat eust tube bi,69706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19225.27,,,,,,,fee schedule,5860.44,26000.79,
Nps surg dilat eust tube bi,69706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15410.73,,,,,,,fee schedule,5860.44,26000.79,
Nps surg dilat eust tube bi,69706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16834.83,,,,,,,fee schedule,5860.44,26000.79,
Nps surg dilat eust tube bi,69706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17699.45,,,,,,,fee schedule,5860.44,26000.79,
Nps surg dilat eust tube bi,69706,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Nps surg dilat eust tube bi,69706,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Nps surg dilat eust tube bi,69706,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Nps surg dilat eust tube bi,69706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Nps surg dilat eust tube bi,69706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Nps surg dilat eust tube bi,69706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Nps surg dilat eust tube bi,69706,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Remove/repair hearing aid,69711,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,3282.2,14562,
Remove/repair hearing aid,69711,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,3282.2,14562,
Remove/repair hearing aid,69711,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,3282.2,14562,
Remove/repair hearing aid,69711,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,3282.2,14562,
Remove/repair hearing aid,69711,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Remove/repair hearing aid,69711,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Remove/repair hearing aid,69711,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Remove/repair hearing aid,69711,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Remove/repair hearing aid,69711,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Remove/repair hearing aid,69711,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Remove/repair hearing aid,69711,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Implant Temple Bone W/Stimul,69714,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10439.4,,,,,,,fee schedule,8368.09,56389.43,
Implant Temple Bone W/Stimul,69714,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8368.09,,,,,,,fee schedule,8368.09,56389.43,
Implant Temple Bone W/Stimul,69714,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9141.38,,,,,,,fee schedule,8368.09,56389.43,
Implant Temple Bone W/Stimul,69714,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9610.88,,,,,,,fee schedule,8368.09,56389.43,
Implant Temple Bone W/Stimul,69714,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,8368.09,56389.43,APC 378
Implant Temple Bone W/Stimul,69714,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,8368.09,56389.43,APC
Implant Temple Bone W/Stimul,69714,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,8368.09,56389.43,APC
Implant Temple Bone W/Stimul,69714,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,8368.09,56389.43,APC
Implant Temple Bone W/Stimul,69714,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,8368.09,56389.43,Radiology
Implant Temple Bone W/Stimul,69714,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,8368.09,56389.43,APC
Implant Temple Bone W/Stimul,69714,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,8368.09,56389.43,APC
Impltj oi implt skl tc esp,69716,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,47602.64,,,,,,,fee schedule,12709.88,56389.43,
Impltj oi implt skl tc esp,69716,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38157.67,,,,,,,fee schedule,12709.88,56389.43,
Impltj oi implt skl tc esp,69716,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,41683.79,,,,,,,fee schedule,12709.88,56389.43,
Impltj oi implt skl tc esp,69716,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,43824.65,,,,,,,fee schedule,12709.88,56389.43,
Impltj oi implt skl tc esp,69716,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,12709.88,56389.43,APC 378
Impltj oi implt skl tc esp,69716,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,12709.88,56389.43,APC
Impltj oi implt skl tc esp,69716,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,12709.88,56389.43,APC
Impltj oi implt skl tc esp,69716,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,12709.88,56389.43,APC
Impltj oi implt skl tc esp,69716,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,12709.88,56389.43,Radiology
Impltj oi implt skl tc esp,69716,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,12709.88,56389.43,APC
Impltj oi implt skl tc esp,69716,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,12709.88,56389.43,APC
Temple Bone Implant Revision,69717,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,7183.42,31870.39,
Temple Bone Implant Revision,69717,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,7183.42,31870.39,
Temple Bone Implant Revision,69717,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,7183.42,31870.39,
Temple Bone Implant Revision,69717,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,7183.42,31870.39,
Temple Bone Implant Revision,69717,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Temple Bone Implant Revision,69717,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Temple Bone Implant Revision,69717,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Temple Bone Implant Revision,69717,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Temple Bone Implant Revision,69717,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Temple Bone Implant Revision,69717,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Temple Bone Implant Revision,69717,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
Revj/rplcmt oi implt tc esp,69719,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,47602.64,,,,,,,fee schedule,12709.88,56389.43,
Revj/rplcmt oi implt tc esp,69719,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38157.67,,,,,,,fee schedule,12709.88,56389.43,
Revj/rplcmt oi implt tc esp,69719,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,41683.79,,,,,,,fee schedule,12709.88,56389.43,
Revj/rplcmt oi implt tc esp,69719,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,43824.65,,,,,,,fee schedule,12709.88,56389.43,
Revj/rplcmt oi implt tc esp,69719,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,12709.88,56389.43,APC 378
Revj/rplcmt oi implt tc esp,69719,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,12709.88,56389.43,APC
Revj/rplcmt oi implt tc esp,69719,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,12709.88,56389.43,APC
Revj/rplcmt oi implt tc esp,69719,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,12709.88,56389.43,APC
Revj/rplcmt oi implt tc esp,69719,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,12709.88,56389.43,Radiology
Revj/rplcmt oi implt tc esp,69719,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,12709.88,56389.43,APC
Revj/rplcmt oi implt tc esp,69719,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,12709.88,56389.43,APC
Release facial nerve,69720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Release facial nerve,69720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Release facial nerve,69720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Release facial nerve,69720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Release facial nerve,69720,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Release facial nerve,69720,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Release facial nerve,69720,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Release facial nerve,69720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Release facial nerve,69720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Release facial nerve,69720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Release facial nerve,69720,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Release facial nerve,69725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Release facial nerve,69725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Release facial nerve,69725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Release facial nerve,69725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Release facial nerve,69725,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Release facial nerve,69725,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Release facial nerve,69725,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Release facial nerve,69725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Release facial nerve,69725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Release facial nerve,69725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Release facial nerve,69725,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Rmvl oi implt skl perq esp,69726,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10932.82,,,,,,,fee schedule,3239.17,14371.12,
Rmvl oi implt skl perq esp,69726,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8763.61,,,,,,,fee schedule,3239.17,14371.12,
Rmvl oi implt skl perq esp,69726,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9573.45,,,,,,,fee schedule,3239.17,14371.12,
Rmvl oi implt skl perq esp,69726,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10065.13,,,,,,,fee schedule,3239.17,14371.12,
Rmvl oi implt skl perq esp,69726,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Rmvl oi implt skl perq esp,69726,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Rmvl oi implt skl perq esp,69726,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Rmvl oi implt skl perq esp,69726,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Rmvl oi implt skl perq esp,69726,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Rmvl oi implt skl perq esp,69726,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Rmvl oi implt skl perq esp,69726,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Rmvl oi implt skl tc esp,69727,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10932.82,,,,,,,fee schedule,3239.17,14371.12,
Rmvl oi implt skl tc esp,69727,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8763.61,,,,,,,fee schedule,3239.17,14371.12,
Rmvl oi implt skl tc esp,69727,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9573.45,,,,,,,fee schedule,3239.17,14371.12,
Rmvl oi implt skl tc esp,69727,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10065.13,,,,,,,fee schedule,3239.17,14371.12,
Rmvl oi implt skl tc esp,69727,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Rmvl oi implt skl tc esp,69727,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Rmvl oi implt skl tc esp,69727,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Rmvl oi implt skl tc esp,69727,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Rmvl oi implt skl tc esp,69727,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Rmvl oi implt skl tc esp,69727,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Rmvl oi implt skl tc esp,69727,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Rmv ntr oi imp sktc esp>=100,69728,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11251.77,,,,,,,fee schedule,3239.17,14371.12,
Rmv ntr oi imp sktc esp>=100,69728,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9019.28,,,,,,,fee schedule,3239.17,14371.12,
Rmv ntr oi imp sktc esp>=100,69728,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9852.74,,,,,,,fee schedule,3239.17,14371.12,
Rmv ntr oi imp sktc esp>=100,69728,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10358.78,,,,,,,fee schedule,3239.17,14371.12,
Rmv ntr oi imp sktc esp>=100,69728,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Rmv ntr oi imp sktc esp>=100,69728,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Rmv ntr oi imp sktc esp>=100,69728,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Rmv ntr oi imp sktc esp>=100,69728,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Rmv ntr oi imp sktc esp>=100,69728,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Rmv ntr oi imp sktc esp>=100,69728,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Rmv ntr oi imp sktc esp>=100,69728,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Impl oi implt sk tc esp>=100,69729,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,49321.74,,,,,,,fee schedule,12709.88,56389.43,
Impl oi implt sk tc esp>=100,69729,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39535.68,,,,,,,fee schedule,12709.88,56389.43,
Impl oi implt sk tc esp>=100,69729,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,43189.14,,,,,,,fee schedule,12709.88,56389.43,
Impl oi implt sk tc esp>=100,69729,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45407.32,,,,,,,fee schedule,12709.88,56389.43,
Impl oi implt sk tc esp>=100,69729,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,12709.88,56389.43,APC 378
Impl oi implt sk tc esp>=100,69729,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,12709.88,56389.43,APC
Impl oi implt sk tc esp>=100,69729,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,12709.88,56389.43,APC
Impl oi implt sk tc esp>=100,69729,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,12709.88,56389.43,APC
Impl oi implt sk tc esp>=100,69729,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,12709.88,56389.43,Radiology
Impl oi implt sk tc esp>=100,69729,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,12709.88,56389.43,APC
Impl oi implt sk tc esp>=100,69729,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,12709.88,56389.43,APC
Rplc oi implt sk tc esp>=100,69730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,49321.74,,,,,,,fee schedule,12709.88,56389.43,
Rplc oi implt sk tc esp>=100,69730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39535.68,,,,,,,fee schedule,12709.88,56389.43,
Rplc oi implt sk tc esp>=100,69730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,43189.14,,,,,,,fee schedule,12709.88,56389.43,
Rplc oi implt sk tc esp>=100,69730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45407.32,,,,,,,fee schedule,12709.88,56389.43,
Rplc oi implt sk tc esp>=100,69730,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,12709.88,56389.43,APC 378
Rplc oi implt sk tc esp>=100,69730,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,12709.88,56389.43,APC
Rplc oi implt sk tc esp>=100,69730,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,12709.88,56389.43,APC
Rplc oi implt sk tc esp>=100,69730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,12709.88,56389.43,APC
Rplc oi implt sk tc esp>=100,69730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,12709.88,56389.43,Radiology
Rplc oi implt sk tc esp>=100,69730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,12709.88,56389.43,APC
Rplc oi implt sk tc esp>=100,69730,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,12709.88,56389.43,APC
Repair facial nerve,69740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Repair facial nerve,69740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Repair facial nerve,69740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Repair facial nerve,69740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Repair facial nerve,69740,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Repair facial nerve,69740,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Repair facial nerve,69740,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Repair facial nerve,69740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Repair facial nerve,69740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Repair facial nerve,69740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Repair facial nerve,69740,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Repair facial nerve,69745,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Repair facial nerve,69745,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Repair facial nerve,69745,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Repair facial nerve,69745,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Repair facial nerve,69745,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Repair facial nerve,69745,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Repair facial nerve,69745,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Repair facial nerve,69745,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Repair facial nerve,69745,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Repair facial nerve,69745,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Repair facial nerve,69745,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Middle ear surgery procedure,69799,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,624,,,,,,,fee schedule,234.47,1040.28,
Middle ear surgery procedure,69799,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,500.19,,,,,,,fee schedule,234.47,1040.28,
Middle ear surgery procedure,69799,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,546.41,,,,,,,fee schedule,234.47,1040.28,
Middle ear surgery procedure,69799,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,574.48,,,,,,,fee schedule,234.47,1040.28,
Middle ear surgery procedure,69799,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1040.28,,,,,,,fee schedule,234.47,1040.28,APC 378
Middle ear surgery procedure,69799,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,246.2,,,,,,,fee schedule,234.47,1040.28,APC
Middle ear surgery procedure,69799,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,243.85,,,,,,,fee schedule,234.47,1040.28,APC
Middle ear surgery procedure,69799,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,234.47,,,,,,,fee schedule,234.47,1040.28,APC
Middle ear surgery procedure,69799,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,358.74,,,,,,,fee schedule,234.47,1040.28,Radiology
Middle ear surgery procedure,69799,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,328.26,,,,,,,fee schedule,234.47,1040.28,APC
Middle ear surgery procedure,69799,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,410.33,,,,,,,fee schedule,234.47,1040.28,APC
Incise inner ear,69801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,1536.02,9952.44,
Incise inner ear,69801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,1536.02,9952.44,
Incise inner ear,69801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,1536.02,9952.44,
Incise inner ear,69801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,1536.02,9952.44,
Incise inner ear,69801,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1536.02,9952.44,APC 378
Incise inner ear,69801,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1536.02,9952.44,APC
Incise inner ear,69801,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1536.02,9952.44,APC
Incise inner ear,69801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1536.02,9952.44,APC
Incise inner ear,69801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1536.02,9952.44,Radiology
Incise inner ear,69801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1536.02,9952.44,APC
Incise inner ear,69801,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1536.02,9952.44,APC
Explore inner ear,69805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5233.25,,,,,,,fee schedule,4194.9,26000.79,
Explore inner ear,69805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4194.9,,,,,,,fee schedule,4194.9,26000.79,
Explore inner ear,69805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4582.55,,,,,,,fee schedule,4194.9,26000.79,
Explore inner ear,69805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4817.91,,,,,,,fee schedule,4194.9,26000.79,
Explore inner ear,69805,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,4194.9,26000.79,APC 378
Explore inner ear,69805,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,4194.9,26000.79,APC
Explore inner ear,69805,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,4194.9,26000.79,APC
Explore inner ear,69805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,4194.9,26000.79,APC
Explore inner ear,69805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,4194.9,26000.79,Radiology
Explore inner ear,69805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,4194.9,26000.79,APC
Explore inner ear,69805,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,4194.9,26000.79,APC
Explore inner ear,69806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12077.81,,,,,,,fee schedule,5860.44,26000.79,
Explore inner ear,69806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9681.42,,,,,,,fee schedule,5860.44,26000.79,
Explore inner ear,69806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10576.07,,,,,,,fee schedule,5860.44,26000.79,
Explore inner ear,69806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11119.25,,,,,,,fee schedule,5860.44,26000.79,
Explore inner ear,69806,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Explore inner ear,69806,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Explore inner ear,69806,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Explore inner ear,69806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Explore inner ear,69806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Explore inner ear,69806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Explore inner ear,69806,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Remove inner ear,69905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Remove inner ear,69905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Remove inner ear,69905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Remove inner ear,69905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Remove inner ear,69905,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Remove inner ear,69905,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Remove inner ear,69905,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Remove inner ear,69905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Remove inner ear,69905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Remove inner ear,69905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Remove inner ear,69905,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Remove inner ear & mastoid,69910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Remove inner ear & mastoid,69910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Remove inner ear & mastoid,69910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Remove inner ear & mastoid,69910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Remove inner ear & mastoid,69910,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Remove inner ear & mastoid,69910,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Remove inner ear & mastoid,69910,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Remove inner ear & mastoid,69910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Remove inner ear & mastoid,69910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Remove inner ear & mastoid,69910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Remove inner ear & mastoid,69910,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Incise inner ear nerve,69915,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,3282.2,14562,
Incise inner ear nerve,69915,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,3282.2,14562,
Incise inner ear nerve,69915,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,3282.2,14562,
Incise inner ear nerve,69915,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,3282.2,14562,
Incise inner ear nerve,69915,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Incise inner ear nerve,69915,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Incise inner ear nerve,69915,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Incise inner ear nerve,69915,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Incise inner ear nerve,69915,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Incise inner ear nerve,69915,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Incise inner ear nerve,69915,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Implant cochlear device,69930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13794.23,,,,,,,fee schedule,11057.28,144818.54,
Implant cochlear device,69930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11057.28,,,,,,,fee schedule,11057.28,144818.54,
Implant cochlear device,69930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12079.07,,,,,,,fee schedule,11057.28,144818.54,
Implant cochlear device,69930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12699.45,,,,,,,fee schedule,11057.28,144818.54,
Implant cochlear device,69930,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,144818.54,,,,,,,fee schedule,11057.28,144818.54,APC 378
Implant cochlear device,69930,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,34273.4,,,,,,,fee schedule,11057.28,144818.54,APC
Implant cochlear device,69930,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,33946.98,,,,,,,fee schedule,11057.28,144818.54,APC
Implant cochlear device,69930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,32641.33,,,,,,,fee schedule,11057.28,144818.54,APC
Implant cochlear device,69930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49941.24,,,,,,,fee schedule,11057.28,144818.54,Radiology
Implant cochlear device,69930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,45697.86,,,,,,,fee schedule,11057.28,144818.54,APC
Implant cochlear device,69930,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,57122.33,,,,,,,fee schedule,11057.28,144818.54,APC
Inner ear surgery procedure,69949,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,624,,,,,,,fee schedule,234.47,1040.28,
Inner ear surgery procedure,69949,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,500.19,,,,,,,fee schedule,234.47,1040.28,
Inner ear surgery procedure,69949,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,546.41,,,,,,,fee schedule,234.47,1040.28,
Inner ear surgery procedure,69949,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,574.48,,,,,,,fee schedule,234.47,1040.28,
Inner ear surgery procedure,69949,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1040.28,,,,,,,fee schedule,234.47,1040.28,APC 378
Inner ear surgery procedure,69949,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,246.2,,,,,,,fee schedule,234.47,1040.28,APC
Inner ear surgery procedure,69949,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,243.85,,,,,,,fee schedule,234.47,1040.28,APC
Inner ear surgery procedure,69949,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,234.47,,,,,,,fee schedule,234.47,1040.28,APC
Inner ear surgery procedure,69949,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,358.74,,,,,,,fee schedule,234.47,1040.28,Radiology
Inner ear surgery procedure,69949,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,328.26,,,,,,,fee schedule,234.47,1040.28,APC
Inner ear surgery procedure,69949,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,410.33,,,,,,,fee schedule,234.47,1040.28,APC
Release facial nerve,69955,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Release facial nerve,69955,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Release facial nerve,69955,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Release facial nerve,69955,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Release facial nerve,69955,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Release facial nerve,69955,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Release facial nerve,69955,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Release facial nerve,69955,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Release facial nerve,69955,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Release facial nerve,69955,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Release facial nerve,69955,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Release inner ear canal,69960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Release inner ear canal,69960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Release inner ear canal,69960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Release inner ear canal,69960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Release inner ear canal,69960,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Release inner ear canal,69960,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Release inner ear canal,69960,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Release inner ear canal,69960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Release inner ear canal,69960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Release inner ear canal,69960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Release inner ear canal,69960,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Remove inner ear lesion,69970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9952.44,,,,,,,fee schedule,5860.44,26000.79,
Remove inner ear lesion,69970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7977.75,,,,,,,fee schedule,5860.44,26000.79,
Remove inner ear lesion,69970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8714.97,,,,,,,fee schedule,5860.44,26000.79,
Remove inner ear lesion,69970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9162.56,,,,,,,fee schedule,5860.44,26000.79,
Remove inner ear lesion,69970,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Remove inner ear lesion,69970,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Remove inner ear lesion,69970,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Remove inner ear lesion,69970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Remove inner ear lesion,69970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Remove inner ear lesion,69970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Remove inner ear lesion,69970,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Temporal bone surgery,69979,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,624,,,,,,,fee schedule,234.47,1040.28,
Temporal bone surgery,69979,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,500.19,,,,,,,fee schedule,234.47,1040.28,
Temporal bone surgery,69979,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,546.41,,,,,,,fee schedule,234.47,1040.28,
Temporal bone surgery,69979,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,574.48,,,,,,,fee schedule,234.47,1040.28,
Temporal bone surgery,69979,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1040.28,,,,,,,fee schedule,234.47,1040.28,APC 378
Temporal bone surgery,69979,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,246.2,,,,,,,fee schedule,234.47,1040.28,APC
Temporal bone surgery,69979,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,243.85,,,,,,,fee schedule,234.47,1040.28,APC
Temporal bone surgery,69979,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,234.47,,,,,,,fee schedule,234.47,1040.28,APC
Temporal bone surgery,69979,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,358.74,,,,,,,fee schedule,234.47,1040.28,Radiology
Temporal bone surgery,69979,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,328.26,,,,,,,fee schedule,234.47,1040.28,APC
Temporal bone surgery,69979,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,410.33,,,,,,,fee schedule,234.47,1040.28,APC
Contrast x-ray of brain,70010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1886.52,,,,,,,fee schedule,345.37,1886.52,
Contrast x-ray of brain,70010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1512.21,,,,,,,fee schedule,345.37,1886.52,
Contrast x-ray of brain,70010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1651.95,,,,,,,fee schedule,345.37,1886.52,
Contrast x-ray of brain,70010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1736.8,,,,,,,fee schedule,345.37,1886.52,
Contrast x-ray of brain,70010,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1532.31,,,,,,,fee schedule,345.37,1886.52,APC 378
Contrast x-ray of brain,70010,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,362.64,,,,,,,fee schedule,345.37,1886.52,APC
Contrast x-ray of brain,70010,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,359.19,,,,,,,fee schedule,345.37,1886.52,APC
Contrast x-ray of brain,70010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,345.37,,,,,,,fee schedule,345.37,1886.52,APC
Contrast x-ray of brain,70010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,528.42,,,,,,,fee schedule,345.37,1886.52,Radiology
Contrast x-ray of brain,70010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,483.52,,,,,,,fee schedule,345.37,1886.52,APC
Contrast x-ray of brain,70010,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,604.4,,,,,,,fee schedule,345.37,1886.52,APC
Contrast x-ray of brain,70015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1886.52,,,,,,,fee schedule,776.06,3443.1,
Contrast x-ray of brain,70015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1512.21,,,,,,,fee schedule,776.06,3443.1,
Contrast x-ray of brain,70015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1651.95,,,,,,,fee schedule,776.06,3443.1,
Contrast x-ray of brain,70015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1736.8,,,,,,,fee schedule,776.06,3443.1,
Contrast x-ray of brain,70015,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3443.1,,,,,,,fee schedule,776.06,3443.1,APC 378
Contrast x-ray of brain,70015,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,814.86,,,,,,,fee schedule,776.06,3443.1,APC
Contrast x-ray of brain,70015,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,807.1,,,,,,,fee schedule,776.06,3443.1,APC
Contrast x-ray of brain,70015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,776.06,,,,,,,fee schedule,776.06,3443.1,APC
Contrast x-ray of brain,70015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1187.37,,,,,,,fee schedule,776.06,3443.1,Radiology
Contrast x-ray of brain,70015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1086.48,,,,,,,fee schedule,776.06,3443.1,APC
Contrast x-ray of brain,70015,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1358.1,,,,,,,fee schedule,776.06,3443.1,APC
X-ray eye for foreign body,70030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46.27,,,,,,,fee schedule,37.09,382.23,
X-ray eye for foreign body,70030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37.09,,,,,,,fee schedule,37.09,382.23,
X-ray eye for foreign body,70030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40.51,,,,,,,fee schedule,37.09,382.23,
X-ray eye for foreign body,70030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42.6,,,,,,,fee schedule,37.09,382.23,
X-ray eye for foreign body,70030,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,37.09,382.23,APC 378
X-ray eye for foreign body,70030,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,37.09,382.23,APC
X-ray eye for foreign body,70030,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,37.09,382.23,APC
X-ray eye for foreign body,70030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,37.09,382.23,APC
X-ray eye for foreign body,70030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,37.09,382.23,Radiology
X-ray eye for foreign body,70030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,37.09,382.23,APC
X-ray eye for foreign body,70030,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,37.09,382.23,APC
X-ray exam of jaw <4views,70100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,282.42,,,,,,,fee schedule,86.15,382.23,
X-ray exam of jaw <4views,70100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,226.39,,,,,,,fee schedule,86.15,382.23,
X-ray exam of jaw <4views,70100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,247.31,,,,,,,fee schedule,86.15,382.23,
X-ray exam of jaw <4views,70100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,260.01,,,,,,,fee schedule,86.15,382.23,
X-ray exam of jaw <4views,70100,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
X-ray exam of jaw <4views,70100,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of jaw <4views,70100,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of jaw <4views,70100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of jaw <4views,70100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
X-ray exam of jaw <4views,70100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of jaw <4views,70100,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of jaw 4/> views,70110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,272.25,,,,,,,fee schedule,103.5,459.18,
X-ray exam of jaw 4/> views,70110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,218.23,,,,,,,fee schedule,103.5,459.18,
X-ray exam of jaw 4/> views,70110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,238.4,,,,,,,fee schedule,103.5,459.18,
X-ray exam of jaw 4/> views,70110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,250.64,,,,,,,fee schedule,103.5,459.18,
X-ray exam of jaw 4/> views,70110,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
X-ray exam of jaw 4/> views,70110,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam of jaw 4/> views,70110,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam of jaw 4/> views,70110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam of jaw 4/> views,70110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
X-ray exam of jaw 4/> views,70110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam of jaw 4/> views,70110,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam of mastoids,70120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,173.54,,,,,,,fee schedule,103.5,459.18,
X-ray exam of mastoids,70120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,139.11,,,,,,,fee schedule,103.5,459.18,
X-ray exam of mastoids,70120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,151.96,,,,,,,fee schedule,103.5,459.18,
X-ray exam of mastoids,70120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,159.77,,,,,,,fee schedule,103.5,459.18,
X-ray exam of mastoids,70120,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
X-ray exam of mastoids,70120,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam of mastoids,70120,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam of mastoids,70120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam of mastoids,70120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
X-ray exam of mastoids,70120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam of mastoids,70120,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam of mastoids,70130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,173.54,,,,,,,fee schedule,103.5,459.18,
X-ray exam of mastoids,70130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,139.11,,,,,,,fee schedule,103.5,459.18,
X-ray exam of mastoids,70130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,151.96,,,,,,,fee schedule,103.5,459.18,
X-ray exam of mastoids,70130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,159.77,,,,,,,fee schedule,103.5,459.18,
X-ray exam of mastoids,70130,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
X-ray exam of mastoids,70130,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam of mastoids,70130,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam of mastoids,70130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam of mastoids,70130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
X-ray exam of mastoids,70130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam of mastoids,70130,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam of middle ear,70134,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,288.75,,,,,,,fee schedule,231.46,2399.94,
X-ray exam of middle ear,70134,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,231.46,,,,,,,fee schedule,231.46,2399.94,
X-ray exam of middle ear,70134,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,252.85,,,,,,,fee schedule,231.46,2399.94,
X-ray exam of middle ear,70134,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,265.84,,,,,,,fee schedule,231.46,2399.94,
X-ray exam of middle ear,70134,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2399.94,,,,,,,fee schedule,231.46,2399.94,APC 378
X-ray exam of middle ear,70134,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,567.98,,,,,,,fee schedule,231.46,2399.94,APC
X-ray exam of middle ear,70134,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,562.57,,,,,,,fee schedule,231.46,2399.94,APC
X-ray exam of middle ear,70134,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,540.93,,,,,,,fee schedule,231.46,2399.94,APC
X-ray exam of middle ear,70134,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,827.63,,,,,,,fee schedule,231.46,2399.94,Radiology
X-ray exam of middle ear,70134,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,757.31,,,,,,,fee schedule,231.46,2399.94,APC
X-ray exam of middle ear,70134,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,946.63,,,,,,,fee schedule,231.46,2399.94,APC
X-ray exam of facial bones,70140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,244.83,,,,,,,fee schedule,86.15,382.23,
X-ray exam of facial bones,70140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,196.25,,,,,,,fee schedule,86.15,382.23,
X-ray exam of facial bones,70140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,214.39,,,,,,,fee schedule,86.15,382.23,
X-ray exam of facial bones,70140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,225.4,,,,,,,fee schedule,86.15,382.23,
X-ray exam of facial bones,70140,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
X-ray exam of facial bones,70140,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of facial bones,70140,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of facial bones,70140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of facial bones,70140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
X-ray exam of facial bones,70140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of facial bones,70140,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of facial bones,70150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,293.03,,,,,,,fee schedule,103.5,459.18,
X-ray exam of facial bones,70150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,234.89,,,,,,,fee schedule,103.5,459.18,
X-ray exam of facial bones,70150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,256.59,,,,,,,fee schedule,103.5,459.18,
X-ray exam of facial bones,70150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,269.77,,,,,,,fee schedule,103.5,459.18,
X-ray exam of facial bones,70150,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
X-ray exam of facial bones,70150,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam of facial bones,70150,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam of facial bones,70150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam of facial bones,70150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
X-ray exam of facial bones,70150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam of facial bones,70150,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam of nasal bones,70160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,211.99,,,,,,,fee schedule,86.15,382.23,
X-ray exam of nasal bones,70160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,169.93,,,,,,,fee schedule,86.15,382.23,
X-ray exam of nasal bones,70160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,185.63,,,,,,,fee schedule,86.15,382.23,
X-ray exam of nasal bones,70160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,195.16,,,,,,,fee schedule,86.15,382.23,
X-ray exam of nasal bones,70160,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
X-ray exam of nasal bones,70160,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of nasal bones,70160,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of nasal bones,70160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of nasal bones,70160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
X-ray exam of nasal bones,70160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of nasal bones,70160,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of tear duct,70170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1338.31,,,,,,,fee schedule,236.21,1338.31,
X-ray exam of tear duct,70170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1072.77,,,,,,,fee schedule,236.21,1338.31,
X-ray exam of tear duct,70170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1171.91,,,,,,,fee schedule,236.21,1338.31,
X-ray exam of tear duct,70170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1232.09,,,,,,,fee schedule,236.21,1338.31,
X-ray exam of tear duct,70170,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,236.21,1338.31,APC 378
X-ray exam of tear duct,70170,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,236.21,1338.31,APC
X-ray exam of tear duct,70170,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,236.21,1338.31,APC
X-ray exam of tear duct,70170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,236.21,1338.31,APC
X-ray exam of tear duct,70170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,236.21,1338.31,Radiology
X-ray exam of tear duct,70170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,236.21,1338.31,APC
X-ray exam of tear duct,70170,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,236.21,1338.31,APC
X-ray exam of eye sockets,70190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,173.54,,,,,,,fee schedule,86.15,382.23,
X-ray exam of eye sockets,70190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,139.11,,,,,,,fee schedule,86.15,382.23,
X-ray exam of eye sockets,70190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,151.96,,,,,,,fee schedule,86.15,382.23,
X-ray exam of eye sockets,70190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,159.77,,,,,,,fee schedule,86.15,382.23,
X-ray exam of eye sockets,70190,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
X-ray exam of eye sockets,70190,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of eye sockets,70190,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of eye sockets,70190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of eye sockets,70190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
X-ray exam of eye sockets,70190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of eye sockets,70190,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of eye sockets,70200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,273.11,,,,,,,fee schedule,103.5,459.18,
X-ray exam of eye sockets,70200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,218.92,,,,,,,fee schedule,103.5,459.18,
X-ray exam of eye sockets,70200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,239.15,,,,,,,fee schedule,103.5,459.18,
X-ray exam of eye sockets,70200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,251.43,,,,,,,fee schedule,103.5,459.18,
X-ray exam of eye sockets,70200,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
X-ray exam of eye sockets,70200,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam of eye sockets,70200,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam of eye sockets,70200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam of eye sockets,70200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
X-ray exam of eye sockets,70200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam of eye sockets,70200,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam of sinuses,70210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,157.76,,,,,,,fee schedule,86.15,382.23,
X-ray exam of sinuses,70210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,126.46,,,,,,,fee schedule,86.15,382.23,
X-ray exam of sinuses,70210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,138.14,,,,,,,fee schedule,86.15,382.23,
X-ray exam of sinuses,70210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,145.24,,,,,,,fee schedule,86.15,382.23,
X-ray exam of sinuses,70210,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
X-ray exam of sinuses,70210,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of sinuses,70210,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of sinuses,70210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of sinuses,70210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
X-ray exam of sinuses,70210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of sinuses,70210,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of sinuses,70220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,250.61,,,,,,,fee schedule,86.15,382.23,
X-ray exam of sinuses,70220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,200.89,,,,,,,fee schedule,86.15,382.23,
X-ray exam of sinuses,70220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,219.45,,,,,,,fee schedule,86.15,382.23,
X-ray exam of sinuses,70220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,230.72,,,,,,,fee schedule,86.15,382.23,
X-ray exam of sinuses,70220,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
X-ray exam of sinuses,70220,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of sinuses,70220,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of sinuses,70220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of sinuses,70220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
X-ray exam of sinuses,70220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of sinuses,70220,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam pituitary saddle,70240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,173.54,,,,,,,fee schedule,86.15,382.23,
X-ray exam pituitary saddle,70240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,139.11,,,,,,,fee schedule,86.15,382.23,
X-ray exam pituitary saddle,70240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,151.96,,,,,,,fee schedule,86.15,382.23,
X-ray exam pituitary saddle,70240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,159.77,,,,,,,fee schedule,86.15,382.23,
X-ray exam pituitary saddle,70240,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
X-ray exam pituitary saddle,70240,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam pituitary saddle,70240,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam pituitary saddle,70240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam pituitary saddle,70240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
X-ray exam pituitary saddle,70240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam pituitary saddle,70240,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of skull,70250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,215.35,,,,,,,fee schedule,103.5,459.18,
X-ray exam of skull,70250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,172.62,,,,,,,fee schedule,103.5,459.18,
X-ray exam of skull,70250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,188.57,,,,,,,fee schedule,103.5,459.18,
X-ray exam of skull,70250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,198.26,,,,,,,fee schedule,103.5,459.18,
X-ray exam of skull,70250,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
X-ray exam of skull,70250,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam of skull,70250,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam of skull,70250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam of skull,70250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
X-ray exam of skull,70250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam of skull,70250,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam of skull,70260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,260.9,,,,,,,fee schedule,103.5,459.18,
X-ray exam of skull,70260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,209.13,,,,,,,fee schedule,103.5,459.18,
X-ray exam of skull,70260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,228.46,,,,,,,fee schedule,103.5,459.18,
X-ray exam of skull,70260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,240.19,,,,,,,fee schedule,103.5,459.18,
X-ray exam of skull,70260,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
X-ray exam of skull,70260,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam of skull,70260,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam of skull,70260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam of skull,70260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
X-ray exam of skull,70260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam of skull,70260,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam of teeth,70300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,143.49,,,,,,,fee schedule,86.15,382.23,
X-ray exam of teeth,70300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,115.02,,,,,,,fee schedule,86.15,382.23,
X-ray exam of teeth,70300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,125.65,,,,,,,fee schedule,86.15,382.23,
X-ray exam of teeth,70300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,132.1,,,,,,,fee schedule,86.15,382.23,
X-ray exam of teeth,70300,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
X-ray exam of teeth,70300,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of teeth,70300,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of teeth,70300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of teeth,70300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
X-ray exam of teeth,70300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of teeth,70300,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of teeth,70310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,143.49,,,,,,,fee schedule,115.02,1047.98,
X-ray exam of teeth,70310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,115.02,,,,,,,fee schedule,115.02,1047.98,
X-ray exam of teeth,70310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,125.65,,,,,,,fee schedule,115.02,1047.98,
X-ray exam of teeth,70310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,132.1,,,,,,,fee schedule,115.02,1047.98,
X-ray exam of teeth,70310,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,115.02,1047.98,APC 378
X-ray exam of teeth,70310,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,115.02,1047.98,APC
X-ray exam of teeth,70310,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,115.02,1047.98,APC
X-ray exam of teeth,70310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,115.02,1047.98,APC
X-ray exam of teeth,70310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,115.02,1047.98,Radiology
X-ray exam of teeth,70310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,115.02,1047.98,APC
X-ray exam of teeth,70310,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,115.02,1047.98,APC
Full mouth x-ray of teeth,70320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,114.38,,,,,,,fee schedule,91.69,1047.98,
Full mouth x-ray of teeth,70320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,91.69,,,,,,,fee schedule,91.69,1047.98,
Full mouth x-ray of teeth,70320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,100.16,,,,,,,fee schedule,91.69,1047.98,
Full mouth x-ray of teeth,70320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,105.3,,,,,,,fee schedule,91.69,1047.98,
Full mouth x-ray of teeth,70320,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,91.69,1047.98,APC 378
Full mouth x-ray of teeth,70320,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,91.69,1047.98,APC
Full mouth x-ray of teeth,70320,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,91.69,1047.98,APC
Full mouth x-ray of teeth,70320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,91.69,1047.98,APC
Full mouth x-ray of teeth,70320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,91.69,1047.98,Radiology
Full mouth x-ray of teeth,70320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,91.69,1047.98,APC
Full mouth x-ray of teeth,70320,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,91.69,1047.98,APC
X-ray exam of jaw joint,70328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,173.54,,,,,,,fee schedule,86.15,382.23,
X-ray exam of jaw joint,70328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,139.11,,,,,,,fee schedule,86.15,382.23,
X-ray exam of jaw joint,70328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,151.96,,,,,,,fee schedule,86.15,382.23,
X-ray exam of jaw joint,70328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,159.77,,,,,,,fee schedule,86.15,382.23,
X-ray exam of jaw joint,70328,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
X-ray exam of jaw joint,70328,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of jaw joint,70328,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of jaw joint,70328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of jaw joint,70328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
X-ray exam of jaw joint,70328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of jaw joint,70328,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of jaw joints,70330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,213.02,,,,,,,fee schedule,86.15,382.23,
X-ray exam of jaw joints,70330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,170.76,,,,,,,fee schedule,86.15,382.23,
X-ray exam of jaw joints,70330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,186.54,,,,,,,fee schedule,86.15,382.23,
X-ray exam of jaw joints,70330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,196.12,,,,,,,fee schedule,86.15,382.23,
X-ray exam of jaw joints,70330,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
X-ray exam of jaw joints,70330,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of jaw joints,70330,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of jaw joints,70330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of jaw joints,70330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
X-ray exam of jaw joints,70330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of jaw joints,70330,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of jaw joint,70332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,999.05,,,,,,,fee schedule,236.21,1047.98,
X-ray exam of jaw joint,70332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,800.83,,,,,,,fee schedule,236.21,1047.98,
X-ray exam of jaw joint,70332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,874.83,,,,,,,fee schedule,236.21,1047.98,
X-ray exam of jaw joint,70332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,919.76,,,,,,,fee schedule,236.21,1047.98,
X-ray exam of jaw joint,70332,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,236.21,1047.98,APC 378
X-ray exam of jaw joint,70332,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,236.21,1047.98,APC
X-ray exam of jaw joint,70332,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,236.21,1047.98,APC
X-ray exam of jaw joint,70332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,236.21,1047.98,APC
X-ray exam of jaw joint,70332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,236.21,1047.98,Radiology
X-ray exam of jaw joint,70332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,236.21,1047.98,APC
X-ray exam of jaw joint,70332,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,236.21,1047.98,APC
Magnetic image jaw joint,70336,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1218.67,,,,,,,fee schedule,236.21,1218.67,
Magnetic image jaw joint,70336,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,976.87,,,,,,,fee schedule,236.21,1218.67,
Magnetic image jaw joint,70336,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1067.14,,,,,,,fee schedule,236.21,1218.67,
Magnetic image jaw joint,70336,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1121.95,,,,,,,fee schedule,236.21,1218.67,
Magnetic image jaw joint,70336,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,236.21,1218.67,APC 378
Magnetic image jaw joint,70336,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,236.21,1218.67,APC
Magnetic image jaw joint,70336,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,236.21,1218.67,APC
Magnetic image jaw joint,70336,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,236.21,1218.67,APC
Magnetic image jaw joint,70336,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,236.21,1218.67,Radiology
Magnetic image jaw joint,70336,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,236.21,1218.67,APC
Magnetic image jaw joint,70336,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,236.21,1218.67,APC
X-ray head for orthodontia,70350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,173.54,,,,,,,fee schedule,86.15,382.23,
X-ray head for orthodontia,70350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,139.11,,,,,,,fee schedule,86.15,382.23,
X-ray head for orthodontia,70350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,151.96,,,,,,,fee schedule,86.15,382.23,
X-ray head for orthodontia,70350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,159.77,,,,,,,fee schedule,86.15,382.23,
X-ray head for orthodontia,70350,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
X-ray head for orthodontia,70350,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
X-ray head for orthodontia,70350,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
X-ray head for orthodontia,70350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
X-ray head for orthodontia,70350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
X-ray head for orthodontia,70350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
X-ray head for orthodontia,70350,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
Panoramic x-ray of jaws,70355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,173.54,,,,,,,fee schedule,86.15,382.23,
Panoramic x-ray of jaws,70355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,139.11,,,,,,,fee schedule,86.15,382.23,
Panoramic x-ray of jaws,70355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,151.96,,,,,,,fee schedule,86.15,382.23,
Panoramic x-ray of jaws,70355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,159.77,,,,,,,fee schedule,86.15,382.23,
Panoramic x-ray of jaws,70355,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
Panoramic x-ray of jaws,70355,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
Panoramic x-ray of jaws,70355,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
Panoramic x-ray of jaws,70355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
Panoramic x-ray of jaws,70355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
Panoramic x-ray of jaws,70355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
Panoramic x-ray of jaws,70355,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of neck,70360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,172.39,,,,,,,fee schedule,86.15,382.23,
X-ray exam of neck,70360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,138.18,,,,,,,fee schedule,86.15,382.23,
X-ray exam of neck,70360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,150.95,,,,,,,fee schedule,86.15,382.23,
X-ray exam of neck,70360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,158.71,,,,,,,fee schedule,86.15,382.23,
X-ray exam of neck,70360,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
X-ray exam of neck,70360,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of neck,70360,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of neck,70360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of neck,70360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
X-ray exam of neck,70360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of neck,70360,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
Throat x-ray & fluoroscopy,70370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,331.2,,,,,,,fee schedule,86.15,382.23,
Throat x-ray & fluoroscopy,70370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,265.49,,,,,,,fee schedule,86.15,382.23,
Throat x-ray & fluoroscopy,70370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,290.02,,,,,,,fee schedule,86.15,382.23,
Throat x-ray & fluoroscopy,70370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,304.92,,,,,,,fee schedule,86.15,382.23,
Throat x-ray & fluoroscopy,70370,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
Throat x-ray & fluoroscopy,70370,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
Throat x-ray & fluoroscopy,70370,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
Throat x-ray & fluoroscopy,70370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
Throat x-ray & fluoroscopy,70370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
Throat x-ray & fluoroscopy,70370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
Throat x-ray & fluoroscopy,70370,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
Speech evaluation complex,70371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,331.2,,,,,,,fee schedule,236.21,1047.98,
Speech evaluation complex,70371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,265.49,,,,,,,fee schedule,236.21,1047.98,
Speech evaluation complex,70371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,290.02,,,,,,,fee schedule,236.21,1047.98,
Speech evaluation complex,70371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,304.92,,,,,,,fee schedule,236.21,1047.98,
Speech evaluation complex,70371,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,236.21,1047.98,APC 378
Speech evaluation complex,70371,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,236.21,1047.98,APC
Speech evaluation complex,70371,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,236.21,1047.98,APC
Speech evaluation complex,70371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,236.21,1047.98,APC
Speech evaluation complex,70371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,236.21,1047.98,Radiology
Speech evaluation complex,70371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,236.21,1047.98,APC
Speech evaluation complex,70371,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,236.21,1047.98,APC
X-ray exam of salivary gland,70380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,173.54,,,,,,,fee schedule,86.15,382.23,
X-ray exam of salivary gland,70380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,139.11,,,,,,,fee schedule,86.15,382.23,
X-ray exam of salivary gland,70380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,151.96,,,,,,,fee schedule,86.15,382.23,
X-ray exam of salivary gland,70380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,159.77,,,,,,,fee schedule,86.15,382.23,
X-ray exam of salivary gland,70380,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
X-ray exam of salivary gland,70380,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of salivary gland,70380,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of salivary gland,70380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of salivary gland,70380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
X-ray exam of salivary gland,70380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of salivary gland,70380,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of salivary duct,70390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,669.82,,,,,,,fee schedule,236.21,1047.98,
X-ray exam of salivary duct,70390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,536.92,,,,,,,fee schedule,236.21,1047.98,
X-ray exam of salivary duct,70390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,586.53,,,,,,,fee schedule,236.21,1047.98,
X-ray exam of salivary duct,70390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,616.66,,,,,,,fee schedule,236.21,1047.98,
X-ray exam of salivary duct,70390,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,236.21,1047.98,APC 378
X-ray exam of salivary duct,70390,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,236.21,1047.98,APC
X-ray exam of salivary duct,70390,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,236.21,1047.98,APC
X-ray exam of salivary duct,70390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,236.21,1047.98,APC
X-ray exam of salivary duct,70390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,236.21,1047.98,Radiology
X-ray exam of salivary duct,70390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,236.21,1047.98,APC
X-ray exam of salivary duct,70390,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,236.21,1047.98,APC
Ct head/brain w/o dye,70450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,488.87,,,,,,,fee schedule,103.5,488.87,
Ct head/brain w/o dye,70450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,391.87,,,,,,,fee schedule,103.5,488.87,
Ct head/brain w/o dye,70450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,428.09,,,,,,,fee schedule,103.5,488.87,
Ct head/brain w/o dye,70450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,450.07,,,,,,,fee schedule,103.5,488.87,
Ct head/brain w/o dye,70450,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,488.87,APC 378
Ct head/brain w/o dye,70450,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,488.87,APC
Ct head/brain w/o dye,70450,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,488.87,APC
Ct head/brain w/o dye,70450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,488.87,APC
Ct head/brain w/o dye,70450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,488.87,Radiology
Ct head/brain w/o dye,70450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,488.87,APC
Ct head/brain w/o dye,70450,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,488.87,APC
Ct head/brain w/dye,70460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1041.77,,,,,,,fee schedule,173.64,1041.77,
Ct head/brain w/dye,70460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,835.07,,,,,,,fee schedule,173.64,1041.77,
Ct head/brain w/dye,70460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,912.24,,,,,,,fee schedule,173.64,1041.77,
Ct head/brain w/dye,70460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,959.09,,,,,,,fee schedule,173.64,1041.77,
Ct head/brain w/dye,70460,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,770.39,,,,,,,fee schedule,173.64,1041.77,APC 378
Ct head/brain w/dye,70460,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,182.32,,,,,,,fee schedule,173.64,1041.77,APC
Ct head/brain w/dye,70460,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,180.59,,,,,,,fee schedule,173.64,1041.77,APC
Ct head/brain w/dye,70460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,173.64,,,,,,,fee schedule,173.64,1041.77,APC
Ct head/brain w/dye,70460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,265.67,,,,,,,fee schedule,173.64,1041.77,Radiology
Ct head/brain w/dye,70460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,243.1,,,,,,,fee schedule,173.64,1041.77,APC
Ct head/brain w/dye,70460,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,303.87,,,,,,,fee schedule,173.64,1041.77,APC
Ct head/brain w/o & w/dye,70470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,898.9,,,,,,,fee schedule,173.64,898.9,
Ct head/brain w/o & w/dye,70470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,720.54,,,,,,,fee schedule,173.64,898.9,
Ct head/brain w/o & w/dye,70470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,787.13,,,,,,,fee schedule,173.64,898.9,
Ct head/brain w/o & w/dye,70470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,827.55,,,,,,,fee schedule,173.64,898.9,
Ct head/brain w/o & w/dye,70470,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,770.39,,,,,,,fee schedule,173.64,898.9,APC 378
Ct head/brain w/o & w/dye,70470,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,182.32,,,,,,,fee schedule,173.64,898.9,APC
Ct head/brain w/o & w/dye,70470,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,180.59,,,,,,,fee schedule,173.64,898.9,APC
Ct head/brain w/o & w/dye,70470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,173.64,,,,,,,fee schedule,173.64,898.9,APC
Ct head/brain w/o & w/dye,70470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,265.67,,,,,,,fee schedule,173.64,898.9,Radiology
Ct head/brain w/o & w/dye,70470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,243.1,,,,,,,fee schedule,173.64,898.9,APC
Ct head/brain w/o & w/dye,70470,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,303.87,,,,,,,fee schedule,173.64,898.9,APC
Cta h&n c+ w/noncontrast img,70471,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1532.31,,,,,,,fee schedule,345.37,1532.31,APC 378
Cta h&n c+ w/noncontrast img,70471,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,362.64,,,,,,,fee schedule,345.37,1532.31,APC
Cta h&n c+ w/noncontrast img,70471,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,359.19,,,,,,,fee schedule,345.37,1532.31,APC
Cta h&n c+ w/noncontrast img,70471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,345.37,,,,,,,fee schedule,345.37,1532.31,APC
Cta h&n c+ w/noncontrast img,70471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,528.42,,,,,,,fee schedule,345.37,1532.31,Radiology
Cta h&n c+ w/noncontrast img,70471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,483.52,,,,,,,fee schedule,345.37,1532.31,APC
Cta h&n c+ w/noncontrast img,70471,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,604.4,,,,,,,fee schedule,345.37,1532.31,APC
Ct cere prfu aly c+wo ct/cta,70473,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,770.39,,,,,,,fee schedule,173.64,770.39,APC 378
Ct cere prfu aly c+wo ct/cta,70473,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,182.32,,,,,,,fee schedule,173.64,770.39,APC
Ct cere prfu aly c+wo ct/cta,70473,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,180.59,,,,,,,fee schedule,173.64,770.39,APC
Ct cere prfu aly c+wo ct/cta,70473,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,173.64,,,,,,,fee schedule,173.64,770.39,APC
Ct cere prfu aly c+wo ct/cta,70473,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,265.67,,,,,,,fee schedule,173.64,770.39,Radiology
Ct cere prfu aly c+wo ct/cta,70473,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,243.1,,,,,,,fee schedule,173.64,770.39,APC
Ct cere prfu aly c+wo ct/cta,70473,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,303.87,,,,,,,fee schedule,173.64,770.39,APC
Ct orbit/ear/fossa w/o dye,70480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,587.1,,,,,,,fee schedule,103.5,587.1,
Ct orbit/ear/fossa w/o dye,70480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,470.61,,,,,,,fee schedule,103.5,587.1,
Ct orbit/ear/fossa w/o dye,70480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,514.1,,,,,,,fee schedule,103.5,587.1,
Ct orbit/ear/fossa w/o dye,70480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,540.51,,,,,,,fee schedule,103.5,587.1,
Ct orbit/ear/fossa w/o dye,70480,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,587.1,APC 378
Ct orbit/ear/fossa w/o dye,70480,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,587.1,APC
Ct orbit/ear/fossa w/o dye,70480,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,587.1,APC
Ct orbit/ear/fossa w/o dye,70480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,587.1,APC
Ct orbit/ear/fossa w/o dye,70480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,587.1,Radiology
Ct orbit/ear/fossa w/o dye,70480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,587.1,APC
Ct orbit/ear/fossa w/o dye,70480,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,587.1,APC
Ct orbit/ear/fossa w/dye,70481,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,740.1,,,,,,,fee schedule,173.64,770.39,
Ct orbit/ear/fossa w/dye,70481,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,593.25,,,,,,,fee schedule,173.64,770.39,
Ct orbit/ear/fossa w/dye,70481,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,648.08,,,,,,,fee schedule,173.64,770.39,
Ct orbit/ear/fossa w/dye,70481,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,681.36,,,,,,,fee schedule,173.64,770.39,
Ct orbit/ear/fossa w/dye,70481,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,770.39,,,,,,,fee schedule,173.64,770.39,APC 378
Ct orbit/ear/fossa w/dye,70481,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,182.32,,,,,,,fee schedule,173.64,770.39,APC
Ct orbit/ear/fossa w/dye,70481,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,180.59,,,,,,,fee schedule,173.64,770.39,APC
Ct orbit/ear/fossa w/dye,70481,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,173.64,,,,,,,fee schedule,173.64,770.39,APC
Ct orbit/ear/fossa w/dye,70481,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,265.67,,,,,,,fee schedule,173.64,770.39,Radiology
Ct orbit/ear/fossa w/dye,70481,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,243.1,,,,,,,fee schedule,173.64,770.39,APC
Ct orbit/ear/fossa w/dye,70481,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,303.87,,,,,,,fee schedule,173.64,770.39,APC
Ct orbit/ear/fossa w/o&w/dye,70482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1140.67,,,,,,,fee schedule,173.64,1140.67,
Ct orbit/ear/fossa w/o&w/dye,70482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,914.35,,,,,,,fee schedule,173.64,1140.67,
Ct orbit/ear/fossa w/o&w/dye,70482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,998.84,,,,,,,fee schedule,173.64,1140.67,
Ct orbit/ear/fossa w/o&w/dye,70482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1050.14,,,,,,,fee schedule,173.64,1140.67,
Ct orbit/ear/fossa w/o&w/dye,70482,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,770.39,,,,,,,fee schedule,173.64,1140.67,APC 378
Ct orbit/ear/fossa w/o&w/dye,70482,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,182.32,,,,,,,fee schedule,173.64,1140.67,APC
Ct orbit/ear/fossa w/o&w/dye,70482,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,180.59,,,,,,,fee schedule,173.64,1140.67,APC
Ct orbit/ear/fossa w/o&w/dye,70482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,173.64,,,,,,,fee schedule,173.64,1140.67,APC
Ct orbit/ear/fossa w/o&w/dye,70482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,265.67,,,,,,,fee schedule,173.64,1140.67,Radiology
Ct orbit/ear/fossa w/o&w/dye,70482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,243.1,,,,,,,fee schedule,173.64,1140.67,APC
Ct orbit/ear/fossa w/o&w/dye,70482,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,303.87,,,,,,,fee schedule,173.64,1140.67,APC
Ct maxillofacial w/o dye,70486,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,490.1,,,,,,,fee schedule,103.5,490.1,
Ct maxillofacial w/o dye,70486,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,392.86,,,,,,,fee schedule,103.5,490.1,
Ct maxillofacial w/o dye,70486,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,429.16,,,,,,,fee schedule,103.5,490.1,
Ct maxillofacial w/o dye,70486,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,451.21,,,,,,,fee schedule,103.5,490.1,
Ct maxillofacial w/o dye,70486,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,490.1,APC 378
Ct maxillofacial w/o dye,70486,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,490.1,APC
Ct maxillofacial w/o dye,70486,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,490.1,APC
Ct maxillofacial w/o dye,70486,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,490.1,APC
Ct maxillofacial w/o dye,70486,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,490.1,Radiology
Ct maxillofacial w/o dye,70486,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,490.1,APC
Ct maxillofacial w/o dye,70486,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,490.1,APC
Ct maxillofacial w/dye,70487,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,708.15,,,,,,,fee schedule,173.64,770.39,
Ct maxillofacial w/dye,70487,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,567.64,,,,,,,fee schedule,173.64,770.39,
Ct maxillofacial w/dye,70487,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,620.1,,,,,,,fee schedule,173.64,770.39,
Ct maxillofacial w/dye,70487,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,651.95,,,,,,,fee schedule,173.64,770.39,
Ct maxillofacial w/dye,70487,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,770.39,,,,,,,fee schedule,173.64,770.39,APC 378
Ct maxillofacial w/dye,70487,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,182.32,,,,,,,fee schedule,173.64,770.39,APC
Ct maxillofacial w/dye,70487,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,180.59,,,,,,,fee schedule,173.64,770.39,APC
Ct maxillofacial w/dye,70487,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,173.64,,,,,,,fee schedule,173.64,770.39,APC
Ct maxillofacial w/dye,70487,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,265.67,,,,,,,fee schedule,173.64,770.39,Radiology
Ct maxillofacial w/dye,70487,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,243.1,,,,,,,fee schedule,173.64,770.39,APC
Ct maxillofacial w/dye,70487,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,303.87,,,,,,,fee schedule,173.64,770.39,APC
Ct maxillofacial w/o & w/dye,70488,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,936.33,,,,,,,fee schedule,173.64,936.33,
Ct maxillofacial w/o & w/dye,70488,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,750.55,,,,,,,fee schedule,173.64,936.33,
Ct maxillofacial w/o & w/dye,70488,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,819.91,,,,,,,fee schedule,173.64,936.33,
Ct maxillofacial w/o & w/dye,70488,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,862.02,,,,,,,fee schedule,173.64,936.33,
Ct maxillofacial w/o & w/dye,70488,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,770.39,,,,,,,fee schedule,173.64,936.33,APC 378
Ct maxillofacial w/o & w/dye,70488,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,182.32,,,,,,,fee schedule,173.64,936.33,APC
Ct maxillofacial w/o & w/dye,70488,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,180.59,,,,,,,fee schedule,173.64,936.33,APC
Ct maxillofacial w/o & w/dye,70488,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,173.64,,,,,,,fee schedule,173.64,936.33,APC
Ct maxillofacial w/o & w/dye,70488,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,265.67,,,,,,,fee schedule,173.64,936.33,Radiology
Ct maxillofacial w/o & w/dye,70488,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,243.1,,,,,,,fee schedule,173.64,936.33,APC
Ct maxillofacial w/o & w/dye,70488,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,303.87,,,,,,,fee schedule,173.64,936.33,APC
Ct soft tissue neck w/o dye,70490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,564.64,,,,,,,fee schedule,103.5,564.64,
Ct soft tissue neck w/o dye,70490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,452.61,,,,,,,fee schedule,103.5,564.64,
Ct soft tissue neck w/o dye,70490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,494.44,,,,,,,fee schedule,103.5,564.64,
Ct soft tissue neck w/o dye,70490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,519.83,,,,,,,fee schedule,103.5,564.64,
Ct soft tissue neck w/o dye,70490,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,564.64,APC 378
Ct soft tissue neck w/o dye,70490,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,564.64,APC
Ct soft tissue neck w/o dye,70490,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,564.64,APC
Ct soft tissue neck w/o dye,70490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,564.64,APC
Ct soft tissue neck w/o dye,70490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,564.64,Radiology
Ct soft tissue neck w/o dye,70490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,564.64,APC
Ct soft tissue neck w/o dye,70490,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,564.64,APC
Ct soft tissue neck w/dye,70491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,801.24,,,,,,,fee schedule,173.64,801.24,
Ct soft tissue neck w/dye,70491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,642.26,,,,,,,fee schedule,173.64,801.24,
Ct soft tissue neck w/dye,70491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,701.61,,,,,,,fee schedule,173.64,801.24,
Ct soft tissue neck w/dye,70491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,737.65,,,,,,,fee schedule,173.64,801.24,
Ct soft tissue neck w/dye,70491,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,770.39,,,,,,,fee schedule,173.64,801.24,APC 378
Ct soft tissue neck w/dye,70491,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,182.32,,,,,,,fee schedule,173.64,801.24,APC
Ct soft tissue neck w/dye,70491,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,180.59,,,,,,,fee schedule,173.64,801.24,APC
Ct soft tissue neck w/dye,70491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,173.64,,,,,,,fee schedule,173.64,801.24,APC
Ct soft tissue neck w/dye,70491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,265.67,,,,,,,fee schedule,173.64,801.24,Radiology
Ct soft tissue neck w/dye,70491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,243.1,,,,,,,fee schedule,173.64,801.24,APC
Ct soft tissue neck w/dye,70491,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,303.87,,,,,,,fee schedule,173.64,801.24,APC
Ct sft tsue nck w/o & w/dye,70492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1039.41,,,,,,,fee schedule,173.64,1039.41,
Ct sft tsue nck w/o & w/dye,70492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,833.18,,,,,,,fee schedule,173.64,1039.41,
Ct sft tsue nck w/o & w/dye,70492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,910.17,,,,,,,fee schedule,173.64,1039.41,
Ct sft tsue nck w/o & w/dye,70492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,956.91,,,,,,,fee schedule,173.64,1039.41,
Ct sft tsue nck w/o & w/dye,70492,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,770.39,,,,,,,fee schedule,173.64,1039.41,APC 378
Ct sft tsue nck w/o & w/dye,70492,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,182.32,,,,,,,fee schedule,173.64,1039.41,APC
Ct sft tsue nck w/o & w/dye,70492,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,180.59,,,,,,,fee schedule,173.64,1039.41,APC
Ct sft tsue nck w/o & w/dye,70492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,173.64,,,,,,,fee schedule,173.64,1039.41,APC
Ct sft tsue nck w/o & w/dye,70492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,265.67,,,,,,,fee schedule,173.64,1039.41,Radiology
Ct sft tsue nck w/o & w/dye,70492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,243.1,,,,,,,fee schedule,173.64,1039.41,APC
Ct sft tsue nck w/o & w/dye,70492,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,303.87,,,,,,,fee schedule,173.64,1039.41,APC
Ct angiography head,70496,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1458.06,,,,,,,fee schedule,173.64,1458.06,
Ct angiography head,70496,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1168.76,,,,,,,fee schedule,173.64,1458.06,
Ct angiography head,70496,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1276.76,,,,,,,fee schedule,173.64,1458.06,
Ct angiography head,70496,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1342.34,,,,,,,fee schedule,173.64,1458.06,
Ct angiography head,70496,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,770.39,,,,,,,fee schedule,173.64,1458.06,APC 378
Ct angiography head,70496,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,182.32,,,,,,,fee schedule,173.64,1458.06,APC
Ct angiography head,70496,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,180.59,,,,,,,fee schedule,173.64,1458.06,APC
Ct angiography head,70496,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,173.64,,,,,,,fee schedule,173.64,1458.06,APC
Ct angiography head,70496,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,265.67,,,,,,,fee schedule,173.64,1458.06,Radiology
Ct angiography head,70496,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,243.1,,,,,,,fee schedule,173.64,1458.06,APC
Ct angiography head,70496,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,303.87,,,,,,,fee schedule,173.64,1458.06,APC
Ct angiography neck,70498,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1489.31,,,,,,,fee schedule,173.64,1489.31,
Ct angiography neck,70498,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1193.81,,,,,,,fee schedule,173.64,1489.31,
Ct angiography neck,70498,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1304.13,,,,,,,fee schedule,173.64,1489.31,
Ct angiography neck,70498,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1371.11,,,,,,,fee schedule,173.64,1489.31,
Ct angiography neck,70498,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,770.39,,,,,,,fee schedule,173.64,1489.31,APC 378
Ct angiography neck,70498,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,182.32,,,,,,,fee schedule,173.64,1489.31,APC
Ct angiography neck,70498,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,180.59,,,,,,,fee schedule,173.64,1489.31,APC
Ct angiography neck,70498,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,173.64,,,,,,,fee schedule,173.64,1489.31,APC
Ct angiography neck,70498,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,265.67,,,,,,,fee schedule,173.64,1489.31,Radiology
Ct angiography neck,70498,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,243.1,,,,,,,fee schedule,173.64,1489.31,APC
Ct angiography neck,70498,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,303.87,,,,,,,fee schedule,173.64,1489.31,APC
Mri orbit/face/neck w/o dye,70540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,871.37,,,,,,,fee schedule,236.21,1047.98,
Mri orbit/face/neck w/o dye,70540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,698.48,,,,,,,fee schedule,236.21,1047.98,
Mri orbit/face/neck w/o dye,70540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,763.03,,,,,,,fee schedule,236.21,1047.98,
Mri orbit/face/neck w/o dye,70540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,802.22,,,,,,,fee schedule,236.21,1047.98,
Mri orbit/face/neck w/o dye,70540,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,236.21,1047.98,APC 378
Mri orbit/face/neck w/o dye,70540,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,236.21,1047.98,APC
Mri orbit/face/neck w/o dye,70540,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,236.21,1047.98,APC
Mri orbit/face/neck w/o dye,70540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,236.21,1047.98,APC
Mri orbit/face/neck w/o dye,70540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,236.21,1047.98,Radiology
Mri orbit/face/neck w/o dye,70540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,236.21,1047.98,APC
Mri orbit/face/neck w/o dye,70540,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,236.21,1047.98,APC
Mri Orbit/Face/Neck W/Dye,70542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1612.28,,,,,,,fee schedule,345.37,1612.28,
Mri Orbit/Face/Neck W/Dye,70542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1292.39,,,,,,,fee schedule,345.37,1612.28,
Mri Orbit/Face/Neck W/Dye,70542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1411.81,,,,,,,fee schedule,345.37,1612.28,
Mri Orbit/Face/Neck W/Dye,70542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1484.32,,,,,,,fee schedule,345.37,1612.28,
Mri Orbit/Face/Neck W/Dye,70542,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1532.31,,,,,,,fee schedule,345.37,1612.28,APC 378
Mri Orbit/Face/Neck W/Dye,70542,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,362.64,,,,,,,fee schedule,345.37,1612.28,APC
Mri Orbit/Face/Neck W/Dye,70542,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,359.19,,,,,,,fee schedule,345.37,1612.28,APC
Mri Orbit/Face/Neck W/Dye,70542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,345.37,,,,,,,fee schedule,345.37,1612.28,APC
Mri Orbit/Face/Neck W/Dye,70542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,528.42,,,,,,,fee schedule,345.37,1612.28,Radiology
Mri Orbit/Face/Neck W/Dye,70542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,483.52,,,,,,,fee schedule,345.37,1612.28,APC
Mri Orbit/Face/Neck W/Dye,70542,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,604.4,,,,,,,fee schedule,345.37,1612.28,APC
Mri orbt/fac/nck w/o &w/dye,70543,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1144.11,,,,,,,fee schedule,345.37,1532.31,
Mri orbt/fac/nck w/o &w/dye,70543,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,917.1,,,,,,,fee schedule,345.37,1532.31,
Mri orbt/fac/nck w/o &w/dye,70543,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1001.85,,,,,,,fee schedule,345.37,1532.31,
Mri orbt/fac/nck w/o &w/dye,70543,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1053.3,,,,,,,fee schedule,345.37,1532.31,
Mri orbt/fac/nck w/o &w/dye,70543,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1532.31,,,,,,,fee schedule,345.37,1532.31,APC 378
Mri orbt/fac/nck w/o &w/dye,70543,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,362.64,,,,,,,fee schedule,345.37,1532.31,APC
Mri orbt/fac/nck w/o &w/dye,70543,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,359.19,,,,,,,fee schedule,345.37,1532.31,APC
Mri orbt/fac/nck w/o &w/dye,70543,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,345.37,,,,,,,fee schedule,345.37,1532.31,APC
Mri orbt/fac/nck w/o &w/dye,70543,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,528.42,,,,,,,fee schedule,345.37,1532.31,Radiology
Mri orbt/fac/nck w/o &w/dye,70543,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,483.52,,,,,,,fee schedule,345.37,1532.31,APC
Mri orbt/fac/nck w/o &w/dye,70543,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,604.4,,,,,,,fee schedule,345.37,1532.31,APC
Mr Angiography Head W/O Dye,70544,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,709.99,,,,,,,fee schedule,236.21,1047.98,
Mr Angiography Head W/O Dye,70544,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,569.12,,,,,,,fee schedule,236.21,1047.98,
Mr Angiography Head W/O Dye,70544,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,621.71,,,,,,,fee schedule,236.21,1047.98,
Mr Angiography Head W/O Dye,70544,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,653.64,,,,,,,fee schedule,236.21,1047.98,
Mr Angiography Head W/O Dye,70544,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,236.21,1047.98,APC 378
Mr Angiography Head W/O Dye,70544,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,236.21,1047.98,APC
Mr Angiography Head W/O Dye,70544,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,236.21,1047.98,APC
Mr Angiography Head W/O Dye,70544,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,236.21,1047.98,APC
Mr Angiography Head W/O Dye,70544,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,236.21,1047.98,Radiology
Mr Angiography Head W/O Dye,70544,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,236.21,1047.98,APC
Mr Angiography Head W/O Dye,70544,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,236.21,1047.98,APC
Mr Angiography Head W/Dye,70545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,838.05,,,,,,,fee schedule,345.37,1532.31,
Mr Angiography Head W/Dye,70545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,671.77,,,,,,,fee schedule,345.37,1532.31,
Mr Angiography Head W/Dye,70545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,733.85,,,,,,,fee schedule,345.37,1532.31,
Mr Angiography Head W/Dye,70545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,771.54,,,,,,,fee schedule,345.37,1532.31,
Mr Angiography Head W/Dye,70545,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1532.31,,,,,,,fee schedule,345.37,1532.31,APC 378
Mr Angiography Head W/Dye,70545,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,362.64,,,,,,,fee schedule,345.37,1532.31,APC
Mr Angiography Head W/Dye,70545,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,359.19,,,,,,,fee schedule,345.37,1532.31,APC
Mr Angiography Head W/Dye,70545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,345.37,,,,,,,fee schedule,345.37,1532.31,APC
Mr Angiography Head W/Dye,70545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,528.42,,,,,,,fee schedule,345.37,1532.31,Radiology
Mr Angiography Head W/Dye,70545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,483.52,,,,,,,fee schedule,345.37,1532.31,APC
Mr Angiography Head W/Dye,70545,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,604.4,,,,,,,fee schedule,345.37,1532.31,APC
Mr angiograph head w/o&w/dye,70546,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,991.89,,,,,,,fee schedule,345.37,1532.31,
Mr angiograph head w/o&w/dye,70546,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,795.08,,,,,,,fee schedule,345.37,1532.31,
Mr angiograph head w/o&w/dye,70546,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,868.56,,,,,,,fee schedule,345.37,1532.31,
Mr angiograph head w/o&w/dye,70546,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,913.16,,,,,,,fee schedule,345.37,1532.31,
Mr angiograph head w/o&w/dye,70546,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1532.31,,,,,,,fee schedule,345.37,1532.31,APC 378
Mr angiograph head w/o&w/dye,70546,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,362.64,,,,,,,fee schedule,345.37,1532.31,APC
Mr angiograph head w/o&w/dye,70546,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,359.19,,,,,,,fee schedule,345.37,1532.31,APC
Mr angiograph head w/o&w/dye,70546,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,345.37,,,,,,,fee schedule,345.37,1532.31,APC
Mr angiograph head w/o&w/dye,70546,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,528.42,,,,,,,fee schedule,345.37,1532.31,Radiology
Mr angiograph head w/o&w/dye,70546,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,483.52,,,,,,,fee schedule,345.37,1532.31,APC
Mr angiograph head w/o&w/dye,70546,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,604.4,,,,,,,fee schedule,345.37,1532.31,APC
Mr Angiography Neck W/O Dye,70547,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,661.12,,,,,,,fee schedule,236.21,1047.98,
Mr Angiography Neck W/O Dye,70547,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,529.95,,,,,,,fee schedule,236.21,1047.98,
Mr Angiography Neck W/O Dye,70547,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,578.92,,,,,,,fee schedule,236.21,1047.98,
Mr Angiography Neck W/O Dye,70547,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,608.65,,,,,,,fee schedule,236.21,1047.98,
Mr Angiography Neck W/O Dye,70547,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,236.21,1047.98,APC 378
Mr Angiography Neck W/O Dye,70547,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,236.21,1047.98,APC
Mr Angiography Neck W/O Dye,70547,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,236.21,1047.98,APC
Mr Angiography Neck W/O Dye,70547,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,236.21,1047.98,APC
Mr Angiography Neck W/O Dye,70547,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,236.21,1047.98,Radiology
Mr Angiography Neck W/O Dye,70547,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,236.21,1047.98,APC
Mr Angiography Neck W/O Dye,70547,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,236.21,1047.98,APC
Mr Angiography Neck W/Dye,70548,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1556.07,,,,,,,fee schedule,345.37,1556.07,
Mr Angiography Neck W/Dye,70548,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1247.33,,,,,,,fee schedule,345.37,1556.07,
Mr Angiography Neck W/Dye,70548,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1362.59,,,,,,,fee schedule,345.37,1556.07,
Mr Angiography Neck W/Dye,70548,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1432.58,,,,,,,fee schedule,345.37,1556.07,
Mr Angiography Neck W/Dye,70548,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1532.31,,,,,,,fee schedule,345.37,1556.07,APC 378
Mr Angiography Neck W/Dye,70548,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,362.64,,,,,,,fee schedule,345.37,1556.07,APC
Mr Angiography Neck W/Dye,70548,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,359.19,,,,,,,fee schedule,345.37,1556.07,APC
Mr Angiography Neck W/Dye,70548,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,345.37,,,,,,,fee schedule,345.37,1556.07,APC
Mr Angiography Neck W/Dye,70548,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,528.42,,,,,,,fee schedule,345.37,1556.07,Radiology
Mr Angiography Neck W/Dye,70548,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,483.52,,,,,,,fee schedule,345.37,1556.07,APC
Mr Angiography Neck W/Dye,70548,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,604.4,,,,,,,fee schedule,345.37,1556.07,APC
Mr angiograph neck w/o&w/dye,70549,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1035.02,,,,,,,fee schedule,345.37,1532.31,
Mr angiograph neck w/o&w/dye,70549,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,829.66,,,,,,,fee schedule,345.37,1532.31,
Mr angiograph neck w/o&w/dye,70549,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,906.33,,,,,,,fee schedule,345.37,1532.31,
Mr angiograph neck w/o&w/dye,70549,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,952.88,,,,,,,fee schedule,345.37,1532.31,
Mr angiograph neck w/o&w/dye,70549,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1532.31,,,,,,,fee schedule,345.37,1532.31,APC 378
Mr angiograph neck w/o&w/dye,70549,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,362.64,,,,,,,fee schedule,345.37,1532.31,APC
Mr angiograph neck w/o&w/dye,70549,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,359.19,,,,,,,fee schedule,345.37,1532.31,APC
Mr angiograph neck w/o&w/dye,70549,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,345.37,,,,,,,fee schedule,345.37,1532.31,APC
Mr angiograph neck w/o&w/dye,70549,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,528.42,,,,,,,fee schedule,345.37,1532.31,Radiology
Mr angiograph neck w/o&w/dye,70549,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,483.52,,,,,,,fee schedule,345.37,1532.31,APC
Mr angiograph neck w/o&w/dye,70549,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,604.4,,,,,,,fee schedule,345.37,1532.31,APC
Mri brain stem w/o dye,70551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,814.57,,,,,,,fee schedule,236.21,1047.98,
Mri brain stem w/o dye,70551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,652.95,,,,,,,fee schedule,236.21,1047.98,
Mri brain stem w/o dye,70551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,713.29,,,,,,,fee schedule,236.21,1047.98,
Mri brain stem w/o dye,70551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,749.92,,,,,,,fee schedule,236.21,1047.98,
Mri brain stem w/o dye,70551,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,236.21,1047.98,APC 378
Mri brain stem w/o dye,70551,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,236.21,1047.98,APC
Mri brain stem w/o dye,70551,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,236.21,1047.98,APC
Mri brain stem w/o dye,70551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,236.21,1047.98,APC
Mri brain stem w/o dye,70551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,236.21,1047.98,Radiology
Mri brain stem w/o dye,70551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,236.21,1047.98,APC
Mri brain stem w/o dye,70551,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,236.21,1047.98,APC
Mri brain stem w/dye,70552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,892.99,,,,,,,fee schedule,345.37,1532.31,
Mri brain stem w/dye,70552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,715.81,,,,,,,fee schedule,345.37,1532.31,
Mri brain stem w/dye,70552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,781.96,,,,,,,fee schedule,345.37,1532.31,
Mri brain stem w/dye,70552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,822.12,,,,,,,fee schedule,345.37,1532.31,
Mri brain stem w/dye,70552,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1532.31,,,,,,,fee schedule,345.37,1532.31,APC 378
Mri brain stem w/dye,70552,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,362.64,,,,,,,fee schedule,345.37,1532.31,APC
Mri brain stem w/dye,70552,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,359.19,,,,,,,fee schedule,345.37,1532.31,APC
Mri brain stem w/dye,70552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,345.37,,,,,,,fee schedule,345.37,1532.31,APC
Mri brain stem w/dye,70552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,528.42,,,,,,,fee schedule,345.37,1532.31,Radiology
Mri brain stem w/dye,70552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,483.52,,,,,,,fee schedule,345.37,1532.31,APC
Mri brain stem w/dye,70552,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,604.4,,,,,,,fee schedule,345.37,1532.31,APC
Mri brain stem w/o & w/dye,70553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1125.58,,,,,,,fee schedule,345.37,1532.31,
Mri brain stem w/o & w/dye,70553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,902.25,,,,,,,fee schedule,345.37,1532.31,
Mri brain stem w/o & w/dye,70553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,985.62,,,,,,,fee schedule,345.37,1532.31,
Mri brain stem w/o & w/dye,70553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1036.25,,,,,,,fee schedule,345.37,1532.31,
Mri brain stem w/o & w/dye,70553,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1532.31,,,,,,,fee schedule,345.37,1532.31,APC 378
Mri brain stem w/o & w/dye,70553,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,362.64,,,,,,,fee schedule,345.37,1532.31,APC
Mri brain stem w/o & w/dye,70553,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,359.19,,,,,,,fee schedule,345.37,1532.31,APC
Mri brain stem w/o & w/dye,70553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,345.37,,,,,,,fee schedule,345.37,1532.31,APC
Mri brain stem w/o & w/dye,70553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,528.42,,,,,,,fee schedule,345.37,1532.31,Radiology
Mri brain stem w/o & w/dye,70553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,483.52,,,,,,,fee schedule,345.37,1532.31,APC
Mri brain stem w/o & w/dye,70553,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,604.4,,,,,,,fee schedule,345.37,1532.31,APC
Fmri brain by tech,70554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1346.02,,,,,,,fee schedule,236.21,1346.02,
Fmri brain by tech,70554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1078.95,,,,,,,fee schedule,236.21,1346.02,
Fmri brain by tech,70554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1178.66,,,,,,,fee schedule,236.21,1346.02,
Fmri brain by tech,70554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1239.19,,,,,,,fee schedule,236.21,1346.02,
Fmri brain by tech,70554,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,236.21,1346.02,APC 378
Fmri brain by tech,70554,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,236.21,1346.02,APC
Fmri brain by tech,70554,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,236.21,1346.02,APC
Fmri brain by tech,70554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,236.21,1346.02,APC
Fmri brain by tech,70554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,236.21,1346.02,Radiology
Fmri brain by tech,70554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,236.21,1346.02,APC
Fmri brain by tech,70554,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,236.21,1346.02,APC
Fmri brain by phys/psych,70555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1346.02,,,,,,,fee schedule,236.21,1346.02,
Fmri brain by phys/psych,70555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1078.95,,,,,,,fee schedule,236.21,1346.02,
Fmri brain by phys/psych,70555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1178.66,,,,,,,fee schedule,236.21,1346.02,
Fmri brain by phys/psych,70555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1239.19,,,,,,,fee schedule,236.21,1346.02,
Fmri brain by phys/psych,70555,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,236.21,1346.02,APC 378
Fmri brain by phys/psych,70555,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,236.21,1346.02,APC
Fmri brain by phys/psych,70555,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,236.21,1346.02,APC
Fmri brain by phys/psych,70555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,236.21,1346.02,APC
Fmri brain by phys/psych,70555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,236.21,1346.02,Radiology
Fmri brain by phys/psych,70555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,236.21,1346.02,APC
Fmri brain by phys/psych,70555,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,236.21,1346.02,APC
Mri brain w/o dye,70557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1346.02,,,,,,,fee schedule,540.93,2399.94,
Mri brain w/o dye,70557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1078.95,,,,,,,fee schedule,540.93,2399.94,
Mri brain w/o dye,70557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1178.66,,,,,,,fee schedule,540.93,2399.94,
Mri brain w/o dye,70557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1239.19,,,,,,,fee schedule,540.93,2399.94,
Mri brain w/o dye,70557,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2399.94,,,,,,,fee schedule,540.93,2399.94,APC 378
Mri brain w/o dye,70557,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,567.98,,,,,,,fee schedule,540.93,2399.94,APC
Mri brain w/o dye,70557,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,562.57,,,,,,,fee schedule,540.93,2399.94,APC
Mri brain w/o dye,70557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,540.93,,,,,,,fee schedule,540.93,2399.94,APC
Mri brain w/o dye,70557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,827.63,,,,,,,fee schedule,540.93,2399.94,Radiology
Mri brain w/o dye,70557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,757.31,,,,,,,fee schedule,540.93,2399.94,APC
Mri brain w/o dye,70557,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,946.63,,,,,,,fee schedule,540.93,2399.94,APC
Mri brain w/dye,70558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1556.07,,,,,,,fee schedule,173.64,1556.07,
Mri brain w/dye,70558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1247.33,,,,,,,fee schedule,173.64,1556.07,
Mri brain w/dye,70558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1362.59,,,,,,,fee schedule,173.64,1556.07,
Mri brain w/dye,70558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1432.58,,,,,,,fee schedule,173.64,1556.07,
Mri brain w/dye,70558,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,770.39,,,,,,,fee schedule,173.64,1556.07,APC 378
Mri brain w/dye,70558,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,182.32,,,,,,,fee schedule,173.64,1556.07,APC
Mri brain w/dye,70558,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,180.59,,,,,,,fee schedule,173.64,1556.07,APC
Mri brain w/dye,70558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,173.64,,,,,,,fee schedule,173.64,1556.07,APC
Mri brain w/dye,70558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,265.67,,,,,,,fee schedule,173.64,1556.07,Radiology
Mri brain w/dye,70558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,243.1,,,,,,,fee schedule,173.64,1556.07,APC
Mri brain w/dye,70558,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,303.87,,,,,,,fee schedule,173.64,1556.07,APC
Mri brain w/o & w/dye,70559,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2058.06,,,,,,,fee schedule,173.64,2058.06,
Mri brain w/o & w/dye,70559,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1649.71,,,,,,,fee schedule,173.64,2058.06,
Mri brain w/o & w/dye,70559,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1802.16,,,,,,,fee schedule,173.64,2058.06,
Mri brain w/o & w/dye,70559,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1894.72,,,,,,,fee schedule,173.64,2058.06,
Mri brain w/o & w/dye,70559,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,770.39,,,,,,,fee schedule,173.64,2058.06,APC 378
Mri brain w/o & w/dye,70559,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,182.32,,,,,,,fee schedule,173.64,2058.06,APC
Mri brain w/o & w/dye,70559,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,180.59,,,,,,,fee schedule,173.64,2058.06,APC
Mri brain w/o & w/dye,70559,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,173.64,,,,,,,fee schedule,173.64,2058.06,APC
Mri brain w/o & w/dye,70559,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,265.67,,,,,,,fee schedule,173.64,2058.06,Radiology
Mri brain w/o & w/dye,70559,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,243.1,,,,,,,fee schedule,173.64,2058.06,APC
Mri brain w/o & w/dye,70559,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,303.87,,,,,,,fee schedule,173.64,2058.06,APC
X-ray exam chest 1 view,71045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,235.49,,,,,,,fee schedule,86.15,382.23,
X-ray exam chest 1 view,71045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,188.77,,,,,,,fee schedule,86.15,382.23,
X-ray exam chest 1 view,71045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,206.21,,,,,,,fee schedule,86.15,382.23,
X-ray exam chest 1 view,71045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,216.8,,,,,,,fee schedule,86.15,382.23,
X-ray exam chest 1 view,71045,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
X-ray exam chest 1 view,71045,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam chest 1 view,71045,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam chest 1 view,71045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam chest 1 view,71045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
X-ray exam chest 1 view,71045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam chest 1 view,71045,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam chest 2 views,71046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,235.49,,,,,,,fee schedule,86.15,382.23,
X-ray exam chest 2 views,71046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,188.77,,,,,,,fee schedule,86.15,382.23,
X-ray exam chest 2 views,71046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,206.21,,,,,,,fee schedule,86.15,382.23,
X-ray exam chest 2 views,71046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,216.8,,,,,,,fee schedule,86.15,382.23,
X-ray exam chest 2 views,71046,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
X-ray exam chest 2 views,71046,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam chest 2 views,71046,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam chest 2 views,71046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam chest 2 views,71046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
X-ray exam chest 2 views,71046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam chest 2 views,71046,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam chest 3 views,71047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,235.49,,,,,,,fee schedule,86.15,382.23,
X-ray exam chest 3 views,71047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,188.77,,,,,,,fee schedule,86.15,382.23,
X-ray exam chest 3 views,71047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,206.21,,,,,,,fee schedule,86.15,382.23,
X-ray exam chest 3 views,71047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,216.8,,,,,,,fee schedule,86.15,382.23,
X-ray exam chest 3 views,71047,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
X-ray exam chest 3 views,71047,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam chest 3 views,71047,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam chest 3 views,71047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam chest 3 views,71047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
X-ray exam chest 3 views,71047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam chest 3 views,71047,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam chest 4+ views,71048,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,425.29,,,,,,,fee schedule,103.5,459.18,
X-ray exam chest 4+ views,71048,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,340.91,,,,,,,fee schedule,103.5,459.18,
X-ray exam chest 4+ views,71048,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,372.41,,,,,,,fee schedule,103.5,459.18,
X-ray exam chest 4+ views,71048,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,391.53,,,,,,,fee schedule,103.5,459.18,
X-ray exam chest 4+ views,71048,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
X-ray exam chest 4+ views,71048,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam chest 4+ views,71048,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam chest 4+ views,71048,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam chest 4+ views,71048,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
X-ray exam chest 4+ views,71048,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam chest 4+ views,71048,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam ribs uni 2 views,71100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,197.35,,,,,,,fee schedule,86.15,382.23,
X-ray exam ribs uni 2 views,71100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,158.19,,,,,,,fee schedule,86.15,382.23,
X-ray exam ribs uni 2 views,71100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,172.81,,,,,,,fee schedule,86.15,382.23,
X-ray exam ribs uni 2 views,71100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,181.69,,,,,,,fee schedule,86.15,382.23,
X-ray exam ribs uni 2 views,71100,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
X-ray exam ribs uni 2 views,71100,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam ribs uni 2 views,71100,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam ribs uni 2 views,71100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam ribs uni 2 views,71100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
X-ray exam ribs uni 2 views,71100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam ribs uni 2 views,71100,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam unilat ribs/chest,71101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,243.01,,,,,,,fee schedule,103.5,459.18,
X-ray exam unilat ribs/chest,71101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,194.8,,,,,,,fee schedule,103.5,459.18,
X-ray exam unilat ribs/chest,71101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,212.8,,,,,,,fee schedule,103.5,459.18,
X-ray exam unilat ribs/chest,71101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,223.73,,,,,,,fee schedule,103.5,459.18,
X-ray exam unilat ribs/chest,71101,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
X-ray exam unilat ribs/chest,71101,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam unilat ribs/chest,71101,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam unilat ribs/chest,71101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam unilat ribs/chest,71101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
X-ray exam unilat ribs/chest,71101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam unilat ribs/chest,71101,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam ribs bil 3 views,71110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,379.78,,,,,,,fee schedule,103.5,459.18,
X-ray exam ribs bil 3 views,71110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,304.42,,,,,,,fee schedule,103.5,459.18,
X-ray exam ribs bil 3 views,71110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,332.56,,,,,,,fee schedule,103.5,459.18,
X-ray exam ribs bil 3 views,71110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,349.64,,,,,,,fee schedule,103.5,459.18,
X-ray exam ribs bil 3 views,71110,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
X-ray exam ribs bil 3 views,71110,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam ribs bil 3 views,71110,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam ribs bil 3 views,71110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam ribs bil 3 views,71110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
X-ray exam ribs bil 3 views,71110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam ribs bil 3 views,71110,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam ribs/chest4/> vws,71111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,298.81,,,,,,,fee schedule,103.5,459.18,
X-ray exam ribs/chest4/> vws,71111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,239.52,,,,,,,fee schedule,103.5,459.18,
X-ray exam ribs/chest4/> vws,71111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,261.66,,,,,,,fee schedule,103.5,459.18,
X-ray exam ribs/chest4/> vws,71111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,275.09,,,,,,,fee schedule,103.5,459.18,
X-ray exam ribs/chest4/> vws,71111,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
X-ray exam ribs/chest4/> vws,71111,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam ribs/chest4/> vws,71111,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam ribs/chest4/> vws,71111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam ribs/chest4/> vws,71111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
X-ray exam ribs/chest4/> vws,71111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam ribs/chest4/> vws,71111,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam breastbone 2/>vws,71120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,211.21,,,,,,,fee schedule,86.15,382.23,
X-ray exam breastbone 2/>vws,71120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,169.31,,,,,,,fee schedule,86.15,382.23,
X-ray exam breastbone 2/>vws,71120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,184.95,,,,,,,fee schedule,86.15,382.23,
X-ray exam breastbone 2/>vws,71120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,194.45,,,,,,,fee schedule,86.15,382.23,
X-ray exam breastbone 2/>vws,71120,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
X-ray exam breastbone 2/>vws,71120,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam breastbone 2/>vws,71120,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam breastbone 2/>vws,71120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam breastbone 2/>vws,71120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
X-ray exam breastbone 2/>vws,71120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam breastbone 2/>vws,71120,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
X-ray strenoclavic jt 3/>vws,71130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,153.07,,,,,,,fee schedule,86.15,382.23,
X-ray strenoclavic jt 3/>vws,71130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,122.7,,,,,,,fee schedule,86.15,382.23,
X-ray strenoclavic jt 3/>vws,71130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,134.04,,,,,,,fee schedule,86.15,382.23,
X-ray strenoclavic jt 3/>vws,71130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,140.92,,,,,,,fee schedule,86.15,382.23,
X-ray strenoclavic jt 3/>vws,71130,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
X-ray strenoclavic jt 3/>vws,71130,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
X-ray strenoclavic jt 3/>vws,71130,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
X-ray strenoclavic jt 3/>vws,71130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
X-ray strenoclavic jt 3/>vws,71130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
X-ray strenoclavic jt 3/>vws,71130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
X-ray strenoclavic jt 3/>vws,71130,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
Ct thorax w/o dye,71250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,558.99,,,,,,,fee schedule,103.5,558.99,
Ct thorax w/o dye,71250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,448.08,,,,,,,fee schedule,103.5,558.99,
Ct thorax w/o dye,71250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,489.48,,,,,,,fee schedule,103.5,558.99,
Ct thorax w/o dye,71250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,514.62,,,,,,,fee schedule,103.5,558.99,
Ct thorax w/o dye,71250,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,558.99,APC 378
Ct thorax w/o dye,71250,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,558.99,APC
Ct thorax w/o dye,71250,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,558.99,APC
Ct thorax w/o dye,71250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,558.99,APC
Ct thorax w/o dye,71250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,558.99,Radiology
Ct thorax w/o dye,71250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,558.99,APC
Ct thorax w/o dye,71250,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,558.99,APC
Ct thorax w/dye,71260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,910.52,,,,,,,fee schedule,173.64,910.52,
Ct thorax w/dye,71260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,729.86,,,,,,,fee schedule,173.64,910.52,
Ct thorax w/dye,71260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,797.31,,,,,,,fee schedule,173.64,910.52,
Ct thorax w/dye,71260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,838.26,,,,,,,fee schedule,173.64,910.52,
Ct thorax w/dye,71260,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,770.39,,,,,,,fee schedule,173.64,910.52,APC 378
Ct thorax w/dye,71260,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,182.32,,,,,,,fee schedule,173.64,910.52,APC
Ct thorax w/dye,71260,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,180.59,,,,,,,fee schedule,173.64,910.52,APC
Ct thorax w/dye,71260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,173.64,,,,,,,fee schedule,173.64,910.52,APC
Ct thorax w/dye,71260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,265.67,,,,,,,fee schedule,173.64,910.52,Radiology
Ct thorax w/dye,71260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,243.1,,,,,,,fee schedule,173.64,910.52,APC
Ct thorax w/dye,71260,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,303.87,,,,,,,fee schedule,173.64,910.52,APC
Ct thorax w/o & w/dye,71270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1123.41,,,,,,,fee schedule,173.64,1123.41,
Ct thorax w/o & w/dye,71270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,900.52,,,,,,,fee schedule,173.64,1123.41,
Ct thorax w/o & w/dye,71270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,983.73,,,,,,,fee schedule,173.64,1123.41,
Ct thorax w/o & w/dye,71270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1034.25,,,,,,,fee schedule,173.64,1123.41,
Ct thorax w/o & w/dye,71270,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,770.39,,,,,,,fee schedule,173.64,1123.41,APC 378
Ct thorax w/o & w/dye,71270,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,182.32,,,,,,,fee schedule,173.64,1123.41,APC
Ct thorax w/o & w/dye,71270,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,180.59,,,,,,,fee schedule,173.64,1123.41,APC
Ct thorax w/o & w/dye,71270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,173.64,,,,,,,fee schedule,173.64,1123.41,APC
Ct thorax w/o & w/dye,71270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,265.67,,,,,,,fee schedule,173.64,1123.41,Radiology
Ct thorax w/o & w/dye,71270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,243.1,,,,,,,fee schedule,173.64,1123.41,APC
Ct thorax w/o & w/dye,71270,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,303.87,,,,,,,fee schedule,173.64,1123.41,APC
Ct thorax lung cancer scr c-,71271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,305.8,,,,,,,fee schedule,103.5,459.18,
Ct thorax lung cancer scr c-,71271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,245.13,,,,,,,fee schedule,103.5,459.18,
Ct thorax lung cancer scr c-,71271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,267.78,,,,,,,fee schedule,103.5,459.18,
Ct thorax lung cancer scr c-,71271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,281.53,,,,,,,fee schedule,103.5,459.18,
Ct thorax lung cancer scr c-,71271,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
Ct thorax lung cancer scr c-,71271,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
Ct thorax lung cancer scr c-,71271,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
Ct thorax lung cancer scr c-,71271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
Ct thorax lung cancer scr c-,71271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
Ct thorax lung cancer scr c-,71271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
Ct thorax lung cancer scr c-,71271,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Ct angiography chest,71275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1529.66,,,,,,,fee schedule,173.64,1529.66,
Ct angiography chest,71275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1226.15,,,,,,,fee schedule,173.64,1529.66,
Ct angiography chest,71275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1339.46,,,,,,,fee schedule,173.64,1529.66,
Ct angiography chest,71275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1408.25,,,,,,,fee schedule,173.64,1529.66,
Ct angiography chest,71275,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,770.39,,,,,,,fee schedule,173.64,1529.66,APC 378
Ct angiography chest,71275,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,182.32,,,,,,,fee schedule,173.64,1529.66,APC
Ct angiography chest,71275,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,180.59,,,,,,,fee schedule,173.64,1529.66,APC
Ct angiography chest,71275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,173.64,,,,,,,fee schedule,173.64,1529.66,APC
Ct angiography chest,71275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,265.67,,,,,,,fee schedule,173.64,1529.66,Radiology
Ct angiography chest,71275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,243.1,,,,,,,fee schedule,173.64,1529.66,APC
Ct angiography chest,71275,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,303.87,,,,,,,fee schedule,173.64,1529.66,APC
Mri chest w/o dye,71550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,946.87,,,,,,,fee schedule,236.21,1047.98,
Mri chest w/o dye,71550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,759,,,,,,,fee schedule,236.21,1047.98,
Mri chest w/o dye,71550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,829.14,,,,,,,fee schedule,236.21,1047.98,
Mri chest w/o dye,71550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,871.72,,,,,,,fee schedule,236.21,1047.98,
Mri chest w/o dye,71550,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,236.21,1047.98,APC 378
Mri chest w/o dye,71550,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,236.21,1047.98,APC
Mri chest w/o dye,71550,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,236.21,1047.98,APC
Mri chest w/o dye,71550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,236.21,1047.98,APC
Mri chest w/o dye,71550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,236.21,1047.98,Radiology
Mri chest w/o dye,71550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,236.21,1047.98,APC
Mri chest w/o dye,71550,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,236.21,1047.98,APC
Mri Chest W/Dye,71551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1556.07,,,,,,,fee schedule,776.06,3443.1,
Mri Chest W/Dye,71551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1247.33,,,,,,,fee schedule,776.06,3443.1,
Mri Chest W/Dye,71551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1362.59,,,,,,,fee schedule,776.06,3443.1,
Mri Chest W/Dye,71551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1432.58,,,,,,,fee schedule,776.06,3443.1,
Mri Chest W/Dye,71551,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3443.1,,,,,,,fee schedule,776.06,3443.1,APC 378
Mri Chest W/Dye,71551,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,814.86,,,,,,,fee schedule,776.06,3443.1,APC
Mri Chest W/Dye,71551,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,807.1,,,,,,,fee schedule,776.06,3443.1,APC
Mri Chest W/Dye,71551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,776.06,,,,,,,fee schedule,776.06,3443.1,APC
Mri Chest W/Dye,71551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1187.37,,,,,,,fee schedule,776.06,3443.1,Radiology
Mri Chest W/Dye,71551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1086.48,,,,,,,fee schedule,776.06,3443.1,APC
Mri Chest W/Dye,71551,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1358.1,,,,,,,fee schedule,776.06,3443.1,APC
Mri chest w/o & w/dye,71552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1142.99,,,,,,,fee schedule,345.37,1532.31,
Mri chest w/o & w/dye,71552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,916.21,,,,,,,fee schedule,345.37,1532.31,
Mri chest w/o & w/dye,71552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1000.88,,,,,,,fee schedule,345.37,1532.31,
Mri chest w/o & w/dye,71552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1052.28,,,,,,,fee schedule,345.37,1532.31,
Mri chest w/o & w/dye,71552,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1532.31,,,,,,,fee schedule,345.37,1532.31,APC 378
Mri chest w/o & w/dye,71552,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,362.64,,,,,,,fee schedule,345.37,1532.31,APC
Mri chest w/o & w/dye,71552,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,359.19,,,,,,,fee schedule,345.37,1532.31,APC
Mri chest w/o & w/dye,71552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,345.37,,,,,,,fee schedule,345.37,1532.31,APC
Mri chest w/o & w/dye,71552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,528.42,,,,,,,fee schedule,345.37,1532.31,Radiology
Mri chest w/o & w/dye,71552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,483.52,,,,,,,fee schedule,345.37,1532.31,APC
Mri chest w/o & w/dye,71552,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,604.4,,,,,,,fee schedule,345.37,1532.31,APC
Mri angio chest w or w/o dye,71555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1794.03,,,,,,,fee schedule,1438.07,1794.03,
Mri angio chest w or w/o dye,71555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1438.07,,,,,,,fee schedule,1438.07,1794.03,
Mri angio chest w or w/o dye,71555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1570.96,,,,,,,fee schedule,1438.07,1794.03,
Mri angio chest w or w/o dye,71555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1651.64,,,,,,,fee schedule,1438.07,1794.03,
X-ray exam of spine 1 view,72020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,113.74,,,,,,,fee schedule,86.15,382.23,
X-ray exam of spine 1 view,72020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,91.17,,,,,,,fee schedule,86.15,382.23,
X-ray exam of spine 1 view,72020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,99.6,,,,,,,fee schedule,86.15,382.23,
X-ray exam of spine 1 view,72020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,104.71,,,,,,,fee schedule,86.15,382.23,
X-ray exam of spine 1 view,72020,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
X-ray exam of spine 1 view,72020,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of spine 1 view,72020,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of spine 1 view,72020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of spine 1 view,72020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
X-ray exam of spine 1 view,72020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of spine 1 view,72020,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam neck spine 2-3 vw,72040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,164.73,,,,,,,fee schedule,86.15,382.23,
X-ray exam neck spine 2-3 vw,72040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,132.05,,,,,,,fee schedule,86.15,382.23,
X-ray exam neck spine 2-3 vw,72040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,144.25,,,,,,,fee schedule,86.15,382.23,
X-ray exam neck spine 2-3 vw,72040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,151.66,,,,,,,fee schedule,86.15,382.23,
X-ray exam neck spine 2-3 vw,72040,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
X-ray exam neck spine 2-3 vw,72040,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam neck spine 2-3 vw,72040,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam neck spine 2-3 vw,72040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam neck spine 2-3 vw,72040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
X-ray exam neck spine 2-3 vw,72040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam neck spine 2-3 vw,72040,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam neck spine 4/5vws,72050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,265.14,,,,,,,fee schedule,103.5,459.18,
X-ray exam neck spine 4/5vws,72050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,212.53,,,,,,,fee schedule,103.5,459.18,
X-ray exam neck spine 4/5vws,72050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,232.17,,,,,,,fee schedule,103.5,459.18,
X-ray exam neck spine 4/5vws,72050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,244.09,,,,,,,fee schedule,103.5,459.18,
X-ray exam neck spine 4/5vws,72050,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
X-ray exam neck spine 4/5vws,72050,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam neck spine 4/5vws,72050,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam neck spine 4/5vws,72050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam neck spine 4/5vws,72050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
X-ray exam neck spine 4/5vws,72050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam neck spine 4/5vws,72050,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam neck spine 6/>vws,72052,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,309.07,,,,,,,fee schedule,103.5,459.18,
X-ray exam neck spine 6/>vws,72052,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,247.75,,,,,,,fee schedule,103.5,459.18,
X-ray exam neck spine 6/>vws,72052,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,270.64,,,,,,,fee schedule,103.5,459.18,
X-ray exam neck spine 6/>vws,72052,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,284.55,,,,,,,fee schedule,103.5,459.18,
X-ray exam neck spine 6/>vws,72052,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
X-ray exam neck spine 6/>vws,72052,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam neck spine 6/>vws,72052,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam neck spine 6/>vws,72052,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam neck spine 6/>vws,72052,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
X-ray exam neck spine 6/>vws,72052,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam neck spine 6/>vws,72052,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam thorac spine 2vws,72070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,214.97,,,,,,,fee schedule,103.5,459.18,
X-ray exam thorac spine 2vws,72070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,172.32,,,,,,,fee schedule,103.5,459.18,
X-ray exam thorac spine 2vws,72070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,188.24,,,,,,,fee schedule,103.5,459.18,
X-ray exam thorac spine 2vws,72070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,197.91,,,,,,,fee schedule,103.5,459.18,
X-ray exam thorac spine 2vws,72070,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
X-ray exam thorac spine 2vws,72070,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam thorac spine 2vws,72070,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam thorac spine 2vws,72070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam thorac spine 2vws,72070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
X-ray exam thorac spine 2vws,72070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam thorac spine 2vws,72070,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam thorac spine 3vws,72072,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,286.21,,,,,,,fee schedule,103.5,459.18,
X-ray exam thorac spine 3vws,72072,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,229.43,,,,,,,fee schedule,103.5,459.18,
X-ray exam thorac spine 3vws,72072,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,250.63,,,,,,,fee schedule,103.5,459.18,
X-ray exam thorac spine 3vws,72072,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,263.5,,,,,,,fee schedule,103.5,459.18,
X-ray exam thorac spine 3vws,72072,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
X-ray exam thorac spine 3vws,72072,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam thorac spine 3vws,72072,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam thorac spine 3vws,72072,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam thorac spine 3vws,72072,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
X-ray exam thorac spine 3vws,72072,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam thorac spine 3vws,72072,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam thorac spine4/>vw,72074,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,415.76,,,,,,,fee schedule,103.5,459.18,
X-ray exam thorac spine4/>vw,72074,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,333.27,,,,,,,fee schedule,103.5,459.18,
X-ray exam thorac spine4/>vw,72074,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,364.07,,,,,,,fee schedule,103.5,459.18,
X-ray exam thorac spine4/>vw,72074,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,382.77,,,,,,,fee schedule,103.5,459.18,
X-ray exam thorac spine4/>vw,72074,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
X-ray exam thorac spine4/>vw,72074,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam thorac spine4/>vw,72074,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam thorac spine4/>vw,72074,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam thorac spine4/>vw,72074,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
X-ray exam thorac spine4/>vw,72074,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam thorac spine4/>vw,72074,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam thoracolmb 2/> vw,72080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,189.57,,,,,,,fee schedule,86.15,382.23,
X-ray exam thoracolmb 2/> vw,72080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,151.95,,,,,,,fee schedule,86.15,382.23,
X-ray exam thoracolmb 2/> vw,72080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,166,,,,,,,fee schedule,86.15,382.23,
X-ray exam thoracolmb 2/> vw,72080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,174.52,,,,,,,fee schedule,86.15,382.23,
X-ray exam thoracolmb 2/> vw,72080,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
X-ray exam thoracolmb 2/> vw,72080,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam thoracolmb 2/> vw,72080,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam thoracolmb 2/> vw,72080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam thoracolmb 2/> vw,72080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
X-ray exam thoracolmb 2/> vw,72080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam thoracolmb 2/> vw,72080,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam entire spi 1 vw,72081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,155.17,,,,,,,fee schedule,86.15,382.23,
X-ray exam entire spi 1 vw,72081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,124.38,,,,,,,fee schedule,86.15,382.23,
X-ray exam entire spi 1 vw,72081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,135.88,,,,,,,fee schedule,86.15,382.23,
X-ray exam entire spi 1 vw,72081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,142.86,,,,,,,fee schedule,86.15,382.23,
X-ray exam entire spi 1 vw,72081,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
X-ray exam entire spi 1 vw,72081,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam entire spi 1 vw,72081,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam entire spi 1 vw,72081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam entire spi 1 vw,72081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
X-ray exam entire spi 1 vw,72081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam entire spi 1 vw,72081,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam entire spi 2/3 vw,72082,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,199.21,,,,,,,fee schedule,103.5,459.18,
X-ray exam entire spi 2/3 vw,72082,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,159.68,,,,,,,fee schedule,103.5,459.18,
X-ray exam entire spi 2/3 vw,72082,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,174.44,,,,,,,fee schedule,103.5,459.18,
X-ray exam entire spi 2/3 vw,72082,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,183.4,,,,,,,fee schedule,103.5,459.18,
X-ray exam entire spi 2/3 vw,72082,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
X-ray exam entire spi 2/3 vw,72082,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam entire spi 2/3 vw,72082,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam entire spi 2/3 vw,72082,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam entire spi 2/3 vw,72082,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
X-ray exam entire spi 2/3 vw,72082,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam entire spi 2/3 vw,72082,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam entire spi 4/5 vw,72083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,725.65,,,,,,,fee schedule,103.5,725.65,
X-ray exam entire spi 4/5 vw,72083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,581.67,,,,,,,fee schedule,103.5,725.65,
X-ray exam entire spi 4/5 vw,72083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,635.42,,,,,,,fee schedule,103.5,725.65,
X-ray exam entire spi 4/5 vw,72083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,668.06,,,,,,,fee schedule,103.5,725.65,
X-ray exam entire spi 4/5 vw,72083,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,725.65,APC 378
X-ray exam entire spi 4/5 vw,72083,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,725.65,APC
X-ray exam entire spi 4/5 vw,72083,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,725.65,APC
X-ray exam entire spi 4/5 vw,72083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,725.65,APC
X-ray exam entire spi 4/5 vw,72083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,725.65,Radiology
X-ray exam entire spi 4/5 vw,72083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,725.65,APC
X-ray exam entire spi 4/5 vw,72083,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,725.65,APC
X-ray exam entire spi 6/> vw,72084,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,725.65,,,,,,,fee schedule,103.5,725.65,
X-ray exam entire spi 6/> vw,72084,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,581.67,,,,,,,fee schedule,103.5,725.65,
X-ray exam entire spi 6/> vw,72084,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,635.42,,,,,,,fee schedule,103.5,725.65,
X-ray exam entire spi 6/> vw,72084,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,668.06,,,,,,,fee schedule,103.5,725.65,
X-ray exam entire spi 6/> vw,72084,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,725.65,APC 378
X-ray exam entire spi 6/> vw,72084,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,725.65,APC
X-ray exam entire spi 6/> vw,72084,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,725.65,APC
X-ray exam entire spi 6/> vw,72084,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,725.65,APC
X-ray exam entire spi 6/> vw,72084,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,725.65,Radiology
X-ray exam entire spi 6/> vw,72084,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,725.65,APC
X-ray exam entire spi 6/> vw,72084,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,725.65,APC
X-ray exam l-s spine 2/3 vws,72100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,230.79,,,,,,,fee schedule,103.5,459.18,
X-ray exam l-s spine 2/3 vws,72100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,185,,,,,,,fee schedule,103.5,459.18,
X-ray exam l-s spine 2/3 vws,72100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,202.09,,,,,,,fee schedule,103.5,459.18,
X-ray exam l-s spine 2/3 vws,72100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,212.47,,,,,,,fee schedule,103.5,459.18,
X-ray exam l-s spine 2/3 vws,72100,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
X-ray exam l-s spine 2/3 vws,72100,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam l-s spine 2/3 vws,72100,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam l-s spine 2/3 vws,72100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam l-s spine 2/3 vws,72100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
X-ray exam l-s spine 2/3 vws,72100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam l-s spine 2/3 vws,72100,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam l-2 spine 4/>vws,72110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,329.26,,,,,,,fee schedule,103.5,459.18,
X-ray exam l-2 spine 4/>vws,72110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,263.93,,,,,,,fee schedule,103.5,459.18,
X-ray exam l-2 spine 4/>vws,72110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,288.32,,,,,,,fee schedule,103.5,459.18,
X-ray exam l-2 spine 4/>vws,72110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,303.13,,,,,,,fee schedule,103.5,459.18,
X-ray exam l-2 spine 4/>vws,72110,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
X-ray exam l-2 spine 4/>vws,72110,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam l-2 spine 4/>vws,72110,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam l-2 spine 4/>vws,72110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam l-2 spine 4/>vws,72110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
X-ray exam l-2 spine 4/>vws,72110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam l-2 spine 4/>vws,72110,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam l-s spine bending,72114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,397.02,,,,,,,fee schedule,103.5,459.18,
X-ray exam l-s spine bending,72114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,318.25,,,,,,,fee schedule,103.5,459.18,
X-ray exam l-s spine bending,72114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,347.66,,,,,,,fee schedule,103.5,459.18,
X-ray exam l-s spine bending,72114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,365.51,,,,,,,fee schedule,103.5,459.18,
X-ray exam l-s spine bending,72114,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
X-ray exam l-s spine bending,72114,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam l-s spine bending,72114,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam l-s spine bending,72114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam l-s spine bending,72114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
X-ray exam l-s spine bending,72114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam l-s spine bending,72114,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
X-ray bend only l-s spine,72120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,137.8,,,,,,,fee schedule,103.5,459.18,
X-ray bend only l-s spine,72120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,110.46,,,,,,,fee schedule,103.5,459.18,
X-ray bend only l-s spine,72120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,120.66,,,,,,,fee schedule,103.5,459.18,
X-ray bend only l-s spine,72120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,126.86,,,,,,,fee schedule,103.5,459.18,
X-ray bend only l-s spine,72120,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
X-ray bend only l-s spine,72120,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
X-ray bend only l-s spine,72120,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
X-ray bend only l-s spine,72120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
X-ray bend only l-s spine,72120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
X-ray bend only l-s spine,72120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
X-ray bend only l-s spine,72120,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Ct neck spine w/o dye,72125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,937.63,,,,,,,fee schedule,103.5,937.63,
Ct neck spine w/o dye,72125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,751.59,,,,,,,fee schedule,103.5,937.63,
Ct neck spine w/o dye,72125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,821.05,,,,,,,fee schedule,103.5,937.63,
Ct neck spine w/o dye,72125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,863.22,,,,,,,fee schedule,103.5,937.63,
Ct neck spine w/o dye,72125,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,937.63,APC 378
Ct neck spine w/o dye,72125,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,937.63,APC
Ct neck spine w/o dye,72125,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,937.63,APC
Ct neck spine w/o dye,72125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,937.63,APC
Ct neck spine w/o dye,72125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,937.63,Radiology
Ct neck spine w/o dye,72125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,937.63,APC
Ct neck spine w/o dye,72125,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,937.63,APC
Ct neck spine w/dye,72126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1333.21,,,,,,,fee schedule,345.37,1532.31,
Ct neck spine w/dye,72126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1068.69,,,,,,,fee schedule,345.37,1532.31,
Ct neck spine w/dye,72126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1167.44,,,,,,,fee schedule,345.37,1532.31,
Ct neck spine w/dye,72126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1227.4,,,,,,,fee schedule,345.37,1532.31,
Ct neck spine w/dye,72126,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1532.31,,,,,,,fee schedule,345.37,1532.31,APC 378
Ct neck spine w/dye,72126,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,362.64,,,,,,,fee schedule,345.37,1532.31,APC
Ct neck spine w/dye,72126,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,359.19,,,,,,,fee schedule,345.37,1532.31,APC
Ct neck spine w/dye,72126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,345.37,,,,,,,fee schedule,345.37,1532.31,APC
Ct neck spine w/dye,72126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,528.42,,,,,,,fee schedule,345.37,1532.31,Radiology
Ct neck spine w/dye,72126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,483.52,,,,,,,fee schedule,345.37,1532.31,APC
Ct neck spine w/dye,72126,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,604.4,,,,,,,fee schedule,345.37,1532.31,APC
Ct neck spine w/o & w/dye,72127,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1232.83,,,,,,,fee schedule,173.64,1232.83,
Ct neck spine w/o & w/dye,72127,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,988.22,,,,,,,fee schedule,173.64,1232.83,
Ct neck spine w/o & w/dye,72127,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1079.54,,,,,,,fee schedule,173.64,1232.83,
Ct neck spine w/o & w/dye,72127,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1134.99,,,,,,,fee schedule,173.64,1232.83,
Ct neck spine w/o & w/dye,72127,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,770.39,,,,,,,fee schedule,173.64,1232.83,APC 378
Ct neck spine w/o & w/dye,72127,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,182.32,,,,,,,fee schedule,173.64,1232.83,APC
Ct neck spine w/o & w/dye,72127,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,180.59,,,,,,,fee schedule,173.64,1232.83,APC
Ct neck spine w/o & w/dye,72127,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,173.64,,,,,,,fee schedule,173.64,1232.83,APC
Ct neck spine w/o & w/dye,72127,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,265.67,,,,,,,fee schedule,173.64,1232.83,Radiology
Ct neck spine w/o & w/dye,72127,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,243.1,,,,,,,fee schedule,173.64,1232.83,APC
Ct neck spine w/o & w/dye,72127,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,303.87,,,,,,,fee schedule,173.64,1232.83,APC
Ct chest spine w/o dye,72128,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,843.96,,,,,,,fee schedule,103.5,843.96,
Ct chest spine w/o dye,72128,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,676.51,,,,,,,fee schedule,103.5,843.96,
Ct chest spine w/o dye,72128,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,739.02,,,,,,,fee schedule,103.5,843.96,
Ct chest spine w/o dye,72128,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,776.98,,,,,,,fee schedule,103.5,843.96,
Ct chest spine w/o dye,72128,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,843.96,APC 378
Ct chest spine w/o dye,72128,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,843.96,APC
Ct chest spine w/o dye,72128,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,843.96,APC
Ct chest spine w/o dye,72128,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,843.96,APC
Ct chest spine w/o dye,72128,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,843.96,Radiology
Ct chest spine w/o dye,72128,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,843.96,APC
Ct chest spine w/o dye,72128,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,843.96,APC
Ct chest spine w/dye,72129,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1070.45,,,,,,,fee schedule,173.64,1070.45,
Ct chest spine w/dye,72129,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,858.06,,,,,,,fee schedule,173.64,1070.45,
Ct chest spine w/dye,72129,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,937.35,,,,,,,fee schedule,173.64,1070.45,
Ct chest spine w/dye,72129,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,985.49,,,,,,,fee schedule,173.64,1070.45,
Ct chest spine w/dye,72129,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,770.39,,,,,,,fee schedule,173.64,1070.45,APC 378
Ct chest spine w/dye,72129,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,182.32,,,,,,,fee schedule,173.64,1070.45,APC
Ct chest spine w/dye,72129,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,180.59,,,,,,,fee schedule,173.64,1070.45,APC
Ct chest spine w/dye,72129,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,173.64,,,,,,,fee schedule,173.64,1070.45,APC
Ct chest spine w/dye,72129,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,265.67,,,,,,,fee schedule,173.64,1070.45,Radiology
Ct chest spine w/dye,72129,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,243.1,,,,,,,fee schedule,173.64,1070.45,APC
Ct chest spine w/dye,72129,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,303.87,,,,,,,fee schedule,173.64,1070.45,APC
Ct chest spine w/o & w/dye,72130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1275.98,,,,,,,fee schedule,173.64,1275.98,
Ct chest spine w/o & w/dye,72130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1022.81,,,,,,,fee schedule,173.64,1275.98,
Ct chest spine w/o & w/dye,72130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1117.32,,,,,,,fee schedule,173.64,1275.98,
Ct chest spine w/o & w/dye,72130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1174.71,,,,,,,fee schedule,173.64,1275.98,
Ct chest spine w/o & w/dye,72130,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,770.39,,,,,,,fee schedule,173.64,1275.98,APC 378
Ct chest spine w/o & w/dye,72130,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,182.32,,,,,,,fee schedule,173.64,1275.98,APC
Ct chest spine w/o & w/dye,72130,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,180.59,,,,,,,fee schedule,173.64,1275.98,APC
Ct chest spine w/o & w/dye,72130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,173.64,,,,,,,fee schedule,173.64,1275.98,APC
Ct chest spine w/o & w/dye,72130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,265.67,,,,,,,fee schedule,173.64,1275.98,Radiology
Ct chest spine w/o & w/dye,72130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,243.1,,,,,,,fee schedule,173.64,1275.98,APC
Ct chest spine w/o & w/dye,72130,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,303.87,,,,,,,fee schedule,173.64,1275.98,APC
Ct lumbar spine w/o dye,72131,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,771.73,,,,,,,fee schedule,103.5,771.73,
Ct lumbar spine w/o dye,72131,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,618.61,,,,,,,fee schedule,103.5,771.73,
Ct lumbar spine w/o dye,72131,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,675.77,,,,,,,fee schedule,103.5,771.73,
Ct lumbar spine w/o dye,72131,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,710.48,,,,,,,fee schedule,103.5,771.73,
Ct lumbar spine w/o dye,72131,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,771.73,APC 378
Ct lumbar spine w/o dye,72131,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,771.73,APC
Ct lumbar spine w/o dye,72131,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,771.73,APC
Ct lumbar spine w/o dye,72131,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,771.73,APC
Ct lumbar spine w/o dye,72131,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,771.73,Radiology
Ct lumbar spine w/o dye,72131,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,771.73,APC
Ct lumbar spine w/o dye,72131,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,771.73,APC
Ct lumbar spine w/dye,72132,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1043.03,,,,,,,fee schedule,345.37,1532.31,
Ct lumbar spine w/dye,72132,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,836.08,,,,,,,fee schedule,345.37,1532.31,
Ct lumbar spine w/dye,72132,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,913.35,,,,,,,fee schedule,345.37,1532.31,
Ct lumbar spine w/dye,72132,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,960.25,,,,,,,fee schedule,345.37,1532.31,
Ct lumbar spine w/dye,72132,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1532.31,,,,,,,fee schedule,345.37,1532.31,APC 378
Ct lumbar spine w/dye,72132,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,362.64,,,,,,,fee schedule,345.37,1532.31,APC
Ct lumbar spine w/dye,72132,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,359.19,,,,,,,fee schedule,345.37,1532.31,APC
Ct lumbar spine w/dye,72132,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,345.37,,,,,,,fee schedule,345.37,1532.31,APC
Ct lumbar spine w/dye,72132,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,528.42,,,,,,,fee schedule,345.37,1532.31,Radiology
Ct lumbar spine w/dye,72132,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,483.52,,,,,,,fee schedule,345.37,1532.31,APC
Ct lumbar spine w/dye,72132,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,604.4,,,,,,,fee schedule,345.37,1532.31,APC
Ct lumbar spine w/o & w/dye,72133,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1639.84,,,,,,,fee schedule,173.64,1639.84,
Ct lumbar spine w/o & w/dye,72133,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1314.47,,,,,,,fee schedule,173.64,1639.84,
Ct lumbar spine w/o & w/dye,72133,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1435.94,,,,,,,fee schedule,173.64,1639.84,
Ct lumbar spine w/o & w/dye,72133,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1509.69,,,,,,,fee schedule,173.64,1639.84,
Ct lumbar spine w/o & w/dye,72133,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,770.39,,,,,,,fee schedule,173.64,1639.84,APC 378
Ct lumbar spine w/o & w/dye,72133,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,182.32,,,,,,,fee schedule,173.64,1639.84,APC
Ct lumbar spine w/o & w/dye,72133,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,180.59,,,,,,,fee schedule,173.64,1639.84,APC
Ct lumbar spine w/o & w/dye,72133,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,173.64,,,,,,,fee schedule,173.64,1639.84,APC
Ct lumbar spine w/o & w/dye,72133,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,265.67,,,,,,,fee schedule,173.64,1639.84,Radiology
Ct lumbar spine w/o & w/dye,72133,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,243.1,,,,,,,fee schedule,173.64,1639.84,APC
Ct lumbar spine w/o & w/dye,72133,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,303.87,,,,,,,fee schedule,173.64,1639.84,APC
Mri neck spine w/o dye,72141,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,710.06,,,,,,,fee schedule,236.21,1047.98,
Mri neck spine w/o dye,72141,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,569.18,,,,,,,fee schedule,236.21,1047.98,
Mri neck spine w/o dye,72141,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,621.77,,,,,,,fee schedule,236.21,1047.98,
Mri neck spine w/o dye,72141,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,653.71,,,,,,,fee schedule,236.21,1047.98,
Mri neck spine w/o dye,72141,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,236.21,1047.98,APC 378
Mri neck spine w/o dye,72141,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,236.21,1047.98,APC
Mri neck spine w/o dye,72141,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,236.21,1047.98,APC
Mri neck spine w/o dye,72141,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,236.21,1047.98,APC
Mri neck spine w/o dye,72141,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,236.21,1047.98,Radiology
Mri neck spine w/o dye,72141,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,236.21,1047.98,APC
Mri neck spine w/o dye,72141,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,236.21,1047.98,APC
Mri neck spine w/dye,72142,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1556.07,,,,,,,fee schedule,345.37,1556.07,
Mri neck spine w/dye,72142,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1247.33,,,,,,,fee schedule,345.37,1556.07,
Mri neck spine w/dye,72142,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1362.59,,,,,,,fee schedule,345.37,1556.07,
Mri neck spine w/dye,72142,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1432.58,,,,,,,fee schedule,345.37,1556.07,
Mri neck spine w/dye,72142,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1532.31,,,,,,,fee schedule,345.37,1556.07,APC 378
Mri neck spine w/dye,72142,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,362.64,,,,,,,fee schedule,345.37,1556.07,APC
Mri neck spine w/dye,72142,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,359.19,,,,,,,fee schedule,345.37,1556.07,APC
Mri neck spine w/dye,72142,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,345.37,,,,,,,fee schedule,345.37,1556.07,APC
Mri neck spine w/dye,72142,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,528.42,,,,,,,fee schedule,345.37,1556.07,Radiology
Mri neck spine w/dye,72142,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,483.52,,,,,,,fee schedule,345.37,1556.07,APC
Mri neck spine w/dye,72142,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,604.4,,,,,,,fee schedule,345.37,1556.07,APC
Mri chest spine w/o dye,72146,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,773.16,,,,,,,fee schedule,236.21,1047.98,
Mri chest spine w/o dye,72146,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,619.75,,,,,,,fee schedule,236.21,1047.98,
Mri chest spine w/o dye,72146,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,677.02,,,,,,,fee schedule,236.21,1047.98,
Mri chest spine w/o dye,72146,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,711.79,,,,,,,fee schedule,236.21,1047.98,
Mri chest spine w/o dye,72146,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,236.21,1047.98,APC 378
Mri chest spine w/o dye,72146,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,236.21,1047.98,APC
Mri chest spine w/o dye,72146,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,236.21,1047.98,APC
Mri chest spine w/o dye,72146,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,236.21,1047.98,APC
Mri chest spine w/o dye,72146,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,236.21,1047.98,Radiology
Mri chest spine w/o dye,72146,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,236.21,1047.98,APC
Mri chest spine w/o dye,72146,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,236.21,1047.98,APC
Mri chest spine w/dye,72147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,852.4,,,,,,,fee schedule,345.37,1532.31,
Mri chest spine w/dye,72147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,683.27,,,,,,,fee schedule,345.37,1532.31,
Mri chest spine w/dye,72147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,746.41,,,,,,,fee schedule,345.37,1532.31,
Mri chest spine w/dye,72147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,784.74,,,,,,,fee schedule,345.37,1532.31,
Mri chest spine w/dye,72147,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1532.31,,,,,,,fee schedule,345.37,1532.31,APC 378
Mri chest spine w/dye,72147,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,362.64,,,,,,,fee schedule,345.37,1532.31,APC
Mri chest spine w/dye,72147,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,359.19,,,,,,,fee schedule,345.37,1532.31,APC
Mri chest spine w/dye,72147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,345.37,,,,,,,fee schedule,345.37,1532.31,APC
Mri chest spine w/dye,72147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,528.42,,,,,,,fee schedule,345.37,1532.31,Radiology
Mri chest spine w/dye,72147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,483.52,,,,,,,fee schedule,345.37,1532.31,APC
Mri chest spine w/dye,72147,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,604.4,,,,,,,fee schedule,345.37,1532.31,APC
Mri lumbar spine w/o dye,72148,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,723.8,,,,,,,fee schedule,236.21,1047.98,
Mri lumbar spine w/o dye,72148,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,580.19,,,,,,,fee schedule,236.21,1047.98,
Mri lumbar spine w/o dye,72148,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,633.8,,,,,,,fee schedule,236.21,1047.98,
Mri lumbar spine w/o dye,72148,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,666.35,,,,,,,fee schedule,236.21,1047.98,
Mri lumbar spine w/o dye,72148,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,236.21,1047.98,APC 378
Mri lumbar spine w/o dye,72148,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,236.21,1047.98,APC
Mri lumbar spine w/o dye,72148,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,236.21,1047.98,APC
Mri lumbar spine w/o dye,72148,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,236.21,1047.98,APC
Mri lumbar spine w/o dye,72148,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,236.21,1047.98,Radiology
Mri lumbar spine w/o dye,72148,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,236.21,1047.98,APC
Mri lumbar spine w/o dye,72148,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,236.21,1047.98,APC
Mri lumbar spine w/dye,72149,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,995.8,,,,,,,fee schedule,345.37,1532.31,
Mri lumbar spine w/dye,72149,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,798.22,,,,,,,fee schedule,345.37,1532.31,
Mri lumbar spine w/dye,72149,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,871.98,,,,,,,fee schedule,345.37,1532.31,
Mri lumbar spine w/dye,72149,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,916.76,,,,,,,fee schedule,345.37,1532.31,
Mri lumbar spine w/dye,72149,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1532.31,,,,,,,fee schedule,345.37,1532.31,APC 378
Mri lumbar spine w/dye,72149,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,362.64,,,,,,,fee schedule,345.37,1532.31,APC
Mri lumbar spine w/dye,72149,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,359.19,,,,,,,fee schedule,345.37,1532.31,APC
Mri lumbar spine w/dye,72149,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,345.37,,,,,,,fee schedule,345.37,1532.31,APC
Mri lumbar spine w/dye,72149,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,528.42,,,,,,,fee schedule,345.37,1532.31,Radiology
Mri lumbar spine w/dye,72149,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,483.52,,,,,,,fee schedule,345.37,1532.31,APC
Mri lumbar spine w/dye,72149,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,604.4,,,,,,,fee schedule,345.37,1532.31,APC
Mri neck spine w/o & w/dye,72156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,984.63,,,,,,,fee schedule,345.37,1532.31,
Mri neck spine w/o & w/dye,72156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,789.27,,,,,,,fee schedule,345.37,1532.31,
Mri neck spine w/o & w/dye,72156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,862.21,,,,,,,fee schedule,345.37,1532.31,
Mri neck spine w/o & w/dye,72156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,906.49,,,,,,,fee schedule,345.37,1532.31,
Mri neck spine w/o & w/dye,72156,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1532.31,,,,,,,fee schedule,345.37,1532.31,APC 378
Mri neck spine w/o & w/dye,72156,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,362.64,,,,,,,fee schedule,345.37,1532.31,APC
Mri neck spine w/o & w/dye,72156,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,359.19,,,,,,,fee schedule,345.37,1532.31,APC
Mri neck spine w/o & w/dye,72156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,345.37,,,,,,,fee schedule,345.37,1532.31,APC
Mri neck spine w/o & w/dye,72156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,528.42,,,,,,,fee schedule,345.37,1532.31,Radiology
Mri neck spine w/o & w/dye,72156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,483.52,,,,,,,fee schedule,345.37,1532.31,APC
Mri neck spine w/o & w/dye,72156,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,604.4,,,,,,,fee schedule,345.37,1532.31,APC
Mri chest spine w/o & w/dye,72157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1069.68,,,,,,,fee schedule,345.37,1532.31,
Mri chest spine w/o & w/dye,72157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,857.44,,,,,,,fee schedule,345.37,1532.31,
Mri chest spine w/o & w/dye,72157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,936.68,,,,,,,fee schedule,345.37,1532.31,
Mri chest spine w/o & w/dye,72157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,984.79,,,,,,,fee schedule,345.37,1532.31,
Mri chest spine w/o & w/dye,72157,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1532.31,,,,,,,fee schedule,345.37,1532.31,APC 378
Mri chest spine w/o & w/dye,72157,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,362.64,,,,,,,fee schedule,345.37,1532.31,APC
Mri chest spine w/o & w/dye,72157,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,359.19,,,,,,,fee schedule,345.37,1532.31,APC
Mri chest spine w/o & w/dye,72157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,345.37,,,,,,,fee schedule,345.37,1532.31,APC
Mri chest spine w/o & w/dye,72157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,528.42,,,,,,,fee schedule,345.37,1532.31,Radiology
Mri chest spine w/o & w/dye,72157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,483.52,,,,,,,fee schedule,345.37,1532.31,APC
Mri chest spine w/o & w/dye,72157,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,604.4,,,,,,,fee schedule,345.37,1532.31,APC
Mri lumbar spine w/o & w/dye,72158,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1003.99,,,,,,,fee schedule,345.37,1532.31,
Mri lumbar spine w/o & w/dye,72158,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,804.79,,,,,,,fee schedule,345.37,1532.31,
Mri lumbar spine w/o & w/dye,72158,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,879.15,,,,,,,fee schedule,345.37,1532.31,
Mri lumbar spine w/o & w/dye,72158,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,924.31,,,,,,,fee schedule,345.37,1532.31,
Mri lumbar spine w/o & w/dye,72158,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1532.31,,,,,,,fee schedule,345.37,1532.31,APC 378
Mri lumbar spine w/o & w/dye,72158,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,362.64,,,,,,,fee schedule,345.37,1532.31,APC
Mri lumbar spine w/o & w/dye,72158,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,359.19,,,,,,,fee schedule,345.37,1532.31,APC
Mri lumbar spine w/o & w/dye,72158,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,345.37,,,,,,,fee schedule,345.37,1532.31,APC
Mri lumbar spine w/o & w/dye,72158,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,528.42,,,,,,,fee schedule,345.37,1532.31,Radiology
Mri lumbar spine w/o & w/dye,72158,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,483.52,,,,,,,fee schedule,345.37,1532.31,APC
Mri lumbar spine w/o & w/dye,72158,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,604.4,,,,,,,fee schedule,345.37,1532.31,APC
X-ray exam of pelvis,72170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,151.62,,,,,,,fee schedule,103.5,459.18,
X-ray exam of pelvis,72170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,121.53,,,,,,,fee schedule,103.5,459.18,
X-ray exam of pelvis,72170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,132.77,,,,,,,fee schedule,103.5,459.18,
X-ray exam of pelvis,72170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,139.58,,,,,,,fee schedule,103.5,459.18,
X-ray exam of pelvis,72170,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
X-ray exam of pelvis,72170,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam of pelvis,72170,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam of pelvis,72170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam of pelvis,72170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
X-ray exam of pelvis,72170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam of pelvis,72170,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam of pelvis,72190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,251.1,,,,,,,fee schedule,103.5,459.18,
X-ray exam of pelvis,72190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,201.28,,,,,,,fee schedule,103.5,459.18,
X-ray exam of pelvis,72190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,219.88,,,,,,,fee schedule,103.5,459.18,
X-ray exam of pelvis,72190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,231.17,,,,,,,fee schedule,103.5,459.18,
X-ray exam of pelvis,72190,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
X-ray exam of pelvis,72190,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam of pelvis,72190,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam of pelvis,72190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam of pelvis,72190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
X-ray exam of pelvis,72190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam of pelvis,72190,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Ct angiograph pelv w/o&w/dye,72191,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1288.83,,,,,,,fee schedule,173.64,1288.83,
Ct angiograph pelv w/o&w/dye,72191,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1033.11,,,,,,,fee schedule,173.64,1288.83,
Ct angiograph pelv w/o&w/dye,72191,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1128.58,,,,,,,fee schedule,173.64,1288.83,
Ct angiograph pelv w/o&w/dye,72191,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1186.54,,,,,,,fee schedule,173.64,1288.83,
Ct angiograph pelv w/o&w/dye,72191,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,770.39,,,,,,,fee schedule,173.64,1288.83,APC 378
Ct angiograph pelv w/o&w/dye,72191,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,182.32,,,,,,,fee schedule,173.64,1288.83,APC
Ct angiograph pelv w/o&w/dye,72191,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,180.59,,,,,,,fee schedule,173.64,1288.83,APC
Ct angiograph pelv w/o&w/dye,72191,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,173.64,,,,,,,fee schedule,173.64,1288.83,APC
Ct angiograph pelv w/o&w/dye,72191,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,265.67,,,,,,,fee schedule,173.64,1288.83,Radiology
Ct angiograph pelv w/o&w/dye,72191,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,243.1,,,,,,,fee schedule,173.64,1288.83,APC
Ct angiograph pelv w/o&w/dye,72191,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,303.87,,,,,,,fee schedule,173.64,1288.83,APC
Ct pelvis w/o dye,72192,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,752.58,,,,,,,fee schedule,103.5,752.58,
Ct pelvis w/o dye,72192,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,603.26,,,,,,,fee schedule,103.5,752.58,
Ct pelvis w/o dye,72192,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,659,,,,,,,fee schedule,103.5,752.58,
Ct pelvis w/o dye,72192,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,692.85,,,,,,,fee schedule,103.5,752.58,
Ct pelvis w/o dye,72192,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,752.58,APC 378
Ct pelvis w/o dye,72192,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,752.58,APC
Ct pelvis w/o dye,72192,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,752.58,APC
Ct pelvis w/o dye,72192,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,752.58,APC
Ct pelvis w/o dye,72192,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,752.58,Radiology
Ct pelvis w/o dye,72192,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,752.58,APC
Ct pelvis w/o dye,72192,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,752.58,APC
Ct pelvis w/dye,72193,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,964.5,,,,,,,fee schedule,173.64,964.5,
Ct pelvis w/dye,72193,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,773.13,,,,,,,fee schedule,173.64,964.5,
Ct pelvis w/dye,72193,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,844.57,,,,,,,fee schedule,173.64,964.5,
Ct pelvis w/dye,72193,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,887.95,,,,,,,fee schedule,173.64,964.5,
Ct pelvis w/dye,72193,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,770.39,,,,,,,fee schedule,173.64,964.5,APC 378
Ct pelvis w/dye,72193,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,182.32,,,,,,,fee schedule,173.64,964.5,APC
Ct pelvis w/dye,72193,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,180.59,,,,,,,fee schedule,173.64,964.5,APC
Ct pelvis w/dye,72193,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,173.64,,,,,,,fee schedule,173.64,964.5,APC
Ct pelvis w/dye,72193,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,265.67,,,,,,,fee schedule,173.64,964.5,Radiology
Ct pelvis w/dye,72193,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,243.1,,,,,,,fee schedule,173.64,964.5,APC
Ct pelvis w/dye,72193,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,303.87,,,,,,,fee schedule,173.64,964.5,APC
Ct pelvis w/o & w/dye,72194,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1179.69,,,,,,,fee schedule,173.64,1179.69,
Ct pelvis w/o & w/dye,72194,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,945.62,,,,,,,fee schedule,173.64,1179.69,
Ct pelvis w/o & w/dye,72194,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1033.01,,,,,,,fee schedule,173.64,1179.69,
Ct pelvis w/o & w/dye,72194,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1086.06,,,,,,,fee schedule,173.64,1179.69,
Ct pelvis w/o & w/dye,72194,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,770.39,,,,,,,fee schedule,173.64,1179.69,APC 378
Ct pelvis w/o & w/dye,72194,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,182.32,,,,,,,fee schedule,173.64,1179.69,APC
Ct pelvis w/o & w/dye,72194,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,180.59,,,,,,,fee schedule,173.64,1179.69,APC
Ct pelvis w/o & w/dye,72194,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,173.64,,,,,,,fee schedule,173.64,1179.69,APC
Ct pelvis w/o & w/dye,72194,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,265.67,,,,,,,fee schedule,173.64,1179.69,Radiology
Ct pelvis w/o & w/dye,72194,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,243.1,,,,,,,fee schedule,173.64,1179.69,APC
Ct pelvis w/o & w/dye,72194,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,303.87,,,,,,,fee schedule,173.64,1179.69,APC
Mri Pelvis W/O Dye,72195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,869.41,,,,,,,fee schedule,236.21,1047.98,
Mri Pelvis W/O Dye,72195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,696.91,,,,,,,fee schedule,236.21,1047.98,
Mri Pelvis W/O Dye,72195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,761.31,,,,,,,fee schedule,236.21,1047.98,
Mri Pelvis W/O Dye,72195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,800.41,,,,,,,fee schedule,236.21,1047.98,
Mri Pelvis W/O Dye,72195,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,236.21,1047.98,APC 378
Mri Pelvis W/O Dye,72195,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,236.21,1047.98,APC
Mri Pelvis W/O Dye,72195,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,236.21,1047.98,APC
Mri Pelvis W/O Dye,72195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,236.21,1047.98,APC
Mri Pelvis W/O Dye,72195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,236.21,1047.98,Radiology
Mri Pelvis W/O Dye,72195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,236.21,1047.98,APC
Mri Pelvis W/O Dye,72195,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,236.21,1047.98,APC
Mri pelvis w/dye,72196,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1556.07,,,,,,,fee schedule,345.37,1556.07,
Mri pelvis w/dye,72196,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1247.33,,,,,,,fee schedule,345.37,1556.07,
Mri pelvis w/dye,72196,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1362.59,,,,,,,fee schedule,345.37,1556.07,
Mri pelvis w/dye,72196,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1432.58,,,,,,,fee schedule,345.37,1556.07,
Mri pelvis w/dye,72196,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1532.31,,,,,,,fee schedule,345.37,1556.07,APC 378
Mri pelvis w/dye,72196,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,362.64,,,,,,,fee schedule,345.37,1556.07,APC
Mri pelvis w/dye,72196,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,359.19,,,,,,,fee schedule,345.37,1556.07,APC
Mri pelvis w/dye,72196,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,345.37,,,,,,,fee schedule,345.37,1556.07,APC
Mri pelvis w/dye,72196,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,528.42,,,,,,,fee schedule,345.37,1556.07,Radiology
Mri pelvis w/dye,72196,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,483.52,,,,,,,fee schedule,345.37,1556.07,APC
Mri pelvis w/dye,72196,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,604.4,,,,,,,fee schedule,345.37,1556.07,APC
Mri pelvis w/o & w/dye,72197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1156.49,,,,,,,fee schedule,345.37,1532.31,
Mri pelvis w/o & w/dye,72197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,927.03,,,,,,,fee schedule,345.37,1532.31,
Mri pelvis w/o & w/dye,72197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1012.69,,,,,,,fee schedule,345.37,1532.31,
Mri pelvis w/o & w/dye,72197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1064.71,,,,,,,fee schedule,345.37,1532.31,
Mri pelvis w/o & w/dye,72197,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1532.31,,,,,,,fee schedule,345.37,1532.31,APC 378
Mri pelvis w/o & w/dye,72197,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,362.64,,,,,,,fee schedule,345.37,1532.31,APC
Mri pelvis w/o & w/dye,72197,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,359.19,,,,,,,fee schedule,345.37,1532.31,APC
Mri pelvis w/o & w/dye,72197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,345.37,,,,,,,fee schedule,345.37,1532.31,APC
Mri pelvis w/o & w/dye,72197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,528.42,,,,,,,fee schedule,345.37,1532.31,Radiology
Mri pelvis w/o & w/dye,72197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,483.52,,,,,,,fee schedule,345.37,1532.31,APC
Mri pelvis w/o & w/dye,72197,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,604.4,,,,,,,fee schedule,345.37,1532.31,APC
Mr angio pelvis w/o & w/dye,72198,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1790.25,,,,,,,fee schedule,1435.04,1790.25,
Mr angio pelvis w/o & w/dye,72198,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1435.04,,,,,,,fee schedule,1435.04,1790.25,
Mr angio pelvis w/o & w/dye,72198,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1567.65,,,,,,,fee schedule,1435.04,1790.25,
Mr angio pelvis w/o & w/dye,72198,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1648.16,,,,,,,fee schedule,1435.04,1790.25,
X-ray exam si joints,72200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,139.74,,,,,,,fee schedule,103.5,459.18,
X-ray exam si joints,72200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,112.01,,,,,,,fee schedule,103.5,459.18,
X-ray exam si joints,72200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,122.36,,,,,,,fee schedule,103.5,459.18,
X-ray exam si joints,72200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,128.65,,,,,,,fee schedule,103.5,459.18,
X-ray exam si joints,72200,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
X-ray exam si joints,72200,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam si joints,72200,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam si joints,72200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam si joints,72200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
X-ray exam si joints,72200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam si joints,72200,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam si joints 3/> vws,72202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,231.34,,,,,,,fee schedule,103.5,459.18,
X-ray exam si joints 3/> vws,72202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,185.44,,,,,,,fee schedule,103.5,459.18,
X-ray exam si joints 3/> vws,72202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,202.57,,,,,,,fee schedule,103.5,459.18,
X-ray exam si joints 3/> vws,72202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,212.98,,,,,,,fee schedule,103.5,459.18,
X-ray exam si joints 3/> vws,72202,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
X-ray exam si joints 3/> vws,72202,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam si joints 3/> vws,72202,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam si joints 3/> vws,72202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam si joints 3/> vws,72202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
X-ray exam si joints 3/> vws,72202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam si joints 3/> vws,72202,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam sacrum tailbone,72220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,212.65,,,,,,,fee schedule,86.15,382.23,
X-ray exam sacrum tailbone,72220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,170.46,,,,,,,fee schedule,86.15,382.23,
X-ray exam sacrum tailbone,72220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,186.21,,,,,,,fee schedule,86.15,382.23,
X-ray exam sacrum tailbone,72220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,195.77,,,,,,,fee schedule,86.15,382.23,
X-ray exam sacrum tailbone,72220,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
X-ray exam sacrum tailbone,72220,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam sacrum tailbone,72220,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam sacrum tailbone,72220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam sacrum tailbone,72220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
X-ray exam sacrum tailbone,72220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam sacrum tailbone,72220,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
Myelography neck spine,72240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,728.07,,,,,,,fee schedule,583.61,3443.1,
Myelography neck spine,72240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,583.61,,,,,,,fee schedule,583.61,3443.1,
Myelography neck spine,72240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,637.54,,,,,,,fee schedule,583.61,3443.1,
Myelography neck spine,72240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,670.28,,,,,,,fee schedule,583.61,3443.1,
Myelography neck spine,72240,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3443.1,,,,,,,fee schedule,583.61,3443.1,APC 378
Myelography neck spine,72240,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,814.86,,,,,,,fee schedule,583.61,3443.1,APC
Myelography neck spine,72240,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,807.1,,,,,,,fee schedule,583.61,3443.1,APC
Myelography neck spine,72240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,776.06,,,,,,,fee schedule,583.61,3443.1,APC
Myelography neck spine,72240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1187.37,,,,,,,fee schedule,583.61,3443.1,Radiology
Myelography neck spine,72240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1086.48,,,,,,,fee schedule,583.61,3443.1,APC
Myelography neck spine,72240,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1358.1,,,,,,,fee schedule,583.61,3443.1,APC
Myelography thoracic spine,72255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1886.52,,,,,,,fee schedule,776.06,3443.1,
Myelography thoracic spine,72255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1512.21,,,,,,,fee schedule,776.06,3443.1,
Myelography thoracic spine,72255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1651.95,,,,,,,fee schedule,776.06,3443.1,
Myelography thoracic spine,72255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1736.8,,,,,,,fee schedule,776.06,3443.1,
Myelography thoracic spine,72255,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3443.1,,,,,,,fee schedule,776.06,3443.1,APC 378
Myelography thoracic spine,72255,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,814.86,,,,,,,fee schedule,776.06,3443.1,APC
Myelography thoracic spine,72255,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,807.1,,,,,,,fee schedule,776.06,3443.1,APC
Myelography thoracic spine,72255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,776.06,,,,,,,fee schedule,776.06,3443.1,APC
Myelography thoracic spine,72255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1187.37,,,,,,,fee schedule,776.06,3443.1,Radiology
Myelography thoracic spine,72255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1086.48,,,,,,,fee schedule,776.06,3443.1,APC
Myelography thoracic spine,72255,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1358.1,,,,,,,fee schedule,776.06,3443.1,APC
Myelography l-s spine,72265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,709.43,,,,,,,fee schedule,568.67,3443.1,
Myelography l-s spine,72265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,568.67,,,,,,,fee schedule,568.67,3443.1,
Myelography l-s spine,72265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,621.22,,,,,,,fee schedule,568.67,3443.1,
Myelography l-s spine,72265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,653.13,,,,,,,fee schedule,568.67,3443.1,
Myelography l-s spine,72265,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3443.1,,,,,,,fee schedule,568.67,3443.1,APC 378
Myelography l-s spine,72265,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,814.86,,,,,,,fee schedule,568.67,3443.1,APC
Myelography l-s spine,72265,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,807.1,,,,,,,fee schedule,568.67,3443.1,APC
Myelography l-s spine,72265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,776.06,,,,,,,fee schedule,568.67,3443.1,APC
Myelography l-s spine,72265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1187.37,,,,,,,fee schedule,568.67,3443.1,Radiology
Myelography l-s spine,72265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1086.48,,,,,,,fee schedule,568.67,3443.1,APC
Myelography l-s spine,72265,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1358.1,,,,,,,fee schedule,568.67,3443.1,APC
Myelogphy 2/> spine regions,72270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1886.52,,,,,,,fee schedule,776.06,3443.1,
Myelogphy 2/> spine regions,72270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1512.21,,,,,,,fee schedule,776.06,3443.1,
Myelogphy 2/> spine regions,72270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1651.95,,,,,,,fee schedule,776.06,3443.1,
Myelogphy 2/> spine regions,72270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1736.8,,,,,,,fee schedule,776.06,3443.1,
Myelogphy 2/> spine regions,72270,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3443.1,,,,,,,fee schedule,776.06,3443.1,APC 378
Myelogphy 2/> spine regions,72270,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,814.86,,,,,,,fee schedule,776.06,3443.1,APC
Myelogphy 2/> spine regions,72270,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,807.1,,,,,,,fee schedule,776.06,3443.1,APC
Myelogphy 2/> spine regions,72270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,776.06,,,,,,,fee schedule,776.06,3443.1,APC
Myelogphy 2/> spine regions,72270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1187.37,,,,,,,fee schedule,776.06,3443.1,Radiology
Myelogphy 2/> spine regions,72270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1086.48,,,,,,,fee schedule,776.06,3443.1,APC
Myelogphy 2/> spine regions,72270,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1358.1,,,,,,,fee schedule,776.06,3443.1,APC
Discography cerv/thor spine,72285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5037,,,,,,,fee schedule,1933.13,8576.66,
Discography cerv/thor spine,72285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4037.6,,,,,,,fee schedule,1933.13,8576.66,
Discography cerv/thor spine,72285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4410.71,,,,,,,fee schedule,1933.13,8576.66,
Discography cerv/thor spine,72285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4637.24,,,,,,,fee schedule,1933.13,8576.66,
Discography cerv/thor spine,72285,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8576.66,,,,,,,fee schedule,1933.13,8576.66,APC 378
Discography cerv/thor spine,72285,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2029.79,,,,,,,fee schedule,1933.13,8576.66,APC
Discography cerv/thor spine,72285,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2010.46,,,,,,,fee schedule,1933.13,8576.66,APC
Discography cerv/thor spine,72285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1933.13,,,,,,,fee schedule,1933.13,8576.66,APC
Discography cerv/thor spine,72285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2957.7,,,,,,,fee schedule,1933.13,8576.66,Radiology
Discography cerv/thor spine,72285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2706.39,,,,,,,fee schedule,1933.13,8576.66,APC
Discography cerv/thor spine,72285,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3382.99,,,,,,,fee schedule,1933.13,8576.66,APC
X-ray of lower spine disk,72295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5037,,,,,,,fee schedule,1933.13,8576.66,
X-ray of lower spine disk,72295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4037.6,,,,,,,fee schedule,1933.13,8576.66,
X-ray of lower spine disk,72295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4410.71,,,,,,,fee schedule,1933.13,8576.66,
X-ray of lower spine disk,72295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4637.24,,,,,,,fee schedule,1933.13,8576.66,
X-ray of lower spine disk,72295,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8576.66,,,,,,,fee schedule,1933.13,8576.66,APC 378
X-ray of lower spine disk,72295,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2029.79,,,,,,,fee schedule,1933.13,8576.66,APC
X-ray of lower spine disk,72295,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2010.46,,,,,,,fee schedule,1933.13,8576.66,APC
X-ray of lower spine disk,72295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1933.13,,,,,,,fee schedule,1933.13,8576.66,APC
X-ray of lower spine disk,72295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2957.7,,,,,,,fee schedule,1933.13,8576.66,Radiology
X-ray of lower spine disk,72295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2706.39,,,,,,,fee schedule,1933.13,8576.66,APC
X-ray of lower spine disk,72295,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3382.99,,,,,,,fee schedule,1933.13,8576.66,APC
X-ray exam of collar bone,73000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,179.19,,,,,,,fee schedule,86.15,382.23,
X-ray exam of collar bone,73000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,143.63,,,,,,,fee schedule,86.15,382.23,
X-ray exam of collar bone,73000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,156.91,,,,,,,fee schedule,86.15,382.23,
X-ray exam of collar bone,73000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,164.97,,,,,,,fee schedule,86.15,382.23,
X-ray exam of collar bone,73000,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
X-ray exam of collar bone,73000,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of collar bone,73000,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of collar bone,73000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of collar bone,73000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
X-ray exam of collar bone,73000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of collar bone,73000,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of shoulder blade,73010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,170.52,,,,,,,fee schedule,103.5,459.18,
X-ray exam of shoulder blade,73010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,136.69,,,,,,,fee schedule,103.5,459.18,
X-ray exam of shoulder blade,73010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,149.32,,,,,,,fee schedule,103.5,459.18,
X-ray exam of shoulder blade,73010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,156.99,,,,,,,fee schedule,103.5,459.18,
X-ray exam of shoulder blade,73010,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
X-ray exam of shoulder blade,73010,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam of shoulder blade,73010,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam of shoulder blade,73010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam of shoulder blade,73010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
X-ray exam of shoulder blade,73010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam of shoulder blade,73010,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam of shoulder,73020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,142.89,,,,,,,fee schedule,86.15,382.23,
X-ray exam of shoulder,73020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,114.54,,,,,,,fee schedule,86.15,382.23,
X-ray exam of shoulder,73020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,125.12,,,,,,,fee schedule,86.15,382.23,
X-ray exam of shoulder,73020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,131.55,,,,,,,fee schedule,86.15,382.23,
X-ray exam of shoulder,73020,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
X-ray exam of shoulder,73020,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of shoulder,73020,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of shoulder,73020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of shoulder,73020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
X-ray exam of shoulder,73020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of shoulder,73020,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of shoulder,73030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,162.85,,,,,,,fee schedule,86.15,382.23,
X-ray exam of shoulder,73030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,130.54,,,,,,,fee schedule,86.15,382.23,
X-ray exam of shoulder,73030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,142.61,,,,,,,fee schedule,86.15,382.23,
X-ray exam of shoulder,73030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,149.93,,,,,,,fee schedule,86.15,382.23,
X-ray exam of shoulder,73030,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
X-ray exam of shoulder,73030,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of shoulder,73030,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of shoulder,73030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of shoulder,73030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
X-ray exam of shoulder,73030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of shoulder,73030,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
Contrast x-ray of shoulder,73040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,400.98,,,,,,,fee schedule,321.42,1532.31,
Contrast x-ray of shoulder,73040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,321.42,,,,,,,fee schedule,321.42,1532.31,
Contrast x-ray of shoulder,73040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,351.12,,,,,,,fee schedule,321.42,1532.31,
Contrast x-ray of shoulder,73040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,369.16,,,,,,,fee schedule,321.42,1532.31,
Contrast x-ray of shoulder,73040,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1532.31,,,,,,,fee schedule,321.42,1532.31,APC 378
Contrast x-ray of shoulder,73040,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,362.64,,,,,,,fee schedule,321.42,1532.31,APC
Contrast x-ray of shoulder,73040,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,359.19,,,,,,,fee schedule,321.42,1532.31,APC
Contrast x-ray of shoulder,73040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,345.37,,,,,,,fee schedule,321.42,1532.31,APC
Contrast x-ray of shoulder,73040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,528.42,,,,,,,fee schedule,321.42,1532.31,Radiology
Contrast x-ray of shoulder,73040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,483.52,,,,,,,fee schedule,321.42,1532.31,APC
Contrast x-ray of shoulder,73040,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,604.4,,,,,,,fee schedule,321.42,1532.31,APC
X-ray exam of shoulders,73050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,199.02,,,,,,,fee schedule,86.15,382.23,
X-ray exam of shoulders,73050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,159.53,,,,,,,fee schedule,86.15,382.23,
X-ray exam of shoulders,73050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,174.28,,,,,,,fee schedule,86.15,382.23,
X-ray exam of shoulders,73050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,183.23,,,,,,,fee schedule,86.15,382.23,
X-ray exam of shoulders,73050,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
X-ray exam of shoulders,73050,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of shoulders,73050,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of shoulders,73050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of shoulders,73050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
X-ray exam of shoulders,73050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of shoulders,73050,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of humerus,73060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,202.67,,,,,,,fee schedule,86.15,382.23,
X-ray exam of humerus,73060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,162.46,,,,,,,fee schedule,86.15,382.23,
X-ray exam of humerus,73060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,177.47,,,,,,,fee schedule,86.15,382.23,
X-ray exam of humerus,73060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,186.59,,,,,,,fee schedule,86.15,382.23,
X-ray exam of humerus,73060,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
X-ray exam of humerus,73060,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of humerus,73060,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of humerus,73060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of humerus,73060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
X-ray exam of humerus,73060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of humerus,73060,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of elbow,73070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,178.73,,,,,,,fee schedule,86.15,382.23,
X-ray exam of elbow,73070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,143.27,,,,,,,fee schedule,86.15,382.23,
X-ray exam of elbow,73070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,156.51,,,,,,,fee schedule,86.15,382.23,
X-ray exam of elbow,73070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,164.54,,,,,,,fee schedule,86.15,382.23,
X-ray exam of elbow,73070,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
X-ray exam of elbow,73070,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of elbow,73070,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of elbow,73070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of elbow,73070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
X-ray exam of elbow,73070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of elbow,73070,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of elbow,73080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,247.85,,,,,,,fee schedule,86.15,382.23,
X-ray exam of elbow,73080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,198.68,,,,,,,fee schedule,86.15,382.23,
X-ray exam of elbow,73080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,217.04,,,,,,,fee schedule,86.15,382.23,
X-ray exam of elbow,73080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,228.18,,,,,,,fee schedule,86.15,382.23,
X-ray exam of elbow,73080,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
X-ray exam of elbow,73080,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of elbow,73080,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of elbow,73080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of elbow,73080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
X-ray exam of elbow,73080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of elbow,73080,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
Contrast x-ray of elbow,73085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,999.05,,,,,,,fee schedule,345.37,1532.31,
Contrast x-ray of elbow,73085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,800.83,,,,,,,fee schedule,345.37,1532.31,
Contrast x-ray of elbow,73085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,874.83,,,,,,,fee schedule,345.37,1532.31,
Contrast x-ray of elbow,73085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,919.76,,,,,,,fee schedule,345.37,1532.31,
Contrast x-ray of elbow,73085,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1532.31,,,,,,,fee schedule,345.37,1532.31,APC 378
Contrast x-ray of elbow,73085,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,362.64,,,,,,,fee schedule,345.37,1532.31,APC
Contrast x-ray of elbow,73085,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,359.19,,,,,,,fee schedule,345.37,1532.31,APC
Contrast x-ray of elbow,73085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,345.37,,,,,,,fee schedule,345.37,1532.31,APC
Contrast x-ray of elbow,73085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,528.42,,,,,,,fee schedule,345.37,1532.31,Radiology
Contrast x-ray of elbow,73085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,483.52,,,,,,,fee schedule,345.37,1532.31,APC
Contrast x-ray of elbow,73085,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,604.4,,,,,,,fee schedule,345.37,1532.31,APC
X-ray exam of forearm,73090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,191.47,,,,,,,fee schedule,86.15,382.23,
X-ray exam of forearm,73090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,153.48,,,,,,,fee schedule,86.15,382.23,
X-ray exam of forearm,73090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,167.66,,,,,,,fee schedule,86.15,382.23,
X-ray exam of forearm,73090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,176.28,,,,,,,fee schedule,86.15,382.23,
X-ray exam of forearm,73090,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
X-ray exam of forearm,73090,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of forearm,73090,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of forearm,73090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of forearm,73090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
X-ray exam of forearm,73090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of forearm,73090,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of arm infant,73092,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,210.13,,,,,,,fee schedule,103.5,459.18,
X-ray exam of arm infant,73092,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,168.44,,,,,,,fee schedule,103.5,459.18,
X-ray exam of arm infant,73092,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,184,,,,,,,fee schedule,103.5,459.18,
X-ray exam of arm infant,73092,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,193.45,,,,,,,fee schedule,103.5,459.18,
X-ray exam of arm infant,73092,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
X-ray exam of arm infant,73092,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam of arm infant,73092,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam of arm infant,73092,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam of arm infant,73092,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
X-ray exam of arm infant,73092,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam of arm infant,73092,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam of wrist,73100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,147.84,,,,,,,fee schedule,86.15,382.23,
X-ray exam of wrist,73100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,118.51,,,,,,,fee schedule,86.15,382.23,
X-ray exam of wrist,73100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,129.46,,,,,,,fee schedule,86.15,382.23,
X-ray exam of wrist,73100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,136.11,,,,,,,fee schedule,86.15,382.23,
X-ray exam of wrist,73100,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
X-ray exam of wrist,73100,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of wrist,73100,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of wrist,73100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of wrist,73100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
X-ray exam of wrist,73100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of wrist,73100,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of wrist,73110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,230.22,,,,,,,fee schedule,86.15,382.23,
X-ray exam of wrist,73110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,184.54,,,,,,,fee schedule,86.15,382.23,
X-ray exam of wrist,73110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,201.59,,,,,,,fee schedule,86.15,382.23,
X-ray exam of wrist,73110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,211.95,,,,,,,fee schedule,86.15,382.23,
X-ray exam of wrist,73110,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
X-ray exam of wrist,73110,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of wrist,73110,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of wrist,73110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of wrist,73110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
X-ray exam of wrist,73110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of wrist,73110,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
Contrast x-ray of wrist,73115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,999.05,,,,,,,fee schedule,345.37,1532.31,
Contrast x-ray of wrist,73115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,800.83,,,,,,,fee schedule,345.37,1532.31,
Contrast x-ray of wrist,73115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,874.83,,,,,,,fee schedule,345.37,1532.31,
Contrast x-ray of wrist,73115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,919.76,,,,,,,fee schedule,345.37,1532.31,
Contrast x-ray of wrist,73115,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1532.31,,,,,,,fee schedule,345.37,1532.31,APC 378
Contrast x-ray of wrist,73115,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,362.64,,,,,,,fee schedule,345.37,1532.31,APC
Contrast x-ray of wrist,73115,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,359.19,,,,,,,fee schedule,345.37,1532.31,APC
Contrast x-ray of wrist,73115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,345.37,,,,,,,fee schedule,345.37,1532.31,APC
Contrast x-ray of wrist,73115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,528.42,,,,,,,fee schedule,345.37,1532.31,Radiology
Contrast x-ray of wrist,73115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,483.52,,,,,,,fee schedule,345.37,1532.31,APC
Contrast x-ray of wrist,73115,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,604.4,,,,,,,fee schedule,345.37,1532.31,APC
X-ray exam of hand,73120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,252.78,,,,,,,fee schedule,103.5,459.18,
X-ray exam of hand,73120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,202.63,,,,,,,fee schedule,103.5,459.18,
X-ray exam of hand,73120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,221.35,,,,,,,fee schedule,103.5,459.18,
X-ray exam of hand,73120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,232.72,,,,,,,fee schedule,103.5,459.18,
X-ray exam of hand,73120,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
X-ray exam of hand,73120,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam of hand,73120,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam of hand,73120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam of hand,73120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
X-ray exam of hand,73120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam of hand,73120,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam of hand,73130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,216.57,,,,,,,fee schedule,86.15,382.23,
X-ray exam of hand,73130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,173.6,,,,,,,fee schedule,86.15,382.23,
X-ray exam of hand,73130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,189.64,,,,,,,fee schedule,86.15,382.23,
X-ray exam of hand,73130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,199.38,,,,,,,fee schedule,86.15,382.23,
X-ray exam of hand,73130,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
X-ray exam of hand,73130,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of hand,73130,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of hand,73130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of hand,73130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
X-ray exam of hand,73130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of hand,73130,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of finger(s),73140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,167.34,,,,,,,fee schedule,86.15,382.23,
X-ray exam of finger(s),73140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,134.13,,,,,,,fee schedule,86.15,382.23,
X-ray exam of finger(s),73140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,146.53,,,,,,,fee schedule,86.15,382.23,
X-ray exam of finger(s),73140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,154.06,,,,,,,fee schedule,86.15,382.23,
X-ray exam of finger(s),73140,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
X-ray exam of finger(s),73140,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of finger(s),73140,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of finger(s),73140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of finger(s),73140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
X-ray exam of finger(s),73140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of finger(s),73140,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
Ct upper extremity w/o dye,73200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,607.77,,,,,,,fee schedule,103.5,607.77,
Ct upper extremity w/o dye,73200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,487.18,,,,,,,fee schedule,103.5,607.77,
Ct upper extremity w/o dye,73200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,532.2,,,,,,,fee schedule,103.5,607.77,
Ct upper extremity w/o dye,73200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,559.53,,,,,,,fee schedule,103.5,607.77,
Ct upper extremity w/o dye,73200,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,607.77,APC 378
Ct upper extremity w/o dye,73200,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,607.77,APC
Ct upper extremity w/o dye,73200,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,607.77,APC
Ct upper extremity w/o dye,73200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,607.77,APC
Ct upper extremity w/o dye,73200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,607.77,Radiology
Ct upper extremity w/o dye,73200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,607.77,APC
Ct upper extremity w/o dye,73200,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,607.77,APC
Ct upper extremity w/dye,73201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,854.93,,,,,,,fee schedule,345.37,1532.31,
Ct upper extremity w/dye,73201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,685.3,,,,,,,fee schedule,345.37,1532.31,
Ct upper extremity w/dye,73201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,748.63,,,,,,,fee schedule,345.37,1532.31,
Ct upper extremity w/dye,73201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,787.07,,,,,,,fee schedule,345.37,1532.31,
Ct upper extremity w/dye,73201,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1532.31,,,,,,,fee schedule,345.37,1532.31,APC 378
Ct upper extremity w/dye,73201,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,362.64,,,,,,,fee schedule,345.37,1532.31,APC
Ct upper extremity w/dye,73201,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,359.19,,,,,,,fee schedule,345.37,1532.31,APC
Ct upper extremity w/dye,73201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,345.37,,,,,,,fee schedule,345.37,1532.31,APC
Ct upper extremity w/dye,73201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,528.42,,,,,,,fee schedule,345.37,1532.31,Radiology
Ct upper extremity w/dye,73201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,483.52,,,,,,,fee schedule,345.37,1532.31,APC
Ct upper extremity w/dye,73201,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,604.4,,,,,,,fee schedule,345.37,1532.31,APC
Ct uppr extremity w/o&w/dye,73202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1005.5,,,,,,,fee schedule,173.64,1005.5,
Ct uppr extremity w/o&w/dye,73202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,805.99,,,,,,,fee schedule,173.64,1005.5,
Ct uppr extremity w/o&w/dye,73202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,880.48,,,,,,,fee schedule,173.64,1005.5,
Ct uppr extremity w/o&w/dye,73202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,925.7,,,,,,,fee schedule,173.64,1005.5,
Ct uppr extremity w/o&w/dye,73202,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,770.39,,,,,,,fee schedule,173.64,1005.5,APC 378
Ct uppr extremity w/o&w/dye,73202,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,182.32,,,,,,,fee schedule,173.64,1005.5,APC
Ct uppr extremity w/o&w/dye,73202,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,180.59,,,,,,,fee schedule,173.64,1005.5,APC
Ct uppr extremity w/o&w/dye,73202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,173.64,,,,,,,fee schedule,173.64,1005.5,APC
Ct uppr extremity w/o&w/dye,73202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,265.67,,,,,,,fee schedule,173.64,1005.5,Radiology
Ct uppr extremity w/o&w/dye,73202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,243.1,,,,,,,fee schedule,173.64,1005.5,APC
Ct uppr extremity w/o&w/dye,73202,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,303.87,,,,,,,fee schedule,173.64,1005.5,APC
Ct angio upr extrm w/o&w/dye,73206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1334.9,,,,,,,fee schedule,173.64,1334.9,
Ct angio upr extrm w/o&w/dye,73206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1070.04,,,,,,,fee schedule,173.64,1334.9,
Ct angio upr extrm w/o&w/dye,73206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1168.92,,,,,,,fee schedule,173.64,1334.9,
Ct angio upr extrm w/o&w/dye,73206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1228.95,,,,,,,fee schedule,173.64,1334.9,
Ct angio upr extrm w/o&w/dye,73206,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,770.39,,,,,,,fee schedule,173.64,1334.9,APC 378
Ct angio upr extrm w/o&w/dye,73206,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,182.32,,,,,,,fee schedule,173.64,1334.9,APC
Ct angio upr extrm w/o&w/dye,73206,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,180.59,,,,,,,fee schedule,173.64,1334.9,APC
Ct angio upr extrm w/o&w/dye,73206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,173.64,,,,,,,fee schedule,173.64,1334.9,APC
Ct angio upr extrm w/o&w/dye,73206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,265.67,,,,,,,fee schedule,173.64,1334.9,Radiology
Ct angio upr extrm w/o&w/dye,73206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,243.1,,,,,,,fee schedule,173.64,1334.9,APC
Ct angio upr extrm w/o&w/dye,73206,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,303.87,,,,,,,fee schedule,173.64,1334.9,APC
Mri Upper Extremity W/O Dye,73218,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,592.59,,,,,,,fee schedule,236.21,1047.98,
Mri Upper Extremity W/O Dye,73218,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,475.01,,,,,,,fee schedule,236.21,1047.98,
Mri Upper Extremity W/O Dye,73218,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,518.9,,,,,,,fee schedule,236.21,1047.98,
Mri Upper Extremity W/O Dye,73218,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,545.55,,,,,,,fee schedule,236.21,1047.98,
Mri Upper Extremity W/O Dye,73218,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,236.21,1047.98,APC 378
Mri Upper Extremity W/O Dye,73218,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,236.21,1047.98,APC
Mri Upper Extremity W/O Dye,73218,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,236.21,1047.98,APC
Mri Upper Extremity W/O Dye,73218,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,236.21,1047.98,APC
Mri Upper Extremity W/O Dye,73218,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,236.21,1047.98,Radiology
Mri Upper Extremity W/O Dye,73218,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,236.21,1047.98,APC
Mri Upper Extremity W/O Dye,73218,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,236.21,1047.98,APC
Mri Upper Extremity W/Dye,73219,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1556.07,,,,,,,fee schedule,345.37,1556.07,
Mri Upper Extremity W/Dye,73219,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1247.33,,,,,,,fee schedule,345.37,1556.07,
Mri Upper Extremity W/Dye,73219,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1362.59,,,,,,,fee schedule,345.37,1556.07,
Mri Upper Extremity W/Dye,73219,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1432.58,,,,,,,fee schedule,345.37,1556.07,
Mri Upper Extremity W/Dye,73219,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1532.31,,,,,,,fee schedule,345.37,1556.07,APC 378
Mri Upper Extremity W/Dye,73219,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,362.64,,,,,,,fee schedule,345.37,1556.07,APC
Mri Upper Extremity W/Dye,73219,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,359.19,,,,,,,fee schedule,345.37,1556.07,APC
Mri Upper Extremity W/Dye,73219,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,345.37,,,,,,,fee schedule,345.37,1556.07,APC
Mri Upper Extremity W/Dye,73219,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,528.42,,,,,,,fee schedule,345.37,1556.07,Radiology
Mri Upper Extremity W/Dye,73219,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,483.52,,,,,,,fee schedule,345.37,1556.07,APC
Mri Upper Extremity W/Dye,73219,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,604.4,,,,,,,fee schedule,345.37,1556.07,APC
Mri uppr extremity w/o&w/dye,73220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,834.26,,,,,,,fee schedule,345.37,1532.31,
Mri uppr extremity w/o&w/dye,73220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,668.73,,,,,,,fee schedule,345.37,1532.31,
Mri uppr extremity w/o&w/dye,73220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,730.53,,,,,,,fee schedule,345.37,1532.31,
Mri uppr extremity w/o&w/dye,73220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,768.05,,,,,,,fee schedule,345.37,1532.31,
Mri uppr extremity w/o&w/dye,73220,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1532.31,,,,,,,fee schedule,345.37,1532.31,APC 378
Mri uppr extremity w/o&w/dye,73220,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,362.64,,,,,,,fee schedule,345.37,1532.31,APC
Mri uppr extremity w/o&w/dye,73220,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,359.19,,,,,,,fee schedule,345.37,1532.31,APC
Mri uppr extremity w/o&w/dye,73220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,345.37,,,,,,,fee schedule,345.37,1532.31,APC
Mri uppr extremity w/o&w/dye,73220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,528.42,,,,,,,fee schedule,345.37,1532.31,Radiology
Mri uppr extremity w/o&w/dye,73220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,483.52,,,,,,,fee schedule,345.37,1532.31,APC
Mri uppr extremity w/o&w/dye,73220,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,604.4,,,,,,,fee schedule,345.37,1532.31,APC
Mri joint upr extrem w/o dye,73221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,780.91,,,,,,,fee schedule,236.21,1047.98,
Mri joint upr extrem w/o dye,73221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,625.97,,,,,,,fee schedule,236.21,1047.98,
Mri joint upr extrem w/o dye,73221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,683.81,,,,,,,fee schedule,236.21,1047.98,
Mri joint upr extrem w/o dye,73221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,718.93,,,,,,,fee schedule,236.21,1047.98,
Mri joint upr extrem w/o dye,73221,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,236.21,1047.98,APC 378
Mri joint upr extrem w/o dye,73221,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,236.21,1047.98,APC
Mri joint upr extrem w/o dye,73221,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,236.21,1047.98,APC
Mri joint upr extrem w/o dye,73221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,236.21,1047.98,APC
Mri joint upr extrem w/o dye,73221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,236.21,1047.98,Radiology
Mri joint upr extrem w/o dye,73221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,236.21,1047.98,APC
Mri joint upr extrem w/o dye,73221,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,236.21,1047.98,APC
Mri joint upr extrem w/dye,73222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,796.3,,,,,,,fee schedule,638.3,3443.1,
Mri joint upr extrem w/dye,73222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,638.3,,,,,,,fee schedule,638.3,3443.1,
Mri joint upr extrem w/dye,73222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,697.29,,,,,,,fee schedule,638.3,3443.1,
Mri joint upr extrem w/dye,73222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,733.1,,,,,,,fee schedule,638.3,3443.1,
Mri joint upr extrem w/dye,73222,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3443.1,,,,,,,fee schedule,638.3,3443.1,APC 378
Mri joint upr extrem w/dye,73222,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,814.86,,,,,,,fee schedule,638.3,3443.1,APC
Mri joint upr extrem w/dye,73222,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,807.1,,,,,,,fee schedule,638.3,3443.1,APC
Mri joint upr extrem w/dye,73222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,776.06,,,,,,,fee schedule,638.3,3443.1,APC
Mri joint upr extrem w/dye,73222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1187.37,,,,,,,fee schedule,638.3,3443.1,Radiology
Mri joint upr extrem w/dye,73222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1086.48,,,,,,,fee schedule,638.3,3443.1,APC
Mri joint upr extrem w/dye,73222,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1358.1,,,,,,,fee schedule,638.3,3443.1,APC
Mri joint upr extr w/o&w/dye,73223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1055.27,,,,,,,fee schedule,345.37,1532.31,
Mri joint upr extr w/o&w/dye,73223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,845.89,,,,,,,fee schedule,345.37,1532.31,
Mri joint upr extr w/o&w/dye,73223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,924.06,,,,,,,fee schedule,345.37,1532.31,
Mri joint upr extr w/o&w/dye,73223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,971.51,,,,,,,fee schedule,345.37,1532.31,
Mri joint upr extr w/o&w/dye,73223,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1532.31,,,,,,,fee schedule,345.37,1532.31,APC 378
Mri joint upr extr w/o&w/dye,73223,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,362.64,,,,,,,fee schedule,345.37,1532.31,APC
Mri joint upr extr w/o&w/dye,73223,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,359.19,,,,,,,fee schedule,345.37,1532.31,APC
Mri joint upr extr w/o&w/dye,73223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,345.37,,,,,,,fee schedule,345.37,1532.31,APC
Mri joint upr extr w/o&w/dye,73223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,528.42,,,,,,,fee schedule,345.37,1532.31,Radiology
Mri joint upr extr w/o&w/dye,73223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,483.52,,,,,,,fee schedule,345.37,1532.31,APC
Mri joint upr extr w/o&w/dye,73223,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,604.4,,,,,,,fee schedule,345.37,1532.31,APC
X-ray exam hip uni 1 view,73501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,89.32,,,,,,,fee schedule,71.6,382.23,
X-ray exam hip uni 1 view,73501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,71.6,,,,,,,fee schedule,71.6,382.23,
X-ray exam hip uni 1 view,73501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,78.22,,,,,,,fee schedule,71.6,382.23,
X-ray exam hip uni 1 view,73501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,82.23,,,,,,,fee schedule,71.6,382.23,
X-ray exam hip uni 1 view,73501,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,71.6,382.23,APC 378
X-ray exam hip uni 1 view,73501,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,71.6,382.23,APC
X-ray exam hip uni 1 view,73501,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,71.6,382.23,APC
X-ray exam hip uni 1 view,73501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,71.6,382.23,APC
X-ray exam hip uni 1 view,73501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,71.6,382.23,Radiology
X-ray exam hip uni 1 view,73501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,71.6,382.23,APC
X-ray exam hip uni 1 view,73501,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,71.6,382.23,APC
X-ray exam hip uni 2-3 views,73502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,187.67,,,,,,,fee schedule,86.15,382.23,
X-ray exam hip uni 2-3 views,73502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,150.43,,,,,,,fee schedule,86.15,382.23,
X-ray exam hip uni 2-3 views,73502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,164.33,,,,,,,fee schedule,86.15,382.23,
X-ray exam hip uni 2-3 views,73502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,172.77,,,,,,,fee schedule,86.15,382.23,
X-ray exam hip uni 2-3 views,73502,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
X-ray exam hip uni 2-3 views,73502,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam hip uni 2-3 views,73502,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam hip uni 2-3 views,73502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam hip uni 2-3 views,73502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
X-ray exam hip uni 2-3 views,73502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam hip uni 2-3 views,73502,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam hip uni 4/> views,73503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,380.61,,,,,,,fee schedule,103.5,459.18,
X-ray exam hip uni 4/> views,73503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,305.09,,,,,,,fee schedule,103.5,459.18,
X-ray exam hip uni 4/> views,73503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,333.28,,,,,,,fee schedule,103.5,459.18,
X-ray exam hip uni 4/> views,73503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,350.4,,,,,,,fee schedule,103.5,459.18,
X-ray exam hip uni 4/> views,73503,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
X-ray exam hip uni 4/> views,73503,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam hip uni 4/> views,73503,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam hip uni 4/> views,73503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam hip uni 4/> views,73503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
X-ray exam hip uni 4/> views,73503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam hip uni 4/> views,73503,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam hips bi 2 views,73521,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,380.61,,,,,,,fee schedule,103.5,459.18,
X-ray exam hips bi 2 views,73521,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,305.09,,,,,,,fee schedule,103.5,459.18,
X-ray exam hips bi 2 views,73521,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,333.28,,,,,,,fee schedule,103.5,459.18,
X-ray exam hips bi 2 views,73521,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,350.4,,,,,,,fee schedule,103.5,459.18,
X-ray exam hips bi 2 views,73521,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
X-ray exam hips bi 2 views,73521,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam hips bi 2 views,73521,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam hips bi 2 views,73521,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam hips bi 2 views,73521,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
X-ray exam hips bi 2 views,73521,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam hips bi 2 views,73521,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam hips bi 3-4 views,73522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,62.69,,,,,,,fee schedule,50.25,459.18,
X-ray exam hips bi 3-4 views,73522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,50.25,,,,,,,fee schedule,50.25,459.18,
X-ray exam hips bi 3-4 views,73522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,54.9,,,,,,,fee schedule,50.25,459.18,
X-ray exam hips bi 3-4 views,73522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,57.72,,,,,,,fee schedule,50.25,459.18,
X-ray exam hips bi 3-4 views,73522,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,50.25,459.18,APC 378
X-ray exam hips bi 3-4 views,73522,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,50.25,459.18,APC
X-ray exam hips bi 3-4 views,73522,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,50.25,459.18,APC
X-ray exam hips bi 3-4 views,73522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,50.25,459.18,APC
X-ray exam hips bi 3-4 views,73522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,50.25,459.18,Radiology
X-ray exam hips bi 3-4 views,73522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,50.25,459.18,APC
X-ray exam hips bi 3-4 views,73522,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,50.25,459.18,APC
X-ray exam hips bi 5/> views,73523,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,725.65,,,,,,,fee schedule,103.5,725.65,
X-ray exam hips bi 5/> views,73523,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,581.67,,,,,,,fee schedule,103.5,725.65,
X-ray exam hips bi 5/> views,73523,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,635.42,,,,,,,fee schedule,103.5,725.65,
X-ray exam hips bi 5/> views,73523,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,668.06,,,,,,,fee schedule,103.5,725.65,
X-ray exam hips bi 5/> views,73523,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,725.65,APC 378
X-ray exam hips bi 5/> views,73523,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,725.65,APC
X-ray exam hips bi 5/> views,73523,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,725.65,APC
X-ray exam hips bi 5/> views,73523,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,725.65,APC
X-ray exam hips bi 5/> views,73523,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,725.65,Radiology
X-ray exam hips bi 5/> views,73523,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,725.65,APC
X-ray exam hips bi 5/> views,73523,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,725.65,APC
Contrast x-ray of hip,73525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,414.48,,,,,,,fee schedule,332.24,1532.31,
Contrast x-ray of hip,73525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,332.24,,,,,,,fee schedule,332.24,1532.31,
Contrast x-ray of hip,73525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,362.94,,,,,,,fee schedule,332.24,1532.31,
Contrast x-ray of hip,73525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,381.58,,,,,,,fee schedule,332.24,1532.31,
Contrast x-ray of hip,73525,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1532.31,,,,,,,fee schedule,332.24,1532.31,APC 378
Contrast x-ray of hip,73525,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,362.64,,,,,,,fee schedule,332.24,1532.31,APC
Contrast x-ray of hip,73525,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,359.19,,,,,,,fee schedule,332.24,1532.31,APC
Contrast x-ray of hip,73525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,345.37,,,,,,,fee schedule,332.24,1532.31,APC
Contrast x-ray of hip,73525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,528.42,,,,,,,fee schedule,332.24,1532.31,Radiology
Contrast x-ray of hip,73525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,483.52,,,,,,,fee schedule,332.24,1532.31,APC
Contrast x-ray of hip,73525,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,604.4,,,,,,,fee schedule,332.24,1532.31,APC
X-ray exam of femur 1,73551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,229.82,,,,,,,fee schedule,86.15,382.23,
X-ray exam of femur 1,73551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,184.22,,,,,,,fee schedule,86.15,382.23,
X-ray exam of femur 1,73551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,201.25,,,,,,,fee schedule,86.15,382.23,
X-ray exam of femur 1,73551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,211.58,,,,,,,fee schedule,86.15,382.23,
X-ray exam of femur 1,73551,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
X-ray exam of femur 1,73551,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of femur 1,73551,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of femur 1,73551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of femur 1,73551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
X-ray exam of femur 1,73551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of femur 1,73551,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of femur 2/>,73552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,165.13,,,,,,,fee schedule,86.15,382.23,
X-ray exam of femur 2/>,73552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,132.37,,,,,,,fee schedule,86.15,382.23,
X-ray exam of femur 2/>,73552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,144.6,,,,,,,fee schedule,86.15,382.23,
X-ray exam of femur 2/>,73552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,152.02,,,,,,,fee schedule,86.15,382.23,
X-ray exam of femur 2/>,73552,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
X-ray exam of femur 2/>,73552,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of femur 2/>,73552,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of femur 2/>,73552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of femur 2/>,73552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
X-ray exam of femur 2/>,73552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of femur 2/>,73552,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of knee 1 or 2,73560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,168.47,,,,,,,fee schedule,86.15,382.23,
X-ray exam of knee 1 or 2,73560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,135.04,,,,,,,fee schedule,86.15,382.23,
X-ray exam of knee 1 or 2,73560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,147.52,,,,,,,fee schedule,86.15,382.23,
X-ray exam of knee 1 or 2,73560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,155.1,,,,,,,fee schedule,86.15,382.23,
X-ray exam of knee 1 or 2,73560,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
X-ray exam of knee 1 or 2,73560,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of knee 1 or 2,73560,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of knee 1 or 2,73560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of knee 1 or 2,73560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
X-ray exam of knee 1 or 2,73560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of knee 1 or 2,73560,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of knee 3,73562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,308.73,,,,,,,fee schedule,86.15,382.23,
X-ray exam of knee 3,73562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,247.48,,,,,,,fee schedule,86.15,382.23,
X-ray exam of knee 3,73562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,270.35,,,,,,,fee schedule,86.15,382.23,
X-ray exam of knee 3,73562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,284.23,,,,,,,fee schedule,86.15,382.23,
X-ray exam of knee 3,73562,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
X-ray exam of knee 3,73562,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of knee 3,73562,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of knee 3,73562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of knee 3,73562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
X-ray exam of knee 3,73562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of knee 3,73562,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam knee 4 or more,73564,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,294.37,,,,,,,fee schedule,103.5,459.18,
X-ray exam knee 4 or more,73564,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,235.96,,,,,,,fee schedule,103.5,459.18,
X-ray exam knee 4 or more,73564,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,257.77,,,,,,,fee schedule,103.5,459.18,
X-ray exam knee 4 or more,73564,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,271.01,,,,,,,fee schedule,103.5,459.18,
X-ray exam knee 4 or more,73564,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
X-ray exam knee 4 or more,73564,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam knee 4 or more,73564,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam knee 4 or more,73564,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam knee 4 or more,73564,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
X-ray exam knee 4 or more,73564,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam knee 4 or more,73564,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam of knees,73565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,143.94,,,,,,,fee schedule,86.15,382.23,
X-ray exam of knees,73565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,115.38,,,,,,,fee schedule,86.15,382.23,
X-ray exam of knees,73565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,126.04,,,,,,,fee schedule,86.15,382.23,
X-ray exam of knees,73565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,132.52,,,,,,,fee schedule,86.15,382.23,
X-ray exam of knees,73565,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
X-ray exam of knees,73565,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of knees,73565,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of knees,73565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of knees,73565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
X-ray exam of knees,73565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of knees,73565,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
Contrast x-ray of knee joint,73580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,524.36,,,,,,,fee schedule,345.37,1532.31,
Contrast x-ray of knee joint,73580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,420.32,,,,,,,fee schedule,345.37,1532.31,
Contrast x-ray of knee joint,73580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,459.16,,,,,,,fee schedule,345.37,1532.31,
Contrast x-ray of knee joint,73580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,482.75,,,,,,,fee schedule,345.37,1532.31,
Contrast x-ray of knee joint,73580,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1532.31,,,,,,,fee schedule,345.37,1532.31,APC 378
Contrast x-ray of knee joint,73580,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,362.64,,,,,,,fee schedule,345.37,1532.31,APC
Contrast x-ray of knee joint,73580,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,359.19,,,,,,,fee schedule,345.37,1532.31,APC
Contrast x-ray of knee joint,73580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,345.37,,,,,,,fee schedule,345.37,1532.31,APC
Contrast x-ray of knee joint,73580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,528.42,,,,,,,fee schedule,345.37,1532.31,Radiology
Contrast x-ray of knee joint,73580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,483.52,,,,,,,fee schedule,345.37,1532.31,APC
Contrast x-ray of knee joint,73580,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,604.4,,,,,,,fee schedule,345.37,1532.31,APC
X-ray exam of lower leg,73590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,187.4,,,,,,,fee schedule,86.15,382.23,
X-ray exam of lower leg,73590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,150.22,,,,,,,fee schedule,86.15,382.23,
X-ray exam of lower leg,73590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,164.1,,,,,,,fee schedule,86.15,382.23,
X-ray exam of lower leg,73590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,172.53,,,,,,,fee schedule,86.15,382.23,
X-ray exam of lower leg,73590,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
X-ray exam of lower leg,73590,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of lower leg,73590,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of lower leg,73590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of lower leg,73590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
X-ray exam of lower leg,73590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of lower leg,73590,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of leg infant,73592,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,34.06,,,,,,,fee schedule,27.3,382.23,
X-ray exam of leg infant,73592,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,27.3,,,,,,,fee schedule,27.3,382.23,
X-ray exam of leg infant,73592,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29.82,,,,,,,fee schedule,27.3,382.23,
X-ray exam of leg infant,73592,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,31.35,,,,,,,fee schedule,27.3,382.23,
X-ray exam of leg infant,73592,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,27.3,382.23,APC 378
X-ray exam of leg infant,73592,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,27.3,382.23,APC
X-ray exam of leg infant,73592,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,27.3,382.23,APC
X-ray exam of leg infant,73592,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,27.3,382.23,APC
X-ray exam of leg infant,73592,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,27.3,382.23,Radiology
X-ray exam of leg infant,73592,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,27.3,382.23,APC
X-ray exam of leg infant,73592,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,27.3,382.23,APC
X-ray exam of ankle,73600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,163.35,,,,,,,fee schedule,86.15,382.23,
X-ray exam of ankle,73600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,130.94,,,,,,,fee schedule,86.15,382.23,
X-ray exam of ankle,73600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,143.04,,,,,,,fee schedule,86.15,382.23,
X-ray exam of ankle,73600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,150.39,,,,,,,fee schedule,86.15,382.23,
X-ray exam of ankle,73600,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
X-ray exam of ankle,73600,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of ankle,73600,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of ankle,73600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of ankle,73600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
X-ray exam of ankle,73600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of ankle,73600,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of ankle,73610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,197.23,,,,,,,fee schedule,86.15,382.23,
X-ray exam of ankle,73610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,158.1,,,,,,,fee schedule,86.15,382.23,
X-ray exam of ankle,73610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,172.71,,,,,,,fee schedule,86.15,382.23,
X-ray exam of ankle,73610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,181.58,,,,,,,fee schedule,86.15,382.23,
X-ray exam of ankle,73610,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
X-ray exam of ankle,73610,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of ankle,73610,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of ankle,73610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of ankle,73610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
X-ray exam of ankle,73610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of ankle,73610,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
Contrast x-ray of ankle,73615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,999.05,,,,,,,fee schedule,345.37,1532.31,
Contrast x-ray of ankle,73615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,800.83,,,,,,,fee schedule,345.37,1532.31,
Contrast x-ray of ankle,73615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,874.83,,,,,,,fee schedule,345.37,1532.31,
Contrast x-ray of ankle,73615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,919.76,,,,,,,fee schedule,345.37,1532.31,
Contrast x-ray of ankle,73615,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1532.31,,,,,,,fee schedule,345.37,1532.31,APC 378
Contrast x-ray of ankle,73615,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,362.64,,,,,,,fee schedule,345.37,1532.31,APC
Contrast x-ray of ankle,73615,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,359.19,,,,,,,fee schedule,345.37,1532.31,APC
Contrast x-ray of ankle,73615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,345.37,,,,,,,fee schedule,345.37,1532.31,APC
Contrast x-ray of ankle,73615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,528.42,,,,,,,fee schedule,345.37,1532.31,Radiology
Contrast x-ray of ankle,73615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,483.52,,,,,,,fee schedule,345.37,1532.31,APC
Contrast x-ray of ankle,73615,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,604.4,,,,,,,fee schedule,345.37,1532.31,APC
X-ray exam of foot,73620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,177.28,,,,,,,fee schedule,86.15,382.23,
X-ray exam of foot,73620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,142.11,,,,,,,fee schedule,86.15,382.23,
X-ray exam of foot,73620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,155.24,,,,,,,fee schedule,86.15,382.23,
X-ray exam of foot,73620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,163.21,,,,,,,fee schedule,86.15,382.23,
X-ray exam of foot,73620,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
X-ray exam of foot,73620,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of foot,73620,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of foot,73620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of foot,73620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
X-ray exam of foot,73620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of foot,73620,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of foot,73630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,203.6,,,,,,,fee schedule,86.15,382.23,
X-ray exam of foot,73630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,163.2,,,,,,,fee schedule,86.15,382.23,
X-ray exam of foot,73630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,178.29,,,,,,,fee schedule,86.15,382.23,
X-ray exam of foot,73630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,187.44,,,,,,,fee schedule,86.15,382.23,
X-ray exam of foot,73630,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
X-ray exam of foot,73630,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of foot,73630,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of foot,73630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of foot,73630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
X-ray exam of foot,73630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of foot,73630,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of heel,73650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,184.75,,,,,,,fee schedule,86.15,382.23,
X-ray exam of heel,73650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,148.09,,,,,,,fee schedule,86.15,382.23,
X-ray exam of heel,73650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,161.78,,,,,,,fee schedule,86.15,382.23,
X-ray exam of heel,73650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,170.09,,,,,,,fee schedule,86.15,382.23,
X-ray exam of heel,73650,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
X-ray exam of heel,73650,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of heel,73650,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of heel,73650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of heel,73650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
X-ray exam of heel,73650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of heel,73650,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of toe(s),73660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,142.77,,,,,,,fee schedule,86.15,382.23,
X-ray exam of toe(s),73660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,114.45,,,,,,,fee schedule,86.15,382.23,
X-ray exam of toe(s),73660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,125.02,,,,,,,fee schedule,86.15,382.23,
X-ray exam of toe(s),73660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,131.44,,,,,,,fee schedule,86.15,382.23,
X-ray exam of toe(s),73660,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
X-ray exam of toe(s),73660,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of toe(s),73660,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of toe(s),73660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of toe(s),73660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
X-ray exam of toe(s),73660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam of toe(s),73660,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
Ct lower extremity w/o dye,73700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,594.16,,,,,,,fee schedule,103.5,594.16,
Ct lower extremity w/o dye,73700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,476.27,,,,,,,fee schedule,103.5,594.16,
Ct lower extremity w/o dye,73700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,520.28,,,,,,,fee schedule,103.5,594.16,
Ct lower extremity w/o dye,73700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,547,,,,,,,fee schedule,103.5,594.16,
Ct lower extremity w/o dye,73700,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,594.16,APC 378
Ct lower extremity w/o dye,73700,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,594.16,APC
Ct lower extremity w/o dye,73700,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,594.16,APC
Ct lower extremity w/o dye,73700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,594.16,APC
Ct lower extremity w/o dye,73700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,594.16,Radiology
Ct lower extremity w/o dye,73700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,594.16,APC
Ct lower extremity w/o dye,73700,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,594.16,APC
Ct lower extremity w/dye,73701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,911.93,,,,,,,fee schedule,173.64,911.93,
Ct lower extremity w/dye,73701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,731,,,,,,,fee schedule,173.64,911.93,
Ct lower extremity w/dye,73701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,798.55,,,,,,,fee schedule,173.64,911.93,
Ct lower extremity w/dye,73701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,839.56,,,,,,,fee schedule,173.64,911.93,
Ct lower extremity w/dye,73701,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,770.39,,,,,,,fee schedule,173.64,911.93,APC 378
Ct lower extremity w/dye,73701,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,182.32,,,,,,,fee schedule,173.64,911.93,APC
Ct lower extremity w/dye,73701,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,180.59,,,,,,,fee schedule,173.64,911.93,APC
Ct lower extremity w/dye,73701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,173.64,,,,,,,fee schedule,173.64,911.93,APC
Ct lower extremity w/dye,73701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,265.67,,,,,,,fee schedule,173.64,911.93,Radiology
Ct lower extremity w/dye,73701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,243.1,,,,,,,fee schedule,173.64,911.93,APC
Ct lower extremity w/dye,73701,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,303.87,,,,,,,fee schedule,173.64,911.93,APC
Ct lwr extremity w/o&w/dye,73702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,986.1,,,,,,,fee schedule,173.64,986.1,
Ct lwr extremity w/o&w/dye,73702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,790.44,,,,,,,fee schedule,173.64,986.1,
Ct lwr extremity w/o&w/dye,73702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,863.49,,,,,,,fee schedule,173.64,986.1,
Ct lwr extremity w/o&w/dye,73702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,907.83,,,,,,,fee schedule,173.64,986.1,
Ct lwr extremity w/o&w/dye,73702,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,770.39,,,,,,,fee schedule,173.64,986.1,APC 378
Ct lwr extremity w/o&w/dye,73702,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,182.32,,,,,,,fee schedule,173.64,986.1,APC
Ct lwr extremity w/o&w/dye,73702,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,180.59,,,,,,,fee schedule,173.64,986.1,APC
Ct lwr extremity w/o&w/dye,73702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,173.64,,,,,,,fee schedule,173.64,986.1,APC
Ct lwr extremity w/o&w/dye,73702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,265.67,,,,,,,fee schedule,173.64,986.1,Radiology
Ct lwr extremity w/o&w/dye,73702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,243.1,,,,,,,fee schedule,173.64,986.1,APC
Ct lwr extremity w/o&w/dye,73702,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,303.87,,,,,,,fee schedule,173.64,986.1,APC
Ct angio lwr extr w/o&w/dye,73706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1995.18,,,,,,,fee schedule,173.64,1995.18,
Ct angio lwr extr w/o&w/dye,73706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1599.31,,,,,,,fee schedule,173.64,1995.18,
Ct angio lwr extr w/o&w/dye,73706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1747.1,,,,,,,fee schedule,173.64,1995.18,
Ct angio lwr extr w/o&w/dye,73706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1836.83,,,,,,,fee schedule,173.64,1995.18,
Ct angio lwr extr w/o&w/dye,73706,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,770.39,,,,,,,fee schedule,173.64,1995.18,APC 378
Ct angio lwr extr w/o&w/dye,73706,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,182.32,,,,,,,fee schedule,173.64,1995.18,APC
Ct angio lwr extr w/o&w/dye,73706,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,180.59,,,,,,,fee schedule,173.64,1995.18,APC
Ct angio lwr extr w/o&w/dye,73706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,173.64,,,,,,,fee schedule,173.64,1995.18,APC
Ct angio lwr extr w/o&w/dye,73706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,265.67,,,,,,,fee schedule,173.64,1995.18,Radiology
Ct angio lwr extr w/o&w/dye,73706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,243.1,,,,,,,fee schedule,173.64,1995.18,APC
Ct angio lwr extr w/o&w/dye,73706,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,303.87,,,,,,,fee schedule,173.64,1995.18,APC
Mri Lower Extremity W/O Dye,73718,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,674.17,,,,,,,fee schedule,236.21,1047.98,
Mri Lower Extremity W/O Dye,73718,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,540.41,,,,,,,fee schedule,236.21,1047.98,
Mri Lower Extremity W/O Dye,73718,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,590.35,,,,,,,fee schedule,236.21,1047.98,
Mri Lower Extremity W/O Dye,73718,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,620.67,,,,,,,fee schedule,236.21,1047.98,
Mri Lower Extremity W/O Dye,73718,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,236.21,1047.98,APC 378
Mri Lower Extremity W/O Dye,73718,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,236.21,1047.98,APC
Mri Lower Extremity W/O Dye,73718,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,236.21,1047.98,APC
Mri Lower Extremity W/O Dye,73718,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,236.21,1047.98,APC
Mri Lower Extremity W/O Dye,73718,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,236.21,1047.98,Radiology
Mri Lower Extremity W/O Dye,73718,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,236.21,1047.98,APC
Mri Lower Extremity W/O Dye,73718,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,236.21,1047.98,APC
Mri Lower Extremity W/Dye,73719,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1556.07,,,,,,,fee schedule,345.37,1556.07,
Mri Lower Extremity W/Dye,73719,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1247.33,,,,,,,fee schedule,345.37,1556.07,
Mri Lower Extremity W/Dye,73719,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1362.59,,,,,,,fee schedule,345.37,1556.07,
Mri Lower Extremity W/Dye,73719,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1432.58,,,,,,,fee schedule,345.37,1556.07,
Mri Lower Extremity W/Dye,73719,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1532.31,,,,,,,fee schedule,345.37,1556.07,APC 378
Mri Lower Extremity W/Dye,73719,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,362.64,,,,,,,fee schedule,345.37,1556.07,APC
Mri Lower Extremity W/Dye,73719,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,359.19,,,,,,,fee schedule,345.37,1556.07,APC
Mri Lower Extremity W/Dye,73719,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,345.37,,,,,,,fee schedule,345.37,1556.07,APC
Mri Lower Extremity W/Dye,73719,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,528.42,,,,,,,fee schedule,345.37,1556.07,Radiology
Mri Lower Extremity W/Dye,73719,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,483.52,,,,,,,fee schedule,345.37,1556.07,APC
Mri Lower Extremity W/Dye,73719,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,604.4,,,,,,,fee schedule,345.37,1556.07,APC
Mri lwr extremity w/o&w/dye,73720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1124.12,,,,,,,fee schedule,345.37,1532.31,
Mri lwr extremity w/o&w/dye,73720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,901.08,,,,,,,fee schedule,345.37,1532.31,
Mri lwr extremity w/o&w/dye,73720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,984.35,,,,,,,fee schedule,345.37,1532.31,
Mri lwr extremity w/o&w/dye,73720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1034.9,,,,,,,fee schedule,345.37,1532.31,
Mri lwr extremity w/o&w/dye,73720,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1532.31,,,,,,,fee schedule,345.37,1532.31,APC 378
Mri lwr extremity w/o&w/dye,73720,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,362.64,,,,,,,fee schedule,345.37,1532.31,APC
Mri lwr extremity w/o&w/dye,73720,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,359.19,,,,,,,fee schedule,345.37,1532.31,APC
Mri lwr extremity w/o&w/dye,73720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,345.37,,,,,,,fee schedule,345.37,1532.31,APC
Mri lwr extremity w/o&w/dye,73720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,528.42,,,,,,,fee schedule,345.37,1532.31,Radiology
Mri lwr extremity w/o&w/dye,73720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,483.52,,,,,,,fee schedule,345.37,1532.31,APC
Mri lwr extremity w/o&w/dye,73720,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,604.4,,,,,,,fee schedule,345.37,1532.31,APC
Mri jnt of lwr extre w/o dye,73721,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,652.05,,,,,,,fee schedule,236.21,1047.98,
Mri jnt of lwr extre w/o dye,73721,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,522.67,,,,,,,fee schedule,236.21,1047.98,
Mri jnt of lwr extre w/o dye,73721,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,570.97,,,,,,,fee schedule,236.21,1047.98,
Mri jnt of lwr extre w/o dye,73721,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,600.3,,,,,,,fee schedule,236.21,1047.98,
Mri jnt of lwr extre w/o dye,73721,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,236.21,1047.98,APC 378
Mri jnt of lwr extre w/o dye,73721,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,236.21,1047.98,APC
Mri jnt of lwr extre w/o dye,73721,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,236.21,1047.98,APC
Mri jnt of lwr extre w/o dye,73721,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,236.21,1047.98,APC
Mri jnt of lwr extre w/o dye,73721,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,236.21,1047.98,Radiology
Mri jnt of lwr extre w/o dye,73721,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,236.21,1047.98,APC
Mri jnt of lwr extre w/o dye,73721,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,236.21,1047.98,APC
Mri Joint Of Lwr Extr W/Dye,73722,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,878.12,,,,,,,fee schedule,703.89,3443.1,
Mri Joint Of Lwr Extr W/Dye,73722,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,703.89,,,,,,,fee schedule,703.89,3443.1,
Mri Joint Of Lwr Extr W/Dye,73722,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,768.94,,,,,,,fee schedule,703.89,3443.1,
Mri Joint Of Lwr Extr W/Dye,73722,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,808.43,,,,,,,fee schedule,703.89,3443.1,
Mri Joint Of Lwr Extr W/Dye,73722,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3443.1,,,,,,,fee schedule,703.89,3443.1,APC 378
Mri Joint Of Lwr Extr W/Dye,73722,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,814.86,,,,,,,fee schedule,703.89,3443.1,APC
Mri Joint Of Lwr Extr W/Dye,73722,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,807.1,,,,,,,fee schedule,703.89,3443.1,APC
Mri Joint Of Lwr Extr W/Dye,73722,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,776.06,,,,,,,fee schedule,703.89,3443.1,APC
Mri Joint Of Lwr Extr W/Dye,73722,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1187.37,,,,,,,fee schedule,703.89,3443.1,Radiology
Mri Joint Of Lwr Extr W/Dye,73722,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1086.48,,,,,,,fee schedule,703.89,3443.1,APC
Mri Joint Of Lwr Extr W/Dye,73722,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1358.1,,,,,,,fee schedule,703.89,3443.1,APC
Mri joint lwr extr w/o&w/dye,73723,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1045.99,,,,,,,fee schedule,345.37,1532.31,
Mri joint lwr extr w/o&w/dye,73723,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,838.45,,,,,,,fee schedule,345.37,1532.31,
Mri joint lwr extr w/o&w/dye,73723,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,915.93,,,,,,,fee schedule,345.37,1532.31,
Mri joint lwr extr w/o&w/dye,73723,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,962.97,,,,,,,fee schedule,345.37,1532.31,
Mri joint lwr extr w/o&w/dye,73723,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1532.31,,,,,,,fee schedule,345.37,1532.31,APC 378
Mri joint lwr extr w/o&w/dye,73723,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,362.64,,,,,,,fee schedule,345.37,1532.31,APC
Mri joint lwr extr w/o&w/dye,73723,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,359.19,,,,,,,fee schedule,345.37,1532.31,APC
Mri joint lwr extr w/o&w/dye,73723,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,345.37,,,,,,,fee schedule,345.37,1532.31,APC
Mri joint lwr extr w/o&w/dye,73723,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,528.42,,,,,,,fee schedule,345.37,1532.31,Radiology
Mri joint lwr extr w/o&w/dye,73723,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,483.52,,,,,,,fee schedule,345.37,1532.31,APC
Mri joint lwr extr w/o&w/dye,73723,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,604.4,,,,,,,fee schedule,345.37,1532.31,APC
Mr ang lwr ext w or w/o dye,73725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1795.65,,,,,,,fee schedule,1439.37,1795.65,
Mr ang lwr ext w or w/o dye,73725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1439.37,,,,,,,fee schedule,1439.37,1795.65,
Mr ang lwr ext w or w/o dye,73725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1572.38,,,,,,,fee schedule,1439.37,1795.65,
Mr ang lwr ext w or w/o dye,73725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1653.14,,,,,,,fee schedule,1439.37,1795.65,
X-ray exam abdomen 1 view,74018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,235.49,,,,,,,fee schedule,86.15,382.23,
X-ray exam abdomen 1 view,74018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,188.77,,,,,,,fee schedule,86.15,382.23,
X-ray exam abdomen 1 view,74018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,206.21,,,,,,,fee schedule,86.15,382.23,
X-ray exam abdomen 1 view,74018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,216.8,,,,,,,fee schedule,86.15,382.23,
X-ray exam abdomen 1 view,74018,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
X-ray exam abdomen 1 view,74018,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam abdomen 1 view,74018,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam abdomen 1 view,74018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam abdomen 1 view,74018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
X-ray exam abdomen 1 view,74018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam abdomen 1 view,74018,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
X-ray exam abdomen 2 views,74019,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,425.29,,,,,,,fee schedule,103.5,459.18,
X-ray exam abdomen 2 views,74019,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,340.91,,,,,,,fee schedule,103.5,459.18,
X-ray exam abdomen 2 views,74019,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,372.41,,,,,,,fee schedule,103.5,459.18,
X-ray exam abdomen 2 views,74019,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,391.53,,,,,,,fee schedule,103.5,459.18,
X-ray exam abdomen 2 views,74019,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
X-ray exam abdomen 2 views,74019,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam abdomen 2 views,74019,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam abdomen 2 views,74019,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam abdomen 2 views,74019,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
X-ray exam abdomen 2 views,74019,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam abdomen 2 views,74019,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam abdomen 3+ views,74021,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,425.29,,,,,,,fee schedule,103.5,459.18,
X-ray exam abdomen 3+ views,74021,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,340.91,,,,,,,fee schedule,103.5,459.18,
X-ray exam abdomen 3+ views,74021,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,372.41,,,,,,,fee schedule,103.5,459.18,
X-ray exam abdomen 3+ views,74021,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,391.53,,,,,,,fee schedule,103.5,459.18,
X-ray exam abdomen 3+ views,74021,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
X-ray exam abdomen 3+ views,74021,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam abdomen 3+ views,74021,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam abdomen 3+ views,74021,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam abdomen 3+ views,74021,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
X-ray exam abdomen 3+ views,74021,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam abdomen 3+ views,74021,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam series abdomen,74022,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,234.75,,,,,,,fee schedule,103.5,459.18,
X-ray exam series abdomen,74022,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,188.18,,,,,,,fee schedule,103.5,459.18,
X-ray exam series abdomen,74022,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,205.57,,,,,,,fee schedule,103.5,459.18,
X-ray exam series abdomen,74022,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,216.12,,,,,,,fee schedule,103.5,459.18,
X-ray exam series abdomen,74022,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
X-ray exam series abdomen,74022,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam series abdomen,74022,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam series abdomen,74022,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam series abdomen,74022,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
X-ray exam series abdomen,74022,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam series abdomen,74022,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Ct abdomen w/o dye,74150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,699.71,,,,,,,fee schedule,103.5,699.71,
Ct abdomen w/o dye,74150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,560.88,,,,,,,fee schedule,103.5,699.71,
Ct abdomen w/o dye,74150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,612.71,,,,,,,fee schedule,103.5,699.71,
Ct abdomen w/o dye,74150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,644.18,,,,,,,fee schedule,103.5,699.71,
Ct abdomen w/o dye,74150,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,699.71,APC 378
Ct abdomen w/o dye,74150,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,699.71,APC
Ct abdomen w/o dye,74150,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,699.71,APC
Ct abdomen w/o dye,74150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,699.71,APC
Ct abdomen w/o dye,74150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,699.71,Radiology
Ct abdomen w/o dye,74150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,699.71,APC
Ct abdomen w/o dye,74150,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,699.71,APC
Ct abdomen w/dye,74160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1010.1,,,,,,,fee schedule,173.64,1010.1,
Ct abdomen w/dye,74160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,809.68,,,,,,,fee schedule,173.64,1010.1,
Ct abdomen w/dye,74160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,884.5,,,,,,,fee schedule,173.64,1010.1,
Ct abdomen w/dye,74160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,929.93,,,,,,,fee schedule,173.64,1010.1,
Ct abdomen w/dye,74160,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,770.39,,,,,,,fee schedule,173.64,1010.1,APC 378
Ct abdomen w/dye,74160,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,182.32,,,,,,,fee schedule,173.64,1010.1,APC
Ct abdomen w/dye,74160,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,180.59,,,,,,,fee schedule,173.64,1010.1,APC
Ct abdomen w/dye,74160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,173.64,,,,,,,fee schedule,173.64,1010.1,APC
Ct abdomen w/dye,74160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,265.67,,,,,,,fee schedule,173.64,1010.1,Radiology
Ct abdomen w/dye,74160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,243.1,,,,,,,fee schedule,173.64,1010.1,APC
Ct abdomen w/dye,74160,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,303.87,,,,,,,fee schedule,173.64,1010.1,APC
Ct abdomen w/o & w/dye,74170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1168.72,,,,,,,fee schedule,173.64,1168.72,
Ct abdomen w/o & w/dye,74170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,936.83,,,,,,,fee schedule,173.64,1168.72,
Ct abdomen w/o & w/dye,74170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1023.4,,,,,,,fee schedule,173.64,1168.72,
Ct abdomen w/o & w/dye,74170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1075.97,,,,,,,fee schedule,173.64,1168.72,
Ct abdomen w/o & w/dye,74170,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,770.39,,,,,,,fee schedule,173.64,1168.72,APC 378
Ct abdomen w/o & w/dye,74170,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,182.32,,,,,,,fee schedule,173.64,1168.72,APC
Ct abdomen w/o & w/dye,74170,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,180.59,,,,,,,fee schedule,173.64,1168.72,APC
Ct abdomen w/o & w/dye,74170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,173.64,,,,,,,fee schedule,173.64,1168.72,APC
Ct abdomen w/o & w/dye,74170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,265.67,,,,,,,fee schedule,173.64,1168.72,Radiology
Ct abdomen w/o & w/dye,74170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,243.1,,,,,,,fee schedule,173.64,1168.72,APC
Ct abdomen w/o & w/dye,74170,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,303.87,,,,,,,fee schedule,173.64,1168.72,APC
Ct angio abd&pelv w/o&w/dye,74174,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2075.1,,,,,,,fee schedule,345.37,2075.1,
Ct angio abd&pelv w/o&w/dye,74174,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1663.38,,,,,,,fee schedule,345.37,2075.1,
Ct angio abd&pelv w/o&w/dye,74174,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1817.09,,,,,,,fee schedule,345.37,2075.1,
Ct angio abd&pelv w/o&w/dye,74174,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1910.41,,,,,,,fee schedule,345.37,2075.1,
Ct angio abd&pelv w/o&w/dye,74174,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1532.31,,,,,,,fee schedule,345.37,2075.1,APC 378
Ct angio abd&pelv w/o&w/dye,74174,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,362.64,,,,,,,fee schedule,345.37,2075.1,APC
Ct angio abd&pelv w/o&w/dye,74174,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,359.19,,,,,,,fee schedule,345.37,2075.1,APC
Ct angio abd&pelv w/o&w/dye,74174,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,345.37,,,,,,,fee schedule,345.37,2075.1,APC
Ct angio abd&pelv w/o&w/dye,74174,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,528.42,,,,,,,fee schedule,345.37,2075.1,Radiology
Ct angio abd&pelv w/o&w/dye,74174,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,483.52,,,,,,,fee schedule,345.37,2075.1,APC
Ct angio abd&pelv w/o&w/dye,74174,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,604.4,,,,,,,fee schedule,345.37,2075.1,APC
Ct angio abdom w/o & w/dye,74175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1478.3,,,,,,,fee schedule,173.64,1478.3,
Ct angio abdom w/o & w/dye,74175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1184.99,,,,,,,fee schedule,173.64,1478.3,
Ct angio abdom w/o & w/dye,74175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1294.49,,,,,,,fee schedule,173.64,1478.3,
Ct angio abdom w/o & w/dye,74175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1360.97,,,,,,,fee schedule,173.64,1478.3,
Ct angio abdom w/o & w/dye,74175,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,770.39,,,,,,,fee schedule,173.64,1478.3,APC 378
Ct angio abdom w/o & w/dye,74175,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,182.32,,,,,,,fee schedule,173.64,1478.3,APC
Ct angio abdom w/o & w/dye,74175,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,180.59,,,,,,,fee schedule,173.64,1478.3,APC
Ct angio abdom w/o & w/dye,74175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,173.64,,,,,,,fee schedule,173.64,1478.3,APC
Ct angio abdom w/o & w/dye,74175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,265.67,,,,,,,fee schedule,173.64,1478.3,Radiology
Ct angio abdom w/o & w/dye,74175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,243.1,,,,,,,fee schedule,173.64,1478.3,APC
Ct angio abdom w/o & w/dye,74175,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,303.87,,,,,,,fee schedule,173.64,1478.3,APC
Ct abd & pelvis w/o contrast,74176,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1546.38,,,,,,,fee schedule,236.21,1546.38,
Ct abd & pelvis w/o contrast,74176,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1239.56,,,,,,,fee schedule,236.21,1546.38,
Ct abd & pelvis w/o contrast,74176,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1354.1,,,,,,,fee schedule,236.21,1546.38,
Ct abd & pelvis w/o contrast,74176,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1423.65,,,,,,,fee schedule,236.21,1546.38,
Ct abd & pelvis w/o contrast,74176,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,236.21,1546.38,APC 378
Ct abd & pelvis w/o contrast,74176,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,236.21,1546.38,APC
Ct abd & pelvis w/o contrast,74176,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,236.21,1546.38,APC
Ct abd & pelvis w/o contrast,74176,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,236.21,1546.38,APC
Ct abd & pelvis w/o contrast,74176,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,236.21,1546.38,Radiology
Ct abd & pelvis w/o contrast,74176,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,236.21,1546.38,APC
Ct abd & pelvis w/o contrast,74176,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,236.21,1546.38,APC
Ct abd & pelv w/contrast,74177,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1898.09,,,,,,,fee schedule,345.37,1898.09,
Ct abd & pelv w/contrast,74177,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1521.48,,,,,,,fee schedule,345.37,1898.09,
Ct abd & pelv w/contrast,74177,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1662.08,,,,,,,fee schedule,345.37,1898.09,
Ct abd & pelv w/contrast,74177,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1747.45,,,,,,,fee schedule,345.37,1898.09,
Ct abd & pelv w/contrast,74177,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1532.31,,,,,,,fee schedule,345.37,1898.09,APC 378
Ct abd & pelv w/contrast,74177,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,362.64,,,,,,,fee schedule,345.37,1898.09,APC
Ct abd & pelv w/contrast,74177,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,359.19,,,,,,,fee schedule,345.37,1898.09,APC
Ct abd & pelv w/contrast,74177,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,345.37,,,,,,,fee schedule,345.37,1898.09,APC
Ct abd & pelv w/contrast,74177,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,528.42,,,,,,,fee schedule,345.37,1898.09,Radiology
Ct abd & pelv w/contrast,74177,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,483.52,,,,,,,fee schedule,345.37,1898.09,APC
Ct abd & pelv w/contrast,74177,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,604.4,,,,,,,fee schedule,345.37,1898.09,APC
Ct abd & pelv 1/> regns,74178,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2149.48,,,,,,,fee schedule,345.37,2149.48,
Ct abd & pelv 1/> regns,74178,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1722.99,,,,,,,fee schedule,345.37,2149.48,
Ct abd & pelv 1/> regns,74178,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1882.21,,,,,,,fee schedule,345.37,2149.48,
Ct abd & pelv 1/> regns,74178,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1978.88,,,,,,,fee schedule,345.37,2149.48,
Ct abd & pelv 1/> regns,74178,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1532.31,,,,,,,fee schedule,345.37,2149.48,APC 378
Ct abd & pelv 1/> regns,74178,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,362.64,,,,,,,fee schedule,345.37,2149.48,APC
Ct abd & pelv 1/> regns,74178,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,359.19,,,,,,,fee schedule,345.37,2149.48,APC
Ct abd & pelv 1/> regns,74178,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,345.37,,,,,,,fee schedule,345.37,2149.48,APC
Ct abd & pelv 1/> regns,74178,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,528.42,,,,,,,fee schedule,345.37,2149.48,Radiology
Ct abd & pelv 1/> regns,74178,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,483.52,,,,,,,fee schedule,345.37,2149.48,APC
Ct abd & pelv 1/> regns,74178,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,604.4,,,,,,,fee schedule,345.37,2149.48,APC
Mri abdomen w/o dye,74181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,617.14,,,,,,,fee schedule,236.21,1047.98,
Mri abdomen w/o dye,74181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,494.69,,,,,,,fee schedule,236.21,1047.98,
Mri abdomen w/o dye,74181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,540.41,,,,,,,fee schedule,236.21,1047.98,
Mri abdomen w/o dye,74181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,568.16,,,,,,,fee schedule,236.21,1047.98,
Mri abdomen w/o dye,74181,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,236.21,1047.98,APC 378
Mri abdomen w/o dye,74181,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,236.21,1047.98,APC
Mri abdomen w/o dye,74181,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,236.21,1047.98,APC
Mri abdomen w/o dye,74181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,236.21,1047.98,APC
Mri abdomen w/o dye,74181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,236.21,1047.98,Radiology
Mri abdomen w/o dye,74181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,236.21,1047.98,APC
Mri abdomen w/o dye,74181,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,236.21,1047.98,APC
Mri Abdomen W/Dye,74182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1556.07,,,,,,,fee schedule,345.37,1556.07,
Mri Abdomen W/Dye,74182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1247.33,,,,,,,fee schedule,345.37,1556.07,
Mri Abdomen W/Dye,74182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1362.59,,,,,,,fee schedule,345.37,1556.07,
Mri Abdomen W/Dye,74182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1432.58,,,,,,,fee schedule,345.37,1556.07,
Mri Abdomen W/Dye,74182,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1532.31,,,,,,,fee schedule,345.37,1556.07,APC 378
Mri Abdomen W/Dye,74182,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,362.64,,,,,,,fee schedule,345.37,1556.07,APC
Mri Abdomen W/Dye,74182,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,359.19,,,,,,,fee schedule,345.37,1556.07,APC
Mri Abdomen W/Dye,74182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,345.37,,,,,,,fee schedule,345.37,1556.07,APC
Mri Abdomen W/Dye,74182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,528.42,,,,,,,fee schedule,345.37,1556.07,Radiology
Mri Abdomen W/Dye,74182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,483.52,,,,,,,fee schedule,345.37,1556.07,APC
Mri Abdomen W/Dye,74182,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,604.4,,,,,,,fee schedule,345.37,1556.07,APC
Mri abdomen w/o & w/dye,74183,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,821.61,,,,,,,fee schedule,345.37,1532.31,
Mri abdomen w/o & w/dye,74183,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,658.59,,,,,,,fee schedule,345.37,1532.31,
Mri abdomen w/o & w/dye,74183,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,719.45,,,,,,,fee schedule,345.37,1532.31,
Mri abdomen w/o & w/dye,74183,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,756.4,,,,,,,fee schedule,345.37,1532.31,
Mri abdomen w/o & w/dye,74183,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1532.31,,,,,,,fee schedule,345.37,1532.31,APC 378
Mri abdomen w/o & w/dye,74183,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,362.64,,,,,,,fee schedule,345.37,1532.31,APC
Mri abdomen w/o & w/dye,74183,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,359.19,,,,,,,fee schedule,345.37,1532.31,APC
Mri abdomen w/o & w/dye,74183,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,345.37,,,,,,,fee schedule,345.37,1532.31,APC
Mri abdomen w/o & w/dye,74183,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,528.42,,,,,,,fee schedule,345.37,1532.31,Radiology
Mri abdomen w/o & w/dye,74183,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,483.52,,,,,,,fee schedule,345.37,1532.31,APC
Mri abdomen w/o & w/dye,74183,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,604.4,,,,,,,fee schedule,345.37,1532.31,APC
Mri angio abdom w orw/o dye,74185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1790.51,,,,,,,fee schedule,1435.25,1790.51,
Mri angio abdom w orw/o dye,74185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1435.25,,,,,,,fee schedule,1435.25,1790.51,
Mri angio abdom w orw/o dye,74185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1567.88,,,,,,,fee schedule,1435.25,1790.51,
Mri angio abdom w orw/o dye,74185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1648.41,,,,,,,fee schedule,1435.25,1790.51,
X-ray exam of peritoneum,74190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1338.31,,,,,,,fee schedule,540.93,2399.94,
X-ray exam of peritoneum,74190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1072.77,,,,,,,fee schedule,540.93,2399.94,
X-ray exam of peritoneum,74190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1171.91,,,,,,,fee schedule,540.93,2399.94,
X-ray exam of peritoneum,74190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1232.09,,,,,,,fee schedule,540.93,2399.94,
X-ray exam of peritoneum,74190,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2399.94,,,,,,,fee schedule,540.93,2399.94,APC 378
X-ray exam of peritoneum,74190,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,567.98,,,,,,,fee schedule,540.93,2399.94,APC
X-ray exam of peritoneum,74190,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,562.57,,,,,,,fee schedule,540.93,2399.94,APC
X-ray exam of peritoneum,74190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,540.93,,,,,,,fee schedule,540.93,2399.94,APC
X-ray exam of peritoneum,74190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,827.63,,,,,,,fee schedule,540.93,2399.94,Radiology
X-ray exam of peritoneum,74190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,757.31,,,,,,,fee schedule,540.93,2399.94,APC
X-ray exam of peritoneum,74190,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,946.63,,,,,,,fee schedule,540.93,2399.94,APC
Contrst x-ray exam of throat,74210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,345.23,,,,,,,fee schedule,173.64,770.39,
Contrst x-ray exam of throat,74210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,276.73,,,,,,,fee schedule,173.64,770.39,
Contrst x-ray exam of throat,74210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,302.3,,,,,,,fee schedule,173.64,770.39,
Contrst x-ray exam of throat,74210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,317.83,,,,,,,fee schedule,173.64,770.39,
Contrst x-ray exam of throat,74210,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,770.39,,,,,,,fee schedule,173.64,770.39,APC 378
Contrst x-ray exam of throat,74210,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,182.32,,,,,,,fee schedule,173.64,770.39,APC
Contrst x-ray exam of throat,74210,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,180.59,,,,,,,fee schedule,173.64,770.39,APC
Contrst x-ray exam of throat,74210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,173.64,,,,,,,fee schedule,173.64,770.39,APC
Contrst x-ray exam of throat,74210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,265.67,,,,,,,fee schedule,173.64,770.39,Radiology
Contrst x-ray exam of throat,74210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,243.1,,,,,,,fee schedule,173.64,770.39,APC
Contrst x-ray exam of throat,74210,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,303.87,,,,,,,fee schedule,173.64,770.39,APC
Contrast x-ray esophagus,74220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,271.42,,,,,,,fee schedule,173.64,770.39,
Contrast x-ray esophagus,74220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,217.57,,,,,,,fee schedule,173.64,770.39,
Contrast x-ray esophagus,74220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,237.67,,,,,,,fee schedule,173.64,770.39,
Contrast x-ray esophagus,74220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,249.88,,,,,,,fee schedule,173.64,770.39,
Contrast x-ray esophagus,74220,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,770.39,,,,,,,fee schedule,173.64,770.39,APC 378
Contrast x-ray esophagus,74220,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,182.32,,,,,,,fee schedule,173.64,770.39,APC
Contrast x-ray esophagus,74220,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,180.59,,,,,,,fee schedule,173.64,770.39,APC
Contrast x-ray esophagus,74220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,173.64,,,,,,,fee schedule,173.64,770.39,APC
Contrast x-ray esophagus,74220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,265.67,,,,,,,fee schedule,173.64,770.39,Radiology
Contrast x-ray esophagus,74220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,243.1,,,,,,,fee schedule,173.64,770.39,APC
Contrast x-ray esophagus,74220,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,303.87,,,,,,,fee schedule,173.64,770.39,APC
X-ray xm esophagus 2cntrst,74221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,688.79,,,,,,,fee schedule,173.64,770.39,
X-ray xm esophagus 2cntrst,74221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,552.13,,,,,,,fee schedule,173.64,770.39,
X-ray xm esophagus 2cntrst,74221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,603.15,,,,,,,fee schedule,173.64,770.39,
X-ray xm esophagus 2cntrst,74221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,634.13,,,,,,,fee schedule,173.64,770.39,
X-ray xm esophagus 2cntrst,74221,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,770.39,,,,,,,fee schedule,173.64,770.39,APC 378
X-ray xm esophagus 2cntrst,74221,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,182.32,,,,,,,fee schedule,173.64,770.39,APC
X-ray xm esophagus 2cntrst,74221,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,180.59,,,,,,,fee schedule,173.64,770.39,APC
X-ray xm esophagus 2cntrst,74221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,173.64,,,,,,,fee schedule,173.64,770.39,APC
X-ray xm esophagus 2cntrst,74221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,265.67,,,,,,,fee schedule,173.64,770.39,Radiology
X-ray xm esophagus 2cntrst,74221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,243.1,,,,,,,fee schedule,173.64,770.39,APC
X-ray xm esophagus 2cntrst,74221,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,303.87,,,,,,,fee schedule,173.64,770.39,APC
Cine/vid x-ray throat/esoph,74230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,250.03,,,,,,,fee schedule,173.64,770.39,
Cine/vid x-ray throat/esoph,74230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,200.42,,,,,,,fee schedule,173.64,770.39,
Cine/vid x-ray throat/esoph,74230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,218.94,,,,,,,fee schedule,173.64,770.39,
Cine/vid x-ray throat/esoph,74230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,230.19,,,,,,,fee schedule,173.64,770.39,
Cine/vid x-ray throat/esoph,74230,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,770.39,,,,,,,fee schedule,173.64,770.39,APC 378
Cine/vid x-ray throat/esoph,74230,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,182.32,,,,,,,fee schedule,173.64,770.39,APC
Cine/vid x-ray throat/esoph,74230,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,180.59,,,,,,,fee schedule,173.64,770.39,APC
Cine/vid x-ray throat/esoph,74230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,173.64,,,,,,,fee schedule,173.64,770.39,APC
Cine/vid x-ray throat/esoph,74230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,265.67,,,,,,,fee schedule,173.64,770.39,Radiology
Cine/vid x-ray throat/esoph,74230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,243.1,,,,,,,fee schedule,173.64,770.39,APC
Cine/vid x-ray throat/esoph,74230,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,303.87,,,,,,,fee schedule,173.64,770.39,APC
X-ray upper gi delay w/o kub,74240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,492.23,,,,,,,fee schedule,173.64,770.39,
X-ray upper gi delay w/o kub,74240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,394.57,,,,,,,fee schedule,173.64,770.39,
X-ray upper gi delay w/o kub,74240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,431.03,,,,,,,fee schedule,173.64,770.39,
X-ray upper gi delay w/o kub,74240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,453.17,,,,,,,fee schedule,173.64,770.39,
X-ray upper gi delay w/o kub,74240,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,770.39,,,,,,,fee schedule,173.64,770.39,APC 378
X-ray upper gi delay w/o kub,74240,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,182.32,,,,,,,fee schedule,173.64,770.39,APC
X-ray upper gi delay w/o kub,74240,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,180.59,,,,,,,fee schedule,173.64,770.39,APC
X-ray upper gi delay w/o kub,74240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,173.64,,,,,,,fee schedule,173.64,770.39,APC
X-ray upper gi delay w/o kub,74240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,265.67,,,,,,,fee schedule,173.64,770.39,Radiology
X-ray upper gi delay w/o kub,74240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,243.1,,,,,,,fee schedule,173.64,770.39,APC
X-ray upper gi delay w/o kub,74240,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,303.87,,,,,,,fee schedule,173.64,770.39,APC
Contrst x-ray uppr gi tract,74246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,404.2,,,,,,,fee schedule,173.64,770.39,
Contrst x-ray uppr gi tract,74246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,324,,,,,,,fee schedule,173.64,770.39,
Contrst x-ray uppr gi tract,74246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.94,,,,,,,fee schedule,173.64,770.39,
Contrst x-ray uppr gi tract,74246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,372.12,,,,,,,fee schedule,173.64,770.39,
Contrst x-ray uppr gi tract,74246,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,770.39,,,,,,,fee schedule,173.64,770.39,APC 378
Contrst x-ray uppr gi tract,74246,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,182.32,,,,,,,fee schedule,173.64,770.39,APC
Contrst x-ray uppr gi tract,74246,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,180.59,,,,,,,fee schedule,173.64,770.39,APC
Contrst x-ray uppr gi tract,74246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,173.64,,,,,,,fee schedule,173.64,770.39,APC
Contrst x-ray uppr gi tract,74246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,265.67,,,,,,,fee schedule,173.64,770.39,Radiology
Contrst x-ray uppr gi tract,74246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,243.1,,,,,,,fee schedule,173.64,770.39,APC
Contrst x-ray uppr gi tract,74246,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,303.87,,,,,,,fee schedule,173.64,770.39,APC
X-ray sm int f-thru std,74248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,131.7,,,,,,,fee schedule,105.57,131.7,
X-ray sm int f-thru std,74248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,105.57,,,,,,,fee schedule,105.57,131.7,
X-ray sm int f-thru std,74248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,115.32,,,,,,,fee schedule,105.57,131.7,
X-ray sm int f-thru std,74248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,121.24,,,,,,,fee schedule,105.57,131.7,
X-ray exam of small bowel,74250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,284.03,,,,,,,fee schedule,173.64,770.39,
X-ray exam of small bowel,74250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,227.67,,,,,,,fee schedule,173.64,770.39,
X-ray exam of small bowel,74250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,248.71,,,,,,,fee schedule,173.64,770.39,
X-ray exam of small bowel,74250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,261.49,,,,,,,fee schedule,173.64,770.39,
X-ray exam of small bowel,74250,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,770.39,,,,,,,fee schedule,173.64,770.39,APC 378
X-ray exam of small bowel,74250,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,182.32,,,,,,,fee schedule,173.64,770.39,APC
X-ray exam of small bowel,74250,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,180.59,,,,,,,fee schedule,173.64,770.39,APC
X-ray exam of small bowel,74250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,173.64,,,,,,,fee schedule,173.64,770.39,APC
X-ray exam of small bowel,74250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,265.67,,,,,,,fee schedule,173.64,770.39,Radiology
X-ray exam of small bowel,74250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,243.1,,,,,,,fee schedule,173.64,770.39,APC
X-ray exam of small bowel,74250,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,303.87,,,,,,,fee schedule,173.64,770.39,APC
X-ray exam of small bowel,74251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,554.6,,,,,,,fee schedule,173.64,770.39,
X-ray exam of small bowel,74251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,444.56,,,,,,,fee schedule,173.64,770.39,
X-ray exam of small bowel,74251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,485.64,,,,,,,fee schedule,173.64,770.39,
X-ray exam of small bowel,74251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,510.59,,,,,,,fee schedule,173.64,770.39,
X-ray exam of small bowel,74251,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,770.39,,,,,,,fee schedule,173.64,770.39,APC 378
X-ray exam of small bowel,74251,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,182.32,,,,,,,fee schedule,173.64,770.39,APC
X-ray exam of small bowel,74251,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,180.59,,,,,,,fee schedule,173.64,770.39,APC
X-ray exam of small bowel,74251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,173.64,,,,,,,fee schedule,173.64,770.39,APC
X-ray exam of small bowel,74251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,265.67,,,,,,,fee schedule,173.64,770.39,Radiology
X-ray exam of small bowel,74251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,243.1,,,,,,,fee schedule,173.64,770.39,APC
X-ray exam of small bowel,74251,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,303.87,,,,,,,fee schedule,173.64,770.39,APC
Ct colonography dx,74261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,764.35,,,,,,,fee schedule,103.5,764.35,
Ct colonography dx,74261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,612.7,,,,,,,fee schedule,103.5,764.35,
Ct colonography dx,74261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,669.32,,,,,,,fee schedule,103.5,764.35,
Ct colonography dx,74261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,703.69,,,,,,,fee schedule,103.5,764.35,
Ct colonography dx,74261,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,764.35,APC 378
Ct colonography dx,74261,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,764.35,APC
Ct colonography dx,74261,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,764.35,APC
Ct colonography dx,74261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,764.35,APC
Ct colonography dx,74261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,764.35,Radiology
Ct colonography dx,74261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,764.35,APC
Ct colonography dx,74261,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,764.35,APC
Ct colonography dx w/dye,74262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1163.86,,,,,,,fee schedule,173.64,1163.86,
Ct colonography dx w/dye,74262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,932.94,,,,,,,fee schedule,173.64,1163.86,
Ct colonography dx w/dye,74262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1019.15,,,,,,,fee schedule,173.64,1163.86,
Ct colonography dx w/dye,74262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1071.49,,,,,,,fee schedule,173.64,1163.86,
Ct colonography dx w/dye,74262,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,770.39,,,,,,,fee schedule,173.64,1163.86,APC 378
Ct colonography dx w/dye,74262,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,182.32,,,,,,,fee schedule,173.64,1163.86,APC
Ct colonography dx w/dye,74262,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,180.59,,,,,,,fee schedule,173.64,1163.86,APC
Ct colonography dx w/dye,74262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,173.64,,,,,,,fee schedule,173.64,1163.86,APC
Ct colonography dx w/dye,74262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,265.67,,,,,,,fee schedule,173.64,1163.86,Radiology
Ct colonography dx w/dye,74262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,243.1,,,,,,,fee schedule,173.64,1163.86,APC
Ct colonography dx w/dye,74262,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,303.87,,,,,,,fee schedule,173.64,1163.86,APC
Ct colonography screening,74263,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,236.21,1047.98,APC 378
Ct colonography screening,74263,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,236.21,1047.98,APC
Ct colonography screening,74263,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,236.21,1047.98,APC
Ct colonography screening,74263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,236.21,1047.98,APC
Ct colonography screening,74263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,236.21,1047.98,Radiology
Ct colonography screening,74263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,236.21,1047.98,APC
Ct colonography screening,74263,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,236.21,1047.98,APC
Contrast x-ray exam of colon,74270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,359.21,,,,,,,fee schedule,173.64,770.39,
Contrast x-ray exam of colon,74270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,287.94,,,,,,,fee schedule,173.64,770.39,
Contrast x-ray exam of colon,74270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,314.55,,,,,,,fee schedule,173.64,770.39,
Contrast x-ray exam of colon,74270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,330.7,,,,,,,fee schedule,173.64,770.39,
Contrast x-ray exam of colon,74270,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,770.39,,,,,,,fee schedule,173.64,770.39,APC 378
Contrast x-ray exam of colon,74270,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,182.32,,,,,,,fee schedule,173.64,770.39,APC
Contrast x-ray exam of colon,74270,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,180.59,,,,,,,fee schedule,173.64,770.39,APC
Contrast x-ray exam of colon,74270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,173.64,,,,,,,fee schedule,173.64,770.39,APC
Contrast x-ray exam of colon,74270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,265.67,,,,,,,fee schedule,173.64,770.39,Radiology
Contrast x-ray exam of colon,74270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,243.1,,,,,,,fee schedule,173.64,770.39,APC
Contrast x-ray exam of colon,74270,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,303.87,,,,,,,fee schedule,173.64,770.39,APC
Contrast x-ray exam of colon,74280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,559.06,,,,,,,fee schedule,173.64,770.39,
Contrast x-ray exam of colon,74280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,448.14,,,,,,,fee schedule,173.64,770.39,
Contrast x-ray exam of colon,74280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,489.55,,,,,,,fee schedule,173.64,770.39,
Contrast x-ray exam of colon,74280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,514.69,,,,,,,fee schedule,173.64,770.39,
Contrast x-ray exam of colon,74280,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,770.39,,,,,,,fee schedule,173.64,770.39,APC 378
Contrast x-ray exam of colon,74280,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,182.32,,,,,,,fee schedule,173.64,770.39,APC
Contrast x-ray exam of colon,74280,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,180.59,,,,,,,fee schedule,173.64,770.39,APC
Contrast x-ray exam of colon,74280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,173.64,,,,,,,fee schedule,173.64,770.39,APC
Contrast x-ray exam of colon,74280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,265.67,,,,,,,fee schedule,173.64,770.39,Radiology
Contrast x-ray exam of colon,74280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,243.1,,,,,,,fee schedule,173.64,770.39,APC
Contrast x-ray exam of colon,74280,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,303.87,,,,,,,fee schedule,173.64,770.39,APC
Contrast x-ray exam of colon,74283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,525.65,,,,,,,fee schedule,173.64,770.39,
Contrast x-ray exam of colon,74283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,421.35,,,,,,,fee schedule,173.64,770.39,
Contrast x-ray exam of colon,74283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,460.29,,,,,,,fee schedule,173.64,770.39,
Contrast x-ray exam of colon,74283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,483.93,,,,,,,fee schedule,173.64,770.39,
Contrast x-ray exam of colon,74283,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,770.39,,,,,,,fee schedule,173.64,770.39,APC 378
Contrast x-ray exam of colon,74283,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,182.32,,,,,,,fee schedule,173.64,770.39,APC
Contrast x-ray exam of colon,74283,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,180.59,,,,,,,fee schedule,173.64,770.39,APC
Contrast x-ray exam of colon,74283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,173.64,,,,,,,fee schedule,173.64,770.39,APC
Contrast x-ray exam of colon,74283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,265.67,,,,,,,fee schedule,173.64,770.39,Radiology
Contrast x-ray exam of colon,74283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,243.1,,,,,,,fee schedule,173.64,770.39,APC
Contrast x-ray exam of colon,74283,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,303.87,,,,,,,fee schedule,173.64,770.39,APC
Contrast x-ray gallbladder,74290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,345.23,,,,,,,fee schedule,173.64,770.39,
Contrast x-ray gallbladder,74290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,276.73,,,,,,,fee schedule,173.64,770.39,
Contrast x-ray gallbladder,74290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,302.3,,,,,,,fee schedule,173.64,770.39,
Contrast x-ray gallbladder,74290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,317.83,,,,,,,fee schedule,173.64,770.39,
Contrast x-ray gallbladder,74290,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,770.39,,,,,,,fee schedule,173.64,770.39,APC 378
Contrast x-ray gallbladder,74290,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,182.32,,,,,,,fee schedule,173.64,770.39,APC
Contrast x-ray gallbladder,74290,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,180.59,,,,,,,fee schedule,173.64,770.39,APC
Contrast x-ray gallbladder,74290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,173.64,,,,,,,fee schedule,173.64,770.39,APC
Contrast x-ray gallbladder,74290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,265.67,,,,,,,fee schedule,173.64,770.39,Radiology
Contrast x-ray gallbladder,74290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,243.1,,,,,,,fee schedule,173.64,770.39,APC
Contrast x-ray gallbladder,74290,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,303.87,,,,,,,fee schedule,173.64,770.39,APC
Contrst x-ray urinary tract,74400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,651.94,,,,,,,fee schedule,173.64,770.39,
Contrst x-ray urinary tract,74400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,522.58,,,,,,,fee schedule,173.64,770.39,
Contrst x-ray urinary tract,74400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,570.88,,,,,,,fee schedule,173.64,770.39,
Contrst x-ray urinary tract,74400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,600.2,,,,,,,fee schedule,173.64,770.39,
Contrst x-ray urinary tract,74400,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,770.39,,,,,,,fee schedule,173.64,770.39,APC 378
Contrst x-ray urinary tract,74400,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,182.32,,,,,,,fee schedule,173.64,770.39,APC
Contrst x-ray urinary tract,74400,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,180.59,,,,,,,fee schedule,173.64,770.39,APC
Contrst x-ray urinary tract,74400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,173.64,,,,,,,fee schedule,173.64,770.39,APC
Contrst x-ray urinary tract,74400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,265.67,,,,,,,fee schedule,173.64,770.39,Radiology
Contrst x-ray urinary tract,74400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,243.1,,,,,,,fee schedule,173.64,770.39,APC
Contrst x-ray urinary tract,74400,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,303.87,,,,,,,fee schedule,173.64,770.39,APC
Contrst x-ray urinary tract,74410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,651.94,,,,,,,fee schedule,173.64,770.39,
Contrst x-ray urinary tract,74410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,522.58,,,,,,,fee schedule,173.64,770.39,
Contrst x-ray urinary tract,74410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,570.88,,,,,,,fee schedule,173.64,770.39,
Contrst x-ray urinary tract,74410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,600.2,,,,,,,fee schedule,173.64,770.39,
Contrst x-ray urinary tract,74410,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,770.39,,,,,,,fee schedule,173.64,770.39,APC 378
Contrst x-ray urinary tract,74410,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,182.32,,,,,,,fee schedule,173.64,770.39,APC
Contrst x-ray urinary tract,74410,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,180.59,,,,,,,fee schedule,173.64,770.39,APC
Contrst x-ray urinary tract,74410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,173.64,,,,,,,fee schedule,173.64,770.39,APC
Contrst x-ray urinary tract,74410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,265.67,,,,,,,fee schedule,173.64,770.39,Radiology
Contrst x-ray urinary tract,74410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,243.1,,,,,,,fee schedule,173.64,770.39,APC
Contrst x-ray urinary tract,74410,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,303.87,,,,,,,fee schedule,173.64,770.39,APC
Contrst x-ray urinary tract,74415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,651.94,,,,,,,fee schedule,173.64,770.39,
Contrst x-ray urinary tract,74415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,522.58,,,,,,,fee schedule,173.64,770.39,
Contrst x-ray urinary tract,74415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,570.88,,,,,,,fee schedule,173.64,770.39,
Contrst x-ray urinary tract,74415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,600.2,,,,,,,fee schedule,173.64,770.39,
Contrst x-ray urinary tract,74415,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,770.39,,,,,,,fee schedule,173.64,770.39,APC 378
Contrst x-ray urinary tract,74415,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,182.32,,,,,,,fee schedule,173.64,770.39,APC
Contrst x-ray urinary tract,74415,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,180.59,,,,,,,fee schedule,173.64,770.39,APC
Contrst x-ray urinary tract,74415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,173.64,,,,,,,fee schedule,173.64,770.39,APC
Contrst x-ray urinary tract,74415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,265.67,,,,,,,fee schedule,173.64,770.39,Radiology
Contrst x-ray urinary tract,74415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,243.1,,,,,,,fee schedule,173.64,770.39,APC
Contrst x-ray urinary tract,74415,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,303.87,,,,,,,fee schedule,173.64,770.39,APC
Contrst x-ray urinary tract,74420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,338.65,,,,,,,fee schedule,271.46,1532.31,
Contrst x-ray urinary tract,74420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,271.46,,,,,,,fee schedule,271.46,1532.31,
Contrst x-ray urinary tract,74420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,296.54,,,,,,,fee schedule,271.46,1532.31,
Contrst x-ray urinary tract,74420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,311.77,,,,,,,fee schedule,271.46,1532.31,
Contrst x-ray urinary tract,74420,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1532.31,,,,,,,fee schedule,271.46,1532.31,APC 378
Contrst x-ray urinary tract,74420,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,362.64,,,,,,,fee schedule,271.46,1532.31,APC
Contrst x-ray urinary tract,74420,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,359.19,,,,,,,fee schedule,271.46,1532.31,APC
Contrst x-ray urinary tract,74420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,345.37,,,,,,,fee schedule,271.46,1532.31,APC
Contrst x-ray urinary tract,74420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,528.42,,,,,,,fee schedule,271.46,1532.31,Radiology
Contrst x-ray urinary tract,74420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,483.52,,,,,,,fee schedule,271.46,1532.31,APC
Contrst x-ray urinary tract,74420,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,604.4,,,,,,,fee schedule,271.46,1532.31,APC
Contrst x-ray urinary tract,74425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,651.94,,,,,,,fee schedule,345.37,1532.31,
Contrst x-ray urinary tract,74425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,522.58,,,,,,,fee schedule,345.37,1532.31,
Contrst x-ray urinary tract,74425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,570.88,,,,,,,fee schedule,345.37,1532.31,
Contrst x-ray urinary tract,74425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,600.2,,,,,,,fee schedule,345.37,1532.31,
Contrst x-ray urinary tract,74425,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1532.31,,,,,,,fee schedule,345.37,1532.31,APC 378
Contrst x-ray urinary tract,74425,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,362.64,,,,,,,fee schedule,345.37,1532.31,APC
Contrst x-ray urinary tract,74425,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,359.19,,,,,,,fee schedule,345.37,1532.31,APC
Contrst x-ray urinary tract,74425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,345.37,,,,,,,fee schedule,345.37,1532.31,APC
Contrst x-ray urinary tract,74425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,528.42,,,,,,,fee schedule,345.37,1532.31,Radiology
Contrst x-ray urinary tract,74425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,483.52,,,,,,,fee schedule,345.37,1532.31,APC
Contrst x-ray urinary tract,74425,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,604.4,,,,,,,fee schedule,345.37,1532.31,APC
Contrast x-ray bladder,74430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,285.31,,,,,,,fee schedule,228.7,1532.31,
Contrast x-ray bladder,74430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,228.7,,,,,,,fee schedule,228.7,1532.31,
Contrast x-ray bladder,74430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,249.84,,,,,,,fee schedule,228.7,1532.31,
Contrast x-ray bladder,74430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,262.67,,,,,,,fee schedule,228.7,1532.31,
Contrast x-ray bladder,74430,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1532.31,,,,,,,fee schedule,228.7,1532.31,APC 378
Contrast x-ray bladder,74430,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,362.64,,,,,,,fee schedule,228.7,1532.31,APC
Contrast x-ray bladder,74430,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,359.19,,,,,,,fee schedule,228.7,1532.31,APC
Contrast x-ray bladder,74430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,345.37,,,,,,,fee schedule,228.7,1532.31,APC
Contrast x-ray bladder,74430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,528.42,,,,,,,fee schedule,228.7,1532.31,Radiology
Contrast x-ray bladder,74430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,483.52,,,,,,,fee schedule,228.7,1532.31,APC
Contrast x-ray bladder,74430,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,604.4,,,,,,,fee schedule,228.7,1532.31,APC
X-ray male genital tract,74440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,651.94,,,,,,,fee schedule,236.21,1047.98,
X-ray male genital tract,74440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,522.58,,,,,,,fee schedule,236.21,1047.98,
X-ray male genital tract,74440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,570.88,,,,,,,fee schedule,236.21,1047.98,
X-ray male genital tract,74440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,600.2,,,,,,,fee schedule,236.21,1047.98,
X-ray male genital tract,74440,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,236.21,1047.98,APC 378
X-ray male genital tract,74440,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,236.21,1047.98,APC
X-ray male genital tract,74440,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,236.21,1047.98,APC
X-ray male genital tract,74440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,236.21,1047.98,APC
X-ray male genital tract,74440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,236.21,1047.98,Radiology
X-ray male genital tract,74440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,236.21,1047.98,APC
X-ray male genital tract,74440,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,236.21,1047.98,APC
X-ray exam of penis,74445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,651.94,,,,,,,fee schedule,103.5,651.94,
X-ray exam of penis,74445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,522.58,,,,,,,fee schedule,103.5,651.94,
X-ray exam of penis,74445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,570.88,,,,,,,fee schedule,103.5,651.94,
X-ray exam of penis,74445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,600.2,,,,,,,fee schedule,103.5,651.94,
X-ray exam of penis,74445,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,651.94,APC 378
X-ray exam of penis,74445,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,651.94,APC
X-ray exam of penis,74445,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,651.94,APC
X-ray exam of penis,74445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,651.94,APC
X-ray exam of penis,74445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,651.94,Radiology
X-ray exam of penis,74445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,651.94,APC
X-ray exam of penis,74445,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,651.94,APC
X-ray urethra/bladder,74450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,259.61,,,,,,,fee schedule,208.1,1047.98,
X-ray urethra/bladder,74450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,208.1,,,,,,,fee schedule,208.1,1047.98,
X-ray urethra/bladder,74450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,227.33,,,,,,,fee schedule,208.1,1047.98,
X-ray urethra/bladder,74450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,239.01,,,,,,,fee schedule,208.1,1047.98,
X-ray urethra/bladder,74450,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,208.1,1047.98,APC 378
X-ray urethra/bladder,74450,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,208.1,1047.98,APC
X-ray urethra/bladder,74450,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,208.1,1047.98,APC
X-ray urethra/bladder,74450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,208.1,1047.98,APC
X-ray urethra/bladder,74450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,208.1,1047.98,Radiology
X-ray urethra/bladder,74450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,208.1,1047.98,APC
X-ray urethra/bladder,74450,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,208.1,1047.98,APC
X-ray urethra/bladder,74455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,368.21,,,,,,,fee schedule,236.21,1047.98,
X-ray urethra/bladder,74455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,295.15,,,,,,,fee schedule,236.21,1047.98,
X-ray urethra/bladder,74455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,322.43,,,,,,,fee schedule,236.21,1047.98,
X-ray urethra/bladder,74455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,338.99,,,,,,,fee schedule,236.21,1047.98,
X-ray urethra/bladder,74455,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,236.21,1047.98,APC 378
X-ray urethra/bladder,74455,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,236.21,1047.98,APC
X-ray urethra/bladder,74455,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,236.21,1047.98,APC
X-ray urethra/bladder,74455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,236.21,1047.98,APC
X-ray urethra/bladder,74455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,236.21,1047.98,Radiology
X-ray urethra/bladder,74455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,236.21,1047.98,APC
X-ray urethra/bladder,74455,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,236.21,1047.98,APC
X-ray exam of kidney lesion,74470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,669.82,,,,,,,fee schedule,536.92,2399.94,
X-ray exam of kidney lesion,74470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,536.92,,,,,,,fee schedule,536.92,2399.94,
X-ray exam of kidney lesion,74470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,586.53,,,,,,,fee schedule,536.92,2399.94,
X-ray exam of kidney lesion,74470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,616.66,,,,,,,fee schedule,536.92,2399.94,
X-ray exam of kidney lesion,74470,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2399.94,,,,,,,fee schedule,536.92,2399.94,APC 378
X-ray exam of kidney lesion,74470,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,567.98,,,,,,,fee schedule,536.92,2399.94,APC
X-ray exam of kidney lesion,74470,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,562.57,,,,,,,fee schedule,536.92,2399.94,APC
X-ray exam of kidney lesion,74470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,540.93,,,,,,,fee schedule,536.92,2399.94,APC
X-ray exam of kidney lesion,74470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,827.63,,,,,,,fee schedule,536.92,2399.94,Radiology
X-ray exam of kidney lesion,74470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,757.31,,,,,,,fee schedule,536.92,2399.94,APC
X-ray exam of kidney lesion,74470,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,946.63,,,,,,,fee schedule,536.92,2399.94,APC
X-ray guide gu dilation,74485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1338.31,,,,,,,fee schedule,1072.77,9181.28,
X-ray guide gu dilation,74485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1072.77,,,,,,,fee schedule,1072.77,9181.28,
X-ray guide gu dilation,74485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1171.91,,,,,,,fee schedule,1072.77,9181.28,
X-ray guide gu dilation,74485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1232.09,,,,,,,fee schedule,1072.77,9181.28,
X-ray guide gu dilation,74485,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9181.28,,,,,,,fee schedule,1072.77,9181.28,APC 378
X-ray guide gu dilation,74485,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2172.88,,,,,,,fee schedule,1072.77,9181.28,APC
X-ray guide gu dilation,74485,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2152.19,,,,,,,fee schedule,1072.77,9181.28,APC
X-ray guide gu dilation,74485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2069.41,,,,,,,fee schedule,1072.77,9181.28,APC
X-ray guide gu dilation,74485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3166.2,,,,,,,fee schedule,1072.77,9181.28,Radiology
X-ray guide gu dilation,74485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2897.18,,,,,,,fee schedule,1072.77,9181.28,APC
X-ray guide gu dilation,74485,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3621.47,,,,,,,fee schedule,1072.77,9181.28,APC
X-ray measurement of pelvis,74710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,288.75,,,,,,,fee schedule,231.46,288.75,
X-ray measurement of pelvis,74710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,231.46,,,,,,,fee schedule,231.46,288.75,
X-ray measurement of pelvis,74710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,252.85,,,,,,,fee schedule,231.46,288.75,
X-ray measurement of pelvis,74710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,265.84,,,,,,,fee schedule,231.46,288.75,
Mri fetal sngl/1st gestation,74712,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1033.98,,,,,,,fee schedule,236.21,1047.98,
Mri fetal sngl/1st gestation,74712,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,828.83,,,,,,,fee schedule,236.21,1047.98,
Mri fetal sngl/1st gestation,74712,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,905.42,,,,,,,fee schedule,236.21,1047.98,
Mri fetal sngl/1st gestation,74712,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,951.92,,,,,,,fee schedule,236.21,1047.98,
Mri fetal sngl/1st gestation,74712,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,236.21,1047.98,APC 378
Mri fetal sngl/1st gestation,74712,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,236.21,1047.98,APC
Mri fetal sngl/1st gestation,74712,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,236.21,1047.98,APC
Mri fetal sngl/1st gestation,74712,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,236.21,1047.98,APC
Mri fetal sngl/1st gestation,74712,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,236.21,1047.98,Radiology
Mri fetal sngl/1st gestation,74712,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,236.21,1047.98,APC
Mri fetal sngl/1st gestation,74712,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,236.21,1047.98,APC
Mri fetal ea addl gestation,74713,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,834.06,,,,,,,fee schedule,668.57,834.06,
Mri fetal ea addl gestation,74713,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,668.57,,,,,,,fee schedule,668.57,834.06,
Mri fetal ea addl gestation,74713,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,730.35,,,,,,,fee schedule,668.57,834.06,
Mri fetal ea addl gestation,74713,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,767.86,,,,,,,fee schedule,668.57,834.06,
X-ray female genital tract,74740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,304.59,,,,,,,fee schedule,236.21,1047.98,
X-ray female genital tract,74740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,244.16,,,,,,,fee schedule,236.21,1047.98,
X-ray female genital tract,74740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,266.72,,,,,,,fee schedule,236.21,1047.98,
X-ray female genital tract,74740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,280.42,,,,,,,fee schedule,236.21,1047.98,
X-ray female genital tract,74740,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,236.21,1047.98,APC 378
X-ray female genital tract,74740,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,236.21,1047.98,APC
X-ray female genital tract,74740,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,236.21,1047.98,APC
X-ray female genital tract,74740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,236.21,1047.98,APC
X-ray female genital tract,74740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,236.21,1047.98,Radiology
X-ray female genital tract,74740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,236.21,1047.98,APC
X-ray female genital tract,74740,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,236.21,1047.98,APC
X-ray exam of perineum,74775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,651.94,,,,,,,fee schedule,236.21,1047.98,
X-ray exam of perineum,74775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,522.58,,,,,,,fee schedule,236.21,1047.98,
X-ray exam of perineum,74775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,570.88,,,,,,,fee schedule,236.21,1047.98,
X-ray exam of perineum,74775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,600.2,,,,,,,fee schedule,236.21,1047.98,
X-ray exam of perineum,74775,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,236.21,1047.98,APC 378
X-ray exam of perineum,74775,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,236.21,1047.98,APC
X-ray exam of perineum,74775,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,236.21,1047.98,APC
X-ray exam of perineum,74775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,236.21,1047.98,APC
X-ray exam of perineum,74775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,236.21,1047.98,Radiology
X-ray exam of perineum,74775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,236.21,1047.98,APC
X-ray exam of perineum,74775,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,236.21,1047.98,APC
Cardiac mri for morph,75557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,454.25,,,,,,,fee schedule,236.21,1047.98,
Cardiac mri for morph,75557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,364.12,,,,,,,fee schedule,236.21,1047.98,
Cardiac mri for morph,75557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,397.76,,,,,,,fee schedule,236.21,1047.98,
Cardiac mri for morph,75557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,418.19,,,,,,,fee schedule,236.21,1047.98,
Cardiac mri for morph,75557,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,236.21,1047.98,APC 378
Cardiac mri for morph,75557,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,236.21,1047.98,APC
Cardiac mri for morph,75557,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,236.21,1047.98,APC
Cardiac mri for morph,75557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,236.21,1047.98,APC
Cardiac mri for morph,75557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,236.21,1047.98,Radiology
Cardiac mri for morph,75557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,236.21,1047.98,APC
Cardiac mri for morph,75557,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,236.21,1047.98,APC
Cardiac mri w/stress img,75559,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1346.02,,,,,,,fee schedule,540.93,2399.94,
Cardiac mri w/stress img,75559,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1078.95,,,,,,,fee schedule,540.93,2399.94,
Cardiac mri w/stress img,75559,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1178.66,,,,,,,fee schedule,540.93,2399.94,
Cardiac mri w/stress img,75559,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1239.19,,,,,,,fee schedule,540.93,2399.94,
Cardiac mri w/stress img,75559,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2399.94,,,,,,,fee schedule,540.93,2399.94,APC 378
Cardiac mri w/stress img,75559,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,567.98,,,,,,,fee schedule,540.93,2399.94,APC
Cardiac mri w/stress img,75559,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,562.57,,,,,,,fee schedule,540.93,2399.94,APC
Cardiac mri w/stress img,75559,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,540.93,,,,,,,fee schedule,540.93,2399.94,APC
Cardiac mri w/stress img,75559,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,827.63,,,,,,,fee schedule,540.93,2399.94,Radiology
Cardiac mri w/stress img,75559,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,757.31,,,,,,,fee schedule,540.93,2399.94,APC
Cardiac mri w/stress img,75559,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,946.63,,,,,,,fee schedule,540.93,2399.94,APC
Cardiac mri for morph w/dye,75561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,614.1,,,,,,,fee schedule,345.37,1532.31,
Cardiac mri for morph w/dye,75561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,492.25,,,,,,,fee schedule,345.37,1532.31,
Cardiac mri for morph w/dye,75561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,537.74,,,,,,,fee schedule,345.37,1532.31,
Cardiac mri for morph w/dye,75561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,565.36,,,,,,,fee schedule,345.37,1532.31,
Cardiac mri for morph w/dye,75561,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1532.31,,,,,,,fee schedule,345.37,1532.31,APC 378
Cardiac mri for morph w/dye,75561,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,362.64,,,,,,,fee schedule,345.37,1532.31,APC
Cardiac mri for morph w/dye,75561,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,359.19,,,,,,,fee schedule,345.37,1532.31,APC
Cardiac mri for morph w/dye,75561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,345.37,,,,,,,fee schedule,345.37,1532.31,APC
Cardiac mri for morph w/dye,75561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,528.42,,,,,,,fee schedule,345.37,1532.31,Radiology
Cardiac mri for morph w/dye,75561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,483.52,,,,,,,fee schedule,345.37,1532.31,APC
Cardiac mri for morph w/dye,75561,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,604.4,,,,,,,fee schedule,345.37,1532.31,APC
Card mri w/stress img & dye,75563,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2058.06,,,,,,,fee schedule,776.06,3443.1,
Card mri w/stress img & dye,75563,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1649.71,,,,,,,fee schedule,776.06,3443.1,
Card mri w/stress img & dye,75563,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1802.16,,,,,,,fee schedule,776.06,3443.1,
Card mri w/stress img & dye,75563,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1894.72,,,,,,,fee schedule,776.06,3443.1,
Card mri w/stress img & dye,75563,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3443.1,,,,,,,fee schedule,776.06,3443.1,APC 378
Card mri w/stress img & dye,75563,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,814.86,,,,,,,fee schedule,776.06,3443.1,APC
Card mri w/stress img & dye,75563,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,807.1,,,,,,,fee schedule,776.06,3443.1,APC
Card mri w/stress img & dye,75563,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,776.06,,,,,,,fee schedule,776.06,3443.1,APC
Card mri w/stress img & dye,75563,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1187.37,,,,,,,fee schedule,776.06,3443.1,Radiology
Card mri w/stress img & dye,75563,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1086.48,,,,,,,fee schedule,776.06,3443.1,APC
Card mri w/stress img & dye,75563,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1358.1,,,,,,,fee schedule,776.06,3443.1,APC
Ct hrt w/o dye w/ca test,75571,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,88.15,,,,,,,fee schedule,70.66,382.23,
Ct hrt w/o dye w/ca test,75571,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,70.66,,,,,,,fee schedule,70.66,382.23,
Ct hrt w/o dye w/ca test,75571,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,77.19,,,,,,,fee schedule,70.66,382.23,
Ct hrt w/o dye w/ca test,75571,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,81.15,,,,,,,fee schedule,70.66,382.23,
Ct hrt w/o dye w/ca test,75571,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,70.66,382.23,APC 378
Ct hrt w/o dye w/ca test,75571,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,70.66,382.23,APC
Ct hrt w/o dye w/ca test,75571,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,70.66,382.23,APC
Ct hrt w/o dye w/ca test,75571,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,70.66,382.23,APC
Ct hrt w/o dye w/ca test,75571,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,70.66,382.23,Radiology
Ct hrt w/o dye w/ca test,75571,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,70.66,382.23,APC
Ct hrt w/o dye w/ca test,75571,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,70.66,382.23,APC
Ct hrt w/3d image,75572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,480.39,,,,,,,fee schedule,345.37,1532.31,
Ct hrt w/3d image,75572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,385.08,,,,,,,fee schedule,345.37,1532.31,
Ct hrt w/3d image,75572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,420.66,,,,,,,fee schedule,345.37,1532.31,
Ct hrt w/3d image,75572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,442.27,,,,,,,fee schedule,345.37,1532.31,
Ct hrt w/3d image,75572,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1532.31,,,,,,,fee schedule,345.37,1532.31,APC 378
Ct hrt w/3d image,75572,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,362.64,,,,,,,fee schedule,345.37,1532.31,APC
Ct hrt w/3d image,75572,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,359.19,,,,,,,fee schedule,345.37,1532.31,APC
Ct hrt w/3d image,75572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,345.37,,,,,,,fee schedule,345.37,1532.31,APC
Ct hrt w/3d image,75572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,528.42,,,,,,,fee schedule,345.37,1532.31,Radiology
Ct hrt w/3d image,75572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,483.52,,,,,,,fee schedule,345.37,1532.31,APC
Ct hrt w/3d image,75572,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,604.4,,,,,,,fee schedule,345.37,1532.31,APC
Ct hrt w/3d image congen,75573,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1054.62,,,,,,,fee schedule,345.37,1532.31,
Ct hrt w/3d image congen,75573,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,845.37,,,,,,,fee schedule,345.37,1532.31,
Ct hrt w/3d image congen,75573,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,923.49,,,,,,,fee schedule,345.37,1532.31,
Ct hrt w/3d image congen,75573,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,970.92,,,,,,,fee schedule,345.37,1532.31,
Ct hrt w/3d image congen,75573,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1532.31,,,,,,,fee schedule,345.37,1532.31,APC 378
Ct hrt w/3d image congen,75573,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,362.64,,,,,,,fee schedule,345.37,1532.31,APC
Ct hrt w/3d image congen,75573,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,359.19,,,,,,,fee schedule,345.37,1532.31,APC
Ct hrt w/3d image congen,75573,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,345.37,,,,,,,fee schedule,345.37,1532.31,APC
Ct hrt w/3d image congen,75573,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,528.42,,,,,,,fee schedule,345.37,1532.31,Radiology
Ct hrt w/3d image congen,75573,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,483.52,,,,,,,fee schedule,345.37,1532.31,APC
Ct hrt w/3d image congen,75573,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,604.4,,,,,,,fee schedule,345.37,1532.31,APC
Ct angio hrt w/3d image,75574,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,480.39,,,,,,,fee schedule,345.37,1532.31,
Ct angio hrt w/3d image,75574,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,385.08,,,,,,,fee schedule,345.37,1532.31,
Ct angio hrt w/3d image,75574,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,420.66,,,,,,,fee schedule,345.37,1532.31,
Ct angio hrt w/3d image,75574,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,442.27,,,,,,,fee schedule,345.37,1532.31,
Ct angio hrt w/3d image,75574,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1532.31,,,,,,,fee schedule,345.37,1532.31,APC 378
Ct angio hrt w/3d image,75574,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,362.64,,,,,,,fee schedule,345.37,1532.31,APC
Ct angio hrt w/3d image,75574,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,359.19,,,,,,,fee schedule,345.37,1532.31,APC
Ct angio hrt w/3d image,75574,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,345.37,,,,,,,fee schedule,345.37,1532.31,APC
Ct angio hrt w/3d image,75574,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,528.42,,,,,,,fee schedule,345.37,1532.31,Radiology
Ct angio hrt w/3d image,75574,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,483.52,,,,,,,fee schedule,345.37,1532.31,APC
Ct angio hrt w/3d image,75574,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,604.4,,,,,,,fee schedule,345.37,1532.31,APC
N-invas est c ffr sw aly cta,75580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3769.49,,,,,,,fee schedule,850.12,3771.72,
N-invas est c ffr sw aly cta,75580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3021.58,,,,,,,fee schedule,850.12,3771.72,
N-invas est c ffr sw aly cta,75580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3300.8,,,,,,,fee schedule,850.12,3771.72,
N-invas est c ffr sw aly cta,75580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3470.33,,,,,,,fee schedule,850.12,3771.72,
N-invas est c ffr sw aly cta,75580,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3771.72,,,,,,,fee schedule,850.12,3771.72,APC 378
N-invas est c ffr sw aly cta,75580,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,892.63,,,,,,,fee schedule,850.12,3771.72,APC
N-invas est c ffr sw aly cta,75580,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,884.13,,,,,,,fee schedule,850.12,3771.72,APC
N-invas est c ffr sw aly cta,75580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,850.12,,,,,,,fee schedule,850.12,3771.72,APC
N-invas est c ffr sw aly cta,75580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1300.69,,,,,,,fee schedule,850.12,3771.72,Radiology
N-invas est c ffr sw aly cta,75580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1190.17,,,,,,,fee schedule,850.12,3771.72,APC
N-invas est c ffr sw aly cta,75580,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1487.72,,,,,,,fee schedule,850.12,3771.72,APC
Contrast exam thoracic aorta,75600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7207.44,,,,,,,fee schedule,3125.8,13868.13,
Contrast exam thoracic aorta,75600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5777.39,,,,,,,fee schedule,3125.8,13868.13,
Contrast exam thoracic aorta,75600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6311.28,,,,,,,fee schedule,3125.8,13868.13,
Contrast exam thoracic aorta,75600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6635.42,,,,,,,fee schedule,3125.8,13868.13,
Contrast exam thoracic aorta,75600,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Contrast exam thoracic aorta,75600,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Contrast exam thoracic aorta,75600,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Contrast exam thoracic aorta,75600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Contrast exam thoracic aorta,75600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Contrast exam thoracic aorta,75600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Contrast exam thoracic aorta,75600,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Contrast exam thoracic aorta,75605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7207.44,,,,,,,fee schedule,5508.66,24440.06,
Contrast exam thoracic aorta,75605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5777.39,,,,,,,fee schedule,5508.66,24440.06,
Contrast exam thoracic aorta,75605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6311.28,,,,,,,fee schedule,5508.66,24440.06,
Contrast exam thoracic aorta,75605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6635.42,,,,,,,fee schedule,5508.66,24440.06,
Contrast exam thoracic aorta,75605,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24440.06,,,,,,,fee schedule,5508.66,24440.06,APC 378
Contrast exam thoracic aorta,75605,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5784.09,,,,,,,fee schedule,5508.66,24440.06,APC
Contrast exam thoracic aorta,75605,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5729.01,,,,,,,fee schedule,5508.66,24440.06,APC
Contrast exam thoracic aorta,75605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5508.66,,,,,,,fee schedule,5508.66,24440.06,APC
Contrast exam thoracic aorta,75605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8428.25,,,,,,,fee schedule,5508.66,24440.06,Radiology
Contrast exam thoracic aorta,75605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7712.13,,,,,,,fee schedule,5508.66,24440.06,APC
Contrast exam thoracic aorta,75605,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9640.16,,,,,,,fee schedule,5508.66,24440.06,APC
Contrast exam abdominl aorta,75625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1691.97,,,,,,,fee schedule,1356.26,13868.13,
Contrast exam abdominl aorta,75625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1356.26,,,,,,,fee schedule,1356.26,13868.13,
Contrast exam abdominl aorta,75625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1481.59,,,,,,,fee schedule,1356.26,13868.13,
Contrast exam abdominl aorta,75625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1557.68,,,,,,,fee schedule,1356.26,13868.13,
Contrast exam abdominl aorta,75625,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,1356.26,13868.13,APC 378
Contrast exam abdominl aorta,75625,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,1356.26,13868.13,APC
Contrast exam abdominl aorta,75625,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,1356.26,13868.13,APC
Contrast exam abdominl aorta,75625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,1356.26,13868.13,APC
Contrast exam abdominl aorta,75625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,1356.26,13868.13,Radiology
Contrast exam abdominl aorta,75625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,1356.26,13868.13,APC
Contrast exam abdominl aorta,75625,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,1356.26,13868.13,APC
X-ray aorta leg arteries,75630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7207.44,,,,,,,fee schedule,3125.8,13868.13,
X-ray aorta leg arteries,75630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5777.39,,,,,,,fee schedule,3125.8,13868.13,
X-ray aorta leg arteries,75630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6311.28,,,,,,,fee schedule,3125.8,13868.13,
X-ray aorta leg arteries,75630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6635.42,,,,,,,fee schedule,3125.8,13868.13,
X-ray aorta leg arteries,75630,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
X-ray aorta leg arteries,75630,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
X-ray aorta leg arteries,75630,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
X-ray aorta leg arteries,75630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
X-ray aorta leg arteries,75630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
X-ray aorta leg arteries,75630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
X-ray aorta leg arteries,75630,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Ct Angio Abdominal Arteries,75635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1493.48,,,,,,,fee schedule,173.64,1493.48,
Ct Angio Abdominal Arteries,75635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1197.16,,,,,,,fee schedule,173.64,1493.48,
Ct Angio Abdominal Arteries,75635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1307.79,,,,,,,fee schedule,173.64,1493.48,
Ct Angio Abdominal Arteries,75635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1374.95,,,,,,,fee schedule,173.64,1493.48,
Ct Angio Abdominal Arteries,75635,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,770.39,,,,,,,fee schedule,173.64,1493.48,APC 378
Ct Angio Abdominal Arteries,75635,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,182.32,,,,,,,fee schedule,173.64,1493.48,APC
Ct Angio Abdominal Arteries,75635,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,180.59,,,,,,,fee schedule,173.64,1493.48,APC
Ct Angio Abdominal Arteries,75635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,173.64,,,,,,,fee schedule,173.64,1493.48,APC
Ct Angio Abdominal Arteries,75635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,265.67,,,,,,,fee schedule,173.64,1493.48,Radiology
Ct Angio Abdominal Arteries,75635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,243.1,,,,,,,fee schedule,173.64,1493.48,APC
Ct Angio Abdominal Arteries,75635,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,303.87,,,,,,,fee schedule,173.64,1493.48,APC
Artery x-rays spine,75705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7207.44,,,,,,,fee schedule,5508.66,24440.06,
Artery x-rays spine,75705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5777.39,,,,,,,fee schedule,5508.66,24440.06,
Artery x-rays spine,75705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6311.28,,,,,,,fee schedule,5508.66,24440.06,
Artery x-rays spine,75705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6635.42,,,,,,,fee schedule,5508.66,24440.06,
Artery x-rays spine,75705,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24440.06,,,,,,,fee schedule,5508.66,24440.06,APC 378
Artery x-rays spine,75705,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5784.09,,,,,,,fee schedule,5508.66,24440.06,APC
Artery x-rays spine,75705,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5729.01,,,,,,,fee schedule,5508.66,24440.06,APC
Artery x-rays spine,75705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5508.66,,,,,,,fee schedule,5508.66,24440.06,APC
Artery x-rays spine,75705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8428.25,,,,,,,fee schedule,5508.66,24440.06,Radiology
Artery x-rays spine,75705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7712.13,,,,,,,fee schedule,5508.66,24440.06,APC
Artery x-rays spine,75705,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9640.16,,,,,,,fee schedule,5508.66,24440.06,APC
Artery x-rays arm/leg,75710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1558.95,,,,,,,fee schedule,1249.63,13868.13,
Artery x-rays arm/leg,75710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1249.63,,,,,,,fee schedule,1249.63,13868.13,
Artery x-rays arm/leg,75710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1365.11,,,,,,,fee schedule,1249.63,13868.13,
Artery x-rays arm/leg,75710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1435.22,,,,,,,fee schedule,1249.63,13868.13,
Artery x-rays arm/leg,75710,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,1249.63,13868.13,APC 378
Artery x-rays arm/leg,75710,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,1249.63,13868.13,APC
Artery x-rays arm/leg,75710,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,1249.63,13868.13,APC
Artery x-rays arm/leg,75710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,1249.63,13868.13,APC
Artery x-rays arm/leg,75710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,1249.63,13868.13,Radiology
Artery x-rays arm/leg,75710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,1249.63,13868.13,APC
Artery x-rays arm/leg,75710,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,1249.63,13868.13,APC
Artery x-rays arms/legs,75716,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7207.44,,,,,,,fee schedule,3125.8,13868.13,
Artery x-rays arms/legs,75716,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5777.39,,,,,,,fee schedule,3125.8,13868.13,
Artery x-rays arms/legs,75716,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6311.28,,,,,,,fee schedule,3125.8,13868.13,
Artery x-rays arms/legs,75716,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6635.42,,,,,,,fee schedule,3125.8,13868.13,
Artery x-rays arms/legs,75716,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Artery x-rays arms/legs,75716,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Artery x-rays arms/legs,75716,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Artery x-rays arms/legs,75716,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Artery x-rays arms/legs,75716,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Artery x-rays arms/legs,75716,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Artery x-rays arms/legs,75716,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Artery x-rays abdomen,75726,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2944.39,,,,,,,fee schedule,2360.19,24440.06,
Artery x-rays abdomen,75726,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2360.19,,,,,,,fee schedule,2360.19,24440.06,
Artery x-rays abdomen,75726,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2578.29,,,,,,,fee schedule,2360.19,24440.06,
Artery x-rays abdomen,75726,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2710.71,,,,,,,fee schedule,2360.19,24440.06,
Artery x-rays abdomen,75726,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24440.06,,,,,,,fee schedule,2360.19,24440.06,APC 378
Artery x-rays abdomen,75726,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5784.09,,,,,,,fee schedule,2360.19,24440.06,APC
Artery x-rays abdomen,75726,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5729.01,,,,,,,fee schedule,2360.19,24440.06,APC
Artery x-rays abdomen,75726,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5508.66,,,,,,,fee schedule,2360.19,24440.06,APC
Artery x-rays abdomen,75726,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8428.25,,,,,,,fee schedule,2360.19,24440.06,Radiology
Artery x-rays abdomen,75726,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7712.13,,,,,,,fee schedule,2360.19,24440.06,APC
Artery x-rays abdomen,75726,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9640.16,,,,,,,fee schedule,2360.19,24440.06,APC
Artery x-rays adrenal gland,75731,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7207.44,,,,,,,fee schedule,3125.8,13868.13,
Artery x-rays adrenal gland,75731,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5777.39,,,,,,,fee schedule,3125.8,13868.13,
Artery x-rays adrenal gland,75731,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6311.28,,,,,,,fee schedule,3125.8,13868.13,
Artery x-rays adrenal gland,75731,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6635.42,,,,,,,fee schedule,3125.8,13868.13,
Artery x-rays adrenal gland,75731,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Artery x-rays adrenal gland,75731,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Artery x-rays adrenal gland,75731,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Artery x-rays adrenal gland,75731,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Artery x-rays adrenal gland,75731,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Artery x-rays adrenal gland,75731,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Artery x-rays adrenal gland,75731,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Artery x-rays adrenals,75733,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7207.44,,,,,,,fee schedule,3125.8,13868.13,
Artery x-rays adrenals,75733,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5777.39,,,,,,,fee schedule,3125.8,13868.13,
Artery x-rays adrenals,75733,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6311.28,,,,,,,fee schedule,3125.8,13868.13,
Artery x-rays adrenals,75733,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6635.42,,,,,,,fee schedule,3125.8,13868.13,
Artery x-rays adrenals,75733,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Artery x-rays adrenals,75733,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Artery x-rays adrenals,75733,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Artery x-rays adrenals,75733,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Artery x-rays adrenals,75733,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Artery x-rays adrenals,75733,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Artery x-rays adrenals,75733,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Artery x-rays pelvis,75736,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7207.44,,,,,,,fee schedule,5508.66,24440.06,
Artery x-rays pelvis,75736,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5777.39,,,,,,,fee schedule,5508.66,24440.06,
Artery x-rays pelvis,75736,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6311.28,,,,,,,fee schedule,5508.66,24440.06,
Artery x-rays pelvis,75736,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6635.42,,,,,,,fee schedule,5508.66,24440.06,
Artery x-rays pelvis,75736,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24440.06,,,,,,,fee schedule,5508.66,24440.06,APC 378
Artery x-rays pelvis,75736,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5784.09,,,,,,,fee schedule,5508.66,24440.06,APC
Artery x-rays pelvis,75736,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5729.01,,,,,,,fee schedule,5508.66,24440.06,APC
Artery x-rays pelvis,75736,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5508.66,,,,,,,fee schedule,5508.66,24440.06,APC
Artery x-rays pelvis,75736,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8428.25,,,,,,,fee schedule,5508.66,24440.06,Radiology
Artery x-rays pelvis,75736,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7712.13,,,,,,,fee schedule,5508.66,24440.06,APC
Artery x-rays pelvis,75736,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9640.16,,,,,,,fee schedule,5508.66,24440.06,APC
Artery x-rays lung,75741,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1520.39,,,,,,,fee schedule,1218.73,13868.13,
Artery x-rays lung,75741,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1218.73,,,,,,,fee schedule,1218.73,13868.13,
Artery x-rays lung,75741,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1331.35,,,,,,,fee schedule,1218.73,13868.13,
Artery x-rays lung,75741,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1399.73,,,,,,,fee schedule,1218.73,13868.13,
Artery x-rays lung,75741,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,1218.73,13868.13,APC 378
Artery x-rays lung,75741,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,1218.73,13868.13,APC
Artery x-rays lung,75741,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,1218.73,13868.13,APC
Artery x-rays lung,75741,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,1218.73,13868.13,APC
Artery x-rays lung,75741,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,1218.73,13868.13,Radiology
Artery x-rays lung,75741,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,1218.73,13868.13,APC
Artery x-rays lung,75741,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,1218.73,13868.13,APC
Artery x-rays lungs,75743,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7207.44,,,,,,,fee schedule,3125.8,13868.13,
Artery x-rays lungs,75743,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5777.39,,,,,,,fee schedule,3125.8,13868.13,
Artery x-rays lungs,75743,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6311.28,,,,,,,fee schedule,3125.8,13868.13,
Artery x-rays lungs,75743,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6635.42,,,,,,,fee schedule,3125.8,13868.13,
Artery x-rays lungs,75743,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Artery x-rays lungs,75743,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Artery x-rays lungs,75743,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Artery x-rays lungs,75743,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Artery x-rays lungs,75743,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Artery x-rays lungs,75743,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Artery x-rays lungs,75743,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Artery x-rays lung,75746,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2333.7,,,,,,,fee schedule,1870.66,13868.13,
Artery x-rays lung,75746,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1870.66,,,,,,,fee schedule,1870.66,13868.13,
Artery x-rays lung,75746,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2043.53,,,,,,,fee schedule,1870.66,13868.13,
Artery x-rays lung,75746,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2148.48,,,,,,,fee schedule,1870.66,13868.13,
Artery x-rays lung,75746,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,1870.66,13868.13,APC 378
Artery x-rays lung,75746,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,1870.66,13868.13,APC
Artery x-rays lung,75746,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,1870.66,13868.13,APC
Artery x-rays lung,75746,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,1870.66,13868.13,APC
Artery x-rays lung,75746,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,1870.66,13868.13,Radiology
Artery x-rays lung,75746,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,1870.66,13868.13,APC
Artery x-rays lung,75746,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,1870.66,13868.13,APC
Artery x-rays chest,75756,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2333.7,,,,,,,fee schedule,1870.66,13868.13,
Artery x-rays chest,75756,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1870.66,,,,,,,fee schedule,1870.66,13868.13,
Artery x-rays chest,75756,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2043.53,,,,,,,fee schedule,1870.66,13868.13,
Artery x-rays chest,75756,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2148.48,,,,,,,fee schedule,1870.66,13868.13,
Artery x-rays chest,75756,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,1870.66,13868.13,APC 378
Artery x-rays chest,75756,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,1870.66,13868.13,APC
Artery x-rays chest,75756,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,1870.66,13868.13,APC
Artery x-rays chest,75756,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,1870.66,13868.13,APC
Artery x-rays chest,75756,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,1870.66,13868.13,Radiology
Artery x-rays chest,75756,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,1870.66,13868.13,APC
Artery x-rays chest,75756,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,1870.66,13868.13,APC
Lymph vessel x-ray arm/leg,75801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1338.31,,,,,,,fee schedule,621.01,2755.21,
Lymph vessel x-ray arm/leg,75801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1072.77,,,,,,,fee schedule,621.01,2755.21,
Lymph vessel x-ray arm/leg,75801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1171.91,,,,,,,fee schedule,621.01,2755.21,
Lymph vessel x-ray arm/leg,75801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1232.09,,,,,,,fee schedule,621.01,2755.21,
Lymph vessel x-ray arm/leg,75801,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2755.21,,,,,,,fee schedule,621.01,2755.21,APC 378
Lymph vessel x-ray arm/leg,75801,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,652.06,,,,,,,fee schedule,621.01,2755.21,APC
Lymph vessel x-ray arm/leg,75801,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,645.85,,,,,,,fee schedule,621.01,2755.21,APC
Lymph vessel x-ray arm/leg,75801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,621.01,,,,,,,fee schedule,621.01,2755.21,APC
Lymph vessel x-ray arm/leg,75801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,950.14,,,,,,,fee schedule,621.01,2755.21,Radiology
Lymph vessel x-ray arm/leg,75801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,869.41,,,,,,,fee schedule,621.01,2755.21,APC
Lymph vessel x-ray arm/leg,75801,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1086.77,,,,,,,fee schedule,621.01,2755.21,APC
Lymph vessel x-ray arms/legs,75803,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1338.31,,,,,,,fee schedule,1072.77,6913.93,
Lymph vessel x-ray arms/legs,75803,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1072.77,,,,,,,fee schedule,1072.77,6913.93,
Lymph vessel x-ray arms/legs,75803,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1171.91,,,,,,,fee schedule,1072.77,6913.93,
Lymph vessel x-ray arms/legs,75803,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1232.09,,,,,,,fee schedule,1072.77,6913.93,
Lymph vessel x-ray arms/legs,75803,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6913.93,,,,,,,fee schedule,1072.77,6913.93,APC 378
Lymph vessel x-ray arms/legs,75803,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1636.28,,,,,,,fee schedule,1072.77,6913.93,APC
Lymph vessel x-ray arms/legs,75803,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1620.7,,,,,,,fee schedule,1072.77,6913.93,APC
Lymph vessel x-ray arms/legs,75803,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1558.36,,,,,,,fee schedule,1072.77,6913.93,APC
Lymph vessel x-ray arms/legs,75803,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2384.29,,,,,,,fee schedule,1072.77,6913.93,Radiology
Lymph vessel x-ray arms/legs,75803,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2181.71,,,,,,,fee schedule,1072.77,6913.93,APC
Lymph vessel x-ray arms/legs,75803,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2727.13,,,,,,,fee schedule,1072.77,6913.93,APC
Lymph vessel x-ray trunk,75805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1338.31,,,,,,,fee schedule,1072.77,13868.13,
Lymph vessel x-ray trunk,75805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1072.77,,,,,,,fee schedule,1072.77,13868.13,
Lymph vessel x-ray trunk,75805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1171.91,,,,,,,fee schedule,1072.77,13868.13,
Lymph vessel x-ray trunk,75805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1232.09,,,,,,,fee schedule,1072.77,13868.13,
Lymph vessel x-ray trunk,75805,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,1072.77,13868.13,APC 378
Lymph vessel x-ray trunk,75805,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,1072.77,13868.13,APC
Lymph vessel x-ray trunk,75805,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,1072.77,13868.13,APC
Lymph vessel x-ray trunk,75805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,1072.77,13868.13,APC
Lymph vessel x-ray trunk,75805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,1072.77,13868.13,Radiology
Lymph vessel x-ray trunk,75805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,1072.77,13868.13,APC
Lymph vessel x-ray trunk,75805,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,1072.77,13868.13,APC
Lymph vessel x-ray trunk,75807,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1338.31,,,,,,,fee schedule,1072.77,13868.13,
Lymph vessel x-ray trunk,75807,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1072.77,,,,,,,fee schedule,1072.77,13868.13,
Lymph vessel x-ray trunk,75807,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1171.91,,,,,,,fee schedule,1072.77,13868.13,
Lymph vessel x-ray trunk,75807,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1232.09,,,,,,,fee schedule,1072.77,13868.13,
Lymph vessel x-ray trunk,75807,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,1072.77,13868.13,APC 378
Lymph vessel x-ray trunk,75807,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,1072.77,13868.13,APC
Lymph vessel x-ray trunk,75807,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,1072.77,13868.13,APC
Lymph vessel x-ray trunk,75807,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,1072.77,13868.13,APC
Lymph vessel x-ray trunk,75807,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,1072.77,13868.13,Radiology
Lymph vessel x-ray trunk,75807,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,1072.77,13868.13,APC
Lymph vessel x-ray trunk,75807,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,1072.77,13868.13,APC
Nonvascular shunt x-ray,75809,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,669.82,,,,,,,fee schedule,103.5,669.82,
Nonvascular shunt x-ray,75809,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,536.92,,,,,,,fee schedule,103.5,669.82,
Nonvascular shunt x-ray,75809,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,586.53,,,,,,,fee schedule,103.5,669.82,
Nonvascular shunt x-ray,75809,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,616.66,,,,,,,fee schedule,103.5,669.82,
Nonvascular shunt x-ray,75809,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,669.82,APC 378
Nonvascular shunt x-ray,75809,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,669.82,APC
Nonvascular shunt x-ray,75809,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,669.82,APC
Nonvascular shunt x-ray,75809,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,669.82,APC
Nonvascular shunt x-ray,75809,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,669.82,Radiology
Nonvascular shunt x-ray,75809,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,669.82,APC
Nonvascular shunt x-ray,75809,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,669.82,APC
Vein x-ray spleen/liver,75810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7207.44,,,,,,,fee schedule,3125.8,13868.13,
Vein x-ray spleen/liver,75810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5777.39,,,,,,,fee schedule,3125.8,13868.13,
Vein x-ray spleen/liver,75810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6311.28,,,,,,,fee schedule,3125.8,13868.13,
Vein x-ray spleen/liver,75810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6635.42,,,,,,,fee schedule,3125.8,13868.13,
Vein x-ray spleen/liver,75810,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Vein x-ray spleen/liver,75810,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Vein x-ray spleen/liver,75810,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Vein x-ray spleen/liver,75810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Vein x-ray spleen/liver,75810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Vein x-ray spleen/liver,75810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Vein x-ray spleen/liver,75810,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Vein x-ray arm/leg,75820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,611.76,,,,,,,fee schedule,490.38,6913.93,
Vein x-ray arm/leg,75820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,490.38,,,,,,,fee schedule,490.38,6913.93,
Vein x-ray arm/leg,75820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,535.69,,,,,,,fee schedule,490.38,6913.93,
Vein x-ray arm/leg,75820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,563.2,,,,,,,fee schedule,490.38,6913.93,
Vein x-ray arm/leg,75820,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6913.93,,,,,,,fee schedule,490.38,6913.93,APC 378
Vein x-ray arm/leg,75820,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1636.28,,,,,,,fee schedule,490.38,6913.93,APC
Vein x-ray arm/leg,75820,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1620.7,,,,,,,fee schedule,490.38,6913.93,APC
Vein x-ray arm/leg,75820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1558.36,,,,,,,fee schedule,490.38,6913.93,APC
Vein x-ray arm/leg,75820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2384.29,,,,,,,fee schedule,490.38,6913.93,Radiology
Vein x-ray arm/leg,75820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2181.71,,,,,,,fee schedule,490.38,6913.93,APC
Vein x-ray arm/leg,75820,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2727.13,,,,,,,fee schedule,490.38,6913.93,APC
Vein x-ray arms/legs,75822,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,544.28,,,,,,,fee schedule,436.29,6913.93,
Vein x-ray arms/legs,75822,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,436.29,,,,,,,fee schedule,436.29,6913.93,
Vein x-ray arms/legs,75822,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,476.61,,,,,,,fee schedule,436.29,6913.93,
Vein x-ray arms/legs,75822,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,501.09,,,,,,,fee schedule,436.29,6913.93,
Vein x-ray arms/legs,75822,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6913.93,,,,,,,fee schedule,436.29,6913.93,APC 378
Vein x-ray arms/legs,75822,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1636.28,,,,,,,fee schedule,436.29,6913.93,APC
Vein x-ray arms/legs,75822,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1620.7,,,,,,,fee schedule,436.29,6913.93,APC
Vein x-ray arms/legs,75822,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1558.36,,,,,,,fee schedule,436.29,6913.93,APC
Vein x-ray arms/legs,75822,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2384.29,,,,,,,fee schedule,436.29,6913.93,Radiology
Vein x-ray arms/legs,75822,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2181.71,,,,,,,fee schedule,436.29,6913.93,APC
Vein x-ray arms/legs,75822,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2727.13,,,,,,,fee schedule,436.29,6913.93,APC
Vein x-ray trunk,75825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7207.44,,,,,,,fee schedule,3125.8,13868.13,
Vein x-ray trunk,75825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5777.39,,,,,,,fee schedule,3125.8,13868.13,
Vein x-ray trunk,75825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6311.28,,,,,,,fee schedule,3125.8,13868.13,
Vein x-ray trunk,75825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6635.42,,,,,,,fee schedule,3125.8,13868.13,
Vein x-ray trunk,75825,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Vein x-ray trunk,75825,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Vein x-ray trunk,75825,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Vein x-ray trunk,75825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Vein x-ray trunk,75825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Vein x-ray trunk,75825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Vein x-ray trunk,75825,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Vein x-ray chest,75827,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1819.84,,,,,,,fee schedule,1458.76,6913.93,
Vein x-ray chest,75827,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1458.76,,,,,,,fee schedule,1458.76,6913.93,
Vein x-ray chest,75827,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1593.57,,,,,,,fee schedule,1458.76,6913.93,
Vein x-ray chest,75827,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1675.41,,,,,,,fee schedule,1458.76,6913.93,
Vein x-ray chest,75827,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6913.93,,,,,,,fee schedule,1458.76,6913.93,APC 378
Vein x-ray chest,75827,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1636.28,,,,,,,fee schedule,1458.76,6913.93,APC
Vein x-ray chest,75827,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1620.7,,,,,,,fee schedule,1458.76,6913.93,APC
Vein x-ray chest,75827,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1558.36,,,,,,,fee schedule,1458.76,6913.93,APC
Vein x-ray chest,75827,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2384.29,,,,,,,fee schedule,1458.76,6913.93,Radiology
Vein x-ray chest,75827,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2181.71,,,,,,,fee schedule,1458.76,6913.93,APC
Vein x-ray chest,75827,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2727.13,,,,,,,fee schedule,1458.76,6913.93,APC
Vein x-ray kidney,75831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7207.44,,,,,,,fee schedule,3125.8,13868.13,
Vein x-ray kidney,75831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5777.39,,,,,,,fee schedule,3125.8,13868.13,
Vein x-ray kidney,75831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6311.28,,,,,,,fee schedule,3125.8,13868.13,
Vein x-ray kidney,75831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6635.42,,,,,,,fee schedule,3125.8,13868.13,
Vein x-ray kidney,75831,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Vein x-ray kidney,75831,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Vein x-ray kidney,75831,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Vein x-ray kidney,75831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Vein x-ray kidney,75831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Vein x-ray kidney,75831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Vein x-ray kidney,75831,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Vein x-ray kidneys,75833,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7207.44,,,,,,,fee schedule,3125.8,13868.13,
Vein x-ray kidneys,75833,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5777.39,,,,,,,fee schedule,3125.8,13868.13,
Vein x-ray kidneys,75833,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6311.28,,,,,,,fee schedule,3125.8,13868.13,
Vein x-ray kidneys,75833,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6635.42,,,,,,,fee schedule,3125.8,13868.13,
Vein x-ray kidneys,75833,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Vein x-ray kidneys,75833,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Vein x-ray kidneys,75833,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Vein x-ray kidneys,75833,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Vein x-ray kidneys,75833,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Vein x-ray kidneys,75833,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Vein x-ray kidneys,75833,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Vein x-ray adrenal gland,75840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7207.44,,,,,,,fee schedule,3125.8,13868.13,
Vein x-ray adrenal gland,75840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5777.39,,,,,,,fee schedule,3125.8,13868.13,
Vein x-ray adrenal gland,75840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6311.28,,,,,,,fee schedule,3125.8,13868.13,
Vein x-ray adrenal gland,75840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6635.42,,,,,,,fee schedule,3125.8,13868.13,
Vein x-ray adrenal gland,75840,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Vein x-ray adrenal gland,75840,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Vein x-ray adrenal gland,75840,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Vein x-ray adrenal gland,75840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Vein x-ray adrenal gland,75840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Vein x-ray adrenal gland,75840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Vein x-ray adrenal gland,75840,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Vein x-ray adrenal glands,75842,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7207.44,,,,,,,fee schedule,5777.39,7207.44,
Vein x-ray adrenal glands,75842,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5777.39,,,,,,,fee schedule,5777.39,7207.44,
Vein x-ray adrenal glands,75842,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6311.28,,,,,,,fee schedule,5777.39,7207.44,
Vein x-ray adrenal glands,75842,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6635.42,,,,,,,fee schedule,5777.39,7207.44,
Vein x-ray neck,75860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2120.58,,,,,,,fee schedule,1699.83,13868.13,
Vein x-ray neck,75860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1699.83,,,,,,,fee schedule,1699.83,13868.13,
Vein x-ray neck,75860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1856.91,,,,,,,fee schedule,1699.83,13868.13,
Vein x-ray neck,75860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1952.28,,,,,,,fee schedule,1699.83,13868.13,
Vein x-ray neck,75860,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,1699.83,13868.13,APC 378
Vein x-ray neck,75860,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,1699.83,13868.13,APC
Vein x-ray neck,75860,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,1699.83,13868.13,APC
Vein x-ray neck,75860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,1699.83,13868.13,APC
Vein x-ray neck,75860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,1699.83,13868.13,Radiology
Vein x-ray neck,75860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,1699.83,13868.13,APC
Vein x-ray neck,75860,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,1699.83,13868.13,APC
Vein x-ray skull,75870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2333.7,,,,,,,fee schedule,1870.66,13868.13,
Vein x-ray skull,75870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1870.66,,,,,,,fee schedule,1870.66,13868.13,
Vein x-ray skull,75870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2043.53,,,,,,,fee schedule,1870.66,13868.13,
Vein x-ray skull,75870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2148.48,,,,,,,fee schedule,1870.66,13868.13,
Vein x-ray skull,75870,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,1870.66,13868.13,APC 378
Vein x-ray skull,75870,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,1870.66,13868.13,APC
Vein x-ray skull,75870,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,1870.66,13868.13,APC
Vein x-ray skull,75870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,1870.66,13868.13,APC
Vein x-ray skull,75870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,1870.66,13868.13,Radiology
Vein x-ray skull,75870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,1870.66,13868.13,APC
Vein x-ray skull,75870,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,1870.66,13868.13,APC
Vein x-ray skull epidural,75872,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2333.7,,,,,,,fee schedule,621.01,2755.21,
Vein x-ray skull epidural,75872,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1870.66,,,,,,,fee schedule,621.01,2755.21,
Vein x-ray skull epidural,75872,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2043.53,,,,,,,fee schedule,621.01,2755.21,
Vein x-ray skull epidural,75872,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2148.48,,,,,,,fee schedule,621.01,2755.21,
Vein x-ray skull epidural,75872,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2755.21,,,,,,,fee schedule,621.01,2755.21,APC 378
Vein x-ray skull epidural,75872,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,652.06,,,,,,,fee schedule,621.01,2755.21,APC
Vein x-ray skull epidural,75872,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,645.85,,,,,,,fee schedule,621.01,2755.21,APC
Vein x-ray skull epidural,75872,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,621.01,,,,,,,fee schedule,621.01,2755.21,APC
Vein x-ray skull epidural,75872,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,950.14,,,,,,,fee schedule,621.01,2755.21,Radiology
Vein x-ray skull epidural,75872,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,869.41,,,,,,,fee schedule,621.01,2755.21,APC
Vein x-ray skull epidural,75872,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1086.77,,,,,,,fee schedule,621.01,2755.21,APC
Vein x-ray eye socket,75880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2333.7,,,,,,,fee schedule,621.01,2755.21,
Vein x-ray eye socket,75880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1870.66,,,,,,,fee schedule,621.01,2755.21,
Vein x-ray eye socket,75880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2043.53,,,,,,,fee schedule,621.01,2755.21,
Vein x-ray eye socket,75880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2148.48,,,,,,,fee schedule,621.01,2755.21,
Vein x-ray eye socket,75880,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2755.21,,,,,,,fee schedule,621.01,2755.21,APC 378
Vein x-ray eye socket,75880,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,652.06,,,,,,,fee schedule,621.01,2755.21,APC
Vein x-ray eye socket,75880,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,645.85,,,,,,,fee schedule,621.01,2755.21,APC
Vein x-ray eye socket,75880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,621.01,,,,,,,fee schedule,621.01,2755.21,APC
Vein x-ray eye socket,75880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,950.14,,,,,,,fee schedule,621.01,2755.21,Radiology
Vein x-ray eye socket,75880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,869.41,,,,,,,fee schedule,621.01,2755.21,APC
Vein x-ray eye socket,75880,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1086.77,,,,,,,fee schedule,621.01,2755.21,APC
Vein x-ray liver w/hemodynam,75885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7207.44,,,,,,,fee schedule,3125.8,13868.13,
Vein x-ray liver w/hemodynam,75885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5777.39,,,,,,,fee schedule,3125.8,13868.13,
Vein x-ray liver w/hemodynam,75885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6311.28,,,,,,,fee schedule,3125.8,13868.13,
Vein x-ray liver w/hemodynam,75885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6635.42,,,,,,,fee schedule,3125.8,13868.13,
Vein x-ray liver w/hemodynam,75885,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,3125.8,13868.13,APC 378
Vein x-ray liver w/hemodynam,75885,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,3125.8,13868.13,APC
Vein x-ray liver w/hemodynam,75885,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,3125.8,13868.13,APC
Vein x-ray liver w/hemodynam,75885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,3125.8,13868.13,APC
Vein x-ray liver w/hemodynam,75885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,3125.8,13868.13,Radiology
Vein x-ray liver w/hemodynam,75885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,3125.8,13868.13,APC
Vein x-ray liver w/hemodynam,75885,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,3125.8,13868.13,APC
Vein x-ray liver w/o hemodyn,75887,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2333.7,,,,,,,fee schedule,1870.66,13868.13,
Vein x-ray liver w/o hemodyn,75887,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1870.66,,,,,,,fee schedule,1870.66,13868.13,
Vein x-ray liver w/o hemodyn,75887,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2043.53,,,,,,,fee schedule,1870.66,13868.13,
Vein x-ray liver w/o hemodyn,75887,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2148.48,,,,,,,fee schedule,1870.66,13868.13,
Vein x-ray liver w/o hemodyn,75887,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,1870.66,13868.13,APC 378
Vein x-ray liver w/o hemodyn,75887,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,1870.66,13868.13,APC
Vein x-ray liver w/o hemodyn,75887,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,1870.66,13868.13,APC
Vein x-ray liver w/o hemodyn,75887,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,1870.66,13868.13,APC
Vein x-ray liver w/o hemodyn,75887,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,1870.66,13868.13,Radiology
Vein x-ray liver w/o hemodyn,75887,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,1870.66,13868.13,APC
Vein x-ray liver w/o hemodyn,75887,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,1870.66,13868.13,APC
Vein x-ray liver w/hemodynam,75889,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1693.89,,,,,,,fee schedule,1357.8,13868.13,
Vein x-ray liver w/hemodynam,75889,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1357.8,,,,,,,fee schedule,1357.8,13868.13,
Vein x-ray liver w/hemodynam,75889,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1483.28,,,,,,,fee schedule,1357.8,13868.13,
Vein x-ray liver w/hemodynam,75889,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1559.46,,,,,,,fee schedule,1357.8,13868.13,
Vein x-ray liver w/hemodynam,75889,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,1357.8,13868.13,APC 378
Vein x-ray liver w/hemodynam,75889,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,1357.8,13868.13,APC
Vein x-ray liver w/hemodynam,75889,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,1357.8,13868.13,APC
Vein x-ray liver w/hemodynam,75889,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,1357.8,13868.13,APC
Vein x-ray liver w/hemodynam,75889,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,1357.8,13868.13,Radiology
Vein x-ray liver w/hemodynam,75889,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,1357.8,13868.13,APC
Vein x-ray liver w/hemodynam,75889,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,1357.8,13868.13,APC
Vein x-ray liver,75891,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1206.16,,,,,,,fee schedule,966.84,13868.13,
Vein x-ray liver,75891,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,966.84,,,,,,,fee schedule,966.84,13868.13,
Vein x-ray liver,75891,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1056.19,,,,,,,fee schedule,966.84,13868.13,
Vein x-ray liver,75891,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1110.43,,,,,,,fee schedule,966.84,13868.13,
Vein x-ray liver,75891,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,966.84,13868.13,APC 378
Vein x-ray liver,75891,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,966.84,13868.13,APC
Vein x-ray liver,75891,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,966.84,13868.13,APC
Vein x-ray liver,75891,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,966.84,13868.13,APC
Vein x-ray liver,75891,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,966.84,13868.13,Radiology
Vein x-ray liver,75891,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,966.84,13868.13,APC
Vein x-ray liver,75891,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,966.84,13868.13,APC
Venous sampling by catheter,75893,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2022.9,,,,,,,fee schedule,1621.53,24440.06,
Venous sampling by catheter,75893,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1621.53,,,,,,,fee schedule,1621.53,24440.06,
Venous sampling by catheter,75893,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1771.38,,,,,,,fee schedule,1621.53,24440.06,
Venous sampling by catheter,75893,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1862.36,,,,,,,fee schedule,1621.53,24440.06,
Venous sampling by catheter,75893,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24440.06,,,,,,,fee schedule,1621.53,24440.06,APC 378
Venous sampling by catheter,75893,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5784.09,,,,,,,fee schedule,1621.53,24440.06,APC
Venous sampling by catheter,75893,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5729.01,,,,,,,fee schedule,1621.53,24440.06,APC
Venous sampling by catheter,75893,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5508.66,,,,,,,fee schedule,1621.53,24440.06,APC
Venous sampling by catheter,75893,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8428.25,,,,,,,fee schedule,1621.53,24440.06,Radiology
Venous sampling by catheter,75893,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7712.13,,,,,,,fee schedule,1621.53,24440.06,APC
Venous sampling by catheter,75893,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9640.16,,,,,,,fee schedule,1621.53,24440.06,APC
Follow-up angiography,75898,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1762.65,,,,,,,fee schedule,1412.92,13868.13,
Follow-up angiography,75898,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1412.92,,,,,,,fee schedule,1412.92,13868.13,
Follow-up angiography,75898,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1543.49,,,,,,,fee schedule,1412.92,13868.13,
Follow-up angiography,75898,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1622.76,,,,,,,fee schedule,1412.92,13868.13,
Follow-up angiography,75898,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,1412.92,13868.13,APC 378
Follow-up angiography,75898,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,1412.92,13868.13,APC
Follow-up angiography,75898,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,1412.92,13868.13,APC
Follow-up angiography,75898,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,1412.92,13868.13,APC
Follow-up angiography,75898,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,1412.92,13868.13,Radiology
Follow-up angiography,75898,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,1412.92,13868.13,APC
Follow-up angiography,75898,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,1412.92,13868.13,APC
Fluoroscope examination,76000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,331.2,,,,,,,fee schedule,236.21,1047.98,
Fluoroscope examination,76000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,265.49,,,,,,,fee schedule,236.21,1047.98,
Fluoroscope examination,76000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,290.02,,,,,,,fee schedule,236.21,1047.98,
Fluoroscope examination,76000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,304.92,,,,,,,fee schedule,236.21,1047.98,
Fluoroscope examination,76000,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,236.21,1047.98,APC 378
Fluoroscope examination,76000,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,236.21,1047.98,APC
Fluoroscope examination,76000,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,236.21,1047.98,APC
Fluoroscope examination,76000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,236.21,1047.98,APC
Fluoroscope examination,76000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,236.21,1047.98,Radiology
Fluoroscope examination,76000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,236.21,1047.98,APC
Fluoroscope examination,76000,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,236.21,1047.98,APC
X-ray nose to rectum,76010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,101.53,,,,,,,fee schedule,81.39,382.23,
X-ray nose to rectum,76010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,81.39,,,,,,,fee schedule,81.39,382.23,
X-ray nose to rectum,76010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,88.91,,,,,,,fee schedule,81.39,382.23,
X-ray nose to rectum,76010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,93.47,,,,,,,fee schedule,81.39,382.23,
X-ray nose to rectum,76010,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,81.39,382.23,APC 378
X-ray nose to rectum,76010,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,81.39,382.23,APC
X-ray nose to rectum,76010,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,81.39,382.23,APC
X-ray nose to rectum,76010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,81.39,382.23,APC
X-ray nose to rectum,76010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,81.39,382.23,Radiology
X-ray nose to rectum,76010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,81.39,382.23,APC
X-ray nose to rectum,76010,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,81.39,382.23,APC
Mr sfty implt&/fb asmt stf 1,76014,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,127.04,,,,,,,fee schedule,28.63,127.04,APC 378
Mr sfty implt&/fb asmt stf 1,76014,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.07,,,,,,,fee schedule,28.63,127.04,APC
Mr sfty implt&/fb asmt stf 1,76014,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,29.78,,,,,,,fee schedule,28.63,127.04,APC
Mr sfty implt&/fb asmt stf 1,76014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,28.63,,,,,,,fee schedule,28.63,127.04,APC
Mr sfty implt&/fb asmt stf 1,76014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43.81,,,,,,,fee schedule,28.63,127.04,Radiology
Mr sfty implt&/fb asmt stf 1,76014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40.09,,,,,,,fee schedule,28.63,127.04,APC
Mr sfty implt&/fb asmt stf 1,76014,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,50.11,,,,,,,fee schedule,28.63,127.04,APC
Mr safety deter phys/qhp,76016,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
Mr safety deter phys/qhp,76016,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
Mr safety deter phys/qhp,76016,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
Mr safety deter phys/qhp,76016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
Mr safety deter phys/qhp,76016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
Mr safety deter phys/qhp,76016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
Mr safety deter phys/qhp,76016,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
Mr sfty med physics xm cstmz,76017,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,236.21,1047.98,APC 378
Mr sfty med physics xm cstmz,76017,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,236.21,1047.98,APC
Mr sfty med physics xm cstmz,76017,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,236.21,1047.98,APC
Mr sfty med physics xm cstmz,76017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,236.21,1047.98,APC
Mr sfty med physics xm cstmz,76017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,236.21,1047.98,Radiology
Mr sfty med physics xm cstmz,76017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,236.21,1047.98,APC
Mr sfty med physics xm cstmz,76017,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,236.21,1047.98,APC
Mr safety implt pos&/immoblj,76019,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,58.4,259.1,APC 378
Mr safety implt pos&/immoblj,76019,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,58.4,259.1,APC
Mr safety implt pos&/immoblj,76019,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,58.4,259.1,APC
Mr safety implt pos&/immoblj,76019,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,58.4,259.1,APC
Mr safety implt pos&/immoblj,76019,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,58.4,259.1,Radiology
Mr safety implt pos&/immoblj,76019,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,58.4,259.1,APC
Mr safety implt pos&/immoblj,76019,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,58.4,259.1,APC
X-ray exam of fistula,76080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,377.21,,,,,,,fee schedule,302.36,2399.94,
X-ray exam of fistula,76080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,302.36,,,,,,,fee schedule,302.36,2399.94,
X-ray exam of fistula,76080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,330.3,,,,,,,fee schedule,302.36,2399.94,
X-ray exam of fistula,76080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,347.27,,,,,,,fee schedule,302.36,2399.94,
X-ray exam of fistula,76080,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2399.94,,,,,,,fee schedule,302.36,2399.94,APC 378
X-ray exam of fistula,76080,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,567.98,,,,,,,fee schedule,302.36,2399.94,APC
X-ray exam of fistula,76080,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,562.57,,,,,,,fee schedule,302.36,2399.94,APC
X-ray exam of fistula,76080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,540.93,,,,,,,fee schedule,302.36,2399.94,APC
X-ray exam of fistula,76080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,827.63,,,,,,,fee schedule,302.36,2399.94,Radiology
X-ray exam of fistula,76080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,757.31,,,,,,,fee schedule,302.36,2399.94,APC
X-ray exam of fistula,76080,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,946.63,,,,,,,fee schedule,302.36,2399.94,APC
X-ray exam breast specimen,76098,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,173.54,,,,,,,fee schedule,139.11,2399.94,
X-ray exam breast specimen,76098,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,139.11,,,,,,,fee schedule,139.11,2399.94,
X-ray exam breast specimen,76098,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,151.96,,,,,,,fee schedule,139.11,2399.94,
X-ray exam breast specimen,76098,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,159.77,,,,,,,fee schedule,139.11,2399.94,
X-ray exam breast specimen,76098,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2399.94,,,,,,,fee schedule,139.11,2399.94,APC 378
X-ray exam breast specimen,76098,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,567.98,,,,,,,fee schedule,139.11,2399.94,APC
X-ray exam breast specimen,76098,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,562.57,,,,,,,fee schedule,139.11,2399.94,APC
X-ray exam breast specimen,76098,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,540.93,,,,,,,fee schedule,139.11,2399.94,APC
X-ray exam breast specimen,76098,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,827.63,,,,,,,fee schedule,139.11,2399.94,Radiology
X-ray exam breast specimen,76098,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,757.31,,,,,,,fee schedule,139.11,2399.94,APC
X-ray exam breast specimen,76098,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,946.63,,,,,,,fee schedule,139.11,2399.94,APC
X-ray exam of body section,76100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,288.75,,,,,,,fee schedule,103.5,459.18,
X-ray exam of body section,76100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,231.46,,,,,,,fee schedule,103.5,459.18,
X-ray exam of body section,76100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,252.85,,,,,,,fee schedule,103.5,459.18,
X-ray exam of body section,76100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,265.84,,,,,,,fee schedule,103.5,459.18,
X-ray exam of body section,76100,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
X-ray exam of body section,76100,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam of body section,76100,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam of body section,76100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam of body section,76100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
X-ray exam of body section,76100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
X-ray exam of body section,76100,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Cine/video x-rays,76120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,331.2,,,,,,,fee schedule,103.5,459.18,
Cine/video x-rays,76120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,265.49,,,,,,,fee schedule,103.5,459.18,
Cine/video x-rays,76120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,290.02,,,,,,,fee schedule,103.5,459.18,
Cine/video x-rays,76120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,304.92,,,,,,,fee schedule,103.5,459.18,
Cine/video x-rays,76120,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
Cine/video x-rays,76120,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
Cine/video x-rays,76120,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
Cine/video x-rays,76120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
Cine/video x-rays,76120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
Cine/video x-rays,76120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
Cine/video x-rays,76120,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Med physic dos eval rad exps,76145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,479.57,,,,,,,fee schedule,369.41,1638.96,
Med physic dos eval rad exps,76145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,384.42,,,,,,,fee schedule,369.41,1638.96,
Med physic dos eval rad exps,76145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,419.94,,,,,,,fee schedule,369.41,1638.96,
Med physic dos eval rad exps,76145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.51,,,,,,,fee schedule,369.41,1638.96,
Med physic dos eval rad exps,76145,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1638.96,,,,,,,fee schedule,369.41,1638.96,APC 378
Med physic dos eval rad exps,76145,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,387.88,,,,,,,fee schedule,369.41,1638.96,APC
Med physic dos eval rad exps,76145,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,384.19,,,,,,,fee schedule,369.41,1638.96,APC
Med physic dos eval rad exps,76145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,369.41,,,,,,,fee schedule,369.41,1638.96,APC
Med physic dos eval rad exps,76145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,565.2,,,,,,,fee schedule,369.41,1638.96,Radiology
Med physic dos eval rad exps,76145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,517.18,,,,,,,fee schedule,369.41,1638.96,APC
Med physic dos eval rad exps,76145,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,646.47,,,,,,,fee schedule,369.41,1638.96,APC
CAT scan follow-up study,76380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,183.47,,,,,,,fee schedule,86.15,382.23,
CAT scan follow-up study,76380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,147.07,,,,,,,fee schedule,86.15,382.23,
CAT scan follow-up study,76380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,160.66,,,,,,,fee schedule,86.15,382.23,
CAT scan follow-up study,76380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,168.91,,,,,,,fee schedule,86.15,382.23,
CAT scan follow-up study,76380,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
CAT scan follow-up study,76380,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
CAT scan follow-up study,76380,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
CAT scan follow-up study,76380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
CAT scan follow-up study,76380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
CAT scan follow-up study,76380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
CAT scan follow-up study,76380,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
Mr spectroscopy,76390,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
Mr spectroscopy,76390,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
Mr spectroscopy,76390,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
Mr spectroscopy,76390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
Mr spectroscopy,76390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
Mr spectroscopy,76390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
Mr spectroscopy,76390,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
Mr elastography,76391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,871.52,,,,,,,fee schedule,236.21,1047.98,
Mr elastography,76391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,698.6,,,,,,,fee schedule,236.21,1047.98,
Mr elastography,76391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,763.15,,,,,,,fee schedule,236.21,1047.98,
Mr elastography,76391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,802.35,,,,,,,fee schedule,236.21,1047.98,
Mr elastography,76391,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,236.21,1047.98,APC 378
Mr elastography,76391,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,236.21,1047.98,APC
Mr elastography,76391,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,236.21,1047.98,APC
Mr elastography,76391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,236.21,1047.98,APC
Mr elastography,76391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,236.21,1047.98,Radiology
Mr elastography,76391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,236.21,1047.98,APC
Mr elastography,76391,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,236.21,1047.98,APC
Fluoroscopic procedure,76496,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,331.2,,,,,,,fee schedule,86.15,382.23,
Fluoroscopic procedure,76496,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,265.49,,,,,,,fee schedule,86.15,382.23,
Fluoroscopic procedure,76496,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,290.02,,,,,,,fee schedule,86.15,382.23,
Fluoroscopic procedure,76496,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,304.92,,,,,,,fee schedule,86.15,382.23,
Fluoroscopic procedure,76496,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
Fluoroscopic procedure,76496,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
Fluoroscopic procedure,76496,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
Fluoroscopic procedure,76496,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
Fluoroscopic procedure,76496,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
Fluoroscopic procedure,76496,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
Fluoroscopic procedure,76496,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
Ct procedure,76497,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,395.27,,,,,,,fee schedule,86.15,395.27,
Ct procedure,76497,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,316.85,,,,,,,fee schedule,86.15,395.27,
Ct procedure,76497,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,346.13,,,,,,,fee schedule,86.15,395.27,
Ct procedure,76497,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,363.9,,,,,,,fee schedule,86.15,395.27,
Ct procedure,76497,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,395.27,APC 378
Ct procedure,76497,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,395.27,APC
Ct procedure,76497,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,395.27,APC
Ct procedure,76497,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,395.27,APC
Ct procedure,76497,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,395.27,Radiology
Ct procedure,76497,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,395.27,APC
Ct procedure,76497,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,395.27,APC
Mri procedure,76498,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1218.67,,,,,,,fee schedule,86.15,1218.67,
Mri procedure,76498,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,976.87,,,,,,,fee schedule,86.15,1218.67,
Mri procedure,76498,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1067.14,,,,,,,fee schedule,86.15,1218.67,
Mri procedure,76498,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1121.95,,,,,,,fee schedule,86.15,1218.67,
Mri procedure,76498,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,1218.67,APC 378
Mri procedure,76498,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,1218.67,APC
Mri procedure,76498,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,1218.67,APC
Mri procedure,76498,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,1218.67,APC
Mri procedure,76498,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,1218.67,Radiology
Mri procedure,76498,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,1218.67,APC
Mri procedure,76498,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,1218.67,APC
Radiographic procedure,76499,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
Radiographic procedure,76499,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
Radiographic procedure,76499,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
Radiographic procedure,76499,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
Radiographic procedure,76499,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
Radiographic procedure,76499,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
Radiographic procedure,76499,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
Echo exam of head,76506,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,234.55,,,,,,,fee schedule,103.5,459.18,
Echo exam of head,76506,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,188.01,,,,,,,fee schedule,103.5,459.18,
Echo exam of head,76506,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,205.39,,,,,,,fee schedule,103.5,459.18,
Echo exam of head,76506,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,215.93,,,,,,,fee schedule,103.5,459.18,
Echo exam of head,76506,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
Echo exam of head,76506,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
Echo exam of head,76506,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
Echo exam of head,76506,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
Echo exam of head,76506,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
Echo exam of head,76506,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
Echo exam of head,76506,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Ophth us b & quant a,76510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1277.07,,,,,,,fee schedule,131.71,1277.07,
Ophth us b & quant a,76510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1023.69,,,,,,,fee schedule,131.71,1277.07,
Ophth us b & quant a,76510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1118.28,,,,,,,fee schedule,131.71,1277.07,
Ophth us b & quant a,76510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1175.72,,,,,,,fee schedule,131.71,1277.07,
Ophth us b & quant a,76510,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,131.71,1277.07,APC 378
Ophth us b & quant a,76510,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,131.71,1277.07,APC
Ophth us b & quant a,76510,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,131.71,1277.07,APC
Ophth us b & quant a,76510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,131.71,1277.07,APC
Ophth us b & quant a,76510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,131.71,1277.07,Radiology
Ophth us b & quant a,76510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,131.71,1277.07,APC
Ophth us b & quant a,76510,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,131.71,1277.07,APC
Ophth us quant a only,76511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,376.71,,,,,,,fee schedule,103.5,459.18,
Ophth us quant a only,76511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,301.97,,,,,,,fee schedule,103.5,459.18,
Ophth us quant a only,76511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,329.87,,,,,,,fee schedule,103.5,459.18,
Ophth us quant a only,76511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,346.82,,,,,,,fee schedule,103.5,459.18,
Ophth us quant a only,76511,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
Ophth us quant a only,76511,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
Ophth us quant a only,76511,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
Ophth us quant a only,76511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
Ophth us quant a only,76511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
Ophth us quant a only,76511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
Ophth us quant a only,76511,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Ophth us b w/non-quant a,76512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,376.71,,,,,,,fee schedule,103.5,459.18,
Ophth us b w/non-quant a,76512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,301.97,,,,,,,fee schedule,103.5,459.18,
Ophth us b w/non-quant a,76512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,329.87,,,,,,,fee schedule,103.5,459.18,
Ophth us b w/non-quant a,76512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,346.82,,,,,,,fee schedule,103.5,459.18,
Ophth us b w/non-quant a,76512,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
Ophth us b w/non-quant a,76512,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
Ophth us b w/non-quant a,76512,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
Ophth us b w/non-quant a,76512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
Ophth us b w/non-quant a,76512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
Ophth us b w/non-quant a,76512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
Ophth us b w/non-quant a,76512,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Echo exam of eye water bath,76513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,376.71,,,,,,,fee schedule,103.5,459.18,
Echo exam of eye water bath,76513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,301.97,,,,,,,fee schedule,103.5,459.18,
Echo exam of eye water bath,76513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,329.87,,,,,,,fee schedule,103.5,459.18,
Echo exam of eye water bath,76513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,346.82,,,,,,,fee schedule,103.5,459.18,
Echo exam of eye water bath,76513,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
Echo exam of eye water bath,76513,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
Echo exam of eye water bath,76513,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
Echo exam of eye water bath,76513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
Echo exam of eye water bath,76513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
Echo exam of eye water bath,76513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
Echo exam of eye water bath,76513,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Echo exam of eye thickness,76514,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,147.34,,,,,,,fee schedule,28.63,147.34,
Echo exam of eye thickness,76514,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,118.11,,,,,,,fee schedule,28.63,147.34,
Echo exam of eye thickness,76514,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,129.02,,,,,,,fee schedule,28.63,147.34,
Echo exam of eye thickness,76514,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,135.65,,,,,,,fee schedule,28.63,147.34,
Echo exam of eye thickness,76514,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,127.04,,,,,,,fee schedule,28.63,147.34,APC 378
Echo exam of eye thickness,76514,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.07,,,,,,,fee schedule,28.63,147.34,APC
Echo exam of eye thickness,76514,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,29.78,,,,,,,fee schedule,28.63,147.34,APC
Echo exam of eye thickness,76514,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,28.63,,,,,,,fee schedule,28.63,147.34,APC
Echo exam of eye thickness,76514,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43.81,,,,,,,fee schedule,28.63,147.34,Radiology
Echo exam of eye thickness,76514,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40.09,,,,,,,fee schedule,28.63,147.34,APC
Echo exam of eye thickness,76514,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,50.11,,,,,,,fee schedule,28.63,147.34,APC
Echo exam of eye,76516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,238.86,,,,,,,fee schedule,103.5,459.18,
Echo exam of eye,76516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,191.47,,,,,,,fee schedule,103.5,459.18,
Echo exam of eye,76516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,209.16,,,,,,,fee schedule,103.5,459.18,
Echo exam of eye,76516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,219.9,,,,,,,fee schedule,103.5,459.18,
Echo exam of eye,76516,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
Echo exam of eye,76516,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
Echo exam of eye,76516,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
Echo exam of eye,76516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
Echo exam of eye,76516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
Echo exam of eye,76516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
Echo exam of eye,76516,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Echo exam of eye,76519,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,376.71,,,,,,,fee schedule,103.5,459.18,
Echo exam of eye,76519,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,301.97,,,,,,,fee schedule,103.5,459.18,
Echo exam of eye,76519,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,329.87,,,,,,,fee schedule,103.5,459.18,
Echo exam of eye,76519,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,346.82,,,,,,,fee schedule,103.5,459.18,
Echo exam of eye,76519,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
Echo exam of eye,76519,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
Echo exam of eye,76519,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
Echo exam of eye,76519,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
Echo exam of eye,76519,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
Echo exam of eye,76519,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
Echo exam of eye,76519,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Echo exam of eye,76529,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,238.86,,,,,,,fee schedule,86.15,382.23,
Echo exam of eye,76529,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,191.47,,,,,,,fee schedule,86.15,382.23,
Echo exam of eye,76529,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,209.16,,,,,,,fee schedule,86.15,382.23,
Echo exam of eye,76529,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,219.9,,,,,,,fee schedule,86.15,382.23,
Echo exam of eye,76529,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
Echo exam of eye,76529,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
Echo exam of eye,76529,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
Echo exam of eye,76529,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
Echo exam of eye,76529,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
Echo exam of eye,76529,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
Echo exam of eye,76529,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
Us exam of head and neck,76536,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,253.62,,,,,,,fee schedule,103.5,459.18,
Us exam of head and neck,76536,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,203.3,,,,,,,fee schedule,103.5,459.18,
Us exam of head and neck,76536,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,222.08,,,,,,,fee schedule,103.5,459.18,
Us exam of head and neck,76536,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,233.49,,,,,,,fee schedule,103.5,459.18,
Us exam of head and neck,76536,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
Us exam of head and neck,76536,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
Us exam of head and neck,76536,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
Us exam of head and neck,76536,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
Us exam of head and neck,76536,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
Us exam of head and neck,76536,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
Us exam of head and neck,76536,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Us exam chest,76604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,197.17,,,,,,,fee schedule,103.5,459.18,
Us exam chest,76604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,158.05,,,,,,,fee schedule,103.5,459.18,
Us exam chest,76604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,172.66,,,,,,,fee schedule,103.5,459.18,
Us exam chest,76604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,181.52,,,,,,,fee schedule,103.5,459.18,
Us exam chest,76604,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
Us exam chest,76604,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
Us exam chest,76604,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
Us exam chest,76604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
Us exam chest,76604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
Us exam chest,76604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
Us exam chest,76604,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Ultrasound breast complete,76641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,228.77,,,,,,,fee schedule,103.5,459.18,
Ultrasound breast complete,76641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,183.38,,,,,,,fee schedule,103.5,459.18,
Ultrasound breast complete,76641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,200.32,,,,,,,fee schedule,103.5,459.18,
Ultrasound breast complete,76641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,210.61,,,,,,,fee schedule,103.5,459.18,
Ultrasound breast complete,76641,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
Ultrasound breast complete,76641,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
Ultrasound breast complete,76641,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
Ultrasound breast complete,76641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
Ultrasound breast complete,76641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
Ultrasound breast complete,76641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
Ultrasound breast complete,76641,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Ultrasound breast limited,76642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,220.65,,,,,,,fee schedule,86.15,382.23,
Ultrasound breast limited,76642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,176.87,,,,,,,fee schedule,86.15,382.23,
Ultrasound breast limited,76642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,193.22,,,,,,,fee schedule,86.15,382.23,
Ultrasound breast limited,76642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,203.14,,,,,,,fee schedule,86.15,382.23,
Ultrasound breast limited,76642,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
Ultrasound breast limited,76642,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
Ultrasound breast limited,76642,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
Ultrasound breast limited,76642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
Ultrasound breast limited,76642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
Ultrasound breast limited,76642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
Ultrasound breast limited,76642,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
Us exam abdom complete,76700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,410.7,,,,,,,fee schedule,103.5,459.18,
Us exam abdom complete,76700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,329.21,,,,,,,fee schedule,103.5,459.18,
Us exam abdom complete,76700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,359.64,,,,,,,fee schedule,103.5,459.18,
Us exam abdom complete,76700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,378.11,,,,,,,fee schedule,103.5,459.18,
Us exam abdom complete,76700,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
Us exam abdom complete,76700,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
Us exam abdom complete,76700,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
Us exam abdom complete,76700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
Us exam abdom complete,76700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
Us exam abdom complete,76700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
Us exam abdom complete,76700,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Echo exam of abdomen,76705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,372.39,,,,,,,fee schedule,103.5,459.18,
Echo exam of abdomen,76705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,298.51,,,,,,,fee schedule,103.5,459.18,
Echo exam of abdomen,76705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,326.09,,,,,,,fee schedule,103.5,459.18,
Echo exam of abdomen,76705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,342.84,,,,,,,fee schedule,103.5,459.18,
Echo exam of abdomen,76705,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
Echo exam of abdomen,76705,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
Echo exam of abdomen,76705,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
Echo exam of abdomen,76705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
Echo exam of abdomen,76705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
Echo exam of abdomen,76705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
Echo exam of abdomen,76705,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Us abdl aorta screen aaa,76706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59.76,,,,,,,fee schedule,47.9,459.18,
Us abdl aorta screen aaa,76706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,47.9,,,,,,,fee schedule,47.9,459.18,
Us abdl aorta screen aaa,76706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52.33,,,,,,,fee schedule,47.9,459.18,
Us abdl aorta screen aaa,76706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55.02,,,,,,,fee schedule,47.9,459.18,
Us abdl aorta screen aaa,76706,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,47.9,459.18,APC 378
Us abdl aorta screen aaa,76706,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,47.9,459.18,APC
Us abdl aorta screen aaa,76706,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,47.9,459.18,APC
Us abdl aorta screen aaa,76706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,47.9,459.18,APC
Us abdl aorta screen aaa,76706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,47.9,459.18,Radiology
Us abdl aorta screen aaa,76706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,47.9,459.18,APC
Us abdl aorta screen aaa,76706,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,47.9,459.18,APC
Us exam abdo back wall comp,76770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,269.69,,,,,,,fee schedule,103.5,459.18,
Us exam abdo back wall comp,76770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,216.18,,,,,,,fee schedule,103.5,459.18,
Us exam abdo back wall comp,76770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,236.15,,,,,,,fee schedule,103.5,459.18,
Us exam abdo back wall comp,76770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,248.28,,,,,,,fee schedule,103.5,459.18,
Us exam abdo back wall comp,76770,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
Us exam abdo back wall comp,76770,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
Us exam abdo back wall comp,76770,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
Us exam abdo back wall comp,76770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
Us exam abdo back wall comp,76770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
Us exam abdo back wall comp,76770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
Us exam abdo back wall comp,76770,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Us exam abdo back wall lim,76775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,265.59,,,,,,,fee schedule,103.5,459.18,
Us exam abdo back wall lim,76775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,212.9,,,,,,,fee schedule,103.5,459.18,
Us exam abdo back wall lim,76775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,232.57,,,,,,,fee schedule,103.5,459.18,
Us exam abdo back wall lim,76775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,244.52,,,,,,,fee schedule,103.5,459.18,
Us exam abdo back wall lim,76775,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
Us exam abdo back wall lim,76775,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
Us exam abdo back wall lim,76775,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
Us exam abdo back wall lim,76775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
Us exam abdo back wall lim,76775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
Us exam abdo back wall lim,76775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
Us exam abdo back wall lim,76775,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Us exam k transpl w/doppler,76776,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,341.86,,,,,,,fee schedule,103.5,459.18,
Us exam k transpl w/doppler,76776,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,274.03,,,,,,,fee schedule,103.5,459.18,
Us exam k transpl w/doppler,76776,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,299.36,,,,,,,fee schedule,103.5,459.18,
Us exam k transpl w/doppler,76776,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,314.73,,,,,,,fee schedule,103.5,459.18,
Us exam k transpl w/doppler,76776,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
Us exam k transpl w/doppler,76776,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
Us exam k transpl w/doppler,76776,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
Us exam k transpl w/doppler,76776,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
Us exam k transpl w/doppler,76776,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
Us exam k transpl w/doppler,76776,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
Us exam k transpl w/doppler,76776,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Us exam spinal canal,76800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,136.87,,,,,,,fee schedule,103.5,459.18,
Us exam spinal canal,76800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,109.72,,,,,,,fee schedule,103.5,459.18,
Us exam spinal canal,76800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,119.86,,,,,,,fee schedule,103.5,459.18,
Us exam spinal canal,76800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,126.01,,,,,,,fee schedule,103.5,459.18,
Us exam spinal canal,76800,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
Us exam spinal canal,76800,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
Us exam spinal canal,76800,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
Us exam spinal canal,76800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
Us exam spinal canal,76800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
Us exam spinal canal,76800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
Us exam spinal canal,76800,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Ob us < 14 wks single fetus,76801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,296.08,,,,,,,fee schedule,103.5,459.18,
Ob us < 14 wks single fetus,76801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,237.33,,,,,,,fee schedule,103.5,459.18,
Ob us < 14 wks single fetus,76801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,259.26,,,,,,,fee schedule,103.5,459.18,
Ob us < 14 wks single fetus,76801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,272.58,,,,,,,fee schedule,103.5,459.18,
Ob us < 14 wks single fetus,76801,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
Ob us < 14 wks single fetus,76801,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
Ob us < 14 wks single fetus,76801,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
Ob us < 14 wks single fetus,76801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
Ob us < 14 wks single fetus,76801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
Ob us < 14 wks single fetus,76801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
Ob us < 14 wks single fetus,76801,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Ob us < 14 wks addl fetus,76802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,206.27,,,,,,,fee schedule,165.35,206.27,
Ob us < 14 wks addl fetus,76802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,165.35,,,,,,,fee schedule,165.35,206.27,
Ob us < 14 wks addl fetus,76802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,180.63,,,,,,,fee schedule,165.35,206.27,
Ob us < 14 wks addl fetus,76802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,189.9,,,,,,,fee schedule,165.35,206.27,
Ob us >/= 14 wks sngl fetus,76805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,310.98,,,,,,,fee schedule,103.5,459.18,
Ob us >/= 14 wks sngl fetus,76805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,249.28,,,,,,,fee schedule,103.5,459.18,
Ob us >/= 14 wks sngl fetus,76805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,272.32,,,,,,,fee schedule,103.5,459.18,
Ob us >/= 14 wks sngl fetus,76805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,286.3,,,,,,,fee schedule,103.5,459.18,
Ob us >/= 14 wks sngl fetus,76805,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
Ob us >/= 14 wks sngl fetus,76805,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
Ob us >/= 14 wks sngl fetus,76805,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
Ob us >/= 14 wks sngl fetus,76805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
Ob us >/= 14 wks sngl fetus,76805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
Ob us >/= 14 wks sngl fetus,76805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
Ob us >/= 14 wks sngl fetus,76805,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Ob us >/= 14 wks addl fetus,76810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,336.72,,,,,,,fee schedule,269.91,336.72,
Ob us >/= 14 wks addl fetus,76810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,269.91,,,,,,,fee schedule,269.91,336.72,
Ob us >/= 14 wks addl fetus,76810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,294.85,,,,,,,fee schedule,269.91,336.72,
Ob us >/= 14 wks addl fetus,76810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,310,,,,,,,fee schedule,269.91,336.72,
Ob us detailed sngl fetus,76811,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,593.8,,,,,,,fee schedule,236.21,1047.98,
Ob us detailed sngl fetus,76811,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,475.98,,,,,,,fee schedule,236.21,1047.98,
Ob us detailed sngl fetus,76811,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,519.97,,,,,,,fee schedule,236.21,1047.98,
Ob us detailed sngl fetus,76811,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,546.67,,,,,,,fee schedule,236.21,1047.98,
Ob us detailed sngl fetus,76811,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,236.21,1047.98,APC 378
Ob us detailed sngl fetus,76811,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,236.21,1047.98,APC
Ob us detailed sngl fetus,76811,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,236.21,1047.98,APC
Ob us detailed sngl fetus,76811,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,236.21,1047.98,APC
Ob us detailed sngl fetus,76811,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,236.21,1047.98,Radiology
Ob us detailed sngl fetus,76811,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,236.21,1047.98,APC
Ob us detailed sngl fetus,76811,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,236.21,1047.98,APC
Ob us detailed addl fetus,76812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,238.86,,,,,,,fee schedule,191.47,238.86,
Ob us detailed addl fetus,76812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,191.47,,,,,,,fee schedule,191.47,238.86,
Ob us detailed addl fetus,76812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,209.16,,,,,,,fee schedule,191.47,238.86,
Ob us detailed addl fetus,76812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,219.9,,,,,,,fee schedule,191.47,238.86,
Ob us nuchal meas 1 gest,76813,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,376.71,,,,,,,fee schedule,103.5,459.18,
Ob us nuchal meas 1 gest,76813,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,301.97,,,,,,,fee schedule,103.5,459.18,
Ob us nuchal meas 1 gest,76813,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,329.87,,,,,,,fee schedule,103.5,459.18,
Ob us nuchal meas 1 gest,76813,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,346.82,,,,,,,fee schedule,103.5,459.18,
Ob us nuchal meas 1 gest,76813,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
Ob us nuchal meas 1 gest,76813,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
Ob us nuchal meas 1 gest,76813,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
Ob us nuchal meas 1 gest,76813,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
Ob us nuchal meas 1 gest,76813,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
Ob us nuchal meas 1 gest,76813,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
Ob us nuchal meas 1 gest,76813,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Ob us nuchal meas add-on,76814,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,238.86,,,,,,,fee schedule,191.47,238.86,
Ob us nuchal meas add-on,76814,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,191.47,,,,,,,fee schedule,191.47,238.86,
Ob us nuchal meas add-on,76814,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,209.16,,,,,,,fee schedule,191.47,238.86,
Ob us nuchal meas add-on,76814,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,219.9,,,,,,,fee schedule,191.47,238.86,
Ob us limited fetus(s),76815,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,151.01,,,,,,,fee schedule,103.5,459.18,
Ob us limited fetus(s),76815,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,121.05,,,,,,,fee schedule,103.5,459.18,
Ob us limited fetus(s),76815,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,132.23,,,,,,,fee schedule,103.5,459.18,
Ob us limited fetus(s),76815,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,139.03,,,,,,,fee schedule,103.5,459.18,
Ob us limited fetus(s),76815,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
Ob us limited fetus(s),76815,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
Ob us limited fetus(s),76815,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
Ob us limited fetus(s),76815,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
Ob us limited fetus(s),76815,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
Ob us limited fetus(s),76815,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
Ob us limited fetus(s),76815,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Ob us follow-up per fetus,76816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,238.86,,,,,,,fee schedule,103.5,459.18,
Ob us follow-up per fetus,76816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,191.47,,,,,,,fee schedule,103.5,459.18,
Ob us follow-up per fetus,76816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,209.16,,,,,,,fee schedule,103.5,459.18,
Ob us follow-up per fetus,76816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,219.9,,,,,,,fee schedule,103.5,459.18,
Ob us follow-up per fetus,76816,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
Ob us follow-up per fetus,76816,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
Ob us follow-up per fetus,76816,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
Ob us follow-up per fetus,76816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
Ob us follow-up per fetus,76816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
Ob us follow-up per fetus,76816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
Ob us follow-up per fetus,76816,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Transvaginal us obstetric,76817,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,190.14,,,,,,,fee schedule,103.5,459.18,
Transvaginal us obstetric,76817,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,152.42,,,,,,,fee schedule,103.5,459.18,
Transvaginal us obstetric,76817,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,166.5,,,,,,,fee schedule,103.5,459.18,
Transvaginal us obstetric,76817,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,175.05,,,,,,,fee schedule,103.5,459.18,
Transvaginal us obstetric,76817,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
Transvaginal us obstetric,76817,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
Transvaginal us obstetric,76817,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
Transvaginal us obstetric,76817,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
Transvaginal us obstetric,76817,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
Transvaginal us obstetric,76817,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
Transvaginal us obstetric,76817,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Fetal biophys profile w/nst,76818,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,376.71,,,,,,,fee schedule,103.5,459.18,
Fetal biophys profile w/nst,76818,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,301.97,,,,,,,fee schedule,103.5,459.18,
Fetal biophys profile w/nst,76818,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,329.87,,,,,,,fee schedule,103.5,459.18,
Fetal biophys profile w/nst,76818,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,346.82,,,,,,,fee schedule,103.5,459.18,
Fetal biophys profile w/nst,76818,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
Fetal biophys profile w/nst,76818,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
Fetal biophys profile w/nst,76818,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
Fetal biophys profile w/nst,76818,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
Fetal biophys profile w/nst,76818,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
Fetal biophys profile w/nst,76818,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
Fetal biophys profile w/nst,76818,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Fetal biophys profil w/o nst,76819,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,226.2,,,,,,,fee schedule,103.5,459.18,
Fetal biophys profil w/o nst,76819,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,181.32,,,,,,,fee schedule,103.5,459.18,
Fetal biophys profil w/o nst,76819,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,198.07,,,,,,,fee schedule,103.5,459.18,
Fetal biophys profil w/o nst,76819,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,208.24,,,,,,,fee schedule,103.5,459.18,
Fetal biophys profil w/o nst,76819,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
Fetal biophys profil w/o nst,76819,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
Fetal biophys profil w/o nst,76819,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
Fetal biophys profil w/o nst,76819,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
Fetal biophys profil w/o nst,76819,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
Fetal biophys profil w/o nst,76819,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
Fetal biophys profil w/o nst,76819,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Umbilical artery echo,76820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,366.58,,,,,,,fee schedule,103.5,459.18,
Umbilical artery echo,76820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,293.85,,,,,,,fee schedule,103.5,459.18,
Umbilical artery echo,76820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,321,,,,,,,fee schedule,103.5,459.18,
Umbilical artery echo,76820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,337.49,,,,,,,fee schedule,103.5,459.18,
Umbilical artery echo,76820,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
Umbilical artery echo,76820,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
Umbilical artery echo,76820,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
Umbilical artery echo,76820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
Umbilical artery echo,76820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
Umbilical artery echo,76820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
Umbilical artery echo,76820,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Middle cerebral artery echo,76821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,366.58,,,,,,,fee schedule,103.5,459.18,
Middle cerebral artery echo,76821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,293.85,,,,,,,fee schedule,103.5,459.18,
Middle cerebral artery echo,76821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,321,,,,,,,fee schedule,103.5,459.18,
Middle cerebral artery echo,76821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,337.49,,,,,,,fee schedule,103.5,459.18,
Middle cerebral artery echo,76821,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
Middle cerebral artery echo,76821,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
Middle cerebral artery echo,76821,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
Middle cerebral artery echo,76821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
Middle cerebral artery echo,76821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
Middle cerebral artery echo,76821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
Middle cerebral artery echo,76821,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Echo exam of fetal heart,76825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,376.71,,,,,,,fee schedule,301.97,2399.94,
Echo exam of fetal heart,76825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,301.97,,,,,,,fee schedule,301.97,2399.94,
Echo exam of fetal heart,76825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,329.87,,,,,,,fee schedule,301.97,2399.94,
Echo exam of fetal heart,76825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,346.82,,,,,,,fee schedule,301.97,2399.94,
Echo exam of fetal heart,76825,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2399.94,,,,,,,fee schedule,301.97,2399.94,APC 378
Echo exam of fetal heart,76825,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,567.98,,,,,,,fee schedule,301.97,2399.94,APC
Echo exam of fetal heart,76825,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,562.57,,,,,,,fee schedule,301.97,2399.94,APC
Echo exam of fetal heart,76825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,540.93,,,,,,,fee schedule,301.97,2399.94,APC
Echo exam of fetal heart,76825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,827.63,,,,,,,fee schedule,301.97,2399.94,Radiology
Echo exam of fetal heart,76825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,757.31,,,,,,,fee schedule,301.97,2399.94,APC
Echo exam of fetal heart,76825,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,946.63,,,,,,,fee schedule,301.97,2399.94,APC
Echo exam of fetal heart,76826,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,238.86,,,,,,,fee schedule,191.47,1047.98,
Echo exam of fetal heart,76826,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,191.47,,,,,,,fee schedule,191.47,1047.98,
Echo exam of fetal heart,76826,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,209.16,,,,,,,fee schedule,191.47,1047.98,
Echo exam of fetal heart,76826,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,219.9,,,,,,,fee schedule,191.47,1047.98,
Echo exam of fetal heart,76826,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,191.47,1047.98,APC 378
Echo exam of fetal heart,76826,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,191.47,1047.98,APC
Echo exam of fetal heart,76826,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,191.47,1047.98,APC
Echo exam of fetal heart,76826,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,191.47,1047.98,APC
Echo exam of fetal heart,76826,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,191.47,1047.98,Radiology
Echo exam of fetal heart,76826,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,191.47,1047.98,APC
Echo exam of fetal heart,76826,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,191.47,1047.98,APC
Echo exam of fetal heart,76827,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,238.86,,,,,,,fee schedule,103.5,459.18,
Echo exam of fetal heart,76827,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,191.47,,,,,,,fee schedule,103.5,459.18,
Echo exam of fetal heart,76827,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,209.16,,,,,,,fee schedule,103.5,459.18,
Echo exam of fetal heart,76827,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,219.9,,,,,,,fee schedule,103.5,459.18,
Echo exam of fetal heart,76827,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
Echo exam of fetal heart,76827,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
Echo exam of fetal heart,76827,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
Echo exam of fetal heart,76827,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
Echo exam of fetal heart,76827,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
Echo exam of fetal heart,76827,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
Echo exam of fetal heart,76827,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Echo exam of fetal heart,76828,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,238.86,,,,,,,fee schedule,103.5,459.18,
Echo exam of fetal heart,76828,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,191.47,,,,,,,fee schedule,103.5,459.18,
Echo exam of fetal heart,76828,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,209.16,,,,,,,fee schedule,103.5,459.18,
Echo exam of fetal heart,76828,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,219.9,,,,,,,fee schedule,103.5,459.18,
Echo exam of fetal heart,76828,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
Echo exam of fetal heart,76828,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
Echo exam of fetal heart,76828,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
Echo exam of fetal heart,76828,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
Echo exam of fetal heart,76828,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
Echo exam of fetal heart,76828,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
Echo exam of fetal heart,76828,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Transvaginal us non-ob,76830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,320.61,,,,,,,fee schedule,103.5,459.18,
Transvaginal us non-ob,76830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,257,,,,,,,fee schedule,103.5,459.18,
Transvaginal us non-ob,76830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,280.74,,,,,,,fee schedule,103.5,459.18,
Transvaginal us non-ob,76830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,295.16,,,,,,,fee schedule,103.5,459.18,
Transvaginal us non-ob,76830,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
Transvaginal us non-ob,76830,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
Transvaginal us non-ob,76830,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
Transvaginal us non-ob,76830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
Transvaginal us non-ob,76830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
Transvaginal us non-ob,76830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
Transvaginal us non-ob,76830,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Echo exam uterus,76831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,249.33,,,,,,,fee schedule,199.86,1047.98,
Echo exam uterus,76831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,199.86,,,,,,,fee schedule,199.86,1047.98,
Echo exam uterus,76831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,218.33,,,,,,,fee schedule,199.86,1047.98,
Echo exam uterus,76831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,229.54,,,,,,,fee schedule,199.86,1047.98,
Echo exam uterus,76831,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,199.86,1047.98,APC 378
Echo exam uterus,76831,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,199.86,1047.98,APC
Echo exam uterus,76831,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,199.86,1047.98,APC
Echo exam uterus,76831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,199.86,1047.98,APC
Echo exam uterus,76831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,199.86,1047.98,Radiology
Echo exam uterus,76831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,199.86,1047.98,APC
Echo exam uterus,76831,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,199.86,1047.98,APC
Us exam pelvic complete,76856,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,339.56,,,,,,,fee schedule,103.5,459.18,
Us exam pelvic complete,76856,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,272.18,,,,,,,fee schedule,103.5,459.18,
Us exam pelvic complete,76856,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,297.34,,,,,,,fee schedule,103.5,459.18,
Us exam pelvic complete,76856,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,312.61,,,,,,,fee schedule,103.5,459.18,
Us exam pelvic complete,76856,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
Us exam pelvic complete,76856,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
Us exam pelvic complete,76856,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
Us exam pelvic complete,76856,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
Us exam pelvic complete,76856,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
Us exam pelvic complete,76856,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
Us exam pelvic complete,76856,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Us exam pelvic limited,76857,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,183.95,,,,,,,fee schedule,103.5,459.18,
Us exam pelvic limited,76857,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,147.46,,,,,,,fee schedule,103.5,459.18,
Us exam pelvic limited,76857,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,161.08,,,,,,,fee schedule,103.5,459.18,
Us exam pelvic limited,76857,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,169.35,,,,,,,fee schedule,103.5,459.18,
Us exam pelvic limited,76857,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
Us exam pelvic limited,76857,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
Us exam pelvic limited,76857,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
Us exam pelvic limited,76857,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
Us exam pelvic limited,76857,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
Us exam pelvic limited,76857,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
Us exam pelvic limited,76857,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Us exam scrotum,76870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,220.46,,,,,,,fee schedule,103.5,459.18,
Us exam scrotum,76870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,176.72,,,,,,,fee schedule,103.5,459.18,
Us exam scrotum,76870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,193.05,,,,,,,fee schedule,103.5,459.18,
Us exam scrotum,76870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,202.96,,,,,,,fee schedule,103.5,459.18,
Us exam scrotum,76870,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
Us exam scrotum,76870,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
Us exam scrotum,76870,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
Us exam scrotum,76870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
Us exam scrotum,76870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
Us exam scrotum,76870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
Us exam scrotum,76870,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Us transrectal,76872,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,326.44,,,,,,,fee schedule,103.5,459.18,
Us transrectal,76872,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,261.67,,,,,,,fee schedule,103.5,459.18,
Us transrectal,76872,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,285.85,,,,,,,fee schedule,103.5,459.18,
Us transrectal,76872,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,300.53,,,,,,,fee schedule,103.5,459.18,
Us transrectal,76872,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
Us transrectal,76872,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
Us transrectal,76872,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
Us transrectal,76872,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
Us transrectal,76872,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
Us transrectal,76872,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
Us transrectal,76872,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Echograp trans r pros study,76873,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,376.71,,,,,,,fee schedule,103.5,459.18,
Echograp trans r pros study,76873,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,301.97,,,,,,,fee schedule,103.5,459.18,
Echograp trans r pros study,76873,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,329.87,,,,,,,fee schedule,103.5,459.18,
Echograp trans r pros study,76873,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,346.82,,,,,,,fee schedule,103.5,459.18,
Echograp trans r pros study,76873,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
Echograp trans r pros study,76873,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
Echograp trans r pros study,76873,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
Echograp trans r pros study,76873,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
Echograp trans r pros study,76873,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
Echograp trans r pros study,76873,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
Echograp trans r pros study,76873,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Us xtr non-vasc complete,76881,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,90.29,,,,,,,fee schedule,72.37,459.18,
Us xtr non-vasc complete,76881,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,72.37,,,,,,,fee schedule,72.37,459.18,
Us xtr non-vasc complete,76881,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,79.06,,,,,,,fee schedule,72.37,459.18,
Us xtr non-vasc complete,76881,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83.12,,,,,,,fee schedule,72.37,459.18,
Us xtr non-vasc complete,76881,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,72.37,459.18,APC 378
Us xtr non-vasc complete,76881,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,72.37,459.18,APC
Us xtr non-vasc complete,76881,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,72.37,459.18,APC
Us xtr non-vasc complete,76881,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,72.37,459.18,APC
Us xtr non-vasc complete,76881,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,72.37,459.18,Radiology
Us xtr non-vasc complete,76881,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,72.37,459.18,APC
Us xtr non-vasc complete,76881,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,72.37,459.18,APC
Us xtr non-vasc lmtd,76882,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,52.21,,,,,,,fee schedule,41.85,459.18,
Us xtr non-vasc lmtd,76882,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,41.85,,,,,,,fee schedule,41.85,459.18,
Us xtr non-vasc lmtd,76882,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,45.72,,,,,,,fee schedule,41.85,459.18,
Us xtr non-vasc lmtd,76882,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,48.06,,,,,,,fee schedule,41.85,459.18,
Us xtr non-vasc lmtd,76882,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,41.85,459.18,APC 378
Us xtr non-vasc lmtd,76882,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,41.85,459.18,APC
Us xtr non-vasc lmtd,76882,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,41.85,459.18,APC
Us xtr non-vasc lmtd,76882,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,41.85,459.18,APC
Us xtr non-vasc lmtd,76882,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,41.85,459.18,Radiology
Us xtr non-vasc lmtd,76882,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,41.85,459.18,APC
Us xtr non-vasc lmtd,76882,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,41.85,459.18,APC
Us nrv&acc strux 1xtr compre,76883,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,404.01,,,,,,,fee schedule,103.5,459.18,
Us nrv&acc strux 1xtr compre,76883,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,323.85,,,,,,,fee schedule,103.5,459.18,
Us nrv&acc strux 1xtr compre,76883,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.77,,,,,,,fee schedule,103.5,459.18,
Us nrv&acc strux 1xtr compre,76883,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,371.94,,,,,,,fee schedule,103.5,459.18,
Us nrv&acc strux 1xtr compre,76883,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
Us nrv&acc strux 1xtr compre,76883,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
Us nrv&acc strux 1xtr compre,76883,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
Us nrv&acc strux 1xtr compre,76883,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
Us nrv&acc strux 1xtr compre,76883,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
Us nrv&acc strux 1xtr compre,76883,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
Us nrv&acc strux 1xtr compre,76883,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Us exam infant hips dynamic,76885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,266.68,,,,,,,fee schedule,86.15,382.23,
Us exam infant hips dynamic,76885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,213.77,,,,,,,fee schedule,86.15,382.23,
Us exam infant hips dynamic,76885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,233.52,,,,,,,fee schedule,86.15,382.23,
Us exam infant hips dynamic,76885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,245.51,,,,,,,fee schedule,86.15,382.23,
Us exam infant hips dynamic,76885,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
Us exam infant hips dynamic,76885,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
Us exam infant hips dynamic,76885,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
Us exam infant hips dynamic,76885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
Us exam infant hips dynamic,76885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
Us exam infant hips dynamic,76885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
Us exam infant hips dynamic,76885,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
Us exam infant hips static,76886,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,238.86,,,,,,,fee schedule,86.15,382.23,
Us exam infant hips static,76886,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,191.47,,,,,,,fee schedule,86.15,382.23,
Us exam infant hips static,76886,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,209.16,,,,,,,fee schedule,86.15,382.23,
Us exam infant hips static,76886,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,219.9,,,,,,,fee schedule,86.15,382.23,
Us exam infant hips static,76886,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
Us exam infant hips static,76886,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
Us exam infant hips static,76886,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
Us exam infant hips static,76886,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
Us exam infant hips static,76886,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
Us exam infant hips static,76886,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
Us exam infant hips static,76886,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
Echo guide for artery repair,76936,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,878.13,,,,,,,fee schedule,213.76,948.37,
Echo guide for artery repair,76936,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,703.9,,,,,,,fee schedule,213.76,948.37,
Echo guide for artery repair,76936,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,768.95,,,,,,,fee schedule,213.76,948.37,
Echo guide for artery repair,76936,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,808.44,,,,,,,fee schedule,213.76,948.37,
Echo guide for artery repair,76936,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,213.76,948.37,APC 378
Echo guide for artery repair,76936,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,213.76,948.37,APC
Echo guide for artery repair,76936,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,213.76,948.37,APC
Echo guide for artery repair,76936,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,213.76,948.37,APC
Echo guide for artery repair,76936,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,213.76,948.37,Radiology
Echo guide for artery repair,76936,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,213.76,948.37,APC
Echo guide for artery repair,76936,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,213.76,948.37,APC
GI endoscopic ultrasound,76975,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,593.8,,,,,,,fee schedule,236.21,1047.98,
GI endoscopic ultrasound,76975,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,475.98,,,,,,,fee schedule,236.21,1047.98,
GI endoscopic ultrasound,76975,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,519.97,,,,,,,fee schedule,236.21,1047.98,
GI endoscopic ultrasound,76975,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,546.67,,,,,,,fee schedule,236.21,1047.98,
GI endoscopic ultrasound,76975,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,236.21,1047.98,APC 378
GI endoscopic ultrasound,76975,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,236.21,1047.98,APC
GI endoscopic ultrasound,76975,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,236.21,1047.98,APC
GI endoscopic ultrasound,76975,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,236.21,1047.98,APC
GI endoscopic ultrasound,76975,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,236.21,1047.98,Radiology
GI endoscopic ultrasound,76975,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,236.21,1047.98,APC
GI endoscopic ultrasound,76975,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,236.21,1047.98,APC
Us bone density measure,76977,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,157.47,,,,,,,fee schedule,103.5,459.18,
Us bone density measure,76977,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,126.23,,,,,,,fee schedule,103.5,459.18,
Us bone density measure,76977,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,137.89,,,,,,,fee schedule,103.5,459.18,
Us bone density measure,76977,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,144.98,,,,,,,fee schedule,103.5,459.18,
Us bone density measure,76977,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
Us bone density measure,76977,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
Us bone density measure,76977,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
Us bone density measure,76977,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
Us bone density measure,76977,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
Us bone density measure,76977,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
Us bone density measure,76977,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Us trgt dyn mbubb 1st les,76978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,762.58,,,,,,,fee schedule,345.37,1532.31,
Us trgt dyn mbubb 1st les,76978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,611.27,,,,,,,fee schedule,345.37,1532.31,
Us trgt dyn mbubb 1st les,76978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,667.76,,,,,,,fee schedule,345.37,1532.31,
Us trgt dyn mbubb 1st les,76978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,702.06,,,,,,,fee schedule,345.37,1532.31,
Us trgt dyn mbubb 1st les,76978,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1532.31,,,,,,,fee schedule,345.37,1532.31,APC 378
Us trgt dyn mbubb 1st les,76978,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,362.64,,,,,,,fee schedule,345.37,1532.31,APC
Us trgt dyn mbubb 1st les,76978,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,359.19,,,,,,,fee schedule,345.37,1532.31,APC
Us trgt dyn mbubb 1st les,76978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,345.37,,,,,,,fee schedule,345.37,1532.31,APC
Us trgt dyn mbubb 1st les,76978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,528.42,,,,,,,fee schedule,345.37,1532.31,Radiology
Us trgt dyn mbubb 1st les,76978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,483.52,,,,,,,fee schedule,345.37,1532.31,APC
Us trgt dyn mbubb 1st les,76978,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,604.4,,,,,,,fee schedule,345.37,1532.31,APC
Us trgt dyn mbubb ea addl,76979,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,163.07,,,,,,,fee schedule,130.71,163.07,
Us trgt dyn mbubb ea addl,76979,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,130.71,,,,,,,fee schedule,130.71,163.07,
Us trgt dyn mbubb ea addl,76979,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,142.79,,,,,,,fee schedule,130.71,163.07,
Us trgt dyn mbubb ea addl,76979,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,150.13,,,,,,,fee schedule,130.71,163.07,
Use parenchyma,76981,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,425.29,,,,,,,fee schedule,103.5,459.18,
Use parenchyma,76981,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,340.91,,,,,,,fee schedule,103.5,459.18,
Use parenchyma,76981,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,372.41,,,,,,,fee schedule,103.5,459.18,
Use parenchyma,76981,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,391.53,,,,,,,fee schedule,103.5,459.18,
Use parenchyma,76981,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
Use parenchyma,76981,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
Use parenchyma,76981,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
Use parenchyma,76981,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
Use parenchyma,76981,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
Use parenchyma,76981,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
Use parenchyma,76981,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Use 1st target lesion,76982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,425.29,,,,,,,fee schedule,103.5,459.18,
Use 1st target lesion,76982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,340.91,,,,,,,fee schedule,103.5,459.18,
Use 1st target lesion,76982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,372.41,,,,,,,fee schedule,103.5,459.18,
Use 1st target lesion,76982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,391.53,,,,,,,fee schedule,103.5,459.18,
Use 1st target lesion,76982,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
Use 1st target lesion,76982,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
Use 1st target lesion,76982,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
Use 1st target lesion,76982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
Use 1st target lesion,76982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
Use 1st target lesion,76982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
Use 1st target lesion,76982,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Use ea addl target lesion,76983,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,94.35,,,,,,,fee schedule,75.63,94.35,
Use ea addl target lesion,76983,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,75.63,,,,,,,fee schedule,75.63,94.35,
Use ea addl target lesion,76983,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,82.62,,,,,,,fee schedule,75.63,94.35,
Use ea addl target lesion,76983,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,86.86,,,,,,,fee schedule,75.63,94.35,
Echo examination procedure,76999,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
Echo examination procedure,76999,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
Echo examination procedure,76999,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
Echo examination procedure,76999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
Echo examination procedure,76999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
Echo examination procedure,76999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
Echo examination procedure,76999,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
Fluoroguide for Vein Device,77001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,358.23,,,,,,,fee schedule,287.15,358.23,
Fluoroguide for Vein Device,77001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,287.15,,,,,,,fee schedule,287.15,358.23,
Fluoroguide for Vein Device,77001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,313.69,,,,,,,fee schedule,287.15,358.23,
Fluoroguide for Vein Device,77001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,329.8,,,,,,,fee schedule,287.15,358.23,
Needle localization by xray,77002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,248.46,,,,,,,fee schedule,199.16,248.46,
Needle localization by xray,77002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,199.16,,,,,,,fee schedule,199.16,248.46,
Needle localization by xray,77002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,217.57,,,,,,,fee schedule,199.16,248.46,
Needle localization by xray,77002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,228.74,,,,,,,fee schedule,199.16,248.46,
Fluoroguide for Spine Inject,77003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,210.81,,,,,,,fee schedule,168.98,210.81,
Fluoroguide for Spine Inject,77003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,168.98,,,,,,,fee schedule,168.98,210.81,
Fluoroguide for Spine Inject,77003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,184.6,,,,,,,fee schedule,168.98,210.81,
Fluoroguide for Spine Inject,77003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,194.08,,,,,,,fee schedule,168.98,210.81,
Mri breast c- unilateral,77046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,871.52,,,,,,,fee schedule,236.21,1047.98,
Mri breast c- unilateral,77046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,698.6,,,,,,,fee schedule,236.21,1047.98,
Mri breast c- unilateral,77046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,763.15,,,,,,,fee schedule,236.21,1047.98,
Mri breast c- unilateral,77046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,802.35,,,,,,,fee schedule,236.21,1047.98,
Mri breast c- unilateral,77046,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,236.21,1047.98,APC 378
Mri breast c- unilateral,77046,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,236.21,1047.98,APC
Mri breast c- unilateral,77046,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,236.21,1047.98,APC
Mri breast c- unilateral,77046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,236.21,1047.98,APC
Mri breast c- unilateral,77046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,236.21,1047.98,Radiology
Mri breast c- unilateral,77046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,236.21,1047.98,APC
Mri breast c- unilateral,77046,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,236.21,1047.98,APC
Mri breast c- bilateral,77047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,871.52,,,,,,,fee schedule,236.21,1047.98,
Mri breast c- bilateral,77047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,698.6,,,,,,,fee schedule,236.21,1047.98,
Mri breast c- bilateral,77047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,763.15,,,,,,,fee schedule,236.21,1047.98,
Mri breast c- bilateral,77047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,802.35,,,,,,,fee schedule,236.21,1047.98,
Mri breast c- bilateral,77047,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,236.21,1047.98,APC 378
Mri breast c- bilateral,77047,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,236.21,1047.98,APC
Mri breast c- bilateral,77047,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,236.21,1047.98,APC
Mri breast c- bilateral,77047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,236.21,1047.98,APC
Mri breast c- bilateral,77047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,236.21,1047.98,Radiology
Mri breast c- bilateral,77047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,236.21,1047.98,APC
Mri breast c- bilateral,77047,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,236.21,1047.98,APC
Mri breast c-+ w/cad uni,77048,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,395.05,,,,,,,fee schedule,316.67,395.05,
Mri breast c-+ w/cad uni,77048,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,316.67,,,,,,,fee schedule,316.67,395.05,
Mri breast c-+ w/cad uni,77048,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,345.93,,,,,,,fee schedule,316.67,395.05,
Mri breast c-+ w/cad uni,77048,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,363.69,,,,,,,fee schedule,316.67,395.05,
Mri breast c-+ w/cad bi,77049,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,434.02,,,,,,,fee schedule,347.9,434.02,
Mri breast c-+ w/cad bi,77049,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,347.9,,,,,,,fee schedule,347.9,434.02,
Mri breast c-+ w/cad bi,77049,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,380.05,,,,,,,fee schedule,347.9,434.02,
Mri breast c-+ w/cad bi,77049,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,399.57,,,,,,,fee schedule,347.9,434.02,
X-Ray of Mammary Duct,77053,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,669.82,,,,,,,fee schedule,236.21,1047.98,
X-Ray of Mammary Duct,77053,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,536.92,,,,,,,fee schedule,236.21,1047.98,
X-Ray of Mammary Duct,77053,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,586.53,,,,,,,fee schedule,236.21,1047.98,
X-Ray of Mammary Duct,77053,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,616.66,,,,,,,fee schedule,236.21,1047.98,
X-Ray of Mammary Duct,77053,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,236.21,1047.98,APC 378
X-Ray of Mammary Duct,77053,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,236.21,1047.98,APC
X-Ray of Mammary Duct,77053,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,236.21,1047.98,APC
X-Ray of Mammary Duct,77053,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,236.21,1047.98,APC
X-Ray of Mammary Duct,77053,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,236.21,1047.98,Radiology
X-Ray of Mammary Duct,77053,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,236.21,1047.98,APC
X-Ray of Mammary Duct,77053,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,236.21,1047.98,APC
X-ray of mammary ducts,77054,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,669.82,,,,,,,fee schedule,236.21,1047.98,
X-ray of mammary ducts,77054,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,536.92,,,,,,,fee schedule,236.21,1047.98,
X-ray of mammary ducts,77054,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,586.53,,,,,,,fee schedule,236.21,1047.98,
X-ray of mammary ducts,77054,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,616.66,,,,,,,fee schedule,236.21,1047.98,
X-ray of mammary ducts,77054,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,236.21,1047.98,APC 378
X-ray of mammary ducts,77054,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,236.21,1047.98,APC
X-ray of mammary ducts,77054,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,236.21,1047.98,APC
X-ray of mammary ducts,77054,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,236.21,1047.98,APC
X-ray of mammary ducts,77054,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,236.21,1047.98,Radiology
X-ray of mammary ducts,77054,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,236.21,1047.98,APC
X-ray of mammary ducts,77054,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,236.21,1047.98,APC
Breast tomosynthesis bi,77063,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,202.87,,,,,,,fee schedule,162.62,202.87,
Breast tomosynthesis bi,77063,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,162.62,,,,,,,fee schedule,162.62,202.87,
Breast tomosynthesis bi,77063,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,177.65,,,,,,,fee schedule,162.62,202.87,
Breast tomosynthesis bi,77063,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,186.77,,,,,,,fee schedule,162.62,202.87,
Breast tomosynthesis bi,77063,HCPCS,,,,,,,facility,outpatient,,,TC,,,Unitedhealthcare,All Commercial Plans,21.44,,,,,,,fee schedule,21.44,37.52,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Breast tomosynthesis bi,77063,HCPCS,,,,,,,facility,outpatient,,,TC,,,Aetna,Medicare Managed Care Plan,22.51,,,,,,,fee schedule,21.44,37.52,APC
Breast tomosynthesis bi,77063,HCPCS,,,,,,,facility,outpatient,,,TC,,,Bcbs,Medicare Managed Care Plan,22.3,,,,,,,fee schedule,21.44,37.52,APC
Breast tomosynthesis bi,77063,HCPCS,,,,,,,facility,outpatient,,,TC,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,32.8,,,,,,,fee schedule,21.44,37.52,Radiology
Breast tomosynthesis bi,77063,HCPCS,,,,,,,facility,outpatient,,,TC,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,30.02,,,,,,,fee schedule,21.44,37.52,APC
Breast tomosynthesis bi,77063,HCPCS,,,,,,,facility,outpatient,,,TC,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,37.52,,,,,,,fee schedule,21.44,37.52,APC
Dx mammo incl cad uni,77065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,161.36,,,,,,,fee schedule,129.35,161.36,
Dx mammo incl cad uni,77065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,129.35,,,,,,,fee schedule,129.35,161.36,
Dx mammo incl cad uni,77065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,141.3,,,,,,,fee schedule,129.35,161.36,
Dx mammo incl cad uni,77065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,148.56,,,,,,,fee schedule,129.35,161.36,
Dx mammo incl cad uni,77065,HCPCS,,,,,,,facility,outpatient,,,TC,,,Unitedhealthcare,All Commercial Plans,79.12,,,,,,,fee schedule,79.12,138.46,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Dx mammo incl cad uni,77065,HCPCS,,,,,,,facility,outpatient,,,TC,,,Aetna,Medicare Managed Care Plan,83.08,,,,,,,fee schedule,79.12,138.46,APC
Dx mammo incl cad uni,77065,HCPCS,,,,,,,facility,outpatient,,,TC,,,Bcbs,Medicare Managed Care Plan,82.28,,,,,,,fee schedule,79.12,138.46,APC
Dx mammo incl cad uni,77065,HCPCS,,,,,,,facility,outpatient,,,TC,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,121.05,,,,,,,fee schedule,79.12,138.46,Radiology
Dx mammo incl cad uni,77065,HCPCS,,,,,,,facility,outpatient,,,TC,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,110.77,,,,,,,fee schedule,79.12,138.46,APC
Dx mammo incl cad uni,77065,HCPCS,,,,,,,facility,outpatient,,,TC,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,138.46,,,,,,,fee schedule,79.12,138.46,APC
Dx mammo incl cad bi,77066,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,200.13,,,,,,,fee schedule,160.42,200.13,
Dx mammo incl cad bi,77066,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,160.42,,,,,,,fee schedule,160.42,200.13,
Dx mammo incl cad bi,77066,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,175.25,,,,,,,fee schedule,160.42,200.13,
Dx mammo incl cad bi,77066,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,184.25,,,,,,,fee schedule,160.42,200.13,
Dx mammo incl cad bi,77066,HCPCS,,,,,,,facility,outpatient,,,TC,,,Unitedhealthcare,All Commercial Plans,101.57,,,,,,,fee schedule,101.57,177.75,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Dx mammo incl cad bi,77066,HCPCS,,,,,,,facility,outpatient,,,TC,,,Aetna,Medicare Managed Care Plan,106.65,,,,,,,fee schedule,101.57,177.75,APC
Dx mammo incl cad bi,77066,HCPCS,,,,,,,facility,outpatient,,,TC,,,Bcbs,Medicare Managed Care Plan,105.63,,,,,,,fee schedule,101.57,177.75,APC
Dx mammo incl cad bi,77066,HCPCS,,,,,,,facility,outpatient,,,TC,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,155.4,,,,,,,fee schedule,101.57,177.75,Radiology
Dx mammo incl cad bi,77066,HCPCS,,,,,,,facility,outpatient,,,TC,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,142.2,,,,,,,fee schedule,101.57,177.75,APC
Dx mammo incl cad bi,77066,HCPCS,,,,,,,facility,outpatient,,,TC,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,177.75,,,,,,,fee schedule,101.57,177.75,APC
Scr mammo bi incl cad,77067,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,165.15,,,,,,,fee schedule,132.38,165.15,
Scr mammo bi incl cad,77067,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,132.38,,,,,,,fee schedule,132.38,165.15,
Scr mammo bi incl cad,77067,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,144.61,,,,,,,fee schedule,132.38,165.15,
Scr mammo bi incl cad,77067,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,152.04,,,,,,,fee schedule,132.38,165.15,
Scr mammo bi incl cad,77067,HCPCS,,,,,,,facility,outpatient,,,TC,,,Unitedhealthcare,All Commercial Plans,83.71,,,,,,,fee schedule,83.71,146.49,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Scr mammo bi incl cad,77067,HCPCS,,,,,,,facility,outpatient,,,TC,,,Aetna,Medicare Managed Care Plan,87.9,,,,,,,fee schedule,83.71,146.49,APC
Scr mammo bi incl cad,77067,HCPCS,,,,,,,facility,outpatient,,,TC,,,Bcbs,Medicare Managed Care Plan,87.06,,,,,,,fee schedule,83.71,146.49,APC
Scr mammo bi incl cad,77067,HCPCS,,,,,,,facility,outpatient,,,TC,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,128.08,,,,,,,fee schedule,83.71,146.49,Radiology
Scr mammo bi incl cad,77067,HCPCS,,,,,,,facility,outpatient,,,TC,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,117.19,,,,,,,fee schedule,83.71,146.49,APC
Scr mammo bi incl cad,77067,HCPCS,,,,,,,facility,outpatient,,,TC,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,146.49,,,,,,,fee schedule,83.71,146.49,APC
X-Ray Stress View,77071,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
X-Ray Stress View,77071,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
X-Ray Stress View,77071,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
X-Ray Stress View,77071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
X-Ray Stress View,77071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
X-Ray Stress View,77071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
X-Ray Stress View,77071,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
X-Rays for Bone Age,77072,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,145.87,,,,,,,fee schedule,103.5,459.18,
X-Rays for Bone Age,77072,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,116.93,,,,,,,fee schedule,103.5,459.18,
X-Rays for Bone Age,77072,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,127.73,,,,,,,fee schedule,103.5,459.18,
X-Rays for Bone Age,77072,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,134.29,,,,,,,fee schedule,103.5,459.18,
X-Rays for Bone Age,77072,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
X-Rays for Bone Age,77072,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
X-Rays for Bone Age,77072,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
X-Rays for Bone Age,77072,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
X-Rays for Bone Age,77072,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
X-Rays for Bone Age,77072,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
X-Rays for Bone Age,77072,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
X-rays bone length studies,77073,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,338.65,,,,,,,fee schedule,103.5,459.18,
X-rays bone length studies,77073,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,271.46,,,,,,,fee schedule,103.5,459.18,
X-rays bone length studies,77073,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,296.54,,,,,,,fee schedule,103.5,459.18,
X-rays bone length studies,77073,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,311.77,,,,,,,fee schedule,103.5,459.18,
X-rays bone length studies,77073,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
X-rays bone length studies,77073,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
X-rays bone length studies,77073,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
X-rays bone length studies,77073,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
X-rays bone length studies,77073,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
X-rays bone length studies,77073,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
X-rays bone length studies,77073,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
X-rays bone survey limited,77074,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,288.75,,,,,,,fee schedule,103.5,459.18,
X-rays bone survey limited,77074,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,231.46,,,,,,,fee schedule,103.5,459.18,
X-rays bone survey limited,77074,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,252.85,,,,,,,fee schedule,103.5,459.18,
X-rays bone survey limited,77074,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,265.84,,,,,,,fee schedule,103.5,459.18,
X-rays bone survey limited,77074,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
X-rays bone survey limited,77074,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
X-rays bone survey limited,77074,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
X-rays bone survey limited,77074,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
X-rays bone survey limited,77074,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
X-rays bone survey limited,77074,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
X-rays bone survey limited,77074,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
X-rays bone survey complete,77075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,427.33,,,,,,,fee schedule,103.5,459.18,
X-rays bone survey complete,77075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,342.54,,,,,,,fee schedule,103.5,459.18,
X-rays bone survey complete,77075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,374.2,,,,,,,fee schedule,103.5,459.18,
X-rays bone survey complete,77075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,393.41,,,,,,,fee schedule,103.5,459.18,
X-rays bone survey complete,77075,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
X-rays bone survey complete,77075,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
X-rays bone survey complete,77075,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
X-rays bone survey complete,77075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
X-rays bone survey complete,77075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
X-rays bone survey complete,77075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
X-rays bone survey complete,77075,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
X-rays bone survey infant,77076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,173.54,,,,,,,fee schedule,103.5,459.18,
X-rays bone survey infant,77076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,139.11,,,,,,,fee schedule,103.5,459.18,
X-rays bone survey infant,77076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,151.96,,,,,,,fee schedule,103.5,459.18,
X-rays bone survey infant,77076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,159.77,,,,,,,fee schedule,103.5,459.18,
X-rays bone survey infant,77076,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
X-rays bone survey infant,77076,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
X-rays bone survey infant,77076,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
X-rays bone survey infant,77076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
X-rays bone survey infant,77076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
X-rays bone survey infant,77076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
X-rays bone survey infant,77076,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Joint survey single view,77077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,173.54,,,,,,,fee schedule,103.5,459.18,
Joint survey single view,77077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,139.11,,,,,,,fee schedule,103.5,459.18,
Joint survey single view,77077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,151.96,,,,,,,fee schedule,103.5,459.18,
Joint survey single view,77077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,159.77,,,,,,,fee schedule,103.5,459.18,
Joint survey single view,77077,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
Joint survey single view,77077,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
Joint survey single view,77077,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
Joint survey single view,77077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
Joint survey single view,77077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
Joint survey single view,77077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
Joint survey single view,77077,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Ct bone density axial,77078,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,284.1,,,,,,,fee schedule,86.15,382.23,
Ct bone density axial,77078,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,227.73,,,,,,,fee schedule,86.15,382.23,
Ct bone density axial,77078,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,248.78,,,,,,,fee schedule,86.15,382.23,
Ct bone density axial,77078,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,261.56,,,,,,,fee schedule,86.15,382.23,
Ct bone density axial,77078,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
Ct bone density axial,77078,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
Ct bone density axial,77078,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
Ct bone density axial,77078,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
Ct bone density axial,77078,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
Ct bone density axial,77078,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
Ct bone density axial,77078,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
Dxa bone density axial,77080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,327.28,,,,,,,fee schedule,103.5,459.18,
Dxa bone density axial,77080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,262.34,,,,,,,fee schedule,103.5,459.18,
Dxa bone density axial,77080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,286.59,,,,,,,fee schedule,103.5,459.18,
Dxa bone density axial,77080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,301.31,,,,,,,fee schedule,103.5,459.18,
Dxa bone density axial,77080,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
Dxa bone density axial,77080,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
Dxa bone density axial,77080,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
Dxa bone density axial,77080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
Dxa bone density axial,77080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
Dxa bone density axial,77080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
Dxa bone density axial,77080,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Dxa bone density/peripheral,77081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,126.97,,,,,,,fee schedule,86.15,382.23,
Dxa bone density/peripheral,77081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,101.78,,,,,,,fee schedule,86.15,382.23,
Dxa bone density/peripheral,77081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,111.18,,,,,,,fee schedule,86.15,382.23,
Dxa bone density/peripheral,77081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,116.89,,,,,,,fee schedule,86.15,382.23,
Dxa bone density/peripheral,77081,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
Dxa bone density/peripheral,77081,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
Dxa bone density/peripheral,77081,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
Dxa bone density/peripheral,77081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
Dxa bone density/peripheral,77081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
Dxa bone density/peripheral,77081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
Dxa bone density/peripheral,77081,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
Magnetic image bone marrow,77084,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1218.67,,,,,,,fee schedule,236.21,1218.67,
Magnetic image bone marrow,77084,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,976.87,,,,,,,fee schedule,236.21,1218.67,
Magnetic image bone marrow,77084,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1067.14,,,,,,,fee schedule,236.21,1218.67,
Magnetic image bone marrow,77084,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1121.95,,,,,,,fee schedule,236.21,1218.67,
Magnetic image bone marrow,77084,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,236.21,1218.67,APC 378
Magnetic image bone marrow,77084,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,236.21,1218.67,APC
Magnetic image bone marrow,77084,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,236.21,1218.67,APC
Magnetic image bone marrow,77084,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,236.21,1218.67,APC
Magnetic image bone marrow,77084,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,236.21,1218.67,Radiology
Magnetic image bone marrow,77084,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,236.21,1218.67,APC
Magnetic image bone marrow,77084,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,236.21,1218.67,APC
Dxa bone density study,77085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,359.18,,,,,,,fee schedule,103.5,459.18,
Dxa bone density study,77085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,287.91,,,,,,,fee schedule,103.5,459.18,
Dxa bone density study,77085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,314.52,,,,,,,fee schedule,103.5,459.18,
Dxa bone density study,77085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,330.67,,,,,,,fee schedule,103.5,459.18,
Dxa bone density study,77085,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
Dxa bone density study,77085,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
Dxa bone density study,77085,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
Dxa bone density study,77085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
Dxa bone density study,77085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
Dxa bone density study,77085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
Dxa bone density study,77085,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Fracture assessment via dxa,77086,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,224.42,,,,,,,fee schedule,86.15,382.23,
Fracture assessment via dxa,77086,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,179.89,,,,,,,fee schedule,86.15,382.23,
Fracture assessment via dxa,77086,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,196.51,,,,,,,fee schedule,86.15,382.23,
Fracture assessment via dxa,77086,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,206.61,,,,,,,fee schedule,86.15,382.23,
Fracture assessment via dxa,77086,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
Fracture assessment via dxa,77086,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
Fracture assessment via dxa,77086,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
Fracture assessment via dxa,77086,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
Fracture assessment via dxa,77086,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
Fracture assessment via dxa,77086,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
Fracture assessment via dxa,77086,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
Tbs techl prep&transmis data,77090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,312.27,,,,,,,fee schedule,86.15,382.23,
Tbs techl prep&transmis data,77090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,250.31,,,,,,,fee schedule,86.15,382.23,
Tbs techl prep&transmis data,77090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,273.44,,,,,,,fee schedule,86.15,382.23,
Tbs techl prep&transmis data,77090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,287.48,,,,,,,fee schedule,86.15,382.23,
Tbs techl prep&transmis data,77090,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
Tbs techl prep&transmis data,77090,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
Tbs techl prep&transmis data,77090,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
Tbs techl prep&transmis data,77090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
Tbs techl prep&transmis data,77090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
Tbs techl prep&transmis data,77090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
Tbs techl prep&transmis data,77090,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
Tbs techl calculation only,77091,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,312.27,,,,,,,fee schedule,86.15,382.23,
Tbs techl calculation only,77091,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,250.31,,,,,,,fee schedule,86.15,382.23,
Tbs techl calculation only,77091,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,273.44,,,,,,,fee schedule,86.15,382.23,
Tbs techl calculation only,77091,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,287.48,,,,,,,fee schedule,86.15,382.23,
Tbs techl calculation only,77091,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
Tbs techl calculation only,77091,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
Tbs techl calculation only,77091,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
Tbs techl calculation only,77091,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
Tbs techl calculation only,77091,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
Tbs techl calculation only,77091,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
Tbs techl calculation only,77091,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
Radiation therapy planning,77261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,261.84,,,,,,,fee schedule,209.89,261.84,
Radiation therapy planning,77261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,209.89,,,,,,,fee schedule,209.89,261.84,
Radiation therapy planning,77261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,229.28,,,,,,,fee schedule,209.89,261.84,
Radiation therapy planning,77261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,241.06,,,,,,,fee schedule,209.89,261.84,
Radiation therapy planning,77262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,393.88,,,,,,,fee schedule,315.73,393.88,
Radiation therapy planning,77262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,315.73,,,,,,,fee schedule,315.73,393.88,
Radiation therapy planning,77262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,344.9,,,,,,,fee schedule,315.73,393.88,
Radiation therapy planning,77262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,362.62,,,,,,,fee schedule,315.73,393.88,
Radiation therapy planning,77263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,584.24,,,,,,,fee schedule,468.32,584.24,
Radiation therapy planning,77263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,468.32,,,,,,,fee schedule,468.32,584.24,
Radiation therapy planning,77263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,511.59,,,,,,,fee schedule,468.32,584.24,
Radiation therapy planning,77263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,537.87,,,,,,,fee schedule,468.32,584.24,
Set radiation therapy field,77280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1054.51,,,,,,,fee schedule,133.06,1054.51,
Set radiation therapy field,77280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,845.28,,,,,,,fee schedule,133.06,1054.51,
Set radiation therapy field,77280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,923.39,,,,,,,fee schedule,133.06,1054.51,
Set radiation therapy field,77280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,970.82,,,,,,,fee schedule,133.06,1054.51,
Set radiation therapy field,77280,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,590.34,,,,,,,fee schedule,133.06,1054.51,APC 378
Set radiation therapy field,77280,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.71,,,,,,,fee schedule,133.06,1054.51,APC
Set radiation therapy field,77280,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,138.38,,,,,,,fee schedule,133.06,1054.51,APC
Set radiation therapy field,77280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,133.06,,,,,,,fee schedule,133.06,1054.51,APC
Set radiation therapy field,77280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,203.58,,,,,,,fee schedule,133.06,1054.51,Radiology
Set radiation therapy field,77280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,186.28,,,,,,,fee schedule,133.06,1054.51,APC
Set radiation therapy field,77280,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,232.86,,,,,,,fee schedule,133.06,1054.51,APC
Set radiation therapy field,77285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1441.83,,,,,,,fee schedule,370.67,1644.55,
Set radiation therapy field,77285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1155.76,,,,,,,fee schedule,370.67,1644.55,
Set radiation therapy field,77285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1262.56,,,,,,,fee schedule,370.67,1644.55,
Set radiation therapy field,77285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1327.4,,,,,,,fee schedule,370.67,1644.55,
Set radiation therapy field,77285,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1644.55,,,,,,,fee schedule,370.67,1644.55,APC 378
Set radiation therapy field,77285,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,389.21,,,,,,,fee schedule,370.67,1644.55,APC
Set radiation therapy field,77285,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,385.5,,,,,,,fee schedule,370.67,1644.55,APC
Set radiation therapy field,77285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,370.67,,,,,,,fee schedule,370.67,1644.55,APC
Set radiation therapy field,77285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,567.13,,,,,,,fee schedule,370.67,1644.55,Radiology
Set radiation therapy field,77285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,518.94,,,,,,,fee schedule,370.67,1644.55,APC
Set radiation therapy field,77285,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,648.68,,,,,,,fee schedule,370.67,1644.55,APC
Set radiation therapy field,77290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1978.57,,,,,,,fee schedule,370.67,1978.57,
Set radiation therapy field,77290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1585.99,,,,,,,fee schedule,370.67,1978.57,
Set radiation therapy field,77290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1732.55,,,,,,,fee schedule,370.67,1978.57,
Set radiation therapy field,77290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1821.54,,,,,,,fee schedule,370.67,1978.57,
Set radiation therapy field,77290,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1644.55,,,,,,,fee schedule,370.67,1978.57,APC 378
Set radiation therapy field,77290,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,389.21,,,,,,,fee schedule,370.67,1978.57,APC
Set radiation therapy field,77290,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,385.5,,,,,,,fee schedule,370.67,1978.57,APC
Set radiation therapy field,77290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,370.67,,,,,,,fee schedule,370.67,1978.57,APC
Set radiation therapy field,77290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,567.13,,,,,,,fee schedule,370.67,1978.57,Radiology
Set radiation therapy field,77290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,518.94,,,,,,,fee schedule,370.67,1978.57,APC
Set radiation therapy field,77290,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,648.68,,,,,,,fee schedule,370.67,1978.57,APC
Respirator motion mgmt simul,77293,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1639.23,,,,,,,fee schedule,1313.99,1639.23,
Respirator motion mgmt simul,77293,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1313.99,,,,,,,fee schedule,1313.99,1639.23,
Respirator motion mgmt simul,77293,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1435.41,,,,,,,fee schedule,1313.99,1639.23,
Respirator motion mgmt simul,77293,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1509.14,,,,,,,fee schedule,1313.99,1639.23,
3-d radiotherapy plan,77295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5613.75,,,,,,,fee schedule,1370.24,6079.31,
3-d radiotherapy plan,77295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4499.91,,,,,,,fee schedule,1370.24,6079.31,
3-d radiotherapy plan,77295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4915.75,,,,,,,fee schedule,1370.24,6079.31,
3-d radiotherapy plan,77295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5168.22,,,,,,,fee schedule,1370.24,6079.31,
3-d radiotherapy plan,77295,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6079.31,,,,,,,fee schedule,1370.24,6079.31,APC 378
3-d radiotherapy plan,77295,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1438.76,,,,,,,fee schedule,1370.24,6079.31,APC
3-d radiotherapy plan,77295,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1425.05,,,,,,,fee schedule,1370.24,6079.31,APC
3-d radiotherapy plan,77295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1370.24,,,,,,,fee schedule,1370.24,6079.31,APC
3-d radiotherapy plan,77295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2096.47,,,,,,,fee schedule,1370.24,6079.31,Radiology
3-d radiotherapy plan,77295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1918.34,,,,,,,fee schedule,1370.24,6079.31,APC
3-d radiotherapy plan,77295,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2397.93,,,,,,,fee schedule,1370.24,6079.31,APC
Radiation therapy planning,77299,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,590.34,,,,,,,fee schedule,133.06,590.34,APC 378
Radiation therapy planning,77299,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.71,,,,,,,fee schedule,133.06,590.34,APC
Radiation therapy planning,77299,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,138.38,,,,,,,fee schedule,133.06,590.34,APC
Radiation therapy planning,77299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,133.06,,,,,,,fee schedule,133.06,590.34,APC
Radiation therapy planning,77299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,203.58,,,,,,,fee schedule,133.06,590.34,Radiology
Radiation therapy planning,77299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,186.28,,,,,,,fee schedule,133.06,590.34,APC
Radiation therapy planning,77299,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,232.86,,,,,,,fee schedule,133.06,590.34,APC
Radiation therapy dose plan,77300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,523.72,,,,,,,fee schedule,133.06,590.34,
Radiation therapy dose plan,77300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,419.81,,,,,,,fee schedule,133.06,590.34,
Radiation therapy dose plan,77300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,458.6,,,,,,,fee schedule,133.06,590.34,
Radiation therapy dose plan,77300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,482.15,,,,,,,fee schedule,133.06,590.34,
Radiation therapy dose plan,77300,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,590.34,,,,,,,fee schedule,133.06,590.34,APC 378
Radiation therapy dose plan,77300,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.71,,,,,,,fee schedule,133.06,590.34,APC
Radiation therapy dose plan,77300,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,138.38,,,,,,,fee schedule,133.06,590.34,APC
Radiation therapy dose plan,77300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,133.06,,,,,,,fee schedule,133.06,590.34,APC
Radiation therapy dose plan,77300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,203.58,,,,,,,fee schedule,133.06,590.34,Radiology
Radiation therapy dose plan,77300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,186.28,,,,,,,fee schedule,133.06,590.34,APC
Radiation therapy dose plan,77300,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,232.86,,,,,,,fee schedule,133.06,590.34,APC
Radiotherapy dose plan imrt,77301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3371.72,,,,,,,fee schedule,1370.24,6079.31,
Radiotherapy dose plan imrt,77301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2702.73,,,,,,,fee schedule,1370.24,6079.31,
Radiotherapy dose plan imrt,77301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2952.49,,,,,,,fee schedule,1370.24,6079.31,
Radiotherapy dose plan imrt,77301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3104.13,,,,,,,fee schedule,1370.24,6079.31,
Radiotherapy dose plan imrt,77301,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6079.31,,,,,,,fee schedule,1370.24,6079.31,APC 378
Radiotherapy dose plan imrt,77301,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1438.76,,,,,,,fee schedule,1370.24,6079.31,APC
Radiotherapy dose plan imrt,77301,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1425.05,,,,,,,fee schedule,1370.24,6079.31,APC
Radiotherapy dose plan imrt,77301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1370.24,,,,,,,fee schedule,1370.24,6079.31,APC
Radiotherapy dose plan imrt,77301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2096.47,,,,,,,fee schedule,1370.24,6079.31,Radiology
Radiotherapy dose plan imrt,77301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1918.34,,,,,,,fee schedule,1370.24,6079.31,APC
Radiotherapy dose plan imrt,77301,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2397.93,,,,,,,fee schedule,1370.24,6079.31,APC
Telethx isodose plan simple,77306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,427.78,,,,,,,fee schedule,342.91,1644.55,
Telethx isodose plan simple,77306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,342.91,,,,,,,fee schedule,342.91,1644.55,
Telethx isodose plan simple,77306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,374.59,,,,,,,fee schedule,342.91,1644.55,
Telethx isodose plan simple,77306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,393.83,,,,,,,fee schedule,342.91,1644.55,
Telethx isodose plan simple,77306,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1644.55,,,,,,,fee schedule,342.91,1644.55,APC 378
Telethx isodose plan simple,77306,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,389.21,,,,,,,fee schedule,342.91,1644.55,APC
Telethx isodose plan simple,77306,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,385.5,,,,,,,fee schedule,342.91,1644.55,APC
Telethx isodose plan simple,77306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,370.67,,,,,,,fee schedule,342.91,1644.55,APC
Telethx isodose plan simple,77306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,567.13,,,,,,,fee schedule,342.91,1644.55,Radiology
Telethx isodose plan simple,77306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,518.94,,,,,,,fee schedule,342.91,1644.55,APC
Telethx isodose plan simple,77306,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,648.68,,,,,,,fee schedule,342.91,1644.55,APC
Telethx isodose plan cplx,77307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1418.22,,,,,,,fee schedule,370.67,1644.55,
Telethx isodose plan cplx,77307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1136.83,,,,,,,fee schedule,370.67,1644.55,
Telethx isodose plan cplx,77307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1241.88,,,,,,,fee schedule,370.67,1644.55,
Telethx isodose plan cplx,77307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1305.66,,,,,,,fee schedule,370.67,1644.55,
Telethx isodose plan cplx,77307,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1644.55,,,,,,,fee schedule,370.67,1644.55,APC 378
Telethx isodose plan cplx,77307,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,389.21,,,,,,,fee schedule,370.67,1644.55,APC
Telethx isodose plan cplx,77307,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,385.5,,,,,,,fee schedule,370.67,1644.55,APC
Telethx isodose plan cplx,77307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,370.67,,,,,,,fee schedule,370.67,1644.55,APC
Telethx isodose plan cplx,77307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,567.13,,,,,,,fee schedule,370.67,1644.55,Radiology
Telethx isodose plan cplx,77307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,518.94,,,,,,,fee schedule,370.67,1644.55,APC
Telethx isodose plan cplx,77307,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,648.68,,,,,,,fee schedule,370.67,1644.55,APC
Brachytx isodose plan simple,77316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,361.14,,,,,,,fee schedule,289.49,1644.55,
Brachytx isodose plan simple,77316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,289.49,,,,,,,fee schedule,289.49,1644.55,
Brachytx isodose plan simple,77316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,316.24,,,,,,,fee schedule,289.49,1644.55,
Brachytx isodose plan simple,77316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,332.48,,,,,,,fee schedule,289.49,1644.55,
Brachytx isodose plan simple,77316,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1644.55,,,,,,,fee schedule,289.49,1644.55,APC 378
Brachytx isodose plan simple,77316,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,389.21,,,,,,,fee schedule,289.49,1644.55,APC
Brachytx isodose plan simple,77316,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,385.5,,,,,,,fee schedule,289.49,1644.55,APC
Brachytx isodose plan simple,77316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,370.67,,,,,,,fee schedule,289.49,1644.55,APC
Brachytx isodose plan simple,77316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,567.13,,,,,,,fee schedule,289.49,1644.55,Radiology
Brachytx isodose plan simple,77316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,518.94,,,,,,,fee schedule,289.49,1644.55,APC
Brachytx isodose plan simple,77316,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,648.68,,,,,,,fee schedule,289.49,1644.55,APC
Brachytx isodose intermed,77317,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,472.31,,,,,,,fee schedule,370.67,1644.55,
Brachytx isodose intermed,77317,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,378.6,,,,,,,fee schedule,370.67,1644.55,
Brachytx isodose intermed,77317,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,413.58,,,,,,,fee schedule,370.67,1644.55,
Brachytx isodose intermed,77317,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,434.83,,,,,,,fee schedule,370.67,1644.55,
Brachytx isodose intermed,77317,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1644.55,,,,,,,fee schedule,370.67,1644.55,APC 378
Brachytx isodose intermed,77317,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,389.21,,,,,,,fee schedule,370.67,1644.55,APC
Brachytx isodose intermed,77317,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,385.5,,,,,,,fee schedule,370.67,1644.55,APC
Brachytx isodose intermed,77317,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,370.67,,,,,,,fee schedule,370.67,1644.55,APC
Brachytx isodose intermed,77317,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,567.13,,,,,,,fee schedule,370.67,1644.55,Radiology
Brachytx isodose intermed,77317,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,518.94,,,,,,,fee schedule,370.67,1644.55,APC
Brachytx isodose intermed,77317,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,648.68,,,,,,,fee schedule,370.67,1644.55,APC
Brachytx isodose complex,77318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,610.47,,,,,,,fee schedule,370.67,1644.55,
Brachytx isodose complex,77318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,489.35,,,,,,,fee schedule,370.67,1644.55,
Brachytx isodose complex,77318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,534.57,,,,,,,fee schedule,370.67,1644.55,
Brachytx isodose complex,77318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,562.02,,,,,,,fee schedule,370.67,1644.55,
Brachytx isodose complex,77318,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1644.55,,,,,,,fee schedule,370.67,1644.55,APC 378
Brachytx isodose complex,77318,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,389.21,,,,,,,fee schedule,370.67,1644.55,APC
Brachytx isodose complex,77318,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,385.5,,,,,,,fee schedule,370.67,1644.55,APC
Brachytx isodose complex,77318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,370.67,,,,,,,fee schedule,370.67,1644.55,APC
Brachytx isodose complex,77318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,567.13,,,,,,,fee schedule,370.67,1644.55,Radiology
Brachytx isodose complex,77318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,518.94,,,,,,,fee schedule,370.67,1644.55,APC
Brachytx isodose complex,77318,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,648.68,,,,,,,fee schedule,370.67,1644.55,APC
Special teletx port plan,77321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,755.7,,,,,,,fee schedule,370.67,1644.55,
Special teletx port plan,77321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,605.76,,,,,,,fee schedule,370.67,1644.55,
Special teletx port plan,77321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,661.74,,,,,,,fee schedule,370.67,1644.55,
Special teletx port plan,77321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,695.72,,,,,,,fee schedule,370.67,1644.55,
Special teletx port plan,77321,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1644.55,,,,,,,fee schedule,370.67,1644.55,APC 378
Special teletx port plan,77321,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,389.21,,,,,,,fee schedule,370.67,1644.55,APC
Special teletx port plan,77321,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,385.5,,,,,,,fee schedule,370.67,1644.55,APC
Special teletx port plan,77321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,370.67,,,,,,,fee schedule,370.67,1644.55,APC
Special teletx port plan,77321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,567.13,,,,,,,fee schedule,370.67,1644.55,Radiology
Special teletx port plan,77321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,518.94,,,,,,,fee schedule,370.67,1644.55,APC
Special teletx port plan,77321,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,648.68,,,,,,,fee schedule,370.67,1644.55,APC
Special radiation dosimetry,77331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,388.74,,,,,,,fee schedule,133.06,590.34,
Special radiation dosimetry,77331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,311.61,,,,,,,fee schedule,133.06,590.34,
Special radiation dosimetry,77331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,340.4,,,,,,,fee schedule,133.06,590.34,
Special radiation dosimetry,77331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,357.88,,,,,,,fee schedule,133.06,590.34,
Special radiation dosimetry,77331,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,590.34,,,,,,,fee schedule,133.06,590.34,APC 378
Special radiation dosimetry,77331,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.71,,,,,,,fee schedule,133.06,590.34,APC
Special radiation dosimetry,77331,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,138.38,,,,,,,fee schedule,133.06,590.34,APC
Special radiation dosimetry,77331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,133.06,,,,,,,fee schedule,133.06,590.34,APC
Special radiation dosimetry,77331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,203.58,,,,,,,fee schedule,133.06,590.34,Radiology
Special radiation dosimetry,77331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,186.28,,,,,,,fee schedule,133.06,590.34,APC
Special radiation dosimetry,77331,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,232.86,,,,,,,fee schedule,133.06,590.34,APC
Radiation treatment aid(s),77332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,455.6,,,,,,,fee schedule,133.06,590.34,
Radiation treatment aid(s),77332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,365.21,,,,,,,fee schedule,133.06,590.34,
Radiation treatment aid(s),77332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,398.95,,,,,,,fee schedule,133.06,590.34,
Radiation treatment aid(s),77332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,419.44,,,,,,,fee schedule,133.06,590.34,
Radiation treatment aid(s),77332,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,590.34,,,,,,,fee schedule,133.06,590.34,APC 378
Radiation treatment aid(s),77332,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.71,,,,,,,fee schedule,133.06,590.34,APC
Radiation treatment aid(s),77332,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,138.38,,,,,,,fee schedule,133.06,590.34,APC
Radiation treatment aid(s),77332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,133.06,,,,,,,fee schedule,133.06,590.34,APC
Radiation treatment aid(s),77332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,203.58,,,,,,,fee schedule,133.06,590.34,Radiology
Radiation treatment aid(s),77332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,186.28,,,,,,,fee schedule,133.06,590.34,APC
Radiation treatment aid(s),77332,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,232.86,,,,,,,fee schedule,133.06,590.34,APC
Radiation treatment aid(s),77333,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,571.91,,,,,,,fee schedule,133.06,590.34,
Radiation treatment aid(s),77333,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,458.44,,,,,,,fee schedule,133.06,590.34,
Radiation treatment aid(s),77333,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,500.8,,,,,,,fee schedule,133.06,590.34,
Radiation treatment aid(s),77333,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,526.52,,,,,,,fee schedule,133.06,590.34,
Radiation treatment aid(s),77333,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,590.34,,,,,,,fee schedule,133.06,590.34,APC 378
Radiation treatment aid(s),77333,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.71,,,,,,,fee schedule,133.06,590.34,APC
Radiation treatment aid(s),77333,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,138.38,,,,,,,fee schedule,133.06,590.34,APC
Radiation treatment aid(s),77333,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,133.06,,,,,,,fee schedule,133.06,590.34,APC
Radiation treatment aid(s),77333,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,203.58,,,,,,,fee schedule,133.06,590.34,Radiology
Radiation treatment aid(s),77333,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,186.28,,,,,,,fee schedule,133.06,590.34,APC
Radiation treatment aid(s),77333,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,232.86,,,,,,,fee schedule,133.06,590.34,APC
Radiation treatment aid(s),77334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1000.53,,,,,,,fee schedule,370.67,1644.55,
Radiation treatment aid(s),77334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,802.01,,,,,,,fee schedule,370.67,1644.55,
Radiation treatment aid(s),77334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,876.12,,,,,,,fee schedule,370.67,1644.55,
Radiation treatment aid(s),77334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,921.12,,,,,,,fee schedule,370.67,1644.55,
Radiation treatment aid(s),77334,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1644.55,,,,,,,fee schedule,370.67,1644.55,APC 378
Radiation treatment aid(s),77334,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,389.21,,,,,,,fee schedule,370.67,1644.55,APC
Radiation treatment aid(s),77334,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,385.5,,,,,,,fee schedule,370.67,1644.55,APC
Radiation treatment aid(s),77334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,370.67,,,,,,,fee schedule,370.67,1644.55,APC
Radiation treatment aid(s),77334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,567.13,,,,,,,fee schedule,370.67,1644.55,Radiology
Radiation treatment aid(s),77334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,518.94,,,,,,,fee schedule,370.67,1644.55,APC
Radiation treatment aid(s),77334,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,648.68,,,,,,,fee schedule,370.67,1644.55,APC
Radiation physics consult,77336,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,590.34,,,,,,,fee schedule,133.06,590.34,APC 378
Radiation physics consult,77336,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.71,,,,,,,fee schedule,133.06,590.34,APC
Radiation physics consult,77336,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,138.38,,,,,,,fee schedule,133.06,590.34,APC
Radiation physics consult,77336,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,133.06,,,,,,,fee schedule,133.06,590.34,APC
Radiation physics consult,77336,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,203.58,,,,,,,fee schedule,133.06,590.34,Radiology
Radiation physics consult,77336,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,186.28,,,,,,,fee schedule,133.06,590.34,APC
Radiation physics consult,77336,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,232.86,,,,,,,fee schedule,133.06,590.34,APC
Design mlc device for imrt,77338,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,741.56,,,,,,,fee schedule,370.67,1644.55,
Design mlc device for imrt,77338,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,594.43,,,,,,,fee schedule,370.67,1644.55,
Design mlc device for imrt,77338,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,649.36,,,,,,,fee schedule,370.67,1644.55,
Design mlc device for imrt,77338,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,682.71,,,,,,,fee schedule,370.67,1644.55,
Design mlc device for imrt,77338,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1644.55,,,,,,,fee schedule,370.67,1644.55,APC 378
Design mlc device for imrt,77338,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,389.21,,,,,,,fee schedule,370.67,1644.55,APC
Design mlc device for imrt,77338,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,385.5,,,,,,,fee schedule,370.67,1644.55,APC
Design mlc device for imrt,77338,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,370.67,,,,,,,fee schedule,370.67,1644.55,APC
Design mlc device for imrt,77338,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,567.13,,,,,,,fee schedule,370.67,1644.55,Radiology
Design mlc device for imrt,77338,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,518.94,,,,,,,fee schedule,370.67,1644.55,APC
Design mlc device for imrt,77338,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,648.68,,,,,,,fee schedule,370.67,1644.55,APC
Radiation physics consult,77370,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,590.34,,,,,,,fee schedule,133.06,590.34,APC 378
Radiation physics consult,77370,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.71,,,,,,,fee schedule,133.06,590.34,APC
Radiation physics consult,77370,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,138.38,,,,,,,fee schedule,133.06,590.34,APC
Radiation physics consult,77370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,133.06,,,,,,,fee schedule,133.06,590.34,APC
Radiation physics consult,77370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,203.58,,,,,,,fee schedule,133.06,590.34,Radiology
Radiation physics consult,77370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,186.28,,,,,,,fee schedule,133.06,590.34,APC
Radiation physics consult,77370,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,232.86,,,,,,,fee schedule,133.06,590.34,APC
Srs multisource,77371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,31562.62,,,,,,,fee schedule,7291.4,32349.47,
Srs multisource,77371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,25300.2,,,,,,,fee schedule,7291.4,32349.47,
Srs multisource,77371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,27638.17,,,,,,,fee schedule,7291.4,32349.47,
Srs multisource,77371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,29057.65,,,,,,,fee schedule,7291.4,32349.47,
Srs multisource,77371,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,32349.47,,,,,,,fee schedule,7291.4,32349.47,APC 378
Srs multisource,77371,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7655.97,,,,,,,fee schedule,7291.4,32349.47,APC
Srs multisource,77371,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7583.06,,,,,,,fee schedule,7291.4,32349.47,APC
Srs multisource,77371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7291.4,,,,,,,fee schedule,7291.4,32349.47,APC
Srs multisource,77371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11155.84,,,,,,,fee schedule,7291.4,32349.47,Radiology
Srs multisource,77371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10207.96,,,,,,,fee schedule,7291.4,32349.47,APC
Srs multisource,77371,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12759.95,,,,,,,fee schedule,7291.4,32349.47,APC
Srs linear based,77372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2725.19,,,,,,,fee schedule,2184.48,32349.47,
Srs linear based,77372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2184.48,,,,,,,fee schedule,2184.48,32349.47,
Srs linear based,77372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2386.34,,,,,,,fee schedule,2184.48,32349.47,
Srs linear based,77372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2508.91,,,,,,,fee schedule,2184.48,32349.47,
Srs linear based,77372,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,32349.47,,,,,,,fee schedule,2184.48,32349.47,APC 378
Srs linear based,77372,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7655.97,,,,,,,fee schedule,2184.48,32349.47,APC
Srs linear based,77372,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7583.06,,,,,,,fee schedule,2184.48,32349.47,APC
Srs linear based,77372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7291.4,,,,,,,fee schedule,2184.48,32349.47,APC
Srs linear based,77372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11155.84,,,,,,,fee schedule,2184.48,32349.47,Radiology
Srs linear based,77372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10207.96,,,,,,,fee schedule,2184.48,32349.47,APC
Srs linear based,77372,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12759.95,,,,,,,fee schedule,2184.48,32349.47,APC
SBRT Delivery,77373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6147.11,,,,,,,fee schedule,1770.11,7853.39,
SBRT Delivery,77373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4927.45,,,,,,,fee schedule,1770.11,7853.39,
SBRT Delivery,77373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5382.79,,,,,,,fee schedule,1770.11,7853.39,
SBRT Delivery,77373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5659.25,,,,,,,fee schedule,1770.11,7853.39,
SBRT Delivery,77373,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7853.39,,,,,,,fee schedule,1770.11,7853.39,APC 378
SBRT Delivery,77373,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1858.62,,,,,,,fee schedule,1770.11,7853.39,APC
SBRT Delivery,77373,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1840.92,,,,,,,fee schedule,1770.11,7853.39,APC
SBRT Delivery,77373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1770.11,,,,,,,fee schedule,1770.11,7853.39,APC
SBRT Delivery,77373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2708.27,,,,,,,fee schedule,1770.11,7853.39,Radiology
SBRT Delivery,77373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2478.16,,,,,,,fee schedule,1770.11,7853.39,APC
SBRT Delivery,77373,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3097.7,,,,,,,fee schedule,1770.11,7853.39,APC
Ntsty modul rad tx dlvr smpl,77385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2902.62,,,,,,,fee schedule,2326.71,2902.62,
Ntsty modul rad tx dlvr smpl,77385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2326.71,,,,,,,fee schedule,2326.71,2902.62,
Ntsty modul rad tx dlvr smpl,77385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2541.72,,,,,,,fee schedule,2326.71,2902.62,
Ntsty modul rad tx dlvr smpl,77385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2672.26,,,,,,,fee schedule,2326.71,2902.62,
Ntsty modul rad tx dlvr cplx,77386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2973.31,,,,,,,fee schedule,2383.37,2973.31,
Ntsty modul rad tx dlvr cplx,77386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2383.37,,,,,,,fee schedule,2383.37,2973.31,
Ntsty modul rad tx dlvr cplx,77386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2603.61,,,,,,,fee schedule,2383.37,2973.31,
Ntsty modul rad tx dlvr cplx,77386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2737.33,,,,,,,fee schedule,2383.37,2973.31,
External radiation dosimetry,77399,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,590.34,,,,,,,fee schedule,133.06,590.34,APC 378
External radiation dosimetry,77399,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.71,,,,,,,fee schedule,133.06,590.34,APC
External radiation dosimetry,77399,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,138.38,,,,,,,fee schedule,133.06,590.34,APC
External radiation dosimetry,77399,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,133.06,,,,,,,fee schedule,133.06,590.34,APC
External radiation dosimetry,77399,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,203.58,,,,,,,fee schedule,133.06,590.34,Radiology
External radiation dosimetry,77399,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,186.28,,,,,,,fee schedule,133.06,590.34,APC
External radiation dosimetry,77399,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,232.86,,,,,,,fee schedule,133.06,590.34,APC
Radiation treatment delivery,77401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,355.13,,,,,,,fee schedule,284.67,355.13,
Radiation treatment delivery,77401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,284.67,,,,,,,fee schedule,284.67,355.13,
Radiation treatment delivery,77401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,310.97,,,,,,,fee schedule,284.67,355.13,
Radiation treatment delivery,77401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,326.95,,,,,,,fee schedule,284.67,355.13,
Radiation treatment delivery,77402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,355.13,,,,,,,fee schedule,101.01,448.13,
Radiation treatment delivery,77402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,284.67,,,,,,,fee schedule,101.01,448.13,
Radiation treatment delivery,77402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,310.97,,,,,,,fee schedule,101.01,448.13,
Radiation treatment delivery,77402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,326.95,,,,,,,fee schedule,101.01,448.13,
Radiation treatment delivery,77402,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,448.13,,,,,,,fee schedule,101.01,448.13,APC 378
Radiation treatment delivery,77402,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,106.06,,,,,,,fee schedule,101.01,448.13,APC
Radiation treatment delivery,77402,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,105.05,,,,,,,fee schedule,101.01,448.13,APC
Radiation treatment delivery,77402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,101.01,,,,,,,fee schedule,101.01,448.13,APC
Radiation treatment delivery,77402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,154.54,,,,,,,fee schedule,101.01,448.13,Radiology
Radiation treatment delivery,77402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,141.41,,,,,,,fee schedule,101.01,448.13,APC
Radiation treatment delivery,77402,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,176.76,,,,,,,fee schedule,101.01,448.13,APC
Radiation treatment delivery,77407,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,384.27,,,,,,,fee schedule,308.03,1694.04,
Radiation treatment delivery,77407,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,308.03,,,,,,,fee schedule,308.03,1694.04,
Radiation treatment delivery,77407,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,336.49,,,,,,,fee schedule,308.03,1694.04,
Radiation treatment delivery,77407,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,353.78,,,,,,,fee schedule,308.03,1694.04,
Radiation treatment delivery,77407,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1694.04,,,,,,,fee schedule,308.03,1694.04,APC 378
Radiation treatment delivery,77407,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,400.92,,,,,,,fee schedule,308.03,1694.04,APC
Radiation treatment delivery,77407,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,397.1,,,,,,,fee schedule,308.03,1694.04,APC
Radiation treatment delivery,77407,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,381.83,,,,,,,fee schedule,308.03,1694.04,APC
Radiation treatment delivery,77407,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,584.19,,,,,,,fee schedule,308.03,1694.04,Radiology
Radiation treatment delivery,77407,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,534.56,,,,,,,fee schedule,308.03,1694.04,APC
Radiation treatment delivery,77407,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,668.2,,,,,,,fee schedule,308.03,1694.04,APC
Radiation treatment delivery,77412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,563.72,,,,,,,fee schedule,451.87,2426.85,
Radiation treatment delivery,77412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,451.87,,,,,,,fee schedule,451.87,2426.85,
Radiation treatment delivery,77412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,493.63,,,,,,,fee schedule,451.87,2426.85,
Radiation treatment delivery,77412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,518.98,,,,,,,fee schedule,451.87,2426.85,
Radiation treatment delivery,77412,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2426.85,,,,,,,fee schedule,451.87,2426.85,APC 378
Radiation treatment delivery,77412,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,574.35,,,,,,,fee schedule,451.87,2426.85,APC
Radiation treatment delivery,77412,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,568.88,,,,,,,fee schedule,451.87,2426.85,APC
Radiation treatment delivery,77412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,547,,,,,,,fee schedule,451.87,2426.85,APC
Radiation treatment delivery,77412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,836.91,,,,,,,fee schedule,451.87,2426.85,Radiology
Radiation treatment delivery,77412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,765.8,,,,,,,fee schedule,451.87,2426.85,APC
Radiation treatment delivery,77412,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,957.25,,,,,,,fee schedule,451.87,2426.85,APC
Neutron beam tx complex,77423,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,553.24,,,,,,,fee schedule,443.47,2426.85,
Neutron beam tx complex,77423,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,443.47,,,,,,,fee schedule,443.47,2426.85,
Neutron beam tx complex,77423,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,484.45,,,,,,,fee schedule,443.47,2426.85,
Neutron beam tx complex,77423,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,509.33,,,,,,,fee schedule,443.47,2426.85,
Neutron beam tx complex,77423,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2426.85,,,,,,,fee schedule,443.47,2426.85,APC 378
Neutron beam tx complex,77423,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,574.35,,,,,,,fee schedule,443.47,2426.85,APC
Neutron beam tx complex,77423,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,568.88,,,,,,,fee schedule,443.47,2426.85,APC
Neutron beam tx complex,77423,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,547,,,,,,,fee schedule,443.47,2426.85,APC
Neutron beam tx complex,77423,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,836.91,,,,,,,fee schedule,443.47,2426.85,Radiology
Neutron beam tx complex,77423,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,765.8,,,,,,,fee schedule,443.47,2426.85,APC
Neutron beam tx complex,77423,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,957.25,,,,,,,fee schedule,443.47,2426.85,APC
Io rad tx delivery by x-ray,77424,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3697.79,,,,,,,fee schedule,2964.1,32349.47,
Io rad tx delivery by x-ray,77424,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2964.1,,,,,,,fee schedule,2964.1,32349.47,
Io rad tx delivery by x-ray,77424,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3238.01,,,,,,,fee schedule,2964.1,32349.47,
Io rad tx delivery by x-ray,77424,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3404.31,,,,,,,fee schedule,2964.1,32349.47,
Io rad tx delivery by x-ray,77424,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,32349.47,,,,,,,fee schedule,2964.1,32349.47,APC 378
Io rad tx delivery by x-ray,77424,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7655.97,,,,,,,fee schedule,2964.1,32349.47,APC
Io rad tx delivery by x-ray,77424,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7583.06,,,,,,,fee schedule,2964.1,32349.47,APC
Io rad tx delivery by x-ray,77424,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7291.4,,,,,,,fee schedule,2964.1,32349.47,APC
Io rad tx delivery by x-ray,77424,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11155.84,,,,,,,fee schedule,2964.1,32349.47,Radiology
Io rad tx delivery by x-ray,77424,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10207.96,,,,,,,fee schedule,2964.1,32349.47,APC
Io rad tx delivery by x-ray,77424,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12759.95,,,,,,,fee schedule,2964.1,32349.47,APC
Io rad tx deliver by elctrns,77425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3697.79,,,,,,,fee schedule,2964.1,32349.47,
Io rad tx deliver by elctrns,77425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2964.1,,,,,,,fee schedule,2964.1,32349.47,
Io rad tx deliver by elctrns,77425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3238.01,,,,,,,fee schedule,2964.1,32349.47,
Io rad tx deliver by elctrns,77425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3404.31,,,,,,,fee schedule,2964.1,32349.47,
Io rad tx deliver by elctrns,77425,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,32349.47,,,,,,,fee schedule,2964.1,32349.47,APC 378
Io rad tx deliver by elctrns,77425,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7655.97,,,,,,,fee schedule,2964.1,32349.47,APC
Io rad tx deliver by elctrns,77425,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7583.06,,,,,,,fee schedule,2964.1,32349.47,APC
Io rad tx deliver by elctrns,77425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7291.4,,,,,,,fee schedule,2964.1,32349.47,APC
Io rad tx deliver by elctrns,77425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11155.84,,,,,,,fee schedule,2964.1,32349.47,Radiology
Io rad tx deliver by elctrns,77425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10207.96,,,,,,,fee schedule,2964.1,32349.47,APC
Io rad tx deliver by elctrns,77425,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12759.95,,,,,,,fee schedule,2964.1,32349.47,APC
Radiation tx management x5,77427,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,693.63,,,,,,,fee schedule,556.01,693.63,
Radiation tx management x5,77427,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,556.01,,,,,,,fee schedule,556.01,693.63,
Radiation tx management x5,77427,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,607.39,,,,,,,fee schedule,556.01,693.63,
Radiation tx management x5,77427,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,638.58,,,,,,,fee schedule,556.01,693.63,
Radiation therapy management,77431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,353.62,,,,,,,fee schedule,283.46,353.62,
Radiation therapy management,77431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,283.46,,,,,,,fee schedule,283.46,353.62,
Radiation therapy management,77431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,309.65,,,,,,,fee schedule,283.46,353.62,
Radiation therapy management,77431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,325.55,,,,,,,fee schedule,283.46,353.62,
Stereotactic radiation trmt,77432,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1478.32,,,,,,,fee schedule,1185,1478.32,
Stereotactic radiation trmt,77432,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1185,,,,,,,fee schedule,1185,1478.32,
Stereotactic radiation trmt,77432,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1294.51,,,,,,,fee schedule,1185,1478.32,
Stereotactic radiation trmt,77432,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1360.99,,,,,,,fee schedule,1185,1478.32,
Surf radj ther tx planning,77436,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.05,,,,,,,fee schedule,36.98,164.05,APC 378
Surf radj ther tx planning,77436,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.83,,,,,,,fee schedule,36.98,164.05,APC
Surf radj ther tx planning,77436,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.46,,,,,,,fee schedule,36.98,164.05,APC
Surf radj ther tx planning,77436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.98,,,,,,,fee schedule,36.98,164.05,APC
Surf radj ther tx planning,77436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.57,,,,,,,fee schedule,36.98,164.05,Radiology
Surf radj ther tx planning,77436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.77,,,,,,,fee schedule,36.98,164.05,APC
Surf radj ther tx planning,77436,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.71,,,,,,,fee schedule,36.98,164.05,APC
Io radiation tx management,77469,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1109.58,,,,,,,fee schedule,889.43,1109.58,
Io radiation tx management,77469,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,889.43,,,,,,,fee schedule,889.43,1109.58,
Io radiation tx management,77469,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,971.62,,,,,,,fee schedule,889.43,1109.58,
Io radiation tx management,77469,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1021.52,,,,,,,fee schedule,889.43,1109.58,
Special radiation treatment,77470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2256.81,,,,,,,fee schedule,547,2426.85,
Special radiation treatment,77470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1809.03,,,,,,,fee schedule,547,2426.85,
Special radiation treatment,77470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1976.2,,,,,,,fee schedule,547,2426.85,
Special radiation treatment,77470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2077.7,,,,,,,fee schedule,547,2426.85,
Special radiation treatment,77470,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2426.85,,,,,,,fee schedule,547,2426.85,APC 378
Special radiation treatment,77470,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,574.35,,,,,,,fee schedule,547,2426.85,APC
Special radiation treatment,77470,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,568.88,,,,,,,fee schedule,547,2426.85,APC
Special radiation treatment,77470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,547,,,,,,,fee schedule,547,2426.85,APC
Special radiation treatment,77470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,836.91,,,,,,,fee schedule,547,2426.85,Radiology
Special radiation treatment,77470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,765.8,,,,,,,fee schedule,547,2426.85,APC
Special radiation treatment,77470,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,957.25,,,,,,,fee schedule,547,2426.85,APC
Proton trmt simple w/o comp,77520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3199.69,,,,,,,fee schedule,547,3199.69,
Proton trmt simple w/o comp,77520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2564.83,,,,,,,fee schedule,547,3199.69,
Proton trmt simple w/o comp,77520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2801.85,,,,,,,fee schedule,547,3199.69,
Proton trmt simple w/o comp,77520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2945.75,,,,,,,fee schedule,547,3199.69,
Proton trmt simple w/o comp,77520,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2426.85,,,,,,,fee schedule,547,3199.69,APC 378
Proton trmt simple w/o comp,77520,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,574.35,,,,,,,fee schedule,547,3199.69,APC
Proton trmt simple w/o comp,77520,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,568.88,,,,,,,fee schedule,547,3199.69,APC
Proton trmt simple w/o comp,77520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,547,,,,,,,fee schedule,547,3199.69,APC
Proton trmt simple w/o comp,77520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,836.91,,,,,,,fee schedule,547,3199.69,Radiology
Proton trmt simple w/o comp,77520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,765.8,,,,,,,fee schedule,547,3199.69,APC
Proton trmt simple w/o comp,77520,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,957.25,,,,,,,fee schedule,547,3199.69,APC
Proton trmt simple w/comp,77522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3199.69,,,,,,,fee schedule,1237.2,5489.05,
Proton trmt simple w/comp,77522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2564.83,,,,,,,fee schedule,1237.2,5489.05,
Proton trmt simple w/comp,77522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2801.85,,,,,,,fee schedule,1237.2,5489.05,
Proton trmt simple w/comp,77522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2945.75,,,,,,,fee schedule,1237.2,5489.05,
Proton trmt simple w/comp,77522,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5489.05,,,,,,,fee schedule,1237.2,5489.05,APC 378
Proton trmt simple w/comp,77522,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1299.06,,,,,,,fee schedule,1237.2,5489.05,APC
Proton trmt simple w/comp,77522,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1286.69,,,,,,,fee schedule,1237.2,5489.05,APC
Proton trmt simple w/comp,77522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1237.2,,,,,,,fee schedule,1237.2,5489.05,APC
Proton trmt simple w/comp,77522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1892.92,,,,,,,fee schedule,1237.2,5489.05,Radiology
Proton trmt simple w/comp,77522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1732.08,,,,,,,fee schedule,1237.2,5489.05,APC
Proton trmt simple w/comp,77522,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2165.11,,,,,,,fee schedule,1237.2,5489.05,APC
Proton trmt intermediate,77523,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3828.57,,,,,,,fee schedule,1237.2,5489.05,
Proton trmt intermediate,77523,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3068.94,,,,,,,fee schedule,1237.2,5489.05,
Proton trmt intermediate,77523,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3352.53,,,,,,,fee schedule,1237.2,5489.05,
Proton trmt intermediate,77523,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3524.72,,,,,,,fee schedule,1237.2,5489.05,
Proton trmt intermediate,77523,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5489.05,,,,,,,fee schedule,1237.2,5489.05,APC 378
Proton trmt intermediate,77523,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1299.06,,,,,,,fee schedule,1237.2,5489.05,APC
Proton trmt intermediate,77523,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1286.69,,,,,,,fee schedule,1237.2,5489.05,APC
Proton trmt intermediate,77523,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1237.2,,,,,,,fee schedule,1237.2,5489.05,APC
Proton trmt intermediate,77523,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1892.92,,,,,,,fee schedule,1237.2,5489.05,Radiology
Proton trmt intermediate,77523,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1732.08,,,,,,,fee schedule,1237.2,5489.05,APC
Proton trmt intermediate,77523,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2165.11,,,,,,,fee schedule,1237.2,5489.05,APC
Proton treatment complex,77525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3828.57,,,,,,,fee schedule,1237.2,5489.05,
Proton treatment complex,77525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3068.94,,,,,,,fee schedule,1237.2,5489.05,
Proton treatment complex,77525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3352.53,,,,,,,fee schedule,1237.2,5489.05,
Proton treatment complex,77525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3524.72,,,,,,,fee schedule,1237.2,5489.05,
Proton treatment complex,77525,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5489.05,,,,,,,fee schedule,1237.2,5489.05,APC 378
Proton treatment complex,77525,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1299.06,,,,,,,fee schedule,1237.2,5489.05,APC
Proton treatment complex,77525,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1286.69,,,,,,,fee schedule,1237.2,5489.05,APC
Proton treatment complex,77525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1237.2,,,,,,,fee schedule,1237.2,5489.05,APC
Proton treatment complex,77525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1892.92,,,,,,,fee schedule,1237.2,5489.05,Radiology
Proton treatment complex,77525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1732.08,,,,,,,fee schedule,1237.2,5489.05,APC
Proton treatment complex,77525,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2165.11,,,,,,,fee schedule,1237.2,5489.05,APC
Hyperthermia treatment,77600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1447.44,,,,,,,fee schedule,381.83,1694.04,
Hyperthermia treatment,77600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1160.25,,,,,,,fee schedule,381.83,1694.04,
Hyperthermia treatment,77600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1267.47,,,,,,,fee schedule,381.83,1694.04,
Hyperthermia treatment,77600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1332.56,,,,,,,fee schedule,381.83,1694.04,
Hyperthermia treatment,77600,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1694.04,,,,,,,fee schedule,381.83,1694.04,APC 378
Hyperthermia treatment,77600,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,400.92,,,,,,,fee schedule,381.83,1694.04,APC
Hyperthermia treatment,77600,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,397.1,,,,,,,fee schedule,381.83,1694.04,APC
Hyperthermia treatment,77600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,381.83,,,,,,,fee schedule,381.83,1694.04,APC
Hyperthermia treatment,77600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,584.19,,,,,,,fee schedule,381.83,1694.04,Radiology
Hyperthermia treatment,77600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,534.56,,,,,,,fee schedule,381.83,1694.04,APC
Hyperthermia treatment,77600,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,668.2,,,,,,,fee schedule,381.83,1694.04,APC
Hyperthermia treatment,77605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1447.44,,,,,,,fee schedule,689.49,3059.02,
Hyperthermia treatment,77605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1160.25,,,,,,,fee schedule,689.49,3059.02,
Hyperthermia treatment,77605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1267.47,,,,,,,fee schedule,689.49,3059.02,
Hyperthermia treatment,77605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1332.56,,,,,,,fee schedule,689.49,3059.02,
Hyperthermia treatment,77605,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3059.02,,,,,,,fee schedule,689.49,3059.02,APC 378
Hyperthermia treatment,77605,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,723.96,,,,,,,fee schedule,689.49,3059.02,APC
Hyperthermia treatment,77605,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,717.07,,,,,,,fee schedule,689.49,3059.02,APC
Hyperthermia treatment,77605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,689.49,,,,,,,fee schedule,689.49,3059.02,APC
Hyperthermia treatment,77605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1054.92,,,,,,,fee schedule,689.49,3059.02,Radiology
Hyperthermia treatment,77605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,965.28,,,,,,,fee schedule,689.49,3059.02,APC
Hyperthermia treatment,77605,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1206.6,,,,,,,fee schedule,689.49,3059.02,APC
Hyperthermia treatment,77610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1447.44,,,,,,,fee schedule,547,2426.85,
Hyperthermia treatment,77610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1160.25,,,,,,,fee schedule,547,2426.85,
Hyperthermia treatment,77610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1267.47,,,,,,,fee schedule,547,2426.85,
Hyperthermia treatment,77610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1332.56,,,,,,,fee schedule,547,2426.85,
Hyperthermia treatment,77610,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2426.85,,,,,,,fee schedule,547,2426.85,APC 378
Hyperthermia treatment,77610,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,574.35,,,,,,,fee schedule,547,2426.85,APC
Hyperthermia treatment,77610,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,568.88,,,,,,,fee schedule,547,2426.85,APC
Hyperthermia treatment,77610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,547,,,,,,,fee schedule,547,2426.85,APC
Hyperthermia treatment,77610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,836.91,,,,,,,fee schedule,547,2426.85,Radiology
Hyperthermia treatment,77610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,765.8,,,,,,,fee schedule,547,2426.85,APC
Hyperthermia treatment,77610,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,957.25,,,,,,,fee schedule,547,2426.85,APC
Hyperthermia treatment,77615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1447.44,,,,,,,fee schedule,547,2426.85,
Hyperthermia treatment,77615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1160.25,,,,,,,fee schedule,547,2426.85,
Hyperthermia treatment,77615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1267.47,,,,,,,fee schedule,547,2426.85,
Hyperthermia treatment,77615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1332.56,,,,,,,fee schedule,547,2426.85,
Hyperthermia treatment,77615,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2426.85,,,,,,,fee schedule,547,2426.85,APC 378
Hyperthermia treatment,77615,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,574.35,,,,,,,fee schedule,547,2426.85,APC
Hyperthermia treatment,77615,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,568.88,,,,,,,fee schedule,547,2426.85,APC
Hyperthermia treatment,77615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,547,,,,,,,fee schedule,547,2426.85,APC
Hyperthermia treatment,77615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,836.91,,,,,,,fee schedule,547,2426.85,Radiology
Hyperthermia treatment,77615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,765.8,,,,,,,fee schedule,547,2426.85,APC
Hyperthermia treatment,77615,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,957.25,,,,,,,fee schedule,547,2426.85,APC
Hyperthermia treatment,77620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1447.44,,,,,,,fee schedule,547,2426.85,
Hyperthermia treatment,77620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1160.25,,,,,,,fee schedule,547,2426.85,
Hyperthermia treatment,77620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1267.47,,,,,,,fee schedule,547,2426.85,
Hyperthermia treatment,77620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1332.56,,,,,,,fee schedule,547,2426.85,
Hyperthermia treatment,77620,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2426.85,,,,,,,fee schedule,547,2426.85,APC 378
Hyperthermia treatment,77620,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,574.35,,,,,,,fee schedule,547,2426.85,APC
Hyperthermia treatment,77620,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,568.88,,,,,,,fee schedule,547,2426.85,APC
Hyperthermia treatment,77620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,547,,,,,,,fee schedule,547,2426.85,APC
Hyperthermia treatment,77620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,836.91,,,,,,,fee schedule,547,2426.85,Radiology
Hyperthermia treatment,77620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,765.8,,,,,,,fee schedule,547,2426.85,APC
Hyperthermia treatment,77620,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,957.25,,,,,,,fee schedule,547,2426.85,APC
Infuse radioactive materials,77750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,553.24,,,,,,,fee schedule,381.83,1694.04,
Infuse radioactive materials,77750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,443.47,,,,,,,fee schedule,381.83,1694.04,
Infuse radioactive materials,77750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,484.45,,,,,,,fee schedule,381.83,1694.04,
Infuse radioactive materials,77750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,509.33,,,,,,,fee schedule,381.83,1694.04,
Infuse radioactive materials,77750,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1694.04,,,,,,,fee schedule,381.83,1694.04,APC 378
Infuse radioactive materials,77750,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,400.92,,,,,,,fee schedule,381.83,1694.04,APC
Infuse radioactive materials,77750,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,397.1,,,,,,,fee schedule,381.83,1694.04,APC
Infuse radioactive materials,77750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,381.83,,,,,,,fee schedule,381.83,1694.04,APC
Infuse radioactive materials,77750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,584.19,,,,,,,fee schedule,381.83,1694.04,Radiology
Infuse radioactive materials,77750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,534.56,,,,,,,fee schedule,381.83,1694.04,APC
Infuse radioactive materials,77750,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,668.2,,,,,,,fee schedule,381.83,1694.04,APC
Apply intrcav radiat simple,77761,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2124.89,,,,,,,fee schedule,547,2426.85,
Apply intrcav radiat simple,77761,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1703.28,,,,,,,fee schedule,547,2426.85,
Apply intrcav radiat simple,77761,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1860.68,,,,,,,fee schedule,547,2426.85,
Apply intrcav radiat simple,77761,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1956.25,,,,,,,fee schedule,547,2426.85,
Apply intrcav radiat simple,77761,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2426.85,,,,,,,fee schedule,547,2426.85,APC 378
Apply intrcav radiat simple,77761,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,574.35,,,,,,,fee schedule,547,2426.85,APC
Apply intrcav radiat simple,77761,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,568.88,,,,,,,fee schedule,547,2426.85,APC
Apply intrcav radiat simple,77761,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,547,,,,,,,fee schedule,547,2426.85,APC
Apply intrcav radiat simple,77761,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,836.91,,,,,,,fee schedule,547,2426.85,Radiology
Apply intrcav radiat simple,77761,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,765.8,,,,,,,fee schedule,547,2426.85,APC
Apply intrcav radiat simple,77761,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,957.25,,,,,,,fee schedule,547,2426.85,APC
Apply intrcav radiat interm,77762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2124.89,,,,,,,fee schedule,547,2426.85,
Apply intrcav radiat interm,77762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1703.28,,,,,,,fee schedule,547,2426.85,
Apply intrcav radiat interm,77762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1860.68,,,,,,,fee schedule,547,2426.85,
Apply intrcav radiat interm,77762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1956.25,,,,,,,fee schedule,547,2426.85,
Apply intrcav radiat interm,77762,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2426.85,,,,,,,fee schedule,547,2426.85,APC 378
Apply intrcav radiat interm,77762,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,574.35,,,,,,,fee schedule,547,2426.85,APC
Apply intrcav radiat interm,77762,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,568.88,,,,,,,fee schedule,547,2426.85,APC
Apply intrcav radiat interm,77762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,547,,,,,,,fee schedule,547,2426.85,APC
Apply intrcav radiat interm,77762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,836.91,,,,,,,fee schedule,547,2426.85,Radiology
Apply intrcav radiat interm,77762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,765.8,,,,,,,fee schedule,547,2426.85,APC
Apply intrcav radiat interm,77762,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,957.25,,,,,,,fee schedule,547,2426.85,APC
Apply intrcav radiat compl,77763,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2124.89,,,,,,,fee schedule,689.49,3059.02,
Apply intrcav radiat compl,77763,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1703.28,,,,,,,fee schedule,689.49,3059.02,
Apply intrcav radiat compl,77763,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1860.68,,,,,,,fee schedule,689.49,3059.02,
Apply intrcav radiat compl,77763,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1956.25,,,,,,,fee schedule,689.49,3059.02,
Apply intrcav radiat compl,77763,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3059.02,,,,,,,fee schedule,689.49,3059.02,APC 378
Apply intrcav radiat compl,77763,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,723.96,,,,,,,fee schedule,689.49,3059.02,APC
Apply intrcav radiat compl,77763,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,717.07,,,,,,,fee schedule,689.49,3059.02,APC
Apply intrcav radiat compl,77763,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,689.49,,,,,,,fee schedule,689.49,3059.02,APC
Apply intrcav radiat compl,77763,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1054.92,,,,,,,fee schedule,689.49,3059.02,Radiology
Apply intrcav radiat compl,77763,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,965.28,,,,,,,fee schedule,689.49,3059.02,APC
Apply intrcav radiat compl,77763,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1206.6,,,,,,,fee schedule,689.49,3059.02,APC
Hdr rdncl skn surf brachytx,77767,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,734.64,,,,,,,fee schedule,381.83,1694.04,
Hdr rdncl skn surf brachytx,77767,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,588.88,,,,,,,fee schedule,381.83,1694.04,
Hdr rdncl skn surf brachytx,77767,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,643.3,,,,,,,fee schedule,381.83,1694.04,
Hdr rdncl skn surf brachytx,77767,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,676.34,,,,,,,fee schedule,381.83,1694.04,
Hdr rdncl skn surf brachytx,77767,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1694.04,,,,,,,fee schedule,381.83,1694.04,APC 378
Hdr rdncl skn surf brachytx,77767,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,400.92,,,,,,,fee schedule,381.83,1694.04,APC
Hdr rdncl skn surf brachytx,77767,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,397.1,,,,,,,fee schedule,381.83,1694.04,APC
Hdr rdncl skn surf brachytx,77767,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,381.83,,,,,,,fee schedule,381.83,1694.04,APC
Hdr rdncl skn surf brachytx,77767,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,584.19,,,,,,,fee schedule,381.83,1694.04,Radiology
Hdr rdncl skn surf brachytx,77767,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,534.56,,,,,,,fee schedule,381.83,1694.04,APC
Hdr rdncl skn surf brachytx,77767,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,668.2,,,,,,,fee schedule,381.83,1694.04,APC
Hdr rdncl skn surf brachytx,77768,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,734.64,,,,,,,fee schedule,381.83,1694.04,
Hdr rdncl skn surf brachytx,77768,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,588.88,,,,,,,fee schedule,381.83,1694.04,
Hdr rdncl skn surf brachytx,77768,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,643.3,,,,,,,fee schedule,381.83,1694.04,
Hdr rdncl skn surf brachytx,77768,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,676.34,,,,,,,fee schedule,381.83,1694.04,
Hdr rdncl skn surf brachytx,77768,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1694.04,,,,,,,fee schedule,381.83,1694.04,APC 378
Hdr rdncl skn surf brachytx,77768,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,400.92,,,,,,,fee schedule,381.83,1694.04,APC
Hdr rdncl skn surf brachytx,77768,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,397.1,,,,,,,fee schedule,381.83,1694.04,APC
Hdr rdncl skn surf brachytx,77768,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,381.83,,,,,,,fee schedule,381.83,1694.04,APC
Hdr rdncl skn surf brachytx,77768,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,584.19,,,,,,,fee schedule,381.83,1694.04,Radiology
Hdr rdncl skn surf brachytx,77768,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,534.56,,,,,,,fee schedule,381.83,1694.04,APC
Hdr rdncl skn surf brachytx,77768,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,668.2,,,,,,,fee schedule,381.83,1694.04,APC
Hdr rdncl ntrstl/icav brchtx,77770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,850.8,,,,,,,fee schedule,681.99,3059.02,
Hdr rdncl ntrstl/icav brchtx,77770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,681.99,,,,,,,fee schedule,681.99,3059.02,
Hdr rdncl ntrstl/icav brchtx,77770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,745.01,,,,,,,fee schedule,681.99,3059.02,
Hdr rdncl ntrstl/icav brchtx,77770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,783.28,,,,,,,fee schedule,681.99,3059.02,
Hdr rdncl ntrstl/icav brchtx,77770,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3059.02,,,,,,,fee schedule,681.99,3059.02,APC 378
Hdr rdncl ntrstl/icav brchtx,77770,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,723.96,,,,,,,fee schedule,681.99,3059.02,APC
Hdr rdncl ntrstl/icav brchtx,77770,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,717.07,,,,,,,fee schedule,681.99,3059.02,APC
Hdr rdncl ntrstl/icav brchtx,77770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,689.49,,,,,,,fee schedule,681.99,3059.02,APC
Hdr rdncl ntrstl/icav brchtx,77770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1054.92,,,,,,,fee schedule,681.99,3059.02,Radiology
Hdr rdncl ntrstl/icav brchtx,77770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,965.28,,,,,,,fee schedule,681.99,3059.02,APC
Hdr rdncl ntrstl/icav brchtx,77770,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1206.6,,,,,,,fee schedule,681.99,3059.02,APC
Hdr rdncl ntrstl/icav brchtx,77771,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1323.76,,,,,,,fee schedule,689.49,3059.02,
Hdr rdncl ntrstl/icav brchtx,77771,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1061.11,,,,,,,fee schedule,689.49,3059.02,
Hdr rdncl ntrstl/icav brchtx,77771,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1159.16,,,,,,,fee schedule,689.49,3059.02,
Hdr rdncl ntrstl/icav brchtx,77771,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1218.7,,,,,,,fee schedule,689.49,3059.02,
Hdr rdncl ntrstl/icav brchtx,77771,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3059.02,,,,,,,fee schedule,689.49,3059.02,APC 378
Hdr rdncl ntrstl/icav brchtx,77771,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,723.96,,,,,,,fee schedule,689.49,3059.02,APC
Hdr rdncl ntrstl/icav brchtx,77771,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,717.07,,,,,,,fee schedule,689.49,3059.02,APC
Hdr rdncl ntrstl/icav brchtx,77771,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,689.49,,,,,,,fee schedule,689.49,3059.02,APC
Hdr rdncl ntrstl/icav brchtx,77771,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1054.92,,,,,,,fee schedule,689.49,3059.02,Radiology
Hdr rdncl ntrstl/icav brchtx,77771,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,965.28,,,,,,,fee schedule,689.49,3059.02,APC
Hdr rdncl ntrstl/icav brchtx,77771,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1206.6,,,,,,,fee schedule,689.49,3059.02,APC
Hdr rdncl ntrstl/icav brchtx,77772,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2631.67,,,,,,,fee schedule,689.49,3059.02,
Hdr rdncl ntrstl/icav brchtx,77772,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2109.52,,,,,,,fee schedule,689.49,3059.02,
Hdr rdncl ntrstl/icav brchtx,77772,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2304.46,,,,,,,fee schedule,689.49,3059.02,
Hdr rdncl ntrstl/icav brchtx,77772,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2422.81,,,,,,,fee schedule,689.49,3059.02,
Hdr rdncl ntrstl/icav brchtx,77772,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3059.02,,,,,,,fee schedule,689.49,3059.02,APC 378
Hdr rdncl ntrstl/icav brchtx,77772,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,723.96,,,,,,,fee schedule,689.49,3059.02,APC
Hdr rdncl ntrstl/icav brchtx,77772,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,717.07,,,,,,,fee schedule,689.49,3059.02,APC
Hdr rdncl ntrstl/icav brchtx,77772,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,689.49,,,,,,,fee schedule,689.49,3059.02,APC
Hdr rdncl ntrstl/icav brchtx,77772,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1054.92,,,,,,,fee schedule,689.49,3059.02,Radiology
Hdr rdncl ntrstl/icav brchtx,77772,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,965.28,,,,,,,fee schedule,689.49,3059.02,APC
Hdr rdncl ntrstl/icav brchtx,77772,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1206.6,,,,,,,fee schedule,689.49,3059.02,APC
Apply interstit radiat compl,77778,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2945.68,,,,,,,fee schedule,689.49,3059.02,
Apply interstit radiat compl,77778,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2361.22,,,,,,,fee schedule,689.49,3059.02,
Apply interstit radiat compl,77778,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2579.42,,,,,,,fee schedule,689.49,3059.02,
Apply interstit radiat compl,77778,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2711.89,,,,,,,fee schedule,689.49,3059.02,
Apply interstit radiat compl,77778,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3059.02,,,,,,,fee schedule,689.49,3059.02,APC 378
Apply interstit radiat compl,77778,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,723.96,,,,,,,fee schedule,689.49,3059.02,APC
Apply interstit radiat compl,77778,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,717.07,,,,,,,fee schedule,689.49,3059.02,APC
Apply interstit radiat compl,77778,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,689.49,,,,,,,fee schedule,689.49,3059.02,APC
Apply interstit radiat compl,77778,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1054.92,,,,,,,fee schedule,689.49,3059.02,Radiology
Apply interstit radiat compl,77778,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,965.28,,,,,,,fee schedule,689.49,3059.02,APC
Apply interstit radiat compl,77778,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1206.6,,,,,,,fee schedule,689.49,3059.02,APC
Apply surf ldr radionuclide,77789,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,355.13,,,,,,,fee schedule,101.01,448.13,
Apply surf ldr radionuclide,77789,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,284.67,,,,,,,fee schedule,101.01,448.13,
Apply surf ldr radionuclide,77789,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,310.97,,,,,,,fee schedule,101.01,448.13,
Apply surf ldr radionuclide,77789,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,326.95,,,,,,,fee schedule,101.01,448.13,
Apply surf ldr radionuclide,77789,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,448.13,,,,,,,fee schedule,101.01,448.13,APC 378
Apply surf ldr radionuclide,77789,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,106.06,,,,,,,fee schedule,101.01,448.13,APC
Apply surf ldr radionuclide,77789,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,105.05,,,,,,,fee schedule,101.01,448.13,APC
Apply surf ldr radionuclide,77789,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,101.01,,,,,,,fee schedule,101.01,448.13,APC
Apply surf ldr radionuclide,77789,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,154.54,,,,,,,fee schedule,101.01,448.13,Radiology
Apply surf ldr radionuclide,77789,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,141.41,,,,,,,fee schedule,101.01,448.13,APC
Apply surf ldr radionuclide,77789,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,176.76,,,,,,,fee schedule,101.01,448.13,APC
Thyroid uptake measurement,78012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,184.43,,,,,,,fee schedule,147.83,1755.86,
Thyroid uptake measurement,78012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,147.83,,,,,,,fee schedule,147.83,1755.86,
Thyroid uptake measurement,78012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,161.49,,,,,,,fee schedule,147.83,1755.86,
Thyroid uptake measurement,78012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,169.79,,,,,,,fee schedule,147.83,1755.86,
Thyroid uptake measurement,78012,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755.86,,,,,,,fee schedule,147.83,1755.86,APC 378
Thyroid uptake measurement,78012,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,415.55,,,,,,,fee schedule,147.83,1755.86,APC
Thyroid uptake measurement,78012,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,411.59,,,,,,,fee schedule,147.83,1755.86,APC
Thyroid uptake measurement,78012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,395.76,,,,,,,fee schedule,147.83,1755.86,APC
Thyroid uptake measurement,78012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,605.51,,,,,,,fee schedule,147.83,1755.86,Radiology
Thyroid uptake measurement,78012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,554.06,,,,,,,fee schedule,147.83,1755.86,APC
Thyroid uptake measurement,78012,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,692.58,,,,,,,fee schedule,147.83,1755.86,APC
Thyroid imaging w/blood flow,78013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,567.15,,,,,,,fee schedule,395.76,1755.86,
Thyroid imaging w/blood flow,78013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,454.62,,,,,,,fee schedule,395.76,1755.86,
Thyroid imaging w/blood flow,78013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,496.63,,,,,,,fee schedule,395.76,1755.86,
Thyroid imaging w/blood flow,78013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,522.14,,,,,,,fee schedule,395.76,1755.86,
Thyroid imaging w/blood flow,78013,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755.86,,,,,,,fee schedule,395.76,1755.86,APC 378
Thyroid imaging w/blood flow,78013,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,415.55,,,,,,,fee schedule,395.76,1755.86,APC
Thyroid imaging w/blood flow,78013,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,411.59,,,,,,,fee schedule,395.76,1755.86,APC
Thyroid imaging w/blood flow,78013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,395.76,,,,,,,fee schedule,395.76,1755.86,APC
Thyroid imaging w/blood flow,78013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,605.51,,,,,,,fee schedule,395.76,1755.86,Radiology
Thyroid imaging w/blood flow,78013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,554.06,,,,,,,fee schedule,395.76,1755.86,APC
Thyroid imaging w/blood flow,78013,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,692.58,,,,,,,fee schedule,395.76,1755.86,APC
Thyroid imaging w/blood flow,78014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,207.9,,,,,,,fee schedule,166.65,1755.86,
Thyroid imaging w/blood flow,78014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,166.65,,,,,,,fee schedule,166.65,1755.86,
Thyroid imaging w/blood flow,78014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,182.05,,,,,,,fee schedule,166.65,1755.86,
Thyroid imaging w/blood flow,78014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,191.4,,,,,,,fee schedule,166.65,1755.86,
Thyroid imaging w/blood flow,78014,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755.86,,,,,,,fee schedule,166.65,1755.86,APC 378
Thyroid imaging w/blood flow,78014,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,415.55,,,,,,,fee schedule,166.65,1755.86,APC
Thyroid imaging w/blood flow,78014,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,411.59,,,,,,,fee schedule,166.65,1755.86,APC
Thyroid imaging w/blood flow,78014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,395.76,,,,,,,fee schedule,166.65,1755.86,APC
Thyroid imaging w/blood flow,78014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,605.51,,,,,,,fee schedule,166.65,1755.86,Radiology
Thyroid imaging w/blood flow,78014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,554.06,,,,,,,fee schedule,166.65,1755.86,APC
Thyroid imaging w/blood flow,78014,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,692.58,,,,,,,fee schedule,166.65,1755.86,APC
Thyroid met imaging,78015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1264.86,,,,,,,fee schedule,395.76,1755.86,
Thyroid met imaging,78015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1013.9,,,,,,,fee schedule,395.76,1755.86,
Thyroid met imaging,78015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1107.59,,,,,,,fee schedule,395.76,1755.86,
Thyroid met imaging,78015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1164.48,,,,,,,fee schedule,395.76,1755.86,
Thyroid met imaging,78015,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755.86,,,,,,,fee schedule,395.76,1755.86,APC 378
Thyroid met imaging,78015,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,415.55,,,,,,,fee schedule,395.76,1755.86,APC
Thyroid met imaging,78015,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,411.59,,,,,,,fee schedule,395.76,1755.86,APC
Thyroid met imaging,78015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,395.76,,,,,,,fee schedule,395.76,1755.86,APC
Thyroid met imaging,78015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,605.51,,,,,,,fee schedule,395.76,1755.86,Radiology
Thyroid met imaging,78015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,554.06,,,,,,,fee schedule,395.76,1755.86,APC
Thyroid met imaging,78015,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,692.58,,,,,,,fee schedule,395.76,1755.86,APC
Thyroid met imaging/studies,78016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,282.1,,,,,,,fee schedule,226.13,1755.86,
Thyroid met imaging/studies,78016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,226.13,,,,,,,fee schedule,226.13,1755.86,
Thyroid met imaging/studies,78016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,247.03,,,,,,,fee schedule,226.13,1755.86,
Thyroid met imaging/studies,78016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,259.71,,,,,,,fee schedule,226.13,1755.86,
Thyroid met imaging/studies,78016,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755.86,,,,,,,fee schedule,226.13,1755.86,APC 378
Thyroid met imaging/studies,78016,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,415.55,,,,,,,fee schedule,226.13,1755.86,APC
Thyroid met imaging/studies,78016,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,411.59,,,,,,,fee schedule,226.13,1755.86,APC
Thyroid met imaging/studies,78016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,395.76,,,,,,,fee schedule,226.13,1755.86,APC
Thyroid met imaging/studies,78016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,605.51,,,,,,,fee schedule,226.13,1755.86,Radiology
Thyroid met imaging/studies,78016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,554.06,,,,,,,fee schedule,226.13,1755.86,APC
Thyroid met imaging/studies,78016,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,692.58,,,,,,,fee schedule,226.13,1755.86,APC
Thyroid met imaging body,78018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1379.02,,,,,,,fee schedule,537.52,2384.8,
Thyroid met imaging body,78018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1105.4,,,,,,,fee schedule,537.52,2384.8,
Thyroid met imaging body,78018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1207.55,,,,,,,fee schedule,537.52,2384.8,
Thyroid met imaging body,78018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1269.57,,,,,,,fee schedule,537.52,2384.8,
Thyroid met imaging body,78018,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2384.8,,,,,,,fee schedule,537.52,2384.8,APC 378
Thyroid met imaging body,78018,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,564.4,,,,,,,fee schedule,537.52,2384.8,APC
Thyroid met imaging body,78018,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,559.02,,,,,,,fee schedule,537.52,2384.8,APC
Thyroid met imaging body,78018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,537.52,,,,,,,fee schedule,537.52,2384.8,APC
Thyroid met imaging body,78018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,822.41,,,,,,,fee schedule,537.52,2384.8,Radiology
Thyroid met imaging body,78018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,752.53,,,,,,,fee schedule,537.52,2384.8,APC
Thyroid met imaging body,78018,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,940.66,,,,,,,fee schedule,537.52,2384.8,APC
Parathyroid planar imaging,78070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,861.39,,,,,,,fee schedule,395.76,1755.86,
Parathyroid planar imaging,78070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,690.48,,,,,,,fee schedule,395.76,1755.86,
Parathyroid planar imaging,78070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,754.28,,,,,,,fee schedule,395.76,1755.86,
Parathyroid planar imaging,78070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,793.02,,,,,,,fee schedule,395.76,1755.86,
Parathyroid planar imaging,78070,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755.86,,,,,,,fee schedule,395.76,1755.86,APC 378
Parathyroid planar imaging,78070,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,415.55,,,,,,,fee schedule,395.76,1755.86,APC
Parathyroid planar imaging,78070,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,411.59,,,,,,,fee schedule,395.76,1755.86,APC
Parathyroid planar imaging,78070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,395.76,,,,,,,fee schedule,395.76,1755.86,APC
Parathyroid planar imaging,78070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,605.51,,,,,,,fee schedule,395.76,1755.86,Radiology
Parathyroid planar imaging,78070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,554.06,,,,,,,fee schedule,395.76,1755.86,APC
Parathyroid planar imaging,78070,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,692.58,,,,,,,fee schedule,395.76,1755.86,APC
Parathyrd planar w/wo subtrj,78071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1707.39,,,,,,,fee schedule,395.76,1755.86,
Parathyrd planar w/wo subtrj,78071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1368.62,,,,,,,fee schedule,395.76,1755.86,
Parathyrd planar w/wo subtrj,78071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1495.09,,,,,,,fee schedule,395.76,1755.86,
Parathyrd planar w/wo subtrj,78071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1571.88,,,,,,,fee schedule,395.76,1755.86,
Parathyrd planar w/wo subtrj,78071,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755.86,,,,,,,fee schedule,395.76,1755.86,APC 378
Parathyrd planar w/wo subtrj,78071,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,415.55,,,,,,,fee schedule,395.76,1755.86,APC
Parathyrd planar w/wo subtrj,78071,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,411.59,,,,,,,fee schedule,395.76,1755.86,APC
Parathyrd planar w/wo subtrj,78071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,395.76,,,,,,,fee schedule,395.76,1755.86,APC
Parathyrd planar w/wo subtrj,78071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,605.51,,,,,,,fee schedule,395.76,1755.86,Radiology
Parathyrd planar w/wo subtrj,78071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,554.06,,,,,,,fee schedule,395.76,1755.86,APC
Parathyrd planar w/wo subtrj,78071,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,692.58,,,,,,,fee schedule,395.76,1755.86,APC
Parathyrd planar w/spect&ct,78072,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1217.31,,,,,,,fee schedule,537.52,2384.8,
Parathyrd planar w/spect&ct,78072,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,975.78,,,,,,,fee schedule,537.52,2384.8,
Parathyrd planar w/spect&ct,78072,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1065.95,,,,,,,fee schedule,537.52,2384.8,
Parathyrd planar w/spect&ct,78072,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1120.7,,,,,,,fee schedule,537.52,2384.8,
Parathyrd planar w/spect&ct,78072,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2384.8,,,,,,,fee schedule,537.52,2384.8,APC 378
Parathyrd planar w/spect&ct,78072,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,564.4,,,,,,,fee schedule,537.52,2384.8,APC
Parathyrd planar w/spect&ct,78072,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,559.02,,,,,,,fee schedule,537.52,2384.8,APC
Parathyrd planar w/spect&ct,78072,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,537.52,,,,,,,fee schedule,537.52,2384.8,APC
Parathyrd planar w/spect&ct,78072,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,822.41,,,,,,,fee schedule,537.52,2384.8,Radiology
Parathyrd planar w/spect&ct,78072,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,752.53,,,,,,,fee schedule,537.52,2384.8,APC
Parathyrd planar w/spect&ct,78072,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,940.66,,,,,,,fee schedule,537.52,2384.8,APC
Adrenal cortex & medulla img,78075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1285.2,,,,,,,fee schedule,1030.2,5686.29,
Adrenal cortex & medulla img,78075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1030.2,,,,,,,fee schedule,1030.2,5686.29,
Adrenal cortex & medulla img,78075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1125.4,,,,,,,fee schedule,1030.2,5686.29,
Adrenal cortex & medulla img,78075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1183.2,,,,,,,fee schedule,1030.2,5686.29,
Adrenal cortex & medulla img,78075,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5686.29,,,,,,,fee schedule,1030.2,5686.29,APC 378
Adrenal cortex & medulla img,78075,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1345.74,,,,,,,fee schedule,1030.2,5686.29,APC
Adrenal cortex & medulla img,78075,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1332.93,,,,,,,fee schedule,1030.2,5686.29,APC
Adrenal cortex & medulla img,78075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1281.66,,,,,,,fee schedule,1030.2,5686.29,APC
Adrenal cortex & medulla img,78075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1960.94,,,,,,,fee schedule,1030.2,5686.29,Radiology
Adrenal cortex & medulla img,78075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1794.32,,,,,,,fee schedule,1030.2,5686.29,APC
Adrenal cortex & medulla img,78075,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2242.91,,,,,,,fee schedule,1030.2,5686.29,APC
Endocrine nuclear procedure,78099,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755.86,,,,,,,fee schedule,395.76,1755.86,APC 378
Endocrine nuclear procedure,78099,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,415.55,,,,,,,fee schedule,395.76,1755.86,APC
Endocrine nuclear procedure,78099,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,411.59,,,,,,,fee schedule,395.76,1755.86,APC
Endocrine nuclear procedure,78099,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,395.76,,,,,,,fee schedule,395.76,1755.86,APC
Endocrine nuclear procedure,78099,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,605.51,,,,,,,fee schedule,395.76,1755.86,Radiology
Endocrine nuclear procedure,78099,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,554.06,,,,,,,fee schedule,395.76,1755.86,APC
Endocrine nuclear procedure,78099,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,692.58,,,,,,,fee schedule,395.76,1755.86,APC
Bone marrow imaging ltd,78102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,980.65,,,,,,,fee schedule,395.76,1755.86,
Bone marrow imaging ltd,78102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,786.07,,,,,,,fee schedule,395.76,1755.86,
Bone marrow imaging ltd,78102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,858.71,,,,,,,fee schedule,395.76,1755.86,
Bone marrow imaging ltd,78102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,902.82,,,,,,,fee schedule,395.76,1755.86,
Bone marrow imaging ltd,78102,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755.86,,,,,,,fee schedule,395.76,1755.86,APC 378
Bone marrow imaging ltd,78102,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,415.55,,,,,,,fee schedule,395.76,1755.86,APC
Bone marrow imaging ltd,78102,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,411.59,,,,,,,fee schedule,395.76,1755.86,APC
Bone marrow imaging ltd,78102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,395.76,,,,,,,fee schedule,395.76,1755.86,APC
Bone marrow imaging ltd,78102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,605.51,,,,,,,fee schedule,395.76,1755.86,Radiology
Bone marrow imaging ltd,78102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,554.06,,,,,,,fee schedule,395.76,1755.86,APC
Bone marrow imaging ltd,78102,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,692.58,,,,,,,fee schedule,395.76,1755.86,APC
Bone marrow imaging mult,78103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,980.65,,,,,,,fee schedule,395.76,1755.86,
Bone marrow imaging mult,78103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,786.07,,,,,,,fee schedule,395.76,1755.86,
Bone marrow imaging mult,78103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,858.71,,,,,,,fee schedule,395.76,1755.86,
Bone marrow imaging mult,78103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,902.82,,,,,,,fee schedule,395.76,1755.86,
Bone marrow imaging mult,78103,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755.86,,,,,,,fee schedule,395.76,1755.86,APC 378
Bone marrow imaging mult,78103,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,415.55,,,,,,,fee schedule,395.76,1755.86,APC
Bone marrow imaging mult,78103,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,411.59,,,,,,,fee schedule,395.76,1755.86,APC
Bone marrow imaging mult,78103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,395.76,,,,,,,fee schedule,395.76,1755.86,APC
Bone marrow imaging mult,78103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,605.51,,,,,,,fee schedule,395.76,1755.86,Radiology
Bone marrow imaging mult,78103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,554.06,,,,,,,fee schedule,395.76,1755.86,APC
Bone marrow imaging mult,78103,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,692.58,,,,,,,fee schedule,395.76,1755.86,APC
Bone marrow imaging body,78104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,980.65,,,,,,,fee schedule,395.76,1755.86,
Bone marrow imaging body,78104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,786.07,,,,,,,fee schedule,395.76,1755.86,
Bone marrow imaging body,78104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,858.71,,,,,,,fee schedule,395.76,1755.86,
Bone marrow imaging body,78104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,902.82,,,,,,,fee schedule,395.76,1755.86,
Bone marrow imaging body,78104,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755.86,,,,,,,fee schedule,395.76,1755.86,APC 378
Bone marrow imaging body,78104,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,415.55,,,,,,,fee schedule,395.76,1755.86,APC
Bone marrow imaging body,78104,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,411.59,,,,,,,fee schedule,395.76,1755.86,APC
Bone marrow imaging body,78104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,395.76,,,,,,,fee schedule,395.76,1755.86,APC
Bone marrow imaging body,78104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,605.51,,,,,,,fee schedule,395.76,1755.86,Radiology
Bone marrow imaging body,78104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,554.06,,,,,,,fee schedule,395.76,1755.86,APC
Bone marrow imaging body,78104,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,692.58,,,,,,,fee schedule,395.76,1755.86,APC
Plasma volume single,78110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1420.6,,,,,,,fee schedule,1138.73,5686.29,
Plasma volume single,78110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1138.73,,,,,,,fee schedule,1138.73,5686.29,
Plasma volume single,78110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1243.96,,,,,,,fee schedule,1138.73,5686.29,
Plasma volume single,78110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1307.85,,,,,,,fee schedule,1138.73,5686.29,
Plasma volume single,78110,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5686.29,,,,,,,fee schedule,1138.73,5686.29,APC 378
Plasma volume single,78110,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1345.74,,,,,,,fee schedule,1138.73,5686.29,APC
Plasma volume single,78110,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1332.93,,,,,,,fee schedule,1138.73,5686.29,APC
Plasma volume single,78110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1281.66,,,,,,,fee schedule,1138.73,5686.29,APC
Plasma volume single,78110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1960.94,,,,,,,fee schedule,1138.73,5686.29,Radiology
Plasma volume single,78110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1794.32,,,,,,,fee schedule,1138.73,5686.29,APC
Plasma volume single,78110,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2242.91,,,,,,,fee schedule,1138.73,5686.29,APC
Plasma volume multiple,78111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1420.6,,,,,,,fee schedule,1138.73,5686.29,
Plasma volume multiple,78111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1138.73,,,,,,,fee schedule,1138.73,5686.29,
Plasma volume multiple,78111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1243.96,,,,,,,fee schedule,1138.73,5686.29,
Plasma volume multiple,78111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1307.85,,,,,,,fee schedule,1138.73,5686.29,
Plasma volume multiple,78111,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5686.29,,,,,,,fee schedule,1138.73,5686.29,APC 378
Plasma volume multiple,78111,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1345.74,,,,,,,fee schedule,1138.73,5686.29,APC
Plasma volume multiple,78111,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1332.93,,,,,,,fee schedule,1138.73,5686.29,APC
Plasma volume multiple,78111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1281.66,,,,,,,fee schedule,1138.73,5686.29,APC
Plasma volume multiple,78111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1960.94,,,,,,,fee schedule,1138.73,5686.29,Radiology
Plasma volume multiple,78111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1794.32,,,,,,,fee schedule,1138.73,5686.29,APC
Plasma volume multiple,78111,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2242.91,,,,,,,fee schedule,1138.73,5686.29,APC
Red cell mass single,78120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1420.6,,,,,,,fee schedule,395.76,1755.86,
Red cell mass single,78120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1138.73,,,,,,,fee schedule,395.76,1755.86,
Red cell mass single,78120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1243.96,,,,,,,fee schedule,395.76,1755.86,
Red cell mass single,78120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1307.85,,,,,,,fee schedule,395.76,1755.86,
Red cell mass single,78120,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755.86,,,,,,,fee schedule,395.76,1755.86,APC 378
Red cell mass single,78120,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,415.55,,,,,,,fee schedule,395.76,1755.86,APC
Red cell mass single,78120,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,411.59,,,,,,,fee schedule,395.76,1755.86,APC
Red cell mass single,78120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,395.76,,,,,,,fee schedule,395.76,1755.86,APC
Red cell mass single,78120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,605.51,,,,,,,fee schedule,395.76,1755.86,Radiology
Red cell mass single,78120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,554.06,,,,,,,fee schedule,395.76,1755.86,APC
Red cell mass single,78120,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,692.58,,,,,,,fee schedule,395.76,1755.86,APC
Red cell mass multiple,78121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1420.6,,,,,,,fee schedule,537.52,2384.8,
Red cell mass multiple,78121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1138.73,,,,,,,fee schedule,537.52,2384.8,
Red cell mass multiple,78121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1243.96,,,,,,,fee schedule,537.52,2384.8,
Red cell mass multiple,78121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1307.85,,,,,,,fee schedule,537.52,2384.8,
Red cell mass multiple,78121,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2384.8,,,,,,,fee schedule,537.52,2384.8,APC 378
Red cell mass multiple,78121,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,564.4,,,,,,,fee schedule,537.52,2384.8,APC
Red cell mass multiple,78121,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,559.02,,,,,,,fee schedule,537.52,2384.8,APC
Red cell mass multiple,78121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,537.52,,,,,,,fee schedule,537.52,2384.8,APC
Red cell mass multiple,78121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,822.41,,,,,,,fee schedule,537.52,2384.8,Radiology
Red cell mass multiple,78121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,752.53,,,,,,,fee schedule,537.52,2384.8,APC
Red cell mass multiple,78121,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,940.66,,,,,,,fee schedule,537.52,2384.8,APC
Blood volume,78122,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1420.6,,,,,,,fee schedule,537.52,2384.8,
Blood volume,78122,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1138.73,,,,,,,fee schedule,537.52,2384.8,
Blood volume,78122,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1243.96,,,,,,,fee schedule,537.52,2384.8,
Blood volume,78122,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1307.85,,,,,,,fee schedule,537.52,2384.8,
Blood volume,78122,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2384.8,,,,,,,fee schedule,537.52,2384.8,APC 378
Blood volume,78122,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,564.4,,,,,,,fee schedule,537.52,2384.8,APC
Blood volume,78122,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,559.02,,,,,,,fee schedule,537.52,2384.8,APC
Blood volume,78122,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,537.52,,,,,,,fee schedule,537.52,2384.8,APC
Blood volume,78122,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,822.41,,,,,,,fee schedule,537.52,2384.8,Radiology
Blood volume,78122,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,752.53,,,,,,,fee schedule,537.52,2384.8,APC
Blood volume,78122,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,940.66,,,,,,,fee schedule,537.52,2384.8,APC
Red cell survival study,78130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1420.6,,,,,,,fee schedule,395.76,1755.86,
Red cell survival study,78130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1138.73,,,,,,,fee schedule,395.76,1755.86,
Red cell survival study,78130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1243.96,,,,,,,fee schedule,395.76,1755.86,
Red cell survival study,78130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1307.85,,,,,,,fee schedule,395.76,1755.86,
Red cell survival study,78130,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755.86,,,,,,,fee schedule,395.76,1755.86,APC 378
Red cell survival study,78130,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,415.55,,,,,,,fee schedule,395.76,1755.86,APC
Red cell survival study,78130,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,411.59,,,,,,,fee schedule,395.76,1755.86,APC
Red cell survival study,78130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,395.76,,,,,,,fee schedule,395.76,1755.86,APC
Red cell survival study,78130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,605.51,,,,,,,fee schedule,395.76,1755.86,Radiology
Red cell survival study,78130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,554.06,,,,,,,fee schedule,395.76,1755.86,APC
Red cell survival study,78130,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,692.58,,,,,,,fee schedule,395.76,1755.86,APC
Red cell sequestration,78140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1420.6,,,,,,,fee schedule,395.76,1755.86,
Red cell sequestration,78140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1138.73,,,,,,,fee schedule,395.76,1755.86,
Red cell sequestration,78140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1243.96,,,,,,,fee schedule,395.76,1755.86,
Red cell sequestration,78140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1307.85,,,,,,,fee schedule,395.76,1755.86,
Red cell sequestration,78140,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755.86,,,,,,,fee schedule,395.76,1755.86,APC 378
Red cell sequestration,78140,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,415.55,,,,,,,fee schedule,395.76,1755.86,APC
Red cell sequestration,78140,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,411.59,,,,,,,fee schedule,395.76,1755.86,APC
Red cell sequestration,78140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,395.76,,,,,,,fee schedule,395.76,1755.86,APC
Red cell sequestration,78140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,605.51,,,,,,,fee schedule,395.76,1755.86,Radiology
Red cell sequestration,78140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,554.06,,,,,,,fee schedule,395.76,1755.86,APC
Red cell sequestration,78140,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,692.58,,,,,,,fee schedule,395.76,1755.86,APC
Spleen imaging,78185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,980.65,,,,,,,fee schedule,395.76,1755.86,
Spleen imaging,78185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,786.07,,,,,,,fee schedule,395.76,1755.86,
Spleen imaging,78185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,858.71,,,,,,,fee schedule,395.76,1755.86,
Spleen imaging,78185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,902.82,,,,,,,fee schedule,395.76,1755.86,
Spleen imaging,78185,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755.86,,,,,,,fee schedule,395.76,1755.86,APC 378
Spleen imaging,78185,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,415.55,,,,,,,fee schedule,395.76,1755.86,APC
Spleen imaging,78185,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,411.59,,,,,,,fee schedule,395.76,1755.86,APC
Spleen imaging,78185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,395.76,,,,,,,fee schedule,395.76,1755.86,APC
Spleen imaging,78185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,605.51,,,,,,,fee schedule,395.76,1755.86,Radiology
Spleen imaging,78185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,554.06,,,,,,,fee schedule,395.76,1755.86,APC
Spleen imaging,78185,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,692.58,,,,,,,fee schedule,395.76,1755.86,APC
Platelet survival,78191,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,724.32,,,,,,,fee schedule,395.76,1755.86,
Platelet survival,78191,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,580.61,,,,,,,fee schedule,395.76,1755.86,
Platelet survival,78191,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,634.26,,,,,,,fee schedule,395.76,1755.86,
Platelet survival,78191,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,666.84,,,,,,,fee schedule,395.76,1755.86,
Platelet survival,78191,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755.86,,,,,,,fee schedule,395.76,1755.86,APC 378
Platelet survival,78191,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,415.55,,,,,,,fee schedule,395.76,1755.86,APC
Platelet survival,78191,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,411.59,,,,,,,fee schedule,395.76,1755.86,APC
Platelet survival,78191,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,395.76,,,,,,,fee schedule,395.76,1755.86,APC
Platelet survival,78191,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,605.51,,,,,,,fee schedule,395.76,1755.86,Radiology
Platelet survival,78191,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,554.06,,,,,,,fee schedule,395.76,1755.86,APC
Platelet survival,78191,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,692.58,,,,,,,fee schedule,395.76,1755.86,APC
Lymph system imaging,78195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1069.29,,,,,,,fee schedule,537.52,2384.8,
Lymph system imaging,78195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,857.13,,,,,,,fee schedule,537.52,2384.8,
Lymph system imaging,78195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,936.33,,,,,,,fee schedule,537.52,2384.8,
Lymph system imaging,78195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,984.42,,,,,,,fee schedule,537.52,2384.8,
Lymph system imaging,78195,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2384.8,,,,,,,fee schedule,537.52,2384.8,APC 378
Lymph system imaging,78195,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,564.4,,,,,,,fee schedule,537.52,2384.8,APC
Lymph system imaging,78195,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,559.02,,,,,,,fee schedule,537.52,2384.8,APC
Lymph system imaging,78195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,537.52,,,,,,,fee schedule,537.52,2384.8,APC
Lymph system imaging,78195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,822.41,,,,,,,fee schedule,537.52,2384.8,Radiology
Lymph system imaging,78195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,752.53,,,,,,,fee schedule,537.52,2384.8,APC
Lymph system imaging,78195,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,940.66,,,,,,,fee schedule,537.52,2384.8,APC
Blood/lymph nuclear exam,78199,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755.86,,,,,,,fee schedule,395.76,1755.86,APC 378
Blood/lymph nuclear exam,78199,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,415.55,,,,,,,fee schedule,395.76,1755.86,APC
Blood/lymph nuclear exam,78199,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,411.59,,,,,,,fee schedule,395.76,1755.86,APC
Blood/lymph nuclear exam,78199,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,395.76,,,,,,,fee schedule,395.76,1755.86,APC
Blood/lymph nuclear exam,78199,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,605.51,,,,,,,fee schedule,395.76,1755.86,Radiology
Blood/lymph nuclear exam,78199,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,554.06,,,,,,,fee schedule,395.76,1755.86,APC
Blood/lymph nuclear exam,78199,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,692.58,,,,,,,fee schedule,395.76,1755.86,APC
Liver imaging,78201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1113.17,,,,,,,fee schedule,537.52,2384.8,
Liver imaging,78201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,892.3,,,,,,,fee schedule,537.52,2384.8,
Liver imaging,78201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,974.76,,,,,,,fee schedule,537.52,2384.8,
Liver imaging,78201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1024.83,,,,,,,fee schedule,537.52,2384.8,
Liver imaging,78201,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2384.8,,,,,,,fee schedule,537.52,2384.8,APC 378
Liver imaging,78201,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,564.4,,,,,,,fee schedule,537.52,2384.8,APC
Liver imaging,78201,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,559.02,,,,,,,fee schedule,537.52,2384.8,APC
Liver imaging,78201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,537.52,,,,,,,fee schedule,537.52,2384.8,APC
Liver imaging,78201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,822.41,,,,,,,fee schedule,537.52,2384.8,Radiology
Liver imaging,78201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,752.53,,,,,,,fee schedule,537.52,2384.8,APC
Liver imaging,78201,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,940.66,,,,,,,fee schedule,537.52,2384.8,APC
Liver imaging with flow,78202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1113.17,,,,,,,fee schedule,537.52,2384.8,
Liver imaging with flow,78202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,892.3,,,,,,,fee schedule,537.52,2384.8,
Liver imaging with flow,78202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,974.76,,,,,,,fee schedule,537.52,2384.8,
Liver imaging with flow,78202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1024.83,,,,,,,fee schedule,537.52,2384.8,
Liver imaging with flow,78202,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2384.8,,,,,,,fee schedule,537.52,2384.8,APC 378
Liver imaging with flow,78202,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,564.4,,,,,,,fee schedule,537.52,2384.8,APC
Liver imaging with flow,78202,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,559.02,,,,,,,fee schedule,537.52,2384.8,APC
Liver imaging with flow,78202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,537.52,,,,,,,fee schedule,537.52,2384.8,APC
Liver imaging with flow,78202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,822.41,,,,,,,fee schedule,537.52,2384.8,Radiology
Liver imaging with flow,78202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,752.53,,,,,,,fee schedule,537.52,2384.8,APC
Liver imaging with flow,78202,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,940.66,,,,,,,fee schedule,537.52,2384.8,APC
Liver and spleen imaging,78215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1400.87,,,,,,,fee schedule,395.76,1755.86,
Liver and spleen imaging,78215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1122.92,,,,,,,fee schedule,395.76,1755.86,
Liver and spleen imaging,78215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1226.69,,,,,,,fee schedule,395.76,1755.86,
Liver and spleen imaging,78215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1289.69,,,,,,,fee schedule,395.76,1755.86,
Liver and spleen imaging,78215,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755.86,,,,,,,fee schedule,395.76,1755.86,APC 378
Liver and spleen imaging,78215,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,415.55,,,,,,,fee schedule,395.76,1755.86,APC
Liver and spleen imaging,78215,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,411.59,,,,,,,fee schedule,395.76,1755.86,APC
Liver and spleen imaging,78215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,395.76,,,,,,,fee schedule,395.76,1755.86,APC
Liver and spleen imaging,78215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,605.51,,,,,,,fee schedule,395.76,1755.86,Radiology
Liver and spleen imaging,78215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,554.06,,,,,,,fee schedule,395.76,1755.86,APC
Liver and spleen imaging,78215,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,692.58,,,,,,,fee schedule,395.76,1755.86,APC
Liver & spleen image/flow,78216,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1113.17,,,,,,,fee schedule,395.76,1755.86,
Liver & spleen image/flow,78216,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,892.3,,,,,,,fee schedule,395.76,1755.86,
Liver & spleen image/flow,78216,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,974.76,,,,,,,fee schedule,395.76,1755.86,
Liver & spleen image/flow,78216,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1024.83,,,,,,,fee schedule,395.76,1755.86,
Liver & spleen image/flow,78216,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755.86,,,,,,,fee schedule,395.76,1755.86,APC 378
Liver & spleen image/flow,78216,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,415.55,,,,,,,fee schedule,395.76,1755.86,APC
Liver & spleen image/flow,78216,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,411.59,,,,,,,fee schedule,395.76,1755.86,APC
Liver & spleen image/flow,78216,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,395.76,,,,,,,fee schedule,395.76,1755.86,APC
Liver & spleen image/flow,78216,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,605.51,,,,,,,fee schedule,395.76,1755.86,Radiology
Liver & spleen image/flow,78216,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,554.06,,,,,,,fee schedule,395.76,1755.86,APC
Liver & spleen image/flow,78216,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,692.58,,,,,,,fee schedule,395.76,1755.86,APC
Hepatobiliary system imaging,78226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,805.75,,,,,,,fee schedule,395.76,1755.86,
Hepatobiliary system imaging,78226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,645.88,,,,,,,fee schedule,395.76,1755.86,
Hepatobiliary system imaging,78226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,705.56,,,,,,,fee schedule,395.76,1755.86,
Hepatobiliary system imaging,78226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,741.8,,,,,,,fee schedule,395.76,1755.86,
Hepatobiliary system imaging,78226,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755.86,,,,,,,fee schedule,395.76,1755.86,APC 378
Hepatobiliary system imaging,78226,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,415.55,,,,,,,fee schedule,395.76,1755.86,APC
Hepatobiliary system imaging,78226,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,411.59,,,,,,,fee schedule,395.76,1755.86,APC
Hepatobiliary system imaging,78226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,395.76,,,,,,,fee schedule,395.76,1755.86,APC
Hepatobiliary system imaging,78226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,605.51,,,,,,,fee schedule,395.76,1755.86,Radiology
Hepatobiliary system imaging,78226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,554.06,,,,,,,fee schedule,395.76,1755.86,APC
Hepatobiliary system imaging,78226,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,692.58,,,,,,,fee schedule,395.76,1755.86,APC
Hepatobil syst image w/drug,78227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1312.83,,,,,,,fee schedule,537.52,2384.8,
Hepatobil syst image w/drug,78227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1052.35,,,,,,,fee schedule,537.52,2384.8,
Hepatobil syst image w/drug,78227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1149.6,,,,,,,fee schedule,537.52,2384.8,
Hepatobil syst image w/drug,78227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1208.64,,,,,,,fee schedule,537.52,2384.8,
Hepatobil syst image w/drug,78227,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2384.8,,,,,,,fee schedule,537.52,2384.8,APC 378
Hepatobil syst image w/drug,78227,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,564.4,,,,,,,fee schedule,537.52,2384.8,APC
Hepatobil syst image w/drug,78227,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,559.02,,,,,,,fee schedule,537.52,2384.8,APC
Hepatobil syst image w/drug,78227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,537.52,,,,,,,fee schedule,537.52,2384.8,APC
Hepatobil syst image w/drug,78227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,822.41,,,,,,,fee schedule,537.52,2384.8,Radiology
Hepatobil syst image w/drug,78227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,752.53,,,,,,,fee schedule,537.52,2384.8,APC
Hepatobil syst image w/drug,78227,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,940.66,,,,,,,fee schedule,537.52,2384.8,APC
Salivary gland imaging,78230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,946.17,,,,,,,fee schedule,395.76,1755.86,
Salivary gland imaging,78230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,758.44,,,,,,,fee schedule,395.76,1755.86,
Salivary gland imaging,78230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,828.53,,,,,,,fee schedule,395.76,1755.86,
Salivary gland imaging,78230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,871.08,,,,,,,fee schedule,395.76,1755.86,
Salivary gland imaging,78230,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755.86,,,,,,,fee schedule,395.76,1755.86,APC 378
Salivary gland imaging,78230,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,415.55,,,,,,,fee schedule,395.76,1755.86,APC
Salivary gland imaging,78230,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,411.59,,,,,,,fee schedule,395.76,1755.86,APC
Salivary gland imaging,78230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,395.76,,,,,,,fee schedule,395.76,1755.86,APC
Salivary gland imaging,78230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,605.51,,,,,,,fee schedule,395.76,1755.86,Radiology
Salivary gland imaging,78230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,554.06,,,,,,,fee schedule,395.76,1755.86,APC
Salivary gland imaging,78230,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,692.58,,,,,,,fee schedule,395.76,1755.86,APC
Serial salivary imaging,78231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,946.17,,,,,,,fee schedule,395.76,1755.86,
Serial salivary imaging,78231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,758.44,,,,,,,fee schedule,395.76,1755.86,
Serial salivary imaging,78231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,828.53,,,,,,,fee schedule,395.76,1755.86,
Serial salivary imaging,78231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,871.08,,,,,,,fee schedule,395.76,1755.86,
Serial salivary imaging,78231,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755.86,,,,,,,fee schedule,395.76,1755.86,APC 378
Serial salivary imaging,78231,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,415.55,,,,,,,fee schedule,395.76,1755.86,APC
Serial salivary imaging,78231,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,411.59,,,,,,,fee schedule,395.76,1755.86,APC
Serial salivary imaging,78231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,395.76,,,,,,,fee schedule,395.76,1755.86,APC
Serial salivary imaging,78231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,605.51,,,,,,,fee schedule,395.76,1755.86,Radiology
Serial salivary imaging,78231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,554.06,,,,,,,fee schedule,395.76,1755.86,APC
Serial salivary imaging,78231,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,692.58,,,,,,,fee schedule,395.76,1755.86,APC
Salivary gland function exam,78232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,946.17,,,,,,,fee schedule,395.76,1755.86,
Salivary gland function exam,78232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,758.44,,,,,,,fee schedule,395.76,1755.86,
Salivary gland function exam,78232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,828.53,,,,,,,fee schedule,395.76,1755.86,
Salivary gland function exam,78232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,871.08,,,,,,,fee schedule,395.76,1755.86,
Salivary gland function exam,78232,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755.86,,,,,,,fee schedule,395.76,1755.86,APC 378
Salivary gland function exam,78232,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,415.55,,,,,,,fee schedule,395.76,1755.86,APC
Salivary gland function exam,78232,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,411.59,,,,,,,fee schedule,395.76,1755.86,APC
Salivary gland function exam,78232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,395.76,,,,,,,fee schedule,395.76,1755.86,APC
Salivary gland function exam,78232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,605.51,,,,,,,fee schedule,395.76,1755.86,Radiology
Salivary gland function exam,78232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,554.06,,,,,,,fee schedule,395.76,1755.86,APC
Salivary gland function exam,78232,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,692.58,,,,,,,fee schedule,395.76,1755.86,APC
Esophageal motility study,78258,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,946.17,,,,,,,fee schedule,395.76,1755.86,
Esophageal motility study,78258,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,758.44,,,,,,,fee schedule,395.76,1755.86,
Esophageal motility study,78258,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,828.53,,,,,,,fee schedule,395.76,1755.86,
Esophageal motility study,78258,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,871.08,,,,,,,fee schedule,395.76,1755.86,
Esophageal motility study,78258,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755.86,,,,,,,fee schedule,395.76,1755.86,APC 378
Esophageal motility study,78258,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,415.55,,,,,,,fee schedule,395.76,1755.86,APC
Esophageal motility study,78258,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,411.59,,,,,,,fee schedule,395.76,1755.86,APC
Esophageal motility study,78258,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,395.76,,,,,,,fee schedule,395.76,1755.86,APC
Esophageal motility study,78258,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,605.51,,,,,,,fee schedule,395.76,1755.86,Radiology
Esophageal motility study,78258,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,554.06,,,,,,,fee schedule,395.76,1755.86,APC
Esophageal motility study,78258,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,692.58,,,,,,,fee schedule,395.76,1755.86,APC
Gastric mucosa imaging,78261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,946.17,,,,,,,fee schedule,395.76,1755.86,
Gastric mucosa imaging,78261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,758.44,,,,,,,fee schedule,395.76,1755.86,
Gastric mucosa imaging,78261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,828.53,,,,,,,fee schedule,395.76,1755.86,
Gastric mucosa imaging,78261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,871.08,,,,,,,fee schedule,395.76,1755.86,
Gastric mucosa imaging,78261,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755.86,,,,,,,fee schedule,395.76,1755.86,APC 378
Gastric mucosa imaging,78261,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,415.55,,,,,,,fee schedule,395.76,1755.86,APC
Gastric mucosa imaging,78261,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,411.59,,,,,,,fee schedule,395.76,1755.86,APC
Gastric mucosa imaging,78261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,395.76,,,,,,,fee schedule,395.76,1755.86,APC
Gastric mucosa imaging,78261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,605.51,,,,,,,fee schedule,395.76,1755.86,Radiology
Gastric mucosa imaging,78261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,554.06,,,,,,,fee schedule,395.76,1755.86,APC
Gastric mucosa imaging,78261,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,692.58,,,,,,,fee schedule,395.76,1755.86,APC
Gastroesophageal reflux exam,78262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,946.17,,,,,,,fee schedule,395.76,1755.86,
Gastroesophageal reflux exam,78262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,758.44,,,,,,,fee schedule,395.76,1755.86,
Gastroesophageal reflux exam,78262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,828.53,,,,,,,fee schedule,395.76,1755.86,
Gastroesophageal reflux exam,78262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,871.08,,,,,,,fee schedule,395.76,1755.86,
Gastroesophageal reflux exam,78262,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755.86,,,,,,,fee schedule,395.76,1755.86,APC 378
Gastroesophageal reflux exam,78262,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,415.55,,,,,,,fee schedule,395.76,1755.86,APC
Gastroesophageal reflux exam,78262,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,411.59,,,,,,,fee schedule,395.76,1755.86,APC
Gastroesophageal reflux exam,78262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,395.76,,,,,,,fee schedule,395.76,1755.86,APC
Gastroesophageal reflux exam,78262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,605.51,,,,,,,fee schedule,395.76,1755.86,Radiology
Gastroesophageal reflux exam,78262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,554.06,,,,,,,fee schedule,395.76,1755.86,APC
Gastroesophageal reflux exam,78262,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,692.58,,,,,,,fee schedule,395.76,1755.86,APC
Gastric emptying imag study,78264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,842.45,,,,,,,fee schedule,395.76,1755.86,
Gastric emptying imag study,78264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,675.3,,,,,,,fee schedule,395.76,1755.86,
Gastric emptying imag study,78264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,737.7,,,,,,,fee schedule,395.76,1755.86,
Gastric emptying imag study,78264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,775.59,,,,,,,fee schedule,395.76,1755.86,
Gastric emptying imag study,78264,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755.86,,,,,,,fee schedule,395.76,1755.86,APC 378
Gastric emptying imag study,78264,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,415.55,,,,,,,fee schedule,395.76,1755.86,APC
Gastric emptying imag study,78264,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,411.59,,,,,,,fee schedule,395.76,1755.86,APC
Gastric emptying imag study,78264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,395.76,,,,,,,fee schedule,395.76,1755.86,APC
Gastric emptying imag study,78264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,605.51,,,,,,,fee schedule,395.76,1755.86,Radiology
Gastric emptying imag study,78264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,554.06,,,,,,,fee schedule,395.76,1755.86,APC
Gastric emptying imag study,78264,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,692.58,,,,,,,fee schedule,395.76,1755.86,APC
Gastric emptying imag study,78265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1257.42,,,,,,,fee schedule,395.76,1755.86,
Gastric emptying imag study,78265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1007.93,,,,,,,fee schedule,395.76,1755.86,
Gastric emptying imag study,78265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1101.07,,,,,,,fee schedule,395.76,1755.86,
Gastric emptying imag study,78265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1157.62,,,,,,,fee schedule,395.76,1755.86,
Gastric emptying imag study,78265,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755.86,,,,,,,fee schedule,395.76,1755.86,APC 378
Gastric emptying imag study,78265,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,415.55,,,,,,,fee schedule,395.76,1755.86,APC
Gastric emptying imag study,78265,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,411.59,,,,,,,fee schedule,395.76,1755.86,APC
Gastric emptying imag study,78265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,395.76,,,,,,,fee schedule,395.76,1755.86,APC
Gastric emptying imag study,78265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,605.51,,,,,,,fee schedule,395.76,1755.86,Radiology
Gastric emptying imag study,78265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,554.06,,,,,,,fee schedule,395.76,1755.86,APC
Gastric emptying imag study,78265,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,692.58,,,,,,,fee schedule,395.76,1755.86,APC
Gastric emptying imag study,78266,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,341.22,,,,,,,fee schedule,273.52,2384.8,
Gastric emptying imag study,78266,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,273.52,,,,,,,fee schedule,273.52,2384.8,
Gastric emptying imag study,78266,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,298.79,,,,,,,fee schedule,273.52,2384.8,
Gastric emptying imag study,78266,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,314.14,,,,,,,fee schedule,273.52,2384.8,
Gastric emptying imag study,78266,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2384.8,,,,,,,fee schedule,273.52,2384.8,APC 378
Gastric emptying imag study,78266,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,564.4,,,,,,,fee schedule,273.52,2384.8,APC
Gastric emptying imag study,78266,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,559.02,,,,,,,fee schedule,273.52,2384.8,APC
Gastric emptying imag study,78266,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,537.52,,,,,,,fee schedule,273.52,2384.8,APC
Gastric emptying imag study,78266,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,822.41,,,,,,,fee schedule,273.52,2384.8,Radiology
Gastric emptying imag study,78266,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,752.53,,,,,,,fee schedule,273.52,2384.8,APC
Gastric emptying imag study,78266,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,940.66,,,,,,,fee schedule,273.52,2384.8,APC
Breath tst attain/anal c-14,78267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,43.39,,,,,,,fee schedule,9.95,43.39,
Breath tst attain/anal c-14,78267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,34.78,,,,,,,fee schedule,9.95,43.39,
Breath tst attain/anal c-14,78267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38,,,,,,,fee schedule,9.95,43.39,
Breath tst attain/anal c-14,78267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,39.95,,,,,,,fee schedule,9.95,43.39,
Breath tst attain/anal c-14,78267,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.95,,,,,,,fee schedule,9.95,43.39,Laboratory
Breath tst attain/anal c-14,78267,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.61,,,,,,,fee schedule,9.95,43.39,APC
Breath tst attain/anal c-14,78267,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11.5,,,,,,,fee schedule,9.95,43.39,APC
Breath tst attain/anal c-14,78267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11.06,,,,,,,fee schedule,9.95,43.39,APC
Breath tst attain/anal c-14,78267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.92,,,,,,,fee schedule,9.95,43.39,Radiology
Breath tst attain/anal c-14,78267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15.48,,,,,,,fee schedule,9.95,43.39,APC
Breath tst attain/anal c-14,78267,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19.36,,,,,,,fee schedule,9.95,43.39,APC
Breath test analysis c-14,78268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,359.4,,,,,,,fee schedule,84.97,359.4,
Breath test analysis c-14,78268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,288.09,,,,,,,fee schedule,84.97,359.4,
Breath test analysis c-14,78268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,314.71,,,,,,,fee schedule,84.97,359.4,
Breath test analysis c-14,78268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,330.88,,,,,,,fee schedule,84.97,359.4,
Breath test analysis c-14,78268,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,84.97,,,,,,,fee schedule,84.97,359.4,Laboratory
Breath test analysis c-14,78268,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,99.13,,,,,,,fee schedule,84.97,359.4,APC
Breath test analysis c-14,78268,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,98.19,,,,,,,fee schedule,84.97,359.4,APC
Breath test analysis c-14,78268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,94.41,,,,,,,fee schedule,84.97,359.4,APC
Breath test analysis c-14,78268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.45,,,,,,,fee schedule,84.97,359.4,Radiology
Breath test analysis c-14,78268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,132.17,,,,,,,fee schedule,84.97,359.4,APC
Breath test analysis c-14,78268,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,165.22,,,,,,,fee schedule,84.97,359.4,APC
Acute GI blood loss imaging,78278,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1098.2,,,,,,,fee schedule,395.76,1755.86,
Acute GI blood loss imaging,78278,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,880.31,,,,,,,fee schedule,395.76,1755.86,
Acute GI blood loss imaging,78278,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,961.65,,,,,,,fee schedule,395.76,1755.86,
Acute GI blood loss imaging,78278,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1011.04,,,,,,,fee schedule,395.76,1755.86,
Acute GI blood loss imaging,78278,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755.86,,,,,,,fee schedule,395.76,1755.86,APC 378
Acute GI blood loss imaging,78278,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,415.55,,,,,,,fee schedule,395.76,1755.86,APC
Acute GI blood loss imaging,78278,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,411.59,,,,,,,fee schedule,395.76,1755.86,APC
Acute GI blood loss imaging,78278,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,395.76,,,,,,,fee schedule,395.76,1755.86,APC
Acute GI blood loss imaging,78278,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,605.51,,,,,,,fee schedule,395.76,1755.86,Radiology
Acute GI blood loss imaging,78278,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,554.06,,,,,,,fee schedule,395.76,1755.86,APC
Acute GI blood loss imaging,78278,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,692.58,,,,,,,fee schedule,395.76,1755.86,APC
GI protein loss exam,78282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,946.17,,,,,,,fee schedule,395.76,1755.86,
GI protein loss exam,78282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,758.44,,,,,,,fee schedule,395.76,1755.86,
GI protein loss exam,78282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,828.53,,,,,,,fee schedule,395.76,1755.86,
GI protein loss exam,78282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,871.08,,,,,,,fee schedule,395.76,1755.86,
GI protein loss exam,78282,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755.86,,,,,,,fee schedule,395.76,1755.86,APC 378
GI protein loss exam,78282,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,415.55,,,,,,,fee schedule,395.76,1755.86,APC
GI protein loss exam,78282,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,411.59,,,,,,,fee schedule,395.76,1755.86,APC
GI protein loss exam,78282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,395.76,,,,,,,fee schedule,395.76,1755.86,APC
GI protein loss exam,78282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,605.51,,,,,,,fee schedule,395.76,1755.86,Radiology
GI protein loss exam,78282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,554.06,,,,,,,fee schedule,395.76,1755.86,APC
GI protein loss exam,78282,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,692.58,,,,,,,fee schedule,395.76,1755.86,APC
Meckels divert exam,78290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,656.09,,,,,,,fee schedule,395.76,1755.86,
Meckels divert exam,78290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,525.92,,,,,,,fee schedule,395.76,1755.86,
Meckels divert exam,78290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,574.52,,,,,,,fee schedule,395.76,1755.86,
Meckels divert exam,78290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,604.02,,,,,,,fee schedule,395.76,1755.86,
Meckels divert exam,78290,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755.86,,,,,,,fee schedule,395.76,1755.86,APC 378
Meckels divert exam,78290,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,415.55,,,,,,,fee schedule,395.76,1755.86,APC
Meckels divert exam,78290,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,411.59,,,,,,,fee schedule,395.76,1755.86,APC
Meckels divert exam,78290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,395.76,,,,,,,fee schedule,395.76,1755.86,APC
Meckels divert exam,78290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,605.51,,,,,,,fee schedule,395.76,1755.86,Radiology
Meckels divert exam,78290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,554.06,,,,,,,fee schedule,395.76,1755.86,APC
Meckels divert exam,78290,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,692.58,,,,,,,fee schedule,395.76,1755.86,APC
Leveen/shunt patency exam,78291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,946.17,,,,,,,fee schedule,395.76,1755.86,
Leveen/shunt patency exam,78291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,758.44,,,,,,,fee schedule,395.76,1755.86,
Leveen/shunt patency exam,78291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,828.53,,,,,,,fee schedule,395.76,1755.86,
Leveen/shunt patency exam,78291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,871.08,,,,,,,fee schedule,395.76,1755.86,
Leveen/shunt patency exam,78291,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755.86,,,,,,,fee schedule,395.76,1755.86,APC 378
Leveen/shunt patency exam,78291,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,415.55,,,,,,,fee schedule,395.76,1755.86,APC
Leveen/shunt patency exam,78291,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,411.59,,,,,,,fee schedule,395.76,1755.86,APC
Leveen/shunt patency exam,78291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,395.76,,,,,,,fee schedule,395.76,1755.86,APC
Leveen/shunt patency exam,78291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,605.51,,,,,,,fee schedule,395.76,1755.86,Radiology
Leveen/shunt patency exam,78291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,554.06,,,,,,,fee schedule,395.76,1755.86,APC
Leveen/shunt patency exam,78291,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,692.58,,,,,,,fee schedule,395.76,1755.86,APC
GI nuclear procedure,78299,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755.86,,,,,,,fee schedule,395.76,1755.86,APC 378
GI nuclear procedure,78299,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,415.55,,,,,,,fee schedule,395.76,1755.86,APC
GI nuclear procedure,78299,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,411.59,,,,,,,fee schedule,395.76,1755.86,APC
GI nuclear procedure,78299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,395.76,,,,,,,fee schedule,395.76,1755.86,APC
GI nuclear procedure,78299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,605.51,,,,,,,fee schedule,395.76,1755.86,Radiology
GI nuclear procedure,78299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,554.06,,,,,,,fee schedule,395.76,1755.86,APC
GI nuclear procedure,78299,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,692.58,,,,,,,fee schedule,395.76,1755.86,APC
Bone imaging limited area,78300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,949.76,,,,,,,fee schedule,395.76,1755.86,
Bone imaging limited area,78300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,761.32,,,,,,,fee schedule,395.76,1755.86,
Bone imaging limited area,78300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,831.67,,,,,,,fee schedule,395.76,1755.86,
Bone imaging limited area,78300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,874.38,,,,,,,fee schedule,395.76,1755.86,
Bone imaging limited area,78300,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755.86,,,,,,,fee schedule,395.76,1755.86,APC 378
Bone imaging limited area,78300,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,415.55,,,,,,,fee schedule,395.76,1755.86,APC
Bone imaging limited area,78300,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,411.59,,,,,,,fee schedule,395.76,1755.86,APC
Bone imaging limited area,78300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,395.76,,,,,,,fee schedule,395.76,1755.86,APC
Bone imaging limited area,78300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,605.51,,,,,,,fee schedule,395.76,1755.86,Radiology
Bone imaging limited area,78300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,554.06,,,,,,,fee schedule,395.76,1755.86,APC
Bone imaging limited area,78300,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,692.58,,,,,,,fee schedule,395.76,1755.86,APC
Bone imaging multiple areas,78305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,949.38,,,,,,,fee schedule,395.76,1755.86,
Bone imaging multiple areas,78305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,761.01,,,,,,,fee schedule,395.76,1755.86,
Bone imaging multiple areas,78305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,831.34,,,,,,,fee schedule,395.76,1755.86,
Bone imaging multiple areas,78305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,874.04,,,,,,,fee schedule,395.76,1755.86,
Bone imaging multiple areas,78305,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755.86,,,,,,,fee schedule,395.76,1755.86,APC 378
Bone imaging multiple areas,78305,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,415.55,,,,,,,fee schedule,395.76,1755.86,APC
Bone imaging multiple areas,78305,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,411.59,,,,,,,fee schedule,395.76,1755.86,APC
Bone imaging multiple areas,78305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,395.76,,,,,,,fee schedule,395.76,1755.86,APC
Bone imaging multiple areas,78305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,605.51,,,,,,,fee schedule,395.76,1755.86,Radiology
Bone imaging multiple areas,78305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,554.06,,,,,,,fee schedule,395.76,1755.86,APC
Bone imaging multiple areas,78305,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,692.58,,,,,,,fee schedule,395.76,1755.86,APC
Bone imaging whole body,78306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1316.04,,,,,,,fee schedule,395.76,1755.86,
Bone imaging whole body,78306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1054.92,,,,,,,fee schedule,395.76,1755.86,
Bone imaging whole body,78306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1152.41,,,,,,,fee schedule,395.76,1755.86,
Bone imaging whole body,78306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1211.6,,,,,,,fee schedule,395.76,1755.86,
Bone imaging whole body,78306,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755.86,,,,,,,fee schedule,395.76,1755.86,APC 378
Bone imaging whole body,78306,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,415.55,,,,,,,fee schedule,395.76,1755.86,APC
Bone imaging whole body,78306,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,411.59,,,,,,,fee schedule,395.76,1755.86,APC
Bone imaging whole body,78306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,395.76,,,,,,,fee schedule,395.76,1755.86,APC
Bone imaging whole body,78306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,605.51,,,,,,,fee schedule,395.76,1755.86,Radiology
Bone imaging whole body,78306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,554.06,,,,,,,fee schedule,395.76,1755.86,APC
Bone imaging whole body,78306,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,692.58,,,,,,,fee schedule,395.76,1755.86,APC
Bone imaging 3 phase,78315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1343.68,,,,,,,fee schedule,395.76,1755.86,
Bone imaging 3 phase,78315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1077.07,,,,,,,fee schedule,395.76,1755.86,
Bone imaging 3 phase,78315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1176.61,,,,,,,fee schedule,395.76,1755.86,
Bone imaging 3 phase,78315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1237.04,,,,,,,fee schedule,395.76,1755.86,
Bone imaging 3 phase,78315,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755.86,,,,,,,fee schedule,395.76,1755.86,APC 378
Bone imaging 3 phase,78315,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,415.55,,,,,,,fee schedule,395.76,1755.86,APC
Bone imaging 3 phase,78315,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,411.59,,,,,,,fee schedule,395.76,1755.86,APC
Bone imaging 3 phase,78315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,395.76,,,,,,,fee schedule,395.76,1755.86,APC
Bone imaging 3 phase,78315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,605.51,,,,,,,fee schedule,395.76,1755.86,Radiology
Bone imaging 3 phase,78315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,554.06,,,,,,,fee schedule,395.76,1755.86,APC
Bone imaging 3 phase,78315,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,692.58,,,,,,,fee schedule,395.76,1755.86,APC
Musculoskeletal nuclear exam,78399,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755.86,,,,,,,fee schedule,395.76,1755.86,APC 378
Musculoskeletal nuclear exam,78399,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,415.55,,,,,,,fee schedule,395.76,1755.86,APC
Musculoskeletal nuclear exam,78399,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,411.59,,,,,,,fee schedule,395.76,1755.86,APC
Musculoskeletal nuclear exam,78399,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,395.76,,,,,,,fee schedule,395.76,1755.86,APC
Musculoskeletal nuclear exam,78399,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,605.51,,,,,,,fee schedule,395.76,1755.86,Radiology
Musculoskeletal nuclear exam,78399,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,554.06,,,,,,,fee schedule,395.76,1755.86,APC
Musculoskeletal nuclear exam,78399,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,692.58,,,,,,,fee schedule,395.76,1755.86,APC
Non-imaging heart function,78414,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1213.42,,,,,,,fee schedule,537.52,2384.8,
Non-imaging heart function,78414,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,972.66,,,,,,,fee schedule,537.52,2384.8,
Non-imaging heart function,78414,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1062.54,,,,,,,fee schedule,537.52,2384.8,
Non-imaging heart function,78414,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1117.11,,,,,,,fee schedule,537.52,2384.8,
Non-imaging heart function,78414,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2384.8,,,,,,,fee schedule,537.52,2384.8,APC 378
Non-imaging heart function,78414,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,564.4,,,,,,,fee schedule,537.52,2384.8,APC
Non-imaging heart function,78414,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,559.02,,,,,,,fee schedule,537.52,2384.8,APC
Non-imaging heart function,78414,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,537.52,,,,,,,fee schedule,537.52,2384.8,APC
Non-imaging heart function,78414,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,822.41,,,,,,,fee schedule,537.52,2384.8,Radiology
Non-imaging heart function,78414,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,752.53,,,,,,,fee schedule,537.52,2384.8,APC
Non-imaging heart function,78414,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,940.66,,,,,,,fee schedule,537.52,2384.8,APC
Cardiac shunt imaging,78428,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1213.42,,,,,,,fee schedule,395.76,1755.86,
Cardiac shunt imaging,78428,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,972.66,,,,,,,fee schedule,395.76,1755.86,
Cardiac shunt imaging,78428,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1062.54,,,,,,,fee schedule,395.76,1755.86,
Cardiac shunt imaging,78428,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1117.11,,,,,,,fee schedule,395.76,1755.86,
Cardiac shunt imaging,78428,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755.86,,,,,,,fee schedule,395.76,1755.86,APC 378
Cardiac shunt imaging,78428,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,415.55,,,,,,,fee schedule,395.76,1755.86,APC
Cardiac shunt imaging,78428,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,411.59,,,,,,,fee schedule,395.76,1755.86,APC
Cardiac shunt imaging,78428,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,395.76,,,,,,,fee schedule,395.76,1755.86,APC
Cardiac shunt imaging,78428,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,605.51,,,,,,,fee schedule,395.76,1755.86,Radiology
Cardiac shunt imaging,78428,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,554.06,,,,,,,fee schedule,395.76,1755.86,APC
Cardiac shunt imaging,78428,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,692.58,,,,,,,fee schedule,395.76,1755.86,APC
Myocrd img pet 1 std w/ct,78429,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5455.14,,,,,,,fee schedule,1415.6,6280.55,
Myocrd img pet 1 std w/ct,78429,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4372.77,,,,,,,fee schedule,1415.6,6280.55,
Myocrd img pet 1 std w/ct,78429,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4776.86,,,,,,,fee schedule,1415.6,6280.55,
Myocrd img pet 1 std w/ct,78429,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5022.2,,,,,,,fee schedule,1415.6,6280.55,
Myocrd img pet 1 std w/ct,78429,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6280.55,,,,,,,fee schedule,1415.6,6280.55,APC 378
Myocrd img pet 1 std w/ct,78429,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1486.38,,,,,,,fee schedule,1415.6,6280.55,APC
Myocrd img pet 1 std w/ct,78429,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1472.23,,,,,,,fee schedule,1415.6,6280.55,APC
Myocrd img pet 1 std w/ct,78429,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1415.6,,,,,,,fee schedule,1415.6,6280.55,APC
Myocrd img pet 1 std w/ct,78429,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2165.87,,,,,,,fee schedule,1415.6,6280.55,Radiology
Myocrd img pet 1 std w/ct,78429,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1981.84,,,,,,,fee schedule,1415.6,6280.55,APC
Myocrd img pet 1 std w/ct,78429,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2477.3,,,,,,,fee schedule,1415.6,6280.55,APC
Myocrd img pet rst/strs w/ct,78430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5455.14,,,,,,,fee schedule,1415.6,6280.55,
Myocrd img pet rst/strs w/ct,78430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4372.77,,,,,,,fee schedule,1415.6,6280.55,
Myocrd img pet rst/strs w/ct,78430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4776.86,,,,,,,fee schedule,1415.6,6280.55,
Myocrd img pet rst/strs w/ct,78430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5022.2,,,,,,,fee schedule,1415.6,6280.55,
Myocrd img pet rst/strs w/ct,78430,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6280.55,,,,,,,fee schedule,1415.6,6280.55,APC 378
Myocrd img pet rst/strs w/ct,78430,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1486.38,,,,,,,fee schedule,1415.6,6280.55,APC
Myocrd img pet rst/strs w/ct,78430,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1472.23,,,,,,,fee schedule,1415.6,6280.55,APC
Myocrd img pet rst/strs w/ct,78430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1415.6,,,,,,,fee schedule,1415.6,6280.55,APC
Myocrd img pet rst/strs w/ct,78430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2165.87,,,,,,,fee schedule,1415.6,6280.55,Radiology
Myocrd img pet rst/strs w/ct,78430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1981.84,,,,,,,fee schedule,1415.6,6280.55,APC
Myocrd img pet rst/strs w/ct,78430,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2477.3,,,,,,,fee schedule,1415.6,6280.55,APC
Myocrd img pet rst&strs ct,78431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8506.89,,,,,,,fee schedule,2180.69,9674.98,
Myocrd img pet rst&strs ct,78431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6819.02,,,,,,,fee schedule,2180.69,9674.98,
Myocrd img pet rst&strs ct,78431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7449.16,,,,,,,fee schedule,2180.69,9674.98,
Myocrd img pet rst&strs ct,78431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7831.74,,,,,,,fee schedule,2180.69,9674.98,
Myocrd img pet rst&strs ct,78431,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9674.98,,,,,,,fee schedule,2180.69,9674.98,APC 378
Myocrd img pet rst&strs ct,78431,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2289.72,,,,,,,fee schedule,2180.69,9674.98,APC
Myocrd img pet rst&strs ct,78431,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2267.92,,,,,,,fee schedule,2180.69,9674.98,APC
Myocrd img pet rst&strs ct,78431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2180.69,,,,,,,fee schedule,2180.69,9674.98,APC
Myocrd img pet rst&strs ct,78431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3336.45,,,,,,,fee schedule,2180.69,9674.98,Radiology
Myocrd img pet rst&strs ct,78431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3052.97,,,,,,,fee schedule,2180.69,9674.98,APC
Myocrd img pet rst&strs ct,78431,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3816.21,,,,,,,fee schedule,2180.69,9674.98,APC
Myocrd img pet 2rtracer,78432,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10396.89,,,,,,,fee schedule,1502.4,10396.89,
Myocrd img pet 2rtracer,78432,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8334.02,,,,,,,fee schedule,1502.4,10396.89,
Myocrd img pet 2rtracer,78432,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9104.16,,,,,,,fee schedule,1502.4,10396.89,
Myocrd img pet 2rtracer,78432,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9571.74,,,,,,,fee schedule,1502.4,10396.89,
Myocrd img pet 2rtracer,78432,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6665.66,,,,,,,fee schedule,1502.4,10396.89,APC 378
Myocrd img pet 2rtracer,78432,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1577.52,,,,,,,fee schedule,1502.4,10396.89,APC
Myocrd img pet 2rtracer,78432,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1562.5,,,,,,,fee schedule,1502.4,10396.89,APC
Myocrd img pet 2rtracer,78432,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1502.4,,,,,,,fee schedule,1502.4,10396.89,APC
Myocrd img pet 2rtracer,78432,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2298.68,,,,,,,fee schedule,1502.4,10396.89,Radiology
Myocrd img pet 2rtracer,78432,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2103.36,,,,,,,fee schedule,1502.4,10396.89,APC
Myocrd img pet 2rtracer,78432,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2629.21,,,,,,,fee schedule,1502.4,10396.89,APC
Myocrd img pet 2rtracer ct,78433,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10396.89,,,,,,,fee schedule,2180.69,10396.89,
Myocrd img pet 2rtracer ct,78433,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8334.02,,,,,,,fee schedule,2180.69,10396.89,
Myocrd img pet 2rtracer ct,78433,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9104.16,,,,,,,fee schedule,2180.69,10396.89,
Myocrd img pet 2rtracer ct,78433,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9571.74,,,,,,,fee schedule,2180.69,10396.89,
Myocrd img pet 2rtracer ct,78433,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9674.98,,,,,,,fee schedule,2180.69,10396.89,APC 378
Myocrd img pet 2rtracer ct,78433,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2289.72,,,,,,,fee schedule,2180.69,10396.89,APC
Myocrd img pet 2rtracer ct,78433,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2267.92,,,,,,,fee schedule,2180.69,10396.89,APC
Myocrd img pet 2rtracer ct,78433,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2180.69,,,,,,,fee schedule,2180.69,10396.89,APC
Myocrd img pet 2rtracer ct,78433,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3336.45,,,,,,,fee schedule,2180.69,10396.89,Radiology
Myocrd img pet 2rtracer ct,78433,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3052.97,,,,,,,fee schedule,2180.69,10396.89,APC
Myocrd img pet 2rtracer ct,78433,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3816.21,,,,,,,fee schedule,2180.69,10396.89,APC
Aqmbf pet rest & rx stress,78434,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,116.88,,,,,,,fee schedule,93.69,116.88,
Aqmbf pet rest & rx stress,78434,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,93.69,,,,,,,fee schedule,93.69,116.88,
Aqmbf pet rest & rx stress,78434,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,102.35,,,,,,,fee schedule,93.69,116.88,
Aqmbf pet rest & rx stress,78434,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,107.6,,,,,,,fee schedule,93.69,116.88,
Vascular flow imaging,78445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,784.5,,,,,,,fee schedule,395.76,1755.86,
Vascular flow imaging,78445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,628.85,,,,,,,fee schedule,395.76,1755.86,
Vascular flow imaging,78445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,686.96,,,,,,,fee schedule,395.76,1755.86,
Vascular flow imaging,78445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,722.24,,,,,,,fee schedule,395.76,1755.86,
Vascular flow imaging,78445,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755.86,,,,,,,fee schedule,395.76,1755.86,APC 378
Vascular flow imaging,78445,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,415.55,,,,,,,fee schedule,395.76,1755.86,APC
Vascular flow imaging,78445,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,411.59,,,,,,,fee schedule,395.76,1755.86,APC
Vascular flow imaging,78445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,395.76,,,,,,,fee schedule,395.76,1755.86,APC
Vascular flow imaging,78445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,605.51,,,,,,,fee schedule,395.76,1755.86,Radiology
Vascular flow imaging,78445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,554.06,,,,,,,fee schedule,395.76,1755.86,APC
Vascular flow imaging,78445,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,692.58,,,,,,,fee schedule,395.76,1755.86,APC
Ht muscle image spect sing,78451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3037.08,,,,,,,fee schedule,1281.66,5686.29,
Ht muscle image spect sing,78451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2434.48,,,,,,,fee schedule,1281.66,5686.29,
Ht muscle image spect sing,78451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2659.45,,,,,,,fee schedule,1281.66,5686.29,
Ht muscle image spect sing,78451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2796.04,,,,,,,fee schedule,1281.66,5686.29,
Ht muscle image spect sing,78451,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5686.29,,,,,,,fee schedule,1281.66,5686.29,APC 378
Ht muscle image spect sing,78451,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1345.74,,,,,,,fee schedule,1281.66,5686.29,APC
Ht muscle image spect sing,78451,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1332.93,,,,,,,fee schedule,1281.66,5686.29,APC
Ht muscle image spect sing,78451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1281.66,,,,,,,fee schedule,1281.66,5686.29,APC
Ht muscle image spect sing,78451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1960.94,,,,,,,fee schedule,1281.66,5686.29,Radiology
Ht muscle image spect sing,78451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1794.32,,,,,,,fee schedule,1281.66,5686.29,APC
Ht muscle image spect sing,78451,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2242.91,,,,,,,fee schedule,1281.66,5686.29,APC
Ht muscle image spect mult,78452,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,955.41,,,,,,,fee schedule,765.84,5686.29,
Ht muscle image spect mult,78452,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,765.84,,,,,,,fee schedule,765.84,5686.29,
Ht muscle image spect mult,78452,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,836.61,,,,,,,fee schedule,765.84,5686.29,
Ht muscle image spect mult,78452,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,879.58,,,,,,,fee schedule,765.84,5686.29,
Ht muscle image spect mult,78452,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5686.29,,,,,,,fee schedule,765.84,5686.29,APC 378
Ht muscle image spect mult,78452,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1345.74,,,,,,,fee schedule,765.84,5686.29,APC
Ht muscle image spect mult,78452,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1332.93,,,,,,,fee schedule,765.84,5686.29,APC
Ht muscle image spect mult,78452,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1281.66,,,,,,,fee schedule,765.84,5686.29,APC
Ht muscle image spect mult,78452,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1960.94,,,,,,,fee schedule,765.84,5686.29,Radiology
Ht muscle image spect mult,78452,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1794.32,,,,,,,fee schedule,765.84,5686.29,APC
Ht muscle image spect mult,78452,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2242.91,,,,,,,fee schedule,765.84,5686.29,APC
Ht muscle image planar sing,78453,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3037.08,,,,,,,fee schedule,1281.66,5686.29,
Ht muscle image planar sing,78453,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2434.48,,,,,,,fee schedule,1281.66,5686.29,
Ht muscle image planar sing,78453,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2659.45,,,,,,,fee schedule,1281.66,5686.29,
Ht muscle image planar sing,78453,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2796.04,,,,,,,fee schedule,1281.66,5686.29,
Ht muscle image planar sing,78453,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5686.29,,,,,,,fee schedule,1281.66,5686.29,APC 378
Ht muscle image planar sing,78453,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1345.74,,,,,,,fee schedule,1281.66,5686.29,APC
Ht muscle image planar sing,78453,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1332.93,,,,,,,fee schedule,1281.66,5686.29,APC
Ht muscle image planar sing,78453,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1281.66,,,,,,,fee schedule,1281.66,5686.29,APC
Ht muscle image planar sing,78453,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1960.94,,,,,,,fee schedule,1281.66,5686.29,Radiology
Ht muscle image planar sing,78453,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1794.32,,,,,,,fee schedule,1281.66,5686.29,APC
Ht muscle image planar sing,78453,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2242.91,,,,,,,fee schedule,1281.66,5686.29,APC
Ht musc image planar mult,78454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3037.08,,,,,,,fee schedule,1281.66,5686.29,
Ht musc image planar mult,78454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2434.48,,,,,,,fee schedule,1281.66,5686.29,
Ht musc image planar mult,78454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2659.45,,,,,,,fee schedule,1281.66,5686.29,
Ht musc image planar mult,78454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2796.04,,,,,,,fee schedule,1281.66,5686.29,
Ht musc image planar mult,78454,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5686.29,,,,,,,fee schedule,1281.66,5686.29,APC 378
Ht musc image planar mult,78454,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1345.74,,,,,,,fee schedule,1281.66,5686.29,APC
Ht musc image planar mult,78454,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1332.93,,,,,,,fee schedule,1281.66,5686.29,APC
Ht musc image planar mult,78454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1281.66,,,,,,,fee schedule,1281.66,5686.29,APC
Ht musc image planar mult,78454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1960.94,,,,,,,fee schedule,1281.66,5686.29,Radiology
Ht musc image planar mult,78454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1794.32,,,,,,,fee schedule,1281.66,5686.29,APC
Ht musc image planar mult,78454,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2242.91,,,,,,,fee schedule,1281.66,5686.29,APC
Acute venous thrombus image,78456,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,784.5,,,,,,,fee schedule,628.85,5686.29,
Acute venous thrombus image,78456,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,628.85,,,,,,,fee schedule,628.85,5686.29,
Acute venous thrombus image,78456,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,686.96,,,,,,,fee schedule,628.85,5686.29,
Acute venous thrombus image,78456,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,722.24,,,,,,,fee schedule,628.85,5686.29,
Acute venous thrombus image,78456,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5686.29,,,,,,,fee schedule,628.85,5686.29,APC 378
Acute venous thrombus image,78456,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1345.74,,,,,,,fee schedule,628.85,5686.29,APC
Acute venous thrombus image,78456,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1332.93,,,,,,,fee schedule,628.85,5686.29,APC
Acute venous thrombus image,78456,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1281.66,,,,,,,fee schedule,628.85,5686.29,APC
Acute venous thrombus image,78456,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1960.94,,,,,,,fee schedule,628.85,5686.29,Radiology
Acute venous thrombus image,78456,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1794.32,,,,,,,fee schedule,628.85,5686.29,APC
Acute venous thrombus image,78456,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2242.91,,,,,,,fee schedule,628.85,5686.29,APC
Venous thrombosis imaging,78457,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,784.5,,,,,,,fee schedule,537.52,2384.8,
Venous thrombosis imaging,78457,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,628.85,,,,,,,fee schedule,537.52,2384.8,
Venous thrombosis imaging,78457,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,686.96,,,,,,,fee schedule,537.52,2384.8,
Venous thrombosis imaging,78457,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,722.24,,,,,,,fee schedule,537.52,2384.8,
Venous thrombosis imaging,78457,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2384.8,,,,,,,fee schedule,537.52,2384.8,APC 378
Venous thrombosis imaging,78457,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,564.4,,,,,,,fee schedule,537.52,2384.8,APC
Venous thrombosis imaging,78457,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,559.02,,,,,,,fee schedule,537.52,2384.8,APC
Venous thrombosis imaging,78457,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,537.52,,,,,,,fee schedule,537.52,2384.8,APC
Venous thrombosis imaging,78457,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,822.41,,,,,,,fee schedule,537.52,2384.8,Radiology
Venous thrombosis imaging,78457,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,752.53,,,,,,,fee schedule,537.52,2384.8,APC
Venous thrombosis imaging,78457,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,940.66,,,,,,,fee schedule,537.52,2384.8,APC
Ven thrombosis images bilat,78458,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,784.5,,,,,,,fee schedule,395.76,1755.86,
Ven thrombosis images bilat,78458,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,628.85,,,,,,,fee schedule,395.76,1755.86,
Ven thrombosis images bilat,78458,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,686.96,,,,,,,fee schedule,395.76,1755.86,
Ven thrombosis images bilat,78458,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,722.24,,,,,,,fee schedule,395.76,1755.86,
Ven thrombosis images bilat,78458,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755.86,,,,,,,fee schedule,395.76,1755.86,APC 378
Ven thrombosis images bilat,78458,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,415.55,,,,,,,fee schedule,395.76,1755.86,APC
Ven thrombosis images bilat,78458,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,411.59,,,,,,,fee schedule,395.76,1755.86,APC
Ven thrombosis images bilat,78458,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,395.76,,,,,,,fee schedule,395.76,1755.86,APC
Ven thrombosis images bilat,78458,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,605.51,,,,,,,fee schedule,395.76,1755.86,Radiology
Ven thrombosis images bilat,78458,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,554.06,,,,,,,fee schedule,395.76,1755.86,APC
Ven thrombosis images bilat,78458,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,692.58,,,,,,,fee schedule,395.76,1755.86,APC
Heart muscle imaging (PET),78459,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5489.54,,,,,,,fee schedule,1281.66,5686.29,
Heart muscle imaging (PET),78459,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4400.35,,,,,,,fee schedule,1281.66,5686.29,
Heart muscle imaging (PET),78459,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4806.98,,,,,,,fee schedule,1281.66,5686.29,
Heart muscle imaging (PET),78459,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5053.86,,,,,,,fee schedule,1281.66,5686.29,
Heart muscle imaging (PET),78459,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5686.29,,,,,,,fee schedule,1281.66,5686.29,APC 378
Heart muscle imaging (PET),78459,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1345.74,,,,,,,fee schedule,1281.66,5686.29,APC
Heart muscle imaging (PET),78459,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1332.93,,,,,,,fee schedule,1281.66,5686.29,APC
Heart muscle imaging (PET),78459,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1281.66,,,,,,,fee schedule,1281.66,5686.29,APC
Heart muscle imaging (PET),78459,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1960.94,,,,,,,fee schedule,1281.66,5686.29,Radiology
Heart muscle imaging (PET),78459,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1794.32,,,,,,,fee schedule,1281.66,5686.29,APC
Heart muscle imaging (PET),78459,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2242.91,,,,,,,fee schedule,1281.66,5686.29,APC
Heart infarct image,78466,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1213.42,,,,,,,fee schedule,395.76,1755.86,
Heart infarct image,78466,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,972.66,,,,,,,fee schedule,395.76,1755.86,
Heart infarct image,78466,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1062.54,,,,,,,fee schedule,395.76,1755.86,
Heart infarct image,78466,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1117.11,,,,,,,fee schedule,395.76,1755.86,
Heart infarct image,78466,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755.86,,,,,,,fee schedule,395.76,1755.86,APC 378
Heart infarct image,78466,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,415.55,,,,,,,fee schedule,395.76,1755.86,APC
Heart infarct image,78466,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,411.59,,,,,,,fee schedule,395.76,1755.86,APC
Heart infarct image,78466,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,395.76,,,,,,,fee schedule,395.76,1755.86,APC
Heart infarct image,78466,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,605.51,,,,,,,fee schedule,395.76,1755.86,Radiology
Heart infarct image,78466,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,554.06,,,,,,,fee schedule,395.76,1755.86,APC
Heart infarct image,78466,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,692.58,,,,,,,fee schedule,395.76,1755.86,APC
Heart infarct image (ef),78468,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1213.42,,,,,,,fee schedule,537.52,2384.8,
Heart infarct image (ef),78468,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,972.66,,,,,,,fee schedule,537.52,2384.8,
Heart infarct image (ef),78468,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1062.54,,,,,,,fee schedule,537.52,2384.8,
Heart infarct image (ef),78468,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1117.11,,,,,,,fee schedule,537.52,2384.8,
Heart infarct image (ef),78468,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2384.8,,,,,,,fee schedule,537.52,2384.8,APC 378
Heart infarct image (ef),78468,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,564.4,,,,,,,fee schedule,537.52,2384.8,APC
Heart infarct image (ef),78468,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,559.02,,,,,,,fee schedule,537.52,2384.8,APC
Heart infarct image (ef),78468,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,537.52,,,,,,,fee schedule,537.52,2384.8,APC
Heart infarct image (ef),78468,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,822.41,,,,,,,fee schedule,537.52,2384.8,Radiology
Heart infarct image (ef),78468,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,752.53,,,,,,,fee schedule,537.52,2384.8,APC
Heart infarct image (ef),78468,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,940.66,,,,,,,fee schedule,537.52,2384.8,APC
Heart infarct image (3D),78469,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1213.42,,,,,,,fee schedule,537.52,2384.8,
Heart infarct image (3D),78469,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,972.66,,,,,,,fee schedule,537.52,2384.8,
Heart infarct image (3D),78469,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1062.54,,,,,,,fee schedule,537.52,2384.8,
Heart infarct image (3D),78469,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1117.11,,,,,,,fee schedule,537.52,2384.8,
Heart infarct image (3D),78469,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2384.8,,,,,,,fee schedule,537.52,2384.8,APC 378
Heart infarct image (3D),78469,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,564.4,,,,,,,fee schedule,537.52,2384.8,APC
Heart infarct image (3D),78469,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,559.02,,,,,,,fee schedule,537.52,2384.8,APC
Heart infarct image (3D),78469,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,537.52,,,,,,,fee schedule,537.52,2384.8,APC
Heart infarct image (3D),78469,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,822.41,,,,,,,fee schedule,537.52,2384.8,Radiology
Heart infarct image (3D),78469,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,752.53,,,,,,,fee schedule,537.52,2384.8,APC
Heart infarct image (3D),78469,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,940.66,,,,,,,fee schedule,537.52,2384.8,APC
Gated heart planar single,78472,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,752.44,,,,,,,fee schedule,395.76,1755.86,
Gated heart planar single,78472,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,603.14,,,,,,,fee schedule,395.76,1755.86,
Gated heart planar single,78472,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,658.88,,,,,,,fee schedule,395.76,1755.86,
Gated heart planar single,78472,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,692.72,,,,,,,fee schedule,395.76,1755.86,
Gated heart planar single,78472,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755.86,,,,,,,fee schedule,395.76,1755.86,APC 378
Gated heart planar single,78472,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,415.55,,,,,,,fee schedule,395.76,1755.86,APC
Gated heart planar single,78472,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,411.59,,,,,,,fee schedule,395.76,1755.86,APC
Gated heart planar single,78472,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,395.76,,,,,,,fee schedule,395.76,1755.86,APC
Gated heart planar single,78472,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,605.51,,,,,,,fee schedule,395.76,1755.86,Radiology
Gated heart planar single,78472,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,554.06,,,,,,,fee schedule,395.76,1755.86,APC
Gated heart planar single,78472,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,692.58,,,,,,,fee schedule,395.76,1755.86,APC
Gated heart multiple,78473,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1213.42,,,,,,,fee schedule,395.76,1755.86,
Gated heart multiple,78473,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,972.66,,,,,,,fee schedule,395.76,1755.86,
Gated heart multiple,78473,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1062.54,,,,,,,fee schedule,395.76,1755.86,
Gated heart multiple,78473,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1117.11,,,,,,,fee schedule,395.76,1755.86,
Gated heart multiple,78473,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755.86,,,,,,,fee schedule,395.76,1755.86,APC 378
Gated heart multiple,78473,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,415.55,,,,,,,fee schedule,395.76,1755.86,APC
Gated heart multiple,78473,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,411.59,,,,,,,fee schedule,395.76,1755.86,APC
Gated heart multiple,78473,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,395.76,,,,,,,fee schedule,395.76,1755.86,APC
Gated heart multiple,78473,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,605.51,,,,,,,fee schedule,395.76,1755.86,Radiology
Gated heart multiple,78473,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,554.06,,,,,,,fee schedule,395.76,1755.86,APC
Gated heart multiple,78473,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,692.58,,,,,,,fee schedule,395.76,1755.86,APC
Heart first pass single,78481,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1213.42,,,,,,,fee schedule,537.52,2384.8,
Heart first pass single,78481,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,972.66,,,,,,,fee schedule,537.52,2384.8,
Heart first pass single,78481,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1062.54,,,,,,,fee schedule,537.52,2384.8,
Heart first pass single,78481,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1117.11,,,,,,,fee schedule,537.52,2384.8,
Heart first pass single,78481,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2384.8,,,,,,,fee schedule,537.52,2384.8,APC 378
Heart first pass single,78481,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,564.4,,,,,,,fee schedule,537.52,2384.8,APC
Heart first pass single,78481,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,559.02,,,,,,,fee schedule,537.52,2384.8,APC
Heart first pass single,78481,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,537.52,,,,,,,fee schedule,537.52,2384.8,APC
Heart first pass single,78481,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,822.41,,,,,,,fee schedule,537.52,2384.8,Radiology
Heart first pass single,78481,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,752.53,,,,,,,fee schedule,537.52,2384.8,APC
Heart first pass single,78481,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,940.66,,,,,,,fee schedule,537.52,2384.8,APC
Heart first pass multiple,78483,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1213.42,,,,,,,fee schedule,537.52,2384.8,
Heart first pass multiple,78483,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,972.66,,,,,,,fee schedule,537.52,2384.8,
Heart first pass multiple,78483,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1062.54,,,,,,,fee schedule,537.52,2384.8,
Heart first pass multiple,78483,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1117.11,,,,,,,fee schedule,537.52,2384.8,
Heart first pass multiple,78483,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2384.8,,,,,,,fee schedule,537.52,2384.8,APC 378
Heart first pass multiple,78483,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,564.4,,,,,,,fee schedule,537.52,2384.8,APC
Heart first pass multiple,78483,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,559.02,,,,,,,fee schedule,537.52,2384.8,APC
Heart first pass multiple,78483,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,537.52,,,,,,,fee schedule,537.52,2384.8,APC
Heart first pass multiple,78483,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,822.41,,,,,,,fee schedule,537.52,2384.8,Radiology
Heart first pass multiple,78483,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,752.53,,,,,,,fee schedule,537.52,2384.8,APC
Heart first pass multiple,78483,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,940.66,,,,,,,fee schedule,537.52,2384.8,APC
Heart image (pet) single,78491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5489.54,,,,,,,fee schedule,1415.6,6280.55,
Heart image (pet) single,78491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4400.35,,,,,,,fee schedule,1415.6,6280.55,
Heart image (pet) single,78491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4806.98,,,,,,,fee schedule,1415.6,6280.55,
Heart image (pet) single,78491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5053.86,,,,,,,fee schedule,1415.6,6280.55,
Heart image (pet) single,78491,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6280.55,,,,,,,fee schedule,1415.6,6280.55,APC 378
Heart image (pet) single,78491,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1486.38,,,,,,,fee schedule,1415.6,6280.55,APC
Heart image (pet) single,78491,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1472.23,,,,,,,fee schedule,1415.6,6280.55,APC
Heart image (pet) single,78491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1415.6,,,,,,,fee schedule,1415.6,6280.55,APC
Heart image (pet) single,78491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2165.87,,,,,,,fee schedule,1415.6,6280.55,Radiology
Heart image (pet) single,78491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1981.84,,,,,,,fee schedule,1415.6,6280.55,APC
Heart image (pet) single,78491,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2477.3,,,,,,,fee schedule,1415.6,6280.55,APC
Heart image (pet) multiple,78492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5489.54,,,,,,,fee schedule,1415.6,6280.55,
Heart image (pet) multiple,78492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4400.35,,,,,,,fee schedule,1415.6,6280.55,
Heart image (pet) multiple,78492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4806.98,,,,,,,fee schedule,1415.6,6280.55,
Heart image (pet) multiple,78492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5053.86,,,,,,,fee schedule,1415.6,6280.55,
Heart image (pet) multiple,78492,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6280.55,,,,,,,fee schedule,1415.6,6280.55,APC 378
Heart image (pet) multiple,78492,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1486.38,,,,,,,fee schedule,1415.6,6280.55,APC
Heart image (pet) multiple,78492,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1472.23,,,,,,,fee schedule,1415.6,6280.55,APC
Heart image (pet) multiple,78492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1415.6,,,,,,,fee schedule,1415.6,6280.55,APC
Heart image (pet) multiple,78492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2165.87,,,,,,,fee schedule,1415.6,6280.55,Radiology
Heart image (pet) multiple,78492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1981.84,,,,,,,fee schedule,1415.6,6280.55,APC
Heart image (pet) multiple,78492,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2477.3,,,,,,,fee schedule,1415.6,6280.55,APC
Heart image spect,78494,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,407.43,,,,,,,fee schedule,326.59,1755.86,
Heart image spect,78494,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,326.59,,,,,,,fee schedule,326.59,1755.86,
Heart image spect,78494,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,356.77,,,,,,,fee schedule,326.59,1755.86,
Heart image spect,78494,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,375.09,,,,,,,fee schedule,326.59,1755.86,
Heart image spect,78494,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755.86,,,,,,,fee schedule,326.59,1755.86,APC 378
Heart image spect,78494,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,415.55,,,,,,,fee schedule,326.59,1755.86,APC
Heart image spect,78494,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,411.59,,,,,,,fee schedule,326.59,1755.86,APC
Heart image spect,78494,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,395.76,,,,,,,fee schedule,326.59,1755.86,APC
Heart image spect,78494,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,605.51,,,,,,,fee schedule,326.59,1755.86,Radiology
Heart image spect,78494,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,554.06,,,,,,,fee schedule,326.59,1755.86,APC
Heart image spect,78494,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,692.58,,,,,,,fee schedule,326.59,1755.86,APC
Cardiovascular nuclear exam,78499,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755.86,,,,,,,fee schedule,395.76,1755.86,APC 378
Cardiovascular nuclear exam,78499,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,415.55,,,,,,,fee schedule,395.76,1755.86,APC
Cardiovascular nuclear exam,78499,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,411.59,,,,,,,fee schedule,395.76,1755.86,APC
Cardiovascular nuclear exam,78499,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,395.76,,,,,,,fee schedule,395.76,1755.86,APC
Cardiovascular nuclear exam,78499,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,605.51,,,,,,,fee schedule,395.76,1755.86,Radiology
Cardiovascular nuclear exam,78499,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,554.06,,,,,,,fee schedule,395.76,1755.86,APC
Cardiovascular nuclear exam,78499,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,692.58,,,,,,,fee schedule,395.76,1755.86,APC
Lung ventilation imaging,78579,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,835.23,,,,,,,fee schedule,395.76,1755.86,
Lung ventilation imaging,78579,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,669.51,,,,,,,fee schedule,395.76,1755.86,
Lung ventilation imaging,78579,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,731.38,,,,,,,fee schedule,395.76,1755.86,
Lung ventilation imaging,78579,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,768.94,,,,,,,fee schedule,395.76,1755.86,
Lung ventilation imaging,78579,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755.86,,,,,,,fee schedule,395.76,1755.86,APC 378
Lung ventilation imaging,78579,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,415.55,,,,,,,fee schedule,395.76,1755.86,APC
Lung ventilation imaging,78579,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,411.59,,,,,,,fee schedule,395.76,1755.86,APC
Lung ventilation imaging,78579,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,395.76,,,,,,,fee schedule,395.76,1755.86,APC
Lung ventilation imaging,78579,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,605.51,,,,,,,fee schedule,395.76,1755.86,Radiology
Lung ventilation imaging,78579,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,554.06,,,,,,,fee schedule,395.76,1755.86,APC
Lung ventilation imaging,78579,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,692.58,,,,,,,fee schedule,395.76,1755.86,APC
Lung perfusion imaging,78580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,571.27,,,,,,,fee schedule,395.76,1755.86,
Lung perfusion imaging,78580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,457.92,,,,,,,fee schedule,395.76,1755.86,
Lung perfusion imaging,78580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,500.24,,,,,,,fee schedule,395.76,1755.86,
Lung perfusion imaging,78580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,525.93,,,,,,,fee schedule,395.76,1755.86,
Lung perfusion imaging,78580,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755.86,,,,,,,fee schedule,395.76,1755.86,APC 378
Lung perfusion imaging,78580,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,415.55,,,,,,,fee schedule,395.76,1755.86,APC
Lung perfusion imaging,78580,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,411.59,,,,,,,fee schedule,395.76,1755.86,APC
Lung perfusion imaging,78580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,395.76,,,,,,,fee schedule,395.76,1755.86,APC
Lung perfusion imaging,78580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,605.51,,,,,,,fee schedule,395.76,1755.86,Radiology
Lung perfusion imaging,78580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,554.06,,,,,,,fee schedule,395.76,1755.86,APC
Lung perfusion imaging,78580,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,692.58,,,,,,,fee schedule,395.76,1755.86,APC
Lung ventilat&perfus imaging,78582,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1002.46,,,,,,,fee schedule,537.52,2384.8,
Lung ventilat&perfus imaging,78582,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,803.56,,,,,,,fee schedule,537.52,2384.8,
Lung ventilat&perfus imaging,78582,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,877.81,,,,,,,fee schedule,537.52,2384.8,
Lung ventilat&perfus imaging,78582,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,922.9,,,,,,,fee schedule,537.52,2384.8,
Lung ventilat&perfus imaging,78582,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2384.8,,,,,,,fee schedule,537.52,2384.8,APC 378
Lung ventilat&perfus imaging,78582,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,564.4,,,,,,,fee schedule,537.52,2384.8,APC
Lung ventilat&perfus imaging,78582,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,559.02,,,,,,,fee schedule,537.52,2384.8,APC
Lung ventilat&perfus imaging,78582,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,537.52,,,,,,,fee schedule,537.52,2384.8,APC
Lung ventilat&perfus imaging,78582,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,822.41,,,,,,,fee schedule,537.52,2384.8,Radiology
Lung ventilat&perfus imaging,78582,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,752.53,,,,,,,fee schedule,537.52,2384.8,APC
Lung ventilat&perfus imaging,78582,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,940.66,,,,,,,fee schedule,537.52,2384.8,APC
Lung perfusion differential,78597,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,835.23,,,,,,,fee schedule,395.76,1755.86,
Lung perfusion differential,78597,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,669.51,,,,,,,fee schedule,395.76,1755.86,
Lung perfusion differential,78597,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,731.38,,,,,,,fee schedule,395.76,1755.86,
Lung perfusion differential,78597,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,768.94,,,,,,,fee schedule,395.76,1755.86,
Lung perfusion differential,78597,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755.86,,,,,,,fee schedule,395.76,1755.86,APC 378
Lung perfusion differential,78597,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,415.55,,,,,,,fee schedule,395.76,1755.86,APC
Lung perfusion differential,78597,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,411.59,,,,,,,fee schedule,395.76,1755.86,APC
Lung perfusion differential,78597,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,395.76,,,,,,,fee schedule,395.76,1755.86,APC
Lung perfusion differential,78597,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,605.51,,,,,,,fee schedule,395.76,1755.86,Radiology
Lung perfusion differential,78597,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,554.06,,,,,,,fee schedule,395.76,1755.86,APC
Lung perfusion differential,78597,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,692.58,,,,,,,fee schedule,395.76,1755.86,APC
Lung perf&ventilat diferentl,78598,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,897.07,,,,,,,fee schedule,537.52,2384.8,
Lung perf&ventilat diferentl,78598,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,719.08,,,,,,,fee schedule,537.52,2384.8,
Lung perf&ventilat diferentl,78598,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,785.53,,,,,,,fee schedule,537.52,2384.8,
Lung perf&ventilat diferentl,78598,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,825.87,,,,,,,fee schedule,537.52,2384.8,
Lung perf&ventilat diferentl,78598,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2384.8,,,,,,,fee schedule,537.52,2384.8,APC 378
Lung perf&ventilat diferentl,78598,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,564.4,,,,,,,fee schedule,537.52,2384.8,APC
Lung perf&ventilat diferentl,78598,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,559.02,,,,,,,fee schedule,537.52,2384.8,APC
Lung perf&ventilat diferentl,78598,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,537.52,,,,,,,fee schedule,537.52,2384.8,APC
Lung perf&ventilat diferentl,78598,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,822.41,,,,,,,fee schedule,537.52,2384.8,Radiology
Lung perf&ventilat diferentl,78598,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,752.53,,,,,,,fee schedule,537.52,2384.8,APC
Lung perf&ventilat diferentl,78598,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,940.66,,,,,,,fee schedule,537.52,2384.8,APC
Respiratory nuclear exam,78599,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755.86,,,,,,,fee schedule,395.76,1755.86,APC 378
Respiratory nuclear exam,78599,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,415.55,,,,,,,fee schedule,395.76,1755.86,APC
Respiratory nuclear exam,78599,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,411.59,,,,,,,fee schedule,395.76,1755.86,APC
Respiratory nuclear exam,78599,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,395.76,,,,,,,fee schedule,395.76,1755.86,APC
Respiratory nuclear exam,78599,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,605.51,,,,,,,fee schedule,395.76,1755.86,Radiology
Respiratory nuclear exam,78599,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,554.06,,,,,,,fee schedule,395.76,1755.86,APC
Respiratory nuclear exam,78599,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,692.58,,,,,,,fee schedule,395.76,1755.86,APC
Brain image < 4 views,78600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,806.01,,,,,,,fee schedule,395.76,1755.86,
Brain image < 4 views,78600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,646.09,,,,,,,fee schedule,395.76,1755.86,
Brain image < 4 views,78600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,705.79,,,,,,,fee schedule,395.76,1755.86,
Brain image < 4 views,78600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,742.04,,,,,,,fee schedule,395.76,1755.86,
Brain image < 4 views,78600,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755.86,,,,,,,fee schedule,395.76,1755.86,APC 378
Brain image < 4 views,78600,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,415.55,,,,,,,fee schedule,395.76,1755.86,APC
Brain image < 4 views,78600,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,411.59,,,,,,,fee schedule,395.76,1755.86,APC
Brain image < 4 views,78600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,395.76,,,,,,,fee schedule,395.76,1755.86,APC
Brain image < 4 views,78600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,605.51,,,,,,,fee schedule,395.76,1755.86,Radiology
Brain image < 4 views,78600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,554.06,,,,,,,fee schedule,395.76,1755.86,APC
Brain image < 4 views,78600,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,692.58,,,,,,,fee schedule,395.76,1755.86,APC
Brain image w/flow < 4 views,78601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,806.01,,,,,,,fee schedule,395.76,1755.86,
Brain image w/flow < 4 views,78601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,646.09,,,,,,,fee schedule,395.76,1755.86,
Brain image w/flow < 4 views,78601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,705.79,,,,,,,fee schedule,395.76,1755.86,
Brain image w/flow < 4 views,78601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,742.04,,,,,,,fee schedule,395.76,1755.86,
Brain image w/flow < 4 views,78601,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755.86,,,,,,,fee schedule,395.76,1755.86,APC 378
Brain image w/flow < 4 views,78601,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,415.55,,,,,,,fee schedule,395.76,1755.86,APC
Brain image w/flow < 4 views,78601,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,411.59,,,,,,,fee schedule,395.76,1755.86,APC
Brain image w/flow < 4 views,78601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,395.76,,,,,,,fee schedule,395.76,1755.86,APC
Brain image w/flow < 4 views,78601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,605.51,,,,,,,fee schedule,395.76,1755.86,Radiology
Brain image w/flow < 4 views,78601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,554.06,,,,,,,fee schedule,395.76,1755.86,APC
Brain image w/flow < 4 views,78601,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,692.58,,,,,,,fee schedule,395.76,1755.86,APC
Brain image 4+ views,78605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,806.01,,,,,,,fee schedule,537.52,2384.8,
Brain image 4+ views,78605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,646.09,,,,,,,fee schedule,537.52,2384.8,
Brain image 4+ views,78605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,705.79,,,,,,,fee schedule,537.52,2384.8,
Brain image 4+ views,78605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,742.04,,,,,,,fee schedule,537.52,2384.8,
Brain image 4+ views,78605,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2384.8,,,,,,,fee schedule,537.52,2384.8,APC 378
Brain image 4+ views,78605,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,564.4,,,,,,,fee schedule,537.52,2384.8,APC
Brain image 4+ views,78605,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,559.02,,,,,,,fee schedule,537.52,2384.8,APC
Brain image 4+ views,78605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,537.52,,,,,,,fee schedule,537.52,2384.8,APC
Brain image 4+ views,78605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,822.41,,,,,,,fee schedule,537.52,2384.8,Radiology
Brain image 4+ views,78605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,752.53,,,,,,,fee schedule,537.52,2384.8,APC
Brain image 4+ views,78605,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,940.66,,,,,,,fee schedule,537.52,2384.8,APC
Brain image w/flow 4 + views,78606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2202.11,,,,,,,fee schedule,537.52,2384.8,
Brain image w/flow 4 + views,78606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1765.19,,,,,,,fee schedule,537.52,2384.8,
Brain image w/flow 4 + views,78606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1928.31,,,,,,,fee schedule,537.52,2384.8,
Brain image w/flow 4 + views,78606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2027.34,,,,,,,fee schedule,537.52,2384.8,
Brain image w/flow 4 + views,78606,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2384.8,,,,,,,fee schedule,537.52,2384.8,APC 378
Brain image w/flow 4 + views,78606,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,564.4,,,,,,,fee schedule,537.52,2384.8,APC
Brain image w/flow 4 + views,78606,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,559.02,,,,,,,fee schedule,537.52,2384.8,APC
Brain image w/flow 4 + views,78606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,537.52,,,,,,,fee schedule,537.52,2384.8,APC
Brain image w/flow 4 + views,78606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,822.41,,,,,,,fee schedule,537.52,2384.8,Radiology
Brain image w/flow 4 + views,78606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,752.53,,,,,,,fee schedule,537.52,2384.8,APC
Brain image w/flow 4 + views,78606,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,940.66,,,,,,,fee schedule,537.52,2384.8,APC
Brain imaging (PET),78608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4142.99,,,,,,,fee schedule,1415.6,6280.55,
Brain imaging (PET),78608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3320.97,,,,,,,fee schedule,1415.6,6280.55,
Brain imaging (PET),78608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3627.86,,,,,,,fee schedule,1415.6,6280.55,
Brain imaging (PET),78608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3814.18,,,,,,,fee schedule,1415.6,6280.55,
Brain imaging (PET),78608,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6280.55,,,,,,,fee schedule,1415.6,6280.55,APC 378
Brain imaging (PET),78608,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1486.38,,,,,,,fee schedule,1415.6,6280.55,APC
Brain imaging (PET),78608,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1472.23,,,,,,,fee schedule,1415.6,6280.55,APC
Brain imaging (PET),78608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1415.6,,,,,,,fee schedule,1415.6,6280.55,APC
Brain imaging (PET),78608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2165.87,,,,,,,fee schedule,1415.6,6280.55,Radiology
Brain imaging (PET),78608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1981.84,,,,,,,fee schedule,1415.6,6280.55,APC
Brain imaging (PET),78608,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2477.3,,,,,,,fee schedule,1415.6,6280.55,APC
Brain flow imaging only,78610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2202.11,,,,,,,fee schedule,537.52,2384.8,
Brain flow imaging only,78610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1765.19,,,,,,,fee schedule,537.52,2384.8,
Brain flow imaging only,78610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1928.31,,,,,,,fee schedule,537.52,2384.8,
Brain flow imaging only,78610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2027.34,,,,,,,fee schedule,537.52,2384.8,
Brain flow imaging only,78610,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2384.8,,,,,,,fee schedule,537.52,2384.8,APC 378
Brain flow imaging only,78610,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,564.4,,,,,,,fee schedule,537.52,2384.8,APC
Brain flow imaging only,78610,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,559.02,,,,,,,fee schedule,537.52,2384.8,APC
Brain flow imaging only,78610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,537.52,,,,,,,fee schedule,537.52,2384.8,APC
Brain flow imaging only,78610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,822.41,,,,,,,fee schedule,537.52,2384.8,Radiology
Brain flow imaging only,78610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,752.53,,,,,,,fee schedule,537.52,2384.8,APC
Brain flow imaging only,78610,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,940.66,,,,,,,fee schedule,537.52,2384.8,APC
Cerebrospinal fluid scan,78630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2202.11,,,,,,,fee schedule,537.52,2384.8,
Cerebrospinal fluid scan,78630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1765.19,,,,,,,fee schedule,537.52,2384.8,
Cerebrospinal fluid scan,78630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1928.31,,,,,,,fee schedule,537.52,2384.8,
Cerebrospinal fluid scan,78630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2027.34,,,,,,,fee schedule,537.52,2384.8,
Cerebrospinal fluid scan,78630,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2384.8,,,,,,,fee schedule,537.52,2384.8,APC 378
Cerebrospinal fluid scan,78630,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,564.4,,,,,,,fee schedule,537.52,2384.8,APC
Cerebrospinal fluid scan,78630,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,559.02,,,,,,,fee schedule,537.52,2384.8,APC
Cerebrospinal fluid scan,78630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,537.52,,,,,,,fee schedule,537.52,2384.8,APC
Cerebrospinal fluid scan,78630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,822.41,,,,,,,fee schedule,537.52,2384.8,Radiology
Cerebrospinal fluid scan,78630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,752.53,,,,,,,fee schedule,537.52,2384.8,APC
Cerebrospinal fluid scan,78630,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,940.66,,,,,,,fee schedule,537.52,2384.8,APC
CSF ventriculography,78635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2202.11,,,,,,,fee schedule,537.52,2384.8,
CSF ventriculography,78635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1765.19,,,,,,,fee schedule,537.52,2384.8,
CSF ventriculography,78635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1928.31,,,,,,,fee schedule,537.52,2384.8,
CSF ventriculography,78635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2027.34,,,,,,,fee schedule,537.52,2384.8,
CSF ventriculography,78635,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2384.8,,,,,,,fee schedule,537.52,2384.8,APC 378
CSF ventriculography,78635,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,564.4,,,,,,,fee schedule,537.52,2384.8,APC
CSF ventriculography,78635,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,559.02,,,,,,,fee schedule,537.52,2384.8,APC
CSF ventriculography,78635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,537.52,,,,,,,fee schedule,537.52,2384.8,APC
CSF ventriculography,78635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,822.41,,,,,,,fee schedule,537.52,2384.8,Radiology
CSF ventriculography,78635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,752.53,,,,,,,fee schedule,537.52,2384.8,APC
CSF ventriculography,78635,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,940.66,,,,,,,fee schedule,537.52,2384.8,APC
CSF shunt evaluation,78645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,806.01,,,,,,,fee schedule,537.52,2384.8,
CSF shunt evaluation,78645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,646.09,,,,,,,fee schedule,537.52,2384.8,
CSF shunt evaluation,78645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,705.79,,,,,,,fee schedule,537.52,2384.8,
CSF shunt evaluation,78645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,742.04,,,,,,,fee schedule,537.52,2384.8,
CSF shunt evaluation,78645,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2384.8,,,,,,,fee schedule,537.52,2384.8,APC 378
CSF shunt evaluation,78645,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,564.4,,,,,,,fee schedule,537.52,2384.8,APC
CSF shunt evaluation,78645,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,559.02,,,,,,,fee schedule,537.52,2384.8,APC
CSF shunt evaluation,78645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,537.52,,,,,,,fee schedule,537.52,2384.8,APC
CSF shunt evaluation,78645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,822.41,,,,,,,fee schedule,537.52,2384.8,Radiology
CSF shunt evaluation,78645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,752.53,,,,,,,fee schedule,537.52,2384.8,APC
CSF shunt evaluation,78645,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,940.66,,,,,,,fee schedule,537.52,2384.8,APC
CSF leakage imaging,78650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2202.11,,,,,,,fee schedule,1281.66,5686.29,
CSF leakage imaging,78650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1765.19,,,,,,,fee schedule,1281.66,5686.29,
CSF leakage imaging,78650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1928.31,,,,,,,fee schedule,1281.66,5686.29,
CSF leakage imaging,78650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2027.34,,,,,,,fee schedule,1281.66,5686.29,
CSF leakage imaging,78650,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5686.29,,,,,,,fee schedule,1281.66,5686.29,APC 378
CSF leakage imaging,78650,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1345.74,,,,,,,fee schedule,1281.66,5686.29,APC
CSF leakage imaging,78650,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1332.93,,,,,,,fee schedule,1281.66,5686.29,APC
CSF leakage imaging,78650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1281.66,,,,,,,fee schedule,1281.66,5686.29,APC
CSF leakage imaging,78650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1960.94,,,,,,,fee schedule,1281.66,5686.29,Radiology
CSF leakage imaging,78650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1794.32,,,,,,,fee schedule,1281.66,5686.29,APC
CSF leakage imaging,78650,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2242.91,,,,,,,fee schedule,1281.66,5686.29,APC
Nuclear exam of tear flow,78660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,806.01,,,,,,,fee schedule,395.76,1755.86,
Nuclear exam of tear flow,78660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,646.09,,,,,,,fee schedule,395.76,1755.86,
Nuclear exam of tear flow,78660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,705.79,,,,,,,fee schedule,395.76,1755.86,
Nuclear exam of tear flow,78660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,742.04,,,,,,,fee schedule,395.76,1755.86,
Nuclear exam of tear flow,78660,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755.86,,,,,,,fee schedule,395.76,1755.86,APC 378
Nuclear exam of tear flow,78660,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,415.55,,,,,,,fee schedule,395.76,1755.86,APC
Nuclear exam of tear flow,78660,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,411.59,,,,,,,fee schedule,395.76,1755.86,APC
Nuclear exam of tear flow,78660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,395.76,,,,,,,fee schedule,395.76,1755.86,APC
Nuclear exam of tear flow,78660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,605.51,,,,,,,fee schedule,395.76,1755.86,Radiology
Nuclear exam of tear flow,78660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,554.06,,,,,,,fee schedule,395.76,1755.86,APC
Nuclear exam of tear flow,78660,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,692.58,,,,,,,fee schedule,395.76,1755.86,APC
Nervous system nuclear exam,78699,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755.86,,,,,,,fee schedule,395.76,1755.86,APC 378
Nervous system nuclear exam,78699,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,415.55,,,,,,,fee schedule,395.76,1755.86,APC
Nervous system nuclear exam,78699,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,411.59,,,,,,,fee schedule,395.76,1755.86,APC
Nervous system nuclear exam,78699,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,395.76,,,,,,,fee schedule,395.76,1755.86,APC
Nervous system nuclear exam,78699,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,605.51,,,,,,,fee schedule,395.76,1755.86,Radiology
Nervous system nuclear exam,78699,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,554.06,,,,,,,fee schedule,395.76,1755.86,APC
Nervous system nuclear exam,78699,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,692.58,,,,,,,fee schedule,395.76,1755.86,APC
Kidney imaging morphol,78700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1268.45,,,,,,,fee schedule,395.76,1755.86,
Kidney imaging morphol,78700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1016.78,,,,,,,fee schedule,395.76,1755.86,
Kidney imaging morphol,78700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1110.74,,,,,,,fee schedule,395.76,1755.86,
Kidney imaging morphol,78700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1167.78,,,,,,,fee schedule,395.76,1755.86,
Kidney imaging morphol,78700,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755.86,,,,,,,fee schedule,395.76,1755.86,APC 378
Kidney imaging morphol,78700,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,415.55,,,,,,,fee schedule,395.76,1755.86,APC
Kidney imaging morphol,78700,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,411.59,,,,,,,fee schedule,395.76,1755.86,APC
Kidney imaging morphol,78700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,395.76,,,,,,,fee schedule,395.76,1755.86,APC
Kidney imaging morphol,78700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,605.51,,,,,,,fee schedule,395.76,1755.86,Radiology
Kidney imaging morphol,78700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,554.06,,,,,,,fee schedule,395.76,1755.86,APC
Kidney imaging morphol,78700,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,692.58,,,,,,,fee schedule,395.76,1755.86,APC
Kidney imaging with flow,78701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1268.45,,,,,,,fee schedule,395.76,1755.86,
Kidney imaging with flow,78701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1016.78,,,,,,,fee schedule,395.76,1755.86,
Kidney imaging with flow,78701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1110.74,,,,,,,fee schedule,395.76,1755.86,
Kidney imaging with flow,78701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1167.78,,,,,,,fee schedule,395.76,1755.86,
Kidney imaging with flow,78701,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755.86,,,,,,,fee schedule,395.76,1755.86,APC 378
Kidney imaging with flow,78701,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,415.55,,,,,,,fee schedule,395.76,1755.86,APC
Kidney imaging with flow,78701,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,411.59,,,,,,,fee schedule,395.76,1755.86,APC
Kidney imaging with flow,78701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,395.76,,,,,,,fee schedule,395.76,1755.86,APC
Kidney imaging with flow,78701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,605.51,,,,,,,fee schedule,395.76,1755.86,Radiology
Kidney imaging with flow,78701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,554.06,,,,,,,fee schedule,395.76,1755.86,APC
Kidney imaging with flow,78701,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,692.58,,,,,,,fee schedule,395.76,1755.86,APC
K flow/funct image w/o drug,78707,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,792.33,,,,,,,fee schedule,537.52,2384.8,
K flow/funct image w/o drug,78707,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,635.12,,,,,,,fee schedule,537.52,2384.8,
K flow/funct image w/o drug,78707,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,693.81,,,,,,,fee schedule,537.52,2384.8,
K flow/funct image w/o drug,78707,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,729.44,,,,,,,fee schedule,537.52,2384.8,
K flow/funct image w/o drug,78707,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2384.8,,,,,,,fee schedule,537.52,2384.8,APC 378
K flow/funct image w/o drug,78707,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,564.4,,,,,,,fee schedule,537.52,2384.8,APC
K flow/funct image w/o drug,78707,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,559.02,,,,,,,fee schedule,537.52,2384.8,APC
K flow/funct image w/o drug,78707,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,537.52,,,,,,,fee schedule,537.52,2384.8,APC
K flow/funct image w/o drug,78707,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,822.41,,,,,,,fee schedule,537.52,2384.8,Radiology
K flow/funct image w/o drug,78707,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,752.53,,,,,,,fee schedule,537.52,2384.8,APC
K flow/funct image w/o drug,78707,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,940.66,,,,,,,fee schedule,537.52,2384.8,APC
K flow/funct image w/drug,78708,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1276.85,,,,,,,fee schedule,537.52,2384.8,
K flow/funct image w/drug,78708,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1023.5,,,,,,,fee schedule,537.52,2384.8,
K flow/funct image w/drug,78708,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1118.08,,,,,,,fee schedule,537.52,2384.8,
K flow/funct image w/drug,78708,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1175.51,,,,,,,fee schedule,537.52,2384.8,
K flow/funct image w/drug,78708,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2384.8,,,,,,,fee schedule,537.52,2384.8,APC 378
K flow/funct image w/drug,78708,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,564.4,,,,,,,fee schedule,537.52,2384.8,APC
K flow/funct image w/drug,78708,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,559.02,,,,,,,fee schedule,537.52,2384.8,APC
K flow/funct image w/drug,78708,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,537.52,,,,,,,fee schedule,537.52,2384.8,APC
K flow/funct image w/drug,78708,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,822.41,,,,,,,fee schedule,537.52,2384.8,Radiology
K flow/funct image w/drug,78708,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,752.53,,,,,,,fee schedule,537.52,2384.8,APC
K flow/funct image w/drug,78708,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,940.66,,,,,,,fee schedule,537.52,2384.8,APC
K flow/funct image multiple,78709,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1268.45,,,,,,,fee schedule,537.52,2384.8,
K flow/funct image multiple,78709,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1016.78,,,,,,,fee schedule,537.52,2384.8,
K flow/funct image multiple,78709,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1110.74,,,,,,,fee schedule,537.52,2384.8,
K flow/funct image multiple,78709,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1167.78,,,,,,,fee schedule,537.52,2384.8,
K flow/funct image multiple,78709,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2384.8,,,,,,,fee schedule,537.52,2384.8,APC 378
K flow/funct image multiple,78709,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,564.4,,,,,,,fee schedule,537.52,2384.8,APC
K flow/funct image multiple,78709,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,559.02,,,,,,,fee schedule,537.52,2384.8,APC
K flow/funct image multiple,78709,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,537.52,,,,,,,fee schedule,537.52,2384.8,APC
K flow/funct image multiple,78709,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,822.41,,,,,,,fee schedule,537.52,2384.8,Radiology
K flow/funct image multiple,78709,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,752.53,,,,,,,fee schedule,537.52,2384.8,APC
K flow/funct image multiple,78709,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,940.66,,,,,,,fee schedule,537.52,2384.8,APC
Kidney function study,78725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,724.32,,,,,,,fee schedule,395.76,1755.86,
Kidney function study,78725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,580.61,,,,,,,fee schedule,395.76,1755.86,
Kidney function study,78725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,634.26,,,,,,,fee schedule,395.76,1755.86,
Kidney function study,78725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,666.84,,,,,,,fee schedule,395.76,1755.86,
Kidney function study,78725,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755.86,,,,,,,fee schedule,395.76,1755.86,APC 378
Kidney function study,78725,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,415.55,,,,,,,fee schedule,395.76,1755.86,APC
Kidney function study,78725,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,411.59,,,,,,,fee schedule,395.76,1755.86,APC
Kidney function study,78725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,395.76,,,,,,,fee schedule,395.76,1755.86,APC
Kidney function study,78725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,605.51,,,,,,,fee schedule,395.76,1755.86,Radiology
Kidney function study,78725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,554.06,,,,,,,fee schedule,395.76,1755.86,APC
Kidney function study,78725,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,692.58,,,,,,,fee schedule,395.76,1755.86,APC
Urinary bladder retention,78730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,453.98,,,,,,,fee schedule,363.9,453.98,
Urinary bladder retention,78730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,363.9,,,,,,,fee schedule,363.9,453.98,
Urinary bladder retention,78730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,397.53,,,,,,,fee schedule,363.9,453.98,
Urinary bladder retention,78730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,417.95,,,,,,,fee schedule,363.9,453.98,
Ureteral reflux study,78740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,538.5,,,,,,,fee schedule,395.76,1755.86,
Ureteral reflux study,78740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,431.65,,,,,,,fee schedule,395.76,1755.86,
Ureteral reflux study,78740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,471.54,,,,,,,fee schedule,395.76,1755.86,
Ureteral reflux study,78740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,495.76,,,,,,,fee schedule,395.76,1755.86,
Ureteral reflux study,78740,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755.86,,,,,,,fee schedule,395.76,1755.86,APC 378
Ureteral reflux study,78740,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,415.55,,,,,,,fee schedule,395.76,1755.86,APC
Ureteral reflux study,78740,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,411.59,,,,,,,fee schedule,395.76,1755.86,APC
Ureteral reflux study,78740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,395.76,,,,,,,fee schedule,395.76,1755.86,APC
Ureteral reflux study,78740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,605.51,,,,,,,fee schedule,395.76,1755.86,Radiology
Ureteral reflux study,78740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,554.06,,,,,,,fee schedule,395.76,1755.86,APC
Ureteral reflux study,78740,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,692.58,,,,,,,fee schedule,395.76,1755.86,APC
Testicular imaging w/flow,78761,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1268.45,,,,,,,fee schedule,395.76,1755.86,
Testicular imaging w/flow,78761,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1016.78,,,,,,,fee schedule,395.76,1755.86,
Testicular imaging w/flow,78761,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1110.74,,,,,,,fee schedule,395.76,1755.86,
Testicular imaging w/flow,78761,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1167.78,,,,,,,fee schedule,395.76,1755.86,
Testicular imaging w/flow,78761,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755.86,,,,,,,fee schedule,395.76,1755.86,APC 378
Testicular imaging w/flow,78761,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,415.55,,,,,,,fee schedule,395.76,1755.86,APC
Testicular imaging w/flow,78761,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,411.59,,,,,,,fee schedule,395.76,1755.86,APC
Testicular imaging w/flow,78761,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,395.76,,,,,,,fee schedule,395.76,1755.86,APC
Testicular imaging w/flow,78761,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,605.51,,,,,,,fee schedule,395.76,1755.86,Radiology
Testicular imaging w/flow,78761,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,554.06,,,,,,,fee schedule,395.76,1755.86,APC
Testicular imaging w/flow,78761,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,692.58,,,,,,,fee schedule,395.76,1755.86,APC
Genitourinary nuclear exam,78799,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755.86,,,,,,,fee schedule,395.76,1755.86,APC 378
Genitourinary nuclear exam,78799,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,415.55,,,,,,,fee schedule,395.76,1755.86,APC
Genitourinary nuclear exam,78799,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,411.59,,,,,,,fee schedule,395.76,1755.86,APC
Genitourinary nuclear exam,78799,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,395.76,,,,,,,fee schedule,395.76,1755.86,APC
Genitourinary nuclear exam,78799,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,605.51,,,,,,,fee schedule,395.76,1755.86,Radiology
Genitourinary nuclear exam,78799,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,554.06,,,,,,,fee schedule,395.76,1755.86,APC
Genitourinary nuclear exam,78799,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,692.58,,,,,,,fee schedule,395.76,1755.86,APC
Tumor imaging limited area,78800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1264.86,,,,,,,fee schedule,395.76,1755.86,
Tumor imaging limited area,78800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1013.9,,,,,,,fee schedule,395.76,1755.86,
Tumor imaging limited area,78800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1107.59,,,,,,,fee schedule,395.76,1755.86,
Tumor imaging limited area,78800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1164.48,,,,,,,fee schedule,395.76,1755.86,
Tumor imaging limited area,78800,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755.86,,,,,,,fee schedule,395.76,1755.86,APC 378
Tumor imaging limited area,78800,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,415.55,,,,,,,fee schedule,395.76,1755.86,APC
Tumor imaging limited area,78800,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,411.59,,,,,,,fee schedule,395.76,1755.86,APC
Tumor imaging limited area,78800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,395.76,,,,,,,fee schedule,395.76,1755.86,APC
Tumor imaging limited area,78800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,605.51,,,,,,,fee schedule,395.76,1755.86,Radiology
Tumor imaging limited area,78800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,554.06,,,,,,,fee schedule,395.76,1755.86,APC
Tumor imaging limited area,78800,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,692.58,,,,,,,fee schedule,395.76,1755.86,APC
Tumor imaging mult areas,78801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1264.86,,,,,,,fee schedule,395.76,1755.86,
Tumor imaging mult areas,78801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1013.9,,,,,,,fee schedule,395.76,1755.86,
Tumor imaging mult areas,78801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1107.59,,,,,,,fee schedule,395.76,1755.86,
Tumor imaging mult areas,78801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1164.48,,,,,,,fee schedule,395.76,1755.86,
Tumor imaging mult areas,78801,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755.86,,,,,,,fee schedule,395.76,1755.86,APC 378
Tumor imaging mult areas,78801,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,415.55,,,,,,,fee schedule,395.76,1755.86,APC
Tumor imaging mult areas,78801,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,411.59,,,,,,,fee schedule,395.76,1755.86,APC
Tumor imaging mult areas,78801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,395.76,,,,,,,fee schedule,395.76,1755.86,APC
Tumor imaging mult areas,78801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,605.51,,,,,,,fee schedule,395.76,1755.86,Radiology
Tumor imaging mult areas,78801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,554.06,,,,,,,fee schedule,395.76,1755.86,APC
Tumor imaging mult areas,78801,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,692.58,,,,,,,fee schedule,395.76,1755.86,APC
Tumor imaging whole body,78802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2100.81,,,,,,,fee schedule,537.52,2384.8,
Tumor imaging whole body,78802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1683.98,,,,,,,fee schedule,537.52,2384.8,
Tumor imaging whole body,78802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1839.6,,,,,,,fee schedule,537.52,2384.8,
Tumor imaging whole body,78802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1934.08,,,,,,,fee schedule,537.52,2384.8,
Tumor imaging whole body,78802,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2384.8,,,,,,,fee schedule,537.52,2384.8,APC 378
Tumor imaging whole body,78802,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,564.4,,,,,,,fee schedule,537.52,2384.8,APC
Tumor imaging whole body,78802,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,559.02,,,,,,,fee schedule,537.52,2384.8,APC
Tumor imaging whole body,78802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,537.52,,,,,,,fee schedule,537.52,2384.8,APC
Tumor imaging whole body,78802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,822.41,,,,,,,fee schedule,537.52,2384.8,Radiology
Tumor imaging whole body,78802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,752.53,,,,,,,fee schedule,537.52,2384.8,APC
Tumor imaging whole body,78802,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,940.66,,,,,,,fee schedule,537.52,2384.8,APC
Tumor imaging (3D),78803,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1433,,,,,,,fee schedule,537.52,2384.8,
Tumor imaging (3D),78803,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1148.67,,,,,,,fee schedule,537.52,2384.8,
Tumor imaging (3D),78803,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1254.82,,,,,,,fee schedule,537.52,2384.8,
Tumor imaging (3D),78803,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1319.27,,,,,,,fee schedule,537.52,2384.8,
Tumor imaging (3D),78803,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2384.8,,,,,,,fee schedule,537.52,2384.8,APC 378
Tumor imaging (3D),78803,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,564.4,,,,,,,fee schedule,537.52,2384.8,APC
Tumor imaging (3D),78803,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,559.02,,,,,,,fee schedule,537.52,2384.8,APC
Tumor imaging (3D),78803,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,537.52,,,,,,,fee schedule,537.52,2384.8,APC
Tumor imaging (3D),78803,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,822.41,,,,,,,fee schedule,537.52,2384.8,Radiology
Tumor imaging (3D),78803,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,752.53,,,,,,,fee schedule,537.52,2384.8,APC
Tumor imaging (3D),78803,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,940.66,,,,,,,fee schedule,537.52,2384.8,APC
Tumor imaging whole body,78804,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2538.91,,,,,,,fee schedule,537.52,2538.91,
Tumor imaging whole body,78804,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2035.16,,,,,,,fee schedule,537.52,2538.91,
Tumor imaging whole body,78804,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2223.23,,,,,,,fee schedule,537.52,2538.91,
Tumor imaging whole body,78804,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2337.41,,,,,,,fee schedule,537.52,2538.91,
Tumor imaging whole body,78804,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2384.8,,,,,,,fee schedule,537.52,2538.91,APC 378
Tumor imaging whole body,78804,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,564.4,,,,,,,fee schedule,537.52,2538.91,APC
Tumor imaging whole body,78804,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,559.02,,,,,,,fee schedule,537.52,2538.91,APC
Tumor imaging whole body,78804,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,537.52,,,,,,,fee schedule,537.52,2538.91,APC
Tumor imaging whole body,78804,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,822.41,,,,,,,fee schedule,537.52,2538.91,Radiology
Tumor imaging whole body,78804,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,752.53,,,,,,,fee schedule,537.52,2538.91,APC
Tumor imaging whole body,78804,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,940.66,,,,,,,fee schedule,537.52,2538.91,APC
Iv inj ra drug dx study,78808,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755.86,,,,,,,fee schedule,395.76,1755.86,APC 378
Iv inj ra drug dx study,78808,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,415.55,,,,,,,fee schedule,395.76,1755.86,APC
Iv inj ra drug dx study,78808,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,411.59,,,,,,,fee schedule,395.76,1755.86,APC
Iv inj ra drug dx study,78808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,395.76,,,,,,,fee schedule,395.76,1755.86,APC
Iv inj ra drug dx study,78808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,605.51,,,,,,,fee schedule,395.76,1755.86,Radiology
Iv inj ra drug dx study,78808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,554.06,,,,,,,fee schedule,395.76,1755.86,APC
Iv inj ra drug dx study,78808,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,692.58,,,,,,,fee schedule,395.76,1755.86,APC
Pet image ltd area,78811,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4142.99,,,,,,,fee schedule,1281.66,5686.29,
Pet image ltd area,78811,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3320.97,,,,,,,fee schedule,1281.66,5686.29,
Pet image ltd area,78811,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3627.86,,,,,,,fee schedule,1281.66,5686.29,
Pet image ltd area,78811,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3814.18,,,,,,,fee schedule,1281.66,5686.29,
Pet image ltd area,78811,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5686.29,,,,,,,fee schedule,1281.66,5686.29,APC 378
Pet image ltd area,78811,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1345.74,,,,,,,fee schedule,1281.66,5686.29,APC
Pet image ltd area,78811,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1332.93,,,,,,,fee schedule,1281.66,5686.29,APC
Pet image ltd area,78811,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1281.66,,,,,,,fee schedule,1281.66,5686.29,APC
Pet image ltd area,78811,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1960.94,,,,,,,fee schedule,1281.66,5686.29,Radiology
Pet image ltd area,78811,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1794.32,,,,,,,fee schedule,1281.66,5686.29,APC
Pet image ltd area,78811,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2242.91,,,,,,,fee schedule,1281.66,5686.29,APC
Pet image skull-thigh,78812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4142.99,,,,,,,fee schedule,1415.6,6280.55,
Pet image skull-thigh,78812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3320.97,,,,,,,fee schedule,1415.6,6280.55,
Pet image skull-thigh,78812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3627.86,,,,,,,fee schedule,1415.6,6280.55,
Pet image skull-thigh,78812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3814.18,,,,,,,fee schedule,1415.6,6280.55,
Pet image skull-thigh,78812,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6280.55,,,,,,,fee schedule,1415.6,6280.55,APC 378
Pet image skull-thigh,78812,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1486.38,,,,,,,fee schedule,1415.6,6280.55,APC
Pet image skull-thigh,78812,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1472.23,,,,,,,fee schedule,1415.6,6280.55,APC
Pet image skull-thigh,78812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1415.6,,,,,,,fee schedule,1415.6,6280.55,APC
Pet image skull-thigh,78812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2165.87,,,,,,,fee schedule,1415.6,6280.55,Radiology
Pet image skull-thigh,78812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1981.84,,,,,,,fee schedule,1415.6,6280.55,APC
Pet image skull-thigh,78812,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2477.3,,,,,,,fee schedule,1415.6,6280.55,APC
Pet image full body,78813,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3167.91,,,,,,,fee schedule,1415.6,6280.55,
Pet image full body,78813,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2539.35,,,,,,,fee schedule,1415.6,6280.55,
Pet image full body,78813,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2774.01,,,,,,,fee schedule,1415.6,6280.55,
Pet image full body,78813,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2916.49,,,,,,,fee schedule,1415.6,6280.55,
Pet image full body,78813,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6280.55,,,,,,,fee schedule,1415.6,6280.55,APC 378
Pet image full body,78813,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1486.38,,,,,,,fee schedule,1415.6,6280.55,APC
Pet image full body,78813,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1472.23,,,,,,,fee schedule,1415.6,6280.55,APC
Pet image full body,78813,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1415.6,,,,,,,fee schedule,1415.6,6280.55,APC
Pet image full body,78813,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2165.87,,,,,,,fee schedule,1415.6,6280.55,Radiology
Pet image full body,78813,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1981.84,,,,,,,fee schedule,1415.6,6280.55,APC
Pet image full body,78813,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2477.3,,,,,,,fee schedule,1415.6,6280.55,APC
Pet image w/ct lmtd,78814,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4142.99,,,,,,,fee schedule,1415.6,6280.55,
Pet image w/ct lmtd,78814,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3320.97,,,,,,,fee schedule,1415.6,6280.55,
Pet image w/ct lmtd,78814,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3627.86,,,,,,,fee schedule,1415.6,6280.55,
Pet image w/ct lmtd,78814,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3814.18,,,,,,,fee schedule,1415.6,6280.55,
Pet image w/ct lmtd,78814,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6280.55,,,,,,,fee schedule,1415.6,6280.55,APC 378
Pet image w/ct lmtd,78814,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1486.38,,,,,,,fee schedule,1415.6,6280.55,APC
Pet image w/ct lmtd,78814,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1472.23,,,,,,,fee schedule,1415.6,6280.55,APC
Pet image w/ct lmtd,78814,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1415.6,,,,,,,fee schedule,1415.6,6280.55,APC
Pet image w/ct lmtd,78814,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2165.87,,,,,,,fee schedule,1415.6,6280.55,Radiology
Pet image w/ct lmtd,78814,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1981.84,,,,,,,fee schedule,1415.6,6280.55,APC
Pet image w/ct lmtd,78814,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2477.3,,,,,,,fee schedule,1415.6,6280.55,APC
Pet image w/ct skull-thigh,78815,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2409.33,,,,,,,fee schedule,1415.6,6280.55,
Pet image w/ct skull-thigh,78815,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1931.29,,,,,,,fee schedule,1415.6,6280.55,
Pet image w/ct skull-thigh,78815,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2109.76,,,,,,,fee schedule,1415.6,6280.55,
Pet image w/ct skull-thigh,78815,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2218.11,,,,,,,fee schedule,1415.6,6280.55,
Pet image w/ct skull-thigh,78815,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6280.55,,,,,,,fee schedule,1415.6,6280.55,APC 378
Pet image w/ct skull-thigh,78815,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1486.38,,,,,,,fee schedule,1415.6,6280.55,APC
Pet image w/ct skull-thigh,78815,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1472.23,,,,,,,fee schedule,1415.6,6280.55,APC
Pet image w/ct skull-thigh,78815,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1415.6,,,,,,,fee schedule,1415.6,6280.55,APC
Pet image w/ct skull-thigh,78815,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2165.87,,,,,,,fee schedule,1415.6,6280.55,Radiology
Pet image w/ct skull-thigh,78815,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1981.84,,,,,,,fee schedule,1415.6,6280.55,APC
Pet image w/ct skull-thigh,78815,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2477.3,,,,,,,fee schedule,1415.6,6280.55,APC
Pet image w/ct full body,78816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2404.5,,,,,,,fee schedule,1415.6,6280.55,
Pet image w/ct full body,78816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1927.42,,,,,,,fee schedule,1415.6,6280.55,
Pet image w/ct full body,78816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2105.53,,,,,,,fee schedule,1415.6,6280.55,
Pet image w/ct full body,78816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2213.67,,,,,,,fee schedule,1415.6,6280.55,
Pet image w/ct full body,78816,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6280.55,,,,,,,fee schedule,1415.6,6280.55,APC 378
Pet image w/ct full body,78816,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1486.38,,,,,,,fee schedule,1415.6,6280.55,APC
Pet image w/ct full body,78816,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1472.23,,,,,,,fee schedule,1415.6,6280.55,APC
Pet image w/ct full body,78816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1415.6,,,,,,,fee schedule,1415.6,6280.55,APC
Pet image w/ct full body,78816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2165.87,,,,,,,fee schedule,1415.6,6280.55,Radiology
Pet image w/ct full body,78816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1981.84,,,,,,,fee schedule,1415.6,6280.55,APC
Pet image w/ct full body,78816,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2477.3,,,,,,,fee schedule,1415.6,6280.55,APC
Rp loclzj tum spect w/ct 1,78830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4808.88,,,,,,,fee schedule,1281.66,5686.29,
Rp loclzj tum spect w/ct 1,78830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3854.74,,,,,,,fee schedule,1281.66,5686.29,
Rp loclzj tum spect w/ct 1,78830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4210.95,,,,,,,fee schedule,1281.66,5686.29,
Rp loclzj tum spect w/ct 1,78830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4427.22,,,,,,,fee schedule,1281.66,5686.29,
Rp loclzj tum spect w/ct 1,78830,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5686.29,,,,,,,fee schedule,1281.66,5686.29,APC 378
Rp loclzj tum spect w/ct 1,78830,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1345.74,,,,,,,fee schedule,1281.66,5686.29,APC
Rp loclzj tum spect w/ct 1,78830,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1332.93,,,,,,,fee schedule,1281.66,5686.29,APC
Rp loclzj tum spect w/ct 1,78830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1281.66,,,,,,,fee schedule,1281.66,5686.29,APC
Rp loclzj tum spect w/ct 1,78830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1960.94,,,,,,,fee schedule,1281.66,5686.29,Radiology
Rp loclzj tum spect w/ct 1,78830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1794.32,,,,,,,fee schedule,1281.66,5686.29,APC
Rp loclzj tum spect w/ct 1,78830,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2242.91,,,,,,,fee schedule,1281.66,5686.29,APC
Rp loclzj tum spect 2 areas,78831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4808.88,,,,,,,fee schedule,1281.66,5686.29,
Rp loclzj tum spect 2 areas,78831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3854.74,,,,,,,fee schedule,1281.66,5686.29,
Rp loclzj tum spect 2 areas,78831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4210.95,,,,,,,fee schedule,1281.66,5686.29,
Rp loclzj tum spect 2 areas,78831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4427.22,,,,,,,fee schedule,1281.66,5686.29,
Rp loclzj tum spect 2 areas,78831,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5686.29,,,,,,,fee schedule,1281.66,5686.29,APC 378
Rp loclzj tum spect 2 areas,78831,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1345.74,,,,,,,fee schedule,1281.66,5686.29,APC
Rp loclzj tum spect 2 areas,78831,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1332.93,,,,,,,fee schedule,1281.66,5686.29,APC
Rp loclzj tum spect 2 areas,78831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1281.66,,,,,,,fee schedule,1281.66,5686.29,APC
Rp loclzj tum spect 2 areas,78831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1960.94,,,,,,,fee schedule,1281.66,5686.29,Radiology
Rp loclzj tum spect 2 areas,78831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1794.32,,,,,,,fee schedule,1281.66,5686.29,APC
Rp loclzj tum spect 2 areas,78831,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2242.91,,,,,,,fee schedule,1281.66,5686.29,APC
Rp loclzj tum spect w/ct 2,78832,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5455.14,,,,,,,fee schedule,1415.6,6280.55,
Rp loclzj tum spect w/ct 2,78832,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4372.77,,,,,,,fee schedule,1415.6,6280.55,
Rp loclzj tum spect w/ct 2,78832,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4776.86,,,,,,,fee schedule,1415.6,6280.55,
Rp loclzj tum spect w/ct 2,78832,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5022.2,,,,,,,fee schedule,1415.6,6280.55,
Rp loclzj tum spect w/ct 2,78832,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6280.55,,,,,,,fee schedule,1415.6,6280.55,APC 378
Rp loclzj tum spect w/ct 2,78832,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1486.38,,,,,,,fee schedule,1415.6,6280.55,APC
Rp loclzj tum spect w/ct 2,78832,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1472.23,,,,,,,fee schedule,1415.6,6280.55,APC
Rp loclzj tum spect w/ct 2,78832,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1415.6,,,,,,,fee schedule,1415.6,6280.55,APC
Rp loclzj tum spect w/ct 2,78832,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2165.87,,,,,,,fee schedule,1415.6,6280.55,Radiology
Rp loclzj tum spect w/ct 2,78832,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1981.84,,,,,,,fee schedule,1415.6,6280.55,APC
Rp loclzj tum spect w/ct 2,78832,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2477.3,,,,,,,fee schedule,1415.6,6280.55,APC
Rp quan meas single area,78835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,85.35,,,,,,,fee schedule,68.42,85.35,
Rp quan meas single area,78835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,68.42,,,,,,,fee schedule,68.42,85.35,
Rp quan meas single area,78835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,74.74,,,,,,,fee schedule,68.42,85.35,
Rp quan meas single area,78835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,78.58,,,,,,,fee schedule,68.42,85.35,
Nuclear diagnostic exam,78999,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755.86,,,,,,,fee schedule,395.76,1755.86,APC 378
Nuclear diagnostic exam,78999,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,415.55,,,,,,,fee schedule,395.76,1755.86,APC
Nuclear diagnostic exam,78999,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,411.59,,,,,,,fee schedule,395.76,1755.86,APC
Nuclear diagnostic exam,78999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,395.76,,,,,,,fee schedule,395.76,1755.86,APC
Nuclear diagnostic exam,78999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,605.51,,,,,,,fee schedule,395.76,1755.86,Radiology
Nuclear diagnostic exam,78999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,554.06,,,,,,,fee schedule,395.76,1755.86,APC
Nuclear diagnostic exam,78999,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,692.58,,,,,,,fee schedule,395.76,1755.86,APC
Nuclear rx oral admin,79005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1088.56,,,,,,,fee schedule,231,1088.56,
Nuclear rx oral admin,79005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,872.58,,,,,,,fee schedule,231,1088.56,
Nuclear rx oral admin,79005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,953.21,,,,,,,fee schedule,231,1088.56,
Nuclear rx oral admin,79005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1002.17,,,,,,,fee schedule,231,1088.56,
Nuclear rx oral admin,79005,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1024.85,,,,,,,fee schedule,231,1088.56,APC 378
Nuclear rx oral admin,79005,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,242.54,,,,,,,fee schedule,231,1088.56,APC
Nuclear rx oral admin,79005,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,240.23,,,,,,,fee schedule,231,1088.56,APC
Nuclear rx oral admin,79005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,231,,,,,,,fee schedule,231,1088.56,APC
Nuclear rx oral admin,79005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,353.42,,,,,,,fee schedule,231,1088.56,Radiology
Nuclear rx oral admin,79005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,323.39,,,,,,,fee schedule,231,1088.56,APC
Nuclear rx oral admin,79005,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,404.24,,,,,,,fee schedule,231,1088.56,APC
Nuclear rx iv admin,79101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,824.12,,,,,,,fee schedule,231,1024.85,
Nuclear rx iv admin,79101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,660.6,,,,,,,fee schedule,231,1024.85,
Nuclear rx iv admin,79101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,721.65,,,,,,,fee schedule,231,1024.85,
Nuclear rx iv admin,79101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,758.71,,,,,,,fee schedule,231,1024.85,
Nuclear rx iv admin,79101,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1024.85,,,,,,,fee schedule,231,1024.85,APC 378
Nuclear rx iv admin,79101,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,242.54,,,,,,,fee schedule,231,1024.85,APC
Nuclear rx iv admin,79101,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,240.23,,,,,,,fee schedule,231,1024.85,APC
Nuclear rx iv admin,79101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,231,,,,,,,fee schedule,231,1024.85,APC
Nuclear rx iv admin,79101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,353.42,,,,,,,fee schedule,231,1024.85,Radiology
Nuclear rx iv admin,79101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,323.39,,,,,,,fee schedule,231,1024.85,APC
Nuclear rx iv admin,79101,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,404.24,,,,,,,fee schedule,231,1024.85,APC
Nuclear rx intracav admin,79200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1316.31,,,,,,,fee schedule,231,1316.31,
Nuclear rx intracav admin,79200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1055.14,,,,,,,fee schedule,231,1316.31,
Nuclear rx intracav admin,79200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1152.64,,,,,,,fee schedule,231,1316.31,
Nuclear rx intracav admin,79200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1211.84,,,,,,,fee schedule,231,1316.31,
Nuclear rx intracav admin,79200,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1024.85,,,,,,,fee schedule,231,1316.31,APC 378
Nuclear rx intracav admin,79200,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,242.54,,,,,,,fee schedule,231,1316.31,APC
Nuclear rx intracav admin,79200,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,240.23,,,,,,,fee schedule,231,1316.31,APC
Nuclear rx intracav admin,79200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,231,,,,,,,fee schedule,231,1316.31,APC
Nuclear rx intracav admin,79200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,353.42,,,,,,,fee schedule,231,1316.31,Radiology
Nuclear rx intracav admin,79200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,323.39,,,,,,,fee schedule,231,1316.31,APC
Nuclear rx intracav admin,79200,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,404.24,,,,,,,fee schedule,231,1316.31,APC
Nuclr rx interstit colloid,79300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,824.12,,,,,,,fee schedule,231,1024.85,
Nuclr rx interstit colloid,79300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,660.6,,,,,,,fee schedule,231,1024.85,
Nuclr rx interstit colloid,79300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,721.65,,,,,,,fee schedule,231,1024.85,
Nuclr rx interstit colloid,79300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,758.71,,,,,,,fee schedule,231,1024.85,
Nuclr rx interstit colloid,79300,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1024.85,,,,,,,fee schedule,231,1024.85,APC 378
Nuclr rx interstit colloid,79300,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,242.54,,,,,,,fee schedule,231,1024.85,APC
Nuclr rx interstit colloid,79300,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,240.23,,,,,,,fee schedule,231,1024.85,APC
Nuclr rx interstit colloid,79300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,231,,,,,,,fee schedule,231,1024.85,APC
Nuclr rx interstit colloid,79300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,353.42,,,,,,,fee schedule,231,1024.85,Radiology
Nuclr rx interstit colloid,79300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,323.39,,,,,,,fee schedule,231,1024.85,APC
Nuclr rx interstit colloid,79300,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,404.24,,,,,,,fee schedule,231,1024.85,APC
Hematopoietic nuclear tx,79403,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1316.31,,,,,,,fee schedule,231,1316.31,
Hematopoietic nuclear tx,79403,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1055.14,,,,,,,fee schedule,231,1316.31,
Hematopoietic nuclear tx,79403,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1152.64,,,,,,,fee schedule,231,1316.31,
Hematopoietic nuclear tx,79403,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1211.84,,,,,,,fee schedule,231,1316.31,
Hematopoietic nuclear tx,79403,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1024.85,,,,,,,fee schedule,231,1316.31,APC 378
Hematopoietic nuclear tx,79403,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,242.54,,,,,,,fee schedule,231,1316.31,APC
Hematopoietic nuclear tx,79403,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,240.23,,,,,,,fee schedule,231,1316.31,APC
Hematopoietic nuclear tx,79403,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,231,,,,,,,fee schedule,231,1316.31,APC
Hematopoietic nuclear tx,79403,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,353.42,,,,,,,fee schedule,231,1316.31,Radiology
Hematopoietic nuclear tx,79403,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,323.39,,,,,,,fee schedule,231,1316.31,APC
Hematopoietic nuclear tx,79403,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,404.24,,,,,,,fee schedule,231,1316.31,APC
Nuclear rx intra-articular,79440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1316.31,,,,,,,fee schedule,231,1316.31,
Nuclear rx intra-articular,79440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1055.14,,,,,,,fee schedule,231,1316.31,
Nuclear rx intra-articular,79440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1152.64,,,,,,,fee schedule,231,1316.31,
Nuclear rx intra-articular,79440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1211.84,,,,,,,fee schedule,231,1316.31,
Nuclear rx intra-articular,79440,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1024.85,,,,,,,fee schedule,231,1316.31,APC 378
Nuclear rx intra-articular,79440,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,242.54,,,,,,,fee schedule,231,1316.31,APC
Nuclear rx intra-articular,79440,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,240.23,,,,,,,fee schedule,231,1316.31,APC
Nuclear rx intra-articular,79440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,231,,,,,,,fee schedule,231,1316.31,APC
Nuclear rx intra-articular,79440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,353.42,,,,,,,fee schedule,231,1316.31,Radiology
Nuclear rx intra-articular,79440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,323.39,,,,,,,fee schedule,231,1316.31,APC
Nuclear rx intra-articular,79440,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,404.24,,,,,,,fee schedule,231,1316.31,APC
Nuclear rx intra-arterial,79445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,855.94,,,,,,,fee schedule,231,1024.85,
Nuclear rx intra-arterial,79445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,686.11,,,,,,,fee schedule,231,1024.85,
Nuclear rx intra-arterial,79445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,749.52,,,,,,,fee schedule,231,1024.85,
Nuclear rx intra-arterial,79445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,788.01,,,,,,,fee schedule,231,1024.85,
Nuclear rx intra-arterial,79445,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1024.85,,,,,,,fee schedule,231,1024.85,APC 378
Nuclear rx intra-arterial,79445,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,242.54,,,,,,,fee schedule,231,1024.85,APC
Nuclear rx intra-arterial,79445,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,240.23,,,,,,,fee schedule,231,1024.85,APC
Nuclear rx intra-arterial,79445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,231,,,,,,,fee schedule,231,1024.85,APC
Nuclear rx intra-arterial,79445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,353.42,,,,,,,fee schedule,231,1024.85,Radiology
Nuclear rx intra-arterial,79445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,323.39,,,,,,,fee schedule,231,1024.85,APC
Nuclear rx intra-arterial,79445,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,404.24,,,,,,,fee schedule,231,1024.85,APC
Nuclear medicine therapy,79999,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1024.85,,,,,,,fee schedule,231,1024.85,APC 378
Nuclear medicine therapy,79999,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,242.54,,,,,,,fee schedule,231,1024.85,APC
Nuclear medicine therapy,79999,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,240.23,,,,,,,fee schedule,231,1024.85,APC
Nuclear medicine therapy,79999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,231,,,,,,,fee schedule,231,1024.85,APC
Nuclear medicine therapy,79999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,353.42,,,,,,,fee schedule,231,1024.85,Radiology
Nuclear medicine therapy,79999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,323.39,,,,,,,fee schedule,231,1024.85,APC
Nuclear medicine therapy,79999,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,404.24,,,,,,,fee schedule,231,1024.85,APC
Metabolic panel ionized ca,80047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46.72,,,,,,,fee schedule,12.36,46.72,
Metabolic panel ionized ca,80047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37.45,,,,,,,fee schedule,12.36,46.72,
Metabolic panel ionized ca,80047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40.91,,,,,,,fee schedule,12.36,46.72,
Metabolic panel ionized ca,80047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,43.01,,,,,,,fee schedule,12.36,46.72,
Metabolic panel ionized ca,80047,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.36,,,,,,,fee schedule,12.36,46.72,Laboratory
Metabolic panel ionized ca,80047,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.42,,,,,,,fee schedule,12.36,46.72,APC
Metabolic panel ionized ca,80047,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,14.28,,,,,,,fee schedule,12.36,46.72,APC
Metabolic panel ionized ca,80047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.73,,,,,,,fee schedule,12.36,46.72,APC
Metabolic panel ionized ca,80047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21.01,,,,,,,fee schedule,12.36,46.72,Radiology
Metabolic panel ionized ca,80047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.22,,,,,,,fee schedule,12.36,46.72,APC
Metabolic panel ionized ca,80047,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,24.03,,,,,,,fee schedule,12.36,46.72,APC
Metabolic panel total ca,80048,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,104.37,,,,,,,fee schedule,7.61,104.37,
Metabolic panel total ca,80048,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,83.67,,,,,,,fee schedule,7.61,104.37,
Metabolic panel total ca,80048,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,91.4,,,,,,,fee schedule,7.61,104.37,
Metabolic panel total ca,80048,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,96.09,,,,,,,fee schedule,7.61,104.37,
Metabolic panel total ca,80048,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.61,,,,,,,fee schedule,7.61,104.37,Laboratory
Metabolic panel total ca,80048,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.88,,,,,,,fee schedule,7.61,104.37,APC
Metabolic panel total ca,80048,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8.8,,,,,,,fee schedule,7.61,104.37,APC
Metabolic panel total ca,80048,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8.46,,,,,,,fee schedule,7.61,104.37,APC
Metabolic panel total ca,80048,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12.94,,,,,,,fee schedule,7.61,104.37,Radiology
Metabolic panel total ca,80048,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11.84,,,,,,,fee schedule,7.61,104.37,APC
Metabolic panel total ca,80048,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14.81,,,,,,,fee schedule,7.61,104.37,APC
Electrolyte panel,80051,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22.21,,,,,,,fee schedule,6.31,22.21,
Electrolyte panel,80051,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17.8,,,,,,,fee schedule,6.31,22.21,
Electrolyte panel,80051,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19.45,,,,,,,fee schedule,6.31,22.21,
Electrolyte panel,80051,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20.45,,,,,,,fee schedule,6.31,22.21,
Electrolyte panel,80051,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.31,,,,,,,fee schedule,6.31,22.21,Laboratory
Electrolyte panel,80051,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.36,,,,,,,fee schedule,6.31,22.21,APC
Electrolyte panel,80051,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7.29,,,,,,,fee schedule,6.31,22.21,APC
Electrolyte panel,80051,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7.01,,,,,,,fee schedule,6.31,22.21,APC
Electrolyte panel,80051,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10.73,,,,,,,fee schedule,6.31,22.21,Radiology
Electrolyte panel,80051,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.81,,,,,,,fee schedule,6.31,22.21,APC
Electrolyte panel,80051,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12.27,,,,,,,fee schedule,6.31,22.21,APC
Comprehen metabolic panel,80053,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,110.55,,,,,,,fee schedule,9.5,110.55,
Comprehen metabolic panel,80053,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,88.62,,,,,,,fee schedule,9.5,110.55,
Comprehen metabolic panel,80053,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,96.81,,,,,,,fee schedule,9.5,110.55,
Comprehen metabolic panel,80053,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,101.78,,,,,,,fee schedule,9.5,110.55,
Comprehen metabolic panel,80053,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.5,,,,,,,fee schedule,9.5,110.55,Laboratory
Comprehen metabolic panel,80053,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.09,,,,,,,fee schedule,9.5,110.55,APC
Comprehen metabolic panel,80053,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10.98,,,,,,,fee schedule,9.5,110.55,APC
Comprehen metabolic panel,80053,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10.56,,,,,,,fee schedule,9.5,110.55,APC
Comprehen metabolic panel,80053,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.16,,,,,,,fee schedule,9.5,110.55,Radiology
Comprehen metabolic panel,80053,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.78,,,,,,,fee schedule,9.5,110.55,APC
Comprehen metabolic panel,80053,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18.48,,,,,,,fee schedule,9.5,110.55,APC
Obstetric panel,80055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,96.25,,,,,,,fee schedule,43.03,96.25,
Obstetric panel,80055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,77.15,,,,,,,fee schedule,43.03,96.25,
Obstetric panel,80055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,84.28,,,,,,,fee schedule,43.03,96.25,
Obstetric panel,80055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,88.61,,,,,,,fee schedule,43.03,96.25,
Obstetric panel,80055,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,43.03,,,,,,,fee schedule,43.03,96.25,Laboratory
Obstetric panel,80055,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,50.2,,,,,,,fee schedule,43.03,96.25,APC
Obstetric panel,80055,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,49.72,,,,,,,fee schedule,43.03,96.25,APC
Obstetric panel,80055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,47.81,,,,,,,fee schedule,43.03,96.25,APC
Obstetric panel,80055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,73.15,,,,,,,fee schedule,43.03,96.25,Radiology
Obstetric panel,80055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,66.93,,,,,,,fee schedule,43.03,96.25,APC
Obstetric panel,80055,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,83.67,,,,,,,fee schedule,43.03,96.25,APC
Lipid panel,80061,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,100.94,,,,,,,fee schedule,12.05,100.94,
Lipid panel,80061,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,80.91,,,,,,,fee schedule,12.05,100.94,
Lipid panel,80061,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,88.39,,,,,,,fee schedule,12.05,100.94,
Lipid panel,80061,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,92.92,,,,,,,fee schedule,12.05,100.94,
Lipid panel,80061,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.05,,,,,,,fee schedule,12.05,100.94,Laboratory
Lipid panel,80061,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.06,,,,,,,fee schedule,12.05,100.94,APC
Lipid panel,80061,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.93,,,,,,,fee schedule,12.05,100.94,APC
Lipid panel,80061,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.39,,,,,,,fee schedule,12.05,100.94,APC
Lipid panel,80061,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.49,,,,,,,fee schedule,12.05,100.94,Radiology
Lipid panel,80061,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.75,,,,,,,fee schedule,12.05,100.94,APC
Lipid panel,80061,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23.43,,,,,,,fee schedule,12.05,100.94,APC
Renal function panel,80069,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,40.28,,,,,,,fee schedule,7.81,40.28,
Renal function panel,80069,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32.29,,,,,,,fee schedule,7.81,40.28,
Renal function panel,80069,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35.27,,,,,,,fee schedule,7.81,40.28,
Renal function panel,80069,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37.08,,,,,,,fee schedule,7.81,40.28,
Renal function panel,80069,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.81,,,,,,,fee schedule,7.81,40.28,Laboratory
Renal function panel,80069,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.11,,,,,,,fee schedule,7.81,40.28,APC
Renal function panel,80069,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9.03,,,,,,,fee schedule,7.81,40.28,APC
Renal function panel,80069,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8.68,,,,,,,fee schedule,7.81,40.28,APC
Renal function panel,80069,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.28,,,,,,,fee schedule,7.81,40.28,Radiology
Renal function panel,80069,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12.15,,,,,,,fee schedule,7.81,40.28,APC
Renal function panel,80069,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15.19,,,,,,,fee schedule,7.81,40.28,APC
Acute hepatitis panel,80074,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,156.88,,,,,,,fee schedule,42.87,156.88,
Acute hepatitis panel,80074,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,125.75,,,,,,,fee schedule,42.87,156.88,
Acute hepatitis panel,80074,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,137.37,,,,,,,fee schedule,42.87,156.88,
Acute hepatitis panel,80074,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,144.43,,,,,,,fee schedule,42.87,156.88,
Acute hepatitis panel,80074,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,42.87,,,,,,,fee schedule,42.87,156.88,Laboratory
Acute hepatitis panel,80074,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,50.01,,,,,,,fee schedule,42.87,156.88,APC
Acute hepatitis panel,80074,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,49.54,,,,,,,fee schedule,42.87,156.88,APC
Acute hepatitis panel,80074,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,47.63,,,,,,,fee schedule,42.87,156.88,APC
Acute hepatitis panel,80074,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,72.87,,,,,,,fee schedule,42.87,156.88,Radiology
Acute hepatitis panel,80074,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,66.68,,,,,,,fee schedule,42.87,156.88,APC
Acute hepatitis panel,80074,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,83.35,,,,,,,fee schedule,42.87,156.88,APC
Hepatic function panel,80076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,100.39,,,,,,,fee schedule,7.35,100.39,
Hepatic function panel,80076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,80.47,,,,,,,fee schedule,7.35,100.39,
Hepatic function panel,80076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,87.91,,,,,,,fee schedule,7.35,100.39,
Hepatic function panel,80076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,92.42,,,,,,,fee schedule,7.35,100.39,
Hepatic function panel,80076,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.35,,,,,,,fee schedule,7.35,100.39,Laboratory
Hepatic function panel,80076,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.58,,,,,,,fee schedule,7.35,100.39,APC
Hepatic function panel,80076,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8.5,,,,,,,fee schedule,7.35,100.39,APC
Hepatic function panel,80076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8.17,,,,,,,fee schedule,7.35,100.39,APC
Hepatic function panel,80076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12.5,,,,,,,fee schedule,7.35,100.39,Radiology
Hepatic function panel,80076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11.44,,,,,,,fee schedule,7.35,100.39,APC
Hepatic function panel,80076,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14.3,,,,,,,fee schedule,7.35,100.39,APC
Obstetric panel,80081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,166.03,,,,,,,fee schedule,67.37,166.03,
Obstetric panel,80081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,133.09,,,,,,,fee schedule,67.37,166.03,
Obstetric panel,80081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,145.39,,,,,,,fee schedule,67.37,166.03,
Obstetric panel,80081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,152.86,,,,,,,fee schedule,67.37,166.03,
Obstetric panel,80081,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,67.37,,,,,,,fee schedule,67.37,166.03,Laboratory
Obstetric panel,80081,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,78.6,,,,,,,fee schedule,67.37,166.03,APC
Obstetric panel,80081,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,77.85,,,,,,,fee schedule,67.37,166.03,APC
Obstetric panel,80081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,74.86,,,,,,,fee schedule,67.37,166.03,APC
Obstetric panel,80081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,114.54,,,,,,,fee schedule,67.37,166.03,Radiology
Obstetric panel,80081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,104.8,,,,,,,fee schedule,67.37,166.03,APC
Obstetric panel,80081,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,131,,,,,,,fee schedule,67.37,166.03,APC
Drug assay acetaminophen,80143,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.78,,,,,,,fee schedule,16.78,32.62,Laboratory
Drug assay acetaminophen,80143,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.57,,,,,,,fee schedule,16.78,32.62,APC
Drug assay acetaminophen,80143,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,19.39,,,,,,,fee schedule,16.78,32.62,APC
Drug assay acetaminophen,80143,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18.64,,,,,,,fee schedule,16.78,32.62,APC
Drug assay acetaminophen,80143,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.52,,,,,,,fee schedule,16.78,32.62,Radiology
Drug assay acetaminophen,80143,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26.1,,,,,,,fee schedule,16.78,32.62,APC
Drug assay acetaminophen,80143,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,32.62,,,,,,,fee schedule,16.78,32.62,APC
Drug assay adalimumab,80145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,145.79,,,,,,,fee schedule,34.71,145.79,
Drug assay adalimumab,80145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,116.87,,,,,,,fee schedule,34.71,145.79,
Drug assay adalimumab,80145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,127.67,,,,,,,fee schedule,34.71,145.79,
Drug assay adalimumab,80145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,134.22,,,,,,,fee schedule,34.71,145.79,
Drug assay adalimumab,80145,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,34.71,,,,,,,fee schedule,34.71,145.79,Laboratory
Drug assay adalimumab,80145,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,40.5,,,,,,,fee schedule,34.71,145.79,APC
Drug assay adalimumab,80145,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,40.11,,,,,,,fee schedule,34.71,145.79,APC
Drug assay adalimumab,80145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,38.57,,,,,,,fee schedule,34.71,145.79,APC
Drug assay adalimumab,80145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,59.01,,,,,,,fee schedule,34.71,145.79,Radiology
Drug assay adalimumab,80145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,54,,,,,,,fee schedule,34.71,145.79,APC
Drug assay adalimumab,80145,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,67.5,,,,,,,fee schedule,34.71,145.79,APC
Assay of amikacin,80150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83.2,,,,,,,fee schedule,13.57,83.2,
Assay of amikacin,80150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66.69,,,,,,,fee schedule,13.57,83.2,
Assay of amikacin,80150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,72.85,,,,,,,fee schedule,13.57,83.2,
Assay of amikacin,80150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,76.59,,,,,,,fee schedule,13.57,83.2,
Assay of amikacin,80150,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.57,,,,,,,fee schedule,13.57,83.2,Laboratory
Assay of amikacin,80150,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.83,,,,,,,fee schedule,13.57,83.2,APC
Assay of amikacin,80150,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,15.68,,,,,,,fee schedule,13.57,83.2,APC
Assay of amikacin,80150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,15.08,,,,,,,fee schedule,13.57,83.2,APC
Assay of amikacin,80150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.07,,,,,,,fee schedule,13.57,83.2,Radiology
Assay of amikacin,80150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21.11,,,,,,,fee schedule,13.57,83.2,APC
Assay of amikacin,80150,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,26.39,,,,,,,fee schedule,13.57,83.2,APC
Drug assay amiodarone,80151,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.78,,,,,,,fee schedule,16.78,32.62,Laboratory
Drug assay amiodarone,80151,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.57,,,,,,,fee schedule,16.78,32.62,APC
Drug assay amiodarone,80151,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,19.39,,,,,,,fee schedule,16.78,32.62,APC
Drug assay amiodarone,80151,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18.64,,,,,,,fee schedule,16.78,32.62,APC
Drug assay amiodarone,80151,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.52,,,,,,,fee schedule,16.78,32.62,Radiology
Drug assay amiodarone,80151,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26.1,,,,,,,fee schedule,16.78,32.62,APC
Drug assay amiodarone,80151,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,32.62,,,,,,,fee schedule,16.78,32.62,APC
Drug assay caffeine,80155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,72.77,,,,,,,fee schedule,34.71,72.77,
Drug assay caffeine,80155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,58.33,,,,,,,fee schedule,34.71,72.77,
Drug assay caffeine,80155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,63.72,,,,,,,fee schedule,34.71,72.77,
Drug assay caffeine,80155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.99,,,,,,,fee schedule,34.71,72.77,
Drug assay caffeine,80155,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,34.71,,,,,,,fee schedule,34.71,72.77,Laboratory
Drug assay caffeine,80155,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,40.5,,,,,,,fee schedule,34.71,72.77,APC
Drug assay caffeine,80155,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,40.11,,,,,,,fee schedule,34.71,72.77,APC
Drug assay caffeine,80155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,38.57,,,,,,,fee schedule,34.71,72.77,APC
Drug assay caffeine,80155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,59.01,,,,,,,fee schedule,34.71,72.77,Radiology
Drug assay caffeine,80155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,54,,,,,,,fee schedule,34.71,72.77,APC
Drug assay caffeine,80155,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,67.5,,,,,,,fee schedule,34.71,72.77,APC
Assay carbamazepine total,80156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,163.63,,,,,,,fee schedule,13.11,163.63,
Assay carbamazepine total,80156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,131.16,,,,,,,fee schedule,13.11,163.63,
Assay carbamazepine total,80156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,143.28,,,,,,,fee schedule,13.11,163.63,
Assay carbamazepine total,80156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,150.64,,,,,,,fee schedule,13.11,163.63,
Assay carbamazepine total,80156,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.11,,,,,,,fee schedule,13.11,163.63,Laboratory
Assay carbamazepine total,80156,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.3,,,,,,,fee schedule,13.11,163.63,APC
Assay carbamazepine total,80156,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,15.15,,,,,,,fee schedule,13.11,163.63,APC
Assay carbamazepine total,80156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14.57,,,,,,,fee schedule,13.11,163.63,APC
Assay carbamazepine total,80156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.29,,,,,,,fee schedule,13.11,163.63,Radiology
Assay carbamazepine total,80156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.4,,,,,,,fee schedule,13.11,163.63,APC
Assay carbamazepine total,80156,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,25.5,,,,,,,fee schedule,13.11,163.63,APC
Assay carbamazepine free,80157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,73.18,,,,,,,fee schedule,11.92,73.18,
Assay carbamazepine free,80157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,58.66,,,,,,,fee schedule,11.92,73.18,
Assay carbamazepine free,80157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,64.08,,,,,,,fee schedule,11.92,73.18,
Assay carbamazepine free,80157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,67.37,,,,,,,fee schedule,11.92,73.18,
Assay carbamazepine free,80157,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.92,,,,,,,fee schedule,11.92,73.18,Laboratory
Assay carbamazepine free,80157,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.91,,,,,,,fee schedule,11.92,73.18,APC
Assay carbamazepine free,80157,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.78,,,,,,,fee schedule,11.92,73.18,APC
Assay carbamazepine free,80157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.25,,,,,,,fee schedule,11.92,73.18,APC
Assay carbamazepine free,80157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.27,,,,,,,fee schedule,11.92,73.18,Radiology
Assay carbamazepine free,80157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.55,,,,,,,fee schedule,11.92,73.18,APC
Assay carbamazepine free,80157,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23.19,,,,,,,fee schedule,11.92,73.18,APC
Drug assay cyclosporine,80158,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,172.51,,,,,,,fee schedule,16.24,172.51,
Drug assay cyclosporine,80158,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,138.28,,,,,,,fee schedule,16.24,172.51,
Drug assay cyclosporine,80158,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,151.06,,,,,,,fee schedule,16.24,172.51,
Drug assay cyclosporine,80158,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,158.82,,,,,,,fee schedule,16.24,172.51,
Drug assay cyclosporine,80158,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.24,,,,,,,fee schedule,16.24,172.51,Laboratory
Drug assay cyclosporine,80158,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.95,,,,,,,fee schedule,16.24,172.51,APC
Drug assay cyclosporine,80158,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18.77,,,,,,,fee schedule,16.24,172.51,APC
Drug assay cyclosporine,80158,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18.05,,,,,,,fee schedule,16.24,172.51,APC
Drug assay cyclosporine,80158,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27.62,,,,,,,fee schedule,16.24,172.51,Radiology
Drug assay cyclosporine,80158,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.27,,,,,,,fee schedule,16.24,172.51,APC
Drug assay cyclosporine,80158,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31.59,,,,,,,fee schedule,16.24,172.51,APC
Drug assay clozapine,80159,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,95.14,,,,,,,fee schedule,18.14,95.14,
Drug assay clozapine,80159,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,76.27,,,,,,,fee schedule,18.14,95.14,
Drug assay clozapine,80159,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,83.31,,,,,,,fee schedule,18.14,95.14,
Drug assay clozapine,80159,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,87.59,,,,,,,fee schedule,18.14,95.14,
Drug assay clozapine,80159,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.13,,,,,,,fee schedule,18.14,95.14,Laboratory
Drug assay clozapine,80159,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.16,,,,,,,fee schedule,18.14,95.14,APC
Drug assay clozapine,80159,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,20.96,,,,,,,fee schedule,18.14,95.14,APC
Drug assay clozapine,80159,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,20.15,,,,,,,fee schedule,18.14,95.14,APC
Drug assay clozapine,80159,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,30.83,,,,,,,fee schedule,18.14,95.14,Radiology
Drug assay clozapine,80159,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.21,,,,,,,fee schedule,18.14,95.14,APC
Drug assay clozapine,80159,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,35.26,,,,,,,fee schedule,18.14,95.14,APC
"Asy carbamazepin 10,11-epxid",80161,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.78,,,,,,,fee schedule,16.78,32.62,Laboratory
"Asy carbamazepin 10,11-epxid",80161,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.57,,,,,,,fee schedule,16.78,32.62,APC
"Asy carbamazepin 10,11-epxid",80161,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,19.39,,,,,,,fee schedule,16.78,32.62,APC
"Asy carbamazepin 10,11-epxid",80161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18.64,,,,,,,fee schedule,16.78,32.62,APC
"Asy carbamazepin 10,11-epxid",80161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.52,,,,,,,fee schedule,16.78,32.62,Radiology
"Asy carbamazepin 10,11-epxid",80161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26.1,,,,,,,fee schedule,16.78,32.62,APC
"Asy carbamazepin 10,11-epxid",80161,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,32.62,,,,,,,fee schedule,16.78,32.62,APC
Assay of digoxin total,80162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,67.38,,,,,,,fee schedule,11.95,67.38,
Assay of digoxin total,80162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,54.01,,,,,,,fee schedule,11.95,67.38,
Assay of digoxin total,80162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,59,,,,,,,fee schedule,11.95,67.38,
Assay of digoxin total,80162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,62.03,,,,,,,fee schedule,11.95,67.38,
Assay of digoxin total,80162,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.95,,,,,,,fee schedule,11.95,67.38,Laboratory
Assay of digoxin total,80162,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.94,,,,,,,fee schedule,11.95,67.38,APC
Assay of digoxin total,80162,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.81,,,,,,,fee schedule,11.95,67.38,APC
Assay of digoxin total,80162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.28,,,,,,,fee schedule,11.95,67.38,APC
Assay of digoxin total,80162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.32,,,,,,,fee schedule,11.95,67.38,Radiology
Assay of digoxin total,80162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.59,,,,,,,fee schedule,11.95,67.38,APC
Assay of digoxin total,80162,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23.24,,,,,,,fee schedule,11.95,67.38,APC
Assay of digoxin free,80163,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,68.3,,,,,,,fee schedule,11.95,68.3,
Assay of digoxin free,80163,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,54.75,,,,,,,fee schedule,11.95,68.3,
Assay of digoxin free,80163,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,59.81,,,,,,,fee schedule,11.95,68.3,
Assay of digoxin free,80163,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,62.88,,,,,,,fee schedule,11.95,68.3,
Assay of digoxin free,80163,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.95,,,,,,,fee schedule,11.95,68.3,Laboratory
Assay of digoxin free,80163,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.94,,,,,,,fee schedule,11.95,68.3,APC
Assay of digoxin free,80163,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.81,,,,,,,fee schedule,11.95,68.3,APC
Assay of digoxin free,80163,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.28,,,,,,,fee schedule,11.95,68.3,APC
Assay of digoxin free,80163,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.32,,,,,,,fee schedule,11.95,68.3,Radiology
Assay of digoxin free,80163,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.59,,,,,,,fee schedule,11.95,68.3,APC
Assay of digoxin free,80163,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23.24,,,,,,,fee schedule,11.95,68.3,APC
Assay dipropylacetic acd tot,80164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41.46,,,,,,,fee schedule,12.19,41.46,
Assay dipropylacetic acd tot,80164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,33.24,,,,,,,fee schedule,12.19,41.46,
Assay dipropylacetic acd tot,80164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36.31,,,,,,,fee schedule,12.19,41.46,
Assay dipropylacetic acd tot,80164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,38.17,,,,,,,fee schedule,12.19,41.46,
Assay dipropylacetic acd tot,80164,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.19,,,,,,,fee schedule,12.19,41.46,Laboratory
Assay dipropylacetic acd tot,80164,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.22,,,,,,,fee schedule,12.19,41.46,APC
Assay dipropylacetic acd tot,80164,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,14.08,,,,,,,fee schedule,12.19,41.46,APC
Assay dipropylacetic acd tot,80164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.54,,,,,,,fee schedule,12.19,41.46,APC
Assay dipropylacetic acd tot,80164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.72,,,,,,,fee schedule,12.19,41.46,Radiology
Assay dipropylacetic acd tot,80164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.96,,,,,,,fee schedule,12.19,41.46,APC
Assay dipropylacetic acd tot,80164,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23.7,,,,,,,fee schedule,12.19,41.46,APC
Dipropylacetic acid free,80165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,69.7,,,,,,,fee schedule,12.19,69.7,
Dipropylacetic acid free,80165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55.87,,,,,,,fee schedule,12.19,69.7,
Dipropylacetic acid free,80165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,61.04,,,,,,,fee schedule,12.19,69.7,
Dipropylacetic acid free,80165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,64.17,,,,,,,fee schedule,12.19,69.7,
Dipropylacetic acid free,80165,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.19,,,,,,,fee schedule,12.19,69.7,Laboratory
Dipropylacetic acid free,80165,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.22,,,,,,,fee schedule,12.19,69.7,APC
Dipropylacetic acid free,80165,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,14.08,,,,,,,fee schedule,12.19,69.7,APC
Dipropylacetic acid free,80165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.54,,,,,,,fee schedule,12.19,69.7,APC
Dipropylacetic acid free,80165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.72,,,,,,,fee schedule,12.19,69.7,Radiology
Dipropylacetic acid free,80165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.96,,,,,,,fee schedule,12.19,69.7,APC
Dipropylacetic acid free,80165,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23.7,,,,,,,fee schedule,12.19,69.7,APC
Drug assay felbamate,80167,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.78,,,,,,,fee schedule,16.78,32.62,Laboratory
Drug assay felbamate,80167,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.57,,,,,,,fee schedule,16.78,32.62,APC
Drug assay felbamate,80167,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,19.39,,,,,,,fee schedule,16.78,32.62,APC
Drug assay felbamate,80167,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18.64,,,,,,,fee schedule,16.78,32.62,APC
Drug assay felbamate,80167,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.52,,,,,,,fee schedule,16.78,32.62,Radiology
Drug assay felbamate,80167,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26.1,,,,,,,fee schedule,16.78,32.62,APC
Drug assay felbamate,80167,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,32.62,,,,,,,fee schedule,16.78,32.62,APC
Assay of ethosuximide,80168,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,90.19,,,,,,,fee schedule,14.71,90.19,
Assay of ethosuximide,80168,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,72.3,,,,,,,fee schedule,14.71,90.19,
Assay of ethosuximide,80168,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,78.98,,,,,,,fee schedule,14.71,90.19,
Assay of ethosuximide,80168,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83.03,,,,,,,fee schedule,14.71,90.19,
Assay of ethosuximide,80168,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.71,,,,,,,fee schedule,14.71,90.19,Laboratory
Assay of ethosuximide,80168,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.16,,,,,,,fee schedule,14.71,90.19,APC
Assay of ethosuximide,80168,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,16.99,,,,,,,fee schedule,14.71,90.19,APC
Assay of ethosuximide,80168,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16.34,,,,,,,fee schedule,14.71,90.19,APC
Assay of ethosuximide,80168,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25,,,,,,,fee schedule,14.71,90.19,Radiology
Assay of ethosuximide,80168,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.88,,,,,,,fee schedule,14.71,90.19,APC
Assay of ethosuximide,80168,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,28.6,,,,,,,fee schedule,14.71,90.19,APC
Drug assay everolimus,80169,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,70.65,,,,,,,fee schedule,12.36,70.65,
Drug assay everolimus,80169,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56.63,,,,,,,fee schedule,12.36,70.65,
Drug assay everolimus,80169,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,61.86,,,,,,,fee schedule,12.36,70.65,
Drug assay everolimus,80169,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,65.04,,,,,,,fee schedule,12.36,70.65,
Drug assay everolimus,80169,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.36,,,,,,,fee schedule,12.36,70.65,Laboratory
Drug assay everolimus,80169,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.42,,,,,,,fee schedule,12.36,70.65,APC
Drug assay everolimus,80169,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,14.28,,,,,,,fee schedule,12.36,70.65,APC
Drug assay everolimus,80169,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.73,,,,,,,fee schedule,12.36,70.65,APC
Drug assay everolimus,80169,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21.01,,,,,,,fee schedule,12.36,70.65,Radiology
Drug assay everolimus,80169,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.22,,,,,,,fee schedule,12.36,70.65,APC
Drug assay everolimus,80169,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,24.03,,,,,,,fee schedule,12.36,70.65,APC
Assay of gentamicin,80170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,90.46,,,,,,,fee schedule,14.74,90.46,
Assay of gentamicin,80170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,72.51,,,,,,,fee schedule,14.74,90.46,
Assay of gentamicin,80170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,79.21,,,,,,,fee schedule,14.74,90.46,
Assay of gentamicin,80170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83.28,,,,,,,fee schedule,14.74,90.46,
Assay of gentamicin,80170,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.74,,,,,,,fee schedule,14.74,90.46,Laboratory
Assay of gentamicin,80170,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.2,,,,,,,fee schedule,14.74,90.46,APC
Assay of gentamicin,80170,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,17.04,,,,,,,fee schedule,14.74,90.46,APC
Assay of gentamicin,80170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16.38,,,,,,,fee schedule,14.74,90.46,APC
Assay of gentamicin,80170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.06,,,,,,,fee schedule,14.74,90.46,Radiology
Assay of gentamicin,80170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.93,,,,,,,fee schedule,14.74,90.46,APC
Assay of gentamicin,80170,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,28.66,,,,,,,fee schedule,14.74,90.46,APC
Drug screen quant gabapentin,80171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,68.19,,,,,,,fee schedule,19.5,68.19,
Drug screen quant gabapentin,80171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,54.66,,,,,,,fee schedule,19.5,68.19,
Drug screen quant gabapentin,80171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,59.71,,,,,,,fee schedule,19.5,68.19,
Drug screen quant gabapentin,80171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,62.78,,,,,,,fee schedule,19.5,68.19,
Drug screen quant gabapentin,80171,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.5,,,,,,,fee schedule,19.5,68.19,Laboratory
Drug screen quant gabapentin,80171,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,22.75,,,,,,,fee schedule,19.5,68.19,APC
Drug screen quant gabapentin,80171,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,22.54,,,,,,,fee schedule,19.5,68.19,APC
Drug screen quant gabapentin,80171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,21.67,,,,,,,fee schedule,19.5,68.19,APC
Drug screen quant gabapentin,80171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,33.16,,,,,,,fee schedule,19.5,68.19,Radiology
Drug screen quant gabapentin,80171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,30.34,,,,,,,fee schedule,19.5,68.19,APC
Drug screen quant gabapentin,80171,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,37.92,,,,,,,fee schedule,19.5,68.19,APC
Assay Of Haloperidol,80173,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,80.36,,,,,,,fee schedule,14.2,80.36,
Assay Of Haloperidol,80173,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,64.42,,,,,,,fee schedule,14.2,80.36,
Assay Of Haloperidol,80173,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,70.37,,,,,,,fee schedule,14.2,80.36,
Assay Of Haloperidol,80173,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,73.98,,,,,,,fee schedule,14.2,80.36,
Assay Of Haloperidol,80173,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.2,,,,,,,fee schedule,14.2,80.36,Laboratory
Assay Of Haloperidol,80173,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.57,,,,,,,fee schedule,14.2,80.36,APC
Assay Of Haloperidol,80173,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,16.41,,,,,,,fee schedule,14.2,80.36,APC
Assay Of Haloperidol,80173,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,15.78,,,,,,,fee schedule,14.2,80.36,APC
Assay Of Haloperidol,80173,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24.14,,,,,,,fee schedule,14.2,80.36,Radiology
Assay Of Haloperidol,80173,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.09,,,,,,,fee schedule,14.2,80.36,APC
Assay Of Haloperidol,80173,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,27.62,,,,,,,fee schedule,14.2,80.36,APC
Drug screen quan lamotrigine,80175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,40.72,,,,,,,fee schedule,11.92,40.72,
Drug screen quan lamotrigine,80175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32.64,,,,,,,fee schedule,11.92,40.72,
Drug screen quan lamotrigine,80175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35.66,,,,,,,fee schedule,11.92,40.72,
Drug screen quan lamotrigine,80175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37.49,,,,,,,fee schedule,11.92,40.72,
Drug screen quan lamotrigine,80175,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.92,,,,,,,fee schedule,11.92,40.72,Laboratory
Drug screen quan lamotrigine,80175,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.91,,,,,,,fee schedule,11.92,40.72,APC
Drug screen quan lamotrigine,80175,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.78,,,,,,,fee schedule,11.92,40.72,APC
Drug screen quan lamotrigine,80175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.25,,,,,,,fee schedule,11.92,40.72,APC
Drug screen quan lamotrigine,80175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.27,,,,,,,fee schedule,11.92,40.72,Radiology
Drug screen quan lamotrigine,80175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.55,,,,,,,fee schedule,11.92,40.72,APC
Drug screen quan lamotrigine,80175,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23.19,,,,,,,fee schedule,11.92,40.72,APC
Assay of lidocaine,80176,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,81.08,,,,,,,fee schedule,13.22,81.08,
Assay of lidocaine,80176,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,64.99,,,,,,,fee schedule,13.22,81.08,
Assay of lidocaine,80176,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,71,,,,,,,fee schedule,13.22,81.08,
Assay of lidocaine,80176,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,74.65,,,,,,,fee schedule,13.22,81.08,
Assay of lidocaine,80176,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.22,,,,,,,fee schedule,13.22,81.08,Laboratory
Assay of lidocaine,80176,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.42,,,,,,,fee schedule,13.22,81.08,APC
Assay of lidocaine,80176,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,15.28,,,,,,,fee schedule,13.22,81.08,APC
Assay of lidocaine,80176,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14.69,,,,,,,fee schedule,13.22,81.08,APC
Assay of lidocaine,80176,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.48,,,,,,,fee schedule,13.22,81.08,Radiology
Assay of lidocaine,80176,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.57,,,,,,,fee schedule,13.22,81.08,APC
Assay of lidocaine,80176,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,25.71,,,,,,,fee schedule,13.22,81.08,APC
Drug scrn quan levetiracetam,80177,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,31.93,,,,,,,fee schedule,11.92,31.93,
Drug scrn quan levetiracetam,80177,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,25.59,,,,,,,fee schedule,11.92,31.93,
Drug scrn quan levetiracetam,80177,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,27.96,,,,,,,fee schedule,11.92,31.93,
Drug scrn quan levetiracetam,80177,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,29.4,,,,,,,fee schedule,11.92,31.93,
Drug scrn quan levetiracetam,80177,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.92,,,,,,,fee schedule,11.92,31.93,Laboratory
Drug scrn quan levetiracetam,80177,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.91,,,,,,,fee schedule,11.92,31.93,APC
Drug scrn quan levetiracetam,80177,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.78,,,,,,,fee schedule,11.92,31.93,APC
Drug scrn quan levetiracetam,80177,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.25,,,,,,,fee schedule,11.92,31.93,APC
Drug scrn quan levetiracetam,80177,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.27,,,,,,,fee schedule,11.92,31.93,Radiology
Drug scrn quan levetiracetam,80177,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.55,,,,,,,fee schedule,11.92,31.93,APC
Drug scrn quan levetiracetam,80177,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23.19,,,,,,,fee schedule,11.92,31.93,APC
Assay of lithium,80178,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,80.42,,,,,,,fee schedule,5.95,80.42,
Assay of lithium,80178,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,64.47,,,,,,,fee schedule,5.95,80.42,
Assay of lithium,80178,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,70.42,,,,,,,fee schedule,5.95,80.42,
Assay of lithium,80178,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,74.04,,,,,,,fee schedule,5.95,80.42,
Assay of lithium,80178,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.95,,,,,,,fee schedule,5.95,80.42,Laboratory
Assay of lithium,80178,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.94,,,,,,,fee schedule,5.95,80.42,APC
Assay of lithium,80178,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6.87,,,,,,,fee schedule,5.95,80.42,APC
Assay of lithium,80178,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6.61,,,,,,,fee schedule,5.95,80.42,APC
Assay of lithium,80178,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10.11,,,,,,,fee schedule,5.95,80.42,Radiology
Assay of lithium,80178,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.25,,,,,,,fee schedule,5.95,80.42,APC
Assay of lithium,80178,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11.57,,,,,,,fee schedule,5.95,80.42,APC
Drug assay salicylate,80179,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.78,,,,,,,fee schedule,16.78,32.62,Laboratory
Drug assay salicylate,80179,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.57,,,,,,,fee schedule,16.78,32.62,APC
Drug assay salicylate,80179,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,19.39,,,,,,,fee schedule,16.78,32.62,APC
Drug assay salicylate,80179,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18.64,,,,,,,fee schedule,16.78,32.62,APC
Drug assay salicylate,80179,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.52,,,,,,,fee schedule,16.78,32.62,Radiology
Drug assay salicylate,80179,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26.1,,,,,,,fee schedule,16.78,32.62,APC
Drug assay salicylate,80179,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,32.62,,,,,,,fee schedule,16.78,32.62,APC
Drug scrn quan mycophenolate,80180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,92.87,,,,,,,fee schedule,16.24,92.87,
Drug scrn quan mycophenolate,80180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,74.45,,,,,,,fee schedule,16.24,92.87,
Drug scrn quan mycophenolate,80180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,81.33,,,,,,,fee schedule,16.24,92.87,
Drug scrn quan mycophenolate,80180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,85.5,,,,,,,fee schedule,16.24,92.87,
Drug scrn quan mycophenolate,80180,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.24,,,,,,,fee schedule,16.24,92.87,Laboratory
Drug scrn quan mycophenolate,80180,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.95,,,,,,,fee schedule,16.24,92.87,APC
Drug scrn quan mycophenolate,80180,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18.77,,,,,,,fee schedule,16.24,92.87,APC
Drug scrn quan mycophenolate,80180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18.05,,,,,,,fee schedule,16.24,92.87,APC
Drug scrn quan mycophenolate,80180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27.62,,,,,,,fee schedule,16.24,92.87,Radiology
Drug scrn quan mycophenolate,80180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.27,,,,,,,fee schedule,16.24,92.87,APC
Drug scrn quan mycophenolate,80180,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31.59,,,,,,,fee schedule,16.24,92.87,APC
Drug assay flecainide,80181,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.78,,,,,,,fee schedule,16.78,32.62,Laboratory
Drug assay flecainide,80181,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.57,,,,,,,fee schedule,16.78,32.62,APC
Drug assay flecainide,80181,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,19.39,,,,,,,fee schedule,16.78,32.62,APC
Drug assay flecainide,80181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18.64,,,,,,,fee schedule,16.78,32.62,APC
Drug assay flecainide,80181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.52,,,,,,,fee schedule,16.78,32.62,Radiology
Drug assay flecainide,80181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26.1,,,,,,,fee schedule,16.78,32.62,APC
Drug assay flecainide,80181,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,32.62,,,,,,,fee schedule,16.78,32.62,APC
Drug scrn quant oxcarbazepin,80183,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,40.72,,,,,,,fee schedule,11.92,40.72,
Drug scrn quant oxcarbazepin,80183,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32.64,,,,,,,fee schedule,11.92,40.72,
Drug scrn quant oxcarbazepin,80183,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35.66,,,,,,,fee schedule,11.92,40.72,
Drug scrn quant oxcarbazepin,80183,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37.49,,,,,,,fee schedule,11.92,40.72,
Drug scrn quant oxcarbazepin,80183,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.92,,,,,,,fee schedule,11.92,40.72,Laboratory
Drug scrn quant oxcarbazepin,80183,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.91,,,,,,,fee schedule,11.92,40.72,APC
Drug scrn quant oxcarbazepin,80183,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.78,,,,,,,fee schedule,11.92,40.72,APC
Drug scrn quant oxcarbazepin,80183,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.25,,,,,,,fee schedule,11.92,40.72,APC
Drug scrn quant oxcarbazepin,80183,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.27,,,,,,,fee schedule,11.92,40.72,Radiology
Drug scrn quant oxcarbazepin,80183,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.55,,,,,,,fee schedule,11.92,40.72,APC
Drug scrn quant oxcarbazepin,80183,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23.19,,,,,,,fee schedule,11.92,40.72,APC
Assay of phenobarbital,80184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,63.2,,,,,,,fee schedule,13.77,63.2,
Assay of phenobarbital,80184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,50.66,,,,,,,fee schedule,13.77,63.2,
Assay of phenobarbital,80184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55.34,,,,,,,fee schedule,13.77,63.2,
Assay of phenobarbital,80184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,58.19,,,,,,,fee schedule,13.77,63.2,
Assay of phenobarbital,80184,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.77,,,,,,,fee schedule,13.77,63.2,Laboratory
Assay of phenobarbital,80184,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.07,,,,,,,fee schedule,13.77,63.2,APC
Assay of phenobarbital,80184,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,15.91,,,,,,,fee schedule,13.77,63.2,APC
Assay of phenobarbital,80184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,15.3,,,,,,,fee schedule,13.77,63.2,APC
Assay of phenobarbital,80184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.41,,,,,,,fee schedule,13.77,63.2,Radiology
Assay of phenobarbital,80184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21.42,,,,,,,fee schedule,13.77,63.2,APC
Assay of phenobarbital,80184,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,26.78,,,,,,,fee schedule,13.77,63.2,APC
Assay of phenytoin total,80185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,102.73,,,,,,,fee schedule,11.92,102.73,
Assay of phenytoin total,80185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,82.35,,,,,,,fee schedule,11.92,102.73,
Assay of phenytoin total,80185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,89.96,,,,,,,fee schedule,11.92,102.73,
Assay of phenytoin total,80185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,94.58,,,,,,,fee schedule,11.92,102.73,
Assay of phenytoin total,80185,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.92,,,,,,,fee schedule,11.92,102.73,Laboratory
Assay of phenytoin total,80185,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.91,,,,,,,fee schedule,11.92,102.73,APC
Assay of phenytoin total,80185,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.78,,,,,,,fee schedule,11.92,102.73,APC
Assay of phenytoin total,80185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.25,,,,,,,fee schedule,11.92,102.73,APC
Assay of phenytoin total,80185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.27,,,,,,,fee schedule,11.92,102.73,Radiology
Assay of phenytoin total,80185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.55,,,,,,,fee schedule,11.92,102.73,APC
Assay of phenytoin total,80185,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23.19,,,,,,,fee schedule,11.92,102.73,APC
Assay of phenytoin free,80186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,75.98,,,,,,,fee schedule,12.38,75.98,
Assay of phenytoin free,80186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,60.9,,,,,,,fee schedule,12.38,75.98,
Assay of phenytoin free,80186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66.53,,,,,,,fee schedule,12.38,75.98,
Assay of phenytoin free,80186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,69.95,,,,,,,fee schedule,12.38,75.98,
Assay of phenytoin free,80186,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.38,,,,,,,fee schedule,12.38,75.98,Laboratory
Assay of phenytoin free,80186,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.45,,,,,,,fee schedule,12.38,75.98,APC
Assay of phenytoin free,80186,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,14.31,,,,,,,fee schedule,12.38,75.98,APC
Assay of phenytoin free,80186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.76,,,,,,,fee schedule,12.38,75.98,APC
Assay of phenytoin free,80186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21.05,,,,,,,fee schedule,12.38,75.98,Radiology
Assay of phenytoin free,80186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.26,,,,,,,fee schedule,12.38,75.98,APC
Assay of phenytoin free,80186,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,24.08,,,,,,,fee schedule,12.38,75.98,APC
Drug assay posaconazole,80187,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,102.48,,,,,,,fee schedule,24.4,102.48,
Drug assay posaconazole,80187,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,82.14,,,,,,,fee schedule,24.4,102.48,
Drug assay posaconazole,80187,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,89.73,,,,,,,fee schedule,24.4,102.48,
Drug assay posaconazole,80187,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,94.34,,,,,,,fee schedule,24.4,102.48,
Drug assay posaconazole,80187,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24.4,,,,,,,fee schedule,24.4,102.48,Laboratory
Drug assay posaconazole,80187,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,28.47,,,,,,,fee schedule,24.4,102.48,APC
Drug assay posaconazole,80187,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,28.19,,,,,,,fee schedule,24.4,102.48,APC
Drug assay posaconazole,80187,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,27.11,,,,,,,fee schedule,24.4,102.48,APC
Drug assay posaconazole,80187,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,41.48,,,,,,,fee schedule,24.4,102.48,Radiology
Drug assay posaconazole,80187,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,37.95,,,,,,,fee schedule,24.4,102.48,APC
Drug assay posaconazole,80187,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,47.44,,,,,,,fee schedule,24.4,102.48,APC
Assay of primidone,80188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,91.59,,,,,,,fee schedule,14.93,91.59,
Assay of primidone,80188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,73.42,,,,,,,fee schedule,14.93,91.59,
Assay of primidone,80188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,80.2,,,,,,,fee schedule,14.93,91.59,
Assay of primidone,80188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,84.32,,,,,,,fee schedule,14.93,91.59,
Assay of primidone,80188,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.93,,,,,,,fee schedule,14.93,91.59,Laboratory
Assay of primidone,80188,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.42,,,,,,,fee schedule,14.93,91.59,APC
Assay of primidone,80188,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,17.25,,,,,,,fee schedule,14.93,91.59,APC
Assay of primidone,80188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16.59,,,,,,,fee schedule,14.93,91.59,APC
Assay of primidone,80188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.38,,,,,,,fee schedule,14.93,91.59,Radiology
Assay of primidone,80188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.23,,,,,,,fee schedule,14.93,91.59,APC
Assay of primidone,80188,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,29.03,,,,,,,fee schedule,14.93,91.59,APC
Drug assay itraconzaole,80189,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24.4,,,,,,,fee schedule,24.4,47.44,Laboratory
Drug assay itraconzaole,80189,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,28.47,,,,,,,fee schedule,24.4,47.44,APC
Drug assay itraconzaole,80189,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,28.19,,,,,,,fee schedule,24.4,47.44,APC
Drug assay itraconzaole,80189,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,27.11,,,,,,,fee schedule,24.4,47.44,APC
Drug assay itraconzaole,80189,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,41.48,,,,,,,fee schedule,24.4,47.44,Radiology
Drug assay itraconzaole,80189,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,37.95,,,,,,,fee schedule,24.4,47.44,APC
Drug assay itraconzaole,80189,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,47.44,,,,,,,fee schedule,24.4,47.44,APC
Assay of procainamide,80190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,92.46,,,,,,,fee schedule,54,105,
Assay of procainamide,80190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,74.11,,,,,,,fee schedule,54,105,
Assay of procainamide,80190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,80.96,,,,,,,fee schedule,54,105,
Assay of procainamide,80190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,85.12,,,,,,,fee schedule,54,105,
Assay of procainamide,80190,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,54,,,,,,,fee schedule,54,105,Laboratory
Assay of procainamide,80190,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,63,,,,,,,fee schedule,54,105,APC
Assay of procainamide,80190,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,62.4,,,,,,,fee schedule,54,105,APC
Assay of procainamide,80190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,60,,,,,,,fee schedule,54,105,APC
Assay of procainamide,80190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,91.8,,,,,,,fee schedule,54,105,Radiology
Assay of procainamide,80190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,84,,,,,,,fee schedule,54,105,APC
Assay of procainamide,80190,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,105,,,,,,,fee schedule,54,105,APC
Assay of procainamide,80192,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,92.46,,,,,,,fee schedule,15.08,92.46,
Assay of procainamide,80192,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,74.11,,,,,,,fee schedule,15.08,92.46,
Assay of procainamide,80192,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,80.96,,,,,,,fee schedule,15.08,92.46,
Assay of procainamide,80192,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,85.12,,,,,,,fee schedule,15.08,92.46,
Assay of procainamide,80192,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.08,,,,,,,fee schedule,15.08,92.46,Laboratory
Assay of procainamide,80192,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.59,,,,,,,fee schedule,15.08,92.46,APC
Assay of procainamide,80192,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,17.42,,,,,,,fee schedule,15.08,92.46,APC
Assay of procainamide,80192,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16.75,,,,,,,fee schedule,15.08,92.46,APC
Assay of procainamide,80192,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.63,,,,,,,fee schedule,15.08,92.46,Radiology
Assay of procainamide,80192,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.45,,,,,,,fee schedule,15.08,92.46,APC
Assay of procainamide,80192,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,29.31,,,,,,,fee schedule,15.08,92.46,APC
Drug assay leflunomide,80193,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,34.71,,,,,,,fee schedule,34.71,67.5,Laboratory
Drug assay leflunomide,80193,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,40.5,,,,,,,fee schedule,34.71,67.5,APC
Drug assay leflunomide,80193,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,40.11,,,,,,,fee schedule,34.71,67.5,APC
Drug assay leflunomide,80193,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,38.57,,,,,,,fee schedule,34.71,67.5,APC
Drug assay leflunomide,80193,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,59.01,,,,,,,fee schedule,34.71,67.5,Radiology
Drug assay leflunomide,80193,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,54,,,,,,,fee schedule,34.71,67.5,APC
Drug assay leflunomide,80193,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,67.5,,,,,,,fee schedule,34.71,67.5,APC
Assay of quinidine,80194,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,80.55,,,,,,,fee schedule,13.14,80.55,
Assay of quinidine,80194,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,64.57,,,,,,,fee schedule,13.14,80.55,
Assay of quinidine,80194,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,70.54,,,,,,,fee schedule,13.14,80.55,
Assay of quinidine,80194,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,74.16,,,,,,,fee schedule,13.14,80.55,
Assay of quinidine,80194,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.14,,,,,,,fee schedule,13.14,80.55,Laboratory
Assay of quinidine,80194,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.33,,,,,,,fee schedule,13.14,80.55,APC
Assay of quinidine,80194,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,15.18,,,,,,,fee schedule,13.14,80.55,APC
Assay of quinidine,80194,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14.6,,,,,,,fee schedule,13.14,80.55,APC
Assay of quinidine,80194,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.34,,,,,,,fee schedule,13.14,80.55,Radiology
Assay of quinidine,80194,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.44,,,,,,,fee schedule,13.14,80.55,APC
Assay of quinidine,80194,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,25.55,,,,,,,fee schedule,13.14,80.55,APC
Assay of sirolimus,80195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46.64,,,,,,,fee schedule,12.36,46.64,
Assay of sirolimus,80195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37.39,,,,,,,fee schedule,12.36,46.64,
Assay of sirolimus,80195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40.84,,,,,,,fee schedule,12.36,46.64,
Assay of sirolimus,80195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42.94,,,,,,,fee schedule,12.36,46.64,
Assay of sirolimus,80195,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.36,,,,,,,fee schedule,12.36,46.64,Laboratory
Assay of sirolimus,80195,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.42,,,,,,,fee schedule,12.36,46.64,APC
Assay of sirolimus,80195,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,14.28,,,,,,,fee schedule,12.36,46.64,APC
Assay of sirolimus,80195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.73,,,,,,,fee schedule,12.36,46.64,APC
Assay of sirolimus,80195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21.01,,,,,,,fee schedule,12.36,46.64,Radiology
Assay of sirolimus,80195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.22,,,,,,,fee schedule,12.36,46.64,APC
Assay of sirolimus,80195,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,24.03,,,,,,,fee schedule,12.36,46.64,APC
Assay of tacrolimus,80197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,70.65,,,,,,,fee schedule,12.36,70.65,
Assay of tacrolimus,80197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56.63,,,,,,,fee schedule,12.36,70.65,
Assay of tacrolimus,80197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,61.86,,,,,,,fee schedule,12.36,70.65,
Assay of tacrolimus,80197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,65.04,,,,,,,fee schedule,12.36,70.65,
Assay of tacrolimus,80197,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.36,,,,,,,fee schedule,12.36,70.65,Laboratory
Assay of tacrolimus,80197,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.42,,,,,,,fee schedule,12.36,70.65,APC
Assay of tacrolimus,80197,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,14.28,,,,,,,fee schedule,12.36,70.65,APC
Assay of tacrolimus,80197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.73,,,,,,,fee schedule,12.36,70.65,APC
Assay of tacrolimus,80197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21.01,,,,,,,fee schedule,12.36,70.65,Radiology
Assay of tacrolimus,80197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.22,,,,,,,fee schedule,12.36,70.65,APC
Assay of tacrolimus,80197,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,24.03,,,,,,,fee schedule,12.36,70.65,APC
Assay of theophylline,80198,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,122.16,,,,,,,fee schedule,12.73,122.16,
Assay of theophylline,80198,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,97.93,,,,,,,fee schedule,12.73,122.16,
Assay of theophylline,80198,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,106.97,,,,,,,fee schedule,12.73,122.16,
Assay of theophylline,80198,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,112.47,,,,,,,fee schedule,12.73,122.16,
Assay of theophylline,80198,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.73,,,,,,,fee schedule,12.73,122.16,Laboratory
Assay of theophylline,80198,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.85,,,,,,,fee schedule,12.73,122.16,APC
Assay of theophylline,80198,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,14.71,,,,,,,fee schedule,12.73,122.16,APC
Assay of theophylline,80198,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14.14,,,,,,,fee schedule,12.73,122.16,APC
Assay of theophylline,80198,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21.63,,,,,,,fee schedule,12.73,122.16,Radiology
Assay of theophylline,80198,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.8,,,,,,,fee schedule,12.73,122.16,APC
Assay of theophylline,80198,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,24.74,,,,,,,fee schedule,12.73,122.16,APC
Drug screen quant tiagabine,80199,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,92.91,,,,,,,fee schedule,24.4,92.91,
Drug screen quant tiagabine,80199,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,74.48,,,,,,,fee schedule,24.4,92.91,
Drug screen quant tiagabine,80199,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,81.36,,,,,,,fee schedule,24.4,92.91,
Drug screen quant tiagabine,80199,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,85.54,,,,,,,fee schedule,24.4,92.91,
Drug screen quant tiagabine,80199,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24.4,,,,,,,fee schedule,24.4,92.91,Laboratory
Drug screen quant tiagabine,80199,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,28.47,,,,,,,fee schedule,24.4,92.91,APC
Drug screen quant tiagabine,80199,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,28.19,,,,,,,fee schedule,24.4,92.91,APC
Drug screen quant tiagabine,80199,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,27.11,,,,,,,fee schedule,24.4,92.91,APC
Drug screen quant tiagabine,80199,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,41.48,,,,,,,fee schedule,24.4,92.91,Radiology
Drug screen quant tiagabine,80199,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,37.95,,,,,,,fee schedule,24.4,92.91,APC
Drug screen quant tiagabine,80199,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,47.44,,,,,,,fee schedule,24.4,92.91,APC
Assay of tobramycin,80200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,88.94,,,,,,,fee schedule,14.52,88.94,
Assay of tobramycin,80200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,71.3,,,,,,,fee schedule,14.52,88.94,
Assay of tobramycin,80200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,77.88,,,,,,,fee schedule,14.52,88.94,
Assay of tobramycin,80200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,81.88,,,,,,,fee schedule,14.52,88.94,
Assay of tobramycin,80200,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.52,,,,,,,fee schedule,14.52,88.94,Laboratory
Assay of tobramycin,80200,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.94,,,,,,,fee schedule,14.52,88.94,APC
Assay of tobramycin,80200,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,16.78,,,,,,,fee schedule,14.52,88.94,APC
Assay of tobramycin,80200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16.13,,,,,,,fee schedule,14.52,88.94,APC
Assay of tobramycin,80200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24.68,,,,,,,fee schedule,14.52,88.94,Radiology
Assay of tobramycin,80200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.58,,,,,,,fee schedule,14.52,88.94,APC
Assay of tobramycin,80200,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,28.23,,,,,,,fee schedule,14.52,88.94,APC
Assay of topiramate,80201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,51.83,,,,,,,fee schedule,10.73,51.83,
Assay of topiramate,80201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,41.54,,,,,,,fee schedule,10.73,51.83,
Assay of topiramate,80201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,45.38,,,,,,,fee schedule,10.73,51.83,
Assay of topiramate,80201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,47.71,,,,,,,fee schedule,10.73,51.83,
Assay of topiramate,80201,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.73,,,,,,,fee schedule,10.73,51.83,Laboratory
Assay of topiramate,80201,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.52,,,,,,,fee schedule,10.73,51.83,APC
Assay of topiramate,80201,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.4,,,,,,,fee schedule,10.73,51.83,APC
Assay of topiramate,80201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11.92,,,,,,,fee schedule,10.73,51.83,APC
Assay of topiramate,80201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.24,,,,,,,fee schedule,10.73,51.83,Radiology
Assay of topiramate,80201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.69,,,,,,,fee schedule,10.73,51.83,APC
Assay of topiramate,80201,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20.86,,,,,,,fee schedule,10.73,51.83,APC
Assay of vancomycin,80202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,114.76,,,,,,,fee schedule,12.19,114.76,
Assay of vancomycin,80202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,91.99,,,,,,,fee schedule,12.19,114.76,
Assay of vancomycin,80202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,100.49,,,,,,,fee schedule,12.19,114.76,
Assay of vancomycin,80202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,105.65,,,,,,,fee schedule,12.19,114.76,
Assay of vancomycin,80202,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.19,,,,,,,fee schedule,12.19,114.76,Laboratory
Assay of vancomycin,80202,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.22,,,,,,,fee schedule,12.19,114.76,APC
Assay of vancomycin,80202,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,14.08,,,,,,,fee schedule,12.19,114.76,APC
Assay of vancomycin,80202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.54,,,,,,,fee schedule,12.19,114.76,APC
Assay of vancomycin,80202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.72,,,,,,,fee schedule,12.19,114.76,Radiology
Assay of vancomycin,80202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.96,,,,,,,fee schedule,12.19,114.76,APC
Assay of vancomycin,80202,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23.7,,,,,,,fee schedule,12.19,114.76,APC
Drug screen quant zonisamide,80203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,40.72,,,,,,,fee schedule,11.92,40.72,
Drug screen quant zonisamide,80203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32.64,,,,,,,fee schedule,11.92,40.72,
Drug screen quant zonisamide,80203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35.66,,,,,,,fee schedule,11.92,40.72,
Drug screen quant zonisamide,80203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37.49,,,,,,,fee schedule,11.92,40.72,
Drug screen quant zonisamide,80203,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.92,,,,,,,fee schedule,11.92,40.72,Laboratory
Drug screen quant zonisamide,80203,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.91,,,,,,,fee schedule,11.92,40.72,APC
Drug screen quant zonisamide,80203,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.78,,,,,,,fee schedule,11.92,40.72,APC
Drug screen quant zonisamide,80203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.25,,,,,,,fee schedule,11.92,40.72,APC
Drug screen quant zonisamide,80203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.27,,,,,,,fee schedule,11.92,40.72,Radiology
Drug screen quant zonisamide,80203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.55,,,,,,,fee schedule,11.92,40.72,APC
Drug screen quant zonisamide,80203,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23.19,,,,,,,fee schedule,11.92,40.72,APC
Drug assay methotrexate,80204,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,34.71,,,,,,,fee schedule,34.71,67.5,Laboratory
Drug assay methotrexate,80204,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,40.5,,,,,,,fee schedule,34.71,67.5,APC
Drug assay methotrexate,80204,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,40.11,,,,,,,fee schedule,34.71,67.5,APC
Drug assay methotrexate,80204,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,38.57,,,,,,,fee schedule,34.71,67.5,APC
Drug assay methotrexate,80204,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,59.01,,,,,,,fee schedule,34.71,67.5,Radiology
Drug assay methotrexate,80204,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,54,,,,,,,fee schedule,34.71,67.5,APC
Drug assay methotrexate,80204,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,67.5,,,,,,,fee schedule,34.71,67.5,APC
Drug assay rufinamide,80210,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24.4,,,,,,,fee schedule,24.4,47.44,Laboratory
Drug assay rufinamide,80210,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,28.47,,,,,,,fee schedule,24.4,47.44,APC
Drug assay rufinamide,80210,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,28.19,,,,,,,fee schedule,24.4,47.44,APC
Drug assay rufinamide,80210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,27.11,,,,,,,fee schedule,24.4,47.44,APC
Drug assay rufinamide,80210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,41.48,,,,,,,fee schedule,24.4,47.44,Radiology
Drug assay rufinamide,80210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,37.95,,,,,,,fee schedule,24.4,47.44,APC
Drug assay rufinamide,80210,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,47.44,,,,,,,fee schedule,24.4,47.44,APC
Drug asy hydroxychloroquine,80220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,70.46,,,,,,,fee schedule,16.78,70.46,
Drug asy hydroxychloroquine,80220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56.48,,,,,,,fee schedule,16.78,70.46,
Drug asy hydroxychloroquine,80220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,61.7,,,,,,,fee schedule,16.78,70.46,
Drug asy hydroxychloroquine,80220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,64.87,,,,,,,fee schedule,16.78,70.46,
Drug asy hydroxychloroquine,80220,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.78,,,,,,,fee schedule,16.78,70.46,Laboratory
Drug asy hydroxychloroquine,80220,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.57,,,,,,,fee schedule,16.78,70.46,APC
Drug asy hydroxychloroquine,80220,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,19.39,,,,,,,fee schedule,16.78,70.46,APC
Drug asy hydroxychloroquine,80220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18.64,,,,,,,fee schedule,16.78,70.46,APC
Drug asy hydroxychloroquine,80220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.52,,,,,,,fee schedule,16.78,70.46,Radiology
Drug asy hydroxychloroquine,80220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26.1,,,,,,,fee schedule,16.78,70.46,APC
Drug asy hydroxychloroquine,80220,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,32.62,,,,,,,fee schedule,16.78,70.46,APC
Drug assay infliximab,80230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,145.79,,,,,,,fee schedule,34.71,145.79,
Drug assay infliximab,80230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,116.87,,,,,,,fee schedule,34.71,145.79,
Drug assay infliximab,80230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,127.67,,,,,,,fee schedule,34.71,145.79,
Drug assay infliximab,80230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,134.22,,,,,,,fee schedule,34.71,145.79,
Drug assay infliximab,80230,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,34.71,,,,,,,fee schedule,34.71,145.79,Laboratory
Drug assay infliximab,80230,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,40.5,,,,,,,fee schedule,34.71,145.79,APC
Drug assay infliximab,80230,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,40.11,,,,,,,fee schedule,34.71,145.79,APC
Drug assay infliximab,80230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,38.57,,,,,,,fee schedule,34.71,145.79,APC
Drug assay infliximab,80230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,59.01,,,,,,,fee schedule,34.71,145.79,Radiology
Drug assay infliximab,80230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,54,,,,,,,fee schedule,34.71,145.79,APC
Drug assay infliximab,80230,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,67.5,,,,,,,fee schedule,34.71,145.79,APC
Drug assay lacosamide,80235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,102.48,,,,,,,fee schedule,24.4,102.48,
Drug assay lacosamide,80235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,82.14,,,,,,,fee schedule,24.4,102.48,
Drug assay lacosamide,80235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,89.73,,,,,,,fee schedule,24.4,102.48,
Drug assay lacosamide,80235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,94.34,,,,,,,fee schedule,24.4,102.48,
Drug assay lacosamide,80235,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24.4,,,,,,,fee schedule,24.4,102.48,Laboratory
Drug assay lacosamide,80235,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,28.47,,,,,,,fee schedule,24.4,102.48,APC
Drug assay lacosamide,80235,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,28.19,,,,,,,fee schedule,24.4,102.48,APC
Drug assay lacosamide,80235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,27.11,,,,,,,fee schedule,24.4,102.48,APC
Drug assay lacosamide,80235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,41.48,,,,,,,fee schedule,24.4,102.48,Radiology
Drug assay lacosamide,80235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,37.95,,,,,,,fee schedule,24.4,102.48,APC
Drug assay lacosamide,80235,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,47.44,,,,,,,fee schedule,24.4,102.48,APC
Drug assay vedolizumab,80280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,145.79,,,,,,,fee schedule,34.71,145.79,
Drug assay vedolizumab,80280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,116.87,,,,,,,fee schedule,34.71,145.79,
Drug assay vedolizumab,80280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,127.67,,,,,,,fee schedule,34.71,145.79,
Drug assay vedolizumab,80280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,134.22,,,,,,,fee schedule,34.71,145.79,
Drug assay vedolizumab,80280,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,34.71,,,,,,,fee schedule,34.71,145.79,Laboratory
Drug assay vedolizumab,80280,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,40.5,,,,,,,fee schedule,34.71,145.79,APC
Drug assay vedolizumab,80280,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,40.11,,,,,,,fee schedule,34.71,145.79,APC
Drug assay vedolizumab,80280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,38.57,,,,,,,fee schedule,34.71,145.79,APC
Drug assay vedolizumab,80280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,59.01,,,,,,,fee schedule,34.71,145.79,Radiology
Drug assay vedolizumab,80280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,54,,,,,,,fee schedule,34.71,145.79,APC
Drug assay vedolizumab,80280,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,67.5,,,,,,,fee schedule,34.71,145.79,APC
Drug assay voriconazole,80285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,102.48,,,,,,,fee schedule,24.4,102.48,
Drug assay voriconazole,80285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,82.14,,,,,,,fee schedule,24.4,102.48,
Drug assay voriconazole,80285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,89.73,,,,,,,fee schedule,24.4,102.48,
Drug assay voriconazole,80285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,94.34,,,,,,,fee schedule,24.4,102.48,
Drug assay voriconazole,80285,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24.4,,,,,,,fee schedule,24.4,102.48,Laboratory
Drug assay voriconazole,80285,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,28.47,,,,,,,fee schedule,24.4,102.48,APC
Drug assay voriconazole,80285,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,28.19,,,,,,,fee schedule,24.4,102.48,APC
Drug assay voriconazole,80285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,27.11,,,,,,,fee schedule,24.4,102.48,APC
Drug assay voriconazole,80285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,41.48,,,,,,,fee schedule,24.4,102.48,Radiology
Drug assay voriconazole,80285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,37.95,,,,,,,fee schedule,24.4,102.48,APC
Drug assay voriconazole,80285,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,47.44,,,,,,,fee schedule,24.4,102.48,APC
Quantitative assay drug,80299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,171.77,,,,,,,fee schedule,16.78,171.77,
Quantitative assay drug,80299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,137.69,,,,,,,fee schedule,16.78,171.77,
Quantitative assay drug,80299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,150.41,,,,,,,fee schedule,16.78,171.77,
Quantitative assay drug,80299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,158.14,,,,,,,fee schedule,16.78,171.77,
Quantitative assay drug,80299,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.78,,,,,,,fee schedule,16.78,171.77,Laboratory
Quantitative assay drug,80299,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.57,,,,,,,fee schedule,16.78,171.77,APC
Quantitative assay drug,80299,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,19.39,,,,,,,fee schedule,16.78,171.77,APC
Quantitative assay drug,80299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18.64,,,,,,,fee schedule,16.78,171.77,APC
Quantitative assay drug,80299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.52,,,,,,,fee schedule,16.78,171.77,Radiology
Quantitative assay drug,80299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26.1,,,,,,,fee schedule,16.78,171.77,APC
Quantitative assay drug,80299,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,32.62,,,,,,,fee schedule,16.78,171.77,APC
Drug test prsmv dir opt obs,80305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46.46,,,,,,,fee schedule,11.34,46.46,
Drug test prsmv dir opt obs,80305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37.24,,,,,,,fee schedule,11.34,46.46,
Drug test prsmv dir opt obs,80305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40.68,,,,,,,fee schedule,11.34,46.46,
Drug test prsmv dir opt obs,80305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42.77,,,,,,,fee schedule,11.34,46.46,
Drug test prsmv dir opt obs,80305,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.34,,,,,,,fee schedule,11.34,46.46,Laboratory
Drug test prsmv dir opt obs,80305,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.23,,,,,,,fee schedule,11.34,46.46,APC
Drug test prsmv dir opt obs,80305,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.1,,,,,,,fee schedule,11.34,46.46,APC
Drug test prsmv dir opt obs,80305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.6,,,,,,,fee schedule,11.34,46.46,APC
Drug test prsmv dir opt obs,80305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.28,,,,,,,fee schedule,11.34,46.46,Radiology
Drug test prsmv dir opt obs,80305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.64,,,,,,,fee schedule,11.34,46.46,APC
Drug test prsmv dir opt obs,80305,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22.05,,,,,,,fee schedule,11.34,46.46,APC
Drug test prsmv instrmnt,80306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,159.38,,,,,,,fee schedule,15.43,159.38,
Drug test prsmv instrmnt,80306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,127.75,,,,,,,fee schedule,15.43,159.38,
Drug test prsmv instrmnt,80306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,139.56,,,,,,,fee schedule,15.43,159.38,
Drug test prsmv instrmnt,80306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,146.73,,,,,,,fee schedule,15.43,159.38,
Drug test prsmv instrmnt,80306,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.43,,,,,,,fee schedule,15.43,159.38,Laboratory
Drug test prsmv instrmnt,80306,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18,,,,,,,fee schedule,15.43,159.38,APC
Drug test prsmv instrmnt,80306,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,17.83,,,,,,,fee schedule,15.43,159.38,APC
Drug test prsmv instrmnt,80306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17.14,,,,,,,fee schedule,15.43,159.38,APC
Drug test prsmv instrmnt,80306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26.22,,,,,,,fee schedule,15.43,159.38,Radiology
Drug test prsmv instrmnt,80306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24,,,,,,,fee schedule,15.43,159.38,APC
Drug test prsmv instrmnt,80306,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30,,,,,,,fee schedule,15.43,159.38,APC
Drug test prsmv chem anlyzr,80307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,146.09,,,,,,,fee schedule,55.93,146.09,
Drug test prsmv chem anlyzr,80307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,117.1,,,,,,,fee schedule,55.93,146.09,
Drug test prsmv chem anlyzr,80307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,127.93,,,,,,,fee schedule,55.93,146.09,
Drug test prsmv chem anlyzr,80307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,134.5,,,,,,,fee schedule,55.93,146.09,
Drug test prsmv chem anlyzr,80307,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,55.93,,,,,,,fee schedule,55.93,146.09,Laboratory
Drug test prsmv chem anlyzr,80307,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,65.25,,,,,,,fee schedule,55.93,146.09,APC
Drug test prsmv chem anlyzr,80307,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,64.63,,,,,,,fee schedule,55.93,146.09,APC
Drug test prsmv chem anlyzr,80307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,62.14,,,,,,,fee schedule,55.93,146.09,APC
Drug test prsmv chem anlyzr,80307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,95.07,,,,,,,fee schedule,55.93,146.09,Radiology
Drug test prsmv chem anlyzr,80307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,87,,,,,,,fee schedule,55.93,146.09,APC
Drug test prsmv chem anlyzr,80307,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,108.74,,,,,,,fee schedule,55.93,146.09,APC
Acth stimulation panel,80400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,192.5,,,,,,,fee schedule,29.36,192.5,
Acth stimulation panel,80400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,154.31,,,,,,,fee schedule,29.36,192.5,
Acth stimulation panel,80400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,168.57,,,,,,,fee schedule,29.36,192.5,
Acth stimulation panel,80400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,177.22,,,,,,,fee schedule,29.36,192.5,
Acth stimulation panel,80400,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,29.36,,,,,,,fee schedule,29.36,192.5,Laboratory
Acth stimulation panel,80400,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,34.25,,,,,,,fee schedule,29.36,192.5,APC
Acth stimulation panel,80400,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,33.92,,,,,,,fee schedule,29.36,192.5,APC
Acth stimulation panel,80400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,32.62,,,,,,,fee schedule,29.36,192.5,APC
Acth stimulation panel,80400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49.91,,,,,,,fee schedule,29.36,192.5,Radiology
Acth stimulation panel,80400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,45.67,,,,,,,fee schedule,29.36,192.5,APC
Acth stimulation panel,80400,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,57.08,,,,,,,fee schedule,29.36,192.5,APC
Acth stimulation panel,80402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,479.83,,,,,,,fee schedule,78.26,479.83,
Acth stimulation panel,80402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,384.63,,,,,,,fee schedule,78.26,479.83,
Acth stimulation panel,80402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,420.17,,,,,,,fee schedule,78.26,479.83,
Acth stimulation panel,80402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.75,,,,,,,fee schedule,78.26,479.83,
Acth stimulation panel,80402,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,78.26,,,,,,,fee schedule,78.26,479.83,Laboratory
Acth stimulation panel,80402,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.31,,,,,,,fee schedule,78.26,479.83,APC
Acth stimulation panel,80402,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,90.44,,,,,,,fee schedule,78.26,479.83,APC
Acth stimulation panel,80402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.96,,,,,,,fee schedule,78.26,479.83,APC
Acth stimulation panel,80402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,133.05,,,,,,,fee schedule,78.26,479.83,Radiology
Acth stimulation panel,80402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,121.74,,,,,,,fee schedule,78.26,479.83,APC
Acth stimulation panel,80402,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,152.18,,,,,,,fee schedule,78.26,479.83,APC
Acth stimulation panel,80406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,431.9,,,,,,,fee schedule,70.43,431.9,
Acth stimulation panel,80406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,346.21,,,,,,,fee schedule,70.43,431.9,
Acth stimulation panel,80406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,378.2,,,,,,,fee schedule,70.43,431.9,
Acth stimulation panel,80406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,397.62,,,,,,,fee schedule,70.43,431.9,
Acth stimulation panel,80406,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,70.43,,,,,,,fee schedule,70.43,431.9,Laboratory
Acth stimulation panel,80406,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,82.17,,,,,,,fee schedule,70.43,431.9,APC
Acth stimulation panel,80406,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,81.39,,,,,,,fee schedule,70.43,431.9,APC
Acth stimulation panel,80406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,78.26,,,,,,,fee schedule,70.43,431.9,APC
Acth stimulation panel,80406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,119.74,,,,,,,fee schedule,70.43,431.9,Radiology
Acth stimulation panel,80406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,109.56,,,,,,,fee schedule,70.43,431.9,APC
Acth stimulation panel,80406,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,136.96,,,,,,,fee schedule,70.43,431.9,APC
Aldosterone suppression eval,80408,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,692.65,,,,,,,fee schedule,112.95,692.65,
Aldosterone suppression eval,80408,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,555.22,,,,,,,fee schedule,112.95,692.65,
Aldosterone suppression eval,80408,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,606.52,,,,,,,fee schedule,112.95,692.65,
Aldosterone suppression eval,80408,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,637.68,,,,,,,fee schedule,112.95,692.65,
Aldosterone suppression eval,80408,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,112.95,,,,,,,fee schedule,112.95,692.65,Laboratory
Aldosterone suppression eval,80408,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,131.78,,,,,,,fee schedule,112.95,692.65,APC
Aldosterone suppression eval,80408,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,130.52,,,,,,,fee schedule,112.95,692.65,APC
Aldosterone suppression eval,80408,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,125.5,,,,,,,fee schedule,112.95,692.65,APC
Aldosterone suppression eval,80408,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,192.02,,,,,,,fee schedule,112.95,692.65,Radiology
Aldosterone suppression eval,80408,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,175.7,,,,,,,fee schedule,112.95,692.65,APC
Aldosterone suppression eval,80408,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,219.62,,,,,,,fee schedule,112.95,692.65,APC
Calcitonin stimul panel,80410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,443.39,,,,,,,fee schedule,72.33,443.39,
Calcitonin stimul panel,80410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,355.42,,,,,,,fee schedule,72.33,443.39,
Calcitonin stimul panel,80410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,388.26,,,,,,,fee schedule,72.33,443.39,
Calcitonin stimul panel,80410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,408.2,,,,,,,fee schedule,72.33,443.39,
Calcitonin stimul panel,80410,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,72.33,,,,,,,fee schedule,72.33,443.39,Laboratory
Calcitonin stimul panel,80410,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,84.39,,,,,,,fee schedule,72.33,443.39,APC
Calcitonin stimul panel,80410,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,83.58,,,,,,,fee schedule,72.33,443.39,APC
Calcitonin stimul panel,80410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,80.37,,,,,,,fee schedule,72.33,443.39,APC
Calcitonin stimul panel,80410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,122.97,,,,,,,fee schedule,72.33,443.39,Radiology
Calcitonin stimul panel,80410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,112.52,,,,,,,fee schedule,72.33,443.39,APC
Calcitonin stimul panel,80410,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,140.65,,,,,,,fee schedule,72.33,443.39,APC
CRH stimulation panel,80412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1819.16,,,,,,,fee schedule,721.46,1819.16,
CRH stimulation panel,80412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1458.22,,,,,,,fee schedule,721.46,1819.16,
CRH stimulation panel,80412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1592.97,,,,,,,fee schedule,721.46,1819.16,
CRH stimulation panel,80412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1674.78,,,,,,,fee schedule,721.46,1819.16,
CRH stimulation panel,80412,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,721.46,,,,,,,fee schedule,721.46,1819.16,Laboratory
CRH stimulation panel,80412,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,841.7,,,,,,,fee schedule,721.46,1819.16,APC
CRH stimulation panel,80412,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,833.68,,,,,,,fee schedule,721.46,1819.16,APC
CRH stimulation panel,80412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,801.62,,,,,,,fee schedule,721.46,1819.16,APC
CRH stimulation panel,80412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1226.48,,,,,,,fee schedule,721.46,1819.16,Radiology
CRH stimulation panel,80412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1122.27,,,,,,,fee schedule,721.46,1819.16,APC
CRH stimulation panel,80412,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1402.84,,,,,,,fee schedule,721.46,1819.16,APC
Testosterone response,80414,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,285.01,,,,,,,fee schedule,46.48,285.01,
Testosterone response,80414,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,228.46,,,,,,,fee schedule,46.48,285.01,
Testosterone response,80414,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,249.57,,,,,,,fee schedule,46.48,285.01,
Testosterone response,80414,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,262.39,,,,,,,fee schedule,46.48,285.01,
Testosterone response,80414,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46.48,,,,,,,fee schedule,46.48,285.01,Laboratory
Testosterone response,80414,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.22,,,,,,,fee schedule,46.48,285.01,APC
Testosterone response,80414,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,53.71,,,,,,,fee schedule,46.48,285.01,APC
Testosterone response,80414,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,51.64,,,,,,,fee schedule,46.48,285.01,APC
Testosterone response,80414,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,79.01,,,,,,,fee schedule,46.48,285.01,Radiology
Testosterone response,80414,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,72.3,,,,,,,fee schedule,46.48,285.01,APC
Testosterone response,80414,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,90.37,,,,,,,fee schedule,46.48,285.01,APC
Estradiol response panel,80415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,308.45,,,,,,,fee schedule,50.3,308.45,
Estradiol response panel,80415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,247.25,,,,,,,fee schedule,50.3,308.45,
Estradiol response panel,80415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,270.1,,,,,,,fee schedule,50.3,308.45,
Estradiol response panel,80415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,283.97,,,,,,,fee schedule,50.3,308.45,
Estradiol response panel,80415,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,50.3,,,,,,,fee schedule,50.3,308.45,Laboratory
Estradiol response panel,80415,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,58.68,,,,,,,fee schedule,50.3,308.45,APC
Estradiol response panel,80415,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,58.13,,,,,,,fee schedule,50.3,308.45,APC
Estradiol response panel,80415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,55.89,,,,,,,fee schedule,50.3,308.45,APC
Estradiol response panel,80415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,85.51,,,,,,,fee schedule,50.3,308.45,Radiology
Estradiol response panel,80415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,78.25,,,,,,,fee schedule,50.3,308.45,APC
Estradiol response panel,80415,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,97.81,,,,,,,fee schedule,50.3,308.45,APC
Renin stimulation panel,80416,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,728.48,,,,,,,fee schedule,188.39,728.48,
Renin stimulation panel,80416,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,583.94,,,,,,,fee schedule,188.39,728.48,
Renin stimulation panel,80416,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,637.9,,,,,,,fee schedule,188.39,728.48,
Renin stimulation panel,80416,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,670.67,,,,,,,fee schedule,188.39,728.48,
Renin stimulation panel,80416,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,188.39,,,,,,,fee schedule,188.39,728.48,Laboratory
Renin stimulation panel,80416,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,219.79,,,,,,,fee schedule,188.39,728.48,APC
Renin stimulation panel,80416,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,217.69,,,,,,,fee schedule,188.39,728.48,APC
Renin stimulation panel,80416,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,209.32,,,,,,,fee schedule,188.39,728.48,APC
Renin stimulation panel,80416,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,320.26,,,,,,,fee schedule,188.39,728.48,Radiology
Renin stimulation panel,80416,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,293.05,,,,,,,fee schedule,188.39,728.48,APC
Renin stimulation panel,80416,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,366.31,,,,,,,fee schedule,188.39,728.48,APC
Renin stimulation panel,80417,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,242.83,,,,,,,fee schedule,39.59,242.83,
Renin stimulation panel,80417,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,194.65,,,,,,,fee schedule,39.59,242.83,
Renin stimulation panel,80417,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,212.63,,,,,,,fee schedule,39.59,242.83,
Renin stimulation panel,80417,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,223.56,,,,,,,fee schedule,39.59,242.83,
Renin stimulation panel,80417,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,39.59,,,,,,,fee schedule,39.59,242.83,Laboratory
Renin stimulation panel,80417,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,46.19,,,,,,,fee schedule,39.59,242.83,APC
Renin stimulation panel,80417,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,45.75,,,,,,,fee schedule,39.59,242.83,APC
Renin stimulation panel,80417,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,43.99,,,,,,,fee schedule,39.59,242.83,APC
Renin stimulation panel,80417,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,67.3,,,,,,,fee schedule,39.59,242.83,Radiology
Renin stimulation panel,80417,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,61.59,,,,,,,fee schedule,39.59,242.83,APC
Renin stimulation panel,80417,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,76.98,,,,,,,fee schedule,39.59,242.83,APC
Pituitary evaluation panel,80418,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3198.79,,,,,,,fee schedule,521.53,3198.79,
Pituitary evaluation panel,80418,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2564.11,,,,,,,fee schedule,521.53,3198.79,
Pituitary evaluation panel,80418,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2801.05,,,,,,,fee schedule,521.53,3198.79,
Pituitary evaluation panel,80418,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2944.92,,,,,,,fee schedule,521.53,3198.79,
Pituitary evaluation panel,80418,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,521.53,,,,,,,fee schedule,521.53,3198.79,Laboratory
Pituitary evaluation panel,80418,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,608.45,,,,,,,fee schedule,521.53,3198.79,APC
Pituitary evaluation panel,80418,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,602.66,,,,,,,fee schedule,521.53,3198.79,APC
Pituitary evaluation panel,80418,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,579.48,,,,,,,fee schedule,521.53,3198.79,APC
Pituitary evaluation panel,80418,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,886.6,,,,,,,fee schedule,521.53,3198.79,Radiology
Pituitary evaluation panel,80418,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,811.27,,,,,,,fee schedule,521.53,3198.79,APC
Pituitary evaluation panel,80418,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1014.09,,,,,,,fee schedule,521.53,3198.79,APC
Dexamethasone panel,80420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,397.58,,,,,,,fee schedule,145.69,397.58,
Dexamethasone panel,80420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,318.7,,,,,,,fee schedule,145.69,397.58,
Dexamethasone panel,80420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,348.15,,,,,,,fee schedule,145.69,397.58,
Dexamethasone panel,80420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,366.03,,,,,,,fee schedule,145.69,397.58,
Dexamethasone panel,80420,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,145.69,,,,,,,fee schedule,145.69,397.58,Laboratory
Dexamethasone panel,80420,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,169.97,,,,,,,fee schedule,145.69,397.58,APC
Dexamethasone panel,80420,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,168.36,,,,,,,fee schedule,145.69,397.58,APC
Dexamethasone panel,80420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,161.88,,,,,,,fee schedule,145.69,397.58,APC
Dexamethasone panel,80420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,247.68,,,,,,,fee schedule,145.69,397.58,Radiology
Dexamethasone panel,80420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,226.63,,,,,,,fee schedule,145.69,397.58,APC
Dexamethasone panel,80420,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,283.29,,,,,,,fee schedule,145.69,397.58,APC
Glucagon tolerance panel,80422,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,254.24,,,,,,,fee schedule,41.46,254.24,
Glucagon tolerance panel,80422,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,203.8,,,,,,,fee schedule,41.46,254.24,
Glucagon tolerance panel,80422,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,222.63,,,,,,,fee schedule,41.46,254.24,
Glucagon tolerance panel,80422,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,234.06,,,,,,,fee schedule,41.46,254.24,
Glucagon tolerance panel,80422,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,41.46,,,,,,,fee schedule,41.46,254.24,Laboratory
Glucagon tolerance panel,80422,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,48.37,,,,,,,fee schedule,41.46,254.24,APC
Glucagon tolerance panel,80422,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,47.91,,,,,,,fee schedule,41.46,254.24,APC
Glucagon tolerance panel,80422,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,46.07,,,,,,,fee schedule,41.46,254.24,APC
Glucagon tolerance panel,80422,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,70.49,,,,,,,fee schedule,41.46,254.24,Radiology
Glucagon tolerance panel,80422,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,64.5,,,,,,,fee schedule,41.46,254.24,APC
Glucagon tolerance panel,80422,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,80.62,,,,,,,fee schedule,41.46,254.24,APC
Glucagon tolerance panel,80424,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,197.16,,,,,,,fee schedule,45.45,197.16,
Glucagon tolerance panel,80424,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,158.04,,,,,,,fee schedule,45.45,197.16,
Glucagon tolerance panel,80424,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,172.65,,,,,,,fee schedule,45.45,197.16,
Glucagon tolerance panel,80424,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,181.52,,,,,,,fee schedule,45.45,197.16,
Glucagon tolerance panel,80424,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,45.45,,,,,,,fee schedule,45.45,197.16,Laboratory
Glucagon tolerance panel,80424,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,53.03,,,,,,,fee schedule,45.45,197.16,APC
Glucagon tolerance panel,80424,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,52.52,,,,,,,fee schedule,45.45,197.16,APC
Glucagon tolerance panel,80424,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,50.5,,,,,,,fee schedule,45.45,197.16,APC
Glucagon tolerance panel,80424,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,77.26,,,,,,,fee schedule,45.45,197.16,Radiology
Glucagon tolerance panel,80424,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,70.7,,,,,,,fee schedule,45.45,197.16,APC
Glucagon tolerance panel,80424,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,88.38,,,,,,,fee schedule,45.45,197.16,APC
Gonadotropin hormone panel,80426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,819.2,,,,,,,fee schedule,133.57,819.2,
Gonadotropin hormone panel,80426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,656.66,,,,,,,fee schedule,133.57,819.2,
Gonadotropin hormone panel,80426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,717.34,,,,,,,fee schedule,133.57,819.2,
Gonadotropin hormone panel,80426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,754.19,,,,,,,fee schedule,133.57,819.2,
Gonadotropin hormone panel,80426,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,133.57,,,,,,,fee schedule,133.57,819.2,Laboratory
Gonadotropin hormone panel,80426,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,155.83,,,,,,,fee schedule,133.57,819.2,APC
Gonadotropin hormone panel,80426,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,154.35,,,,,,,fee schedule,133.57,819.2,APC
Gonadotropin hormone panel,80426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,148.41,,,,,,,fee schedule,133.57,819.2,APC
Gonadotropin hormone panel,80426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,227.07,,,,,,,fee schedule,133.57,819.2,Radiology
Gonadotropin hormone panel,80426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,207.77,,,,,,,fee schedule,133.57,819.2,APC
Gonadotropin hormone panel,80426,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,259.72,,,,,,,fee schedule,133.57,819.2,APC
Growth hormone panel,80428,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,368.02,,,,,,,fee schedule,60.03,368.02,
Growth hormone panel,80428,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,295,,,,,,,fee schedule,60.03,368.02,
Growth hormone panel,80428,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,322.26,,,,,,,fee schedule,60.03,368.02,
Growth hormone panel,80428,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,338.81,,,,,,,fee schedule,60.03,368.02,
Growth hormone panel,80428,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,60.03,,,,,,,fee schedule,60.03,368.02,Laboratory
Growth hormone panel,80428,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,70.04,,,,,,,fee schedule,60.03,368.02,APC
Growth hormone panel,80428,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,69.37,,,,,,,fee schedule,60.03,368.02,APC
Growth hormone panel,80428,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,66.7,,,,,,,fee schedule,60.03,368.02,APC
Growth hormone panel,80428,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,102.05,,,,,,,fee schedule,60.03,368.02,Radiology
Growth hormone panel,80428,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,93.38,,,,,,,fee schedule,60.03,368.02,APC
Growth hormone panel,80428,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,116.72,,,,,,,fee schedule,60.03,368.02,APC
Growth hormone panel,80430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,433,,,,,,,fee schedule,116.4,433,
Growth hormone panel,80430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,347.09,,,,,,,fee schedule,116.4,433,
Growth hormone panel,80430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,379.16,,,,,,,fee schedule,116.4,433,
Growth hormone panel,80430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,398.63,,,,,,,fee schedule,116.4,433,
Growth hormone panel,80430,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,116.4,,,,,,,fee schedule,116.4,433,Laboratory
Growth hormone panel,80430,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,135.8,,,,,,,fee schedule,116.4,433,APC
Growth hormone panel,80430,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,134.5,,,,,,,fee schedule,116.4,433,APC
Growth hormone panel,80430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,129.33,,,,,,,fee schedule,116.4,433,APC
Growth hormone panel,80430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,197.87,,,,,,,fee schedule,116.4,433,Radiology
Growth hormone panel,80430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,181.06,,,,,,,fee schedule,116.4,433,APC
Growth hormone panel,80430,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,226.33,,,,,,,fee schedule,116.4,433,APC
Insulin suppression panel,80432,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,740.65,,,,,,,fee schedule,149.05,740.65,
Insulin suppression panel,80432,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,593.7,,,,,,,fee schedule,149.05,740.65,
Insulin suppression panel,80432,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,648.56,,,,,,,fee schedule,149.05,740.65,
Insulin suppression panel,80432,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,681.87,,,,,,,fee schedule,149.05,740.65,
Insulin suppression panel,80432,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,149.05,,,,,,,fee schedule,149.05,740.65,Laboratory
Insulin suppression panel,80432,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,173.89,,,,,,,fee schedule,149.05,740.65,APC
Insulin suppression panel,80432,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,172.23,,,,,,,fee schedule,149.05,740.65,APC
Insulin suppression panel,80432,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,165.61,,,,,,,fee schedule,149.05,740.65,APC
Insulin suppression panel,80432,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,253.38,,,,,,,fee schedule,149.05,740.65,Radiology
Insulin suppression panel,80432,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,231.85,,,,,,,fee schedule,149.05,740.65,APC
Insulin suppression panel,80432,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,289.82,,,,,,,fee schedule,149.05,740.65,APC
Insulin tolerance panel,80434,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,558.31,,,,,,,fee schedule,256.53,558.31,
Insulin tolerance panel,80434,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,447.53,,,,,,,fee schedule,256.53,558.31,
Insulin tolerance panel,80434,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,488.89,,,,,,,fee schedule,256.53,558.31,
Insulin tolerance panel,80434,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,514,,,,,,,fee schedule,256.53,558.31,
Insulin tolerance panel,80434,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,256.53,,,,,,,fee schedule,256.53,558.31,Laboratory
Insulin tolerance panel,80434,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,299.28,,,,,,,fee schedule,256.53,558.31,APC
Insulin tolerance panel,80434,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,296.43,,,,,,,fee schedule,256.53,558.31,APC
Insulin tolerance panel,80434,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,285.03,,,,,,,fee schedule,256.53,558.31,APC
Insulin tolerance panel,80434,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,436.1,,,,,,,fee schedule,256.53,558.31,Radiology
Insulin tolerance panel,80434,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,399.04,,,,,,,fee schedule,256.53,558.31,APC
Insulin tolerance panel,80434,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,498.8,,,,,,,fee schedule,256.53,558.31,APC
Insulin tolerance panel,80435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,568.32,,,,,,,fee schedule,92.7,568.32,
Insulin tolerance panel,80435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,455.56,,,,,,,fee schedule,92.7,568.32,
Insulin tolerance panel,80435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,497.66,,,,,,,fee schedule,92.7,568.32,
Insulin tolerance panel,80435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,523.22,,,,,,,fee schedule,92.7,568.32,
Insulin tolerance panel,80435,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,92.7,,,,,,,fee schedule,92.7,568.32,Laboratory
Insulin tolerance panel,80435,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.15,,,,,,,fee schedule,92.7,568.32,APC
Insulin tolerance panel,80435,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.12,,,,,,,fee schedule,92.7,568.32,APC
Insulin tolerance panel,80435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103,,,,,,,fee schedule,92.7,568.32,APC
Insulin tolerance panel,80435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,157.59,,,,,,,fee schedule,92.7,568.32,Radiology
Insulin tolerance panel,80435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.2,,,,,,,fee schedule,92.7,568.32,APC
Insulin tolerance panel,80435,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,180.25,,,,,,,fee schedule,92.7,568.32,APC
Metyrapone panel,80436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,503.12,,,,,,,fee schedule,82.04,503.12,
Metyrapone panel,80436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,403.29,,,,,,,fee schedule,82.04,503.12,
Metyrapone panel,80436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,440.56,,,,,,,fee schedule,82.04,503.12,
Metyrapone panel,80436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,463.19,,,,,,,fee schedule,82.04,503.12,
Metyrapone panel,80436,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,82.04,,,,,,,fee schedule,82.04,503.12,Laboratory
Metyrapone panel,80436,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,95.72,,,,,,,fee schedule,82.04,503.12,APC
Metyrapone panel,80436,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,94.81,,,,,,,fee schedule,82.04,503.12,APC
Metyrapone panel,80436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,91.16,,,,,,,fee schedule,82.04,503.12,APC
Metyrapone panel,80436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,139.47,,,,,,,fee schedule,82.04,503.12,Radiology
Metyrapone panel,80436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,127.62,,,,,,,fee schedule,82.04,503.12,APC
Metyrapone panel,80436,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,159.53,,,,,,,fee schedule,82.04,503.12,APC
TRH stimulation panel,80438,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,278.17,,,,,,,fee schedule,45.37,278.17,
TRH stimulation panel,80438,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,222.98,,,,,,,fee schedule,45.37,278.17,
TRH stimulation panel,80438,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,243.58,,,,,,,fee schedule,45.37,278.17,
TRH stimulation panel,80438,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,256.09,,,,,,,fee schedule,45.37,278.17,
TRH stimulation panel,80438,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,45.37,,,,,,,fee schedule,45.37,278.17,Laboratory
TRH stimulation panel,80438,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,52.93,,,,,,,fee schedule,45.37,278.17,APC
TRH stimulation panel,80438,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,52.43,,,,,,,fee schedule,45.37,278.17,APC
TRH stimulation panel,80438,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,50.41,,,,,,,fee schedule,45.37,278.17,APC
TRH stimulation panel,80438,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,77.13,,,,,,,fee schedule,45.37,278.17,Radiology
TRH stimulation panel,80438,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,70.57,,,,,,,fee schedule,45.37,278.17,APC
TRH stimulation panel,80438,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,88.22,,,,,,,fee schedule,45.37,278.17,APC
TRH stimulation panel,80439,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,370.89,,,,,,,fee schedule,60.49,370.89,
TRH stimulation panel,80439,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,297.3,,,,,,,fee schedule,60.49,370.89,
TRH stimulation panel,80439,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,324.78,,,,,,,fee schedule,60.49,370.89,
TRH stimulation panel,80439,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,341.46,,,,,,,fee schedule,60.49,370.89,
TRH stimulation panel,80439,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,60.49,,,,,,,fee schedule,60.49,370.89,Laboratory
TRH stimulation panel,80439,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,70.57,,,,,,,fee schedule,60.49,370.89,APC
TRH stimulation panel,80439,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,69.9,,,,,,,fee schedule,60.49,370.89,APC
TRH stimulation panel,80439,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,67.21,,,,,,,fee schedule,60.49,370.89,APC
TRH stimulation panel,80439,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,102.83,,,,,,,fee schedule,60.49,370.89,Radiology
TRH stimulation panel,80439,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,94.09,,,,,,,fee schedule,60.49,370.89,APC
TRH stimulation panel,80439,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,117.62,,,,,,,fee schedule,60.49,370.89,APC
Path clin consltj sf 5-20,80503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,191.84,,,,,,,fee schedule,51.59,228.88,
Path clin consltj sf 5-20,80503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,153.77,,,,,,,fee schedule,51.59,228.88,
Path clin consltj sf 5-20,80503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,167.98,,,,,,,fee schedule,51.59,228.88,
Path clin consltj sf 5-20,80503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,176.61,,,,,,,fee schedule,51.59,228.88,
Path clin consltj sf 5-20,80503,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,228.88,,,,,,,fee schedule,51.59,228.88,APC 378
Path clin consltj sf 5-20,80503,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.17,,,,,,,fee schedule,51.59,228.88,APC
Path clin consltj sf 5-20,80503,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,53.65,,,,,,,fee schedule,51.59,228.88,APC
Path clin consltj sf 5-20,80503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,51.59,,,,,,,fee schedule,51.59,228.88,APC
Path clin consltj sf 5-20,80503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,78.93,,,,,,,fee schedule,51.59,228.88,Radiology
Path clin consltj sf 5-20,80503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,72.22,,,,,,,fee schedule,51.59,228.88,APC
Path clin consltj sf 5-20,80503,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,90.28,,,,,,,fee schedule,51.59,228.88,APC
Path clin consltj mod 21-40,80504,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,575.77,,,,,,,fee schedule,168.66,748.29,
Path clin consltj mod 21-40,80504,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,461.53,,,,,,,fee schedule,168.66,748.29,
Path clin consltj mod 21-40,80504,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,504.18,,,,,,,fee schedule,168.66,748.29,
Path clin consltj mod 21-40,80504,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,530.07,,,,,,,fee schedule,168.66,748.29,
Path clin consltj mod 21-40,80504,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,748.29,,,,,,,fee schedule,168.66,748.29,APC 378
Path clin consltj mod 21-40,80504,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,177.09,,,,,,,fee schedule,168.66,748.29,APC
Path clin consltj mod 21-40,80504,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,175.41,,,,,,,fee schedule,168.66,748.29,APC
Path clin consltj mod 21-40,80504,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,168.66,,,,,,,fee schedule,168.66,748.29,APC
Path clin consltj mod 21-40,80504,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,258.05,,,,,,,fee schedule,168.66,748.29,Radiology
Path clin consltj mod 21-40,80504,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,236.12,,,,,,,fee schedule,168.66,748.29,APC
Path clin consltj mod 21-40,80504,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,295.16,,,,,,,fee schedule,168.66,748.29,APC
Path clin consltj high 41-60,80505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,575.77,,,,,,,fee schedule,168.66,748.29,
Path clin consltj high 41-60,80505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,461.53,,,,,,,fee schedule,168.66,748.29,
Path clin consltj high 41-60,80505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,504.18,,,,,,,fee schedule,168.66,748.29,
Path clin consltj high 41-60,80505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,530.07,,,,,,,fee schedule,168.66,748.29,
Path clin consltj high 41-60,80505,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,748.29,,,,,,,fee schedule,168.66,748.29,APC 378
Path clin consltj high 41-60,80505,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,177.09,,,,,,,fee schedule,168.66,748.29,APC
Path clin consltj high 41-60,80505,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,175.41,,,,,,,fee schedule,168.66,748.29,APC
Path clin consltj high 41-60,80505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,168.66,,,,,,,fee schedule,168.66,748.29,APC
Path clin consltj high 41-60,80505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,258.05,,,,,,,fee schedule,168.66,748.29,Radiology
Path clin consltj high 41-60,80505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,236.12,,,,,,,fee schedule,168.66,748.29,APC
Path clin consltj high 41-60,80505,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,295.16,,,,,,,fee schedule,168.66,748.29,APC
Urinalysis nonauto w/scope,81000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17.5,,,,,,,fee schedule,3.62,17.5,
Urinalysis nonauto w/scope,81000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14.03,,,,,,,fee schedule,3.62,17.5,
Urinalysis nonauto w/scope,81000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15.33,,,,,,,fee schedule,3.62,17.5,
Urinalysis nonauto w/scope,81000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16.11,,,,,,,fee schedule,3.62,17.5,
Urinalysis nonauto w/scope,81000,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.62,,,,,,,fee schedule,3.62,17.5,Laboratory
Urinalysis nonauto w/scope,81000,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.22,,,,,,,fee schedule,3.62,17.5,APC
Urinalysis nonauto w/scope,81000,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4.18,,,,,,,fee schedule,3.62,17.5,APC
Urinalysis nonauto w/scope,81000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4.02,,,,,,,fee schedule,3.62,17.5,APC
Urinalysis nonauto w/scope,81000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.15,,,,,,,fee schedule,3.62,17.5,Radiology
Urinalysis nonauto w/scope,81000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.63,,,,,,,fee schedule,3.62,17.5,APC
Urinalysis nonauto w/scope,81000,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7.03,,,,,,,fee schedule,3.62,17.5,APC
Urinalysis auto w/scope,81001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.17,,,,,,,fee schedule,2.85,60.17,
Urinalysis auto w/scope,81001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48.23,,,,,,,fee schedule,2.85,60.17,
Urinalysis auto w/scope,81001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52.69,,,,,,,fee schedule,2.85,60.17,
Urinalysis auto w/scope,81001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55.39,,,,,,,fee schedule,2.85,60.17,
Urinalysis auto w/scope,81001,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.85,,,,,,,fee schedule,2.85,60.17,Laboratory
Urinalysis auto w/scope,81001,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3.33,,,,,,,fee schedule,2.85,60.17,APC
Urinalysis auto w/scope,81001,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3.3,,,,,,,fee schedule,2.85,60.17,APC
Urinalysis auto w/scope,81001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3.17,,,,,,,fee schedule,2.85,60.17,APC
Urinalysis auto w/scope,81001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4.85,,,,,,,fee schedule,2.85,60.17,Radiology
Urinalysis auto w/scope,81001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4.44,,,,,,,fee schedule,2.85,60.17,APC
Urinalysis auto w/scope,81001,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5.55,,,,,,,fee schedule,2.85,60.17,APC
Urinalysis nonauto w/o scope,81002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,32.21,,,,,,,fee schedule,3.13,32.21,
Urinalysis nonauto w/o scope,81002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,25.82,,,,,,,fee schedule,3.13,32.21,
Urinalysis nonauto w/o scope,81002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28.21,,,,,,,fee schedule,3.13,32.21,
Urinalysis nonauto w/o scope,81002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,29.66,,,,,,,fee schedule,3.13,32.21,
Urinalysis nonauto w/o scope,81002,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.13,,,,,,,fee schedule,3.13,32.21,Laboratory
Urinalysis nonauto w/o scope,81002,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3.65,,,,,,,fee schedule,3.13,32.21,APC
Urinalysis nonauto w/o scope,81002,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3.62,,,,,,,fee schedule,3.13,32.21,APC
Urinalysis nonauto w/o scope,81002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3.48,,,,,,,fee schedule,3.13,32.21,APC
Urinalysis nonauto w/o scope,81002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.32,,,,,,,fee schedule,3.13,32.21,Radiology
Urinalysis nonauto w/o scope,81002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4.87,,,,,,,fee schedule,3.13,32.21,APC
Urinalysis nonauto w/o scope,81002,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6.09,,,,,,,fee schedule,3.13,32.21,APC
Urinalysis auto w/o scope,81003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42.14,,,,,,,fee schedule,2.02,42.14,
Urinalysis auto w/o scope,81003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,33.78,,,,,,,fee schedule,2.02,42.14,
Urinalysis auto w/o scope,81003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36.9,,,,,,,fee schedule,2.02,42.14,
Urinalysis auto w/o scope,81003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,38.8,,,,,,,fee schedule,2.02,42.14,
Urinalysis auto w/o scope,81003,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.02,,,,,,,fee schedule,2.02,42.14,Laboratory
Urinalysis auto w/o scope,81003,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2.36,,,,,,,fee schedule,2.02,42.14,APC
Urinalysis auto w/o scope,81003,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2.34,,,,,,,fee schedule,2.02,42.14,APC
Urinalysis auto w/o scope,81003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2.25,,,,,,,fee schedule,2.02,42.14,APC
Urinalysis auto w/o scope,81003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3.44,,,,,,,fee schedule,2.02,42.14,Radiology
Urinalysis auto w/o scope,81003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3.15,,,,,,,fee schedule,2.02,42.14,APC
Urinalysis auto w/o scope,81003,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3.94,,,,,,,fee schedule,2.02,42.14,APC
Urinalysis,81005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11.94,,,,,,,fee schedule,1.95,11.94,
Urinalysis,81005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.57,,,,,,,fee schedule,1.95,11.94,
Urinalysis,81005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10.46,,,,,,,fee schedule,1.95,11.94,
Urinalysis,81005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11,,,,,,,fee schedule,1.95,11.94,
Urinalysis,81005,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1.95,,,,,,,fee schedule,1.95,11.94,Laboratory
Urinalysis,81005,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2.28,,,,,,,fee schedule,1.95,11.94,APC
Urinalysis,81005,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2.26,,,,,,,fee schedule,1.95,11.94,APC
Urinalysis,81005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2.17,,,,,,,fee schedule,1.95,11.94,APC
Urinalysis,81005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3.32,,,,,,,fee schedule,1.95,11.94,Radiology
Urinalysis,81005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3.04,,,,,,,fee schedule,1.95,11.94,APC
Urinalysis,81005,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3.8,,,,,,,fee schedule,1.95,11.94,APC
Urine screen for bacteria,81007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14.18,,,,,,,fee schedule,11.36,52.46,
Urine screen for bacteria,81007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11.36,,,,,,,fee schedule,11.36,52.46,
Urine screen for bacteria,81007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12.41,,,,,,,fee schedule,11.36,52.46,
Urine screen for bacteria,81007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13.05,,,,,,,fee schedule,11.36,52.46,
Urine screen for bacteria,81007,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26.98,,,,,,,fee schedule,11.36,52.46,Laboratory
Urine screen for bacteria,81007,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,31.48,,,,,,,fee schedule,11.36,52.46,APC
Urine screen for bacteria,81007,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,31.18,,,,,,,fee schedule,11.36,52.46,APC
Urine screen for bacteria,81007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,29.98,,,,,,,fee schedule,11.36,52.46,APC
Urine screen for bacteria,81007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,45.87,,,,,,,fee schedule,11.36,52.46,Radiology
Urine screen for bacteria,81007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,41.97,,,,,,,fee schedule,11.36,52.46,APC
Urine screen for bacteria,81007,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,52.46,,,,,,,fee schedule,11.36,52.46,APC
Microscopic exam of urine,81015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.63,,,,,,,fee schedule,2.74,9.63,
Microscopic exam of urine,81015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7.72,,,,,,,fee schedule,2.74,9.63,
Microscopic exam of urine,81015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.43,,,,,,,fee schedule,2.74,9.63,
Microscopic exam of urine,81015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8.86,,,,,,,fee schedule,2.74,9.63,
Microscopic exam of urine,81015,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.74,,,,,,,fee schedule,2.74,9.63,Laboratory
Microscopic exam of urine,81015,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3.2,,,,,,,fee schedule,2.74,9.63,APC
Microscopic exam of urine,81015,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3.17,,,,,,,fee schedule,2.74,9.63,APC
Microscopic exam of urine,81015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3.05,,,,,,,fee schedule,2.74,9.63,APC
Microscopic exam of urine,81015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4.67,,,,,,,fee schedule,2.74,9.63,Radiology
Microscopic exam of urine,81015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4.27,,,,,,,fee schedule,2.74,9.63,APC
Microscopic exam of urine,81015,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5.34,,,,,,,fee schedule,2.74,9.63,APC
Urinalysis glass test,81020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20.34,,,,,,,fee schedule,4.23,20.34,
Urinalysis glass test,81020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.3,,,,,,,fee schedule,4.23,20.34,
Urinalysis glass test,81020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17.81,,,,,,,fee schedule,4.23,20.34,
Urinalysis glass test,81020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18.72,,,,,,,fee schedule,4.23,20.34,
Urinalysis glass test,81020,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.23,,,,,,,fee schedule,4.23,20.34,Laboratory
Urinalysis glass test,81020,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.94,,,,,,,fee schedule,4.23,20.34,APC
Urinalysis glass test,81020,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4.89,,,,,,,fee schedule,4.23,20.34,APC
Urinalysis glass test,81020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4.7,,,,,,,fee schedule,4.23,20.34,APC
Urinalysis glass test,81020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.19,,,,,,,fee schedule,4.23,20.34,Radiology
Urinalysis glass test,81020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.58,,,,,,,fee schedule,4.23,20.34,APC
Urinalysis glass test,81020,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8.22,,,,,,,fee schedule,4.23,20.34,APC
Urine pregnancy test,81025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,68.09,,,,,,,fee schedule,7.75,68.09,
Urine pregnancy test,81025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,54.58,,,,,,,fee schedule,7.75,68.09,
Urine pregnancy test,81025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,59.63,,,,,,,fee schedule,7.75,68.09,
Urine pregnancy test,81025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,62.69,,,,,,,fee schedule,7.75,68.09,
Urine pregnancy test,81025,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.75,,,,,,,fee schedule,7.75,68.09,Laboratory
Urine pregnancy test,81025,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.04,,,,,,,fee schedule,7.75,68.09,APC
Urine pregnancy test,81025,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8.95,,,,,,,fee schedule,7.75,68.09,APC
Urine pregnancy test,81025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8.61,,,,,,,fee schedule,7.75,68.09,APC
Urine pregnancy test,81025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.17,,,,,,,fee schedule,7.75,68.09,Radiology
Urine pregnancy test,81025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12.05,,,,,,,fee schedule,7.75,68.09,APC
Urine pregnancy test,81025,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15.07,,,,,,,fee schedule,7.75,68.09,APC
Urinalysis volume measure,81050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.63,,,,,,,fee schedule,3.28,9.63,
Urinalysis volume measure,81050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7.72,,,,,,,fee schedule,3.28,9.63,
Urinalysis volume measure,81050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.43,,,,,,,fee schedule,3.28,9.63,
Urinalysis volume measure,81050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8.86,,,,,,,fee schedule,3.28,9.63,
Urinalysis volume measure,81050,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.28,,,,,,,fee schedule,3.28,9.63,Laboratory
Urinalysis volume measure,81050,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3.82,,,,,,,fee schedule,3.28,9.63,APC
Urinalysis volume measure,81050,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3.79,,,,,,,fee schedule,3.28,9.63,APC
Urinalysis volume measure,81050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3.64,,,,,,,fee schedule,3.28,9.63,APC
Urinalysis volume measure,81050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.57,,,,,,,fee schedule,3.28,9.63,Radiology
Urinalysis volume measure,81050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.1,,,,,,,fee schedule,3.28,9.63,APC
Urinalysis volume measure,81050,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6.37,,,,,,,fee schedule,3.28,9.63,APC
Hpa-1 genotyping,81105,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,110,,,,,,,fee schedule,110,213.88,Laboratory
Hpa-1 genotyping,81105,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,128.33,,,,,,,fee schedule,110,213.88,APC
Hpa-1 genotyping,81105,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,127.11,,,,,,,fee schedule,110,213.88,APC
Hpa-1 genotyping,81105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,122.22,,,,,,,fee schedule,110,213.88,APC
Hpa-1 genotyping,81105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,187,,,,,,,fee schedule,110,213.88,Radiology
Hpa-1 genotyping,81105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,171.11,,,,,,,fee schedule,110,213.88,APC
Hpa-1 genotyping,81105,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,213.88,,,,,,,fee schedule,110,213.88,APC
Hpa-2 genotyping,81106,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,110,,,,,,,fee schedule,110,213.88,Laboratory
Hpa-2 genotyping,81106,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,128.33,,,,,,,fee schedule,110,213.88,APC
Hpa-2 genotyping,81106,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,127.11,,,,,,,fee schedule,110,213.88,APC
Hpa-2 genotyping,81106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,122.22,,,,,,,fee schedule,110,213.88,APC
Hpa-2 genotyping,81106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,187,,,,,,,fee schedule,110,213.88,Radiology
Hpa-2 genotyping,81106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,171.11,,,,,,,fee schedule,110,213.88,APC
Hpa-2 genotyping,81106,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,213.88,,,,,,,fee schedule,110,213.88,APC
Hpa-3 genotyping,81107,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,110,,,,,,,fee schedule,110,213.88,Laboratory
Hpa-3 genotyping,81107,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,128.33,,,,,,,fee schedule,110,213.88,APC
Hpa-3 genotyping,81107,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,127.11,,,,,,,fee schedule,110,213.88,APC
Hpa-3 genotyping,81107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,122.22,,,,,,,fee schedule,110,213.88,APC
Hpa-3 genotyping,81107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,187,,,,,,,fee schedule,110,213.88,Radiology
Hpa-3 genotyping,81107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,171.11,,,,,,,fee schedule,110,213.88,APC
Hpa-3 genotyping,81107,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,213.88,,,,,,,fee schedule,110,213.88,APC
Hpa-4 genotyping,81108,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,110,,,,,,,fee schedule,110,213.88,Laboratory
Hpa-4 genotyping,81108,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,128.33,,,,,,,fee schedule,110,213.88,APC
Hpa-4 genotyping,81108,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,127.11,,,,,,,fee schedule,110,213.88,APC
Hpa-4 genotyping,81108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,122.22,,,,,,,fee schedule,110,213.88,APC
Hpa-4 genotyping,81108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,187,,,,,,,fee schedule,110,213.88,Radiology
Hpa-4 genotyping,81108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,171.11,,,,,,,fee schedule,110,213.88,APC
Hpa-4 genotyping,81108,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,213.88,,,,,,,fee schedule,110,213.88,APC
Hpa-5 genotyping,81109,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,110,,,,,,,fee schedule,110,213.88,Laboratory
Hpa-5 genotyping,81109,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,128.33,,,,,,,fee schedule,110,213.88,APC
Hpa-5 genotyping,81109,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,127.11,,,,,,,fee schedule,110,213.88,APC
Hpa-5 genotyping,81109,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,122.22,,,,,,,fee schedule,110,213.88,APC
Hpa-5 genotyping,81109,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,187,,,,,,,fee schedule,110,213.88,Radiology
Hpa-5 genotyping,81109,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,171.11,,,,,,,fee schedule,110,213.88,APC
Hpa-5 genotyping,81109,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,213.88,,,,,,,fee schedule,110,213.88,APC
Hpa-6 genotyping,81110,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,110,,,,,,,fee schedule,110,213.88,Laboratory
Hpa-6 genotyping,81110,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,128.33,,,,,,,fee schedule,110,213.88,APC
Hpa-6 genotyping,81110,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,127.11,,,,,,,fee schedule,110,213.88,APC
Hpa-6 genotyping,81110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,122.22,,,,,,,fee schedule,110,213.88,APC
Hpa-6 genotyping,81110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,187,,,,,,,fee schedule,110,213.88,Radiology
Hpa-6 genotyping,81110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,171.11,,,,,,,fee schedule,110,213.88,APC
Hpa-6 genotyping,81110,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,213.88,,,,,,,fee schedule,110,213.88,APC
Hpa-9 genotyping,81111,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,110,,,,,,,fee schedule,110,213.88,Laboratory
Hpa-9 genotyping,81111,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,128.33,,,,,,,fee schedule,110,213.88,APC
Hpa-9 genotyping,81111,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,127.11,,,,,,,fee schedule,110,213.88,APC
Hpa-9 genotyping,81111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,122.22,,,,,,,fee schedule,110,213.88,APC
Hpa-9 genotyping,81111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,187,,,,,,,fee schedule,110,213.88,Radiology
Hpa-9 genotyping,81111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,171.11,,,,,,,fee schedule,110,213.88,APC
Hpa-9 genotyping,81111,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,213.88,,,,,,,fee schedule,110,213.88,APC
Hpa-15 genotyping,81112,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,110,,,,,,,fee schedule,110,213.88,Laboratory
Hpa-15 genotyping,81112,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,128.33,,,,,,,fee schedule,110,213.88,APC
Hpa-15 genotyping,81112,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,127.11,,,,,,,fee schedule,110,213.88,APC
Hpa-15 genotyping,81112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,122.22,,,,,,,fee schedule,110,213.88,APC
Hpa-15 genotyping,81112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,187,,,,,,,fee schedule,110,213.88,Radiology
Hpa-15 genotyping,81112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,171.11,,,,,,,fee schedule,110,213.88,APC
Hpa-15 genotyping,81112,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,213.88,,,,,,,fee schedule,110,213.88,APC
Idh1 common variants,81120,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,173.92,,,,,,,fee schedule,173.92,338.19,Laboratory
Idh1 common variants,81120,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,202.91,,,,,,,fee schedule,173.92,338.19,APC
Idh1 common variants,81120,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,200.98,,,,,,,fee schedule,173.92,338.19,APC
Idh1 common variants,81120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,193.25,,,,,,,fee schedule,173.92,338.19,APC
Idh1 common variants,81120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,295.67,,,,,,,fee schedule,173.92,338.19,Radiology
Idh1 common variants,81120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,270.55,,,,,,,fee schedule,173.92,338.19,APC
Idh1 common variants,81120,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,338.19,,,,,,,fee schedule,173.92,338.19,APC
Idh2 common variants,81121,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,266.21,,,,,,,fee schedule,266.21,517.63,Laboratory
Idh2 common variants,81121,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,310.58,,,,,,,fee schedule,266.21,517.63,APC
Idh2 common variants,81121,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,307.62,,,,,,,fee schedule,266.21,517.63,APC
Idh2 common variants,81121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,295.79,,,,,,,fee schedule,266.21,517.63,APC
Idh2 common variants,81121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,452.56,,,,,,,fee schedule,266.21,517.63,Radiology
Idh2 common variants,81121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,414.11,,,,,,,fee schedule,266.21,517.63,APC
Idh2 common variants,81121,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,517.63,,,,,,,fee schedule,266.21,517.63,APC
DMD dup/delet analysis,81161,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,251.1,,,,,,,fee schedule,251.1,488.25,Laboratory
DMD dup/delet analysis,81161,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,292.95,,,,,,,fee schedule,251.1,488.25,APC
DMD dup/delet analysis,81161,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,290.16,,,,,,,fee schedule,251.1,488.25,APC
DMD dup/delet analysis,81161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,279,,,,,,,fee schedule,251.1,488.25,APC
DMD dup/delet analysis,81161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,426.87,,,,,,,fee schedule,251.1,488.25,Radiology
DMD dup/delet analysis,81161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,390.6,,,,,,,fee schedule,251.1,488.25,APC
DMD dup/delet analysis,81161,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,488.25,,,,,,,fee schedule,251.1,488.25,APC
Brca1&2 seq & full dup/del,81162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,71591.46,,,,,,,fee schedule,1642.39,71591.46,
Brca1&2 seq & full dup/del,81162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57386.81,,,,,,,fee schedule,1642.39,71591.46,
Brca1&2 seq & full dup/del,81162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,62689.88,,,,,,,fee schedule,1642.39,71591.46,
Brca1&2 seq & full dup/del,81162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,65909.6,,,,,,,fee schedule,1642.39,71591.46,
Brca1&2 seq & full dup/del,81162,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1642.39,,,,,,,fee schedule,1642.39,71591.46,Laboratory
Brca1&2 seq & full dup/del,81162,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1916.12,,,,,,,fee schedule,1642.39,71591.46,APC
Brca1&2 seq & full dup/del,81162,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1897.88,,,,,,,fee schedule,1642.39,71591.46,APC
Brca1&2 seq & full dup/del,81162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1824.88,,,,,,,fee schedule,1642.39,71591.46,APC
Brca1&2 seq & full dup/del,81162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2792.07,,,,,,,fee schedule,1642.39,71591.46,Radiology
Brca1&2 seq & full dup/del,81162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2554.83,,,,,,,fee schedule,1642.39,71591.46,APC
Brca1&2 seq & full dup/del,81162,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3193.54,,,,,,,fee schedule,1642.39,71591.46,APC
Brca1&2 gene full seq alys,81163,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,421.2,,,,,,,fee schedule,421.2,819,Laboratory
Brca1&2 gene full seq alys,81163,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,491.4,,,,,,,fee schedule,421.2,819,APC
Brca1&2 gene full seq alys,81163,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,486.72,,,,,,,fee schedule,421.2,819,APC
Brca1&2 gene full seq alys,81163,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,468,,,,,,,fee schedule,421.2,819,APC
Brca1&2 gene full seq alys,81163,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,716.04,,,,,,,fee schedule,421.2,819,Radiology
Brca1&2 gene full seq alys,81163,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,655.2,,,,,,,fee schedule,421.2,819,APC
Brca1&2 gene full seq alys,81163,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,819,,,,,,,fee schedule,421.2,819,APC
Brca1&2 gen ful dup/del alys,81164,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,525.81,,,,,,,fee schedule,525.81,1022.4,Laboratory
Brca1&2 gen ful dup/del alys,81164,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,613.44,,,,,,,fee schedule,525.81,1022.4,APC
Brca1&2 gen ful dup/del alys,81164,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,607.6,,,,,,,fee schedule,525.81,1022.4,APC
Brca1&2 gen ful dup/del alys,81164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,584.23,,,,,,,fee schedule,525.81,1022.4,APC
Brca1&2 gen ful dup/del alys,81164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,893.87,,,,,,,fee schedule,525.81,1022.4,Radiology
Brca1&2 gen ful dup/del alys,81164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,817.92,,,,,,,fee schedule,525.81,1022.4,APC
Brca1&2 gen ful dup/del alys,81164,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1022.4,,,,,,,fee schedule,525.81,1022.4,APC
Brca1 gene full seq alys,81165,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,254.59,,,,,,,fee schedule,254.59,495.04,Laboratory
Brca1 gene full seq alys,81165,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,297.02,,,,,,,fee schedule,254.59,495.04,APC
Brca1 gene full seq alys,81165,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,294.2,,,,,,,fee schedule,254.59,495.04,APC
Brca1 gene full seq alys,81165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,282.88,,,,,,,fee schedule,254.59,495.04,APC
Brca1 gene full seq alys,81165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,432.81,,,,,,,fee schedule,254.59,495.04,Radiology
Brca1 gene full seq alys,81165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,396.03,,,,,,,fee schedule,254.59,495.04,APC
Brca1 gene full seq alys,81165,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,495.04,,,,,,,fee schedule,254.59,495.04,APC
Brca1 gene full dup/del alys,81166,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,271.22,,,,,,,fee schedule,271.21,527.36,Laboratory
Brca1 gene full dup/del alys,81166,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,316.42,,,,,,,fee schedule,271.21,527.36,APC
Brca1 gene full dup/del alys,81166,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,313.4,,,,,,,fee schedule,271.21,527.36,APC
Brca1 gene full dup/del alys,81166,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,301.35,,,,,,,fee schedule,271.21,527.36,APC
Brca1 gene full dup/del alys,81166,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,461.07,,,,,,,fee schedule,271.21,527.36,Radiology
Brca1 gene full dup/del alys,81166,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,421.89,,,,,,,fee schedule,271.21,527.36,APC
Brca1 gene full dup/del alys,81166,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,527.36,,,,,,,fee schedule,271.21,527.36,APC
Brca2 gene full dup/del alys,81167,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,254.59,,,,,,,fee schedule,254.59,495.04,Laboratory
Brca2 gene full dup/del alys,81167,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,297.02,,,,,,,fee schedule,254.59,495.04,APC
Brca2 gene full dup/del alys,81167,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,294.2,,,,,,,fee schedule,254.59,495.04,APC
Brca2 gene full dup/del alys,81167,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,282.88,,,,,,,fee schedule,254.59,495.04,APC
Brca2 gene full dup/del alys,81167,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,432.81,,,,,,,fee schedule,254.59,495.04,Radiology
Brca2 gene full dup/del alys,81167,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,396.03,,,,,,,fee schedule,254.59,495.04,APC
Brca2 gene full dup/del alys,81167,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,495.04,,,,,,,fee schedule,254.59,495.04,APC
Ccnd1/igh translocation alys,81168,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,186.58,,,,,,,fee schedule,186.58,362.79,Laboratory
Ccnd1/igh translocation alys,81168,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,217.68,,,,,,,fee schedule,186.58,362.79,APC
Ccnd1/igh translocation alys,81168,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,215.6,,,,,,,fee schedule,186.58,362.79,APC
Ccnd1/igh translocation alys,81168,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,207.31,,,,,,,fee schedule,186.58,362.79,APC
Ccnd1/igh translocation alys,81168,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,317.18,,,,,,,fee schedule,186.58,362.79,Radiology
Ccnd1/igh translocation alys,81168,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,290.23,,,,,,,fee schedule,186.58,362.79,APC
Ccnd1/igh translocation alys,81168,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,362.79,,,,,,,fee schedule,186.58,362.79,APC
Abl1 gene,81170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,921.72,,,,,,,fee schedule,270,921.72,
Abl1 gene,81170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,738.84,,,,,,,fee schedule,270,921.72,
Abl1 gene,81170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,807.11,,,,,,,fee schedule,270,921.72,
Abl1 gene,81170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,848.56,,,,,,,fee schedule,270,921.72,
Abl1 gene,81170,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,270,,,,,,,fee schedule,270,921.72,Laboratory
Abl1 gene,81170,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,315,,,,,,,fee schedule,270,921.72,APC
Abl1 gene,81170,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,312,,,,,,,fee schedule,270,921.72,APC
Abl1 gene,81170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,300,,,,,,,fee schedule,270,921.72,APC
Abl1 gene,81170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,459,,,,,,,fee schedule,270,921.72,Radiology
Abl1 gene,81170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,420,,,,,,,fee schedule,270,921.72,APC
Abl1 gene,81170,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,525,,,,,,,fee schedule,270,921.72,APC
Aff2 gene detc abnor alleles,81171,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,123.3,,,,,,,fee schedule,123.3,239.75,Laboratory
Aff2 gene detc abnor alleles,81171,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,143.85,,,,,,,fee schedule,123.3,239.75,APC
Aff2 gene detc abnor alleles,81171,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,142.48,,,,,,,fee schedule,123.3,239.75,APC
Aff2 gene detc abnor alleles,81171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,137,,,,,,,fee schedule,123.3,239.75,APC
Aff2 gene detc abnor alleles,81171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,209.61,,,,,,,fee schedule,123.3,239.75,Radiology
Aff2 gene detc abnor alleles,81171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,191.8,,,,,,,fee schedule,123.3,239.75,APC
Aff2 gene detc abnor alleles,81171,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,239.75,,,,,,,fee schedule,123.3,239.75,APC
Aff2 gene charac alleles,81172,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,247.35,,,,,,,fee schedule,247.35,480.95,Laboratory
Aff2 gene charac alleles,81172,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,288.57,,,,,,,fee schedule,247.35,480.95,APC
Aff2 gene charac alleles,81172,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,285.82,,,,,,,fee schedule,247.35,480.95,APC
Aff2 gene charac alleles,81172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,274.83,,,,,,,fee schedule,247.35,480.95,APC
Aff2 gene charac alleles,81172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,420.49,,,,,,,fee schedule,247.35,480.95,Radiology
Aff2 gene charac alleles,81172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,384.76,,,,,,,fee schedule,247.35,480.95,APC
Aff2 gene charac alleles,81172,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,480.95,,,,,,,fee schedule,247.35,480.95,APC
Ar gene full gene sequence,81173,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,271.22,,,,,,,fee schedule,271.21,527.36,Laboratory
Ar gene full gene sequence,81173,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,316.42,,,,,,,fee schedule,271.21,527.36,APC
Ar gene full gene sequence,81173,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,313.4,,,,,,,fee schedule,271.21,527.36,APC
Ar gene full gene sequence,81173,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,301.35,,,,,,,fee schedule,271.21,527.36,APC
Ar gene full gene sequence,81173,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,461.07,,,,,,,fee schedule,271.21,527.36,Radiology
Ar gene full gene sequence,81173,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,421.89,,,,,,,fee schedule,271.21,527.36,APC
Ar gene full gene sequence,81173,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,527.36,,,,,,,fee schedule,271.21,527.36,APC
Ar gene known famil variant,81174,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,166.68,,,,,,,fee schedule,166.68,324.1,Laboratory
Ar gene known famil variant,81174,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,194.46,,,,,,,fee schedule,166.68,324.1,APC
Ar gene known famil variant,81174,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,192.61,,,,,,,fee schedule,166.68,324.1,APC
Ar gene known famil variant,81174,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,185.2,,,,,,,fee schedule,166.68,324.1,APC
Ar gene known famil variant,81174,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,283.36,,,,,,,fee schedule,166.68,324.1,Radiology
Ar gene known famil variant,81174,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,259.28,,,,,,,fee schedule,166.68,324.1,APC
Ar gene known famil variant,81174,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,324.1,,,,,,,fee schedule,166.68,324.1,APC
Asxl1 full gene sequence,81175,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,608.85,,,,,,,fee schedule,608.85,1183.88,Laboratory
Asxl1 full gene sequence,81175,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,710.32,,,,,,,fee schedule,608.85,1183.88,APC
Asxl1 full gene sequence,81175,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,703.56,,,,,,,fee schedule,608.85,1183.88,APC
Asxl1 full gene sequence,81175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,676.5,,,,,,,fee schedule,608.85,1183.88,APC
Asxl1 full gene sequence,81175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1035.04,,,,,,,fee schedule,608.85,1183.88,Radiology
Asxl1 full gene sequence,81175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,947.1,,,,,,,fee schedule,608.85,1183.88,APC
Asxl1 full gene sequence,81175,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1183.88,,,,,,,fee schedule,608.85,1183.88,APC
Asxl1 gene target seq alys,81176,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,217.71,,,,,,,fee schedule,217.71,423.32,Laboratory
Asxl1 gene target seq alys,81176,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,254,,,,,,,fee schedule,217.71,423.32,APC
Asxl1 gene target seq alys,81176,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,251.58,,,,,,,fee schedule,217.71,423.32,APC
Asxl1 gene target seq alys,81176,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,241.9,,,,,,,fee schedule,217.71,423.32,APC
Asxl1 gene target seq alys,81176,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,370.11,,,,,,,fee schedule,217.71,423.32,Radiology
Asxl1 gene target seq alys,81176,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,338.66,,,,,,,fee schedule,217.71,423.32,APC
Asxl1 gene target seq alys,81176,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,423.32,,,,,,,fee schedule,217.71,423.32,APC
Atn1 gene detc abnor alleles,81177,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,123.3,,,,,,,fee schedule,123.3,239.75,Laboratory
Atn1 gene detc abnor alleles,81177,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,143.85,,,,,,,fee schedule,123.3,239.75,APC
Atn1 gene detc abnor alleles,81177,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,142.48,,,,,,,fee schedule,123.3,239.75,APC
Atn1 gene detc abnor alleles,81177,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,137,,,,,,,fee schedule,123.3,239.75,APC
Atn1 gene detc abnor alleles,81177,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,209.61,,,,,,,fee schedule,123.3,239.75,Radiology
Atn1 gene detc abnor alleles,81177,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,191.8,,,,,,,fee schedule,123.3,239.75,APC
Atn1 gene detc abnor alleles,81177,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,239.75,,,,,,,fee schedule,123.3,239.75,APC
Atxn1 gene detc abnor allele,81178,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,123.3,,,,,,,fee schedule,123.3,239.75,Laboratory
Atxn1 gene detc abnor allele,81178,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,143.85,,,,,,,fee schedule,123.3,239.75,APC
Atxn1 gene detc abnor allele,81178,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,142.48,,,,,,,fee schedule,123.3,239.75,APC
Atxn1 gene detc abnor allele,81178,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,137,,,,,,,fee schedule,123.3,239.75,APC
Atxn1 gene detc abnor allele,81178,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,209.61,,,,,,,fee schedule,123.3,239.75,Radiology
Atxn1 gene detc abnor allele,81178,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,191.8,,,,,,,fee schedule,123.3,239.75,APC
Atxn1 gene detc abnor allele,81178,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,239.75,,,,,,,fee schedule,123.3,239.75,APC
Atxn2 gene detc abnor allele,81179,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,123.3,,,,,,,fee schedule,123.3,239.75,Laboratory
Atxn2 gene detc abnor allele,81179,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,143.85,,,,,,,fee schedule,123.3,239.75,APC
Atxn2 gene detc abnor allele,81179,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,142.48,,,,,,,fee schedule,123.3,239.75,APC
Atxn2 gene detc abnor allele,81179,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,137,,,,,,,fee schedule,123.3,239.75,APC
Atxn2 gene detc abnor allele,81179,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,209.61,,,,,,,fee schedule,123.3,239.75,Radiology
Atxn2 gene detc abnor allele,81179,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,191.8,,,,,,,fee schedule,123.3,239.75,APC
Atxn2 gene detc abnor allele,81179,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,239.75,,,,,,,fee schedule,123.3,239.75,APC
Atxn3 gene detc abnor allele,81180,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,123.3,,,,,,,fee schedule,123.3,239.75,Laboratory
Atxn3 gene detc abnor allele,81180,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,143.85,,,,,,,fee schedule,123.3,239.75,APC
Atxn3 gene detc abnor allele,81180,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,142.48,,,,,,,fee schedule,123.3,239.75,APC
Atxn3 gene detc abnor allele,81180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,137,,,,,,,fee schedule,123.3,239.75,APC
Atxn3 gene detc abnor allele,81180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,209.61,,,,,,,fee schedule,123.3,239.75,Radiology
Atxn3 gene detc abnor allele,81180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,191.8,,,,,,,fee schedule,123.3,239.75,APC
Atxn3 gene detc abnor allele,81180,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,239.75,,,,,,,fee schedule,123.3,239.75,APC
Atxn7 gene detc abnor allele,81181,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,123.3,,,,,,,fee schedule,123.3,239.75,Laboratory
Atxn7 gene detc abnor allele,81181,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,143.85,,,,,,,fee schedule,123.3,239.75,APC
Atxn7 gene detc abnor allele,81181,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,142.48,,,,,,,fee schedule,123.3,239.75,APC
Atxn7 gene detc abnor allele,81181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,137,,,,,,,fee schedule,123.3,239.75,APC
Atxn7 gene detc abnor allele,81181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,209.61,,,,,,,fee schedule,123.3,239.75,Radiology
Atxn7 gene detc abnor allele,81181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,191.8,,,,,,,fee schedule,123.3,239.75,APC
Atxn7 gene detc abnor allele,81181,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,239.75,,,,,,,fee schedule,123.3,239.75,APC
Atxn8os gen detc abnor allel,81182,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,123.3,,,,,,,fee schedule,123.3,239.75,Laboratory
Atxn8os gen detc abnor allel,81182,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,143.85,,,,,,,fee schedule,123.3,239.75,APC
Atxn8os gen detc abnor allel,81182,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,142.48,,,,,,,fee schedule,123.3,239.75,APC
Atxn8os gen detc abnor allel,81182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,137,,,,,,,fee schedule,123.3,239.75,APC
Atxn8os gen detc abnor allel,81182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,209.61,,,,,,,fee schedule,123.3,239.75,Radiology
Atxn8os gen detc abnor allel,81182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,191.8,,,,,,,fee schedule,123.3,239.75,APC
Atxn8os gen detc abnor allel,81182,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,239.75,,,,,,,fee schedule,123.3,239.75,APC
Atxn10 gene detc abnor allel,81183,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,123.3,,,,,,,fee schedule,123.3,239.75,Laboratory
Atxn10 gene detc abnor allel,81183,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,143.85,,,,,,,fee schedule,123.3,239.75,APC
Atxn10 gene detc abnor allel,81183,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,142.48,,,,,,,fee schedule,123.3,239.75,APC
Atxn10 gene detc abnor allel,81183,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,137,,,,,,,fee schedule,123.3,239.75,APC
Atxn10 gene detc abnor allel,81183,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,209.61,,,,,,,fee schedule,123.3,239.75,Radiology
Atxn10 gene detc abnor allel,81183,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,191.8,,,,,,,fee schedule,123.3,239.75,APC
Atxn10 gene detc abnor allel,81183,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,239.75,,,,,,,fee schedule,123.3,239.75,APC
Cacna1a gen detc abnor allel,81184,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,123.3,,,,,,,fee schedule,123.3,239.75,Laboratory
Cacna1a gen detc abnor allel,81184,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,143.85,,,,,,,fee schedule,123.3,239.75,APC
Cacna1a gen detc abnor allel,81184,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,142.48,,,,,,,fee schedule,123.3,239.75,APC
Cacna1a gen detc abnor allel,81184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,137,,,,,,,fee schedule,123.3,239.75,APC
Cacna1a gen detc abnor allel,81184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,209.61,,,,,,,fee schedule,123.3,239.75,Radiology
Cacna1a gen detc abnor allel,81184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,191.8,,,,,,,fee schedule,123.3,239.75,APC
Cacna1a gen detc abnor allel,81184,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,239.75,,,,,,,fee schedule,123.3,239.75,APC
Cacna1a gene full gene seq,81185,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,761.64,,,,,,,fee schedule,761.64,1480.97,Laboratory
Cacna1a gene full gene seq,81185,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,888.58,,,,,,,fee schedule,761.64,1480.97,APC
Cacna1a gene full gene seq,81185,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,880.12,,,,,,,fee schedule,761.64,1480.97,APC
Cacna1a gene full gene seq,81185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,846.27,,,,,,,fee schedule,761.64,1480.97,APC
Cacna1a gene full gene seq,81185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1294.79,,,,,,,fee schedule,761.64,1480.97,Radiology
Cacna1a gene full gene seq,81185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1184.78,,,,,,,fee schedule,761.64,1480.97,APC
Cacna1a gene full gene seq,81185,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1480.97,,,,,,,fee schedule,761.64,1480.97,APC
Cacna1a gen known famil vrnt,81186,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,166.68,,,,,,,fee schedule,166.68,324.1,Laboratory
Cacna1a gen known famil vrnt,81186,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,194.46,,,,,,,fee schedule,166.68,324.1,APC
Cacna1a gen known famil vrnt,81186,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,192.61,,,,,,,fee schedule,166.68,324.1,APC
Cacna1a gen known famil vrnt,81186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,185.2,,,,,,,fee schedule,166.68,324.1,APC
Cacna1a gen known famil vrnt,81186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,283.36,,,,,,,fee schedule,166.68,324.1,Radiology
Cacna1a gen known famil vrnt,81186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,259.28,,,,,,,fee schedule,166.68,324.1,APC
Cacna1a gen known famil vrnt,81186,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,324.1,,,,,,,fee schedule,166.68,324.1,APC
Cnbp gene detc abnor allele,81187,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,123.3,,,,,,,fee schedule,123.3,239.75,Laboratory
Cnbp gene detc abnor allele,81187,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,143.85,,,,,,,fee schedule,123.3,239.75,APC
Cnbp gene detc abnor allele,81187,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,142.48,,,,,,,fee schedule,123.3,239.75,APC
Cnbp gene detc abnor allele,81187,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,137,,,,,,,fee schedule,123.3,239.75,APC
Cnbp gene detc abnor allele,81187,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,209.61,,,,,,,fee schedule,123.3,239.75,Radiology
Cnbp gene detc abnor allele,81187,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,191.8,,,,,,,fee schedule,123.3,239.75,APC
Cnbp gene detc abnor allele,81187,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,239.75,,,,,,,fee schedule,123.3,239.75,APC
Cstb gene detc abnor allele,81188,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,123.3,,,,,,,fee schedule,123.3,239.75,Laboratory
Cstb gene detc abnor allele,81188,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,143.85,,,,,,,fee schedule,123.3,239.75,APC
Cstb gene detc abnor allele,81188,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,142.48,,,,,,,fee schedule,123.3,239.75,APC
Cstb gene detc abnor allele,81188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,137,,,,,,,fee schedule,123.3,239.75,APC
Cstb gene detc abnor allele,81188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,209.61,,,,,,,fee schedule,123.3,239.75,Radiology
Cstb gene detc abnor allele,81188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,191.8,,,,,,,fee schedule,123.3,239.75,APC
Cstb gene detc abnor allele,81188,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,239.75,,,,,,,fee schedule,123.3,239.75,APC
Cstb gene full gene sequence,81189,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,247.35,,,,,,,fee schedule,247.35,480.95,Laboratory
Cstb gene full gene sequence,81189,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,288.57,,,,,,,fee schedule,247.35,480.95,APC
Cstb gene full gene sequence,81189,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,285.82,,,,,,,fee schedule,247.35,480.95,APC
Cstb gene full gene sequence,81189,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,274.83,,,,,,,fee schedule,247.35,480.95,APC
Cstb gene full gene sequence,81189,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,420.49,,,,,,,fee schedule,247.35,480.95,Radiology
Cstb gene full gene sequence,81189,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,384.76,,,,,,,fee schedule,247.35,480.95,APC
Cstb gene full gene sequence,81189,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,480.95,,,,,,,fee schedule,247.35,480.95,APC
Cstb gene known famil vrnt,81190,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,166.68,,,,,,,fee schedule,166.68,324.1,Laboratory
Cstb gene known famil vrnt,81190,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,194.46,,,,,,,fee schedule,166.68,324.1,APC
Cstb gene known famil vrnt,81190,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,192.61,,,,,,,fee schedule,166.68,324.1,APC
Cstb gene known famil vrnt,81190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,185.2,,,,,,,fee schedule,166.68,324.1,APC
Cstb gene known famil vrnt,81190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,283.36,,,,,,,fee schedule,166.68,324.1,Radiology
Cstb gene known famil vrnt,81190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,259.28,,,,,,,fee schedule,166.68,324.1,APC
Cstb gene known famil vrnt,81190,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,324.1,,,,,,,fee schedule,166.68,324.1,APC
Ntrk1 translocation analysis,81191,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,186.58,,,,,,,fee schedule,186.58,362.79,Laboratory
Ntrk1 translocation analysis,81191,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,217.68,,,,,,,fee schedule,186.58,362.79,APC
Ntrk1 translocation analysis,81191,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,215.6,,,,,,,fee schedule,186.58,362.79,APC
Ntrk1 translocation analysis,81191,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,207.31,,,,,,,fee schedule,186.58,362.79,APC
Ntrk1 translocation analysis,81191,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,317.18,,,,,,,fee schedule,186.58,362.79,Radiology
Ntrk1 translocation analysis,81191,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,290.23,,,,,,,fee schedule,186.58,362.79,APC
Ntrk1 translocation analysis,81191,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,362.79,,,,,,,fee schedule,186.58,362.79,APC
Ntrk2 translocation analysis,81192,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,186.58,,,,,,,fee schedule,186.58,362.79,Laboratory
Ntrk2 translocation analysis,81192,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,217.68,,,,,,,fee schedule,186.58,362.79,APC
Ntrk2 translocation analysis,81192,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,215.6,,,,,,,fee schedule,186.58,362.79,APC
Ntrk2 translocation analysis,81192,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,207.31,,,,,,,fee schedule,186.58,362.79,APC
Ntrk2 translocation analysis,81192,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,317.18,,,,,,,fee schedule,186.58,362.79,Radiology
Ntrk2 translocation analysis,81192,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,290.23,,,,,,,fee schedule,186.58,362.79,APC
Ntrk2 translocation analysis,81192,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,362.79,,,,,,,fee schedule,186.58,362.79,APC
Ntrk3 translocation analysis,81193,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,186.58,,,,,,,fee schedule,186.58,362.79,Laboratory
Ntrk3 translocation analysis,81193,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,217.68,,,,,,,fee schedule,186.58,362.79,APC
Ntrk3 translocation analysis,81193,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,215.6,,,,,,,fee schedule,186.58,362.79,APC
Ntrk3 translocation analysis,81193,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,207.31,,,,,,,fee schedule,186.58,362.79,APC
Ntrk3 translocation analysis,81193,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,317.18,,,,,,,fee schedule,186.58,362.79,Radiology
Ntrk3 translocation analysis,81193,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,290.23,,,,,,,fee schedule,186.58,362.79,APC
Ntrk3 translocation analysis,81193,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,362.79,,,,,,,fee schedule,186.58,362.79,APC
Ntrk translocation analysis,81194,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,466.45,,,,,,,fee schedule,466.45,906.99,Laboratory
Ntrk translocation analysis,81194,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,544.19,,,,,,,fee schedule,466.45,906.99,APC
Ntrk translocation analysis,81194,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,539.01,,,,,,,fee schedule,466.45,906.99,APC
Ntrk translocation analysis,81194,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,518.28,,,,,,,fee schedule,466.45,906.99,APC
Ntrk translocation analysis,81194,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,792.97,,,,,,,fee schedule,466.45,906.99,Radiology
Ntrk translocation analysis,81194,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,725.59,,,,,,,fee schedule,466.45,906.99,APC
Ntrk translocation analysis,81194,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,906.99,,,,,,,fee schedule,466.45,906.99,APC
Cytog genom-wid alys hem mal,81195,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1676.9,,,,,,,fee schedule,1676.9,3260.64,Laboratory
Cytog genom-wid alys hem mal,81195,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1956.38,,,,,,,fee schedule,1676.9,3260.64,APC
Cytog genom-wid alys hem mal,81195,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1937.75,,,,,,,fee schedule,1676.9,3260.64,APC
Cytog genom-wid alys hem mal,81195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1863.22,,,,,,,fee schedule,1676.9,3260.64,APC
Cytog genom-wid alys hem mal,81195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2850.73,,,,,,,fee schedule,1676.9,3260.64,Radiology
Cytog genom-wid alys hem mal,81195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2608.51,,,,,,,fee schedule,1676.9,3260.64,APC
Cytog genom-wid alys hem mal,81195,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3260.64,,,,,,,fee schedule,1676.9,3260.64,APC
Aspa gene,81200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,354.94,,,,,,,fee schedule,42.52,354.94,
Aspa gene,81200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,284.52,,,,,,,fee schedule,42.52,354.94,
Aspa gene,81200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,310.81,,,,,,,fee schedule,42.52,354.94,
Aspa gene,81200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,326.77,,,,,,,fee schedule,42.52,354.94,
Aspa gene,81200,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,42.52,,,,,,,fee schedule,42.52,354.94,Laboratory
Aspa gene,81200,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,49.61,,,,,,,fee schedule,42.52,354.94,APC
Aspa gene,81200,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,49.14,,,,,,,fee schedule,42.52,354.94,APC
Aspa gene,81200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,47.25,,,,,,,fee schedule,42.52,354.94,APC
Aspa gene,81200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,72.29,,,,,,,fee schedule,42.52,354.94,Radiology
Aspa gene,81200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,66.15,,,,,,,fee schedule,42.52,354.94,APC
Aspa gene,81200,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,82.69,,,,,,,fee schedule,42.52,354.94,APC
Apc gene full sequence,81201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2834.7,,,,,,,fee schedule,702,2834.7,
Apc gene full sequence,81201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2272.26,,,,,,,fee schedule,702,2834.7,
Apc gene full sequence,81201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2482.24,,,,,,,fee schedule,702,2834.7,
Apc gene full sequence,81201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2609.72,,,,,,,fee schedule,702,2834.7,
Apc gene full sequence,81201,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,702,,,,,,,fee schedule,702,2834.7,Laboratory
Apc gene full sequence,81201,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,819,,,,,,,fee schedule,702,2834.7,APC
Apc gene full sequence,81201,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,811.2,,,,,,,fee schedule,702,2834.7,APC
Apc gene full sequence,81201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,780,,,,,,,fee schedule,702,2834.7,APC
Apc gene full sequence,81201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1193.4,,,,,,,fee schedule,702,2834.7,Radiology
Apc gene full sequence,81201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1092,,,,,,,fee schedule,702,2834.7,APC
Apc gene full sequence,81201,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1365,,,,,,,fee schedule,702,2834.7,APC
Apc gene known fam variants,81202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,355.09,,,,,,,fee schedule,252,490,
Apc gene known fam variants,81202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,284.64,,,,,,,fee schedule,252,490,
Apc gene known fam variants,81202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,310.94,,,,,,,fee schedule,252,490,
Apc gene known fam variants,81202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,326.91,,,,,,,fee schedule,252,490,
Apc gene known fam variants,81202,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252,,,,,,,fee schedule,252,490,Laboratory
Apc gene known fam variants,81202,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,294,,,,,,,fee schedule,252,490,APC
Apc gene known fam variants,81202,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,291.2,,,,,,,fee schedule,252,490,APC
Apc gene known fam variants,81202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,280,,,,,,,fee schedule,252,490,APC
Apc gene known fam variants,81202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,428.4,,,,,,,fee schedule,252,490,Radiology
Apc gene known fam variants,81202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,392,,,,,,,fee schedule,252,490,APC
Apc gene known fam variants,81202,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,490,,,,,,,fee schedule,252,490,APC
Apc gene dup/delet variants,81203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2154.79,,,,,,,fee schedule,180,2154.79,
Apc gene dup/delet variants,81203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1727.25,,,,,,,fee schedule,180,2154.79,
Apc gene dup/delet variants,81203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1886.87,,,,,,,fee schedule,180,2154.79,
Apc gene dup/delet variants,81203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1983.77,,,,,,,fee schedule,180,2154.79,
Apc gene dup/delet variants,81203,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,180,,,,,,,fee schedule,180,2154.79,Laboratory
Apc gene dup/delet variants,81203,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,210,,,,,,,fee schedule,180,2154.79,APC
Apc gene dup/delet variants,81203,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,208,,,,,,,fee schedule,180,2154.79,APC
Apc gene dup/delet variants,81203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,200,,,,,,,fee schedule,180,2154.79,APC
Apc gene dup/delet variants,81203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,306,,,,,,,fee schedule,180,2154.79,Radiology
Apc gene dup/delet variants,81203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,280,,,,,,,fee schedule,180,2154.79,APC
Apc gene dup/delet variants,81203,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,350,,,,,,,fee schedule,180,2154.79,APC
Ar gene charac alleles,81204,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,123.3,,,,,,,fee schedule,123.3,239.75,Laboratory
Ar gene charac alleles,81204,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,143.85,,,,,,,fee schedule,123.3,239.75,APC
Ar gene charac alleles,81204,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,142.48,,,,,,,fee schedule,123.3,239.75,APC
Ar gene charac alleles,81204,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,137,,,,,,,fee schedule,123.3,239.75,APC
Ar gene charac alleles,81204,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,209.61,,,,,,,fee schedule,123.3,239.75,Radiology
Ar gene charac alleles,81204,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,191.8,,,,,,,fee schedule,123.3,239.75,APC
Ar gene charac alleles,81204,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,239.75,,,,,,,fee schedule,123.3,239.75,APC
Bckdhb gene,81205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,466.3,,,,,,,fee schedule,85.49,466.3,
Bckdhb gene,81205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,373.78,,,,,,,fee schedule,85.49,466.3,
Bckdhb gene,81205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,408.32,,,,,,,fee schedule,85.49,466.3,
Bckdhb gene,81205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,429.29,,,,,,,fee schedule,85.49,466.3,
Bckdhb gene,81205,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,85.49,,,,,,,fee schedule,85.49,466.3,Laboratory
Bckdhb gene,81205,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,99.74,,,,,,,fee schedule,85.49,466.3,APC
Bckdhb gene,81205,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,98.79,,,,,,,fee schedule,85.49,466.3,APC
Bckdhb gene,81205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,94.99,,,,,,,fee schedule,85.49,466.3,APC
Bckdhb gene,81205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,145.33,,,,,,,fee schedule,85.49,466.3,Radiology
Bckdhb gene,81205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,132.99,,,,,,,fee schedule,85.49,466.3,APC
Bckdhb gene,81205,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,166.23,,,,,,,fee schedule,85.49,466.3,APC
Bcr/abl1 gene major bp,81206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,658.21,,,,,,,fee schedule,147.56,658.21,
Bcr/abl1 gene major bp,81206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,527.61,,,,,,,fee schedule,147.56,658.21,
Bcr/abl1 gene major bp,81206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,576.37,,,,,,,fee schedule,147.56,658.21,
Bcr/abl1 gene major bp,81206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,605.97,,,,,,,fee schedule,147.56,658.21,
Bcr/abl1 gene major bp,81206,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,147.56,,,,,,,fee schedule,147.56,658.21,Laboratory
Bcr/abl1 gene major bp,81206,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,172.16,,,,,,,fee schedule,147.56,658.21,APC
Bcr/abl1 gene major bp,81206,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,170.52,,,,,,,fee schedule,147.56,658.21,APC
Bcr/abl1 gene major bp,81206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,163.96,,,,,,,fee schedule,147.56,658.21,APC
Bcr/abl1 gene major bp,81206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,250.86,,,,,,,fee schedule,147.56,658.21,Radiology
Bcr/abl1 gene major bp,81206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,229.54,,,,,,,fee schedule,147.56,658.21,APC
Bcr/abl1 gene major bp,81206,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,286.93,,,,,,,fee schedule,147.56,658.21,APC
Bcr/abl1 gene minor bp,81207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,539.74,,,,,,,fee schedule,130.36,539.74,
Bcr/abl1 gene minor bp,81207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,432.65,,,,,,,fee schedule,130.36,539.74,
Bcr/abl1 gene minor bp,81207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,472.63,,,,,,,fee schedule,130.36,539.74,
Bcr/abl1 gene minor bp,81207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,496.91,,,,,,,fee schedule,130.36,539.74,
Bcr/abl1 gene minor bp,81207,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,130.36,,,,,,,fee schedule,130.36,539.74,Laboratory
Bcr/abl1 gene minor bp,81207,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,152.08,,,,,,,fee schedule,130.36,539.74,APC
Bcr/abl1 gene minor bp,81207,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,150.63,,,,,,,fee schedule,130.36,539.74,APC
Bcr/abl1 gene minor bp,81207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,144.84,,,,,,,fee schedule,130.36,539.74,APC
Bcr/abl1 gene minor bp,81207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,221.61,,,,,,,fee schedule,130.36,539.74,Radiology
Bcr/abl1 gene minor bp,81207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,202.78,,,,,,,fee schedule,130.36,539.74,APC
Bcr/abl1 gene minor bp,81207,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,253.47,,,,,,,fee schedule,130.36,539.74,APC
Bcr/abl1 gene other bp,81208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,567.64,,,,,,,fee schedule,193.16,567.64,
Bcr/abl1 gene other bp,81208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,455.02,,,,,,,fee schedule,193.16,567.64,
Bcr/abl1 gene other bp,81208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,497.06,,,,,,,fee schedule,193.16,567.64,
Bcr/abl1 gene other bp,81208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,522.59,,,,,,,fee schedule,193.16,567.64,
Bcr/abl1 gene other bp,81208,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,193.16,,,,,,,fee schedule,193.16,567.64,Laboratory
Bcr/abl1 gene other bp,81208,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.35,,,,,,,fee schedule,193.16,567.64,APC
Bcr/abl1 gene other bp,81208,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,223.2,,,,,,,fee schedule,193.16,567.64,APC
Bcr/abl1 gene other bp,81208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,214.62,,,,,,,fee schedule,193.16,567.64,APC
Bcr/abl1 gene other bp,81208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,328.37,,,,,,,fee schedule,193.16,567.64,Radiology
Bcr/abl1 gene other bp,81208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,300.47,,,,,,,fee schedule,193.16,567.64,APC
Bcr/abl1 gene other bp,81208,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,375.58,,,,,,,fee schedule,193.16,567.64,APC
Blm gene,81209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,354.94,,,,,,,fee schedule,35.38,354.94,
Blm gene,81209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,284.52,,,,,,,fee schedule,35.38,354.94,
Blm gene,81209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,310.81,,,,,,,fee schedule,35.38,354.94,
Blm gene,81209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,326.77,,,,,,,fee schedule,35.38,354.94,
Blm gene,81209,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,35.38,,,,,,,fee schedule,35.38,354.94,Laboratory
Blm gene,81209,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,41.28,,,,,,,fee schedule,35.38,354.94,APC
Blm gene,81209,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,40.88,,,,,,,fee schedule,35.38,354.94,APC
Blm gene,81209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,39.31,,,,,,,fee schedule,35.38,354.94,APC
Blm gene,81209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,60.14,,,,,,,fee schedule,35.38,354.94,Radiology
Blm gene,81209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,55.03,,,,,,,fee schedule,35.38,354.94,APC
Blm gene,81209,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,68.79,,,,,,,fee schedule,35.38,354.94,APC
Braf gene,81210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,265.06,,,,,,,fee schedule,157.86,306.95,
Braf gene,81210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,212.47,,,,,,,fee schedule,157.86,306.95,
Braf gene,81210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,232.1,,,,,,,fee schedule,157.86,306.95,
Braf gene,81210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,244.02,,,,,,,fee schedule,157.86,306.95,
Braf gene,81210,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,157.86,,,,,,,fee schedule,157.86,306.95,Laboratory
Braf gene,81210,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,184.17,,,,,,,fee schedule,157.86,306.95,APC
Braf gene,81210,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,182.42,,,,,,,fee schedule,157.86,306.95,APC
Braf gene,81210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,175.4,,,,,,,fee schedule,157.86,306.95,APC
Braf gene,81210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,268.36,,,,,,,fee schedule,157.86,306.95,Radiology
Braf gene,81210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,245.56,,,,,,,fee schedule,157.86,306.95,APC
Braf gene,81210,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,306.95,,,,,,,fee schedule,157.86,306.95,APC
Brca1&2 185&5385&6174 var,81212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,672.99,,,,,,,fee schedule,396,770,
Brca1&2 185&5385&6174 var,81212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,539.46,,,,,,,fee schedule,396,770,
Brca1&2 185&5385&6174 var,81212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,589.31,,,,,,,fee schedule,396,770,
Brca1&2 185&5385&6174 var,81212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,619.58,,,,,,,fee schedule,396,770,
Brca1&2 185&5385&6174 var,81212,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,396,,,,,,,fee schedule,396,770,Laboratory
Brca1&2 185&5385&6174 var,81212,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,462,,,,,,,fee schedule,396,770,APC
Brca1&2 185&5385&6174 var,81212,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,457.6,,,,,,,fee schedule,396,770,APC
Brca1&2 185&5385&6174 var,81212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,440,,,,,,,fee schedule,396,770,APC
Brca1&2 185&5385&6174 var,81212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,673.2,,,,,,,fee schedule,396,770,Radiology
Brca1&2 185&5385&6174 var,81212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,616,,,,,,,fee schedule,396,770,APC
Brca1&2 185&5385&6174 var,81212,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,770,,,,,,,fee schedule,396,770,APC
Brca1 gene known fam variant,81215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,355.09,,,,,,,fee schedule,284.64,656.69,
Brca1 gene known fam variant,81215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,284.64,,,,,,,fee schedule,284.64,656.69,
Brca1 gene known fam variant,81215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,310.94,,,,,,,fee schedule,284.64,656.69,
Brca1 gene known fam variant,81215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,326.91,,,,,,,fee schedule,284.64,656.69,
Brca1 gene known fam variant,81215,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,337.72,,,,,,,fee schedule,284.64,656.69,Laboratory
Brca1 gene known fam variant,81215,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,394.01,,,,,,,fee schedule,284.64,656.69,APC
Brca1 gene known fam variant,81215,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,390.26,,,,,,,fee schedule,284.64,656.69,APC
Brca1 gene known fam variant,81215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,375.25,,,,,,,fee schedule,284.64,656.69,APC
Brca1 gene known fam variant,81215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,574.13,,,,,,,fee schedule,284.64,656.69,Radiology
Brca1 gene known fam variant,81215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,525.35,,,,,,,fee schedule,284.64,656.69,APC
Brca1 gene known fam variant,81215,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,656.69,,,,,,,fee schedule,284.64,656.69,APC
Brca2 gene full sequence,81216,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6603.81,,,,,,,fee schedule,166.61,6603.81,
Brca2 gene full sequence,81216,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5293.53,,,,,,,fee schedule,166.61,6603.81,
Brca2 gene full sequence,81216,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5782.7,,,,,,,fee schedule,166.61,6603.81,
Brca2 gene full sequence,81216,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6079.7,,,,,,,fee schedule,166.61,6603.81,
Brca2 gene full sequence,81216,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,166.61,,,,,,,fee schedule,166.61,6603.81,Laboratory
Brca2 gene full sequence,81216,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,194.38,,,,,,,fee schedule,166.61,6603.81,APC
Brca2 gene full sequence,81216,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,192.52,,,,,,,fee schedule,166.61,6603.81,APC
Brca2 gene full sequence,81216,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,185.12,,,,,,,fee schedule,166.61,6603.81,APC
Brca2 gene full sequence,81216,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,283.23,,,,,,,fee schedule,166.61,6603.81,Radiology
Brca2 gene full sequence,81216,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,259.17,,,,,,,fee schedule,166.61,6603.81,APC
Brca2 gene full sequence,81216,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,323.96,,,,,,,fee schedule,166.61,6603.81,APC
Brca2 gene known fam variant,81217,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,355.09,,,,,,,fee schedule,284.64,656.69,
Brca2 gene known fam variant,81217,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,284.64,,,,,,,fee schedule,284.64,656.69,
Brca2 gene known fam variant,81217,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,310.94,,,,,,,fee schedule,284.64,656.69,
Brca2 gene known fam variant,81217,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,326.91,,,,,,,fee schedule,284.64,656.69,
Brca2 gene known fam variant,81217,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,337.72,,,,,,,fee schedule,284.64,656.69,Laboratory
Brca2 gene known fam variant,81217,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,394.01,,,,,,,fee schedule,284.64,656.69,APC
Brca2 gene known fam variant,81217,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,390.26,,,,,,,fee schedule,284.64,656.69,APC
Brca2 gene known fam variant,81217,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,375.25,,,,,,,fee schedule,284.64,656.69,APC
Brca2 gene known fam variant,81217,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,574.13,,,,,,,fee schedule,284.64,656.69,Radiology
Brca2 gene known fam variant,81217,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,525.35,,,,,,,fee schedule,284.64,656.69,APC
Brca2 gene known fam variant,81217,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,656.69,,,,,,,fee schedule,284.64,656.69,APC
Cebpa gene full sequence,81218,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,921.72,,,,,,,fee schedule,217.71,921.72,
Cebpa gene full sequence,81218,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,738.84,,,,,,,fee schedule,217.71,921.72,
Cebpa gene full sequence,81218,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,807.11,,,,,,,fee schedule,217.71,921.72,
Cebpa gene full sequence,81218,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,848.56,,,,,,,fee schedule,217.71,921.72,
Cebpa gene full sequence,81218,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,217.71,,,,,,,fee schedule,217.71,921.72,Laboratory
Cebpa gene full sequence,81218,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,254,,,,,,,fee schedule,217.71,921.72,APC
Cebpa gene full sequence,81218,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,251.58,,,,,,,fee schedule,217.71,921.72,APC
Cebpa gene full sequence,81218,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,241.9,,,,,,,fee schedule,217.71,921.72,APC
Cebpa gene full sequence,81218,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,370.11,,,,,,,fee schedule,217.71,921.72,Radiology
Cebpa gene full sequence,81218,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,338.66,,,,,,,fee schedule,217.71,921.72,APC
Cebpa gene full sequence,81218,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,423.32,,,,,,,fee schedule,217.71,921.72,APC
Calr gene com variants,81219,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,463.43,,,,,,,fee schedule,109.47,463.43,
Calr gene com variants,81219,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,371.48,,,,,,,fee schedule,109.47,463.43,
Calr gene com variants,81219,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,405.81,,,,,,,fee schedule,109.47,463.43,
Calr gene com variants,81219,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,426.65,,,,,,,fee schedule,109.47,463.43,
Calr gene com variants,81219,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,109.47,,,,,,,fee schedule,109.47,463.43,Laboratory
Calr gene com variants,81219,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,127.71,,,,,,,fee schedule,109.47,463.43,APC
Calr gene com variants,81219,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,126.5,,,,,,,fee schedule,109.47,463.43,APC
Calr gene com variants,81219,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,121.63,,,,,,,fee schedule,109.47,463.43,APC
Calr gene com variants,81219,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,186.09,,,,,,,fee schedule,109.47,463.43,Radiology
Calr gene com variants,81219,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,170.28,,,,,,,fee schedule,109.47,463.43,APC
Calr gene com variants,81219,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,212.85,,,,,,,fee schedule,109.47,463.43,APC
Cftr gene com variants,81220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5078.69,,,,,,,fee schedule,500.94,5078.69,
Cftr gene com variants,81220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4071.02,,,,,,,fee schedule,500.94,5078.69,
Cftr gene com variants,81220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4447.22,,,,,,,fee schedule,500.94,5078.69,
Cftr gene com variants,81220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4675.62,,,,,,,fee schedule,500.94,5078.69,
Cftr gene com variants,81220,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,500.94,,,,,,,fee schedule,500.94,5078.69,Laboratory
Cftr gene com variants,81220,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,584.43,,,,,,,fee schedule,500.94,5078.69,APC
Cftr gene com variants,81220,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,578.86,,,,,,,fee schedule,500.94,5078.69,APC
Cftr gene com variants,81220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,556.6,,,,,,,fee schedule,500.94,5078.69,APC
Cftr gene com variants,81220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,851.6,,,,,,,fee schedule,500.94,5078.69,Radiology
Cftr gene com variants,81220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,779.24,,,,,,,fee schedule,500.94,5078.69,APC
Cftr gene com variants,81220,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,974.05,,,,,,,fee schedule,500.94,5078.69,APC
Cftr gene known fam variants,81221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,355.09,,,,,,,fee schedule,87.5,355.09,
Cftr gene known fam variants,81221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,284.64,,,,,,,fee schedule,87.5,355.09,
Cftr gene known fam variants,81221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,310.94,,,,,,,fee schedule,87.5,355.09,
Cftr gene known fam variants,81221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,326.91,,,,,,,fee schedule,87.5,355.09,
Cftr gene known fam variants,81221,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,87.5,,,,,,,fee schedule,87.5,355.09,Laboratory
Cftr gene known fam variants,81221,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,102.08,,,,,,,fee schedule,87.5,355.09,APC
Cftr gene known fam variants,81221,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,101.11,,,,,,,fee schedule,87.5,355.09,APC
Cftr gene known fam variants,81221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,97.22,,,,,,,fee schedule,87.5,355.09,APC
Cftr gene known fam variants,81221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,148.75,,,,,,,fee schedule,87.5,355.09,Radiology
Cftr gene known fam variants,81221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,136.11,,,,,,,fee schedule,87.5,355.09,APC
Cftr gene known fam variants,81221,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,170.14,,,,,,,fee schedule,87.5,355.09,APC
Cftr gene dup/delet variants,81222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1738.99,,,,,,,fee schedule,391.56,1738.99,
Cftr gene dup/delet variants,81222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1393.95,,,,,,,fee schedule,391.56,1738.99,
Cftr gene dup/delet variants,81222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1522.77,,,,,,,fee schedule,391.56,1738.99,
Cftr gene dup/delet variants,81222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1600.97,,,,,,,fee schedule,391.56,1738.99,
Cftr gene dup/delet variants,81222,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,391.56,,,,,,,fee schedule,391.56,1738.99,Laboratory
Cftr gene dup/delet variants,81222,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,456.82,,,,,,,fee schedule,391.56,1738.99,APC
Cftr gene dup/delet variants,81222,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,452.47,,,,,,,fee schedule,391.56,1738.99,APC
Cftr gene dup/delet variants,81222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,435.07,,,,,,,fee schedule,391.56,1738.99,APC
Cftr gene dup/delet variants,81222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,665.66,,,,,,,fee schedule,391.56,1738.99,Radiology
Cftr gene dup/delet variants,81222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,609.1,,,,,,,fee schedule,391.56,1738.99,APC
Cftr gene dup/delet variants,81222,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,761.37,,,,,,,fee schedule,391.56,1738.99,APC
Cftr gene full sequence,81223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5875.86,,,,,,,fee schedule,449.1,5875.86,
Cftr gene full sequence,81223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4710.01,,,,,,,fee schedule,449.1,5875.86,
Cftr gene full sequence,81223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5145.26,,,,,,,fee schedule,449.1,5875.86,
Cftr gene full sequence,81223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5409.52,,,,,,,fee schedule,449.1,5875.86,
Cftr gene full sequence,81223,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,449.1,,,,,,,fee schedule,449.1,5875.86,Laboratory
Cftr gene full sequence,81223,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,523.95,,,,,,,fee schedule,449.1,5875.86,APC
Cftr gene full sequence,81223,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,518.96,,,,,,,fee schedule,449.1,5875.86,APC
Cftr gene full sequence,81223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,499,,,,,,,fee schedule,449.1,5875.86,APC
Cftr gene full sequence,81223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,763.47,,,,,,,fee schedule,449.1,5875.86,Radiology
Cftr gene full sequence,81223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,698.6,,,,,,,fee schedule,449.1,5875.86,APC
Cftr gene full sequence,81223,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,873.25,,,,,,,fee schedule,449.1,5875.86,APC
Cftr gene intron poly t,81224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,312.15,,,,,,,fee schedule,151.88,312.15,
Cftr gene intron poly t,81224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,250.22,,,,,,,fee schedule,151.88,312.15,
Cftr gene intron poly t,81224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,273.34,,,,,,,fee schedule,151.88,312.15,
Cftr gene intron poly t,81224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,287.38,,,,,,,fee schedule,151.88,312.15,
Cftr gene intron poly t,81224,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,151.88,,,,,,,fee schedule,151.88,312.15,Laboratory
Cftr gene intron poly t,81224,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,177.19,,,,,,,fee schedule,151.88,312.15,APC
Cftr gene intron poly t,81224,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,175.5,,,,,,,fee schedule,151.88,312.15,APC
Cftr gene intron poly t,81224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,168.75,,,,,,,fee schedule,151.88,312.15,APC
Cftr gene intron poly t,81224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,258.19,,,,,,,fee schedule,151.88,312.15,Radiology
Cftr gene intron poly t,81224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,236.25,,,,,,,fee schedule,151.88,312.15,APC
Cftr gene intron poly t,81224,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,295.31,,,,,,,fee schedule,151.88,312.15,APC
Cyp2c19 gene com variants,81225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,511.28,,,,,,,fee schedule,262.22,511.28,
Cyp2c19 gene com variants,81225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,409.84,,,,,,,fee schedule,262.22,511.28,
Cyp2c19 gene com variants,81225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,447.71,,,,,,,fee schedule,262.22,511.28,
Cyp2c19 gene com variants,81225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,470.7,,,,,,,fee schedule,262.22,511.28,
Cyp2c19 gene com variants,81225,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,262.22,,,,,,,fee schedule,262.22,511.28,Laboratory
Cyp2c19 gene com variants,81225,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,305.93,,,,,,,fee schedule,262.22,511.28,APC
Cyp2c19 gene com variants,81225,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,303.01,,,,,,,fee schedule,262.22,511.28,APC
Cyp2c19 gene com variants,81225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,291.36,,,,,,,fee schedule,262.22,511.28,APC
Cyp2c19 gene com variants,81225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,445.78,,,,,,,fee schedule,262.22,511.28,Radiology
Cyp2c19 gene com variants,81225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,407.9,,,,,,,fee schedule,262.22,511.28,APC
Cyp2c19 gene com variants,81225,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,509.88,,,,,,,fee schedule,262.22,511.28,APC
Cyp2d6 gene com variants,81226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,557.55,,,,,,,fee schedule,405.82,789.09,
Cyp2d6 gene com variants,81226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,446.93,,,,,,,fee schedule,405.82,789.09,
Cyp2d6 gene com variants,81226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,488.23,,,,,,,fee schedule,405.82,789.09,
Cyp2d6 gene com variants,81226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,513.3,,,,,,,fee schedule,405.82,789.09,
Cyp2d6 gene com variants,81226,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,405.82,,,,,,,fee schedule,405.82,789.09,Laboratory
Cyp2d6 gene com variants,81226,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,473.46,,,,,,,fee schedule,405.82,789.09,APC
Cyp2d6 gene com variants,81226,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,468.95,,,,,,,fee schedule,405.82,789.09,APC
Cyp2d6 gene com variants,81226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,450.91,,,,,,,fee schedule,405.82,789.09,APC
Cyp2d6 gene com variants,81226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,689.89,,,,,,,fee schedule,405.82,789.09,Radiology
Cyp2d6 gene com variants,81226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,631.27,,,,,,,fee schedule,405.82,789.09,APC
Cyp2d6 gene com variants,81226,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,789.09,,,,,,,fee schedule,405.82,789.09,APC
Cyp2c9 gene com variants,81227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,365.83,,,,,,,fee schedule,157.33,365.83,
Cyp2c9 gene com variants,81227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,293.24,,,,,,,fee schedule,157.33,365.83,
Cyp2c9 gene com variants,81227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,320.34,,,,,,,fee schedule,157.33,365.83,
Cyp2c9 gene com variants,81227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,336.79,,,,,,,fee schedule,157.33,365.83,
Cyp2c9 gene com variants,81227,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,157.33,,,,,,,fee schedule,157.33,365.83,Laboratory
Cyp2c9 gene com variants,81227,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.55,,,,,,,fee schedule,157.33,365.83,APC
Cyp2c9 gene com variants,81227,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,181.8,,,,,,,fee schedule,157.33,365.83,APC
Cyp2c9 gene com variants,81227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,174.81,,,,,,,fee schedule,157.33,365.83,APC
Cyp2c9 gene com variants,81227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,267.46,,,,,,,fee schedule,157.33,365.83,Radiology
Cyp2c9 gene com variants,81227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,244.73,,,,,,,fee schedule,157.33,365.83,APC
Cyp2c9 gene com variants,81227,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,305.92,,,,,,,fee schedule,157.33,365.83,APC
Cytogen micrarray copy nmbr,81228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2442.41,,,,,,,fee schedule,810,2442.41,
Cytogen micrarray copy nmbr,81228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1957.8,,,,,,,fee schedule,810,2442.41,
Cytogen micrarray copy nmbr,81228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2138.72,,,,,,,fee schedule,810,2442.41,
Cytogen micrarray copy nmbr,81228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2248.57,,,,,,,fee schedule,810,2442.41,
Cytogen micrarray copy nmbr,81228,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,810,,,,,,,fee schedule,810,2442.41,Laboratory
Cytogen micrarray copy nmbr,81228,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,945,,,,,,,fee schedule,810,2442.41,APC
Cytogen micrarray copy nmbr,81228,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,936,,,,,,,fee schedule,810,2442.41,APC
Cytogen micrarray copy nmbr,81228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,900,,,,,,,fee schedule,810,2442.41,APC
Cytogen micrarray copy nmbr,81228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1377,,,,,,,fee schedule,810,2442.41,Radiology
Cytogen micrarray copy nmbr,81228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1260,,,,,,,fee schedule,810,2442.41,APC
Cytogen micrarray copy nmbr,81228,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1575,,,,,,,fee schedule,810,2442.41,APC
Cytogen m array copy no&snp,81229,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2553.62,,,,,,,fee schedule,1044,2553.62,
Cytogen m array copy no&snp,81229,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2046.95,,,,,,,fee schedule,1044,2553.62,
Cytogen m array copy no&snp,81229,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2236.1,,,,,,,fee schedule,1044,2553.62,
Cytogen m array copy no&snp,81229,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2350.95,,,,,,,fee schedule,1044,2553.62,
Cytogen m array copy no&snp,81229,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1044,,,,,,,fee schedule,1044,2553.62,Laboratory
Cytogen m array copy no&snp,81229,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1218,,,,,,,fee schedule,1044,2553.62,APC
Cytogen m array copy no&snp,81229,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1206.4,,,,,,,fee schedule,1044,2553.62,APC
Cytogen m array copy no&snp,81229,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1160,,,,,,,fee schedule,1044,2553.62,APC
Cytogen m array copy no&snp,81229,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1774.8,,,,,,,fee schedule,1044,2553.62,Radiology
Cytogen m array copy no&snp,81229,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1624,,,,,,,fee schedule,1044,2553.62,APC
Cytogen m array copy no&snp,81229,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2030,,,,,,,fee schedule,1044,2553.62,APC
Cyp3a4 gene common variants,81230,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,157.33,,,,,,,fee schedule,157.33,305.92,Laboratory
Cyp3a4 gene common variants,81230,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.55,,,,,,,fee schedule,157.33,305.92,APC
Cyp3a4 gene common variants,81230,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,181.8,,,,,,,fee schedule,157.33,305.92,APC
Cyp3a4 gene common variants,81230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,174.81,,,,,,,fee schedule,157.33,305.92,APC
Cyp3a4 gene common variants,81230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,267.46,,,,,,,fee schedule,157.33,305.92,Radiology
Cyp3a4 gene common variants,81230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,244.73,,,,,,,fee schedule,157.33,305.92,APC
Cyp3a4 gene common variants,81230,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,305.92,,,,,,,fee schedule,157.33,305.92,APC
Cyp3a5 gene common variants,81231,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,157.33,,,,,,,fee schedule,157.33,305.92,Laboratory
Cyp3a5 gene common variants,81231,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.55,,,,,,,fee schedule,157.33,305.92,APC
Cyp3a5 gene common variants,81231,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,181.8,,,,,,,fee schedule,157.33,305.92,APC
Cyp3a5 gene common variants,81231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,174.81,,,,,,,fee schedule,157.33,305.92,APC
Cyp3a5 gene common variants,81231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,267.46,,,,,,,fee schedule,157.33,305.92,Radiology
Cyp3a5 gene common variants,81231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,244.73,,,,,,,fee schedule,157.33,305.92,APC
Cyp3a5 gene common variants,81231,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,305.92,,,,,,,fee schedule,157.33,305.92,APC
Dpyd gene common variants,81232,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,157.33,,,,,,,fee schedule,157.33,305.92,Laboratory
Dpyd gene common variants,81232,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.55,,,,,,,fee schedule,157.33,305.92,APC
Dpyd gene common variants,81232,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,181.8,,,,,,,fee schedule,157.33,305.92,APC
Dpyd gene common variants,81232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,174.81,,,,,,,fee schedule,157.33,305.92,APC
Dpyd gene common variants,81232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,267.46,,,,,,,fee schedule,157.33,305.92,Radiology
Dpyd gene common variants,81232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,244.73,,,,,,,fee schedule,157.33,305.92,APC
Dpyd gene common variants,81232,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,305.92,,,,,,,fee schedule,157.33,305.92,APC
Btk gene common variants,81233,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,157.86,,,,,,,fee schedule,157.86,306.95,Laboratory
Btk gene common variants,81233,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,184.17,,,,,,,fee schedule,157.86,306.95,APC
Btk gene common variants,81233,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,182.42,,,,,,,fee schedule,157.86,306.95,APC
Btk gene common variants,81233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,175.4,,,,,,,fee schedule,157.86,306.95,APC
Btk gene common variants,81233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,268.36,,,,,,,fee schedule,157.86,306.95,Radiology
Btk gene common variants,81233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,245.56,,,,,,,fee schedule,157.86,306.95,APC
Btk gene common variants,81233,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,306.95,,,,,,,fee schedule,157.86,306.95,APC
Dmpk gene detc abnor allele,81234,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,123.3,,,,,,,fee schedule,123.3,239.75,Laboratory
Dmpk gene detc abnor allele,81234,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,143.85,,,,,,,fee schedule,123.3,239.75,APC
Dmpk gene detc abnor allele,81234,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,142.48,,,,,,,fee schedule,123.3,239.75,APC
Dmpk gene detc abnor allele,81234,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,137,,,,,,,fee schedule,123.3,239.75,APC
Dmpk gene detc abnor allele,81234,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,209.61,,,,,,,fee schedule,123.3,239.75,Radiology
Dmpk gene detc abnor allele,81234,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,191.8,,,,,,,fee schedule,123.3,239.75,APC
Dmpk gene detc abnor allele,81234,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,239.75,,,,,,,fee schedule,123.3,239.75,APC
Egfr gene com variants,81235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,918.82,,,,,,,fee schedule,292.12,918.82,
Egfr gene com variants,81235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,736.52,,,,,,,fee schedule,292.12,918.82,
Egfr gene com variants,81235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,804.58,,,,,,,fee schedule,292.12,918.82,
Egfr gene com variants,81235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,845.9,,,,,,,fee schedule,292.12,918.82,
Egfr gene com variants,81235,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,292.12,,,,,,,fee schedule,292.12,918.82,Laboratory
Egfr gene com variants,81235,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,340.81,,,,,,,fee schedule,292.12,918.82,APC
Egfr gene com variants,81235,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,337.56,,,,,,,fee schedule,292.12,918.82,APC
Egfr gene com variants,81235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,324.58,,,,,,,fee schedule,292.12,918.82,APC
Egfr gene com variants,81235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,496.61,,,,,,,fee schedule,292.12,918.82,Radiology
Egfr gene com variants,81235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,454.41,,,,,,,fee schedule,292.12,918.82,APC
Egfr gene com variants,81235,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,568.02,,,,,,,fee schedule,292.12,918.82,APC
Ezh2 gene full gene sequence,81236,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,254.59,,,,,,,fee schedule,254.59,495.04,Laboratory
Ezh2 gene full gene sequence,81236,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,297.02,,,,,,,fee schedule,254.59,495.04,APC
Ezh2 gene full gene sequence,81236,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,294.2,,,,,,,fee schedule,254.59,495.04,APC
Ezh2 gene full gene sequence,81236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,282.88,,,,,,,fee schedule,254.59,495.04,APC
Ezh2 gene full gene sequence,81236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,432.81,,,,,,,fee schedule,254.59,495.04,Radiology
Ezh2 gene full gene sequence,81236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,396.03,,,,,,,fee schedule,254.59,495.04,APC
Ezh2 gene full gene sequence,81236,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,495.04,,,,,,,fee schedule,254.59,495.04,APC
Ezh2 gene common variants,81237,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,157.86,,,,,,,fee schedule,157.86,306.95,Laboratory
Ezh2 gene common variants,81237,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,184.17,,,,,,,fee schedule,157.86,306.95,APC
Ezh2 gene common variants,81237,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,182.42,,,,,,,fee schedule,157.86,306.95,APC
Ezh2 gene common variants,81237,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,175.4,,,,,,,fee schedule,157.86,306.95,APC
Ezh2 gene common variants,81237,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,268.36,,,,,,,fee schedule,157.86,306.95,Radiology
Ezh2 gene common variants,81237,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,245.56,,,,,,,fee schedule,157.86,306.95,APC
Ezh2 gene common variants,81237,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,306.95,,,,,,,fee schedule,157.86,306.95,APC
F9 full gene sequence,81238,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,540,,,,,,,fee schedule,540,1050,Laboratory
F9 full gene sequence,81238,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,630,,,,,,,fee schedule,540,1050,APC
F9 full gene sequence,81238,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,624,,,,,,,fee schedule,540,1050,APC
F9 full gene sequence,81238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,600,,,,,,,fee schedule,540,1050,APC
F9 full gene sequence,81238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,918,,,,,,,fee schedule,540,1050,Radiology
F9 full gene sequence,81238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,840,,,,,,,fee schedule,540,1050,APC
F9 full gene sequence,81238,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1050,,,,,,,fee schedule,540,1050,APC
Dmpk gene charac alleles,81239,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,247.35,,,,,,,fee schedule,247.35,480.95,Laboratory
Dmpk gene charac alleles,81239,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,288.57,,,,,,,fee schedule,247.35,480.95,APC
Dmpk gene charac alleles,81239,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,285.82,,,,,,,fee schedule,247.35,480.95,APC
Dmpk gene charac alleles,81239,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,274.83,,,,,,,fee schedule,247.35,480.95,APC
Dmpk gene charac alleles,81239,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,420.49,,,,,,,fee schedule,247.35,480.95,Radiology
Dmpk gene charac alleles,81239,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,384.76,,,,,,,fee schedule,247.35,480.95,APC
Dmpk gene charac alleles,81239,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,480.95,,,,,,,fee schedule,247.35,480.95,APC
F2 gene,81240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,554.47,,,,,,,fee schedule,59.12,554.47,
F2 gene,81240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,444.46,,,,,,,fee schedule,59.12,554.47,
F2 gene,81240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,485.53,,,,,,,fee schedule,59.12,554.47,
F2 gene,81240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,510.46,,,,,,,fee schedule,59.12,554.47,
F2 gene,81240,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,59.12,,,,,,,fee schedule,59.12,554.47,Laboratory
F2 gene,81240,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,68.97,,,,,,,fee schedule,59.12,554.47,APC
F2 gene,81240,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,68.32,,,,,,,fee schedule,59.12,554.47,APC
F2 gene,81240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,65.69,,,,,,,fee schedule,59.12,554.47,APC
F2 gene,81240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,100.51,,,,,,,fee schedule,59.12,554.47,Radiology
F2 gene,81240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,91.97,,,,,,,fee schedule,59.12,554.47,APC
F2 gene,81240,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,114.96,,,,,,,fee schedule,59.12,554.47,APC
F5 gene,81241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,558.85,,,,,,,fee schedule,66.03,558.85,
F5 gene,81241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,447.96,,,,,,,fee schedule,66.03,558.85,
F5 gene,81241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,489.36,,,,,,,fee schedule,66.03,558.85,
F5 gene,81241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,514.49,,,,,,,fee schedule,66.03,558.85,
F5 gene,81241,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,66.03,,,,,,,fee schedule,66.03,558.85,Laboratory
F5 gene,81241,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,77.04,,,,,,,fee schedule,66.03,558.85,APC
F5 gene,81241,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,76.3,,,,,,,fee schedule,66.03,558.85,APC
F5 gene,81241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,73.37,,,,,,,fee schedule,66.03,558.85,APC
F5 gene,81241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,112.26,,,,,,,fee schedule,66.03,558.85,Radiology
F5 gene,81241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,102.72,,,,,,,fee schedule,66.03,558.85,APC
F5 gene,81241,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,128.4,,,,,,,fee schedule,66.03,558.85,APC
Fancc gene,81242,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,354.94,,,,,,,fee schedule,32.96,354.94,
Fancc gene,81242,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,284.52,,,,,,,fee schedule,32.96,354.94,
Fancc gene,81242,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,310.81,,,,,,,fee schedule,32.96,354.94,
Fancc gene,81242,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,326.77,,,,,,,fee schedule,32.96,354.94,
Fancc gene,81242,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,32.96,,,,,,,fee schedule,32.96,354.94,Laboratory
Fancc gene,81242,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.45,,,,,,,fee schedule,32.96,354.94,APC
Fancc gene,81242,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.08,,,,,,,fee schedule,32.96,354.94,APC
Fancc gene,81242,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.62,,,,,,,fee schedule,32.96,354.94,APC
Fancc gene,81242,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.03,,,,,,,fee schedule,32.96,354.94,Radiology
Fancc gene,81242,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.27,,,,,,,fee schedule,32.96,354.94,APC
Fancc gene,81242,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.08,,,,,,,fee schedule,32.96,354.94,APC
Fmr1 gene detection,81243,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,228.73,,,,,,,fee schedule,51.34,228.73,
Fmr1 gene detection,81243,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,183.35,,,,,,,fee schedule,51.34,228.73,
Fmr1 gene detection,81243,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,200.29,,,,,,,fee schedule,51.34,228.73,
Fmr1 gene detection,81243,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,210.57,,,,,,,fee schedule,51.34,228.73,
Fmr1 gene detection,81243,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,51.34,,,,,,,fee schedule,51.34,228.73,Laboratory
Fmr1 gene detection,81243,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,59.89,,,,,,,fee schedule,51.34,228.73,APC
Fmr1 gene detection,81243,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,59.32,,,,,,,fee schedule,51.34,228.73,APC
Fmr1 gene detection,81243,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,57.04,,,,,,,fee schedule,51.34,228.73,APC
Fmr1 gene detection,81243,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,87.27,,,,,,,fee schedule,51.34,228.73,Radiology
Fmr1 gene detection,81243,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,79.86,,,,,,,fee schedule,51.34,228.73,APC
Fmr1 gene detection,81243,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,99.82,,,,,,,fee schedule,51.34,228.73,APC
Fmr1 gene characterization,81244,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,378.34,,,,,,,fee schedule,40.4,378.34,
Fmr1 gene characterization,81244,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,303.27,,,,,,,fee schedule,40.4,378.34,
Fmr1 gene characterization,81244,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,331.3,,,,,,,fee schedule,40.4,378.34,
Fmr1 gene characterization,81244,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,348.31,,,,,,,fee schedule,40.4,378.34,
Fmr1 gene characterization,81244,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,40.4,,,,,,,fee schedule,40.4,378.34,Laboratory
Fmr1 gene characterization,81244,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,47.13,,,,,,,fee schedule,40.4,378.34,APC
Fmr1 gene characterization,81244,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,46.69,,,,,,,fee schedule,40.4,378.34,APC
Fmr1 gene characterization,81244,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,44.89,,,,,,,fee schedule,40.4,378.34,APC
Fmr1 gene characterization,81244,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,68.68,,,,,,,fee schedule,40.4,378.34,Radiology
Fmr1 gene characterization,81244,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,62.85,,,,,,,fee schedule,40.4,378.34,APC
Fmr1 gene characterization,81244,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,78.56,,,,,,,fee schedule,40.4,378.34,APC
Flt3 gene,81245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,423.36,,,,,,,fee schedule,148.96,423.36,
Flt3 gene,81245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,339.36,,,,,,,fee schedule,148.96,423.36,
Flt3 gene,81245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,370.72,,,,,,,fee schedule,148.96,423.36,
Flt3 gene,81245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,389.76,,,,,,,fee schedule,148.96,423.36,
Flt3 gene,81245,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,148.96,,,,,,,fee schedule,148.96,423.36,Laboratory
Flt3 gene,81245,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,173.79,,,,,,,fee schedule,148.96,423.36,APC
Flt3 gene,81245,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,172.13,,,,,,,fee schedule,148.96,423.36,APC
Flt3 gene,81245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,165.51,,,,,,,fee schedule,148.96,423.36,APC
Flt3 gene,81245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,253.23,,,,,,,fee schedule,148.96,423.36,Radiology
Flt3 gene,81245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,231.71,,,,,,,fee schedule,148.96,423.36,APC
Flt3 gene,81245,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,289.64,,,,,,,fee schedule,148.96,423.36,APC
Flt3 gene analysis,81246,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,74.7,,,,,,,fee schedule,74.7,145.25,Laboratory
Flt3 gene analysis,81246,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,87.15,,,,,,,fee schedule,74.7,145.25,APC
Flt3 gene analysis,81246,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,86.32,,,,,,,fee schedule,74.7,145.25,APC
Flt3 gene analysis,81246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,83,,,,,,,fee schedule,74.7,145.25,APC
Flt3 gene analysis,81246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,126.99,,,,,,,fee schedule,74.7,145.25,Radiology
Flt3 gene analysis,81246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,116.2,,,,,,,fee schedule,74.7,145.25,APC
Flt3 gene analysis,81246,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,145.25,,,,,,,fee schedule,74.7,145.25,APC
G6pd gene alys cmn variant,81247,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,157.33,,,,,,,fee schedule,157.33,305.92,Laboratory
G6pd gene alys cmn variant,81247,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.55,,,,,,,fee schedule,157.33,305.92,APC
G6pd gene alys cmn variant,81247,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,181.8,,,,,,,fee schedule,157.33,305.92,APC
G6pd gene alys cmn variant,81247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,174.81,,,,,,,fee schedule,157.33,305.92,APC
G6pd gene alys cmn variant,81247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,267.46,,,,,,,fee schedule,157.33,305.92,Radiology
G6pd gene alys cmn variant,81247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,244.73,,,,,,,fee schedule,157.33,305.92,APC
G6pd gene alys cmn variant,81247,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,305.92,,,,,,,fee schedule,157.33,305.92,APC
G6pd known familial variant,81248,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,337.72,,,,,,,fee schedule,337.72,656.69,Laboratory
G6pd known familial variant,81248,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,394.01,,,,,,,fee schedule,337.72,656.69,APC
G6pd known familial variant,81248,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,390.26,,,,,,,fee schedule,337.72,656.69,APC
G6pd known familial variant,81248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,375.25,,,,,,,fee schedule,337.72,656.69,APC
G6pd known familial variant,81248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,574.13,,,,,,,fee schedule,337.72,656.69,Radiology
G6pd known familial variant,81248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,525.35,,,,,,,fee schedule,337.72,656.69,APC
G6pd known familial variant,81248,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,656.69,,,,,,,fee schedule,337.72,656.69,APC
G6pd full gene sequence,81249,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,540,,,,,,,fee schedule,540,1050,Laboratory
G6pd full gene sequence,81249,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,630,,,,,,,fee schedule,540,1050,APC
G6pd full gene sequence,81249,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,624,,,,,,,fee schedule,540,1050,APC
G6pd full gene sequence,81249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,600,,,,,,,fee schedule,540,1050,APC
G6pd full gene sequence,81249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,918,,,,,,,fee schedule,540,1050,Radiology
G6pd full gene sequence,81249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,840,,,,,,,fee schedule,540,1050,APC
G6pd full gene sequence,81249,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1050,,,,,,,fee schedule,540,1050,APC
G6pc gene,81250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,354.94,,,,,,,fee schedule,52.64,354.94,
G6pc gene,81250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,284.52,,,,,,,fee schedule,52.64,354.94,
G6pc gene,81250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,310.81,,,,,,,fee schedule,52.64,354.94,
G6pc gene,81250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,326.77,,,,,,,fee schedule,52.64,354.94,
G6pc gene,81250,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,52.64,,,,,,,fee schedule,52.64,354.94,Laboratory
G6pc gene,81250,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.41,,,,,,,fee schedule,52.64,354.94,APC
G6pc gene,81250,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.83,,,,,,,fee schedule,52.64,354.94,APC
G6pc gene,81250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.49,,,,,,,fee schedule,52.64,354.94,APC
G6pc gene,81250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.49,,,,,,,fee schedule,52.64,354.94,Radiology
G6pc gene,81250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.89,,,,,,,fee schedule,52.64,354.94,APC
G6pc gene,81250,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.36,,,,,,,fee schedule,52.64,354.94,APC
Gba gene,81251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,354.94,,,,,,,fee schedule,42.52,354.94,
Gba gene,81251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,284.52,,,,,,,fee schedule,42.52,354.94,
Gba gene,81251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,310.81,,,,,,,fee schedule,42.52,354.94,
Gba gene,81251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,326.77,,,,,,,fee schedule,42.52,354.94,
Gba gene,81251,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,42.52,,,,,,,fee schedule,42.52,354.94,Laboratory
Gba gene,81251,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,49.61,,,,,,,fee schedule,42.52,354.94,APC
Gba gene,81251,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,49.14,,,,,,,fee schedule,42.52,354.94,APC
Gba gene,81251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,47.25,,,,,,,fee schedule,42.52,354.94,APC
Gba gene,81251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,72.29,,,,,,,fee schedule,42.52,354.94,Radiology
Gba gene,81251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,66.15,,,,,,,fee schedule,42.52,354.94,APC
Gba gene,81251,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,82.69,,,,,,,fee schedule,42.52,354.94,APC
Gjb2 gene full sequence,81252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,592.1,,,,,,,fee schedule,91.01,592.1,
Gjb2 gene full sequence,81252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,474.62,,,,,,,fee schedule,91.01,592.1,
Gjb2 gene full sequence,81252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,518.48,,,,,,,fee schedule,91.01,592.1,
Gjb2 gene full sequence,81252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,545.11,,,,,,,fee schedule,91.01,592.1,
Gjb2 gene full sequence,81252,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,91.01,,,,,,,fee schedule,91.01,592.1,Laboratory
Gjb2 gene full sequence,81252,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,106.18,,,,,,,fee schedule,91.01,592.1,APC
Gjb2 gene full sequence,81252,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,105.16,,,,,,,fee schedule,91.01,592.1,APC
Gjb2 gene full sequence,81252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,101.12,,,,,,,fee schedule,91.01,592.1,APC
Gjb2 gene full sequence,81252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,154.71,,,,,,,fee schedule,91.01,592.1,Radiology
Gjb2 gene full sequence,81252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,141.57,,,,,,,fee schedule,91.01,592.1,APC
Gjb2 gene full sequence,81252,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,176.96,,,,,,,fee schedule,91.01,592.1,APC
Gjb2 gene known fam variants,81253,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,308.3,,,,,,,fee schedule,55.37,308.3,
Gjb2 gene known fam variants,81253,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,247.13,,,,,,,fee schedule,55.37,308.3,
Gjb2 gene known fam variants,81253,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,269.96,,,,,,,fee schedule,55.37,308.3,
Gjb2 gene known fam variants,81253,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,283.83,,,,,,,fee schedule,55.37,308.3,
Gjb2 gene known fam variants,81253,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,55.37,,,,,,,fee schedule,55.37,308.3,Laboratory
Gjb2 gene known fam variants,81253,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,64.6,,,,,,,fee schedule,55.37,308.3,APC
Gjb2 gene known fam variants,81253,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,63.98,,,,,,,fee schedule,55.37,308.3,APC
Gjb2 gene known fam variants,81253,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,61.52,,,,,,,fee schedule,55.37,308.3,APC
Gjb2 gene known fam variants,81253,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,94.13,,,,,,,fee schedule,55.37,308.3,Radiology
Gjb2 gene known fam variants,81253,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,86.13,,,,,,,fee schedule,55.37,308.3,APC
Gjb2 gene known fam variants,81253,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,107.66,,,,,,,fee schedule,55.37,308.3,APC
Gjb6 gene com variants,81254,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,283.39,,,,,,,fee schedule,31.5,283.39,
Gjb6 gene com variants,81254,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,227.16,,,,,,,fee schedule,31.5,283.39,
Gjb6 gene com variants,81254,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,248.15,,,,,,,fee schedule,31.5,283.39,
Gjb6 gene com variants,81254,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,260.9,,,,,,,fee schedule,31.5,283.39,
Gjb6 gene com variants,81254,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31.5,,,,,,,fee schedule,31.5,283.39,Laboratory
Gjb6 gene com variants,81254,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.75,,,,,,,fee schedule,31.5,283.39,APC
Gjb6 gene com variants,81254,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,36.4,,,,,,,fee schedule,31.5,283.39,APC
Gjb6 gene com variants,81254,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,35,,,,,,,fee schedule,31.5,283.39,APC
Gjb6 gene com variants,81254,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,53.55,,,,,,,fee schedule,31.5,283.39,Radiology
Gjb6 gene com variants,81254,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49,,,,,,,fee schedule,31.5,283.39,APC
Gjb6 gene com variants,81254,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,61.25,,,,,,,fee schedule,31.5,283.39,APC
Hexa gene,81255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,354.94,,,,,,,fee schedule,46.3,354.94,
Hexa gene,81255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,284.52,,,,,,,fee schedule,46.3,354.94,
Hexa gene,81255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,310.81,,,,,,,fee schedule,46.3,354.94,
Hexa gene,81255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,326.77,,,,,,,fee schedule,46.3,354.94,
Hexa gene,81255,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46.31,,,,,,,fee schedule,46.3,354.94,Laboratory
Hexa gene,81255,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.02,,,,,,,fee schedule,46.3,354.94,APC
Hexa gene,81255,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,53.51,,,,,,,fee schedule,46.3,354.94,APC
Hexa gene,81255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,51.45,,,,,,,fee schedule,46.3,354.94,APC
Hexa gene,81255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,78.72,,,,,,,fee schedule,46.3,354.94,Radiology
Hexa gene,81255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,72.03,,,,,,,fee schedule,46.3,354.94,APC
Hexa gene,81255,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,90.04,,,,,,,fee schedule,46.3,354.94,APC
Hfe gene,81256,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,862.55,,,,,,,fee schedule,58.82,862.55,
Hfe gene,81256,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,691.41,,,,,,,fee schedule,58.82,862.55,
Hfe gene,81256,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,755.31,,,,,,,fee schedule,58.82,862.55,
Hfe gene,81256,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,794.1,,,,,,,fee schedule,58.82,862.55,
Hfe gene,81256,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,58.82,,,,,,,fee schedule,58.82,862.55,Laboratory
Hfe gene,81256,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,68.63,,,,,,,fee schedule,58.82,862.55,APC
Hfe gene,81256,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,67.97,,,,,,,fee schedule,58.82,862.55,APC
Hfe gene,81256,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,65.36,,,,,,,fee schedule,58.82,862.55,APC
Hfe gene,81256,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,100,,,,,,,fee schedule,58.82,862.55,Radiology
Hfe gene,81256,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,91.5,,,,,,,fee schedule,58.82,862.55,APC
Hfe gene,81256,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,114.38,,,,,,,fee schedule,58.82,862.55,APC
Hba1/hba2 gene,81257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,692.57,,,,,,,fee schedule,92.03,692.57,
Hba1/hba2 gene,81257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,555.16,,,,,,,fee schedule,92.03,692.57,
Hba1/hba2 gene,81257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,606.46,,,,,,,fee schedule,92.03,692.57,
Hba1/hba2 gene,81257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,637.61,,,,,,,fee schedule,92.03,692.57,
Hba1/hba2 gene,81257,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,92.03,,,,,,,fee schedule,92.03,692.57,Laboratory
Hba1/hba2 gene,81257,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,107.37,,,,,,,fee schedule,92.03,692.57,APC
Hba1/hba2 gene,81257,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,106.35,,,,,,,fee schedule,92.03,692.57,APC
Hba1/hba2 gene,81257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,102.26,,,,,,,fee schedule,92.03,692.57,APC
Hba1/hba2 gene,81257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,156.46,,,,,,,fee schedule,92.03,692.57,Radiology
Hba1/hba2 gene,81257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,143.16,,,,,,,fee schedule,92.03,692.57,APC
Hba1/hba2 gene,81257,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,178.96,,,,,,,fee schedule,92.03,692.57,APC
Hba1/hba2 gene fam vrnt,81258,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,337.72,,,,,,,fee schedule,337.72,656.69,Laboratory
Hba1/hba2 gene fam vrnt,81258,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,394.01,,,,,,,fee schedule,337.72,656.69,APC
Hba1/hba2 gene fam vrnt,81258,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,390.26,,,,,,,fee schedule,337.72,656.69,APC
Hba1/hba2 gene fam vrnt,81258,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,375.25,,,,,,,fee schedule,337.72,656.69,APC
Hba1/hba2 gene fam vrnt,81258,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,574.13,,,,,,,fee schedule,337.72,656.69,Radiology
Hba1/hba2 gene fam vrnt,81258,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,525.35,,,,,,,fee schedule,337.72,656.69,APC
Hba1/hba2 gene fam vrnt,81258,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,656.69,,,,,,,fee schedule,337.72,656.69,APC
Hba1/hba2 full gene sequence,81259,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,540,,,,,,,fee schedule,540,1050,Laboratory
Hba1/hba2 full gene sequence,81259,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,630,,,,,,,fee schedule,540,1050,APC
Hba1/hba2 full gene sequence,81259,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,624,,,,,,,fee schedule,540,1050,APC
Hba1/hba2 full gene sequence,81259,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,600,,,,,,,fee schedule,540,1050,APC
Hba1/hba2 full gene sequence,81259,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,918,,,,,,,fee schedule,540,1050,Radiology
Hba1/hba2 full gene sequence,81259,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,840,,,,,,,fee schedule,540,1050,APC
Hba1/hba2 full gene sequence,81259,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1050,,,,,,,fee schedule,540,1050,APC
Ikbkap gene,81260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,354.94,,,,,,,fee schedule,35.38,354.94,
Ikbkap gene,81260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,284.52,,,,,,,fee schedule,35.38,354.94,
Ikbkap gene,81260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,310.81,,,,,,,fee schedule,35.38,354.94,
Ikbkap gene,81260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,326.77,,,,,,,fee schedule,35.38,354.94,
Ikbkap gene,81260,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,35.38,,,,,,,fee schedule,35.38,354.94,Laboratory
Ikbkap gene,81260,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,41.28,,,,,,,fee schedule,35.38,354.94,APC
Ikbkap gene,81260,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,40.88,,,,,,,fee schedule,35.38,354.94,APC
Ikbkap gene,81260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,39.31,,,,,,,fee schedule,35.38,354.94,APC
Ikbkap gene,81260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,60.14,,,,,,,fee schedule,35.38,354.94,Radiology
Ikbkap gene,81260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,55.03,,,,,,,fee schedule,35.38,354.94,APC
Ikbkap gene,81260,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,68.79,,,,,,,fee schedule,35.38,354.94,APC
Igh gene rearrange amp meth,81261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,361.31,,,,,,,fee schedule,178.19,361.31,
Igh gene rearrange amp meth,81261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,289.62,,,,,,,fee schedule,178.19,361.31,
Igh gene rearrange amp meth,81261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,316.39,,,,,,,fee schedule,178.19,361.31,
Igh gene rearrange amp meth,81261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,332.64,,,,,,,fee schedule,178.19,361.31,
Igh gene rearrange amp meth,81261,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,178.19,,,,,,,fee schedule,178.19,361.31,Laboratory
Igh gene rearrange amp meth,81261,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,207.89,,,,,,,fee schedule,178.19,361.31,APC
Igh gene rearrange amp meth,81261,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,205.91,,,,,,,fee schedule,178.19,361.31,APC
Igh gene rearrange amp meth,81261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,197.99,,,,,,,fee schedule,178.19,361.31,APC
Igh gene rearrange amp meth,81261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,302.92,,,,,,,fee schedule,178.19,361.31,Radiology
Igh gene rearrange amp meth,81261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,277.19,,,,,,,fee schedule,178.19,361.31,APC
Igh gene rearrange amp meth,81261,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,346.48,,,,,,,fee schedule,178.19,361.31,APC
Igh gene rearrang dir probe,81262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,193.23,,,,,,,fee schedule,61.7,193.23,
Igh gene rearrang dir probe,81262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,154.89,,,,,,,fee schedule,61.7,193.23,
Igh gene rearrang dir probe,81262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,169.21,,,,,,,fee schedule,61.7,193.23,
Igh gene rearrang dir probe,81262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,177.9,,,,,,,fee schedule,61.7,193.23,
Igh gene rearrang dir probe,81262,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,61.7,,,,,,,fee schedule,61.7,193.23,Laboratory
Igh gene rearrang dir probe,81262,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,71.98,,,,,,,fee schedule,61.7,193.23,APC
Igh gene rearrang dir probe,81262,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,71.29,,,,,,,fee schedule,61.7,193.23,APC
Igh gene rearrang dir probe,81262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,68.55,,,,,,,fee schedule,61.7,193.23,APC
Igh gene rearrang dir probe,81262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,104.88,,,,,,,fee schedule,61.7,193.23,Radiology
Igh gene rearrang dir probe,81262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,95.97,,,,,,,fee schedule,61.7,193.23,APC
Igh gene rearrang dir probe,81262,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,119.96,,,,,,,fee schedule,61.7,193.23,APC
Igh vari regional mutation,81263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,361.31,,,,,,,fee schedule,265.07,515.41,
Igh vari regional mutation,81263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,289.62,,,,,,,fee schedule,265.07,515.41,
Igh vari regional mutation,81263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,316.39,,,,,,,fee schedule,265.07,515.41,
Igh vari regional mutation,81263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,332.64,,,,,,,fee schedule,265.07,515.41,
Igh vari regional mutation,81263,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,265.07,,,,,,,fee schedule,265.07,515.41,Laboratory
Igh vari regional mutation,81263,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,309.25,,,,,,,fee schedule,265.07,515.41,APC
Igh vari regional mutation,81263,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,306.3,,,,,,,fee schedule,265.07,515.41,APC
Igh vari regional mutation,81263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,294.52,,,,,,,fee schedule,265.07,515.41,APC
Igh vari regional mutation,81263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,450.62,,,,,,,fee schedule,265.07,515.41,Radiology
Igh vari regional mutation,81263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,412.33,,,,,,,fee schedule,265.07,515.41,APC
Igh vari regional mutation,81263,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,515.41,,,,,,,fee schedule,265.07,515.41,APC
Igk rearrangeabn clonal pop,81264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,423.28,,,,,,,fee schedule,155.46,423.28,
Igk rearrangeabn clonal pop,81264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,339.3,,,,,,,fee schedule,155.46,423.28,
Igk rearrangeabn clonal pop,81264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,370.65,,,,,,,fee schedule,155.46,423.28,
Igk rearrangeabn clonal pop,81264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,389.69,,,,,,,fee schedule,155.46,423.28,
Igk rearrangeabn clonal pop,81264,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,155.46,,,,,,,fee schedule,155.46,423.28,Laboratory
Igk rearrangeabn clonal pop,81264,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,181.37,,,,,,,fee schedule,155.46,423.28,APC
Igk rearrangeabn clonal pop,81264,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,179.64,,,,,,,fee schedule,155.46,423.28,APC
Igk rearrangeabn clonal pop,81264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,172.73,,,,,,,fee schedule,155.46,423.28,APC
Igk rearrangeabn clonal pop,81264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,264.28,,,,,,,fee schedule,155.46,423.28,Radiology
Igk rearrangeabn clonal pop,81264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,241.82,,,,,,,fee schedule,155.46,423.28,APC
Igk rearrangeabn clonal pop,81264,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,302.28,,,,,,,fee schedule,155.46,423.28,APC
Str markers specimen anal,81265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1568.47,,,,,,,fee schedule,209.76,1568.47,
Str markers specimen anal,81265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1257.27,,,,,,,fee schedule,209.76,1568.47,
Str markers specimen anal,81265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1373.45,,,,,,,fee schedule,209.76,1568.47,
Str markers specimen anal,81265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1443.99,,,,,,,fee schedule,209.76,1568.47,
Str markers specimen anal,81265,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,209.76,,,,,,,fee schedule,209.76,1568.47,Laboratory
Str markers specimen anal,81265,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,244.72,,,,,,,fee schedule,209.76,1568.47,APC
Str markers specimen anal,81265,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,242.39,,,,,,,fee schedule,209.76,1568.47,APC
Str markers specimen anal,81265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,233.07,,,,,,,fee schedule,209.76,1568.47,APC
Str markers specimen anal,81265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,356.6,,,,,,,fee schedule,209.76,1568.47,Radiology
Str markers specimen anal,81265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,326.3,,,,,,,fee schedule,209.76,1568.47,APC
Str markers specimen anal,81265,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,407.87,,,,,,,fee schedule,209.76,1568.47,APC
Str markers spec anal addl,81266,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,274.33,,,,,,,fee schedule,274.33,533.42,Laboratory
Str markers spec anal addl,81266,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,320.05,,,,,,,fee schedule,274.33,533.42,APC
Str markers spec anal addl,81266,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,317,,,,,,,fee schedule,274.33,533.42,APC
Str markers spec anal addl,81266,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,304.81,,,,,,,fee schedule,274.33,533.42,APC
Str markers spec anal addl,81266,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,466.36,,,,,,,fee schedule,274.33,533.42,Radiology
Str markers spec anal addl,81266,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,426.73,,,,,,,fee schedule,274.33,533.42,APC
Str markers spec anal addl,81266,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,533.42,,,,,,,fee schedule,274.33,533.42,APC
Chimerism anal no cell selec,81267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,565.94,,,,,,,fee schedule,186.71,565.94,
Chimerism anal no cell selec,81267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,453.65,,,,,,,fee schedule,186.71,565.94,
Chimerism anal no cell selec,81267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,495.57,,,,,,,fee schedule,186.71,565.94,
Chimerism anal no cell selec,81267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,521.03,,,,,,,fee schedule,186.71,565.94,
Chimerism anal no cell selec,81267,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,186.71,,,,,,,fee schedule,186.71,565.94,Laboratory
Chimerism anal no cell selec,81267,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,217.83,,,,,,,fee schedule,186.71,565.94,APC
Chimerism anal no cell selec,81267,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,215.76,,,,,,,fee schedule,186.71,565.94,APC
Chimerism anal no cell selec,81267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,207.46,,,,,,,fee schedule,186.71,565.94,APC
Chimerism anal no cell selec,81267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,317.41,,,,,,,fee schedule,186.71,565.94,Radiology
Chimerism anal no cell selec,81267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,290.44,,,,,,,fee schedule,186.71,565.94,APC
Chimerism anal no cell selec,81267,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,363.06,,,,,,,fee schedule,186.71,565.94,APC
Chimerism anal w/cell select,81268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,565.94,,,,,,,fee schedule,234.71,565.94,
Chimerism anal w/cell select,81268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,453.65,,,,,,,fee schedule,234.71,565.94,
Chimerism anal w/cell select,81268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,495.57,,,,,,,fee schedule,234.71,565.94,
Chimerism anal w/cell select,81268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,521.03,,,,,,,fee schedule,234.71,565.94,
Chimerism anal w/cell select,81268,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,234.71,,,,,,,fee schedule,234.71,565.94,Laboratory
Chimerism anal w/cell select,81268,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,273.83,,,,,,,fee schedule,234.71,565.94,APC
Chimerism anal w/cell select,81268,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,271.22,,,,,,,fee schedule,234.71,565.94,APC
Chimerism anal w/cell select,81268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,260.79,,,,,,,fee schedule,234.71,565.94,APC
Chimerism anal w/cell select,81268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,399.01,,,,,,,fee schedule,234.71,565.94,Radiology
Chimerism anal w/cell select,81268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,365.11,,,,,,,fee schedule,234.71,565.94,APC
Chimerism anal w/cell select,81268,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,456.38,,,,,,,fee schedule,234.71,565.94,APC
Hba1/hba2 gene dup/del vrnts,81269,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,182.16,,,,,,,fee schedule,182.16,354.2,Laboratory
Hba1/hba2 gene dup/del vrnts,81269,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,212.52,,,,,,,fee schedule,182.16,354.2,APC
Hba1/hba2 gene dup/del vrnts,81269,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,210.5,,,,,,,fee schedule,182.16,354.2,APC
Hba1/hba2 gene dup/del vrnts,81269,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,202.4,,,,,,,fee schedule,182.16,354.2,APC
Hba1/hba2 gene dup/del vrnts,81269,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,309.67,,,,,,,fee schedule,182.16,354.2,Radiology
Hba1/hba2 gene dup/del vrnts,81269,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,283.36,,,,,,,fee schedule,182.16,354.2,APC
Hba1/hba2 gene dup/del vrnts,81269,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,354.2,,,,,,,fee schedule,182.16,354.2,APC
Jak2 gene,81270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,251.73,,,,,,,fee schedule,82.49,251.73,
Jak2 gene,81270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,201.79,,,,,,,fee schedule,82.49,251.73,
Jak2 gene,81270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,220.43,,,,,,,fee schedule,82.49,251.73,
Jak2 gene,81270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,231.75,,,,,,,fee schedule,82.49,251.73,
Jak2 gene,81270,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,82.49,,,,,,,fee schedule,82.49,251.73,Laboratory
Jak2 gene,81270,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,96.24,,,,,,,fee schedule,82.49,251.73,APC
Jak2 gene,81270,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,95.33,,,,,,,fee schedule,82.49,251.73,APC
Jak2 gene,81270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,91.66,,,,,,,fee schedule,82.49,251.73,APC
Jak2 gene,81270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,140.24,,,,,,,fee schedule,82.49,251.73,Radiology
Jak2 gene,81270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,128.32,,,,,,,fee schedule,82.49,251.73,APC
Jak2 gene,81270,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,160.4,,,,,,,fee schedule,82.49,251.73,APC
Htt gene detc abnor alleles,81271,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,123.3,,,,,,,fee schedule,123.3,239.75,Laboratory
Htt gene detc abnor alleles,81271,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,143.85,,,,,,,fee schedule,123.3,239.75,APC
Htt gene detc abnor alleles,81271,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,142.48,,,,,,,fee schedule,123.3,239.75,APC
Htt gene detc abnor alleles,81271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,137,,,,,,,fee schedule,123.3,239.75,APC
Htt gene detc abnor alleles,81271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,209.61,,,,,,,fee schedule,123.3,239.75,Radiology
Htt gene detc abnor alleles,81271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,191.8,,,,,,,fee schedule,123.3,239.75,APC
Htt gene detc abnor alleles,81271,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,239.75,,,,,,,fee schedule,123.3,239.75,APC
Kit gene targeted seq analys,81272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,921.72,,,,,,,fee schedule,296.56,921.72,
Kit gene targeted seq analys,81272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,738.84,,,,,,,fee schedule,296.56,921.72,
Kit gene targeted seq analys,81272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,807.11,,,,,,,fee schedule,296.56,921.72,
Kit gene targeted seq analys,81272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,848.56,,,,,,,fee schedule,296.56,921.72,
Kit gene targeted seq analys,81272,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,296.56,,,,,,,fee schedule,296.56,921.72,Laboratory
Kit gene targeted seq analys,81272,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,345.99,,,,,,,fee schedule,296.56,921.72,APC
Kit gene targeted seq analys,81272,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,342.69,,,,,,,fee schedule,296.56,921.72,APC
Kit gene targeted seq analys,81272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,329.51,,,,,,,fee schedule,296.56,921.72,APC
Kit gene targeted seq analys,81272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,504.15,,,,,,,fee schedule,296.56,921.72,Radiology
Kit gene targeted seq analys,81272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,461.31,,,,,,,fee schedule,296.56,921.72,APC
Kit gene targeted seq analys,81272,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,576.64,,,,,,,fee schedule,296.56,921.72,APC
Kit gene analys d816 variant,81273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,349.27,,,,,,,fee schedule,112.38,349.27,
Kit gene analys d816 variant,81273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,279.97,,,,,,,fee schedule,112.38,349.27,
Kit gene analys d816 variant,81273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,305.84,,,,,,,fee schedule,112.38,349.27,
Kit gene analys d816 variant,81273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,321.55,,,,,,,fee schedule,112.38,349.27,
Kit gene analys d816 variant,81273,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,112.38,,,,,,,fee schedule,112.38,349.27,Laboratory
Kit gene analys d816 variant,81273,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,131.11,,,,,,,fee schedule,112.38,349.27,APC
Kit gene analys d816 variant,81273,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,129.86,,,,,,,fee schedule,112.38,349.27,APC
Kit gene analys d816 variant,81273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,124.87,,,,,,,fee schedule,112.38,349.27,APC
Kit gene analys d816 variant,81273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,191.05,,,,,,,fee schedule,112.38,349.27,Radiology
Kit gene analys d816 variant,81273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,174.82,,,,,,,fee schedule,112.38,349.27,APC
Kit gene analys d816 variant,81273,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,218.52,,,,,,,fee schedule,112.38,349.27,APC
Htt gene charac alleles,81274,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,247.35,,,,,,,fee schedule,247.35,480.95,Laboratory
Htt gene charac alleles,81274,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,288.57,,,,,,,fee schedule,247.35,480.95,APC
Htt gene charac alleles,81274,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,285.82,,,,,,,fee schedule,247.35,480.95,APC
Htt gene charac alleles,81274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,274.83,,,,,,,fee schedule,247.35,480.95,APC
Htt gene charac alleles,81274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,420.49,,,,,,,fee schedule,247.35,480.95,Radiology
Htt gene charac alleles,81274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,384.76,,,,,,,fee schedule,247.35,480.95,APC
Htt gene charac alleles,81274,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,480.95,,,,,,,fee schedule,247.35,480.95,APC
Kras gene variants exon 2,81275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,387.96,,,,,,,fee schedule,173.92,387.96,
Kras gene variants exon 2,81275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,310.99,,,,,,,fee schedule,173.92,387.96,
Kras gene variants exon 2,81275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,339.73,,,,,,,fee schedule,173.92,387.96,
Kras gene variants exon 2,81275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,357.17,,,,,,,fee schedule,173.92,387.96,
Kras gene variants exon 2,81275,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,173.92,,,,,,,fee schedule,173.92,387.96,Laboratory
Kras gene variants exon 2,81275,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,202.91,,,,,,,fee schedule,173.92,387.96,APC
Kras gene variants exon 2,81275,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,200.98,,,,,,,fee schedule,173.92,387.96,APC
Kras gene variants exon 2,81275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,193.25,,,,,,,fee schedule,173.92,387.96,APC
Kras gene variants exon 2,81275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,295.67,,,,,,,fee schedule,173.92,387.96,Radiology
Kras gene variants exon 2,81275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,270.55,,,,,,,fee schedule,173.92,387.96,APC
Kras gene variants exon 2,81275,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,338.19,,,,,,,fee schedule,173.92,387.96,APC
Kras gene addl variants,81276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,551.58,,,,,,,fee schedule,173.92,551.58,
Kras gene addl variants,81276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,442.14,,,,,,,fee schedule,173.92,551.58,
Kras gene addl variants,81276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,483,,,,,,,fee schedule,173.92,551.58,
Kras gene addl variants,81276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,507.8,,,,,,,fee schedule,173.92,551.58,
Kras gene addl variants,81276,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,173.92,,,,,,,fee schedule,173.92,551.58,Laboratory
Kras gene addl variants,81276,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,202.91,,,,,,,fee schedule,173.92,551.58,APC
Kras gene addl variants,81276,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,200.98,,,,,,,fee schedule,173.92,551.58,APC
Kras gene addl variants,81276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,193.25,,,,,,,fee schedule,173.92,551.58,APC
Kras gene addl variants,81276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,295.67,,,,,,,fee schedule,173.92,551.58,Radiology
Kras gene addl variants,81276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,270.55,,,,,,,fee schedule,173.92,551.58,APC
Kras gene addl variants,81276,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,338.19,,,,,,,fee schedule,173.92,551.58,APC
Cytogenomic neo microra alys,81277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4384.8,,,,,,,fee schedule,1044,4384.8,
Cytogenomic neo microra alys,81277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3514.8,,,,,,,fee schedule,1044,4384.8,
Cytogenomic neo microra alys,81277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3839.6,,,,,,,fee schedule,1044,4384.8,
Cytogenomic neo microra alys,81277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4036.8,,,,,,,fee schedule,1044,4384.8,
Cytogenomic neo microra alys,81277,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1044,,,,,,,fee schedule,1044,4384.8,Laboratory
Cytogenomic neo microra alys,81277,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1218,,,,,,,fee schedule,1044,4384.8,APC
Cytogenomic neo microra alys,81277,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1206.4,,,,,,,fee schedule,1044,4384.8,APC
Cytogenomic neo microra alys,81277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1160,,,,,,,fee schedule,1044,4384.8,APC
Cytogenomic neo microra alys,81277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1774.8,,,,,,,fee schedule,1044,4384.8,Radiology
Cytogenomic neo microra alys,81277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1624,,,,,,,fee schedule,1044,4384.8,APC
Cytogenomic neo microra alys,81277,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2030,,,,,,,fee schedule,1044,4384.8,APC
Igh@/bcl2 translocation alys,81278,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,186.58,,,,,,,fee schedule,186.58,362.79,Laboratory
Igh@/bcl2 translocation alys,81278,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,217.68,,,,,,,fee schedule,186.58,362.79,APC
Igh@/bcl2 translocation alys,81278,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,215.6,,,,,,,fee schedule,186.58,362.79,APC
Igh@/bcl2 translocation alys,81278,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,207.31,,,,,,,fee schedule,186.58,362.79,APC
Igh@/bcl2 translocation alys,81278,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,317.18,,,,,,,fee schedule,186.58,362.79,Radiology
Igh@/bcl2 translocation alys,81278,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,290.23,,,,,,,fee schedule,186.58,362.79,APC
Igh@/bcl2 translocation alys,81278,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,362.79,,,,,,,fee schedule,186.58,362.79,APC
Jak2 gene trgt sequence alys,81279,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,166.68,,,,,,,fee schedule,166.68,324.1,Laboratory
Jak2 gene trgt sequence alys,81279,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,194.46,,,,,,,fee schedule,166.68,324.1,APC
Jak2 gene trgt sequence alys,81279,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,192.61,,,,,,,fee schedule,166.68,324.1,APC
Jak2 gene trgt sequence alys,81279,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,185.2,,,,,,,fee schedule,166.68,324.1,APC
Jak2 gene trgt sequence alys,81279,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,283.36,,,,,,,fee schedule,166.68,324.1,Radiology
Jak2 gene trgt sequence alys,81279,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,259.28,,,,,,,fee schedule,166.68,324.1,APC
Jak2 gene trgt sequence alys,81279,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,324.1,,,,,,,fee schedule,166.68,324.1,APC
Ifnl3 gene,81283,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,66.03,,,,,,,fee schedule,66.03,128.4,Laboratory
Ifnl3 gene,81283,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,77.04,,,,,,,fee schedule,66.03,128.4,APC
Ifnl3 gene,81283,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,76.3,,,,,,,fee schedule,66.03,128.4,APC
Ifnl3 gene,81283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,73.37,,,,,,,fee schedule,66.03,128.4,APC
Ifnl3 gene,81283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,112.26,,,,,,,fee schedule,66.03,128.4,Radiology
Ifnl3 gene,81283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,102.72,,,,,,,fee schedule,66.03,128.4,APC
Ifnl3 gene,81283,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,128.4,,,,,,,fee schedule,66.03,128.4,APC
Fxn gene detc abnor alleles,81284,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,123.3,,,,,,,fee schedule,123.3,239.75,Laboratory
Fxn gene detc abnor alleles,81284,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,143.85,,,,,,,fee schedule,123.3,239.75,APC
Fxn gene detc abnor alleles,81284,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,142.48,,,,,,,fee schedule,123.3,239.75,APC
Fxn gene detc abnor alleles,81284,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,137,,,,,,,fee schedule,123.3,239.75,APC
Fxn gene detc abnor alleles,81284,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,209.61,,,,,,,fee schedule,123.3,239.75,Radiology
Fxn gene detc abnor alleles,81284,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,191.8,,,,,,,fee schedule,123.3,239.75,APC
Fxn gene detc abnor alleles,81284,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,239.75,,,,,,,fee schedule,123.3,239.75,APC
Fxn gene charac alleles,81285,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,247.35,,,,,,,fee schedule,247.35,480.95,Laboratory
Fxn gene charac alleles,81285,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,288.57,,,,,,,fee schedule,247.35,480.95,APC
Fxn gene charac alleles,81285,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,285.82,,,,,,,fee schedule,247.35,480.95,APC
Fxn gene charac alleles,81285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,274.83,,,,,,,fee schedule,247.35,480.95,APC
Fxn gene charac alleles,81285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,420.49,,,,,,,fee schedule,247.35,480.95,Radiology
Fxn gene charac alleles,81285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,384.76,,,,,,,fee schedule,247.35,480.95,APC
Fxn gene charac alleles,81285,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,480.95,,,,,,,fee schedule,247.35,480.95,APC
Fxn gene full gene sequence,81286,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,247.35,,,,,,,fee schedule,247.35,480.95,Laboratory
Fxn gene full gene sequence,81286,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,288.57,,,,,,,fee schedule,247.35,480.95,APC
Fxn gene full gene sequence,81286,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,285.82,,,,,,,fee schedule,247.35,480.95,APC
Fxn gene full gene sequence,81286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,274.83,,,,,,,fee schedule,247.35,480.95,APC
Fxn gene full gene sequence,81286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,420.49,,,,,,,fee schedule,247.35,480.95,Radiology
Fxn gene full gene sequence,81286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,384.76,,,,,,,fee schedule,247.35,480.95,APC
Fxn gene full gene sequence,81286,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,480.95,,,,,,,fee schedule,247.35,480.95,APC
Mgmt gene methylation anal,81287,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,112.18,,,,,,,fee schedule,112.18,218.12,Laboratory
Mgmt gene methylation anal,81287,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.87,,,,,,,fee schedule,112.18,218.12,APC
Mgmt gene methylation anal,81287,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,129.63,,,,,,,fee schedule,112.18,218.12,APC
Mgmt gene methylation anal,81287,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,124.64,,,,,,,fee schedule,112.18,218.12,APC
Mgmt gene methylation anal,81287,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,190.7,,,,,,,fee schedule,112.18,218.12,Radiology
Mgmt gene methylation anal,81287,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,174.5,,,,,,,fee schedule,112.18,218.12,APC
Mgmt gene methylation anal,81287,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,218.12,,,,,,,fee schedule,112.18,218.12,APC
Mlh1 gene,81288,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,173.09,,,,,,,fee schedule,173.09,336.56,Laboratory
Mlh1 gene,81288,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,201.94,,,,,,,fee schedule,173.09,336.56,APC
Mlh1 gene,81288,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,200.01,,,,,,,fee schedule,173.09,336.56,APC
Mlh1 gene,81288,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,192.32,,,,,,,fee schedule,173.09,336.56,APC
Mlh1 gene,81288,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,294.25,,,,,,,fee schedule,173.09,336.56,Radiology
Mlh1 gene,81288,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,269.25,,,,,,,fee schedule,173.09,336.56,APC
Mlh1 gene,81288,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,336.56,,,,,,,fee schedule,173.09,336.56,APC
Fxn gene known famil variant,81289,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,166.68,,,,,,,fee schedule,166.68,324.1,Laboratory
Fxn gene known famil variant,81289,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,194.46,,,,,,,fee schedule,166.68,324.1,APC
Fxn gene known famil variant,81289,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,192.61,,,,,,,fee schedule,166.68,324.1,APC
Fxn gene known famil variant,81289,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,185.2,,,,,,,fee schedule,166.68,324.1,APC
Fxn gene known famil variant,81289,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,283.36,,,,,,,fee schedule,166.68,324.1,Radiology
Fxn gene known famil variant,81289,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,259.28,,,,,,,fee schedule,166.68,324.1,APC
Fxn gene known famil variant,81289,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,324.1,,,,,,,fee schedule,166.68,324.1,APC
Mcoln1 gene,81290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,354.94,,,,,,,fee schedule,35.38,354.94,
Mcoln1 gene,81290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,284.52,,,,,,,fee schedule,35.38,354.94,
Mcoln1 gene,81290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,310.81,,,,,,,fee schedule,35.38,354.94,
Mcoln1 gene,81290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,326.77,,,,,,,fee schedule,35.38,354.94,
Mcoln1 gene,81290,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,35.38,,,,,,,fee schedule,35.38,354.94,Laboratory
Mcoln1 gene,81290,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,41.28,,,,,,,fee schedule,35.38,354.94,APC
Mcoln1 gene,81290,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,40.88,,,,,,,fee schedule,35.38,354.94,APC
Mcoln1 gene,81290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,39.31,,,,,,,fee schedule,35.38,354.94,APC
Mcoln1 gene,81290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,60.14,,,,,,,fee schedule,35.38,354.94,Radiology
Mcoln1 gene,81290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,55.03,,,,,,,fee schedule,35.38,354.94,APC
Mcoln1 gene,81290,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,68.79,,,,,,,fee schedule,35.38,354.94,APC
Mthfr gene,81291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,351.24,,,,,,,fee schedule,58.81,351.24,
Mthfr gene,81291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,281.55,,,,,,,fee schedule,58.81,351.24,
Mthfr gene,81291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,307.57,,,,,,,fee schedule,58.81,351.24,
Mthfr gene,81291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,323.36,,,,,,,fee schedule,58.81,351.24,
Mthfr gene,81291,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,58.81,,,,,,,fee schedule,58.81,351.24,Laboratory
Mthfr gene,81291,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,68.61,,,,,,,fee schedule,58.81,351.24,APC
Mthfr gene,81291,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,67.95,,,,,,,fee schedule,58.81,351.24,APC
Mthfr gene,81291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,65.34,,,,,,,fee schedule,58.81,351.24,APC
Mthfr gene,81291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,99.97,,,,,,,fee schedule,58.81,351.24,Radiology
Mthfr gene,81291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,91.48,,,,,,,fee schedule,58.81,351.24,APC
Mthfr gene,81291,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,114.34,,,,,,,fee schedule,58.81,351.24,APC
Mlh1 gene full seq,81292,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3036.4,,,,,,,fee schedule,607.86,3036.4,
Mlh1 gene full seq,81292,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2433.94,,,,,,,fee schedule,607.86,3036.4,
Mlh1 gene full seq,81292,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2658.86,,,,,,,fee schedule,607.86,3036.4,
Mlh1 gene full seq,81292,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2795.41,,,,,,,fee schedule,607.86,3036.4,
Mlh1 gene full seq,81292,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,607.86,,,,,,,fee schedule,607.86,3036.4,Laboratory
Mlh1 gene full seq,81292,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,709.17,,,,,,,fee schedule,607.86,3036.4,APC
Mlh1 gene full seq,81292,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,702.42,,,,,,,fee schedule,607.86,3036.4,APC
Mlh1 gene full seq,81292,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,675.4,,,,,,,fee schedule,607.86,3036.4,APC
Mlh1 gene full seq,81292,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1033.36,,,,,,,fee schedule,607.86,3036.4,Radiology
Mlh1 gene full seq,81292,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,945.56,,,,,,,fee schedule,607.86,3036.4,APC
Mlh1 gene full seq,81292,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1181.95,,,,,,,fee schedule,607.86,3036.4,APC
Mlh1 gene known variants,81293,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,355.09,,,,,,,fee schedule,284.64,579.25,
Mlh1 gene known variants,81293,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,284.64,,,,,,,fee schedule,284.64,579.25,
Mlh1 gene known variants,81293,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,310.94,,,,,,,fee schedule,284.64,579.25,
Mlh1 gene known variants,81293,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,326.91,,,,,,,fee schedule,284.64,579.25,
Mlh1 gene known variants,81293,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,297.9,,,,,,,fee schedule,284.64,579.25,Laboratory
Mlh1 gene known variants,81293,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,347.55,,,,,,,fee schedule,284.64,579.25,APC
Mlh1 gene known variants,81293,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,344.24,,,,,,,fee schedule,284.64,579.25,APC
Mlh1 gene known variants,81293,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,331,,,,,,,fee schedule,284.64,579.25,APC
Mlh1 gene known variants,81293,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,506.43,,,,,,,fee schedule,284.64,579.25,Radiology
Mlh1 gene known variants,81293,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,463.4,,,,,,,fee schedule,284.64,579.25,APC
Mlh1 gene known variants,81293,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,579.25,,,,,,,fee schedule,284.64,579.25,APC
Mlh1 gene dup/delete variant,81294,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1859.61,,,,,,,fee schedule,182.16,1859.61,
Mlh1 gene dup/delete variant,81294,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1490.64,,,,,,,fee schedule,182.16,1859.61,
Mlh1 gene dup/delete variant,81294,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1628.39,,,,,,,fee schedule,182.16,1859.61,
Mlh1 gene dup/delete variant,81294,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1712.02,,,,,,,fee schedule,182.16,1859.61,
Mlh1 gene dup/delete variant,81294,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,182.16,,,,,,,fee schedule,182.16,1859.61,Laboratory
Mlh1 gene dup/delete variant,81294,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,212.52,,,,,,,fee schedule,182.16,1859.61,APC
Mlh1 gene dup/delete variant,81294,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,210.5,,,,,,,fee schedule,182.16,1859.61,APC
Mlh1 gene dup/delete variant,81294,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,202.4,,,,,,,fee schedule,182.16,1859.61,APC
Mlh1 gene dup/delete variant,81294,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,309.67,,,,,,,fee schedule,182.16,1859.61,Radiology
Mlh1 gene dup/delete variant,81294,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,283.36,,,,,,,fee schedule,182.16,1859.61,APC
Mlh1 gene dup/delete variant,81294,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,354.2,,,,,,,fee schedule,182.16,1859.61,APC
Msh2 gene full seq,81295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2975.69,,,,,,,fee schedule,343.53,2975.69,
Msh2 gene full seq,81295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2385.28,,,,,,,fee schedule,343.53,2975.69,
Msh2 gene full seq,81295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2605.7,,,,,,,fee schedule,343.53,2975.69,
Msh2 gene full seq,81295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2739.53,,,,,,,fee schedule,343.53,2975.69,
Msh2 gene full seq,81295,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,343.53,,,,,,,fee schedule,343.53,2975.69,Laboratory
Msh2 gene full seq,81295,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,400.78,,,,,,,fee schedule,343.53,2975.69,APC
Msh2 gene full seq,81295,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,396.97,,,,,,,fee schedule,343.53,2975.69,APC
Msh2 gene full seq,81295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,381.7,,,,,,,fee schedule,343.53,2975.69,APC
Msh2 gene full seq,81295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,584,,,,,,,fee schedule,343.53,2975.69,Radiology
Msh2 gene full seq,81295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,534.38,,,,,,,fee schedule,343.53,2975.69,APC
Msh2 gene full seq,81295,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,667.98,,,,,,,fee schedule,343.53,2975.69,APC
Msh2 gene known variants,81296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,355.09,,,,,,,fee schedule,284.64,591.03,
Msh2 gene known variants,81296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,284.64,,,,,,,fee schedule,284.64,591.03,
Msh2 gene known variants,81296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,310.94,,,,,,,fee schedule,284.64,591.03,
Msh2 gene known variants,81296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,326.91,,,,,,,fee schedule,284.64,591.03,
Msh2 gene known variants,81296,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,303.96,,,,,,,fee schedule,284.64,591.03,Laboratory
Msh2 gene known variants,81296,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,354.62,,,,,,,fee schedule,284.64,591.03,APC
Msh2 gene known variants,81296,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,351.24,,,,,,,fee schedule,284.64,591.03,APC
Msh2 gene known variants,81296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,337.73,,,,,,,fee schedule,284.64,591.03,APC
Msh2 gene known variants,81296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,516.73,,,,,,,fee schedule,284.64,591.03,Radiology
Msh2 gene known variants,81296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,472.82,,,,,,,fee schedule,284.64,591.03,APC
Msh2 gene known variants,81296,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,591.03,,,,,,,fee schedule,284.64,591.03,APC
Msh2 gene dup/delete variant,81297,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2051.67,,,,,,,fee schedule,191.97,2051.67,
Msh2 gene dup/delete variant,81297,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1644.59,,,,,,,fee schedule,191.97,2051.67,
Msh2 gene dup/delete variant,81297,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1796.57,,,,,,,fee schedule,191.97,2051.67,
Msh2 gene dup/delete variant,81297,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1888.84,,,,,,,fee schedule,191.97,2051.67,
Msh2 gene dup/delete variant,81297,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,191.97,,,,,,,fee schedule,191.97,2051.67,Laboratory
Msh2 gene dup/delete variant,81297,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,223.97,,,,,,,fee schedule,191.97,2051.67,APC
Msh2 gene dup/delete variant,81297,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,221.83,,,,,,,fee schedule,191.97,2051.67,APC
Msh2 gene dup/delete variant,81297,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.3,,,,,,,fee schedule,191.97,2051.67,APC
Msh2 gene dup/delete variant,81297,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,326.35,,,,,,,fee schedule,191.97,2051.67,Radiology
Msh2 gene dup/delete variant,81297,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,298.62,,,,,,,fee schedule,191.97,2051.67,APC
Msh2 gene dup/delete variant,81297,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,373.28,,,,,,,fee schedule,191.97,2051.67,APC
Msh6 gene full seq,81298,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2334.57,,,,,,,fee schedule,577.66,2334.57,
Msh6 gene full seq,81298,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1871.36,,,,,,,fee schedule,577.66,2334.57,
Msh6 gene full seq,81298,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2044.29,,,,,,,fee schedule,577.66,2334.57,
Msh6 gene full seq,81298,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2149.28,,,,,,,fee schedule,577.66,2334.57,
Msh6 gene full seq,81298,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,577.67,,,,,,,fee schedule,577.66,2334.57,Laboratory
Msh6 gene full seq,81298,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,673.94,,,,,,,fee schedule,577.66,2334.57,APC
Msh6 gene full seq,81298,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,667.52,,,,,,,fee schedule,577.66,2334.57,APC
Msh6 gene full seq,81298,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,641.85,,,,,,,fee schedule,577.66,2334.57,APC
Msh6 gene full seq,81298,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,982.03,,,,,,,fee schedule,577.66,2334.57,Radiology
Msh6 gene full seq,81298,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,898.59,,,,,,,fee schedule,577.66,2334.57,APC
Msh6 gene full seq,81298,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1123.24,,,,,,,fee schedule,577.66,2334.57,APC
Msh6 gene known variants,81299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,355.09,,,,,,,fee schedule,277.2,539,
Msh6 gene known variants,81299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,284.64,,,,,,,fee schedule,277.2,539,
Msh6 gene known variants,81299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,310.94,,,,,,,fee schedule,277.2,539,
Msh6 gene known variants,81299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,326.91,,,,,,,fee schedule,277.2,539,
Msh6 gene known variants,81299,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,277.2,,,,,,,fee schedule,277.2,539,Laboratory
Msh6 gene known variants,81299,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,323.4,,,,,,,fee schedule,277.2,539,APC
Msh6 gene known variants,81299,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,320.32,,,,,,,fee schedule,277.2,539,APC
Msh6 gene known variants,81299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,308,,,,,,,fee schedule,277.2,539,APC
Msh6 gene known variants,81299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,471.24,,,,,,,fee schedule,277.2,539,Radiology
Msh6 gene known variants,81299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,431.2,,,,,,,fee schedule,277.2,539,APC
Msh6 gene known variants,81299,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,539,,,,,,,fee schedule,277.2,539,APC
Msh6 gene dup/delete variant,81300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1909.47,,,,,,,fee schedule,214.2,1909.47,
Msh6 gene dup/delete variant,81300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1530.6,,,,,,,fee schedule,214.2,1909.47,
Msh6 gene dup/delete variant,81300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1672.05,,,,,,,fee schedule,214.2,1909.47,
Msh6 gene dup/delete variant,81300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1757.92,,,,,,,fee schedule,214.2,1909.47,
Msh6 gene dup/delete variant,81300,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,214.2,,,,,,,fee schedule,214.2,1909.47,Laboratory
Msh6 gene dup/delete variant,81300,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.9,,,,,,,fee schedule,214.2,1909.47,APC
Msh6 gene dup/delete variant,81300,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,247.52,,,,,,,fee schedule,214.2,1909.47,APC
Msh6 gene dup/delete variant,81300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,238,,,,,,,fee schedule,214.2,1909.47,APC
Msh6 gene dup/delete variant,81300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,364.14,,,,,,,fee schedule,214.2,1909.47,Radiology
Msh6 gene dup/delete variant,81300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,333.2,,,,,,,fee schedule,214.2,1909.47,APC
Msh6 gene dup/delete variant,81300,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,416.5,,,,,,,fee schedule,214.2,1909.47,APC
Microsatellite instability,81301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1477.08,,,,,,,fee schedule,313.7,1477.08,
Microsatellite instability,81301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1184.01,,,,,,,fee schedule,313.7,1477.08,
Microsatellite instability,81301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1293.42,,,,,,,fee schedule,313.7,1477.08,
Microsatellite instability,81301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1359.85,,,,,,,fee schedule,313.7,1477.08,
Microsatellite instability,81301,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,313.7,,,,,,,fee schedule,313.7,1477.08,Laboratory
Microsatellite instability,81301,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365.99,,,,,,,fee schedule,313.7,1477.08,APC
Microsatellite instability,81301,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,362.5,,,,,,,fee schedule,313.7,1477.08,APC
Microsatellite instability,81301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,348.56,,,,,,,fee schedule,313.7,1477.08,APC
Microsatellite instability,81301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,533.3,,,,,,,fee schedule,313.7,1477.08,Radiology
Microsatellite instability,81301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,487.98,,,,,,,fee schedule,313.7,1477.08,APC
Microsatellite instability,81301,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,609.98,,,,,,,fee schedule,313.7,1477.08,APC
Mecp2 gene full seq,81302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1182.91,,,,,,,fee schedule,475.08,1182.91,
Mecp2 gene full seq,81302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,948.21,,,,,,,fee schedule,475.08,1182.91,
Mecp2 gene full seq,81302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1035.83,,,,,,,fee schedule,475.08,1182.91,
Mecp2 gene full seq,81302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1089.03,,,,,,,fee schedule,475.08,1182.91,
Mecp2 gene full seq,81302,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,475.08,,,,,,,fee schedule,475.08,1182.91,Laboratory
Mecp2 gene full seq,81302,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,554.26,,,,,,,fee schedule,475.08,1182.91,APC
Mecp2 gene full seq,81302,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,548.98,,,,,,,fee schedule,475.08,1182.91,APC
Mecp2 gene full seq,81302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,527.87,,,,,,,fee schedule,475.08,1182.91,APC
Mecp2 gene full seq,81302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,807.64,,,,,,,fee schedule,475.08,1182.91,Radiology
Mecp2 gene full seq,81302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,739.02,,,,,,,fee schedule,475.08,1182.91,APC
Mecp2 gene full seq,81302,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,923.77,,,,,,,fee schedule,475.08,1182.91,APC
Mecp2 gene known variant,81303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,444.83,,,,,,,fee schedule,108,444.83,
Mecp2 gene known variant,81303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,356.57,,,,,,,fee schedule,108,444.83,
Mecp2 gene known variant,81303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,389.52,,,,,,,fee schedule,108,444.83,
Mecp2 gene known variant,81303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,409.53,,,,,,,fee schedule,108,444.83,
Mecp2 gene known variant,81303,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,108,,,,,,,fee schedule,108,444.83,Laboratory
Mecp2 gene known variant,81303,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,126,,,,,,,fee schedule,108,444.83,APC
Mecp2 gene known variant,81303,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,124.8,,,,,,,fee schedule,108,444.83,APC
Mecp2 gene known variant,81303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,120,,,,,,,fee schedule,108,444.83,APC
Mecp2 gene known variant,81303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,183.6,,,,,,,fee schedule,108,444.83,Radiology
Mecp2 gene known variant,81303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,168,,,,,,,fee schedule,108,444.83,APC
Mecp2 gene known variant,81303,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,210,,,,,,,fee schedule,108,444.83,APC
Mecp2 gene dup/delet variant,81304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,322.89,,,,,,,fee schedule,135,322.89,
Mecp2 gene dup/delet variant,81304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,258.82,,,,,,,fee schedule,135,322.89,
Mecp2 gene dup/delet variant,81304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,282.74,,,,,,,fee schedule,135,322.89,
Mecp2 gene dup/delet variant,81304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,297.26,,,,,,,fee schedule,135,322.89,
Mecp2 gene dup/delet variant,81304,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,135,,,,,,,fee schedule,135,322.89,Laboratory
Mecp2 gene dup/delet variant,81304,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,157.5,,,,,,,fee schedule,135,322.89,APC
Mecp2 gene dup/delet variant,81304,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,156,,,,,,,fee schedule,135,322.89,APC
Mecp2 gene dup/delet variant,81304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,150,,,,,,,fee schedule,135,322.89,APC
Mecp2 gene dup/delet variant,81304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,229.5,,,,,,,fee schedule,135,322.89,Radiology
Mecp2 gene dup/delet variant,81304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,210,,,,,,,fee schedule,135,322.89,APC
Mecp2 gene dup/delet variant,81304,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,262.5,,,,,,,fee schedule,135,322.89,APC
Myd88 gene p.leu265pro vrnt,81305,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,157.86,,,,,,,fee schedule,157.86,306.95,Laboratory
Myd88 gene p.leu265pro vrnt,81305,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,184.17,,,,,,,fee schedule,157.86,306.95,APC
Myd88 gene p.leu265pro vrnt,81305,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,182.42,,,,,,,fee schedule,157.86,306.95,APC
Myd88 gene p.leu265pro vrnt,81305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,175.4,,,,,,,fee schedule,157.86,306.95,APC
Myd88 gene p.leu265pro vrnt,81305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,268.36,,,,,,,fee schedule,157.86,306.95,Radiology
Myd88 gene p.leu265pro vrnt,81305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,245.56,,,,,,,fee schedule,157.86,306.95,APC
Myd88 gene p.leu265pro vrnt,81305,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,306.95,,,,,,,fee schedule,157.86,306.95,APC
Nudt15 gene common variants,81306,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,262.22,,,,,,,fee schedule,262.22,509.88,Laboratory
Nudt15 gene common variants,81306,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,305.93,,,,,,,fee schedule,262.22,509.88,APC
Nudt15 gene common variants,81306,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,303.01,,,,,,,fee schedule,262.22,509.88,APC
Nudt15 gene common variants,81306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,291.36,,,,,,,fee schedule,262.22,509.88,APC
Nudt15 gene common variants,81306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,445.78,,,,,,,fee schedule,262.22,509.88,Radiology
Nudt15 gene common variants,81306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,407.9,,,,,,,fee schedule,262.22,509.88,APC
Nudt15 gene common variants,81306,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,509.88,,,,,,,fee schedule,262.22,509.88,APC
Palb2 gene full gene seq,81307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1069.29,,,,,,,fee schedule,608.85,1183.88,
Palb2 gene full gene seq,81307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,857.13,,,,,,,fee schedule,608.85,1183.88,
Palb2 gene full gene seq,81307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,936.33,,,,,,,fee schedule,608.85,1183.88,
Palb2 gene full gene seq,81307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,984.42,,,,,,,fee schedule,608.85,1183.88,
Palb2 gene full gene seq,81307,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,608.85,,,,,,,fee schedule,608.85,1183.88,Laboratory
Palb2 gene full gene seq,81307,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,710.32,,,,,,,fee schedule,608.85,1183.88,APC
Palb2 gene full gene seq,81307,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,703.56,,,,,,,fee schedule,608.85,1183.88,APC
Palb2 gene full gene seq,81307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,676.5,,,,,,,fee schedule,608.85,1183.88,APC
Palb2 gene full gene seq,81307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1035.04,,,,,,,fee schedule,608.85,1183.88,Radiology
Palb2 gene full gene seq,81307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,947.1,,,,,,,fee schedule,608.85,1183.88,APC
Palb2 gene full gene seq,81307,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1183.88,,,,,,,fee schedule,608.85,1183.88,APC
Palb2 gene known famil vrnt,81308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1139.1,,,,,,,fee schedule,271.21,1139.1,
Palb2 gene known famil vrnt,81308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,913.09,,,,,,,fee schedule,271.21,1139.1,
Palb2 gene known famil vrnt,81308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,997.47,,,,,,,fee schedule,271.21,1139.1,
Palb2 gene known famil vrnt,81308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1048.7,,,,,,,fee schedule,271.21,1139.1,
Palb2 gene known famil vrnt,81308,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,271.22,,,,,,,fee schedule,271.21,1139.1,Laboratory
Palb2 gene known famil vrnt,81308,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,316.42,,,,,,,fee schedule,271.21,1139.1,APC
Palb2 gene known famil vrnt,81308,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,313.4,,,,,,,fee schedule,271.21,1139.1,APC
Palb2 gene known famil vrnt,81308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,301.35,,,,,,,fee schedule,271.21,1139.1,APC
Palb2 gene known famil vrnt,81308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,461.07,,,,,,,fee schedule,271.21,1139.1,Radiology
Palb2 gene known famil vrnt,81308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,421.89,,,,,,,fee schedule,271.21,1139.1,APC
Palb2 gene known famil vrnt,81308,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,527.36,,,,,,,fee schedule,271.21,1139.1,APC
Pik3ca gene trgt seq alys,81309,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1038.86,,,,,,,fee schedule,247.35,1038.86,
Pik3ca gene trgt seq alys,81309,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,832.73,,,,,,,fee schedule,247.35,1038.86,
Pik3ca gene trgt seq alys,81309,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,909.69,,,,,,,fee schedule,247.35,1038.86,
Pik3ca gene trgt seq alys,81309,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,956.41,,,,,,,fee schedule,247.35,1038.86,
Pik3ca gene trgt seq alys,81309,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,247.35,,,,,,,fee schedule,247.35,1038.86,Laboratory
Pik3ca gene trgt seq alys,81309,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,288.57,,,,,,,fee schedule,247.35,1038.86,APC
Pik3ca gene trgt seq alys,81309,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,285.82,,,,,,,fee schedule,247.35,1038.86,APC
Pik3ca gene trgt seq alys,81309,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,274.83,,,,,,,fee schedule,247.35,1038.86,APC
Pik3ca gene trgt seq alys,81309,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,420.49,,,,,,,fee schedule,247.35,1038.86,Radiology
Pik3ca gene trgt seq alys,81309,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,384.76,,,,,,,fee schedule,247.35,1038.86,APC
Pik3ca gene trgt seq alys,81309,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,480.95,,,,,,,fee schedule,247.35,1038.86,APC
Npm1 gene,81310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,222.42,,,,,,,fee schedule,178.29,431.41,
Npm1 gene,81310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,178.29,,,,,,,fee schedule,178.29,431.41,
Npm1 gene,81310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,194.76,,,,,,,fee schedule,178.29,431.41,
Npm1 gene,81310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,204.76,,,,,,,fee schedule,178.29,431.41,
Npm1 gene,81310,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,221.87,,,,,,,fee schedule,178.29,431.41,Laboratory
Npm1 gene,81310,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,258.85,,,,,,,fee schedule,178.29,431.41,APC
Npm1 gene,81310,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,256.38,,,,,,,fee schedule,178.29,431.41,APC
Npm1 gene,81310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,246.52,,,,,,,fee schedule,178.29,431.41,APC
Npm1 gene,81310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,377.18,,,,,,,fee schedule,178.29,431.41,Radiology
Npm1 gene,81310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,345.13,,,,,,,fee schedule,178.29,431.41,APC
Npm1 gene,81310,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,431.41,,,,,,,fee schedule,178.29,431.41,APC
Nras gene variants exon 2&3,81311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,827.37,,,,,,,fee schedule,266.21,827.37,
Nras gene variants exon 2&3,81311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,663.21,,,,,,,fee schedule,266.21,827.37,
Nras gene variants exon 2&3,81311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,724.49,,,,,,,fee schedule,266.21,827.37,
Nras gene variants exon 2&3,81311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,761.7,,,,,,,fee schedule,266.21,827.37,
Nras gene variants exon 2&3,81311,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,266.21,,,,,,,fee schedule,266.21,827.37,Laboratory
Nras gene variants exon 2&3,81311,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,310.58,,,,,,,fee schedule,266.21,827.37,APC
Nras gene variants exon 2&3,81311,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,307.62,,,,,,,fee schedule,266.21,827.37,APC
Nras gene variants exon 2&3,81311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,295.79,,,,,,,fee schedule,266.21,827.37,APC
Nras gene variants exon 2&3,81311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,452.56,,,,,,,fee schedule,266.21,827.37,Radiology
Nras gene variants exon 2&3,81311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,414.11,,,,,,,fee schedule,266.21,827.37,APC
Nras gene variants exon 2&3,81311,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,517.63,,,,,,,fee schedule,266.21,827.37,APC
Pabpn1 gene detc abnor allel,81312,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,123.3,,,,,,,fee schedule,123.3,239.75,Laboratory
Pabpn1 gene detc abnor allel,81312,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,143.85,,,,,,,fee schedule,123.3,239.75,APC
Pabpn1 gene detc abnor allel,81312,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,142.48,,,,,,,fee schedule,123.3,239.75,APC
Pabpn1 gene detc abnor allel,81312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,137,,,,,,,fee schedule,123.3,239.75,APC
Pabpn1 gene detc abnor allel,81312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,209.61,,,,,,,fee schedule,123.3,239.75,Radiology
Pabpn1 gene detc abnor allel,81312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,191.8,,,,,,,fee schedule,123.3,239.75,APC
Pabpn1 gene detc abnor allel,81312,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,239.75,,,,,,,fee schedule,123.3,239.75,APC
Pca3/klk3 antigen,81313,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,229.54,,,,,,,fee schedule,229.54,446.34,Laboratory
Pca3/klk3 antigen,81313,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,267.8,,,,,,,fee schedule,229.54,446.34,APC
Pca3/klk3 antigen,81313,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,265.25,,,,,,,fee schedule,229.54,446.34,APC
Pca3/klk3 antigen,81313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,255.05,,,,,,,fee schedule,229.54,446.34,APC
Pca3/klk3 antigen,81313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,390.23,,,,,,,fee schedule,229.54,446.34,Radiology
Pca3/klk3 antigen,81313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,357.07,,,,,,,fee schedule,229.54,446.34,APC
Pca3/klk3 antigen,81313,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,446.34,,,,,,,fee schedule,229.54,446.34,APC
Pdgfra gene,81314,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,921.72,,,,,,,fee schedule,296.56,921.72,
Pdgfra gene,81314,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,738.84,,,,,,,fee schedule,296.56,921.72,
Pdgfra gene,81314,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,807.11,,,,,,,fee schedule,296.56,921.72,
Pdgfra gene,81314,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,848.56,,,,,,,fee schedule,296.56,921.72,
Pdgfra gene,81314,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,296.56,,,,,,,fee schedule,296.56,921.72,Laboratory
Pdgfra gene,81314,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,345.99,,,,,,,fee schedule,296.56,921.72,APC
Pdgfra gene,81314,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,342.69,,,,,,,fee schedule,296.56,921.72,APC
Pdgfra gene,81314,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,329.51,,,,,,,fee schedule,296.56,921.72,APC
Pdgfra gene,81314,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,504.15,,,,,,,fee schedule,296.56,921.72,Radiology
Pdgfra gene,81314,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,461.31,,,,,,,fee schedule,296.56,921.72,APC
Pdgfra gene,81314,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,576.64,,,,,,,fee schedule,296.56,921.72,APC
Pml/raralpha com breakpoints,81315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,444.3,,,,,,,fee schedule,186.58,444.3,
Pml/raralpha com breakpoints,81315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,356.15,,,,,,,fee schedule,186.58,444.3,
Pml/raralpha com breakpoints,81315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,389.06,,,,,,,fee schedule,186.58,444.3,
Pml/raralpha com breakpoints,81315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,409.04,,,,,,,fee schedule,186.58,444.3,
Pml/raralpha com breakpoints,81315,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,186.58,,,,,,,fee schedule,186.58,444.3,Laboratory
Pml/raralpha com breakpoints,81315,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,217.68,,,,,,,fee schedule,186.58,444.3,APC
Pml/raralpha com breakpoints,81315,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,215.6,,,,,,,fee schedule,186.58,444.3,APC
Pml/raralpha com breakpoints,81315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,207.31,,,,,,,fee schedule,186.58,444.3,APC
Pml/raralpha com breakpoints,81315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,317.18,,,,,,,fee schedule,186.58,444.3,Radiology
Pml/raralpha com breakpoints,81315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,290.23,,,,,,,fee schedule,186.58,444.3,APC
Pml/raralpha com breakpoints,81315,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,362.79,,,,,,,fee schedule,186.58,444.3,APC
Pml/raralpha 1 breakpoint,81316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1626.57,,,,,,,fee schedule,186.58,1626.57,
Pml/raralpha 1 breakpoint,81316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1303.84,,,,,,,fee schedule,186.58,1626.57,
Pml/raralpha 1 breakpoint,81316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1424.33,,,,,,,fee schedule,186.58,1626.57,
Pml/raralpha 1 breakpoint,81316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1497.48,,,,,,,fee schedule,186.58,1626.57,
Pml/raralpha 1 breakpoint,81316,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,186.58,,,,,,,fee schedule,186.58,1626.57,Laboratory
Pml/raralpha 1 breakpoint,81316,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,217.68,,,,,,,fee schedule,186.58,1626.57,APC
Pml/raralpha 1 breakpoint,81316,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,215.6,,,,,,,fee schedule,186.58,1626.57,APC
Pml/raralpha 1 breakpoint,81316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,207.31,,,,,,,fee schedule,186.58,1626.57,APC
Pml/raralpha 1 breakpoint,81316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,317.18,,,,,,,fee schedule,186.58,1626.57,Radiology
Pml/raralpha 1 breakpoint,81316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,290.23,,,,,,,fee schedule,186.58,1626.57,APC
Pml/raralpha 1 breakpoint,81316,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,362.79,,,,,,,fee schedule,186.58,1626.57,APC
Pms2 gene full seq analysis,81317,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2428.95,,,,,,,fee schedule,608.85,2428.95,
Pms2 gene full seq analysis,81317,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1947.02,,,,,,,fee schedule,608.85,2428.95,
Pms2 gene full seq analysis,81317,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2126.94,,,,,,,fee schedule,608.85,2428.95,
Pms2 gene full seq analysis,81317,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2236.18,,,,,,,fee schedule,608.85,2428.95,
Pms2 gene full seq analysis,81317,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,608.85,,,,,,,fee schedule,608.85,2428.95,Laboratory
Pms2 gene full seq analysis,81317,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,710.32,,,,,,,fee schedule,608.85,2428.95,APC
Pms2 gene full seq analysis,81317,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,703.56,,,,,,,fee schedule,608.85,2428.95,APC
Pms2 gene full seq analysis,81317,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,676.5,,,,,,,fee schedule,608.85,2428.95,APC
Pms2 gene full seq analysis,81317,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1035.04,,,,,,,fee schedule,608.85,2428.95,Radiology
Pms2 gene full seq analysis,81317,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,947.1,,,,,,,fee schedule,608.85,2428.95,APC
Pms2 gene full seq analysis,81317,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1183.88,,,,,,,fee schedule,608.85,2428.95,APC
Pms2 known familial variants,81318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,355.09,,,,,,,fee schedule,284.64,579.25,
Pms2 known familial variants,81318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,284.64,,,,,,,fee schedule,284.64,579.25,
Pms2 known familial variants,81318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,310.94,,,,,,,fee schedule,284.64,579.25,
Pms2 known familial variants,81318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,326.91,,,,,,,fee schedule,284.64,579.25,
Pms2 known familial variants,81318,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,297.9,,,,,,,fee schedule,284.64,579.25,Laboratory
Pms2 known familial variants,81318,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,347.55,,,,,,,fee schedule,284.64,579.25,APC
Pms2 known familial variants,81318,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,344.24,,,,,,,fee schedule,284.64,579.25,APC
Pms2 known familial variants,81318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,331,,,,,,,fee schedule,284.64,579.25,APC
Pms2 known familial variants,81318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,506.43,,,,,,,fee schedule,284.64,579.25,Radiology
Pms2 known familial variants,81318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,463.4,,,,,,,fee schedule,284.64,579.25,APC
Pms2 known familial variants,81318,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,579.25,,,,,,,fee schedule,284.64,579.25,APC
Pms2 gene dup/delet variants,81319,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1747.95,,,,,,,fee schedule,183.15,1747.95,
Pms2 gene dup/delet variants,81319,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1401.13,,,,,,,fee schedule,183.15,1747.95,
Pms2 gene dup/delet variants,81319,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1530.61,,,,,,,fee schedule,183.15,1747.95,
Pms2 gene dup/delet variants,81319,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1609.22,,,,,,,fee schedule,183.15,1747.95,
Pms2 gene dup/delet variants,81319,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,183.15,,,,,,,fee schedule,183.15,1747.95,Laboratory
Pms2 gene dup/delet variants,81319,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,213.68,,,,,,,fee schedule,183.15,1747.95,APC
Pms2 gene dup/delet variants,81319,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,211.64,,,,,,,fee schedule,183.15,1747.95,APC
Pms2 gene dup/delet variants,81319,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,203.5,,,,,,,fee schedule,183.15,1747.95,APC
Pms2 gene dup/delet variants,81319,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,311.36,,,,,,,fee schedule,183.15,1747.95,Radiology
Pms2 gene dup/delet variants,81319,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,284.9,,,,,,,fee schedule,183.15,1747.95,APC
Pms2 gene dup/delet variants,81319,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,356.12,,,,,,,fee schedule,183.15,1747.95,APC
Plcg2 gene common variants,81320,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,262.22,,,,,,,fee schedule,262.22,509.88,Laboratory
Plcg2 gene common variants,81320,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,305.93,,,,,,,fee schedule,262.22,509.88,APC
Plcg2 gene common variants,81320,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,303.01,,,,,,,fee schedule,262.22,509.88,APC
Plcg2 gene common variants,81320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,291.36,,,,,,,fee schedule,262.22,509.88,APC
Plcg2 gene common variants,81320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,445.78,,,,,,,fee schedule,262.22,509.88,Radiology
Plcg2 gene common variants,81320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,407.9,,,,,,,fee schedule,262.22,509.88,APC
Plcg2 gene common variants,81320,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,509.88,,,,,,,fee schedule,262.22,509.88,APC
Pten gene full sequence,81321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2287.81,,,,,,,fee schedule,540,2287.81,
Pten gene full sequence,81321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1833.88,,,,,,,fee schedule,540,2287.81,
Pten gene full sequence,81321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2003.34,,,,,,,fee schedule,540,2287.81,
Pten gene full sequence,81321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2106.24,,,,,,,fee schedule,540,2287.81,
Pten gene full sequence,81321,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,540,,,,,,,fee schedule,540,2287.81,Laboratory
Pten gene full sequence,81321,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,630,,,,,,,fee schedule,540,2287.81,APC
Pten gene full sequence,81321,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,624,,,,,,,fee schedule,540,2287.81,APC
Pten gene full sequence,81321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,600,,,,,,,fee schedule,540,2287.81,APC
Pten gene full sequence,81321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,918,,,,,,,fee schedule,540,2287.81,Radiology
Pten gene full sequence,81321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,840,,,,,,,fee schedule,540,2287.81,APC
Pten gene full sequence,81321,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1050,,,,,,,fee schedule,540,2287.81,APC
Pten gene known fam variant,81322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,222.42,,,,,,,fee schedule,41.94,222.42,
Pten gene known fam variant,81322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,178.29,,,,,,,fee schedule,41.94,222.42,
Pten gene known fam variant,81322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,194.76,,,,,,,fee schedule,41.94,222.42,
Pten gene known fam variant,81322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,204.76,,,,,,,fee schedule,41.94,222.42,
Pten gene known fam variant,81322,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,41.94,,,,,,,fee schedule,41.94,222.42,Laboratory
Pten gene known fam variant,81322,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,48.93,,,,,,,fee schedule,41.94,222.42,APC
Pten gene known fam variant,81322,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,48.46,,,,,,,fee schedule,41.94,222.42,APC
Pten gene known fam variant,81322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,46.6,,,,,,,fee schedule,41.94,222.42,APC
Pten gene known fam variant,81322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,71.3,,,,,,,fee schedule,41.94,222.42,Radiology
Pten gene known fam variant,81322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,65.24,,,,,,,fee schedule,41.94,222.42,APC
Pten gene known fam variant,81322,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,81.55,,,,,,,fee schedule,41.94,222.42,APC
Pten gene dup/delet variant,81323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,333.62,,,,,,,fee schedule,267.43,525,
Pten gene dup/delet variant,81323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,267.43,,,,,,,fee schedule,267.43,525,
Pten gene dup/delet variant,81323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,292.14,,,,,,,fee schedule,267.43,525,
Pten gene dup/delet variant,81323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,307.14,,,,,,,fee schedule,267.43,525,
Pten gene dup/delet variant,81323,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,270,,,,,,,fee schedule,267.43,525,Laboratory
Pten gene dup/delet variant,81323,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,315,,,,,,,fee schedule,267.43,525,APC
Pten gene dup/delet variant,81323,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,312,,,,,,,fee schedule,267.43,525,APC
Pten gene dup/delet variant,81323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,300,,,,,,,fee schedule,267.43,525,APC
Pten gene dup/delet variant,81323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,459,,,,,,,fee schedule,267.43,525,Radiology
Pten gene dup/delet variant,81323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,420,,,,,,,fee schedule,267.43,525,APC
Pten gene dup/delet variant,81323,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,525,,,,,,,fee schedule,267.43,525,APC
Pmp22 gene dup/delet,81324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1837.68,,,,,,,fee schedule,682.52,1837.68,
Pmp22 gene dup/delet,81324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1473.06,,,,,,,fee schedule,682.52,1837.68,
Pmp22 gene dup/delet,81324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1609.19,,,,,,,fee schedule,682.52,1837.68,
Pmp22 gene dup/delet,81324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1691.84,,,,,,,fee schedule,682.52,1837.68,
Pmp22 gene dup/delet,81324,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,682.52,,,,,,,fee schedule,682.52,1837.68,Laboratory
Pmp22 gene dup/delet,81324,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,796.28,,,,,,,fee schedule,682.52,1837.68,APC
Pmp22 gene dup/delet,81324,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,788.69,,,,,,,fee schedule,682.52,1837.68,APC
Pmp22 gene dup/delet,81324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,758.36,,,,,,,fee schedule,682.52,1837.68,APC
Pmp22 gene dup/delet,81324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1160.29,,,,,,,fee schedule,682.52,1837.68,Radiology
Pmp22 gene dup/delet,81324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1061.7,,,,,,,fee schedule,682.52,1837.68,APC
Pmp22 gene dup/delet,81324,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1327.13,,,,,,,fee schedule,682.52,1837.68,APC
Pmp22 gene full sequence,81325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1123.57,,,,,,,fee schedule,692.62,1346.76,
Pmp22 gene full sequence,81325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,900.64,,,,,,,fee schedule,692.62,1346.76,
Pmp22 gene full sequence,81325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,983.86,,,,,,,fee schedule,692.62,1346.76,
Pmp22 gene full sequence,81325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1034.4,,,,,,,fee schedule,692.62,1346.76,
Pmp22 gene full sequence,81325,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,692.62,,,,,,,fee schedule,692.62,1346.76,Laboratory
Pmp22 gene full sequence,81325,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,808.06,,,,,,,fee schedule,692.62,1346.76,APC
Pmp22 gene full sequence,81325,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,800.36,,,,,,,fee schedule,692.62,1346.76,APC
Pmp22 gene full sequence,81325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,769.58,,,,,,,fee schedule,692.62,1346.76,APC
Pmp22 gene full sequence,81325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1177.46,,,,,,,fee schedule,692.62,1346.76,Radiology
Pmp22 gene full sequence,81325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1077.41,,,,,,,fee schedule,692.62,1346.76,APC
Pmp22 gene full sequence,81325,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1346.76,,,,,,,fee schedule,692.62,1346.76,APC
Pmp22 gene known fam variant,81326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,355.09,,,,,,,fee schedule,41.94,355.09,
Pmp22 gene known fam variant,81326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,284.64,,,,,,,fee schedule,41.94,355.09,
Pmp22 gene known fam variant,81326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,310.94,,,,,,,fee schedule,41.94,355.09,
Pmp22 gene known fam variant,81326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,326.91,,,,,,,fee schedule,41.94,355.09,
Pmp22 gene known fam variant,81326,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,41.94,,,,,,,fee schedule,41.94,355.09,Laboratory
Pmp22 gene known fam variant,81326,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,48.93,,,,,,,fee schedule,41.94,355.09,APC
Pmp22 gene known fam variant,81326,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,48.46,,,,,,,fee schedule,41.94,355.09,APC
Pmp22 gene known fam variant,81326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,46.6,,,,,,,fee schedule,41.94,355.09,APC
Pmp22 gene known fam variant,81326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,71.3,,,,,,,fee schedule,41.94,355.09,Radiology
Pmp22 gene known fam variant,81326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,65.24,,,,,,,fee schedule,41.94,355.09,APC
Pmp22 gene known fam variant,81326,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,81.55,,,,,,,fee schedule,41.94,355.09,APC
Sept9 methylation analysis,81327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,316.27,,,,,,,fee schedule,172.8,336,
Sept9 methylation analysis,81327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,253.52,,,,,,,fee schedule,172.8,336,
Sept9 methylation analysis,81327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,276.95,,,,,,,fee schedule,172.8,336,
Sept9 methylation analysis,81327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,291.17,,,,,,,fee schedule,172.8,336,
Sept9 methylation analysis,81327,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,172.8,,,,,,,fee schedule,172.8,336,Laboratory
Sept9 methylation analysis,81327,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,201.6,,,,,,,fee schedule,172.8,336,APC
Sept9 methylation analysis,81327,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,199.68,,,,,,,fee schedule,172.8,336,APC
Sept9 methylation analysis,81327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,192,,,,,,,fee schedule,172.8,336,APC
Sept9 methylation analysis,81327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,293.76,,,,,,,fee schedule,172.8,336,Radiology
Sept9 methylation analysis,81327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,268.8,,,,,,,fee schedule,172.8,336,APC
Sept9 methylation analysis,81327,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,336,,,,,,,fee schedule,172.8,336,APC
Slco1b1 gene com variants,81328,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,157.33,,,,,,,fee schedule,157.33,305.92,Laboratory
Slco1b1 gene com variants,81328,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.55,,,,,,,fee schedule,157.33,305.92,APC
Slco1b1 gene com variants,81328,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,181.8,,,,,,,fee schedule,157.33,305.92,APC
Slco1b1 gene com variants,81328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,174.81,,,,,,,fee schedule,157.33,305.92,APC
Slco1b1 gene com variants,81328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,267.46,,,,,,,fee schedule,157.33,305.92,Radiology
Slco1b1 gene com variants,81328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,244.73,,,,,,,fee schedule,157.33,305.92,APC
Slco1b1 gene com variants,81328,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,305.92,,,,,,,fee schedule,157.33,305.92,APC
Smn1 gene dos/deletion alys,81329,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,123.3,,,,,,,fee schedule,123.3,239.75,Laboratory
Smn1 gene dos/deletion alys,81329,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,143.85,,,,,,,fee schedule,123.3,239.75,APC
Smn1 gene dos/deletion alys,81329,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,142.48,,,,,,,fee schedule,123.3,239.75,APC
Smn1 gene dos/deletion alys,81329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,137,,,,,,,fee schedule,123.3,239.75,APC
Smn1 gene dos/deletion alys,81329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,209.61,,,,,,,fee schedule,123.3,239.75,Radiology
Smn1 gene dos/deletion alys,81329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,191.8,,,,,,,fee schedule,123.3,239.75,APC
Smn1 gene dos/deletion alys,81329,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,239.75,,,,,,,fee schedule,123.3,239.75,APC
Smpd1 gene common variants,81330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,354.94,,,,,,,fee schedule,42.3,354.94,
Smpd1 gene common variants,81330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,284.52,,,,,,,fee schedule,42.3,354.94,
Smpd1 gene common variants,81330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,310.81,,,,,,,fee schedule,42.3,354.94,
Smpd1 gene common variants,81330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,326.77,,,,,,,fee schedule,42.3,354.94,
Smpd1 gene common variants,81330,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,42.3,,,,,,,fee schedule,42.3,354.94,Laboratory
Smpd1 gene common variants,81330,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,49.35,,,,,,,fee schedule,42.3,354.94,APC
Smpd1 gene common variants,81330,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,48.88,,,,,,,fee schedule,42.3,354.94,APC
Smpd1 gene common variants,81330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,47,,,,,,,fee schedule,42.3,354.94,APC
Smpd1 gene common variants,81330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,71.91,,,,,,,fee schedule,42.3,354.94,Radiology
Smpd1 gene common variants,81330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,65.8,,,,,,,fee schedule,42.3,354.94,APC
Smpd1 gene common variants,81330,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,82.25,,,,,,,fee schedule,42.3,354.94,APC
Snrpn/ube3a gene,81331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,276.77,,,,,,,fee schedule,45.96,276.77,
Snrpn/ube3a gene,81331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,221.86,,,,,,,fee schedule,45.96,276.77,
Snrpn/ube3a gene,81331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,242.36,,,,,,,fee schedule,45.96,276.77,
Snrpn/ube3a gene,81331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,254.81,,,,,,,fee schedule,45.96,276.77,
Snrpn/ube3a gene,81331,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,45.96,,,,,,,fee schedule,45.96,276.77,Laboratory
Snrpn/ube3a gene,81331,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,53.62,,,,,,,fee schedule,45.96,276.77,APC
Snrpn/ube3a gene,81331,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,53.11,,,,,,,fee schedule,45.96,276.77,APC
Snrpn/ube3a gene,81331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,51.07,,,,,,,fee schedule,45.96,276.77,APC
Snrpn/ube3a gene,81331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,78.14,,,,,,,fee schedule,45.96,276.77,Radiology
Snrpn/ube3a gene,81331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,71.5,,,,,,,fee schedule,45.96,276.77,APC
Snrpn/ube3a gene,81331,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,89.37,,,,,,,fee schedule,45.96,276.77,APC
Serpina1 gene,81332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,265.36,,,,,,,fee schedule,39.28,265.36,
Serpina1 gene,81332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,212.71,,,,,,,fee schedule,39.28,265.36,
Serpina1 gene,81332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,232.36,,,,,,,fee schedule,39.28,265.36,
Serpina1 gene,81332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,244.3,,,,,,,fee schedule,39.28,265.36,
Serpina1 gene,81332,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,39.28,,,,,,,fee schedule,39.28,265.36,Laboratory
Serpina1 gene,81332,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,45.83,,,,,,,fee schedule,39.28,265.36,APC
Serpina1 gene,81332,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,45.4,,,,,,,fee schedule,39.28,265.36,APC
Serpina1 gene,81332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,43.65,,,,,,,fee schedule,39.28,265.36,APC
Serpina1 gene,81332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,66.78,,,,,,,fee schedule,39.28,265.36,Radiology
Serpina1 gene,81332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,61.11,,,,,,,fee schedule,39.28,265.36,APC
Serpina1 gene,81332,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,76.39,,,,,,,fee schedule,39.28,265.36,APC
Tgfbi gene common variants,81333,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,123.3,,,,,,,fee schedule,123.3,239.75,Laboratory
Tgfbi gene common variants,81333,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,143.85,,,,,,,fee schedule,123.3,239.75,APC
Tgfbi gene common variants,81333,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,142.48,,,,,,,fee schedule,123.3,239.75,APC
Tgfbi gene common variants,81333,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,137,,,,,,,fee schedule,123.3,239.75,APC
Tgfbi gene common variants,81333,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,209.61,,,,,,,fee schedule,123.3,239.75,Radiology
Tgfbi gene common variants,81333,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,191.8,,,,,,,fee schedule,123.3,239.75,APC
Tgfbi gene common variants,81333,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,239.75,,,,,,,fee schedule,123.3,239.75,APC
Runx1 gene targeted seq alys,81334,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,296.56,,,,,,,fee schedule,296.56,576.64,Laboratory
Runx1 gene targeted seq alys,81334,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,345.99,,,,,,,fee schedule,296.56,576.64,APC
Runx1 gene targeted seq alys,81334,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,342.69,,,,,,,fee schedule,296.56,576.64,APC
Runx1 gene targeted seq alys,81334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,329.51,,,,,,,fee schedule,296.56,576.64,APC
Runx1 gene targeted seq alys,81334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,504.15,,,,,,,fee schedule,296.56,576.64,Radiology
Runx1 gene targeted seq alys,81334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,461.31,,,,,,,fee schedule,296.56,576.64,APC
Runx1 gene targeted seq alys,81334,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,576.64,,,,,,,fee schedule,296.56,576.64,APC
Tpmt gene com variants,81335,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,157.33,,,,,,,fee schedule,157.33,305.92,Laboratory
Tpmt gene com variants,81335,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.55,,,,,,,fee schedule,157.33,305.92,APC
Tpmt gene com variants,81335,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,181.8,,,,,,,fee schedule,157.33,305.92,APC
Tpmt gene com variants,81335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,174.81,,,,,,,fee schedule,157.33,305.92,APC
Tpmt gene com variants,81335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,267.46,,,,,,,fee schedule,157.33,305.92,Radiology
Tpmt gene com variants,81335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,244.73,,,,,,,fee schedule,157.33,305.92,APC
Tpmt gene com variants,81335,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,305.92,,,,,,,fee schedule,157.33,305.92,APC
Smn1 gene full gene sequence,81336,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,271.22,,,,,,,fee schedule,271.21,527.36,Laboratory
Smn1 gene full gene sequence,81336,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,316.42,,,,,,,fee schedule,271.21,527.36,APC
Smn1 gene full gene sequence,81336,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,313.4,,,,,,,fee schedule,271.21,527.36,APC
Smn1 gene full gene sequence,81336,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,301.35,,,,,,,fee schedule,271.21,527.36,APC
Smn1 gene full gene sequence,81336,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,461.07,,,,,,,fee schedule,271.21,527.36,Radiology
Smn1 gene full gene sequence,81336,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,421.89,,,,,,,fee schedule,271.21,527.36,APC
Smn1 gene full gene sequence,81336,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,527.36,,,,,,,fee schedule,271.21,527.36,APC
Smn1 gen nown famil seq vrnt,81337,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,166.68,,,,,,,fee schedule,166.68,324.1,Laboratory
Smn1 gen nown famil seq vrnt,81337,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,194.46,,,,,,,fee schedule,166.68,324.1,APC
Smn1 gen nown famil seq vrnt,81337,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,192.61,,,,,,,fee schedule,166.68,324.1,APC
Smn1 gen nown famil seq vrnt,81337,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,185.2,,,,,,,fee schedule,166.68,324.1,APC
Smn1 gen nown famil seq vrnt,81337,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,283.36,,,,,,,fee schedule,166.68,324.1,Radiology
Smn1 gen nown famil seq vrnt,81337,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,259.28,,,,,,,fee schedule,166.68,324.1,APC
Smn1 gen nown famil seq vrnt,81337,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,324.1,,,,,,,fee schedule,166.68,324.1,APC
Mpl gene common variants,81338,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,135.3,,,,,,,fee schedule,135.3,263.08,Laboratory
Mpl gene common variants,81338,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,157.85,,,,,,,fee schedule,135.3,263.08,APC
Mpl gene common variants,81338,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,156.34,,,,,,,fee schedule,135.3,263.08,APC
Mpl gene common variants,81338,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,150.33,,,,,,,fee schedule,135.3,263.08,APC
Mpl gene common variants,81338,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,230,,,,,,,fee schedule,135.3,263.08,Radiology
Mpl gene common variants,81338,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,210.46,,,,,,,fee schedule,135.3,263.08,APC
Mpl gene common variants,81338,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,263.08,,,,,,,fee schedule,135.3,263.08,APC
Mpl gene seq alys exon 10,81339,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,166.68,,,,,,,fee schedule,166.68,324.1,Laboratory
Mpl gene seq alys exon 10,81339,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,194.46,,,,,,,fee schedule,166.68,324.1,APC
Mpl gene seq alys exon 10,81339,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,192.61,,,,,,,fee schedule,166.68,324.1,APC
Mpl gene seq alys exon 10,81339,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,185.2,,,,,,,fee schedule,166.68,324.1,APC
Mpl gene seq alys exon 10,81339,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,283.36,,,,,,,fee schedule,166.68,324.1,Radiology
Mpl gene seq alys exon 10,81339,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,259.28,,,,,,,fee schedule,166.68,324.1,APC
Mpl gene seq alys exon 10,81339,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,324.1,,,,,,,fee schedule,166.68,324.1,APC
Trb@ gene rearrange amplify,81340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,559.89,,,,,,,fee schedule,188.03,559.89,
Trb@ gene rearrange amplify,81340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,448.8,,,,,,,fee schedule,188.03,559.89,
Trb@ gene rearrange amplify,81340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,490.28,,,,,,,fee schedule,188.03,559.89,
Trb@ gene rearrange amplify,81340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,515.46,,,,,,,fee schedule,188.03,559.89,
Trb@ gene rearrange amplify,81340,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,188.03,,,,,,,fee schedule,188.03,559.89,Laboratory
Trb@ gene rearrange amplify,81340,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,219.37,,,,,,,fee schedule,188.03,559.89,APC
Trb@ gene rearrange amplify,81340,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,217.28,,,,,,,fee schedule,188.03,559.89,APC
Trb@ gene rearrange amplify,81340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,208.92,,,,,,,fee schedule,188.03,559.89,APC
Trb@ gene rearrange amplify,81340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,319.65,,,,,,,fee schedule,188.03,559.89,Radiology
Trb@ gene rearrange amplify,81340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,292.49,,,,,,,fee schedule,188.03,559.89,APC
Trb@ gene rearrange amplify,81340,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,365.61,,,,,,,fee schedule,188.03,559.89,APC
Trb@ gene rearrange dirprobe,81341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,171.76,,,,,,,fee schedule,44.63,171.76,
Trb@ gene rearrange dirprobe,81341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,137.68,,,,,,,fee schedule,44.63,171.76,
Trb@ gene rearrange dirprobe,81341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,150.41,,,,,,,fee schedule,44.63,171.76,
Trb@ gene rearrange dirprobe,81341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,158.13,,,,,,,fee schedule,44.63,171.76,
Trb@ gene rearrange dirprobe,81341,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,44.63,,,,,,,fee schedule,44.63,171.76,Laboratory
Trb@ gene rearrange dirprobe,81341,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,52.07,,,,,,,fee schedule,44.63,171.76,APC
Trb@ gene rearrange dirprobe,81341,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,51.57,,,,,,,fee schedule,44.63,171.76,APC
Trb@ gene rearrange dirprobe,81341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,49.59,,,,,,,fee schedule,44.63,171.76,APC
Trb@ gene rearrange dirprobe,81341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,75.87,,,,,,,fee schedule,44.63,171.76,Radiology
Trb@ gene rearrange dirprobe,81341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,69.43,,,,,,,fee schedule,44.63,171.76,APC
Trb@ gene rearrange dirprobe,81341,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,86.78,,,,,,,fee schedule,44.63,171.76,APC
Trg gene rearrangement anal,81342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,475.33,,,,,,,fee schedule,181.35,475.33,
Trg gene rearrangement anal,81342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,381.02,,,,,,,fee schedule,181.35,475.33,
Trg gene rearrangement anal,81342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,416.23,,,,,,,fee schedule,181.35,475.33,
Trg gene rearrangement anal,81342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,437.61,,,,,,,fee schedule,181.35,475.33,
Trg gene rearrangement anal,81342,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,181.35,,,,,,,fee schedule,181.35,475.33,Laboratory
Trg gene rearrangement anal,81342,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,211.58,,,,,,,fee schedule,181.35,475.33,APC
Trg gene rearrangement anal,81342,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,209.56,,,,,,,fee schedule,181.35,475.33,APC
Trg gene rearrangement anal,81342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,201.5,,,,,,,fee schedule,181.35,475.33,APC
Trg gene rearrangement anal,81342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,308.3,,,,,,,fee schedule,181.35,475.33,Radiology
Trg gene rearrangement anal,81342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,282.1,,,,,,,fee schedule,181.35,475.33,APC
Trg gene rearrangement anal,81342,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,352.62,,,,,,,fee schedule,181.35,475.33,APC
Ppp2r2b gen detc abnor allel,81343,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,123.3,,,,,,,fee schedule,123.3,239.75,Laboratory
Ppp2r2b gen detc abnor allel,81343,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,143.85,,,,,,,fee schedule,123.3,239.75,APC
Ppp2r2b gen detc abnor allel,81343,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,142.48,,,,,,,fee schedule,123.3,239.75,APC
Ppp2r2b gen detc abnor allel,81343,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,137,,,,,,,fee schedule,123.3,239.75,APC
Ppp2r2b gen detc abnor allel,81343,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,209.61,,,,,,,fee schedule,123.3,239.75,Radiology
Ppp2r2b gen detc abnor allel,81343,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,191.8,,,,,,,fee schedule,123.3,239.75,APC
Ppp2r2b gen detc abnor allel,81343,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,239.75,,,,,,,fee schedule,123.3,239.75,APC
Tbp gene detc abnor alleles,81344,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,123.3,,,,,,,fee schedule,123.3,239.75,Laboratory
Tbp gene detc abnor alleles,81344,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,143.85,,,,,,,fee schedule,123.3,239.75,APC
Tbp gene detc abnor alleles,81344,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,142.48,,,,,,,fee schedule,123.3,239.75,APC
Tbp gene detc abnor alleles,81344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,137,,,,,,,fee schedule,123.3,239.75,APC
Tbp gene detc abnor alleles,81344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,209.61,,,,,,,fee schedule,123.3,239.75,Radiology
Tbp gene detc abnor alleles,81344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,191.8,,,,,,,fee schedule,123.3,239.75,APC
Tbp gene detc abnor alleles,81344,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,239.75,,,,,,,fee schedule,123.3,239.75,APC
Tert gene targeted seq alys,81345,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,166.68,,,,,,,fee schedule,166.68,324.1,Laboratory
Tert gene targeted seq alys,81345,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,194.46,,,,,,,fee schedule,166.68,324.1,APC
Tert gene targeted seq alys,81345,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,192.61,,,,,,,fee schedule,166.68,324.1,APC
Tert gene targeted seq alys,81345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,185.2,,,,,,,fee schedule,166.68,324.1,APC
Tert gene targeted seq alys,81345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,283.36,,,,,,,fee schedule,166.68,324.1,Radiology
Tert gene targeted seq alys,81345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,259.28,,,,,,,fee schedule,166.68,324.1,APC
Tert gene targeted seq alys,81345,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,324.1,,,,,,,fee schedule,166.68,324.1,APC
Tyms gene com variants,81346,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,157.33,,,,,,,fee schedule,157.33,305.92,Laboratory
Tyms gene com variants,81346,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.55,,,,,,,fee schedule,157.33,305.92,APC
Tyms gene com variants,81346,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,181.8,,,,,,,fee schedule,157.33,305.92,APC
Tyms gene com variants,81346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,174.81,,,,,,,fee schedule,157.33,305.92,APC
Tyms gene com variants,81346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,267.46,,,,,,,fee schedule,157.33,305.92,Radiology
Tyms gene com variants,81346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,244.73,,,,,,,fee schedule,157.33,305.92,APC
Tyms gene com variants,81346,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,305.92,,,,,,,fee schedule,157.33,305.92,APC
Sf3b1 gene common variants,81347,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,173.92,,,,,,,fee schedule,173.92,338.19,Laboratory
Sf3b1 gene common variants,81347,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,202.91,,,,,,,fee schedule,173.92,338.19,APC
Sf3b1 gene common variants,81347,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,200.98,,,,,,,fee schedule,173.92,338.19,APC
Sf3b1 gene common variants,81347,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,193.25,,,,,,,fee schedule,173.92,338.19,APC
Sf3b1 gene common variants,81347,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,295.67,,,,,,,fee schedule,173.92,338.19,Radiology
Sf3b1 gene common variants,81347,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,270.55,,,,,,,fee schedule,173.92,338.19,APC
Sf3b1 gene common variants,81347,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,338.19,,,,,,,fee schedule,173.92,338.19,APC
Srsf2 gene common variants,81348,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,157.86,,,,,,,fee schedule,157.86,306.95,Laboratory
Srsf2 gene common variants,81348,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,184.17,,,,,,,fee schedule,157.86,306.95,APC
Srsf2 gene common variants,81348,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,182.42,,,,,,,fee schedule,157.86,306.95,APC
Srsf2 gene common variants,81348,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,175.4,,,,,,,fee schedule,157.86,306.95,APC
Srsf2 gene common variants,81348,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,268.36,,,,,,,fee schedule,157.86,306.95,Radiology
Srsf2 gene common variants,81348,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,245.56,,,,,,,fee schedule,157.86,306.95,APC
Srsf2 gene common variants,81348,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,306.95,,,,,,,fee schedule,157.86,306.95,APC
Cytog alys chrml abnr lw-ps,81349,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1078.15,,,,,,,fee schedule,1078.15,2096.4,Laboratory
Cytog alys chrml abnr lw-ps,81349,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1257.84,,,,,,,fee schedule,1078.15,2096.4,APC
Cytog alys chrml abnr lw-ps,81349,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1245.86,,,,,,,fee schedule,1078.15,2096.4,APC
Cytog alys chrml abnr lw-ps,81349,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1197.94,,,,,,,fee schedule,1078.15,2096.4,APC
Cytog alys chrml abnr lw-ps,81349,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1832.85,,,,,,,fee schedule,1078.15,2096.4,Radiology
Cytog alys chrml abnr lw-ps,81349,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1677.12,,,,,,,fee schedule,1078.15,2096.4,APC
Cytog alys chrml abnr lw-ps,81349,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2096.4,,,,,,,fee schedule,1078.15,2096.4,APC
Ugt1a1 gene,81350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,254.21,,,,,,,fee schedule,203.77,409.5,
Ugt1a1 gene,81350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,203.77,,,,,,,fee schedule,203.77,409.5,
Ugt1a1 gene,81350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,222.6,,,,,,,fee schedule,203.77,409.5,
Ugt1a1 gene,81350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,234.03,,,,,,,fee schedule,203.77,409.5,
Ugt1a1 gene,81350,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,210.6,,,,,,,fee schedule,203.77,409.5,Laboratory
Ugt1a1 gene,81350,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,245.7,,,,,,,fee schedule,203.77,409.5,APC
Ugt1a1 gene,81350,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,243.36,,,,,,,fee schedule,203.77,409.5,APC
Ugt1a1 gene,81350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,234,,,,,,,fee schedule,203.77,409.5,APC
Ugt1a1 gene,81350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,358.02,,,,,,,fee schedule,203.77,409.5,Radiology
Ugt1a1 gene,81350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.6,,,,,,,fee schedule,203.77,409.5,APC
Ugt1a1 gene,81350,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,409.5,,,,,,,fee schedule,203.77,409.5,APC
Tp53 gene full gene sequence,81351,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,577.67,,,,,,,fee schedule,577.66,1123.24,Laboratory
Tp53 gene full gene sequence,81351,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,673.94,,,,,,,fee schedule,577.66,1123.24,APC
Tp53 gene full gene sequence,81351,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,667.52,,,,,,,fee schedule,577.66,1123.24,APC
Tp53 gene full gene sequence,81351,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,641.85,,,,,,,fee schedule,577.66,1123.24,APC
Tp53 gene full gene sequence,81351,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,982.03,,,,,,,fee schedule,577.66,1123.24,Radiology
Tp53 gene full gene sequence,81351,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,898.59,,,,,,,fee schedule,577.66,1123.24,APC
Tp53 gene full gene sequence,81351,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1123.24,,,,,,,fee schedule,577.66,1123.24,APC
Tp53 gene trgt sequence alys,81352,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,296.56,,,,,,,fee schedule,296.56,576.64,Laboratory
Tp53 gene trgt sequence alys,81352,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,345.99,,,,,,,fee schedule,296.56,576.64,APC
Tp53 gene trgt sequence alys,81352,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,342.69,,,,,,,fee schedule,296.56,576.64,APC
Tp53 gene trgt sequence alys,81352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,329.51,,,,,,,fee schedule,296.56,576.64,APC
Tp53 gene trgt sequence alys,81352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,504.15,,,,,,,fee schedule,296.56,576.64,Radiology
Tp53 gene trgt sequence alys,81352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,461.31,,,,,,,fee schedule,296.56,576.64,APC
Tp53 gene trgt sequence alys,81352,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,576.64,,,,,,,fee schedule,296.56,576.64,APC
Tp53 gene known famil vrnt,81353,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,277.2,,,,,,,fee schedule,277.2,539,Laboratory
Tp53 gene known famil vrnt,81353,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,323.4,,,,,,,fee schedule,277.2,539,APC
Tp53 gene known famil vrnt,81353,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,320.32,,,,,,,fee schedule,277.2,539,APC
Tp53 gene known famil vrnt,81353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,308,,,,,,,fee schedule,277.2,539,APC
Tp53 gene known famil vrnt,81353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,471.24,,,,,,,fee schedule,277.2,539,Radiology
Tp53 gene known famil vrnt,81353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,431.2,,,,,,,fee schedule,277.2,539,APC
Tp53 gene known famil vrnt,81353,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,539,,,,,,,fee schedule,277.2,539,APC
Cytog alys chrml abnor ogm,81354,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1137.18,,,,,,,fee schedule,1137.18,2211.18,Laboratory
Cytog alys chrml abnor ogm,81354,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1326.71,,,,,,,fee schedule,1137.18,2211.18,APC
Cytog alys chrml abnor ogm,81354,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1314.07,,,,,,,fee schedule,1137.18,2211.18,APC
Cytog alys chrml abnor ogm,81354,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1263.53,,,,,,,fee schedule,1137.18,2211.18,APC
Cytog alys chrml abnor ogm,81354,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1933.2,,,,,,,fee schedule,1137.18,2211.18,Radiology
Cytog alys chrml abnor ogm,81354,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1768.94,,,,,,,fee schedule,1137.18,2211.18,APC
Cytog alys chrml abnor ogm,81354,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2211.18,,,,,,,fee schedule,1137.18,2211.18,APC
Vkorc1 gene,81355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,314.46,,,,,,,fee schedule,79.38,314.46,
Vkorc1 gene,81355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,252.07,,,,,,,fee schedule,79.38,314.46,
Vkorc1 gene,81355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,275.36,,,,,,,fee schedule,79.38,314.46,
Vkorc1 gene,81355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,289.5,,,,,,,fee schedule,79.38,314.46,
Vkorc1 gene,81355,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,79.38,,,,,,,fee schedule,79.38,314.46,Laboratory
Vkorc1 gene,81355,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,92.61,,,,,,,fee schedule,79.38,314.46,APC
Vkorc1 gene,81355,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,91.73,,,,,,,fee schedule,79.38,314.46,APC
Vkorc1 gene,81355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,88.2,,,,,,,fee schedule,79.38,314.46,APC
Vkorc1 gene,81355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,134.95,,,,,,,fee schedule,79.38,314.46,Radiology
Vkorc1 gene,81355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,123.48,,,,,,,fee schedule,79.38,314.46,APC
Vkorc1 gene,81355,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,154.35,,,,,,,fee schedule,79.38,314.46,APC
U2af1 gene common variants,81357,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,173.92,,,,,,,fee schedule,173.92,338.19,Laboratory
U2af1 gene common variants,81357,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,202.91,,,,,,,fee schedule,173.92,338.19,APC
U2af1 gene common variants,81357,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,200.98,,,,,,,fee schedule,173.92,338.19,APC
U2af1 gene common variants,81357,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,193.25,,,,,,,fee schedule,173.92,338.19,APC
U2af1 gene common variants,81357,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,295.67,,,,,,,fee schedule,173.92,338.19,Radiology
U2af1 gene common variants,81357,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,270.55,,,,,,,fee schedule,173.92,338.19,APC
U2af1 gene common variants,81357,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,338.19,,,,,,,fee schedule,173.92,338.19,APC
Zrsr2 gene common variants,81360,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,173.92,,,,,,,fee schedule,173.92,338.19,Laboratory
Zrsr2 gene common variants,81360,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,202.91,,,,,,,fee schedule,173.92,338.19,APC
Zrsr2 gene common variants,81360,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,200.98,,,,,,,fee schedule,173.92,338.19,APC
Zrsr2 gene common variants,81360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,193.25,,,,,,,fee schedule,173.92,338.19,APC
Zrsr2 gene common variants,81360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,295.67,,,,,,,fee schedule,173.92,338.19,Radiology
Zrsr2 gene common variants,81360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,270.55,,,,,,,fee schedule,173.92,338.19,APC
Zrsr2 gene common variants,81360,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,338.19,,,,,,,fee schedule,173.92,338.19,APC
Hbb gene com variants,81361,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,157.33,,,,,,,fee schedule,157.33,305.92,Laboratory
Hbb gene com variants,81361,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.55,,,,,,,fee schedule,157.33,305.92,APC
Hbb gene com variants,81361,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,181.8,,,,,,,fee schedule,157.33,305.92,APC
Hbb gene com variants,81361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,174.81,,,,,,,fee schedule,157.33,305.92,APC
Hbb gene com variants,81361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,267.46,,,,,,,fee schedule,157.33,305.92,Radiology
Hbb gene com variants,81361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,244.73,,,,,,,fee schedule,157.33,305.92,APC
Hbb gene com variants,81361,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,305.92,,,,,,,fee schedule,157.33,305.92,APC
Hbb gene known fam variant,81362,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,337.72,,,,,,,fee schedule,337.72,656.69,Laboratory
Hbb gene known fam variant,81362,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,394.01,,,,,,,fee schedule,337.72,656.69,APC
Hbb gene known fam variant,81362,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,390.26,,,,,,,fee schedule,337.72,656.69,APC
Hbb gene known fam variant,81362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,375.25,,,,,,,fee schedule,337.72,656.69,APC
Hbb gene known fam variant,81362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,574.13,,,,,,,fee schedule,337.72,656.69,Radiology
Hbb gene known fam variant,81362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,525.35,,,,,,,fee schedule,337.72,656.69,APC
Hbb gene known fam variant,81362,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,656.69,,,,,,,fee schedule,337.72,656.69,APC
Hbb gene dup/del variants,81363,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,182.16,,,,,,,fee schedule,182.16,354.2,Laboratory
Hbb gene dup/del variants,81363,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,212.52,,,,,,,fee schedule,182.16,354.2,APC
Hbb gene dup/del variants,81363,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,210.5,,,,,,,fee schedule,182.16,354.2,APC
Hbb gene dup/del variants,81363,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,202.4,,,,,,,fee schedule,182.16,354.2,APC
Hbb gene dup/del variants,81363,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,309.67,,,,,,,fee schedule,182.16,354.2,Radiology
Hbb gene dup/del variants,81363,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,283.36,,,,,,,fee schedule,182.16,354.2,APC
Hbb gene dup/del variants,81363,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,354.2,,,,,,,fee schedule,182.16,354.2,APC
Hbb full gene sequence,81364,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,292.12,,,,,,,fee schedule,292.12,568.02,Laboratory
Hbb full gene sequence,81364,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,340.81,,,,,,,fee schedule,292.12,568.02,APC
Hbb full gene sequence,81364,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,337.56,,,,,,,fee schedule,292.12,568.02,APC
Hbb full gene sequence,81364,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,324.58,,,,,,,fee schedule,292.12,568.02,APC
Hbb full gene sequence,81364,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,496.61,,,,,,,fee schedule,292.12,568.02,Radiology
Hbb full gene sequence,81364,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,454.41,,,,,,,fee schedule,292.12,568.02,APC
Hbb full gene sequence,81364,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,568.02,,,,,,,fee schedule,292.12,568.02,APC
Hla i & ii typing lr,81370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2324.08,,,,,,,fee schedule,361.91,2324.08,
Hla i & ii typing lr,81370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1862.96,,,,,,,fee schedule,361.91,2324.08,
Hla i & ii typing lr,81370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2035.11,,,,,,,fee schedule,361.91,2324.08,
Hla i & ii typing lr,81370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2139.63,,,,,,,fee schedule,361.91,2324.08,
Hla i & ii typing lr,81370,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,361.91,,,,,,,fee schedule,361.91,2324.08,Laboratory
Hla i & ii typing lr,81370,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,422.23,,,,,,,fee schedule,361.91,2324.08,APC
Hla i & ii typing lr,81370,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,418.2,,,,,,,fee schedule,361.91,2324.08,APC
Hla i & ii typing lr,81370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,402.12,,,,,,,fee schedule,361.91,2324.08,APC
Hla i & ii typing lr,81370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,615.24,,,,,,,fee schedule,361.91,2324.08,Radiology
Hla i & ii typing lr,81370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,562.97,,,,,,,fee schedule,361.91,2324.08,APC
Hla i & ii typing lr,81370,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,703.71,,,,,,,fee schedule,361.91,2324.08,APC
Hla i & ii type verify lr,81371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1250.58,,,,,,,fee schedule,364.07,1250.58,
Hla i & ii type verify lr,81371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1002.45,,,,,,,fee schedule,364.07,1250.58,
Hla i & ii type verify lr,81371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1095.08,,,,,,,fee schedule,364.07,1250.58,
Hla i & ii type verify lr,81371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1151.32,,,,,,,fee schedule,364.07,1250.58,
Hla i & ii type verify lr,81371,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,364.07,,,,,,,fee schedule,364.07,1250.58,Laboratory
Hla i & ii type verify lr,81371,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,424.75,,,,,,,fee schedule,364.07,1250.58,APC
Hla i & ii type verify lr,81371,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,420.7,,,,,,,fee schedule,364.07,1250.58,APC
Hla i & ii type verify lr,81371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,404.52,,,,,,,fee schedule,364.07,1250.58,APC
Hla i & ii type verify lr,81371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,618.92,,,,,,,fee schedule,364.07,1250.58,Radiology
Hla i & ii type verify lr,81371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,566.33,,,,,,,fee schedule,364.07,1250.58,APC
Hla i & ii type verify lr,81371,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,707.91,,,,,,,fee schedule,364.07,1250.58,APC
Hla i typing complete lr,81372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1147.76,,,,,,,fee schedule,363.23,1147.76,
Hla i typing complete lr,81372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,920.03,,,,,,,fee schedule,363.23,1147.76,
Hla i typing complete lr,81372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1005.05,,,,,,,fee schedule,363.23,1147.76,
Hla i typing complete lr,81372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1056.67,,,,,,,fee schedule,363.23,1147.76,
Hla i typing complete lr,81372,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,363.23,,,,,,,fee schedule,363.23,1147.76,Laboratory
Hla i typing complete lr,81372,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,423.77,,,,,,,fee schedule,363.23,1147.76,APC
Hla i typing complete lr,81372,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,419.73,,,,,,,fee schedule,363.23,1147.76,APC
Hla i typing complete lr,81372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,403.59,,,,,,,fee schedule,363.23,1147.76,APC
Hla i typing complete lr,81372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,617.49,,,,,,,fee schedule,363.23,1147.76,Radiology
Hla i typing complete lr,81372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,565.03,,,,,,,fee schedule,363.23,1147.76,APC
Hla i typing complete lr,81372,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,706.28,,,,,,,fee schedule,363.23,1147.76,APC
Hla i typing 1 locus lr,81373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,578.64,,,,,,,fee schedule,114.69,578.64,
Hla i typing 1 locus lr,81373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,463.83,,,,,,,fee schedule,114.69,578.64,
Hla i typing 1 locus lr,81373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,506.69,,,,,,,fee schedule,114.69,578.64,
Hla i typing 1 locus lr,81373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,532.72,,,,,,,fee schedule,114.69,578.64,
Hla i typing 1 locus lr,81373,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,114.69,,,,,,,fee schedule,114.69,578.64,Laboratory
Hla i typing 1 locus lr,81373,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,133.8,,,,,,,fee schedule,114.69,578.64,APC
Hla i typing 1 locus lr,81373,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,132.53,,,,,,,fee schedule,114.69,578.64,APC
Hla i typing 1 locus lr,81373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,127.43,,,,,,,fee schedule,114.69,578.64,APC
Hla i typing 1 locus lr,81373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,194.97,,,,,,,fee schedule,114.69,578.64,Radiology
Hla i typing 1 locus lr,81373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,178.4,,,,,,,fee schedule,114.69,578.64,APC
Hla i typing 1 locus lr,81373,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,223,,,,,,,fee schedule,114.69,578.64,APC
Hla i typing 1 antigen lr,81374,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,184.36,,,,,,,fee schedule,66.9,184.36,
Hla i typing 1 antigen lr,81374,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,147.78,,,,,,,fee schedule,66.9,184.36,
Hla i typing 1 antigen lr,81374,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,161.43,,,,,,,fee schedule,66.9,184.36,
Hla i typing 1 antigen lr,81374,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,169.73,,,,,,,fee schedule,66.9,184.36,
Hla i typing 1 antigen lr,81374,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,66.9,,,,,,,fee schedule,66.9,184.36,Laboratory
Hla i typing 1 antigen lr,81374,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,78.05,,,,,,,fee schedule,66.9,184.36,APC
Hla i typing 1 antigen lr,81374,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,77.3,,,,,,,fee schedule,66.9,184.36,APC
Hla i typing 1 antigen lr,81374,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,74.33,,,,,,,fee schedule,66.9,184.36,APC
Hla i typing 1 antigen lr,81374,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,113.72,,,,,,,fee schedule,66.9,184.36,Radiology
Hla i typing 1 antigen lr,81374,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,104.06,,,,,,,fee schedule,66.9,184.36,APC
Hla i typing 1 antigen lr,81374,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,130.08,,,,,,,fee schedule,66.9,184.36,APC
Hla ii typing ag equiv lr,81375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1146.97,,,,,,,fee schedule,198.67,1146.97,
Hla ii typing ag equiv lr,81375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,919.39,,,,,,,fee schedule,198.67,1146.97,
Hla ii typing ag equiv lr,81375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1004.35,,,,,,,fee schedule,198.67,1146.97,
Hla ii typing ag equiv lr,81375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1055.94,,,,,,,fee schedule,198.67,1146.97,
Hla ii typing ag equiv lr,81375,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,198.67,,,,,,,fee schedule,198.67,1146.97,Laboratory
Hla ii typing ag equiv lr,81375,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,231.78,,,,,,,fee schedule,198.67,1146.97,APC
Hla ii typing ag equiv lr,81375,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,229.57,,,,,,,fee schedule,198.67,1146.97,APC
Hla ii typing ag equiv lr,81375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,220.74,,,,,,,fee schedule,198.67,1146.97,APC
Hla ii typing ag equiv lr,81375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,337.73,,,,,,,fee schedule,198.67,1146.97,Radiology
Hla ii typing ag equiv lr,81375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,309.04,,,,,,,fee schedule,198.67,1146.97,APC
Hla ii typing ag equiv lr,81375,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,386.3,,,,,,,fee schedule,198.67,1146.97,APC
Hla ii typing 1 locus lr,81376,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,204.35,,,,,,,fee schedule,110,213.88,
Hla ii typing 1 locus lr,81376,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,163.8,,,,,,,fee schedule,110,213.88,
Hla ii typing 1 locus lr,81376,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,178.94,,,,,,,fee schedule,110,213.88,
Hla ii typing 1 locus lr,81376,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,188.13,,,,,,,fee schedule,110,213.88,
Hla ii typing 1 locus lr,81376,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,110,,,,,,,fee schedule,110,213.88,Laboratory
Hla ii typing 1 locus lr,81376,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,128.33,,,,,,,fee schedule,110,213.88,APC
Hla ii typing 1 locus lr,81376,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,127.11,,,,,,,fee schedule,110,213.88,APC
Hla ii typing 1 locus lr,81376,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,122.22,,,,,,,fee schedule,110,213.88,APC
Hla ii typing 1 locus lr,81376,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,187,,,,,,,fee schedule,110,213.88,Radiology
Hla ii typing 1 locus lr,81376,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,171.11,,,,,,,fee schedule,110,213.88,APC
Hla ii typing 1 locus lr,81376,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,213.88,,,,,,,fee schedule,110,213.88,APC
Hla ii type 1 ag equiv lr,81377,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,477.04,,,,,,,fee schedule,85.27,477.04,
Hla ii type 1 ag equiv lr,81377,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,382.39,,,,,,,fee schedule,85.27,477.04,
Hla ii type 1 ag equiv lr,81377,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,417.72,,,,,,,fee schedule,85.27,477.04,
Hla ii type 1 ag equiv lr,81377,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,439.18,,,,,,,fee schedule,85.27,477.04,
Hla ii type 1 ag equiv lr,81377,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,85.27,,,,,,,fee schedule,85.27,477.04,Laboratory
Hla ii type 1 ag equiv lr,81377,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,99.48,,,,,,,fee schedule,85.27,477.04,APC
Hla ii type 1 ag equiv lr,81377,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,98.53,,,,,,,fee schedule,85.27,477.04,APC
Hla ii type 1 ag equiv lr,81377,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,94.74,,,,,,,fee schedule,85.27,477.04,APC
Hla ii type 1 ag equiv lr,81377,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.95,,,,,,,fee schedule,85.27,477.04,Radiology
Hla ii type 1 ag equiv lr,81377,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,132.64,,,,,,,fee schedule,85.27,477.04,APC
Hla ii type 1 ag equiv lr,81377,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,165.8,,,,,,,fee schedule,85.27,477.04,APC
Hla i & ii typing hr,81378,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1795.5,,,,,,,fee schedule,311.01,1795.5,
Hla i & ii typing hr,81378,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1439.25,,,,,,,fee schedule,311.01,1795.5,
Hla i & ii typing hr,81378,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1572.25,,,,,,,fee schedule,311.01,1795.5,
Hla i & ii typing hr,81378,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1653,,,,,,,fee schedule,311.01,1795.5,
Hla i & ii typing hr,81378,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,311.01,,,,,,,fee schedule,311.01,1795.5,Laboratory
Hla i & ii typing hr,81378,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,362.85,,,,,,,fee schedule,311.01,1795.5,APC
Hla i & ii typing hr,81378,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,359.39,,,,,,,fee schedule,311.01,1795.5,APC
Hla i & ii typing hr,81378,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,345.57,,,,,,,fee schedule,311.01,1795.5,APC
Hla i & ii typing hr,81378,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,528.72,,,,,,,fee schedule,311.01,1795.5,Radiology
Hla i & ii typing hr,81378,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,483.8,,,,,,,fee schedule,311.01,1795.5,APC
Hla i & ii typing hr,81378,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,604.75,,,,,,,fee schedule,311.01,1795.5,APC
Hla i typing complete hr,81379,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1742.58,,,,,,,fee schedule,301.84,1742.58,
Hla i typing complete hr,81379,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1396.83,,,,,,,fee schedule,301.84,1742.58,
Hla i typing complete hr,81379,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1525.91,,,,,,,fee schedule,301.84,1742.58,
Hla i typing complete hr,81379,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1604.28,,,,,,,fee schedule,301.84,1742.58,
Hla i typing complete hr,81379,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,301.84,,,,,,,fee schedule,301.84,1742.58,Laboratory
Hla i typing complete hr,81379,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,352.15,,,,,,,fee schedule,301.84,1742.58,APC
Hla i typing complete hr,81379,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,348.8,,,,,,,fee schedule,301.84,1742.58,APC
Hla i typing complete hr,81379,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,335.38,,,,,,,fee schedule,301.84,1742.58,APC
Hla i typing complete hr,81379,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,513.13,,,,,,,fee schedule,301.84,1742.58,Radiology
Hla i typing complete hr,81379,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,469.53,,,,,,,fee schedule,301.84,1742.58,APC
Hla i typing complete hr,81379,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,586.92,,,,,,,fee schedule,301.84,1742.58,APC
Hla i typing 1 locus hr,81380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,920.96,,,,,,,fee schedule,159.52,920.96,
Hla i typing 1 locus hr,81380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,738.23,,,,,,,fee schedule,159.52,920.96,
Hla i typing 1 locus hr,81380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,806.45,,,,,,,fee schedule,159.52,920.96,
Hla i typing 1 locus hr,81380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,847.87,,,,,,,fee schedule,159.52,920.96,
Hla i typing 1 locus hr,81380,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,159.52,,,,,,,fee schedule,159.52,920.96,Laboratory
Hla i typing 1 locus hr,81380,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,186.11,,,,,,,fee schedule,159.52,920.96,APC
Hla i typing 1 locus hr,81380,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,184.34,,,,,,,fee schedule,159.52,920.96,APC
Hla i typing 1 locus hr,81380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,177.25,,,,,,,fee schedule,159.52,920.96,APC
Hla i typing 1 locus hr,81380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,271.19,,,,,,,fee schedule,159.52,920.96,Radiology
Hla i typing 1 locus hr,81380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,248.15,,,,,,,fee schedule,159.52,920.96,APC
Hla i typing 1 locus hr,81380,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,310.19,,,,,,,fee schedule,159.52,920.96,APC
Hla i typing 1 allele hr,81381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,491.4,,,,,,,fee schedule,152.91,491.4,
Hla i typing 1 allele hr,81381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,393.9,,,,,,,fee schedule,152.91,491.4,
Hla i typing 1 allele hr,81381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,430.3,,,,,,,fee schedule,152.91,491.4,
Hla i typing 1 allele hr,81381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,452.4,,,,,,,fee schedule,152.91,491.4,
Hla i typing 1 allele hr,81381,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,152.91,,,,,,,fee schedule,152.91,491.4,Laboratory
Hla i typing 1 allele hr,81381,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,178.4,,,,,,,fee schedule,152.91,491.4,APC
Hla i typing 1 allele hr,81381,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,176.7,,,,,,,fee schedule,152.91,491.4,APC
Hla i typing 1 allele hr,81381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,169.9,,,,,,,fee schedule,152.91,491.4,APC
Hla i typing 1 allele hr,81381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,259.95,,,,,,,fee schedule,152.91,491.4,Radiology
Hla i typing 1 allele hr,81381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,237.86,,,,,,,fee schedule,152.91,491.4,APC
Hla i typing 1 allele hr,81381,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,297.32,,,,,,,fee schedule,152.91,491.4,APC
Hla ii typing 1 loc hr,81382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,642.6,,,,,,,fee schedule,111.31,642.6,
Hla ii typing 1 loc hr,81382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,515.1,,,,,,,fee schedule,111.31,642.6,
Hla ii typing 1 loc hr,81382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,562.7,,,,,,,fee schedule,111.31,642.6,
Hla ii typing 1 loc hr,81382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,591.6,,,,,,,fee schedule,111.31,642.6,
Hla ii typing 1 loc hr,81382,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,111.31,,,,,,,fee schedule,111.31,642.6,Laboratory
Hla ii typing 1 loc hr,81382,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.86,,,,,,,fee schedule,111.31,642.6,APC
Hla ii typing 1 loc hr,81382,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.63,,,,,,,fee schedule,111.31,642.6,APC
Hla ii typing 1 loc hr,81382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.68,,,,,,,fee schedule,111.31,642.6,APC
Hla ii typing 1 loc hr,81382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,189.23,,,,,,,fee schedule,111.31,642.6,Radiology
Hla ii typing 1 loc hr,81382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,173.15,,,,,,,fee schedule,111.31,642.6,APC
Hla ii typing 1 loc hr,81382,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,216.44,,,,,,,fee schedule,111.31,642.6,APC
Hla ii typing 1 allele hr,81383,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,567,,,,,,,fee schedule,98.22,567,
Hla ii typing 1 allele hr,81383,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,454.5,,,,,,,fee schedule,98.22,567,
Hla ii typing 1 allele hr,81383,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,496.5,,,,,,,fee schedule,98.22,567,
Hla ii typing 1 allele hr,81383,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,522,,,,,,,fee schedule,98.22,567,
Hla ii typing 1 allele hr,81383,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,98.22,,,,,,,fee schedule,98.22,567,Laboratory
Hla ii typing 1 allele hr,81383,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,114.59,,,,,,,fee schedule,98.22,567,APC
Hla ii typing 1 allele hr,81383,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,113.5,,,,,,,fee schedule,98.22,567,APC
Hla ii typing 1 allele hr,81383,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,109.13,,,,,,,fee schedule,98.22,567,APC
Hla ii typing 1 allele hr,81383,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,166.97,,,,,,,fee schedule,98.22,567,Radiology
Hla ii typing 1 allele hr,81383,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,152.78,,,,,,,fee schedule,98.22,567,APC
Hla ii typing 1 allele hr,81383,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,190.98,,,,,,,fee schedule,98.22,567,APC
Mopath procedure level 1,81400,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,57.56,,,,,,,fee schedule,57.56,111.93,Laboratory
Mopath procedure level 1,81400,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,67.16,,,,,,,fee schedule,57.56,111.93,APC
Mopath procedure level 1,81400,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,66.52,,,,,,,fee schedule,57.56,111.93,APC
Mopath procedure level 1,81400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,63.96,,,,,,,fee schedule,57.56,111.93,APC
Mopath procedure level 1,81400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,97.86,,,,,,,fee schedule,57.56,111.93,Radiology
Mopath procedure level 1,81400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.54,,,,,,,fee schedule,57.56,111.93,APC
Mopath procedure level 1,81400,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,111.93,,,,,,,fee schedule,57.56,111.93,APC
Mopath procedure level 2,81401,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,123.3,,,,,,,fee schedule,123.3,239.75,Laboratory
Mopath procedure level 2,81401,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,143.85,,,,,,,fee schedule,123.3,239.75,APC
Mopath procedure level 2,81401,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,142.48,,,,,,,fee schedule,123.3,239.75,APC
Mopath procedure level 2,81401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,137,,,,,,,fee schedule,123.3,239.75,APC
Mopath procedure level 2,81401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,209.61,,,,,,,fee schedule,123.3,239.75,Radiology
Mopath procedure level 2,81401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,191.8,,,,,,,fee schedule,123.3,239.75,APC
Mopath procedure level 2,81401,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,239.75,,,,,,,fee schedule,123.3,239.75,APC
Mopath procedure level 3,81402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,265.06,,,,,,,fee schedule,135.3,265.06,
Mopath procedure level 3,81402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,212.47,,,,,,,fee schedule,135.3,265.06,
Mopath procedure level 3,81402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,232.1,,,,,,,fee schedule,135.3,265.06,
Mopath procedure level 3,81402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,244.02,,,,,,,fee schedule,135.3,265.06,
Mopath procedure level 3,81402,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,135.3,,,,,,,fee schedule,135.3,265.06,Laboratory
Mopath procedure level 3,81402,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,157.85,,,,,,,fee schedule,135.3,265.06,APC
Mopath procedure level 3,81402,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,156.34,,,,,,,fee schedule,135.3,265.06,APC
Mopath procedure level 3,81402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,150.33,,,,,,,fee schedule,135.3,265.06,APC
Mopath procedure level 3,81402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,230,,,,,,,fee schedule,135.3,265.06,Radiology
Mopath procedure level 3,81402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,210.46,,,,,,,fee schedule,135.3,265.06,APC
Mopath procedure level 3,81402,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,263.08,,,,,,,fee schedule,135.3,265.06,APC
Mopath procedure level 4,81403,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,166.68,,,,,,,fee schedule,166.68,324.1,Laboratory
Mopath procedure level 4,81403,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,194.46,,,,,,,fee schedule,166.68,324.1,APC
Mopath procedure level 4,81403,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,192.61,,,,,,,fee schedule,166.68,324.1,APC
Mopath procedure level 4,81403,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,185.2,,,,,,,fee schedule,166.68,324.1,APC
Mopath procedure level 4,81403,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,283.36,,,,,,,fee schedule,166.68,324.1,Radiology
Mopath procedure level 4,81403,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,259.28,,,,,,,fee schedule,166.68,324.1,APC
Mopath procedure level 4,81403,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,324.1,,,,,,,fee schedule,166.68,324.1,APC
Mopath procedure level 5,81404,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,247.35,,,,,,,fee schedule,247.35,480.95,Laboratory
Mopath procedure level 5,81404,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,288.57,,,,,,,fee schedule,247.35,480.95,APC
Mopath procedure level 5,81404,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,285.82,,,,,,,fee schedule,247.35,480.95,APC
Mopath procedure level 5,81404,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,274.83,,,,,,,fee schedule,247.35,480.95,APC
Mopath procedure level 5,81404,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,420.49,,,,,,,fee schedule,247.35,480.95,Radiology
Mopath procedure level 5,81404,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,384.76,,,,,,,fee schedule,247.35,480.95,APC
Mopath procedure level 5,81404,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,480.95,,,,,,,fee schedule,247.35,480.95,APC
Mopath procedure level 6,81405,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,271.22,,,,,,,fee schedule,271.21,527.36,Laboratory
Mopath procedure level 6,81405,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,316.42,,,,,,,fee schedule,271.21,527.36,APC
Mopath procedure level 6,81405,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,313.4,,,,,,,fee schedule,271.21,527.36,APC
Mopath procedure level 6,81405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,301.35,,,,,,,fee schedule,271.21,527.36,APC
Mopath procedure level 6,81405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,461.07,,,,,,,fee schedule,271.21,527.36,Radiology
Mopath procedure level 6,81405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,421.89,,,,,,,fee schedule,271.21,527.36,APC
Mopath procedure level 6,81405,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,527.36,,,,,,,fee schedule,271.21,527.36,APC
Mopath procedure level 7,81406,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,254.59,,,,,,,fee schedule,254.59,495.04,Laboratory
Mopath procedure level 7,81406,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,297.02,,,,,,,fee schedule,254.59,495.04,APC
Mopath procedure level 7,81406,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,294.2,,,,,,,fee schedule,254.59,495.04,APC
Mopath procedure level 7,81406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,282.88,,,,,,,fee schedule,254.59,495.04,APC
Mopath procedure level 7,81406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,432.81,,,,,,,fee schedule,254.59,495.04,Radiology
Mopath procedure level 7,81406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,396.03,,,,,,,fee schedule,254.59,495.04,APC
Mopath procedure level 7,81406,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,495.04,,,,,,,fee schedule,254.59,495.04,APC
Mopath procedure level 8,81407,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,761.64,,,,,,,fee schedule,761.64,1480.97,Laboratory
Mopath procedure level 8,81407,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,888.58,,,,,,,fee schedule,761.64,1480.97,APC
Mopath procedure level 8,81407,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,880.12,,,,,,,fee schedule,761.64,1480.97,APC
Mopath procedure level 8,81407,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,846.27,,,,,,,fee schedule,761.64,1480.97,APC
Mopath procedure level 8,81407,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1294.79,,,,,,,fee schedule,761.64,1480.97,Radiology
Mopath procedure level 8,81407,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1184.78,,,,,,,fee schedule,761.64,1480.97,APC
Mopath procedure level 8,81407,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1480.97,,,,,,,fee schedule,761.64,1480.97,APC
Mopath procedure level 9,81408,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1800,,,,,,,fee schedule,1800,3500,Laboratory
Mopath procedure level 9,81408,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2100,,,,,,,fee schedule,1800,3500,APC
Mopath procedure level 9,81408,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2080,,,,,,,fee schedule,1800,3500,APC
Mopath procedure level 9,81408,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2000,,,,,,,fee schedule,1800,3500,APC
Mopath procedure level 9,81408,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3060,,,,,,,fee schedule,1800,3500,Radiology
Mopath procedure level 9,81408,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2800,,,,,,,fee schedule,1800,3500,APC
Mopath procedure level 9,81408,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3500,,,,,,,fee schedule,1800,3500,APC
Aortic dysfunction/dilation,81410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1905.12,,,,,,,fee schedule,453.6,1905.12,
Aortic dysfunction/dilation,81410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1527.12,,,,,,,fee schedule,453.6,1905.12,
Aortic dysfunction/dilation,81410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1668.24,,,,,,,fee schedule,453.6,1905.12,
Aortic dysfunction/dilation,81410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1753.92,,,,,,,fee schedule,453.6,1905.12,
Aortic dysfunction/dilation,81410,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,453.6,,,,,,,fee schedule,453.6,1905.12,Laboratory
Aortic dysfunction/dilation,81410,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,529.2,,,,,,,fee schedule,453.6,1905.12,APC
Aortic dysfunction/dilation,81410,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,524.16,,,,,,,fee schedule,453.6,1905.12,APC
Aortic dysfunction/dilation,81410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,504,,,,,,,fee schedule,453.6,1905.12,APC
Aortic dysfunction/dilation,81410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,771.12,,,,,,,fee schedule,453.6,1905.12,Radiology
Aortic dysfunction/dilation,81410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,705.6,,,,,,,fee schedule,453.6,1905.12,APC
Aortic dysfunction/dilation,81410,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,882,,,,,,,fee schedule,453.6,1905.12,APC
Aortic dysfunction/dilation,81411,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5103.72,,,,,,,fee schedule,1215.17,5103.72,
Aortic dysfunction/dilation,81411,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4091.08,,,,,,,fee schedule,1215.17,5103.72,
Aortic dysfunction/dilation,81411,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4469.13,,,,,,,fee schedule,1215.17,5103.72,
Aortic dysfunction/dilation,81411,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4698.66,,,,,,,fee schedule,1215.17,5103.72,
Aortic dysfunction/dilation,81411,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1215.17,,,,,,,fee schedule,1215.17,5103.72,Laboratory
Aortic dysfunction/dilation,81411,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1417.7,,,,,,,fee schedule,1215.17,5103.72,APC
Aortic dysfunction/dilation,81411,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1404.2,,,,,,,fee schedule,1215.17,5103.72,APC
Aortic dysfunction/dilation,81411,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1350.19,,,,,,,fee schedule,1215.17,5103.72,APC
Aortic dysfunction/dilation,81411,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2065.79,,,,,,,fee schedule,1215.17,5103.72,Radiology
Aortic dysfunction/dilation,81411,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1890.27,,,,,,,fee schedule,1215.17,5103.72,APC
Aortic dysfunction/dilation,81411,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2362.83,,,,,,,fee schedule,1215.17,5103.72,APC
Ashkenazi jewish assoc dis,81412,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2203.7,,,,,,,fee schedule,2203.7,4284.98,Laboratory
Ashkenazi jewish assoc dis,81412,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2570.99,,,,,,,fee schedule,2203.7,4284.98,APC
Ashkenazi jewish assoc dis,81412,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2546.5,,,,,,,fee schedule,2203.7,4284.98,APC
Ashkenazi jewish assoc dis,81412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2448.56,,,,,,,fee schedule,2203.7,4284.98,APC
Ashkenazi jewish assoc dis,81412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3746.3,,,,,,,fee schedule,2203.7,4284.98,Radiology
Ashkenazi jewish assoc dis,81412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3427.98,,,,,,,fee schedule,2203.7,4284.98,APC
Ashkenazi jewish assoc dis,81412,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4284.98,,,,,,,fee schedule,2203.7,4284.98,APC
Car ion chnnlpath inc 10 gns,81413,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3032.81,,,,,,,fee schedule,526.41,3032.81,
Car ion chnnlpath inc 10 gns,81413,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2431.06,,,,,,,fee schedule,526.41,3032.81,
Car ion chnnlpath inc 10 gns,81413,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2655.71,,,,,,,fee schedule,526.41,3032.81,
Car ion chnnlpath inc 10 gns,81413,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2792.11,,,,,,,fee schedule,526.41,3032.81,
Car ion chnnlpath inc 10 gns,81413,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,526.41,,,,,,,fee schedule,526.41,3032.81,Laboratory
Car ion chnnlpath inc 10 gns,81413,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,614.14,,,,,,,fee schedule,526.41,3032.81,APC
Car ion chnnlpath inc 10 gns,81413,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,608.3,,,,,,,fee schedule,526.41,3032.81,APC
Car ion chnnlpath inc 10 gns,81413,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,584.9,,,,,,,fee schedule,526.41,3032.81,APC
Car ion chnnlpath inc 10 gns,81413,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,894.9,,,,,,,fee schedule,526.41,3032.81,Radiology
Car ion chnnlpath inc 10 gns,81413,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,818.86,,,,,,,fee schedule,526.41,3032.81,APC
Car ion chnnlpath inc 10 gns,81413,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1023.58,,,,,,,fee schedule,526.41,3032.81,APC
Car ion chnnlpath inc 2 gns,81414,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3032.81,,,,,,,fee schedule,526.41,3032.81,
Car ion chnnlpath inc 2 gns,81414,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2431.06,,,,,,,fee schedule,526.41,3032.81,
Car ion chnnlpath inc 2 gns,81414,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2655.71,,,,,,,fee schedule,526.41,3032.81,
Car ion chnnlpath inc 2 gns,81414,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2792.11,,,,,,,fee schedule,526.41,3032.81,
Car ion chnnlpath inc 2 gns,81414,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,526.41,,,,,,,fee schedule,526.41,3032.81,Laboratory
Car ion chnnlpath inc 2 gns,81414,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,614.14,,,,,,,fee schedule,526.41,3032.81,APC
Car ion chnnlpath inc 2 gns,81414,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,608.3,,,,,,,fee schedule,526.41,3032.81,APC
Car ion chnnlpath inc 2 gns,81414,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,584.9,,,,,,,fee schedule,526.41,3032.81,APC
Car ion chnnlpath inc 2 gns,81414,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,894.9,,,,,,,fee schedule,526.41,3032.81,Radiology
Car ion chnnlpath inc 2 gns,81414,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,818.86,,,,,,,fee schedule,526.41,3032.81,APC
Car ion chnnlpath inc 2 gns,81414,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1023.58,,,,,,,fee schedule,526.41,3032.81,APC
Exome sequence analysis,81415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18068.4,,,,,,,fee schedule,4302,18068.4,
Exome sequence analysis,81415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14483.4,,,,,,,fee schedule,4302,18068.4,
Exome sequence analysis,81415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15821.8,,,,,,,fee schedule,4302,18068.4,
Exome sequence analysis,81415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16634.4,,,,,,,fee schedule,4302,18068.4,
Exome sequence analysis,81415,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4302,,,,,,,fee schedule,4302,18068.4,Laboratory
Exome sequence analysis,81415,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5019,,,,,,,fee schedule,4302,18068.4,APC
Exome sequence analysis,81415,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4971.2,,,,,,,fee schedule,4302,18068.4,APC
Exome sequence analysis,81415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4780,,,,,,,fee schedule,4302,18068.4,APC
Exome sequence analysis,81415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7313.4,,,,,,,fee schedule,4302,18068.4,Radiology
Exome sequence analysis,81415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6692,,,,,,,fee schedule,4302,18068.4,APC
Exome sequence analysis,81415,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8365,,,,,,,fee schedule,4302,18068.4,APC
Exome sequence analysis,81416,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45360,,,,,,,fee schedule,10800,45360,
Exome sequence analysis,81416,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36360,,,,,,,fee schedule,10800,45360,
Exome sequence analysis,81416,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39720,,,,,,,fee schedule,10800,45360,
Exome sequence analysis,81416,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41760,,,,,,,fee schedule,10800,45360,
Exome sequence analysis,81416,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10800,,,,,,,fee schedule,10800,45360,Laboratory
Exome sequence analysis,81416,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12600,,,,,,,fee schedule,10800,45360,APC
Exome sequence analysis,81416,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12480,,,,,,,fee schedule,10800,45360,APC
Exome sequence analysis,81416,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12000,,,,,,,fee schedule,10800,45360,APC
Exome sequence analysis,81416,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18360,,,,,,,fee schedule,10800,45360,Radiology
Exome sequence analysis,81416,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16800,,,,,,,fee schedule,10800,45360,APC
Exome sequence analysis,81416,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21000,,,,,,,fee schedule,10800,45360,APC
Exome re-evaluation,81417,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1209.6,,,,,,,fee schedule,288,1209.6,
Exome re-evaluation,81417,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,969.6,,,,,,,fee schedule,288,1209.6,
Exome re-evaluation,81417,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1059.2,,,,,,,fee schedule,288,1209.6,
Exome re-evaluation,81417,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1113.6,,,,,,,fee schedule,288,1209.6,
Exome re-evaluation,81417,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,288,,,,,,,fee schedule,288,1209.6,Laboratory
Exome re-evaluation,81417,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,336,,,,,,,fee schedule,288,1209.6,APC
Exome re-evaluation,81417,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,332.8,,,,,,,fee schedule,288,1209.6,APC
Exome re-evaluation,81417,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,320,,,,,,,fee schedule,288,1209.6,APC
Exome re-evaluation,81417,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,489.6,,,,,,,fee schedule,288,1209.6,Radiology
Exome re-evaluation,81417,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,448,,,,,,,fee schedule,288,1209.6,APC
Exome re-evaluation,81417,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,560,,,,,,,fee schedule,288,1209.6,APC
Rx metab gen seq alys pnl 6,81418,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,825.37,,,,,,,fee schedule,825.37,1604.89,Laboratory
Rx metab gen seq alys pnl 6,81418,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,962.93,,,,,,,fee schedule,825.37,1604.89,APC
Rx metab gen seq alys pnl 6,81418,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,953.76,,,,,,,fee schedule,825.37,1604.89,APC
Rx metab gen seq alys pnl 6,81418,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,917.08,,,,,,,fee schedule,825.37,1604.89,APC
Rx metab gen seq alys pnl 6,81418,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1403.13,,,,,,,fee schedule,825.37,1604.89,Radiology
Rx metab gen seq alys pnl 6,81418,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1283.91,,,,,,,fee schedule,825.37,1604.89,APC
Rx metab gen seq alys pnl 6,81418,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1604.89,,,,,,,fee schedule,825.37,1604.89,APC
Epilepsy gen seq alys panel,81419,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2203.7,,,,,,,fee schedule,2203.7,4284.98,Laboratory
Epilepsy gen seq alys panel,81419,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2570.99,,,,,,,fee schedule,2203.7,4284.98,APC
Epilepsy gen seq alys panel,81419,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2546.5,,,,,,,fee schedule,2203.7,4284.98,APC
Epilepsy gen seq alys panel,81419,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2448.56,,,,,,,fee schedule,2203.7,4284.98,APC
Epilepsy gen seq alys panel,81419,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3746.3,,,,,,,fee schedule,2203.7,4284.98,Radiology
Epilepsy gen seq alys panel,81419,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3427.98,,,,,,,fee schedule,2203.7,4284.98,APC
Epilepsy gen seq alys panel,81419,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4284.98,,,,,,,fee schedule,2203.7,4284.98,APC
Fetal chrmoml aneuploidy,81420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2869.21,,,,,,,fee schedule,683.14,2869.21,
Fetal chrmoml aneuploidy,81420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2299.92,,,,,,,fee schedule,683.14,2869.21,
Fetal chrmoml aneuploidy,81420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2512.46,,,,,,,fee schedule,683.14,2869.21,
Fetal chrmoml aneuploidy,81420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2641.49,,,,,,,fee schedule,683.14,2869.21,
Fetal chrmoml aneuploidy,81420,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,683.14,,,,,,,fee schedule,683.14,2869.21,Laboratory
Fetal chrmoml aneuploidy,81420,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,797,,,,,,,fee schedule,683.14,2869.21,APC
Fetal chrmoml aneuploidy,81420,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,789.41,,,,,,,fee schedule,683.14,2869.21,APC
Fetal chrmoml aneuploidy,81420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,759.05,,,,,,,fee schedule,683.14,2869.21,APC
Fetal chrmoml aneuploidy,81420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1161.35,,,,,,,fee schedule,683.14,2869.21,Radiology
Fetal chrmoml aneuploidy,81420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1062.67,,,,,,,fee schedule,683.14,2869.21,APC
Fetal chrmoml aneuploidy,81420,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1328.34,,,,,,,fee schedule,683.14,2869.21,APC
Fetal chrmoml microdeltj,81422,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3032.81,,,,,,,fee schedule,683.14,3032.81,
Fetal chrmoml microdeltj,81422,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2431.06,,,,,,,fee schedule,683.14,3032.81,
Fetal chrmoml microdeltj,81422,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2655.71,,,,,,,fee schedule,683.14,3032.81,
Fetal chrmoml microdeltj,81422,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2792.11,,,,,,,fee schedule,683.14,3032.81,
Fetal chrmoml microdeltj,81422,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,683.14,,,,,,,fee schedule,683.14,3032.81,Laboratory
Fetal chrmoml microdeltj,81422,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,797,,,,,,,fee schedule,683.14,3032.81,APC
Fetal chrmoml microdeltj,81422,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,789.41,,,,,,,fee schedule,683.14,3032.81,APC
Fetal chrmoml microdeltj,81422,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,759.05,,,,,,,fee schedule,683.14,3032.81,APC
Fetal chrmoml microdeltj,81422,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1161.35,,,,,,,fee schedule,683.14,3032.81,Radiology
Fetal chrmoml microdeltj,81422,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1062.67,,,,,,,fee schedule,683.14,3032.81,APC
Fetal chrmoml microdeltj,81422,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1328.34,,,,,,,fee schedule,683.14,3032.81,APC
Genome sequence analysis,81425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19017.94,,,,,,,fee schedule,4528.08,19017.94,
Genome sequence analysis,81425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15244.54,,,,,,,fee schedule,4528.08,19017.94,
Genome sequence analysis,81425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16653.27,,,,,,,fee schedule,4528.08,19017.94,
Genome sequence analysis,81425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17508.58,,,,,,,fee schedule,4528.08,19017.94,
Genome sequence analysis,81425,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4528.08,,,,,,,fee schedule,4528.08,19017.94,Laboratory
Genome sequence analysis,81425,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5282.76,,,,,,,fee schedule,4528.08,19017.94,APC
Genome sequence analysis,81425,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5232.45,,,,,,,fee schedule,4528.08,19017.94,APC
Genome sequence analysis,81425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5031.2,,,,,,,fee schedule,4528.08,19017.94,APC
Genome sequence analysis,81425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7697.74,,,,,,,fee schedule,4528.08,19017.94,Radiology
Genome sequence analysis,81425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7043.68,,,,,,,fee schedule,4528.08,19017.94,APC
Genome sequence analysis,81425,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8804.6,,,,,,,fee schedule,4528.08,19017.94,APC
Genome sequence analysis,81426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10243.61,,,,,,,fee schedule,2438.96,10243.61,
Genome sequence analysis,81426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8211.15,,,,,,,fee schedule,2438.96,10243.61,
Genome sequence analysis,81426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8969.93,,,,,,,fee schedule,2438.96,10243.61,
Genome sequence analysis,81426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9430.63,,,,,,,fee schedule,2438.96,10243.61,
Genome sequence analysis,81426,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2438.96,,,,,,,fee schedule,2438.96,10243.61,Laboratory
Genome sequence analysis,81426,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2845.45,,,,,,,fee schedule,2438.96,10243.61,APC
Genome sequence analysis,81426,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2818.35,,,,,,,fee schedule,2438.96,10243.61,APC
Genome sequence analysis,81426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2709.95,,,,,,,fee schedule,2438.96,10243.61,APC
Genome sequence analysis,81426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4146.22,,,,,,,fee schedule,2438.96,10243.61,Radiology
Genome sequence analysis,81426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3793.93,,,,,,,fee schedule,2438.96,10243.61,APC
Genome sequence analysis,81426,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4742.41,,,,,,,fee schedule,2438.96,10243.61,APC
Genome re-evaluation,81427,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8836.32,,,,,,,fee schedule,2103.89,8836.32,
Genome re-evaluation,81427,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7083.08,,,,,,,fee schedule,2103.89,8836.32,
Genome re-evaluation,81427,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7737.62,,,,,,,fee schedule,2103.89,8836.32,
Genome re-evaluation,81427,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8135.02,,,,,,,fee schedule,2103.89,8836.32,
Genome re-evaluation,81427,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2103.89,,,,,,,fee schedule,2103.89,8836.32,Laboratory
Genome re-evaluation,81427,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2454.53,,,,,,,fee schedule,2103.89,8836.32,APC
Genome re-evaluation,81427,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2431.16,,,,,,,fee schedule,2103.89,8836.32,APC
Genome re-evaluation,81427,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2337.65,,,,,,,fee schedule,2103.89,8836.32,APC
Genome re-evaluation,81427,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3576.6,,,,,,,fee schedule,2103.89,8836.32,Radiology
Genome re-evaluation,81427,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3272.71,,,,,,,fee schedule,2103.89,8836.32,APC
Genome re-evaluation,81427,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4090.89,,,,,,,fee schedule,2103.89,8836.32,APC
Hearing loss sequence analys,81430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6142.5,,,,,,,fee schedule,1462.5,6142.5,
Hearing loss sequence analys,81430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4923.75,,,,,,,fee schedule,1462.5,6142.5,
Hearing loss sequence analys,81430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5378.75,,,,,,,fee schedule,1462.5,6142.5,
Hearing loss sequence analys,81430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5655,,,,,,,fee schedule,1462.5,6142.5,
Hearing loss sequence analys,81430,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1462.5,,,,,,,fee schedule,1462.5,6142.5,Laboratory
Hearing loss sequence analys,81430,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1706.25,,,,,,,fee schedule,1462.5,6142.5,APC
Hearing loss sequence analys,81430,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1690,,,,,,,fee schedule,1462.5,6142.5,APC
Hearing loss sequence analys,81430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1625,,,,,,,fee schedule,1462.5,6142.5,APC
Hearing loss sequence analys,81430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2486.25,,,,,,,fee schedule,1462.5,6142.5,Radiology
Hearing loss sequence analys,81430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2275,,,,,,,fee schedule,1462.5,6142.5,APC
Hearing loss sequence analys,81430,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2843.75,,,,,,,fee schedule,1462.5,6142.5,APC
Hearing loss dup/del analys,81431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2568.77,,,,,,,fee schedule,611.61,2568.77,
Hearing loss dup/del analys,81431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2059.1,,,,,,,fee schedule,611.61,2568.77,
Hearing loss dup/del analys,81431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2249.38,,,,,,,fee schedule,611.61,2568.77,
Hearing loss dup/del analys,81431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2364.9,,,,,,,fee schedule,611.61,2568.77,
Hearing loss dup/del analys,81431,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,611.61,,,,,,,fee schedule,611.61,2568.77,Laboratory
Hearing loss dup/del analys,81431,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,713.55,,,,,,,fee schedule,611.61,2568.77,APC
Hearing loss dup/del analys,81431,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,706.75,,,,,,,fee schedule,611.61,2568.77,APC
Hearing loss dup/del analys,81431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,679.57,,,,,,,fee schedule,611.61,2568.77,APC
Hearing loss dup/del analys,81431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1039.74,,,,,,,fee schedule,611.61,2568.77,Radiology
Hearing loss dup/del analys,81431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,951.4,,,,,,,fee schedule,611.61,2568.77,APC
Hearing loss dup/del analys,81431,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1189.25,,,,,,,fee schedule,611.61,2568.77,APC
Hrdtry brst ca-rlatd dsordrs,81432,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1173.56,,,,,,,fee schedule,1173.56,2281.91,Laboratory
Hrdtry brst ca-rlatd dsordrs,81432,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1369.15,,,,,,,fee schedule,1173.56,2281.91,APC
Hrdtry brst ca-rlatd dsordrs,81432,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1356.11,,,,,,,fee schedule,1173.56,2281.91,APC
Hrdtry brst ca-rlatd dsordrs,81432,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1303.95,,,,,,,fee schedule,1173.56,2281.91,APC
Hrdtry brst ca-rlatd dsordrs,81432,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1995.04,,,,,,,fee schedule,1173.56,2281.91,Radiology
Hrdtry brst ca-rlatd dsordrs,81432,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1825.53,,,,,,,fee schedule,1173.56,2281.91,APC
Hrdtry brst ca-rlatd dsordrs,81432,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2281.91,,,,,,,fee schedule,1173.56,2281.91,APC
Hereditary retinal disorders,81434,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,538.12,,,,,,,fee schedule,538.12,1046.34,Laboratory
Hereditary retinal disorders,81434,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,627.81,,,,,,,fee schedule,538.12,1046.34,APC
Hereditary retinal disorders,81434,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,621.83,,,,,,,fee schedule,538.12,1046.34,APC
Hereditary retinal disorders,81434,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,597.91,,,,,,,fee schedule,538.12,1046.34,APC
Hereditary retinal disorders,81434,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,914.8,,,,,,,fee schedule,538.12,1046.34,Radiology
Hereditary retinal disorders,81434,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,837.07,,,,,,,fee schedule,538.12,1046.34,APC
Hereditary retinal disorders,81434,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1046.34,,,,,,,fee schedule,538.12,1046.34,APC
Hereditary colon ca dsordrs,81435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2210.92,,,,,,,fee schedule,1173.56,2281.91,
Hereditary colon ca dsordrs,81435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1772.25,,,,,,,fee schedule,1173.56,2281.91,
Hereditary colon ca dsordrs,81435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1936.02,,,,,,,fee schedule,1173.56,2281.91,
Hereditary colon ca dsordrs,81435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2035.45,,,,,,,fee schedule,1173.56,2281.91,
Hereditary colon ca dsordrs,81435,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1173.56,,,,,,,fee schedule,1173.56,2281.91,Laboratory
Hereditary colon ca dsordrs,81435,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1369.15,,,,,,,fee schedule,1173.56,2281.91,APC
Hereditary colon ca dsordrs,81435,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1356.11,,,,,,,fee schedule,1173.56,2281.91,APC
Hereditary colon ca dsordrs,81435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1303.95,,,,,,,fee schedule,1173.56,2281.91,APC
Hereditary colon ca dsordrs,81435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1995.04,,,,,,,fee schedule,1173.56,2281.91,Radiology
Hereditary colon ca dsordrs,81435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1825.53,,,,,,,fee schedule,1173.56,2281.91,APC
Hereditary colon ca dsordrs,81435,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2281.91,,,,,,,fee schedule,1173.56,2281.91,APC
Hereditary colon ca dsordrs,81436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2210.92,,,,,,,fee schedule,1772.25,2210.92,
Hereditary colon ca dsordrs,81436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1772.25,,,,,,,fee schedule,1772.25,2210.92,
Hereditary colon ca dsordrs,81436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1936.02,,,,,,,fee schedule,1772.25,2210.92,
Hereditary colon ca dsordrs,81436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2035.45,,,,,,,fee schedule,1772.25,2210.92,
Heredtry nurondcrn tum dsrdr,81437,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1173.56,,,,,,,fee schedule,1173.56,2281.91,Laboratory
Heredtry nurondcrn tum dsrdr,81437,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1369.15,,,,,,,fee schedule,1173.56,2281.91,APC
Heredtry nurondcrn tum dsrdr,81437,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1356.11,,,,,,,fee schedule,1173.56,2281.91,APC
Heredtry nurondcrn tum dsrdr,81437,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1303.95,,,,,,,fee schedule,1173.56,2281.91,APC
Heredtry nurondcrn tum dsrdr,81437,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1995.04,,,,,,,fee schedule,1173.56,2281.91,Radiology
Heredtry nurondcrn tum dsrdr,81437,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1825.53,,,,,,,fee schedule,1173.56,2281.91,APC
Heredtry nurondcrn tum dsrdr,81437,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2281.91,,,,,,,fee schedule,1173.56,2281.91,APC
Inherited cardmypthy 5 gns,81439,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3032.81,,,,,,,fee schedule,526.41,3032.81,
Inherited cardmypthy 5 gns,81439,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2431.06,,,,,,,fee schedule,526.41,3032.81,
Inherited cardmypthy 5 gns,81439,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2655.71,,,,,,,fee schedule,526.41,3032.81,
Inherited cardmypthy 5 gns,81439,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2792.11,,,,,,,fee schedule,526.41,3032.81,
Inherited cardmypthy 5 gns,81439,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,526.41,,,,,,,fee schedule,526.41,3032.81,Laboratory
Inherited cardmypthy 5 gns,81439,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,614.14,,,,,,,fee schedule,526.41,3032.81,APC
Inherited cardmypthy 5 gns,81439,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,608.3,,,,,,,fee schedule,526.41,3032.81,APC
Inherited cardmypthy 5 gns,81439,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,584.9,,,,,,,fee schedule,526.41,3032.81,APC
Inherited cardmypthy 5 gns,81439,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,894.9,,,,,,,fee schedule,526.41,3032.81,Radiology
Inherited cardmypthy 5 gns,81439,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,818.86,,,,,,,fee schedule,526.41,3032.81,APC
Inherited cardmypthy 5 gns,81439,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1023.58,,,,,,,fee schedule,526.41,3032.81,APC
Mitochondrial gene,81440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12564.72,,,,,,,fee schedule,2991.6,12564.72,
Mitochondrial gene,81440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10071.72,,,,,,,fee schedule,2991.6,12564.72,
Mitochondrial gene,81440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11002.44,,,,,,,fee schedule,2991.6,12564.72,
Mitochondrial gene,81440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11567.52,,,,,,,fee schedule,2991.6,12564.72,
Mitochondrial gene,81440,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2991.6,,,,,,,fee schedule,2991.6,12564.72,Laboratory
Mitochondrial gene,81440,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3490.2,,,,,,,fee schedule,2991.6,12564.72,APC
Mitochondrial gene,81440,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3456.96,,,,,,,fee schedule,2991.6,12564.72,APC
Mitochondrial gene,81440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3324,,,,,,,fee schedule,2991.6,12564.72,APC
Mitochondrial gene,81440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5085.72,,,,,,,fee schedule,2991.6,12564.72,Radiology
Mitochondrial gene,81440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4653.6,,,,,,,fee schedule,2991.6,12564.72,APC
Mitochondrial gene,81440,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5817,,,,,,,fee schedule,2991.6,12564.72,APC
Ibmfs seq alys pnl 30 genes,81441,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2203.7,,,,,,,fee schedule,2203.7,4284.98,Laboratory
Ibmfs seq alys pnl 30 genes,81441,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2570.99,,,,,,,fee schedule,2203.7,4284.98,APC
Ibmfs seq alys pnl 30 genes,81441,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2546.5,,,,,,,fee schedule,2203.7,4284.98,APC
Ibmfs seq alys pnl 30 genes,81441,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2448.56,,,,,,,fee schedule,2203.7,4284.98,APC
Ibmfs seq alys pnl 30 genes,81441,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3746.3,,,,,,,fee schedule,2203.7,4284.98,Radiology
Ibmfs seq alys pnl 30 genes,81441,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3427.98,,,,,,,fee schedule,2203.7,4284.98,APC
Ibmfs seq alys pnl 30 genes,81441,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4284.98,,,,,,,fee schedule,2203.7,4284.98,APC
Noonan spectrum disorders,81442,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1929.24,,,,,,,fee schedule,1929.24,3751.3,Laboratory
Noonan spectrum disorders,81442,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2250.78,,,,,,,fee schedule,1929.24,3751.3,APC
Noonan spectrum disorders,81442,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2229.34,,,,,,,fee schedule,1929.24,3751.3,APC
Noonan spectrum disorders,81442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2143.6,,,,,,,fee schedule,1929.24,3751.3,APC
Noonan spectrum disorders,81442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3279.71,,,,,,,fee schedule,1929.24,3751.3,Radiology
Noonan spectrum disorders,81442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3001.04,,,,,,,fee schedule,1929.24,3751.3,APC
Noonan spectrum disorders,81442,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3751.3,,,,,,,fee schedule,1929.24,3751.3,APC
Genetic tstg severe inh cond,81443,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2203.7,,,,,,,fee schedule,2203.7,4284.98,Laboratory
Genetic tstg severe inh cond,81443,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2570.99,,,,,,,fee schedule,2203.7,4284.98,APC
Genetic tstg severe inh cond,81443,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2546.5,,,,,,,fee schedule,2203.7,4284.98,APC
Genetic tstg severe inh cond,81443,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2448.56,,,,,,,fee schedule,2203.7,4284.98,APC
Genetic tstg severe inh cond,81443,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3746.3,,,,,,,fee schedule,2203.7,4284.98,Radiology
Genetic tstg severe inh cond,81443,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3427.98,,,,,,,fee schedule,2203.7,4284.98,APC
Genetic tstg severe inh cond,81443,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4284.98,,,,,,,fee schedule,2203.7,4284.98,APC
Targeted genomic seq analys,81445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2260.1,,,,,,,fee schedule,538.12,2260.1,
Targeted genomic seq analys,81445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1811.67,,,,,,,fee schedule,538.12,2260.1,
Targeted genomic seq analys,81445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1979.08,,,,,,,fee schedule,538.12,2260.1,
Targeted genomic seq analys,81445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2080.73,,,,,,,fee schedule,538.12,2260.1,
Targeted genomic seq analys,81445,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,538.12,,,,,,,fee schedule,538.12,2260.1,Laboratory
Targeted genomic seq analys,81445,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,627.81,,,,,,,fee schedule,538.12,2260.1,APC
Targeted genomic seq analys,81445,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,621.83,,,,,,,fee schedule,538.12,2260.1,APC
Targeted genomic seq analys,81445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,597.91,,,,,,,fee schedule,538.12,2260.1,APC
Targeted genomic seq analys,81445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,914.8,,,,,,,fee schedule,538.12,2260.1,Radiology
Targeted genomic seq analys,81445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,837.07,,,,,,,fee schedule,538.12,2260.1,APC
Targeted genomic seq analys,81445,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1046.34,,,,,,,fee schedule,538.12,2260.1,APC
Hrdtry perph neurphy panel,81448,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,526.41,,,,,,,fee schedule,526.41,1023.58,Laboratory
Hrdtry perph neurphy panel,81448,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,614.14,,,,,,,fee schedule,526.41,1023.58,APC
Hrdtry perph neurphy panel,81448,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,608.3,,,,,,,fee schedule,526.41,1023.58,APC
Hrdtry perph neurphy panel,81448,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,584.9,,,,,,,fee schedule,526.41,1023.58,APC
Hrdtry perph neurphy panel,81448,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,894.9,,,,,,,fee schedule,526.41,1023.58,Radiology
Hrdtry perph neurphy panel,81448,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,818.86,,,,,,,fee schedule,526.41,1023.58,APC
Hrdtry perph neurphy panel,81448,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1023.58,,,,,,,fee schedule,526.41,1023.58,APC
Tgsap so neo 5-50 rna alys,81449,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,538.12,,,,,,,fee schedule,538.12,1046.34,Laboratory
Tgsap so neo 5-50 rna alys,81449,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,627.81,,,,,,,fee schedule,538.12,1046.34,APC
Tgsap so neo 5-50 rna alys,81449,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,621.83,,,,,,,fee schedule,538.12,1046.34,APC
Tgsap so neo 5-50 rna alys,81449,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,597.91,,,,,,,fee schedule,538.12,1046.34,APC
Tgsap so neo 5-50 rna alys,81449,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,914.8,,,,,,,fee schedule,538.12,1046.34,Radiology
Tgsap so neo 5-50 rna alys,81449,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,837.07,,,,,,,fee schedule,538.12,1046.34,APC
Tgsap so neo 5-50 rna alys,81449,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1046.34,,,,,,,fee schedule,538.12,1046.34,APC
Targeted genomic seq analys,81450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2871.02,,,,,,,fee schedule,683.58,2871.02,
Targeted genomic seq analys,81450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2301.38,,,,,,,fee schedule,683.58,2871.02,
Targeted genomic seq analys,81450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2514.04,,,,,,,fee schedule,683.58,2871.02,
Targeted genomic seq analys,81450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2643.16,,,,,,,fee schedule,683.58,2871.02,
Targeted genomic seq analys,81450,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,683.58,,,,,,,fee schedule,683.58,2871.02,Laboratory
Targeted genomic seq analys,81450,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,797.51,,,,,,,fee schedule,683.58,2871.02,APC
Targeted genomic seq analys,81450,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,789.91,,,,,,,fee schedule,683.58,2871.02,APC
Targeted genomic seq analys,81450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,759.53,,,,,,,fee schedule,683.58,2871.02,APC
Targeted genomic seq analys,81450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1162.08,,,,,,,fee schedule,683.58,2871.02,Radiology
Targeted genomic seq analys,81450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1063.34,,,,,,,fee schedule,683.58,2871.02,APC
Targeted genomic seq analys,81450,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1329.18,,,,,,,fee schedule,683.58,2871.02,APC
Tgsap hl neo 5-50 rna alys,81451,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,683.58,,,,,,,fee schedule,683.58,1329.18,Laboratory
Tgsap hl neo 5-50 rna alys,81451,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,797.51,,,,,,,fee schedule,683.58,1329.18,APC
Tgsap hl neo 5-50 rna alys,81451,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,789.91,,,,,,,fee schedule,683.58,1329.18,APC
Tgsap hl neo 5-50 rna alys,81451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,759.53,,,,,,,fee schedule,683.58,1329.18,APC
Tgsap hl neo 5-50 rna alys,81451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1162.08,,,,,,,fee schedule,683.58,1329.18,Radiology
Tgsap hl neo 5-50 rna alys,81451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1063.34,,,,,,,fee schedule,683.58,1329.18,APC
Tgsap hl neo 5-50 rna alys,81451,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1329.18,,,,,,,fee schedule,683.58,1329.18,APC
Targeted genomic seq analys,81455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11036.09,,,,,,,fee schedule,2627.64,11036.09,
Targeted genomic seq analys,81455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8846.39,,,,,,,fee schedule,2627.64,11036.09,
Targeted genomic seq analys,81455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9663.88,,,,,,,fee schedule,2627.64,11036.09,
Targeted genomic seq analys,81455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10160.21,,,,,,,fee schedule,2627.64,11036.09,
Targeted genomic seq analys,81455,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2627.64,,,,,,,fee schedule,2627.64,11036.09,Laboratory
Targeted genomic seq analys,81455,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3065.58,,,,,,,fee schedule,2627.64,11036.09,APC
Targeted genomic seq analys,81455,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3036.38,,,,,,,fee schedule,2627.64,11036.09,APC
Targeted genomic seq analys,81455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2919.6,,,,,,,fee schedule,2627.64,11036.09,APC
Targeted genomic seq analys,81455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4466.99,,,,,,,fee schedule,2627.64,11036.09,Radiology
Targeted genomic seq analys,81455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4087.44,,,,,,,fee schedule,2627.64,11036.09,APC
Targeted genomic seq analys,81455,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5109.3,,,,,,,fee schedule,2627.64,11036.09,APC
Tgsap so/hl 51/< rna alys,81456,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2627.64,,,,,,,fee schedule,2627.64,5109.3,Laboratory
Tgsap so/hl 51/< rna alys,81456,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3065.58,,,,,,,fee schedule,2627.64,5109.3,APC
Tgsap so/hl 51/< rna alys,81456,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3036.38,,,,,,,fee schedule,2627.64,5109.3,APC
Tgsap so/hl 51/< rna alys,81456,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2919.6,,,,,,,fee schedule,2627.64,5109.3,APC
Tgsap so/hl 51/< rna alys,81456,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4466.99,,,,,,,fee schedule,2627.64,5109.3,Radiology
Tgsap so/hl 51/< rna alys,81456,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4087.44,,,,,,,fee schedule,2627.64,5109.3,APC
Tgsap so/hl 51/< rna alys,81456,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5109.3,,,,,,,fee schedule,2627.64,5109.3,APC
So neo gsap dna mcrstl ins,81457,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,807.18,,,,,,,fee schedule,807.18,1569.52,Laboratory
So neo gsap dna mcrstl ins,81457,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,941.71,,,,,,,fee schedule,807.18,1569.52,APC
So neo gsap dna mcrstl ins,81457,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,932.74,,,,,,,fee schedule,807.18,1569.52,APC
So neo gsap dna mcrstl ins,81457,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,896.87,,,,,,,fee schedule,807.18,1569.52,APC
So neo gsap dna mcrstl ins,81457,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1372.21,,,,,,,fee schedule,807.18,1569.52,Radiology
So neo gsap dna mcrstl ins,81457,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1255.62,,,,,,,fee schedule,807.18,1569.52,APC
So neo gsap dna mcrstl ins,81457,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1569.52,,,,,,,fee schedule,807.18,1569.52,APC
So gsap dna cpy nmbr&mcrstl,81458,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,941.71,,,,,,,fee schedule,941.72,1831.11,Laboratory
So gsap dna cpy nmbr&mcrstl,81458,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1098.67,,,,,,,fee schedule,941.72,1831.11,APC
So gsap dna cpy nmbr&mcrstl,81458,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1088.2,,,,,,,fee schedule,941.72,1831.11,APC
So gsap dna cpy nmbr&mcrstl,81458,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1046.35,,,,,,,fee schedule,941.72,1831.11,APC
So gsap dna cpy nmbr&mcrstl,81458,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1600.92,,,,,,,fee schedule,941.72,1831.11,Radiology
So gsap dna cpy nmbr&mcrstl,81458,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1464.89,,,,,,,fee schedule,941.72,1831.11,APC
So gsap dna cpy nmbr&mcrstl,81458,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1831.11,,,,,,,fee schedule,941.72,1831.11,APC
So neo gsap dna/dna&rna,81459,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2690.6,,,,,,,fee schedule,2690.6,5231.71,Laboratory
So neo gsap dna/dna&rna,81459,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3139.03,,,,,,,fee schedule,2690.6,5231.71,APC
So neo gsap dna/dna&rna,81459,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3109.13,,,,,,,fee schedule,2690.6,5231.71,APC
So neo gsap dna/dna&rna,81459,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2989.55,,,,,,,fee schedule,2690.6,5231.71,APC
So neo gsap dna/dna&rna,81459,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4574.01,,,,,,,fee schedule,2690.6,5231.71,Radiology
So neo gsap dna/dna&rna,81459,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4185.37,,,,,,,fee schedule,2690.6,5231.71,APC
So neo gsap dna/dna&rna,81459,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5231.71,,,,,,,fee schedule,2690.6,5231.71,APC
Whole mitochondrial genome,81460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4864.86,,,,,,,fee schedule,1158.3,4864.86,
Whole mitochondrial genome,81460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3899.61,,,,,,,fee schedule,1158.3,4864.86,
Whole mitochondrial genome,81460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4259.97,,,,,,,fee schedule,1158.3,4864.86,
Whole mitochondrial genome,81460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4478.76,,,,,,,fee schedule,1158.3,4864.86,
Whole mitochondrial genome,81460,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1158.3,,,,,,,fee schedule,1158.3,4864.86,Laboratory
Whole mitochondrial genome,81460,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1351.35,,,,,,,fee schedule,1158.3,4864.86,APC
Whole mitochondrial genome,81460,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1338.48,,,,,,,fee schedule,1158.3,4864.86,APC
Whole mitochondrial genome,81460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1287,,,,,,,fee schedule,1158.3,4864.86,APC
Whole mitochondrial genome,81460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1969.11,,,,,,,fee schedule,1158.3,4864.86,Radiology
Whole mitochondrial genome,81460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1801.8,,,,,,,fee schedule,1158.3,4864.86,APC
Whole mitochondrial genome,81460,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2252.25,,,,,,,fee schedule,1158.3,4864.86,APC
So gsap cll fr dna/dna&rna,81462,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1076.25,,,,,,,fee schedule,1076.25,2092.7,Laboratory
So gsap cll fr dna/dna&rna,81462,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1255.62,,,,,,,fee schedule,1076.25,2092.7,APC
So gsap cll fr dna/dna&rna,81462,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1243.66,,,,,,,fee schedule,1076.25,2092.7,APC
So gsap cll fr dna/dna&rna,81462,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1195.83,,,,,,,fee schedule,1076.25,2092.7,APC
So gsap cll fr dna/dna&rna,81462,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1829.62,,,,,,,fee schedule,1076.25,2092.7,Radiology
So gsap cll fr dna/dna&rna,81462,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1674.16,,,,,,,fee schedule,1076.25,2092.7,APC
So gsap cll fr dna/dna&rna,81462,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2092.7,,,,,,,fee schedule,1076.25,2092.7,APC
So gsap cl fr cpy nmbr&mcrst,81463,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1210.78,,,,,,,fee schedule,1210.78,2354.29,Laboratory
So gsap cl fr cpy nmbr&mcrst,81463,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1412.58,,,,,,,fee schedule,1210.78,2354.29,APC
So gsap cl fr cpy nmbr&mcrst,81463,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1399.12,,,,,,,fee schedule,1210.78,2354.29,APC
So gsap cl fr cpy nmbr&mcrst,81463,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1345.31,,,,,,,fee schedule,1210.78,2354.29,APC
So gsap cl fr cpy nmbr&mcrst,81463,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2058.32,,,,,,,fee schedule,1210.78,2354.29,Radiology
So gsap cl fr cpy nmbr&mcrst,81463,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1883.43,,,,,,,fee schedule,1210.78,2354.29,APC
So gsap cl fr cpy nmbr&mcrst,81463,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2354.29,,,,,,,fee schedule,1210.78,2354.29,APC
So gsap cll fr mcrstl ins,81464,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2959.66,,,,,,,fee schedule,2959.66,5754.89,Laboratory
So gsap cll fr mcrstl ins,81464,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3452.94,,,,,,,fee schedule,2959.66,5754.89,APC
So gsap cll fr mcrstl ins,81464,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3420.05,,,,,,,fee schedule,2959.66,5754.89,APC
So gsap cll fr mcrstl ins,81464,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3288.51,,,,,,,fee schedule,2959.66,5754.89,APC
So gsap cll fr mcrstl ins,81464,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5031.42,,,,,,,fee schedule,2959.66,5754.89,Radiology
So gsap cll fr mcrstl ins,81464,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4603.91,,,,,,,fee schedule,2959.66,5754.89,APC
So gsap cll fr mcrstl ins,81464,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5754.89,,,,,,,fee schedule,2959.66,5754.89,APC
Whole mitochondrial genome,81465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3538.08,,,,,,,fee schedule,842.4,3538.08,
Whole mitochondrial genome,81465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2836.08,,,,,,,fee schedule,842.4,3538.08,
Whole mitochondrial genome,81465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3098.16,,,,,,,fee schedule,842.4,3538.08,
Whole mitochondrial genome,81465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3257.28,,,,,,,fee schedule,842.4,3538.08,
Whole mitochondrial genome,81465,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,842.4,,,,,,,fee schedule,842.4,3538.08,Laboratory
Whole mitochondrial genome,81465,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,982.8,,,,,,,fee schedule,842.4,3538.08,APC
Whole mitochondrial genome,81465,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,973.44,,,,,,,fee schedule,842.4,3538.08,APC
Whole mitochondrial genome,81465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,936,,,,,,,fee schedule,842.4,3538.08,APC
Whole mitochondrial genome,81465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1432.08,,,,,,,fee schedule,842.4,3538.08,Radiology
Whole mitochondrial genome,81465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1310.4,,,,,,,fee schedule,842.4,3538.08,APC
Whole mitochondrial genome,81465,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1638,,,,,,,fee schedule,842.4,3538.08,APC
X-linked intellectual dblt,81470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3454.92,,,,,,,fee schedule,822.6,3454.92,
X-linked intellectual dblt,81470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2769.42,,,,,,,fee schedule,822.6,3454.92,
X-linked intellectual dblt,81470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3025.34,,,,,,,fee schedule,822.6,3454.92,
X-linked intellectual dblt,81470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3180.72,,,,,,,fee schedule,822.6,3454.92,
X-linked intellectual dblt,81470,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,822.6,,,,,,,fee schedule,822.6,3454.92,Laboratory
X-linked intellectual dblt,81470,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,959.7,,,,,,,fee schedule,822.6,3454.92,APC
X-linked intellectual dblt,81470,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,950.56,,,,,,,fee schedule,822.6,3454.92,APC
X-linked intellectual dblt,81470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,914,,,,,,,fee schedule,822.6,3454.92,APC
X-linked intellectual dblt,81470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1398.42,,,,,,,fee schedule,822.6,3454.92,Radiology
X-linked intellectual dblt,81470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1279.6,,,,,,,fee schedule,822.6,3454.92,APC
X-linked intellectual dblt,81470,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1599.5,,,,,,,fee schedule,822.6,3454.92,APC
X-linked intellectual dblt,81471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3454.92,,,,,,,fee schedule,822.6,3454.92,
X-linked intellectual dblt,81471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2769.42,,,,,,,fee schedule,822.6,3454.92,
X-linked intellectual dblt,81471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3025.34,,,,,,,fee schedule,822.6,3454.92,
X-linked intellectual dblt,81471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3180.72,,,,,,,fee schedule,822.6,3454.92,
X-linked intellectual dblt,81471,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,822.6,,,,,,,fee schedule,822.6,3454.92,Laboratory
X-linked intellectual dblt,81471,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,959.7,,,,,,,fee schedule,822.6,3454.92,APC
X-linked intellectual dblt,81471,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,950.56,,,,,,,fee schedule,822.6,3454.92,APC
X-linked intellectual dblt,81471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,914,,,,,,,fee schedule,822.6,3454.92,APC
X-linked intellectual dblt,81471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1398.42,,,,,,,fee schedule,822.6,3454.92,Radiology
X-linked intellectual dblt,81471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1279.6,,,,,,,fee schedule,822.6,3454.92,APC
X-linked intellectual dblt,81471,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1599.5,,,,,,,fee schedule,822.6,3454.92,APC
Autoimmune rheumatoid arthr,81490,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,756.58,,,,,,,fee schedule,756.58,1471.14,Laboratory
Autoimmune rheumatoid arthr,81490,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,882.68,,,,,,,fee schedule,756.58,1471.14,APC
Autoimmune rheumatoid arthr,81490,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,874.28,,,,,,,fee schedule,756.58,1471.14,APC
Autoimmune rheumatoid arthr,81490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,840.65,,,,,,,fee schedule,756.58,1471.14,APC
Autoimmune rheumatoid arthr,81490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1286.19,,,,,,,fee schedule,756.58,1471.14,Radiology
Autoimmune rheumatoid arthr,81490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1176.91,,,,,,,fee schedule,756.58,1471.14,APC
Autoimmune rheumatoid arthr,81490,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1471.14,,,,,,,fee schedule,756.58,1471.14,APC
Cor artery disease mrna,81493,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,945,,,,,,,fee schedule,945,1837.5,Laboratory
Cor artery disease mrna,81493,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1102.5,,,,,,,fee schedule,945,1837.5,APC
Cor artery disease mrna,81493,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1092,,,,,,,fee schedule,945,1837.5,APC
Cor artery disease mrna,81493,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1050,,,,,,,fee schedule,945,1837.5,APC
Cor artery disease mrna,81493,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1606.5,,,,,,,fee schedule,945,1837.5,Radiology
Cor artery disease mrna,81493,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1470,,,,,,,fee schedule,945,1837.5,APC
Cor artery disease mrna,81493,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1837.5,,,,,,,fee schedule,945,1837.5,APC
Onco (ovar) two proteins,81500,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,234.45,,,,,,,fee schedule,234.45,455.88,Laboratory
Onco (ovar) two proteins,81500,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,273.53,,,,,,,fee schedule,234.45,455.88,APC
Onco (ovar) two proteins,81500,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,270.92,,,,,,,fee schedule,234.45,455.88,APC
Onco (ovar) two proteins,81500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,260.5,,,,,,,fee schedule,234.45,455.88,APC
Onco (ovar) two proteins,81500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,398.56,,,,,,,fee schedule,234.45,455.88,Radiology
Onco (ovar) two proteins,81500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,364.7,,,,,,,fee schedule,234.45,455.88,APC
Onco (ovar) two proteins,81500,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,455.88,,,,,,,fee schedule,234.45,455.88,APC
Onco (ovar) five proteins,81503,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,807.3,,,,,,,fee schedule,807.3,1569.75,Laboratory
Onco (ovar) five proteins,81503,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,941.85,,,,,,,fee schedule,807.3,1569.75,APC
Onco (ovar) five proteins,81503,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,932.88,,,,,,,fee schedule,807.3,1569.75,APC
Onco (ovar) five proteins,81503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,897,,,,,,,fee schedule,807.3,1569.75,APC
Onco (ovar) five proteins,81503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1372.41,,,,,,,fee schedule,807.3,1569.75,Radiology
Onco (ovar) five proteins,81503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1255.8,,,,,,,fee schedule,807.3,1569.75,APC
Onco (ovar) five proteins,81503,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1569.75,,,,,,,fee schedule,807.3,1569.75,APC
Oncology tissue of origin,81504,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,468,,,,,,,fee schedule,468,910,Laboratory
Oncology tissue of origin,81504,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,546,,,,,,,fee schedule,468,910,APC
Oncology tissue of origin,81504,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,540.8,,,,,,,fee schedule,468,910,APC
Oncology tissue of origin,81504,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,520,,,,,,,fee schedule,468,910,APC
Oncology tissue of origin,81504,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,795.6,,,,,,,fee schedule,468,910,Radiology
Oncology tissue of origin,81504,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,728,,,,,,,fee schedule,468,910,APC
Oncology tissue of origin,81504,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,910,,,,,,,fee schedule,468,910,APC
Endo assay seven anal,81506,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,62.03,,,,,,,fee schedule,62.03,120.61,Laboratory
Endo assay seven anal,81506,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,72.37,,,,,,,fee schedule,62.03,120.61,APC
Endo assay seven anal,81506,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,71.68,,,,,,,fee schedule,62.03,120.61,APC
Endo assay seven anal,81506,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,68.92,,,,,,,fee schedule,62.03,120.61,APC
Endo assay seven anal,81506,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,105.45,,,,,,,fee schedule,62.03,120.61,Radiology
Endo assay seven anal,81506,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,96.49,,,,,,,fee schedule,62.03,120.61,APC
Endo assay seven anal,81506,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,120.61,,,,,,,fee schedule,62.03,120.61,APC
Fetal aneuploidy trisom risk,81507,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,715.5,,,,,,,fee schedule,715.5,1391.25,Laboratory
Fetal aneuploidy trisom risk,81507,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,834.75,,,,,,,fee schedule,715.5,1391.25,APC
Fetal aneuploidy trisom risk,81507,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,826.8,,,,,,,fee schedule,715.5,1391.25,APC
Fetal aneuploidy trisom risk,81507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,795,,,,,,,fee schedule,715.5,1391.25,APC
Fetal aneuploidy trisom risk,81507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1216.35,,,,,,,fee schedule,715.5,1391.25,Radiology
Fetal aneuploidy trisom risk,81507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1113,,,,,,,fee schedule,715.5,1391.25,APC
Fetal aneuploidy trisom risk,81507,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1391.25,,,,,,,fee schedule,715.5,1391.25,APC
Ftl cgen abnor two proteins,81508,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,48.87,,,,,,,fee schedule,48.87,95.02,Laboratory
Ftl cgen abnor two proteins,81508,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,57.02,,,,,,,fee schedule,48.87,95.02,APC
Ftl cgen abnor two proteins,81508,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,56.47,,,,,,,fee schedule,48.87,95.02,APC
Ftl cgen abnor two proteins,81508,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,54.3,,,,,,,fee schedule,48.87,95.02,APC
Ftl cgen abnor two proteins,81508,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,83.08,,,,,,,fee schedule,48.87,95.02,Radiology
Ftl cgen abnor two proteins,81508,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,76.02,,,,,,,fee schedule,48.87,95.02,APC
Ftl cgen abnor two proteins,81508,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,95.02,,,,,,,fee schedule,48.87,95.02,APC
Ftl cgen abnor 3 proteins,81509,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1338.63,,,,,,,fee schedule,1338.63,2602.9,Laboratory
Ftl cgen abnor 3 proteins,81509,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1561.74,,,,,,,fee schedule,1338.63,2602.9,APC
Ftl cgen abnor 3 proteins,81509,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1546.86,,,,,,,fee schedule,1338.63,2602.9,APC
Ftl cgen abnor 3 proteins,81509,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1487.37,,,,,,,fee schedule,1338.63,2602.9,APC
Ftl cgen abnor 3 proteins,81509,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2275.68,,,,,,,fee schedule,1338.63,2602.9,Radiology
Ftl cgen abnor 3 proteins,81509,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2082.32,,,,,,,fee schedule,1338.63,2602.9,APC
Ftl cgen abnor 3 proteins,81509,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2602.9,,,,,,,fee schedule,1338.63,2602.9,APC
Ftl cgen abnor three anal,81510,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,49.99,,,,,,,fee schedule,49.99,97.2,Laboratory
Ftl cgen abnor three anal,81510,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,58.32,,,,,,,fee schedule,49.99,97.2,APC
Ftl cgen abnor three anal,81510,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,57.76,,,,,,,fee schedule,49.99,97.2,APC
Ftl cgen abnor three anal,81510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,55.54,,,,,,,fee schedule,49.99,97.2,APC
Ftl cgen abnor three anal,81510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,84.98,,,,,,,fee schedule,49.99,97.2,Radiology
Ftl cgen abnor three anal,81510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,77.76,,,,,,,fee schedule,49.99,97.2,APC
Ftl cgen abnor three anal,81510,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,97.2,,,,,,,fee schedule,49.99,97.2,APC
Ftl cgen abnor four anal,81511,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,138.15,,,,,,,fee schedule,138.15,268.62,Laboratory
Ftl cgen abnor four anal,81511,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,161.18,,,,,,,fee schedule,138.15,268.62,APC
Ftl cgen abnor four anal,81511,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,159.64,,,,,,,fee schedule,138.15,268.62,APC
Ftl cgen abnor four anal,81511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,153.5,,,,,,,fee schedule,138.15,268.62,APC
Ftl cgen abnor four anal,81511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,234.86,,,,,,,fee schedule,138.15,268.62,Radiology
Ftl cgen abnor four anal,81511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,214.9,,,,,,,fee schedule,138.15,268.62,APC
Ftl cgen abnor four anal,81511,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,268.62,,,,,,,fee schedule,138.15,268.62,APC
Ftl cgen abnor five anal,81512,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,62.57,,,,,,,fee schedule,62.57,121.66,Laboratory
Ftl cgen abnor five anal,81512,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,73,,,,,,,fee schedule,62.57,121.66,APC
Ftl cgen abnor five anal,81512,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,72.3,,,,,,,fee schedule,62.57,121.66,APC
Ftl cgen abnor five anal,81512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,69.52,,,,,,,fee schedule,62.57,121.66,APC
Ftl cgen abnor five anal,81512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,106.37,,,,,,,fee schedule,62.57,121.66,Radiology
Ftl cgen abnor five anal,81512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,97.33,,,,,,,fee schedule,62.57,121.66,APC
Ftl cgen abnor five anal,81512,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,121.66,,,,,,,fee schedule,62.57,121.66,APC
Nfct ds bv rna vag flu alg,81513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,539.14,,,,,,,fee schedule,128.37,539.14,
Nfct ds bv rna vag flu alg,81513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,432.17,,,,,,,fee schedule,128.37,539.14,
Nfct ds bv rna vag flu alg,81513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,472.11,,,,,,,fee schedule,128.37,539.14,
Nfct ds bv rna vag flu alg,81513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,496.35,,,,,,,fee schedule,128.37,539.14,
Nfct ds bv rna vag flu alg,81513,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,128.37,,,,,,,fee schedule,128.37,539.14,Laboratory
Nfct ds bv rna vag flu alg,81513,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,149.76,,,,,,,fee schedule,128.37,539.14,APC
Nfct ds bv rna vag flu alg,81513,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,148.34,,,,,,,fee schedule,128.37,539.14,APC
Nfct ds bv rna vag flu alg,81513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,142.63,,,,,,,fee schedule,128.37,539.14,APC
Nfct ds bv rna vag flu alg,81513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,218.22,,,,,,,fee schedule,128.37,539.14,Radiology
Nfct ds bv rna vag flu alg,81513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,199.68,,,,,,,fee schedule,128.37,539.14,APC
Nfct ds bv rna vag flu alg,81513,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,249.6,,,,,,,fee schedule,128.37,539.14,APC
Nfct ds bv&vaginitis dna alg,81514,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,994.1,,,,,,,fee schedule,236.69,994.1,
Nfct ds bv&vaginitis dna alg,81514,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,796.86,,,,,,,fee schedule,236.69,994.1,
Nfct ds bv&vaginitis dna alg,81514,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,870.5,,,,,,,fee schedule,236.69,994.1,
Nfct ds bv&vaginitis dna alg,81514,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,915.21,,,,,,,fee schedule,236.69,994.1,
Nfct ds bv&vaginitis dna alg,81514,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,236.69,,,,,,,fee schedule,236.69,994.1,Laboratory
Nfct ds bv&vaginitis dna alg,81514,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,276.14,,,,,,,fee schedule,236.69,994.1,APC
Nfct ds bv&vaginitis dna alg,81514,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,273.51,,,,,,,fee schedule,236.69,994.1,APC
Nfct ds bv&vaginitis dna alg,81514,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,262.99,,,,,,,fee schedule,236.69,994.1,APC
Nfct ds bv&vaginitis dna alg,81514,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,402.37,,,,,,,fee schedule,236.69,994.1,Radiology
Nfct ds bv&vaginitis dna alg,81514,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,368.19,,,,,,,fee schedule,236.69,994.1,APC
Nfct ds bv&vaginitis dna alg,81514,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,460.23,,,,,,,fee schedule,236.69,994.1,APC
Nfct ds bv&vaginitis dna alg,81515,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,236.69,,,,,,,fee schedule,236.69,460.23,Laboratory
Nfct ds bv&vaginitis dna alg,81515,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,276.14,,,,,,,fee schedule,236.69,460.23,APC
Nfct ds bv&vaginitis dna alg,81515,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,273.51,,,,,,,fee schedule,236.69,460.23,APC
Nfct ds bv&vaginitis dna alg,81515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,262.99,,,,,,,fee schedule,236.69,460.23,APC
Nfct ds bv&vaginitis dna alg,81515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,402.37,,,,,,,fee schedule,236.69,460.23,Radiology
Nfct ds bv&vaginitis dna alg,81515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,368.19,,,,,,,fee schedule,236.69,460.23,APC
Nfct ds bv&vaginitis dna alg,81515,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,460.23,,,,,,,fee schedule,236.69,460.23,APC
Liver ds alys 3 bmrk srm alg,81517,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,158.57,,,,,,,fee schedule,158.57,308.33,Laboratory
Liver ds alys 3 bmrk srm alg,81517,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,185,,,,,,,fee schedule,158.57,308.33,APC
Liver ds alys 3 bmrk srm alg,81517,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,183.24,,,,,,,fee schedule,158.57,308.33,APC
Liver ds alys 3 bmrk srm alg,81517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,176.19,,,,,,,fee schedule,158.57,308.33,APC
Liver ds alys 3 bmrk srm alg,81517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,269.57,,,,,,,fee schedule,158.57,308.33,Radiology
Liver ds alys 3 bmrk srm alg,81517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,246.67,,,,,,,fee schedule,158.57,308.33,APC
Liver ds alys 3 bmrk srm alg,81517,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,308.33,,,,,,,fee schedule,158.57,308.33,APC
Onc brst mrna 11 genes,81518,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3485.7,,,,,,,fee schedule,3485.7,6777.75,Laboratory
Onc brst mrna 11 genes,81518,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4066.65,,,,,,,fee schedule,3485.7,6777.75,APC
Onc brst mrna 11 genes,81518,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4027.92,,,,,,,fee schedule,3485.7,6777.75,APC
Onc brst mrna 11 genes,81518,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3873,,,,,,,fee schedule,3485.7,6777.75,APC
Onc brst mrna 11 genes,81518,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5925.69,,,,,,,fee schedule,3485.7,6777.75,Radiology
Onc brst mrna 11 genes,81518,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5422.2,,,,,,,fee schedule,3485.7,6777.75,APC
Onc brst mrna 11 genes,81518,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6777.75,,,,,,,fee schedule,3485.7,6777.75,APC
Oncology breast mrna,81519,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14639.94,,,,,,,fee schedule,3485.7,14639.94,
Oncology breast mrna,81519,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11735.19,,,,,,,fee schedule,3485.7,14639.94,
Oncology breast mrna,81519,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12819.63,,,,,,,fee schedule,3485.7,14639.94,
Oncology breast mrna,81519,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13478.04,,,,,,,fee schedule,3485.7,14639.94,
Oncology breast mrna,81519,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3485.7,,,,,,,fee schedule,3485.7,14639.94,Laboratory
Oncology breast mrna,81519,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4066.65,,,,,,,fee schedule,3485.7,14639.94,APC
Oncology breast mrna,81519,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4027.92,,,,,,,fee schedule,3485.7,14639.94,APC
Oncology breast mrna,81519,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3873,,,,,,,fee schedule,3485.7,14639.94,APC
Oncology breast mrna,81519,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5925.69,,,,,,,fee schedule,3485.7,14639.94,Radiology
Oncology breast mrna,81519,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5422.2,,,,,,,fee schedule,3485.7,14639.94,APC
Oncology breast mrna,81519,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6777.75,,,,,,,fee schedule,3485.7,14639.94,APC
Onc breast mrna 58 genes,81520,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2259.19,,,,,,,fee schedule,2259.19,4392.87,Laboratory
Onc breast mrna 58 genes,81520,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2635.72,,,,,,,fee schedule,2259.19,4392.87,APC
Onc breast mrna 58 genes,81520,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2610.62,,,,,,,fee schedule,2259.19,4392.87,APC
Onc breast mrna 58 genes,81520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2510.21,,,,,,,fee schedule,2259.19,4392.87,APC
Onc breast mrna 58 genes,81520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3840.62,,,,,,,fee schedule,2259.19,4392.87,Radiology
Onc breast mrna 58 genes,81520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3514.29,,,,,,,fee schedule,2259.19,4392.87,APC
Onc breast mrna 58 genes,81520,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4392.87,,,,,,,fee schedule,2259.19,4392.87,APC
Onc breast mrna 70 genes,81521,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3485.7,,,,,,,fee schedule,3485.7,6777.75,Laboratory
Onc breast mrna 70 genes,81521,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4066.65,,,,,,,fee schedule,3485.7,6777.75,APC
Onc breast mrna 70 genes,81521,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4027.92,,,,,,,fee schedule,3485.7,6777.75,APC
Onc breast mrna 70 genes,81521,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3873,,,,,,,fee schedule,3485.7,6777.75,APC
Onc breast mrna 70 genes,81521,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5925.69,,,,,,,fee schedule,3485.7,6777.75,Radiology
Onc breast mrna 70 genes,81521,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5422.2,,,,,,,fee schedule,3485.7,6777.75,APC
Onc breast mrna 70 genes,81521,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6777.75,,,,,,,fee schedule,3485.7,6777.75,APC
Onc breast mrna 12 genes,81522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14639.94,,,,,,,fee schedule,3485.7,14639.94,
Onc breast mrna 12 genes,81522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11735.19,,,,,,,fee schedule,3485.7,14639.94,
Onc breast mrna 12 genes,81522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12819.63,,,,,,,fee schedule,3485.7,14639.94,
Onc breast mrna 12 genes,81522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13478.04,,,,,,,fee schedule,3485.7,14639.94,
Onc breast mrna 12 genes,81522,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3485.7,,,,,,,fee schedule,3485.7,14639.94,Laboratory
Onc breast mrna 12 genes,81522,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4066.65,,,,,,,fee schedule,3485.7,14639.94,APC
Onc breast mrna 12 genes,81522,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4027.92,,,,,,,fee schedule,3485.7,14639.94,APC
Onc breast mrna 12 genes,81522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3873,,,,,,,fee schedule,3485.7,14639.94,APC
Onc breast mrna 12 genes,81522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5925.69,,,,,,,fee schedule,3485.7,14639.94,Radiology
Onc breast mrna 12 genes,81522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5422.2,,,,,,,fee schedule,3485.7,14639.94,APC
Onc breast mrna 12 genes,81522,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6777.75,,,,,,,fee schedule,3485.7,14639.94,APC
Onc brst mrna 70 cnt 31 gene,81523,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14639.94,,,,,,,fee schedule,3485.7,14639.94,
Onc brst mrna 70 cnt 31 gene,81523,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11735.19,,,,,,,fee schedule,3485.7,14639.94,
Onc brst mrna 70 cnt 31 gene,81523,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12819.63,,,,,,,fee schedule,3485.7,14639.94,
Onc brst mrna 70 cnt 31 gene,81523,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13478.04,,,,,,,fee schedule,3485.7,14639.94,
Onc brst mrna 70 cnt 31 gene,81523,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3485.7,,,,,,,fee schedule,3485.7,14639.94,Laboratory
Onc brst mrna 70 cnt 31 gene,81523,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4066.65,,,,,,,fee schedule,3485.7,14639.94,APC
Onc brst mrna 70 cnt 31 gene,81523,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4027.92,,,,,,,fee schedule,3485.7,14639.94,APC
Onc brst mrna 70 cnt 31 gene,81523,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3873,,,,,,,fee schedule,3485.7,14639.94,APC
Onc brst mrna 70 cnt 31 gene,81523,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5925.69,,,,,,,fee schedule,3485.7,14639.94,Radiology
Onc brst mrna 70 cnt 31 gene,81523,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5422.2,,,,,,,fee schedule,3485.7,14639.94,APC
Onc brst mrna 70 cnt 31 gene,81523,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6777.75,,,,,,,fee schedule,3485.7,14639.94,APC
Oncology colon mrna,81525,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2804.4,,,,,,,fee schedule,2804.4,5453,Laboratory
Oncology colon mrna,81525,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3271.8,,,,,,,fee schedule,2804.4,5453,APC
Oncology colon mrna,81525,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3240.64,,,,,,,fee schedule,2804.4,5453,APC
Oncology colon mrna,81525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3116,,,,,,,fee schedule,2804.4,5453,APC
Oncology colon mrna,81525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4767.48,,,,,,,fee schedule,2804.4,5453,Radiology
Oncology colon mrna,81525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4362.4,,,,,,,fee schedule,2804.4,5453,APC
Oncology colon mrna,81525,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5453,,,,,,,fee schedule,2804.4,5453,APC
Oncology colorectal scr,81528,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1379.62,,,,,,,fee schedule,457.98,1379.62,
Oncology colorectal scr,81528,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1105.89,,,,,,,fee schedule,457.98,1379.62,
Oncology colorectal scr,81528,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1208.08,,,,,,,fee schedule,457.98,1379.62,
Oncology colorectal scr,81528,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1270.13,,,,,,,fee schedule,457.98,1379.62,
Oncology colorectal scr,81528,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,457.98,,,,,,,fee schedule,457.98,1379.62,Laboratory
Oncology colorectal scr,81528,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,534.31,,,,,,,fee schedule,457.98,1379.62,APC
Oncology colorectal scr,81528,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,529.22,,,,,,,fee schedule,457.98,1379.62,APC
Oncology colorectal scr,81528,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,508.87,,,,,,,fee schedule,457.98,1379.62,APC
Oncology colorectal scr,81528,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,778.57,,,,,,,fee schedule,457.98,1379.62,Radiology
Oncology colorectal scr,81528,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,712.42,,,,,,,fee schedule,457.98,1379.62,APC
Oncology colorectal scr,81528,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,890.52,,,,,,,fee schedule,457.98,1379.62,APC
Onc cutan mlnma mrna 31 gene,81529,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6473.7,,,,,,,fee schedule,6473.7,12587.75,Laboratory
Onc cutan mlnma mrna 31 gene,81529,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7552.65,,,,,,,fee schedule,6473.7,12587.75,APC
Onc cutan mlnma mrna 31 gene,81529,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7480.72,,,,,,,fee schedule,6473.7,12587.75,APC
Onc cutan mlnma mrna 31 gene,81529,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7193,,,,,,,fee schedule,6473.7,12587.75,APC
Onc cutan mlnma mrna 31 gene,81529,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11005.29,,,,,,,fee schedule,6473.7,12587.75,Radiology
Onc cutan mlnma mrna 31 gene,81529,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10070.2,,,,,,,fee schedule,6473.7,12587.75,APC
Onc cutan mlnma mrna 31 gene,81529,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12587.75,,,,,,,fee schedule,6473.7,12587.75,APC
Oncology gynecologic,81535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2190.36,,,,,,,fee schedule,521.51,2190.36,
Oncology gynecologic,81535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1755.76,,,,,,,fee schedule,521.51,2190.36,
Oncology gynecologic,81535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1918.01,,,,,,,fee schedule,521.51,2190.36,
Oncology gynecologic,81535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2016.52,,,,,,,fee schedule,521.51,2190.36,
Oncology gynecologic,81535,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,521.51,,,,,,,fee schedule,521.51,2190.36,Laboratory
Oncology gynecologic,81535,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,608.43,,,,,,,fee schedule,521.51,2190.36,APC
Oncology gynecologic,81535,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,602.64,,,,,,,fee schedule,521.51,2190.36,APC
Oncology gynecologic,81535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,579.46,,,,,,,fee schedule,521.51,2190.36,APC
Oncology gynecologic,81535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,886.57,,,,,,,fee schedule,521.51,2190.36,Radiology
Oncology gynecologic,81535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,811.24,,,,,,,fee schedule,521.51,2190.36,APC
Oncology gynecologic,81535,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1014.06,,,,,,,fee schedule,521.51,2190.36,APC
Oncology gynecologic,81536,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,671.18,,,,,,,fee schedule,159.8,671.18,
Oncology gynecologic,81536,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,538.01,,,,,,,fee schedule,159.8,671.18,
Oncology gynecologic,81536,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,587.72,,,,,,,fee schedule,159.8,671.18,
Oncology gynecologic,81536,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,617.91,,,,,,,fee schedule,159.8,671.18,
Oncology gynecologic,81536,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,159.8,,,,,,,fee schedule,159.8,671.18,Laboratory
Oncology gynecologic,81536,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,186.44,,,,,,,fee schedule,159.8,671.18,APC
Oncology gynecologic,81536,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,184.66,,,,,,,fee schedule,159.8,671.18,APC
Oncology gynecologic,81536,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,177.56,,,,,,,fee schedule,159.8,671.18,APC
Oncology gynecologic,81536,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,271.67,,,,,,,fee schedule,159.8,671.18,Radiology
Oncology gynecologic,81536,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,248.58,,,,,,,fee schedule,159.8,671.18,APC
Oncology gynecologic,81536,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,310.73,,,,,,,fee schedule,159.8,671.18,APC
Oncology lung,81538,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2583.9,,,,,,,fee schedule,2583.9,5024.25,Laboratory
Oncology lung,81538,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3014.55,,,,,,,fee schedule,2583.9,5024.25,APC
Oncology lung,81538,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2985.84,,,,,,,fee schedule,2583.9,5024.25,APC
Oncology lung,81538,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2871,,,,,,,fee schedule,2583.9,5024.25,APC
Oncology lung,81538,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4392.63,,,,,,,fee schedule,2583.9,5024.25,Radiology
Oncology lung,81538,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4019.4,,,,,,,fee schedule,2583.9,5024.25,APC
Oncology lung,81538,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5024.25,,,,,,,fee schedule,2583.9,5024.25,APC
Oncology prostate prob score,81539,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2275.94,,,,,,,fee schedule,684,2275.94,
Oncology prostate prob score,81539,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1824.36,,,,,,,fee schedule,684,2275.94,
Oncology prostate prob score,81539,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1992.95,,,,,,,fee schedule,684,2275.94,
Oncology prostate prob score,81539,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2095.31,,,,,,,fee schedule,684,2275.94,
Oncology prostate prob score,81539,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,684,,,,,,,fee schedule,684,2275.94,Laboratory
Oncology prostate prob score,81539,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,798,,,,,,,fee schedule,684,2275.94,APC
Oncology prostate prob score,81539,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,790.4,,,,,,,fee schedule,684,2275.94,APC
Oncology prostate prob score,81539,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,760,,,,,,,fee schedule,684,2275.94,APC
Oncology prostate prob score,81539,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1162.8,,,,,,,fee schedule,684,2275.94,Radiology
Oncology prostate prob score,81539,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1064,,,,,,,fee schedule,684,2275.94,APC
Oncology prostate prob score,81539,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1330,,,,,,,fee schedule,684,2275.94,APC
Oncology tum unknown origin,81540,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3375,,,,,,,fee schedule,3375,6562.5,Laboratory
Oncology tum unknown origin,81540,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3937.5,,,,,,,fee schedule,3375,6562.5,APC
Oncology tum unknown origin,81540,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3900,,,,,,,fee schedule,3375,6562.5,APC
Oncology tum unknown origin,81540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3750,,,,,,,fee schedule,3375,6562.5,APC
Oncology tum unknown origin,81540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5737.5,,,,,,,fee schedule,3375,6562.5,Radiology
Oncology tum unknown origin,81540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5250,,,,,,,fee schedule,3375,6562.5,APC
Oncology tum unknown origin,81540,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6562.5,,,,,,,fee schedule,3375,6562.5,APC
Onc prostate mrna 46 genes,81541,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3485.7,,,,,,,fee schedule,3485.7,6777.75,Laboratory
Onc prostate mrna 46 genes,81541,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4066.65,,,,,,,fee schedule,3485.7,6777.75,APC
Onc prostate mrna 46 genes,81541,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4027.92,,,,,,,fee schedule,3485.7,6777.75,APC
Onc prostate mrna 46 genes,81541,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3873,,,,,,,fee schedule,3485.7,6777.75,APC
Onc prostate mrna 46 genes,81541,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5925.69,,,,,,,fee schedule,3485.7,6777.75,Radiology
Onc prostate mrna 46 genes,81541,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5422.2,,,,,,,fee schedule,3485.7,6777.75,APC
Onc prostate mrna 46 genes,81541,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6777.75,,,,,,,fee schedule,3485.7,6777.75,APC
Onc prostate mrna 22 cnt gen,81542,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3485.7,,,,,,,fee schedule,3485.7,6777.75,Laboratory
Onc prostate mrna 22 cnt gen,81542,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4066.65,,,,,,,fee schedule,3485.7,6777.75,APC
Onc prostate mrna 22 cnt gen,81542,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4027.92,,,,,,,fee schedule,3485.7,6777.75,APC
Onc prostate mrna 22 cnt gen,81542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3873,,,,,,,fee schedule,3485.7,6777.75,APC
Onc prostate mrna 22 cnt gen,81542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5925.69,,,,,,,fee schedule,3485.7,6777.75,Radiology
Onc prostate mrna 22 cnt gen,81542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5422.2,,,,,,,fee schedule,3485.7,6777.75,APC
Onc prostate mrna 22 cnt gen,81542,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6777.75,,,,,,,fee schedule,3485.7,6777.75,APC
"Onc thyr mrna 10,196 gen alg",81546,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3240,,,,,,,fee schedule,3240,6300,Laboratory
"Onc thyr mrna 10,196 gen alg",81546,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3780,,,,,,,fee schedule,3240,6300,APC
"Onc thyr mrna 10,196 gen alg",81546,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3744,,,,,,,fee schedule,3240,6300,APC
"Onc thyr mrna 10,196 gen alg",81546,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3600,,,,,,,fee schedule,3240,6300,APC
"Onc thyr mrna 10,196 gen alg",81546,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5508,,,,,,,fee schedule,3240,6300,Radiology
"Onc thyr mrna 10,196 gen alg",81546,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5040,,,,,,,fee schedule,3240,6300,APC
"Onc thyr mrna 10,196 gen alg",81546,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6300,,,,,,,fee schedule,3240,6300,APC
Onc prostate 3 genes,81551,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1827,,,,,,,fee schedule,1827,3552.5,Laboratory
Onc prostate 3 genes,81551,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2131.5,,,,,,,fee schedule,1827,3552.5,APC
Onc prostate 3 genes,81551,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2111.2,,,,,,,fee schedule,1827,3552.5,APC
Onc prostate 3 genes,81551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2030,,,,,,,fee schedule,1827,3552.5,APC
Onc prostate 3 genes,81551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3105.9,,,,,,,fee schedule,1827,3552.5,Radiology
Onc prostate 3 genes,81551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2842,,,,,,,fee schedule,1827,3552.5,APC
Onc prostate 3 genes,81551,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3552.5,,,,,,,fee schedule,1827,3552.5,APC
Onc uveal mlnma mrna 15 gene,81552,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6998.4,,,,,,,fee schedule,6998.4,13608,Laboratory
Onc uveal mlnma mrna 15 gene,81552,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8164.8,,,,,,,fee schedule,6998.4,13608,APC
Onc uveal mlnma mrna 15 gene,81552,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8087.04,,,,,,,fee schedule,6998.4,13608,APC
Onc uveal mlnma mrna 15 gene,81552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7776,,,,,,,fee schedule,6998.4,13608,APC
Onc uveal mlnma mrna 15 gene,81552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11897.28,,,,,,,fee schedule,6998.4,13608,Radiology
Onc uveal mlnma mrna 15 gene,81552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10886.4,,,,,,,fee schedule,6998.4,13608,APC
Onc uveal mlnma mrna 15 gene,81552,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,13608,,,,,,,fee schedule,6998.4,13608,APC
Pulm ds ipf mrna 190 gen alg,81554,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4868.64,,,,,,,fee schedule,4868.64,9466.8,Laboratory
Pulm ds ipf mrna 190 gen alg,81554,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5680.08,,,,,,,fee schedule,4868.64,9466.8,APC
Pulm ds ipf mrna 190 gen alg,81554,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5625.98,,,,,,,fee schedule,4868.64,9466.8,APC
Pulm ds ipf mrna 190 gen alg,81554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5409.6,,,,,,,fee schedule,4868.64,9466.8,APC
Pulm ds ipf mrna 190 gen alg,81554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8276.69,,,,,,,fee schedule,4868.64,9466.8,Radiology
Pulm ds ipf mrna 190 gen alg,81554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7573.44,,,,,,,fee schedule,4868.64,9466.8,APC
Pulm ds ipf mrna 190 gen alg,81554,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9466.8,,,,,,,fee schedule,4868.64,9466.8,APC
Trnspl rej kdn mrna qpcr 139,81558,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2916,,,,,,,fee schedule,2916,5670,Laboratory
Trnspl rej kdn mrna qpcr 139,81558,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3402,,,,,,,fee schedule,2916,5670,APC
Trnspl rej kdn mrna qpcr 139,81558,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3369.6,,,,,,,fee schedule,2916,5670,APC
Trnspl rej kdn mrna qpcr 139,81558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3240,,,,,,,fee schedule,2916,5670,APC
Trnspl rej kdn mrna qpcr 139,81558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4957.2,,,,,,,fee schedule,2916,5670,Radiology
Trnspl rej kdn mrna qpcr 139,81558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4536,,,,,,,fee schedule,2916,5670,APC
Trnspl rej kdn mrna qpcr 139,81558,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5670,,,,,,,fee schedule,2916,5670,APC
Trnsplj pd lvr&bwl cd154+cll,81560,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,576.66,,,,,,,fee schedule,576.66,1121.28,Laboratory
Trnsplj pd lvr&bwl cd154+cll,81560,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672.77,,,,,,,fee schedule,576.66,1121.28,APC
Trnsplj pd lvr&bwl cd154+cll,81560,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,666.36,,,,,,,fee schedule,576.66,1121.28,APC
Trnsplj pd lvr&bwl cd154+cll,81560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640.73,,,,,,,fee schedule,576.66,1121.28,APC
Trnsplj pd lvr&bwl cd154+cll,81560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,980.32,,,,,,,fee schedule,576.66,1121.28,Radiology
Trnsplj pd lvr&bwl cd154+cll,81560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,897.02,,,,,,,fee schedule,576.66,1121.28,APC
Trnsplj pd lvr&bwl cd154+cll,81560,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1121.28,,,,,,,fee schedule,576.66,1121.28,APC
Cardiology hrt trnspl mrna,81595,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2916,,,,,,,fee schedule,2916,5670,Laboratory
Cardiology hrt trnspl mrna,81595,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3402,,,,,,,fee schedule,2916,5670,APC
Cardiology hrt trnspl mrna,81595,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3369.6,,,,,,,fee schedule,2916,5670,APC
Cardiology hrt trnspl mrna,81595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3240,,,,,,,fee schedule,2916,5670,APC
Cardiology hrt trnspl mrna,81595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4957.2,,,,,,,fee schedule,2916,5670,Radiology
Cardiology hrt trnspl mrna,81595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4536,,,,,,,fee schedule,2916,5670,APC
Cardiology hrt trnspl mrna,81595,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5670,,,,,,,fee schedule,2916,5670,APC
Nfct ds chrnc hcv 6 assays,81596,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,64.97,,,,,,,fee schedule,64.97,126.33,Laboratory
Nfct ds chrnc hcv 6 assays,81596,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,75.8,,,,,,,fee schedule,64.97,126.33,APC
Nfct ds chrnc hcv 6 assays,81596,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,75.08,,,,,,,fee schedule,64.97,126.33,APC
Nfct ds chrnc hcv 6 assays,81596,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,72.19,,,,,,,fee schedule,64.97,126.33,APC
Nfct ds chrnc hcv 6 assays,81596,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,110.45,,,,,,,fee schedule,64.97,126.33,Radiology
Nfct ds chrnc hcv 6 assays,81596,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,101.07,,,,,,,fee schedule,64.97,126.33,APC
Nfct ds chrnc hcv 6 assays,81596,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,126.33,,,,,,,fee schedule,64.97,126.33,APC
Test for acetone/ketones,82009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,44.02,,,,,,,fee schedule,4.07,44.02,
Test for acetone/ketones,82009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35.29,,,,,,,fee schedule,4.07,44.02,
Test for acetone/ketones,82009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38.55,,,,,,,fee schedule,4.07,44.02,
Test for acetone/ketones,82009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,40.53,,,,,,,fee schedule,4.07,44.02,
Test for acetone/ketones,82009,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.07,,,,,,,fee schedule,4.07,44.02,Laboratory
Test for acetone/ketones,82009,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.75,,,,,,,fee schedule,4.07,44.02,APC
Test for acetone/ketones,82009,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4.7,,,,,,,fee schedule,4.07,44.02,APC
Test for acetone/ketones,82009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4.52,,,,,,,fee schedule,4.07,44.02,APC
Test for acetone/ketones,82009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.92,,,,,,,fee schedule,4.07,44.02,Radiology
Test for acetone/ketones,82009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.33,,,,,,,fee schedule,4.07,44.02,APC
Test for acetone/ketones,82009,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7.91,,,,,,,fee schedule,4.07,44.02,APC
Acetone assay,82010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,38.5,,,,,,,fee schedule,7.35,38.5,
Acetone assay,82010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,30.86,,,,,,,fee schedule,7.35,38.5,
Acetone assay,82010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,33.71,,,,,,,fee schedule,7.35,38.5,
Acetone assay,82010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,35.44,,,,,,,fee schedule,7.35,38.5,
Acetone assay,82010,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.35,,,,,,,fee schedule,7.35,38.5,Laboratory
Acetone assay,82010,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.58,,,,,,,fee schedule,7.35,38.5,APC
Acetone assay,82010,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8.5,,,,,,,fee schedule,7.35,38.5,APC
Acetone assay,82010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8.17,,,,,,,fee schedule,7.35,38.5,APC
Acetone assay,82010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12.5,,,,,,,fee schedule,7.35,38.5,Radiology
Acetone assay,82010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11.44,,,,,,,fee schedule,7.35,38.5,APC
Acetone assay,82010,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14.3,,,,,,,fee schedule,7.35,38.5,APC
Acetylcholinesterase assay,82013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,61.65,,,,,,,fee schedule,11.06,61.65,
Acetylcholinesterase assay,82013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,49.42,,,,,,,fee schedule,11.06,61.65,
Acetylcholinesterase assay,82013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.99,,,,,,,fee schedule,11.06,61.65,
Acetylcholinesterase assay,82013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,56.76,,,,,,,fee schedule,11.06,61.65,
Acetylcholinesterase assay,82013,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.06,,,,,,,fee schedule,11.06,61.65,Laboratory
Acetylcholinesterase assay,82013,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.9,,,,,,,fee schedule,11.06,61.65,APC
Acetylcholinesterase assay,82013,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.78,,,,,,,fee schedule,11.06,61.65,APC
Acetylcholinesterase assay,82013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.29,,,,,,,fee schedule,11.06,61.65,APC
Acetylcholinesterase assay,82013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.8,,,,,,,fee schedule,11.06,61.65,Radiology
Acetylcholinesterase assay,82013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.21,,,,,,,fee schedule,11.06,61.65,APC
Acetylcholinesterase assay,82013,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21.51,,,,,,,fee schedule,11.06,61.65,APC
Acylcarnitines qual,82016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,76.51,,,,,,,fee schedule,14.84,76.51,
Acylcarnitines qual,82016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,61.33,,,,,,,fee schedule,14.84,76.51,
Acylcarnitines qual,82016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66.99,,,,,,,fee schedule,14.84,76.51,
Acylcarnitines qual,82016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,70.44,,,,,,,fee schedule,14.84,76.51,
Acylcarnitines qual,82016,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.84,,,,,,,fee schedule,14.84,76.51,Laboratory
Acylcarnitines qual,82016,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.31,,,,,,,fee schedule,14.84,76.51,APC
Acylcarnitines qual,82016,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,17.15,,,,,,,fee schedule,14.84,76.51,APC
Acylcarnitines qual,82016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16.49,,,,,,,fee schedule,14.84,76.51,APC
Acylcarnitines qual,82016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.23,,,,,,,fee schedule,14.84,76.51,Radiology
Acylcarnitines qual,82016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.09,,,,,,,fee schedule,14.84,76.51,APC
Acylcarnitines qual,82016,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,28.86,,,,,,,fee schedule,14.84,76.51,APC
Acylcarnitines quant,82017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,52.57,,,,,,,fee schedule,15.18,52.57,
Acylcarnitines quant,82017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.14,,,,,,,fee schedule,15.18,52.57,
Acylcarnitines quant,82017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.03,,,,,,,fee schedule,15.18,52.57,
Acylcarnitines quant,82017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,48.4,,,,,,,fee schedule,15.18,52.57,
Acylcarnitines quant,82017,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.18,,,,,,,fee schedule,15.18,52.57,Laboratory
Acylcarnitines quant,82017,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.71,,,,,,,fee schedule,15.18,52.57,APC
Acylcarnitines quant,82017,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,17.54,,,,,,,fee schedule,15.18,52.57,APC
Acylcarnitines quant,82017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16.87,,,,,,,fee schedule,15.18,52.57,APC
Acylcarnitines quant,82017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.81,,,,,,,fee schedule,15.18,52.57,Radiology
Acylcarnitines quant,82017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.62,,,,,,,fee schedule,15.18,52.57,APC
Acylcarnitines quant,82017,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,29.52,,,,,,,fee schedule,15.18,52.57,APC
Assay of acth,82024,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,299.29,,,,,,,fee schedule,34.76,299.29,
Assay of acth,82024,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,239.91,,,,,,,fee schedule,34.76,299.29,
Assay of acth,82024,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,262.08,,,,,,,fee schedule,34.76,299.29,
Assay of acth,82024,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,275.54,,,,,,,fee schedule,34.76,299.29,
Assay of acth,82024,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,34.76,,,,,,,fee schedule,34.76,299.29,Laboratory
Assay of acth,82024,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,40.55,,,,,,,fee schedule,34.76,299.29,APC
Assay of acth,82024,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,40.16,,,,,,,fee schedule,34.76,299.29,APC
Assay of acth,82024,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,38.62,,,,,,,fee schedule,34.76,299.29,APC
Assay of acth,82024,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,59.09,,,,,,,fee schedule,34.76,299.29,Radiology
Assay of acth,82024,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,54.07,,,,,,,fee schedule,34.76,299.29,APC
Assay of acth,82024,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,67.58,,,,,,,fee schedule,34.76,299.29,APC
Assay of adp & amp,82030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,142.39,,,,,,,fee schedule,23.22,142.39,
Assay of adp & amp,82030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,114.14,,,,,,,fee schedule,23.22,142.39,
Assay of adp & amp,82030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,124.69,,,,,,,fee schedule,23.22,142.39,
Assay of adp & amp,82030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,131.09,,,,,,,fee schedule,23.22,142.39,
Assay of adp & amp,82030,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23.22,,,,,,,fee schedule,23.22,142.39,Laboratory
Assay of adp & amp,82030,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,27.09,,,,,,,fee schedule,23.22,142.39,APC
Assay of adp & amp,82030,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,26.83,,,,,,,fee schedule,23.22,142.39,APC
Assay of adp & amp,82030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,25.8,,,,,,,fee schedule,23.22,142.39,APC
Assay of adp & amp,82030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,39.47,,,,,,,fee schedule,23.22,142.39,Radiology
Assay of adp & amp,82030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,36.12,,,,,,,fee schedule,23.22,142.39,APC
Assay of adp & amp,82030,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,45.15,,,,,,,fee schedule,23.22,142.39,APC
Assay of serum albumin,82040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,99.92,,,,,,,fee schedule,4.46,99.92,
Assay of serum albumin,82040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,80.09,,,,,,,fee schedule,4.46,99.92,
Assay of serum albumin,82040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,87.49,,,,,,,fee schedule,4.46,99.92,
Assay of serum albumin,82040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,91.99,,,,,,,fee schedule,4.46,99.92,
Assay of serum albumin,82040,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.46,,,,,,,fee schedule,4.46,99.92,Laboratory
Assay of serum albumin,82040,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.2,,,,,,,fee schedule,4.46,99.92,APC
Assay of serum albumin,82040,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5.15,,,,,,,fee schedule,4.46,99.92,APC
Assay of serum albumin,82040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4.95,,,,,,,fee schedule,4.46,99.92,APC
Assay of serum albumin,82040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.57,,,,,,,fee schedule,4.46,99.92,Radiology
Assay of serum albumin,82040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.93,,,,,,,fee schedule,4.46,99.92,APC
Assay of serum albumin,82040,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8.66,,,,,,,fee schedule,4.46,99.92,APC
Assay of urine albumin,82042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,31.1,,,,,,,fee schedule,7,31.1,
Assay of urine albumin,82042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24.93,,,,,,,fee schedule,7,31.1,
Assay of urine albumin,82042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,27.23,,,,,,,fee schedule,7,31.1,
Assay of urine albumin,82042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,28.63,,,,,,,fee schedule,7,31.1,
Assay of urine albumin,82042,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7,,,,,,,fee schedule,7,31.1,Laboratory
Assay of urine albumin,82042,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.17,,,,,,,fee schedule,7,31.1,APC
Assay of urine albumin,82042,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8.09,,,,,,,fee schedule,7,31.1,APC
Assay of urine albumin,82042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7.78,,,,,,,fee schedule,7,31.1,APC
Assay of urine albumin,82042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11.9,,,,,,,fee schedule,7,31.1,Radiology
Assay of urine albumin,82042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10.89,,,,,,,fee schedule,7,31.1,APC
Assay of urine albumin,82042,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,13.62,,,,,,,fee schedule,7,31.1,APC
Microalbumin quantitative,82043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,65.43,,,,,,,fee schedule,5.2,65.43,
Microalbumin quantitative,82043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52.45,,,,,,,fee schedule,5.2,65.43,
Microalbumin quantitative,82043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.3,,,,,,,fee schedule,5.2,65.43,
Microalbumin quantitative,82043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.24,,,,,,,fee schedule,5.2,65.43,
Microalbumin quantitative,82043,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.2,,,,,,,fee schedule,5.2,65.43,Laboratory
Microalbumin quantitative,82043,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.07,,,,,,,fee schedule,5.2,65.43,APC
Microalbumin quantitative,82043,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6.01,,,,,,,fee schedule,5.2,65.43,APC
Microalbumin quantitative,82043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5.78,,,,,,,fee schedule,5.2,65.43,APC
Microalbumin quantitative,82043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8.84,,,,,,,fee schedule,5.2,65.43,Radiology
Microalbumin quantitative,82043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8.09,,,,,,,fee schedule,5.2,65.43,APC
Microalbumin quantitative,82043,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10.12,,,,,,,fee schedule,5.2,65.43,APC
Microalbumin semiquant,82044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,25.25,,,,,,,fee schedule,5.61,25.25,
Microalbumin semiquant,82044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20.24,,,,,,,fee schedule,5.61,25.25,
Microalbumin semiquant,82044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22.11,,,,,,,fee schedule,5.61,25.25,
Microalbumin semiquant,82044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23.25,,,,,,,fee schedule,5.61,25.25,
Microalbumin semiquant,82044,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.61,,,,,,,fee schedule,5.61,25.25,Laboratory
Microalbumin semiquant,82044,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.54,,,,,,,fee schedule,5.61,25.25,APC
Microalbumin semiquant,82044,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6.48,,,,,,,fee schedule,5.61,25.25,APC
Microalbumin semiquant,82044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6.23,,,,,,,fee schedule,5.61,25.25,APC
Microalbumin semiquant,82044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.53,,,,,,,fee schedule,5.61,25.25,Radiology
Microalbumin semiquant,82044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8.72,,,,,,,fee schedule,5.61,25.25,APC
Microalbumin semiquant,82044,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10.9,,,,,,,fee schedule,5.61,25.25,APC
Albumin ischemia modified,82045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,187.34,,,,,,,fee schedule,30.55,187.34,
Albumin ischemia modified,82045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,150.17,,,,,,,fee schedule,30.55,187.34,
Albumin ischemia modified,82045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,164.04,,,,,,,fee schedule,30.55,187.34,
Albumin ischemia modified,82045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,172.47,,,,,,,fee schedule,30.55,187.34,
Albumin ischemia modified,82045,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,30.55,,,,,,,fee schedule,30.55,187.34,Laboratory
Albumin ischemia modified,82045,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,35.64,,,,,,,fee schedule,30.55,187.34,APC
Albumin ischemia modified,82045,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,35.3,,,,,,,fee schedule,30.55,187.34,APC
Albumin ischemia modified,82045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,33.94,,,,,,,fee schedule,30.55,187.34,APC
Albumin ischemia modified,82045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.93,,,,,,,fee schedule,30.55,187.34,Radiology
Albumin ischemia modified,82045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,47.52,,,,,,,fee schedule,30.55,187.34,APC
Albumin ischemia modified,82045,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,59.4,,,,,,,fee schedule,30.55,187.34,APC
Assay of breath ethanol,82075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37.02,,,,,,,fee schedule,27,52.5,
Assay of breath ethanol,82075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29.67,,,,,,,fee schedule,27,52.5,
Assay of breath ethanol,82075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32.42,,,,,,,fee schedule,27,52.5,
Assay of breath ethanol,82075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,34.08,,,,,,,fee schedule,27,52.5,
Assay of breath ethanol,82075,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,27,,,,,,,fee schedule,27,52.5,Laboratory
Assay of breath ethanol,82075,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,31.5,,,,,,,fee schedule,27,52.5,APC
Assay of breath ethanol,82075,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,31.2,,,,,,,fee schedule,27,52.5,APC
Assay of breath ethanol,82075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,30,,,,,,,fee schedule,27,52.5,APC
Assay of breath ethanol,82075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,45.9,,,,,,,fee schedule,27,52.5,Radiology
Assay of breath ethanol,82075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,42,,,,,,,fee schedule,27,52.5,APC
Assay of breath ethanol,82075,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,52.5,,,,,,,fee schedule,27,52.5,APC
Assay spec xcp ur&breath ia,82077,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.54,,,,,,,fee schedule,15.54,30.22,Laboratory
Assay spec xcp ur&breath ia,82077,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.13,,,,,,,fee schedule,15.54,30.22,APC
Assay spec xcp ur&breath ia,82077,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,17.96,,,,,,,fee schedule,15.54,30.22,APC
Assay spec xcp ur&breath ia,82077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17.27,,,,,,,fee schedule,15.54,30.22,APC
Assay spec xcp ur&breath ia,82077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26.42,,,,,,,fee schedule,15.54,30.22,Radiology
Assay spec xcp ur&breath ia,82077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24.18,,,,,,,fee schedule,15.54,30.22,APC
Assay spec xcp ur&breath ia,82077,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30.22,,,,,,,fee schedule,15.54,30.22,APC
Assay of aldolase,82085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,112.91,,,,,,,fee schedule,8.74,112.91,
Assay of aldolase,82085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,90.51,,,,,,,fee schedule,8.74,112.91,
Assay of aldolase,82085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,98.87,,,,,,,fee schedule,8.74,112.91,
Assay of aldolase,82085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,103.95,,,,,,,fee schedule,8.74,112.91,
Assay of aldolase,82085,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.74,,,,,,,fee schedule,8.74,112.91,Laboratory
Assay of aldolase,82085,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.2,,,,,,,fee schedule,8.74,112.91,APC
Assay of aldolase,82085,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10.1,,,,,,,fee schedule,8.74,112.91,APC
Assay of aldolase,82085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9.71,,,,,,,fee schedule,8.74,112.91,APC
Assay of aldolase,82085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.86,,,,,,,fee schedule,8.74,112.91,Radiology
Assay of aldolase,82085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.59,,,,,,,fee schedule,8.74,112.91,APC
Assay of aldolase,82085,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16.99,,,,,,,fee schedule,8.74,112.91,APC
Assay of aldosterone,82088,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,286.98,,,,,,,fee schedule,36.67,286.98,
Assay of aldosterone,82088,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,230.04,,,,,,,fee schedule,36.67,286.98,
Assay of aldosterone,82088,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,251.29,,,,,,,fee schedule,36.67,286.98,
Assay of aldosterone,82088,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,264.2,,,,,,,fee schedule,36.67,286.98,
Assay of aldosterone,82088,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,36.68,,,,,,,fee schedule,36.67,286.98,Laboratory
Assay of aldosterone,82088,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,42.79,,,,,,,fee schedule,36.67,286.98,APC
Assay of aldosterone,82088,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,42.38,,,,,,,fee schedule,36.67,286.98,APC
Assay of aldosterone,82088,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,40.75,,,,,,,fee schedule,36.67,286.98,APC
Assay of aldosterone,82088,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,62.35,,,,,,,fee schedule,36.67,286.98,Radiology
Assay of aldosterone,82088,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,57.05,,,,,,,fee schedule,36.67,286.98,APC
Assay of aldosterone,82088,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,71.31,,,,,,,fee schedule,36.67,286.98,APC
Alpha-1-antitrypsin total,82103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,67.13,,,,,,,fee schedule,12.1,67.13,
Alpha-1-antitrypsin total,82103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.81,,,,,,,fee schedule,12.1,67.13,
Alpha-1-antitrypsin total,82103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,58.78,,,,,,,fee schedule,12.1,67.13,
Alpha-1-antitrypsin total,82103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,61.8,,,,,,,fee schedule,12.1,67.13,
Alpha-1-antitrypsin total,82103,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.1,,,,,,,fee schedule,12.1,67.13,Laboratory
Alpha-1-antitrypsin total,82103,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.11,,,,,,,fee schedule,12.1,67.13,APC
Alpha-1-antitrypsin total,82103,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.98,,,,,,,fee schedule,12.1,67.13,APC
Alpha-1-antitrypsin total,82103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.44,,,,,,,fee schedule,12.1,67.13,APC
Alpha-1-antitrypsin total,82103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.56,,,,,,,fee schedule,12.1,67.13,Radiology
Alpha-1-antitrypsin total,82103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.82,,,,,,,fee schedule,12.1,67.13,APC
Alpha-1-antitrypsin total,82103,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23.52,,,,,,,fee schedule,12.1,67.13,APC
Alpha-1-antitrypsin pheno,82104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,99.95,,,,,,,fee schedule,13.01,99.95,
Alpha-1-antitrypsin pheno,82104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,80.12,,,,,,,fee schedule,13.01,99.95,
Alpha-1-antitrypsin pheno,82104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,87.52,,,,,,,fee schedule,13.01,99.95,
Alpha-1-antitrypsin pheno,82104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,92.02,,,,,,,fee schedule,13.01,99.95,
Alpha-1-antitrypsin pheno,82104,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.01,,,,,,,fee schedule,13.01,99.95,Laboratory
Alpha-1-antitrypsin pheno,82104,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.18,,,,,,,fee schedule,13.01,99.95,APC
Alpha-1-antitrypsin pheno,82104,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,15.04,,,,,,,fee schedule,13.01,99.95,APC
Alpha-1-antitrypsin pheno,82104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14.46,,,,,,,fee schedule,13.01,99.95,APC
Alpha-1-antitrypsin pheno,82104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.12,,,,,,,fee schedule,13.01,99.95,Radiology
Alpha-1-antitrypsin pheno,82104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.24,,,,,,,fee schedule,13.01,99.95,APC
Alpha-1-antitrypsin pheno,82104,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,25.3,,,,,,,fee schedule,13.01,99.95,APC
Alpha-fetoprotein serum,82105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83.66,,,,,,,fee schedule,15.09,83.66,
Alpha-fetoprotein serum,82105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,67.06,,,,,,,fee schedule,15.09,83.66,
Alpha-fetoprotein serum,82105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,73.26,,,,,,,fee schedule,15.09,83.66,
Alpha-fetoprotein serum,82105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,77.02,,,,,,,fee schedule,15.09,83.66,
Alpha-fetoprotein serum,82105,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.09,,,,,,,fee schedule,15.09,83.66,Laboratory
Alpha-fetoprotein serum,82105,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.61,,,,,,,fee schedule,15.09,83.66,APC
Alpha-fetoprotein serum,82105,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,17.44,,,,,,,fee schedule,15.09,83.66,APC
Alpha-fetoprotein serum,82105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16.77,,,,,,,fee schedule,15.09,83.66,APC
Alpha-fetoprotein serum,82105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.66,,,,,,,fee schedule,15.09,83.66,Radiology
Alpha-fetoprotein serum,82105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.48,,,,,,,fee schedule,15.09,83.66,APC
Alpha-fetoprotein serum,82105,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,29.35,,,,,,,fee schedule,15.09,83.66,APC
Alpha-fetoprotein amniotic,82106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,92.57,,,,,,,fee schedule,15.3,92.57,
Alpha-fetoprotein amniotic,82106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,74.2,,,,,,,fee schedule,15.3,92.57,
Alpha-fetoprotein amniotic,82106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,81.06,,,,,,,fee schedule,15.3,92.57,
Alpha-fetoprotein amniotic,82106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,85.23,,,,,,,fee schedule,15.3,92.57,
Alpha-fetoprotein amniotic,82106,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.3,,,,,,,fee schedule,15.3,92.57,Laboratory
Alpha-fetoprotein amniotic,82106,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.85,,,,,,,fee schedule,15.3,92.57,APC
Alpha-fetoprotein amniotic,82106,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,17.68,,,,,,,fee schedule,15.3,92.57,APC
Alpha-fetoprotein amniotic,82106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17,,,,,,,fee schedule,15.3,92.57,APC
Alpha-fetoprotein amniotic,82106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26.01,,,,,,,fee schedule,15.3,92.57,Radiology
Alpha-fetoprotein amniotic,82106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.8,,,,,,,fee schedule,15.3,92.57,APC
Alpha-fetoprotein amniotic,82106,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,29.75,,,,,,,fee schedule,15.3,92.57,APC
Alpha-Fetoprotein L3,82107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,355.47,,,,,,,fee schedule,57.97,355.47,
Alpha-Fetoprotein L3,82107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,284.94,,,,,,,fee schedule,57.97,355.47,
Alpha-Fetoprotein L3,82107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,311.27,,,,,,,fee schedule,57.97,355.47,
Alpha-Fetoprotein L3,82107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,327.26,,,,,,,fee schedule,57.97,355.47,
Alpha-Fetoprotein L3,82107,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,57.97,,,,,,,fee schedule,57.97,355.47,Laboratory
Alpha-Fetoprotein L3,82107,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,67.63,,,,,,,fee schedule,57.97,355.47,APC
Alpha-Fetoprotein L3,82107,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,66.99,,,,,,,fee schedule,57.97,355.47,APC
Alpha-Fetoprotein L3,82107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,64.41,,,,,,,fee schedule,57.97,355.47,APC
Alpha-Fetoprotein L3,82107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,98.55,,,,,,,fee schedule,57.97,355.47,Radiology
Alpha-Fetoprotein L3,82107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,90.17,,,,,,,fee schedule,57.97,355.47,APC
Alpha-Fetoprotein L3,82107,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,112.72,,,,,,,fee schedule,57.97,355.47,APC
Assay of aluminum,82108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,103.23,,,,,,,fee schedule,22.93,103.23,
Assay of aluminum,82108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,82.75,,,,,,,fee schedule,22.93,103.23,
Assay of aluminum,82108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,90.4,,,,,,,fee schedule,22.93,103.23,
Assay of aluminum,82108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,95.04,,,,,,,fee schedule,22.93,103.23,
Assay of aluminum,82108,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22.93,,,,,,,fee schedule,22.93,103.23,Laboratory
Assay of aluminum,82108,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,26.75,,,,,,,fee schedule,22.93,103.23,APC
Assay of aluminum,82108,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,26.5,,,,,,,fee schedule,22.93,103.23,APC
Assay of aluminum,82108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,25.48,,,,,,,fee schedule,22.93,103.23,APC
Assay of aluminum,82108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,38.98,,,,,,,fee schedule,22.93,103.23,Radiology
Assay of aluminum,82108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,35.67,,,,,,,fee schedule,22.93,103.23,APC
Assay of aluminum,82108,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,44.59,,,,,,,fee schedule,22.93,103.23,APC
Amines vaginal fluid qual,82120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20.75,,,,,,,fee schedule,5.39,20.75,
Amines vaginal fluid qual,82120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.63,,,,,,,fee schedule,5.39,20.75,
Amines vaginal fluid qual,82120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18.17,,,,,,,fee schedule,5.39,20.75,
Amines vaginal fluid qual,82120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19.11,,,,,,,fee schedule,5.39,20.75,
Amines vaginal fluid qual,82120,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.39,,,,,,,fee schedule,5.39,20.75,Laboratory
Amines vaginal fluid qual,82120,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.29,,,,,,,fee schedule,5.39,20.75,APC
Amines vaginal fluid qual,82120,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6.23,,,,,,,fee schedule,5.39,20.75,APC
Amines vaginal fluid qual,82120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5.99,,,,,,,fee schedule,5.39,20.75,APC
Amines vaginal fluid qual,82120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.16,,,,,,,fee schedule,5.39,20.75,Radiology
Amines vaginal fluid qual,82120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8.39,,,,,,,fee schedule,5.39,20.75,APC
Amines vaginal fluid qual,82120,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10.48,,,,,,,fee schedule,5.39,20.75,APC
Amino acid single qual,82127,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,76.51,,,,,,,fee schedule,12.76,76.51,
Amino acid single qual,82127,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,61.33,,,,,,,fee schedule,12.76,76.51,
Amino acid single qual,82127,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66.99,,,,,,,fee schedule,12.76,76.51,
Amino acid single qual,82127,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,70.44,,,,,,,fee schedule,12.76,76.51,
Amino acid single qual,82127,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.76,,,,,,,fee schedule,12.76,76.51,Laboratory
Amino acid single qual,82127,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.89,,,,,,,fee schedule,12.76,76.51,APC
Amino acid single qual,82127,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,14.75,,,,,,,fee schedule,12.76,76.51,APC
Amino acid single qual,82127,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14.18,,,,,,,fee schedule,12.76,76.51,APC
Amino acid single qual,82127,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21.7,,,,,,,fee schedule,12.76,76.51,Radiology
Amino acid single qual,82127,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.85,,,,,,,fee schedule,12.76,76.51,APC
Amino acid single qual,82127,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,24.82,,,,,,,fee schedule,12.76,76.51,APC
Amino acids mult qual,82128,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,76.51,,,,,,,fee schedule,12.48,76.51,
Amino acids mult qual,82128,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,61.33,,,,,,,fee schedule,12.48,76.51,
Amino acids mult qual,82128,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66.99,,,,,,,fee schedule,12.48,76.51,
Amino acids mult qual,82128,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,70.44,,,,,,,fee schedule,12.48,76.51,
Amino acids mult qual,82128,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.48,,,,,,,fee schedule,12.48,76.51,Laboratory
Amino acids mult qual,82128,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.56,,,,,,,fee schedule,12.48,76.51,APC
Amino acids mult qual,82128,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,14.42,,,,,,,fee schedule,12.48,76.51,APC
Amino acids mult qual,82128,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.87,,,,,,,fee schedule,12.48,76.51,APC
Amino acids mult qual,82128,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21.22,,,,,,,fee schedule,12.48,76.51,Radiology
Amino acids mult qual,82128,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.42,,,,,,,fee schedule,12.48,76.51,APC
Amino acids mult qual,82128,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,24.27,,,,,,,fee schedule,12.48,76.51,APC
Amino acids single quant,82131,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,93.1,,,,,,,fee schedule,20.68,93.1,
Amino acids single quant,82131,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,74.63,,,,,,,fee schedule,20.68,93.1,
Amino acids single quant,82131,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,81.53,,,,,,,fee schedule,20.68,93.1,
Amino acids single quant,82131,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,85.71,,,,,,,fee schedule,20.68,93.1,
Amino acids single quant,82131,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,20.68,,,,,,,fee schedule,20.68,93.1,Laboratory
Amino acids single quant,82131,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,24.13,,,,,,,fee schedule,20.68,93.1,APC
Amino acids single quant,82131,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,23.9,,,,,,,fee schedule,20.68,93.1,APC
Amino acids single quant,82131,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,22.98,,,,,,,fee schedule,20.68,93.1,APC
Amino acids single quant,82131,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,35.16,,,,,,,fee schedule,20.68,93.1,Radiology
Amino acids single quant,82131,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,32.17,,,,,,,fee schedule,20.68,93.1,APC
Amino acids single quant,82131,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,40.22,,,,,,,fee schedule,20.68,93.1,APC
Assay aminolevulinic acid,82135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,90.87,,,,,,,fee schedule,14.8,90.87,
Assay aminolevulinic acid,82135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,72.84,,,,,,,fee schedule,14.8,90.87,
Assay aminolevulinic acid,82135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,79.57,,,,,,,fee schedule,14.8,90.87,
Assay aminolevulinic acid,82135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83.66,,,,,,,fee schedule,14.8,90.87,
Assay aminolevulinic acid,82135,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.8,,,,,,,fee schedule,14.8,90.87,Laboratory
Assay aminolevulinic acid,82135,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.27,,,,,,,fee schedule,14.8,90.87,APC
Assay aminolevulinic acid,82135,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,17.11,,,,,,,fee schedule,14.8,90.87,APC
Assay aminolevulinic acid,82135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16.45,,,,,,,fee schedule,14.8,90.87,APC
Assay aminolevulinic acid,82135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.17,,,,,,,fee schedule,14.8,90.87,Radiology
Assay aminolevulinic acid,82135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.03,,,,,,,fee schedule,14.8,90.87,APC
Assay aminolevulinic acid,82135,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,28.79,,,,,,,fee schedule,14.8,90.87,APC
Amino acids quant 2-5,82136,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,93.1,,,,,,,fee schedule,17.65,93.1,
Amino acids quant 2-5,82136,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,74.63,,,,,,,fee schedule,17.65,93.1,
Amino acids quant 2-5,82136,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,81.53,,,,,,,fee schedule,17.65,93.1,
Amino acids quant 2-5,82136,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,85.71,,,,,,,fee schedule,17.65,93.1,
Amino acids quant 2-5,82136,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.65,,,,,,,fee schedule,17.65,93.1,Laboratory
Amino acids quant 2-5,82136,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20.59,,,,,,,fee schedule,17.65,93.1,APC
Amino acids quant 2-5,82136,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,20.39,,,,,,,fee schedule,17.65,93.1,APC
Amino acids quant 2-5,82136,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,19.61,,,,,,,fee schedule,17.65,93.1,APC
Amino acids quant 2-5,82136,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,30,,,,,,,fee schedule,17.65,93.1,Radiology
Amino acids quant 2-5,82136,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27.45,,,,,,,fee schedule,17.65,93.1,APC
Amino acids quant 2-5,82136,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,34.32,,,,,,,fee schedule,17.65,93.1,APC
Amino acids quan 6 or more,82139,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,784.81,,,,,,,fee schedule,15.18,784.81,
Amino acids quan 6 or more,82139,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,629.1,,,,,,,fee schedule,15.18,784.81,
Amino acids quan 6 or more,82139,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,687.23,,,,,,,fee schedule,15.18,784.81,
Amino acids quan 6 or more,82139,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,722.53,,,,,,,fee schedule,15.18,784.81,
Amino acids quan 6 or more,82139,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.18,,,,,,,fee schedule,15.18,784.81,Laboratory
Amino acids quan 6 or more,82139,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.71,,,,,,,fee schedule,15.18,784.81,APC
Amino acids quan 6 or more,82139,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,17.54,,,,,,,fee schedule,15.18,784.81,APC
Amino acids quan 6 or more,82139,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16.87,,,,,,,fee schedule,15.18,784.81,APC
Amino acids quan 6 or more,82139,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.81,,,,,,,fee schedule,15.18,784.81,Radiology
Amino acids quan 6 or more,82139,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.62,,,,,,,fee schedule,15.18,784.81,APC
Amino acids quan 6 or more,82139,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,29.52,,,,,,,fee schedule,15.18,784.81,APC
Assay of ammonia,82140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,84.67,,,,,,,fee schedule,13.11,84.67,
Assay of ammonia,82140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,67.87,,,,,,,fee schedule,13.11,84.67,
Assay of ammonia,82140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,74.15,,,,,,,fee schedule,13.11,84.67,
Assay of ammonia,82140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,77.95,,,,,,,fee schedule,13.11,84.67,
Assay of ammonia,82140,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.11,,,,,,,fee schedule,13.11,84.67,Laboratory
Assay of ammonia,82140,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.3,,,,,,,fee schedule,13.11,84.67,APC
Assay of ammonia,82140,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,15.15,,,,,,,fee schedule,13.11,84.67,APC
Assay of ammonia,82140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14.57,,,,,,,fee schedule,13.11,84.67,APC
Assay of ammonia,82140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.29,,,,,,,fee schedule,13.11,84.67,Radiology
Assay of ammonia,82140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.4,,,,,,,fee schedule,13.11,84.67,APC
Assay of ammonia,82140,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,25.5,,,,,,,fee schedule,13.11,84.67,APC
Amniotic fluid scan,82143,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37.91,,,,,,,fee schedule,8.41,37.91,
Amniotic fluid scan,82143,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,30.39,,,,,,,fee schedule,8.41,37.91,
Amniotic fluid scan,82143,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,33.2,,,,,,,fee schedule,8.41,37.91,
Amniotic fluid scan,82143,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,34.9,,,,,,,fee schedule,8.41,37.91,
Amniotic fluid scan,82143,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.41,,,,,,,fee schedule,8.41,37.91,Laboratory
Amniotic fluid scan,82143,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.82,,,,,,,fee schedule,8.41,37.91,APC
Amniotic fluid scan,82143,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9.72,,,,,,,fee schedule,8.41,37.91,APC
Amniotic fluid scan,82143,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9.35,,,,,,,fee schedule,8.41,37.91,APC
Amniotic fluid scan,82143,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.31,,,,,,,fee schedule,8.41,37.91,Radiology
Amniotic fluid scan,82143,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.09,,,,,,,fee schedule,8.41,37.91,APC
Amniotic fluid scan,82143,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16.36,,,,,,,fee schedule,8.41,37.91,APC
Assay of amylase,82150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.52,,,,,,,fee schedule,5.83,66.52,
Assay of amylase,82150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.32,,,,,,,fee schedule,5.83,66.52,
Assay of amylase,82150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,58.25,,,,,,,fee schedule,5.83,66.52,
Assay of amylase,82150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,61.24,,,,,,,fee schedule,5.83,66.52,
Assay of amylase,82150,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.83,,,,,,,fee schedule,5.83,66.52,Laboratory
Assay of amylase,82150,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.8,,,,,,,fee schedule,5.83,66.52,APC
Assay of amylase,82150,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6.74,,,,,,,fee schedule,5.83,66.52,APC
Assay of amylase,82150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6.48,,,,,,,fee schedule,5.83,66.52,APC
Assay of amylase,82150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.91,,,,,,,fee schedule,5.83,66.52,Radiology
Assay of amylase,82150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.07,,,,,,,fee schedule,5.83,66.52,APC
Assay of amylase,82150,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11.34,,,,,,,fee schedule,5.83,66.52,APC
Androstanediol glucuronide,82154,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,159.14,,,,,,,fee schedule,25.95,159.14,
Androstanediol glucuronide,82154,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,127.56,,,,,,,fee schedule,25.95,159.14,
Androstanediol glucuronide,82154,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,139.35,,,,,,,fee schedule,25.95,159.14,
Androstanediol glucuronide,82154,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,146.51,,,,,,,fee schedule,25.95,159.14,
Androstanediol glucuronide,82154,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25.95,,,,,,,fee schedule,25.95,159.14,Laboratory
Androstanediol glucuronide,82154,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.27,,,,,,,fee schedule,25.95,159.14,APC
Androstanediol glucuronide,82154,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,29.98,,,,,,,fee schedule,25.95,159.14,APC
Androstanediol glucuronide,82154,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,28.83,,,,,,,fee schedule,25.95,159.14,APC
Androstanediol glucuronide,82154,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,44.11,,,,,,,fee schedule,25.95,159.14,Radiology
Androstanediol glucuronide,82154,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40.36,,,,,,,fee schedule,25.95,159.14,APC
Androstanediol glucuronide,82154,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,50.45,,,,,,,fee schedule,25.95,159.14,APC
Assay of androstenedione,82157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,161.56,,,,,,,fee schedule,26.35,161.56,
Assay of androstenedione,82157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,129.5,,,,,,,fee schedule,26.35,161.56,
Assay of androstenedione,82157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,141.47,,,,,,,fee schedule,26.35,161.56,
Assay of androstenedione,82157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,148.74,,,,,,,fee schedule,26.35,161.56,
Assay of androstenedione,82157,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26.35,,,,,,,fee schedule,26.35,161.56,Laboratory
Assay of androstenedione,82157,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.74,,,,,,,fee schedule,26.35,161.56,APC
Assay of androstenedione,82157,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,30.45,,,,,,,fee schedule,26.35,161.56,APC
Assay of androstenedione,82157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,29.28,,,,,,,fee schedule,26.35,161.56,APC
Assay of androstenedione,82157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,44.8,,,,,,,fee schedule,26.35,161.56,Radiology
Assay of androstenedione,82157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40.99,,,,,,,fee schedule,26.35,161.56,APC
Assay of androstenedione,82157,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,51.24,,,,,,,fee schedule,26.35,161.56,APC
Assay of androsterone,82160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,138.01,,,,,,,fee schedule,23,138.01,
Assay of androsterone,82160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,110.63,,,,,,,fee schedule,23,138.01,
Assay of androsterone,82160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,120.85,,,,,,,fee schedule,23,138.01,
Assay of androsterone,82160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,127.05,,,,,,,fee schedule,23,138.01,
Assay of androsterone,82160,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23,,,,,,,fee schedule,23,138.01,Laboratory
Assay of androsterone,82160,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,26.83,,,,,,,fee schedule,23,138.01,APC
Assay of androsterone,82160,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,26.57,,,,,,,fee schedule,23,138.01,APC
Assay of androsterone,82160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,25.55,,,,,,,fee schedule,23,138.01,APC
Assay of androsterone,82160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,39.09,,,,,,,fee schedule,23,138.01,Radiology
Assay of androsterone,82160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,35.77,,,,,,,fee schedule,23,138.01,APC
Assay of androsterone,82160,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,44.71,,,,,,,fee schedule,23,138.01,APC
Assay of angiotensin II,82163,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,62.19,,,,,,,fee schedule,18.47,62.19,
Assay of angiotensin II,82163,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,49.85,,,,,,,fee schedule,18.47,62.19,
Assay of angiotensin II,82163,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,54.46,,,,,,,fee schedule,18.47,62.19,
Assay of angiotensin II,82163,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,57.26,,,,,,,fee schedule,18.47,62.19,
Assay of angiotensin II,82163,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.47,,,,,,,fee schedule,18.47,62.19,Laboratory
Assay of angiotensin II,82163,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.55,,,,,,,fee schedule,18.47,62.19,APC
Assay of angiotensin II,82163,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,21.34,,,,,,,fee schedule,18.47,62.19,APC
Assay of angiotensin II,82163,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,20.52,,,,,,,fee schedule,18.47,62.19,APC
Assay of angiotensin II,82163,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,31.4,,,,,,,fee schedule,18.47,62.19,Radiology
Assay of angiotensin II,82163,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.73,,,,,,,fee schedule,18.47,62.19,APC
Assay of angiotensin II,82163,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,35.91,,,,,,,fee schedule,18.47,62.19,APC
Angiotensin I enzyme test,82164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,163.63,,,,,,,fee schedule,13.14,163.63,
Angiotensin I enzyme test,82164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,131.16,,,,,,,fee schedule,13.14,163.63,
Angiotensin I enzyme test,82164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,143.28,,,,,,,fee schedule,13.14,163.63,
Angiotensin I enzyme test,82164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,150.64,,,,,,,fee schedule,13.14,163.63,
Angiotensin I enzyme test,82164,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.14,,,,,,,fee schedule,13.14,163.63,Laboratory
Angiotensin I enzyme test,82164,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.33,,,,,,,fee schedule,13.14,163.63,APC
Angiotensin I enzyme test,82164,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,15.18,,,,,,,fee schedule,13.14,163.63,APC
Angiotensin I enzyme test,82164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14.6,,,,,,,fee schedule,13.14,163.63,APC
Angiotensin I enzyme test,82164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.34,,,,,,,fee schedule,13.14,163.63,Radiology
Angiotensin I enzyme test,82164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.44,,,,,,,fee schedule,13.14,163.63,APC
Angiotensin I enzyme test,82164,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,25.55,,,,,,,fee schedule,13.14,163.63,APC
Assay anti-mullerian horm,82166,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,34.76,,,,,,,fee schedule,34.76,67.58,Laboratory
Assay anti-mullerian horm,82166,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,40.55,,,,,,,fee schedule,34.76,67.58,APC
Assay anti-mullerian horm,82166,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,40.16,,,,,,,fee schedule,34.76,67.58,APC
Assay anti-mullerian horm,82166,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,38.62,,,,,,,fee schedule,34.76,67.58,APC
Assay anti-mullerian horm,82166,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,59.09,,,,,,,fee schedule,34.76,67.58,Radiology
Assay anti-mullerian horm,82166,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,54.07,,,,,,,fee schedule,34.76,67.58,APC
Assay anti-mullerian horm,82166,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,67.58,,,,,,,fee schedule,34.76,67.58,APC
Assay of apolipoprotein,82172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,85.5,,,,,,,fee schedule,18.98,85.5,
Assay of apolipoprotein,82172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,68.54,,,,,,,fee schedule,18.98,85.5,
Assay of apolipoprotein,82172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,74.87,,,,,,,fee schedule,18.98,85.5,
Assay of apolipoprotein,82172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,78.72,,,,,,,fee schedule,18.98,85.5,
Assay of apolipoprotein,82172,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.98,,,,,,,fee schedule,18.98,85.5,Laboratory
Assay of apolipoprotein,82172,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,22.14,,,,,,,fee schedule,18.98,85.5,APC
Assay of apolipoprotein,82172,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,21.93,,,,,,,fee schedule,18.98,85.5,APC
Assay of apolipoprotein,82172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,21.09,,,,,,,fee schedule,18.98,85.5,APC
Assay of apolipoprotein,82172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,32.27,,,,,,,fee schedule,18.98,85.5,Radiology
Assay of apolipoprotein,82172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29.53,,,,,,,fee schedule,18.98,85.5,APC
Assay of apolipoprotein,82172,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,36.91,,,,,,,fee schedule,18.98,85.5,APC
Assay of arsenic,82175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59.23,,,,,,,fee schedule,17.07,59.23,
Assay of arsenic,82175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,47.48,,,,,,,fee schedule,17.07,59.23,
Assay of arsenic,82175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.87,,,,,,,fee schedule,17.07,59.23,
Assay of arsenic,82175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,54.53,,,,,,,fee schedule,17.07,59.23,
Assay of arsenic,82175,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.07,,,,,,,fee schedule,17.07,59.23,Laboratory
Assay of arsenic,82175,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.92,,,,,,,fee schedule,17.07,59.23,APC
Assay of arsenic,82175,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,19.73,,,,,,,fee schedule,17.07,59.23,APC
Assay of arsenic,82175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18.97,,,,,,,fee schedule,17.07,59.23,APC
Assay of arsenic,82175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29.02,,,,,,,fee schedule,17.07,59.23,Radiology
Assay of arsenic,82175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26.56,,,,,,,fee schedule,17.07,59.23,APC
Assay of arsenic,82175,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,33.2,,,,,,,fee schedule,17.07,59.23,APC
Assay of ascorbic acid,82180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,54.55,,,,,,,fee schedule,8.9,54.55,
Assay of ascorbic acid,82180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,43.72,,,,,,,fee schedule,8.9,54.55,
Assay of ascorbic acid,82180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,47.76,,,,,,,fee schedule,8.9,54.55,
Assay of ascorbic acid,82180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,50.22,,,,,,,fee schedule,8.9,54.55,
Assay of ascorbic acid,82180,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.9,,,,,,,fee schedule,8.9,54.55,Laboratory
Assay of ascorbic acid,82180,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.38,,,,,,,fee schedule,8.9,54.55,APC
Assay of ascorbic acid,82180,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10.29,,,,,,,fee schedule,8.9,54.55,APC
Assay of ascorbic acid,82180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9.89,,,,,,,fee schedule,8.9,54.55,APC
Assay of ascorbic acid,82180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15.13,,,,,,,fee schedule,8.9,54.55,Radiology
Assay of ascorbic acid,82180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.85,,,,,,,fee schedule,8.9,54.55,APC
Assay of ascorbic acid,82180,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,17.31,,,,,,,fee schedule,8.9,54.55,APC
Atomic absorption,82190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,82.29,,,,,,,fee schedule,14.31,82.29,
Atomic absorption,82190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,65.96,,,,,,,fee schedule,14.31,82.29,
Atomic absorption,82190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,72.06,,,,,,,fee schedule,14.31,82.29,
Atomic absorption,82190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,75.76,,,,,,,fee schedule,14.31,82.29,
Atomic absorption,82190,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.31,,,,,,,fee schedule,14.31,82.29,Laboratory
Atomic absorption,82190,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.7,,,,,,,fee schedule,14.31,82.29,APC
Atomic absorption,82190,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,16.54,,,,,,,fee schedule,14.31,82.29,APC
Atomic absorption,82190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,15.9,,,,,,,fee schedule,14.31,82.29,APC
Atomic absorption,82190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24.33,,,,,,,fee schedule,14.31,82.29,Radiology
Atomic absorption,82190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.26,,,,,,,fee schedule,14.31,82.29,APC
Atomic absorption,82190,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,27.82,,,,,,,fee schedule,14.31,82.29,APC
Assay of beta-2 protein,82232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,70.34,,,,,,,fee schedule,14.56,70.34,
Assay of beta-2 protein,82232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56.38,,,,,,,fee schedule,14.56,70.34,
Assay of beta-2 protein,82232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,61.59,,,,,,,fee schedule,14.56,70.34,
Assay of beta-2 protein,82232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,64.75,,,,,,,fee schedule,14.56,70.34,
Assay of beta-2 protein,82232,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.56,,,,,,,fee schedule,14.56,70.34,Laboratory
Assay of beta-2 protein,82232,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.99,,,,,,,fee schedule,14.56,70.34,APC
Assay of beta-2 protein,82232,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,16.83,,,,,,,fee schedule,14.56,70.34,APC
Assay of beta-2 protein,82232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16.18,,,,,,,fee schedule,14.56,70.34,APC
Assay of beta-2 protein,82232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24.76,,,,,,,fee schedule,14.56,70.34,Radiology
Assay of beta-2 protein,82232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.65,,,,,,,fee schedule,14.56,70.34,APC
Assay of beta-2 protein,82232,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,28.32,,,,,,,fee schedule,14.56,70.34,APC
Beta-amyloid 1-40 (abeta 40),82233,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,116.03,,,,,,,fee schedule,116.03,225.61,Laboratory
Beta-amyloid 1-40 (abeta 40),82233,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,135.37,,,,,,,fee schedule,116.03,225.61,APC
Beta-amyloid 1-40 (abeta 40),82233,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,134.08,,,,,,,fee schedule,116.03,225.61,APC
Beta-amyloid 1-40 (abeta 40),82233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,128.92,,,,,,,fee schedule,116.03,225.61,APC
Beta-amyloid 1-40 (abeta 40),82233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,197.25,,,,,,,fee schedule,116.03,225.61,Radiology
Beta-amyloid 1-40 (abeta 40),82233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,180.49,,,,,,,fee schedule,116.03,225.61,APC
Beta-amyloid 1-40 (abeta 40),82233,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,225.61,,,,,,,fee schedule,116.03,225.61,APC
Beta-amyloid 1-42 (abeta 42),82234,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,116.03,,,,,,,fee schedule,116.03,225.61,Laboratory
Beta-amyloid 1-42 (abeta 42),82234,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,135.37,,,,,,,fee schedule,116.03,225.61,APC
Beta-amyloid 1-42 (abeta 42),82234,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,134.08,,,,,,,fee schedule,116.03,225.61,APC
Beta-amyloid 1-42 (abeta 42),82234,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,128.92,,,,,,,fee schedule,116.03,225.61,APC
Beta-amyloid 1-42 (abeta 42),82234,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,197.25,,,,,,,fee schedule,116.03,225.61,Radiology
Beta-amyloid 1-42 (abeta 42),82234,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,180.49,,,,,,,fee schedule,116.03,225.61,APC
Beta-amyloid 1-42 (abeta 42),82234,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,225.61,,,,,,,fee schedule,116.03,225.61,APC
Bile acids total,82239,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,53.31,,,,,,,fee schedule,15.41,53.31,
Bile acids total,82239,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.73,,,,,,,fee schedule,15.41,53.31,
Bile acids total,82239,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.68,,,,,,,fee schedule,15.41,53.31,
Bile acids total,82239,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,49.08,,,,,,,fee schedule,15.41,53.31,
Bile acids total,82239,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.41,,,,,,,fee schedule,15.41,53.31,Laboratory
Bile acids total,82239,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.98,,,,,,,fee schedule,15.41,53.31,APC
Bile acids total,82239,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,17.8,,,,,,,fee schedule,15.41,53.31,APC
Bile acids total,82239,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17.12,,,,,,,fee schedule,15.41,53.31,APC
Bile acids total,82239,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26.19,,,,,,,fee schedule,15.41,53.31,Radiology
Bile acids total,82239,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.97,,,,,,,fee schedule,15.41,53.31,APC
Bile acids total,82239,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,29.96,,,,,,,fee schedule,15.41,53.31,APC
Bile acids cholylglycine,82240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,146.7,,,,,,,fee schedule,23.92,146.7,
Bile acids cholylglycine,82240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,117.59,,,,,,,fee schedule,23.92,146.7,
Bile acids cholylglycine,82240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,128.46,,,,,,,fee schedule,23.92,146.7,
Bile acids cholylglycine,82240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,135.06,,,,,,,fee schedule,23.92,146.7,
Bile acids cholylglycine,82240,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23.92,,,,,,,fee schedule,23.92,146.7,Laboratory
Bile acids cholylglycine,82240,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,27.91,,,,,,,fee schedule,23.92,146.7,APC
Bile acids cholylglycine,82240,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,27.64,,,,,,,fee schedule,23.92,146.7,APC
Bile acids cholylglycine,82240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,26.58,,,,,,,fee schedule,23.92,146.7,APC
Bile acids cholylglycine,82240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40.67,,,,,,,fee schedule,23.92,146.7,Radiology
Bile acids cholylglycine,82240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,37.21,,,,,,,fee schedule,23.92,146.7,APC
Bile acids cholylglycine,82240,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,46.52,,,,,,,fee schedule,23.92,146.7,APC
Bilirubin total,82247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,84.91,,,,,,,fee schedule,4.52,84.91,
Bilirubin total,82247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,68.06,,,,,,,fee schedule,4.52,84.91,
Bilirubin total,82247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,74.35,,,,,,,fee schedule,4.52,84.91,
Bilirubin total,82247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,78.17,,,,,,,fee schedule,4.52,84.91,
Bilirubin total,82247,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.52,,,,,,,fee schedule,4.52,84.91,Laboratory
Bilirubin total,82247,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.27,,,,,,,fee schedule,4.52,84.91,APC
Bilirubin total,82247,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5.22,,,,,,,fee schedule,4.52,84.91,APC
Bilirubin total,82247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5.02,,,,,,,fee schedule,4.52,84.91,APC
Bilirubin total,82247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.68,,,,,,,fee schedule,4.52,84.91,Radiology
Bilirubin total,82247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.03,,,,,,,fee schedule,4.52,84.91,APC
Bilirubin total,82247,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8.78,,,,,,,fee schedule,4.52,84.91,APC
Bilirubin direct,82248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,71.86,,,,,,,fee schedule,4.52,71.86,
Bilirubin direct,82248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.6,,,,,,,fee schedule,4.52,71.86,
Bilirubin direct,82248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,62.92,,,,,,,fee schedule,4.52,71.86,
Bilirubin direct,82248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.16,,,,,,,fee schedule,4.52,71.86,
Bilirubin direct,82248,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.52,,,,,,,fee schedule,4.52,71.86,Laboratory
Bilirubin direct,82248,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.27,,,,,,,fee schedule,4.52,71.86,APC
Bilirubin direct,82248,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5.22,,,,,,,fee schedule,4.52,71.86,APC
Bilirubin direct,82248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5.02,,,,,,,fee schedule,4.52,71.86,APC
Bilirubin direct,82248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.68,,,,,,,fee schedule,4.52,71.86,Radiology
Bilirubin direct,82248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.03,,,,,,,fee schedule,4.52,71.86,APC
Bilirubin direct,82248,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8.78,,,,,,,fee schedule,4.52,71.86,APC
Fecal bilirubin test,82252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,25.1,,,,,,,fee schedule,4.1,25.1,
Fecal bilirubin test,82252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20.12,,,,,,,fee schedule,4.1,25.1,
Fecal bilirubin test,82252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21.98,,,,,,,fee schedule,4.1,25.1,
Fecal bilirubin test,82252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23.11,,,,,,,fee schedule,4.1,25.1,
Fecal bilirubin test,82252,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.1,,,,,,,fee schedule,4.1,25.1,Laboratory
Fecal bilirubin test,82252,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.79,,,,,,,fee schedule,4.1,25.1,APC
Fecal bilirubin test,82252,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4.74,,,,,,,fee schedule,4.1,25.1,APC
Fecal bilirubin test,82252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4.56,,,,,,,fee schedule,4.1,25.1,APC
Fecal bilirubin test,82252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.98,,,,,,,fee schedule,4.1,25.1,Radiology
Fecal bilirubin test,82252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.38,,,,,,,fee schedule,4.1,25.1,APC
Fecal bilirubin test,82252,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7.98,,,,,,,fee schedule,4.1,25.1,APC
Assay of biotinidase,82261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,93.1,,,,,,,fee schedule,15.18,93.1,
Assay of biotinidase,82261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,74.63,,,,,,,fee schedule,15.18,93.1,
Assay of biotinidase,82261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,81.53,,,,,,,fee schedule,15.18,93.1,
Assay of biotinidase,82261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,85.71,,,,,,,fee schedule,15.18,93.1,
Assay of biotinidase,82261,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.18,,,,,,,fee schedule,15.18,93.1,Laboratory
Assay of biotinidase,82261,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.71,,,,,,,fee schedule,15.18,93.1,APC
Assay of biotinidase,82261,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,17.54,,,,,,,fee schedule,15.18,93.1,APC
Assay of biotinidase,82261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16.87,,,,,,,fee schedule,15.18,93.1,APC
Assay of biotinidase,82261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.81,,,,,,,fee schedule,15.18,93.1,Radiology
Assay of biotinidase,82261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.62,,,,,,,fee schedule,15.18,93.1,APC
Assay of biotinidase,82261,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,29.52,,,,,,,fee schedule,15.18,93.1,APC
Occult blood feces,82270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23.54,,,,,,,fee schedule,3.94,23.54,
Occult blood feces,82270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18.87,,,,,,,fee schedule,3.94,23.54,
Occult blood feces,82270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20.62,,,,,,,fee schedule,3.94,23.54,
Occult blood feces,82270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21.68,,,,,,,fee schedule,3.94,23.54,
Occult blood feces,82270,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.94,,,,,,,fee schedule,3.94,23.54,Laboratory
Occult blood feces,82270,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.6,,,,,,,fee schedule,3.94,23.54,APC
Occult blood feces,82270,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4.56,,,,,,,fee schedule,3.94,23.54,APC
Occult blood feces,82270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4.38,,,,,,,fee schedule,3.94,23.54,APC
Occult blood feces,82270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.7,,,,,,,fee schedule,3.94,23.54,Radiology
Occult blood feces,82270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.13,,,,,,,fee schedule,3.94,23.54,APC
Occult blood feces,82270,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7.66,,,,,,,fee schedule,3.94,23.54,APC
Occult blood other sources,82271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17.96,,,,,,,fee schedule,4.79,17.96,
Occult blood other sources,82271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14.39,,,,,,,fee schedule,4.79,17.96,
Occult blood other sources,82271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15.72,,,,,,,fee schedule,4.79,17.96,
Occult blood other sources,82271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16.53,,,,,,,fee schedule,4.79,17.96,
Occult blood other sources,82271,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.79,,,,,,,fee schedule,4.79,17.96,Laboratory
Occult blood other sources,82271,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.59,,,,,,,fee schedule,4.79,17.96,APC
Occult blood other sources,82271,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5.53,,,,,,,fee schedule,4.79,17.96,APC
Occult blood other sources,82271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5.32,,,,,,,fee schedule,4.79,17.96,APC
Occult blood other sources,82271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8.14,,,,,,,fee schedule,4.79,17.96,Radiology
Occult blood other sources,82271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.45,,,,,,,fee schedule,4.79,17.96,APC
Occult blood other sources,82271,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9.31,,,,,,,fee schedule,4.79,17.96,APC
Occult bld feces 1-3 tests,82272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.63,,,,,,,fee schedule,3.81,9.63,
Occult bld feces 1-3 tests,82272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7.72,,,,,,,fee schedule,3.81,9.63,
Occult bld feces 1-3 tests,82272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.43,,,,,,,fee schedule,3.81,9.63,
Occult bld feces 1-3 tests,82272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8.86,,,,,,,fee schedule,3.81,9.63,
Occult bld feces 1-3 tests,82272,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.81,,,,,,,fee schedule,3.81,9.63,Laboratory
Occult bld feces 1-3 tests,82272,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.44,,,,,,,fee schedule,3.81,9.63,APC
Occult bld feces 1-3 tests,82272,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4.4,,,,,,,fee schedule,3.81,9.63,APC
Occult bld feces 1-3 tests,82272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4.23,,,,,,,fee schedule,3.81,9.63,APC
Occult bld feces 1-3 tests,82272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.47,,,,,,,fee schedule,3.81,9.63,Radiology
Occult bld feces 1-3 tests,82272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.92,,,,,,,fee schedule,3.81,9.63,APC
Occult bld feces 1-3 tests,82272,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7.4,,,,,,,fee schedule,3.81,9.63,APC
Assay test for blood fecal,82274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,51.83,,,,,,,fee schedule,14.33,51.83,
Assay test for blood fecal,82274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,41.54,,,,,,,fee schedule,14.33,51.83,
Assay test for blood fecal,82274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,45.38,,,,,,,fee schedule,14.33,51.83,
Assay test for blood fecal,82274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,47.71,,,,,,,fee schedule,14.33,51.83,
Assay test for blood fecal,82274,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.33,,,,,,,fee schedule,14.33,51.83,Laboratory
Assay test for blood fecal,82274,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.72,,,,,,,fee schedule,14.33,51.83,APC
Assay test for blood fecal,82274,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,16.56,,,,,,,fee schedule,14.33,51.83,APC
Assay test for blood fecal,82274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,15.92,,,,,,,fee schedule,14.33,51.83,APC
Assay test for blood fecal,82274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24.36,,,,,,,fee schedule,14.33,51.83,Radiology
Assay test for blood fecal,82274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.29,,,,,,,fee schedule,14.33,51.83,APC
Assay test for blood fecal,82274,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,27.86,,,,,,,fee schedule,14.33,51.83,APC
Assay of bradykinin,82286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,38.03,,,,,,,fee schedule,4.64,38.03,
Assay of bradykinin,82286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,30.48,,,,,,,fee schedule,4.64,38.03,
Assay of bradykinin,82286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,33.3,,,,,,,fee schedule,4.64,38.03,
Assay of bradykinin,82286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,35.01,,,,,,,fee schedule,4.64,38.03,
Assay of bradykinin,82286,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.64,,,,,,,fee schedule,4.64,38.03,Laboratory
Assay of bradykinin,82286,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.42,,,,,,,fee schedule,4.64,38.03,APC
Assay of bradykinin,82286,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5.37,,,,,,,fee schedule,4.64,38.03,APC
Assay of bradykinin,82286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5.16,,,,,,,fee schedule,4.64,38.03,APC
Assay of bradykinin,82286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.89,,,,,,,fee schedule,4.64,38.03,Radiology
Assay of bradykinin,82286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.22,,,,,,,fee schedule,4.64,38.03,APC
Assay of bradykinin,82286,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9.03,,,,,,,fee schedule,4.64,38.03,APC
Assay of cadmium,82300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,127.73,,,,,,,fee schedule,21.28,127.73,
Assay of cadmium,82300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,102.38,,,,,,,fee schedule,21.28,127.73,
Assay of cadmium,82300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,111.84,,,,,,,fee schedule,21.28,127.73,
Assay of cadmium,82300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,117.59,,,,,,,fee schedule,21.28,127.73,
Assay of cadmium,82300,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21.28,,,,,,,fee schedule,21.28,127.73,Laboratory
Assay of cadmium,82300,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,24.82,,,,,,,fee schedule,21.28,127.73,APC
Assay of cadmium,82300,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,24.59,,,,,,,fee schedule,21.28,127.73,APC
Assay of cadmium,82300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,23.64,,,,,,,fee schedule,21.28,127.73,APC
Assay of cadmium,82300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,36.17,,,,,,,fee schedule,21.28,127.73,Radiology
Assay of cadmium,82300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,33.1,,,,,,,fee schedule,21.28,127.73,APC
Assay of cadmium,82300,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,41.37,,,,,,,fee schedule,21.28,127.73,APC
Vitamin d 25 hydroxy,82306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,86.02,,,,,,,fee schedule,26.64,86.02,
Vitamin d 25 hydroxy,82306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,68.96,,,,,,,fee schedule,26.64,86.02,
Vitamin d 25 hydroxy,82306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,75.33,,,,,,,fee schedule,26.64,86.02,
Vitamin d 25 hydroxy,82306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,79.2,,,,,,,fee schedule,26.64,86.02,
Vitamin d 25 hydroxy,82306,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26.64,,,,,,,fee schedule,26.64,86.02,Laboratory
Vitamin d 25 hydroxy,82306,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,31.08,,,,,,,fee schedule,26.64,86.02,APC
Vitamin d 25 hydroxy,82306,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,30.78,,,,,,,fee schedule,26.64,86.02,APC
Vitamin d 25 hydroxy,82306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,29.6,,,,,,,fee schedule,26.64,86.02,APC
Vitamin d 25 hydroxy,82306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,45.29,,,,,,,fee schedule,26.64,86.02,Radiology
Vitamin d 25 hydroxy,82306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,41.44,,,,,,,fee schedule,26.64,86.02,APC
Vitamin d 25 hydroxy,82306,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,51.8,,,,,,,fee schedule,26.64,86.02,APC
Assay of calcitonin,82308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83.66,,,,,,,fee schedule,24.11,83.66,
Assay of calcitonin,82308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,67.06,,,,,,,fee schedule,24.11,83.66,
Assay of calcitonin,82308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,73.26,,,,,,,fee schedule,24.11,83.66,
Assay of calcitonin,82308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,77.02,,,,,,,fee schedule,24.11,83.66,
Assay of calcitonin,82308,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24.11,,,,,,,fee schedule,24.11,83.66,Laboratory
Assay of calcitonin,82308,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,28.13,,,,,,,fee schedule,24.11,83.66,APC
Assay of calcitonin,82308,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,27.86,,,,,,,fee schedule,24.11,83.66,APC
Assay of calcitonin,82308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,26.79,,,,,,,fee schedule,24.11,83.66,APC
Assay of calcitonin,82308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40.99,,,,,,,fee schedule,24.11,83.66,Radiology
Assay of calcitonin,82308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,37.51,,,,,,,fee schedule,24.11,83.66,APC
Assay of calcitonin,82308,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,46.88,,,,,,,fee schedule,24.11,83.66,APC
Assay of calcium,82310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.53,,,,,,,fee schedule,4.64,60.53,
Assay of calcium,82310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48.52,,,,,,,fee schedule,4.64,60.53,
Assay of calcium,82310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53,,,,,,,fee schedule,4.64,60.53,
Assay of calcium,82310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55.72,,,,,,,fee schedule,4.64,60.53,
Assay of calcium,82310,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.64,,,,,,,fee schedule,4.64,60.53,Laboratory
Assay of calcium,82310,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.42,,,,,,,fee schedule,4.64,60.53,APC
Assay of calcium,82310,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5.37,,,,,,,fee schedule,4.64,60.53,APC
Assay of calcium,82310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5.16,,,,,,,fee schedule,4.64,60.53,APC
Assay of calcium,82310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.89,,,,,,,fee schedule,4.64,60.53,Radiology
Assay of calcium,82310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.22,,,,,,,fee schedule,4.64,60.53,APC
Assay of calcium,82310,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9.03,,,,,,,fee schedule,4.64,60.53,APC
Assay of calcium,82330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,159.42,,,,,,,fee schedule,12.31,159.42,
Assay of calcium,82330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,127.79,,,,,,,fee schedule,12.31,159.42,
Assay of calcium,82330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,139.6,,,,,,,fee schedule,12.31,159.42,
Assay of calcium,82330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,146.77,,,,,,,fee schedule,12.31,159.42,
Assay of calcium,82330,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.31,,,,,,,fee schedule,12.31,159.42,Laboratory
Assay of calcium,82330,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.36,,,,,,,fee schedule,12.31,159.42,APC
Assay of calcium,82330,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,14.23,,,,,,,fee schedule,12.31,159.42,APC
Assay of calcium,82330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.68,,,,,,,fee schedule,12.31,159.42,APC
Assay of calcium,82330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.93,,,,,,,fee schedule,12.31,159.42,Radiology
Assay of calcium,82330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.15,,,,,,,fee schedule,12.31,159.42,APC
Assay of calcium,82330,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23.94,,,,,,,fee schedule,12.31,159.42,APC
Calcium infusion test,82331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,28.58,,,,,,,fee schedule,12.01,28.58,
Calcium infusion test,82331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22.91,,,,,,,fee schedule,12.01,28.58,
Calcium infusion test,82331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,25.02,,,,,,,fee schedule,12.01,28.58,
Calcium infusion test,82331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26.31,,,,,,,fee schedule,12.01,28.58,
Calcium infusion test,82331,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.01,,,,,,,fee schedule,12.01,28.58,Laboratory
Calcium infusion test,82331,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.01,,,,,,,fee schedule,12.01,28.58,APC
Calcium infusion test,82331,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.87,,,,,,,fee schedule,12.01,28.58,APC
Calcium infusion test,82331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.34,,,,,,,fee schedule,12.01,28.58,APC
Calcium infusion test,82331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.41,,,,,,,fee schedule,12.01,28.58,Radiology
Calcium infusion test,82331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.68,,,,,,,fee schedule,12.01,28.58,APC
Calcium infusion test,82331,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23.34,,,,,,,fee schedule,12.01,28.58,APC
Assay of calcium in urine,82340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41.96,,,,,,,fee schedule,5.43,41.96,
Assay of calcium in urine,82340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,33.63,,,,,,,fee schedule,5.43,41.96,
Assay of calcium in urine,82340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36.74,,,,,,,fee schedule,5.43,41.96,
Assay of calcium in urine,82340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,38.63,,,,,,,fee schedule,5.43,41.96,
Assay of calcium in urine,82340,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.43,,,,,,,fee schedule,5.43,41.96,Laboratory
Assay of calcium in urine,82340,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.33,,,,,,,fee schedule,5.43,41.96,APC
Assay of calcium in urine,82340,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6.27,,,,,,,fee schedule,5.43,41.96,APC
Assay of calcium in urine,82340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6.03,,,,,,,fee schedule,5.43,41.96,APC
Assay of calcium in urine,82340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.23,,,,,,,fee schedule,5.43,41.96,Radiology
Assay of calcium in urine,82340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8.44,,,,,,,fee schedule,5.43,41.96,APC
Assay of calcium in urine,82340,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10.55,,,,,,,fee schedule,5.43,41.96,APC
Calculus analysis qual,82355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,63.84,,,,,,,fee schedule,10.42,63.84,
Calculus analysis qual,82355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.18,,,,,,,fee schedule,10.42,63.84,
Calculus analysis qual,82355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55.91,,,,,,,fee schedule,10.42,63.84,
Calculus analysis qual,82355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,58.78,,,,,,,fee schedule,10.42,63.84,
Calculus analysis qual,82355,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.42,,,,,,,fee schedule,10.42,63.84,Laboratory
Calculus analysis qual,82355,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.16,,,,,,,fee schedule,10.42,63.84,APC
Calculus analysis qual,82355,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.04,,,,,,,fee schedule,10.42,63.84,APC
Calculus analysis qual,82355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11.58,,,,,,,fee schedule,10.42,63.84,APC
Calculus analysis qual,82355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.72,,,,,,,fee schedule,10.42,63.84,Radiology
Calculus analysis qual,82355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.21,,,,,,,fee schedule,10.42,63.84,APC
Calculus analysis qual,82355,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20.26,,,,,,,fee schedule,10.42,63.84,APC
Calculus assay quant,82360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,71.06,,,,,,,fee schedule,11.58,71.06,
Calculus assay quant,82360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56.96,,,,,,,fee schedule,11.58,71.06,
Calculus assay quant,82360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,62.23,,,,,,,fee schedule,11.58,71.06,
Calculus assay quant,82360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,65.42,,,,,,,fee schedule,11.58,71.06,
Calculus assay quant,82360,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.58,,,,,,,fee schedule,11.58,71.06,Laboratory
Calculus assay quant,82360,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.51,,,,,,,fee schedule,11.58,71.06,APC
Calculus assay quant,82360,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.38,,,,,,,fee schedule,11.58,71.06,APC
Calculus assay quant,82360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.87,,,,,,,fee schedule,11.58,71.06,APC
Calculus assay quant,82360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.69,,,,,,,fee schedule,11.58,71.06,Radiology
Calculus assay quant,82360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.02,,,,,,,fee schedule,11.58,71.06,APC
Calculus assay quant,82360,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22.52,,,,,,,fee schedule,11.58,71.06,APC
Calculus spectroscopy,82365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,120.72,,,,,,,fee schedule,11.61,120.72,
Calculus spectroscopy,82365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,96.76,,,,,,,fee schedule,11.61,120.72,
Calculus spectroscopy,82365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,105.71,,,,,,,fee schedule,11.61,120.72,
Calculus spectroscopy,82365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,111.14,,,,,,,fee schedule,11.61,120.72,
Calculus spectroscopy,82365,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.61,,,,,,,fee schedule,11.61,120.72,Laboratory
Calculus spectroscopy,82365,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.55,,,,,,,fee schedule,11.61,120.72,APC
Calculus spectroscopy,82365,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.42,,,,,,,fee schedule,11.61,120.72,APC
Calculus spectroscopy,82365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.9,,,,,,,fee schedule,11.61,120.72,APC
Calculus spectroscopy,82365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.74,,,,,,,fee schedule,11.61,120.72,Radiology
Calculus spectroscopy,82365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.06,,,,,,,fee schedule,11.61,120.72,APC
Calculus spectroscopy,82365,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22.58,,,,,,,fee schedule,11.61,120.72,APC
X-ray assay calculus,82370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,69.14,,,,,,,fee schedule,11.27,69.14,
X-ray assay calculus,82370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55.42,,,,,,,fee schedule,11.27,69.14,
X-ray assay calculus,82370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,60.54,,,,,,,fee schedule,11.27,69.14,
X-ray assay calculus,82370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,63.65,,,,,,,fee schedule,11.27,69.14,
X-ray assay calculus,82370,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.27,,,,,,,fee schedule,11.27,69.14,Laboratory
X-ray assay calculus,82370,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.15,,,,,,,fee schedule,11.27,69.14,APC
X-ray assay calculus,82370,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.02,,,,,,,fee schedule,11.27,69.14,APC
X-ray assay calculus,82370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.52,,,,,,,fee schedule,11.27,69.14,APC
X-ray assay calculus,82370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.16,,,,,,,fee schedule,11.27,69.14,Radiology
X-ray assay calculus,82370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.53,,,,,,,fee schedule,11.27,69.14,APC
X-ray assay calculus,82370,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21.91,,,,,,,fee schedule,11.27,69.14,APC
Assay c-d transfer measure,82373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,99.68,,,,,,,fee schedule,16.25,99.68,
Assay c-d transfer measure,82373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,79.9,,,,,,,fee schedule,16.25,99.68,
Assay c-d transfer measure,82373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,87.28,,,,,,,fee schedule,16.25,99.68,
Assay c-d transfer measure,82373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,91.77,,,,,,,fee schedule,16.25,99.68,
Assay c-d transfer measure,82373,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.25,,,,,,,fee schedule,16.25,99.68,Laboratory
Assay c-d transfer measure,82373,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.96,,,,,,,fee schedule,16.25,99.68,APC
Assay c-d transfer measure,82373,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18.78,,,,,,,fee schedule,16.25,99.68,APC
Assay c-d transfer measure,82373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18.06,,,,,,,fee schedule,16.25,99.68,APC
Assay c-d transfer measure,82373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27.63,,,,,,,fee schedule,16.25,99.68,Radiology
Assay c-d transfer measure,82373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.28,,,,,,,fee schedule,16.25,99.68,APC
Assay c-d transfer measure,82373,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31.6,,,,,,,fee schedule,16.25,99.68,APC
Assay blood carbon dioxide,82374,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26.99,,,,,,,fee schedule,4.39,26.99,
Assay blood carbon dioxide,82374,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21.63,,,,,,,fee schedule,4.39,26.99,
Assay blood carbon dioxide,82374,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23.63,,,,,,,fee schedule,4.39,26.99,
Assay blood carbon dioxide,82374,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24.85,,,,,,,fee schedule,4.39,26.99,
Assay blood carbon dioxide,82374,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.39,,,,,,,fee schedule,4.39,26.99,Laboratory
Assay blood carbon dioxide,82374,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.12,,,,,,,fee schedule,4.39,26.99,APC
Assay blood carbon dioxide,82374,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5.08,,,,,,,fee schedule,4.39,26.99,APC
Assay blood carbon dioxide,82374,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4.88,,,,,,,fee schedule,4.39,26.99,APC
Assay blood carbon dioxide,82374,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.47,,,,,,,fee schedule,4.39,26.99,Radiology
Assay blood carbon dioxide,82374,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.83,,,,,,,fee schedule,4.39,26.99,APC
Assay blood carbon dioxide,82374,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8.54,,,,,,,fee schedule,4.39,26.99,APC
Assay carboxyhb quant,82375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,108.1,,,,,,,fee schedule,11.09,108.1,
Assay carboxyhb quant,82375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,86.65,,,,,,,fee schedule,11.09,108.1,
Assay carboxyhb quant,82375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,94.66,,,,,,,fee schedule,11.09,108.1,
Assay carboxyhb quant,82375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,99.52,,,,,,,fee schedule,11.09,108.1,
Assay carboxyhb quant,82375,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.09,,,,,,,fee schedule,11.09,108.1,Laboratory
Assay carboxyhb quant,82375,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.94,,,,,,,fee schedule,11.09,108.1,APC
Assay carboxyhb quant,82375,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.81,,,,,,,fee schedule,11.09,108.1,APC
Assay carboxyhb quant,82375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.32,,,,,,,fee schedule,11.09,108.1,APC
Assay carboxyhb quant,82375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.85,,,,,,,fee schedule,11.09,108.1,Radiology
Assay carboxyhb quant,82375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.25,,,,,,,fee schedule,11.09,108.1,APC
Assay carboxyhb quant,82375,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21.56,,,,,,,fee schedule,11.09,108.1,APC
Assay carboxyhb qual,82376,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,28.77,,,,,,,fee schedule,12.66,28.77,
Assay carboxyhb qual,82376,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23.06,,,,,,,fee schedule,12.66,28.77,
Assay carboxyhb qual,82376,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,25.19,,,,,,,fee schedule,12.66,28.77,
Assay carboxyhb qual,82376,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26.48,,,,,,,fee schedule,12.66,28.77,
Assay carboxyhb qual,82376,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.66,,,,,,,fee schedule,12.66,28.77,Laboratory
Assay carboxyhb qual,82376,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.77,,,,,,,fee schedule,12.66,28.77,APC
Assay carboxyhb qual,82376,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,14.63,,,,,,,fee schedule,12.66,28.77,APC
Assay carboxyhb qual,82376,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14.07,,,,,,,fee schedule,12.66,28.77,APC
Assay carboxyhb qual,82376,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21.53,,,,,,,fee schedule,12.66,28.77,Radiology
Assay carboxyhb qual,82376,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.7,,,,,,,fee schedule,12.66,28.77,APC
Assay carboxyhb qual,82376,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,24.62,,,,,,,fee schedule,12.66,28.77,APC
Carcinoembryonic antigen,82378,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,123.65,,,,,,,fee schedule,17.06,123.65,
Carcinoembryonic antigen,82378,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,99.11,,,,,,,fee schedule,17.06,123.65,
Carcinoembryonic antigen,82378,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,108.27,,,,,,,fee schedule,17.06,123.65,
Carcinoembryonic antigen,82378,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,113.83,,,,,,,fee schedule,17.06,123.65,
Carcinoembryonic antigen,82378,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.06,,,,,,,fee schedule,17.06,123.65,Laboratory
Carcinoembryonic antigen,82378,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.91,,,,,,,fee schedule,17.06,123.65,APC
Carcinoembryonic antigen,82378,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,19.72,,,,,,,fee schedule,17.06,123.65,APC
Carcinoembryonic antigen,82378,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18.96,,,,,,,fee schedule,17.06,123.65,APC
Carcinoembryonic antigen,82378,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29.01,,,,,,,fee schedule,17.06,123.65,Radiology
Carcinoembryonic antigen,82378,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26.54,,,,,,,fee schedule,17.06,123.65,APC
Carcinoembryonic antigen,82378,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,33.18,,,,,,,fee schedule,17.06,123.65,APC
Assay of carnitine,82379,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,52.57,,,,,,,fee schedule,15.18,52.57,
Assay of carnitine,82379,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.14,,,,,,,fee schedule,15.18,52.57,
Assay of carnitine,82379,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.03,,,,,,,fee schedule,15.18,52.57,
Assay of carnitine,82379,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,48.4,,,,,,,fee schedule,15.18,52.57,
Assay of carnitine,82379,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.18,,,,,,,fee schedule,15.18,52.57,Laboratory
Assay of carnitine,82379,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.71,,,,,,,fee schedule,15.18,52.57,APC
Assay of carnitine,82379,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,17.54,,,,,,,fee schedule,15.18,52.57,APC
Assay of carnitine,82379,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16.87,,,,,,,fee schedule,15.18,52.57,APC
Assay of carnitine,82379,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.81,,,,,,,fee schedule,15.18,52.57,Radiology
Assay of carnitine,82379,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.62,,,,,,,fee schedule,15.18,52.57,APC
Assay of carnitine,82379,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,29.52,,,,,,,fee schedule,15.18,52.57,APC
Assay of carotene,82380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,95.51,,,,,,,fee schedule,8.3,95.51,
Assay of carotene,82380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,76.56,,,,,,,fee schedule,8.3,95.51,
Assay of carotene,82380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,83.63,,,,,,,fee schedule,8.3,95.51,
Assay of carotene,82380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,87.93,,,,,,,fee schedule,8.3,95.51,
Assay of carotene,82380,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.3,,,,,,,fee schedule,8.3,95.51,Laboratory
Assay of carotene,82380,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.68,,,,,,,fee schedule,8.3,95.51,APC
Assay of carotene,82380,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9.59,,,,,,,fee schedule,8.3,95.51,APC
Assay of carotene,82380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9.22,,,,,,,fee schedule,8.3,95.51,APC
Assay of carotene,82380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.11,,,,,,,fee schedule,8.3,95.51,Radiology
Assay of carotene,82380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12.91,,,,,,,fee schedule,8.3,95.51,APC
Assay of carotene,82380,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16.14,,,,,,,fee schedule,8.3,95.51,APC
Assay urine catecholamines,82382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,94.88,,,,,,,fee schedule,24.57,94.88,
Assay urine catecholamines,82382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,76.05,,,,,,,fee schedule,24.57,94.88,
Assay urine catecholamines,82382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,83.08,,,,,,,fee schedule,24.57,94.88,
Assay urine catecholamines,82382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,87.35,,,,,,,fee schedule,24.57,94.88,
Assay urine catecholamines,82382,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24.57,,,,,,,fee schedule,24.57,94.88,Laboratory
Assay urine catecholamines,82382,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,28.67,,,,,,,fee schedule,24.57,94.88,APC
Assay urine catecholamines,82382,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,28.39,,,,,,,fee schedule,24.57,94.88,APC
Assay urine catecholamines,82382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,27.3,,,,,,,fee schedule,24.57,94.88,APC
Assay urine catecholamines,82382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,41.77,,,,,,,fee schedule,24.57,94.88,Radiology
Assay urine catecholamines,82382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,38.22,,,,,,,fee schedule,24.57,94.88,APC
Assay urine catecholamines,82382,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,47.78,,,,,,,fee schedule,24.57,94.88,APC
Assay blood catecholamines,82383,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,138.31,,,,,,,fee schedule,26.17,138.31,
Assay blood catecholamines,82383,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,110.87,,,,,,,fee schedule,26.17,138.31,
Assay blood catecholamines,82383,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,121.11,,,,,,,fee schedule,26.17,138.31,
Assay blood catecholamines,82383,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,127.33,,,,,,,fee schedule,26.17,138.31,
Assay blood catecholamines,82383,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26.17,,,,,,,fee schedule,26.17,138.31,Laboratory
Assay blood catecholamines,82383,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.53,,,,,,,fee schedule,26.17,138.31,APC
Assay blood catecholamines,82383,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,30.24,,,,,,,fee schedule,26.17,138.31,APC
Assay blood catecholamines,82383,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,29.08,,,,,,,fee schedule,26.17,138.31,APC
Assay blood catecholamines,82383,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,44.49,,,,,,,fee schedule,26.17,138.31,Radiology
Assay blood catecholamines,82383,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40.71,,,,,,,fee schedule,26.17,138.31,APC
Assay blood catecholamines,82383,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,50.89,,,,,,,fee schedule,26.17,138.31,APC
Assay three catecholamines,82384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,299.86,,,,,,,fee schedule,22.72,299.86,
Assay three catecholamines,82384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,240.36,,,,,,,fee schedule,22.72,299.86,
Assay three catecholamines,82384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,262.57,,,,,,,fee schedule,22.72,299.86,
Assay three catecholamines,82384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,276.06,,,,,,,fee schedule,22.72,299.86,
Assay three catecholamines,82384,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22.72,,,,,,,fee schedule,22.72,299.86,Laboratory
Assay three catecholamines,82384,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,26.51,,,,,,,fee schedule,22.72,299.86,APC
Assay three catecholamines,82384,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,26.26,,,,,,,fee schedule,22.72,299.86,APC
Assay three catecholamines,82384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,25.25,,,,,,,fee schedule,22.72,299.86,APC
Assay three catecholamines,82384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,38.63,,,,,,,fee schedule,22.72,299.86,Radiology
Assay three catecholamines,82384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,35.35,,,,,,,fee schedule,22.72,299.86,APC
Assay three catecholamines,82384,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,44.19,,,,,,,fee schedule,22.72,299.86,APC
Assay of cathepsin-d,82387,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,114.84,,,,,,,fee schedule,16.25,114.84,
Assay of cathepsin-d,82387,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,92.05,,,,,,,fee schedule,16.25,114.84,
Assay of cathepsin-d,82387,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,100.56,,,,,,,fee schedule,16.25,114.84,
Assay of cathepsin-d,82387,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,105.72,,,,,,,fee schedule,16.25,114.84,
Assay of cathepsin-d,82387,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.25,,,,,,,fee schedule,16.25,114.84,Laboratory
Assay of cathepsin-d,82387,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.96,,,,,,,fee schedule,16.25,114.84,APC
Assay of cathepsin-d,82387,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18.78,,,,,,,fee schedule,16.25,114.84,APC
Assay of cathepsin-d,82387,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18.06,,,,,,,fee schedule,16.25,114.84,APC
Assay of cathepsin-d,82387,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27.63,,,,,,,fee schedule,16.25,114.84,Radiology
Assay of cathepsin-d,82387,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.28,,,,,,,fee schedule,16.25,114.84,APC
Assay of cathepsin-d,82387,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31.6,,,,,,,fee schedule,16.25,114.84,APC
Assay of ceruloplasmin,82390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,81.15,,,,,,,fee schedule,9.67,81.15,
Assay of ceruloplasmin,82390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,65.05,,,,,,,fee schedule,9.67,81.15,
Assay of ceruloplasmin,82390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,71.06,,,,,,,fee schedule,9.67,81.15,
Assay of ceruloplasmin,82390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,74.71,,,,,,,fee schedule,9.67,81.15,
Assay of ceruloplasmin,82390,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.67,,,,,,,fee schedule,9.67,81.15,Laboratory
Assay of ceruloplasmin,82390,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.28,,,,,,,fee schedule,9.67,81.15,APC
Assay of ceruloplasmin,82390,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11.17,,,,,,,fee schedule,9.67,81.15,APC
Assay of ceruloplasmin,82390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10.74,,,,,,,fee schedule,9.67,81.15,APC
Assay of ceruloplasmin,82390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.43,,,,,,,fee schedule,9.67,81.15,Radiology
Assay of ceruloplasmin,82390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15.04,,,,,,,fee schedule,9.67,81.15,APC
Assay of ceruloplasmin,82390,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18.8,,,,,,,fee schedule,9.67,81.15,APC
Chemiluminescent assay,82397,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59.97,,,,,,,fee schedule,12.71,59.97,
Chemiluminescent assay,82397,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48.07,,,,,,,fee schedule,12.71,59.97,
Chemiluminescent assay,82397,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52.51,,,,,,,fee schedule,12.71,59.97,
Chemiluminescent assay,82397,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55.21,,,,,,,fee schedule,12.71,59.97,
Chemiluminescent assay,82397,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.71,,,,,,,fee schedule,12.71,59.97,Laboratory
Chemiluminescent assay,82397,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.83,,,,,,,fee schedule,12.71,59.97,APC
Chemiluminescent assay,82397,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,14.68,,,,,,,fee schedule,12.71,59.97,APC
Chemiluminescent assay,82397,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14.12,,,,,,,fee schedule,12.71,59.97,APC
Chemiluminescent assay,82397,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21.6,,,,,,,fee schedule,12.71,59.97,Radiology
Chemiluminescent assay,82397,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.77,,,,,,,fee schedule,12.71,59.97,APC
Chemiluminescent assay,82397,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,24.71,,,,,,,fee schedule,12.71,59.97,APC
Assay of chloramphenicol,82415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,69.93,,,,,,,fee schedule,11.4,69.93,
Assay of chloramphenicol,82415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56.06,,,,,,,fee schedule,11.4,69.93,
Assay of chloramphenicol,82415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,61.24,,,,,,,fee schedule,11.4,69.93,
Assay of chloramphenicol,82415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,64.38,,,,,,,fee schedule,11.4,69.93,
Assay of chloramphenicol,82415,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.4,,,,,,,fee schedule,11.4,69.93,Laboratory
Assay of chloramphenicol,82415,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.3,,,,,,,fee schedule,11.4,69.93,APC
Assay of chloramphenicol,82415,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.18,,,,,,,fee schedule,11.4,69.93,APC
Assay of chloramphenicol,82415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.67,,,,,,,fee schedule,11.4,69.93,APC
Assay of chloramphenicol,82415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.39,,,,,,,fee schedule,11.4,69.93,Radiology
Assay of chloramphenicol,82415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.74,,,,,,,fee schedule,11.4,69.93,APC
Assay of chloramphenicol,82415,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22.17,,,,,,,fee schedule,11.4,69.93,APC
Assay of blood chloride,82435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,52.24,,,,,,,fee schedule,4.14,52.24,
Assay of blood chloride,82435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,41.87,,,,,,,fee schedule,4.14,52.24,
Assay of blood chloride,82435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,45.74,,,,,,,fee schedule,4.14,52.24,
Assay of blood chloride,82435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,48.09,,,,,,,fee schedule,4.14,52.24,
Assay of blood chloride,82435,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.14,,,,,,,fee schedule,4.14,52.24,Laboratory
Assay of blood chloride,82435,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.83,,,,,,,fee schedule,4.14,52.24,APC
Assay of blood chloride,82435,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4.78,,,,,,,fee schedule,4.14,52.24,APC
Assay of blood chloride,82435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4.6,,,,,,,fee schedule,4.14,52.24,APC
Assay of blood chloride,82435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.04,,,,,,,fee schedule,4.14,52.24,Radiology
Assay of blood chloride,82435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.44,,,,,,,fee schedule,4.14,52.24,APC
Assay of blood chloride,82435,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8.05,,,,,,,fee schedule,4.14,52.24,APC
Assay of urine chloride,82436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,64.41,,,,,,,fee schedule,5.18,64.41,
Assay of urine chloride,82436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.63,,,,,,,fee schedule,5.18,64.41,
Assay of urine chloride,82436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56.4,,,,,,,fee schedule,5.18,64.41,
Assay of urine chloride,82436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59.3,,,,,,,fee schedule,5.18,64.41,
Assay of urine chloride,82436,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.18,,,,,,,fee schedule,5.18,64.41,Laboratory
Assay of urine chloride,82436,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.04,,,,,,,fee schedule,5.18,64.41,APC
Assay of urine chloride,82436,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5.98,,,,,,,fee schedule,5.18,64.41,APC
Assay of urine chloride,82436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5.75,,,,,,,fee schedule,5.18,64.41,APC
Assay of urine chloride,82436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8.8,,,,,,,fee schedule,5.18,64.41,Radiology
Assay of urine chloride,82436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8.05,,,,,,,fee schedule,5.18,64.41,APC
Assay of urine chloride,82436,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10.06,,,,,,,fee schedule,5.18,64.41,APC
Assay other fluid chlorides,82438,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21.05,,,,,,,fee schedule,4.5,21.05,
Assay other fluid chlorides,82438,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.88,,,,,,,fee schedule,4.5,21.05,
Assay other fluid chlorides,82438,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18.44,,,,,,,fee schedule,4.5,21.05,
Assay other fluid chlorides,82438,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19.38,,,,,,,fee schedule,4.5,21.05,
Assay other fluid chlorides,82438,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.5,,,,,,,fee schedule,4.5,21.05,Laboratory
Assay other fluid chlorides,82438,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.25,,,,,,,fee schedule,4.5,21.05,APC
Assay other fluid chlorides,82438,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5.2,,,,,,,fee schedule,4.5,21.05,APC
Assay other fluid chlorides,82438,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5,,,,,,,fee schedule,4.5,21.05,APC
Assay other fluid chlorides,82438,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.65,,,,,,,fee schedule,4.5,21.05,Radiology
Assay other fluid chlorides,82438,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7,,,,,,,fee schedule,4.5,21.05,APC
Assay other fluid chlorides,82438,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8.75,,,,,,,fee schedule,4.5,21.05,APC
Test for chlorohydrocarbons,82441,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33.11,,,,,,,fee schedule,5.41,33.11,
Test for chlorohydrocarbons,82441,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26.54,,,,,,,fee schedule,5.41,33.11,
Test for chlorohydrocarbons,82441,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29,,,,,,,fee schedule,5.41,33.11,
Test for chlorohydrocarbons,82441,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30.48,,,,,,,fee schedule,5.41,33.11,
Test for chlorohydrocarbons,82441,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.41,,,,,,,fee schedule,5.41,33.11,Laboratory
Test for chlorohydrocarbons,82441,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.31,,,,,,,fee schedule,5.41,33.11,APC
Test for chlorohydrocarbons,82441,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6.25,,,,,,,fee schedule,5.41,33.11,APC
Test for chlorohydrocarbons,82441,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6.01,,,,,,,fee schedule,5.41,33.11,APC
Test for chlorohydrocarbons,82441,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.2,,,,,,,fee schedule,5.41,33.11,Radiology
Test for chlorohydrocarbons,82441,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8.41,,,,,,,fee schedule,5.41,33.11,APC
Test for chlorohydrocarbons,82441,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10.52,,,,,,,fee schedule,5.41,33.11,APC
Assay bld/serum cholesterol,82465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,40.47,,,,,,,fee schedule,3.92,40.47,
Assay bld/serum cholesterol,82465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32.44,,,,,,,fee schedule,3.92,40.47,
Assay bld/serum cholesterol,82465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35.44,,,,,,,fee schedule,3.92,40.47,
Assay bld/serum cholesterol,82465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37.26,,,,,,,fee schedule,3.92,40.47,
Assay bld/serum cholesterol,82465,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.91,,,,,,,fee schedule,3.92,40.47,Laboratory
Assay bld/serum cholesterol,82465,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.57,,,,,,,fee schedule,3.92,40.47,APC
Assay bld/serum cholesterol,82465,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4.52,,,,,,,fee schedule,3.92,40.47,APC
Assay bld/serum cholesterol,82465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4.35,,,,,,,fee schedule,3.92,40.47,APC
Assay bld/serum cholesterol,82465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.66,,,,,,,fee schedule,3.92,40.47,Radiology
Assay bld/serum cholesterol,82465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.09,,,,,,,fee schedule,3.92,40.47,APC
Assay bld/serum cholesterol,82465,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7.61,,,,,,,fee schedule,3.92,40.47,APC
Assay serum cholinesterase,82480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,43.51,,,,,,,fee schedule,7.08,43.51,
Assay serum cholinesterase,82480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,34.88,,,,,,,fee schedule,7.08,43.51,
Assay serum cholinesterase,82480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38.1,,,,,,,fee schedule,7.08,43.51,
Assay serum cholinesterase,82480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,40.05,,,,,,,fee schedule,7.08,43.51,
Assay serum cholinesterase,82480,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.08,,,,,,,fee schedule,7.08,43.51,Laboratory
Assay serum cholinesterase,82480,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.26,,,,,,,fee schedule,7.08,43.51,APC
Assay serum cholinesterase,82480,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8.18,,,,,,,fee schedule,7.08,43.51,APC
Assay serum cholinesterase,82480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7.87,,,,,,,fee schedule,7.08,43.51,APC
Assay serum cholinesterase,82480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12.04,,,,,,,fee schedule,7.08,43.51,Radiology
Assay serum cholinesterase,82480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11.02,,,,,,,fee schedule,7.08,43.51,APC
Assay serum cholinesterase,82480,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,13.77,,,,,,,fee schedule,7.08,43.51,APC
Assay rbc cholinesterase,82482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42.41,,,,,,,fee schedule,8.83,42.41,
Assay rbc cholinesterase,82482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,34,,,,,,,fee schedule,8.83,42.41,
Assay rbc cholinesterase,82482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37.14,,,,,,,fee schedule,8.83,42.41,
Assay rbc cholinesterase,82482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,39.05,,,,,,,fee schedule,8.83,42.41,
Assay rbc cholinesterase,82482,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.83,,,,,,,fee schedule,8.83,42.41,Laboratory
Assay rbc cholinesterase,82482,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.3,,,,,,,fee schedule,8.83,42.41,APC
Assay rbc cholinesterase,82482,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10.2,,,,,,,fee schedule,8.83,42.41,APC
Assay rbc cholinesterase,82482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9.81,,,,,,,fee schedule,8.83,42.41,APC
Assay rbc cholinesterase,82482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15.01,,,,,,,fee schedule,8.83,42.41,Radiology
Assay rbc cholinesterase,82482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.73,,,,,,,fee schedule,8.83,42.41,APC
Assay rbc cholinesterase,82482,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,17.17,,,,,,,fee schedule,8.83,42.41,APC
Assay chondroitin sulfate,82485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,113.97,,,,,,,fee schedule,18.58,113.97,
Assay chondroitin sulfate,82485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,91.35,,,,,,,fee schedule,18.58,113.97,
Assay chondroitin sulfate,82485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,99.8,,,,,,,fee schedule,18.58,113.97,
Assay chondroitin sulfate,82485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,104.92,,,,,,,fee schedule,18.58,113.97,
Assay chondroitin sulfate,82485,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.58,,,,,,,fee schedule,18.58,113.97,Laboratory
Assay chondroitin sulfate,82485,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.68,,,,,,,fee schedule,18.58,113.97,APC
Assay chondroitin sulfate,82485,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,21.48,,,,,,,fee schedule,18.58,113.97,APC
Assay chondroitin sulfate,82485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,20.65,,,,,,,fee schedule,18.58,113.97,APC
Assay chondroitin sulfate,82485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,31.59,,,,,,,fee schedule,18.58,113.97,Radiology
Assay chondroitin sulfate,82485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.91,,,,,,,fee schedule,18.58,113.97,APC
Assay chondroitin sulfate,82485,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,36.14,,,,,,,fee schedule,18.58,113.97,APC
Assay of chromium,82495,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,107.35,,,,,,,fee schedule,18.25,107.35,
Assay of chromium,82495,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,86.05,,,,,,,fee schedule,18.25,107.35,
Assay of chromium,82495,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,94,,,,,,,fee schedule,18.25,107.35,
Assay of chromium,82495,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,98.83,,,,,,,fee schedule,18.25,107.35,
Assay of chromium,82495,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.25,,,,,,,fee schedule,18.25,107.35,Laboratory
Assay of chromium,82495,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.29,,,,,,,fee schedule,18.25,107.35,APC
Assay of chromium,82495,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,21.09,,,,,,,fee schedule,18.25,107.35,APC
Assay of chromium,82495,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,20.28,,,,,,,fee schedule,18.25,107.35,APC
Assay of chromium,82495,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,31.03,,,,,,,fee schedule,18.25,107.35,Radiology
Assay of chromium,82495,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.39,,,,,,,fee schedule,18.25,107.35,APC
Assay of chromium,82495,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,35.49,,,,,,,fee schedule,18.25,107.35,APC
Assay of citrate,82507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,111.06,,,,,,,fee schedule,25.02,111.06,
Assay of citrate,82507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,89.02,,,,,,,fee schedule,25.02,111.06,
Assay of citrate,82507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,97.25,,,,,,,fee schedule,25.02,111.06,
Assay of citrate,82507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,102.24,,,,,,,fee schedule,25.02,111.06,
Assay of citrate,82507,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25.02,,,,,,,fee schedule,25.02,111.06,Laboratory
Assay of citrate,82507,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,29.19,,,,,,,fee schedule,25.02,111.06,APC
Assay of citrate,82507,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,28.91,,,,,,,fee schedule,25.02,111.06,APC
Assay of citrate,82507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,27.8,,,,,,,fee schedule,25.02,111.06,APC
Assay of citrate,82507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,42.53,,,,,,,fee schedule,25.02,111.06,Radiology
Assay of citrate,82507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,38.92,,,,,,,fee schedule,25.02,111.06,APC
Assay of citrate,82507,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,48.65,,,,,,,fee schedule,25.02,111.06,APC
Collagen crosslinks,82523,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,107.65,,,,,,,fee schedule,16.81,107.65,
Collagen crosslinks,82523,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,86.29,,,,,,,fee schedule,16.81,107.65,
Collagen crosslinks,82523,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,94.27,,,,,,,fee schedule,16.81,107.65,
Collagen crosslinks,82523,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,99.11,,,,,,,fee schedule,16.81,107.65,
Collagen crosslinks,82523,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.81,,,,,,,fee schedule,16.81,107.65,Laboratory
Collagen crosslinks,82523,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.61,,,,,,,fee schedule,16.81,107.65,APC
Collagen crosslinks,82523,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,19.43,,,,,,,fee schedule,16.81,107.65,APC
Collagen crosslinks,82523,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18.68,,,,,,,fee schedule,16.81,107.65,APC
Collagen crosslinks,82523,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.58,,,,,,,fee schedule,16.81,107.65,Radiology
Collagen crosslinks,82523,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26.15,,,,,,,fee schedule,16.81,107.65,APC
Collagen crosslinks,82523,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,32.69,,,,,,,fee schedule,16.81,107.65,APC
Assay of copper,82525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,90.33,,,,,,,fee schedule,11.17,90.33,
Assay of copper,82525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,72.41,,,,,,,fee schedule,11.17,90.33,
Assay of copper,82525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,79.1,,,,,,,fee schedule,11.17,90.33,
Assay of copper,82525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83.16,,,,,,,fee schedule,11.17,90.33,
Assay of copper,82525,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.17,,,,,,,fee schedule,11.17,90.33,Laboratory
Assay of copper,82525,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.03,,,,,,,fee schedule,11.17,90.33,APC
Assay of copper,82525,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.91,,,,,,,fee schedule,11.17,90.33,APC
Assay of copper,82525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.41,,,,,,,fee schedule,11.17,90.33,APC
Assay of copper,82525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.99,,,,,,,fee schedule,11.17,90.33,Radiology
Assay of copper,82525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.37,,,,,,,fee schedule,11.17,90.33,APC
Assay of copper,82525,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21.72,,,,,,,fee schedule,11.17,90.33,APC
Assay of corticosterone,82528,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,124.21,,,,,,,fee schedule,20.27,124.21,
Assay of corticosterone,82528,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,99.57,,,,,,,fee schedule,20.27,124.21,
Assay of corticosterone,82528,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,108.77,,,,,,,fee schedule,20.27,124.21,
Assay of corticosterone,82528,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,114.35,,,,,,,fee schedule,20.27,124.21,
Assay of corticosterone,82528,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,20.27,,,,,,,fee schedule,20.27,124.21,Laboratory
Assay of corticosterone,82528,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,23.65,,,,,,,fee schedule,20.27,124.21,APC
Assay of corticosterone,82528,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,23.42,,,,,,,fee schedule,20.27,124.21,APC
Assay of corticosterone,82528,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,22.52,,,,,,,fee schedule,20.27,124.21,APC
Assay of corticosterone,82528,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,34.46,,,,,,,fee schedule,20.27,124.21,Radiology
Assay of corticosterone,82528,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,31.53,,,,,,,fee schedule,20.27,124.21,APC
Assay of corticosterone,82528,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,39.41,,,,,,,fee schedule,20.27,124.21,APC
Cortisol free,82530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,141.41,,,,,,,fee schedule,15.04,141.41,
Cortisol free,82530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,113.36,,,,,,,fee schedule,15.04,141.41,
Cortisol free,82530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,123.83,,,,,,,fee schedule,15.04,141.41,
Cortisol free,82530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,130.19,,,,,,,fee schedule,15.04,141.41,
Cortisol free,82530,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.04,,,,,,,fee schedule,15.04,141.41,Laboratory
Cortisol free,82530,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.55,,,,,,,fee schedule,15.04,141.41,APC
Cortisol free,82530,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,17.38,,,,,,,fee schedule,15.04,141.41,APC
Cortisol free,82530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16.71,,,,,,,fee schedule,15.04,141.41,APC
Cortisol free,82530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.57,,,,,,,fee schedule,15.04,141.41,Radiology
Cortisol free,82530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.39,,,,,,,fee schedule,15.04,141.41,APC
Cortisol free,82530,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,29.24,,,,,,,fee schedule,15.04,141.41,APC
Total cortisol,82533,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,111.61,,,,,,,fee schedule,14.67,111.61,
Total cortisol,82533,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,89.47,,,,,,,fee schedule,14.67,111.61,
Total cortisol,82533,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,97.74,,,,,,,fee schedule,14.67,111.61,
Total cortisol,82533,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,102.76,,,,,,,fee schedule,14.67,111.61,
Total cortisol,82533,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.67,,,,,,,fee schedule,14.67,111.61,Laboratory
Total cortisol,82533,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.12,,,,,,,fee schedule,14.67,111.61,APC
Total cortisol,82533,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,16.95,,,,,,,fee schedule,14.67,111.61,APC
Total cortisol,82533,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16.3,,,,,,,fee schedule,14.67,111.61,APC
Total cortisol,82533,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24.94,,,,,,,fee schedule,14.67,111.61,Radiology
Total cortisol,82533,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.82,,,,,,,fee schedule,14.67,111.61,APC
Total cortisol,82533,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,28.52,,,,,,,fee schedule,14.67,111.61,APC
Assay of creatine,82540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,25.55,,,,,,,fee schedule,4.18,25.55,
Assay of creatine,82540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20.48,,,,,,,fee schedule,4.18,25.55,
Assay of creatine,82540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22.38,,,,,,,fee schedule,4.18,25.55,
Assay of creatine,82540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23.52,,,,,,,fee schedule,4.18,25.55,
Assay of creatine,82540,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.18,,,,,,,fee schedule,4.18,25.55,Laboratory
Assay of creatine,82540,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.87,,,,,,,fee schedule,4.18,25.55,APC
Assay of creatine,82540,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4.83,,,,,,,fee schedule,4.18,25.55,APC
Assay of creatine,82540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4.64,,,,,,,fee schedule,4.18,25.55,APC
Assay of creatine,82540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.1,,,,,,,fee schedule,4.18,25.55,Radiology
Assay of creatine,82540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.5,,,,,,,fee schedule,4.18,25.55,APC
Assay of creatine,82540,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8.12,,,,,,,fee schedule,4.18,25.55,APC
Col chromotography qual/quan,82542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,71.23,,,,,,,fee schedule,21.68,71.23,
Col chromotography qual/quan,82542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.09,,,,,,,fee schedule,21.68,71.23,
Col chromotography qual/quan,82542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,62.37,,,,,,,fee schedule,21.68,71.23,
Col chromotography qual/quan,82542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,65.57,,,,,,,fee schedule,21.68,71.23,
Col chromotography qual/quan,82542,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21.68,,,,,,,fee schedule,21.68,71.23,Laboratory
Col chromotography qual/quan,82542,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,25.29,,,,,,,fee schedule,21.68,71.23,APC
Col chromotography qual/quan,82542,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,25.05,,,,,,,fee schedule,21.68,71.23,APC
Col chromotography qual/quan,82542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,24.09,,,,,,,fee schedule,21.68,71.23,APC
Col chromotography qual/quan,82542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,36.86,,,,,,,fee schedule,21.68,71.23,Radiology
Col chromotography qual/quan,82542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,33.73,,,,,,,fee schedule,21.68,71.23,APC
Col chromotography qual/quan,82542,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,42.16,,,,,,,fee schedule,21.68,71.23,APC
Assay of ck (cpk),82550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,43.51,,,,,,,fee schedule,5.86,43.51,
Assay of ck (cpk),82550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,34.88,,,,,,,fee schedule,5.86,43.51,
Assay of ck (cpk),82550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38.1,,,,,,,fee schedule,5.86,43.51,
Assay of ck (cpk),82550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,40.06,,,,,,,fee schedule,5.86,43.51,
Assay of ck (cpk),82550,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.86,,,,,,,fee schedule,5.86,43.51,Laboratory
Assay of ck (cpk),82550,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.84,,,,,,,fee schedule,5.86,43.51,APC
Assay of ck (cpk),82550,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6.77,,,,,,,fee schedule,5.86,43.51,APC
Assay of ck (cpk),82550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6.51,,,,,,,fee schedule,5.86,43.51,APC
Assay of ck (cpk),82550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.96,,,,,,,fee schedule,5.86,43.51,Radiology
Assay of ck (cpk),82550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.11,,,,,,,fee schedule,5.86,43.51,APC
Assay of ck (cpk),82550,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11.39,,,,,,,fee schedule,5.86,43.51,APC
Assay of cpk in blood,82552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42.2,,,,,,,fee schedule,12.05,42.2,
Assay of cpk in blood,82552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,33.83,,,,,,,fee schedule,12.05,42.2,
Assay of cpk in blood,82552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36.95,,,,,,,fee schedule,12.05,42.2,
Assay of cpk in blood,82552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,38.85,,,,,,,fee schedule,12.05,42.2,
Assay of cpk in blood,82552,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.05,,,,,,,fee schedule,12.05,42.2,Laboratory
Assay of cpk in blood,82552,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.06,,,,,,,fee schedule,12.05,42.2,APC
Assay of cpk in blood,82552,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.93,,,,,,,fee schedule,12.05,42.2,APC
Assay of cpk in blood,82552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.39,,,,,,,fee schedule,12.05,42.2,APC
Assay of cpk in blood,82552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.49,,,,,,,fee schedule,12.05,42.2,Radiology
Assay of cpk in blood,82552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.75,,,,,,,fee schedule,12.05,42.2,APC
Assay of cpk in blood,82552,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23.43,,,,,,,fee schedule,12.05,42.2,APC
Creatine mb fraction,82553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,69.97,,,,,,,fee schedule,10.4,69.97,
Creatine mb fraction,82553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56.08,,,,,,,fee schedule,10.4,69.97,
Creatine mb fraction,82553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,61.27,,,,,,,fee schedule,10.4,69.97,
Creatine mb fraction,82553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,64.41,,,,,,,fee schedule,10.4,69.97,
Creatine mb fraction,82553,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.4,,,,,,,fee schedule,10.4,69.97,Laboratory
Creatine mb fraction,82553,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.13,,,,,,,fee schedule,10.4,69.97,APC
Creatine mb fraction,82553,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.01,,,,,,,fee schedule,10.4,69.97,APC
Creatine mb fraction,82553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11.55,,,,,,,fee schedule,10.4,69.97,APC
Creatine mb fraction,82553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.67,,,,,,,fee schedule,10.4,69.97,Radiology
Creatine mb fraction,82553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.17,,,,,,,fee schedule,10.4,69.97,APC
Creatine mb fraction,82553,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20.21,,,,,,,fee schedule,10.4,69.97,APC
Creatine isoforms,82554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,65.51,,,,,,,fee schedule,10.68,65.51,
Creatine isoforms,82554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52.51,,,,,,,fee schedule,10.68,65.51,
Creatine isoforms,82554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.36,,,,,,,fee schedule,10.68,65.51,
Creatine isoforms,82554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.31,,,,,,,fee schedule,10.68,65.51,
Creatine isoforms,82554,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.68,,,,,,,fee schedule,10.68,65.51,Laboratory
Creatine isoforms,82554,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.46,,,,,,,fee schedule,10.68,65.51,APC
Creatine isoforms,82554,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.34,,,,,,,fee schedule,10.68,65.51,APC
Creatine isoforms,82554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11.87,,,,,,,fee schedule,10.68,65.51,APC
Creatine isoforms,82554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.16,,,,,,,fee schedule,10.68,65.51,Radiology
Creatine isoforms,82554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.62,,,,,,,fee schedule,10.68,65.51,APC
Creatine isoforms,82554,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20.77,,,,,,,fee schedule,10.68,65.51,APC
Assay of creatinine,82565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55.96,,,,,,,fee schedule,4.61,55.96,
Assay of creatinine,82565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,44.86,,,,,,,fee schedule,4.61,55.96,
Assay of creatinine,82565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,49,,,,,,,fee schedule,4.61,55.96,
Assay of creatinine,82565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,51.52,,,,,,,fee schedule,4.61,55.96,
Assay of creatinine,82565,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.61,,,,,,,fee schedule,4.61,55.96,Laboratory
Assay of creatinine,82565,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.38,,,,,,,fee schedule,4.61,55.96,APC
Assay of creatinine,82565,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5.32,,,,,,,fee schedule,4.61,55.96,APC
Assay of creatinine,82565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5.12,,,,,,,fee schedule,4.61,55.96,APC
Assay of creatinine,82565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.83,,,,,,,fee schedule,4.61,55.96,Radiology
Assay of creatinine,82565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.17,,,,,,,fee schedule,4.61,55.96,APC
Assay of creatinine,82565,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8.96,,,,,,,fee schedule,4.61,55.96,APC
Assay of urine creatinine,82570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46.55,,,,,,,fee schedule,4.66,46.55,
Assay of urine creatinine,82570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37.32,,,,,,,fee schedule,4.66,46.55,
Assay of urine creatinine,82570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40.77,,,,,,,fee schedule,4.66,46.55,
Assay of urine creatinine,82570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42.86,,,,,,,fee schedule,4.66,46.55,
Assay of urine creatinine,82570,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.66,,,,,,,fee schedule,4.66,46.55,Laboratory
Assay of urine creatinine,82570,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.44,,,,,,,fee schedule,4.66,46.55,APC
Assay of urine creatinine,82570,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5.39,,,,,,,fee schedule,4.66,46.55,APC
Assay of urine creatinine,82570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5.18,,,,,,,fee schedule,4.66,46.55,APC
Assay of urine creatinine,82570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.93,,,,,,,fee schedule,4.66,46.55,Radiology
Assay of urine creatinine,82570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.25,,,,,,,fee schedule,4.66,46.55,APC
Assay of urine creatinine,82570,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9.06,,,,,,,fee schedule,4.66,46.55,APC
Creatinine clearance test,82575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,52.57,,,,,,,fee schedule,8.51,52.57,
Creatinine clearance test,82575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.14,,,,,,,fee schedule,8.51,52.57,
Creatinine clearance test,82575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.03,,,,,,,fee schedule,8.51,52.57,
Creatinine clearance test,82575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,48.4,,,,,,,fee schedule,8.51,52.57,
Creatinine clearance test,82575,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.51,,,,,,,fee schedule,8.51,52.57,Laboratory
Creatinine clearance test,82575,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.93,,,,,,,fee schedule,8.51,52.57,APC
Creatinine clearance test,82575,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9.84,,,,,,,fee schedule,8.51,52.57,APC
Creatinine clearance test,82575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9.46,,,,,,,fee schedule,8.51,52.57,APC
Creatinine clearance test,82575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.47,,,,,,,fee schedule,8.51,52.57,Radiology
Creatinine clearance test,82575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.24,,,,,,,fee schedule,8.51,52.57,APC
Creatinine clearance test,82575,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16.56,,,,,,,fee schedule,8.51,52.57,APC
Assay of cryofibrinogen,82585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,47.33,,,,,,,fee schedule,12.73,47.33,
Assay of cryofibrinogen,82585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37.94,,,,,,,fee schedule,12.73,47.33,
Assay of cryofibrinogen,82585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,41.44,,,,,,,fee schedule,12.73,47.33,
Assay of cryofibrinogen,82585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,43.57,,,,,,,fee schedule,12.73,47.33,
Assay of cryofibrinogen,82585,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.73,,,,,,,fee schedule,12.73,47.33,Laboratory
Assay of cryofibrinogen,82585,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.85,,,,,,,fee schedule,12.73,47.33,APC
Assay of cryofibrinogen,82585,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,14.71,,,,,,,fee schedule,12.73,47.33,APC
Assay of cryofibrinogen,82585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14.14,,,,,,,fee schedule,12.73,47.33,APC
Assay of cryofibrinogen,82585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21.63,,,,,,,fee schedule,12.73,47.33,Radiology
Assay of cryofibrinogen,82585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.8,,,,,,,fee schedule,12.73,47.33,APC
Assay of cryofibrinogen,82585,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,24.74,,,,,,,fee schedule,12.73,47.33,APC
Assay of cryoglobulin,82595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19.99,,,,,,,fee schedule,5.82,19.99,
Assay of cryoglobulin,82595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.02,,,,,,,fee schedule,5.82,19.99,
Assay of cryoglobulin,82595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17.5,,,,,,,fee schedule,5.82,19.99,
Assay of cryoglobulin,82595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18.4,,,,,,,fee schedule,5.82,19.99,
Assay of cryoglobulin,82595,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.82,,,,,,,fee schedule,5.82,19.99,Laboratory
Assay of cryoglobulin,82595,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.79,,,,,,,fee schedule,5.82,19.99,APC
Assay of cryoglobulin,82595,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6.73,,,,,,,fee schedule,5.82,19.99,APC
Assay of cryoglobulin,82595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6.47,,,,,,,fee schedule,5.82,19.99,APC
Assay of cryoglobulin,82595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.9,,,,,,,fee schedule,5.82,19.99,Radiology
Assay of cryoglobulin,82595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.06,,,,,,,fee schedule,5.82,19.99,APC
Assay of cryoglobulin,82595,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11.32,,,,,,,fee schedule,5.82,19.99,APC
Assay of cyanide,82600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,107.09,,,,,,,fee schedule,17.46,107.09,
Assay of cyanide,82600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,85.84,,,,,,,fee schedule,17.46,107.09,
Assay of cyanide,82600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,93.77,,,,,,,fee schedule,17.46,107.09,
Assay of cyanide,82600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,98.59,,,,,,,fee schedule,17.46,107.09,
Assay of cyanide,82600,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.46,,,,,,,fee schedule,17.46,107.09,Laboratory
Assay of cyanide,82600,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20.37,,,,,,,fee schedule,17.46,107.09,APC
Assay of cyanide,82600,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,20.18,,,,,,,fee schedule,17.46,107.09,APC
Assay of cyanide,82600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,19.4,,,,,,,fee schedule,17.46,107.09,APC
Assay of cyanide,82600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29.68,,,,,,,fee schedule,17.46,107.09,Radiology
Assay of cyanide,82600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27.16,,,,,,,fee schedule,17.46,107.09,APC
Assay of cyanide,82600,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,33.95,,,,,,,fee schedule,17.46,107.09,APC
Vitamin B-12,82607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,82.89,,,,,,,fee schedule,13.57,82.89,
Vitamin B-12,82607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66.44,,,,,,,fee schedule,13.57,82.89,
Vitamin B-12,82607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,72.58,,,,,,,fee schedule,13.57,82.89,
Vitamin B-12,82607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,76.31,,,,,,,fee schedule,13.57,82.89,
Vitamin B-12,82607,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.57,,,,,,,fee schedule,13.57,82.89,Laboratory
Vitamin B-12,82607,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.83,,,,,,,fee schedule,13.57,82.89,APC
Vitamin B-12,82607,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,15.68,,,,,,,fee schedule,13.57,82.89,APC
Vitamin B-12,82607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,15.08,,,,,,,fee schedule,13.57,82.89,APC
Vitamin B-12,82607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.07,,,,,,,fee schedule,13.57,82.89,Radiology
Vitamin B-12,82607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21.11,,,,,,,fee schedule,13.57,82.89,APC
Vitamin B-12,82607,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,26.39,,,,,,,fee schedule,13.57,82.89,APC
B-12 binding capacity,82608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,79.04,,,,,,,fee schedule,12.89,79.04,
B-12 binding capacity,82608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,63.36,,,,,,,fee schedule,12.89,79.04,
B-12 binding capacity,82608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,69.21,,,,,,,fee schedule,12.89,79.04,
B-12 binding capacity,82608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,72.77,,,,,,,fee schedule,12.89,79.04,
B-12 binding capacity,82608,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.89,,,,,,,fee schedule,12.89,79.04,Laboratory
B-12 binding capacity,82608,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.04,,,,,,,fee schedule,12.89,79.04,APC
B-12 binding capacity,82608,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,14.89,,,,,,,fee schedule,12.89,79.04,APC
B-12 binding capacity,82608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14.32,,,,,,,fee schedule,12.89,79.04,APC
B-12 binding capacity,82608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21.91,,,,,,,fee schedule,12.89,79.04,Radiology
B-12 binding capacity,82608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.05,,,,,,,fee schedule,12.89,79.04,APC
B-12 binding capacity,82608,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,25.06,,,,,,,fee schedule,12.89,79.04,APC
Cystatin c,82610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45.16,,,,,,,fee schedule,16.67,45.16,
Cystatin c,82610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36.2,,,,,,,fee schedule,16.67,45.16,
Cystatin c,82610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39.55,,,,,,,fee schedule,16.67,45.16,
Cystatin c,82610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41.58,,,,,,,fee schedule,16.67,45.16,
Cystatin c,82610,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.67,,,,,,,fee schedule,16.67,45.16,Laboratory
Cystatin c,82610,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.45,,,,,,,fee schedule,16.67,45.16,APC
Cystatin c,82610,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,19.26,,,,,,,fee schedule,16.67,45.16,APC
Cystatin c,82610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18.52,,,,,,,fee schedule,16.67,45.16,APC
Cystatin c,82610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.34,,,,,,,fee schedule,16.67,45.16,Radiology
Cystatin c,82610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.93,,,,,,,fee schedule,16.67,45.16,APC
Cystatin c,82610,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,32.41,,,,,,,fee schedule,16.67,45.16,APC
Test for urine cystines,82615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45.06,,,,,,,fee schedule,8.6,45.06,
Test for urine cystines,82615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36.12,,,,,,,fee schedule,8.6,45.06,
Test for urine cystines,82615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39.46,,,,,,,fee schedule,8.6,45.06,
Test for urine cystines,82615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41.48,,,,,,,fee schedule,8.6,45.06,
Test for urine cystines,82615,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.6,,,,,,,fee schedule,8.6,45.06,Laboratory
Test for urine cystines,82615,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.03,,,,,,,fee schedule,8.6,45.06,APC
Test for urine cystines,82615,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9.93,,,,,,,fee schedule,8.6,45.06,APC
Test for urine cystines,82615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9.55,,,,,,,fee schedule,8.6,45.06,APC
Test for urine cystines,82615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.61,,,,,,,fee schedule,8.6,45.06,Radiology
Test for urine cystines,82615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.37,,,,,,,fee schedule,8.6,45.06,APC
Test for urine cystines,82615,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16.71,,,,,,,fee schedule,8.6,45.06,APC
Dehydroepiandrosterone,82626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,215.45,,,,,,,fee schedule,22.74,215.45,
Dehydroepiandrosterone,82626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,172.7,,,,,,,fee schedule,22.74,215.45,
Dehydroepiandrosterone,82626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,188.66,,,,,,,fee schedule,22.74,215.45,
Dehydroepiandrosterone,82626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,198.35,,,,,,,fee schedule,22.74,215.45,
Dehydroepiandrosterone,82626,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22.74,,,,,,,fee schedule,22.74,215.45,Laboratory
Dehydroepiandrosterone,82626,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,26.53,,,,,,,fee schedule,22.74,215.45,APC
Dehydroepiandrosterone,82626,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,26.28,,,,,,,fee schedule,22.74,215.45,APC
Dehydroepiandrosterone,82626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,25.27,,,,,,,fee schedule,22.74,215.45,APC
Dehydroepiandrosterone,82626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,38.66,,,,,,,fee schedule,22.74,215.45,Radiology
Dehydroepiandrosterone,82626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,35.38,,,,,,,fee schedule,22.74,215.45,APC
Dehydroepiandrosterone,82626,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,44.22,,,,,,,fee schedule,22.74,215.45,APC
Dehydroepiandrosterone,82627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,77.25,,,,,,,fee schedule,20.01,77.25,
Dehydroepiandrosterone,82627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,61.92,,,,,,,fee schedule,20.01,77.25,
Dehydroepiandrosterone,82627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,67.64,,,,,,,fee schedule,20.01,77.25,
Dehydroepiandrosterone,82627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,71.12,,,,,,,fee schedule,20.01,77.25,
Dehydroepiandrosterone,82627,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,20.01,,,,,,,fee schedule,20.01,77.25,Laboratory
Dehydroepiandrosterone,82627,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,23.34,,,,,,,fee schedule,20.01,77.25,APC
Dehydroepiandrosterone,82627,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,23.12,,,,,,,fee schedule,20.01,77.25,APC
Dehydroepiandrosterone,82627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,22.23,,,,,,,fee schedule,20.01,77.25,APC
Dehydroepiandrosterone,82627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,34.01,,,,,,,fee schedule,20.01,77.25,Radiology
Dehydroepiandrosterone,82627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,31.12,,,,,,,fee schedule,20.01,77.25,APC
Dehydroepiandrosterone,82627,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,38.9,,,,,,,fee schedule,20.01,77.25,APC
Desoxycorticosterone,82633,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,170.97,,,,,,,fee schedule,27.88,170.97,
Desoxycorticosterone,82633,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,137.05,,,,,,,fee schedule,27.88,170.97,
Desoxycorticosterone,82633,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,149.71,,,,,,,fee schedule,27.88,170.97,
Desoxycorticosterone,82633,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,157.4,,,,,,,fee schedule,27.88,170.97,
Desoxycorticosterone,82633,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,27.88,,,,,,,fee schedule,27.88,170.97,Laboratory
Desoxycorticosterone,82633,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,32.53,,,,,,,fee schedule,27.88,170.97,APC
Desoxycorticosterone,82633,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,32.22,,,,,,,fee schedule,27.88,170.97,APC
Desoxycorticosterone,82633,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,30.98,,,,,,,fee schedule,27.88,170.97,APC
Desoxycorticosterone,82633,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,47.4,,,,,,,fee schedule,27.88,170.97,Radiology
Desoxycorticosterone,82633,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43.37,,,,,,,fee schedule,27.88,170.97,APC
Desoxycorticosterone,82633,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,54.22,,,,,,,fee schedule,27.88,170.97,APC
Deoxycortisol,82634,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,161.56,,,,,,,fee schedule,26.35,161.56,
Deoxycortisol,82634,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,129.5,,,,,,,fee schedule,26.35,161.56,
Deoxycortisol,82634,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,141.47,,,,,,,fee schedule,26.35,161.56,
Deoxycortisol,82634,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,148.74,,,,,,,fee schedule,26.35,161.56,
Deoxycortisol,82634,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26.35,,,,,,,fee schedule,26.35,161.56,Laboratory
Deoxycortisol,82634,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.74,,,,,,,fee schedule,26.35,161.56,APC
Deoxycortisol,82634,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,30.45,,,,,,,fee schedule,26.35,161.56,APC
Deoxycortisol,82634,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,29.28,,,,,,,fee schedule,26.35,161.56,APC
Deoxycortisol,82634,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,44.8,,,,,,,fee schedule,26.35,161.56,Radiology
Deoxycortisol,82634,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40.99,,,,,,,fee schedule,26.35,161.56,APC
Deoxycortisol,82634,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,51.24,,,,,,,fee schedule,26.35,161.56,APC
Assay of dibucaine number,82638,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,67.59,,,,,,,fee schedule,11.02,67.59,
Assay of dibucaine number,82638,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,54.18,,,,,,,fee schedule,11.02,67.59,
Assay of dibucaine number,82638,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,59.18,,,,,,,fee schedule,11.02,67.59,
Assay of dibucaine number,82638,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,62.22,,,,,,,fee schedule,11.02,67.59,
Assay of dibucaine number,82638,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.02,,,,,,,fee schedule,11.02,67.59,Laboratory
Assay of dibucaine number,82638,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.86,,,,,,,fee schedule,11.02,67.59,APC
Assay of dibucaine number,82638,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.74,,,,,,,fee schedule,11.02,67.59,APC
Assay of dibucaine number,82638,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.25,,,,,,,fee schedule,11.02,67.59,APC
Assay of dibucaine number,82638,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.74,,,,,,,fee schedule,11.02,67.59,Radiology
Assay of dibucaine number,82638,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.15,,,,,,,fee schedule,11.02,67.59,APC
Assay of dibucaine number,82638,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21.44,,,,,,,fee schedule,11.02,67.59,APC
Dihydrotestosterone,82642,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26.35,,,,,,,fee schedule,26.35,51.24,Laboratory
Dihydrotestosterone,82642,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.74,,,,,,,fee schedule,26.35,51.24,APC
Dihydrotestosterone,82642,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,30.45,,,,,,,fee schedule,26.35,51.24,APC
Dihydrotestosterone,82642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,29.28,,,,,,,fee schedule,26.35,51.24,APC
Dihydrotestosterone,82642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,44.8,,,,,,,fee schedule,26.35,51.24,Radiology
Dihydrotestosterone,82642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40.99,,,,,,,fee schedule,26.35,51.24,APC
Dihydrotestosterone,82642,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,51.24,,,,,,,fee schedule,26.35,51.24,APC
Vit d 1 25-dihydroxy,82652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,439.79,,,,,,,fee schedule,34.65,439.79,
Vit d 1 25-dihydroxy,82652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,352.53,,,,,,,fee schedule,34.65,439.79,
Vit d 1 25-dihydroxy,82652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,385.11,,,,,,,fee schedule,34.65,439.79,
Vit d 1 25-dihydroxy,82652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,404.89,,,,,,,fee schedule,34.65,439.79,
Vit d 1 25-dihydroxy,82652,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,34.65,,,,,,,fee schedule,34.65,439.79,Laboratory
Vit d 1 25-dihydroxy,82652,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,40.43,,,,,,,fee schedule,34.65,439.79,APC
Vit d 1 25-dihydroxy,82652,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,40.04,,,,,,,fee schedule,34.65,439.79,APC
Vit d 1 25-dihydroxy,82652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,38.5,,,,,,,fee schedule,34.65,439.79,APC
Vit d 1 25-dihydroxy,82652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,58.9,,,,,,,fee schedule,34.65,439.79,Radiology
Vit d 1 25-dihydroxy,82652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,53.9,,,,,,,fee schedule,34.65,439.79,APC
Vit d 1 25-dihydroxy,82652,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,67.38,,,,,,,fee schedule,34.65,439.79,APC
El-1 fecal quantitative,82653,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,86.83,,,,,,,fee schedule,20.67,86.83,
El-1 fecal quantitative,82653,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,69.6,,,,,,,fee schedule,20.67,86.83,
El-1 fecal quantitative,82653,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,76.03,,,,,,,fee schedule,20.67,86.83,
El-1 fecal quantitative,82653,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,79.94,,,,,,,fee schedule,20.67,86.83,
El-1 fecal quantitative,82653,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,20.67,,,,,,,fee schedule,20.67,86.83,Laboratory
El-1 fecal quantitative,82653,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,24.12,,,,,,,fee schedule,20.67,86.83,APC
El-1 fecal quantitative,82653,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,23.89,,,,,,,fee schedule,20.67,86.83,APC
El-1 fecal quantitative,82653,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,22.97,,,,,,,fee schedule,20.67,86.83,APC
El-1 fecal quantitative,82653,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,35.14,,,,,,,fee schedule,20.67,86.83,Radiology
El-1 fecal quantitative,82653,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,32.16,,,,,,,fee schedule,20.67,86.83,APC
El-1 fecal quantitative,82653,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,40.2,,,,,,,fee schedule,20.67,86.83,APC
Pancreatic elastase fecal,82656,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,63.69,,,,,,,fee schedule,10.38,63.69,
Pancreatic elastase fecal,82656,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.06,,,,,,,fee schedule,10.38,63.69,
Pancreatic elastase fecal,82656,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55.77,,,,,,,fee schedule,10.38,63.69,
Pancreatic elastase fecal,82656,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,58.64,,,,,,,fee schedule,10.38,63.69,
Pancreatic elastase fecal,82656,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.38,,,,,,,fee schedule,10.38,63.69,Laboratory
Pancreatic elastase fecal,82656,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.11,,,,,,,fee schedule,10.38,63.69,APC
Pancreatic elastase fecal,82656,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11.99,,,,,,,fee schedule,10.38,63.69,APC
Pancreatic elastase fecal,82656,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11.53,,,,,,,fee schedule,10.38,63.69,APC
Pancreatic elastase fecal,82656,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.64,,,,,,,fee schedule,10.38,63.69,Radiology
Pancreatic elastase fecal,82656,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.14,,,,,,,fee schedule,10.38,63.69,APC
Pancreatic elastase fecal,82656,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20.18,,,,,,,fee schedule,10.38,63.69,APC
Enzyme cell activity,82657,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,63.67,,,,,,,fee schedule,19.95,63.67,
Enzyme cell activity,82657,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.04,,,,,,,fee schedule,19.95,63.67,
Enzyme cell activity,82657,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55.76,,,,,,,fee schedule,19.95,63.67,
Enzyme cell activity,82657,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,58.62,,,,,,,fee schedule,19.95,63.67,
Enzyme cell activity,82657,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.95,,,,,,,fee schedule,19.95,63.67,Laboratory
Enzyme cell activity,82657,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,23.28,,,,,,,fee schedule,19.95,63.67,APC
Enzyme cell activity,82657,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,23.06,,,,,,,fee schedule,19.95,63.67,APC
Enzyme cell activity,82657,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,22.17,,,,,,,fee schedule,19.95,63.67,APC
Enzyme cell activity,82657,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,33.92,,,,,,,fee schedule,19.95,63.67,Radiology
Enzyme cell activity,82657,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,31.04,,,,,,,fee schedule,19.95,63.67,APC
Enzyme cell activity,82657,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,38.8,,,,,,,fee schedule,19.95,63.67,APC
Enzyme cell activity ra,82658,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,99.68,,,,,,,fee schedule,39.63,99.68,
Enzyme cell activity ra,82658,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,79.9,,,,,,,fee schedule,39.63,99.68,
Enzyme cell activity ra,82658,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,87.28,,,,,,,fee schedule,39.63,99.68,
Enzyme cell activity ra,82658,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,91.77,,,,,,,fee schedule,39.63,99.68,
Enzyme cell activity ra,82658,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,39.63,,,,,,,fee schedule,39.63,99.68,Laboratory
Enzyme cell activity ra,82658,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,46.23,,,,,,,fee schedule,39.63,99.68,APC
Enzyme cell activity ra,82658,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,45.79,,,,,,,fee schedule,39.63,99.68,APC
Enzyme cell activity ra,82658,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,44.03,,,,,,,fee schedule,39.63,99.68,APC
Enzyme cell activity ra,82658,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,67.37,,,,,,,fee schedule,39.63,99.68,Radiology
Enzyme cell activity ra,82658,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,61.64,,,,,,,fee schedule,39.63,99.68,APC
Enzyme cell activity ra,82658,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,77.05,,,,,,,fee schedule,39.63,99.68,APC
Electrophoretic test,82664,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,189.6,,,,,,,fee schedule,55.35,189.6,
Electrophoretic test,82664,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,151.98,,,,,,,fee schedule,55.35,189.6,
Electrophoretic test,82664,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,166.03,,,,,,,fee schedule,55.35,189.6,
Electrophoretic test,82664,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,174.56,,,,,,,fee schedule,55.35,189.6,
Electrophoretic test,82664,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,55.35,,,,,,,fee schedule,55.35,189.6,Laboratory
Electrophoretic test,82664,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,64.58,,,,,,,fee schedule,55.35,189.6,APC
Electrophoretic test,82664,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,63.96,,,,,,,fee schedule,55.35,189.6,APC
Electrophoretic test,82664,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,61.5,,,,,,,fee schedule,55.35,189.6,APC
Electrophoretic test,82664,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,94.1,,,,,,,fee schedule,55.35,189.6,Radiology
Electrophoretic test,82664,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,86.1,,,,,,,fee schedule,55.35,189.6,APC
Electrophoretic test,82664,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,107.62,,,,,,,fee schedule,55.35,189.6,APC
Assay of erythropoietin,82668,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,138.64,,,,,,,fee schedule,16.91,138.64,
Assay of erythropoietin,82668,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,111.13,,,,,,,fee schedule,16.91,138.64,
Assay of erythropoietin,82668,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,121.4,,,,,,,fee schedule,16.91,138.64,
Assay of erythropoietin,82668,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,127.64,,,,,,,fee schedule,16.91,138.64,
Assay of erythropoietin,82668,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.91,,,,,,,fee schedule,16.91,138.64,Laboratory
Assay of erythropoietin,82668,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.73,,,,,,,fee schedule,16.91,138.64,APC
Assay of erythropoietin,82668,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,19.54,,,,,,,fee schedule,16.91,138.64,APC
Assay of erythropoietin,82668,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18.79,,,,,,,fee schedule,16.91,138.64,APC
Assay of erythropoietin,82668,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.75,,,,,,,fee schedule,16.91,138.64,Radiology
Assay of erythropoietin,82668,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26.31,,,,,,,fee schedule,16.91,138.64,APC
Assay of erythropoietin,82668,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,32.88,,,,,,,fee schedule,16.91,138.64,APC
Assay of estradiol,82670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,150.97,,,,,,,fee schedule,25.15,150.97,
Assay of estradiol,82670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,121.02,,,,,,,fee schedule,25.15,150.97,
Assay of estradiol,82670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,132.2,,,,,,,fee schedule,25.15,150.97,
Assay of estradiol,82670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,138.99,,,,,,,fee schedule,25.15,150.97,
Assay of estradiol,82670,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25.15,,,,,,,fee schedule,25.15,150.97,Laboratory
Assay of estradiol,82670,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,29.34,,,,,,,fee schedule,25.15,150.97,APC
Assay of estradiol,82670,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,29.06,,,,,,,fee schedule,25.15,150.97,APC
Assay of estradiol,82670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,27.94,,,,,,,fee schedule,25.15,150.97,APC
Assay of estradiol,82670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,42.75,,,,,,,fee schedule,25.15,150.97,Radiology
Assay of estradiol,82670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,39.12,,,,,,,fee schedule,25.15,150.97,APC
Assay of estradiol,82670,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,48.9,,,,,,,fee schedule,25.15,150.97,APC
Assay of estrogens,82671,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,111.06,,,,,,,fee schedule,29.07,111.06,
Assay of estrogens,82671,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,89.02,,,,,,,fee schedule,29.07,111.06,
Assay of estrogens,82671,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,97.25,,,,,,,fee schedule,29.07,111.06,
Assay of estrogens,82671,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,102.24,,,,,,,fee schedule,29.07,111.06,
Assay of estrogens,82671,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,29.07,,,,,,,fee schedule,29.07,111.06,Laboratory
Assay of estrogens,82671,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,33.92,,,,,,,fee schedule,29.07,111.06,APC
Assay of estrogens,82671,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,33.59,,,,,,,fee schedule,29.07,111.06,APC
Assay of estrogens,82671,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,32.3,,,,,,,fee schedule,29.07,111.06,APC
Assay of estrogens,82671,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49.42,,,,,,,fee schedule,29.07,111.06,Radiology
Assay of estrogens,82671,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,45.22,,,,,,,fee schedule,29.07,111.06,APC
Assay of estrogens,82671,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,56.52,,,,,,,fee schedule,29.07,111.06,APC
Assay of estrogen,82672,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,119.67,,,,,,,fee schedule,19.53,119.67,
Assay of estrogen,82672,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,95.93,,,,,,,fee schedule,19.53,119.67,
Assay of estrogen,82672,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,104.79,,,,,,,fee schedule,19.53,119.67,
Assay of estrogen,82672,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,110.18,,,,,,,fee schedule,19.53,119.67,
Assay of estrogen,82672,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.53,,,,,,,fee schedule,19.53,119.67,Laboratory
Assay of estrogen,82672,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,22.78,,,,,,,fee schedule,19.53,119.67,APC
Assay of estrogen,82672,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,22.57,,,,,,,fee schedule,19.53,119.67,APC
Assay of estrogen,82672,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,21.7,,,,,,,fee schedule,19.53,119.67,APC
Assay of estrogen,82672,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,33.2,,,,,,,fee schedule,19.53,119.67,Radiology
Assay of estrogen,82672,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,30.38,,,,,,,fee schedule,19.53,119.67,APC
Assay of estrogen,82672,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,37.98,,,,,,,fee schedule,19.53,119.67,APC
Assay of estriol,82677,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,93.59,,,,,,,fee schedule,21.76,93.59,
Assay of estriol,82677,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,75.02,,,,,,,fee schedule,21.76,93.59,
Assay of estriol,82677,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,81.95,,,,,,,fee schedule,21.76,93.59,
Assay of estriol,82677,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,86.16,,,,,,,fee schedule,21.76,93.59,
Assay of estriol,82677,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21.76,,,,,,,fee schedule,21.76,93.59,Laboratory
Assay of estriol,82677,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,25.39,,,,,,,fee schedule,21.76,93.59,APC
Assay of estriol,82677,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,25.15,,,,,,,fee schedule,21.76,93.59,APC
Assay of estriol,82677,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,24.18,,,,,,,fee schedule,21.76,93.59,APC
Assay of estriol,82677,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,37,,,,,,,fee schedule,21.76,93.59,Radiology
Assay of estriol,82677,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,33.85,,,,,,,fee schedule,21.76,93.59,APC
Assay of estriol,82677,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,42.32,,,,,,,fee schedule,21.76,93.59,APC
Assay of estrone,82679,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,77.74,,,,,,,fee schedule,22.46,77.74,
Assay of estrone,82679,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,62.32,,,,,,,fee schedule,22.46,77.74,
Assay of estrone,82679,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,68.07,,,,,,,fee schedule,22.46,77.74,
Assay of estrone,82679,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,71.57,,,,,,,fee schedule,22.46,77.74,
Assay of estrone,82679,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22.46,,,,,,,fee schedule,22.46,77.74,Laboratory
Assay of estrone,82679,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,26.2,,,,,,,fee schedule,22.46,77.74,APC
Assay of estrone,82679,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,25.95,,,,,,,fee schedule,22.46,77.74,APC
Assay of estrone,82679,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,24.95,,,,,,,fee schedule,22.46,77.74,APC
Assay of estrone,82679,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,38.17,,,,,,,fee schedule,22.46,77.74,Radiology
Assay of estrone,82679,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,34.93,,,,,,,fee schedule,22.46,77.74,APC
Assay of estrone,82679,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,43.66,,,,,,,fee schedule,22.46,77.74,APC
Assay dir meas fr estradiol,82681,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25.15,,,,,,,fee schedule,25.15,48.9,Laboratory
Assay dir meas fr estradiol,82681,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,29.34,,,,,,,fee schedule,25.15,48.9,APC
Assay dir meas fr estradiol,82681,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,29.06,,,,,,,fee schedule,25.15,48.9,APC
Assay dir meas fr estradiol,82681,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,27.94,,,,,,,fee schedule,25.15,48.9,APC
Assay dir meas fr estradiol,82681,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,42.75,,,,,,,fee schedule,25.15,48.9,Radiology
Assay dir meas fr estradiol,82681,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,39.12,,,,,,,fee schedule,25.15,48.9,APC
Assay dir meas fr estradiol,82681,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,48.9,,,,,,,fee schedule,25.15,48.9,APC
Assay of ethylene glycol,82693,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,136.48,,,,,,,fee schedule,13.41,136.48,
Assay of ethylene glycol,82693,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,109.4,,,,,,,fee schedule,13.41,136.48,
Assay of ethylene glycol,82693,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,119.51,,,,,,,fee schedule,13.41,136.48,
Assay of ethylene glycol,82693,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,125.65,,,,,,,fee schedule,13.41,136.48,
Assay of ethylene glycol,82693,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.41,,,,,,,fee schedule,13.41,136.48,Laboratory
Assay of ethylene glycol,82693,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.65,,,,,,,fee schedule,13.41,136.48,APC
Assay of ethylene glycol,82693,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,15.5,,,,,,,fee schedule,13.41,136.48,APC
Assay of ethylene glycol,82693,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14.9,,,,,,,fee schedule,13.41,136.48,APC
Assay of ethylene glycol,82693,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.8,,,,,,,fee schedule,13.41,136.48,Radiology
Assay of ethylene glycol,82693,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.86,,,,,,,fee schedule,13.41,136.48,APC
Assay of ethylene glycol,82693,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,26.08,,,,,,,fee schedule,13.41,136.48,APC
Assay of etiocholanolone,82696,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,130.15,,,,,,,fee schedule,23.62,130.15,
Assay of etiocholanolone,82696,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,104.32,,,,,,,fee schedule,23.62,130.15,
Assay of etiocholanolone,82696,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,113.96,,,,,,,fee schedule,23.62,130.15,
Assay of etiocholanolone,82696,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,119.82,,,,,,,fee schedule,23.62,130.15,
Assay of etiocholanolone,82696,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23.62,,,,,,,fee schedule,23.62,130.15,Laboratory
Assay of etiocholanolone,82696,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,27.55,,,,,,,fee schedule,23.62,130.15,APC
Assay of etiocholanolone,82696,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,27.29,,,,,,,fee schedule,23.62,130.15,APC
Assay of etiocholanolone,82696,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,26.24,,,,,,,fee schedule,23.62,130.15,APC
Assay of etiocholanolone,82696,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40.15,,,,,,,fee schedule,23.62,130.15,Radiology
Assay of etiocholanolone,82696,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,36.74,,,,,,,fee schedule,23.62,130.15,APC
Assay of etiocholanolone,82696,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,45.92,,,,,,,fee schedule,23.62,130.15,APC
Fats/lipids feces qual,82705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,31.54,,,,,,,fee schedule,4.59,31.54,
Fats/lipids feces qual,82705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,25.28,,,,,,,fee schedule,4.59,31.54,
Fats/lipids feces qual,82705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,27.62,,,,,,,fee schedule,4.59,31.54,
Fats/lipids feces qual,82705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,29.04,,,,,,,fee schedule,4.59,31.54,
Fats/lipids feces qual,82705,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.59,,,,,,,fee schedule,4.59,31.54,Laboratory
Fats/lipids feces qual,82705,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.36,,,,,,,fee schedule,4.59,31.54,APC
Fats/lipids feces qual,82705,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5.3,,,,,,,fee schedule,4.59,31.54,APC
Fats/lipids feces qual,82705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5.1,,,,,,,fee schedule,4.59,31.54,APC
Fats/lipids feces qual,82705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.8,,,,,,,fee schedule,4.59,31.54,Radiology
Fats/lipids feces qual,82705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.14,,,,,,,fee schedule,4.59,31.54,APC
Fats/lipids feces qual,82705,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8.92,,,,,,,fee schedule,4.59,31.54,APC
Fats/lipids feces quant,82710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,92.72,,,,,,,fee schedule,15.12,92.72,
Fats/lipids feces quant,82710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,74.33,,,,,,,fee schedule,15.12,92.72,
Fats/lipids feces quant,82710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,81.19,,,,,,,fee schedule,15.12,92.72,
Fats/lipids feces quant,82710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,85.36,,,,,,,fee schedule,15.12,92.72,
Fats/lipids feces quant,82710,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.12,,,,,,,fee schedule,15.12,92.72,Laboratory
Fats/lipids feces quant,82710,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.64,,,,,,,fee schedule,15.12,92.72,APC
Fats/lipids feces quant,82710,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,17.47,,,,,,,fee schedule,15.12,92.72,APC
Fats/lipids feces quant,82710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16.8,,,,,,,fee schedule,15.12,92.72,APC
Fats/lipids feces quant,82710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.7,,,,,,,fee schedule,15.12,92.72,Radiology
Fats/lipids feces quant,82710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.52,,,,,,,fee schedule,15.12,92.72,APC
Fats/lipids feces quant,82710,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,29.4,,,,,,,fee schedule,15.12,92.72,APC
Assay of fecal fat,82715,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,49.25,,,,,,,fee schedule,20.67,49.25,
Assay of fecal fat,82715,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39.48,,,,,,,fee schedule,20.67,49.25,
Assay of fecal fat,82715,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,43.13,,,,,,,fee schedule,20.67,49.25,
Assay of fecal fat,82715,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45.34,,,,,,,fee schedule,20.67,49.25,
Assay of fecal fat,82715,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,20.67,,,,,,,fee schedule,20.67,49.25,Laboratory
Assay of fecal fat,82715,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,24.12,,,,,,,fee schedule,20.67,49.25,APC
Assay of fecal fat,82715,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,23.89,,,,,,,fee schedule,20.67,49.25,APC
Assay of fecal fat,82715,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,22.97,,,,,,,fee schedule,20.67,49.25,APC
Assay of fecal fat,82715,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,35.14,,,,,,,fee schedule,20.67,49.25,Radiology
Assay of fecal fat,82715,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,32.16,,,,,,,fee schedule,20.67,49.25,APC
Assay of fecal fat,82715,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,40.2,,,,,,,fee schedule,20.67,49.25,APC
Assay of blood fatty acids,82725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,73.48,,,,,,,fee schedule,16.89,73.48,
Assay of blood fatty acids,82725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,58.9,,,,,,,fee schedule,16.89,73.48,
Assay of blood fatty acids,82725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,64.35,,,,,,,fee schedule,16.89,73.48,
Assay of blood fatty acids,82725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,67.65,,,,,,,fee schedule,16.89,73.48,
Assay of blood fatty acids,82725,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.89,,,,,,,fee schedule,16.89,73.48,Laboratory
Assay of blood fatty acids,82725,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.71,,,,,,,fee schedule,16.89,73.48,APC
Assay of blood fatty acids,82725,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,19.52,,,,,,,fee schedule,16.89,73.48,APC
Assay of blood fatty acids,82725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18.77,,,,,,,fee schedule,16.89,73.48,APC
Assay of blood fatty acids,82725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.72,,,,,,,fee schedule,16.89,73.48,Radiology
Assay of blood fatty acids,82725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26.28,,,,,,,fee schedule,16.89,73.48,APC
Assay of blood fatty acids,82725,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,32.85,,,,,,,fee schedule,16.89,73.48,APC
Long chain fatty acids,82726,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,99.68,,,,,,,fee schedule,17.77,99.68,
Long chain fatty acids,82726,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,79.9,,,,,,,fee schedule,17.77,99.68,
Long chain fatty acids,82726,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,87.28,,,,,,,fee schedule,17.77,99.68,
Long chain fatty acids,82726,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,91.77,,,,,,,fee schedule,17.77,99.68,
Long chain fatty acids,82726,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.78,,,,,,,fee schedule,17.77,99.68,Laboratory
Long chain fatty acids,82726,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20.74,,,,,,,fee schedule,17.77,99.68,APC
Long chain fatty acids,82726,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,20.54,,,,,,,fee schedule,17.77,99.68,APC
Long chain fatty acids,82726,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,19.75,,,,,,,fee schedule,17.77,99.68,APC
Long chain fatty acids,82726,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,30.22,,,,,,,fee schedule,17.77,99.68,Radiology
Long chain fatty acids,82726,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27.65,,,,,,,fee schedule,17.77,99.68,APC
Long chain fatty acids,82726,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,34.56,,,,,,,fee schedule,17.77,99.68,APC
Assay of ferritin,82728,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83.72,,,,,,,fee schedule,12.27,83.72,
Assay of ferritin,82728,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,67.11,,,,,,,fee schedule,12.27,83.72,
Assay of ferritin,82728,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,73.31,,,,,,,fee schedule,12.27,83.72,
Assay of ferritin,82728,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,77.08,,,,,,,fee schedule,12.27,83.72,
Assay of ferritin,82728,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.27,,,,,,,fee schedule,12.27,83.72,Laboratory
Assay of ferritin,82728,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.31,,,,,,,fee schedule,12.27,83.72,APC
Assay of ferritin,82728,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,14.18,,,,,,,fee schedule,12.27,83.72,APC
Assay of ferritin,82728,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.63,,,,,,,fee schedule,12.27,83.72,APC
Assay of ferritin,82728,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.85,,,,,,,fee schedule,12.27,83.72,Radiology
Assay of ferritin,82728,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.08,,,,,,,fee schedule,12.27,83.72,APC
Assay of ferritin,82728,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23.85,,,,,,,fee schedule,12.27,83.72,APC
Assay of fetal fibronectin,82731,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,315.34,,,,,,,fee schedule,57.97,315.34,
Assay of fetal fibronectin,82731,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,252.77,,,,,,,fee schedule,57.97,315.34,
Assay of fetal fibronectin,82731,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,276.13,,,,,,,fee schedule,57.97,315.34,
Assay of fetal fibronectin,82731,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,290.31,,,,,,,fee schedule,57.97,315.34,
Assay of fetal fibronectin,82731,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,57.97,,,,,,,fee schedule,57.97,315.34,Laboratory
Assay of fetal fibronectin,82731,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,67.63,,,,,,,fee schedule,57.97,315.34,APC
Assay of fetal fibronectin,82731,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,66.99,,,,,,,fee schedule,57.97,315.34,APC
Assay of fetal fibronectin,82731,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,64.41,,,,,,,fee schedule,57.97,315.34,APC
Assay of fetal fibronectin,82731,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,98.55,,,,,,,fee schedule,57.97,315.34,Radiology
Assay of fetal fibronectin,82731,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,90.17,,,,,,,fee schedule,57.97,315.34,APC
Assay of fetal fibronectin,82731,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,112.72,,,,,,,fee schedule,57.97,315.34,APC
Assay of fluoride,82735,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,102.36,,,,,,,fee schedule,16.69,102.36,
Assay of fluoride,82735,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,82.05,,,,,,,fee schedule,16.69,102.36,
Assay of fluoride,82735,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,89.63,,,,,,,fee schedule,16.69,102.36,
Assay of fluoride,82735,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,94.24,,,,,,,fee schedule,16.69,102.36,
Assay of fluoride,82735,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.69,,,,,,,fee schedule,16.69,102.36,Laboratory
Assay of fluoride,82735,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.47,,,,,,,fee schedule,16.69,102.36,APC
Assay of fluoride,82735,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,19.28,,,,,,,fee schedule,16.69,102.36,APC
Assay of fluoride,82735,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18.54,,,,,,,fee schedule,16.69,102.36,APC
Assay of fluoride,82735,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.37,,,,,,,fee schedule,16.69,102.36,Radiology
Assay of fluoride,82735,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.96,,,,,,,fee schedule,16.69,102.36,APC
Assay of fluoride,82735,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,32.44,,,,,,,fee schedule,16.69,102.36,APC
Assay of folic acid serum,82746,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,121.05,,,,,,,fee schedule,13.23,121.05,
Assay of folic acid serum,82746,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,97.03,,,,,,,fee schedule,13.23,121.05,
Assay of folic acid serum,82746,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,106,,,,,,,fee schedule,13.23,121.05,
Assay of folic acid serum,82746,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,111.44,,,,,,,fee schedule,13.23,121.05,
Assay of folic acid serum,82746,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.23,,,,,,,fee schedule,13.23,121.05,Laboratory
Assay of folic acid serum,82746,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.44,,,,,,,fee schedule,13.23,121.05,APC
Assay of folic acid serum,82746,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,15.29,,,,,,,fee schedule,13.23,121.05,APC
Assay of folic acid serum,82746,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14.7,,,,,,,fee schedule,13.23,121.05,APC
Assay of folic acid serum,82746,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.49,,,,,,,fee schedule,13.23,121.05,Radiology
Assay of folic acid serum,82746,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.58,,,,,,,fee schedule,13.23,121.05,APC
Assay of folic acid serum,82746,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,25.72,,,,,,,fee schedule,13.23,121.05,APC
Assay of folic acid rbc,82747,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,95.6,,,,,,,fee schedule,15.88,95.6,
Assay of folic acid rbc,82747,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,76.63,,,,,,,fee schedule,15.88,95.6,
Assay of folic acid rbc,82747,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,83.71,,,,,,,fee schedule,15.88,95.6,
Assay of folic acid rbc,82747,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,88.01,,,,,,,fee schedule,15.88,95.6,
Assay of folic acid rbc,82747,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.88,,,,,,,fee schedule,15.88,95.6,Laboratory
Assay of folic acid rbc,82747,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.53,,,,,,,fee schedule,15.88,95.6,APC
Assay of folic acid rbc,82747,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18.36,,,,,,,fee schedule,15.88,95.6,APC
Assay of folic acid rbc,82747,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17.65,,,,,,,fee schedule,15.88,95.6,APC
Assay of folic acid rbc,82747,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27,,,,,,,fee schedule,15.88,95.6,Radiology
Assay of folic acid rbc,82747,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24.71,,,,,,,fee schedule,15.88,95.6,APC
Assay of folic acid rbc,82747,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30.89,,,,,,,fee schedule,15.88,95.6,APC
Assay of semen fructose,82757,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,95.71,,,,,,,fee schedule,15.61,95.71,
Assay of semen fructose,82757,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,76.72,,,,,,,fee schedule,15.61,95.71,
Assay of semen fructose,82757,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,83.81,,,,,,,fee schedule,15.61,95.71,
Assay of semen fructose,82757,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,88.11,,,,,,,fee schedule,15.61,95.71,
Assay of semen fructose,82757,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.61,,,,,,,fee schedule,15.61,95.71,Laboratory
Assay of semen fructose,82757,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.21,,,,,,,fee schedule,15.61,95.71,APC
Assay of semen fructose,82757,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18.03,,,,,,,fee schedule,15.61,95.71,APC
Assay of semen fructose,82757,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17.34,,,,,,,fee schedule,15.61,95.71,APC
Assay of semen fructose,82757,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26.53,,,,,,,fee schedule,15.61,95.71,Radiology
Assay of semen fructose,82757,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24.28,,,,,,,fee schedule,15.61,95.71,APC
Assay of semen fructose,82757,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30.34,,,,,,,fee schedule,15.61,95.71,APC
Assay of rbc galactokinase,82759,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,118.58,,,,,,,fee schedule,19.33,118.58,
Assay of rbc galactokinase,82759,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,95.05,,,,,,,fee schedule,19.33,118.58,
Assay of rbc galactokinase,82759,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,103.83,,,,,,,fee schedule,19.33,118.58,
Assay of rbc galactokinase,82759,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,109.17,,,,,,,fee schedule,19.33,118.58,
Assay of rbc galactokinase,82759,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.33,,,,,,,fee schedule,19.33,118.58,Laboratory
Assay of rbc galactokinase,82759,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,22.55,,,,,,,fee schedule,19.33,118.58,APC
Assay of rbc galactokinase,82759,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,22.34,,,,,,,fee schedule,19.33,118.58,APC
Assay of rbc galactokinase,82759,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,21.48,,,,,,,fee schedule,19.33,118.58,APC
Assay of rbc galactokinase,82759,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,32.86,,,,,,,fee schedule,19.33,118.58,Radiology
Assay of rbc galactokinase,82759,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,30.07,,,,,,,fee schedule,19.33,118.58,APC
Assay of rbc galactokinase,82759,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,37.59,,,,,,,fee schedule,19.33,118.58,APC
Assay of galactose,82760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,61.8,,,,,,,fee schedule,10.08,61.8,
Assay of galactose,82760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,49.54,,,,,,,fee schedule,10.08,61.8,
Assay of galactose,82760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,54.12,,,,,,,fee schedule,10.08,61.8,
Assay of galactose,82760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,56.9,,,,,,,fee schedule,10.08,61.8,
Assay of galactose,82760,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.08,,,,,,,fee schedule,10.08,61.8,Laboratory
Assay of galactose,82760,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.76,,,,,,,fee schedule,10.08,61.8,APC
Assay of galactose,82760,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11.65,,,,,,,fee schedule,10.08,61.8,APC
Assay of galactose,82760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11.2,,,,,,,fee schedule,10.08,61.8,APC
Assay of galactose,82760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.14,,,,,,,fee schedule,10.08,61.8,Radiology
Assay of galactose,82760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15.68,,,,,,,fee schedule,10.08,61.8,APC
Assay of galactose,82760,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19.6,,,,,,,fee schedule,10.08,61.8,APC
Assay galactose transferase,82775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,116.24,,,,,,,fee schedule,18.96,116.24,
Assay galactose transferase,82775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,93.17,,,,,,,fee schedule,18.96,116.24,
Assay galactose transferase,82775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,101.78,,,,,,,fee schedule,18.96,116.24,
Assay galactose transferase,82775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,107.01,,,,,,,fee schedule,18.96,116.24,
Assay galactose transferase,82775,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.96,,,,,,,fee schedule,18.96,116.24,Laboratory
Assay galactose transferase,82775,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,22.12,,,,,,,fee schedule,18.96,116.24,APC
Assay galactose transferase,82775,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,21.91,,,,,,,fee schedule,18.96,116.24,APC
Assay galactose transferase,82775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,21.07,,,,,,,fee schedule,18.96,116.24,APC
Assay galactose transferase,82775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,32.24,,,,,,,fee schedule,18.96,116.24,Radiology
Assay galactose transferase,82775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29.5,,,,,,,fee schedule,18.96,116.24,APC
Assay galactose transferase,82775,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,36.87,,,,,,,fee schedule,18.96,116.24,APC
Galactose transferase test,82776,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46.27,,,,,,,fee schedule,10.57,46.27,
Galactose transferase test,82776,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37.09,,,,,,,fee schedule,10.57,46.27,
Galactose transferase test,82776,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40.51,,,,,,,fee schedule,10.57,46.27,
Galactose transferase test,82776,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42.6,,,,,,,fee schedule,10.57,46.27,
Galactose transferase test,82776,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.57,,,,,,,fee schedule,10.57,46.27,Laboratory
Galactose transferase test,82776,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.33,,,,,,,fee schedule,10.57,46.27,APC
Galactose transferase test,82776,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.21,,,,,,,fee schedule,10.57,46.27,APC
Galactose transferase test,82776,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11.74,,,,,,,fee schedule,10.57,46.27,APC
Galactose transferase test,82776,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.96,,,,,,,fee schedule,10.57,46.27,Radiology
Galactose transferase test,82776,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.44,,,,,,,fee schedule,10.57,46.27,APC
Galactose transferase test,82776,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20.54,,,,,,,fee schedule,10.57,46.27,APC
Galectin-3,82777,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,67.28,,,,,,,fee schedule,39.83,77.44,
Galectin-3,82777,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.93,,,,,,,fee schedule,39.83,77.44,
Galectin-3,82777,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,58.92,,,,,,,fee schedule,39.83,77.44,
Galectin-3,82777,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,61.94,,,,,,,fee schedule,39.83,77.44,
Galectin-3,82777,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,39.83,,,,,,,fee schedule,39.83,77.44,Laboratory
Galectin-3,82777,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,46.46,,,,,,,fee schedule,39.83,77.44,APC
Galectin-3,82777,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,46.02,,,,,,,fee schedule,39.83,77.44,APC
Galectin-3,82777,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,44.25,,,,,,,fee schedule,39.83,77.44,APC
Galectin-3,82777,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,67.7,,,,,,,fee schedule,39.83,77.44,Radiology
Galectin-3,82777,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,61.95,,,,,,,fee schedule,39.83,77.44,APC
Galectin-3,82777,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,77.44,,,,,,,fee schedule,39.83,77.44,APC
Assay iga/igd/igg/igm each,82784,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,212.08,,,,,,,fee schedule,8.37,212.08,
Assay iga/igd/igg/igm each,82784,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,170,,,,,,,fee schedule,8.37,212.08,
Assay iga/igd/igg/igm each,82784,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,185.71,,,,,,,fee schedule,8.37,212.08,
Assay iga/igd/igg/igm each,82784,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,195.24,,,,,,,fee schedule,8.37,212.08,
Assay iga/igd/igg/igm each,82784,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.37,,,,,,,fee schedule,8.37,212.08,Laboratory
Assay iga/igd/igg/igm each,82784,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.76,,,,,,,fee schedule,8.37,212.08,APC
Assay iga/igd/igg/igm each,82784,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9.67,,,,,,,fee schedule,8.37,212.08,APC
Assay iga/igd/igg/igm each,82784,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9.3,,,,,,,fee schedule,8.37,212.08,APC
Assay iga/igd/igg/igm each,82784,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.23,,,,,,,fee schedule,8.37,212.08,Radiology
Assay iga/igd/igg/igm each,82784,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.02,,,,,,,fee schedule,8.37,212.08,APC
Assay iga/igd/igg/igm each,82784,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16.28,,,,,,,fee schedule,8.37,212.08,APC
Assay of ige,82785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,75.24,,,,,,,fee schedule,14.81,75.24,
Assay of ige,82785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,60.31,,,,,,,fee schedule,14.81,75.24,
Assay of ige,82785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,65.89,,,,,,,fee schedule,14.81,75.24,
Assay of ige,82785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,69.27,,,,,,,fee schedule,14.81,75.24,
Assay of ige,82785,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.81,,,,,,,fee schedule,14.81,75.24,Laboratory
Assay of ige,82785,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.28,,,,,,,fee schedule,14.81,75.24,APC
Assay of ige,82785,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,17.12,,,,,,,fee schedule,14.81,75.24,APC
Assay of ige,82785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16.46,,,,,,,fee schedule,14.81,75.24,APC
Assay of ige,82785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.18,,,,,,,fee schedule,14.81,75.24,Radiology
Assay of ige,82785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.04,,,,,,,fee schedule,14.81,75.24,APC
Assay of ige,82785,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,28.8,,,,,,,fee schedule,14.81,75.24,APC
Igg 1 2 3 or 4 each,82787,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,256.55,,,,,,,fee schedule,7.22,256.55,
Igg 1 2 3 or 4 each,82787,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,205.64,,,,,,,fee schedule,7.22,256.55,
Igg 1 2 3 or 4 each,82787,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,224.65,,,,,,,fee schedule,7.22,256.55,
Igg 1 2 3 or 4 each,82787,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,236.18,,,,,,,fee schedule,7.22,256.55,
Igg 1 2 3 or 4 each,82787,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.22,,,,,,,fee schedule,7.22,256.55,Laboratory
Igg 1 2 3 or 4 each,82787,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.42,,,,,,,fee schedule,7.22,256.55,APC
Igg 1 2 3 or 4 each,82787,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8.34,,,,,,,fee schedule,7.22,256.55,APC
Igg 1 2 3 or 4 each,82787,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8.02,,,,,,,fee schedule,7.22,256.55,APC
Igg 1 2 3 or 4 each,82787,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12.27,,,,,,,fee schedule,7.22,256.55,Radiology
Igg 1 2 3 or 4 each,82787,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11.23,,,,,,,fee schedule,7.22,256.55,APC
Igg 1 2 3 or 4 each,82787,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14.04,,,,,,,fee schedule,7.22,256.55,APC
Blood pH,82800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42.94,,,,,,,fee schedule,9.9,42.94,
Blood pH,82800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,34.42,,,,,,,fee schedule,9.9,42.94,
Blood pH,82800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37.6,,,,,,,fee schedule,9.9,42.94,
Blood pH,82800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,39.53,,,,,,,fee schedule,9.9,42.94,
Blood pH,82800,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.9,,,,,,,fee schedule,9.9,42.94,Laboratory
Blood pH,82800,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.55,,,,,,,fee schedule,9.9,42.94,APC
Blood pH,82800,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11.44,,,,,,,fee schedule,9.9,42.94,APC
Blood pH,82800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11,,,,,,,fee schedule,9.9,42.94,APC
Blood pH,82800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.83,,,,,,,fee schedule,9.9,42.94,Radiology
Blood pH,82800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15.4,,,,,,,fee schedule,9.9,42.94,APC
Blood pH,82800,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19.25,,,,,,,fee schedule,9.9,42.94,APC
Blood gases any combination,82803,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,186.31,,,,,,,fee schedule,23.46,186.31,
Blood gases any combination,82803,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,149.35,,,,,,,fee schedule,23.46,186.31,
Blood gases any combination,82803,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,163.15,,,,,,,fee schedule,23.46,186.31,
Blood gases any combination,82803,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,171.53,,,,,,,fee schedule,23.46,186.31,
Blood gases any combination,82803,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23.46,,,,,,,fee schedule,23.46,186.31,Laboratory
Blood gases any combination,82803,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,27.37,,,,,,,fee schedule,23.46,186.31,APC
Blood gases any combination,82803,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,27.11,,,,,,,fee schedule,23.46,186.31,APC
Blood gases any combination,82803,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,26.07,,,,,,,fee schedule,23.46,186.31,APC
Blood gases any combination,82803,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,39.89,,,,,,,fee schedule,23.46,186.31,Radiology
Blood gases any combination,82803,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,36.5,,,,,,,fee schedule,23.46,186.31,APC
Blood gases any combination,82803,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,45.62,,,,,,,fee schedule,23.46,186.31,APC
Blood gases w/o2 saturation,82805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,149.83,,,,,,,fee schedule,70.89,149.83,
Blood gases w/o2 saturation,82805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,120.1,,,,,,,fee schedule,70.89,149.83,
Blood gases w/o2 saturation,82805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,131.2,,,,,,,fee schedule,70.89,149.83,
Blood gases w/o2 saturation,82805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,137.94,,,,,,,fee schedule,70.89,149.83,
Blood gases w/o2 saturation,82805,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,70.89,,,,,,,fee schedule,70.89,149.83,Laboratory
Blood gases w/o2 saturation,82805,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,82.71,,,,,,,fee schedule,70.89,149.83,APC
Blood gases w/o2 saturation,82805,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,81.92,,,,,,,fee schedule,70.89,149.83,APC
Blood gases w/o2 saturation,82805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,78.77,,,,,,,fee schedule,70.89,149.83,APC
Blood gases w/o2 saturation,82805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.52,,,,,,,fee schedule,70.89,149.83,Radiology
Blood gases w/o2 saturation,82805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,110.28,,,,,,,fee schedule,70.89,149.83,APC
Blood gases w/o2 saturation,82805,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,137.85,,,,,,,fee schedule,70.89,149.83,APC
Blood gases o2 sat only,82810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,48.16,,,,,,,fee schedule,8.79,48.16,
Blood gases o2 sat only,82810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38.6,,,,,,,fee schedule,8.79,48.16,
Blood gases o2 sat only,82810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.17,,,,,,,fee schedule,8.79,48.16,
Blood gases o2 sat only,82810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,44.34,,,,,,,fee schedule,8.79,48.16,
Blood gases o2 sat only,82810,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.79,,,,,,,fee schedule,8.79,48.16,Laboratory
Blood gases o2 sat only,82810,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.26,,,,,,,fee schedule,8.79,48.16,APC
Blood gases o2 sat only,82810,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10.16,,,,,,,fee schedule,8.79,48.16,APC
Blood gases o2 sat only,82810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9.77,,,,,,,fee schedule,8.79,48.16,APC
Blood gases o2 sat only,82810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.95,,,,,,,fee schedule,8.79,48.16,Radiology
Blood gases o2 sat only,82810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.68,,,,,,,fee schedule,8.79,48.16,APC
Blood gases o2 sat only,82810,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,17.1,,,,,,,fee schedule,8.79,48.16,APC
Hemoglobin-oxygen affinity,82820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55.15,,,,,,,fee schedule,12.01,55.15,
Hemoglobin-oxygen affinity,82820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,44.21,,,,,,,fee schedule,12.01,55.15,
Hemoglobin-oxygen affinity,82820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48.29,,,,,,,fee schedule,12.01,55.15,
Hemoglobin-oxygen affinity,82820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,50.77,,,,,,,fee schedule,12.01,55.15,
Hemoglobin-oxygen affinity,82820,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.01,,,,,,,fee schedule,12.01,55.15,Laboratory
Hemoglobin-oxygen affinity,82820,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.01,,,,,,,fee schedule,12.01,55.15,APC
Hemoglobin-oxygen affinity,82820,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.87,,,,,,,fee schedule,12.01,55.15,APC
Hemoglobin-oxygen affinity,82820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.34,,,,,,,fee schedule,12.01,55.15,APC
Hemoglobin-oxygen affinity,82820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.41,,,,,,,fee schedule,12.01,55.15,Radiology
Hemoglobin-oxygen affinity,82820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.68,,,,,,,fee schedule,12.01,55.15,APC
Hemoglobin-oxygen affinity,82820,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23.34,,,,,,,fee schedule,12.01,55.15,APC
Gastric analy w/ph ea spec,82930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17.4,,,,,,,fee schedule,6.04,17.4,
Gastric analy w/ph ea spec,82930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13.95,,,,,,,fee schedule,6.04,17.4,
Gastric analy w/ph ea spec,82930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15.24,,,,,,,fee schedule,6.04,17.4,
Gastric analy w/ph ea spec,82930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16.02,,,,,,,fee schedule,6.04,17.4,
Gastric analy w/ph ea spec,82930,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.04,,,,,,,fee schedule,6.04,17.4,Laboratory
Gastric analy w/ph ea spec,82930,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.05,,,,,,,fee schedule,6.04,17.4,APC
Gastric analy w/ph ea spec,82930,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6.98,,,,,,,fee schedule,6.04,17.4,APC
Gastric analy w/ph ea spec,82930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6.71,,,,,,,fee schedule,6.04,17.4,APC
Gastric analy w/ph ea spec,82930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10.27,,,,,,,fee schedule,6.04,17.4,Radiology
Gastric analy w/ph ea spec,82930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.39,,,,,,,fee schedule,6.04,17.4,APC
Gastric analy w/ph ea spec,82930,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11.74,,,,,,,fee schedule,6.04,17.4,APC
Gastrin test,82938,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,97.64,,,,,,,fee schedule,15.92,97.64,
Gastrin test,82938,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,78.26,,,,,,,fee schedule,15.92,97.64,
Gastrin test,82938,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,85.5,,,,,,,fee schedule,15.92,97.64,
Gastrin test,82938,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,89.89,,,,,,,fee schedule,15.92,97.64,
Gastrin test,82938,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.92,,,,,,,fee schedule,15.92,97.64,Laboratory
Gastrin test,82938,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.57,,,,,,,fee schedule,15.92,97.64,APC
Gastrin test,82938,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18.4,,,,,,,fee schedule,15.92,97.64,APC
Gastrin test,82938,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17.69,,,,,,,fee schedule,15.92,97.64,APC
Gastrin test,82938,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27.07,,,,,,,fee schedule,15.92,97.64,Radiology
Gastrin test,82938,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24.77,,,,,,,fee schedule,15.92,97.64,APC
Gastrin test,82938,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30.96,,,,,,,fee schedule,15.92,97.64,APC
Assay of gastrin,82941,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,54.79,,,,,,,fee schedule,15.87,54.79,
Assay of gastrin,82941,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,43.92,,,,,,,fee schedule,15.87,54.79,
Assay of gastrin,82941,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,47.98,,,,,,,fee schedule,15.87,54.79,
Assay of gastrin,82941,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,50.44,,,,,,,fee schedule,15.87,54.79,
Assay of gastrin,82941,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.87,,,,,,,fee schedule,15.87,54.79,Laboratory
Assay of gastrin,82941,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.51,,,,,,,fee schedule,15.87,54.79,APC
Assay of gastrin,82941,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18.34,,,,,,,fee schedule,15.87,54.79,APC
Assay of gastrin,82941,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17.63,,,,,,,fee schedule,15.87,54.79,APC
Assay of gastrin,82941,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26.97,,,,,,,fee schedule,15.87,54.79,Radiology
Assay of gastrin,82941,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24.68,,,,,,,fee schedule,15.87,54.79,APC
Assay of gastrin,82941,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30.85,,,,,,,fee schedule,15.87,54.79,APC
Assay of glucagon,82943,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,44.42,,,,,,,fee schedule,12.86,44.42,
Assay of glucagon,82943,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35.61,,,,,,,fee schedule,12.86,44.42,
Assay of glucagon,82943,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38.9,,,,,,,fee schedule,12.86,44.42,
Assay of glucagon,82943,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,40.9,,,,,,,fee schedule,12.86,44.42,
Assay of glucagon,82943,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.86,,,,,,,fee schedule,12.86,44.42,Laboratory
Assay of glucagon,82943,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15,,,,,,,fee schedule,12.86,44.42,APC
Assay of glucagon,82943,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,14.86,,,,,,,fee schedule,12.86,44.42,APC
Assay of glucagon,82943,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14.29,,,,,,,fee schedule,12.86,44.42,APC
Assay of glucagon,82943,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21.86,,,,,,,fee schedule,12.86,44.42,Radiology
Assay of glucagon,82943,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.01,,,,,,,fee schedule,12.86,44.42,APC
Assay of glucagon,82943,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,25.01,,,,,,,fee schedule,12.86,44.42,APC
Glucose Other Fluid,82945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,72.56,,,,,,,fee schedule,3.54,72.56,
Glucose Other Fluid,82945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,58.16,,,,,,,fee schedule,3.54,72.56,
Glucose Other Fluid,82945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,63.54,,,,,,,fee schedule,3.54,72.56,
Glucose Other Fluid,82945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.8,,,,,,,fee schedule,3.54,72.56,
Glucose Other Fluid,82945,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.54,,,,,,,fee schedule,3.54,72.56,Laboratory
Glucose Other Fluid,82945,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.13,,,,,,,fee schedule,3.54,72.56,APC
Glucose Other Fluid,82945,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4.09,,,,,,,fee schedule,3.54,72.56,APC
Glucose Other Fluid,82945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3.93,,,,,,,fee schedule,3.54,72.56,APC
Glucose Other Fluid,82945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.01,,,,,,,fee schedule,3.54,72.56,Radiology
Glucose Other Fluid,82945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.5,,,,,,,fee schedule,3.54,72.56,APC
Glucose Other Fluid,82945,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6.88,,,,,,,fee schedule,3.54,72.56,APC
Glucagon tolerance test,82946,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83.2,,,,,,,fee schedule,15.99,83.2,
Glucagon tolerance test,82946,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66.69,,,,,,,fee schedule,15.99,83.2,
Glucagon tolerance test,82946,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,72.85,,,,,,,fee schedule,15.99,83.2,
Glucagon tolerance test,82946,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,76.59,,,,,,,fee schedule,15.99,83.2,
Glucagon tolerance test,82946,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.99,,,,,,,fee schedule,15.99,83.2,Laboratory
Glucagon tolerance test,82946,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.66,,,,,,,fee schedule,15.99,83.2,APC
Glucagon tolerance test,82946,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18.48,,,,,,,fee schedule,15.99,83.2,APC
Glucagon tolerance test,82946,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17.77,,,,,,,fee schedule,15.99,83.2,APC
Glucagon tolerance test,82946,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27.19,,,,,,,fee schedule,15.99,83.2,Radiology
Glucagon tolerance test,82946,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24.88,,,,,,,fee schedule,15.99,83.2,APC
Glucagon tolerance test,82946,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31.1,,,,,,,fee schedule,15.99,83.2,APC
Assay glucose blood quant,82947,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,43.26,,,,,,,fee schedule,3.54,43.26,
Assay glucose blood quant,82947,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,34.68,,,,,,,fee schedule,3.54,43.26,
Assay glucose blood quant,82947,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37.89,,,,,,,fee schedule,3.54,43.26,
Assay glucose blood quant,82947,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,39.83,,,,,,,fee schedule,3.54,43.26,
Assay glucose blood quant,82947,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.54,,,,,,,fee schedule,3.54,43.26,Laboratory
Assay glucose blood quant,82947,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.13,,,,,,,fee schedule,3.54,43.26,APC
Assay glucose blood quant,82947,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4.09,,,,,,,fee schedule,3.54,43.26,APC
Assay glucose blood quant,82947,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3.93,,,,,,,fee schedule,3.54,43.26,APC
Assay glucose blood quant,82947,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.01,,,,,,,fee schedule,3.54,43.26,Radiology
Assay glucose blood quant,82947,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.5,,,,,,,fee schedule,3.54,43.26,APC
Assay glucose blood quant,82947,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6.88,,,,,,,fee schedule,3.54,43.26,APC
Reagent strip/blood glucose,82948,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17.5,,,,,,,fee schedule,4.54,17.5,
Reagent strip/blood glucose,82948,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14.03,,,,,,,fee schedule,4.54,17.5,
Reagent strip/blood glucose,82948,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15.33,,,,,,,fee schedule,4.54,17.5,
Reagent strip/blood glucose,82948,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16.11,,,,,,,fee schedule,4.54,17.5,
Reagent strip/blood glucose,82948,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.54,,,,,,,fee schedule,4.54,17.5,Laboratory
Reagent strip/blood glucose,82948,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.29,,,,,,,fee schedule,4.54,17.5,APC
Reagent strip/blood glucose,82948,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5.24,,,,,,,fee schedule,4.54,17.5,APC
Reagent strip/blood glucose,82948,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5.04,,,,,,,fee schedule,4.54,17.5,APC
Reagent strip/blood glucose,82948,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.71,,,,,,,fee schedule,4.54,17.5,Radiology
Reagent strip/blood glucose,82948,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.06,,,,,,,fee schedule,4.54,17.5,APC
Reagent strip/blood glucose,82948,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8.82,,,,,,,fee schedule,4.54,17.5,APC
Glucose test,82950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,31.84,,,,,,,fee schedule,4.28,31.84,
Glucose test,82950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,25.52,,,,,,,fee schedule,4.28,31.84,
Glucose test,82950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,27.88,,,,,,,fee schedule,4.28,31.84,
Glucose test,82950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,29.31,,,,,,,fee schedule,4.28,31.84,
Glucose test,82950,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.28,,,,,,,fee schedule,4.28,31.84,Laboratory
Glucose test,82950,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.99,,,,,,,fee schedule,4.28,31.84,APC
Glucose test,82950,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4.94,,,,,,,fee schedule,4.28,31.84,APC
Glucose test,82950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4.75,,,,,,,fee schedule,4.28,31.84,APC
Glucose test,82950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.27,,,,,,,fee schedule,4.28,31.84,Radiology
Glucose test,82950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.65,,,,,,,fee schedule,4.28,31.84,APC
Glucose test,82950,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8.31,,,,,,,fee schedule,4.28,31.84,APC
Glucose tolerance test (GTT),82951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,77.07,,,,,,,fee schedule,11.58,77.07,
Glucose tolerance test (GTT),82951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,61.78,,,,,,,fee schedule,11.58,77.07,
Glucose tolerance test (GTT),82951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,67.49,,,,,,,fee schedule,11.58,77.07,
Glucose tolerance test (GTT),82951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,70.96,,,,,,,fee schedule,11.58,77.07,
Glucose tolerance test (GTT),82951,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.58,,,,,,,fee schedule,11.58,77.07,Laboratory
Glucose tolerance test (GTT),82951,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.51,,,,,,,fee schedule,11.58,77.07,APC
Glucose tolerance test (GTT),82951,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.38,,,,,,,fee schedule,11.58,77.07,APC
Glucose tolerance test (GTT),82951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.87,,,,,,,fee schedule,11.58,77.07,APC
Glucose tolerance test (GTT),82951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.69,,,,,,,fee schedule,11.58,77.07,Radiology
Glucose tolerance test (GTT),82951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.02,,,,,,,fee schedule,11.58,77.07,APC
Glucose tolerance test (GTT),82951,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22.52,,,,,,,fee schedule,11.58,77.07,APC
GTT-added samples,82952,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14.81,,,,,,,fee schedule,3.53,14.81,
GTT-added samples,82952,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11.87,,,,,,,fee schedule,3.53,14.81,
GTT-added samples,82952,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12.97,,,,,,,fee schedule,3.53,14.81,
GTT-added samples,82952,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13.63,,,,,,,fee schedule,3.53,14.81,
GTT-added samples,82952,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.53,,,,,,,fee schedule,3.53,14.81,Laboratory
GTT-added samples,82952,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.12,,,,,,,fee schedule,3.53,14.81,APC
GTT-added samples,82952,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4.08,,,,,,,fee schedule,3.53,14.81,APC
GTT-added samples,82952,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3.92,,,,,,,fee schedule,3.53,14.81,APC
GTT-added samples,82952,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6,,,,,,,fee schedule,3.53,14.81,Radiology
GTT-added samples,82952,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.49,,,,,,,fee schedule,3.53,14.81,APC
GTT-added samples,82952,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6.86,,,,,,,fee schedule,3.53,14.81,APC
Assay of g6pd enzyme,82955,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,71.08,,,,,,,fee schedule,8.73,71.08,
Assay of g6pd enzyme,82955,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56.97,,,,,,,fee schedule,8.73,71.08,
Assay of g6pd enzyme,82955,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,62.24,,,,,,,fee schedule,8.73,71.08,
Assay of g6pd enzyme,82955,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,65.44,,,,,,,fee schedule,8.73,71.08,
Assay of g6pd enzyme,82955,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.73,,,,,,,fee schedule,8.73,71.08,Laboratory
Assay of g6pd enzyme,82955,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.18,,,,,,,fee schedule,8.73,71.08,APC
Assay of g6pd enzyme,82955,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10.09,,,,,,,fee schedule,8.73,71.08,APC
Assay of g6pd enzyme,82955,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9.7,,,,,,,fee schedule,8.73,71.08,APC
Assay of g6pd enzyme,82955,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.84,,,,,,,fee schedule,8.73,71.08,Radiology
Assay of g6pd enzyme,82955,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.58,,,,,,,fee schedule,8.73,71.08,APC
Assay of g6pd enzyme,82955,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16.97,,,,,,,fee schedule,8.73,71.08,APC
Test for G6PD enzyme,82960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33.42,,,,,,,fee schedule,5.44,33.42,
Test for G6PD enzyme,82960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26.79,,,,,,,fee schedule,5.44,33.42,
Test for G6PD enzyme,82960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29.26,,,,,,,fee schedule,5.44,33.42,
Test for G6PD enzyme,82960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30.76,,,,,,,fee schedule,5.44,33.42,
Test for G6PD enzyme,82960,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.44,,,,,,,fee schedule,5.44,33.42,Laboratory
Test for G6PD enzyme,82960,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.35,,,,,,,fee schedule,5.44,33.42,APC
Test for G6PD enzyme,82960,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6.29,,,,,,,fee schedule,5.44,33.42,APC
Test for G6PD enzyme,82960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6.05,,,,,,,fee schedule,5.44,33.42,APC
Test for G6PD enzyme,82960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.26,,,,,,,fee schedule,5.44,33.42,Radiology
Test for G6PD enzyme,82960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8.47,,,,,,,fee schedule,5.44,33.42,APC
Test for G6PD enzyme,82960,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10.59,,,,,,,fee schedule,5.44,33.42,APC
Glucose blood test,82962,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,52.19,,,,,,,fee schedule,2.95,52.19,
Glucose blood test,82962,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,41.83,,,,,,,fee schedule,2.95,52.19,
Glucose blood test,82962,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,45.7,,,,,,,fee schedule,2.95,52.19,
Glucose blood test,82962,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,48.04,,,,,,,fee schedule,2.95,52.19,
Glucose blood test,82962,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.95,,,,,,,fee schedule,2.95,52.19,Laboratory
Glucose blood test,82962,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3.44,,,,,,,fee schedule,2.95,52.19,APC
Glucose blood test,82962,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3.41,,,,,,,fee schedule,2.95,52.19,APC
Glucose blood test,82962,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3.28,,,,,,,fee schedule,2.95,52.19,APC
Glucose blood test,82962,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.02,,,,,,,fee schedule,2.95,52.19,Radiology
Glucose blood test,82962,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4.59,,,,,,,fee schedule,2.95,52.19,APC
Glucose blood test,82962,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5.74,,,,,,,fee schedule,2.95,52.19,APC
Assay of glucosidase,82963,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,118.58,,,,,,,fee schedule,19.33,118.58,
Assay of glucosidase,82963,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,95.05,,,,,,,fee schedule,19.33,118.58,
Assay of glucosidase,82963,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,103.83,,,,,,,fee schedule,19.33,118.58,
Assay of glucosidase,82963,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,109.17,,,,,,,fee schedule,19.33,118.58,
Assay of glucosidase,82963,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.33,,,,,,,fee schedule,19.33,118.58,Laboratory
Assay of glucosidase,82963,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,22.55,,,,,,,fee schedule,19.33,118.58,APC
Assay of glucosidase,82963,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,22.34,,,,,,,fee schedule,19.33,118.58,APC
Assay of glucosidase,82963,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,21.48,,,,,,,fee schedule,19.33,118.58,APC
Assay of glucosidase,82963,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,32.86,,,,,,,fee schedule,19.33,118.58,Radiology
Assay of glucosidase,82963,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,30.07,,,,,,,fee schedule,19.33,118.58,APC
Assay of glucosidase,82963,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,37.59,,,,,,,fee schedule,19.33,118.58,APC
Assay of gdh enzyme,82965,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42.68,,,,,,,fee schedule,11.84,42.68,
Assay of gdh enzyme,82965,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,34.21,,,,,,,fee schedule,11.84,42.68,
Assay of gdh enzyme,82965,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37.37,,,,,,,fee schedule,11.84,42.68,
Assay of gdh enzyme,82965,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,39.29,,,,,,,fee schedule,11.84,42.68,
Assay of gdh enzyme,82965,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.84,,,,,,,fee schedule,11.84,42.68,Laboratory
Assay of gdh enzyme,82965,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.81,,,,,,,fee schedule,11.84,42.68,APC
Assay of gdh enzyme,82965,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.68,,,,,,,fee schedule,11.84,42.68,APC
Assay of gdh enzyme,82965,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.15,,,,,,,fee schedule,11.84,42.68,APC
Assay of gdh enzyme,82965,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.12,,,,,,,fee schedule,11.84,42.68,Radiology
Assay of gdh enzyme,82965,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.41,,,,,,,fee schedule,11.84,42.68,APC
Assay of gdh enzyme,82965,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23.01,,,,,,,fee schedule,11.84,42.68,APC
Assay of GGT,82977,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,64.69,,,,,,,fee schedule,6.48,64.69,
Assay of GGT,82977,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.86,,,,,,,fee schedule,6.48,64.69,
Assay of GGT,82977,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56.65,,,,,,,fee schedule,6.48,64.69,
Assay of GGT,82977,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59.56,,,,,,,fee schedule,6.48,64.69,
Assay of GGT,82977,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.48,,,,,,,fee schedule,6.48,64.69,Laboratory
Assay of GGT,82977,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.56,,,,,,,fee schedule,6.48,64.69,APC
Assay of GGT,82977,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7.49,,,,,,,fee schedule,6.48,64.69,APC
Assay of GGT,82977,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7.2,,,,,,,fee schedule,6.48,64.69,APC
Assay of GGT,82977,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11.02,,,,,,,fee schedule,6.48,64.69,Radiology
Assay of GGT,82977,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10.08,,,,,,,fee schedule,6.48,64.69,APC
Assay of GGT,82977,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12.6,,,,,,,fee schedule,6.48,64.69,APC
Assay of glutathione,82978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,78.66,,,,,,,fee schedule,13.9,78.66,
Assay of glutathione,82978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,63.05,,,,,,,fee schedule,13.9,78.66,
Assay of glutathione,82978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,68.88,,,,,,,fee schedule,13.9,78.66,
Assay of glutathione,82978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,72.42,,,,,,,fee schedule,13.9,78.66,
Assay of glutathione,82978,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.9,,,,,,,fee schedule,13.9,78.66,Laboratory
Assay of glutathione,82978,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.22,,,,,,,fee schedule,13.9,78.66,APC
Assay of glutathione,82978,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,16.07,,,,,,,fee schedule,13.9,78.66,APC
Assay of glutathione,82978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,15.45,,,,,,,fee schedule,13.9,78.66,APC
Assay of glutathione,82978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.64,,,,,,,fee schedule,13.9,78.66,Radiology
Assay of glutathione,82978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21.63,,,,,,,fee schedule,13.9,78.66,APC
Assay of glutathione,82978,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,27.04,,,,,,,fee schedule,13.9,78.66,APC
Assay rbc glutathione,82979,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,38.03,,,,,,,fee schedule,8.5,38.03,
Assay rbc glutathione,82979,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,30.48,,,,,,,fee schedule,8.5,38.03,
Assay rbc glutathione,82979,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,33.3,,,,,,,fee schedule,8.5,38.03,
Assay rbc glutathione,82979,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,35.01,,,,,,,fee schedule,8.5,38.03,
Assay rbc glutathione,82979,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.5,,,,,,,fee schedule,8.5,38.03,Laboratory
Assay rbc glutathione,82979,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.91,,,,,,,fee schedule,8.5,38.03,APC
Assay rbc glutathione,82979,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9.82,,,,,,,fee schedule,8.5,38.03,APC
Assay rbc glutathione,82979,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9.44,,,,,,,fee schedule,8.5,38.03,APC
Assay rbc glutathione,82979,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.44,,,,,,,fee schedule,8.5,38.03,Radiology
Assay rbc glutathione,82979,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.22,,,,,,,fee schedule,8.5,38.03,APC
Assay rbc glutathione,82979,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16.52,,,,,,,fee schedule,8.5,38.03,APC
Assay of glycated protein,82985,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,47.38,,,,,,,fee schedule,15.08,47.38,
Assay of glycated protein,82985,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37.98,,,,,,,fee schedule,15.08,47.38,
Assay of glycated protein,82985,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,41.49,,,,,,,fee schedule,15.08,47.38,
Assay of glycated protein,82985,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,43.62,,,,,,,fee schedule,15.08,47.38,
Assay of glycated protein,82985,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.08,,,,,,,fee schedule,15.08,47.38,Laboratory
Assay of glycated protein,82985,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.6,,,,,,,fee schedule,15.08,47.38,APC
Assay of glycated protein,82985,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,17.43,,,,,,,fee schedule,15.08,47.38,APC
Assay of glycated protein,82985,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16.76,,,,,,,fee schedule,15.08,47.38,APC
Assay of glycated protein,82985,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.64,,,,,,,fee schedule,15.08,47.38,Radiology
Assay of glycated protein,82985,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.46,,,,,,,fee schedule,15.08,47.38,APC
Assay of glycated protein,82985,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,29.33,,,,,,,fee schedule,15.08,47.38,APC
Assay of gonadotropin (fsh),83001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,81.72,,,,,,,fee schedule,16.72,81.72,
Assay of gonadotropin (fsh),83001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,65.5,,,,,,,fee schedule,16.72,81.72,
Assay of gonadotropin (fsh),83001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,71.56,,,,,,,fee schedule,16.72,81.72,
Assay of gonadotropin (fsh),83001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,75.23,,,,,,,fee schedule,16.72,81.72,
Assay of gonadotropin (fsh),83001,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.72,,,,,,,fee schedule,16.72,81.72,Laboratory
Assay of gonadotropin (fsh),83001,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.51,,,,,,,fee schedule,16.72,81.72,APC
Assay of gonadotropin (fsh),83001,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,19.32,,,,,,,fee schedule,16.72,81.72,APC
Assay of gonadotropin (fsh),83001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18.58,,,,,,,fee schedule,16.72,81.72,APC
Assay of gonadotropin (fsh),83001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.43,,,,,,,fee schedule,16.72,81.72,Radiology
Assay of gonadotropin (fsh),83001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26.01,,,,,,,fee schedule,16.72,81.72,APC
Assay of gonadotropin (fsh),83001,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,32.52,,,,,,,fee schedule,16.72,81.72,APC
Assay of gonadotropin (lh),83002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,88.31,,,,,,,fee schedule,16.67,88.31,
Assay of gonadotropin (lh),83002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,70.78,,,,,,,fee schedule,16.67,88.31,
Assay of gonadotropin (lh),83002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,77.33,,,,,,,fee schedule,16.67,88.31,
Assay of gonadotropin (lh),83002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,81.3,,,,,,,fee schedule,16.67,88.31,
Assay of gonadotropin (lh),83002,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.67,,,,,,,fee schedule,16.67,88.31,Laboratory
Assay of gonadotropin (lh),83002,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.45,,,,,,,fee schedule,16.67,88.31,APC
Assay of gonadotropin (lh),83002,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,19.26,,,,,,,fee schedule,16.67,88.31,APC
Assay of gonadotropin (lh),83002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18.52,,,,,,,fee schedule,16.67,88.31,APC
Assay of gonadotropin (lh),83002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.34,,,,,,,fee schedule,16.67,88.31,Radiology
Assay of gonadotropin (lh),83002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.93,,,,,,,fee schedule,16.67,88.31,APC
Assay of gonadotropin (lh),83002,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,32.41,,,,,,,fee schedule,16.67,88.31,APC
Assay growth hormone (hgh),83003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,216.93,,,,,,,fee schedule,15,216.93,
Assay growth hormone (hgh),83003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,173.89,,,,,,,fee schedule,15,216.93,
Assay growth hormone (hgh),83003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,189.96,,,,,,,fee schedule,15,216.93,
Assay growth hormone (hgh),83003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,199.72,,,,,,,fee schedule,15,216.93,
Assay growth hormone (hgh),83003,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15,,,,,,,fee schedule,15,216.93,Laboratory
Assay growth hormone (hgh),83003,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.5,,,,,,,fee schedule,15,216.93,APC
Assay growth hormone (hgh),83003,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,17.34,,,,,,,fee schedule,15,216.93,APC
Assay growth hormone (hgh),83003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16.67,,,,,,,fee schedule,15,216.93,APC
Assay growth hormone (hgh),83003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.51,,,,,,,fee schedule,15,216.93,Radiology
Assay growth hormone (hgh),83003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.34,,,,,,,fee schedule,15,216.93,APC
Assay growth hormone (hgh),83003,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,29.17,,,,,,,fee schedule,15,216.93,APC
Growth stimulation gene 2,83006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,113.14,,,,,,,fee schedule,68.04,132.3,
Growth stimulation gene 2,83006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,90.69,,,,,,,fee schedule,68.04,132.3,
Growth stimulation gene 2,83006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,99.07,,,,,,,fee schedule,68.04,132.3,
Growth stimulation gene 2,83006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,104.16,,,,,,,fee schedule,68.04,132.3,
Growth stimulation gene 2,83006,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,68.04,,,,,,,fee schedule,68.04,132.3,Laboratory
Growth stimulation gene 2,83006,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,79.38,,,,,,,fee schedule,68.04,132.3,APC
Growth stimulation gene 2,83006,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,78.62,,,,,,,fee schedule,68.04,132.3,APC
Growth stimulation gene 2,83006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,75.6,,,,,,,fee schedule,68.04,132.3,APC
Growth stimulation gene 2,83006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,115.67,,,,,,,fee schedule,68.04,132.3,Radiology
Growth stimulation gene 2,83006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,105.84,,,,,,,fee schedule,68.04,132.3,APC
Growth stimulation gene 2,83006,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,132.3,,,,,,,fee schedule,68.04,132.3,APC
H pylori (c-13) blood,83009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,359.4,,,,,,,fee schedule,60.62,359.4,
H pylori (c-13) blood,83009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,288.09,,,,,,,fee schedule,60.62,359.4,
H pylori (c-13) blood,83009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,314.71,,,,,,,fee schedule,60.62,359.4,
H pylori (c-13) blood,83009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,330.88,,,,,,,fee schedule,60.62,359.4,
H pylori (c-13) blood,83009,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,60.62,,,,,,,fee schedule,60.62,359.4,Laboratory
H pylori (c-13) blood,83009,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,70.73,,,,,,,fee schedule,60.62,359.4,APC
H pylori (c-13) blood,83009,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,70.05,,,,,,,fee schedule,60.62,359.4,APC
H pylori (c-13) blood,83009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,67.36,,,,,,,fee schedule,60.62,359.4,APC
H pylori (c-13) blood,83009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,103.06,,,,,,,fee schedule,60.62,359.4,Radiology
H pylori (c-13) blood,83009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,94.3,,,,,,,fee schedule,60.62,359.4,APC
H pylori (c-13) blood,83009,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,117.88,,,,,,,fee schedule,60.62,359.4,APC
Assay of haptoglobin quant,83010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,134.01,,,,,,,fee schedule,11.32,134.01,
Assay of haptoglobin quant,83010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,107.42,,,,,,,fee schedule,11.32,134.01,
Assay of haptoglobin quant,83010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,117.35,,,,,,,fee schedule,11.32,134.01,
Assay of haptoglobin quant,83010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,123.37,,,,,,,fee schedule,11.32,134.01,
Assay of haptoglobin quant,83010,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.32,,,,,,,fee schedule,11.32,134.01,Laboratory
Assay of haptoglobin quant,83010,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.21,,,,,,,fee schedule,11.32,134.01,APC
Assay of haptoglobin quant,83010,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.08,,,,,,,fee schedule,11.32,134.01,APC
Assay of haptoglobin quant,83010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.58,,,,,,,fee schedule,11.32,134.01,APC
Assay of haptoglobin quant,83010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.25,,,,,,,fee schedule,11.32,134.01,Radiology
Assay of haptoglobin quant,83010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.61,,,,,,,fee schedule,11.32,134.01,APC
Assay of haptoglobin quant,83010,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22.02,,,,,,,fee schedule,11.32,134.01,APC
Assay of haptoglobins,83012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,94.88,,,,,,,fee schedule,24.2,94.88,
Assay of haptoglobins,83012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,76.05,,,,,,,fee schedule,24.2,94.88,
Assay of haptoglobins,83012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,83.08,,,,,,,fee schedule,24.2,94.88,
Assay of haptoglobins,83012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,87.35,,,,,,,fee schedule,24.2,94.88,
Assay of haptoglobins,83012,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24.2,,,,,,,fee schedule,24.2,94.88,Laboratory
Assay of haptoglobins,83012,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,28.23,,,,,,,fee schedule,24.2,94.88,APC
Assay of haptoglobins,83012,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,27.97,,,,,,,fee schedule,24.2,94.88,APC
Assay of haptoglobins,83012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,26.89,,,,,,,fee schedule,24.2,94.88,APC
Assay of haptoglobins,83012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,41.14,,,,,,,fee schedule,24.2,94.88,Radiology
Assay of haptoglobins,83012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,37.65,,,,,,,fee schedule,24.2,94.88,APC
Assay of haptoglobins,83012,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,47.06,,,,,,,fee schedule,24.2,94.88,APC
H pylori (c-13) breath,83013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,359.4,,,,,,,fee schedule,60.62,359.4,
H pylori (c-13) breath,83013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,288.09,,,,,,,fee schedule,60.62,359.4,
H pylori (c-13) breath,83013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,314.71,,,,,,,fee schedule,60.62,359.4,
H pylori (c-13) breath,83013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,330.88,,,,,,,fee schedule,60.62,359.4,
H pylori (c-13) breath,83013,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,60.62,,,,,,,fee schedule,60.62,359.4,Laboratory
H pylori (c-13) breath,83013,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,70.73,,,,,,,fee schedule,60.62,359.4,APC
H pylori (c-13) breath,83013,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,70.05,,,,,,,fee schedule,60.62,359.4,APC
H pylori (c-13) breath,83013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,67.36,,,,,,,fee schedule,60.62,359.4,APC
H pylori (c-13) breath,83013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,103.06,,,,,,,fee schedule,60.62,359.4,Radiology
H pylori (c-13) breath,83013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,94.3,,,,,,,fee schedule,60.62,359.4,APC
H pylori (c-13) breath,83013,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,117.88,,,,,,,fee schedule,60.62,359.4,APC
H pylori drug admin,83014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,43.39,,,,,,,fee schedule,7.07,43.39,
H pylori drug admin,83014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,34.78,,,,,,,fee schedule,7.07,43.39,
H pylori drug admin,83014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38,,,,,,,fee schedule,7.07,43.39,
H pylori drug admin,83014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,39.95,,,,,,,fee schedule,7.07,43.39,
H pylori drug admin,83014,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.07,,,,,,,fee schedule,7.07,43.39,Laboratory
H pylori drug admin,83014,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.25,,,,,,,fee schedule,7.07,43.39,APC
H pylori drug admin,83014,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8.17,,,,,,,fee schedule,7.07,43.39,APC
H pylori drug admin,83014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7.86,,,,,,,fee schedule,7.07,43.39,APC
H pylori drug admin,83014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12.03,,,,,,,fee schedule,7.07,43.39,Radiology
H pylori drug admin,83014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11,,,,,,,fee schedule,7.07,43.39,APC
H pylori drug admin,83014,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,13.76,,,,,,,fee schedule,7.07,43.39,APC
Heavy metal qual any anal,83015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,65.73,,,,,,,fee schedule,18.85,65.73,
Heavy metal qual any anal,83015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52.69,,,,,,,fee schedule,18.85,65.73,
Heavy metal qual any anal,83015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.56,,,,,,,fee schedule,18.85,65.73,
Heavy metal qual any anal,83015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.52,,,,,,,fee schedule,18.85,65.73,
Heavy metal qual any anal,83015,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.85,,,,,,,fee schedule,18.85,65.73,Laboratory
Heavy metal qual any anal,83015,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.99,,,,,,,fee schedule,18.85,65.73,APC
Heavy metal qual any anal,83015,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,21.78,,,,,,,fee schedule,18.85,65.73,APC
Heavy metal qual any anal,83015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,20.94,,,,,,,fee schedule,18.85,65.73,APC
Heavy metal qual any anal,83015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,32.04,,,,,,,fee schedule,18.85,65.73,Radiology
Heavy metal qual any anal,83015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29.32,,,,,,,fee schedule,18.85,65.73,APC
Heavy metal qual any anal,83015,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,36.65,,,,,,,fee schedule,18.85,65.73,APC
Heavy metal quant each nes,83018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,68.86,,,,,,,fee schedule,19.76,68.86,
Heavy metal quant each nes,83018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55.19,,,,,,,fee schedule,19.76,68.86,
Heavy metal quant each nes,83018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,60.29,,,,,,,fee schedule,19.76,68.86,
Heavy metal quant each nes,83018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,63.39,,,,,,,fee schedule,19.76,68.86,
Heavy metal quant each nes,83018,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.76,,,,,,,fee schedule,19.76,68.86,Laboratory
Heavy metal quant each nes,83018,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,23.06,,,,,,,fee schedule,19.76,68.86,APC
Heavy metal quant each nes,83018,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,22.84,,,,,,,fee schedule,19.76,68.86,APC
Heavy metal quant each nes,83018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,21.96,,,,,,,fee schedule,19.76,68.86,APC
Heavy metal quant each nes,83018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,33.6,,,,,,,fee schedule,19.76,68.86,Radiology
Heavy metal quant each nes,83018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,30.74,,,,,,,fee schedule,19.76,68.86,APC
Heavy metal quant each nes,83018,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,38.43,,,,,,,fee schedule,19.76,68.86,APC
Hemoglobin electrophoresis,83020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,124.14,,,,,,,fee schedule,11.58,124.14,
Hemoglobin electrophoresis,83020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,99.51,,,,,,,fee schedule,11.58,124.14,
Hemoglobin electrophoresis,83020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,108.7,,,,,,,fee schedule,11.58,124.14,
Hemoglobin electrophoresis,83020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,114.29,,,,,,,fee schedule,11.58,124.14,
Hemoglobin electrophoresis,83020,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.58,,,,,,,fee schedule,11.58,124.14,Laboratory
Hemoglobin electrophoresis,83020,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.51,,,,,,,fee schedule,11.58,124.14,APC
Hemoglobin electrophoresis,83020,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.38,,,,,,,fee schedule,11.58,124.14,APC
Hemoglobin electrophoresis,83020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.87,,,,,,,fee schedule,11.58,124.14,APC
Hemoglobin electrophoresis,83020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.69,,,,,,,fee schedule,11.58,124.14,Radiology
Hemoglobin electrophoresis,83020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.02,,,,,,,fee schedule,11.58,124.14,APC
Hemoglobin electrophoresis,83020,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22.52,,,,,,,fee schedule,11.58,124.14,APC
Hemoglobin chromotography,83021,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,99.68,,,,,,,fee schedule,16.25,99.68,
Hemoglobin chromotography,83021,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,79.9,,,,,,,fee schedule,16.25,99.68,
Hemoglobin chromotography,83021,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,87.28,,,,,,,fee schedule,16.25,99.68,
Hemoglobin chromotography,83021,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,91.77,,,,,,,fee schedule,16.25,99.68,
Hemoglobin chromotography,83021,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.25,,,,,,,fee schedule,16.25,99.68,Laboratory
Hemoglobin chromotography,83021,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.96,,,,,,,fee schedule,16.25,99.68,APC
Hemoglobin chromotography,83021,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18.78,,,,,,,fee schedule,16.25,99.68,APC
Hemoglobin chromotography,83021,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18.06,,,,,,,fee schedule,16.25,99.68,APC
Hemoglobin chromotography,83021,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27.63,,,,,,,fee schedule,16.25,99.68,Radiology
Hemoglobin chromotography,83021,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.28,,,,,,,fee schedule,16.25,99.68,APC
Hemoglobin chromotography,83021,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31.6,,,,,,,fee schedule,16.25,99.68,APC
Hemoglobin copper sulfate,83026,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13.04,,,,,,,fee schedule,3.61,13.04,
Hemoglobin copper sulfate,83026,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10.45,,,,,,,fee schedule,3.61,13.04,
Hemoglobin copper sulfate,83026,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11.42,,,,,,,fee schedule,3.61,13.04,
Hemoglobin copper sulfate,83026,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12.01,,,,,,,fee schedule,3.61,13.04,
Hemoglobin copper sulfate,83026,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.61,,,,,,,fee schedule,3.61,13.04,Laboratory
Hemoglobin copper sulfate,83026,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.21,,,,,,,fee schedule,3.61,13.04,APC
Hemoglobin copper sulfate,83026,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4.17,,,,,,,fee schedule,3.61,13.04,APC
Hemoglobin copper sulfate,83026,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4.01,,,,,,,fee schedule,3.61,13.04,APC
Hemoglobin copper sulfate,83026,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.14,,,,,,,fee schedule,3.61,13.04,Radiology
Hemoglobin copper sulfate,83026,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.61,,,,,,,fee schedule,3.61,13.04,APC
Hemoglobin copper sulfate,83026,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7.02,,,,,,,fee schedule,3.61,13.04,APC
Fetal hemoglobin chemical,83030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45.66,,,,,,,fee schedule,9.67,45.66,
Fetal hemoglobin chemical,83030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36.6,,,,,,,fee schedule,9.67,45.66,
Fetal hemoglobin chemical,83030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39.98,,,,,,,fee schedule,9.67,45.66,
Fetal hemoglobin chemical,83030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42.04,,,,,,,fee schedule,9.67,45.66,
Fetal hemoglobin chemical,83030,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.67,,,,,,,fee schedule,9.67,45.66,Laboratory
Fetal hemoglobin chemical,83030,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.28,,,,,,,fee schedule,9.67,45.66,APC
Fetal hemoglobin chemical,83030,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11.17,,,,,,,fee schedule,9.67,45.66,APC
Fetal hemoglobin chemical,83030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10.74,,,,,,,fee schedule,9.67,45.66,APC
Fetal hemoglobin chemical,83030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.43,,,,,,,fee schedule,9.67,45.66,Radiology
Fetal hemoglobin chemical,83030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15.04,,,,,,,fee schedule,9.67,45.66,APC
Fetal hemoglobin chemical,83030,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18.8,,,,,,,fee schedule,9.67,45.66,APC
Fetal hemoglobin assay qual,83033,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,32.89,,,,,,,fee schedule,7.2,32.89,
Fetal hemoglobin assay qual,83033,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26.36,,,,,,,fee schedule,7.2,32.89,
Fetal hemoglobin assay qual,83033,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28.8,,,,,,,fee schedule,7.2,32.89,
Fetal hemoglobin assay qual,83033,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30.28,,,,,,,fee schedule,7.2,32.89,
Fetal hemoglobin assay qual,83033,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.2,,,,,,,fee schedule,7.2,32.89,Laboratory
Fetal hemoglobin assay qual,83033,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.4,,,,,,,fee schedule,7.2,32.89,APC
Fetal hemoglobin assay qual,83033,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8.32,,,,,,,fee schedule,7.2,32.89,APC
Fetal hemoglobin assay qual,83033,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8,,,,,,,fee schedule,7.2,32.89,APC
Fetal hemoglobin assay qual,83033,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12.24,,,,,,,fee schedule,7.2,32.89,Radiology
Fetal hemoglobin assay qual,83033,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11.2,,,,,,,fee schedule,7.2,32.89,APC
Fetal hemoglobin assay qual,83033,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14,,,,,,,fee schedule,7.2,32.89,APC
Glycosylated hemoglobin test,83036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42.45,,,,,,,fee schedule,8.74,42.45,
Glycosylated hemoglobin test,83036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,34.03,,,,,,,fee schedule,8.74,42.45,
Glycosylated hemoglobin test,83036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37.17,,,,,,,fee schedule,8.74,42.45,
Glycosylated hemoglobin test,83036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,39.08,,,,,,,fee schedule,8.74,42.45,
Glycosylated hemoglobin test,83036,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.74,,,,,,,fee schedule,8.74,42.45,Laboratory
Glycosylated hemoglobin test,83036,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.2,,,,,,,fee schedule,8.74,42.45,APC
Glycosylated hemoglobin test,83036,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10.1,,,,,,,fee schedule,8.74,42.45,APC
Glycosylated hemoglobin test,83036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9.71,,,,,,,fee schedule,8.74,42.45,APC
Glycosylated hemoglobin test,83036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.86,,,,,,,fee schedule,8.74,42.45,Radiology
Glycosylated hemoglobin test,83036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.59,,,,,,,fee schedule,8.74,42.45,APC
Glycosylated hemoglobin test,83036,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16.99,,,,,,,fee schedule,8.74,42.45,APC
Glycosylated hb home device,83037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,53.56,,,,,,,fee schedule,8.74,53.56,
Glycosylated hb home device,83037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.94,,,,,,,fee schedule,8.74,53.56,
Glycosylated hb home device,83037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.9,,,,,,,fee schedule,8.74,53.56,
Glycosylated hb home device,83037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,49.31,,,,,,,fee schedule,8.74,53.56,
Glycosylated hb home device,83037,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.74,,,,,,,fee schedule,8.74,53.56,Laboratory
Glycosylated hb home device,83037,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.2,,,,,,,fee schedule,8.74,53.56,APC
Glycosylated hb home device,83037,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10.1,,,,,,,fee schedule,8.74,53.56,APC
Glycosylated hb home device,83037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9.71,,,,,,,fee schedule,8.74,53.56,APC
Glycosylated hb home device,83037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.86,,,,,,,fee schedule,8.74,53.56,Radiology
Glycosylated hb home device,83037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.59,,,,,,,fee schedule,8.74,53.56,APC
Glycosylated hb home device,83037,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16.99,,,,,,,fee schedule,8.74,53.56,APC
Blood methemoglobin test,83045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27.37,,,,,,,fee schedule,5.84,27.37,
Blood methemoglobin test,83045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21.94,,,,,,,fee schedule,5.84,27.37,
Blood methemoglobin test,83045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23.96,,,,,,,fee schedule,5.84,27.37,
Blood methemoglobin test,83045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,25.2,,,,,,,fee schedule,5.84,27.37,
Blood methemoglobin test,83045,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.84,,,,,,,fee schedule,5.84,27.37,Laboratory
Blood methemoglobin test,83045,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.81,,,,,,,fee schedule,5.84,27.37,APC
Blood methemoglobin test,83045,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6.75,,,,,,,fee schedule,5.84,27.37,APC
Blood methemoglobin test,83045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6.49,,,,,,,fee schedule,5.84,27.37,APC
Blood methemoglobin test,83045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.93,,,,,,,fee schedule,5.84,27.37,Radiology
Blood methemoglobin test,83045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.09,,,,,,,fee schedule,5.84,27.37,APC
Blood methemoglobin test,83045,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11.36,,,,,,,fee schedule,5.84,27.37,APC
Blood methemoglobin assay,83050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,91.81,,,,,,,fee schedule,7.38,91.81,
Blood methemoglobin assay,83050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,73.59,,,,,,,fee schedule,7.38,91.81,
Blood methemoglobin assay,83050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,80.39,,,,,,,fee schedule,7.38,91.81,
Blood methemoglobin assay,83050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,84.52,,,,,,,fee schedule,7.38,91.81,
Blood methemoglobin assay,83050,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.38,,,,,,,fee schedule,7.38,91.81,Laboratory
Blood methemoglobin assay,83050,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.61,,,,,,,fee schedule,7.38,91.81,APC
Blood methemoglobin assay,83050,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8.53,,,,,,,fee schedule,7.38,91.81,APC
Blood methemoglobin assay,83050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8.2,,,,,,,fee schedule,7.38,91.81,APC
Blood methemoglobin assay,83050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12.55,,,,,,,fee schedule,7.38,91.81,Radiology
Blood methemoglobin assay,83050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11.48,,,,,,,fee schedule,7.38,91.81,APC
Blood methemoglobin assay,83050,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14.35,,,,,,,fee schedule,7.38,91.81,APC
Assay of plasma hemoglobin,83051,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,40.33,,,,,,,fee schedule,6.58,40.33,
Assay of plasma hemoglobin,83051,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32.33,,,,,,,fee schedule,6.58,40.33,
Assay of plasma hemoglobin,83051,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35.32,,,,,,,fee schedule,6.58,40.33,
Assay of plasma hemoglobin,83051,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37.13,,,,,,,fee schedule,6.58,40.33,
Assay of plasma hemoglobin,83051,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.58,,,,,,,fee schedule,6.58,40.33,Laboratory
Assay of plasma hemoglobin,83051,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.68,,,,,,,fee schedule,6.58,40.33,APC
Assay of plasma hemoglobin,83051,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7.6,,,,,,,fee schedule,6.58,40.33,APC
Assay of plasma hemoglobin,83051,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7.31,,,,,,,fee schedule,6.58,40.33,APC
Assay of plasma hemoglobin,83051,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11.18,,,,,,,fee schedule,6.58,40.33,Radiology
Assay of plasma hemoglobin,83051,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10.23,,,,,,,fee schedule,6.58,40.33,APC
Assay of plasma hemoglobin,83051,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12.79,,,,,,,fee schedule,6.58,40.33,APC
Blood sulfhemoglobin assay,83060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45.66,,,,,,,fee schedule,7.92,45.66,
Blood sulfhemoglobin assay,83060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36.6,,,,,,,fee schedule,7.92,45.66,
Blood sulfhemoglobin assay,83060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39.98,,,,,,,fee schedule,7.92,45.66,
Blood sulfhemoglobin assay,83060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42.04,,,,,,,fee schedule,7.92,45.66,
Blood sulfhemoglobin assay,83060,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.92,,,,,,,fee schedule,7.92,45.66,Laboratory
Blood sulfhemoglobin assay,83060,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.24,,,,,,,fee schedule,7.92,45.66,APC
Blood sulfhemoglobin assay,83060,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9.15,,,,,,,fee schedule,7.92,45.66,APC
Blood sulfhemoglobin assay,83060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8.8,,,,,,,fee schedule,7.92,45.66,APC
Blood sulfhemoglobin assay,83060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.46,,,,,,,fee schedule,7.92,45.66,Radiology
Blood sulfhemoglobin assay,83060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12.32,,,,,,,fee schedule,7.92,45.66,APC
Blood sulfhemoglobin assay,83060,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15.4,,,,,,,fee schedule,7.92,45.66,APC
Assay of hemoglobin heat,83065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,38.03,,,,,,,fee schedule,8.1,38.03,
Assay of hemoglobin heat,83065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,30.48,,,,,,,fee schedule,8.1,38.03,
Assay of hemoglobin heat,83065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,33.3,,,,,,,fee schedule,8.1,38.03,
Assay of hemoglobin heat,83065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,35.01,,,,,,,fee schedule,8.1,38.03,
Assay of hemoglobin heat,83065,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.1,,,,,,,fee schedule,8.1,38.03,Laboratory
Assay of hemoglobin heat,83065,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.45,,,,,,,fee schedule,8.1,38.03,APC
Assay of hemoglobin heat,83065,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9.36,,,,,,,fee schedule,8.1,38.03,APC
Assay of hemoglobin heat,83065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9,,,,,,,fee schedule,8.1,38.03,APC
Assay of hemoglobin heat,83065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.77,,,,,,,fee schedule,8.1,38.03,Radiology
Assay of hemoglobin heat,83065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12.6,,,,,,,fee schedule,8.1,38.03,APC
Assay of hemoglobin heat,83065,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15.75,,,,,,,fee schedule,8.1,38.03,APC
Hemoglobin stability screen,83068,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46.76,,,,,,,fee schedule,8.52,46.76,
Hemoglobin stability screen,83068,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37.48,,,,,,,fee schedule,8.52,46.76,
Hemoglobin stability screen,83068,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40.94,,,,,,,fee schedule,8.52,46.76,
Hemoglobin stability screen,83068,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,43.05,,,,,,,fee schedule,8.52,46.76,
Hemoglobin stability screen,83068,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.52,,,,,,,fee schedule,8.52,46.76,Laboratory
Hemoglobin stability screen,83068,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.94,,,,,,,fee schedule,8.52,46.76,APC
Hemoglobin stability screen,83068,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9.85,,,,,,,fee schedule,8.52,46.76,APC
Hemoglobin stability screen,83068,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9.47,,,,,,,fee schedule,8.52,46.76,APC
Hemoglobin stability screen,83068,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.49,,,,,,,fee schedule,8.52,46.76,Radiology
Hemoglobin stability screen,83068,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.26,,,,,,,fee schedule,8.52,46.76,APC
Hemoglobin stability screen,83068,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16.57,,,,,,,fee schedule,8.52,46.76,APC
Assay of urine hemoglobin,83069,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21.77,,,,,,,fee schedule,3.56,21.77,
Assay of urine hemoglobin,83069,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17.45,,,,,,,fee schedule,3.56,21.77,
Assay of urine hemoglobin,83069,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19.07,,,,,,,fee schedule,3.56,21.77,
Assay of urine hemoglobin,83069,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20.04,,,,,,,fee schedule,3.56,21.77,
Assay of urine hemoglobin,83069,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.56,,,,,,,fee schedule,3.56,21.77,Laboratory
Assay of urine hemoglobin,83069,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.15,,,,,,,fee schedule,3.56,21.77,APC
Assay of urine hemoglobin,83069,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4.11,,,,,,,fee schedule,3.56,21.77,APC
Assay of urine hemoglobin,83069,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3.95,,,,,,,fee schedule,3.56,21.77,APC
Assay of urine hemoglobin,83069,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.04,,,,,,,fee schedule,3.56,21.77,Radiology
Assay of urine hemoglobin,83069,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.53,,,,,,,fee schedule,3.56,21.77,APC
Assay of urine hemoglobin,83069,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6.91,,,,,,,fee schedule,3.56,21.77,APC
Assay of hemosiderin qual,83070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26.2,,,,,,,fee schedule,4.28,26.2,
Assay of hemosiderin qual,83070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21,,,,,,,fee schedule,4.28,26.2,
Assay of hemosiderin qual,83070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22.94,,,,,,,fee schedule,4.28,26.2,
Assay of hemosiderin qual,83070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24.12,,,,,,,fee schedule,4.28,26.2,
Assay of hemosiderin qual,83070,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.28,,,,,,,fee schedule,4.28,26.2,Laboratory
Assay of hemosiderin qual,83070,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.99,,,,,,,fee schedule,4.28,26.2,APC
Assay of hemosiderin qual,83070,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4.94,,,,,,,fee schedule,4.28,26.2,APC
Assay of hemosiderin qual,83070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4.75,,,,,,,fee schedule,4.28,26.2,APC
Assay of hemosiderin qual,83070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.27,,,,,,,fee schedule,4.28,26.2,Radiology
Assay of hemosiderin qual,83070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.65,,,,,,,fee schedule,4.28,26.2,APC
Assay of hemosiderin qual,83070,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8.31,,,,,,,fee schedule,4.28,26.2,APC
Assay of b hexosaminidase,83080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,93.1,,,,,,,fee schedule,15.18,93.1,
Assay of b hexosaminidase,83080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,74.63,,,,,,,fee schedule,15.18,93.1,
Assay of b hexosaminidase,83080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,81.53,,,,,,,fee schedule,15.18,93.1,
Assay of b hexosaminidase,83080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,85.71,,,,,,,fee schedule,15.18,93.1,
Assay of b hexosaminidase,83080,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.18,,,,,,,fee schedule,15.18,93.1,Laboratory
Assay of b hexosaminidase,83080,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.71,,,,,,,fee schedule,15.18,93.1,APC
Assay of b hexosaminidase,83080,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,17.54,,,,,,,fee schedule,15.18,93.1,APC
Assay of b hexosaminidase,83080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16.87,,,,,,,fee schedule,15.18,93.1,APC
Assay of b hexosaminidase,83080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.81,,,,,,,fee schedule,15.18,93.1,Radiology
Assay of b hexosaminidase,83080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.62,,,,,,,fee schedule,15.18,93.1,APC
Assay of b hexosaminidase,83080,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,29.52,,,,,,,fee schedule,15.18,93.1,APC
Assay of histamine,83088,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,162.99,,,,,,,fee schedule,26.58,162.99,
Assay of histamine,83088,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,130.65,,,,,,,fee schedule,26.58,162.99,
Assay of histamine,83088,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,142.73,,,,,,,fee schedule,26.58,162.99,
Assay of histamine,83088,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,150.06,,,,,,,fee schedule,26.58,162.99,
Assay of histamine,83088,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26.58,,,,,,,fee schedule,26.58,162.99,Laboratory
Assay of histamine,83088,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,31.01,,,,,,,fee schedule,26.58,162.99,APC
Assay of histamine,83088,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,30.71,,,,,,,fee schedule,26.58,162.99,APC
Assay of histamine,83088,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,29.53,,,,,,,fee schedule,26.58,162.99,APC
Assay of histamine,83088,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,45.18,,,,,,,fee schedule,26.58,162.99,Radiology
Assay of histamine,83088,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,41.34,,,,,,,fee schedule,26.58,162.99,APC
Assay of histamine,83088,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,51.68,,,,,,,fee schedule,26.58,162.99,APC
Assay Of Homocystine,83090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,200.79,,,,,,,fee schedule,16.13,200.79,
Assay Of Homocystine,83090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,160.95,,,,,,,fee schedule,16.13,200.79,
Assay Of Homocystine,83090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,175.83,,,,,,,fee schedule,16.13,200.79,
Assay Of Homocystine,83090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,184.86,,,,,,,fee schedule,16.13,200.79,
Assay Of Homocystine,83090,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.13,,,,,,,fee schedule,16.13,200.79,Laboratory
Assay Of Homocystine,83090,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.82,,,,,,,fee schedule,16.13,200.79,APC
Assay Of Homocystine,83090,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18.64,,,,,,,fee schedule,16.13,200.79,APC
Assay Of Homocystine,83090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17.92,,,,,,,fee schedule,16.13,200.79,APC
Assay Of Homocystine,83090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27.42,,,,,,,fee schedule,16.13,200.79,Radiology
Assay Of Homocystine,83090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.09,,,,,,,fee schedule,16.13,200.79,APC
Assay Of Homocystine,83090,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31.36,,,,,,,fee schedule,16.13,200.79,APC
Assay of homovanillic acid,83150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,61.69,,,,,,,fee schedule,20.17,61.69,
Assay of homovanillic acid,83150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,49.45,,,,,,,fee schedule,20.17,61.69,
Assay of homovanillic acid,83150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,54.02,,,,,,,fee schedule,20.17,61.69,
Assay of homovanillic acid,83150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,56.79,,,,,,,fee schedule,20.17,61.69,
Assay of homovanillic acid,83150,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,20.17,,,,,,,fee schedule,20.17,61.69,Laboratory
Assay of homovanillic acid,83150,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,23.53,,,,,,,fee schedule,20.17,61.69,APC
Assay of homovanillic acid,83150,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,23.31,,,,,,,fee schedule,20.17,61.69,APC
Assay of homovanillic acid,83150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,22.41,,,,,,,fee schedule,20.17,61.69,APC
Assay of homovanillic acid,83150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,34.29,,,,,,,fee schedule,20.17,61.69,Radiology
Assay of homovanillic acid,83150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,31.37,,,,,,,fee schedule,20.17,61.69,APC
Assay of homovanillic acid,83150,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,39.22,,,,,,,fee schedule,20.17,61.69,APC
Assay of corticosteroids 17,83491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,96.65,,,,,,,fee schedule,16.11,96.65,
Assay of corticosteroids 17,83491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,77.48,,,,,,,fee schedule,16.11,96.65,
Assay of corticosteroids 17,83491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,84.64,,,,,,,fee schedule,16.11,96.65,
Assay of corticosteroids 17,83491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,88.98,,,,,,,fee schedule,16.11,96.65,
Assay of corticosteroids 17,83491,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.11,,,,,,,fee schedule,16.11,96.65,Laboratory
Assay of corticosteroids 17,83491,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.79,,,,,,,fee schedule,16.11,96.65,APC
Assay of corticosteroids 17,83491,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18.62,,,,,,,fee schedule,16.11,96.65,APC
Assay of corticosteroids 17,83491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17.9,,,,,,,fee schedule,16.11,96.65,APC
Assay of corticosteroids 17,83491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27.39,,,,,,,fee schedule,16.11,96.65,Radiology
Assay of corticosteroids 17,83491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.06,,,,,,,fee schedule,16.11,96.65,APC
Assay of corticosteroids 17,83491,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31.32,,,,,,,fee schedule,16.11,96.65,APC
Assay of 5-hiaa,83497,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,40.72,,,,,,,fee schedule,11.61,40.72,
Assay of 5-hiaa,83497,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32.64,,,,,,,fee schedule,11.61,40.72,
Assay of 5-hiaa,83497,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35.66,,,,,,,fee schedule,11.61,40.72,
Assay of 5-hiaa,83497,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37.49,,,,,,,fee schedule,11.61,40.72,
Assay of 5-hiaa,83497,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.61,,,,,,,fee schedule,11.61,40.72,Laboratory
Assay of 5-hiaa,83497,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.55,,,,,,,fee schedule,11.61,40.72,APC
Assay of 5-hiaa,83497,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.42,,,,,,,fee schedule,11.61,40.72,APC
Assay of 5-hiaa,83497,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.9,,,,,,,fee schedule,11.61,40.72,APC
Assay of 5-hiaa,83497,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.74,,,,,,,fee schedule,11.61,40.72,Radiology
Assay of 5-hiaa,83497,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.06,,,,,,,fee schedule,11.61,40.72,APC
Assay of 5-hiaa,83497,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22.58,,,,,,,fee schedule,11.61,40.72,APC
Assay of progesterone 17-d,83498,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,132.65,,,,,,,fee schedule,24.45,132.65,
Assay of progesterone 17-d,83498,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,106.33,,,,,,,fee schedule,24.45,132.65,
Assay of progesterone 17-d,83498,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,116.16,,,,,,,fee schedule,24.45,132.65,
Assay of progesterone 17-d,83498,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,122.13,,,,,,,fee schedule,24.45,132.65,
Assay of progesterone 17-d,83498,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24.45,,,,,,,fee schedule,24.45,132.65,Laboratory
Assay of progesterone 17-d,83498,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,28.53,,,,,,,fee schedule,24.45,132.65,APC
Assay of progesterone 17-d,83498,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,28.26,,,,,,,fee schedule,24.45,132.65,APC
Assay of progesterone 17-d,83498,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,27.17,,,,,,,fee schedule,24.45,132.65,APC
Assay of progesterone 17-d,83498,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,41.57,,,,,,,fee schedule,24.45,132.65,Radiology
Assay of progesterone 17-d,83498,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,38.04,,,,,,,fee schedule,24.45,132.65,APC
Assay of progesterone 17-d,83498,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,47.55,,,,,,,fee schedule,24.45,132.65,APC
Assay free hydroxyproline,83500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,125,,,,,,,fee schedule,20.39,125,
Assay free hydroxyproline,83500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,100.2,,,,,,,fee schedule,20.39,125,
Assay free hydroxyproline,83500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,109.46,,,,,,,fee schedule,20.39,125,
Assay free hydroxyproline,83500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,115.08,,,,,,,fee schedule,20.39,125,
Assay free hydroxyproline,83500,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,20.38,,,,,,,fee schedule,20.39,125,Laboratory
Assay free hydroxyproline,83500,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,23.78,,,,,,,fee schedule,20.39,125,APC
Assay free hydroxyproline,83500,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,23.56,,,,,,,fee schedule,20.39,125,APC
Assay free hydroxyproline,83500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,22.65,,,,,,,fee schedule,20.39,125,APC
Assay free hydroxyproline,83500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,34.65,,,,,,,fee schedule,20.39,125,Radiology
Assay free hydroxyproline,83500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,31.71,,,,,,,fee schedule,20.39,125,APC
Assay free hydroxyproline,83500,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,39.64,,,,,,,fee schedule,20.39,125,APC
Assay total hydroxyproline,83505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,134.15,,,,,,,fee schedule,21.87,134.15,
Assay total hydroxyproline,83505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,107.53,,,,,,,fee schedule,21.87,134.15,
Assay total hydroxyproline,83505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,117.47,,,,,,,fee schedule,21.87,134.15,
Assay total hydroxyproline,83505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,123.51,,,,,,,fee schedule,21.87,134.15,
Assay total hydroxyproline,83505,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21.87,,,,,,,fee schedule,21.87,134.15,Laboratory
Assay total hydroxyproline,83505,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,25.52,,,,,,,fee schedule,21.87,134.15,APC
Assay total hydroxyproline,83505,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,25.27,,,,,,,fee schedule,21.87,134.15,APC
Assay total hydroxyproline,83505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,24.3,,,,,,,fee schedule,21.87,134.15,APC
Assay total hydroxyproline,83505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,37.18,,,,,,,fee schedule,21.87,134.15,Radiology
Assay total hydroxyproline,83505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,34.02,,,,,,,fee schedule,21.87,134.15,APC
Assay total hydroxyproline,83505,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,42.52,,,,,,,fee schedule,21.87,134.15,APC
Immunoassay nonantibody,83516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,88.37,,,,,,,fee schedule,10.38,88.37,
Immunoassay nonantibody,83516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,70.84,,,,,,,fee schedule,10.38,88.37,
Immunoassay nonantibody,83516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,77.38,,,,,,,fee schedule,10.38,88.37,
Immunoassay nonantibody,83516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,81.36,,,,,,,fee schedule,10.38,88.37,
Immunoassay nonantibody,83516,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.38,,,,,,,fee schedule,10.38,88.37,Laboratory
Immunoassay nonantibody,83516,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.11,,,,,,,fee schedule,10.38,88.37,APC
Immunoassay nonantibody,83516,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11.99,,,,,,,fee schedule,10.38,88.37,APC
Immunoassay nonantibody,83516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11.53,,,,,,,fee schedule,10.38,88.37,APC
Immunoassay nonantibody,83516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.64,,,,,,,fee schedule,10.38,88.37,Radiology
Immunoassay nonantibody,83516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.14,,,,,,,fee schedule,10.38,88.37,APC
Immunoassay nonantibody,83516,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20.18,,,,,,,fee schedule,10.38,88.37,APC
Immunoassay dipstick,83518,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46.8,,,,,,,fee schedule,8.68,46.8,
Immunoassay dipstick,83518,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37.51,,,,,,,fee schedule,8.68,46.8,
Immunoassay dipstick,83518,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40.98,,,,,,,fee schedule,8.68,46.8,
Immunoassay dipstick,83518,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,43.08,,,,,,,fee schedule,8.68,46.8,
Immunoassay dipstick,83518,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.68,,,,,,,fee schedule,8.68,46.8,Laboratory
Immunoassay dipstick,83518,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.12,,,,,,,fee schedule,8.68,46.8,APC
Immunoassay dipstick,83518,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10.03,,,,,,,fee schedule,8.68,46.8,APC
Immunoassay dipstick,83518,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9.64,,,,,,,fee schedule,8.68,46.8,APC
Immunoassay dipstick,83518,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.75,,,,,,,fee schedule,8.68,46.8,Radiology
Immunoassay dipstick,83518,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.5,,,,,,,fee schedule,8.68,46.8,APC
Immunoassay dipstick,83518,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16.87,,,,,,,fee schedule,8.68,46.8,APC
Ria nonantibody,83519,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,91.56,,,,,,,fee schedule,16.56,91.56,
Ria nonantibody,83519,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,73.39,,,,,,,fee schedule,16.56,91.56,
Ria nonantibody,83519,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,80.18,,,,,,,fee schedule,16.56,91.56,
Ria nonantibody,83519,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,84.29,,,,,,,fee schedule,16.56,91.56,
Ria nonantibody,83519,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.56,,,,,,,fee schedule,16.56,91.56,Laboratory
Ria nonantibody,83519,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.32,,,,,,,fee schedule,16.56,91.56,APC
Ria nonantibody,83519,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,19.14,,,,,,,fee schedule,16.56,91.56,APC
Ria nonantibody,83519,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18.4,,,,,,,fee schedule,16.56,91.56,APC
Ria nonantibody,83519,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.15,,,,,,,fee schedule,16.56,91.56,Radiology
Ria nonantibody,83519,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.76,,,,,,,fee schedule,16.56,91.56,APC
Ria nonantibody,83519,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,32.2,,,,,,,fee schedule,16.56,91.56,APC
Immunoassay quant nos nonab,83520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,104.22,,,,,,,fee schedule,15.54,104.22,
Immunoassay quant nos nonab,83520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,83.54,,,,,,,fee schedule,15.54,104.22,
Immunoassay quant nos nonab,83520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,91.27,,,,,,,fee schedule,15.54,104.22,
Immunoassay quant nos nonab,83520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,95.95,,,,,,,fee schedule,15.54,104.22,
Immunoassay quant nos nonab,83520,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.54,,,,,,,fee schedule,15.54,104.22,Laboratory
Immunoassay quant nos nonab,83520,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.13,,,,,,,fee schedule,15.54,104.22,APC
Immunoassay quant nos nonab,83520,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,17.96,,,,,,,fee schedule,15.54,104.22,APC
Immunoassay quant nos nonab,83520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17.27,,,,,,,fee schedule,15.54,104.22,APC
Immunoassay quant nos nonab,83520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26.42,,,,,,,fee schedule,15.54,104.22,Radiology
Immunoassay quant nos nonab,83520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24.18,,,,,,,fee schedule,15.54,104.22,APC
Immunoassay quant nos nonab,83520,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30.22,,,,,,,fee schedule,15.54,104.22,APC
Ig light chains free each,83521,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,65.28,,,,,,,fee schedule,15.54,65.28,
Ig light chains free each,83521,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52.33,,,,,,,fee schedule,15.54,65.28,
Ig light chains free each,83521,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.16,,,,,,,fee schedule,15.54,65.28,
Ig light chains free each,83521,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.1,,,,,,,fee schedule,15.54,65.28,
Ig light chains free each,83521,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.54,,,,,,,fee schedule,15.54,65.28,Laboratory
Ig light chains free each,83521,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.13,,,,,,,fee schedule,15.54,65.28,APC
Ig light chains free each,83521,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,17.96,,,,,,,fee schedule,15.54,65.28,APC
Ig light chains free each,83521,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17.27,,,,,,,fee schedule,15.54,65.28,APC
Ig light chains free each,83521,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26.42,,,,,,,fee schedule,15.54,65.28,Radiology
Ig light chains free each,83521,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24.18,,,,,,,fee schedule,15.54,65.28,APC
Ig light chains free each,83521,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30.22,,,,,,,fee schedule,15.54,65.28,APC
Assay of insulin,83525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,79.72,,,,,,,fee schedule,10.29,79.72,
Assay of insulin,83525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,63.9,,,,,,,fee schedule,10.29,79.72,
Assay of insulin,83525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,69.8,,,,,,,fee schedule,10.29,79.72,
Assay of insulin,83525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,73.39,,,,,,,fee schedule,10.29,79.72,
Assay of insulin,83525,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.29,,,,,,,fee schedule,10.29,79.72,Laboratory
Assay of insulin,83525,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12,,,,,,,fee schedule,10.29,79.72,APC
Assay of insulin,83525,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11.89,,,,,,,fee schedule,10.29,79.72,APC
Assay of insulin,83525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11.43,,,,,,,fee schedule,10.29,79.72,APC
Assay of insulin,83525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.49,,,,,,,fee schedule,10.29,79.72,Radiology
Assay of insulin,83525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16,,,,,,,fee schedule,10.29,79.72,APC
Assay of insulin,83525,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20,,,,,,,fee schedule,10.29,79.72,APC
Assay of insulin,83527,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,71.48,,,,,,,fee schedule,11.66,71.48,
Assay of insulin,83527,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.3,,,,,,,fee schedule,11.66,71.48,
Assay of insulin,83527,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,62.59,,,,,,,fee schedule,11.66,71.48,
Assay of insulin,83527,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,65.81,,,,,,,fee schedule,11.66,71.48,
Assay of insulin,83527,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.66,,,,,,,fee schedule,11.66,71.48,Laboratory
Assay of insulin,83527,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.6,,,,,,,fee schedule,11.66,71.48,APC
Assay of insulin,83527,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.47,,,,,,,fee schedule,11.66,71.48,APC
Assay of insulin,83527,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.95,,,,,,,fee schedule,11.66,71.48,APC
Assay of insulin,83527,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.81,,,,,,,fee schedule,11.66,71.48,Radiology
Assay of insulin,83527,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.13,,,,,,,fee schedule,11.66,71.48,APC
Assay of insulin,83527,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22.66,,,,,,,fee schedule,11.66,71.48,APC
Assay of intrinsic factor,83528,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,87.77,,,,,,,fee schedule,17.84,87.77,
Assay of intrinsic factor,83528,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,70.36,,,,,,,fee schedule,17.84,87.77,
Assay of intrinsic factor,83528,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,76.86,,,,,,,fee schedule,17.84,87.77,
Assay of intrinsic factor,83528,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,80.81,,,,,,,fee schedule,17.84,87.77,
Assay of intrinsic factor,83528,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.84,,,,,,,fee schedule,17.84,87.77,Laboratory
Assay of intrinsic factor,83528,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20.81,,,,,,,fee schedule,17.84,87.77,APC
Assay of intrinsic factor,83528,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,20.61,,,,,,,fee schedule,17.84,87.77,APC
Assay of intrinsic factor,83528,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,19.82,,,,,,,fee schedule,17.84,87.77,APC
Assay of intrinsic factor,83528,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,30.32,,,,,,,fee schedule,17.84,87.77,Radiology
Assay of intrinsic factor,83528,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27.75,,,,,,,fee schedule,17.84,87.77,APC
Assay of intrinsic factor,83528,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,34.68,,,,,,,fee schedule,17.84,87.77,APC
Asay of interleukin-6 (il-6),83529,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,65.28,,,,,,,fee schedule,15.54,65.28,
Asay of interleukin-6 (il-6),83529,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52.33,,,,,,,fee schedule,15.54,65.28,
Asay of interleukin-6 (il-6),83529,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.16,,,,,,,fee schedule,15.54,65.28,
Asay of interleukin-6 (il-6),83529,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.1,,,,,,,fee schedule,15.54,65.28,
Asay of interleukin-6 (il-6),83529,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.54,,,,,,,fee schedule,15.54,65.28,Laboratory
Asay of interleukin-6 (il-6),83529,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.13,,,,,,,fee schedule,15.54,65.28,APC
Asay of interleukin-6 (il-6),83529,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,17.96,,,,,,,fee schedule,15.54,65.28,APC
Asay of interleukin-6 (il-6),83529,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17.27,,,,,,,fee schedule,15.54,65.28,APC
Asay of interleukin-6 (il-6),83529,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26.42,,,,,,,fee schedule,15.54,65.28,Radiology
Asay of interleukin-6 (il-6),83529,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24.18,,,,,,,fee schedule,15.54,65.28,APC
Asay of interleukin-6 (il-6),83529,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30.22,,,,,,,fee schedule,15.54,65.28,APC
Assay of iron,83540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46.68,,,,,,,fee schedule,5.82,46.68,
Assay of iron,83540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37.42,,,,,,,fee schedule,5.82,46.68,
Assay of iron,83540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40.88,,,,,,,fee schedule,5.82,46.68,
Assay of iron,83540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42.98,,,,,,,fee schedule,5.82,46.68,
Assay of iron,83540,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.82,,,,,,,fee schedule,5.82,46.68,Laboratory
Assay of iron,83540,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.79,,,,,,,fee schedule,5.82,46.68,APC
Assay of iron,83540,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6.73,,,,,,,fee schedule,5.82,46.68,APC
Assay of iron,83540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6.47,,,,,,,fee schedule,5.82,46.68,APC
Assay of iron,83540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.9,,,,,,,fee schedule,5.82,46.68,Radiology
Assay of iron,83540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.06,,,,,,,fee schedule,5.82,46.68,APC
Assay of iron,83540,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11.32,,,,,,,fee schedule,5.82,46.68,APC
Iron binding test,83550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,87.81,,,,,,,fee schedule,7.87,87.81,
Iron binding test,83550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,70.39,,,,,,,fee schedule,7.87,87.81,
Iron binding test,83550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,76.89,,,,,,,fee schedule,7.87,87.81,
Iron binding test,83550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,80.84,,,,,,,fee schedule,7.87,87.81,
Iron binding test,83550,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.87,,,,,,,fee schedule,7.87,87.81,Laboratory
Iron binding test,83550,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.18,,,,,,,fee schedule,7.87,87.81,APC
Iron binding test,83550,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9.09,,,,,,,fee schedule,7.87,87.81,APC
Iron binding test,83550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8.74,,,,,,,fee schedule,7.87,87.81,APC
Iron binding test,83550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.37,,,,,,,fee schedule,7.87,87.81,Radiology
Iron binding test,83550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12.24,,,,,,,fee schedule,7.87,87.81,APC
Iron binding test,83550,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15.3,,,,,,,fee schedule,7.87,87.81,APC
Assay of idh enzyme,83570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,48.8,,,,,,,fee schedule,7.96,48.8,
Assay of idh enzyme,83570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39.12,,,,,,,fee schedule,7.96,48.8,
Assay of idh enzyme,83570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.73,,,,,,,fee schedule,7.96,48.8,
Assay of idh enzyme,83570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,44.93,,,,,,,fee schedule,7.96,48.8,
Assay of idh enzyme,83570,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.96,,,,,,,fee schedule,7.96,48.8,Laboratory
Assay of idh enzyme,83570,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.29,,,,,,,fee schedule,7.96,48.8,APC
Assay of idh enzyme,83570,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9.2,,,,,,,fee schedule,7.96,48.8,APC
Assay of idh enzyme,83570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8.85,,,,,,,fee schedule,7.96,48.8,APC
Assay of idh enzyme,83570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.54,,,,,,,fee schedule,7.96,48.8,Radiology
Assay of idh enzyme,83570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12.39,,,,,,,fee schedule,7.96,48.8,APC
Assay of idh enzyme,83570,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15.49,,,,,,,fee schedule,7.96,48.8,APC
Assay of ketogenic steroids,83582,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,78.21,,,,,,,fee schedule,13.92,78.21,
Assay of ketogenic steroids,83582,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,62.69,,,,,,,fee schedule,13.92,78.21,
Assay of ketogenic steroids,83582,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,68.48,,,,,,,fee schedule,13.92,78.21,
Assay of ketogenic steroids,83582,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,72,,,,,,,fee schedule,13.92,78.21,
Assay of ketogenic steroids,83582,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.92,,,,,,,fee schedule,13.92,78.21,Laboratory
Assay of ketogenic steroids,83582,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.24,,,,,,,fee schedule,13.92,78.21,APC
Assay of ketogenic steroids,83582,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,16.09,,,,,,,fee schedule,13.92,78.21,APC
Assay of ketogenic steroids,83582,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,15.47,,,,,,,fee schedule,13.92,78.21,APC
Assay of ketogenic steroids,83582,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.67,,,,,,,fee schedule,13.92,78.21,Radiology
Assay of ketogenic steroids,83582,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21.66,,,,,,,fee schedule,13.92,78.21,APC
Assay of ketogenic steroids,83582,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,27.07,,,,,,,fee schedule,13.92,78.21,APC
Assay 17- ketosteroids,83586,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,70.65,,,,,,,fee schedule,11.52,70.65,
Assay 17- ketosteroids,83586,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56.63,,,,,,,fee schedule,11.52,70.65,
Assay 17- ketosteroids,83586,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,61.86,,,,,,,fee schedule,11.52,70.65,
Assay 17- ketosteroids,83586,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,65.04,,,,,,,fee schedule,11.52,70.65,
Assay 17- ketosteroids,83586,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.52,,,,,,,fee schedule,11.52,70.65,Laboratory
Assay 17- ketosteroids,83586,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.44,,,,,,,fee schedule,11.52,70.65,APC
Assay 17- ketosteroids,83586,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.31,,,,,,,fee schedule,11.52,70.65,APC
Assay 17- ketosteroids,83586,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.8,,,,,,,fee schedule,11.52,70.65,APC
Assay 17- ketosteroids,83586,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.58,,,,,,,fee schedule,11.52,70.65,Radiology
Assay 17- ketosteroids,83586,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.92,,,,,,,fee schedule,11.52,70.65,APC
Assay 17- ketosteroids,83586,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22.4,,,,,,,fee schedule,11.52,70.65,APC
Fractionation ketosteroids,83593,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,145.15,,,,,,,fee schedule,25.65,145.15,
Fractionation ketosteroids,83593,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,116.35,,,,,,,fee schedule,25.65,145.15,
Fractionation ketosteroids,83593,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,127.1,,,,,,,fee schedule,25.65,145.15,
Fractionation ketosteroids,83593,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,133.63,,,,,,,fee schedule,25.65,145.15,
Fractionation ketosteroids,83593,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25.65,,,,,,,fee schedule,25.65,145.15,Laboratory
Fractionation ketosteroids,83593,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,29.92,,,,,,,fee schedule,25.65,145.15,APC
Fractionation ketosteroids,83593,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,29.64,,,,,,,fee schedule,25.65,145.15,APC
Fractionation ketosteroids,83593,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,28.5,,,,,,,fee schedule,25.65,145.15,APC
Fractionation ketosteroids,83593,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43.6,,,,,,,fee schedule,25.65,145.15,Radiology
Fractionation ketosteroids,83593,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,39.9,,,,,,,fee schedule,25.65,145.15,APC
Fractionation ketosteroids,83593,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,49.88,,,,,,,fee schedule,25.65,145.15,APC
Assay of lactic acid,83605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,124.65,,,,,,,fee schedule,10.41,124.65,
Assay of lactic acid,83605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,99.91,,,,,,,fee schedule,10.41,124.65,
Assay of lactic acid,83605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,109.15,,,,,,,fee schedule,10.41,124.65,
Assay of lactic acid,83605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,114.75,,,,,,,fee schedule,10.41,124.65,
Assay of lactic acid,83605,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.41,,,,,,,fee schedule,10.41,124.65,Laboratory
Assay of lactic acid,83605,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.15,,,,,,,fee schedule,10.41,124.65,APC
Assay of lactic acid,83605,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.03,,,,,,,fee schedule,10.41,124.65,APC
Assay of lactic acid,83605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11.57,,,,,,,fee schedule,10.41,124.65,APC
Assay of lactic acid,83605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.7,,,,,,,fee schedule,10.41,124.65,Radiology
Assay of lactic acid,83605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.2,,,,,,,fee schedule,10.41,124.65,APC
Assay of lactic acid,83605,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20.25,,,,,,,fee schedule,10.41,124.65,APC
Lactate (LD) (LDH) enzyme,83615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,76.3,,,,,,,fee schedule,5.44,76.3,
Lactate (LD) (LDH) enzyme,83615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,61.16,,,,,,,fee schedule,5.44,76.3,
Lactate (LD) (LDH) enzyme,83615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66.81,,,,,,,fee schedule,5.44,76.3,
Lactate (LD) (LDH) enzyme,83615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,70.24,,,,,,,fee schedule,5.44,76.3,
Lactate (LD) (LDH) enzyme,83615,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.44,,,,,,,fee schedule,5.44,76.3,Laboratory
Lactate (LD) (LDH) enzyme,83615,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.34,,,,,,,fee schedule,5.44,76.3,APC
Lactate (LD) (LDH) enzyme,83615,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6.28,,,,,,,fee schedule,5.44,76.3,APC
Lactate (LD) (LDH) enzyme,83615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6.04,,,,,,,fee schedule,5.44,76.3,APC
Lactate (LD) (LDH) enzyme,83615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.24,,,,,,,fee schedule,5.44,76.3,Radiology
Lactate (LD) (LDH) enzyme,83615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8.46,,,,,,,fee schedule,5.44,76.3,APC
Lactate (LD) (LDH) enzyme,83615,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10.57,,,,,,,fee schedule,5.44,76.3,APC
Assay of ldh enzymes,83625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,162.15,,,,,,,fee schedule,11.51,162.15,
Assay of ldh enzymes,83625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,129.97,,,,,,,fee schedule,11.51,162.15,
Assay of ldh enzymes,83625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,141.98,,,,,,,fee schedule,11.51,162.15,
Assay of ldh enzymes,83625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,149.28,,,,,,,fee schedule,11.51,162.15,
Assay of ldh enzymes,83625,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.51,,,,,,,fee schedule,11.51,162.15,Laboratory
Assay of ldh enzymes,83625,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.43,,,,,,,fee schedule,11.51,162.15,APC
Assay of ldh enzymes,83625,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.3,,,,,,,fee schedule,11.51,162.15,APC
Assay of ldh enzymes,83625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.79,,,,,,,fee schedule,11.51,162.15,APC
Assay of ldh enzymes,83625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.57,,,,,,,fee schedule,11.51,162.15,Radiology
Assay of ldh enzymes,83625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.91,,,,,,,fee schedule,11.51,162.15,APC
Assay of ldh enzymes,83625,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22.38,,,,,,,fee schedule,11.51,162.15,APC
Lactoferrin fecal (qual),83630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,61.45,,,,,,,fee schedule,17.73,61.45,
Lactoferrin fecal (qual),83630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,49.26,,,,,,,fee schedule,17.73,61.45,
Lactoferrin fecal (qual),83630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.81,,,,,,,fee schedule,17.73,61.45,
Lactoferrin fecal (qual),83630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,56.58,,,,,,,fee schedule,17.73,61.45,
Lactoferrin fecal (qual),83630,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.73,,,,,,,fee schedule,17.73,61.45,Laboratory
Lactoferrin fecal (qual),83630,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20.68,,,,,,,fee schedule,17.73,61.45,APC
Lactoferrin fecal (qual),83630,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,20.49,,,,,,,fee schedule,17.73,61.45,APC
Lactoferrin fecal (qual),83630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,19.7,,,,,,,fee schedule,17.73,61.45,APC
Lactoferrin fecal (qual),83630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,30.14,,,,,,,fee schedule,17.73,61.45,Radiology
Lactoferrin fecal (qual),83630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27.58,,,,,,,fee schedule,17.73,61.45,APC
Lactoferrin fecal (qual),83630,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,34.48,,,,,,,fee schedule,17.73,61.45,APC
Lactoferrin fecal (quant),83631,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,108.33,,,,,,,fee schedule,17.67,108.33,
Lactoferrin fecal (quant),83631,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,86.84,,,,,,,fee schedule,17.67,108.33,
Lactoferrin fecal (quant),83631,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,94.86,,,,,,,fee schedule,17.67,108.33,
Lactoferrin fecal (quant),83631,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,99.74,,,,,,,fee schedule,17.67,108.33,
Lactoferrin fecal (quant),83631,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.67,,,,,,,fee schedule,17.67,108.33,Laboratory
Lactoferrin fecal (quant),83631,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20.61,,,,,,,fee schedule,17.67,108.33,APC
Lactoferrin fecal (quant),83631,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,20.42,,,,,,,fee schedule,17.67,108.33,APC
Lactoferrin fecal (quant),83631,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,19.63,,,,,,,fee schedule,17.67,108.33,APC
Lactoferrin fecal (quant),83631,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,30.03,,,,,,,fee schedule,17.67,108.33,Radiology
Lactoferrin fecal (quant),83631,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27.48,,,,,,,fee schedule,17.67,108.33,APC
Lactoferrin fecal (quant),83631,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,34.35,,,,,,,fee schedule,17.67,108.33,APC
Placental lactogen,83632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,111.55,,,,,,,fee schedule,18.2,111.55,
Placental lactogen,83632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,89.42,,,,,,,fee schedule,18.2,111.55,
Placental lactogen,83632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,97.68,,,,,,,fee schedule,18.2,111.55,
Placental lactogen,83632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,102.69,,,,,,,fee schedule,18.2,111.55,
Placental lactogen,83632,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.2,,,,,,,fee schedule,18.2,111.55,Laboratory
Placental lactogen,83632,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.23,,,,,,,fee schedule,18.2,111.55,APC
Placental lactogen,83632,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,21.03,,,,,,,fee schedule,18.2,111.55,APC
Placental lactogen,83632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,20.22,,,,,,,fee schedule,18.2,111.55,APC
Placental lactogen,83632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,30.94,,,,,,,fee schedule,18.2,111.55,Radiology
Placental lactogen,83632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.31,,,,,,,fee schedule,18.2,111.55,APC
Placental lactogen,83632,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,35.38,,,,,,,fee schedule,18.2,111.55,APC
Test urine for lactose,83633,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30.39,,,,,,,fee schedule,10.12,30.39,
Test urine for lactose,83633,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24.36,,,,,,,fee schedule,10.12,30.39,
Test urine for lactose,83633,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26.61,,,,,,,fee schedule,10.12,30.39,
Test urine for lactose,83633,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27.98,,,,,,,fee schedule,10.12,30.39,
Test urine for lactose,83633,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.12,,,,,,,fee schedule,10.12,30.39,Laboratory
Test urine for lactose,83633,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.81,,,,,,,fee schedule,10.12,30.39,APC
Test urine for lactose,83633,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11.7,,,,,,,fee schedule,10.12,30.39,APC
Test urine for lactose,83633,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11.25,,,,,,,fee schedule,10.12,30.39,APC
Test urine for lactose,83633,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.21,,,,,,,fee schedule,10.12,30.39,Radiology
Test urine for lactose,83633,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15.75,,,,,,,fee schedule,10.12,30.39,APC
Test urine for lactose,83633,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19.69,,,,,,,fee schedule,10.12,30.39,APC
Assay of lead,83655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46.46,,,,,,,fee schedule,10.9,46.46,
Assay of lead,83655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37.24,,,,,,,fee schedule,10.9,46.46,
Assay of lead,83655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40.68,,,,,,,fee schedule,10.9,46.46,
Assay of lead,83655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42.77,,,,,,,fee schedule,10.9,46.46,
Assay of lead,83655,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.9,,,,,,,fee schedule,10.9,46.46,Laboratory
Assay of lead,83655,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.72,,,,,,,fee schedule,10.9,46.46,APC
Assay of lead,83655,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.59,,,,,,,fee schedule,10.9,46.46,APC
Assay of lead,83655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.11,,,,,,,fee schedule,10.9,46.46,APC
Assay of lead,83655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.53,,,,,,,fee schedule,10.9,46.46,Radiology
Assay of lead,83655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.95,,,,,,,fee schedule,10.9,46.46,APC
Assay of lead,83655,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21.19,,,,,,,fee schedule,10.9,46.46,APC
L/s ratio fetal lung,83661,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,121.3,,,,,,,fee schedule,19.79,121.3,
L/s ratio fetal lung,83661,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,97.23,,,,,,,fee schedule,19.79,121.3,
L/s ratio fetal lung,83661,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,106.22,,,,,,,fee schedule,19.79,121.3,
L/s ratio fetal lung,83661,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,111.67,,,,,,,fee schedule,19.79,121.3,
L/s ratio fetal lung,83661,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.79,,,,,,,fee schedule,19.79,121.3,Laboratory
L/s ratio fetal lung,83661,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,23.09,,,,,,,fee schedule,19.79,121.3,APC
L/s ratio fetal lung,83661,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,22.87,,,,,,,fee schedule,19.79,121.3,APC
L/s ratio fetal lung,83661,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,21.99,,,,,,,fee schedule,19.79,121.3,APC
L/s ratio fetal lung,83661,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,33.64,,,,,,,fee schedule,19.79,121.3,Radiology
L/s ratio fetal lung,83661,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,30.79,,,,,,,fee schedule,19.79,121.3,APC
L/s ratio fetal lung,83661,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,38.48,,,,,,,fee schedule,19.79,121.3,APC
Foam stability fetal lung,83662,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,104.4,,,,,,,fee schedule,17.02,104.4,
Foam stability fetal lung,83662,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,83.69,,,,,,,fee schedule,17.02,104.4,
Foam stability fetal lung,83662,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,91.42,,,,,,,fee schedule,17.02,104.4,
Foam stability fetal lung,83662,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,96.12,,,,,,,fee schedule,17.02,104.4,
Foam stability fetal lung,83662,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.02,,,,,,,fee schedule,17.02,104.4,Laboratory
Foam stability fetal lung,83662,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.86,,,,,,,fee schedule,17.02,104.4,APC
Foam stability fetal lung,83662,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,19.67,,,,,,,fee schedule,17.02,104.4,APC
Foam stability fetal lung,83662,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18.91,,,,,,,fee schedule,17.02,104.4,APC
Foam stability fetal lung,83662,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.93,,,,,,,fee schedule,17.02,104.4,Radiology
Foam stability fetal lung,83662,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26.47,,,,,,,fee schedule,17.02,104.4,APC
Foam stability fetal lung,83662,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,33.09,,,,,,,fee schedule,17.02,104.4,APC
Fluoro polarize fetal lung,83663,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,104.4,,,,,,,fee schedule,17.02,104.4,
Fluoro polarize fetal lung,83663,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,83.69,,,,,,,fee schedule,17.02,104.4,
Fluoro polarize fetal lung,83663,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,91.42,,,,,,,fee schedule,17.02,104.4,
Fluoro polarize fetal lung,83663,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,96.12,,,,,,,fee schedule,17.02,104.4,
Fluoro polarize fetal lung,83663,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.02,,,,,,,fee schedule,17.02,104.4,Laboratory
Fluoro polarize fetal lung,83663,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.86,,,,,,,fee schedule,17.02,104.4,APC
Fluoro polarize fetal lung,83663,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,19.67,,,,,,,fee schedule,17.02,104.4,APC
Fluoro polarize fetal lung,83663,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18.91,,,,,,,fee schedule,17.02,104.4,APC
Fluoro polarize fetal lung,83663,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.93,,,,,,,fee schedule,17.02,104.4,Radiology
Fluoro polarize fetal lung,83663,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26.47,,,,,,,fee schedule,17.02,104.4,APC
Fluoro polarize fetal lung,83663,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,33.09,,,,,,,fee schedule,17.02,104.4,APC
Lamellar bdy fetal lung,83664,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,104.4,,,,,,,fee schedule,17.39,104.4,
Lamellar bdy fetal lung,83664,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,83.69,,,,,,,fee schedule,17.39,104.4,
Lamellar bdy fetal lung,83664,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,91.42,,,,,,,fee schedule,17.39,104.4,
Lamellar bdy fetal lung,83664,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,96.12,,,,,,,fee schedule,17.39,104.4,
Lamellar bdy fetal lung,83664,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.39,,,,,,,fee schedule,17.39,104.4,Laboratory
Lamellar bdy fetal lung,83664,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20.29,,,,,,,fee schedule,17.39,104.4,APC
Lamellar bdy fetal lung,83664,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,20.09,,,,,,,fee schedule,17.39,104.4,APC
Lamellar bdy fetal lung,83664,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,19.32,,,,,,,fee schedule,17.39,104.4,APC
Lamellar bdy fetal lung,83664,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29.56,,,,,,,fee schedule,17.39,104.4,Radiology
Lamellar bdy fetal lung,83664,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27.05,,,,,,,fee schedule,17.39,104.4,APC
Lamellar bdy fetal lung,83664,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,33.81,,,,,,,fee schedule,17.39,104.4,APC
Assay of lap enzyme,83670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,50.58,,,,,,,fee schedule,8.83,50.58,
Assay of lap enzyme,83670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40.54,,,,,,,fee schedule,8.83,50.58,
Assay of lap enzyme,83670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,44.29,,,,,,,fee schedule,8.83,50.58,
Assay of lap enzyme,83670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46.56,,,,,,,fee schedule,8.83,50.58,
Assay of lap enzyme,83670,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.83,,,,,,,fee schedule,8.83,50.58,Laboratory
Assay of lap enzyme,83670,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.3,,,,,,,fee schedule,8.83,50.58,APC
Assay of lap enzyme,83670,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10.2,,,,,,,fee schedule,8.83,50.58,APC
Assay of lap enzyme,83670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9.81,,,,,,,fee schedule,8.83,50.58,APC
Assay of lap enzyme,83670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15.01,,,,,,,fee schedule,8.83,50.58,Radiology
Assay of lap enzyme,83670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.73,,,,,,,fee schedule,8.83,50.58,APC
Assay of lap enzyme,83670,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,17.17,,,,,,,fee schedule,8.83,50.58,APC
Assay of lipase,83690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,126.27,,,,,,,fee schedule,6.2,126.27,
Assay of lipase,83690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,101.22,,,,,,,fee schedule,6.2,126.27,
Assay of lipase,83690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,110.57,,,,,,,fee schedule,6.2,126.27,
Assay of lipase,83690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,116.25,,,,,,,fee schedule,6.2,126.27,
Assay of lipase,83690,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.2,,,,,,,fee schedule,6.2,126.27,Laboratory
Assay of lipase,83690,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.23,,,,,,,fee schedule,6.2,126.27,APC
Assay of lipase,83690,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7.17,,,,,,,fee schedule,6.2,126.27,APC
Assay of lipase,83690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6.89,,,,,,,fee schedule,6.2,126.27,APC
Assay of lipase,83690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10.54,,,,,,,fee schedule,6.2,126.27,Radiology
Assay of lipase,83690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.65,,,,,,,fee schedule,6.2,126.27,APC
Assay of lipase,83690,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12.06,,,,,,,fee schedule,6.2,126.27,APC
Assay of lipoprotein(a),83695,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,71.48,,,,,,,fee schedule,12.89,71.48,
Assay of lipoprotein(a),83695,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.3,,,,,,,fee schedule,12.89,71.48,
Assay of lipoprotein(a),83695,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,62.59,,,,,,,fee schedule,12.89,71.48,
Assay of lipoprotein(a),83695,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,65.81,,,,,,,fee schedule,12.89,71.48,
Assay of lipoprotein(a),83695,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.89,,,,,,,fee schedule,12.89,71.48,Laboratory
Assay of lipoprotein(a),83695,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.04,,,,,,,fee schedule,12.89,71.48,APC
Assay of lipoprotein(a),83695,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,14.89,,,,,,,fee schedule,12.89,71.48,APC
Assay of lipoprotein(a),83695,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14.32,,,,,,,fee schedule,12.89,71.48,APC
Assay of lipoprotein(a),83695,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21.91,,,,,,,fee schedule,12.89,71.48,Radiology
Assay of lipoprotein(a),83695,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.05,,,,,,,fee schedule,12.89,71.48,APC
Assay of lipoprotein(a),83695,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,25.06,,,,,,,fee schedule,12.89,71.48,APC
Assay Lipoprotein Pla2,83698,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,187.34,,,,,,,fee schedule,41.68,187.34,
Assay Lipoprotein Pla2,83698,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,150.17,,,,,,,fee schedule,41.68,187.34,
Assay Lipoprotein Pla2,83698,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,164.04,,,,,,,fee schedule,41.68,187.34,
Assay Lipoprotein Pla2,83698,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,172.47,,,,,,,fee schedule,41.68,187.34,
Assay Lipoprotein Pla2,83698,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,41.68,,,,,,,fee schedule,41.68,187.34,Laboratory
Assay Lipoprotein Pla2,83698,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,48.63,,,,,,,fee schedule,41.68,187.34,APC
Assay Lipoprotein Pla2,83698,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,48.16,,,,,,,fee schedule,41.68,187.34,APC
Assay Lipoprotein Pla2,83698,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,46.31,,,,,,,fee schedule,41.68,187.34,APC
Assay Lipoprotein Pla2,83698,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,70.85,,,,,,,fee schedule,41.68,187.34,Radiology
Assay Lipoprotein Pla2,83698,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,64.83,,,,,,,fee schedule,41.68,187.34,APC
Assay Lipoprotein Pla2,83698,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,81.04,,,,,,,fee schedule,41.68,187.34,APC
Lipopro bld electrophoretic,83700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,62.14,,,,,,,fee schedule,10.13,62.14,
Lipopro bld electrophoretic,83700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,49.81,,,,,,,fee schedule,10.13,62.14,
Lipopro bld electrophoretic,83700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,54.42,,,,,,,fee schedule,10.13,62.14,
Lipopro bld electrophoretic,83700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,57.21,,,,,,,fee schedule,10.13,62.14,
Lipopro bld electrophoretic,83700,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.13,,,,,,,fee schedule,10.13,62.14,Laboratory
Lipopro bld electrophoretic,83700,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.82,,,,,,,fee schedule,10.13,62.14,APC
Lipopro bld electrophoretic,83700,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11.71,,,,,,,fee schedule,10.13,62.14,APC
Lipopro bld electrophoretic,83700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11.26,,,,,,,fee schedule,10.13,62.14,APC
Lipopro bld electrophoretic,83700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.23,,,,,,,fee schedule,10.13,62.14,Radiology
Lipopro bld electrophoretic,83700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15.76,,,,,,,fee schedule,10.13,62.14,APC
Lipopro bld electrophoretic,83700,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19.7,,,,,,,fee schedule,10.13,62.14,APC
Lipoprotein bld hr fraction,83701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,136.99,,,,,,,fee schedule,30.47,136.99,
Lipoprotein bld hr fraction,83701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,109.81,,,,,,,fee schedule,30.47,136.99,
Lipoprotein bld hr fraction,83701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,119.95,,,,,,,fee schedule,30.47,136.99,
Lipoprotein bld hr fraction,83701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,126.12,,,,,,,fee schedule,30.47,136.99,
Lipoprotein bld hr fraction,83701,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,30.47,,,,,,,fee schedule,30.47,136.99,Laboratory
Lipoprotein bld hr fraction,83701,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,35.55,,,,,,,fee schedule,30.47,136.99,APC
Lipoprotein bld hr fraction,83701,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,35.21,,,,,,,fee schedule,30.47,136.99,APC
Lipoprotein bld hr fraction,83701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,33.86,,,,,,,fee schedule,30.47,136.99,APC
Lipoprotein bld hr fraction,83701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.81,,,,,,,fee schedule,30.47,136.99,Radiology
Lipoprotein bld hr fraction,83701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,47.4,,,,,,,fee schedule,30.47,136.99,APC
Lipoprotein bld hr fraction,83701,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,59.26,,,,,,,fee schedule,30.47,136.99,APC
Lipoprotein bld quan part,83704,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,98.47,,,,,,,fee schedule,30.77,98.47,
Lipoprotein bld quan part,83704,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,78.93,,,,,,,fee schedule,30.77,98.47,
Lipoprotein bld quan part,83704,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,86.23,,,,,,,fee schedule,30.77,98.47,
Lipoprotein bld quan part,83704,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,90.66,,,,,,,fee schedule,30.77,98.47,
Lipoprotein bld quan part,83704,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,30.77,,,,,,,fee schedule,30.77,98.47,Laboratory
Lipoprotein bld quan part,83704,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,35.9,,,,,,,fee schedule,30.77,98.47,APC
Lipoprotein bld quan part,83704,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,35.56,,,,,,,fee schedule,30.77,98.47,APC
Lipoprotein bld quan part,83704,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,34.19,,,,,,,fee schedule,30.77,98.47,APC
Lipoprotein bld quan part,83704,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,52.31,,,,,,,fee schedule,30.77,98.47,Radiology
Lipoprotein bld quan part,83704,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,47.87,,,,,,,fee schedule,30.77,98.47,APC
Lipoprotein bld quan part,83704,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,59.83,,,,,,,fee schedule,30.77,98.47,APC
Assay of lipoprotein,83718,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,82.18,,,,,,,fee schedule,7.37,82.18,
Assay of lipoprotein,83718,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,65.88,,,,,,,fee schedule,7.37,82.18,
Assay of lipoprotein,83718,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,71.96,,,,,,,fee schedule,7.37,82.18,
Assay of lipoprotein,83718,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,75.66,,,,,,,fee schedule,7.37,82.18,
Assay of lipoprotein,83718,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.37,,,,,,,fee schedule,7.37,82.18,Laboratory
Assay of lipoprotein,83718,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.6,,,,,,,fee schedule,7.37,82.18,APC
Assay of lipoprotein,83718,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8.52,,,,,,,fee schedule,7.37,82.18,APC
Assay of lipoprotein,83718,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8.19,,,,,,,fee schedule,7.37,82.18,APC
Assay of lipoprotein,83718,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12.53,,,,,,,fee schedule,7.37,82.18,Radiology
Assay of lipoprotein,83718,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11.47,,,,,,,fee schedule,7.37,82.18,APC
Assay of lipoprotein,83718,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14.33,,,,,,,fee schedule,7.37,82.18,APC
Assay of blood lipoprotein,83719,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,39.01,,,,,,,fee schedule,11.48,39.01,
Assay of blood lipoprotein,83719,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31.27,,,,,,,fee schedule,11.48,39.01,
Assay of blood lipoprotein,83719,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,34.16,,,,,,,fee schedule,11.48,39.01,
Assay of blood lipoprotein,83719,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,35.91,,,,,,,fee schedule,11.48,39.01,
Assay of blood lipoprotein,83719,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.48,,,,,,,fee schedule,11.48,39.01,Laboratory
Assay of blood lipoprotein,83719,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.39,,,,,,,fee schedule,11.48,39.01,APC
Assay of blood lipoprotein,83719,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.26,,,,,,,fee schedule,11.48,39.01,APC
Assay of blood lipoprotein,83719,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.75,,,,,,,fee schedule,11.48,39.01,APC
Assay of blood lipoprotein,83719,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.51,,,,,,,fee schedule,11.48,39.01,Radiology
Assay of blood lipoprotein,83719,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.85,,,,,,,fee schedule,11.48,39.01,APC
Assay of blood lipoprotein,83719,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22.31,,,,,,,fee schedule,11.48,39.01,APC
Assay of blood lipoprotein,83721,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,36.34,,,,,,,fee schedule,9.45,36.34,
Assay of blood lipoprotein,83721,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29.13,,,,,,,fee schedule,9.45,36.34,
Assay of blood lipoprotein,83721,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31.82,,,,,,,fee schedule,9.45,36.34,
Assay of blood lipoprotein,83721,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33.46,,,,,,,fee schedule,9.45,36.34,
Assay of blood lipoprotein,83721,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.45,,,,,,,fee schedule,9.45,36.34,Laboratory
Assay of blood lipoprotein,83721,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.02,,,,,,,fee schedule,9.45,36.34,APC
Assay of blood lipoprotein,83721,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10.92,,,,,,,fee schedule,9.45,36.34,APC
Assay of blood lipoprotein,83721,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10.5,,,,,,,fee schedule,9.45,36.34,APC
Assay of blood lipoprotein,83721,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.07,,,,,,,fee schedule,9.45,36.34,Radiology
Assay of blood lipoprotein,83721,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.7,,,,,,,fee schedule,9.45,36.34,APC
Assay of blood lipoprotein,83721,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18.38,,,,,,,fee schedule,9.45,36.34,APC
Lipoprtn dir meas sd ldl chl,83722,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,30.77,,,,,,,fee schedule,30.77,59.83,Laboratory
Lipoprtn dir meas sd ldl chl,83722,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,35.9,,,,,,,fee schedule,30.77,59.83,APC
Lipoprtn dir meas sd ldl chl,83722,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,35.56,,,,,,,fee schedule,30.77,59.83,APC
Lipoprtn dir meas sd ldl chl,83722,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,34.19,,,,,,,fee schedule,30.77,59.83,APC
Lipoprtn dir meas sd ldl chl,83722,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,52.31,,,,,,,fee schedule,30.77,59.83,Radiology
Lipoprtn dir meas sd ldl chl,83722,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,47.87,,,,,,,fee schedule,30.77,59.83,APC
Lipoprtn dir meas sd ldl chl,83722,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,59.83,,,,,,,fee schedule,30.77,59.83,APC
Assay of lrh hormone,83727,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,94.88,,,,,,,fee schedule,15.47,94.88,
Assay of lrh hormone,83727,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,76.05,,,,,,,fee schedule,15.47,94.88,
Assay of lrh hormone,83727,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,83.08,,,,,,,fee schedule,15.47,94.88,
Assay of lrh hormone,83727,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,87.35,,,,,,,fee schedule,15.47,94.88,
Assay of lrh hormone,83727,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.47,,,,,,,fee schedule,15.47,94.88,Laboratory
Assay of lrh hormone,83727,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.05,,,,,,,fee schedule,15.47,94.88,APC
Assay of lrh hormone,83727,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,17.88,,,,,,,fee schedule,15.47,94.88,APC
Assay of lrh hormone,83727,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17.19,,,,,,,fee schedule,15.47,94.88,APC
Assay of lrh hormone,83727,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26.3,,,,,,,fee schedule,15.47,94.88,Radiology
Assay of lrh hormone,83727,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24.07,,,,,,,fee schedule,15.47,94.88,APC
Assay of lrh hormone,83727,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30.08,,,,,,,fee schedule,15.47,94.88,APC
Assay of magnesium,83735,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,54.27,,,,,,,fee schedule,6.03,54.27,
Assay of magnesium,83735,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,43.5,,,,,,,fee schedule,6.03,54.27,
Assay of magnesium,83735,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,47.52,,,,,,,fee schedule,6.03,54.27,
Assay of magnesium,83735,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,49.96,,,,,,,fee schedule,6.03,54.27,
Assay of magnesium,83735,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.03,,,,,,,fee schedule,6.03,54.27,Laboratory
Assay of magnesium,83735,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.04,,,,,,,fee schedule,6.03,54.27,APC
Assay of magnesium,83735,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6.97,,,,,,,fee schedule,6.03,54.27,APC
Assay of magnesium,83735,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6.7,,,,,,,fee schedule,6.03,54.27,APC
Assay of magnesium,83735,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10.25,,,,,,,fee schedule,6.03,54.27,Radiology
Assay of magnesium,83735,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.38,,,,,,,fee schedule,6.03,54.27,APC
Assay of magnesium,83735,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11.72,,,,,,,fee schedule,6.03,54.27,APC
Assay malate dehydrogenase,83775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,40.71,,,,,,,fee schedule,6.63,40.71,
Assay malate dehydrogenase,83775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32.63,,,,,,,fee schedule,6.63,40.71,
Assay malate dehydrogenase,83775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35.65,,,,,,,fee schedule,6.63,40.71,
Assay malate dehydrogenase,83775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37.48,,,,,,,fee schedule,6.63,40.71,
Assay malate dehydrogenase,83775,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.63,,,,,,,fee schedule,6.63,40.71,Laboratory
Assay malate dehydrogenase,83775,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.74,,,,,,,fee schedule,6.63,40.71,APC
Assay malate dehydrogenase,83775,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7.66,,,,,,,fee schedule,6.63,40.71,APC
Assay malate dehydrogenase,83775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7.37,,,,,,,fee schedule,6.63,40.71,APC
Assay malate dehydrogenase,83775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11.28,,,,,,,fee schedule,6.63,40.71,Radiology
Assay malate dehydrogenase,83775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10.32,,,,,,,fee schedule,6.63,40.71,APC
Assay malate dehydrogenase,83775,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12.9,,,,,,,fee schedule,6.63,40.71,APC
Assay of manganese,83785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,77,,,,,,,fee schedule,23.98,77,
Assay of manganese,83785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,61.72,,,,,,,fee schedule,23.98,77,
Assay of manganese,83785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,67.43,,,,,,,fee schedule,23.98,77,
Assay of manganese,83785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,70.89,,,,,,,fee schedule,23.98,77,
Assay of manganese,83785,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23.98,,,,,,,fee schedule,23.98,77,Laboratory
Assay of manganese,83785,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,27.98,,,,,,,fee schedule,23.98,77,APC
Assay of manganese,83785,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,27.72,,,,,,,fee schedule,23.98,77,APC
Assay of manganese,83785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,26.65,,,,,,,fee schedule,23.98,77,APC
Assay of manganese,83785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40.77,,,,,,,fee schedule,23.98,77,Radiology
Assay of manganese,83785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,37.31,,,,,,,fee schedule,23.98,77,APC
Assay of manganese,83785,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,46.64,,,,,,,fee schedule,23.98,77,APC
Mass spectrometry qual/quan,83789,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,62.38,,,,,,,fee schedule,21.7,62.38,
Mass spectrometry qual/quan,83789,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,50,,,,,,,fee schedule,21.7,62.38,
Mass spectrometry qual/quan,83789,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,54.62,,,,,,,fee schedule,21.7,62.38,
Mass spectrometry qual/quan,83789,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,57.43,,,,,,,fee schedule,21.7,62.38,
Mass spectrometry qual/quan,83789,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21.7,,,,,,,fee schedule,21.7,62.38,Laboratory
Mass spectrometry qual/quan,83789,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,25.32,,,,,,,fee schedule,21.7,62.38,APC
Mass spectrometry qual/quan,83789,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,25.07,,,,,,,fee schedule,21.7,62.38,APC
Mass spectrometry qual/quan,83789,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,24.11,,,,,,,fee schedule,21.7,62.38,APC
Mass spectrometry qual/quan,83789,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,36.89,,,,,,,fee schedule,21.7,62.38,Radiology
Mass spectrometry qual/quan,83789,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,33.75,,,,,,,fee schedule,21.7,62.38,APC
Mass spectrometry qual/quan,83789,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,42.19,,,,,,,fee schedule,21.7,62.38,APC
Assay of mercury,83825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,51.09,,,,,,,fee schedule,14.63,51.09,
Assay of mercury,83825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40.95,,,,,,,fee schedule,14.63,51.09,
Assay of mercury,83825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,44.73,,,,,,,fee schedule,14.63,51.09,
Assay of mercury,83825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,47.03,,,,,,,fee schedule,14.63,51.09,
Assay of mercury,83825,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.63,,,,,,,fee schedule,14.63,51.09,Laboratory
Assay of mercury,83825,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.07,,,,,,,fee schedule,14.63,51.09,APC
Assay of mercury,83825,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,16.91,,,,,,,fee schedule,14.63,51.09,APC
Assay of mercury,83825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16.26,,,,,,,fee schedule,14.63,51.09,APC
Assay of mercury,83825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24.88,,,,,,,fee schedule,14.63,51.09,Radiology
Assay of mercury,83825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.76,,,,,,,fee schedule,14.63,51.09,APC
Assay of mercury,83825,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,28.46,,,,,,,fee schedule,14.63,51.09,APC
Assay of metanephrines,83835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59.97,,,,,,,fee schedule,15.25,59.97,
Assay of metanephrines,83835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48.07,,,,,,,fee schedule,15.25,59.97,
Assay of metanephrines,83835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52.51,,,,,,,fee schedule,15.25,59.97,
Assay of metanephrines,83835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55.21,,,,,,,fee schedule,15.25,59.97,
Assay of metanephrines,83835,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.25,,,,,,,fee schedule,15.25,59.97,Laboratory
Assay of metanephrines,83835,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.79,,,,,,,fee schedule,15.25,59.97,APC
Assay of metanephrines,83835,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,17.62,,,,,,,fee schedule,15.25,59.97,APC
Assay of metanephrines,83835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16.94,,,,,,,fee schedule,15.25,59.97,APC
Assay of metanephrines,83835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.92,,,,,,,fee schedule,15.25,59.97,Radiology
Assay of metanephrines,83835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.72,,,,,,,fee schedule,15.25,59.97,APC
Assay of metanephrines,83835,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,29.65,,,,,,,fee schedule,15.25,59.97,APC
Assay of methemalbumin,83857,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59.27,,,,,,,fee schedule,9.67,59.27,
Assay of methemalbumin,83857,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,47.51,,,,,,,fee schedule,9.67,59.27,
Assay of methemalbumin,83857,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.9,,,,,,,fee schedule,9.67,59.27,
Assay of methemalbumin,83857,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,54.57,,,,,,,fee schedule,9.67,59.27,
Assay of methemalbumin,83857,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.67,,,,,,,fee schedule,9.67,59.27,Laboratory
Assay of methemalbumin,83857,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.28,,,,,,,fee schedule,9.67,59.27,APC
Assay of methemalbumin,83857,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11.17,,,,,,,fee schedule,9.67,59.27,APC
Assay of methemalbumin,83857,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10.74,,,,,,,fee schedule,9.67,59.27,APC
Assay of methemalbumin,83857,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.43,,,,,,,fee schedule,9.67,59.27,Radiology
Assay of methemalbumin,83857,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15.04,,,,,,,fee schedule,9.67,59.27,APC
Assay of methemalbumin,83857,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18.8,,,,,,,fee schedule,9.67,59.27,APC
Microfluid analy tears,83861,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,85.84,,,,,,,fee schedule,20.23,85.84,
Microfluid analy tears,83861,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,68.81,,,,,,,fee schedule,20.23,85.84,
Microfluid analy tears,83861,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,75.17,,,,,,,fee schedule,20.23,85.84,
Microfluid analy tears,83861,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,79.03,,,,,,,fee schedule,20.23,85.84,
Microfluid analy tears,83861,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,20.23,,,,,,,fee schedule,20.23,85.84,Laboratory
Microfluid analy tears,83861,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,23.6,,,,,,,fee schedule,20.23,85.84,APC
Microfluid analy tears,83861,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,23.38,,,,,,,fee schedule,20.23,85.84,APC
Microfluid analy tears,83861,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,22.48,,,,,,,fee schedule,20.23,85.84,APC
Microfluid analy tears,83861,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,34.39,,,,,,,fee schedule,20.23,85.84,Radiology
Microfluid analy tears,83861,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,31.47,,,,,,,fee schedule,20.23,85.84,APC
Microfluid analy tears,83861,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,39.34,,,,,,,fee schedule,20.23,85.84,APC
Mucopolysaccharides,83864,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,109.88,,,,,,,fee schedule,25.65,109.88,
Mucopolysaccharides,83864,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,88.08,,,,,,,fee schedule,25.65,109.88,
Mucopolysaccharides,83864,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,96.22,,,,,,,fee schedule,25.65,109.88,
Mucopolysaccharides,83864,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,101.16,,,,,,,fee schedule,25.65,109.88,
Mucopolysaccharides,83864,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25.65,,,,,,,fee schedule,25.65,109.88,Laboratory
Mucopolysaccharides,83864,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,29.92,,,,,,,fee schedule,25.65,109.88,APC
Mucopolysaccharides,83864,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,29.64,,,,,,,fee schedule,25.65,109.88,APC
Mucopolysaccharides,83864,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,28.5,,,,,,,fee schedule,25.65,109.88,APC
Mucopolysaccharides,83864,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43.6,,,,,,,fee schedule,25.65,109.88,Radiology
Mucopolysaccharides,83864,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,39.9,,,,,,,fee schedule,25.65,109.88,APC
Mucopolysaccharides,83864,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,49.88,,,,,,,fee schedule,25.65,109.88,APC
Assay synovial fluid mucin,83872,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,32.36,,,,,,,fee schedule,5.27,32.36,
Assay synovial fluid mucin,83872,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,25.94,,,,,,,fee schedule,5.27,32.36,
Assay synovial fluid mucin,83872,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28.33,,,,,,,fee schedule,5.27,32.36,
Assay synovial fluid mucin,83872,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,29.79,,,,,,,fee schedule,5.27,32.36,
Assay synovial fluid mucin,83872,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.27,,,,,,,fee schedule,5.27,32.36,Laboratory
Assay synovial fluid mucin,83872,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.15,,,,,,,fee schedule,5.27,32.36,APC
Assay synovial fluid mucin,83872,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6.09,,,,,,,fee schedule,5.27,32.36,APC
Assay synovial fluid mucin,83872,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5.86,,,,,,,fee schedule,5.27,32.36,APC
Assay synovial fluid mucin,83872,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8.97,,,,,,,fee schedule,5.27,32.36,Radiology
Assay synovial fluid mucin,83872,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8.2,,,,,,,fee schedule,5.27,32.36,APC
Assay synovial fluid mucin,83872,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10.26,,,,,,,fee schedule,5.27,32.36,APC
Assay of csf protein,83873,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,207.31,,,,,,,fee schedule,15.48,207.31,
Assay of csf protein,83873,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,166.18,,,,,,,fee schedule,15.48,207.31,
Assay of csf protein,83873,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,181.53,,,,,,,fee schedule,15.48,207.31,
Assay of csf protein,83873,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,190.86,,,,,,,fee schedule,15.48,207.31,
Assay of csf protein,83873,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.48,,,,,,,fee schedule,15.48,207.31,Laboratory
Assay of csf protein,83873,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.06,,,,,,,fee schedule,15.48,207.31,APC
Assay of csf protein,83873,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,17.89,,,,,,,fee schedule,15.48,207.31,APC
Assay of csf protein,83873,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17.2,,,,,,,fee schedule,15.48,207.31,APC
Assay of csf protein,83873,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26.32,,,,,,,fee schedule,15.48,207.31,Radiology
Assay of csf protein,83873,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24.08,,,,,,,fee schedule,15.48,207.31,APC
Assay of csf protein,83873,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30.1,,,,,,,fee schedule,15.48,207.31,APC
Assay of myoglobin,83874,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,153.26,,,,,,,fee schedule,11.63,153.26,
Assay of myoglobin,83874,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,122.85,,,,,,,fee schedule,11.63,153.26,
Assay of myoglobin,83874,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,134.2,,,,,,,fee schedule,11.63,153.26,
Assay of myoglobin,83874,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,141.1,,,,,,,fee schedule,11.63,153.26,
Assay of myoglobin,83874,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.63,,,,,,,fee schedule,11.63,153.26,Laboratory
Assay of myoglobin,83874,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.57,,,,,,,fee schedule,11.63,153.26,APC
Assay of myoglobin,83874,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.44,,,,,,,fee schedule,11.63,153.26,APC
Assay of myoglobin,83874,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.92,,,,,,,fee schedule,11.63,153.26,APC
Assay of myoglobin,83874,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.77,,,,,,,fee schedule,11.63,153.26,Radiology
Assay of myoglobin,83874,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.09,,,,,,,fee schedule,11.63,153.26,APC
Assay of myoglobin,83874,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22.61,,,,,,,fee schedule,11.63,153.26,APC
Assay myeloperoxidase,83876,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,71.48,,,,,,,fee schedule,45.77,89,
Assay myeloperoxidase,83876,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.3,,,,,,,fee schedule,45.77,89,
Assay myeloperoxidase,83876,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,62.59,,,,,,,fee schedule,45.77,89,
Assay myeloperoxidase,83876,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,65.81,,,,,,,fee schedule,45.77,89,
Assay myeloperoxidase,83876,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,45.77,,,,,,,fee schedule,45.77,89,Laboratory
Assay myeloperoxidase,83876,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,53.4,,,,,,,fee schedule,45.77,89,APC
Assay myeloperoxidase,83876,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,52.89,,,,,,,fee schedule,45.77,89,APC
Assay myeloperoxidase,83876,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,50.86,,,,,,,fee schedule,45.77,89,APC
Assay myeloperoxidase,83876,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,77.82,,,,,,,fee schedule,45.77,89,Radiology
Assay myeloperoxidase,83876,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,71.2,,,,,,,fee schedule,45.77,89,APC
Assay myeloperoxidase,83876,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,89,,,,,,,fee schedule,45.77,89,APC
Assay of natriuretic peptide,83880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,112.71,,,,,,,fee schedule,35.33,112.71,
Assay of natriuretic peptide,83880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,90.35,,,,,,,fee schedule,35.33,112.71,
Assay of natriuretic peptide,83880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,98.7,,,,,,,fee schedule,35.33,112.71,
Assay of natriuretic peptide,83880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,103.77,,,,,,,fee schedule,35.33,112.71,
Assay of natriuretic peptide,83880,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,35.33,,,,,,,fee schedule,35.33,112.71,Laboratory
Assay of natriuretic peptide,83880,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,41.22,,,,,,,fee schedule,35.33,112.71,APC
Assay of natriuretic peptide,83880,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,40.83,,,,,,,fee schedule,35.33,112.71,APC
Assay of natriuretic peptide,83880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,39.26,,,,,,,fee schedule,35.33,112.71,APC
Assay of natriuretic peptide,83880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,60.07,,,,,,,fee schedule,35.33,112.71,Radiology
Assay of natriuretic peptide,83880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,54.96,,,,,,,fee schedule,35.33,112.71,APC
Assay of natriuretic peptide,83880,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,68.7,,,,,,,fee schedule,35.33,112.71,APC
Assay nephelometry not spec,83883,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,50.8,,,,,,,fee schedule,12.24,50.8,
Assay nephelometry not spec,83883,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40.72,,,,,,,fee schedule,12.24,50.8,
Assay nephelometry not spec,83883,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,44.49,,,,,,,fee schedule,12.24,50.8,
Assay nephelometry not spec,83883,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46.77,,,,,,,fee schedule,12.24,50.8,
Assay nephelometry not spec,83883,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.24,,,,,,,fee schedule,12.24,50.8,Laboratory
Assay nephelometry not spec,83883,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.28,,,,,,,fee schedule,12.24,50.8,APC
Assay nephelometry not spec,83883,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,14.14,,,,,,,fee schedule,12.24,50.8,APC
Assay nephelometry not spec,83883,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.6,,,,,,,fee schedule,12.24,50.8,APC
Assay nephelometry not spec,83883,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.81,,,,,,,fee schedule,12.24,50.8,Radiology
Assay nephelometry not spec,83883,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.04,,,,,,,fee schedule,12.24,50.8,APC
Assay nephelometry not spec,83883,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23.8,,,,,,,fee schedule,12.24,50.8,APC
Assay neurflmnt light chain,83884,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,104.61,,,,,,,fee schedule,104.61,203.4,Laboratory
Assay neurflmnt light chain,83884,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,122.04,,,,,,,fee schedule,104.61,203.4,APC
Assay neurflmnt light chain,83884,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,120.88,,,,,,,fee schedule,104.61,203.4,APC
Assay neurflmnt light chain,83884,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,116.23,,,,,,,fee schedule,104.61,203.4,APC
Assay neurflmnt light chain,83884,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,177.83,,,,,,,fee schedule,104.61,203.4,Radiology
Assay neurflmnt light chain,83884,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,162.72,,,,,,,fee schedule,104.61,203.4,APC
Assay neurflmnt light chain,83884,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,203.4,,,,,,,fee schedule,104.61,203.4,APC
Assay of nickel,83885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,135.21,,,,,,,fee schedule,22.06,135.21,
Assay of nickel,83885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,108.38,,,,,,,fee schedule,22.06,135.21,
Assay of nickel,83885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,118.4,,,,,,,fee schedule,22.06,135.21,
Assay of nickel,83885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,124.48,,,,,,,fee schedule,22.06,135.21,
Assay of nickel,83885,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22.06,,,,,,,fee schedule,22.06,135.21,Laboratory
Assay of nickel,83885,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,25.74,,,,,,,fee schedule,22.06,135.21,APC
Assay of nickel,83885,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,25.49,,,,,,,fee schedule,22.06,135.21,APC
Assay of nickel,83885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,24.51,,,,,,,fee schedule,22.06,135.21,APC
Assay of nickel,83885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,37.5,,,,,,,fee schedule,22.06,135.21,Radiology
Assay of nickel,83885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,34.31,,,,,,,fee schedule,22.06,135.21,APC
Assay of nickel,83885,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,42.89,,,,,,,fee schedule,22.06,135.21,APC
Assay of nucleotidase,83915,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,61.58,,,,,,,fee schedule,10.04,61.58,
Assay of nucleotidase,83915,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,49.36,,,,,,,fee schedule,10.04,61.58,
Assay of nucleotidase,83915,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.92,,,,,,,fee schedule,10.04,61.58,
Assay of nucleotidase,83915,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,56.69,,,,,,,fee schedule,10.04,61.58,
Assay of nucleotidase,83915,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.04,,,,,,,fee schedule,10.04,61.58,Laboratory
Assay of nucleotidase,83915,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.71,,,,,,,fee schedule,10.04,61.58,APC
Assay of nucleotidase,83915,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11.6,,,,,,,fee schedule,10.04,61.58,APC
Assay of nucleotidase,83915,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11.15,,,,,,,fee schedule,10.04,61.58,APC
Assay of nucleotidase,83915,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.06,,,,,,,fee schedule,10.04,61.58,Radiology
Assay of nucleotidase,83915,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15.61,,,,,,,fee schedule,10.04,61.58,APC
Assay of nucleotidase,83915,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19.51,,,,,,,fee schedule,10.04,61.58,APC
Oligoclonal bands,83916,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,109.58,,,,,,,fee schedule,24.65,109.58,
Oligoclonal bands,83916,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,87.84,,,,,,,fee schedule,24.65,109.58,
Oligoclonal bands,83916,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,95.95,,,,,,,fee schedule,24.65,109.58,
Oligoclonal bands,83916,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,100.88,,,,,,,fee schedule,24.65,109.58,
Oligoclonal bands,83916,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24.65,,,,,,,fee schedule,24.65,109.58,Laboratory
Oligoclonal bands,83916,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,28.76,,,,,,,fee schedule,24.65,109.58,APC
Oligoclonal bands,83916,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,28.49,,,,,,,fee schedule,24.65,109.58,APC
Oligoclonal bands,83916,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,27.39,,,,,,,fee schedule,24.65,109.58,APC
Oligoclonal bands,83916,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,41.91,,,,,,,fee schedule,24.65,109.58,Radiology
Oligoclonal bands,83916,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,38.35,,,,,,,fee schedule,24.65,109.58,APC
Oligoclonal bands,83916,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,47.93,,,,,,,fee schedule,24.65,109.58,APC
Organic acids total quant,83918,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,90.87,,,,,,,fee schedule,21.24,90.87,
Organic acids total quant,83918,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,72.84,,,,,,,fee schedule,21.24,90.87,
Organic acids total quant,83918,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,79.57,,,,,,,fee schedule,21.24,90.87,
Organic acids total quant,83918,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83.66,,,,,,,fee schedule,21.24,90.87,
Organic acids total quant,83918,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21.24,,,,,,,fee schedule,21.24,90.87,Laboratory
Organic acids total quant,83918,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,24.78,,,,,,,fee schedule,21.24,90.87,APC
Organic acids total quant,83918,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,24.54,,,,,,,fee schedule,21.24,90.87,APC
Organic acids total quant,83918,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,23.6,,,,,,,fee schedule,21.24,90.87,APC
Organic acids total quant,83918,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,36.11,,,,,,,fee schedule,21.24,90.87,Radiology
Organic acids total quant,83918,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,33.04,,,,,,,fee schedule,21.24,90.87,APC
Organic acids total quant,83918,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,41.3,,,,,,,fee schedule,21.24,90.87,APC
Organic acids qual each,83919,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,90.87,,,,,,,fee schedule,14.8,90.87,
Organic acids qual each,83919,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,72.84,,,,,,,fee schedule,14.8,90.87,
Organic acids qual each,83919,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,79.57,,,,,,,fee schedule,14.8,90.87,
Organic acids qual each,83919,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83.66,,,,,,,fee schedule,14.8,90.87,
Organic acids qual each,83919,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.8,,,,,,,fee schedule,14.8,90.87,Laboratory
Organic acids qual each,83919,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.27,,,,,,,fee schedule,14.8,90.87,APC
Organic acids qual each,83919,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,17.11,,,,,,,fee schedule,14.8,90.87,APC
Organic acids qual each,83919,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16.45,,,,,,,fee schedule,14.8,90.87,APC
Organic acids qual each,83919,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.17,,,,,,,fee schedule,14.8,90.87,Radiology
Organic acids qual each,83919,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.03,,,,,,,fee schedule,14.8,90.87,APC
Organic acids qual each,83919,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,28.79,,,,,,,fee schedule,14.8,90.87,APC
Organic acid single quant,83921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,70.78,,,,,,,fee schedule,19.09,70.78,
Organic acid single quant,83921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56.74,,,,,,,fee schedule,19.09,70.78,
Organic acid single quant,83921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,61.98,,,,,,,fee schedule,19.09,70.78,
Organic acid single quant,83921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,65.16,,,,,,,fee schedule,19.09,70.78,
Organic acid single quant,83921,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.09,,,,,,,fee schedule,19.09,70.78,Laboratory
Organic acid single quant,83921,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,22.27,,,,,,,fee schedule,19.09,70.78,APC
Organic acid single quant,83921,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,22.06,,,,,,,fee schedule,19.09,70.78,APC
Organic acid single quant,83921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,21.21,,,,,,,fee schedule,19.09,70.78,APC
Organic acid single quant,83921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,32.45,,,,,,,fee schedule,19.09,70.78,Radiology
Organic acid single quant,83921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29.69,,,,,,,fee schedule,19.09,70.78,APC
Organic acid single quant,83921,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,37.12,,,,,,,fee schedule,19.09,70.78,APC
Assay of blood osmolality,83930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.64,,,,,,,fee schedule,5.95,66.64,
Assay of blood osmolality,83930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.41,,,,,,,fee schedule,5.95,66.64,
Assay of blood osmolality,83930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,58.35,,,,,,,fee schedule,5.95,66.64,
Assay of blood osmolality,83930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,61.35,,,,,,,fee schedule,5.95,66.64,
Assay of blood osmolality,83930,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.95,,,,,,,fee schedule,5.95,66.64,Laboratory
Assay of blood osmolality,83930,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.94,,,,,,,fee schedule,5.95,66.64,APC
Assay of blood osmolality,83930,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6.87,,,,,,,fee schedule,5.95,66.64,APC
Assay of blood osmolality,83930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6.61,,,,,,,fee schedule,5.95,66.64,APC
Assay of blood osmolality,83930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10.11,,,,,,,fee schedule,5.95,66.64,Radiology
Assay of blood osmolality,83930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.25,,,,,,,fee schedule,5.95,66.64,APC
Assay of blood osmolality,83930,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11.57,,,,,,,fee schedule,5.95,66.64,APC
Assay of urine osmolality,83935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.64,,,,,,,fee schedule,6.14,66.64,
Assay of urine osmolality,83935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.41,,,,,,,fee schedule,6.14,66.64,
Assay of urine osmolality,83935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,58.35,,,,,,,fee schedule,6.14,66.64,
Assay of urine osmolality,83935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,61.35,,,,,,,fee schedule,6.14,66.64,
Assay of urine osmolality,83935,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.14,,,,,,,fee schedule,6.14,66.64,Laboratory
Assay of urine osmolality,83935,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.16,,,,,,,fee schedule,6.14,66.64,APC
Assay of urine osmolality,83935,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7.09,,,,,,,fee schedule,6.14,66.64,APC
Assay of urine osmolality,83935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6.82,,,,,,,fee schedule,6.14,66.64,APC
Assay of urine osmolality,83935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10.43,,,,,,,fee schedule,6.14,66.64,Radiology
Assay of urine osmolality,83935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.55,,,,,,,fee schedule,6.14,66.64,APC
Assay of urine osmolality,83935,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11.94,,,,,,,fee schedule,6.14,66.64,APC
Assay of osteocalcin,83937,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,156,,,,,,,fee schedule,26.86,156,
Assay of osteocalcin,83937,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,125.05,,,,,,,fee schedule,26.86,156,
Assay of osteocalcin,83937,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,136.6,,,,,,,fee schedule,26.86,156,
Assay of osteocalcin,83937,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,143.62,,,,,,,fee schedule,26.86,156,
Assay of osteocalcin,83937,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26.86,,,,,,,fee schedule,26.86,156,Laboratory
Assay of osteocalcin,83937,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,31.34,,,,,,,fee schedule,26.86,156,APC
Assay of osteocalcin,83937,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,31.04,,,,,,,fee schedule,26.86,156,APC
Assay of osteocalcin,83937,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,29.85,,,,,,,fee schedule,26.86,156,APC
Assay of osteocalcin,83937,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,45.67,,,,,,,fee schedule,26.86,156,Radiology
Assay of osteocalcin,83937,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,41.79,,,,,,,fee schedule,26.86,156,APC
Assay of osteocalcin,83937,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,52.24,,,,,,,fee schedule,26.86,156,APC
Assay of oxalate,83945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,113.28,,,,,,,fee schedule,13,113.28,
Assay of oxalate,83945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,90.8,,,,,,,fee schedule,13,113.28,
Assay of oxalate,83945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,99.19,,,,,,,fee schedule,13,113.28,
Assay of oxalate,83945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,104.29,,,,,,,fee schedule,13,113.28,
Assay of oxalate,83945,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13,,,,,,,fee schedule,13,113.28,Laboratory
Assay of oxalate,83945,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.17,,,,,,,fee schedule,13,113.28,APC
Assay of oxalate,83945,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,15.03,,,,,,,fee schedule,13,113.28,APC
Assay of oxalate,83945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14.45,,,,,,,fee schedule,13,113.28,APC
Assay of oxalate,83945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.11,,,,,,,fee schedule,13,113.28,Radiology
Assay of oxalate,83945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.23,,,,,,,fee schedule,13,113.28,APC
Assay of oxalate,83945,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,25.29,,,,,,,fee schedule,13,113.28,APC
Oncoprotein her-2/neu,83950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,355.47,,,,,,,fee schedule,57.97,355.47,
Oncoprotein her-2/neu,83950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,284.94,,,,,,,fee schedule,57.97,355.47,
Oncoprotein her-2/neu,83950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,311.27,,,,,,,fee schedule,57.97,355.47,
Oncoprotein her-2/neu,83950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,327.26,,,,,,,fee schedule,57.97,355.47,
Oncoprotein her-2/neu,83950,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,57.97,,,,,,,fee schedule,57.97,355.47,Laboratory
Oncoprotein her-2/neu,83950,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,67.63,,,,,,,fee schedule,57.97,355.47,APC
Oncoprotein her-2/neu,83950,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,66.99,,,,,,,fee schedule,57.97,355.47,APC
Oncoprotein her-2/neu,83950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,64.41,,,,,,,fee schedule,57.97,355.47,APC
Oncoprotein her-2/neu,83950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,98.55,,,,,,,fee schedule,57.97,355.47,Radiology
Oncoprotein her-2/neu,83950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,90.17,,,,,,,fee schedule,57.97,355.47,APC
Oncoprotein her-2/neu,83950,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,112.72,,,,,,,fee schedule,57.97,355.47,APC
Oncoprotein dcp,83951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,355.47,,,,,,,fee schedule,57.97,355.47,
Oncoprotein dcp,83951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,284.94,,,,,,,fee schedule,57.97,355.47,
Oncoprotein dcp,83951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,311.27,,,,,,,fee schedule,57.97,355.47,
Oncoprotein dcp,83951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,327.26,,,,,,,fee schedule,57.97,355.47,
Oncoprotein dcp,83951,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,57.97,,,,,,,fee schedule,57.97,355.47,Laboratory
Oncoprotein dcp,83951,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,67.63,,,,,,,fee schedule,57.97,355.47,APC
Oncoprotein dcp,83951,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,66.99,,,,,,,fee schedule,57.97,355.47,APC
Oncoprotein dcp,83951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,64.41,,,,,,,fee schedule,57.97,355.47,APC
Oncoprotein dcp,83951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,98.55,,,,,,,fee schedule,57.97,355.47,Radiology
Oncoprotein dcp,83951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,90.17,,,,,,,fee schedule,57.97,355.47,APC
Oncoprotein dcp,83951,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,112.72,,,,,,,fee schedule,57.97,355.47,APC
Assay of parathormone,83970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,266.9,,,,,,,fee schedule,37.15,266.9,
Assay of parathormone,83970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,213.94,,,,,,,fee schedule,37.15,266.9,
Assay of parathormone,83970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,233.71,,,,,,,fee schedule,37.15,266.9,
Assay of parathormone,83970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,245.71,,,,,,,fee schedule,37.15,266.9,
Assay of parathormone,83970,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,37.15,,,,,,,fee schedule,37.15,266.9,Laboratory
Assay of parathormone,83970,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,43.34,,,,,,,fee schedule,37.15,266.9,APC
Assay of parathormone,83970,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,42.93,,,,,,,fee schedule,37.15,266.9,APC
Assay of parathormone,83970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,41.28,,,,,,,fee schedule,37.15,266.9,APC
Assay of parathormone,83970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,63.16,,,,,,,fee schedule,37.15,266.9,Radiology
Assay of parathormone,83970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,57.79,,,,,,,fee schedule,37.15,266.9,APC
Assay of parathormone,83970,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,72.24,,,,,,,fee schedule,37.15,266.9,APC
Assay ph body fluid nos,83986,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,39.24,,,,,,,fee schedule,3.22,39.24,
Assay ph body fluid nos,83986,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31.45,,,,,,,fee schedule,3.22,39.24,
Assay ph body fluid nos,83986,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,34.36,,,,,,,fee schedule,3.22,39.24,
Assay ph body fluid nos,83986,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,36.13,,,,,,,fee schedule,3.22,39.24,
Assay ph body fluid nos,83986,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.22,,,,,,,fee schedule,3.22,39.24,Laboratory
Assay ph body fluid nos,83986,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3.76,,,,,,,fee schedule,3.22,39.24,APC
Assay ph body fluid nos,83986,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3.72,,,,,,,fee schedule,3.22,39.24,APC
Assay ph body fluid nos,83986,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3.58,,,,,,,fee schedule,3.22,39.24,APC
Assay ph body fluid nos,83986,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.48,,,,,,,fee schedule,3.22,39.24,Radiology
Assay ph body fluid nos,83986,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.01,,,,,,,fee schedule,3.22,39.24,APC
Assay ph body fluid nos,83986,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6.26,,,,,,,fee schedule,3.22,39.24,APC
Exhaled breath condensate,83987,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,85.96,,,,,,,fee schedule,3.22,85.96,
Exhaled breath condensate,83987,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,68.9,,,,,,,fee schedule,3.22,85.96,
Exhaled breath condensate,83987,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,75.27,,,,,,,fee schedule,3.22,85.96,
Exhaled breath condensate,83987,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,79.14,,,,,,,fee schedule,3.22,85.96,
Exhaled breath condensate,83987,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.22,,,,,,,fee schedule,3.22,85.96,Laboratory
Exhaled breath condensate,83987,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3.76,,,,,,,fee schedule,3.22,85.96,APC
Exhaled breath condensate,83987,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3.72,,,,,,,fee schedule,3.22,85.96,APC
Exhaled breath condensate,83987,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3.58,,,,,,,fee schedule,3.22,85.96,APC
Exhaled breath condensate,83987,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.48,,,,,,,fee schedule,3.22,85.96,Radiology
Exhaled breath condensate,83987,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.01,,,,,,,fee schedule,3.22,85.96,APC
Exhaled breath condensate,83987,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6.26,,,,,,,fee schedule,3.22,85.96,APC
Assay for phencyclidine,83992,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,81.12,,,,,,,fee schedule,65.02,81.12,
Assay for phencyclidine,83992,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,65.02,,,,,,,fee schedule,65.02,81.12,
Assay for phencyclidine,83992,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,71.03,,,,,,,fee schedule,65.02,81.12,
Assay for phencyclidine,83992,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,74.68,,,,,,,fee schedule,65.02,81.12,
Assay for calprotectin fecal,83993,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,61.9,,,,,,,fee schedule,17.67,61.9,
Assay for calprotectin fecal,83993,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,49.62,,,,,,,fee schedule,17.67,61.9,
Assay for calprotectin fecal,83993,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,54.2,,,,,,,fee schedule,17.67,61.9,
Assay for calprotectin fecal,83993,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,56.98,,,,,,,fee schedule,17.67,61.9,
Assay for calprotectin fecal,83993,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.67,,,,,,,fee schedule,17.67,61.9,Laboratory
Assay for calprotectin fecal,83993,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20.61,,,,,,,fee schedule,17.67,61.9,APC
Assay for calprotectin fecal,83993,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,20.42,,,,,,,fee schedule,17.67,61.9,APC
Assay for calprotectin fecal,83993,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,19.63,,,,,,,fee schedule,17.67,61.9,APC
Assay for calprotectin fecal,83993,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,30.03,,,,,,,fee schedule,17.67,61.9,Radiology
Assay for calprotectin fecal,83993,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27.48,,,,,,,fee schedule,17.67,61.9,APC
Assay for calprotectin fecal,83993,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,34.35,,,,,,,fee schedule,17.67,61.9,APC
Assay of blood pku,84030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30.39,,,,,,,fee schedule,4.95,30.39,
Assay of blood pku,84030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24.36,,,,,,,fee schedule,4.95,30.39,
Assay of blood pku,84030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26.61,,,,,,,fee schedule,4.95,30.39,
Assay of blood pku,84030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27.98,,,,,,,fee schedule,4.95,30.39,
Assay of blood pku,84030,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.95,,,,,,,fee schedule,4.95,30.39,Laboratory
Assay of blood pku,84030,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.78,,,,,,,fee schedule,4.95,30.39,APC
Assay of blood pku,84030,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5.72,,,,,,,fee schedule,4.95,30.39,APC
Assay of blood pku,84030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5.5,,,,,,,fee schedule,4.95,30.39,APC
Assay of blood pku,84030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8.42,,,,,,,fee schedule,4.95,30.39,Radiology
Assay of blood pku,84030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.7,,,,,,,fee schedule,4.95,30.39,APC
Assay of blood pku,84030,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9.62,,,,,,,fee schedule,4.95,30.39,APC
Assay of phenylketones,84035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20.19,,,,,,,fee schedule,3.58,20.19,
Assay of phenylketones,84035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.18,,,,,,,fee schedule,3.58,20.19,
Assay of phenylketones,84035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17.68,,,,,,,fee schedule,3.58,20.19,
Assay of phenylketones,84035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18.58,,,,,,,fee schedule,3.58,20.19,
Assay of phenylketones,84035,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.58,,,,,,,fee schedule,3.58,20.19,Laboratory
Assay of phenylketones,84035,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.18,,,,,,,fee schedule,3.58,20.19,APC
Assay of phenylketones,84035,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4.14,,,,,,,fee schedule,3.58,20.19,APC
Assay of phenylketones,84035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3.98,,,,,,,fee schedule,3.58,20.19,APC
Assay of phenylketones,84035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.09,,,,,,,fee schedule,3.58,20.19,Radiology
Assay of phenylketones,84035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.57,,,,,,,fee schedule,3.58,20.19,APC
Assay of phenylketones,84035,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6.96,,,,,,,fee schedule,3.58,20.19,APC
Assay acid phosphatase,84060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,40.75,,,,,,,fee schedule,6.88,40.75,
Assay acid phosphatase,84060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32.66,,,,,,,fee schedule,6.88,40.75,
Assay acid phosphatase,84060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35.68,,,,,,,fee schedule,6.88,40.75,
Assay acid phosphatase,84060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37.51,,,,,,,fee schedule,6.88,40.75,
Assay acid phosphatase,84060,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.88,,,,,,,fee schedule,6.88,40.75,Laboratory
Assay acid phosphatase,84060,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.02,,,,,,,fee schedule,6.88,40.75,APC
Assay acid phosphatase,84060,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7.95,,,,,,,fee schedule,6.88,40.75,APC
Assay acid phosphatase,84060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7.64,,,,,,,fee schedule,6.88,40.75,APC
Assay acid phosphatase,84060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11.69,,,,,,,fee schedule,6.88,40.75,Radiology
Assay acid phosphatase,84060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10.7,,,,,,,fee schedule,6.88,40.75,APC
Assay acid phosphatase,84060,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,13.37,,,,,,,fee schedule,6.88,40.75,APC
Assay prostate phosphatase,84066,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,53.3,,,,,,,fee schedule,8.69,53.3,
Assay prostate phosphatase,84066,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.72,,,,,,,fee schedule,8.69,53.3,
Assay prostate phosphatase,84066,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.67,,,,,,,fee schedule,8.69,53.3,
Assay prostate phosphatase,84066,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,49.07,,,,,,,fee schedule,8.69,53.3,
Assay prostate phosphatase,84066,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.69,,,,,,,fee schedule,8.69,53.3,Laboratory
Assay prostate phosphatase,84066,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.14,,,,,,,fee schedule,8.69,53.3,APC
Assay prostate phosphatase,84066,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10.05,,,,,,,fee schedule,8.69,53.3,APC
Assay prostate phosphatase,84066,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9.66,,,,,,,fee schedule,8.69,53.3,APC
Assay prostate phosphatase,84066,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.78,,,,,,,fee schedule,8.69,53.3,Radiology
Assay prostate phosphatase,84066,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.52,,,,,,,fee schedule,8.69,53.3,APC
Assay prostate phosphatase,84066,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16.9,,,,,,,fee schedule,8.69,53.3,APC
Assay alkaline phosphatase,84075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,51.83,,,,,,,fee schedule,4.66,51.83,
Assay alkaline phosphatase,84075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,41.54,,,,,,,fee schedule,4.66,51.83,
Assay alkaline phosphatase,84075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,45.38,,,,,,,fee schedule,4.66,51.83,
Assay alkaline phosphatase,84075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,47.71,,,,,,,fee schedule,4.66,51.83,
Assay alkaline phosphatase,84075,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.66,,,,,,,fee schedule,4.66,51.83,Laboratory
Assay alkaline phosphatase,84075,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.44,,,,,,,fee schedule,4.66,51.83,APC
Assay alkaline phosphatase,84075,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5.39,,,,,,,fee schedule,4.66,51.83,APC
Assay alkaline phosphatase,84075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5.18,,,,,,,fee schedule,4.66,51.83,APC
Assay alkaline phosphatase,84075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.93,,,,,,,fee schedule,4.66,51.83,Radiology
Assay alkaline phosphatase,84075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.25,,,,,,,fee schedule,4.66,51.83,APC
Assay alkaline phosphatase,84075,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9.06,,,,,,,fee schedule,4.66,51.83,APC
Assay alkaline phosphatase,84078,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,40.29,,,,,,,fee schedule,7.43,40.29,
Assay alkaline phosphatase,84078,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32.3,,,,,,,fee schedule,7.43,40.29,
Assay alkaline phosphatase,84078,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35.28,,,,,,,fee schedule,7.43,40.29,
Assay alkaline phosphatase,84078,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37.1,,,,,,,fee schedule,7.43,40.29,
Assay alkaline phosphatase,84078,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.43,,,,,,,fee schedule,7.43,40.29,Laboratory
Assay alkaline phosphatase,84078,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.67,,,,,,,fee schedule,7.43,40.29,APC
Assay alkaline phosphatase,84078,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8.59,,,,,,,fee schedule,7.43,40.29,APC
Assay alkaline phosphatase,84078,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8.26,,,,,,,fee schedule,7.43,40.29,APC
Assay alkaline phosphatase,84078,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12.64,,,,,,,fee schedule,7.43,40.29,Radiology
Assay alkaline phosphatase,84078,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11.56,,,,,,,fee schedule,7.43,40.29,APC
Assay alkaline phosphatase,84078,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14.46,,,,,,,fee schedule,7.43,40.29,APC
Assay alkaline phosphatases,84080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45.9,,,,,,,fee schedule,13.3,45.9,
Assay alkaline phosphatases,84080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36.8,,,,,,,fee schedule,13.3,45.9,
Assay alkaline phosphatases,84080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40.2,,,,,,,fee schedule,13.3,45.9,
Assay alkaline phosphatases,84080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42.26,,,,,,,fee schedule,13.3,45.9,
Assay alkaline phosphatases,84080,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.3,,,,,,,fee schedule,13.3,45.9,Laboratory
Assay alkaline phosphatases,84080,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.52,,,,,,,fee schedule,13.3,45.9,APC
Assay alkaline phosphatases,84080,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,15.37,,,,,,,fee schedule,13.3,45.9,APC
Assay alkaline phosphatases,84080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14.78,,,,,,,fee schedule,13.3,45.9,APC
Assay alkaline phosphatases,84080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.61,,,,,,,fee schedule,13.3,45.9,Radiology
Assay alkaline phosphatases,84080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.69,,,,,,,fee schedule,13.3,45.9,APC
Assay alkaline phosphatases,84080,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,25.86,,,,,,,fee schedule,13.3,45.9,APC
Assay phosphatidylglycerol,84081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,91.17,,,,,,,fee schedule,14.87,91.17,
Assay phosphatidylglycerol,84081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,73.08,,,,,,,fee schedule,14.87,91.17,
Assay phosphatidylglycerol,84081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,79.84,,,,,,,fee schedule,14.87,91.17,
Assay phosphatidylglycerol,84081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83.94,,,,,,,fee schedule,14.87,91.17,
Assay phosphatidylglycerol,84081,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.87,,,,,,,fee schedule,14.87,91.17,Laboratory
Assay phosphatidylglycerol,84081,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.35,,,,,,,fee schedule,14.87,91.17,APC
Assay phosphatidylglycerol,84081,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,17.18,,,,,,,fee schedule,14.87,91.17,APC
Assay phosphatidylglycerol,84081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16.52,,,,,,,fee schedule,14.87,91.17,APC
Assay phosphatidylglycerol,84081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.28,,,,,,,fee schedule,14.87,91.17,Radiology
Assay phosphatidylglycerol,84081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.13,,,,,,,fee schedule,14.87,91.17,APC
Assay phosphatidylglycerol,84081,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,28.91,,,,,,,fee schedule,14.87,91.17,APC
Assay of rbc pg6d enzyme,84085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37.2,,,,,,,fee schedule,8.5,37.2,
Assay of rbc pg6d enzyme,84085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29.82,,,,,,,fee schedule,8.5,37.2,
Assay of rbc pg6d enzyme,84085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32.57,,,,,,,fee schedule,8.5,37.2,
Assay of rbc pg6d enzyme,84085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,34.24,,,,,,,fee schedule,8.5,37.2,
Assay of rbc pg6d enzyme,84085,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.5,,,,,,,fee schedule,8.5,37.2,Laboratory
Assay of rbc pg6d enzyme,84085,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.91,,,,,,,fee schedule,8.5,37.2,APC
Assay of rbc pg6d enzyme,84085,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9.82,,,,,,,fee schedule,8.5,37.2,APC
Assay of rbc pg6d enzyme,84085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9.44,,,,,,,fee schedule,8.5,37.2,APC
Assay of rbc pg6d enzyme,84085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.44,,,,,,,fee schedule,8.5,37.2,Radiology
Assay of rbc pg6d enzyme,84085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.22,,,,,,,fee schedule,8.5,37.2,APC
Assay of rbc pg6d enzyme,84085,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16.52,,,,,,,fee schedule,8.5,37.2,APC
Assay phosphohexose enzymes,84087,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,56.96,,,,,,,fee schedule,9.66,56.96,
Assay phosphohexose enzymes,84087,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,45.66,,,,,,,fee schedule,9.66,56.96,
Assay phosphohexose enzymes,84087,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,49.88,,,,,,,fee schedule,9.66,56.96,
Assay phosphohexose enzymes,84087,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,52.44,,,,,,,fee schedule,9.66,56.96,
Assay phosphohexose enzymes,84087,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.66,,,,,,,fee schedule,9.66,56.96,Laboratory
Assay phosphohexose enzymes,84087,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.27,,,,,,,fee schedule,9.66,56.96,APC
Assay phosphohexose enzymes,84087,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11.16,,,,,,,fee schedule,9.66,56.96,APC
Assay phosphohexose enzymes,84087,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10.73,,,,,,,fee schedule,9.66,56.96,APC
Assay phosphohexose enzymes,84087,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.42,,,,,,,fee schedule,9.66,56.96,Radiology
Assay phosphohexose enzymes,84087,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15.02,,,,,,,fee schedule,9.66,56.96,APC
Assay phosphohexose enzymes,84087,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18.78,,,,,,,fee schedule,9.66,56.96,APC
Assay of phosphorus,84100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,57.5,,,,,,,fee schedule,4.27,57.5,
Assay of phosphorus,84100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.09,,,,,,,fee schedule,4.27,57.5,
Assay of phosphorus,84100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,50.35,,,,,,,fee schedule,4.27,57.5,
Assay of phosphorus,84100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,52.93,,,,,,,fee schedule,4.27,57.5,
Assay of phosphorus,84100,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.27,,,,,,,fee schedule,4.27,57.5,Laboratory
Assay of phosphorus,84100,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.98,,,,,,,fee schedule,4.27,57.5,APC
Assay of phosphorus,84100,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4.93,,,,,,,fee schedule,4.27,57.5,APC
Assay of phosphorus,84100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4.74,,,,,,,fee schedule,4.27,57.5,APC
Assay of phosphorus,84100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.25,,,,,,,fee schedule,4.27,57.5,Radiology
Assay of phosphorus,84100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.64,,,,,,,fee schedule,4.27,57.5,APC
Assay of phosphorus,84100,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8.3,,,,,,,fee schedule,4.27,57.5,APC
Assay of urine phosphorus,84105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59.23,,,,,,,fee schedule,5.2,59.23,
Assay of urine phosphorus,84105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,47.48,,,,,,,fee schedule,5.2,59.23,
Assay of urine phosphorus,84105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.87,,,,,,,fee schedule,5.2,59.23,
Assay of urine phosphorus,84105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,54.53,,,,,,,fee schedule,5.2,59.23,
Assay of urine phosphorus,84105,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.2,,,,,,,fee schedule,5.2,59.23,Laboratory
Assay of urine phosphorus,84105,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.07,,,,,,,fee schedule,5.2,59.23,APC
Assay of urine phosphorus,84105,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6.01,,,,,,,fee schedule,5.2,59.23,APC
Assay of urine phosphorus,84105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5.78,,,,,,,fee schedule,5.2,59.23,APC
Assay of urine phosphorus,84105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8.84,,,,,,,fee schedule,5.2,59.23,Radiology
Assay of urine phosphorus,84105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8.09,,,,,,,fee schedule,5.2,59.23,APC
Assay of urine phosphorus,84105,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10.12,,,,,,,fee schedule,5.2,59.23,APC
Test for porphobilinogen,84106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23.63,,,,,,,fee schedule,5.24,23.63,
Test for porphobilinogen,84106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18.94,,,,,,,fee schedule,5.24,23.63,
Test for porphobilinogen,84106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20.69,,,,,,,fee schedule,5.24,23.63,
Test for porphobilinogen,84106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21.75,,,,,,,fee schedule,5.24,23.63,
Test for porphobilinogen,84106,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.24,,,,,,,fee schedule,5.24,23.63,Laboratory
Test for porphobilinogen,84106,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.11,,,,,,,fee schedule,5.24,23.63,APC
Test for porphobilinogen,84106,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6.05,,,,,,,fee schedule,5.24,23.63,APC
Test for porphobilinogen,84106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5.82,,,,,,,fee schedule,5.24,23.63,APC
Test for porphobilinogen,84106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8.9,,,,,,,fee schedule,5.24,23.63,Radiology
Test for porphobilinogen,84106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8.15,,,,,,,fee schedule,5.24,23.63,APC
Test for porphobilinogen,84106,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10.18,,,,,,,fee schedule,5.24,23.63,APC
Assay of porphobilinogen,84110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46.65,,,,,,,fee schedule,7.6,46.65,
Assay of porphobilinogen,84110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37.39,,,,,,,fee schedule,7.6,46.65,
Assay of porphobilinogen,84110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40.85,,,,,,,fee schedule,7.6,46.65,
Assay of porphobilinogen,84110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42.94,,,,,,,fee schedule,7.6,46.65,
Assay of porphobilinogen,84110,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.6,,,,,,,fee schedule,7.6,46.65,Laboratory
Assay of porphobilinogen,84110,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.86,,,,,,,fee schedule,7.6,46.65,APC
Assay of porphobilinogen,84110,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8.78,,,,,,,fee schedule,7.6,46.65,APC
Assay of porphobilinogen,84110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8.44,,,,,,,fee schedule,7.6,46.65,APC
Assay of porphobilinogen,84110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12.91,,,,,,,fee schedule,7.6,46.65,Radiology
Assay of porphobilinogen,84110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11.82,,,,,,,fee schedule,7.6,46.65,APC
Assay of porphobilinogen,84110,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14.77,,,,,,,fee schedule,7.6,46.65,APC
Eval amniotic fluid protein,84112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,73.58,,,,,,,fee schedule,58.98,171.69,
Eval amniotic fluid protein,84112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,58.98,,,,,,,fee schedule,58.98,171.69,
Eval amniotic fluid protein,84112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,64.43,,,,,,,fee schedule,58.98,171.69,
Eval amniotic fluid protein,84112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,67.74,,,,,,,fee schedule,58.98,171.69,
Eval amniotic fluid protein,84112,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,88.3,,,,,,,fee schedule,58.98,171.69,Laboratory
Eval amniotic fluid protein,84112,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,103.02,,,,,,,fee schedule,58.98,171.69,APC
Eval amniotic fluid protein,84112,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,102.03,,,,,,,fee schedule,58.98,171.69,APC
Eval amniotic fluid protein,84112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,98.11,,,,,,,fee schedule,58.98,171.69,APC
Eval amniotic fluid protein,84112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,150.11,,,,,,,fee schedule,58.98,171.69,Radiology
Eval amniotic fluid protein,84112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,137.35,,,,,,,fee schedule,58.98,171.69,APC
Eval amniotic fluid protein,84112,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,171.69,,,,,,,fee schedule,58.98,171.69,APC
Test urine for porphyrins,84119,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,47.51,,,,,,,fee schedule,12.02,47.51,
Test urine for porphyrins,84119,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38.09,,,,,,,fee schedule,12.02,47.51,
Test urine for porphyrins,84119,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,41.61,,,,,,,fee schedule,12.02,47.51,
Test urine for porphyrins,84119,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,43.74,,,,,,,fee schedule,12.02,47.51,
Test urine for porphyrins,84119,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.02,,,,,,,fee schedule,12.02,47.51,Laboratory
Test urine for porphyrins,84119,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.03,,,,,,,fee schedule,12.02,47.51,APC
Test urine for porphyrins,84119,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.89,,,,,,,fee schedule,12.02,47.51,APC
Test urine for porphyrins,84119,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.36,,,,,,,fee schedule,12.02,47.51,APC
Test urine for porphyrins,84119,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.44,,,,,,,fee schedule,12.02,47.51,Radiology
Test urine for porphyrins,84119,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.7,,,,,,,fee schedule,12.02,47.51,APC
Test urine for porphyrins,84119,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23.38,,,,,,,fee schedule,12.02,47.51,APC
Assay of urine porphyrins,84120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45.9,,,,,,,fee schedule,13.24,45.9,
Assay of urine porphyrins,84120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36.8,,,,,,,fee schedule,13.24,45.9,
Assay of urine porphyrins,84120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40.2,,,,,,,fee schedule,13.24,45.9,
Assay of urine porphyrins,84120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42.26,,,,,,,fee schedule,13.24,45.9,
Assay of urine porphyrins,84120,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.24,,,,,,,fee schedule,13.24,45.9,Laboratory
Assay of urine porphyrins,84120,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.45,,,,,,,fee schedule,13.24,45.9,APC
Assay of urine porphyrins,84120,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,15.3,,,,,,,fee schedule,13.24,45.9,APC
Assay of urine porphyrins,84120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14.71,,,,,,,fee schedule,13.24,45.9,APC
Assay of urine porphyrins,84120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.51,,,,,,,fee schedule,13.24,45.9,Radiology
Assay of urine porphyrins,84120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.59,,,,,,,fee schedule,13.24,45.9,APC
Assay of urine porphyrins,84120,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,25.74,,,,,,,fee schedule,13.24,45.9,APC
Assay of feces porphyrins,84126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,140.58,,,,,,,fee schedule,35.2,140.58,
Assay of feces porphyrins,84126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,112.69,,,,,,,fee schedule,35.2,140.58,
Assay of feces porphyrins,84126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,123.1,,,,,,,fee schedule,35.2,140.58,
Assay of feces porphyrins,84126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,129.42,,,,,,,fee schedule,35.2,140.58,
Assay of feces porphyrins,84126,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,35.2,,,,,,,fee schedule,35.2,140.58,Laboratory
Assay of feces porphyrins,84126,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,41.07,,,,,,,fee schedule,35.2,140.58,APC
Assay of feces porphyrins,84126,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,40.67,,,,,,,fee schedule,35.2,140.58,APC
Assay of feces porphyrins,84126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,39.11,,,,,,,fee schedule,35.2,140.58,APC
Assay of feces porphyrins,84126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,59.84,,,,,,,fee schedule,35.2,140.58,Radiology
Assay of feces porphyrins,84126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,54.75,,,,,,,fee schedule,35.2,140.58,APC
Assay of feces porphyrins,84126,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,68.44,,,,,,,fee schedule,35.2,140.58,APC
Assay of serum potassium,84132,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,32.37,,,,,,,fee schedule,4.28,32.37,
Assay of serum potassium,84132,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,25.94,,,,,,,fee schedule,4.28,32.37,
Assay of serum potassium,84132,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28.34,,,,,,,fee schedule,4.28,32.37,
Assay of serum potassium,84132,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,29.8,,,,,,,fee schedule,4.28,32.37,
Assay of serum potassium,84132,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.28,,,,,,,fee schedule,4.28,32.37,Laboratory
Assay of serum potassium,84132,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5,,,,,,,fee schedule,4.28,32.37,APC
Assay of serum potassium,84132,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4.95,,,,,,,fee schedule,4.28,32.37,APC
Assay of serum potassium,84132,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4.76,,,,,,,fee schedule,4.28,32.37,APC
Assay of serum potassium,84132,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.28,,,,,,,fee schedule,4.28,32.37,Radiology
Assay of serum potassium,84132,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.66,,,,,,,fee schedule,4.28,32.37,APC
Assay of serum potassium,84132,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8.33,,,,,,,fee schedule,4.28,32.37,APC
Assay of urine potassium,84133,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,69.6,,,,,,,fee schedule,4.26,69.6,
Assay of urine potassium,84133,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55.79,,,,,,,fee schedule,4.26,69.6,
Assay of urine potassium,84133,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,60.94,,,,,,,fee schedule,4.26,69.6,
Assay of urine potassium,84133,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,64.07,,,,,,,fee schedule,4.26,69.6,
Assay of urine potassium,84133,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.26,,,,,,,fee schedule,4.26,69.6,Laboratory
Assay of urine potassium,84133,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.97,,,,,,,fee schedule,4.26,69.6,APC
Assay of urine potassium,84133,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4.92,,,,,,,fee schedule,4.26,69.6,APC
Assay of urine potassium,84133,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4.73,,,,,,,fee schedule,4.26,69.6,APC
Assay of urine potassium,84133,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.24,,,,,,,fee schedule,4.26,69.6,Radiology
Assay of urine potassium,84133,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.62,,,,,,,fee schedule,4.26,69.6,APC
Assay of urine potassium,84133,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8.28,,,,,,,fee schedule,4.26,69.6,APC
Assay of prealbumin,84134,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33.32,,,,,,,fee schedule,13.13,33.32,
Assay of prealbumin,84134,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26.71,,,,,,,fee schedule,13.13,33.32,
Assay of prealbumin,84134,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29.17,,,,,,,fee schedule,13.13,33.32,
Assay of prealbumin,84134,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30.67,,,,,,,fee schedule,13.13,33.32,
Assay of prealbumin,84134,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.13,,,,,,,fee schedule,13.13,33.32,Laboratory
Assay of prealbumin,84134,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.32,,,,,,,fee schedule,13.13,33.32,APC
Assay of prealbumin,84134,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,15.17,,,,,,,fee schedule,13.13,33.32,APC
Assay of prealbumin,84134,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14.59,,,,,,,fee schedule,13.13,33.32,APC
Assay of prealbumin,84134,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.32,,,,,,,fee schedule,13.13,33.32,Radiology
Assay of prealbumin,84134,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.43,,,,,,,fee schedule,13.13,33.32,APC
Assay of prealbumin,84134,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,25.53,,,,,,,fee schedule,13.13,33.32,APC
Assay of pregnanediol,84135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,105.61,,,,,,,fee schedule,19.14,105.61,
Assay of pregnanediol,84135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,84.66,,,,,,,fee schedule,19.14,105.61,
Assay of pregnanediol,84135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,92.48,,,,,,,fee schedule,19.14,105.61,
Assay of pregnanediol,84135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,97.23,,,,,,,fee schedule,19.14,105.61,
Assay of pregnanediol,84135,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.14,,,,,,,fee schedule,19.14,105.61,Laboratory
Assay of pregnanediol,84135,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,22.33,,,,,,,fee schedule,19.14,105.61,APC
Assay of pregnanediol,84135,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,22.12,,,,,,,fee schedule,19.14,105.61,APC
Assay of pregnanediol,84135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,21.27,,,,,,,fee schedule,19.14,105.61,APC
Assay of pregnanediol,84135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,32.54,,,,,,,fee schedule,19.14,105.61,Radiology
Assay of pregnanediol,84135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29.78,,,,,,,fee schedule,19.14,105.61,APC
Assay of pregnanediol,84135,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,37.22,,,,,,,fee schedule,19.14,105.61,APC
Assay of pregnanetriol,84138,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,104.52,,,,,,,fee schedule,18.94,104.52,
Assay of pregnanetriol,84138,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,83.78,,,,,,,fee schedule,18.94,104.52,
Assay of pregnanetriol,84138,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,91.52,,,,,,,fee schedule,18.94,104.52,
Assay of pregnanetriol,84138,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,96.22,,,,,,,fee schedule,18.94,104.52,
Assay of pregnanetriol,84138,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.94,,,,,,,fee schedule,18.94,104.52,Laboratory
Assay of pregnanetriol,84138,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,22.1,,,,,,,fee schedule,18.94,104.52,APC
Assay of pregnanetriol,84138,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,21.89,,,,,,,fee schedule,18.94,104.52,APC
Assay of pregnanetriol,84138,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,21.05,,,,,,,fee schedule,18.94,104.52,APC
Assay of pregnanetriol,84138,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,32.21,,,,,,,fee schedule,18.94,104.52,Radiology
Assay of pregnanetriol,84138,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29.47,,,,,,,fee schedule,18.94,104.52,APC
Assay of pregnanetriol,84138,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,36.84,,,,,,,fee schedule,18.94,104.52,APC
Assay of pregnenolone,84140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,114.12,,,,,,,fee schedule,18.6,114.12,
Assay of pregnenolone,84140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,91.48,,,,,,,fee schedule,18.6,114.12,
Assay of pregnenolone,84140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,99.93,,,,,,,fee schedule,18.6,114.12,
Assay of pregnenolone,84140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,105.06,,,,,,,fee schedule,18.6,114.12,
Assay of pregnenolone,84140,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.6,,,,,,,fee schedule,18.6,114.12,Laboratory
Assay of pregnenolone,84140,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.7,,,,,,,fee schedule,18.6,114.12,APC
Assay of pregnenolone,84140,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,21.5,,,,,,,fee schedule,18.6,114.12,APC
Assay of pregnenolone,84140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,20.67,,,,,,,fee schedule,18.6,114.12,APC
Assay of pregnenolone,84140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,31.63,,,,,,,fee schedule,18.6,114.12,Radiology
Assay of pregnenolone,84140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.94,,,,,,,fee schedule,18.6,114.12,APC
Assay of pregnenolone,84140,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,36.17,,,,,,,fee schedule,18.6,114.12,APC
Assay of 17-hydroxypregneno,84143,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,125.95,,,,,,,fee schedule,20.53,125.95,
Assay of 17-hydroxypregneno,84143,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,100.96,,,,,,,fee schedule,20.53,125.95,
Assay of 17-hydroxypregneno,84143,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,110.29,,,,,,,fee schedule,20.53,125.95,
Assay of 17-hydroxypregneno,84143,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,115.95,,,,,,,fee schedule,20.53,125.95,
Assay of 17-hydroxypregneno,84143,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,20.53,,,,,,,fee schedule,20.53,125.95,Laboratory
Assay of 17-hydroxypregneno,84143,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,23.95,,,,,,,fee schedule,20.53,125.95,APC
Assay of 17-hydroxypregneno,84143,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,23.72,,,,,,,fee schedule,20.53,125.95,APC
Assay of 17-hydroxypregneno,84143,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,22.81,,,,,,,fee schedule,20.53,125.95,APC
Assay of 17-hydroxypregneno,84143,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,34.9,,,,,,,fee schedule,20.53,125.95,Radiology
Assay of 17-hydroxypregneno,84143,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,31.93,,,,,,,fee schedule,20.53,125.95,APC
Assay of 17-hydroxypregneno,84143,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,39.92,,,,,,,fee schedule,20.53,125.95,APC
Assay of progesterone,84144,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,110.81,,,,,,,fee schedule,18.77,110.81,
Assay of progesterone,84144,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,88.83,,,,,,,fee schedule,18.77,110.81,
Assay of progesterone,84144,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,97.03,,,,,,,fee schedule,18.77,110.81,
Assay of progesterone,84144,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,102.02,,,,,,,fee schedule,18.77,110.81,
Assay of progesterone,84144,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.77,,,,,,,fee schedule,18.77,110.81,Laboratory
Assay of progesterone,84144,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.9,,,,,,,fee schedule,18.77,110.81,APC
Assay of progesterone,84144,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,21.69,,,,,,,fee schedule,18.77,110.81,APC
Assay of progesterone,84144,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,20.86,,,,,,,fee schedule,18.77,110.81,APC
Assay of progesterone,84144,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,31.92,,,,,,,fee schedule,18.77,110.81,Radiology
Assay of progesterone,84144,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29.2,,,,,,,fee schedule,18.77,110.81,APC
Assay of progesterone,84144,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,36.5,,,,,,,fee schedule,18.77,110.81,APC
Procalcitonin (PCT),84145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83.48,,,,,,,fee schedule,24.5,83.48,
Procalcitonin (PCT),84145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66.92,,,,,,,fee schedule,24.5,83.48,
Procalcitonin (PCT),84145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,73.1,,,,,,,fee schedule,24.5,83.48,
Procalcitonin (PCT),84145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,76.85,,,,,,,fee schedule,24.5,83.48,
Procalcitonin (PCT),84145,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24.5,,,,,,,fee schedule,24.5,83.48,Laboratory
Procalcitonin (PCT),84145,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,28.58,,,,,,,fee schedule,24.5,83.48,APC
Procalcitonin (PCT),84145,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,28.31,,,,,,,fee schedule,24.5,83.48,APC
Procalcitonin (PCT),84145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,27.22,,,,,,,fee schedule,24.5,83.48,APC
Procalcitonin (PCT),84145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,41.65,,,,,,,fee schedule,24.5,83.48,Radiology
Procalcitonin (PCT),84145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,38.11,,,,,,,fee schedule,24.5,83.48,APC
Procalcitonin (PCT),84145,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,47.64,,,,,,,fee schedule,24.5,83.48,APC
Assay of prolactin,84146,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,103.39,,,,,,,fee schedule,17.44,103.39,
Assay of prolactin,84146,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,82.87,,,,,,,fee schedule,17.44,103.39,
Assay of prolactin,84146,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,90.53,,,,,,,fee schedule,17.44,103.39,
Assay of prolactin,84146,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,95.18,,,,,,,fee schedule,17.44,103.39,
Assay of prolactin,84146,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.44,,,,,,,fee schedule,17.44,103.39,Laboratory
Assay of prolactin,84146,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20.35,,,,,,,fee schedule,17.44,103.39,APC
Assay of prolactin,84146,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,20.16,,,,,,,fee schedule,17.44,103.39,APC
Assay of prolactin,84146,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,19.38,,,,,,,fee schedule,17.44,103.39,APC
Assay of prolactin,84146,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29.65,,,,,,,fee schedule,17.44,103.39,Radiology
Assay of prolactin,84146,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27.13,,,,,,,fee schedule,17.44,103.39,APC
Assay of prolactin,84146,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,33.92,,,,,,,fee schedule,17.44,103.39,APC
Assay of prostaglandin,84150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,137.78,,,,,,,fee schedule,37.59,137.78,
Assay of prostaglandin,84150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,110.44,,,,,,,fee schedule,37.59,137.78,
Assay of prostaglandin,84150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,120.65,,,,,,,fee schedule,37.59,137.78,
Assay of prostaglandin,84150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,126.85,,,,,,,fee schedule,37.59,137.78,
Assay of prostaglandin,84150,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,37.59,,,,,,,fee schedule,37.59,137.78,Laboratory
Assay of prostaglandin,84150,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,43.86,,,,,,,fee schedule,37.59,137.78,APC
Assay of prostaglandin,84150,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,43.44,,,,,,,fee schedule,37.59,137.78,APC
Assay of prostaglandin,84150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,41.77,,,,,,,fee schedule,37.59,137.78,APC
Assay of prostaglandin,84150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,63.91,,,,,,,fee schedule,37.59,137.78,Radiology
Assay of prostaglandin,84150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,58.48,,,,,,,fee schedule,37.59,137.78,APC
Assay of prostaglandin,84150,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,73.1,,,,,,,fee schedule,37.59,137.78,APC
Assay of psa complexed,84152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,101.49,,,,,,,fee schedule,16.55,101.49,
Assay of psa complexed,84152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,81.36,,,,,,,fee schedule,16.55,101.49,
Assay of psa complexed,84152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,88.87,,,,,,,fee schedule,16.55,101.49,
Assay of psa complexed,84152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,93.44,,,,,,,fee schedule,16.55,101.49,
Assay of psa complexed,84152,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.55,,,,,,,fee schedule,16.55,101.49,Laboratory
Assay of psa complexed,84152,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.31,,,,,,,fee schedule,16.55,101.49,APC
Assay of psa complexed,84152,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,19.13,,,,,,,fee schedule,16.55,101.49,APC
Assay of psa complexed,84152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18.39,,,,,,,fee schedule,16.55,101.49,APC
Assay of psa complexed,84152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.14,,,,,,,fee schedule,16.55,101.49,Radiology
Assay of psa complexed,84152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.75,,,,,,,fee schedule,16.55,101.49,APC
Assay of psa complexed,84152,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,32.18,,,,,,,fee schedule,16.55,101.49,APC
Assay of psa total,84153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,85.39,,,,,,,fee schedule,16.55,85.39,
Assay of psa total,84153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,68.45,,,,,,,fee schedule,16.55,85.39,
Assay of psa total,84153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,74.77,,,,,,,fee schedule,16.55,85.39,
Assay of psa total,84153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,78.61,,,,,,,fee schedule,16.55,85.39,
Assay of psa total,84153,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.55,,,,,,,fee schedule,16.55,85.39,Laboratory
Assay of psa total,84153,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.31,,,,,,,fee schedule,16.55,85.39,APC
Assay of psa total,84153,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,19.13,,,,,,,fee schedule,16.55,85.39,APC
Assay of psa total,84153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18.39,,,,,,,fee schedule,16.55,85.39,APC
Assay of psa total,84153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.14,,,,,,,fee schedule,16.55,85.39,Radiology
Assay of psa total,84153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.75,,,,,,,fee schedule,16.55,85.39,APC
Assay of psa total,84153,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,32.18,,,,,,,fee schedule,16.55,85.39,APC
Assay of psa free,84154,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.55,,,,,,,fee schedule,16.55,60.55,
Assay of psa free,84154,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48.54,,,,,,,fee schedule,16.55,60.55,
Assay of psa free,84154,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.02,,,,,,,fee schedule,16.55,60.55,
Assay of psa free,84154,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55.75,,,,,,,fee schedule,16.55,60.55,
Assay of psa free,84154,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.55,,,,,,,fee schedule,16.55,60.55,Laboratory
Assay of psa free,84154,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.31,,,,,,,fee schedule,16.55,60.55,APC
Assay of psa free,84154,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,19.13,,,,,,,fee schedule,16.55,60.55,APC
Assay of psa free,84154,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18.39,,,,,,,fee schedule,16.55,60.55,APC
Assay of psa free,84154,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.14,,,,,,,fee schedule,16.55,60.55,Radiology
Assay of psa free,84154,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.75,,,,,,,fee schedule,16.55,60.55,APC
Assay of psa free,84154,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,32.18,,,,,,,fee schedule,16.55,60.55,APC
Assay of protein serum,84155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,64.43,,,,,,,fee schedule,3.3,64.43,
Assay of protein serum,84155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.64,,,,,,,fee schedule,3.3,64.43,
Assay of protein serum,84155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56.41,,,,,,,fee schedule,3.3,64.43,
Assay of protein serum,84155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59.31,,,,,,,fee schedule,3.3,64.43,
Assay of protein serum,84155,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.3,,,,,,,fee schedule,3.3,64.43,Laboratory
Assay of protein serum,84155,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3.85,,,,,,,fee schedule,3.3,64.43,APC
Assay of protein serum,84155,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3.82,,,,,,,fee schedule,3.3,64.43,APC
Assay of protein serum,84155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3.67,,,,,,,fee schedule,3.3,64.43,APC
Assay of protein serum,84155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.62,,,,,,,fee schedule,3.3,64.43,Radiology
Assay of protein serum,84155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.14,,,,,,,fee schedule,3.3,64.43,APC
Assay of protein serum,84155,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6.42,,,,,,,fee schedule,3.3,64.43,APC
Assay of protein urine,84156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,58.9,,,,,,,fee schedule,3.3,58.9,
Assay of protein urine,84156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,47.22,,,,,,,fee schedule,3.3,58.9,
Assay of protein urine,84156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.58,,,,,,,fee schedule,3.3,58.9,
Assay of protein urine,84156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,54.23,,,,,,,fee schedule,3.3,58.9,
Assay of protein urine,84156,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.3,,,,,,,fee schedule,3.3,58.9,Laboratory
Assay of protein urine,84156,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3.85,,,,,,,fee schedule,3.3,58.9,APC
Assay of protein urine,84156,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3.82,,,,,,,fee schedule,3.3,58.9,APC
Assay of protein urine,84156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3.67,,,,,,,fee schedule,3.3,58.9,APC
Assay of protein urine,84156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.62,,,,,,,fee schedule,3.3,58.9,Radiology
Assay of protein urine,84156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.14,,,,,,,fee schedule,3.3,58.9,APC
Assay of protein urine,84156,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6.42,,,,,,,fee schedule,3.3,58.9,APC
Assay of protein other,84157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,82.81,,,,,,,fee schedule,3.6,82.81,
Assay of protein other,84157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66.38,,,,,,,fee schedule,3.6,82.81,
Assay of protein other,84157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,72.52,,,,,,,fee schedule,3.6,82.81,
Assay of protein other,84157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,76.24,,,,,,,fee schedule,3.6,82.81,
Assay of protein other,84157,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.6,,,,,,,fee schedule,3.6,82.81,Laboratory
Assay of protein other,84157,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.2,,,,,,,fee schedule,3.6,82.81,APC
Assay of protein other,84157,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4.16,,,,,,,fee schedule,3.6,82.81,APC
Assay of protein other,84157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4,,,,,,,fee schedule,3.6,82.81,APC
Assay of protein other,84157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.12,,,,,,,fee schedule,3.6,82.81,Radiology
Assay of protein other,84157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.6,,,,,,,fee schedule,3.6,82.81,APC
Assay of protein other,84157,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7,,,,,,,fee schedule,3.6,82.81,APC
Assay of protein any source,84160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,28.58,,,,,,,fee schedule,5.05,28.58,
Assay of protein any source,84160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22.91,,,,,,,fee schedule,5.05,28.58,
Assay of protein any source,84160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,25.02,,,,,,,fee schedule,5.05,28.58,
Assay of protein any source,84160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26.31,,,,,,,fee schedule,5.05,28.58,
Assay of protein any source,84160,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.05,,,,,,,fee schedule,5.05,28.58,Laboratory
Assay of protein any source,84160,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.89,,,,,,,fee schedule,5.05,28.58,APC
Assay of protein any source,84160,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5.83,,,,,,,fee schedule,5.05,28.58,APC
Assay of protein any source,84160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5.61,,,,,,,fee schedule,5.05,28.58,APC
Assay of protein any source,84160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8.58,,,,,,,fee schedule,5.05,28.58,Radiology
Assay of protein any source,84160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.85,,,,,,,fee schedule,5.05,28.58,APC
Assay of protein any source,84160,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9.82,,,,,,,fee schedule,5.05,28.58,APC
Pappa serum,84163,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83.08,,,,,,,fee schedule,13.54,83.08,
Pappa serum,84163,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66.6,,,,,,,fee schedule,13.54,83.08,
Pappa serum,84163,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,72.75,,,,,,,fee schedule,13.54,83.08,
Pappa serum,84163,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,76.49,,,,,,,fee schedule,13.54,83.08,
Pappa serum,84163,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.55,,,,,,,fee schedule,13.54,83.08,Laboratory
Pappa serum,84163,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.8,,,,,,,fee schedule,13.54,83.08,APC
Pappa serum,84163,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,15.65,,,,,,,fee schedule,13.54,83.08,APC
Pappa serum,84163,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,15.05,,,,,,,fee schedule,13.54,83.08,APC
Pappa serum,84163,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.03,,,,,,,fee schedule,13.54,83.08,Radiology
Pappa serum,84163,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21.07,,,,,,,fee schedule,13.54,83.08,APC
Pappa serum,84163,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,26.34,,,,,,,fee schedule,13.54,83.08,APC
Protein e-phoresis serum,84165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,64.41,,,,,,,fee schedule,9.67,64.41,
Protein e-phoresis serum,84165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.63,,,,,,,fee schedule,9.67,64.41,
Protein e-phoresis serum,84165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56.4,,,,,,,fee schedule,9.67,64.41,
Protein e-phoresis serum,84165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59.3,,,,,,,fee schedule,9.67,64.41,
Protein e-phoresis serum,84165,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.67,,,,,,,fee schedule,9.67,64.41,Laboratory
Protein e-phoresis serum,84165,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.28,,,,,,,fee schedule,9.67,64.41,APC
Protein e-phoresis serum,84165,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11.17,,,,,,,fee schedule,9.67,64.41,APC
Protein e-phoresis serum,84165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10.74,,,,,,,fee schedule,9.67,64.41,APC
Protein e-phoresis serum,84165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.43,,,,,,,fee schedule,9.67,64.41,Radiology
Protein e-phoresis serum,84165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15.04,,,,,,,fee schedule,9.67,64.41,APC
Protein e-phoresis serum,84165,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18.8,,,,,,,fee schedule,9.67,64.41,APC
Protein e-phoresis/urine/csf,84166,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,61.45,,,,,,,fee schedule,16.05,61.45,
Protein e-phoresis/urine/csf,84166,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,49.26,,,,,,,fee schedule,16.05,61.45,
Protein e-phoresis/urine/csf,84166,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.81,,,,,,,fee schedule,16.05,61.45,
Protein e-phoresis/urine/csf,84166,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,56.58,,,,,,,fee schedule,16.05,61.45,
Protein e-phoresis/urine/csf,84166,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.05,,,,,,,fee schedule,16.05,61.45,Laboratory
Protein e-phoresis/urine/csf,84166,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.72,,,,,,,fee schedule,16.05,61.45,APC
Protein e-phoresis/urine/csf,84166,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18.54,,,,,,,fee schedule,16.05,61.45,APC
Protein e-phoresis/urine/csf,84166,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17.83,,,,,,,fee schedule,16.05,61.45,APC
Protein e-phoresis/urine/csf,84166,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27.28,,,,,,,fee schedule,16.05,61.45,Radiology
Protein e-phoresis/urine/csf,84166,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24.96,,,,,,,fee schedule,16.05,61.45,APC
Protein e-phoresis/urine/csf,84166,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31.2,,,,,,,fee schedule,16.05,61.45,APC
Western blot test,84181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,94.01,,,,,,,fee schedule,15.33,94.01,
Western blot test,84181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,75.36,,,,,,,fee schedule,15.33,94.01,
Western blot test,84181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,82.32,,,,,,,fee schedule,15.33,94.01,
Western blot test,84181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,86.55,,,,,,,fee schedule,15.33,94.01,
Western blot test,84181,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.33,,,,,,,fee schedule,15.33,94.01,Laboratory
Western blot test,84181,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.88,,,,,,,fee schedule,15.33,94.01,APC
Western blot test,84181,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,17.71,,,,,,,fee schedule,15.33,94.01,APC
Western blot test,84181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17.03,,,,,,,fee schedule,15.33,94.01,APC
Western blot test,84181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26.06,,,,,,,fee schedule,15.33,94.01,Radiology
Western blot test,84181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.84,,,,,,,fee schedule,15.33,94.01,APC
Western blot test,84181,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,29.8,,,,,,,fee schedule,15.33,94.01,APC
Protein western blot test,84182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,99.34,,,,,,,fee schedule,26.29,99.34,
Protein western blot test,84182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,79.63,,,,,,,fee schedule,26.29,99.34,
Protein western blot test,84182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,86.99,,,,,,,fee schedule,26.29,99.34,
Protein western blot test,84182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,91.45,,,,,,,fee schedule,26.29,99.34,
Protein western blot test,84182,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26.29,,,,,,,fee schedule,26.29,99.34,Laboratory
Protein western blot test,84182,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.67,,,,,,,fee schedule,26.29,99.34,APC
Protein western blot test,84182,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,30.38,,,,,,,fee schedule,26.29,99.34,APC
Protein western blot test,84182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,29.21,,,,,,,fee schedule,26.29,99.34,APC
Protein western blot test,84182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,44.69,,,,,,,fee schedule,26.29,99.34,Radiology
Protein western blot test,84182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40.89,,,,,,,fee schedule,26.29,99.34,APC
Protein western blot test,84182,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,51.12,,,,,,,fee schedule,26.29,99.34,APC
Assay RBC protoporphyrin,84202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,79.19,,,,,,,fee schedule,12.92,79.19,
Assay RBC protoporphyrin,84202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,63.48,,,,,,,fee schedule,12.92,79.19,
Assay RBC protoporphyrin,84202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,69.34,,,,,,,fee schedule,12.92,79.19,
Assay RBC protoporphyrin,84202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,72.91,,,,,,,fee schedule,12.92,79.19,
Assay RBC protoporphyrin,84202,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.92,,,,,,,fee schedule,12.92,79.19,Laboratory
Assay RBC protoporphyrin,84202,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.07,,,,,,,fee schedule,12.92,79.19,APC
Assay RBC protoporphyrin,84202,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,14.92,,,,,,,fee schedule,12.92,79.19,APC
Assay RBC protoporphyrin,84202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14.35,,,,,,,fee schedule,12.92,79.19,APC
Assay RBC protoporphyrin,84202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21.96,,,,,,,fee schedule,12.92,79.19,Radiology
Assay RBC protoporphyrin,84202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.09,,,,,,,fee schedule,12.92,79.19,APC
Assay RBC protoporphyrin,84202,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,25.11,,,,,,,fee schedule,12.92,79.19,APC
Test RBC protoporphyrin,84203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,47.51,,,,,,,fee schedule,8.77,47.51,
Test RBC protoporphyrin,84203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38.09,,,,,,,fee schedule,8.77,47.51,
Test RBC protoporphyrin,84203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,41.61,,,,,,,fee schedule,8.77,47.51,
Test RBC protoporphyrin,84203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,43.74,,,,,,,fee schedule,8.77,47.51,
Test RBC protoporphyrin,84203,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.77,,,,,,,fee schedule,8.77,47.51,Laboratory
Test RBC protoporphyrin,84203,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.23,,,,,,,fee schedule,8.77,47.51,APC
Test RBC protoporphyrin,84203,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10.13,,,,,,,fee schedule,8.77,47.51,APC
Test RBC protoporphyrin,84203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9.74,,,,,,,fee schedule,8.77,47.51,APC
Test RBC protoporphyrin,84203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.9,,,,,,,fee schedule,8.77,47.51,Radiology
Test RBC protoporphyrin,84203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.64,,,,,,,fee schedule,8.77,47.51,APC
Test RBC protoporphyrin,84203,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,17.05,,,,,,,fee schedule,8.77,47.51,APC
Assay of proinsulin,84206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55.53,,,,,,,fee schedule,24.02,55.53,
Assay of proinsulin,84206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,44.51,,,,,,,fee schedule,24.02,55.53,
Assay of proinsulin,84206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48.62,,,,,,,fee schedule,24.02,55.53,
Assay of proinsulin,84206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,51.12,,,,,,,fee schedule,24.02,55.53,
Assay of proinsulin,84206,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24.02,,,,,,,fee schedule,24.02,55.53,Laboratory
Assay of proinsulin,84206,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,28.02,,,,,,,fee schedule,24.02,55.53,APC
Assay of proinsulin,84206,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,27.76,,,,,,,fee schedule,24.02,55.53,APC
Assay of proinsulin,84206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,26.69,,,,,,,fee schedule,24.02,55.53,APC
Assay of proinsulin,84206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40.84,,,,,,,fee schedule,24.02,55.53,Radiology
Assay of proinsulin,84206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,37.37,,,,,,,fee schedule,24.02,55.53,APC
Assay of proinsulin,84206,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,46.71,,,,,,,fee schedule,24.02,55.53,APC
Assay of vitamin b-6,84207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,113.82,,,,,,,fee schedule,25.29,113.82,
Assay of vitamin b-6,84207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,91.24,,,,,,,fee schedule,25.29,113.82,
Assay of vitamin b-6,84207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,99.67,,,,,,,fee schedule,25.29,113.82,
Assay of vitamin b-6,84207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,104.79,,,,,,,fee schedule,25.29,113.82,
Assay of vitamin b-6,84207,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25.29,,,,,,,fee schedule,25.29,113.82,Laboratory
Assay of vitamin b-6,84207,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,29.51,,,,,,,fee schedule,25.29,113.82,APC
Assay of vitamin b-6,84207,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,29.22,,,,,,,fee schedule,25.29,113.82,APC
Assay of vitamin b-6,84207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,28.1,,,,,,,fee schedule,25.29,113.82,APC
Assay of vitamin b-6,84207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,42.99,,,,,,,fee schedule,25.29,113.82,Radiology
Assay of vitamin b-6,84207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,39.34,,,,,,,fee schedule,25.29,113.82,APC
Assay of vitamin b-6,84207,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,49.18,,,,,,,fee schedule,25.29,113.82,APC
Assay of pyruvate,84210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,32.58,,,,,,,fee schedule,13.03,32.58,
Assay of pyruvate,84210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26.11,,,,,,,fee schedule,13.03,32.58,
Assay of pyruvate,84210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28.53,,,,,,,fee schedule,13.03,32.58,
Assay of pyruvate,84210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,29.99,,,,,,,fee schedule,13.03,32.58,
Assay of pyruvate,84210,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.03,,,,,,,fee schedule,13.03,32.58,Laboratory
Assay of pyruvate,84210,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.2,,,,,,,fee schedule,13.03,32.58,APC
Assay of pyruvate,84210,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,15.06,,,,,,,fee schedule,13.03,32.58,APC
Assay of pyruvate,84210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14.48,,,,,,,fee schedule,13.03,32.58,APC
Assay of pyruvate,84210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.15,,,,,,,fee schedule,13.03,32.58,Radiology
Assay of pyruvate,84210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.27,,,,,,,fee schedule,13.03,32.58,APC
Assay of pyruvate,84210,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,25.34,,,,,,,fee schedule,13.03,32.58,APC
Assay of pyruvate kinase,84220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,52.05,,,,,,,fee schedule,8.5,52.05,
Assay of pyruvate kinase,84220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,41.72,,,,,,,fee schedule,8.5,52.05,
Assay of pyruvate kinase,84220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,45.58,,,,,,,fee schedule,8.5,52.05,
Assay of pyruvate kinase,84220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,47.92,,,,,,,fee schedule,8.5,52.05,
Assay of pyruvate kinase,84220,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.5,,,,,,,fee schedule,8.5,52.05,Laboratory
Assay of pyruvate kinase,84220,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.91,,,,,,,fee schedule,8.5,52.05,APC
Assay of pyruvate kinase,84220,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9.82,,,,,,,fee schedule,8.5,52.05,APC
Assay of pyruvate kinase,84220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9.44,,,,,,,fee schedule,8.5,52.05,APC
Assay of pyruvate kinase,84220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.44,,,,,,,fee schedule,8.5,52.05,Radiology
Assay of pyruvate kinase,84220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.22,,,,,,,fee schedule,8.5,52.05,APC
Assay of pyruvate kinase,84220,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16.52,,,,,,,fee schedule,8.5,52.05,APC
Assay of quinine,84228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,64.22,,,,,,,fee schedule,10.47,64.22,
Assay of quinine,84228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.48,,,,,,,fee schedule,10.47,64.22,
Assay of quinine,84228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56.24,,,,,,,fee schedule,10.47,64.22,
Assay of quinine,84228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59.13,,,,,,,fee schedule,10.47,64.22,
Assay of quinine,84228,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.47,,,,,,,fee schedule,10.47,64.22,Laboratory
Assay of quinine,84228,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.21,,,,,,,fee schedule,10.47,64.22,APC
Assay of quinine,84228,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.1,,,,,,,fee schedule,10.47,64.22,APC
Assay of quinine,84228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11.63,,,,,,,fee schedule,10.47,64.22,APC
Assay of quinine,84228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.79,,,,,,,fee schedule,10.47,64.22,Radiology
Assay of quinine,84228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.28,,,,,,,fee schedule,10.47,64.22,APC
Assay of quinine,84228,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20.35,,,,,,,fee schedule,10.47,64.22,APC
Assay of estrogen,84233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,355.47,,,,,,,fee schedule,79.09,355.47,
Assay of estrogen,84233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,284.94,,,,,,,fee schedule,79.09,355.47,
Assay of estrogen,84233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,311.27,,,,,,,fee schedule,79.09,355.47,
Assay of estrogen,84233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,327.26,,,,,,,fee schedule,79.09,355.47,
Assay of estrogen,84233,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,79.09,,,,,,,fee schedule,79.09,355.47,Laboratory
Assay of estrogen,84233,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,92.27,,,,,,,fee schedule,79.09,355.47,APC
Assay of estrogen,84233,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,91.4,,,,,,,fee schedule,79.09,355.47,APC
Assay of estrogen,84233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,87.88,,,,,,,fee schedule,79.09,355.47,APC
Assay of estrogen,84233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,134.46,,,,,,,fee schedule,79.09,355.47,Radiology
Assay of estrogen,84233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,123.03,,,,,,,fee schedule,79.09,355.47,APC
Assay of estrogen,84233,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,153.79,,,,,,,fee schedule,79.09,355.47,APC
Assay of progesterone,84234,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,358.04,,,,,,,fee schedule,58.39,358.04,
Assay of progesterone,84234,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,287,,,,,,,fee schedule,58.39,358.04,
Assay of progesterone,84234,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,313.52,,,,,,,fee schedule,58.39,358.04,
Assay of progesterone,84234,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,329.63,,,,,,,fee schedule,58.39,358.04,
Assay of progesterone,84234,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,58.39,,,,,,,fee schedule,58.39,358.04,Laboratory
Assay of progesterone,84234,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,68.12,,,,,,,fee schedule,58.39,358.04,APC
Assay of progesterone,84234,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,67.48,,,,,,,fee schedule,58.39,358.04,APC
Assay of progesterone,84234,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,64.88,,,,,,,fee schedule,58.39,358.04,APC
Assay of progesterone,84234,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,99.27,,,,,,,fee schedule,58.39,358.04,Radiology
Assay of progesterone,84234,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,90.83,,,,,,,fee schedule,58.39,358.04,APC
Assay of progesterone,84234,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,113.54,,,,,,,fee schedule,58.39,358.04,APC
Assay of endocrine hormone,84235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,288.83,,,,,,,fee schedule,64.11,288.83,
Assay of endocrine hormone,84235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,231.52,,,,,,,fee schedule,64.11,288.83,
Assay of endocrine hormone,84235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,252.92,,,,,,,fee schedule,64.11,288.83,
Assay of endocrine hormone,84235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,265.91,,,,,,,fee schedule,64.11,288.83,
Assay of endocrine hormone,84235,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,64.11,,,,,,,fee schedule,64.11,288.83,Laboratory
Assay of endocrine hormone,84235,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,74.79,,,,,,,fee schedule,64.11,288.83,APC
Assay of endocrine hormone,84235,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,74.08,,,,,,,fee schedule,64.11,288.83,APC
Assay of endocrine hormone,84235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,71.23,,,,,,,fee schedule,64.11,288.83,APC
Assay of endocrine hormone,84235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,108.98,,,,,,,fee schedule,64.11,288.83,Radiology
Assay of endocrine hormone,84235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,99.72,,,,,,,fee schedule,64.11,288.83,APC
Assay of endocrine hormone,84235,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,124.65,,,,,,,fee schedule,64.11,288.83,APC
Assay nonendocrine receptor,84238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,308,,,,,,,fee schedule,32.91,308,
Assay nonendocrine receptor,84238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,246.89,,,,,,,fee schedule,32.91,308,
Assay nonendocrine receptor,84238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,269.71,,,,,,,fee schedule,32.91,308,
Assay nonendocrine receptor,84238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,283.56,,,,,,,fee schedule,32.91,308,
Assay nonendocrine receptor,84238,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,32.91,,,,,,,fee schedule,32.91,308,Laboratory
Assay nonendocrine receptor,84238,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.4,,,,,,,fee schedule,32.91,308,APC
Assay nonendocrine receptor,84238,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.03,,,,,,,fee schedule,32.91,308,APC
Assay nonendocrine receptor,84238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.57,,,,,,,fee schedule,32.91,308,APC
Assay nonendocrine receptor,84238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,55.95,,,,,,,fee schedule,32.91,308,Radiology
Assay nonendocrine receptor,84238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.2,,,,,,,fee schedule,32.91,308,APC
Assay nonendocrine receptor,84238,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64,,,,,,,fee schedule,32.91,308,APC
Assay of renin,84244,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,68.86,,,,,,,fee schedule,19.79,68.86,
Assay of renin,84244,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55.19,,,,,,,fee schedule,19.79,68.86,
Assay of renin,84244,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,60.29,,,,,,,fee schedule,19.79,68.86,
Assay of renin,84244,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,63.39,,,,,,,fee schedule,19.79,68.86,
Assay of renin,84244,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.79,,,,,,,fee schedule,19.79,68.86,Laboratory
Assay of renin,84244,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,23.09,,,,,,,fee schedule,19.79,68.86,APC
Assay of renin,84244,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,22.87,,,,,,,fee schedule,19.79,68.86,APC
Assay of renin,84244,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,21.99,,,,,,,fee schedule,19.79,68.86,APC
Assay of renin,84244,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,33.64,,,,,,,fee schedule,19.79,68.86,Radiology
Assay of renin,84244,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,30.79,,,,,,,fee schedule,19.79,68.86,APC
Assay of renin,84244,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,38.48,,,,,,,fee schedule,19.79,68.86,APC
Assay of vitamin b-2,84252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,111.7,,,,,,,fee schedule,18.22,111.7,
Assay of vitamin b-2,84252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,89.54,,,,,,,fee schedule,18.22,111.7,
Assay of vitamin b-2,84252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,97.81,,,,,,,fee schedule,18.22,111.7,
Assay of vitamin b-2,84252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,102.83,,,,,,,fee schedule,18.22,111.7,
Assay of vitamin b-2,84252,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.22,,,,,,,fee schedule,18.22,111.7,Laboratory
Assay of vitamin b-2,84252,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.25,,,,,,,fee schedule,18.22,111.7,APC
Assay of vitamin b-2,84252,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,21.05,,,,,,,fee schedule,18.22,111.7,APC
Assay of vitamin b-2,84252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,20.24,,,,,,,fee schedule,18.22,111.7,APC
Assay of vitamin b-2,84252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,30.97,,,,,,,fee schedule,18.22,111.7,Radiology
Assay of vitamin b-2,84252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.34,,,,,,,fee schedule,18.22,111.7,APC
Assay of vitamin b-2,84252,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,35.42,,,,,,,fee schedule,18.22,111.7,APC
Assay of selenium,84255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,25.17,,,,,,,fee schedule,20.18,44.68,
Assay of selenium,84255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20.18,,,,,,,fee schedule,20.18,44.68,
Assay of selenium,84255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22.04,,,,,,,fee schedule,20.18,44.68,
Assay of selenium,84255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23.18,,,,,,,fee schedule,20.18,44.68,
Assay of selenium,84255,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22.98,,,,,,,fee schedule,20.18,44.68,Laboratory
Assay of selenium,84255,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,26.81,,,,,,,fee schedule,20.18,44.68,APC
Assay of selenium,84255,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,26.55,,,,,,,fee schedule,20.18,44.68,APC
Assay of selenium,84255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,25.53,,,,,,,fee schedule,20.18,44.68,APC
Assay of selenium,84255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,39.06,,,,,,,fee schedule,20.18,44.68,Radiology
Assay of selenium,84255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,35.74,,,,,,,fee schedule,20.18,44.68,APC
Assay of selenium,84255,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,44.68,,,,,,,fee schedule,20.18,44.68,APC
Assay of serotonin,84260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,64.41,,,,,,,fee schedule,27.88,64.41,
Assay of serotonin,84260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.63,,,,,,,fee schedule,27.88,64.41,
Assay of serotonin,84260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56.4,,,,,,,fee schedule,27.88,64.41,
Assay of serotonin,84260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59.3,,,,,,,fee schedule,27.88,64.41,
Assay of serotonin,84260,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,27.88,,,,,,,fee schedule,27.88,64.41,Laboratory
Assay of serotonin,84260,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,32.53,,,,,,,fee schedule,27.88,64.41,APC
Assay of serotonin,84260,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,32.22,,,,,,,fee schedule,27.88,64.41,APC
Assay of serotonin,84260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,30.98,,,,,,,fee schedule,27.88,64.41,APC
Assay of serotonin,84260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,47.4,,,,,,,fee schedule,27.88,64.41,Radiology
Assay of serotonin,84260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43.37,,,,,,,fee schedule,27.88,64.41,APC
Assay of serotonin,84260,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,54.22,,,,,,,fee schedule,27.88,64.41,APC
Assay of sex hormone globul,84270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,82.22,,,,,,,fee schedule,19.56,82.22,
Assay of sex hormone globul,84270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,65.91,,,,,,,fee schedule,19.56,82.22,
Assay of sex hormone globul,84270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,72,,,,,,,fee schedule,19.56,82.22,
Assay of sex hormone globul,84270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,75.69,,,,,,,fee schedule,19.56,82.22,
Assay of sex hormone globul,84270,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.56,,,,,,,fee schedule,19.56,82.22,Laboratory
Assay of sex hormone globul,84270,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,22.82,,,,,,,fee schedule,19.56,82.22,APC
Assay of sex hormone globul,84270,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,22.6,,,,,,,fee schedule,19.56,82.22,APC
Assay of sex hormone globul,84270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,21.73,,,,,,,fee schedule,19.56,82.22,APC
Assay of sex hormone globul,84270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,33.25,,,,,,,fee schedule,19.56,82.22,Radiology
Assay of sex hormone globul,84270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,30.42,,,,,,,fee schedule,19.56,82.22,APC
Assay of sex hormone globul,84270,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,38.03,,,,,,,fee schedule,19.56,82.22,APC
Assay of sialic acid,84275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,74.13,,,,,,,fee schedule,12.1,74.13,
Assay of sialic acid,84275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,59.42,,,,,,,fee schedule,12.1,74.13,
Assay of sialic acid,84275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,64.91,,,,,,,fee schedule,12.1,74.13,
Assay of sialic acid,84275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,68.24,,,,,,,fee schedule,12.1,74.13,
Assay of sialic acid,84275,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.1,,,,,,,fee schedule,12.1,74.13,Laboratory
Assay of sialic acid,84275,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.11,,,,,,,fee schedule,12.1,74.13,APC
Assay of sialic acid,84275,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.98,,,,,,,fee schedule,12.1,74.13,APC
Assay of sialic acid,84275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.44,,,,,,,fee schedule,12.1,74.13,APC
Assay of sialic acid,84275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.56,,,,,,,fee schedule,12.1,74.13,Radiology
Assay of sialic acid,84275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.82,,,,,,,fee schedule,12.1,74.13,APC
Assay of sialic acid,84275,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23.52,,,,,,,fee schedule,12.1,74.13,APC
Assay of silica,84285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,129.96,,,,,,,fee schedule,22.69,129.96,
Assay of silica,84285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,104.17,,,,,,,fee schedule,22.69,129.96,
Assay of silica,84285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,113.8,,,,,,,fee schedule,22.69,129.96,
Assay of silica,84285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,119.64,,,,,,,fee schedule,22.69,129.96,
Assay of silica,84285,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22.69,,,,,,,fee schedule,22.69,129.96,Laboratory
Assay of silica,84285,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,26.47,,,,,,,fee schedule,22.69,129.96,APC
Assay of silica,84285,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,26.22,,,,,,,fee schedule,22.69,129.96,APC
Assay of silica,84285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,25.21,,,,,,,fee schedule,22.69,129.96,APC
Assay of silica,84285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,38.57,,,,,,,fee schedule,22.69,129.96,Radiology
Assay of silica,84285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,35.29,,,,,,,fee schedule,22.69,129.96,APC
Assay of silica,84285,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,44.12,,,,,,,fee schedule,22.69,129.96,APC
Assay of serum sodium,84295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45.79,,,,,,,fee schedule,4.33,45.79,
Assay of serum sodium,84295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36.7,,,,,,,fee schedule,4.33,45.79,
Assay of serum sodium,84295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40.09,,,,,,,fee schedule,4.33,45.79,
Assay of serum sodium,84295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42.15,,,,,,,fee schedule,4.33,45.79,
Assay of serum sodium,84295,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.33,,,,,,,fee schedule,4.33,45.79,Laboratory
Assay of serum sodium,84295,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.05,,,,,,,fee schedule,4.33,45.79,APC
Assay of serum sodium,84295,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5,,,,,,,fee schedule,4.33,45.79,APC
Assay of serum sodium,84295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4.81,,,,,,,fee schedule,4.33,45.79,APC
Assay of serum sodium,84295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.36,,,,,,,fee schedule,4.33,45.79,Radiology
Assay of serum sodium,84295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.73,,,,,,,fee schedule,4.33,45.79,APC
Assay of serum sodium,84295,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8.42,,,,,,,fee schedule,4.33,45.79,APC
Assay of urine sodium,84300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,58.24,,,,,,,fee schedule,4.55,58.24,
Assay of urine sodium,84300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.69,,,,,,,fee schedule,4.55,58.24,
Assay of urine sodium,84300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51,,,,,,,fee schedule,4.55,58.24,
Assay of urine sodium,84300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,53.62,,,,,,,fee schedule,4.55,58.24,
Assay of urine sodium,84300,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.55,,,,,,,fee schedule,4.55,58.24,Laboratory
Assay of urine sodium,84300,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.31,,,,,,,fee schedule,4.55,58.24,APC
Assay of urine sodium,84300,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5.26,,,,,,,fee schedule,4.55,58.24,APC
Assay of urine sodium,84300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5.06,,,,,,,fee schedule,4.55,58.24,APC
Assay of urine sodium,84300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.74,,,,,,,fee schedule,4.55,58.24,Radiology
Assay of urine sodium,84300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.08,,,,,,,fee schedule,4.55,58.24,APC
Assay of urine sodium,84300,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8.85,,,,,,,fee schedule,4.55,58.24,APC
Assay of sweat sodium,84302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26.84,,,,,,,fee schedule,4.37,26.84,
Assay of sweat sodium,84302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21.51,,,,,,,fee schedule,4.37,26.84,
Assay of sweat sodium,84302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23.5,,,,,,,fee schedule,4.37,26.84,
Assay of sweat sodium,84302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24.71,,,,,,,fee schedule,4.37,26.84,
Assay of sweat sodium,84302,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.37,,,,,,,fee schedule,4.37,26.84,Laboratory
Assay of sweat sodium,84302,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.1,,,,,,,fee schedule,4.37,26.84,APC
Assay of sweat sodium,84302,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5.05,,,,,,,fee schedule,4.37,26.84,APC
Assay of sweat sodium,84302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4.86,,,,,,,fee schedule,4.37,26.84,APC
Assay of sweat sodium,84302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.44,,,,,,,fee schedule,4.37,26.84,Radiology
Assay of sweat sodium,84302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.8,,,,,,,fee schedule,4.37,26.84,APC
Assay of sweat sodium,84302,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8.51,,,,,,,fee schedule,4.37,26.84,APC
Assay of somatomedin,84305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,183.1,,,,,,,fee schedule,19.13,183.1,
Assay of somatomedin,84305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,146.77,,,,,,,fee schedule,19.13,183.1,
Assay of somatomedin,84305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,160.34,,,,,,,fee schedule,19.13,183.1,
Assay of somatomedin,84305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,168.57,,,,,,,fee schedule,19.13,183.1,
Assay of somatomedin,84305,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.13,,,,,,,fee schedule,19.13,183.1,Laboratory
Assay of somatomedin,84305,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,22.32,,,,,,,fee schedule,19.13,183.1,APC
Assay of somatomedin,84305,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,22.11,,,,,,,fee schedule,19.13,183.1,APC
Assay of somatomedin,84305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,21.26,,,,,,,fee schedule,19.13,183.1,APC
Assay of somatomedin,84305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,32.53,,,,,,,fee schedule,19.13,183.1,Radiology
Assay of somatomedin,84305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29.76,,,,,,,fee schedule,19.13,183.1,APC
Assay of somatomedin,84305,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,37.21,,,,,,,fee schedule,19.13,183.1,APC
Assay of somatostatin,84307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,100.93,,,,,,,fee schedule,16.45,100.93,
Assay of somatostatin,84307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,80.9,,,,,,,fee schedule,16.45,100.93,
Assay of somatostatin,84307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,88.38,,,,,,,fee schedule,16.45,100.93,
Assay of somatostatin,84307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,92.92,,,,,,,fee schedule,16.45,100.93,
Assay of somatostatin,84307,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.45,,,,,,,fee schedule,16.45,100.93,Laboratory
Assay of somatostatin,84307,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.19,,,,,,,fee schedule,16.45,100.93,APC
Assay of somatostatin,84307,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,19.01,,,,,,,fee schedule,16.45,100.93,APC
Assay of somatostatin,84307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18.28,,,,,,,fee schedule,16.45,100.93,APC
Assay of somatostatin,84307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27.97,,,,,,,fee schedule,16.45,100.93,Radiology
Assay of somatostatin,84307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.59,,,,,,,fee schedule,16.45,100.93,APC
Assay of somatostatin,84307,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31.99,,,,,,,fee schedule,16.45,100.93,APC
Spectrophotometry,84311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,64.41,,,,,,,fee schedule,7.29,64.41,
Spectrophotometry,84311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.63,,,,,,,fee schedule,7.29,64.41,
Spectrophotometry,84311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56.4,,,,,,,fee schedule,7.29,64.41,
Spectrophotometry,84311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59.3,,,,,,,fee schedule,7.29,64.41,
Spectrophotometry,84311,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.29,,,,,,,fee schedule,7.29,64.41,Laboratory
Spectrophotometry,84311,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.51,,,,,,,fee schedule,7.29,64.41,APC
Spectrophotometry,84311,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8.42,,,,,,,fee schedule,7.29,64.41,APC
Spectrophotometry,84311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8.1,,,,,,,fee schedule,7.29,64.41,APC
Spectrophotometry,84311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12.39,,,,,,,fee schedule,7.29,64.41,Radiology
Spectrophotometry,84311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11.34,,,,,,,fee schedule,7.29,64.41,APC
Spectrophotometry,84311,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14.18,,,,,,,fee schedule,7.29,64.41,APC
Body fluid specific gravity,84315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13.83,,,,,,,fee schedule,2.95,13.83,
Body fluid specific gravity,84315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11.09,,,,,,,fee schedule,2.95,13.83,
Body fluid specific gravity,84315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12.11,,,,,,,fee schedule,2.95,13.83,
Body fluid specific gravity,84315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12.74,,,,,,,fee schedule,2.95,13.83,
Body fluid specific gravity,84315,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.95,,,,,,,fee schedule,2.95,13.83,Laboratory
Body fluid specific gravity,84315,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3.44,,,,,,,fee schedule,2.95,13.83,APC
Body fluid specific gravity,84315,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3.41,,,,,,,fee schedule,2.95,13.83,APC
Body fluid specific gravity,84315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3.28,,,,,,,fee schedule,2.95,13.83,APC
Body fluid specific gravity,84315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.02,,,,,,,fee schedule,2.95,13.83,Radiology
Body fluid specific gravity,84315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4.59,,,,,,,fee schedule,2.95,13.83,APC
Body fluid specific gravity,84315,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5.74,,,,,,,fee schedule,2.95,13.83,APC
Chromatogram assay sugars,84375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,108.18,,,,,,,fee schedule,35.1,108.18,
Chromatogram assay sugars,84375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,86.72,,,,,,,fee schedule,35.1,108.18,
Chromatogram assay sugars,84375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,94.73,,,,,,,fee schedule,35.1,108.18,
Chromatogram assay sugars,84375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,99.6,,,,,,,fee schedule,35.1,108.18,
Chromatogram assay sugars,84375,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,35.1,,,,,,,fee schedule,35.1,108.18,Laboratory
Chromatogram assay sugars,84375,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,40.95,,,,,,,fee schedule,35.1,108.18,APC
Chromatogram assay sugars,84375,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,40.56,,,,,,,fee schedule,35.1,108.18,APC
Chromatogram assay sugars,84375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,39,,,,,,,fee schedule,35.1,108.18,APC
Chromatogram assay sugars,84375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,59.67,,,,,,,fee schedule,35.1,108.18,Radiology
Chromatogram assay sugars,84375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,54.6,,,,,,,fee schedule,35.1,108.18,APC
Chromatogram assay sugars,84375,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,68.25,,,,,,,fee schedule,35.1,108.18,APC
Sugars single qual,84376,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30.39,,,,,,,fee schedule,4.95,30.39,
Sugars single qual,84376,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24.36,,,,,,,fee schedule,4.95,30.39,
Sugars single qual,84376,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26.61,,,,,,,fee schedule,4.95,30.39,
Sugars single qual,84376,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27.98,,,,,,,fee schedule,4.95,30.39,
Sugars single qual,84376,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.95,,,,,,,fee schedule,4.95,30.39,Laboratory
Sugars single qual,84376,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.78,,,,,,,fee schedule,4.95,30.39,APC
Sugars single qual,84376,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5.72,,,,,,,fee schedule,4.95,30.39,APC
Sugars single qual,84376,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5.5,,,,,,,fee schedule,4.95,30.39,APC
Sugars single qual,84376,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8.42,,,,,,,fee schedule,4.95,30.39,Radiology
Sugars single qual,84376,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.7,,,,,,,fee schedule,4.95,30.39,APC
Sugars single qual,84376,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9.62,,,,,,,fee schedule,4.95,30.39,APC
Sugars multiple qual,84377,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30.39,,,,,,,fee schedule,4.95,30.39,
Sugars multiple qual,84377,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24.36,,,,,,,fee schedule,4.95,30.39,
Sugars multiple qual,84377,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26.61,,,,,,,fee schedule,4.95,30.39,
Sugars multiple qual,84377,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27.98,,,,,,,fee schedule,4.95,30.39,
Sugars multiple qual,84377,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.95,,,,,,,fee schedule,4.95,30.39,Laboratory
Sugars multiple qual,84377,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.78,,,,,,,fee schedule,4.95,30.39,APC
Sugars multiple qual,84377,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5.72,,,,,,,fee schedule,4.95,30.39,APC
Sugars multiple qual,84377,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5.5,,,,,,,fee schedule,4.95,30.39,APC
Sugars multiple qual,84377,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8.42,,,,,,,fee schedule,4.95,30.39,Radiology
Sugars multiple qual,84377,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.7,,,,,,,fee schedule,4.95,30.39,APC
Sugars multiple qual,84377,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9.62,,,,,,,fee schedule,4.95,30.39,APC
Sugars single quant,84378,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,63.62,,,,,,,fee schedule,10.38,63.62,
Sugars single quant,84378,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,50.99,,,,,,,fee schedule,10.38,63.62,
Sugars single quant,84378,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55.71,,,,,,,fee schedule,10.38,63.62,
Sugars single quant,84378,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,58.57,,,,,,,fee schedule,10.38,63.62,
Sugars single quant,84378,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.38,,,,,,,fee schedule,10.38,63.62,Laboratory
Sugars single quant,84378,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.11,,,,,,,fee schedule,10.38,63.62,APC
Sugars single quant,84378,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11.99,,,,,,,fee schedule,10.38,63.62,APC
Sugars single quant,84378,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11.53,,,,,,,fee schedule,10.38,63.62,APC
Sugars single quant,84378,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.64,,,,,,,fee schedule,10.38,63.62,Radiology
Sugars single quant,84378,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.14,,,,,,,fee schedule,10.38,63.62,APC
Sugars single quant,84378,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20.18,,,,,,,fee schedule,10.38,63.62,APC
Sugars multiple quant,84379,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,63.62,,,,,,,fee schedule,10.38,63.62,
Sugars multiple quant,84379,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,50.99,,,,,,,fee schedule,10.38,63.62,
Sugars multiple quant,84379,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55.71,,,,,,,fee schedule,10.38,63.62,
Sugars multiple quant,84379,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,58.57,,,,,,,fee schedule,10.38,63.62,
Sugars multiple quant,84379,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.38,,,,,,,fee schedule,10.38,63.62,Laboratory
Sugars multiple quant,84379,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.11,,,,,,,fee schedule,10.38,63.62,APC
Sugars multiple quant,84379,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11.99,,,,,,,fee schedule,10.38,63.62,APC
Sugars multiple quant,84379,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11.53,,,,,,,fee schedule,10.38,63.62,APC
Sugars multiple quant,84379,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.64,,,,,,,fee schedule,10.38,63.62,Radiology
Sugars multiple quant,84379,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.14,,,,,,,fee schedule,10.38,63.62,APC
Sugars multiple quant,84379,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20.18,,,,,,,fee schedule,10.38,63.62,APC
Assay of urine sulfate,84392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26.2,,,,,,,fee schedule,4.94,26.2,
Assay of urine sulfate,84392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21,,,,,,,fee schedule,4.94,26.2,
Assay of urine sulfate,84392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22.94,,,,,,,fee schedule,4.94,26.2,
Assay of urine sulfate,84392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24.12,,,,,,,fee schedule,4.94,26.2,
Assay of urine sulfate,84392,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.94,,,,,,,fee schedule,4.94,26.2,Laboratory
Assay of urine sulfate,84392,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.76,,,,,,,fee schedule,4.94,26.2,APC
Assay of urine sulfate,84392,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5.71,,,,,,,fee schedule,4.94,26.2,APC
Assay of urine sulfate,84392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5.49,,,,,,,fee schedule,4.94,26.2,APC
Assay of urine sulfate,84392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8.4,,,,,,,fee schedule,4.94,26.2,Radiology
Assay of urine sulfate,84392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.69,,,,,,,fee schedule,4.94,26.2,APC
Assay of urine sulfate,84392,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9.61,,,,,,,fee schedule,4.94,26.2,APC
Tau phosphorylated ea,84393,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,116.03,,,,,,,fee schedule,116.03,225.61,Laboratory
Tau phosphorylated ea,84393,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,135.37,,,,,,,fee schedule,116.03,225.61,APC
Tau phosphorylated ea,84393,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,134.08,,,,,,,fee schedule,116.03,225.61,APC
Tau phosphorylated ea,84393,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,128.92,,,,,,,fee schedule,116.03,225.61,APC
Tau phosphorylated ea,84393,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,197.25,,,,,,,fee schedule,116.03,225.61,Radiology
Tau phosphorylated ea,84393,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,180.49,,,,,,,fee schedule,116.03,225.61,APC
Tau phosphorylated ea,84393,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,225.61,,,,,,,fee schedule,116.03,225.61,APC
Total tau,84394,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,116.03,,,,,,,fee schedule,116.03,225.61,Laboratory
Total tau,84394,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,135.37,,,,,,,fee schedule,116.03,225.61,APC
Total tau,84394,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,134.08,,,,,,,fee schedule,116.03,225.61,APC
Total tau,84394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,128.92,,,,,,,fee schedule,116.03,225.61,APC
Total tau,84394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,197.25,,,,,,,fee schedule,116.03,225.61,Radiology
Total tau,84394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,180.49,,,,,,,fee schedule,116.03,225.61,APC
Total tau,84394,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,225.61,,,,,,,fee schedule,116.03,225.61,APC
Assay of free testosterone,84402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,140.54,,,,,,,fee schedule,22.92,140.54,
Assay of free testosterone,84402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,112.66,,,,,,,fee schedule,22.92,140.54,
Assay of free testosterone,84402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,123.07,,,,,,,fee schedule,22.92,140.54,
Assay of free testosterone,84402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,129.39,,,,,,,fee schedule,22.92,140.54,
Assay of free testosterone,84402,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22.92,,,,,,,fee schedule,22.92,140.54,Laboratory
Assay of free testosterone,84402,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,26.74,,,,,,,fee schedule,22.92,140.54,APC
Assay of free testosterone,84402,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,26.49,,,,,,,fee schedule,22.92,140.54,APC
Assay of free testosterone,84402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,25.47,,,,,,,fee schedule,22.92,140.54,APC
Assay of free testosterone,84402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,38.97,,,,,,,fee schedule,22.92,140.54,Radiology
Assay of free testosterone,84402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,35.66,,,,,,,fee schedule,22.92,140.54,APC
Assay of free testosterone,84402,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,44.57,,,,,,,fee schedule,22.92,140.54,APC
Assay of total testosterone,84403,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,102.88,,,,,,,fee schedule,23.23,102.88,
Assay of total testosterone,84403,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,82.47,,,,,,,fee schedule,23.23,102.88,
Assay of total testosterone,84403,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,90.09,,,,,,,fee schedule,23.23,102.88,
Assay of total testosterone,84403,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,94.72,,,,,,,fee schedule,23.23,102.88,
Assay of total testosterone,84403,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23.23,,,,,,,fee schedule,23.23,102.88,Laboratory
Assay of total testosterone,84403,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,27.1,,,,,,,fee schedule,23.23,102.88,APC
Assay of total testosterone,84403,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,26.84,,,,,,,fee schedule,23.23,102.88,APC
Assay of total testosterone,84403,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,25.81,,,,,,,fee schedule,23.23,102.88,APC
Assay of total testosterone,84403,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,39.49,,,,,,,fee schedule,23.23,102.88,Radiology
Assay of total testosterone,84403,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,36.13,,,,,,,fee schedule,23.23,102.88,APC
Assay of total testosterone,84403,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,45.17,,,,,,,fee schedule,23.23,102.88,APC
Testosterone bioavailable,84410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,274.24,,,,,,,fee schedule,46.15,274.24,
Testosterone bioavailable,84410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,219.83,,,,,,,fee schedule,46.15,274.24,
Testosterone bioavailable,84410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,240.14,,,,,,,fee schedule,46.15,274.24,
Testosterone bioavailable,84410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,252.47,,,,,,,fee schedule,46.15,274.24,
Testosterone bioavailable,84410,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46.15,,,,,,,fee schedule,46.15,274.24,Laboratory
Testosterone bioavailable,84410,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,53.84,,,,,,,fee schedule,46.15,274.24,APC
Testosterone bioavailable,84410,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,53.33,,,,,,,fee schedule,46.15,274.24,APC
Testosterone bioavailable,84410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,51.28,,,,,,,fee schedule,46.15,274.24,APC
Testosterone bioavailable,84410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,78.46,,,,,,,fee schedule,46.15,274.24,Radiology
Testosterone bioavailable,84410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,71.79,,,,,,,fee schedule,46.15,274.24,APC
Testosterone bioavailable,84410,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,89.74,,,,,,,fee schedule,46.15,274.24,APC
Assay of vitamin b-1,84425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,72.08,,,,,,,fee schedule,19.11,72.08,
Assay of vitamin b-1,84425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.78,,,,,,,fee schedule,19.11,72.08,
Assay of vitamin b-1,84425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,63.12,,,,,,,fee schedule,19.11,72.08,
Assay of vitamin b-1,84425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.36,,,,,,,fee schedule,19.11,72.08,
Assay of vitamin b-1,84425,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.11,,,,,,,fee schedule,19.11,72.08,Laboratory
Assay of vitamin b-1,84425,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,22.29,,,,,,,fee schedule,19.11,72.08,APC
Assay of vitamin b-1,84425,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,22.08,,,,,,,fee schedule,19.11,72.08,APC
Assay of vitamin b-1,84425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,21.23,,,,,,,fee schedule,19.11,72.08,APC
Assay of vitamin b-1,84425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,32.48,,,,,,,fee schedule,19.11,72.08,Radiology
Assay of vitamin b-1,84425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29.72,,,,,,,fee schedule,19.11,72.08,APC
Assay of vitamin b-1,84425,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,37.15,,,,,,,fee schedule,19.11,72.08,APC
Assay of thiocyanate,84430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,202.13,,,,,,,fee schedule,10.47,202.13,
Assay of thiocyanate,84430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,162.02,,,,,,,fee schedule,10.47,202.13,
Assay of thiocyanate,84430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,176.99,,,,,,,fee schedule,10.47,202.13,
Assay of thiocyanate,84430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,186.08,,,,,,,fee schedule,10.47,202.13,
Assay of thiocyanate,84430,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.47,,,,,,,fee schedule,10.47,202.13,Laboratory
Assay of thiocyanate,84430,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.21,,,,,,,fee schedule,10.47,202.13,APC
Assay of thiocyanate,84430,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.1,,,,,,,fee schedule,10.47,202.13,APC
Assay of thiocyanate,84430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11.63,,,,,,,fee schedule,10.47,202.13,APC
Assay of thiocyanate,84430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.79,,,,,,,fee schedule,10.47,202.13,Radiology
Assay of thiocyanate,84430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.28,,,,,,,fee schedule,10.47,202.13,APC
Assay of thiocyanate,84430,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20.35,,,,,,,fee schedule,10.47,202.13,APC
Thromboxane urine,84431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,70.08,,,,,,,fee schedule,31.6,70.08,
Thromboxane urine,84431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56.18,,,,,,,fee schedule,31.6,70.08,
Thromboxane urine,84431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,61.37,,,,,,,fee schedule,31.6,70.08,
Thromboxane urine,84431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,64.52,,,,,,,fee schedule,31.6,70.08,
Thromboxane urine,84431,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31.6,,,,,,,fee schedule,31.6,70.08,Laboratory
Thromboxane urine,84431,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.87,,,,,,,fee schedule,31.6,70.08,APC
Thromboxane urine,84431,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,36.51,,,,,,,fee schedule,31.6,70.08,APC
Thromboxane urine,84431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,35.11,,,,,,,fee schedule,31.6,70.08,APC
Thromboxane urine,84431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,53.72,,,,,,,fee schedule,31.6,70.08,Radiology
Thromboxane urine,84431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49.15,,,,,,,fee schedule,31.6,70.08,APC
Thromboxane urine,84431,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,61.44,,,,,,,fee schedule,31.6,70.08,APC
Assay of thyroglobulin,84432,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,148.57,,,,,,,fee schedule,14.45,148.57,
Assay of thyroglobulin,84432,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,119.09,,,,,,,fee schedule,14.45,148.57,
Assay of thyroglobulin,84432,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,130.1,,,,,,,fee schedule,14.45,148.57,
Assay of thyroglobulin,84432,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,136.78,,,,,,,fee schedule,14.45,148.57,
Assay of thyroglobulin,84432,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.45,,,,,,,fee schedule,14.45,148.57,Laboratory
Assay of thyroglobulin,84432,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.86,,,,,,,fee schedule,14.45,148.57,APC
Assay of thyroglobulin,84432,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,16.7,,,,,,,fee schedule,14.45,148.57,APC
Assay of thyroglobulin,84432,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16.06,,,,,,,fee schedule,14.45,148.57,APC
Assay of thyroglobulin,84432,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24.57,,,,,,,fee schedule,14.45,148.57,Radiology
Assay of thyroglobulin,84432,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.48,,,,,,,fee schedule,14.45,148.57,APC
Assay of thyroglobulin,84432,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,28.1,,,,,,,fee schedule,14.45,148.57,APC
Asy thiopurin s-mthyltrnsfrs,84433,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.95,,,,,,,fee schedule,19.95,38.8,Laboratory
Asy thiopurin s-mthyltrnsfrs,84433,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,23.28,,,,,,,fee schedule,19.95,38.8,APC
Asy thiopurin s-mthyltrnsfrs,84433,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,23.06,,,,,,,fee schedule,19.95,38.8,APC
Asy thiopurin s-mthyltrnsfrs,84433,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,22.17,,,,,,,fee schedule,19.95,38.8,APC
Asy thiopurin s-mthyltrnsfrs,84433,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,33.92,,,,,,,fee schedule,19.95,38.8,Radiology
Asy thiopurin s-mthyltrnsfrs,84433,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,31.04,,,,,,,fee schedule,19.95,38.8,APC
Asy thiopurin s-mthyltrnsfrs,84433,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,38.8,,,,,,,fee schedule,19.95,38.8,APC
Assay of total thyroxine,84436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,94.03,,,,,,,fee schedule,6.18,94.03,
Assay of total thyroxine,84436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,75.37,,,,,,,fee schedule,6.18,94.03,
Assay of total thyroxine,84436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,82.34,,,,,,,fee schedule,6.18,94.03,
Assay of total thyroxine,84436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,86.57,,,,,,,fee schedule,6.18,94.03,
Assay of total thyroxine,84436,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.18,,,,,,,fee schedule,6.18,94.03,Laboratory
Assay of total thyroxine,84436,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.21,,,,,,,fee schedule,6.18,94.03,APC
Assay of total thyroxine,84436,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7.14,,,,,,,fee schedule,6.18,94.03,APC
Assay of total thyroxine,84436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6.87,,,,,,,fee schedule,6.18,94.03,APC
Assay of total thyroxine,84436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10.51,,,,,,,fee schedule,6.18,94.03,Radiology
Assay of total thyroxine,84436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.62,,,,,,,fee schedule,6.18,94.03,APC
Assay of total thyroxine,84436,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12.02,,,,,,,fee schedule,6.18,94.03,APC
Assay of neonatal thyroxine,84437,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,35.72,,,,,,,fee schedule,5.82,35.72,
Assay of neonatal thyroxine,84437,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28.63,,,,,,,fee schedule,5.82,35.72,
Assay of neonatal thyroxine,84437,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31.28,,,,,,,fee schedule,5.82,35.72,
Assay of neonatal thyroxine,84437,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,32.89,,,,,,,fee schedule,5.82,35.72,
Assay of neonatal thyroxine,84437,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.82,,,,,,,fee schedule,5.82,35.72,Laboratory
Assay of neonatal thyroxine,84437,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.79,,,,,,,fee schedule,5.82,35.72,APC
Assay of neonatal thyroxine,84437,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6.73,,,,,,,fee schedule,5.82,35.72,APC
Assay of neonatal thyroxine,84437,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6.47,,,,,,,fee schedule,5.82,35.72,APC
Assay of neonatal thyroxine,84437,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.9,,,,,,,fee schedule,5.82,35.72,Radiology
Assay of neonatal thyroxine,84437,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.06,,,,,,,fee schedule,5.82,35.72,APC
Assay of neonatal thyroxine,84437,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11.32,,,,,,,fee schedule,5.82,35.72,APC
Assay of free thyroxine,84439,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,73.74,,,,,,,fee schedule,8.12,73.74,
Assay of free thyroxine,84439,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,59.11,,,,,,,fee schedule,8.12,73.74,
Assay of free thyroxine,84439,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,64.57,,,,,,,fee schedule,8.12,73.74,
Assay of free thyroxine,84439,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,67.89,,,,,,,fee schedule,8.12,73.74,
Assay of free thyroxine,84439,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.12,,,,,,,fee schedule,8.12,73.74,Laboratory
Assay of free thyroxine,84439,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.47,,,,,,,fee schedule,8.12,73.74,APC
Assay of free thyroxine,84439,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9.38,,,,,,,fee schedule,8.12,73.74,APC
Assay of free thyroxine,84439,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9.02,,,,,,,fee schedule,8.12,73.74,APC
Assay of free thyroxine,84439,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.8,,,,,,,fee schedule,8.12,73.74,Radiology
Assay of free thyroxine,84439,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12.63,,,,,,,fee schedule,8.12,73.74,APC
Assay of free thyroxine,84439,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15.78,,,,,,,fee schedule,8.12,73.74,APC
Assay of thyroid activity,84442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,81.61,,,,,,,fee schedule,13.3,81.61,
Assay of thyroid activity,84442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,65.42,,,,,,,fee schedule,13.3,81.61,
Assay of thyroid activity,84442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,71.46,,,,,,,fee schedule,13.3,81.61,
Assay of thyroid activity,84442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,75.13,,,,,,,fee schedule,13.3,81.61,
Assay of thyroid activity,84442,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.3,,,,,,,fee schedule,13.3,81.61,Laboratory
Assay of thyroid activity,84442,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.52,,,,,,,fee schedule,13.3,81.61,APC
Assay of thyroid activity,84442,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,15.37,,,,,,,fee schedule,13.3,81.61,APC
Assay of thyroid activity,84442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14.78,,,,,,,fee schedule,13.3,81.61,APC
Assay of thyroid activity,84442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.61,,,,,,,fee schedule,13.3,81.61,Radiology
Assay of thyroid activity,84442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.69,,,,,,,fee schedule,13.3,81.61,APC
Assay of thyroid activity,84442,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,25.86,,,,,,,fee schedule,13.3,81.61,APC
Assay thyroid stim hormone,84443,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83.74,,,,,,,fee schedule,15.12,83.74,
Assay thyroid stim hormone,84443,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,67.12,,,,,,,fee schedule,15.12,83.74,
Assay thyroid stim hormone,84443,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,73.33,,,,,,,fee schedule,15.12,83.74,
Assay thyroid stim hormone,84443,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,77.09,,,,,,,fee schedule,15.12,83.74,
Assay thyroid stim hormone,84443,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.12,,,,,,,fee schedule,15.12,83.74,Laboratory
Assay thyroid stim hormone,84443,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.64,,,,,,,fee schedule,15.12,83.74,APC
Assay thyroid stim hormone,84443,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,17.47,,,,,,,fee schedule,15.12,83.74,APC
Assay thyroid stim hormone,84443,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16.8,,,,,,,fee schedule,15.12,83.74,APC
Assay thyroid stim hormone,84443,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.7,,,,,,,fee schedule,15.12,83.74,Radiology
Assay thyroid stim hormone,84443,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.52,,,,,,,fee schedule,15.12,83.74,APC
Assay thyroid stim hormone,84443,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,29.4,,,,,,,fee schedule,15.12,83.74,APC
Assay of tsi globulin,84445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,204.35,,,,,,,fee schedule,45.77,204.35,
Assay of tsi globulin,84445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,163.8,,,,,,,fee schedule,45.77,204.35,
Assay of tsi globulin,84445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,178.94,,,,,,,fee schedule,45.77,204.35,
Assay of tsi globulin,84445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,188.13,,,,,,,fee schedule,45.77,204.35,
Assay of tsi globulin,84445,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,45.77,,,,,,,fee schedule,45.77,204.35,Laboratory
Assay of tsi globulin,84445,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,53.4,,,,,,,fee schedule,45.77,204.35,APC
Assay of tsi globulin,84445,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,52.89,,,,,,,fee schedule,45.77,204.35,APC
Assay of tsi globulin,84445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,50.86,,,,,,,fee schedule,45.77,204.35,APC
Assay of tsi globulin,84445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,77.82,,,,,,,fee schedule,45.77,204.35,Radiology
Assay of tsi globulin,84445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,71.2,,,,,,,fee schedule,45.77,204.35,APC
Assay of tsi globulin,84445,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,89,,,,,,,fee schedule,45.77,204.35,APC
Assay of vitamin e,84446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,44.42,,,,,,,fee schedule,12.76,44.42,
Assay of vitamin e,84446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35.61,,,,,,,fee schedule,12.76,44.42,
Assay of vitamin e,84446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38.9,,,,,,,fee schedule,12.76,44.42,
Assay of vitamin e,84446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,40.9,,,,,,,fee schedule,12.76,44.42,
Assay of vitamin e,84446,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.76,,,,,,,fee schedule,12.76,44.42,Laboratory
Assay of vitamin e,84446,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.89,,,,,,,fee schedule,12.76,44.42,APC
Assay of vitamin e,84446,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,14.75,,,,,,,fee schedule,12.76,44.42,APC
Assay of vitamin e,84446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14.18,,,,,,,fee schedule,12.76,44.42,APC
Assay of vitamin e,84446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21.7,,,,,,,fee schedule,12.76,44.42,Radiology
Assay of vitamin e,84446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.85,,,,,,,fee schedule,12.76,44.42,APC
Assay of vitamin e,84446,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,24.82,,,,,,,fee schedule,12.76,44.42,APC
Assay of transcortin,84449,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,99.34,,,,,,,fee schedule,16.2,99.34,
Assay of transcortin,84449,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,79.63,,,,,,,fee schedule,16.2,99.34,
Assay of transcortin,84449,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,86.99,,,,,,,fee schedule,16.2,99.34,
Assay of transcortin,84449,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,91.45,,,,,,,fee schedule,16.2,99.34,
Assay of transcortin,84449,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.2,,,,,,,fee schedule,16.2,99.34,Laboratory
Assay of transcortin,84449,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.9,,,,,,,fee schedule,16.2,99.34,APC
Assay of transcortin,84449,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18.72,,,,,,,fee schedule,16.2,99.34,APC
Assay of transcortin,84449,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18,,,,,,,fee schedule,16.2,99.34,APC
Assay of transcortin,84449,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27.54,,,,,,,fee schedule,16.2,99.34,Radiology
Assay of transcortin,84449,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.2,,,,,,,fee schedule,16.2,99.34,APC
Assay of transcortin,84449,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31.5,,,,,,,fee schedule,16.2,99.34,APC
Transferase (AST) (SGOT),84450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83.93,,,,,,,fee schedule,4.66,83.93,
Transferase (AST) (SGOT),84450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,67.27,,,,,,,fee schedule,4.66,83.93,
Transferase (AST) (SGOT),84450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,73.49,,,,,,,fee schedule,4.66,83.93,
Transferase (AST) (SGOT),84450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,77.27,,,,,,,fee schedule,4.66,83.93,
Transferase (AST) (SGOT),84450,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.66,,,,,,,fee schedule,4.66,83.93,Laboratory
Transferase (AST) (SGOT),84450,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.44,,,,,,,fee schedule,4.66,83.93,APC
Transferase (AST) (SGOT),84450,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5.39,,,,,,,fee schedule,4.66,83.93,APC
Transferase (AST) (SGOT),84450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5.18,,,,,,,fee schedule,4.66,83.93,APC
Transferase (AST) (SGOT),84450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.93,,,,,,,fee schedule,4.66,83.93,Radiology
Transferase (AST) (SGOT),84450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.25,,,,,,,fee schedule,4.66,83.93,APC
Transferase (AST) (SGOT),84450,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9.06,,,,,,,fee schedule,4.66,83.93,APC
Alanine amino (ALT) (SGPT),84460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,84.11,,,,,,,fee schedule,4.77,84.11,
Alanine amino (ALT) (SGPT),84460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,67.42,,,,,,,fee schedule,4.77,84.11,
Alanine amino (ALT) (SGPT),84460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,73.65,,,,,,,fee schedule,4.77,84.11,
Alanine amino (ALT) (SGPT),84460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,77.43,,,,,,,fee schedule,4.77,84.11,
Alanine amino (ALT) (SGPT),84460,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.77,,,,,,,fee schedule,4.77,84.11,Laboratory
Alanine amino (ALT) (SGPT),84460,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.56,,,,,,,fee schedule,4.77,84.11,APC
Alanine amino (ALT) (SGPT),84460,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5.51,,,,,,,fee schedule,4.77,84.11,APC
Alanine amino (ALT) (SGPT),84460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5.3,,,,,,,fee schedule,4.77,84.11,APC
Alanine amino (ALT) (SGPT),84460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8.11,,,,,,,fee schedule,4.77,84.11,Radiology
Alanine amino (ALT) (SGPT),84460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.42,,,,,,,fee schedule,4.77,84.11,APC
Alanine amino (ALT) (SGPT),84460,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9.28,,,,,,,fee schedule,4.77,84.11,APC
Assay of transferrin,84466,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,70.71,,,,,,,fee schedule,11.48,70.71,
Assay of transferrin,84466,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56.68,,,,,,,fee schedule,11.48,70.71,
Assay of transferrin,84466,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,61.92,,,,,,,fee schedule,11.48,70.71,
Assay of transferrin,84466,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,65.1,,,,,,,fee schedule,11.48,70.71,
Assay of transferrin,84466,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.48,,,,,,,fee schedule,11.48,70.71,Laboratory
Assay of transferrin,84466,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.4,,,,,,,fee schedule,11.48,70.71,APC
Assay of transferrin,84466,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.27,,,,,,,fee schedule,11.48,70.71,APC
Assay of transferrin,84466,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.76,,,,,,,fee schedule,11.48,70.71,APC
Assay of transferrin,84466,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.52,,,,,,,fee schedule,11.48,70.71,Radiology
Assay of transferrin,84466,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.86,,,,,,,fee schedule,11.48,70.71,APC
Assay of transferrin,84466,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22.33,,,,,,,fee schedule,11.48,70.71,APC
Assay of triglycerides,84478,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,74.04,,,,,,,fee schedule,5.17,74.04,
Assay of triglycerides,84478,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,59.35,,,,,,,fee schedule,5.17,74.04,
Assay of triglycerides,84478,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,64.83,,,,,,,fee schedule,5.17,74.04,
Assay of triglycerides,84478,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,68.16,,,,,,,fee schedule,5.17,74.04,
Assay of triglycerides,84478,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.17,,,,,,,fee schedule,5.17,74.04,Laboratory
Assay of triglycerides,84478,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.03,,,,,,,fee schedule,5.17,74.04,APC
Assay of triglycerides,84478,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5.97,,,,,,,fee schedule,5.17,74.04,APC
Assay of triglycerides,84478,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5.74,,,,,,,fee schedule,5.17,74.04,APC
Assay of triglycerides,84478,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8.78,,,,,,,fee schedule,5.17,74.04,Radiology
Assay of triglycerides,84478,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8.04,,,,,,,fee schedule,5.17,74.04,APC
Assay of triglycerides,84478,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10.04,,,,,,,fee schedule,5.17,74.04,APC
Assay of thyroid (t3 or t4),84479,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,36.03,,,,,,,fee schedule,5.82,36.03,
Assay of thyroid (t3 or t4),84479,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28.88,,,,,,,fee schedule,5.82,36.03,
Assay of thyroid (t3 or t4),84479,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31.55,,,,,,,fee schedule,5.82,36.03,
Assay of thyroid (t3 or t4),84479,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33.17,,,,,,,fee schedule,5.82,36.03,
Assay of thyroid (t3 or t4),84479,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.82,,,,,,,fee schedule,5.82,36.03,Laboratory
Assay of thyroid (t3 or t4),84479,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.79,,,,,,,fee schedule,5.82,36.03,APC
Assay of thyroid (t3 or t4),84479,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6.73,,,,,,,fee schedule,5.82,36.03,APC
Assay of thyroid (t3 or t4),84479,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6.47,,,,,,,fee schedule,5.82,36.03,APC
Assay of thyroid (t3 or t4),84479,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.9,,,,,,,fee schedule,5.82,36.03,Radiology
Assay of thyroid (t3 or t4),84479,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.06,,,,,,,fee schedule,5.82,36.03,APC
Assay of thyroid (t3 or t4),84479,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11.32,,,,,,,fee schedule,5.82,36.03,APC
Assay triiodothyronine (t3),84480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,56.31,,,,,,,fee schedule,12.76,56.31,
Assay triiodothyronine (t3),84480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,45.13,,,,,,,fee schedule,12.76,56.31,
Assay triiodothyronine (t3),84480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,49.31,,,,,,,fee schedule,12.76,56.31,
Assay triiodothyronine (t3),84480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,51.84,,,,,,,fee schedule,12.76,56.31,
Assay triiodothyronine (t3),84480,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.76,,,,,,,fee schedule,12.76,56.31,Laboratory
Assay triiodothyronine (t3),84480,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.89,,,,,,,fee schedule,12.76,56.31,APC
Assay triiodothyronine (t3),84480,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,14.75,,,,,,,fee schedule,12.76,56.31,APC
Assay triiodothyronine (t3),84480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14.18,,,,,,,fee schedule,12.76,56.31,APC
Assay triiodothyronine (t3),84480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21.7,,,,,,,fee schedule,12.76,56.31,Radiology
Assay triiodothyronine (t3),84480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.85,,,,,,,fee schedule,12.76,56.31,APC
Assay triiodothyronine (t3),84480,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,24.82,,,,,,,fee schedule,12.76,56.31,APC
Free assay (FT-3),84481,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,99.71,,,,,,,fee schedule,15.25,99.71,
Free assay (FT-3),84481,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,79.93,,,,,,,fee schedule,15.25,99.71,
Free assay (FT-3),84481,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,87.31,,,,,,,fee schedule,15.25,99.71,
Free assay (FT-3),84481,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,91.8,,,,,,,fee schedule,15.25,99.71,
Free assay (FT-3),84481,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.25,,,,,,,fee schedule,15.25,99.71,Laboratory
Free assay (FT-3),84481,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.79,,,,,,,fee schedule,15.25,99.71,APC
Free assay (FT-3),84481,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,17.62,,,,,,,fee schedule,15.25,99.71,APC
Free assay (FT-3),84481,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16.94,,,,,,,fee schedule,15.25,99.71,APC
Free assay (FT-3),84481,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.92,,,,,,,fee schedule,15.25,99.71,Radiology
Free assay (FT-3),84481,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.72,,,,,,,fee schedule,15.25,99.71,APC
Free assay (FT-3),84481,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,29.65,,,,,,,fee schedule,15.25,99.71,APC
T3 reverse,84482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46.64,,,,,,,fee schedule,14.18,46.64,
T3 reverse,84482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37.39,,,,,,,fee schedule,14.18,46.64,
T3 reverse,84482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40.84,,,,,,,fee schedule,14.18,46.64,
T3 reverse,84482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42.94,,,,,,,fee schedule,14.18,46.64,
T3 reverse,84482,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.18,,,,,,,fee schedule,14.18,46.64,Laboratory
T3 reverse,84482,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.55,,,,,,,fee schedule,14.18,46.64,APC
T3 reverse,84482,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,16.39,,,,,,,fee schedule,14.18,46.64,APC
T3 reverse,84482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,15.76,,,,,,,fee schedule,14.18,46.64,APC
T3 reverse,84482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24.11,,,,,,,fee schedule,14.18,46.64,Radiology
T3 reverse,84482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.06,,,,,,,fee schedule,14.18,46.64,APC
T3 reverse,84482,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,27.58,,,,,,,fee schedule,14.18,46.64,APC
Assay of troponin quant,84484,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,156,,,,,,,fee schedule,11.22,156,
Assay of troponin quant,84484,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,125.05,,,,,,,fee schedule,11.22,156,
Assay of troponin quant,84484,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,136.6,,,,,,,fee schedule,11.22,156,
Assay of troponin quant,84484,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,143.62,,,,,,,fee schedule,11.22,156,
Assay of troponin quant,84484,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.22,,,,,,,fee schedule,11.22,156,Laboratory
Assay of troponin quant,84484,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.09,,,,,,,fee schedule,11.22,156,APC
Assay of troponin quant,84484,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.97,,,,,,,fee schedule,11.22,156,APC
Assay of troponin quant,84484,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.47,,,,,,,fee schedule,11.22,156,APC
Assay of troponin quant,84484,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.08,,,,,,,fee schedule,11.22,156,Radiology
Assay of troponin quant,84484,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.46,,,,,,,fee schedule,11.22,156,APC
Assay of troponin quant,84484,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21.82,,,,,,,fee schedule,11.22,156,APC
Assay duodenal fluid trypsin,84485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41.43,,,,,,,fee schedule,6.48,41.43,
Assay duodenal fluid trypsin,84485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,33.21,,,,,,,fee schedule,6.48,41.43,
Assay duodenal fluid trypsin,84485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36.28,,,,,,,fee schedule,6.48,41.43,
Assay duodenal fluid trypsin,84485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,38.14,,,,,,,fee schedule,6.48,41.43,
Assay duodenal fluid trypsin,84485,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.48,,,,,,,fee schedule,6.48,41.43,Laboratory
Assay duodenal fluid trypsin,84485,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.56,,,,,,,fee schedule,6.48,41.43,APC
Assay duodenal fluid trypsin,84485,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7.49,,,,,,,fee schedule,6.48,41.43,APC
Assay duodenal fluid trypsin,84485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7.2,,,,,,,fee schedule,6.48,41.43,APC
Assay duodenal fluid trypsin,84485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11.02,,,,,,,fee schedule,6.48,41.43,Radiology
Assay duodenal fluid trypsin,84485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10.08,,,,,,,fee schedule,6.48,41.43,APC
Assay duodenal fluid trypsin,84485,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12.6,,,,,,,fee schedule,6.48,41.43,APC
Test feces for trypsin,84488,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,40.29,,,,,,,fee schedule,6.57,40.29,
Test feces for trypsin,84488,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32.3,,,,,,,fee schedule,6.57,40.29,
Test feces for trypsin,84488,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35.28,,,,,,,fee schedule,6.57,40.29,
Test feces for trypsin,84488,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37.1,,,,,,,fee schedule,6.57,40.29,
Test feces for trypsin,84488,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.57,,,,,,,fee schedule,6.57,40.29,Laboratory
Test feces for trypsin,84488,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.66,,,,,,,fee schedule,6.57,40.29,APC
Test feces for trypsin,84488,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7.59,,,,,,,fee schedule,6.57,40.29,APC
Test feces for trypsin,84488,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7.3,,,,,,,fee schedule,6.57,40.29,APC
Test feces for trypsin,84488,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11.17,,,,,,,fee schedule,6.57,40.29,Radiology
Test feces for trypsin,84488,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10.22,,,,,,,fee schedule,6.57,40.29,APC
Test feces for trypsin,84488,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12.78,,,,,,,fee schedule,6.57,40.29,APC
Assay of feces for trypsin,84490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42,,,,,,,fee schedule,8.94,42,
Assay of feces for trypsin,84490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,33.66,,,,,,,fee schedule,8.94,42,
Assay of feces for trypsin,84490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36.77,,,,,,,fee schedule,8.94,42,
Assay of feces for trypsin,84490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,38.66,,,,,,,fee schedule,8.94,42,
Assay of feces for trypsin,84490,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.94,,,,,,,fee schedule,8.94,42,Laboratory
Assay of feces for trypsin,84490,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.43,,,,,,,fee schedule,8.94,42,APC
Assay of feces for trypsin,84490,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10.33,,,,,,,fee schedule,8.94,42,APC
Assay of feces for trypsin,84490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9.93,,,,,,,fee schedule,8.94,42,APC
Assay of feces for trypsin,84490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15.19,,,,,,,fee schedule,8.94,42,Radiology
Assay of feces for trypsin,84490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.9,,,,,,,fee schedule,8.94,42,APC
Assay of feces for trypsin,84490,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,17.38,,,,,,,fee schedule,8.94,42,APC
Assay of tyrosine,84510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,57.38,,,,,,,fee schedule,9.57,57.38,
Assay of tyrosine,84510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46,,,,,,,fee schedule,9.57,57.38,
Assay of tyrosine,84510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,50.25,,,,,,,fee schedule,9.57,57.38,
Assay of tyrosine,84510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,52.83,,,,,,,fee schedule,9.57,57.38,
Assay of tyrosine,84510,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.57,,,,,,,fee schedule,9.57,57.38,Laboratory
Assay of tyrosine,84510,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.16,,,,,,,fee schedule,9.57,57.38,APC
Assay of tyrosine,84510,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11.06,,,,,,,fee schedule,9.57,57.38,APC
Assay of tyrosine,84510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10.63,,,,,,,fee schedule,9.57,57.38,APC
Assay of tyrosine,84510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.26,,,,,,,fee schedule,9.57,57.38,Radiology
Assay of tyrosine,84510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.88,,,,,,,fee schedule,9.57,57.38,APC
Assay of tyrosine,84510,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18.6,,,,,,,fee schedule,9.57,57.38,APC
Assay of troponin qual,84512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42.49,,,,,,,fee schedule,9.08,42.49,
Assay of troponin qual,84512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,34.06,,,,,,,fee schedule,9.08,42.49,
Assay of troponin qual,84512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37.2,,,,,,,fee schedule,9.08,42.49,
Assay of troponin qual,84512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,39.12,,,,,,,fee schedule,9.08,42.49,
Assay of troponin qual,84512,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.08,,,,,,,fee schedule,9.08,42.49,Laboratory
Assay of troponin qual,84512,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.59,,,,,,,fee schedule,9.08,42.49,APC
Assay of troponin qual,84512,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10.49,,,,,,,fee schedule,9.08,42.49,APC
Assay of troponin qual,84512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10.09,,,,,,,fee schedule,9.08,42.49,APC
Assay of troponin qual,84512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15.44,,,,,,,fee schedule,9.08,42.49,Radiology
Assay of troponin qual,84512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.13,,,,,,,fee schedule,9.08,42.49,APC
Assay of troponin qual,84512,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,17.66,,,,,,,fee schedule,9.08,42.49,APC
Assay of urea nitrogen,84520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,53,,,,,,,fee schedule,3.56,53,
Assay of urea nitrogen,84520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.48,,,,,,,fee schedule,3.56,53,
Assay of urea nitrogen,84520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.41,,,,,,,fee schedule,3.56,53,
Assay of urea nitrogen,84520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,48.79,,,,,,,fee schedule,3.56,53,
Assay of urea nitrogen,84520,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.56,,,,,,,fee schedule,3.56,53,Laboratory
Assay of urea nitrogen,84520,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.15,,,,,,,fee schedule,3.56,53,APC
Assay of urea nitrogen,84520,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4.11,,,,,,,fee schedule,3.56,53,APC
Assay of urea nitrogen,84520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3.95,,,,,,,fee schedule,3.56,53,APC
Assay of urea nitrogen,84520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.04,,,,,,,fee schedule,3.56,53,Radiology
Assay of urea nitrogen,84520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.53,,,,,,,fee schedule,3.56,53,APC
Assay of urea nitrogen,84520,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6.91,,,,,,,fee schedule,3.56,53,APC
Urea nitrogen semi-quant,84525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20.75,,,,,,,fee schedule,4.62,20.75,
Urea nitrogen semi-quant,84525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.63,,,,,,,fee schedule,4.62,20.75,
Urea nitrogen semi-quant,84525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18.17,,,,,,,fee schedule,4.62,20.75,
Urea nitrogen semi-quant,84525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19.11,,,,,,,fee schedule,4.62,20.75,
Urea nitrogen semi-quant,84525,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.62,,,,,,,fee schedule,4.62,20.75,Laboratory
Urea nitrogen semi-quant,84525,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.39,,,,,,,fee schedule,4.62,20.75,APC
Urea nitrogen semi-quant,84525,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5.34,,,,,,,fee schedule,4.62,20.75,APC
Urea nitrogen semi-quant,84525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5.13,,,,,,,fee schedule,4.62,20.75,APC
Urea nitrogen semi-quant,84525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.85,,,,,,,fee schedule,4.62,20.75,Radiology
Urea nitrogen semi-quant,84525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.18,,,,,,,fee schedule,4.62,20.75,APC
Urea nitrogen semi-quant,84525,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8.98,,,,,,,fee schedule,4.62,20.75,APC
Assay of urine/urea-n,84540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,74.04,,,,,,,fee schedule,5,74.04,
Assay of urine/urea-n,84540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,59.35,,,,,,,fee schedule,5,74.04,
Assay of urine/urea-n,84540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,64.83,,,,,,,fee schedule,5,74.04,
Assay of urine/urea-n,84540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,68.16,,,,,,,fee schedule,5,74.04,
Assay of urine/urea-n,84540,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5,,,,,,,fee schedule,5,74.04,Laboratory
Assay of urine/urea-n,84540,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.84,,,,,,,fee schedule,5,74.04,APC
Assay of urine/urea-n,84540,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5.78,,,,,,,fee schedule,5,74.04,APC
Assay of urine/urea-n,84540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5.56,,,,,,,fee schedule,5,74.04,APC
Assay of urine/urea-n,84540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8.51,,,,,,,fee schedule,5,74.04,Radiology
Assay of urine/urea-n,84540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.78,,,,,,,fee schedule,5,74.04,APC
Assay of urine/urea-n,84540,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9.73,,,,,,,fee schedule,5,74.04,APC
Urea-N clearance test,84545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,36.44,,,,,,,fee schedule,6.48,36.44,
Urea-N clearance test,84545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29.21,,,,,,,fee schedule,6.48,36.44,
Urea-N clearance test,84545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31.91,,,,,,,fee schedule,6.48,36.44,
Urea-N clearance test,84545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33.55,,,,,,,fee schedule,6.48,36.44,
Urea-N clearance test,84545,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.48,,,,,,,fee schedule,6.48,36.44,Laboratory
Urea-N clearance test,84545,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.56,,,,,,,fee schedule,6.48,36.44,APC
Urea-N clearance test,84545,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7.49,,,,,,,fee schedule,6.48,36.44,APC
Urea-N clearance test,84545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7.2,,,,,,,fee schedule,6.48,36.44,APC
Urea-N clearance test,84545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11.02,,,,,,,fee schedule,6.48,36.44,Radiology
Urea-N clearance test,84545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10.08,,,,,,,fee schedule,6.48,36.44,APC
Urea-N clearance test,84545,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12.6,,,,,,,fee schedule,6.48,36.44,APC
Assay of blood/uric acid,84550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,63.67,,,,,,,fee schedule,4.07,63.67,
Assay of blood/uric acid,84550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.04,,,,,,,fee schedule,4.07,63.67,
Assay of blood/uric acid,84550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55.75,,,,,,,fee schedule,4.07,63.67,
Assay of blood/uric acid,84550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,58.62,,,,,,,fee schedule,4.07,63.67,
Assay of blood/uric acid,84550,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.07,,,,,,,fee schedule,4.07,63.67,Laboratory
Assay of blood/uric acid,84550,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.75,,,,,,,fee schedule,4.07,63.67,APC
Assay of blood/uric acid,84550,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4.7,,,,,,,fee schedule,4.07,63.67,APC
Assay of blood/uric acid,84550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4.52,,,,,,,fee schedule,4.07,63.67,APC
Assay of blood/uric acid,84550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.92,,,,,,,fee schedule,4.07,63.67,Radiology
Assay of blood/uric acid,84550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.33,,,,,,,fee schedule,4.07,63.67,APC
Assay of blood/uric acid,84550,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7.91,,,,,,,fee schedule,4.07,63.67,APC
Assay of urine/uric acid,84560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,62.69,,,,,,,fee schedule,4.57,62.69,
Assay of urine/uric acid,84560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,50.25,,,,,,,fee schedule,4.57,62.69,
Assay of urine/uric acid,84560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,54.89,,,,,,,fee schedule,4.57,62.69,
Assay of urine/uric acid,84560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,57.71,,,,,,,fee schedule,4.57,62.69,
Assay of urine/uric acid,84560,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.57,,,,,,,fee schedule,4.57,62.69,Laboratory
Assay of urine/uric acid,84560,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.33,,,,,,,fee schedule,4.57,62.69,APC
Assay of urine/uric acid,84560,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5.28,,,,,,,fee schedule,4.57,62.69,APC
Assay of urine/uric acid,84560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5.08,,,,,,,fee schedule,4.57,62.69,APC
Assay of urine/uric acid,84560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.77,,,,,,,fee schedule,4.57,62.69,Radiology
Assay of urine/uric acid,84560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.11,,,,,,,fee schedule,4.57,62.69,APC
Assay of urine/uric acid,84560,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8.89,,,,,,,fee schedule,4.57,62.69,APC
Assay of feces/urobilinogen,84577,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,68.87,,,,,,,fee schedule,15.12,68.87,
Assay of feces/urobilinogen,84577,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55.21,,,,,,,fee schedule,15.12,68.87,
Assay of feces/urobilinogen,84577,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,60.31,,,,,,,fee schedule,15.12,68.87,
Assay of feces/urobilinogen,84577,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,63.41,,,,,,,fee schedule,15.12,68.87,
Assay of feces/urobilinogen,84577,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.12,,,,,,,fee schedule,15.12,68.87,Laboratory
Assay of feces/urobilinogen,84577,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.64,,,,,,,fee schedule,15.12,68.87,APC
Assay of feces/urobilinogen,84577,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,17.47,,,,,,,fee schedule,15.12,68.87,APC
Assay of feces/urobilinogen,84577,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16.8,,,,,,,fee schedule,15.12,68.87,APC
Assay of feces/urobilinogen,84577,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.7,,,,,,,fee schedule,15.12,68.87,Radiology
Assay of feces/urobilinogen,84577,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.52,,,,,,,fee schedule,15.12,68.87,APC
Assay of feces/urobilinogen,84577,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,29.4,,,,,,,fee schedule,15.12,68.87,APC
Test urine urobilinogen,84578,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17.92,,,,,,,fee schedule,4.02,17.92,
Test urine urobilinogen,84578,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14.36,,,,,,,fee schedule,4.02,17.92,
Test urine urobilinogen,84578,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15.69,,,,,,,fee schedule,4.02,17.92,
Test urine urobilinogen,84578,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16.5,,,,,,,fee schedule,4.02,17.92,
Test urine urobilinogen,84578,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.02,,,,,,,fee schedule,4.02,17.92,Laboratory
Test urine urobilinogen,84578,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.69,,,,,,,fee schedule,4.02,17.92,APC
Test urine urobilinogen,84578,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4.65,,,,,,,fee schedule,4.02,17.92,APC
Test urine urobilinogen,84578,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4.47,,,,,,,fee schedule,4.02,17.92,APC
Test urine urobilinogen,84578,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.84,,,,,,,fee schedule,4.02,17.92,Radiology
Test urine urobilinogen,84578,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.26,,,,,,,fee schedule,4.02,17.92,APC
Test urine urobilinogen,84578,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7.82,,,,,,,fee schedule,4.02,17.92,APC
Assay of urine urobilinogen,84580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20,,,,,,,fee schedule,8.6,20,
Assay of urine urobilinogen,84580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.03,,,,,,,fee schedule,8.6,20,
Assay of urine urobilinogen,84580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17.51,,,,,,,fee schedule,8.6,20,
Assay of urine urobilinogen,84580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18.41,,,,,,,fee schedule,8.6,20,
Assay of urine urobilinogen,84580,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.6,,,,,,,fee schedule,8.6,20,Laboratory
Assay of urine urobilinogen,84580,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.03,,,,,,,fee schedule,8.6,20,APC
Assay of urine urobilinogen,84580,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9.93,,,,,,,fee schedule,8.6,20,APC
Assay of urine urobilinogen,84580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9.55,,,,,,,fee schedule,8.6,20,APC
Assay of urine urobilinogen,84580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.61,,,,,,,fee schedule,8.6,20,Radiology
Assay of urine urobilinogen,84580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.37,,,,,,,fee schedule,8.6,20,APC
Assay of urine urobilinogen,84580,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16.71,,,,,,,fee schedule,8.6,20,APC
Assay of urine urobilinogen,84583,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27.75,,,,,,,fee schedule,5.44,27.75,
Assay of urine urobilinogen,84583,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22.24,,,,,,,fee schedule,5.44,27.75,
Assay of urine urobilinogen,84583,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24.3,,,,,,,fee schedule,5.44,27.75,
Assay of urine urobilinogen,84583,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,25.54,,,,,,,fee schedule,5.44,27.75,
Assay of urine urobilinogen,84583,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.44,,,,,,,fee schedule,5.44,27.75,Laboratory
Assay of urine urobilinogen,84583,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.35,,,,,,,fee schedule,5.44,27.75,APC
Assay of urine urobilinogen,84583,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6.29,,,,,,,fee schedule,5.44,27.75,APC
Assay of urine urobilinogen,84583,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6.05,,,,,,,fee schedule,5.44,27.75,APC
Assay of urine urobilinogen,84583,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.26,,,,,,,fee schedule,5.44,27.75,Radiology
Assay of urine urobilinogen,84583,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8.47,,,,,,,fee schedule,5.44,27.75,APC
Assay of urine urobilinogen,84583,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10.59,,,,,,,fee schedule,5.44,27.75,APC
Assay of urine vma,84585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,85.58,,,,,,,fee schedule,13.95,85.58,
Assay of urine vma,84585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,68.6,,,,,,,fee schedule,13.95,85.58,
Assay of urine vma,84585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,74.94,,,,,,,fee schedule,13.95,85.58,
Assay of urine vma,84585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,78.79,,,,,,,fee schedule,13.95,85.58,
Assay of urine vma,84585,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.95,,,,,,,fee schedule,13.95,85.58,Laboratory
Assay of urine vma,84585,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.28,,,,,,,fee schedule,13.95,85.58,APC
Assay of urine vma,84585,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,16.12,,,,,,,fee schedule,13.95,85.58,APC
Assay of urine vma,84585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,15.5,,,,,,,fee schedule,13.95,85.58,APC
Assay of urine vma,84585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.72,,,,,,,fee schedule,13.95,85.58,Radiology
Assay of urine vma,84585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21.7,,,,,,,fee schedule,13.95,85.58,APC
Assay of urine vma,84585,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,27.12,,,,,,,fee schedule,13.95,85.58,APC
Assay of vip,84586,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,195.01,,,,,,,fee schedule,31.8,195.01,
Assay of vip,84586,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,156.32,,,,,,,fee schedule,31.8,195.01,
Assay of vip,84586,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,170.76,,,,,,,fee schedule,31.8,195.01,
Assay of vip,84586,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,179.53,,,,,,,fee schedule,31.8,195.01,
Assay of vip,84586,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31.8,,,,,,,fee schedule,31.8,195.01,Laboratory
Assay of vip,84586,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,37.1,,,,,,,fee schedule,31.8,195.01,APC
Assay of vip,84586,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,36.74,,,,,,,fee schedule,31.8,195.01,APC
Assay of vip,84586,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,35.33,,,,,,,fee schedule,31.8,195.01,APC
Assay of vip,84586,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,54.05,,,,,,,fee schedule,31.8,195.01,Radiology
Assay of vip,84586,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49.46,,,,,,,fee schedule,31.8,195.01,APC
Assay of vip,84586,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,61.83,,,,,,,fee schedule,31.8,195.01,APC
Assay of vasopressin,84588,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,180.66,,,,,,,fee schedule,30.55,180.66,
Assay of vasopressin,84588,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,144.81,,,,,,,fee schedule,30.55,180.66,
Assay of vasopressin,84588,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,158.19,,,,,,,fee schedule,30.55,180.66,
Assay of vasopressin,84588,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,166.32,,,,,,,fee schedule,30.55,180.66,
Assay of vasopressin,84588,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,30.55,,,,,,,fee schedule,30.55,180.66,Laboratory
Assay of vasopressin,84588,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,35.64,,,,,,,fee schedule,30.55,180.66,APC
Assay of vasopressin,84588,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,35.3,,,,,,,fee schedule,30.55,180.66,APC
Assay of vasopressin,84588,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,33.94,,,,,,,fee schedule,30.55,180.66,APC
Assay of vasopressin,84588,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.93,,,,,,,fee schedule,30.55,180.66,Radiology
Assay of vasopressin,84588,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,47.52,,,,,,,fee schedule,30.55,180.66,APC
Assay of vasopressin,84588,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,59.4,,,,,,,fee schedule,30.55,180.66,APC
Assay of vitamin a,84590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,36.28,,,,,,,fee schedule,10.45,36.28,
Assay of vitamin a,84590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29.08,,,,,,,fee schedule,10.45,36.28,
Assay of vitamin a,84590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31.77,,,,,,,fee schedule,10.45,36.28,
Assay of vitamin a,84590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33.4,,,,,,,fee schedule,10.45,36.28,
Assay of vitamin a,84590,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.45,,,,,,,fee schedule,10.45,36.28,Laboratory
Assay of vitamin a,84590,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.19,,,,,,,fee schedule,10.45,36.28,APC
Assay of vitamin a,84590,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.07,,,,,,,fee schedule,10.45,36.28,APC
Assay of vitamin a,84590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11.61,,,,,,,fee schedule,10.45,36.28,APC
Assay of vitamin a,84590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.76,,,,,,,fee schedule,10.45,36.28,Radiology
Assay of vitamin a,84590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.25,,,,,,,fee schedule,10.45,36.28,APC
Assay of vitamin a,84590,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20.32,,,,,,,fee schedule,10.45,36.28,APC
Assay Of Nos Vitamin,84591,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,64,,,,,,,fee schedule,15.35,64,
Assay Of Nos Vitamin,84591,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.3,,,,,,,fee schedule,15.35,64,
Assay Of Nos Vitamin,84591,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56.04,,,,,,,fee schedule,15.35,64,
Assay Of Nos Vitamin,84591,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,58.92,,,,,,,fee schedule,15.35,64,
Assay Of Nos Vitamin,84591,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.35,,,,,,,fee schedule,15.35,64,Laboratory
Assay Of Nos Vitamin,84591,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.91,,,,,,,fee schedule,15.35,64,APC
Assay Of Nos Vitamin,84591,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,17.74,,,,,,,fee schedule,15.35,64,APC
Assay Of Nos Vitamin,84591,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17.06,,,,,,,fee schedule,15.35,64,APC
Assay Of Nos Vitamin,84591,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26.1,,,,,,,fee schedule,15.35,64,Radiology
Assay Of Nos Vitamin,84591,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.88,,,,,,,fee schedule,15.35,64,APC
Assay Of Nos Vitamin,84591,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,29.85,,,,,,,fee schedule,15.35,64,APC
Assay of vitamin k,84597,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,75.64,,,,,,,fee schedule,12.35,75.64,
Assay of vitamin k,84597,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,60.63,,,,,,,fee schedule,12.35,75.64,
Assay of vitamin k,84597,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66.23,,,,,,,fee schedule,12.35,75.64,
Assay of vitamin k,84597,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,69.63,,,,,,,fee schedule,12.35,75.64,
Assay of vitamin k,84597,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.35,,,,,,,fee schedule,12.35,75.64,Laboratory
Assay of vitamin k,84597,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.41,,,,,,,fee schedule,12.35,75.64,APC
Assay of vitamin k,84597,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,14.27,,,,,,,fee schedule,12.35,75.64,APC
Assay of vitamin k,84597,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.72,,,,,,,fee schedule,12.35,75.64,APC
Assay of vitamin k,84597,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.99,,,,,,,fee schedule,12.35,75.64,Radiology
Assay of vitamin k,84597,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.21,,,,,,,fee schedule,12.35,75.64,APC
Assay of vitamin k,84597,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,24.01,,,,,,,fee schedule,12.35,75.64,APC
Assay of volatiles,84600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,146.3,,,,,,,fee schedule,15.4,146.3,
Assay of volatiles,84600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,117.27,,,,,,,fee schedule,15.4,146.3,
Assay of volatiles,84600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,128.11,,,,,,,fee schedule,15.4,146.3,
Assay of volatiles,84600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,134.69,,,,,,,fee schedule,15.4,146.3,
Assay of volatiles,84600,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.4,,,,,,,fee schedule,15.4,146.3,Laboratory
Assay of volatiles,84600,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.97,,,,,,,fee schedule,15.4,146.3,APC
Assay of volatiles,84600,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,17.79,,,,,,,fee schedule,15.4,146.3,APC
Assay of volatiles,84600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17.11,,,,,,,fee schedule,15.4,146.3,APC
Assay of volatiles,84600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26.18,,,,,,,fee schedule,15.4,146.3,Radiology
Assay of volatiles,84600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.95,,,,,,,fee schedule,15.4,146.3,APC
Assay of volatiles,84600,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,29.94,,,,,,,fee schedule,15.4,146.3,APC
Xylose tolerance test,84620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,65.36,,,,,,,fee schedule,11.62,65.36,
Xylose tolerance test,84620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52.39,,,,,,,fee schedule,11.62,65.36,
Xylose tolerance test,84620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.23,,,,,,,fee schedule,11.62,65.36,
Xylose tolerance test,84620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.17,,,,,,,fee schedule,11.62,65.36,
Xylose tolerance test,84620,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.62,,,,,,,fee schedule,11.62,65.36,Laboratory
Xylose tolerance test,84620,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.56,,,,,,,fee schedule,11.62,65.36,APC
Xylose tolerance test,84620,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.43,,,,,,,fee schedule,11.62,65.36,APC
Xylose tolerance test,84620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.91,,,,,,,fee schedule,11.62,65.36,APC
Xylose tolerance test,84620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.75,,,,,,,fee schedule,11.62,65.36,Radiology
Xylose tolerance test,84620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.07,,,,,,,fee schedule,11.62,65.36,APC
Xylose tolerance test,84620,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22.59,,,,,,,fee schedule,11.62,65.36,APC
Assay of zinc,84630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,53.1,,,,,,,fee schedule,10.25,53.1,
Assay of zinc,84630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.56,,,,,,,fee schedule,10.25,53.1,
Assay of zinc,84630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.49,,,,,,,fee schedule,10.25,53.1,
Assay of zinc,84630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,48.88,,,,,,,fee schedule,10.25,53.1,
Assay of zinc,84630,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.25,,,,,,,fee schedule,10.25,53.1,Laboratory
Assay of zinc,84630,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.96,,,,,,,fee schedule,10.25,53.1,APC
Assay of zinc,84630,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11.85,,,,,,,fee schedule,10.25,53.1,APC
Assay of zinc,84630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11.39,,,,,,,fee schedule,10.25,53.1,APC
Assay of zinc,84630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.43,,,,,,,fee schedule,10.25,53.1,Radiology
Assay of zinc,84630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15.95,,,,,,,fee schedule,10.25,53.1,APC
Assay of zinc,84630,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19.93,,,,,,,fee schedule,10.25,53.1,APC
Assay of c-peptide,84681,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,71.08,,,,,,,fee schedule,18.73,71.08,
Assay of c-peptide,84681,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56.97,,,,,,,fee schedule,18.73,71.08,
Assay of c-peptide,84681,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,62.24,,,,,,,fee schedule,18.73,71.08,
Assay of c-peptide,84681,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,65.44,,,,,,,fee schedule,18.73,71.08,
Assay of c-peptide,84681,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.73,,,,,,,fee schedule,18.73,71.08,Laboratory
Assay of c-peptide,84681,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.85,,,,,,,fee schedule,18.73,71.08,APC
Assay of c-peptide,84681,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,21.64,,,,,,,fee schedule,18.73,71.08,APC
Assay of c-peptide,84681,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,20.81,,,,,,,fee schedule,18.73,71.08,APC
Assay of c-peptide,84681,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,31.84,,,,,,,fee schedule,18.73,71.08,Radiology
Assay of c-peptide,84681,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29.13,,,,,,,fee schedule,18.73,71.08,APC
Assay of c-peptide,84681,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,36.42,,,,,,,fee schedule,18.73,71.08,APC
Chorionic gonadotropin test,84702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,141.61,,,,,,,fee schedule,13.54,141.61,
Chorionic gonadotropin test,84702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,113.51,,,,,,,fee schedule,13.54,141.61,
Chorionic gonadotropin test,84702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,124,,,,,,,fee schedule,13.54,141.61,
Chorionic gonadotropin test,84702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,130.37,,,,,,,fee schedule,13.54,141.61,
Chorionic gonadotropin test,84702,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.55,,,,,,,fee schedule,13.54,141.61,Laboratory
Chorionic gonadotropin test,84702,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.8,,,,,,,fee schedule,13.54,141.61,APC
Chorionic gonadotropin test,84702,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,15.65,,,,,,,fee schedule,13.54,141.61,APC
Chorionic gonadotropin test,84702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,15.05,,,,,,,fee schedule,13.54,141.61,APC
Chorionic gonadotropin test,84702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.03,,,,,,,fee schedule,13.54,141.61,Radiology
Chorionic gonadotropin test,84702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21.07,,,,,,,fee schedule,13.54,141.61,APC
Chorionic gonadotropin test,84702,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,26.34,,,,,,,fee schedule,13.54,141.61,APC
Chorionic gonadotropin assay,84703,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,71.08,,,,,,,fee schedule,6.77,71.08,
Chorionic gonadotropin assay,84703,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56.97,,,,,,,fee schedule,6.77,71.08,
Chorionic gonadotropin assay,84703,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,62.24,,,,,,,fee schedule,6.77,71.08,
Chorionic gonadotropin assay,84703,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,65.44,,,,,,,fee schedule,6.77,71.08,
Chorionic gonadotropin assay,84703,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.77,,,,,,,fee schedule,6.77,71.08,Laboratory
Chorionic gonadotropin assay,84703,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.9,,,,,,,fee schedule,6.77,71.08,APC
Chorionic gonadotropin assay,84703,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7.82,,,,,,,fee schedule,6.77,71.08,APC
Chorionic gonadotropin assay,84703,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7.52,,,,,,,fee schedule,6.77,71.08,APC
Chorionic gonadotropin assay,84703,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11.51,,,,,,,fee schedule,6.77,71.08,Radiology
Chorionic gonadotropin assay,84703,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10.53,,,,,,,fee schedule,6.77,71.08,APC
Chorionic gonadotropin assay,84703,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,13.16,,,,,,,fee schedule,6.77,71.08,APC
Hcg free betachain test,84704,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83.08,,,,,,,fee schedule,13.76,83.08,
Hcg free betachain test,84704,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66.6,,,,,,,fee schedule,13.76,83.08,
Hcg free betachain test,84704,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,72.75,,,,,,,fee schedule,13.76,83.08,
Hcg free betachain test,84704,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,76.49,,,,,,,fee schedule,13.76,83.08,
Hcg free betachain test,84704,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.76,,,,,,,fee schedule,13.76,83.08,Laboratory
Hcg free betachain test,84704,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.05,,,,,,,fee schedule,13.76,83.08,APC
Hcg free betachain test,84704,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,15.9,,,,,,,fee schedule,13.76,83.08,APC
Hcg free betachain test,84704,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,15.29,,,,,,,fee schedule,13.76,83.08,APC
Hcg free betachain test,84704,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.39,,,,,,,fee schedule,13.76,83.08,Radiology
Hcg free betachain test,84704,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21.41,,,,,,,fee schedule,13.76,83.08,APC
Hcg free betachain test,84704,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,26.76,,,,,,,fee schedule,13.76,83.08,APC
Ovulation tests,84830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55.38,,,,,,,fee schedule,11.43,55.38,
Ovulation tests,84830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,44.39,,,,,,,fee schedule,11.43,55.38,
Ovulation tests,84830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48.49,,,,,,,fee schedule,11.43,55.38,
Ovulation tests,84830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,50.98,,,,,,,fee schedule,11.43,55.38,
Ovulation tests,84830,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.43,,,,,,,fee schedule,11.43,55.38,Laboratory
Ovulation tests,84830,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.34,,,,,,,fee schedule,11.43,55.38,APC
Ovulation tests,84830,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.21,,,,,,,fee schedule,11.43,55.38,APC
Ovulation tests,84830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.7,,,,,,,fee schedule,11.43,55.38,APC
Ovulation tests,84830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.43,,,,,,,fee schedule,11.43,55.38,Radiology
Ovulation tests,84830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.78,,,,,,,fee schedule,11.43,55.38,APC
Ovulation tests,84830,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22.22,,,,,,,fee schedule,11.43,55.38,APC
Bleeding time test,85002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24.83,,,,,,,fee schedule,4.34,24.83,
Bleeding time test,85002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19.91,,,,,,,fee schedule,4.34,24.83,
Bleeding time test,85002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21.75,,,,,,,fee schedule,4.34,24.83,
Bleeding time test,85002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22.86,,,,,,,fee schedule,4.34,24.83,
Bleeding time test,85002,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.34,,,,,,,fee schedule,4.34,24.83,Laboratory
Bleeding time test,85002,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.06,,,,,,,fee schedule,4.34,24.83,APC
Bleeding time test,85002,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5.01,,,,,,,fee schedule,4.34,24.83,APC
Bleeding time test,85002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4.82,,,,,,,fee schedule,4.34,24.83,APC
Bleeding time test,85002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.37,,,,,,,fee schedule,4.34,24.83,Radiology
Bleeding time test,85002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.75,,,,,,,fee schedule,4.34,24.83,APC
Bleeding time test,85002,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8.44,,,,,,,fee schedule,4.34,24.83,APC
Automated diff wbc count,85004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,35.72,,,,,,,fee schedule,5.82,35.72,
Automated diff wbc count,85004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28.63,,,,,,,fee schedule,5.82,35.72,
Automated diff wbc count,85004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31.28,,,,,,,fee schedule,5.82,35.72,
Automated diff wbc count,85004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,32.89,,,,,,,fee schedule,5.82,35.72,
Automated diff wbc count,85004,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.82,,,,,,,fee schedule,5.82,35.72,Laboratory
Automated diff wbc count,85004,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.79,,,,,,,fee schedule,5.82,35.72,APC
Automated diff wbc count,85004,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6.73,,,,,,,fee schedule,5.82,35.72,APC
Automated diff wbc count,85004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6.47,,,,,,,fee schedule,5.82,35.72,APC
Automated diff wbc count,85004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.9,,,,,,,fee schedule,5.82,35.72,Radiology
Automated diff wbc count,85004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.06,,,,,,,fee schedule,5.82,35.72,APC
Automated diff wbc count,85004,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11.32,,,,,,,fee schedule,5.82,35.72,APC
Bl smear w/diff wbc count,85007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18.98,,,,,,,fee schedule,3.42,18.98,
Bl smear w/diff wbc count,85007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15.21,,,,,,,fee schedule,3.42,18.98,
Bl smear w/diff wbc count,85007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.62,,,,,,,fee schedule,3.42,18.98,
Bl smear w/diff wbc count,85007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17.47,,,,,,,fee schedule,3.42,18.98,
Bl smear w/diff wbc count,85007,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.42,,,,,,,fee schedule,3.42,18.98,Laboratory
Bl smear w/diff wbc count,85007,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3.99,,,,,,,fee schedule,3.42,18.98,APC
Bl smear w/diff wbc count,85007,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3.95,,,,,,,fee schedule,3.42,18.98,APC
Bl smear w/diff wbc count,85007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3.8,,,,,,,fee schedule,3.42,18.98,APC
Bl smear w/diff wbc count,85007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.81,,,,,,,fee schedule,3.42,18.98,Radiology
Bl smear w/diff wbc count,85007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.32,,,,,,,fee schedule,3.42,18.98,APC
Bl smear w/diff wbc count,85007,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6.65,,,,,,,fee schedule,3.42,18.98,APC
Bl smear w/o diff wbc count,85008,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18.98,,,,,,,fee schedule,3.09,18.98,
Bl smear w/o diff wbc count,85008,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15.21,,,,,,,fee schedule,3.09,18.98,
Bl smear w/o diff wbc count,85008,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.62,,,,,,,fee schedule,3.09,18.98,
Bl smear w/o diff wbc count,85008,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17.47,,,,,,,fee schedule,3.09,18.98,
Bl smear w/o diff wbc count,85008,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.09,,,,,,,fee schedule,3.09,18.98,Laboratory
Bl smear w/o diff wbc count,85008,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3.6,,,,,,,fee schedule,3.09,18.98,APC
Bl smear w/o diff wbc count,85008,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3.57,,,,,,,fee schedule,3.09,18.98,APC
Bl smear w/o diff wbc count,85008,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3.43,,,,,,,fee schedule,3.09,18.98,APC
Bl smear w/o diff wbc count,85008,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.25,,,,,,,fee schedule,3.09,18.98,Radiology
Bl smear w/o diff wbc count,85008,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4.8,,,,,,,fee schedule,3.09,18.98,APC
Bl smear w/o diff wbc count,85008,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6,,,,,,,fee schedule,3.09,18.98,APC
Manual diff wbc count b-coat,85009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20.53,,,,,,,fee schedule,4.56,20.53,
Manual diff wbc count b-coat,85009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.45,,,,,,,fee schedule,4.56,20.53,
Manual diff wbc count b-coat,85009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17.97,,,,,,,fee schedule,4.56,20.53,
Manual diff wbc count b-coat,85009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18.9,,,,,,,fee schedule,4.56,20.53,
Manual diff wbc count b-coat,85009,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.56,,,,,,,fee schedule,4.56,20.53,Laboratory
Manual diff wbc count b-coat,85009,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.32,,,,,,,fee schedule,4.56,20.53,APC
Manual diff wbc count b-coat,85009,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5.27,,,,,,,fee schedule,4.56,20.53,APC
Manual diff wbc count b-coat,85009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5.07,,,,,,,fee schedule,4.56,20.53,APC
Manual diff wbc count b-coat,85009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.76,,,,,,,fee schedule,4.56,20.53,Radiology
Manual diff wbc count b-coat,85009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.1,,,,,,,fee schedule,4.56,20.53,APC
Manual diff wbc count b-coat,85009,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8.87,,,,,,,fee schedule,4.56,20.53,APC
Spun microhematocrit,85013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13.08,,,,,,,fee schedule,6.3,13.08,
Spun microhematocrit,85013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10.48,,,,,,,fee schedule,6.3,13.08,
Spun microhematocrit,85013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11.45,,,,,,,fee schedule,6.3,13.08,
Spun microhematocrit,85013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12.04,,,,,,,fee schedule,6.3,13.08,
Spun microhematocrit,85013,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.3,,,,,,,fee schedule,6.3,13.08,Laboratory
Spun microhematocrit,85013,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.35,,,,,,,fee schedule,6.3,13.08,APC
Spun microhematocrit,85013,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7.28,,,,,,,fee schedule,6.3,13.08,APC
Spun microhematocrit,85013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7,,,,,,,fee schedule,6.3,13.08,APC
Spun microhematocrit,85013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10.71,,,,,,,fee schedule,6.3,13.08,Radiology
Spun microhematocrit,85013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.8,,,,,,,fee schedule,6.3,13.08,APC
Spun microhematocrit,85013,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12.25,,,,,,,fee schedule,6.3,13.08,APC
Hematocrit,85014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,32.49,,,,,,,fee schedule,2.13,32.49,
Hematocrit,85014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26.04,,,,,,,fee schedule,2.13,32.49,
Hematocrit,85014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28.45,,,,,,,fee schedule,2.13,32.49,
Hematocrit,85014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,29.91,,,,,,,fee schedule,2.13,32.49,
Hematocrit,85014,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.13,,,,,,,fee schedule,2.13,32.49,Laboratory
Hematocrit,85014,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2.49,,,,,,,fee schedule,2.13,32.49,APC
Hematocrit,85014,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2.46,,,,,,,fee schedule,2.13,32.49,APC
Hematocrit,85014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2.37,,,,,,,fee schedule,2.13,32.49,APC
Hematocrit,85014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3.63,,,,,,,fee schedule,2.13,32.49,Radiology
Hematocrit,85014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3.32,,,,,,,fee schedule,2.13,32.49,APC
Hematocrit,85014,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4.15,,,,,,,fee schedule,2.13,32.49,APC
Hemoglobin,85018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33.5,,,,,,,fee schedule,2.13,33.5,
Hemoglobin,85018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26.85,,,,,,,fee schedule,2.13,33.5,
Hemoglobin,85018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29.34,,,,,,,fee schedule,2.13,33.5,
Hemoglobin,85018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30.84,,,,,,,fee schedule,2.13,33.5,
Hemoglobin,85018,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.13,,,,,,,fee schedule,2.13,33.5,Laboratory
Hemoglobin,85018,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2.49,,,,,,,fee schedule,2.13,33.5,APC
Hemoglobin,85018,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2.46,,,,,,,fee schedule,2.13,33.5,APC
Hemoglobin,85018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2.37,,,,,,,fee schedule,2.13,33.5,APC
Hemoglobin,85018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3.63,,,,,,,fee schedule,2.13,33.5,Radiology
Hemoglobin,85018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3.32,,,,,,,fee schedule,2.13,33.5,APC
Hemoglobin,85018,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4.15,,,,,,,fee schedule,2.13,33.5,APC
Complete cbc w/auto diff wbc,85025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,68.57,,,,,,,fee schedule,6.99,68.57,
Complete cbc w/auto diff wbc,85025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,54.97,,,,,,,fee schedule,6.99,68.57,
Complete cbc w/auto diff wbc,85025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,60.05,,,,,,,fee schedule,6.99,68.57,
Complete cbc w/auto diff wbc,85025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,63.13,,,,,,,fee schedule,6.99,68.57,
Complete cbc w/auto diff wbc,85025,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.99,,,,,,,fee schedule,6.99,68.57,Laboratory
Complete cbc w/auto diff wbc,85025,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.16,,,,,,,fee schedule,6.99,68.57,APC
Complete cbc w/auto diff wbc,85025,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8.08,,,,,,,fee schedule,6.99,68.57,APC
Complete cbc w/auto diff wbc,85025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7.77,,,,,,,fee schedule,6.99,68.57,APC
Complete cbc w/auto diff wbc,85025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11.89,,,,,,,fee schedule,6.99,68.57,Radiology
Complete cbc w/auto diff wbc,85025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10.88,,,,,,,fee schedule,6.99,68.57,APC
Complete cbc w/auto diff wbc,85025,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,13.6,,,,,,,fee schedule,6.99,68.57,APC
Complete cbc automated,85027,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46.81,,,,,,,fee schedule,5.82,46.81,
Complete cbc automated,85027,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37.52,,,,,,,fee schedule,5.82,46.81,
Complete cbc automated,85027,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40.99,,,,,,,fee schedule,5.82,46.81,
Complete cbc automated,85027,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,43.1,,,,,,,fee schedule,5.82,46.81,
Complete cbc automated,85027,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.82,,,,,,,fee schedule,5.82,46.81,Laboratory
Complete cbc automated,85027,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.79,,,,,,,fee schedule,5.82,46.81,APC
Complete cbc automated,85027,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6.73,,,,,,,fee schedule,5.82,46.81,APC
Complete cbc automated,85027,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6.47,,,,,,,fee schedule,5.82,46.81,APC
Complete cbc automated,85027,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.9,,,,,,,fee schedule,5.82,46.81,Radiology
Complete cbc automated,85027,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.06,,,,,,,fee schedule,5.82,46.81,APC
Complete cbc automated,85027,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11.32,,,,,,,fee schedule,5.82,46.81,APC
Manual cell count each,85032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23.74,,,,,,,fee schedule,3.88,23.74,
Manual cell count each,85032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19.03,,,,,,,fee schedule,3.88,23.74,
Manual cell count each,85032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20.79,,,,,,,fee schedule,3.88,23.74,
Manual cell count each,85032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21.85,,,,,,,fee schedule,3.88,23.74,
Manual cell count each,85032,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.88,,,,,,,fee schedule,3.88,23.74,Laboratory
Manual cell count each,85032,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.53,,,,,,,fee schedule,3.88,23.74,APC
Manual cell count each,85032,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4.48,,,,,,,fee schedule,3.88,23.74,APC
Manual cell count each,85032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4.31,,,,,,,fee schedule,3.88,23.74,APC
Manual cell count each,85032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.59,,,,,,,fee schedule,3.88,23.74,Radiology
Manual cell count each,85032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.03,,,,,,,fee schedule,3.88,23.74,APC
Manual cell count each,85032,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7.54,,,,,,,fee schedule,3.88,23.74,APC
Automated rbc count,85041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16.63,,,,,,,fee schedule,2.72,16.63,
Automated rbc count,85041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13.33,,,,,,,fee schedule,2.72,16.63,
Automated rbc count,85041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14.56,,,,,,,fee schedule,2.72,16.63,
Automated rbc count,85041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15.31,,,,,,,fee schedule,2.72,16.63,
Automated rbc count,85041,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.72,,,,,,,fee schedule,2.72,16.63,Laboratory
Automated rbc count,85041,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3.17,,,,,,,fee schedule,2.72,16.63,APC
Automated rbc count,85041,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3.14,,,,,,,fee schedule,2.72,16.63,APC
Automated rbc count,85041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3.02,,,,,,,fee schedule,2.72,16.63,APC
Automated rbc count,85041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4.62,,,,,,,fee schedule,2.72,16.63,Radiology
Automated rbc count,85041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4.23,,,,,,,fee schedule,2.72,16.63,APC
Automated rbc count,85041,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5.28,,,,,,,fee schedule,2.72,16.63,APC
Manual reticulocyte count,85044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23.74,,,,,,,fee schedule,3.88,23.74,
Manual reticulocyte count,85044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19.03,,,,,,,fee schedule,3.88,23.74,
Manual reticulocyte count,85044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20.79,,,,,,,fee schedule,3.88,23.74,
Manual reticulocyte count,85044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21.85,,,,,,,fee schedule,3.88,23.74,
Manual reticulocyte count,85044,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.88,,,,,,,fee schedule,3.88,23.74,Laboratory
Manual reticulocyte count,85044,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.53,,,,,,,fee schedule,3.88,23.74,APC
Manual reticulocyte count,85044,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4.48,,,,,,,fee schedule,3.88,23.74,APC
Manual reticulocyte count,85044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4.31,,,,,,,fee schedule,3.88,23.74,APC
Manual reticulocyte count,85044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.59,,,,,,,fee schedule,3.88,23.74,Radiology
Manual reticulocyte count,85044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.03,,,,,,,fee schedule,3.88,23.74,APC
Manual reticulocyte count,85044,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7.54,,,,,,,fee schedule,3.88,23.74,APC
Automated reticulocyte count,85045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,53.05,,,,,,,fee schedule,3.59,53.05,
Automated reticulocyte count,85045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.53,,,,,,,fee schedule,3.59,53.05,
Automated reticulocyte count,85045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.46,,,,,,,fee schedule,3.59,53.05,
Automated reticulocyte count,85045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,48.84,,,,,,,fee schedule,3.59,53.05,
Automated reticulocyte count,85045,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.59,,,,,,,fee schedule,3.59,53.05,Laboratory
Automated reticulocyte count,85045,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.19,,,,,,,fee schedule,3.59,53.05,APC
Automated reticulocyte count,85045,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4.15,,,,,,,fee schedule,3.59,53.05,APC
Automated reticulocyte count,85045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3.99,,,,,,,fee schedule,3.59,53.05,APC
Automated reticulocyte count,85045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.1,,,,,,,fee schedule,3.59,53.05,Radiology
Automated reticulocyte count,85045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.59,,,,,,,fee schedule,3.59,53.05,APC
Automated reticulocyte count,85045,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6.98,,,,,,,fee schedule,3.59,53.05,APC
Reticyte/hgb concentrate,85046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30.81,,,,,,,fee schedule,5.01,30.81,
Reticyte/hgb concentrate,85046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24.69,,,,,,,fee schedule,5.01,30.81,
Reticyte/hgb concentrate,85046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26.98,,,,,,,fee schedule,5.01,30.81,
Reticyte/hgb concentrate,85046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,28.36,,,,,,,fee schedule,5.01,30.81,
Reticyte/hgb concentrate,85046,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.01,,,,,,,fee schedule,5.01,30.81,Laboratory
Reticyte/hgb concentrate,85046,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.85,,,,,,,fee schedule,5.01,30.81,APC
Reticyte/hgb concentrate,85046,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5.79,,,,,,,fee schedule,5.01,30.81,APC
Reticyte/hgb concentrate,85046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5.57,,,,,,,fee schedule,5.01,30.81,APC
Reticyte/hgb concentrate,85046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8.52,,,,,,,fee schedule,5.01,30.81,Radiology
Reticyte/hgb concentrate,85046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.8,,,,,,,fee schedule,5.01,30.81,APC
Reticyte/hgb concentrate,85046,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9.75,,,,,,,fee schedule,5.01,30.81,APC
Automated leukocyte count,85048,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37.39,,,,,,,fee schedule,2.29,37.39,
Automated leukocyte count,85048,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29.97,,,,,,,fee schedule,2.29,37.39,
Automated leukocyte count,85048,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32.74,,,,,,,fee schedule,2.29,37.39,
Automated leukocyte count,85048,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,34.42,,,,,,,fee schedule,2.29,37.39,
Automated leukocyte count,85048,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.29,,,,,,,fee schedule,2.29,37.39,Laboratory
Automated leukocyte count,85048,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2.67,,,,,,,fee schedule,2.29,37.39,APC
Automated leukocyte count,85048,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2.64,,,,,,,fee schedule,2.29,37.39,APC
Automated leukocyte count,85048,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2.54,,,,,,,fee schedule,2.29,37.39,APC
Automated leukocyte count,85048,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3.89,,,,,,,fee schedule,2.29,37.39,Radiology
Automated leukocyte count,85048,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3.56,,,,,,,fee schedule,2.29,37.39,APC
Automated leukocyte count,85048,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4.44,,,,,,,fee schedule,2.29,37.39,APC
Automated platelet count,85049,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,54.79,,,,,,,fee schedule,4.03,54.79,
Automated platelet count,85049,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,43.92,,,,,,,fee schedule,4.03,54.79,
Automated platelet count,85049,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,47.98,,,,,,,fee schedule,4.03,54.79,
Automated platelet count,85049,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,50.44,,,,,,,fee schedule,4.03,54.79,
Automated platelet count,85049,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.03,,,,,,,fee schedule,4.03,54.79,Laboratory
Automated platelet count,85049,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.7,,,,,,,fee schedule,4.03,54.79,APC
Automated platelet count,85049,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4.66,,,,,,,fee schedule,4.03,54.79,APC
Automated platelet count,85049,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4.48,,,,,,,fee schedule,4.03,54.79,APC
Automated platelet count,85049,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.85,,,,,,,fee schedule,4.03,54.79,Radiology
Automated platelet count,85049,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.27,,,,,,,fee schedule,4.03,54.79,APC
Automated platelet count,85049,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7.84,,,,,,,fee schedule,4.03,54.79,APC
Reticulated platelet assay,85055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,81.44,,,,,,,fee schedule,32.17,81.44,
Reticulated platelet assay,85055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,65.28,,,,,,,fee schedule,32.17,81.44,
Reticulated platelet assay,85055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,71.32,,,,,,,fee schedule,32.17,81.44,
Reticulated platelet assay,85055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,74.98,,,,,,,fee schedule,32.17,81.44,
Reticulated platelet assay,85055,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,32.17,,,,,,,fee schedule,32.17,81.44,Laboratory
Reticulated platelet assay,85055,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,37.53,,,,,,,fee schedule,32.17,81.44,APC
Reticulated platelet assay,85055,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,37.17,,,,,,,fee schedule,32.17,81.44,APC
Reticulated platelet assay,85055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,35.74,,,,,,,fee schedule,32.17,81.44,APC
Reticulated platelet assay,85055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,54.68,,,,,,,fee schedule,32.17,81.44,Radiology
Reticulated platelet assay,85055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,50.04,,,,,,,fee schedule,32.17,81.44,APC
Reticulated platelet assay,85055,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,62.54,,,,,,,fee schedule,32.17,81.44,APC
Blood smear interpretation,85060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,82.56,,,,,,,fee schedule,66.18,82.56,
Blood smear interpretation,85060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66.18,,,,,,,fee schedule,66.18,82.56,
Blood smear interpretation,85060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,72.29,,,,,,,fee schedule,66.18,82.56,
Blood smear interpretation,85060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,76,,,,,,,fee schedule,66.18,82.56,
Bone marrow interpretation,85097,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,128.33,,,,,,,fee schedule,102.87,3538.67,
Bone marrow interpretation,85097,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,102.87,,,,,,,fee schedule,102.87,3538.67,
Bone marrow interpretation,85097,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,112.37,,,,,,,fee schedule,102.87,3538.67,
Bone marrow interpretation,85097,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,118.15,,,,,,,fee schedule,102.87,3538.67,
Bone marrow interpretation,85097,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3538.67,,,,,,,fee schedule,102.87,3538.67,APC 378
Bone marrow interpretation,85097,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,837.48,,,,,,,fee schedule,102.87,3538.67,APC
Bone marrow interpretation,85097,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,829.5,,,,,,,fee schedule,102.87,3538.67,APC
Bone marrow interpretation,85097,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,797.6,,,,,,,fee schedule,102.87,3538.67,APC
Bone marrow interpretation,85097,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1220.32,,,,,,,fee schedule,102.87,3538.67,Radiology
Bone marrow interpretation,85097,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1116.64,,,,,,,fee schedule,102.87,3538.67,APC
Bone marrow interpretation,85097,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1395.79,,,,,,,fee schedule,102.87,3538.67,APC
Chromogenic substrate assay,85130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,65.66,,,,,,,fee schedule,10.7,65.66,
Chromogenic substrate assay,85130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52.63,,,,,,,fee schedule,10.7,65.66,
Chromogenic substrate assay,85130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.49,,,,,,,fee schedule,10.7,65.66,
Chromogenic substrate assay,85130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.45,,,,,,,fee schedule,10.7,65.66,
Chromogenic substrate assay,85130,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.7,,,,,,,fee schedule,10.7,65.66,Laboratory
Chromogenic substrate assay,85130,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.48,,,,,,,fee schedule,10.7,65.66,APC
Chromogenic substrate assay,85130,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.37,,,,,,,fee schedule,10.7,65.66,APC
Chromogenic substrate assay,85130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11.89,,,,,,,fee schedule,10.7,65.66,APC
Chromogenic substrate assay,85130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.19,,,,,,,fee schedule,10.7,65.66,Radiology
Chromogenic substrate assay,85130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.65,,,,,,,fee schedule,10.7,65.66,APC
Chromogenic substrate assay,85130,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20.81,,,,,,,fee schedule,10.7,65.66,APC
Blood clot retraction,85170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19.96,,,,,,,fee schedule,14.67,28.52,
Blood clot retraction,85170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16,,,,,,,fee schedule,14.67,28.52,
Blood clot retraction,85170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17.48,,,,,,,fee schedule,14.67,28.52,
Blood clot retraction,85170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18.37,,,,,,,fee schedule,14.67,28.52,
Blood clot retraction,85170,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.67,,,,,,,fee schedule,14.67,28.52,Laboratory
Blood clot retraction,85170,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.12,,,,,,,fee schedule,14.67,28.52,APC
Blood clot retraction,85170,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,16.95,,,,,,,fee schedule,14.67,28.52,APC
Blood clot retraction,85170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16.3,,,,,,,fee schedule,14.67,28.52,APC
Blood clot retraction,85170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24.94,,,,,,,fee schedule,14.67,28.52,Radiology
Blood clot retraction,85170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.82,,,,,,,fee schedule,14.67,28.52,APC
Blood clot retraction,85170,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,28.52,,,,,,,fee schedule,14.67,28.52,APC
Blood clot lysis time,85175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,25.1,,,,,,,fee schedule,18.33,35.65,
Blood clot lysis time,85175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20.12,,,,,,,fee schedule,18.33,35.65,
Blood clot lysis time,85175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21.98,,,,,,,fee schedule,18.33,35.65,
Blood clot lysis time,85175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23.11,,,,,,,fee schedule,18.33,35.65,
Blood clot lysis time,85175,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.33,,,,,,,fee schedule,18.33,35.65,Laboratory
Blood clot lysis time,85175,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.39,,,,,,,fee schedule,18.33,35.65,APC
Blood clot lysis time,85175,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,21.18,,,,,,,fee schedule,18.33,35.65,APC
Blood clot lysis time,85175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,20.37,,,,,,,fee schedule,18.33,35.65,APC
Blood clot lysis time,85175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,31.17,,,,,,,fee schedule,18.33,35.65,Radiology
Blood clot lysis time,85175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.52,,,,,,,fee schedule,18.33,35.65,APC
Blood clot lysis time,85175,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,35.65,,,,,,,fee schedule,18.33,35.65,APC
Clot factor ii prothrom spec,85210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,71.67,,,,,,,fee schedule,11.68,71.67,
Clot factor ii prothrom spec,85210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.45,,,,,,,fee schedule,11.68,71.67,
Clot factor ii prothrom spec,85210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,62.76,,,,,,,fee schedule,11.68,71.67,
Clot factor ii prothrom spec,85210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,65.98,,,,,,,fee schedule,11.68,71.67,
Clot factor ii prothrom spec,85210,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.68,,,,,,,fee schedule,11.68,71.67,Laboratory
Clot factor ii prothrom spec,85210,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.63,,,,,,,fee schedule,11.68,71.67,APC
Clot factor ii prothrom spec,85210,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.5,,,,,,,fee schedule,11.68,71.67,APC
Clot factor ii prothrom spec,85210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.98,,,,,,,fee schedule,11.68,71.67,APC
Clot factor ii prothrom spec,85210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.86,,,,,,,fee schedule,11.68,71.67,Radiology
Clot factor ii prothrom spec,85210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.17,,,,,,,fee schedule,11.68,71.67,APC
Clot factor ii prothrom spec,85210,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22.72,,,,,,,fee schedule,11.68,71.67,APC
Blooc clot factor v test,85220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,97.41,,,,,,,fee schedule,15.88,97.41,
Blooc clot factor v test,85220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,78.08,,,,,,,fee schedule,15.88,97.41,
Blooc clot factor v test,85220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,85.3,,,,,,,fee schedule,15.88,97.41,
Blooc clot factor v test,85220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,89.68,,,,,,,fee schedule,15.88,97.41,
Blooc clot factor v test,85220,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.88,,,,,,,fee schedule,15.88,97.41,Laboratory
Blooc clot factor v test,85220,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.53,,,,,,,fee schedule,15.88,97.41,APC
Blooc clot factor v test,85220,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18.36,,,,,,,fee schedule,15.88,97.41,APC
Blooc clot factor v test,85220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17.65,,,,,,,fee schedule,15.88,97.41,APC
Blooc clot factor v test,85220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27,,,,,,,fee schedule,15.88,97.41,Radiology
Blooc clot factor v test,85220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24.71,,,,,,,fee schedule,15.88,97.41,APC
Blooc clot factor v test,85220,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30.89,,,,,,,fee schedule,15.88,97.41,APC
Clot factor vii proconvertin,85230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,314.67,,,,,,,fee schedule,16.11,314.67,
Clot factor vii proconvertin,85230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,252.23,,,,,,,fee schedule,16.11,314.67,
Clot factor vii proconvertin,85230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,275.54,,,,,,,fee schedule,16.11,314.67,
Clot factor vii proconvertin,85230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,289.69,,,,,,,fee schedule,16.11,314.67,
Clot factor vii proconvertin,85230,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.11,,,,,,,fee schedule,16.11,314.67,Laboratory
Clot factor vii proconvertin,85230,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.79,,,,,,,fee schedule,16.11,314.67,APC
Clot factor vii proconvertin,85230,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18.62,,,,,,,fee schedule,16.11,314.67,APC
Clot factor vii proconvertin,85230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17.9,,,,,,,fee schedule,16.11,314.67,APC
Clot factor vii proconvertin,85230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27.39,,,,,,,fee schedule,16.11,314.67,Radiology
Clot factor vii proconvertin,85230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.06,,,,,,,fee schedule,16.11,314.67,APC
Clot factor vii proconvertin,85230,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31.32,,,,,,,fee schedule,16.11,314.67,APC
Clot factor viii ahg 1 stage,85240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,165.11,,,,,,,fee schedule,16.11,165.11,
Clot factor viii ahg 1 stage,85240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,132.35,,,,,,,fee schedule,16.11,165.11,
Clot factor viii ahg 1 stage,85240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,144.58,,,,,,,fee schedule,16.11,165.11,
Clot factor viii ahg 1 stage,85240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,152,,,,,,,fee schedule,16.11,165.11,
Clot factor viii ahg 1 stage,85240,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.11,,,,,,,fee schedule,16.11,165.11,Laboratory
Clot factor viii ahg 1 stage,85240,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.79,,,,,,,fee schedule,16.11,165.11,APC
Clot factor viii ahg 1 stage,85240,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18.62,,,,,,,fee schedule,16.11,165.11,APC
Clot factor viii ahg 1 stage,85240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17.9,,,,,,,fee schedule,16.11,165.11,APC
Clot factor viii ahg 1 stage,85240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27.39,,,,,,,fee schedule,16.11,165.11,Radiology
Clot factor viii ahg 1 stage,85240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.06,,,,,,,fee schedule,16.11,165.11,APC
Clot factor viii ahg 1 stage,85240,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31.32,,,,,,,fee schedule,16.11,165.11,APC
Clot factor viii reltd antgn,85244,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,112.68,,,,,,,fee schedule,18.38,112.68,
Clot factor viii reltd antgn,85244,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,90.32,,,,,,,fee schedule,18.38,112.68,
Clot factor viii reltd antgn,85244,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,98.67,,,,,,,fee schedule,18.38,112.68,
Clot factor viii reltd antgn,85244,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,103.74,,,,,,,fee schedule,18.38,112.68,
Clot factor viii reltd antgn,85244,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.38,,,,,,,fee schedule,18.38,112.68,Laboratory
Clot factor viii reltd antgn,85244,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.44,,,,,,,fee schedule,18.38,112.68,APC
Clot factor viii reltd antgn,85244,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,21.24,,,,,,,fee schedule,18.38,112.68,APC
Clot factor viii reltd antgn,85244,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,20.42,,,,,,,fee schedule,18.38,112.68,APC
Clot factor viii reltd antgn,85244,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,31.24,,,,,,,fee schedule,18.38,112.68,Radiology
Clot factor viii reltd antgn,85244,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.59,,,,,,,fee schedule,18.38,112.68,APC
Clot factor viii reltd antgn,85244,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,35.74,,,,,,,fee schedule,18.38,112.68,APC
Clot factor viii vw ristoctn,85245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,134.38,,,,,,,fee schedule,20.65,134.38,
Clot factor viii vw ristoctn,85245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,107.72,,,,,,,fee schedule,20.65,134.38,
Clot factor viii vw ristoctn,85245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,117.67,,,,,,,fee schedule,20.65,134.38,
Clot factor viii vw ristoctn,85245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,123.72,,,,,,,fee schedule,20.65,134.38,
Clot factor viii vw ristoctn,85245,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,20.65,,,,,,,fee schedule,20.65,134.38,Laboratory
Clot factor viii vw ristoctn,85245,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,24.09,,,,,,,fee schedule,20.65,134.38,APC
Clot factor viii vw ristoctn,85245,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,23.86,,,,,,,fee schedule,20.65,134.38,APC
Clot factor viii vw ristoctn,85245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,22.94,,,,,,,fee schedule,20.65,134.38,APC
Clot factor viii vw ristoctn,85245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,35.1,,,,,,,fee schedule,20.65,134.38,Radiology
Clot factor viii vw ristoctn,85245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,32.12,,,,,,,fee schedule,20.65,134.38,APC
Clot factor viii vw ristoctn,85245,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,40.15,,,,,,,fee schedule,20.65,134.38,APC
Clot factor viii vw antigen,85246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,91.44,,,,,,,fee schedule,20.65,91.44,
Clot factor viii vw antigen,85246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,73.3,,,,,,,fee schedule,20.65,91.44,
Clot factor viii vw antigen,85246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,80.07,,,,,,,fee schedule,20.65,91.44,
Clot factor viii vw antigen,85246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,84.18,,,,,,,fee schedule,20.65,91.44,
Clot factor viii vw antigen,85246,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,20.65,,,,,,,fee schedule,20.65,91.44,Laboratory
Clot factor viii vw antigen,85246,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,24.09,,,,,,,fee schedule,20.65,91.44,APC
Clot factor viii vw antigen,85246,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,23.86,,,,,,,fee schedule,20.65,91.44,APC
Clot factor viii vw antigen,85246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,22.94,,,,,,,fee schedule,20.65,91.44,APC
Clot factor viii vw antigen,85246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,35.1,,,,,,,fee schedule,20.65,91.44,Radiology
Clot factor viii vw antigen,85246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,32.12,,,,,,,fee schedule,20.65,91.44,APC
Clot factor viii vw antigen,85246,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,40.15,,,,,,,fee schedule,20.65,91.44,APC
Clot factor viii multimetric,85247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,126.67,,,,,,,fee schedule,20.65,126.67,
Clot factor viii multimetric,85247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,101.54,,,,,,,fee schedule,20.65,126.67,
Clot factor viii multimetric,85247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,110.92,,,,,,,fee schedule,20.65,126.67,
Clot factor viii multimetric,85247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,116.61,,,,,,,fee schedule,20.65,126.67,
Clot factor viii multimetric,85247,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,20.65,,,,,,,fee schedule,20.65,126.67,Laboratory
Clot factor viii multimetric,85247,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,24.09,,,,,,,fee schedule,20.65,126.67,APC
Clot factor viii multimetric,85247,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,23.86,,,,,,,fee schedule,20.65,126.67,APC
Clot factor viii multimetric,85247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,22.94,,,,,,,fee schedule,20.65,126.67,APC
Clot factor viii multimetric,85247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,35.1,,,,,,,fee schedule,20.65,126.67,Radiology
Clot factor viii multimetric,85247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,32.12,,,,,,,fee schedule,20.65,126.67,APC
Clot factor viii multimetric,85247,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,40.15,,,,,,,fee schedule,20.65,126.67,APC
Clot factor ix ptc/chrstmas,85250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,105.05,,,,,,,fee schedule,17.14,105.05,
Clot factor ix ptc/chrstmas,85250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,84.2,,,,,,,fee schedule,17.14,105.05,
Clot factor ix ptc/chrstmas,85250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,91.98,,,,,,,fee schedule,17.14,105.05,
Clot factor ix ptc/chrstmas,85250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,96.71,,,,,,,fee schedule,17.14,105.05,
Clot factor ix ptc/chrstmas,85250,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.14,,,,,,,fee schedule,17.14,105.05,Laboratory
Clot factor ix ptc/chrstmas,85250,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.99,,,,,,,fee schedule,17.14,105.05,APC
Clot factor ix ptc/chrstmas,85250,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,19.8,,,,,,,fee schedule,17.14,105.05,APC
Clot factor ix ptc/chrstmas,85250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,19.04,,,,,,,fee schedule,17.14,105.05,APC
Clot factor ix ptc/chrstmas,85250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29.13,,,,,,,fee schedule,17.14,105.05,Radiology
Clot factor ix ptc/chrstmas,85250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26.66,,,,,,,fee schedule,17.14,105.05,APC
Clot factor ix ptc/chrstmas,85250,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,33.32,,,,,,,fee schedule,17.14,105.05,APC
Clot factor x stuart-power,85260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,314.67,,,,,,,fee schedule,16.11,314.67,
Clot factor x stuart-power,85260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,252.23,,,,,,,fee schedule,16.11,314.67,
Clot factor x stuart-power,85260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,275.54,,,,,,,fee schedule,16.11,314.67,
Clot factor x stuart-power,85260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,289.69,,,,,,,fee schedule,16.11,314.67,
Clot factor x stuart-power,85260,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.11,,,,,,,fee schedule,16.11,314.67,Laboratory
Clot factor x stuart-power,85260,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.79,,,,,,,fee schedule,16.11,314.67,APC
Clot factor x stuart-power,85260,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18.62,,,,,,,fee schedule,16.11,314.67,APC
Clot factor x stuart-power,85260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17.9,,,,,,,fee schedule,16.11,314.67,APC
Clot factor x stuart-power,85260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27.39,,,,,,,fee schedule,16.11,314.67,Radiology
Clot factor x stuart-power,85260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.06,,,,,,,fee schedule,16.11,314.67,APC
Clot factor x stuart-power,85260,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31.32,,,,,,,fee schedule,16.11,314.67,APC
Clot factor xi pta,85270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,98.81,,,,,,,fee schedule,16.11,98.81,
Clot factor xi pta,85270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,79.2,,,,,,,fee schedule,16.11,98.81,
Clot factor xi pta,85270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,86.52,,,,,,,fee schedule,16.11,98.81,
Clot factor xi pta,85270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,90.97,,,,,,,fee schedule,16.11,98.81,
Clot factor xi pta,85270,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.11,,,,,,,fee schedule,16.11,98.81,Laboratory
Clot factor xi pta,85270,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.79,,,,,,,fee schedule,16.11,98.81,APC
Clot factor xi pta,85270,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18.62,,,,,,,fee schedule,16.11,98.81,APC
Clot factor xi pta,85270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17.9,,,,,,,fee schedule,16.11,98.81,APC
Clot factor xi pta,85270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27.39,,,,,,,fee schedule,16.11,98.81,Radiology
Clot factor xi pta,85270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.06,,,,,,,fee schedule,16.11,98.81,APC
Clot factor xi pta,85270,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31.32,,,,,,,fee schedule,16.11,98.81,APC
Clot factor xii hageman,85280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.71,,,,,,,fee schedule,17.42,60.71,
Clot factor xii hageman,85280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48.67,,,,,,,fee schedule,17.42,60.71,
Clot factor xii hageman,85280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.16,,,,,,,fee schedule,17.42,60.71,
Clot factor xii hageman,85280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55.89,,,,,,,fee schedule,17.42,60.71,
Clot factor xii hageman,85280,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.42,,,,,,,fee schedule,17.42,60.71,Laboratory
Clot factor xii hageman,85280,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20.32,,,,,,,fee schedule,17.42,60.71,APC
Clot factor xii hageman,85280,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,20.12,,,,,,,fee schedule,17.42,60.71,APC
Clot factor xii hageman,85280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,19.35,,,,,,,fee schedule,17.42,60.71,APC
Clot factor xii hageman,85280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29.61,,,,,,,fee schedule,17.42,60.71,Radiology
Clot factor xii hageman,85280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27.09,,,,,,,fee schedule,17.42,60.71,APC
Clot factor xii hageman,85280,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,33.86,,,,,,,fee schedule,17.42,60.71,APC
Clot factor xiii fibrin stab,85290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,90.19,,,,,,,fee schedule,14.71,90.19,
Clot factor xiii fibrin stab,85290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,72.3,,,,,,,fee schedule,14.71,90.19,
Clot factor xiii fibrin stab,85290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,78.98,,,,,,,fee schedule,14.71,90.19,
Clot factor xiii fibrin stab,85290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83.03,,,,,,,fee schedule,14.71,90.19,
Clot factor xiii fibrin stab,85290,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.71,,,,,,,fee schedule,14.71,90.19,Laboratory
Clot factor xiii fibrin stab,85290,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.16,,,,,,,fee schedule,14.71,90.19,APC
Clot factor xiii fibrin stab,85290,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,16.99,,,,,,,fee schedule,14.71,90.19,APC
Clot factor xiii fibrin stab,85290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16.34,,,,,,,fee schedule,14.71,90.19,APC
Clot factor xiii fibrin stab,85290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25,,,,,,,fee schedule,14.71,90.19,Radiology
Clot factor xiii fibrin stab,85290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.88,,,,,,,fee schedule,14.71,90.19,APC
Clot factor xiii fibrin stab,85290,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,28.6,,,,,,,fee schedule,14.71,90.19,APC
Clot factor xiii fibrin scrn,85291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,49.06,,,,,,,fee schedule,8.2,49.06,
Clot factor xiii fibrin scrn,85291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39.33,,,,,,,fee schedule,8.2,49.06,
Clot factor xiii fibrin scrn,85291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.96,,,,,,,fee schedule,8.2,49.06,
Clot factor xiii fibrin scrn,85291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45.17,,,,,,,fee schedule,8.2,49.06,
Clot factor xiii fibrin scrn,85291,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.2,,,,,,,fee schedule,8.2,49.06,Laboratory
Clot factor xiii fibrin scrn,85291,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.57,,,,,,,fee schedule,8.2,49.06,APC
Clot factor xiii fibrin scrn,85291,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9.47,,,,,,,fee schedule,8.2,49.06,APC
Clot factor xiii fibrin scrn,85291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9.11,,,,,,,fee schedule,8.2,49.06,APC
Clot factor xiii fibrin scrn,85291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.94,,,,,,,fee schedule,8.2,49.06,Radiology
Clot factor xiii fibrin scrn,85291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12.75,,,,,,,fee schedule,8.2,49.06,APC
Clot factor xiii fibrin scrn,85291,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15.94,,,,,,,fee schedule,8.2,49.06,APC
Clot factor fletcher fact,85292,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,104.52,,,,,,,fee schedule,17.04,104.52,
Clot factor fletcher fact,85292,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,83.78,,,,,,,fee schedule,17.04,104.52,
Clot factor fletcher fact,85292,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,91.52,,,,,,,fee schedule,17.04,104.52,
Clot factor fletcher fact,85292,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,96.22,,,,,,,fee schedule,17.04,104.52,
Clot factor fletcher fact,85292,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.04,,,,,,,fee schedule,17.04,104.52,Laboratory
Clot factor fletcher fact,85292,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.88,,,,,,,fee schedule,17.04,104.52,APC
Clot factor fletcher fact,85292,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,19.69,,,,,,,fee schedule,17.04,104.52,APC
Clot factor fletcher fact,85292,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18.93,,,,,,,fee schedule,17.04,104.52,APC
Clot factor fletcher fact,85292,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.96,,,,,,,fee schedule,17.04,104.52,Radiology
Clot factor fletcher fact,85292,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26.5,,,,,,,fee schedule,17.04,104.52,APC
Clot factor fletcher fact,85292,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,33.13,,,,,,,fee schedule,17.04,104.52,APC
Clot factor wght kininogen,85293,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,104.52,,,,,,,fee schedule,17.04,104.52,
Clot factor wght kininogen,85293,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,83.78,,,,,,,fee schedule,17.04,104.52,
Clot factor wght kininogen,85293,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,91.52,,,,,,,fee schedule,17.04,104.52,
Clot factor wght kininogen,85293,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,96.22,,,,,,,fee schedule,17.04,104.52,
Clot factor wght kininogen,85293,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.04,,,,,,,fee schedule,17.04,104.52,Laboratory
Clot factor wght kininogen,85293,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.88,,,,,,,fee schedule,17.04,104.52,APC
Clot factor wght kininogen,85293,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,19.69,,,,,,,fee schedule,17.04,104.52,APC
Clot factor wght kininogen,85293,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18.93,,,,,,,fee schedule,17.04,104.52,APC
Clot factor wght kininogen,85293,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.96,,,,,,,fee schedule,17.04,104.52,Radiology
Clot factor wght kininogen,85293,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26.5,,,,,,,fee schedule,17.04,104.52,APC
Clot factor wght kininogen,85293,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,33.13,,,,,,,fee schedule,17.04,104.52,APC
Antithrombin iii activity,85300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,146.04,,,,,,,fee schedule,10.66,146.04,
Antithrombin iii activity,85300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,117.07,,,,,,,fee schedule,10.66,146.04,
Antithrombin iii activity,85300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,127.88,,,,,,,fee schedule,10.66,146.04,
Antithrombin iii activity,85300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,134.45,,,,,,,fee schedule,10.66,146.04,
Antithrombin iii activity,85300,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.66,,,,,,,fee schedule,10.66,146.04,Laboratory
Antithrombin iii activity,85300,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.44,,,,,,,fee schedule,10.66,146.04,APC
Antithrombin iii activity,85300,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.32,,,,,,,fee schedule,10.66,146.04,APC
Antithrombin iii activity,85300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11.85,,,,,,,fee schedule,10.66,146.04,APC
Antithrombin iii activity,85300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.13,,,,,,,fee schedule,10.66,146.04,Radiology
Antithrombin iii activity,85300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.59,,,,,,,fee schedule,10.66,146.04,APC
Antithrombin iii activity,85300,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20.74,,,,,,,fee schedule,10.66,146.04,APC
Antithrombin iii antigen,85301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59.69,,,,,,,fee schedule,9.73,59.69,
Antithrombin iii antigen,85301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,47.84,,,,,,,fee schedule,9.73,59.69,
Antithrombin iii antigen,85301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52.26,,,,,,,fee schedule,9.73,59.69,
Antithrombin iii antigen,85301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,54.95,,,,,,,fee schedule,9.73,59.69,
Antithrombin iii antigen,85301,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.73,,,,,,,fee schedule,9.73,59.69,Laboratory
Antithrombin iii antigen,85301,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.35,,,,,,,fee schedule,9.73,59.69,APC
Antithrombin iii antigen,85301,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11.24,,,,,,,fee schedule,9.73,59.69,APC
Antithrombin iii antigen,85301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10.81,,,,,,,fee schedule,9.73,59.69,APC
Antithrombin iii antigen,85301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.54,,,,,,,fee schedule,9.73,59.69,Radiology
Antithrombin iii antigen,85301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15.13,,,,,,,fee schedule,9.73,59.69,APC
Antithrombin iii antigen,85301,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18.92,,,,,,,fee schedule,9.73,59.69,APC
Clot inhibit prot c antigen,85302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,39.24,,,,,,,fee schedule,10.81,39.24,
Clot inhibit prot c antigen,85302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31.45,,,,,,,fee schedule,10.81,39.24,
Clot inhibit prot c antigen,85302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,34.36,,,,,,,fee schedule,10.81,39.24,
Clot inhibit prot c antigen,85302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,36.13,,,,,,,fee schedule,10.81,39.24,
Clot inhibit prot c antigen,85302,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.81,,,,,,,fee schedule,10.81,39.24,Laboratory
Clot inhibit prot c antigen,85302,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.61,,,,,,,fee schedule,10.81,39.24,APC
Clot inhibit prot c antigen,85302,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.49,,,,,,,fee schedule,10.81,39.24,APC
Clot inhibit prot c antigen,85302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.01,,,,,,,fee schedule,10.81,39.24,APC
Clot inhibit prot c antigen,85302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.38,,,,,,,fee schedule,10.81,39.24,Radiology
Clot inhibit prot c antigen,85302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.81,,,,,,,fee schedule,10.81,39.24,APC
Clot inhibit prot c antigen,85302,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21.02,,,,,,,fee schedule,10.81,39.24,APC
Clot inhibit prot c activity,85303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,234.46,,,,,,,fee schedule,12.46,234.46,
Clot inhibit prot c activity,85303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,187.94,,,,,,,fee schedule,12.46,234.46,
Clot inhibit prot c activity,85303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,205.3,,,,,,,fee schedule,12.46,234.46,
Clot inhibit prot c activity,85303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,215.85,,,,,,,fee schedule,12.46,234.46,
Clot inhibit prot c activity,85303,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.46,,,,,,,fee schedule,12.46,234.46,Laboratory
Clot inhibit prot c activity,85303,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.53,,,,,,,fee schedule,12.46,234.46,APC
Clot inhibit prot c activity,85303,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,14.39,,,,,,,fee schedule,12.46,234.46,APC
Clot inhibit prot c activity,85303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.84,,,,,,,fee schedule,12.46,234.46,APC
Clot inhibit prot c activity,85303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21.18,,,,,,,fee schedule,12.46,234.46,Radiology
Clot inhibit prot c activity,85303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.38,,,,,,,fee schedule,12.46,234.46,APC
Clot inhibit prot c activity,85303,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,24.22,,,,,,,fee schedule,12.46,234.46,APC
Clot inhibit prot s total,85305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,64,,,,,,,fee schedule,10.45,64,
Clot inhibit prot s total,85305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.3,,,,,,,fee schedule,10.45,64,
Clot inhibit prot s total,85305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56.04,,,,,,,fee schedule,10.45,64,
Clot inhibit prot s total,85305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,58.92,,,,,,,fee schedule,10.45,64,
Clot inhibit prot s total,85305,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.45,,,,,,,fee schedule,10.45,64,Laboratory
Clot inhibit prot s total,85305,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.19,,,,,,,fee schedule,10.45,64,APC
Clot inhibit prot s total,85305,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.07,,,,,,,fee schedule,10.45,64,APC
Clot inhibit prot s total,85305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11.61,,,,,,,fee schedule,10.45,64,APC
Clot inhibit prot s total,85305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.76,,,,,,,fee schedule,10.45,64,Radiology
Clot inhibit prot s total,85305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.25,,,,,,,fee schedule,10.45,64,APC
Clot inhibit prot s total,85305,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20.32,,,,,,,fee schedule,10.45,64,APC
Clot inhibit prot s free,85306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,109.33,,,,,,,fee schedule,13.79,109.33,
Clot inhibit prot s free,85306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,87.64,,,,,,,fee schedule,13.79,109.33,
Clot inhibit prot s free,85306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,95.74,,,,,,,fee schedule,13.79,109.33,
Clot inhibit prot s free,85306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,100.65,,,,,,,fee schedule,13.79,109.33,
Clot inhibit prot s free,85306,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.79,,,,,,,fee schedule,13.79,109.33,Laboratory
Clot inhibit prot s free,85306,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.09,,,,,,,fee schedule,13.79,109.33,APC
Clot inhibit prot s free,85306,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,15.93,,,,,,,fee schedule,13.79,109.33,APC
Clot inhibit prot s free,85306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,15.32,,,,,,,fee schedule,13.79,109.33,APC
Clot inhibit prot s free,85306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.44,,,,,,,fee schedule,13.79,109.33,Radiology
Clot inhibit prot s free,85306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21.45,,,,,,,fee schedule,13.79,109.33,APC
Clot inhibit prot s free,85306,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,26.81,,,,,,,fee schedule,13.79,109.33,APC
Assay Activated Protein C,85307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,84.56,,,,,,,fee schedule,13.79,84.56,
Assay Activated Protein C,85307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,67.78,,,,,,,fee schedule,13.79,84.56,
Assay Activated Protein C,85307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,74.04,,,,,,,fee schedule,13.79,84.56,
Assay Activated Protein C,85307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,77.85,,,,,,,fee schedule,13.79,84.56,
Assay Activated Protein C,85307,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.79,,,,,,,fee schedule,13.79,84.56,Laboratory
Assay Activated Protein C,85307,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.09,,,,,,,fee schedule,13.79,84.56,APC
Assay Activated Protein C,85307,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,15.93,,,,,,,fee schedule,13.79,84.56,APC
Assay Activated Protein C,85307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,15.32,,,,,,,fee schedule,13.79,84.56,APC
Assay Activated Protein C,85307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.44,,,,,,,fee schedule,13.79,84.56,Radiology
Assay Activated Protein C,85307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21.45,,,,,,,fee schedule,13.79,84.56,APC
Assay Activated Protein C,85307,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,26.81,,,,,,,fee schedule,13.79,84.56,APC
Factor inhibitor test,85335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,71.06,,,,,,,fee schedule,11.58,71.06,
Factor inhibitor test,85335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56.96,,,,,,,fee schedule,11.58,71.06,
Factor inhibitor test,85335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,62.23,,,,,,,fee schedule,11.58,71.06,
Factor inhibitor test,85335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,65.42,,,,,,,fee schedule,11.58,71.06,
Factor inhibitor test,85335,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.58,,,,,,,fee schedule,11.58,71.06,Laboratory
Factor inhibitor test,85335,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.51,,,,,,,fee schedule,11.58,71.06,APC
Factor inhibitor test,85335,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.38,,,,,,,fee schedule,11.58,71.06,APC
Factor inhibitor test,85335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.87,,,,,,,fee schedule,11.58,71.06,APC
Factor inhibitor test,85335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.69,,,,,,,fee schedule,11.58,71.06,Radiology
Factor inhibitor test,85335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.02,,,,,,,fee schedule,11.58,71.06,APC
Factor inhibitor test,85335,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22.52,,,,,,,fee schedule,11.58,71.06,APC
Thrombomodulin,85337,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,57.53,,,,,,,fee schedule,15.54,57.53,
Thrombomodulin,85337,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.12,,,,,,,fee schedule,15.54,57.53,
Thrombomodulin,85337,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,50.38,,,,,,,fee schedule,15.54,57.53,
Thrombomodulin,85337,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,52.97,,,,,,,fee schedule,15.54,57.53,
Thrombomodulin,85337,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.54,,,,,,,fee schedule,15.54,57.53,Laboratory
Thrombomodulin,85337,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.13,,,,,,,fee schedule,15.54,57.53,APC
Thrombomodulin,85337,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,17.96,,,,,,,fee schedule,15.54,57.53,APC
Thrombomodulin,85337,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17.27,,,,,,,fee schedule,15.54,57.53,APC
Thrombomodulin,85337,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26.42,,,,,,,fee schedule,15.54,57.53,Radiology
Thrombomodulin,85337,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24.18,,,,,,,fee schedule,15.54,57.53,APC
Thrombomodulin,85337,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30.22,,,,,,,fee schedule,15.54,57.53,APC
Coagulation time lee & white,85345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23.74,,,,,,,fee schedule,4.22,23.74,
Coagulation time lee & white,85345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19.03,,,,,,,fee schedule,4.22,23.74,
Coagulation time lee & white,85345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20.79,,,,,,,fee schedule,4.22,23.74,
Coagulation time lee & white,85345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21.85,,,,,,,fee schedule,4.22,23.74,
Coagulation time lee & white,85345,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.22,,,,,,,fee schedule,4.22,23.74,Laboratory
Coagulation time lee & white,85345,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.92,,,,,,,fee schedule,4.22,23.74,APC
Coagulation time lee & white,85345,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4.88,,,,,,,fee schedule,4.22,23.74,APC
Coagulation time lee & white,85345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4.69,,,,,,,fee schedule,4.22,23.74,APC
Coagulation time lee & white,85345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.18,,,,,,,fee schedule,4.22,23.74,Radiology
Coagulation time lee & white,85345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.57,,,,,,,fee schedule,4.22,23.74,APC
Coagulation time lee & white,85345,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8.21,,,,,,,fee schedule,4.22,23.74,APC
Coagulation time activated,85347,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,44.42,,,,,,,fee schedule,3.85,44.42,
Coagulation time activated,85347,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35.61,,,,,,,fee schedule,3.85,44.42,
Coagulation time activated,85347,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38.9,,,,,,,fee schedule,3.85,44.42,
Coagulation time activated,85347,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,40.9,,,,,,,fee schedule,3.85,44.42,
Coagulation time activated,85347,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.85,,,,,,,fee schedule,3.85,44.42,Laboratory
Coagulation time activated,85347,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.49,,,,,,,fee schedule,3.85,44.42,APC
Coagulation time activated,85347,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4.45,,,,,,,fee schedule,3.85,44.42,APC
Coagulation time activated,85347,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4.28,,,,,,,fee schedule,3.85,44.42,APC
Coagulation time activated,85347,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.55,,,,,,,fee schedule,3.85,44.42,Radiology
Coagulation time activated,85347,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.99,,,,,,,fee schedule,3.85,44.42,APC
Coagulation time activated,85347,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7.49,,,,,,,fee schedule,3.85,44.42,APC
Coagulation time otr method,85348,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20.56,,,,,,,fee schedule,4.04,20.56,
Coagulation time otr method,85348,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.48,,,,,,,fee schedule,4.04,20.56,
Coagulation time otr method,85348,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18.01,,,,,,,fee schedule,4.04,20.56,
Coagulation time otr method,85348,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18.93,,,,,,,fee schedule,4.04,20.56,
Coagulation time otr method,85348,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.04,,,,,,,fee schedule,4.04,20.56,Laboratory
Coagulation time otr method,85348,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.71,,,,,,,fee schedule,4.04,20.56,APC
Coagulation time otr method,85348,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4.67,,,,,,,fee schedule,4.04,20.56,APC
Coagulation time otr method,85348,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4.49,,,,,,,fee schedule,4.04,20.56,APC
Coagulation time otr method,85348,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.87,,,,,,,fee schedule,4.04,20.56,Radiology
Coagulation time otr method,85348,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.29,,,,,,,fee schedule,4.04,20.56,APC
Coagulation time otr method,85348,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7.86,,,,,,,fee schedule,4.04,20.56,APC
Euglobulin lysis,85360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46.34,,,,,,,fee schedule,7.57,46.34,
Euglobulin lysis,85360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37.15,,,,,,,fee schedule,7.57,46.34,
Euglobulin lysis,85360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40.58,,,,,,,fee schedule,7.57,46.34,
Euglobulin lysis,85360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42.66,,,,,,,fee schedule,7.57,46.34,
Euglobulin lysis,85360,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.57,,,,,,,fee schedule,7.57,46.34,Laboratory
Euglobulin lysis,85360,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.83,,,,,,,fee schedule,7.57,46.34,APC
Euglobulin lysis,85360,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8.75,,,,,,,fee schedule,7.57,46.34,APC
Euglobulin lysis,85360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8.41,,,,,,,fee schedule,7.57,46.34,APC
Euglobulin lysis,85360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12.87,,,,,,,fee schedule,7.57,46.34,Radiology
Euglobulin lysis,85360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11.77,,,,,,,fee schedule,7.57,46.34,APC
Euglobulin lysis,85360,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14.72,,,,,,,fee schedule,7.57,46.34,APC
Fibrin degradation products,85362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,32.89,,,,,,,fee schedule,6.2,32.89,
Fibrin degradation products,85362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26.36,,,,,,,fee schedule,6.2,32.89,
Fibrin degradation products,85362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28.8,,,,,,,fee schedule,6.2,32.89,
Fibrin degradation products,85362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30.28,,,,,,,fee schedule,6.2,32.89,
Fibrin degradation products,85362,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.2,,,,,,,fee schedule,6.2,32.89,Laboratory
Fibrin degradation products,85362,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.23,,,,,,,fee schedule,6.2,32.89,APC
Fibrin degradation products,85362,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7.17,,,,,,,fee schedule,6.2,32.89,APC
Fibrin degradation products,85362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6.89,,,,,,,fee schedule,6.2,32.89,APC
Fibrin degradation products,85362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10.54,,,,,,,fee schedule,6.2,32.89,Radiology
Fibrin degradation products,85362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.65,,,,,,,fee schedule,6.2,32.89,APC
Fibrin degradation products,85362,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12.06,,,,,,,fee schedule,6.2,32.89,APC
Fibrinogen test,85366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,47.51,,,,,,,fee schedule,38.09,140.8,
Fibrinogen test,85366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38.09,,,,,,,fee schedule,38.09,140.8,
Fibrinogen test,85366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,41.61,,,,,,,fee schedule,38.09,140.8,
Fibrinogen test,85366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,43.74,,,,,,,fee schedule,38.09,140.8,
Fibrinogen test,85366,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,72.41,,,,,,,fee schedule,38.09,140.8,Laboratory
Fibrinogen test,85366,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,84.48,,,,,,,fee schedule,38.09,140.8,APC
Fibrinogen test,85366,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,83.68,,,,,,,fee schedule,38.09,140.8,APC
Fibrinogen test,85366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,80.46,,,,,,,fee schedule,38.09,140.8,APC
Fibrinogen test,85366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,123.1,,,,,,,fee schedule,38.09,140.8,Radiology
Fibrinogen test,85366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,112.64,,,,,,,fee schedule,38.09,140.8,APC
Fibrinogen test,85366,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,140.8,,,,,,,fee schedule,38.09,140.8,APC
Fibrinogen test,85370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,62.67,,,,,,,fee schedule,11.19,62.67,
Fibrinogen test,85370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,50.24,,,,,,,fee schedule,11.19,62.67,
Fibrinogen test,85370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,54.88,,,,,,,fee schedule,11.19,62.67,
Fibrinogen test,85370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,57.7,,,,,,,fee schedule,11.19,62.67,
Fibrinogen test,85370,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.19,,,,,,,fee schedule,11.19,62.67,Laboratory
Fibrinogen test,85370,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.05,,,,,,,fee schedule,11.19,62.67,APC
Fibrinogen test,85370,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.93,,,,,,,fee schedule,11.19,62.67,APC
Fibrinogen test,85370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.43,,,,,,,fee schedule,11.19,62.67,APC
Fibrinogen test,85370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.02,,,,,,,fee schedule,11.19,62.67,Radiology
Fibrinogen test,85370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.4,,,,,,,fee schedule,11.19,62.67,APC
Fibrinogen test,85370,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21.75,,,,,,,fee schedule,11.19,62.67,APC
Fibrin degrade semiquant,85378,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,39.35,,,,,,,fee schedule,8.75,39.35,
Fibrin degrade semiquant,85378,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31.54,,,,,,,fee schedule,8.75,39.35,
Fibrin degrade semiquant,85378,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,34.46,,,,,,,fee schedule,8.75,39.35,
Fibrin degrade semiquant,85378,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,36.23,,,,,,,fee schedule,8.75,39.35,
Fibrin degrade semiquant,85378,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.75,,,,,,,fee schedule,8.75,39.35,Laboratory
Fibrin degrade semiquant,85378,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.21,,,,,,,fee schedule,8.75,39.35,APC
Fibrin degrade semiquant,85378,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10.11,,,,,,,fee schedule,8.75,39.35,APC
Fibrin degrade semiquant,85378,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9.72,,,,,,,fee schedule,8.75,39.35,APC
Fibrin degrade semiquant,85378,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.87,,,,,,,fee schedule,8.75,39.35,Radiology
Fibrin degrade semiquant,85378,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.61,,,,,,,fee schedule,8.75,39.35,APC
Fibrin degrade semiquant,85378,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,17.01,,,,,,,fee schedule,8.75,39.35,APC
Fibrin degradation quant,85379,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,116.69,,,,,,,fee schedule,9.16,116.69,
Fibrin degradation quant,85379,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,93.54,,,,,,,fee schedule,9.16,116.69,
Fibrin degradation quant,85379,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,102.18,,,,,,,fee schedule,9.16,116.69,
Fibrin degradation quant,85379,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,107.43,,,,,,,fee schedule,9.16,116.69,
Fibrin degradation quant,85379,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.16,,,,,,,fee schedule,9.16,116.69,Laboratory
Fibrin degradation quant,85379,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.69,,,,,,,fee schedule,9.16,116.69,APC
Fibrin degradation quant,85379,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10.59,,,,,,,fee schedule,9.16,116.69,APC
Fibrin degradation quant,85379,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10.18,,,,,,,fee schedule,9.16,116.69,APC
Fibrin degradation quant,85379,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15.58,,,,,,,fee schedule,9.16,116.69,Radiology
Fibrin degradation quant,85379,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.25,,,,,,,fee schedule,9.16,116.69,APC
Fibrin degradation quant,85379,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,17.81,,,,,,,fee schedule,9.16,116.69,APC
Fibrin degradj d-dimer,85380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,56.13,,,,,,,fee schedule,9.16,56.13,
Fibrin degradj d-dimer,85380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,45,,,,,,,fee schedule,9.16,56.13,
Fibrin degradj d-dimer,85380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,49.15,,,,,,,fee schedule,9.16,56.13,
Fibrin degradj d-dimer,85380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,51.68,,,,,,,fee schedule,9.16,56.13,
Fibrin degradj d-dimer,85380,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.16,,,,,,,fee schedule,9.16,56.13,Laboratory
Fibrin degradj d-dimer,85380,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.69,,,,,,,fee schedule,9.16,56.13,APC
Fibrin degradj d-dimer,85380,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10.59,,,,,,,fee schedule,9.16,56.13,APC
Fibrin degradj d-dimer,85380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10.18,,,,,,,fee schedule,9.16,56.13,APC
Fibrin degradj d-dimer,85380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15.58,,,,,,,fee schedule,9.16,56.13,Radiology
Fibrin degradj d-dimer,85380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.25,,,,,,,fee schedule,9.16,56.13,APC
Fibrin degradj d-dimer,85380,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,17.81,,,,,,,fee schedule,9.16,56.13,APC
Fibrinogen activity,85384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83.91,,,,,,,fee schedule,8.75,83.91,
Fibrinogen activity,85384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,67.26,,,,,,,fee schedule,8.75,83.91,
Fibrinogen activity,85384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,73.48,,,,,,,fee schedule,8.75,83.91,
Fibrinogen activity,85384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,77.25,,,,,,,fee schedule,8.75,83.91,
Fibrinogen activity,85384,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.75,,,,,,,fee schedule,8.75,83.91,Laboratory
Fibrinogen activity,85384,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.21,,,,,,,fee schedule,8.75,83.91,APC
Fibrinogen activity,85384,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10.11,,,,,,,fee schedule,8.75,83.91,APC
Fibrinogen activity,85384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9.72,,,,,,,fee schedule,8.75,83.91,APC
Fibrinogen activity,85384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.87,,,,,,,fee schedule,8.75,83.91,Radiology
Fibrinogen activity,85384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.61,,,,,,,fee schedule,8.75,83.91,APC
Fibrinogen activity,85384,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,17.01,,,,,,,fee schedule,8.75,83.91,APC
Fibrinogen antigen,85385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46.87,,,,,,,fee schedule,13.01,46.87,
Fibrinogen antigen,85385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37.57,,,,,,,fee schedule,13.01,46.87,
Fibrinogen antigen,85385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,41.04,,,,,,,fee schedule,13.01,46.87,
Fibrinogen antigen,85385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,43.15,,,,,,,fee schedule,13.01,46.87,
Fibrinogen antigen,85385,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.01,,,,,,,fee schedule,13.01,46.87,Laboratory
Fibrinogen antigen,85385,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.18,,,,,,,fee schedule,13.01,46.87,APC
Fibrinogen antigen,85385,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,15.04,,,,,,,fee schedule,13.01,46.87,APC
Fibrinogen antigen,85385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14.46,,,,,,,fee schedule,13.01,46.87,APC
Fibrinogen antigen,85385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.12,,,,,,,fee schedule,13.01,46.87,Radiology
Fibrinogen antigen,85385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.24,,,,,,,fee schedule,13.01,46.87,APC
Fibrinogen antigen,85385,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,25.3,,,,,,,fee schedule,13.01,46.87,APC
Fibrinolysins screen i&r,85390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16.29,,,,,,,fee schedule,13.06,27.09,
Fibrinolysins screen i&r,85390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13.06,,,,,,,fee schedule,13.06,27.09,
Fibrinolysins screen i&r,85390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14.26,,,,,,,fee schedule,13.06,27.09,
Fibrinolysins screen i&r,85390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15,,,,,,,fee schedule,13.06,27.09,
Fibrinolysins screen i&r,85390,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.93,,,,,,,fee schedule,13.06,27.09,Laboratory
Fibrinolysins screen i&r,85390,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.25,,,,,,,fee schedule,13.06,27.09,APC
Fibrinolysins screen i&r,85390,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,16.1,,,,,,,fee schedule,13.06,27.09,APC
Fibrinolysins screen i&r,85390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,15.48,,,,,,,fee schedule,13.06,27.09,APC
Fibrinolysins screen i&r,85390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.68,,,,,,,fee schedule,13.06,27.09,Radiology
Fibrinolysins screen i&r,85390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21.67,,,,,,,fee schedule,13.06,27.09,APC
Fibrinolysins screen i&r,85390,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,27.09,,,,,,,fee schedule,13.06,27.09,APC
Clotting funct activity,85397,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,126.67,,,,,,,fee schedule,27.77,126.67,
Clotting funct activity,85397,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,101.54,,,,,,,fee schedule,27.77,126.67,
Clotting funct activity,85397,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,110.92,,,,,,,fee schedule,27.77,126.67,
Clotting funct activity,85397,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,116.61,,,,,,,fee schedule,27.77,126.67,
Clotting funct activity,85397,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,27.77,,,,,,,fee schedule,27.77,126.67,Laboratory
Clotting funct activity,85397,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,32.4,,,,,,,fee schedule,27.77,126.67,APC
Clotting funct activity,85397,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,32.09,,,,,,,fee schedule,27.77,126.67,APC
Clotting funct activity,85397,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,30.86,,,,,,,fee schedule,27.77,126.67,APC
Clotting funct activity,85397,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,47.22,,,,,,,fee schedule,27.77,126.67,Radiology
Clotting funct activity,85397,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43.2,,,,,,,fee schedule,27.77,126.67,APC
Clotting funct activity,85397,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,54,,,,,,,fee schedule,27.77,126.67,APC
Fibrinolytic plasmin,85400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,48.8,,,,,,,fee schedule,6.94,48.8,
Fibrinolytic plasmin,85400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39.12,,,,,,,fee schedule,6.94,48.8,
Fibrinolytic plasmin,85400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.73,,,,,,,fee schedule,6.94,48.8,
Fibrinolytic plasmin,85400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,44.93,,,,,,,fee schedule,6.94,48.8,
Fibrinolytic plasmin,85400,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.94,,,,,,,fee schedule,6.94,48.8,Laboratory
Fibrinolytic plasmin,85400,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.1,,,,,,,fee schedule,6.94,48.8,APC
Fibrinolytic plasmin,85400,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8.02,,,,,,,fee schedule,6.94,48.8,APC
Fibrinolytic plasmin,85400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7.71,,,,,,,fee schedule,6.94,48.8,APC
Fibrinolytic plasmin,85400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11.8,,,,,,,fee schedule,6.94,48.8,Radiology
Fibrinolytic plasmin,85400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10.79,,,,,,,fee schedule,6.94,48.8,APC
Fibrinolytic plasmin,85400,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,13.49,,,,,,,fee schedule,6.94,48.8,APC
Fibrinolytic antiplasmin,85410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42.56,,,,,,,fee schedule,6.94,42.56,
Fibrinolytic antiplasmin,85410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,34.12,,,,,,,fee schedule,6.94,42.56,
Fibrinolytic antiplasmin,85410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37.27,,,,,,,fee schedule,6.94,42.56,
Fibrinolytic antiplasmin,85410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,39.18,,,,,,,fee schedule,6.94,42.56,
Fibrinolytic antiplasmin,85410,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.94,,,,,,,fee schedule,6.94,42.56,Laboratory
Fibrinolytic antiplasmin,85410,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.1,,,,,,,fee schedule,6.94,42.56,APC
Fibrinolytic antiplasmin,85410,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8.02,,,,,,,fee schedule,6.94,42.56,APC
Fibrinolytic antiplasmin,85410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7.71,,,,,,,fee schedule,6.94,42.56,APC
Fibrinolytic antiplasmin,85410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11.8,,,,,,,fee schedule,6.94,42.56,Radiology
Fibrinolytic antiplasmin,85410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10.79,,,,,,,fee schedule,6.94,42.56,APC
Fibrinolytic antiplasmin,85410,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,13.49,,,,,,,fee schedule,6.94,42.56,APC
Fibrinolytic plasminogen,85415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,94.88,,,,,,,fee schedule,15.47,94.88,
Fibrinolytic plasminogen,85415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,76.05,,,,,,,fee schedule,15.47,94.88,
Fibrinolytic plasminogen,85415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,83.08,,,,,,,fee schedule,15.47,94.88,
Fibrinolytic plasminogen,85415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,87.35,,,,,,,fee schedule,15.47,94.88,
Fibrinolytic plasminogen,85415,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.47,,,,,,,fee schedule,15.47,94.88,Laboratory
Fibrinolytic plasminogen,85415,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.05,,,,,,,fee schedule,15.47,94.88,APC
Fibrinolytic plasminogen,85415,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,17.88,,,,,,,fee schedule,15.47,94.88,APC
Fibrinolytic plasminogen,85415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17.19,,,,,,,fee schedule,15.47,94.88,APC
Fibrinolytic plasminogen,85415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26.3,,,,,,,fee schedule,15.47,94.88,Radiology
Fibrinolytic plasminogen,85415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24.07,,,,,,,fee schedule,15.47,94.88,APC
Fibrinolytic plasminogen,85415,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30.08,,,,,,,fee schedule,15.47,94.88,APC
Fibrinolytic plasminogen,85420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20.73,,,,,,,fee schedule,5.88,20.73,
Fibrinolytic plasminogen,85420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.62,,,,,,,fee schedule,5.88,20.73,
Fibrinolytic plasminogen,85420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18.15,,,,,,,fee schedule,5.88,20.73,
Fibrinolytic plasminogen,85420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19.09,,,,,,,fee schedule,5.88,20.73,
Fibrinolytic plasminogen,85420,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.88,,,,,,,fee schedule,5.88,20.73,Laboratory
Fibrinolytic plasminogen,85420,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.86,,,,,,,fee schedule,5.88,20.73,APC
Fibrinolytic plasminogen,85420,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6.79,,,,,,,fee schedule,5.88,20.73,APC
Fibrinolytic plasminogen,85420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6.53,,,,,,,fee schedule,5.88,20.73,APC
Fibrinolytic plasminogen,85420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.99,,,,,,,fee schedule,5.88,20.73,Radiology
Fibrinolytic plasminogen,85420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.14,,,,,,,fee schedule,5.88,20.73,APC
Fibrinolytic plasminogen,85420,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11.43,,,,,,,fee schedule,5.88,20.73,APC
Fibrinolytic plasminogen,85421,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,56.21,,,,,,,fee schedule,9.16,56.21,
Fibrinolytic plasminogen,85421,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,45.06,,,,,,,fee schedule,9.16,56.21,
Fibrinolytic plasminogen,85421,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,49.22,,,,,,,fee schedule,9.16,56.21,
Fibrinolytic plasminogen,85421,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,51.75,,,,,,,fee schedule,9.16,56.21,
Fibrinolytic plasminogen,85421,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.16,,,,,,,fee schedule,9.16,56.21,Laboratory
Fibrinolytic plasminogen,85421,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.69,,,,,,,fee schedule,9.16,56.21,APC
Fibrinolytic plasminogen,85421,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10.59,,,,,,,fee schedule,9.16,56.21,APC
Fibrinolytic plasminogen,85421,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10.18,,,,,,,fee schedule,9.16,56.21,APC
Fibrinolytic plasminogen,85421,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15.58,,,,,,,fee schedule,9.16,56.21,Radiology
Fibrinolytic plasminogen,85421,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.25,,,,,,,fee schedule,9.16,56.21,APC
Fibrinolytic plasminogen,85421,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,17.81,,,,,,,fee schedule,9.16,56.21,APC
Heinz bodies direct,85441,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23.21,,,,,,,fee schedule,3.78,23.21,
Heinz bodies direct,85441,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18.6,,,,,,,fee schedule,3.78,23.21,
Heinz bodies direct,85441,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20.32,,,,,,,fee schedule,3.78,23.21,
Heinz bodies direct,85441,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21.37,,,,,,,fee schedule,3.78,23.21,
Heinz bodies direct,85441,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.78,,,,,,,fee schedule,3.78,23.21,Laboratory
Heinz bodies direct,85441,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.41,,,,,,,fee schedule,3.78,23.21,APC
Heinz bodies direct,85441,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4.37,,,,,,,fee schedule,3.78,23.21,APC
Heinz bodies direct,85441,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4.2,,,,,,,fee schedule,3.78,23.21,APC
Heinz bodies direct,85441,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.43,,,,,,,fee schedule,3.78,23.21,Radiology
Heinz bodies direct,85441,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.88,,,,,,,fee schedule,3.78,23.21,APC
Heinz bodies direct,85441,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7.35,,,,,,,fee schedule,3.78,23.21,APC
Heinz bodies induced,85445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37.61,,,,,,,fee schedule,6.14,37.61,
Heinz bodies induced,85445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,30.15,,,,,,,fee schedule,6.14,37.61,
Heinz bodies induced,85445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32.93,,,,,,,fee schedule,6.14,37.61,
Heinz bodies induced,85445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,34.63,,,,,,,fee schedule,6.14,37.61,
Heinz bodies induced,85445,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.14,,,,,,,fee schedule,6.14,37.61,Laboratory
Heinz bodies induced,85445,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.16,,,,,,,fee schedule,6.14,37.61,APC
Heinz bodies induced,85445,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7.09,,,,,,,fee schedule,6.14,37.61,APC
Heinz bodies induced,85445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6.82,,,,,,,fee schedule,6.14,37.61,APC
Heinz bodies induced,85445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10.43,,,,,,,fee schedule,6.14,37.61,Radiology
Heinz bodies induced,85445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.55,,,,,,,fee schedule,6.14,37.61,APC
Heinz bodies induced,85445,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11.94,,,,,,,fee schedule,6.14,37.61,APC
Hemoglobin fetal,85460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,162.15,,,,,,,fee schedule,6.96,162.15,
Hemoglobin fetal,85460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,129.97,,,,,,,fee schedule,6.96,162.15,
Hemoglobin fetal,85460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,141.98,,,,,,,fee schedule,6.96,162.15,
Hemoglobin fetal,85460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,149.28,,,,,,,fee schedule,6.96,162.15,
Hemoglobin fetal,85460,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.96,,,,,,,fee schedule,6.96,162.15,Laboratory
Hemoglobin fetal,85460,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.12,,,,,,,fee schedule,6.96,162.15,APC
Hemoglobin fetal,85460,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8.04,,,,,,,fee schedule,6.96,162.15,APC
Hemoglobin fetal,85460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7.73,,,,,,,fee schedule,6.96,162.15,APC
Hemoglobin fetal,85460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11.83,,,,,,,fee schedule,6.96,162.15,Radiology
Hemoglobin fetal,85460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10.82,,,,,,,fee schedule,6.96,162.15,APC
Hemoglobin fetal,85460,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,13.53,,,,,,,fee schedule,6.96,162.15,APC
Hemoglobin fetal,85461,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,48.13,,,,,,,fee schedule,8.42,48.13,
Hemoglobin fetal,85461,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38.58,,,,,,,fee schedule,8.42,48.13,
Hemoglobin fetal,85461,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.14,,,,,,,fee schedule,8.42,48.13,
Hemoglobin fetal,85461,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,44.31,,,,,,,fee schedule,8.42,48.13,
Hemoglobin fetal,85461,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.42,,,,,,,fee schedule,8.42,48.13,Laboratory
Hemoglobin fetal,85461,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.83,,,,,,,fee schedule,8.42,48.13,APC
Hemoglobin fetal,85461,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9.73,,,,,,,fee schedule,8.42,48.13,APC
Hemoglobin fetal,85461,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9.36,,,,,,,fee schedule,8.42,48.13,APC
Hemoglobin fetal,85461,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.32,,,,,,,fee schedule,8.42,48.13,Radiology
Hemoglobin fetal,85461,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.1,,,,,,,fee schedule,8.42,48.13,APC
Hemoglobin fetal,85461,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16.38,,,,,,,fee schedule,8.42,48.13,APC
Hemolysin acid,85475,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,48.95,,,,,,,fee schedule,7.98,48.95,
Hemolysin acid,85475,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39.24,,,,,,,fee schedule,7.98,48.95,
Hemolysin acid,85475,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.86,,,,,,,fee schedule,7.98,48.95,
Hemolysin acid,85475,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45.07,,,,,,,fee schedule,7.98,48.95,
Hemolysin acid,85475,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.98,,,,,,,fee schedule,7.98,48.95,Laboratory
Hemolysin acid,85475,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.31,,,,,,,fee schedule,7.98,48.95,APC
Hemolysin acid,85475,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9.22,,,,,,,fee schedule,7.98,48.95,APC
Hemolysin acid,85475,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8.87,,,,,,,fee schedule,7.98,48.95,APC
Hemolysin acid,85475,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.57,,,,,,,fee schedule,7.98,48.95,Radiology
Hemolysin acid,85475,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12.42,,,,,,,fee schedule,7.98,48.95,APC
Hemolysin acid,85475,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15.52,,,,,,,fee schedule,7.98,48.95,APC
Heparin assay,85520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,63.67,,,,,,,fee schedule,11.78,63.67,
Heparin assay,85520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.04,,,,,,,fee schedule,11.78,63.67,
Heparin assay,85520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55.76,,,,,,,fee schedule,11.78,63.67,
Heparin assay,85520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,58.62,,,,,,,fee schedule,11.78,63.67,
Heparin assay,85520,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.78,,,,,,,fee schedule,11.78,63.67,Laboratory
Heparin assay,85520,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.74,,,,,,,fee schedule,11.78,63.67,APC
Heparin assay,85520,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.61,,,,,,,fee schedule,11.78,63.67,APC
Heparin assay,85520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.09,,,,,,,fee schedule,11.78,63.67,APC
Heparin assay,85520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.03,,,,,,,fee schedule,11.78,63.67,Radiology
Heparin assay,85520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.33,,,,,,,fee schedule,11.78,63.67,APC
Heparin assay,85520,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22.91,,,,,,,fee schedule,11.78,63.67,APC
Heparin neutralization,85525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,65.39,,,,,,,fee schedule,10.66,65.39,
Heparin neutralization,85525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52.42,,,,,,,fee schedule,10.66,65.39,
Heparin neutralization,85525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.26,,,,,,,fee schedule,10.66,65.39,
Heparin neutralization,85525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.2,,,,,,,fee schedule,10.66,65.39,
Heparin neutralization,85525,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.66,,,,,,,fee schedule,10.66,65.39,Laboratory
Heparin neutralization,85525,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.43,,,,,,,fee schedule,10.66,65.39,APC
Heparin neutralization,85525,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.31,,,,,,,fee schedule,10.66,65.39,APC
Heparin neutralization,85525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11.84,,,,,,,fee schedule,10.66,65.39,APC
Heparin neutralization,85525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.12,,,,,,,fee schedule,10.66,65.39,Radiology
Heparin neutralization,85525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.58,,,,,,,fee schedule,10.66,65.39,APC
Heparin neutralization,85525,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20.72,,,,,,,fee schedule,10.66,65.39,APC
Heparin-protamine tolerance,85530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,78.25,,,,,,,fee schedule,11.78,78.25,
Heparin-protamine tolerance,85530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,62.72,,,,,,,fee schedule,11.78,78.25,
Heparin-protamine tolerance,85530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,68.52,,,,,,,fee schedule,11.78,78.25,
Heparin-protamine tolerance,85530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,72.04,,,,,,,fee schedule,11.78,78.25,
Heparin-protamine tolerance,85530,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.78,,,,,,,fee schedule,11.78,78.25,Laboratory
Heparin-protamine tolerance,85530,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.74,,,,,,,fee schedule,11.78,78.25,APC
Heparin-protamine tolerance,85530,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.61,,,,,,,fee schedule,11.78,78.25,APC
Heparin-protamine tolerance,85530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.09,,,,,,,fee schedule,11.78,78.25,APC
Heparin-protamine tolerance,85530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.03,,,,,,,fee schedule,11.78,78.25,Radiology
Heparin-protamine tolerance,85530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.33,,,,,,,fee schedule,11.78,78.25,APC
Heparin-protamine tolerance,85530,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22.91,,,,,,,fee schedule,11.78,78.25,APC
Iron Stain Peripheral Blood,85536,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,35.72,,,,,,,fee schedule,6.19,35.72,
Iron Stain Peripheral Blood,85536,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28.63,,,,,,,fee schedule,6.19,35.72,
Iron Stain Peripheral Blood,85536,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31.28,,,,,,,fee schedule,6.19,35.72,
Iron Stain Peripheral Blood,85536,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,32.89,,,,,,,fee schedule,6.19,35.72,
Iron Stain Peripheral Blood,85536,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.19,,,,,,,fee schedule,6.19,35.72,Laboratory
Iron Stain Peripheral Blood,85536,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.22,,,,,,,fee schedule,6.19,35.72,APC
Iron Stain Peripheral Blood,85536,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7.16,,,,,,,fee schedule,6.19,35.72,APC
Iron Stain Peripheral Blood,85536,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6.88,,,,,,,fee schedule,6.19,35.72,APC
Iron Stain Peripheral Blood,85536,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10.53,,,,,,,fee schedule,6.19,35.72,Radiology
Iron Stain Peripheral Blood,85536,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.63,,,,,,,fee schedule,6.19,35.72,APC
Iron Stain Peripheral Blood,85536,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12.04,,,,,,,fee schedule,6.19,35.72,APC
Wbc alkaline phosphatase,85540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,47.48,,,,,,,fee schedule,7.74,47.48,
Wbc alkaline phosphatase,85540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38.06,,,,,,,fee schedule,7.74,47.48,
Wbc alkaline phosphatase,85540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,41.57,,,,,,,fee schedule,7.74,47.48,
Wbc alkaline phosphatase,85540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,43.71,,,,,,,fee schedule,7.74,47.48,
Wbc alkaline phosphatase,85540,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.74,,,,,,,fee schedule,7.74,47.48,Laboratory
Wbc alkaline phosphatase,85540,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.03,,,,,,,fee schedule,7.74,47.48,APC
Wbc alkaline phosphatase,85540,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8.94,,,,,,,fee schedule,7.74,47.48,APC
Wbc alkaline phosphatase,85540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8.6,,,,,,,fee schedule,7.74,47.48,APC
Wbc alkaline phosphatase,85540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.16,,,,,,,fee schedule,7.74,47.48,Radiology
Wbc alkaline phosphatase,85540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12.04,,,,,,,fee schedule,7.74,47.48,APC
Wbc alkaline phosphatase,85540,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15.05,,,,,,,fee schedule,7.74,47.48,APC
RBC mechanical fragility,85547,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,47.48,,,,,,,fee schedule,7.74,47.48,
RBC mechanical fragility,85547,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38.06,,,,,,,fee schedule,7.74,47.48,
RBC mechanical fragility,85547,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,41.57,,,,,,,fee schedule,7.74,47.48,
RBC mechanical fragility,85547,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,43.71,,,,,,,fee schedule,7.74,47.48,
RBC mechanical fragility,85547,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.74,,,,,,,fee schedule,7.74,47.48,Laboratory
RBC mechanical fragility,85547,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.03,,,,,,,fee schedule,7.74,47.48,APC
RBC mechanical fragility,85547,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8.94,,,,,,,fee schedule,7.74,47.48,APC
RBC mechanical fragility,85547,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8.6,,,,,,,fee schedule,7.74,47.48,APC
RBC mechanical fragility,85547,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.16,,,,,,,fee schedule,7.74,47.48,Radiology
RBC mechanical fragility,85547,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12.04,,,,,,,fee schedule,7.74,47.48,APC
RBC mechanical fragility,85547,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15.05,,,,,,,fee schedule,7.74,47.48,APC
Muramidase,85549,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,103.53,,,,,,,fee schedule,16.88,103.53,
Muramidase,85549,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,82.99,,,,,,,fee schedule,16.88,103.53,
Muramidase,85549,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,90.66,,,,,,,fee schedule,16.88,103.53,
Muramidase,85549,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,95.32,,,,,,,fee schedule,16.88,103.53,
Muramidase,85549,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.88,,,,,,,fee schedule,16.88,103.53,Laboratory
Muramidase,85549,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.69,,,,,,,fee schedule,16.88,103.53,APC
Muramidase,85549,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,19.5,,,,,,,fee schedule,16.88,103.53,APC
Muramidase,85549,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18.75,,,,,,,fee schedule,16.88,103.53,APC
Muramidase,85549,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.69,,,,,,,fee schedule,16.88,103.53,Radiology
Muramidase,85549,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26.25,,,,,,,fee schedule,16.88,103.53,APC
Muramidase,85549,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,32.81,,,,,,,fee schedule,16.88,103.53,APC
RBC osmotic fragility,85555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,32.58,,,,,,,fee schedule,6.72,32.58,
RBC osmotic fragility,85555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26.11,,,,,,,fee schedule,6.72,32.58,
RBC osmotic fragility,85555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28.53,,,,,,,fee schedule,6.72,32.58,
RBC osmotic fragility,85555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,29.99,,,,,,,fee schedule,6.72,32.58,
RBC osmotic fragility,85555,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.72,,,,,,,fee schedule,6.72,32.58,Laboratory
RBC osmotic fragility,85555,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.84,,,,,,,fee schedule,6.72,32.58,APC
RBC osmotic fragility,85555,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7.77,,,,,,,fee schedule,6.72,32.58,APC
RBC osmotic fragility,85555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7.47,,,,,,,fee schedule,6.72,32.58,APC
RBC osmotic fragility,85555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11.43,,,,,,,fee schedule,6.72,32.58,Radiology
RBC osmotic fragility,85555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10.46,,,,,,,fee schedule,6.72,32.58,APC
RBC osmotic fragility,85555,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,13.07,,,,,,,fee schedule,6.72,32.58,APC
RBC osmotic fragility,85557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,73.71,,,,,,,fee schedule,12.02,73.71,
RBC osmotic fragility,85557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,59.09,,,,,,,fee schedule,12.02,73.71,
RBC osmotic fragility,85557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,64.55,,,,,,,fee schedule,12.02,73.71,
RBC osmotic fragility,85557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,67.86,,,,,,,fee schedule,12.02,73.71,
RBC osmotic fragility,85557,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.02,,,,,,,fee schedule,12.02,73.71,Laboratory
RBC osmotic fragility,85557,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.03,,,,,,,fee schedule,12.02,73.71,APC
RBC osmotic fragility,85557,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.89,,,,,,,fee schedule,12.02,73.71,APC
RBC osmotic fragility,85557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.36,,,,,,,fee schedule,12.02,73.71,APC
RBC osmotic fragility,85557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.44,,,,,,,fee schedule,12.02,73.71,Radiology
RBC osmotic fragility,85557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.7,,,,,,,fee schedule,12.02,73.71,APC
RBC osmotic fragility,85557,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23.38,,,,,,,fee schedule,12.02,73.71,APC
Blood platelet aggregation,85576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,442.38,,,,,,,fee schedule,22.42,442.38,
Blood platelet aggregation,85576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,354.61,,,,,,,fee schedule,22.42,442.38,
Blood platelet aggregation,85576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,387.38,,,,,,,fee schedule,22.42,442.38,
Blood platelet aggregation,85576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,407.27,,,,,,,fee schedule,22.42,442.38,
Blood platelet aggregation,85576,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22.42,,,,,,,fee schedule,22.42,442.38,Laboratory
Blood platelet aggregation,85576,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,26.16,,,,,,,fee schedule,22.42,442.38,APC
Blood platelet aggregation,85576,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,25.91,,,,,,,fee schedule,22.42,442.38,APC
Blood platelet aggregation,85576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,24.91,,,,,,,fee schedule,22.42,442.38,APC
Blood platelet aggregation,85576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,38.11,,,,,,,fee schedule,22.42,442.38,Radiology
Blood platelet aggregation,85576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,34.87,,,,,,,fee schedule,22.42,442.38,APC
Blood platelet aggregation,85576,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,43.59,,,,,,,fee schedule,22.42,442.38,APC
Phospholipid pltlt neutraliz,85597,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,56.86,,,,,,,fee schedule,16.18,56.86,
Phospholipid pltlt neutraliz,85597,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,45.58,,,,,,,fee schedule,16.18,56.86,
Phospholipid pltlt neutraliz,85597,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,49.79,,,,,,,fee schedule,16.18,56.86,
Phospholipid pltlt neutraliz,85597,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,52.35,,,,,,,fee schedule,16.18,56.86,
Phospholipid pltlt neutraliz,85597,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.18,,,,,,,fee schedule,16.18,56.86,Laboratory
Phospholipid pltlt neutraliz,85597,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.88,,,,,,,fee schedule,16.18,56.86,APC
Phospholipid pltlt neutraliz,85597,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18.7,,,,,,,fee schedule,16.18,56.86,APC
Phospholipid pltlt neutraliz,85597,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17.98,,,,,,,fee schedule,16.18,56.86,APC
Phospholipid pltlt neutraliz,85597,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27.51,,,,,,,fee schedule,16.18,56.86,Radiology
Phospholipid pltlt neutraliz,85597,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.17,,,,,,,fee schedule,16.18,56.86,APC
Phospholipid pltlt neutraliz,85597,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31.46,,,,,,,fee schedule,16.18,56.86,APC
Hexagnal phosph pltlt neutrl,85598,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.18,,,,,,,fee schedule,16.18,31.46,Laboratory
Hexagnal phosph pltlt neutrl,85598,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.88,,,,,,,fee schedule,16.18,31.46,APC
Hexagnal phosph pltlt neutrl,85598,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18.7,,,,,,,fee schedule,16.18,31.46,APC
Hexagnal phosph pltlt neutrl,85598,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17.98,,,,,,,fee schedule,16.18,31.46,APC
Hexagnal phosph pltlt neutrl,85598,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27.51,,,,,,,fee schedule,16.18,31.46,Radiology
Hexagnal phosph pltlt neutrl,85598,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.17,,,,,,,fee schedule,16.18,31.46,APC
Hexagnal phosph pltlt neutrl,85598,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31.46,,,,,,,fee schedule,16.18,31.46,APC
Prothrombin time,85610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41.45,,,,,,,fee schedule,3.86,41.45,
Prothrombin time,85610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,33.23,,,,,,,fee schedule,3.86,41.45,
Prothrombin time,85610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36.3,,,,,,,fee schedule,3.86,41.45,
Prothrombin time,85610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,38.16,,,,,,,fee schedule,3.86,41.45,
Prothrombin time,85610,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.86,,,,,,,fee schedule,3.86,41.45,Laboratory
Prothrombin time,85610,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.5,,,,,,,fee schedule,3.86,41.45,APC
Prothrombin time,85610,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4.46,,,,,,,fee schedule,3.86,41.45,APC
Prothrombin time,85610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4.29,,,,,,,fee schedule,3.86,41.45,APC
Prothrombin time,85610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.56,,,,,,,fee schedule,3.86,41.45,Radiology
Prothrombin time,85610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.01,,,,,,,fee schedule,3.86,41.45,APC
Prothrombin time,85610,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7.51,,,,,,,fee schedule,3.86,41.45,APC
Prothrombin test,85611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21.74,,,,,,,fee schedule,3.55,21.74,
Prothrombin test,85611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17.42,,,,,,,fee schedule,3.55,21.74,
Prothrombin test,85611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19.03,,,,,,,fee schedule,3.55,21.74,
Prothrombin test,85611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20.01,,,,,,,fee schedule,3.55,21.74,
Prothrombin test,85611,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.55,,,,,,,fee schedule,3.55,21.74,Laboratory
Prothrombin test,85611,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.14,,,,,,,fee schedule,3.55,21.74,APC
Prothrombin test,85611,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4.1,,,,,,,fee schedule,3.55,21.74,APC
Prothrombin test,85611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3.94,,,,,,,fee schedule,3.55,21.74,APC
Prothrombin test,85611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.03,,,,,,,fee schedule,3.55,21.74,Radiology
Prothrombin test,85611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.52,,,,,,,fee schedule,3.55,21.74,APC
Prothrombin test,85611,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6.9,,,,,,,fee schedule,3.55,21.74,APC
Viper venom prothrombin time,85612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,52.81,,,,,,,fee schedule,15.74,52.81,
Viper venom prothrombin time,85612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.33,,,,,,,fee schedule,15.74,52.81,
Viper venom prothrombin time,85612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.24,,,,,,,fee schedule,15.74,52.81,
Viper venom prothrombin time,85612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,48.62,,,,,,,fee schedule,15.74,52.81,
Viper venom prothrombin time,85612,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.74,,,,,,,fee schedule,15.74,52.81,Laboratory
Viper venom prothrombin time,85612,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.36,,,,,,,fee schedule,15.74,52.81,APC
Viper venom prothrombin time,85612,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18.19,,,,,,,fee schedule,15.74,52.81,APC
Viper venom prothrombin time,85612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17.49,,,,,,,fee schedule,15.74,52.81,APC
Viper venom prothrombin time,85612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26.76,,,,,,,fee schedule,15.74,52.81,Radiology
Viper venom prothrombin time,85612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24.49,,,,,,,fee schedule,15.74,52.81,APC
Viper venom prothrombin time,85612,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30.61,,,,,,,fee schedule,15.74,52.81,APC
Russell viper venom diluted,85613,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,146.07,,,,,,,fee schedule,8.62,146.07,
Russell viper venom diluted,85613,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,117.09,,,,,,,fee schedule,8.62,146.07,
Russell viper venom diluted,85613,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,127.91,,,,,,,fee schedule,8.62,146.07,
Russell viper venom diluted,85613,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,134.48,,,,,,,fee schedule,8.62,146.07,
Russell viper venom diluted,85613,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.62,,,,,,,fee schedule,8.62,146.07,Laboratory
Russell viper venom diluted,85613,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.06,,,,,,,fee schedule,8.62,146.07,APC
Russell viper venom diluted,85613,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9.96,,,,,,,fee schedule,8.62,146.07,APC
Russell viper venom diluted,85613,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9.58,,,,,,,fee schedule,8.62,146.07,APC
Russell viper venom diluted,85613,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.66,,,,,,,fee schedule,8.62,146.07,Radiology
Russell viper venom diluted,85613,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.41,,,,,,,fee schedule,8.62,146.07,APC
Russell viper venom diluted,85613,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16.76,,,,,,,fee schedule,8.62,146.07,APC
Reptilase test,85635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,54.36,,,,,,,fee schedule,8.86,54.36,
Reptilase test,85635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,43.57,,,,,,,fee schedule,8.86,54.36,
Reptilase test,85635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,47.6,,,,,,,fee schedule,8.86,54.36,
Reptilase test,85635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,50.04,,,,,,,fee schedule,8.86,54.36,
Reptilase test,85635,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.86,,,,,,,fee schedule,8.86,54.36,Laboratory
Reptilase test,85635,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.34,,,,,,,fee schedule,8.86,54.36,APC
Reptilase test,85635,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10.24,,,,,,,fee schedule,8.86,54.36,APC
Reptilase test,85635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9.85,,,,,,,fee schedule,8.86,54.36,APC
Reptilase test,85635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15.07,,,,,,,fee schedule,8.86,54.36,Radiology
Reptilase test,85635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.79,,,,,,,fee schedule,8.86,54.36,APC
Reptilase test,85635,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,17.24,,,,,,,fee schedule,8.86,54.36,APC
Rbc sed rate nonautomated,85651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,40.77,,,,,,,fee schedule,3.84,40.77,
Rbc sed rate nonautomated,85651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32.68,,,,,,,fee schedule,3.84,40.77,
Rbc sed rate nonautomated,85651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35.7,,,,,,,fee schedule,3.84,40.77,
Rbc sed rate nonautomated,85651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37.54,,,,,,,fee schedule,3.84,40.77,
Rbc sed rate nonautomated,85651,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.84,,,,,,,fee schedule,3.84,40.77,Laboratory
Rbc sed rate nonautomated,85651,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.48,,,,,,,fee schedule,3.84,40.77,APC
Rbc sed rate nonautomated,85651,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4.44,,,,,,,fee schedule,3.84,40.77,APC
Rbc sed rate nonautomated,85651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4.27,,,,,,,fee schedule,3.84,40.77,APC
Rbc sed rate nonautomated,85651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.53,,,,,,,fee schedule,3.84,40.77,Radiology
Rbc sed rate nonautomated,85651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.98,,,,,,,fee schedule,3.84,40.77,APC
Rbc sed rate nonautomated,85651,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7.47,,,,,,,fee schedule,3.84,40.77,APC
Rbc sed rate automated,85652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,56.04,,,,,,,fee schedule,2.43,56.04,
Rbc sed rate automated,85652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,44.92,,,,,,,fee schedule,2.43,56.04,
Rbc sed rate automated,85652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,49.07,,,,,,,fee schedule,2.43,56.04,
Rbc sed rate automated,85652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,51.59,,,,,,,fee schedule,2.43,56.04,
Rbc sed rate automated,85652,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2.43,,,,,,,fee schedule,2.43,56.04,Laboratory
Rbc sed rate automated,85652,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2.84,,,,,,,fee schedule,2.43,56.04,APC
Rbc sed rate automated,85652,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2.81,,,,,,,fee schedule,2.43,56.04,APC
Rbc sed rate automated,85652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2.7,,,,,,,fee schedule,2.43,56.04,APC
Rbc sed rate automated,85652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4.13,,,,,,,fee schedule,2.43,56.04,Radiology
Rbc sed rate automated,85652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3.78,,,,,,,fee schedule,2.43,56.04,APC
Rbc sed rate automated,85652,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4.73,,,,,,,fee schedule,2.43,56.04,APC
RBC sickle cell test,85660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30.47,,,,,,,fee schedule,4.96,30.47,
RBC sickle cell test,85660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24.42,,,,,,,fee schedule,4.96,30.47,
RBC sickle cell test,85660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26.68,,,,,,,fee schedule,4.96,30.47,
RBC sickle cell test,85660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,28.05,,,,,,,fee schedule,4.96,30.47,
RBC sickle cell test,85660,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.96,,,,,,,fee schedule,4.96,30.47,Laboratory
RBC sickle cell test,85660,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.79,,,,,,,fee schedule,4.96,30.47,APC
RBC sickle cell test,85660,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5.73,,,,,,,fee schedule,4.96,30.47,APC
RBC sickle cell test,85660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5.51,,,,,,,fee schedule,4.96,30.47,APC
RBC sickle cell test,85660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8.43,,,,,,,fee schedule,4.96,30.47,Radiology
RBC sickle cell test,85660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.71,,,,,,,fee schedule,4.96,30.47,APC
RBC sickle cell test,85660,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9.64,,,,,,,fee schedule,4.96,30.47,APC
Thrombin time plasma,85670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,86.63,,,,,,,fee schedule,5.19,86.63,
Thrombin time plasma,85670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,69.44,,,,,,,fee schedule,5.19,86.63,
Thrombin time plasma,85670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,75.85,,,,,,,fee schedule,5.19,86.63,
Thrombin time plasma,85670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,79.75,,,,,,,fee schedule,5.19,86.63,
Thrombin time plasma,85670,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.19,,,,,,,fee schedule,5.19,86.63,Laboratory
Thrombin time plasma,85670,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.06,,,,,,,fee schedule,5.19,86.63,APC
Thrombin time plasma,85670,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6,,,,,,,fee schedule,5.19,86.63,APC
Thrombin time plasma,85670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5.77,,,,,,,fee schedule,5.19,86.63,APC
Thrombin time plasma,85670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8.83,,,,,,,fee schedule,5.19,86.63,Radiology
Thrombin time plasma,85670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8.08,,,,,,,fee schedule,5.19,86.63,APC
Thrombin time plasma,85670,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10.1,,,,,,,fee schedule,5.19,86.63,APC
Thrombin time titer,85675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37.8,,,,,,,fee schedule,6.16,37.8,
Thrombin time titer,85675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,30.3,,,,,,,fee schedule,6.16,37.8,
Thrombin time titer,85675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,33.1,,,,,,,fee schedule,6.16,37.8,
Thrombin time titer,85675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,34.8,,,,,,,fee schedule,6.16,37.8,
Thrombin time titer,85675,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.16,,,,,,,fee schedule,6.16,37.8,Laboratory
Thrombin time titer,85675,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.19,,,,,,,fee schedule,6.16,37.8,APC
Thrombin time titer,85675,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7.12,,,,,,,fee schedule,6.16,37.8,APC
Thrombin time titer,85675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6.85,,,,,,,fee schedule,6.16,37.8,APC
Thrombin time titer,85675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10.48,,,,,,,fee schedule,6.16,37.8,Radiology
Thrombin time titer,85675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.59,,,,,,,fee schedule,6.16,37.8,APC
Thrombin time titer,85675,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11.99,,,,,,,fee schedule,6.16,37.8,APC
Thromboplastin inhibition,85705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,53.15,,,,,,,fee schedule,8.67,53.15,
Thromboplastin inhibition,85705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.6,,,,,,,fee schedule,8.67,53.15,
Thromboplastin inhibition,85705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.54,,,,,,,fee schedule,8.67,53.15,
Thromboplastin inhibition,85705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,48.93,,,,,,,fee schedule,8.67,53.15,
Thromboplastin inhibition,85705,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.67,,,,,,,fee schedule,8.67,53.15,Laboratory
Thromboplastin inhibition,85705,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.11,,,,,,,fee schedule,8.67,53.15,APC
Thromboplastin inhibition,85705,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10.02,,,,,,,fee schedule,8.67,53.15,APC
Thromboplastin inhibition,85705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9.63,,,,,,,fee schedule,8.67,53.15,APC
Thromboplastin inhibition,85705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.73,,,,,,,fee schedule,8.67,53.15,Radiology
Thromboplastin inhibition,85705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.48,,,,,,,fee schedule,8.67,53.15,APC
Thromboplastin inhibition,85705,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16.85,,,,,,,fee schedule,8.67,53.15,APC
Thromboplastin time partial,85730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,57.42,,,,,,,fee schedule,5.41,57.42,
Thromboplastin time partial,85730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.03,,,,,,,fee schedule,5.41,57.42,
Thromboplastin time partial,85730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,50.28,,,,,,,fee schedule,5.41,57.42,
Thromboplastin time partial,85730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,52.86,,,,,,,fee schedule,5.41,57.42,
Thromboplastin time partial,85730,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.41,,,,,,,fee schedule,5.41,57.42,Laboratory
Thromboplastin time partial,85730,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.31,,,,,,,fee schedule,5.41,57.42,APC
Thromboplastin time partial,85730,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6.25,,,,,,,fee schedule,5.41,57.42,APC
Thromboplastin time partial,85730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6.01,,,,,,,fee schedule,5.41,57.42,APC
Thromboplastin time partial,85730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.2,,,,,,,fee schedule,5.41,57.42,Radiology
Thromboplastin time partial,85730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8.41,,,,,,,fee schedule,5.41,57.42,APC
Thromboplastin time partial,85730,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10.52,,,,,,,fee schedule,5.41,57.42,APC
Thromboplastin time partial,85732,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,35.72,,,,,,,fee schedule,5.82,35.72,
Thromboplastin time partial,85732,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28.63,,,,,,,fee schedule,5.82,35.72,
Thromboplastin time partial,85732,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31.28,,,,,,,fee schedule,5.82,35.72,
Thromboplastin time partial,85732,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,32.89,,,,,,,fee schedule,5.82,35.72,
Thromboplastin time partial,85732,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.82,,,,,,,fee schedule,5.82,35.72,Laboratory
Thromboplastin time partial,85732,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.79,,,,,,,fee schedule,5.82,35.72,APC
Thromboplastin time partial,85732,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6.73,,,,,,,fee schedule,5.82,35.72,APC
Thromboplastin time partial,85732,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6.47,,,,,,,fee schedule,5.82,35.72,APC
Thromboplastin time partial,85732,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.9,,,,,,,fee schedule,5.82,35.72,Radiology
Thromboplastin time partial,85732,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.06,,,,,,,fee schedule,5.82,35.72,APC
Thromboplastin time partial,85732,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11.32,,,,,,,fee schedule,5.82,35.72,APC
Blood viscosity examination,85810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,144.38,,,,,,,fee schedule,10.5,144.38,
Blood viscosity examination,85810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,115.73,,,,,,,fee schedule,10.5,144.38,
Blood viscosity examination,85810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,126.42,,,,,,,fee schedule,10.5,144.38,
Blood viscosity examination,85810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,132.92,,,,,,,fee schedule,10.5,144.38,
Blood viscosity examination,85810,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.5,,,,,,,fee schedule,10.5,144.38,Laboratory
Blood viscosity examination,85810,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.25,,,,,,,fee schedule,10.5,144.38,APC
Blood viscosity examination,85810,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.14,,,,,,,fee schedule,10.5,144.38,APC
Blood viscosity examination,85810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11.67,,,,,,,fee schedule,10.5,144.38,APC
Blood viscosity examination,85810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.86,,,,,,,fee schedule,10.5,144.38,Radiology
Blood viscosity examination,85810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.34,,,,,,,fee schedule,10.5,144.38,APC
Blood viscosity examination,85810,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20.42,,,,,,,fee schedule,10.5,144.38,APC
Agglutinins febrile antigen,86000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,38.52,,,,,,,fee schedule,6.28,38.52,
Agglutinins febrile antigen,86000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,30.88,,,,,,,fee schedule,6.28,38.52,
Agglutinins febrile antigen,86000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,33.73,,,,,,,fee schedule,6.28,38.52,
Agglutinins febrile antigen,86000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,35.46,,,,,,,fee schedule,6.28,38.52,
Agglutinins febrile antigen,86000,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.28,,,,,,,fee schedule,6.28,38.52,Laboratory
Agglutinins febrile antigen,86000,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.33,,,,,,,fee schedule,6.28,38.52,APC
Agglutinins febrile antigen,86000,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7.26,,,,,,,fee schedule,6.28,38.52,APC
Agglutinins febrile antigen,86000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6.98,,,,,,,fee schedule,6.28,38.52,APC
Agglutinins febrile antigen,86000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10.68,,,,,,,fee schedule,6.28,38.52,Radiology
Agglutinins febrile antigen,86000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.77,,,,,,,fee schedule,6.28,38.52,APC
Agglutinins febrile antigen,86000,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12.22,,,,,,,fee schedule,6.28,38.52,APC
Allergen Specific Igg,86001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16.29,,,,,,,fee schedule,7.04,16.29,
Allergen Specific Igg,86001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13.06,,,,,,,fee schedule,7.04,16.29,
Allergen Specific Igg,86001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14.26,,,,,,,fee schedule,7.04,16.29,
Allergen Specific Igg,86001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15,,,,,,,fee schedule,7.04,16.29,
Allergen Specific Igg,86001,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.04,,,,,,,fee schedule,7.04,16.29,Laboratory
Allergen Specific Igg,86001,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.21,,,,,,,fee schedule,7.04,16.29,APC
Allergen Specific Igg,86001,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8.13,,,,,,,fee schedule,7.04,16.29,APC
Allergen Specific Igg,86001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7.82,,,,,,,fee schedule,7.04,16.29,APC
Allergen Specific Igg,86001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11.96,,,,,,,fee schedule,7.04,16.29,Radiology
Allergen Specific Igg,86001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10.95,,,,,,,fee schedule,7.04,16.29,APC
Allergen Specific Igg,86001,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,13.68,,,,,,,fee schedule,7.04,16.29,APC
Allergen specific IgE,86003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,34.72,,,,,,,fee schedule,4.7,34.72,
Allergen specific IgE,86003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,27.83,,,,,,,fee schedule,4.7,34.72,
Allergen specific IgE,86003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,30.4,,,,,,,fee schedule,4.7,34.72,
Allergen specific IgE,86003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,31.96,,,,,,,fee schedule,4.7,34.72,
Allergen specific IgE,86003,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.7,,,,,,,fee schedule,4.7,34.72,Laboratory
Allergen specific IgE,86003,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.48,,,,,,,fee schedule,4.7,34.72,APC
Allergen specific IgE,86003,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5.43,,,,,,,fee schedule,4.7,34.72,APC
Allergen specific IgE,86003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5.22,,,,,,,fee schedule,4.7,34.72,APC
Allergen specific IgE,86003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.99,,,,,,,fee schedule,4.7,34.72,Radiology
Allergen specific IgE,86003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.31,,,,,,,fee schedule,4.7,34.72,APC
Allergen specific IgE,86003,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9.14,,,,,,,fee schedule,4.7,34.72,APC
Allergen specific IgE,86005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,44,,,,,,,fee schedule,7.17,44,
Allergen specific IgE,86005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35.27,,,,,,,fee schedule,7.17,44,
Allergen specific IgE,86005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38.53,,,,,,,fee schedule,7.17,44,
Allergen specific IgE,86005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,40.51,,,,,,,fee schedule,7.17,44,
Allergen specific IgE,86005,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.17,,,,,,,fee schedule,7.17,44,Laboratory
Allergen specific IgE,86005,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.37,,,,,,,fee schedule,7.17,44,APC
Allergen specific IgE,86005,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8.29,,,,,,,fee schedule,7.17,44,APC
Allergen specific IgE,86005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7.97,,,,,,,fee schedule,7.17,44,APC
Allergen specific IgE,86005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12.19,,,,,,,fee schedule,7.17,44,Radiology
Allergen specific IgE,86005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11.16,,,,,,,fee schedule,7.17,44,APC
Allergen specific IgE,86005,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,13.95,,,,,,,fee schedule,7.17,44,APC
Allg spec ige recomb ea,86008,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.14,,,,,,,fee schedule,16.14,31.38,Laboratory
Allg spec ige recomb ea,86008,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.83,,,,,,,fee schedule,16.14,31.38,APC
Allg spec ige recomb ea,86008,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18.65,,,,,,,fee schedule,16.14,31.38,APC
Allg spec ige recomb ea,86008,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17.93,,,,,,,fee schedule,16.14,31.38,APC
Allg spec ige recomb ea,86008,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27.43,,,,,,,fee schedule,16.14,31.38,Radiology
Allg spec ige recomb ea,86008,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.1,,,,,,,fee schedule,16.14,31.38,APC
Allg spec ige recomb ea,86008,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31.38,,,,,,,fee schedule,16.14,31.38,APC
Actin antibody each,86015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,43.58,,,,,,,fee schedule,10.84,43.58,
Actin antibody each,86015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,34.94,,,,,,,fee schedule,10.84,43.58,
Actin antibody each,86015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38.16,,,,,,,fee schedule,10.84,43.58,
Actin antibody each,86015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,40.12,,,,,,,fee schedule,10.84,43.58,
Actin antibody each,86015,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.84,,,,,,,fee schedule,10.84,43.58,Laboratory
Actin antibody each,86015,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.65,,,,,,,fee schedule,10.84,43.58,APC
Actin antibody each,86015,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.53,,,,,,,fee schedule,10.84,43.58,APC
Actin antibody each,86015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.05,,,,,,,fee schedule,10.84,43.58,APC
Actin antibody each,86015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.44,,,,,,,fee schedule,10.84,43.58,Radiology
Actin antibody each,86015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.87,,,,,,,fee schedule,10.84,43.58,APC
Actin antibody each,86015,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21.09,,,,,,,fee schedule,10.84,43.58,APC
WBC antibody identification,86021,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,140.3,,,,,,,fee schedule,13.54,140.3,
WBC antibody identification,86021,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,112.47,,,,,,,fee schedule,13.54,140.3,
WBC antibody identification,86021,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,122.86,,,,,,,fee schedule,13.54,140.3,
WBC antibody identification,86021,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,129.17,,,,,,,fee schedule,13.54,140.3,
WBC antibody identification,86021,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.55,,,,,,,fee schedule,13.54,140.3,Laboratory
WBC antibody identification,86021,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.8,,,,,,,fee schedule,13.54,140.3,APC
WBC antibody identification,86021,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,15.65,,,,,,,fee schedule,13.54,140.3,APC
WBC antibody identification,86021,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,15.05,,,,,,,fee schedule,13.54,140.3,APC
WBC antibody identification,86021,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.03,,,,,,,fee schedule,13.54,140.3,Radiology
WBC antibody identification,86021,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21.07,,,,,,,fee schedule,13.54,140.3,APC
WBC antibody identification,86021,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,26.34,,,,,,,fee schedule,13.54,140.3,APC
Platelet antibodies,86022,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,176.58,,,,,,,fee schedule,16.53,176.58,
Platelet antibodies,86022,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,141.55,,,,,,,fee schedule,16.53,176.58,
Platelet antibodies,86022,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,154.63,,,,,,,fee schedule,16.53,176.58,
Platelet antibodies,86022,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,162.57,,,,,,,fee schedule,16.53,176.58,
Platelet antibodies,86022,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.53,,,,,,,fee schedule,16.53,176.58,Laboratory
Platelet antibodies,86022,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.29,,,,,,,fee schedule,16.53,176.58,APC
Platelet antibodies,86022,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,19.1,,,,,,,fee schedule,16.53,176.58,APC
Platelet antibodies,86022,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18.37,,,,,,,fee schedule,16.53,176.58,APC
Platelet antibodies,86022,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.11,,,,,,,fee schedule,16.53,176.58,Radiology
Platelet antibodies,86022,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.72,,,,,,,fee schedule,16.53,176.58,APC
Platelet antibodies,86022,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,32.15,,,,,,,fee schedule,16.53,176.58,APC
Immunoglobulin assay,86023,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83.66,,,,,,,fee schedule,11.21,83.66,
Immunoglobulin assay,86023,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,67.06,,,,,,,fee schedule,11.21,83.66,
Immunoglobulin assay,86023,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,73.26,,,,,,,fee schedule,11.21,83.66,
Immunoglobulin assay,86023,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,77.02,,,,,,,fee schedule,11.21,83.66,
Immunoglobulin assay,86023,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.21,,,,,,,fee schedule,11.21,83.66,Laboratory
Immunoglobulin assay,86023,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.08,,,,,,,fee schedule,11.21,83.66,APC
Immunoglobulin assay,86023,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.96,,,,,,,fee schedule,11.21,83.66,APC
Immunoglobulin assay,86023,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.46,,,,,,,fee schedule,11.21,83.66,APC
Immunoglobulin assay,86023,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.06,,,,,,,fee schedule,11.21,83.66,Radiology
Immunoglobulin assay,86023,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.44,,,,,,,fee schedule,11.21,83.66,APC
Immunoglobulin assay,86023,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21.8,,,,,,,fee schedule,11.21,83.66,APC
Anca screen each antibody,86036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45.55,,,,,,,fee schedule,10.84,45.55,
Anca screen each antibody,86036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36.51,,,,,,,fee schedule,10.84,45.55,
Anca screen each antibody,86036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39.89,,,,,,,fee schedule,10.84,45.55,
Anca screen each antibody,86036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41.93,,,,,,,fee schedule,10.84,45.55,
Anca screen each antibody,86036,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.84,,,,,,,fee schedule,10.84,45.55,Laboratory
Anca screen each antibody,86036,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.65,,,,,,,fee schedule,10.84,45.55,APC
Anca screen each antibody,86036,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.53,,,,,,,fee schedule,10.84,45.55,APC
Anca screen each antibody,86036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.05,,,,,,,fee schedule,10.84,45.55,APC
Anca screen each antibody,86036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.44,,,,,,,fee schedule,10.84,45.55,Radiology
Anca screen each antibody,86036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.87,,,,,,,fee schedule,10.84,45.55,APC
Anca screen each antibody,86036,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21.09,,,,,,,fee schedule,10.84,45.55,APC
Anca titer each antibody,86037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45.55,,,,,,,fee schedule,10.84,45.55,
Anca titer each antibody,86037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36.51,,,,,,,fee schedule,10.84,45.55,
Anca titer each antibody,86037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39.89,,,,,,,fee schedule,10.84,45.55,
Anca titer each antibody,86037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41.93,,,,,,,fee schedule,10.84,45.55,
Anca titer each antibody,86037,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.84,,,,,,,fee schedule,10.84,45.55,Laboratory
Anca titer each antibody,86037,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.65,,,,,,,fee schedule,10.84,45.55,APC
Anca titer each antibody,86037,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.53,,,,,,,fee schedule,10.84,45.55,APC
Anca titer each antibody,86037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.05,,,,,,,fee schedule,10.84,45.55,APC
Anca titer each antibody,86037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.44,,,,,,,fee schedule,10.84,45.55,Radiology
Anca titer each antibody,86037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.87,,,,,,,fee schedule,10.84,45.55,APC
Anca titer each antibody,86037,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21.09,,,,,,,fee schedule,10.84,45.55,APC
Antinuclear antibodies,86038,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,56.74,,,,,,,fee schedule,10.88,56.74,
Antinuclear antibodies,86038,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,45.49,,,,,,,fee schedule,10.88,56.74,
Antinuclear antibodies,86038,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,49.69,,,,,,,fee schedule,10.88,56.74,
Antinuclear antibodies,86038,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,52.24,,,,,,,fee schedule,10.88,56.74,
Antinuclear antibodies,86038,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.88,,,,,,,fee schedule,10.88,56.74,Laboratory
Antinuclear antibodies,86038,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.69,,,,,,,fee schedule,10.88,56.74,APC
Antinuclear antibodies,86038,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.57,,,,,,,fee schedule,10.88,56.74,APC
Antinuclear antibodies,86038,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.09,,,,,,,fee schedule,10.88,56.74,APC
Antinuclear antibodies,86038,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.5,,,,,,,fee schedule,10.88,56.74,Radiology
Antinuclear antibodies,86038,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.93,,,,,,,fee schedule,10.88,56.74,APC
Antinuclear antibodies,86038,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21.16,,,,,,,fee schedule,10.88,56.74,APC
Antinuclear antibodies (ANA),86039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59.68,,,,,,,fee schedule,10.04,59.68,
Antinuclear antibodies (ANA),86039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,47.84,,,,,,,fee schedule,10.04,59.68,
Antinuclear antibodies (ANA),86039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52.26,,,,,,,fee schedule,10.04,59.68,
Antinuclear antibodies (ANA),86039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,54.94,,,,,,,fee schedule,10.04,59.68,
Antinuclear antibodies (ANA),86039,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.04,,,,,,,fee schedule,10.04,59.68,Laboratory
Antinuclear antibodies (ANA),86039,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.72,,,,,,,fee schedule,10.04,59.68,APC
Antinuclear antibodies (ANA),86039,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11.61,,,,,,,fee schedule,10.04,59.68,APC
Antinuclear antibodies (ANA),86039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11.16,,,,,,,fee schedule,10.04,59.68,APC
Antinuclear antibodies (ANA),86039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.07,,,,,,,fee schedule,10.04,59.68,Radiology
Antinuclear antibodies (ANA),86039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15.62,,,,,,,fee schedule,10.04,59.68,APC
Antinuclear antibodies (ANA),86039,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19.53,,,,,,,fee schedule,10.04,59.68,APC
Acetylcholn rcptr bndng antb,86041,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.56,,,,,,,fee schedule,16.56,32.2,Laboratory
Acetylcholn rcptr bndng antb,86041,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.32,,,,,,,fee schedule,16.56,32.2,APC
Acetylcholn rcptr bndng antb,86041,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,19.14,,,,,,,fee schedule,16.56,32.2,APC
Acetylcholn rcptr bndng antb,86041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18.4,,,,,,,fee schedule,16.56,32.2,APC
Acetylcholn rcptr bndng antb,86041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.15,,,,,,,fee schedule,16.56,32.2,Radiology
Acetylcholn rcptr bndng antb,86041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.76,,,,,,,fee schedule,16.56,32.2,APC
Acetylcholn rcptr bndng antb,86041,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,32.2,,,,,,,fee schedule,16.56,32.2,APC
Acetylcholn rcptr blckg antb,86042,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.56,,,,,,,fee schedule,16.56,32.2,Laboratory
Acetylcholn rcptr blckg antb,86042,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.32,,,,,,,fee schedule,16.56,32.2,APC
Acetylcholn rcptr blckg antb,86042,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,19.14,,,,,,,fee schedule,16.56,32.2,APC
Acetylcholn rcptr blckg antb,86042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18.4,,,,,,,fee schedule,16.56,32.2,APC
Acetylcholn rcptr blckg antb,86042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.15,,,,,,,fee schedule,16.56,32.2,Radiology
Acetylcholn rcptr blckg antb,86042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.76,,,,,,,fee schedule,16.56,32.2,APC
Acetylcholn rcptr blckg antb,86042,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,32.2,,,,,,,fee schedule,16.56,32.2,APC
Acetylcholn rcptr modlg antb,86043,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.84,,,,,,,fee schedule,10.84,21.09,Laboratory
Acetylcholn rcptr modlg antb,86043,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.65,,,,,,,fee schedule,10.84,21.09,APC
Acetylcholn rcptr modlg antb,86043,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.53,,,,,,,fee schedule,10.84,21.09,APC
Acetylcholn rcptr modlg antb,86043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.05,,,,,,,fee schedule,10.84,21.09,APC
Acetylcholn rcptr modlg antb,86043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.44,,,,,,,fee schedule,10.84,21.09,Radiology
Acetylcholn rcptr modlg antb,86043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.87,,,,,,,fee schedule,10.84,21.09,APC
Acetylcholn rcptr modlg antb,86043,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21.09,,,,,,,fee schedule,10.84,21.09,APC
Aquaporin-4 antb elisa,86051,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,43.58,,,,,,,fee schedule,10.38,43.58,
Aquaporin-4 antb elisa,86051,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,34.94,,,,,,,fee schedule,10.38,43.58,
Aquaporin-4 antb elisa,86051,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38.16,,,,,,,fee schedule,10.38,43.58,
Aquaporin-4 antb elisa,86051,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,40.12,,,,,,,fee schedule,10.38,43.58,
Aquaporin-4 antb elisa,86051,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.38,,,,,,,fee schedule,10.38,43.58,Laboratory
Aquaporin-4 antb elisa,86051,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.11,,,,,,,fee schedule,10.38,43.58,APC
Aquaporin-4 antb elisa,86051,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11.99,,,,,,,fee schedule,10.38,43.58,APC
Aquaporin-4 antb elisa,86051,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11.53,,,,,,,fee schedule,10.38,43.58,APC
Aquaporin-4 antb elisa,86051,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.64,,,,,,,fee schedule,10.38,43.58,Radiology
Aquaporin-4 antb elisa,86051,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.14,,,,,,,fee schedule,10.38,43.58,APC
Aquaporin-4 antb elisa,86051,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20.18,,,,,,,fee schedule,10.38,43.58,APC
Aquaporin-4 antb cba each,86052,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45.55,,,,,,,fee schedule,10.84,45.55,
Aquaporin-4 antb cba each,86052,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36.51,,,,,,,fee schedule,10.84,45.55,
Aquaporin-4 antb cba each,86052,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39.89,,,,,,,fee schedule,10.84,45.55,
Aquaporin-4 antb cba each,86052,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41.93,,,,,,,fee schedule,10.84,45.55,
Aquaporin-4 antb cba each,86052,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.84,,,,,,,fee schedule,10.84,45.55,Laboratory
Aquaporin-4 antb cba each,86052,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.65,,,,,,,fee schedule,10.84,45.55,APC
Aquaporin-4 antb cba each,86052,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.53,,,,,,,fee schedule,10.84,45.55,APC
Aquaporin-4 antb cba each,86052,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.05,,,,,,,fee schedule,10.84,45.55,APC
Aquaporin-4 antb cba each,86052,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.44,,,,,,,fee schedule,10.84,45.55,Radiology
Aquaporin-4 antb cba each,86052,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.87,,,,,,,fee schedule,10.84,45.55,APC
Aquaporin-4 antb cba each,86052,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21.09,,,,,,,fee schedule,10.84,45.55,APC
Aqaprn-4 antb flo cytmtry ea,86053,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45.55,,,,,,,fee schedule,33.96,66.03,
Aqaprn-4 antb flo cytmtry ea,86053,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36.51,,,,,,,fee schedule,33.96,66.03,
Aqaprn-4 antb flo cytmtry ea,86053,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39.89,,,,,,,fee schedule,33.96,66.03,
Aqaprn-4 antb flo cytmtry ea,86053,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41.93,,,,,,,fee schedule,33.96,66.03,
Aqaprn-4 antb flo cytmtry ea,86053,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,33.96,,,,,,,fee schedule,33.96,66.03,Laboratory
Aqaprn-4 antb flo cytmtry ea,86053,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.62,,,,,,,fee schedule,33.96,66.03,APC
Aqaprn-4 antb flo cytmtry ea,86053,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,39.24,,,,,,,fee schedule,33.96,66.03,APC
Aqaprn-4 antb flo cytmtry ea,86053,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,37.73,,,,,,,fee schedule,33.96,66.03,APC
Aqaprn-4 antb flo cytmtry ea,86053,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,57.73,,,,,,,fee schedule,33.96,66.03,Radiology
Aqaprn-4 antb flo cytmtry ea,86053,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,52.82,,,,,,,fee schedule,33.96,66.03,APC
Aqaprn-4 antb flo cytmtry ea,86053,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,66.03,,,,,,,fee schedule,33.96,66.03,APC
Antistreptolysin o titer,86060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,85.04,,,,,,,fee schedule,6.57,85.04,
Antistreptolysin o titer,86060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,68.17,,,,,,,fee schedule,6.57,85.04,
Antistreptolysin o titer,86060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,74.47,,,,,,,fee schedule,6.57,85.04,
Antistreptolysin o titer,86060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,78.29,,,,,,,fee schedule,6.57,85.04,
Antistreptolysin o titer,86060,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.57,,,,,,,fee schedule,6.57,85.04,Laboratory
Antistreptolysin o titer,86060,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.66,,,,,,,fee schedule,6.57,85.04,APC
Antistreptolysin o titer,86060,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7.59,,,,,,,fee schedule,6.57,85.04,APC
Antistreptolysin o titer,86060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7.3,,,,,,,fee schedule,6.57,85.04,APC
Antistreptolysin o titer,86060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11.17,,,,,,,fee schedule,6.57,85.04,Radiology
Antistreptolysin o titer,86060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10.22,,,,,,,fee schedule,6.57,85.04,APC
Antistreptolysin o titer,86060,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12.78,,,,,,,fee schedule,6.57,85.04,APC
Antistreptolysin o screen,86063,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,31.9,,,,,,,fee schedule,5.19,31.9,
Antistreptolysin o screen,86063,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,25.57,,,,,,,fee schedule,5.19,31.9,
Antistreptolysin o screen,86063,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,27.94,,,,,,,fee schedule,5.19,31.9,
Antistreptolysin o screen,86063,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,29.37,,,,,,,fee schedule,5.19,31.9,
Antistreptolysin o screen,86063,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.19,,,,,,,fee schedule,5.19,31.9,Laboratory
Antistreptolysin o screen,86063,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.06,,,,,,,fee schedule,5.19,31.9,APC
Antistreptolysin o screen,86063,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6,,,,,,,fee schedule,5.19,31.9,APC
Antistreptolysin o screen,86063,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5.77,,,,,,,fee schedule,5.19,31.9,APC
Antistreptolysin o screen,86063,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8.83,,,,,,,fee schedule,5.19,31.9,Radiology
Antistreptolysin o screen,86063,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8.08,,,,,,,fee schedule,5.19,31.9,APC
Antistreptolysin o screen,86063,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10.1,,,,,,,fee schedule,5.19,31.9,APC
Phys blood bank serv xmatch,86077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59.84,,,,,,,fee schedule,28.63,127.04,
Phys blood bank serv xmatch,86077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,47.96,,,,,,,fee schedule,28.63,127.04,
Phys blood bank serv xmatch,86077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52.4,,,,,,,fee schedule,28.63,127.04,
Phys blood bank serv xmatch,86077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55.09,,,,,,,fee schedule,28.63,127.04,
Phys blood bank serv xmatch,86077,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,127.04,,,,,,,fee schedule,28.63,127.04,APC 378
Phys blood bank serv xmatch,86077,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.07,,,,,,,fee schedule,28.63,127.04,APC
Phys blood bank serv xmatch,86077,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,29.78,,,,,,,fee schedule,28.63,127.04,APC
Phys blood bank serv xmatch,86077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,28.63,,,,,,,fee schedule,28.63,127.04,APC
Phys blood bank serv xmatch,86077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43.81,,,,,,,fee schedule,28.63,127.04,Radiology
Phys blood bank serv xmatch,86077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40.09,,,,,,,fee schedule,28.63,127.04,APC
Phys blood bank serv xmatch,86077,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,50.11,,,,,,,fee schedule,28.63,127.04,APC
Phys blood bank serv reactj,86078,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,128.33,,,,,,,fee schedule,102.87,748.29,
Phys blood bank serv reactj,86078,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,102.87,,,,,,,fee schedule,102.87,748.29,
Phys blood bank serv reactj,86078,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,112.37,,,,,,,fee schedule,102.87,748.29,
Phys blood bank serv reactj,86078,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,118.15,,,,,,,fee schedule,102.87,748.29,
Phys blood bank serv reactj,86078,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,748.29,,,,,,,fee schedule,102.87,748.29,APC 378
Phys blood bank serv reactj,86078,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,177.09,,,,,,,fee schedule,102.87,748.29,APC
Phys blood bank serv reactj,86078,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,175.41,,,,,,,fee schedule,102.87,748.29,APC
Phys blood bank serv reactj,86078,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,168.66,,,,,,,fee schedule,102.87,748.29,APC
Phys blood bank serv reactj,86078,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,258.05,,,,,,,fee schedule,102.87,748.29,Radiology
Phys blood bank serv reactj,86078,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,236.12,,,,,,,fee schedule,102.87,748.29,APC
Phys blood bank serv reactj,86078,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,295.16,,,,,,,fee schedule,102.87,748.29,APC
Phys blood bank serv authrj,86079,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59.84,,,,,,,fee schedule,47.96,228.88,
Phys blood bank serv authrj,86079,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,47.96,,,,,,,fee schedule,47.96,228.88,
Phys blood bank serv authrj,86079,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52.4,,,,,,,fee schedule,47.96,228.88,
Phys blood bank serv authrj,86079,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55.09,,,,,,,fee schedule,47.96,228.88,
Phys blood bank serv authrj,86079,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,228.88,,,,,,,fee schedule,47.96,228.88,APC 378
Phys blood bank serv authrj,86079,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.17,,,,,,,fee schedule,47.96,228.88,APC
Phys blood bank serv authrj,86079,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,53.65,,,,,,,fee schedule,47.96,228.88,APC
Phys blood bank serv authrj,86079,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,51.59,,,,,,,fee schedule,47.96,228.88,APC
Phys blood bank serv authrj,86079,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,78.93,,,,,,,fee schedule,47.96,228.88,Radiology
Phys blood bank serv authrj,86079,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,72.22,,,,,,,fee schedule,47.96,228.88,APC
Phys blood bank serv authrj,86079,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,90.28,,,,,,,fee schedule,47.96,228.88,APC
C-reactive protein,86140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21.5,,,,,,,fee schedule,4.66,21.5,
C-reactive protein,86140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17.24,,,,,,,fee schedule,4.66,21.5,
C-reactive protein,86140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18.83,,,,,,,fee schedule,4.66,21.5,
C-reactive protein,86140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19.8,,,,,,,fee schedule,4.66,21.5,
C-reactive protein,86140,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.66,,,,,,,fee schedule,4.66,21.5,Laboratory
C-reactive protein,86140,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.44,,,,,,,fee schedule,4.66,21.5,APC
C-reactive protein,86140,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5.39,,,,,,,fee schedule,4.66,21.5,APC
C-reactive protein,86140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5.18,,,,,,,fee schedule,4.66,21.5,APC
C-reactive protein,86140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.93,,,,,,,fee schedule,4.66,21.5,Radiology
C-reactive protein,86140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.25,,,,,,,fee schedule,4.66,21.5,APC
C-reactive protein,86140,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9.06,,,,,,,fee schedule,4.66,21.5,APC
C-reactive protein hs,86141,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45.9,,,,,,,fee schedule,11.66,45.9,
C-reactive protein hs,86141,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36.8,,,,,,,fee schedule,11.66,45.9,
C-reactive protein hs,86141,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40.2,,,,,,,fee schedule,11.66,45.9,
C-reactive protein hs,86141,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42.26,,,,,,,fee schedule,11.66,45.9,
C-reactive protein hs,86141,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.66,,,,,,,fee schedule,11.66,45.9,Laboratory
C-reactive protein hs,86141,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.6,,,,,,,fee schedule,11.66,45.9,APC
C-reactive protein hs,86141,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.47,,,,,,,fee schedule,11.66,45.9,APC
C-reactive protein hs,86141,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.95,,,,,,,fee schedule,11.66,45.9,APC
C-reactive protein hs,86141,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.81,,,,,,,fee schedule,11.66,45.9,Radiology
C-reactive protein hs,86141,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.13,,,,,,,fee schedule,11.66,45.9,APC
C-reactive protein hs,86141,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22.66,,,,,,,fee schedule,11.66,45.9,APC
Beta-2 glycoprotein antibody,86146,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,86.51,,,,,,,fee schedule,22.9,86.51,
Beta-2 glycoprotein antibody,86146,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,69.34,,,,,,,fee schedule,22.9,86.51,
Beta-2 glycoprotein antibody,86146,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,75.75,,,,,,,fee schedule,22.9,86.51,
Beta-2 glycoprotein antibody,86146,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,79.64,,,,,,,fee schedule,22.9,86.51,
Beta-2 glycoprotein antibody,86146,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22.9,,,,,,,fee schedule,22.9,86.51,Laboratory
Beta-2 glycoprotein antibody,86146,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,26.72,,,,,,,fee schedule,22.9,86.51,APC
Beta-2 glycoprotein antibody,86146,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,26.47,,,,,,,fee schedule,22.9,86.51,APC
Beta-2 glycoprotein antibody,86146,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,25.45,,,,,,,fee schedule,22.9,86.51,APC
Beta-2 glycoprotein antibody,86146,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,38.94,,,,,,,fee schedule,22.9,86.51,Radiology
Beta-2 glycoprotein antibody,86146,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,35.63,,,,,,,fee schedule,22.9,86.51,APC
Beta-2 glycoprotein antibody,86146,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,44.54,,,,,,,fee schedule,22.9,86.51,APC
Cardiolipin antibody ea ig,86147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,318.92,,,,,,,fee schedule,22.9,318.92,
Cardiolipin antibody ea ig,86147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,255.64,,,,,,,fee schedule,22.9,318.92,
Cardiolipin antibody ea ig,86147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,279.27,,,,,,,fee schedule,22.9,318.92,
Cardiolipin antibody ea ig,86147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,293.61,,,,,,,fee schedule,22.9,318.92,
Cardiolipin antibody ea ig,86147,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22.9,,,,,,,fee schedule,22.9,318.92,Laboratory
Cardiolipin antibody ea ig,86147,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,26.72,,,,,,,fee schedule,22.9,318.92,APC
Cardiolipin antibody ea ig,86147,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,26.47,,,,,,,fee schedule,22.9,318.92,APC
Cardiolipin antibody ea ig,86147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,25.45,,,,,,,fee schedule,22.9,318.92,APC
Cardiolipin antibody ea ig,86147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,38.94,,,,,,,fee schedule,22.9,318.92,Radiology
Cardiolipin antibody ea ig,86147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,35.63,,,,,,,fee schedule,22.9,318.92,APC
Cardiolipin antibody ea ig,86147,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,44.54,,,,,,,fee schedule,22.9,318.92,APC
Anti-phospholipid antibody,86148,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,88.64,,,,,,,fee schedule,14.46,88.64,
Anti-phospholipid antibody,86148,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,71.05,,,,,,,fee schedule,14.46,88.64,
Anti-phospholipid antibody,86148,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,77.62,,,,,,,fee schedule,14.46,88.64,
Anti-phospholipid antibody,86148,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,81.61,,,,,,,fee schedule,14.46,88.64,
Anti-phospholipid antibody,86148,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.46,,,,,,,fee schedule,14.46,88.64,Laboratory
Anti-phospholipid antibody,86148,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.87,,,,,,,fee schedule,14.46,88.64,APC
Anti-phospholipid antibody,86148,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,16.71,,,,,,,fee schedule,14.46,88.64,APC
Anti-phospholipid antibody,86148,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16.07,,,,,,,fee schedule,14.46,88.64,APC
Anti-phospholipid antibody,86148,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24.59,,,,,,,fee schedule,14.46,88.64,Radiology
Anti-phospholipid antibody,86148,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.5,,,,,,,fee schedule,14.46,88.64,APC
Anti-phospholipid antibody,86148,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,28.12,,,,,,,fee schedule,14.46,88.64,APC
Cell enumeration & id,86152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,48.04,,,,,,,fee schedule,38.51,438.86,
Cell enumeration & id,86152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38.51,,,,,,,fee schedule,38.51,438.86,
Cell enumeration & id,86152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.07,,,,,,,fee schedule,38.51,438.86,
Cell enumeration & id,86152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,44.23,,,,,,,fee schedule,38.51,438.86,
Cell enumeration & id,86152,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,225.7,,,,,,,fee schedule,38.51,438.86,Laboratory
Cell enumeration & id,86152,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,263.32,,,,,,,fee schedule,38.51,438.86,APC
Cell enumeration & id,86152,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,260.81,,,,,,,fee schedule,38.51,438.86,APC
Cell enumeration & id,86152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,250.78,,,,,,,fee schedule,38.51,438.86,APC
Cell enumeration & id,86152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,383.69,,,,,,,fee schedule,38.51,438.86,Radiology
Cell enumeration & id,86152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,351.09,,,,,,,fee schedule,38.51,438.86,APC
Cell enumeration & id,86152,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,438.86,,,,,,,fee schedule,38.51,438.86,APC
Cell enumeration phys interp,86153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,48.04,,,,,,,fee schedule,38.51,48.04,
Cell enumeration phys interp,86153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38.51,,,,,,,fee schedule,38.51,48.04,
Cell enumeration phys interp,86153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.07,,,,,,,fee schedule,38.51,48.04,
Cell enumeration phys interp,86153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,44.23,,,,,,,fee schedule,38.51,48.04,
Chemotaxis assay,86155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,88.19,,,,,,,fee schedule,14.39,88.19,
Chemotaxis assay,86155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,70.69,,,,,,,fee schedule,14.39,88.19,
Chemotaxis assay,86155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,77.22,,,,,,,fee schedule,14.39,88.19,
Chemotaxis assay,86155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,81.19,,,,,,,fee schedule,14.39,88.19,
Chemotaxis assay,86155,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.39,,,,,,,fee schedule,14.39,88.19,Laboratory
Chemotaxis assay,86155,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.79,,,,,,,fee schedule,14.39,88.19,APC
Chemotaxis assay,86155,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,16.63,,,,,,,fee schedule,14.39,88.19,APC
Chemotaxis assay,86155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,15.99,,,,,,,fee schedule,14.39,88.19,APC
Chemotaxis assay,86155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24.46,,,,,,,fee schedule,14.39,88.19,Radiology
Chemotaxis assay,86155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.39,,,,,,,fee schedule,14.39,88.19,APC
Chemotaxis assay,86155,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,27.98,,,,,,,fee schedule,14.39,88.19,APC
Cold agglutinin screen,86156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,36.97,,,,,,,fee schedule,7.26,36.97,
Cold agglutinin screen,86156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29.63,,,,,,,fee schedule,7.26,36.97,
Cold agglutinin screen,86156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32.37,,,,,,,fee schedule,7.26,36.97,
Cold agglutinin screen,86156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,34.03,,,,,,,fee schedule,7.26,36.97,
Cold agglutinin screen,86156,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.26,,,,,,,fee schedule,7.26,36.97,Laboratory
Cold agglutinin screen,86156,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.47,,,,,,,fee schedule,7.26,36.97,APC
Cold agglutinin screen,86156,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8.39,,,,,,,fee schedule,7.26,36.97,APC
Cold agglutinin screen,86156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8.07,,,,,,,fee schedule,7.26,36.97,APC
Cold agglutinin screen,86156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12.35,,,,,,,fee schedule,7.26,36.97,Radiology
Cold agglutinin screen,86156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11.3,,,,,,,fee schedule,7.26,36.97,APC
Cold agglutinin screen,86156,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14.12,,,,,,,fee schedule,7.26,36.97,APC
Cold agglutinin titer,86157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,25.17,,,,,,,fee schedule,7.25,25.17,
Cold agglutinin titer,86157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20.18,,,,,,,fee schedule,7.25,25.17,
Cold agglutinin titer,86157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22.04,,,,,,,fee schedule,7.25,25.17,
Cold agglutinin titer,86157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23.18,,,,,,,fee schedule,7.25,25.17,
Cold agglutinin titer,86157,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.25,,,,,,,fee schedule,7.25,25.17,Laboratory
Cold agglutinin titer,86157,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.46,,,,,,,fee schedule,7.25,25.17,APC
Cold agglutinin titer,86157,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8.38,,,,,,,fee schedule,7.25,25.17,APC
Cold agglutinin titer,86157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8.06,,,,,,,fee schedule,7.25,25.17,APC
Cold agglutinin titer,86157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12.33,,,,,,,fee schedule,7.25,25.17,Radiology
Cold agglutinin titer,86157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11.28,,,,,,,fee schedule,7.25,25.17,APC
Cold agglutinin titer,86157,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14.1,,,,,,,fee schedule,7.25,25.17,APC
Complement antigen,86160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,93.61,,,,,,,fee schedule,10.8,93.61,
Complement antigen,86160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,75.04,,,,,,,fee schedule,10.8,93.61,
Complement antigen,86160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,81.97,,,,,,,fee schedule,10.8,93.61,
Complement antigen,86160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,86.18,,,,,,,fee schedule,10.8,93.61,
Complement antigen,86160,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.8,,,,,,,fee schedule,10.8,93.61,Laboratory
Complement antigen,86160,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.6,,,,,,,fee schedule,10.8,93.61,APC
Complement antigen,86160,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.48,,,,,,,fee schedule,10.8,93.61,APC
Complement antigen,86160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12,,,,,,,fee schedule,10.8,93.61,APC
Complement antigen,86160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.36,,,,,,,fee schedule,10.8,93.61,Radiology
Complement antigen,86160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.8,,,,,,,fee schedule,10.8,93.61,APC
Complement antigen,86160,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21,,,,,,,fee schedule,10.8,93.61,APC
Complement/function activity,86161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,57.75,,,,,,,fee schedule,10.8,57.75,
Complement/function activity,86161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.29,,,,,,,fee schedule,10.8,57.75,
Complement/function activity,86161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,50.57,,,,,,,fee schedule,10.8,57.75,
Complement/function activity,86161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,53.17,,,,,,,fee schedule,10.8,57.75,
Complement/function activity,86161,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.8,,,,,,,fee schedule,10.8,57.75,Laboratory
Complement/function activity,86161,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.6,,,,,,,fee schedule,10.8,57.75,APC
Complement/function activity,86161,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.48,,,,,,,fee schedule,10.8,57.75,APC
Complement/function activity,86161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12,,,,,,,fee schedule,10.8,57.75,APC
Complement/function activity,86161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.36,,,,,,,fee schedule,10.8,57.75,Radiology
Complement/function activity,86161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.8,,,,,,,fee schedule,10.8,57.75,APC
Complement/function activity,86161,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21,,,,,,,fee schedule,10.8,57.75,APC
Complement total (ch50),86162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,86.77,,,,,,,fee schedule,18.29,86.77,
Complement total (ch50),86162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,69.56,,,,,,,fee schedule,18.29,86.77,
Complement total (ch50),86162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,75.98,,,,,,,fee schedule,18.29,86.77,
Complement total (ch50),86162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,79.89,,,,,,,fee schedule,18.29,86.77,
Complement total (ch50),86162,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.29,,,,,,,fee schedule,18.29,86.77,Laboratory
Complement total (ch50),86162,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.34,,,,,,,fee schedule,18.29,86.77,APC
Complement total (ch50),86162,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,21.13,,,,,,,fee schedule,18.29,86.77,APC
Complement total (ch50),86162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,20.32,,,,,,,fee schedule,18.29,86.77,APC
Complement total (ch50),86162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,31.09,,,,,,,fee schedule,18.29,86.77,Radiology
Complement total (ch50),86162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.45,,,,,,,fee schedule,18.29,86.77,APC
Complement total (ch50),86162,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,35.56,,,,,,,fee schedule,18.29,86.77,APC
Complement fixation each,86171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55.3,,,,,,,fee schedule,9.01,55.3,
Complement fixation each,86171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,44.33,,,,,,,fee schedule,9.01,55.3,
Complement fixation each,86171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48.43,,,,,,,fee schedule,9.01,55.3,
Complement fixation each,86171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,50.91,,,,,,,fee schedule,9.01,55.3,
Complement fixation each,86171,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.01,,,,,,,fee schedule,9.01,55.3,Laboratory
Complement fixation each,86171,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.51,,,,,,,fee schedule,9.01,55.3,APC
Complement fixation each,86171,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10.41,,,,,,,fee schedule,9.01,55.3,APC
Complement fixation each,86171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10.01,,,,,,,fee schedule,9.01,55.3,APC
Complement fixation each,86171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15.32,,,,,,,fee schedule,9.01,55.3,Radiology
Complement fixation each,86171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.01,,,,,,,fee schedule,9.01,55.3,APC
Complement fixation each,86171,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,17.52,,,,,,,fee schedule,9.01,55.3,APC
Ccp antibody,86200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46.18,,,,,,,fee schedule,11.66,46.18,
Ccp antibody,86200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37.02,,,,,,,fee schedule,11.66,46.18,
Ccp antibody,86200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40.44,,,,,,,fee schedule,11.66,46.18,
Ccp antibody,86200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42.52,,,,,,,fee schedule,11.66,46.18,
Ccp antibody,86200,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.66,,,,,,,fee schedule,11.66,46.18,Laboratory
Ccp antibody,86200,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.6,,,,,,,fee schedule,11.66,46.18,APC
Ccp antibody,86200,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.47,,,,,,,fee schedule,11.66,46.18,APC
Ccp antibody,86200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.95,,,,,,,fee schedule,11.66,46.18,APC
Ccp antibody,86200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.81,,,,,,,fee schedule,11.66,46.18,Radiology
Ccp antibody,86200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.13,,,,,,,fee schedule,11.66,46.18,APC
Ccp antibody,86200,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22.66,,,,,,,fee schedule,11.66,46.18,APC
Deoxyribonuclease antibody,86215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,163.63,,,,,,,fee schedule,11.92,163.63,
Deoxyribonuclease antibody,86215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,131.16,,,,,,,fee schedule,11.92,163.63,
Deoxyribonuclease antibody,86215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,143.28,,,,,,,fee schedule,11.92,163.63,
Deoxyribonuclease antibody,86215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,150.64,,,,,,,fee schedule,11.92,163.63,
Deoxyribonuclease antibody,86215,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.92,,,,,,,fee schedule,11.92,163.63,Laboratory
Deoxyribonuclease antibody,86215,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.91,,,,,,,fee schedule,11.92,163.63,APC
Deoxyribonuclease antibody,86215,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.78,,,,,,,fee schedule,11.92,163.63,APC
Deoxyribonuclease antibody,86215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.25,,,,,,,fee schedule,11.92,163.63,APC
Deoxyribonuclease antibody,86215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.27,,,,,,,fee schedule,11.92,163.63,Radiology
Deoxyribonuclease antibody,86215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.55,,,,,,,fee schedule,11.92,163.63,APC
Deoxyribonuclease antibody,86215,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23.19,,,,,,,fee schedule,11.92,163.63,APC
Dna antibody native,86225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83.29,,,,,,,fee schedule,12.37,83.29,
Dna antibody native,86225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66.77,,,,,,,fee schedule,12.37,83.29,
Dna antibody native,86225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,72.94,,,,,,,fee schedule,12.37,83.29,
Dna antibody native,86225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,76.68,,,,,,,fee schedule,12.37,83.29,
Dna antibody native,86225,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.37,,,,,,,fee schedule,12.37,83.29,Laboratory
Dna antibody native,86225,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.43,,,,,,,fee schedule,12.37,83.29,APC
Dna antibody native,86225,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,14.29,,,,,,,fee schedule,12.37,83.29,APC
Dna antibody native,86225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.74,,,,,,,fee schedule,12.37,83.29,APC
Dna antibody native,86225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21.02,,,,,,,fee schedule,12.37,83.29,Radiology
Dna antibody native,86225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.24,,,,,,,fee schedule,12.37,83.29,APC
Dna antibody native,86225,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,24.04,,,,,,,fee schedule,12.37,83.29,APC
Dna antibody single strand,86226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.83,,,,,,,fee schedule,10.9,66.83,
Dna antibody single strand,86226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.57,,,,,,,fee schedule,10.9,66.83,
Dna antibody single strand,86226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,58.52,,,,,,,fee schedule,10.9,66.83,
Dna antibody single strand,86226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,61.53,,,,,,,fee schedule,10.9,66.83,
Dna antibody single strand,86226,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.9,,,,,,,fee schedule,10.9,66.83,Laboratory
Dna antibody single strand,86226,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.72,,,,,,,fee schedule,10.9,66.83,APC
Dna antibody single strand,86226,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.59,,,,,,,fee schedule,10.9,66.83,APC
Dna antibody single strand,86226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.11,,,,,,,fee schedule,10.9,66.83,APC
Dna antibody single strand,86226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.53,,,,,,,fee schedule,10.9,66.83,Radiology
Dna antibody single strand,86226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.95,,,,,,,fee schedule,10.9,66.83,APC
Dna antibody single strand,86226,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21.19,,,,,,,fee schedule,10.9,66.83,APC
Ema each ig class,86231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45.7,,,,,,,fee schedule,10.88,45.7,
Ema each ig class,86231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36.63,,,,,,,fee schedule,10.88,45.7,
Ema each ig class,86231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40.02,,,,,,,fee schedule,10.88,45.7,
Ema each ig class,86231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42.07,,,,,,,fee schedule,10.88,45.7,
Ema each ig class,86231,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.88,,,,,,,fee schedule,10.88,45.7,Laboratory
Ema each ig class,86231,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.69,,,,,,,fee schedule,10.88,45.7,APC
Ema each ig class,86231,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.57,,,,,,,fee schedule,10.88,45.7,APC
Ema each ig class,86231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.09,,,,,,,fee schedule,10.88,45.7,APC
Ema each ig class,86231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.5,,,,,,,fee schedule,10.88,45.7,Radiology
Ema each ig class,86231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.93,,,,,,,fee schedule,10.88,45.7,APC
Ema each ig class,86231,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21.16,,,,,,,fee schedule,10.88,45.7,APC
Nuclear antigen antibody,86235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,74.52,,,,,,,fee schedule,16.14,74.52,
Nuclear antigen antibody,86235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,59.74,,,,,,,fee schedule,16.14,74.52,
Nuclear antigen antibody,86235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,65.26,,,,,,,fee schedule,16.14,74.52,
Nuclear antigen antibody,86235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,68.61,,,,,,,fee schedule,16.14,74.52,
Nuclear antigen antibody,86235,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.14,,,,,,,fee schedule,16.14,74.52,Laboratory
Nuclear antigen antibody,86235,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.83,,,,,,,fee schedule,16.14,74.52,APC
Nuclear antigen antibody,86235,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18.65,,,,,,,fee schedule,16.14,74.52,APC
Nuclear antigen antibody,86235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17.93,,,,,,,fee schedule,16.14,74.52,APC
Nuclear antigen antibody,86235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27.43,,,,,,,fee schedule,16.14,74.52,Radiology
Nuclear antigen antibody,86235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.1,,,,,,,fee schedule,16.14,74.52,APC
Nuclear antigen antibody,86235,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31.38,,,,,,,fee schedule,16.14,74.52,APC
Fluorescent antibody screen,86255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,127.68,,,,,,,fee schedule,10.84,127.68,
Fluorescent antibody screen,86255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,102.35,,,,,,,fee schedule,10.84,127.68,
Fluorescent antibody screen,86255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,111.81,,,,,,,fee schedule,10.84,127.68,
Fluorescent antibody screen,86255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,117.55,,,,,,,fee schedule,10.84,127.68,
Fluorescent antibody screen,86255,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.84,,,,,,,fee schedule,10.84,127.68,Laboratory
Fluorescent antibody screen,86255,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.65,,,,,,,fee schedule,10.84,127.68,APC
Fluorescent antibody screen,86255,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.53,,,,,,,fee schedule,10.84,127.68,APC
Fluorescent antibody screen,86255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.05,,,,,,,fee schedule,10.84,127.68,APC
Fluorescent antibody screen,86255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.44,,,,,,,fee schedule,10.84,127.68,Radiology
Fluorescent antibody screen,86255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.87,,,,,,,fee schedule,10.84,127.68,APC
Fluorescent antibody screen,86255,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21.09,,,,,,,fee schedule,10.84,127.68,APC
Fluorescent antibody titer,86256,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,73.3,,,,,,,fee schedule,10.84,73.3,
Fluorescent antibody titer,86256,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,58.76,,,,,,,fee schedule,10.84,73.3,
Fluorescent antibody titer,86256,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,64.18,,,,,,,fee schedule,10.84,73.3,
Fluorescent antibody titer,86256,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,67.48,,,,,,,fee schedule,10.84,73.3,
Fluorescent antibody titer,86256,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.84,,,,,,,fee schedule,10.84,73.3,Laboratory
Fluorescent antibody titer,86256,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.65,,,,,,,fee schedule,10.84,73.3,APC
Fluorescent antibody titer,86256,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.53,,,,,,,fee schedule,10.84,73.3,APC
Fluorescent antibody titer,86256,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.05,,,,,,,fee schedule,10.84,73.3,APC
Fluorescent antibody titer,86256,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.44,,,,,,,fee schedule,10.84,73.3,Radiology
Fluorescent antibody titer,86256,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.87,,,,,,,fee schedule,10.84,73.3,APC
Fluorescent antibody titer,86256,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21.09,,,,,,,fee schedule,10.84,73.3,APC
Dgp antibody each ig class,86258,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,43.58,,,,,,,fee schedule,10.84,43.58,
Dgp antibody each ig class,86258,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,34.94,,,,,,,fee schedule,10.84,43.58,
Dgp antibody each ig class,86258,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38.16,,,,,,,fee schedule,10.84,43.58,
Dgp antibody each ig class,86258,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,40.12,,,,,,,fee schedule,10.84,43.58,
Dgp antibody each ig class,86258,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.84,,,,,,,fee schedule,10.84,43.58,Laboratory
Dgp antibody each ig class,86258,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.65,,,,,,,fee schedule,10.84,43.58,APC
Dgp antibody each ig class,86258,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.53,,,,,,,fee schedule,10.84,43.58,APC
Dgp antibody each ig class,86258,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.05,,,,,,,fee schedule,10.84,43.58,APC
Dgp antibody each ig class,86258,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.44,,,,,,,fee schedule,10.84,43.58,Radiology
Dgp antibody each ig class,86258,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.87,,,,,,,fee schedule,10.84,43.58,APC
Dgp antibody each ig class,86258,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21.09,,,,,,,fee schedule,10.84,43.58,APC
Growth hormone antibody,86277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,86.86,,,,,,,fee schedule,14.17,86.86,
Growth hormone antibody,86277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,69.63,,,,,,,fee schedule,14.17,86.86,
Growth hormone antibody,86277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,76.06,,,,,,,fee schedule,14.17,86.86,
Growth hormone antibody,86277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,79.97,,,,,,,fee schedule,14.17,86.86,
Growth hormone antibody,86277,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.17,,,,,,,fee schedule,14.17,86.86,Laboratory
Growth hormone antibody,86277,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.53,,,,,,,fee schedule,14.17,86.86,APC
Growth hormone antibody,86277,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,16.37,,,,,,,fee schedule,14.17,86.86,APC
Growth hormone antibody,86277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,15.74,,,,,,,fee schedule,14.17,86.86,APC
Growth hormone antibody,86277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24.08,,,,,,,fee schedule,14.17,86.86,Radiology
Growth hormone antibody,86277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.04,,,,,,,fee schedule,14.17,86.86,APC
Growth hormone antibody,86277,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,27.54,,,,,,,fee schedule,14.17,86.86,APC
Hemagglutination inhibition,86280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45.21,,,,,,,fee schedule,7.37,45.21,
Hemagglutination inhibition,86280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36.24,,,,,,,fee schedule,7.37,45.21,
Hemagglutination inhibition,86280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39.59,,,,,,,fee schedule,7.37,45.21,
Hemagglutination inhibition,86280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41.62,,,,,,,fee schedule,7.37,45.21,
Hemagglutination inhibition,86280,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.37,,,,,,,fee schedule,7.37,45.21,Laboratory
Hemagglutination inhibition,86280,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.6,,,,,,,fee schedule,7.37,45.21,APC
Hemagglutination inhibition,86280,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8.52,,,,,,,fee schedule,7.37,45.21,APC
Hemagglutination inhibition,86280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8.19,,,,,,,fee schedule,7.37,45.21,APC
Hemagglutination inhibition,86280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12.53,,,,,,,fee schedule,7.37,45.21,Radiology
Hemagglutination inhibition,86280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11.47,,,,,,,fee schedule,7.37,45.21,APC
Hemagglutination inhibition,86280,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14.33,,,,,,,fee schedule,7.37,45.21,APC
Immunoassay tumor qual,86294,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,63.73,,,,,,,fee schedule,23.01,63.73,
Immunoassay tumor qual,86294,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.09,,,,,,,fee schedule,23.01,63.73,
Immunoassay tumor qual,86294,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55.81,,,,,,,fee schedule,23.01,63.73,
Immunoassay tumor qual,86294,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,58.67,,,,,,,fee schedule,23.01,63.73,
Immunoassay tumor qual,86294,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23.01,,,,,,,fee schedule,23.01,63.73,Laboratory
Immunoassay tumor qual,86294,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,26.85,,,,,,,fee schedule,23.01,63.73,APC
Immunoassay tumor qual,86294,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,26.59,,,,,,,fee schedule,23.01,63.73,APC
Immunoassay tumor qual,86294,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,25.57,,,,,,,fee schedule,23.01,63.73,APC
Immunoassay tumor qual,86294,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,39.12,,,,,,,fee schedule,23.01,63.73,Radiology
Immunoassay tumor qual,86294,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,35.8,,,,,,,fee schedule,23.01,63.73,APC
Immunoassay tumor qual,86294,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,44.75,,,,,,,fee schedule,23.01,63.73,APC
Immunoassay tumor ca 15-3,86300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,116.69,,,,,,,fee schedule,18.73,116.69,
Immunoassay tumor ca 15-3,86300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,93.53,,,,,,,fee schedule,18.73,116.69,
Immunoassay tumor ca 15-3,86300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,102.18,,,,,,,fee schedule,18.73,116.69,
Immunoassay tumor ca 15-3,86300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,107.42,,,,,,,fee schedule,18.73,116.69,
Immunoassay tumor ca 15-3,86300,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.73,,,,,,,fee schedule,18.73,116.69,Laboratory
Immunoassay tumor ca 15-3,86300,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.85,,,,,,,fee schedule,18.73,116.69,APC
Immunoassay tumor ca 15-3,86300,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,21.64,,,,,,,fee schedule,18.73,116.69,APC
Immunoassay tumor ca 15-3,86300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,20.81,,,,,,,fee schedule,18.73,116.69,APC
Immunoassay tumor ca 15-3,86300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,31.84,,,,,,,fee schedule,18.73,116.69,Radiology
Immunoassay tumor ca 15-3,86300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29.13,,,,,,,fee schedule,18.73,116.69,APC
Immunoassay tumor ca 15-3,86300,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,36.42,,,,,,,fee schedule,18.73,116.69,APC
Immunoassay tumor ca 19-9,86301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,232.48,,,,,,,fee schedule,18.73,232.48,
Immunoassay tumor ca 19-9,86301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,186.36,,,,,,,fee schedule,18.73,232.48,
Immunoassay tumor ca 19-9,86301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,203.58,,,,,,,fee schedule,18.73,232.48,
Immunoassay tumor ca 19-9,86301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,214.03,,,,,,,fee schedule,18.73,232.48,
Immunoassay tumor ca 19-9,86301,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.73,,,,,,,fee schedule,18.73,232.48,Laboratory
Immunoassay tumor ca 19-9,86301,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.85,,,,,,,fee schedule,18.73,232.48,APC
Immunoassay tumor ca 19-9,86301,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,21.64,,,,,,,fee schedule,18.73,232.48,APC
Immunoassay tumor ca 19-9,86301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,20.81,,,,,,,fee schedule,18.73,232.48,APC
Immunoassay tumor ca 19-9,86301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,31.84,,,,,,,fee schedule,18.73,232.48,Radiology
Immunoassay tumor ca 19-9,86301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29.13,,,,,,,fee schedule,18.73,232.48,APC
Immunoassay tumor ca 19-9,86301,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,36.42,,,,,,,fee schedule,18.73,232.48,APC
Immunoassay tumor ca 125,86304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,181.15,,,,,,,fee schedule,18.73,181.15,
Immunoassay tumor ca 125,86304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,145.21,,,,,,,fee schedule,18.73,181.15,
Immunoassay tumor ca 125,86304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,158.63,,,,,,,fee schedule,18.73,181.15,
Immunoassay tumor ca 125,86304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,166.77,,,,,,,fee schedule,18.73,181.15,
Immunoassay tumor ca 125,86304,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.73,,,,,,,fee schedule,18.73,181.15,Laboratory
Immunoassay tumor ca 125,86304,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.85,,,,,,,fee schedule,18.73,181.15,APC
Immunoassay tumor ca 125,86304,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,21.64,,,,,,,fee schedule,18.73,181.15,APC
Immunoassay tumor ca 125,86304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,20.81,,,,,,,fee schedule,18.73,181.15,APC
Immunoassay tumor ca 125,86304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,31.84,,,,,,,fee schedule,18.73,181.15,Radiology
Immunoassay tumor ca 125,86304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29.13,,,,,,,fee schedule,18.73,181.15,APC
Immunoassay tumor ca 125,86304,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,36.42,,,,,,,fee schedule,18.73,181.15,APC
Human epididymis protein 4,86305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,57.83,,,,,,,fee schedule,18.73,57.83,
Human epididymis protein 4,86305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.36,,,,,,,fee schedule,18.73,57.83,
Human epididymis protein 4,86305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,50.64,,,,,,,fee schedule,18.73,57.83,
Human epididymis protein 4,86305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,53.24,,,,,,,fee schedule,18.73,57.83,
Human epididymis protein 4,86305,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.73,,,,,,,fee schedule,18.73,57.83,Laboratory
Human epididymis protein 4,86305,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.85,,,,,,,fee schedule,18.73,57.83,APC
Human epididymis protein 4,86305,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,21.64,,,,,,,fee schedule,18.73,57.83,APC
Human epididymis protein 4,86305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,20.81,,,,,,,fee schedule,18.73,57.83,APC
Human epididymis protein 4,86305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,31.84,,,,,,,fee schedule,18.73,57.83,Radiology
Human epididymis protein 4,86305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29.13,,,,,,,fee schedule,18.73,57.83,APC
Human epididymis protein 4,86305,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,36.42,,,,,,,fee schedule,18.73,57.83,APC
Heterophile antibody screen,86308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,71.92,,,,,,,fee schedule,4.66,71.92,
Heterophile antibody screen,86308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.65,,,,,,,fee schedule,4.66,71.92,
Heterophile antibody screen,86308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,62.98,,,,,,,fee schedule,4.66,71.92,
Heterophile antibody screen,86308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.21,,,,,,,fee schedule,4.66,71.92,
Heterophile antibody screen,86308,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.66,,,,,,,fee schedule,4.66,71.92,Laboratory
Heterophile antibody screen,86308,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.44,,,,,,,fee schedule,4.66,71.92,APC
Heterophile antibody screen,86308,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5.39,,,,,,,fee schedule,4.66,71.92,APC
Heterophile antibody screen,86308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5.18,,,,,,,fee schedule,4.66,71.92,APC
Heterophile antibody screen,86308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.93,,,,,,,fee schedule,4.66,71.92,Radiology
Heterophile antibody screen,86308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.25,,,,,,,fee schedule,4.66,71.92,APC
Heterophile antibody screen,86308,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9.06,,,,,,,fee schedule,4.66,71.92,APC
Heterophile antibody titer,86309,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,35.72,,,,,,,fee schedule,5.82,35.72,
Heterophile antibody titer,86309,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28.63,,,,,,,fee schedule,5.82,35.72,
Heterophile antibody titer,86309,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31.28,,,,,,,fee schedule,5.82,35.72,
Heterophile antibody titer,86309,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,32.89,,,,,,,fee schedule,5.82,35.72,
Heterophile antibody titer,86309,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.82,,,,,,,fee schedule,5.82,35.72,Laboratory
Heterophile antibody titer,86309,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.79,,,,,,,fee schedule,5.82,35.72,APC
Heterophile antibody titer,86309,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6.73,,,,,,,fee schedule,5.82,35.72,APC
Heterophile antibody titer,86309,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6.47,,,,,,,fee schedule,5.82,35.72,APC
Heterophile antibody titer,86309,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.9,,,,,,,fee schedule,5.82,35.72,Radiology
Heterophile antibody titer,86309,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.06,,,,,,,fee schedule,5.82,35.72,APC
Heterophile antibody titer,86309,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11.32,,,,,,,fee schedule,5.82,35.72,APC
Heterophile antibody absrbj,86310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,40.71,,,,,,,fee schedule,6.63,40.71,
Heterophile antibody absrbj,86310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32.63,,,,,,,fee schedule,6.63,40.71,
Heterophile antibody absrbj,86310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35.65,,,,,,,fee schedule,6.63,40.71,
Heterophile antibody absrbj,86310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37.48,,,,,,,fee schedule,6.63,40.71,
Heterophile antibody absrbj,86310,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.63,,,,,,,fee schedule,6.63,40.71,Laboratory
Heterophile antibody absrbj,86310,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.74,,,,,,,fee schedule,6.63,40.71,APC
Heterophile antibody absrbj,86310,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7.66,,,,,,,fee schedule,6.63,40.71,APC
Heterophile antibody absrbj,86310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7.37,,,,,,,fee schedule,6.63,40.71,APC
Heterophile antibody absrbj,86310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11.28,,,,,,,fee schedule,6.63,40.71,Radiology
Heterophile antibody absrbj,86310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10.32,,,,,,,fee schedule,6.63,40.71,APC
Heterophile antibody absrbj,86310,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12.9,,,,,,,fee schedule,6.63,40.71,APC
Immunoassay tumor other,86316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,65.15,,,,,,,fee schedule,18.73,65.15,
Immunoassay tumor other,86316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52.23,,,,,,,fee schedule,18.73,65.15,
Immunoassay tumor other,86316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.05,,,,,,,fee schedule,18.73,65.15,
Immunoassay tumor other,86316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59.98,,,,,,,fee schedule,18.73,65.15,
Immunoassay tumor other,86316,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.73,,,,,,,fee schedule,18.73,65.15,Laboratory
Immunoassay tumor other,86316,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.85,,,,,,,fee schedule,18.73,65.15,APC
Immunoassay tumor other,86316,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,21.64,,,,,,,fee schedule,18.73,65.15,APC
Immunoassay tumor other,86316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,20.81,,,,,,,fee schedule,18.73,65.15,APC
Immunoassay tumor other,86316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,31.84,,,,,,,fee schedule,18.73,65.15,Radiology
Immunoassay tumor other,86316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29.13,,,,,,,fee schedule,18.73,65.15,APC
Immunoassay tumor other,86316,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,36.42,,,,,,,fee schedule,18.73,65.15,APC
Immunoassay infectious agent,86317,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,48.13,,,,,,,fee schedule,13.49,48.13,
Immunoassay infectious agent,86317,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38.58,,,,,,,fee schedule,13.49,48.13,
Immunoassay infectious agent,86317,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.14,,,,,,,fee schedule,13.49,48.13,
Immunoassay infectious agent,86317,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,44.31,,,,,,,fee schedule,13.49,48.13,
Immunoassay infectious agent,86317,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.49,,,,,,,fee schedule,13.49,48.13,Laboratory
Immunoassay infectious agent,86317,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.74,,,,,,,fee schedule,13.49,48.13,APC
Immunoassay infectious agent,86317,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,15.59,,,,,,,fee schedule,13.49,48.13,APC
Immunoassay infectious agent,86317,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14.99,,,,,,,fee schedule,13.49,48.13,APC
Immunoassay infectious agent,86317,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.93,,,,,,,fee schedule,13.49,48.13,Radiology
Immunoassay infectious agent,86317,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.99,,,,,,,fee schedule,13.49,48.13,APC
Immunoassay infectious agent,86317,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,26.23,,,,,,,fee schedule,13.49,48.13,APC
Immunoassay infectious agent,86318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,71.48,,,,,,,fee schedule,16.28,71.48,
Immunoassay infectious agent,86318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.3,,,,,,,fee schedule,16.28,71.48,
Immunoassay infectious agent,86318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,62.59,,,,,,,fee schedule,16.28,71.48,
Immunoassay infectious agent,86318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,65.81,,,,,,,fee schedule,16.28,71.48,
Immunoassay infectious agent,86318,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.28,,,,,,,fee schedule,16.28,71.48,Laboratory
Immunoassay infectious agent,86318,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.99,,,,,,,fee schedule,16.28,71.48,APC
Immunoassay infectious agent,86318,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18.81,,,,,,,fee schedule,16.28,71.48,APC
Immunoassay infectious agent,86318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18.09,,,,,,,fee schedule,16.28,71.48,APC
Immunoassay infectious agent,86318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27.68,,,,,,,fee schedule,16.28,71.48,Radiology
Immunoassay infectious agent,86318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.33,,,,,,,fee schedule,16.28,71.48,APC
Immunoassay infectious agent,86318,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31.66,,,,,,,fee schedule,16.28,71.48,APC
Serum immunoelectrophoresis,86320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,123.68,,,,,,,fee schedule,26.93,123.68,
Serum immunoelectrophoresis,86320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,99.14,,,,,,,fee schedule,26.93,123.68,
Serum immunoelectrophoresis,86320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,108.3,,,,,,,fee schedule,26.93,123.68,
Serum immunoelectrophoresis,86320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,113.87,,,,,,,fee schedule,26.93,123.68,
Serum immunoelectrophoresis,86320,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26.93,,,,,,,fee schedule,26.93,123.68,Laboratory
Serum immunoelectrophoresis,86320,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,31.42,,,,,,,fee schedule,26.93,123.68,APC
Serum immunoelectrophoresis,86320,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,31.12,,,,,,,fee schedule,26.93,123.68,APC
Serum immunoelectrophoresis,86320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,29.92,,,,,,,fee schedule,26.93,123.68,APC
Serum immunoelectrophoresis,86320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,45.78,,,,,,,fee schedule,26.93,123.68,Radiology
Serum immunoelectrophoresis,86320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,41.89,,,,,,,fee schedule,26.93,123.68,APC
Serum immunoelectrophoresis,86320,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,52.36,,,,,,,fee schedule,26.93,123.68,APC
Other immunoelectrophoresis,86325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,123.42,,,,,,,fee schedule,20.82,123.42,
Other immunoelectrophoresis,86325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,98.93,,,,,,,fee schedule,20.82,123.42,
Other immunoelectrophoresis,86325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,108.07,,,,,,,fee schedule,20.82,123.42,
Other immunoelectrophoresis,86325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,113.62,,,,,,,fee schedule,20.82,123.42,
Other immunoelectrophoresis,86325,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,20.82,,,,,,,fee schedule,20.82,123.42,Laboratory
Other immunoelectrophoresis,86325,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,24.29,,,,,,,fee schedule,20.82,123.42,APC
Other immunoelectrophoresis,86325,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,24.06,,,,,,,fee schedule,20.82,123.42,APC
Other immunoelectrophoresis,86325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,23.13,,,,,,,fee schedule,20.82,123.42,APC
Other immunoelectrophoresis,86325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,35.39,,,,,,,fee schedule,20.82,123.42,Radiology
Other immunoelectrophoresis,86325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,32.38,,,,,,,fee schedule,20.82,123.42,APC
Other immunoelectrophoresis,86325,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,40.48,,,,,,,fee schedule,20.82,123.42,APC
Immunoelectrophoresis assay,86327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,125.23,,,,,,,fee schedule,100.38,125.23,
Immunoelectrophoresis assay,86327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,100.38,,,,,,,fee schedule,100.38,125.23,
Immunoelectrophoresis assay,86327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,109.66,,,,,,,fee schedule,100.38,125.23,
Immunoelectrophoresis assay,86327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,115.29,,,,,,,fee schedule,100.38,125.23,
Ia nfct ab sarscov2 covid19,86328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,170.97,,,,,,,fee schedule,40.75,170.97,
Ia nfct ab sarscov2 covid19,86328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,137.05,,,,,,,fee schedule,40.75,170.97,
Ia nfct ab sarscov2 covid19,86328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,149.71,,,,,,,fee schedule,40.75,170.97,
Ia nfct ab sarscov2 covid19,86328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,157.4,,,,,,,fee schedule,40.75,170.97,
Ia nfct ab sarscov2 covid19,86328,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,40.75,,,,,,,fee schedule,40.75,170.97,Laboratory
Ia nfct ab sarscov2 covid19,86328,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,47.54,,,,,,,fee schedule,40.75,170.97,APC
Ia nfct ab sarscov2 covid19,86328,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,47.09,,,,,,,fee schedule,40.75,170.97,APC
Ia nfct ab sarscov2 covid19,86328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,45.28,,,,,,,fee schedule,40.75,170.97,APC
Ia nfct ab sarscov2 covid19,86328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,69.28,,,,,,,fee schedule,40.75,170.97,Radiology
Ia nfct ab sarscov2 covid19,86328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,63.39,,,,,,,fee schedule,40.75,170.97,APC
Ia nfct ab sarscov2 covid19,86328,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,79.24,,,,,,,fee schedule,40.75,170.97,APC
Immunodiffusion nes,86329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,77.53,,,,,,,fee schedule,12.64,77.53,
Immunodiffusion nes,86329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,62.15,,,,,,,fee schedule,12.64,77.53,
Immunodiffusion nes,86329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,67.89,,,,,,,fee schedule,12.64,77.53,
Immunodiffusion nes,86329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,71.37,,,,,,,fee schedule,12.64,77.53,
Immunodiffusion nes,86329,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.65,,,,,,,fee schedule,12.64,77.53,Laboratory
Immunodiffusion nes,86329,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.75,,,,,,,fee schedule,12.64,77.53,APC
Immunodiffusion nes,86329,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,14.61,,,,,,,fee schedule,12.64,77.53,APC
Immunodiffusion nes,86329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14.05,,,,,,,fee schedule,12.64,77.53,APC
Immunodiffusion nes,86329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21.5,,,,,,,fee schedule,12.64,77.53,Radiology
Immunodiffusion nes,86329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.67,,,,,,,fee schedule,12.64,77.53,APC
Immunodiffusion nes,86329,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,24.59,,,,,,,fee schedule,12.64,77.53,APC
Immunodiffusion ouchterlony,86331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,56.76,,,,,,,fee schedule,10.78,56.76,
Immunodiffusion ouchterlony,86331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,45.5,,,,,,,fee schedule,10.78,56.76,
Immunodiffusion ouchterlony,86331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,49.71,,,,,,,fee schedule,10.78,56.76,
Immunodiffusion ouchterlony,86331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,52.26,,,,,,,fee schedule,10.78,56.76,
Immunodiffusion ouchterlony,86331,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.78,,,,,,,fee schedule,10.78,56.76,Laboratory
Immunodiffusion ouchterlony,86331,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.58,,,,,,,fee schedule,10.78,56.76,APC
Immunodiffusion ouchterlony,86331,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.46,,,,,,,fee schedule,10.78,56.76,APC
Immunodiffusion ouchterlony,86331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11.98,,,,,,,fee schedule,10.78,56.76,APC
Immunodiffusion ouchterlony,86331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.33,,,,,,,fee schedule,10.78,56.76,Radiology
Immunodiffusion ouchterlony,86331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.77,,,,,,,fee schedule,10.78,56.76,APC
Immunodiffusion ouchterlony,86331,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20.96,,,,,,,fee schedule,10.78,56.76,APC
Immune complex assay,86332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,134.53,,,,,,,fee schedule,21.93,134.53,
Immune complex assay,86332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,107.84,,,,,,,fee schedule,21.93,134.53,
Immune complex assay,86332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,117.8,,,,,,,fee schedule,21.93,134.53,
Immune complex assay,86332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,123.85,,,,,,,fee schedule,21.93,134.53,
Immune complex assay,86332,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21.93,,,,,,,fee schedule,21.93,134.53,Laboratory
Immune complex assay,86332,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,25.59,,,,,,,fee schedule,21.93,134.53,APC
Immune complex assay,86332,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,25.34,,,,,,,fee schedule,21.93,134.53,APC
Immune complex assay,86332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,24.37,,,,,,,fee schedule,21.93,134.53,APC
Immune complex assay,86332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,37.29,,,,,,,fee schedule,21.93,134.53,Radiology
Immune complex assay,86332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,34.12,,,,,,,fee schedule,21.93,134.53,APC
Immune complex assay,86332,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,42.65,,,,,,,fee schedule,21.93,134.53,APC
Immunofix e-phoresis serum,86334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,281.35,,,,,,,fee schedule,20.11,281.35,
Immunofix e-phoresis serum,86334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,225.53,,,,,,,fee schedule,20.11,281.35,
Immunofix e-phoresis serum,86334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,246.37,,,,,,,fee schedule,20.11,281.35,
Immunofix e-phoresis serum,86334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,259.02,,,,,,,fee schedule,20.11,281.35,
Immunofix e-phoresis serum,86334,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,20.11,,,,,,,fee schedule,20.11,281.35,Laboratory
Immunofix e-phoresis serum,86334,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,23.46,,,,,,,fee schedule,20.11,281.35,APC
Immunofix e-phoresis serum,86334,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,23.23,,,,,,,fee schedule,20.11,281.35,APC
Immunofix e-phoresis serum,86334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,22.34,,,,,,,fee schedule,20.11,281.35,APC
Immunofix e-phoresis serum,86334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,34.18,,,,,,,fee schedule,20.11,281.35,Radiology
Immunofix e-phoresis serum,86334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,31.28,,,,,,,fee schedule,20.11,281.35,APC
Immunofix e-phoresis serum,86334,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,39.1,,,,,,,fee schedule,20.11,281.35,APC
Immunfix e-phorsis/urine/csf,86335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,161.97,,,,,,,fee schedule,26.42,161.97,
Immunfix e-phorsis/urine/csf,86335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,129.84,,,,,,,fee schedule,26.42,161.97,
Immunfix e-phorsis/urine/csf,86335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,141.83,,,,,,,fee schedule,26.42,161.97,
Immunfix e-phorsis/urine/csf,86335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,149.12,,,,,,,fee schedule,26.42,161.97,
Immunfix e-phorsis/urine/csf,86335,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26.42,,,,,,,fee schedule,26.42,161.97,Laboratory
Immunfix e-phorsis/urine/csf,86335,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.82,,,,,,,fee schedule,26.42,161.97,APC
Immunfix e-phorsis/urine/csf,86335,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,30.52,,,,,,,fee schedule,26.42,161.97,APC
Immunfix e-phorsis/urine/csf,86335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,29.35,,,,,,,fee schedule,26.42,161.97,APC
Immunfix e-phorsis/urine/csf,86335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,44.91,,,,,,,fee schedule,26.42,161.97,Radiology
Immunfix e-phorsis/urine/csf,86335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,41.09,,,,,,,fee schedule,26.42,161.97,APC
Immunfix e-phorsis/urine/csf,86335,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,51.36,,,,,,,fee schedule,26.42,161.97,APC
Inhibin A,86336,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.42,,,,,,,fee schedule,14.03,60.42,
Inhibin A,86336,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48.43,,,,,,,fee schedule,14.03,60.42,
Inhibin A,86336,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52.9,,,,,,,fee schedule,14.03,60.42,
Inhibin A,86336,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55.62,,,,,,,fee schedule,14.03,60.42,
Inhibin A,86336,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.03,,,,,,,fee schedule,14.03,60.42,Laboratory
Inhibin A,86336,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.37,,,,,,,fee schedule,14.03,60.42,APC
Inhibin A,86336,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,16.21,,,,,,,fee schedule,14.03,60.42,APC
Inhibin A,86336,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,15.59,,,,,,,fee schedule,14.03,60.42,APC
Inhibin A,86336,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.85,,,,,,,fee schedule,14.03,60.42,Radiology
Inhibin A,86336,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21.83,,,,,,,fee schedule,14.03,60.42,APC
Inhibin A,86336,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,27.28,,,,,,,fee schedule,14.03,60.42,APC
Insulin antibodies,86337,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.64,,,,,,,fee schedule,19.27,66.64,
Insulin antibodies,86337,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.41,,,,,,,fee schedule,19.27,66.64,
Insulin antibodies,86337,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,58.35,,,,,,,fee schedule,19.27,66.64,
Insulin antibodies,86337,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,61.35,,,,,,,fee schedule,19.27,66.64,
Insulin antibodies,86337,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.27,,,,,,,fee schedule,19.27,66.64,Laboratory
Insulin antibodies,86337,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,22.48,,,,,,,fee schedule,19.27,66.64,APC
Insulin antibodies,86337,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,22.27,,,,,,,fee schedule,19.27,66.64,APC
Insulin antibodies,86337,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,21.41,,,,,,,fee schedule,19.27,66.64,APC
Insulin antibodies,86337,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,32.76,,,,,,,fee schedule,19.27,66.64,Radiology
Insulin antibodies,86337,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29.97,,,,,,,fee schedule,19.27,66.64,APC
Insulin antibodies,86337,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,37.47,,,,,,,fee schedule,19.27,66.64,APC
Intrinsic factor antibody,86340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,217.67,,,,,,,fee schedule,13.57,217.67,
Intrinsic factor antibody,86340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,174.49,,,,,,,fee schedule,13.57,217.67,
Intrinsic factor antibody,86340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,190.61,,,,,,,fee schedule,13.57,217.67,
Intrinsic factor antibody,86340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,200.4,,,,,,,fee schedule,13.57,217.67,
Intrinsic factor antibody,86340,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.57,,,,,,,fee schedule,13.57,217.67,Laboratory
Intrinsic factor antibody,86340,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.83,,,,,,,fee schedule,13.57,217.67,APC
Intrinsic factor antibody,86340,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,15.68,,,,,,,fee schedule,13.57,217.67,APC
Intrinsic factor antibody,86340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,15.08,,,,,,,fee schedule,13.57,217.67,APC
Intrinsic factor antibody,86340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.07,,,,,,,fee schedule,13.57,217.67,Radiology
Intrinsic factor antibody,86340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21.11,,,,,,,fee schedule,13.57,217.67,APC
Intrinsic factor antibody,86340,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,26.39,,,,,,,fee schedule,13.57,217.67,APC
Islet cell antibody,86341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,61.64,,,,,,,fee schedule,21.21,61.64,
Islet cell antibody,86341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,49.41,,,,,,,fee schedule,21.21,61.64,
Islet cell antibody,86341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.97,,,,,,,fee schedule,21.21,61.64,
Islet cell antibody,86341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,56.75,,,,,,,fee schedule,21.21,61.64,
Islet cell antibody,86341,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21.21,,,,,,,fee schedule,21.21,61.64,Laboratory
Islet cell antibody,86341,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,24.75,,,,,,,fee schedule,21.21,61.64,APC
Islet cell antibody,86341,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,24.51,,,,,,,fee schedule,21.21,61.64,APC
Islet cell antibody,86341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,23.57,,,,,,,fee schedule,21.21,61.64,APC
Islet cell antibody,86341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,36.06,,,,,,,fee schedule,21.21,61.64,Radiology
Islet cell antibody,86341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,33,,,,,,,fee schedule,21.21,61.64,APC
Islet cell antibody,86341,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,41.25,,,,,,,fee schedule,21.21,61.64,APC
Leukocyte histamine release,86343,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,68.8,,,,,,,fee schedule,11.21,68.8,
Leukocyte histamine release,86343,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55.15,,,,,,,fee schedule,11.21,68.8,
Leukocyte histamine release,86343,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,60.24,,,,,,,fee schedule,11.21,68.8,
Leukocyte histamine release,86343,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,63.34,,,,,,,fee schedule,11.21,68.8,
Leukocyte histamine release,86343,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.21,,,,,,,fee schedule,11.21,68.8,Laboratory
Leukocyte histamine release,86343,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.08,,,,,,,fee schedule,11.21,68.8,APC
Leukocyte histamine release,86343,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.96,,,,,,,fee schedule,11.21,68.8,APC
Leukocyte histamine release,86343,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.46,,,,,,,fee schedule,11.21,68.8,APC
Leukocyte histamine release,86343,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.06,,,,,,,fee schedule,11.21,68.8,Radiology
Leukocyte histamine release,86343,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.44,,,,,,,fee schedule,11.21,68.8,APC
Leukocyte histamine release,86343,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21.8,,,,,,,fee schedule,11.21,68.8,APC
Leukocyte phagocytosis,86344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,44.07,,,,,,,fee schedule,9.35,44.07,
Leukocyte phagocytosis,86344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35.33,,,,,,,fee schedule,9.35,44.07,
Leukocyte phagocytosis,86344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38.59,,,,,,,fee schedule,9.35,44.07,
Leukocyte phagocytosis,86344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,40.58,,,,,,,fee schedule,9.35,44.07,
Leukocyte phagocytosis,86344,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.35,,,,,,,fee schedule,9.35,44.07,Laboratory
Leukocyte phagocytosis,86344,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.91,,,,,,,fee schedule,9.35,44.07,APC
Leukocyte phagocytosis,86344,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10.81,,,,,,,fee schedule,9.35,44.07,APC
Leukocyte phagocytosis,86344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10.39,,,,,,,fee schedule,9.35,44.07,APC
Leukocyte phagocytosis,86344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15.9,,,,,,,fee schedule,9.35,44.07,Radiology
Leukocyte phagocytosis,86344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.55,,,,,,,fee schedule,9.35,44.07,APC
Leukocyte phagocytosis,86344,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18.18,,,,,,,fee schedule,9.35,44.07,APC
Cell function assay w/stim,86352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,222.86,,,,,,,fee schedule,122.27,237.76,
Cell function assay w/stim,86352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,178.64,,,,,,,fee schedule,122.27,237.76,
Cell function assay w/stim,86352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,195.15,,,,,,,fee schedule,122.27,237.76,
Cell function assay w/stim,86352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,205.17,,,,,,,fee schedule,122.27,237.76,
Cell function assay w/stim,86352,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,122.27,,,,,,,fee schedule,122.27,237.76,Laboratory
Cell function assay w/stim,86352,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,142.65,,,,,,,fee schedule,122.27,237.76,APC
Cell function assay w/stim,86352,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,141.29,,,,,,,fee schedule,122.27,237.76,APC
Cell function assay w/stim,86352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,135.86,,,,,,,fee schedule,122.27,237.76,APC
Cell function assay w/stim,86352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,207.87,,,,,,,fee schedule,122.27,237.76,Radiology
Cell function assay w/stim,86352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,190.2,,,,,,,fee schedule,122.27,237.76,APC
Cell function assay w/stim,86352,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,237.76,,,,,,,fee schedule,122.27,237.76,APC
Lymphocyte transformation,86353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,270.57,,,,,,,fee schedule,44.13,270.57,
Lymphocyte transformation,86353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,216.89,,,,,,,fee schedule,44.13,270.57,
Lymphocyte transformation,86353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,236.93,,,,,,,fee schedule,44.13,270.57,
Lymphocyte transformation,86353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,249.1,,,,,,,fee schedule,44.13,270.57,
Lymphocyte transformation,86353,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,44.13,,,,,,,fee schedule,44.13,270.57,Laboratory
Lymphocyte transformation,86353,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,51.48,,,,,,,fee schedule,44.13,270.57,APC
Lymphocyte transformation,86353,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,50.99,,,,,,,fee schedule,44.13,270.57,APC
Lymphocyte transformation,86353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,49.03,,,,,,,fee schedule,44.13,270.57,APC
Lymphocyte transformation,86353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,75.02,,,,,,,fee schedule,44.13,270.57,Radiology
Lymphocyte transformation,86353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,68.64,,,,,,,fee schedule,44.13,270.57,APC
Lymphocyte transformation,86353,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,85.8,,,,,,,fee schedule,44.13,270.57,APC
B cells total count,86355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,169.12,,,,,,,fee schedule,33.96,169.12,
B cells total count,86355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,135.56,,,,,,,fee schedule,33.96,169.12,
B cells total count,86355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,148.09,,,,,,,fee schedule,33.96,169.12,
B cells total count,86355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,155.7,,,,,,,fee schedule,33.96,169.12,
B cells total count,86355,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,33.96,,,,,,,fee schedule,33.96,169.12,Laboratory
B cells total count,86355,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.62,,,,,,,fee schedule,33.96,169.12,APC
B cells total count,86355,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,39.24,,,,,,,fee schedule,33.96,169.12,APC
B cells total count,86355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,37.73,,,,,,,fee schedule,33.96,169.12,APC
B cells total count,86355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,57.73,,,,,,,fee schedule,33.96,169.12,Radiology
B cells total count,86355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,52.82,,,,,,,fee schedule,33.96,169.12,APC
B cells total count,86355,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,66.03,,,,,,,fee schedule,33.96,169.12,APC
Mononuclear cell antigen,86356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,78.48,,,,,,,fee schedule,24.1,78.48,
Mononuclear cell antigen,86356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,62.91,,,,,,,fee schedule,24.1,78.48,
Mononuclear cell antigen,86356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,68.72,,,,,,,fee schedule,24.1,78.48,
Mononuclear cell antigen,86356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,72.25,,,,,,,fee schedule,24.1,78.48,
Mononuclear cell antigen,86356,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24.1,,,,,,,fee schedule,24.1,78.48,Laboratory
Mononuclear cell antigen,86356,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,28.12,,,,,,,fee schedule,24.1,78.48,APC
Mononuclear cell antigen,86356,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,27.85,,,,,,,fee schedule,24.1,78.48,APC
Mononuclear cell antigen,86356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,26.78,,,,,,,fee schedule,24.1,78.48,APC
Mononuclear cell antigen,86356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40.97,,,,,,,fee schedule,24.1,78.48,Radiology
Mononuclear cell antigen,86356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,37.49,,,,,,,fee schedule,24.1,78.48,APC
Mononuclear cell antigen,86356,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,46.86,,,,,,,fee schedule,24.1,78.48,APC
Nk cells total count,86357,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,169.12,,,,,,,fee schedule,33.96,169.12,
Nk cells total count,86357,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,135.56,,,,,,,fee schedule,33.96,169.12,
Nk cells total count,86357,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,148.09,,,,,,,fee schedule,33.96,169.12,
Nk cells total count,86357,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,155.7,,,,,,,fee schedule,33.96,169.12,
Nk cells total count,86357,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,33.96,,,,,,,fee schedule,33.96,169.12,Laboratory
Nk cells total count,86357,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.62,,,,,,,fee schedule,33.96,169.12,APC
Nk cells total count,86357,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,39.24,,,,,,,fee schedule,33.96,169.12,APC
Nk cells total count,86357,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,37.73,,,,,,,fee schedule,33.96,169.12,APC
Nk cells total count,86357,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,57.73,,,,,,,fee schedule,33.96,169.12,Radiology
Nk cells total count,86357,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,52.82,,,,,,,fee schedule,33.96,169.12,APC
Nk cells total count,86357,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,66.03,,,,,,,fee schedule,33.96,169.12,APC
T cells total count,86359,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,169.12,,,,,,,fee schedule,33.96,169.12,
T cells total count,86359,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,135.56,,,,,,,fee schedule,33.96,169.12,
T cells total count,86359,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,148.09,,,,,,,fee schedule,33.96,169.12,
T cells total count,86359,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,155.7,,,,,,,fee schedule,33.96,169.12,
T cells total count,86359,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,33.96,,,,,,,fee schedule,33.96,169.12,Laboratory
T cells total count,86359,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.62,,,,,,,fee schedule,33.96,169.12,APC
T cells total count,86359,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,39.24,,,,,,,fee schedule,33.96,169.12,APC
T cells total count,86359,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,37.73,,,,,,,fee schedule,33.96,169.12,APC
T cells total count,86359,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,57.73,,,,,,,fee schedule,33.96,169.12,Radiology
T cells total count,86359,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,52.82,,,,,,,fee schedule,33.96,169.12,APC
T cells total count,86359,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,66.03,,,,,,,fee schedule,33.96,169.12,APC
T cell absolute count/ratio,86360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,259.31,,,,,,,fee schedule,42.28,259.31,
T cell absolute count/ratio,86360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,207.86,,,,,,,fee schedule,42.28,259.31,
T cell absolute count/ratio,86360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,227.07,,,,,,,fee schedule,42.28,259.31,
T cell absolute count/ratio,86360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,238.73,,,,,,,fee schedule,42.28,259.31,
T cell absolute count/ratio,86360,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,42.28,,,,,,,fee schedule,42.28,259.31,Laboratory
T cell absolute count/ratio,86360,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,49.33,,,,,,,fee schedule,42.28,259.31,APC
T cell absolute count/ratio,86360,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,48.86,,,,,,,fee schedule,42.28,259.31,APC
T cell absolute count/ratio,86360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,46.98,,,,,,,fee schedule,42.28,259.31,APC
T cell absolute count/ratio,86360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,71.88,,,,,,,fee schedule,42.28,259.31,Radiology
T cell absolute count/ratio,86360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,65.77,,,,,,,fee schedule,42.28,259.31,APC
T cell absolute count/ratio,86360,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,82.21,,,,,,,fee schedule,42.28,259.31,APC
T cell absolute count,86361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,256.18,,,,,,,fee schedule,24.1,256.18,
T cell absolute count,86361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,205.35,,,,,,,fee schedule,24.1,256.18,
T cell absolute count,86361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,224.32,,,,,,,fee schedule,24.1,256.18,
T cell absolute count,86361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,235.84,,,,,,,fee schedule,24.1,256.18,
T cell absolute count,86361,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24.1,,,,,,,fee schedule,24.1,256.18,Laboratory
T cell absolute count,86361,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,28.12,,,,,,,fee schedule,24.1,256.18,APC
T cell absolute count,86361,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,27.85,,,,,,,fee schedule,24.1,256.18,APC
T cell absolute count,86361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,26.78,,,,,,,fee schedule,24.1,256.18,APC
T cell absolute count,86361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40.97,,,,,,,fee schedule,24.1,256.18,Radiology
T cell absolute count,86361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,37.49,,,,,,,fee schedule,24.1,256.18,APC
T cell absolute count,86361,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,46.86,,,,,,,fee schedule,24.1,256.18,APC
Mog-igg1 antb cba each,86362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45.55,,,,,,,fee schedule,10.84,45.55,
Mog-igg1 antb cba each,86362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36.51,,,,,,,fee schedule,10.84,45.55,
Mog-igg1 antb cba each,86362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39.89,,,,,,,fee schedule,10.84,45.55,
Mog-igg1 antb cba each,86362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41.93,,,,,,,fee schedule,10.84,45.55,
Mog-igg1 antb cba each,86362,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.84,,,,,,,fee schedule,10.84,45.55,Laboratory
Mog-igg1 antb cba each,86362,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.65,,,,,,,fee schedule,10.84,45.55,APC
Mog-igg1 antb cba each,86362,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.53,,,,,,,fee schedule,10.84,45.55,APC
Mog-igg1 antb cba each,86362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.05,,,,,,,fee schedule,10.84,45.55,APC
Mog-igg1 antb cba each,86362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.44,,,,,,,fee schedule,10.84,45.55,Radiology
Mog-igg1 antb cba each,86362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.87,,,,,,,fee schedule,10.84,45.55,APC
Mog-igg1 antb cba each,86362,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21.09,,,,,,,fee schedule,10.84,45.55,APC
Mog-igg1 antb flo cytmtry ea,86363,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45.55,,,,,,,fee schedule,33.96,66.03,
Mog-igg1 antb flo cytmtry ea,86363,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36.51,,,,,,,fee schedule,33.96,66.03,
Mog-igg1 antb flo cytmtry ea,86363,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39.89,,,,,,,fee schedule,33.96,66.03,
Mog-igg1 antb flo cytmtry ea,86363,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41.93,,,,,,,fee schedule,33.96,66.03,
Mog-igg1 antb flo cytmtry ea,86363,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,33.96,,,,,,,fee schedule,33.96,66.03,Laboratory
Mog-igg1 antb flo cytmtry ea,86363,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.62,,,,,,,fee schedule,33.96,66.03,APC
Mog-igg1 antb flo cytmtry ea,86363,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,39.24,,,,,,,fee schedule,33.96,66.03,APC
Mog-igg1 antb flo cytmtry ea,86363,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,37.73,,,,,,,fee schedule,33.96,66.03,APC
Mog-igg1 antb flo cytmtry ea,86363,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,57.73,,,,,,,fee schedule,33.96,66.03,Radiology
Mog-igg1 antb flo cytmtry ea,86363,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,52.82,,,,,,,fee schedule,33.96,66.03,APC
Mog-igg1 antb flo cytmtry ea,86363,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,66.03,,,,,,,fee schedule,33.96,66.03,APC
Tiss trnsgltmnase ea ig clas,86364,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,43.58,,,,,,,fee schedule,10.38,43.58,
Tiss trnsgltmnase ea ig clas,86364,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,34.94,,,,,,,fee schedule,10.38,43.58,
Tiss trnsgltmnase ea ig clas,86364,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38.16,,,,,,,fee schedule,10.38,43.58,
Tiss trnsgltmnase ea ig clas,86364,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,40.12,,,,,,,fee schedule,10.38,43.58,
Tiss trnsgltmnase ea ig clas,86364,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.38,,,,,,,fee schedule,10.38,43.58,Laboratory
Tiss trnsgltmnase ea ig clas,86364,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.11,,,,,,,fee schedule,10.38,43.58,APC
Tiss trnsgltmnase ea ig clas,86364,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11.99,,,,,,,fee schedule,10.38,43.58,APC
Tiss trnsgltmnase ea ig clas,86364,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11.53,,,,,,,fee schedule,10.38,43.58,APC
Tiss trnsgltmnase ea ig clas,86364,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.64,,,,,,,fee schedule,10.38,43.58,Radiology
Tiss trnsgltmnase ea ig clas,86364,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.14,,,,,,,fee schedule,10.38,43.58,APC
Tiss trnsgltmnase ea ig clas,86364,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20.18,,,,,,,fee schedule,10.38,43.58,APC
Muscle-specific kinase antb,86366,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.56,,,,,,,fee schedule,16.56,32.2,Laboratory
Muscle-specific kinase antb,86366,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.32,,,,,,,fee schedule,16.56,32.2,APC
Muscle-specific kinase antb,86366,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,19.14,,,,,,,fee schedule,16.56,32.2,APC
Muscle-specific kinase antb,86366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18.4,,,,,,,fee schedule,16.56,32.2,APC
Muscle-specific kinase antb,86366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.15,,,,,,,fee schedule,16.56,32.2,Radiology
Muscle-specific kinase antb,86366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.76,,,,,,,fee schedule,16.56,32.2,APC
Muscle-specific kinase antb,86366,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,32.2,,,,,,,fee schedule,16.56,32.2,APC
Stem cells total count,86367,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,169.12,,,,,,,fee schedule,70,169.12,
Stem cells total count,86367,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,135.56,,,,,,,fee schedule,70,169.12,
Stem cells total count,86367,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,148.09,,,,,,,fee schedule,70,169.12,
Stem cells total count,86367,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,155.7,,,,,,,fee schedule,70,169.12,
Stem cells total count,86367,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,70,,,,,,,fee schedule,70,169.12,Laboratory
Stem cells total count,86367,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,81.67,,,,,,,fee schedule,70,169.12,APC
Stem cells total count,86367,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,80.89,,,,,,,fee schedule,70,169.12,APC
Stem cells total count,86367,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,77.78,,,,,,,fee schedule,70,169.12,APC
Stem cells total count,86367,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,119,,,,,,,fee schedule,70,169.12,Radiology
Stem cells total count,86367,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,108.89,,,,,,,fee schedule,70,169.12,APC
Stem cells total count,86367,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,136.12,,,,,,,fee schedule,70,169.12,APC
Microsomal antibody each,86376,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,53.14,,,,,,,fee schedule,13.1,53.14,
Microsomal antibody each,86376,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.6,,,,,,,fee schedule,13.1,53.14,
Microsomal antibody each,86376,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.53,,,,,,,fee schedule,13.1,53.14,
Microsomal antibody each,86376,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,48.92,,,,,,,fee schedule,13.1,53.14,
Microsomal antibody each,86376,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.1,,,,,,,fee schedule,13.1,53.14,Laboratory
Microsomal antibody each,86376,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.28,,,,,,,fee schedule,13.1,53.14,APC
Microsomal antibody each,86376,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,15.13,,,,,,,fee schedule,13.1,53.14,APC
Microsomal antibody each,86376,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14.55,,,,,,,fee schedule,13.1,53.14,APC
Microsomal antibody each,86376,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.26,,,,,,,fee schedule,13.1,53.14,Radiology
Microsomal antibody each,86376,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.37,,,,,,,fee schedule,13.1,53.14,APC
Microsomal antibody each,86376,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,25.46,,,,,,,fee schedule,13.1,53.14,APC
Mitochondrial antibody each,86381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,96.2,,,,,,,fee schedule,22.9,96.2,
Mitochondrial antibody each,86381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,77.11,,,,,,,fee schedule,22.9,96.2,
Mitochondrial antibody each,86381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,84.24,,,,,,,fee schedule,22.9,96.2,
Mitochondrial antibody each,86381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,88.57,,,,,,,fee schedule,22.9,96.2,
Mitochondrial antibody each,86381,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22.9,,,,,,,fee schedule,22.9,96.2,Laboratory
Mitochondrial antibody each,86381,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,26.72,,,,,,,fee schedule,22.9,96.2,APC
Mitochondrial antibody each,86381,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,26.47,,,,,,,fee schedule,22.9,96.2,APC
Mitochondrial antibody each,86381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,25.45,,,,,,,fee schedule,22.9,96.2,APC
Mitochondrial antibody each,86381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,38.94,,,,,,,fee schedule,22.9,96.2,Radiology
Mitochondrial antibody each,86381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,35.63,,,,,,,fee schedule,22.9,96.2,APC
Mitochondrial antibody each,86381,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,44.54,,,,,,,fee schedule,22.9,96.2,APC
Neutralization test viral,86382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,93.33,,,,,,,fee schedule,15.22,93.33,
Neutralization test viral,86382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,74.81,,,,,,,fee schedule,15.22,93.33,
Neutralization test viral,86382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,81.72,,,,,,,fee schedule,15.22,93.33,
Neutralization test viral,86382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,85.92,,,,,,,fee schedule,15.22,93.33,
Neutralization test viral,86382,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.22,,,,,,,fee schedule,15.22,93.33,Laboratory
Neutralization test viral,86382,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.76,,,,,,,fee schedule,15.22,93.33,APC
Neutralization test viral,86382,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,17.59,,,,,,,fee schedule,15.22,93.33,APC
Neutralization test viral,86382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16.91,,,,,,,fee schedule,15.22,93.33,APC
Neutralization test viral,86382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.87,,,,,,,fee schedule,15.22,93.33,Radiology
Neutralization test viral,86382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.67,,,,,,,fee schedule,15.22,93.33,APC
Neutralization test viral,86382,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,29.59,,,,,,,fee schedule,15.22,93.33,APC
Nitroblue tetrazolium dye,86384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,62.86,,,,,,,fee schedule,12.25,62.86,
Nitroblue tetrazolium dye,86384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,50.39,,,,,,,fee schedule,12.25,62.86,
Nitroblue tetrazolium dye,86384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55.05,,,,,,,fee schedule,12.25,62.86,
Nitroblue tetrazolium dye,86384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,57.87,,,,,,,fee schedule,12.25,62.86,
Nitroblue tetrazolium dye,86384,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.25,,,,,,,fee schedule,12.25,62.86,Laboratory
Nitroblue tetrazolium dye,86384,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.29,,,,,,,fee schedule,12.25,62.86,APC
Nitroblue tetrazolium dye,86384,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,14.15,,,,,,,fee schedule,12.25,62.86,APC
Nitroblue tetrazolium dye,86384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.61,,,,,,,fee schedule,12.25,62.86,APC
Nitroblue tetrazolium dye,86384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.82,,,,,,,fee schedule,12.25,62.86,Radiology
Nitroblue tetrazolium dye,86384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.05,,,,,,,fee schedule,12.25,62.86,APC
Nitroblue tetrazolium dye,86384,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23.82,,,,,,,fee schedule,12.25,62.86,APC
Nuclear matrix protein 22,86386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,82.97,,,,,,,fee schedule,19.6,82.97,
Nuclear matrix protein 22,86386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66.51,,,,,,,fee schedule,19.6,82.97,
Nuclear matrix protein 22,86386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,72.65,,,,,,,fee schedule,19.6,82.97,
Nuclear matrix protein 22,86386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,76.39,,,,,,,fee schedule,19.6,82.97,
Nuclear matrix protein 22,86386,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.6,,,,,,,fee schedule,19.6,82.97,Laboratory
Nuclear matrix protein 22,86386,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,22.87,,,,,,,fee schedule,19.6,82.97,APC
Nuclear matrix protein 22,86386,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,22.65,,,,,,,fee schedule,19.6,82.97,APC
Nuclear matrix protein 22,86386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,21.78,,,,,,,fee schedule,19.6,82.97,APC
Nuclear matrix protein 22,86386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,33.32,,,,,,,fee schedule,19.6,82.97,Radiology
Nuclear matrix protein 22,86386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,30.49,,,,,,,fee schedule,19.6,82.97,APC
Nuclear matrix protein 22,86386,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,38.12,,,,,,,fee schedule,19.6,82.97,APC
Particle agglut antbdy scrn,86403,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,25.17,,,,,,,fee schedule,10.39,25.17,
Particle agglut antbdy scrn,86403,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20.18,,,,,,,fee schedule,10.39,25.17,
Particle agglut antbdy scrn,86403,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22.04,,,,,,,fee schedule,10.39,25.17,
Particle agglut antbdy scrn,86403,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23.18,,,,,,,fee schedule,10.39,25.17,
Particle agglut antbdy scrn,86403,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.39,,,,,,,fee schedule,10.39,25.17,Laboratory
Particle agglut antbdy scrn,86403,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.12,,,,,,,fee schedule,10.39,25.17,APC
Particle agglut antbdy scrn,86403,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12,,,,,,,fee schedule,10.39,25.17,APC
Particle agglut antbdy scrn,86403,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11.54,,,,,,,fee schedule,10.39,25.17,APC
Particle agglut antbdy scrn,86403,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.66,,,,,,,fee schedule,10.39,25.17,Radiology
Particle agglut antbdy scrn,86403,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.16,,,,,,,fee schedule,10.39,25.17,APC
Particle agglut antbdy scrn,86403,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20.2,,,,,,,fee schedule,10.39,25.17,APC
Particle agglut antbdy titr,86406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,58.7,,,,,,,fee schedule,9.58,58.7,
Particle agglut antbdy titr,86406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,47.06,,,,,,,fee schedule,9.58,58.7,
Particle agglut antbdy titr,86406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.4,,,,,,,fee schedule,9.58,58.7,
Particle agglut antbdy titr,86406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,54.04,,,,,,,fee schedule,9.58,58.7,
Particle agglut antbdy titr,86406,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.58,,,,,,,fee schedule,9.58,58.7,Laboratory
Particle agglut antbdy titr,86406,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.17,,,,,,,fee schedule,9.58,58.7,APC
Particle agglut antbdy titr,86406,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11.07,,,,,,,fee schedule,9.58,58.7,APC
Particle agglut antbdy titr,86406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10.64,,,,,,,fee schedule,9.58,58.7,APC
Particle agglut antbdy titr,86406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.28,,,,,,,fee schedule,9.58,58.7,Radiology
Particle agglut antbdy titr,86406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.9,,,,,,,fee schedule,9.58,58.7,APC
Particle agglut antbdy titr,86406,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18.62,,,,,,,fee schedule,9.58,58.7,APC
Neutrlzg antb sarscov2 scr,86408,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,159.25,,,,,,,fee schedule,37.92,159.25,
Neutrlzg antb sarscov2 scr,86408,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,127.65,,,,,,,fee schedule,37.92,159.25,
Neutrlzg antb sarscov2 scr,86408,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,139.45,,,,,,,fee schedule,37.92,159.25,
Neutrlzg antb sarscov2 scr,86408,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,146.61,,,,,,,fee schedule,37.92,159.25,
Neutrlzg antb sarscov2 scr,86408,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,37.92,,,,,,,fee schedule,37.92,159.25,Laboratory
Neutrlzg antb sarscov2 scr,86408,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,44.24,,,,,,,fee schedule,37.92,159.25,APC
Neutrlzg antb sarscov2 scr,86408,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,43.82,,,,,,,fee schedule,37.92,159.25,APC
Neutrlzg antb sarscov2 scr,86408,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,42.13,,,,,,,fee schedule,37.92,159.25,APC
Neutrlzg antb sarscov2 scr,86408,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,64.46,,,,,,,fee schedule,37.92,159.25,Radiology
Neutrlzg antb sarscov2 scr,86408,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,58.98,,,,,,,fee schedule,37.92,159.25,APC
Neutrlzg antb sarscov2 scr,86408,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,73.73,,,,,,,fee schedule,37.92,159.25,APC
Neutrlzg antb sarscov2 titer,86409,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,398.15,,,,,,,fee schedule,71.65,398.15,
Neutrlzg antb sarscov2 titer,86409,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,319.15,,,,,,,fee schedule,71.65,398.15,
Neutrlzg antb sarscov2 titer,86409,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,348.64,,,,,,,fee schedule,71.65,398.15,
Neutrlzg antb sarscov2 titer,86409,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,366.55,,,,,,,fee schedule,71.65,398.15,
Neutrlzg antb sarscov2 titer,86409,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,71.65,,,,,,,fee schedule,71.65,398.15,Laboratory
Neutrlzg antb sarscov2 titer,86409,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,83.59,,,,,,,fee schedule,71.65,398.15,APC
Neutrlzg antb sarscov2 titer,86409,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,82.79,,,,,,,fee schedule,71.65,398.15,APC
Neutrlzg antb sarscov2 titer,86409,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,79.61,,,,,,,fee schedule,71.65,398.15,APC
Neutrlzg antb sarscov2 titer,86409,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,121.8,,,,,,,fee schedule,71.65,398.15,Radiology
Neutrlzg antb sarscov2 titer,86409,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,111.45,,,,,,,fee schedule,71.65,398.15,APC
Neutrlzg antb sarscov2 titer,86409,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,139.32,,,,,,,fee schedule,71.65,398.15,APC
Sars-cov-2 antb quantitative,86413,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,159.25,,,,,,,fee schedule,46.29,159.25,
Sars-cov-2 antb quantitative,86413,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,127.65,,,,,,,fee schedule,46.29,159.25,
Sars-cov-2 antb quantitative,86413,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,139.45,,,,,,,fee schedule,46.29,159.25,
Sars-cov-2 antb quantitative,86413,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,146.61,,,,,,,fee schedule,46.29,159.25,
Sars-cov-2 antb quantitative,86413,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46.29,,,,,,,fee schedule,46.29,159.25,Laboratory
Sars-cov-2 antb quantitative,86413,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54,,,,,,,fee schedule,46.29,159.25,APC
Sars-cov-2 antb quantitative,86413,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,53.49,,,,,,,fee schedule,46.29,159.25,APC
Sars-cov-2 antb quantitative,86413,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,51.43,,,,,,,fee schedule,46.29,159.25,APC
Sars-cov-2 antb quantitative,86413,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,78.69,,,,,,,fee schedule,46.29,159.25,Radiology
Sars-cov-2 antb quantitative,86413,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,72,,,,,,,fee schedule,46.29,159.25,APC
Sars-cov-2 antb quantitative,86413,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,90,,,,,,,fee schedule,46.29,159.25,APC
Rheumatoid factor test qual,86430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,31.34,,,,,,,fee schedule,5.53,31.34,
Rheumatoid factor test qual,86430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,25.12,,,,,,,fee schedule,5.53,31.34,
Rheumatoid factor test qual,86430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,27.44,,,,,,,fee schedule,5.53,31.34,
Rheumatoid factor test qual,86430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,28.85,,,,,,,fee schedule,5.53,31.34,
Rheumatoid factor test qual,86430,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.53,,,,,,,fee schedule,5.53,31.34,Laboratory
Rheumatoid factor test qual,86430,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.45,,,,,,,fee schedule,5.53,31.34,APC
Rheumatoid factor test qual,86430,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6.39,,,,,,,fee schedule,5.53,31.34,APC
Rheumatoid factor test qual,86430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6.14,,,,,,,fee schedule,5.53,31.34,APC
Rheumatoid factor test qual,86430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.39,,,,,,,fee schedule,5.53,31.34,Radiology
Rheumatoid factor test qual,86430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8.6,,,,,,,fee schedule,5.53,31.34,APC
Rheumatoid factor test qual,86430,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10.74,,,,,,,fee schedule,5.53,31.34,APC
Rheumatoid factor quant,86431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46.33,,,,,,,fee schedule,5.1,46.33,
Rheumatoid factor quant,86431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37.14,,,,,,,fee schedule,5.1,46.33,
Rheumatoid factor quant,86431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40.57,,,,,,,fee schedule,5.1,46.33,
Rheumatoid factor quant,86431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42.66,,,,,,,fee schedule,5.1,46.33,
Rheumatoid factor quant,86431,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.1,,,,,,,fee schedule,5.1,46.33,Laboratory
Rheumatoid factor quant,86431,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.95,,,,,,,fee schedule,5.1,46.33,APC
Rheumatoid factor quant,86431,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5.9,,,,,,,fee schedule,5.1,46.33,APC
Rheumatoid factor quant,86431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5.67,,,,,,,fee schedule,5.1,46.33,APC
Rheumatoid factor quant,86431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8.68,,,,,,,fee schedule,5.1,46.33,Radiology
Rheumatoid factor quant,86431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.94,,,,,,,fee schedule,5.1,46.33,APC
Rheumatoid factor quant,86431,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9.92,,,,,,,fee schedule,5.1,46.33,APC
Tb test cell immun measure,86480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,193.7,,,,,,,fee schedule,55.78,193.7,
Tb test cell immun measure,86480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,155.27,,,,,,,fee schedule,55.78,193.7,
Tb test cell immun measure,86480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,169.62,,,,,,,fee schedule,55.78,193.7,
Tb test cell immun measure,86480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,178.33,,,,,,,fee schedule,55.78,193.7,
Tb test cell immun measure,86480,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,55.78,,,,,,,fee schedule,55.78,193.7,Laboratory
Tb test cell immun measure,86480,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,65.08,,,,,,,fee schedule,55.78,193.7,APC
Tb test cell immun measure,86480,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,64.46,,,,,,,fee schedule,55.78,193.7,APC
Tb test cell immun measure,86480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,61.98,,,,,,,fee schedule,55.78,193.7,APC
Tb test cell immun measure,86480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,94.83,,,,,,,fee schedule,55.78,193.7,Radiology
Tb test cell immun measure,86480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,86.77,,,,,,,fee schedule,55.78,193.7,APC
Tb test cell immun measure,86480,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,108.46,,,,,,,fee schedule,55.78,193.7,APC
Tb ag response t-cell susp,86481,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,90,,,,,,,fee schedule,90,175,Laboratory
Tb ag response t-cell susp,86481,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,105,,,,,,,fee schedule,90,175,APC
Tb ag response t-cell susp,86481,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,104,,,,,,,fee schedule,90,175,APC
Tb ag response t-cell susp,86481,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,100,,,,,,,fee schedule,90,175,APC
Tb ag response t-cell susp,86481,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,153,,,,,,,fee schedule,90,175,Radiology
Tb ag response t-cell susp,86481,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,140,,,,,,,fee schedule,90,175,APC
Tb ag response t-cell susp,86481,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,175,,,,,,,fee schedule,90,175,APC
Skin test candida,86485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21.09,,,,,,,fee schedule,16.91,127.04,
Skin test candida,86485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.91,,,,,,,fee schedule,16.91,127.04,
Skin test candida,86485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18.47,,,,,,,fee schedule,16.91,127.04,
Skin test candida,86485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19.42,,,,,,,fee schedule,16.91,127.04,
Skin test candida,86485,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,127.04,,,,,,,fee schedule,16.91,127.04,APC 378
Skin test candida,86485,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.07,,,,,,,fee schedule,16.91,127.04,APC
Skin test candida,86485,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,29.78,,,,,,,fee schedule,16.91,127.04,APC
Skin test candida,86485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,28.63,,,,,,,fee schedule,16.91,127.04,APC
Skin test candida,86485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43.81,,,,,,,fee schedule,16.91,127.04,Radiology
Skin test candida,86485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40.09,,,,,,,fee schedule,16.91,127.04,APC
Skin test candida,86485,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,50.11,,,,,,,fee schedule,16.91,127.04,APC
Skin test nos antigen,86486,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17.54,,,,,,,fee schedule,14.06,127.04,
Skin test nos antigen,86486,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14.06,,,,,,,fee schedule,14.06,127.04,
Skin test nos antigen,86486,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15.36,,,,,,,fee schedule,14.06,127.04,
Skin test nos antigen,86486,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16.15,,,,,,,fee schedule,14.06,127.04,
Skin test nos antigen,86486,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,127.04,,,,,,,fee schedule,14.06,127.04,APC 378
Skin test nos antigen,86486,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.07,,,,,,,fee schedule,14.06,127.04,APC
Skin test nos antigen,86486,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,29.78,,,,,,,fee schedule,14.06,127.04,APC
Skin test nos antigen,86486,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,28.63,,,,,,,fee schedule,14.06,127.04,APC
Skin test nos antigen,86486,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43.81,,,,,,,fee schedule,14.06,127.04,Radiology
Skin test nos antigen,86486,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40.09,,,,,,,fee schedule,14.06,127.04,APC
Skin test nos antigen,86486,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,50.11,,,,,,,fee schedule,14.06,127.04,APC
Coccidioidomycosis skin test,86490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21.09,,,,,,,fee schedule,16.91,21.09,
Coccidioidomycosis skin test,86490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.91,,,,,,,fee schedule,16.91,21.09,
Coccidioidomycosis skin test,86490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18.47,,,,,,,fee schedule,16.91,21.09,
Coccidioidomycosis skin test,86490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19.42,,,,,,,fee schedule,16.91,21.09,
Histoplasmosis skin test,86510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21.09,,,,,,,fee schedule,16.91,164.05,
Histoplasmosis skin test,86510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.91,,,,,,,fee schedule,16.91,164.05,
Histoplasmosis skin test,86510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18.47,,,,,,,fee schedule,16.91,164.05,
Histoplasmosis skin test,86510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19.42,,,,,,,fee schedule,16.91,164.05,
Histoplasmosis skin test,86510,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.05,,,,,,,fee schedule,16.91,164.05,APC 378
Histoplasmosis skin test,86510,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.83,,,,,,,fee schedule,16.91,164.05,APC
Histoplasmosis skin test,86510,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.46,,,,,,,fee schedule,16.91,164.05,APC
Histoplasmosis skin test,86510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.98,,,,,,,fee schedule,16.91,164.05,APC
Histoplasmosis skin test,86510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.57,,,,,,,fee schedule,16.91,164.05,Radiology
Histoplasmosis skin test,86510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.77,,,,,,,fee schedule,16.91,164.05,APC
Histoplasmosis skin test,86510,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.71,,,,,,,fee schedule,16.91,164.05,APC
TB intradermal test,86580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14.07,,,,,,,fee schedule,11.28,127.04,
TB intradermal test,86580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11.28,,,,,,,fee schedule,11.28,127.04,
TB intradermal test,86580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12.32,,,,,,,fee schedule,11.28,127.04,
TB intradermal test,86580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12.95,,,,,,,fee schedule,11.28,127.04,
TB intradermal test,86580,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,127.04,,,,,,,fee schedule,11.28,127.04,APC 378
TB intradermal test,86580,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.07,,,,,,,fee schedule,11.28,127.04,APC
TB intradermal test,86580,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,29.78,,,,,,,fee schedule,11.28,127.04,APC
TB intradermal test,86580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,28.63,,,,,,,fee schedule,11.28,127.04,APC
TB intradermal test,86580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43.81,,,,,,,fee schedule,11.28,127.04,Radiology
TB intradermal test,86580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40.09,,,,,,,fee schedule,11.28,127.04,APC
TB intradermal test,86580,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,50.11,,,,,,,fee schedule,11.28,127.04,APC
Strptcs pneum antb serot ia,86581,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,82.83,,,,,,,fee schedule,82.83,161.05,Laboratory
Strptcs pneum antb serot ia,86581,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,96.63,,,,,,,fee schedule,82.83,161.05,APC
Strptcs pneum antb serot ia,86581,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,95.71,,,,,,,fee schedule,82.83,161.05,APC
Strptcs pneum antb serot ia,86581,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,92.03,,,,,,,fee schedule,82.83,161.05,APC
Strptcs pneum antb serot ia,86581,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,140.81,,,,,,,fee schedule,82.83,161.05,Radiology
Strptcs pneum antb serot ia,86581,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,128.84,,,,,,,fee schedule,82.83,161.05,APC
Strptcs pneum antb serot ia,86581,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,161.05,,,,,,,fee schedule,82.83,161.05,APC
Streptokinase antibody,86590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.9,,,,,,,fee schedule,11.39,60.9,
Streptokinase antibody,86590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48.81,,,,,,,fee schedule,11.39,60.9,
Streptokinase antibody,86590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.32,,,,,,,fee schedule,11.39,60.9,
Streptokinase antibody,86590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,56.06,,,,,,,fee schedule,11.39,60.9,
Streptokinase antibody,86590,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.39,,,,,,,fee schedule,11.39,60.9,Laboratory
Streptokinase antibody,86590,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.29,,,,,,,fee schedule,11.39,60.9,APC
Streptokinase antibody,86590,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.17,,,,,,,fee schedule,11.39,60.9,APC
Streptokinase antibody,86590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.66,,,,,,,fee schedule,11.39,60.9,APC
Streptokinase antibody,86590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.37,,,,,,,fee schedule,11.39,60.9,Radiology
Streptokinase antibody,86590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.72,,,,,,,fee schedule,11.39,60.9,APC
Streptokinase antibody,86590,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22.16,,,,,,,fee schedule,11.39,60.9,APC
Syphilis test non-trep qual,86592,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,74.04,,,,,,,fee schedule,3.84,74.04,
Syphilis test non-trep qual,86592,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,59.35,,,,,,,fee schedule,3.84,74.04,
Syphilis test non-trep qual,86592,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,64.83,,,,,,,fee schedule,3.84,74.04,
Syphilis test non-trep qual,86592,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,68.16,,,,,,,fee schedule,3.84,74.04,
Syphilis test non-trep qual,86592,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.84,,,,,,,fee schedule,3.84,74.04,Laboratory
Syphilis test non-trep qual,86592,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.48,,,,,,,fee schedule,3.84,74.04,APC
Syphilis test non-trep qual,86592,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4.44,,,,,,,fee schedule,3.84,74.04,APC
Syphilis test non-trep qual,86592,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4.27,,,,,,,fee schedule,3.84,74.04,APC
Syphilis test non-trep qual,86592,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.53,,,,,,,fee schedule,3.84,74.04,Radiology
Syphilis test non-trep qual,86592,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.98,,,,,,,fee schedule,3.84,74.04,APC
Syphilis test non-trep qual,86592,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7.47,,,,,,,fee schedule,3.84,74.04,APC
Syphilis test non-trep quant,86593,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14.07,,,,,,,fee schedule,3.96,14.07,
Syphilis test non-trep quant,86593,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11.28,,,,,,,fee schedule,3.96,14.07,
Syphilis test non-trep quant,86593,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12.32,,,,,,,fee schedule,3.96,14.07,
Syphilis test non-trep quant,86593,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12.95,,,,,,,fee schedule,3.96,14.07,
Syphilis test non-trep quant,86593,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.96,,,,,,,fee schedule,3.96,14.07,Laboratory
Syphilis test non-trep quant,86593,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.62,,,,,,,fee schedule,3.96,14.07,APC
Syphilis test non-trep quant,86593,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4.58,,,,,,,fee schedule,3.96,14.07,APC
Syphilis test non-trep quant,86593,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4.4,,,,,,,fee schedule,3.96,14.07,APC
Syphilis test non-trep quant,86593,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.73,,,,,,,fee schedule,3.96,14.07,Radiology
Syphilis test non-trep quant,86593,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.16,,,,,,,fee schedule,3.96,14.07,APC
Syphilis test non-trep quant,86593,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7.7,,,,,,,fee schedule,3.96,14.07,APC
Voltage-gtd ca chnl antb ea,86596,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,69.55,,,,,,,fee schedule,10.84,69.55,
Voltage-gtd ca chnl antb ea,86596,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55.75,,,,,,,fee schedule,10.84,69.55,
Voltage-gtd ca chnl antb ea,86596,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,60.9,,,,,,,fee schedule,10.84,69.55,
Voltage-gtd ca chnl antb ea,86596,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,64.03,,,,,,,fee schedule,10.84,69.55,
Voltage-gtd ca chnl antb ea,86596,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.84,,,,,,,fee schedule,10.84,69.55,Laboratory
Voltage-gtd ca chnl antb ea,86596,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.65,,,,,,,fee schedule,10.84,69.55,APC
Voltage-gtd ca chnl antb ea,86596,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.53,,,,,,,fee schedule,10.84,69.55,APC
Voltage-gtd ca chnl antb ea,86596,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.05,,,,,,,fee schedule,10.84,69.55,APC
Voltage-gtd ca chnl antb ea,86596,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.44,,,,,,,fee schedule,10.84,69.55,Radiology
Voltage-gtd ca chnl antb ea,86596,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.87,,,,,,,fee schedule,10.84,69.55,APC
Voltage-gtd ca chnl antb ea,86596,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21.09,,,,,,,fee schedule,10.84,69.55,APC
Antinomyces antibody,86602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,50.61,,,,,,,fee schedule,9.16,50.61,
Antinomyces antibody,86602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40.57,,,,,,,fee schedule,9.16,50.61,
Antinomyces antibody,86602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,44.32,,,,,,,fee schedule,9.16,50.61,
Antinomyces antibody,86602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46.6,,,,,,,fee schedule,9.16,50.61,
Antinomyces antibody,86602,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.16,,,,,,,fee schedule,9.16,50.61,Laboratory
Antinomyces antibody,86602,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.69,,,,,,,fee schedule,9.16,50.61,APC
Antinomyces antibody,86602,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10.59,,,,,,,fee schedule,9.16,50.61,APC
Antinomyces antibody,86602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10.18,,,,,,,fee schedule,9.16,50.61,APC
Antinomyces antibody,86602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15.58,,,,,,,fee schedule,9.16,50.61,Radiology
Antinomyces antibody,86602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.25,,,,,,,fee schedule,9.16,50.61,APC
Antinomyces antibody,86602,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,17.81,,,,,,,fee schedule,9.16,50.61,APC
Adenovirus antibody,86603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,71.03,,,,,,,fee schedule,11.58,71.03,
Adenovirus antibody,86603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56.93,,,,,,,fee schedule,11.58,71.03,
Adenovirus antibody,86603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,62.19,,,,,,,fee schedule,11.58,71.03,
Adenovirus antibody,86603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,65.39,,,,,,,fee schedule,11.58,71.03,
Adenovirus antibody,86603,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.58,,,,,,,fee schedule,11.58,71.03,Laboratory
Adenovirus antibody,86603,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.51,,,,,,,fee schedule,11.58,71.03,APC
Adenovirus antibody,86603,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.38,,,,,,,fee schedule,11.58,71.03,APC
Adenovirus antibody,86603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.87,,,,,,,fee schedule,11.58,71.03,APC
Adenovirus antibody,86603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.69,,,,,,,fee schedule,11.58,71.03,Radiology
Adenovirus antibody,86603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.02,,,,,,,fee schedule,11.58,71.03,APC
Adenovirus antibody,86603,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22.52,,,,,,,fee schedule,11.58,71.03,APC
Aspergillus antibody,86606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,112.54,,,,,,,fee schedule,13.54,112.54,
Aspergillus antibody,86606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,90.21,,,,,,,fee schedule,13.54,112.54,
Aspergillus antibody,86606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,98.55,,,,,,,fee schedule,13.54,112.54,
Aspergillus antibody,86606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,103.61,,,,,,,fee schedule,13.54,112.54,
Aspergillus antibody,86606,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.55,,,,,,,fee schedule,13.54,112.54,Laboratory
Aspergillus antibody,86606,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.8,,,,,,,fee schedule,13.54,112.54,APC
Aspergillus antibody,86606,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,15.65,,,,,,,fee schedule,13.54,112.54,APC
Aspergillus antibody,86606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,15.05,,,,,,,fee schedule,13.54,112.54,APC
Aspergillus antibody,86606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.03,,,,,,,fee schedule,13.54,112.54,Radiology
Aspergillus antibody,86606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21.07,,,,,,,fee schedule,13.54,112.54,APC
Aspergillus antibody,86606,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,26.34,,,,,,,fee schedule,13.54,112.54,APC
Bacterium antibody,86609,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,53.26,,,,,,,fee schedule,11.59,53.26,
Bacterium antibody,86609,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.69,,,,,,,fee schedule,11.59,53.26,
Bacterium antibody,86609,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.64,,,,,,,fee schedule,11.59,53.26,
Bacterium antibody,86609,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,49.03,,,,,,,fee schedule,11.59,53.26,
Bacterium antibody,86609,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.59,,,,,,,fee schedule,11.59,53.26,Laboratory
Bacterium antibody,86609,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.52,,,,,,,fee schedule,11.59,53.26,APC
Bacterium antibody,86609,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.4,,,,,,,fee schedule,11.59,53.26,APC
Bacterium antibody,86609,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.88,,,,,,,fee schedule,11.59,53.26,APC
Bacterium antibody,86609,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.71,,,,,,,fee schedule,11.59,53.26,Radiology
Bacterium antibody,86609,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.03,,,,,,,fee schedule,11.59,53.26,APC
Bacterium antibody,86609,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22.54,,,,,,,fee schedule,11.59,53.26,APC
Bartonella Antibody,86611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,64.41,,,,,,,fee schedule,9.16,64.41,
Bartonella Antibody,86611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.63,,,,,,,fee schedule,9.16,64.41,
Bartonella Antibody,86611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56.4,,,,,,,fee schedule,9.16,64.41,
Bartonella Antibody,86611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59.3,,,,,,,fee schedule,9.16,64.41,
Bartonella Antibody,86611,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.16,,,,,,,fee schedule,9.16,64.41,Laboratory
Bartonella Antibody,86611,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.69,,,,,,,fee schedule,9.16,64.41,APC
Bartonella Antibody,86611,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10.59,,,,,,,fee schedule,9.16,64.41,APC
Bartonella Antibody,86611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10.18,,,,,,,fee schedule,9.16,64.41,APC
Bartonella Antibody,86611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15.58,,,,,,,fee schedule,9.16,64.41,Radiology
Bartonella Antibody,86611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.25,,,,,,,fee schedule,9.16,64.41,APC
Bartonella Antibody,86611,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,17.81,,,,,,,fee schedule,9.16,64.41,APC
Blastomyces antibody,86612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,122.9,,,,,,,fee schedule,11.61,122.9,
Blastomyces antibody,86612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,98.52,,,,,,,fee schedule,11.61,122.9,
Blastomyces antibody,86612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,107.62,,,,,,,fee schedule,11.61,122.9,
Blastomyces antibody,86612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,113.15,,,,,,,fee schedule,11.61,122.9,
Blastomyces antibody,86612,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.61,,,,,,,fee schedule,11.61,122.9,Laboratory
Blastomyces antibody,86612,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.55,,,,,,,fee schedule,11.61,122.9,APC
Blastomyces antibody,86612,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.42,,,,,,,fee schedule,11.61,122.9,APC
Blastomyces antibody,86612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.9,,,,,,,fee schedule,11.61,122.9,APC
Blastomyces antibody,86612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.74,,,,,,,fee schedule,11.61,122.9,Radiology
Blastomyces antibody,86612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.06,,,,,,,fee schedule,11.61,122.9,APC
Blastomyces antibody,86612,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22.58,,,,,,,fee schedule,11.61,122.9,APC
Bordetella antibody,86615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,72.77,,,,,,,fee schedule,11.87,72.77,
Bordetella antibody,86615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,58.33,,,,,,,fee schedule,11.87,72.77,
Bordetella antibody,86615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,63.72,,,,,,,fee schedule,11.87,72.77,
Bordetella antibody,86615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.99,,,,,,,fee schedule,11.87,72.77,
Bordetella antibody,86615,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.87,,,,,,,fee schedule,11.87,72.77,Laboratory
Bordetella antibody,86615,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.85,,,,,,,fee schedule,11.87,72.77,APC
Bordetella antibody,86615,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.72,,,,,,,fee schedule,11.87,72.77,APC
Bordetella antibody,86615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.19,,,,,,,fee schedule,11.87,72.77,APC
Bordetella antibody,86615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.18,,,,,,,fee schedule,11.87,72.77,Radiology
Bordetella antibody,86615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.47,,,,,,,fee schedule,11.87,72.77,APC
Bordetella antibody,86615,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23.08,,,,,,,fee schedule,11.87,72.77,APC
Lyme disease antibody,86617,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45.9,,,,,,,fee schedule,13.94,45.9,
Lyme disease antibody,86617,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36.8,,,,,,,fee schedule,13.94,45.9,
Lyme disease antibody,86617,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40.2,,,,,,,fee schedule,13.94,45.9,
Lyme disease antibody,86617,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42.26,,,,,,,fee schedule,13.94,45.9,
Lyme disease antibody,86617,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.94,,,,,,,fee schedule,13.94,45.9,Laboratory
Lyme disease antibody,86617,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.26,,,,,,,fee schedule,13.94,45.9,APC
Lyme disease antibody,86617,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,16.11,,,,,,,fee schedule,13.94,45.9,APC
Lyme disease antibody,86617,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,15.49,,,,,,,fee schedule,13.94,45.9,APC
Lyme disease antibody,86617,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.7,,,,,,,fee schedule,13.94,45.9,Radiology
Lyme disease antibody,86617,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21.69,,,,,,,fee schedule,13.94,45.9,APC
Lyme disease antibody,86617,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,27.11,,,,,,,fee schedule,13.94,45.9,APC
Lyme disease antibody,86618,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,190.65,,,,,,,fee schedule,15.33,190.65,
Lyme disease antibody,86618,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,152.82,,,,,,,fee schedule,15.33,190.65,
Lyme disease antibody,86618,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,166.95,,,,,,,fee schedule,15.33,190.65,
Lyme disease antibody,86618,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,175.52,,,,,,,fee schedule,15.33,190.65,
Lyme disease antibody,86618,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.33,,,,,,,fee schedule,15.33,190.65,Laboratory
Lyme disease antibody,86618,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.88,,,,,,,fee schedule,15.33,190.65,APC
Lyme disease antibody,86618,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,17.71,,,,,,,fee schedule,15.33,190.65,APC
Lyme disease antibody,86618,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17.03,,,,,,,fee schedule,15.33,190.65,APC
Lyme disease antibody,86618,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26.06,,,,,,,fee schedule,15.33,190.65,Radiology
Lyme disease antibody,86618,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.84,,,,,,,fee schedule,15.33,190.65,APC
Lyme disease antibody,86618,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,29.8,,,,,,,fee schedule,15.33,190.65,APC
Borrelia antibody,86619,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,73.86,,,,,,,fee schedule,12.04,73.86,
Borrelia antibody,86619,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,59.21,,,,,,,fee schedule,12.04,73.86,
Borrelia antibody,86619,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,64.68,,,,,,,fee schedule,12.04,73.86,
Borrelia antibody,86619,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,68,,,,,,,fee schedule,12.04,73.86,
Borrelia antibody,86619,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.04,,,,,,,fee schedule,12.04,73.86,Laboratory
Borrelia antibody,86619,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.05,,,,,,,fee schedule,12.04,73.86,APC
Borrelia antibody,86619,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.92,,,,,,,fee schedule,12.04,73.86,APC
Borrelia antibody,86619,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.38,,,,,,,fee schedule,12.04,73.86,APC
Borrelia antibody,86619,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.47,,,,,,,fee schedule,12.04,73.86,Radiology
Borrelia antibody,86619,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.73,,,,,,,fee schedule,12.04,73.86,APC
Borrelia antibody,86619,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23.42,,,,,,,fee schedule,12.04,73.86,APC
Brucella antibody,86622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,49.33,,,,,,,fee schedule,8.04,49.33,
Brucella antibody,86622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39.54,,,,,,,fee schedule,8.04,49.33,
Brucella antibody,86622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,43.2,,,,,,,fee schedule,8.04,49.33,
Brucella antibody,86622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45.41,,,,,,,fee schedule,8.04,49.33,
Brucella antibody,86622,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.04,,,,,,,fee schedule,8.04,49.33,Laboratory
Brucella antibody,86622,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.38,,,,,,,fee schedule,8.04,49.33,APC
Brucella antibody,86622,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9.29,,,,,,,fee schedule,8.04,49.33,APC
Brucella antibody,86622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8.93,,,,,,,fee schedule,8.04,49.33,APC
Brucella antibody,86622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.66,,,,,,,fee schedule,8.04,49.33,Radiology
Brucella antibody,86622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12.5,,,,,,,fee schedule,8.04,49.33,APC
Brucella antibody,86622,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15.63,,,,,,,fee schedule,8.04,49.33,APC
Campylobacter antibody,86625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,72.42,,,,,,,fee schedule,11.81,72.42,
Campylobacter antibody,86625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,58.05,,,,,,,fee schedule,11.81,72.42,
Campylobacter antibody,86625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,63.42,,,,,,,fee schedule,11.81,72.42,
Campylobacter antibody,86625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.68,,,,,,,fee schedule,11.81,72.42,
Campylobacter antibody,86625,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.81,,,,,,,fee schedule,11.81,72.42,Laboratory
Campylobacter antibody,86625,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.78,,,,,,,fee schedule,11.81,72.42,APC
Campylobacter antibody,86625,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.64,,,,,,,fee schedule,11.81,72.42,APC
Campylobacter antibody,86625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.12,,,,,,,fee schedule,11.81,72.42,APC
Campylobacter antibody,86625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.07,,,,,,,fee schedule,11.81,72.42,Radiology
Campylobacter antibody,86625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.37,,,,,,,fee schedule,11.81,72.42,APC
Campylobacter antibody,86625,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22.96,,,,,,,fee schedule,11.81,72.42,APC
Candida antibody,86628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45.9,,,,,,,fee schedule,10.81,45.9,
Candida antibody,86628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36.8,,,,,,,fee schedule,10.81,45.9,
Candida antibody,86628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40.2,,,,,,,fee schedule,10.81,45.9,
Candida antibody,86628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42.26,,,,,,,fee schedule,10.81,45.9,
Candida antibody,86628,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.81,,,,,,,fee schedule,10.81,45.9,Laboratory
Candida antibody,86628,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.61,,,,,,,fee schedule,10.81,45.9,APC
Candida antibody,86628,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.49,,,,,,,fee schedule,10.81,45.9,APC
Candida antibody,86628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.01,,,,,,,fee schedule,10.81,45.9,APC
Candida antibody,86628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.38,,,,,,,fee schedule,10.81,45.9,Radiology
Candida antibody,86628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.81,,,,,,,fee schedule,10.81,45.9,APC
Candida antibody,86628,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21.02,,,,,,,fee schedule,10.81,45.9,APC
Chlamydia antibody,86631,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,72.56,,,,,,,fee schedule,10.64,72.56,
Chlamydia antibody,86631,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,58.16,,,,,,,fee schedule,10.64,72.56,
Chlamydia antibody,86631,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,63.54,,,,,,,fee schedule,10.64,72.56,
Chlamydia antibody,86631,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.8,,,,,,,fee schedule,10.64,72.56,
Chlamydia antibody,86631,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.64,,,,,,,fee schedule,10.64,72.56,Laboratory
Chlamydia antibody,86631,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.41,,,,,,,fee schedule,10.64,72.56,APC
Chlamydia antibody,86631,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.29,,,,,,,fee schedule,10.64,72.56,APC
Chlamydia antibody,86631,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11.82,,,,,,,fee schedule,10.64,72.56,APC
Chlamydia antibody,86631,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.08,,,,,,,fee schedule,10.64,72.56,Radiology
Chlamydia antibody,86631,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.55,,,,,,,fee schedule,10.64,72.56,APC
Chlamydia antibody,86631,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20.68,,,,,,,fee schedule,10.64,72.56,APC
Chlamydia igm antibody,86632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.71,,,,,,,fee schedule,11.41,60.71,
Chlamydia igm antibody,86632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48.67,,,,,,,fee schedule,11.41,60.71,
Chlamydia igm antibody,86632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.16,,,,,,,fee schedule,11.41,60.71,
Chlamydia igm antibody,86632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55.89,,,,,,,fee schedule,11.41,60.71,
Chlamydia igm antibody,86632,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.41,,,,,,,fee schedule,11.41,60.71,Laboratory
Chlamydia igm antibody,86632,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.31,,,,,,,fee schedule,11.41,60.71,APC
Chlamydia igm antibody,86632,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.19,,,,,,,fee schedule,11.41,60.71,APC
Chlamydia igm antibody,86632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.68,,,,,,,fee schedule,11.41,60.71,APC
Chlamydia igm antibody,86632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.4,,,,,,,fee schedule,11.41,60.71,Radiology
Chlamydia igm antibody,86632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.75,,,,,,,fee schedule,11.41,60.71,APC
Chlamydia igm antibody,86632,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22.19,,,,,,,fee schedule,11.41,60.71,APC
Coccidioides antibody,86635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,205.09,,,,,,,fee schedule,10.32,205.09,
Coccidioides antibody,86635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,164.4,,,,,,,fee schedule,10.32,205.09,
Coccidioides antibody,86635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,179.59,,,,,,,fee schedule,10.32,205.09,
Coccidioides antibody,86635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,188.81,,,,,,,fee schedule,10.32,205.09,
Coccidioides antibody,86635,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.32,,,,,,,fee schedule,10.32,205.09,Laboratory
Coccidioides antibody,86635,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.04,,,,,,,fee schedule,10.32,205.09,APC
Coccidioides antibody,86635,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11.93,,,,,,,fee schedule,10.32,205.09,APC
Coccidioides antibody,86635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11.47,,,,,,,fee schedule,10.32,205.09,APC
Coccidioides antibody,86635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.55,,,,,,,fee schedule,10.32,205.09,Radiology
Coccidioides antibody,86635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.06,,,,,,,fee schedule,10.32,205.09,APC
Coccidioides antibody,86635,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20.07,,,,,,,fee schedule,10.32,205.09,APC
Q fever antibody,86638,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,131.05,,,,,,,fee schedule,10.91,131.05,
Q fever antibody,86638,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,105.05,,,,,,,fee schedule,10.91,131.05,
Q fever antibody,86638,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,114.75,,,,,,,fee schedule,10.91,131.05,
Q fever antibody,86638,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,120.65,,,,,,,fee schedule,10.91,131.05,
Q fever antibody,86638,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.91,,,,,,,fee schedule,10.91,131.05,Laboratory
Q fever antibody,86638,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.73,,,,,,,fee schedule,10.91,131.05,APC
Q fever antibody,86638,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.6,,,,,,,fee schedule,10.91,131.05,APC
Q fever antibody,86638,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.12,,,,,,,fee schedule,10.91,131.05,APC
Q fever antibody,86638,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.54,,,,,,,fee schedule,10.91,131.05,Radiology
Q fever antibody,86638,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.97,,,,,,,fee schedule,10.91,131.05,APC
Q fever antibody,86638,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21.21,,,,,,,fee schedule,10.91,131.05,APC
Cryptococcus antibody,86641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,79.57,,,,,,,fee schedule,12.97,79.57,
Cryptococcus antibody,86641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,63.78,,,,,,,fee schedule,12.97,79.57,
Cryptococcus antibody,86641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,69.68,,,,,,,fee schedule,12.97,79.57,
Cryptococcus antibody,86641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,73.25,,,,,,,fee schedule,12.97,79.57,
Cryptococcus antibody,86641,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.97,,,,,,,fee schedule,12.97,79.57,Laboratory
Cryptococcus antibody,86641,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.13,,,,,,,fee schedule,12.97,79.57,APC
Cryptococcus antibody,86641,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,14.99,,,,,,,fee schedule,12.97,79.57,APC
Cryptococcus antibody,86641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14.41,,,,,,,fee schedule,12.97,79.57,APC
Cryptococcus antibody,86641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.05,,,,,,,fee schedule,12.97,79.57,Radiology
Cryptococcus antibody,86641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.17,,,,,,,fee schedule,12.97,79.57,APC
Cryptococcus antibody,86641,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,25.22,,,,,,,fee schedule,12.97,79.57,APC
CMV antibody,86644,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,70.55,,,,,,,fee schedule,12.95,70.55,
CMV antibody,86644,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56.55,,,,,,,fee schedule,12.95,70.55,
CMV antibody,86644,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,61.78,,,,,,,fee schedule,12.95,70.55,
CMV antibody,86644,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,64.95,,,,,,,fee schedule,12.95,70.55,
CMV antibody,86644,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.95,,,,,,,fee schedule,12.95,70.55,Laboratory
CMV antibody,86644,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.11,,,,,,,fee schedule,12.95,70.55,APC
CMV antibody,86644,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,14.97,,,,,,,fee schedule,12.95,70.55,APC
CMV antibody,86644,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14.39,,,,,,,fee schedule,12.95,70.55,APC
CMV antibody,86644,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.02,,,,,,,fee schedule,12.95,70.55,Radiology
CMV antibody,86644,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.15,,,,,,,fee schedule,12.95,70.55,APC
CMV antibody,86644,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,25.18,,,,,,,fee schedule,12.95,70.55,APC
Cmv antibody igm,86645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,49.24,,,,,,,fee schedule,15.16,49.24,
Cmv antibody igm,86645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39.47,,,,,,,fee schedule,15.16,49.24,
Cmv antibody igm,86645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,43.11,,,,,,,fee schedule,15.16,49.24,
Cmv antibody igm,86645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45.33,,,,,,,fee schedule,15.16,49.24,
Cmv antibody igm,86645,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.16,,,,,,,fee schedule,15.16,49.24,Laboratory
Cmv antibody igm,86645,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.69,,,,,,,fee schedule,15.16,49.24,APC
Cmv antibody igm,86645,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,17.52,,,,,,,fee schedule,15.16,49.24,APC
Cmv antibody igm,86645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16.85,,,,,,,fee schedule,15.16,49.24,APC
Cmv antibody igm,86645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.78,,,,,,,fee schedule,15.16,49.24,Radiology
Cmv antibody igm,86645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.59,,,,,,,fee schedule,15.16,49.24,APC
Cmv antibody igm,86645,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,29.49,,,,,,,fee schedule,15.16,49.24,APC
Diphtheria antibody,86648,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83.95,,,,,,,fee schedule,13.69,83.95,
Diphtheria antibody,86648,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,67.3,,,,,,,fee schedule,13.69,83.95,
Diphtheria antibody,86648,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,73.52,,,,,,,fee schedule,13.69,83.95,
Diphtheria antibody,86648,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,77.29,,,,,,,fee schedule,13.69,83.95,
Diphtheria antibody,86648,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.69,,,,,,,fee schedule,13.69,83.95,Laboratory
Diphtheria antibody,86648,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.97,,,,,,,fee schedule,13.69,83.95,APC
Diphtheria antibody,86648,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,15.82,,,,,,,fee schedule,13.69,83.95,APC
Diphtheria antibody,86648,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,15.21,,,,,,,fee schedule,13.69,83.95,APC
Diphtheria antibody,86648,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.27,,,,,,,fee schedule,13.69,83.95,Radiology
Diphtheria antibody,86648,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21.29,,,,,,,fee schedule,13.69,83.95,APC
Diphtheria antibody,86648,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,26.62,,,,,,,fee schedule,13.69,83.95,APC
Encephalitis californ antbdy,86651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,72.77,,,,,,,fee schedule,11.87,72.77,
Encephalitis californ antbdy,86651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,58.33,,,,,,,fee schedule,11.87,72.77,
Encephalitis californ antbdy,86651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,63.72,,,,,,,fee schedule,11.87,72.77,
Encephalitis californ antbdy,86651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.99,,,,,,,fee schedule,11.87,72.77,
Encephalitis californ antbdy,86651,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.87,,,,,,,fee schedule,11.87,72.77,Laboratory
Encephalitis californ antbdy,86651,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.85,,,,,,,fee schedule,11.87,72.77,APC
Encephalitis californ antbdy,86651,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.72,,,,,,,fee schedule,11.87,72.77,APC
Encephalitis californ antbdy,86651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.19,,,,,,,fee schedule,11.87,72.77,APC
Encephalitis californ antbdy,86651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.18,,,,,,,fee schedule,11.87,72.77,Radiology
Encephalitis californ antbdy,86651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.47,,,,,,,fee schedule,11.87,72.77,APC
Encephalitis californ antbdy,86651,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23.08,,,,,,,fee schedule,11.87,72.77,APC
Encephaltis east eqne anbdy,86652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,72.77,,,,,,,fee schedule,11.87,72.77,
Encephaltis east eqne anbdy,86652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,58.33,,,,,,,fee schedule,11.87,72.77,
Encephaltis east eqne anbdy,86652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,63.72,,,,,,,fee schedule,11.87,72.77,
Encephaltis east eqne anbdy,86652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.99,,,,,,,fee schedule,11.87,72.77,
Encephaltis east eqne anbdy,86652,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.87,,,,,,,fee schedule,11.87,72.77,Laboratory
Encephaltis east eqne anbdy,86652,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.85,,,,,,,fee schedule,11.87,72.77,APC
Encephaltis east eqne anbdy,86652,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.72,,,,,,,fee schedule,11.87,72.77,APC
Encephaltis east eqne anbdy,86652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.19,,,,,,,fee schedule,11.87,72.77,APC
Encephaltis east eqne anbdy,86652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.18,,,,,,,fee schedule,11.87,72.77,Radiology
Encephaltis east eqne anbdy,86652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.47,,,,,,,fee schedule,11.87,72.77,APC
Encephaltis east eqne anbdy,86652,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23.08,,,,,,,fee schedule,11.87,72.77,APC
Encephaltis st louis antbody,86653,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,72.77,,,,,,,fee schedule,11.87,72.77,
Encephaltis st louis antbody,86653,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,58.33,,,,,,,fee schedule,11.87,72.77,
Encephaltis st louis antbody,86653,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,63.72,,,,,,,fee schedule,11.87,72.77,
Encephaltis st louis antbody,86653,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.99,,,,,,,fee schedule,11.87,72.77,
Encephaltis st louis antbody,86653,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.87,,,,,,,fee schedule,11.87,72.77,Laboratory
Encephaltis st louis antbody,86653,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.85,,,,,,,fee schedule,11.87,72.77,APC
Encephaltis st louis antbody,86653,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.72,,,,,,,fee schedule,11.87,72.77,APC
Encephaltis st louis antbody,86653,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.19,,,,,,,fee schedule,11.87,72.77,APC
Encephaltis st louis antbody,86653,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.18,,,,,,,fee schedule,11.87,72.77,Radiology
Encephaltis st louis antbody,86653,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.47,,,,,,,fee schedule,11.87,72.77,APC
Encephaltis st louis antbody,86653,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23.08,,,,,,,fee schedule,11.87,72.77,APC
Encephaltis west eqne antbdy,86654,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,72.77,,,,,,,fee schedule,11.87,72.77,
Encephaltis west eqne antbdy,86654,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,58.33,,,,,,,fee schedule,11.87,72.77,
Encephaltis west eqne antbdy,86654,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,63.72,,,,,,,fee schedule,11.87,72.77,
Encephaltis west eqne antbdy,86654,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.99,,,,,,,fee schedule,11.87,72.77,
Encephaltis west eqne antbdy,86654,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.87,,,,,,,fee schedule,11.87,72.77,Laboratory
Encephaltis west eqne antbdy,86654,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.85,,,,,,,fee schedule,11.87,72.77,APC
Encephaltis west eqne antbdy,86654,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.72,,,,,,,fee schedule,11.87,72.77,APC
Encephaltis west eqne antbdy,86654,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.19,,,,,,,fee schedule,11.87,72.77,APC
Encephaltis west eqne antbdy,86654,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.18,,,,,,,fee schedule,11.87,72.77,Radiology
Encephaltis west eqne antbdy,86654,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.47,,,,,,,fee schedule,11.87,72.77,APC
Encephaltis west eqne antbdy,86654,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23.08,,,,,,,fee schedule,11.87,72.77,APC
Enterovirus antibody,86658,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,58.98,,,,,,,fee schedule,11.73,58.98,
Enterovirus antibody,86658,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,47.28,,,,,,,fee schedule,11.73,58.98,
Enterovirus antibody,86658,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.65,,,,,,,fee schedule,11.73,58.98,
Enterovirus antibody,86658,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,54.3,,,,,,,fee schedule,11.73,58.98,
Enterovirus antibody,86658,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.73,,,,,,,fee schedule,11.73,58.98,Laboratory
Enterovirus antibody,86658,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.68,,,,,,,fee schedule,11.73,58.98,APC
Enterovirus antibody,86658,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.55,,,,,,,fee schedule,11.73,58.98,APC
Enterovirus antibody,86658,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.03,,,,,,,fee schedule,11.73,58.98,APC
Enterovirus antibody,86658,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.94,,,,,,,fee schedule,11.73,58.98,Radiology
Enterovirus antibody,86658,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.24,,,,,,,fee schedule,11.73,58.98,APC
Enterovirus antibody,86658,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22.8,,,,,,,fee schedule,11.73,58.98,APC
Epstein-barr antibody,86663,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,82.18,,,,,,,fee schedule,11.81,82.18,
Epstein-barr antibody,86663,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,65.88,,,,,,,fee schedule,11.81,82.18,
Epstein-barr antibody,86663,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,71.96,,,,,,,fee schedule,11.81,82.18,
Epstein-barr antibody,86663,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,75.66,,,,,,,fee schedule,11.81,82.18,
Epstein-barr antibody,86663,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.81,,,,,,,fee schedule,11.81,82.18,Laboratory
Epstein-barr antibody,86663,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.78,,,,,,,fee schedule,11.81,82.18,APC
Epstein-barr antibody,86663,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.64,,,,,,,fee schedule,11.81,82.18,APC
Epstein-barr antibody,86663,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.12,,,,,,,fee schedule,11.81,82.18,APC
Epstein-barr antibody,86663,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.07,,,,,,,fee schedule,11.81,82.18,Radiology
Epstein-barr antibody,86663,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.37,,,,,,,fee schedule,11.81,82.18,APC
Epstein-barr antibody,86663,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22.96,,,,,,,fee schedule,11.81,82.18,APC
Epstein-barr nuclear antigen,86664,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,82.18,,,,,,,fee schedule,13.76,82.18,
Epstein-barr nuclear antigen,86664,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,65.88,,,,,,,fee schedule,13.76,82.18,
Epstein-barr nuclear antigen,86664,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,71.96,,,,,,,fee schedule,13.76,82.18,
Epstein-barr nuclear antigen,86664,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,75.66,,,,,,,fee schedule,13.76,82.18,
Epstein-barr nuclear antigen,86664,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.76,,,,,,,fee schedule,13.76,82.18,Laboratory
Epstein-barr nuclear antigen,86664,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.05,,,,,,,fee schedule,13.76,82.18,APC
Epstein-barr nuclear antigen,86664,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,15.9,,,,,,,fee schedule,13.76,82.18,APC
Epstein-barr nuclear antigen,86664,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,15.29,,,,,,,fee schedule,13.76,82.18,APC
Epstein-barr nuclear antigen,86664,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.39,,,,,,,fee schedule,13.76,82.18,Radiology
Epstein-barr nuclear antigen,86664,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21.41,,,,,,,fee schedule,13.76,82.18,APC
Epstein-barr nuclear antigen,86664,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,26.76,,,,,,,fee schedule,13.76,82.18,APC
Epstein-barr capsid vca,86665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,74.99,,,,,,,fee schedule,16.33,74.99,
Epstein-barr capsid vca,86665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,60.11,,,,,,,fee schedule,16.33,74.99,
Epstein-barr capsid vca,86665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,65.67,,,,,,,fee schedule,16.33,74.99,
Epstein-barr capsid vca,86665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,69.04,,,,,,,fee schedule,16.33,74.99,
Epstein-barr capsid vca,86665,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.33,,,,,,,fee schedule,16.33,74.99,Laboratory
Epstein-barr capsid vca,86665,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.05,,,,,,,fee schedule,16.33,74.99,APC
Epstein-barr capsid vca,86665,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18.87,,,,,,,fee schedule,16.33,74.99,APC
Epstein-barr capsid vca,86665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18.14,,,,,,,fee schedule,16.33,74.99,APC
Epstein-barr capsid vca,86665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27.75,,,,,,,fee schedule,16.33,74.99,Radiology
Epstein-barr capsid vca,86665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.4,,,,,,,fee schedule,16.33,74.99,APC
Epstein-barr capsid vca,86665,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31.74,,,,,,,fee schedule,16.33,74.99,APC
Ehrlichia Antibody,86666,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,43.68,,,,,,,fee schedule,9.16,43.68,
Ehrlichia Antibody,86666,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35.02,,,,,,,fee schedule,9.16,43.68,
Ehrlichia Antibody,86666,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38.25,,,,,,,fee schedule,9.16,43.68,
Ehrlichia Antibody,86666,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,40.22,,,,,,,fee schedule,9.16,43.68,
Ehrlichia Antibody,86666,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.16,,,,,,,fee schedule,9.16,43.68,Laboratory
Ehrlichia Antibody,86666,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.69,,,,,,,fee schedule,9.16,43.68,APC
Ehrlichia Antibody,86666,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10.59,,,,,,,fee schedule,9.16,43.68,APC
Ehrlichia Antibody,86666,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10.18,,,,,,,fee schedule,9.16,43.68,APC
Ehrlichia Antibody,86666,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15.58,,,,,,,fee schedule,9.16,43.68,Radiology
Ehrlichia Antibody,86666,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.25,,,,,,,fee schedule,9.16,43.68,APC
Ehrlichia Antibody,86666,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,17.81,,,,,,,fee schedule,9.16,43.68,APC
Francisella tularensis,86668,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,57.38,,,,,,,fee schedule,12.74,57.38,
Francisella tularensis,86668,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46,,,,,,,fee schedule,12.74,57.38,
Francisella tularensis,86668,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,50.25,,,,,,,fee schedule,12.74,57.38,
Francisella tularensis,86668,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,52.83,,,,,,,fee schedule,12.74,57.38,
Francisella tularensis,86668,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.74,,,,,,,fee schedule,12.74,57.38,Laboratory
Francisella tularensis,86668,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.87,,,,,,,fee schedule,12.74,57.38,APC
Francisella tularensis,86668,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,14.73,,,,,,,fee schedule,12.74,57.38,APC
Francisella tularensis,86668,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14.16,,,,,,,fee schedule,12.74,57.38,APC
Francisella tularensis,86668,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21.66,,,,,,,fee schedule,12.74,57.38,Radiology
Francisella tularensis,86668,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.82,,,,,,,fee schedule,12.74,57.38,APC
Francisella tularensis,86668,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,24.78,,,,,,,fee schedule,12.74,57.38,APC
Fungus nes antibody,86671,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,38.5,,,,,,,fee schedule,11.02,38.5,
Fungus nes antibody,86671,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,30.86,,,,,,,fee schedule,11.02,38.5,
Fungus nes antibody,86671,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,33.71,,,,,,,fee schedule,11.02,38.5,
Fungus nes antibody,86671,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,35.44,,,,,,,fee schedule,11.02,38.5,
Fungus nes antibody,86671,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.02,,,,,,,fee schedule,11.02,38.5,Laboratory
Fungus nes antibody,86671,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.86,,,,,,,fee schedule,11.02,38.5,APC
Fungus nes antibody,86671,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.74,,,,,,,fee schedule,11.02,38.5,APC
Fungus nes antibody,86671,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.25,,,,,,,fee schedule,11.02,38.5,APC
Fungus nes antibody,86671,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.74,,,,,,,fee schedule,11.02,38.5,Radiology
Fungus nes antibody,86671,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.15,,,,,,,fee schedule,11.02,38.5,APC
Fungus nes antibody,86671,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21.44,,,,,,,fee schedule,11.02,38.5,APC
Giardia lamblia antibody,86674,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,81.27,,,,,,,fee schedule,13.25,81.27,
Giardia lamblia antibody,86674,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,65.15,,,,,,,fee schedule,13.25,81.27,
Giardia lamblia antibody,86674,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,71.17,,,,,,,fee schedule,13.25,81.27,
Giardia lamblia antibody,86674,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,74.82,,,,,,,fee schedule,13.25,81.27,
Giardia lamblia antibody,86674,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.25,,,,,,,fee schedule,13.25,81.27,Laboratory
Giardia lamblia antibody,86674,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.46,,,,,,,fee schedule,13.25,81.27,APC
Giardia lamblia antibody,86674,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,15.31,,,,,,,fee schedule,13.25,81.27,APC
Giardia lamblia antibody,86674,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14.72,,,,,,,fee schedule,13.25,81.27,APC
Giardia lamblia antibody,86674,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.52,,,,,,,fee schedule,13.25,81.27,Radiology
Giardia lamblia antibody,86674,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.61,,,,,,,fee schedule,13.25,81.27,APC
Giardia lamblia antibody,86674,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,25.76,,,,,,,fee schedule,13.25,81.27,APC
Helicobacter pylori antibody,86677,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83.19,,,,,,,fee schedule,15.16,83.19,
Helicobacter pylori antibody,86677,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66.68,,,,,,,fee schedule,15.16,83.19,
Helicobacter pylori antibody,86677,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,72.84,,,,,,,fee schedule,15.16,83.19,
Helicobacter pylori antibody,86677,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,76.58,,,,,,,fee schedule,15.16,83.19,
Helicobacter pylori antibody,86677,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.16,,,,,,,fee schedule,15.16,83.19,Laboratory
Helicobacter pylori antibody,86677,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.69,,,,,,,fee schedule,15.16,83.19,APC
Helicobacter pylori antibody,86677,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,17.52,,,,,,,fee schedule,15.16,83.19,APC
Helicobacter pylori antibody,86677,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16.85,,,,,,,fee schedule,15.16,83.19,APC
Helicobacter pylori antibody,86677,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.78,,,,,,,fee schedule,15.16,83.19,Radiology
Helicobacter pylori antibody,86677,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.59,,,,,,,fee schedule,15.16,83.19,APC
Helicobacter pylori antibody,86677,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,29.49,,,,,,,fee schedule,15.16,83.19,APC
Helminth antibody,86682,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,85.14,,,,,,,fee schedule,11.71,85.14,
Helminth antibody,86682,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,68.25,,,,,,,fee schedule,11.71,85.14,
Helminth antibody,86682,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,74.56,,,,,,,fee schedule,11.71,85.14,
Helminth antibody,86682,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,78.39,,,,,,,fee schedule,11.71,85.14,
Helminth antibody,86682,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.71,,,,,,,fee schedule,11.71,85.14,Laboratory
Helminth antibody,86682,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.66,,,,,,,fee schedule,11.71,85.14,APC
Helminth antibody,86682,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.53,,,,,,,fee schedule,11.71,85.14,APC
Helminth antibody,86682,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.01,,,,,,,fee schedule,11.71,85.14,APC
Helminth antibody,86682,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.91,,,,,,,fee schedule,11.71,85.14,Radiology
Helminth antibody,86682,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.21,,,,,,,fee schedule,11.71,85.14,APC
Helminth antibody,86682,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22.77,,,,,,,fee schedule,11.71,85.14,APC
Hemophilus influenza antibdy,86684,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,87.43,,,,,,,fee schedule,14.26,87.43,
Hemophilus influenza antibdy,86684,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,70.08,,,,,,,fee schedule,14.26,87.43,
Hemophilus influenza antibdy,86684,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,76.56,,,,,,,fee schedule,14.26,87.43,
Hemophilus influenza antibdy,86684,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,80.49,,,,,,,fee schedule,14.26,87.43,
Hemophilus influenza antibdy,86684,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.26,,,,,,,fee schedule,14.26,87.43,Laboratory
Hemophilus influenza antibdy,86684,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.63,,,,,,,fee schedule,14.26,87.43,APC
Hemophilus influenza antibdy,86684,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,16.47,,,,,,,fee schedule,14.26,87.43,APC
Hemophilus influenza antibdy,86684,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,15.84,,,,,,,fee schedule,14.26,87.43,APC
Hemophilus influenza antibdy,86684,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24.24,,,,,,,fee schedule,14.26,87.43,Radiology
Hemophilus influenza antibdy,86684,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.18,,,,,,,fee schedule,14.26,87.43,APC
Hemophilus influenza antibdy,86684,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,27.72,,,,,,,fee schedule,14.26,87.43,APC
Htlv-i antibody,86687,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46.31,,,,,,,fee schedule,8.18,46.31,
Htlv-i antibody,86687,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37.12,,,,,,,fee schedule,8.18,46.31,
Htlv-i antibody,86687,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40.55,,,,,,,fee schedule,8.18,46.31,
Htlv-i antibody,86687,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42.63,,,,,,,fee schedule,8.18,46.31,
Htlv-i antibody,86687,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.18,,,,,,,fee schedule,8.18,46.31,Laboratory
Htlv-i antibody,86687,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.54,,,,,,,fee schedule,8.18,46.31,APC
Htlv-i antibody,86687,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9.45,,,,,,,fee schedule,8.18,46.31,APC
Htlv-i antibody,86687,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9.09,,,,,,,fee schedule,8.18,46.31,APC
Htlv-i antibody,86687,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.91,,,,,,,fee schedule,8.18,46.31,Radiology
Htlv-i antibody,86687,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12.73,,,,,,,fee schedule,8.18,46.31,APC
Htlv-i antibody,86687,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15.91,,,,,,,fee schedule,8.18,46.31,APC
Htlv-ii antibody,86688,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,35.42,,,,,,,fee schedule,12.6,35.42,
Htlv-ii antibody,86688,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28.39,,,,,,,fee schedule,12.6,35.42,
Htlv-ii antibody,86688,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31.01,,,,,,,fee schedule,12.6,35.42,
Htlv-ii antibody,86688,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,32.61,,,,,,,fee schedule,12.6,35.42,
Htlv-ii antibody,86688,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.6,,,,,,,fee schedule,12.6,35.42,Laboratory
Htlv-ii antibody,86688,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.7,,,,,,,fee schedule,12.6,35.42,APC
Htlv-ii antibody,86688,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,14.56,,,,,,,fee schedule,12.6,35.42,APC
Htlv-ii antibody,86688,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14,,,,,,,fee schedule,12.6,35.42,APC
Htlv-ii antibody,86688,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21.42,,,,,,,fee schedule,12.6,35.42,Radiology
Htlv-ii antibody,86688,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.6,,,,,,,fee schedule,12.6,35.42,APC
Htlv-ii antibody,86688,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,24.5,,,,,,,fee schedule,12.6,35.42,APC
Htlv/hiv confirmj antibody,86689,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,322.81,,,,,,,fee schedule,17.42,322.81,
Htlv/hiv confirmj antibody,86689,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,258.76,,,,,,,fee schedule,17.42,322.81,
Htlv/hiv confirmj antibody,86689,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,282.67,,,,,,,fee schedule,17.42,322.81,
Htlv/hiv confirmj antibody,86689,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,297.19,,,,,,,fee schedule,17.42,322.81,
Htlv/hiv confirmj antibody,86689,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.42,,,,,,,fee schedule,17.42,322.81,Laboratory
Htlv/hiv confirmj antibody,86689,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20.32,,,,,,,fee schedule,17.42,322.81,APC
Htlv/hiv confirmj antibody,86689,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,20.12,,,,,,,fee schedule,17.42,322.81,APC
Htlv/hiv confirmj antibody,86689,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,19.35,,,,,,,fee schedule,17.42,322.81,APC
Htlv/hiv confirmj antibody,86689,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29.61,,,,,,,fee schedule,17.42,322.81,Radiology
Htlv/hiv confirmj antibody,86689,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27.09,,,,,,,fee schedule,17.42,322.81,APC
Htlv/hiv confirmj antibody,86689,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,33.86,,,,,,,fee schedule,17.42,322.81,APC
Hepatitis delta agent antbdy,86692,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,94.73,,,,,,,fee schedule,15.44,94.73,
Hepatitis delta agent antbdy,86692,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,75.93,,,,,,,fee schedule,15.44,94.73,
Hepatitis delta agent antbdy,86692,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,82.95,,,,,,,fee schedule,15.44,94.73,
Hepatitis delta agent antbdy,86692,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,87.21,,,,,,,fee schedule,15.44,94.73,
Hepatitis delta agent antbdy,86692,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.44,,,,,,,fee schedule,15.44,94.73,Laboratory
Hepatitis delta agent antbdy,86692,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.02,,,,,,,fee schedule,15.44,94.73,APC
Hepatitis delta agent antbdy,86692,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,17.85,,,,,,,fee schedule,15.44,94.73,APC
Hepatitis delta agent antbdy,86692,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17.16,,,,,,,fee schedule,15.44,94.73,APC
Hepatitis delta agent antbdy,86692,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26.25,,,,,,,fee schedule,15.44,94.73,Radiology
Hepatitis delta agent antbdy,86692,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24.02,,,,,,,fee schedule,15.44,94.73,APC
Hepatitis delta agent antbdy,86692,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30.03,,,,,,,fee schedule,15.44,94.73,APC
Herpes simplex nes antbdy,86694,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,71.82,,,,,,,fee schedule,12.95,71.82,
Herpes simplex nes antbdy,86694,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.57,,,,,,,fee schedule,12.95,71.82,
Herpes simplex nes antbdy,86694,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,62.89,,,,,,,fee schedule,12.95,71.82,
Herpes simplex nes antbdy,86694,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.12,,,,,,,fee schedule,12.95,71.82,
Herpes simplex nes antbdy,86694,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.95,,,,,,,fee schedule,12.95,71.82,Laboratory
Herpes simplex nes antbdy,86694,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.11,,,,,,,fee schedule,12.95,71.82,APC
Herpes simplex nes antbdy,86694,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,14.97,,,,,,,fee schedule,12.95,71.82,APC
Herpes simplex nes antbdy,86694,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14.39,,,,,,,fee schedule,12.95,71.82,APC
Herpes simplex nes antbdy,86694,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.02,,,,,,,fee schedule,12.95,71.82,Radiology
Herpes simplex nes antbdy,86694,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.15,,,,,,,fee schedule,12.95,71.82,APC
Herpes simplex nes antbdy,86694,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,25.18,,,,,,,fee schedule,12.95,71.82,APC
Herpes simplex type 1 test,86695,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45.23,,,,,,,fee schedule,11.87,45.23,
Herpes simplex type 1 test,86695,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36.26,,,,,,,fee schedule,11.87,45.23,
Herpes simplex type 1 test,86695,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39.61,,,,,,,fee schedule,11.87,45.23,
Herpes simplex type 1 test,86695,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41.64,,,,,,,fee schedule,11.87,45.23,
Herpes simplex type 1 test,86695,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.87,,,,,,,fee schedule,11.87,45.23,Laboratory
Herpes simplex type 1 test,86695,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.85,,,,,,,fee schedule,11.87,45.23,APC
Herpes simplex type 1 test,86695,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.72,,,,,,,fee schedule,11.87,45.23,APC
Herpes simplex type 1 test,86695,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.19,,,,,,,fee schedule,11.87,45.23,APC
Herpes simplex type 1 test,86695,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.18,,,,,,,fee schedule,11.87,45.23,Radiology
Herpes simplex type 1 test,86695,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.47,,,,,,,fee schedule,11.87,45.23,APC
Herpes simplex type 1 test,86695,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23.08,,,,,,,fee schedule,11.87,45.23,APC
Herpes simplex type 2 test,86696,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59.64,,,,,,,fee schedule,17.42,59.64,
Herpes simplex type 2 test,86696,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,47.8,,,,,,,fee schedule,17.42,59.64,
Herpes simplex type 2 test,86696,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52.22,,,,,,,fee schedule,17.42,59.64,
Herpes simplex type 2 test,86696,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,54.9,,,,,,,fee schedule,17.42,59.64,
Herpes simplex type 2 test,86696,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.42,,,,,,,fee schedule,17.42,59.64,Laboratory
Herpes simplex type 2 test,86696,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20.32,,,,,,,fee schedule,17.42,59.64,APC
Herpes simplex type 2 test,86696,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,20.12,,,,,,,fee schedule,17.42,59.64,APC
Herpes simplex type 2 test,86696,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,19.35,,,,,,,fee schedule,17.42,59.64,APC
Herpes simplex type 2 test,86696,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29.61,,,,,,,fee schedule,17.42,59.64,Radiology
Herpes simplex type 2 test,86696,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27.09,,,,,,,fee schedule,17.42,59.64,APC
Herpes simplex type 2 test,86696,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,33.86,,,,,,,fee schedule,17.42,59.64,APC
Histoplasma antibody,86698,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59.97,,,,,,,fee schedule,12.41,59.97,
Histoplasma antibody,86698,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48.07,,,,,,,fee schedule,12.41,59.97,
Histoplasma antibody,86698,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52.51,,,,,,,fee schedule,12.41,59.97,
Histoplasma antibody,86698,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55.21,,,,,,,fee schedule,12.41,59.97,
Histoplasma antibody,86698,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.41,,,,,,,fee schedule,12.41,59.97,Laboratory
Histoplasma antibody,86698,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.48,,,,,,,fee schedule,12.41,59.97,APC
Histoplasma antibody,86698,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,14.34,,,,,,,fee schedule,12.41,59.97,APC
Histoplasma antibody,86698,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.79,,,,,,,fee schedule,12.41,59.97,APC
Histoplasma antibody,86698,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21.1,,,,,,,fee schedule,12.41,59.97,Radiology
Histoplasma antibody,86698,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.31,,,,,,,fee schedule,12.41,59.97,APC
Histoplasma antibody,86698,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,24.13,,,,,,,fee schedule,12.41,59.97,APC
Hiv-1antibody,86701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,48.99,,,,,,,fee schedule,8,48.99,
Hiv-1antibody,86701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39.27,,,,,,,fee schedule,8,48.99,
Hiv-1antibody,86701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.9,,,,,,,fee schedule,8,48.99,
Hiv-1antibody,86701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45.1,,,,,,,fee schedule,8,48.99,
Hiv-1antibody,86701,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8,,,,,,,fee schedule,8,48.99,Laboratory
Hiv-1antibody,86701,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.33,,,,,,,fee schedule,8,48.99,APC
Hiv-1antibody,86701,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9.25,,,,,,,fee schedule,8,48.99,APC
Hiv-1antibody,86701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8.89,,,,,,,fee schedule,8,48.99,APC
Hiv-1antibody,86701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.6,,,,,,,fee schedule,8,48.99,Radiology
Hiv-1antibody,86701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12.45,,,,,,,fee schedule,8,48.99,APC
Hiv-1antibody,86701,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15.56,,,,,,,fee schedule,8,48.99,APC
Hiv-2 antibody,86702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,74.62,,,,,,,fee schedule,12.17,74.62,
Hiv-2 antibody,86702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,59.81,,,,,,,fee schedule,12.17,74.62,
Hiv-2 antibody,86702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,65.34,,,,,,,fee schedule,12.17,74.62,
Hiv-2 antibody,86702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,68.7,,,,,,,fee schedule,12.17,74.62,
Hiv-2 antibody,86702,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.17,,,,,,,fee schedule,12.17,74.62,Laboratory
Hiv-2 antibody,86702,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.2,,,,,,,fee schedule,12.17,74.62,APC
Hiv-2 antibody,86702,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,14.06,,,,,,,fee schedule,12.17,74.62,APC
Hiv-2 antibody,86702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.52,,,,,,,fee schedule,12.17,74.62,APC
Hiv-2 antibody,86702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.69,,,,,,,fee schedule,12.17,74.62,Radiology
Hiv-2 antibody,86702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.93,,,,,,,fee schedule,12.17,74.62,APC
Hiv-2 antibody,86702,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23.66,,,,,,,fee schedule,12.17,74.62,APC
Hiv-1/hiv-2 1 result antbdy,86703,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,40.09,,,,,,,fee schedule,12.34,40.09,
Hiv-1/hiv-2 1 result antbdy,86703,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32.13,,,,,,,fee schedule,12.34,40.09,
Hiv-1/hiv-2 1 result antbdy,86703,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35.1,,,,,,,fee schedule,12.34,40.09,
Hiv-1/hiv-2 1 result antbdy,86703,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,36.91,,,,,,,fee schedule,12.34,40.09,
Hiv-1/hiv-2 1 result antbdy,86703,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.34,,,,,,,fee schedule,12.34,40.09,Laboratory
Hiv-1/hiv-2 1 result antbdy,86703,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.4,,,,,,,fee schedule,12.34,40.09,APC
Hiv-1/hiv-2 1 result antbdy,86703,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,14.26,,,,,,,fee schedule,12.34,40.09,APC
Hiv-1/hiv-2 1 result antbdy,86703,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.71,,,,,,,fee schedule,12.34,40.09,APC
Hiv-1/hiv-2 1 result antbdy,86703,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.98,,,,,,,fee schedule,12.34,40.09,Radiology
Hiv-1/hiv-2 1 result antbdy,86703,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.19,,,,,,,fee schedule,12.34,40.09,APC
Hiv-1/hiv-2 1 result antbdy,86703,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23.99,,,,,,,fee schedule,12.34,40.09,APC
Hep b core antibody total,86704,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,36.28,,,,,,,fee schedule,10.84,36.28,
Hep b core antibody total,86704,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29.08,,,,,,,fee schedule,10.84,36.28,
Hep b core antibody total,86704,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31.77,,,,,,,fee schedule,10.84,36.28,
Hep b core antibody total,86704,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33.4,,,,,,,fee schedule,10.84,36.28,
Hep b core antibody total,86704,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.84,,,,,,,fee schedule,10.84,36.28,Laboratory
Hep b core antibody total,86704,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.65,,,,,,,fee schedule,10.84,36.28,APC
Hep b core antibody total,86704,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.53,,,,,,,fee schedule,10.84,36.28,APC
Hep b core antibody total,86704,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.05,,,,,,,fee schedule,10.84,36.28,APC
Hep b core antibody total,86704,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.44,,,,,,,fee schedule,10.84,36.28,Radiology
Hep b core antibody total,86704,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.87,,,,,,,fee schedule,10.84,36.28,APC
Hep b core antibody total,86704,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21.09,,,,,,,fee schedule,10.84,36.28,APC
Hep b core antibody igm,86705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37.02,,,,,,,fee schedule,10.59,37.02,
Hep b core antibody igm,86705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29.67,,,,,,,fee schedule,10.59,37.02,
Hep b core antibody igm,86705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32.42,,,,,,,fee schedule,10.59,37.02,
Hep b core antibody igm,86705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,34.08,,,,,,,fee schedule,10.59,37.02,
Hep b core antibody igm,86705,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.59,,,,,,,fee schedule,10.59,37.02,Laboratory
Hep b core antibody igm,86705,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.36,,,,,,,fee schedule,10.59,37.02,APC
Hep b core antibody igm,86705,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.24,,,,,,,fee schedule,10.59,37.02,APC
Hep b core antibody igm,86705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11.77,,,,,,,fee schedule,10.59,37.02,APC
Hep b core antibody igm,86705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.01,,,,,,,fee schedule,10.59,37.02,Radiology
Hep b core antibody igm,86705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.48,,,,,,,fee schedule,10.59,37.02,APC
Hep b core antibody igm,86705,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20.6,,,,,,,fee schedule,10.59,37.02,APC
Hep b surface antibody,86706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,58.79,,,,,,,fee schedule,9.67,58.79,
Hep b surface antibody,86706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,47.12,,,,,,,fee schedule,9.67,58.79,
Hep b surface antibody,86706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.48,,,,,,,fee schedule,9.67,58.79,
Hep b surface antibody,86706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,54.12,,,,,,,fee schedule,9.67,58.79,
Hep b surface antibody,86706,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.67,,,,,,,fee schedule,9.67,58.79,Laboratory
Hep b surface antibody,86706,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.28,,,,,,,fee schedule,9.67,58.79,APC
Hep b surface antibody,86706,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11.17,,,,,,,fee schedule,9.67,58.79,APC
Hep b surface antibody,86706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10.74,,,,,,,fee schedule,9.67,58.79,APC
Hep b surface antibody,86706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.43,,,,,,,fee schedule,9.67,58.79,Radiology
Hep b surface antibody,86706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15.04,,,,,,,fee schedule,9.67,58.79,APC
Hep b surface antibody,86706,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18.8,,,,,,,fee schedule,9.67,58.79,APC
Hepatitis be antibody,86707,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,36.28,,,,,,,fee schedule,10.41,36.28,
Hepatitis be antibody,86707,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29.08,,,,,,,fee schedule,10.41,36.28,
Hepatitis be antibody,86707,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31.77,,,,,,,fee schedule,10.41,36.28,
Hepatitis be antibody,86707,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33.4,,,,,,,fee schedule,10.41,36.28,
Hepatitis be antibody,86707,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.41,,,,,,,fee schedule,10.41,36.28,Laboratory
Hepatitis be antibody,86707,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.15,,,,,,,fee schedule,10.41,36.28,APC
Hepatitis be antibody,86707,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.03,,,,,,,fee schedule,10.41,36.28,APC
Hepatitis be antibody,86707,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11.57,,,,,,,fee schedule,10.41,36.28,APC
Hepatitis be antibody,86707,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.7,,,,,,,fee schedule,10.41,36.28,Radiology
Hepatitis be antibody,86707,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.2,,,,,,,fee schedule,10.41,36.28,APC
Hepatitis be antibody,86707,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20.25,,,,,,,fee schedule,10.41,36.28,APC
Hepatitis a antibody,86708,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33.32,,,,,,,fee schedule,11.15,33.32,
Hepatitis a antibody,86708,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26.71,,,,,,,fee schedule,11.15,33.32,
Hepatitis a antibody,86708,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29.17,,,,,,,fee schedule,11.15,33.32,
Hepatitis a antibody,86708,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30.67,,,,,,,fee schedule,11.15,33.32,
Hepatitis a antibody,86708,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.15,,,,,,,fee schedule,11.15,33.32,Laboratory
Hepatitis a antibody,86708,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.01,,,,,,,fee schedule,11.15,33.32,APC
Hepatitis a antibody,86708,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.89,,,,,,,fee schedule,11.15,33.32,APC
Hepatitis a antibody,86708,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.39,,,,,,,fee schedule,11.15,33.32,APC
Hepatitis a antibody,86708,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.96,,,,,,,fee schedule,11.15,33.32,Radiology
Hepatitis a antibody,86708,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.35,,,,,,,fee schedule,11.15,33.32,APC
Hepatitis a antibody,86708,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21.68,,,,,,,fee schedule,11.15,33.32,APC
Hepatitis a igm antibody,86709,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37.51,,,,,,,fee schedule,10.13,37.51,
Hepatitis a igm antibody,86709,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,30.07,,,,,,,fee schedule,10.13,37.51,
Hepatitis a igm antibody,86709,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32.85,,,,,,,fee schedule,10.13,37.51,
Hepatitis a igm antibody,86709,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,34.54,,,,,,,fee schedule,10.13,37.51,
Hepatitis a igm antibody,86709,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.13,,,,,,,fee schedule,10.13,37.51,Laboratory
Hepatitis a igm antibody,86709,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.82,,,,,,,fee schedule,10.13,37.51,APC
Hepatitis a igm antibody,86709,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11.71,,,,,,,fee schedule,10.13,37.51,APC
Hepatitis a igm antibody,86709,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11.26,,,,,,,fee schedule,10.13,37.51,APC
Hepatitis a igm antibody,86709,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.23,,,,,,,fee schedule,10.13,37.51,Radiology
Hepatitis a igm antibody,86709,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15.76,,,,,,,fee schedule,10.13,37.51,APC
Hepatitis a igm antibody,86709,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19.7,,,,,,,fee schedule,10.13,37.51,APC
Influenza virus antibody,86710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,82.92,,,,,,,fee schedule,12.2,82.92,
Influenza virus antibody,86710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66.47,,,,,,,fee schedule,12.2,82.92,
Influenza virus antibody,86710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,72.61,,,,,,,fee schedule,12.2,82.92,
Influenza virus antibody,86710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,76.34,,,,,,,fee schedule,12.2,82.92,
Influenza virus antibody,86710,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.2,,,,,,,fee schedule,12.2,82.92,Laboratory
Influenza virus antibody,86710,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.23,,,,,,,fee schedule,12.2,82.92,APC
Influenza virus antibody,86710,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,14.09,,,,,,,fee schedule,12.2,82.92,APC
Influenza virus antibody,86710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.55,,,,,,,fee schedule,12.2,82.92,APC
Influenza virus antibody,86710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.73,,,,,,,fee schedule,12.2,82.92,Radiology
Influenza virus antibody,86710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.97,,,,,,,fee schedule,12.2,82.92,APC
Influenza virus antibody,86710,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23.71,,,,,,,fee schedule,12.2,82.92,APC
John cunningham antibody,86711,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,93.06,,,,,,,fee schedule,15.2,93.06,
John cunningham antibody,86711,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,74.6,,,,,,,fee schedule,15.2,93.06,
John cunningham antibody,86711,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,81.49,,,,,,,fee schedule,15.2,93.06,
John cunningham antibody,86711,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,85.68,,,,,,,fee schedule,15.2,93.06,
John cunningham antibody,86711,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.2,,,,,,,fee schedule,15.2,93.06,Laboratory
John cunningham antibody,86711,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.73,,,,,,,fee schedule,15.2,93.06,APC
John cunningham antibody,86711,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,17.57,,,,,,,fee schedule,15.2,93.06,APC
John cunningham antibody,86711,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16.89,,,,,,,fee schedule,15.2,93.06,APC
John cunningham antibody,86711,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.84,,,,,,,fee schedule,15.2,93.06,Radiology
John cunningham antibody,86711,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.65,,,,,,,fee schedule,15.2,93.06,APC
John cunningham antibody,86711,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,29.56,,,,,,,fee schedule,15.2,93.06,APC
Legionella antibody,86713,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,84.48,,,,,,,fee schedule,13.77,84.48,
Legionella antibody,86713,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,67.72,,,,,,,fee schedule,13.77,84.48,
Legionella antibody,86713,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,73.98,,,,,,,fee schedule,13.77,84.48,
Legionella antibody,86713,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,77.78,,,,,,,fee schedule,13.77,84.48,
Legionella antibody,86713,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.77,,,,,,,fee schedule,13.77,84.48,Laboratory
Legionella antibody,86713,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.07,,,,,,,fee schedule,13.77,84.48,APC
Legionella antibody,86713,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,15.91,,,,,,,fee schedule,13.77,84.48,APC
Legionella antibody,86713,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,15.3,,,,,,,fee schedule,13.77,84.48,APC
Legionella antibody,86713,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.41,,,,,,,fee schedule,13.77,84.48,Radiology
Legionella antibody,86713,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21.42,,,,,,,fee schedule,13.77,84.48,APC
Legionella antibody,86713,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,26.78,,,,,,,fee schedule,13.77,84.48,APC
Leishmania antibody,86717,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,50.61,,,,,,,fee schedule,11.02,50.61,
Leishmania antibody,86717,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40.57,,,,,,,fee schedule,11.02,50.61,
Leishmania antibody,86717,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,44.32,,,,,,,fee schedule,11.02,50.61,
Leishmania antibody,86717,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46.6,,,,,,,fee schedule,11.02,50.61,
Leishmania antibody,86717,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.02,,,,,,,fee schedule,11.02,50.61,Laboratory
Leishmania antibody,86717,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.86,,,,,,,fee schedule,11.02,50.61,APC
Leishmania antibody,86717,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.74,,,,,,,fee schedule,11.02,50.61,APC
Leishmania antibody,86717,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.25,,,,,,,fee schedule,11.02,50.61,APC
Leishmania antibody,86717,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.74,,,,,,,fee schedule,11.02,50.61,Radiology
Leishmania antibody,86717,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.15,,,,,,,fee schedule,11.02,50.61,APC
Leishmania antibody,86717,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21.44,,,,,,,fee schedule,11.02,50.61,APC
Leptospira antibody,86720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,72.77,,,,,,,fee schedule,14.58,72.77,
Leptospira antibody,86720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,58.33,,,,,,,fee schedule,14.58,72.77,
Leptospira antibody,86720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,63.72,,,,,,,fee schedule,14.58,72.77,
Leptospira antibody,86720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.99,,,,,,,fee schedule,14.58,72.77,
Leptospira antibody,86720,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.58,,,,,,,fee schedule,14.58,72.77,Laboratory
Leptospira antibody,86720,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.01,,,,,,,fee schedule,14.58,72.77,APC
Leptospira antibody,86720,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,16.85,,,,,,,fee schedule,14.58,72.77,APC
Leptospira antibody,86720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16.2,,,,,,,fee schedule,14.58,72.77,APC
Leptospira antibody,86720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24.79,,,,,,,fee schedule,14.58,72.77,Radiology
Leptospira antibody,86720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.68,,,,,,,fee schedule,14.58,72.77,APC
Leptospira antibody,86720,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,28.35,,,,,,,fee schedule,14.58,72.77,APC
Listeria monocytogenes,86723,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,39.98,,,,,,,fee schedule,11.87,39.98,
Listeria monocytogenes,86723,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32.05,,,,,,,fee schedule,11.87,39.98,
Listeria monocytogenes,86723,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35.01,,,,,,,fee schedule,11.87,39.98,
Listeria monocytogenes,86723,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,36.81,,,,,,,fee schedule,11.87,39.98,
Listeria monocytogenes,86723,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.87,,,,,,,fee schedule,11.87,39.98,Laboratory
Listeria monocytogenes,86723,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.85,,,,,,,fee schedule,11.87,39.98,APC
Listeria monocytogenes,86723,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.72,,,,,,,fee schedule,11.87,39.98,APC
Listeria monocytogenes,86723,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.19,,,,,,,fee schedule,11.87,39.98,APC
Listeria monocytogenes,86723,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.18,,,,,,,fee schedule,11.87,39.98,Radiology
Listeria monocytogenes,86723,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.47,,,,,,,fee schedule,11.87,39.98,APC
Listeria monocytogenes,86723,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23.08,,,,,,,fee schedule,11.87,39.98,APC
Lymph choriomeningitis ab,86727,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,71.03,,,,,,,fee schedule,11.58,71.03,
Lymph choriomeningitis ab,86727,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56.93,,,,,,,fee schedule,11.58,71.03,
Lymph choriomeningitis ab,86727,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,62.19,,,,,,,fee schedule,11.58,71.03,
Lymph choriomeningitis ab,86727,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,65.39,,,,,,,fee schedule,11.58,71.03,
Lymph choriomeningitis ab,86727,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.58,,,,,,,fee schedule,11.58,71.03,Laboratory
Lymph choriomeningitis ab,86727,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.51,,,,,,,fee schedule,11.58,71.03,APC
Lymph choriomeningitis ab,86727,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.38,,,,,,,fee schedule,11.58,71.03,APC
Lymph choriomeningitis ab,86727,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.87,,,,,,,fee schedule,11.58,71.03,APC
Lymph choriomeningitis ab,86727,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.69,,,,,,,fee schedule,11.58,71.03,Radiology
Lymph choriomeningitis ab,86727,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.02,,,,,,,fee schedule,11.58,71.03,APC
Lymph choriomeningitis ab,86727,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22.52,,,,,,,fee schedule,11.58,71.03,APC
Mucormycosis antibody,86732,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,72.77,,,,,,,fee schedule,13.5,72.77,
Mucormycosis antibody,86732,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,58.33,,,,,,,fee schedule,13.5,72.77,
Mucormycosis antibody,86732,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,63.72,,,,,,,fee schedule,13.5,72.77,
Mucormycosis antibody,86732,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.99,,,,,,,fee schedule,13.5,72.77,
Mucormycosis antibody,86732,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.5,,,,,,,fee schedule,13.5,72.77,Laboratory
Mucormycosis antibody,86732,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.75,,,,,,,fee schedule,13.5,72.77,APC
Mucormycosis antibody,86732,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,15.6,,,,,,,fee schedule,13.5,72.77,APC
Mucormycosis antibody,86732,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,15,,,,,,,fee schedule,13.5,72.77,APC
Mucormycosis antibody,86732,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.95,,,,,,,fee schedule,13.5,72.77,Radiology
Mucormycosis antibody,86732,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21,,,,,,,fee schedule,13.5,72.77,APC
Mucormycosis antibody,86732,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,26.25,,,,,,,fee schedule,13.5,72.77,APC
Mumps antibody,86735,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,49.7,,,,,,,fee schedule,11.74,49.7,
Mumps antibody,86735,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39.84,,,,,,,fee schedule,11.74,49.7,
Mumps antibody,86735,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,43.52,,,,,,,fee schedule,11.74,49.7,
Mumps antibody,86735,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45.75,,,,,,,fee schedule,11.74,49.7,
Mumps antibody,86735,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.74,,,,,,,fee schedule,11.74,49.7,Laboratory
Mumps antibody,86735,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.7,,,,,,,fee schedule,11.74,49.7,APC
Mumps antibody,86735,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.57,,,,,,,fee schedule,11.74,49.7,APC
Mumps antibody,86735,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.05,,,,,,,fee schedule,11.74,49.7,APC
Mumps antibody,86735,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.97,,,,,,,fee schedule,11.74,49.7,Radiology
Mumps antibody,86735,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.27,,,,,,,fee schedule,11.74,49.7,APC
Mumps antibody,86735,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22.84,,,,,,,fee schedule,11.74,49.7,APC
Mycoplasma antibody,86738,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,77,,,,,,,fee schedule,11.92,77,
Mycoplasma antibody,86738,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,61.72,,,,,,,fee schedule,11.92,77,
Mycoplasma antibody,86738,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,67.43,,,,,,,fee schedule,11.92,77,
Mycoplasma antibody,86738,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,70.89,,,,,,,fee schedule,11.92,77,
Mycoplasma antibody,86738,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.92,,,,,,,fee schedule,11.92,77,Laboratory
Mycoplasma antibody,86738,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.9,,,,,,,fee schedule,11.92,77,APC
Mycoplasma antibody,86738,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.77,,,,,,,fee schedule,11.92,77,APC
Mycoplasma antibody,86738,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.24,,,,,,,fee schedule,11.92,77,APC
Mycoplasma antibody,86738,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.26,,,,,,,fee schedule,11.92,77,Radiology
Mycoplasma antibody,86738,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.54,,,,,,,fee schedule,11.92,77,APC
Mycoplasma antibody,86738,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23.17,,,,,,,fee schedule,11.92,77,APC
Neisseria meningitidis,86741,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,72.77,,,,,,,fee schedule,11.87,72.77,
Neisseria meningitidis,86741,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,58.33,,,,,,,fee schedule,11.87,72.77,
Neisseria meningitidis,86741,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,63.72,,,,,,,fee schedule,11.87,72.77,
Neisseria meningitidis,86741,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.99,,,,,,,fee schedule,11.87,72.77,
Neisseria meningitidis,86741,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.87,,,,,,,fee schedule,11.87,72.77,Laboratory
Neisseria meningitidis,86741,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.85,,,,,,,fee schedule,11.87,72.77,APC
Neisseria meningitidis,86741,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.72,,,,,,,fee schedule,11.87,72.77,APC
Neisseria meningitidis,86741,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.19,,,,,,,fee schedule,11.87,72.77,APC
Neisseria meningitidis,86741,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.18,,,,,,,fee schedule,11.87,72.77,Radiology
Neisseria meningitidis,86741,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.47,,,,,,,fee schedule,11.87,72.77,APC
Neisseria meningitidis,86741,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23.08,,,,,,,fee schedule,11.87,72.77,APC
Nocardia antibody,86744,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,72.77,,,,,,,fee schedule,14.39,72.77,
Nocardia antibody,86744,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,58.33,,,,,,,fee schedule,14.39,72.77,
Nocardia antibody,86744,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,63.72,,,,,,,fee schedule,14.39,72.77,
Nocardia antibody,86744,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.99,,,,,,,fee schedule,14.39,72.77,
Nocardia antibody,86744,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.39,,,,,,,fee schedule,14.39,72.77,Laboratory
Nocardia antibody,86744,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.79,,,,,,,fee schedule,14.39,72.77,APC
Nocardia antibody,86744,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,16.63,,,,,,,fee schedule,14.39,72.77,APC
Nocardia antibody,86744,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,15.99,,,,,,,fee schedule,14.39,72.77,APC
Nocardia antibody,86744,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24.46,,,,,,,fee schedule,14.39,72.77,Radiology
Nocardia antibody,86744,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.39,,,,,,,fee schedule,14.39,72.77,APC
Nocardia antibody,86744,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,27.98,,,,,,,fee schedule,14.39,72.77,APC
Parvovirus antibody,86747,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,91.81,,,,,,,fee schedule,13.53,91.81,
Parvovirus antibody,86747,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,73.59,,,,,,,fee schedule,13.53,91.81,
Parvovirus antibody,86747,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,80.39,,,,,,,fee schedule,13.53,91.81,
Parvovirus antibody,86747,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,84.52,,,,,,,fee schedule,13.53,91.81,
Parvovirus antibody,86747,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.53,,,,,,,fee schedule,13.53,91.81,Laboratory
Parvovirus antibody,86747,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.78,,,,,,,fee schedule,13.53,91.81,APC
Parvovirus antibody,86747,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,15.63,,,,,,,fee schedule,13.53,91.81,APC
Parvovirus antibody,86747,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,15.03,,,,,,,fee schedule,13.53,91.81,APC
Parvovirus antibody,86747,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23,,,,,,,fee schedule,13.53,91.81,Radiology
Parvovirus antibody,86747,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21.04,,,,,,,fee schedule,13.53,91.81,APC
Parvovirus antibody,86747,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,26.3,,,,,,,fee schedule,13.53,91.81,APC
Malaria antibody,86750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,50.61,,,,,,,fee schedule,11.87,50.61,
Malaria antibody,86750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40.57,,,,,,,fee schedule,11.87,50.61,
Malaria antibody,86750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,44.32,,,,,,,fee schedule,11.87,50.61,
Malaria antibody,86750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46.6,,,,,,,fee schedule,11.87,50.61,
Malaria antibody,86750,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.87,,,,,,,fee schedule,11.87,50.61,Laboratory
Malaria antibody,86750,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.85,,,,,,,fee schedule,11.87,50.61,APC
Malaria antibody,86750,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.72,,,,,,,fee schedule,11.87,50.61,APC
Malaria antibody,86750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.19,,,,,,,fee schedule,11.87,50.61,APC
Malaria antibody,86750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.18,,,,,,,fee schedule,11.87,50.61,Radiology
Malaria antibody,86750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.47,,,,,,,fee schedule,11.87,50.61,APC
Malaria antibody,86750,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23.08,,,,,,,fee schedule,11.87,50.61,APC
Protozoa antibody nos,86753,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,53.31,,,,,,,fee schedule,11.15,53.31,
Protozoa antibody nos,86753,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.73,,,,,,,fee schedule,11.15,53.31,
Protozoa antibody nos,86753,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.68,,,,,,,fee schedule,11.15,53.31,
Protozoa antibody nos,86753,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,49.08,,,,,,,fee schedule,11.15,53.31,
Protozoa antibody nos,86753,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.15,,,,,,,fee schedule,11.15,53.31,Laboratory
Protozoa antibody nos,86753,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.01,,,,,,,fee schedule,11.15,53.31,APC
Protozoa antibody nos,86753,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.89,,,,,,,fee schedule,11.15,53.31,APC
Protozoa antibody nos,86753,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.39,,,,,,,fee schedule,11.15,53.31,APC
Protozoa antibody nos,86753,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.96,,,,,,,fee schedule,11.15,53.31,Radiology
Protozoa antibody nos,86753,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.35,,,,,,,fee schedule,11.15,53.31,APC
Protozoa antibody nos,86753,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21.68,,,,,,,fee schedule,11.15,53.31,APC
Respiratory virus antibody,86756,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,71.14,,,,,,,fee schedule,14.3,71.14,
Respiratory virus antibody,86756,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.02,,,,,,,fee schedule,14.3,71.14,
Respiratory virus antibody,86756,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,62.29,,,,,,,fee schedule,14.3,71.14,
Respiratory virus antibody,86756,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,65.49,,,,,,,fee schedule,14.3,71.14,
Respiratory virus antibody,86756,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.3,,,,,,,fee schedule,14.3,71.14,Laboratory
Respiratory virus antibody,86756,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.68,,,,,,,fee schedule,14.3,71.14,APC
Respiratory virus antibody,86756,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,16.53,,,,,,,fee schedule,14.3,71.14,APC
Respiratory virus antibody,86756,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,15.89,,,,,,,fee schedule,14.3,71.14,APC
Respiratory virus antibody,86756,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24.31,,,,,,,fee schedule,14.3,71.14,Radiology
Respiratory virus antibody,86756,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.25,,,,,,,fee schedule,14.3,71.14,APC
Respiratory virus antibody,86756,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,27.81,,,,,,,fee schedule,14.3,71.14,APC
Rickettsia Antibody,86757,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,82.18,,,,,,,fee schedule,17.42,82.18,
Rickettsia Antibody,86757,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,65.88,,,,,,,fee schedule,17.42,82.18,
Rickettsia Antibody,86757,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,71.96,,,,,,,fee schedule,17.42,82.18,
Rickettsia Antibody,86757,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,75.66,,,,,,,fee schedule,17.42,82.18,
Rickettsia Antibody,86757,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.42,,,,,,,fee schedule,17.42,82.18,Laboratory
Rickettsia Antibody,86757,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20.32,,,,,,,fee schedule,17.42,82.18,APC
Rickettsia Antibody,86757,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,20.12,,,,,,,fee schedule,17.42,82.18,APC
Rickettsia Antibody,86757,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,19.35,,,,,,,fee schedule,17.42,82.18,APC
Rickettsia Antibody,86757,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29.61,,,,,,,fee schedule,17.42,82.18,Radiology
Rickettsia Antibody,86757,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27.09,,,,,,,fee schedule,17.42,82.18,APC
Rickettsia Antibody,86757,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,33.86,,,,,,,fee schedule,17.42,82.18,APC
Rotavirus antibody,86759,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,72.77,,,,,,,fee schedule,16.41,72.77,
Rotavirus antibody,86759,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,58.33,,,,,,,fee schedule,16.41,72.77,
Rotavirus antibody,86759,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,63.72,,,,,,,fee schedule,16.41,72.77,
Rotavirus antibody,86759,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.99,,,,,,,fee schedule,16.41,72.77,
Rotavirus antibody,86759,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.41,,,,,,,fee schedule,16.41,72.77,Laboratory
Rotavirus antibody,86759,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.14,,,,,,,fee schedule,16.41,72.77,APC
Rotavirus antibody,86759,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18.96,,,,,,,fee schedule,16.41,72.77,APC
Rotavirus antibody,86759,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18.23,,,,,,,fee schedule,16.41,72.77,APC
Rotavirus antibody,86759,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27.89,,,,,,,fee schedule,16.41,72.77,Radiology
Rotavirus antibody,86759,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.52,,,,,,,fee schedule,16.41,72.77,APC
Rotavirus antibody,86759,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31.9,,,,,,,fee schedule,16.41,72.77,APC
Rubella antibody,86762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,53.03,,,,,,,fee schedule,12.95,53.03,
Rubella antibody,86762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.51,,,,,,,fee schedule,12.95,53.03,
Rubella antibody,86762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.44,,,,,,,fee schedule,12.95,53.03,
Rubella antibody,86762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,48.82,,,,,,,fee schedule,12.95,53.03,
Rubella antibody,86762,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.95,,,,,,,fee schedule,12.95,53.03,Laboratory
Rubella antibody,86762,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.11,,,,,,,fee schedule,12.95,53.03,APC
Rubella antibody,86762,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,14.97,,,,,,,fee schedule,12.95,53.03,APC
Rubella antibody,86762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14.39,,,,,,,fee schedule,12.95,53.03,APC
Rubella antibody,86762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.02,,,,,,,fee schedule,12.95,53.03,Radiology
Rubella antibody,86762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.15,,,,,,,fee schedule,12.95,53.03,APC
Rubella antibody,86762,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,25.18,,,,,,,fee schedule,12.95,53.03,APC
Rubeola antibody,86765,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46.54,,,,,,,fee schedule,11.59,46.54,
Rubeola antibody,86765,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37.3,,,,,,,fee schedule,11.59,46.54,
Rubeola antibody,86765,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40.75,,,,,,,fee schedule,11.59,46.54,
Rubeola antibody,86765,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42.85,,,,,,,fee schedule,11.59,46.54,
Rubeola antibody,86765,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.59,,,,,,,fee schedule,11.59,46.54,Laboratory
Rubeola antibody,86765,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.52,,,,,,,fee schedule,11.59,46.54,APC
Rubeola antibody,86765,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.4,,,,,,,fee schedule,11.59,46.54,APC
Rubeola antibody,86765,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.88,,,,,,,fee schedule,11.59,46.54,APC
Rubeola antibody,86765,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.71,,,,,,,fee schedule,11.59,46.54,Radiology
Rubeola antibody,86765,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.03,,,,,,,fee schedule,11.59,46.54,APC
Rubeola antibody,86765,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22.54,,,,,,,fee schedule,11.59,46.54,APC
Salmonella antibody,86768,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,50.61,,,,,,,fee schedule,11.87,50.61,
Salmonella antibody,86768,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40.57,,,,,,,fee schedule,11.87,50.61,
Salmonella antibody,86768,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,44.32,,,,,,,fee schedule,11.87,50.61,
Salmonella antibody,86768,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46.6,,,,,,,fee schedule,11.87,50.61,
Salmonella antibody,86768,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.87,,,,,,,fee schedule,11.87,50.61,Laboratory
Salmonella antibody,86768,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.85,,,,,,,fee schedule,11.87,50.61,APC
Salmonella antibody,86768,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.72,,,,,,,fee schedule,11.87,50.61,APC
Salmonella antibody,86768,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.19,,,,,,,fee schedule,11.87,50.61,APC
Salmonella antibody,86768,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.18,,,,,,,fee schedule,11.87,50.61,Radiology
Salmonella antibody,86768,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.47,,,,,,,fee schedule,11.87,50.61,APC
Salmonella antibody,86768,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23.08,,,,,,,fee schedule,11.87,50.61,APC
Sars-cov-2 covid-19 antibody,86769,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,159.25,,,,,,,fee schedule,37.92,159.25,
Sars-cov-2 covid-19 antibody,86769,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,127.65,,,,,,,fee schedule,37.92,159.25,
Sars-cov-2 covid-19 antibody,86769,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,139.45,,,,,,,fee schedule,37.92,159.25,
Sars-cov-2 covid-19 antibody,86769,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,146.61,,,,,,,fee schedule,37.92,159.25,
Sars-cov-2 covid-19 antibody,86769,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,37.92,,,,,,,fee schedule,37.92,159.25,Laboratory
Sars-cov-2 covid-19 antibody,86769,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,44.24,,,,,,,fee schedule,37.92,159.25,APC
Sars-cov-2 covid-19 antibody,86769,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,43.82,,,,,,,fee schedule,37.92,159.25,APC
Sars-cov-2 covid-19 antibody,86769,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,42.13,,,,,,,fee schedule,37.92,159.25,APC
Sars-cov-2 covid-19 antibody,86769,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,64.46,,,,,,,fee schedule,37.92,159.25,Radiology
Sars-cov-2 covid-19 antibody,86769,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,58.98,,,,,,,fee schedule,37.92,159.25,APC
Sars-cov-2 covid-19 antibody,86769,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,73.73,,,,,,,fee schedule,37.92,159.25,APC
Shigella antibody,86771,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,72.77,,,,,,,fee schedule,22.03,72.77,
Shigella antibody,86771,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,58.33,,,,,,,fee schedule,22.03,72.77,
Shigella antibody,86771,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,63.72,,,,,,,fee schedule,22.03,72.77,
Shigella antibody,86771,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.99,,,,,,,fee schedule,22.03,72.77,
Shigella antibody,86771,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22.03,,,,,,,fee schedule,22.03,72.77,Laboratory
Shigella antibody,86771,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,25.7,,,,,,,fee schedule,22.03,72.77,APC
Shigella antibody,86771,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,25.46,,,,,,,fee schedule,22.03,72.77,APC
Shigella antibody,86771,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,24.48,,,,,,,fee schedule,22.03,72.77,APC
Shigella antibody,86771,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,37.45,,,,,,,fee schedule,22.03,72.77,Radiology
Shigella antibody,86771,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,34.27,,,,,,,fee schedule,22.03,72.77,APC
Shigella antibody,86771,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,42.84,,,,,,,fee schedule,22.03,72.77,APC
Tetanus antibody,86774,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,81.69,,,,,,,fee schedule,13.32,81.69,
Tetanus antibody,86774,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,65.48,,,,,,,fee schedule,13.32,81.69,
Tetanus antibody,86774,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,71.53,,,,,,,fee schedule,13.32,81.69,
Tetanus antibody,86774,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,75.2,,,,,,,fee schedule,13.32,81.69,
Tetanus antibody,86774,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.32,,,,,,,fee schedule,13.32,81.69,Laboratory
Tetanus antibody,86774,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.54,,,,,,,fee schedule,13.32,81.69,APC
Tetanus antibody,86774,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,15.39,,,,,,,fee schedule,13.32,81.69,APC
Tetanus antibody,86774,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14.8,,,,,,,fee schedule,13.32,81.69,APC
Tetanus antibody,86774,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.64,,,,,,,fee schedule,13.32,81.69,Radiology
Tetanus antibody,86774,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.72,,,,,,,fee schedule,13.32,81.69,APC
Tetanus antibody,86774,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,25.9,,,,,,,fee schedule,13.32,81.69,APC
Toxoplasma antibody,86777,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45.16,,,,,,,fee schedule,12.95,45.16,
Toxoplasma antibody,86777,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36.2,,,,,,,fee schedule,12.95,45.16,
Toxoplasma antibody,86777,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39.55,,,,,,,fee schedule,12.95,45.16,
Toxoplasma antibody,86777,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41.58,,,,,,,fee schedule,12.95,45.16,
Toxoplasma antibody,86777,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.95,,,,,,,fee schedule,12.95,45.16,Laboratory
Toxoplasma antibody,86777,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.11,,,,,,,fee schedule,12.95,45.16,APC
Toxoplasma antibody,86777,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,14.97,,,,,,,fee schedule,12.95,45.16,APC
Toxoplasma antibody,86777,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14.39,,,,,,,fee schedule,12.95,45.16,APC
Toxoplasma antibody,86777,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.02,,,,,,,fee schedule,12.95,45.16,Radiology
Toxoplasma antibody,86777,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.15,,,,,,,fee schedule,12.95,45.16,APC
Toxoplasma antibody,86777,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,25.18,,,,,,,fee schedule,12.95,45.16,APC
Toxoplasma antibody igm,86778,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45.16,,,,,,,fee schedule,12.97,45.16,
Toxoplasma antibody igm,86778,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36.2,,,,,,,fee schedule,12.97,45.16,
Toxoplasma antibody igm,86778,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39.55,,,,,,,fee schedule,12.97,45.16,
Toxoplasma antibody igm,86778,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41.58,,,,,,,fee schedule,12.97,45.16,
Toxoplasma antibody igm,86778,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.97,,,,,,,fee schedule,12.97,45.16,Laboratory
Toxoplasma antibody igm,86778,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.13,,,,,,,fee schedule,12.97,45.16,APC
Toxoplasma antibody igm,86778,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,14.99,,,,,,,fee schedule,12.97,45.16,APC
Toxoplasma antibody igm,86778,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14.41,,,,,,,fee schedule,12.97,45.16,APC
Toxoplasma antibody igm,86778,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.05,,,,,,,fee schedule,12.97,45.16,Radiology
Toxoplasma antibody igm,86778,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.17,,,,,,,fee schedule,12.97,45.16,APC
Toxoplasma antibody igm,86778,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,25.22,,,,,,,fee schedule,12.97,45.16,APC
Treponema pallidum,86780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,47.7,,,,,,,fee schedule,11.92,47.7,
Treponema pallidum,86780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38.23,,,,,,,fee schedule,11.92,47.7,
Treponema pallidum,86780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,41.77,,,,,,,fee schedule,11.92,47.7,
Treponema pallidum,86780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,43.91,,,,,,,fee schedule,11.92,47.7,
Treponema pallidum,86780,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.92,,,,,,,fee schedule,11.92,47.7,Laboratory
Treponema pallidum,86780,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.9,,,,,,,fee schedule,11.92,47.7,APC
Treponema pallidum,86780,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.77,,,,,,,fee schedule,11.92,47.7,APC
Treponema pallidum,86780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.24,,,,,,,fee schedule,11.92,47.7,APC
Treponema pallidum,86780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.26,,,,,,,fee schedule,11.92,47.7,Radiology
Treponema pallidum,86780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.54,,,,,,,fee schedule,11.92,47.7,APC
Treponema pallidum,86780,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23.17,,,,,,,fee schedule,11.92,47.7,APC
Trichinella antibody,86784,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,69.33,,,,,,,fee schedule,11.3,69.33,
Trichinella antibody,86784,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55.57,,,,,,,fee schedule,11.3,69.33,
Trichinella antibody,86784,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,60.71,,,,,,,fee schedule,11.3,69.33,
Trichinella antibody,86784,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,63.82,,,,,,,fee schedule,11.3,69.33,
Trichinella antibody,86784,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.3,,,,,,,fee schedule,11.3,69.33,Laboratory
Trichinella antibody,86784,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.19,,,,,,,fee schedule,11.3,69.33,APC
Trichinella antibody,86784,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.06,,,,,,,fee schedule,11.3,69.33,APC
Trichinella antibody,86784,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.56,,,,,,,fee schedule,11.3,69.33,APC
Trichinella antibody,86784,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.22,,,,,,,fee schedule,11.3,69.33,Radiology
Trichinella antibody,86784,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.58,,,,,,,fee schedule,11.3,69.33,APC
Trichinella antibody,86784,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21.98,,,,,,,fee schedule,11.3,69.33,APC
Varicella-zoster antibody,86787,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,63.73,,,,,,,fee schedule,11.59,63.73,
Varicella-zoster antibody,86787,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.09,,,,,,,fee schedule,11.59,63.73,
Varicella-zoster antibody,86787,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55.81,,,,,,,fee schedule,11.59,63.73,
Varicella-zoster antibody,86787,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,58.68,,,,,,,fee schedule,11.59,63.73,
Varicella-zoster antibody,86787,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.59,,,,,,,fee schedule,11.59,63.73,Laboratory
Varicella-zoster antibody,86787,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.52,,,,,,,fee schedule,11.59,63.73,APC
Varicella-zoster antibody,86787,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.4,,,,,,,fee schedule,11.59,63.73,APC
Varicella-zoster antibody,86787,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.88,,,,,,,fee schedule,11.59,63.73,APC
Varicella-zoster antibody,86787,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.71,,,,,,,fee schedule,11.59,63.73,Radiology
Varicella-zoster antibody,86787,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.03,,,,,,,fee schedule,11.59,63.73,APC
Varicella-zoster antibody,86787,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22.54,,,,,,,fee schedule,11.59,63.73,APC
West nile virus ab igm,86788,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,64.72,,,,,,,fee schedule,15.16,64.72,
West nile virus ab igm,86788,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.88,,,,,,,fee schedule,15.16,64.72,
West nile virus ab igm,86788,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56.67,,,,,,,fee schedule,15.16,64.72,
West nile virus ab igm,86788,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59.59,,,,,,,fee schedule,15.16,64.72,
West nile virus ab igm,86788,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.16,,,,,,,fee schedule,15.16,64.72,Laboratory
West nile virus ab igm,86788,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.69,,,,,,,fee schedule,15.16,64.72,APC
West nile virus ab igm,86788,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,17.52,,,,,,,fee schedule,15.16,64.72,APC
West nile virus ab igm,86788,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16.85,,,,,,,fee schedule,15.16,64.72,APC
West nile virus ab igm,86788,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.78,,,,,,,fee schedule,15.16,64.72,Radiology
West nile virus ab igm,86788,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.59,,,,,,,fee schedule,15.16,64.72,APC
West nile virus ab igm,86788,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,29.49,,,,,,,fee schedule,15.16,64.72,APC
West Nile Virus Antibody,86789,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,56.58,,,,,,,fee schedule,12.95,56.58,
West Nile Virus Antibody,86789,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,45.35,,,,,,,fee schedule,12.95,56.58,
West Nile Virus Antibody,86789,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,49.54,,,,,,,fee schedule,12.95,56.58,
West Nile Virus Antibody,86789,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,52.09,,,,,,,fee schedule,12.95,56.58,
West Nile Virus Antibody,86789,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.95,,,,,,,fee schedule,12.95,56.58,Laboratory
West Nile Virus Antibody,86789,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.11,,,,,,,fee schedule,12.95,56.58,APC
West Nile Virus Antibody,86789,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,14.97,,,,,,,fee schedule,12.95,56.58,APC
West Nile Virus Antibody,86789,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14.39,,,,,,,fee schedule,12.95,56.58,APC
West Nile Virus Antibody,86789,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.02,,,,,,,fee schedule,12.95,56.58,Radiology
West Nile Virus Antibody,86789,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.15,,,,,,,fee schedule,12.95,56.58,APC
West Nile Virus Antibody,86789,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,25.18,,,,,,,fee schedule,12.95,56.58,APC
Virus antibody nos,86790,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,79.96,,,,,,,fee schedule,11.59,79.96,
Virus antibody nos,86790,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,64.1,,,,,,,fee schedule,11.59,79.96,
Virus antibody nos,86790,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,70.02,,,,,,,fee schedule,11.59,79.96,
Virus antibody nos,86790,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,73.62,,,,,,,fee schedule,11.59,79.96,
Virus antibody nos,86790,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.59,,,,,,,fee schedule,11.59,79.96,Laboratory
Virus antibody nos,86790,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.52,,,,,,,fee schedule,11.59,79.96,APC
Virus antibody nos,86790,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.4,,,,,,,fee schedule,11.59,79.96,APC
Virus antibody nos,86790,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.88,,,,,,,fee schedule,11.59,79.96,APC
Virus antibody nos,86790,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.71,,,,,,,fee schedule,11.59,79.96,Radiology
Virus antibody nos,86790,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.03,,,,,,,fee schedule,11.59,79.96,APC
Virus antibody nos,86790,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22.54,,,,,,,fee schedule,11.59,79.96,APC
Yersinia antibody,86793,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,72.77,,,,,,,fee schedule,11.87,72.77,
Yersinia antibody,86793,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,58.33,,,,,,,fee schedule,11.87,72.77,
Yersinia antibody,86793,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,63.72,,,,,,,fee schedule,11.87,72.77,
Yersinia antibody,86793,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.99,,,,,,,fee schedule,11.87,72.77,
Yersinia antibody,86793,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.87,,,,,,,fee schedule,11.87,72.77,Laboratory
Yersinia antibody,86793,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.85,,,,,,,fee schedule,11.87,72.77,APC
Yersinia antibody,86793,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.72,,,,,,,fee schedule,11.87,72.77,APC
Yersinia antibody,86793,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.19,,,,,,,fee schedule,11.87,72.77,APC
Yersinia antibody,86793,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.18,,,,,,,fee schedule,11.87,72.77,Radiology
Yersinia antibody,86793,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.47,,,,,,,fee schedule,11.87,72.77,APC
Yersinia antibody,86793,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23.08,,,,,,,fee schedule,11.87,72.77,APC
Zika virus igm antibody,86794,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.16,,,,,,,fee schedule,15.16,29.49,Laboratory
Zika virus igm antibody,86794,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.69,,,,,,,fee schedule,15.16,29.49,APC
Zika virus igm antibody,86794,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,17.52,,,,,,,fee schedule,15.16,29.49,APC
Zika virus igm antibody,86794,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16.85,,,,,,,fee schedule,15.16,29.49,APC
Zika virus igm antibody,86794,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.78,,,,,,,fee schedule,15.16,29.49,Radiology
Zika virus igm antibody,86794,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.59,,,,,,,fee schedule,15.16,29.49,APC
Zika virus igm antibody,86794,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,29.49,,,,,,,fee schedule,15.16,29.49,APC
Thyroglobulin antibody,86800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,56.48,,,,,,,fee schedule,14.32,56.48,
Thyroglobulin antibody,86800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,45.27,,,,,,,fee schedule,14.32,56.48,
Thyroglobulin antibody,86800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,49.46,,,,,,,fee schedule,14.32,56.48,
Thyroglobulin antibody,86800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,52,,,,,,,fee schedule,14.32,56.48,
Thyroglobulin antibody,86800,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.32,,,,,,,fee schedule,14.32,56.48,Laboratory
Thyroglobulin antibody,86800,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.71,,,,,,,fee schedule,14.32,56.48,APC
Thyroglobulin antibody,86800,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,16.55,,,,,,,fee schedule,14.32,56.48,APC
Thyroglobulin antibody,86800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,15.91,,,,,,,fee schedule,14.32,56.48,APC
Thyroglobulin antibody,86800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24.34,,,,,,,fee schedule,14.32,56.48,Radiology
Thyroglobulin antibody,86800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.27,,,,,,,fee schedule,14.32,56.48,APC
Thyroglobulin antibody,86800,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,27.84,,,,,,,fee schedule,14.32,56.48,APC
Hepatitis c ab test,86803,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,57.95,,,,,,,fee schedule,12.84,57.95,
Hepatitis c ab test,86803,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.45,,,,,,,fee schedule,12.84,57.95,
Hepatitis c ab test,86803,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,50.75,,,,,,,fee schedule,12.84,57.95,
Hepatitis c ab test,86803,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,53.35,,,,,,,fee schedule,12.84,57.95,
Hepatitis c ab test,86803,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.84,,,,,,,fee schedule,12.84,57.95,Laboratory
Hepatitis c ab test,86803,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.98,,,,,,,fee schedule,12.84,57.95,APC
Hepatitis c ab test,86803,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,14.84,,,,,,,fee schedule,12.84,57.95,APC
Hepatitis c ab test,86803,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14.27,,,,,,,fee schedule,12.84,57.95,APC
Hepatitis c ab test,86803,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21.83,,,,,,,fee schedule,12.84,57.95,Radiology
Hepatitis c ab test,86803,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.98,,,,,,,fee schedule,12.84,57.95,APC
Hepatitis c ab test,86803,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,24.97,,,,,,,fee schedule,12.84,57.95,APC
Hep c ab test confirm,86804,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,85.47,,,,,,,fee schedule,13.94,85.47,
Hep c ab test confirm,86804,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,68.51,,,,,,,fee schedule,13.94,85.47,
Hep c ab test confirm,86804,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,74.84,,,,,,,fee schedule,13.94,85.47,
Hep c ab test confirm,86804,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,78.68,,,,,,,fee schedule,13.94,85.47,
Hep c ab test confirm,86804,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.94,,,,,,,fee schedule,13.94,85.47,Laboratory
Hep c ab test confirm,86804,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.26,,,,,,,fee schedule,13.94,85.47,APC
Hep c ab test confirm,86804,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,16.11,,,,,,,fee schedule,13.94,85.47,APC
Hep c ab test confirm,86804,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,15.49,,,,,,,fee schedule,13.94,85.47,APC
Hep c ab test confirm,86804,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.7,,,,,,,fee schedule,13.94,85.47,Radiology
Hep c ab test confirm,86804,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21.69,,,,,,,fee schedule,13.94,85.47,APC
Hep c ab test confirm,86804,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,27.11,,,,,,,fee schedule,13.94,85.47,APC
Lymphocytotoxicity assay,86805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,288.57,,,,,,,fee schedule,170.56,331.64,
Lymphocytotoxicity assay,86805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,231.31,,,,,,,fee schedule,170.56,331.64,
Lymphocytotoxicity assay,86805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,252.69,,,,,,,fee schedule,170.56,331.64,
Lymphocytotoxicity assay,86805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,265.66,,,,,,,fee schedule,170.56,331.64,
Lymphocytotoxicity assay,86805,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,170.56,,,,,,,fee schedule,170.56,331.64,Laboratory
Lymphocytotoxicity assay,86805,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,198.99,,,,,,,fee schedule,170.56,331.64,APC
Lymphocytotoxicity assay,86805,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,197.09,,,,,,,fee schedule,170.56,331.64,APC
Lymphocytotoxicity assay,86805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,189.51,,,,,,,fee schedule,170.56,331.64,APC
Lymphocytotoxicity assay,86805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,289.95,,,,,,,fee schedule,170.56,331.64,Radiology
Lymphocytotoxicity assay,86805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,265.31,,,,,,,fee schedule,170.56,331.64,APC
Lymphocytotoxicity assay,86805,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,331.64,,,,,,,fee schedule,170.56,331.64,APC
Lymphocytotoxicity assay,86806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,262.63,,,,,,,fee schedule,42.83,262.63,
Lymphocytotoxicity assay,86806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,210.52,,,,,,,fee schedule,42.83,262.63,
Lymphocytotoxicity assay,86806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,229.98,,,,,,,fee schedule,42.83,262.63,
Lymphocytotoxicity assay,86806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,241.79,,,,,,,fee schedule,42.83,262.63,
Lymphocytotoxicity assay,86806,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,42.83,,,,,,,fee schedule,42.83,262.63,Laboratory
Lymphocytotoxicity assay,86806,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,49.97,,,,,,,fee schedule,42.83,262.63,APC
Lymphocytotoxicity assay,86806,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,49.49,,,,,,,fee schedule,42.83,262.63,APC
Lymphocytotoxicity assay,86806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,47.59,,,,,,,fee schedule,42.83,262.63,APC
Lymphocytotoxicity assay,86806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,72.81,,,,,,,fee schedule,42.83,262.63,Radiology
Lymphocytotoxicity assay,86806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,66.63,,,,,,,fee schedule,42.83,262.63,APC
Lymphocytotoxicity assay,86806,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,83.28,,,,,,,fee schedule,42.83,262.63,APC
Cytotoxic antibody screening,86807,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,218.37,,,,,,,fee schedule,70.78,218.37,
Cytotoxic antibody screening,86807,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,175.04,,,,,,,fee schedule,70.78,218.37,
Cytotoxic antibody screening,86807,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,191.22,,,,,,,fee schedule,70.78,218.37,
Cytotoxic antibody screening,86807,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,201.04,,,,,,,fee schedule,70.78,218.37,
Cytotoxic antibody screening,86807,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,70.79,,,,,,,fee schedule,70.78,218.37,Laboratory
Cytotoxic antibody screening,86807,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,82.58,,,,,,,fee schedule,70.78,218.37,APC
Cytotoxic antibody screening,86807,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,81.8,,,,,,,fee schedule,70.78,218.37,APC
Cytotoxic antibody screening,86807,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,78.65,,,,,,,fee schedule,70.78,218.37,APC
Cytotoxic antibody screening,86807,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.33,,,,,,,fee schedule,70.78,218.37,Radiology
Cytotoxic antibody screening,86807,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,110.11,,,,,,,fee schedule,70.78,218.37,APC
Cytotoxic antibody screening,86807,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,137.64,,,,,,,fee schedule,70.78,218.37,APC
Cytotoxic antibody screening,86808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,163.79,,,,,,,fee schedule,26.71,163.79,
Cytotoxic antibody screening,86808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,131.29,,,,,,,fee schedule,26.71,163.79,
Cytotoxic antibody screening,86808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,143.42,,,,,,,fee schedule,26.71,163.79,
Cytotoxic antibody screening,86808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,150.79,,,,,,,fee schedule,26.71,163.79,
Cytotoxic antibody screening,86808,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26.71,,,,,,,fee schedule,26.71,163.79,Laboratory
Cytotoxic antibody screening,86808,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,31.16,,,,,,,fee schedule,26.71,163.79,APC
Cytotoxic antibody screening,86808,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,30.87,,,,,,,fee schedule,26.71,163.79,APC
Cytotoxic antibody screening,86808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,29.68,,,,,,,fee schedule,26.71,163.79,APC
Cytotoxic antibody screening,86808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,45.41,,,,,,,fee schedule,26.71,163.79,Radiology
Cytotoxic antibody screening,86808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,41.55,,,,,,,fee schedule,26.71,163.79,APC
Cytotoxic antibody screening,86808,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,51.94,,,,,,,fee schedule,26.71,163.79,APC
Hla typing a b or c,86812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,142.43,,,,,,,fee schedule,23.23,142.43,
Hla typing a b or c,86812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,114.17,,,,,,,fee schedule,23.23,142.43,
Hla typing a b or c,86812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,124.72,,,,,,,fee schedule,23.23,142.43,
Hla typing a b or c,86812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,131.13,,,,,,,fee schedule,23.23,142.43,
Hla typing a b or c,86812,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23.23,,,,,,,fee schedule,23.23,142.43,Laboratory
Hla typing a b or c,86812,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,27.1,,,,,,,fee schedule,23.23,142.43,APC
Hla typing a b or c,86812,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,26.84,,,,,,,fee schedule,23.23,142.43,APC
Hla typing a b or c,86812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,25.81,,,,,,,fee schedule,23.23,142.43,APC
Hla typing a b or c,86812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,39.49,,,,,,,fee schedule,23.23,142.43,Radiology
Hla typing a b or c,86812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,36.13,,,,,,,fee schedule,23.23,142.43,APC
Hla typing a b or c,86812,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,45.17,,,,,,,fee schedule,23.23,142.43,APC
Hla typing a b or c,86813,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,162.77,,,,,,,fee schedule,52.2,162.77,
Hla typing a b or c,86813,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,130.47,,,,,,,fee schedule,52.2,162.77,
Hla typing a b or c,86813,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,142.53,,,,,,,fee schedule,52.2,162.77,
Hla typing a b or c,86813,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,149.85,,,,,,,fee schedule,52.2,162.77,
Hla typing a b or c,86813,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,52.2,,,,,,,fee schedule,52.2,162.77,Laboratory
Hla typing a b or c,86813,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,60.9,,,,,,,fee schedule,52.2,162.77,APC
Hla typing a b or c,86813,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.32,,,,,,,fee schedule,52.2,162.77,APC
Hla typing a b or c,86813,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58,,,,,,,fee schedule,52.2,162.77,APC
Hla typing a b or c,86813,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,88.74,,,,,,,fee schedule,52.2,162.77,Radiology
Hla typing a b or c,86813,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.2,,,,,,,fee schedule,52.2,162.77,APC
Hla typing a b or c,86813,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,101.5,,,,,,,fee schedule,52.2,162.77,APC
Hla typing dr/dq,86816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,153.73,,,,,,,fee schedule,27.15,153.73,
Hla typing dr/dq,86816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,123.23,,,,,,,fee schedule,27.15,153.73,
Hla typing dr/dq,86816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,134.62,,,,,,,fee schedule,27.15,153.73,
Hla typing dr/dq,86816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,141.53,,,,,,,fee schedule,27.15,153.73,
Hla typing dr/dq,86816,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,27.15,,,,,,,fee schedule,27.15,153.73,Laboratory
Hla typing dr/dq,86816,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,31.68,,,,,,,fee schedule,27.15,153.73,APC
Hla typing dr/dq,86816,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,31.38,,,,,,,fee schedule,27.15,153.73,APC
Hla typing dr/dq,86816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,30.17,,,,,,,fee schedule,27.15,153.73,APC
Hla typing dr/dq,86816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,46.16,,,,,,,fee schedule,27.15,153.73,Radiology
Hla typing dr/dq,86816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,42.24,,,,,,,fee schedule,27.15,153.73,APC
Hla typing dr/dq,86816,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,52.8,,,,,,,fee schedule,27.15,153.73,APC
Hla typing dr/dq,86817,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,355.32,,,,,,,fee schedule,95.53,355.32,
Hla typing dr/dq,86817,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,284.82,,,,,,,fee schedule,95.53,355.32,
Hla typing dr/dq,86817,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,311.14,,,,,,,fee schedule,95.53,355.32,
Hla typing dr/dq,86817,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,327.12,,,,,,,fee schedule,95.53,355.32,
Hla typing dr/dq,86817,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,95.53,,,,,,,fee schedule,95.53,355.32,Laboratory
Hla typing dr/dq,86817,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,111.45,,,,,,,fee schedule,95.53,355.32,APC
Hla typing dr/dq,86817,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,110.39,,,,,,,fee schedule,95.53,355.32,APC
Hla typing dr/dq,86817,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,106.14,,,,,,,fee schedule,95.53,355.32,APC
Hla typing dr/dq,86817,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,162.39,,,,,,,fee schedule,95.53,355.32,Radiology
Hla typing dr/dq,86817,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,148.6,,,,,,,fee schedule,95.53,355.32,APC
Hla typing dr/dq,86817,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,185.74,,,,,,,fee schedule,95.53,355.32,APC
Lymphocyte culture mixed,86821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,311.62,,,,,,,fee schedule,32.9,311.62,
Lymphocyte culture mixed,86821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,249.79,,,,,,,fee schedule,32.9,311.62,
Lymphocyte culture mixed,86821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,272.88,,,,,,,fee schedule,32.9,311.62,
Lymphocyte culture mixed,86821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,286.89,,,,,,,fee schedule,32.9,311.62,
Lymphocyte culture mixed,86821,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,32.9,,,,,,,fee schedule,32.9,311.62,Laboratory
Lymphocyte culture mixed,86821,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.39,,,,,,,fee schedule,32.9,311.62,APC
Lymphocyte culture mixed,86821,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.02,,,,,,,fee schedule,32.9,311.62,APC
Lymphocyte culture mixed,86821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.56,,,,,,,fee schedule,32.9,311.62,APC
Lymphocyte culture mixed,86821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,55.94,,,,,,,fee schedule,32.9,311.62,Radiology
Lymphocyte culture mixed,86821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.18,,,,,,,fee schedule,32.9,311.62,APC
Lymphocyte culture mixed,86821,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,63.98,,,,,,,fee schedule,32.9,311.62,APC
Hla x-math non-cytotoxic,86825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,434.85,,,,,,,fee schedule,98.54,434.85,
Hla x-math non-cytotoxic,86825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,348.57,,,,,,,fee schedule,98.54,434.85,
Hla x-math non-cytotoxic,86825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,380.78,,,,,,,fee schedule,98.54,434.85,
Hla x-math non-cytotoxic,86825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,400.34,,,,,,,fee schedule,98.54,434.85,
Hla x-math non-cytotoxic,86825,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,98.54,,,,,,,fee schedule,98.54,434.85,Laboratory
Hla x-math non-cytotoxic,86825,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,114.96,,,,,,,fee schedule,98.54,434.85,APC
Hla x-math non-cytotoxic,86825,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,113.87,,,,,,,fee schedule,98.54,434.85,APC
Hla x-math non-cytotoxic,86825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,109.49,,,,,,,fee schedule,98.54,434.85,APC
Hla x-math non-cytotoxic,86825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,167.52,,,,,,,fee schedule,98.54,434.85,Radiology
Hla x-math non-cytotoxic,86825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,153.29,,,,,,,fee schedule,98.54,434.85,APC
Hla x-math non-cytotoxic,86825,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,191.61,,,,,,,fee schedule,98.54,434.85,APC
Hla x-match noncytotoxc addl,86826,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,144.96,,,,,,,fee schedule,32.88,144.96,
Hla x-match noncytotoxc addl,86826,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,116.2,,,,,,,fee schedule,32.88,144.96,
Hla x-match noncytotoxc addl,86826,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,126.94,,,,,,,fee schedule,32.88,144.96,
Hla x-match noncytotoxc addl,86826,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,133.46,,,,,,,fee schedule,32.88,144.96,
Hla x-match noncytotoxc addl,86826,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,32.88,,,,,,,fee schedule,32.88,144.96,Laboratory
Hla x-match noncytotoxc addl,86826,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.36,,,,,,,fee schedule,32.88,144.96,APC
Hla x-match noncytotoxc addl,86826,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,37.99,,,,,,,fee schedule,32.88,144.96,APC
Hla x-match noncytotoxc addl,86826,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.53,,,,,,,fee schedule,32.88,144.96,APC
Hla x-match noncytotoxc addl,86826,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,55.89,,,,,,,fee schedule,32.88,144.96,Radiology
Hla x-match noncytotoxc addl,86826,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.14,,,,,,,fee schedule,32.88,144.96,APC
Hla x-match noncytotoxc addl,86826,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,63.93,,,,,,,fee schedule,32.88,144.96,APC
Hla class i&ii antibody qual,86828,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,125.13,,,,,,,fee schedule,57.77,125.13,
Hla class i&ii antibody qual,86828,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,100.3,,,,,,,fee schedule,57.77,125.13,
Hla class i&ii antibody qual,86828,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,109.57,,,,,,,fee schedule,57.77,125.13,
Hla class i&ii antibody qual,86828,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,115.2,,,,,,,fee schedule,57.77,125.13,
Hla class i&ii antibody qual,86828,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,57.77,,,,,,,fee schedule,57.77,125.13,Laboratory
Hla class i&ii antibody qual,86828,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,67.4,,,,,,,fee schedule,57.77,125.13,APC
Hla class i&ii antibody qual,86828,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,66.76,,,,,,,fee schedule,57.77,125.13,APC
Hla class i&ii antibody qual,86828,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,64.19,,,,,,,fee schedule,57.77,125.13,APC
Hla class i&ii antibody qual,86828,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,98.21,,,,,,,fee schedule,57.77,125.13,Radiology
Hla class i&ii antibody qual,86828,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.87,,,,,,,fee schedule,57.77,125.13,APC
Hla class i&ii antibody qual,86828,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,112.33,,,,,,,fee schedule,57.77,125.13,APC
Hla class i/ii antibody qual,86829,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,154.22,,,,,,,fee schedule,57.77,154.22,
Hla class i/ii antibody qual,86829,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,123.62,,,,,,,fee schedule,57.77,154.22,
Hla class i/ii antibody qual,86829,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,135.05,,,,,,,fee schedule,57.77,154.22,
Hla class i/ii antibody qual,86829,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,141.98,,,,,,,fee schedule,57.77,154.22,
Hla class i/ii antibody qual,86829,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,57.77,,,,,,,fee schedule,57.77,154.22,Laboratory
Hla class i/ii antibody qual,86829,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,67.4,,,,,,,fee schedule,57.77,154.22,APC
Hla class i/ii antibody qual,86829,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,66.76,,,,,,,fee schedule,57.77,154.22,APC
Hla class i/ii antibody qual,86829,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,64.19,,,,,,,fee schedule,57.77,154.22,APC
Hla class i/ii antibody qual,86829,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,98.21,,,,,,,fee schedule,57.77,154.22,Radiology
Hla class i/ii antibody qual,86829,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.87,,,,,,,fee schedule,57.77,154.22,APC
Hla class i/ii antibody qual,86829,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,112.33,,,,,,,fee schedule,57.77,154.22,APC
Hla class i phenotype qual,86830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,419.54,,,,,,,fee schedule,85.97,419.54,
Hla class i phenotype qual,86830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,336.3,,,,,,,fee schedule,85.97,419.54,
Hla class i phenotype qual,86830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,367.38,,,,,,,fee schedule,85.97,419.54,
Hla class i phenotype qual,86830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,386.25,,,,,,,fee schedule,85.97,419.54,
Hla class i phenotype qual,86830,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,85.97,,,,,,,fee schedule,85.97,419.54,Laboratory
Hla class i phenotype qual,86830,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,100.3,,,,,,,fee schedule,85.97,419.54,APC
Hla class i phenotype qual,86830,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,99.34,,,,,,,fee schedule,85.97,419.54,APC
Hla class i phenotype qual,86830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,95.52,,,,,,,fee schedule,85.97,419.54,APC
Hla class i phenotype qual,86830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,146.15,,,,,,,fee schedule,85.97,419.54,Radiology
Hla class i phenotype qual,86830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,133.73,,,,,,,fee schedule,85.97,419.54,APC
Hla class i phenotype qual,86830,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,167.16,,,,,,,fee schedule,85.97,419.54,APC
Hla class ii phenotype qual,86831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,359.59,,,,,,,fee schedule,73.69,359.59,
Hla class ii phenotype qual,86831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,288.24,,,,,,,fee schedule,73.69,359.59,
Hla class ii phenotype qual,86831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,314.88,,,,,,,fee schedule,73.69,359.59,
Hla class ii phenotype qual,86831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,331.05,,,,,,,fee schedule,73.69,359.59,
Hla class ii phenotype qual,86831,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,73.69,,,,,,,fee schedule,73.69,359.59,Laboratory
Hla class ii phenotype qual,86831,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,85.97,,,,,,,fee schedule,73.69,359.59,APC
Hla class ii phenotype qual,86831,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,85.16,,,,,,,fee schedule,73.69,359.59,APC
Hla class ii phenotype qual,86831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,81.88,,,,,,,fee schedule,73.69,359.59,APC
Hla class ii phenotype qual,86831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,125.28,,,,,,,fee schedule,73.69,359.59,Radiology
Hla class ii phenotype qual,86831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,114.63,,,,,,,fee schedule,73.69,359.59,APC
Hla class ii phenotype qual,86831,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,143.29,,,,,,,fee schedule,73.69,359.59,APC
Hla class i high defin qual,86832,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,396.85,,,,,,,fee schedule,291.38,566.56,
Hla class i high defin qual,86832,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,318.11,,,,,,,fee schedule,291.38,566.56,
Hla class i high defin qual,86832,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,347.51,,,,,,,fee schedule,291.38,566.56,
Hla class i high defin qual,86832,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,365.35,,,,,,,fee schedule,291.38,566.56,
Hla class i high defin qual,86832,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,291.38,,,,,,,fee schedule,291.38,566.56,Laboratory
Hla class i high defin qual,86832,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,339.94,,,,,,,fee schedule,291.38,566.56,APC
Hla class i high defin qual,86832,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,336.7,,,,,,,fee schedule,291.38,566.56,APC
Hla class i high defin qual,86832,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,323.75,,,,,,,fee schedule,291.38,566.56,APC
Hla class i high defin qual,86832,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,495.34,,,,,,,fee schedule,291.38,566.56,Radiology
Hla class i high defin qual,86832,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,453.25,,,,,,,fee schedule,291.38,566.56,APC
Hla class i high defin qual,86832,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,566.56,,,,,,,fee schedule,291.38,566.56,APC
Hla class ii high defin qual,86833,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,599.32,,,,,,,fee schedule,293.22,599.32,
Hla class ii high defin qual,86833,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,480.41,,,,,,,fee schedule,293.22,599.32,
Hla class ii high defin qual,86833,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,524.8,,,,,,,fee schedule,293.22,599.32,
Hla class ii high defin qual,86833,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,551.75,,,,,,,fee schedule,293.22,599.32,
Hla class ii high defin qual,86833,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,293.22,,,,,,,fee schedule,293.22,599.32,Laboratory
Hla class ii high defin qual,86833,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,342.09,,,,,,,fee schedule,293.22,599.32,APC
Hla class ii high defin qual,86833,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,338.83,,,,,,,fee schedule,293.22,599.32,APC
Hla class ii high defin qual,86833,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,325.8,,,,,,,fee schedule,293.22,599.32,APC
Hla class ii high defin qual,86833,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,498.47,,,,,,,fee schedule,293.22,599.32,Radiology
Hla class ii high defin qual,86833,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,456.12,,,,,,,fee schedule,293.22,599.32,APC
Hla class ii high defin qual,86833,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,570.15,,,,,,,fee schedule,293.22,599.32,APC
Hla class i semiquant panel,86834,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1857.83,,,,,,,fee schedule,321.8,1857.83,
Hla class i semiquant panel,86834,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1489.21,,,,,,,fee schedule,321.8,1857.83,
Hla class i semiquant panel,86834,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1626.83,,,,,,,fee schedule,321.8,1857.83,
Hla class i semiquant panel,86834,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1710.39,,,,,,,fee schedule,321.8,1857.83,
Hla class i semiquant panel,86834,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,321.8,,,,,,,fee schedule,321.8,1857.83,Laboratory
Hla class i semiquant panel,86834,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,375.44,,,,,,,fee schedule,321.8,1857.83,APC
Hla class i semiquant panel,86834,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,371.86,,,,,,,fee schedule,321.8,1857.83,APC
Hla class i semiquant panel,86834,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,357.56,,,,,,,fee schedule,321.8,1857.83,APC
Hla class i semiquant panel,86834,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,547.07,,,,,,,fee schedule,321.8,1857.83,Radiology
Hla class i semiquant panel,86834,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,500.58,,,,,,,fee schedule,321.8,1857.83,APC
Hla class i semiquant panel,86834,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,625.73,,,,,,,fee schedule,321.8,1857.83,APC
Hla class ii semiquant panel,86835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1678.06,,,,,,,fee schedule,290.66,1678.06,
Hla class ii semiquant panel,86835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1345.11,,,,,,,fee schedule,290.66,1678.06,
Hla class ii semiquant panel,86835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1469.41,,,,,,,fee schedule,290.66,1678.06,
Hla class ii semiquant panel,86835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1544.88,,,,,,,fee schedule,290.66,1678.06,
Hla class ii semiquant panel,86835,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,290.66,,,,,,,fee schedule,290.66,1678.06,Laboratory
Hla class ii semiquant panel,86835,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,339.11,,,,,,,fee schedule,290.66,1678.06,APC
Hla class ii semiquant panel,86835,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,335.88,,,,,,,fee schedule,290.66,1678.06,APC
Hla class ii semiquant panel,86835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,322.96,,,,,,,fee schedule,290.66,1678.06,APC
Hla class ii semiquant panel,86835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,494.13,,,,,,,fee schedule,290.66,1678.06,Radiology
Hla class ii semiquant panel,86835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,452.14,,,,,,,fee schedule,290.66,1678.06,APC
Hla class ii semiquant panel,86835,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,565.18,,,,,,,fee schedule,290.66,1678.06,APC
RBC antibody screen,86850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,149.09,,,,,,,fee schedule,51.59,228.88,
RBC antibody screen,86850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,119.51,,,,,,,fee schedule,51.59,228.88,
RBC antibody screen,86850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,130.55,,,,,,,fee schedule,51.59,228.88,
RBC antibody screen,86850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,137.25,,,,,,,fee schedule,51.59,228.88,
RBC antibody screen,86850,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,228.88,,,,,,,fee schedule,51.59,228.88,APC 378
RBC antibody screen,86850,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.17,,,,,,,fee schedule,51.59,228.88,APC
RBC antibody screen,86850,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,53.65,,,,,,,fee schedule,51.59,228.88,APC
RBC antibody screen,86850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,51.59,,,,,,,fee schedule,51.59,228.88,APC
RBC antibody screen,86850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,78.93,,,,,,,fee schedule,51.59,228.88,Radiology
RBC antibody screen,86850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,72.22,,,,,,,fee schedule,51.59,228.88,APC
RBC antibody screen,86850,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,90.28,,,,,,,fee schedule,51.59,228.88,APC
RBC antibody elution,86860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83.5,,,,,,,fee schedule,66.93,748.29,
RBC antibody elution,86860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66.93,,,,,,,fee schedule,66.93,748.29,
RBC antibody elution,86860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,73.12,,,,,,,fee schedule,66.93,748.29,
RBC antibody elution,86860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,76.87,,,,,,,fee schedule,66.93,748.29,
RBC antibody elution,86860,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,748.29,,,,,,,fee schedule,66.93,748.29,APC 378
RBC antibody elution,86860,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,177.09,,,,,,,fee schedule,66.93,748.29,APC
RBC antibody elution,86860,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,175.41,,,,,,,fee schedule,66.93,748.29,APC
RBC antibody elution,86860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,168.66,,,,,,,fee schedule,66.93,748.29,APC
RBC antibody elution,86860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,258.05,,,,,,,fee schedule,66.93,748.29,Radiology
RBC antibody elution,86860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,236.12,,,,,,,fee schedule,66.93,748.29,APC
RBC antibody elution,86860,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,295.16,,,,,,,fee schedule,66.93,748.29,APC
RBC antibody identification,86870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,324.29,,,,,,,fee schedule,259.95,1574.35,
RBC antibody identification,86870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,259.95,,,,,,,fee schedule,259.95,1574.35,
RBC antibody identification,86870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,283.97,,,,,,,fee schedule,259.95,1574.35,
RBC antibody identification,86870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,298.55,,,,,,,fee schedule,259.95,1574.35,
RBC antibody identification,86870,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1574.35,,,,,,,fee schedule,259.95,1574.35,APC 378
RBC antibody identification,86870,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,372.59,,,,,,,fee schedule,259.95,1574.35,APC
RBC antibody identification,86870,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,369.04,,,,,,,fee schedule,259.95,1574.35,APC
RBC antibody identification,86870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,354.85,,,,,,,fee schedule,259.95,1574.35,APC
RBC antibody identification,86870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,542.92,,,,,,,fee schedule,259.95,1574.35,Radiology
RBC antibody identification,86870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,496.79,,,,,,,fee schedule,259.95,1574.35,APC
RBC antibody identification,86870,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,620.99,,,,,,,fee schedule,259.95,1574.35,APC
Coombs test direct,86880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,151.78,,,,,,,fee schedule,58.4,259.1,
Coombs test direct,86880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,121.66,,,,,,,fee schedule,58.4,259.1,
Coombs test direct,86880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,132.91,,,,,,,fee schedule,58.4,259.1,
Coombs test direct,86880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,139.73,,,,,,,fee schedule,58.4,259.1,
Coombs test direct,86880,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,58.4,259.1,APC 378
Coombs test direct,86880,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,58.4,259.1,APC
Coombs test direct,86880,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,58.4,259.1,APC
Coombs test direct,86880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,58.4,259.1,APC
Coombs test direct,86880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,58.4,259.1,Radiology
Coombs test direct,86880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,58.4,259.1,APC
Coombs test direct,86880,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,58.4,259.1,APC
Coombs test indirect qual,86885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,109.39,,,,,,,fee schedule,87.68,748.29,
Coombs test indirect qual,86885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,87.68,,,,,,,fee schedule,87.68,748.29,
Coombs test indirect qual,86885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,95.79,,,,,,,fee schedule,87.68,748.29,
Coombs test indirect qual,86885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,100.71,,,,,,,fee schedule,87.68,748.29,
Coombs test indirect qual,86885,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,748.29,,,,,,,fee schedule,87.68,748.29,APC 378
Coombs test indirect qual,86885,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,177.09,,,,,,,fee schedule,87.68,748.29,APC
Coombs test indirect qual,86885,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,175.41,,,,,,,fee schedule,87.68,748.29,APC
Coombs test indirect qual,86885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,168.66,,,,,,,fee schedule,87.68,748.29,APC
Coombs test indirect qual,86885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,258.05,,,,,,,fee schedule,87.68,748.29,Radiology
Coombs test indirect qual,86885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,236.12,,,,,,,fee schedule,87.68,748.29,APC
Coombs test indirect qual,86885,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,295.16,,,,,,,fee schedule,87.68,748.29,APC
Coombs test indirect titer,86886,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,217.67,,,,,,,fee schedule,168.66,748.29,
Coombs test indirect titer,86886,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,174.49,,,,,,,fee schedule,168.66,748.29,
Coombs test indirect titer,86886,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,190.61,,,,,,,fee schedule,168.66,748.29,
Coombs test indirect titer,86886,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,200.4,,,,,,,fee schedule,168.66,748.29,
Coombs test indirect titer,86886,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,748.29,,,,,,,fee schedule,168.66,748.29,APC 378
Coombs test indirect titer,86886,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,177.09,,,,,,,fee schedule,168.66,748.29,APC
Coombs test indirect titer,86886,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,175.41,,,,,,,fee schedule,168.66,748.29,APC
Coombs test indirect titer,86886,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,168.66,,,,,,,fee schedule,168.66,748.29,APC
Coombs test indirect titer,86886,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,258.05,,,,,,,fee schedule,168.66,748.29,Radiology
Coombs test indirect titer,86886,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,236.12,,,,,,,fee schedule,168.66,748.29,APC
Coombs test indirect titer,86886,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,295.16,,,,,,,fee schedule,168.66,748.29,APC
Autologous blood process,86890,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,193.12,,,,,,,fee schedule,154.8,748.29,
Autologous blood process,86890,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,154.8,,,,,,,fee schedule,154.8,748.29,
Autologous blood process,86890,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,169.11,,,,,,,fee schedule,154.8,748.29,
Autologous blood process,86890,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,177.79,,,,,,,fee schedule,154.8,748.29,
Autologous blood process,86890,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,748.29,,,,,,,fee schedule,154.8,748.29,APC 378
Autologous blood process,86890,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,177.09,,,,,,,fee schedule,154.8,748.29,APC
Autologous blood process,86890,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,175.41,,,,,,,fee schedule,154.8,748.29,APC
Autologous blood process,86890,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,168.66,,,,,,,fee schedule,154.8,748.29,APC
Autologous blood process,86890,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,258.05,,,,,,,fee schedule,154.8,748.29,Radiology
Autologous blood process,86890,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,236.12,,,,,,,fee schedule,154.8,748.29,APC
Autologous blood process,86890,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,295.16,,,,,,,fee schedule,154.8,748.29,APC
Autologous blood op salvage,86891,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83.5,,,,,,,fee schedule,66.93,3538.67,
Autologous blood op salvage,86891,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66.93,,,,,,,fee schedule,66.93,3538.67,
Autologous blood op salvage,86891,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,73.12,,,,,,,fee schedule,66.93,3538.67,
Autologous blood op salvage,86891,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,76.87,,,,,,,fee schedule,66.93,3538.67,
Autologous blood op salvage,86891,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3538.67,,,,,,,fee schedule,66.93,3538.67,APC 378
Autologous blood op salvage,86891,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,837.48,,,,,,,fee schedule,66.93,3538.67,APC
Autologous blood op salvage,86891,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,829.5,,,,,,,fee schedule,66.93,3538.67,APC
Autologous blood op salvage,86891,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,797.6,,,,,,,fee schedule,66.93,3538.67,APC
Autologous blood op salvage,86891,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1220.32,,,,,,,fee schedule,66.93,3538.67,Radiology
Autologous blood op salvage,86891,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1116.64,,,,,,,fee schedule,66.93,3538.67,APC
Autologous blood op salvage,86891,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1395.79,,,,,,,fee schedule,66.93,3538.67,APC
Blood typing serologic abo,86900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,67.58,,,,,,,fee schedule,54.17,584.37,
Blood typing serologic abo,86900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,54.17,,,,,,,fee schedule,54.17,584.37,
Blood typing serologic abo,86900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,59.18,,,,,,,fee schedule,54.17,584.37,
Blood typing serologic abo,86900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,62.21,,,,,,,fee schedule,54.17,584.37,
Blood typing serologic abo,86900,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,54.17,584.37,APC 378
Blood typing serologic abo,86900,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,54.17,584.37,APC
Blood typing serologic abo,86900,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,54.17,584.37,APC
Blood typing serologic abo,86900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,54.17,584.37,APC
Blood typing serologic abo,86900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,54.17,584.37,Radiology
Blood typing serologic abo,86900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,54.17,584.37,APC
Blood typing serologic abo,86900,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,54.17,584.37,APC
Blood typing serologic rh(d),86901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55.79,,,,,,,fee schedule,36.98,164.05,
Blood typing serologic rh(d),86901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,44.72,,,,,,,fee schedule,36.98,164.05,
Blood typing serologic rh(d),86901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48.85,,,,,,,fee schedule,36.98,164.05,
Blood typing serologic rh(d),86901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,51.36,,,,,,,fee schedule,36.98,164.05,
Blood typing serologic rh(d),86901,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.05,,,,,,,fee schedule,36.98,164.05,APC 378
Blood typing serologic rh(d),86901,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.83,,,,,,,fee schedule,36.98,164.05,APC
Blood typing serologic rh(d),86901,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.46,,,,,,,fee schedule,36.98,164.05,APC
Blood typing serologic rh(d),86901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.98,,,,,,,fee schedule,36.98,164.05,APC
Blood typing serologic rh(d),86901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.57,,,,,,,fee schedule,36.98,164.05,Radiology
Blood typing serologic rh(d),86901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.77,,,,,,,fee schedule,36.98,164.05,APC
Blood typing serologic rh(d),86901,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.71,,,,,,,fee schedule,36.98,164.05,APC
Blood type antigen donor ea,86902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,69.6,,,,,,,fee schedule,55.79,1574.35,
Blood type antigen donor ea,86902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55.79,,,,,,,fee schedule,55.79,1574.35,
Blood type antigen donor ea,86902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,60.94,,,,,,,fee schedule,55.79,1574.35,
Blood type antigen donor ea,86902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,64.07,,,,,,,fee schedule,55.79,1574.35,
Blood type antigen donor ea,86902,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1574.35,,,,,,,fee schedule,55.79,1574.35,APC 378
Blood type antigen donor ea,86902,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,372.59,,,,,,,fee schedule,55.79,1574.35,APC
Blood type antigen donor ea,86902,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,369.04,,,,,,,fee schedule,55.79,1574.35,APC
Blood type antigen donor ea,86902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,354.85,,,,,,,fee schedule,55.79,1574.35,APC
Blood type antigen donor ea,86902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,542.92,,,,,,,fee schedule,55.79,1574.35,Radiology
Blood type antigen donor ea,86902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,496.79,,,,,,,fee schedule,55.79,1574.35,APC
Blood type antigen donor ea,86902,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,620.99,,,,,,,fee schedule,55.79,1574.35,APC
Blood typing patient serum,86904,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83.5,,,,,,,fee schedule,58.4,259.1,
Blood typing patient serum,86904,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66.93,,,,,,,fee schedule,58.4,259.1,
Blood typing patient serum,86904,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,73.12,,,,,,,fee schedule,58.4,259.1,
Blood typing patient serum,86904,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,76.87,,,,,,,fee schedule,58.4,259.1,
Blood typing patient serum,86904,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,58.4,259.1,APC 378
Blood typing patient serum,86904,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,58.4,259.1,APC
Blood typing patient serum,86904,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,58.4,259.1,APC
Blood typing patient serum,86904,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,58.4,259.1,APC
Blood typing patient serum,86904,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,58.4,259.1,Radiology
Blood typing patient serum,86904,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,58.4,259.1,APC
Blood typing patient serum,86904,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,58.4,259.1,APC
Blood typing rbc antigens,86905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59.67,,,,,,,fee schedule,47.83,1574.35,
Blood typing rbc antigens,86905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,47.83,,,,,,,fee schedule,47.83,1574.35,
Blood typing rbc antigens,86905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52.25,,,,,,,fee schedule,47.83,1574.35,
Blood typing rbc antigens,86905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,54.93,,,,,,,fee schedule,47.83,1574.35,
Blood typing rbc antigens,86905,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1574.35,,,,,,,fee schedule,47.83,1574.35,APC 378
Blood typing rbc antigens,86905,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,372.59,,,,,,,fee schedule,47.83,1574.35,APC
Blood typing rbc antigens,86905,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,369.04,,,,,,,fee schedule,47.83,1574.35,APC
Blood typing rbc antigens,86905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,354.85,,,,,,,fee schedule,47.83,1574.35,APC
Blood typing rbc antigens,86905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,542.92,,,,,,,fee schedule,47.83,1574.35,Radiology
Blood typing rbc antigens,86905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,496.79,,,,,,,fee schedule,47.83,1574.35,APC
Blood typing rbc antigens,86905,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,620.99,,,,,,,fee schedule,47.83,1574.35,APC
Bld typing serologic rh phnt,86906,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,53.41,,,,,,,fee schedule,36.98,164.05,
Bld typing serologic rh phnt,86906,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.81,,,,,,,fee schedule,36.98,164.05,
Bld typing serologic rh phnt,86906,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.77,,,,,,,fee schedule,36.98,164.05,
Bld typing serologic rh phnt,86906,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,49.17,,,,,,,fee schedule,36.98,164.05,
Bld typing serologic rh phnt,86906,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.05,,,,,,,fee schedule,36.98,164.05,APC 378
Bld typing serologic rh phnt,86906,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.83,,,,,,,fee schedule,36.98,164.05,APC
Bld typing serologic rh phnt,86906,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.46,,,,,,,fee schedule,36.98,164.05,APC
Bld typing serologic rh phnt,86906,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.98,,,,,,,fee schedule,36.98,164.05,APC
Bld typing serologic rh phnt,86906,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.57,,,,,,,fee schedule,36.98,164.05,Radiology
Bld typing serologic rh phnt,86906,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.77,,,,,,,fee schedule,36.98,164.05,APC
Bld typing serologic rh phnt,86906,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.71,,,,,,,fee schedule,36.98,164.05,APC
Compatibility test spin,86920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83.5,,,,,,,fee schedule,66.93,748.29,
Compatibility test spin,86920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66.93,,,,,,,fee schedule,66.93,748.29,
Compatibility test spin,86920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,73.12,,,,,,,fee schedule,66.93,748.29,
Compatibility test spin,86920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,76.87,,,,,,,fee schedule,66.93,748.29,
Compatibility test spin,86920,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,748.29,,,,,,,fee schedule,66.93,748.29,APC 378
Compatibility test spin,86920,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,177.09,,,,,,,fee schedule,66.93,748.29,APC
Compatibility test spin,86920,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,175.41,,,,,,,fee schedule,66.93,748.29,APC
Compatibility test spin,86920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,168.66,,,,,,,fee schedule,66.93,748.29,APC
Compatibility test spin,86920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,258.05,,,,,,,fee schedule,66.93,748.29,Radiology
Compatibility test spin,86920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,236.12,,,,,,,fee schedule,66.93,748.29,APC
Compatibility test spin,86920,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,295.16,,,,,,,fee schedule,66.93,748.29,APC
Compatibility test incubate,86921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,53.41,,,,,,,fee schedule,42.81,748.29,
Compatibility test incubate,86921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.81,,,,,,,fee schedule,42.81,748.29,
Compatibility test incubate,86921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.77,,,,,,,fee schedule,42.81,748.29,
Compatibility test incubate,86921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,49.17,,,,,,,fee schedule,42.81,748.29,
Compatibility test incubate,86921,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,748.29,,,,,,,fee schedule,42.81,748.29,APC 378
Compatibility test incubate,86921,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,177.09,,,,,,,fee schedule,42.81,748.29,APC
Compatibility test incubate,86921,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,175.41,,,,,,,fee schedule,42.81,748.29,APC
Compatibility test incubate,86921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,168.66,,,,,,,fee schedule,42.81,748.29,APC
Compatibility test incubate,86921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,258.05,,,,,,,fee schedule,42.81,748.29,Radiology
Compatibility test incubate,86921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,236.12,,,,,,,fee schedule,42.81,748.29,APC
Compatibility test incubate,86921,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,295.16,,,,,,,fee schedule,42.81,748.29,APC
Compatibility test antiglob,86922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,128.68,,,,,,,fee schedule,103.15,748.29,
Compatibility test antiglob,86922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,103.15,,,,,,,fee schedule,103.15,748.29,
Compatibility test antiglob,86922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,112.68,,,,,,,fee schedule,103.15,748.29,
Compatibility test antiglob,86922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,118.47,,,,,,,fee schedule,103.15,748.29,
Compatibility test antiglob,86922,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,748.29,,,,,,,fee schedule,103.15,748.29,APC 378
Compatibility test antiglob,86922,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,177.09,,,,,,,fee schedule,103.15,748.29,APC
Compatibility test antiglob,86922,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,175.41,,,,,,,fee schedule,103.15,748.29,APC
Compatibility test antiglob,86922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,168.66,,,,,,,fee schedule,103.15,748.29,APC
Compatibility test antiglob,86922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,258.05,,,,,,,fee schedule,103.15,748.29,Radiology
Compatibility test antiglob,86922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,236.12,,,,,,,fee schedule,103.15,748.29,APC
Compatibility test antiglob,86922,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,295.16,,,,,,,fee schedule,103.15,748.29,APC
Compatibility test electric,86923,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,109.13,,,,,,,fee schedule,87.47,748.29,
Compatibility test electric,86923,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,87.47,,,,,,,fee schedule,87.47,748.29,
Compatibility test electric,86923,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,95.56,,,,,,,fee schedule,87.47,748.29,
Compatibility test electric,86923,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,100.46,,,,,,,fee schedule,87.47,748.29,
Compatibility test electric,86923,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,748.29,,,,,,,fee schedule,87.47,748.29,APC 378
Compatibility test electric,86923,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,177.09,,,,,,,fee schedule,87.47,748.29,APC
Compatibility test electric,86923,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,175.41,,,,,,,fee schedule,87.47,748.29,APC
Compatibility test electric,86923,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,168.66,,,,,,,fee schedule,87.47,748.29,APC
Compatibility test electric,86923,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,258.05,,,,,,,fee schedule,87.47,748.29,Radiology
Compatibility test electric,86923,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,236.12,,,,,,,fee schedule,87.47,748.29,APC
Compatibility test electric,86923,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,295.16,,,,,,,fee schedule,87.47,748.29,APC
Plasma fresh frozen,86927,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,53.41,,,,,,,fee schedule,42.81,748.29,
Plasma fresh frozen,86927,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.81,,,,,,,fee schedule,42.81,748.29,
Plasma fresh frozen,86927,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.77,,,,,,,fee schedule,42.81,748.29,
Plasma fresh frozen,86927,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,49.17,,,,,,,fee schedule,42.81,748.29,
Plasma fresh frozen,86927,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,748.29,,,,,,,fee schedule,42.81,748.29,APC 378
Plasma fresh frozen,86927,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,177.09,,,,,,,fee schedule,42.81,748.29,APC
Plasma fresh frozen,86927,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,175.41,,,,,,,fee schedule,42.81,748.29,APC
Plasma fresh frozen,86927,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,168.66,,,,,,,fee schedule,42.81,748.29,APC
Plasma fresh frozen,86927,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,258.05,,,,,,,fee schedule,42.81,748.29,Radiology
Plasma fresh frozen,86927,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,236.12,,,,,,,fee schedule,42.81,748.29,APC
Plasma fresh frozen,86927,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,295.16,,,,,,,fee schedule,42.81,748.29,APC
Frozen blood prep,86930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,193.12,,,,,,,fee schedule,154.8,748.29,
Frozen blood prep,86930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,154.8,,,,,,,fee schedule,154.8,748.29,
Frozen blood prep,86930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,169.11,,,,,,,fee schedule,154.8,748.29,
Frozen blood prep,86930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,177.79,,,,,,,fee schedule,154.8,748.29,
Frozen blood prep,86930,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,748.29,,,,,,,fee schedule,154.8,748.29,APC 378
Frozen blood prep,86930,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,177.09,,,,,,,fee schedule,154.8,748.29,APC
Frozen blood prep,86930,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,175.41,,,,,,,fee schedule,154.8,748.29,APC
Frozen blood prep,86930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,168.66,,,,,,,fee schedule,154.8,748.29,APC
Frozen blood prep,86930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,258.05,,,,,,,fee schedule,154.8,748.29,Radiology
Frozen blood prep,86930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,236.12,,,,,,,fee schedule,154.8,748.29,APC
Frozen blood prep,86930,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,295.16,,,,,,,fee schedule,154.8,748.29,APC
Frozen blood thaw,86931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,193.12,,,,,,,fee schedule,154.8,748.29,
Frozen blood thaw,86931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,154.8,,,,,,,fee schedule,154.8,748.29,
Frozen blood thaw,86931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,169.11,,,,,,,fee schedule,154.8,748.29,
Frozen blood thaw,86931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,177.79,,,,,,,fee schedule,154.8,748.29,
Frozen blood thaw,86931,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,748.29,,,,,,,fee schedule,154.8,748.29,APC 378
Frozen blood thaw,86931,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,177.09,,,,,,,fee schedule,154.8,748.29,APC
Frozen blood thaw,86931,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,175.41,,,,,,,fee schedule,154.8,748.29,APC
Frozen blood thaw,86931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,168.66,,,,,,,fee schedule,154.8,748.29,APC
Frozen blood thaw,86931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,258.05,,,,,,,fee schedule,154.8,748.29,Radiology
Frozen blood thaw,86931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,236.12,,,,,,,fee schedule,154.8,748.29,APC
Frozen blood thaw,86931,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,295.16,,,,,,,fee schedule,154.8,748.29,APC
Frozen blood freeze/thaw,86932,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,193.12,,,,,,,fee schedule,36.98,193.12,
Frozen blood freeze/thaw,86932,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,154.8,,,,,,,fee schedule,36.98,193.12,
Frozen blood freeze/thaw,86932,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,169.11,,,,,,,fee schedule,36.98,193.12,
Frozen blood freeze/thaw,86932,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,177.79,,,,,,,fee schedule,36.98,193.12,
Frozen blood freeze/thaw,86932,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.05,,,,,,,fee schedule,36.98,193.12,APC 378
Frozen blood freeze/thaw,86932,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.83,,,,,,,fee schedule,36.98,193.12,APC
Frozen blood freeze/thaw,86932,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.46,,,,,,,fee schedule,36.98,193.12,APC
Frozen blood freeze/thaw,86932,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.98,,,,,,,fee schedule,36.98,193.12,APC
Frozen blood freeze/thaw,86932,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.57,,,,,,,fee schedule,36.98,193.12,Radiology
Frozen blood freeze/thaw,86932,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.77,,,,,,,fee schedule,36.98,193.12,APC
Frozen blood freeze/thaw,86932,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.71,,,,,,,fee schedule,36.98,193.12,APC
Hemolysins/agglutinins auto,86940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45.25,,,,,,,fee schedule,7.89,45.25,
Hemolysins/agglutinins auto,86940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36.27,,,,,,,fee schedule,7.89,45.25,
Hemolysins/agglutinins auto,86940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39.62,,,,,,,fee schedule,7.89,45.25,
Hemolysins/agglutinins auto,86940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41.66,,,,,,,fee schedule,7.89,45.25,
Hemolysins/agglutinins auto,86940,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.89,,,,,,,fee schedule,7.89,45.25,Laboratory
Hemolysins/agglutinins auto,86940,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.21,,,,,,,fee schedule,7.89,45.25,APC
Hemolysins/agglutinins auto,86940,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9.12,,,,,,,fee schedule,7.89,45.25,APC
Hemolysins/agglutinins auto,86940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8.77,,,,,,,fee schedule,7.89,45.25,APC
Hemolysins/agglutinins auto,86940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.42,,,,,,,fee schedule,7.89,45.25,Radiology
Hemolysins/agglutinins auto,86940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12.28,,,,,,,fee schedule,7.89,45.25,APC
Hemolysins/agglutinins auto,86940,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15.35,,,,,,,fee schedule,7.89,45.25,APC
Hemolysins/agglutinins,86941,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.83,,,,,,,fee schedule,10.9,66.83,
Hemolysins/agglutinins,86941,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.57,,,,,,,fee schedule,10.9,66.83,
Hemolysins/agglutinins,86941,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,58.52,,,,,,,fee schedule,10.9,66.83,
Hemolysins/agglutinins,86941,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,61.53,,,,,,,fee schedule,10.9,66.83,
Hemolysins/agglutinins,86941,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.9,,,,,,,fee schedule,10.9,66.83,Laboratory
Hemolysins/agglutinins,86941,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.72,,,,,,,fee schedule,10.9,66.83,APC
Hemolysins/agglutinins,86941,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.59,,,,,,,fee schedule,10.9,66.83,APC
Hemolysins/agglutinins,86941,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.11,,,,,,,fee schedule,10.9,66.83,APC
Hemolysins/agglutinins,86941,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.53,,,,,,,fee schedule,10.9,66.83,Radiology
Hemolysins/agglutinins,86941,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.95,,,,,,,fee schedule,10.9,66.83,APC
Hemolysins/agglutinins,86941,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21.19,,,,,,,fee schedule,10.9,66.83,APC
Blood product/irradiation,86945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,53.41,,,,,,,fee schedule,36.98,164.05,
Blood product/irradiation,86945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.81,,,,,,,fee schedule,36.98,164.05,
Blood product/irradiation,86945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.77,,,,,,,fee schedule,36.98,164.05,
Blood product/irradiation,86945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,49.17,,,,,,,fee schedule,36.98,164.05,
Blood product/irradiation,86945,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.05,,,,,,,fee schedule,36.98,164.05,APC 378
Blood product/irradiation,86945,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.83,,,,,,,fee schedule,36.98,164.05,APC
Blood product/irradiation,86945,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.46,,,,,,,fee schedule,36.98,164.05,APC
Blood product/irradiation,86945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.98,,,,,,,fee schedule,36.98,164.05,APC
Blood product/irradiation,86945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.57,,,,,,,fee schedule,36.98,164.05,Radiology
Blood product/irradiation,86945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.77,,,,,,,fee schedule,36.98,164.05,APC
Blood product/irradiation,86945,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.71,,,,,,,fee schedule,36.98,164.05,APC
Leukacyte transfusion,86950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,53.41,,,,,,,fee schedule,42.81,748.29,
Leukacyte transfusion,86950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.81,,,,,,,fee schedule,42.81,748.29,
Leukacyte transfusion,86950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.77,,,,,,,fee schedule,42.81,748.29,
Leukacyte transfusion,86950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,49.17,,,,,,,fee schedule,42.81,748.29,
Leukacyte transfusion,86950,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,748.29,,,,,,,fee schedule,42.81,748.29,APC 378
Leukacyte transfusion,86950,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,177.09,,,,,,,fee schedule,42.81,748.29,APC
Leukacyte transfusion,86950,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,175.41,,,,,,,fee schedule,42.81,748.29,APC
Leukacyte transfusion,86950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,168.66,,,,,,,fee schedule,42.81,748.29,APC
Leukacyte transfusion,86950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,258.05,,,,,,,fee schedule,42.81,748.29,Radiology
Leukacyte transfusion,86950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,236.12,,,,,,,fee schedule,42.81,748.29,APC
Leukacyte transfusion,86950,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,295.16,,,,,,,fee schedule,42.81,748.29,APC
Vol reduction of blood/prod,86960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,53.41,,,,,,,fee schedule,42.81,748.29,
Vol reduction of blood/prod,86960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.81,,,,,,,fee schedule,42.81,748.29,
Vol reduction of blood/prod,86960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.77,,,,,,,fee schedule,42.81,748.29,
Vol reduction of blood/prod,86960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,49.17,,,,,,,fee schedule,42.81,748.29,
Vol reduction of blood/prod,86960,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,748.29,,,,,,,fee schedule,42.81,748.29,APC 378
Vol reduction of blood/prod,86960,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,177.09,,,,,,,fee schedule,42.81,748.29,APC
Vol reduction of blood/prod,86960,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,175.41,,,,,,,fee schedule,42.81,748.29,APC
Vol reduction of blood/prod,86960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,168.66,,,,,,,fee schedule,42.81,748.29,APC
Vol reduction of blood/prod,86960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,258.05,,,,,,,fee schedule,42.81,748.29,Radiology
Vol reduction of blood/prod,86960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,236.12,,,,,,,fee schedule,42.81,748.29,APC
Vol reduction of blood/prod,86960,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,295.16,,,,,,,fee schedule,42.81,748.29,APC
Pooling blood platelets,86965,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83.5,,,,,,,fee schedule,66.93,748.29,
Pooling blood platelets,86965,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66.93,,,,,,,fee schedule,66.93,748.29,
Pooling blood platelets,86965,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,73.12,,,,,,,fee schedule,66.93,748.29,
Pooling blood platelets,86965,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,76.87,,,,,,,fee schedule,66.93,748.29,
Pooling blood platelets,86965,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,748.29,,,,,,,fee schedule,66.93,748.29,APC 378
Pooling blood platelets,86965,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,177.09,,,,,,,fee schedule,66.93,748.29,APC
Pooling blood platelets,86965,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,175.41,,,,,,,fee schedule,66.93,748.29,APC
Pooling blood platelets,86965,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,168.66,,,,,,,fee schedule,66.93,748.29,APC
Pooling blood platelets,86965,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,258.05,,,,,,,fee schedule,66.93,748.29,Radiology
Pooling blood platelets,86965,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,236.12,,,,,,,fee schedule,66.93,748.29,APC
Pooling blood platelets,86965,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,295.16,,,,,,,fee schedule,66.93,748.29,APC
Rbc pretx incubatj w/chemicl,86970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,53.41,,,,,,,fee schedule,42.81,259.1,
Rbc pretx incubatj w/chemicl,86970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.81,,,,,,,fee schedule,42.81,259.1,
Rbc pretx incubatj w/chemicl,86970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.77,,,,,,,fee schedule,42.81,259.1,
Rbc pretx incubatj w/chemicl,86970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,49.17,,,,,,,fee schedule,42.81,259.1,
Rbc pretx incubatj w/chemicl,86970,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,42.81,259.1,APC 378
Rbc pretx incubatj w/chemicl,86970,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,42.81,259.1,APC
Rbc pretx incubatj w/chemicl,86970,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,42.81,259.1,APC
Rbc pretx incubatj w/chemicl,86970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,42.81,259.1,APC
Rbc pretx incubatj w/chemicl,86970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,42.81,259.1,Radiology
Rbc pretx incubatj w/chemicl,86970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,42.81,259.1,APC
Rbc pretx incubatj w/chemicl,86970,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,42.81,259.1,APC
Rbc pretx incubatj w/enzymes,86971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,53.41,,,,,,,fee schedule,42.81,748.29,
Rbc pretx incubatj w/enzymes,86971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.81,,,,,,,fee schedule,42.81,748.29,
Rbc pretx incubatj w/enzymes,86971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.77,,,,,,,fee schedule,42.81,748.29,
Rbc pretx incubatj w/enzymes,86971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,49.17,,,,,,,fee schedule,42.81,748.29,
Rbc pretx incubatj w/enzymes,86971,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,748.29,,,,,,,fee schedule,42.81,748.29,APC 378
Rbc pretx incubatj w/enzymes,86971,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,177.09,,,,,,,fee schedule,42.81,748.29,APC
Rbc pretx incubatj w/enzymes,86971,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,175.41,,,,,,,fee schedule,42.81,748.29,APC
Rbc pretx incubatj w/enzymes,86971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,168.66,,,,,,,fee schedule,42.81,748.29,APC
Rbc pretx incubatj w/enzymes,86971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,258.05,,,,,,,fee schedule,42.81,748.29,Radiology
Rbc pretx incubatj w/enzymes,86971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,236.12,,,,,,,fee schedule,42.81,748.29,APC
Rbc pretx incubatj w/enzymes,86971,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,295.16,,,,,,,fee schedule,42.81,748.29,APC
Rbc pretx incubatj w/density,86972,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83.5,,,,,,,fee schedule,66.93,748.29,
Rbc pretx incubatj w/density,86972,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66.93,,,,,,,fee schedule,66.93,748.29,
Rbc pretx incubatj w/density,86972,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,73.12,,,,,,,fee schedule,66.93,748.29,
Rbc pretx incubatj w/density,86972,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,76.87,,,,,,,fee schedule,66.93,748.29,
Rbc pretx incubatj w/density,86972,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,748.29,,,,,,,fee schedule,66.93,748.29,APC 378
Rbc pretx incubatj w/density,86972,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,177.09,,,,,,,fee schedule,66.93,748.29,APC
Rbc pretx incubatj w/density,86972,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,175.41,,,,,,,fee schedule,66.93,748.29,APC
Rbc pretx incubatj w/density,86972,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,168.66,,,,,,,fee schedule,66.93,748.29,APC
Rbc pretx incubatj w/density,86972,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,258.05,,,,,,,fee schedule,66.93,748.29,Radiology
Rbc pretx incubatj w/density,86972,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,236.12,,,,,,,fee schedule,66.93,748.29,APC
Rbc pretx incubatj w/density,86972,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,295.16,,,,,,,fee schedule,66.93,748.29,APC
Rbc serum pretx incubj drugs,86975,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83.5,,,,,,,fee schedule,66.93,1962.08,
Rbc serum pretx incubj drugs,86975,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66.93,,,,,,,fee schedule,66.93,1962.08,
Rbc serum pretx incubj drugs,86975,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,73.12,,,,,,,fee schedule,66.93,1962.08,
Rbc serum pretx incubj drugs,86975,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,76.87,,,,,,,fee schedule,66.93,1962.08,
Rbc serum pretx incubj drugs,86975,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1962.08,,,,,,,fee schedule,66.93,1962.08,APC 378
Rbc serum pretx incubj drugs,86975,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,464.35,,,,,,,fee schedule,66.93,1962.08,APC
Rbc serum pretx incubj drugs,86975,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,459.93,,,,,,,fee schedule,66.93,1962.08,APC
Rbc serum pretx incubj drugs,86975,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,442.24,,,,,,,fee schedule,66.93,1962.08,APC
Rbc serum pretx incubj drugs,86975,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,676.63,,,,,,,fee schedule,66.93,1962.08,Radiology
Rbc serum pretx incubj drugs,86975,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,619.14,,,,,,,fee schedule,66.93,1962.08,APC
Rbc serum pretx incubj drugs,86975,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,773.92,,,,,,,fee schedule,66.93,1962.08,APC
Rbc serum pretx id dilution,86976,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,53.41,,,,,,,fee schedule,28.63,127.04,
Rbc serum pretx id dilution,86976,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.81,,,,,,,fee schedule,28.63,127.04,
Rbc serum pretx id dilution,86976,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.77,,,,,,,fee schedule,28.63,127.04,
Rbc serum pretx id dilution,86976,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,49.17,,,,,,,fee schedule,28.63,127.04,
Rbc serum pretx id dilution,86976,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,127.04,,,,,,,fee schedule,28.63,127.04,APC 378
Rbc serum pretx id dilution,86976,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.07,,,,,,,fee schedule,28.63,127.04,APC
Rbc serum pretx id dilution,86976,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,29.78,,,,,,,fee schedule,28.63,127.04,APC
Rbc serum pretx id dilution,86976,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,28.63,,,,,,,fee schedule,28.63,127.04,APC
Rbc serum pretx id dilution,86976,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43.81,,,,,,,fee schedule,28.63,127.04,Radiology
Rbc serum pretx id dilution,86976,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40.09,,,,,,,fee schedule,28.63,127.04,APC
Rbc serum pretx id dilution,86976,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,50.11,,,,,,,fee schedule,28.63,127.04,APC
Rbc serum pretx incubj/inhib,86977,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83.5,,,,,,,fee schedule,66.93,748.29,
Rbc serum pretx incubj/inhib,86977,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66.93,,,,,,,fee schedule,66.93,748.29,
Rbc serum pretx incubj/inhib,86977,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,73.12,,,,,,,fee schedule,66.93,748.29,
Rbc serum pretx incubj/inhib,86977,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,76.87,,,,,,,fee schedule,66.93,748.29,
Rbc serum pretx incubj/inhib,86977,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,748.29,,,,,,,fee schedule,66.93,748.29,APC 378
Rbc serum pretx incubj/inhib,86977,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,177.09,,,,,,,fee schedule,66.93,748.29,APC
Rbc serum pretx incubj/inhib,86977,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,175.41,,,,,,,fee schedule,66.93,748.29,APC
Rbc serum pretx incubj/inhib,86977,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,168.66,,,,,,,fee schedule,66.93,748.29,APC
Rbc serum pretx incubj/inhib,86977,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,258.05,,,,,,,fee schedule,66.93,748.29,Radiology
Rbc serum pretx incubj/inhib,86977,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,236.12,,,,,,,fee schedule,66.93,748.29,APC
Rbc serum pretx incubj/inhib,86977,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,295.16,,,,,,,fee schedule,66.93,748.29,APC
Rbc pretreatment serum,86978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83.5,,,,,,,fee schedule,58.4,259.1,
Rbc pretreatment serum,86978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66.93,,,,,,,fee schedule,58.4,259.1,
Rbc pretreatment serum,86978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,73.12,,,,,,,fee schedule,58.4,259.1,
Rbc pretreatment serum,86978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,76.87,,,,,,,fee schedule,58.4,259.1,
Rbc pretreatment serum,86978,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,58.4,259.1,APC 378
Rbc pretreatment serum,86978,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,58.4,259.1,APC
Rbc pretreatment serum,86978,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,58.4,259.1,APC
Rbc pretreatment serum,86978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,58.4,259.1,APC
Rbc pretreatment serum,86978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,58.4,259.1,Radiology
Rbc pretreatment serum,86978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,58.4,259.1,APC
Rbc pretreatment serum,86978,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,58.4,259.1,APC
Split blood or products,86985,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,53.41,,,,,,,fee schedule,42.81,748.29,
Split blood or products,86985,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.81,,,,,,,fee schedule,42.81,748.29,
Split blood or products,86985,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.77,,,,,,,fee schedule,42.81,748.29,
Split blood or products,86985,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,49.17,,,,,,,fee schedule,42.81,748.29,
Split blood or products,86985,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,748.29,,,,,,,fee schedule,42.81,748.29,APC 378
Split blood or products,86985,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,177.09,,,,,,,fee schedule,42.81,748.29,APC
Split blood or products,86985,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,175.41,,,,,,,fee schedule,42.81,748.29,APC
Split blood or products,86985,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,168.66,,,,,,,fee schedule,42.81,748.29,APC
Split blood or products,86985,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,258.05,,,,,,,fee schedule,42.81,748.29,Radiology
Split blood or products,86985,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,236.12,,,,,,,fee schedule,42.81,748.29,APC
Split blood or products,86985,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,295.16,,,,,,,fee schedule,42.81,748.29,APC
Transfusion procedure,86999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,53.41,,,,,,,fee schedule,28.63,127.04,
Transfusion procedure,86999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.81,,,,,,,fee schedule,28.63,127.04,
Transfusion procedure,86999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.77,,,,,,,fee schedule,28.63,127.04,
Transfusion procedure,86999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,49.17,,,,,,,fee schedule,28.63,127.04,
Transfusion procedure,86999,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,127.04,,,,,,,fee schedule,28.63,127.04,APC 378
Transfusion procedure,86999,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.07,,,,,,,fee schedule,28.63,127.04,APC
Transfusion procedure,86999,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,29.78,,,,,,,fee schedule,28.63,127.04,APC
Transfusion procedure,86999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,28.63,,,,,,,fee schedule,28.63,127.04,APC
Transfusion procedure,86999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43.81,,,,,,,fee schedule,28.63,127.04,Radiology
Transfusion procedure,86999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40.09,,,,,,,fee schedule,28.63,127.04,APC
Transfusion procedure,86999,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,50.11,,,,,,,fee schedule,28.63,127.04,APC
Small animal inoculation,87003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,92.91,,,,,,,fee schedule,15.16,92.91,
Small animal inoculation,87003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,74.48,,,,,,,fee schedule,15.16,92.91,
Small animal inoculation,87003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,81.36,,,,,,,fee schedule,15.16,92.91,
Small animal inoculation,87003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,85.54,,,,,,,fee schedule,15.16,92.91,
Small animal inoculation,87003,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.16,,,,,,,fee schedule,15.16,92.91,Laboratory
Small animal inoculation,87003,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.68,,,,,,,fee schedule,15.16,92.91,APC
Small animal inoculation,87003,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,17.51,,,,,,,fee schedule,15.16,92.91,APC
Small animal inoculation,87003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16.84,,,,,,,fee schedule,15.16,92.91,APC
Small animal inoculation,87003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.77,,,,,,,fee schedule,15.16,92.91,Radiology
Small animal inoculation,87003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.58,,,,,,,fee schedule,15.16,92.91,APC
Small animal inoculation,87003,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,29.47,,,,,,,fee schedule,15.16,92.91,APC
Specimen infect agnt concntj,87015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59.81,,,,,,,fee schedule,6.01,59.81,
Specimen infect agnt concntj,87015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,47.95,,,,,,,fee schedule,6.01,59.81,
Specimen infect agnt concntj,87015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52.38,,,,,,,fee schedule,6.01,59.81,
Specimen infect agnt concntj,87015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55.07,,,,,,,fee schedule,6.01,59.81,
Specimen infect agnt concntj,87015,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.01,,,,,,,fee schedule,6.01,59.81,Laboratory
Specimen infect agnt concntj,87015,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.01,,,,,,,fee schedule,6.01,59.81,APC
Specimen infect agnt concntj,87015,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6.95,,,,,,,fee schedule,6.01,59.81,APC
Specimen infect agnt concntj,87015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6.68,,,,,,,fee schedule,6.01,59.81,APC
Specimen infect agnt concntj,87015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10.22,,,,,,,fee schedule,6.01,59.81,Radiology
Specimen infect agnt concntj,87015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.35,,,,,,,fee schedule,6.01,59.81,APC
Specimen infect agnt concntj,87015,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11.69,,,,,,,fee schedule,6.01,59.81,APC
Blood culture for bacteria,87040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,133,,,,,,,fee schedule,9.29,133,
Blood culture for bacteria,87040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,106.61,,,,,,,fee schedule,9.29,133,
Blood culture for bacteria,87040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,116.46,,,,,,,fee schedule,9.29,133,
Blood culture for bacteria,87040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,122.44,,,,,,,fee schedule,9.29,133,
Blood culture for bacteria,87040,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.29,,,,,,,fee schedule,9.29,133,Laboratory
Blood culture for bacteria,87040,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.84,,,,,,,fee schedule,9.29,133,APC
Blood culture for bacteria,87040,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10.73,,,,,,,fee schedule,9.29,133,APC
Blood culture for bacteria,87040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10.32,,,,,,,fee schedule,9.29,133,APC
Blood culture for bacteria,87040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15.79,,,,,,,fee schedule,9.29,133,Radiology
Blood culture for bacteria,87040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.45,,,,,,,fee schedule,9.29,133,APC
Blood culture for bacteria,87040,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18.06,,,,,,,fee schedule,9.29,133,APC
Feces culture aerobic bact,87045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,86.75,,,,,,,fee schedule,8.5,86.75,
Feces culture aerobic bact,87045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,69.54,,,,,,,fee schedule,8.5,86.75,
Feces culture aerobic bact,87045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,75.97,,,,,,,fee schedule,8.5,86.75,
Feces culture aerobic bact,87045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,79.87,,,,,,,fee schedule,8.5,86.75,
Feces culture aerobic bact,87045,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.5,,,,,,,fee schedule,8.5,86.75,Laboratory
Feces culture aerobic bact,87045,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.91,,,,,,,fee schedule,8.5,86.75,APC
Feces culture aerobic bact,87045,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9.82,,,,,,,fee schedule,8.5,86.75,APC
Feces culture aerobic bact,87045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9.44,,,,,,,fee schedule,8.5,86.75,APC
Feces culture aerobic bact,87045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.44,,,,,,,fee schedule,8.5,86.75,Radiology
Feces culture aerobic bact,87045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.22,,,,,,,fee schedule,8.5,86.75,APC
Feces culture aerobic bact,87045,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16.52,,,,,,,fee schedule,8.5,86.75,APC
Stool cultr aerobic bact ea,87046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,38.07,,,,,,,fee schedule,8.5,38.07,
Stool cultr aerobic bact ea,87046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,30.51,,,,,,,fee schedule,8.5,38.07,
Stool cultr aerobic bact ea,87046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,33.33,,,,,,,fee schedule,8.5,38.07,
Stool cultr aerobic bact ea,87046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,35.05,,,,,,,fee schedule,8.5,38.07,
Stool cultr aerobic bact ea,87046,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.5,,,,,,,fee schedule,8.5,38.07,Laboratory
Stool cultr aerobic bact ea,87046,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.91,,,,,,,fee schedule,8.5,38.07,APC
Stool cultr aerobic bact ea,87046,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9.82,,,,,,,fee schedule,8.5,38.07,APC
Stool cultr aerobic bact ea,87046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9.44,,,,,,,fee schedule,8.5,38.07,APC
Stool cultr aerobic bact ea,87046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.44,,,,,,,fee schedule,8.5,38.07,Radiology
Stool cultr aerobic bact ea,87046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.22,,,,,,,fee schedule,8.5,38.07,APC
Stool cultr aerobic bact ea,87046,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16.52,,,,,,,fee schedule,8.5,38.07,APC
Culture othr specimn aerobic,87070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,112.63,,,,,,,fee schedule,7.76,112.63,
Culture othr specimn aerobic,87070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,90.28,,,,,,,fee schedule,7.76,112.63,
Culture othr specimn aerobic,87070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,98.62,,,,,,,fee schedule,7.76,112.63,
Culture othr specimn aerobic,87070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,103.69,,,,,,,fee schedule,7.76,112.63,
Culture othr specimn aerobic,87070,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.76,,,,,,,fee schedule,7.76,112.63,Laboratory
Culture othr specimn aerobic,87070,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.05,,,,,,,fee schedule,7.76,112.63,APC
Culture othr specimn aerobic,87070,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8.96,,,,,,,fee schedule,7.76,112.63,APC
Culture othr specimn aerobic,87070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8.62,,,,,,,fee schedule,7.76,112.63,APC
Culture othr specimn aerobic,87070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.19,,,,,,,fee schedule,7.76,112.63,Radiology
Culture othr specimn aerobic,87070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12.07,,,,,,,fee schedule,7.76,112.63,APC
Culture othr specimn aerobic,87070,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15.08,,,,,,,fee schedule,7.76,112.63,APC
Culture aerobic quant other,87071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45.9,,,,,,,fee schedule,8.9,45.9,
Culture aerobic quant other,87071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36.8,,,,,,,fee schedule,8.9,45.9,
Culture aerobic quant other,87071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40.2,,,,,,,fee schedule,8.9,45.9,
Culture aerobic quant other,87071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42.26,,,,,,,fee schedule,8.9,45.9,
Culture aerobic quant other,87071,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.9,,,,,,,fee schedule,8.9,45.9,Laboratory
Culture aerobic quant other,87071,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.38,,,,,,,fee schedule,8.9,45.9,APC
Culture aerobic quant other,87071,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10.29,,,,,,,fee schedule,8.9,45.9,APC
Culture aerobic quant other,87071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9.89,,,,,,,fee schedule,8.9,45.9,APC
Culture aerobic quant other,87071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15.13,,,,,,,fee schedule,8.9,45.9,Radiology
Culture aerobic quant other,87071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.85,,,,,,,fee schedule,8.9,45.9,APC
Culture aerobic quant other,87071,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,17.31,,,,,,,fee schedule,8.9,45.9,APC
Culture Bacteria Anaerobic,87073,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,52.05,,,,,,,fee schedule,8.69,52.05,
Culture Bacteria Anaerobic,87073,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,41.72,,,,,,,fee schedule,8.69,52.05,
Culture Bacteria Anaerobic,87073,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,45.58,,,,,,,fee schedule,8.69,52.05,
Culture Bacteria Anaerobic,87073,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,47.92,,,,,,,fee schedule,8.69,52.05,
Culture Bacteria Anaerobic,87073,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.69,,,,,,,fee schedule,8.69,52.05,Laboratory
Culture Bacteria Anaerobic,87073,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.14,,,,,,,fee schedule,8.69,52.05,APC
Culture Bacteria Anaerobic,87073,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10.05,,,,,,,fee schedule,8.69,52.05,APC
Culture Bacteria Anaerobic,87073,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9.66,,,,,,,fee schedule,8.69,52.05,APC
Culture Bacteria Anaerobic,87073,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.78,,,,,,,fee schedule,8.69,52.05,Radiology
Culture Bacteria Anaerobic,87073,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.52,,,,,,,fee schedule,8.69,52.05,APC
Culture Bacteria Anaerobic,87073,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16.9,,,,,,,fee schedule,8.69,52.05,APC
Cultr bacteria except blood,87075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,220.76,,,,,,,fee schedule,8.52,220.76,
Cultr bacteria except blood,87075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,176.96,,,,,,,fee schedule,8.52,220.76,
Cultr bacteria except blood,87075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,193.31,,,,,,,fee schedule,8.52,220.76,
Cultr bacteria except blood,87075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,203.24,,,,,,,fee schedule,8.52,220.76,
Cultr bacteria except blood,87075,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.52,,,,,,,fee schedule,8.52,220.76,Laboratory
Cultr bacteria except blood,87075,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.94,,,,,,,fee schedule,8.52,220.76,APC
Cultr bacteria except blood,87075,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9.85,,,,,,,fee schedule,8.52,220.76,APC
Cultr bacteria except blood,87075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9.47,,,,,,,fee schedule,8.52,220.76,APC
Cultr bacteria except blood,87075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.49,,,,,,,fee schedule,8.52,220.76,Radiology
Cultr bacteria except blood,87075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.26,,,,,,,fee schedule,8.52,220.76,APC
Cultr bacteria except blood,87075,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16.57,,,,,,,fee schedule,8.52,220.76,APC
Culture anaerobe ident each,87076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41.05,,,,,,,fee schedule,7.27,41.05,
Culture anaerobe ident each,87076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32.91,,,,,,,fee schedule,7.27,41.05,
Culture anaerobe ident each,87076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35.95,,,,,,,fee schedule,7.27,41.05,
Culture anaerobe ident each,87076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37.79,,,,,,,fee schedule,7.27,41.05,
Culture anaerobe ident each,87076,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.27,,,,,,,fee schedule,7.27,41.05,Laboratory
Culture anaerobe ident each,87076,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.48,,,,,,,fee schedule,7.27,41.05,APC
Culture anaerobe ident each,87076,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8.4,,,,,,,fee schedule,7.27,41.05,APC
Culture anaerobe ident each,87076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8.08,,,,,,,fee schedule,7.27,41.05,APC
Culture anaerobe ident each,87076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12.36,,,,,,,fee schedule,7.27,41.05,Radiology
Culture anaerobe ident each,87076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11.31,,,,,,,fee schedule,7.27,41.05,APC
Culture anaerobe ident each,87076,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14.14,,,,,,,fee schedule,7.27,41.05,APC
Culture Aerobic Identify,87077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.87,,,,,,,fee schedule,7.27,60.87,
Culture Aerobic Identify,87077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48.79,,,,,,,fee schedule,7.27,60.87,
Culture Aerobic Identify,87077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.3,,,,,,,fee schedule,7.27,60.87,
Culture Aerobic Identify,87077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,56.03,,,,,,,fee schedule,7.27,60.87,
Culture Aerobic Identify,87077,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.27,,,,,,,fee schedule,7.27,60.87,Laboratory
Culture Aerobic Identify,87077,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.48,,,,,,,fee schedule,7.27,60.87,APC
Culture Aerobic Identify,87077,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8.4,,,,,,,fee schedule,7.27,60.87,APC
Culture Aerobic Identify,87077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8.08,,,,,,,fee schedule,7.27,60.87,APC
Culture Aerobic Identify,87077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12.36,,,,,,,fee schedule,7.27,60.87,Radiology
Culture Aerobic Identify,87077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11.31,,,,,,,fee schedule,7.27,60.87,APC
Culture Aerobic Identify,87077,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14.14,,,,,,,fee schedule,7.27,60.87,APC
Culture screen only,87081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.06,,,,,,,fee schedule,5.97,66.06,
Culture screen only,87081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52.95,,,,,,,fee schedule,5.97,66.06,
Culture screen only,87081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.85,,,,,,,fee schedule,5.97,66.06,
Culture screen only,87081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.82,,,,,,,fee schedule,5.97,66.06,
Culture screen only,87081,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.97,,,,,,,fee schedule,5.97,66.06,Laboratory
Culture screen only,87081,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.96,,,,,,,fee schedule,5.97,66.06,APC
Culture screen only,87081,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6.9,,,,,,,fee schedule,5.97,66.06,APC
Culture screen only,87081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6.63,,,,,,,fee schedule,5.97,66.06,APC
Culture screen only,87081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10.14,,,,,,,fee schedule,5.97,66.06,Radiology
Culture screen only,87081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.28,,,,,,,fee schedule,5.97,66.06,APC
Culture screen only,87081,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11.6,,,,,,,fee schedule,5.97,66.06,APC
Culture of specimen by kit,87084,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,44.11,,,,,,,fee schedule,24.36,47.37,
Culture of specimen by kit,87084,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35.36,,,,,,,fee schedule,24.36,47.37,
Culture of specimen by kit,87084,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38.63,,,,,,,fee schedule,24.36,47.37,
Culture of specimen by kit,87084,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,40.61,,,,,,,fee schedule,24.36,47.37,
Culture of specimen by kit,87084,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24.36,,,,,,,fee schedule,24.36,47.37,Laboratory
Culture of specimen by kit,87084,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,28.42,,,,,,,fee schedule,24.36,47.37,APC
Culture of specimen by kit,87084,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,28.15,,,,,,,fee schedule,24.36,47.37,APC
Culture of specimen by kit,87084,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,27.07,,,,,,,fee schedule,24.36,47.37,APC
Culture of specimen by kit,87084,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,41.42,,,,,,,fee schedule,24.36,47.37,Radiology
Culture of specimen by kit,87084,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,37.9,,,,,,,fee schedule,24.36,47.37,APC
Culture of specimen by kit,87084,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,47.37,,,,,,,fee schedule,24.36,47.37,APC
Urine culture/colony count,87086,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41.19,,,,,,,fee schedule,7.26,41.19,
Urine culture/colony count,87086,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,33.02,,,,,,,fee schedule,7.26,41.19,
Urine culture/colony count,87086,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36.07,,,,,,,fee schedule,7.26,41.19,
Urine culture/colony count,87086,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37.93,,,,,,,fee schedule,7.26,41.19,
Urine culture/colony count,87086,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.26,,,,,,,fee schedule,7.26,41.19,Laboratory
Urine culture/colony count,87086,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.47,,,,,,,fee schedule,7.26,41.19,APC
Urine culture/colony count,87086,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8.39,,,,,,,fee schedule,7.26,41.19,APC
Urine culture/colony count,87086,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8.07,,,,,,,fee schedule,7.26,41.19,APC
Urine culture/colony count,87086,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12.35,,,,,,,fee schedule,7.26,41.19,Radiology
Urine culture/colony count,87086,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11.3,,,,,,,fee schedule,7.26,41.19,APC
Urine culture/colony count,87086,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14.12,,,,,,,fee schedule,7.26,41.19,APC
Urine bacteria culture,87088,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,39.02,,,,,,,fee schedule,7.28,39.02,
Urine bacteria culture,87088,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31.28,,,,,,,fee schedule,7.28,39.02,
Urine bacteria culture,87088,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,34.17,,,,,,,fee schedule,7.28,39.02,
Urine bacteria culture,87088,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,35.92,,,,,,,fee schedule,7.28,39.02,
Urine bacteria culture,87088,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.28,,,,,,,fee schedule,7.28,39.02,Laboratory
Urine bacteria culture,87088,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.49,,,,,,,fee schedule,7.28,39.02,APC
Urine bacteria culture,87088,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8.41,,,,,,,fee schedule,7.28,39.02,APC
Urine bacteria culture,87088,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8.09,,,,,,,fee schedule,7.28,39.02,APC
Urine bacteria culture,87088,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12.38,,,,,,,fee schedule,7.28,39.02,Radiology
Urine bacteria culture,87088,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11.33,,,,,,,fee schedule,7.28,39.02,APC
Urine bacteria culture,87088,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14.16,,,,,,,fee schedule,7.28,39.02,APC
Skin fungi culture,87101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41.05,,,,,,,fee schedule,6.94,41.05,
Skin fungi culture,87101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32.91,,,,,,,fee schedule,6.94,41.05,
Skin fungi culture,87101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35.95,,,,,,,fee schedule,6.94,41.05,
Skin fungi culture,87101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37.79,,,,,,,fee schedule,6.94,41.05,
Skin fungi culture,87101,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.94,,,,,,,fee schedule,6.94,41.05,Laboratory
Skin fungi culture,87101,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.1,,,,,,,fee schedule,6.94,41.05,APC
Skin fungi culture,87101,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8.02,,,,,,,fee schedule,6.94,41.05,APC
Skin fungi culture,87101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7.71,,,,,,,fee schedule,6.94,41.05,APC
Skin fungi culture,87101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11.8,,,,,,,fee schedule,6.94,41.05,Radiology
Skin fungi culture,87101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10.79,,,,,,,fee schedule,6.94,41.05,APC
Skin fungi culture,87101,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,13.49,,,,,,,fee schedule,6.94,41.05,APC
Fungus isolation culture,87102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,154.39,,,,,,,fee schedule,7.57,154.39,
Fungus isolation culture,87102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,123.76,,,,,,,fee schedule,7.57,154.39,
Fungus isolation culture,87102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,135.19,,,,,,,fee schedule,7.57,154.39,
Fungus isolation culture,87102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,142.13,,,,,,,fee schedule,7.57,154.39,
Fungus isolation culture,87102,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.57,,,,,,,fee schedule,7.57,154.39,Laboratory
Fungus isolation culture,87102,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.83,,,,,,,fee schedule,7.57,154.39,APC
Fungus isolation culture,87102,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8.75,,,,,,,fee schedule,7.57,154.39,APC
Fungus isolation culture,87102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8.41,,,,,,,fee schedule,7.57,154.39,APC
Fungus isolation culture,87102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12.87,,,,,,,fee schedule,7.57,154.39,Radiology
Fungus isolation culture,87102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11.77,,,,,,,fee schedule,7.57,154.39,APC
Fungus isolation culture,87102,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14.72,,,,,,,fee schedule,7.57,154.39,APC
Blood fungus culture,87103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,49.78,,,,,,,fee schedule,18.41,49.78,
Blood fungus culture,87103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39.91,,,,,,,fee schedule,18.41,49.78,
Blood fungus culture,87103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,43.59,,,,,,,fee schedule,18.41,49.78,
Blood fungus culture,87103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45.83,,,,,,,fee schedule,18.41,49.78,
Blood fungus culture,87103,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.41,,,,,,,fee schedule,18.41,49.78,Laboratory
Blood fungus culture,87103,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.48,,,,,,,fee schedule,18.41,49.78,APC
Blood fungus culture,87103,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,21.28,,,,,,,fee schedule,18.41,49.78,APC
Blood fungus culture,87103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,20.46,,,,,,,fee schedule,18.41,49.78,APC
Blood fungus culture,87103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,31.3,,,,,,,fee schedule,18.41,49.78,Radiology
Blood fungus culture,87103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.64,,,,,,,fee schedule,18.41,49.78,APC
Blood fungus culture,87103,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,35.8,,,,,,,fee schedule,18.41,49.78,APC
Fungi identification yeast,87106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,56.96,,,,,,,fee schedule,9.29,56.96,
Fungi identification yeast,87106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,45.66,,,,,,,fee schedule,9.29,56.96,
Fungi identification yeast,87106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,49.88,,,,,,,fee schedule,9.29,56.96,
Fungi identification yeast,87106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,52.44,,,,,,,fee schedule,9.29,56.96,
Fungi identification yeast,87106,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.29,,,,,,,fee schedule,9.29,56.96,Laboratory
Fungi identification yeast,87106,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.84,,,,,,,fee schedule,9.29,56.96,APC
Fungi identification yeast,87106,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10.73,,,,,,,fee schedule,9.29,56.96,APC
Fungi identification yeast,87106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10.32,,,,,,,fee schedule,9.29,56.96,APC
Fungi identification yeast,87106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15.79,,,,,,,fee schedule,9.29,56.96,Radiology
Fungi identification yeast,87106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.45,,,,,,,fee schedule,9.29,56.96,APC
Fungi identification yeast,87106,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18.06,,,,,,,fee schedule,9.29,56.96,APC
Fungi identification mold,87107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45.16,,,,,,,fee schedule,9.29,45.16,
Fungi identification mold,87107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36.2,,,,,,,fee schedule,9.29,45.16,
Fungi identification mold,87107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39.55,,,,,,,fee schedule,9.29,45.16,
Fungi identification mold,87107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41.58,,,,,,,fee schedule,9.29,45.16,
Fungi identification mold,87107,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.29,,,,,,,fee schedule,9.29,45.16,Laboratory
Fungi identification mold,87107,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.84,,,,,,,fee schedule,9.29,45.16,APC
Fungi identification mold,87107,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10.73,,,,,,,fee schedule,9.29,45.16,APC
Fungi identification mold,87107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10.32,,,,,,,fee schedule,9.29,45.16,APC
Fungi identification mold,87107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15.79,,,,,,,fee schedule,9.29,45.16,Radiology
Fungi identification mold,87107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.45,,,,,,,fee schedule,9.29,45.16,APC
Fungi identification mold,87107,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18.06,,,,,,,fee schedule,9.29,45.16,APC
Mycoplasma,87109,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,48.13,,,,,,,fee schedule,13.85,48.13,
Mycoplasma,87109,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38.58,,,,,,,fee schedule,13.85,48.13,
Mycoplasma,87109,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.14,,,,,,,fee schedule,13.85,48.13,
Mycoplasma,87109,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,44.31,,,,,,,fee schedule,13.85,48.13,
Mycoplasma,87109,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.85,,,,,,,fee schedule,13.85,48.13,Laboratory
Mycoplasma,87109,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.16,,,,,,,fee schedule,13.85,48.13,APC
Mycoplasma,87109,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,16.01,,,,,,,fee schedule,13.85,48.13,APC
Mycoplasma,87109,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,15.39,,,,,,,fee schedule,13.85,48.13,APC
Mycoplasma,87109,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.55,,,,,,,fee schedule,13.85,48.13,Radiology
Mycoplasma,87109,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21.55,,,,,,,fee schedule,13.85,48.13,APC
Mycoplasma,87109,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,26.93,,,,,,,fee schedule,13.85,48.13,APC
Chlamydia culture,87110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,108.11,,,,,,,fee schedule,17.64,108.11,
Chlamydia culture,87110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,86.66,,,,,,,fee schedule,17.64,108.11,
Chlamydia culture,87110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,94.67,,,,,,,fee schedule,17.64,108.11,
Chlamydia culture,87110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,99.53,,,,,,,fee schedule,17.64,108.11,
Chlamydia culture,87110,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.64,,,,,,,fee schedule,17.64,108.11,Laboratory
Chlamydia culture,87110,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20.58,,,,,,,fee schedule,17.64,108.11,APC
Chlamydia culture,87110,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,20.38,,,,,,,fee schedule,17.64,108.11,APC
Chlamydia culture,87110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,19.6,,,,,,,fee schedule,17.64,108.11,APC
Chlamydia culture,87110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29.99,,,,,,,fee schedule,17.64,108.11,Radiology
Chlamydia culture,87110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27.44,,,,,,,fee schedule,17.64,108.11,APC
Chlamydia culture,87110,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,34.3,,,,,,,fee schedule,17.64,108.11,APC
Mycobacteria culture,87116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,169.2,,,,,,,fee schedule,9.72,169.2,
Mycobacteria culture,87116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,135.63,,,,,,,fee schedule,9.72,169.2,
Mycobacteria culture,87116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,148.16,,,,,,,fee schedule,9.72,169.2,
Mycobacteria culture,87116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,155.77,,,,,,,fee schedule,9.72,169.2,
Mycobacteria culture,87116,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.72,,,,,,,fee schedule,9.72,169.2,Laboratory
Mycobacteria culture,87116,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.34,,,,,,,fee schedule,9.72,169.2,APC
Mycobacteria culture,87116,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11.23,,,,,,,fee schedule,9.72,169.2,APC
Mycobacteria culture,87116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10.8,,,,,,,fee schedule,9.72,169.2,APC
Mycobacteria culture,87116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.52,,,,,,,fee schedule,9.72,169.2,Radiology
Mycobacteria culture,87116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15.12,,,,,,,fee schedule,9.72,169.2,APC
Mycobacteria culture,87116,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18.9,,,,,,,fee schedule,9.72,169.2,APC
Mycobacteric identification,87118,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.4,,,,,,,fee schedule,13.15,60.4,
Mycobacteric identification,87118,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48.42,,,,,,,fee schedule,13.15,60.4,
Mycobacteric identification,87118,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52.89,,,,,,,fee schedule,13.15,60.4,
Mycobacteric identification,87118,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55.61,,,,,,,fee schedule,13.15,60.4,
Mycobacteric identification,87118,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.15,,,,,,,fee schedule,13.15,60.4,Laboratory
Mycobacteric identification,87118,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.34,,,,,,,fee schedule,13.15,60.4,APC
Mycobacteric identification,87118,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,15.19,,,,,,,fee schedule,13.15,60.4,APC
Mycobacteric identification,87118,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14.61,,,,,,,fee schedule,13.15,60.4,APC
Mycobacteric identification,87118,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.35,,,,,,,fee schedule,13.15,60.4,Radiology
Mycobacteric identification,87118,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.45,,,,,,,fee schedule,13.15,60.4,APC
Mycobacteric identification,87118,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,25.57,,,,,,,fee schedule,13.15,60.4,APC
Culture type immunofluoresc,87140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30.77,,,,,,,fee schedule,5.01,30.77,
Culture type immunofluoresc,87140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24.66,,,,,,,fee schedule,5.01,30.77,
Culture type immunofluoresc,87140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26.94,,,,,,,fee schedule,5.01,30.77,
Culture type immunofluoresc,87140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,28.33,,,,,,,fee schedule,5.01,30.77,
Culture type immunofluoresc,87140,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.01,,,,,,,fee schedule,5.01,30.77,Laboratory
Culture type immunofluoresc,87140,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.85,,,,,,,fee schedule,5.01,30.77,APC
Culture type immunofluoresc,87140,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5.79,,,,,,,fee schedule,5.01,30.77,APC
Culture type immunofluoresc,87140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5.57,,,,,,,fee schedule,5.01,30.77,APC
Culture type immunofluoresc,87140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8.52,,,,,,,fee schedule,5.01,30.77,Radiology
Culture type immunofluoresc,87140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.8,,,,,,,fee schedule,5.01,30.77,APC
Culture type immunofluoresc,87140,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9.75,,,,,,,fee schedule,5.01,30.77,APC
Culture typing glc/hplc,87143,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,69.14,,,,,,,fee schedule,11.27,69.14,
Culture typing glc/hplc,87143,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55.42,,,,,,,fee schedule,11.27,69.14,
Culture typing glc/hplc,87143,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,60.54,,,,,,,fee schedule,11.27,69.14,
Culture typing glc/hplc,87143,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,63.65,,,,,,,fee schedule,11.27,69.14,
Culture typing glc/hplc,87143,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.27,,,,,,,fee schedule,11.27,69.14,Laboratory
Culture typing glc/hplc,87143,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.15,,,,,,,fee schedule,11.27,69.14,APC
Culture typing glc/hplc,87143,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.02,,,,,,,fee schedule,11.27,69.14,APC
Culture typing glc/hplc,87143,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.52,,,,,,,fee schedule,11.27,69.14,APC
Culture typing glc/hplc,87143,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.16,,,,,,,fee schedule,11.27,69.14,Radiology
Culture typing glc/hplc,87143,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.53,,,,,,,fee schedule,11.27,69.14,APC
Culture typing glc/hplc,87143,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21.91,,,,,,,fee schedule,11.27,69.14,APC
Culture type immunologic,87147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24.36,,,,,,,fee schedule,4.66,24.36,
Culture type immunologic,87147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19.53,,,,,,,fee schedule,4.66,24.36,
Culture type immunologic,87147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21.33,,,,,,,fee schedule,4.66,24.36,
Culture type immunologic,87147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22.43,,,,,,,fee schedule,4.66,24.36,
Culture type immunologic,87147,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.66,,,,,,,fee schedule,4.66,24.36,Laboratory
Culture type immunologic,87147,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.44,,,,,,,fee schedule,4.66,24.36,APC
Culture type immunologic,87147,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5.39,,,,,,,fee schedule,4.66,24.36,APC
Culture type immunologic,87147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5.18,,,,,,,fee schedule,4.66,24.36,APC
Culture type immunologic,87147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.93,,,,,,,fee schedule,4.66,24.36,Radiology
Culture type immunologic,87147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.25,,,,,,,fee schedule,4.66,24.36,APC
Culture type immunologic,87147,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9.06,,,,,,,fee schedule,4.66,24.36,APC
Dna/rna direct probe,87149,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,110.64,,,,,,,fee schedule,18.05,110.64,
Dna/rna direct probe,87149,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,88.69,,,,,,,fee schedule,18.05,110.64,
Dna/rna direct probe,87149,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,96.88,,,,,,,fee schedule,18.05,110.64,
Dna/rna direct probe,87149,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,101.86,,,,,,,fee schedule,18.05,110.64,
Dna/rna direct probe,87149,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.05,,,,,,,fee schedule,18.05,110.64,Laboratory
Dna/rna direct probe,87149,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.05,,,,,,,fee schedule,18.05,110.64,APC
Dna/rna direct probe,87149,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,20.85,,,,,,,fee schedule,18.05,110.64,APC
Dna/rna direct probe,87149,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,20.05,,,,,,,fee schedule,18.05,110.64,APC
Dna/rna direct probe,87149,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,30.68,,,,,,,fee schedule,18.05,110.64,Radiology
Dna/rna direct probe,87149,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.07,,,,,,,fee schedule,18.05,110.64,APC
Dna/rna direct probe,87149,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,35.09,,,,,,,fee schedule,18.05,110.64,APC
Dna/rna amplified probe,87150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,106.62,,,,,,,fee schedule,31.58,106.62,
Dna/rna amplified probe,87150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,85.46,,,,,,,fee schedule,31.58,106.62,
Dna/rna amplified probe,87150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,93.36,,,,,,,fee schedule,31.58,106.62,
Dna/rna amplified probe,87150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,98.15,,,,,,,fee schedule,31.58,106.62,
Dna/rna amplified probe,87150,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31.58,,,,,,,fee schedule,31.58,106.62,Laboratory
Dna/rna amplified probe,87150,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,31.58,106.62,APC
Dna/rna amplified probe,87150,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,36.49,,,,,,,fee schedule,31.58,106.62,APC
Dna/rna amplified probe,87150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,35.09,,,,,,,fee schedule,31.58,106.62,APC
Dna/rna amplified probe,87150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,53.69,,,,,,,fee schedule,31.58,106.62,Radiology
Dna/rna amplified probe,87150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49.13,,,,,,,fee schedule,31.58,106.62,APC
Dna/rna amplified probe,87150,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,61.41,,,,,,,fee schedule,31.58,106.62,APC
Culture Type Pulse Field Gel,87152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,28.88,,,,,,,fee schedule,6.97,28.88,
Culture Type Pulse Field Gel,87152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23.15,,,,,,,fee schedule,6.97,28.88,
Culture Type Pulse Field Gel,87152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,25.29,,,,,,,fee schedule,6.97,28.88,
Culture Type Pulse Field Gel,87152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26.59,,,,,,,fee schedule,6.97,28.88,
Culture Type Pulse Field Gel,87152,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.97,,,,,,,fee schedule,6.97,28.88,Laboratory
Culture Type Pulse Field Gel,87152,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.13,,,,,,,fee schedule,6.97,28.88,APC
Culture Type Pulse Field Gel,87152,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8.05,,,,,,,fee schedule,6.97,28.88,APC
Culture Type Pulse Field Gel,87152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7.74,,,,,,,fee schedule,6.97,28.88,APC
Culture Type Pulse Field Gel,87152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11.84,,,,,,,fee schedule,6.97,28.88,Radiology
Culture Type Pulse Field Gel,87152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10.84,,,,,,,fee schedule,6.97,28.88,APC
Culture Type Pulse Field Gel,87152,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,13.54,,,,,,,fee schedule,6.97,28.88,APC
Dna/rna sequencing,87153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,348.72,,,,,,,fee schedule,103.82,348.72,
Dna/rna sequencing,87153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,279.53,,,,,,,fee schedule,103.82,348.72,
Dna/rna sequencing,87153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,305.36,,,,,,,fee schedule,103.82,348.72,
Dna/rna sequencing,87153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,321.05,,,,,,,fee schedule,103.82,348.72,
Dna/rna sequencing,87153,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,103.82,,,,,,,fee schedule,103.82,348.72,Laboratory
Dna/rna sequencing,87153,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,121.13,,,,,,,fee schedule,103.82,348.72,APC
Dna/rna sequencing,87153,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,119.97,,,,,,,fee schedule,103.82,348.72,APC
Dna/rna sequencing,87153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,115.36,,,,,,,fee schedule,103.82,348.72,APC
Dna/rna sequencing,87153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,176.5,,,,,,,fee schedule,103.82,348.72,Radiology
Dna/rna sequencing,87153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,161.5,,,,,,,fee schedule,103.82,348.72,APC
Dna/rna sequencing,87153,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,201.88,,,,,,,fee schedule,103.82,348.72,APC
Cul typ id bld pthgn 6+ trgt,87154,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,824.27,,,,,,,fee schedule,196.25,824.27,
Cul typ id bld pthgn 6+ trgt,87154,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,660.72,,,,,,,fee schedule,196.25,824.27,
Cul typ id bld pthgn 6+ trgt,87154,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,721.78,,,,,,,fee schedule,196.25,824.27,
Cul typ id bld pthgn 6+ trgt,87154,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,758.85,,,,,,,fee schedule,196.25,824.27,
Cul typ id bld pthgn 6+ trgt,87154,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,196.25,,,,,,,fee schedule,196.25,824.27,Laboratory
Cul typ id bld pthgn 6+ trgt,87154,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,228.96,,,,,,,fee schedule,196.25,824.27,APC
Cul typ id bld pthgn 6+ trgt,87154,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,226.78,,,,,,,fee schedule,196.25,824.27,APC
Cul typ id bld pthgn 6+ trgt,87154,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,218.06,,,,,,,fee schedule,196.25,824.27,APC
Cul typ id bld pthgn 6+ trgt,87154,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,333.63,,,,,,,fee schedule,196.25,824.27,Radiology
Cul typ id bld pthgn 6+ trgt,87154,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,305.28,,,,,,,fee schedule,196.25,824.27,APC
Cul typ id bld pthgn 6+ trgt,87154,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,381.6,,,,,,,fee schedule,196.25,824.27,APC
Culture typing added method,87158,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,28.88,,,,,,,fee schedule,6.97,28.88,
Culture typing added method,87158,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23.15,,,,,,,fee schedule,6.97,28.88,
Culture typing added method,87158,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,25.29,,,,,,,fee schedule,6.97,28.88,
Culture typing added method,87158,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26.59,,,,,,,fee schedule,6.97,28.88,
Culture typing added method,87158,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.97,,,,,,,fee schedule,6.97,28.88,Laboratory
Culture typing added method,87158,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.13,,,,,,,fee schedule,6.97,28.88,APC
Culture typing added method,87158,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8.05,,,,,,,fee schedule,6.97,28.88,APC
Culture typing added method,87158,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7.74,,,,,,,fee schedule,6.97,28.88,APC
Culture typing added method,87158,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11.84,,,,,,,fee schedule,6.97,28.88,Radiology
Culture typing added method,87158,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10.84,,,,,,,fee schedule,6.97,28.88,APC
Culture typing added method,87158,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,13.54,,,,,,,fee schedule,6.97,28.88,APC
Dark field examination,87164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59.27,,,,,,,fee schedule,9.67,59.27,
Dark field examination,87164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,47.51,,,,,,,fee schedule,9.67,59.27,
Dark field examination,87164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.9,,,,,,,fee schedule,9.67,59.27,
Dark field examination,87164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,54.57,,,,,,,fee schedule,9.67,59.27,
Dark field examination,87164,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.67,,,,,,,fee schedule,9.67,59.27,Laboratory
Dark field examination,87164,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.28,,,,,,,fee schedule,9.67,59.27,APC
Dark field examination,87164,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11.17,,,,,,,fee schedule,9.67,59.27,APC
Dark field examination,87164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10.74,,,,,,,fee schedule,9.67,59.27,APC
Dark field examination,87164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.43,,,,,,,fee schedule,9.67,59.27,Radiology
Dark field examination,87164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15.04,,,,,,,fee schedule,9.67,59.27,APC
Dark field examination,87164,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18.8,,,,,,,fee schedule,9.67,59.27,APC
Dark field examination,87166,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,62.33,,,,,,,fee schedule,10.17,62.33,
Dark field examination,87166,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,49.96,,,,,,,fee schedule,10.17,62.33,
Dark field examination,87166,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,54.58,,,,,,,fee schedule,10.17,62.33,
Dark field examination,87166,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,57.39,,,,,,,fee schedule,10.17,62.33,
Dark field examination,87166,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.17,,,,,,,fee schedule,10.17,62.33,Laboratory
Dark field examination,87166,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.87,,,,,,,fee schedule,10.17,62.33,APC
Dark field examination,87166,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11.75,,,,,,,fee schedule,10.17,62.33,APC
Dark field examination,87166,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11.3,,,,,,,fee schedule,10.17,62.33,APC
Dark field examination,87166,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.29,,,,,,,fee schedule,10.17,62.33,Radiology
Dark field examination,87166,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15.82,,,,,,,fee schedule,10.17,62.33,APC
Dark field examination,87166,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19.78,,,,,,,fee schedule,10.17,62.33,APC
Macroscopic Exam Arthropod,87168,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23.55,,,,,,,fee schedule,3.84,23.55,
Macroscopic Exam Arthropod,87168,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18.88,,,,,,,fee schedule,3.84,23.55,
Macroscopic Exam Arthropod,87168,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20.62,,,,,,,fee schedule,3.84,23.55,
Macroscopic Exam Arthropod,87168,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21.68,,,,,,,fee schedule,3.84,23.55,
Macroscopic Exam Arthropod,87168,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.84,,,,,,,fee schedule,3.84,23.55,Laboratory
Macroscopic Exam Arthropod,87168,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.48,,,,,,,fee schedule,3.84,23.55,APC
Macroscopic Exam Arthropod,87168,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4.44,,,,,,,fee schedule,3.84,23.55,APC
Macroscopic Exam Arthropod,87168,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4.27,,,,,,,fee schedule,3.84,23.55,APC
Macroscopic Exam Arthropod,87168,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.53,,,,,,,fee schedule,3.84,23.55,Radiology
Macroscopic Exam Arthropod,87168,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.98,,,,,,,fee schedule,3.84,23.55,APC
Macroscopic Exam Arthropod,87168,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7.47,,,,,,,fee schedule,3.84,23.55,APC
Macroscopic exam parasite,87169,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,35.54,,,,,,,fee schedule,3.88,35.54,
Macroscopic exam parasite,87169,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28.49,,,,,,,fee schedule,3.88,35.54,
Macroscopic exam parasite,87169,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31.12,,,,,,,fee schedule,3.88,35.54,
Macroscopic exam parasite,87169,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,32.72,,,,,,,fee schedule,3.88,35.54,
Macroscopic exam parasite,87169,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.88,,,,,,,fee schedule,3.88,35.54,Laboratory
Macroscopic exam parasite,87169,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.53,,,,,,,fee schedule,3.88,35.54,APC
Macroscopic exam parasite,87169,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4.48,,,,,,,fee schedule,3.88,35.54,APC
Macroscopic exam parasite,87169,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4.31,,,,,,,fee schedule,3.88,35.54,APC
Macroscopic exam parasite,87169,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.59,,,,,,,fee schedule,3.88,35.54,Radiology
Macroscopic exam parasite,87169,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.03,,,,,,,fee schedule,3.88,35.54,APC
Macroscopic exam parasite,87169,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7.54,,,,,,,fee schedule,3.88,35.54,APC
Pinworm Exam,87172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13.33,,,,,,,fee schedule,3.84,13.33,
Pinworm Exam,87172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10.68,,,,,,,fee schedule,3.84,13.33,
Pinworm Exam,87172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11.67,,,,,,,fee schedule,3.84,13.33,
Pinworm Exam,87172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12.27,,,,,,,fee schedule,3.84,13.33,
Pinworm Exam,87172,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.84,,,,,,,fee schedule,3.84,13.33,Laboratory
Pinworm Exam,87172,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.48,,,,,,,fee schedule,3.84,13.33,APC
Pinworm Exam,87172,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4.44,,,,,,,fee schedule,3.84,13.33,APC
Pinworm Exam,87172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4.27,,,,,,,fee schedule,3.84,13.33,APC
Pinworm Exam,87172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.53,,,,,,,fee schedule,3.84,13.33,Radiology
Pinworm Exam,87172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.98,,,,,,,fee schedule,3.84,13.33,APC
Pinworm Exam,87172,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7.47,,,,,,,fee schedule,3.84,13.33,APC
Tissue homogenization cultr,87176,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37.02,,,,,,,fee schedule,5.29,37.02,
Tissue homogenization cultr,87176,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29.67,,,,,,,fee schedule,5.29,37.02,
Tissue homogenization cultr,87176,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32.42,,,,,,,fee schedule,5.29,37.02,
Tissue homogenization cultr,87176,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,34.08,,,,,,,fee schedule,5.29,37.02,
Tissue homogenization cultr,87176,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.29,,,,,,,fee schedule,5.29,37.02,Laboratory
Tissue homogenization cultr,87176,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.17,,,,,,,fee schedule,5.29,37.02,APC
Tissue homogenization cultr,87176,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6.12,,,,,,,fee schedule,5.29,37.02,APC
Tissue homogenization cultr,87176,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5.88,,,,,,,fee schedule,5.29,37.02,APC
Tissue homogenization cultr,87176,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9,,,,,,,fee schedule,5.29,37.02,Radiology
Tissue homogenization cultr,87176,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8.23,,,,,,,fee schedule,5.29,37.02,APC
Tissue homogenization cultr,87176,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10.29,,,,,,,fee schedule,5.29,37.02,APC
Ova and parasites smears,87177,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,57.94,,,,,,,fee schedule,8.01,57.94,
Ova and parasites smears,87177,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.44,,,,,,,fee schedule,8.01,57.94,
Ova and parasites smears,87177,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,50.73,,,,,,,fee schedule,8.01,57.94,
Ova and parasites smears,87177,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,53.34,,,,,,,fee schedule,8.01,57.94,
Ova and parasites smears,87177,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.01,,,,,,,fee schedule,8.01,57.94,Laboratory
Ova and parasites smears,87177,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.35,,,,,,,fee schedule,8.01,57.94,APC
Ova and parasites smears,87177,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9.26,,,,,,,fee schedule,8.01,57.94,APC
Ova and parasites smears,87177,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8.9,,,,,,,fee schedule,8.01,57.94,APC
Ova and parasites smears,87177,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.62,,,,,,,fee schedule,8.01,57.94,Radiology
Ova and parasites smears,87177,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12.46,,,,,,,fee schedule,8.01,57.94,APC
Ova and parasites smears,87177,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15.58,,,,,,,fee schedule,8.01,57.94,APC
Microbe susceptible diffuse,87181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26.2,,,,,,,fee schedule,4.28,26.2,
Microbe susceptible diffuse,87181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21,,,,,,,fee schedule,4.28,26.2,
Microbe susceptible diffuse,87181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22.94,,,,,,,fee schedule,4.28,26.2,
Microbe susceptible diffuse,87181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24.12,,,,,,,fee schedule,4.28,26.2,
Microbe susceptible diffuse,87181,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.28,,,,,,,fee schedule,4.28,26.2,Laboratory
Microbe susceptible diffuse,87181,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.99,,,,,,,fee schedule,4.28,26.2,APC
Microbe susceptible diffuse,87181,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4.94,,,,,,,fee schedule,4.28,26.2,APC
Microbe susceptible diffuse,87181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4.75,,,,,,,fee schedule,4.28,26.2,APC
Microbe susceptible diffuse,87181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.27,,,,,,,fee schedule,4.28,26.2,Radiology
Microbe susceptible diffuse,87181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.65,,,,,,,fee schedule,4.28,26.2,APC
Microbe susceptible diffuse,87181,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8.31,,,,,,,fee schedule,4.28,26.2,APC
Sc std carbapenem resist gen,87183,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31.58,,,,,,,fee schedule,31.58,61.41,Laboratory
Sc std carbapenem resist gen,87183,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,31.58,61.41,APC
Sc std carbapenem resist gen,87183,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,36.49,,,,,,,fee schedule,31.58,61.41,APC
Sc std carbapenem resist gen,87183,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,35.09,,,,,,,fee schedule,31.58,61.41,APC
Sc std carbapenem resist gen,87183,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,53.69,,,,,,,fee schedule,31.58,61.41,Radiology
Sc std carbapenem resist gen,87183,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49.13,,,,,,,fee schedule,31.58,61.41,APC
Sc std carbapenem resist gen,87183,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,61.41,,,,,,,fee schedule,31.58,61.41,APC
Microbe susceptible disk,87184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,62.32,,,,,,,fee schedule,6.73,62.32,
Microbe susceptible disk,87184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,49.95,,,,,,,fee schedule,6.73,62.32,
Microbe susceptible disk,87184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,54.57,,,,,,,fee schedule,6.73,62.32,
Microbe susceptible disk,87184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,57.37,,,,,,,fee schedule,6.73,62.32,
Microbe susceptible disk,87184,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.73,,,,,,,fee schedule,6.73,62.32,Laboratory
Microbe susceptible disk,87184,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.85,,,,,,,fee schedule,6.73,62.32,APC
Microbe susceptible disk,87184,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7.78,,,,,,,fee schedule,6.73,62.32,APC
Microbe susceptible disk,87184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7.48,,,,,,,fee schedule,6.73,62.32,APC
Microbe susceptible disk,87184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11.44,,,,,,,fee schedule,6.73,62.32,Radiology
Microbe susceptible disk,87184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10.47,,,,,,,fee schedule,6.73,62.32,APC
Microbe susceptible disk,87184,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,13.09,,,,,,,fee schedule,6.73,62.32,APC
Microbe susceptible enzyme,87185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41.46,,,,,,,fee schedule,4.28,41.46,
Microbe susceptible enzyme,87185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,33.24,,,,,,,fee schedule,4.28,41.46,
Microbe susceptible enzyme,87185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36.31,,,,,,,fee schedule,4.28,41.46,
Microbe susceptible enzyme,87185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,38.17,,,,,,,fee schedule,4.28,41.46,
Microbe susceptible enzyme,87185,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.28,,,,,,,fee schedule,4.28,41.46,Laboratory
Microbe susceptible enzyme,87185,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.99,,,,,,,fee schedule,4.28,41.46,APC
Microbe susceptible enzyme,87185,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4.94,,,,,,,fee schedule,4.28,41.46,APC
Microbe susceptible enzyme,87185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4.75,,,,,,,fee schedule,4.28,41.46,APC
Microbe susceptible enzyme,87185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.27,,,,,,,fee schedule,4.28,41.46,Radiology
Microbe susceptible enzyme,87185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.65,,,,,,,fee schedule,4.28,41.46,APC
Microbe susceptible enzyme,87185,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8.31,,,,,,,fee schedule,4.28,41.46,APC
Microbe susceptible mic,87186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,70.65,,,,,,,fee schedule,7.78,70.65,
Microbe susceptible mic,87186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56.63,,,,,,,fee schedule,7.78,70.65,
Microbe susceptible mic,87186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,61.87,,,,,,,fee schedule,7.78,70.65,
Microbe susceptible mic,87186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,65.04,,,,,,,fee schedule,7.78,70.65,
Microbe susceptible mic,87186,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.78,,,,,,,fee schedule,7.78,70.65,Laboratory
Microbe susceptible mic,87186,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.08,,,,,,,fee schedule,7.78,70.65,APC
Microbe susceptible mic,87186,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9,,,,,,,fee schedule,7.78,70.65,APC
Microbe susceptible mic,87186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8.65,,,,,,,fee schedule,7.78,70.65,APC
Microbe susceptible mic,87186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.23,,,,,,,fee schedule,7.78,70.65,Radiology
Microbe susceptible mic,87186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12.11,,,,,,,fee schedule,7.78,70.65,APC
Microbe susceptible mic,87186,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15.14,,,,,,,fee schedule,7.78,70.65,APC
Microbe susceptible mlc,87187,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,44.64,,,,,,,fee schedule,35.78,70.3,
Microbe susceptible mlc,87187,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35.78,,,,,,,fee schedule,35.78,70.3,
Microbe susceptible mlc,87187,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39.09,,,,,,,fee schedule,35.78,70.3,
Microbe susceptible mlc,87187,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41.1,,,,,,,fee schedule,35.78,70.3,
Microbe susceptible mlc,87187,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,36.15,,,,,,,fee schedule,35.78,70.3,Laboratory
Microbe susceptible mlc,87187,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,42.18,,,,,,,fee schedule,35.78,70.3,APC
Microbe susceptible mlc,87187,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,41.78,,,,,,,fee schedule,35.78,70.3,APC
Microbe susceptible mlc,87187,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,40.17,,,,,,,fee schedule,35.78,70.3,APC
Microbe susceptible mlc,87187,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,61.46,,,,,,,fee schedule,35.78,70.3,Radiology
Microbe susceptible mlc,87187,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.24,,,,,,,fee schedule,35.78,70.3,APC
Microbe susceptible mlc,87187,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,70.3,,,,,,,fee schedule,35.78,70.3,APC
Microbe suscept macrobroth,87188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,36.63,,,,,,,fee schedule,5.98,36.63,
Microbe suscept macrobroth,87188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29.36,,,,,,,fee schedule,5.98,36.63,
Microbe suscept macrobroth,87188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32.07,,,,,,,fee schedule,5.98,36.63,
Microbe suscept macrobroth,87188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33.72,,,,,,,fee schedule,5.98,36.63,
Microbe suscept macrobroth,87188,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.98,,,,,,,fee schedule,5.98,36.63,Laboratory
Microbe suscept macrobroth,87188,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.97,,,,,,,fee schedule,5.98,36.63,APC
Microbe suscept macrobroth,87188,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6.91,,,,,,,fee schedule,5.98,36.63,APC
Microbe suscept macrobroth,87188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6.64,,,,,,,fee schedule,5.98,36.63,APC
Microbe suscept macrobroth,87188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10.16,,,,,,,fee schedule,5.98,36.63,Radiology
Microbe suscept macrobroth,87188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.3,,,,,,,fee schedule,5.98,36.63,APC
Microbe suscept macrobroth,87188,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11.62,,,,,,,fee schedule,5.98,36.63,APC
Microbe suscept mycobacteri,87190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24.61,,,,,,,fee schedule,6.58,24.61,
Microbe suscept mycobacteri,87190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19.73,,,,,,,fee schedule,6.58,24.61,
Microbe suscept mycobacteri,87190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21.55,,,,,,,fee schedule,6.58,24.61,
Microbe suscept mycobacteri,87190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22.65,,,,,,,fee schedule,6.58,24.61,
Microbe suscept mycobacteri,87190,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.58,,,,,,,fee schedule,6.58,24.61,Laboratory
Microbe suscept mycobacteri,87190,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.68,,,,,,,fee schedule,6.58,24.61,APC
Microbe suscept mycobacteri,87190,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7.6,,,,,,,fee schedule,6.58,24.61,APC
Microbe suscept mycobacteri,87190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7.31,,,,,,,fee schedule,6.58,24.61,APC
Microbe suscept mycobacteri,87190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11.18,,,,,,,fee schedule,6.58,24.61,Radiology
Microbe suscept mycobacteri,87190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10.23,,,,,,,fee schedule,6.58,24.61,APC
Microbe suscept mycobacteri,87190,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12.79,,,,,,,fee schedule,6.58,24.61,APC
Bactericidal level serum,87197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,82.9,,,,,,,fee schedule,13.52,82.9,
Bactericidal level serum,87197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66.45,,,,,,,fee schedule,13.52,82.9,
Bactericidal level serum,87197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,72.59,,,,,,,fee schedule,13.52,82.9,
Bactericidal level serum,87197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,76.32,,,,,,,fee schedule,13.52,82.9,
Bactericidal level serum,87197,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.52,,,,,,,fee schedule,13.52,82.9,Laboratory
Bactericidal level serum,87197,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.77,,,,,,,fee schedule,13.52,82.9,APC
Bactericidal level serum,87197,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,15.62,,,,,,,fee schedule,13.52,82.9,APC
Bactericidal level serum,87197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,15.02,,,,,,,fee schedule,13.52,82.9,APC
Bactericidal level serum,87197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.98,,,,,,,fee schedule,13.52,82.9,Radiology
Bactericidal level serum,87197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21.03,,,,,,,fee schedule,13.52,82.9,APC
Bactericidal level serum,87197,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,26.28,,,,,,,fee schedule,13.52,82.9,APC
Smear gram stain,87205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,35.25,,,,,,,fee schedule,3.84,35.25,
Smear gram stain,87205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28.25,,,,,,,fee schedule,3.84,35.25,
Smear gram stain,87205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,30.87,,,,,,,fee schedule,3.84,35.25,
Smear gram stain,87205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,32.45,,,,,,,fee schedule,3.84,35.25,
Smear gram stain,87205,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.84,,,,,,,fee schedule,3.84,35.25,Laboratory
Smear gram stain,87205,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.48,,,,,,,fee schedule,3.84,35.25,APC
Smear gram stain,87205,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4.44,,,,,,,fee schedule,3.84,35.25,APC
Smear gram stain,87205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4.27,,,,,,,fee schedule,3.84,35.25,APC
Smear gram stain,87205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.53,,,,,,,fee schedule,3.84,35.25,Radiology
Smear gram stain,87205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.98,,,,,,,fee schedule,3.84,35.25,APC
Smear gram stain,87205,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7.47,,,,,,,fee schedule,3.84,35.25,APC
Smear fluorescent/acid stai,87206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,86.9,,,,,,,fee schedule,4.85,86.9,
Smear fluorescent/acid stai,87206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,69.66,,,,,,,fee schedule,4.85,86.9,
Smear fluorescent/acid stai,87206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,76.09,,,,,,,fee schedule,4.85,86.9,
Smear fluorescent/acid stai,87206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,80,,,,,,,fee schedule,4.85,86.9,
Smear fluorescent/acid stai,87206,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.85,,,,,,,fee schedule,4.85,86.9,Laboratory
Smear fluorescent/acid stai,87206,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.66,,,,,,,fee schedule,4.85,86.9,APC
Smear fluorescent/acid stai,87206,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5.61,,,,,,,fee schedule,4.85,86.9,APC
Smear fluorescent/acid stai,87206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5.39,,,,,,,fee schedule,4.85,86.9,APC
Smear fluorescent/acid stai,87206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8.25,,,,,,,fee schedule,4.85,86.9,Radiology
Smear fluorescent/acid stai,87206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.55,,,,,,,fee schedule,4.85,86.9,APC
Smear fluorescent/acid stai,87206,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9.43,,,,,,,fee schedule,4.85,86.9,APC
Smear special stain,87207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,111.06,,,,,,,fee schedule,5.39,111.06,
Smear special stain,87207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,89.02,,,,,,,fee schedule,5.39,111.06,
Smear special stain,87207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,97.25,,,,,,,fee schedule,5.39,111.06,
Smear special stain,87207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,102.24,,,,,,,fee schedule,5.39,111.06,
Smear special stain,87207,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.39,,,,,,,fee schedule,5.39,111.06,Laboratory
Smear special stain,87207,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.29,,,,,,,fee schedule,5.39,111.06,APC
Smear special stain,87207,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6.23,,,,,,,fee schedule,5.39,111.06,APC
Smear special stain,87207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5.99,,,,,,,fee schedule,5.39,111.06,APC
Smear special stain,87207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.16,,,,,,,fee schedule,5.39,111.06,Radiology
Smear special stain,87207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8.39,,,,,,,fee schedule,5.39,111.06,APC
Smear special stain,87207,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10.48,,,,,,,fee schedule,5.39,111.06,APC
Smear complex stain,87209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,44.42,,,,,,,fee schedule,16.18,44.42,
Smear complex stain,87209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35.61,,,,,,,fee schedule,16.18,44.42,
Smear complex stain,87209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38.9,,,,,,,fee schedule,16.18,44.42,
Smear complex stain,87209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,40.9,,,,,,,fee schedule,16.18,44.42,
Smear complex stain,87209,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.18,,,,,,,fee schedule,16.18,44.42,Laboratory
Smear complex stain,87209,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.88,,,,,,,fee schedule,16.18,44.42,APC
Smear complex stain,87209,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18.7,,,,,,,fee schedule,16.18,44.42,APC
Smear complex stain,87209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17.98,,,,,,,fee schedule,16.18,44.42,APC
Smear complex stain,87209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27.51,,,,,,,fee schedule,16.18,44.42,Radiology
Smear complex stain,87209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.17,,,,,,,fee schedule,16.18,44.42,APC
Smear complex stain,87209,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31.46,,,,,,,fee schedule,16.18,44.42,APC
Smear wet mount saline/ink,87210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,36.04,,,,,,,fee schedule,5.24,36.04,
Smear wet mount saline/ink,87210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28.89,,,,,,,fee schedule,5.24,36.04,
Smear wet mount saline/ink,87210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31.55,,,,,,,fee schedule,5.24,36.04,
Smear wet mount saline/ink,87210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33.18,,,,,,,fee schedule,5.24,36.04,
Smear wet mount saline/ink,87210,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.24,,,,,,,fee schedule,5.24,36.04,Laboratory
Smear wet mount saline/ink,87210,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.11,,,,,,,fee schedule,5.24,36.04,APC
Smear wet mount saline/ink,87210,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6.05,,,,,,,fee schedule,5.24,36.04,APC
Smear wet mount saline/ink,87210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5.82,,,,,,,fee schedule,5.24,36.04,APC
Smear wet mount saline/ink,87210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8.9,,,,,,,fee schedule,5.24,36.04,Radiology
Smear wet mount saline/ink,87210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8.15,,,,,,,fee schedule,5.24,36.04,APC
Smear wet mount saline/ink,87210,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10.18,,,,,,,fee schedule,5.24,36.04,APC
Tissue exam for fungi,87220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13.33,,,,,,,fee schedule,3.84,13.33,
Tissue exam for fungi,87220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10.68,,,,,,,fee schedule,3.84,13.33,
Tissue exam for fungi,87220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11.67,,,,,,,fee schedule,3.84,13.33,
Tissue exam for fungi,87220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12.27,,,,,,,fee schedule,3.84,13.33,
Tissue exam for fungi,87220,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.84,,,,,,,fee schedule,3.84,13.33,Laboratory
Tissue exam for fungi,87220,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.48,,,,,,,fee schedule,3.84,13.33,APC
Tissue exam for fungi,87220,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4.44,,,,,,,fee schedule,3.84,13.33,APC
Tissue exam for fungi,87220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4.27,,,,,,,fee schedule,3.84,13.33,APC
Tissue exam for fungi,87220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.53,,,,,,,fee schedule,3.84,13.33,Radiology
Tissue exam for fungi,87220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.98,,,,,,,fee schedule,3.84,13.33,APC
Tissue exam for fungi,87220,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7.47,,,,,,,fee schedule,3.84,13.33,APC
Assay toxin or antitoxin,87230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,108.98,,,,,,,fee schedule,17.77,108.98,
Assay toxin or antitoxin,87230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,87.35,,,,,,,fee schedule,17.77,108.98,
Assay toxin or antitoxin,87230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,95.43,,,,,,,fee schedule,17.77,108.98,
Assay toxin or antitoxin,87230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,100.33,,,,,,,fee schedule,17.77,108.98,
Assay toxin or antitoxin,87230,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.77,,,,,,,fee schedule,17.77,108.98,Laboratory
Assay toxin or antitoxin,87230,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20.73,,,,,,,fee schedule,17.77,108.98,APC
Assay toxin or antitoxin,87230,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,20.53,,,,,,,fee schedule,17.77,108.98,APC
Assay toxin or antitoxin,87230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,19.74,,,,,,,fee schedule,17.77,108.98,APC
Assay toxin or antitoxin,87230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,30.2,,,,,,,fee schedule,17.77,108.98,Radiology
Assay toxin or antitoxin,87230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27.64,,,,,,,fee schedule,17.77,108.98,APC
Assay toxin or antitoxin,87230,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,34.54,,,,,,,fee schedule,17.77,108.98,APC
Virus inoculate eggs/animal,87250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,107.92,,,,,,,fee schedule,17.6,107.92,
Virus inoculate eggs/animal,87250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,86.51,,,,,,,fee schedule,17.6,107.92,
Virus inoculate eggs/animal,87250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,94.5,,,,,,,fee schedule,17.6,107.92,
Virus inoculate eggs/animal,87250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,99.35,,,,,,,fee schedule,17.6,107.92,
Virus inoculate eggs/animal,87250,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.6,,,,,,,fee schedule,17.6,107.92,Laboratory
Virus inoculate eggs/animal,87250,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20.54,,,,,,,fee schedule,17.6,107.92,APC
Virus inoculate eggs/animal,87250,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,20.34,,,,,,,fee schedule,17.6,107.92,APC
Virus inoculate eggs/animal,87250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,19.56,,,,,,,fee schedule,17.6,107.92,APC
Virus inoculate eggs/animal,87250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29.93,,,,,,,fee schedule,17.6,107.92,Radiology
Virus inoculate eggs/animal,87250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27.38,,,,,,,fee schedule,17.6,107.92,APC
Virus inoculate eggs/animal,87250,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,34.23,,,,,,,fee schedule,17.6,107.92,APC
Virus inoculation tissue,87252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,143.87,,,,,,,fee schedule,23.46,143.87,
Virus inoculation tissue,87252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,115.32,,,,,,,fee schedule,23.46,143.87,
Virus inoculation tissue,87252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,125.98,,,,,,,fee schedule,23.46,143.87,
Virus inoculation tissue,87252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,132.45,,,,,,,fee schedule,23.46,143.87,
Virus inoculation tissue,87252,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23.46,,,,,,,fee schedule,23.46,143.87,Laboratory
Virus inoculation tissue,87252,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,27.37,,,,,,,fee schedule,23.46,143.87,APC
Virus inoculation tissue,87252,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,27.11,,,,,,,fee schedule,23.46,143.87,APC
Virus inoculation tissue,87252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,26.07,,,,,,,fee schedule,23.46,143.87,APC
Virus inoculation tissue,87252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,39.89,,,,,,,fee schedule,23.46,143.87,Radiology
Virus inoculation tissue,87252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,36.5,,,,,,,fee schedule,23.46,143.87,APC
Virus inoculation tissue,87252,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,45.62,,,,,,,fee schedule,23.46,143.87,APC
Virus inoculate tissue addl,87253,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,101.19,,,,,,,fee schedule,18.18,101.19,
Virus inoculate tissue addl,87253,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,81.11,,,,,,,fee schedule,18.18,101.19,
Virus inoculate tissue addl,87253,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,88.61,,,,,,,fee schedule,18.18,101.19,
Virus inoculate tissue addl,87253,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,93.16,,,,,,,fee schedule,18.18,101.19,
Virus inoculate tissue addl,87253,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.18,,,,,,,fee schedule,18.18,101.19,Laboratory
Virus inoculate tissue addl,87253,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.21,,,,,,,fee schedule,18.18,101.19,APC
Virus inoculate tissue addl,87253,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,21.01,,,,,,,fee schedule,18.18,101.19,APC
Virus inoculate tissue addl,87253,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,20.2,,,,,,,fee schedule,18.18,101.19,APC
Virus inoculate tissue addl,87253,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,30.91,,,,,,,fee schedule,18.18,101.19,Radiology
Virus inoculate tissue addl,87253,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.28,,,,,,,fee schedule,18.18,101.19,APC
Virus inoculate tissue addl,87253,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,35.35,,,,,,,fee schedule,18.18,101.19,APC
Virus inoculation shell via,87254,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,99.95,,,,,,,fee schedule,17.6,99.95,
Virus inoculation shell via,87254,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,80.12,,,,,,,fee schedule,17.6,99.95,
Virus inoculation shell via,87254,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,87.52,,,,,,,fee schedule,17.6,99.95,
Virus inoculation shell via,87254,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,92.02,,,,,,,fee schedule,17.6,99.95,
Virus inoculation shell via,87254,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.6,,,,,,,fee schedule,17.6,99.95,Laboratory
Virus inoculation shell via,87254,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20.54,,,,,,,fee schedule,17.6,99.95,APC
Virus inoculation shell via,87254,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,20.34,,,,,,,fee schedule,17.6,99.95,APC
Virus inoculation shell via,87254,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,19.56,,,,,,,fee schedule,17.6,99.95,APC
Virus inoculation shell via,87254,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29.93,,,,,,,fee schedule,17.6,99.95,Radiology
Virus inoculation shell via,87254,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27.38,,,,,,,fee schedule,17.6,99.95,APC
Virus inoculation shell via,87254,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,34.23,,,,,,,fee schedule,17.6,99.95,APC
Genet virus isolate hsv,87255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,85.39,,,,,,,fee schedule,30.47,85.39,
Genet virus isolate hsv,87255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,68.45,,,,,,,fee schedule,30.47,85.39,
Genet virus isolate hsv,87255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,74.77,,,,,,,fee schedule,30.47,85.39,
Genet virus isolate hsv,87255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,78.61,,,,,,,fee schedule,30.47,85.39,
Genet virus isolate hsv,87255,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,30.47,,,,,,,fee schedule,30.47,85.39,Laboratory
Genet virus isolate hsv,87255,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,35.55,,,,,,,fee schedule,30.47,85.39,APC
Genet virus isolate hsv,87255,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,35.21,,,,,,,fee schedule,30.47,85.39,APC
Genet virus isolate hsv,87255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,33.86,,,,,,,fee schedule,30.47,85.39,APC
Genet virus isolate hsv,87255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.81,,,,,,,fee schedule,30.47,85.39,Radiology
Genet virus isolate hsv,87255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,47.4,,,,,,,fee schedule,30.47,85.39,APC
Genet virus isolate hsv,87255,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,59.26,,,,,,,fee schedule,30.47,85.39,APC
Adenovirus ag if,87260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.23,,,,,,,fee schedule,12.99,66.23,
Adenovirus ag if,87260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.09,,,,,,,fee schedule,12.99,66.23,
Adenovirus ag if,87260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.99,,,,,,,fee schedule,12.99,66.23,
Adenovirus ag if,87260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.97,,,,,,,fee schedule,12.99,66.23,
Adenovirus ag if,87260,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.99,,,,,,,fee schedule,12.99,66.23,Laboratory
Adenovirus ag if,87260,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.15,,,,,,,fee schedule,12.99,66.23,APC
Adenovirus ag if,87260,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,15.01,,,,,,,fee schedule,12.99,66.23,APC
Adenovirus ag if,87260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14.43,,,,,,,fee schedule,12.99,66.23,APC
Adenovirus ag if,87260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.08,,,,,,,fee schedule,12.99,66.23,Radiology
Adenovirus ag if,87260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.2,,,,,,,fee schedule,12.99,66.23,APC
Adenovirus ag if,87260,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,25.25,,,,,,,fee schedule,12.99,66.23,APC
Pertussis ag if,87265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.23,,,,,,,fee schedule,10.78,66.23,
Pertussis ag if,87265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.09,,,,,,,fee schedule,10.78,66.23,
Pertussis ag if,87265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.99,,,,,,,fee schedule,10.78,66.23,
Pertussis ag if,87265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.97,,,,,,,fee schedule,10.78,66.23,
Pertussis ag if,87265,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.78,,,,,,,fee schedule,10.78,66.23,Laboratory
Pertussis ag if,87265,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.58,,,,,,,fee schedule,10.78,66.23,APC
Pertussis ag if,87265,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.46,,,,,,,fee schedule,10.78,66.23,APC
Pertussis ag if,87265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11.98,,,,,,,fee schedule,10.78,66.23,APC
Pertussis ag if,87265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.33,,,,,,,fee schedule,10.78,66.23,Radiology
Pertussis ag if,87265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.77,,,,,,,fee schedule,10.78,66.23,APC
Pertussis ag if,87265,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20.96,,,,,,,fee schedule,10.78,66.23,APC
Enterovirus antibody dfa,87267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.23,,,,,,,fee schedule,12.08,66.23,
Enterovirus antibody dfa,87267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.09,,,,,,,fee schedule,12.08,66.23,
Enterovirus antibody dfa,87267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.99,,,,,,,fee schedule,12.08,66.23,
Enterovirus antibody dfa,87267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.97,,,,,,,fee schedule,12.08,66.23,
Enterovirus antibody dfa,87267,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.08,,,,,,,fee schedule,12.08,66.23,Laboratory
Enterovirus antibody dfa,87267,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.09,,,,,,,fee schedule,12.08,66.23,APC
Enterovirus antibody dfa,87267,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.96,,,,,,,fee schedule,12.08,66.23,APC
Enterovirus antibody dfa,87267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.42,,,,,,,fee schedule,12.08,66.23,APC
Enterovirus antibody dfa,87267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.53,,,,,,,fee schedule,12.08,66.23,Radiology
Enterovirus antibody dfa,87267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.79,,,,,,,fee schedule,12.08,66.23,APC
Enterovirus antibody dfa,87267,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23.48,,,,,,,fee schedule,12.08,66.23,APC
Giardia ag if,87269,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.23,,,,,,,fee schedule,12.25,66.23,
Giardia ag if,87269,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.09,,,,,,,fee schedule,12.25,66.23,
Giardia ag if,87269,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.99,,,,,,,fee schedule,12.25,66.23,
Giardia ag if,87269,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.97,,,,,,,fee schedule,12.25,66.23,
Giardia ag if,87269,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.25,,,,,,,fee schedule,12.25,66.23,Laboratory
Giardia ag if,87269,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.29,,,,,,,fee schedule,12.25,66.23,APC
Giardia ag if,87269,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,14.15,,,,,,,fee schedule,12.25,66.23,APC
Giardia ag if,87269,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.61,,,,,,,fee schedule,12.25,66.23,APC
Giardia ag if,87269,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.82,,,,,,,fee schedule,12.25,66.23,Radiology
Giardia ag if,87269,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.05,,,,,,,fee schedule,12.25,66.23,APC
Giardia ag if,87269,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23.82,,,,,,,fee schedule,12.25,66.23,APC
Chlamydia trachomatis ag if,87270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.23,,,,,,,fee schedule,10.78,66.23,
Chlamydia trachomatis ag if,87270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.09,,,,,,,fee schedule,10.78,66.23,
Chlamydia trachomatis ag if,87270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.99,,,,,,,fee schedule,10.78,66.23,
Chlamydia trachomatis ag if,87270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.97,,,,,,,fee schedule,10.78,66.23,
Chlamydia trachomatis ag if,87270,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.78,,,,,,,fee schedule,10.78,66.23,Laboratory
Chlamydia trachomatis ag if,87270,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.58,,,,,,,fee schedule,10.78,66.23,APC
Chlamydia trachomatis ag if,87270,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.46,,,,,,,fee schedule,10.78,66.23,APC
Chlamydia trachomatis ag if,87270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11.98,,,,,,,fee schedule,10.78,66.23,APC
Chlamydia trachomatis ag if,87270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.33,,,,,,,fee schedule,10.78,66.23,Radiology
Chlamydia trachomatis ag if,87270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.77,,,,,,,fee schedule,10.78,66.23,APC
Chlamydia trachomatis ag if,87270,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20.96,,,,,,,fee schedule,10.78,66.23,APC
Cytomegalovirus dfa,87271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.23,,,,,,,fee schedule,12.08,66.23,
Cytomegalovirus dfa,87271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.09,,,,,,,fee schedule,12.08,66.23,
Cytomegalovirus dfa,87271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.99,,,,,,,fee schedule,12.08,66.23,
Cytomegalovirus dfa,87271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.97,,,,,,,fee schedule,12.08,66.23,
Cytomegalovirus dfa,87271,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.08,,,,,,,fee schedule,12.08,66.23,Laboratory
Cytomegalovirus dfa,87271,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.09,,,,,,,fee schedule,12.08,66.23,APC
Cytomegalovirus dfa,87271,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.96,,,,,,,fee schedule,12.08,66.23,APC
Cytomegalovirus dfa,87271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.42,,,,,,,fee schedule,12.08,66.23,APC
Cytomegalovirus dfa,87271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.53,,,,,,,fee schedule,12.08,66.23,Radiology
Cytomegalovirus dfa,87271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.79,,,,,,,fee schedule,12.08,66.23,APC
Cytomegalovirus dfa,87271,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23.48,,,,,,,fee schedule,12.08,66.23,APC
Cryptosporidium ag if,87272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.23,,,,,,,fee schedule,10.78,66.23,
Cryptosporidium ag if,87272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.09,,,,,,,fee schedule,10.78,66.23,
Cryptosporidium ag if,87272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.99,,,,,,,fee schedule,10.78,66.23,
Cryptosporidium ag if,87272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.97,,,,,,,fee schedule,10.78,66.23,
Cryptosporidium ag if,87272,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.78,,,,,,,fee schedule,10.78,66.23,Laboratory
Cryptosporidium ag if,87272,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.58,,,,,,,fee schedule,10.78,66.23,APC
Cryptosporidium ag if,87272,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.46,,,,,,,fee schedule,10.78,66.23,APC
Cryptosporidium ag if,87272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11.98,,,,,,,fee schedule,10.78,66.23,APC
Cryptosporidium ag if,87272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.33,,,,,,,fee schedule,10.78,66.23,Radiology
Cryptosporidium ag if,87272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.77,,,,,,,fee schedule,10.78,66.23,APC
Cryptosporidium ag if,87272,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20.96,,,,,,,fee schedule,10.78,66.23,APC
Herpes simplex 2 ag if,87273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,61.45,,,,,,,fee schedule,10.78,61.45,
Herpes simplex 2 ag if,87273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,49.26,,,,,,,fee schedule,10.78,61.45,
Herpes simplex 2 ag if,87273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.81,,,,,,,fee schedule,10.78,61.45,
Herpes simplex 2 ag if,87273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,56.58,,,,,,,fee schedule,10.78,61.45,
Herpes simplex 2 ag if,87273,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.78,,,,,,,fee schedule,10.78,61.45,Laboratory
Herpes simplex 2 ag if,87273,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.58,,,,,,,fee schedule,10.78,61.45,APC
Herpes simplex 2 ag if,87273,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.46,,,,,,,fee schedule,10.78,61.45,APC
Herpes simplex 2 ag if,87273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11.98,,,,,,,fee schedule,10.78,61.45,APC
Herpes simplex 2 ag if,87273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.33,,,,,,,fee schedule,10.78,61.45,Radiology
Herpes simplex 2 ag if,87273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.77,,,,,,,fee schedule,10.78,61.45,APC
Herpes simplex 2 ag if,87273,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20.96,,,,,,,fee schedule,10.78,61.45,APC
Herpes simplex 1 ag if,87274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,79.96,,,,,,,fee schedule,10.78,79.96,
Herpes simplex 1 ag if,87274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,64.1,,,,,,,fee schedule,10.78,79.96,
Herpes simplex 1 ag if,87274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,70.02,,,,,,,fee schedule,10.78,79.96,
Herpes simplex 1 ag if,87274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,73.62,,,,,,,fee schedule,10.78,79.96,
Herpes simplex 1 ag if,87274,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.78,,,,,,,fee schedule,10.78,79.96,Laboratory
Herpes simplex 1 ag if,87274,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.58,,,,,,,fee schedule,10.78,79.96,APC
Herpes simplex 1 ag if,87274,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.46,,,,,,,fee schedule,10.78,79.96,APC
Herpes simplex 1 ag if,87274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11.98,,,,,,,fee schedule,10.78,79.96,APC
Herpes simplex 1 ag if,87274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.33,,,,,,,fee schedule,10.78,79.96,Radiology
Herpes simplex 1 ag if,87274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.77,,,,,,,fee schedule,10.78,79.96,APC
Herpes simplex 1 ag if,87274,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20.96,,,,,,,fee schedule,10.78,79.96,APC
Influenza b ag if,87275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.23,,,,,,,fee schedule,11.02,66.23,
Influenza b ag if,87275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.09,,,,,,,fee schedule,11.02,66.23,
Influenza b ag if,87275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.99,,,,,,,fee schedule,11.02,66.23,
Influenza b ag if,87275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.97,,,,,,,fee schedule,11.02,66.23,
Influenza b ag if,87275,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.02,,,,,,,fee schedule,11.02,66.23,Laboratory
Influenza b ag if,87275,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.86,,,,,,,fee schedule,11.02,66.23,APC
Influenza b ag if,87275,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.74,,,,,,,fee schedule,11.02,66.23,APC
Influenza b ag if,87275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.25,,,,,,,fee schedule,11.02,66.23,APC
Influenza b ag if,87275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.74,,,,,,,fee schedule,11.02,66.23,Radiology
Influenza b ag if,87275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.15,,,,,,,fee schedule,11.02,66.23,APC
Influenza b ag if,87275,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21.44,,,,,,,fee schedule,11.02,66.23,APC
Influenza a ag if,87276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.23,,,,,,,fee schedule,14.46,66.23,
Influenza a ag if,87276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.09,,,,,,,fee schedule,14.46,66.23,
Influenza a ag if,87276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.99,,,,,,,fee schedule,14.46,66.23,
Influenza a ag if,87276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.97,,,,,,,fee schedule,14.46,66.23,
Influenza a ag if,87276,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.46,,,,,,,fee schedule,14.46,66.23,Laboratory
Influenza a ag if,87276,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.87,,,,,,,fee schedule,14.46,66.23,APC
Influenza a ag if,87276,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,16.71,,,,,,,fee schedule,14.46,66.23,APC
Influenza a ag if,87276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16.07,,,,,,,fee schedule,14.46,66.23,APC
Influenza a ag if,87276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24.59,,,,,,,fee schedule,14.46,66.23,Radiology
Influenza a ag if,87276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.5,,,,,,,fee schedule,14.46,66.23,APC
Influenza a ag if,87276,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,28.12,,,,,,,fee schedule,14.46,66.23,APC
Legion pneumophilia ag if,87278,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.23,,,,,,,fee schedule,14.04,66.23,
Legion pneumophilia ag if,87278,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.09,,,,,,,fee schedule,14.04,66.23,
Legion pneumophilia ag if,87278,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.99,,,,,,,fee schedule,14.04,66.23,
Legion pneumophilia ag if,87278,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.97,,,,,,,fee schedule,14.04,66.23,
Legion pneumophilia ag if,87278,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.04,,,,,,,fee schedule,14.04,66.23,Laboratory
Legion pneumophilia ag if,87278,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.38,,,,,,,fee schedule,14.04,66.23,APC
Legion pneumophilia ag if,87278,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,16.22,,,,,,,fee schedule,14.04,66.23,APC
Legion pneumophilia ag if,87278,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,15.6,,,,,,,fee schedule,14.04,66.23,APC
Legion pneumophilia ag if,87278,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.87,,,,,,,fee schedule,14.04,66.23,Radiology
Legion pneumophilia ag if,87278,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21.84,,,,,,,fee schedule,14.04,66.23,APC
Legion pneumophilia ag if,87278,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,27.3,,,,,,,fee schedule,14.04,66.23,APC
Parainfluenza ag if,87279,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.23,,,,,,,fee schedule,14.79,66.23,
Parainfluenza ag if,87279,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.09,,,,,,,fee schedule,14.79,66.23,
Parainfluenza ag if,87279,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.99,,,,,,,fee schedule,14.79,66.23,
Parainfluenza ag if,87279,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.97,,,,,,,fee schedule,14.79,66.23,
Parainfluenza ag if,87279,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.79,,,,,,,fee schedule,14.79,66.23,Laboratory
Parainfluenza ag if,87279,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.25,,,,,,,fee schedule,14.79,66.23,APC
Parainfluenza ag if,87279,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,17.09,,,,,,,fee schedule,14.79,66.23,APC
Parainfluenza ag if,87279,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16.43,,,,,,,fee schedule,14.79,66.23,APC
Parainfluenza ag if,87279,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.14,,,,,,,fee schedule,14.79,66.23,Radiology
Parainfluenza ag if,87279,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23,,,,,,,fee schedule,14.79,66.23,APC
Parainfluenza ag if,87279,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,28.75,,,,,,,fee schedule,14.79,66.23,APC
Respiratory syncytial ag if,87280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.23,,,,,,,fee schedule,12.08,66.23,
Respiratory syncytial ag if,87280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.09,,,,,,,fee schedule,12.08,66.23,
Respiratory syncytial ag if,87280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.99,,,,,,,fee schedule,12.08,66.23,
Respiratory syncytial ag if,87280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.97,,,,,,,fee schedule,12.08,66.23,
Respiratory syncytial ag if,87280,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.08,,,,,,,fee schedule,12.08,66.23,Laboratory
Respiratory syncytial ag if,87280,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.09,,,,,,,fee schedule,12.08,66.23,APC
Respiratory syncytial ag if,87280,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.96,,,,,,,fee schedule,12.08,66.23,APC
Respiratory syncytial ag if,87280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.42,,,,,,,fee schedule,12.08,66.23,APC
Respiratory syncytial ag if,87280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.53,,,,,,,fee schedule,12.08,66.23,Radiology
Respiratory syncytial ag if,87280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.79,,,,,,,fee schedule,12.08,66.23,APC
Respiratory syncytial ag if,87280,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23.48,,,,,,,fee schedule,12.08,66.23,APC
Pneumocystis carinii ag if,87281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.23,,,,,,,fee schedule,10.78,66.23,
Pneumocystis carinii ag if,87281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.09,,,,,,,fee schedule,10.78,66.23,
Pneumocystis carinii ag if,87281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.99,,,,,,,fee schedule,10.78,66.23,
Pneumocystis carinii ag if,87281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.97,,,,,,,fee schedule,10.78,66.23,
Pneumocystis carinii ag if,87281,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.78,,,,,,,fee schedule,10.78,66.23,Laboratory
Pneumocystis carinii ag if,87281,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.58,,,,,,,fee schedule,10.78,66.23,APC
Pneumocystis carinii ag if,87281,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.46,,,,,,,fee schedule,10.78,66.23,APC
Pneumocystis carinii ag if,87281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11.98,,,,,,,fee schedule,10.78,66.23,APC
Pneumocystis carinii ag if,87281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.33,,,,,,,fee schedule,10.78,66.23,Radiology
Pneumocystis carinii ag if,87281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.77,,,,,,,fee schedule,10.78,66.23,APC
Pneumocystis carinii ag if,87281,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20.96,,,,,,,fee schedule,10.78,66.23,APC
Rubeola ag if,87283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.23,,,,,,,fee schedule,53.09,106.4,
Rubeola ag if,87283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.09,,,,,,,fee schedule,53.09,106.4,
Rubeola ag if,87283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.99,,,,,,,fee schedule,53.09,106.4,
Rubeola ag if,87283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.97,,,,,,,fee schedule,53.09,106.4,
Rubeola ag if,87283,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,54.72,,,,,,,fee schedule,53.09,106.4,Laboratory
Rubeola ag if,87283,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,63.84,,,,,,,fee schedule,53.09,106.4,APC
Rubeola ag if,87283,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,63.23,,,,,,,fee schedule,53.09,106.4,APC
Rubeola ag if,87283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,60.8,,,,,,,fee schedule,53.09,106.4,APC
Rubeola ag if,87283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,93.02,,,,,,,fee schedule,53.09,106.4,Radiology
Rubeola ag if,87283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,85.12,,,,,,,fee schedule,53.09,106.4,APC
Rubeola ag if,87283,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,106.4,,,,,,,fee schedule,53.09,106.4,APC
Treponema pallidum ag if,87285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.23,,,,,,,fee schedule,10.96,66.23,
Treponema pallidum ag if,87285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.09,,,,,,,fee schedule,10.96,66.23,
Treponema pallidum ag if,87285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.99,,,,,,,fee schedule,10.96,66.23,
Treponema pallidum ag if,87285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.97,,,,,,,fee schedule,10.96,66.23,
Treponema pallidum ag if,87285,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.96,,,,,,,fee schedule,10.96,66.23,Laboratory
Treponema pallidum ag if,87285,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.79,,,,,,,fee schedule,10.96,66.23,APC
Treponema pallidum ag if,87285,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.67,,,,,,,fee schedule,10.96,66.23,APC
Treponema pallidum ag if,87285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.18,,,,,,,fee schedule,10.96,66.23,APC
Treponema pallidum ag if,87285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.64,,,,,,,fee schedule,10.96,66.23,Radiology
Treponema pallidum ag if,87285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.05,,,,,,,fee schedule,10.96,66.23,APC
Treponema pallidum ag if,87285,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21.32,,,,,,,fee schedule,10.96,66.23,APC
Varicella zoster ag if,87290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.23,,,,,,,fee schedule,12.08,66.23,
Varicella zoster ag if,87290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.09,,,,,,,fee schedule,12.08,66.23,
Varicella zoster ag if,87290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.99,,,,,,,fee schedule,12.08,66.23,
Varicella zoster ag if,87290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.97,,,,,,,fee schedule,12.08,66.23,
Varicella zoster ag if,87290,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.08,,,,,,,fee schedule,12.08,66.23,Laboratory
Varicella zoster ag if,87290,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.09,,,,,,,fee schedule,12.08,66.23,APC
Varicella zoster ag if,87290,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.96,,,,,,,fee schedule,12.08,66.23,APC
Varicella zoster ag if,87290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.42,,,,,,,fee schedule,12.08,66.23,APC
Varicella zoster ag if,87290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.53,,,,,,,fee schedule,12.08,66.23,Radiology
Varicella zoster ag if,87290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.79,,,,,,,fee schedule,12.08,66.23,APC
Varicella zoster ag if,87290,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23.48,,,,,,,fee schedule,12.08,66.23,APC
Antibody detection nos if,87299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.23,,,,,,,fee schedule,14.49,66.23,
Antibody detection nos if,87299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.09,,,,,,,fee schedule,14.49,66.23,
Antibody detection nos if,87299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.99,,,,,,,fee schedule,14.49,66.23,
Antibody detection nos if,87299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.97,,,,,,,fee schedule,14.49,66.23,
Antibody detection nos if,87299,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.49,,,,,,,fee schedule,14.49,66.23,Laboratory
Antibody detection nos if,87299,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.9,,,,,,,fee schedule,14.49,66.23,APC
Antibody detection nos if,87299,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,16.74,,,,,,,fee schedule,14.49,66.23,APC
Antibody detection nos if,87299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16.1,,,,,,,fee schedule,14.49,66.23,APC
Antibody detection nos if,87299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24.63,,,,,,,fee schedule,14.49,66.23,Radiology
Antibody detection nos if,87299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.54,,,,,,,fee schedule,14.49,66.23,APC
Antibody detection nos if,87299,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,28.18,,,,,,,fee schedule,14.49,66.23,APC
Ag detection polyval if,87300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.23,,,,,,,fee schedule,10.78,66.23,
Ag detection polyval if,87300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.09,,,,,,,fee schedule,10.78,66.23,
Ag detection polyval if,87300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.99,,,,,,,fee schedule,10.78,66.23,
Ag detection polyval if,87300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.97,,,,,,,fee schedule,10.78,66.23,
Ag detection polyval if,87300,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.78,,,,,,,fee schedule,10.78,66.23,Laboratory
Ag detection polyval if,87300,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.58,,,,,,,fee schedule,10.78,66.23,APC
Ag detection polyval if,87300,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.46,,,,,,,fee schedule,10.78,66.23,APC
Ag detection polyval if,87300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11.98,,,,,,,fee schedule,10.78,66.23,APC
Ag detection polyval if,87300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.33,,,,,,,fee schedule,10.78,66.23,Radiology
Ag detection polyval if,87300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.77,,,,,,,fee schedule,10.78,66.23,APC
Ag detection polyval if,87300,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20.96,,,,,,,fee schedule,10.78,66.23,APC
Adenovirus ag ia,87301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.23,,,,,,,fee schedule,10.78,66.23,
Adenovirus ag ia,87301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.09,,,,,,,fee schedule,10.78,66.23,
Adenovirus ag ia,87301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.99,,,,,,,fee schedule,10.78,66.23,
Adenovirus ag ia,87301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.97,,,,,,,fee schedule,10.78,66.23,
Adenovirus ag ia,87301,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.78,,,,,,,fee schedule,10.78,66.23,Laboratory
Adenovirus ag ia,87301,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.58,,,,,,,fee schedule,10.78,66.23,APC
Adenovirus ag ia,87301,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.46,,,,,,,fee schedule,10.78,66.23,APC
Adenovirus ag ia,87301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11.98,,,,,,,fee schedule,10.78,66.23,APC
Adenovirus ag ia,87301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.33,,,,,,,fee schedule,10.78,66.23,Radiology
Adenovirus ag ia,87301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.77,,,,,,,fee schedule,10.78,66.23,APC
Adenovirus ag ia,87301,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20.96,,,,,,,fee schedule,10.78,66.23,APC
Aspergillus ag ia,87305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.23,,,,,,,fee schedule,10.78,66.23,
Aspergillus ag ia,87305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.09,,,,,,,fee schedule,10.78,66.23,
Aspergillus ag ia,87305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.99,,,,,,,fee schedule,10.78,66.23,
Aspergillus ag ia,87305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.97,,,,,,,fee schedule,10.78,66.23,
Aspergillus ag ia,87305,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.78,,,,,,,fee schedule,10.78,66.23,Laboratory
Aspergillus ag ia,87305,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.58,,,,,,,fee schedule,10.78,66.23,APC
Aspergillus ag ia,87305,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.46,,,,,,,fee schedule,10.78,66.23,APC
Aspergillus ag ia,87305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11.98,,,,,,,fee schedule,10.78,66.23,APC
Aspergillus ag ia,87305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.33,,,,,,,fee schedule,10.78,66.23,Radiology
Aspergillus ag ia,87305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.77,,,,,,,fee schedule,10.78,66.23,APC
Aspergillus ag ia,87305,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20.96,,,,,,,fee schedule,10.78,66.23,APC
Chylmd trach ag ia,87320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.23,,,,,,,fee schedule,13.5,66.23,
Chylmd trach ag ia,87320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.09,,,,,,,fee schedule,13.5,66.23,
Chylmd trach ag ia,87320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.99,,,,,,,fee schedule,13.5,66.23,
Chylmd trach ag ia,87320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.97,,,,,,,fee schedule,13.5,66.23,
Chylmd trach ag ia,87320,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.5,,,,,,,fee schedule,13.5,66.23,Laboratory
Chylmd trach ag ia,87320,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.75,,,,,,,fee schedule,13.5,66.23,APC
Chylmd trach ag ia,87320,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,15.6,,,,,,,fee schedule,13.5,66.23,APC
Chylmd trach ag ia,87320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,15,,,,,,,fee schedule,13.5,66.23,APC
Chylmd trach ag ia,87320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.95,,,,,,,fee schedule,13.5,66.23,Radiology
Chylmd trach ag ia,87320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21,,,,,,,fee schedule,13.5,66.23,APC
Chylmd trach ag ia,87320,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,26.25,,,,,,,fee schedule,13.5,66.23,APC
Clostridium ag ia,87324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,111.8,,,,,,,fee schedule,10.78,111.8,
Clostridium ag ia,87324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,89.62,,,,,,,fee schedule,10.78,111.8,
Clostridium ag ia,87324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,97.9,,,,,,,fee schedule,10.78,111.8,
Clostridium ag ia,87324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,102.93,,,,,,,fee schedule,10.78,111.8,
Clostridium ag ia,87324,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.78,,,,,,,fee schedule,10.78,111.8,Laboratory
Clostridium ag ia,87324,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.58,,,,,,,fee schedule,10.78,111.8,APC
Clostridium ag ia,87324,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.46,,,,,,,fee schedule,10.78,111.8,APC
Clostridium ag ia,87324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11.98,,,,,,,fee schedule,10.78,111.8,APC
Clostridium ag ia,87324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.33,,,,,,,fee schedule,10.78,111.8,Radiology
Clostridium ag ia,87324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.77,,,,,,,fee schedule,10.78,111.8,APC
Clostridium ag ia,87324,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20.96,,,,,,,fee schedule,10.78,111.8,APC
Cryptococcus neoform ag ia,87327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,31.39,,,,,,,fee schedule,12.08,31.39,
Cryptococcus neoform ag ia,87327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,25.16,,,,,,,fee schedule,12.08,31.39,
Cryptococcus neoform ag ia,87327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,27.49,,,,,,,fee schedule,12.08,31.39,
Cryptococcus neoform ag ia,87327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,28.9,,,,,,,fee schedule,12.08,31.39,
Cryptococcus neoform ag ia,87327,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.08,,,,,,,fee schedule,12.08,31.39,Laboratory
Cryptococcus neoform ag ia,87327,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.09,,,,,,,fee schedule,12.08,31.39,APC
Cryptococcus neoform ag ia,87327,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.96,,,,,,,fee schedule,12.08,31.39,APC
Cryptococcus neoform ag ia,87327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.42,,,,,,,fee schedule,12.08,31.39,APC
Cryptococcus neoform ag ia,87327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.53,,,,,,,fee schedule,12.08,31.39,Radiology
Cryptococcus neoform ag ia,87327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.79,,,,,,,fee schedule,12.08,31.39,APC
Cryptococcus neoform ag ia,87327,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23.48,,,,,,,fee schedule,12.08,31.39,APC
Cryptosporidium ag ia,87328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,48.51,,,,,,,fee schedule,12.44,48.51,
Cryptosporidium ag ia,87328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38.88,,,,,,,fee schedule,12.44,48.51,
Cryptosporidium ag ia,87328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.48,,,,,,,fee schedule,12.44,48.51,
Cryptosporidium ag ia,87328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,44.66,,,,,,,fee schedule,12.44,48.51,
Cryptosporidium ag ia,87328,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.44,,,,,,,fee schedule,12.44,48.51,Laboratory
Cryptosporidium ag ia,87328,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.51,,,,,,,fee schedule,12.44,48.51,APC
Cryptosporidium ag ia,87328,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,14.37,,,,,,,fee schedule,12.44,48.51,APC
Cryptosporidium ag ia,87328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.82,,,,,,,fee schedule,12.44,48.51,APC
Cryptosporidium ag ia,87328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21.14,,,,,,,fee schedule,12.44,48.51,Radiology
Cryptosporidium ag ia,87328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.35,,,,,,,fee schedule,12.44,48.51,APC
Cryptosporidium ag ia,87328,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,24.18,,,,,,,fee schedule,12.44,48.51,APC
Giardia ag ia,87329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,50.87,,,,,,,fee schedule,10.78,50.87,
Giardia ag ia,87329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40.78,,,,,,,fee schedule,10.78,50.87,
Giardia ag ia,87329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,44.55,,,,,,,fee schedule,10.78,50.87,
Giardia ag ia,87329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46.83,,,,,,,fee schedule,10.78,50.87,
Giardia ag ia,87329,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.78,,,,,,,fee schedule,10.78,50.87,Laboratory
Giardia ag ia,87329,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.58,,,,,,,fee schedule,10.78,50.87,APC
Giardia ag ia,87329,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.46,,,,,,,fee schedule,10.78,50.87,APC
Giardia ag ia,87329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11.98,,,,,,,fee schedule,10.78,50.87,APC
Giardia ag ia,87329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.33,,,,,,,fee schedule,10.78,50.87,Radiology
Giardia ag ia,87329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.77,,,,,,,fee schedule,10.78,50.87,APC
Giardia ag ia,87329,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20.96,,,,,,,fee schedule,10.78,50.87,APC
Cytomegalovirus ag ia,87332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.23,,,,,,,fee schedule,10.78,66.23,
Cytomegalovirus ag ia,87332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.09,,,,,,,fee schedule,10.78,66.23,
Cytomegalovirus ag ia,87332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.99,,,,,,,fee schedule,10.78,66.23,
Cytomegalovirus ag ia,87332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.97,,,,,,,fee schedule,10.78,66.23,
Cytomegalovirus ag ia,87332,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.78,,,,,,,fee schedule,10.78,66.23,Laboratory
Cytomegalovirus ag ia,87332,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.58,,,,,,,fee schedule,10.78,66.23,APC
Cytomegalovirus ag ia,87332,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.46,,,,,,,fee schedule,10.78,66.23,APC
Cytomegalovirus ag ia,87332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11.98,,,,,,,fee schedule,10.78,66.23,APC
Cytomegalovirus ag ia,87332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.33,,,,,,,fee schedule,10.78,66.23,Radiology
Cytomegalovirus ag ia,87332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.77,,,,,,,fee schedule,10.78,66.23,APC
Cytomegalovirus ag ia,87332,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20.96,,,,,,,fee schedule,10.78,66.23,APC
E coli 0157 ag ia,87335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.23,,,,,,,fee schedule,11.39,66.23,
E coli 0157 ag ia,87335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.09,,,,,,,fee schedule,11.39,66.23,
E coli 0157 ag ia,87335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.99,,,,,,,fee schedule,11.39,66.23,
E coli 0157 ag ia,87335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.97,,,,,,,fee schedule,11.39,66.23,
E coli 0157 ag ia,87335,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.39,,,,,,,fee schedule,11.39,66.23,Laboratory
E coli 0157 ag ia,87335,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.29,,,,,,,fee schedule,11.39,66.23,APC
E coli 0157 ag ia,87335,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.17,,,,,,,fee schedule,11.39,66.23,APC
E coli 0157 ag ia,87335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.66,,,,,,,fee schedule,11.39,66.23,APC
E coli 0157 ag ia,87335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.37,,,,,,,fee schedule,11.39,66.23,Radiology
E coli 0157 ag ia,87335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.72,,,,,,,fee schedule,11.39,66.23,APC
E coli 0157 ag ia,87335,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22.16,,,,,,,fee schedule,11.39,66.23,APC
Entamoeb hist dispr ag ia,87336,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.23,,,,,,,fee schedule,14.4,66.23,
Entamoeb hist dispr ag ia,87336,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.09,,,,,,,fee schedule,14.4,66.23,
Entamoeb hist dispr ag ia,87336,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.99,,,,,,,fee schedule,14.4,66.23,
Entamoeb hist dispr ag ia,87336,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.97,,,,,,,fee schedule,14.4,66.23,
Entamoeb hist dispr ag ia,87336,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.4,,,,,,,fee schedule,14.4,66.23,Laboratory
Entamoeb hist dispr ag ia,87336,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.8,,,,,,,fee schedule,14.4,66.23,APC
Entamoeb hist dispr ag ia,87336,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,16.64,,,,,,,fee schedule,14.4,66.23,APC
Entamoeb hist dispr ag ia,87336,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16,,,,,,,fee schedule,14.4,66.23,APC
Entamoeb hist dispr ag ia,87336,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24.48,,,,,,,fee schedule,14.4,66.23,Radiology
Entamoeb hist dispr ag ia,87336,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.4,,,,,,,fee schedule,14.4,66.23,APC
Entamoeb hist dispr ag ia,87336,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,28,,,,,,,fee schedule,14.4,66.23,APC
Entamoeb hist group ag ia,87337,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,38.5,,,,,,,fee schedule,10.78,38.5,
Entamoeb hist group ag ia,87337,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,30.86,,,,,,,fee schedule,10.78,38.5,
Entamoeb hist group ag ia,87337,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,33.71,,,,,,,fee schedule,10.78,38.5,
Entamoeb hist group ag ia,87337,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,35.44,,,,,,,fee schedule,10.78,38.5,
Entamoeb hist group ag ia,87337,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.78,,,,,,,fee schedule,10.78,38.5,Laboratory
Entamoeb hist group ag ia,87337,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.58,,,,,,,fee schedule,10.78,38.5,APC
Entamoeb hist group ag ia,87337,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.46,,,,,,,fee schedule,10.78,38.5,APC
Entamoeb hist group ag ia,87337,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11.98,,,,,,,fee schedule,10.78,38.5,APC
Entamoeb hist group ag ia,87337,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.33,,,,,,,fee schedule,10.78,38.5,Radiology
Entamoeb hist group ag ia,87337,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.77,,,,,,,fee schedule,10.78,38.5,APC
Entamoeb hist group ag ia,87337,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20.96,,,,,,,fee schedule,10.78,38.5,APC
Hpylori stool ia,87338,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,28.78,,,,,,,fee schedule,12.94,28.78,
Hpylori stool ia,87338,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23.07,,,,,,,fee schedule,12.94,28.78,
Hpylori stool ia,87338,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,25.2,,,,,,,fee schedule,12.94,28.78,
Hpylori stool ia,87338,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26.5,,,,,,,fee schedule,12.94,28.78,
Hpylori stool ia,87338,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.94,,,,,,,fee schedule,12.94,28.78,Laboratory
Hpylori stool ia,87338,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.1,,,,,,,fee schedule,12.94,28.78,APC
Hpylori stool ia,87338,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,14.96,,,,,,,fee schedule,12.94,28.78,APC
Hpylori stool ia,87338,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14.38,,,,,,,fee schedule,12.94,28.78,APC
Hpylori stool ia,87338,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22,,,,,,,fee schedule,12.94,28.78,Radiology
Hpylori stool ia,87338,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.13,,,,,,,fee schedule,12.94,28.78,APC
Hpylori stool ia,87338,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,25.17,,,,,,,fee schedule,12.94,28.78,APC
H pylori ag ia,87339,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.23,,,,,,,fee schedule,14.4,66.23,
H pylori ag ia,87339,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.09,,,,,,,fee schedule,14.4,66.23,
H pylori ag ia,87339,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.99,,,,,,,fee schedule,14.4,66.23,
H pylori ag ia,87339,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.97,,,,,,,fee schedule,14.4,66.23,
H pylori ag ia,87339,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.4,,,,,,,fee schedule,14.4,66.23,Laboratory
H pylori ag ia,87339,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.8,,,,,,,fee schedule,14.4,66.23,APC
H pylori ag ia,87339,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,16.64,,,,,,,fee schedule,14.4,66.23,APC
H pylori ag ia,87339,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16,,,,,,,fee schedule,14.4,66.23,APC
H pylori ag ia,87339,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24.48,,,,,,,fee schedule,14.4,66.23,Radiology
H pylori ag ia,87339,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.4,,,,,,,fee schedule,14.4,66.23,APC
H pylori ag ia,87339,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,28,,,,,,,fee schedule,14.4,66.23,APC
Hepatitis b surface ag ia,87340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42.05,,,,,,,fee schedule,9.3,42.05,
Hepatitis b surface ag ia,87340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,33.71,,,,,,,fee schedule,9.3,42.05,
Hepatitis b surface ag ia,87340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36.83,,,,,,,fee schedule,9.3,42.05,
Hepatitis b surface ag ia,87340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,38.72,,,,,,,fee schedule,9.3,42.05,
Hepatitis b surface ag ia,87340,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.3,,,,,,,fee schedule,9.3,42.05,Laboratory
Hepatitis b surface ag ia,87340,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.85,,,,,,,fee schedule,9.3,42.05,APC
Hepatitis b surface ag ia,87340,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10.74,,,,,,,fee schedule,9.3,42.05,APC
Hepatitis b surface ag ia,87340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10.33,,,,,,,fee schedule,9.3,42.05,APC
Hepatitis b surface ag ia,87340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15.8,,,,,,,fee schedule,9.3,42.05,Radiology
Hepatitis b surface ag ia,87340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.46,,,,,,,fee schedule,9.3,42.05,APC
Hepatitis b surface ag ia,87340,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18.08,,,,,,,fee schedule,9.3,42.05,APC
Hepatitis b surface ag ia,87341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,57,,,,,,,fee schedule,9.3,57,
Hepatitis b surface ag ia,87341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,45.69,,,,,,,fee schedule,9.3,57,
Hepatitis b surface ag ia,87341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,49.91,,,,,,,fee schedule,9.3,57,
Hepatitis b surface ag ia,87341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,52.48,,,,,,,fee schedule,9.3,57,
Hepatitis b surface ag ia,87341,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.3,,,,,,,fee schedule,9.3,57,Laboratory
Hepatitis b surface ag ia,87341,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.85,,,,,,,fee schedule,9.3,57,APC
Hepatitis b surface ag ia,87341,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10.74,,,,,,,fee schedule,9.3,57,APC
Hepatitis b surface ag ia,87341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10.33,,,,,,,fee schedule,9.3,57,APC
Hepatitis b surface ag ia,87341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15.8,,,,,,,fee schedule,9.3,57,Radiology
Hepatitis b surface ag ia,87341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.46,,,,,,,fee schedule,9.3,57,APC
Hepatitis b surface ag ia,87341,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18.08,,,,,,,fee schedule,9.3,57,APC
Hepatitis be ag ia,87350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,36.28,,,,,,,fee schedule,10.38,36.28,
Hepatitis be ag ia,87350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29.08,,,,,,,fee schedule,10.38,36.28,
Hepatitis be ag ia,87350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31.77,,,,,,,fee schedule,10.38,36.28,
Hepatitis be ag ia,87350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33.4,,,,,,,fee schedule,10.38,36.28,
Hepatitis be ag ia,87350,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.38,,,,,,,fee schedule,10.38,36.28,Laboratory
Hepatitis be ag ia,87350,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.11,,,,,,,fee schedule,10.38,36.28,APC
Hepatitis be ag ia,87350,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11.99,,,,,,,fee schedule,10.38,36.28,APC
Hepatitis be ag ia,87350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11.53,,,,,,,fee schedule,10.38,36.28,APC
Hepatitis be ag ia,87350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.64,,,,,,,fee schedule,10.38,36.28,Radiology
Hepatitis be ag ia,87350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.14,,,,,,,fee schedule,10.38,36.28,APC
Hepatitis be ag ia,87350,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20.18,,,,,,,fee schedule,10.38,36.28,APC
Hepatitis delta ag ia,87380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,176.21,,,,,,,fee schedule,16.52,176.21,
Hepatitis delta ag ia,87380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,141.25,,,,,,,fee schedule,16.52,176.21,
Hepatitis delta ag ia,87380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,154.3,,,,,,,fee schedule,16.52,176.21,
Hepatitis delta ag ia,87380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,162.23,,,,,,,fee schedule,16.52,176.21,
Hepatitis delta ag ia,87380,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.52,,,,,,,fee schedule,16.52,176.21,Laboratory
Hepatitis delta ag ia,87380,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.28,,,,,,,fee schedule,16.52,176.21,APC
Hepatitis delta ag ia,87380,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,19.09,,,,,,,fee schedule,16.52,176.21,APC
Hepatitis delta ag ia,87380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18.36,,,,,,,fee schedule,16.52,176.21,APC
Hepatitis delta ag ia,87380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.09,,,,,,,fee schedule,16.52,176.21,Radiology
Hepatitis delta ag ia,87380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.7,,,,,,,fee schedule,16.52,176.21,APC
Hepatitis delta ag ia,87380,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,32.13,,,,,,,fee schedule,16.52,176.21,APC
Histoplasma capsul ag ia,87385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46.64,,,,,,,fee schedule,11.92,46.64,
Histoplasma capsul ag ia,87385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37.39,,,,,,,fee schedule,11.92,46.64,
Histoplasma capsul ag ia,87385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40.84,,,,,,,fee schedule,11.92,46.64,
Histoplasma capsul ag ia,87385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42.94,,,,,,,fee schedule,11.92,46.64,
Histoplasma capsul ag ia,87385,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.92,,,,,,,fee schedule,11.92,46.64,Laboratory
Histoplasma capsul ag ia,87385,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.91,,,,,,,fee schedule,11.92,46.64,APC
Histoplasma capsul ag ia,87385,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.78,,,,,,,fee schedule,11.92,46.64,APC
Histoplasma capsul ag ia,87385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.25,,,,,,,fee schedule,11.92,46.64,APC
Histoplasma capsul ag ia,87385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.27,,,,,,,fee schedule,11.92,46.64,Radiology
Histoplasma capsul ag ia,87385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.55,,,,,,,fee schedule,11.92,46.64,APC
Histoplasma capsul ag ia,87385,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23.19,,,,,,,fee schedule,11.92,46.64,APC
Hiv-1 ag w/hiv-1 & hiv-2 ab,87389,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,91.67,,,,,,,fee schedule,21.67,91.67,
Hiv-1 ag w/hiv-1 & hiv-2 ab,87389,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,73.48,,,,,,,fee schedule,21.67,91.67,
Hiv-1 ag w/hiv-1 & hiv-2 ab,87389,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,80.27,,,,,,,fee schedule,21.67,91.67,
Hiv-1 ag w/hiv-1 & hiv-2 ab,87389,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,84.39,,,,,,,fee schedule,21.67,91.67,
Hiv-1 ag w/hiv-1 & hiv-2 ab,87389,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21.67,,,,,,,fee schedule,21.67,91.67,Laboratory
Hiv-1 ag w/hiv-1 & hiv-2 ab,87389,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,25.28,,,,,,,fee schedule,21.67,91.67,APC
Hiv-1 ag w/hiv-1 & hiv-2 ab,87389,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,25.04,,,,,,,fee schedule,21.67,91.67,APC
Hiv-1 ag w/hiv-1 & hiv-2 ab,87389,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,24.08,,,,,,,fee schedule,21.67,91.67,APC
Hiv-1 ag w/hiv-1 & hiv-2 ab,87389,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,36.84,,,,,,,fee schedule,21.67,91.67,Radiology
Hiv-1 ag w/hiv-1 & hiv-2 ab,87389,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,33.71,,,,,,,fee schedule,21.67,91.67,APC
Hiv-1 ag w/hiv-1 & hiv-2 ab,87389,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,42.14,,,,,,,fee schedule,21.67,91.67,APC
Hiv-1 ag ia,87390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,97.37,,,,,,,fee schedule,21.65,97.37,
Hiv-1 ag ia,87390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,78.05,,,,,,,fee schedule,21.65,97.37,
Hiv-1 ag ia,87390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,85.27,,,,,,,fee schedule,21.65,97.37,
Hiv-1 ag ia,87390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,89.64,,,,,,,fee schedule,21.65,97.37,
Hiv-1 ag ia,87390,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21.65,,,,,,,fee schedule,21.65,97.37,Laboratory
Hiv-1 ag ia,87390,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,25.26,,,,,,,fee schedule,21.65,97.37,APC
Hiv-1 ag ia,87390,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,25.02,,,,,,,fee schedule,21.65,97.37,APC
Hiv-1 ag ia,87390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,24.06,,,,,,,fee schedule,21.65,97.37,APC
Hiv-1 ag ia,87390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,36.81,,,,,,,fee schedule,21.65,97.37,Radiology
Hiv-1 ag ia,87390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,33.68,,,,,,,fee schedule,21.65,97.37,APC
Hiv-1 ag ia,87390,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,42.1,,,,,,,fee schedule,21.65,97.37,APC
Hiv-2 ag ia,87391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,97.37,,,,,,,fee schedule,19.71,97.37,
Hiv-2 ag ia,87391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,78.05,,,,,,,fee schedule,19.71,97.37,
Hiv-2 ag ia,87391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,85.27,,,,,,,fee schedule,19.71,97.37,
Hiv-2 ag ia,87391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,89.64,,,,,,,fee schedule,19.71,97.37,
Hiv-2 ag ia,87391,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.71,,,,,,,fee schedule,19.71,97.37,Laboratory
Hiv-2 ag ia,87391,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,23,,,,,,,fee schedule,19.71,97.37,APC
Hiv-2 ag ia,87391,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,22.78,,,,,,,fee schedule,19.71,97.37,APC
Hiv-2 ag ia,87391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,21.9,,,,,,,fee schedule,19.71,97.37,APC
Hiv-2 ag ia,87391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,33.51,,,,,,,fee schedule,19.71,97.37,Radiology
Hiv-2 ag ia,87391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,30.66,,,,,,,fee schedule,19.71,97.37,APC
Hiv-2 ag ia,87391,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,38.32,,,,,,,fee schedule,19.71,97.37,APC
Influenza a/b ag ia,87400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.23,,,,,,,fee schedule,12.72,66.23,
Influenza a/b ag ia,87400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.09,,,,,,,fee schedule,12.72,66.23,
Influenza a/b ag ia,87400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.99,,,,,,,fee schedule,12.72,66.23,
Influenza a/b ag ia,87400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.97,,,,,,,fee schedule,12.72,66.23,
Influenza a/b ag ia,87400,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.72,,,,,,,fee schedule,12.72,66.23,Laboratory
Influenza a/b ag ia,87400,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.84,,,,,,,fee schedule,12.72,66.23,APC
Influenza a/b ag ia,87400,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,14.7,,,,,,,fee schedule,12.72,66.23,APC
Influenza a/b ag ia,87400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14.13,,,,,,,fee schedule,12.72,66.23,APC
Influenza a/b ag ia,87400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21.62,,,,,,,fee schedule,12.72,66.23,Radiology
Influenza a/b ag ia,87400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.78,,,,,,,fee schedule,12.72,66.23,APC
Influenza a/b ag ia,87400,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,24.73,,,,,,,fee schedule,12.72,66.23,APC
Resp syncytial ag ia,87420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.23,,,,,,,fee schedule,12.52,66.23,
Resp syncytial ag ia,87420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.09,,,,,,,fee schedule,12.52,66.23,
Resp syncytial ag ia,87420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.99,,,,,,,fee schedule,12.52,66.23,
Resp syncytial ag ia,87420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.97,,,,,,,fee schedule,12.52,66.23,
Resp syncytial ag ia,87420,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.52,,,,,,,fee schedule,12.52,66.23,Laboratory
Resp syncytial ag ia,87420,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.61,,,,,,,fee schedule,12.52,66.23,APC
Resp syncytial ag ia,87420,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,14.47,,,,,,,fee schedule,12.52,66.23,APC
Resp syncytial ag ia,87420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.91,,,,,,,fee schedule,12.52,66.23,APC
Resp syncytial ag ia,87420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21.28,,,,,,,fee schedule,12.52,66.23,Radiology
Resp syncytial ag ia,87420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.47,,,,,,,fee schedule,12.52,66.23,APC
Resp syncytial ag ia,87420,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,24.34,,,,,,,fee schedule,12.52,66.23,APC
Rotavirus ag ia,87425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33.32,,,,,,,fee schedule,10.78,33.32,
Rotavirus ag ia,87425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26.71,,,,,,,fee schedule,10.78,33.32,
Rotavirus ag ia,87425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29.17,,,,,,,fee schedule,10.78,33.32,
Rotavirus ag ia,87425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30.67,,,,,,,fee schedule,10.78,33.32,
Rotavirus ag ia,87425,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.78,,,,,,,fee schedule,10.78,33.32,Laboratory
Rotavirus ag ia,87425,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.58,,,,,,,fee schedule,10.78,33.32,APC
Rotavirus ag ia,87425,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.46,,,,,,,fee schedule,10.78,33.32,APC
Rotavirus ag ia,87425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11.98,,,,,,,fee schedule,10.78,33.32,APC
Rotavirus ag ia,87425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.33,,,,,,,fee schedule,10.78,33.32,Radiology
Rotavirus ag ia,87425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.77,,,,,,,fee schedule,10.78,33.32,APC
Rotavirus ag ia,87425,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20.96,,,,,,,fee schedule,10.78,33.32,APC
Coronavirus ag ia,87426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,170.97,,,,,,,fee schedule,31.8,170.97,
Coronavirus ag ia,87426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,137.05,,,,,,,fee schedule,31.8,170.97,
Coronavirus ag ia,87426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,149.71,,,,,,,fee schedule,31.8,170.97,
Coronavirus ag ia,87426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,157.4,,,,,,,fee schedule,31.8,170.97,
Coronavirus ag ia,87426,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31.8,,,,,,,fee schedule,31.8,170.97,Laboratory
Coronavirus ag ia,87426,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,37.1,,,,,,,fee schedule,31.8,170.97,APC
Coronavirus ag ia,87426,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,36.74,,,,,,,fee schedule,31.8,170.97,APC
Coronavirus ag ia,87426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,35.33,,,,,,,fee schedule,31.8,170.97,APC
Coronavirus ag ia,87426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,54.05,,,,,,,fee schedule,31.8,170.97,Radiology
Coronavirus ag ia,87426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49.46,,,,,,,fee schedule,31.8,170.97,APC
Coronavirus ag ia,87426,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,61.83,,,,,,,fee schedule,31.8,170.97,APC
Shiga-like toxin ag ia,87427,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30.07,,,,,,,fee schedule,10.78,30.07,
Shiga-like toxin ag ia,87427,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24.1,,,,,,,fee schedule,10.78,30.07,
Shiga-like toxin ag ia,87427,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26.33,,,,,,,fee schedule,10.78,30.07,
Shiga-like toxin ag ia,87427,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27.68,,,,,,,fee schedule,10.78,30.07,
Shiga-like toxin ag ia,87427,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.78,,,,,,,fee schedule,10.78,30.07,Laboratory
Shiga-like toxin ag ia,87427,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.58,,,,,,,fee schedule,10.78,30.07,APC
Shiga-like toxin ag ia,87427,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.46,,,,,,,fee schedule,10.78,30.07,APC
Shiga-like toxin ag ia,87427,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11.98,,,,,,,fee schedule,10.78,30.07,APC
Shiga-like toxin ag ia,87427,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.33,,,,,,,fee schedule,10.78,30.07,Radiology
Shiga-like toxin ag ia,87427,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.77,,,,,,,fee schedule,10.78,30.07,APC
Shiga-like toxin ag ia,87427,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20.96,,,,,,,fee schedule,10.78,30.07,APC
Sarscov & inf vir a&b ag ia,87428,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.23,,,,,,,fee schedule,53.09,123.01,
Sarscov & inf vir a&b ag ia,87428,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.09,,,,,,,fee schedule,53.09,123.01,
Sarscov & inf vir a&b ag ia,87428,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.99,,,,,,,fee schedule,53.09,123.01,
Sarscov & inf vir a&b ag ia,87428,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.97,,,,,,,fee schedule,53.09,123.01,
Sarscov & inf vir a&b ag ia,87428,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,63.26,,,,,,,fee schedule,53.09,123.01,Laboratory
Sarscov & inf vir a&b ag ia,87428,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,73.8,,,,,,,fee schedule,53.09,123.01,APC
Sarscov & inf vir a&b ag ia,87428,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,73.1,,,,,,,fee schedule,53.09,123.01,APC
Sarscov & inf vir a&b ag ia,87428,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,70.29,,,,,,,fee schedule,53.09,123.01,APC
Sarscov & inf vir a&b ag ia,87428,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,107.54,,,,,,,fee schedule,53.09,123.01,Radiology
Sarscov & inf vir a&b ag ia,87428,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,98.41,,,,,,,fee schedule,53.09,123.01,APC
Sarscov & inf vir a&b ag ia,87428,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,123.01,,,,,,,fee schedule,53.09,123.01,APC
Strep a ag ia,87430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,63.49,,,,,,,fee schedule,15.13,63.49,
Strep a ag ia,87430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,50.89,,,,,,,fee schedule,15.13,63.49,
Strep a ag ia,87430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55.59,,,,,,,fee schedule,15.13,63.49,
Strep a ag ia,87430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,58.45,,,,,,,fee schedule,15.13,63.49,
Strep a ag ia,87430,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.13,,,,,,,fee schedule,15.13,63.49,Laboratory
Strep a ag ia,87430,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.65,,,,,,,fee schedule,15.13,63.49,APC
Strep a ag ia,87430,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,17.48,,,,,,,fee schedule,15.13,63.49,APC
Strep a ag ia,87430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16.81,,,,,,,fee schedule,15.13,63.49,APC
Strep a ag ia,87430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.72,,,,,,,fee schedule,15.13,63.49,Radiology
Strep a ag ia,87430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.53,,,,,,,fee schedule,15.13,63.49,APC
Strep a ag ia,87430,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,29.42,,,,,,,fee schedule,15.13,63.49,APC
Ag detect nos ia mult,87449,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37.49,,,,,,,fee schedule,10.78,37.49,
Ag detect nos ia mult,87449,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,30.05,,,,,,,fee schedule,10.78,37.49,
Ag detect nos ia mult,87449,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32.82,,,,,,,fee schedule,10.78,37.49,
Ag detect nos ia mult,87449,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,34.51,,,,,,,fee schedule,10.78,37.49,
Ag detect nos ia mult,87449,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.78,,,,,,,fee schedule,10.78,37.49,Laboratory
Ag detect nos ia mult,87449,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.58,,,,,,,fee schedule,10.78,37.49,APC
Ag detect nos ia mult,87449,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.46,,,,,,,fee schedule,10.78,37.49,APC
Ag detect nos ia mult,87449,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11.98,,,,,,,fee schedule,10.78,37.49,APC
Ag detect nos ia mult,87449,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.33,,,,,,,fee schedule,10.78,37.49,Radiology
Ag detect nos ia mult,87449,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.77,,,,,,,fee schedule,10.78,37.49,APC
Ag detect nos ia mult,87449,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20.96,,,,,,,fee schedule,10.78,37.49,APC
Ag detect polyval ia mult,87451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,52.88,,,,,,,fee schedule,9.46,52.88,
Ag detect polyval ia mult,87451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.39,,,,,,,fee schedule,9.46,52.88,
Ag detect polyval ia mult,87451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.31,,,,,,,fee schedule,9.46,52.88,
Ag detect polyval ia mult,87451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,48.69,,,,,,,fee schedule,9.46,52.88,
Ag detect polyval ia mult,87451,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.46,,,,,,,fee schedule,9.46,52.88,Laboratory
Ag detect polyval ia mult,87451,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.04,,,,,,,fee schedule,9.46,52.88,APC
Ag detect polyval ia mult,87451,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10.93,,,,,,,fee schedule,9.46,52.88,APC
Ag detect polyval ia mult,87451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10.51,,,,,,,fee schedule,9.46,52.88,APC
Ag detect polyval ia mult,87451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.08,,,,,,,fee schedule,9.46,52.88,Radiology
Ag detect polyval ia mult,87451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.71,,,,,,,fee schedule,9.46,52.88,APC
Ag detect polyval ia mult,87451,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18.39,,,,,,,fee schedule,9.46,52.88,APC
Hepatitis b surface ag quan,87467,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22.79,,,,,,,fee schedule,22.79,44.31,Laboratory
Hepatitis b surface ag quan,87467,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,26.59,,,,,,,fee schedule,22.79,44.31,APC
Hepatitis b surface ag quan,87467,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,26.33,,,,,,,fee schedule,22.79,44.31,APC
Hepatitis b surface ag quan,87467,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,25.32,,,,,,,fee schedule,22.79,44.31,APC
Hepatitis b surface ag quan,87467,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,38.74,,,,,,,fee schedule,22.79,44.31,Radiology
Hepatitis b surface ag quan,87467,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,35.45,,,,,,,fee schedule,22.79,44.31,APC
Hepatitis b surface ag quan,87467,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,44.31,,,,,,,fee schedule,22.79,44.31,APC
Anaplsma phgcytophlm amp prb,87468,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31.58,,,,,,,fee schedule,31.58,61.41,Laboratory
Anaplsma phgcytophlm amp prb,87468,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,31.58,61.41,APC
Anaplsma phgcytophlm amp prb,87468,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,36.49,,,,,,,fee schedule,31.58,61.41,APC
Anaplsma phgcytophlm amp prb,87468,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,35.09,,,,,,,fee schedule,31.58,61.41,APC
Anaplsma phgcytophlm amp prb,87468,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,53.69,,,,,,,fee schedule,31.58,61.41,Radiology
Anaplsma phgcytophlm amp prb,87468,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49.13,,,,,,,fee schedule,31.58,61.41,APC
Anaplsma phgcytophlm amp prb,87468,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,61.41,,,,,,,fee schedule,31.58,61.41,APC
Babesia microti amp prb,87469,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31.58,,,,,,,fee schedule,31.58,61.41,Laboratory
Babesia microti amp prb,87469,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,31.58,61.41,APC
Babesia microti amp prb,87469,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,36.49,,,,,,,fee schedule,31.58,61.41,APC
Babesia microti amp prb,87469,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,35.09,,,,,,,fee schedule,31.58,61.41,APC
Babesia microti amp prb,87469,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,53.69,,,,,,,fee schedule,31.58,61.41,Radiology
Babesia microti amp prb,87469,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49.13,,,,,,,fee schedule,31.58,61.41,APC
Babesia microti amp prb,87469,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,61.41,,,,,,,fee schedule,31.58,61.41,APC
Bartonella dna amp probe,87471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,193.73,,,,,,,fee schedule,31.58,193.73,
Bartonella dna amp probe,87471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,155.29,,,,,,,fee schedule,31.58,193.73,
Bartonella dna amp probe,87471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,169.64,,,,,,,fee schedule,31.58,193.73,
Bartonella dna amp probe,87471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,178.35,,,,,,,fee schedule,31.58,193.73,
Bartonella dna amp probe,87471,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31.58,,,,,,,fee schedule,31.58,193.73,Laboratory
Bartonella dna amp probe,87471,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,31.58,193.73,APC
Bartonella dna amp probe,87471,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,36.49,,,,,,,fee schedule,31.58,193.73,APC
Bartonella dna amp probe,87471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,35.09,,,,,,,fee schedule,31.58,193.73,APC
Bartonella dna amp probe,87471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,53.69,,,,,,,fee schedule,31.58,193.73,Radiology
Bartonella dna amp probe,87471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49.13,,,,,,,fee schedule,31.58,193.73,APC
Bartonella dna amp probe,87471,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,61.41,,,,,,,fee schedule,31.58,193.73,APC
Bartonella dna quant,87472,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,236.4,,,,,,,fee schedule,38.56,236.4,
Bartonella dna quant,87472,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,189.5,,,,,,,fee schedule,38.56,236.4,
Bartonella dna quant,87472,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,207.01,,,,,,,fee schedule,38.56,236.4,
Bartonella dna quant,87472,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,217.64,,,,,,,fee schedule,38.56,236.4,
Bartonella dna quant,87472,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,38.56,,,,,,,fee schedule,38.56,236.4,Laboratory
Bartonella dna quant,87472,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,44.98,,,,,,,fee schedule,38.56,236.4,APC
Bartonella dna quant,87472,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,44.55,,,,,,,fee schedule,38.56,236.4,APC
Bartonella dna quant,87472,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,42.84,,,,,,,fee schedule,38.56,236.4,APC
Bartonella dna quant,87472,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,65.55,,,,,,,fee schedule,38.56,236.4,Radiology
Bartonella dna quant,87472,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,59.98,,,,,,,fee schedule,38.56,236.4,APC
Bartonella dna quant,87472,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,74.97,,,,,,,fee schedule,38.56,236.4,APC
Lyme dis dna dir probe,87475,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,110.64,,,,,,,fee schedule,18.05,110.64,
Lyme dis dna dir probe,87475,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,88.69,,,,,,,fee schedule,18.05,110.64,
Lyme dis dna dir probe,87475,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,96.88,,,,,,,fee schedule,18.05,110.64,
Lyme dis dna dir probe,87475,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,101.86,,,,,,,fee schedule,18.05,110.64,
Lyme dis dna dir probe,87475,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.05,,,,,,,fee schedule,18.05,110.64,Laboratory
Lyme dis dna dir probe,87475,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.05,,,,,,,fee schedule,18.05,110.64,APC
Lyme dis dna dir probe,87475,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,20.85,,,,,,,fee schedule,18.05,110.64,APC
Lyme dis dna dir probe,87475,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,20.05,,,,,,,fee schedule,18.05,110.64,APC
Lyme dis dna dir probe,87475,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,30.68,,,,,,,fee schedule,18.05,110.64,Radiology
Lyme dis dna dir probe,87475,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.07,,,,,,,fee schedule,18.05,110.64,APC
Lyme dis dna dir probe,87475,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,35.09,,,,,,,fee schedule,18.05,110.64,APC
Lyme dis dna amp probe,87476,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,135.49,,,,,,,fee schedule,31.58,135.49,
Lyme dis dna amp probe,87476,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,108.61,,,,,,,fee schedule,31.58,135.49,
Lyme dis dna amp probe,87476,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,118.64,,,,,,,fee schedule,31.58,135.49,
Lyme dis dna amp probe,87476,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,124.74,,,,,,,fee schedule,31.58,135.49,
Lyme dis dna amp probe,87476,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31.58,,,,,,,fee schedule,31.58,135.49,Laboratory
Lyme dis dna amp probe,87476,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,31.58,135.49,APC
Lyme dis dna amp probe,87476,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,36.49,,,,,,,fee schedule,31.58,135.49,APC
Lyme dis dna amp probe,87476,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,35.09,,,,,,,fee schedule,31.58,135.49,APC
Lyme dis dna amp probe,87476,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,53.69,,,,,,,fee schedule,31.58,135.49,Radiology
Lyme dis dna amp probe,87476,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49.13,,,,,,,fee schedule,31.58,135.49,APC
Lyme dis dna amp probe,87476,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,61.41,,,,,,,fee schedule,31.58,135.49,APC
Borrelia miyamotoi amp prb,87478,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31.58,,,,,,,fee schedule,31.58,61.41,Laboratory
Borrelia miyamotoi amp prb,87478,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,31.58,61.41,APC
Borrelia miyamotoi amp prb,87478,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,36.49,,,,,,,fee schedule,31.58,61.41,APC
Borrelia miyamotoi amp prb,87478,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,35.09,,,,,,,fee schedule,31.58,61.41,APC
Borrelia miyamotoi amp prb,87478,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,53.69,,,,,,,fee schedule,31.58,61.41,Radiology
Borrelia miyamotoi amp prb,87478,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49.13,,,,,,,fee schedule,31.58,61.41,APC
Borrelia miyamotoi amp prb,87478,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,61.41,,,,,,,fee schedule,31.58,61.41,APC
Candida dna dir probe,87480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,63.29,,,,,,,fee schedule,18.05,63.29,
Candida dna dir probe,87480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,50.73,,,,,,,fee schedule,18.05,63.29,
Candida dna dir probe,87480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55.42,,,,,,,fee schedule,18.05,63.29,
Candida dna dir probe,87480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,58.26,,,,,,,fee schedule,18.05,63.29,
Candida dna dir probe,87480,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.05,,,,,,,fee schedule,18.05,63.29,Laboratory
Candida dna dir probe,87480,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.05,,,,,,,fee schedule,18.05,63.29,APC
Candida dna dir probe,87480,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,20.85,,,,,,,fee schedule,18.05,63.29,APC
Candida dna dir probe,87480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,20.05,,,,,,,fee schedule,18.05,63.29,APC
Candida dna dir probe,87480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,30.68,,,,,,,fee schedule,18.05,63.29,Radiology
Candida dna dir probe,87480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.07,,,,,,,fee schedule,18.05,63.29,APC
Candida dna dir probe,87480,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,35.09,,,,,,,fee schedule,18.05,63.29,APC
Candida dna amp probe,87481,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,193.73,,,,,,,fee schedule,31.58,193.73,
Candida dna amp probe,87481,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,155.29,,,,,,,fee schedule,31.58,193.73,
Candida dna amp probe,87481,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,169.64,,,,,,,fee schedule,31.58,193.73,
Candida dna amp probe,87481,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,178.35,,,,,,,fee schedule,31.58,193.73,
Candida dna amp probe,87481,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31.58,,,,,,,fee schedule,31.58,193.73,Laboratory
Candida dna amp probe,87481,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,31.58,193.73,APC
Candida dna amp probe,87481,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,36.49,,,,,,,fee schedule,31.58,193.73,APC
Candida dna amp probe,87481,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,35.09,,,,,,,fee schedule,31.58,193.73,APC
Candida dna amp probe,87481,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,53.69,,,,,,,fee schedule,31.58,193.73,Radiology
Candida dna amp probe,87481,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49.13,,,,,,,fee schedule,31.58,193.73,APC
Candida dna amp probe,87481,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,61.41,,,,,,,fee schedule,31.58,193.73,APC
Candida dna quant,87482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,88.49,,,,,,,fee schedule,50.17,97.54,
Candida dna quant,87482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,70.93,,,,,,,fee schedule,50.17,97.54,
Candida dna quant,87482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,77.49,,,,,,,fee schedule,50.17,97.54,
Candida dna quant,87482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,81.47,,,,,,,fee schedule,50.17,97.54,
Candida dna quant,87482,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,50.17,,,,,,,fee schedule,50.17,97.54,Laboratory
Candida dna quant,87482,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,58.53,,,,,,,fee schedule,50.17,97.54,APC
Candida dna quant,87482,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,57.97,,,,,,,fee schedule,50.17,97.54,APC
Candida dna quant,87482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,55.74,,,,,,,fee schedule,50.17,97.54,APC
Candida dna quant,87482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,85.28,,,,,,,fee schedule,50.17,97.54,Radiology
Candida dna quant,87482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,78.04,,,,,,,fee schedule,50.17,97.54,APC
Candida dna quant,87482,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,97.54,,,,,,,fee schedule,50.17,97.54,APC
Cns dna amp probe type 12-25,87483,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2161.1,,,,,,,fee schedule,375.1,2161.1,
Cns dna amp probe type 12-25,87483,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1732.31,,,,,,,fee schedule,375.1,2161.1,
Cns dna amp probe type 12-25,87483,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1892.39,,,,,,,fee schedule,375.1,2161.1,
Cns dna amp probe type 12-25,87483,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1989.59,,,,,,,fee schedule,375.1,2161.1,
Cns dna amp probe type 12-25,87483,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,375.1,,,,,,,fee schedule,375.1,2161.1,Laboratory
Cns dna amp probe type 12-25,87483,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,437.62,,,,,,,fee schedule,375.1,2161.1,APC
Cns dna amp probe type 12-25,87483,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,433.45,,,,,,,fee schedule,375.1,2161.1,APC
Cns dna amp probe type 12-25,87483,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,416.78,,,,,,,fee schedule,375.1,2161.1,APC
Cns dna amp probe type 12-25,87483,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,637.67,,,,,,,fee schedule,375.1,2161.1,Radiology
Cns dna amp probe type 12-25,87483,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,583.49,,,,,,,fee schedule,375.1,2161.1,APC
Cns dna amp probe type 12-25,87483,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,729.36,,,,,,,fee schedule,375.1,2161.1,APC
Ehrlicha chaffeensis amp prb,87484,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31.58,,,,,,,fee schedule,31.58,61.41,Laboratory
Ehrlicha chaffeensis amp prb,87484,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,31.58,61.41,APC
Ehrlicha chaffeensis amp prb,87484,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,36.49,,,,,,,fee schedule,31.58,61.41,APC
Ehrlicha chaffeensis amp prb,87484,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,35.09,,,,,,,fee schedule,31.58,61.41,APC
Ehrlicha chaffeensis amp prb,87484,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,53.69,,,,,,,fee schedule,31.58,61.41,Radiology
Ehrlicha chaffeensis amp prb,87484,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49.13,,,,,,,fee schedule,31.58,61.41,APC
Ehrlicha chaffeensis amp prb,87484,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,61.41,,,,,,,fee schedule,31.58,61.41,APC
Chylmd pneum dna dir probe,87485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,110.64,,,,,,,fee schedule,18.05,110.64,
Chylmd pneum dna dir probe,87485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,88.69,,,,,,,fee schedule,18.05,110.64,
Chylmd pneum dna dir probe,87485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,96.88,,,,,,,fee schedule,18.05,110.64,
Chylmd pneum dna dir probe,87485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,101.86,,,,,,,fee schedule,18.05,110.64,
Chylmd pneum dna dir probe,87485,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.05,,,,,,,fee schedule,18.05,110.64,Laboratory
Chylmd pneum dna dir probe,87485,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.05,,,,,,,fee schedule,18.05,110.64,APC
Chylmd pneum dna dir probe,87485,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,20.85,,,,,,,fee schedule,18.05,110.64,APC
Chylmd pneum dna dir probe,87485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,20.05,,,,,,,fee schedule,18.05,110.64,APC
Chylmd pneum dna dir probe,87485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,30.68,,,,,,,fee schedule,18.05,110.64,Radiology
Chylmd pneum dna dir probe,87485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.07,,,,,,,fee schedule,18.05,110.64,APC
Chylmd pneum dna dir probe,87485,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,35.09,,,,,,,fee schedule,18.05,110.64,APC
Chylmd pneum dna amp probe,87486,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,193.73,,,,,,,fee schedule,31.58,193.73,
Chylmd pneum dna amp probe,87486,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,155.29,,,,,,,fee schedule,31.58,193.73,
Chylmd pneum dna amp probe,87486,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,169.64,,,,,,,fee schedule,31.58,193.73,
Chylmd pneum dna amp probe,87486,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,178.35,,,,,,,fee schedule,31.58,193.73,
Chylmd pneum dna amp probe,87486,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31.58,,,,,,,fee schedule,31.58,193.73,Laboratory
Chylmd pneum dna amp probe,87486,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,31.58,193.73,APC
Chylmd pneum dna amp probe,87486,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,36.49,,,,,,,fee schedule,31.58,193.73,APC
Chylmd pneum dna amp probe,87486,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,35.09,,,,,,,fee schedule,31.58,193.73,APC
Chylmd pneum dna amp probe,87486,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,53.69,,,,,,,fee schedule,31.58,193.73,Radiology
Chylmd pneum dna amp probe,87486,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49.13,,,,,,,fee schedule,31.58,193.73,APC
Chylmd pneum dna amp probe,87486,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,61.41,,,,,,,fee schedule,31.58,193.73,APC
Chylmd pneum dna quant,87487,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,236.4,,,,,,,fee schedule,38.56,236.4,
Chylmd pneum dna quant,87487,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,189.5,,,,,,,fee schedule,38.56,236.4,
Chylmd pneum dna quant,87487,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,207.01,,,,,,,fee schedule,38.56,236.4,
Chylmd pneum dna quant,87487,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,217.64,,,,,,,fee schedule,38.56,236.4,
Chylmd pneum dna quant,87487,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,38.56,,,,,,,fee schedule,38.56,236.4,Laboratory
Chylmd pneum dna quant,87487,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,44.98,,,,,,,fee schedule,38.56,236.4,APC
Chylmd pneum dna quant,87487,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,44.55,,,,,,,fee schedule,38.56,236.4,APC
Chylmd pneum dna quant,87487,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,42.84,,,,,,,fee schedule,38.56,236.4,APC
Chylmd pneum dna quant,87487,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,65.55,,,,,,,fee schedule,38.56,236.4,Radiology
Chylmd pneum dna quant,87487,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,59.98,,,,,,,fee schedule,38.56,236.4,APC
Chylmd pneum dna quant,87487,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,74.97,,,,,,,fee schedule,38.56,236.4,APC
Chylmd trach dna dir probe,87490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,110.64,,,,,,,fee schedule,20.48,110.64,
Chylmd trach dna dir probe,87490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,88.69,,,,,,,fee schedule,20.48,110.64,
Chylmd trach dna dir probe,87490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,96.88,,,,,,,fee schedule,20.48,110.64,
Chylmd trach dna dir probe,87490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,101.86,,,,,,,fee schedule,20.48,110.64,
Chylmd trach dna dir probe,87490,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,20.48,,,,,,,fee schedule,20.48,110.64,Laboratory
Chylmd trach dna dir probe,87490,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,23.89,,,,,,,fee schedule,20.48,110.64,APC
Chylmd trach dna dir probe,87490,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,23.66,,,,,,,fee schedule,20.48,110.64,APC
Chylmd trach dna dir probe,87490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,22.75,,,,,,,fee schedule,20.48,110.64,APC
Chylmd trach dna dir probe,87490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,34.81,,,,,,,fee schedule,20.48,110.64,Radiology
Chylmd trach dna dir probe,87490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,31.85,,,,,,,fee schedule,20.48,110.64,APC
Chylmd trach dna dir probe,87490,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,39.81,,,,,,,fee schedule,20.48,110.64,APC
Chylmd trach dna amp probe,87491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,127.16,,,,,,,fee schedule,31.58,127.16,
Chylmd trach dna amp probe,87491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,101.93,,,,,,,fee schedule,31.58,127.16,
Chylmd trach dna amp probe,87491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,111.35,,,,,,,fee schedule,31.58,127.16,
Chylmd trach dna amp probe,87491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,117.07,,,,,,,fee schedule,31.58,127.16,
Chylmd trach dna amp probe,87491,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31.58,,,,,,,fee schedule,31.58,127.16,Laboratory
Chylmd trach dna amp probe,87491,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,31.58,127.16,APC
Chylmd trach dna amp probe,87491,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,36.49,,,,,,,fee schedule,31.58,127.16,APC
Chylmd trach dna amp probe,87491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,35.09,,,,,,,fee schedule,31.58,127.16,APC
Chylmd trach dna amp probe,87491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,53.69,,,,,,,fee schedule,31.58,127.16,Radiology
Chylmd trach dna amp probe,87491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49.13,,,,,,,fee schedule,31.58,127.16,APC
Chylmd trach dna amp probe,87491,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,61.41,,,,,,,fee schedule,31.58,127.16,APC
Chylmd trach dna quant,87492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,88.49,,,,,,,fee schedule,48.12,93.57,
Chylmd trach dna quant,87492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,70.93,,,,,,,fee schedule,48.12,93.57,
Chylmd trach dna quant,87492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,77.49,,,,,,,fee schedule,48.12,93.57,
Chylmd trach dna quant,87492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,81.47,,,,,,,fee schedule,48.12,93.57,
Chylmd trach dna quant,87492,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,48.12,,,,,,,fee schedule,48.12,93.57,Laboratory
Chylmd trach dna quant,87492,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,56.14,,,,,,,fee schedule,48.12,93.57,APC
Chylmd trach dna quant,87492,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,55.61,,,,,,,fee schedule,48.12,93.57,APC
Chylmd trach dna quant,87492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,53.47,,,,,,,fee schedule,48.12,93.57,APC
Chylmd trach dna quant,87492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.81,,,,,,,fee schedule,48.12,93.57,Radiology
Chylmd trach dna quant,87492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,74.86,,,,,,,fee schedule,48.12,93.57,APC
Chylmd trach dna quant,87492,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,93.57,,,,,,,fee schedule,48.12,93.57,APC
C diff amplified probe,87493,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,106.62,,,,,,,fee schedule,33.54,106.62,
C diff amplified probe,87493,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,85.46,,,,,,,fee schedule,33.54,106.62,
C diff amplified probe,87493,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,93.36,,,,,,,fee schedule,33.54,106.62,
C diff amplified probe,87493,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,98.15,,,,,,,fee schedule,33.54,106.62,
C diff amplified probe,87493,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,33.54,,,,,,,fee schedule,33.54,106.62,Laboratory
C diff amplified probe,87493,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.13,,,,,,,fee schedule,33.54,106.62,APC
C diff amplified probe,87493,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.76,,,,,,,fee schedule,33.54,106.62,APC
C diff amplified probe,87493,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,37.27,,,,,,,fee schedule,33.54,106.62,APC
C diff amplified probe,87493,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,57.02,,,,,,,fee schedule,33.54,106.62,Radiology
C diff amplified probe,87493,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,52.18,,,,,,,fee schedule,33.54,106.62,APC
C diff amplified probe,87493,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,65.22,,,,,,,fee schedule,33.54,106.62,APC
Chlmy trch&neisra gonor mult,87494,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,63.16,,,,,,,fee schedule,63.16,122.82,Laboratory
Chlmy trch&neisra gonor mult,87494,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,73.69,,,,,,,fee schedule,63.16,122.82,APC
Chlmy trch&neisra gonor mult,87494,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,72.99,,,,,,,fee schedule,63.16,122.82,APC
Chlmy trch&neisra gonor mult,87494,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,70.18,,,,,,,fee schedule,63.16,122.82,APC
Chlmy trch&neisra gonor mult,87494,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,107.38,,,,,,,fee schedule,63.16,122.82,Radiology
Chlmy trch&neisra gonor mult,87494,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,98.25,,,,,,,fee schedule,63.16,122.82,APC
Chlmy trch&neisra gonor mult,87494,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,122.82,,,,,,,fee schedule,63.16,122.82,APC
Cytomeg dna dir probe,87495,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,110.64,,,,,,,fee schedule,27.03,110.64,
Cytomeg dna dir probe,87495,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,88.69,,,,,,,fee schedule,27.03,110.64,
Cytomeg dna dir probe,87495,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,96.88,,,,,,,fee schedule,27.03,110.64,
Cytomeg dna dir probe,87495,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,101.86,,,,,,,fee schedule,27.03,110.64,
Cytomeg dna dir probe,87495,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,27.03,,,,,,,fee schedule,27.03,110.64,Laboratory
Cytomeg dna dir probe,87495,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,31.53,,,,,,,fee schedule,27.03,110.64,APC
Cytomeg dna dir probe,87495,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,31.23,,,,,,,fee schedule,27.03,110.64,APC
Cytomeg dna dir probe,87495,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,30.03,,,,,,,fee schedule,27.03,110.64,APC
Cytomeg dna dir probe,87495,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,45.95,,,,,,,fee schedule,27.03,110.64,Radiology
Cytomeg dna dir probe,87495,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,42.04,,,,,,,fee schedule,27.03,110.64,APC
Cytomeg dna dir probe,87495,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,52.55,,,,,,,fee schedule,27.03,110.64,APC
Cytomeg dna amp probe,87496,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,193.73,,,,,,,fee schedule,31.58,193.73,
Cytomeg dna amp probe,87496,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,155.29,,,,,,,fee schedule,31.58,193.73,
Cytomeg dna amp probe,87496,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,169.64,,,,,,,fee schedule,31.58,193.73,
Cytomeg dna amp probe,87496,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,178.35,,,,,,,fee schedule,31.58,193.73,
Cytomeg dna amp probe,87496,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31.58,,,,,,,fee schedule,31.58,193.73,Laboratory
Cytomeg dna amp probe,87496,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,31.58,193.73,APC
Cytomeg dna amp probe,87496,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,36.49,,,,,,,fee schedule,31.58,193.73,APC
Cytomeg dna amp probe,87496,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,35.09,,,,,,,fee schedule,31.58,193.73,APC
Cytomeg dna amp probe,87496,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,53.69,,,,,,,fee schedule,31.58,193.73,Radiology
Cytomeg dna amp probe,87496,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49.13,,,,,,,fee schedule,31.58,193.73,APC
Cytomeg dna amp probe,87496,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,61.41,,,,,,,fee schedule,31.58,193.73,APC
Cytomeg dna quant,87497,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,139.93,,,,,,,fee schedule,38.56,139.93,
Cytomeg dna quant,87497,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,112.17,,,,,,,fee schedule,38.56,139.93,
Cytomeg dna quant,87497,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,122.53,,,,,,,fee schedule,38.56,139.93,
Cytomeg dna quant,87497,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,128.83,,,,,,,fee schedule,38.56,139.93,
Cytomeg dna quant,87497,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,38.56,,,,,,,fee schedule,38.56,139.93,Laboratory
Cytomeg dna quant,87497,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,44.98,,,,,,,fee schedule,38.56,139.93,APC
Cytomeg dna quant,87497,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,44.55,,,,,,,fee schedule,38.56,139.93,APC
Cytomeg dna quant,87497,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,42.84,,,,,,,fee schedule,38.56,139.93,APC
Cytomeg dna quant,87497,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,65.55,,,,,,,fee schedule,38.56,139.93,Radiology
Cytomeg dna quant,87497,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,59.98,,,,,,,fee schedule,38.56,139.93,APC
Cytomeg dna quant,87497,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,74.97,,,,,,,fee schedule,38.56,139.93,APC
Enterovirus probe&revrs trns,87498,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,112.91,,,,,,,fee schedule,31.58,112.91,
Enterovirus probe&revrs trns,87498,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,90.51,,,,,,,fee schedule,31.58,112.91,
Enterovirus probe&revrs trns,87498,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,98.87,,,,,,,fee schedule,31.58,112.91,
Enterovirus probe&revrs trns,87498,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,103.95,,,,,,,fee schedule,31.58,112.91,
Enterovirus probe&revrs trns,87498,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31.58,,,,,,,fee schedule,31.58,112.91,Laboratory
Enterovirus probe&revrs trns,87498,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,31.58,112.91,APC
Enterovirus probe&revrs trns,87498,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,36.49,,,,,,,fee schedule,31.58,112.91,APC
Enterovirus probe&revrs trns,87498,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,35.09,,,,,,,fee schedule,31.58,112.91,APC
Enterovirus probe&revrs trns,87498,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,53.69,,,,,,,fee schedule,31.58,112.91,Radiology
Enterovirus probe&revrs trns,87498,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49.13,,,,,,,fee schedule,31.58,112.91,APC
Enterovirus probe&revrs trns,87498,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,61.41,,,,,,,fee schedule,31.58,112.91,APC
Vanomycin dna amp probe,87500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,193.73,,,,,,,fee schedule,31.58,193.73,
Vanomycin dna amp probe,87500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,155.29,,,,,,,fee schedule,31.58,193.73,
Vanomycin dna amp probe,87500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,169.64,,,,,,,fee schedule,31.58,193.73,
Vanomycin dna amp probe,87500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,178.35,,,,,,,fee schedule,31.58,193.73,
Vanomycin dna amp probe,87500,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31.58,,,,,,,fee schedule,31.58,193.73,Laboratory
Vanomycin dna amp probe,87500,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,31.58,193.73,APC
Vanomycin dna amp probe,87500,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,36.49,,,,,,,fee schedule,31.58,193.73,APC
Vanomycin dna amp probe,87500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,35.09,,,,,,,fee schedule,31.58,193.73,APC
Vanomycin dna amp probe,87500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,53.69,,,,,,,fee schedule,31.58,193.73,Radiology
Vanomycin dna amp probe,87500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49.13,,,,,,,fee schedule,31.58,193.73,APC
Vanomycin dna amp probe,87500,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,61.41,,,,,,,fee schedule,31.58,193.73,APC
Influenza dna amp prob 1+,87501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,266.64,,,,,,,fee schedule,46.18,266.64,
Influenza dna amp prob 1+,87501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,213.74,,,,,,,fee schedule,46.18,266.64,
Influenza dna amp prob 1+,87501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,233.49,,,,,,,fee schedule,46.18,266.64,
Influenza dna amp prob 1+,87501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,245.48,,,,,,,fee schedule,46.18,266.64,
Influenza dna amp prob 1+,87501,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46.18,,,,,,,fee schedule,46.18,266.64,Laboratory
Influenza dna amp prob 1+,87501,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,53.88,,,,,,,fee schedule,46.18,266.64,APC
Influenza dna amp prob 1+,87501,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,53.36,,,,,,,fee schedule,46.18,266.64,APC
Influenza dna amp prob 1+,87501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,51.31,,,,,,,fee schedule,46.18,266.64,APC
Influenza dna amp prob 1+,87501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,78.5,,,,,,,fee schedule,46.18,266.64,Radiology
Influenza dna amp prob 1+,87501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,71.83,,,,,,,fee schedule,46.18,266.64,APC
Influenza dna amp prob 1+,87501,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,89.79,,,,,,,fee schedule,46.18,266.64,APC
Influenza dna amp probe,87502,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,86.22,,,,,,,fee schedule,86.22,167.65,Laboratory
Influenza dna amp probe,87502,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,100.59,,,,,,,fee schedule,86.22,167.65,APC
Influenza dna amp probe,87502,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,99.63,,,,,,,fee schedule,86.22,167.65,APC
Influenza dna amp probe,87502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,95.8,,,,,,,fee schedule,86.22,167.65,APC
Influenza dna amp probe,87502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,146.57,,,,,,,fee schedule,86.22,167.65,Radiology
Influenza dna amp probe,87502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,134.12,,,,,,,fee schedule,86.22,167.65,APC
Influenza dna amp probe,87502,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,167.65,,,,,,,fee schedule,86.22,167.65,APC
Influenza dna amp prob addl,87503,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26.3,,,,,,,fee schedule,26.3,51.14,Laboratory
Influenza dna amp prob addl,87503,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.68,,,,,,,fee schedule,26.3,51.14,APC
Influenza dna amp prob addl,87503,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,30.39,,,,,,,fee schedule,26.3,51.14,APC
Influenza dna amp prob addl,87503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,29.22,,,,,,,fee schedule,26.3,51.14,APC
Influenza dna amp prob addl,87503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,44.71,,,,,,,fee schedule,26.3,51.14,Radiology
Influenza dna amp prob addl,87503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40.91,,,,,,,fee schedule,26.3,51.14,APC
Influenza dna amp prob addl,87503,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,51.14,,,,,,,fee schedule,26.3,51.14,APC
Nfct agent detection gi,87505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,659.91,,,,,,,fee schedule,115.46,659.91,
Nfct agent detection gi,87505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,528.98,,,,,,,fee schedule,115.46,659.91,
Nfct agent detection gi,87505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,577.86,,,,,,,fee schedule,115.46,659.91,
Nfct agent detection gi,87505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,607.54,,,,,,,fee schedule,115.46,659.91,
Nfct agent detection gi,87505,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,115.46,,,,,,,fee schedule,115.46,659.91,Laboratory
Nfct agent detection gi,87505,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134.7,,,,,,,fee schedule,115.46,659.91,APC
Nfct agent detection gi,87505,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,133.42,,,,,,,fee schedule,115.46,659.91,APC
Nfct agent detection gi,87505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,128.29,,,,,,,fee schedule,115.46,659.91,APC
Nfct agent detection gi,87505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,196.28,,,,,,,fee schedule,115.46,659.91,Radiology
Nfct agent detection gi,87505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,179.61,,,,,,,fee schedule,115.46,659.91,APC
Nfct agent detection gi,87505,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,224.51,,,,,,,fee schedule,115.46,659.91,APC
Iadna-dna/rna probe tq 6-11,87506,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1097.9,,,,,,,fee schedule,236.69,1097.9,
Iadna-dna/rna probe tq 6-11,87506,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,880.06,,,,,,,fee schedule,236.69,1097.9,
Iadna-dna/rna probe tq 6-11,87506,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,961.39,,,,,,,fee schedule,236.69,1097.9,
Iadna-dna/rna probe tq 6-11,87506,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1010.77,,,,,,,fee schedule,236.69,1097.9,
Iadna-dna/rna probe tq 6-11,87506,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,236.69,,,,,,,fee schedule,236.69,1097.9,Laboratory
Iadna-dna/rna probe tq 6-11,87506,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,276.14,,,,,,,fee schedule,236.69,1097.9,APC
Iadna-dna/rna probe tq 6-11,87506,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,273.51,,,,,,,fee schedule,236.69,1097.9,APC
Iadna-dna/rna probe tq 6-11,87506,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,262.99,,,,,,,fee schedule,236.69,1097.9,APC
Iadna-dna/rna probe tq 6-11,87506,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,402.37,,,,,,,fee schedule,236.69,1097.9,Radiology
Iadna-dna/rna probe tq 6-11,87506,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,368.19,,,,,,,fee schedule,236.69,1097.9,APC
Iadna-dna/rna probe tq 6-11,87506,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,460.23,,,,,,,fee schedule,236.69,1097.9,APC
Iadna-dna/rna probe tq 12-25,87507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2143.94,,,,,,,fee schedule,375.1,2143.94,
Iadna-dna/rna probe tq 12-25,87507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1718.56,,,,,,,fee schedule,375.1,2143.94,
Iadna-dna/rna probe tq 12-25,87507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1877.37,,,,,,,fee schedule,375.1,2143.94,
Iadna-dna/rna probe tq 12-25,87507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1973.79,,,,,,,fee schedule,375.1,2143.94,
Iadna-dna/rna probe tq 12-25,87507,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,375.1,,,,,,,fee schedule,375.1,2143.94,Laboratory
Iadna-dna/rna probe tq 12-25,87507,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,437.62,,,,,,,fee schedule,375.1,2143.94,APC
Iadna-dna/rna probe tq 12-25,87507,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,433.45,,,,,,,fee schedule,375.1,2143.94,APC
Iadna-dna/rna probe tq 12-25,87507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,416.78,,,,,,,fee schedule,375.1,2143.94,APC
Iadna-dna/rna probe tq 12-25,87507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,637.67,,,,,,,fee schedule,375.1,2143.94,Radiology
Iadna-dna/rna probe tq 12-25,87507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,583.49,,,,,,,fee schedule,375.1,2143.94,APC
Iadna-dna/rna probe tq 12-25,87507,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,729.36,,,,,,,fee schedule,375.1,2143.94,APC
Gardner vag dna dir probe,87510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,63.29,,,,,,,fee schedule,18.05,63.29,
Gardner vag dna dir probe,87510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,50.73,,,,,,,fee schedule,18.05,63.29,
Gardner vag dna dir probe,87510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55.42,,,,,,,fee schedule,18.05,63.29,
Gardner vag dna dir probe,87510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,58.26,,,,,,,fee schedule,18.05,63.29,
Gardner vag dna dir probe,87510,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.05,,,,,,,fee schedule,18.05,63.29,Laboratory
Gardner vag dna dir probe,87510,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.05,,,,,,,fee schedule,18.05,63.29,APC
Gardner vag dna dir probe,87510,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,20.85,,,,,,,fee schedule,18.05,63.29,APC
Gardner vag dna dir probe,87510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,20.05,,,,,,,fee schedule,18.05,63.29,APC
Gardner vag dna dir probe,87510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,30.68,,,,,,,fee schedule,18.05,63.29,Radiology
Gardner vag dna dir probe,87510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.07,,,,,,,fee schedule,18.05,63.29,APC
Gardner vag dna dir probe,87510,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,35.09,,,,,,,fee schedule,18.05,63.29,APC
Gardner vag dna amp probe,87511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,193.73,,,,,,,fee schedule,31.58,193.73,
Gardner vag dna amp probe,87511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,155.29,,,,,,,fee schedule,31.58,193.73,
Gardner vag dna amp probe,87511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,169.64,,,,,,,fee schedule,31.58,193.73,
Gardner vag dna amp probe,87511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,178.35,,,,,,,fee schedule,31.58,193.73,
Gardner vag dna amp probe,87511,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31.58,,,,,,,fee schedule,31.58,193.73,Laboratory
Gardner vag dna amp probe,87511,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,31.58,193.73,APC
Gardner vag dna amp probe,87511,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,36.49,,,,,,,fee schedule,31.58,193.73,APC
Gardner vag dna amp probe,87511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,35.09,,,,,,,fee schedule,31.58,193.73,APC
Gardner vag dna amp probe,87511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,53.69,,,,,,,fee schedule,31.58,193.73,Radiology
Gardner vag dna amp probe,87511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49.13,,,,,,,fee schedule,31.58,193.73,APC
Gardner vag dna amp probe,87511,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,61.41,,,,,,,fee schedule,31.58,193.73,APC
Gardner vag dna quant,87512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,88.49,,,,,,,fee schedule,37.58,88.49,
Gardner vag dna quant,87512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,70.93,,,,,,,fee schedule,37.58,88.49,
Gardner vag dna quant,87512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,77.49,,,,,,,fee schedule,37.58,88.49,
Gardner vag dna quant,87512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,81.47,,,,,,,fee schedule,37.58,88.49,
Gardner vag dna quant,87512,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,37.58,,,,,,,fee schedule,37.58,88.49,Laboratory
Gardner vag dna quant,87512,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,43.85,,,,,,,fee schedule,37.58,88.49,APC
Gardner vag dna quant,87512,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,43.43,,,,,,,fee schedule,37.58,88.49,APC
Gardner vag dna quant,87512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,41.76,,,,,,,fee schedule,37.58,88.49,APC
Gardner vag dna quant,87512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,63.89,,,,,,,fee schedule,37.58,88.49,Radiology
Gardner vag dna quant,87512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,58.46,,,,,,,fee schedule,37.58,88.49,APC
Gardner vag dna quant,87512,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,73.08,,,,,,,fee schedule,37.58,88.49,APC
H pylri clrthmcn rst amp prb,87513,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31.58,,,,,,,fee schedule,31.58,61.41,Laboratory
H pylri clrthmcn rst amp prb,87513,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,31.58,61.41,APC
H pylri clrthmcn rst amp prb,87513,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,36.49,,,,,,,fee schedule,31.58,61.41,APC
H pylri clrthmcn rst amp prb,87513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,35.09,,,,,,,fee schedule,31.58,61.41,APC
H pylri clrthmcn rst amp prb,87513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,53.69,,,,,,,fee schedule,31.58,61.41,Radiology
H pylri clrthmcn rst amp prb,87513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49.13,,,,,,,fee schedule,31.58,61.41,APC
H pylri clrthmcn rst amp prb,87513,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,61.41,,,,,,,fee schedule,31.58,61.41,APC
Hepatitis b dna amp probe,87516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,193.73,,,,,,,fee schedule,31.58,193.73,
Hepatitis b dna amp probe,87516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,155.29,,,,,,,fee schedule,31.58,193.73,
Hepatitis b dna amp probe,87516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,169.64,,,,,,,fee schedule,31.58,193.73,
Hepatitis b dna amp probe,87516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,178.35,,,,,,,fee schedule,31.58,193.73,
Hepatitis b dna amp probe,87516,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31.58,,,,,,,fee schedule,31.58,193.73,Laboratory
Hepatitis b dna amp probe,87516,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,31.58,193.73,APC
Hepatitis b dna amp probe,87516,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,36.49,,,,,,,fee schedule,31.58,193.73,APC
Hepatitis b dna amp probe,87516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,35.09,,,,,,,fee schedule,31.58,193.73,APC
Hepatitis b dna amp probe,87516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,53.69,,,,,,,fee schedule,31.58,193.73,Radiology
Hepatitis b dna amp probe,87516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49.13,,,,,,,fee schedule,31.58,193.73,APC
Hepatitis b dna amp probe,87516,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,61.41,,,,,,,fee schedule,31.58,193.73,APC
Hepatitis b dna quant,87517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,236.4,,,,,,,fee schedule,38.56,236.4,
Hepatitis b dna quant,87517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,189.5,,,,,,,fee schedule,38.56,236.4,
Hepatitis b dna quant,87517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,207.01,,,,,,,fee schedule,38.56,236.4,
Hepatitis b dna quant,87517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,217.64,,,,,,,fee schedule,38.56,236.4,
Hepatitis b dna quant,87517,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,38.56,,,,,,,fee schedule,38.56,236.4,Laboratory
Hepatitis b dna quant,87517,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,44.98,,,,,,,fee schedule,38.56,236.4,APC
Hepatitis b dna quant,87517,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,44.55,,,,,,,fee schedule,38.56,236.4,APC
Hepatitis b dna quant,87517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,42.84,,,,,,,fee schedule,38.56,236.4,APC
Hepatitis b dna quant,87517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,65.55,,,,,,,fee schedule,38.56,236.4,Radiology
Hepatitis b dna quant,87517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,59.98,,,,,,,fee schedule,38.56,236.4,APC
Hepatitis b dna quant,87517,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,74.97,,,,,,,fee schedule,38.56,236.4,APC
Hepatitis c rna dir probe,87520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,110.64,,,,,,,fee schedule,28.1,110.64,
Hepatitis c rna dir probe,87520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,88.69,,,,,,,fee schedule,28.1,110.64,
Hepatitis c rna dir probe,87520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,96.88,,,,,,,fee schedule,28.1,110.64,
Hepatitis c rna dir probe,87520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,101.86,,,,,,,fee schedule,28.1,110.64,
Hepatitis c rna dir probe,87520,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,28.1,,,,,,,fee schedule,28.1,110.64,Laboratory
Hepatitis c rna dir probe,87520,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,32.78,,,,,,,fee schedule,28.1,110.64,APC
Hepatitis c rna dir probe,87520,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,32.47,,,,,,,fee schedule,28.1,110.64,APC
Hepatitis c rna dir probe,87520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,31.22,,,,,,,fee schedule,28.1,110.64,APC
Hepatitis c rna dir probe,87520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,47.77,,,,,,,fee schedule,28.1,110.64,Radiology
Hepatitis c rna dir probe,87520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43.71,,,,,,,fee schedule,28.1,110.64,APC
Hepatitis c rna dir probe,87520,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,54.64,,,,,,,fee schedule,28.1,110.64,APC
Hepatitis c probe&rvrs trnsc,87521,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,193.73,,,,,,,fee schedule,31.58,193.73,
Hepatitis c probe&rvrs trnsc,87521,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,155.29,,,,,,,fee schedule,31.58,193.73,
Hepatitis c probe&rvrs trnsc,87521,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,169.64,,,,,,,fee schedule,31.58,193.73,
Hepatitis c probe&rvrs trnsc,87521,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,178.35,,,,,,,fee schedule,31.58,193.73,
Hepatitis c probe&rvrs trnsc,87521,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31.58,,,,,,,fee schedule,31.58,193.73,Laboratory
Hepatitis c probe&rvrs trnsc,87521,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,31.58,193.73,APC
Hepatitis c probe&rvrs trnsc,87521,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,36.49,,,,,,,fee schedule,31.58,193.73,APC
Hepatitis c probe&rvrs trnsc,87521,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,35.09,,,,,,,fee schedule,31.58,193.73,APC
Hepatitis c probe&rvrs trnsc,87521,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,53.69,,,,,,,fee schedule,31.58,193.73,Radiology
Hepatitis c probe&rvrs trnsc,87521,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49.13,,,,,,,fee schedule,31.58,193.73,APC
Hepatitis c probe&rvrs trnsc,87521,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,61.41,,,,,,,fee schedule,31.58,193.73,APC
Hepatitis c revrs trnscrpj,87522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,139.05,,,,,,,fee schedule,38.56,139.05,
Hepatitis c revrs trnscrpj,87522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,111.46,,,,,,,fee schedule,38.56,139.05,
Hepatitis c revrs trnscrpj,87522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,121.76,,,,,,,fee schedule,38.56,139.05,
Hepatitis c revrs trnscrpj,87522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,128.01,,,,,,,fee schedule,38.56,139.05,
Hepatitis c revrs trnscrpj,87522,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,38.56,,,,,,,fee schedule,38.56,139.05,Laboratory
Hepatitis c revrs trnscrpj,87522,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,44.98,,,,,,,fee schedule,38.56,139.05,APC
Hepatitis c revrs trnscrpj,87522,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,44.55,,,,,,,fee schedule,38.56,139.05,APC
Hepatitis c revrs trnscrpj,87522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,42.84,,,,,,,fee schedule,38.56,139.05,APC
Hepatitis c revrs trnscrpj,87522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,65.55,,,,,,,fee schedule,38.56,139.05,Radiology
Hepatitis c revrs trnscrpj,87522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,59.98,,,,,,,fee schedule,38.56,139.05,APC
Hepatitis c revrs trnscrpj,87522,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,74.97,,,,,,,fee schedule,38.56,139.05,APC
Hepatitis d quantification,87523,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,38.56,,,,,,,fee schedule,38.56,74.97,Laboratory
Hepatitis d quantification,87523,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,44.98,,,,,,,fee schedule,38.56,74.97,APC
Hepatitis d quantification,87523,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,44.55,,,,,,,fee schedule,38.56,74.97,APC
Hepatitis d quantification,87523,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,42.84,,,,,,,fee schedule,38.56,74.97,APC
Hepatitis d quantification,87523,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,65.55,,,,,,,fee schedule,38.56,74.97,Radiology
Hepatitis d quantification,87523,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,59.98,,,,,,,fee schedule,38.56,74.97,APC
Hepatitis d quantification,87523,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,74.97,,,,,,,fee schedule,38.56,74.97,APC
Hepatitis g dna dir probe,87525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,110.64,,,,,,,fee schedule,26.82,110.64,
Hepatitis g dna dir probe,87525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,88.69,,,,,,,fee schedule,26.82,110.64,
Hepatitis g dna dir probe,87525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,96.88,,,,,,,fee schedule,26.82,110.64,
Hepatitis g dna dir probe,87525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,101.86,,,,,,,fee schedule,26.82,110.64,
Hepatitis g dna dir probe,87525,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26.82,,,,,,,fee schedule,26.82,110.64,Laboratory
Hepatitis g dna dir probe,87525,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,31.29,,,,,,,fee schedule,26.82,110.64,APC
Hepatitis g dna dir probe,87525,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,30.99,,,,,,,fee schedule,26.82,110.64,APC
Hepatitis g dna dir probe,87525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,29.8,,,,,,,fee schedule,26.82,110.64,APC
Hepatitis g dna dir probe,87525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,45.59,,,,,,,fee schedule,26.82,110.64,Radiology
Hepatitis g dna dir probe,87525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,41.72,,,,,,,fee schedule,26.82,110.64,APC
Hepatitis g dna dir probe,87525,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,52.15,,,,,,,fee schedule,26.82,110.64,APC
Hepatitis g dna amp probe,87526,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,193.73,,,,,,,fee schedule,35.33,193.73,
Hepatitis g dna amp probe,87526,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,155.29,,,,,,,fee schedule,35.33,193.73,
Hepatitis g dna amp probe,87526,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,169.64,,,,,,,fee schedule,35.33,193.73,
Hepatitis g dna amp probe,87526,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,178.35,,,,,,,fee schedule,35.33,193.73,
Hepatitis g dna amp probe,87526,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,35.33,,,,,,,fee schedule,35.33,193.73,Laboratory
Hepatitis g dna amp probe,87526,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,41.22,,,,,,,fee schedule,35.33,193.73,APC
Hepatitis g dna amp probe,87526,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,40.83,,,,,,,fee schedule,35.33,193.73,APC
Hepatitis g dna amp probe,87526,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,39.26,,,,,,,fee schedule,35.33,193.73,APC
Hepatitis g dna amp probe,87526,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,60.07,,,,,,,fee schedule,35.33,193.73,Radiology
Hepatitis g dna amp probe,87526,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,54.96,,,,,,,fee schedule,35.33,193.73,APC
Hepatitis g dna amp probe,87526,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,68.7,,,,,,,fee schedule,35.33,193.73,APC
Hepatitis g dna quant,87527,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,88.49,,,,,,,fee schedule,37.58,88.49,
Hepatitis g dna quant,87527,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,70.93,,,,,,,fee schedule,37.58,88.49,
Hepatitis g dna quant,87527,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,77.49,,,,,,,fee schedule,37.58,88.49,
Hepatitis g dna quant,87527,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,81.47,,,,,,,fee schedule,37.58,88.49,
Hepatitis g dna quant,87527,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,37.58,,,,,,,fee schedule,37.58,88.49,Laboratory
Hepatitis g dna quant,87527,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,43.85,,,,,,,fee schedule,37.58,88.49,APC
Hepatitis g dna quant,87527,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,43.43,,,,,,,fee schedule,37.58,88.49,APC
Hepatitis g dna quant,87527,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,41.76,,,,,,,fee schedule,37.58,88.49,APC
Hepatitis g dna quant,87527,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,63.89,,,,,,,fee schedule,37.58,88.49,Radiology
Hepatitis g dna quant,87527,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,58.46,,,,,,,fee schedule,37.58,88.49,APC
Hepatitis g dna quant,87527,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,73.08,,,,,,,fee schedule,37.58,88.49,APC
Hsv dna dir probe,87528,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,110.64,,,,,,,fee schedule,18.05,110.64,
Hsv dna dir probe,87528,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,88.69,,,,,,,fee schedule,18.05,110.64,
Hsv dna dir probe,87528,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,96.88,,,,,,,fee schedule,18.05,110.64,
Hsv dna dir probe,87528,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,101.86,,,,,,,fee schedule,18.05,110.64,
Hsv dna dir probe,87528,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.05,,,,,,,fee schedule,18.05,110.64,Laboratory
Hsv dna dir probe,87528,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.05,,,,,,,fee schedule,18.05,110.64,APC
Hsv dna dir probe,87528,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,20.85,,,,,,,fee schedule,18.05,110.64,APC
Hsv dna dir probe,87528,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,20.05,,,,,,,fee schedule,18.05,110.64,APC
Hsv dna dir probe,87528,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,30.68,,,,,,,fee schedule,18.05,110.64,Radiology
Hsv dna dir probe,87528,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.07,,,,,,,fee schedule,18.05,110.64,APC
Hsv dna dir probe,87528,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,35.09,,,,,,,fee schedule,18.05,110.64,APC
Hsv dna amp probe,87529,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,175.97,,,,,,,fee schedule,31.58,175.97,
Hsv dna amp probe,87529,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,141.05,,,,,,,fee schedule,31.58,175.97,
Hsv dna amp probe,87529,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,154.09,,,,,,,fee schedule,31.58,175.97,
Hsv dna amp probe,87529,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,162,,,,,,,fee schedule,31.58,175.97,
Hsv dna amp probe,87529,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31.58,,,,,,,fee schedule,31.58,175.97,Laboratory
Hsv dna amp probe,87529,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,31.58,175.97,APC
Hsv dna amp probe,87529,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,36.49,,,,,,,fee schedule,31.58,175.97,APC
Hsv dna amp probe,87529,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,35.09,,,,,,,fee schedule,31.58,175.97,APC
Hsv dna amp probe,87529,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,53.69,,,,,,,fee schedule,31.58,175.97,Radiology
Hsv dna amp probe,87529,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49.13,,,,,,,fee schedule,31.58,175.97,APC
Hsv dna amp probe,87529,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,61.41,,,,,,,fee schedule,31.58,175.97,APC
Hsv dna quant,87530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,236.4,,,,,,,fee schedule,38.56,236.4,
Hsv dna quant,87530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,189.5,,,,,,,fee schedule,38.56,236.4,
Hsv dna quant,87530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,207.01,,,,,,,fee schedule,38.56,236.4,
Hsv dna quant,87530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,217.64,,,,,,,fee schedule,38.56,236.4,
Hsv dna quant,87530,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,38.56,,,,,,,fee schedule,38.56,236.4,Laboratory
Hsv dna quant,87530,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,44.98,,,,,,,fee schedule,38.56,236.4,APC
Hsv dna quant,87530,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,44.55,,,,,,,fee schedule,38.56,236.4,APC
Hsv dna quant,87530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,42.84,,,,,,,fee schedule,38.56,236.4,APC
Hsv dna quant,87530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,65.55,,,,,,,fee schedule,38.56,236.4,Radiology
Hsv dna quant,87530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,59.98,,,,,,,fee schedule,38.56,236.4,APC
Hsv dna quant,87530,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,74.97,,,,,,,fee schedule,38.56,236.4,APC
Hhv-6 dna dir probe,87531,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,110.64,,,,,,,fee schedule,52.2,110.64,
Hhv-6 dna dir probe,87531,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,88.69,,,,,,,fee schedule,52.2,110.64,
Hhv-6 dna dir probe,87531,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,96.88,,,,,,,fee schedule,52.2,110.64,
Hhv-6 dna dir probe,87531,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,101.86,,,,,,,fee schedule,52.2,110.64,
Hhv-6 dna dir probe,87531,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,52.2,,,,,,,fee schedule,52.2,110.64,Laboratory
Hhv-6 dna dir probe,87531,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,60.9,,,,,,,fee schedule,52.2,110.64,APC
Hhv-6 dna dir probe,87531,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.32,,,,,,,fee schedule,52.2,110.64,APC
Hhv-6 dna dir probe,87531,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58,,,,,,,fee schedule,52.2,110.64,APC
Hhv-6 dna dir probe,87531,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,88.74,,,,,,,fee schedule,52.2,110.64,Radiology
Hhv-6 dna dir probe,87531,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.2,,,,,,,fee schedule,52.2,110.64,APC
Hhv-6 dna dir probe,87531,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,101.5,,,,,,,fee schedule,52.2,110.64,APC
Hhv-6 dna amp probe,87532,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,193.73,,,,,,,fee schedule,31.58,193.73,
Hhv-6 dna amp probe,87532,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,155.29,,,,,,,fee schedule,31.58,193.73,
Hhv-6 dna amp probe,87532,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,169.64,,,,,,,fee schedule,31.58,193.73,
Hhv-6 dna amp probe,87532,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,178.35,,,,,,,fee schedule,31.58,193.73,
Hhv-6 dna amp probe,87532,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31.58,,,,,,,fee schedule,31.58,193.73,Laboratory
Hhv-6 dna amp probe,87532,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,31.58,193.73,APC
Hhv-6 dna amp probe,87532,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,36.49,,,,,,,fee schedule,31.58,193.73,APC
Hhv-6 dna amp probe,87532,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,35.09,,,,,,,fee schedule,31.58,193.73,APC
Hhv-6 dna amp probe,87532,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,53.69,,,,,,,fee schedule,31.58,193.73,Radiology
Hhv-6 dna amp probe,87532,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49.13,,,,,,,fee schedule,31.58,193.73,APC
Hhv-6 dna amp probe,87532,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,61.41,,,,,,,fee schedule,31.58,193.73,APC
Hhv-6 dna quant,87533,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,88.49,,,,,,,fee schedule,37.58,88.49,
Hhv-6 dna quant,87533,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,70.93,,,,,,,fee schedule,37.58,88.49,
Hhv-6 dna quant,87533,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,77.49,,,,,,,fee schedule,37.58,88.49,
Hhv-6 dna quant,87533,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,81.47,,,,,,,fee schedule,37.58,88.49,
Hhv-6 dna quant,87533,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,37.58,,,,,,,fee schedule,37.58,88.49,Laboratory
Hhv-6 dna quant,87533,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,43.85,,,,,,,fee schedule,37.58,88.49,APC
Hhv-6 dna quant,87533,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,43.43,,,,,,,fee schedule,37.58,88.49,APC
Hhv-6 dna quant,87533,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,41.76,,,,,,,fee schedule,37.58,88.49,APC
Hhv-6 dna quant,87533,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,63.89,,,,,,,fee schedule,37.58,88.49,Radiology
Hhv-6 dna quant,87533,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,58.46,,,,,,,fee schedule,37.58,88.49,APC
Hhv-6 dna quant,87533,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,73.08,,,,,,,fee schedule,37.58,88.49,APC
Hiv-1 dna dir probe,87534,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,110.64,,,,,,,fee schedule,19.73,110.64,
Hiv-1 dna dir probe,87534,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,88.69,,,,,,,fee schedule,19.73,110.64,
Hiv-1 dna dir probe,87534,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,96.88,,,,,,,fee schedule,19.73,110.64,
Hiv-1 dna dir probe,87534,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,101.86,,,,,,,fee schedule,19.73,110.64,
Hiv-1 dna dir probe,87534,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.73,,,,,,,fee schedule,19.73,110.64,Laboratory
Hiv-1 dna dir probe,87534,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,23.02,,,,,,,fee schedule,19.73,110.64,APC
Hiv-1 dna dir probe,87534,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,22.8,,,,,,,fee schedule,19.73,110.64,APC
Hiv-1 dna dir probe,87534,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,21.92,,,,,,,fee schedule,19.73,110.64,APC
Hiv-1 dna dir probe,87534,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,33.54,,,,,,,fee schedule,19.73,110.64,Radiology
Hiv-1 dna dir probe,87534,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,30.69,,,,,,,fee schedule,19.73,110.64,APC
Hiv-1 dna dir probe,87534,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,38.36,,,,,,,fee schedule,19.73,110.64,APC
Hiv-1 probe&reverse trnscrpj,87535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,138.45,,,,,,,fee schedule,31.58,138.45,
Hiv-1 probe&reverse trnscrpj,87535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,110.98,,,,,,,fee schedule,31.58,138.45,
Hiv-1 probe&reverse trnscrpj,87535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,121.24,,,,,,,fee schedule,31.58,138.45,
Hiv-1 probe&reverse trnscrpj,87535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,127.46,,,,,,,fee schedule,31.58,138.45,
Hiv-1 probe&reverse trnscrpj,87535,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31.58,,,,,,,fee schedule,31.58,138.45,Laboratory
Hiv-1 probe&reverse trnscrpj,87535,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,31.58,138.45,APC
Hiv-1 probe&reverse trnscrpj,87535,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,36.49,,,,,,,fee schedule,31.58,138.45,APC
Hiv-1 probe&reverse trnscrpj,87535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,35.09,,,,,,,fee schedule,31.58,138.45,APC
Hiv-1 probe&reverse trnscrpj,87535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,53.69,,,,,,,fee schedule,31.58,138.45,Radiology
Hiv-1 probe&reverse trnscrpj,87535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49.13,,,,,,,fee schedule,31.58,138.45,APC
Hiv-1 probe&reverse trnscrpj,87535,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,61.41,,,,,,,fee schedule,31.58,138.45,APC
Hiv-1 quant&revrse trnscrpj,87536,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,469.63,,,,,,,fee schedule,76.59,469.63,
Hiv-1 quant&revrse trnscrpj,87536,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,376.45,,,,,,,fee schedule,76.59,469.63,
Hiv-1 quant&revrse trnscrpj,87536,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,411.23,,,,,,,fee schedule,76.59,469.63,
Hiv-1 quant&revrse trnscrpj,87536,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,432.36,,,,,,,fee schedule,76.59,469.63,
Hiv-1 quant&revrse trnscrpj,87536,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,76.59,,,,,,,fee schedule,76.59,469.63,Laboratory
Hiv-1 quant&revrse trnscrpj,87536,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,89.36,,,,,,,fee schedule,76.59,469.63,APC
Hiv-1 quant&revrse trnscrpj,87536,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,88.5,,,,,,,fee schedule,76.59,469.63,APC
Hiv-1 quant&revrse trnscrpj,87536,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,85.1,,,,,,,fee schedule,76.59,469.63,APC
Hiv-1 quant&revrse trnscrpj,87536,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,130.2,,,,,,,fee schedule,76.59,469.63,Radiology
Hiv-1 quant&revrse trnscrpj,87536,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,119.14,,,,,,,fee schedule,76.59,469.63,APC
Hiv-1 quant&revrse trnscrpj,87536,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,148.92,,,,,,,fee schedule,76.59,469.63,APC
Hiv-2 dna dir probe,87537,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,110.64,,,,,,,fee schedule,19.73,110.64,
Hiv-2 dna dir probe,87537,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,88.69,,,,,,,fee schedule,19.73,110.64,
Hiv-2 dna dir probe,87537,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,96.88,,,,,,,fee schedule,19.73,110.64,
Hiv-2 dna dir probe,87537,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,101.86,,,,,,,fee schedule,19.73,110.64,
Hiv-2 dna dir probe,87537,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.73,,,,,,,fee schedule,19.73,110.64,Laboratory
Hiv-2 dna dir probe,87537,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,23.02,,,,,,,fee schedule,19.73,110.64,APC
Hiv-2 dna dir probe,87537,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,22.8,,,,,,,fee schedule,19.73,110.64,APC
Hiv-2 dna dir probe,87537,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,21.92,,,,,,,fee schedule,19.73,110.64,APC
Hiv-2 dna dir probe,87537,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,33.54,,,,,,,fee schedule,19.73,110.64,Radiology
Hiv-2 dna dir probe,87537,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,30.69,,,,,,,fee schedule,19.73,110.64,APC
Hiv-2 dna dir probe,87537,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,38.36,,,,,,,fee schedule,19.73,110.64,APC
Hiv-2 probe&revrse trnscripj,87538,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,193.73,,,,,,,fee schedule,31.58,193.73,
Hiv-2 probe&revrse trnscripj,87538,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,155.29,,,,,,,fee schedule,31.58,193.73,
Hiv-2 probe&revrse trnscripj,87538,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,169.64,,,,,,,fee schedule,31.58,193.73,
Hiv-2 probe&revrse trnscripj,87538,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,178.35,,,,,,,fee schedule,31.58,193.73,
Hiv-2 probe&revrse trnscripj,87538,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31.58,,,,,,,fee schedule,31.58,193.73,Laboratory
Hiv-2 probe&revrse trnscripj,87538,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,31.58,193.73,APC
Hiv-2 probe&revrse trnscripj,87538,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,36.49,,,,,,,fee schedule,31.58,193.73,APC
Hiv-2 probe&revrse trnscripj,87538,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,35.09,,,,,,,fee schedule,31.58,193.73,APC
Hiv-2 probe&revrse trnscripj,87538,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,53.69,,,,,,,fee schedule,31.58,193.73,Radiology
Hiv-2 probe&revrse trnscripj,87538,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49.13,,,,,,,fee schedule,31.58,193.73,APC
Hiv-2 probe&revrse trnscripj,87538,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,61.41,,,,,,,fee schedule,31.58,193.73,APC
Hiv-2 quant&revrse trnscripj,87539,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,88.49,,,,,,,fee schedule,52.76,102.58,
Hiv-2 quant&revrse trnscripj,87539,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,70.93,,,,,,,fee schedule,52.76,102.58,
Hiv-2 quant&revrse trnscripj,87539,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,77.49,,,,,,,fee schedule,52.76,102.58,
Hiv-2 quant&revrse trnscripj,87539,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,81.47,,,,,,,fee schedule,52.76,102.58,
Hiv-2 quant&revrse trnscripj,87539,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,52.76,,,,,,,fee schedule,52.76,102.58,Laboratory
Hiv-2 quant&revrse trnscripj,87539,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.55,,,,,,,fee schedule,52.76,102.58,APC
Hiv-2 quant&revrse trnscripj,87539,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.96,,,,,,,fee schedule,52.76,102.58,APC
Hiv-2 quant&revrse trnscripj,87539,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.62,,,,,,,fee schedule,52.76,102.58,APC
Hiv-2 quant&revrse trnscripj,87539,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.69,,,,,,,fee schedule,52.76,102.58,Radiology
Hiv-2 quant&revrse trnscripj,87539,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,82.07,,,,,,,fee schedule,52.76,102.58,APC
Hiv-2 quant&revrse trnscripj,87539,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.58,,,,,,,fee schedule,52.76,102.58,APC
Legion pneumo dna dir prob,87540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,110.64,,,,,,,fee schedule,18.05,110.64,
Legion pneumo dna dir prob,87540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,88.69,,,,,,,fee schedule,18.05,110.64,
Legion pneumo dna dir prob,87540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,96.88,,,,,,,fee schedule,18.05,110.64,
Legion pneumo dna dir prob,87540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,101.86,,,,,,,fee schedule,18.05,110.64,
Legion pneumo dna dir prob,87540,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.05,,,,,,,fee schedule,18.05,110.64,Laboratory
Legion pneumo dna dir prob,87540,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.05,,,,,,,fee schedule,18.05,110.64,APC
Legion pneumo dna dir prob,87540,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,20.85,,,,,,,fee schedule,18.05,110.64,APC
Legion pneumo dna dir prob,87540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,20.05,,,,,,,fee schedule,18.05,110.64,APC
Legion pneumo dna dir prob,87540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,30.68,,,,,,,fee schedule,18.05,110.64,Radiology
Legion pneumo dna dir prob,87540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.07,,,,,,,fee schedule,18.05,110.64,APC
Legion pneumo dna dir prob,87540,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,35.09,,,,,,,fee schedule,18.05,110.64,APC
Legion pneumo dna amp prob,87541,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,193.73,,,,,,,fee schedule,31.58,193.73,
Legion pneumo dna amp prob,87541,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,155.29,,,,,,,fee schedule,31.58,193.73,
Legion pneumo dna amp prob,87541,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,169.64,,,,,,,fee schedule,31.58,193.73,
Legion pneumo dna amp prob,87541,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,178.35,,,,,,,fee schedule,31.58,193.73,
Legion pneumo dna amp prob,87541,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31.58,,,,,,,fee schedule,31.58,193.73,Laboratory
Legion pneumo dna amp prob,87541,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,31.58,193.73,APC
Legion pneumo dna amp prob,87541,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,36.49,,,,,,,fee schedule,31.58,193.73,APC
Legion pneumo dna amp prob,87541,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,35.09,,,,,,,fee schedule,31.58,193.73,APC
Legion pneumo dna amp prob,87541,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,53.69,,,,,,,fee schedule,31.58,193.73,Radiology
Legion pneumo dna amp prob,87541,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49.13,,,,,,,fee schedule,31.58,193.73,APC
Legion pneumo dna amp prob,87541,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,61.41,,,,,,,fee schedule,31.58,193.73,APC
Legion pneumo dna quant,87542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,88.49,,,,,,,fee schedule,37.58,88.49,
Legion pneumo dna quant,87542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,70.93,,,,,,,fee schedule,37.58,88.49,
Legion pneumo dna quant,87542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,77.49,,,,,,,fee schedule,37.58,88.49,
Legion pneumo dna quant,87542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,81.47,,,,,,,fee schedule,37.58,88.49,
Legion pneumo dna quant,87542,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,37.58,,,,,,,fee schedule,37.58,88.49,Laboratory
Legion pneumo dna quant,87542,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,43.85,,,,,,,fee schedule,37.58,88.49,APC
Legion pneumo dna quant,87542,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,43.43,,,,,,,fee schedule,37.58,88.49,APC
Legion pneumo dna quant,87542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,41.76,,,,,,,fee schedule,37.58,88.49,APC
Legion pneumo dna quant,87542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,63.89,,,,,,,fee schedule,37.58,88.49,Radiology
Legion pneumo dna quant,87542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,58.46,,,,,,,fee schedule,37.58,88.49,APC
Legion pneumo dna quant,87542,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,73.08,,,,,,,fee schedule,37.58,88.49,APC
Mycobacteria dna dir probe,87550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,110.64,,,,,,,fee schedule,18.05,110.64,
Mycobacteria dna dir probe,87550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,88.69,,,,,,,fee schedule,18.05,110.64,
Mycobacteria dna dir probe,87550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,96.88,,,,,,,fee schedule,18.05,110.64,
Mycobacteria dna dir probe,87550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,101.86,,,,,,,fee schedule,18.05,110.64,
Mycobacteria dna dir probe,87550,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.05,,,,,,,fee schedule,18.05,110.64,Laboratory
Mycobacteria dna dir probe,87550,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.05,,,,,,,fee schedule,18.05,110.64,APC
Mycobacteria dna dir probe,87550,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,20.85,,,,,,,fee schedule,18.05,110.64,APC
Mycobacteria dna dir probe,87550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,20.05,,,,,,,fee schedule,18.05,110.64,APC
Mycobacteria dna dir probe,87550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,30.68,,,,,,,fee schedule,18.05,110.64,Radiology
Mycobacteria dna dir probe,87550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.07,,,,,,,fee schedule,18.05,110.64,APC
Mycobacteria dna dir probe,87550,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,35.09,,,,,,,fee schedule,18.05,110.64,APC
Mycobacteria dna amp probe,87551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,193.73,,,,,,,fee schedule,43.42,193.73,
Mycobacteria dna amp probe,87551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,155.29,,,,,,,fee schedule,43.42,193.73,
Mycobacteria dna amp probe,87551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,169.64,,,,,,,fee schedule,43.42,193.73,
Mycobacteria dna amp probe,87551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,178.35,,,,,,,fee schedule,43.42,193.73,
Mycobacteria dna amp probe,87551,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,43.42,,,,,,,fee schedule,43.42,193.73,Laboratory
Mycobacteria dna amp probe,87551,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,50.65,,,,,,,fee schedule,43.42,193.73,APC
Mycobacteria dna amp probe,87551,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,50.17,,,,,,,fee schedule,43.42,193.73,APC
Mycobacteria dna amp probe,87551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,48.24,,,,,,,fee schedule,43.42,193.73,APC
Mycobacteria dna amp probe,87551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,73.81,,,,,,,fee schedule,43.42,193.73,Radiology
Mycobacteria dna amp probe,87551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,67.54,,,,,,,fee schedule,43.42,193.73,APC
Mycobacteria dna amp probe,87551,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,84.42,,,,,,,fee schedule,43.42,193.73,APC
Mycobacteria dna quant,87552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,236.4,,,,,,,fee schedule,38.56,236.4,
Mycobacteria dna quant,87552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,189.5,,,,,,,fee schedule,38.56,236.4,
Mycobacteria dna quant,87552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,207.01,,,,,,,fee schedule,38.56,236.4,
Mycobacteria dna quant,87552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,217.64,,,,,,,fee schedule,38.56,236.4,
Mycobacteria dna quant,87552,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,38.56,,,,,,,fee schedule,38.56,236.4,Laboratory
Mycobacteria dna quant,87552,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,44.98,,,,,,,fee schedule,38.56,236.4,APC
Mycobacteria dna quant,87552,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,44.55,,,,,,,fee schedule,38.56,236.4,APC
Mycobacteria dna quant,87552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,42.84,,,,,,,fee schedule,38.56,236.4,APC
Mycobacteria dna quant,87552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,65.55,,,,,,,fee schedule,38.56,236.4,Radiology
Mycobacteria dna quant,87552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,59.98,,,,,,,fee schedule,38.56,236.4,APC
Mycobacteria dna quant,87552,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,74.97,,,,,,,fee schedule,38.56,236.4,APC
M.tuberculo dna dir probe,87555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,110.64,,,,,,,fee schedule,24.19,110.64,
M.tuberculo dna dir probe,87555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,88.69,,,,,,,fee schedule,24.19,110.64,
M.tuberculo dna dir probe,87555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,96.88,,,,,,,fee schedule,24.19,110.64,
M.tuberculo dna dir probe,87555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,101.86,,,,,,,fee schedule,24.19,110.64,
M.tuberculo dna dir probe,87555,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24.19,,,,,,,fee schedule,24.19,110.64,Laboratory
M.tuberculo dna dir probe,87555,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,28.22,,,,,,,fee schedule,24.19,110.64,APC
M.tuberculo dna dir probe,87555,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,27.96,,,,,,,fee schedule,24.19,110.64,APC
M.tuberculo dna dir probe,87555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,26.88,,,,,,,fee schedule,24.19,110.64,APC
M.tuberculo dna dir probe,87555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,41.13,,,,,,,fee schedule,24.19,110.64,Radiology
M.tuberculo dna dir probe,87555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,37.63,,,,,,,fee schedule,24.19,110.64,APC
M.tuberculo dna dir probe,87555,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,47.04,,,,,,,fee schedule,24.19,110.64,APC
M.tuberculo dna amp probe,87556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,193.73,,,,,,,fee schedule,37.51,193.73,
M.tuberculo dna amp probe,87556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,155.29,,,,,,,fee schedule,37.51,193.73,
M.tuberculo dna amp probe,87556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,169.64,,,,,,,fee schedule,37.51,193.73,
M.tuberculo dna amp probe,87556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,178.35,,,,,,,fee schedule,37.51,193.73,
M.tuberculo dna amp probe,87556,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,37.51,,,,,,,fee schedule,37.51,193.73,Laboratory
M.tuberculo dna amp probe,87556,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,43.76,,,,,,,fee schedule,37.51,193.73,APC
M.tuberculo dna amp probe,87556,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,43.35,,,,,,,fee schedule,37.51,193.73,APC
M.tuberculo dna amp probe,87556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,41.68,,,,,,,fee schedule,37.51,193.73,APC
M.tuberculo dna amp probe,87556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,63.77,,,,,,,fee schedule,37.51,193.73,Radiology
M.tuberculo dna amp probe,87556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,58.35,,,,,,,fee schedule,37.51,193.73,APC
M.tuberculo dna amp probe,87556,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,72.94,,,,,,,fee schedule,37.51,193.73,APC
M.tuberculo dna quant,87557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,236.4,,,,,,,fee schedule,38.56,236.4,
M.tuberculo dna quant,87557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,189.5,,,,,,,fee schedule,38.56,236.4,
M.tuberculo dna quant,87557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,207.01,,,,,,,fee schedule,38.56,236.4,
M.tuberculo dna quant,87557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,217.64,,,,,,,fee schedule,38.56,236.4,
M.tuberculo dna quant,87557,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,38.56,,,,,,,fee schedule,38.56,236.4,Laboratory
M.tuberculo dna quant,87557,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,44.98,,,,,,,fee schedule,38.56,236.4,APC
M.tuberculo dna quant,87557,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,44.55,,,,,,,fee schedule,38.56,236.4,APC
M.tuberculo dna quant,87557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,42.84,,,,,,,fee schedule,38.56,236.4,APC
M.tuberculo dna quant,87557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,65.55,,,,,,,fee schedule,38.56,236.4,Radiology
M.tuberculo dna quant,87557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,59.98,,,,,,,fee schedule,38.56,236.4,APC
M.tuberculo dna quant,87557,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,74.97,,,,,,,fee schedule,38.56,236.4,APC
M.avium-intra dna dir prob,87560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,110.64,,,,,,,fee schedule,24.56,110.64,
M.avium-intra dna dir prob,87560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,88.69,,,,,,,fee schedule,24.56,110.64,
M.avium-intra dna dir prob,87560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,96.88,,,,,,,fee schedule,24.56,110.64,
M.avium-intra dna dir prob,87560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,101.86,,,,,,,fee schedule,24.56,110.64,
M.avium-intra dna dir prob,87560,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24.56,,,,,,,fee schedule,24.56,110.64,Laboratory
M.avium-intra dna dir prob,87560,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,28.65,,,,,,,fee schedule,24.56,110.64,APC
M.avium-intra dna dir prob,87560,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,28.38,,,,,,,fee schedule,24.56,110.64,APC
M.avium-intra dna dir prob,87560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,27.29,,,,,,,fee schedule,24.56,110.64,APC
M.avium-intra dna dir prob,87560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,41.75,,,,,,,fee schedule,24.56,110.64,Radiology
M.avium-intra dna dir prob,87560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,38.21,,,,,,,fee schedule,24.56,110.64,APC
M.avium-intra dna dir prob,87560,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,47.76,,,,,,,fee schedule,24.56,110.64,APC
M.avium-intra dna amp prob,87561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,193.73,,,,,,,fee schedule,31.58,193.73,
M.avium-intra dna amp prob,87561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,155.29,,,,,,,fee schedule,31.58,193.73,
M.avium-intra dna amp prob,87561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,169.64,,,,,,,fee schedule,31.58,193.73,
M.avium-intra dna amp prob,87561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,178.35,,,,,,,fee schedule,31.58,193.73,
M.avium-intra dna amp prob,87561,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31.58,,,,,,,fee schedule,31.58,193.73,Laboratory
M.avium-intra dna amp prob,87561,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,31.58,193.73,APC
M.avium-intra dna amp prob,87561,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,36.49,,,,,,,fee schedule,31.58,193.73,APC
M.avium-intra dna amp prob,87561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,35.09,,,,,,,fee schedule,31.58,193.73,APC
M.avium-intra dna amp prob,87561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,53.69,,,,,,,fee schedule,31.58,193.73,Radiology
M.avium-intra dna amp prob,87561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49.13,,,,,,,fee schedule,31.58,193.73,APC
M.avium-intra dna amp prob,87561,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,61.41,,,,,,,fee schedule,31.58,193.73,APC
M.avium-intra dna quant,87562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,236.4,,,,,,,fee schedule,38.56,236.4,
M.avium-intra dna quant,87562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,189.5,,,,,,,fee schedule,38.56,236.4,
M.avium-intra dna quant,87562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,207.01,,,,,,,fee schedule,38.56,236.4,
M.avium-intra dna quant,87562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,217.64,,,,,,,fee schedule,38.56,236.4,
M.avium-intra dna quant,87562,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,38.56,,,,,,,fee schedule,38.56,236.4,Laboratory
M.avium-intra dna quant,87562,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,44.98,,,,,,,fee schedule,38.56,236.4,APC
M.avium-intra dna quant,87562,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,44.55,,,,,,,fee schedule,38.56,236.4,APC
M.avium-intra dna quant,87562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,42.84,,,,,,,fee schedule,38.56,236.4,APC
M.avium-intra dna quant,87562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,65.55,,,,,,,fee schedule,38.56,236.4,Radiology
M.avium-intra dna quant,87562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,59.98,,,,,,,fee schedule,38.56,236.4,APC
M.avium-intra dna quant,87562,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,74.97,,,,,,,fee schedule,38.56,236.4,APC
M. genitalium amp probe,87563,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,132.64,,,,,,,fee schedule,31.58,132.64,
M. genitalium amp probe,87563,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,106.32,,,,,,,fee schedule,31.58,132.64,
M. genitalium amp probe,87563,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,116.15,,,,,,,fee schedule,31.58,132.64,
M. genitalium amp probe,87563,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,122.11,,,,,,,fee schedule,31.58,132.64,
M. genitalium amp probe,87563,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31.58,,,,,,,fee schedule,31.58,132.64,Laboratory
M. genitalium amp probe,87563,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,31.58,132.64,APC
M. genitalium amp probe,87563,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,36.49,,,,,,,fee schedule,31.58,132.64,APC
M. genitalium amp probe,87563,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,35.09,,,,,,,fee schedule,31.58,132.64,APC
M. genitalium amp probe,87563,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,53.69,,,,,,,fee schedule,31.58,132.64,Radiology
M. genitalium amp probe,87563,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49.13,,,,,,,fee schedule,31.58,132.64,APC
M. genitalium amp probe,87563,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,61.41,,,,,,,fee schedule,31.58,132.64,APC
Mtb rifampin rst amp prb tq,87564,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,69.09,,,,,,,fee schedule,69.09,134.35,Laboratory
Mtb rifampin rst amp prb tq,87564,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,80.61,,,,,,,fee schedule,69.09,134.35,APC
Mtb rifampin rst amp prb tq,87564,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,79.84,,,,,,,fee schedule,69.09,134.35,APC
Mtb rifampin rst amp prb tq,87564,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,76.77,,,,,,,fee schedule,69.09,134.35,APC
Mtb rifampin rst amp prb tq,87564,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,117.46,,,,,,,fee schedule,69.09,134.35,Radiology
Mtb rifampin rst amp prb tq,87564,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,107.48,,,,,,,fee schedule,69.09,134.35,APC
Mtb rifampin rst amp prb tq,87564,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,134.35,,,,,,,fee schedule,69.09,134.35,APC
M.pneumon dna dir probe,87580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,110.64,,,,,,,fee schedule,18.05,110.64,
M.pneumon dna dir probe,87580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,88.69,,,,,,,fee schedule,18.05,110.64,
M.pneumon dna dir probe,87580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,96.88,,,,,,,fee schedule,18.05,110.64,
M.pneumon dna dir probe,87580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,101.86,,,,,,,fee schedule,18.05,110.64,
M.pneumon dna dir probe,87580,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.05,,,,,,,fee schedule,18.05,110.64,Laboratory
M.pneumon dna dir probe,87580,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.05,,,,,,,fee schedule,18.05,110.64,APC
M.pneumon dna dir probe,87580,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,20.85,,,,,,,fee schedule,18.05,110.64,APC
M.pneumon dna dir probe,87580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,20.05,,,,,,,fee schedule,18.05,110.64,APC
M.pneumon dna dir probe,87580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,30.68,,,,,,,fee schedule,18.05,110.64,Radiology
M.pneumon dna dir probe,87580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.07,,,,,,,fee schedule,18.05,110.64,APC
M.pneumon dna dir probe,87580,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,35.09,,,,,,,fee schedule,18.05,110.64,APC
M.pneumon dna amp probe,87581,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,193.73,,,,,,,fee schedule,31.58,193.73,
M.pneumon dna amp probe,87581,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,155.29,,,,,,,fee schedule,31.58,193.73,
M.pneumon dna amp probe,87581,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,169.64,,,,,,,fee schedule,31.58,193.73,
M.pneumon dna amp probe,87581,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,178.35,,,,,,,fee schedule,31.58,193.73,
M.pneumon dna amp probe,87581,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31.58,,,,,,,fee schedule,31.58,193.73,Laboratory
M.pneumon dna amp probe,87581,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,31.58,193.73,APC
M.pneumon dna amp probe,87581,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,36.49,,,,,,,fee schedule,31.58,193.73,APC
M.pneumon dna amp probe,87581,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,35.09,,,,,,,fee schedule,31.58,193.73,APC
M.pneumon dna amp probe,87581,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,53.69,,,,,,,fee schedule,31.58,193.73,Radiology
M.pneumon dna amp probe,87581,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49.13,,,,,,,fee schedule,31.58,193.73,APC
M.pneumon dna amp probe,87581,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,61.41,,,,,,,fee schedule,31.58,193.73,APC
M.pneumon dna quant,87582,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,88.49,,,,,,,fee schedule,70.93,529.58,
M.pneumon dna quant,87582,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,70.93,,,,,,,fee schedule,70.93,529.58,
M.pneumon dna quant,87582,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,77.49,,,,,,,fee schedule,70.93,529.58,
M.pneumon dna quant,87582,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,81.47,,,,,,,fee schedule,70.93,529.58,
M.pneumon dna quant,87582,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,272.36,,,,,,,fee schedule,70.93,529.58,Laboratory
M.pneumon dna quant,87582,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,317.75,,,,,,,fee schedule,70.93,529.58,APC
M.pneumon dna quant,87582,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,314.72,,,,,,,fee schedule,70.93,529.58,APC
M.pneumon dna quant,87582,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,302.62,,,,,,,fee schedule,70.93,529.58,APC
M.pneumon dna quant,87582,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,463.01,,,,,,,fee schedule,70.93,529.58,Radiology
M.pneumon dna quant,87582,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,423.67,,,,,,,fee schedule,70.93,529.58,APC
M.pneumon dna quant,87582,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,529.58,,,,,,,fee schedule,70.93,529.58,APC
N.gonorrhoeae dna dir prob,87590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,110.64,,,,,,,fee schedule,24.19,110.64,
N.gonorrhoeae dna dir prob,87590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,88.69,,,,,,,fee schedule,24.19,110.64,
N.gonorrhoeae dna dir prob,87590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,96.88,,,,,,,fee schedule,24.19,110.64,
N.gonorrhoeae dna dir prob,87590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,101.86,,,,,,,fee schedule,24.19,110.64,
N.gonorrhoeae dna dir prob,87590,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24.19,,,,,,,fee schedule,24.19,110.64,Laboratory
N.gonorrhoeae dna dir prob,87590,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,28.22,,,,,,,fee schedule,24.19,110.64,APC
N.gonorrhoeae dna dir prob,87590,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,27.96,,,,,,,fee schedule,24.19,110.64,APC
N.gonorrhoeae dna dir prob,87590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,26.88,,,,,,,fee schedule,24.19,110.64,APC
N.gonorrhoeae dna dir prob,87590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,41.13,,,,,,,fee schedule,24.19,110.64,Radiology
N.gonorrhoeae dna dir prob,87590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,37.63,,,,,,,fee schedule,24.19,110.64,APC
N.gonorrhoeae dna dir prob,87590,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,47.04,,,,,,,fee schedule,24.19,110.64,APC
N.gonorrhoeae dna amp prob,87591,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,116.6,,,,,,,fee schedule,31.58,116.6,
N.gonorrhoeae dna amp prob,87591,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,93.47,,,,,,,fee schedule,31.58,116.6,
N.gonorrhoeae dna amp prob,87591,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,102.1,,,,,,,fee schedule,31.58,116.6,
N.gonorrhoeae dna amp prob,87591,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,107.35,,,,,,,fee schedule,31.58,116.6,
N.gonorrhoeae dna amp prob,87591,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31.58,,,,,,,fee schedule,31.58,116.6,Laboratory
N.gonorrhoeae dna amp prob,87591,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,31.58,116.6,APC
N.gonorrhoeae dna amp prob,87591,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,36.49,,,,,,,fee schedule,31.58,116.6,APC
N.gonorrhoeae dna amp prob,87591,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,35.09,,,,,,,fee schedule,31.58,116.6,APC
N.gonorrhoeae dna amp prob,87591,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,53.69,,,,,,,fee schedule,31.58,116.6,Radiology
N.gonorrhoeae dna amp prob,87591,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49.13,,,,,,,fee schedule,31.58,116.6,APC
N.gonorrhoeae dna amp prob,87591,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,61.41,,,,,,,fee schedule,31.58,116.6,APC
N.gonorrhoeae dna quant,87592,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,88.49,,,,,,,fee schedule,38.56,88.49,
N.gonorrhoeae dna quant,87592,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,70.93,,,,,,,fee schedule,38.56,88.49,
N.gonorrhoeae dna quant,87592,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,77.49,,,,,,,fee schedule,38.56,88.49,
N.gonorrhoeae dna quant,87592,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,81.47,,,,,,,fee schedule,38.56,88.49,
N.gonorrhoeae dna quant,87592,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,38.56,,,,,,,fee schedule,38.56,88.49,Laboratory
N.gonorrhoeae dna quant,87592,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,44.98,,,,,,,fee schedule,38.56,88.49,APC
N.gonorrhoeae dna quant,87592,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,44.55,,,,,,,fee schedule,38.56,88.49,APC
N.gonorrhoeae dna quant,87592,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,42.84,,,,,,,fee schedule,38.56,88.49,APC
N.gonorrhoeae dna quant,87592,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,65.55,,,,,,,fee schedule,38.56,88.49,Radiology
N.gonorrhoeae dna quant,87592,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,59.98,,,,,,,fee schedule,38.56,88.49,APC
N.gonorrhoeae dna quant,87592,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,74.97,,,,,,,fee schedule,38.56,88.49,APC
Orthopoxvirus amp prb each,87593,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46.18,,,,,,,fee schedule,46.18,89.79,Laboratory
Orthopoxvirus amp prb each,87593,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,53.88,,,,,,,fee schedule,46.18,89.79,APC
Orthopoxvirus amp prb each,87593,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,53.36,,,,,,,fee schedule,46.18,89.79,APC
Orthopoxvirus amp prb each,87593,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,51.31,,,,,,,fee schedule,46.18,89.79,APC
Orthopoxvirus amp prb each,87593,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,78.5,,,,,,,fee schedule,46.18,89.79,Radiology
Orthopoxvirus amp prb each,87593,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,71.83,,,,,,,fee schedule,46.18,89.79,APC
Orthopoxvirus amp prb each,87593,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,89.79,,,,,,,fee schedule,46.18,89.79,APC
Pneumcysts jirovecii amp prb,87594,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31.58,,,,,,,fee schedule,31.58,61.41,Laboratory
Pneumcysts jirovecii amp prb,87594,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,31.58,61.41,APC
Pneumcysts jirovecii amp prb,87594,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,36.49,,,,,,,fee schedule,31.58,61.41,APC
Pneumcysts jirovecii amp prb,87594,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,35.09,,,,,,,fee schedule,31.58,61.41,APC
Pneumcysts jirovecii amp prb,87594,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,53.69,,,,,,,fee schedule,31.58,61.41,Radiology
Pneumcysts jirovecii amp prb,87594,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49.13,,,,,,,fee schedule,31.58,61.41,APC
Pneumcysts jirovecii amp prb,87594,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,61.41,,,,,,,fee schedule,31.58,61.41,APC
Hpv low-risk types,87623,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,180.53,,,,,,,fee schedule,31.58,180.53,
Hpv low-risk types,87623,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,144.71,,,,,,,fee schedule,31.58,180.53,
Hpv low-risk types,87623,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,158.09,,,,,,,fee schedule,31.58,180.53,
Hpv low-risk types,87623,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,166.2,,,,,,,fee schedule,31.58,180.53,
Hpv low-risk types,87623,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31.58,,,,,,,fee schedule,31.58,180.53,Laboratory
Hpv low-risk types,87623,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,31.58,180.53,APC
Hpv low-risk types,87623,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,36.49,,,,,,,fee schedule,31.58,180.53,APC
Hpv low-risk types,87623,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,35.09,,,,,,,fee schedule,31.58,180.53,APC
Hpv low-risk types,87623,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,53.69,,,,,,,fee schedule,31.58,180.53,Radiology
Hpv low-risk types,87623,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49.13,,,,,,,fee schedule,31.58,180.53,APC
Hpv low-risk types,87623,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,61.41,,,,,,,fee schedule,31.58,180.53,APC
Hpv high-risk types,87624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,180.53,,,,,,,fee schedule,31.58,180.53,
Hpv high-risk types,87624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,144.71,,,,,,,fee schedule,31.58,180.53,
Hpv high-risk types,87624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,158.09,,,,,,,fee schedule,31.58,180.53,
Hpv high-risk types,87624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,166.2,,,,,,,fee schedule,31.58,180.53,
Hpv high-risk types,87624,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31.58,,,,,,,fee schedule,31.58,180.53,Laboratory
Hpv high-risk types,87624,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,31.58,180.53,APC
Hpv high-risk types,87624,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,36.49,,,,,,,fee schedule,31.58,180.53,APC
Hpv high-risk types,87624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,35.09,,,,,,,fee schedule,31.58,180.53,APC
Hpv high-risk types,87624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,53.69,,,,,,,fee schedule,31.58,180.53,Radiology
Hpv high-risk types,87624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49.13,,,,,,,fee schedule,31.58,180.53,APC
Hpv high-risk types,87624,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,61.41,,,,,,,fee schedule,31.58,180.53,APC
Hpv types 16 & 18 only,87625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,180.53,,,,,,,fee schedule,36.49,180.53,
Hpv types 16 & 18 only,87625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,144.71,,,,,,,fee schedule,36.49,180.53,
Hpv types 16 & 18 only,87625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,158.09,,,,,,,fee schedule,36.49,180.53,
Hpv types 16 & 18 only,87625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,166.2,,,,,,,fee schedule,36.49,180.53,
Hpv types 16 & 18 only,87625,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,36.49,,,,,,,fee schedule,36.49,180.53,Laboratory
Hpv types 16 & 18 only,87625,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,42.58,,,,,,,fee schedule,36.49,180.53,APC
Hpv types 16 & 18 only,87625,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,42.17,,,,,,,fee schedule,36.49,180.53,APC
Hpv types 16 & 18 only,87625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,40.55,,,,,,,fee schedule,36.49,180.53,APC
Hpv types 16 & 18 only,87625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,62.04,,,,,,,fee schedule,36.49,180.53,Radiology
Hpv types 16 & 18 only,87625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.77,,,,,,,fee schedule,36.49,180.53,APC
Hpv types 16 & 18 only,87625,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,70.96,,,,,,,fee schedule,36.49,180.53,APC
Hpv sep hi-rsk typ&pool rslt,87626,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,63.18,,,,,,,fee schedule,63.18,122.85,Laboratory
Hpv sep hi-rsk typ&pool rslt,87626,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,73.71,,,,,,,fee schedule,63.18,122.85,APC
Hpv sep hi-rsk typ&pool rslt,87626,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,73.01,,,,,,,fee schedule,63.18,122.85,APC
Hpv sep hi-rsk typ&pool rslt,87626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,70.2,,,,,,,fee schedule,63.18,122.85,APC
Hpv sep hi-rsk typ&pool rslt,87626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,107.41,,,,,,,fee schedule,63.18,122.85,Radiology
Hpv sep hi-rsk typ&pool rslt,87626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,98.28,,,,,,,fee schedule,63.18,122.85,APC
Hpv sep hi-rsk typ&pool rslt,87626,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,122.85,,,,,,,fee schedule,63.18,122.85,APC
Jt spc pthgn&rx rsist gen26+,87627,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,611.79,,,,,,,fee schedule,611.79,1189.6,Laboratory
Jt spc pthgn&rx rsist gen26+,87627,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,713.76,,,,,,,fee schedule,611.79,1189.6,APC
Jt spc pthgn&rx rsist gen26+,87627,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,706.96,,,,,,,fee schedule,611.79,1189.6,APC
Jt spc pthgn&rx rsist gen26+,87627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,679.77,,,,,,,fee schedule,611.79,1189.6,APC
Jt spc pthgn&rx rsist gen26+,87627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1040.05,,,,,,,fee schedule,611.79,1189.6,Radiology
Jt spc pthgn&rx rsist gen26+,87627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,951.68,,,,,,,fee schedule,611.79,1189.6,APC
Jt spc pthgn&rx rsist gen26+,87627,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1189.6,,,,,,,fee schedule,611.79,1189.6,APC
Resp virus 3-5 targets,87631,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,390.12,,,,,,,fee schedule,128.37,390.12,
Resp virus 3-5 targets,87631,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,312.72,,,,,,,fee schedule,128.37,390.12,
Resp virus 3-5 targets,87631,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,341.61,,,,,,,fee schedule,128.37,390.12,
Resp virus 3-5 targets,87631,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,359.16,,,,,,,fee schedule,128.37,390.12,
Resp virus 3-5 targets,87631,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,128.37,,,,,,,fee schedule,128.37,390.12,Laboratory
Resp virus 3-5 targets,87631,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,149.76,,,,,,,fee schedule,128.37,390.12,APC
Resp virus 3-5 targets,87631,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,148.34,,,,,,,fee schedule,128.37,390.12,APC
Resp virus 3-5 targets,87631,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,142.63,,,,,,,fee schedule,128.37,390.12,APC
Resp virus 3-5 targets,87631,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,218.22,,,,,,,fee schedule,128.37,390.12,Radiology
Resp virus 3-5 targets,87631,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,199.68,,,,,,,fee schedule,128.37,390.12,APC
Resp virus 3-5 targets,87631,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,249.6,,,,,,,fee schedule,128.37,390.12,APC
Resp virus 6-11 targets,87632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,642.54,,,,,,,fee schedule,196.25,642.54,
Resp virus 6-11 targets,87632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,515.06,,,,,,,fee schedule,196.25,642.54,
Resp virus 6-11 targets,87632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,562.65,,,,,,,fee schedule,196.25,642.54,
Resp virus 6-11 targets,87632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,591.55,,,,,,,fee schedule,196.25,642.54,
Resp virus 6-11 targets,87632,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,196.25,,,,,,,fee schedule,196.25,642.54,Laboratory
Resp virus 6-11 targets,87632,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,228.96,,,,,,,fee schedule,196.25,642.54,APC
Resp virus 6-11 targets,87632,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,226.78,,,,,,,fee schedule,196.25,642.54,APC
Resp virus 6-11 targets,87632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,218.06,,,,,,,fee schedule,196.25,642.54,APC
Resp virus 6-11 targets,87632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,333.63,,,,,,,fee schedule,196.25,642.54,Radiology
Resp virus 6-11 targets,87632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,305.28,,,,,,,fee schedule,196.25,642.54,APC
Resp virus 6-11 targets,87632,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,381.6,,,,,,,fee schedule,196.25,642.54,APC
Resp virus 12-25 targets,87633,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2165.6,,,,,,,fee schedule,375.1,2165.6,
Resp virus 12-25 targets,87633,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1735.92,,,,,,,fee schedule,375.1,2165.6,
Resp virus 12-25 targets,87633,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1896.33,,,,,,,fee schedule,375.1,2165.6,
Resp virus 12-25 targets,87633,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1993.73,,,,,,,fee schedule,375.1,2165.6,
Resp virus 12-25 targets,87633,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,375.1,,,,,,,fee schedule,375.1,2165.6,Laboratory
Resp virus 12-25 targets,87633,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,437.62,,,,,,,fee schedule,375.1,2165.6,APC
Resp virus 12-25 targets,87633,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,433.45,,,,,,,fee schedule,375.1,2165.6,APC
Resp virus 12-25 targets,87633,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,416.78,,,,,,,fee schedule,375.1,2165.6,APC
Resp virus 12-25 targets,87633,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,637.67,,,,,,,fee schedule,375.1,2165.6,Radiology
Resp virus 12-25 targets,87633,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,583.49,,,,,,,fee schedule,375.1,2165.6,APC
Resp virus 12-25 targets,87633,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,729.36,,,,,,,fee schedule,375.1,2165.6,APC
Rsv dna/rna amp probe,87634,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,63.18,,,,,,,fee schedule,63.18,122.85,Laboratory
Rsv dna/rna amp probe,87634,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,73.71,,,,,,,fee schedule,63.18,122.85,APC
Rsv dna/rna amp probe,87634,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,73.01,,,,,,,fee schedule,63.18,122.85,APC
Rsv dna/rna amp probe,87634,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,70.2,,,,,,,fee schedule,63.18,122.85,APC
Rsv dna/rna amp probe,87634,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,107.41,,,,,,,fee schedule,63.18,122.85,Radiology
Rsv dna/rna amp probe,87634,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,98.28,,,,,,,fee schedule,63.18,122.85,APC
Rsv dna/rna amp probe,87634,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,122.85,,,,,,,fee schedule,63.18,122.85,APC
Sars-cov-2 covid-19 amp prb,87635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,194.03,,,,,,,fee schedule,46.18,194.03,
Sars-cov-2 covid-19 amp prb,87635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,155.53,,,,,,,fee schedule,46.18,194.03,
Sars-cov-2 covid-19 amp prb,87635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,169.9,,,,,,,fee schedule,46.18,194.03,
Sars-cov-2 covid-19 amp prb,87635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,178.63,,,,,,,fee schedule,46.18,194.03,
Sars-cov-2 covid-19 amp prb,87635,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46.18,,,,,,,fee schedule,46.18,194.03,Laboratory
Sars-cov-2 covid-19 amp prb,87635,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,53.88,,,,,,,fee schedule,46.18,194.03,APC
Sars-cov-2 covid-19 amp prb,87635,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,53.36,,,,,,,fee schedule,46.18,194.03,APC
Sars-cov-2 covid-19 amp prb,87635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,51.31,,,,,,,fee schedule,46.18,194.03,APC
Sars-cov-2 covid-19 amp prb,87635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,78.5,,,,,,,fee schedule,46.18,194.03,Radiology
Sars-cov-2 covid-19 amp prb,87635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,71.83,,,,,,,fee schedule,46.18,194.03,APC
Sars-cov-2 covid-19 amp prb,87635,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,89.79,,,,,,,fee schedule,46.18,194.03,APC
Sarscov2 & inf a&b amp prb,87636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,539.14,,,,,,,fee schedule,128.37,539.14,
Sarscov2 & inf a&b amp prb,87636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,432.17,,,,,,,fee schedule,128.37,539.14,
Sarscov2 & inf a&b amp prb,87636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,472.11,,,,,,,fee schedule,128.37,539.14,
Sarscov2 & inf a&b amp prb,87636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,496.35,,,,,,,fee schedule,128.37,539.14,
Sarscov2 & inf a&b amp prb,87636,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,128.37,,,,,,,fee schedule,128.37,539.14,Laboratory
Sarscov2 & inf a&b amp prb,87636,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,149.76,,,,,,,fee schedule,128.37,539.14,APC
Sarscov2 & inf a&b amp prb,87636,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,148.34,,,,,,,fee schedule,128.37,539.14,APC
Sarscov2 & inf a&b amp prb,87636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,142.63,,,,,,,fee schedule,128.37,539.14,APC
Sarscov2 & inf a&b amp prb,87636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,218.22,,,,,,,fee schedule,128.37,539.14,Radiology
Sarscov2 & inf a&b amp prb,87636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,199.68,,,,,,,fee schedule,128.37,539.14,APC
Sarscov2 & inf a&b amp prb,87636,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,249.6,,,,,,,fee schedule,128.37,539.14,APC
Sarscov2&inf a&b&rsv amp prb,87637,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,539.14,,,,,,,fee schedule,128.37,539.14,
Sarscov2&inf a&b&rsv amp prb,87637,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,432.17,,,,,,,fee schedule,128.37,539.14,
Sarscov2&inf a&b&rsv amp prb,87637,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,472.11,,,,,,,fee schedule,128.37,539.14,
Sarscov2&inf a&b&rsv amp prb,87637,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,496.35,,,,,,,fee schedule,128.37,539.14,
Sarscov2&inf a&b&rsv amp prb,87637,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,128.37,,,,,,,fee schedule,128.37,539.14,Laboratory
Sarscov2&inf a&b&rsv amp prb,87637,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,149.76,,,,,,,fee schedule,128.37,539.14,APC
Sarscov2&inf a&b&rsv amp prb,87637,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,148.34,,,,,,,fee schedule,128.37,539.14,APC
Sarscov2&inf a&b&rsv amp prb,87637,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,142.63,,,,,,,fee schedule,128.37,539.14,APC
Sarscov2&inf a&b&rsv amp prb,87637,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,218.22,,,,,,,fee schedule,128.37,539.14,Radiology
Sarscov2&inf a&b&rsv amp prb,87637,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,199.68,,,,,,,fee schedule,128.37,539.14,APC
Sarscov2&inf a&b&rsv amp prb,87637,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,249.6,,,,,,,fee schedule,128.37,539.14,APC
Staph a dna amp probe,87640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,193.73,,,,,,,fee schedule,31.58,193.73,
Staph a dna amp probe,87640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,155.29,,,,,,,fee schedule,31.58,193.73,
Staph a dna amp probe,87640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,169.64,,,,,,,fee schedule,31.58,193.73,
Staph a dna amp probe,87640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,178.35,,,,,,,fee schedule,31.58,193.73,
Staph a dna amp probe,87640,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31.58,,,,,,,fee schedule,31.58,193.73,Laboratory
Staph a dna amp probe,87640,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,31.58,193.73,APC
Staph a dna amp probe,87640,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,36.49,,,,,,,fee schedule,31.58,193.73,APC
Staph a dna amp probe,87640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,35.09,,,,,,,fee schedule,31.58,193.73,APC
Staph a dna amp probe,87640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,53.69,,,,,,,fee schedule,31.58,193.73,Radiology
Staph a dna amp probe,87640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49.13,,,,,,,fee schedule,31.58,193.73,APC
Staph a dna amp probe,87640,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,61.41,,,,,,,fee schedule,31.58,193.73,APC
Mr-staph dna amp probe,87641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,119.2,,,,,,,fee schedule,31.58,119.2,
Mr-staph dna amp probe,87641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,95.55,,,,,,,fee schedule,31.58,119.2,
Mr-staph dna amp probe,87641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,104.38,,,,,,,fee schedule,31.58,119.2,
Mr-staph dna amp probe,87641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,109.74,,,,,,,fee schedule,31.58,119.2,
Mr-staph dna amp probe,87641,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31.58,,,,,,,fee schedule,31.58,119.2,Laboratory
Mr-staph dna amp probe,87641,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,31.58,119.2,APC
Mr-staph dna amp probe,87641,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,36.49,,,,,,,fee schedule,31.58,119.2,APC
Mr-staph dna amp probe,87641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,35.09,,,,,,,fee schedule,31.58,119.2,APC
Mr-staph dna amp probe,87641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,53.69,,,,,,,fee schedule,31.58,119.2,Radiology
Mr-staph dna amp probe,87641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49.13,,,,,,,fee schedule,31.58,119.2,APC
Mr-staph dna amp probe,87641,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,61.41,,,,,,,fee schedule,31.58,119.2,APC
Strep a dna dir probe,87650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,64.07,,,,,,,fee schedule,18.05,64.07,
Strep a dna dir probe,87650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.36,,,,,,,fee schedule,18.05,64.07,
Strep a dna dir probe,87650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56.11,,,,,,,fee schedule,18.05,64.07,
Strep a dna dir probe,87650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,58.99,,,,,,,fee schedule,18.05,64.07,
Strep a dna dir probe,87650,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.05,,,,,,,fee schedule,18.05,64.07,Laboratory
Strep a dna dir probe,87650,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.05,,,,,,,fee schedule,18.05,64.07,APC
Strep a dna dir probe,87650,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,20.85,,,,,,,fee schedule,18.05,64.07,APC
Strep a dna dir probe,87650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,20.05,,,,,,,fee schedule,18.05,64.07,APC
Strep a dna dir probe,87650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,30.68,,,,,,,fee schedule,18.05,64.07,Radiology
Strep a dna dir probe,87650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.07,,,,,,,fee schedule,18.05,64.07,APC
Strep a dna dir probe,87650,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,35.09,,,,,,,fee schedule,18.05,64.07,APC
Strep a dna amp probe,87651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,193.73,,,,,,,fee schedule,31.58,193.73,
Strep a dna amp probe,87651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,155.29,,,,,,,fee schedule,31.58,193.73,
Strep a dna amp probe,87651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,169.64,,,,,,,fee schedule,31.58,193.73,
Strep a dna amp probe,87651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,178.35,,,,,,,fee schedule,31.58,193.73,
Strep a dna amp probe,87651,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31.58,,,,,,,fee schedule,31.58,193.73,Laboratory
Strep a dna amp probe,87651,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,31.58,193.73,APC
Strep a dna amp probe,87651,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,36.49,,,,,,,fee schedule,31.58,193.73,APC
Strep a dna amp probe,87651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,35.09,,,,,,,fee schedule,31.58,193.73,APC
Strep a dna amp probe,87651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,53.69,,,,,,,fee schedule,31.58,193.73,Radiology
Strep a dna amp probe,87651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49.13,,,,,,,fee schedule,31.58,193.73,APC
Strep a dna amp probe,87651,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,61.41,,,,,,,fee schedule,31.58,193.73,APC
Strep a dna quant,87652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,88.49,,,,,,,fee schedule,37.58,88.49,
Strep a dna quant,87652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,70.93,,,,,,,fee schedule,37.58,88.49,
Strep a dna quant,87652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,77.49,,,,,,,fee schedule,37.58,88.49,
Strep a dna quant,87652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,81.47,,,,,,,fee schedule,37.58,88.49,
Strep a dna quant,87652,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,37.58,,,,,,,fee schedule,37.58,88.49,Laboratory
Strep a dna quant,87652,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,43.85,,,,,,,fee schedule,37.58,88.49,APC
Strep a dna quant,87652,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,43.43,,,,,,,fee schedule,37.58,88.49,APC
Strep a dna quant,87652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,41.76,,,,,,,fee schedule,37.58,88.49,APC
Strep a dna quant,87652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,63.89,,,,,,,fee schedule,37.58,88.49,Radiology
Strep a dna quant,87652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,58.46,,,,,,,fee schedule,37.58,88.49,APC
Strep a dna quant,87652,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,73.08,,,,,,,fee schedule,37.58,88.49,APC
Strep b dna amp probe,87653,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,114.09,,,,,,,fee schedule,31.58,114.09,
Strep b dna amp probe,87653,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,91.45,,,,,,,fee schedule,31.58,114.09,
Strep b dna amp probe,87653,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,99.9,,,,,,,fee schedule,31.58,114.09,
Strep b dna amp probe,87653,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,105.04,,,,,,,fee schedule,31.58,114.09,
Strep b dna amp probe,87653,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31.58,,,,,,,fee schedule,31.58,114.09,Laboratory
Strep b dna amp probe,87653,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,31.58,114.09,APC
Strep b dna amp probe,87653,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,36.49,,,,,,,fee schedule,31.58,114.09,APC
Strep b dna amp probe,87653,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,35.09,,,,,,,fee schedule,31.58,114.09,APC
Strep b dna amp probe,87653,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,53.69,,,,,,,fee schedule,31.58,114.09,Radiology
Strep b dna amp probe,87653,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49.13,,,,,,,fee schedule,31.58,114.09,APC
Strep b dna amp probe,87653,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,61.41,,,,,,,fee schedule,31.58,114.09,APC
Trichomonas vagin dir probe,87660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,63.29,,,,,,,fee schedule,18.05,63.29,
Trichomonas vagin dir probe,87660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,50.73,,,,,,,fee schedule,18.05,63.29,
Trichomonas vagin dir probe,87660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55.42,,,,,,,fee schedule,18.05,63.29,
Trichomonas vagin dir probe,87660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,58.26,,,,,,,fee schedule,18.05,63.29,
Trichomonas vagin dir probe,87660,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.05,,,,,,,fee schedule,18.05,63.29,Laboratory
Trichomonas vagin dir probe,87660,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.05,,,,,,,fee schedule,18.05,63.29,APC
Trichomonas vagin dir probe,87660,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,20.85,,,,,,,fee schedule,18.05,63.29,APC
Trichomonas vagin dir probe,87660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,20.05,,,,,,,fee schedule,18.05,63.29,APC
Trichomonas vagin dir probe,87660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,30.68,,,,,,,fee schedule,18.05,63.29,Radiology
Trichomonas vagin dir probe,87660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.07,,,,,,,fee schedule,18.05,63.29,APC
Trichomonas vagin dir probe,87660,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,35.09,,,,,,,fee schedule,18.05,63.29,APC
Trichomonas vaginalis amplif,87661,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,180.53,,,,,,,fee schedule,31.58,180.53,
Trichomonas vaginalis amplif,87661,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,144.71,,,,,,,fee schedule,31.58,180.53,
Trichomonas vaginalis amplif,87661,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,158.09,,,,,,,fee schedule,31.58,180.53,
Trichomonas vaginalis amplif,87661,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,166.2,,,,,,,fee schedule,31.58,180.53,
Trichomonas vaginalis amplif,87661,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31.58,,,,,,,fee schedule,31.58,180.53,Laboratory
Trichomonas vaginalis amplif,87661,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,31.58,180.53,APC
Trichomonas vaginalis amplif,87661,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,36.49,,,,,,,fee schedule,31.58,180.53,APC
Trichomonas vaginalis amplif,87661,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,35.09,,,,,,,fee schedule,31.58,180.53,APC
Trichomonas vaginalis amplif,87661,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,53.69,,,,,,,fee schedule,31.58,180.53,Radiology
Trichomonas vaginalis amplif,87661,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49.13,,,,,,,fee schedule,31.58,180.53,APC
Trichomonas vaginalis amplif,87661,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,61.41,,,,,,,fee schedule,31.58,180.53,APC
Zika virus dna/rna amp probe,87662,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46.18,,,,,,,fee schedule,46.18,89.79,Laboratory
Zika virus dna/rna amp probe,87662,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,53.88,,,,,,,fee schedule,46.18,89.79,APC
Zika virus dna/rna amp probe,87662,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,53.36,,,,,,,fee schedule,46.18,89.79,APC
Zika virus dna/rna amp probe,87662,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,51.31,,,,,,,fee schedule,46.18,89.79,APC
Zika virus dna/rna amp probe,87662,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,78.5,,,,,,,fee schedule,46.18,89.79,Radiology
Zika virus dna/rna amp probe,87662,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,71.83,,,,,,,fee schedule,46.18,89.79,APC
Zika virus dna/rna amp probe,87662,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,89.79,,,,,,,fee schedule,46.18,89.79,APC
Detect agent nos dna dir,87797,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,110.64,,,,,,,fee schedule,27.03,110.64,
Detect agent nos dna dir,87797,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,88.69,,,,,,,fee schedule,27.03,110.64,
Detect agent nos dna dir,87797,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,96.88,,,,,,,fee schedule,27.03,110.64,
Detect agent nos dna dir,87797,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,101.86,,,,,,,fee schedule,27.03,110.64,
Detect agent nos dna dir,87797,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,27.03,,,,,,,fee schedule,27.03,110.64,Laboratory
Detect agent nos dna dir,87797,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,31.53,,,,,,,fee schedule,27.03,110.64,APC
Detect agent nos dna dir,87797,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,31.23,,,,,,,fee schedule,27.03,110.64,APC
Detect agent nos dna dir,87797,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,30.03,,,,,,,fee schedule,27.03,110.64,APC
Detect agent nos dna dir,87797,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,45.95,,,,,,,fee schedule,27.03,110.64,Radiology
Detect agent nos dna dir,87797,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,42.04,,,,,,,fee schedule,27.03,110.64,APC
Detect agent nos dna dir,87797,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,52.55,,,,,,,fee schedule,27.03,110.64,APC
Detect agent nos dna amp,87798,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,143.31,,,,,,,fee schedule,31.58,143.31,
Detect agent nos dna amp,87798,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,114.88,,,,,,,fee schedule,31.58,143.31,
Detect agent nos dna amp,87798,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,125.49,,,,,,,fee schedule,31.58,143.31,
Detect agent nos dna amp,87798,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,131.94,,,,,,,fee schedule,31.58,143.31,
Detect agent nos dna amp,87798,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31.58,,,,,,,fee schedule,31.58,143.31,Laboratory
Detect agent nos dna amp,87798,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,31.58,143.31,APC
Detect agent nos dna amp,87798,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,36.49,,,,,,,fee schedule,31.58,143.31,APC
Detect agent nos dna amp,87798,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,35.09,,,,,,,fee schedule,31.58,143.31,APC
Detect agent nos dna amp,87798,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,53.69,,,,,,,fee schedule,31.58,143.31,Radiology
Detect agent nos dna amp,87798,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49.13,,,,,,,fee schedule,31.58,143.31,APC
Detect agent nos dna amp,87798,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,61.41,,,,,,,fee schedule,31.58,143.31,APC
Detect agent nos dna quant,87799,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,164.7,,,,,,,fee schedule,38.56,164.7,
Detect agent nos dna quant,87799,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,132.02,,,,,,,fee schedule,38.56,164.7,
Detect agent nos dna quant,87799,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,144.22,,,,,,,fee schedule,38.56,164.7,
Detect agent nos dna quant,87799,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,151.62,,,,,,,fee schedule,38.56,164.7,
Detect agent nos dna quant,87799,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,38.56,,,,,,,fee schedule,38.56,164.7,Laboratory
Detect agent nos dna quant,87799,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,44.98,,,,,,,fee schedule,38.56,164.7,APC
Detect agent nos dna quant,87799,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,44.55,,,,,,,fee schedule,38.56,164.7,APC
Detect agent nos dna quant,87799,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,42.84,,,,,,,fee schedule,38.56,164.7,APC
Detect agent nos dna quant,87799,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,65.55,,,,,,,fee schedule,38.56,164.7,Radiology
Detect agent nos dna quant,87799,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,59.98,,,,,,,fee schedule,38.56,164.7,APC
Detect agent nos dna quant,87799,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,74.97,,,,,,,fee schedule,38.56,164.7,APC
Detect agnt mult dna direc,87800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,221.36,,,,,,,fee schedule,39.3,221.36,
Detect agnt mult dna direc,87800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,177.44,,,,,,,fee schedule,39.3,221.36,
Detect agnt mult dna direc,87800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,193.83,,,,,,,fee schedule,39.3,221.36,
Detect agnt mult dna direc,87800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,203.79,,,,,,,fee schedule,39.3,221.36,
Detect agnt mult dna direc,87800,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,39.3,,,,,,,fee schedule,39.3,221.36,Laboratory
Detect agnt mult dna direc,87800,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,45.85,,,,,,,fee schedule,39.3,221.36,APC
Detect agnt mult dna direc,87800,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,45.42,,,,,,,fee schedule,39.3,221.36,APC
Detect agnt mult dna direc,87800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,43.67,,,,,,,fee schedule,39.3,221.36,APC
Detect agnt mult dna direc,87800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,66.82,,,,,,,fee schedule,39.3,221.36,Radiology
Detect agnt mult dna direc,87800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,61.14,,,,,,,fee schedule,39.3,221.36,APC
Detect agnt mult dna direc,87800,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,76.42,,,,,,,fee schedule,39.3,221.36,APC
Detect agnt mult dna ampli,87801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,194.28,,,,,,,fee schedule,63.18,194.28,
Detect agnt mult dna ampli,87801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,155.73,,,,,,,fee schedule,63.18,194.28,
Detect agnt mult dna ampli,87801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,170.12,,,,,,,fee schedule,63.18,194.28,
Detect agnt mult dna ampli,87801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,178.86,,,,,,,fee schedule,63.18,194.28,
Detect agnt mult dna ampli,87801,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,63.18,,,,,,,fee schedule,63.18,194.28,Laboratory
Detect agnt mult dna ampli,87801,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,73.71,,,,,,,fee schedule,63.18,194.28,APC
Detect agnt mult dna ampli,87801,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,73.01,,,,,,,fee schedule,63.18,194.28,APC
Detect agnt mult dna ampli,87801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,70.2,,,,,,,fee schedule,63.18,194.28,APC
Detect agnt mult dna ampli,87801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,107.41,,,,,,,fee schedule,63.18,194.28,Radiology
Detect agnt mult dna ampli,87801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,98.28,,,,,,,fee schedule,63.18,194.28,APC
Detect agnt mult dna ampli,87801,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,122.85,,,,,,,fee schedule,63.18,194.28,APC
Strep b assay w/optic,87802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.23,,,,,,,fee schedule,11.46,66.23,
Strep b assay w/optic,87802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.09,,,,,,,fee schedule,11.46,66.23,
Strep b assay w/optic,87802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.99,,,,,,,fee schedule,11.46,66.23,
Strep b assay w/optic,87802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.97,,,,,,,fee schedule,11.46,66.23,
Strep b assay w/optic,87802,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.46,,,,,,,fee schedule,11.46,66.23,Laboratory
Strep b assay w/optic,87802,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.37,,,,,,,fee schedule,11.46,66.23,APC
Strep b assay w/optic,87802,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.24,,,,,,,fee schedule,11.46,66.23,APC
Strep b assay w/optic,87802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.73,,,,,,,fee schedule,11.46,66.23,APC
Strep b assay w/optic,87802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.48,,,,,,,fee schedule,11.46,66.23,Radiology
Strep b assay w/optic,87802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.82,,,,,,,fee schedule,11.46,66.23,APC
Strep b assay w/optic,87802,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22.28,,,,,,,fee schedule,11.46,66.23,APC
Clostridium toxin a w/optic,87803,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.23,,,,,,,fee schedule,14.4,66.23,
Clostridium toxin a w/optic,87803,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.09,,,,,,,fee schedule,14.4,66.23,
Clostridium toxin a w/optic,87803,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.99,,,,,,,fee schedule,14.4,66.23,
Clostridium toxin a w/optic,87803,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.97,,,,,,,fee schedule,14.4,66.23,
Clostridium toxin a w/optic,87803,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.4,,,,,,,fee schedule,14.4,66.23,Laboratory
Clostridium toxin a w/optic,87803,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.8,,,,,,,fee schedule,14.4,66.23,APC
Clostridium toxin a w/optic,87803,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,16.64,,,,,,,fee schedule,14.4,66.23,APC
Clostridium toxin a w/optic,87803,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16,,,,,,,fee schedule,14.4,66.23,APC
Clostridium toxin a w/optic,87803,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24.48,,,,,,,fee schedule,14.4,66.23,Radiology
Clostridium toxin a w/optic,87803,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.4,,,,,,,fee schedule,14.4,66.23,APC
Clostridium toxin a w/optic,87803,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,28,,,,,,,fee schedule,14.4,66.23,APC
Influenza assay w/optic,87804,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37.43,,,,,,,fee schedule,14.9,37.43,
Influenza assay w/optic,87804,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,30,,,,,,,fee schedule,14.9,37.43,
Influenza assay w/optic,87804,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32.78,,,,,,,fee schedule,14.9,37.43,
Influenza assay w/optic,87804,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,34.46,,,,,,,fee schedule,14.9,37.43,
Influenza assay w/optic,87804,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.9,,,,,,,fee schedule,14.9,37.43,Laboratory
Influenza assay w/optic,87804,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.38,,,,,,,fee schedule,14.9,37.43,APC
Influenza assay w/optic,87804,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,17.21,,,,,,,fee schedule,14.9,37.43,APC
Influenza assay w/optic,87804,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16.55,,,,,,,fee schedule,14.9,37.43,APC
Influenza assay w/optic,87804,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.32,,,,,,,fee schedule,14.9,37.43,Radiology
Influenza assay w/optic,87804,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.17,,,,,,,fee schedule,14.9,37.43,APC
Influenza assay w/optic,87804,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,28.96,,,,,,,fee schedule,14.9,37.43,APC
Hiv antigen w/hiv antibodies,87806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,123.87,,,,,,,fee schedule,29.49,123.87,
Hiv antigen w/hiv antibodies,87806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,99.29,,,,,,,fee schedule,29.49,123.87,
Hiv antigen w/hiv antibodies,87806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,108.47,,,,,,,fee schedule,29.49,123.87,
Hiv antigen w/hiv antibodies,87806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,114.04,,,,,,,fee schedule,29.49,123.87,
Hiv antigen w/hiv antibodies,87806,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,29.49,,,,,,,fee schedule,29.49,123.87,Laboratory
Hiv antigen w/hiv antibodies,87806,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,34.41,,,,,,,fee schedule,29.49,123.87,APC
Hiv antigen w/hiv antibodies,87806,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,34.08,,,,,,,fee schedule,29.49,123.87,APC
Hiv antigen w/hiv antibodies,87806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,32.77,,,,,,,fee schedule,29.49,123.87,APC
Hiv antigen w/hiv antibodies,87806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,50.14,,,,,,,fee schedule,29.49,123.87,Radiology
Hiv antigen w/hiv antibodies,87806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,45.88,,,,,,,fee schedule,29.49,123.87,APC
Hiv antigen w/hiv antibodies,87806,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,57.35,,,,,,,fee schedule,29.49,123.87,APC
Rsv assay w/optic,87807,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,51.68,,,,,,,fee schedule,11.79,51.68,
Rsv assay w/optic,87807,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,41.43,,,,,,,fee schedule,11.79,51.68,
Rsv assay w/optic,87807,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,45.25,,,,,,,fee schedule,11.79,51.68,
Rsv assay w/optic,87807,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,47.58,,,,,,,fee schedule,11.79,51.68,
Rsv assay w/optic,87807,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.79,,,,,,,fee schedule,11.79,51.68,Laboratory
Rsv assay w/optic,87807,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.76,,,,,,,fee schedule,11.79,51.68,APC
Rsv assay w/optic,87807,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.62,,,,,,,fee schedule,11.79,51.68,APC
Rsv assay w/optic,87807,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.1,,,,,,,fee schedule,11.79,51.68,APC
Rsv assay w/optic,87807,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.04,,,,,,,fee schedule,11.79,51.68,Radiology
Rsv assay w/optic,87807,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.34,,,,,,,fee schedule,11.79,51.68,APC
Rsv assay w/optic,87807,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22.92,,,,,,,fee schedule,11.79,51.68,APC
Trichomonas assay w/optic,87808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.23,,,,,,,fee schedule,13.76,66.23,
Trichomonas assay w/optic,87808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.09,,,,,,,fee schedule,13.76,66.23,
Trichomonas assay w/optic,87808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.99,,,,,,,fee schedule,13.76,66.23,
Trichomonas assay w/optic,87808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.97,,,,,,,fee schedule,13.76,66.23,
Trichomonas assay w/optic,87808,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.76,,,,,,,fee schedule,13.76,66.23,Laboratory
Trichomonas assay w/optic,87808,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.05,,,,,,,fee schedule,13.76,66.23,APC
Trichomonas assay w/optic,87808,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,15.9,,,,,,,fee schedule,13.76,66.23,APC
Trichomonas assay w/optic,87808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,15.29,,,,,,,fee schedule,13.76,66.23,APC
Trichomonas assay w/optic,87808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.39,,,,,,,fee schedule,13.76,66.23,Radiology
Trichomonas assay w/optic,87808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21.41,,,,,,,fee schedule,13.76,66.23,APC
Trichomonas assay w/optic,87808,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,26.76,,,,,,,fee schedule,13.76,66.23,APC
Adenovirus assay w/optic,87809,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.23,,,,,,,fee schedule,19.58,66.23,
Adenovirus assay w/optic,87809,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.09,,,,,,,fee schedule,19.58,66.23,
Adenovirus assay w/optic,87809,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.99,,,,,,,fee schedule,19.58,66.23,
Adenovirus assay w/optic,87809,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.97,,,,,,,fee schedule,19.58,66.23,
Adenovirus assay w/optic,87809,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.58,,,,,,,fee schedule,19.58,66.23,Laboratory
Adenovirus assay w/optic,87809,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,22.85,,,,,,,fee schedule,19.58,66.23,APC
Adenovirus assay w/optic,87809,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,22.63,,,,,,,fee schedule,19.58,66.23,APC
Adenovirus assay w/optic,87809,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,21.76,,,,,,,fee schedule,19.58,66.23,APC
Adenovirus assay w/optic,87809,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,33.29,,,,,,,fee schedule,19.58,66.23,Radiology
Adenovirus assay w/optic,87809,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,30.46,,,,,,,fee schedule,19.58,66.23,APC
Adenovirus assay w/optic,87809,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,38.08,,,,,,,fee schedule,19.58,66.23,APC
Chylmd trach assay w/optic,87810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.23,,,,,,,fee schedule,31.76,66.23,
Chylmd trach assay w/optic,87810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.09,,,,,,,fee schedule,31.76,66.23,
Chylmd trach assay w/optic,87810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.99,,,,,,,fee schedule,31.76,66.23,
Chylmd trach assay w/optic,87810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.97,,,,,,,fee schedule,31.76,66.23,
Chylmd trach assay w/optic,87810,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31.76,,,,,,,fee schedule,31.76,66.23,Laboratory
Chylmd trach assay w/optic,87810,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,37.05,,,,,,,fee schedule,31.76,66.23,APC
Chylmd trach assay w/optic,87810,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,36.7,,,,,,,fee schedule,31.76,66.23,APC
Chylmd trach assay w/optic,87810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,35.29,,,,,,,fee schedule,31.76,66.23,APC
Chylmd trach assay w/optic,87810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,53.99,,,,,,,fee schedule,31.76,66.23,Radiology
Chylmd trach assay w/optic,87810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49.41,,,,,,,fee schedule,31.76,66.23,APC
Chylmd trach assay w/optic,87810,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,61.76,,,,,,,fee schedule,31.76,66.23,APC
Sars-cov-2 covid19 w/optic,87811,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,156.42,,,,,,,fee schedule,37.24,156.42,
Sars-cov-2 covid19 w/optic,87811,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,125.38,,,,,,,fee schedule,37.24,156.42,
Sars-cov-2 covid19 w/optic,87811,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,136.97,,,,,,,fee schedule,37.24,156.42,
Sars-cov-2 covid19 w/optic,87811,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,144,,,,,,,fee schedule,37.24,156.42,
Sars-cov-2 covid19 w/optic,87811,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,37.24,,,,,,,fee schedule,37.24,156.42,Laboratory
Sars-cov-2 covid19 w/optic,87811,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,43.45,,,,,,,fee schedule,37.24,156.42,APC
Sars-cov-2 covid19 w/optic,87811,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,43.04,,,,,,,fee schedule,37.24,156.42,APC
Sars-cov-2 covid19 w/optic,87811,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,41.38,,,,,,,fee schedule,37.24,156.42,APC
Sars-cov-2 covid19 w/optic,87811,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,63.31,,,,,,,fee schedule,37.24,156.42,Radiology
Sars-cov-2 covid19 w/optic,87811,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,57.93,,,,,,,fee schedule,37.24,156.42,APC
Sars-cov-2 covid19 w/optic,87811,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,72.42,,,,,,,fee schedule,37.24,156.42,APC
Sarscov2&inf typ a&b w/optic,87812,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,67.03,,,,,,,fee schedule,67.03,130.34,Laboratory
Sarscov2&inf typ a&b w/optic,87812,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,78.2,,,,,,,fee schedule,67.03,130.34,APC
Sarscov2&inf typ a&b w/optic,87812,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,77.46,,,,,,,fee schedule,67.03,130.34,APC
Sarscov2&inf typ a&b w/optic,87812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,74.48,,,,,,,fee schedule,67.03,130.34,APC
Sarscov2&inf typ a&b w/optic,87812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,113.95,,,,,,,fee schedule,67.03,130.34,Radiology
Sarscov2&inf typ a&b w/optic,87812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,104.27,,,,,,,fee schedule,67.03,130.34,APC
Sarscov2&inf typ a&b w/optic,87812,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,130.34,,,,,,,fee schedule,67.03,130.34,APC
N. gonorrhoeae assay w/optic,87850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.23,,,,,,,fee schedule,22.1,66.23,
N. gonorrhoeae assay w/optic,87850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.09,,,,,,,fee schedule,22.1,66.23,
N. gonorrhoeae assay w/optic,87850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.99,,,,,,,fee schedule,22.1,66.23,
N. gonorrhoeae assay w/optic,87850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.97,,,,,,,fee schedule,22.1,66.23,
N. gonorrhoeae assay w/optic,87850,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22.1,,,,,,,fee schedule,22.1,66.23,Laboratory
N. gonorrhoeae assay w/optic,87850,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,25.79,,,,,,,fee schedule,22.1,66.23,APC
N. gonorrhoeae assay w/optic,87850,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,25.54,,,,,,,fee schedule,22.1,66.23,APC
N. gonorrhoeae assay w/optic,87850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,24.56,,,,,,,fee schedule,22.1,66.23,APC
N. gonorrhoeae assay w/optic,87850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,37.58,,,,,,,fee schedule,22.1,66.23,Radiology
N. gonorrhoeae assay w/optic,87850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,34.38,,,,,,,fee schedule,22.1,66.23,APC
N. gonorrhoeae assay w/optic,87850,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,42.98,,,,,,,fee schedule,22.1,66.23,APC
Strep a assay w/optic,87880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,64.77,,,,,,,fee schedule,14.88,64.77,
Strep a assay w/optic,87880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.92,,,,,,,fee schedule,14.88,64.77,
Strep a assay w/optic,87880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56.71,,,,,,,fee schedule,14.88,64.77,
Strep a assay w/optic,87880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59.63,,,,,,,fee schedule,14.88,64.77,
Strep a assay w/optic,87880,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.88,,,,,,,fee schedule,14.88,64.77,Laboratory
Strep a assay w/optic,87880,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.36,,,,,,,fee schedule,14.88,64.77,APC
Strep a assay w/optic,87880,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,17.19,,,,,,,fee schedule,14.88,64.77,APC
Strep a assay w/optic,87880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16.53,,,,,,,fee schedule,14.88,64.77,APC
Strep a assay w/optic,87880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.29,,,,,,,fee schedule,14.88,64.77,Radiology
Strep a assay w/optic,87880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.14,,,,,,,fee schedule,14.88,64.77,APC
Strep a assay w/optic,87880,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,28.93,,,,,,,fee schedule,14.88,64.77,APC
Agent nos assay w/optic,87899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45.9,,,,,,,fee schedule,14.46,45.9,
Agent nos assay w/optic,87899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36.8,,,,,,,fee schedule,14.46,45.9,
Agent nos assay w/optic,87899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40.2,,,,,,,fee schedule,14.46,45.9,
Agent nos assay w/optic,87899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42.26,,,,,,,fee schedule,14.46,45.9,
Agent nos assay w/optic,87899,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.46,,,,,,,fee schedule,14.46,45.9,Laboratory
Agent nos assay w/optic,87899,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.87,,,,,,,fee schedule,14.46,45.9,APC
Agent nos assay w/optic,87899,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,16.71,,,,,,,fee schedule,14.46,45.9,APC
Agent nos assay w/optic,87899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16.07,,,,,,,fee schedule,14.46,45.9,APC
Agent nos assay w/optic,87899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24.59,,,,,,,fee schedule,14.46,45.9,Radiology
Agent nos assay w/optic,87899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.5,,,,,,,fee schedule,14.46,45.9,APC
Agent nos assay w/optic,87899,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,28.12,,,,,,,fee schedule,14.46,45.9,APC
Phenotype infect agent drug,87900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,719.37,,,,,,,fee schedule,117.32,719.37,
Phenotype infect agent drug,87900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,576.64,,,,,,,fee schedule,117.32,719.37,
Phenotype infect agent drug,87900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,629.93,,,,,,,fee schedule,117.32,719.37,
Phenotype infect agent drug,87900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,662.28,,,,,,,fee schedule,117.32,719.37,
Phenotype infect agent drug,87900,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,117.32,,,,,,,fee schedule,117.32,719.37,Laboratory
Phenotype infect agent drug,87900,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,136.87,,,,,,,fee schedule,117.32,719.37,APC
Phenotype infect agent drug,87900,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,135.56,,,,,,,fee schedule,117.32,719.37,APC
Phenotype infect agent drug,87900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,130.35,,,,,,,fee schedule,117.32,719.37,APC
Phenotype infect agent drug,87900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,199.44,,,,,,,fee schedule,117.32,719.37,Radiology
Phenotype infect agent drug,87900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,182.49,,,,,,,fee schedule,117.32,719.37,APC
Phenotype infect agent drug,87900,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,228.11,,,,,,,fee schedule,117.32,719.37,APC
Genotype dna hiv reverse t,87901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1420.83,,,,,,,fee schedule,231.7,1420.83,
Genotype dna hiv reverse t,87901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1138.92,,,,,,,fee schedule,231.7,1420.83,
Genotype dna hiv reverse t,87901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1244.16,,,,,,,fee schedule,231.7,1420.83,
Genotype dna hiv reverse t,87901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1308.06,,,,,,,fee schedule,231.7,1420.83,
Genotype dna hiv reverse t,87901,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,231.7,,,,,,,fee schedule,231.7,1420.83,Laboratory
Genotype dna hiv reverse t,87901,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,270.32,,,,,,,fee schedule,231.7,1420.83,APC
Genotype dna hiv reverse t,87901,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,267.75,,,,,,,fee schedule,231.7,1420.83,APC
Genotype dna hiv reverse t,87901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,257.45,,,,,,,fee schedule,231.7,1420.83,APC
Genotype dna hiv reverse t,87901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,393.9,,,,,,,fee schedule,231.7,1420.83,Radiology
Genotype dna hiv reverse t,87901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,360.43,,,,,,,fee schedule,231.7,1420.83,APC
Genotype dna hiv reverse t,87901,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,450.54,,,,,,,fee schedule,231.7,1420.83,APC
Genotype dna/rna hep c,87902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,799.62,,,,,,,fee schedule,231.7,799.62,
Genotype dna/rna hep c,87902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,640.97,,,,,,,fee schedule,231.7,799.62,
Genotype dna/rna hep c,87902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,700.2,,,,,,,fee schedule,231.7,799.62,
Genotype dna/rna hep c,87902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,736.16,,,,,,,fee schedule,231.7,799.62,
Genotype dna/rna hep c,87902,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,231.7,,,,,,,fee schedule,231.7,799.62,Laboratory
Genotype dna/rna hep c,87902,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,270.32,,,,,,,fee schedule,231.7,799.62,APC
Genotype dna/rna hep c,87902,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,267.75,,,,,,,fee schedule,231.7,799.62,APC
Genotype dna/rna hep c,87902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,257.45,,,,,,,fee schedule,231.7,799.62,APC
Genotype dna/rna hep c,87902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,393.9,,,,,,,fee schedule,231.7,799.62,Radiology
Genotype dna/rna hep c,87902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,360.43,,,,,,,fee schedule,231.7,799.62,APC
Genotype dna/rna hep c,87902,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,450.54,,,,,,,fee schedule,231.7,799.62,APC
Phenotype dna hiv w/culture,87903,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2696.77,,,,,,,fee schedule,439.79,2696.77,
Phenotype dna hiv w/culture,87903,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2161.69,,,,,,,fee schedule,439.79,2696.77,
Phenotype dna hiv w/culture,87903,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2361.45,,,,,,,fee schedule,439.79,2696.77,
Phenotype dna hiv w/culture,87903,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2482.74,,,,,,,fee schedule,439.79,2696.77,
Phenotype dna hiv w/culture,87903,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,439.79,,,,,,,fee schedule,439.79,2696.77,Laboratory
Phenotype dna hiv w/culture,87903,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,513.09,,,,,,,fee schedule,439.79,2696.77,APC
Phenotype dna hiv w/culture,87903,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,508.21,,,,,,,fee schedule,439.79,2696.77,APC
Phenotype dna hiv w/culture,87903,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,488.66,,,,,,,fee schedule,439.79,2696.77,APC
Phenotype dna hiv w/culture,87903,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,747.65,,,,,,,fee schedule,439.79,2696.77,Radiology
Phenotype dna hiv w/culture,87903,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,684.12,,,,,,,fee schedule,439.79,2696.77,APC
Phenotype dna hiv w/culture,87903,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,855.16,,,,,,,fee schedule,439.79,2696.77,APC
Phenotype dna hiv w/clt add,87904,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,143.87,,,,,,,fee schedule,23.46,143.87,
Phenotype dna hiv w/clt add,87904,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,115.32,,,,,,,fee schedule,23.46,143.87,
Phenotype dna hiv w/clt add,87904,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,125.98,,,,,,,fee schedule,23.46,143.87,
Phenotype dna hiv w/clt add,87904,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,132.45,,,,,,,fee schedule,23.46,143.87,
Phenotype dna hiv w/clt add,87904,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23.46,,,,,,,fee schedule,23.46,143.87,Laboratory
Phenotype dna hiv w/clt add,87904,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,27.37,,,,,,,fee schedule,23.46,143.87,APC
Phenotype dna hiv w/clt add,87904,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,27.11,,,,,,,fee schedule,23.46,143.87,APC
Phenotype dna hiv w/clt add,87904,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,26.07,,,,,,,fee schedule,23.46,143.87,APC
Phenotype dna hiv w/clt add,87904,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,39.89,,,,,,,fee schedule,23.46,143.87,Radiology
Phenotype dna hiv w/clt add,87904,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,36.5,,,,,,,fee schedule,23.46,143.87,APC
Phenotype dna hiv w/clt add,87904,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,45.62,,,,,,,fee schedule,23.46,143.87,APC
Sialidase enzyme assay,87905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,67.44,,,,,,,fee schedule,11,67.44,
Sialidase enzyme assay,87905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,54.06,,,,,,,fee schedule,11,67.44,
Sialidase enzyme assay,87905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,59.05,,,,,,,fee schedule,11,67.44,
Sialidase enzyme assay,87905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,62.08,,,,,,,fee schedule,11,67.44,
Sialidase enzyme assay,87905,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11,,,,,,,fee schedule,11,67.44,Laboratory
Sialidase enzyme assay,87905,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.83,,,,,,,fee schedule,11,67.44,APC
Sialidase enzyme assay,87905,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.71,,,,,,,fee schedule,11,67.44,APC
Sialidase enzyme assay,87905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.22,,,,,,,fee schedule,11,67.44,APC
Sialidase enzyme assay,87905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.7,,,,,,,fee schedule,11,67.44,Radiology
Sialidase enzyme assay,87905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.11,,,,,,,fee schedule,11,67.44,APC
Sialidase enzyme assay,87905,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21.38,,,,,,,fee schedule,11,67.44,APC
Genotype dna/rna hiv,87906,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,115.86,,,,,,,fee schedule,115.86,225.28,Laboratory
Genotype dna/rna hiv,87906,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,135.17,,,,,,,fee schedule,115.86,225.28,APC
Genotype dna/rna hiv,87906,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,133.88,,,,,,,fee schedule,115.86,225.28,APC
Genotype dna/rna hiv,87906,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,128.73,,,,,,,fee schedule,115.86,225.28,APC
Genotype dna/rna hiv,87906,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,196.96,,,,,,,fee schedule,115.86,225.28,Radiology
Genotype dna/rna hiv,87906,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,180.22,,,,,,,fee schedule,115.86,225.28,APC
Genotype dna/rna hiv,87906,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,225.28,,,,,,,fee schedule,115.86,225.28,APC
Genotype cytomegalovirus,87910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1337.67,,,,,,,fee schedule,231.7,1337.67,
Genotype cytomegalovirus,87910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1072.26,,,,,,,fee schedule,231.7,1337.67,
Genotype cytomegalovirus,87910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1171.34,,,,,,,fee schedule,231.7,1337.67,
Genotype cytomegalovirus,87910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1231.5,,,,,,,fee schedule,231.7,1337.67,
Genotype cytomegalovirus,87910,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,231.7,,,,,,,fee schedule,231.7,1337.67,Laboratory
Genotype cytomegalovirus,87910,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,270.32,,,,,,,fee schedule,231.7,1337.67,APC
Genotype cytomegalovirus,87910,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,267.75,,,,,,,fee schedule,231.7,1337.67,APC
Genotype cytomegalovirus,87910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,257.45,,,,,,,fee schedule,231.7,1337.67,APC
Genotype cytomegalovirus,87910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,393.9,,,,,,,fee schedule,231.7,1337.67,Radiology
Genotype cytomegalovirus,87910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,360.43,,,,,,,fee schedule,231.7,1337.67,APC
Genotype cytomegalovirus,87910,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,450.54,,,,,,,fee schedule,231.7,1337.67,APC
Genotype dna hepatitis b,87912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1337.67,,,,,,,fee schedule,231.7,1337.67,
Genotype dna hepatitis b,87912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1072.26,,,,,,,fee schedule,231.7,1337.67,
Genotype dna hepatitis b,87912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1171.34,,,,,,,fee schedule,231.7,1337.67,
Genotype dna hepatitis b,87912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1231.5,,,,,,,fee schedule,231.7,1337.67,
Genotype dna hepatitis b,87912,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,231.7,,,,,,,fee schedule,231.7,1337.67,Laboratory
Genotype dna hepatitis b,87912,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,270.32,,,,,,,fee schedule,231.7,1337.67,APC
Genotype dna hepatitis b,87912,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,267.75,,,,,,,fee schedule,231.7,1337.67,APC
Genotype dna hepatitis b,87912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,257.45,,,,,,,fee schedule,231.7,1337.67,APC
Genotype dna hepatitis b,87912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,393.9,,,,,,,fee schedule,231.7,1337.67,Radiology
Genotype dna hepatitis b,87912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,360.43,,,,,,,fee schedule,231.7,1337.67,APC
Genotype dna hepatitis b,87912,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,450.54,,,,,,,fee schedule,231.7,1337.67,APC
Nfct agt gntyp alys sarscov2,87913,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,231.7,,,,,,,fee schedule,231.7,450.54,Laboratory
Nfct agt gntyp alys sarscov2,87913,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,270.32,,,,,,,fee schedule,231.7,450.54,APC
Nfct agt gntyp alys sarscov2,87913,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,267.75,,,,,,,fee schedule,231.7,450.54,APC
Nfct agt gntyp alys sarscov2,87913,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,257.45,,,,,,,fee schedule,231.7,450.54,APC
Nfct agt gntyp alys sarscov2,87913,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,393.9,,,,,,,fee schedule,231.7,450.54,Radiology
Nfct agt gntyp alys sarscov2,87913,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,360.43,,,,,,,fee schedule,231.7,450.54,APC
Nfct agt gntyp alys sarscov2,87913,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,450.54,,,,,,,fee schedule,231.7,450.54,APC
Cytopath fl nongyn smears,88104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59.84,,,,,,,fee schedule,36.98,164.05,
Cytopath fl nongyn smears,88104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,47.96,,,,,,,fee schedule,36.98,164.05,
Cytopath fl nongyn smears,88104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52.4,,,,,,,fee schedule,36.98,164.05,
Cytopath fl nongyn smears,88104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55.09,,,,,,,fee schedule,36.98,164.05,
Cytopath fl nongyn smears,88104,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.05,,,,,,,fee schedule,36.98,164.05,APC 378
Cytopath fl nongyn smears,88104,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.83,,,,,,,fee schedule,36.98,164.05,APC
Cytopath fl nongyn smears,88104,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.46,,,,,,,fee schedule,36.98,164.05,APC
Cytopath fl nongyn smears,88104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.98,,,,,,,fee schedule,36.98,164.05,APC
Cytopath fl nongyn smears,88104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.57,,,,,,,fee schedule,36.98,164.05,Radiology
Cytopath fl nongyn smears,88104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.77,,,,,,,fee schedule,36.98,164.05,APC
Cytopath fl nongyn smears,88104,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.71,,,,,,,fee schedule,36.98,164.05,APC
Cytopath fl nongyn filter,88106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59.84,,,,,,,fee schedule,28.63,127.04,
Cytopath fl nongyn filter,88106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,47.96,,,,,,,fee schedule,28.63,127.04,
Cytopath fl nongyn filter,88106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52.4,,,,,,,fee schedule,28.63,127.04,
Cytopath fl nongyn filter,88106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55.09,,,,,,,fee schedule,28.63,127.04,
Cytopath fl nongyn filter,88106,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,127.04,,,,,,,fee schedule,28.63,127.04,APC 378
Cytopath fl nongyn filter,88106,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.07,,,,,,,fee schedule,28.63,127.04,APC
Cytopath fl nongyn filter,88106,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,29.78,,,,,,,fee schedule,28.63,127.04,APC
Cytopath fl nongyn filter,88106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,28.63,,,,,,,fee schedule,28.63,127.04,APC
Cytopath fl nongyn filter,88106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43.81,,,,,,,fee schedule,28.63,127.04,Radiology
Cytopath fl nongyn filter,88106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40.09,,,,,,,fee schedule,28.63,127.04,APC
Cytopath fl nongyn filter,88106,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,50.11,,,,,,,fee schedule,28.63,127.04,APC
Cytopath concentrate tech,88108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,73.3,,,,,,,fee schedule,36.98,164.05,
Cytopath concentrate tech,88108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,58.76,,,,,,,fee schedule,36.98,164.05,
Cytopath concentrate tech,88108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,64.18,,,,,,,fee schedule,36.98,164.05,
Cytopath concentrate tech,88108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,67.48,,,,,,,fee schedule,36.98,164.05,
Cytopath concentrate tech,88108,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.05,,,,,,,fee schedule,36.98,164.05,APC 378
Cytopath concentrate tech,88108,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.83,,,,,,,fee schedule,36.98,164.05,APC
Cytopath concentrate tech,88108,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.46,,,,,,,fee schedule,36.98,164.05,APC
Cytopath concentrate tech,88108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.98,,,,,,,fee schedule,36.98,164.05,APC
Cytopath concentrate tech,88108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.57,,,,,,,fee schedule,36.98,164.05,Radiology
Cytopath concentrate tech,88108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.77,,,,,,,fee schedule,36.98,164.05,APC
Cytopath concentrate tech,88108,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.71,,,,,,,fee schedule,36.98,164.05,APC
Cytopath cell enhance tech,88112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,94.03,,,,,,,fee schedule,51.59,228.88,
Cytopath cell enhance tech,88112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,75.37,,,,,,,fee schedule,51.59,228.88,
Cytopath cell enhance tech,88112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,82.34,,,,,,,fee schedule,51.59,228.88,
Cytopath cell enhance tech,88112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,86.57,,,,,,,fee schedule,51.59,228.88,
Cytopath cell enhance tech,88112,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,228.88,,,,,,,fee schedule,51.59,228.88,APC 378
Cytopath cell enhance tech,88112,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.17,,,,,,,fee schedule,51.59,228.88,APC
Cytopath cell enhance tech,88112,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,53.65,,,,,,,fee schedule,51.59,228.88,APC
Cytopath cell enhance tech,88112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,51.59,,,,,,,fee schedule,51.59,228.88,APC
Cytopath cell enhance tech,88112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,78.93,,,,,,,fee schedule,51.59,228.88,Radiology
Cytopath cell enhance tech,88112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,72.22,,,,,,,fee schedule,51.59,228.88,APC
Cytopath cell enhance tech,88112,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,90.28,,,,,,,fee schedule,51.59,228.88,APC
Cytp urne 3-5 probes ea spec,88120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,226.56,,,,,,,fee schedule,168.66,748.29,
Cytp urne 3-5 probes ea spec,88120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,181.61,,,,,,,fee schedule,168.66,748.29,
Cytp urne 3-5 probes ea spec,88120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,198.39,,,,,,,fee schedule,168.66,748.29,
Cytp urne 3-5 probes ea spec,88120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,208.58,,,,,,,fee schedule,168.66,748.29,
Cytp urne 3-5 probes ea spec,88120,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,748.29,,,,,,,fee schedule,168.66,748.29,APC 378
Cytp urne 3-5 probes ea spec,88120,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,177.09,,,,,,,fee schedule,168.66,748.29,APC
Cytp urne 3-5 probes ea spec,88120,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,175.41,,,,,,,fee schedule,168.66,748.29,APC
Cytp urne 3-5 probes ea spec,88120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,168.66,,,,,,,fee schedule,168.66,748.29,APC
Cytp urne 3-5 probes ea spec,88120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,258.05,,,,,,,fee schedule,168.66,748.29,Radiology
Cytp urne 3-5 probes ea spec,88120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,236.12,,,,,,,fee schedule,168.66,748.29,APC
Cytp urne 3-5 probes ea spec,88120,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,295.16,,,,,,,fee schedule,168.66,748.29,APC
Cytp urine 3-5 probes cmptr,88121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,695.56,,,,,,,fee schedule,168.66,748.29,
Cytp urine 3-5 probes cmptr,88121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,557.55,,,,,,,fee schedule,168.66,748.29,
Cytp urine 3-5 probes cmptr,88121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,609.07,,,,,,,fee schedule,168.66,748.29,
Cytp urine 3-5 probes cmptr,88121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,640.35,,,,,,,fee schedule,168.66,748.29,
Cytp urine 3-5 probes cmptr,88121,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,748.29,,,,,,,fee schedule,168.66,748.29,APC 378
Cytp urine 3-5 probes cmptr,88121,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,177.09,,,,,,,fee schedule,168.66,748.29,APC
Cytp urine 3-5 probes cmptr,88121,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,175.41,,,,,,,fee schedule,168.66,748.29,APC
Cytp urine 3-5 probes cmptr,88121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,168.66,,,,,,,fee schedule,168.66,748.29,APC
Cytp urine 3-5 probes cmptr,88121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,258.05,,,,,,,fee schedule,168.66,748.29,Radiology
Cytp urine 3-5 probes cmptr,88121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,236.12,,,,,,,fee schedule,168.66,748.29,APC
Cytp urine 3-5 probes cmptr,88121,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,295.16,,,,,,,fee schedule,168.66,748.29,APC
Forensic cytopathology,88125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59.84,,,,,,,fee schedule,47.96,228.88,
Forensic cytopathology,88125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,47.96,,,,,,,fee schedule,47.96,228.88,
Forensic cytopathology,88125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52.4,,,,,,,fee schedule,47.96,228.88,
Forensic cytopathology,88125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55.09,,,,,,,fee schedule,47.96,228.88,
Forensic cytopathology,88125,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,228.88,,,,,,,fee schedule,47.96,228.88,APC 378
Forensic cytopathology,88125,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.17,,,,,,,fee schedule,47.96,228.88,APC
Forensic cytopathology,88125,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,53.65,,,,,,,fee schedule,47.96,228.88,APC
Forensic cytopathology,88125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,51.59,,,,,,,fee schedule,47.96,228.88,APC
Forensic cytopathology,88125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,78.93,,,,,,,fee schedule,47.96,228.88,Radiology
Forensic cytopathology,88125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,72.22,,,,,,,fee schedule,47.96,228.88,APC
Forensic cytopathology,88125,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,90.28,,,,,,,fee schedule,47.96,228.88,APC
Sex chromatin identification,88130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83.05,,,,,,,fee schedule,16.18,83.05,
Sex chromatin identification,88130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66.57,,,,,,,fee schedule,16.18,83.05,
Sex chromatin identification,88130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,72.72,,,,,,,fee schedule,16.18,83.05,
Sex chromatin identification,88130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,76.46,,,,,,,fee schedule,16.18,83.05,
Sex chromatin identification,88130,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.18,,,,,,,fee schedule,16.18,83.05,Laboratory
Sex chromatin identification,88130,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.88,,,,,,,fee schedule,16.18,83.05,APC
Sex chromatin identification,88130,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18.7,,,,,,,fee schedule,16.18,83.05,APC
Sex chromatin identification,88130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17.98,,,,,,,fee schedule,16.18,83.05,APC
Sex chromatin identification,88130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27.51,,,,,,,fee schedule,16.18,83.05,Radiology
Sex chromatin identification,88130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.17,,,,,,,fee schedule,16.18,83.05,APC
Sex chromatin identification,88130,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31.46,,,,,,,fee schedule,16.18,83.05,APC
Sex chromatin identification,88140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41.05,,,,,,,fee schedule,7.19,41.05,
Sex chromatin identification,88140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32.91,,,,,,,fee schedule,7.19,41.05,
Sex chromatin identification,88140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35.95,,,,,,,fee schedule,7.19,41.05,
Sex chromatin identification,88140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37.79,,,,,,,fee schedule,7.19,41.05,
Sex chromatin identification,88140,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.19,,,,,,,fee schedule,7.19,41.05,Laboratory
Sex chromatin identification,88140,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.39,,,,,,,fee schedule,7.19,41.05,APC
Sex chromatin identification,88140,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8.31,,,,,,,fee schedule,7.19,41.05,APC
Sex chromatin identification,88140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7.99,,,,,,,fee schedule,7.19,41.05,APC
Sex chromatin identification,88140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12.22,,,,,,,fee schedule,7.19,41.05,Radiology
Sex chromatin identification,88140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11.19,,,,,,,fee schedule,7.19,41.05,APC
Sex chromatin identification,88140,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,13.98,,,,,,,fee schedule,7.19,41.05,APC
Cytopath c/v thin layer,88142,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83.35,,,,,,,fee schedule,18.23,83.35,
Cytopath c/v thin layer,88142,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66.81,,,,,,,fee schedule,18.23,83.35,
Cytopath c/v thin layer,88142,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,72.99,,,,,,,fee schedule,18.23,83.35,
Cytopath c/v thin layer,88142,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,76.73,,,,,,,fee schedule,18.23,83.35,
Cytopath c/v thin layer,88142,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.23,,,,,,,fee schedule,18.23,83.35,Laboratory
Cytopath c/v thin layer,88142,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.27,,,,,,,fee schedule,18.23,83.35,APC
Cytopath c/v thin layer,88142,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,21.07,,,,,,,fee schedule,18.23,83.35,APC
Cytopath c/v thin layer,88142,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,20.26,,,,,,,fee schedule,18.23,83.35,APC
Cytopath c/v thin layer,88142,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,31,,,,,,,fee schedule,18.23,83.35,Radiology
Cytopath c/v thin layer,88142,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.36,,,,,,,fee schedule,18.23,83.35,APC
Cytopath c/v thin layer,88142,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,35.46,,,,,,,fee schedule,18.23,83.35,APC
Cytopath c/v thin layer redo,88143,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,75.86,,,,,,,fee schedule,20.74,75.86,
Cytopath c/v thin layer redo,88143,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,60.81,,,,,,,fee schedule,20.74,75.86,
Cytopath c/v thin layer redo,88143,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66.43,,,,,,,fee schedule,20.74,75.86,
Cytopath c/v thin layer redo,88143,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,69.84,,,,,,,fee schedule,20.74,75.86,
Cytopath c/v thin layer redo,88143,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,20.74,,,,,,,fee schedule,20.74,75.86,Laboratory
Cytopath c/v thin layer redo,88143,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,24.19,,,,,,,fee schedule,20.74,75.86,APC
Cytopath c/v thin layer redo,88143,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,23.96,,,,,,,fee schedule,20.74,75.86,APC
Cytopath c/v thin layer redo,88143,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,23.04,,,,,,,fee schedule,20.74,75.86,APC
Cytopath c/v thin layer redo,88143,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,35.25,,,,,,,fee schedule,20.74,75.86,Radiology
Cytopath c/v thin layer redo,88143,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,32.26,,,,,,,fee schedule,20.74,75.86,APC
Cytopath c/v thin layer redo,88143,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,40.32,,,,,,,fee schedule,20.74,75.86,APC
Cytopath c/v automated,88147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,58.29,,,,,,,fee schedule,45.5,88.48,
Cytopath c/v automated,88147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.72,,,,,,,fee schedule,45.5,88.48,
Cytopath c/v automated,88147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.04,,,,,,,fee schedule,45.5,88.48,
Cytopath c/v automated,88147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,53.66,,,,,,,fee schedule,45.5,88.48,
Cytopath c/v automated,88147,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,45.5,,,,,,,fee schedule,45.5,88.48,Laboratory
Cytopath c/v automated,88147,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,53.09,,,,,,,fee schedule,45.5,88.48,APC
Cytopath c/v automated,88147,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,52.58,,,,,,,fee schedule,45.5,88.48,APC
Cytopath c/v automated,88147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,50.56,,,,,,,fee schedule,45.5,88.48,APC
Cytopath c/v automated,88147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,77.36,,,,,,,fee schedule,45.5,88.48,Radiology
Cytopath c/v automated,88147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,70.78,,,,,,,fee schedule,45.5,88.48,APC
Cytopath c/v automated,88147,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,88.48,,,,,,,fee schedule,45.5,88.48,APC
Cytopath c/v auto rescreen,88148,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,58.29,,,,,,,fee schedule,16.69,58.29,
Cytopath c/v auto rescreen,88148,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.72,,,,,,,fee schedule,16.69,58.29,
Cytopath c/v auto rescreen,88148,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.04,,,,,,,fee schedule,16.69,58.29,
Cytopath c/v auto rescreen,88148,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,53.66,,,,,,,fee schedule,16.69,58.29,
Cytopath c/v auto rescreen,88148,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.69,,,,,,,fee schedule,16.69,58.29,Laboratory
Cytopath c/v auto rescreen,88148,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.47,,,,,,,fee schedule,16.69,58.29,APC
Cytopath c/v auto rescreen,88148,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,19.28,,,,,,,fee schedule,16.69,58.29,APC
Cytopath c/v auto rescreen,88148,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18.54,,,,,,,fee schedule,16.69,58.29,APC
Cytopath c/v auto rescreen,88148,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.37,,,,,,,fee schedule,16.69,58.29,Radiology
Cytopath c/v auto rescreen,88148,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.96,,,,,,,fee schedule,16.69,58.29,APC
Cytopath c/v auto rescreen,88148,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,32.44,,,,,,,fee schedule,16.69,58.29,APC
Cytopath c/v manual,88150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,58.29,,,,,,,fee schedule,16.69,58.29,
Cytopath c/v manual,88150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.72,,,,,,,fee schedule,16.69,58.29,
Cytopath c/v manual,88150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.04,,,,,,,fee schedule,16.69,58.29,
Cytopath c/v manual,88150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,53.66,,,,,,,fee schedule,16.69,58.29,
Cytopath c/v manual,88150,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.69,,,,,,,fee schedule,16.69,58.29,Laboratory
Cytopath c/v manual,88150,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.47,,,,,,,fee schedule,16.69,58.29,APC
Cytopath c/v manual,88150,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,19.28,,,,,,,fee schedule,16.69,58.29,APC
Cytopath c/v manual,88150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18.54,,,,,,,fee schedule,16.69,58.29,APC
Cytopath c/v manual,88150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.37,,,,,,,fee schedule,16.69,58.29,Radiology
Cytopath c/v manual,88150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.96,,,,,,,fee schedule,16.69,58.29,APC
Cytopath c/v manual,88150,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,32.44,,,,,,,fee schedule,16.69,58.29,APC
Cytopath c/v auto redo,88152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,58.29,,,,,,,fee schedule,24.88,58.29,
Cytopath c/v auto redo,88152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.72,,,,,,,fee schedule,24.88,58.29,
Cytopath c/v auto redo,88152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.04,,,,,,,fee schedule,24.88,58.29,
Cytopath c/v auto redo,88152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,53.66,,,,,,,fee schedule,24.88,58.29,
Cytopath c/v auto redo,88152,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24.88,,,,,,,fee schedule,24.88,58.29,Laboratory
Cytopath c/v auto redo,88152,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,29.02,,,,,,,fee schedule,24.88,58.29,APC
Cytopath c/v auto redo,88152,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,28.75,,,,,,,fee schedule,24.88,58.29,APC
Cytopath c/v auto redo,88152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,27.64,,,,,,,fee schedule,24.88,58.29,APC
Cytopath c/v auto redo,88152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,42.29,,,,,,,fee schedule,24.88,58.29,Radiology
Cytopath c/v auto redo,88152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,38.7,,,,,,,fee schedule,24.88,58.29,APC
Cytopath c/v auto redo,88152,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,48.37,,,,,,,fee schedule,24.88,58.29,APC
Cytopath c/v redo,88153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,58.29,,,,,,,fee schedule,21.63,58.29,
Cytopath c/v redo,88153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.72,,,,,,,fee schedule,21.63,58.29,
Cytopath c/v redo,88153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.04,,,,,,,fee schedule,21.63,58.29,
Cytopath c/v redo,88153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,53.66,,,,,,,fee schedule,21.63,58.29,
Cytopath c/v redo,88153,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21.63,,,,,,,fee schedule,21.63,58.29,Laboratory
Cytopath c/v redo,88153,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,25.23,,,,,,,fee schedule,21.63,58.29,APC
Cytopath c/v redo,88153,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,24.99,,,,,,,fee schedule,21.63,58.29,APC
Cytopath c/v redo,88153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,24.03,,,,,,,fee schedule,21.63,58.29,APC
Cytopath c/v redo,88153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,36.77,,,,,,,fee schedule,21.63,58.29,Radiology
Cytopath c/v redo,88153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,33.64,,,,,,,fee schedule,21.63,58.29,APC
Cytopath c/v redo,88153,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,42.05,,,,,,,fee schedule,21.63,58.29,APC
Cytopath c/v index add-on,88155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33.08,,,,,,,fee schedule,13.18,33.08,
Cytopath c/v index add-on,88155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26.51,,,,,,,fee schedule,13.18,33.08,
Cytopath c/v index add-on,88155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28.96,,,,,,,fee schedule,13.18,33.08,
Cytopath c/v index add-on,88155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30.45,,,,,,,fee schedule,13.18,33.08,
Cytopath c/v index add-on,88155,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.18,,,,,,,fee schedule,13.18,33.08,Laboratory
Cytopath c/v index add-on,88155,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.38,,,,,,,fee schedule,13.18,33.08,APC
Cytopath c/v index add-on,88155,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,15.24,,,,,,,fee schedule,13.18,33.08,APC
Cytopath c/v index add-on,88155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14.65,,,,,,,fee schedule,13.18,33.08,APC
Cytopath c/v index add-on,88155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.41,,,,,,,fee schedule,13.18,33.08,Radiology
Cytopath c/v index add-on,88155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.51,,,,,,,fee schedule,13.18,33.08,APC
Cytopath c/v index add-on,88155,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,25.64,,,,,,,fee schedule,13.18,33.08,APC
Cytopath smear other source,88160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,48.13,,,,,,,fee schedule,28.63,127.04,
Cytopath smear other source,88160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38.58,,,,,,,fee schedule,28.63,127.04,
Cytopath smear other source,88160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.14,,,,,,,fee schedule,28.63,127.04,
Cytopath smear other source,88160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,44.31,,,,,,,fee schedule,28.63,127.04,
Cytopath smear other source,88160,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,127.04,,,,,,,fee schedule,28.63,127.04,APC 378
Cytopath smear other source,88160,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.07,,,,,,,fee schedule,28.63,127.04,APC
Cytopath smear other source,88160,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,29.78,,,,,,,fee schedule,28.63,127.04,APC
Cytopath smear other source,88160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,28.63,,,,,,,fee schedule,28.63,127.04,APC
Cytopath smear other source,88160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43.81,,,,,,,fee schedule,28.63,127.04,Radiology
Cytopath smear other source,88160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40.09,,,,,,,fee schedule,28.63,127.04,APC
Cytopath smear other source,88160,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,50.11,,,,,,,fee schedule,28.63,127.04,APC
Cytopath smear other source,88161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59.84,,,,,,,fee schedule,28.63,127.04,
Cytopath smear other source,88161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,47.96,,,,,,,fee schedule,28.63,127.04,
Cytopath smear other source,88161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52.4,,,,,,,fee schedule,28.63,127.04,
Cytopath smear other source,88161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55.09,,,,,,,fee schedule,28.63,127.04,
Cytopath smear other source,88161,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,127.04,,,,,,,fee schedule,28.63,127.04,APC 378
Cytopath smear other source,88161,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.07,,,,,,,fee schedule,28.63,127.04,APC
Cytopath smear other source,88161,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,29.78,,,,,,,fee schedule,28.63,127.04,APC
Cytopath smear other source,88161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,28.63,,,,,,,fee schedule,28.63,127.04,APC
Cytopath smear other source,88161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43.81,,,,,,,fee schedule,28.63,127.04,Radiology
Cytopath smear other source,88161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40.09,,,,,,,fee schedule,28.63,127.04,APC
Cytopath smear other source,88161,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,50.11,,,,,,,fee schedule,28.63,127.04,APC
Cytopath smear other source,88162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,128.33,,,,,,,fee schedule,51.59,228.88,
Cytopath smear other source,88162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,102.87,,,,,,,fee schedule,51.59,228.88,
Cytopath smear other source,88162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,112.37,,,,,,,fee schedule,51.59,228.88,
Cytopath smear other source,88162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,118.15,,,,,,,fee schedule,51.59,228.88,
Cytopath smear other source,88162,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,228.88,,,,,,,fee schedule,51.59,228.88,APC 378
Cytopath smear other source,88162,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.17,,,,,,,fee schedule,51.59,228.88,APC
Cytopath smear other source,88162,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,53.65,,,,,,,fee schedule,51.59,228.88,APC
Cytopath smear other source,88162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,51.59,,,,,,,fee schedule,51.59,228.88,APC
Cytopath smear other source,88162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,78.93,,,,,,,fee schedule,51.59,228.88,Radiology
Cytopath smear other source,88162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,72.22,,,,,,,fee schedule,51.59,228.88,APC
Cytopath smear other source,88162,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,90.28,,,,,,,fee schedule,51.59,228.88,APC
Cytopath tbs c/v manual,88164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,58.29,,,,,,,fee schedule,16.69,58.29,
Cytopath tbs c/v manual,88164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.72,,,,,,,fee schedule,16.69,58.29,
Cytopath tbs c/v manual,88164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.04,,,,,,,fee schedule,16.69,58.29,
Cytopath tbs c/v manual,88164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,53.66,,,,,,,fee schedule,16.69,58.29,
Cytopath tbs c/v manual,88164,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.69,,,,,,,fee schedule,16.69,58.29,Laboratory
Cytopath tbs c/v manual,88164,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.47,,,,,,,fee schedule,16.69,58.29,APC
Cytopath tbs c/v manual,88164,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,19.28,,,,,,,fee schedule,16.69,58.29,APC
Cytopath tbs c/v manual,88164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18.54,,,,,,,fee schedule,16.69,58.29,APC
Cytopath tbs c/v manual,88164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.37,,,,,,,fee schedule,16.69,58.29,Radiology
Cytopath tbs c/v manual,88164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.96,,,,,,,fee schedule,16.69,58.29,APC
Cytopath tbs c/v manual,88164,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,32.44,,,,,,,fee schedule,16.69,58.29,APC
Cytopath tbs c/v redo,88165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,58.29,,,,,,,fee schedule,38,73.89,
Cytopath tbs c/v redo,88165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.72,,,,,,,fee schedule,38,73.89,
Cytopath tbs c/v redo,88165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.04,,,,,,,fee schedule,38,73.89,
Cytopath tbs c/v redo,88165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,53.66,,,,,,,fee schedule,38,73.89,
Cytopath tbs c/v redo,88165,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,38,,,,,,,fee schedule,38,73.89,Laboratory
Cytopath tbs c/v redo,88165,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,44.33,,,,,,,fee schedule,38,73.89,APC
Cytopath tbs c/v redo,88165,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,43.91,,,,,,,fee schedule,38,73.89,APC
Cytopath tbs c/v redo,88165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,42.22,,,,,,,fee schedule,38,73.89,APC
Cytopath tbs c/v redo,88165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,64.6,,,,,,,fee schedule,38,73.89,Radiology
Cytopath tbs c/v redo,88165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,59.11,,,,,,,fee schedule,38,73.89,APC
Cytopath tbs c/v redo,88165,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,73.88,,,,,,,fee schedule,38,73.89,APC
Cytopath tbs c/v auto redo,88166,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,58.29,,,,,,,fee schedule,16.69,58.29,
Cytopath tbs c/v auto redo,88166,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.72,,,,,,,fee schedule,16.69,58.29,
Cytopath tbs c/v auto redo,88166,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.04,,,,,,,fee schedule,16.69,58.29,
Cytopath tbs c/v auto redo,88166,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,53.66,,,,,,,fee schedule,16.69,58.29,
Cytopath tbs c/v auto redo,88166,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.69,,,,,,,fee schedule,16.69,58.29,Laboratory
Cytopath tbs c/v auto redo,88166,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.47,,,,,,,fee schedule,16.69,58.29,APC
Cytopath tbs c/v auto redo,88166,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,19.28,,,,,,,fee schedule,16.69,58.29,APC
Cytopath tbs c/v auto redo,88166,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18.54,,,,,,,fee schedule,16.69,58.29,APC
Cytopath tbs c/v auto redo,88166,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.37,,,,,,,fee schedule,16.69,58.29,Radiology
Cytopath tbs c/v auto redo,88166,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.96,,,,,,,fee schedule,16.69,58.29,APC
Cytopath tbs c/v auto redo,88166,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,32.44,,,,,,,fee schedule,16.69,58.29,APC
Cytopath tbs c/v select,88167,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,58.29,,,,,,,fee schedule,16.69,58.29,
Cytopath tbs c/v select,88167,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.72,,,,,,,fee schedule,16.69,58.29,
Cytopath tbs c/v select,88167,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.04,,,,,,,fee schedule,16.69,58.29,
Cytopath tbs c/v select,88167,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,53.66,,,,,,,fee schedule,16.69,58.29,
Cytopath tbs c/v select,88167,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.69,,,,,,,fee schedule,16.69,58.29,Laboratory
Cytopath tbs c/v select,88167,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.47,,,,,,,fee schedule,16.69,58.29,APC
Cytopath tbs c/v select,88167,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,19.28,,,,,,,fee schedule,16.69,58.29,APC
Cytopath tbs c/v select,88167,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18.54,,,,,,,fee schedule,16.69,58.29,APC
Cytopath tbs c/v select,88167,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.37,,,,,,,fee schedule,16.69,58.29,Radiology
Cytopath tbs c/v select,88167,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.96,,,,,,,fee schedule,16.69,58.29,APC
Cytopath tbs c/v select,88167,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,32.44,,,,,,,fee schedule,16.69,58.29,APC
Cytp dx eval fna 1st ea site,88172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59.97,,,,,,,fee schedule,48.07,748.29,
Cytp dx eval fna 1st ea site,88172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48.07,,,,,,,fee schedule,48.07,748.29,
Cytp dx eval fna 1st ea site,88172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52.51,,,,,,,fee schedule,48.07,748.29,
Cytp dx eval fna 1st ea site,88172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55.21,,,,,,,fee schedule,48.07,748.29,
Cytp dx eval fna 1st ea site,88172,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,748.29,,,,,,,fee schedule,48.07,748.29,APC 378
Cytp dx eval fna 1st ea site,88172,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,177.09,,,,,,,fee schedule,48.07,748.29,APC
Cytp dx eval fna 1st ea site,88172,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,175.41,,,,,,,fee schedule,48.07,748.29,APC
Cytp dx eval fna 1st ea site,88172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,168.66,,,,,,,fee schedule,48.07,748.29,APC
Cytp dx eval fna 1st ea site,88172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,258.05,,,,,,,fee schedule,48.07,748.29,Radiology
Cytp dx eval fna 1st ea site,88172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,236.12,,,,,,,fee schedule,48.07,748.29,APC
Cytp dx eval fna 1st ea site,88172,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,295.16,,,,,,,fee schedule,48.07,748.29,APC
Cytopath eval fna report,88173,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,97.1,,,,,,,fee schedule,51.59,228.88,
Cytopath eval fna report,88173,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,77.84,,,,,,,fee schedule,51.59,228.88,
Cytopath eval fna report,88173,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,85.03,,,,,,,fee schedule,51.59,228.88,
Cytopath eval fna report,88173,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,89.4,,,,,,,fee schedule,51.59,228.88,
Cytopath eval fna report,88173,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,228.88,,,,,,,fee schedule,51.59,228.88,APC 378
Cytopath eval fna report,88173,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.17,,,,,,,fee schedule,51.59,228.88,APC
Cytopath eval fna report,88173,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,53.65,,,,,,,fee schedule,51.59,228.88,APC
Cytopath eval fna report,88173,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,51.59,,,,,,,fee schedule,51.59,228.88,APC
Cytopath eval fna report,88173,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,78.93,,,,,,,fee schedule,51.59,228.88,Radiology
Cytopath eval fna report,88173,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,72.22,,,,,,,fee schedule,51.59,228.88,APC
Cytopath eval fna report,88173,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,90.28,,,,,,,fee schedule,51.59,228.88,APC
Cytopath c/v auto in fluid,88174,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,80.55,,,,,,,fee schedule,22.83,80.55,
Cytopath c/v auto in fluid,88174,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,64.57,,,,,,,fee schedule,22.83,80.55,
Cytopath c/v auto in fluid,88174,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,70.54,,,,,,,fee schedule,22.83,80.55,
Cytopath c/v auto in fluid,88174,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,74.16,,,,,,,fee schedule,22.83,80.55,
Cytopath c/v auto in fluid,88174,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22.83,,,,,,,fee schedule,22.83,80.55,Laboratory
Cytopath c/v auto in fluid,88174,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,26.64,,,,,,,fee schedule,22.83,80.55,APC
Cytopath c/v auto in fluid,88174,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,26.38,,,,,,,fee schedule,22.83,80.55,APC
Cytopath c/v auto in fluid,88174,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,25.37,,,,,,,fee schedule,22.83,80.55,APC
Cytopath c/v auto in fluid,88174,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,38.82,,,,,,,fee schedule,22.83,80.55,Radiology
Cytopath c/v auto in fluid,88174,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,35.52,,,,,,,fee schedule,22.83,80.55,APC
Cytopath c/v auto in fluid,88174,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,44.4,,,,,,,fee schedule,22.83,80.55,APC
Cytopath c/v auto fluid redo,88175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,80.06,,,,,,,fee schedule,23.95,80.06,
Cytopath c/v auto fluid redo,88175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,64.17,,,,,,,fee schedule,23.95,80.06,
Cytopath c/v auto fluid redo,88175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,70.1,,,,,,,fee schedule,23.95,80.06,
Cytopath c/v auto fluid redo,88175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,73.7,,,,,,,fee schedule,23.95,80.06,
Cytopath c/v auto fluid redo,88175,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23.95,,,,,,,fee schedule,23.95,80.06,Laboratory
Cytopath c/v auto fluid redo,88175,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,27.94,,,,,,,fee schedule,23.95,80.06,APC
Cytopath c/v auto fluid redo,88175,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,27.67,,,,,,,fee schedule,23.95,80.06,APC
Cytopath c/v auto fluid redo,88175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,26.61,,,,,,,fee schedule,23.95,80.06,APC
Cytopath c/v auto fluid redo,88175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40.71,,,,,,,fee schedule,23.95,80.06,Radiology
Cytopath c/v auto fluid redo,88175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,37.25,,,,,,,fee schedule,23.95,80.06,APC
Cytopath c/v auto fluid redo,88175,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,46.57,,,,,,,fee schedule,23.95,80.06,APC
Cell marker study,88182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,128.33,,,,,,,fee schedule,51.59,228.88,
Cell marker study,88182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,102.87,,,,,,,fee schedule,51.59,228.88,
Cell marker study,88182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,112.37,,,,,,,fee schedule,51.59,228.88,
Cell marker study,88182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,118.15,,,,,,,fee schedule,51.59,228.88,
Cell marker study,88182,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,228.88,,,,,,,fee schedule,51.59,228.88,APC 378
Cell marker study,88182,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.17,,,,,,,fee schedule,51.59,228.88,APC
Cell marker study,88182,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,53.65,,,,,,,fee schedule,51.59,228.88,APC
Cell marker study,88182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,51.59,,,,,,,fee schedule,51.59,228.88,APC
Cell marker study,88182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,78.93,,,,,,,fee schedule,51.59,228.88,Radiology
Cell marker study,88182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,72.22,,,,,,,fee schedule,51.59,228.88,APC
Cell marker study,88182,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,90.28,,,,,,,fee schedule,51.59,228.88,APC
Flowcytometry/ tc 1 marker,88184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,335.4,,,,,,,fee schedule,268.85,1574.35,
Flowcytometry/ tc 1 marker,88184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,268.85,,,,,,,fee schedule,268.85,1574.35,
Flowcytometry/ tc 1 marker,88184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,293.69,,,,,,,fee schedule,268.85,1574.35,
Flowcytometry/ tc 1 marker,88184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,308.78,,,,,,,fee schedule,268.85,1574.35,
Flowcytometry/ tc 1 marker,88184,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1574.35,,,,,,,fee schedule,268.85,1574.35,APC 378
Flowcytometry/ tc 1 marker,88184,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,372.59,,,,,,,fee schedule,268.85,1574.35,APC
Flowcytometry/ tc 1 marker,88184,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,369.04,,,,,,,fee schedule,268.85,1574.35,APC
Flowcytometry/ tc 1 marker,88184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,354.85,,,,,,,fee schedule,268.85,1574.35,APC
Flowcytometry/ tc 1 marker,88184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,542.92,,,,,,,fee schedule,268.85,1574.35,Radiology
Flowcytometry/ tc 1 marker,88184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,496.79,,,,,,,fee schedule,268.85,1574.35,APC
Flowcytometry/ tc 1 marker,88184,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,620.99,,,,,,,fee schedule,268.85,1574.35,APC
Flowcytometry/tc add-on,88185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,335.4,,,,,,,fee schedule,268.85,335.4,
Flowcytometry/tc add-on,88185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,268.85,,,,,,,fee schedule,268.85,335.4,
Flowcytometry/tc add-on,88185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,293.69,,,,,,,fee schedule,268.85,335.4,
Flowcytometry/tc add-on,88185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,308.78,,,,,,,fee schedule,268.85,335.4,
Flowcytometry/read 2-8,88187,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59.84,,,,,,,fee schedule,47.96,59.84,
Flowcytometry/read 2-8,88187,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,47.96,,,,,,,fee schedule,47.96,59.84,
Flowcytometry/read 2-8,88187,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52.4,,,,,,,fee schedule,47.96,59.84,
Flowcytometry/read 2-8,88187,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55.09,,,,,,,fee schedule,47.96,59.84,
Flowcytometry/read 9-15,88188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59.84,,,,,,,fee schedule,47.96,59.84,
Flowcytometry/read 9-15,88188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,47.96,,,,,,,fee schedule,47.96,59.84,
Flowcytometry/read 9-15,88188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52.4,,,,,,,fee schedule,47.96,59.84,
Flowcytometry/read 9-15,88188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55.09,,,,,,,fee schedule,47.96,59.84,
Flowcytometry/read 16 & >,88189,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,128.33,,,,,,,fee schedule,102.87,128.33,
Flowcytometry/read 16 & >,88189,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,102.87,,,,,,,fee schedule,102.87,128.33,
Flowcytometry/read 16 & >,88189,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,112.37,,,,,,,fee schedule,102.87,128.33,
Flowcytometry/read 16 & >,88189,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,118.15,,,,,,,fee schedule,102.87,128.33,
Cytopathology procedure,88199,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24.19,,,,,,,fee schedule,19.39,228.88,
Cytopathology procedure,88199,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19.39,,,,,,,fee schedule,19.39,228.88,
Cytopathology procedure,88199,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21.18,,,,,,,fee schedule,19.39,228.88,
Cytopathology procedure,88199,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22.27,,,,,,,fee schedule,19.39,228.88,
Cytopathology procedure,88199,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,228.88,,,,,,,fee schedule,19.39,228.88,APC 378
Cytopathology procedure,88199,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.17,,,,,,,fee schedule,19.39,228.88,APC
Cytopathology procedure,88199,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,53.65,,,,,,,fee schedule,19.39,228.88,APC
Cytopathology procedure,88199,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,51.59,,,,,,,fee schedule,19.39,228.88,APC
Cytopathology procedure,88199,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,78.93,,,,,,,fee schedule,19.39,228.88,Radiology
Cytopathology procedure,88199,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,72.22,,,,,,,fee schedule,19.39,228.88,APC
Cytopathology procedure,88199,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,90.28,,,,,,,fee schedule,19.39,228.88,APC
Tissue culture lymphocyte,88230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,527.9,,,,,,,fee schedule,104.84,527.9,
Tissue culture lymphocyte,88230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,423.16,,,,,,,fee schedule,104.84,527.9,
Tissue culture lymphocyte,88230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,462.26,,,,,,,fee schedule,104.84,527.9,
Tissue culture lymphocyte,88230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,486,,,,,,,fee schedule,104.84,527.9,
Tissue culture lymphocyte,88230,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,104.84,,,,,,,fee schedule,104.84,527.9,Laboratory
Tissue culture lymphocyte,88230,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,122.31,,,,,,,fee schedule,104.84,527.9,APC
Tissue culture lymphocyte,88230,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,121.15,,,,,,,fee schedule,104.84,527.9,APC
Tissue culture lymphocyte,88230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,116.49,,,,,,,fee schedule,104.84,527.9,APC
Tissue culture lymphocyte,88230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,178.23,,,,,,,fee schedule,104.84,527.9,Radiology
Tissue culture lymphocyte,88230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,163.09,,,,,,,fee schedule,104.84,527.9,APC
Tissue culture lymphocyte,88230,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,203.86,,,,,,,fee schedule,104.84,527.9,APC
Tissue culture skin/biopsy,88233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,195.71,,,,,,,fee schedule,126.66,246.28,
Tissue culture skin/biopsy,88233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,156.88,,,,,,,fee schedule,126.66,246.28,
Tissue culture skin/biopsy,88233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,171.38,,,,,,,fee schedule,126.66,246.28,
Tissue culture skin/biopsy,88233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,180.18,,,,,,,fee schedule,126.66,246.28,
Tissue culture skin/biopsy,88233,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,126.66,,,,,,,fee schedule,126.66,246.28,Laboratory
Tissue culture skin/biopsy,88233,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,147.77,,,,,,,fee schedule,126.66,246.28,APC
Tissue culture skin/biopsy,88233,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,146.36,,,,,,,fee schedule,126.66,246.28,APC
Tissue culture skin/biopsy,88233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,140.73,,,,,,,fee schedule,126.66,246.28,APC
Tissue culture skin/biopsy,88233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,215.32,,,,,,,fee schedule,126.66,246.28,Radiology
Tissue culture skin/biopsy,88233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,197.02,,,,,,,fee schedule,126.66,246.28,APC
Tissue culture skin/biopsy,88233,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,246.28,,,,,,,fee schedule,126.66,246.28,APC
Tissue culture placenta,88235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,812.7,,,,,,,fee schedule,135.27,812.7,
Tissue culture placenta,88235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,651.45,,,,,,,fee schedule,135.27,812.7,
Tissue culture placenta,88235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,711.65,,,,,,,fee schedule,135.27,812.7,
Tissue culture placenta,88235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,748.2,,,,,,,fee schedule,135.27,812.7,
Tissue culture placenta,88235,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,135.27,,,,,,,fee schedule,135.27,812.7,Laboratory
Tissue culture placenta,88235,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,157.82,,,,,,,fee schedule,135.27,812.7,APC
Tissue culture placenta,88235,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,156.31,,,,,,,fee schedule,135.27,812.7,APC
Tissue culture placenta,88235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,150.3,,,,,,,fee schedule,135.27,812.7,APC
Tissue culture placenta,88235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,229.96,,,,,,,fee schedule,135.27,812.7,Radiology
Tissue culture placenta,88235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,210.42,,,,,,,fee schedule,135.27,812.7,APC
Tissue culture placenta,88235,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,263.03,,,,,,,fee schedule,135.27,812.7,APC
Tissue culture bone marrow,88237,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,739.65,,,,,,,fee schedule,129.38,739.65,
Tissue culture bone marrow,88237,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,592.89,,,,,,,fee schedule,129.38,739.65,
Tissue culture bone marrow,88237,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,647.68,,,,,,,fee schedule,129.38,739.65,
Tissue culture bone marrow,88237,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,680.95,,,,,,,fee schedule,129.38,739.65,
Tissue culture bone marrow,88237,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,129.38,,,,,,,fee schedule,129.38,739.65,Laboratory
Tissue culture bone marrow,88237,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,150.94,,,,,,,fee schedule,129.38,739.65,APC
Tissue culture bone marrow,88237,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,149.5,,,,,,,fee schedule,129.38,739.65,APC
Tissue culture bone marrow,88237,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,143.75,,,,,,,fee schedule,129.38,739.65,APC
Tissue culture bone marrow,88237,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,219.94,,,,,,,fee schedule,129.38,739.65,Radiology
Tissue culture bone marrow,88237,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.25,,,,,,,fee schedule,129.38,739.65,APC
Tissue culture bone marrow,88237,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,251.56,,,,,,,fee schedule,129.38,739.65,APC
Tissue culture tumor,88239,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,814.17,,,,,,,fee schedule,132.77,814.17,
Tissue culture tumor,88239,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,652.63,,,,,,,fee schedule,132.77,814.17,
Tissue culture tumor,88239,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,712.94,,,,,,,fee schedule,132.77,814.17,
Tissue culture tumor,88239,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,749.56,,,,,,,fee schedule,132.77,814.17,
Tissue culture tumor,88239,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,132.77,,,,,,,fee schedule,132.77,814.17,Laboratory
Tissue culture tumor,88239,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,154.9,,,,,,,fee schedule,132.77,814.17,APC
Tissue culture tumor,88239,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,153.42,,,,,,,fee schedule,132.77,814.17,APC
Tissue culture tumor,88239,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,147.52,,,,,,,fee schedule,132.77,814.17,APC
Tissue culture tumor,88239,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,225.71,,,,,,,fee schedule,132.77,814.17,Radiology
Tissue culture tumor,88239,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,206.53,,,,,,,fee schedule,132.77,814.17,APC
Tissue culture tumor,88239,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,258.16,,,,,,,fee schedule,132.77,814.17,APC
Cell cryopreserve/storage,88240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,50.61,,,,,,,fee schedule,11.76,50.61,
Cell cryopreserve/storage,88240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40.57,,,,,,,fee schedule,11.76,50.61,
Cell cryopreserve/storage,88240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,44.32,,,,,,,fee schedule,11.76,50.61,
Cell cryopreserve/storage,88240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46.6,,,,,,,fee schedule,11.76,50.61,
Cell cryopreserve/storage,88240,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.76,,,,,,,fee schedule,11.76,50.61,Laboratory
Cell cryopreserve/storage,88240,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.72,,,,,,,fee schedule,11.76,50.61,APC
Cell cryopreserve/storage,88240,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.59,,,,,,,fee schedule,11.76,50.61,APC
Cell cryopreserve/storage,88240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.07,,,,,,,fee schedule,11.76,50.61,APC
Cell cryopreserve/storage,88240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20,,,,,,,fee schedule,11.76,50.61,Radiology
Cell cryopreserve/storage,88240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.3,,,,,,,fee schedule,11.76,50.61,APC
Cell cryopreserve/storage,88240,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22.87,,,,,,,fee schedule,11.76,50.61,APC
Frozen cell preparation,88241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,50.61,,,,,,,fee schedule,10.88,50.61,
Frozen cell preparation,88241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40.57,,,,,,,fee schedule,10.88,50.61,
Frozen cell preparation,88241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,44.32,,,,,,,fee schedule,10.88,50.61,
Frozen cell preparation,88241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46.6,,,,,,,fee schedule,10.88,50.61,
Frozen cell preparation,88241,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.88,,,,,,,fee schedule,10.88,50.61,Laboratory
Frozen cell preparation,88241,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.69,,,,,,,fee schedule,10.88,50.61,APC
Frozen cell preparation,88241,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.57,,,,,,,fee schedule,10.88,50.61,APC
Frozen cell preparation,88241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.09,,,,,,,fee schedule,10.88,50.61,APC
Frozen cell preparation,88241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.5,,,,,,,fee schedule,10.88,50.61,Radiology
Frozen cell preparation,88241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.93,,,,,,,fee schedule,10.88,50.61,APC
Frozen cell preparation,88241,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21.16,,,,,,,fee schedule,10.88,50.61,APC
Chromosome analysis 20-25,88245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,821.58,,,,,,,fee schedule,155.85,821.58,
Chromosome analysis 20-25,88245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,658.57,,,,,,,fee schedule,155.85,821.58,
Chromosome analysis 20-25,88245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,719.43,,,,,,,fee schedule,155.85,821.58,
Chromosome analysis 20-25,88245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,756.38,,,,,,,fee schedule,155.85,821.58,
Chromosome analysis 20-25,88245,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,155.85,,,,,,,fee schedule,155.85,821.58,Laboratory
Chromosome analysis 20-25,88245,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,181.83,,,,,,,fee schedule,155.85,821.58,APC
Chromosome analysis 20-25,88245,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,180.1,,,,,,,fee schedule,155.85,821.58,APC
Chromosome analysis 20-25,88245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,173.17,,,,,,,fee schedule,155.85,821.58,APC
Chromosome analysis 20-25,88245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,264.95,,,,,,,fee schedule,155.85,821.58,Radiology
Chromosome analysis 20-25,88245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,242.44,,,,,,,fee schedule,155.85,821.58,APC
Chromosome analysis 20-25,88245,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,303.05,,,,,,,fee schedule,155.85,821.58,APC
Chromosome analysis 50-100,88248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,955.74,,,,,,,fee schedule,155.85,955.74,
Chromosome analysis 50-100,88248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,766.11,,,,,,,fee schedule,155.85,955.74,
Chromosome analysis 50-100,88248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,836.9,,,,,,,fee schedule,155.85,955.74,
Chromosome analysis 50-100,88248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,879.88,,,,,,,fee schedule,155.85,955.74,
Chromosome analysis 50-100,88248,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,155.85,,,,,,,fee schedule,155.85,955.74,Laboratory
Chromosome analysis 50-100,88248,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,181.83,,,,,,,fee schedule,155.85,955.74,APC
Chromosome analysis 50-100,88248,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,180.1,,,,,,,fee schedule,155.85,955.74,APC
Chromosome analysis 50-100,88248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,173.17,,,,,,,fee schedule,155.85,955.74,APC
Chromosome analysis 50-100,88248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,264.95,,,,,,,fee schedule,155.85,955.74,Radiology
Chromosome analysis 50-100,88248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,242.44,,,,,,,fee schedule,155.85,955.74,APC
Chromosome analysis 50-100,88248,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,303.05,,,,,,,fee schedule,155.85,955.74,APC
Chromosome analysis 100,88249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,955.74,,,,,,,fee schedule,155.85,955.74,
Chromosome analysis 100,88249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,766.11,,,,,,,fee schedule,155.85,955.74,
Chromosome analysis 100,88249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,836.9,,,,,,,fee schedule,155.85,955.74,
Chromosome analysis 100,88249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,879.88,,,,,,,fee schedule,155.85,955.74,
Chromosome analysis 100,88249,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,155.85,,,,,,,fee schedule,155.85,955.74,Laboratory
Chromosome analysis 100,88249,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,181.83,,,,,,,fee schedule,155.85,955.74,APC
Chromosome analysis 100,88249,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,180.1,,,,,,,fee schedule,155.85,955.74,APC
Chromosome analysis 100,88249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,173.17,,,,,,,fee schedule,155.85,955.74,APC
Chromosome analysis 100,88249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,264.95,,,,,,,fee schedule,155.85,955.74,Radiology
Chromosome analysis 100,88249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,242.44,,,,,,,fee schedule,155.85,955.74,APC
Chromosome analysis 100,88249,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,303.05,,,,,,,fee schedule,155.85,955.74,APC
Chromosome analysis 5,88261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,975.43,,,,,,,fee schedule,237.91,975.43,
Chromosome analysis 5,88261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,781.89,,,,,,,fee schedule,237.91,975.43,
Chromosome analysis 5,88261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,854.15,,,,,,,fee schedule,237.91,975.43,
Chromosome analysis 5,88261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,898.01,,,,,,,fee schedule,237.91,975.43,
Chromosome analysis 5,88261,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,237.91,,,,,,,fee schedule,237.91,975.43,Laboratory
Chromosome analysis 5,88261,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,277.56,,,,,,,fee schedule,237.91,975.43,APC
Chromosome analysis 5,88261,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,274.91,,,,,,,fee schedule,237.91,975.43,APC
Chromosome analysis 5,88261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,264.34,,,,,,,fee schedule,237.91,975.43,APC
Chromosome analysis 5,88261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,404.44,,,,,,,fee schedule,237.91,975.43,Radiology
Chromosome analysis 5,88261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,370.08,,,,,,,fee schedule,237.91,975.43,APC
Chromosome analysis 5,88261,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,462.6,,,,,,,fee schedule,237.91,975.43,APC
Chromosome analysis 15-20,88262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,419.8,,,,,,,fee schedule,112.94,419.8,
Chromosome analysis 15-20,88262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,336.51,,,,,,,fee schedule,112.94,419.8,
Chromosome analysis 15-20,88262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,367.6,,,,,,,fee schedule,112.94,419.8,
Chromosome analysis 15-20,88262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,386.48,,,,,,,fee schedule,112.94,419.8,
Chromosome analysis 15-20,88262,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,112.94,,,,,,,fee schedule,112.94,419.8,Laboratory
Chromosome analysis 15-20,88262,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,131.76,,,,,,,fee schedule,112.94,419.8,APC
Chromosome analysis 15-20,88262,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,130.51,,,,,,,fee schedule,112.94,419.8,APC
Chromosome analysis 15-20,88262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,125.49,,,,,,,fee schedule,112.94,419.8,APC
Chromosome analysis 15-20,88262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,192,,,,,,,fee schedule,112.94,419.8,Radiology
Chromosome analysis 15-20,88262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,175.69,,,,,,,fee schedule,112.94,419.8,APC
Chromosome analysis 15-20,88262,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,219.61,,,,,,,fee schedule,112.94,419.8,APC
Chromosome analysis 45,88263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,829.41,,,,,,,fee schedule,135.26,829.41,
Chromosome analysis 45,88263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,664.84,,,,,,,fee schedule,135.26,829.41,
Chromosome analysis 45,88263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,726.28,,,,,,,fee schedule,135.26,829.41,
Chromosome analysis 45,88263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,763.58,,,,,,,fee schedule,135.26,829.41,
Chromosome analysis 45,88263,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,135.26,,,,,,,fee schedule,135.26,829.41,Laboratory
Chromosome analysis 45,88263,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,157.8,,,,,,,fee schedule,135.26,829.41,APC
Chromosome analysis 45,88263,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,156.3,,,,,,,fee schedule,135.26,829.41,APC
Chromosome analysis 45,88263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,150.29,,,,,,,fee schedule,135.26,829.41,APC
Chromosome analysis 45,88263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,229.94,,,,,,,fee schedule,135.26,829.41,Radiology
Chromosome analysis 45,88263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,210.41,,,,,,,fee schedule,135.26,829.41,APC
Chromosome analysis 45,88263,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,263.01,,,,,,,fee schedule,135.26,829.41,APC
Chromosome analysis 20-25,88264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,687.88,,,,,,,fee schedule,130.15,687.88,
Chromosome analysis 20-25,88264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,551.4,,,,,,,fee schedule,130.15,687.88,
Chromosome analysis 20-25,88264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,602.35,,,,,,,fee schedule,130.15,687.88,
Chromosome analysis 20-25,88264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,633.29,,,,,,,fee schedule,130.15,687.88,
Chromosome analysis 20-25,88264,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,130.15,,,,,,,fee schedule,130.15,687.88,Laboratory
Chromosome analysis 20-25,88264,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,151.84,,,,,,,fee schedule,130.15,687.88,APC
Chromosome analysis 20-25,88264,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,150.39,,,,,,,fee schedule,130.15,687.88,APC
Chromosome analysis 20-25,88264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,144.61,,,,,,,fee schedule,130.15,687.88,APC
Chromosome analysis 20-25,88264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,221.25,,,,,,,fee schedule,130.15,687.88,Radiology
Chromosome analysis 20-25,88264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,202.45,,,,,,,fee schedule,130.15,687.88,APC
Chromosome analysis 20-25,88264,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,253.07,,,,,,,fee schedule,130.15,687.88,APC
Chromosome analys placenta,88267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,992.14,,,,,,,fee schedule,169.71,992.14,
Chromosome analys placenta,88267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,795.28,,,,,,,fee schedule,169.71,992.14,
Chromosome analys placenta,88267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,868.78,,,,,,,fee schedule,169.71,992.14,
Chromosome analys placenta,88267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,913.4,,,,,,,fee schedule,169.71,992.14,
Chromosome analys placenta,88267,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,169.71,,,,,,,fee schedule,169.71,992.14,Laboratory
Chromosome analys placenta,88267,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,198,,,,,,,fee schedule,169.71,992.14,APC
Chromosome analys placenta,88267,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,196.11,,,,,,,fee schedule,169.71,992.14,APC
Chromosome analys placenta,88267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,188.57,,,,,,,fee schedule,169.71,992.14,APC
Chromosome analys placenta,88267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,288.51,,,,,,,fee schedule,169.71,992.14,Radiology
Chromosome analys placenta,88267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,264,,,,,,,fee schedule,169.71,992.14,APC
Chromosome analys placenta,88267,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,330,,,,,,,fee schedule,169.71,992.14,APC
Chromosome analys amniotic,88269,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,917.94,,,,,,,fee schedule,156.29,917.94,
Chromosome analys amniotic,88269,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,735.81,,,,,,,fee schedule,156.29,917.94,
Chromosome analys amniotic,88269,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,803.8,,,,,,,fee schedule,156.29,917.94,
Chromosome analys amniotic,88269,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,845.08,,,,,,,fee schedule,156.29,917.94,
Chromosome analys amniotic,88269,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,156.29,,,,,,,fee schedule,156.29,917.94,Laboratory
Chromosome analys amniotic,88269,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,182.34,,,,,,,fee schedule,156.29,917.94,APC
Chromosome analys amniotic,88269,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,180.61,,,,,,,fee schedule,156.29,917.94,APC
Chromosome analys amniotic,88269,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,173.66,,,,,,,fee schedule,156.29,917.94,APC
Chromosome analys amniotic,88269,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,265.7,,,,,,,fee schedule,156.29,917.94,Radiology
Chromosome analys amniotic,88269,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,243.12,,,,,,,fee schedule,156.29,917.94,APC
Chromosome analys amniotic,88269,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,303.9,,,,,,,fee schedule,156.29,917.94,APC
Cytogenetics dna probe,88271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,118.2,,,,,,,fee schedule,19.28,118.2,
Cytogenetics dna probe,88271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,94.75,,,,,,,fee schedule,19.28,118.2,
Cytogenetics dna probe,88271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,103.5,,,,,,,fee schedule,19.28,118.2,
Cytogenetics dna probe,88271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,108.82,,,,,,,fee schedule,19.28,118.2,
Cytogenetics dna probe,88271,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.28,,,,,,,fee schedule,19.28,118.2,Laboratory
Cytogenetics dna probe,88271,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,22.49,,,,,,,fee schedule,19.28,118.2,APC
Cytogenetics dna probe,88271,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,22.28,,,,,,,fee schedule,19.28,118.2,APC
Cytogenetics dna probe,88271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,21.42,,,,,,,fee schedule,19.28,118.2,APC
Cytogenetics dna probe,88271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,32.77,,,,,,,fee schedule,19.28,118.2,Radiology
Cytogenetics dna probe,88271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29.99,,,,,,,fee schedule,19.28,118.2,APC
Cytogenetics dna probe,88271,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,37.48,,,,,,,fee schedule,19.28,118.2,APC
Cytogenetics 3-5,88272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,147.76,,,,,,,fee schedule,36.63,147.76,
Cytogenetics 3-5,88272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,118.44,,,,,,,fee schedule,36.63,147.76,
Cytogenetics 3-5,88272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,129.39,,,,,,,fee schedule,36.63,147.76,
Cytogenetics 3-5,88272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,136.03,,,,,,,fee schedule,36.63,147.76,
Cytogenetics 3-5,88272,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,36.63,,,,,,,fee schedule,36.63,147.76,Laboratory
Cytogenetics 3-5,88272,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,42.74,,,,,,,fee schedule,36.63,147.76,APC
Cytogenetics 3-5,88272,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,42.33,,,,,,,fee schedule,36.63,147.76,APC
Cytogenetics 3-5,88272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,40.7,,,,,,,fee schedule,36.63,147.76,APC
Cytogenetics 3-5,88272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,62.27,,,,,,,fee schedule,36.63,147.76,Radiology
Cytogenetics 3-5,88272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.98,,,,,,,fee schedule,36.63,147.76,APC
Cytogenetics 3-5,88272,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,71.23,,,,,,,fee schedule,36.63,147.76,APC
Cytogenetics 10-30,88273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,177.32,,,,,,,fee schedule,31.33,177.32,
Cytogenetics 10-30,88273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,142.14,,,,,,,fee schedule,31.33,177.32,
Cytogenetics 10-30,88273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,155.27,,,,,,,fee schedule,31.33,177.32,
Cytogenetics 10-30,88273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,163.25,,,,,,,fee schedule,31.33,177.32,
Cytogenetics 10-30,88273,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31.33,,,,,,,fee schedule,31.33,177.32,Laboratory
Cytogenetics 10-30,88273,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.55,,,,,,,fee schedule,31.33,177.32,APC
Cytogenetics 10-30,88273,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,36.2,,,,,,,fee schedule,31.33,177.32,APC
Cytogenetics 10-30,88273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,34.81,,,,,,,fee schedule,31.33,177.32,APC
Cytogenetics 10-30,88273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,53.26,,,,,,,fee schedule,31.33,177.32,Radiology
Cytogenetics 10-30,88273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,48.73,,,,,,,fee schedule,31.33,177.32,APC
Cytogenetics 10-30,88273,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,60.92,,,,,,,fee schedule,31.33,177.32,APC
Cytogenetics 25-99,88274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,192.1,,,,,,,fee schedule,38.14,192.1,
Cytogenetics 25-99,88274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,153.98,,,,,,,fee schedule,38.14,192.1,
Cytogenetics 25-99,88274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,168.21,,,,,,,fee schedule,38.14,192.1,
Cytogenetics 25-99,88274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,176.85,,,,,,,fee schedule,38.14,192.1,
Cytogenetics 25-99,88274,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,38.14,,,,,,,fee schedule,38.14,192.1,Laboratory
Cytogenetics 25-99,88274,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,44.5,,,,,,,fee schedule,38.14,192.1,APC
Cytogenetics 25-99,88274,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,44.08,,,,,,,fee schedule,38.14,192.1,APC
Cytogenetics 25-99,88274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,42.38,,,,,,,fee schedule,38.14,192.1,APC
Cytogenetics 25-99,88274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,64.84,,,,,,,fee schedule,38.14,192.1,Radiology
Cytogenetics 25-99,88274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,59.33,,,,,,,fee schedule,38.14,192.1,APC
Cytogenetics 25-99,88274,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,74.17,,,,,,,fee schedule,38.14,192.1,APC
Cytogenetics 100-300,88275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,221.66,,,,,,,fee schedule,46.07,221.66,
Cytogenetics 100-300,88275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,177.68,,,,,,,fee schedule,46.07,221.66,
Cytogenetics 100-300,88275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,194.1,,,,,,,fee schedule,46.07,221.66,
Cytogenetics 100-300,88275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,204.07,,,,,,,fee schedule,46.07,221.66,
Cytogenetics 100-300,88275,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46.07,,,,,,,fee schedule,46.07,221.66,Laboratory
Cytogenetics 100-300,88275,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,53.75,,,,,,,fee schedule,46.07,221.66,APC
Cytogenetics 100-300,88275,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,53.24,,,,,,,fee schedule,46.07,221.66,APC
Cytogenetics 100-300,88275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,51.19,,,,,,,fee schedule,46.07,221.66,APC
Cytogenetics 100-300,88275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,78.32,,,,,,,fee schedule,46.07,221.66,Radiology
Cytogenetics 100-300,88275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,71.67,,,,,,,fee schedule,46.07,221.66,APC
Cytogenetics 100-300,88275,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,89.58,,,,,,,fee schedule,46.07,221.66,APC
Chromosome karyotype study,88280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,138.5,,,,,,,fee schedule,30.12,138.5,
Chromosome karyotype study,88280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,111.02,,,,,,,fee schedule,30.12,138.5,
Chromosome karyotype study,88280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,121.28,,,,,,,fee schedule,30.12,138.5,
Chromosome karyotype study,88280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,127.51,,,,,,,fee schedule,30.12,138.5,
Chromosome karyotype study,88280,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,30.12,,,,,,,fee schedule,30.12,138.5,Laboratory
Chromosome karyotype study,88280,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,35.14,,,,,,,fee schedule,30.12,138.5,APC
Chromosome karyotype study,88280,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,34.81,,,,,,,fee schedule,30.12,138.5,APC
Chromosome karyotype study,88280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,33.47,,,,,,,fee schedule,30.12,138.5,APC
Chromosome karyotype study,88280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.21,,,,,,,fee schedule,30.12,138.5,Radiology
Chromosome karyotype study,88280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,46.86,,,,,,,fee schedule,30.12,138.5,APC
Chromosome karyotype study,88280,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,58.57,,,,,,,fee schedule,30.12,138.5,APC
Chromosome banding study,88283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,378.57,,,,,,,fee schedule,61.74,378.57,
Chromosome banding study,88283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,303.45,,,,,,,fee schedule,61.74,378.57,
Chromosome banding study,88283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,331.5,,,,,,,fee schedule,61.74,378.57,
Chromosome banding study,88283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,348.52,,,,,,,fee schedule,61.74,378.57,
Chromosome banding study,88283,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,61.74,,,,,,,fee schedule,61.74,378.57,Laboratory
Chromosome banding study,88283,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,72.03,,,,,,,fee schedule,61.74,378.57,APC
Chromosome banding study,88283,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,71.34,,,,,,,fee schedule,61.74,378.57,APC
Chromosome banding study,88283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,68.6,,,,,,,fee schedule,61.74,378.57,APC
Chromosome banding study,88283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,104.96,,,,,,,fee schedule,61.74,378.57,Radiology
Chromosome banding study,88283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,96.04,,,,,,,fee schedule,61.74,378.57,APC
Chromosome banding study,88283,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,120.05,,,,,,,fee schedule,61.74,378.57,APC
Chromosome count additional,88285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,104.86,,,,,,,fee schedule,24.22,104.86,
Chromosome count additional,88285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,84.05,,,,,,,fee schedule,24.22,104.86,
Chromosome count additional,88285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,91.82,,,,,,,fee schedule,24.22,104.86,
Chromosome count additional,88285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,96.54,,,,,,,fee schedule,24.22,104.86,
Chromosome count additional,88285,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24.22,,,,,,,fee schedule,24.22,104.86,Laboratory
Chromosome count additional,88285,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,28.26,,,,,,,fee schedule,24.22,104.86,APC
Chromosome count additional,88285,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,27.99,,,,,,,fee schedule,24.22,104.86,APC
Chromosome count additional,88285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,26.91,,,,,,,fee schedule,24.22,104.86,APC
Chromosome count additional,88285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,41.17,,,,,,,fee schedule,24.22,104.86,Radiology
Chromosome count additional,88285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,37.67,,,,,,,fee schedule,24.22,104.86,APC
Chromosome count additional,88285,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,47.09,,,,,,,fee schedule,24.22,104.86,APC
Chromosome study additional,88289,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,190.06,,,,,,,fee schedule,30.99,190.06,
Chromosome study additional,88289,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,152.35,,,,,,,fee schedule,30.99,190.06,
Chromosome study additional,88289,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,166.43,,,,,,,fee schedule,30.99,190.06,
Chromosome study additional,88289,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,174.97,,,,,,,fee schedule,30.99,190.06,
Chromosome study additional,88289,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,30.99,,,,,,,fee schedule,30.99,190.06,Laboratory
Chromosome study additional,88289,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.15,,,,,,,fee schedule,30.99,190.06,APC
Chromosome study additional,88289,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,35.81,,,,,,,fee schedule,30.99,190.06,APC
Chromosome study additional,88289,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,34.43,,,,,,,fee schedule,30.99,190.06,APC
Chromosome study additional,88289,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,52.68,,,,,,,fee schedule,30.99,190.06,Radiology
Chromosome study additional,88289,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,48.2,,,,,,,fee schedule,30.99,190.06,APC
Chromosome study additional,88289,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,60.25,,,,,,,fee schedule,30.99,190.06,APC
Cytogenetic study,88299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24.19,,,,,,,fee schedule,19.39,228.88,
Cytogenetic study,88299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19.39,,,,,,,fee schedule,19.39,228.88,
Cytogenetic study,88299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21.18,,,,,,,fee schedule,19.39,228.88,
Cytogenetic study,88299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22.27,,,,,,,fee schedule,19.39,228.88,
Cytogenetic study,88299,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,228.88,,,,,,,fee schedule,19.39,228.88,APC 378
Cytogenetic study,88299,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.17,,,,,,,fee schedule,19.39,228.88,APC
Cytogenetic study,88299,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,53.65,,,,,,,fee schedule,19.39,228.88,APC
Cytogenetic study,88299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,51.59,,,,,,,fee schedule,19.39,228.88,APC
Cytogenetic study,88299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,78.93,,,,,,,fee schedule,19.39,228.88,Radiology
Cytogenetic study,88299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,72.22,,,,,,,fee schedule,19.39,228.88,APC
Cytogenetic study,88299,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,90.28,,,,,,,fee schedule,19.39,228.88,APC
Surgical path gross,88300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27.14,,,,,,,fee schedule,21.75,127.04,
Surgical path gross,88300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21.75,,,,,,,fee schedule,21.75,127.04,
Surgical path gross,88300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23.76,,,,,,,fee schedule,21.75,127.04,
Surgical path gross,88300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24.98,,,,,,,fee schedule,21.75,127.04,
Surgical path gross,88300,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,127.04,,,,,,,fee schedule,21.75,127.04,APC 378
Surgical path gross,88300,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.07,,,,,,,fee schedule,21.75,127.04,APC
Surgical path gross,88300,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,29.78,,,,,,,fee schedule,21.75,127.04,APC
Surgical path gross,88300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,28.63,,,,,,,fee schedule,21.75,127.04,APC
Surgical path gross,88300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43.81,,,,,,,fee schedule,21.75,127.04,Radiology
Surgical path gross,88300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40.09,,,,,,,fee schedule,21.75,127.04,APC
Surgical path gross,88300,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,50.11,,,,,,,fee schedule,21.75,127.04,APC
Tissue exam by pathologist,88302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,49.56,,,,,,,fee schedule,36.98,164.05,
Tissue exam by pathologist,88302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39.73,,,,,,,fee schedule,36.98,164.05,
Tissue exam by pathologist,88302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,43.4,,,,,,,fee schedule,36.98,164.05,
Tissue exam by pathologist,88302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45.63,,,,,,,fee schedule,36.98,164.05,
Tissue exam by pathologist,88302,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.05,,,,,,,fee schedule,36.98,164.05,APC 378
Tissue exam by pathologist,88302,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.83,,,,,,,fee schedule,36.98,164.05,APC
Tissue exam by pathologist,88302,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.46,,,,,,,fee schedule,36.98,164.05,APC
Tissue exam by pathologist,88302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.98,,,,,,,fee schedule,36.98,164.05,APC
Tissue exam by pathologist,88302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.57,,,,,,,fee schedule,36.98,164.05,Radiology
Tissue exam by pathologist,88302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.77,,,,,,,fee schedule,36.98,164.05,APC
Tissue exam by pathologist,88302,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.71,,,,,,,fee schedule,36.98,164.05,APC
Tissue exam by pathologist,88304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,58.36,,,,,,,fee schedule,46.78,228.88,
Tissue exam by pathologist,88304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.78,,,,,,,fee schedule,46.78,228.88,
Tissue exam by pathologist,88304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.1,,,,,,,fee schedule,46.78,228.88,
Tissue exam by pathologist,88304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,53.73,,,,,,,fee schedule,46.78,228.88,
Tissue exam by pathologist,88304,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,228.88,,,,,,,fee schedule,46.78,228.88,APC 378
Tissue exam by pathologist,88304,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.17,,,,,,,fee schedule,46.78,228.88,APC
Tissue exam by pathologist,88304,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,53.65,,,,,,,fee schedule,46.78,228.88,APC
Tissue exam by pathologist,88304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,51.59,,,,,,,fee schedule,46.78,228.88,APC
Tissue exam by pathologist,88304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,78.93,,,,,,,fee schedule,46.78,228.88,Radiology
Tissue exam by pathologist,88304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,72.22,,,,,,,fee schedule,46.78,228.88,APC
Tissue exam by pathologist,88304,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,90.28,,,,,,,fee schedule,46.78,228.88,APC
Tissue exam by pathologist,88305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,170.22,,,,,,,fee schedule,51.59,228.88,
Tissue exam by pathologist,88305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,136.44,,,,,,,fee schedule,51.59,228.88,
Tissue exam by pathologist,88305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,149.05,,,,,,,fee schedule,51.59,228.88,
Tissue exam by pathologist,88305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,156.71,,,,,,,fee schedule,51.59,228.88,
Tissue exam by pathologist,88305,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,228.88,,,,,,,fee schedule,51.59,228.88,APC 378
Tissue exam by pathologist,88305,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.17,,,,,,,fee schedule,51.59,228.88,APC
Tissue exam by pathologist,88305,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,53.65,,,,,,,fee schedule,51.59,228.88,APC
Tissue exam by pathologist,88305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,51.59,,,,,,,fee schedule,51.59,228.88,APC
Tissue exam by pathologist,88305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,78.93,,,,,,,fee schedule,51.59,228.88,Radiology
Tissue exam by pathologist,88305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,72.22,,,,,,,fee schedule,51.59,228.88,APC
Tissue exam by pathologist,88305,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,90.28,,,,,,,fee schedule,51.59,228.88,APC
Tissue exam by pathologist,88307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,166.36,,,,,,,fee schedule,133.35,1574.35,
Tissue exam by pathologist,88307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,133.35,,,,,,,fee schedule,133.35,1574.35,
Tissue exam by pathologist,88307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,145.67,,,,,,,fee schedule,133.35,1574.35,
Tissue exam by pathologist,88307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,153.16,,,,,,,fee schedule,133.35,1574.35,
Tissue exam by pathologist,88307,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1574.35,,,,,,,fee schedule,133.35,1574.35,APC 378
Tissue exam by pathologist,88307,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,372.59,,,,,,,fee schedule,133.35,1574.35,APC
Tissue exam by pathologist,88307,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,369.04,,,,,,,fee schedule,133.35,1574.35,APC
Tissue exam by pathologist,88307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,354.85,,,,,,,fee schedule,133.35,1574.35,APC
Tissue exam by pathologist,88307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,542.92,,,,,,,fee schedule,133.35,1574.35,Radiology
Tissue exam by pathologist,88307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,496.79,,,,,,,fee schedule,133.35,1574.35,APC
Tissue exam by pathologist,88307,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,620.99,,,,,,,fee schedule,133.35,1574.35,APC
Tissue exam by pathologist,88309,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,268.02,,,,,,,fee schedule,214.84,3538.67,
Tissue exam by pathologist,88309,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,214.84,,,,,,,fee schedule,214.84,3538.67,
Tissue exam by pathologist,88309,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,234.7,,,,,,,fee schedule,214.84,3538.67,
Tissue exam by pathologist,88309,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,246.75,,,,,,,fee schedule,214.84,3538.67,
Tissue exam by pathologist,88309,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3538.67,,,,,,,fee schedule,214.84,3538.67,APC 378
Tissue exam by pathologist,88309,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,837.48,,,,,,,fee schedule,214.84,3538.67,APC
Tissue exam by pathologist,88309,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,829.5,,,,,,,fee schedule,214.84,3538.67,APC
Tissue exam by pathologist,88309,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,797.6,,,,,,,fee schedule,214.84,3538.67,APC
Tissue exam by pathologist,88309,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1220.32,,,,,,,fee schedule,214.84,3538.67,Radiology
Tissue exam by pathologist,88309,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1116.64,,,,,,,fee schedule,214.84,3538.67,APC
Tissue exam by pathologist,88309,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1395.79,,,,,,,fee schedule,214.84,3538.67,APC
Decalcify tissue,88311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27.39,,,,,,,fee schedule,21.96,27.39,
Decalcify tissue,88311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21.96,,,,,,,fee schedule,21.96,27.39,
Decalcify tissue,88311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23.99,,,,,,,fee schedule,21.96,27.39,
Decalcify tissue,88311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,25.22,,,,,,,fee schedule,21.96,27.39,
Special stains group 1,88312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,65.83,,,,,,,fee schedule,51.59,228.88,
Special stains group 1,88312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52.77,,,,,,,fee schedule,51.59,228.88,
Special stains group 1,88312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.65,,,,,,,fee schedule,51.59,228.88,
Special stains group 1,88312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.61,,,,,,,fee schedule,51.59,228.88,
Special stains group 1,88312,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,228.88,,,,,,,fee schedule,51.59,228.88,APC 378
Special stains group 1,88312,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.17,,,,,,,fee schedule,51.59,228.88,APC
Special stains group 1,88312,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,53.65,,,,,,,fee schedule,51.59,228.88,APC
Special stains group 1,88312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,51.59,,,,,,,fee schedule,51.59,228.88,APC
Special stains group 1,88312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,78.93,,,,,,,fee schedule,51.59,228.88,Radiology
Special stains group 1,88312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,72.22,,,,,,,fee schedule,51.59,228.88,APC
Special stains group 1,88312,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,90.28,,,,,,,fee schedule,51.59,228.88,APC
Special stains group 2,88313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,49.61,,,,,,,fee schedule,39.76,584.37,
Special stains group 2,88313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39.76,,,,,,,fee schedule,39.76,584.37,
Special stains group 2,88313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,43.44,,,,,,,fee schedule,39.76,584.37,
Special stains group 2,88313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45.67,,,,,,,fee schedule,39.76,584.37,
Special stains group 2,88313,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,39.76,584.37,APC 378
Special stains group 2,88313,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,39.76,584.37,APC
Special stains group 2,88313,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,39.76,584.37,APC
Special stains group 2,88313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,39.76,584.37,APC
Special stains group 2,88313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,39.76,584.37,Radiology
Special stains group 2,88313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,39.76,584.37,APC
Special stains group 2,88313,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,39.76,584.37,APC
Histochemical stains add-on,88314,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,141.41,,,,,,,fee schedule,113.36,141.41,
Histochemical stains add-on,88314,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,113.36,,,,,,,fee schedule,113.36,141.41,
Histochemical stains add-on,88314,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,123.83,,,,,,,fee schedule,113.36,141.41,
Histochemical stains add-on,88314,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,130.19,,,,,,,fee schedule,113.36,141.41,
Enzyme histochemistry,88319,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,268.02,,,,,,,fee schedule,214.84,3538.67,
Enzyme histochemistry,88319,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,214.84,,,,,,,fee schedule,214.84,3538.67,
Enzyme histochemistry,88319,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,234.7,,,,,,,fee schedule,214.84,3538.67,
Enzyme histochemistry,88319,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,246.75,,,,,,,fee schedule,214.84,3538.67,
Enzyme histochemistry,88319,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3538.67,,,,,,,fee schedule,214.84,3538.67,APC 378
Enzyme histochemistry,88319,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,837.48,,,,,,,fee schedule,214.84,3538.67,APC
Enzyme histochemistry,88319,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,829.5,,,,,,,fee schedule,214.84,3538.67,APC
Enzyme histochemistry,88319,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,797.6,,,,,,,fee schedule,214.84,3538.67,APC
Enzyme histochemistry,88319,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1220.32,,,,,,,fee schedule,214.84,3538.67,Radiology
Enzyme histochemistry,88319,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1116.64,,,,,,,fee schedule,214.84,3538.67,APC
Enzyme histochemistry,88319,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1395.79,,,,,,,fee schedule,214.84,3538.67,APC
Microslide consultation,88321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59.84,,,,,,,fee schedule,36.98,164.05,
Microslide consultation,88321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,47.96,,,,,,,fee schedule,36.98,164.05,
Microslide consultation,88321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52.4,,,,,,,fee schedule,36.98,164.05,
Microslide consultation,88321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55.09,,,,,,,fee schedule,36.98,164.05,
Microslide consultation,88321,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.05,,,,,,,fee schedule,36.98,164.05,APC 378
Microslide consultation,88321,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.83,,,,,,,fee schedule,36.98,164.05,APC
Microslide consultation,88321,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.46,,,,,,,fee schedule,36.98,164.05,APC
Microslide consultation,88321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.98,,,,,,,fee schedule,36.98,164.05,APC
Microslide consultation,88321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.57,,,,,,,fee schedule,36.98,164.05,Radiology
Microslide consultation,88321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.77,,,,,,,fee schedule,36.98,164.05,APC
Microslide consultation,88321,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.71,,,,,,,fee schedule,36.98,164.05,APC
Microslide consultation,88323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,135.49,,,,,,,fee schedule,51.59,228.88,
Microslide consultation,88323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,108.61,,,,,,,fee schedule,51.59,228.88,
Microslide consultation,88323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,118.64,,,,,,,fee schedule,51.59,228.88,
Microslide consultation,88323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,124.74,,,,,,,fee schedule,51.59,228.88,
Microslide consultation,88323,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,228.88,,,,,,,fee schedule,51.59,228.88,APC 378
Microslide consultation,88323,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.17,,,,,,,fee schedule,51.59,228.88,APC
Microslide consultation,88323,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,53.65,,,,,,,fee schedule,51.59,228.88,APC
Microslide consultation,88323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,51.59,,,,,,,fee schedule,51.59,228.88,APC
Microslide consultation,88323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,78.93,,,,,,,fee schedule,51.59,228.88,Radiology
Microslide consultation,88323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,72.22,,,,,,,fee schedule,51.59,228.88,APC
Microslide consultation,88323,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,90.28,,,,,,,fee schedule,51.59,228.88,APC
Comprehensive review of data,88325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,203.82,,,,,,,fee schedule,163.38,748.29,
Comprehensive review of data,88325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,163.38,,,,,,,fee schedule,163.38,748.29,
Comprehensive review of data,88325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,178.48,,,,,,,fee schedule,163.38,748.29,
Comprehensive review of data,88325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,187.64,,,,,,,fee schedule,163.38,748.29,
Comprehensive review of data,88325,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,748.29,,,,,,,fee schedule,163.38,748.29,APC 378
Comprehensive review of data,88325,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,177.09,,,,,,,fee schedule,163.38,748.29,APC
Comprehensive review of data,88325,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,175.41,,,,,,,fee schedule,163.38,748.29,APC
Comprehensive review of data,88325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,168.66,,,,,,,fee schedule,163.38,748.29,APC
Comprehensive review of data,88325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,258.05,,,,,,,fee schedule,163.38,748.29,Radiology
Comprehensive review of data,88325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,236.12,,,,,,,fee schedule,163.38,748.29,APC
Comprehensive review of data,88325,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,295.16,,,,,,,fee schedule,163.38,748.29,APC
Path consult introp,88329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59.84,,,,,,,fee schedule,47.96,259.1,
Path consult introp,88329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,47.96,,,,,,,fee schedule,47.96,259.1,
Path consult introp,88329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52.4,,,,,,,fee schedule,47.96,259.1,
Path consult introp,88329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55.09,,,,,,,fee schedule,47.96,259.1,
Path consult introp,88329,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,47.96,259.1,APC 378
Path consult introp,88329,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,47.96,259.1,APC
Path consult introp,88329,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,47.96,259.1,APC
Path consult introp,88329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,47.96,259.1,APC
Path consult introp,88329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,47.96,259.1,Radiology
Path consult introp,88329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,47.96,259.1,APC
Path consult introp,88329,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,47.96,259.1,APC
Path consult intraop 1 bloc,88331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,167.33,,,,,,,fee schedule,134.13,748.29,
Path consult intraop 1 bloc,88331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,134.13,,,,,,,fee schedule,134.13,748.29,
Path consult intraop 1 bloc,88331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,146.52,,,,,,,fee schedule,134.13,748.29,
Path consult intraop 1 bloc,88331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,154.05,,,,,,,fee schedule,134.13,748.29,
Path consult intraop 1 bloc,88331,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,748.29,,,,,,,fee schedule,134.13,748.29,APC 378
Path consult intraop 1 bloc,88331,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,177.09,,,,,,,fee schedule,134.13,748.29,APC
Path consult intraop 1 bloc,88331,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,175.41,,,,,,,fee schedule,134.13,748.29,APC
Path consult intraop 1 bloc,88331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,168.66,,,,,,,fee schedule,134.13,748.29,APC
Path consult intraop 1 bloc,88331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,258.05,,,,,,,fee schedule,134.13,748.29,Radiology
Path consult intraop 1 bloc,88331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,236.12,,,,,,,fee schedule,134.13,748.29,APC
Path consult intraop 1 bloc,88331,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,295.16,,,,,,,fee schedule,134.13,748.29,APC
Path consult intraop addl,88332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,32.58,,,,,,,fee schedule,26.11,32.58,
Path consult intraop addl,88332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26.11,,,,,,,fee schedule,26.11,32.58,
Path consult intraop addl,88332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28.53,,,,,,,fee schedule,26.11,32.58,
Path consult intraop addl,88332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,29.99,,,,,,,fee schedule,26.11,32.58,
Intraop cyto path consult 1,88333,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,268.02,,,,,,,fee schedule,214.84,3538.67,
Intraop cyto path consult 1,88333,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,214.84,,,,,,,fee schedule,214.84,3538.67,
Intraop cyto path consult 1,88333,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,234.7,,,,,,,fee schedule,214.84,3538.67,
Intraop cyto path consult 1,88333,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,246.75,,,,,,,fee schedule,214.84,3538.67,
Intraop cyto path consult 1,88333,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3538.67,,,,,,,fee schedule,214.84,3538.67,APC 378
Intraop cyto path consult 1,88333,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,837.48,,,,,,,fee schedule,214.84,3538.67,APC
Intraop cyto path consult 1,88333,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,829.5,,,,,,,fee schedule,214.84,3538.67,APC
Intraop cyto path consult 1,88333,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,797.6,,,,,,,fee schedule,214.84,3538.67,APC
Intraop cyto path consult 1,88333,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1220.32,,,,,,,fee schedule,214.84,3538.67,Radiology
Intraop cyto path consult 1,88333,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1116.64,,,,,,,fee schedule,214.84,3538.67,APC
Intraop cyto path consult 1,88333,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1395.79,,,,,,,fee schedule,214.84,3538.67,APC
Intraop cyto path consult 2,88334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,167.33,,,,,,,fee schedule,134.13,167.33,
Intraop cyto path consult 2,88334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,134.13,,,,,,,fee schedule,134.13,167.33,
Intraop cyto path consult 2,88334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,146.52,,,,,,,fee schedule,134.13,167.33,
Intraop cyto path consult 2,88334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,154.05,,,,,,,fee schedule,134.13,167.33,
Immunohisto antb addl slide,88341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,86.63,,,,,,,fee schedule,69.44,86.63,
Immunohisto antb addl slide,88341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,69.44,,,,,,,fee schedule,69.44,86.63,
Immunohisto antb addl slide,88341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,75.85,,,,,,,fee schedule,69.44,86.63,
Immunohisto antb addl slide,88341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,79.75,,,,,,,fee schedule,69.44,86.63,
Immunohisto antb 1st stain,88342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,169.04,,,,,,,fee schedule,135.5,748.29,
Immunohisto antb 1st stain,88342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,135.5,,,,,,,fee schedule,135.5,748.29,
Immunohisto antb 1st stain,88342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,148.02,,,,,,,fee schedule,135.5,748.29,
Immunohisto antb 1st stain,88342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,155.63,,,,,,,fee schedule,135.5,748.29,
Immunohisto antb 1st stain,88342,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,748.29,,,,,,,fee schedule,135.5,748.29,APC 378
Immunohisto antb 1st stain,88342,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,177.09,,,,,,,fee schedule,135.5,748.29,APC
Immunohisto antb 1st stain,88342,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,175.41,,,,,,,fee schedule,135.5,748.29,APC
Immunohisto antb 1st stain,88342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,168.66,,,,,,,fee schedule,135.5,748.29,APC
Immunohisto antb 1st stain,88342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,258.05,,,,,,,fee schedule,135.5,748.29,Radiology
Immunohisto antb 1st stain,88342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,236.12,,,,,,,fee schedule,135.5,748.29,APC
Immunohisto antb 1st stain,88342,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,295.16,,,,,,,fee schedule,135.5,748.29,APC
Immunohisto antibody slide,88344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,167.33,,,,,,,fee schedule,134.13,1574.35,
Immunohisto antibody slide,88344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,134.13,,,,,,,fee schedule,134.13,1574.35,
Immunohisto antibody slide,88344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,146.52,,,,,,,fee schedule,134.13,1574.35,
Immunohisto antibody slide,88344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,154.05,,,,,,,fee schedule,134.13,1574.35,
Immunohisto antibody slide,88344,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1574.35,,,,,,,fee schedule,134.13,1574.35,APC 378
Immunohisto antibody slide,88344,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,372.59,,,,,,,fee schedule,134.13,1574.35,APC
Immunohisto antibody slide,88344,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,369.04,,,,,,,fee schedule,134.13,1574.35,APC
Immunohisto antibody slide,88344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,354.85,,,,,,,fee schedule,134.13,1574.35,APC
Immunohisto antibody slide,88344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,542.92,,,,,,,fee schedule,134.13,1574.35,Radiology
Immunohisto antibody slide,88344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,496.79,,,,,,,fee schedule,134.13,1574.35,APC
Immunohisto antibody slide,88344,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,620.99,,,,,,,fee schedule,134.13,1574.35,APC
Immunofluor antb 1st stain,88346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,167.33,,,,,,,fee schedule,134.13,748.29,
Immunofluor antb 1st stain,88346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,134.13,,,,,,,fee schedule,134.13,748.29,
Immunofluor antb 1st stain,88346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,146.52,,,,,,,fee schedule,134.13,748.29,
Immunofluor antb 1st stain,88346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,154.05,,,,,,,fee schedule,134.13,748.29,
Immunofluor antb 1st stain,88346,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,748.29,,,,,,,fee schedule,134.13,748.29,APC 378
Immunofluor antb 1st stain,88346,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,177.09,,,,,,,fee schedule,134.13,748.29,APC
Immunofluor antb 1st stain,88346,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,175.41,,,,,,,fee schedule,134.13,748.29,APC
Immunofluor antb 1st stain,88346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,168.66,,,,,,,fee schedule,134.13,748.29,APC
Immunofluor antb 1st stain,88346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,258.05,,,,,,,fee schedule,134.13,748.29,Radiology
Immunofluor antb 1st stain,88346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,236.12,,,,,,,fee schedule,134.13,748.29,APC
Immunofluor antb 1st stain,88346,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,295.16,,,,,,,fee schedule,134.13,748.29,APC
Electron microscopy,88348,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,672.58,,,,,,,fee schedule,539.13,3538.67,
Electron microscopy,88348,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,539.13,,,,,,,fee schedule,539.13,3538.67,
Electron microscopy,88348,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,588.95,,,,,,,fee schedule,539.13,3538.67,
Electron microscopy,88348,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,619.2,,,,,,,fee schedule,539.13,3538.67,
Electron microscopy,88348,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3538.67,,,,,,,fee schedule,539.13,3538.67,APC 378
Electron microscopy,88348,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,837.48,,,,,,,fee schedule,539.13,3538.67,APC
Electron microscopy,88348,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,829.5,,,,,,,fee schedule,539.13,3538.67,APC
Electron microscopy,88348,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,797.6,,,,,,,fee schedule,539.13,3538.67,APC
Electron microscopy,88348,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1220.32,,,,,,,fee schedule,539.13,3538.67,Radiology
Electron microscopy,88348,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1116.64,,,,,,,fee schedule,539.13,3538.67,APC
Electron microscopy,88348,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1395.79,,,,,,,fee schedule,539.13,3538.67,APC
Immunofluor antb addl stain,88350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,257.87,,,,,,,fee schedule,206.71,257.87,
Immunofluor antb addl stain,88350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,206.71,,,,,,,fee schedule,206.71,257.87,
Immunofluor antb addl stain,88350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,225.81,,,,,,,fee schedule,206.71,257.87,
Immunofluor antb addl stain,88350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,237.41,,,,,,,fee schedule,206.71,257.87,
Analysis skeletal muscle,88355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,128.33,,,,,,,fee schedule,102.87,748.29,
Analysis skeletal muscle,88355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,102.87,,,,,,,fee schedule,102.87,748.29,
Analysis skeletal muscle,88355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,112.37,,,,,,,fee schedule,102.87,748.29,
Analysis skeletal muscle,88355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,118.15,,,,,,,fee schedule,102.87,748.29,
Analysis skeletal muscle,88355,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,748.29,,,,,,,fee schedule,102.87,748.29,APC 378
Analysis skeletal muscle,88355,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,177.09,,,,,,,fee schedule,102.87,748.29,APC
Analysis skeletal muscle,88355,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,175.41,,,,,,,fee schedule,102.87,748.29,APC
Analysis skeletal muscle,88355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,168.66,,,,,,,fee schedule,102.87,748.29,APC
Analysis skeletal muscle,88355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,258.05,,,,,,,fee schedule,102.87,748.29,Radiology
Analysis skeletal muscle,88355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,236.12,,,,,,,fee schedule,102.87,748.29,APC
Analysis skeletal muscle,88355,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,295.16,,,,,,,fee schedule,102.87,748.29,APC
Analysis nerve,88356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,203.82,,,,,,,fee schedule,51.59,228.88,
Analysis nerve,88356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,163.38,,,,,,,fee schedule,51.59,228.88,
Analysis nerve,88356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,178.48,,,,,,,fee schedule,51.59,228.88,
Analysis nerve,88356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,187.64,,,,,,,fee schedule,51.59,228.88,
Analysis nerve,88356,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,228.88,,,,,,,fee schedule,51.59,228.88,APC 378
Analysis nerve,88356,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.17,,,,,,,fee schedule,51.59,228.88,APC
Analysis nerve,88356,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,53.65,,,,,,,fee schedule,51.59,228.88,APC
Analysis nerve,88356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,51.59,,,,,,,fee schedule,51.59,228.88,APC
Analysis nerve,88356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,78.93,,,,,,,fee schedule,51.59,228.88,Radiology
Analysis nerve,88356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,72.22,,,,,,,fee schedule,51.59,228.88,APC
Analysis nerve,88356,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,90.28,,,,,,,fee schedule,51.59,228.88,APC
Analysis tumor,88358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,203.82,,,,,,,fee schedule,163.38,748.29,
Analysis tumor,88358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,163.38,,,,,,,fee schedule,163.38,748.29,
Analysis tumor,88358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,178.48,,,,,,,fee schedule,163.38,748.29,
Analysis tumor,88358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,187.64,,,,,,,fee schedule,163.38,748.29,
Analysis tumor,88358,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,748.29,,,,,,,fee schedule,163.38,748.29,APC 378
Analysis tumor,88358,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,177.09,,,,,,,fee schedule,163.38,748.29,APC
Analysis tumor,88358,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,175.41,,,,,,,fee schedule,163.38,748.29,APC
Analysis tumor,88358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,168.66,,,,,,,fee schedule,163.38,748.29,APC
Analysis tumor,88358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,258.05,,,,,,,fee schedule,163.38,748.29,Radiology
Analysis tumor,88358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,236.12,,,,,,,fee schedule,163.38,748.29,APC
Analysis tumor,88358,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,295.16,,,,,,,fee schedule,163.38,748.29,APC
Tumor immunohistochem/manual,88360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,167.33,,,,,,,fee schedule,134.13,748.29,
Tumor immunohistochem/manual,88360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,134.13,,,,,,,fee schedule,134.13,748.29,
Tumor immunohistochem/manual,88360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,146.52,,,,,,,fee schedule,134.13,748.29,
Tumor immunohistochem/manual,88360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,154.05,,,,,,,fee schedule,134.13,748.29,
Tumor immunohistochem/manual,88360,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,748.29,,,,,,,fee schedule,134.13,748.29,APC 378
Tumor immunohistochem/manual,88360,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,177.09,,,,,,,fee schedule,134.13,748.29,APC
Tumor immunohistochem/manual,88360,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,175.41,,,,,,,fee schedule,134.13,748.29,APC
Tumor immunohistochem/manual,88360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,168.66,,,,,,,fee schedule,134.13,748.29,APC
Tumor immunohistochem/manual,88360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,258.05,,,,,,,fee schedule,134.13,748.29,Radiology
Tumor immunohistochem/manual,88360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,236.12,,,,,,,fee schedule,134.13,748.29,APC
Tumor immunohistochem/manual,88360,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,295.16,,,,,,,fee schedule,134.13,748.29,APC
Tumor immunohistochem/comput,88361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,203.82,,,,,,,fee schedule,163.38,1574.35,
Tumor immunohistochem/comput,88361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,163.38,,,,,,,fee schedule,163.38,1574.35,
Tumor immunohistochem/comput,88361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,178.48,,,,,,,fee schedule,163.38,1574.35,
Tumor immunohistochem/comput,88361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,187.64,,,,,,,fee schedule,163.38,1574.35,
Tumor immunohistochem/comput,88361,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1574.35,,,,,,,fee schedule,163.38,1574.35,APC 378
Tumor immunohistochem/comput,88361,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,372.59,,,,,,,fee schedule,163.38,1574.35,APC
Tumor immunohistochem/comput,88361,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,369.04,,,,,,,fee schedule,163.38,1574.35,APC
Tumor immunohistochem/comput,88361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,354.85,,,,,,,fee schedule,163.38,1574.35,APC
Tumor immunohistochem/comput,88361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,542.92,,,,,,,fee schedule,163.38,1574.35,Radiology
Tumor immunohistochem/comput,88361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,496.79,,,,,,,fee schedule,163.38,1574.35,APC
Tumor immunohistochem/comput,88361,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,620.99,,,,,,,fee schedule,163.38,1574.35,APC
Nerve teasing preparations,88362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,203.82,,,,,,,fee schedule,163.38,3538.67,
Nerve teasing preparations,88362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,163.38,,,,,,,fee schedule,163.38,3538.67,
Nerve teasing preparations,88362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,178.48,,,,,,,fee schedule,163.38,3538.67,
Nerve teasing preparations,88362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,187.64,,,,,,,fee schedule,163.38,3538.67,
Nerve teasing preparations,88362,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3538.67,,,,,,,fee schedule,163.38,3538.67,APC 378
Nerve teasing preparations,88362,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,837.48,,,,,,,fee schedule,163.38,3538.67,APC
Nerve teasing preparations,88362,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,829.5,,,,,,,fee schedule,163.38,3538.67,APC
Nerve teasing preparations,88362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,797.6,,,,,,,fee schedule,163.38,3538.67,APC
Nerve teasing preparations,88362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1220.32,,,,,,,fee schedule,163.38,3538.67,Radiology
Nerve teasing preparations,88362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1116.64,,,,,,,fee schedule,163.38,3538.67,APC
Nerve teasing preparations,88362,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1395.79,,,,,,,fee schedule,163.38,3538.67,APC
Xm archive tissue molec anal,88363,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,47.7,,,,,,,fee schedule,28.63,127.04,
Xm archive tissue molec anal,88363,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38.24,,,,,,,fee schedule,28.63,127.04,
Xm archive tissue molec anal,88363,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,41.77,,,,,,,fee schedule,28.63,127.04,
Xm archive tissue molec anal,88363,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,43.92,,,,,,,fee schedule,28.63,127.04,
Xm archive tissue molec anal,88363,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,127.04,,,,,,,fee schedule,28.63,127.04,APC 378
Xm archive tissue molec anal,88363,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.07,,,,,,,fee schedule,28.63,127.04,APC
Xm archive tissue molec anal,88363,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,29.78,,,,,,,fee schedule,28.63,127.04,APC
Xm archive tissue molec anal,88363,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,28.63,,,,,,,fee schedule,28.63,127.04,APC
Xm archive tissue molec anal,88363,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43.81,,,,,,,fee schedule,28.63,127.04,Radiology
Xm archive tissue molec anal,88363,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40.09,,,,,,,fee schedule,28.63,127.04,APC
Xm archive tissue molec anal,88363,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,50.11,,,,,,,fee schedule,28.63,127.04,APC
Insitu hybridization (fish),88364,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,344.28,,,,,,,fee schedule,275.97,344.28,
Insitu hybridization (fish),88364,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,275.97,,,,,,,fee schedule,275.97,344.28,
Insitu hybridization (fish),88364,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,301.47,,,,,,,fee schedule,275.97,344.28,
Insitu hybridization (fish),88364,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,316.96,,,,,,,fee schedule,275.97,344.28,
Insitu hybridization (fish),88365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,145.12,,,,,,,fee schedule,116.32,748.29,
Insitu hybridization (fish),88365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,116.32,,,,,,,fee schedule,116.32,748.29,
Insitu hybridization (fish),88365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,127.07,,,,,,,fee schedule,116.32,748.29,
Insitu hybridization (fish),88365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,133.6,,,,,,,fee schedule,116.32,748.29,
Insitu hybridization (fish),88365,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,748.29,,,,,,,fee schedule,116.32,748.29,APC 378
Insitu hybridization (fish),88365,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,177.09,,,,,,,fee schedule,116.32,748.29,APC
Insitu hybridization (fish),88365,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,175.41,,,,,,,fee schedule,116.32,748.29,APC
Insitu hybridization (fish),88365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,168.66,,,,,,,fee schedule,116.32,748.29,APC
Insitu hybridization (fish),88365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,258.05,,,,,,,fee schedule,116.32,748.29,Radiology
Insitu hybridization (fish),88365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,236.12,,,,,,,fee schedule,116.32,748.29,APC
Insitu hybridization (fish),88365,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,295.16,,,,,,,fee schedule,116.32,748.29,APC
Insitu hybridization (fish),88366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,695.56,,,,,,,fee schedule,168.66,748.29,
Insitu hybridization (fish),88366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,557.55,,,,,,,fee schedule,168.66,748.29,
Insitu hybridization (fish),88366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,609.07,,,,,,,fee schedule,168.66,748.29,
Insitu hybridization (fish),88366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,640.35,,,,,,,fee schedule,168.66,748.29,
Insitu hybridization (fish),88366,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,748.29,,,,,,,fee schedule,168.66,748.29,APC 378
Insitu hybridization (fish),88366,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,177.09,,,,,,,fee schedule,168.66,748.29,APC
Insitu hybridization (fish),88366,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,175.41,,,,,,,fee schedule,168.66,748.29,APC
Insitu hybridization (fish),88366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,168.66,,,,,,,fee schedule,168.66,748.29,APC
Insitu hybridization (fish),88366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,258.05,,,,,,,fee schedule,168.66,748.29,Radiology
Insitu hybridization (fish),88366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,236.12,,,,,,,fee schedule,168.66,748.29,APC
Insitu hybridization (fish),88366,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,295.16,,,,,,,fee schedule,168.66,748.29,APC
Insitu hybridization auto,88367,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,203.82,,,,,,,fee schedule,163.38,1574.35,
Insitu hybridization auto,88367,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,163.38,,,,,,,fee schedule,163.38,1574.35,
Insitu hybridization auto,88367,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,178.48,,,,,,,fee schedule,163.38,1574.35,
Insitu hybridization auto,88367,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,187.64,,,,,,,fee schedule,163.38,1574.35,
Insitu hybridization auto,88367,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1574.35,,,,,,,fee schedule,163.38,1574.35,APC 378
Insitu hybridization auto,88367,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,372.59,,,,,,,fee schedule,163.38,1574.35,APC
Insitu hybridization auto,88367,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,369.04,,,,,,,fee schedule,163.38,1574.35,APC
Insitu hybridization auto,88367,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,354.85,,,,,,,fee schedule,163.38,1574.35,APC
Insitu hybridization auto,88367,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,542.92,,,,,,,fee schedule,163.38,1574.35,Radiology
Insitu hybridization auto,88367,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,496.79,,,,,,,fee schedule,163.38,1574.35,APC
Insitu hybridization auto,88367,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,620.99,,,,,,,fee schedule,163.38,1574.35,APC
Insitu hybridization manual,88368,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,128.33,,,,,,,fee schedule,102.87,1574.35,
Insitu hybridization manual,88368,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,102.87,,,,,,,fee schedule,102.87,1574.35,
Insitu hybridization manual,88368,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,112.37,,,,,,,fee schedule,102.87,1574.35,
Insitu hybridization manual,88368,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,118.15,,,,,,,fee schedule,102.87,1574.35,
Insitu hybridization manual,88368,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1574.35,,,,,,,fee schedule,102.87,1574.35,APC 378
Insitu hybridization manual,88368,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,372.59,,,,,,,fee schedule,102.87,1574.35,APC
Insitu hybridization manual,88368,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,369.04,,,,,,,fee schedule,102.87,1574.35,APC
Insitu hybridization manual,88368,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,354.85,,,,,,,fee schedule,102.87,1574.35,APC
Insitu hybridization manual,88368,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,542.92,,,,,,,fee schedule,102.87,1574.35,Radiology
Insitu hybridization manual,88368,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,496.79,,,,,,,fee schedule,102.87,1574.35,APC
Insitu hybridization manual,88368,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,620.99,,,,,,,fee schedule,102.87,1574.35,APC
M/phmtrc alysishquant/semiq,88369,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,262.33,,,,,,,fee schedule,210.28,262.33,
M/phmtrc alysishquant/semiq,88369,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,210.28,,,,,,,fee schedule,210.28,262.33,
M/phmtrc alysishquant/semiq,88369,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,229.71,,,,,,,fee schedule,210.28,262.33,
M/phmtrc alysishquant/semiq,88369,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,241.51,,,,,,,fee schedule,210.28,262.33,
Protein western blot tissue,88371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,122.62,,,,,,,fee schedule,98.29,122.62,
Protein western blot tissue,88371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,98.29,,,,,,,fee schedule,98.29,122.62,
Protein western blot tissue,88371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,107.38,,,,,,,fee schedule,98.29,122.62,
Protein western blot tissue,88371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,112.89,,,,,,,fee schedule,98.29,122.62,
Protein analysis w/probe,88372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,125.57,,,,,,,fee schedule,100.66,125.57,
Protein analysis w/probe,88372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,100.66,,,,,,,fee schedule,100.66,125.57,
Protein analysis w/probe,88372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,109.96,,,,,,,fee schedule,100.66,125.57,
Protein analysis w/probe,88372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,115.61,,,,,,,fee schedule,100.66,125.57,
M/phmtrc alys ishquant/semiq,88373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,215.27,,,,,,,fee schedule,172.56,215.27,
M/phmtrc alys ishquant/semiq,88373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,172.56,,,,,,,fee schedule,172.56,215.27,
M/phmtrc alys ishquant/semiq,88373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,188.5,,,,,,,fee schedule,172.56,215.27,
M/phmtrc alys ishquant/semiq,88373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,198.19,,,,,,,fee schedule,172.56,215.27,
M/phmtrc alys ishquant/semiq,88374,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,694.35,,,,,,,fee schedule,168.66,748.29,
M/phmtrc alys ishquant/semiq,88374,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,556.58,,,,,,,fee schedule,168.66,748.29,
M/phmtrc alys ishquant/semiq,88374,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,608.01,,,,,,,fee schedule,168.66,748.29,
M/phmtrc alys ishquant/semiq,88374,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,639.24,,,,,,,fee schedule,168.66,748.29,
M/phmtrc alys ishquant/semiq,88374,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,748.29,,,,,,,fee schedule,168.66,748.29,APC 378
M/phmtrc alys ishquant/semiq,88374,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,177.09,,,,,,,fee schedule,168.66,748.29,APC
M/phmtrc alys ishquant/semiq,88374,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,175.41,,,,,,,fee schedule,168.66,748.29,APC
M/phmtrc alys ishquant/semiq,88374,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,168.66,,,,,,,fee schedule,168.66,748.29,APC
M/phmtrc alys ishquant/semiq,88374,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,258.05,,,,,,,fee schedule,168.66,748.29,Radiology
M/phmtrc alys ishquant/semiq,88374,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,236.12,,,,,,,fee schedule,168.66,748.29,APC
M/phmtrc alys ishquant/semiq,88374,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,295.16,,,,,,,fee schedule,168.66,748.29,APC
Optical endomicroscpy interp,88375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,48.04,,,,,,,fee schedule,38.51,48.04,
Optical endomicroscpy interp,88375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38.51,,,,,,,fee schedule,38.51,48.04,
Optical endomicroscpy interp,88375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.07,,,,,,,fee schedule,38.51,48.04,
Optical endomicroscpy interp,88375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,44.23,,,,,,,fee schedule,38.51,48.04,
M/phmtrc alys ishquant/semiq,88377,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,167.33,,,,,,,fee schedule,134.13,748.29,
M/phmtrc alys ishquant/semiq,88377,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,134.13,,,,,,,fee schedule,134.13,748.29,
M/phmtrc alys ishquant/semiq,88377,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,146.52,,,,,,,fee schedule,134.13,748.29,
M/phmtrc alys ishquant/semiq,88377,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,154.05,,,,,,,fee schedule,134.13,748.29,
M/phmtrc alys ishquant/semiq,88377,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,748.29,,,,,,,fee schedule,134.13,748.29,APC 378
M/phmtrc alys ishquant/semiq,88377,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,177.09,,,,,,,fee schedule,134.13,748.29,APC
M/phmtrc alys ishquant/semiq,88377,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,175.41,,,,,,,fee schedule,134.13,748.29,APC
M/phmtrc alys ishquant/semiq,88377,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,168.66,,,,,,,fee schedule,134.13,748.29,APC
M/phmtrc alys ishquant/semiq,88377,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,258.05,,,,,,,fee schedule,134.13,748.29,Radiology
M/phmtrc alys ishquant/semiq,88377,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,236.12,,,,,,,fee schedule,134.13,748.29,APC
M/phmtrc alys ishquant/semiq,88377,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,295.16,,,,,,,fee schedule,134.13,748.29,APC
Surgical pathology procedure,88399,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24.19,,,,,,,fee schedule,19.39,228.88,
Surgical pathology procedure,88399,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19.39,,,,,,,fee schedule,19.39,228.88,
Surgical pathology procedure,88399,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21.18,,,,,,,fee schedule,19.39,228.88,
Surgical pathology procedure,88399,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22.27,,,,,,,fee schedule,19.39,228.88,
Surgical pathology procedure,88399,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,228.88,,,,,,,fee schedule,19.39,228.88,APC 378
Surgical pathology procedure,88399,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.17,,,,,,,fee schedule,19.39,228.88,APC
Surgical pathology procedure,88399,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,53.65,,,,,,,fee schedule,19.39,228.88,APC
Surgical pathology procedure,88399,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,51.59,,,,,,,fee schedule,19.39,228.88,APC
Surgical pathology procedure,88399,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,78.93,,,,,,,fee schedule,19.39,228.88,Radiology
Surgical pathology procedure,88399,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,72.22,,,,,,,fee schedule,19.39,228.88,APC
Surgical pathology procedure,88399,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,90.28,,,,,,,fee schedule,19.39,228.88,APC
Bilirubin total transcut,88720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27.71,,,,,,,fee schedule,4.52,27.71,
Bilirubin total transcut,88720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22.21,,,,,,,fee schedule,4.52,27.71,
Bilirubin total transcut,88720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24.26,,,,,,,fee schedule,4.52,27.71,
Bilirubin total transcut,88720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,25.51,,,,,,,fee schedule,4.52,27.71,
Bilirubin total transcut,88720,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.52,,,,,,,fee schedule,4.52,27.71,Laboratory
Bilirubin total transcut,88720,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.27,,,,,,,fee schedule,4.52,27.71,APC
Bilirubin total transcut,88720,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5.22,,,,,,,fee schedule,4.52,27.71,APC
Bilirubin total transcut,88720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5.02,,,,,,,fee schedule,4.52,27.71,APC
Bilirubin total transcut,88720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.68,,,,,,,fee schedule,4.52,27.71,Radiology
Bilirubin total transcut,88720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.03,,,,,,,fee schedule,4.52,27.71,APC
Bilirubin total transcut,88720,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8.78,,,,,,,fee schedule,4.52,27.71,APC
Hgb quant transcutaneous,88738,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17.03,,,,,,,fee schedule,4.52,17.03,
Hgb quant transcutaneous,88738,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13.65,,,,,,,fee schedule,4.52,17.03,
Hgb quant transcutaneous,88738,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14.91,,,,,,,fee schedule,4.52,17.03,
Hgb quant transcutaneous,88738,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15.68,,,,,,,fee schedule,4.52,17.03,
Hgb quant transcutaneous,88738,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.52,,,,,,,fee schedule,4.52,17.03,Laboratory
Hgb quant transcutaneous,88738,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.27,,,,,,,fee schedule,4.52,17.03,APC
Hgb quant transcutaneous,88738,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5.22,,,,,,,fee schedule,4.52,17.03,APC
Hgb quant transcutaneous,88738,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5.02,,,,,,,fee schedule,4.52,17.03,APC
Hgb quant transcutaneous,88738,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.68,,,,,,,fee schedule,4.52,17.03,Radiology
Hgb quant transcutaneous,88738,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.03,,,,,,,fee schedule,4.52,17.03,APC
Hgb quant transcutaneous,88738,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8.78,,,,,,,fee schedule,4.52,17.03,APC
Transcutaneous carboxyhb,88740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27.71,,,,,,,fee schedule,8.43,27.71,
Transcutaneous carboxyhb,88740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22.21,,,,,,,fee schedule,8.43,27.71,
Transcutaneous carboxyhb,88740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24.26,,,,,,,fee schedule,8.43,27.71,
Transcutaneous carboxyhb,88740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,25.51,,,,,,,fee schedule,8.43,27.71,
Transcutaneous carboxyhb,88740,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.43,,,,,,,fee schedule,8.43,27.71,Laboratory
Transcutaneous carboxyhb,88740,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.84,,,,,,,fee schedule,8.43,27.71,APC
Transcutaneous carboxyhb,88740,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9.74,,,,,,,fee schedule,8.43,27.71,APC
Transcutaneous carboxyhb,88740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9.37,,,,,,,fee schedule,8.43,27.71,APC
Transcutaneous carboxyhb,88740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.34,,,,,,,fee schedule,8.43,27.71,Radiology
Transcutaneous carboxyhb,88740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.12,,,,,,,fee schedule,8.43,27.71,APC
Transcutaneous carboxyhb,88740,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16.4,,,,,,,fee schedule,8.43,27.71,APC
Transcutaneous methb,88741,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27.71,,,,,,,fee schedule,8.43,27.71,
Transcutaneous methb,88741,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22.21,,,,,,,fee schedule,8.43,27.71,
Transcutaneous methb,88741,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24.26,,,,,,,fee schedule,8.43,27.71,
Transcutaneous methb,88741,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,25.51,,,,,,,fee schedule,8.43,27.71,
Transcutaneous methb,88741,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.43,,,,,,,fee schedule,8.43,27.71,Laboratory
Transcutaneous methb,88741,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.84,,,,,,,fee schedule,8.43,27.71,APC
Transcutaneous methb,88741,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9.74,,,,,,,fee schedule,8.43,27.71,APC
Transcutaneous methb,88741,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9.37,,,,,,,fee schedule,8.43,27.71,APC
Transcutaneous methb,88741,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.34,,,,,,,fee schedule,8.43,27.71,Radiology
Transcutaneous methb,88741,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.12,,,,,,,fee schedule,8.43,27.71,APC
Transcutaneous methb,88741,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16.4,,,,,,,fee schedule,8.43,27.71,APC
Chct for mal hyperthermia,89049,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,128.33,,,,,,,fee schedule,102.87,748.29,
Chct for mal hyperthermia,89049,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,102.87,,,,,,,fee schedule,102.87,748.29,
Chct for mal hyperthermia,89049,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,112.37,,,,,,,fee schedule,102.87,748.29,
Chct for mal hyperthermia,89049,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,118.15,,,,,,,fee schedule,102.87,748.29,
Chct for mal hyperthermia,89049,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,748.29,,,,,,,fee schedule,102.87,748.29,APC 378
Chct for mal hyperthermia,89049,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,177.09,,,,,,,fee schedule,102.87,748.29,APC
Chct for mal hyperthermia,89049,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,175.41,,,,,,,fee schedule,102.87,748.29,APC
Chct for mal hyperthermia,89049,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,168.66,,,,,,,fee schedule,102.87,748.29,APC
Chct for mal hyperthermia,89049,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,258.05,,,,,,,fee schedule,102.87,748.29,Radiology
Chct for mal hyperthermia,89049,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,236.12,,,,,,,fee schedule,102.87,748.29,APC
Chct for mal hyperthermia,89049,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,295.16,,,,,,,fee schedule,102.87,748.29,APC
Body fluid cell count,89050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21.1,,,,,,,fee schedule,4.25,21.1,
Body fluid cell count,89050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.91,,,,,,,fee schedule,4.25,21.1,
Body fluid cell count,89050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18.48,,,,,,,fee schedule,4.25,21.1,
Body fluid cell count,89050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19.43,,,,,,,fee schedule,4.25,21.1,
Body fluid cell count,89050,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.25,,,,,,,fee schedule,4.25,21.1,Laboratory
Body fluid cell count,89050,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.96,,,,,,,fee schedule,4.25,21.1,APC
Body fluid cell count,89050,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4.91,,,,,,,fee schedule,4.25,21.1,APC
Body fluid cell count,89050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4.72,,,,,,,fee schedule,4.25,21.1,APC
Body fluid cell count,89050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.22,,,,,,,fee schedule,4.25,21.1,Radiology
Body fluid cell count,89050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.61,,,,,,,fee schedule,4.25,21.1,APC
Body fluid cell count,89050,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8.26,,,,,,,fee schedule,4.25,21.1,APC
Body fluid cell count,89051,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,67.51,,,,,,,fee schedule,5.04,67.51,
Body fluid cell count,89051,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,54.11,,,,,,,fee schedule,5.04,67.51,
Body fluid cell count,89051,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,59.11,,,,,,,fee schedule,5.04,67.51,
Body fluid cell count,89051,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,62.15,,,,,,,fee schedule,5.04,67.51,
Body fluid cell count,89051,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.04,,,,,,,fee schedule,5.04,67.51,Laboratory
Body fluid cell count,89051,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.88,,,,,,,fee schedule,5.04,67.51,APC
Body fluid cell count,89051,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5.82,,,,,,,fee schedule,5.04,67.51,APC
Body fluid cell count,89051,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5.6,,,,,,,fee schedule,5.04,67.51,APC
Body fluid cell count,89051,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8.57,,,,,,,fee schedule,5.04,67.51,Radiology
Body fluid cell count,89051,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.84,,,,,,,fee schedule,5.04,67.51,APC
Body fluid cell count,89051,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9.8,,,,,,,fee schedule,5.04,67.51,APC
Leukocyte assessment fecal,89055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23.55,,,,,,,fee schedule,3.84,23.55,
Leukocyte assessment fecal,89055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18.88,,,,,,,fee schedule,3.84,23.55,
Leukocyte assessment fecal,89055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20.62,,,,,,,fee schedule,3.84,23.55,
Leukocyte assessment fecal,89055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21.68,,,,,,,fee schedule,3.84,23.55,
Leukocyte assessment fecal,89055,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.84,,,,,,,fee schedule,3.84,23.55,Laboratory
Leukocyte assessment fecal,89055,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.48,,,,,,,fee schedule,3.84,23.55,APC
Leukocyte assessment fecal,89055,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4.44,,,,,,,fee schedule,3.84,23.55,APC
Leukocyte assessment fecal,89055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4.27,,,,,,,fee schedule,3.84,23.55,APC
Leukocyte assessment fecal,89055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.53,,,,,,,fee schedule,3.84,23.55,Radiology
Leukocyte assessment fecal,89055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.98,,,,,,,fee schedule,3.84,23.55,APC
Leukocyte assessment fecal,89055,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7.47,,,,,,,fee schedule,3.84,23.55,APC
Exam synovial fluid crystals,89060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26.86,,,,,,,fee schedule,6.6,26.86,
Exam synovial fluid crystals,89060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21.53,,,,,,,fee schedule,6.6,26.86,
Exam synovial fluid crystals,89060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23.52,,,,,,,fee schedule,6.6,26.86,
Exam synovial fluid crystals,89060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24.72,,,,,,,fee schedule,6.6,26.86,
Exam synovial fluid crystals,89060,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.6,,,,,,,fee schedule,6.6,26.86,Laboratory
Exam synovial fluid crystals,89060,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.7,,,,,,,fee schedule,6.6,26.86,APC
Exam synovial fluid crystals,89060,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7.62,,,,,,,fee schedule,6.6,26.86,APC
Exam synovial fluid crystals,89060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7.33,,,,,,,fee schedule,6.6,26.86,APC
Exam synovial fluid crystals,89060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11.21,,,,,,,fee schedule,6.6,26.86,Radiology
Exam synovial fluid crystals,89060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10.26,,,,,,,fee schedule,6.6,26.86,APC
Exam synovial fluid crystals,89060,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12.83,,,,,,,fee schedule,6.6,26.86,APC
Specimen fat stain,89125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23.81,,,,,,,fee schedule,5.29,23.81,
Specimen fat stain,89125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19.09,,,,,,,fee schedule,5.29,23.81,
Specimen fat stain,89125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20.85,,,,,,,fee schedule,5.29,23.81,
Specimen fat stain,89125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21.92,,,,,,,fee schedule,5.29,23.81,
Specimen fat stain,89125,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.29,,,,,,,fee schedule,5.29,23.81,Laboratory
Specimen fat stain,89125,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.17,,,,,,,fee schedule,5.29,23.81,APC
Specimen fat stain,89125,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6.12,,,,,,,fee schedule,5.29,23.81,APC
Specimen fat stain,89125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5.88,,,,,,,fee schedule,5.29,23.81,APC
Specimen fat stain,89125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9,,,,,,,fee schedule,5.29,23.81,Radiology
Specimen fat stain,89125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8.23,,,,,,,fee schedule,5.29,23.81,APC
Specimen fat stain,89125,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10.29,,,,,,,fee schedule,5.29,23.81,APC
Exam feces for meat fibers,89160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20.34,,,,,,,fee schedule,4.36,20.34,
Exam feces for meat fibers,89160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.3,,,,,,,fee schedule,4.36,20.34,
Exam feces for meat fibers,89160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17.81,,,,,,,fee schedule,4.36,20.34,
Exam feces for meat fibers,89160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18.72,,,,,,,fee schedule,4.36,20.34,
Exam feces for meat fibers,89160,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.36,,,,,,,fee schedule,4.36,20.34,Laboratory
Exam feces for meat fibers,89160,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.09,,,,,,,fee schedule,4.36,20.34,APC
Exam feces for meat fibers,89160,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5.04,,,,,,,fee schedule,4.36,20.34,APC
Exam feces for meat fibers,89160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4.85,,,,,,,fee schedule,4.36,20.34,APC
Exam feces for meat fibers,89160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.42,,,,,,,fee schedule,4.36,20.34,Radiology
Exam feces for meat fibers,89160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.79,,,,,,,fee schedule,4.36,20.34,APC
Exam feces for meat fibers,89160,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8.49,,,,,,,fee schedule,4.36,20.34,APC
Nasal smear for eosinophils,89190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26.2,,,,,,,fee schedule,5.21,26.2,
Nasal smear for eosinophils,89190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21,,,,,,,fee schedule,5.21,26.2,
Nasal smear for eosinophils,89190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22.94,,,,,,,fee schedule,5.21,26.2,
Nasal smear for eosinophils,89190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24.12,,,,,,,fee schedule,5.21,26.2,
Nasal smear for eosinophils,89190,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.21,,,,,,,fee schedule,5.21,26.2,Laboratory
Nasal smear for eosinophils,89190,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.08,,,,,,,fee schedule,5.21,26.2,APC
Nasal smear for eosinophils,89190,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6.02,,,,,,,fee schedule,5.21,26.2,APC
Nasal smear for eosinophils,89190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5.79,,,,,,,fee schedule,5.21,26.2,APC
Nasal smear for eosinophils,89190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8.86,,,,,,,fee schedule,5.21,26.2,Radiology
Nasal smear for eosinophils,89190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8.11,,,,,,,fee schedule,5.21,26.2,APC
Nasal smear for eosinophils,89190,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10.13,,,,,,,fee schedule,5.21,26.2,APC
Sputum specimen collection,89220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,128.33,,,,,,,fee schedule,102.87,748.29,
Sputum specimen collection,89220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,102.87,,,,,,,fee schedule,102.87,748.29,
Sputum specimen collection,89220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,112.37,,,,,,,fee schedule,102.87,748.29,
Sputum specimen collection,89220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,118.15,,,,,,,fee schedule,102.87,748.29,
Sputum specimen collection,89220,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,748.29,,,,,,,fee schedule,102.87,748.29,APC 378
Sputum specimen collection,89220,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,177.09,,,,,,,fee schedule,102.87,748.29,APC
Sputum specimen collection,89220,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,175.41,,,,,,,fee schedule,102.87,748.29,APC
Sputum specimen collection,89220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,168.66,,,,,,,fee schedule,102.87,748.29,APC
Sputum specimen collection,89220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,258.05,,,,,,,fee schedule,102.87,748.29,Radiology
Sputum specimen collection,89220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,236.12,,,,,,,fee schedule,102.87,748.29,APC
Sputum specimen collection,89220,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,295.16,,,,,,,fee schedule,102.87,748.29,APC
Collect sweat for test,89230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,128.33,,,,,,,fee schedule,51.59,228.88,
Collect sweat for test,89230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,102.87,,,,,,,fee schedule,51.59,228.88,
Collect sweat for test,89230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,112.37,,,,,,,fee schedule,51.59,228.88,
Collect sweat for test,89230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,118.15,,,,,,,fee schedule,51.59,228.88,
Collect sweat for test,89230,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,228.88,,,,,,,fee schedule,51.59,228.88,APC 378
Collect sweat for test,89230,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.17,,,,,,,fee schedule,51.59,228.88,APC
Collect sweat for test,89230,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,53.65,,,,,,,fee schedule,51.59,228.88,APC
Collect sweat for test,89230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,51.59,,,,,,,fee schedule,51.59,228.88,APC
Collect sweat for test,89230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,78.93,,,,,,,fee schedule,51.59,228.88,Radiology
Collect sweat for test,89230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,72.22,,,,,,,fee schedule,51.59,228.88,APC
Collect sweat for test,89230,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,90.28,,,,,,,fee schedule,51.59,228.88,APC
Pathology lab procedure,89240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24.19,,,,,,,fee schedule,19.39,228.88,
Pathology lab procedure,89240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19.39,,,,,,,fee schedule,19.39,228.88,
Pathology lab procedure,89240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21.18,,,,,,,fee schedule,19.39,228.88,
Pathology lab procedure,89240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22.27,,,,,,,fee schedule,19.39,228.88,
Pathology lab procedure,89240,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,228.88,,,,,,,fee schedule,19.39,228.88,APC 378
Pathology lab procedure,89240,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.17,,,,,,,fee schedule,19.39,228.88,APC
Pathology lab procedure,89240,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,53.65,,,,,,,fee schedule,19.39,228.88,APC
Pathology lab procedure,89240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,51.59,,,,,,,fee schedule,19.39,228.88,APC
Pathology lab procedure,89240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,78.93,,,,,,,fee schedule,19.39,228.88,Radiology
Pathology lab procedure,89240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,72.22,,,,,,,fee schedule,19.39,228.88,APC
Pathology lab procedure,89240,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,90.28,,,,,,,fee schedule,19.39,228.88,APC
Cultr oocyte/embryo <4 days,89250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,203.82,,,,,,,fee schedule,163.38,748.29,
Cultr oocyte/embryo <4 days,89250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,163.38,,,,,,,fee schedule,163.38,748.29,
Cultr oocyte/embryo <4 days,89250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,178.48,,,,,,,fee schedule,163.38,748.29,
Cultr oocyte/embryo <4 days,89250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,187.64,,,,,,,fee schedule,163.38,748.29,
Cultr oocyte/embryo <4 days,89250,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,748.29,,,,,,,fee schedule,163.38,748.29,APC 378
Cultr oocyte/embryo <4 days,89250,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,177.09,,,,,,,fee schedule,163.38,748.29,APC
Cultr oocyte/embryo <4 days,89250,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,175.41,,,,,,,fee schedule,163.38,748.29,APC
Cultr oocyte/embryo <4 days,89250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,168.66,,,,,,,fee schedule,163.38,748.29,APC
Cultr oocyte/embryo <4 days,89250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,258.05,,,,,,,fee schedule,163.38,748.29,Radiology
Cultr oocyte/embryo <4 days,89250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,236.12,,,,,,,fee schedule,163.38,748.29,APC
Cultr oocyte/embryo <4 days,89250,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,295.16,,,,,,,fee schedule,163.38,748.29,APC
Cultr oocyte/embryo <4 days,89251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,203.82,,,,,,,fee schedule,163.38,748.29,
Cultr oocyte/embryo <4 days,89251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,163.38,,,,,,,fee schedule,163.38,748.29,
Cultr oocyte/embryo <4 days,89251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,178.48,,,,,,,fee schedule,163.38,748.29,
Cultr oocyte/embryo <4 days,89251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,187.64,,,,,,,fee schedule,163.38,748.29,
Cultr oocyte/embryo <4 days,89251,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,748.29,,,,,,,fee schedule,163.38,748.29,APC 378
Cultr oocyte/embryo <4 days,89251,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,177.09,,,,,,,fee schedule,163.38,748.29,APC
Cultr oocyte/embryo <4 days,89251,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,175.41,,,,,,,fee schedule,163.38,748.29,APC
Cultr oocyte/embryo <4 days,89251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,168.66,,,,,,,fee schedule,163.38,748.29,APC
Cultr oocyte/embryo <4 days,89251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,258.05,,,,,,,fee schedule,163.38,748.29,Radiology
Cultr oocyte/embryo <4 days,89251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,236.12,,,,,,,fee schedule,163.38,748.29,APC
Cultr oocyte/embryo <4 days,89251,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,295.16,,,,,,,fee schedule,163.38,748.29,APC
Embryo hatching,89253,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,203.82,,,,,,,fee schedule,163.38,748.29,
Embryo hatching,89253,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,163.38,,,,,,,fee schedule,163.38,748.29,
Embryo hatching,89253,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,178.48,,,,,,,fee schedule,163.38,748.29,
Embryo hatching,89253,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,187.64,,,,,,,fee schedule,163.38,748.29,
Embryo hatching,89253,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,748.29,,,,,,,fee schedule,163.38,748.29,APC 378
Embryo hatching,89253,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,177.09,,,,,,,fee schedule,163.38,748.29,APC
Embryo hatching,89253,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,175.41,,,,,,,fee schedule,163.38,748.29,APC
Embryo hatching,89253,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,168.66,,,,,,,fee schedule,163.38,748.29,APC
Embryo hatching,89253,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,258.05,,,,,,,fee schedule,163.38,748.29,Radiology
Embryo hatching,89253,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,236.12,,,,,,,fee schedule,163.38,748.29,APC
Embryo hatching,89253,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,295.16,,,,,,,fee schedule,163.38,748.29,APC
Oocyte identification,89254,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,203.82,,,,,,,fee schedule,163.38,748.29,
Oocyte identification,89254,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,163.38,,,,,,,fee schedule,163.38,748.29,
Oocyte identification,89254,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,178.48,,,,,,,fee schedule,163.38,748.29,
Oocyte identification,89254,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,187.64,,,,,,,fee schedule,163.38,748.29,
Oocyte identification,89254,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,748.29,,,,,,,fee schedule,163.38,748.29,APC 378
Oocyte identification,89254,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,177.09,,,,,,,fee schedule,163.38,748.29,APC
Oocyte identification,89254,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,175.41,,,,,,,fee schedule,163.38,748.29,APC
Oocyte identification,89254,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,168.66,,,,,,,fee schedule,163.38,748.29,APC
Oocyte identification,89254,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,258.05,,,,,,,fee schedule,163.38,748.29,Radiology
Oocyte identification,89254,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,236.12,,,,,,,fee schedule,163.38,748.29,APC
Oocyte identification,89254,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,295.16,,,,,,,fee schedule,163.38,748.29,APC
Prepare embryo for transfer,89255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,203.82,,,,,,,fee schedule,51.59,228.88,
Prepare embryo for transfer,89255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,163.38,,,,,,,fee schedule,51.59,228.88,
Prepare embryo for transfer,89255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,178.48,,,,,,,fee schedule,51.59,228.88,
Prepare embryo for transfer,89255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,187.64,,,,,,,fee schedule,51.59,228.88,
Prepare embryo for transfer,89255,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,228.88,,,,,,,fee schedule,51.59,228.88,APC 378
Prepare embryo for transfer,89255,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.17,,,,,,,fee schedule,51.59,228.88,APC
Prepare embryo for transfer,89255,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,53.65,,,,,,,fee schedule,51.59,228.88,APC
Prepare embryo for transfer,89255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,51.59,,,,,,,fee schedule,51.59,228.88,APC
Prepare embryo for transfer,89255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,78.93,,,,,,,fee schedule,51.59,228.88,Radiology
Prepare embryo for transfer,89255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,72.22,,,,,,,fee schedule,51.59,228.88,APC
Prepare embryo for transfer,89255,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,90.28,,,,,,,fee schedule,51.59,228.88,APC
Sperm identification,89257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,203.82,,,,,,,fee schedule,51.59,228.88,
Sperm identification,89257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,163.38,,,,,,,fee schedule,51.59,228.88,
Sperm identification,89257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,178.48,,,,,,,fee schedule,51.59,228.88,
Sperm identification,89257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,187.64,,,,,,,fee schedule,51.59,228.88,
Sperm identification,89257,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,228.88,,,,,,,fee schedule,51.59,228.88,APC 378
Sperm identification,89257,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.17,,,,,,,fee schedule,51.59,228.88,APC
Sperm identification,89257,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,53.65,,,,,,,fee schedule,51.59,228.88,APC
Sperm identification,89257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,51.59,,,,,,,fee schedule,51.59,228.88,APC
Sperm identification,89257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,78.93,,,,,,,fee schedule,51.59,228.88,Radiology
Sperm identification,89257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,72.22,,,,,,,fee schedule,51.59,228.88,APC
Sperm identification,89257,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,90.28,,,,,,,fee schedule,51.59,228.88,APC
Cryopreservation embryo(s),89258,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,203.82,,,,,,,fee schedule,163.38,3538.67,
Cryopreservation embryo(s),89258,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,163.38,,,,,,,fee schedule,163.38,3538.67,
Cryopreservation embryo(s),89258,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,178.48,,,,,,,fee schedule,163.38,3538.67,
Cryopreservation embryo(s),89258,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,187.64,,,,,,,fee schedule,163.38,3538.67,
Cryopreservation embryo(s),89258,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3538.67,,,,,,,fee schedule,163.38,3538.67,APC 378
Cryopreservation embryo(s),89258,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,837.48,,,,,,,fee schedule,163.38,3538.67,APC
Cryopreservation embryo(s),89258,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,829.5,,,,,,,fee schedule,163.38,3538.67,APC
Cryopreservation embryo(s),89258,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,797.6,,,,,,,fee schedule,163.38,3538.67,APC
Cryopreservation embryo(s),89258,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1220.32,,,,,,,fee schedule,163.38,3538.67,Radiology
Cryopreservation embryo(s),89258,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1116.64,,,,,,,fee schedule,163.38,3538.67,APC
Cryopreservation embryo(s),89258,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1395.79,,,,,,,fee schedule,163.38,3538.67,APC
Cryopreservation sperm,89259,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,203.82,,,,,,,fee schedule,163.38,748.29,
Cryopreservation sperm,89259,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,163.38,,,,,,,fee schedule,163.38,748.29,
Cryopreservation sperm,89259,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,178.48,,,,,,,fee schedule,163.38,748.29,
Cryopreservation sperm,89259,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,187.64,,,,,,,fee schedule,163.38,748.29,
Cryopreservation sperm,89259,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,748.29,,,,,,,fee schedule,163.38,748.29,APC 378
Cryopreservation sperm,89259,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,177.09,,,,,,,fee schedule,163.38,748.29,APC
Cryopreservation sperm,89259,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,175.41,,,,,,,fee schedule,163.38,748.29,APC
Cryopreservation sperm,89259,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,168.66,,,,,,,fee schedule,163.38,748.29,APC
Cryopreservation sperm,89259,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,258.05,,,,,,,fee schedule,163.38,748.29,Radiology
Cryopreservation sperm,89259,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,236.12,,,,,,,fee schedule,163.38,748.29,APC
Cryopreservation sperm,89259,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,295.16,,,,,,,fee schedule,163.38,748.29,APC
Sperm isolation simple,89260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,203.82,,,,,,,fee schedule,51.59,228.88,
Sperm isolation simple,89260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,163.38,,,,,,,fee schedule,51.59,228.88,
Sperm isolation simple,89260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,178.48,,,,,,,fee schedule,51.59,228.88,
Sperm isolation simple,89260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,187.64,,,,,,,fee schedule,51.59,228.88,
Sperm isolation simple,89260,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,228.88,,,,,,,fee schedule,51.59,228.88,APC 378
Sperm isolation simple,89260,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.17,,,,,,,fee schedule,51.59,228.88,APC
Sperm isolation simple,89260,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,53.65,,,,,,,fee schedule,51.59,228.88,APC
Sperm isolation simple,89260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,51.59,,,,,,,fee schedule,51.59,228.88,APC
Sperm isolation simple,89260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,78.93,,,,,,,fee schedule,51.59,228.88,Radiology
Sperm isolation simple,89260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,72.22,,,,,,,fee schedule,51.59,228.88,APC
Sperm isolation simple,89260,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,90.28,,,,,,,fee schedule,51.59,228.88,APC
Sperm isolation complex,89261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,203.82,,,,,,,fee schedule,51.59,228.88,
Sperm isolation complex,89261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,163.38,,,,,,,fee schedule,51.59,228.88,
Sperm isolation complex,89261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,178.48,,,,,,,fee schedule,51.59,228.88,
Sperm isolation complex,89261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,187.64,,,,,,,fee schedule,51.59,228.88,
Sperm isolation complex,89261,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,228.88,,,,,,,fee schedule,51.59,228.88,APC 378
Sperm isolation complex,89261,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.17,,,,,,,fee schedule,51.59,228.88,APC
Sperm isolation complex,89261,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,53.65,,,,,,,fee schedule,51.59,228.88,APC
Sperm isolation complex,89261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,51.59,,,,,,,fee schedule,51.59,228.88,APC
Sperm isolation complex,89261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,78.93,,,,,,,fee schedule,51.59,228.88,Radiology
Sperm isolation complex,89261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,72.22,,,,,,,fee schedule,51.59,228.88,APC
Sperm isolation complex,89261,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,90.28,,,,,,,fee schedule,51.59,228.88,APC
Identify sperm tissue,89264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,203.82,,,,,,,fee schedule,51.59,228.88,
Identify sperm tissue,89264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,163.38,,,,,,,fee schedule,51.59,228.88,
Identify sperm tissue,89264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,178.48,,,,,,,fee schedule,51.59,228.88,
Identify sperm tissue,89264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,187.64,,,,,,,fee schedule,51.59,228.88,
Identify sperm tissue,89264,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,228.88,,,,,,,fee schedule,51.59,228.88,APC 378
Identify sperm tissue,89264,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.17,,,,,,,fee schedule,51.59,228.88,APC
Identify sperm tissue,89264,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,53.65,,,,,,,fee schedule,51.59,228.88,APC
Identify sperm tissue,89264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,51.59,,,,,,,fee schedule,51.59,228.88,APC
Identify sperm tissue,89264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,78.93,,,,,,,fee schedule,51.59,228.88,Radiology
Identify sperm tissue,89264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,72.22,,,,,,,fee schedule,51.59,228.88,APC
Identify sperm tissue,89264,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,90.28,,,,,,,fee schedule,51.59,228.88,APC
Insemination of oocytes,89268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,203.82,,,,,,,fee schedule,163.38,748.29,
Insemination of oocytes,89268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,163.38,,,,,,,fee schedule,163.38,748.29,
Insemination of oocytes,89268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,178.48,,,,,,,fee schedule,163.38,748.29,
Insemination of oocytes,89268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,187.64,,,,,,,fee schedule,163.38,748.29,
Insemination of oocytes,89268,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,748.29,,,,,,,fee schedule,163.38,748.29,APC 378
Insemination of oocytes,89268,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,177.09,,,,,,,fee schedule,163.38,748.29,APC
Insemination of oocytes,89268,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,175.41,,,,,,,fee schedule,163.38,748.29,APC
Insemination of oocytes,89268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,168.66,,,,,,,fee schedule,163.38,748.29,APC
Insemination of oocytes,89268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,258.05,,,,,,,fee schedule,163.38,748.29,Radiology
Insemination of oocytes,89268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,236.12,,,,,,,fee schedule,163.38,748.29,APC
Insemination of oocytes,89268,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,295.16,,,,,,,fee schedule,163.38,748.29,APC
Extended culture of oocytes,89272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,203.82,,,,,,,fee schedule,163.38,3538.67,
Extended culture of oocytes,89272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,163.38,,,,,,,fee schedule,163.38,3538.67,
Extended culture of oocytes,89272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,178.48,,,,,,,fee schedule,163.38,3538.67,
Extended culture of oocytes,89272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,187.64,,,,,,,fee schedule,163.38,3538.67,
Extended culture of oocytes,89272,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3538.67,,,,,,,fee schedule,163.38,3538.67,APC 378
Extended culture of oocytes,89272,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,837.48,,,,,,,fee schedule,163.38,3538.67,APC
Extended culture of oocytes,89272,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,829.5,,,,,,,fee schedule,163.38,3538.67,APC
Extended culture of oocytes,89272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,797.6,,,,,,,fee schedule,163.38,3538.67,APC
Extended culture of oocytes,89272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1220.32,,,,,,,fee schedule,163.38,3538.67,Radiology
Extended culture of oocytes,89272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1116.64,,,,,,,fee schedule,163.38,3538.67,APC
Extended culture of oocytes,89272,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1395.79,,,,,,,fee schedule,163.38,3538.67,APC
Assist oocyte fertilization,89280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,203.82,,,,,,,fee schedule,163.38,3538.67,
Assist oocyte fertilization,89280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,163.38,,,,,,,fee schedule,163.38,3538.67,
Assist oocyte fertilization,89280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,178.48,,,,,,,fee schedule,163.38,3538.67,
Assist oocyte fertilization,89280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,187.64,,,,,,,fee schedule,163.38,3538.67,
Assist oocyte fertilization,89280,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3538.67,,,,,,,fee schedule,163.38,3538.67,APC 378
Assist oocyte fertilization,89280,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,837.48,,,,,,,fee schedule,163.38,3538.67,APC
Assist oocyte fertilization,89280,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,829.5,,,,,,,fee schedule,163.38,3538.67,APC
Assist oocyte fertilization,89280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,797.6,,,,,,,fee schedule,163.38,3538.67,APC
Assist oocyte fertilization,89280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1220.32,,,,,,,fee schedule,163.38,3538.67,Radiology
Assist oocyte fertilization,89280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1116.64,,,,,,,fee schedule,163.38,3538.67,APC
Assist oocyte fertilization,89280,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1395.79,,,,,,,fee schedule,163.38,3538.67,APC
Assist oocyte fertilization,89281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,203.82,,,,,,,fee schedule,163.38,748.29,
Assist oocyte fertilization,89281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,163.38,,,,,,,fee schedule,163.38,748.29,
Assist oocyte fertilization,89281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,178.48,,,,,,,fee schedule,163.38,748.29,
Assist oocyte fertilization,89281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,187.64,,,,,,,fee schedule,163.38,748.29,
Assist oocyte fertilization,89281,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,748.29,,,,,,,fee schedule,163.38,748.29,APC 378
Assist oocyte fertilization,89281,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,177.09,,,,,,,fee schedule,163.38,748.29,APC
Assist oocyte fertilization,89281,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,175.41,,,,,,,fee schedule,163.38,748.29,APC
Assist oocyte fertilization,89281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,168.66,,,,,,,fee schedule,163.38,748.29,APC
Assist oocyte fertilization,89281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,258.05,,,,,,,fee schedule,163.38,748.29,Radiology
Assist oocyte fertilization,89281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,236.12,,,,,,,fee schedule,163.38,748.29,APC
Assist oocyte fertilization,89281,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,295.16,,,,,,,fee schedule,163.38,748.29,APC
Biopsy oocyte polar body,89290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,203.82,,,,,,,fee schedule,163.38,748.29,
Biopsy oocyte polar body,89290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,163.38,,,,,,,fee schedule,163.38,748.29,
Biopsy oocyte polar body,89290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,178.48,,,,,,,fee schedule,163.38,748.29,
Biopsy oocyte polar body,89290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,187.64,,,,,,,fee schedule,163.38,748.29,
Biopsy oocyte polar body,89290,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,748.29,,,,,,,fee schedule,163.38,748.29,APC 378
Biopsy oocyte polar body,89290,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,177.09,,,,,,,fee schedule,163.38,748.29,APC
Biopsy oocyte polar body,89290,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,175.41,,,,,,,fee schedule,163.38,748.29,APC
Biopsy oocyte polar body,89290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,168.66,,,,,,,fee schedule,163.38,748.29,APC
Biopsy oocyte polar body,89290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,258.05,,,,,,,fee schedule,163.38,748.29,Radiology
Biopsy oocyte polar body,89290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,236.12,,,,,,,fee schedule,163.38,748.29,APC
Biopsy oocyte polar body,89290,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,295.16,,,,,,,fee schedule,163.38,748.29,APC
Biopsy oocyte polar body,89291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,203.82,,,,,,,fee schedule,163.38,748.29,
Biopsy oocyte polar body,89291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,163.38,,,,,,,fee schedule,163.38,748.29,
Biopsy oocyte polar body,89291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,178.48,,,,,,,fee schedule,163.38,748.29,
Biopsy oocyte polar body,89291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,187.64,,,,,,,fee schedule,163.38,748.29,
Biopsy oocyte polar body,89291,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,748.29,,,,,,,fee schedule,163.38,748.29,APC 378
Biopsy oocyte polar body,89291,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,177.09,,,,,,,fee schedule,163.38,748.29,APC
Biopsy oocyte polar body,89291,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,175.41,,,,,,,fee schedule,163.38,748.29,APC
Biopsy oocyte polar body,89291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,168.66,,,,,,,fee schedule,163.38,748.29,APC
Biopsy oocyte polar body,89291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,258.05,,,,,,,fee schedule,163.38,748.29,Radiology
Biopsy oocyte polar body,89291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,236.12,,,,,,,fee schedule,163.38,748.29,APC
Biopsy oocyte polar body,89291,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,295.16,,,,,,,fee schedule,163.38,748.29,APC
Semen analysis w/huhner,89300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,49.22,,,,,,,fee schedule,8.86,49.22,
Semen analysis w/huhner,89300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39.45,,,,,,,fee schedule,8.86,49.22,
Semen analysis w/huhner,89300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,43.1,,,,,,,fee schedule,8.86,49.22,
Semen analysis w/huhner,89300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45.31,,,,,,,fee schedule,8.86,49.22,
Semen analysis w/huhner,89300,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.86,,,,,,,fee schedule,8.86,49.22,Laboratory
Semen analysis w/huhner,89300,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.33,,,,,,,fee schedule,8.86,49.22,APC
Semen analysis w/huhner,89300,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10.23,,,,,,,fee schedule,8.86,49.22,APC
Semen analysis w/huhner,89300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9.84,,,,,,,fee schedule,8.86,49.22,APC
Semen analysis w/huhner,89300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15.06,,,,,,,fee schedule,8.86,49.22,Radiology
Semen analysis w/huhner,89300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.78,,,,,,,fee schedule,8.86,49.22,APC
Semen analysis w/huhner,89300,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,17.22,,,,,,,fee schedule,8.86,49.22,APC
Semen analysis w/count,89310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,47.51,,,,,,,fee schedule,7.75,47.51,
Semen analysis w/count,89310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38.09,,,,,,,fee schedule,7.75,47.51,
Semen analysis w/count,89310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,41.61,,,,,,,fee schedule,7.75,47.51,
Semen analysis w/count,89310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,43.74,,,,,,,fee schedule,7.75,47.51,
Semen analysis w/count,89310,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.75,,,,,,,fee schedule,7.75,47.51,Laboratory
Semen analysis w/count,89310,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.04,,,,,,,fee schedule,7.75,47.51,APC
Semen analysis w/count,89310,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8.95,,,,,,,fee schedule,7.75,47.51,APC
Semen analysis w/count,89310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8.61,,,,,,,fee schedule,7.75,47.51,APC
Semen analysis w/count,89310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.17,,,,,,,fee schedule,7.75,47.51,Radiology
Semen analysis w/count,89310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12.05,,,,,,,fee schedule,7.75,47.51,APC
Semen analysis w/count,89310,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15.07,,,,,,,fee schedule,7.75,47.51,APC
Semen anal vol/count/mot,89320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37.76,,,,,,,fee schedule,11.08,37.76,
Semen anal vol/count/mot,89320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,30.27,,,,,,,fee schedule,11.08,37.76,
Semen anal vol/count/mot,89320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,33.06,,,,,,,fee schedule,11.08,37.76,
Semen anal vol/count/mot,89320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,34.76,,,,,,,fee schedule,11.08,37.76,
Semen anal vol/count/mot,89320,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.08,,,,,,,fee schedule,11.08,37.76,Laboratory
Semen anal vol/count/mot,89320,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.93,,,,,,,fee schedule,11.08,37.76,APC
Semen anal vol/count/mot,89320,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.8,,,,,,,fee schedule,11.08,37.76,APC
Semen anal vol/count/mot,89320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.31,,,,,,,fee schedule,11.08,37.76,APC
Semen anal vol/count/mot,89320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.83,,,,,,,fee schedule,11.08,37.76,Radiology
Semen anal vol/count/mot,89320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.23,,,,,,,fee schedule,11.08,37.76,APC
Semen anal vol/count/mot,89320,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21.54,,,,,,,fee schedule,11.08,37.76,APC
Semen anal sperm detection,89321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37.76,,,,,,,fee schedule,10.84,37.76,
Semen anal sperm detection,89321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,30.27,,,,,,,fee schedule,10.84,37.76,
Semen anal sperm detection,89321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,33.06,,,,,,,fee schedule,10.84,37.76,
Semen anal sperm detection,89321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,34.76,,,,,,,fee schedule,10.84,37.76,
Semen anal sperm detection,89321,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.84,,,,,,,fee schedule,10.84,37.76,Laboratory
Semen anal sperm detection,89321,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.65,,,,,,,fee schedule,10.84,37.76,APC
Semen anal sperm detection,89321,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.53,,,,,,,fee schedule,10.84,37.76,APC
Semen anal sperm detection,89321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.05,,,,,,,fee schedule,10.84,37.76,APC
Semen anal sperm detection,89321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.44,,,,,,,fee schedule,10.84,37.76,Radiology
Semen anal sperm detection,89321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.87,,,,,,,fee schedule,10.84,37.76,APC
Semen anal sperm detection,89321,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21.09,,,,,,,fee schedule,10.84,37.76,APC
Semen anal strict criteria,89322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,85.54,,,,,,,fee schedule,13.95,85.54,
Semen anal strict criteria,89322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,68.57,,,,,,,fee schedule,13.95,85.54,
Semen anal strict criteria,89322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,74.91,,,,,,,fee schedule,13.95,85.54,
Semen anal strict criteria,89322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,78.75,,,,,,,fee schedule,13.95,85.54,
Semen anal strict criteria,89322,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.95,,,,,,,fee schedule,13.95,85.54,Laboratory
Semen anal strict criteria,89322,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.28,,,,,,,fee schedule,13.95,85.54,APC
Semen anal strict criteria,89322,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,16.12,,,,,,,fee schedule,13.95,85.54,APC
Semen anal strict criteria,89322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,15.5,,,,,,,fee schedule,13.95,85.54,APC
Semen anal strict criteria,89322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.72,,,,,,,fee schedule,13.95,85.54,Radiology
Semen anal strict criteria,89322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21.7,,,,,,,fee schedule,13.95,85.54,APC
Semen anal strict criteria,89322,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,27.12,,,,,,,fee schedule,13.95,85.54,APC
Sperm antibody test,89325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,58.89,,,,,,,fee schedule,9.6,58.89,
Sperm antibody test,89325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,47.21,,,,,,,fee schedule,9.6,58.89,
Sperm antibody test,89325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.57,,,,,,,fee schedule,9.6,58.89,
Sperm antibody test,89325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,54.22,,,,,,,fee schedule,9.6,58.89,
Sperm antibody test,89325,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.6,,,,,,,fee schedule,9.6,58.89,Laboratory
Sperm antibody test,89325,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.2,,,,,,,fee schedule,9.6,58.89,APC
Sperm antibody test,89325,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11.1,,,,,,,fee schedule,9.6,58.89,APC
Sperm antibody test,89325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10.67,,,,,,,fee schedule,9.6,58.89,APC
Sperm antibody test,89325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.33,,,,,,,fee schedule,9.6,58.89,Radiology
Sperm antibody test,89325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.94,,,,,,,fee schedule,9.6,58.89,APC
Sperm antibody test,89325,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18.67,,,,,,,fee schedule,9.6,58.89,APC
Sperm evaluation test,89329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,115.71,,,,,,,fee schedule,17.63,115.71,
Sperm evaluation test,89329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,92.75,,,,,,,fee schedule,17.63,115.71,
Sperm evaluation test,89329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,101.32,,,,,,,fee schedule,17.63,115.71,
Sperm evaluation test,89329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,106.52,,,,,,,fee schedule,17.63,115.71,
Sperm evaluation test,89329,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.63,,,,,,,fee schedule,17.63,115.71,Laboratory
Sperm evaluation test,89329,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20.57,,,,,,,fee schedule,17.63,115.71,APC
Sperm evaluation test,89329,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,20.37,,,,,,,fee schedule,17.63,115.71,APC
Sperm evaluation test,89329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,19.59,,,,,,,fee schedule,17.63,115.71,APC
Sperm evaluation test,89329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29.97,,,,,,,fee schedule,17.63,115.71,Radiology
Sperm evaluation test,89329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27.43,,,,,,,fee schedule,17.63,115.71,APC
Sperm evaluation test,89329,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,34.28,,,,,,,fee schedule,17.63,115.71,APC
Evaluation cervical mucus,89330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,54.62,,,,,,,fee schedule,9.34,54.62,
Evaluation cervical mucus,89330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,43.78,,,,,,,fee schedule,9.34,54.62,
Evaluation cervical mucus,89330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,47.83,,,,,,,fee schedule,9.34,54.62,
Evaluation cervical mucus,89330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,50.29,,,,,,,fee schedule,9.34,54.62,
Evaluation cervical mucus,89330,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.34,,,,,,,fee schedule,9.34,54.62,Laboratory
Evaluation cervical mucus,89330,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.9,,,,,,,fee schedule,9.34,54.62,APC
Evaluation cervical mucus,89330,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10.8,,,,,,,fee schedule,9.34,54.62,APC
Evaluation cervical mucus,89330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10.38,,,,,,,fee schedule,9.34,54.62,APC
Evaluation cervical mucus,89330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15.88,,,,,,,fee schedule,9.34,54.62,Radiology
Evaluation cervical mucus,89330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.53,,,,,,,fee schedule,9.34,54.62,APC
Evaluation cervical mucus,89330,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18.17,,,,,,,fee schedule,9.34,54.62,APC
Retrograde ejaculation anal,89331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,108.11,,,,,,,fee schedule,17.63,108.11,
Retrograde ejaculation anal,89331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,86.66,,,,,,,fee schedule,17.63,108.11,
Retrograde ejaculation anal,89331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,94.67,,,,,,,fee schedule,17.63,108.11,
Retrograde ejaculation anal,89331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,99.53,,,,,,,fee schedule,17.63,108.11,
Retrograde ejaculation anal,89331,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.63,,,,,,,fee schedule,17.63,108.11,Laboratory
Retrograde ejaculation anal,89331,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20.57,,,,,,,fee schedule,17.63,108.11,APC
Retrograde ejaculation anal,89331,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,20.37,,,,,,,fee schedule,17.63,108.11,APC
Retrograde ejaculation anal,89331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,19.59,,,,,,,fee schedule,17.63,108.11,APC
Retrograde ejaculation anal,89331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29.97,,,,,,,fee schedule,17.63,108.11,Radiology
Retrograde ejaculation anal,89331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27.43,,,,,,,fee schedule,17.63,108.11,APC
Retrograde ejaculation anal,89331,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,34.28,,,,,,,fee schedule,17.63,108.11,APC
Cryopreserve testicular tiss,89335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,203.82,,,,,,,fee schedule,51.59,228.88,
Cryopreserve testicular tiss,89335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,163.38,,,,,,,fee schedule,51.59,228.88,
Cryopreserve testicular tiss,89335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,178.48,,,,,,,fee schedule,51.59,228.88,
Cryopreserve testicular tiss,89335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,187.64,,,,,,,fee schedule,51.59,228.88,
Cryopreserve testicular tiss,89335,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,228.88,,,,,,,fee schedule,51.59,228.88,APC 378
Cryopreserve testicular tiss,89335,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.17,,,,,,,fee schedule,51.59,228.88,APC
Cryopreserve testicular tiss,89335,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,53.65,,,,,,,fee schedule,51.59,228.88,APC
Cryopreserve testicular tiss,89335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,51.59,,,,,,,fee schedule,51.59,228.88,APC
Cryopreserve testicular tiss,89335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,78.93,,,,,,,fee schedule,51.59,228.88,Radiology
Cryopreserve testicular tiss,89335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,72.22,,,,,,,fee schedule,51.59,228.88,APC
Cryopreserve testicular tiss,89335,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,90.28,,,,,,,fee schedule,51.59,228.88,APC
Cryopreservation oocyte(s),89337,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,694.35,,,,,,,fee schedule,168.66,748.29,
Cryopreservation oocyte(s),89337,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,556.58,,,,,,,fee schedule,168.66,748.29,
Cryopreservation oocyte(s),89337,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,608.01,,,,,,,fee schedule,168.66,748.29,
Cryopreservation oocyte(s),89337,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,639.24,,,,,,,fee schedule,168.66,748.29,
Cryopreservation oocyte(s),89337,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,748.29,,,,,,,fee schedule,168.66,748.29,APC 378
Cryopreservation oocyte(s),89337,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,177.09,,,,,,,fee schedule,168.66,748.29,APC
Cryopreservation oocyte(s),89337,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,175.41,,,,,,,fee schedule,168.66,748.29,APC
Cryopreservation oocyte(s),89337,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,168.66,,,,,,,fee schedule,168.66,748.29,APC
Cryopreservation oocyte(s),89337,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,258.05,,,,,,,fee schedule,168.66,748.29,Radiology
Cryopreservation oocyte(s),89337,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,236.12,,,,,,,fee schedule,168.66,748.29,APC
Cryopreservation oocyte(s),89337,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,295.16,,,,,,,fee schedule,168.66,748.29,APC
Storage/year embryo(s),89342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,203.82,,,,,,,fee schedule,163.38,748.29,
Storage/year embryo(s),89342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,163.38,,,,,,,fee schedule,163.38,748.29,
Storage/year embryo(s),89342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,178.48,,,,,,,fee schedule,163.38,748.29,
Storage/year embryo(s),89342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,187.64,,,,,,,fee schedule,163.38,748.29,
Storage/year embryo(s),89342,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,748.29,,,,,,,fee schedule,163.38,748.29,APC 378
Storage/year embryo(s),89342,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,177.09,,,,,,,fee schedule,163.38,748.29,APC
Storage/year embryo(s),89342,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,175.41,,,,,,,fee schedule,163.38,748.29,APC
Storage/year embryo(s),89342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,168.66,,,,,,,fee schedule,163.38,748.29,APC
Storage/year embryo(s),89342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,258.05,,,,,,,fee schedule,163.38,748.29,Radiology
Storage/year embryo(s),89342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,236.12,,,,,,,fee schedule,163.38,748.29,APC
Storage/year embryo(s),89342,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,295.16,,,,,,,fee schedule,163.38,748.29,APC
Storage/year sperm/semen,89343,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,203.82,,,,,,,fee schedule,163.38,748.29,
Storage/year sperm/semen,89343,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,163.38,,,,,,,fee schedule,163.38,748.29,
Storage/year sperm/semen,89343,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,178.48,,,,,,,fee schedule,163.38,748.29,
Storage/year sperm/semen,89343,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,187.64,,,,,,,fee schedule,163.38,748.29,
Storage/year sperm/semen,89343,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,748.29,,,,,,,fee schedule,163.38,748.29,APC 378
Storage/year sperm/semen,89343,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,177.09,,,,,,,fee schedule,163.38,748.29,APC
Storage/year sperm/semen,89343,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,175.41,,,,,,,fee schedule,163.38,748.29,APC
Storage/year sperm/semen,89343,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,168.66,,,,,,,fee schedule,163.38,748.29,APC
Storage/year sperm/semen,89343,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,258.05,,,,,,,fee schedule,163.38,748.29,Radiology
Storage/year sperm/semen,89343,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,236.12,,,,,,,fee schedule,163.38,748.29,APC
Storage/year sperm/semen,89343,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,295.16,,,,,,,fee schedule,163.38,748.29,APC
Storage/year reprod tissue,89344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,203.82,,,,,,,fee schedule,163.38,748.29,
Storage/year reprod tissue,89344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,163.38,,,,,,,fee schedule,163.38,748.29,
Storage/year reprod tissue,89344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,178.48,,,,,,,fee schedule,163.38,748.29,
Storage/year reprod tissue,89344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,187.64,,,,,,,fee schedule,163.38,748.29,
Storage/year reprod tissue,89344,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,748.29,,,,,,,fee schedule,163.38,748.29,APC 378
Storage/year reprod tissue,89344,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,177.09,,,,,,,fee schedule,163.38,748.29,APC
Storage/year reprod tissue,89344,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,175.41,,,,,,,fee schedule,163.38,748.29,APC
Storage/year reprod tissue,89344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,168.66,,,,,,,fee schedule,163.38,748.29,APC
Storage/year reprod tissue,89344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,258.05,,,,,,,fee schedule,163.38,748.29,Radiology
Storage/year reprod tissue,89344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,236.12,,,,,,,fee schedule,163.38,748.29,APC
Storage/year reprod tissue,89344,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,295.16,,,,,,,fee schedule,163.38,748.29,APC
Storage/year oocyte(s),89346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,203.82,,,,,,,fee schedule,163.38,748.29,
Storage/year oocyte(s),89346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,163.38,,,,,,,fee schedule,163.38,748.29,
Storage/year oocyte(s),89346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,178.48,,,,,,,fee schedule,163.38,748.29,
Storage/year oocyte(s),89346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,187.64,,,,,,,fee schedule,163.38,748.29,
Storage/year oocyte(s),89346,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,748.29,,,,,,,fee schedule,163.38,748.29,APC 378
Storage/year oocyte(s),89346,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,177.09,,,,,,,fee schedule,163.38,748.29,APC
Storage/year oocyte(s),89346,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,175.41,,,,,,,fee schedule,163.38,748.29,APC
Storage/year oocyte(s),89346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,168.66,,,,,,,fee schedule,163.38,748.29,APC
Storage/year oocyte(s),89346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,258.05,,,,,,,fee schedule,163.38,748.29,Radiology
Storage/year oocyte(s),89346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,236.12,,,,,,,fee schedule,163.38,748.29,APC
Storage/year oocyte(s),89346,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,295.16,,,,,,,fee schedule,163.38,748.29,APC
Thawing cryopresrved embryo,89352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,203.82,,,,,,,fee schedule,163.38,748.29,
Thawing cryopresrved embryo,89352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,163.38,,,,,,,fee schedule,163.38,748.29,
Thawing cryopresrved embryo,89352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,178.48,,,,,,,fee schedule,163.38,748.29,
Thawing cryopresrved embryo,89352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,187.64,,,,,,,fee schedule,163.38,748.29,
Thawing cryopresrved embryo,89352,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,748.29,,,,,,,fee schedule,163.38,748.29,APC 378
Thawing cryopresrved embryo,89352,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,177.09,,,,,,,fee schedule,163.38,748.29,APC
Thawing cryopresrved embryo,89352,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,175.41,,,,,,,fee schedule,163.38,748.29,APC
Thawing cryopresrved embryo,89352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,168.66,,,,,,,fee schedule,163.38,748.29,APC
Thawing cryopresrved embryo,89352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,258.05,,,,,,,fee schedule,163.38,748.29,Radiology
Thawing cryopresrved embryo,89352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,236.12,,,,,,,fee schedule,163.38,748.29,APC
Thawing cryopresrved embryo,89352,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,295.16,,,,,,,fee schedule,163.38,748.29,APC
Thawing cryopresrved sperm,89353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,203.82,,,,,,,fee schedule,51.59,228.88,
Thawing cryopresrved sperm,89353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,163.38,,,,,,,fee schedule,51.59,228.88,
Thawing cryopresrved sperm,89353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,178.48,,,,,,,fee schedule,51.59,228.88,
Thawing cryopresrved sperm,89353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,187.64,,,,,,,fee schedule,51.59,228.88,
Thawing cryopresrved sperm,89353,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,228.88,,,,,,,fee schedule,51.59,228.88,APC 378
Thawing cryopresrved sperm,89353,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.17,,,,,,,fee schedule,51.59,228.88,APC
Thawing cryopresrved sperm,89353,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,53.65,,,,,,,fee schedule,51.59,228.88,APC
Thawing cryopresrved sperm,89353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,51.59,,,,,,,fee schedule,51.59,228.88,APC
Thawing cryopresrved sperm,89353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,78.93,,,,,,,fee schedule,51.59,228.88,Radiology
Thawing cryopresrved sperm,89353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,72.22,,,,,,,fee schedule,51.59,228.88,APC
Thawing cryopresrved sperm,89353,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,90.28,,,,,,,fee schedule,51.59,228.88,APC
Thaw cryoprsvrd reprod tiss,89354,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,203.82,,,,,,,fee schedule,163.38,748.29,
Thaw cryoprsvrd reprod tiss,89354,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,163.38,,,,,,,fee schedule,163.38,748.29,
Thaw cryoprsvrd reprod tiss,89354,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,178.48,,,,,,,fee schedule,163.38,748.29,
Thaw cryoprsvrd reprod tiss,89354,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,187.64,,,,,,,fee schedule,163.38,748.29,
Thaw cryoprsvrd reprod tiss,89354,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,748.29,,,,,,,fee schedule,163.38,748.29,APC 378
Thaw cryoprsvrd reprod tiss,89354,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,177.09,,,,,,,fee schedule,163.38,748.29,APC
Thaw cryoprsvrd reprod tiss,89354,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,175.41,,,,,,,fee schedule,163.38,748.29,APC
Thaw cryoprsvrd reprod tiss,89354,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,168.66,,,,,,,fee schedule,163.38,748.29,APC
Thaw cryoprsvrd reprod tiss,89354,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,258.05,,,,,,,fee schedule,163.38,748.29,Radiology
Thaw cryoprsvrd reprod tiss,89354,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,236.12,,,,,,,fee schedule,163.38,748.29,APC
Thaw cryoprsvrd reprod tiss,89354,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,295.16,,,,,,,fee schedule,163.38,748.29,APC
Thawing cryopresrved oocyte,89356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,203.82,,,,,,,fee schedule,163.38,748.29,
Thawing cryopresrved oocyte,89356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,163.38,,,,,,,fee schedule,163.38,748.29,
Thawing cryopresrved oocyte,89356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,178.48,,,,,,,fee schedule,163.38,748.29,
Thawing cryopresrved oocyte,89356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,187.64,,,,,,,fee schedule,163.38,748.29,
Thawing cryopresrved oocyte,89356,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,748.29,,,,,,,fee schedule,163.38,748.29,APC 378
Thawing cryopresrved oocyte,89356,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,177.09,,,,,,,fee schedule,163.38,748.29,APC
Thawing cryopresrved oocyte,89356,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,175.41,,,,,,,fee schedule,163.38,748.29,APC
Thawing cryopresrved oocyte,89356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,168.66,,,,,,,fee schedule,163.38,748.29,APC
Thawing cryopresrved oocyte,89356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,258.05,,,,,,,fee schedule,163.38,748.29,Radiology
Thawing cryopresrved oocyte,89356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,236.12,,,,,,,fee schedule,163.38,748.29,APC
Thawing cryopresrved oocyte,89356,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,295.16,,,,,,,fee schedule,163.38,748.29,APC
Unlisted reprod med lab proc,89398,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,150.07,,,,,,,fee schedule,51.59,228.88,
Unlisted reprod med lab proc,89398,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,120.29,,,,,,,fee schedule,51.59,228.88,
Unlisted reprod med lab proc,89398,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,131.41,,,,,,,fee schedule,51.59,228.88,
Unlisted reprod med lab proc,89398,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,138.16,,,,,,,fee schedule,51.59,228.88,
Unlisted reprod med lab proc,89398,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,228.88,,,,,,,fee schedule,51.59,228.88,APC 378
Unlisted reprod med lab proc,89398,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.17,,,,,,,fee schedule,51.59,228.88,APC
Unlisted reprod med lab proc,89398,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,53.65,,,,,,,fee schedule,51.59,228.88,APC
Unlisted reprod med lab proc,89398,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,51.59,,,,,,,fee schedule,51.59,228.88,APC
Unlisted reprod med lab proc,89398,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,78.93,,,,,,,fee schedule,51.59,228.88,Radiology
Unlisted reprod med lab proc,89398,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,72.22,,,,,,,fee schedule,51.59,228.88,APC
Unlisted reprod med lab proc,89398,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,90.28,,,,,,,fee schedule,51.59,228.88,APC
Hep b ig im,90371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,480.78,,,,,,,fee schedule,140.21,480.78,
Hep b ig im,90371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,385.39,,,,,,,fee schedule,140.21,480.78,
Hep b ig im,90371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,421,,,,,,,fee schedule,140.21,480.78,
Hep b ig im,90371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,442.62,,,,,,,fee schedule,140.21,480.78,
Hep b ig im,90371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,162.64,,,,,,,fee schedule,140.21,480.78,OP High Cost Drugs
Hep b ig im,90371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,140.21,,,,,,,fee schedule,140.21,480.78,Other Pharmacy
Hep b ig im,90371,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,147.22,,,,,,,fee schedule,140.21,480.78,APC
Hep b ig im,90371,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,145.82,,,,,,,fee schedule,140.21,480.78,APC
Hep b ig im,90371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,214.52,,,,,,,fee schedule,140.21,480.78,Radiology
Hep b ig im,90371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,196.29,,,,,,,fee schedule,140.21,480.78,APC
Hep b ig im,90371,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,245.37,,,,,,,fee schedule,140.21,480.78,APC
Rabies ig im/sc,90375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,352.83,,,,,,,fee schedule,275.18,481.56,
Rabies ig im/sc,90375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,282.82,,,,,,,fee schedule,275.18,481.56,
Rabies ig im/sc,90375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,308.96,,,,,,,fee schedule,275.18,481.56,
Rabies ig im/sc,90375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,324.82,,,,,,,fee schedule,275.18,481.56,
Rabies ig im/sc,90375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,319.21,,,,,,,fee schedule,275.18,481.56,OP High Cost Drugs
Rabies ig im/sc,90375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,275.18,,,,,,,fee schedule,275.18,481.56,Other Pharmacy
Rabies ig im/sc,90375,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,288.94,,,,,,,fee schedule,275.18,481.56,APC
Rabies ig im/sc,90375,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,286.19,,,,,,,fee schedule,275.18,481.56,APC
Rabies ig im/sc,90375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,421.03,,,,,,,fee schedule,275.18,481.56,Radiology
Rabies ig im/sc,90375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,385.25,,,,,,,fee schedule,275.18,481.56,APC
Rabies ig im/sc,90375,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,481.56,,,,,,,fee schedule,275.18,481.56,APC
Rabies ig heat treated,90376,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,380.68,,,,,,,fee schedule,305.15,1563.66,
Rabies ig heat treated,90376,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,305.15,,,,,,,fee schedule,305.15,1563.66,
Rabies ig heat treated,90376,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,333.35,,,,,,,fee schedule,305.15,1563.66,
Rabies ig heat treated,90376,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,350.47,,,,,,,fee schedule,305.15,1563.66,
Rabies ig heat treated,90376,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1563.66,,,,,,,fee schedule,305.15,1563.66,APC 378
Rabies ig heat treated,90376,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,370.06,,,,,,,fee schedule,305.15,1563.66,APC
Rabies ig heat treated,90376,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,366.54,,,,,,,fee schedule,305.15,1563.66,APC
Rabies ig heat treated,90376,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,352.44,,,,,,,fee schedule,305.15,1563.66,APC
Rabies ig heat treated,90376,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,539.23,,,,,,,fee schedule,305.15,1563.66,Radiology
Rabies ig heat treated,90376,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,493.42,,,,,,,fee schedule,305.15,1563.66,APC
Rabies ig heat treated,90376,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,616.77,,,,,,,fee schedule,305.15,1563.66,APC
Rabies ig ht&sol human im/sc,90377,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,911.74,,,,,,,fee schedule,242.18,911.74,
Rabies ig ht&sol human im/sc,90377,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,730.84,,,,,,,fee schedule,242.18,911.74,
Rabies ig ht&sol human im/sc,90377,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,798.37,,,,,,,fee schedule,242.18,911.74,
Rabies ig ht&sol human im/sc,90377,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,839.38,,,,,,,fee schedule,242.18,911.74,
Rabies ig ht&sol human im/sc,90377,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,280.93,,,,,,,fee schedule,242.18,911.74,OP High Cost Drugs
Rabies ig ht&sol human im/sc,90377,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,242.18,,,,,,,fee schedule,242.18,911.74,Other Pharmacy
Rabies ig ht&sol human im/sc,90377,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,254.29,,,,,,,fee schedule,242.18,911.74,APC
Rabies ig ht&sol human im/sc,90377,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,251.86,,,,,,,fee schedule,242.18,911.74,APC
Rabies ig ht&sol human im/sc,90377,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,370.53,,,,,,,fee schedule,242.18,911.74,Radiology
Rabies ig ht&sol human im/sc,90377,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,339.05,,,,,,,fee schedule,242.18,911.74,APC
Rabies ig ht&sol human im/sc,90377,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,423.81,,,,,,,fee schedule,242.18,911.74,APC
Rsv mab im 50mg,90378,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,666.6,,,,,,,fee schedule,436.75,1937.71,
Rsv mab im 50mg,90378,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,534.34,,,,,,,fee schedule,436.75,1937.71,
Rsv mab im 50mg,90378,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,583.72,,,,,,,fee schedule,436.75,1937.71,
Rsv mab im 50mg,90378,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,613.7,,,,,,,fee schedule,436.75,1937.71,
Rsv mab im 50mg,90378,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1937.71,,,,,,,fee schedule,436.75,1937.71,APC 378
Rsv mab im 50mg,90378,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,458.59,,,,,,,fee schedule,436.75,1937.71,APC
Rsv mab im 50mg,90378,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,454.22,,,,,,,fee schedule,436.75,1937.71,APC
Rsv mab im 50mg,90378,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,436.75,,,,,,,fee schedule,436.75,1937.71,APC
Rsv mab im 50mg,90378,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,668.23,,,,,,,fee schedule,436.75,1937.71,Radiology
Rsv mab im 50mg,90378,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,611.45,,,,,,,fee schedule,436.75,1937.71,APC
Rsv mab im 50mg,90378,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,764.31,,,,,,,fee schedule,436.75,1937.71,APC
Rh ig minidose im,90385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,572.33,,,,,,,fee schedule,80,572.33,
Rh ig minidose im,90385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,458.77,,,,,,,fee schedule,80,572.33,
Rh ig minidose im,90385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,501.17,,,,,,,fee schedule,80,572.33,
Rh ig minidose im,90385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,526.91,,,,,,,fee schedule,80,572.33,
Rh ig minidose im,90385,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,354.93,,,,,,,fee schedule,80,572.33,APC 378
Rh ig minidose im,90385,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,84,,,,,,,fee schedule,80,572.33,APC
Rh ig minidose im,90385,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,83.2,,,,,,,fee schedule,80,572.33,APC
Rh ig minidose im,90385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,80,,,,,,,fee schedule,80,572.33,APC
Rh ig minidose im,90385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,122.4,,,,,,,fee schedule,80,572.33,Radiology
Rh ig minidose im,90385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,112,,,,,,,fee schedule,80,572.33,APC
Rh ig minidose im,90385,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,140,,,,,,,fee schedule,80,572.33,APC
Varicella-zoster ig im,90396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,434.7,,,,,,,fee schedule,348.45,10484.94,
Varicella-zoster ig im,90396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,348.45,,,,,,,fee schedule,348.45,10484.94,
Varicella-zoster ig im,90396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,380.65,,,,,,,fee schedule,348.45,10484.94,
Varicella-zoster ig im,90396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,400.2,,,,,,,fee schedule,348.45,10484.94,
Varicella-zoster ig im,90396,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10484.94,,,,,,,fee schedule,348.45,10484.94,APC 378
Varicella-zoster ig im,90396,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2481.41,,,,,,,fee schedule,348.45,10484.94,APC
Varicella-zoster ig im,90396,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2457.78,,,,,,,fee schedule,348.45,10484.94,APC
Varicella-zoster ig im,90396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2363.25,,,,,,,fee schedule,348.45,10484.94,APC
Varicella-zoster ig im,90396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3615.77,,,,,,,fee schedule,348.45,10484.94,Radiology
Varicella-zoster ig im,90396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3308.55,,,,,,,fee schedule,348.45,10484.94,APC
Varicella-zoster ig im,90396,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4135.69,,,,,,,fee schedule,348.45,10484.94,APC
Im admin 1st/only component,90460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,91.48,,,,,,,fee schedule,73.33,91.48,
Im admin 1st/only component,90460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,73.33,,,,,,,fee schedule,73.33,91.48,
Im admin 1st/only component,90460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,80.1,,,,,,,fee schedule,73.33,91.48,
Im admin 1st/only component,90460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,84.22,,,,,,,fee schedule,73.33,91.48,
Immunization admin,90471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,75.01,,,,,,,fee schedule,60.12,316.24,
Immunization admin,90471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,60.12,,,,,,,fee schedule,60.12,316.24,
Immunization admin,90471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,65.68,,,,,,,fee schedule,60.12,316.24,
Immunization admin,90471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,69.05,,,,,,,fee schedule,60.12,316.24,
Immunization admin,90471,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,316.24,,,,,,,fee schedule,60.12,316.24,APC 378
Immunization admin,90471,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,74.84,,,,,,,fee schedule,60.12,316.24,APC
Immunization admin,90471,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,74.13,,,,,,,fee schedule,60.12,316.24,APC
Immunization admin,90471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,71.28,,,,,,,fee schedule,60.12,316.24,APC
Immunization admin,90471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,109.06,,,,,,,fee schedule,60.12,316.24,Radiology
Immunization admin,90471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,99.79,,,,,,,fee schedule,60.12,316.24,APC
Immunization admin,90471,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,124.74,,,,,,,fee schedule,60.12,316.24,APC
Immunization admin each add,90472,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33.59,,,,,,,fee schedule,26.93,33.59,
Immunization admin each add,90472,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26.93,,,,,,,fee schedule,26.93,33.59,
Immunization admin each add,90472,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29.41,,,,,,,fee schedule,26.93,33.59,
Immunization admin each add,90472,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30.93,,,,,,,fee schedule,26.93,33.59,
Immune admin oral/nasal,90473,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,63.5,,,,,,,fee schedule,50.9,316.24,
Immune admin oral/nasal,90473,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,50.9,,,,,,,fee schedule,50.9,316.24,
Immune admin oral/nasal,90473,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55.61,,,,,,,fee schedule,50.9,316.24,
Immune admin oral/nasal,90473,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,58.46,,,,,,,fee schedule,50.9,316.24,
Immune admin oral/nasal,90473,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,316.24,,,,,,,fee schedule,50.9,316.24,APC 378
Immune admin oral/nasal,90473,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,74.84,,,,,,,fee schedule,50.9,316.24,APC
Immune admin oral/nasal,90473,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,74.13,,,,,,,fee schedule,50.9,316.24,APC
Immune admin oral/nasal,90473,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,71.28,,,,,,,fee schedule,50.9,316.24,APC
Immune admin oral/nasal,90473,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,109.06,,,,,,,fee schedule,50.9,316.24,Radiology
Immune admin oral/nasal,90473,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,99.79,,,,,,,fee schedule,50.9,316.24,APC
Immune admin oral/nasal,90473,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,124.74,,,,,,,fee schedule,50.9,316.24,APC
Immune admin oral/nasal addl,90474,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,63.5,,,,,,,fee schedule,50.9,63.5,
Immune admin oral/nasal addl,90474,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,50.9,,,,,,,fee schedule,50.9,63.5,
Immune admin oral/nasal addl,90474,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55.61,,,,,,,fee schedule,50.9,63.5,
Immune admin oral/nasal addl,90474,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,58.46,,,,,,,fee schedule,50.9,63.5,
Adenovirus vaccine type 4,90476,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1353.16,,,,,,,fee schedule,1084.68,1353.16,
Adenovirus vaccine type 4,90476,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1084.68,,,,,,,fee schedule,1084.68,1353.16,
Adenovirus vaccine type 4,90476,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1184.91,,,,,,,fee schedule,1084.68,1353.16,
Adenovirus vaccine type 4,90476,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1245.77,,,,,,,fee schedule,1084.68,1353.16,
Admn sarscov2 vacc 1 dose,90480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,156.95,,,,,,,fee schedule,40.23,178.5,
Admn sarscov2 vacc 1 dose,90480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,125.81,,,,,,,fee schedule,40.23,178.5,
Admn sarscov2 vacc 1 dose,90480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,137.43,,,,,,,fee schedule,40.23,178.5,
Admn sarscov2 vacc 1 dose,90480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,144.49,,,,,,,fee schedule,40.23,178.5,
Admn sarscov2 vacc 1 dose,90480,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,178.5,,,,,,,fee schedule,40.23,178.5,APC 378
Admn sarscov2 vacc 1 dose,90480,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,42.24,,,,,,,fee schedule,40.23,178.5,APC
Admn sarscov2 vacc 1 dose,90480,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,41.84,,,,,,,fee schedule,40.23,178.5,APC
Admn sarscov2 vacc 1 dose,90480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,40.23,,,,,,,fee schedule,40.23,178.5,APC
Admn sarscov2 vacc 1 dose,90480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,61.56,,,,,,,fee schedule,40.23,178.5,Radiology
Admn sarscov2 vacc 1 dose,90480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.32,,,,,,,fee schedule,40.23,178.5,APC
Admn sarscov2 vacc 1 dose,90480,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,70.41,,,,,,,fee schedule,40.23,178.5,APC
Bcg vaccine percut,90585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,458.4,,,,,,,fee schedule,367.45,458.4,
Bcg vaccine percut,90585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,367.45,,,,,,,fee schedule,367.45,458.4,
Bcg vaccine percut,90585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,401.4,,,,,,,fee schedule,367.45,458.4,
Bcg vaccine percut,90585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,422.02,,,,,,,fee schedule,367.45,458.4,
Bcg vaccine intravesical,90586,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,473.82,,,,,,,fee schedule,379.81,473.82,
Bcg vaccine intravesical,90586,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,379.81,,,,,,,fee schedule,379.81,473.82,
Bcg vaccine intravesical,90586,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,414.91,,,,,,,fee schedule,379.81,473.82,
Bcg vaccine intravesical,90586,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,436.22,,,,,,,fee schedule,379.81,473.82,
Smallpox&monkeypox vac 0.5ml,90611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.04,,,,,,,fee schedule,0.01,0.04,
Smallpox&monkeypox vac 0.5ml,90611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.03,,,,,,,fee schedule,0.01,0.04,
Smallpox&monkeypox vac 0.5ml,90611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.03,,,,,,,fee schedule,0.01,0.04,
Smallpox&monkeypox vac 0.5ml,90611,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.04,,,,,,,fee schedule,0.01,0.04,APC 378
Smallpox&monkeypox vac 0.5ml,90611,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,0.01,,,,,,,fee schedule,0.01,0.04,APC
Smallpox&monkeypox vac 0.5ml,90611,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,0.01,,,,,,,fee schedule,0.01,0.04,APC
Smallpox&monkeypox vac 0.5ml,90611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,0.01,,,,,,,fee schedule,0.01,0.04,APC
Smallpox&monkeypox vac 0.5ml,90611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,0.02,,,,,,,fee schedule,0.01,0.04,Radiology
Smallpox&monkeypox vac 0.5ml,90611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,0.01,,,,,,,fee schedule,0.01,0.04,APC
Smallpox&monkeypox vac 0.5ml,90611,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,0.02,,,,,,,fee schedule,0.01,0.04,APC
Menb rp w/omv vaccine im,90620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,591.95,,,,,,,fee schedule,474.5,591.95,
Menb rp w/omv vaccine im,90620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,474.5,,,,,,,fee schedule,474.5,591.95,
Menb rp w/omv vaccine im,90620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,518.35,,,,,,,fee schedule,474.5,591.95,
Menb rp w/omv vaccine im,90620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,544.97,,,,,,,fee schedule,474.5,591.95,
Menb rlp vaccine im,90621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,463.81,,,,,,,fee schedule,371.78,463.81,
Menb rlp vaccine im,90621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,371.78,,,,,,,fee schedule,371.78,463.81,
Menb rlp vaccine im,90621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,406.14,,,,,,,fee schedule,371.78,463.81,
Menb rlp vaccine im,90621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,427,,,,,,,fee schedule,371.78,463.81,
Vaccinia vrs vac 0.3 ml perq,90622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.04,,,,,,,fee schedule,0.01,0.04,
Vaccinia vrs vac 0.3 ml perq,90622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.03,,,,,,,fee schedule,0.01,0.04,
Vaccinia vrs vac 0.3 ml perq,90622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.03,,,,,,,fee schedule,0.01,0.04,
Vaccinia vrs vac 0.3 ml perq,90622,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,0.04,,,,,,,fee schedule,0.01,0.04,APC 378
Vaccinia vrs vac 0.3 ml perq,90622,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,0.01,,,,,,,fee schedule,0.01,0.04,APC
Vaccinia vrs vac 0.3 ml perq,90622,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,0.01,,,,,,,fee schedule,0.01,0.04,APC
Vaccinia vrs vac 0.3 ml perq,90622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,0.01,,,,,,,fee schedule,0.01,0.04,APC
Vaccinia vrs vac 0.3 ml perq,90622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,0.02,,,,,,,fee schedule,0.01,0.04,Radiology
Vaccinia vrs vac 0.3 ml perq,90622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,0.01,,,,,,,fee schedule,0.01,0.04,APC
Vaccinia vrs vac 0.3 ml perq,90622,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,0.02,,,,,,,fee schedule,0.01,0.04,APC
Hib-mency vacc 6wk-18m0 im,90644,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,95.41,,,,,,,fee schedule,76.48,95.41,
Hib-mency vacc 6wk-18m0 im,90644,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,76.48,,,,,,,fee schedule,76.48,95.41,
Hib-mency vacc 6wk-18m0 im,90644,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,83.54,,,,,,,fee schedule,76.48,95.41,
Hib-mency vacc 6wk-18m0 im,90644,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,87.84,,,,,,,fee schedule,76.48,95.41,
4vhpv vaccine 3 dose im,90649,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,568.93,,,,,,,fee schedule,456.05,568.93,
4vhpv vaccine 3 dose im,90649,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,456.05,,,,,,,fee schedule,456.05,568.93,
4vhpv vaccine 3 dose im,90649,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,498.19,,,,,,,fee schedule,456.05,568.93,
4vhpv vaccine 3 dose im,90649,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,523.77,,,,,,,fee schedule,456.05,568.93,
Flu vacc iiv3 no preserv id,90654,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,71.74,,,,,,,fee schedule,57.51,71.74,
Flu vacc iiv3 no preserv id,90654,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.51,,,,,,,fee schedule,57.51,71.74,
Flu vacc iiv3 no preserv id,90654,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,62.82,,,,,,,fee schedule,57.51,71.74,
Flu vacc iiv3 no preserv id,90654,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.05,,,,,,,fee schedule,57.51,71.74,
Iiv3 vacc no prsv 0.25 ml im,90655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,63.81,,,,,,,fee schedule,51.15,63.81,
Iiv3 vacc no prsv 0.25 ml im,90655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.15,,,,,,,fee schedule,51.15,63.81,
Iiv3 vacc no prsv 0.25 ml im,90655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55.87,,,,,,,fee schedule,51.15,63.81,
Iiv3 vacc no prsv 0.25 ml im,90655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,58.74,,,,,,,fee schedule,51.15,63.81,
Iiv3 vacc no prsv 0.5 ml im,90656,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,68.8,,,,,,,fee schedule,55.15,68.8,
Iiv3 vacc no prsv 0.5 ml im,90656,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55.15,,,,,,,fee schedule,55.15,68.8,
Iiv3 vacc no prsv 0.5 ml im,90656,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,60.24,,,,,,,fee schedule,55.15,68.8,
Iiv3 vacc no prsv 0.5 ml im,90656,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,63.34,,,,,,,fee schedule,55.15,68.8,
Iiv3 vaccine splt 0.25 ml im,90657,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24.99,,,,,,,fee schedule,20.03,24.99,
Iiv3 vaccine splt 0.25 ml im,90657,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20.03,,,,,,,fee schedule,20.03,24.99,
Iiv3 vaccine splt 0.25 ml im,90657,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21.88,,,,,,,fee schedule,20.03,24.99,
Iiv3 vaccine splt 0.25 ml im,90657,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23,,,,,,,fee schedule,20.03,24.99,
Iiv3 vaccine splt 0.5 ml im,90658,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,49.97,,,,,,,fee schedule,40.06,49.97,
Iiv3 vaccine splt 0.5 ml im,90658,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40.06,,,,,,,fee schedule,40.06,49.97,
Iiv3 vaccine splt 0.5 ml im,90658,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,43.76,,,,,,,fee schedule,40.06,49.97,
Iiv3 vaccine splt 0.5 ml im,90658,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46.01,,,,,,,fee schedule,40.06,49.97,
Laiv3 vaccine intranasal,90660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,84.37,,,,,,,fee schedule,67.63,84.37,
Laiv3 vaccine intranasal,90660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,67.63,,,,,,,fee schedule,67.63,84.37,
Laiv3 vaccine intranasal,90660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,73.88,,,,,,,fee schedule,67.63,84.37,
Laiv3 vaccine intranasal,90660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,77.67,,,,,,,fee schedule,67.63,84.37,
Pcv13 vaccine im,90670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,551.73,,,,,,,fee schedule,442.26,551.73,
Pcv13 vaccine im,90670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,442.26,,,,,,,fee schedule,442.26,551.73,
Pcv13 vaccine im,90670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,483.13,,,,,,,fee schedule,442.26,551.73,
Pcv13 vaccine im,90670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,507.94,,,,,,,fee schedule,442.26,551.73,
Laiv4 vaccine intranasal,90672,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,97.3,,,,,,,fee schedule,77.99,97.3,
Laiv4 vaccine intranasal,90672,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,77.99,,,,,,,fee schedule,77.99,97.3,
Laiv4 vaccine intranasal,90672,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,85.2,,,,,,,fee schedule,77.99,97.3,
Laiv4 vaccine intranasal,90672,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,89.58,,,,,,,fee schedule,77.99,97.3,
Riv3 vaccine no preserv im,90673,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,137.89,,,,,,,fee schedule,110.53,137.89,
Riv3 vaccine no preserv im,90673,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,110.53,,,,,,,fee schedule,110.53,137.89,
Riv3 vaccine no preserv im,90673,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,120.75,,,,,,,fee schedule,110.53,137.89,
Riv3 vaccine no preserv im,90673,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,126.95,,,,,,,fee schedule,110.53,137.89,
Cciiv4 vac no prsv 0.5 ml im,90674,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,79.87,,,,,,,fee schedule,64.02,79.87,
Cciiv4 vac no prsv 0.5 ml im,90674,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,64.02,,,,,,,fee schedule,64.02,79.87,
Cciiv4 vac no prsv 0.5 ml im,90674,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,69.94,,,,,,,fee schedule,64.02,79.87,
Cciiv4 vac no prsv 0.5 ml im,90674,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,73.53,,,,,,,fee schedule,64.02,79.87,
Rabies vaccine im,90675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,570.14,,,,,,,fee schedule,315.22,570.14,
Rabies vaccine im,90675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,457.01,,,,,,,fee schedule,315.22,570.14,
Rabies vaccine im,90675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,499.25,,,,,,,fee schedule,315.22,570.14,
Rabies vaccine im,90675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,524.89,,,,,,,fee schedule,315.22,570.14,
Rabies vaccine im,90675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,365.65,,,,,,,fee schedule,315.22,570.14,OP High Cost Drugs
Rabies vaccine im,90675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,315.22,,,,,,,fee schedule,315.22,570.14,Other Pharmacy
Rabies vaccine im,90675,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,330.98,,,,,,,fee schedule,315.22,570.14,APC
Rabies vaccine im,90675,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,327.83,,,,,,,fee schedule,315.22,570.14,APC
Rabies vaccine im,90675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,482.29,,,,,,,fee schedule,315.22,570.14,Radiology
Rabies vaccine im,90675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,441.31,,,,,,,fee schedule,315.22,570.14,APC
Rabies vaccine im,90675,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,551.63,,,,,,,fee schedule,315.22,570.14,APC
Rabies vaccine id,90676,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,465.58,,,,,,,fee schedule,236.86,1050.87,
Rabies vaccine id,90676,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,373.21,,,,,,,fee schedule,236.86,1050.87,
Rabies vaccine id,90676,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,407.69,,,,,,,fee schedule,236.86,1050.87,
Rabies vaccine id,90676,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,428.63,,,,,,,fee schedule,236.86,1050.87,
Rabies vaccine id,90676,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1050.87,,,,,,,fee schedule,236.86,1050.87,APC 378
Rabies vaccine id,90676,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.7,,,,,,,fee schedule,236.86,1050.87,APC
Rabies vaccine id,90676,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,246.33,,,,,,,fee schedule,236.86,1050.87,APC
Rabies vaccine id,90676,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.86,,,,,,,fee schedule,236.86,1050.87,APC
Rabies vaccine id,90676,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,362.4,,,,,,,fee schedule,236.86,1050.87,Radiology
Rabies vaccine id,90676,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,331.6,,,,,,,fee schedule,236.86,1050.87,APC
Rabies vaccine id,90676,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,414.5,,,,,,,fee schedule,236.86,1050.87,APC
Iiv4 vacc no prsv 0.25 ml im,90685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,90.34,,,,,,,fee schedule,72.42,90.34,
Iiv4 vacc no prsv 0.25 ml im,90685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,72.42,,,,,,,fee schedule,72.42,90.34,
Iiv4 vacc no prsv 0.25 ml im,90685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,79.11,,,,,,,fee schedule,72.42,90.34,
Iiv4 vacc no prsv 0.25 ml im,90685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83.17,,,,,,,fee schedule,72.42,90.34,
Iiv4 vacc no prsv 0.5 ml im,90686,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,67.96,,,,,,,fee schedule,54.48,67.96,
Iiv4 vacc no prsv 0.5 ml im,90686,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,54.48,,,,,,,fee schedule,54.48,67.96,
Iiv4 vacc no prsv 0.5 ml im,90686,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,59.51,,,,,,,fee schedule,54.48,67.96,
Iiv4 vacc no prsv 0.5 ml im,90686,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,62.57,,,,,,,fee schedule,54.48,67.96,
Iiv4 vaccine splt 0.25 ml im,90687,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,34.51,,,,,,,fee schedule,27.66,34.51,
Iiv4 vaccine splt 0.25 ml im,90687,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,27.66,,,,,,,fee schedule,27.66,34.51,
Iiv4 vaccine splt 0.25 ml im,90687,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,30.22,,,,,,,fee schedule,27.66,34.51,
Iiv4 vaccine splt 0.25 ml im,90687,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,31.77,,,,,,,fee schedule,27.66,34.51,
Iiv4 vaccine splt 0.5 ml im,90688,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,63.66,,,,,,,fee schedule,51.03,63.66,
Iiv4 vaccine splt 0.5 ml im,90688,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.03,,,,,,,fee schedule,51.03,63.66,
Iiv4 vaccine splt 0.5 ml im,90688,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55.74,,,,,,,fee schedule,51.03,63.66,
Iiv4 vaccine splt 0.5 ml im,90688,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,58.6,,,,,,,fee schedule,51.03,63.66,
Mmrv vaccine sc,90710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,604.8,,,,,,,fee schedule,484.8,604.8,
Mmrv vaccine sc,90710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,484.8,,,,,,,fee schedule,484.8,604.8,
Mmrv vaccine sc,90710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,529.6,,,,,,,fee schedule,484.8,604.8,
Mmrv vaccine sc,90710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,556.8,,,,,,,fee schedule,484.8,604.8,
Var vaccine live subq,90716,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,292.65,,,,,,,fee schedule,234.58,292.65,
Var vaccine live subq,90716,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,234.58,,,,,,,fee schedule,234.58,292.65,
Var vaccine live subq,90716,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,256.26,,,,,,,fee schedule,234.58,292.65,
Var vaccine live subq,90716,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,269.42,,,,,,,fee schedule,234.58,292.65,
Ppsv23 vacc 2 yrs+ subq/im,90732,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,123.61,,,,,,,fee schedule,99.08,123.61,
Ppsv23 vacc 2 yrs+ subq/im,90732,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,99.08,,,,,,,fee schedule,99.08,123.61,
Ppsv23 vacc 2 yrs+ subq/im,90732,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,108.24,,,,,,,fee schedule,99.08,123.61,
Ppsv23 vacc 2 yrs+ subq/im,90732,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,113.8,,,,,,,fee schedule,99.08,123.61,
Mpsv4 vaccine subq,90733,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,364.32,,,,,,,fee schedule,292.03,364.32,
Mpsv4 vaccine subq,90733,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,292.03,,,,,,,fee schedule,292.03,364.32,
Mpsv4 vaccine subq,90733,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,319.02,,,,,,,fee schedule,292.03,364.32,
Mpsv4 vaccine subq,90733,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,335.4,,,,,,,fee schedule,292.03,364.32,
Mcv4 menacwy vaccine im,90734,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,318.28,,,,,,,fee schedule,255.13,318.28,
Mcv4 menacwy vaccine im,90734,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,255.13,,,,,,,fee schedule,255.13,318.28,
Mcv4 menacwy vaccine im,90734,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,278.7,,,,,,,fee schedule,255.13,318.28,
Mcv4 menacwy vaccine im,90734,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,293.02,,,,,,,fee schedule,255.13,318.28,
Hepb vacc 3 dose immunsup im,90740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,451.41,,,,,,,fee schedule,361.84,451.41,
Hepb vacc 3 dose immunsup im,90740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,361.84,,,,,,,fee schedule,361.84,451.41,
Hepb vacc 3 dose immunsup im,90740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,395.28,,,,,,,fee schedule,361.84,451.41,
Hepb vacc 3 dose immunsup im,90740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,415.58,,,,,,,fee schedule,361.84,451.41,
Hepb vacc 2 dose adolesc im,90743,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,91.55,,,,,,,fee schedule,73.39,91.55,
Hepb vacc 2 dose adolesc im,90743,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,73.39,,,,,,,fee schedule,73.39,91.55,
Hepb vacc 2 dose adolesc im,90743,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,80.17,,,,,,,fee schedule,73.39,91.55,
Hepb vacc 2 dose adolesc im,90743,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,84.29,,,,,,,fee schedule,73.39,91.55,
Hepb vacc 3 dose ped/adol im,90744,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,91.55,,,,,,,fee schedule,73.39,91.55,
Hepb vacc 3 dose ped/adol im,90744,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,73.39,,,,,,,fee schedule,73.39,91.55,
Hepb vacc 3 dose ped/adol im,90744,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,80.17,,,,,,,fee schedule,73.39,91.55,
Hepb vacc 3 dose ped/adol im,90744,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,84.29,,,,,,,fee schedule,73.39,91.55,
Hepb vaccine 3 dose adult im,90746,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,225.7,,,,,,,fee schedule,180.92,225.7,
Hepb vaccine 3 dose adult im,90746,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,180.92,,,,,,,fee schedule,180.92,225.7,
Hepb vaccine 3 dose adult im,90746,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,197.64,,,,,,,fee schedule,180.92,225.7,
Hepb vaccine 3 dose adult im,90746,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,207.79,,,,,,,fee schedule,180.92,225.7,
Hepb vacc 4 dose immunsup im,90747,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,451.41,,,,,,,fee schedule,361.84,451.41,
Hepb vacc 4 dose immunsup im,90747,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,361.84,,,,,,,fee schedule,361.84,451.41,
Hepb vacc 4 dose immunsup im,90747,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,395.28,,,,,,,fee schedule,361.84,451.41,
Hepb vacc 4 dose immunsup im,90747,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,415.58,,,,,,,fee schedule,361.84,451.41,
Psytx complex interactive,90785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17.8,,,,,,,fee schedule,14.27,17.8,
Psytx complex interactive,90785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14.27,,,,,,,fee schedule,14.27,17.8,
Psytx complex interactive,90785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15.59,,,,,,,fee schedule,14.27,17.8,
Psytx complex interactive,90785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16.39,,,,,,,fee schedule,14.27,17.8,
Psych diagnostic evaluation,90791,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,416.4,,,,,,,fee schedule,175.71,779.59,
Psych diagnostic evaluation,90791,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,333.78,,,,,,,fee schedule,175.71,779.59,
Psych diagnostic evaluation,90791,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,364.63,,,,,,,fee schedule,175.71,779.59,
Psych diagnostic evaluation,90791,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,383.36,,,,,,,fee schedule,175.71,779.59,
Psych diagnostic evaluation,90791,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,779.59,,,,,,,fee schedule,175.71,779.59,APC 378
Psych diagnostic evaluation,90791,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,184.5,,,,,,,fee schedule,175.71,779.59,APC
Psych diagnostic evaluation,90791,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,182.74,,,,,,,fee schedule,175.71,779.59,APC
Psych diagnostic evaluation,90791,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,175.71,,,,,,,fee schedule,175.71,779.59,APC
Psych diagnostic evaluation,90791,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,268.84,,,,,,,fee schedule,175.71,779.59,Radiology
Psych diagnostic evaluation,90791,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,246,,,,,,,fee schedule,175.71,779.59,APC
Psych diagnostic evaluation,90791,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,307.5,,,,,,,fee schedule,175.71,779.59,APC
Psych diag eval w/med srvcs,90792,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,416.4,,,,,,,fee schedule,175.71,779.59,
Psych diag eval w/med srvcs,90792,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,333.78,,,,,,,fee schedule,175.71,779.59,
Psych diag eval w/med srvcs,90792,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,364.63,,,,,,,fee schedule,175.71,779.59,
Psych diag eval w/med srvcs,90792,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,383.36,,,,,,,fee schedule,175.71,779.59,
Psych diag eval w/med srvcs,90792,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,779.59,,,,,,,fee schedule,175.71,779.59,APC 378
Psych diag eval w/med srvcs,90792,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,184.5,,,,,,,fee schedule,175.71,779.59,APC
Psych diag eval w/med srvcs,90792,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,182.74,,,,,,,fee schedule,175.71,779.59,APC
Psych diag eval w/med srvcs,90792,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,175.71,,,,,,,fee schedule,175.71,779.59,APC
Psych diag eval w/med srvcs,90792,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,268.84,,,,,,,fee schedule,175.71,779.59,Radiology
Psych diag eval w/med srvcs,90792,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,246,,,,,,,fee schedule,175.71,779.59,APC
Psych diag eval w/med srvcs,90792,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,307.5,,,,,,,fee schedule,175.71,779.59,APC
Psytx w pt 30 minutes,90832,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,313.21,,,,,,,fee schedule,175.71,779.59,
Psytx w pt 30 minutes,90832,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,251.07,,,,,,,fee schedule,175.71,779.59,
Psytx w pt 30 minutes,90832,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,274.27,,,,,,,fee schedule,175.71,779.59,
Psytx w pt 30 minutes,90832,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,288.35,,,,,,,fee schedule,175.71,779.59,
Psytx w pt 30 minutes,90832,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,779.59,,,,,,,fee schedule,175.71,779.59,APC 378
Psytx w pt 30 minutes,90832,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,184.5,,,,,,,fee schedule,175.71,779.59,APC
Psytx w pt 30 minutes,90832,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,182.74,,,,,,,fee schedule,175.71,779.59,APC
Psytx w pt 30 minutes,90832,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,175.71,,,,,,,fee schedule,175.71,779.59,APC
Psytx w pt 30 minutes,90832,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,268.84,,,,,,,fee schedule,175.71,779.59,Radiology
Psytx w pt 30 minutes,90832,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,246,,,,,,,fee schedule,175.71,779.59,APC
Psytx w pt 30 minutes,90832,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,307.5,,,,,,,fee schedule,175.71,779.59,APC
Psytx w pt w e/m 30 min,90833,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,153.54,,,,,,,fee schedule,123.08,153.54,
Psytx w pt w e/m 30 min,90833,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,123.08,,,,,,,fee schedule,123.08,153.54,
Psytx w pt w e/m 30 min,90833,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,134.45,,,,,,,fee schedule,123.08,153.54,
Psytx w pt w e/m 30 min,90833,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,141.36,,,,,,,fee schedule,123.08,153.54,
Psytx w pt 45 minutes,90834,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,416.4,,,,,,,fee schedule,175.71,779.59,
Psytx w pt 45 minutes,90834,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,333.78,,,,,,,fee schedule,175.71,779.59,
Psytx w pt 45 minutes,90834,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,364.63,,,,,,,fee schedule,175.71,779.59,
Psytx w pt 45 minutes,90834,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,383.36,,,,,,,fee schedule,175.71,779.59,
Psytx w pt 45 minutes,90834,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,779.59,,,,,,,fee schedule,175.71,779.59,APC 378
Psytx w pt 45 minutes,90834,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,184.5,,,,,,,fee schedule,175.71,779.59,APC
Psytx w pt 45 minutes,90834,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,182.74,,,,,,,fee schedule,175.71,779.59,APC
Psytx w pt 45 minutes,90834,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,175.71,,,,,,,fee schedule,175.71,779.59,APC
Psytx w pt 45 minutes,90834,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,268.84,,,,,,,fee schedule,175.71,779.59,Radiology
Psytx w pt 45 minutes,90834,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,246,,,,,,,fee schedule,175.71,779.59,APC
Psytx w pt 45 minutes,90834,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,307.5,,,,,,,fee schedule,175.71,779.59,APC
Psytx w pt w e/m 45 min,90836,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,251.14,,,,,,,fee schedule,201.31,251.14,
Psytx w pt w e/m 45 min,90836,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,201.31,,,,,,,fee schedule,201.31,251.14,
Psytx w pt w e/m 45 min,90836,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,219.92,,,,,,,fee schedule,201.31,251.14,
Psytx w pt w e/m 45 min,90836,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,231.21,,,,,,,fee schedule,201.31,251.14,
Psytx w pt 60 minutes,90837,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,416.4,,,,,,,fee schedule,175.71,779.59,
Psytx w pt 60 minutes,90837,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,333.78,,,,,,,fee schedule,175.71,779.59,
Psytx w pt 60 minutes,90837,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,364.63,,,,,,,fee schedule,175.71,779.59,
Psytx w pt 60 minutes,90837,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,383.36,,,,,,,fee schedule,175.71,779.59,
Psytx w pt 60 minutes,90837,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,779.59,,,,,,,fee schedule,175.71,779.59,APC 378
Psytx w pt 60 minutes,90837,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,184.5,,,,,,,fee schedule,175.71,779.59,APC
Psytx w pt 60 minutes,90837,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,182.74,,,,,,,fee schedule,175.71,779.59,APC
Psytx w pt 60 minutes,90837,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,175.71,,,,,,,fee schedule,175.71,779.59,APC
Psytx w pt 60 minutes,90837,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,268.84,,,,,,,fee schedule,175.71,779.59,Radiology
Psytx w pt 60 minutes,90837,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,246,,,,,,,fee schedule,175.71,779.59,APC
Psytx w pt 60 minutes,90837,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,307.5,,,,,,,fee schedule,175.71,779.59,APC
Psytx w pt w e/m 60 min,90838,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,403.33,,,,,,,fee schedule,323.3,403.33,
Psytx w pt w e/m 60 min,90838,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,323.3,,,,,,,fee schedule,323.3,403.33,
Psytx w pt w e/m 60 min,90838,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.18,,,,,,,fee schedule,323.3,403.33,
Psytx w pt w e/m 60 min,90838,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,371.32,,,,,,,fee schedule,323.3,403.33,
Psytx crisis initial 60 min,90839,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,416.4,,,,,,,fee schedule,175.71,779.59,
Psytx crisis initial 60 min,90839,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,333.78,,,,,,,fee schedule,175.71,779.59,
Psytx crisis initial 60 min,90839,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,364.63,,,,,,,fee schedule,175.71,779.59,
Psytx crisis initial 60 min,90839,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,383.36,,,,,,,fee schedule,175.71,779.59,
Psytx crisis initial 60 min,90839,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,779.59,,,,,,,fee schedule,175.71,779.59,APC 378
Psytx crisis initial 60 min,90839,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,184.5,,,,,,,fee schedule,175.71,779.59,APC
Psytx crisis initial 60 min,90839,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,182.74,,,,,,,fee schedule,175.71,779.59,APC
Psytx crisis initial 60 min,90839,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,175.71,,,,,,,fee schedule,175.71,779.59,APC
Psytx crisis initial 60 min,90839,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,268.84,,,,,,,fee schedule,175.71,779.59,Radiology
Psytx crisis initial 60 min,90839,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,246,,,,,,,fee schedule,175.71,779.59,APC
Psytx crisis initial 60 min,90839,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,307.5,,,,,,,fee schedule,175.71,779.59,APC
Psytx crisis ea addl 30 min,90840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,237.91,,,,,,,fee schedule,190.71,237.91,
Psytx crisis ea addl 30 min,90840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,190.71,,,,,,,fee schedule,190.71,237.91,
Psytx crisis ea addl 30 min,90840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,208.33,,,,,,,fee schedule,190.71,237.91,
Psytx crisis ea addl 30 min,90840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,219.03,,,,,,,fee schedule,190.71,237.91,
Psychoanalysis,90845,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,400.42,,,,,,,fee schedule,175.71,779.59,
Psychoanalysis,90845,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,320.97,,,,,,,fee schedule,175.71,779.59,
Psychoanalysis,90845,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,350.63,,,,,,,fee schedule,175.71,779.59,
Psychoanalysis,90845,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,368.64,,,,,,,fee schedule,175.71,779.59,
Psychoanalysis,90845,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,779.59,,,,,,,fee schedule,175.71,779.59,APC 378
Psychoanalysis,90845,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,184.5,,,,,,,fee schedule,175.71,779.59,APC
Psychoanalysis,90845,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,182.74,,,,,,,fee schedule,175.71,779.59,APC
Psychoanalysis,90845,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,175.71,,,,,,,fee schedule,175.71,779.59,APC
Psychoanalysis,90845,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,268.84,,,,,,,fee schedule,175.71,779.59,Radiology
Psychoanalysis,90845,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,246,,,,,,,fee schedule,175.71,779.59,APC
Psychoanalysis,90845,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,307.5,,,,,,,fee schedule,175.71,779.59,APC
Family psytx w/o pt 50 min,90846,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,589.42,,,,,,,fee schedule,175.71,779.59,
Family psytx w/o pt 50 min,90846,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,472.47,,,,,,,fee schedule,175.71,779.59,
Family psytx w/o pt 50 min,90846,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,516.13,,,,,,,fee schedule,175.71,779.59,
Family psytx w/o pt 50 min,90846,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,542.64,,,,,,,fee schedule,175.71,779.59,
Family psytx w/o pt 50 min,90846,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,779.59,,,,,,,fee schedule,175.71,779.59,APC 378
Family psytx w/o pt 50 min,90846,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,184.5,,,,,,,fee schedule,175.71,779.59,APC
Family psytx w/o pt 50 min,90846,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,182.74,,,,,,,fee schedule,175.71,779.59,APC
Family psytx w/o pt 50 min,90846,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,175.71,,,,,,,fee schedule,175.71,779.59,APC
Family psytx w/o pt 50 min,90846,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,268.84,,,,,,,fee schedule,175.71,779.59,Radiology
Family psytx w/o pt 50 min,90846,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,246,,,,,,,fee schedule,175.71,779.59,APC
Family psytx w/o pt 50 min,90846,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,307.5,,,,,,,fee schedule,175.71,779.59,APC
Family psytx w/pt 50 min,90847,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,589.42,,,,,,,fee schedule,175.71,779.59,
Family psytx w/pt 50 min,90847,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,472.47,,,,,,,fee schedule,175.71,779.59,
Family psytx w/pt 50 min,90847,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,516.13,,,,,,,fee schedule,175.71,779.59,
Family psytx w/pt 50 min,90847,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,542.64,,,,,,,fee schedule,175.71,779.59,
Family psytx w/pt 50 min,90847,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,779.59,,,,,,,fee schedule,175.71,779.59,APC 378
Family psytx w/pt 50 min,90847,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,184.5,,,,,,,fee schedule,175.71,779.59,APC
Family psytx w/pt 50 min,90847,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,182.74,,,,,,,fee schedule,175.71,779.59,APC
Family psytx w/pt 50 min,90847,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,175.71,,,,,,,fee schedule,175.71,779.59,APC
Family psytx w/pt 50 min,90847,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,268.84,,,,,,,fee schedule,175.71,779.59,Radiology
Family psytx w/pt 50 min,90847,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,246,,,,,,,fee schedule,175.71,779.59,APC
Family psytx w/pt 50 min,90847,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,307.5,,,,,,,fee schedule,175.71,779.59,APC
Multiple family group psytx,90849,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,247.4,,,,,,,fee schedule,175.71,779.59,
Multiple family group psytx,90849,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,198.31,,,,,,,fee schedule,175.71,779.59,
Multiple family group psytx,90849,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,216.64,,,,,,,fee schedule,175.71,779.59,
Multiple family group psytx,90849,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,227.77,,,,,,,fee schedule,175.71,779.59,
Multiple family group psytx,90849,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,779.59,,,,,,,fee schedule,175.71,779.59,APC 378
Multiple family group psytx,90849,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,184.5,,,,,,,fee schedule,175.71,779.59,APC
Multiple family group psytx,90849,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,182.74,,,,,,,fee schedule,175.71,779.59,APC
Multiple family group psytx,90849,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,175.71,,,,,,,fee schedule,175.71,779.59,APC
Multiple family group psytx,90849,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,268.84,,,,,,,fee schedule,175.71,779.59,Radiology
Multiple family group psytx,90849,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,246,,,,,,,fee schedule,175.71,779.59,APC
Multiple family group psytx,90849,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,307.5,,,,,,,fee schedule,175.71,779.59,APC
Group psychotherapy,90853,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,247.4,,,,,,,fee schedule,100.57,446.2,
Group psychotherapy,90853,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,198.31,,,,,,,fee schedule,100.57,446.2,
Group psychotherapy,90853,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,216.64,,,,,,,fee schedule,100.57,446.2,
Group psychotherapy,90853,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,227.77,,,,,,,fee schedule,100.57,446.2,
Group psychotherapy,90853,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,446.2,,,,,,,fee schedule,100.57,446.2,APC 378
Group psychotherapy,90853,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,105.6,,,,,,,fee schedule,100.57,446.2,APC
Group psychotherapy,90853,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,104.59,,,,,,,fee schedule,100.57,446.2,APC
Group psychotherapy,90853,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,100.57,,,,,,,fee schedule,100.57,446.2,APC
Group psychotherapy,90853,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,153.87,,,,,,,fee schedule,100.57,446.2,Radiology
Group psychotherapy,90853,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,140.8,,,,,,,fee schedule,100.57,446.2,APC
Group psychotherapy,90853,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,176,,,,,,,fee schedule,100.57,446.2,APC
Narcosynthesis,90865,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,400.42,,,,,,,fee schedule,175.71,779.59,
Narcosynthesis,90865,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,320.97,,,,,,,fee schedule,175.71,779.59,
Narcosynthesis,90865,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,350.63,,,,,,,fee schedule,175.71,779.59,
Narcosynthesis,90865,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,368.64,,,,,,,fee schedule,175.71,779.59,
Narcosynthesis,90865,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,779.59,,,,,,,fee schedule,175.71,779.59,APC 378
Narcosynthesis,90865,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,184.5,,,,,,,fee schedule,175.71,779.59,APC
Narcosynthesis,90865,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,182.74,,,,,,,fee schedule,175.71,779.59,APC
Narcosynthesis,90865,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,175.71,,,,,,,fee schedule,175.71,779.59,APC
Narcosynthesis,90865,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,268.84,,,,,,,fee schedule,175.71,779.59,Radiology
Narcosynthesis,90865,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,246,,,,,,,fee schedule,175.71,779.59,APC
Narcosynthesis,90865,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,307.5,,,,,,,fee schedule,175.71,779.59,APC
Tcranial magn stim tx plan,90867,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,703.72,,,,,,,fee schedule,213.76,948.37,
Tcranial magn stim tx plan,90867,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,564.1,,,,,,,fee schedule,213.76,948.37,
Tcranial magn stim tx plan,90867,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,616.22,,,,,,,fee schedule,213.76,948.37,
Tcranial magn stim tx plan,90867,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,647.87,,,,,,,fee schedule,213.76,948.37,
Tcranial magn stim tx plan,90867,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,213.76,948.37,APC 378
Tcranial magn stim tx plan,90867,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,213.76,948.37,APC
Tcranial magn stim tx plan,90867,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,213.76,948.37,APC
Tcranial magn stim tx plan,90867,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,213.76,948.37,APC
Tcranial magn stim tx plan,90867,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,213.76,948.37,Radiology
Tcranial magn stim tx plan,90867,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,213.76,948.37,APC
Tcranial magn stim tx plan,90867,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,213.76,948.37,APC
Tcranial magn stim tx deli,90868,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,703.72,,,,,,,fee schedule,213.76,948.37,
Tcranial magn stim tx deli,90868,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,564.1,,,,,,,fee schedule,213.76,948.37,
Tcranial magn stim tx deli,90868,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,616.22,,,,,,,fee schedule,213.76,948.37,
Tcranial magn stim tx deli,90868,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,647.87,,,,,,,fee schedule,213.76,948.37,
Tcranial magn stim tx deli,90868,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,213.76,948.37,APC 378
Tcranial magn stim tx deli,90868,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,213.76,948.37,APC
Tcranial magn stim tx deli,90868,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,213.76,948.37,APC
Tcranial magn stim tx deli,90868,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,213.76,948.37,APC
Tcranial magn stim tx deli,90868,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,213.76,948.37,Radiology
Tcranial magn stim tx deli,90868,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,213.76,948.37,APC
Tcranial magn stim tx deli,90868,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,213.76,948.37,APC
Tcran magn stim redetemine,90869,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,695.6,,,,,,,fee schedule,213.76,948.37,
Tcran magn stim redetemine,90869,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,557.58,,,,,,,fee schedule,213.76,948.37,
Tcran magn stim redetemine,90869,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,609.11,,,,,,,fee schedule,213.76,948.37,
Tcran magn stim redetemine,90869,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,640.39,,,,,,,fee schedule,213.76,948.37,
Tcran magn stim redetemine,90869,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,213.76,948.37,APC 378
Tcran magn stim redetemine,90869,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,213.76,948.37,APC
Tcran magn stim redetemine,90869,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,213.76,948.37,APC
Tcran magn stim redetemine,90869,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,213.76,948.37,APC
Tcran magn stim redetemine,90869,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,213.76,948.37,Radiology
Tcran magn stim redetemine,90869,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,213.76,948.37,APC
Tcran magn stim redetemine,90869,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,213.76,948.37,APC
Electroconvulsive therapy,90870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1430.05,,,,,,,fee schedule,850.12,3771.72,
Electroconvulsive therapy,90870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1146.31,,,,,,,fee schedule,850.12,3771.72,
Electroconvulsive therapy,90870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1252.24,,,,,,,fee schedule,850.12,3771.72,
Electroconvulsive therapy,90870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1316.55,,,,,,,fee schedule,850.12,3771.72,
Electroconvulsive therapy,90870,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3771.72,,,,,,,fee schedule,850.12,3771.72,APC 378
Electroconvulsive therapy,90870,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,892.63,,,,,,,fee schedule,850.12,3771.72,APC
Electroconvulsive therapy,90870,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,884.13,,,,,,,fee schedule,850.12,3771.72,APC
Electroconvulsive therapy,90870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,850.12,,,,,,,fee schedule,850.12,3771.72,APC
Electroconvulsive therapy,90870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1300.69,,,,,,,fee schedule,850.12,3771.72,Radiology
Electroconvulsive therapy,90870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1190.17,,,,,,,fee schedule,850.12,3771.72,APC
Electroconvulsive therapy,90870,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1487.72,,,,,,,fee schedule,850.12,3771.72,APC
Hypnotherapy,90880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,400.42,,,,,,,fee schedule,100.57,446.2,
Hypnotherapy,90880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,320.97,,,,,,,fee schedule,100.57,446.2,
Hypnotherapy,90880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,350.63,,,,,,,fee schedule,100.57,446.2,
Hypnotherapy,90880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,368.64,,,,,,,fee schedule,100.57,446.2,
Hypnotherapy,90880,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,446.2,,,,,,,fee schedule,100.57,446.2,APC 378
Hypnotherapy,90880,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,105.6,,,,,,,fee schedule,100.57,446.2,APC
Hypnotherapy,90880,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,104.59,,,,,,,fee schedule,100.57,446.2,APC
Hypnotherapy,90880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,100.57,,,,,,,fee schedule,100.57,446.2,APC
Hypnotherapy,90880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,153.87,,,,,,,fee schedule,100.57,446.2,Radiology
Hypnotherapy,90880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,140.8,,,,,,,fee schedule,100.57,446.2,APC
Hypnotherapy,90880,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,176,,,,,,,fee schedule,100.57,446.2,APC
Psychiatric service/therapy,90899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,292.72,,,,,,,fee schedule,37.09,292.72,
Psychiatric service/therapy,90899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,234.64,,,,,,,fee schedule,37.09,292.72,
Psychiatric service/therapy,90899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,256.33,,,,,,,fee schedule,37.09,292.72,
Psychiatric service/therapy,90899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,269.49,,,,,,,fee schedule,37.09,292.72,
Psychiatric service/therapy,90899,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.57,,,,,,,fee schedule,37.09,292.72,APC 378
Psychiatric service/therapy,90899,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.95,,,,,,,fee schedule,37.09,292.72,APC
Psychiatric service/therapy,90899,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.58,,,,,,,fee schedule,37.09,292.72,APC
Psychiatric service/therapy,90899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,37.09,,,,,,,fee schedule,37.09,292.72,APC
Psychiatric service/therapy,90899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.75,,,,,,,fee schedule,37.09,292.72,Radiology
Psychiatric service/therapy,90899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.93,,,,,,,fee schedule,37.09,292.72,APC
Psychiatric service/therapy,90899,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.91,,,,,,,fee schedule,37.09,292.72,APC
Biofeedback train any meth,90901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,73.45,,,,,,,fee schedule,16.24,73.45,
Biofeedback train any meth,90901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,58.87,,,,,,,fee schedule,16.24,73.45,
Biofeedback train any meth,90901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,64.31,,,,,,,fee schedule,16.24,73.45,
Biofeedback train any meth,90901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,67.62,,,,,,,fee schedule,16.24,73.45,
Biofeedback train any meth,90901,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.24,,,,,,,fee schedule,16.24,73.45,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Biofeedback train any meth,90901,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.05,,,,,,,fee schedule,16.24,73.45,APC
Biofeedback train any meth,90901,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,16.89,,,,,,,fee schedule,16.24,73.45,APC
Biofeedback train any meth,90901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24.85,,,,,,,fee schedule,16.24,73.45,Radiology
Biofeedback train any meth,90901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.74,,,,,,,fee schedule,16.24,73.45,APC
Biofeedback train any meth,90901,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,28.42,,,,,,,fee schedule,16.24,73.45,APC
Bfb training 1st 15 min,90912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,168.17,,,,,,,fee schedule,37.27,168.17,
Bfb training 1st 15 min,90912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,134.8,,,,,,,fee schedule,37.27,168.17,
Bfb training 1st 15 min,90912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,147.26,,,,,,,fee schedule,37.27,168.17,
Bfb training 1st 15 min,90912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,154.83,,,,,,,fee schedule,37.27,168.17,
Bfb training 1st 15 min,90912,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,37.27,,,,,,,fee schedule,37.27,168.17,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Bfb training 1st 15 min,90912,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.13,,,,,,,fee schedule,37.27,168.17,APC
Bfb training 1st 15 min,90912,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.76,,,,,,,fee schedule,37.27,168.17,APC
Bfb training 1st 15 min,90912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,57.02,,,,,,,fee schedule,37.27,168.17,Radiology
Bfb training 1st 15 min,90912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,52.18,,,,,,,fee schedule,37.27,168.17,APC
Bfb training 1st 15 min,90912,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,65.22,,,,,,,fee schedule,37.27,168.17,APC
Bfb training ea addl 15 min,90913,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,93.52,,,,,,,fee schedule,20.97,93.52,
Bfb training ea addl 15 min,90913,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,74.96,,,,,,,fee schedule,20.97,93.52,
Bfb training ea addl 15 min,90913,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,81.89,,,,,,,fee schedule,20.97,93.52,
Bfb training ea addl 15 min,90913,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,86.1,,,,,,,fee schedule,20.97,93.52,
Bfb training ea addl 15 min,90913,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,20.97,,,,,,,fee schedule,20.97,93.52,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Bfb training ea addl 15 min,90913,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,22.02,,,,,,,fee schedule,20.97,93.52,APC
Bfb training ea addl 15 min,90913,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,21.81,,,,,,,fee schedule,20.97,93.52,APC
Bfb training ea addl 15 min,90913,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,32.08,,,,,,,fee schedule,20.97,93.52,Radiology
Bfb training ea addl 15 min,90913,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29.36,,,,,,,fee schedule,20.97,93.52,APC
Bfb training ea addl 15 min,90913,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,36.7,,,,,,,fee schedule,20.97,93.52,APC
Hemodialysis one evaluation,90935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1631.79,,,,,,,fee schedule,679.43,3014.4,
Hemodialysis one evaluation,90935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1308.02,,,,,,,fee schedule,679.43,3014.4,
Hemodialysis one evaluation,90935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1428.89,,,,,,,fee schedule,679.43,3014.4,
Hemodialysis one evaluation,90935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1502.28,,,,,,,fee schedule,679.43,3014.4,
Hemodialysis one evaluation,90935,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3014.4,,,,,,,fee schedule,679.43,3014.4,APC 378
Hemodialysis one evaluation,90935,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,713.4,,,,,,,fee schedule,679.43,3014.4,APC
Hemodialysis one evaluation,90935,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,706.61,,,,,,,fee schedule,679.43,3014.4,APC
Hemodialysis one evaluation,90935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,679.43,,,,,,,fee schedule,679.43,3014.4,APC
Hemodialysis one evaluation,90935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1039.53,,,,,,,fee schedule,679.43,3014.4,Radiology
Hemodialysis one evaluation,90935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,951.2,,,,,,,fee schedule,679.43,3014.4,APC
Hemodialysis one evaluation,90935,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1189,,,,,,,fee schedule,679.43,3014.4,APC
Hemodialysis repeated eval,90937,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,400.04,,,,,,,fee schedule,320.66,400.04,
Hemodialysis repeated eval,90937,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,320.66,,,,,,,fee schedule,320.66,400.04,
Hemodialysis repeated eval,90937,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,350.3,,,,,,,fee schedule,320.66,400.04,
Hemodialysis repeated eval,90937,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,368.29,,,,,,,fee schedule,320.66,400.04,
Dialysis one evaluation,90945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1631.79,,,,,,,fee schedule,413.08,1832.68,
Dialysis one evaluation,90945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1308.02,,,,,,,fee schedule,413.08,1832.68,
Dialysis one evaluation,90945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1428.89,,,,,,,fee schedule,413.08,1832.68,
Dialysis one evaluation,90945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1502.28,,,,,,,fee schedule,413.08,1832.68,
Dialysis one evaluation,90945,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1832.68,,,,,,,fee schedule,413.08,1832.68,APC 378
Dialysis one evaluation,90945,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,433.73,,,,,,,fee schedule,413.08,1832.68,APC
Dialysis one evaluation,90945,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,429.6,,,,,,,fee schedule,413.08,1832.68,APC
Dialysis one evaluation,90945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,413.08,,,,,,,fee schedule,413.08,1832.68,APC
Dialysis one evaluation,90945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,632.01,,,,,,,fee schedule,413.08,1832.68,Radiology
Dialysis one evaluation,90945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,578.31,,,,,,,fee schedule,413.08,1832.68,APC
Dialysis one evaluation,90945,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,722.88,,,,,,,fee schedule,413.08,1832.68,APC
Dialysis repeated eval,90947,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,409.3,,,,,,,fee schedule,328.09,409.3,
Dialysis repeated eval,90947,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,328.09,,,,,,,fee schedule,328.09,409.3,
Dialysis repeated eval,90947,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,358.41,,,,,,,fee schedule,328.09,409.3,
Dialysis repeated eval,90947,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,376.81,,,,,,,fee schedule,328.09,409.3,
Esrd serv 4 visits p mo <2yr,90951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3529.99,,,,,,,fee schedule,2829.6,3529.99,
Esrd serv 4 visits p mo <2yr,90951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2829.6,,,,,,,fee schedule,2829.6,3529.99,
Esrd serv 4 visits p mo <2yr,90951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3091.08,,,,,,,fee schedule,2829.6,3529.99,
Esrd serv 4 visits p mo <2yr,90951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3249.83,,,,,,,fee schedule,2829.6,3529.99,
Esrd serv 2-3 vsts p mo <2yr,90952,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2560.76,,,,,,,fee schedule,2052.67,2560.76,
Esrd serv 2-3 vsts p mo <2yr,90952,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2052.67,,,,,,,fee schedule,2052.67,2560.76,
Esrd serv 2-3 vsts p mo <2yr,90952,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2242.36,,,,,,,fee schedule,2052.67,2560.76,
Esrd serv 2-3 vsts p mo <2yr,90952,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2357.53,,,,,,,fee schedule,2052.67,2560.76,
Esrd serv 1 visit p mo <2yrs,90953,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1705.91,,,,,,,fee schedule,1367.44,1705.91,
Esrd serv 1 visit p mo <2yrs,90953,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1367.44,,,,,,,fee schedule,1367.44,1705.91,
Esrd serv 1 visit p mo <2yrs,90953,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1493.8,,,,,,,fee schedule,1367.44,1705.91,
Esrd serv 1 visit p mo <2yrs,90953,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1570.52,,,,,,,fee schedule,1367.44,1705.91,
Esrd serv 4 vsts p mo 2-11,90954,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2906.56,,,,,,,fee schedule,2329.86,2906.56,
Esrd serv 4 vsts p mo 2-11,90954,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2329.86,,,,,,,fee schedule,2329.86,2906.56,
Esrd serv 4 vsts p mo 2-11,90954,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2545.16,,,,,,,fee schedule,2329.86,2906.56,
Esrd serv 4 vsts p mo 2-11,90954,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2675.88,,,,,,,fee schedule,2329.86,2906.56,
Esrd srv 2-3 vsts p mo 2-11,90955,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1643.88,,,,,,,fee schedule,1317.72,1643.88,
Esrd srv 2-3 vsts p mo 2-11,90955,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1317.72,,,,,,,fee schedule,1317.72,1643.88,
Esrd srv 2-3 vsts p mo 2-11,90955,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1439.49,,,,,,,fee schedule,1317.72,1643.88,
Esrd srv 2-3 vsts p mo 2-11,90955,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1513.42,,,,,,,fee schedule,1317.72,1643.88,
Esrd srv 1 visit p mo 2-11,90956,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1112.83,,,,,,,fee schedule,892.03,1112.83,
Esrd srv 1 visit p mo 2-11,90956,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,892.03,,,,,,,fee schedule,892.03,1112.83,
Esrd srv 1 visit p mo 2-11,90956,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,974.46,,,,,,,fee schedule,892.03,1112.83,
Esrd srv 1 visit p mo 2-11,90956,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1024.51,,,,,,,fee schedule,892.03,1112.83,
Esrd srv 4 vsts p mo 12-19,90957,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2328.71,,,,,,,fee schedule,1866.66,2328.71,
Esrd srv 4 vsts p mo 12-19,90957,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1866.66,,,,,,,fee schedule,1866.66,2328.71,
Esrd srv 4 vsts p mo 12-19,90957,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2039.16,,,,,,,fee schedule,1866.66,2328.71,
Esrd srv 4 vsts p mo 12-19,90957,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2143.89,,,,,,,fee schedule,1866.66,2328.71,
Esrd srv 2-3 vsts p mo 12-19,90958,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1570.74,,,,,,,fee schedule,1259.09,1570.74,
Esrd srv 2-3 vsts p mo 12-19,90958,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1259.09,,,,,,,fee schedule,1259.09,1570.74,
Esrd srv 2-3 vsts p mo 12-19,90958,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1375.44,,,,,,,fee schedule,1259.09,1570.74,
Esrd srv 2-3 vsts p mo 12-19,90958,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1446.08,,,,,,,fee schedule,1259.09,1570.74,
Esrd serv 1 vst p mo 12-19,90959,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1030.01,,,,,,,fee schedule,825.64,1030.01,
Esrd serv 1 vst p mo 12-19,90959,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,825.64,,,,,,,fee schedule,825.64,1030.01,
Esrd serv 1 vst p mo 12-19,90959,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,901.94,,,,,,,fee schedule,825.64,1030.01,
Esrd serv 1 vst p mo 12-19,90959,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,948.27,,,,,,,fee schedule,825.64,1030.01,
Esrd srv 4 visits p mo 20+,90960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1030.09,,,,,,,fee schedule,825.71,1030.09,
Esrd srv 4 visits p mo 20+,90960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,825.71,,,,,,,fee schedule,825.71,1030.09,
Esrd srv 4 visits p mo 20+,90960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,902.01,,,,,,,fee schedule,825.71,1030.09,
Esrd srv 4 visits p mo 20+,90960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,948.33,,,,,,,fee schedule,825.71,1030.09,
Esrd srv 2-3 vsts p mo 20+,90961,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,832.24,,,,,,,fee schedule,667.12,832.24,
Esrd srv 2-3 vsts p mo 20+,90961,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,667.12,,,,,,,fee schedule,667.12,832.24,
Esrd srv 2-3 vsts p mo 20+,90961,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,728.76,,,,,,,fee schedule,667.12,832.24,
Esrd srv 2-3 vsts p mo 20+,90961,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,766.19,,,,,,,fee schedule,667.12,832.24,
Esrd serv 1 visit p mo 20+,90962,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,602.12,,,,,,,fee schedule,482.65,602.12,
Esrd serv 1 visit p mo 20+,90962,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,482.65,,,,,,,fee schedule,482.65,602.12,
Esrd serv 1 visit p mo 20+,90962,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,527.25,,,,,,,fee schedule,482.65,602.12,
Esrd serv 1 visit p mo 20+,90962,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,554.33,,,,,,,fee schedule,482.65,602.12,
Esrd home pt serv p mo <2yrs,90963,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1995.76,,,,,,,fee schedule,1599.78,1995.76,
Esrd home pt serv p mo <2yrs,90963,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1599.78,,,,,,,fee schedule,1599.78,1995.76,
Esrd home pt serv p mo <2yrs,90963,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1747.61,,,,,,,fee schedule,1599.78,1995.76,
Esrd home pt serv p mo <2yrs,90963,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1837.37,,,,,,,fee schedule,1599.78,1995.76,
Esrd home pt serv p mo 2-11,90964,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1669.1,,,,,,,fee schedule,1337.93,1669.1,
Esrd home pt serv p mo 2-11,90964,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1337.93,,,,,,,fee schedule,1337.93,1669.1,
Esrd home pt serv p mo 2-11,90964,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1461.56,,,,,,,fee schedule,1337.93,1669.1,
Esrd home pt serv p mo 2-11,90964,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1536.63,,,,,,,fee schedule,1337.93,1669.1,
Esrd home pt serv p mo 12-19,90965,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1586.01,,,,,,,fee schedule,1271.33,1586.01,
Esrd home pt serv p mo 12-19,90965,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1271.33,,,,,,,fee schedule,1271.33,1586.01,
Esrd home pt serv p mo 12-19,90965,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1388.81,,,,,,,fee schedule,1271.33,1586.01,
Esrd home pt serv p mo 12-19,90965,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1460.14,,,,,,,fee schedule,1271.33,1586.01,
Esrd home pt serv p mo 20+,90966,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,823.74,,,,,,,fee schedule,660.3,823.74,
Esrd home pt serv p mo 20+,90966,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,660.3,,,,,,,fee schedule,660.3,823.74,
Esrd home pt serv p mo 20+,90966,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,721.32,,,,,,,fee schedule,660.3,823.74,
Esrd home pt serv p mo 20+,90966,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,758.36,,,,,,,fee schedule,660.3,823.74,
Esrd home pt serv p day <2,90967,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,71.06,,,,,,,fee schedule,56.96,71.06,
Esrd home pt serv p day <2,90967,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56.96,,,,,,,fee schedule,56.96,71.06,
Esrd home pt serv p day <2,90967,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,62.23,,,,,,,fee schedule,56.96,71.06,
Esrd home pt serv p day <2,90967,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,65.42,,,,,,,fee schedule,56.96,71.06,
Esrd home pt srv p day 2-11,90968,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55.76,,,,,,,fee schedule,44.69,55.76,
Esrd home pt srv p day 2-11,90968,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,44.69,,,,,,,fee schedule,44.69,55.76,
Esrd home pt srv p day 2-11,90968,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48.82,,,,,,,fee schedule,44.69,55.76,
Esrd home pt srv p day 2-11,90968,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,51.33,,,,,,,fee schedule,44.69,55.76,
Esrd home pt srv p day 12-19,90969,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,54.39,,,,,,,fee schedule,43.6,54.39,
Esrd home pt srv p day 12-19,90969,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,43.6,,,,,,,fee schedule,43.6,54.39,
Esrd home pt srv p day 12-19,90969,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,47.63,,,,,,,fee schedule,43.6,54.39,
Esrd home pt srv p day 12-19,90969,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,50.08,,,,,,,fee schedule,43.6,54.39,
Esrd home pt serv p day 20+,90970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,29.07,,,,,,,fee schedule,23.3,29.07,
Esrd home pt serv p day 20+,90970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23.3,,,,,,,fee schedule,23.3,29.07,
Esrd home pt serv p day 20+,90970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,25.45,,,,,,,fee schedule,23.3,29.07,
Esrd home pt serv p day 20+,90970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26.76,,,,,,,fee schedule,23.3,29.07,
Dialysis training complete,90989,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1255.64,,,,,,,fee schedule,1006.51,1255.64,
Dialysis training complete,90989,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1006.51,,,,,,,fee schedule,1006.51,1255.64,
Dialysis training complete,90989,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1099.52,,,,,,,fee schedule,1006.51,1255.64,
Dialysis training complete,90989,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1155.99,,,,,,,fee schedule,1006.51,1255.64,
Dialysis training incompl,90993,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,271.78,,,,,,,fee schedule,217.86,271.78,
Dialysis training incompl,90993,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,217.86,,,,,,,fee schedule,217.86,271.78,
Dialysis training incompl,90993,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,237.99,,,,,,,fee schedule,217.86,271.78,
Dialysis training incompl,90993,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,250.21,,,,,,,fee schedule,217.86,271.78,
Hemoperfusion,90997,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,327.76,,,,,,,fee schedule,262.73,327.76,
Hemoperfusion,90997,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,262.73,,,,,,,fee schedule,262.73,327.76,
Hemoperfusion,90997,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,287.01,,,,,,,fee schedule,262.73,327.76,
Hemoperfusion,90997,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,301.75,,,,,,,fee schedule,262.73,327.76,
Esophagus motility study,91010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1987.42,,,,,,,fee schedule,369.41,1987.42,
Esophagus motility study,91010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1593.09,,,,,,,fee schedule,369.41,1987.42,
Esophagus motility study,91010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1740.31,,,,,,,fee schedule,369.41,1987.42,
Esophagus motility study,91010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1829.69,,,,,,,fee schedule,369.41,1987.42,
Esophagus motility study,91010,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1638.96,,,,,,,fee schedule,369.41,1987.42,APC 378
Esophagus motility study,91010,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,387.88,,,,,,,fee schedule,369.41,1987.42,APC
Esophagus motility study,91010,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,384.19,,,,,,,fee schedule,369.41,1987.42,APC
Esophagus motility study,91010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,369.41,,,,,,,fee schedule,369.41,1987.42,APC
Esophagus motility study,91010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,565.2,,,,,,,fee schedule,369.41,1987.42,Radiology
Esophagus motility study,91010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,517.18,,,,,,,fee schedule,369.41,1987.42,APC
Esophagus motility study,91010,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,646.47,,,,,,,fee schedule,369.41,1987.42,APC
Esophgl motil w/stim/perfus,91013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1067.77,,,,,,,fee schedule,855.91,1067.77,
Esophgl motil w/stim/perfus,91013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,855.91,,,,,,,fee schedule,855.91,1067.77,
Esophgl motil w/stim/perfus,91013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,935.01,,,,,,,fee schedule,855.91,1067.77,
Esophgl motil w/stim/perfus,91013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,983.03,,,,,,,fee schedule,855.91,1067.77,
Gastric motility studies,91020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,500.36,,,,,,,fee schedule,369.41,1638.96,
Gastric motility studies,91020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,401.08,,,,,,,fee schedule,369.41,1638.96,
Gastric motility studies,91020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,438.14,,,,,,,fee schedule,369.41,1638.96,
Gastric motility studies,91020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,460.65,,,,,,,fee schedule,369.41,1638.96,
Gastric motility studies,91020,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1638.96,,,,,,,fee schedule,369.41,1638.96,APC 378
Gastric motility studies,91020,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,387.88,,,,,,,fee schedule,369.41,1638.96,APC
Gastric motility studies,91020,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,384.19,,,,,,,fee schedule,369.41,1638.96,APC
Gastric motility studies,91020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,369.41,,,,,,,fee schedule,369.41,1638.96,APC
Gastric motility studies,91020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,565.2,,,,,,,fee schedule,369.41,1638.96,Radiology
Gastric motility studies,91020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,517.18,,,,,,,fee schedule,369.41,1638.96,APC
Gastric motility studies,91020,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,646.47,,,,,,,fee schedule,369.41,1638.96,APC
Duodenal motility study,91022,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,359.63,,,,,,,fee schedule,288.27,1638.96,
Duodenal motility study,91022,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,288.27,,,,,,,fee schedule,288.27,1638.96,
Duodenal motility study,91022,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,314.91,,,,,,,fee schedule,288.27,1638.96,
Duodenal motility study,91022,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,331.09,,,,,,,fee schedule,288.27,1638.96,
Duodenal motility study,91022,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1638.96,,,,,,,fee schedule,288.27,1638.96,APC 378
Duodenal motility study,91022,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,387.88,,,,,,,fee schedule,288.27,1638.96,APC
Duodenal motility study,91022,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,384.19,,,,,,,fee schedule,288.27,1638.96,APC
Duodenal motility study,91022,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,369.41,,,,,,,fee schedule,288.27,1638.96,APC
Duodenal motility study,91022,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,565.2,,,,,,,fee schedule,288.27,1638.96,Radiology
Duodenal motility study,91022,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,517.18,,,,,,,fee schedule,288.27,1638.96,APC
Duodenal motility study,91022,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,646.47,,,,,,,fee schedule,288.27,1638.96,APC
Acid perfusion of esophagus,91030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,286.9,,,,,,,fee schedule,229.98,1638.96,
Acid perfusion of esophagus,91030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,229.98,,,,,,,fee schedule,229.98,1638.96,
Acid perfusion of esophagus,91030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,251.23,,,,,,,fee schedule,229.98,1638.96,
Acid perfusion of esophagus,91030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,264.13,,,,,,,fee schedule,229.98,1638.96,
Acid perfusion of esophagus,91030,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1638.96,,,,,,,fee schedule,229.98,1638.96,APC 378
Acid perfusion of esophagus,91030,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,387.88,,,,,,,fee schedule,229.98,1638.96,APC
Acid perfusion of esophagus,91030,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,384.19,,,,,,,fee schedule,229.98,1638.96,APC
Acid perfusion of esophagus,91030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,369.41,,,,,,,fee schedule,229.98,1638.96,APC
Acid perfusion of esophagus,91030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,565.2,,,,,,,fee schedule,229.98,1638.96,Radiology
Acid perfusion of esophagus,91030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,517.18,,,,,,,fee schedule,229.98,1638.96,APC
Acid perfusion of esophagus,91030,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,646.47,,,,,,,fee schedule,229.98,1638.96,APC
Gastroesophageal reflux test,91034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,479.76,,,,,,,fee schedule,369.41,1638.96,
Gastroesophageal reflux test,91034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,384.57,,,,,,,fee schedule,369.41,1638.96,
Gastroesophageal reflux test,91034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,420.11,,,,,,,fee schedule,369.41,1638.96,
Gastroesophageal reflux test,91034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.68,,,,,,,fee schedule,369.41,1638.96,
Gastroesophageal reflux test,91034,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1638.96,,,,,,,fee schedule,369.41,1638.96,APC 378
Gastroesophageal reflux test,91034,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,387.88,,,,,,,fee schedule,369.41,1638.96,APC
Gastroesophageal reflux test,91034,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,384.19,,,,,,,fee schedule,369.41,1638.96,APC
Gastroesophageal reflux test,91034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,369.41,,,,,,,fee schedule,369.41,1638.96,APC
Gastroesophageal reflux test,91034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,565.2,,,,,,,fee schedule,369.41,1638.96,Radiology
Gastroesophageal reflux test,91034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,517.18,,,,,,,fee schedule,369.41,1638.96,APC
Gastroesophageal reflux test,91034,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,646.47,,,,,,,fee schedule,369.41,1638.96,APC
G-esoph reflx tst w/electrod,91035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1250.24,,,,,,,fee schedule,850.12,3771.72,
G-esoph reflx tst w/electrod,91035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1002.17,,,,,,,fee schedule,850.12,3771.72,
G-esoph reflx tst w/electrod,91035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1094.78,,,,,,,fee schedule,850.12,3771.72,
G-esoph reflx tst w/electrod,91035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1151.01,,,,,,,fee schedule,850.12,3771.72,
G-esoph reflx tst w/electrod,91035,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3771.72,,,,,,,fee schedule,850.12,3771.72,APC 378
G-esoph reflx tst w/electrod,91035,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,892.63,,,,,,,fee schedule,850.12,3771.72,APC
G-esoph reflx tst w/electrod,91035,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,884.13,,,,,,,fee schedule,850.12,3771.72,APC
G-esoph reflx tst w/electrod,91035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,850.12,,,,,,,fee schedule,850.12,3771.72,APC
G-esoph reflx tst w/electrod,91035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1300.69,,,,,,,fee schedule,850.12,3771.72,Radiology
G-esoph reflx tst w/electrod,91035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1190.17,,,,,,,fee schedule,850.12,3771.72,APC
G-esoph reflx tst w/electrod,91035,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1487.72,,,,,,,fee schedule,850.12,3771.72,APC
Esoph imped function test,91037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,348.71,,,,,,,fee schedule,213.76,948.37,
Esoph imped function test,91037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,279.52,,,,,,,fee schedule,213.76,948.37,
Esoph imped function test,91037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,305.35,,,,,,,fee schedule,213.76,948.37,
Esoph imped function test,91037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,321.03,,,,,,,fee schedule,213.76,948.37,
Esoph imped function test,91037,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,213.76,948.37,APC 378
Esoph imped function test,91037,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,213.76,948.37,APC
Esoph imped function test,91037,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,213.76,948.37,APC
Esoph imped function test,91037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,213.76,948.37,APC
Esoph imped function test,91037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,213.76,948.37,Radiology
Esoph imped function test,91037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,213.76,948.37,APC
Esoph imped function test,91037,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,213.76,948.37,APC
Esoph imped funct test > 1hr,91038,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,263.77,,,,,,,fee schedule,211.43,1638.96,
Esoph imped funct test > 1hr,91038,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,211.43,,,,,,,fee schedule,211.43,1638.96,
Esoph imped funct test > 1hr,91038,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,230.97,,,,,,,fee schedule,211.43,1638.96,
Esoph imped funct test > 1hr,91038,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,242.83,,,,,,,fee schedule,211.43,1638.96,
Esoph imped funct test > 1hr,91038,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1638.96,,,,,,,fee schedule,211.43,1638.96,APC 378
Esoph imped funct test > 1hr,91038,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,387.88,,,,,,,fee schedule,211.43,1638.96,APC
Esoph imped funct test > 1hr,91038,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,384.19,,,,,,,fee schedule,211.43,1638.96,APC
Esoph imped funct test > 1hr,91038,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,369.41,,,,,,,fee schedule,211.43,1638.96,APC
Esoph imped funct test > 1hr,91038,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,565.2,,,,,,,fee schedule,211.43,1638.96,Radiology
Esoph imped funct test > 1hr,91038,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,517.18,,,,,,,fee schedule,211.43,1638.96,APC
Esoph imped funct test > 1hr,91038,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,646.47,,,,,,,fee schedule,211.43,1638.96,APC
Esoph balloon distension tst,91040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1060.93,,,,,,,fee schedule,369.41,1638.96,
Esoph balloon distension tst,91040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,850.43,,,,,,,fee schedule,369.41,1638.96,
Esoph balloon distension tst,91040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,929.02,,,,,,,fee schedule,369.41,1638.96,
Esoph balloon distension tst,91040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,976.73,,,,,,,fee schedule,369.41,1638.96,
Esoph balloon distension tst,91040,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1638.96,,,,,,,fee schedule,369.41,1638.96,APC 378
Esoph balloon distension tst,91040,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,387.88,,,,,,,fee schedule,369.41,1638.96,APC
Esoph balloon distension tst,91040,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,384.19,,,,,,,fee schedule,369.41,1638.96,APC
Esoph balloon distension tst,91040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,369.41,,,,,,,fee schedule,369.41,1638.96,APC
Esoph balloon distension tst,91040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,565.2,,,,,,,fee schedule,369.41,1638.96,Radiology
Esoph balloon distension tst,91040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,517.18,,,,,,,fee schedule,369.41,1638.96,APC
Esoph balloon distension tst,91040,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,646.47,,,,,,,fee schedule,369.41,1638.96,APC
Breath hydrogen/methane test,91065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,180.15,,,,,,,fee schedule,144.41,948.37,
Breath hydrogen/methane test,91065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,144.41,,,,,,,fee schedule,144.41,948.37,
Breath hydrogen/methane test,91065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,157.75,,,,,,,fee schedule,144.41,948.37,
Breath hydrogen/methane test,91065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,165.86,,,,,,,fee schedule,144.41,948.37,
Breath hydrogen/methane test,91065,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,144.41,948.37,APC 378
Breath hydrogen/methane test,91065,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,144.41,948.37,APC
Breath hydrogen/methane test,91065,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,144.41,948.37,APC
Breath hydrogen/methane test,91065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,144.41,948.37,APC
Breath hydrogen/methane test,91065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,144.41,948.37,Radiology
Breath hydrogen/methane test,91065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,144.41,948.37,APC
Breath hydrogen/methane test,91065,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,144.41,948.37,APC
Gi tract capsule endoscopy,91110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2300.05,,,,,,,fee schedule,897.89,3983.62,
Gi tract capsule endoscopy,91110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1843.69,,,,,,,fee schedule,897.89,3983.62,
Gi tract capsule endoscopy,91110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2014.07,,,,,,,fee schedule,897.89,3983.62,
Gi tract capsule endoscopy,91110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2117.51,,,,,,,fee schedule,897.89,3983.62,
Gi tract capsule endoscopy,91110,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3983.62,,,,,,,fee schedule,897.89,3983.62,APC 378
Gi tract capsule endoscopy,91110,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,942.78,,,,,,,fee schedule,897.89,3983.62,APC
Gi tract capsule endoscopy,91110,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,933.8,,,,,,,fee schedule,897.89,3983.62,APC
Gi tract capsule endoscopy,91110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,897.89,,,,,,,fee schedule,897.89,3983.62,APC
Gi tract capsule endoscopy,91110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1373.77,,,,,,,fee schedule,897.89,3983.62,Radiology
Gi tract capsule endoscopy,91110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1257.04,,,,,,,fee schedule,897.89,3983.62,APC
Gi tract capsule endoscopy,91110,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1571.3,,,,,,,fee schedule,897.89,3983.62,APC
Esophageal Capsule Endoscopy,91111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2120.28,,,,,,,fee schedule,897.89,3983.62,
Esophageal Capsule Endoscopy,91111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1699.59,,,,,,,fee schedule,897.89,3983.62,
Esophageal Capsule Endoscopy,91111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1856.65,,,,,,,fee schedule,897.89,3983.62,
Esophageal Capsule Endoscopy,91111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1952,,,,,,,fee schedule,897.89,3983.62,
Esophageal Capsule Endoscopy,91111,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3983.62,,,,,,,fee schedule,897.89,3983.62,APC 378
Esophageal Capsule Endoscopy,91111,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,942.78,,,,,,,fee schedule,897.89,3983.62,APC
Esophageal Capsule Endoscopy,91111,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,933.8,,,,,,,fee schedule,897.89,3983.62,APC
Esophageal Capsule Endoscopy,91111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,897.89,,,,,,,fee schedule,897.89,3983.62,APC
Esophageal Capsule Endoscopy,91111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1373.77,,,,,,,fee schedule,897.89,3983.62,Radiology
Esophageal Capsule Endoscopy,91111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1257.04,,,,,,,fee schedule,897.89,3983.62,APC
Esophageal Capsule Endoscopy,91111,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1571.3,,,,,,,fee schedule,897.89,3983.62,APC
Gi wireless capsule measure,91112,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3983.62,,,,,,,fee schedule,897.89,3983.62,APC 378
Gi wireless capsule measure,91112,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,942.78,,,,,,,fee schedule,897.89,3983.62,APC
Gi wireless capsule measure,91112,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,933.8,,,,,,,fee schedule,897.89,3983.62,APC
Gi wireless capsule measure,91112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,897.89,,,,,,,fee schedule,897.89,3983.62,APC
Gi wireless capsule measure,91112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1373.77,,,,,,,fee schedule,897.89,3983.62,Radiology
Gi wireless capsule measure,91112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1257.04,,,,,,,fee schedule,897.89,3983.62,APC
Gi wireless capsule measure,91112,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1571.3,,,,,,,fee schedule,897.89,3983.62,APC
Gi trc img intral colon i&r,91113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3063.61,,,,,,,fee schedule,920.63,4084.51,
Gi trc img intral colon i&r,91113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2455.75,,,,,,,fee schedule,920.63,4084.51,
Gi trc img intral colon i&r,91113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2682.69,,,,,,,fee schedule,920.63,4084.51,
Gi trc img intral colon i&r,91113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2820.47,,,,,,,fee schedule,920.63,4084.51,
Gi trc img intral colon i&r,91113,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4084.51,,,,,,,fee schedule,920.63,4084.51,APC 378
Gi trc img intral colon i&r,91113,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,966.66,,,,,,,fee schedule,920.63,4084.51,APC
Gi trc img intral colon i&r,91113,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,957.45,,,,,,,fee schedule,920.63,4084.51,APC
Gi trc img intral colon i&r,91113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,920.63,,,,,,,fee schedule,920.63,4084.51,APC
Gi trc img intral colon i&r,91113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1408.56,,,,,,,fee schedule,920.63,4084.51,Radiology
Gi trc img intral colon i&r,91113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1288.88,,,,,,,fee schedule,920.63,4084.51,APC
Gi trc img intral colon i&r,91113,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1611.1,,,,,,,fee schedule,920.63,4084.51,APC
Colon motility 6 hr study,91117,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,836.14,,,,,,,fee schedule,213.76,948.37,
Colon motility 6 hr study,91117,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,670.24,,,,,,,fee schedule,213.76,948.37,
Colon motility 6 hr study,91117,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,732.17,,,,,,,fee schedule,213.76,948.37,
Colon motility 6 hr study,91117,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,769.78,,,,,,,fee schedule,213.76,948.37,
Colon motility 6 hr study,91117,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,213.76,948.37,APC 378
Colon motility 6 hr study,91117,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,213.76,948.37,APC
Colon motility 6 hr study,91117,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,213.76,948.37,APC
Colon motility 6 hr study,91117,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,213.76,948.37,APC
Colon motility 6 hr study,91117,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,213.76,948.37,Radiology
Colon motility 6 hr study,91117,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,213.76,948.37,APC
Colon motility 6 hr study,91117,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,213.76,948.37,APC
Rectal sensation test,91120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1107.69,,,,,,,fee schedule,887.91,1107.69,
Rectal sensation test,91120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,887.91,,,,,,,fee schedule,887.91,1107.69,
Rectal sensation test,91120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,969.96,,,,,,,fee schedule,887.91,1107.69,
Rectal sensation test,91120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1019.78,,,,,,,fee schedule,887.91,1107.69,
Anal pressure record,91122,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,459.69,,,,,,,fee schedule,368.48,459.69,
Anal pressure record,91122,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,368.48,,,,,,,fee schedule,368.48,459.69,
Anal pressure record,91122,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,402.53,,,,,,,fee schedule,368.48,459.69,
Anal pressure record,91122,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,423.2,,,,,,,fee schedule,368.48,459.69,
Rct snsatn tone&cmplianc std,91124,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,213.76,948.37,APC 378
Rct snsatn tone&cmplianc std,91124,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,213.76,948.37,APC
Rct snsatn tone&cmplianc std,91124,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,213.76,948.37,APC
Rct snsatn tone&cmplianc std,91124,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,213.76,948.37,APC
Rct snsatn tone&cmplianc std,91124,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,213.76,948.37,Radiology
Rct snsatn tone&cmplianc std,91124,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,213.76,948.37,APC
Rct snsatn tone&cmplianc std,91124,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,213.76,948.37,APC
Anrct mano rct snsatn&balo,91125,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1638.96,,,,,,,fee schedule,369.41,1638.96,APC 378
Anrct mano rct snsatn&balo,91125,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,387.88,,,,,,,fee schedule,369.41,1638.96,APC
Anrct mano rct snsatn&balo,91125,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,384.19,,,,,,,fee schedule,369.41,1638.96,APC
Anrct mano rct snsatn&balo,91125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,369.41,,,,,,,fee schedule,369.41,1638.96,APC
Anrct mano rct snsatn&balo,91125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,565.2,,,,,,,fee schedule,369.41,1638.96,Radiology
Anrct mano rct snsatn&balo,91125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,517.18,,,,,,,fee schedule,369.41,1638.96,APC
Anrct mano rct snsatn&balo,91125,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,646.47,,,,,,,fee schedule,369.41,1638.96,APC
Electrogastrography,91132,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,382.57,,,,,,,fee schedule,213.76,948.37,
Electrogastrography,91132,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,306.67,,,,,,,fee schedule,213.76,948.37,
Electrogastrography,91132,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,335.01,,,,,,,fee schedule,213.76,948.37,
Electrogastrography,91132,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,352.21,,,,,,,fee schedule,213.76,948.37,
Electrogastrography,91132,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,213.76,948.37,APC 378
Electrogastrography,91132,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,213.76,948.37,APC
Electrogastrography,91132,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,213.76,948.37,APC
Electrogastrography,91132,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,213.76,948.37,APC
Electrogastrography,91132,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,213.76,948.37,Radiology
Electrogastrography,91132,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,213.76,948.37,APC
Electrogastrography,91132,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,213.76,948.37,APC
Electrogastrography W/Test,91133,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,382.57,,,,,,,fee schedule,131.71,584.37,
Electrogastrography W/Test,91133,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,306.67,,,,,,,fee schedule,131.71,584.37,
Electrogastrography W/Test,91133,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,335.01,,,,,,,fee schedule,131.71,584.37,
Electrogastrography W/Test,91133,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,352.21,,,,,,,fee schedule,131.71,584.37,
Electrogastrography W/Test,91133,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,131.71,584.37,APC 378
Electrogastrography W/Test,91133,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,131.71,584.37,APC
Electrogastrography W/Test,91133,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,131.71,584.37,APC
Electrogastrography W/Test,91133,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,131.71,584.37,APC
Electrogastrography W/Test,91133,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,131.71,584.37,Radiology
Electrogastrography W/Test,91133,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,131.71,584.37,APC
Electrogastrography W/Test,91133,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,131.71,584.37,APC
Liver elastography,91200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,509.73,,,,,,,fee schedule,127.38,565.15,
Liver elastography,91200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,408.6,,,,,,,fee schedule,127.38,565.15,
Liver elastography,91200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,446.35,,,,,,,fee schedule,127.38,565.15,
Liver elastography,91200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,469.28,,,,,,,fee schedule,127.38,565.15,
Liver elastography,91200,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,565.15,,,,,,,fee schedule,127.38,565.15,APC 378
Liver elastography,91200,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,133.75,,,,,,,fee schedule,127.38,565.15,APC
Liver elastography,91200,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,132.48,,,,,,,fee schedule,127.38,565.15,APC
Liver elastography,91200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,127.38,,,,,,,fee schedule,127.38,565.15,APC
Liver elastography,91200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,194.89,,,,,,,fee schedule,127.38,565.15,Radiology
Liver elastography,91200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,178.33,,,,,,,fee schedule,127.38,565.15,APC
Liver elastography,91200,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,222.92,,,,,,,fee schedule,127.38,565.15,APC
Gastroenterology procedure,91299,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,565.15,,,,,,,fee schedule,127.38,565.15,APC 378
Gastroenterology procedure,91299,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,133.75,,,,,,,fee schedule,127.38,565.15,APC
Gastroenterology procedure,91299,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,132.48,,,,,,,fee schedule,127.38,565.15,APC
Gastroenterology procedure,91299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,127.38,,,,,,,fee schedule,127.38,565.15,APC
Gastroenterology procedure,91299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,194.89,,,,,,,fee schedule,127.38,565.15,Radiology
Gastroenterology procedure,91299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,178.33,,,,,,,fee schedule,127.38,565.15,APC
Gastroenterology procedure,91299,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,222.92,,,,,,,fee schedule,127.38,565.15,APC
Sarscov2 vac 30mcg/0.3ml im,91300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.04,,,,,,,fee schedule,0.03,0.04,
Sarscov2 vac 30mcg/0.3ml im,91300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.03,,,,,,,fee schedule,0.03,0.04,
Sarscov2 vac 30mcg/0.3ml im,91300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.03,,,,,,,fee schedule,0.03,0.04,
Sarscov2 vac 100mcg/0.5ml im,91301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.04,,,,,,,fee schedule,0.03,0.04,
Sarscov2 vac 100mcg/0.5ml im,91301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.03,,,,,,,fee schedule,0.03,0.04,
Sarscov2 vac 100mcg/0.5ml im,91301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.03,,,,,,,fee schedule,0.03,0.04,
Coronavirus vaccine 4,91303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.04,,,,,,,fee schedule,0.03,0.04,
Coronavirus vaccine 4,91303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.03,,,,,,,fee schedule,0.03,0.04,
Coronavirus vaccine 4,91303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.03,,,,,,,fee schedule,0.03,0.04,
Coronavirus vaccine 5,91304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.04,,,,,,,fee schedule,0.03,0.04,
Coronavirus vaccine 5,91304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.03,,,,,,,fee schedule,0.03,0.04,
Coronavirus vaccine 5,91304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.03,,,,,,,fee schedule,0.03,0.04,
Coronavirus vaccine 6,91305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.04,,,,,,,fee schedule,0.03,0.04,
Coronavirus vaccine 6,91305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.03,,,,,,,fee schedule,0.03,0.04,
Coronavirus vaccine 6,91305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.03,,,,,,,fee schedule,0.03,0.04,
Coronavirus vaccine 7,91306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.04,,,,,,,fee schedule,0.03,0.04,
Coronavirus vaccine 7,91306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.03,,,,,,,fee schedule,0.03,0.04,
Coronavirus vaccine 7,91306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.03,,,,,,,fee schedule,0.03,0.04,
Coronavirus vaccine 8,91307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.04,,,,,,,fee schedule,0.03,0.04,
Coronavirus vaccine 8,91307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.03,,,,,,,fee schedule,0.03,0.04,
Coronavirus vaccine 8,91307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.03,,,,,,,fee schedule,0.03,0.04,
Coronavirus vaccine 9,91308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.04,,,,,,,fee schedule,0.03,0.04,
Coronavirus vaccine 9,91308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.03,,,,,,,fee schedule,0.03,0.04,
Coronavirus vaccine 9,91308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.03,,,,,,,fee schedule,0.03,0.04,
Coronavirus vaccine 10,91309,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.04,,,,,,,fee schedule,0.03,0.04,
Coronavirus vaccine 10,91309,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.03,,,,,,,fee schedule,0.03,0.04,
Coronavirus vaccine 10,91309,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.03,,,,,,,fee schedule,0.03,0.04,
Sarscov2 vac 25mcg/0.25ml im,91311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.04,,,,,,,fee schedule,0.03,0.04,
Sarscov2 vac 25mcg/0.25ml im,91311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.03,,,,,,,fee schedule,0.03,0.04,
Sarscov2 vac 25mcg/0.25ml im,91311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.03,,,,,,,fee schedule,0.03,0.04,
Sarscov2 vac bvl 30mcg/0.3ml,91312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.04,,,,,,,fee schedule,0.03,0.04,
Sarscov2 vac bvl 30mcg/0.3ml,91312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.03,,,,,,,fee schedule,0.03,0.04,
Sarscov2 vac bvl 30mcg/0.3ml,91312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.03,,,,,,,fee schedule,0.03,0.04,
Sarscov2 vac bvl 50mcg/0.5ml,91313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.04,,,,,,,fee schedule,0.03,0.04,
Sarscov2 vac bvl 50mcg/0.5ml,91313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.03,,,,,,,fee schedule,0.03,0.04,
Sarscov2 vac bvl 50mcg/0.5ml,91313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.03,,,,,,,fee schedule,0.03,0.04,
Sarscov2 vac bvl 25mcg/.25ml,91314,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.04,,,,,,,fee schedule,0.03,0.04,
Sarscov2 vac bvl 25mcg/.25ml,91314,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.03,,,,,,,fee schedule,0.03,0.04,
Sarscov2 vac bvl 25mcg/.25ml,91314,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.03,,,,,,,fee schedule,0.03,0.04,
Sarscov2 vac bvl 10mcg/0.2ml,91315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.04,,,,,,,fee schedule,0.03,0.04,
Sarscov2 vac bvl 10mcg/0.2ml,91315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.03,,,,,,,fee schedule,0.03,0.04,
Sarscov2 vac bvl 10mcg/0.2ml,91315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.03,,,,,,,fee schedule,0.03,0.04,
Eye exam new patient,92002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,248.65,,,,,,,fee schedule,131.8,584.75,
Eye exam new patient,92002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,199.31,,,,,,,fee schedule,131.8,584.75,
Eye exam new patient,92002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,217.73,,,,,,,fee schedule,131.8,584.75,
Eye exam new patient,92002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,228.91,,,,,,,fee schedule,131.8,584.75,
Eye exam new patient,92002,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.75,,,,,,,fee schedule,131.8,584.75,APC 378
Eye exam new patient,92002,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.39,,,,,,,fee schedule,131.8,584.75,APC
Eye exam new patient,92002,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,137.07,,,,,,,fee schedule,131.8,584.75,APC
Eye exam new patient,92002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.8,,,,,,,fee schedule,131.8,584.75,APC
Eye exam new patient,92002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.66,,,,,,,fee schedule,131.8,584.75,Radiology
Eye exam new patient,92002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.52,,,,,,,fee schedule,131.8,584.75,APC
Eye exam new patient,92002,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.65,,,,,,,fee schedule,131.8,584.75,APC
Eye exam new patient,92004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,330.07,,,,,,,fee schedule,131.8,584.75,
Eye exam new patient,92004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,264.58,,,,,,,fee schedule,131.8,584.75,
Eye exam new patient,92004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,289.03,,,,,,,fee schedule,131.8,584.75,
Eye exam new patient,92004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,303.87,,,,,,,fee schedule,131.8,584.75,
Eye exam new patient,92004,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.75,,,,,,,fee schedule,131.8,584.75,APC 378
Eye exam new patient,92004,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.39,,,,,,,fee schedule,131.8,584.75,APC
Eye exam new patient,92004,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,137.07,,,,,,,fee schedule,131.8,584.75,APC
Eye exam new patient,92004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.8,,,,,,,fee schedule,131.8,584.75,APC
Eye exam new patient,92004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.66,,,,,,,fee schedule,131.8,584.75,Radiology
Eye exam new patient,92004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.52,,,,,,,fee schedule,131.8,584.75,APC
Eye exam new patient,92004,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.65,,,,,,,fee schedule,131.8,584.75,APC
Eye exam establish patient,92012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,209.37,,,,,,,fee schedule,131.8,584.75,
Eye exam establish patient,92012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,167.83,,,,,,,fee schedule,131.8,584.75,
Eye exam establish patient,92012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,183.34,,,,,,,fee schedule,131.8,584.75,
Eye exam establish patient,92012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,192.76,,,,,,,fee schedule,131.8,584.75,
Eye exam establish patient,92012,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.75,,,,,,,fee schedule,131.8,584.75,APC 378
Eye exam establish patient,92012,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.39,,,,,,,fee schedule,131.8,584.75,APC
Eye exam establish patient,92012,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,137.07,,,,,,,fee schedule,131.8,584.75,APC
Eye exam establish patient,92012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.8,,,,,,,fee schedule,131.8,584.75,APC
Eye exam establish patient,92012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.66,,,,,,,fee schedule,131.8,584.75,Radiology
Eye exam establish patient,92012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.52,,,,,,,fee schedule,131.8,584.75,APC
Eye exam establish patient,92012,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.65,,,,,,,fee schedule,131.8,584.75,APC
Eye exam&tx estab pt 1/>vst,92014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,248.65,,,,,,,fee schedule,131.8,584.75,
Eye exam&tx estab pt 1/>vst,92014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,199.31,,,,,,,fee schedule,131.8,584.75,
Eye exam&tx estab pt 1/>vst,92014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,217.73,,,,,,,fee schedule,131.8,584.75,
Eye exam&tx estab pt 1/>vst,92014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,228.91,,,,,,,fee schedule,131.8,584.75,
Eye exam&tx estab pt 1/>vst,92014,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.75,,,,,,,fee schedule,131.8,584.75,APC 378
Eye exam&tx estab pt 1/>vst,92014,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.39,,,,,,,fee schedule,131.8,584.75,APC
Eye exam&tx estab pt 1/>vst,92014,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,137.07,,,,,,,fee schedule,131.8,584.75,APC
Eye exam&tx estab pt 1/>vst,92014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.8,,,,,,,fee schedule,131.8,584.75,APC
Eye exam&tx estab pt 1/>vst,92014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.66,,,,,,,fee schedule,131.8,584.75,Radiology
Eye exam&tx estab pt 1/>vst,92014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.52,,,,,,,fee schedule,131.8,584.75,APC
Eye exam&tx estab pt 1/>vst,92014,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.65,,,,,,,fee schedule,131.8,584.75,APC
New eye exam & treatment,92018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2396.55,,,,,,,fee schedule,1921.05,10442.27,
New eye exam & treatment,92018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1921.05,,,,,,,fee schedule,1921.05,10442.27,
New eye exam & treatment,92018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2098.57,,,,,,,fee schedule,1921.05,10442.27,
New eye exam & treatment,92018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2206.35,,,,,,,fee schedule,1921.05,10442.27,
New eye exam & treatment,92018,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,1921.05,10442.27,APC 378
New eye exam & treatment,92018,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,1921.05,10442.27,APC
New eye exam & treatment,92018,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,1921.05,10442.27,APC
New eye exam & treatment,92018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,1921.05,10442.27,APC
New eye exam & treatment,92018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,1921.05,10442.27,Radiology
New eye exam & treatment,92018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,1921.05,10442.27,APC
New eye exam & treatment,92018,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,1921.05,10442.27,APC
Eye exam & treatment,92019,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3430.46,,,,,,,fee schedule,2353.63,10442.27,
Eye exam & treatment,92019,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2749.82,,,,,,,fee schedule,2353.63,10442.27,
Eye exam & treatment,92019,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3003.92,,,,,,,fee schedule,2353.63,10442.27,
Eye exam & treatment,92019,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3158.2,,,,,,,fee schedule,2353.63,10442.27,
Eye exam & treatment,92019,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10442.27,,,,,,,fee schedule,2353.63,10442.27,APC 378
Eye exam & treatment,92019,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2471.31,,,,,,,fee schedule,2353.63,10442.27,APC
Eye exam & treatment,92019,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2447.78,,,,,,,fee schedule,2353.63,10442.27,APC
Eye exam & treatment,92019,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2353.63,,,,,,,fee schedule,2353.63,10442.27,APC
Eye exam & treatment,92019,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3601.06,,,,,,,fee schedule,2353.63,10442.27,Radiology
Eye exam & treatment,92019,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3295.09,,,,,,,fee schedule,2353.63,10442.27,APC
Eye exam & treatment,92019,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4118.86,,,,,,,fee schedule,2353.63,10442.27,APC
Special eye evaluation,92020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,147.34,,,,,,,fee schedule,118.11,584.37,
Special eye evaluation,92020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,118.11,,,,,,,fee schedule,118.11,584.37,
Special eye evaluation,92020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,129.02,,,,,,,fee schedule,118.11,584.37,
Special eye evaluation,92020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,135.65,,,,,,,fee schedule,118.11,584.37,
Special eye evaluation,92020,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,118.11,584.37,APC 378
Special eye evaluation,92020,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,118.11,584.37,APC
Special eye evaluation,92020,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,118.11,584.37,APC
Special eye evaluation,92020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,118.11,584.37,APC
Special eye evaluation,92020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,118.11,584.37,Radiology
Special eye evaluation,92020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,118.11,584.37,APC
Special eye evaluation,92020,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,118.11,584.37,APC
Corneal Topography,92025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45.17,,,,,,,fee schedule,36.21,259.1,
Corneal Topography,92025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36.21,,,,,,,fee schedule,36.21,259.1,
Corneal Topography,92025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39.55,,,,,,,fee schedule,36.21,259.1,
Corneal Topography,92025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41.59,,,,,,,fee schedule,36.21,259.1,
Corneal Topography,92025,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,36.21,259.1,APC 378
Corneal Topography,92025,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,36.21,259.1,APC
Corneal Topography,92025,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,36.21,259.1,APC
Corneal Topography,92025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,36.21,259.1,APC
Corneal Topography,92025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,36.21,259.1,Radiology
Corneal Topography,92025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,36.21,259.1,APC
Corneal Topography,92025,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,36.21,259.1,APC
Special eye evaluation,92060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,63.39,,,,,,,fee schedule,50.81,259.1,
Special eye evaluation,92060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,50.81,,,,,,,fee schedule,50.81,259.1,
Special eye evaluation,92060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55.51,,,,,,,fee schedule,50.81,259.1,
Special eye evaluation,92060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,58.36,,,,,,,fee schedule,50.81,259.1,
Special eye evaluation,92060,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,50.81,259.1,APC 378
Special eye evaluation,92060,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,50.81,259.1,APC
Special eye evaluation,92060,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,50.81,259.1,APC
Special eye evaluation,92060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,50.81,259.1,APC
Special eye evaluation,92060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,50.81,259.1,Radiology
Special eye evaluation,92060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,50.81,259.1,APC
Special eye evaluation,92060,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,50.81,259.1,APC
Orthoptic/pleoptic training,92065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,82.78,,,,,,,fee schedule,66.36,82.78,
Orthoptic/pleoptic training,92065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66.36,,,,,,,fee schedule,66.36,82.78,
Orthoptic/pleoptic training,92065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,72.49,,,,,,,fee schedule,66.36,82.78,
Orthoptic/pleoptic training,92065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,76.21,,,,,,,fee schedule,66.36,82.78,
Orthop traing supvj phys/qhp,92066,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,217.27,,,,,,,fee schedule,58.4,259.1,
Orthop traing supvj phys/qhp,92066,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,174.16,,,,,,,fee schedule,58.4,259.1,
Orthop traing supvj phys/qhp,92066,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,190.26,,,,,,,fee schedule,58.4,259.1,
Orthop traing supvj phys/qhp,92066,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,200.03,,,,,,,fee schedule,58.4,259.1,
Orthop traing supvj phys/qhp,92066,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,58.4,259.1,APC 378
Orthop traing supvj phys/qhp,92066,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,58.4,259.1,APC
Orthop traing supvj phys/qhp,92066,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,58.4,259.1,APC
Orthop traing supvj phys/qhp,92066,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,58.4,259.1,APC
Orthop traing supvj phys/qhp,92066,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,58.4,259.1,Radiology
Orthop traing supvj phys/qhp,92066,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,58.4,259.1,APC
Orthop traing supvj phys/qhp,92066,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,58.4,259.1,APC
Contact lens fitting for tx,92071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,111.74,,,,,,,fee schedule,89.57,111.74,
Contact lens fitting for tx,92071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,89.57,,,,,,,fee schedule,89.57,111.74,
Contact lens fitting for tx,92071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,97.84,,,,,,,fee schedule,89.57,111.74,
Contact lens fitting for tx,92071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,102.87,,,,,,,fee schedule,89.57,111.74,
Fit contac lens for managmnt,92072,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,361.71,,,,,,,fee schedule,289.94,361.71,
Fit contac lens for managmnt,92072,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,289.94,,,,,,,fee schedule,289.94,361.71,
Fit contac lens for managmnt,92072,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,316.73,,,,,,,fee schedule,289.94,361.71,
Fit contac lens for managmnt,92072,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,333,,,,,,,fee schedule,289.94,361.71,
Visual field examination(s),92081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,101,,,,,,,fee schedule,58.4,259.1,
Visual field examination(s),92081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,80.96,,,,,,,fee schedule,58.4,259.1,
Visual field examination(s),92081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,88.44,,,,,,,fee schedule,58.4,259.1,
Visual field examination(s),92081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,92.99,,,,,,,fee schedule,58.4,259.1,
Visual field examination(s),92081,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,58.4,259.1,APC 378
Visual field examination(s),92081,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,58.4,259.1,APC
Visual field examination(s),92081,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,58.4,259.1,APC
Visual field examination(s),92081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,58.4,259.1,APC
Visual field examination(s),92081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,58.4,259.1,Radiology
Visual field examination(s),92081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,58.4,259.1,APC
Visual field examination(s),92081,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,58.4,259.1,APC
Visual field examination(s),92082,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,139.82,,,,,,,fee schedule,58.4,259.1,
Visual field examination(s),92082,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,112.08,,,,,,,fee schedule,58.4,259.1,
Visual field examination(s),92082,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,122.44,,,,,,,fee schedule,58.4,259.1,
Visual field examination(s),92082,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,128.73,,,,,,,fee schedule,58.4,259.1,
Visual field examination(s),92082,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,58.4,259.1,APC 378
Visual field examination(s),92082,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,58.4,259.1,APC
Visual field examination(s),92082,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,58.4,259.1,APC
Visual field examination(s),92082,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,58.4,259.1,APC
Visual field examination(s),92082,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,58.4,259.1,Radiology
Visual field examination(s),92082,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,58.4,259.1,APC
Visual field examination(s),92082,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,58.4,259.1,APC
Visual field examination(s),92083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,159.21,,,,,,,fee schedule,127.62,584.37,
Visual field examination(s),92083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,127.62,,,,,,,fee schedule,127.62,584.37,
Visual field examination(s),92083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,139.42,,,,,,,fee schedule,127.62,584.37,
Visual field examination(s),92083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,146.58,,,,,,,fee schedule,127.62,584.37,
Visual field examination(s),92083,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,127.62,584.37,APC 378
Visual field examination(s),92083,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,127.62,584.37,APC
Visual field examination(s),92083,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,127.62,584.37,APC
Visual field examination(s),92083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,127.62,584.37,APC
Visual field examination(s),92083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,127.62,584.37,Radiology
Visual field examination(s),92083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,127.62,584.37,APC
Visual field examination(s),92083,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,127.62,584.37,APC
Cmptr ophth dx img ant segmt,92132,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,157.59,,,,,,,fee schedule,58.4,259.1,
Cmptr ophth dx img ant segmt,92132,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,126.32,,,,,,,fee schedule,58.4,259.1,
Cmptr ophth dx img ant segmt,92132,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,137.99,,,,,,,fee schedule,58.4,259.1,
Cmptr ophth dx img ant segmt,92132,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,145.08,,,,,,,fee schedule,58.4,259.1,
Cmptr ophth dx img ant segmt,92132,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,58.4,259.1,APC 378
Cmptr ophth dx img ant segmt,92132,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,58.4,259.1,APC
Cmptr ophth dx img ant segmt,92132,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,58.4,259.1,APC
Cmptr ophth dx img ant segmt,92132,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,58.4,259.1,APC
Cmptr ophth dx img ant segmt,92132,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,58.4,259.1,Radiology
Cmptr ophth dx img ant segmt,92132,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,58.4,259.1,APC
Cmptr ophth dx img ant segmt,92132,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,58.4,259.1,APC
Cmptr ophth img optic nerve,92133,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,157.59,,,,,,,fee schedule,58.4,259.1,
Cmptr ophth img optic nerve,92133,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,126.32,,,,,,,fee schedule,58.4,259.1,
Cmptr ophth img optic nerve,92133,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,137.99,,,,,,,fee schedule,58.4,259.1,
Cmptr ophth img optic nerve,92133,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,145.08,,,,,,,fee schedule,58.4,259.1,
Cmptr ophth img optic nerve,92133,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,58.4,259.1,APC 378
Cmptr ophth img optic nerve,92133,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,58.4,259.1,APC
Cmptr ophth img optic nerve,92133,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,58.4,259.1,APC
Cmptr ophth img optic nerve,92133,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,58.4,259.1,APC
Cmptr ophth img optic nerve,92133,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,58.4,259.1,Radiology
Cmptr ophth img optic nerve,92133,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,58.4,259.1,APC
Cmptr ophth img optic nerve,92133,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,58.4,259.1,APC
Cptr ophth dx img post segmt,92134,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,157.59,,,,,,,fee schedule,58.4,259.1,
Cptr ophth dx img post segmt,92134,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,126.32,,,,,,,fee schedule,58.4,259.1,
Cptr ophth dx img post segmt,92134,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,137.99,,,,,,,fee schedule,58.4,259.1,
Cptr ophth dx img post segmt,92134,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,145.08,,,,,,,fee schedule,58.4,259.1,
Cptr ophth dx img post segmt,92134,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,58.4,259.1,APC 378
Cptr ophth dx img post segmt,92134,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,58.4,259.1,APC
Cptr ophth dx img post segmt,92134,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,58.4,259.1,APC
Cptr ophth dx img post segmt,92134,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,58.4,259.1,APC
Cptr ophth dx img post segmt,92134,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,58.4,259.1,Radiology
Cptr ophth dx img post segmt,92134,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,58.4,259.1,APC
Cptr ophth dx img post segmt,92134,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,58.4,259.1,APC
Ophthalmic biometry,92136,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,163.33,,,,,,,fee schedule,130.93,584.37,
Ophthalmic biometry,92136,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,130.93,,,,,,,fee schedule,130.93,584.37,
Ophthalmic biometry,92136,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,143.03,,,,,,,fee schedule,130.93,584.37,
Ophthalmic biometry,92136,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,150.37,,,,,,,fee schedule,130.93,584.37,
Ophthalmic biometry,92136,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,130.93,584.37,APC 378
Ophthalmic biometry,92136,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,130.93,584.37,APC
Ophthalmic biometry,92136,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,130.93,584.37,APC
Ophthalmic biometry,92136,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,130.93,584.37,APC
Ophthalmic biometry,92136,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,130.93,584.37,Radiology
Ophthalmic biometry,92136,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,130.93,584.37,APC
Ophthalmic biometry,92136,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,130.93,584.37,APC
Cptrz oph img pst sg rta oct,92137,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,213.76,948.37,APC 378
Cptrz oph img pst sg rta oct,92137,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,213.76,948.37,APC
Cptrz oph img pst sg rta oct,92137,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,213.76,948.37,APC
Cptrz oph img pst sg rta oct,92137,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,213.76,948.37,APC
Cptrz oph img pst sg rta oct,92137,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,213.76,948.37,Radiology
Cptrz oph img pst sg rta oct,92137,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,213.76,948.37,APC
Cptrz oph img pst sg rta oct,92137,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,213.76,948.37,APC
Corneal hysteresis deter,92145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,196.79,,,,,,,fee schedule,58.4,259.1,
Corneal hysteresis deter,92145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,157.74,,,,,,,fee schedule,58.4,259.1,
Corneal hysteresis deter,92145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,172.32,,,,,,,fee schedule,58.4,259.1,
Corneal hysteresis deter,92145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,181.17,,,,,,,fee schedule,58.4,259.1,
Corneal hysteresis deter,92145,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,58.4,259.1,APC 378
Corneal hysteresis deter,92145,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,58.4,259.1,APC
Corneal hysteresis deter,92145,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,58.4,259.1,APC
Corneal hysteresis deter,92145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,58.4,259.1,APC
Corneal hysteresis deter,92145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,58.4,259.1,Radiology
Corneal hysteresis deter,92145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,58.4,259.1,APC
Corneal hysteresis deter,92145,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,58.4,259.1,APC
Opscpy extnd rta draw uni/bi,92201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,207.94,,,,,,,fee schedule,58.4,259.1,
Opscpy extnd rta draw uni/bi,92201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,166.68,,,,,,,fee schedule,58.4,259.1,
Opscpy extnd rta draw uni/bi,92201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,182.08,,,,,,,fee schedule,58.4,259.1,
Opscpy extnd rta draw uni/bi,92201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,191.43,,,,,,,fee schedule,58.4,259.1,
Opscpy extnd rta draw uni/bi,92201,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,58.4,259.1,APC 378
Opscpy extnd rta draw uni/bi,92201,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,58.4,259.1,APC
Opscpy extnd rta draw uni/bi,92201,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,58.4,259.1,APC
Opscpy extnd rta draw uni/bi,92201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,58.4,259.1,APC
Opscpy extnd rta draw uni/bi,92201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,58.4,259.1,Radiology
Opscpy extnd rta draw uni/bi,92201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,58.4,259.1,APC
Opscpy extnd rta draw uni/bi,92201,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,58.4,259.1,APC
Opscpy extnd on/mac draw,92202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,207.94,,,,,,,fee schedule,58.4,259.1,
Opscpy extnd on/mac draw,92202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,166.68,,,,,,,fee schedule,58.4,259.1,
Opscpy extnd on/mac draw,92202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,182.08,,,,,,,fee schedule,58.4,259.1,
Opscpy extnd on/mac draw,92202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,191.43,,,,,,,fee schedule,58.4,259.1,
Opscpy extnd on/mac draw,92202,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,58.4,259.1,APC 378
Opscpy extnd on/mac draw,92202,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,58.4,259.1,APC
Opscpy extnd on/mac draw,92202,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,58.4,259.1,APC
Opscpy extnd on/mac draw,92202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,58.4,259.1,APC
Opscpy extnd on/mac draw,92202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,58.4,259.1,Radiology
Opscpy extnd on/mac draw,92202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,58.4,259.1,APC
Opscpy extnd on/mac draw,92202,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,58.4,259.1,APC
Remote dx retinal imaging,92227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,69.63,,,,,,,fee schedule,55.81,259.1,
Remote dx retinal imaging,92227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55.81,,,,,,,fee schedule,55.81,259.1,
Remote dx retinal imaging,92227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,60.97,,,,,,,fee schedule,55.81,259.1,
Remote dx retinal imaging,92227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,64.1,,,,,,,fee schedule,55.81,259.1,
Remote dx retinal imaging,92227,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,55.81,259.1,APC 378
Remote dx retinal imaging,92227,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,55.81,259.1,APC
Remote dx retinal imaging,92227,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,55.81,259.1,APC
Remote dx retinal imaging,92227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,55.81,259.1,APC
Remote dx retinal imaging,92227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,55.81,259.1,Radiology
Remote dx retinal imaging,92227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,55.81,259.1,APC
Remote dx retinal imaging,92227,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,55.81,259.1,APC
Remote retinal imaging mgmt,92228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,69.63,,,,,,,fee schedule,36.98,164.05,
Remote retinal imaging mgmt,92228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55.81,,,,,,,fee schedule,36.98,164.05,
Remote retinal imaging mgmt,92228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,60.97,,,,,,,fee schedule,36.98,164.05,
Remote retinal imaging mgmt,92228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,64.1,,,,,,,fee schedule,36.98,164.05,
Remote retinal imaging mgmt,92228,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.05,,,,,,,fee schedule,36.98,164.05,APC 378
Remote retinal imaging mgmt,92228,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.83,,,,,,,fee schedule,36.98,164.05,APC
Remote retinal imaging mgmt,92228,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.46,,,,,,,fee schedule,36.98,164.05,APC
Remote retinal imaging mgmt,92228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.98,,,,,,,fee schedule,36.98,164.05,APC
Remote retinal imaging mgmt,92228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.57,,,,,,,fee schedule,36.98,164.05,Radiology
Remote retinal imaging mgmt,92228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.77,,,,,,,fee schedule,36.98,164.05,APC
Remote retinal imaging mgmt,92228,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.71,,,,,,,fee schedule,36.98,164.05,APC
Img rta detc/mntr ds poc aly,92229,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,210.39,,,,,,,fee schedule,58.4,259.1,
Img rta detc/mntr ds poc aly,92229,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,168.65,,,,,,,fee schedule,58.4,259.1,
Img rta detc/mntr ds poc aly,92229,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,184.23,,,,,,,fee schedule,58.4,259.1,
Img rta detc/mntr ds poc aly,92229,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,193.7,,,,,,,fee schedule,58.4,259.1,
Img rta detc/mntr ds poc aly,92229,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,58.4,259.1,APC 378
Img rta detc/mntr ds poc aly,92229,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,58.4,259.1,APC
Img rta detc/mntr ds poc aly,92229,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,58.4,259.1,APC
Img rta detc/mntr ds poc aly,92229,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,58.4,259.1,APC
Img rta detc/mntr ds poc aly,92229,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,58.4,259.1,Radiology
Img rta detc/mntr ds poc aly,92229,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,58.4,259.1,APC
Img rta detc/mntr ds poc aly,92229,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,58.4,259.1,APC
Eye exam with photos,92230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,543.83,,,,,,,fee schedule,369.41,1638.96,
Eye exam with photos,92230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,435.93,,,,,,,fee schedule,369.41,1638.96,
Eye exam with photos,92230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,476.21,,,,,,,fee schedule,369.41,1638.96,
Eye exam with photos,92230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,500.67,,,,,,,fee schedule,369.41,1638.96,
Eye exam with photos,92230,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1638.96,,,,,,,fee schedule,369.41,1638.96,APC 378
Eye exam with photos,92230,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,387.88,,,,,,,fee schedule,369.41,1638.96,APC
Eye exam with photos,92230,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,384.19,,,,,,,fee schedule,369.41,1638.96,APC
Eye exam with photos,92230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,369.41,,,,,,,fee schedule,369.41,1638.96,APC
Eye exam with photos,92230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,565.2,,,,,,,fee schedule,369.41,1638.96,Radiology
Eye exam with photos,92230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,517.18,,,,,,,fee schedule,369.41,1638.96,APC
Eye exam with photos,92230,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,646.47,,,,,,,fee schedule,369.41,1638.96,APC
Fluorescein angrph uni/bi,92235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,254.05,,,,,,,fee schedule,203.65,948.37,
Fluorescein angrph uni/bi,92235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,203.65,,,,,,,fee schedule,203.65,948.37,
Fluorescein angrph uni/bi,92235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,222.47,,,,,,,fee schedule,203.65,948.37,
Fluorescein angrph uni/bi,92235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,233.89,,,,,,,fee schedule,203.65,948.37,
Fluorescein angrph uni/bi,92235,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,203.65,948.37,APC 378
Fluorescein angrph uni/bi,92235,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,203.65,948.37,APC
Fluorescein angrph uni/bi,92235,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,203.65,948.37,APC
Fluorescein angrph uni/bi,92235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,203.65,948.37,APC
Fluorescein angrph uni/bi,92235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,203.65,948.37,Radiology
Fluorescein angrph uni/bi,92235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,203.65,948.37,APC
Fluorescein angrph uni/bi,92235,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,203.65,948.37,APC
Icg angiography uni/bi,92240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,479.46,,,,,,,fee schedule,213.76,948.37,
Icg angiography uni/bi,92240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,384.33,,,,,,,fee schedule,213.76,948.37,
Icg angiography uni/bi,92240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,419.84,,,,,,,fee schedule,213.76,948.37,
Icg angiography uni/bi,92240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.4,,,,,,,fee schedule,213.76,948.37,
Icg angiography uni/bi,92240,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,213.76,948.37,APC 378
Icg angiography uni/bi,92240,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,213.76,948.37,APC
Icg angiography uni/bi,92240,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,213.76,948.37,APC
Icg angiography uni/bi,92240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,213.76,948.37,APC
Icg angiography uni/bi,92240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,213.76,948.37,Radiology
Icg angiography uni/bi,92240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,213.76,948.37,APC
Icg angiography uni/bi,92240,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,213.76,948.37,APC
Fluorescein icg angiography,92242,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,878.13,,,,,,,fee schedule,213.76,948.37,
Fluorescein icg angiography,92242,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,703.9,,,,,,,fee schedule,213.76,948.37,
Fluorescein icg angiography,92242,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,768.95,,,,,,,fee schedule,213.76,948.37,
Fluorescein icg angiography,92242,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,808.44,,,,,,,fee schedule,213.76,948.37,
Fluorescein icg angiography,92242,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,213.76,948.37,APC 378
Fluorescein icg angiography,92242,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,213.76,948.37,APC
Fluorescein icg angiography,92242,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,213.76,948.37,APC
Fluorescein icg angiography,92242,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,213.76,948.37,APC
Fluorescein icg angiography,92242,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,213.76,948.37,Radiology
Fluorescein icg angiography,92242,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,213.76,948.37,APC
Fluorescein icg angiography,92242,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,213.76,948.37,APC
Eye exam with photos,92250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,145.87,,,,,,,fee schedule,116.93,584.37,
Eye exam with photos,92250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,116.93,,,,,,,fee schedule,116.93,584.37,
Eye exam with photos,92250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,127.73,,,,,,,fee schedule,116.93,584.37,
Eye exam with photos,92250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,134.29,,,,,,,fee schedule,116.93,584.37,
Eye exam with photos,92250,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,116.93,584.37,APC 378
Eye exam with photos,92250,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,116.93,584.37,APC
Eye exam with photos,92250,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,116.93,584.37,APC
Eye exam with photos,92250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,116.93,584.37,APC
Eye exam with photos,92250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,116.93,584.37,Radiology
Eye exam with photos,92250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,116.93,584.37,APC
Eye exam with photos,92250,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,116.93,584.37,APC
Ophthalmoscopy/dynamometry,92260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,147.34,,,,,,,fee schedule,36.98,164.05,
Ophthalmoscopy/dynamometry,92260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,118.11,,,,,,,fee schedule,36.98,164.05,
Ophthalmoscopy/dynamometry,92260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,129.02,,,,,,,fee schedule,36.98,164.05,
Ophthalmoscopy/dynamometry,92260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,135.65,,,,,,,fee schedule,36.98,164.05,
Ophthalmoscopy/dynamometry,92260,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.05,,,,,,,fee schedule,36.98,164.05,APC 378
Ophthalmoscopy/dynamometry,92260,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.83,,,,,,,fee schedule,36.98,164.05,APC
Ophthalmoscopy/dynamometry,92260,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.46,,,,,,,fee schedule,36.98,164.05,APC
Ophthalmoscopy/dynamometry,92260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.98,,,,,,,fee schedule,36.98,164.05,APC
Ophthalmoscopy/dynamometry,92260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.57,,,,,,,fee schedule,36.98,164.05,Radiology
Ophthalmoscopy/dynamometry,92260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.77,,,,,,,fee schedule,36.98,164.05,APC
Ophthalmoscopy/dynamometry,92260,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.71,,,,,,,fee schedule,36.98,164.05,APC
Eye muscle evaluation,92265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,106.1,,,,,,,fee schedule,58.4,259.1,
Eye muscle evaluation,92265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,85.05,,,,,,,fee schedule,58.4,259.1,
Eye muscle evaluation,92265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,92.91,,,,,,,fee schedule,58.4,259.1,
Eye muscle evaluation,92265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,97.68,,,,,,,fee schedule,58.4,259.1,
Eye muscle evaluation,92265,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,58.4,259.1,APC 378
Eye muscle evaluation,92265,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,58.4,259.1,APC
Eye muscle evaluation,92265,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,58.4,259.1,APC
Eye muscle evaluation,92265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,58.4,259.1,APC
Eye muscle evaluation,92265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,58.4,259.1,Radiology
Eye muscle evaluation,92265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,58.4,259.1,APC
Eye muscle evaluation,92265,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,58.4,259.1,APC
Electro-oculography,92270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,140.09,,,,,,,fee schedule,112.29,584.37,
Electro-oculography,92270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,112.29,,,,,,,fee schedule,112.29,584.37,
Electro-oculography,92270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,122.67,,,,,,,fee schedule,112.29,584.37,
Electro-oculography,92270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,128.97,,,,,,,fee schedule,112.29,584.37,
Electro-oculography,92270,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,112.29,584.37,APC 378
Electro-oculography,92270,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,112.29,584.37,APC
Electro-oculography,92270,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,112.29,584.37,APC
Electro-oculography,92270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,112.29,584.37,APC
Electro-oculography,92270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,112.29,584.37,Radiology
Electro-oculography,92270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,112.29,584.37,APC
Electro-oculography,92270,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,112.29,584.37,APC
Full field erg w/i&r,92273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,953.73,,,,,,,fee schedule,213.76,953.73,
Full field erg w/i&r,92273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,764.5,,,,,,,fee schedule,213.76,953.73,
Full field erg w/i&r,92273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,835.15,,,,,,,fee schedule,213.76,953.73,
Full field erg w/i&r,92273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,878.04,,,,,,,fee schedule,213.76,953.73,
Full field erg w/i&r,92273,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,213.76,953.73,APC 378
Full field erg w/i&r,92273,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,213.76,953.73,APC
Full field erg w/i&r,92273,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,213.76,953.73,APC
Full field erg w/i&r,92273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,213.76,953.73,APC
Full field erg w/i&r,92273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,213.76,953.73,Radiology
Full field erg w/i&r,92273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,213.76,953.73,APC
Full field erg w/i&r,92273,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,213.76,953.73,APC
Multifocal erg w/i&r,92274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,513.89,,,,,,,fee schedule,127.38,565.15,
Multifocal erg w/i&r,92274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,411.93,,,,,,,fee schedule,127.38,565.15,
Multifocal erg w/i&r,92274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,449.99,,,,,,,fee schedule,127.38,565.15,
Multifocal erg w/i&r,92274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,473.11,,,,,,,fee schedule,127.38,565.15,
Multifocal erg w/i&r,92274,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,565.15,,,,,,,fee schedule,127.38,565.15,APC 378
Multifocal erg w/i&r,92274,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,133.75,,,,,,,fee schedule,127.38,565.15,APC
Multifocal erg w/i&r,92274,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,132.48,,,,,,,fee schedule,127.38,565.15,APC
Multifocal erg w/i&r,92274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,127.38,,,,,,,fee schedule,127.38,565.15,APC
Multifocal erg w/i&r,92274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,194.89,,,,,,,fee schedule,127.38,565.15,Radiology
Multifocal erg w/i&r,92274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,178.33,,,,,,,fee schedule,127.38,565.15,APC
Multifocal erg w/i&r,92274,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,222.92,,,,,,,fee schedule,127.38,565.15,APC
Color vision examination,92283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,110.68,,,,,,,fee schedule,58.4,259.1,
Color vision examination,92283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,88.72,,,,,,,fee schedule,58.4,259.1,
Color vision examination,92283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,96.92,,,,,,,fee schedule,58.4,259.1,
Color vision examination,92283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,101.89,,,,,,,fee schedule,58.4,259.1,
Color vision examination,92283,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,58.4,259.1,APC 378
Color vision examination,92283,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,58.4,259.1,APC
Color vision examination,92283,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,58.4,259.1,APC
Color vision examination,92283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,58.4,259.1,APC
Color vision examination,92283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,58.4,259.1,Radiology
Color vision examination,92283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,58.4,259.1,APC
Color vision examination,92283,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,58.4,259.1,APC
Dark adaptation eye exam,92284,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,148.33,,,,,,,fee schedule,118.9,1962.08,
Dark adaptation eye exam,92284,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,118.9,,,,,,,fee schedule,118.9,1962.08,
Dark adaptation eye exam,92284,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,129.88,,,,,,,fee schedule,118.9,1962.08,
Dark adaptation eye exam,92284,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,136.56,,,,,,,fee schedule,118.9,1962.08,
Dark adaptation eye exam,92284,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1962.08,,,,,,,fee schedule,118.9,1962.08,APC 378
Dark adaptation eye exam,92284,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,464.35,,,,,,,fee schedule,118.9,1962.08,APC
Dark adaptation eye exam,92284,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,459.93,,,,,,,fee schedule,118.9,1962.08,APC
Dark adaptation eye exam,92284,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,442.24,,,,,,,fee schedule,118.9,1962.08,APC
Dark adaptation eye exam,92284,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,676.63,,,,,,,fee schedule,118.9,1962.08,Radiology
Dark adaptation eye exam,92284,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,619.14,,,,,,,fee schedule,118.9,1962.08,APC
Dark adaptation eye exam,92284,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,773.92,,,,,,,fee schedule,118.9,1962.08,APC
Eye photography,92285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,93.71,,,,,,,fee schedule,36.98,164.05,
Eye photography,92285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,75.11,,,,,,,fee schedule,36.98,164.05,
Eye photography,92285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,82.05,,,,,,,fee schedule,36.98,164.05,
Eye photography,92285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,86.27,,,,,,,fee schedule,36.98,164.05,
Eye photography,92285,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.05,,,,,,,fee schedule,36.98,164.05,APC 378
Eye photography,92285,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.83,,,,,,,fee schedule,36.98,164.05,APC
Eye photography,92285,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.46,,,,,,,fee schedule,36.98,164.05,APC
Eye photography,92285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.98,,,,,,,fee schedule,36.98,164.05,APC
Eye photography,92285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.57,,,,,,,fee schedule,36.98,164.05,Radiology
Eye photography,92285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.77,,,,,,,fee schedule,36.98,164.05,APC
Eye photography,92285,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.71,,,,,,,fee schedule,36.98,164.05,APC
Internal eye photography,92286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,254.17,,,,,,,fee schedule,131.71,584.37,
Internal eye photography,92286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,203.74,,,,,,,fee schedule,131.71,584.37,
Internal eye photography,92286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,222.56,,,,,,,fee schedule,131.71,584.37,
Internal eye photography,92286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,234,,,,,,,fee schedule,131.71,584.37,
Internal eye photography,92286,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,131.71,584.37,APC 378
Internal eye photography,92286,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,131.71,584.37,APC
Internal eye photography,92286,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,131.71,584.37,APC
Internal eye photography,92286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,131.71,584.37,APC
Internal eye photography,92286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,131.71,584.37,Radiology
Internal eye photography,92286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,131.71,584.37,APC
Internal eye photography,92286,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,131.71,584.37,APC
Internal eye photography,92287,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,543.83,,,,,,,fee schedule,131.71,584.37,
Internal eye photography,92287,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,435.93,,,,,,,fee schedule,131.71,584.37,
Internal eye photography,92287,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,476.21,,,,,,,fee schedule,131.71,584.37,
Internal eye photography,92287,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,500.67,,,,,,,fee schedule,131.71,584.37,
Internal eye photography,92287,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,131.71,584.37,APC 378
Internal eye photography,92287,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,131.71,584.37,APC
Internal eye photography,92287,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,131.71,584.37,APC
Internal eye photography,92287,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,131.71,584.37,APC
Internal eye photography,92287,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,131.71,584.37,Radiology
Internal eye photography,92287,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,131.71,584.37,APC
Internal eye photography,92287,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,131.71,584.37,APC
Contact lens fitting,92311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,217.05,,,,,,,fee schedule,173.98,1962.08,
Contact lens fitting,92311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,173.98,,,,,,,fee schedule,173.98,1962.08,
Contact lens fitting,92311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,190.06,,,,,,,fee schedule,173.98,1962.08,
Contact lens fitting,92311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,199.82,,,,,,,fee schedule,173.98,1962.08,
Contact lens fitting,92311,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1962.08,,,,,,,fee schedule,173.98,1962.08,APC 378
Contact lens fitting,92311,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,464.35,,,,,,,fee schedule,173.98,1962.08,APC
Contact lens fitting,92311,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,459.93,,,,,,,fee schedule,173.98,1962.08,APC
Contact lens fitting,92311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,442.24,,,,,,,fee schedule,173.98,1962.08,APC
Contact lens fitting,92311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,676.63,,,,,,,fee schedule,173.98,1962.08,Radiology
Contact lens fitting,92311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,619.14,,,,,,,fee schedule,173.98,1962.08,APC
Contact lens fitting,92311,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,773.92,,,,,,,fee schedule,173.98,1962.08,APC
Contact lens fitting,92312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,217.05,,,,,,,fee schedule,131.71,584.37,
Contact lens fitting,92312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,173.98,,,,,,,fee schedule,131.71,584.37,
Contact lens fitting,92312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,190.06,,,,,,,fee schedule,131.71,584.37,
Contact lens fitting,92312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,199.82,,,,,,,fee schedule,131.71,584.37,
Contact lens fitting,92312,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,131.71,584.37,APC 378
Contact lens fitting,92312,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,131.71,584.37,APC
Contact lens fitting,92312,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,131.71,584.37,APC
Contact lens fitting,92312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,131.71,584.37,APC
Contact lens fitting,92312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,131.71,584.37,Radiology
Contact lens fitting,92312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,131.71,584.37,APC
Contact lens fitting,92312,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,131.71,584.37,APC
Contact lens fitting,92313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,147.34,,,,,,,fee schedule,118.11,584.37,
Contact lens fitting,92313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,118.11,,,,,,,fee schedule,118.11,584.37,
Contact lens fitting,92313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,129.02,,,,,,,fee schedule,118.11,584.37,
Contact lens fitting,92313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,135.65,,,,,,,fee schedule,118.11,584.37,
Contact lens fitting,92313,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,118.11,584.37,APC 378
Contact lens fitting,92313,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,118.11,584.37,APC
Contact lens fitting,92313,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,118.11,584.37,APC
Contact lens fitting,92313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,118.11,584.37,APC
Contact lens fitting,92313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,118.11,584.37,Radiology
Contact lens fitting,92313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,118.11,584.37,APC
Contact lens fitting,92313,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,118.11,584.37,APC
Rx cntact lens aphakia 1 eye,92315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,147.34,,,,,,,fee schedule,118.11,584.37,
Rx cntact lens aphakia 1 eye,92315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,118.11,,,,,,,fee schedule,118.11,584.37,
Rx cntact lens aphakia 1 eye,92315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,129.02,,,,,,,fee schedule,118.11,584.37,
Rx cntact lens aphakia 1 eye,92315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,135.65,,,,,,,fee schedule,118.11,584.37,
Rx cntact lens aphakia 1 eye,92315,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,118.11,584.37,APC 378
Rx cntact lens aphakia 1 eye,92315,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,118.11,584.37,APC
Rx cntact lens aphakia 1 eye,92315,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,118.11,584.37,APC
Rx cntact lens aphakia 1 eye,92315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,118.11,584.37,APC
Rx cntact lens aphakia 1 eye,92315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,118.11,584.37,Radiology
Rx cntact lens aphakia 1 eye,92315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,118.11,584.37,APC
Rx cntact lens aphakia 1 eye,92315,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,118.11,584.37,APC
Rx cntact lens aphakia 2 eye,92316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,217.05,,,,,,,fee schedule,131.71,584.37,
Rx cntact lens aphakia 2 eye,92316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,173.98,,,,,,,fee schedule,131.71,584.37,
Rx cntact lens aphakia 2 eye,92316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,190.06,,,,,,,fee schedule,131.71,584.37,
Rx cntact lens aphakia 2 eye,92316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,199.82,,,,,,,fee schedule,131.71,584.37,
Rx cntact lens aphakia 2 eye,92316,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,131.71,584.37,APC 378
Rx cntact lens aphakia 2 eye,92316,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,131.71,584.37,APC
Rx cntact lens aphakia 2 eye,92316,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,131.71,584.37,APC
Rx cntact lens aphakia 2 eye,92316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,131.71,584.37,APC
Rx cntact lens aphakia 2 eye,92316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,131.71,584.37,Radiology
Rx cntact lens aphakia 2 eye,92316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,131.71,584.37,APC
Rx cntact lens aphakia 2 eye,92316,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,131.71,584.37,APC
Rx corneoscleral cntact lens,92317,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,147.34,,,,,,,fee schedule,36.98,164.05,
Rx corneoscleral cntact lens,92317,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,118.11,,,,,,,fee schedule,36.98,164.05,
Rx corneoscleral cntact lens,92317,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,129.02,,,,,,,fee schedule,36.98,164.05,
Rx corneoscleral cntact lens,92317,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,135.65,,,,,,,fee schedule,36.98,164.05,
Rx corneoscleral cntact lens,92317,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.05,,,,,,,fee schedule,36.98,164.05,APC 378
Rx corneoscleral cntact lens,92317,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.83,,,,,,,fee schedule,36.98,164.05,APC
Rx corneoscleral cntact lens,92317,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.46,,,,,,,fee schedule,36.98,164.05,APC
Rx corneoscleral cntact lens,92317,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.98,,,,,,,fee schedule,36.98,164.05,APC
Rx corneoscleral cntact lens,92317,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.57,,,,,,,fee schedule,36.98,164.05,Radiology
Rx corneoscleral cntact lens,92317,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.77,,,,,,,fee schedule,36.98,164.05,APC
Rx corneoscleral cntact lens,92317,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.71,,,,,,,fee schedule,36.98,164.05,APC
Modification of contact lens,92325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,147.34,,,,,,,fee schedule,118.11,584.37,
Modification of contact lens,92325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,118.11,,,,,,,fee schedule,118.11,584.37,
Modification of contact lens,92325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,129.02,,,,,,,fee schedule,118.11,584.37,
Modification of contact lens,92325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,135.65,,,,,,,fee schedule,118.11,584.37,
Modification of contact lens,92325,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,118.11,584.37,APC 378
Modification of contact lens,92325,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,118.11,584.37,APC
Modification of contact lens,92325,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,118.11,584.37,APC
Modification of contact lens,92325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,118.11,584.37,APC
Modification of contact lens,92325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,118.11,584.37,Radiology
Modification of contact lens,92325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,118.11,584.37,APC
Modification of contact lens,92325,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,118.11,584.37,APC
Replacement of contact lens,92326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,217.05,,,,,,,fee schedule,58.4,259.1,
Replacement of contact lens,92326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,173.98,,,,,,,fee schedule,58.4,259.1,
Replacement of contact lens,92326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,190.06,,,,,,,fee schedule,58.4,259.1,
Replacement of contact lens,92326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,199.82,,,,,,,fee schedule,58.4,259.1,
Replacement of contact lens,92326,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,58.4,259.1,APC 378
Replacement of contact lens,92326,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,58.4,259.1,APC
Replacement of contact lens,92326,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,58.4,259.1,APC
Replacement of contact lens,92326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,58.4,259.1,APC
Replacement of contact lens,92326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,58.4,259.1,Radiology
Replacement of contact lens,92326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,58.4,259.1,APC
Replacement of contact lens,92326,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,58.4,259.1,APC
Fit aphakia spectcl monofocl,92352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,217.05,,,,,,,fee schedule,58.4,259.1,
Fit aphakia spectcl monofocl,92352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,173.98,,,,,,,fee schedule,58.4,259.1,
Fit aphakia spectcl monofocl,92352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,190.06,,,,,,,fee schedule,58.4,259.1,
Fit aphakia spectcl monofocl,92352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,199.82,,,,,,,fee schedule,58.4,259.1,
Fit aphakia spectcl monofocl,92352,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,58.4,259.1,APC 378
Fit aphakia spectcl monofocl,92352,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,58.4,259.1,APC
Fit aphakia spectcl monofocl,92352,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,58.4,259.1,APC
Fit aphakia spectcl monofocl,92352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,58.4,259.1,APC
Fit aphakia spectcl monofocl,92352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,58.4,259.1,Radiology
Fit aphakia spectcl monofocl,92352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,58.4,259.1,APC
Fit aphakia spectcl monofocl,92352,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,58.4,259.1,APC
Fit aphakia spectcl multifoc,92353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,147.34,,,,,,,fee schedule,58.4,259.1,
Fit aphakia spectcl multifoc,92353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,118.11,,,,,,,fee schedule,58.4,259.1,
Fit aphakia spectcl multifoc,92353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,129.02,,,,,,,fee schedule,58.4,259.1,
Fit aphakia spectcl multifoc,92353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,135.65,,,,,,,fee schedule,58.4,259.1,
Fit aphakia spectcl multifoc,92353,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,58.4,259.1,APC 378
Fit aphakia spectcl multifoc,92353,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,58.4,259.1,APC
Fit aphakia spectcl multifoc,92353,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,58.4,259.1,APC
Fit aphakia spectcl multifoc,92353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,58.4,259.1,APC
Fit aphakia spectcl multifoc,92353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,58.4,259.1,Radiology
Fit aphakia spectcl multifoc,92353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,58.4,259.1,APC
Fit aphakia spectcl multifoc,92353,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,58.4,259.1,APC
Fit spectacles single system,92354,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,147.34,,,,,,,fee schedule,36.98,164.05,
Fit spectacles single system,92354,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,118.11,,,,,,,fee schedule,36.98,164.05,
Fit spectacles single system,92354,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,129.02,,,,,,,fee schedule,36.98,164.05,
Fit spectacles single system,92354,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,135.65,,,,,,,fee schedule,36.98,164.05,
Fit spectacles single system,92354,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.05,,,,,,,fee schedule,36.98,164.05,APC 378
Fit spectacles single system,92354,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.83,,,,,,,fee schedule,36.98,164.05,APC
Fit spectacles single system,92354,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.46,,,,,,,fee schedule,36.98,164.05,APC
Fit spectacles single system,92354,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.98,,,,,,,fee schedule,36.98,164.05,APC
Fit spectacles single system,92354,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.57,,,,,,,fee schedule,36.98,164.05,Radiology
Fit spectacles single system,92354,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.77,,,,,,,fee schedule,36.98,164.05,APC
Fit spectacles single system,92354,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.71,,,,,,,fee schedule,36.98,164.05,APC
Fit spectacles compound lens,92355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,147.34,,,,,,,fee schedule,36.98,164.05,
Fit spectacles compound lens,92355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,118.11,,,,,,,fee schedule,36.98,164.05,
Fit spectacles compound lens,92355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,129.02,,,,,,,fee schedule,36.98,164.05,
Fit spectacles compound lens,92355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,135.65,,,,,,,fee schedule,36.98,164.05,
Fit spectacles compound lens,92355,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.05,,,,,,,fee schedule,36.98,164.05,APC 378
Fit spectacles compound lens,92355,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.83,,,,,,,fee schedule,36.98,164.05,APC
Fit spectacles compound lens,92355,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.46,,,,,,,fee schedule,36.98,164.05,APC
Fit spectacles compound lens,92355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.98,,,,,,,fee schedule,36.98,164.05,APC
Fit spectacles compound lens,92355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.57,,,,,,,fee schedule,36.98,164.05,Radiology
Fit spectacles compound lens,92355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.77,,,,,,,fee schedule,36.98,164.05,APC
Fit spectacles compound lens,92355,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.71,,,,,,,fee schedule,36.98,164.05,APC
Aphakia prosth service temp,92358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,147.34,,,,,,,fee schedule,58.4,259.1,
Aphakia prosth service temp,92358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,118.11,,,,,,,fee schedule,58.4,259.1,
Aphakia prosth service temp,92358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,129.02,,,,,,,fee schedule,58.4,259.1,
Aphakia prosth service temp,92358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,135.65,,,,,,,fee schedule,58.4,259.1,
Aphakia prosth service temp,92358,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,58.4,259.1,APC 378
Aphakia prosth service temp,92358,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,58.4,259.1,APC
Aphakia prosth service temp,92358,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,58.4,259.1,APC
Aphakia prosth service temp,92358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,58.4,259.1,APC
Aphakia prosth service temp,92358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,58.4,259.1,Radiology
Aphakia prosth service temp,92358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,58.4,259.1,APC
Aphakia prosth service temp,92358,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,58.4,259.1,APC
Repair & adjust spectacles,92371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,147.34,,,,,,,fee schedule,58.4,259.1,
Repair & adjust spectacles,92371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,118.11,,,,,,,fee schedule,58.4,259.1,
Repair & adjust spectacles,92371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,129.02,,,,,,,fee schedule,58.4,259.1,
Repair & adjust spectacles,92371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,135.65,,,,,,,fee schedule,58.4,259.1,
Repair & adjust spectacles,92371,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,58.4,259.1,APC 378
Repair & adjust spectacles,92371,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,58.4,259.1,APC
Repair & adjust spectacles,92371,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,58.4,259.1,APC
Repair & adjust spectacles,92371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,58.4,259.1,APC
Repair & adjust spectacles,92371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,58.4,259.1,Radiology
Repair & adjust spectacles,92371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,58.4,259.1,APC
Repair & adjust spectacles,92371,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,58.4,259.1,APC
Eye service or procedure,92499,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,127.04,,,,,,,fee schedule,28.63,127.04,APC 378
Eye service or procedure,92499,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.07,,,,,,,fee schedule,28.63,127.04,APC
Eye service or procedure,92499,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,29.78,,,,,,,fee schedule,28.63,127.04,APC
Eye service or procedure,92499,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,28.63,,,,,,,fee schedule,28.63,127.04,APC
Eye service or procedure,92499,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43.81,,,,,,,fee schedule,28.63,127.04,Radiology
Eye service or procedure,92499,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40.09,,,,,,,fee schedule,28.63,127.04,APC
Eye service or procedure,92499,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,50.11,,,,,,,fee schedule,28.63,127.04,APC
Ear and throat examination,92502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,624,,,,,,,fee schedule,500.19,2368.81,
Ear and throat examination,92502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,500.19,,,,,,,fee schedule,500.19,2368.81,
Ear and throat examination,92502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,546.41,,,,,,,fee schedule,500.19,2368.81,
Ear and throat examination,92502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,574.48,,,,,,,fee schedule,500.19,2368.81,
Ear and throat examination,92502,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2368.81,,,,,,,fee schedule,500.19,2368.81,APC 378
Ear and throat examination,92502,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,560.61,,,,,,,fee schedule,500.19,2368.81,APC
Ear and throat examination,92502,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,555.27,,,,,,,fee schedule,500.19,2368.81,APC
Ear and throat examination,92502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,533.92,,,,,,,fee schedule,500.19,2368.81,APC
Ear and throat examination,92502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,816.89,,,,,,,fee schedule,500.19,2368.81,Radiology
Ear and throat examination,92502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,747.48,,,,,,,fee schedule,500.19,2368.81,APC
Ear and throat examination,92502,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,934.36,,,,,,,fee schedule,500.19,2368.81,APC
Speech/hearing therapy,92507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,191.86,,,,,,,fee schedule,73.53,191.86,
Speech/hearing therapy,92507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,153.79,,,,,,,fee schedule,73.53,191.86,
Speech/hearing therapy,92507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,168.01,,,,,,,fee schedule,73.53,191.86,
Speech/hearing therapy,92507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,176.63,,,,,,,fee schedule,73.53,191.86,
Speech/hearing therapy,92507,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,73.53,,,,,,,fee schedule,73.53,191.86,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Speech/hearing therapy,92507,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,77.21,,,,,,,fee schedule,73.53,191.86,APC
Speech/hearing therapy,92507,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,76.47,,,,,,,fee schedule,73.53,191.86,APC
Speech/hearing therapy,92507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,112.5,,,,,,,fee schedule,73.53,191.86,Radiology
Speech/hearing therapy,92507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,102.94,,,,,,,fee schedule,73.53,191.86,APC
Speech/hearing therapy,92507,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,128.68,,,,,,,fee schedule,73.53,191.86,APC
Speech/hearing therapy,92508,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,49.06,,,,,,,fee schedule,23.06,49.06,
Speech/hearing therapy,92508,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39.33,,,,,,,fee schedule,23.06,49.06,
Speech/hearing therapy,92508,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.96,,,,,,,fee schedule,23.06,49.06,
Speech/hearing therapy,92508,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45.17,,,,,,,fee schedule,23.06,49.06,
Speech/hearing therapy,92508,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23.06,,,,,,,fee schedule,23.06,49.06,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Speech/hearing therapy,92508,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,24.21,,,,,,,fee schedule,23.06,49.06,APC
Speech/hearing therapy,92508,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,23.98,,,,,,,fee schedule,23.06,49.06,APC
Speech/hearing therapy,92508,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,35.28,,,,,,,fee schedule,23.06,49.06,Radiology
Speech/hearing therapy,92508,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,32.28,,,,,,,fee schedule,23.06,49.06,APC
Speech/hearing therapy,92508,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,40.35,,,,,,,fee schedule,23.06,49.06,APC
Nasopharyngoscopy,92511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,205.25,,,,,,,fee schedule,164.53,876.7,
Nasopharyngoscopy,92511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,164.53,,,,,,,fee schedule,164.53,876.7,
Nasopharyngoscopy,92511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,179.73,,,,,,,fee schedule,164.53,876.7,
Nasopharyngoscopy,92511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,188.96,,,,,,,fee schedule,164.53,876.7,
Nasopharyngoscopy,92511,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,876.7,,,,,,,fee schedule,164.53,876.7,APC 378
Nasopharyngoscopy,92511,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,207.48,,,,,,,fee schedule,164.53,876.7,APC
Nasopharyngoscopy,92511,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,205.51,,,,,,,fee schedule,164.53,876.7,APC
Nasopharyngoscopy,92511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,197.6,,,,,,,fee schedule,164.53,876.7,APC
Nasopharyngoscopy,92511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,302.33,,,,,,,fee schedule,164.53,876.7,Radiology
Nasopharyngoscopy,92511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,276.65,,,,,,,fee schedule,164.53,876.7,APC
Nasopharyngoscopy,92511,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,345.81,,,,,,,fee schedule,164.53,876.7,APC
Nasal function studies,92512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,201.32,,,,,,,fee schedule,161.38,948.37,
Nasal function studies,92512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,161.38,,,,,,,fee schedule,161.38,948.37,
Nasal function studies,92512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,176.29,,,,,,,fee schedule,161.38,948.37,
Nasal function studies,92512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,185.34,,,,,,,fee schedule,161.38,948.37,
Nasal function studies,92512,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,161.38,948.37,APC 378
Nasal function studies,92512,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,161.38,948.37,APC
Nasal function studies,92512,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,161.38,948.37,APC
Nasal function studies,92512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,161.38,948.37,APC
Nasal function studies,92512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,161.38,948.37,Radiology
Nasal function studies,92512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,161.38,948.37,APC
Nasal function studies,92512,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,161.38,948.37,APC
Facial nerve function test,92516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,357.21,,,,,,,fee schedule,213.76,948.37,
Facial nerve function test,92516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,286.34,,,,,,,fee schedule,213.76,948.37,
Facial nerve function test,92516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,312.8,,,,,,,fee schedule,213.76,948.37,
Facial nerve function test,92516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,328.86,,,,,,,fee schedule,213.76,948.37,
Facial nerve function test,92516,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,213.76,948.37,APC 378
Facial nerve function test,92516,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,213.76,948.37,APC
Facial nerve function test,92516,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,213.76,948.37,APC
Facial nerve function test,92516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,213.76,948.37,APC
Facial nerve function test,92516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,213.76,948.37,Radiology
Facial nerve function test,92516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,213.76,948.37,APC
Facial nerve function test,92516,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,213.76,948.37,APC
Vemp test i&r cervical,92517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,527.5,,,,,,,fee schedule,127.38,565.15,
Vemp test i&r cervical,92517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,422.84,,,,,,,fee schedule,127.38,565.15,
Vemp test i&r cervical,92517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,461.91,,,,,,,fee schedule,127.38,565.15,
Vemp test i&r cervical,92517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,485.63,,,,,,,fee schedule,127.38,565.15,
Vemp test i&r cervical,92517,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,565.15,,,,,,,fee schedule,127.38,565.15,APC 378
Vemp test i&r cervical,92517,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,133.75,,,,,,,fee schedule,127.38,565.15,APC
Vemp test i&r cervical,92517,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,132.48,,,,,,,fee schedule,127.38,565.15,APC
Vemp test i&r cervical,92517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,127.38,,,,,,,fee schedule,127.38,565.15,APC
Vemp test i&r cervical,92517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,194.89,,,,,,,fee schedule,127.38,565.15,Radiology
Vemp test i&r cervical,92517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,178.33,,,,,,,fee schedule,127.38,565.15,APC
Vemp test i&r cervical,92517,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,222.92,,,,,,,fee schedule,127.38,565.15,APC
Vemp test i&r ocular,92518,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,527.5,,,,,,,fee schedule,127.38,565.15,
Vemp test i&r ocular,92518,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,422.84,,,,,,,fee schedule,127.38,565.15,
Vemp test i&r ocular,92518,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,461.91,,,,,,,fee schedule,127.38,565.15,
Vemp test i&r ocular,92518,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,485.63,,,,,,,fee schedule,127.38,565.15,
Vemp test i&r ocular,92518,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,565.15,,,,,,,fee schedule,127.38,565.15,APC 378
Vemp test i&r ocular,92518,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,133.75,,,,,,,fee schedule,127.38,565.15,APC
Vemp test i&r ocular,92518,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,132.48,,,,,,,fee schedule,127.38,565.15,APC
Vemp test i&r ocular,92518,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,127.38,,,,,,,fee schedule,127.38,565.15,APC
Vemp test i&r ocular,92518,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,194.89,,,,,,,fee schedule,127.38,565.15,Radiology
Vemp test i&r ocular,92518,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,178.33,,,,,,,fee schedule,127.38,565.15,APC
Vemp test i&r ocular,92518,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,222.92,,,,,,,fee schedule,127.38,565.15,APC
Vemp tst i&r cervical&ocular,92519,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,999.62,,,,,,,fee schedule,213.76,999.62,
Vemp tst i&r cervical&ocular,92519,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,801.28,,,,,,,fee schedule,213.76,999.62,
Vemp tst i&r cervical&ocular,92519,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,875.33,,,,,,,fee schedule,213.76,999.62,
Vemp tst i&r cervical&ocular,92519,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,920.29,,,,,,,fee schedule,213.76,999.62,
Vemp tst i&r cervical&ocular,92519,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,213.76,999.62,APC 378
Vemp tst i&r cervical&ocular,92519,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,213.76,999.62,APC
Vemp tst i&r cervical&ocular,92519,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,213.76,999.62,APC
Vemp tst i&r cervical&ocular,92519,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,213.76,999.62,APC
Vemp tst i&r cervical&ocular,92519,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,213.76,999.62,Radiology
Vemp tst i&r cervical&ocular,92519,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,213.76,999.62,APC
Vemp tst i&r cervical&ocular,92519,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,213.76,999.62,APC
Laryngeal function studies,92520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,357.21,,,,,,,fee schedule,131.71,584.37,
Laryngeal function studies,92520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,286.34,,,,,,,fee schedule,131.71,584.37,
Laryngeal function studies,92520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,312.8,,,,,,,fee schedule,131.71,584.37,
Laryngeal function studies,92520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,328.86,,,,,,,fee schedule,131.71,584.37,
Laryngeal function studies,92520,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,131.71,584.37,APC 378
Laryngeal function studies,92520,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,131.71,584.37,APC
Laryngeal function studies,92520,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,131.71,584.37,APC
Laryngeal function studies,92520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,131.71,584.37,APC
Laryngeal function studies,92520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,131.71,584.37,Radiology
Laryngeal function studies,92520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,131.71,584.37,APC
Laryngeal function studies,92520,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,131.71,584.37,APC
Evaluation of speech fluency,92521,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,271.98,,,,,,,fee schedule,128.51,271.98,
Evaluation of speech fluency,92521,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,218.02,,,,,,,fee schedule,128.51,271.98,
Evaluation of speech fluency,92521,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,238.17,,,,,,,fee schedule,128.51,271.98,
Evaluation of speech fluency,92521,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,250.4,,,,,,,fee schedule,128.51,271.98,
Evaluation of speech fluency,92521,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,128.51,,,,,,,fee schedule,128.51,271.98,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Evaluation of speech fluency,92521,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134.94,,,,,,,fee schedule,128.51,271.98,APC
Evaluation of speech fluency,92521,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,133.65,,,,,,,fee schedule,128.51,271.98,APC
Evaluation of speech fluency,92521,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,196.62,,,,,,,fee schedule,128.51,271.98,Radiology
Evaluation of speech fluency,92521,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,179.91,,,,,,,fee schedule,128.51,271.98,APC
Evaluation of speech fluency,92521,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,224.89,,,,,,,fee schedule,128.51,271.98,APC
Evaluate speech production,92522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,271.98,,,,,,,fee schedule,108.31,271.98,
Evaluate speech production,92522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,218.02,,,,,,,fee schedule,108.31,271.98,
Evaluate speech production,92522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,238.17,,,,,,,fee schedule,108.31,271.98,
Evaluate speech production,92522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,250.4,,,,,,,fee schedule,108.31,271.98,
Evaluate speech production,92522,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,108.31,,,,,,,fee schedule,108.31,271.98,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Evaluate speech production,92522,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,113.73,,,,,,,fee schedule,108.31,271.98,APC
Evaluate speech production,92522,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,112.64,,,,,,,fee schedule,108.31,271.98,APC
Evaluate speech production,92522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,165.71,,,,,,,fee schedule,108.31,271.98,Radiology
Evaluate speech production,92522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,151.63,,,,,,,fee schedule,108.31,271.98,APC
Evaluate speech production,92522,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,189.54,,,,,,,fee schedule,108.31,271.98,APC
Speech sound lang comprehen,92523,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,260.88,,,,,,,fee schedule,209.12,382.2,
Speech sound lang comprehen,92523,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,209.12,,,,,,,fee schedule,209.12,382.2,
Speech sound lang comprehen,92523,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,228.44,,,,,,,fee schedule,209.12,382.2,
Speech sound lang comprehen,92523,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,240.17,,,,,,,fee schedule,209.12,382.2,
Speech sound lang comprehen,92523,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,218.4,,,,,,,fee schedule,209.12,382.2,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Speech sound lang comprehen,92523,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,229.32,,,,,,,fee schedule,209.12,382.2,APC
Speech sound lang comprehen,92523,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,227.14,,,,,,,fee schedule,209.12,382.2,APC
Speech sound lang comprehen,92523,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,334.15,,,,,,,fee schedule,209.12,382.2,Radiology
Speech sound lang comprehen,92523,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,305.76,,,,,,,fee schedule,209.12,382.2,APC
Speech sound lang comprehen,92523,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,382.2,,,,,,,fee schedule,209.12,382.2,APC
Behavral qualit analys voice,92524,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,271.98,,,,,,,fee schedule,106.07,271.98,
Behavral qualit analys voice,92524,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,218.02,,,,,,,fee schedule,106.07,271.98,
Behavral qualit analys voice,92524,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,238.17,,,,,,,fee schedule,106.07,271.98,
Behavral qualit analys voice,92524,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,250.4,,,,,,,fee schedule,106.07,271.98,
Behavral qualit analys voice,92524,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,106.07,,,,,,,fee schedule,106.07,271.98,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Behavral qualit analys voice,92524,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,111.37,,,,,,,fee schedule,106.07,271.98,APC
Behavral qualit analys voice,92524,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,110.31,,,,,,,fee schedule,106.07,271.98,APC
Behavral qualit analys voice,92524,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,162.29,,,,,,,fee schedule,106.07,271.98,Radiology
Behavral qualit analys voice,92524,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,148.5,,,,,,,fee schedule,106.07,271.98,APC
Behavral qualit analys voice,92524,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,185.62,,,,,,,fee schedule,106.07,271.98,APC
Oral function therapy,92526,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,184.21,,,,,,,fee schedule,80.99,184.21,
Oral function therapy,92526,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,147.66,,,,,,,fee schedule,80.99,184.21,
Oral function therapy,92526,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,161.31,,,,,,,fee schedule,80.99,184.21,
Oral function therapy,92526,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,169.59,,,,,,,fee schedule,80.99,184.21,
Oral function therapy,92526,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,80.99,,,,,,,fee schedule,80.99,184.21,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Oral function therapy,92526,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,85.04,,,,,,,fee schedule,80.99,184.21,APC
Oral function therapy,92526,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,84.23,,,,,,,fee schedule,80.99,184.21,APC
Oral function therapy,92526,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,123.91,,,,,,,fee schedule,80.99,184.21,Radiology
Oral function therapy,92526,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,113.39,,,,,,,fee schedule,80.99,184.21,APC
Oral function therapy,92526,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,141.73,,,,,,,fee schedule,80.99,184.21,APC
Caloric vstblr test w/rec,92537,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,832.92,,,,,,,fee schedule,127.38,832.92,
Caloric vstblr test w/rec,92537,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,667.66,,,,,,,fee schedule,127.38,832.92,
Caloric vstblr test w/rec,92537,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,729.36,,,,,,,fee schedule,127.38,832.92,
Caloric vstblr test w/rec,92537,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,766.82,,,,,,,fee schedule,127.38,832.92,
Caloric vstblr test w/rec,92537,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,565.15,,,,,,,fee schedule,127.38,832.92,APC 378
Caloric vstblr test w/rec,92537,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,133.75,,,,,,,fee schedule,127.38,832.92,APC
Caloric vstblr test w/rec,92537,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,132.48,,,,,,,fee schedule,127.38,832.92,APC
Caloric vstblr test w/rec,92537,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,127.38,,,,,,,fee schedule,127.38,832.92,APC
Caloric vstblr test w/rec,92537,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,194.89,,,,,,,fee schedule,127.38,832.92,Radiology
Caloric vstblr test w/rec,92537,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,178.33,,,,,,,fee schedule,127.38,832.92,APC
Caloric vstblr test w/rec,92537,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,222.92,,,,,,,fee schedule,127.38,832.92,APC
Caloric vstblr test w/rec,92538,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,832.92,,,,,,,fee schedule,213.76,948.37,
Caloric vstblr test w/rec,92538,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,667.66,,,,,,,fee schedule,213.76,948.37,
Caloric vstblr test w/rec,92538,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,729.36,,,,,,,fee schedule,213.76,948.37,
Caloric vstblr test w/rec,92538,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,766.82,,,,,,,fee schedule,213.76,948.37,
Caloric vstblr test w/rec,92538,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,213.76,948.37,APC 378
Caloric vstblr test w/rec,92538,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,213.76,948.37,APC
Caloric vstblr test w/rec,92538,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,213.76,948.37,APC
Caloric vstblr test w/rec,92538,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,213.76,948.37,APC
Caloric vstblr test w/rec,92538,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,213.76,948.37,Radiology
Caloric vstblr test w/rec,92538,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,213.76,948.37,APC
Caloric vstblr test w/rec,92538,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,213.76,948.37,APC
Basic vestibular evaluation,92540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,396.71,,,,,,,fee schedule,213.76,948.37,
Basic vestibular evaluation,92540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,318,,,,,,,fee schedule,213.76,948.37,
Basic vestibular evaluation,92540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,347.38,,,,,,,fee schedule,213.76,948.37,
Basic vestibular evaluation,92540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,365.23,,,,,,,fee schedule,213.76,948.37,
Basic vestibular evaluation,92540,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,213.76,948.37,APC 378
Basic vestibular evaluation,92540,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,213.76,948.37,APC
Basic vestibular evaluation,92540,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,213.76,948.37,APC
Basic vestibular evaluation,92540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,213.76,948.37,APC
Basic vestibular evaluation,92540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,213.76,948.37,Radiology
Basic vestibular evaluation,92540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,213.76,948.37,APC
Basic vestibular evaluation,92540,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,213.76,948.37,APC
Spontaneous nystagmus test,92541,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,124.32,,,,,,,fee schedule,99.66,584.37,
Spontaneous nystagmus test,92541,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,99.66,,,,,,,fee schedule,99.66,584.37,
Spontaneous nystagmus test,92541,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,108.87,,,,,,,fee schedule,99.66,584.37,
Spontaneous nystagmus test,92541,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,114.46,,,,,,,fee schedule,99.66,584.37,
Spontaneous nystagmus test,92541,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,99.66,584.37,APC 378
Spontaneous nystagmus test,92541,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,99.66,584.37,APC
Spontaneous nystagmus test,92541,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,99.66,584.37,APC
Spontaneous nystagmus test,92541,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,99.66,584.37,APC
Spontaneous nystagmus test,92541,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,99.66,584.37,Radiology
Spontaneous nystagmus test,92541,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,99.66,584.37,APC
Spontaneous nystagmus test,92541,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,99.66,584.37,APC
Positional nystagmus test,92542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,143.75,,,,,,,fee schedule,115.23,584.37,
Positional nystagmus test,92542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,115.23,,,,,,,fee schedule,115.23,584.37,
Positional nystagmus test,92542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,125.88,,,,,,,fee schedule,115.23,584.37,
Positional nystagmus test,92542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,132.34,,,,,,,fee schedule,115.23,584.37,
Positional nystagmus test,92542,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,115.23,584.37,APC 378
Positional nystagmus test,92542,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,115.23,584.37,APC
Positional nystagmus test,92542,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,115.23,584.37,APC
Positional nystagmus test,92542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,115.23,584.37,APC
Positional nystagmus test,92542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,115.23,584.37,Radiology
Positional nystagmus test,92542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,115.23,584.37,APC
Positional nystagmus test,92542,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,115.23,584.37,APC
Optokinetic nystagmus test,92544,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,117.03,,,,,,,fee schedule,93.81,565.15,
Optokinetic nystagmus test,92544,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,93.81,,,,,,,fee schedule,93.81,565.15,
Optokinetic nystagmus test,92544,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,102.48,,,,,,,fee schedule,93.81,565.15,
Optokinetic nystagmus test,92544,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,107.74,,,,,,,fee schedule,93.81,565.15,
Optokinetic nystagmus test,92544,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,565.15,,,,,,,fee schedule,93.81,565.15,APC 378
Optokinetic nystagmus test,92544,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,133.75,,,,,,,fee schedule,93.81,565.15,APC
Optokinetic nystagmus test,92544,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,132.48,,,,,,,fee schedule,93.81,565.15,APC
Optokinetic nystagmus test,92544,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,127.38,,,,,,,fee schedule,93.81,565.15,APC
Optokinetic nystagmus test,92544,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,194.89,,,,,,,fee schedule,93.81,565.15,Radiology
Optokinetic nystagmus test,92544,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,178.33,,,,,,,fee schedule,93.81,565.15,APC
Optokinetic nystagmus test,92544,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,222.92,,,,,,,fee schedule,93.81,565.15,APC
Oscillating tracking test,92545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,112.19,,,,,,,fee schedule,89.93,948.37,
Oscillating tracking test,92545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,89.93,,,,,,,fee schedule,89.93,948.37,
Oscillating tracking test,92545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,98.24,,,,,,,fee schedule,89.93,948.37,
Oscillating tracking test,92545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,103.29,,,,,,,fee schedule,89.93,948.37,
Oscillating tracking test,92545,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,89.93,948.37,APC 378
Oscillating tracking test,92545,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,89.93,948.37,APC
Oscillating tracking test,92545,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,89.93,948.37,APC
Oscillating tracking test,92545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,89.93,948.37,APC
Oscillating tracking test,92545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,89.93,948.37,Radiology
Oscillating tracking test,92545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,89.93,948.37,APC
Oscillating tracking test,92545,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,89.93,948.37,APC
Sinusoidal rotational test,92546,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,221.39,,,,,,,fee schedule,127.38,565.15,
Sinusoidal rotational test,92546,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,177.47,,,,,,,fee schedule,127.38,565.15,
Sinusoidal rotational test,92546,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,193.87,,,,,,,fee schedule,127.38,565.15,
Sinusoidal rotational test,92546,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,203.82,,,,,,,fee schedule,127.38,565.15,
Sinusoidal rotational test,92546,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,565.15,,,,,,,fee schedule,127.38,565.15,APC 378
Sinusoidal rotational test,92546,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,133.75,,,,,,,fee schedule,127.38,565.15,APC
Sinusoidal rotational test,92546,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,132.48,,,,,,,fee schedule,127.38,565.15,APC
Sinusoidal rotational test,92546,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,127.38,,,,,,,fee schedule,127.38,565.15,APC
Sinusoidal rotational test,92546,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,194.89,,,,,,,fee schedule,127.38,565.15,Radiology
Sinusoidal rotational test,92546,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,178.33,,,,,,,fee schedule,127.38,565.15,APC
Sinusoidal rotational test,92546,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,222.92,,,,,,,fee schedule,127.38,565.15,APC
Posturography,92548,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,228.12,,,,,,,fee schedule,131.71,584.37,
Posturography,92548,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,182.86,,,,,,,fee schedule,131.71,584.37,
Posturography,92548,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,199.76,,,,,,,fee schedule,131.71,584.37,
Posturography,92548,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,210.02,,,,,,,fee schedule,131.71,584.37,
Posturography,92548,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,131.71,584.37,APC 378
Posturography,92548,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,131.71,584.37,APC
Posturography,92548,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,131.71,584.37,APC
Posturography,92548,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,131.71,584.37,APC
Posturography,92548,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,131.71,584.37,Radiology
Posturography,92548,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,131.71,584.37,APC
Posturography,92548,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,131.71,584.37,APC
Cdp-sot 6 cond w/i&r mct&adt,92549,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,412.13,,,,,,,fee schedule,131.71,584.37,
Cdp-sot 6 cond w/i&r mct&adt,92549,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,330.36,,,,,,,fee schedule,131.71,584.37,
Cdp-sot 6 cond w/i&r mct&adt,92549,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,360.89,,,,,,,fee schedule,131.71,584.37,
Cdp-sot 6 cond w/i&r mct&adt,92549,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,379.42,,,,,,,fee schedule,131.71,584.37,
Cdp-sot 6 cond w/i&r mct&adt,92549,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,131.71,584.37,APC 378
Cdp-sot 6 cond w/i&r mct&adt,92549,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,131.71,584.37,APC
Cdp-sot 6 cond w/i&r mct&adt,92549,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,131.71,584.37,APC
Cdp-sot 6 cond w/i&r mct&adt,92549,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,131.71,584.37,APC
Cdp-sot 6 cond w/i&r mct&adt,92549,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,131.71,584.37,Radiology
Cdp-sot 6 cond w/i&r mct&adt,92549,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,131.71,584.37,APC
Cdp-sot 6 cond w/i&r mct&adt,92549,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,131.71,584.37,APC
Tympanometry & reflex thresh,92550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,124.15,,,,,,,fee schedule,99.52,948.37,
Tympanometry & reflex thresh,92550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,99.52,,,,,,,fee schedule,99.52,948.37,
Tympanometry & reflex thresh,92550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,108.71,,,,,,,fee schedule,99.52,948.37,
Tympanometry & reflex thresh,92550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,114.3,,,,,,,fee schedule,99.52,948.37,
Tympanometry & reflex thresh,92550,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,99.52,948.37,APC 378
Tympanometry & reflex thresh,92550,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,99.52,948.37,APC
Tympanometry & reflex thresh,92550,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,99.52,948.37,APC
Tympanometry & reflex thresh,92550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,99.52,948.37,APC
Tympanometry & reflex thresh,92550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,99.52,948.37,Radiology
Tympanometry & reflex thresh,92550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,99.52,948.37,APC
Tympanometry & reflex thresh,92550,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,99.52,948.37,APC
Pure tone audiometry air,92552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,112.08,,,,,,,fee schedule,89.84,584.37,
Pure tone audiometry air,92552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,89.84,,,,,,,fee schedule,89.84,584.37,
Pure tone audiometry air,92552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,98.14,,,,,,,fee schedule,89.84,584.37,
Pure tone audiometry air,92552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,103.18,,,,,,,fee schedule,89.84,584.37,
Pure tone audiometry air,92552,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,89.84,584.37,APC 378
Pure tone audiometry air,92552,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,89.84,584.37,APC
Pure tone audiometry air,92552,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,89.84,584.37,APC
Pure tone audiometry air,92552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,89.84,584.37,APC
Pure tone audiometry air,92552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,89.84,584.37,Radiology
Pure tone audiometry air,92552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,89.84,584.37,APC
Pure tone audiometry air,92552,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,89.84,584.37,APC
Audiometry air & bone,92553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,313.21,,,,,,,fee schedule,127.38,565.15,
Audiometry air & bone,92553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,251.07,,,,,,,fee schedule,127.38,565.15,
Audiometry air & bone,92553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,274.27,,,,,,,fee schedule,127.38,565.15,
Audiometry air & bone,92553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,288.35,,,,,,,fee schedule,127.38,565.15,
Audiometry air & bone,92553,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,565.15,,,,,,,fee schedule,127.38,565.15,APC 378
Audiometry air & bone,92553,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,133.75,,,,,,,fee schedule,127.38,565.15,APC
Audiometry air & bone,92553,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,132.48,,,,,,,fee schedule,127.38,565.15,APC
Audiometry air & bone,92553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,127.38,,,,,,,fee schedule,127.38,565.15,APC
Audiometry air & bone,92553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,194.89,,,,,,,fee schedule,127.38,565.15,Radiology
Audiometry air & bone,92553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,178.33,,,,,,,fee schedule,127.38,565.15,APC
Audiometry air & bone,92553,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,222.92,,,,,,,fee schedule,127.38,565.15,APC
Speech threshold audiometry,92555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,112.08,,,,,,,fee schedule,58.4,259.1,
Speech threshold audiometry,92555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,89.84,,,,,,,fee schedule,58.4,259.1,
Speech threshold audiometry,92555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,98.14,,,,,,,fee schedule,58.4,259.1,
Speech threshold audiometry,92555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,103.18,,,,,,,fee schedule,58.4,259.1,
Speech threshold audiometry,92555,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,58.4,259.1,APC 378
Speech threshold audiometry,92555,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,58.4,259.1,APC
Speech threshold audiometry,92555,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,58.4,259.1,APC
Speech threshold audiometry,92555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,58.4,259.1,APC
Speech threshold audiometry,92555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,58.4,259.1,Radiology
Speech threshold audiometry,92555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,58.4,259.1,APC
Speech threshold audiometry,92555,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,58.4,259.1,APC
Speech audiometry complete,92556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,112.08,,,,,,,fee schedule,58.4,259.1,
Speech audiometry complete,92556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,89.84,,,,,,,fee schedule,58.4,259.1,
Speech audiometry complete,92556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,98.14,,,,,,,fee schedule,58.4,259.1,
Speech audiometry complete,92556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,103.18,,,,,,,fee schedule,58.4,259.1,
Speech audiometry complete,92556,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,58.4,259.1,APC 378
Speech audiometry complete,92556,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,58.4,259.1,APC
Speech audiometry complete,92556,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,58.4,259.1,APC
Speech audiometry complete,92556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,58.4,259.1,APC
Speech audiometry complete,92556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,58.4,259.1,Radiology
Speech audiometry complete,92556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,58.4,259.1,APC
Speech audiometry complete,92556,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,58.4,259.1,APC
Comprehensive hearing test,92557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,274.15,,,,,,,fee schedule,127.38,565.15,
Comprehensive hearing test,92557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,219.76,,,,,,,fee schedule,127.38,565.15,
Comprehensive hearing test,92557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,240.06,,,,,,,fee schedule,127.38,565.15,
Comprehensive hearing test,92557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,252.39,,,,,,,fee schedule,127.38,565.15,
Comprehensive hearing test,92557,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,565.15,,,,,,,fee schedule,127.38,565.15,APC 378
Comprehensive hearing test,92557,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,133.75,,,,,,,fee schedule,127.38,565.15,APC
Comprehensive hearing test,92557,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,132.48,,,,,,,fee schedule,127.38,565.15,APC
Comprehensive hearing test,92557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,127.38,,,,,,,fee schedule,127.38,565.15,APC
Comprehensive hearing test,92557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,194.89,,,,,,,fee schedule,127.38,565.15,Radiology
Comprehensive hearing test,92557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,178.33,,,,,,,fee schedule,127.38,565.15,APC
Comprehensive hearing test,92557,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,222.92,,,,,,,fee schedule,127.38,565.15,APC
Evoked auditory test qual,92558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,34.28,,,,,,,fee schedule,27.48,34.28,
Evoked auditory test qual,92558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,27.48,,,,,,,fee schedule,27.48,34.28,
Evoked auditory test qual,92558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,30.02,,,,,,,fee schedule,27.48,34.28,
Evoked auditory test qual,92558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,31.56,,,,,,,fee schedule,27.48,34.28,
Loudness balance test,92562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,112.08,,,,,,,fee schedule,89.84,948.37,
Loudness balance test,92562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,89.84,,,,,,,fee schedule,89.84,948.37,
Loudness balance test,92562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,98.14,,,,,,,fee schedule,89.84,948.37,
Loudness balance test,92562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,103.18,,,,,,,fee schedule,89.84,948.37,
Loudness balance test,92562,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,89.84,948.37,APC 378
Loudness balance test,92562,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,89.84,948.37,APC
Loudness balance test,92562,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,89.84,948.37,APC
Loudness balance test,92562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,89.84,948.37,APC
Loudness balance test,92562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,89.84,948.37,Radiology
Loudness balance test,92562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,89.84,948.37,APC
Loudness balance test,92562,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,89.84,948.37,APC
Tone decay hearing test,92563,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,112.08,,,,,,,fee schedule,36.98,164.05,
Tone decay hearing test,92563,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,89.84,,,,,,,fee schedule,36.98,164.05,
Tone decay hearing test,92563,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,98.14,,,,,,,fee schedule,36.98,164.05,
Tone decay hearing test,92563,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,103.18,,,,,,,fee schedule,36.98,164.05,
Tone decay hearing test,92563,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.05,,,,,,,fee schedule,36.98,164.05,APC 378
Tone decay hearing test,92563,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.83,,,,,,,fee schedule,36.98,164.05,APC
Tone decay hearing test,92563,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.46,,,,,,,fee schedule,36.98,164.05,APC
Tone decay hearing test,92563,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.98,,,,,,,fee schedule,36.98,164.05,APC
Tone decay hearing test,92563,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.57,,,,,,,fee schedule,36.98,164.05,Radiology
Tone decay hearing test,92563,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.77,,,,,,,fee schedule,36.98,164.05,APC
Tone decay hearing test,92563,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.71,,,,,,,fee schedule,36.98,164.05,APC
Stenger test pure tone,92565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,112.08,,,,,,,fee schedule,58.4,259.1,
Stenger test pure tone,92565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,89.84,,,,,,,fee schedule,58.4,259.1,
Stenger test pure tone,92565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,98.14,,,,,,,fee schedule,58.4,259.1,
Stenger test pure tone,92565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,103.18,,,,,,,fee schedule,58.4,259.1,
Stenger test pure tone,92565,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,58.4,259.1,APC 378
Stenger test pure tone,92565,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,58.4,259.1,APC
Stenger test pure tone,92565,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,58.4,259.1,APC
Stenger test pure tone,92565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,58.4,259.1,APC
Stenger test pure tone,92565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,58.4,259.1,Radiology
Stenger test pure tone,92565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,58.4,259.1,APC
Stenger test pure tone,92565,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,58.4,259.1,APC
Tympanometry,92567,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,109.44,,,,,,,fee schedule,36.98,164.05,
Tympanometry,92567,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,87.73,,,,,,,fee schedule,36.98,164.05,
Tympanometry,92567,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,95.84,,,,,,,fee schedule,36.98,164.05,
Tympanometry,92567,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,100.76,,,,,,,fee schedule,36.98,164.05,
Tympanometry,92567,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.05,,,,,,,fee schedule,36.98,164.05,APC 378
Tympanometry,92567,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.83,,,,,,,fee schedule,36.98,164.05,APC
Tympanometry,92567,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.46,,,,,,,fee schedule,36.98,164.05,APC
Tympanometry,92567,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.98,,,,,,,fee schedule,36.98,164.05,APC
Tympanometry,92567,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.57,,,,,,,fee schedule,36.98,164.05,Radiology
Tympanometry,92567,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.77,,,,,,,fee schedule,36.98,164.05,APC
Tympanometry,92567,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.71,,,,,,,fee schedule,36.98,164.05,APC
Acoustic refl threshold tst,92568,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,112.08,,,,,,,fee schedule,36.98,164.05,
Acoustic refl threshold tst,92568,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,89.84,,,,,,,fee schedule,36.98,164.05,
Acoustic refl threshold tst,92568,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,98.14,,,,,,,fee schedule,36.98,164.05,
Acoustic refl threshold tst,92568,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,103.18,,,,,,,fee schedule,36.98,164.05,
Acoustic refl threshold tst,92568,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.05,,,,,,,fee schedule,36.98,164.05,APC 378
Acoustic refl threshold tst,92568,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.83,,,,,,,fee schedule,36.98,164.05,APC
Acoustic refl threshold tst,92568,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.46,,,,,,,fee schedule,36.98,164.05,APC
Acoustic refl threshold tst,92568,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.98,,,,,,,fee schedule,36.98,164.05,APC
Acoustic refl threshold tst,92568,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.57,,,,,,,fee schedule,36.98,164.05,Radiology
Acoustic refl threshold tst,92568,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.77,,,,,,,fee schedule,36.98,164.05,APC
Acoustic refl threshold tst,92568,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.71,,,,,,,fee schedule,36.98,164.05,APC
Acoustic immitance testing,92570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,183.23,,,,,,,fee schedule,127.38,565.15,
Acoustic immitance testing,92570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,146.87,,,,,,,fee schedule,127.38,565.15,
Acoustic immitance testing,92570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,160.44,,,,,,,fee schedule,127.38,565.15,
Acoustic immitance testing,92570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,168.69,,,,,,,fee schedule,127.38,565.15,
Acoustic immitance testing,92570,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,565.15,,,,,,,fee schedule,127.38,565.15,APC 378
Acoustic immitance testing,92570,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,133.75,,,,,,,fee schedule,127.38,565.15,APC
Acoustic immitance testing,92570,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,132.48,,,,,,,fee schedule,127.38,565.15,APC
Acoustic immitance testing,92570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,127.38,,,,,,,fee schedule,127.38,565.15,APC
Acoustic immitance testing,92570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,194.89,,,,,,,fee schedule,127.38,565.15,Radiology
Acoustic immitance testing,92570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,178.33,,,,,,,fee schedule,127.38,565.15,APC
Acoustic immitance testing,92570,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,222.92,,,,,,,fee schedule,127.38,565.15,APC
Filtered speech hearing test,92571,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,112.08,,,,,,,fee schedule,36.98,164.05,
Filtered speech hearing test,92571,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,89.84,,,,,,,fee schedule,36.98,164.05,
Filtered speech hearing test,92571,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,98.14,,,,,,,fee schedule,36.98,164.05,
Filtered speech hearing test,92571,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,103.18,,,,,,,fee schedule,36.98,164.05,
Filtered speech hearing test,92571,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.05,,,,,,,fee schedule,36.98,164.05,APC 378
Filtered speech hearing test,92571,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.83,,,,,,,fee schedule,36.98,164.05,APC
Filtered speech hearing test,92571,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.46,,,,,,,fee schedule,36.98,164.05,APC
Filtered speech hearing test,92571,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.98,,,,,,,fee schedule,36.98,164.05,APC
Filtered speech hearing test,92571,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.57,,,,,,,fee schedule,36.98,164.05,Radiology
Filtered speech hearing test,92571,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.77,,,,,,,fee schedule,36.98,164.05,APC
Filtered speech hearing test,92571,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.71,,,,,,,fee schedule,36.98,164.05,APC
Staggered spondaic word test,92572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,439.84,,,,,,,fee schedule,127.38,565.15,
Staggered spondaic word test,92572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,352.57,,,,,,,fee schedule,127.38,565.15,
Staggered spondaic word test,92572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,385.15,,,,,,,fee schedule,127.38,565.15,
Staggered spondaic word test,92572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,404.93,,,,,,,fee schedule,127.38,565.15,
Staggered spondaic word test,92572,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,565.15,,,,,,,fee schedule,127.38,565.15,APC 378
Staggered spondaic word test,92572,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,133.75,,,,,,,fee schedule,127.38,565.15,APC
Staggered spondaic word test,92572,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,132.48,,,,,,,fee schedule,127.38,565.15,APC
Staggered spondaic word test,92572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,127.38,,,,,,,fee schedule,127.38,565.15,APC
Staggered spondaic word test,92572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,194.89,,,,,,,fee schedule,127.38,565.15,Radiology
Staggered spondaic word test,92572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,178.33,,,,,,,fee schedule,127.38,565.15,APC
Staggered spondaic word test,92572,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,222.92,,,,,,,fee schedule,127.38,565.15,APC
Sensorineural acuity test,92575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,112.08,,,,,,,fee schedule,36.98,164.05,
Sensorineural acuity test,92575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,89.84,,,,,,,fee schedule,36.98,164.05,
Sensorineural acuity test,92575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,98.14,,,,,,,fee schedule,36.98,164.05,
Sensorineural acuity test,92575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,103.18,,,,,,,fee schedule,36.98,164.05,
Sensorineural acuity test,92575,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.05,,,,,,,fee schedule,36.98,164.05,APC 378
Sensorineural acuity test,92575,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.83,,,,,,,fee schedule,36.98,164.05,APC
Sensorineural acuity test,92575,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.46,,,,,,,fee schedule,36.98,164.05,APC
Sensorineural acuity test,92575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.98,,,,,,,fee schedule,36.98,164.05,APC
Sensorineural acuity test,92575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.57,,,,,,,fee schedule,36.98,164.05,Radiology
Sensorineural acuity test,92575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.77,,,,,,,fee schedule,36.98,164.05,APC
Sensorineural acuity test,92575,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.71,,,,,,,fee schedule,36.98,164.05,APC
Synthetic sentence test,92576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,112.08,,,,,,,fee schedule,36.98,164.05,
Synthetic sentence test,92576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,89.84,,,,,,,fee schedule,36.98,164.05,
Synthetic sentence test,92576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,98.14,,,,,,,fee schedule,36.98,164.05,
Synthetic sentence test,92576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,103.18,,,,,,,fee schedule,36.98,164.05,
Synthetic sentence test,92576,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.05,,,,,,,fee schedule,36.98,164.05,APC 378
Synthetic sentence test,92576,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.83,,,,,,,fee schedule,36.98,164.05,APC
Synthetic sentence test,92576,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.46,,,,,,,fee schedule,36.98,164.05,APC
Synthetic sentence test,92576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.98,,,,,,,fee schedule,36.98,164.05,APC
Synthetic sentence test,92576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.57,,,,,,,fee schedule,36.98,164.05,Radiology
Synthetic sentence test,92576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.77,,,,,,,fee schedule,36.98,164.05,APC
Synthetic sentence test,92576,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.71,,,,,,,fee schedule,36.98,164.05,APC
Stenger test speech,92577,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,439.84,,,,,,,fee schedule,352.57,1638.96,
Stenger test speech,92577,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,352.57,,,,,,,fee schedule,352.57,1638.96,
Stenger test speech,92577,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,385.15,,,,,,,fee schedule,352.57,1638.96,
Stenger test speech,92577,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,404.93,,,,,,,fee schedule,352.57,1638.96,
Stenger test speech,92577,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1638.96,,,,,,,fee schedule,352.57,1638.96,APC 378
Stenger test speech,92577,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,387.88,,,,,,,fee schedule,352.57,1638.96,APC
Stenger test speech,92577,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,384.19,,,,,,,fee schedule,352.57,1638.96,APC
Stenger test speech,92577,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,369.41,,,,,,,fee schedule,352.57,1638.96,APC
Stenger test speech,92577,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,565.2,,,,,,,fee schedule,352.57,1638.96,Radiology
Stenger test speech,92577,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,517.18,,,,,,,fee schedule,352.57,1638.96,APC
Stenger test speech,92577,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,646.47,,,,,,,fee schedule,352.57,1638.96,APC
Visual audiometry (vra),92579,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,119.2,,,,,,,fee schedule,95.55,948.37,
Visual audiometry (vra),92579,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,95.55,,,,,,,fee schedule,95.55,948.37,
Visual audiometry (vra),92579,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,104.38,,,,,,,fee schedule,95.55,948.37,
Visual audiometry (vra),92579,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,109.74,,,,,,,fee schedule,95.55,948.37,
Visual audiometry (vra),92579,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,95.55,948.37,APC 378
Visual audiometry (vra),92579,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,95.55,948.37,APC
Visual audiometry (vra),92579,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,95.55,948.37,APC
Visual audiometry (vra),92579,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,95.55,948.37,APC
Visual audiometry (vra),92579,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,95.55,948.37,Radiology
Visual audiometry (vra),92579,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,95.55,948.37,APC
Visual audiometry (vra),92579,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,95.55,948.37,APC
Conditioning play audiometry,92582,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,313.21,,,,,,,fee schedule,127.38,565.15,
Conditioning play audiometry,92582,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,251.07,,,,,,,fee schedule,127.38,565.15,
Conditioning play audiometry,92582,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,274.27,,,,,,,fee schedule,127.38,565.15,
Conditioning play audiometry,92582,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,288.35,,,,,,,fee schedule,127.38,565.15,
Conditioning play audiometry,92582,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,565.15,,,,,,,fee schedule,127.38,565.15,APC 378
Conditioning play audiometry,92582,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,133.75,,,,,,,fee schedule,127.38,565.15,APC
Conditioning play audiometry,92582,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,132.48,,,,,,,fee schedule,127.38,565.15,APC
Conditioning play audiometry,92582,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,127.38,,,,,,,fee schedule,127.38,565.15,APC
Conditioning play audiometry,92582,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,194.89,,,,,,,fee schedule,127.38,565.15,Radiology
Conditioning play audiometry,92582,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,178.33,,,,,,,fee schedule,127.38,565.15,APC
Conditioning play audiometry,92582,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,222.92,,,,,,,fee schedule,127.38,565.15,APC
Select picture audiometry,92583,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,112.08,,,,,,,fee schedule,58.4,259.1,
Select picture audiometry,92583,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,89.84,,,,,,,fee schedule,58.4,259.1,
Select picture audiometry,92583,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,98.14,,,,,,,fee schedule,58.4,259.1,
Select picture audiometry,92583,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,103.18,,,,,,,fee schedule,58.4,259.1,
Select picture audiometry,92583,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,58.4,259.1,APC 378
Select picture audiometry,92583,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,58.4,259.1,APC
Select picture audiometry,92583,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,58.4,259.1,APC
Select picture audiometry,92583,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,58.4,259.1,APC
Select picture audiometry,92583,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,58.4,259.1,Radiology
Select picture audiometry,92583,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,58.4,259.1,APC
Select picture audiometry,92583,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,58.4,259.1,APC
Electrocochleography,92584,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,670.01,,,,,,,fee schedule,127.38,670.01,
Electrocochleography,92584,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,537.07,,,,,,,fee schedule,127.38,670.01,
Electrocochleography,92584,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,586.7,,,,,,,fee schedule,127.38,670.01,
Electrocochleography,92584,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,616.83,,,,,,,fee schedule,127.38,670.01,
Electrocochleography,92584,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,565.15,,,,,,,fee schedule,127.38,670.01,APC 378
Electrocochleography,92584,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,133.75,,,,,,,fee schedule,127.38,670.01,APC
Electrocochleography,92584,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,132.48,,,,,,,fee schedule,127.38,670.01,APC
Electrocochleography,92584,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,127.38,,,,,,,fee schedule,127.38,670.01,APC
Electrocochleography,92584,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,194.89,,,,,,,fee schedule,127.38,670.01,Radiology
Electrocochleography,92584,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,178.33,,,,,,,fee schedule,127.38,670.01,APC
Electrocochleography,92584,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,222.92,,,,,,,fee schedule,127.38,670.01,APC
Evoked auditory test limited,92587,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,109.85,,,,,,,fee schedule,88.05,948.37,
Evoked auditory test limited,92587,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,88.05,,,,,,,fee schedule,88.05,948.37,
Evoked auditory test limited,92587,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,96.19,,,,,,,fee schedule,88.05,948.37,
Evoked auditory test limited,92587,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,101.13,,,,,,,fee schedule,88.05,948.37,
Evoked auditory test limited,92587,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,88.05,948.37,APC 378
Evoked auditory test limited,92587,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,88.05,948.37,APC
Evoked auditory test limited,92587,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,88.05,948.37,APC
Evoked auditory test limited,92587,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,88.05,948.37,APC
Evoked auditory test limited,92587,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,88.05,948.37,Radiology
Evoked auditory test limited,92587,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,88.05,948.37,APC
Evoked auditory test limited,92587,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,88.05,948.37,APC
Evoked auditory tst complete,92588,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,154.11,,,,,,,fee schedule,123.53,1638.96,
Evoked auditory tst complete,92588,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,123.53,,,,,,,fee schedule,123.53,1638.96,
Evoked auditory tst complete,92588,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,134.95,,,,,,,fee schedule,123.53,1638.96,
Evoked auditory tst complete,92588,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,141.88,,,,,,,fee schedule,123.53,1638.96,
Evoked auditory tst complete,92588,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1638.96,,,,,,,fee schedule,123.53,1638.96,APC 378
Evoked auditory tst complete,92588,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,387.88,,,,,,,fee schedule,123.53,1638.96,APC
Evoked auditory tst complete,92588,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,384.19,,,,,,,fee schedule,123.53,1638.96,APC
Evoked auditory tst complete,92588,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,369.41,,,,,,,fee schedule,123.53,1638.96,APC
Evoked auditory tst complete,92588,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,565.2,,,,,,,fee schedule,123.53,1638.96,Radiology
Evoked auditory tst complete,92588,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,517.18,,,,,,,fee schedule,123.53,1638.96,APC
Evoked auditory tst complete,92588,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,646.47,,,,,,,fee schedule,123.53,1638.96,APC
Ear protector evaluation,92596,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,112.08,,,,,,,fee schedule,36.98,164.05,
Ear protector evaluation,92596,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,89.84,,,,,,,fee schedule,36.98,164.05,
Ear protector evaluation,92596,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,98.14,,,,,,,fee schedule,36.98,164.05,
Ear protector evaluation,92596,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,103.18,,,,,,,fee schedule,36.98,164.05,
Ear protector evaluation,92596,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.05,,,,,,,fee schedule,36.98,164.05,APC 378
Ear protector evaluation,92596,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.83,,,,,,,fee schedule,36.98,164.05,APC
Ear protector evaluation,92596,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.46,,,,,,,fee schedule,36.98,164.05,APC
Ear protector evaluation,92596,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.98,,,,,,,fee schedule,36.98,164.05,APC
Ear protector evaluation,92596,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.57,,,,,,,fee schedule,36.98,164.05,Radiology
Ear protector evaluation,92596,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.77,,,,,,,fee schedule,36.98,164.05,APC
Ear protector evaluation,92596,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.71,,,,,,,fee schedule,36.98,164.05,APC
Oral speech device eval,92597,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,162.99,,,,,,,fee schedule,68.84,162.99,
Oral speech device eval,92597,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,130.65,,,,,,,fee schedule,68.84,162.99,
Oral speech device eval,92597,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,142.73,,,,,,,fee schedule,68.84,162.99,
Oral speech device eval,92597,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,150.06,,,,,,,fee schedule,68.84,162.99,
Oral speech device eval,92597,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,68.84,,,,,,,fee schedule,68.84,162.99,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Oral speech device eval,92597,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,72.28,,,,,,,fee schedule,68.84,162.99,APC
Oral speech device eval,92597,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,71.59,,,,,,,fee schedule,68.84,162.99,APC
Oral speech device eval,92597,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,105.33,,,,,,,fee schedule,68.84,162.99,Radiology
Oral speech device eval,92597,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,96.38,,,,,,,fee schedule,68.84,162.99,APC
Oral speech device eval,92597,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,120.47,,,,,,,fee schedule,68.84,162.99,APC
Cochlear implt f/up exam <7,92601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,439.84,,,,,,,fee schedule,127.38,565.15,
Cochlear implt f/up exam <7,92601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,352.57,,,,,,,fee schedule,127.38,565.15,
Cochlear implt f/up exam <7,92601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,385.15,,,,,,,fee schedule,127.38,565.15,
Cochlear implt f/up exam <7,92601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,404.93,,,,,,,fee schedule,127.38,565.15,
Cochlear implt f/up exam <7,92601,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,565.15,,,,,,,fee schedule,127.38,565.15,APC 378
Cochlear implt f/up exam <7,92601,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,133.75,,,,,,,fee schedule,127.38,565.15,APC
Cochlear implt f/up exam <7,92601,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,132.48,,,,,,,fee schedule,127.38,565.15,APC
Cochlear implt f/up exam <7,92601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,127.38,,,,,,,fee schedule,127.38,565.15,APC
Cochlear implt f/up exam <7,92601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,194.89,,,,,,,fee schedule,127.38,565.15,Radiology
Cochlear implt f/up exam <7,92601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,178.33,,,,,,,fee schedule,127.38,565.15,APC
Cochlear implt f/up exam <7,92601,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,222.92,,,,,,,fee schedule,127.38,565.15,APC
Reprogram cochlear implt 7/>,92602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,439.84,,,,,,,fee schedule,127.38,565.15,
Reprogram cochlear implt 7/>,92602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,352.57,,,,,,,fee schedule,127.38,565.15,
Reprogram cochlear implt 7/>,92602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,385.15,,,,,,,fee schedule,127.38,565.15,
Reprogram cochlear implt 7/>,92602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,404.93,,,,,,,fee schedule,127.38,565.15,
Reprogram cochlear implt 7/>,92602,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,565.15,,,,,,,fee schedule,127.38,565.15,APC 378
Reprogram cochlear implt 7/>,92602,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,133.75,,,,,,,fee schedule,127.38,565.15,APC
Reprogram cochlear implt 7/>,92602,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,132.48,,,,,,,fee schedule,127.38,565.15,APC
Reprogram cochlear implt 7/>,92602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,127.38,,,,,,,fee schedule,127.38,565.15,APC
Reprogram cochlear implt 7/>,92602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,194.89,,,,,,,fee schedule,127.38,565.15,Radiology
Reprogram cochlear implt 7/>,92602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,178.33,,,,,,,fee schedule,127.38,565.15,APC
Reprogram cochlear implt 7/>,92602,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,222.92,,,,,,,fee schedule,127.38,565.15,APC
Cochlear implt f/up exam 7/>,92603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,439.84,,,,,,,fee schedule,127.38,565.15,
Cochlear implt f/up exam 7/>,92603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,352.57,,,,,,,fee schedule,127.38,565.15,
Cochlear implt f/up exam 7/>,92603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,385.15,,,,,,,fee schedule,127.38,565.15,
Cochlear implt f/up exam 7/>,92603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,404.93,,,,,,,fee schedule,127.38,565.15,
Cochlear implt f/up exam 7/>,92603,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,565.15,,,,,,,fee schedule,127.38,565.15,APC 378
Cochlear implt f/up exam 7/>,92603,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,133.75,,,,,,,fee schedule,127.38,565.15,APC
Cochlear implt f/up exam 7/>,92603,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,132.48,,,,,,,fee schedule,127.38,565.15,APC
Cochlear implt f/up exam 7/>,92603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,127.38,,,,,,,fee schedule,127.38,565.15,APC
Cochlear implt f/up exam 7/>,92603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,194.89,,,,,,,fee schedule,127.38,565.15,Radiology
Cochlear implt f/up exam 7/>,92603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,178.33,,,,,,,fee schedule,127.38,565.15,APC
Cochlear implt f/up exam 7/>,92603,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,222.92,,,,,,,fee schedule,127.38,565.15,APC
Reprogram cochlear implt 7/>,92604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,439.84,,,,,,,fee schedule,127.38,565.15,
Reprogram cochlear implt 7/>,92604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,352.57,,,,,,,fee schedule,127.38,565.15,
Reprogram cochlear implt 7/>,92604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,385.15,,,,,,,fee schedule,127.38,565.15,
Reprogram cochlear implt 7/>,92604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,404.93,,,,,,,fee schedule,127.38,565.15,
Reprogram cochlear implt 7/>,92604,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,565.15,,,,,,,fee schedule,127.38,565.15,APC 378
Reprogram cochlear implt 7/>,92604,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,133.75,,,,,,,fee schedule,127.38,565.15,APC
Reprogram cochlear implt 7/>,92604,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,132.48,,,,,,,fee schedule,127.38,565.15,APC
Reprogram cochlear implt 7/>,92604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,127.38,,,,,,,fee schedule,127.38,565.15,APC
Reprogram cochlear implt 7/>,92604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,194.89,,,,,,,fee schedule,127.38,565.15,Radiology
Reprogram cochlear implt 7/>,92604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,178.33,,,,,,,fee schedule,127.38,565.15,APC
Reprogram cochlear implt 7/>,92604,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,222.92,,,,,,,fee schedule,127.38,565.15,APC
Ex for speech device rx 1hr,92607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,507.39,,,,,,,fee schedule,117.32,507.39,
Ex for speech device rx 1hr,92607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,406.72,,,,,,,fee schedule,117.32,507.39,
Ex for speech device rx 1hr,92607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,444.3,,,,,,,fee schedule,117.32,507.39,
Ex for speech device rx 1hr,92607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,467.12,,,,,,,fee schedule,117.32,507.39,
Ex for speech device rx 1hr,92607,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,117.32,,,,,,,fee schedule,117.32,507.39,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Ex for speech device rx 1hr,92607,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,123.19,,,,,,,fee schedule,117.32,507.39,APC
Ex for speech device rx 1hr,92607,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,122.01,,,,,,,fee schedule,117.32,507.39,APC
Ex for speech device rx 1hr,92607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,179.5,,,,,,,fee schedule,117.32,507.39,Radiology
Ex for speech device rx 1hr,92607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,164.25,,,,,,,fee schedule,117.32,507.39,APC
Ex for speech device rx 1hr,92607,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,205.31,,,,,,,fee schedule,117.32,507.39,APC
Ex for speech device rx addl,92608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,99.68,,,,,,,fee schedule,45.74,99.68,
Ex for speech device rx addl,92608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,79.9,,,,,,,fee schedule,45.74,99.68,
Ex for speech device rx addl,92608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,87.28,,,,,,,fee schedule,45.74,99.68,
Ex for speech device rx addl,92608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,91.77,,,,,,,fee schedule,45.74,99.68,
Ex for speech device rx addl,92608,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,45.74,,,,,,,fee schedule,45.74,99.68,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Ex for speech device rx addl,92608,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,48.03,,,,,,,fee schedule,45.74,99.68,APC
Ex for speech device rx addl,92608,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,47.57,,,,,,,fee schedule,45.74,99.68,APC
Ex for speech device rx addl,92608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,69.98,,,,,,,fee schedule,45.74,99.68,Radiology
Ex for speech device rx addl,92608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,64.04,,,,,,,fee schedule,45.74,99.68,APC
Ex for speech device rx addl,92608,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,80.04,,,,,,,fee schedule,45.74,99.68,APC
Use of speech device service,92609,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,270.5,,,,,,,fee schedule,98.28,270.5,
Use of speech device service,92609,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,216.83,,,,,,,fee schedule,98.28,270.5,
Use of speech device service,92609,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,236.86,,,,,,,fee schedule,98.28,270.5,
Use of speech device service,92609,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,249.03,,,,,,,fee schedule,98.28,270.5,
Use of speech device service,92609,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,98.28,,,,,,,fee schedule,98.28,270.5,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Use of speech device service,92609,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,103.19,,,,,,,fee schedule,98.28,270.5,APC
Use of speech device service,92609,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,102.21,,,,,,,fee schedule,98.28,270.5,APC
Use of speech device service,92609,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,150.37,,,,,,,fee schedule,98.28,270.5,Radiology
Use of speech device service,92609,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,137.59,,,,,,,fee schedule,98.28,270.5,APC
Use of speech device service,92609,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,171.99,,,,,,,fee schedule,98.28,270.5,APC
Evaluate swallowing function,92610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,512.54,,,,,,,fee schedule,56.69,512.54,
Evaluate swallowing function,92610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,410.85,,,,,,,fee schedule,56.69,512.54,
Evaluate swallowing function,92610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,448.81,,,,,,,fee schedule,56.69,512.54,
Evaluate swallowing function,92610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,471.86,,,,,,,fee schedule,56.69,512.54,
Evaluate swallowing function,92610,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56.69,,,,,,,fee schedule,56.69,512.54,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Evaluate swallowing function,92610,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,59.52,,,,,,,fee schedule,56.69,512.54,APC
Evaluate swallowing function,92610,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,58.96,,,,,,,fee schedule,56.69,512.54,APC
Evaluate swallowing function,92610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,86.74,,,,,,,fee schedule,56.69,512.54,Radiology
Evaluate swallowing function,92610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,79.37,,,,,,,fee schedule,56.69,512.54,APC
Evaluate swallowing function,92610,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,99.21,,,,,,,fee schedule,56.69,512.54,APC
Motion fluoroscopy/swallow,92611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,432.15,,,,,,,fee schedule,88.03,432.15,
Motion fluoroscopy/swallow,92611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,346.41,,,,,,,fee schedule,88.03,432.15,
Motion fluoroscopy/swallow,92611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,378.42,,,,,,,fee schedule,88.03,432.15,
Motion fluoroscopy/swallow,92611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,397.85,,,,,,,fee schedule,88.03,432.15,
Motion fluoroscopy/swallow,92611,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,88.03,,,,,,,fee schedule,88.03,432.15,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Motion fluoroscopy/swallow,92611,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,92.43,,,,,,,fee schedule,88.03,432.15,APC
Motion fluoroscopy/swallow,92611,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,91.55,,,,,,,fee schedule,88.03,432.15,APC
Motion fluoroscopy/swallow,92611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,134.69,,,,,,,fee schedule,88.03,432.15,Radiology
Motion fluoroscopy/swallow,92611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,123.24,,,,,,,fee schedule,88.03,432.15,APC
Motion fluoroscopy/swallow,92611,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,154.05,,,,,,,fee schedule,88.03,432.15,APC
Endoscopy swallow (fees) vid,92612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,239.8,,,,,,,fee schedule,53.53,239.8,
Endoscopy swallow (fees) vid,92612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,192.22,,,,,,,fee schedule,53.53,239.8,
Endoscopy swallow (fees) vid,92612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,209.99,,,,,,,fee schedule,53.53,239.8,
Endoscopy swallow (fees) vid,92612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,220.77,,,,,,,fee schedule,53.53,239.8,
Endoscopy swallow (fees) vid,92612,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,53.53,,,,,,,fee schedule,53.53,239.8,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Endoscopy swallow (fees) vid,92612,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,56.21,,,,,,,fee schedule,53.53,239.8,APC
Endoscopy swallow (fees) vid,92612,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,55.67,,,,,,,fee schedule,53.53,239.8,APC
Endoscopy swallow (fees) vid,92612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.9,,,,,,,fee schedule,53.53,239.8,Radiology
Endoscopy swallow (fees) vid,92612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,74.94,,,,,,,fee schedule,53.53,239.8,APC
Endoscopy swallow (fees) vid,92612,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,93.68,,,,,,,fee schedule,53.53,239.8,APC
Endoscopy swallow (fees) i&r,92613,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,139.44,,,,,,,fee schedule,111.78,139.44,
Endoscopy swallow (fees) i&r,92613,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,111.78,,,,,,,fee schedule,111.78,139.44,
Endoscopy swallow (fees) i&r,92613,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,122.11,,,,,,,fee schedule,111.78,139.44,
Endoscopy swallow (fees) i&r,92613,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,128.38,,,,,,,fee schedule,111.78,139.44,
Laryngoscopic sensory vid,92614,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,239.8,,,,,,,fee schedule,53.63,239.8,
Laryngoscopic sensory vid,92614,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,192.22,,,,,,,fee schedule,53.63,239.8,
Laryngoscopic sensory vid,92614,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,209.99,,,,,,,fee schedule,53.63,239.8,
Laryngoscopic sensory vid,92614,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,220.77,,,,,,,fee schedule,53.63,239.8,
Laryngoscopic sensory vid,92614,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,53.63,,,,,,,fee schedule,53.63,239.8,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Laryngoscopic sensory vid,92614,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,56.31,,,,,,,fee schedule,53.63,239.8,APC
Laryngoscopic sensory vid,92614,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,55.78,,,,,,,fee schedule,53.63,239.8,APC
Laryngoscopic sensory vid,92614,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,82.05,,,,,,,fee schedule,53.63,239.8,Radiology
Laryngoscopic sensory vid,92614,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,75.08,,,,,,,fee schedule,53.63,239.8,APC
Laryngoscopic sensory vid,92614,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,93.85,,,,,,,fee schedule,53.63,239.8,APC
Fees w/laryngeal sense test,92616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,353.85,,,,,,,fee schedule,78.94,353.85,
Fees w/laryngeal sense test,92616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,283.64,,,,,,,fee schedule,78.94,353.85,
Fees w/laryngeal sense test,92616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,309.85,,,,,,,fee schedule,78.94,353.85,
Fees w/laryngeal sense test,92616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,325.76,,,,,,,fee schedule,78.94,353.85,
Fees w/laryngeal sense test,92616,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,78.94,,,,,,,fee schedule,78.94,353.85,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Fees w/laryngeal sense test,92616,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,82.89,,,,,,,fee schedule,78.94,353.85,APC
Fees w/laryngeal sense test,92616,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,82.1,,,,,,,fee schedule,78.94,353.85,APC
Fees w/laryngeal sense test,92616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.78,,,,,,,fee schedule,78.94,353.85,Radiology
Fees w/laryngeal sense test,92616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,110.52,,,,,,,fee schedule,78.94,353.85,APC
Fees w/laryngeal sense test,92616,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,138.14,,,,,,,fee schedule,78.94,353.85,APC
Ex for nonspeech dev rx add,92618,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,118.09,,,,,,,fee schedule,94.66,118.09,
Ex for nonspeech dev rx add,92618,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,94.66,,,,,,,fee schedule,94.66,118.09,
Ex for nonspeech dev rx add,92618,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,103.4,,,,,,,fee schedule,94.66,118.09,
Ex for nonspeech dev rx add,92618,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,108.72,,,,,,,fee schedule,94.66,118.09,
Auditory function 60 min,92620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,313.21,,,,,,,fee schedule,127.38,565.15,
Auditory function 60 min,92620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,251.07,,,,,,,fee schedule,127.38,565.15,
Auditory function 60 min,92620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,274.27,,,,,,,fee schedule,127.38,565.15,
Auditory function 60 min,92620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,288.35,,,,,,,fee schedule,127.38,565.15,
Auditory function 60 min,92620,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,565.15,,,,,,,fee schedule,127.38,565.15,APC 378
Auditory function 60 min,92620,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,133.75,,,,,,,fee schedule,127.38,565.15,APC
Auditory function 60 min,92620,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,132.48,,,,,,,fee schedule,127.38,565.15,APC
Auditory function 60 min,92620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,127.38,,,,,,,fee schedule,127.38,565.15,APC
Auditory function 60 min,92620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,194.89,,,,,,,fee schedule,127.38,565.15,Radiology
Auditory function 60 min,92620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,178.33,,,,,,,fee schedule,127.38,565.15,APC
Auditory function 60 min,92620,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,222.92,,,,,,,fee schedule,127.38,565.15,APC
Dx aly aud oi snd prcsr 1st,92622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,563.14,,,,,,,fee schedule,127.38,565.15,
Dx aly aud oi snd prcsr 1st,92622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,451.41,,,,,,,fee schedule,127.38,565.15,
Dx aly aud oi snd prcsr 1st,92622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,493.12,,,,,,,fee schedule,127.38,565.15,
Dx aly aud oi snd prcsr 1st,92622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,518.45,,,,,,,fee schedule,127.38,565.15,
Dx aly aud oi snd prcsr 1st,92622,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,565.15,,,,,,,fee schedule,127.38,565.15,APC 378
Dx aly aud oi snd prcsr 1st,92622,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,133.75,,,,,,,fee schedule,127.38,565.15,APC
Dx aly aud oi snd prcsr 1st,92622,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,132.48,,,,,,,fee schedule,127.38,565.15,APC
Dx aly aud oi snd prcsr 1st,92622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,127.38,,,,,,,fee schedule,127.38,565.15,APC
Dx aly aud oi snd prcsr 1st,92622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,194.89,,,,,,,fee schedule,127.38,565.15,Radiology
Dx aly aud oi snd prcsr 1st,92622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,178.33,,,,,,,fee schedule,127.38,565.15,APC
Dx aly aud oi snd prcsr 1st,92622,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,222.92,,,,,,,fee schedule,127.38,565.15,APC
Tinnitus assessment,92625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,313.21,,,,,,,fee schedule,127.38,565.15,
Tinnitus assessment,92625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,251.07,,,,,,,fee schedule,127.38,565.15,
Tinnitus assessment,92625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,274.27,,,,,,,fee schedule,127.38,565.15,
Tinnitus assessment,92625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,288.35,,,,,,,fee schedule,127.38,565.15,
Tinnitus assessment,92625,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,565.15,,,,,,,fee schedule,127.38,565.15,APC 378
Tinnitus assessment,92625,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,133.75,,,,,,,fee schedule,127.38,565.15,APC
Tinnitus assessment,92625,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,132.48,,,,,,,fee schedule,127.38,565.15,APC
Tinnitus assessment,92625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,127.38,,,,,,,fee schedule,127.38,565.15,APC
Tinnitus assessment,92625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,194.89,,,,,,,fee schedule,127.38,565.15,Radiology
Tinnitus assessment,92625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,178.33,,,,,,,fee schedule,127.38,565.15,APC
Tinnitus assessment,92625,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,222.92,,,,,,,fee schedule,127.38,565.15,APC
Eval aud rehab status,92626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,313.21,,,,,,,fee schedule,127.38,565.15,
Eval aud rehab status,92626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,251.07,,,,,,,fee schedule,127.38,565.15,
Eval aud rehab status,92626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,274.27,,,,,,,fee schedule,127.38,565.15,
Eval aud rehab status,92626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,288.35,,,,,,,fee schedule,127.38,565.15,
Eval aud rehab status,92626,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,565.15,,,,,,,fee schedule,127.38,565.15,APC 378
Eval aud rehab status,92626,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,133.75,,,,,,,fee schedule,127.38,565.15,APC
Eval aud rehab status,92626,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,132.48,,,,,,,fee schedule,127.38,565.15,APC
Eval aud rehab status,92626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,127.38,,,,,,,fee schedule,127.38,565.15,APC
Eval aud rehab status,92626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,194.89,,,,,,,fee schedule,127.38,565.15,Radiology
Eval aud rehab status,92626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,178.33,,,,,,,fee schedule,127.38,565.15,APC
Eval aud rehab status,92626,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,222.92,,,,,,,fee schedule,127.38,565.15,APC
Aud brainstem implt programg,92640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,313.21,,,,,,,fee schedule,127.38,565.15,
Aud brainstem implt programg,92640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,251.07,,,,,,,fee schedule,127.38,565.15,
Aud brainstem implt programg,92640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,274.27,,,,,,,fee schedule,127.38,565.15,
Aud brainstem implt programg,92640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,288.35,,,,,,,fee schedule,127.38,565.15,
Aud brainstem implt programg,92640,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,565.15,,,,,,,fee schedule,127.38,565.15,APC 378
Aud brainstem implt programg,92640,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,133.75,,,,,,,fee schedule,127.38,565.15,APC
Aud brainstem implt programg,92640,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,132.48,,,,,,,fee schedule,127.38,565.15,APC
Aud brainstem implt programg,92640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,127.38,,,,,,,fee schedule,127.38,565.15,APC
Aud brainstem implt programg,92640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,194.89,,,,,,,fee schedule,127.38,565.15,Radiology
Aud brainstem implt programg,92640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,178.33,,,,,,,fee schedule,127.38,565.15,APC
Aud brainstem implt programg,92640,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,222.92,,,,,,,fee schedule,127.38,565.15,APC
Aep hearing status deter i&r,92651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,527.5,,,,,,,fee schedule,213.76,948.37,
Aep hearing status deter i&r,92651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,422.84,,,,,,,fee schedule,213.76,948.37,
Aep hearing status deter i&r,92651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,461.91,,,,,,,fee schedule,213.76,948.37,
Aep hearing status deter i&r,92651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,485.63,,,,,,,fee schedule,213.76,948.37,
Aep hearing status deter i&r,92651,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,213.76,948.37,APC 378
Aep hearing status deter i&r,92651,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,213.76,948.37,APC
Aep hearing status deter i&r,92651,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,213.76,948.37,APC
Aep hearing status deter i&r,92651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,213.76,948.37,APC
Aep hearing status deter i&r,92651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,213.76,948.37,Radiology
Aep hearing status deter i&r,92651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,213.76,948.37,APC
Aep hearing status deter i&r,92651,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,213.76,948.37,APC
Aep thrshld est mlt freq i&r,92652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,999.62,,,,,,,fee schedule,213.76,999.62,
Aep thrshld est mlt freq i&r,92652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,801.28,,,,,,,fee schedule,213.76,999.62,
Aep thrshld est mlt freq i&r,92652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,875.33,,,,,,,fee schedule,213.76,999.62,
Aep thrshld est mlt freq i&r,92652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,920.29,,,,,,,fee schedule,213.76,999.62,
Aep thrshld est mlt freq i&r,92652,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,213.76,999.62,APC 378
Aep thrshld est mlt freq i&r,92652,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,213.76,999.62,APC
Aep thrshld est mlt freq i&r,92652,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,213.76,999.62,APC
Aep thrshld est mlt freq i&r,92652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,213.76,999.62,APC
Aep thrshld est mlt freq i&r,92652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,213.76,999.62,Radiology
Aep thrshld est mlt freq i&r,92652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,213.76,999.62,APC
Aep thrshld est mlt freq i&r,92652,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,213.76,999.62,APC
Aep neurodiagnostic i&r,92653,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,999.62,,,,,,,fee schedule,213.76,999.62,
Aep neurodiagnostic i&r,92653,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,801.28,,,,,,,fee schedule,213.76,999.62,
Aep neurodiagnostic i&r,92653,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,875.33,,,,,,,fee schedule,213.76,999.62,
Aep neurodiagnostic i&r,92653,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,920.29,,,,,,,fee schedule,213.76,999.62,
Aep neurodiagnostic i&r,92653,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,213.76,999.62,APC 378
Aep neurodiagnostic i&r,92653,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,213.76,999.62,APC
Aep neurodiagnostic i&r,92653,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,213.76,999.62,APC
Aep neurodiagnostic i&r,92653,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,213.76,999.62,APC
Aep neurodiagnostic i&r,92653,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,213.76,999.62,Radiology
Aep neurodiagnostic i&r,92653,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,213.76,999.62,APC
Aep neurodiagnostic i&r,92653,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,213.76,999.62,APC
Ent procedure/service,92700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,112.08,,,,,,,fee schedule,28.63,127.04,
Ent procedure/service,92700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,89.84,,,,,,,fee schedule,28.63,127.04,
Ent procedure/service,92700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,98.14,,,,,,,fee schedule,28.63,127.04,
Ent procedure/service,92700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,103.18,,,,,,,fee schedule,28.63,127.04,
Ent procedure/service,92700,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,127.04,,,,,,,fee schedule,28.63,127.04,APC 378
Ent procedure/service,92700,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.07,,,,,,,fee schedule,28.63,127.04,APC
Ent procedure/service,92700,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,29.78,,,,,,,fee schedule,28.63,127.04,APC
Ent procedure/service,92700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,28.63,,,,,,,fee schedule,28.63,127.04,APC
Ent procedure/service,92700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43.81,,,,,,,fee schedule,28.63,127.04,Radiology
Ent procedure/service,92700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40.09,,,,,,,fee schedule,28.63,127.04,APC
Ent procedure/service,92700,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,50.11,,,,,,,fee schedule,28.63,127.04,APC
Prq cardiac angioplast 1 art,92920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13761.72,,,,,,,fee schedule,5634.46,24998.21,
Prq cardiac angioplast 1 art,92920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11031.22,,,,,,,fee schedule,5634.46,24998.21,
Prq cardiac angioplast 1 art,92920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12050.61,,,,,,,fee schedule,5634.46,24998.21,
Prq cardiac angioplast 1 art,92920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12669.52,,,,,,,fee schedule,5634.46,24998.21,
Prq cardiac angioplast 1 art,92920,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24998.21,,,,,,,fee schedule,5634.46,24998.21,APC 378
Prq cardiac angioplast 1 art,92920,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5916.19,,,,,,,fee schedule,5634.46,24998.21,APC
Prq cardiac angioplast 1 art,92920,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5859.84,,,,,,,fee schedule,5634.46,24998.21,APC
Prq cardiac angioplast 1 art,92920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5634.46,,,,,,,fee schedule,5634.46,24998.21,APC
Prq cardiac angioplast 1 art,92920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8620.73,,,,,,,fee schedule,5634.46,24998.21,Radiology
Prq cardiac angioplast 1 art,92920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7888.25,,,,,,,fee schedule,5634.46,24998.21,APC
Prq cardiac angioplast 1 art,92920,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9860.31,,,,,,,fee schedule,5634.46,24998.21,APC
Prq cardiac angio addl art,92921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7247.12,,,,,,,fee schedule,5809.2,7247.12,
Prq cardiac angio addl art,92921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5809.2,,,,,,,fee schedule,5809.2,7247.12,
Prq cardiac angio addl art,92921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6346.02,,,,,,,fee schedule,5809.2,7247.12,
Prq cardiac angio addl art,92921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6671.95,,,,,,,fee schedule,5809.2,7247.12,
Prq card angio/athrect 1 art,92924,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12824.41,,,,,,,fee schedule,10279.88,50703.82,
Prq card angio/athrect 1 art,92924,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10279.88,,,,,,,fee schedule,10279.88,50703.82,
Prq card angio/athrect 1 art,92924,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11229.84,,,,,,,fee schedule,10279.88,50703.82,
Prq card angio/athrect 1 art,92924,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11806.6,,,,,,,fee schedule,10279.88,50703.82,
Prq card angio/athrect 1 art,92924,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,50703.82,,,,,,,fee schedule,10279.88,50703.82,APC 378
Prq card angio/athrect 1 art,92924,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11999.79,,,,,,,fee schedule,10279.88,50703.82,APC
Prq card angio/athrect 1 art,92924,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11885.51,,,,,,,fee schedule,10279.88,50703.82,APC
Prq card angio/athrect 1 art,92924,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11428.37,,,,,,,fee schedule,10279.88,50703.82,APC
Prq card angio/athrect 1 art,92924,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17485.41,,,,,,,fee schedule,10279.88,50703.82,Radiology
Prq card angio/athrect 1 art,92924,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15999.72,,,,,,,fee schedule,10279.88,50703.82,APC
Prq card angio/athrect 1 art,92924,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19999.65,,,,,,,fee schedule,10279.88,50703.82,APC
Prq card angio/athrect addl,92925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,28997.06,,,,,,,fee schedule,23243.68,28997.06,
Prq card angio/athrect addl,92925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23243.68,,,,,,,fee schedule,23243.68,28997.06,
Prq card angio/athrect addl,92925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,25391.61,,,,,,,fee schedule,23243.68,28997.06,
Prq card angio/athrect addl,92925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26695.71,,,,,,,fee schedule,23243.68,28997.06,
Prq card stent w/angio 1 vsl,92928,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23097.46,,,,,,,fee schedule,11428.37,50703.82,
Prq card stent w/angio 1 vsl,92928,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18514.63,,,,,,,fee schedule,11428.37,50703.82,
Prq card stent w/angio 1 vsl,92928,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20225.56,,,,,,,fee schedule,11428.37,50703.82,
Prq card stent w/angio 1 vsl,92928,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21264.33,,,,,,,fee schedule,11428.37,50703.82,
Prq card stent w/angio 1 vsl,92928,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,50703.82,,,,,,,fee schedule,11428.37,50703.82,APC 378
Prq card stent w/angio 1 vsl,92928,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11999.79,,,,,,,fee schedule,11428.37,50703.82,APC
Prq card stent w/angio 1 vsl,92928,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11885.51,,,,,,,fee schedule,11428.37,50703.82,APC
Prq card stent w/angio 1 vsl,92928,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11428.37,,,,,,,fee schedule,11428.37,50703.82,APC
Prq card stent w/angio 1 vsl,92928,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17485.41,,,,,,,fee schedule,11428.37,50703.82,Radiology
Prq card stent w/angio 1 vsl,92928,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15999.72,,,,,,,fee schedule,11428.37,50703.82,APC
Prq card stent w/angio 1 vsl,92928,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19999.65,,,,,,,fee schedule,11428.37,50703.82,APC
Prq card stent w/angio addl,92929,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23097.46,,,,,,,fee schedule,18514.63,23097.46,
Prq card stent w/angio addl,92929,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18514.63,,,,,,,fee schedule,18514.63,23097.46,
Prq card stent w/angio addl,92929,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20225.56,,,,,,,fee schedule,18514.63,23097.46,
Prq card stent w/angio addl,92929,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21264.33,,,,,,,fee schedule,18514.63,23097.46,
Prq tcat plmt ntrac st 2+les,92930,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,80515.32,,,,,,,fee schedule,18147.73,80515.32,APC 378
Prq tcat plmt ntrac st 2+les,92930,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19055.11,,,,,,,fee schedule,18147.73,80515.32,APC
Prq tcat plmt ntrac st 2+les,92930,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18873.64,,,,,,,fee schedule,18147.73,80515.32,APC
Prq tcat plmt ntrac st 2+les,92930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18147.73,,,,,,,fee schedule,18147.73,80515.32,APC
Prq tcat plmt ntrac st 2+les,92930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27766.02,,,,,,,fee schedule,18147.73,80515.32,Radiology
Prq tcat plmt ntrac st 2+les,92930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25406.82,,,,,,,fee schedule,18147.73,80515.32,APC
Prq tcat plmt ntrac st 2+les,92930,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31758.52,,,,,,,fee schedule,18147.73,80515.32,APC
Prq card stent/ath/angio,92933,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19774.62,,,,,,,fee schedule,15851.08,80515.32,
Prq card stent/ath/angio,92933,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15851.08,,,,,,,fee schedule,15851.08,80515.32,
Prq card stent/ath/angio,92933,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17315.87,,,,,,,fee schedule,15851.08,80515.32,
Prq card stent/ath/angio,92933,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18205.2,,,,,,,fee schedule,15851.08,80515.32,
Prq card stent/ath/angio,92933,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,80515.32,,,,,,,fee schedule,15851.08,80515.32,APC 378
Prq card stent/ath/angio,92933,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19055.11,,,,,,,fee schedule,15851.08,80515.32,APC
Prq card stent/ath/angio,92933,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18873.64,,,,,,,fee schedule,15851.08,80515.32,APC
Prq card stent/ath/angio,92933,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18147.73,,,,,,,fee schedule,15851.08,80515.32,APC
Prq card stent/ath/angio,92933,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27766.02,,,,,,,fee schedule,15851.08,80515.32,Radiology
Prq card stent/ath/angio,92933,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25406.82,,,,,,,fee schedule,15851.08,80515.32,APC
Prq card stent/ath/angio,92933,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31758.52,,,,,,,fee schedule,15851.08,80515.32,APC
Prq card stent/ath/angio,92934,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23097.46,,,,,,,fee schedule,18514.63,23097.46,
Prq card stent/ath/angio,92934,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18514.63,,,,,,,fee schedule,18514.63,23097.46,
Prq card stent/ath/angio,92934,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20225.56,,,,,,,fee schedule,18514.63,23097.46,
Prq card stent/ath/angio,92934,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21264.33,,,,,,,fee schedule,18514.63,23097.46,
Prq revasc byp graft 1 vsl,92937,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23097.46,,,,,,,fee schedule,11428.37,50703.82,
Prq revasc byp graft 1 vsl,92937,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18514.63,,,,,,,fee schedule,11428.37,50703.82,
Prq revasc byp graft 1 vsl,92937,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20225.56,,,,,,,fee schedule,11428.37,50703.82,
Prq revasc byp graft 1 vsl,92937,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21264.33,,,,,,,fee schedule,11428.37,50703.82,
Prq revasc byp graft 1 vsl,92937,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,50703.82,,,,,,,fee schedule,11428.37,50703.82,APC 378
Prq revasc byp graft 1 vsl,92937,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11999.79,,,,,,,fee schedule,11428.37,50703.82,APC
Prq revasc byp graft 1 vsl,92937,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11885.51,,,,,,,fee schedule,11428.37,50703.82,APC
Prq revasc byp graft 1 vsl,92937,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11428.37,,,,,,,fee schedule,11428.37,50703.82,APC
Prq revasc byp graft 1 vsl,92937,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17485.41,,,,,,,fee schedule,11428.37,50703.82,Radiology
Prq revasc byp graft 1 vsl,92937,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15999.72,,,,,,,fee schedule,11428.37,50703.82,APC
Prq revasc byp graft 1 vsl,92937,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19999.65,,,,,,,fee schedule,11428.37,50703.82,APC
Prq revasc byp graft addl,92938,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23097.46,,,,,,,fee schedule,18514.63,23097.46,
Prq revasc byp graft addl,92938,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18514.63,,,,,,,fee schedule,18514.63,23097.46,
Prq revasc byp graft addl,92938,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20225.56,,,,,,,fee schedule,18514.63,23097.46,
Prq revasc byp graft addl,92938,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21264.33,,,,,,,fee schedule,18514.63,23097.46,
Prq card revasc mi 1 vsl,92941,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23097.46,,,,,,,fee schedule,18514.63,23097.46,
Prq card revasc mi 1 vsl,92941,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18514.63,,,,,,,fee schedule,18514.63,23097.46,
Prq card revasc mi 1 vsl,92941,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20225.56,,,,,,,fee schedule,18514.63,23097.46,
Prq card revasc mi 1 vsl,92941,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21264.33,,,,,,,fee schedule,18514.63,23097.46,
Prq card revasc chronic 1vsl,92943,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23097.46,,,,,,,fee schedule,11428.37,50703.82,
Prq card revasc chronic 1vsl,92943,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18514.63,,,,,,,fee schedule,11428.37,50703.82,
Prq card revasc chronic 1vsl,92943,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20225.56,,,,,,,fee schedule,11428.37,50703.82,
Prq card revasc chronic 1vsl,92943,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21264.33,,,,,,,fee schedule,11428.37,50703.82,
Prq card revasc chronic 1vsl,92943,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,50703.82,,,,,,,fee schedule,11428.37,50703.82,APC 378
Prq card revasc chronic 1vsl,92943,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11999.79,,,,,,,fee schedule,11428.37,50703.82,APC
Prq card revasc chronic 1vsl,92943,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11885.51,,,,,,,fee schedule,11428.37,50703.82,APC
Prq card revasc chronic 1vsl,92943,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11428.37,,,,,,,fee schedule,11428.37,50703.82,APC
Prq card revasc chronic 1vsl,92943,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17485.41,,,,,,,fee schedule,11428.37,50703.82,Radiology
Prq card revasc chronic 1vsl,92943,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15999.72,,,,,,,fee schedule,11428.37,50703.82,APC
Prq card revasc chronic 1vsl,92943,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19999.65,,,,,,,fee schedule,11428.37,50703.82,APC
Prq card revasc chronic addl,92944,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23097.46,,,,,,,fee schedule,18514.63,23097.46,
Prq card revasc chronic addl,92944,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18514.63,,,,,,,fee schedule,18514.63,23097.46,
Prq card revasc chronic addl,92944,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20225.56,,,,,,,fee schedule,18514.63,23097.46,
Prq card revasc chronic addl,92944,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21264.33,,,,,,,fee schedule,18514.63,23097.46,
Prq trl rvs ch occ ant&rtrgr,92945,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,50703.82,,,,,,,fee schedule,11428.37,50703.82,APC 378
Prq trl rvs ch occ ant&rtrgr,92945,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11999.79,,,,,,,fee schedule,11428.37,50703.82,APC
Prq trl rvs ch occ ant&rtrgr,92945,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11885.51,,,,,,,fee schedule,11428.37,50703.82,APC
Prq trl rvs ch occ ant&rtrgr,92945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11428.37,,,,,,,fee schedule,11428.37,50703.82,APC
Prq trl rvs ch occ ant&rtrgr,92945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17485.41,,,,,,,fee schedule,11428.37,50703.82,Radiology
Prq trl rvs ch occ ant&rtrgr,92945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15999.72,,,,,,,fee schedule,11428.37,50703.82,APC
Prq trl rvs ch occ ant&rtrgr,92945,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19999.65,,,,,,,fee schedule,11428.37,50703.82,APC
Heart/lung resuscitation cpr,92950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1009.19,,,,,,,fee schedule,213.76,1009.19,
Heart/lung resuscitation cpr,92950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,808.96,,,,,,,fee schedule,213.76,1009.19,
Heart/lung resuscitation cpr,92950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,883.71,,,,,,,fee schedule,213.76,1009.19,
Heart/lung resuscitation cpr,92950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,929.1,,,,,,,fee schedule,213.76,1009.19,
Heart/lung resuscitation cpr,92950,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,213.76,1009.19,APC 378
Heart/lung resuscitation cpr,92950,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,213.76,1009.19,APC
Heart/lung resuscitation cpr,92950,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,213.76,1009.19,APC
Heart/lung resuscitation cpr,92950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,213.76,1009.19,APC
Heart/lung resuscitation cpr,92950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,213.76,1009.19,Radiology
Heart/lung resuscitation cpr,92950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,213.76,1009.19,APC
Heart/lung resuscitation cpr,92950,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,213.76,1009.19,APC
Temporary external pacing,92953,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,613.68,,,,,,,fee schedule,491.92,2902.97,
Temporary external pacing,92953,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,491.92,,,,,,,fee schedule,491.92,2902.97,
Temporary external pacing,92953,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,537.38,,,,,,,fee schedule,491.92,2902.97,
Temporary external pacing,92953,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,564.98,,,,,,,fee schedule,491.92,2902.97,
Temporary external pacing,92953,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2902.97,,,,,,,fee schedule,491.92,2902.97,APC 378
Temporary external pacing,92953,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,687.03,,,,,,,fee schedule,491.92,2902.97,APC
Temporary external pacing,92953,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,680.49,,,,,,,fee schedule,491.92,2902.97,APC
Temporary external pacing,92953,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,654.31,,,,,,,fee schedule,491.92,2902.97,APC
Temporary external pacing,92953,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1001.1,,,,,,,fee schedule,491.92,2902.97,Radiology
Temporary external pacing,92953,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,916.04,,,,,,,fee schedule,491.92,2902.97,APC
Temporary external pacing,92953,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1145.05,,,,,,,fee schedule,491.92,2902.97,APC
Cardioversion electric ext,92960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1637.32,,,,,,,fee schedule,654.31,2902.97,
Cardioversion electric ext,92960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1312.45,,,,,,,fee schedule,654.31,2902.97,
Cardioversion electric ext,92960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1433.74,,,,,,,fee schedule,654.31,2902.97,
Cardioversion electric ext,92960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1507.37,,,,,,,fee schedule,654.31,2902.97,
Cardioversion electric ext,92960,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2902.97,,,,,,,fee schedule,654.31,2902.97,APC 378
Cardioversion electric ext,92960,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,687.03,,,,,,,fee schedule,654.31,2902.97,APC
Cardioversion electric ext,92960,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,680.49,,,,,,,fee schedule,654.31,2902.97,APC
Cardioversion electric ext,92960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,654.31,,,,,,,fee schedule,654.31,2902.97,APC
Cardioversion electric ext,92960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1001.1,,,,,,,fee schedule,654.31,2902.97,Radiology
Cardioversion electric ext,92960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,916.04,,,,,,,fee schedule,654.31,2902.97,APC
Cardioversion electric ext,92960,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1145.05,,,,,,,fee schedule,654.31,2902.97,APC
Cardioversion electric int,92961,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1360.27,,,,,,,fee schedule,654.31,2902.97,
Cardioversion electric int,92961,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1090.38,,,,,,,fee schedule,654.31,2902.97,
Cardioversion electric int,92961,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1191.14,,,,,,,fee schedule,654.31,2902.97,
Cardioversion electric int,92961,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1252.31,,,,,,,fee schedule,654.31,2902.97,
Cardioversion electric int,92961,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2902.97,,,,,,,fee schedule,654.31,2902.97,APC 378
Cardioversion electric int,92961,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,687.03,,,,,,,fee schedule,654.31,2902.97,APC
Cardioversion electric int,92961,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,680.49,,,,,,,fee schedule,654.31,2902.97,APC
Cardioversion electric int,92961,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,654.31,,,,,,,fee schedule,654.31,2902.97,APC
Cardioversion electric int,92961,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1001.1,,,,,,,fee schedule,654.31,2902.97,Radiology
Cardioversion electric int,92961,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,916.04,,,,,,,fee schedule,654.31,2902.97,APC
Cardioversion electric int,92961,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1145.05,,,,,,,fee schedule,654.31,2902.97,APC
Prq coronary mech thrombect,92973,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5541.53,,,,,,,fee schedule,4442.02,5541.53,
Prq coronary mech thrombect,92973,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4442.02,,,,,,,fee schedule,4442.02,5541.53,
Prq coronary mech thrombect,92973,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4852.5,,,,,,,fee schedule,4442.02,5541.53,
Prq coronary mech thrombect,92973,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5101.73,,,,,,,fee schedule,4442.02,5541.53,
Cath place cardio brachytx,92974,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3658.17,,,,,,,fee schedule,2932.34,3658.17,
Cath place cardio brachytx,92974,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2932.34,,,,,,,fee schedule,2932.34,3658.17,
Cath place cardio brachytx,92974,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3203.32,,,,,,,fee schedule,2932.34,3658.17,
Cath place cardio brachytx,92974,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3367.84,,,,,,,fee schedule,2932.34,3658.17,
Dissolve clot heart vessel,92977,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,619.54,,,,,,,fee schedule,496.62,619.54,
Dissolve clot heart vessel,92977,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,496.62,,,,,,,fee schedule,496.62,619.54,
Dissolve clot heart vessel,92977,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,542.51,,,,,,,fee schedule,496.62,619.54,
Dissolve clot heart vessel,92977,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,570.37,,,,,,,fee schedule,496.62,619.54,
Revision of aortic valve,92986,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11326.85,,,,,,,fee schedule,5634.46,24998.21,
Revision of aortic valve,92986,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9079.46,,,,,,,fee schedule,5634.46,24998.21,
Revision of aortic valve,92986,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9918.48,,,,,,,fee schedule,5634.46,24998.21,
Revision of aortic valve,92986,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10427.89,,,,,,,fee schedule,5634.46,24998.21,
Revision of aortic valve,92986,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24998.21,,,,,,,fee schedule,5634.46,24998.21,APC 378
Revision of aortic valve,92986,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5916.19,,,,,,,fee schedule,5634.46,24998.21,APC
Revision of aortic valve,92986,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5859.84,,,,,,,fee schedule,5634.46,24998.21,APC
Revision of aortic valve,92986,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5634.46,,,,,,,fee schedule,5634.46,24998.21,APC
Revision of aortic valve,92986,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8620.73,,,,,,,fee schedule,5634.46,24998.21,Radiology
Revision of aortic valve,92986,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7888.25,,,,,,,fee schedule,5634.46,24998.21,APC
Revision of aortic valve,92986,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9860.31,,,,,,,fee schedule,5634.46,24998.21,APC
Revision of mitral valve,92987,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12645.61,,,,,,,fee schedule,10136.56,50703.82,
Revision of mitral valve,92987,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10136.56,,,,,,,fee schedule,10136.56,50703.82,
Revision of mitral valve,92987,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11073.27,,,,,,,fee schedule,10136.56,50703.82,
Revision of mitral valve,92987,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11641.99,,,,,,,fee schedule,10136.56,50703.82,
Revision of mitral valve,92987,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,50703.82,,,,,,,fee schedule,10136.56,50703.82,APC 378
Revision of mitral valve,92987,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11999.79,,,,,,,fee schedule,10136.56,50703.82,APC
Revision of mitral valve,92987,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11885.51,,,,,,,fee schedule,10136.56,50703.82,APC
Revision of mitral valve,92987,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11428.37,,,,,,,fee schedule,10136.56,50703.82,APC
Revision of mitral valve,92987,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17485.41,,,,,,,fee schedule,10136.56,50703.82,Radiology
Revision of mitral valve,92987,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15999.72,,,,,,,fee schedule,10136.56,50703.82,APC
Revision of mitral valve,92987,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19999.65,,,,,,,fee schedule,10136.56,50703.82,APC
Revision of pulmonary valve,92990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14107.39,,,,,,,fee schedule,11308.3,50703.82,
Revision of pulmonary valve,92990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11308.3,,,,,,,fee schedule,11308.3,50703.82,
Revision of pulmonary valve,92990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12353.3,,,,,,,fee schedule,11308.3,50703.82,
Revision of pulmonary valve,92990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12987.75,,,,,,,fee schedule,11308.3,50703.82,
Revision of pulmonary valve,92990,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,50703.82,,,,,,,fee schedule,11308.3,50703.82,APC 378
Revision of pulmonary valve,92990,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11999.79,,,,,,,fee schedule,11308.3,50703.82,APC
Revision of pulmonary valve,92990,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11885.51,,,,,,,fee schedule,11308.3,50703.82,APC
Revision of pulmonary valve,92990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11428.37,,,,,,,fee schedule,11308.3,50703.82,APC
Revision of pulmonary valve,92990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17485.41,,,,,,,fee schedule,11308.3,50703.82,Radiology
Revision of pulmonary valve,92990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15999.72,,,,,,,fee schedule,11308.3,50703.82,APC
Revision of pulmonary valve,92990,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19999.65,,,,,,,fee schedule,11308.3,50703.82,APC
Pul art balloon repr percut,92997,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17371.19,,,,,,,fee schedule,11428.37,50703.82,
Pul art balloon repr percut,92997,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13924.53,,,,,,,fee schedule,11428.37,50703.82,
Pul art balloon repr percut,92997,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15211.28,,,,,,,fee schedule,11428.37,50703.82,
Pul art balloon repr percut,92997,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15992.53,,,,,,,fee schedule,11428.37,50703.82,
Pul art balloon repr percut,92997,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,50703.82,,,,,,,fee schedule,11428.37,50703.82,APC 378
Pul art balloon repr percut,92997,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11999.79,,,,,,,fee schedule,11428.37,50703.82,APC
Pul art balloon repr percut,92997,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11885.51,,,,,,,fee schedule,11428.37,50703.82,APC
Pul art balloon repr percut,92997,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11428.37,,,,,,,fee schedule,11428.37,50703.82,APC
Pul art balloon repr percut,92997,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17485.41,,,,,,,fee schedule,11428.37,50703.82,Radiology
Pul art balloon repr percut,92997,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15999.72,,,,,,,fee schedule,11428.37,50703.82,APC
Pul art balloon repr percut,92997,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19999.65,,,,,,,fee schedule,11428.37,50703.82,APC
Pul art balloon repr percut,92998,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11326.85,,,,,,,fee schedule,9079.46,11326.85,
Pul art balloon repr percut,92998,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9079.46,,,,,,,fee schedule,9079.46,11326.85,
Pul art balloon repr percut,92998,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9918.48,,,,,,,fee schedule,9079.46,11326.85,
Pul art balloon repr percut,92998,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10427.89,,,,,,,fee schedule,9079.46,11326.85,
Electrocardiogram complete,93000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,73.75,,,,,,,fee schedule,59.12,73.75,
Electrocardiogram complete,93000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,59.12,,,,,,,fee schedule,59.12,73.75,
Electrocardiogram complete,93000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,64.58,,,,,,,fee schedule,59.12,73.75,
Electrocardiogram complete,93000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,67.89,,,,,,,fee schedule,59.12,73.75,
Electrocardiogram tracing,93005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,332.51,,,,,,,fee schedule,58.4,332.51,
Electrocardiogram tracing,93005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,266.54,,,,,,,fee schedule,58.4,332.51,
Electrocardiogram tracing,93005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,291.17,,,,,,,fee schedule,58.4,332.51,
Electrocardiogram tracing,93005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,306.12,,,,,,,fee schedule,58.4,332.51,
Electrocardiogram tracing,93005,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,58.4,332.51,APC 378
Electrocardiogram tracing,93005,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,58.4,332.51,APC
Electrocardiogram tracing,93005,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,58.4,332.51,APC
Electrocardiogram tracing,93005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,58.4,332.51,APC
Electrocardiogram tracing,93005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,58.4,332.51,Radiology
Electrocardiogram tracing,93005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,58.4,332.51,APC
Electrocardiogram tracing,93005,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,58.4,332.51,APC
Electrocardiogram report,93010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33.15,,,,,,,fee schedule,26.57,33.15,
Electrocardiogram report,93010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26.57,,,,,,,fee schedule,26.57,33.15,
Electrocardiogram report,93010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29.03,,,,,,,fee schedule,26.57,33.15,
Electrocardiogram report,93010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30.52,,,,,,,fee schedule,26.57,33.15,
Cardiovascular stress test,93015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,352.49,,,,,,,fee schedule,282.55,352.49,
Cardiovascular stress test,93015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,282.55,,,,,,,fee schedule,282.55,352.49,
Cardiovascular stress test,93015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,308.66,,,,,,,fee schedule,282.55,352.49,
Cardiovascular stress test,93015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,324.51,,,,,,,fee schedule,282.55,352.49,
Cardiovascular stress test,93016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,89.81,,,,,,,fee schedule,71.99,89.81,
Cardiovascular stress test,93016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,71.99,,,,,,,fee schedule,71.99,89.81,
Cardiovascular stress test,93016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,78.65,,,,,,,fee schedule,71.99,89.81,
Cardiovascular stress test,93016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,82.68,,,,,,,fee schedule,71.99,89.81,
Cardiovascular stress test,93017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1150.94,,,,,,,fee schedule,213.76,1150.94,
Cardiovascular stress test,93017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,922.58,,,,,,,fee schedule,213.76,1150.94,
Cardiovascular stress test,93017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1007.83,,,,,,,fee schedule,213.76,1150.94,
Cardiovascular stress test,93017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1059.59,,,,,,,fee schedule,213.76,1150.94,
Cardiovascular stress test,93017,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,213.76,1150.94,APC 378
Cardiovascular stress test,93017,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,213.76,1150.94,APC
Cardiovascular stress test,93017,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,213.76,1150.94,APC
Cardiovascular stress test,93017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,213.76,1150.94,APC
Cardiovascular stress test,93017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,213.76,1150.94,Radiology
Cardiovascular stress test,93017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,213.76,1150.94,APC
Cardiovascular stress test,93017,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,213.76,1150.94,APC
Cardiovascular stress test,93018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59.38,,,,,,,fee schedule,47.6,59.38,
Cardiovascular stress test,93018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,47.6,,,,,,,fee schedule,47.6,59.38,
Cardiovascular stress test,93018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52,,,,,,,fee schedule,47.6,59.38,
Cardiovascular stress test,93018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,54.67,,,,,,,fee schedule,47.6,59.38,
Cardiac drug stress test,93024,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,200.04,,,,,,,fee schedule,160.35,1962.08,
Cardiac drug stress test,93024,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,160.35,,,,,,,fee schedule,160.35,1962.08,
Cardiac drug stress test,93024,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,175.17,,,,,,,fee schedule,160.35,1962.08,
Cardiac drug stress test,93024,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,184.16,,,,,,,fee schedule,160.35,1962.08,
Cardiac drug stress test,93024,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1962.08,,,,,,,fee schedule,160.35,1962.08,APC 378
Cardiac drug stress test,93024,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,464.35,,,,,,,fee schedule,160.35,1962.08,APC
Cardiac drug stress test,93024,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,459.93,,,,,,,fee schedule,160.35,1962.08,APC
Cardiac drug stress test,93024,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,442.24,,,,,,,fee schedule,160.35,1962.08,APC
Cardiac drug stress test,93024,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,676.63,,,,,,,fee schedule,160.35,1962.08,Radiology
Cardiac drug stress test,93024,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,619.14,,,,,,,fee schedule,160.35,1962.08,APC
Cardiac drug stress test,93024,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,773.92,,,,,,,fee schedule,160.35,1962.08,APC
Microvolt t-wave assess,93025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,581.86,,,,,,,fee schedule,127.38,581.86,
Microvolt t-wave assess,93025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,466.41,,,,,,,fee schedule,127.38,581.86,
Microvolt t-wave assess,93025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,509.51,,,,,,,fee schedule,127.38,581.86,
Microvolt t-wave assess,93025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,535.68,,,,,,,fee schedule,127.38,581.86,
Microvolt t-wave assess,93025,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,565.15,,,,,,,fee schedule,127.38,581.86,APC 378
Microvolt t-wave assess,93025,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,133.75,,,,,,,fee schedule,127.38,581.86,APC
Microvolt t-wave assess,93025,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,132.48,,,,,,,fee schedule,127.38,581.86,APC
Microvolt t-wave assess,93025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,127.38,,,,,,,fee schedule,127.38,581.86,APC
Microvolt t-wave assess,93025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,194.89,,,,,,,fee schedule,127.38,581.86,Radiology
Microvolt t-wave assess,93025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,178.33,,,,,,,fee schedule,127.38,581.86,APC
Microvolt t-wave assess,93025,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,222.92,,,,,,,fee schedule,127.38,581.86,APC
Rhythm ECG with report,93040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,47.85,,,,,,,fee schedule,38.36,47.85,
Rhythm ECG with report,93040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38.36,,,,,,,fee schedule,38.36,47.85,
Rhythm ECG with report,93040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,41.9,,,,,,,fee schedule,38.36,47.85,
Rhythm ECG with report,93040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,44.06,,,,,,,fee schedule,38.36,47.85,
Rhythm ecg tracing,93041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,97.15,,,,,,,fee schedule,58.4,259.1,
Rhythm ecg tracing,93041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,77.87,,,,,,,fee schedule,58.4,259.1,
Rhythm ecg tracing,93041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,85.07,,,,,,,fee schedule,58.4,259.1,
Rhythm ecg tracing,93041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,89.44,,,,,,,fee schedule,58.4,259.1,
Rhythm ecg tracing,93041,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,58.4,259.1,APC 378
Rhythm ecg tracing,93041,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,58.4,259.1,APC
Rhythm ecg tracing,93041,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,58.4,259.1,APC
Rhythm ecg tracing,93041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,58.4,259.1,APC
Rhythm ecg tracing,93041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,58.4,259.1,Radiology
Rhythm ecg tracing,93041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,58.4,259.1,APC
Rhythm ecg tracing,93041,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,58.4,259.1,APC
Rhythm ecg report,93042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,29.37,,,,,,,fee schedule,23.54,29.37,
Rhythm ecg report,93042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23.54,,,,,,,fee schedule,23.54,29.37,
Rhythm ecg report,93042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,25.72,,,,,,,fee schedule,23.54,29.37,
Rhythm ecg report,93042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27.04,,,,,,,fee schedule,23.54,29.37,
Art pressure waveform analys,93050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,115.33,,,,,,,fee schedule,28.63,127.04,
Art pressure waveform analys,93050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,92.45,,,,,,,fee schedule,28.63,127.04,
Art pressure waveform analys,93050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,100.99,,,,,,,fee schedule,28.63,127.04,
Art pressure waveform analys,93050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,106.17,,,,,,,fee schedule,28.63,127.04,
Art pressure waveform analys,93050,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,127.04,,,,,,,fee schedule,28.63,127.04,APC 378
Art pressure waveform analys,93050,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.07,,,,,,,fee schedule,28.63,127.04,APC
Art pressure waveform analys,93050,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,29.78,,,,,,,fee schedule,28.63,127.04,APC
Art pressure waveform analys,93050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,28.63,,,,,,,fee schedule,28.63,127.04,APC
Art pressure waveform analys,93050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43.81,,,,,,,fee schedule,28.63,127.04,Radiology
Art pressure waveform analys,93050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40.09,,,,,,,fee schedule,28.63,127.04,APC
Art pressure waveform analys,93050,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,50.11,,,,,,,fee schedule,28.63,127.04,APC
Interrog crtd sins bat ip wo,93145,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,565.15,,,,,,,fee schedule,127.38,565.15,APC 378
Interrog crtd sins bat ip wo,93145,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,133.75,,,,,,,fee schedule,127.38,565.15,APC
Interrog crtd sins bat ip wo,93145,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,132.48,,,,,,,fee schedule,127.38,565.15,APC
Interrog crtd sins bat ip wo,93145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,127.38,,,,,,,fee schedule,127.38,565.15,APC
Interrog crtd sins bat ip wo,93145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,194.89,,,,,,,fee schedule,127.38,565.15,Radiology
Interrog crtd sins bat ip wo,93145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,178.33,,,,,,,fee schedule,127.38,565.15,APC
Interrog crtd sins bat ip wo,93145,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,222.92,,,,,,,fee schedule,127.38,565.15,APC
Interrog crtd sins bat ip w/,93146,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,565.15,,,,,,,fee schedule,127.38,565.15,APC 378
Interrog crtd sins bat ip w/,93146,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,133.75,,,,,,,fee schedule,127.38,565.15,APC
Interrog crtd sins bat ip w/,93146,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,132.48,,,,,,,fee schedule,127.38,565.15,APC
Interrog crtd sins bat ip w/,93146,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,127.38,,,,,,,fee schedule,127.38,565.15,APC
Interrog crtd sins bat ip w/,93146,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,194.89,,,,,,,fee schedule,127.38,565.15,Radiology
Interrog crtd sins bat ip w/,93146,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,178.33,,,,,,,fee schedule,127.38,565.15,APC
Interrog crtd sins bat ip w/,93146,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,222.92,,,,,,,fee schedule,127.38,565.15,APC
Therapy activation ipnss,93150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,349.01,,,,,,,fee schedule,94.12,417.57,
Therapy activation ipnss,93150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,279.76,,,,,,,fee schedule,94.12,417.57,
Therapy activation ipnss,93150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,305.61,,,,,,,fee schedule,94.12,417.57,
Therapy activation ipnss,93150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,321.31,,,,,,,fee schedule,94.12,417.57,
Therapy activation ipnss,93150,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,417.57,,,,,,,fee schedule,94.12,417.57,APC 378
Therapy activation ipnss,93150,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,98.82,,,,,,,fee schedule,94.12,417.57,APC
Therapy activation ipnss,93150,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,97.88,,,,,,,fee schedule,94.12,417.57,APC
Therapy activation ipnss,93150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,94.12,,,,,,,fee schedule,94.12,417.57,APC
Therapy activation ipnss,93150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144,,,,,,,fee schedule,94.12,417.57,Radiology
Therapy activation ipnss,93150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.76,,,,,,,fee schedule,94.12,417.57,APC
Therapy activation ipnss,93150,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,164.7,,,,,,,fee schedule,94.12,417.57,APC
Interrog&prgrmg ipnss,93151,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,349.01,,,,,,,fee schedule,94.12,417.57,
Interrog&prgrmg ipnss,93151,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,279.76,,,,,,,fee schedule,94.12,417.57,
Interrog&prgrmg ipnss,93151,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,305.61,,,,,,,fee schedule,94.12,417.57,
Interrog&prgrmg ipnss,93151,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,321.31,,,,,,,fee schedule,94.12,417.57,
Interrog&prgrmg ipnss,93151,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,417.57,,,,,,,fee schedule,94.12,417.57,APC 378
Interrog&prgrmg ipnss,93151,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,98.82,,,,,,,fee schedule,94.12,417.57,APC
Interrog&prgrmg ipnss,93151,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,97.88,,,,,,,fee schedule,94.12,417.57,APC
Interrog&prgrmg ipnss,93151,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,94.12,,,,,,,fee schedule,94.12,417.57,APC
Interrog&prgrmg ipnss,93151,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144,,,,,,,fee schedule,94.12,417.57,Radiology
Interrog&prgrmg ipnss,93151,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.76,,,,,,,fee schedule,94.12,417.57,APC
Interrog&prgrmg ipnss,93151,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,164.7,,,,,,,fee schedule,94.12,417.57,APC
Interrog&prgrmg ipnss polysm,93152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1076.85,,,,,,,fee schedule,304.06,1348.99,
Interrog&prgrmg ipnss polysm,93152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,863.19,,,,,,,fee schedule,304.06,1348.99,
Interrog&prgrmg ipnss polysm,93152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,942.95,,,,,,,fee schedule,304.06,1348.99,
Interrog&prgrmg ipnss polysm,93152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,991.38,,,,,,,fee schedule,304.06,1348.99,
Interrog&prgrmg ipnss polysm,93152,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1348.99,,,,,,,fee schedule,304.06,1348.99,APC 378
Interrog&prgrmg ipnss polysm,93152,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,319.26,,,,,,,fee schedule,304.06,1348.99,APC
Interrog&prgrmg ipnss polysm,93152,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,316.22,,,,,,,fee schedule,304.06,1348.99,APC
Interrog&prgrmg ipnss polysm,93152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,304.06,,,,,,,fee schedule,304.06,1348.99,APC
Interrog&prgrmg ipnss polysm,93152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,465.21,,,,,,,fee schedule,304.06,1348.99,Radiology
Interrog&prgrmg ipnss polysm,93152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,425.68,,,,,,,fee schedule,304.06,1348.99,APC
Interrog&prgrmg ipnss polysm,93152,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,532.1,,,,,,,fee schedule,304.06,1348.99,APC
Interrog w/o prgrmg ipnss,93153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,349.01,,,,,,,fee schedule,94.12,417.57,
Interrog w/o prgrmg ipnss,93153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,279.76,,,,,,,fee schedule,94.12,417.57,
Interrog w/o prgrmg ipnss,93153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,305.61,,,,,,,fee schedule,94.12,417.57,
Interrog w/o prgrmg ipnss,93153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,321.31,,,,,,,fee schedule,94.12,417.57,
Interrog w/o prgrmg ipnss,93153,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,417.57,,,,,,,fee schedule,94.12,417.57,APC 378
Interrog w/o prgrmg ipnss,93153,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,98.82,,,,,,,fee schedule,94.12,417.57,APC
Interrog w/o prgrmg ipnss,93153,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,97.88,,,,,,,fee schedule,94.12,417.57,APC
Interrog w/o prgrmg ipnss,93153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,94.12,,,,,,,fee schedule,94.12,417.57,APC
Interrog w/o prgrmg ipnss,93153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144,,,,,,,fee schedule,94.12,417.57,Radiology
Interrog w/o prgrmg ipnss,93153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.76,,,,,,,fee schedule,94.12,417.57,APC
Interrog w/o prgrmg ipnss,93153,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,164.7,,,,,,,fee schedule,94.12,417.57,APC
Ecg monit/reprt up to 48 hrs,93224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,416.14,,,,,,,fee schedule,333.57,416.14,
Ecg monit/reprt up to 48 hrs,93224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,333.57,,,,,,,fee schedule,333.57,416.14,
Ecg monit/reprt up to 48 hrs,93224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,364.4,,,,,,,fee schedule,333.57,416.14,
Ecg monit/reprt up to 48 hrs,93224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,383.11,,,,,,,fee schedule,333.57,416.14,
Ecg monit/reprt up to 48 hrs,93225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,410.09,,,,,,,fee schedule,131.71,584.37,
Ecg monit/reprt up to 48 hrs,93225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,328.73,,,,,,,fee schedule,131.71,584.37,
Ecg monit/reprt up to 48 hrs,93225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,359.1,,,,,,,fee schedule,131.71,584.37,
Ecg monit/reprt up to 48 hrs,93225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,377.55,,,,,,,fee schedule,131.71,584.37,
Ecg monit/reprt up to 48 hrs,93225,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,131.71,584.37,APC 378
Ecg monit/reprt up to 48 hrs,93225,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,131.71,584.37,APC
Ecg monit/reprt up to 48 hrs,93225,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,131.71,584.37,APC
Ecg monit/reprt up to 48 hrs,93225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,131.71,584.37,APC
Ecg monit/reprt up to 48 hrs,93225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,131.71,584.37,Radiology
Ecg monit/reprt up to 48 hrs,93225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,131.71,584.37,APC
Ecg monit/reprt up to 48 hrs,93225,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,131.71,584.37,APC
Ecg monit/reprt up to 48 hrs,93226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,172.29,,,,,,,fee schedule,58.4,259.1,
Ecg monit/reprt up to 48 hrs,93226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,138.11,,,,,,,fee schedule,58.4,259.1,
Ecg monit/reprt up to 48 hrs,93226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,150.87,,,,,,,fee schedule,58.4,259.1,
Ecg monit/reprt up to 48 hrs,93226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,158.62,,,,,,,fee schedule,58.4,259.1,
Ecg monit/reprt up to 48 hrs,93226,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,58.4,259.1,APC 378
Ecg monit/reprt up to 48 hrs,93226,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,58.4,259.1,APC
Ecg monit/reprt up to 48 hrs,93226,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,58.4,259.1,APC
Ecg monit/reprt up to 48 hrs,93226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,58.4,259.1,APC
Ecg monit/reprt up to 48 hrs,93226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,58.4,259.1,Radiology
Ecg monit/reprt up to 48 hrs,93226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,58.4,259.1,APC
Ecg monit/reprt up to 48 hrs,93226,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,58.4,259.1,APC
Ecg monit/reprt up to 48 hrs,93227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,104.21,,,,,,,fee schedule,83.54,104.21,
Ecg monit/reprt up to 48 hrs,93227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,83.54,,,,,,,fee schedule,83.54,104.21,
Ecg monit/reprt up to 48 hrs,93227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,91.26,,,,,,,fee schedule,83.54,104.21,
Ecg monit/reprt up to 48 hrs,93227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,95.94,,,,,,,fee schedule,83.54,104.21,
Remote 30 day ecg rev/report,93228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,94.5,,,,,,,fee schedule,75.75,94.5,
Remote 30 day ecg rev/report,93228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,75.75,,,,,,,fee schedule,75.75,94.5,
Remote 30 day ecg rev/report,93228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,82.75,,,,,,,fee schedule,75.75,94.5,
Remote 30 day ecg rev/report,93228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,87,,,,,,,fee schedule,75.75,94.5,
Remote 30 day ecg tech supp,93229,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,652.47,,,,,,,fee schedule,369.41,1638.96,
Remote 30 day ecg tech supp,93229,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,523.01,,,,,,,fee schedule,369.41,1638.96,
Remote 30 day ecg tech supp,93229,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,571.34,,,,,,,fee schedule,369.41,1638.96,
Remote 30 day ecg tech supp,93229,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,600.68,,,,,,,fee schedule,369.41,1638.96,
Remote 30 day ecg tech supp,93229,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1638.96,,,,,,,fee schedule,369.41,1638.96,APC 378
Remote 30 day ecg tech supp,93229,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,387.88,,,,,,,fee schedule,369.41,1638.96,APC
Remote 30 day ecg tech supp,93229,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,384.19,,,,,,,fee schedule,369.41,1638.96,APC
Remote 30 day ecg tech supp,93229,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,369.41,,,,,,,fee schedule,369.41,1638.96,APC
Remote 30 day ecg tech supp,93229,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,565.2,,,,,,,fee schedule,369.41,1638.96,Radiology
Remote 30 day ecg tech supp,93229,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,517.18,,,,,,,fee schedule,369.41,1638.96,APC
Remote 30 day ecg tech supp,93229,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,646.47,,,,,,,fee schedule,369.41,1638.96,APC
Ext ecg>48hr<7d recording,93242,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,127.92,,,,,,,fee schedule,36.98,164.05,
Ext ecg>48hr<7d recording,93242,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,102.54,,,,,,,fee schedule,36.98,164.05,
Ext ecg>48hr<7d recording,93242,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,112.01,,,,,,,fee schedule,36.98,164.05,
Ext ecg>48hr<7d recording,93242,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,117.76,,,,,,,fee schedule,36.98,164.05,
Ext ecg>48hr<7d recording,93242,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.05,,,,,,,fee schedule,36.98,164.05,APC 378
Ext ecg>48hr<7d recording,93242,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.83,,,,,,,fee schedule,36.98,164.05,APC
Ext ecg>48hr<7d recording,93242,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.46,,,,,,,fee schedule,36.98,164.05,APC
Ext ecg>48hr<7d recording,93242,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.98,,,,,,,fee schedule,36.98,164.05,APC
Ext ecg>48hr<7d recording,93242,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.57,,,,,,,fee schedule,36.98,164.05,Radiology
Ext ecg>48hr<7d recording,93242,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.77,,,,,,,fee schedule,36.98,164.05,APC
Ext ecg>48hr<7d recording,93242,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.71,,,,,,,fee schedule,36.98,164.05,APC
Ext ecg>48hr<7d scan a/r,93243,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,210.39,,,,,,,fee schedule,131.71,584.37,
Ext ecg>48hr<7d scan a/r,93243,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,168.65,,,,,,,fee schedule,131.71,584.37,
Ext ecg>48hr<7d scan a/r,93243,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,184.23,,,,,,,fee schedule,131.71,584.37,
Ext ecg>48hr<7d scan a/r,93243,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,193.7,,,,,,,fee schedule,131.71,584.37,
Ext ecg>48hr<7d scan a/r,93243,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,131.71,584.37,APC 378
Ext ecg>48hr<7d scan a/r,93243,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,131.71,584.37,APC
Ext ecg>48hr<7d scan a/r,93243,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,131.71,584.37,APC
Ext ecg>48hr<7d scan a/r,93243,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,131.71,584.37,APC
Ext ecg>48hr<7d scan a/r,93243,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,131.71,584.37,Radiology
Ext ecg>48hr<7d scan a/r,93243,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,131.71,584.37,APC
Ext ecg>48hr<7d scan a/r,93243,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,131.71,584.37,APC
Ext ecg>7d<15d recording,93246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,210.39,,,,,,,fee schedule,36.98,210.39,
Ext ecg>7d<15d recording,93246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,168.65,,,,,,,fee schedule,36.98,210.39,
Ext ecg>7d<15d recording,93246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,184.23,,,,,,,fee schedule,36.98,210.39,
Ext ecg>7d<15d recording,93246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,193.7,,,,,,,fee schedule,36.98,210.39,
Ext ecg>7d<15d recording,93246,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.05,,,,,,,fee schedule,36.98,210.39,APC 378
Ext ecg>7d<15d recording,93246,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.83,,,,,,,fee schedule,36.98,210.39,APC
Ext ecg>7d<15d recording,93246,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.46,,,,,,,fee schedule,36.98,210.39,APC
Ext ecg>7d<15d recording,93246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.98,,,,,,,fee schedule,36.98,210.39,APC
Ext ecg>7d<15d recording,93246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.57,,,,,,,fee schedule,36.98,210.39,Radiology
Ext ecg>7d<15d recording,93246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.77,,,,,,,fee schedule,36.98,210.39,APC
Ext ecg>7d<15d recording,93246,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.71,,,,,,,fee schedule,36.98,210.39,APC
Ext ecg>7d<15d scan a/r,93247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,423.17,,,,,,,fee schedule,131.71,584.37,
Ext ecg>7d<15d scan a/r,93247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,339.21,,,,,,,fee schedule,131.71,584.37,
Ext ecg>7d<15d scan a/r,93247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,370.55,,,,,,,fee schedule,131.71,584.37,
Ext ecg>7d<15d scan a/r,93247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,389.59,,,,,,,fee schedule,131.71,584.37,
Ext ecg>7d<15d scan a/r,93247,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,131.71,584.37,APC 378
Ext ecg>7d<15d scan a/r,93247,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,131.71,584.37,APC
Ext ecg>7d<15d scan a/r,93247,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,131.71,584.37,APC
Ext ecg>7d<15d scan a/r,93247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,131.71,584.37,APC
Ext ecg>7d<15d scan a/r,93247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,131.71,584.37,Radiology
Ext ecg>7d<15d scan a/r,93247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,131.71,584.37,APC
Ext ecg>7d<15d scan a/r,93247,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,131.71,584.37,APC
Prgrmg dev eval impltbl sys,93260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,132.87,,,,,,,fee schedule,36.95,163.92,
Prgrmg dev eval impltbl sys,93260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,106.5,,,,,,,fee schedule,36.95,163.92,
Prgrmg dev eval impltbl sys,93260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,116.35,,,,,,,fee schedule,36.95,163.92,
Prgrmg dev eval impltbl sys,93260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,122.32,,,,,,,fee schedule,36.95,163.92,
Prgrmg dev eval impltbl sys,93260,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,163.92,,,,,,,fee schedule,36.95,163.92,APC 378
Prgrmg dev eval impltbl sys,93260,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.79,,,,,,,fee schedule,36.95,163.92,APC
Prgrmg dev eval impltbl sys,93260,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.43,,,,,,,fee schedule,36.95,163.92,APC
Prgrmg dev eval impltbl sys,93260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.95,,,,,,,fee schedule,36.95,163.92,APC
Prgrmg dev eval impltbl sys,93260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.53,,,,,,,fee schedule,36.95,163.92,Radiology
Prgrmg dev eval impltbl sys,93260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.73,,,,,,,fee schedule,36.95,163.92,APC
Prgrmg dev eval impltbl sys,93260,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.66,,,,,,,fee schedule,36.95,163.92,APC
Interrogate subq defib,93261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,132.87,,,,,,,fee schedule,36.95,163.92,
Interrogate subq defib,93261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,106.5,,,,,,,fee schedule,36.95,163.92,
Interrogate subq defib,93261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,116.35,,,,,,,fee schedule,36.95,163.92,
Interrogate subq defib,93261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,122.32,,,,,,,fee schedule,36.95,163.92,
Interrogate subq defib,93261,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,163.92,,,,,,,fee schedule,36.95,163.92,APC 378
Interrogate subq defib,93261,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.79,,,,,,,fee schedule,36.95,163.92,APC
Interrogate subq defib,93261,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.43,,,,,,,fee schedule,36.95,163.92,APC
Interrogate subq defib,93261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.95,,,,,,,fee schedule,36.95,163.92,APC
Interrogate subq defib,93261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.53,,,,,,,fee schedule,36.95,163.92,Radiology
Interrogate subq defib,93261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.73,,,,,,,fee schedule,36.95,163.92,APC
Interrogate subq defib,93261,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.66,,,,,,,fee schedule,36.95,163.92,APC
Rem mntr wrls p-art prs snr,93264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,137.44,,,,,,,fee schedule,36.95,163.92,
Rem mntr wrls p-art prs snr,93264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,110.17,,,,,,,fee schedule,36.95,163.92,
Rem mntr wrls p-art prs snr,93264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,120.35,,,,,,,fee schedule,36.95,163.92,
Rem mntr wrls p-art prs snr,93264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,126.53,,,,,,,fee schedule,36.95,163.92,
Rem mntr wrls p-art prs snr,93264,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,163.92,,,,,,,fee schedule,36.95,163.92,APC 378
Rem mntr wrls p-art prs snr,93264,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.79,,,,,,,fee schedule,36.95,163.92,APC
Rem mntr wrls p-art prs snr,93264,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.43,,,,,,,fee schedule,36.95,163.92,APC
Rem mntr wrls p-art prs snr,93264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.95,,,,,,,fee schedule,36.95,163.92,APC
Rem mntr wrls p-art prs snr,93264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.53,,,,,,,fee schedule,36.95,163.92,Radiology
Rem mntr wrls p-art prs snr,93264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.73,,,,,,,fee schedule,36.95,163.92,APC
Rem mntr wrls p-art prs snr,93264,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.66,,,,,,,fee schedule,36.95,163.92,APC
ECG record/review,93268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,908.67,,,,,,,fee schedule,728.38,908.67,
ECG record/review,93268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,728.38,,,,,,,fee schedule,728.38,908.67,
ECG record/review,93268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,795.69,,,,,,,fee schedule,728.38,908.67,
ECG record/review,93268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,836.56,,,,,,,fee schedule,728.38,908.67,
Remote 30 day ecg rev/report,93270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,127.86,,,,,,,fee schedule,36.95,163.92,
Remote 30 day ecg rev/report,93270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,102.49,,,,,,,fee schedule,36.95,163.92,
Remote 30 day ecg rev/report,93270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,111.97,,,,,,,fee schedule,36.95,163.92,
Remote 30 day ecg rev/report,93270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,117.72,,,,,,,fee schedule,36.95,163.92,
Remote 30 day ecg rev/report,93270,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,163.92,,,,,,,fee schedule,36.95,163.92,APC 378
Remote 30 day ecg rev/report,93270,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.79,,,,,,,fee schedule,36.95,163.92,APC
Remote 30 day ecg rev/report,93270,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.43,,,,,,,fee schedule,36.95,163.92,APC
Remote 30 day ecg rev/report,93270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.95,,,,,,,fee schedule,36.95,163.92,APC
Remote 30 day ecg rev/report,93270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.53,,,,,,,fee schedule,36.95,163.92,Radiology
Remote 30 day ecg rev/report,93270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.73,,,,,,,fee schedule,36.95,163.92,APC
Remote 30 day ecg rev/report,93270,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.66,,,,,,,fee schedule,36.95,163.92,APC
Ecg/monitoring and analysis,93271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,382.16,,,,,,,fee schedule,94.12,417.57,
Ecg/monitoring and analysis,93271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,306.33,,,,,,,fee schedule,94.12,417.57,
Ecg/monitoring and analysis,93271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,334.64,,,,,,,fee schedule,94.12,417.57,
Ecg/monitoring and analysis,93271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,351.83,,,,,,,fee schedule,94.12,417.57,
Ecg/monitoring and analysis,93271,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,417.57,,,,,,,fee schedule,94.12,417.57,APC 378
Ecg/monitoring and analysis,93271,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,98.82,,,,,,,fee schedule,94.12,417.57,APC
Ecg/monitoring and analysis,93271,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,97.88,,,,,,,fee schedule,94.12,417.57,APC
Ecg/monitoring and analysis,93271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,94.12,,,,,,,fee schedule,94.12,417.57,APC
Ecg/monitoring and analysis,93271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144,,,,,,,fee schedule,94.12,417.57,Radiology
Ecg/monitoring and analysis,93271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.76,,,,,,,fee schedule,94.12,417.57,APC
Ecg/monitoring and analysis,93271,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,164.7,,,,,,,fee schedule,94.12,417.57,APC
Ecg/review interpret only,93272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,100.59,,,,,,,fee schedule,80.63,100.59,
Ecg/review interpret only,93272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,80.63,,,,,,,fee schedule,80.63,100.59,
Ecg/review interpret only,93272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,88.08,,,,,,,fee schedule,80.63,100.59,
Ecg/review interpret only,93272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,92.6,,,,,,,fee schedule,80.63,100.59,
ECG/signal-averaged,93278,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,96.5,,,,,,,fee schedule,58.4,259.1,
ECG/signal-averaged,93278,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,77.36,,,,,,,fee schedule,58.4,259.1,
ECG/signal-averaged,93278,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,84.5,,,,,,,fee schedule,58.4,259.1,
ECG/signal-averaged,93278,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,88.84,,,,,,,fee schedule,58.4,259.1,
ECG/signal-averaged,93278,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,58.4,259.1,APC 378
ECG/signal-averaged,93278,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,58.4,259.1,APC
ECG/signal-averaged,93278,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,58.4,259.1,APC
ECG/signal-averaged,93278,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,58.4,259.1,APC
ECG/signal-averaged,93278,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,58.4,259.1,Radiology
ECG/signal-averaged,93278,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,58.4,259.1,APC
ECG/signal-averaged,93278,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,58.4,259.1,APC
Pm device progr eval sngl,93279,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,67.85,,,,,,,fee schedule,36.95,163.92,
Pm device progr eval sngl,93279,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,54.39,,,,,,,fee schedule,36.95,163.92,
Pm device progr eval sngl,93279,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,59.41,,,,,,,fee schedule,36.95,163.92,
Pm device progr eval sngl,93279,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,62.47,,,,,,,fee schedule,36.95,163.92,
Pm device progr eval sngl,93279,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,163.92,,,,,,,fee schedule,36.95,163.92,APC 378
Pm device progr eval sngl,93279,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.79,,,,,,,fee schedule,36.95,163.92,APC
Pm device progr eval sngl,93279,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.43,,,,,,,fee schedule,36.95,163.92,APC
Pm device progr eval sngl,93279,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.95,,,,,,,fee schedule,36.95,163.92,APC
Pm device progr eval sngl,93279,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.53,,,,,,,fee schedule,36.95,163.92,Radiology
Pm device progr eval sngl,93279,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.73,,,,,,,fee schedule,36.95,163.92,APC
Pm device progr eval sngl,93279,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.66,,,,,,,fee schedule,36.95,163.92,APC
Pm device progr eval dual,93280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,77.3,,,,,,,fee schedule,36.95,163.92,
Pm device progr eval dual,93280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,61.96,,,,,,,fee schedule,36.95,163.92,
Pm device progr eval dual,93280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,67.69,,,,,,,fee schedule,36.95,163.92,
Pm device progr eval dual,93280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,71.17,,,,,,,fee schedule,36.95,163.92,
Pm device progr eval dual,93280,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,163.92,,,,,,,fee schedule,36.95,163.92,APC 378
Pm device progr eval dual,93280,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.79,,,,,,,fee schedule,36.95,163.92,APC
Pm device progr eval dual,93280,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.43,,,,,,,fee schedule,36.95,163.92,APC
Pm device progr eval dual,93280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.95,,,,,,,fee schedule,36.95,163.92,APC
Pm device progr eval dual,93280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.53,,,,,,,fee schedule,36.95,163.92,Radiology
Pm device progr eval dual,93280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.73,,,,,,,fee schedule,36.95,163.92,APC
Pm device progr eval dual,93280,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.66,,,,,,,fee schedule,36.95,163.92,APC
Pm device progr eval multi,93281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,90.91,,,,,,,fee schedule,36.95,163.92,
Pm device progr eval multi,93281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,72.87,,,,,,,fee schedule,36.95,163.92,
Pm device progr eval multi,93281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,79.61,,,,,,,fee schedule,36.95,163.92,
Pm device progr eval multi,93281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83.69,,,,,,,fee schedule,36.95,163.92,
Pm device progr eval multi,93281,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,163.92,,,,,,,fee schedule,36.95,163.92,APC 378
Pm device progr eval multi,93281,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.79,,,,,,,fee schedule,36.95,163.92,APC
Pm device progr eval multi,93281,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.43,,,,,,,fee schedule,36.95,163.92,APC
Pm device progr eval multi,93281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.95,,,,,,,fee schedule,36.95,163.92,APC
Pm device progr eval multi,93281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.53,,,,,,,fee schedule,36.95,163.92,Radiology
Pm device progr eval multi,93281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.73,,,,,,,fee schedule,36.95,163.92,APC
Pm device progr eval multi,93281,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.66,,,,,,,fee schedule,36.95,163.92,APC
Prgrmg eval implantable dfb,93282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,82.4,,,,,,,fee schedule,36.95,163.92,
Prgrmg eval implantable dfb,93282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66.05,,,,,,,fee schedule,36.95,163.92,
Prgrmg eval implantable dfb,93282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,72.16,,,,,,,fee schedule,36.95,163.92,
Prgrmg eval implantable dfb,93282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,75.86,,,,,,,fee schedule,36.95,163.92,
Prgrmg eval implantable dfb,93282,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,163.92,,,,,,,fee schedule,36.95,163.92,APC 378
Prgrmg eval implantable dfb,93282,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.79,,,,,,,fee schedule,36.95,163.92,APC
Prgrmg eval implantable dfb,93282,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.43,,,,,,,fee schedule,36.95,163.92,APC
Prgrmg eval implantable dfb,93282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.95,,,,,,,fee schedule,36.95,163.92,APC
Prgrmg eval implantable dfb,93282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.53,,,,,,,fee schedule,36.95,163.92,Radiology
Prgrmg eval implantable dfb,93282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.73,,,,,,,fee schedule,36.95,163.92,APC
Prgrmg eval implantable dfb,93282,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.66,,,,,,,fee schedule,36.95,163.92,APC
Prgrmg eval implantable dfb,93283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,93.33,,,,,,,fee schedule,36.95,163.92,
Prgrmg eval implantable dfb,93283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,74.81,,,,,,,fee schedule,36.95,163.92,
Prgrmg eval implantable dfb,93283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,81.72,,,,,,,fee schedule,36.95,163.92,
Prgrmg eval implantable dfb,93283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,85.92,,,,,,,fee schedule,36.95,163.92,
Prgrmg eval implantable dfb,93283,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,163.92,,,,,,,fee schedule,36.95,163.92,APC 378
Prgrmg eval implantable dfb,93283,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.79,,,,,,,fee schedule,36.95,163.92,APC
Prgrmg eval implantable dfb,93283,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.43,,,,,,,fee schedule,36.95,163.92,APC
Prgrmg eval implantable dfb,93283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.95,,,,,,,fee schedule,36.95,163.92,APC
Prgrmg eval implantable dfb,93283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.53,,,,,,,fee schedule,36.95,163.92,Radiology
Prgrmg eval implantable dfb,93283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.73,,,,,,,fee schedule,36.95,163.92,APC
Prgrmg eval implantable dfb,93283,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.66,,,,,,,fee schedule,36.95,163.92,APC
Prgrmg eval implantable dfb,93284,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,105.46,,,,,,,fee schedule,36.95,163.92,
Prgrmg eval implantable dfb,93284,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,84.54,,,,,,,fee schedule,36.95,163.92,
Prgrmg eval implantable dfb,93284,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,92.35,,,,,,,fee schedule,36.95,163.92,
Prgrmg eval implantable dfb,93284,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,97.09,,,,,,,fee schedule,36.95,163.92,
Prgrmg eval implantable dfb,93284,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,163.92,,,,,,,fee schedule,36.95,163.92,APC 378
Prgrmg eval implantable dfb,93284,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.79,,,,,,,fee schedule,36.95,163.92,APC
Prgrmg eval implantable dfb,93284,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.43,,,,,,,fee schedule,36.95,163.92,APC
Prgrmg eval implantable dfb,93284,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.95,,,,,,,fee schedule,36.95,163.92,APC
Prgrmg eval implantable dfb,93284,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.53,,,,,,,fee schedule,36.95,163.92,Radiology
Prgrmg eval implantable dfb,93284,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.73,,,,,,,fee schedule,36.95,163.92,APC
Prgrmg eval implantable dfb,93284,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.66,,,,,,,fee schedule,36.95,163.92,APC
Ilr device eval progr,93285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,64.22,,,,,,,fee schedule,36.95,163.92,
Ilr device eval progr,93285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.48,,,,,,,fee schedule,36.95,163.92,
Ilr device eval progr,93285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56.24,,,,,,,fee schedule,36.95,163.92,
Ilr device eval progr,93285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59.13,,,,,,,fee schedule,36.95,163.92,
Ilr device eval progr,93285,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,163.92,,,,,,,fee schedule,36.95,163.92,APC 378
Ilr device eval progr,93285,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.79,,,,,,,fee schedule,36.95,163.92,APC
Ilr device eval progr,93285,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.43,,,,,,,fee schedule,36.95,163.92,APC
Ilr device eval progr,93285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.95,,,,,,,fee schedule,36.95,163.92,APC
Ilr device eval progr,93285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.53,,,,,,,fee schedule,36.95,163.92,Radiology
Ilr device eval progr,93285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.73,,,,,,,fee schedule,36.95,163.92,APC
Ilr device eval progr,93285,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.66,,,,,,,fee schedule,36.95,163.92,APC
Peri-px pacemaker device evl,93286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41.81,,,,,,,fee schedule,33.51,41.81,
Peri-px pacemaker device evl,93286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,33.51,,,,,,,fee schedule,33.51,41.81,
Peri-px pacemaker device evl,93286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36.61,,,,,,,fee schedule,33.51,41.81,
Peri-px pacemaker device evl,93286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,38.49,,,,,,,fee schedule,33.51,41.81,
Peri-px device eval & prgr,93287,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,48.46,,,,,,,fee schedule,38.84,48.46,
Peri-px device eval & prgr,93287,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38.84,,,,,,,fee schedule,38.84,48.46,
Peri-px device eval & prgr,93287,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.43,,,,,,,fee schedule,38.84,48.46,
Peri-px device eval & prgr,93287,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,44.61,,,,,,,fee schedule,38.84,48.46,
Pm device eval in person,93288,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,65.43,,,,,,,fee schedule,36.95,163.92,
Pm device eval in person,93288,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52.45,,,,,,,fee schedule,36.95,163.92,
Pm device eval in person,93288,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.3,,,,,,,fee schedule,36.95,163.92,
Pm device eval in person,93288,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.24,,,,,,,fee schedule,36.95,163.92,
Pm device eval in person,93288,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,163.92,,,,,,,fee schedule,36.95,163.92,APC 378
Pm device eval in person,93288,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.79,,,,,,,fee schedule,36.95,163.92,APC
Pm device eval in person,93288,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.43,,,,,,,fee schedule,36.95,163.92,APC
Pm device eval in person,93288,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.95,,,,,,,fee schedule,36.95,163.92,APC
Pm device eval in person,93288,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.53,,,,,,,fee schedule,36.95,163.92,Radiology
Pm device eval in person,93288,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.73,,,,,,,fee schedule,36.95,163.92,APC
Pm device eval in person,93288,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.66,,,,,,,fee schedule,36.95,163.92,APC
Interrog device eval heart,93289,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,77.3,,,,,,,fee schedule,36.95,163.92,
Interrog device eval heart,93289,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,61.96,,,,,,,fee schedule,36.95,163.92,
Interrog device eval heart,93289,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,67.69,,,,,,,fee schedule,36.95,163.92,
Interrog device eval heart,93289,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,71.17,,,,,,,fee schedule,36.95,163.92,
Interrog device eval heart,93289,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,163.92,,,,,,,fee schedule,36.95,163.92,APC 378
Interrog device eval heart,93289,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.79,,,,,,,fee schedule,36.95,163.92,APC
Interrog device eval heart,93289,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.43,,,,,,,fee schedule,36.95,163.92,APC
Interrog device eval heart,93289,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.95,,,,,,,fee schedule,36.95,163.92,APC
Interrog device eval heart,93289,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.53,,,,,,,fee schedule,36.95,163.92,Radiology
Interrog device eval heart,93289,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.73,,,,,,,fee schedule,36.95,163.92,APC
Interrog device eval heart,93289,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.66,,,,,,,fee schedule,36.95,163.92,APC
Icm device eval,93290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37.54,,,,,,,fee schedule,30.09,163.92,
Icm device eval,93290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,30.09,,,,,,,fee schedule,30.09,163.92,
Icm device eval,93290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32.87,,,,,,,fee schedule,30.09,163.92,
Icm device eval,93290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,34.56,,,,,,,fee schedule,30.09,163.92,
Icm device eval,93290,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,163.92,,,,,,,fee schedule,30.09,163.92,APC 378
Icm device eval,93290,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.79,,,,,,,fee schedule,30.09,163.92,APC
Icm device eval,93290,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.43,,,,,,,fee schedule,30.09,163.92,APC
Icm device eval,93290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.95,,,,,,,fee schedule,30.09,163.92,APC
Icm device eval,93290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.53,,,,,,,fee schedule,30.09,163.92,Radiology
Icm device eval,93290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.73,,,,,,,fee schedule,30.09,163.92,APC
Icm device eval,93290,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.66,,,,,,,fee schedule,30.09,163.92,APC
Ilr device interrogate,93291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,57.87,,,,,,,fee schedule,28.63,127.04,
Ilr device interrogate,93291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.39,,,,,,,fee schedule,28.63,127.04,
Ilr device interrogate,93291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,50.68,,,,,,,fee schedule,28.63,127.04,
Ilr device interrogate,93291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,53.28,,,,,,,fee schedule,28.63,127.04,
Ilr device interrogate,93291,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,127.04,,,,,,,fee schedule,28.63,127.04,APC 378
Ilr device interrogate,93291,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.07,,,,,,,fee schedule,28.63,127.04,APC
Ilr device interrogate,93291,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,29.78,,,,,,,fee schedule,28.63,127.04,APC
Ilr device interrogate,93291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,28.63,,,,,,,fee schedule,28.63,127.04,APC
Ilr device interrogate,93291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43.81,,,,,,,fee schedule,28.63,127.04,Radiology
Ilr device interrogate,93291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40.09,,,,,,,fee schedule,28.63,127.04,APC
Ilr device interrogate,93291,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,50.11,,,,,,,fee schedule,28.63,127.04,APC
Wcd device interrogate,93292,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46,,,,,,,fee schedule,36.88,163.92,
Wcd device interrogate,93292,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36.88,,,,,,,fee schedule,36.88,163.92,
Wcd device interrogate,93292,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40.28,,,,,,,fee schedule,36.88,163.92,
Wcd device interrogate,93292,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42.35,,,,,,,fee schedule,36.88,163.92,
Wcd device interrogate,93292,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,163.92,,,,,,,fee schedule,36.88,163.92,APC 378
Wcd device interrogate,93292,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.79,,,,,,,fee schedule,36.88,163.92,APC
Wcd device interrogate,93292,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.43,,,,,,,fee schedule,36.88,163.92,APC
Wcd device interrogate,93292,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.95,,,,,,,fee schedule,36.88,163.92,APC
Wcd device interrogate,93292,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.53,,,,,,,fee schedule,36.88,163.92,Radiology
Wcd device interrogate,93292,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.73,,,,,,,fee schedule,36.88,163.92,APC
Wcd device interrogate,93292,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.66,,,,,,,fee schedule,36.88,163.92,APC
Pm phone r-strip device eval,93293,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,147.5,,,,,,,fee schedule,36.95,163.92,
Pm phone r-strip device eval,93293,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,118.23,,,,,,,fee schedule,36.95,163.92,
Pm phone r-strip device eval,93293,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,129.16,,,,,,,fee schedule,36.95,163.92,
Pm phone r-strip device eval,93293,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,135.79,,,,,,,fee schedule,36.95,163.92,
Pm phone r-strip device eval,93293,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,163.92,,,,,,,fee schedule,36.95,163.92,APC 378
Pm phone r-strip device eval,93293,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.79,,,,,,,fee schedule,36.95,163.92,APC
Pm phone r-strip device eval,93293,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.43,,,,,,,fee schedule,36.95,163.92,APC
Pm phone r-strip device eval,93293,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.95,,,,,,,fee schedule,36.95,163.92,APC
Pm phone r-strip device eval,93293,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.53,,,,,,,fee schedule,36.95,163.92,Radiology
Pm phone r-strip device eval,93293,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.73,,,,,,,fee schedule,36.95,163.92,APC
Pm phone r-strip device eval,93293,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.66,,,,,,,fee schedule,36.95,163.92,APC
Pm device interrogate remote,93294,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,134.34,,,,,,,fee schedule,107.69,134.34,
Pm device interrogate remote,93294,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,107.69,,,,,,,fee schedule,107.69,134.34,
Pm device interrogate remote,93294,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,117.64,,,,,,,fee schedule,107.69,134.34,
Pm device interrogate remote,93294,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,123.68,,,,,,,fee schedule,107.69,134.34,
Dev interrog remote 1/2/mlt,93295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,241.92,,,,,,,fee schedule,193.92,241.92,
Dev interrog remote 1/2/mlt,93295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,193.92,,,,,,,fee schedule,193.92,241.92,
Dev interrog remote 1/2/mlt,93295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,211.84,,,,,,,fee schedule,193.92,241.92,
Dev interrog remote 1/2/mlt,93295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,222.72,,,,,,,fee schedule,193.92,241.92,
Pm/icd remote tech serv,93296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,122.81,,,,,,,fee schedule,36.95,163.92,
Pm/icd remote tech serv,93296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,98.44,,,,,,,fee schedule,36.95,163.92,
Pm/icd remote tech serv,93296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,107.54,,,,,,,fee schedule,36.95,163.92,
Pm/icd remote tech serv,93296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,113.07,,,,,,,fee schedule,36.95,163.92,
Pm/icd remote tech serv,93296,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,163.92,,,,,,,fee schedule,36.95,163.92,APC 378
Pm/icd remote tech serv,93296,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.79,,,,,,,fee schedule,36.95,163.92,APC
Pm/icd remote tech serv,93296,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.43,,,,,,,fee schedule,36.95,163.92,APC
Pm/icd remote tech serv,93296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.95,,,,,,,fee schedule,36.95,163.92,APC
Pm/icd remote tech serv,93296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.53,,,,,,,fee schedule,36.95,163.92,Radiology
Pm/icd remote tech serv,93296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.73,,,,,,,fee schedule,36.95,163.92,APC
Pm/icd remote tech serv,93296,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.66,,,,,,,fee schedule,36.95,163.92,APC
Icm device interrogat remote,93297,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,94.5,,,,,,,fee schedule,36.95,163.92,
Icm device interrogat remote,93297,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,75.75,,,,,,,fee schedule,36.95,163.92,
Icm device interrogat remote,93297,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,82.75,,,,,,,fee schedule,36.95,163.92,
Icm device interrogat remote,93297,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,87,,,,,,,fee schedule,36.95,163.92,
Icm device interrogat remote,93297,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,163.92,,,,,,,fee schedule,36.95,163.92,APC 378
Icm device interrogat remote,93297,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.79,,,,,,,fee schedule,36.95,163.92,APC
Icm device interrogat remote,93297,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.43,,,,,,,fee schedule,36.95,163.92,APC
Icm device interrogat remote,93297,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.95,,,,,,,fee schedule,36.95,163.92,APC
Icm device interrogat remote,93297,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.53,,,,,,,fee schedule,36.95,163.92,Radiology
Icm device interrogat remote,93297,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.73,,,,,,,fee schedule,36.95,163.92,APC
Icm device interrogat remote,93297,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.66,,,,,,,fee schedule,36.95,163.92,APC
Ilr device interrogat remote,93298,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,107.84,,,,,,,fee schedule,36.95,163.92,
Ilr device interrogat remote,93298,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,86.45,,,,,,,fee schedule,36.95,163.92,
Ilr device interrogat remote,93298,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,94.43,,,,,,,fee schedule,36.95,163.92,
Ilr device interrogat remote,93298,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,99.28,,,,,,,fee schedule,36.95,163.92,
Ilr device interrogat remote,93298,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,163.92,,,,,,,fee schedule,36.95,163.92,APC 378
Ilr device interrogat remote,93298,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.79,,,,,,,fee schedule,36.95,163.92,APC
Ilr device interrogat remote,93298,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.43,,,,,,,fee schedule,36.95,163.92,APC
Ilr device interrogat remote,93298,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.95,,,,,,,fee schedule,36.95,163.92,APC
Ilr device interrogat remote,93298,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.53,,,,,,,fee schedule,36.95,163.92,Radiology
Ilr device interrogat remote,93298,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.73,,,,,,,fee schedule,36.95,163.92,APC
Ilr device interrogat remote,93298,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.66,,,,,,,fee schedule,36.95,163.92,APC
Echo transthoracic,93303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,508.79,,,,,,,fee schedule,407.84,2399.94,
Echo transthoracic,93303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,407.84,,,,,,,fee schedule,407.84,2399.94,
Echo transthoracic,93303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,445.53,,,,,,,fee schedule,407.84,2399.94,
Echo transthoracic,93303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,468.41,,,,,,,fee schedule,407.84,2399.94,
Echo transthoracic,93303,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2399.94,,,,,,,fee schedule,407.84,2399.94,APC 378
Echo transthoracic,93303,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,567.98,,,,,,,fee schedule,407.84,2399.94,APC
Echo transthoracic,93303,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,562.57,,,,,,,fee schedule,407.84,2399.94,APC
Echo transthoracic,93303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,540.93,,,,,,,fee schedule,407.84,2399.94,APC
Echo transthoracic,93303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,827.63,,,,,,,fee schedule,407.84,2399.94,Radiology
Echo transthoracic,93303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,757.31,,,,,,,fee schedule,407.84,2399.94,APC
Echo transthoracic,93303,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,946.63,,,,,,,fee schedule,407.84,2399.94,APC
Echo transthoracic,93304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,326.4,,,,,,,fee schedule,261.64,2399.94,
Echo transthoracic,93304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,261.64,,,,,,,fee schedule,261.64,2399.94,
Echo transthoracic,93304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,285.82,,,,,,,fee schedule,261.64,2399.94,
Echo transthoracic,93304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,300.5,,,,,,,fee schedule,261.64,2399.94,
Echo transthoracic,93304,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2399.94,,,,,,,fee schedule,261.64,2399.94,APC 378
Echo transthoracic,93304,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,567.98,,,,,,,fee schedule,261.64,2399.94,APC
Echo transthoracic,93304,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,562.57,,,,,,,fee schedule,261.64,2399.94,APC
Echo transthoracic,93304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,540.93,,,,,,,fee schedule,261.64,2399.94,APC
Echo transthoracic,93304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,827.63,,,,,,,fee schedule,261.64,2399.94,Radiology
Echo transthoracic,93304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,757.31,,,,,,,fee schedule,261.64,2399.94,APC
Echo transthoracic,93304,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,946.63,,,,,,,fee schedule,261.64,2399.94,APC
Tte w/doppler complete,93306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,668.12,,,,,,,fee schedule,535.55,2399.94,
Tte w/doppler complete,93306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,535.55,,,,,,,fee schedule,535.55,2399.94,
Tte w/doppler complete,93306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,585.04,,,,,,,fee schedule,535.55,2399.94,
Tte w/doppler complete,93306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,615.09,,,,,,,fee schedule,535.55,2399.94,
Tte w/doppler complete,93306,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2399.94,,,,,,,fee schedule,535.55,2399.94,APC 378
Tte w/doppler complete,93306,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,567.98,,,,,,,fee schedule,535.55,2399.94,APC
Tte w/doppler complete,93306,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,562.57,,,,,,,fee schedule,535.55,2399.94,APC
Tte w/doppler complete,93306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,540.93,,,,,,,fee schedule,535.55,2399.94,APC
Tte w/doppler complete,93306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,827.63,,,,,,,fee schedule,535.55,2399.94,Radiology
Tte w/doppler complete,93306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,757.31,,,,,,,fee schedule,535.55,2399.94,APC
Tte w/doppler complete,93306,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,946.63,,,,,,,fee schedule,535.55,2399.94,APC
Tte w/o doppler complete,93307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,434.78,,,,,,,fee schedule,236.21,1047.98,
Tte w/o doppler complete,93307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,348.51,,,,,,,fee schedule,236.21,1047.98,
Tte w/o doppler complete,93307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,380.72,,,,,,,fee schedule,236.21,1047.98,
Tte w/o doppler complete,93307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,400.27,,,,,,,fee schedule,236.21,1047.98,
Tte w/o doppler complete,93307,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,236.21,1047.98,APC 378
Tte w/o doppler complete,93307,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,236.21,1047.98,APC
Tte w/o doppler complete,93307,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,236.21,1047.98,APC
Tte w/o doppler complete,93307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,236.21,1047.98,APC
Tte w/o doppler complete,93307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,236.21,1047.98,Radiology
Tte w/o doppler complete,93307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,236.21,1047.98,APC
Tte w/o doppler complete,93307,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,236.21,1047.98,APC
Tte f-up or lmtd,93308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,281.5,,,,,,,fee schedule,225.64,1047.98,
Tte f-up or lmtd,93308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,225.64,,,,,,,fee schedule,225.64,1047.98,
Tte f-up or lmtd,93308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,246.5,,,,,,,fee schedule,225.64,1047.98,
Tte f-up or lmtd,93308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,259.16,,,,,,,fee schedule,225.64,1047.98,
Tte f-up or lmtd,93308,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,225.64,1047.98,APC 378
Tte f-up or lmtd,93308,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,225.64,1047.98,APC
Tte f-up or lmtd,93308,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,225.64,1047.98,APC
Tte f-up or lmtd,93308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,225.64,1047.98,APC
Tte f-up or lmtd,93308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,225.64,1047.98,Radiology
Tte f-up or lmtd,93308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,225.64,1047.98,APC
Tte f-up or lmtd,93308,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,225.64,1047.98,APC
Echo transesophageal,93312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,713.1,,,,,,,fee schedule,540.93,2399.94,
Echo transesophageal,93312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,571.61,,,,,,,fee schedule,540.93,2399.94,
Echo transesophageal,93312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,624.43,,,,,,,fee schedule,540.93,2399.94,
Echo transesophageal,93312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,656.5,,,,,,,fee schedule,540.93,2399.94,
Echo transesophageal,93312,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2399.94,,,,,,,fee schedule,540.93,2399.94,APC 378
Echo transesophageal,93312,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,567.98,,,,,,,fee schedule,540.93,2399.94,APC
Echo transesophageal,93312,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,562.57,,,,,,,fee schedule,540.93,2399.94,APC
Echo transesophageal,93312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,540.93,,,,,,,fee schedule,540.93,2399.94,APC
Echo transesophageal,93312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,827.63,,,,,,,fee schedule,540.93,2399.94,Radiology
Echo transesophageal,93312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,757.31,,,,,,,fee schedule,540.93,2399.94,APC
Echo transesophageal,93312,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,946.63,,,,,,,fee schedule,540.93,2399.94,APC
Echo transesophageal,93313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2050.61,,,,,,,fee schedule,540.93,2399.94,
Echo transesophageal,93313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1643.74,,,,,,,fee schedule,540.93,2399.94,
Echo transesophageal,93313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1795.64,,,,,,,fee schedule,540.93,2399.94,
Echo transesophageal,93313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1887.87,,,,,,,fee schedule,540.93,2399.94,
Echo transesophageal,93313,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2399.94,,,,,,,fee schedule,540.93,2399.94,APC 378
Echo transesophageal,93313,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,567.98,,,,,,,fee schedule,540.93,2399.94,APC
Echo transesophageal,93313,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,562.57,,,,,,,fee schedule,540.93,2399.94,APC
Echo transesophageal,93313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,540.93,,,,,,,fee schedule,540.93,2399.94,APC
Echo transesophageal,93313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,827.63,,,,,,,fee schedule,540.93,2399.94,Radiology
Echo transesophageal,93313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,757.31,,,,,,,fee schedule,540.93,2399.94,APC
Echo transesophageal,93313,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,946.63,,,,,,,fee schedule,540.93,2399.94,APC
Echo transesophageal,93315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1889.47,,,,,,,fee schedule,540.93,2399.94,
Echo transesophageal,93315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1514.58,,,,,,,fee schedule,540.93,2399.94,
Echo transesophageal,93315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1654.54,,,,,,,fee schedule,540.93,2399.94,
Echo transesophageal,93315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1739.51,,,,,,,fee schedule,540.93,2399.94,
Echo transesophageal,93315,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2399.94,,,,,,,fee schedule,540.93,2399.94,APC 378
Echo transesophageal,93315,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,567.98,,,,,,,fee schedule,540.93,2399.94,APC
Echo transesophageal,93315,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,562.57,,,,,,,fee schedule,540.93,2399.94,APC
Echo transesophageal,93315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,540.93,,,,,,,fee schedule,540.93,2399.94,APC
Echo transesophageal,93315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,827.63,,,,,,,fee schedule,540.93,2399.94,Radiology
Echo transesophageal,93315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,757.31,,,,,,,fee schedule,540.93,2399.94,APC
Echo transesophageal,93315,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,946.63,,,,,,,fee schedule,540.93,2399.94,APC
Echo transesophageal,93316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2050.61,,,,,,,fee schedule,540.93,2399.94,
Echo transesophageal,93316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1643.74,,,,,,,fee schedule,540.93,2399.94,
Echo transesophageal,93316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1795.64,,,,,,,fee schedule,540.93,2399.94,
Echo transesophageal,93316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1887.87,,,,,,,fee schedule,540.93,2399.94,
Echo transesophageal,93316,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2399.94,,,,,,,fee schedule,540.93,2399.94,APC 378
Echo transesophageal,93316,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,567.98,,,,,,,fee schedule,540.93,2399.94,APC
Echo transesophageal,93316,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,562.57,,,,,,,fee schedule,540.93,2399.94,APC
Echo transesophageal,93316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,540.93,,,,,,,fee schedule,540.93,2399.94,APC
Echo transesophageal,93316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,827.63,,,,,,,fee schedule,540.93,2399.94,Radiology
Echo transesophageal,93316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,757.31,,,,,,,fee schedule,540.93,2399.94,APC
Echo transesophageal,93316,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,946.63,,,,,,,fee schedule,540.93,2399.94,APC
Echo Transesophageal Intraop,93318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1889.47,,,,,,,fee schedule,540.93,2399.94,
Echo Transesophageal Intraop,93318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1514.58,,,,,,,fee schedule,540.93,2399.94,
Echo Transesophageal Intraop,93318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1654.54,,,,,,,fee schedule,540.93,2399.94,
Echo Transesophageal Intraop,93318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1739.51,,,,,,,fee schedule,540.93,2399.94,
Echo Transesophageal Intraop,93318,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2399.94,,,,,,,fee schedule,540.93,2399.94,APC 378
Echo Transesophageal Intraop,93318,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,567.98,,,,,,,fee schedule,540.93,2399.94,APC
Echo Transesophageal Intraop,93318,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,562.57,,,,,,,fee schedule,540.93,2399.94,APC
Echo Transesophageal Intraop,93318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,540.93,,,,,,,fee schedule,540.93,2399.94,APC
Echo Transesophageal Intraop,93318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,827.63,,,,,,,fee schedule,540.93,2399.94,Radiology
Echo Transesophageal Intraop,93318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,757.31,,,,,,,fee schedule,540.93,2399.94,APC
Echo Transesophageal Intraop,93318,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,946.63,,,,,,,fee schedule,540.93,2399.94,APC
Stress tte only,93350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,445.32,,,,,,,fee schedule,356.96,2399.94,
Stress tte only,93350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,356.96,,,,,,,fee schedule,356.96,2399.94,
Stress tte only,93350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,389.95,,,,,,,fee schedule,356.96,2399.94,
Stress tte only,93350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,409.98,,,,,,,fee schedule,356.96,2399.94,
Stress tte only,93350,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2399.94,,,,,,,fee schedule,356.96,2399.94,APC 378
Stress tte only,93350,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,567.98,,,,,,,fee schedule,356.96,2399.94,APC
Stress tte only,93350,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,562.57,,,,,,,fee schedule,356.96,2399.94,APC
Stress tte only,93350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,540.93,,,,,,,fee schedule,356.96,2399.94,APC
Stress tte only,93350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,827.63,,,,,,,fee schedule,356.96,2399.94,Radiology
Stress tte only,93350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,757.31,,,,,,,fee schedule,356.96,2399.94,APC
Stress tte only,93350,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,946.63,,,,,,,fee schedule,356.96,2399.94,APC
Stress tte complete,93351,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,962.24,,,,,,,fee schedule,540.93,2399.94,
Stress tte complete,93351,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,771.32,,,,,,,fee schedule,540.93,2399.94,
Stress tte complete,93351,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,842.59,,,,,,,fee schedule,540.93,2399.94,
Stress tte complete,93351,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,885.87,,,,,,,fee schedule,540.93,2399.94,
Stress tte complete,93351,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2399.94,,,,,,,fee schedule,540.93,2399.94,APC 378
Stress tte complete,93351,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,567.98,,,,,,,fee schedule,540.93,2399.94,APC
Stress tte complete,93351,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,562.57,,,,,,,fee schedule,540.93,2399.94,APC
Stress tte complete,93351,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,540.93,,,,,,,fee schedule,540.93,2399.94,APC
Stress tte complete,93351,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,827.63,,,,,,,fee schedule,540.93,2399.94,Radiology
Stress tte complete,93351,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,757.31,,,,,,,fee schedule,540.93,2399.94,APC
Stress tte complete,93351,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,946.63,,,,,,,fee schedule,540.93,2399.94,APC
Admin ecg contrast agent,93352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,133.81,,,,,,,fee schedule,107.26,133.81,
Admin ecg contrast agent,93352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,107.26,,,,,,,fee schedule,107.26,133.81,
Admin ecg contrast agent,93352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,117.17,,,,,,,fee schedule,107.26,133.81,
Admin ecg contrast agent,93352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,123.19,,,,,,,fee schedule,107.26,133.81,
Echo transesophageal (tee),93355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,860.14,,,,,,,fee schedule,689.48,860.14,
Echo transesophageal (tee),93355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,689.48,,,,,,,fee schedule,689.48,860.14,
Echo transesophageal (tee),93355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,753.19,,,,,,,fee schedule,689.48,860.14,
Echo transesophageal (tee),93355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,791.87,,,,,,,fee schedule,689.48,860.14,
Myocrd strain img spckl trck,93356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45.62,,,,,,,fee schedule,36.57,45.62,
Myocrd strain img spckl trck,93356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36.57,,,,,,,fee schedule,36.57,45.62,
Myocrd strain img spckl trck,93356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39.95,,,,,,,fee schedule,36.57,45.62,
Myocrd strain img spckl trck,93356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42,,,,,,,fee schedule,36.57,45.62,
Right heart cath,93451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4087.34,,,,,,,fee schedule,3209.41,14239.05,
Right heart cath,93451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3276.36,,,,,,,fee schedule,3209.41,14239.05,
Right heart cath,93451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3579.13,,,,,,,fee schedule,3209.41,14239.05,
Right heart cath,93451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3762.95,,,,,,,fee schedule,3209.41,14239.05,
Right heart cath,93451,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14239.05,,,,,,,fee schedule,3209.41,14239.05,APC 378
Right heart cath,93451,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3369.88,,,,,,,fee schedule,3209.41,14239.05,APC
Right heart cath,93451,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3337.78,,,,,,,fee schedule,3209.41,14239.05,APC
Right heart cath,93451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3209.41,,,,,,,fee schedule,3209.41,14239.05,APC
Right heart cath,93451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4910.39,,,,,,,fee schedule,3209.41,14239.05,Radiology
Right heart cath,93451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4493.17,,,,,,,fee schedule,3209.41,14239.05,APC
Right heart cath,93451,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5616.46,,,,,,,fee schedule,3209.41,14239.05,APC
Left hrt cath w/ventrclgrphy,93452,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10307.49,,,,,,,fee schedule,3209.41,14239.05,
Left hrt cath w/ventrclgrphy,93452,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8262.36,,,,,,,fee schedule,3209.41,14239.05,
Left hrt cath w/ventrclgrphy,93452,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9025.87,,,,,,,fee schedule,3209.41,14239.05,
Left hrt cath w/ventrclgrphy,93452,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9489.44,,,,,,,fee schedule,3209.41,14239.05,
Left hrt cath w/ventrclgrphy,93452,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14239.05,,,,,,,fee schedule,3209.41,14239.05,APC 378
Left hrt cath w/ventrclgrphy,93452,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3369.88,,,,,,,fee schedule,3209.41,14239.05,APC
Left hrt cath w/ventrclgrphy,93452,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3337.78,,,,,,,fee schedule,3209.41,14239.05,APC
Left hrt cath w/ventrclgrphy,93452,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3209.41,,,,,,,fee schedule,3209.41,14239.05,APC
Left hrt cath w/ventrclgrphy,93452,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4910.39,,,,,,,fee schedule,3209.41,14239.05,Radiology
Left hrt cath w/ventrclgrphy,93452,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4493.17,,,,,,,fee schedule,3209.41,14239.05,APC
Left hrt cath w/ventrclgrphy,93452,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5616.46,,,,,,,fee schedule,3209.41,14239.05,APC
R&l hrt cath w/ventriclgrphy,93453,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10307.49,,,,,,,fee schedule,3209.41,14239.05,
R&l hrt cath w/ventriclgrphy,93453,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8262.36,,,,,,,fee schedule,3209.41,14239.05,
R&l hrt cath w/ventriclgrphy,93453,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9025.87,,,,,,,fee schedule,3209.41,14239.05,
R&l hrt cath w/ventriclgrphy,93453,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9489.44,,,,,,,fee schedule,3209.41,14239.05,
R&l hrt cath w/ventriclgrphy,93453,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14239.05,,,,,,,fee schedule,3209.41,14239.05,APC 378
R&l hrt cath w/ventriclgrphy,93453,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3369.88,,,,,,,fee schedule,3209.41,14239.05,APC
R&l hrt cath w/ventriclgrphy,93453,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3337.78,,,,,,,fee schedule,3209.41,14239.05,APC
R&l hrt cath w/ventriclgrphy,93453,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3209.41,,,,,,,fee schedule,3209.41,14239.05,APC
R&l hrt cath w/ventriclgrphy,93453,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4910.39,,,,,,,fee schedule,3209.41,14239.05,Radiology
R&l hrt cath w/ventriclgrphy,93453,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4493.17,,,,,,,fee schedule,3209.41,14239.05,APC
R&l hrt cath w/ventriclgrphy,93453,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5616.46,,,,,,,fee schedule,3209.41,14239.05,APC
Coronary artery angio s&i,93454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4087.34,,,,,,,fee schedule,3209.41,14239.05,
Coronary artery angio s&i,93454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3276.36,,,,,,,fee schedule,3209.41,14239.05,
Coronary artery angio s&i,93454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3579.13,,,,,,,fee schedule,3209.41,14239.05,
Coronary artery angio s&i,93454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3762.95,,,,,,,fee schedule,3209.41,14239.05,
Coronary artery angio s&i,93454,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14239.05,,,,,,,fee schedule,3209.41,14239.05,APC 378
Coronary artery angio s&i,93454,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3369.88,,,,,,,fee schedule,3209.41,14239.05,APC
Coronary artery angio s&i,93454,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3337.78,,,,,,,fee schedule,3209.41,14239.05,APC
Coronary artery angio s&i,93454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3209.41,,,,,,,fee schedule,3209.41,14239.05,APC
Coronary artery angio s&i,93454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4910.39,,,,,,,fee schedule,3209.41,14239.05,Radiology
Coronary artery angio s&i,93454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4493.17,,,,,,,fee schedule,3209.41,14239.05,APC
Coronary artery angio s&i,93454,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5616.46,,,,,,,fee schedule,3209.41,14239.05,APC
Coronary art/grft angio s&i,93455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4087.34,,,,,,,fee schedule,3209.41,14239.05,
Coronary art/grft angio s&i,93455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3276.36,,,,,,,fee schedule,3209.41,14239.05,
Coronary art/grft angio s&i,93455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3579.13,,,,,,,fee schedule,3209.41,14239.05,
Coronary art/grft angio s&i,93455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3762.95,,,,,,,fee schedule,3209.41,14239.05,
Coronary art/grft angio s&i,93455,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14239.05,,,,,,,fee schedule,3209.41,14239.05,APC 378
Coronary art/grft angio s&i,93455,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3369.88,,,,,,,fee schedule,3209.41,14239.05,APC
Coronary art/grft angio s&i,93455,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3337.78,,,,,,,fee schedule,3209.41,14239.05,APC
Coronary art/grft angio s&i,93455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3209.41,,,,,,,fee schedule,3209.41,14239.05,APC
Coronary art/grft angio s&i,93455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4910.39,,,,,,,fee schedule,3209.41,14239.05,Radiology
Coronary art/grft angio s&i,93455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4493.17,,,,,,,fee schedule,3209.41,14239.05,APC
Coronary art/grft angio s&i,93455,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5616.46,,,,,,,fee schedule,3209.41,14239.05,APC
R hrt coronary artery angio,93456,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4087.34,,,,,,,fee schedule,3209.41,14239.05,
R hrt coronary artery angio,93456,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3276.36,,,,,,,fee schedule,3209.41,14239.05,
R hrt coronary artery angio,93456,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3579.13,,,,,,,fee schedule,3209.41,14239.05,
R hrt coronary artery angio,93456,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3762.95,,,,,,,fee schedule,3209.41,14239.05,
R hrt coronary artery angio,93456,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14239.05,,,,,,,fee schedule,3209.41,14239.05,APC 378
R hrt coronary artery angio,93456,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3369.88,,,,,,,fee schedule,3209.41,14239.05,APC
R hrt coronary artery angio,93456,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3337.78,,,,,,,fee schedule,3209.41,14239.05,APC
R hrt coronary artery angio,93456,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3209.41,,,,,,,fee schedule,3209.41,14239.05,APC
R hrt coronary artery angio,93456,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4910.39,,,,,,,fee schedule,3209.41,14239.05,Radiology
R hrt coronary artery angio,93456,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4493.17,,,,,,,fee schedule,3209.41,14239.05,APC
R hrt coronary artery angio,93456,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5616.46,,,,,,,fee schedule,3209.41,14239.05,APC
R hrt art/grft angio,93457,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10307.49,,,,,,,fee schedule,3209.41,14239.05,
R hrt art/grft angio,93457,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8262.36,,,,,,,fee schedule,3209.41,14239.05,
R hrt art/grft angio,93457,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9025.87,,,,,,,fee schedule,3209.41,14239.05,
R hrt art/grft angio,93457,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9489.44,,,,,,,fee schedule,3209.41,14239.05,
R hrt art/grft angio,93457,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14239.05,,,,,,,fee schedule,3209.41,14239.05,APC 378
R hrt art/grft angio,93457,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3369.88,,,,,,,fee schedule,3209.41,14239.05,APC
R hrt art/grft angio,93457,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3337.78,,,,,,,fee schedule,3209.41,14239.05,APC
R hrt art/grft angio,93457,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3209.41,,,,,,,fee schedule,3209.41,14239.05,APC
R hrt art/grft angio,93457,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4910.39,,,,,,,fee schedule,3209.41,14239.05,Radiology
R hrt art/grft angio,93457,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4493.17,,,,,,,fee schedule,3209.41,14239.05,APC
R hrt art/grft angio,93457,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5616.46,,,,,,,fee schedule,3209.41,14239.05,APC
L hrt artery/ventricle angio,93458,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4087.34,,,,,,,fee schedule,3209.41,14239.05,
L hrt artery/ventricle angio,93458,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3276.36,,,,,,,fee schedule,3209.41,14239.05,
L hrt artery/ventricle angio,93458,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3579.13,,,,,,,fee schedule,3209.41,14239.05,
L hrt artery/ventricle angio,93458,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3762.95,,,,,,,fee schedule,3209.41,14239.05,
L hrt artery/ventricle angio,93458,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14239.05,,,,,,,fee schedule,3209.41,14239.05,APC 378
L hrt artery/ventricle angio,93458,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3369.88,,,,,,,fee schedule,3209.41,14239.05,APC
L hrt artery/ventricle angio,93458,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3337.78,,,,,,,fee schedule,3209.41,14239.05,APC
L hrt artery/ventricle angio,93458,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3209.41,,,,,,,fee schedule,3209.41,14239.05,APC
L hrt artery/ventricle angio,93458,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4910.39,,,,,,,fee schedule,3209.41,14239.05,Radiology
L hrt artery/ventricle angio,93458,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4493.17,,,,,,,fee schedule,3209.41,14239.05,APC
L hrt artery/ventricle angio,93458,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5616.46,,,,,,,fee schedule,3209.41,14239.05,APC
L hrt art/grft angio,93459,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4087.34,,,,,,,fee schedule,3209.41,14239.05,
L hrt art/grft angio,93459,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3276.36,,,,,,,fee schedule,3209.41,14239.05,
L hrt art/grft angio,93459,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3579.13,,,,,,,fee schedule,3209.41,14239.05,
L hrt art/grft angio,93459,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3762.95,,,,,,,fee schedule,3209.41,14239.05,
L hrt art/grft angio,93459,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14239.05,,,,,,,fee schedule,3209.41,14239.05,APC 378
L hrt art/grft angio,93459,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3369.88,,,,,,,fee schedule,3209.41,14239.05,APC
L hrt art/grft angio,93459,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3337.78,,,,,,,fee schedule,3209.41,14239.05,APC
L hrt art/grft angio,93459,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3209.41,,,,,,,fee schedule,3209.41,14239.05,APC
L hrt art/grft angio,93459,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4910.39,,,,,,,fee schedule,3209.41,14239.05,Radiology
L hrt art/grft angio,93459,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4493.17,,,,,,,fee schedule,3209.41,14239.05,APC
L hrt art/grft angio,93459,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5616.46,,,,,,,fee schedule,3209.41,14239.05,APC
R&l hrt art/ventricle angio,93460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4087.34,,,,,,,fee schedule,3209.41,14239.05,
R&l hrt art/ventricle angio,93460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3276.36,,,,,,,fee schedule,3209.41,14239.05,
R&l hrt art/ventricle angio,93460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3579.13,,,,,,,fee schedule,3209.41,14239.05,
R&l hrt art/ventricle angio,93460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3762.95,,,,,,,fee schedule,3209.41,14239.05,
R&l hrt art/ventricle angio,93460,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14239.05,,,,,,,fee schedule,3209.41,14239.05,APC 378
R&l hrt art/ventricle angio,93460,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3369.88,,,,,,,fee schedule,3209.41,14239.05,APC
R&l hrt art/ventricle angio,93460,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3337.78,,,,,,,fee schedule,3209.41,14239.05,APC
R&l hrt art/ventricle angio,93460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3209.41,,,,,,,fee schedule,3209.41,14239.05,APC
R&l hrt art/ventricle angio,93460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4910.39,,,,,,,fee schedule,3209.41,14239.05,Radiology
R&l hrt art/ventricle angio,93460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4493.17,,,,,,,fee schedule,3209.41,14239.05,APC
R&l hrt art/ventricle angio,93460,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5616.46,,,,,,,fee schedule,3209.41,14239.05,APC
R&l hrt art/ventricle angio,93461,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3715.66,,,,,,,fee schedule,2978.43,14239.05,
R&l hrt art/ventricle angio,93461,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2978.43,,,,,,,fee schedule,2978.43,14239.05,
R&l hrt art/ventricle angio,93461,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3253.66,,,,,,,fee schedule,2978.43,14239.05,
R&l hrt art/ventricle angio,93461,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3420.77,,,,,,,fee schedule,2978.43,14239.05,
R&l hrt art/ventricle angio,93461,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14239.05,,,,,,,fee schedule,2978.43,14239.05,APC 378
R&l hrt art/ventricle angio,93461,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3369.88,,,,,,,fee schedule,2978.43,14239.05,APC
R&l hrt art/ventricle angio,93461,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3337.78,,,,,,,fee schedule,2978.43,14239.05,APC
R&l hrt art/ventricle angio,93461,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3209.41,,,,,,,fee schedule,2978.43,14239.05,APC
R&l hrt art/ventricle angio,93461,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4910.39,,,,,,,fee schedule,2978.43,14239.05,Radiology
R&l hrt art/ventricle angio,93461,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4493.17,,,,,,,fee schedule,2978.43,14239.05,APC
R&l hrt art/ventricle angio,93461,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5616.46,,,,,,,fee schedule,2978.43,14239.05,APC
L hrt cath trnsptl puncture,93462,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4087.34,,,,,,,fee schedule,3276.36,4087.34,
L hrt cath trnsptl puncture,93462,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3276.36,,,,,,,fee schedule,3276.36,4087.34,
L hrt cath trnsptl puncture,93462,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3579.13,,,,,,,fee schedule,3276.36,4087.34,
L hrt cath trnsptl puncture,93462,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3762.95,,,,,,,fee schedule,3276.36,4087.34,
Insert/place heart catheter,93503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3658.17,,,,,,,fee schedule,1558.36,6913.93,
Insert/place heart catheter,93503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2932.34,,,,,,,fee schedule,1558.36,6913.93,
Insert/place heart catheter,93503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3203.32,,,,,,,fee schedule,1558.36,6913.93,
Insert/place heart catheter,93503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3367.84,,,,,,,fee schedule,1558.36,6913.93,
Insert/place heart catheter,93503,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6913.93,,,,,,,fee schedule,1558.36,6913.93,APC 378
Insert/place heart catheter,93503,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1636.28,,,,,,,fee schedule,1558.36,6913.93,APC
Insert/place heart catheter,93503,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1620.7,,,,,,,fee schedule,1558.36,6913.93,APC
Insert/place heart catheter,93503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1558.36,,,,,,,fee schedule,1558.36,6913.93,APC
Insert/place heart catheter,93503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2384.29,,,,,,,fee schedule,1558.36,6913.93,Radiology
Insert/place heart catheter,93503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2181.71,,,,,,,fee schedule,1558.36,6913.93,APC
Insert/place heart catheter,93503,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2727.13,,,,,,,fee schedule,1558.36,6913.93,APC
Biopsy of heart lining,93505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1689.85,,,,,,,fee schedule,1354.56,13868.13,
Biopsy of heart lining,93505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1354.56,,,,,,,fee schedule,1354.56,13868.13,
Biopsy of heart lining,93505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1479.74,,,,,,,fee schedule,1354.56,13868.13,
Biopsy of heart lining,93505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1555.73,,,,,,,fee schedule,1354.56,13868.13,
Biopsy of heart lining,93505,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13868.13,,,,,,,fee schedule,1354.56,13868.13,APC 378
Biopsy of heart lining,93505,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3282.09,,,,,,,fee schedule,1354.56,13868.13,APC
Biopsy of heart lining,93505,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3250.84,,,,,,,fee schedule,1354.56,13868.13,APC
Biopsy of heart lining,93505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3125.8,,,,,,,fee schedule,1354.56,13868.13,APC
Biopsy of heart lining,93505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4782.48,,,,,,,fee schedule,1354.56,13868.13,Radiology
Biopsy of heart lining,93505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4376.12,,,,,,,fee schedule,1354.56,13868.13,APC
Biopsy of heart lining,93505,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5470.16,,,,,,,fee schedule,1354.56,13868.13,APC
Transcath closure of asd,93580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19213.31,,,,,,,fee schedule,15401.15,80515.32,
Transcath closure of asd,93580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15401.15,,,,,,,fee schedule,15401.15,80515.32,
Transcath closure of asd,93580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16824.35,,,,,,,fee schedule,15401.15,80515.32,
Transcath closure of asd,93580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17688.45,,,,,,,fee schedule,15401.15,80515.32,
Transcath closure of asd,93580,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,80515.32,,,,,,,fee schedule,15401.15,80515.32,APC 378
Transcath closure of asd,93580,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19055.11,,,,,,,fee schedule,15401.15,80515.32,APC
Transcath closure of asd,93580,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18873.64,,,,,,,fee schedule,15401.15,80515.32,APC
Transcath closure of asd,93580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18147.73,,,,,,,fee schedule,15401.15,80515.32,APC
Transcath closure of asd,93580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27766.02,,,,,,,fee schedule,15401.15,80515.32,Radiology
Transcath closure of asd,93580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25406.82,,,,,,,fee schedule,15401.15,80515.32,APC
Transcath closure of asd,93580,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31758.52,,,,,,,fee schedule,15401.15,80515.32,APC
Transcath closure of vsd,93581,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33046.99,,,,,,,fee schedule,18147.73,80515.32,
Transcath closure of vsd,93581,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26490.05,,,,,,,fee schedule,18147.73,80515.32,
Transcath closure of vsd,93581,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28937.97,,,,,,,fee schedule,18147.73,80515.32,
Transcath closure of vsd,93581,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30424.21,,,,,,,fee schedule,18147.73,80515.32,
Transcath closure of vsd,93581,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,80515.32,,,,,,,fee schedule,18147.73,80515.32,APC 378
Transcath closure of vsd,93581,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19055.11,,,,,,,fee schedule,18147.73,80515.32,APC
Transcath closure of vsd,93581,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18873.64,,,,,,,fee schedule,18147.73,80515.32,APC
Transcath closure of vsd,93581,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18147.73,,,,,,,fee schedule,18147.73,80515.32,APC
Transcath closure of vsd,93581,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27766.02,,,,,,,fee schedule,18147.73,80515.32,Radiology
Transcath closure of vsd,93581,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25406.82,,,,,,,fee schedule,18147.73,80515.32,APC
Transcath closure of vsd,93581,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31758.52,,,,,,,fee schedule,18147.73,80515.32,APC
Perq transcath closure pda,93582,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17321.35,,,,,,,fee schedule,13884.57,80515.32,
Perq transcath closure pda,93582,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13884.57,,,,,,,fee schedule,13884.57,80515.32,
Perq transcath closure pda,93582,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15167.63,,,,,,,fee schedule,13884.57,80515.32,
Perq transcath closure pda,93582,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15946.64,,,,,,,fee schedule,13884.57,80515.32,
Perq transcath closure pda,93582,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,80515.32,,,,,,,fee schedule,13884.57,80515.32,APC 378
Perq transcath closure pda,93582,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19055.11,,,,,,,fee schedule,13884.57,80515.32,APC
Perq transcath closure pda,93582,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18873.64,,,,,,,fee schedule,13884.57,80515.32,APC
Perq transcath closure pda,93582,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18147.73,,,,,,,fee schedule,13884.57,80515.32,APC
Perq transcath closure pda,93582,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27766.02,,,,,,,fee schedule,13884.57,80515.32,Radiology
Perq transcath closure pda,93582,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25406.82,,,,,,,fee schedule,13884.57,80515.32,APC
Perq transcath closure pda,93582,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31758.52,,,,,,,fee schedule,13884.57,80515.32,APC
Perq transcath septal reduxn,93583,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2953.16,,,,,,,fee schedule,2367.22,2953.16,
Perq transcath septal reduxn,93583,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2367.22,,,,,,,fee schedule,2367.22,2953.16,
Perq transcath septal reduxn,93583,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2585.97,,,,,,,fee schedule,2367.22,2953.16,
Perq transcath septal reduxn,93583,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2718.78,,,,,,,fee schedule,2367.22,2953.16,
Perq transcath cls mitral,93590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55876.49,,,,,,,fee schedule,18147.73,80515.32,
Perq transcath cls mitral,93590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,44789.88,,,,,,,fee schedule,18147.73,80515.32,
Perq transcath cls mitral,93590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48928.88,,,,,,,fee schedule,18147.73,80515.32,
Perq transcath cls mitral,93590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,51441.85,,,,,,,fee schedule,18147.73,80515.32,
Perq transcath cls mitral,93590,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,80515.32,,,,,,,fee schedule,18147.73,80515.32,APC 378
Perq transcath cls mitral,93590,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19055.11,,,,,,,fee schedule,18147.73,80515.32,APC
Perq transcath cls mitral,93590,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18873.64,,,,,,,fee schedule,18147.73,80515.32,APC
Perq transcath cls mitral,93590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18147.73,,,,,,,fee schedule,18147.73,80515.32,APC
Perq transcath cls mitral,93590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27766.02,,,,,,,fee schedule,18147.73,80515.32,Radiology
Perq transcath cls mitral,93590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25406.82,,,,,,,fee schedule,18147.73,80515.32,APC
Perq transcath cls mitral,93590,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31758.52,,,,,,,fee schedule,18147.73,80515.32,APC
Perq transcath cls aortic,93591,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55876.49,,,,,,,fee schedule,18147.73,80515.32,
Perq transcath cls aortic,93591,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,44789.88,,,,,,,fee schedule,18147.73,80515.32,
Perq transcath cls aortic,93591,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48928.88,,,,,,,fee schedule,18147.73,80515.32,
Perq transcath cls aortic,93591,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,51441.85,,,,,,,fee schedule,18147.73,80515.32,
Perq transcath cls aortic,93591,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,80515.32,,,,,,,fee schedule,18147.73,80515.32,APC 378
Perq transcath cls aortic,93591,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19055.11,,,,,,,fee schedule,18147.73,80515.32,APC
Perq transcath cls aortic,93591,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18873.64,,,,,,,fee schedule,18147.73,80515.32,APC
Perq transcath cls aortic,93591,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18147.73,,,,,,,fee schedule,18147.73,80515.32,APC
Perq transcath cls aortic,93591,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27766.02,,,,,,,fee schedule,18147.73,80515.32,Radiology
Perq transcath cls aortic,93591,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25406.82,,,,,,,fee schedule,18147.73,80515.32,APC
Perq transcath cls aortic,93591,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31758.52,,,,,,,fee schedule,18147.73,80515.32,APC
Perq transcath closure each,93592,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1742.66,,,,,,,fee schedule,1396.9,1742.66,
Perq transcath closure each,93592,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1396.9,,,,,,,fee schedule,1396.9,1742.66,
Perq transcath closure each,93592,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1525.98,,,,,,,fee schedule,1396.9,1742.66,
Perq transcath closure each,93592,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1604.36,,,,,,,fee schedule,1396.9,1742.66,
R hrt cath chd nml nt cnj,93593,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11194.55,,,,,,,fee schedule,3209.41,14239.05,
R hrt cath chd nml nt cnj,93593,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8973.41,,,,,,,fee schedule,3209.41,14239.05,
R hrt cath chd nml nt cnj,93593,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9802.63,,,,,,,fee schedule,3209.41,14239.05,
R hrt cath chd nml nt cnj,93593,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10306.09,,,,,,,fee schedule,3209.41,14239.05,
R hrt cath chd nml nt cnj,93593,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14239.05,,,,,,,fee schedule,3209.41,14239.05,APC 378
R hrt cath chd nml nt cnj,93593,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3369.88,,,,,,,fee schedule,3209.41,14239.05,APC
R hrt cath chd nml nt cnj,93593,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3337.78,,,,,,,fee schedule,3209.41,14239.05,APC
R hrt cath chd nml nt cnj,93593,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3209.41,,,,,,,fee schedule,3209.41,14239.05,APC
R hrt cath chd nml nt cnj,93593,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4910.39,,,,,,,fee schedule,3209.41,14239.05,Radiology
R hrt cath chd nml nt cnj,93593,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4493.17,,,,,,,fee schedule,3209.41,14239.05,APC
R hrt cath chd nml nt cnj,93593,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5616.46,,,,,,,fee schedule,3209.41,14239.05,APC
R hrt cath chd abnl nt cnj,93594,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11194.55,,,,,,,fee schedule,3209.41,14239.05,
R hrt cath chd abnl nt cnj,93594,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8973.41,,,,,,,fee schedule,3209.41,14239.05,
R hrt cath chd abnl nt cnj,93594,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9802.63,,,,,,,fee schedule,3209.41,14239.05,
R hrt cath chd abnl nt cnj,93594,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10306.09,,,,,,,fee schedule,3209.41,14239.05,
R hrt cath chd abnl nt cnj,93594,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14239.05,,,,,,,fee schedule,3209.41,14239.05,APC 378
R hrt cath chd abnl nt cnj,93594,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3369.88,,,,,,,fee schedule,3209.41,14239.05,APC
R hrt cath chd abnl nt cnj,93594,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3337.78,,,,,,,fee schedule,3209.41,14239.05,APC
R hrt cath chd abnl nt cnj,93594,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3209.41,,,,,,,fee schedule,3209.41,14239.05,APC
R hrt cath chd abnl nt cnj,93594,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4910.39,,,,,,,fee schedule,3209.41,14239.05,Radiology
R hrt cath chd abnl nt cnj,93594,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4493.17,,,,,,,fee schedule,3209.41,14239.05,APC
R hrt cath chd abnl nt cnj,93594,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5616.46,,,,,,,fee schedule,3209.41,14239.05,APC
L hrt cath chd nm/abn nt cnj,93595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11194.55,,,,,,,fee schedule,3209.41,14239.05,
L hrt cath chd nm/abn nt cnj,93595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8973.41,,,,,,,fee schedule,3209.41,14239.05,
L hrt cath chd nm/abn nt cnj,93595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9802.63,,,,,,,fee schedule,3209.41,14239.05,
L hrt cath chd nm/abn nt cnj,93595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10306.09,,,,,,,fee schedule,3209.41,14239.05,
L hrt cath chd nm/abn nt cnj,93595,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14239.05,,,,,,,fee schedule,3209.41,14239.05,APC 378
L hrt cath chd nm/abn nt cnj,93595,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3369.88,,,,,,,fee schedule,3209.41,14239.05,APC
L hrt cath chd nm/abn nt cnj,93595,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3337.78,,,,,,,fee schedule,3209.41,14239.05,APC
L hrt cath chd nm/abn nt cnj,93595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3209.41,,,,,,,fee schedule,3209.41,14239.05,APC
L hrt cath chd nm/abn nt cnj,93595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4910.39,,,,,,,fee schedule,3209.41,14239.05,Radiology
L hrt cath chd nm/abn nt cnj,93595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4493.17,,,,,,,fee schedule,3209.41,14239.05,APC
L hrt cath chd nm/abn nt cnj,93595,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5616.46,,,,,,,fee schedule,3209.41,14239.05,APC
R&l hrt cath chd nml nt cnj,93596,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11194.55,,,,,,,fee schedule,3209.41,14239.05,
R&l hrt cath chd nml nt cnj,93596,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8973.41,,,,,,,fee schedule,3209.41,14239.05,
R&l hrt cath chd nml nt cnj,93596,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9802.63,,,,,,,fee schedule,3209.41,14239.05,
R&l hrt cath chd nml nt cnj,93596,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10306.09,,,,,,,fee schedule,3209.41,14239.05,
R&l hrt cath chd nml nt cnj,93596,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14239.05,,,,,,,fee schedule,3209.41,14239.05,APC 378
R&l hrt cath chd nml nt cnj,93596,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3369.88,,,,,,,fee schedule,3209.41,14239.05,APC
R&l hrt cath chd nml nt cnj,93596,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3337.78,,,,,,,fee schedule,3209.41,14239.05,APC
R&l hrt cath chd nml nt cnj,93596,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3209.41,,,,,,,fee schedule,3209.41,14239.05,APC
R&l hrt cath chd nml nt cnj,93596,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4910.39,,,,,,,fee schedule,3209.41,14239.05,Radiology
R&l hrt cath chd nml nt cnj,93596,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4493.17,,,,,,,fee schedule,3209.41,14239.05,APC
R&l hrt cath chd nml nt cnj,93596,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5616.46,,,,,,,fee schedule,3209.41,14239.05,APC
R&l hrt cath chd abnl nt cnj,93597,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11194.55,,,,,,,fee schedule,3209.41,14239.05,
R&l hrt cath chd abnl nt cnj,93597,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8973.41,,,,,,,fee schedule,3209.41,14239.05,
R&l hrt cath chd abnl nt cnj,93597,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9802.63,,,,,,,fee schedule,3209.41,14239.05,
R&l hrt cath chd abnl nt cnj,93597,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10306.09,,,,,,,fee schedule,3209.41,14239.05,
R&l hrt cath chd abnl nt cnj,93597,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14239.05,,,,,,,fee schedule,3209.41,14239.05,APC 378
R&l hrt cath chd abnl nt cnj,93597,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3369.88,,,,,,,fee schedule,3209.41,14239.05,APC
R&l hrt cath chd abnl nt cnj,93597,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3337.78,,,,,,,fee schedule,3209.41,14239.05,APC
R&l hrt cath chd abnl nt cnj,93597,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3209.41,,,,,,,fee schedule,3209.41,14239.05,APC
R&l hrt cath chd abnl nt cnj,93597,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4910.39,,,,,,,fee schedule,3209.41,14239.05,Radiology
R&l hrt cath chd abnl nt cnj,93597,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4493.17,,,,,,,fee schedule,3209.41,14239.05,APC
R&l hrt cath chd abnl nt cnj,93597,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5616.46,,,,,,,fee schedule,3209.41,14239.05,APC
Bundle of His recording,93600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2391.8,,,,,,,fee schedule,1917.23,34257.3,
Bundle of His recording,93600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1917.23,,,,,,,fee schedule,1917.23,34257.3,
Bundle of His recording,93600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2094.4,,,,,,,fee schedule,1917.23,34257.3,
Bundle of His recording,93600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2201.97,,,,,,,fee schedule,1917.23,34257.3,
Bundle of His recording,93600,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,34257.3,,,,,,,fee schedule,1917.23,34257.3,APC 378
Bundle of His recording,93600,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8107.48,,,,,,,fee schedule,1917.23,34257.3,APC
Bundle of His recording,93600,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8030.27,,,,,,,fee schedule,1917.23,34257.3,APC
Bundle of His recording,93600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7721.41,,,,,,,fee schedule,1917.23,34257.3,APC
Bundle of His recording,93600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11813.76,,,,,,,fee schedule,1917.23,34257.3,Radiology
Bundle of His recording,93600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10809.98,,,,,,,fee schedule,1917.23,34257.3,APC
Bundle of His recording,93600,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,13512.47,,,,,,,fee schedule,1917.23,34257.3,APC
Intra-atrial recording,93602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2391.8,,,,,,,fee schedule,1917.23,34257.3,
Intra-atrial recording,93602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1917.23,,,,,,,fee schedule,1917.23,34257.3,
Intra-atrial recording,93602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2094.4,,,,,,,fee schedule,1917.23,34257.3,
Intra-atrial recording,93602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2201.97,,,,,,,fee schedule,1917.23,34257.3,
Intra-atrial recording,93602,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,34257.3,,,,,,,fee schedule,1917.23,34257.3,APC 378
Intra-atrial recording,93602,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8107.48,,,,,,,fee schedule,1917.23,34257.3,APC
Intra-atrial recording,93602,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8030.27,,,,,,,fee schedule,1917.23,34257.3,APC
Intra-atrial recording,93602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7721.41,,,,,,,fee schedule,1917.23,34257.3,APC
Intra-atrial recording,93602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11813.76,,,,,,,fee schedule,1917.23,34257.3,Radiology
Intra-atrial recording,93602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10809.98,,,,,,,fee schedule,1917.23,34257.3,APC
Intra-atrial recording,93602,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,13512.47,,,,,,,fee schedule,1917.23,34257.3,APC
Right ventricular recording,93603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2391.8,,,,,,,fee schedule,1205.32,5347.61,
Right ventricular recording,93603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1917.23,,,,,,,fee schedule,1205.32,5347.61,
Right ventricular recording,93603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2094.4,,,,,,,fee schedule,1205.32,5347.61,
Right ventricular recording,93603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2201.97,,,,,,,fee schedule,1205.32,5347.61,
Right ventricular recording,93603,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5347.61,,,,,,,fee schedule,1205.32,5347.61,APC 378
Right ventricular recording,93603,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1265.59,,,,,,,fee schedule,1205.32,5347.61,APC
Right ventricular recording,93603,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1253.54,,,,,,,fee schedule,1205.32,5347.61,APC
Right ventricular recording,93603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1205.32,,,,,,,fee schedule,1205.32,5347.61,APC
Right ventricular recording,93603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1844.15,,,,,,,fee schedule,1205.32,5347.61,Radiology
Right ventricular recording,93603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1687.45,,,,,,,fee schedule,1205.32,5347.61,APC
Right ventricular recording,93603,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2109.32,,,,,,,fee schedule,1205.32,5347.61,APC
Intra-atrial pacing,93610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2391.8,,,,,,,fee schedule,1917.23,34257.3,
Intra-atrial pacing,93610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1917.23,,,,,,,fee schedule,1917.23,34257.3,
Intra-atrial pacing,93610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2094.4,,,,,,,fee schedule,1917.23,34257.3,
Intra-atrial pacing,93610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2201.97,,,,,,,fee schedule,1917.23,34257.3,
Intra-atrial pacing,93610,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,34257.3,,,,,,,fee schedule,1917.23,34257.3,APC 378
Intra-atrial pacing,93610,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8107.48,,,,,,,fee schedule,1917.23,34257.3,APC
Intra-atrial pacing,93610,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8030.27,,,,,,,fee schedule,1917.23,34257.3,APC
Intra-atrial pacing,93610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7721.41,,,,,,,fee schedule,1917.23,34257.3,APC
Intra-atrial pacing,93610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11813.76,,,,,,,fee schedule,1917.23,34257.3,Radiology
Intra-atrial pacing,93610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10809.98,,,,,,,fee schedule,1917.23,34257.3,APC
Intra-atrial pacing,93610,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,13512.47,,,,,,,fee schedule,1917.23,34257.3,APC
Intraventricular pacing,93612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2391.8,,,,,,,fee schedule,1917.23,34257.3,
Intraventricular pacing,93612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1917.23,,,,,,,fee schedule,1917.23,34257.3,
Intraventricular pacing,93612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2094.4,,,,,,,fee schedule,1917.23,34257.3,
Intraventricular pacing,93612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2201.97,,,,,,,fee schedule,1917.23,34257.3,
Intraventricular pacing,93612,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,34257.3,,,,,,,fee schedule,1917.23,34257.3,APC 378
Intraventricular pacing,93612,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8107.48,,,,,,,fee schedule,1917.23,34257.3,APC
Intraventricular pacing,93612,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8030.27,,,,,,,fee schedule,1917.23,34257.3,APC
Intraventricular pacing,93612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7721.41,,,,,,,fee schedule,1917.23,34257.3,APC
Intraventricular pacing,93612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11813.76,,,,,,,fee schedule,1917.23,34257.3,Radiology
Intraventricular pacing,93612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10809.98,,,,,,,fee schedule,1917.23,34257.3,APC
Intraventricular pacing,93612,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,13512.47,,,,,,,fee schedule,1917.23,34257.3,APC
Esophageal recording,93615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2391.8,,,,,,,fee schedule,1205.32,5347.61,
Esophageal recording,93615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1917.23,,,,,,,fee schedule,1205.32,5347.61,
Esophageal recording,93615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2094.4,,,,,,,fee schedule,1205.32,5347.61,
Esophageal recording,93615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2201.97,,,,,,,fee schedule,1205.32,5347.61,
Esophageal recording,93615,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5347.61,,,,,,,fee schedule,1205.32,5347.61,APC 378
Esophageal recording,93615,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1265.59,,,,,,,fee schedule,1205.32,5347.61,APC
Esophageal recording,93615,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1253.54,,,,,,,fee schedule,1205.32,5347.61,APC
Esophageal recording,93615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1205.32,,,,,,,fee schedule,1205.32,5347.61,APC
Esophageal recording,93615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1844.15,,,,,,,fee schedule,1205.32,5347.61,Radiology
Esophageal recording,93615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1687.45,,,,,,,fee schedule,1205.32,5347.61,APC
Esophageal recording,93615,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2109.32,,,,,,,fee schedule,1205.32,5347.61,APC
Esophageal recording,93616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2391.8,,,,,,,fee schedule,1205.32,5347.61,
Esophageal recording,93616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1917.23,,,,,,,fee schedule,1205.32,5347.61,
Esophageal recording,93616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2094.4,,,,,,,fee schedule,1205.32,5347.61,
Esophageal recording,93616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2201.97,,,,,,,fee schedule,1205.32,5347.61,
Esophageal recording,93616,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5347.61,,,,,,,fee schedule,1205.32,5347.61,APC 378
Esophageal recording,93616,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1265.59,,,,,,,fee schedule,1205.32,5347.61,APC
Esophageal recording,93616,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1253.54,,,,,,,fee schedule,1205.32,5347.61,APC
Esophageal recording,93616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1205.32,,,,,,,fee schedule,1205.32,5347.61,APC
Esophageal recording,93616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1844.15,,,,,,,fee schedule,1205.32,5347.61,Radiology
Esophageal recording,93616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1687.45,,,,,,,fee schedule,1205.32,5347.61,APC
Esophageal recording,93616,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2109.32,,,,,,,fee schedule,1205.32,5347.61,APC
Heart rhythm pacing,93618,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2391.8,,,,,,,fee schedule,1205.32,5347.61,
Heart rhythm pacing,93618,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1917.23,,,,,,,fee schedule,1205.32,5347.61,
Heart rhythm pacing,93618,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2094.4,,,,,,,fee schedule,1205.32,5347.61,
Heart rhythm pacing,93618,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2201.97,,,,,,,fee schedule,1205.32,5347.61,
Heart rhythm pacing,93618,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5347.61,,,,,,,fee schedule,1205.32,5347.61,APC 378
Heart rhythm pacing,93618,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1265.59,,,,,,,fee schedule,1205.32,5347.61,APC
Heart rhythm pacing,93618,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1253.54,,,,,,,fee schedule,1205.32,5347.61,APC
Heart rhythm pacing,93618,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1205.32,,,,,,,fee schedule,1205.32,5347.61,APC
Heart rhythm pacing,93618,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1844.15,,,,,,,fee schedule,1205.32,5347.61,Radiology
Heart rhythm pacing,93618,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1687.45,,,,,,,fee schedule,1205.32,5347.61,APC
Heart rhythm pacing,93618,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2109.32,,,,,,,fee schedule,1205.32,5347.61,APC
Electrophysiology evaluation,93619,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6669.56,,,,,,,fee schedule,5346.23,34257.3,
Electrophysiology evaluation,93619,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5346.23,,,,,,,fee schedule,5346.23,34257.3,
Electrophysiology evaluation,93619,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5840.27,,,,,,,fee schedule,5346.23,34257.3,
Electrophysiology evaluation,93619,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6140.23,,,,,,,fee schedule,5346.23,34257.3,
Electrophysiology evaluation,93619,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,34257.3,,,,,,,fee schedule,5346.23,34257.3,APC 378
Electrophysiology evaluation,93619,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8107.48,,,,,,,fee schedule,5346.23,34257.3,APC
Electrophysiology evaluation,93619,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8030.27,,,,,,,fee schedule,5346.23,34257.3,APC
Electrophysiology evaluation,93619,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7721.41,,,,,,,fee schedule,5346.23,34257.3,APC
Electrophysiology evaluation,93619,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11813.76,,,,,,,fee schedule,5346.23,34257.3,Radiology
Electrophysiology evaluation,93619,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10809.98,,,,,,,fee schedule,5346.23,34257.3,APC
Electrophysiology evaluation,93619,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,13512.47,,,,,,,fee schedule,5346.23,34257.3,APC
Electrophysiology evaluation,93620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1172.59,,,,,,,fee schedule,939.94,34257.3,
Electrophysiology evaluation,93620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,939.94,,,,,,,fee schedule,939.94,34257.3,
Electrophysiology evaluation,93620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1026.8,,,,,,,fee schedule,939.94,34257.3,
Electrophysiology evaluation,93620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1079.53,,,,,,,fee schedule,939.94,34257.3,
Electrophysiology evaluation,93620,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,34257.3,,,,,,,fee schedule,939.94,34257.3,APC 378
Electrophysiology evaluation,93620,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8107.48,,,,,,,fee schedule,939.94,34257.3,APC
Electrophysiology evaluation,93620,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8030.27,,,,,,,fee schedule,939.94,34257.3,APC
Electrophysiology evaluation,93620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7721.41,,,,,,,fee schedule,939.94,34257.3,APC
Electrophysiology evaluation,93620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11813.76,,,,,,,fee schedule,939.94,34257.3,Radiology
Electrophysiology evaluation,93620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10809.98,,,,,,,fee schedule,939.94,34257.3,APC
Electrophysiology evaluation,93620,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,13512.47,,,,,,,fee schedule,939.94,34257.3,APC
Electrophysiologic study,93624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11803.62,,,,,,,fee schedule,7721.41,34257.3,
Electrophysiologic study,93624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9461.63,,,,,,,fee schedule,7721.41,34257.3,
Electrophysiologic study,93624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10335.97,,,,,,,fee schedule,7721.41,34257.3,
Electrophysiologic study,93624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10866.82,,,,,,,fee schedule,7721.41,34257.3,
Electrophysiologic study,93624,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,34257.3,,,,,,,fee schedule,7721.41,34257.3,APC 378
Electrophysiologic study,93624,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8107.48,,,,,,,fee schedule,7721.41,34257.3,APC
Electrophysiologic study,93624,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8030.27,,,,,,,fee schedule,7721.41,34257.3,APC
Electrophysiologic study,93624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7721.41,,,,,,,fee schedule,7721.41,34257.3,APC
Electrophysiologic study,93624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11813.76,,,,,,,fee schedule,7721.41,34257.3,Radiology
Electrophysiologic study,93624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10809.98,,,,,,,fee schedule,7721.41,34257.3,APC
Electrophysiologic study,93624,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,13512.47,,,,,,,fee schedule,7721.41,34257.3,APC
Electrophysiology evaluation,93642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,687.62,,,,,,,fee schedule,551.19,5347.61,
Electrophysiology evaluation,93642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,551.19,,,,,,,fee schedule,551.19,5347.61,
Electrophysiology evaluation,93642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,602.12,,,,,,,fee schedule,551.19,5347.61,
Electrophysiology evaluation,93642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,633.05,,,,,,,fee schedule,551.19,5347.61,
Electrophysiology evaluation,93642,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5347.61,,,,,,,fee schedule,551.19,5347.61,APC 378
Electrophysiology evaluation,93642,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1265.59,,,,,,,fee schedule,551.19,5347.61,APC
Electrophysiology evaluation,93642,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1253.54,,,,,,,fee schedule,551.19,5347.61,APC
Electrophysiology evaluation,93642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1205.32,,,,,,,fee schedule,551.19,5347.61,APC
Electrophysiology evaluation,93642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1844.15,,,,,,,fee schedule,551.19,5347.61,Radiology
Electrophysiology evaluation,93642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1687.45,,,,,,,fee schedule,551.19,5347.61,APC
Electrophysiology evaluation,93642,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2109.32,,,,,,,fee schedule,551.19,5347.61,APC
Electrophysiology evaluation,93644,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1112.19,,,,,,,fee schedule,891.52,1112.19,
Electrophysiology evaluation,93644,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,891.52,,,,,,,fee schedule,891.52,1112.19,
Electrophysiology evaluation,93644,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,973.9,,,,,,,fee schedule,891.52,1112.19,
Electrophysiology evaluation,93644,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1023.92,,,,,,,fee schedule,891.52,1112.19,
Ablate heart dysrhythm focus,93650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17736.36,,,,,,,fee schedule,7721.41,34257.3,
Ablate heart dysrhythm focus,93650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14217.24,,,,,,,fee schedule,7721.41,34257.3,
Ablate heart dysrhythm focus,93650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15531.05,,,,,,,fee schedule,7721.41,34257.3,
Ablate heart dysrhythm focus,93650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16328.72,,,,,,,fee schedule,7721.41,34257.3,
Ablate heart dysrhythm focus,93650,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,34257.3,,,,,,,fee schedule,7721.41,34257.3,APC 378
Ablate heart dysrhythm focus,93650,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8107.48,,,,,,,fee schedule,7721.41,34257.3,APC
Ablate heart dysrhythm focus,93650,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8030.27,,,,,,,fee schedule,7721.41,34257.3,APC
Ablate heart dysrhythm focus,93650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7721.41,,,,,,,fee schedule,7721.41,34257.3,APC
Ablate heart dysrhythm focus,93650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11813.76,,,,,,,fee schedule,7721.41,34257.3,Radiology
Ablate heart dysrhythm focus,93650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10809.98,,,,,,,fee schedule,7721.41,34257.3,APC
Ablate heart dysrhythm focus,93650,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,13512.47,,,,,,,fee schedule,7721.41,34257.3,APC
Ep & ablate supravent arrhyt,93653,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24156.69,,,,,,,fee schedule,19363.7,114801.42,
Ep & ablate supravent arrhyt,93653,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19363.7,,,,,,,fee schedule,19363.7,114801.42,
Ep & ablate supravent arrhyt,93653,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21153.08,,,,,,,fee schedule,19363.7,114801.42,
Ep & ablate supravent arrhyt,93653,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22239.5,,,,,,,fee schedule,19363.7,114801.42,
Ep & ablate supravent arrhyt,93653,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,114801.42,,,,,,,fee schedule,19363.7,114801.42,APC 378
Ep & ablate supravent arrhyt,93653,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,27169.41,,,,,,,fee schedule,19363.7,114801.42,APC
Ep & ablate supravent arrhyt,93653,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,26910.66,,,,,,,fee schedule,19363.7,114801.42,APC
Ep & ablate supravent arrhyt,93653,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,25875.63,,,,,,,fee schedule,19363.7,114801.42,APC
Ep & ablate supravent arrhyt,93653,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,39589.72,,,,,,,fee schedule,19363.7,114801.42,Radiology
Ep & ablate supravent arrhyt,93653,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,36225.89,,,,,,,fee schedule,19363.7,114801.42,APC
Ep & ablate supravent arrhyt,93653,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,45282.36,,,,,,,fee schedule,19363.7,114801.42,APC
Ep & ablate ventric tachy,93654,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26142.93,,,,,,,fee schedule,20955.84,114801.42,
Ep & ablate ventric tachy,93654,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20955.84,,,,,,,fee schedule,20955.84,114801.42,
Ep & ablate ventric tachy,93654,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22892.36,,,,,,,fee schedule,20955.84,114801.42,
Ep & ablate ventric tachy,93654,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24068.1,,,,,,,fee schedule,20955.84,114801.42,
Ep & ablate ventric tachy,93654,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,114801.42,,,,,,,fee schedule,20955.84,114801.42,APC 378
Ep & ablate ventric tachy,93654,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,27169.41,,,,,,,fee schedule,20955.84,114801.42,APC
Ep & ablate ventric tachy,93654,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,26910.66,,,,,,,fee schedule,20955.84,114801.42,APC
Ep & ablate ventric tachy,93654,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,25875.63,,,,,,,fee schedule,20955.84,114801.42,APC
Ep & ablate ventric tachy,93654,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,39589.72,,,,,,,fee schedule,20955.84,114801.42,Radiology
Ep & ablate ventric tachy,93654,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,36225.89,,,,,,,fee schedule,20955.84,114801.42,APC
Ep & ablate ventric tachy,93654,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,45282.36,,,,,,,fee schedule,20955.84,114801.42,APC
Ablate arrhythmia add on,93655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1522.24,,,,,,,fee schedule,1220.21,1522.24,
Ablate arrhythmia add on,93655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1220.21,,,,,,,fee schedule,1220.21,1522.24,
Ablate arrhythmia add on,93655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1332.97,,,,,,,fee schedule,1220.21,1522.24,
Ablate arrhythmia add on,93655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1401.43,,,,,,,fee schedule,1220.21,1522.24,
Tx atrial fib pulm vein isol,93656,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16926.92,,,,,,,fee schedule,13568.4,114801.42,
Tx atrial fib pulm vein isol,93656,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13568.4,,,,,,,fee schedule,13568.4,114801.42,
Tx atrial fib pulm vein isol,93656,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14822.25,,,,,,,fee schedule,13568.4,114801.42,
Tx atrial fib pulm vein isol,93656,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15583.51,,,,,,,fee schedule,13568.4,114801.42,
Tx atrial fib pulm vein isol,93656,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,114801.42,,,,,,,fee schedule,13568.4,114801.42,APC 378
Tx atrial fib pulm vein isol,93656,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,27169.41,,,,,,,fee schedule,13568.4,114801.42,APC
Tx atrial fib pulm vein isol,93656,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,26910.66,,,,,,,fee schedule,13568.4,114801.42,APC
Tx atrial fib pulm vein isol,93656,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,25875.63,,,,,,,fee schedule,13568.4,114801.42,APC
Tx atrial fib pulm vein isol,93656,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,39589.72,,,,,,,fee schedule,13568.4,114801.42,Radiology
Tx atrial fib pulm vein isol,93656,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,36225.89,,,,,,,fee schedule,13568.4,114801.42,APC
Tx atrial fib pulm vein isol,93656,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,45282.36,,,,,,,fee schedule,13568.4,114801.42,APC
Tx l/r atrial fib addl,93657,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1523.53,,,,,,,fee schedule,1221.24,1523.53,
Tx l/r atrial fib addl,93657,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1221.24,,,,,,,fee schedule,1221.24,1523.53,
Tx l/r atrial fib addl,93657,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1334.1,,,,,,,fee schedule,1221.24,1523.53,
Tx l/r atrial fib addl,93657,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1402.61,,,,,,,fee schedule,1221.24,1523.53,
Tilt table evaluation,93660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,227.44,,,,,,,fee schedule,182.32,1638.96,
Tilt table evaluation,93660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,182.32,,,,,,,fee schedule,182.32,1638.96,
Tilt table evaluation,93660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,199.16,,,,,,,fee schedule,182.32,1638.96,
Tilt table evaluation,93660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,209.39,,,,,,,fee schedule,182.32,1638.96,
Tilt table evaluation,93660,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1638.96,,,,,,,fee schedule,182.32,1638.96,APC 378
Tilt table evaluation,93660,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,387.88,,,,,,,fee schedule,182.32,1638.96,APC
Tilt table evaluation,93660,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,384.19,,,,,,,fee schedule,182.32,1638.96,APC
Tilt table evaluation,93660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,369.41,,,,,,,fee schedule,182.32,1638.96,APC
Tilt table evaluation,93660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,565.2,,,,,,,fee schedule,182.32,1638.96,Radiology
Tilt table evaluation,93660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,517.18,,,,,,,fee schedule,182.32,1638.96,APC
Tilt table evaluation,93660,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,646.47,,,,,,,fee schedule,182.32,1638.96,APC
Peripheral Vascular Rehab,93668,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,58.4,259.1,APC 378
Peripheral Vascular Rehab,93668,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,58.4,259.1,APC
Peripheral Vascular Rehab,93668,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,58.4,259.1,APC
Peripheral Vascular Rehab,93668,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,58.4,259.1,APC
Peripheral Vascular Rehab,93668,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,58.4,259.1,Radiology
Peripheral Vascular Rehab,93668,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,58.4,259.1,APC
Peripheral Vascular Rehab,93668,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,58.4,259.1,APC
Bioimpedance cv analysis,93701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83.99,,,,,,,fee schedule,67.33,584.37,
Bioimpedance cv analysis,93701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,67.33,,,,,,,fee schedule,67.33,584.37,
Bioimpedance cv analysis,93701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,73.55,,,,,,,fee schedule,67.33,584.37,
Bioimpedance cv analysis,93701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,77.33,,,,,,,fee schedule,67.33,584.37,
Bioimpedance cv analysis,93701,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,67.33,584.37,APC 378
Bioimpedance cv analysis,93701,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,67.33,584.37,APC
Bioimpedance cv analysis,93701,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,67.33,584.37,APC
Bioimpedance cv analysis,93701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,67.33,584.37,APC
Bioimpedance cv analysis,93701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,67.33,584.37,Radiology
Bioimpedance cv analysis,93701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,67.33,584.37,APC
Bioimpedance cv analysis,93701,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,67.33,584.37,APC
Bis xtracell fluid analysis,93702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,426.04,,,,,,,fee schedule,127.38,565.15,
Bis xtracell fluid analysis,93702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,341.51,,,,,,,fee schedule,127.38,565.15,
Bis xtracell fluid analysis,93702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,373.07,,,,,,,fee schedule,127.38,565.15,
Bis xtracell fluid analysis,93702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,392.23,,,,,,,fee schedule,127.38,565.15,
Bis xtracell fluid analysis,93702,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,565.15,,,,,,,fee schedule,127.38,565.15,APC 378
Bis xtracell fluid analysis,93702,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,133.75,,,,,,,fee schedule,127.38,565.15,APC
Bis xtracell fluid analysis,93702,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,132.48,,,,,,,fee schedule,127.38,565.15,APC
Bis xtracell fluid analysis,93702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,127.38,,,,,,,fee schedule,127.38,565.15,APC
Bis xtracell fluid analysis,93702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,194.89,,,,,,,fee schedule,127.38,565.15,Radiology
Bis xtracell fluid analysis,93702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,178.33,,,,,,,fee schedule,127.38,565.15,APC
Bis xtracell fluid analysis,93702,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,222.92,,,,,,,fee schedule,127.38,565.15,APC
Analyze pacemaker system,93724,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,233.64,,,,,,,fee schedule,187.28,1348.99,
Analyze pacemaker system,93724,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,187.28,,,,,,,fee schedule,187.28,1348.99,
Analyze pacemaker system,93724,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,204.59,,,,,,,fee schedule,187.28,1348.99,
Analyze pacemaker system,93724,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,215.1,,,,,,,fee schedule,187.28,1348.99,
Analyze pacemaker system,93724,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1348.99,,,,,,,fee schedule,187.28,1348.99,APC 378
Analyze pacemaker system,93724,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,319.26,,,,,,,fee schedule,187.28,1348.99,APC
Analyze pacemaker system,93724,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,316.22,,,,,,,fee schedule,187.28,1348.99,APC
Analyze pacemaker system,93724,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,304.06,,,,,,,fee schedule,187.28,1348.99,APC
Analyze pacemaker system,93724,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,465.21,,,,,,,fee schedule,187.28,1348.99,Radiology
Analyze pacemaker system,93724,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,425.68,,,,,,,fee schedule,187.28,1348.99,APC
Analyze pacemaker system,93724,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,532.1,,,,,,,fee schedule,187.28,1348.99,APC
Temperature gradient studies,93740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.35,,,,,,,fee schedule,5.09,565.15,
Temperature gradient studies,93740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.09,,,,,,,fee schedule,5.09,565.15,
Temperature gradient studies,93740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.56,,,,,,,fee schedule,5.09,565.15,
Temperature gradient studies,93740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.85,,,,,,,fee schedule,5.09,565.15,
Temperature gradient studies,93740,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,565.15,,,,,,,fee schedule,5.09,565.15,APC 378
Temperature gradient studies,93740,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,133.75,,,,,,,fee schedule,5.09,565.15,APC
Temperature gradient studies,93740,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,132.48,,,,,,,fee schedule,5.09,565.15,APC
Temperature gradient studies,93740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,127.38,,,,,,,fee schedule,5.09,565.15,APC
Temperature gradient studies,93740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,194.89,,,,,,,fee schedule,5.09,565.15,Radiology
Temperature gradient studies,93740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,178.33,,,,,,,fee schedule,5.09,565.15,APC
Temperature gradient studies,93740,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,222.92,,,,,,,fee schedule,5.09,565.15,APC
Set-up cardiovert-defibrill,93745,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,146.93,,,,,,,fee schedule,117.78,1348.99,
Set-up cardiovert-defibrill,93745,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,117.78,,,,,,,fee schedule,117.78,1348.99,
Set-up cardiovert-defibrill,93745,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,128.66,,,,,,,fee schedule,117.78,1348.99,
Set-up cardiovert-defibrill,93745,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,135.27,,,,,,,fee schedule,117.78,1348.99,
Set-up cardiovert-defibrill,93745,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1348.99,,,,,,,fee schedule,117.78,1348.99,APC 378
Set-up cardiovert-defibrill,93745,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,319.26,,,,,,,fee schedule,117.78,1348.99,APC
Set-up cardiovert-defibrill,93745,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,316.22,,,,,,,fee schedule,117.78,1348.99,APC
Set-up cardiovert-defibrill,93745,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,304.06,,,,,,,fee schedule,117.78,1348.99,APC
Set-up cardiovert-defibrill,93745,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,465.21,,,,,,,fee schedule,117.78,1348.99,Radiology
Set-up cardiovert-defibrill,93745,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,425.68,,,,,,,fee schedule,117.78,1348.99,APC
Set-up cardiovert-defibrill,93745,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,532.1,,,,,,,fee schedule,117.78,1348.99,APC
Interrogation vad in person,93750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,419.96,,,,,,,fee schedule,94.12,419.96,
Interrogation vad in person,93750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,336.63,,,,,,,fee schedule,94.12,419.96,
Interrogation vad in person,93750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,367.74,,,,,,,fee schedule,94.12,419.96,
Interrogation vad in person,93750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,386.63,,,,,,,fee schedule,94.12,419.96,
Interrogation vad in person,93750,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,417.57,,,,,,,fee schedule,94.12,419.96,APC 378
Interrogation vad in person,93750,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,98.82,,,,,,,fee schedule,94.12,419.96,APC
Interrogation vad in person,93750,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,97.88,,,,,,,fee schedule,94.12,419.96,APC
Interrogation vad in person,93750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,94.12,,,,,,,fee schedule,94.12,419.96,APC
Interrogation vad in person,93750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144,,,,,,,fee schedule,94.12,419.96,Radiology
Interrogation vad in person,93750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.76,,,,,,,fee schedule,94.12,419.96,APC
Interrogation vad in person,93750,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,164.7,,,,,,,fee schedule,94.12,419.96,APC
Ambulatory BP recording,93786,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,249.93,,,,,,,fee schedule,131.71,584.37,
Ambulatory BP recording,93786,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,200.34,,,,,,,fee schedule,131.71,584.37,
Ambulatory BP recording,93786,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,218.86,,,,,,,fee schedule,131.71,584.37,
Ambulatory BP recording,93786,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,230.1,,,,,,,fee schedule,131.71,584.37,
Ambulatory BP recording,93786,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,131.71,584.37,APC 378
Ambulatory BP recording,93786,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,131.71,584.37,APC
Ambulatory BP recording,93786,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,131.71,584.37,APC
Ambulatory BP recording,93786,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,131.71,584.37,APC
Ambulatory BP recording,93786,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,131.71,584.37,Radiology
Ambulatory BP recording,93786,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,131.71,584.37,APC
Ambulatory BP recording,93786,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,131.71,584.37,APC
Ambulatory BP analysis,93788,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,249.93,,,,,,,fee schedule,131.71,584.37,
Ambulatory BP analysis,93788,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,200.34,,,,,,,fee schedule,131.71,584.37,
Ambulatory BP analysis,93788,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,218.86,,,,,,,fee schedule,131.71,584.37,
Ambulatory BP analysis,93788,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,230.1,,,,,,,fee schedule,131.71,584.37,
Ambulatory BP analysis,93788,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,131.71,584.37,APC 378
Ambulatory BP analysis,93788,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,131.71,584.37,APC
Ambulatory BP analysis,93788,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,131.71,584.37,APC
Ambulatory BP analysis,93788,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,131.71,584.37,APC
Ambulatory BP analysis,93788,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,131.71,584.37,Radiology
Ambulatory BP analysis,93788,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,131.71,584.37,APC
Ambulatory BP analysis,93788,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,131.71,584.37,APC
Review/report BP recording,93790,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,70.27,,,,,,,fee schedule,56.33,70.27,
Review/report BP recording,93790,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56.33,,,,,,,fee schedule,56.33,70.27,
Review/report BP recording,93790,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,61.53,,,,,,,fee schedule,56.33,70.27,
Review/report BP recording,93790,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,64.69,,,,,,,fee schedule,56.33,70.27,
Pt/caregiver trainj home inr,93792,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,229.14,,,,,,,fee schedule,183.68,229.14,
Pt/caregiver trainj home inr,93792,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,183.68,,,,,,,fee schedule,183.68,229.14,
Pt/caregiver trainj home inr,93792,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,200.65,,,,,,,fee schedule,183.68,229.14,
Pt/caregiver trainj home inr,93792,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,210.96,,,,,,,fee schedule,183.68,229.14,
Anticoag mgmt pt warfarin,93793,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,43.28,,,,,,,fee schedule,34.69,43.28,
Anticoag mgmt pt warfarin,93793,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,34.69,,,,,,,fee schedule,34.69,43.28,
Anticoag mgmt pt warfarin,93793,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37.9,,,,,,,fee schedule,34.69,43.28,
Anticoag mgmt pt warfarin,93793,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,39.85,,,,,,,fee schedule,34.69,43.28,
Cardiac rehab,93797,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,247.06,,,,,,,fee schedule,127.61,566.18,
Cardiac rehab,93797,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,198.04,,,,,,,fee schedule,127.61,566.18,
Cardiac rehab,93797,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,216.34,,,,,,,fee schedule,127.61,566.18,
Cardiac rehab,93797,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,227.45,,,,,,,fee schedule,127.61,566.18,
Cardiac rehab,93797,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,566.18,,,,,,,fee schedule,127.61,566.18,APC 378
Cardiac rehab,93797,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134,,,,,,,fee schedule,127.61,566.18,APC
Cardiac rehab,93797,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,132.72,,,,,,,fee schedule,127.61,566.18,APC
Cardiac rehab,93797,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,127.61,,,,,,,fee schedule,127.61,566.18,APC
Cardiac rehab,93797,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,195.25,,,,,,,fee schedule,127.61,566.18,Radiology
Cardiac rehab,93797,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,178.66,,,,,,,fee schedule,127.61,566.18,APC
Cardiac rehab,93797,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,223.33,,,,,,,fee schedule,127.61,566.18,APC
Cardiac rehab/monitor,93798,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,365.17,,,,,,,fee schedule,127.61,566.18,
Cardiac rehab/monitor,93798,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,292.72,,,,,,,fee schedule,127.61,566.18,
Cardiac rehab/monitor,93798,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,319.77,,,,,,,fee schedule,127.61,566.18,
Cardiac rehab/monitor,93798,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,336.19,,,,,,,fee schedule,127.61,566.18,
Cardiac rehab/monitor,93798,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,566.18,,,,,,,fee schedule,127.61,566.18,APC 378
Cardiac rehab/monitor,93798,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134,,,,,,,fee schedule,127.61,566.18,APC
Cardiac rehab/monitor,93798,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,132.72,,,,,,,fee schedule,127.61,566.18,APC
Cardiac rehab/monitor,93798,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,127.61,,,,,,,fee schedule,127.61,566.18,APC
Cardiac rehab/monitor,93798,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,195.25,,,,,,,fee schedule,127.61,566.18,Radiology
Cardiac rehab/monitor,93798,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,178.66,,,,,,,fee schedule,127.61,566.18,APC
Cardiac rehab/monitor,93798,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,223.33,,,,,,,fee schedule,127.61,566.18,APC
Cardiovascular procedure,93799,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,565.15,,,,,,,fee schedule,127.38,565.15,APC 378
Cardiovascular procedure,93799,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,133.75,,,,,,,fee schedule,127.38,565.15,APC
Cardiovascular procedure,93799,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,132.48,,,,,,,fee schedule,127.38,565.15,APC
Cardiovascular procedure,93799,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,127.38,,,,,,,fee schedule,127.38,565.15,APC
Cardiovascular procedure,93799,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,194.89,,,,,,,fee schedule,127.38,565.15,Radiology
Cardiovascular procedure,93799,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,178.33,,,,,,,fee schedule,127.38,565.15,APC
Cardiovascular procedure,93799,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,222.92,,,,,,,fee schedule,127.38,565.15,APC
Extracranial bilat study,93880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,522.7,,,,,,,fee schedule,236.21,1047.98,
Extracranial bilat study,93880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,418.99,,,,,,,fee schedule,236.21,1047.98,
Extracranial bilat study,93880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,457.71,,,,,,,fee schedule,236.21,1047.98,
Extracranial bilat study,93880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,481.21,,,,,,,fee schedule,236.21,1047.98,
Extracranial bilat study,93880,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,236.21,1047.98,APC 378
Extracranial bilat study,93880,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,236.21,1047.98,APC
Extracranial bilat study,93880,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,236.21,1047.98,APC
Extracranial bilat study,93880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,236.21,1047.98,APC
Extracranial bilat study,93880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,236.21,1047.98,Radiology
Extracranial bilat study,93880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,236.21,1047.98,APC
Extracranial bilat study,93880,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,236.21,1047.98,APC
Extracranial uni/ltd study,93882,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,487.88,,,,,,,fee schedule,103.5,487.88,
Extracranial uni/ltd study,93882,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,391.08,,,,,,,fee schedule,103.5,487.88,
Extracranial uni/ltd study,93882,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,427.22,,,,,,,fee schedule,103.5,487.88,
Extracranial uni/ltd study,93882,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,449.16,,,,,,,fee schedule,103.5,487.88,
Extracranial uni/ltd study,93882,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,487.88,APC 378
Extracranial uni/ltd study,93882,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,487.88,APC
Extracranial uni/ltd study,93882,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,487.88,APC
Extracranial uni/ltd study,93882,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,487.88,APC
Extracranial uni/ltd study,93882,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,487.88,Radiology
Extracranial uni/ltd study,93882,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,487.88,APC
Extracranial uni/ltd study,93882,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,487.88,APC
Intracranial complete study,93886,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,522.43,,,,,,,fee schedule,236.21,1047.98,
Intracranial complete study,93886,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,418.78,,,,,,,fee schedule,236.21,1047.98,
Intracranial complete study,93886,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,457.48,,,,,,,fee schedule,236.21,1047.98,
Intracranial complete study,93886,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,480.97,,,,,,,fee schedule,236.21,1047.98,
Intracranial complete study,93886,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,236.21,1047.98,APC 378
Intracranial complete study,93886,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,236.21,1047.98,APC
Intracranial complete study,93886,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,236.21,1047.98,APC
Intracranial complete study,93886,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,236.21,1047.98,APC
Intracranial complete study,93886,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,236.21,1047.98,Radiology
Intracranial complete study,93886,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,236.21,1047.98,APC
Intracranial complete study,93886,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,236.21,1047.98,APC
Intracranial limited study,93888,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,212.7,,,,,,,fee schedule,103.5,459.18,
Intracranial limited study,93888,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,170.5,,,,,,,fee schedule,103.5,459.18,
Intracranial limited study,93888,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,186.25,,,,,,,fee schedule,103.5,459.18,
Intracranial limited study,93888,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,195.82,,,,,,,fee schedule,103.5,459.18,
Intracranial limited study,93888,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
Intracranial limited study,93888,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
Intracranial limited study,93888,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
Intracranial limited study,93888,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
Intracranial limited study,93888,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
Intracranial limited study,93888,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
Intracranial limited study,93888,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Tcd vasoreactivity study,93890,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,333.89,,,,,,,fee schedule,267.64,333.89,
Tcd vasoreactivity study,93890,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,267.64,,,,,,,fee schedule,267.64,333.89,
Tcd vasoreactivity study,93890,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,292.37,,,,,,,fee schedule,267.64,333.89,
Tcd vasoreactivity study,93890,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,307.39,,,,,,,fee schedule,267.64,333.89,
Tcd emboli detect w/o inj,93892,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,333.59,,,,,,,fee schedule,103.5,459.18,
Tcd emboli detect w/o inj,93892,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,267.4,,,,,,,fee schedule,103.5,459.18,
Tcd emboli detect w/o inj,93892,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,292.11,,,,,,,fee schedule,103.5,459.18,
Tcd emboli detect w/o inj,93892,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,307.11,,,,,,,fee schedule,103.5,459.18,
Tcd emboli detect w/o inj,93892,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
Tcd emboli detect w/o inj,93892,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
Tcd emboli detect w/o inj,93892,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
Tcd emboli detect w/o inj,93892,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
Tcd emboli detect w/o inj,93892,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
Tcd emboli detect w/o inj,93892,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
Tcd emboli detect w/o inj,93892,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Tcd emboli detect w/inj,93893,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,333.59,,,,,,,fee schedule,103.5,459.18,
Tcd emboli detect w/inj,93893,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,267.4,,,,,,,fee schedule,103.5,459.18,
Tcd emboli detect w/inj,93893,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,292.11,,,,,,,fee schedule,103.5,459.18,
Tcd emboli detect w/inj,93893,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,307.11,,,,,,,fee schedule,103.5,459.18,
Tcd emboli detect w/inj,93893,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
Tcd emboli detect w/inj,93893,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
Tcd emboli detect w/inj,93893,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
Tcd emboli detect w/inj,93893,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
Tcd emboli detect w/inj,93893,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
Tcd emboli detect w/inj,93893,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
Tcd emboli detect w/inj,93893,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Carotid intima atheroma eval,93895,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,197.96,,,,,,,fee schedule,158.68,197.96,
Carotid intima atheroma eval,93895,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,158.68,,,,,,,fee schedule,158.68,197.96,
Carotid intima atheroma eval,93895,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,173.34,,,,,,,fee schedule,158.68,197.96,
Carotid intima atheroma eval,93895,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,182.25,,,,,,,fee schedule,158.68,197.96,
Upr/l xtremity art 2 levels,93922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,366.43,,,,,,,fee schedule,131.71,584.37,
Upr/l xtremity art 2 levels,93922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,293.73,,,,,,,fee schedule,131.71,584.37,
Upr/l xtremity art 2 levels,93922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,320.87,,,,,,,fee schedule,131.71,584.37,
Upr/l xtremity art 2 levels,93922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,337.35,,,,,,,fee schedule,131.71,584.37,
Upr/l xtremity art 2 levels,93922,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,131.71,584.37,APC 378
Upr/l xtremity art 2 levels,93922,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,131.71,584.37,APC
Upr/l xtremity art 2 levels,93922,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,131.71,584.37,APC
Upr/l xtremity art 2 levels,93922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,131.71,584.37,APC
Upr/l xtremity art 2 levels,93922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,131.71,584.37,Radiology
Upr/l xtremity art 2 levels,93922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,131.71,584.37,APC
Upr/l xtremity art 2 levels,93922,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,131.71,584.37,APC
Upr/lxtr art stdy 3+ lvls,93923,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,554.6,,,,,,,fee schedule,213.76,948.37,
Upr/lxtr art stdy 3+ lvls,93923,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,444.56,,,,,,,fee schedule,213.76,948.37,
Upr/lxtr art stdy 3+ lvls,93923,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,485.64,,,,,,,fee schedule,213.76,948.37,
Upr/lxtr art stdy 3+ lvls,93923,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,510.59,,,,,,,fee schedule,213.76,948.37,
Upr/lxtr art stdy 3+ lvls,93923,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,213.76,948.37,APC 378
Upr/lxtr art stdy 3+ lvls,93923,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,213.76,948.37,APC
Upr/lxtr art stdy 3+ lvls,93923,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,213.76,948.37,APC
Upr/lxtr art stdy 3+ lvls,93923,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,213.76,948.37,APC
Upr/lxtr art stdy 3+ lvls,93923,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,213.76,948.37,Radiology
Upr/lxtr art stdy 3+ lvls,93923,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,213.76,948.37,APC
Upr/lxtr art stdy 3+ lvls,93923,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,213.76,948.37,APC
Lwr xtr vasc stdy bilat,93924,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,688.94,,,,,,,fee schedule,213.76,948.37,
Lwr xtr vasc stdy bilat,93924,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,552.25,,,,,,,fee schedule,213.76,948.37,
Lwr xtr vasc stdy bilat,93924,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,603.28,,,,,,,fee schedule,213.76,948.37,
Lwr xtr vasc stdy bilat,93924,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,634.26,,,,,,,fee schedule,213.76,948.37,
Lwr xtr vasc stdy bilat,93924,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,213.76,948.37,APC 378
Lwr xtr vasc stdy bilat,93924,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,213.76,948.37,APC
Lwr xtr vasc stdy bilat,93924,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,213.76,948.37,APC
Lwr xtr vasc stdy bilat,93924,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,213.76,948.37,APC
Lwr xtr vasc stdy bilat,93924,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,213.76,948.37,Radiology
Lwr xtr vasc stdy bilat,93924,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,213.76,948.37,APC
Lwr xtr vasc stdy bilat,93924,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,213.76,948.37,APC
Lower extremity study,93925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,519.79,,,,,,,fee schedule,236.21,1047.98,
Lower extremity study,93925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,416.66,,,,,,,fee schedule,236.21,1047.98,
Lower extremity study,93925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,455.16,,,,,,,fee schedule,236.21,1047.98,
Lower extremity study,93925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,478.53,,,,,,,fee schedule,236.21,1047.98,
Lower extremity study,93925,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,236.21,1047.98,APC 378
Lower extremity study,93925,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,236.21,1047.98,APC
Lower extremity study,93925,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,236.21,1047.98,APC
Lower extremity study,93925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,236.21,1047.98,APC
Lower extremity study,93925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,236.21,1047.98,Radiology
Lower extremity study,93925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,236.21,1047.98,APC
Lower extremity study,93925,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,236.21,1047.98,APC
Lower extremity study,93926,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,332.45,,,,,,,fee schedule,103.5,459.18,
Lower extremity study,93926,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,266.49,,,,,,,fee schedule,103.5,459.18,
Lower extremity study,93926,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,291.11,,,,,,,fee schedule,103.5,459.18,
Lower extremity study,93926,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,306.07,,,,,,,fee schedule,103.5,459.18,
Lower extremity study,93926,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
Lower extremity study,93926,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
Lower extremity study,93926,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
Lower extremity study,93926,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
Lower extremity study,93926,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
Lower extremity study,93926,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
Lower extremity study,93926,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Upper extremity study,93930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,522.96,,,,,,,fee schedule,236.21,1047.98,
Upper extremity study,93930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,419.2,,,,,,,fee schedule,236.21,1047.98,
Upper extremity study,93930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,457.94,,,,,,,fee schedule,236.21,1047.98,
Upper extremity study,93930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,481.46,,,,,,,fee schedule,236.21,1047.98,
Upper extremity study,93930,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,236.21,1047.98,APC 378
Upper extremity study,93930,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,236.21,1047.98,APC
Upper extremity study,93930,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,236.21,1047.98,APC
Upper extremity study,93930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,236.21,1047.98,APC
Upper extremity study,93930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,236.21,1047.98,Radiology
Upper extremity study,93930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,236.21,1047.98,APC
Upper extremity study,93930,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,236.21,1047.98,APC
Upper extremity study,93931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,333.32,,,,,,,fee schedule,103.5,459.18,
Upper extremity study,93931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,267.19,,,,,,,fee schedule,103.5,459.18,
Upper extremity study,93931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,291.88,,,,,,,fee schedule,103.5,459.18,
Upper extremity study,93931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,306.87,,,,,,,fee schedule,103.5,459.18,
Upper extremity study,93931,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
Upper extremity study,93931,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
Upper extremity study,93931,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
Upper extremity study,93931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
Upper extremity study,93931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
Upper extremity study,93931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
Upper extremity study,93931,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Extremity study,93970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,523.53,,,,,,,fee schedule,236.21,1047.98,
Extremity study,93970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,419.66,,,,,,,fee schedule,236.21,1047.98,
Extremity study,93970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,458.44,,,,,,,fee schedule,236.21,1047.98,
Extremity study,93970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,481.98,,,,,,,fee schedule,236.21,1047.98,
Extremity study,93970,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,236.21,1047.98,APC 378
Extremity study,93970,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,236.21,1047.98,APC
Extremity study,93970,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,236.21,1047.98,APC
Extremity study,93970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,236.21,1047.98,APC
Extremity study,93970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,236.21,1047.98,Radiology
Extremity study,93970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,236.21,1047.98,APC
Extremity study,93970,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,236.21,1047.98,APC
Extremity study,93971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,333.89,,,,,,,fee schedule,103.5,459.18,
Extremity study,93971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,267.64,,,,,,,fee schedule,103.5,459.18,
Extremity study,93971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,292.37,,,,,,,fee schedule,103.5,459.18,
Extremity study,93971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,307.39,,,,,,,fee schedule,103.5,459.18,
Extremity study,93971,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
Extremity study,93971,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
Extremity study,93971,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
Extremity study,93971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
Extremity study,93971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
Extremity study,93971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
Extremity study,93971,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Vascular study,93975,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,522.13,,,,,,,fee schedule,236.21,1047.98,
Vascular study,93975,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,418.53,,,,,,,fee schedule,236.21,1047.98,
Vascular study,93975,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,457.21,,,,,,,fee schedule,236.21,1047.98,
Vascular study,93975,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,480.69,,,,,,,fee schedule,236.21,1047.98,
Vascular study,93975,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,236.21,1047.98,APC 378
Vascular study,93975,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,236.21,1047.98,APC
Vascular study,93975,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,236.21,1047.98,APC
Vascular study,93975,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,236.21,1047.98,APC
Vascular study,93975,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,236.21,1047.98,Radiology
Vascular study,93975,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,236.21,1047.98,APC
Vascular study,93975,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,236.21,1047.98,APC
Vascular study,93976,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,522.62,,,,,,,fee schedule,103.5,522.62,
Vascular study,93976,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,418.93,,,,,,,fee schedule,103.5,522.62,
Vascular study,93976,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,457.64,,,,,,,fee schedule,103.5,522.62,
Vascular study,93976,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,481.14,,,,,,,fee schedule,103.5,522.62,
Vascular study,93976,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,522.62,APC 378
Vascular study,93976,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,522.62,APC
Vascular study,93976,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,522.62,APC
Vascular study,93976,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,522.62,APC
Vascular study,93976,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,522.62,Radiology
Vascular study,93976,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,522.62,APC
Vascular study,93976,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,522.62,APC
Vascular study,93978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,523.53,,,,,,,fee schedule,236.21,1047.98,
Vascular study,93978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,419.66,,,,,,,fee schedule,236.21,1047.98,
Vascular study,93978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,458.44,,,,,,,fee schedule,236.21,1047.98,
Vascular study,93978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,481.98,,,,,,,fee schedule,236.21,1047.98,
Vascular study,93978,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,236.21,1047.98,APC 378
Vascular study,93978,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,236.21,1047.98,APC
Vascular study,93978,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,236.21,1047.98,APC
Vascular study,93978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,236.21,1047.98,APC
Vascular study,93978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,236.21,1047.98,Radiology
Vascular study,93978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,236.21,1047.98,APC
Vascular study,93978,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,236.21,1047.98,APC
Vascular study,93979,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,333.32,,,,,,,fee schedule,103.5,459.18,
Vascular study,93979,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,267.19,,,,,,,fee schedule,103.5,459.18,
Vascular study,93979,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,291.88,,,,,,,fee schedule,103.5,459.18,
Vascular study,93979,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,306.87,,,,,,,fee schedule,103.5,459.18,
Vascular study,93979,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
Vascular study,93979,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
Vascular study,93979,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
Vascular study,93979,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
Vascular study,93979,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
Vascular study,93979,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
Vascular study,93979,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Penile vascular study,93980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,411.15,,,,,,,fee schedule,103.5,459.18,
Penile vascular study,93980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,329.57,,,,,,,fee schedule,103.5,459.18,
Penile vascular study,93980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,360.03,,,,,,,fee schedule,103.5,459.18,
Penile vascular study,93980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,378.52,,,,,,,fee schedule,103.5,459.18,
Penile vascular study,93980,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
Penile vascular study,93980,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
Penile vascular study,93980,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
Penile vascular study,93980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
Penile vascular study,93980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
Penile vascular study,93980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
Penile vascular study,93980,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Penile vascular study,93981,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,371.5,,,,,,,fee schedule,103.5,459.18,
Penile vascular study,93981,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,297.79,,,,,,,fee schedule,103.5,459.18,
Penile vascular study,93981,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,325.31,,,,,,,fee schedule,103.5,459.18,
Penile vascular study,93981,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,342.01,,,,,,,fee schedule,103.5,459.18,
Penile vascular study,93981,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
Penile vascular study,93981,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
Penile vascular study,93981,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
Penile vascular study,93981,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
Penile vascular study,93981,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
Penile vascular study,93981,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
Penile vascular study,93981,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Dup-scan hemo compl bi std,93985,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,880.89,,,,,,,fee schedule,236.21,1047.98,
Dup-scan hemo compl bi std,93985,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,706.11,,,,,,,fee schedule,236.21,1047.98,
Dup-scan hemo compl bi std,93985,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,771.36,,,,,,,fee schedule,236.21,1047.98,
Dup-scan hemo compl bi std,93985,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,810.98,,,,,,,fee schedule,236.21,1047.98,
Dup-scan hemo compl bi std,93985,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,236.21,1047.98,APC 378
Dup-scan hemo compl bi std,93985,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,236.21,1047.98,APC
Dup-scan hemo compl bi std,93985,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,236.21,1047.98,APC
Dup-scan hemo compl bi std,93985,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,236.21,1047.98,APC
Dup-scan hemo compl bi std,93985,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,236.21,1047.98,Radiology
Dup-scan hemo compl bi std,93985,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,236.21,1047.98,APC
Dup-scan hemo compl bi std,93985,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,236.21,1047.98,APC
Dup-scan hemo compl uni std,93986,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,423.66,,,,,,,fee schedule,103.5,459.18,
Dup-scan hemo compl uni std,93986,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,339.6,,,,,,,fee schedule,103.5,459.18,
Dup-scan hemo compl uni std,93986,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,370.98,,,,,,,fee schedule,103.5,459.18,
Dup-scan hemo compl uni std,93986,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,390.04,,,,,,,fee schedule,103.5,459.18,
Dup-scan hemo compl uni std,93986,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
Dup-scan hemo compl uni std,93986,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
Dup-scan hemo compl uni std,93986,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
Dup-scan hemo compl uni std,93986,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
Dup-scan hemo compl uni std,93986,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
Dup-scan hemo compl uni std,93986,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
Dup-scan hemo compl uni std,93986,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Doppler flow testing,93990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,332.19,,,,,,,fee schedule,103.5,459.18,
Doppler flow testing,93990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,266.28,,,,,,,fee schedule,103.5,459.18,
Doppler flow testing,93990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,290.88,,,,,,,fee schedule,103.5,459.18,
Doppler flow testing,93990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,305.82,,,,,,,fee schedule,103.5,459.18,
Doppler flow testing,93990,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
Doppler flow testing,93990,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
Doppler flow testing,93990,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
Doppler flow testing,93990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
Doppler flow testing,93990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
Doppler flow testing,93990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
Doppler flow testing,93990,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Noninvas vasc dx study proc,93998,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,88.57,,,,,,,fee schedule,28.63,127.04,
Noninvas vasc dx study proc,93998,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,70.99,,,,,,,fee schedule,28.63,127.04,
Noninvas vasc dx study proc,93998,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,77.55,,,,,,,fee schedule,28.63,127.04,
Noninvas vasc dx study proc,93998,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,81.54,,,,,,,fee schedule,28.63,127.04,
Noninvas vasc dx study proc,93998,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,127.04,,,,,,,fee schedule,28.63,127.04,APC 378
Noninvas vasc dx study proc,93998,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.07,,,,,,,fee schedule,28.63,127.04,APC
Noninvas vasc dx study proc,93998,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,29.78,,,,,,,fee schedule,28.63,127.04,APC
Noninvas vasc dx study proc,93998,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,28.63,,,,,,,fee schedule,28.63,127.04,APC
Noninvas vasc dx study proc,93998,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43.81,,,,,,,fee schedule,28.63,127.04,Radiology
Noninvas vasc dx study proc,93998,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40.09,,,,,,,fee schedule,28.63,127.04,APC
Noninvas vasc dx study proc,93998,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,50.11,,,,,,,fee schedule,28.63,127.04,APC
Vent mgmt inpat init day,94002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1837.79,,,,,,,fee schedule,611.59,2713.42,
Vent mgmt inpat init day,94002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1473.15,,,,,,,fee schedule,611.59,2713.42,
Vent mgmt inpat init day,94002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1609.28,,,,,,,fee schedule,611.59,2713.42,
Vent mgmt inpat init day,94002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1691.93,,,,,,,fee schedule,611.59,2713.42,
Vent mgmt inpat init day,94002,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2713.42,,,,,,,fee schedule,611.59,2713.42,APC 378
Vent mgmt inpat init day,94002,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,642.17,,,,,,,fee schedule,611.59,2713.42,APC
Vent mgmt inpat init day,94002,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,636.05,,,,,,,fee schedule,611.59,2713.42,APC
Vent mgmt inpat init day,94002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,611.59,,,,,,,fee schedule,611.59,2713.42,APC
Vent mgmt inpat init day,94002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,935.73,,,,,,,fee schedule,611.59,2713.42,Radiology
Vent mgmt inpat init day,94002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,856.23,,,,,,,fee schedule,611.59,2713.42,APC
Vent mgmt inpat init day,94002,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1070.28,,,,,,,fee schedule,611.59,2713.42,APC
Vent mgmt inpat subq day,94003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,618.52,,,,,,,fee schedule,495.8,2713.42,
Vent mgmt inpat subq day,94003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,495.8,,,,,,,fee schedule,495.8,2713.42,
Vent mgmt inpat subq day,94003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,541.62,,,,,,,fee schedule,495.8,2713.42,
Vent mgmt inpat subq day,94003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,569.43,,,,,,,fee schedule,495.8,2713.42,
Vent mgmt inpat subq day,94003,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2713.42,,,,,,,fee schedule,495.8,2713.42,APC 378
Vent mgmt inpat subq day,94003,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,642.17,,,,,,,fee schedule,495.8,2713.42,APC
Vent mgmt inpat subq day,94003,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,636.05,,,,,,,fee schedule,495.8,2713.42,APC
Vent mgmt inpat subq day,94003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,611.59,,,,,,,fee schedule,495.8,2713.42,APC
Vent mgmt inpat subq day,94003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,935.73,,,,,,,fee schedule,495.8,2713.42,Radiology
Vent mgmt inpat subq day,94003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,856.23,,,,,,,fee schedule,495.8,2713.42,APC
Vent mgmt inpat subq day,94003,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1070.28,,,,,,,fee schedule,495.8,2713.42,APC
Vent Mgmt NF per day,94004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,171.42,,,,,,,fee schedule,137.41,171.42,
Vent Mgmt NF per day,94004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,137.41,,,,,,,fee schedule,137.41,171.42,
Vent Mgmt NF per day,94004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,150.11,,,,,,,fee schedule,137.41,171.42,
Vent Mgmt NF per day,94004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,157.82,,,,,,,fee schedule,137.41,171.42,
Breathing capacity test,94010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83.08,,,,,,,fee schedule,66.6,948.37,
Breathing capacity test,94010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66.6,,,,,,,fee schedule,66.6,948.37,
Breathing capacity test,94010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,72.75,,,,,,,fee schedule,66.6,948.37,
Breathing capacity test,94010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,76.49,,,,,,,fee schedule,66.6,948.37,
Breathing capacity test,94010,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,66.6,948.37,APC 378
Breathing capacity test,94010,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,66.6,948.37,APC
Breathing capacity test,94010,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,66.6,948.37,APC
Breathing capacity test,94010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,66.6,948.37,APC
Breathing capacity test,94010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,66.6,948.37,Radiology
Breathing capacity test,94010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,66.6,948.37,APC
Breathing capacity test,94010,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,66.6,948.37,APC
Spirometry up to 2 yrs old,94011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,224.38,,,,,,,fee schedule,127.38,565.15,
Spirometry up to 2 yrs old,94011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,179.86,,,,,,,fee schedule,127.38,565.15,
Spirometry up to 2 yrs old,94011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,196.48,,,,,,,fee schedule,127.38,565.15,
Spirometry up to 2 yrs old,94011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,206.57,,,,,,,fee schedule,127.38,565.15,
Spirometry up to 2 yrs old,94011,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,565.15,,,,,,,fee schedule,127.38,565.15,APC 378
Spirometry up to 2 yrs old,94011,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,133.75,,,,,,,fee schedule,127.38,565.15,APC
Spirometry up to 2 yrs old,94011,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,132.48,,,,,,,fee schedule,127.38,565.15,APC
Spirometry up to 2 yrs old,94011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,127.38,,,,,,,fee schedule,127.38,565.15,APC
Spirometry up to 2 yrs old,94011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,194.89,,,,,,,fee schedule,127.38,565.15,Radiology
Spirometry up to 2 yrs old,94011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,178.33,,,,,,,fee schedule,127.38,565.15,APC
Spirometry up to 2 yrs old,94011,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,222.92,,,,,,,fee schedule,127.38,565.15,APC
Spirmtry w/brnchdil inf-2 yr,94012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,224.38,,,,,,,fee schedule,179.86,948.37,
Spirmtry w/brnchdil inf-2 yr,94012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,179.86,,,,,,,fee schedule,179.86,948.37,
Spirmtry w/brnchdil inf-2 yr,94012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,196.48,,,,,,,fee schedule,179.86,948.37,
Spirmtry w/brnchdil inf-2 yr,94012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,206.57,,,,,,,fee schedule,179.86,948.37,
Spirmtry w/brnchdil inf-2 yr,94012,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,179.86,948.37,APC 378
Spirmtry w/brnchdil inf-2 yr,94012,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,179.86,948.37,APC
Spirmtry w/brnchdil inf-2 yr,94012,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,179.86,948.37,APC
Spirmtry w/brnchdil inf-2 yr,94012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,179.86,948.37,APC
Spirmtry w/brnchdil inf-2 yr,94012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,179.86,948.37,Radiology
Spirmtry w/brnchdil inf-2 yr,94012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,179.86,948.37,APC
Spirmtry w/brnchdil inf-2 yr,94012,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,179.86,948.37,APC
Meas lung vol thru 2 yrs,94013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,692.72,,,,,,,fee schedule,369.41,1638.96,
Meas lung vol thru 2 yrs,94013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,555.28,,,,,,,fee schedule,369.41,1638.96,
Meas lung vol thru 2 yrs,94013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,606.59,,,,,,,fee schedule,369.41,1638.96,
Meas lung vol thru 2 yrs,94013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,637.74,,,,,,,fee schedule,369.41,1638.96,
Meas lung vol thru 2 yrs,94013,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1638.96,,,,,,,fee schedule,369.41,1638.96,APC 378
Meas lung vol thru 2 yrs,94013,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,387.88,,,,,,,fee schedule,369.41,1638.96,APC
Meas lung vol thru 2 yrs,94013,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,384.19,,,,,,,fee schedule,369.41,1638.96,APC
Meas lung vol thru 2 yrs,94013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,369.41,,,,,,,fee schedule,369.41,1638.96,APC
Meas lung vol thru 2 yrs,94013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,565.2,,,,,,,fee schedule,369.41,1638.96,Radiology
Meas lung vol thru 2 yrs,94013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,517.18,,,,,,,fee schedule,369.41,1638.96,APC
Meas lung vol thru 2 yrs,94013,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,646.47,,,,,,,fee schedule,369.41,1638.96,APC
Patient recorded spirometry,94014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,141.67,,,,,,,fee schedule,113.56,1962.08,
Patient recorded spirometry,94014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,113.56,,,,,,,fee schedule,113.56,1962.08,
Patient recorded spirometry,94014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,124.06,,,,,,,fee schedule,113.56,1962.08,
Patient recorded spirometry,94014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,130.43,,,,,,,fee schedule,113.56,1962.08,
Patient recorded spirometry,94014,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1962.08,,,,,,,fee schedule,113.56,1962.08,APC 378
Patient recorded spirometry,94014,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,464.35,,,,,,,fee schedule,113.56,1962.08,APC
Patient recorded spirometry,94014,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,459.93,,,,,,,fee schedule,113.56,1962.08,APC
Patient recorded spirometry,94014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,442.24,,,,,,,fee schedule,113.56,1962.08,APC
Patient recorded spirometry,94014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,676.63,,,,,,,fee schedule,113.56,1962.08,Radiology
Patient recorded spirometry,94014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,619.14,,,,,,,fee schedule,113.56,1962.08,APC
Patient recorded spirometry,94014,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,773.92,,,,,,,fee schedule,113.56,1962.08,APC
Patient recorded spirometry,94015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,141.67,,,,,,,fee schedule,113.56,948.37,
Patient recorded spirometry,94015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,113.56,,,,,,,fee schedule,113.56,948.37,
Patient recorded spirometry,94015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,124.06,,,,,,,fee schedule,113.56,948.37,
Patient recorded spirometry,94015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,130.43,,,,,,,fee schedule,113.56,948.37,
Patient recorded spirometry,94015,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,113.56,948.37,APC 378
Patient recorded spirometry,94015,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,113.56,948.37,APC
Patient recorded spirometry,94015,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,113.56,948.37,APC
Patient recorded spirometry,94015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,113.56,948.37,APC
Patient recorded spirometry,94015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,113.56,948.37,Radiology
Patient recorded spirometry,94015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,113.56,948.37,APC
Patient recorded spirometry,94015,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,113.56,948.37,APC
Review patient spirometry,94016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,92.08,,,,,,,fee schedule,24.27,92.08,
Review patient spirometry,94016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,73.81,,,,,,,fee schedule,24.27,92.08,
Review patient spirometry,94016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,80.63,,,,,,,fee schedule,24.27,92.08,
Review patient spirometry,94016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,84.77,,,,,,,fee schedule,24.27,92.08,
Review patient spirometry,94016,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24.27,,,,,,,fee schedule,24.27,92.08,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Review patient spirometry,94016,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,25.48,,,,,,,fee schedule,24.27,92.08,APC
Review patient spirometry,94016,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,25.24,,,,,,,fee schedule,24.27,92.08,APC
Review patient spirometry,94016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,37.13,,,,,,,fee schedule,24.27,92.08,Radiology
Review patient spirometry,94016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,33.98,,,,,,,fee schedule,24.27,92.08,APC
Review patient spirometry,94016,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,42.47,,,,,,,fee schedule,24.27,92.08,APC
Evaluation of wheezing,94060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,147.27,,,,,,,fee schedule,118.05,1638.96,
Evaluation of wheezing,94060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,118.05,,,,,,,fee schedule,118.05,1638.96,
Evaluation of wheezing,94060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,128.96,,,,,,,fee schedule,118.05,1638.96,
Evaluation of wheezing,94060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,135.58,,,,,,,fee schedule,118.05,1638.96,
Evaluation of wheezing,94060,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1638.96,,,,,,,fee schedule,118.05,1638.96,APC 378
Evaluation of wheezing,94060,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,387.88,,,,,,,fee schedule,118.05,1638.96,APC
Evaluation of wheezing,94060,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,384.19,,,,,,,fee schedule,118.05,1638.96,APC
Evaluation of wheezing,94060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,369.41,,,,,,,fee schedule,118.05,1638.96,APC
Evaluation of wheezing,94060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,565.2,,,,,,,fee schedule,118.05,1638.96,Radiology
Evaluation of wheezing,94060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,517.18,,,,,,,fee schedule,118.05,1638.96,APC
Evaluation of wheezing,94060,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,646.47,,,,,,,fee schedule,118.05,1638.96,APC
Evaluation of wheezing,94070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,109.58,,,,,,,fee schedule,87.84,1638.96,
Evaluation of wheezing,94070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,87.84,,,,,,,fee schedule,87.84,1638.96,
Evaluation of wheezing,94070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,95.96,,,,,,,fee schedule,87.84,1638.96,
Evaluation of wheezing,94070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,100.89,,,,,,,fee schedule,87.84,1638.96,
Evaluation of wheezing,94070,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1638.96,,,,,,,fee schedule,87.84,1638.96,APC 378
Evaluation of wheezing,94070,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,387.88,,,,,,,fee schedule,87.84,1638.96,APC
Evaluation of wheezing,94070,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,384.19,,,,,,,fee schedule,87.84,1638.96,APC
Evaluation of wheezing,94070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,369.41,,,,,,,fee schedule,87.84,1638.96,APC
Evaluation of wheezing,94070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,565.2,,,,,,,fee schedule,87.84,1638.96,Radiology
Evaluation of wheezing,94070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,517.18,,,,,,,fee schedule,87.84,1638.96,APC
Evaluation of wheezing,94070,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,646.47,,,,,,,fee schedule,87.84,1638.96,APC
Vital capacity test,94150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,62.14,,,,,,,fee schedule,49.81,565.15,
Vital capacity test,94150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,49.81,,,,,,,fee schedule,49.81,565.15,
Vital capacity test,94150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,54.42,,,,,,,fee schedule,49.81,565.15,
Vital capacity test,94150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,57.21,,,,,,,fee schedule,49.81,565.15,
Vital capacity test,94150,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,565.15,,,,,,,fee schedule,49.81,565.15,APC 378
Vital capacity test,94150,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,133.75,,,,,,,fee schedule,49.81,565.15,APC
Vital capacity test,94150,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,132.48,,,,,,,fee schedule,49.81,565.15,APC
Vital capacity test,94150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,127.38,,,,,,,fee schedule,49.81,565.15,APC
Vital capacity test,94150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,194.89,,,,,,,fee schedule,49.81,565.15,Radiology
Vital capacity test,94150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,178.33,,,,,,,fee schedule,49.81,565.15,APC
Vital capacity test,94150,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,222.92,,,,,,,fee schedule,49.81,565.15,APC
Lung function test (MBC/MVV),94200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,57.61,,,,,,,fee schedule,46.18,259.1,
Lung function test (MBC/MVV),94200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.18,,,,,,,fee schedule,46.18,259.1,
Lung function test (MBC/MVV),94200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,50.44,,,,,,,fee schedule,46.18,259.1,
Lung function test (MBC/MVV),94200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,53.04,,,,,,,fee schedule,46.18,259.1,
Lung function test (MBC/MVV),94200,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,46.18,259.1,APC 378
Lung function test (MBC/MVV),94200,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,46.18,259.1,APC
Lung function test (MBC/MVV),94200,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,46.18,259.1,APC
Lung function test (MBC/MVV),94200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,46.18,259.1,APC
Lung function test (MBC/MVV),94200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,46.18,259.1,Radiology
Lung function test (MBC/MVV),94200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,46.18,259.1,APC
Lung function test (MBC/MVV),94200,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,46.18,259.1,APC
Respiratory flow volume loop,94375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,75.79,,,,,,,fee schedule,60.75,948.37,
Respiratory flow volume loop,94375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,60.75,,,,,,,fee schedule,60.75,948.37,
Respiratory flow volume loop,94375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66.37,,,,,,,fee schedule,60.75,948.37,
Respiratory flow volume loop,94375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,69.77,,,,,,,fee schedule,60.75,948.37,
Respiratory flow volume loop,94375,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,60.75,948.37,APC 378
Respiratory flow volume loop,94375,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,60.75,948.37,APC
Respiratory flow volume loop,94375,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,60.75,948.37,APC
Respiratory flow volume loop,94375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,60.75,948.37,APC
Respiratory flow volume loop,94375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,60.75,948.37,Radiology
Respiratory flow volume loop,94375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,60.75,948.37,APC
Respiratory flow volume loop,94375,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,60.75,948.37,APC
Hypoxia response curve,94450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,106.1,,,,,,,fee schedule,85.05,565.15,
Hypoxia response curve,94450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,85.05,,,,,,,fee schedule,85.05,565.15,
Hypoxia response curve,94450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,92.91,,,,,,,fee schedule,85.05,565.15,
Hypoxia response curve,94450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,97.68,,,,,,,fee schedule,85.05,565.15,
Hypoxia response curve,94450,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,565.15,,,,,,,fee schedule,85.05,565.15,APC 378
Hypoxia response curve,94450,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,133.75,,,,,,,fee schedule,85.05,565.15,APC
Hypoxia response curve,94450,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,132.48,,,,,,,fee schedule,85.05,565.15,APC
Hypoxia response curve,94450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,127.38,,,,,,,fee schedule,85.05,565.15,APC
Hypoxia response curve,94450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,194.89,,,,,,,fee schedule,85.05,565.15,Radiology
Hypoxia response curve,94450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,178.33,,,,,,,fee schedule,85.05,565.15,APC
Hypoxia response curve,94450,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,222.92,,,,,,,fee schedule,85.05,565.15,APC
Hast w/report,94452,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,136.46,,,,,,,fee schedule,109.38,584.37,
Hast w/report,94452,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,109.38,,,,,,,fee schedule,109.38,584.37,
Hast w/report,94452,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,119.49,,,,,,,fee schedule,109.38,584.37,
Hast w/report,94452,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,125.63,,,,,,,fee schedule,109.38,584.37,
Hast w/report,94452,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,109.38,584.37,APC 378
Hast w/report,94452,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,109.38,584.37,APC
Hast w/report,94452,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,109.38,584.37,APC
Hast w/report,94452,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,109.38,584.37,APC
Hast w/report,94452,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,109.38,584.37,Radiology
Hast w/report,94452,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,109.38,584.37,APC
Hast w/report,94452,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,109.38,584.37,APC
Hast w/oxygen titrate,94453,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,183.78,,,,,,,fee schedule,131.71,584.37,
Hast w/oxygen titrate,94453,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,147.32,,,,,,,fee schedule,131.71,584.37,
Hast w/oxygen titrate,94453,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,160.93,,,,,,,fee schedule,131.71,584.37,
Hast w/oxygen titrate,94453,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,169.2,,,,,,,fee schedule,131.71,584.37,
Hast w/oxygen titrate,94453,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,131.71,584.37,APC 378
Hast w/oxygen titrate,94453,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,131.71,584.37,APC
Hast w/oxygen titrate,94453,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,131.71,584.37,APC
Hast w/oxygen titrate,94453,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,131.71,584.37,APC
Hast w/oxygen titrate,94453,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,131.71,584.37,Radiology
Hast w/oxygen titrate,94453,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,131.71,584.37,APC
Hast w/oxygen titrate,94453,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,131.71,584.37,APC
Surfactant Admin Thru Tube,94610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,96.73,,,,,,,fee schedule,77.54,961.78,
Surfactant Admin Thru Tube,94610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,77.54,,,,,,,fee schedule,77.54,961.78,
Surfactant Admin Thru Tube,94610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,84.7,,,,,,,fee schedule,77.54,961.78,
Surfactant Admin Thru Tube,94610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,89.05,,,,,,,fee schedule,77.54,961.78,
Surfactant Admin Thru Tube,94610,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,961.78,,,,,,,fee schedule,77.54,961.78,APC 378
Surfactant Admin Thru Tube,94610,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,227.62,,,,,,,fee schedule,77.54,961.78,APC
Surfactant Admin Thru Tube,94610,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,225.45,,,,,,,fee schedule,77.54,961.78,APC
Surfactant Admin Thru Tube,94610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,216.78,,,,,,,fee schedule,77.54,961.78,APC
Surfactant Admin Thru Tube,94610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,331.67,,,,,,,fee schedule,77.54,961.78,Radiology
Surfactant Admin Thru Tube,94610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.49,,,,,,,fee schedule,77.54,961.78,APC
Surfactant Admin Thru Tube,94610,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,379.37,,,,,,,fee schedule,77.54,961.78,APC
Exercise tst brncspsm,94617,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,402.49,,,,,,,fee schedule,131.71,584.37,
Exercise tst brncspsm,94617,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,322.63,,,,,,,fee schedule,131.71,584.37,
Exercise tst brncspsm,94617,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,352.45,,,,,,,fee schedule,131.71,584.37,
Exercise tst brncspsm,94617,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,370.55,,,,,,,fee schedule,131.71,584.37,
Exercise tst brncspsm,94617,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,131.71,584.37,APC 378
Exercise tst brncspsm,94617,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,131.71,584.37,APC
Exercise tst brncspsm,94617,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,131.71,584.37,APC
Exercise tst brncspsm,94617,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,131.71,584.37,APC
Exercise tst brncspsm,94617,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,131.71,584.37,Radiology
Exercise tst brncspsm,94617,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,131.71,584.37,APC
Exercise tst brncspsm,94617,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,131.71,584.37,APC
Pulmonary stress testing,94618,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,402.49,,,,,,,fee schedule,131.71,584.37,
Pulmonary stress testing,94618,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,322.63,,,,,,,fee schedule,131.71,584.37,
Pulmonary stress testing,94618,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,352.45,,,,,,,fee schedule,131.71,584.37,
Pulmonary stress testing,94618,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,370.55,,,,,,,fee schedule,131.71,584.37,
Pulmonary stress testing,94618,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,131.71,584.37,APC 378
Pulmonary stress testing,94618,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,131.71,584.37,APC
Pulmonary stress testing,94618,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,131.71,584.37,APC
Pulmonary stress testing,94618,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,131.71,584.37,APC
Pulmonary stress testing,94618,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,131.71,584.37,Radiology
Pulmonary stress testing,94618,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,131.71,584.37,APC
Pulmonary stress testing,94618,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,131.71,584.37,APC
Exercise tst brncspsm wo ecg,94619,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,210.39,,,,,,,fee schedule,58.4,259.1,
Exercise tst brncspsm wo ecg,94619,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,168.65,,,,,,,fee schedule,58.4,259.1,
Exercise tst brncspsm wo ecg,94619,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,184.23,,,,,,,fee schedule,58.4,259.1,
Exercise tst brncspsm wo ecg,94619,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,193.7,,,,,,,fee schedule,58.4,259.1,
Exercise tst brncspsm wo ecg,94619,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,58.4,259.1,APC 378
Exercise tst brncspsm wo ecg,94619,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,58.4,259.1,APC
Exercise tst brncspsm wo ecg,94619,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,58.4,259.1,APC
Exercise tst brncspsm wo ecg,94619,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,58.4,259.1,APC
Exercise tst brncspsm wo ecg,94619,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,58.4,259.1,Radiology
Exercise tst brncspsm wo ecg,94619,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,58.4,259.1,APC
Exercise tst brncspsm wo ecg,94619,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,58.4,259.1,APC
Pulm stress test/complex,94621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,307.35,,,,,,,fee schedule,246.37,1638.96,
Pulm stress test/complex,94621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,246.37,,,,,,,fee schedule,246.37,1638.96,
Pulm stress test/complex,94621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,269.14,,,,,,,fee schedule,246.37,1638.96,
Pulm stress test/complex,94621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,282.96,,,,,,,fee schedule,246.37,1638.96,
Pulm stress test/complex,94621,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1638.96,,,,,,,fee schedule,246.37,1638.96,APC 378
Pulm stress test/complex,94621,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,387.88,,,,,,,fee schedule,246.37,1638.96,APC
Pulm stress test/complex,94621,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,384.19,,,,,,,fee schedule,246.37,1638.96,APC
Pulm stress test/complex,94621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,369.41,,,,,,,fee schedule,246.37,1638.96,APC
Pulm stress test/complex,94621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,565.2,,,,,,,fee schedule,246.37,1638.96,Radiology
Pulm stress test/complex,94621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,517.18,,,,,,,fee schedule,246.37,1638.96,APC
Pulm stress test/complex,94621,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,646.47,,,,,,,fee schedule,246.37,1638.96,APC
Phy/qhp op pulm rhb w/o mntr,94625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,214.89,,,,,,,fee schedule,58.4,259.1,
Phy/qhp op pulm rhb w/o mntr,94625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,172.26,,,,,,,fee schedule,58.4,259.1,
Phy/qhp op pulm rhb w/o mntr,94625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,188.17,,,,,,,fee schedule,58.4,259.1,
Phy/qhp op pulm rhb w/o mntr,94625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,197.84,,,,,,,fee schedule,58.4,259.1,
Phy/qhp op pulm rhb w/o mntr,94625,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,58.4,259.1,APC 378
Phy/qhp op pulm rhb w/o mntr,94625,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,58.4,259.1,APC
Phy/qhp op pulm rhb w/o mntr,94625,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,58.4,259.1,APC
Phy/qhp op pulm rhb w/o mntr,94625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,58.4,259.1,APC
Phy/qhp op pulm rhb w/o mntr,94625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,58.4,259.1,Radiology
Phy/qhp op pulm rhb w/o mntr,94625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,58.4,259.1,APC
Phy/qhp op pulm rhb w/o mntr,94625,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,58.4,259.1,APC
Phy/qhp op pulm rhb w/mntr,94626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,214.89,,,,,,,fee schedule,58.4,259.1,
Phy/qhp op pulm rhb w/mntr,94626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,172.26,,,,,,,fee schedule,58.4,259.1,
Phy/qhp op pulm rhb w/mntr,94626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,188.17,,,,,,,fee schedule,58.4,259.1,
Phy/qhp op pulm rhb w/mntr,94626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,197.84,,,,,,,fee schedule,58.4,259.1,
Phy/qhp op pulm rhb w/mntr,94626,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,58.4,259.1,APC 378
Phy/qhp op pulm rhb w/mntr,94626,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,58.4,259.1,APC
Phy/qhp op pulm rhb w/mntr,94626,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,58.4,259.1,APC
Phy/qhp op pulm rhb w/mntr,94626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,58.4,259.1,APC
Phy/qhp op pulm rhb w/mntr,94626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,58.4,259.1,Radiology
Phy/qhp op pulm rhb w/mntr,94626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,58.4,259.1,APC
Phy/qhp op pulm rhb w/mntr,94626,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,58.4,259.1,APC
Airway inhalation treatment,94640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,208.04,,,,,,,fee schedule,166.76,961.78,
Airway inhalation treatment,94640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,166.76,,,,,,,fee schedule,166.76,961.78,
Airway inhalation treatment,94640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,182.17,,,,,,,fee schedule,166.76,961.78,
Airway inhalation treatment,94640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,191.53,,,,,,,fee schedule,166.76,961.78,
Airway inhalation treatment,94640,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,961.78,,,,,,,fee schedule,166.76,961.78,APC 378
Airway inhalation treatment,94640,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,227.62,,,,,,,fee schedule,166.76,961.78,APC
Airway inhalation treatment,94640,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,225.45,,,,,,,fee schedule,166.76,961.78,APC
Airway inhalation treatment,94640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,216.78,,,,,,,fee schedule,166.76,961.78,APC
Airway inhalation treatment,94640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,331.67,,,,,,,fee schedule,166.76,961.78,Radiology
Airway inhalation treatment,94640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.49,,,,,,,fee schedule,166.76,961.78,APC
Airway inhalation treatment,94640,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,379.37,,,,,,,fee schedule,166.76,961.78,APC
Aerosol inhalation treatment,94642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,231.89,,,,,,,fee schedule,185.88,961.78,
Aerosol inhalation treatment,94642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,185.88,,,,,,,fee schedule,185.88,961.78,
Aerosol inhalation treatment,94642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,203.06,,,,,,,fee schedule,185.88,961.78,
Aerosol inhalation treatment,94642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,213.49,,,,,,,fee schedule,185.88,961.78,
Aerosol inhalation treatment,94642,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,961.78,,,,,,,fee schedule,185.88,961.78,APC 378
Aerosol inhalation treatment,94642,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,227.62,,,,,,,fee schedule,185.88,961.78,APC
Aerosol inhalation treatment,94642,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,225.45,,,,,,,fee schedule,185.88,961.78,APC
Aerosol inhalation treatment,94642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,216.78,,,,,,,fee schedule,185.88,961.78,APC
Aerosol inhalation treatment,94642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,331.67,,,,,,,fee schedule,185.88,961.78,Radiology
Aerosol inhalation treatment,94642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.49,,,,,,,fee schedule,185.88,961.78,APC
Aerosol inhalation treatment,94642,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,379.37,,,,,,,fee schedule,185.88,961.78,APC
Cbt 1st hour,94644,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,138.7,,,,,,,fee schedule,111.18,584.37,
Cbt 1st hour,94644,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,111.18,,,,,,,fee schedule,111.18,584.37,
Cbt 1st hour,94644,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,121.45,,,,,,,fee schedule,111.18,584.37,
Cbt 1st hour,94644,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,127.69,,,,,,,fee schedule,111.18,584.37,
Cbt 1st hour,94644,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,111.18,584.37,APC 378
Cbt 1st hour,94644,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,111.18,584.37,APC
Cbt 1st hour,94644,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,111.18,584.37,APC
Cbt 1st hour,94644,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,111.18,584.37,APC
Cbt 1st hour,94644,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,111.18,584.37,Radiology
Cbt 1st hour,94644,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,111.18,584.37,APC
Cbt 1st hour,94644,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,111.18,584.37,APC
Cbt each addl hour,94645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,111.61,,,,,,,fee schedule,89.47,111.61,
Cbt each addl hour,94645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,89.47,,,,,,,fee schedule,89.47,111.61,
Cbt each addl hour,94645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,97.73,,,,,,,fee schedule,89.47,111.61,
Cbt each addl hour,94645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,102.75,,,,,,,fee schedule,89.47,111.61,
Pos airway pressure cpap,94660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,642.57,,,,,,,fee schedule,216.78,961.78,
Pos airway pressure cpap,94660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,515.08,,,,,,,fee schedule,216.78,961.78,
Pos airway pressure cpap,94660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,562.68,,,,,,,fee schedule,216.78,961.78,
Pos airway pressure cpap,94660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,591.58,,,,,,,fee schedule,216.78,961.78,
Pos airway pressure cpap,94660,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,961.78,,,,,,,fee schedule,216.78,961.78,APC 378
Pos airway pressure cpap,94660,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,227.62,,,,,,,fee schedule,216.78,961.78,APC
Pos airway pressure cpap,94660,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,225.45,,,,,,,fee schedule,216.78,961.78,APC
Pos airway pressure cpap,94660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,216.78,,,,,,,fee schedule,216.78,961.78,APC
Pos airway pressure cpap,94660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,331.67,,,,,,,fee schedule,216.78,961.78,Radiology
Pos airway pressure cpap,94660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.49,,,,,,,fee schedule,216.78,961.78,APC
Pos airway pressure cpap,94660,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,379.37,,,,,,,fee schedule,216.78,961.78,APC
Neg press ventilation cnp,94662,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,618.52,,,,,,,fee schedule,495.8,618.52,
Neg press ventilation cnp,94662,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,495.8,,,,,,,fee schedule,495.8,618.52,
Neg press ventilation cnp,94662,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,541.62,,,,,,,fee schedule,495.8,618.52,
Neg press ventilation cnp,94662,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,569.43,,,,,,,fee schedule,495.8,618.52,
Evaluate pt use of inhaler,94664,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,109.44,,,,,,,fee schedule,87.73,961.78,
Evaluate pt use of inhaler,94664,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,87.73,,,,,,,fee schedule,87.73,961.78,
Evaluate pt use of inhaler,94664,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,95.84,,,,,,,fee schedule,87.73,961.78,
Evaluate pt use of inhaler,94664,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,100.76,,,,,,,fee schedule,87.73,961.78,
Evaluate pt use of inhaler,94664,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,961.78,,,,,,,fee schedule,87.73,961.78,APC 378
Evaluate pt use of inhaler,94664,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,227.62,,,,,,,fee schedule,87.73,961.78,APC
Evaluate pt use of inhaler,94664,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,225.45,,,,,,,fee schedule,87.73,961.78,APC
Evaluate pt use of inhaler,94664,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,216.78,,,,,,,fee schedule,87.73,961.78,APC
Evaluate pt use of inhaler,94664,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,331.67,,,,,,,fee schedule,87.73,961.78,Radiology
Evaluate pt use of inhaler,94664,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.49,,,,,,,fee schedule,87.73,961.78,APC
Evaluate pt use of inhaler,94664,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,379.37,,,,,,,fee schedule,87.73,961.78,APC
Chest wall manipulation,94667,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,231.89,,,,,,,fee schedule,131.71,584.37,
Chest wall manipulation,94667,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,185.88,,,,,,,fee schedule,131.71,584.37,
Chest wall manipulation,94667,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,203.06,,,,,,,fee schedule,131.71,584.37,
Chest wall manipulation,94667,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,213.49,,,,,,,fee schedule,131.71,584.37,
Chest wall manipulation,94667,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,131.71,584.37,APC 378
Chest wall manipulation,94667,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,131.71,584.37,APC
Chest wall manipulation,94667,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,131.71,584.37,APC
Chest wall manipulation,94667,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,131.71,584.37,APC
Chest wall manipulation,94667,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,131.71,584.37,Radiology
Chest wall manipulation,94667,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,131.71,584.37,APC
Chest wall manipulation,94667,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,131.71,584.37,APC
Chest wall manipulation,94668,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,138.7,,,,,,,fee schedule,111.18,584.37,
Chest wall manipulation,94668,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,111.18,,,,,,,fee schedule,111.18,584.37,
Chest wall manipulation,94668,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,121.45,,,,,,,fee schedule,111.18,584.37,
Chest wall manipulation,94668,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,127.69,,,,,,,fee schedule,111.18,584.37,
Chest wall manipulation,94668,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,111.18,584.37,APC 378
Chest wall manipulation,94668,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,111.18,584.37,APC
Chest wall manipulation,94668,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,111.18,584.37,APC
Chest wall manipulation,94668,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,111.18,584.37,APC
Chest wall manipulation,94668,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,111.18,584.37,Radiology
Chest wall manipulation,94668,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,111.18,584.37,APC
Chest wall manipulation,94668,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,111.18,584.37,APC
Mechanical chest wall oscill,94669,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,622.3,,,,,,,fee schedule,216.78,961.78,
Mechanical chest wall oscill,94669,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,498.83,,,,,,,fee schedule,216.78,961.78,
Mechanical chest wall oscill,94669,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,544.93,,,,,,,fee schedule,216.78,961.78,
Mechanical chest wall oscill,94669,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,572.91,,,,,,,fee schedule,216.78,961.78,
Mechanical chest wall oscill,94669,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,961.78,,,,,,,fee schedule,216.78,961.78,APC 378
Mechanical chest wall oscill,94669,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,227.62,,,,,,,fee schedule,216.78,961.78,APC
Mechanical chest wall oscill,94669,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,225.45,,,,,,,fee schedule,216.78,961.78,APC
Mechanical chest wall oscill,94669,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,216.78,,,,,,,fee schedule,216.78,961.78,APC
Mechanical chest wall oscill,94669,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,331.67,,,,,,,fee schedule,216.78,961.78,Radiology
Mechanical chest wall oscill,94669,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.49,,,,,,,fee schedule,216.78,961.78,APC
Mechanical chest wall oscill,94669,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,379.37,,,,,,,fee schedule,216.78,961.78,APC
Exhaled air analysis o2,94680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,153.35,,,,,,,fee schedule,122.93,565.15,
Exhaled air analysis o2,94680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,122.93,,,,,,,fee schedule,122.93,565.15,
Exhaled air analysis o2,94680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,134.29,,,,,,,fee schedule,122.93,565.15,
Exhaled air analysis o2,94680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,141.18,,,,,,,fee schedule,122.93,565.15,
Exhaled air analysis o2,94680,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,565.15,,,,,,,fee schedule,122.93,565.15,APC 378
Exhaled air analysis o2,94680,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,133.75,,,,,,,fee schedule,122.93,565.15,APC
Exhaled air analysis o2,94680,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,132.48,,,,,,,fee schedule,122.93,565.15,APC
Exhaled air analysis o2,94680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,127.38,,,,,,,fee schedule,122.93,565.15,APC
Exhaled air analysis o2,94680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,194.89,,,,,,,fee schedule,122.93,565.15,Radiology
Exhaled air analysis o2,94680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,178.33,,,,,,,fee schedule,122.93,565.15,APC
Exhaled air analysis o2,94680,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,222.92,,,,,,,fee schedule,122.93,565.15,APC
Exhaled air analysis o2/co2,94681,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,182.95,,,,,,,fee schedule,146.65,1638.96,
Exhaled air analysis o2/co2,94681,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,146.65,,,,,,,fee schedule,146.65,1638.96,
Exhaled air analysis o2/co2,94681,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,160.2,,,,,,,fee schedule,146.65,1638.96,
Exhaled air analysis o2/co2,94681,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,168.43,,,,,,,fee schedule,146.65,1638.96,
Exhaled air analysis o2/co2,94681,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1638.96,,,,,,,fee schedule,146.65,1638.96,APC 378
Exhaled air analysis o2/co2,94681,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,387.88,,,,,,,fee schedule,146.65,1638.96,APC
Exhaled air analysis o2/co2,94681,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,384.19,,,,,,,fee schedule,146.65,1638.96,APC
Exhaled air analysis o2/co2,94681,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,369.41,,,,,,,fee schedule,146.65,1638.96,APC
Exhaled air analysis o2/co2,94681,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,565.2,,,,,,,fee schedule,146.65,1638.96,Radiology
Exhaled air analysis o2/co2,94681,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,517.18,,,,,,,fee schedule,146.65,1638.96,APC
Exhaled air analysis o2/co2,94681,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,646.47,,,,,,,fee schedule,146.65,1638.96,APC
Exhaled air analysis,94690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,157.66,,,,,,,fee schedule,58.4,259.1,
Exhaled air analysis,94690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,126.38,,,,,,,fee schedule,58.4,259.1,
Exhaled air analysis,94690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,138.06,,,,,,,fee schedule,58.4,259.1,
Exhaled air analysis,94690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,145.15,,,,,,,fee schedule,58.4,259.1,
Exhaled air analysis,94690,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,58.4,259.1,APC 378
Exhaled air analysis,94690,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,58.4,259.1,APC
Exhaled air analysis,94690,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,58.4,259.1,APC
Exhaled air analysis,94690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,58.4,259.1,APC
Exhaled air analysis,94690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,58.4,259.1,Radiology
Exhaled air analysis,94690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,58.4,259.1,APC
Exhaled air analysis,94690,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,58.4,259.1,APC
Pulm funct tst plethysmograp,94726,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,166.32,,,,,,,fee schedule,133.32,1638.96,
Pulm funct tst plethysmograp,94726,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,133.32,,,,,,,fee schedule,133.32,1638.96,
Pulm funct tst plethysmograp,94726,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,145.64,,,,,,,fee schedule,133.32,1638.96,
Pulm funct tst plethysmograp,94726,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,153.12,,,,,,,fee schedule,133.32,1638.96,
Pulm funct tst plethysmograp,94726,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1638.96,,,,,,,fee schedule,133.32,1638.96,APC 378
Pulm funct tst plethysmograp,94726,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,387.88,,,,,,,fee schedule,133.32,1638.96,APC
Pulm funct tst plethysmograp,94726,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,384.19,,,,,,,fee schedule,133.32,1638.96,APC
Pulm funct tst plethysmograp,94726,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,369.41,,,,,,,fee schedule,133.32,1638.96,APC
Pulm funct tst plethysmograp,94726,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,565.2,,,,,,,fee schedule,133.32,1638.96,Radiology
Pulm funct tst plethysmograp,94726,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,517.18,,,,,,,fee schedule,133.32,1638.96,APC
Pulm funct tst plethysmograp,94726,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,646.47,,,,,,,fee schedule,133.32,1638.96,APC
Pulm function test by gas,94727,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,120.28,,,,,,,fee schedule,96.41,948.37,
Pulm function test by gas,94727,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,96.41,,,,,,,fee schedule,96.41,948.37,
Pulm function test by gas,94727,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,105.32,,,,,,,fee schedule,96.41,948.37,
Pulm function test by gas,94727,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,110.73,,,,,,,fee schedule,96.41,948.37,
Pulm function test by gas,94727,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,96.41,948.37,APC 378
Pulm function test by gas,94727,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,96.41,948.37,APC
Pulm function test by gas,94727,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,96.41,948.37,APC
Pulm function test by gas,94727,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,96.41,948.37,APC
Pulm function test by gas,94727,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,96.41,948.37,Radiology
Pulm function test by gas,94727,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,96.41,948.37,APC
Pulm function test by gas,94727,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,96.41,948.37,APC
Pulm funct test oscillometry,94728,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,114.38,,,,,,,fee schedule,91.69,565.15,
Pulm funct test oscillometry,94728,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,91.69,,,,,,,fee schedule,91.69,565.15,
Pulm funct test oscillometry,94728,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,100.16,,,,,,,fee schedule,91.69,565.15,
Pulm funct test oscillometry,94728,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,105.3,,,,,,,fee schedule,91.69,565.15,
Pulm funct test oscillometry,94728,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,565.15,,,,,,,fee schedule,91.69,565.15,APC 378
Pulm funct test oscillometry,94728,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,133.75,,,,,,,fee schedule,91.69,565.15,APC
Pulm funct test oscillometry,94728,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,132.48,,,,,,,fee schedule,91.69,565.15,APC
Pulm funct test oscillometry,94728,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,127.38,,,,,,,fee schedule,91.69,565.15,APC
Pulm funct test oscillometry,94728,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,194.89,,,,,,,fee schedule,91.69,565.15,Radiology
Pulm funct test oscillometry,94728,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,178.33,,,,,,,fee schedule,91.69,565.15,APC
Pulm funct test oscillometry,94728,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,222.92,,,,,,,fee schedule,91.69,565.15,APC
Co/membane diffuse capacity,94729,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,183.9,,,,,,,fee schedule,147.41,183.9,
Co/membane diffuse capacity,94729,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,147.41,,,,,,,fee schedule,147.41,183.9,
Co/membane diffuse capacity,94729,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,161.03,,,,,,,fee schedule,147.41,183.9,
Co/membane diffuse capacity,94729,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,169.3,,,,,,,fee schedule,147.41,183.9,
Measure blood oxygen level,94762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,177.9,,,,,,,fee schedule,127.38,565.15,
Measure blood oxygen level,94762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,142.6,,,,,,,fee schedule,127.38,565.15,
Measure blood oxygen level,94762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,155.78,,,,,,,fee schedule,127.38,565.15,
Measure blood oxygen level,94762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,163.78,,,,,,,fee schedule,127.38,565.15,
Measure blood oxygen level,94762,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,565.15,,,,,,,fee schedule,127.38,565.15,APC 378
Measure blood oxygen level,94762,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,133.75,,,,,,,fee schedule,127.38,565.15,APC
Measure blood oxygen level,94762,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,132.48,,,,,,,fee schedule,127.38,565.15,APC
Measure blood oxygen level,94762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,127.38,,,,,,,fee schedule,127.38,565.15,APC
Measure blood oxygen level,94762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,194.89,,,,,,,fee schedule,127.38,565.15,Radiology
Measure blood oxygen level,94762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,178.33,,,,,,,fee schedule,127.38,565.15,APC
Measure blood oxygen level,94762,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,222.92,,,,,,,fee schedule,127.38,565.15,APC
Breath recording infant,94772,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,687.58,,,,,,,fee schedule,369.41,1638.96,
Breath recording infant,94772,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,551.16,,,,,,,fee schedule,369.41,1638.96,
Breath recording infant,94772,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,602.09,,,,,,,fee schedule,369.41,1638.96,
Breath recording infant,94772,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,633.01,,,,,,,fee schedule,369.41,1638.96,
Breath recording infant,94772,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1638.96,,,,,,,fee schedule,369.41,1638.96,APC 378
Breath recording infant,94772,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,387.88,,,,,,,fee schedule,369.41,1638.96,APC
Breath recording infant,94772,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,384.19,,,,,,,fee schedule,369.41,1638.96,APC
Breath recording infant,94772,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,369.41,,,,,,,fee schedule,369.41,1638.96,APC
Breath recording infant,94772,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,565.2,,,,,,,fee schedule,369.41,1638.96,Radiology
Breath recording infant,94772,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,517.18,,,,,,,fee schedule,369.41,1638.96,APC
Breath recording infant,94772,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,646.47,,,,,,,fee schedule,369.41,1638.96,APC
Ped home apnea rec hk-up,94775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,249.93,,,,,,,fee schedule,127.38,565.15,
Ped home apnea rec hk-up,94775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,200.34,,,,,,,fee schedule,127.38,565.15,
Ped home apnea rec hk-up,94775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,218.86,,,,,,,fee schedule,127.38,565.15,
Ped home apnea rec hk-up,94775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,230.1,,,,,,,fee schedule,127.38,565.15,
Ped home apnea rec hk-up,94775,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,565.15,,,,,,,fee schedule,127.38,565.15,APC 378
Ped home apnea rec hk-up,94775,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,133.75,,,,,,,fee schedule,127.38,565.15,APC
Ped home apnea rec hk-up,94775,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,132.48,,,,,,,fee schedule,127.38,565.15,APC
Ped home apnea rec hk-up,94775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,127.38,,,,,,,fee schedule,127.38,565.15,APC
Ped home apnea rec hk-up,94775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,194.89,,,,,,,fee schedule,127.38,565.15,Radiology
Ped home apnea rec hk-up,94775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,178.33,,,,,,,fee schedule,127.38,565.15,APC
Ped home apnea rec hk-up,94775,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,222.92,,,,,,,fee schedule,127.38,565.15,APC
Ped home apnea rec downld,94776,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,249.93,,,,,,,fee schedule,127.38,565.15,
Ped home apnea rec downld,94776,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,200.34,,,,,,,fee schedule,127.38,565.15,
Ped home apnea rec downld,94776,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,218.86,,,,,,,fee schedule,127.38,565.15,
Ped home apnea rec downld,94776,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,230.1,,,,,,,fee schedule,127.38,565.15,
Ped home apnea rec downld,94776,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,565.15,,,,,,,fee schedule,127.38,565.15,APC 378
Ped home apnea rec downld,94776,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,133.75,,,,,,,fee schedule,127.38,565.15,APC
Ped home apnea rec downld,94776,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,132.48,,,,,,,fee schedule,127.38,565.15,APC
Ped home apnea rec downld,94776,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,127.38,,,,,,,fee schedule,127.38,565.15,APC
Ped home apnea rec downld,94776,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,194.89,,,,,,,fee schedule,127.38,565.15,Radiology
Ped home apnea rec downld,94776,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,178.33,,,,,,,fee schedule,127.38,565.15,APC
Ped home apnea rec downld,94776,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,222.92,,,,,,,fee schedule,127.38,565.15,APC
Car seat/bed test 60 min,94780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,187.64,,,,,,,fee schedule,36.98,187.64,
Car seat/bed test 60 min,94780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,150.41,,,,,,,fee schedule,36.98,187.64,
Car seat/bed test 60 min,94780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,164.31,,,,,,,fee schedule,36.98,187.64,
Car seat/bed test 60 min,94780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,172.75,,,,,,,fee schedule,36.98,187.64,
Car seat/bed test 60 min,94780,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.05,,,,,,,fee schedule,36.98,187.64,APC 378
Car seat/bed test 60 min,94780,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.83,,,,,,,fee schedule,36.98,187.64,APC
Car seat/bed test 60 min,94780,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.46,,,,,,,fee schedule,36.98,187.64,APC
Car seat/bed test 60 min,94780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.98,,,,,,,fee schedule,36.98,187.64,APC
Car seat/bed test 60 min,94780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.57,,,,,,,fee schedule,36.98,187.64,Radiology
Car seat/bed test 60 min,94780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.77,,,,,,,fee schedule,36.98,187.64,APC
Car seat/bed test 60 min,94780,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.71,,,,,,,fee schedule,36.98,187.64,APC
Car seat/bed test + 30 min,94781,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,187.64,,,,,,,fee schedule,150.41,187.64,
Car seat/bed test + 30 min,94781,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,150.41,,,,,,,fee schedule,150.41,187.64,
Car seat/bed test + 30 min,94781,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,164.31,,,,,,,fee schedule,150.41,187.64,
Car seat/bed test + 30 min,94781,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,172.75,,,,,,,fee schedule,150.41,187.64,
Pulmonary service/procedure,94799,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,565.15,,,,,,,fee schedule,127.38,565.15,APC 378
Pulmonary service/procedure,94799,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,133.75,,,,,,,fee schedule,127.38,565.15,APC
Pulmonary service/procedure,94799,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,132.48,,,,,,,fee schedule,127.38,565.15,APC
Pulmonary service/procedure,94799,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,127.38,,,,,,,fee schedule,127.38,565.15,APC
Pulmonary service/procedure,94799,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,194.89,,,,,,,fee schedule,127.38,565.15,Radiology
Pulmonary service/procedure,94799,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,178.33,,,,,,,fee schedule,127.38,565.15,APC
Pulmonary service/procedure,94799,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,222.92,,,,,,,fee schedule,127.38,565.15,APC
Percut allergy skin tests,95004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,69.21,,,,,,,fee schedule,55.48,3771.72,
Percut allergy skin tests,95004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55.48,,,,,,,fee schedule,55.48,3771.72,
Percut allergy skin tests,95004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,60.61,,,,,,,fee schedule,55.48,3771.72,
Percut allergy skin tests,95004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,63.72,,,,,,,fee schedule,55.48,3771.72,
Percut allergy skin tests,95004,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3771.72,,,,,,,fee schedule,55.48,3771.72,APC 378
Percut allergy skin tests,95004,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,892.63,,,,,,,fee schedule,55.48,3771.72,APC
Percut allergy skin tests,95004,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,884.13,,,,,,,fee schedule,55.48,3771.72,APC
Percut allergy skin tests,95004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,850.12,,,,,,,fee schedule,55.48,3771.72,APC
Percut allergy skin tests,95004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1300.69,,,,,,,fee schedule,55.48,3771.72,Radiology
Percut allergy skin tests,95004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1190.17,,,,,,,fee schedule,55.48,3771.72,APC
Percut allergy skin tests,95004,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1487.72,,,,,,,fee schedule,55.48,3771.72,APC
Exhaled Nitric Oxide Meas,95012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,141.67,,,,,,,fee schedule,36.98,164.05,
Exhaled Nitric Oxide Meas,95012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,113.56,,,,,,,fee schedule,36.98,164.05,
Exhaled Nitric Oxide Meas,95012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,124.06,,,,,,,fee schedule,36.98,164.05,
Exhaled Nitric Oxide Meas,95012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,130.43,,,,,,,fee schedule,36.98,164.05,
Exhaled Nitric Oxide Meas,95012,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.05,,,,,,,fee schedule,36.98,164.05,APC 378
Exhaled Nitric Oxide Meas,95012,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.83,,,,,,,fee schedule,36.98,164.05,APC
Exhaled Nitric Oxide Meas,95012,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.46,,,,,,,fee schedule,36.98,164.05,APC
Exhaled Nitric Oxide Meas,95012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.98,,,,,,,fee schedule,36.98,164.05,APC
Exhaled Nitric Oxide Meas,95012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.57,,,,,,,fee schedule,36.98,164.05,Radiology
Exhaled Nitric Oxide Meas,95012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.77,,,,,,,fee schedule,36.98,164.05,APC
Exhaled Nitric Oxide Meas,95012,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.71,,,,,,,fee schedule,36.98,164.05,APC
Perq & icut allg test venoms,95017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,93.74,,,,,,,fee schedule,28.63,127.04,
Perq & icut allg test venoms,95017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,75.14,,,,,,,fee schedule,28.63,127.04,
Perq & icut allg test venoms,95017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,82.09,,,,,,,fee schedule,28.63,127.04,
Perq & icut allg test venoms,95017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,86.3,,,,,,,fee schedule,28.63,127.04,
Perq & icut allg test venoms,95017,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,127.04,,,,,,,fee schedule,28.63,127.04,APC 378
Perq & icut allg test venoms,95017,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.07,,,,,,,fee schedule,28.63,127.04,APC
Perq & icut allg test venoms,95017,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,29.78,,,,,,,fee schedule,28.63,127.04,APC
Perq & icut allg test venoms,95017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,28.63,,,,,,,fee schedule,28.63,127.04,APC
Perq & icut allg test venoms,95017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43.81,,,,,,,fee schedule,28.63,127.04,Radiology
Perq & icut allg test venoms,95017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40.09,,,,,,,fee schedule,28.63,127.04,APC
Perq & icut allg test venoms,95017,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,50.11,,,,,,,fee schedule,28.63,127.04,APC
Perq&ic allg test drugs/biol,95018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,93.74,,,,,,,fee schedule,36.98,164.05,
Perq&ic allg test drugs/biol,95018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,75.14,,,,,,,fee schedule,36.98,164.05,
Perq&ic allg test drugs/biol,95018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,82.09,,,,,,,fee schedule,36.98,164.05,
Perq&ic allg test drugs/biol,95018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,86.3,,,,,,,fee schedule,36.98,164.05,
Perq&ic allg test drugs/biol,95018,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.05,,,,,,,fee schedule,36.98,164.05,APC 378
Perq&ic allg test drugs/biol,95018,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.83,,,,,,,fee schedule,36.98,164.05,APC
Perq&ic allg test drugs/biol,95018,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.46,,,,,,,fee schedule,36.98,164.05,APC
Perq&ic allg test drugs/biol,95018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.98,,,,,,,fee schedule,36.98,164.05,APC
Perq&ic allg test drugs/biol,95018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.57,,,,,,,fee schedule,36.98,164.05,Radiology
Perq&ic allg test drugs/biol,95018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.77,,,,,,,fee schedule,36.98,164.05,APC
Perq&ic allg test drugs/biol,95018,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.71,,,,,,,fee schedule,36.98,164.05,APC
Icut allergy test drug/bug,95024,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,69.21,,,,,,,fee schedule,55.48,259.1,
Icut allergy test drug/bug,95024,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55.48,,,,,,,fee schedule,55.48,259.1,
Icut allergy test drug/bug,95024,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,60.61,,,,,,,fee schedule,55.48,259.1,
Icut allergy test drug/bug,95024,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,63.72,,,,,,,fee schedule,55.48,259.1,
Icut allergy test drug/bug,95024,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,55.48,259.1,APC 378
Icut allergy test drug/bug,95024,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,55.48,259.1,APC
Icut allergy test drug/bug,95024,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,55.48,259.1,APC
Icut allergy test drug/bug,95024,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,55.48,259.1,APC
Icut allergy test drug/bug,95024,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,55.48,259.1,Radiology
Icut allergy test drug/bug,95024,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,55.48,259.1,APC
Icut allergy test drug/bug,95024,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,55.48,259.1,APC
Icut allergy titrate-airborn,95027,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,69.21,,,,,,,fee schedule,28.63,127.04,
Icut allergy titrate-airborn,95027,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55.48,,,,,,,fee schedule,28.63,127.04,
Icut allergy titrate-airborn,95027,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,60.61,,,,,,,fee schedule,28.63,127.04,
Icut allergy titrate-airborn,95027,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,63.72,,,,,,,fee schedule,28.63,127.04,
Icut allergy titrate-airborn,95027,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,127.04,,,,,,,fee schedule,28.63,127.04,APC 378
Icut allergy titrate-airborn,95027,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.07,,,,,,,fee schedule,28.63,127.04,APC
Icut allergy titrate-airborn,95027,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,29.78,,,,,,,fee schedule,28.63,127.04,APC
Icut allergy titrate-airborn,95027,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,28.63,,,,,,,fee schedule,28.63,127.04,APC
Icut allergy titrate-airborn,95027,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43.81,,,,,,,fee schedule,28.63,127.04,Radiology
Icut allergy titrate-airborn,95027,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40.09,,,,,,,fee schedule,28.63,127.04,APC
Icut allergy titrate-airborn,95027,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,50.11,,,,,,,fee schedule,28.63,127.04,APC
Icut allergy test-delayed,95028,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,69.21,,,,,,,fee schedule,36.98,164.05,
Icut allergy test-delayed,95028,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55.48,,,,,,,fee schedule,36.98,164.05,
Icut allergy test-delayed,95028,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,60.61,,,,,,,fee schedule,36.98,164.05,
Icut allergy test-delayed,95028,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,63.72,,,,,,,fee schedule,36.98,164.05,
Icut allergy test-delayed,95028,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.05,,,,,,,fee schedule,36.98,164.05,APC 378
Icut allergy test-delayed,95028,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.83,,,,,,,fee schedule,36.98,164.05,APC
Icut allergy test-delayed,95028,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.46,,,,,,,fee schedule,36.98,164.05,APC
Icut allergy test-delayed,95028,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.98,,,,,,,fee schedule,36.98,164.05,APC
Icut allergy test-delayed,95028,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.57,,,,,,,fee schedule,36.98,164.05,Radiology
Icut allergy test-delayed,95028,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.77,,,,,,,fee schedule,36.98,164.05,APC
Icut allergy test-delayed,95028,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.71,,,,,,,fee schedule,36.98,164.05,APC
Allergy patch tests,95044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,69.21,,,,,,,fee schedule,55.48,3771.72,
Allergy patch tests,95044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55.48,,,,,,,fee schedule,55.48,3771.72,
Allergy patch tests,95044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,60.61,,,,,,,fee schedule,55.48,3771.72,
Allergy patch tests,95044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,63.72,,,,,,,fee schedule,55.48,3771.72,
Allergy patch tests,95044,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3771.72,,,,,,,fee schedule,55.48,3771.72,APC 378
Allergy patch tests,95044,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,892.63,,,,,,,fee schedule,55.48,3771.72,APC
Allergy patch tests,95044,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,884.13,,,,,,,fee schedule,55.48,3771.72,APC
Allergy patch tests,95044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,850.12,,,,,,,fee schedule,55.48,3771.72,APC
Allergy patch tests,95044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1300.69,,,,,,,fee schedule,55.48,3771.72,Radiology
Allergy patch tests,95044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1190.17,,,,,,,fee schedule,55.48,3771.72,APC
Allergy patch tests,95044,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1487.72,,,,,,,fee schedule,55.48,3771.72,APC
Photo patch test,95052,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,69.21,,,,,,,fee schedule,55.48,259.1,
Photo patch test,95052,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55.48,,,,,,,fee schedule,55.48,259.1,
Photo patch test,95052,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,60.61,,,,,,,fee schedule,55.48,259.1,
Photo patch test,95052,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,63.72,,,,,,,fee schedule,55.48,259.1,
Photo patch test,95052,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,55.48,259.1,APC 378
Photo patch test,95052,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,55.48,259.1,APC
Photo patch test,95052,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,55.48,259.1,APC
Photo patch test,95052,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,55.48,259.1,APC
Photo patch test,95052,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,55.48,259.1,Radiology
Photo patch test,95052,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,55.48,259.1,APC
Photo patch test,95052,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,55.48,259.1,APC
Photosensitivity tests,95056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,260.29,,,,,,,fee schedule,131.71,584.37,
Photosensitivity tests,95056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,208.65,,,,,,,fee schedule,131.71,584.37,
Photosensitivity tests,95056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,227.93,,,,,,,fee schedule,131.71,584.37,
Photosensitivity tests,95056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,239.63,,,,,,,fee schedule,131.71,584.37,
Photosensitivity tests,95056,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,131.71,584.37,APC 378
Photosensitivity tests,95056,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,131.71,584.37,APC
Photosensitivity tests,95056,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,131.71,584.37,APC
Photosensitivity tests,95056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,131.71,584.37,APC
Photosensitivity tests,95056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,131.71,584.37,Radiology
Photosensitivity tests,95056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,131.71,584.37,APC
Photosensitivity tests,95056,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,131.71,584.37,APC
Eye allergy tests,95060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,260.29,,,,,,,fee schedule,131.71,584.37,
Eye allergy tests,95060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,208.65,,,,,,,fee schedule,131.71,584.37,
Eye allergy tests,95060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,227.93,,,,,,,fee schedule,131.71,584.37,
Eye allergy tests,95060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,239.63,,,,,,,fee schedule,131.71,584.37,
Eye allergy tests,95060,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,131.71,584.37,APC 378
Eye allergy tests,95060,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,131.71,584.37,APC
Eye allergy tests,95060,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,131.71,584.37,APC
Eye allergy tests,95060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,131.71,584.37,APC
Eye allergy tests,95060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,131.71,584.37,Radiology
Eye allergy tests,95060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,131.71,584.37,APC
Eye allergy tests,95060,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,131.71,584.37,APC
Nose allergy test,95065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,69.21,,,,,,,fee schedule,36.98,164.05,
Nose allergy test,95065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55.48,,,,,,,fee schedule,36.98,164.05,
Nose allergy test,95065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,60.61,,,,,,,fee schedule,36.98,164.05,
Nose allergy test,95065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,63.72,,,,,,,fee schedule,36.98,164.05,
Nose allergy test,95065,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.05,,,,,,,fee schedule,36.98,164.05,APC 378
Nose allergy test,95065,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.83,,,,,,,fee schedule,36.98,164.05,APC
Nose allergy test,95065,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.46,,,,,,,fee schedule,36.98,164.05,APC
Nose allergy test,95065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.98,,,,,,,fee schedule,36.98,164.05,APC
Nose allergy test,95065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.57,,,,,,,fee schedule,36.98,164.05,Radiology
Nose allergy test,95065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.77,,,,,,,fee schedule,36.98,164.05,APC
Nose allergy test,95065,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.71,,,,,,,fee schedule,36.98,164.05,APC
Bronchial allergy tests,95070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,687.58,,,,,,,fee schedule,369.41,1638.96,
Bronchial allergy tests,95070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,551.16,,,,,,,fee schedule,369.41,1638.96,
Bronchial allergy tests,95070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,602.09,,,,,,,fee schedule,369.41,1638.96,
Bronchial allergy tests,95070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,633.01,,,,,,,fee schedule,369.41,1638.96,
Bronchial allergy tests,95070,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1638.96,,,,,,,fee schedule,369.41,1638.96,APC 378
Bronchial allergy tests,95070,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,387.88,,,,,,,fee schedule,369.41,1638.96,APC
Bronchial allergy tests,95070,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,384.19,,,,,,,fee schedule,369.41,1638.96,APC
Bronchial allergy tests,95070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,369.41,,,,,,,fee schedule,369.41,1638.96,APC
Bronchial allergy tests,95070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,565.2,,,,,,,fee schedule,369.41,1638.96,Radiology
Bronchial allergy tests,95070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,517.18,,,,,,,fee schedule,369.41,1638.96,APC
Bronchial allergy tests,95070,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,646.47,,,,,,,fee schedule,369.41,1638.96,APC
Ingest challenge ini 120 min,95076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1143.83,,,,,,,fee schedule,369.41,1638.96,
Ingest challenge ini 120 min,95076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,916.88,,,,,,,fee schedule,369.41,1638.96,
Ingest challenge ini 120 min,95076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1001.61,,,,,,,fee schedule,369.41,1638.96,
Ingest challenge ini 120 min,95076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1053.05,,,,,,,fee schedule,369.41,1638.96,
Ingest challenge ini 120 min,95076,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1638.96,,,,,,,fee schedule,369.41,1638.96,APC 378
Ingest challenge ini 120 min,95076,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,387.88,,,,,,,fee schedule,369.41,1638.96,APC
Ingest challenge ini 120 min,95076,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,384.19,,,,,,,fee schedule,369.41,1638.96,APC
Ingest challenge ini 120 min,95076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,369.41,,,,,,,fee schedule,369.41,1638.96,APC
Ingest challenge ini 120 min,95076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,565.2,,,,,,,fee schedule,369.41,1638.96,Radiology
Ingest challenge ini 120 min,95076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,517.18,,,,,,,fee schedule,369.41,1638.96,APC
Ingest challenge ini 120 min,95076,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,646.47,,,,,,,fee schedule,369.41,1638.96,APC
Ingest challenge addl 60 min,95079,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,518.88,,,,,,,fee schedule,415.93,518.88,
Ingest challenge addl 60 min,95079,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,415.93,,,,,,,fee schedule,415.93,518.88,
Ingest challenge addl 60 min,95079,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,454.36,,,,,,,fee schedule,415.93,518.88,
Ingest challenge addl 60 min,95079,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,477.7,,,,,,,fee schedule,415.93,518.88,
Immunotherapy one injection,95115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,63.5,,,,,,,fee schedule,46.36,205.67,
Immunotherapy one injection,95115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,50.9,,,,,,,fee schedule,46.36,205.67,
Immunotherapy one injection,95115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55.61,,,,,,,fee schedule,46.36,205.67,
Immunotherapy one injection,95115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,58.46,,,,,,,fee schedule,46.36,205.67,
Immunotherapy one injection,95115,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,205.67,,,,,,,fee schedule,46.36,205.67,APC 378
Immunotherapy one injection,95115,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,48.67,,,,,,,fee schedule,46.36,205.67,APC
Immunotherapy one injection,95115,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,48.21,,,,,,,fee schedule,46.36,205.67,APC
Immunotherapy one injection,95115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,46.36,,,,,,,fee schedule,46.36,205.67,APC
Immunotherapy one injection,95115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,70.92,,,,,,,fee schedule,46.36,205.67,Radiology
Immunotherapy one injection,95115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,64.9,,,,,,,fee schedule,46.36,205.67,APC
Immunotherapy one injection,95115,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,81.12,,,,,,,fee schedule,46.36,205.67,APC
Immunotherapy injections,95117,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,98.47,,,,,,,fee schedule,46.36,205.67,
Immunotherapy injections,95117,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,78.93,,,,,,,fee schedule,46.36,205.67,
Immunotherapy injections,95117,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,86.23,,,,,,,fee schedule,46.36,205.67,
Immunotherapy injections,95117,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,90.65,,,,,,,fee schedule,46.36,205.67,
Immunotherapy injections,95117,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,205.67,,,,,,,fee schedule,46.36,205.67,APC 378
Immunotherapy injections,95117,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,48.67,,,,,,,fee schedule,46.36,205.67,APC
Immunotherapy injections,95117,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,48.21,,,,,,,fee schedule,46.36,205.67,APC
Immunotherapy injections,95117,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,46.36,,,,,,,fee schedule,46.36,205.67,APC
Immunotherapy injections,95117,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,70.92,,,,,,,fee schedule,46.36,205.67,Radiology
Immunotherapy injections,95117,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,64.9,,,,,,,fee schedule,46.36,205.67,APC
Immunotherapy injections,95117,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,81.12,,,,,,,fee schedule,46.36,205.67,APC
Antigen therapy services,95144,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,98.47,,,,,,,fee schedule,46.36,205.67,
Antigen therapy services,95144,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,78.93,,,,,,,fee schedule,46.36,205.67,
Antigen therapy services,95144,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,86.23,,,,,,,fee schedule,46.36,205.67,
Antigen therapy services,95144,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,90.65,,,,,,,fee schedule,46.36,205.67,
Antigen therapy services,95144,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,205.67,,,,,,,fee schedule,46.36,205.67,APC 378
Antigen therapy services,95144,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,48.67,,,,,,,fee schedule,46.36,205.67,APC
Antigen therapy services,95144,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,48.21,,,,,,,fee schedule,46.36,205.67,APC
Antigen therapy services,95144,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,46.36,,,,,,,fee schedule,46.36,205.67,APC
Antigen therapy services,95144,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,70.92,,,,,,,fee schedule,46.36,205.67,Radiology
Antigen therapy services,95144,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,64.9,,,,,,,fee schedule,46.36,205.67,APC
Antigen therapy services,95144,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,81.12,,,,,,,fee schedule,46.36,205.67,APC
Antigen therapy services,95145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,98.47,,,,,,,fee schedule,46.36,205.67,
Antigen therapy services,95145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,78.93,,,,,,,fee schedule,46.36,205.67,
Antigen therapy services,95145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,86.23,,,,,,,fee schedule,46.36,205.67,
Antigen therapy services,95145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,90.65,,,,,,,fee schedule,46.36,205.67,
Antigen therapy services,95145,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,205.67,,,,,,,fee schedule,46.36,205.67,APC 378
Antigen therapy services,95145,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,48.67,,,,,,,fee schedule,46.36,205.67,APC
Antigen therapy services,95145,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,48.21,,,,,,,fee schedule,46.36,205.67,APC
Antigen therapy services,95145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,46.36,,,,,,,fee schedule,46.36,205.67,APC
Antigen therapy services,95145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,70.92,,,,,,,fee schedule,46.36,205.67,Radiology
Antigen therapy services,95145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,64.9,,,,,,,fee schedule,46.36,205.67,APC
Antigen therapy services,95145,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,81.12,,,,,,,fee schedule,46.36,205.67,APC
Antigen therapy services,95146,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,98.47,,,,,,,fee schedule,46.36,205.67,
Antigen therapy services,95146,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,78.93,,,,,,,fee schedule,46.36,205.67,
Antigen therapy services,95146,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,86.23,,,,,,,fee schedule,46.36,205.67,
Antigen therapy services,95146,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,90.65,,,,,,,fee schedule,46.36,205.67,
Antigen therapy services,95146,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,205.67,,,,,,,fee schedule,46.36,205.67,APC 378
Antigen therapy services,95146,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,48.67,,,,,,,fee schedule,46.36,205.67,APC
Antigen therapy services,95146,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,48.21,,,,,,,fee schedule,46.36,205.67,APC
Antigen therapy services,95146,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,46.36,,,,,,,fee schedule,46.36,205.67,APC
Antigen therapy services,95146,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,70.92,,,,,,,fee schedule,46.36,205.67,Radiology
Antigen therapy services,95146,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,64.9,,,,,,,fee schedule,46.36,205.67,APC
Antigen therapy services,95146,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,81.12,,,,,,,fee schedule,46.36,205.67,APC
Antigen therapy services,95147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,98.47,,,,,,,fee schedule,71.28,316.24,
Antigen therapy services,95147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,78.93,,,,,,,fee schedule,71.28,316.24,
Antigen therapy services,95147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,86.23,,,,,,,fee schedule,71.28,316.24,
Antigen therapy services,95147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,90.65,,,,,,,fee schedule,71.28,316.24,
Antigen therapy services,95147,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,316.24,,,,,,,fee schedule,71.28,316.24,APC 378
Antigen therapy services,95147,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,74.84,,,,,,,fee schedule,71.28,316.24,APC
Antigen therapy services,95147,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,74.13,,,,,,,fee schedule,71.28,316.24,APC
Antigen therapy services,95147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,71.28,,,,,,,fee schedule,71.28,316.24,APC
Antigen therapy services,95147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,109.06,,,,,,,fee schedule,71.28,316.24,Radiology
Antigen therapy services,95147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,99.79,,,,,,,fee schedule,71.28,316.24,APC
Antigen therapy services,95147,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,124.74,,,,,,,fee schedule,71.28,316.24,APC
Antigen therapy services,95148,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,98.47,,,,,,,fee schedule,71.28,316.24,
Antigen therapy services,95148,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,78.93,,,,,,,fee schedule,71.28,316.24,
Antigen therapy services,95148,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,86.23,,,,,,,fee schedule,71.28,316.24,
Antigen therapy services,95148,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,90.65,,,,,,,fee schedule,71.28,316.24,
Antigen therapy services,95148,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,316.24,,,,,,,fee schedule,71.28,316.24,APC 378
Antigen therapy services,95148,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,74.84,,,,,,,fee schedule,71.28,316.24,APC
Antigen therapy services,95148,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,74.13,,,,,,,fee schedule,71.28,316.24,APC
Antigen therapy services,95148,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,71.28,,,,,,,fee schedule,71.28,316.24,APC
Antigen therapy services,95148,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,109.06,,,,,,,fee schedule,71.28,316.24,Radiology
Antigen therapy services,95148,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,99.79,,,,,,,fee schedule,71.28,316.24,APC
Antigen therapy services,95148,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,124.74,,,,,,,fee schedule,71.28,316.24,APC
Antigen therapy services,95149,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,98.47,,,,,,,fee schedule,71.28,316.24,
Antigen therapy services,95149,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,78.93,,,,,,,fee schedule,71.28,316.24,
Antigen therapy services,95149,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,86.23,,,,,,,fee schedule,71.28,316.24,
Antigen therapy services,95149,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,90.65,,,,,,,fee schedule,71.28,316.24,
Antigen therapy services,95149,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,316.24,,,,,,,fee schedule,71.28,316.24,APC 378
Antigen therapy services,95149,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,74.84,,,,,,,fee schedule,71.28,316.24,APC
Antigen therapy services,95149,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,74.13,,,,,,,fee schedule,71.28,316.24,APC
Antigen therapy services,95149,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,71.28,,,,,,,fee schedule,71.28,316.24,APC
Antigen therapy services,95149,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,109.06,,,,,,,fee schedule,71.28,316.24,Radiology
Antigen therapy services,95149,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,99.79,,,,,,,fee schedule,71.28,316.24,APC
Antigen therapy services,95149,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,124.74,,,,,,,fee schedule,71.28,316.24,APC
Antigen therapy services,95165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,98.47,,,,,,,fee schedule,46.36,205.67,
Antigen therapy services,95165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,78.93,,,,,,,fee schedule,46.36,205.67,
Antigen therapy services,95165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,86.23,,,,,,,fee schedule,46.36,205.67,
Antigen therapy services,95165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,90.65,,,,,,,fee schedule,46.36,205.67,
Antigen therapy services,95165,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,205.67,,,,,,,fee schedule,46.36,205.67,APC 378
Antigen therapy services,95165,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,48.67,,,,,,,fee schedule,46.36,205.67,APC
Antigen therapy services,95165,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,48.21,,,,,,,fee schedule,46.36,205.67,APC
Antigen therapy services,95165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,46.36,,,,,,,fee schedule,46.36,205.67,APC
Antigen therapy services,95165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,70.92,,,,,,,fee schedule,46.36,205.67,Radiology
Antigen therapy services,95165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,64.9,,,,,,,fee schedule,46.36,205.67,APC
Antigen therapy services,95165,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,81.12,,,,,,,fee schedule,46.36,205.67,APC
Antigen therapy services,95170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,98.47,,,,,,,fee schedule,46.36,205.67,
Antigen therapy services,95170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,78.93,,,,,,,fee schedule,46.36,205.67,
Antigen therapy services,95170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,86.23,,,,,,,fee schedule,46.36,205.67,
Antigen therapy services,95170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,90.65,,,,,,,fee schedule,46.36,205.67,
Antigen therapy services,95170,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,205.67,,,,,,,fee schedule,46.36,205.67,APC 378
Antigen therapy services,95170,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,48.67,,,,,,,fee schedule,46.36,205.67,APC
Antigen therapy services,95170,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,48.21,,,,,,,fee schedule,46.36,205.67,APC
Antigen therapy services,95170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,46.36,,,,,,,fee schedule,46.36,205.67,APC
Antigen therapy services,95170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,70.92,,,,,,,fee schedule,46.36,205.67,Radiology
Antigen therapy services,95170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,64.9,,,,,,,fee schedule,46.36,205.67,APC
Antigen therapy services,95170,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,81.12,,,,,,,fee schedule,46.36,205.67,APC
Rapid desensitization,95180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,260.29,,,,,,,fee schedule,208.65,1962.08,
Rapid desensitization,95180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,208.65,,,,,,,fee schedule,208.65,1962.08,
Rapid desensitization,95180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,227.93,,,,,,,fee schedule,208.65,1962.08,
Rapid desensitization,95180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,239.63,,,,,,,fee schedule,208.65,1962.08,
Rapid desensitization,95180,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1962.08,,,,,,,fee schedule,208.65,1962.08,APC 378
Rapid desensitization,95180,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,464.35,,,,,,,fee schedule,208.65,1962.08,APC
Rapid desensitization,95180,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,459.93,,,,,,,fee schedule,208.65,1962.08,APC
Rapid desensitization,95180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,442.24,,,,,,,fee schedule,208.65,1962.08,APC
Rapid desensitization,95180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,676.63,,,,,,,fee schedule,208.65,1962.08,Radiology
Rapid desensitization,95180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,619.14,,,,,,,fee schedule,208.65,1962.08,APC
Rapid desensitization,95180,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,773.92,,,,,,,fee schedule,208.65,1962.08,APC
Allergy immunology services,95199,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,69.21,,,,,,,fee schedule,28.63,127.04,
Allergy immunology services,95199,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55.48,,,,,,,fee schedule,28.63,127.04,
Allergy immunology services,95199,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,60.61,,,,,,,fee schedule,28.63,127.04,
Allergy immunology services,95199,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,63.72,,,,,,,fee schedule,28.63,127.04,
Allergy immunology services,95199,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,127.04,,,,,,,fee schedule,28.63,127.04,APC 378
Allergy immunology services,95199,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.07,,,,,,,fee schedule,28.63,127.04,APC
Allergy immunology services,95199,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,29.78,,,,,,,fee schedule,28.63,127.04,APC
Allergy immunology services,95199,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,28.63,,,,,,,fee schedule,28.63,127.04,APC
Allergy immunology services,95199,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43.81,,,,,,,fee schedule,28.63,127.04,Radiology
Allergy immunology services,95199,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40.09,,,,,,,fee schedule,28.63,127.04,APC
Allergy immunology services,95199,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,50.11,,,,,,,fee schedule,28.63,127.04,APC
Cont gluc mntr pt prov eqp,95249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,211.3,,,,,,,fee schedule,58.4,259.1,
Cont gluc mntr pt prov eqp,95249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,169.38,,,,,,,fee schedule,58.4,259.1,
Cont gluc mntr pt prov eqp,95249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,185.03,,,,,,,fee schedule,58.4,259.1,
Cont gluc mntr pt prov eqp,95249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,194.53,,,,,,,fee schedule,58.4,259.1,
Cont gluc mntr pt prov eqp,95249,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,58.4,259.1,APC 378
Cont gluc mntr pt prov eqp,95249,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,58.4,259.1,APC
Cont gluc mntr pt prov eqp,95249,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,58.4,259.1,APC
Cont gluc mntr pt prov eqp,95249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,58.4,259.1,APC
Cont gluc mntr pt prov eqp,95249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,58.4,259.1,Radiology
Cont gluc mntr pt prov eqp,95249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,58.4,259.1,APC
Cont gluc mntr pt prov eqp,95249,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,58.4,259.1,APC
Glucose monitoring cont,95250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,414.4,,,,,,,fee schedule,131.8,584.75,
Glucose monitoring cont,95250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,332.18,,,,,,,fee schedule,131.8,584.75,
Glucose monitoring cont,95250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,362.88,,,,,,,fee schedule,131.8,584.75,
Glucose monitoring cont,95250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,381.51,,,,,,,fee schedule,131.8,584.75,
Glucose monitoring cont,95250,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.75,,,,,,,fee schedule,131.8,584.75,APC 378
Glucose monitoring cont,95250,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.39,,,,,,,fee schedule,131.8,584.75,APC
Glucose monitoring cont,95250,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,137.07,,,,,,,fee schedule,131.8,584.75,APC
Glucose monitoring cont,95250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.8,,,,,,,fee schedule,131.8,584.75,APC
Glucose monitoring cont,95250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.66,,,,,,,fee schedule,131.8,584.75,Radiology
Glucose monitoring cont,95250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.52,,,,,,,fee schedule,131.8,584.75,APC
Glucose monitoring cont,95250,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.65,,,,,,,fee schedule,131.8,584.75,APC
Gluc monitor cont phys i&r,95251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,146.78,,,,,,,fee schedule,117.65,146.78,
Gluc monitor cont phys i&r,95251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,117.65,,,,,,,fee schedule,117.65,146.78,
Gluc monitor cont phys i&r,95251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,128.53,,,,,,,fee schedule,117.65,146.78,
Gluc monitor cont phys i&r,95251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,135.13,,,,,,,fee schedule,117.65,146.78,
Eeg cont rec w/vid eeg tech,95700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,956.72,,,,,,,fee schedule,213.76,956.72,
Eeg cont rec w/vid eeg tech,95700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,766.89,,,,,,,fee schedule,213.76,956.72,
Eeg cont rec w/vid eeg tech,95700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,837.76,,,,,,,fee schedule,213.76,956.72,
Eeg cont rec w/vid eeg tech,95700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,880.79,,,,,,,fee schedule,213.76,956.72,
Eeg cont rec w/vid eeg tech,95700,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,213.76,956.72,APC 378
Eeg cont rec w/vid eeg tech,95700,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,213.76,956.72,APC
Eeg cont rec w/vid eeg tech,95700,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,213.76,956.72,APC
Eeg cont rec w/vid eeg tech,95700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,213.76,956.72,APC
Eeg cont rec w/vid eeg tech,95700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,213.76,956.72,Radiology
Eeg cont rec w/vid eeg tech,95700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,213.76,956.72,APC
Eeg cont rec w/vid eeg tech,95700,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,213.76,956.72,APC
Eeg w/o vid 2-12 hr unmntr,95705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,956.72,,,,,,,fee schedule,213.76,956.72,
Eeg w/o vid 2-12 hr unmntr,95705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,766.89,,,,,,,fee schedule,213.76,956.72,
Eeg w/o vid 2-12 hr unmntr,95705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,837.76,,,,,,,fee schedule,213.76,956.72,
Eeg w/o vid 2-12 hr unmntr,95705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,880.79,,,,,,,fee schedule,213.76,956.72,
Eeg w/o vid 2-12 hr unmntr,95705,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,213.76,956.72,APC 378
Eeg w/o vid 2-12 hr unmntr,95705,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,213.76,956.72,APC
Eeg w/o vid 2-12 hr unmntr,95705,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,213.76,956.72,APC
Eeg w/o vid 2-12 hr unmntr,95705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,213.76,956.72,APC
Eeg w/o vid 2-12 hr unmntr,95705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,213.76,956.72,Radiology
Eeg w/o vid 2-12 hr unmntr,95705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,213.76,956.72,APC
Eeg w/o vid 2-12 hr unmntr,95705,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,213.76,956.72,APC
Eeg wo vid 2-12hr intmt mntr,95706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,956.72,,,,,,,fee schedule,213.76,956.72,
Eeg wo vid 2-12hr intmt mntr,95706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,766.89,,,,,,,fee schedule,213.76,956.72,
Eeg wo vid 2-12hr intmt mntr,95706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,837.76,,,,,,,fee schedule,213.76,956.72,
Eeg wo vid 2-12hr intmt mntr,95706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,880.79,,,,,,,fee schedule,213.76,956.72,
Eeg wo vid 2-12hr intmt mntr,95706,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,213.76,956.72,APC 378
Eeg wo vid 2-12hr intmt mntr,95706,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,213.76,956.72,APC
Eeg wo vid 2-12hr intmt mntr,95706,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,213.76,956.72,APC
Eeg wo vid 2-12hr intmt mntr,95706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,213.76,956.72,APC
Eeg wo vid 2-12hr intmt mntr,95706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,213.76,956.72,Radiology
Eeg wo vid 2-12hr intmt mntr,95706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,213.76,956.72,APC
Eeg wo vid 2-12hr intmt mntr,95706,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,213.76,956.72,APC
Eeg w/o vid 2-12hr cont mntr,95707,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,956.72,,,,,,,fee schedule,213.76,956.72,
Eeg w/o vid 2-12hr cont mntr,95707,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,766.89,,,,,,,fee schedule,213.76,956.72,
Eeg w/o vid 2-12hr cont mntr,95707,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,837.76,,,,,,,fee schedule,213.76,956.72,
Eeg w/o vid 2-12hr cont mntr,95707,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,880.79,,,,,,,fee schedule,213.76,956.72,
Eeg w/o vid 2-12hr cont mntr,95707,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,213.76,956.72,APC 378
Eeg w/o vid 2-12hr cont mntr,95707,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,213.76,956.72,APC
Eeg w/o vid 2-12hr cont mntr,95707,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,213.76,956.72,APC
Eeg w/o vid 2-12hr cont mntr,95707,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,213.76,956.72,APC
Eeg w/o vid 2-12hr cont mntr,95707,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,213.76,956.72,Radiology
Eeg w/o vid 2-12hr cont mntr,95707,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,213.76,956.72,APC
Eeg w/o vid 2-12hr cont mntr,95707,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,213.76,956.72,APC
Eeg wo vid ea 12-26hr unmntr,95708,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1835.61,,,,,,,fee schedule,369.41,1835.61,
Eeg wo vid ea 12-26hr unmntr,95708,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1471.4,,,,,,,fee schedule,369.41,1835.61,
Eeg wo vid ea 12-26hr unmntr,95708,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1607.37,,,,,,,fee schedule,369.41,1835.61,
Eeg wo vid ea 12-26hr unmntr,95708,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1689.92,,,,,,,fee schedule,369.41,1835.61,
Eeg wo vid ea 12-26hr unmntr,95708,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1638.96,,,,,,,fee schedule,369.41,1835.61,APC 378
Eeg wo vid ea 12-26hr unmntr,95708,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,387.88,,,,,,,fee schedule,369.41,1835.61,APC
Eeg wo vid ea 12-26hr unmntr,95708,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,384.19,,,,,,,fee schedule,369.41,1835.61,APC
Eeg wo vid ea 12-26hr unmntr,95708,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,369.41,,,,,,,fee schedule,369.41,1835.61,APC
Eeg wo vid ea 12-26hr unmntr,95708,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,565.2,,,,,,,fee schedule,369.41,1835.61,Radiology
Eeg wo vid ea 12-26hr unmntr,95708,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,517.18,,,,,,,fee schedule,369.41,1835.61,APC
Eeg wo vid ea 12-26hr unmntr,95708,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,646.47,,,,,,,fee schedule,369.41,1835.61,APC
Eeg w/o vid ea 12-26hr intmt,95709,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1835.61,,,,,,,fee schedule,369.41,1835.61,
Eeg w/o vid ea 12-26hr intmt,95709,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1471.4,,,,,,,fee schedule,369.41,1835.61,
Eeg w/o vid ea 12-26hr intmt,95709,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1607.37,,,,,,,fee schedule,369.41,1835.61,
Eeg w/o vid ea 12-26hr intmt,95709,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1689.92,,,,,,,fee schedule,369.41,1835.61,
Eeg w/o vid ea 12-26hr intmt,95709,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1638.96,,,,,,,fee schedule,369.41,1835.61,APC 378
Eeg w/o vid ea 12-26hr intmt,95709,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,387.88,,,,,,,fee schedule,369.41,1835.61,APC
Eeg w/o vid ea 12-26hr intmt,95709,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,384.19,,,,,,,fee schedule,369.41,1835.61,APC
Eeg w/o vid ea 12-26hr intmt,95709,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,369.41,,,,,,,fee schedule,369.41,1835.61,APC
Eeg w/o vid ea 12-26hr intmt,95709,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,565.2,,,,,,,fee schedule,369.41,1835.61,Radiology
Eeg w/o vid ea 12-26hr intmt,95709,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,517.18,,,,,,,fee schedule,369.41,1835.61,APC
Eeg w/o vid ea 12-26hr intmt,95709,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,646.47,,,,,,,fee schedule,369.41,1835.61,APC
Eeg w/o vid ea 12-26hr cont,95710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1835.61,,,,,,,fee schedule,369.41,1835.61,
Eeg w/o vid ea 12-26hr cont,95710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1471.4,,,,,,,fee schedule,369.41,1835.61,
Eeg w/o vid ea 12-26hr cont,95710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1607.37,,,,,,,fee schedule,369.41,1835.61,
Eeg w/o vid ea 12-26hr cont,95710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1689.92,,,,,,,fee schedule,369.41,1835.61,
Eeg w/o vid ea 12-26hr cont,95710,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1638.96,,,,,,,fee schedule,369.41,1835.61,APC 378
Eeg w/o vid ea 12-26hr cont,95710,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,387.88,,,,,,,fee schedule,369.41,1835.61,APC
Eeg w/o vid ea 12-26hr cont,95710,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,384.19,,,,,,,fee schedule,369.41,1835.61,APC
Eeg w/o vid ea 12-26hr cont,95710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,369.41,,,,,,,fee schedule,369.41,1835.61,APC
Eeg w/o vid ea 12-26hr cont,95710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,565.2,,,,,,,fee schedule,369.41,1835.61,Radiology
Eeg w/o vid ea 12-26hr cont,95710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,517.18,,,,,,,fee schedule,369.41,1835.61,APC
Eeg w/o vid ea 12-26hr cont,95710,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,646.47,,,,,,,fee schedule,369.41,1835.61,APC
Veeg 2-12 hr unmonitored,95711,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,956.72,,,,,,,fee schedule,213.76,956.72,
Veeg 2-12 hr unmonitored,95711,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,766.89,,,,,,,fee schedule,213.76,956.72,
Veeg 2-12 hr unmonitored,95711,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,837.76,,,,,,,fee schedule,213.76,956.72,
Veeg 2-12 hr unmonitored,95711,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,880.79,,,,,,,fee schedule,213.76,956.72,
Veeg 2-12 hr unmonitored,95711,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,213.76,956.72,APC 378
Veeg 2-12 hr unmonitored,95711,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,213.76,956.72,APC
Veeg 2-12 hr unmonitored,95711,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,213.76,956.72,APC
Veeg 2-12 hr unmonitored,95711,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,213.76,956.72,APC
Veeg 2-12 hr unmonitored,95711,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,213.76,956.72,Radiology
Veeg 2-12 hr unmonitored,95711,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,213.76,956.72,APC
Veeg 2-12 hr unmonitored,95711,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,213.76,956.72,APC
Veeg 2-12 hr intmt mntr,95712,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,956.72,,,,,,,fee schedule,369.41,1638.96,
Veeg 2-12 hr intmt mntr,95712,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,766.89,,,,,,,fee schedule,369.41,1638.96,
Veeg 2-12 hr intmt mntr,95712,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,837.76,,,,,,,fee schedule,369.41,1638.96,
Veeg 2-12 hr intmt mntr,95712,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,880.79,,,,,,,fee schedule,369.41,1638.96,
Veeg 2-12 hr intmt mntr,95712,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1638.96,,,,,,,fee schedule,369.41,1638.96,APC 378
Veeg 2-12 hr intmt mntr,95712,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,387.88,,,,,,,fee schedule,369.41,1638.96,APC
Veeg 2-12 hr intmt mntr,95712,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,384.19,,,,,,,fee schedule,369.41,1638.96,APC
Veeg 2-12 hr intmt mntr,95712,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,369.41,,,,,,,fee schedule,369.41,1638.96,APC
Veeg 2-12 hr intmt mntr,95712,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,565.2,,,,,,,fee schedule,369.41,1638.96,Radiology
Veeg 2-12 hr intmt mntr,95712,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,517.18,,,,,,,fee schedule,369.41,1638.96,APC
Veeg 2-12 hr intmt mntr,95712,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,646.47,,,,,,,fee schedule,369.41,1638.96,APC
Veeg 2-12 hr cont mntr,95713,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1835.61,,,,,,,fee schedule,369.41,1835.61,
Veeg 2-12 hr cont mntr,95713,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1471.4,,,,,,,fee schedule,369.41,1835.61,
Veeg 2-12 hr cont mntr,95713,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1607.37,,,,,,,fee schedule,369.41,1835.61,
Veeg 2-12 hr cont mntr,95713,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1689.92,,,,,,,fee schedule,369.41,1835.61,
Veeg 2-12 hr cont mntr,95713,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1638.96,,,,,,,fee schedule,369.41,1835.61,APC 378
Veeg 2-12 hr cont mntr,95713,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,387.88,,,,,,,fee schedule,369.41,1835.61,APC
Veeg 2-12 hr cont mntr,95713,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,384.19,,,,,,,fee schedule,369.41,1835.61,APC
Veeg 2-12 hr cont mntr,95713,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,369.41,,,,,,,fee schedule,369.41,1835.61,APC
Veeg 2-12 hr cont mntr,95713,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,565.2,,,,,,,fee schedule,369.41,1835.61,Radiology
Veeg 2-12 hr cont mntr,95713,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,517.18,,,,,,,fee schedule,369.41,1835.61,APC
Veeg 2-12 hr cont mntr,95713,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,646.47,,,,,,,fee schedule,369.41,1835.61,APC
Veeg ea 12-26 hr unmntr,95714,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1835.61,,,,,,,fee schedule,369.41,1835.61,
Veeg ea 12-26 hr unmntr,95714,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1471.4,,,,,,,fee schedule,369.41,1835.61,
Veeg ea 12-26 hr unmntr,95714,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1607.37,,,,,,,fee schedule,369.41,1835.61,
Veeg ea 12-26 hr unmntr,95714,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1689.92,,,,,,,fee schedule,369.41,1835.61,
Veeg ea 12-26 hr unmntr,95714,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1638.96,,,,,,,fee schedule,369.41,1835.61,APC 378
Veeg ea 12-26 hr unmntr,95714,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,387.88,,,,,,,fee schedule,369.41,1835.61,APC
Veeg ea 12-26 hr unmntr,95714,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,384.19,,,,,,,fee schedule,369.41,1835.61,APC
Veeg ea 12-26 hr unmntr,95714,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,369.41,,,,,,,fee schedule,369.41,1835.61,APC
Veeg ea 12-26 hr unmntr,95714,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,565.2,,,,,,,fee schedule,369.41,1835.61,Radiology
Veeg ea 12-26 hr unmntr,95714,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,517.18,,,,,,,fee schedule,369.41,1835.61,APC
Veeg ea 12-26 hr unmntr,95714,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,646.47,,,,,,,fee schedule,369.41,1835.61,APC
Veeg ea 12-26hr intmt mntr,95715,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1835.61,,,,,,,fee schedule,369.41,1835.61,
Veeg ea 12-26hr intmt mntr,95715,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1471.4,,,,,,,fee schedule,369.41,1835.61,
Veeg ea 12-26hr intmt mntr,95715,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1607.37,,,,,,,fee schedule,369.41,1835.61,
Veeg ea 12-26hr intmt mntr,95715,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1689.92,,,,,,,fee schedule,369.41,1835.61,
Veeg ea 12-26hr intmt mntr,95715,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1638.96,,,,,,,fee schedule,369.41,1835.61,APC 378
Veeg ea 12-26hr intmt mntr,95715,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,387.88,,,,,,,fee schedule,369.41,1835.61,APC
Veeg ea 12-26hr intmt mntr,95715,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,384.19,,,,,,,fee schedule,369.41,1835.61,APC
Veeg ea 12-26hr intmt mntr,95715,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,369.41,,,,,,,fee schedule,369.41,1835.61,APC
Veeg ea 12-26hr intmt mntr,95715,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,565.2,,,,,,,fee schedule,369.41,1835.61,Radiology
Veeg ea 12-26hr intmt mntr,95715,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,517.18,,,,,,,fee schedule,369.41,1835.61,APC
Veeg ea 12-26hr intmt mntr,95715,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,646.47,,,,,,,fee schedule,369.41,1835.61,APC
Veeg ea 12-26hr cont mntr,95716,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3435.83,,,,,,,fee schedule,850.12,3771.72,
Veeg ea 12-26hr cont mntr,95716,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2754.12,,,,,,,fee schedule,850.12,3771.72,
Veeg ea 12-26hr cont mntr,95716,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3008.62,,,,,,,fee schedule,850.12,3771.72,
Veeg ea 12-26hr cont mntr,95716,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3163.15,,,,,,,fee schedule,850.12,3771.72,
Veeg ea 12-26hr cont mntr,95716,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3771.72,,,,,,,fee schedule,850.12,3771.72,APC 378
Veeg ea 12-26hr cont mntr,95716,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,892.63,,,,,,,fee schedule,850.12,3771.72,APC
Veeg ea 12-26hr cont mntr,95716,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,884.13,,,,,,,fee schedule,850.12,3771.72,APC
Veeg ea 12-26hr cont mntr,95716,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,850.12,,,,,,,fee schedule,850.12,3771.72,APC
Veeg ea 12-26hr cont mntr,95716,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1300.69,,,,,,,fee schedule,850.12,3771.72,Radiology
Veeg ea 12-26hr cont mntr,95716,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1190.17,,,,,,,fee schedule,850.12,3771.72,APC
Veeg ea 12-26hr cont mntr,95716,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1487.72,,,,,,,fee schedule,850.12,3771.72,APC
Eeg phys/qhp 2-12 hr w/o vid,95717,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,386.47,,,,,,,fee schedule,309.79,386.47,
Eeg phys/qhp 2-12 hr w/o vid,95717,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,309.79,,,,,,,fee schedule,309.79,386.47,
Eeg phys/qhp 2-12 hr w/o vid,95717,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,338.41,,,,,,,fee schedule,309.79,386.47,
Eeg phys/qhp 2-12 hr w/o vid,95717,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,355.8,,,,,,,fee schedule,309.79,386.47,
Eeg phys/qhp 2-12 hr w/veeg,95718,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,507.24,,,,,,,fee schedule,406.6,507.24,
Eeg phys/qhp 2-12 hr w/veeg,95718,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,406.6,,,,,,,fee schedule,406.6,507.24,
Eeg phys/qhp 2-12 hr w/veeg,95718,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,444.17,,,,,,,fee schedule,406.6,507.24,
Eeg phys/qhp 2-12 hr w/veeg,95718,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,466.98,,,,,,,fee schedule,406.6,507.24,
Eeg phys/qhp ea incr w/o vid,95719,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,599.55,,,,,,,fee schedule,480.59,599.55,
Eeg phys/qhp ea incr w/o vid,95719,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,480.59,,,,,,,fee schedule,480.59,599.55,
Eeg phys/qhp ea incr w/o vid,95719,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,525,,,,,,,fee schedule,480.59,599.55,
Eeg phys/qhp ea incr w/o vid,95719,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,551.96,,,,,,,fee schedule,480.59,599.55,
Eeg phy/qhp ea incr w/veeg,95720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,785.41,,,,,,,fee schedule,629.57,785.41,
Eeg phy/qhp ea incr w/veeg,95720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,629.57,,,,,,,fee schedule,629.57,785.41,
Eeg phy/qhp ea incr w/veeg,95720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,687.75,,,,,,,fee schedule,629.57,785.41,
Eeg phy/qhp ea incr w/veeg,95720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,723.07,,,,,,,fee schedule,629.57,785.41,
Eeg phy/qhp>36<60 hr w/o vid,95721,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,787.9,,,,,,,fee schedule,631.57,787.9,
Eeg phy/qhp>36<60 hr w/o vid,95721,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,631.57,,,,,,,fee schedule,631.57,787.9,
Eeg phy/qhp>36<60 hr w/o vid,95721,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,689.94,,,,,,,fee schedule,631.57,787.9,
Eeg phy/qhp>36<60 hr w/o vid,95721,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,725.37,,,,,,,fee schedule,631.57,787.9,
Eeg phy/qhp>36<60 hr w/veeg,95722,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,958.72,,,,,,,fee schedule,768.5,958.72,
Eeg phy/qhp>36<60 hr w/veeg,95722,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,768.5,,,,,,,fee schedule,768.5,958.72,
Eeg phy/qhp>36<60 hr w/veeg,95722,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,839.52,,,,,,,fee schedule,768.5,958.72,
Eeg phy/qhp>36<60 hr w/veeg,95722,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,882.63,,,,,,,fee schedule,768.5,958.72,
Eeg phy/qhp>60<84 hr w/o vid,95723,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,976.19,,,,,,,fee schedule,782.5,976.19,
Eeg phy/qhp>60<84 hr w/o vid,95723,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,782.5,,,,,,,fee schedule,782.5,976.19,
Eeg phy/qhp>60<84 hr w/o vid,95723,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,854.81,,,,,,,fee schedule,782.5,976.19,
Eeg phy/qhp>60<84 hr w/o vid,95723,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,898.71,,,,,,,fee schedule,782.5,976.19,
Eeg phy/qhp>60<84 hr w/veeg,95724,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1222.19,,,,,,,fee schedule,979.69,1222.19,
Eeg phy/qhp>60<84 hr w/veeg,95724,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,979.69,,,,,,,fee schedule,979.69,1222.19,
Eeg phy/qhp>60<84 hr w/veeg,95724,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1070.22,,,,,,,fee schedule,979.69,1222.19,
Eeg phy/qhp>60<84 hr w/veeg,95724,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1125.19,,,,,,,fee schedule,979.69,1222.19,
Eeg phy/qhp>84 hr w/o vid,95725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1110.6,,,,,,,fee schedule,890.24,1110.6,
Eeg phy/qhp>84 hr w/o vid,95725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,890.24,,,,,,,fee schedule,890.24,1110.6,
Eeg phy/qhp>84 hr w/o vid,95725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,972.51,,,,,,,fee schedule,890.24,1110.6,
Eeg phy/qhp>84 hr w/o vid,95725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1022.46,,,,,,,fee schedule,890.24,1110.6,
Eeg phy/qhp>84 hr w/veeg,95726,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1544.51,,,,,,,fee schedule,1238.06,1544.51,
Eeg phy/qhp>84 hr w/veeg,95726,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1238.06,,,,,,,fee schedule,1238.06,1544.51,
Eeg phy/qhp>84 hr w/veeg,95726,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1352.47,,,,,,,fee schedule,1238.06,1544.51,
Eeg phy/qhp>84 hr w/veeg,95726,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1421.93,,,,,,,fee schedule,1238.06,1544.51,
Polysom <6 yrs 4/> paramtrs,95782,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4482.85,,,,,,,fee schedule,850.12,4482.85,
Polysom <6 yrs 4/> paramtrs,95782,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3593.4,,,,,,,fee schedule,850.12,4482.85,
Polysom <6 yrs 4/> paramtrs,95782,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3925.46,,,,,,,fee schedule,850.12,4482.85,
Polysom <6 yrs 4/> paramtrs,95782,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4127.07,,,,,,,fee schedule,850.12,4482.85,
Polysom <6 yrs 4/> paramtrs,95782,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3771.72,,,,,,,fee schedule,850.12,4482.85,APC 378
Polysom <6 yrs 4/> paramtrs,95782,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,892.63,,,,,,,fee schedule,850.12,4482.85,APC
Polysom <6 yrs 4/> paramtrs,95782,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,884.13,,,,,,,fee schedule,850.12,4482.85,APC
Polysom <6 yrs 4/> paramtrs,95782,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,850.12,,,,,,,fee schedule,850.12,4482.85,APC
Polysom <6 yrs 4/> paramtrs,95782,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1300.69,,,,,,,fee schedule,850.12,4482.85,Radiology
Polysom <6 yrs 4/> paramtrs,95782,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1190.17,,,,,,,fee schedule,850.12,4482.85,APC
Polysom <6 yrs 4/> paramtrs,95782,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1487.72,,,,,,,fee schedule,850.12,4482.85,APC
Polysom <6 yrs cpap/bilvl,95783,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4482.85,,,,,,,fee schedule,850.12,4482.85,
Polysom <6 yrs cpap/bilvl,95783,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3593.4,,,,,,,fee schedule,850.12,4482.85,
Polysom <6 yrs cpap/bilvl,95783,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3925.46,,,,,,,fee schedule,850.12,4482.85,
Polysom <6 yrs cpap/bilvl,95783,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4127.07,,,,,,,fee schedule,850.12,4482.85,
Polysom <6 yrs cpap/bilvl,95783,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3771.72,,,,,,,fee schedule,850.12,4482.85,APC 378
Polysom <6 yrs cpap/bilvl,95783,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,892.63,,,,,,,fee schedule,850.12,4482.85,APC
Polysom <6 yrs cpap/bilvl,95783,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,884.13,,,,,,,fee schedule,850.12,4482.85,APC
Polysom <6 yrs cpap/bilvl,95783,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,850.12,,,,,,,fee schedule,850.12,4482.85,APC
Polysom <6 yrs cpap/bilvl,95783,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1300.69,,,,,,,fee schedule,850.12,4482.85,Radiology
Polysom <6 yrs cpap/bilvl,95783,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1190.17,,,,,,,fee schedule,850.12,4482.85,APC
Polysom <6 yrs cpap/bilvl,95783,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1487.72,,,,,,,fee schedule,850.12,4482.85,APC
Slp stdy unattended,95800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,629.9,,,,,,,fee schedule,213.76,948.37,
Slp stdy unattended,95800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,504.92,,,,,,,fee schedule,213.76,948.37,
Slp stdy unattended,95800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,551.58,,,,,,,fee schedule,213.76,948.37,
Slp stdy unattended,95800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,579.91,,,,,,,fee schedule,213.76,948.37,
Slp stdy unattended,95800,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,213.76,948.37,APC 378
Slp stdy unattended,95800,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,213.76,948.37,APC
Slp stdy unattended,95800,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,213.76,948.37,APC
Slp stdy unattended,95800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,213.76,948.37,APC
Slp stdy unattended,95800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,213.76,948.37,Radiology
Slp stdy unattended,95800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,213.76,948.37,APC
Slp stdy unattended,95800,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,213.76,948.37,APC
Slp stdy unatnd w/anal,95801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,629.9,,,,,,,fee schedule,58.4,629.9,
Slp stdy unatnd w/anal,95801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,504.92,,,,,,,fee schedule,58.4,629.9,
Slp stdy unatnd w/anal,95801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,551.58,,,,,,,fee schedule,58.4,629.9,
Slp stdy unatnd w/anal,95801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,579.91,,,,,,,fee schedule,58.4,629.9,
Slp stdy unatnd w/anal,95801,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,58.4,629.9,APC 378
Slp stdy unatnd w/anal,95801,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,58.4,629.9,APC
Slp stdy unatnd w/anal,95801,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,58.4,629.9,APC
Slp stdy unatnd w/anal,95801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,58.4,629.9,APC
Slp stdy unatnd w/anal,95801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,58.4,629.9,Radiology
Slp stdy unatnd w/anal,95801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,58.4,629.9,APC
Slp stdy unatnd w/anal,95801,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,58.4,629.9,APC
Actigraphy testing,95803,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,301.76,,,,,,,fee schedule,58.4,301.76,
Actigraphy testing,95803,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,241.88,,,,,,,fee schedule,58.4,301.76,
Actigraphy testing,95803,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,264.24,,,,,,,fee schedule,58.4,301.76,
Actigraphy testing,95803,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,277.81,,,,,,,fee schedule,58.4,301.76,
Actigraphy testing,95803,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,58.4,301.76,APC 378
Actigraphy testing,95803,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,58.4,301.76,APC
Actigraphy testing,95803,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,58.4,301.76,APC
Actigraphy testing,95803,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,58.4,301.76,APC
Actigraphy testing,95803,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,58.4,301.76,Radiology
Actigraphy testing,95803,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,58.4,301.76,APC
Actigraphy testing,95803,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,58.4,301.76,APC
Multiple sleep latency test,95805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1121,,,,,,,fee schedule,850.12,3771.72,
Multiple sleep latency test,95805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,898.58,,,,,,,fee schedule,850.12,3771.72,
Multiple sleep latency test,95805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,981.61,,,,,,,fee schedule,850.12,3771.72,
Multiple sleep latency test,95805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1032.03,,,,,,,fee schedule,850.12,3771.72,
Multiple sleep latency test,95805,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3771.72,,,,,,,fee schedule,850.12,3771.72,APC 378
Multiple sleep latency test,95805,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,892.63,,,,,,,fee schedule,850.12,3771.72,APC
Multiple sleep latency test,95805,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,884.13,,,,,,,fee schedule,850.12,3771.72,APC
Multiple sleep latency test,95805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,850.12,,,,,,,fee schedule,850.12,3771.72,APC
Multiple sleep latency test,95805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1300.69,,,,,,,fee schedule,850.12,3771.72,Radiology
Multiple sleep latency test,95805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1190.17,,,,,,,fee schedule,850.12,3771.72,APC
Multiple sleep latency test,95805,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1487.72,,,,,,,fee schedule,850.12,3771.72,APC
Sleep study unatt&resp efft,95806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,440.67,,,,,,,fee schedule,213.76,948.37,
Sleep study unatt&resp efft,95806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.24,,,,,,,fee schedule,213.76,948.37,
Sleep study unatt&resp efft,95806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,385.88,,,,,,,fee schedule,213.76,948.37,
Sleep study unatt&resp efft,95806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,405.7,,,,,,,fee schedule,213.76,948.37,
Sleep study unatt&resp efft,95806,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,213.76,948.37,APC 378
Sleep study unatt&resp efft,95806,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,213.76,948.37,APC
Sleep study unatt&resp efft,95806,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,213.76,948.37,APC
Sleep study unatt&resp efft,95806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,213.76,948.37,APC
Sleep study unatt&resp efft,95806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,213.76,948.37,Radiology
Sleep study unatt&resp efft,95806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,213.76,948.37,APC
Sleep study unatt&resp efft,95806,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,213.76,948.37,APC
Sleep study attended,95807,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1402.3,,,,,,,fee schedule,369.41,1638.96,
Sleep study attended,95807,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1124.07,,,,,,,fee schedule,369.41,1638.96,
Sleep study attended,95807,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1227.94,,,,,,,fee schedule,369.41,1638.96,
Sleep study attended,95807,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1291.01,,,,,,,fee schedule,369.41,1638.96,
Sleep study attended,95807,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1638.96,,,,,,,fee schedule,369.41,1638.96,APC 378
Sleep study attended,95807,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,387.88,,,,,,,fee schedule,369.41,1638.96,APC
Sleep study attended,95807,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,384.19,,,,,,,fee schedule,369.41,1638.96,APC
Sleep study attended,95807,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,369.41,,,,,,,fee schedule,369.41,1638.96,APC
Sleep study attended,95807,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,565.2,,,,,,,fee schedule,369.41,1638.96,Radiology
Sleep study attended,95807,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,517.18,,,,,,,fee schedule,369.41,1638.96,APC
Sleep study attended,95807,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,646.47,,,,,,,fee schedule,369.41,1638.96,APC
Polysom any age 1-3> param,95808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1750.52,,,,,,,fee schedule,850.12,3771.72,
Polysom any age 1-3> param,95808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1403.19,,,,,,,fee schedule,850.12,3771.72,
Polysom any age 1-3> param,95808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1532.86,,,,,,,fee schedule,850.12,3771.72,
Polysom any age 1-3> param,95808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1611.59,,,,,,,fee schedule,850.12,3771.72,
Polysom any age 1-3> param,95808,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3771.72,,,,,,,fee schedule,850.12,3771.72,APC 378
Polysom any age 1-3> param,95808,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,892.63,,,,,,,fee schedule,850.12,3771.72,APC
Polysom any age 1-3> param,95808,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,884.13,,,,,,,fee schedule,850.12,3771.72,APC
Polysom any age 1-3> param,95808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,850.12,,,,,,,fee schedule,850.12,3771.72,APC
Polysom any age 1-3> param,95808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1300.69,,,,,,,fee schedule,850.12,3771.72,Radiology
Polysom any age 1-3> param,95808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1190.17,,,,,,,fee schedule,850.12,3771.72,APC
Polysom any age 1-3> param,95808,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1487.72,,,,,,,fee schedule,850.12,3771.72,APC
Polysom 6/> yrs 4/> param,95810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2024.76,,,,,,,fee schedule,850.12,3771.72,
Polysom 6/> yrs 4/> param,95810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1623.02,,,,,,,fee schedule,850.12,3771.72,
Polysom 6/> yrs 4/> param,95810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1773,,,,,,,fee schedule,850.12,3771.72,
Polysom 6/> yrs 4/> param,95810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1864.06,,,,,,,fee schedule,850.12,3771.72,
Polysom 6/> yrs 4/> param,95810,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3771.72,,,,,,,fee schedule,850.12,3771.72,APC 378
Polysom 6/> yrs 4/> param,95810,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,892.63,,,,,,,fee schedule,850.12,3771.72,APC
Polysom 6/> yrs 4/> param,95810,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,884.13,,,,,,,fee schedule,850.12,3771.72,APC
Polysom 6/> yrs 4/> param,95810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,850.12,,,,,,,fee schedule,850.12,3771.72,APC
Polysom 6/> yrs 4/> param,95810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1300.69,,,,,,,fee schedule,850.12,3771.72,Radiology
Polysom 6/> yrs 4/> param,95810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1190.17,,,,,,,fee schedule,850.12,3771.72,APC
Polysom 6/> yrs 4/> param,95810,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1487.72,,,,,,,fee schedule,850.12,3771.72,APC
Polysom 6/>yrs cpap 4/> parm,95811,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2244.64,,,,,,,fee schedule,850.12,3771.72,
Polysom 6/>yrs cpap 4/> parm,95811,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1799.27,,,,,,,fee schedule,850.12,3771.72,
Polysom 6/>yrs cpap 4/> parm,95811,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1965.54,,,,,,,fee schedule,850.12,3771.72,
Polysom 6/>yrs cpap 4/> parm,95811,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2066.49,,,,,,,fee schedule,850.12,3771.72,
Polysom 6/>yrs cpap 4/> parm,95811,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3771.72,,,,,,,fee schedule,850.12,3771.72,APC 378
Polysom 6/>yrs cpap 4/> parm,95811,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,892.63,,,,,,,fee schedule,850.12,3771.72,APC
Polysom 6/>yrs cpap 4/> parm,95811,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,884.13,,,,,,,fee schedule,850.12,3771.72,APC
Polysom 6/>yrs cpap 4/> parm,95811,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,850.12,,,,,,,fee schedule,850.12,3771.72,APC
Polysom 6/>yrs cpap 4/> parm,95811,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1300.69,,,,,,,fee schedule,850.12,3771.72,Radiology
Polysom 6/>yrs cpap 4/> parm,95811,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1190.17,,,,,,,fee schedule,850.12,3771.72,APC
Polysom 6/>yrs cpap 4/> parm,95811,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1487.72,,,,,,,fee schedule,850.12,3771.72,APC
Eeg 41-60 minutes,95812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,613.42,,,,,,,fee schedule,213.76,948.37,
Eeg 41-60 minutes,95812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,491.71,,,,,,,fee schedule,213.76,948.37,
Eeg 41-60 minutes,95812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,537.15,,,,,,,fee schedule,213.76,948.37,
Eeg 41-60 minutes,95812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,564.73,,,,,,,fee schedule,213.76,948.37,
Eeg 41-60 minutes,95812,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,213.76,948.37,APC 378
Eeg 41-60 minutes,95812,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,213.76,948.37,APC
Eeg 41-60 minutes,95812,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,213.76,948.37,APC
Eeg 41-60 minutes,95812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,213.76,948.37,APC
Eeg 41-60 minutes,95812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,213.76,948.37,Radiology
Eeg 41-60 minutes,95812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,213.76,948.37,APC
Eeg 41-60 minutes,95812,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,213.76,948.37,APC
Eeg over 1 hour,95813,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,685.01,,,,,,,fee schedule,213.76,948.37,
Eeg over 1 hour,95813,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,549.1,,,,,,,fee schedule,213.76,948.37,
Eeg over 1 hour,95813,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,599.84,,,,,,,fee schedule,213.76,948.37,
Eeg over 1 hour,95813,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,630.65,,,,,,,fee schedule,213.76,948.37,
Eeg over 1 hour,95813,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,213.76,948.37,APC 378
Eeg over 1 hour,95813,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,213.76,948.37,APC
Eeg over 1 hour,95813,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,213.76,948.37,APC
Eeg over 1 hour,95813,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,213.76,948.37,APC
Eeg over 1 hour,95813,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,213.76,948.37,Radiology
Eeg over 1 hour,95813,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,213.76,948.37,APC
Eeg over 1 hour,95813,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,213.76,948.37,APC
Eeg awake and drowsy,95816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,547.61,,,,,,,fee schedule,213.76,948.37,
Eeg awake and drowsy,95816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,438.96,,,,,,,fee schedule,213.76,948.37,
Eeg awake and drowsy,95816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,479.52,,,,,,,fee schedule,213.76,948.37,
Eeg awake and drowsy,95816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,504.15,,,,,,,fee schedule,213.76,948.37,
Eeg awake and drowsy,95816,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,213.76,948.37,APC 378
Eeg awake and drowsy,95816,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,213.76,948.37,APC
Eeg awake and drowsy,95816,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,213.76,948.37,APC
Eeg awake and drowsy,95816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,213.76,948.37,APC
Eeg awake and drowsy,95816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,213.76,948.37,Radiology
Eeg awake and drowsy,95816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,213.76,948.37,APC
Eeg awake and drowsy,95816,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,213.76,948.37,APC
Eeg awake and asleep,95819,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,600.98,,,,,,,fee schedule,213.76,948.37,
Eeg awake and asleep,95819,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,481.74,,,,,,,fee schedule,213.76,948.37,
Eeg awake and asleep,95819,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,526.26,,,,,,,fee schedule,213.76,948.37,
Eeg awake and asleep,95819,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,553.29,,,,,,,fee schedule,213.76,948.37,
Eeg awake and asleep,95819,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,213.76,948.37,APC 378
Eeg awake and asleep,95819,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,213.76,948.37,APC
Eeg awake and asleep,95819,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,213.76,948.37,APC
Eeg awake and asleep,95819,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,213.76,948.37,APC
Eeg awake and asleep,95819,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,213.76,948.37,Radiology
Eeg awake and asleep,95819,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,213.76,948.37,APC
Eeg awake and asleep,95819,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,213.76,948.37,APC
Eeg coma or sleep only,95822,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,599.39,,,,,,,fee schedule,213.76,948.37,
Eeg coma or sleep only,95822,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,480.47,,,,,,,fee schedule,213.76,948.37,
Eeg coma or sleep only,95822,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,524.87,,,,,,,fee schedule,213.76,948.37,
Eeg coma or sleep only,95822,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,551.82,,,,,,,fee schedule,213.76,948.37,
Eeg coma or sleep only,95822,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,213.76,948.37,APC 378
Eeg coma or sleep only,95822,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,213.76,948.37,APC
Eeg coma or sleep only,95822,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,213.76,948.37,APC
Eeg coma or sleep only,95822,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,213.76,948.37,APC
Eeg coma or sleep only,95822,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,213.76,948.37,Radiology
Eeg coma or sleep only,95822,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,213.76,948.37,APC
Eeg coma or sleep only,95822,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,213.76,948.37,APC
Eeg cerebral death only,95824,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,670.01,,,,,,,fee schedule,369.41,1638.96,
Eeg cerebral death only,95824,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,537.07,,,,,,,fee schedule,369.41,1638.96,
Eeg cerebral death only,95824,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,586.7,,,,,,,fee schedule,369.41,1638.96,
Eeg cerebral death only,95824,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,616.83,,,,,,,fee schedule,369.41,1638.96,
Eeg cerebral death only,95824,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1638.96,,,,,,,fee schedule,369.41,1638.96,APC 378
Eeg cerebral death only,95824,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,387.88,,,,,,,fee schedule,369.41,1638.96,APC
Eeg cerebral death only,95824,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,384.19,,,,,,,fee schedule,369.41,1638.96,APC
Eeg cerebral death only,95824,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,369.41,,,,,,,fee schedule,369.41,1638.96,APC
Eeg cerebral death only,95824,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,565.2,,,,,,,fee schedule,369.41,1638.96,Radiology
Eeg cerebral death only,95824,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,517.18,,,,,,,fee schedule,369.41,1638.96,APC
Eeg cerebral death only,95824,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,646.47,,,,,,,fee schedule,369.41,1638.96,APC
Insert electrodes for EEG,95830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,313.74,,,,,,,fee schedule,251.49,313.74,
Insert electrodes for EEG,95830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,251.49,,,,,,,fee schedule,251.49,313.74,
Insert electrodes for EEG,95830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,274.73,,,,,,,fee schedule,251.49,313.74,
Insert electrodes for EEG,95830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,288.84,,,,,,,fee schedule,251.49,313.74,
Ecog impltd brn npgt <=30 d,95836,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,140.46,,,,,,,fee schedule,36.95,163.92,
Ecog impltd brn npgt <=30 d,95836,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,112.59,,,,,,,fee schedule,36.95,163.92,
Ecog impltd brn npgt <=30 d,95836,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,123,,,,,,,fee schedule,36.95,163.92,
Ecog impltd brn npgt <=30 d,95836,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,129.32,,,,,,,fee schedule,36.95,163.92,
Ecog impltd brn npgt <=30 d,95836,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,163.92,,,,,,,fee schedule,36.95,163.92,APC 378
Ecog impltd brn npgt <=30 d,95836,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.79,,,,,,,fee schedule,36.95,163.92,APC
Ecog impltd brn npgt <=30 d,95836,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.43,,,,,,,fee schedule,36.95,163.92,APC
Ecog impltd brn npgt <=30 d,95836,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.95,,,,,,,fee schedule,36.95,163.92,APC
Ecog impltd brn npgt <=30 d,95836,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.53,,,,,,,fee schedule,36.95,163.92,Radiology
Ecog impltd brn npgt <=30 d,95836,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.73,,,,,,,fee schedule,36.95,163.92,APC
Ecog impltd brn npgt <=30 d,95836,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.66,,,,,,,fee schedule,36.95,163.92,APC
Range of motion measurements,95851,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,29.37,,,,,,,fee schedule,6.66,29.37,
Range of motion measurements,95851,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23.54,,,,,,,fee schedule,6.66,29.37,
Range of motion measurements,95851,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,25.72,,,,,,,fee schedule,6.66,29.37,
Range of motion measurements,95851,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27.04,,,,,,,fee schedule,6.66,29.37,
Range of motion measurements,95851,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.66,,,,,,,fee schedule,6.66,29.37,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Range of motion measurements,95851,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.99,,,,,,,fee schedule,6.66,29.37,APC
Range of motion measurements,95851,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6.93,,,,,,,fee schedule,6.66,29.37,APC
Range of motion measurements,95851,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10.19,,,,,,,fee schedule,6.66,29.37,Radiology
Range of motion measurements,95851,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.32,,,,,,,fee schedule,6.66,29.37,APC
Range of motion measurements,95851,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11.66,,,,,,,fee schedule,6.66,29.37,APC
Range of motion measurements,95852,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21.36,,,,,,,fee schedule,4.99,21.36,
Range of motion measurements,95852,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17.12,,,,,,,fee schedule,4.99,21.36,
Range of motion measurements,95852,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18.7,,,,,,,fee schedule,4.99,21.36,
Range of motion measurements,95852,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19.66,,,,,,,fee schedule,4.99,21.36,
Range of motion measurements,95852,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.99,,,,,,,fee schedule,4.99,21.36,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Range of motion measurements,95852,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.24,,,,,,,fee schedule,4.99,21.36,APC
Range of motion measurements,95852,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5.19,,,,,,,fee schedule,4.99,21.36,APC
Range of motion measurements,95852,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.63,,,,,,,fee schedule,4.99,21.36,Radiology
Range of motion measurements,95852,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.99,,,,,,,fee schedule,4.99,21.36,APC
Range of motion measurements,95852,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8.73,,,,,,,fee schedule,4.99,21.36,APC
Cholinesterase challenge,95857,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,288.26,,,,,,,fee schedule,213.76,948.37,
Cholinesterase challenge,95857,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,231.07,,,,,,,fee schedule,213.76,948.37,
Cholinesterase challenge,95857,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,252.42,,,,,,,fee schedule,213.76,948.37,
Cholinesterase challenge,95857,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,265.38,,,,,,,fee schedule,213.76,948.37,
Cholinesterase challenge,95857,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,213.76,948.37,APC 378
Cholinesterase challenge,95857,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,213.76,948.37,APC
Cholinesterase challenge,95857,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,213.76,948.37,APC
Cholinesterase challenge,95857,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,213.76,948.37,APC
Cholinesterase challenge,95857,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,213.76,948.37,Radiology
Cholinesterase challenge,95857,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,213.76,948.37,APC
Cholinesterase challenge,95857,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,213.76,948.37,APC
Muscle test one limb,95860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,106.1,,,,,,,fee schedule,85.05,584.37,
Muscle test one limb,95860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,85.05,,,,,,,fee schedule,85.05,584.37,
Muscle test one limb,95860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,92.91,,,,,,,fee schedule,85.05,584.37,
Muscle test one limb,95860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,97.68,,,,,,,fee schedule,85.05,584.37,
Muscle test one limb,95860,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,85.05,584.37,APC 378
Muscle test one limb,95860,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,85.05,584.37,APC
Muscle test one limb,95860,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,85.05,584.37,APC
Muscle test one limb,95860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,85.05,584.37,APC
Muscle test one limb,95860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,85.05,584.37,Radiology
Muscle test one limb,95860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,85.05,584.37,APC
Muscle test one limb,95860,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,85.05,584.37,APC
Muscle test 2 limbs,95861,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,131.51,,,,,,,fee schedule,105.41,584.37,
Muscle test 2 limbs,95861,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,105.41,,,,,,,fee schedule,105.41,584.37,
Muscle test 2 limbs,95861,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,115.15,,,,,,,fee schedule,105.41,584.37,
Muscle test 2 limbs,95861,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,121.07,,,,,,,fee schedule,105.41,584.37,
Muscle test 2 limbs,95861,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,105.41,584.37,APC 378
Muscle test 2 limbs,95861,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,105.41,584.37,APC
Muscle test 2 limbs,95861,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,105.41,584.37,APC
Muscle test 2 limbs,95861,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,105.41,584.37,APC
Muscle test 2 limbs,95861,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,105.41,584.37,Radiology
Muscle test 2 limbs,95861,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,105.41,584.37,APC
Muscle test 2 limbs,95861,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,105.41,584.37,APC
Muscle test 3 limbs,95863,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,154.56,,,,,,,fee schedule,123.9,565.15,
Muscle test 3 limbs,95863,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,123.9,,,,,,,fee schedule,123.9,565.15,
Muscle test 3 limbs,95863,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,135.35,,,,,,,fee schedule,123.9,565.15,
Muscle test 3 limbs,95863,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,142.3,,,,,,,fee schedule,123.9,565.15,
Muscle test 3 limbs,95863,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,565.15,,,,,,,fee schedule,123.9,565.15,APC 378
Muscle test 3 limbs,95863,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,133.75,,,,,,,fee schedule,123.9,565.15,APC
Muscle test 3 limbs,95863,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,132.48,,,,,,,fee schedule,123.9,565.15,APC
Muscle test 3 limbs,95863,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,127.38,,,,,,,fee schedule,123.9,565.15,APC
Muscle test 3 limbs,95863,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,194.89,,,,,,,fee schedule,123.9,565.15,Radiology
Muscle test 3 limbs,95863,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,178.33,,,,,,,fee schedule,123.9,565.15,APC
Muscle test 3 limbs,95863,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,222.92,,,,,,,fee schedule,123.9,565.15,APC
Muscle test 4 limbs,95864,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,204.8,,,,,,,fee schedule,127.38,565.15,
Muscle test 4 limbs,95864,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,164.17,,,,,,,fee schedule,127.38,565.15,
Muscle test 4 limbs,95864,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,179.34,,,,,,,fee schedule,127.38,565.15,
Muscle test 4 limbs,95864,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,188.55,,,,,,,fee schedule,127.38,565.15,
Muscle test 4 limbs,95864,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,565.15,,,,,,,fee schedule,127.38,565.15,APC 378
Muscle test 4 limbs,95864,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,133.75,,,,,,,fee schedule,127.38,565.15,APC
Muscle test 4 limbs,95864,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,132.48,,,,,,,fee schedule,127.38,565.15,APC
Muscle test 4 limbs,95864,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,127.38,,,,,,,fee schedule,127.38,565.15,APC
Muscle test 4 limbs,95864,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,194.89,,,,,,,fee schedule,127.38,565.15,Radiology
Muscle test 4 limbs,95864,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,178.33,,,,,,,fee schedule,127.38,565.15,APC
Muscle test 4 limbs,95864,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,222.92,,,,,,,fee schedule,127.38,565.15,APC
Muscle test larynx,95865,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,105.2,,,,,,,fee schedule,84.32,584.37,
Muscle test larynx,95865,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,84.32,,,,,,,fee schedule,84.32,584.37,
Muscle test larynx,95865,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,92.12,,,,,,,fee schedule,84.32,584.37,
Muscle test larynx,95865,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,96.85,,,,,,,fee schedule,84.32,584.37,
Muscle test larynx,95865,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,84.32,584.37,APC 378
Muscle test larynx,95865,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,84.32,584.37,APC
Muscle test larynx,95865,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,84.32,584.37,APC
Muscle test larynx,95865,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,84.32,584.37,APC
Muscle test larynx,95865,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,84.32,584.37,Radiology
Muscle test larynx,95865,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,84.32,584.37,APC
Muscle test larynx,95865,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,84.32,584.37,APC
Muscle test hemidiaphragm,95866,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,93.06,,,,,,,fee schedule,74.6,565.15,
Muscle test hemidiaphragm,95866,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,74.6,,,,,,,fee schedule,74.6,565.15,
Muscle test hemidiaphragm,95866,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,81.49,,,,,,,fee schedule,74.6,565.15,
Muscle test hemidiaphragm,95866,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,85.68,,,,,,,fee schedule,74.6,565.15,
Muscle test hemidiaphragm,95866,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,565.15,,,,,,,fee schedule,74.6,565.15,APC 378
Muscle test hemidiaphragm,95866,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,133.75,,,,,,,fee schedule,74.6,565.15,APC
Muscle test hemidiaphragm,95866,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,132.48,,,,,,,fee schedule,74.6,565.15,APC
Muscle test hemidiaphragm,95866,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,127.38,,,,,,,fee schedule,74.6,565.15,APC
Muscle test hemidiaphragm,95866,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,194.89,,,,,,,fee schedule,74.6,565.15,Radiology
Muscle test hemidiaphragm,95866,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,178.33,,,,,,,fee schedule,74.6,565.15,APC
Muscle test hemidiaphragm,95866,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,222.92,,,,,,,fee schedule,74.6,565.15,APC
Muscle test cran nerv unilat,95867,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,103.04,,,,,,,fee schedule,82.6,948.37,
Muscle test cran nerv unilat,95867,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,82.6,,,,,,,fee schedule,82.6,948.37,
Muscle test cran nerv unilat,95867,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,90.23,,,,,,,fee schedule,82.6,948.37,
Muscle test cran nerv unilat,95867,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,94.86,,,,,,,fee schedule,82.6,948.37,
Muscle test cran nerv unilat,95867,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,82.6,948.37,APC 378
Muscle test cran nerv unilat,95867,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,82.6,948.37,APC
Muscle test cran nerv unilat,95867,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,82.6,948.37,APC
Muscle test cran nerv unilat,95867,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,82.6,948.37,APC
Muscle test cran nerv unilat,95867,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,82.6,948.37,Radiology
Muscle test cran nerv unilat,95867,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,82.6,948.37,APC
Muscle test cran nerv unilat,95867,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,82.6,948.37,APC
Muscle test cran nerve bilat,95868,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,125.16,,,,,,,fee schedule,100.32,948.37,
Muscle test cran nerve bilat,95868,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,100.32,,,,,,,fee schedule,100.32,948.37,
Muscle test cran nerve bilat,95868,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,109.59,,,,,,,fee schedule,100.32,948.37,
Muscle test cran nerve bilat,95868,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,115.22,,,,,,,fee schedule,100.32,948.37,
Muscle test cran nerve bilat,95868,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,100.32,948.37,APC 378
Muscle test cran nerve bilat,95868,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,100.32,948.37,APC
Muscle test cran nerve bilat,95868,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,100.32,948.37,APC
Muscle test cran nerve bilat,95868,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,100.32,948.37,APC
Muscle test cran nerve bilat,95868,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,100.32,948.37,Radiology
Muscle test cran nerve bilat,95868,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,100.32,948.37,APC
Muscle test cran nerve bilat,95868,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,100.32,948.37,APC
Muscle test thor paraspinal,95869,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,87.92,,,,,,,fee schedule,70.48,948.37,
Muscle test thor paraspinal,95869,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,70.48,,,,,,,fee schedule,70.48,948.37,
Muscle test thor paraspinal,95869,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,76.99,,,,,,,fee schedule,70.48,948.37,
Muscle test thor paraspinal,95869,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,80.94,,,,,,,fee schedule,70.48,948.37,
Muscle test thor paraspinal,95869,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,70.48,948.37,APC 378
Muscle test thor paraspinal,95869,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,70.48,948.37,APC
Muscle test thor paraspinal,95869,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,70.48,948.37,APC
Muscle test thor paraspinal,95869,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,70.48,948.37,APC
Muscle test thor paraspinal,95869,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,70.48,948.37,Radiology
Muscle test thor paraspinal,95869,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,70.48,948.37,APC
Muscle test thor paraspinal,95869,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,70.48,948.37,APC
Muscle test nonparaspinal,95870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,84.29,,,,,,,fee schedule,67.57,584.37,
Muscle test nonparaspinal,95870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,67.57,,,,,,,fee schedule,67.57,584.37,
Muscle test nonparaspinal,95870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,73.81,,,,,,,fee schedule,67.57,584.37,
Muscle test nonparaspinal,95870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,77.6,,,,,,,fee schedule,67.57,584.37,
Muscle test nonparaspinal,95870,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,67.57,584.37,APC 378
Muscle test nonparaspinal,95870,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,67.57,584.37,APC
Muscle test nonparaspinal,95870,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,67.57,584.37,APC
Muscle test nonparaspinal,95870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,67.57,584.37,APC
Muscle test nonparaspinal,95870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,67.57,584.37,Radiology
Muscle test nonparaspinal,95870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,67.57,584.37,APC
Muscle test nonparaspinal,95870,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,67.57,584.37,APC
Muscle test one fiber,95872,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,91.17,,,,,,,fee schedule,73.08,948.37,
Muscle test one fiber,95872,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,73.08,,,,,,,fee schedule,73.08,948.37,
Muscle test one fiber,95872,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,79.84,,,,,,,fee schedule,73.08,948.37,
Muscle test one fiber,95872,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83.94,,,,,,,fee schedule,73.08,948.37,
Muscle test one fiber,95872,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,73.08,948.37,APC 378
Muscle test one fiber,95872,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,73.08,948.37,APC
Muscle test one fiber,95872,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,73.08,948.37,APC
Muscle test one fiber,95872,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,73.08,948.37,APC
Muscle test one fiber,95872,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,73.08,948.37,Radiology
Muscle test one fiber,95872,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,73.08,948.37,APC
Muscle test one fiber,95872,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,73.08,948.37,APC
Limb exercise test,95875,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,126.67,,,,,,,fee schedule,101.54,565.15,
Limb exercise test,95875,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,101.54,,,,,,,fee schedule,101.54,565.15,
Limb exercise test,95875,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,110.92,,,,,,,fee schedule,101.54,565.15,
Limb exercise test,95875,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,116.61,,,,,,,fee schedule,101.54,565.15,
Limb exercise test,95875,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,565.15,,,,,,,fee schedule,101.54,565.15,APC 378
Limb exercise test,95875,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,133.75,,,,,,,fee schedule,101.54,565.15,APC
Limb exercise test,95875,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,132.48,,,,,,,fee schedule,101.54,565.15,APC
Limb exercise test,95875,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,127.38,,,,,,,fee schedule,101.54,565.15,APC
Limb exercise test,95875,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,194.89,,,,,,,fee schedule,101.54,565.15,Radiology
Limb exercise test,95875,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,178.33,,,,,,,fee schedule,101.54,565.15,APC
Limb exercise test,95875,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,222.92,,,,,,,fee schedule,101.54,565.15,APC
Musc tst done w/nerv tst lim,95885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,148.55,,,,,,,fee schedule,119.08,148.55,
Musc tst done w/nerv tst lim,95885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,119.08,,,,,,,fee schedule,119.08,148.55,
Musc tst done w/nerv tst lim,95885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,130.08,,,,,,,fee schedule,119.08,148.55,
Musc tst done w/nerv tst lim,95885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,136.76,,,,,,,fee schedule,119.08,148.55,
Musc test done w/n test comp,95886,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,166.21,,,,,,,fee schedule,133.23,166.21,
Musc test done w/n test comp,95886,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,133.23,,,,,,,fee schedule,133.23,166.21,
Musc test done w/n test comp,95886,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,145.54,,,,,,,fee schedule,133.23,166.21,
Musc test done w/n test comp,95886,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,153.02,,,,,,,fee schedule,133.23,166.21,
Musc tst done w/n tst nonext,95887,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,162.69,,,,,,,fee schedule,130.41,162.69,
Musc tst done w/n tst nonext,95887,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,130.41,,,,,,,fee schedule,130.41,162.69,
Musc tst done w/n tst nonext,95887,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,142.46,,,,,,,fee schedule,130.41,162.69,
Musc tst done w/n tst nonext,95887,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,149.78,,,,,,,fee schedule,130.41,162.69,
Motor &/ sens nrve cndj test,95905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,162.01,,,,,,,fee schedule,129.87,1962.08,
Motor &/ sens nrve cndj test,95905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,129.87,,,,,,,fee schedule,129.87,1962.08,
Motor &/ sens nrve cndj test,95905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,141.87,,,,,,,fee schedule,129.87,1962.08,
Motor &/ sens nrve cndj test,95905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,149.15,,,,,,,fee schedule,129.87,1962.08,
Motor &/ sens nrve cndj test,95905,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1962.08,,,,,,,fee schedule,129.87,1962.08,APC 378
Motor &/ sens nrve cndj test,95905,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,464.35,,,,,,,fee schedule,129.87,1962.08,APC
Motor &/ sens nrve cndj test,95905,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,459.93,,,,,,,fee schedule,129.87,1962.08,APC
Motor &/ sens nrve cndj test,95905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,442.24,,,,,,,fee schedule,129.87,1962.08,APC
Motor &/ sens nrve cndj test,95905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,676.63,,,,,,,fee schedule,129.87,1962.08,Radiology
Motor &/ sens nrve cndj test,95905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,619.14,,,,,,,fee schedule,129.87,1962.08,APC
Motor &/ sens nrve cndj test,95905,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,773.92,,,,,,,fee schedule,129.87,1962.08,APC
Nvr cndj tst 1-2 studies,95907,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,162.96,,,,,,,fee schedule,130.62,948.37,
Nvr cndj tst 1-2 studies,95907,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,130.62,,,,,,,fee schedule,130.62,948.37,
Nvr cndj tst 1-2 studies,95907,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,142.69,,,,,,,fee schedule,130.62,948.37,
Nvr cndj tst 1-2 studies,95907,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,150.02,,,,,,,fee schedule,130.62,948.37,
Nvr cndj tst 1-2 studies,95907,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,130.62,948.37,APC 378
Nvr cndj tst 1-2 studies,95907,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,130.62,948.37,APC
Nvr cndj tst 1-2 studies,95907,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,130.62,948.37,APC
Nvr cndj tst 1-2 studies,95907,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,130.62,948.37,APC
Nvr cndj tst 1-2 studies,95907,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,130.62,948.37,Radiology
Nvr cndj tst 1-2 studies,95907,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,130.62,948.37,APC
Nvr cndj tst 1-2 studies,95907,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,130.62,948.37,APC
Nrv cndj tst 3-4 studies,95908,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,162.96,,,,,,,fee schedule,130.62,948.37,
Nrv cndj tst 3-4 studies,95908,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,130.62,,,,,,,fee schedule,130.62,948.37,
Nrv cndj tst 3-4 studies,95908,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,142.69,,,,,,,fee schedule,130.62,948.37,
Nrv cndj tst 3-4 studies,95908,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,150.02,,,,,,,fee schedule,130.62,948.37,
Nrv cndj tst 3-4 studies,95908,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,130.62,948.37,APC 378
Nrv cndj tst 3-4 studies,95908,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,130.62,948.37,APC
Nrv cndj tst 3-4 studies,95908,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,130.62,948.37,APC
Nrv cndj tst 3-4 studies,95908,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,130.62,948.37,APC
Nrv cndj tst 3-4 studies,95908,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,130.62,948.37,Radiology
Nrv cndj tst 3-4 studies,95908,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,130.62,948.37,APC
Nrv cndj tst 3-4 studies,95908,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,130.62,948.37,APC
Nrv cndj tst 5-6 studies,95909,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,162.96,,,,,,,fee schedule,130.62,948.37,
Nrv cndj tst 5-6 studies,95909,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,130.62,,,,,,,fee schedule,130.62,948.37,
Nrv cndj tst 5-6 studies,95909,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,142.69,,,,,,,fee schedule,130.62,948.37,
Nrv cndj tst 5-6 studies,95909,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,150.02,,,,,,,fee schedule,130.62,948.37,
Nrv cndj tst 5-6 studies,95909,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,130.62,948.37,APC 378
Nrv cndj tst 5-6 studies,95909,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,130.62,948.37,APC
Nrv cndj tst 5-6 studies,95909,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,130.62,948.37,APC
Nrv cndj tst 5-6 studies,95909,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,130.62,948.37,APC
Nrv cndj tst 5-6 studies,95909,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,130.62,948.37,Radiology
Nrv cndj tst 5-6 studies,95909,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,130.62,948.37,APC
Nrv cndj tst 5-6 studies,95909,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,130.62,948.37,APC
Nrv cndj test 7-8 studies,95910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,162.96,,,,,,,fee schedule,130.62,1638.96,
Nrv cndj test 7-8 studies,95910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,130.62,,,,,,,fee schedule,130.62,1638.96,
Nrv cndj test 7-8 studies,95910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,142.69,,,,,,,fee schedule,130.62,1638.96,
Nrv cndj test 7-8 studies,95910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,150.02,,,,,,,fee schedule,130.62,1638.96,
Nrv cndj test 7-8 studies,95910,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1638.96,,,,,,,fee schedule,130.62,1638.96,APC 378
Nrv cndj test 7-8 studies,95910,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,387.88,,,,,,,fee schedule,130.62,1638.96,APC
Nrv cndj test 7-8 studies,95910,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,384.19,,,,,,,fee schedule,130.62,1638.96,APC
Nrv cndj test 7-8 studies,95910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,369.41,,,,,,,fee schedule,130.62,1638.96,APC
Nrv cndj test 7-8 studies,95910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,565.2,,,,,,,fee schedule,130.62,1638.96,Radiology
Nrv cndj test 7-8 studies,95910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,517.18,,,,,,,fee schedule,130.62,1638.96,APC
Nrv cndj test 7-8 studies,95910,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,646.47,,,,,,,fee schedule,130.62,1638.96,APC
Nrv cndj test 9-10 studies,95911,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,301.76,,,,,,,fee schedule,241.88,1638.96,
Nrv cndj test 9-10 studies,95911,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,241.88,,,,,,,fee schedule,241.88,1638.96,
Nrv cndj test 9-10 studies,95911,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,264.24,,,,,,,fee schedule,241.88,1638.96,
Nrv cndj test 9-10 studies,95911,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,277.81,,,,,,,fee schedule,241.88,1638.96,
Nrv cndj test 9-10 studies,95911,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1638.96,,,,,,,fee schedule,241.88,1638.96,APC 378
Nrv cndj test 9-10 studies,95911,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,387.88,,,,,,,fee schedule,241.88,1638.96,APC
Nrv cndj test 9-10 studies,95911,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,384.19,,,,,,,fee schedule,241.88,1638.96,APC
Nrv cndj test 9-10 studies,95911,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,369.41,,,,,,,fee schedule,241.88,1638.96,APC
Nrv cndj test 9-10 studies,95911,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,565.2,,,,,,,fee schedule,241.88,1638.96,Radiology
Nrv cndj test 9-10 studies,95911,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,517.18,,,,,,,fee schedule,241.88,1638.96,APC
Nrv cndj test 9-10 studies,95911,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,646.47,,,,,,,fee schedule,241.88,1638.96,APC
Nrv cndj test 11-12 studies,95912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,301.76,,,,,,,fee schedule,241.88,1638.96,
Nrv cndj test 11-12 studies,95912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,241.88,,,,,,,fee schedule,241.88,1638.96,
Nrv cndj test 11-12 studies,95912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,264.24,,,,,,,fee schedule,241.88,1638.96,
Nrv cndj test 11-12 studies,95912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,277.81,,,,,,,fee schedule,241.88,1638.96,
Nrv cndj test 11-12 studies,95912,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1638.96,,,,,,,fee schedule,241.88,1638.96,APC 378
Nrv cndj test 11-12 studies,95912,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,387.88,,,,,,,fee schedule,241.88,1638.96,APC
Nrv cndj test 11-12 studies,95912,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,384.19,,,,,,,fee schedule,241.88,1638.96,APC
Nrv cndj test 11-12 studies,95912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,369.41,,,,,,,fee schedule,241.88,1638.96,APC
Nrv cndj test 11-12 studies,95912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,565.2,,,,,,,fee schedule,241.88,1638.96,Radiology
Nrv cndj test 11-12 studies,95912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,517.18,,,,,,,fee schedule,241.88,1638.96,APC
Nrv cndj test 11-12 studies,95912,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,646.47,,,,,,,fee schedule,241.88,1638.96,APC
Nrv cndj test 13/> studies,95913,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,301.76,,,,,,,fee schedule,241.88,1638.96,
Nrv cndj test 13/> studies,95913,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,241.88,,,,,,,fee schedule,241.88,1638.96,
Nrv cndj test 13/> studies,95913,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,264.24,,,,,,,fee schedule,241.88,1638.96,
Nrv cndj test 13/> studies,95913,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,277.81,,,,,,,fee schedule,241.88,1638.96,
Nrv cndj test 13/> studies,95913,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1638.96,,,,,,,fee schedule,241.88,1638.96,APC 378
Nrv cndj test 13/> studies,95913,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,387.88,,,,,,,fee schedule,241.88,1638.96,APC
Nrv cndj test 13/> studies,95913,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,384.19,,,,,,,fee schedule,241.88,1638.96,APC
Nrv cndj test 13/> studies,95913,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,369.41,,,,,,,fee schedule,241.88,1638.96,APC
Nrv cndj test 13/> studies,95913,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,565.2,,,,,,,fee schedule,241.88,1638.96,Radiology
Nrv cndj test 13/> studies,95913,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,517.18,,,,,,,fee schedule,241.88,1638.96,APC
Nrv cndj test 13/> studies,95913,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,646.47,,,,,,,fee schedule,241.88,1638.96,APC
Quan puplmtry phy/qhp uni/bi,95919,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,438.9,,,,,,,fee schedule,131.71,584.37,
Quan puplmtry phy/qhp uni/bi,95919,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,351.81,,,,,,,fee schedule,131.71,584.37,
Quan puplmtry phy/qhp uni/bi,95919,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,384.32,,,,,,,fee schedule,131.71,584.37,
Quan puplmtry phy/qhp uni/bi,95919,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,404.06,,,,,,,fee schedule,131.71,584.37,
Quan puplmtry phy/qhp uni/bi,95919,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,131.71,584.37,APC 378
Quan puplmtry phy/qhp uni/bi,95919,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,131.71,584.37,APC
Quan puplmtry phy/qhp uni/bi,95919,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,131.71,584.37,APC
Quan puplmtry phy/qhp uni/bi,95919,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,131.71,584.37,APC
Quan puplmtry phy/qhp uni/bi,95919,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,131.71,584.37,Radiology
Quan puplmtry phy/qhp uni/bi,95919,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,131.71,584.37,APC
Quan puplmtry phy/qhp uni/bi,95919,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,131.71,584.37,APC
Autonomic nrv parasym inervj,95921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,95.22,,,,,,,fee schedule,76.33,565.15,
Autonomic nrv parasym inervj,95921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,76.33,,,,,,,fee schedule,76.33,565.15,
Autonomic nrv parasym inervj,95921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,83.38,,,,,,,fee schedule,76.33,565.15,
Autonomic nrv parasym inervj,95921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,87.66,,,,,,,fee schedule,76.33,565.15,
Autonomic nrv parasym inervj,95921,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,565.15,,,,,,,fee schedule,76.33,565.15,APC 378
Autonomic nrv parasym inervj,95921,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,133.75,,,,,,,fee schedule,76.33,565.15,APC
Autonomic nrv parasym inervj,95921,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,132.48,,,,,,,fee schedule,76.33,565.15,APC
Autonomic nrv parasym inervj,95921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,127.38,,,,,,,fee schedule,76.33,565.15,APC
Autonomic nrv parasym inervj,95921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,194.89,,,,,,,fee schedule,76.33,565.15,Radiology
Autonomic nrv parasym inervj,95921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,178.33,,,,,,,fee schedule,76.33,565.15,APC
Autonomic nrv parasym inervj,95921,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,222.92,,,,,,,fee schedule,76.33,565.15,APC
Autonomic nrv adrenrg inervj,95922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,132.83,,,,,,,fee schedule,106.47,584.37,
Autonomic nrv adrenrg inervj,95922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,106.47,,,,,,,fee schedule,106.47,584.37,
Autonomic nrv adrenrg inervj,95922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,116.31,,,,,,,fee schedule,106.47,584.37,
Autonomic nrv adrenrg inervj,95922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,122.29,,,,,,,fee schedule,106.47,584.37,
Autonomic nrv adrenrg inervj,95922,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,106.47,584.37,APC 378
Autonomic nrv adrenrg inervj,95922,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,106.47,584.37,APC
Autonomic nrv adrenrg inervj,95922,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,106.47,584.37,APC
Autonomic nrv adrenrg inervj,95922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,106.47,584.37,APC
Autonomic nrv adrenrg inervj,95922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,106.47,584.37,Radiology
Autonomic nrv adrenrg inervj,95922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,106.47,584.37,APC
Autonomic nrv adrenrg inervj,95922,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,106.47,584.37,APC
Autonomic nrv syst funj test,95923,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,232.32,,,,,,,fee schedule,131.71,584.37,
Autonomic nrv syst funj test,95923,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,186.22,,,,,,,fee schedule,131.71,584.37,
Autonomic nrv syst funj test,95923,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,203.43,,,,,,,fee schedule,131.71,584.37,
Autonomic nrv syst funj test,95923,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,213.88,,,,,,,fee schedule,131.71,584.37,
Autonomic nrv syst funj test,95923,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,131.71,584.37,APC 378
Autonomic nrv syst funj test,95923,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,131.71,584.37,APC
Autonomic nrv syst funj test,95923,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,131.71,584.37,APC
Autonomic nrv syst funj test,95923,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,131.71,584.37,APC
Autonomic nrv syst funj test,95923,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,131.71,584.37,Radiology
Autonomic nrv syst funj test,95923,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,131.71,584.37,APC
Autonomic nrv syst funj test,95923,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,131.71,584.37,APC
Ans parasymp & symp w/tilt,95924,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,210.96,,,,,,,fee schedule,169.1,948.37,
Ans parasymp & symp w/tilt,95924,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,169.1,,,,,,,fee schedule,169.1,948.37,
Ans parasymp & symp w/tilt,95924,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,184.73,,,,,,,fee schedule,169.1,948.37,
Ans parasymp & symp w/tilt,95924,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,194.22,,,,,,,fee schedule,169.1,948.37,
Ans parasymp & symp w/tilt,95924,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,169.1,948.37,APC 378
Ans parasymp & symp w/tilt,95924,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,169.1,948.37,APC
Ans parasymp & symp w/tilt,95924,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,169.1,948.37,APC
Ans parasymp & symp w/tilt,95924,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,169.1,948.37,APC
Ans parasymp & symp w/tilt,95924,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,169.1,948.37,Radiology
Ans parasymp & symp w/tilt,95924,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,169.1,948.37,APC
Ans parasymp & symp w/tilt,95924,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,169.1,948.37,APC
Somatosensory testing,95925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,300.17,,,,,,,fee schedule,213.76,948.37,
Somatosensory testing,95925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,240.61,,,,,,,fee schedule,213.76,948.37,
Somatosensory testing,95925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,262.85,,,,,,,fee schedule,213.76,948.37,
Somatosensory testing,95925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,276.35,,,,,,,fee schedule,213.76,948.37,
Somatosensory testing,95925,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,213.76,948.37,APC 378
Somatosensory testing,95925,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,213.76,948.37,APC
Somatosensory testing,95925,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,213.76,948.37,APC
Somatosensory testing,95925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,213.76,948.37,APC
Somatosensory testing,95925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,213.76,948.37,Radiology
Somatosensory testing,95925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,213.76,948.37,APC
Somatosensory testing,95925,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,213.76,948.37,APC
Somatosensory testing,95926,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,294.12,,,,,,,fee schedule,213.76,948.37,
Somatosensory testing,95926,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,235.76,,,,,,,fee schedule,213.76,948.37,
Somatosensory testing,95926,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,257.55,,,,,,,fee schedule,213.76,948.37,
Somatosensory testing,95926,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,270.78,,,,,,,fee schedule,213.76,948.37,
Somatosensory testing,95926,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,213.76,948.37,APC 378
Somatosensory testing,95926,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,213.76,948.37,APC
Somatosensory testing,95926,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,213.76,948.37,APC
Somatosensory testing,95926,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,213.76,948.37,APC
Somatosensory testing,95926,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,213.76,948.37,Radiology
Somatosensory testing,95926,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,213.76,948.37,APC
Somatosensory testing,95926,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,213.76,948.37,APC
Somatosensory testing,95927,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,301.38,,,,,,,fee schedule,213.76,948.37,
Somatosensory testing,95927,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,241.58,,,,,,,fee schedule,213.76,948.37,
Somatosensory testing,95927,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,263.91,,,,,,,fee schedule,213.76,948.37,
Somatosensory testing,95927,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,277.46,,,,,,,fee schedule,213.76,948.37,
Somatosensory testing,95927,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,213.76,948.37,APC 378
Somatosensory testing,95927,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,213.76,948.37,APC
Somatosensory testing,95927,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,213.76,948.37,APC
Somatosensory testing,95927,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,213.76,948.37,APC
Somatosensory testing,95927,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,213.76,948.37,Radiology
Somatosensory testing,95927,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,213.76,948.37,APC
Somatosensory testing,95927,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,213.76,948.37,APC
C motor evoked uppr limbs,95928,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,374.56,,,,,,,fee schedule,300.24,3771.72,
C motor evoked uppr limbs,95928,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,300.24,,,,,,,fee schedule,300.24,3771.72,
C motor evoked uppr limbs,95928,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,327.99,,,,,,,fee schedule,300.24,3771.72,
C motor evoked uppr limbs,95928,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,344.83,,,,,,,fee schedule,300.24,3771.72,
C motor evoked uppr limbs,95928,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3771.72,,,,,,,fee schedule,300.24,3771.72,APC 378
C motor evoked uppr limbs,95928,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,892.63,,,,,,,fee schedule,300.24,3771.72,APC
C motor evoked uppr limbs,95928,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,884.13,,,,,,,fee schedule,300.24,3771.72,APC
C motor evoked uppr limbs,95928,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,850.12,,,,,,,fee schedule,300.24,3771.72,APC
C motor evoked uppr limbs,95928,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1300.69,,,,,,,fee schedule,300.24,3771.72,Radiology
C motor evoked uppr limbs,95928,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1190.17,,,,,,,fee schedule,300.24,3771.72,APC
C motor evoked uppr limbs,95928,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1487.72,,,,,,,fee schedule,300.24,3771.72,APC
C motor evoked lwr limbs,95929,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,407.33,,,,,,,fee schedule,326.51,1638.96,
C motor evoked lwr limbs,95929,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,326.51,,,,,,,fee schedule,326.51,1638.96,
C motor evoked lwr limbs,95929,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,356.69,,,,,,,fee schedule,326.51,1638.96,
C motor evoked lwr limbs,95929,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,375,,,,,,,fee schedule,326.51,1638.96,
C motor evoked lwr limbs,95929,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1638.96,,,,,,,fee schedule,326.51,1638.96,APC 378
C motor evoked lwr limbs,95929,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,387.88,,,,,,,fee schedule,326.51,1638.96,APC
C motor evoked lwr limbs,95929,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,384.19,,,,,,,fee schedule,326.51,1638.96,APC
C motor evoked lwr limbs,95929,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,369.41,,,,,,,fee schedule,326.51,1638.96,APC
C motor evoked lwr limbs,95929,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,565.2,,,,,,,fee schedule,326.51,1638.96,Radiology
C motor evoked lwr limbs,95929,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,517.18,,,,,,,fee schedule,326.51,1638.96,APC
C motor evoked lwr limbs,95929,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,646.47,,,,,,,fee schedule,326.51,1638.96,APC
Visual evoked potential test,95930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,285.43,,,,,,,fee schedule,213.76,948.37,
Visual evoked potential test,95930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,228.8,,,,,,,fee schedule,213.76,948.37,
Visual evoked potential test,95930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,249.94,,,,,,,fee schedule,213.76,948.37,
Visual evoked potential test,95930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,262.77,,,,,,,fee schedule,213.76,948.37,
Visual evoked potential test,95930,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,213.76,948.37,APC 378
Visual evoked potential test,95930,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,213.76,948.37,APC
Visual evoked potential test,95930,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,213.76,948.37,APC
Visual evoked potential test,95930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,213.76,948.37,APC
Visual evoked potential test,95930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,213.76,948.37,Radiology
Visual evoked potential test,95930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,213.76,948.37,APC
Visual evoked potential test,95930,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,213.76,948.37,APC
Blink reflex test,95933,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,114.53,,,,,,,fee schedule,58.4,259.1,
Blink reflex test,95933,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,91.81,,,,,,,fee schedule,58.4,259.1,
Blink reflex test,95933,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,100.29,,,,,,,fee schedule,58.4,259.1,
Blink reflex test,95933,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,105.44,,,,,,,fee schedule,58.4,259.1,
Blink reflex test,95933,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,58.4,259.1,APC 378
Blink reflex test,95933,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,58.4,259.1,APC
Blink reflex test,95933,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,58.4,259.1,APC
Blink reflex test,95933,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,58.4,259.1,APC
Blink reflex test,95933,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,58.4,259.1,Radiology
Blink reflex test,95933,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,58.4,259.1,APC
Blink reflex test,95933,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,58.4,259.1,APC
Neuromuscular junction test,95937,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,75.79,,,,,,,fee schedule,60.75,565.15,
Neuromuscular junction test,95937,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,60.75,,,,,,,fee schedule,60.75,565.15,
Neuromuscular junction test,95937,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66.37,,,,,,,fee schedule,60.75,565.15,
Neuromuscular junction test,95937,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,69.77,,,,,,,fee schedule,60.75,565.15,
Neuromuscular junction test,95937,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,565.15,,,,,,,fee schedule,60.75,565.15,APC 378
Neuromuscular junction test,95937,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,133.75,,,,,,,fee schedule,60.75,565.15,APC
Neuromuscular junction test,95937,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,132.48,,,,,,,fee schedule,60.75,565.15,APC
Neuromuscular junction test,95937,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,127.38,,,,,,,fee schedule,60.75,565.15,APC
Neuromuscular junction test,95937,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,194.89,,,,,,,fee schedule,60.75,565.15,Radiology
Neuromuscular junction test,95937,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,178.33,,,,,,,fee schedule,60.75,565.15,APC
Neuromuscular junction test,95937,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,222.92,,,,,,,fee schedule,60.75,565.15,APC
Somatosensory testing,95938,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1000.45,,,,,,,fee schedule,801.95,3771.72,
Somatosensory testing,95938,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,801.95,,,,,,,fee schedule,801.95,3771.72,
Somatosensory testing,95938,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,876.06,,,,,,,fee schedule,801.95,3771.72,
Somatosensory testing,95938,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,921.05,,,,,,,fee schedule,801.95,3771.72,
Somatosensory testing,95938,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3771.72,,,,,,,fee schedule,801.95,3771.72,APC 378
Somatosensory testing,95938,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,892.63,,,,,,,fee schedule,801.95,3771.72,APC
Somatosensory testing,95938,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,884.13,,,,,,,fee schedule,801.95,3771.72,APC
Somatosensory testing,95938,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,850.12,,,,,,,fee schedule,801.95,3771.72,APC
Somatosensory testing,95938,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1300.69,,,,,,,fee schedule,801.95,3771.72,Radiology
Somatosensory testing,95938,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1190.17,,,,,,,fee schedule,801.95,3771.72,APC
Somatosensory testing,95938,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1487.72,,,,,,,fee schedule,801.95,3771.72,APC
C motor evoked upr&lwr limbs,95939,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1358.68,,,,,,,fee schedule,850.12,3771.72,
C motor evoked upr&lwr limbs,95939,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1089.1,,,,,,,fee schedule,850.12,3771.72,
C motor evoked upr&lwr limbs,95939,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1189.75,,,,,,,fee schedule,850.12,3771.72,
C motor evoked upr&lwr limbs,95939,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1250.85,,,,,,,fee schedule,850.12,3771.72,
C motor evoked upr&lwr limbs,95939,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3771.72,,,,,,,fee schedule,850.12,3771.72,APC 378
C motor evoked upr&lwr limbs,95939,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,892.63,,,,,,,fee schedule,850.12,3771.72,APC
C motor evoked upr&lwr limbs,95939,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,884.13,,,,,,,fee schedule,850.12,3771.72,APC
C motor evoked upr&lwr limbs,95939,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,850.12,,,,,,,fee schedule,850.12,3771.72,APC
C motor evoked upr&lwr limbs,95939,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1300.69,,,,,,,fee schedule,850.12,3771.72,Radiology
C motor evoked upr&lwr limbs,95939,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1190.17,,,,,,,fee schedule,850.12,3771.72,APC
C motor evoked upr&lwr limbs,95939,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1487.72,,,,,,,fee schedule,850.12,3771.72,APC
Ionm in operatng room 15 min,95940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,117.52,,,,,,,fee schedule,94.2,117.52,
Ionm in operatng room 15 min,95940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,94.2,,,,,,,fee schedule,94.2,117.52,
Ionm in operatng room 15 min,95940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,102.91,,,,,,,fee schedule,94.2,117.52,
Ionm in operatng room 15 min,95940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,108.19,,,,,,,fee schedule,94.2,117.52,
EEG monitoring/giving drugs,95954,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,439.69,,,,,,,fee schedule,352.45,1638.96,
EEG monitoring/giving drugs,95954,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,352.45,,,,,,,fee schedule,352.45,1638.96,
EEG monitoring/giving drugs,95954,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,385.02,,,,,,,fee schedule,352.45,1638.96,
EEG monitoring/giving drugs,95954,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,404.79,,,,,,,fee schedule,352.45,1638.96,
EEG monitoring/giving drugs,95954,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1638.96,,,,,,,fee schedule,352.45,1638.96,APC 378
EEG monitoring/giving drugs,95954,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,387.88,,,,,,,fee schedule,352.45,1638.96,APC
EEG monitoring/giving drugs,95954,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,384.19,,,,,,,fee schedule,352.45,1638.96,APC
EEG monitoring/giving drugs,95954,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,369.41,,,,,,,fee schedule,352.45,1638.96,APC
EEG monitoring/giving drugs,95954,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,565.2,,,,,,,fee schedule,352.45,1638.96,Radiology
EEG monitoring/giving drugs,95954,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,517.18,,,,,,,fee schedule,352.45,1638.96,APC
EEG monitoring/giving drugs,95954,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,646.47,,,,,,,fee schedule,352.45,1638.96,APC
EEG monitoring/function test,95958,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,564.2,,,,,,,fee schedule,452.26,3771.72,
EEG monitoring/function test,95958,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,452.26,,,,,,,fee schedule,452.26,3771.72,
EEG monitoring/function test,95958,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,494.05,,,,,,,fee schedule,452.26,3771.72,
EEG monitoring/function test,95958,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,519.42,,,,,,,fee schedule,452.26,3771.72,
EEG monitoring/function test,95958,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3771.72,,,,,,,fee schedule,452.26,3771.72,APC 378
EEG monitoring/function test,95958,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,892.63,,,,,,,fee schedule,452.26,3771.72,APC
EEG monitoring/function test,95958,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,884.13,,,,,,,fee schedule,452.26,3771.72,APC
EEG monitoring/function test,95958,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,850.12,,,,,,,fee schedule,452.26,3771.72,APC
EEG monitoring/function test,95958,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1300.69,,,,,,,fee schedule,452.26,3771.72,Radiology
EEG monitoring/function test,95958,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1190.17,,,,,,,fee schedule,452.26,3771.72,APC
EEG monitoring/function test,95958,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1487.72,,,,,,,fee schedule,452.26,3771.72,APC
Electrode stimulation brain,95961,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,238.56,,,,,,,fee schedule,191.22,3771.72,
Electrode stimulation brain,95961,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,191.22,,,,,,,fee schedule,191.22,3771.72,
Electrode stimulation brain,95961,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,208.89,,,,,,,fee schedule,191.22,3771.72,
Electrode stimulation brain,95961,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,219.62,,,,,,,fee schedule,191.22,3771.72,
Electrode stimulation brain,95961,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3771.72,,,,,,,fee schedule,191.22,3771.72,APC 378
Electrode stimulation brain,95961,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,892.63,,,,,,,fee schedule,191.22,3771.72,APC
Electrode stimulation brain,95961,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,884.13,,,,,,,fee schedule,191.22,3771.72,APC
Electrode stimulation brain,95961,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,850.12,,,,,,,fee schedule,191.22,3771.72,APC
Electrode stimulation brain,95961,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1300.69,,,,,,,fee schedule,191.22,3771.72,Radiology
Electrode stimulation brain,95961,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1190.17,,,,,,,fee schedule,191.22,3771.72,APC
Electrode stimulation brain,95961,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1487.72,,,,,,,fee schedule,191.22,3771.72,APC
Electrode stim brain add-on,95962,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,160.91,,,,,,,fee schedule,128.99,160.91,
Electrode stim brain add-on,95962,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,128.99,,,,,,,fee schedule,128.99,160.91,
Electrode stim brain add-on,95962,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,140.91,,,,,,,fee schedule,128.99,160.91,
Electrode stim brain add-on,95962,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,148.14,,,,,,,fee schedule,128.99,160.91,
Meg spontaneous,95965,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15397.94,,,,,,,fee schedule,850.12,15397.94,
Meg spontaneous,95965,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12342.8,,,,,,,fee schedule,850.12,15397.94,
Meg spontaneous,95965,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13483.38,,,,,,,fee schedule,850.12,15397.94,
Meg spontaneous,95965,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14175.88,,,,,,,fee schedule,850.12,15397.94,
Meg spontaneous,95965,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3771.72,,,,,,,fee schedule,850.12,15397.94,APC 378
Meg spontaneous,95965,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,892.63,,,,,,,fee schedule,850.12,15397.94,APC
Meg spontaneous,95965,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,884.13,,,,,,,fee schedule,850.12,15397.94,APC
Meg spontaneous,95965,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,850.12,,,,,,,fee schedule,850.12,15397.94,APC
Meg spontaneous,95965,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1300.69,,,,,,,fee schedule,850.12,15397.94,Radiology
Meg spontaneous,95965,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1190.17,,,,,,,fee schedule,850.12,15397.94,APC
Meg spontaneous,95965,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1487.72,,,,,,,fee schedule,850.12,15397.94,APC
Meg evoked single,95966,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4140.73,,,,,,,fee schedule,850.12,4140.73,
Meg evoked single,95966,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3319.15,,,,,,,fee schedule,850.12,4140.73,
Meg evoked single,95966,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3625.87,,,,,,,fee schedule,850.12,4140.73,
Meg evoked single,95966,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3812.1,,,,,,,fee schedule,850.12,4140.73,
Meg evoked single,95966,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3771.72,,,,,,,fee schedule,850.12,4140.73,APC 378
Meg evoked single,95966,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,892.63,,,,,,,fee schedule,850.12,4140.73,APC
Meg evoked single,95966,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,884.13,,,,,,,fee schedule,850.12,4140.73,APC
Meg evoked single,95966,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,850.12,,,,,,,fee schedule,850.12,4140.73,APC
Meg evoked single,95966,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1300.69,,,,,,,fee schedule,850.12,4140.73,Radiology
Meg evoked single,95966,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1190.17,,,,,,,fee schedule,850.12,4140.73,APC
Meg evoked single,95966,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1487.72,,,,,,,fee schedule,850.12,4140.73,APC
Meg evoked each addl,95967,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4140.73,,,,,,,fee schedule,3319.15,4140.73,
Meg evoked each addl,95967,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3319.15,,,,,,,fee schedule,3319.15,4140.73,
Meg evoked each addl,95967,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3625.87,,,,,,,fee schedule,3319.15,4140.73,
Meg evoked each addl,95967,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3812.1,,,,,,,fee schedule,3319.15,4140.73,
Analyze neurostim no prog,95970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,288.26,,,,,,,fee schedule,131.71,584.37,
Analyze neurostim no prog,95970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,231.07,,,,,,,fee schedule,131.71,584.37,
Analyze neurostim no prog,95970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,252.42,,,,,,,fee schedule,131.71,584.37,
Analyze neurostim no prog,95970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,265.38,,,,,,,fee schedule,131.71,584.37,
Analyze neurostim no prog,95970,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,131.71,584.37,APC 378
Analyze neurostim no prog,95970,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,131.71,584.37,APC
Analyze neurostim no prog,95970,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,131.71,584.37,APC
Analyze neurostim no prog,95970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,131.71,584.37,APC
Analyze neurostim no prog,95970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,131.71,584.37,Radiology
Analyze neurostim no prog,95970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,131.71,584.37,APC
Analyze neurostim no prog,95970,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,131.71,584.37,APC
Analyze neurostim simple,95971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,458.59,,,,,,,fee schedule,94.12,458.59,
Analyze neurostim simple,95971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,367.6,,,,,,,fee schedule,94.12,458.59,
Analyze neurostim simple,95971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,401.57,,,,,,,fee schedule,94.12,458.59,
Analyze neurostim simple,95971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,422.19,,,,,,,fee schedule,94.12,458.59,
Analyze neurostim simple,95971,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,417.57,,,,,,,fee schedule,94.12,458.59,APC 378
Analyze neurostim simple,95971,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,98.82,,,,,,,fee schedule,94.12,458.59,APC
Analyze neurostim simple,95971,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,97.88,,,,,,,fee schedule,94.12,458.59,APC
Analyze neurostim simple,95971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,94.12,,,,,,,fee schedule,94.12,458.59,APC
Analyze neurostim simple,95971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144,,,,,,,fee schedule,94.12,458.59,Radiology
Analyze neurostim simple,95971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.76,,,,,,,fee schedule,94.12,458.59,APC
Analyze neurostim simple,95971,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,164.7,,,,,,,fee schedule,94.12,458.59,APC
Analyze neurostim complex,95972,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3401.78,,,,,,,fee schedule,94.12,3401.78,
Analyze neurostim complex,95972,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2726.82,,,,,,,fee schedule,94.12,3401.78,
Analyze neurostim complex,95972,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2978.81,,,,,,,fee schedule,94.12,3401.78,
Analyze neurostim complex,95972,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3131.8,,,,,,,fee schedule,94.12,3401.78,
Analyze neurostim complex,95972,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,417.57,,,,,,,fee schedule,94.12,3401.78,APC 378
Analyze neurostim complex,95972,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,98.82,,,,,,,fee schedule,94.12,3401.78,APC
Analyze neurostim complex,95972,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,97.88,,,,,,,fee schedule,94.12,3401.78,APC
Analyze neurostim complex,95972,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,94.12,,,,,,,fee schedule,94.12,3401.78,APC
Analyze neurostim complex,95972,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144,,,,,,,fee schedule,94.12,3401.78,Radiology
Analyze neurostim complex,95972,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.76,,,,,,,fee schedule,94.12,3401.78,APC
Analyze neurostim complex,95972,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,164.7,,,,,,,fee schedule,94.12,3401.78,APC
Alys smpl cn npgt prgrmg,95976,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,140.46,,,,,,,fee schedule,36.95,163.92,
Alys smpl cn npgt prgrmg,95976,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,112.59,,,,,,,fee schedule,36.95,163.92,
Alys smpl cn npgt prgrmg,95976,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,123,,,,,,,fee schedule,36.95,163.92,
Alys smpl cn npgt prgrmg,95976,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,129.32,,,,,,,fee schedule,36.95,163.92,
Alys smpl cn npgt prgrmg,95976,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,163.92,,,,,,,fee schedule,36.95,163.92,APC 378
Alys smpl cn npgt prgrmg,95976,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.79,,,,,,,fee schedule,36.95,163.92,APC
Alys smpl cn npgt prgrmg,95976,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.43,,,,,,,fee schedule,36.95,163.92,APC
Alys smpl cn npgt prgrmg,95976,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.95,,,,,,,fee schedule,36.95,163.92,APC
Alys smpl cn npgt prgrmg,95976,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.53,,,,,,,fee schedule,36.95,163.92,Radiology
Alys smpl cn npgt prgrmg,95976,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.73,,,,,,,fee schedule,36.95,163.92,APC
Alys smpl cn npgt prgrmg,95976,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.66,,,,,,,fee schedule,36.95,163.92,APC
Alys cplx cn npgt prgrmg,95977,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,444.3,,,,,,,fee schedule,94.12,444.3,
Alys cplx cn npgt prgrmg,95977,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,356.15,,,,,,,fee schedule,94.12,444.3,
Alys cplx cn npgt prgrmg,95977,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,389.06,,,,,,,fee schedule,94.12,444.3,
Alys cplx cn npgt prgrmg,95977,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,409.04,,,,,,,fee schedule,94.12,444.3,
Alys cplx cn npgt prgrmg,95977,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,417.57,,,,,,,fee schedule,94.12,444.3,APC 378
Alys cplx cn npgt prgrmg,95977,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,98.82,,,,,,,fee schedule,94.12,444.3,APC
Alys cplx cn npgt prgrmg,95977,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,97.88,,,,,,,fee schedule,94.12,444.3,APC
Alys cplx cn npgt prgrmg,95977,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,94.12,,,,,,,fee schedule,94.12,444.3,APC
Alys cplx cn npgt prgrmg,95977,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144,,,,,,,fee schedule,94.12,444.3,Radiology
Alys cplx cn npgt prgrmg,95977,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.76,,,,,,,fee schedule,94.12,444.3,APC
Alys cplx cn npgt prgrmg,95977,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,164.7,,,,,,,fee schedule,94.12,444.3,APC
Io anal gast n-stim subsq,95981,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,288.26,,,,,,,fee schedule,58.4,288.26,
Io anal gast n-stim subsq,95981,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,231.07,,,,,,,fee schedule,58.4,288.26,
Io anal gast n-stim subsq,95981,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,252.42,,,,,,,fee schedule,58.4,288.26,
Io anal gast n-stim subsq,95981,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,265.38,,,,,,,fee schedule,58.4,288.26,
Io anal gast n-stim subsq,95981,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,58.4,288.26,APC 378
Io anal gast n-stim subsq,95981,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,58.4,288.26,APC
Io anal gast n-stim subsq,95981,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,58.4,288.26,APC
Io anal gast n-stim subsq,95981,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,58.4,288.26,APC
Io anal gast n-stim subsq,95981,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,58.4,288.26,Radiology
Io anal gast n-stim subsq,95981,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,58.4,288.26,APC
Io anal gast n-stim subsq,95981,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,58.4,288.26,APC
Io ga n-stim subsq w/reprog,95982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,458.59,,,,,,,fee schedule,36.95,458.59,
Io ga n-stim subsq w/reprog,95982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,367.6,,,,,,,fee schedule,36.95,458.59,
Io ga n-stim subsq w/reprog,95982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,401.57,,,,,,,fee schedule,36.95,458.59,
Io ga n-stim subsq w/reprog,95982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,422.19,,,,,,,fee schedule,36.95,458.59,
Io ga n-stim subsq w/reprog,95982,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,163.92,,,,,,,fee schedule,36.95,458.59,APC 378
Io ga n-stim subsq w/reprog,95982,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.79,,,,,,,fee schedule,36.95,458.59,APC
Io ga n-stim subsq w/reprog,95982,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.43,,,,,,,fee schedule,36.95,458.59,APC
Io ga n-stim subsq w/reprog,95982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.95,,,,,,,fee schedule,36.95,458.59,APC
Io ga n-stim subsq w/reprog,95982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.53,,,,,,,fee schedule,36.95,458.59,Radiology
Io ga n-stim subsq w/reprog,95982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.73,,,,,,,fee schedule,36.95,458.59,APC
Io ga n-stim subsq w/reprog,95982,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.66,,,,,,,fee schedule,36.95,458.59,APC
Alys brn npgt prgrmg 15 min,95983,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,140.46,,,,,,,fee schedule,94.12,417.57,
Alys brn npgt prgrmg 15 min,95983,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,112.59,,,,,,,fee schedule,94.12,417.57,
Alys brn npgt prgrmg 15 min,95983,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,123,,,,,,,fee schedule,94.12,417.57,
Alys brn npgt prgrmg 15 min,95983,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,129.32,,,,,,,fee schedule,94.12,417.57,
Alys brn npgt prgrmg 15 min,95983,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,417.57,,,,,,,fee schedule,94.12,417.57,APC 378
Alys brn npgt prgrmg 15 min,95983,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,98.82,,,,,,,fee schedule,94.12,417.57,APC
Alys brn npgt prgrmg 15 min,95983,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,97.88,,,,,,,fee schedule,94.12,417.57,APC
Alys brn npgt prgrmg 15 min,95983,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,94.12,,,,,,,fee schedule,94.12,417.57,APC
Alys brn npgt prgrmg 15 min,95983,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144,,,,,,,fee schedule,94.12,417.57,Radiology
Alys brn npgt prgrmg 15 min,95983,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.76,,,,,,,fee schedule,94.12,417.57,APC
Alys brn npgt prgrmg 15 min,95983,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,164.7,,,,,,,fee schedule,94.12,417.57,APC
Alys brn npgt prgrmg addl 15,95984,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,169.95,,,,,,,fee schedule,136.23,169.95,
Alys brn npgt prgrmg addl 15,95984,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,136.23,,,,,,,fee schedule,136.23,169.95,
Alys brn npgt prgrmg addl 15,95984,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,148.82,,,,,,,fee schedule,136.23,169.95,
Alys brn npgt prgrmg addl 15,95984,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,156.46,,,,,,,fee schedule,136.23,169.95,
Spin/brain pump refil & main,95990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,587.6,,,,,,,fee schedule,326.99,1450.75,
Spin/brain pump refil & main,95990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,471.01,,,,,,,fee schedule,326.99,1450.75,
Spin/brain pump refil & main,95990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,514.54,,,,,,,fee schedule,326.99,1450.75,
Spin/brain pump refil & main,95990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,540.97,,,,,,,fee schedule,326.99,1450.75,
Spin/brain pump refil & main,95990,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1450.75,,,,,,,fee schedule,326.99,1450.75,APC 378
Spin/brain pump refil & main,95990,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,343.34,,,,,,,fee schedule,326.99,1450.75,APC
Spin/brain pump refil & main,95990,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,340.07,,,,,,,fee schedule,326.99,1450.75,APC
Spin/brain pump refil & main,95990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,326.99,,,,,,,fee schedule,326.99,1450.75,APC
Spin/brain pump refil & main,95990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,500.3,,,,,,,fee schedule,326.99,1450.75,Radiology
Spin/brain pump refil & main,95990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,457.79,,,,,,,fee schedule,326.99,1450.75,APC
Spin/brain pump refil & main,95990,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,572.24,,,,,,,fee schedule,326.99,1450.75,APC
Spin/brain pump refil & main,95991,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,254.65,,,,,,,fee schedule,204.12,1348.18,
Spin/brain pump refil & main,95991,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,204.12,,,,,,,fee schedule,204.12,1348.18,
Spin/brain pump refil & main,95991,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,222.98,,,,,,,fee schedule,204.12,1348.18,
Spin/brain pump refil & main,95991,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,234.44,,,,,,,fee schedule,204.12,1348.18,
Spin/brain pump refil & main,95991,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1348.18,,,,,,,fee schedule,204.12,1348.18,APC 378
Spin/brain pump refil & main,95991,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,319.07,,,,,,,fee schedule,204.12,1348.18,APC
Spin/brain pump refil & main,95991,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,316.03,,,,,,,fee schedule,204.12,1348.18,APC
Spin/brain pump refil & main,95991,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,303.87,,,,,,,fee schedule,204.12,1348.18,APC
Spin/brain pump refil & main,95991,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,464.92,,,,,,,fee schedule,204.12,1348.18,Radiology
Spin/brain pump refil & main,95991,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,425.42,,,,,,,fee schedule,204.12,1348.18,APC
Spin/brain pump refil & main,95991,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,531.78,,,,,,,fee schedule,204.12,1348.18,APC
Canalith repositioning proc,95992,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,107.9,,,,,,,fee schedule,29.47,107.9,
Canalith repositioning proc,95992,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,86.49,,,,,,,fee schedule,29.47,107.9,
Canalith repositioning proc,95992,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,94.48,,,,,,,fee schedule,29.47,107.9,
Canalith repositioning proc,95992,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,99.33,,,,,,,fee schedule,29.47,107.9,
Canalith repositioning proc,95992,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,29.47,,,,,,,fee schedule,29.47,107.9,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Canalith repositioning proc,95992,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.94,,,,,,,fee schedule,29.47,107.9,APC
Canalith repositioning proc,95992,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,30.65,,,,,,,fee schedule,29.47,107.9,APC
Canalith repositioning proc,95992,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,45.09,,,,,,,fee schedule,29.47,107.9,Radiology
Canalith repositioning proc,95992,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,41.26,,,,,,,fee schedule,29.47,107.9,APC
Canalith repositioning proc,95992,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,51.57,,,,,,,fee schedule,29.47,107.9,APC
Neurological procedure,95999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,144.85,,,,,,,fee schedule,116.11,565.15,
Neurological procedure,95999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,116.11,,,,,,,fee schedule,116.11,565.15,
Neurological procedure,95999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,126.84,,,,,,,fee schedule,116.11,565.15,
Neurological procedure,95999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,133.35,,,,,,,fee schedule,116.11,565.15,
Neurological procedure,95999,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,565.15,,,,,,,fee schedule,116.11,565.15,APC 378
Neurological procedure,95999,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,133.75,,,,,,,fee schedule,116.11,565.15,APC
Neurological procedure,95999,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,132.48,,,,,,,fee schedule,116.11,565.15,APC
Neurological procedure,95999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,127.38,,,,,,,fee schedule,116.11,565.15,APC
Neurological procedure,95999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,194.89,,,,,,,fee schedule,116.11,565.15,Radiology
Neurological procedure,95999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,178.33,,,,,,,fee schedule,116.11,565.15,APC
Neurological procedure,95999,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,222.92,,,,,,,fee schedule,116.11,565.15,APC
Motion analysis video/3d,96000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,670.01,,,,,,,fee schedule,369.41,1638.96,
Motion analysis video/3d,96000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,537.07,,,,,,,fee schedule,369.41,1638.96,
Motion analysis video/3d,96000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,586.7,,,,,,,fee schedule,369.41,1638.96,
Motion analysis video/3d,96000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,616.83,,,,,,,fee schedule,369.41,1638.96,
Motion analysis video/3d,96000,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1638.96,,,,,,,fee schedule,369.41,1638.96,APC 378
Motion analysis video/3d,96000,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,387.88,,,,,,,fee schedule,369.41,1638.96,APC
Motion analysis video/3d,96000,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,384.19,,,,,,,fee schedule,369.41,1638.96,APC
Motion analysis video/3d,96000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,369.41,,,,,,,fee schedule,369.41,1638.96,APC
Motion analysis video/3d,96000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,565.2,,,,,,,fee schedule,369.41,1638.96,Radiology
Motion analysis video/3d,96000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,517.18,,,,,,,fee schedule,369.41,1638.96,APC
Motion analysis video/3d,96000,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,646.47,,,,,,,fee schedule,369.41,1638.96,APC
Motion test w/ft press meas,96001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,670.01,,,,,,,fee schedule,537.07,3771.72,
Motion test w/ft press meas,96001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,537.07,,,,,,,fee schedule,537.07,3771.72,
Motion test w/ft press meas,96001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,586.7,,,,,,,fee schedule,537.07,3771.72,
Motion test w/ft press meas,96001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,616.83,,,,,,,fee schedule,537.07,3771.72,
Motion test w/ft press meas,96001,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3771.72,,,,,,,fee schedule,537.07,3771.72,APC 378
Motion test w/ft press meas,96001,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,892.63,,,,,,,fee schedule,537.07,3771.72,APC
Motion test w/ft press meas,96001,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,884.13,,,,,,,fee schedule,537.07,3771.72,APC
Motion test w/ft press meas,96001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,850.12,,,,,,,fee schedule,537.07,3771.72,APC
Motion test w/ft press meas,96001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1300.69,,,,,,,fee schedule,537.07,3771.72,Radiology
Motion test w/ft press meas,96001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1190.17,,,,,,,fee schedule,537.07,3771.72,APC
Motion test w/ft press meas,96001,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1487.72,,,,,,,fee schedule,537.07,3771.72,APC
Dynamic surface emg,96002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,288.26,,,,,,,fee schedule,213.76,948.37,
Dynamic surface emg,96002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,231.07,,,,,,,fee schedule,213.76,948.37,
Dynamic surface emg,96002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,252.42,,,,,,,fee schedule,213.76,948.37,
Dynamic surface emg,96002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,265.38,,,,,,,fee schedule,213.76,948.37,
Dynamic surface emg,96002,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,213.76,948.37,APC 378
Dynamic surface emg,96002,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,213.76,948.37,APC
Dynamic surface emg,96002,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,213.76,948.37,APC
Dynamic surface emg,96002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,213.76,948.37,APC
Dynamic surface emg,96002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,213.76,948.37,Radiology
Dynamic surface emg,96002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,213.76,948.37,APC
Dynamic surface emg,96002,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,213.76,948.37,APC
Dynamic fine wire emg,96003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,144.85,,,,,,,fee schedule,116.11,144.85,
Dynamic fine wire emg,96003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,116.11,,,,,,,fee schedule,116.11,144.85,
Dynamic fine wire emg,96003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,126.84,,,,,,,fee schedule,116.11,144.85,
Dynamic fine wire emg,96003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,133.35,,,,,,,fee schedule,116.11,144.85,
Phys review of motion tests,96004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,404.04,,,,,,,fee schedule,323.88,404.04,
Phys review of motion tests,96004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,323.88,,,,,,,fee schedule,323.88,404.04,
Phys review of motion tests,96004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.81,,,,,,,fee schedule,323.88,404.04,
Phys review of motion tests,96004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,371.98,,,,,,,fee schedule,323.88,404.04,
Genetic counseling 30 min,96040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,134.95,,,,,,,fee schedule,108.17,134.95,
Genetic counseling 30 min,96040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,108.17,,,,,,,fee schedule,108.17,134.95,
Genetic counseling 30 min,96040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,118.17,,,,,,,fee schedule,108.17,134.95,
Genetic counseling 30 min,96040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,124.24,,,,,,,fee schedule,108.17,134.95,
Assessment of aphasia,96105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,195.05,,,,,,,fee schedule,94.46,195.05,
Assessment of aphasia,96105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,156.35,,,,,,,fee schedule,94.46,195.05,
Assessment of aphasia,96105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,170.8,,,,,,,fee schedule,94.46,195.05,
Assessment of aphasia,96105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,179.57,,,,,,,fee schedule,94.46,195.05,
Assessment of aphasia,96105,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,94.46,,,,,,,fee schedule,94.46,195.05,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Assessment of aphasia,96105,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,99.18,,,,,,,fee schedule,94.46,195.05,APC
Assessment of aphasia,96105,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,98.24,,,,,,,fee schedule,94.46,195.05,APC
Assessment of aphasia,96105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.52,,,,,,,fee schedule,94.46,195.05,Radiology
Assessment of aphasia,96105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,132.24,,,,,,,fee schedule,94.46,195.05,APC
Assessment of aphasia,96105,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,165.3,,,,,,,fee schedule,94.46,195.05,APC
Developmental screen w/score,96110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,310.68,,,,,,,fee schedule,249.04,310.68,
Developmental screen w/score,96110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,249.04,,,,,,,fee schedule,249.04,310.68,
Developmental screen w/score,96110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,272.05,,,,,,,fee schedule,249.04,310.68,
Developmental screen w/score,96110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,286.02,,,,,,,fee schedule,249.04,310.68,
Devel tst phys/qhp 1st hr,96112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,513.89,,,,,,,fee schedule,127.38,565.15,
Devel tst phys/qhp 1st hr,96112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,411.93,,,,,,,fee schedule,127.38,565.15,
Devel tst phys/qhp 1st hr,96112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,449.99,,,,,,,fee schedule,127.38,565.15,
Devel tst phys/qhp 1st hr,96112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,473.11,,,,,,,fee schedule,127.38,565.15,
Devel tst phys/qhp 1st hr,96112,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,565.15,,,,,,,fee schedule,127.38,565.15,APC 378
Devel tst phys/qhp 1st hr,96112,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,133.75,,,,,,,fee schedule,127.38,565.15,APC
Devel tst phys/qhp 1st hr,96112,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,132.48,,,,,,,fee schedule,127.38,565.15,APC
Devel tst phys/qhp 1st hr,96112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,127.38,,,,,,,fee schedule,127.38,565.15,APC
Devel tst phys/qhp 1st hr,96112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,194.89,,,,,,,fee schedule,127.38,565.15,Radiology
Devel tst phys/qhp 1st hr,96112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,178.33,,,,,,,fee schedule,127.38,565.15,APC
Devel tst phys/qhp 1st hr,96112,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,222.92,,,,,,,fee schedule,127.38,565.15,APC
Devel tst phys/qhp ea addl,96113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,219.81,,,,,,,fee schedule,176.19,219.81,
Devel tst phys/qhp ea addl,96113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,176.19,,,,,,,fee schedule,176.19,219.81,
Devel tst phys/qhp ea addl,96113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,192.48,,,,,,,fee schedule,176.19,219.81,
Devel tst phys/qhp ea addl,96113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,202.36,,,,,,,fee schedule,176.19,219.81,
Neurobehavioral status exam,96116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,653.11,,,,,,,fee schedule,213.76,948.37,
Neurobehavioral status exam,96116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,523.52,,,,,,,fee schedule,213.76,948.37,
Neurobehavioral status exam,96116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,571.9,,,,,,,fee schedule,213.76,948.37,
Neurobehavioral status exam,96116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,601.27,,,,,,,fee schedule,213.76,948.37,
Neurobehavioral status exam,96116,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,213.76,948.37,APC 378
Neurobehavioral status exam,96116,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,213.76,948.37,APC
Neurobehavioral status exam,96116,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,213.76,948.37,APC
Neurobehavioral status exam,96116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,213.76,948.37,APC
Neurobehavioral status exam,96116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,213.76,948.37,Radiology
Neurobehavioral status exam,96116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,213.76,948.37,APC
Neurobehavioral status exam,96116,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,213.76,948.37,APC
Nubhvl xm phy/qhp ea addl hr,96121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,297.79,,,,,,,fee schedule,238.7,297.79,
Nubhvl xm phy/qhp ea addl hr,96121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,238.7,,,,,,,fee schedule,238.7,297.79,
Nubhvl xm phy/qhp ea addl hr,96121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,260.76,,,,,,,fee schedule,238.7,297.79,
Nubhvl xm phy/qhp ea addl hr,96121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,274.15,,,,,,,fee schedule,238.7,297.79,
Cognitive test by hc pro,96125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,377.09,,,,,,,fee schedule,99.43,377.09,
Cognitive test by hc pro,96125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,302.27,,,,,,,fee schedule,99.43,377.09,
Cognitive test by hc pro,96125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,330.21,,,,,,,fee schedule,99.43,377.09,
Cognitive test by hc pro,96125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,347.16,,,,,,,fee schedule,99.43,377.09,
Cognitive test by hc pro,96125,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,99.43,,,,,,,fee schedule,99.43,377.09,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Cognitive test by hc pro,96125,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,104.4,,,,,,,fee schedule,99.43,377.09,APC
Cognitive test by hc pro,96125,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,103.41,,,,,,,fee schedule,99.43,377.09,APC
Cognitive test by hc pro,96125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,152.13,,,,,,,fee schedule,99.43,377.09,Radiology
Cognitive test by hc pro,96125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,139.2,,,,,,,fee schedule,99.43,377.09,APC
Cognitive test by hc pro,96125,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,174,,,,,,,fee schedule,99.43,377.09,APC
Brief emotional/behav assmt,96127,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,110.53,,,,,,,fee schedule,36.98,164.05,
Brief emotional/behav assmt,96127,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,88.6,,,,,,,fee schedule,36.98,164.05,
Brief emotional/behav assmt,96127,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,96.78,,,,,,,fee schedule,36.98,164.05,
Brief emotional/behav assmt,96127,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,101.76,,,,,,,fee schedule,36.98,164.05,
Brief emotional/behav assmt,96127,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.05,,,,,,,fee schedule,36.98,164.05,APC 378
Brief emotional/behav assmt,96127,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.83,,,,,,,fee schedule,36.98,164.05,APC
Brief emotional/behav assmt,96127,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.46,,,,,,,fee schedule,36.98,164.05,APC
Brief emotional/behav assmt,96127,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.98,,,,,,,fee schedule,36.98,164.05,APC
Brief emotional/behav assmt,96127,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.57,,,,,,,fee schedule,36.98,164.05,Radiology
Brief emotional/behav assmt,96127,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.77,,,,,,,fee schedule,36.98,164.05,APC
Brief emotional/behav assmt,96127,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.71,,,,,,,fee schedule,36.98,164.05,APC
Psycl tst eval phys/qhp 1st,96130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,513.89,,,,,,,fee schedule,213.76,948.37,
Psycl tst eval phys/qhp 1st,96130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,411.93,,,,,,,fee schedule,213.76,948.37,
Psycl tst eval phys/qhp 1st,96130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,449.99,,,,,,,fee schedule,213.76,948.37,
Psycl tst eval phys/qhp 1st,96130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,473.11,,,,,,,fee schedule,213.76,948.37,
Psycl tst eval phys/qhp 1st,96130,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,213.76,948.37,APC 378
Psycl tst eval phys/qhp 1st,96130,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,213.76,948.37,APC
Psycl tst eval phys/qhp 1st,96130,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,213.76,948.37,APC
Psycl tst eval phys/qhp 1st,96130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,213.76,948.37,APC
Psycl tst eval phys/qhp 1st,96130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,213.76,948.37,Radiology
Psycl tst eval phys/qhp 1st,96130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,213.76,948.37,APC
Psycl tst eval phys/qhp 1st,96130,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,213.76,948.37,APC
Psycl tst eval phys/qhp ea,96131,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,319.15,,,,,,,fee schedule,255.82,319.15,
Psycl tst eval phys/qhp ea,96131,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,255.82,,,,,,,fee schedule,255.82,319.15,
Psycl tst eval phys/qhp ea,96131,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,279.46,,,,,,,fee schedule,255.82,319.15,
Psycl tst eval phys/qhp ea,96131,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,293.82,,,,,,,fee schedule,255.82,319.15,
Nrpsyc tst eval phys/qhp 1st,96132,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,513.89,,,,,,,fee schedule,369.41,1638.96,
Nrpsyc tst eval phys/qhp 1st,96132,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,411.93,,,,,,,fee schedule,369.41,1638.96,
Nrpsyc tst eval phys/qhp 1st,96132,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,449.99,,,,,,,fee schedule,369.41,1638.96,
Nrpsyc tst eval phys/qhp 1st,96132,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,473.11,,,,,,,fee schedule,369.41,1638.96,
Nrpsyc tst eval phys/qhp 1st,96132,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1638.96,,,,,,,fee schedule,369.41,1638.96,APC 378
Nrpsyc tst eval phys/qhp 1st,96132,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,387.88,,,,,,,fee schedule,369.41,1638.96,APC
Nrpsyc tst eval phys/qhp 1st,96132,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,384.19,,,,,,,fee schedule,369.41,1638.96,APC
Nrpsyc tst eval phys/qhp 1st,96132,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,369.41,,,,,,,fee schedule,369.41,1638.96,APC
Nrpsyc tst eval phys/qhp 1st,96132,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,565.2,,,,,,,fee schedule,369.41,1638.96,Radiology
Nrpsyc tst eval phys/qhp 1st,96132,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,517.18,,,,,,,fee schedule,369.41,1638.96,APC
Nrpsyc tst eval phys/qhp 1st,96132,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,646.47,,,,,,,fee schedule,369.41,1638.96,APC
Nrpsyc tst eval phys/qhp ea,96133,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,315.03,,,,,,,fee schedule,252.52,315.03,
Nrpsyc tst eval phys/qhp ea,96133,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,252.52,,,,,,,fee schedule,252.52,315.03,
Nrpsyc tst eval phys/qhp ea,96133,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,275.86,,,,,,,fee schedule,252.52,315.03,
Nrpsyc tst eval phys/qhp ea,96133,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,290.02,,,,,,,fee schedule,252.52,315.03,
Psycl/nrpsyc tst phy/qhp 1st,96136,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,64.9,,,,,,,fee schedule,52.03,584.37,
Psycl/nrpsyc tst phy/qhp 1st,96136,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52.03,,,,,,,fee schedule,52.03,584.37,
Psycl/nrpsyc tst phy/qhp 1st,96136,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56.83,,,,,,,fee schedule,52.03,584.37,
Psycl/nrpsyc tst phy/qhp 1st,96136,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59.75,,,,,,,fee schedule,52.03,584.37,
Psycl/nrpsyc tst phy/qhp 1st,96136,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,52.03,584.37,APC 378
Psycl/nrpsyc tst phy/qhp 1st,96136,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,52.03,584.37,APC
Psycl/nrpsyc tst phy/qhp 1st,96136,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,52.03,584.37,APC
Psycl/nrpsyc tst phy/qhp 1st,96136,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,52.03,584.37,APC
Psycl/nrpsyc tst phy/qhp 1st,96136,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,52.03,584.37,Radiology
Psycl/nrpsyc tst phy/qhp 1st,96136,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,52.03,584.37,APC
Psycl/nrpsyc tst phy/qhp 1st,96136,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,52.03,584.37,APC
Psycl/nrpsyc tst phy/qhp ea,96137,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,74.09,,,,,,,fee schedule,59.39,74.09,
Psycl/nrpsyc tst phy/qhp ea,96137,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,59.39,,,,,,,fee schedule,59.39,74.09,
Psycl/nrpsyc tst phy/qhp ea,96137,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,64.88,,,,,,,fee schedule,59.39,74.09,
Psycl/nrpsyc tst phy/qhp ea,96137,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,68.21,,,,,,,fee schedule,59.39,74.09,
Psycl/nrpsyc tech 1st,96138,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,64.9,,,,,,,fee schedule,52.03,1962.08,
Psycl/nrpsyc tech 1st,96138,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52.03,,,,,,,fee schedule,52.03,1962.08,
Psycl/nrpsyc tech 1st,96138,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56.83,,,,,,,fee schedule,52.03,1962.08,
Psycl/nrpsyc tech 1st,96138,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59.75,,,,,,,fee schedule,52.03,1962.08,
Psycl/nrpsyc tech 1st,96138,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1962.08,,,,,,,fee schedule,52.03,1962.08,APC 378
Psycl/nrpsyc tech 1st,96138,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,464.35,,,,,,,fee schedule,52.03,1962.08,APC
Psycl/nrpsyc tech 1st,96138,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,459.93,,,,,,,fee schedule,52.03,1962.08,APC
Psycl/nrpsyc tech 1st,96138,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,442.24,,,,,,,fee schedule,52.03,1962.08,APC
Psycl/nrpsyc tech 1st,96138,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,676.63,,,,,,,fee schedule,52.03,1962.08,Radiology
Psycl/nrpsyc tech 1st,96138,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,619.14,,,,,,,fee schedule,52.03,1962.08,APC
Psycl/nrpsyc tech 1st,96138,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,773.92,,,,,,,fee schedule,52.03,1962.08,APC
Psycl/nrpsyc tst tech ea,96139,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,132.94,,,,,,,fee schedule,106.57,132.94,
Psycl/nrpsyc tst tech ea,96139,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,106.57,,,,,,,fee schedule,106.57,132.94,
Psycl/nrpsyc tst tech ea,96139,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,116.41,,,,,,,fee schedule,106.57,132.94,
Psycl/nrpsyc tst tech ea,96139,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,122.39,,,,,,,fee schedule,106.57,132.94,
Psycl/nrpsyc tst auto result,96146,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,64.9,,,,,,,fee schedule,28.63,127.04,
Psycl/nrpsyc tst auto result,96146,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52.03,,,,,,,fee schedule,28.63,127.04,
Psycl/nrpsyc tst auto result,96146,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56.83,,,,,,,fee schedule,28.63,127.04,
Psycl/nrpsyc tst auto result,96146,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59.75,,,,,,,fee schedule,28.63,127.04,
Psycl/nrpsyc tst auto result,96146,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,127.04,,,,,,,fee schedule,28.63,127.04,APC 378
Psycl/nrpsyc tst auto result,96146,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.07,,,,,,,fee schedule,28.63,127.04,APC
Psycl/nrpsyc tst auto result,96146,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,29.78,,,,,,,fee schedule,28.63,127.04,APC
Psycl/nrpsyc tst auto result,96146,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,28.63,,,,,,,fee schedule,28.63,127.04,APC
Psycl/nrpsyc tst auto result,96146,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43.81,,,,,,,fee schedule,28.63,127.04,Radiology
Psycl/nrpsyc tst auto result,96146,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40.09,,,,,,,fee schedule,28.63,127.04,APC
Psycl/nrpsyc tst auto result,96146,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,50.11,,,,,,,fee schedule,28.63,127.04,APC
Hlth bhv assmt/reassessment,96156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,296.88,,,,,,,fee schedule,100.57,446.2,
Hlth bhv assmt/reassessment,96156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,237.98,,,,,,,fee schedule,100.57,446.2,
Hlth bhv assmt/reassessment,96156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,259.97,,,,,,,fee schedule,100.57,446.2,
Hlth bhv assmt/reassessment,96156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,273.32,,,,,,,fee schedule,100.57,446.2,
Hlth bhv assmt/reassessment,96156,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,446.2,,,,,,,fee schedule,100.57,446.2,APC 378
Hlth bhv assmt/reassessment,96156,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,105.6,,,,,,,fee schedule,100.57,446.2,APC
Hlth bhv assmt/reassessment,96156,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,104.59,,,,,,,fee schedule,100.57,446.2,APC
Hlth bhv assmt/reassessment,96156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,100.57,,,,,,,fee schedule,100.57,446.2,APC
Hlth bhv assmt/reassessment,96156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,153.87,,,,,,,fee schedule,100.57,446.2,Radiology
Hlth bhv assmt/reassessment,96156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,140.8,,,,,,,fee schedule,100.57,446.2,APC
Hlth bhv assmt/reassessment,96156,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,176,,,,,,,fee schedule,100.57,446.2,APC
Hlth bhv ivntj indiv 1st 30,96158,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,296.88,,,,,,,fee schedule,175.71,779.59,
Hlth bhv ivntj indiv 1st 30,96158,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,237.98,,,,,,,fee schedule,175.71,779.59,
Hlth bhv ivntj indiv 1st 30,96158,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,259.97,,,,,,,fee schedule,175.71,779.59,
Hlth bhv ivntj indiv 1st 30,96158,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,273.32,,,,,,,fee schedule,175.71,779.59,
Hlth bhv ivntj indiv 1st 30,96158,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,779.59,,,,,,,fee schedule,175.71,779.59,APC 378
Hlth bhv ivntj indiv 1st 30,96158,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,184.5,,,,,,,fee schedule,175.71,779.59,APC
Hlth bhv ivntj indiv 1st 30,96158,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,182.74,,,,,,,fee schedule,175.71,779.59,APC
Hlth bhv ivntj indiv 1st 30,96158,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,175.71,,,,,,,fee schedule,175.71,779.59,APC
Hlth bhv ivntj indiv 1st 30,96158,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,268.84,,,,,,,fee schedule,175.71,779.59,Radiology
Hlth bhv ivntj indiv 1st 30,96158,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,246,,,,,,,fee schedule,175.71,779.59,APC
Hlth bhv ivntj indiv 1st 30,96158,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,307.5,,,,,,,fee schedule,175.71,779.59,APC
Hlth bhv ivntj indiv ea addl,96159,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,79.49,,,,,,,fee schedule,63.72,79.49,
Hlth bhv ivntj indiv ea addl,96159,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,63.72,,,,,,,fee schedule,63.72,79.49,
Hlth bhv ivntj indiv ea addl,96159,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,69.61,,,,,,,fee schedule,63.72,79.49,
Hlth bhv ivntj indiv ea addl,96159,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,73.18,,,,,,,fee schedule,63.72,79.49,
Pt-focused hlth risk assmt,96160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,95.37,,,,,,,fee schedule,37.09,164.57,
Pt-focused hlth risk assmt,96160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,76.45,,,,,,,fee schedule,37.09,164.57,
Pt-focused hlth risk assmt,96160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,83.51,,,,,,,fee schedule,37.09,164.57,
Pt-focused hlth risk assmt,96160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,87.8,,,,,,,fee schedule,37.09,164.57,
Pt-focused hlth risk assmt,96160,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.57,,,,,,,fee schedule,37.09,164.57,APC 378
Pt-focused hlth risk assmt,96160,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.95,,,,,,,fee schedule,37.09,164.57,APC
Pt-focused hlth risk assmt,96160,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.58,,,,,,,fee schedule,37.09,164.57,APC
Pt-focused hlth risk assmt,96160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,37.09,,,,,,,fee schedule,37.09,164.57,APC
Pt-focused hlth risk assmt,96160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.75,,,,,,,fee schedule,37.09,164.57,Radiology
Pt-focused hlth risk assmt,96160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.93,,,,,,,fee schedule,37.09,164.57,APC
Pt-focused hlth risk assmt,96160,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.91,,,,,,,fee schedule,37.09,164.57,APC
Caregiver health risk assmt,96161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,95.37,,,,,,,fee schedule,37.09,164.57,
Caregiver health risk assmt,96161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,76.45,,,,,,,fee schedule,37.09,164.57,
Caregiver health risk assmt,96161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,83.51,,,,,,,fee schedule,37.09,164.57,
Caregiver health risk assmt,96161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,87.8,,,,,,,fee schedule,37.09,164.57,
Caregiver health risk assmt,96161,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.57,,,,,,,fee schedule,37.09,164.57,APC 378
Caregiver health risk assmt,96161,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.95,,,,,,,fee schedule,37.09,164.57,APC
Caregiver health risk assmt,96161,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.58,,,,,,,fee schedule,37.09,164.57,APC
Caregiver health risk assmt,96161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,37.09,,,,,,,fee schedule,37.09,164.57,APC
Caregiver health risk assmt,96161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.75,,,,,,,fee schedule,37.09,164.57,Radiology
Caregiver health risk assmt,96161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.93,,,,,,,fee schedule,37.09,164.57,APC
Caregiver health risk assmt,96161,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.91,,,,,,,fee schedule,37.09,164.57,APC
Hlth bhv ivntj grp 1st 30,96164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,103.27,,,,,,,fee schedule,37.09,164.57,
Hlth bhv ivntj grp 1st 30,96164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,82.78,,,,,,,fee schedule,37.09,164.57,
Hlth bhv ivntj grp 1st 30,96164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,90.43,,,,,,,fee schedule,37.09,164.57,
Hlth bhv ivntj grp 1st 30,96164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,95.07,,,,,,,fee schedule,37.09,164.57,
Hlth bhv ivntj grp 1st 30,96164,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.57,,,,,,,fee schedule,37.09,164.57,APC 378
Hlth bhv ivntj grp 1st 30,96164,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.95,,,,,,,fee schedule,37.09,164.57,APC
Hlth bhv ivntj grp 1st 30,96164,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.58,,,,,,,fee schedule,37.09,164.57,APC
Hlth bhv ivntj grp 1st 30,96164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,37.09,,,,,,,fee schedule,37.09,164.57,APC
Hlth bhv ivntj grp 1st 30,96164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.75,,,,,,,fee schedule,37.09,164.57,Radiology
Hlth bhv ivntj grp 1st 30,96164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.93,,,,,,,fee schedule,37.09,164.57,APC
Hlth bhv ivntj grp 1st 30,96164,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.91,,,,,,,fee schedule,37.09,164.57,APC
Hlth bhv ivntj grp ea addl,96165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14.74,,,,,,,fee schedule,11.82,14.74,
Hlth bhv ivntj grp ea addl,96165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11.82,,,,,,,fee schedule,11.82,14.74,
Hlth bhv ivntj grp ea addl,96165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12.91,,,,,,,fee schedule,11.82,14.74,
Hlth bhv ivntj grp ea addl,96165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13.57,,,,,,,fee schedule,11.82,14.74,
Hlth bhv ivntj fam 1st 30,96167,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,103.27,,,,,,,fee schedule,37.09,164.57,
Hlth bhv ivntj fam 1st 30,96167,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,82.78,,,,,,,fee schedule,37.09,164.57,
Hlth bhv ivntj fam 1st 30,96167,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,90.43,,,,,,,fee schedule,37.09,164.57,
Hlth bhv ivntj fam 1st 30,96167,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,95.07,,,,,,,fee schedule,37.09,164.57,
Hlth bhv ivntj fam 1st 30,96167,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.57,,,,,,,fee schedule,37.09,164.57,APC 378
Hlth bhv ivntj fam 1st 30,96167,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.95,,,,,,,fee schedule,37.09,164.57,APC
Hlth bhv ivntj fam 1st 30,96167,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.58,,,,,,,fee schedule,37.09,164.57,APC
Hlth bhv ivntj fam 1st 30,96167,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,37.09,,,,,,,fee schedule,37.09,164.57,APC
Hlth bhv ivntj fam 1st 30,96167,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.75,,,,,,,fee schedule,37.09,164.57,Radiology
Hlth bhv ivntj fam 1st 30,96167,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.93,,,,,,,fee schedule,37.09,164.57,APC
Hlth bhv ivntj fam 1st 30,96167,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.91,,,,,,,fee schedule,37.09,164.57,APC
Hlth bhv ivntj fam ea addl,96168,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,87.47,,,,,,,fee schedule,70.11,87.47,
Hlth bhv ivntj fam ea addl,96168,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,70.11,,,,,,,fee schedule,70.11,87.47,
Hlth bhv ivntj fam ea addl,96168,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,76.59,,,,,,,fee schedule,70.11,87.47,
Hlth bhv ivntj fam ea addl,96168,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,80.53,,,,,,,fee schedule,70.11,87.47,
Hlth bhv ivntj fam wo pt 1st,96170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,292.53,,,,,,,fee schedule,234.49,292.53,
Hlth bhv ivntj fam wo pt 1st,96170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,234.49,,,,,,,fee schedule,234.49,292.53,
Hlth bhv ivntj fam wo pt 1st,96170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,256.16,,,,,,,fee schedule,234.49,292.53,
Hlth bhv ivntj fam wo pt 1st,96170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,269.32,,,,,,,fee schedule,234.49,292.53,
Hlth bhv ivntj fam w/o pt ea,96171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,107.16,,,,,,,fee schedule,85.9,107.16,
Hlth bhv ivntj fam w/o pt ea,96171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,85.9,,,,,,,fee schedule,85.9,107.16,
Hlth bhv ivntj fam w/o pt ea,96171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,93.84,,,,,,,fee schedule,85.9,107.16,
Hlth bhv ivntj fam w/o pt ea,96171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,98.66,,,,,,,fee schedule,85.9,107.16,
Mlt fam grp bhv train 1st 60,96202,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.21,,,,,,,fee schedule,17.21,30.12,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Mlt fam grp bhv train 1st 60,96202,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.07,,,,,,,fee schedule,17.21,30.12,APC
Mlt fam grp bhv train 1st 60,96202,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,17.9,,,,,,,fee schedule,17.21,30.12,APC
Mlt fam grp bhv train 1st 60,96202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26.33,,,,,,,fee schedule,17.21,30.12,Radiology
Mlt fam grp bhv train 1st 60,96202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24.09,,,,,,,fee schedule,17.21,30.12,APC
Mlt fam grp bhv train 1st 60,96202,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30.12,,,,,,,fee schedule,17.21,30.12,APC
Mlt fam grp bhv train ea add,96203,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.02,,,,,,,fee schedule,5.02,8.78,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Mlt fam grp bhv train ea add,96203,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.27,,,,,,,fee schedule,5.02,8.78,APC
Mlt fam grp bhv train ea add,96203,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5.22,,,,,,,fee schedule,5.02,8.78,APC
Mlt fam grp bhv train ea add,96203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.68,,,,,,,fee schedule,5.02,8.78,Radiology
Mlt fam grp bhv train ea add,96203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.03,,,,,,,fee schedule,5.02,8.78,APC
Mlt fam grp bhv train ea add,96203,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8.78,,,,,,,fee schedule,5.02,8.78,APC
Hydration iv infusion init,96360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,673.87,,,,,,,fee schedule,210.57,934.22,
Hydration iv infusion init,96360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,540.17,,,,,,,fee schedule,210.57,934.22,
Hydration iv infusion init,96360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,590.08,,,,,,,fee schedule,210.57,934.22,
Hydration iv infusion init,96360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,620.39,,,,,,,fee schedule,210.57,934.22,
Hydration iv infusion init,96360,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,934.22,,,,,,,fee schedule,210.57,934.22,APC 378
Hydration iv infusion init,96360,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,221.1,,,,,,,fee schedule,210.57,934.22,APC
Hydration iv infusion init,96360,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,218.99,,,,,,,fee schedule,210.57,934.22,APC
Hydration iv infusion init,96360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,210.57,,,,,,,fee schedule,210.57,934.22,APC
Hydration iv infusion init,96360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,322.17,,,,,,,fee schedule,210.57,934.22,Radiology
Hydration iv infusion init,96360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,294.8,,,,,,,fee schedule,210.57,934.22,APC
Hydration iv infusion init,96360,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,368.5,,,,,,,fee schedule,210.57,934.22,APC
Hydrate iv infusion add-on,96361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,261.57,,,,,,,fee schedule,46.36,261.57,
Hydrate iv infusion add-on,96361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,209.67,,,,,,,fee schedule,46.36,261.57,
Hydrate iv infusion add-on,96361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,229.05,,,,,,,fee schedule,46.36,261.57,
Hydrate iv infusion add-on,96361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,240.81,,,,,,,fee schedule,46.36,261.57,
Hydrate iv infusion add-on,96361,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,205.67,,,,,,,fee schedule,46.36,261.57,APC 378
Hydrate iv infusion add-on,96361,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,48.67,,,,,,,fee schedule,46.36,261.57,APC
Hydrate iv infusion add-on,96361,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,48.21,,,,,,,fee schedule,46.36,261.57,APC
Hydrate iv infusion add-on,96361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,46.36,,,,,,,fee schedule,46.36,261.57,APC
Hydrate iv infusion add-on,96361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,70.92,,,,,,,fee schedule,46.36,261.57,Radiology
Hydrate iv infusion add-on,96361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,64.9,,,,,,,fee schedule,46.36,261.57,APC
Hydrate iv infusion add-on,96361,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,81.12,,,,,,,fee schedule,46.36,261.57,APC
Ther/proph/diag iv inf init,96365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,680.87,,,,,,,fee schedule,210.57,934.22,
Ther/proph/diag iv inf init,96365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,545.78,,,,,,,fee schedule,210.57,934.22,
Ther/proph/diag iv inf init,96365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,596.21,,,,,,,fee schedule,210.57,934.22,
Ther/proph/diag iv inf init,96365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,626.84,,,,,,,fee schedule,210.57,934.22,
Ther/proph/diag iv inf init,96365,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,934.22,,,,,,,fee schedule,210.57,934.22,APC 378
Ther/proph/diag iv inf init,96365,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,221.1,,,,,,,fee schedule,210.57,934.22,APC
Ther/proph/diag iv inf init,96365,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,218.99,,,,,,,fee schedule,210.57,934.22,APC
Ther/proph/diag iv inf init,96365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,210.57,,,,,,,fee schedule,210.57,934.22,APC
Ther/proph/diag iv inf init,96365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,322.17,,,,,,,fee schedule,210.57,934.22,Radiology
Ther/proph/diag iv inf init,96365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,294.8,,,,,,,fee schedule,210.57,934.22,APC
Ther/proph/diag iv inf init,96365,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,368.5,,,,,,,fee schedule,210.57,934.22,APC
Ther/proph/diag iv inf addon,96366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,165.48,,,,,,,fee schedule,46.36,205.67,
Ther/proph/diag iv inf addon,96366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,132.65,,,,,,,fee schedule,46.36,205.67,
Ther/proph/diag iv inf addon,96366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,144.9,,,,,,,fee schedule,46.36,205.67,
Ther/proph/diag iv inf addon,96366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,152.35,,,,,,,fee schedule,46.36,205.67,
Ther/proph/diag iv inf addon,96366,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,205.67,,,,,,,fee schedule,46.36,205.67,APC 378
Ther/proph/diag iv inf addon,96366,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,48.67,,,,,,,fee schedule,46.36,205.67,APC
Ther/proph/diag iv inf addon,96366,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,48.21,,,,,,,fee schedule,46.36,205.67,APC
Ther/proph/diag iv inf addon,96366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,46.36,,,,,,,fee schedule,46.36,205.67,APC
Ther/proph/diag iv inf addon,96366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,70.92,,,,,,,fee schedule,46.36,205.67,Radiology
Ther/proph/diag iv inf addon,96366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,64.9,,,,,,,fee schedule,46.36,205.67,APC
Ther/proph/diag iv inf addon,96366,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,81.12,,,,,,,fee schedule,46.36,205.67,APC
Tx/proph/dg addl seq iv inf,96367,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,633.91,,,,,,,fee schedule,71.28,633.91,
Tx/proph/dg addl seq iv inf,96367,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,508.13,,,,,,,fee schedule,71.28,633.91,
Tx/proph/dg addl seq iv inf,96367,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,555.09,,,,,,,fee schedule,71.28,633.91,
Tx/proph/dg addl seq iv inf,96367,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,583.6,,,,,,,fee schedule,71.28,633.91,
Tx/proph/dg addl seq iv inf,96367,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,316.24,,,,,,,fee schedule,71.28,633.91,APC 378
Tx/proph/dg addl seq iv inf,96367,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,74.84,,,,,,,fee schedule,71.28,633.91,APC
Tx/proph/dg addl seq iv inf,96367,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,74.13,,,,,,,fee schedule,71.28,633.91,APC
Tx/proph/dg addl seq iv inf,96367,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,71.28,,,,,,,fee schedule,71.28,633.91,APC
Tx/proph/dg addl seq iv inf,96367,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,109.06,,,,,,,fee schedule,71.28,633.91,Radiology
Tx/proph/dg addl seq iv inf,96367,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,99.79,,,,,,,fee schedule,71.28,633.91,APC
Tx/proph/dg addl seq iv inf,96367,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,124.74,,,,,,,fee schedule,71.28,633.91,APC
Ther/diag concurrent inf,96368,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,72.84,,,,,,,fee schedule,58.39,72.84,
Ther/diag concurrent inf,96368,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,58.39,,,,,,,fee schedule,58.39,72.84,
Ther/diag concurrent inf,96368,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,63.78,,,,,,,fee schedule,58.39,72.84,
Ther/diag concurrent inf,96368,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,67.06,,,,,,,fee schedule,58.39,72.84,
Sc ther infusion up to 1 hr,96369,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,508.37,,,,,,,fee schedule,210.57,934.22,
Sc ther infusion up to 1 hr,96369,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,407.5,,,,,,,fee schedule,210.57,934.22,
Sc ther infusion up to 1 hr,96369,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,445.16,,,,,,,fee schedule,210.57,934.22,
Sc ther infusion up to 1 hr,96369,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,468.03,,,,,,,fee schedule,210.57,934.22,
Sc ther infusion up to 1 hr,96369,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,934.22,,,,,,,fee schedule,210.57,934.22,APC 378
Sc ther infusion up to 1 hr,96369,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,221.1,,,,,,,fee schedule,210.57,934.22,APC
Sc ther infusion up to 1 hr,96369,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,218.99,,,,,,,fee schedule,210.57,934.22,APC
Sc ther infusion up to 1 hr,96369,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,210.57,,,,,,,fee schedule,210.57,934.22,APC
Sc ther infusion up to 1 hr,96369,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,322.17,,,,,,,fee schedule,210.57,934.22,Radiology
Sc ther infusion up to 1 hr,96369,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,294.8,,,,,,,fee schedule,210.57,934.22,APC
Sc ther infusion up to 1 hr,96369,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,368.5,,,,,,,fee schedule,210.57,934.22,APC
Sc ther infusion addl hr,96370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,57.19,,,,,,,fee schedule,45.84,205.67,
Sc ther infusion addl hr,96370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,45.84,,,,,,,fee schedule,45.84,205.67,
Sc ther infusion addl hr,96370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,50.08,,,,,,,fee schedule,45.84,205.67,
Sc ther infusion addl hr,96370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,52.65,,,,,,,fee schedule,45.84,205.67,
Sc ther infusion addl hr,96370,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,205.67,,,,,,,fee schedule,45.84,205.67,APC 378
Sc ther infusion addl hr,96370,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,48.67,,,,,,,fee schedule,45.84,205.67,APC
Sc ther infusion addl hr,96370,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,48.21,,,,,,,fee schedule,45.84,205.67,APC
Sc ther infusion addl hr,96370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,46.36,,,,,,,fee schedule,45.84,205.67,APC
Sc ther infusion addl hr,96370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,70.92,,,,,,,fee schedule,45.84,205.67,Radiology
Sc ther infusion addl hr,96370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,64.9,,,,,,,fee schedule,45.84,205.67,APC
Sc ther infusion addl hr,96370,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,81.12,,,,,,,fee schedule,45.84,205.67,APC
Sc ther infusion reset pump,96371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,244.15,,,,,,,fee schedule,71.28,316.24,
Sc ther infusion reset pump,96371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,195.71,,,,,,,fee schedule,71.28,316.24,
Sc ther infusion reset pump,96371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,213.79,,,,,,,fee schedule,71.28,316.24,
Sc ther infusion reset pump,96371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,224.77,,,,,,,fee schedule,71.28,316.24,
Sc ther infusion reset pump,96371,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,316.24,,,,,,,fee schedule,71.28,316.24,APC 378
Sc ther infusion reset pump,96371,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,74.84,,,,,,,fee schedule,71.28,316.24,APC
Sc ther infusion reset pump,96371,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,74.13,,,,,,,fee schedule,71.28,316.24,APC
Sc ther infusion reset pump,96371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,71.28,,,,,,,fee schedule,71.28,316.24,APC
Sc ther infusion reset pump,96371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,109.06,,,,,,,fee schedule,71.28,316.24,Radiology
Sc ther infusion reset pump,96371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,99.79,,,,,,,fee schedule,71.28,316.24,APC
Sc ther infusion reset pump,96371,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,124.74,,,,,,,fee schedule,71.28,316.24,APC
Ther/proph/diag inj sc/im,96372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,118.7,,,,,,,fee schedule,71.28,316.24,
Ther/proph/diag inj sc/im,96372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,95.15,,,,,,,fee schedule,71.28,316.24,
Ther/proph/diag inj sc/im,96372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,103.94,,,,,,,fee schedule,71.28,316.24,
Ther/proph/diag inj sc/im,96372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,109.28,,,,,,,fee schedule,71.28,316.24,
Ther/proph/diag inj sc/im,96372,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,316.24,,,,,,,fee schedule,71.28,316.24,APC 378
Ther/proph/diag inj sc/im,96372,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,74.84,,,,,,,fee schedule,71.28,316.24,APC
Ther/proph/diag inj sc/im,96372,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,74.13,,,,,,,fee schedule,71.28,316.24,APC
Ther/proph/diag inj sc/im,96372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,71.28,,,,,,,fee schedule,71.28,316.24,APC
Ther/proph/diag inj sc/im,96372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,109.06,,,,,,,fee schedule,71.28,316.24,Radiology
Ther/proph/diag inj sc/im,96372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,99.79,,,,,,,fee schedule,71.28,316.24,APC
Ther/proph/diag inj sc/im,96372,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,124.74,,,,,,,fee schedule,71.28,316.24,APC
Ther/proph/diag inj ia,96373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,152.17,,,,,,,fee schedule,121.98,934.22,
Ther/proph/diag inj ia,96373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,121.98,,,,,,,fee schedule,121.98,934.22,
Ther/proph/diag inj ia,96373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,133.25,,,,,,,fee schedule,121.98,934.22,
Ther/proph/diag inj ia,96373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,140.09,,,,,,,fee schedule,121.98,934.22,
Ther/proph/diag inj ia,96373,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,934.22,,,,,,,fee schedule,121.98,934.22,APC 378
Ther/proph/diag inj ia,96373,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,221.1,,,,,,,fee schedule,121.98,934.22,APC
Ther/proph/diag inj ia,96373,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,218.99,,,,,,,fee schedule,121.98,934.22,APC
Ther/proph/diag inj ia,96373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,210.57,,,,,,,fee schedule,121.98,934.22,APC
Ther/proph/diag inj ia,96373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,322.17,,,,,,,fee schedule,121.98,934.22,Radiology
Ther/proph/diag inj ia,96373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,294.8,,,,,,,fee schedule,121.98,934.22,APC
Ther/proph/diag inj ia,96373,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,368.5,,,,,,,fee schedule,121.98,934.22,APC
Ther/proph/diag inj iv push,96374,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,337.58,,,,,,,fee schedule,210.57,934.22,
Ther/proph/diag inj iv push,96374,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,270.6,,,,,,,fee schedule,210.57,934.22,
Ther/proph/diag inj iv push,96374,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,295.61,,,,,,,fee schedule,210.57,934.22,
Ther/proph/diag inj iv push,96374,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,310.79,,,,,,,fee schedule,210.57,934.22,
Ther/proph/diag inj iv push,96374,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,934.22,,,,,,,fee schedule,210.57,934.22,APC 378
Ther/proph/diag inj iv push,96374,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,221.1,,,,,,,fee schedule,210.57,934.22,APC
Ther/proph/diag inj iv push,96374,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,218.99,,,,,,,fee schedule,210.57,934.22,APC
Ther/proph/diag inj iv push,96374,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,210.57,,,,,,,fee schedule,210.57,934.22,APC
Ther/proph/diag inj iv push,96374,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,322.17,,,,,,,fee schedule,210.57,934.22,Radiology
Ther/proph/diag inj iv push,96374,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,294.8,,,,,,,fee schedule,210.57,934.22,APC
Ther/proph/diag inj iv push,96374,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,368.5,,,,,,,fee schedule,210.57,934.22,APC
Tx/pro/dx inj new drug addon,96375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,161.16,,,,,,,fee schedule,46.36,205.67,
Tx/pro/dx inj new drug addon,96375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,129.19,,,,,,,fee schedule,46.36,205.67,
Tx/pro/dx inj new drug addon,96375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,141.12,,,,,,,fee schedule,46.36,205.67,
Tx/pro/dx inj new drug addon,96375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,148.37,,,,,,,fee schedule,46.36,205.67,
Tx/pro/dx inj new drug addon,96375,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,205.67,,,,,,,fee schedule,46.36,205.67,APC 378
Tx/pro/dx inj new drug addon,96375,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,48.67,,,,,,,fee schedule,46.36,205.67,APC
Tx/pro/dx inj new drug addon,96375,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,48.21,,,,,,,fee schedule,46.36,205.67,APC
Tx/pro/dx inj new drug addon,96375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,46.36,,,,,,,fee schedule,46.36,205.67,APC
Tx/pro/dx inj new drug addon,96375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,70.92,,,,,,,fee schedule,46.36,205.67,Radiology
Tx/pro/dx inj new drug addon,96375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,64.9,,,,,,,fee schedule,46.36,205.67,APC
Tx/pro/dx inj new drug addon,96375,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,81.12,,,,,,,fee schedule,46.36,205.67,APC
Tx/pro/dx inj same drug adon,96376,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,72.12,,,,,,,fee schedule,57.81,72.12,
Tx/pro/dx inj same drug adon,96376,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.81,,,,,,,fee schedule,57.81,72.12,
Tx/pro/dx inj same drug adon,96376,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,63.15,,,,,,,fee schedule,57.81,72.12,
Tx/pro/dx inj same drug adon,96376,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.4,,,,,,,fee schedule,57.81,72.12,
Applicaton on-body injector,96377,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,151.2,,,,,,,fee schedule,46.36,205.67,
Applicaton on-body injector,96377,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,121.2,,,,,,,fee schedule,46.36,205.67,
Applicaton on-body injector,96377,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,132.4,,,,,,,fee schedule,46.36,205.67,
Applicaton on-body injector,96377,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,139.2,,,,,,,fee schedule,46.36,205.67,
Applicaton on-body injector,96377,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,205.67,,,,,,,fee schedule,46.36,205.67,APC 378
Applicaton on-body injector,96377,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,48.67,,,,,,,fee schedule,46.36,205.67,APC
Applicaton on-body injector,96377,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,48.21,,,,,,,fee schedule,46.36,205.67,APC
Applicaton on-body injector,96377,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,46.36,,,,,,,fee schedule,46.36,205.67,APC
Applicaton on-body injector,96377,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,70.92,,,,,,,fee schedule,46.36,205.67,Radiology
Applicaton on-body injector,96377,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,64.9,,,,,,,fee schedule,46.36,205.67,APC
Applicaton on-body injector,96377,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,81.12,,,,,,,fee schedule,46.36,205.67,APC
Ther/prop/diag inj/inf proc,96379,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,102.1,,,,,,,fee schedule,46.36,205.67,
Ther/prop/diag inj/inf proc,96379,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,81.84,,,,,,,fee schedule,46.36,205.67,
Ther/prop/diag inj/inf proc,96379,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,89.4,,,,,,,fee schedule,46.36,205.67,
Ther/prop/diag inj/inf proc,96379,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,93.99,,,,,,,fee schedule,46.36,205.67,
Ther/prop/diag inj/inf proc,96379,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,205.67,,,,,,,fee schedule,46.36,205.67,APC 378
Ther/prop/diag inj/inf proc,96379,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,48.67,,,,,,,fee schedule,46.36,205.67,APC
Ther/prop/diag inj/inf proc,96379,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,48.21,,,,,,,fee schedule,46.36,205.67,APC
Ther/prop/diag inj/inf proc,96379,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,46.36,,,,,,,fee schedule,46.36,205.67,APC
Ther/prop/diag inj/inf proc,96379,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,70.92,,,,,,,fee schedule,46.36,205.67,Radiology
Ther/prop/diag inj/inf proc,96379,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,64.9,,,,,,,fee schedule,46.36,205.67,APC
Ther/prop/diag inj/inf proc,96379,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,81.12,,,,,,,fee schedule,46.36,205.67,APC
Chemo anti-neopl sq/im,96401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,229.18,,,,,,,fee schedule,71.28,316.24,
Chemo anti-neopl sq/im,96401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,183.71,,,,,,,fee schedule,71.28,316.24,
Chemo anti-neopl sq/im,96401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,200.69,,,,,,,fee schedule,71.28,316.24,
Chemo anti-neopl sq/im,96401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,210.99,,,,,,,fee schedule,71.28,316.24,
Chemo anti-neopl sq/im,96401,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,316.24,,,,,,,fee schedule,71.28,316.24,APC 378
Chemo anti-neopl sq/im,96401,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,74.84,,,,,,,fee schedule,71.28,316.24,APC
Chemo anti-neopl sq/im,96401,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,74.13,,,,,,,fee schedule,71.28,316.24,APC
Chemo anti-neopl sq/im,96401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,71.28,,,,,,,fee schedule,71.28,316.24,APC
Chemo anti-neopl sq/im,96401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,109.06,,,,,,,fee schedule,71.28,316.24,Radiology
Chemo anti-neopl sq/im,96401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,99.79,,,,,,,fee schedule,71.28,316.24,APC
Chemo anti-neopl sq/im,96401,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,124.74,,,,,,,fee schedule,71.28,316.24,APC
Chemo hormon antineopl sq/im,96402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,177.71,,,,,,,fee schedule,71.28,316.24,
Chemo hormon antineopl sq/im,96402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,142.45,,,,,,,fee schedule,71.28,316.24,
Chemo hormon antineopl sq/im,96402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,155.61,,,,,,,fee schedule,71.28,316.24,
Chemo hormon antineopl sq/im,96402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,163.61,,,,,,,fee schedule,71.28,316.24,
Chemo hormon antineopl sq/im,96402,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,316.24,,,,,,,fee schedule,71.28,316.24,APC 378
Chemo hormon antineopl sq/im,96402,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,74.84,,,,,,,fee schedule,71.28,316.24,APC
Chemo hormon antineopl sq/im,96402,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,74.13,,,,,,,fee schedule,71.28,316.24,APC
Chemo hormon antineopl sq/im,96402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,71.28,,,,,,,fee schedule,71.28,316.24,APC
Chemo hormon antineopl sq/im,96402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,109.06,,,,,,,fee schedule,71.28,316.24,Radiology
Chemo hormon antineopl sq/im,96402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,99.79,,,,,,,fee schedule,71.28,316.24,APC
Chemo hormon antineopl sq/im,96402,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,124.74,,,,,,,fee schedule,71.28,316.24,APC
Chemo intralesional up to 7,96405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,200.68,,,,,,,fee schedule,71.28,316.24,
Chemo intralesional up to 7,96405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,160.86,,,,,,,fee schedule,71.28,316.24,
Chemo intralesional up to 7,96405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,175.73,,,,,,,fee schedule,71.28,316.24,
Chemo intralesional up to 7,96405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,184.75,,,,,,,fee schedule,71.28,316.24,
Chemo intralesional up to 7,96405,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,316.24,,,,,,,fee schedule,71.28,316.24,APC 378
Chemo intralesional up to 7,96405,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,74.84,,,,,,,fee schedule,71.28,316.24,APC
Chemo intralesional up to 7,96405,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,74.13,,,,,,,fee schedule,71.28,316.24,APC
Chemo intralesional up to 7,96405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,71.28,,,,,,,fee schedule,71.28,316.24,APC
Chemo intralesional up to 7,96405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,109.06,,,,,,,fee schedule,71.28,316.24,Radiology
Chemo intralesional up to 7,96405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,99.79,,,,,,,fee schedule,71.28,316.24,APC
Chemo intralesional up to 7,96405,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,124.74,,,,,,,fee schedule,71.28,316.24,APC
Chemo intralesional over 7,96406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,200.68,,,,,,,fee schedule,160.86,934.22,
Chemo intralesional over 7,96406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,160.86,,,,,,,fee schedule,160.86,934.22,
Chemo intralesional over 7,96406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,175.73,,,,,,,fee schedule,160.86,934.22,
Chemo intralesional over 7,96406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,184.75,,,,,,,fee schedule,160.86,934.22,
Chemo intralesional over 7,96406,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,934.22,,,,,,,fee schedule,160.86,934.22,APC 378
Chemo intralesional over 7,96406,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,221.1,,,,,,,fee schedule,160.86,934.22,APC
Chemo intralesional over 7,96406,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,218.99,,,,,,,fee schedule,160.86,934.22,APC
Chemo intralesional over 7,96406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,210.57,,,,,,,fee schedule,160.86,934.22,APC
Chemo intralesional over 7,96406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,322.17,,,,,,,fee schedule,160.86,934.22,Radiology
Chemo intralesional over 7,96406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,294.8,,,,,,,fee schedule,160.86,934.22,APC
Chemo intralesional over 7,96406,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,368.5,,,,,,,fee schedule,160.86,934.22,APC
Chemo iv push sngl drug,96409,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,514.71,,,,,,,fee schedule,326.99,1450.75,
Chemo iv push sngl drug,96409,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,412.59,,,,,,,fee schedule,326.99,1450.75,
Chemo iv push sngl drug,96409,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,450.71,,,,,,,fee schedule,326.99,1450.75,
Chemo iv push sngl drug,96409,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,473.86,,,,,,,fee schedule,326.99,1450.75,
Chemo iv push sngl drug,96409,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1450.75,,,,,,,fee schedule,326.99,1450.75,APC 378
Chemo iv push sngl drug,96409,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,343.34,,,,,,,fee schedule,326.99,1450.75,APC
Chemo iv push sngl drug,96409,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,340.07,,,,,,,fee schedule,326.99,1450.75,APC
Chemo iv push sngl drug,96409,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,326.99,,,,,,,fee schedule,326.99,1450.75,APC
Chemo iv push sngl drug,96409,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,500.3,,,,,,,fee schedule,326.99,1450.75,Radiology
Chemo iv push sngl drug,96409,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,457.79,,,,,,,fee schedule,326.99,1450.75,APC
Chemo iv push sngl drug,96409,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,572.24,,,,,,,fee schedule,326.99,1450.75,APC
Chemo iv push addl drug,96411,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,131.12,,,,,,,fee schedule,71.28,316.24,
Chemo iv push addl drug,96411,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,105.1,,,,,,,fee schedule,71.28,316.24,
Chemo iv push addl drug,96411,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,114.81,,,,,,,fee schedule,71.28,316.24,
Chemo iv push addl drug,96411,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,120.71,,,,,,,fee schedule,71.28,316.24,
Chemo iv push addl drug,96411,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,316.24,,,,,,,fee schedule,71.28,316.24,APC 378
Chemo iv push addl drug,96411,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,74.84,,,,,,,fee schedule,71.28,316.24,APC
Chemo iv push addl drug,96411,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,74.13,,,,,,,fee schedule,71.28,316.24,APC
Chemo iv push addl drug,96411,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,71.28,,,,,,,fee schedule,71.28,316.24,APC
Chemo iv push addl drug,96411,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,109.06,,,,,,,fee schedule,71.28,316.24,Radiology
Chemo iv push addl drug,96411,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,99.79,,,,,,,fee schedule,71.28,316.24,APC
Chemo iv push addl drug,96411,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,124.74,,,,,,,fee schedule,71.28,316.24,APC
Chemo iv infusion 1 hr,96413,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,736.11,,,,,,,fee schedule,326.99,1450.75,
Chemo iv infusion 1 hr,96413,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,590.06,,,,,,,fee schedule,326.99,1450.75,
Chemo iv infusion 1 hr,96413,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,644.59,,,,,,,fee schedule,326.99,1450.75,
Chemo iv infusion 1 hr,96413,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,677.69,,,,,,,fee schedule,326.99,1450.75,
Chemo iv infusion 1 hr,96413,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1450.75,,,,,,,fee schedule,326.99,1450.75,APC 378
Chemo iv infusion 1 hr,96413,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,343.34,,,,,,,fee schedule,326.99,1450.75,APC
Chemo iv infusion 1 hr,96413,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,340.07,,,,,,,fee schedule,326.99,1450.75,APC
Chemo iv infusion 1 hr,96413,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,326.99,,,,,,,fee schedule,326.99,1450.75,APC
Chemo iv infusion 1 hr,96413,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,500.3,,,,,,,fee schedule,326.99,1450.75,Radiology
Chemo iv infusion 1 hr,96413,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,457.79,,,,,,,fee schedule,326.99,1450.75,APC
Chemo iv infusion 1 hr,96413,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,572.24,,,,,,,fee schedule,326.99,1450.75,APC
Chemo iv infusion addl hr,96415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,168.17,,,,,,,fee schedule,71.28,316.24,
Chemo iv infusion addl hr,96415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,134.81,,,,,,,fee schedule,71.28,316.24,
Chemo iv infusion addl hr,96415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,147.26,,,,,,,fee schedule,71.28,316.24,
Chemo iv infusion addl hr,96415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,154.83,,,,,,,fee schedule,71.28,316.24,
Chemo iv infusion addl hr,96415,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,316.24,,,,,,,fee schedule,71.28,316.24,APC 378
Chemo iv infusion addl hr,96415,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,74.84,,,,,,,fee schedule,71.28,316.24,APC
Chemo iv infusion addl hr,96415,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,74.13,,,,,,,fee schedule,71.28,316.24,APC
Chemo iv infusion addl hr,96415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,71.28,,,,,,,fee schedule,71.28,316.24,APC
Chemo iv infusion addl hr,96415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,109.06,,,,,,,fee schedule,71.28,316.24,Radiology
Chemo iv infusion addl hr,96415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,99.79,,,,,,,fee schedule,71.28,316.24,APC
Chemo iv infusion addl hr,96415,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,124.74,,,,,,,fee schedule,71.28,316.24,APC
Chemo prolong infuse w/pump,96416,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,171.21,,,,,,,fee schedule,137.24,1450.75,
Chemo prolong infuse w/pump,96416,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,137.24,,,,,,,fee schedule,137.24,1450.75,
Chemo prolong infuse w/pump,96416,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,149.92,,,,,,,fee schedule,137.24,1450.75,
Chemo prolong infuse w/pump,96416,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,157.62,,,,,,,fee schedule,137.24,1450.75,
Chemo prolong infuse w/pump,96416,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1450.75,,,,,,,fee schedule,137.24,1450.75,APC 378
Chemo prolong infuse w/pump,96416,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,343.34,,,,,,,fee schedule,137.24,1450.75,APC
Chemo prolong infuse w/pump,96416,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,340.07,,,,,,,fee schedule,137.24,1450.75,APC
Chemo prolong infuse w/pump,96416,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,326.99,,,,,,,fee schedule,137.24,1450.75,APC
Chemo prolong infuse w/pump,96416,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,500.3,,,,,,,fee schedule,137.24,1450.75,Radiology
Chemo prolong infuse w/pump,96416,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,457.79,,,,,,,fee schedule,137.24,1450.75,APC
Chemo prolong infuse w/pump,96416,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,572.24,,,,,,,fee schedule,137.24,1450.75,APC
Chemo iv infus each addl seq,96417,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,628.49,,,,,,,fee schedule,71.28,628.49,
Chemo iv infus each addl seq,96417,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,503.79,,,,,,,fee schedule,71.28,628.49,
Chemo iv infus each addl seq,96417,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,550.34,,,,,,,fee schedule,71.28,628.49,
Chemo iv infus each addl seq,96417,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,578.61,,,,,,,fee schedule,71.28,628.49,
Chemo iv infus each addl seq,96417,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,316.24,,,,,,,fee schedule,71.28,628.49,APC 378
Chemo iv infus each addl seq,96417,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,74.84,,,,,,,fee schedule,71.28,628.49,APC
Chemo iv infus each addl seq,96417,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,74.13,,,,,,,fee schedule,71.28,628.49,APC
Chemo iv infus each addl seq,96417,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,71.28,,,,,,,fee schedule,71.28,628.49,APC
Chemo iv infus each addl seq,96417,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,109.06,,,,,,,fee schedule,71.28,628.49,Radiology
Chemo iv infus each addl seq,96417,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,99.79,,,,,,,fee schedule,71.28,628.49,APC
Chemo iv infus each addl seq,96417,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,124.74,,,,,,,fee schedule,71.28,628.49,APC
Chemo ia push tecnique,96420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,412.93,,,,,,,fee schedule,326.99,1450.75,
Chemo ia push tecnique,96420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,331,,,,,,,fee schedule,326.99,1450.75,
Chemo ia push tecnique,96420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,361.58,,,,,,,fee schedule,326.99,1450.75,
Chemo ia push tecnique,96420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,380.16,,,,,,,fee schedule,326.99,1450.75,
Chemo ia push tecnique,96420,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1450.75,,,,,,,fee schedule,326.99,1450.75,APC 378
Chemo ia push tecnique,96420,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,343.34,,,,,,,fee schedule,326.99,1450.75,APC
Chemo ia push tecnique,96420,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,340.07,,,,,,,fee schedule,326.99,1450.75,APC
Chemo ia push tecnique,96420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,326.99,,,,,,,fee schedule,326.99,1450.75,APC
Chemo ia push tecnique,96420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,500.3,,,,,,,fee schedule,326.99,1450.75,Radiology
Chemo ia push tecnique,96420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,457.79,,,,,,,fee schedule,326.99,1450.75,APC
Chemo ia push tecnique,96420,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,572.24,,,,,,,fee schedule,326.99,1450.75,APC
Chemo ia infusion up to 1 hr,96422,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,585.18,,,,,,,fee schedule,326.99,1450.75,
Chemo ia infusion up to 1 hr,96422,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,469.07,,,,,,,fee schedule,326.99,1450.75,
Chemo ia infusion up to 1 hr,96422,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,512.42,,,,,,,fee schedule,326.99,1450.75,
Chemo ia infusion up to 1 hr,96422,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,538.74,,,,,,,fee schedule,326.99,1450.75,
Chemo ia infusion up to 1 hr,96422,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1450.75,,,,,,,fee schedule,326.99,1450.75,APC 378
Chemo ia infusion up to 1 hr,96422,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,343.34,,,,,,,fee schedule,326.99,1450.75,APC
Chemo ia infusion up to 1 hr,96422,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,340.07,,,,,,,fee schedule,326.99,1450.75,APC
Chemo ia infusion up to 1 hr,96422,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,326.99,,,,,,,fee schedule,326.99,1450.75,APC
Chemo ia infusion up to 1 hr,96422,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,500.3,,,,,,,fee schedule,326.99,1450.75,Radiology
Chemo ia infusion up to 1 hr,96422,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,457.79,,,,,,,fee schedule,326.99,1450.75,APC
Chemo ia infusion up to 1 hr,96422,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,572.24,,,,,,,fee schedule,326.99,1450.75,APC
Chemo ia infuse each addl hr,96423,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,200.68,,,,,,,fee schedule,46.36,205.67,
Chemo ia infuse each addl hr,96423,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,160.86,,,,,,,fee schedule,46.36,205.67,
Chemo ia infuse each addl hr,96423,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,175.73,,,,,,,fee schedule,46.36,205.67,
Chemo ia infuse each addl hr,96423,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,184.75,,,,,,,fee schedule,46.36,205.67,
Chemo ia infuse each addl hr,96423,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,205.67,,,,,,,fee schedule,46.36,205.67,APC 378
Chemo ia infuse each addl hr,96423,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,48.67,,,,,,,fee schedule,46.36,205.67,APC
Chemo ia infuse each addl hr,96423,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,48.21,,,,,,,fee schedule,46.36,205.67,APC
Chemo ia infuse each addl hr,96423,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,46.36,,,,,,,fee schedule,46.36,205.67,APC
Chemo ia infuse each addl hr,96423,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,70.92,,,,,,,fee schedule,46.36,205.67,Radiology
Chemo ia infuse each addl hr,96423,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,64.9,,,,,,,fee schedule,46.36,205.67,APC
Chemo ia infuse each addl hr,96423,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,81.12,,,,,,,fee schedule,46.36,205.67,APC
Chemotherapy infusion method,96425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,585.18,,,,,,,fee schedule,326.99,1450.75,
Chemotherapy infusion method,96425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,469.07,,,,,,,fee schedule,326.99,1450.75,
Chemotherapy infusion method,96425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,512.42,,,,,,,fee schedule,326.99,1450.75,
Chemotherapy infusion method,96425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,538.74,,,,,,,fee schedule,326.99,1450.75,
Chemotherapy infusion method,96425,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1450.75,,,,,,,fee schedule,326.99,1450.75,APC 378
Chemotherapy infusion method,96425,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,343.34,,,,,,,fee schedule,326.99,1450.75,APC
Chemotherapy infusion method,96425,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,340.07,,,,,,,fee schedule,326.99,1450.75,APC
Chemotherapy infusion method,96425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,326.99,,,,,,,fee schedule,326.99,1450.75,APC
Chemotherapy infusion method,96425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,500.3,,,,,,,fee schedule,326.99,1450.75,Radiology
Chemotherapy infusion method,96425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,457.79,,,,,,,fee schedule,326.99,1450.75,APC
Chemotherapy infusion method,96425,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,572.24,,,,,,,fee schedule,326.99,1450.75,APC
Chemotherapy intracavitary,96440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,585.18,,,,,,,fee schedule,326.99,1450.75,
Chemotherapy intracavitary,96440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,469.07,,,,,,,fee schedule,326.99,1450.75,
Chemotherapy intracavitary,96440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,512.42,,,,,,,fee schedule,326.99,1450.75,
Chemotherapy intracavitary,96440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,538.74,,,,,,,fee schedule,326.99,1450.75,
Chemotherapy intracavitary,96440,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1450.75,,,,,,,fee schedule,326.99,1450.75,APC 378
Chemotherapy intracavitary,96440,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,343.34,,,,,,,fee schedule,326.99,1450.75,APC
Chemotherapy intracavitary,96440,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,340.07,,,,,,,fee schedule,326.99,1450.75,APC
Chemotherapy intracavitary,96440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,326.99,,,,,,,fee schedule,326.99,1450.75,APC
Chemotherapy intracavitary,96440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,500.3,,,,,,,fee schedule,326.99,1450.75,Radiology
Chemotherapy intracavitary,96440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,457.79,,,,,,,fee schedule,326.99,1450.75,APC
Chemotherapy intracavitary,96440,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,572.24,,,,,,,fee schedule,326.99,1450.75,APC
Chemotx admn prtl cavity,96446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,485.5,,,,,,,fee schedule,326.99,1450.75,
Chemotx admn prtl cavity,96446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,389.17,,,,,,,fee schedule,326.99,1450.75,
Chemotx admn prtl cavity,96446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,425.14,,,,,,,fee schedule,326.99,1450.75,
Chemotx admn prtl cavity,96446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,446.97,,,,,,,fee schedule,326.99,1450.75,
Chemotx admn prtl cavity,96446,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1450.75,,,,,,,fee schedule,326.99,1450.75,APC 378
Chemotx admn prtl cavity,96446,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,343.34,,,,,,,fee schedule,326.99,1450.75,APC
Chemotx admn prtl cavity,96446,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,340.07,,,,,,,fee schedule,326.99,1450.75,APC
Chemotx admn prtl cavity,96446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,326.99,,,,,,,fee schedule,326.99,1450.75,APC
Chemotx admn prtl cavity,96446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,500.3,,,,,,,fee schedule,326.99,1450.75,Radiology
Chemotx admn prtl cavity,96446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,457.79,,,,,,,fee schedule,326.99,1450.75,APC
Chemotx admn prtl cavity,96446,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,572.24,,,,,,,fee schedule,326.99,1450.75,APC
Chemotherapy into cns,96450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,543.97,,,,,,,fee schedule,326.99,1450.75,
Chemotherapy into cns,96450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,436.04,,,,,,,fee schedule,326.99,1450.75,
Chemotherapy into cns,96450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,476.33,,,,,,,fee schedule,326.99,1450.75,
Chemotherapy into cns,96450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,500.8,,,,,,,fee schedule,326.99,1450.75,
Chemotherapy into cns,96450,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1450.75,,,,,,,fee schedule,326.99,1450.75,APC 378
Chemotherapy into cns,96450,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,343.34,,,,,,,fee schedule,326.99,1450.75,APC
Chemotherapy into cns,96450,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,340.07,,,,,,,fee schedule,326.99,1450.75,APC
Chemotherapy into cns,96450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,326.99,,,,,,,fee schedule,326.99,1450.75,APC
Chemotherapy into cns,96450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,500.3,,,,,,,fee schedule,326.99,1450.75,Radiology
Chemotherapy into cns,96450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,457.79,,,,,,,fee schedule,326.99,1450.75,APC
Chemotherapy into cns,96450,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,572.24,,,,,,,fee schedule,326.99,1450.75,APC
Refill/maint portable pump,96521,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,224.31,,,,,,,fee schedule,179.8,934.22,
Refill/maint portable pump,96521,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,179.8,,,,,,,fee schedule,179.8,934.22,
Refill/maint portable pump,96521,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,196.42,,,,,,,fee schedule,179.8,934.22,
Refill/maint portable pump,96521,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,206.5,,,,,,,fee schedule,179.8,934.22,
Refill/maint portable pump,96521,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,934.22,,,,,,,fee schedule,179.8,934.22,APC 378
Refill/maint portable pump,96521,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,221.1,,,,,,,fee schedule,179.8,934.22,APC
Refill/maint portable pump,96521,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,218.99,,,,,,,fee schedule,179.8,934.22,APC
Refill/maint portable pump,96521,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,210.57,,,,,,,fee schedule,179.8,934.22,APC
Refill/maint portable pump,96521,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,322.17,,,,,,,fee schedule,179.8,934.22,Radiology
Refill/maint portable pump,96521,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,294.8,,,,,,,fee schedule,179.8,934.22,APC
Refill/maint portable pump,96521,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,368.5,,,,,,,fee schedule,179.8,934.22,APC
Refill/maint pump/resvr syst,96522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,449.22,,,,,,,fee schedule,210.57,934.22,
Refill/maint pump/resvr syst,96522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,360.09,,,,,,,fee schedule,210.57,934.22,
Refill/maint pump/resvr syst,96522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,393.36,,,,,,,fee schedule,210.57,934.22,
Refill/maint pump/resvr syst,96522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,413.56,,,,,,,fee schedule,210.57,934.22,
Refill/maint pump/resvr syst,96522,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,934.22,,,,,,,fee schedule,210.57,934.22,APC 378
Refill/maint pump/resvr syst,96522,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,221.1,,,,,,,fee schedule,210.57,934.22,APC
Refill/maint pump/resvr syst,96522,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,218.99,,,,,,,fee schedule,210.57,934.22,APC
Refill/maint pump/resvr syst,96522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,210.57,,,,,,,fee schedule,210.57,934.22,APC
Refill/maint pump/resvr syst,96522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,322.17,,,,,,,fee schedule,210.57,934.22,Radiology
Refill/maint pump/resvr syst,96522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,294.8,,,,,,,fee schedule,210.57,934.22,APC
Refill/maint pump/resvr syst,96522,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,368.5,,,,,,,fee schedule,210.57,934.22,APC
Irrig drug delivery device,96523,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,129.31,,,,,,,fee schedule,58.4,259.1,
Irrig drug delivery device,96523,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,103.65,,,,,,,fee schedule,58.4,259.1,
Irrig drug delivery device,96523,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,113.23,,,,,,,fee schedule,58.4,259.1,
Irrig drug delivery device,96523,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,119.05,,,,,,,fee schedule,58.4,259.1,
Irrig drug delivery device,96523,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,58.4,259.1,APC 378
Irrig drug delivery device,96523,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,58.4,259.1,APC
Irrig drug delivery device,96523,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,58.4,259.1,APC
Irrig drug delivery device,96523,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,58.4,259.1,APC
Irrig drug delivery device,96523,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,58.4,259.1,Radiology
Irrig drug delivery device,96523,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,58.4,259.1,APC
Irrig drug delivery device,96523,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,58.4,259.1,APC
Chemotherapy injection,96542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,200.68,,,,,,,fee schedule,160.86,1450.75,
Chemotherapy injection,96542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,160.86,,,,,,,fee schedule,160.86,1450.75,
Chemotherapy injection,96542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,175.73,,,,,,,fee schedule,160.86,1450.75,
Chemotherapy injection,96542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,184.75,,,,,,,fee schedule,160.86,1450.75,
Chemotherapy injection,96542,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1450.75,,,,,,,fee schedule,160.86,1450.75,APC 378
Chemotherapy injection,96542,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,343.34,,,,,,,fee schedule,160.86,1450.75,APC
Chemotherapy injection,96542,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,340.07,,,,,,,fee schedule,160.86,1450.75,APC
Chemotherapy injection,96542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,326.99,,,,,,,fee schedule,160.86,1450.75,APC
Chemotherapy injection,96542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,500.3,,,,,,,fee schedule,160.86,1450.75,Radiology
Chemotherapy injection,96542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,457.79,,,,,,,fee schedule,160.86,1450.75,APC
Chemotherapy injection,96542,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,572.24,,,,,,,fee schedule,160.86,1450.75,APC
Chemotherapy unspecified,96549,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,63.5,,,,,,,fee schedule,46.36,205.67,
Chemotherapy unspecified,96549,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,50.9,,,,,,,fee schedule,46.36,205.67,
Chemotherapy unspecified,96549,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55.61,,,,,,,fee schedule,46.36,205.67,
Chemotherapy unspecified,96549,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,58.46,,,,,,,fee schedule,46.36,205.67,
Chemotherapy unspecified,96549,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,205.67,,,,,,,fee schedule,46.36,205.67,APC 378
Chemotherapy unspecified,96549,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,48.67,,,,,,,fee schedule,46.36,205.67,APC
Chemotherapy unspecified,96549,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,48.21,,,,,,,fee schedule,46.36,205.67,APC
Chemotherapy unspecified,96549,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,46.36,,,,,,,fee schedule,46.36,205.67,APC
Chemotherapy unspecified,96549,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,70.92,,,,,,,fee schedule,46.36,205.67,Radiology
Chemotherapy unspecified,96549,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,64.9,,,,,,,fee schedule,46.36,205.67,APC
Chemotherapy unspecified,96549,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,81.12,,,,,,,fee schedule,46.36,205.67,APC
Photodynamic tx skin,96567,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,197.92,,,,,,,fee schedule,158.65,881.22,
Photodynamic tx skin,96567,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,158.65,,,,,,,fee schedule,158.65,881.22,
Photodynamic tx skin,96567,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,173.31,,,,,,,fee schedule,158.65,881.22,
Photodynamic tx skin,96567,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,182.21,,,,,,,fee schedule,158.65,881.22,
Photodynamic tx skin,96567,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,881.22,,,,,,,fee schedule,158.65,881.22,APC 378
Photodynamic tx skin,96567,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.55,,,,,,,fee schedule,158.65,881.22,APC
Photodynamic tx skin,96567,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,206.57,,,,,,,fee schedule,158.65,881.22,APC
Photodynamic tx skin,96567,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.62,,,,,,,fee schedule,158.65,881.22,APC
Photodynamic tx skin,96567,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.89,,,,,,,fee schedule,158.65,881.22,Radiology
Photodynamic tx skin,96567,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,278.07,,,,,,,fee schedule,158.65,881.22,APC
Photodynamic tx skin,96567,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,347.59,,,,,,,fee schedule,158.65,881.22,APC
Photodynmc tx 30 min add-on,96570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,364.24,,,,,,,fee schedule,291.97,364.24,
Photodynmc tx 30 min add-on,96570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,291.97,,,,,,,fee schedule,291.97,364.24,
Photodynmc tx 30 min add-on,96570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,318.95,,,,,,,fee schedule,291.97,364.24,
Photodynmc tx 30 min add-on,96570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,335.33,,,,,,,fee schedule,291.97,364.24,
Photodynamic tx addl 15 min,96571,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,364.24,,,,,,,fee schedule,291.97,364.24,
Photodynamic tx addl 15 min,96571,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,291.97,,,,,,,fee schedule,291.97,364.24,
Photodynamic tx addl 15 min,96571,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,318.95,,,,,,,fee schedule,291.97,364.24,
Photodynamic tx addl 15 min,96571,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,335.33,,,,,,,fee schedule,291.97,364.24,
Pdt dstr prmlg les phys/qhp,96573,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,666.98,,,,,,,fee schedule,198.62,881.22,
Pdt dstr prmlg les phys/qhp,96573,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,534.64,,,,,,,fee schedule,198.62,881.22,
Pdt dstr prmlg les phys/qhp,96573,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,584.05,,,,,,,fee schedule,198.62,881.22,
Pdt dstr prmlg les phys/qhp,96573,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,614.05,,,,,,,fee schedule,198.62,881.22,
Pdt dstr prmlg les phys/qhp,96573,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,881.22,,,,,,,fee schedule,198.62,881.22,APC 378
Pdt dstr prmlg les phys/qhp,96573,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.55,,,,,,,fee schedule,198.62,881.22,APC
Pdt dstr prmlg les phys/qhp,96573,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,206.57,,,,,,,fee schedule,198.62,881.22,APC
Pdt dstr prmlg les phys/qhp,96573,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.62,,,,,,,fee schedule,198.62,881.22,APC
Pdt dstr prmlg les phys/qhp,96573,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.89,,,,,,,fee schedule,198.62,881.22,Radiology
Pdt dstr prmlg les phys/qhp,96573,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,278.07,,,,,,,fee schedule,198.62,881.22,APC
Pdt dstr prmlg les phys/qhp,96573,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,347.59,,,,,,,fee schedule,198.62,881.22,APC
Dbrdmt prmlg les w/pdt,96574,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,666.98,,,,,,,fee schedule,198.62,881.22,
Dbrdmt prmlg les w/pdt,96574,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,534.64,,,,,,,fee schedule,198.62,881.22,
Dbrdmt prmlg les w/pdt,96574,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,584.05,,,,,,,fee schedule,198.62,881.22,
Dbrdmt prmlg les w/pdt,96574,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,614.05,,,,,,,fee schedule,198.62,881.22,
Dbrdmt prmlg les w/pdt,96574,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,881.22,,,,,,,fee schedule,198.62,881.22,APC 378
Dbrdmt prmlg les w/pdt,96574,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.55,,,,,,,fee schedule,198.62,881.22,APC
Dbrdmt prmlg les w/pdt,96574,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,206.57,,,,,,,fee schedule,198.62,881.22,APC
Dbrdmt prmlg les w/pdt,96574,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.62,,,,,,,fee schedule,198.62,881.22,APC
Dbrdmt prmlg les w/pdt,96574,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.89,,,,,,,fee schedule,198.62,881.22,Radiology
Dbrdmt prmlg les w/pdt,96574,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,278.07,,,,,,,fee schedule,198.62,881.22,APC
Dbrdmt prmlg les w/pdt,96574,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,347.59,,,,,,,fee schedule,198.62,881.22,APC
Ultraviolet light therapy,96900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,119.94,,,,,,,fee schedule,36.98,164.05,
Ultraviolet light therapy,96900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,96.14,,,,,,,fee schedule,36.98,164.05,
Ultraviolet light therapy,96900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,105.03,,,,,,,fee schedule,36.98,164.05,
Ultraviolet light therapy,96900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,110.42,,,,,,,fee schedule,36.98,164.05,
Ultraviolet light therapy,96900,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.05,,,,,,,fee schedule,36.98,164.05,APC 378
Ultraviolet light therapy,96900,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.83,,,,,,,fee schedule,36.98,164.05,APC
Ultraviolet light therapy,96900,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.46,,,,,,,fee schedule,36.98,164.05,APC
Ultraviolet light therapy,96900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.98,,,,,,,fee schedule,36.98,164.05,APC
Ultraviolet light therapy,96900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.57,,,,,,,fee schedule,36.98,164.05,Radiology
Ultraviolet light therapy,96900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.77,,,,,,,fee schedule,36.98,164.05,APC
Ultraviolet light therapy,96900,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.71,,,,,,,fee schedule,36.98,164.05,APC
Photochemotherapy with UV-B,96910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,119.94,,,,,,,fee schedule,58.4,259.1,
Photochemotherapy with UV-B,96910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,96.14,,,,,,,fee schedule,58.4,259.1,
Photochemotherapy with UV-B,96910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,105.03,,,,,,,fee schedule,58.4,259.1,
Photochemotherapy with UV-B,96910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,110.42,,,,,,,fee schedule,58.4,259.1,
Photochemotherapy with UV-B,96910,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,58.4,259.1,APC 378
Photochemotherapy with UV-B,96910,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,58.4,259.1,APC
Photochemotherapy with UV-B,96910,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,58.4,259.1,APC
Photochemotherapy with UV-B,96910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,58.4,259.1,APC
Photochemotherapy with UV-B,96910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,58.4,259.1,Radiology
Photochemotherapy with UV-B,96910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,58.4,259.1,APC
Photochemotherapy with UV-B,96910,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,58.4,259.1,APC
Photochemotherapy with UV-A,96912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,119.94,,,,,,,fee schedule,58.4,259.1,
Photochemotherapy with UV-A,96912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,96.14,,,,,,,fee schedule,58.4,259.1,
Photochemotherapy with UV-A,96912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,105.03,,,,,,,fee schedule,58.4,259.1,
Photochemotherapy with UV-A,96912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,110.42,,,,,,,fee schedule,58.4,259.1,
Photochemotherapy with UV-A,96912,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,58.4,259.1,APC 378
Photochemotherapy with UV-A,96912,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,58.4,259.1,APC
Photochemotherapy with UV-A,96912,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,58.4,259.1,APC
Photochemotherapy with UV-A,96912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,58.4,259.1,APC
Photochemotherapy with UV-A,96912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,58.4,259.1,Radiology
Photochemotherapy with UV-A,96912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,58.4,259.1,APC
Photochemotherapy with UV-A,96912,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,58.4,259.1,APC
Photochemotherapy uv-a or b,96913,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,650.01,,,,,,,fee schedule,402.44,1785.48,
Photochemotherapy uv-a or b,96913,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,521.04,,,,,,,fee schedule,402.44,1785.48,
Photochemotherapy uv-a or b,96913,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,569.19,,,,,,,fee schedule,402.44,1785.48,
Photochemotherapy uv-a or b,96913,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,598.42,,,,,,,fee schedule,402.44,1785.48,
Photochemotherapy uv-a or b,96913,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1785.48,,,,,,,fee schedule,402.44,1785.48,APC 378
Photochemotherapy uv-a or b,96913,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,422.56,,,,,,,fee schedule,402.44,1785.48,APC
Photochemotherapy uv-a or b,96913,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,418.53,,,,,,,fee schedule,402.44,1785.48,APC
Photochemotherapy uv-a or b,96913,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,402.44,,,,,,,fee schedule,402.44,1785.48,APC
Photochemotherapy uv-a or b,96913,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,615.73,,,,,,,fee schedule,402.44,1785.48,Radiology
Photochemotherapy uv-a or b,96913,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,563.41,,,,,,,fee schedule,402.44,1785.48,APC
Photochemotherapy uv-a or b,96913,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,704.26,,,,,,,fee schedule,402.44,1785.48,APC
Laser tx skin < 250 sq cm,96920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,364.24,,,,,,,fee schedule,198.62,881.22,
Laser tx skin < 250 sq cm,96920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,291.97,,,,,,,fee schedule,198.62,881.22,
Laser tx skin < 250 sq cm,96920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,318.95,,,,,,,fee schedule,198.62,881.22,
Laser tx skin < 250 sq cm,96920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,335.33,,,,,,,fee schedule,198.62,881.22,
Laser tx skin < 250 sq cm,96920,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,881.22,,,,,,,fee schedule,198.62,881.22,APC 378
Laser tx skin < 250 sq cm,96920,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.55,,,,,,,fee schedule,198.62,881.22,APC
Laser tx skin < 250 sq cm,96920,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,206.57,,,,,,,fee schedule,198.62,881.22,APC
Laser tx skin < 250 sq cm,96920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.62,,,,,,,fee schedule,198.62,881.22,APC
Laser tx skin < 250 sq cm,96920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.89,,,,,,,fee schedule,198.62,881.22,Radiology
Laser tx skin < 250 sq cm,96920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,278.07,,,,,,,fee schedule,198.62,881.22,APC
Laser tx skin < 250 sq cm,96920,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,347.59,,,,,,,fee schedule,198.62,881.22,APC
Laser tx skin 250-500 sq cm,96921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,364.24,,,,,,,fee schedule,198.62,881.22,
Laser tx skin 250-500 sq cm,96921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,291.97,,,,,,,fee schedule,198.62,881.22,
Laser tx skin 250-500 sq cm,96921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,318.95,,,,,,,fee schedule,198.62,881.22,
Laser tx skin 250-500 sq cm,96921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,335.33,,,,,,,fee schedule,198.62,881.22,
Laser tx skin 250-500 sq cm,96921,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,881.22,,,,,,,fee schedule,198.62,881.22,APC 378
Laser tx skin 250-500 sq cm,96921,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.55,,,,,,,fee schedule,198.62,881.22,APC
Laser tx skin 250-500 sq cm,96921,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,206.57,,,,,,,fee schedule,198.62,881.22,APC
Laser tx skin 250-500 sq cm,96921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.62,,,,,,,fee schedule,198.62,881.22,APC
Laser tx skin 250-500 sq cm,96921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.89,,,,,,,fee schedule,198.62,881.22,Radiology
Laser tx skin 250-500 sq cm,96921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,278.07,,,,,,,fee schedule,198.62,881.22,APC
Laser tx skin 250-500 sq cm,96921,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,347.59,,,,,,,fee schedule,198.62,881.22,APC
Laser tx skin >500 sq cm,96922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,364.24,,,,,,,fee schedule,291.97,1785.48,
Laser tx skin >500 sq cm,96922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,291.97,,,,,,,fee schedule,291.97,1785.48,
Laser tx skin >500 sq cm,96922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,318.95,,,,,,,fee schedule,291.97,1785.48,
Laser tx skin >500 sq cm,96922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,335.33,,,,,,,fee schedule,291.97,1785.48,
Laser tx skin >500 sq cm,96922,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1785.48,,,,,,,fee schedule,291.97,1785.48,APC 378
Laser tx skin >500 sq cm,96922,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,422.56,,,,,,,fee schedule,291.97,1785.48,APC
Laser tx skin >500 sq cm,96922,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,418.53,,,,,,,fee schedule,291.97,1785.48,APC
Laser tx skin >500 sq cm,96922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,402.44,,,,,,,fee schedule,291.97,1785.48,APC
Laser tx skin >500 sq cm,96922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,615.73,,,,,,,fee schedule,291.97,1785.48,Radiology
Laser tx skin >500 sq cm,96922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,563.41,,,,,,,fee schedule,291.97,1785.48,APC
Laser tx skin >500 sq cm,96922,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,704.26,,,,,,,fee schedule,291.97,1785.48,APC
Rcm celulr subcelulr img skn,96932,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,115.33,,,,,,,fee schedule,92.45,115.33,
Rcm celulr subcelulr img skn,96932,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,92.45,,,,,,,fee schedule,92.45,115.33,
Rcm celulr subcelulr img skn,96932,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,100.99,,,,,,,fee schedule,92.45,115.33,
Rcm celulr subcelulr img skn,96932,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,106.17,,,,,,,fee schedule,92.45,115.33,
Dermatological procedure,96999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,73.94,,,,,,,fee schedule,59.27,881.22,
Dermatological procedure,96999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,59.27,,,,,,,fee schedule,59.27,881.22,
Dermatological procedure,96999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,64.74,,,,,,,fee schedule,59.27,881.22,
Dermatological procedure,96999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,68.07,,,,,,,fee schedule,59.27,881.22,
Dermatological procedure,96999,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,881.22,,,,,,,fee schedule,59.27,881.22,APC 378
Dermatological procedure,96999,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.55,,,,,,,fee schedule,59.27,881.22,APC
Dermatological procedure,96999,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,206.57,,,,,,,fee schedule,59.27,881.22,APC
Dermatological procedure,96999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.62,,,,,,,fee schedule,59.27,881.22,APC
Dermatological procedure,96999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.89,,,,,,,fee schedule,59.27,881.22,Radiology
Dermatological procedure,96999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,278.07,,,,,,,fee schedule,59.27,881.22,APC
Dermatological procedure,96999,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,347.59,,,,,,,fee schedule,59.27,881.22,APC
Hot or cold packs therapy,97010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16.97,,,,,,,fee schedule,13.6,16.97,
Hot or cold packs therapy,97010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13.6,,,,,,,fee schedule,13.6,16.97,
Hot or cold packs therapy,97010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14.86,,,,,,,fee schedule,13.6,16.97,
Hot or cold packs therapy,97010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15.63,,,,,,,fee schedule,13.6,16.97,
Mechanical traction therapy,97012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,103.86,,,,,,,fee schedule,13.93,103.86,
Mechanical traction therapy,97012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,83.25,,,,,,,fee schedule,13.93,103.86,
Mechanical traction therapy,97012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,90.95,,,,,,,fee schedule,13.93,103.86,
Mechanical traction therapy,97012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,95.62,,,,,,,fee schedule,13.93,103.86,
Mechanical traction therapy,97012,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.93,,,,,,,fee schedule,13.93,103.86,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Mechanical traction therapy,97012,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.63,,,,,,,fee schedule,13.93,103.86,APC
Mechanical traction therapy,97012,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,14.49,,,,,,,fee schedule,13.93,103.86,APC
Mechanical traction therapy,97012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21.31,,,,,,,fee schedule,13.93,103.86,Radiology
Mechanical traction therapy,97012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.5,,,,,,,fee schedule,13.93,103.86,APC
Mechanical traction therapy,97012,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,24.38,,,,,,,fee schedule,13.93,103.86,APC
Vasopneumatic device therapy,97016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83.42,,,,,,,fee schedule,11.62,83.42,
Vasopneumatic device therapy,97016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66.87,,,,,,,fee schedule,11.62,83.42,
Vasopneumatic device therapy,97016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,73.04,,,,,,,fee schedule,11.62,83.42,
Vasopneumatic device therapy,97016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,76.8,,,,,,,fee schedule,11.62,83.42,
Vasopneumatic device therapy,97016,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.62,,,,,,,fee schedule,11.62,83.42,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Vasopneumatic device therapy,97016,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.2,,,,,,,fee schedule,11.62,83.42,APC
Vasopneumatic device therapy,97016,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.08,,,,,,,fee schedule,11.62,83.42,APC
Vasopneumatic device therapy,97016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.78,,,,,,,fee schedule,11.62,83.42,Radiology
Vasopneumatic device therapy,97016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.27,,,,,,,fee schedule,11.62,83.42,APC
Vasopneumatic device therapy,97016,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20.33,,,,,,,fee schedule,11.62,83.42,APC
Paraffin bath therapy,97018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.1,,,,,,,fee schedule,5.77,66.1,
Paraffin bath therapy,97018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52.98,,,,,,,fee schedule,5.77,66.1,
Paraffin bath therapy,97018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.88,,,,,,,fee schedule,5.77,66.1,
Paraffin bath therapy,97018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.85,,,,,,,fee schedule,5.77,66.1,
Paraffin bath therapy,97018,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.77,,,,,,,fee schedule,5.77,66.1,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Paraffin bath therapy,97018,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.06,,,,,,,fee schedule,5.77,66.1,APC
Paraffin bath therapy,97018,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6,,,,,,,fee schedule,5.77,66.1,APC
Paraffin bath therapy,97018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8.83,,,,,,,fee schedule,5.77,66.1,Radiology
Paraffin bath therapy,97018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8.08,,,,,,,fee schedule,5.77,66.1,APC
Paraffin bath therapy,97018,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10.1,,,,,,,fee schedule,5.77,66.1,APC
Whirlpool therapy,97022,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,94.14,,,,,,,fee schedule,14.96,94.14,
Whirlpool therapy,97022,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,75.46,,,,,,,fee schedule,14.96,94.14,
Whirlpool therapy,97022,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,82.43,,,,,,,fee schedule,14.96,94.14,
Whirlpool therapy,97022,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,86.67,,,,,,,fee schedule,14.96,94.14,
Whirlpool therapy,97022,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.96,,,,,,,fee schedule,14.96,94.14,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Whirlpool therapy,97022,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.71,,,,,,,fee schedule,14.96,94.14,APC
Whirlpool therapy,97022,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,15.56,,,,,,,fee schedule,14.96,94.14,APC
Whirlpool therapy,97022,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.89,,,,,,,fee schedule,14.96,94.14,Radiology
Whirlpool therapy,97022,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.94,,,,,,,fee schedule,14.96,94.14,APC
Whirlpool therapy,97022,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,26.18,,,,,,,fee schedule,14.96,94.14,APC
Diathermy eg microwave,97024,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19.39,,,,,,,fee schedule,7,19.39,
Diathermy eg microwave,97024,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15.54,,,,,,,fee schedule,7,19.39,
Diathermy eg microwave,97024,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.98,,,,,,,fee schedule,7,19.39,
Diathermy eg microwave,97024,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17.85,,,,,,,fee schedule,7,19.39,
Diathermy eg microwave,97024,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7,,,,,,,fee schedule,7,19.39,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Diathermy eg microwave,97024,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.35,,,,,,,fee schedule,7,19.39,APC
Diathermy eg microwave,97024,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7.28,,,,,,,fee schedule,7,19.39,APC
Diathermy eg microwave,97024,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10.71,,,,,,,fee schedule,7,19.39,Radiology
Diathermy eg microwave,97024,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.8,,,,,,,fee schedule,7,19.39,APC
Diathermy eg microwave,97024,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12.25,,,,,,,fee schedule,7,19.39,APC
Infrared therapy,97026,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,54.18,,,,,,,fee schedule,6.39,54.18,
Infrared therapy,97026,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,43.43,,,,,,,fee schedule,6.39,54.18,
Infrared therapy,97026,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,47.44,,,,,,,fee schedule,6.39,54.18,
Infrared therapy,97026,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,49.88,,,,,,,fee schedule,6.39,54.18,
Infrared therapy,97026,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.39,,,,,,,fee schedule,6.39,54.18,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Infrared therapy,97026,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.71,,,,,,,fee schedule,6.39,54.18,APC
Infrared therapy,97026,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6.65,,,,,,,fee schedule,6.39,54.18,APC
Infrared therapy,97026,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.78,,,,,,,fee schedule,6.39,54.18,Radiology
Infrared therapy,97026,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8.95,,,,,,,fee schedule,6.39,54.18,APC
Infrared therapy,97026,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11.18,,,,,,,fee schedule,6.39,54.18,APC
Ultraviolet therapy,97028,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22.11,,,,,,,fee schedule,7.97,22.11,
Ultraviolet therapy,97028,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17.73,,,,,,,fee schedule,7.97,22.11,
Ultraviolet therapy,97028,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19.36,,,,,,,fee schedule,7.97,22.11,
Ultraviolet therapy,97028,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20.36,,,,,,,fee schedule,7.97,22.11,
Ultraviolet therapy,97028,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.97,,,,,,,fee schedule,7.97,22.11,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Ultraviolet therapy,97028,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.37,,,,,,,fee schedule,7.97,22.11,APC
Ultraviolet therapy,97028,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8.29,,,,,,,fee schedule,7.97,22.11,APC
Ultraviolet therapy,97028,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12.19,,,,,,,fee schedule,7.97,22.11,Radiology
Ultraviolet therapy,97028,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11.16,,,,,,,fee schedule,7.97,22.11,APC
Ultraviolet therapy,97028,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,13.95,,,,,,,fee schedule,7.97,22.11,APC
Electrical stimulation,97032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,101.74,,,,,,,fee schedule,14.26,101.74,
Electrical stimulation,97032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,81.55,,,,,,,fee schedule,14.26,101.74,
Electrical stimulation,97032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,89.09,,,,,,,fee schedule,14.26,101.74,
Electrical stimulation,97032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,93.66,,,,,,,fee schedule,14.26,101.74,
Electrical stimulation,97032,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.26,,,,,,,fee schedule,14.26,101.74,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Electrical stimulation,97032,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.97,,,,,,,fee schedule,14.26,101.74,APC
Electrical stimulation,97032,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,14.83,,,,,,,fee schedule,14.26,101.74,APC
Electrical stimulation,97032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21.82,,,,,,,fee schedule,14.26,101.74,Radiology
Electrical stimulation,97032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.96,,,,,,,fee schedule,14.26,101.74,APC
Electrical stimulation,97032,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,24.96,,,,,,,fee schedule,14.26,101.74,APC
Electric current therapy,97033,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,97.98,,,,,,,fee schedule,18.27,97.98,
Electric current therapy,97033,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,78.54,,,,,,,fee schedule,18.27,97.98,
Electric current therapy,97033,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,85.8,,,,,,,fee schedule,18.27,97.98,
Electric current therapy,97033,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,90.2,,,,,,,fee schedule,18.27,97.98,
Electric current therapy,97033,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.27,,,,,,,fee schedule,18.27,97.98,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Electric current therapy,97033,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.18,,,,,,,fee schedule,18.27,97.98,APC
Electric current therapy,97033,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,19,,,,,,,fee schedule,18.27,97.98,APC
Electric current therapy,97033,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27.95,,,,,,,fee schedule,18.27,97.98,Radiology
Electric current therapy,97033,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.58,,,,,,,fee schedule,18.27,97.98,APC
Electric current therapy,97033,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31.97,,,,,,,fee schedule,18.27,97.98,APC
Contrast bath therapy,97034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,53.18,,,,,,,fee schedule,13.54,53.18,
Contrast bath therapy,97034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.63,,,,,,,fee schedule,13.54,53.18,
Contrast bath therapy,97034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.57,,,,,,,fee schedule,13.54,53.18,
Contrast bath therapy,97034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,48.96,,,,,,,fee schedule,13.54,53.18,
Contrast bath therapy,97034,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.54,,,,,,,fee schedule,13.54,53.18,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Contrast bath therapy,97034,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.22,,,,,,,fee schedule,13.54,53.18,APC
Contrast bath therapy,97034,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,14.08,,,,,,,fee schedule,13.54,53.18,APC
Contrast bath therapy,97034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.72,,,,,,,fee schedule,13.54,53.18,Radiology
Contrast bath therapy,97034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.96,,,,,,,fee schedule,13.54,53.18,APC
Contrast bath therapy,97034,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23.7,,,,,,,fee schedule,13.54,53.18,APC
Ultrasound therapy,97035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,155.53,,,,,,,fee schedule,13.85,155.53,
Ultrasound therapy,97035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,124.67,,,,,,,fee schedule,13.85,155.53,
Ultrasound therapy,97035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,136.2,,,,,,,fee schedule,13.85,155.53,
Ultrasound therapy,97035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,143.19,,,,,,,fee schedule,13.85,155.53,
Ultrasound therapy,97035,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13.85,,,,,,,fee schedule,13.85,155.53,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Ultrasound therapy,97035,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.54,,,,,,,fee schedule,13.85,155.53,APC
Ultrasound therapy,97035,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,14.4,,,,,,,fee schedule,13.85,155.53,APC
Ultrasound therapy,97035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21.19,,,,,,,fee schedule,13.85,155.53,Radiology
Ultrasound therapy,97035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.39,,,,,,,fee schedule,13.85,155.53,APC
Ultrasound therapy,97035,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,24.24,,,,,,,fee schedule,13.85,155.53,APC
Hydrotherapy,97036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,89.4,,,,,,,fee schedule,32.72,89.4,
Hydrotherapy,97036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,71.66,,,,,,,fee schedule,32.72,89.4,
Hydrotherapy,97036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,78.28,,,,,,,fee schedule,32.72,89.4,
Hydrotherapy,97036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,82.3,,,,,,,fee schedule,32.72,89.4,
Hydrotherapy,97036,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,32.72,,,,,,,fee schedule,32.72,89.4,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Hydrotherapy,97036,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,34.36,,,,,,,fee schedule,32.72,89.4,APC
Hydrotherapy,97036,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,34.03,,,,,,,fee schedule,32.72,89.4,APC
Hydrotherapy,97036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,50.06,,,,,,,fee schedule,32.72,89.4,Radiology
Hydrotherapy,97036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,45.81,,,,,,,fee schedule,32.72,89.4,APC
Hydrotherapy,97036,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,57.26,,,,,,,fee schedule,32.72,89.4,APC
Appl modality 1+lllt po pain,97037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,144.62,,,,,,,fee schedule,36.98,164.05,
Appl modality 1+lllt po pain,97037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,115.93,,,,,,,fee schedule,36.98,164.05,
Appl modality 1+lllt po pain,97037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,126.64,,,,,,,fee schedule,36.98,164.05,
Appl modality 1+lllt po pain,97037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,133.14,,,,,,,fee schedule,36.98,164.05,
Appl modality 1+lllt po pain,97037,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.05,,,,,,,fee schedule,36.98,164.05,APC 378
Appl modality 1+lllt po pain,97037,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.83,,,,,,,fee schedule,36.98,164.05,APC
Appl modality 1+lllt po pain,97037,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.46,,,,,,,fee schedule,36.98,164.05,APC
Appl modality 1+lllt po pain,97037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.98,,,,,,,fee schedule,36.98,164.05,APC
Appl modality 1+lllt po pain,97037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.57,,,,,,,fee schedule,36.98,164.05,Radiology
Appl modality 1+lllt po pain,97037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.77,,,,,,,fee schedule,36.98,164.05,APC
Appl modality 1+lllt po pain,97037,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.71,,,,,,,fee schedule,36.98,164.05,APC
Therapeutic exercises,97110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,126.38,,,,,,,fee schedule,27.99,126.38,
Therapeutic exercises,97110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,101.31,,,,,,,fee schedule,27.99,126.38,
Therapeutic exercises,97110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,110.67,,,,,,,fee schedule,27.99,126.38,
Therapeutic exercises,97110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,116.35,,,,,,,fee schedule,27.99,126.38,
Therapeutic exercises,97110,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,27.99,,,,,,,fee schedule,27.99,126.38,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Therapeutic exercises,97110,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,29.39,,,,,,,fee schedule,27.99,126.38,APC
Therapeutic exercises,97110,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,29.11,,,,,,,fee schedule,27.99,126.38,APC
Therapeutic exercises,97110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,42.82,,,,,,,fee schedule,27.99,126.38,Radiology
Therapeutic exercises,97110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,39.19,,,,,,,fee schedule,27.99,126.38,APC
Therapeutic exercises,97110,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,48.98,,,,,,,fee schedule,27.99,126.38,APC
Neuromuscular reeducation,97112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,154.63,,,,,,,fee schedule,31.5,154.63,
Neuromuscular reeducation,97112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,123.95,,,,,,,fee schedule,31.5,154.63,
Neuromuscular reeducation,97112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,135.4,,,,,,,fee schedule,31.5,154.63,
Neuromuscular reeducation,97112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,142.36,,,,,,,fee schedule,31.5,154.63,
Neuromuscular reeducation,97112,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31.5,,,,,,,fee schedule,31.5,154.63,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Neuromuscular reeducation,97112,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,33.08,,,,,,,fee schedule,31.5,154.63,APC
Neuromuscular reeducation,97112,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,32.76,,,,,,,fee schedule,31.5,154.63,APC
Neuromuscular reeducation,97112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,48.2,,,,,,,fee schedule,31.5,154.63,Radiology
Neuromuscular reeducation,97112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,44.1,,,,,,,fee schedule,31.5,154.63,APC
Neuromuscular reeducation,97112,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,55.12,,,,,,,fee schedule,31.5,154.63,APC
Aquatic therapy/exercises,97113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,118.56,,,,,,,fee schedule,35.42,118.56,
Aquatic therapy/exercises,97113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,95.03,,,,,,,fee schedule,35.42,118.56,
Aquatic therapy/exercises,97113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,103.81,,,,,,,fee schedule,35.42,118.56,
Aquatic therapy/exercises,97113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,109.15,,,,,,,fee schedule,35.42,118.56,
Aquatic therapy/exercises,97113,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,35.42,,,,,,,fee schedule,35.42,118.56,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Aquatic therapy/exercises,97113,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,37.19,,,,,,,fee schedule,35.42,118.56,APC
Aquatic therapy/exercises,97113,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,35.42,118.56,APC
Aquatic therapy/exercises,97113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,54.19,,,,,,,fee schedule,35.42,118.56,Radiology
Aquatic therapy/exercises,97113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49.59,,,,,,,fee schedule,35.42,118.56,APC
Aquatic therapy/exercises,97113,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,61.98,,,,,,,fee schedule,35.42,118.56,APC
Gait training therapy,97116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,86.49,,,,,,,fee schedule,27.99,86.49,
Gait training therapy,97116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,69.33,,,,,,,fee schedule,27.99,86.49,
Gait training therapy,97116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,75.74,,,,,,,fee schedule,27.99,86.49,
Gait training therapy,97116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,79.63,,,,,,,fee schedule,27.99,86.49,
Gait training therapy,97116,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,27.99,,,,,,,fee schedule,27.99,86.49,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Gait training therapy,97116,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,29.39,,,,,,,fee schedule,27.99,86.49,APC
Gait training therapy,97116,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,29.11,,,,,,,fee schedule,27.99,86.49,APC
Gait training therapy,97116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,42.82,,,,,,,fee schedule,27.99,86.49,Radiology
Gait training therapy,97116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,39.19,,,,,,,fee schedule,27.99,86.49,APC
Gait training therapy,97116,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,48.98,,,,,,,fee schedule,27.99,86.49,APC
Massage therapy,97124,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,80.74,,,,,,,fee schedule,28.32,80.74,
Massage therapy,97124,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,64.72,,,,,,,fee schedule,28.32,80.74,
Massage therapy,97124,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,70.7,,,,,,,fee schedule,28.32,80.74,
Massage therapy,97124,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,74.33,,,,,,,fee schedule,28.32,80.74,
Massage therapy,97124,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,28.32,,,,,,,fee schedule,28.32,80.74,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Massage therapy,97124,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,29.74,,,,,,,fee schedule,28.32,80.74,APC
Massage therapy,97124,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,29.45,,,,,,,fee schedule,28.32,80.74,APC
Massage therapy,97124,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43.33,,,,,,,fee schedule,28.32,80.74,Radiology
Massage therapy,97124,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,39.65,,,,,,,fee schedule,28.32,80.74,APC
Massage therapy,97124,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,49.56,,,,,,,fee schedule,28.32,80.74,APC
Ther ivntj 1st 15 min,97129,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,89.4,,,,,,,fee schedule,19.55,89.4,
Ther ivntj 1st 15 min,97129,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,71.66,,,,,,,fee schedule,19.55,89.4,
Ther ivntj 1st 15 min,97129,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,78.28,,,,,,,fee schedule,19.55,89.4,
Ther ivntj 1st 15 min,97129,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,82.3,,,,,,,fee schedule,19.55,89.4,
Ther ivntj 1st 15 min,97129,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.55,,,,,,,fee schedule,19.55,89.4,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Ther ivntj 1st 15 min,97129,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20.53,,,,,,,fee schedule,19.55,89.4,APC
Ther ivntj 1st 15 min,97129,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,20.33,,,,,,,fee schedule,19.55,89.4,APC
Ther ivntj 1st 15 min,97129,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29.91,,,,,,,fee schedule,19.55,89.4,Radiology
Ther ivntj 1st 15 min,97129,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27.37,,,,,,,fee schedule,19.55,89.4,APC
Ther ivntj 1st 15 min,97129,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,34.21,,,,,,,fee schedule,19.55,89.4,APC
Ther ivntj ea addl 15 min,97130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,86.71,,,,,,,fee schedule,18.18,86.71,
Ther ivntj ea addl 15 min,97130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,69.51,,,,,,,fee schedule,18.18,86.71,
Ther ivntj ea addl 15 min,97130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,75.93,,,,,,,fee schedule,18.18,86.71,
Ther ivntj ea addl 15 min,97130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,79.83,,,,,,,fee schedule,18.18,86.71,
Ther ivntj ea addl 15 min,97130,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.18,,,,,,,fee schedule,18.18,86.71,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Ther ivntj ea addl 15 min,97130,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.09,,,,,,,fee schedule,18.18,86.71,APC
Ther ivntj ea addl 15 min,97130,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18.91,,,,,,,fee schedule,18.18,86.71,APC
Ther ivntj ea addl 15 min,97130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27.82,,,,,,,fee schedule,18.18,86.71,Radiology
Ther ivntj ea addl 15 min,97130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.45,,,,,,,fee schedule,18.18,86.71,APC
Ther ivntj ea addl 15 min,97130,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31.82,,,,,,,fee schedule,18.18,86.71,APC
Manual therapy 1/> regions,97140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,92.06,,,,,,,fee schedule,26.71,92.06,
Manual therapy 1/> regions,97140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,73.8,,,,,,,fee schedule,26.71,92.06,
Manual therapy 1/> regions,97140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,80.62,,,,,,,fee schedule,26.71,92.06,
Manual therapy 1/> regions,97140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,84.76,,,,,,,fee schedule,26.71,92.06,
Manual therapy 1/> regions,97140,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26.71,,,,,,,fee schedule,26.71,92.06,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Manual therapy 1/> regions,97140,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,28.05,,,,,,,fee schedule,26.71,92.06,APC
Manual therapy 1/> regions,97140,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,27.78,,,,,,,fee schedule,26.71,92.06,APC
Manual therapy 1/> regions,97140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40.87,,,,,,,fee schedule,26.71,92.06,Radiology
Manual therapy 1/> regions,97140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,37.39,,,,,,,fee schedule,26.71,92.06,APC
Manual therapy 1/> regions,97140,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,46.74,,,,,,,fee schedule,26.71,92.06,APC
Group therapeutic procedures,97150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,119.4,,,,,,,fee schedule,17.44,119.4,
Group therapeutic procedures,97150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,95.71,,,,,,,fee schedule,17.44,119.4,
Group therapeutic procedures,97150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,104.55,,,,,,,fee schedule,17.44,119.4,
Group therapeutic procedures,97150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,109.92,,,,,,,fee schedule,17.44,119.4,
Group therapeutic procedures,97150,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.44,,,,,,,fee schedule,17.44,119.4,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Group therapeutic procedures,97150,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.31,,,,,,,fee schedule,17.44,119.4,APC
Group therapeutic procedures,97150,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18.14,,,,,,,fee schedule,17.44,119.4,APC
Group therapeutic procedures,97150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26.68,,,,,,,fee schedule,17.44,119.4,Radiology
Group therapeutic procedures,97150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24.42,,,,,,,fee schedule,17.44,119.4,APC
Group therapeutic procedures,97150,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30.52,,,,,,,fee schedule,17.44,119.4,APC
Bhv id assmt by phys/qhp,97151,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,126.18,,,,,,,fee schedule,100.57,446.2,
Bhv id assmt by phys/qhp,97151,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,101.14,,,,,,,fee schedule,100.57,446.2,
Bhv id assmt by phys/qhp,97151,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,110.49,,,,,,,fee schedule,100.57,446.2,
Bhv id assmt by phys/qhp,97151,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,116.16,,,,,,,fee schedule,100.57,446.2,
Bhv id assmt by phys/qhp,97151,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,446.2,,,,,,,fee schedule,100.57,446.2,APC 378
Bhv id assmt by phys/qhp,97151,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,105.6,,,,,,,fee schedule,100.57,446.2,APC
Bhv id assmt by phys/qhp,97151,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,104.59,,,,,,,fee schedule,100.57,446.2,APC
Bhv id assmt by phys/qhp,97151,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,100.57,,,,,,,fee schedule,100.57,446.2,APC
Bhv id assmt by phys/qhp,97151,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,153.87,,,,,,,fee schedule,100.57,446.2,Radiology
Bhv id assmt by phys/qhp,97151,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,140.8,,,,,,,fee schedule,100.57,446.2,APC
Bhv id assmt by phys/qhp,97151,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,176,,,,,,,fee schedule,100.57,446.2,APC
Bhv id suprt assmt by 1 tech,97152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,126.18,,,,,,,fee schedule,100.57,446.2,
Bhv id suprt assmt by 1 tech,97152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,101.14,,,,,,,fee schedule,100.57,446.2,
Bhv id suprt assmt by 1 tech,97152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,110.49,,,,,,,fee schedule,100.57,446.2,
Bhv id suprt assmt by 1 tech,97152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,116.16,,,,,,,fee schedule,100.57,446.2,
Bhv id suprt assmt by 1 tech,97152,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,446.2,,,,,,,fee schedule,100.57,446.2,APC 378
Bhv id suprt assmt by 1 tech,97152,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,105.6,,,,,,,fee schedule,100.57,446.2,APC
Bhv id suprt assmt by 1 tech,97152,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,104.59,,,,,,,fee schedule,100.57,446.2,APC
Bhv id suprt assmt by 1 tech,97152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,100.57,,,,,,,fee schedule,100.57,446.2,APC
Bhv id suprt assmt by 1 tech,97152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,153.87,,,,,,,fee schedule,100.57,446.2,Radiology
Bhv id suprt assmt by 1 tech,97152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,140.8,,,,,,,fee schedule,100.57,446.2,APC
Bhv id suprt assmt by 1 tech,97152,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,176,,,,,,,fee schedule,100.57,446.2,APC
Adaptive behavior tx by tech,97153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,126.18,,,,,,,fee schedule,100.57,446.2,
Adaptive behavior tx by tech,97153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,101.14,,,,,,,fee schedule,100.57,446.2,
Adaptive behavior tx by tech,97153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,110.49,,,,,,,fee schedule,100.57,446.2,
Adaptive behavior tx by tech,97153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,116.16,,,,,,,fee schedule,100.57,446.2,
Adaptive behavior tx by tech,97153,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,446.2,,,,,,,fee schedule,100.57,446.2,APC 378
Adaptive behavior tx by tech,97153,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,105.6,,,,,,,fee schedule,100.57,446.2,APC
Adaptive behavior tx by tech,97153,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,104.59,,,,,,,fee schedule,100.57,446.2,APC
Adaptive behavior tx by tech,97153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,100.57,,,,,,,fee schedule,100.57,446.2,APC
Adaptive behavior tx by tech,97153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,153.87,,,,,,,fee schedule,100.57,446.2,Radiology
Adaptive behavior tx by tech,97153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,140.8,,,,,,,fee schedule,100.57,446.2,APC
Adaptive behavior tx by tech,97153,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,176,,,,,,,fee schedule,100.57,446.2,APC
Grp adapt bhv tx by tech,97154,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,126.18,,,,,,,fee schedule,37.09,164.57,
Grp adapt bhv tx by tech,97154,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,101.14,,,,,,,fee schedule,37.09,164.57,
Grp adapt bhv tx by tech,97154,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,110.49,,,,,,,fee schedule,37.09,164.57,
Grp adapt bhv tx by tech,97154,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,116.16,,,,,,,fee schedule,37.09,164.57,
Grp adapt bhv tx by tech,97154,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.57,,,,,,,fee schedule,37.09,164.57,APC 378
Grp adapt bhv tx by tech,97154,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.95,,,,,,,fee schedule,37.09,164.57,APC
Grp adapt bhv tx by tech,97154,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.58,,,,,,,fee schedule,37.09,164.57,APC
Grp adapt bhv tx by tech,97154,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,37.09,,,,,,,fee schedule,37.09,164.57,APC
Grp adapt bhv tx by tech,97154,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.75,,,,,,,fee schedule,37.09,164.57,Radiology
Grp adapt bhv tx by tech,97154,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.93,,,,,,,fee schedule,37.09,164.57,APC
Grp adapt bhv tx by tech,97154,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.91,,,,,,,fee schedule,37.09,164.57,APC
Adapt behavior tx phys/qhp,97155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,126.18,,,,,,,fee schedule,101.14,779.59,
Adapt behavior tx phys/qhp,97155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,101.14,,,,,,,fee schedule,101.14,779.59,
Adapt behavior tx phys/qhp,97155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,110.49,,,,,,,fee schedule,101.14,779.59,
Adapt behavior tx phys/qhp,97155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,116.16,,,,,,,fee schedule,101.14,779.59,
Adapt behavior tx phys/qhp,97155,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,779.59,,,,,,,fee schedule,101.14,779.59,APC 378
Adapt behavior tx phys/qhp,97155,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,184.5,,,,,,,fee schedule,101.14,779.59,APC
Adapt behavior tx phys/qhp,97155,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,182.74,,,,,,,fee schedule,101.14,779.59,APC
Adapt behavior tx phys/qhp,97155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,175.71,,,,,,,fee schedule,101.14,779.59,APC
Adapt behavior tx phys/qhp,97155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,268.84,,,,,,,fee schedule,101.14,779.59,Radiology
Adapt behavior tx phys/qhp,97155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,246,,,,,,,fee schedule,101.14,779.59,APC
Adapt behavior tx phys/qhp,97155,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,307.5,,,,,,,fee schedule,101.14,779.59,APC
Fam adapt bhv tx gdn phy/qhp,97156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,126.18,,,,,,,fee schedule,37.09,164.57,
Fam adapt bhv tx gdn phy/qhp,97156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,101.14,,,,,,,fee schedule,37.09,164.57,
Fam adapt bhv tx gdn phy/qhp,97156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,110.49,,,,,,,fee schedule,37.09,164.57,
Fam adapt bhv tx gdn phy/qhp,97156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,116.16,,,,,,,fee schedule,37.09,164.57,
Fam adapt bhv tx gdn phy/qhp,97156,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.57,,,,,,,fee schedule,37.09,164.57,APC 378
Fam adapt bhv tx gdn phy/qhp,97156,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.95,,,,,,,fee schedule,37.09,164.57,APC
Fam adapt bhv tx gdn phy/qhp,97156,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.58,,,,,,,fee schedule,37.09,164.57,APC
Fam adapt bhv tx gdn phy/qhp,97156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,37.09,,,,,,,fee schedule,37.09,164.57,APC
Fam adapt bhv tx gdn phy/qhp,97156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.75,,,,,,,fee schedule,37.09,164.57,Radiology
Fam adapt bhv tx gdn phy/qhp,97156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.93,,,,,,,fee schedule,37.09,164.57,APC
Fam adapt bhv tx gdn phy/qhp,97156,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.91,,,,,,,fee schedule,37.09,164.57,APC
Mult fam adapt bhv tx gdn,97157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,126.18,,,,,,,fee schedule,37.09,164.57,
Mult fam adapt bhv tx gdn,97157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,101.14,,,,,,,fee schedule,37.09,164.57,
Mult fam adapt bhv tx gdn,97157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,110.49,,,,,,,fee schedule,37.09,164.57,
Mult fam adapt bhv tx gdn,97157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,116.16,,,,,,,fee schedule,37.09,164.57,
Mult fam adapt bhv tx gdn,97157,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.57,,,,,,,fee schedule,37.09,164.57,APC 378
Mult fam adapt bhv tx gdn,97157,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.95,,,,,,,fee schedule,37.09,164.57,APC
Mult fam adapt bhv tx gdn,97157,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.58,,,,,,,fee schedule,37.09,164.57,APC
Mult fam adapt bhv tx gdn,97157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,37.09,,,,,,,fee schedule,37.09,164.57,APC
Mult fam adapt bhv tx gdn,97157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.75,,,,,,,fee schedule,37.09,164.57,Radiology
Mult fam adapt bhv tx gdn,97157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.93,,,,,,,fee schedule,37.09,164.57,APC
Mult fam adapt bhv tx gdn,97157,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.91,,,,,,,fee schedule,37.09,164.57,APC
Grp adapt bhv tx by phy/qhp,97158,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,126.18,,,,,,,fee schedule,37.09,164.57,
Grp adapt bhv tx by phy/qhp,97158,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,101.14,,,,,,,fee schedule,37.09,164.57,
Grp adapt bhv tx by phy/qhp,97158,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,110.49,,,,,,,fee schedule,37.09,164.57,
Grp adapt bhv tx by phy/qhp,97158,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,116.16,,,,,,,fee schedule,37.09,164.57,
Grp adapt bhv tx by phy/qhp,97158,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.57,,,,,,,fee schedule,37.09,164.57,APC 378
Grp adapt bhv tx by phy/qhp,97158,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.95,,,,,,,fee schedule,37.09,164.57,APC
Grp adapt bhv tx by phy/qhp,97158,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.58,,,,,,,fee schedule,37.09,164.57,APC
Grp adapt bhv tx by phy/qhp,97158,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,37.09,,,,,,,fee schedule,37.09,164.57,APC
Grp adapt bhv tx by phy/qhp,97158,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.75,,,,,,,fee schedule,37.09,164.57,Radiology
Grp adapt bhv tx by phy/qhp,97158,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.93,,,,,,,fee schedule,37.09,164.57,APC
Grp adapt bhv tx by phy/qhp,97158,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.91,,,,,,,fee schedule,37.09,164.57,APC
Pt eval low complex 20 min,97161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,293.34,,,,,,,fee schedule,94.11,293.34,
Pt eval low complex 20 min,97161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,235.14,,,,,,,fee schedule,94.11,293.34,
Pt eval low complex 20 min,97161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,256.87,,,,,,,fee schedule,94.11,293.34,
Pt eval low complex 20 min,97161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,270.06,,,,,,,fee schedule,94.11,293.34,
Pt eval low complex 20 min,97161,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,94.11,,,,,,,fee schedule,94.11,293.34,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Pt eval low complex 20 min,97161,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,98.82,,,,,,,fee schedule,94.11,293.34,APC
Pt eval low complex 20 min,97161,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,97.87,,,,,,,fee schedule,94.11,293.34,APC
Pt eval low complex 20 min,97161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,143.99,,,,,,,fee schedule,94.11,293.34,Radiology
Pt eval low complex 20 min,97161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.75,,,,,,,fee schedule,94.11,293.34,APC
Pt eval low complex 20 min,97161,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,164.69,,,,,,,fee schedule,94.11,293.34,APC
Pt eval mod complex 30 min,97162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,288.6,,,,,,,fee schedule,94.11,288.6,
Pt eval mod complex 30 min,97162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,231.34,,,,,,,fee schedule,94.11,288.6,
Pt eval mod complex 30 min,97162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,252.71,,,,,,,fee schedule,94.11,288.6,
Pt eval mod complex 30 min,97162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,265.69,,,,,,,fee schedule,94.11,288.6,
Pt eval mod complex 30 min,97162,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,94.11,,,,,,,fee schedule,94.11,288.6,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Pt eval mod complex 30 min,97162,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,98.82,,,,,,,fee schedule,94.11,288.6,APC
Pt eval mod complex 30 min,97162,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,97.87,,,,,,,fee schedule,94.11,288.6,APC
Pt eval mod complex 30 min,97162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,143.99,,,,,,,fee schedule,94.11,288.6,Radiology
Pt eval mod complex 30 min,97162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.75,,,,,,,fee schedule,94.11,288.6,APC
Pt eval mod complex 30 min,97162,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,164.69,,,,,,,fee schedule,94.11,288.6,APC
Pt eval high complex 45 min,97163,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,288.28,,,,,,,fee schedule,94.11,288.28,
Pt eval high complex 45 min,97163,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,231.08,,,,,,,fee schedule,94.11,288.28,
Pt eval high complex 45 min,97163,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,252.44,,,,,,,fee schedule,94.11,288.28,
Pt eval high complex 45 min,97163,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,265.4,,,,,,,fee schedule,94.11,288.28,
Pt eval high complex 45 min,97163,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,94.11,,,,,,,fee schedule,94.11,288.28,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Pt eval high complex 45 min,97163,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,98.82,,,,,,,fee schedule,94.11,288.28,APC
Pt eval high complex 45 min,97163,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,97.87,,,,,,,fee schedule,94.11,288.28,APC
Pt eval high complex 45 min,97163,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,143.99,,,,,,,fee schedule,94.11,288.28,Radiology
Pt eval high complex 45 min,97163,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.75,,,,,,,fee schedule,94.11,288.28,APC
Pt eval high complex 45 min,97163,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,164.69,,,,,,,fee schedule,94.11,288.28,APC
Pt re-eval est plan care,97164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,113.92,,,,,,,fee schedule,64.63,113.92,
Pt re-eval est plan care,97164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,91.32,,,,,,,fee schedule,64.63,113.92,
Pt re-eval est plan care,97164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,99.75,,,,,,,fee schedule,64.63,113.92,
Pt re-eval est plan care,97164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,104.88,,,,,,,fee schedule,64.63,113.92,
Pt re-eval est plan care,97164,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,64.63,,,,,,,fee schedule,64.63,113.92,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Pt re-eval est plan care,97164,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,67.86,,,,,,,fee schedule,64.63,113.92,APC
Pt re-eval est plan care,97164,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,67.22,,,,,,,fee schedule,64.63,113.92,APC
Pt re-eval est plan care,97164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,98.88,,,,,,,fee schedule,64.63,113.92,Radiology
Pt re-eval est plan care,97164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,90.48,,,,,,,fee schedule,64.63,113.92,APC
Pt re-eval est plan care,97164,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,113.1,,,,,,,fee schedule,64.63,113.92,APC
Ot eval low complex 30 min,97165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,288.24,,,,,,,fee schedule,96.56,288.24,
Ot eval low complex 30 min,97165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,231.05,,,,,,,fee schedule,96.56,288.24,
Ot eval low complex 30 min,97165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,252.4,,,,,,,fee schedule,96.56,288.24,
Ot eval low complex 30 min,97165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,265.36,,,,,,,fee schedule,96.56,288.24,
Ot eval low complex 30 min,97165,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,96.56,,,,,,,fee schedule,96.56,288.24,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Ot eval low complex 30 min,97165,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,101.39,,,,,,,fee schedule,96.56,288.24,APC
Ot eval low complex 30 min,97165,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,100.42,,,,,,,fee schedule,96.56,288.24,APC
Ot eval low complex 30 min,97165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,147.74,,,,,,,fee schedule,96.56,288.24,Radiology
Ot eval low complex 30 min,97165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,135.18,,,,,,,fee schedule,96.56,288.24,APC
Ot eval low complex 30 min,97165,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,168.98,,,,,,,fee schedule,96.56,288.24,APC
Ot eval mod complex 45 min,97166,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,287.6,,,,,,,fee schedule,96.56,287.6,
Ot eval mod complex 45 min,97166,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,230.54,,,,,,,fee schedule,96.56,287.6,
Ot eval mod complex 45 min,97166,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,251.84,,,,,,,fee schedule,96.56,287.6,
Ot eval mod complex 45 min,97166,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,264.77,,,,,,,fee schedule,96.56,287.6,
Ot eval mod complex 45 min,97166,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,96.56,,,,,,,fee schedule,96.56,287.6,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Ot eval mod complex 45 min,97166,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,101.39,,,,,,,fee schedule,96.56,287.6,APC
Ot eval mod complex 45 min,97166,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,100.42,,,,,,,fee schedule,96.56,287.6,APC
Ot eval mod complex 45 min,97166,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,147.74,,,,,,,fee schedule,96.56,287.6,Radiology
Ot eval mod complex 45 min,97166,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,135.18,,,,,,,fee schedule,96.56,287.6,APC
Ot eval mod complex 45 min,97166,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,168.98,,,,,,,fee schedule,96.56,287.6,APC
Ot eval high complex 60 min,97167,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,288.24,,,,,,,fee schedule,96.56,288.24,
Ot eval high complex 60 min,97167,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,231.05,,,,,,,fee schedule,96.56,288.24,
Ot eval high complex 60 min,97167,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,252.4,,,,,,,fee schedule,96.56,288.24,
Ot eval high complex 60 min,97167,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,265.36,,,,,,,fee schedule,96.56,288.24,
Ot eval high complex 60 min,97167,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,96.56,,,,,,,fee schedule,96.56,288.24,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Ot eval high complex 60 min,97167,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,101.39,,,,,,,fee schedule,96.56,288.24,APC
Ot eval high complex 60 min,97167,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,100.42,,,,,,,fee schedule,96.56,288.24,APC
Ot eval high complex 60 min,97167,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,147.74,,,,,,,fee schedule,96.56,288.24,Radiology
Ot eval high complex 60 min,97167,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,135.18,,,,,,,fee schedule,96.56,288.24,APC
Ot eval high complex 60 min,97167,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,168.98,,,,,,,fee schedule,96.56,288.24,APC
Ot re-eval est plan care,97168,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,139.13,,,,,,,fee schedule,65.54,139.13,
Ot re-eval est plan care,97168,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,111.53,,,,,,,fee schedule,65.54,139.13,
Ot re-eval est plan care,97168,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,121.83,,,,,,,fee schedule,65.54,139.13,
Ot re-eval est plan care,97168,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,128.09,,,,,,,fee schedule,65.54,139.13,
Ot re-eval est plan care,97168,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,65.54,,,,,,,fee schedule,65.54,139.13,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Ot re-eval est plan care,97168,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,68.82,,,,,,,fee schedule,65.54,139.13,APC
Ot re-eval est plan care,97168,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,68.16,,,,,,,fee schedule,65.54,139.13,APC
Ot re-eval est plan care,97168,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,100.28,,,,,,,fee schedule,65.54,139.13,Radiology
Ot re-eval est plan care,97168,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,91.76,,,,,,,fee schedule,65.54,139.13,APC
Ot re-eval est plan care,97168,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,114.7,,,,,,,fee schedule,65.54,139.13,APC
Athletic trn eval low cmplx,97169,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,199.83,,,,,,,fee schedule,160.18,199.83,
Athletic trn eval low cmplx,97169,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,160.18,,,,,,,fee schedule,160.18,199.83,
Athletic trn eval low cmplx,97169,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,174.98,,,,,,,fee schedule,160.18,199.83,
Athletic trn eval low cmplx,97169,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,183.97,,,,,,,fee schedule,160.18,199.83,
Athletic trn eval mod cmplx,97170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,199.83,,,,,,,fee schedule,160.18,199.83,
Athletic trn eval mod cmplx,97170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,160.18,,,,,,,fee schedule,160.18,199.83,
Athletic trn eval mod cmplx,97170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,174.98,,,,,,,fee schedule,160.18,199.83,
Athletic trn eval mod cmplx,97170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,183.97,,,,,,,fee schedule,160.18,199.83,
Athletic trn eval high cmplx,97171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,199.83,,,,,,,fee schedule,160.18,199.83,
Athletic trn eval high cmplx,97171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,160.18,,,,,,,fee schedule,160.18,199.83,
Athletic trn eval high cmplx,97171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,174.98,,,,,,,fee schedule,160.18,199.83,
Athletic trn eval high cmplx,97171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,183.97,,,,,,,fee schedule,160.18,199.83,
Athletic trn re-eval plan cr,97172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,99.97,,,,,,,fee schedule,80.13,99.97,
Athletic trn re-eval plan cr,97172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,80.13,,,,,,,fee schedule,80.13,99.97,
Athletic trn re-eval plan cr,97172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,87.54,,,,,,,fee schedule,80.13,99.97,
Athletic trn re-eval plan cr,97172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,92.04,,,,,,,fee schedule,80.13,99.97,
Therapeutic activities,97530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,106.27,,,,,,,fee schedule,33.47,106.27,
Therapeutic activities,97530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,85.18,,,,,,,fee schedule,33.47,106.27,
Therapeutic activities,97530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,93.06,,,,,,,fee schedule,33.47,106.27,
Therapeutic activities,97530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,97.83,,,,,,,fee schedule,33.47,106.27,
Therapeutic activities,97530,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,33.47,,,,,,,fee schedule,33.47,106.27,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Therapeutic activities,97530,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,35.14,,,,,,,fee schedule,33.47,106.27,APC
Therapeutic activities,97530,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,34.81,,,,,,,fee schedule,33.47,106.27,APC
Therapeutic activities,97530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.21,,,,,,,fee schedule,33.47,106.27,Radiology
Therapeutic activities,97530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,46.86,,,,,,,fee schedule,33.47,106.27,APC
Therapeutic activities,97530,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,58.57,,,,,,,fee schedule,33.47,106.27,APC
Sensory Integration,97533,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,130.03,,,,,,,fee schedule,57.17,130.03,
Sensory Integration,97533,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,104.23,,,,,,,fee schedule,57.17,130.03,
Sensory Integration,97533,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,113.86,,,,,,,fee schedule,57.17,130.03,
Sensory Integration,97533,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,119.71,,,,,,,fee schedule,57.17,130.03,
Sensory Integration,97533,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,57.17,,,,,,,fee schedule,57.17,130.03,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Sensory Integration,97533,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,60.03,,,,,,,fee schedule,57.17,130.03,APC
Sensory Integration,97533,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,59.46,,,,,,,fee schedule,57.17,130.03,APC
Sensory Integration,97533,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,87.47,,,,,,,fee schedule,57.17,130.03,Radiology
Sensory Integration,97533,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,80.04,,,,,,,fee schedule,57.17,130.03,APC
Sensory Integration,97533,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,100.05,,,,,,,fee schedule,57.17,130.03,APC
Self care mngment training,97535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,94.27,,,,,,,fee schedule,31.05,94.27,
Self care mngment training,97535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,75.57,,,,,,,fee schedule,31.05,94.27,
Self care mngment training,97535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,82.55,,,,,,,fee schedule,31.05,94.27,
Self care mngment training,97535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,86.79,,,,,,,fee schedule,31.05,94.27,
Self care mngment training,97535,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31.05,,,,,,,fee schedule,31.05,94.27,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Self care mngment training,97535,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,32.6,,,,,,,fee schedule,31.05,94.27,APC
Self care mngment training,97535,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,32.29,,,,,,,fee schedule,31.05,94.27,APC
Self care mngment training,97535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,47.51,,,,,,,fee schedule,31.05,94.27,Radiology
Self care mngment training,97535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43.47,,,,,,,fee schedule,31.05,94.27,APC
Self care mngment training,97535,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,54.34,,,,,,,fee schedule,31.05,94.27,APC
Community/work reintegration,97537,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,96.81,,,,,,,fee schedule,30.83,96.81,
Community/work reintegration,97537,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,77.6,,,,,,,fee schedule,30.83,96.81,
Community/work reintegration,97537,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,84.77,,,,,,,fee schedule,30.83,96.81,
Community/work reintegration,97537,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,89.12,,,,,,,fee schedule,30.83,96.81,
Community/work reintegration,97537,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,30.83,,,,,,,fee schedule,30.83,96.81,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Community/work reintegration,97537,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,32.37,,,,,,,fee schedule,30.83,96.81,APC
Community/work reintegration,97537,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,32.06,,,,,,,fee schedule,30.83,96.81,APC
Community/work reintegration,97537,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,47.17,,,,,,,fee schedule,30.83,96.81,Radiology
Community/work reintegration,97537,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43.16,,,,,,,fee schedule,30.83,96.81,APC
Community/work reintegration,97537,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,53.95,,,,,,,fee schedule,30.83,96.81,APC
Wheelchair mngment training,97542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59.6,,,,,,,fee schedule,29.91,59.6,
Wheelchair mngment training,97542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,47.77,,,,,,,fee schedule,29.91,59.6,
Wheelchair mngment training,97542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52.19,,,,,,,fee schedule,29.91,59.6,
Wheelchair mngment training,97542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,54.87,,,,,,,fee schedule,29.91,59.6,
Wheelchair mngment training,97542,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,29.91,,,,,,,fee schedule,29.91,59.6,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Wheelchair mngment training,97542,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,31.41,,,,,,,fee schedule,29.91,59.6,APC
Wheelchair mngment training,97542,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,31.11,,,,,,,fee schedule,29.91,59.6,APC
Wheelchair mngment training,97542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,45.76,,,,,,,fee schedule,29.91,59.6,Radiology
Wheelchair mngment training,97542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,41.87,,,,,,,fee schedule,29.91,59.6,APC
Wheelchair mngment training,97542,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,52.34,,,,,,,fee schedule,29.91,59.6,APC
Work hardening,97545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,413.46,,,,,,,fee schedule,331.42,413.46,
Work hardening,97545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,331.42,,,,,,,fee schedule,331.42,413.46,
Work hardening,97545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,362.05,,,,,,,fee schedule,331.42,413.46,
Work hardening,97545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,380.64,,,,,,,fee schedule,331.42,413.46,
Work hardening add-on,97546,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,164.66,,,,,,,fee schedule,131.99,164.66,
Work hardening add-on,97546,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,131.99,,,,,,,fee schedule,131.99,164.66,
Work hardening add-on,97546,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,144.18,,,,,,,fee schedule,131.99,164.66,
Work hardening add-on,97546,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,151.59,,,,,,,fee schedule,131.99,164.66,
Caregiver traing 1st 30 min,97550,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,39.32,,,,,,,fee schedule,39.32,68.81,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Caregiver traing 1st 30 min,97550,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,41.29,,,,,,,fee schedule,39.32,68.81,APC
Caregiver traing 1st 30 min,97550,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,40.89,,,,,,,fee schedule,39.32,68.81,APC
Caregiver traing 1st 30 min,97550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,60.16,,,,,,,fee schedule,39.32,68.81,Radiology
Caregiver traing 1st 30 min,97550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,55.05,,,,,,,fee schedule,39.32,68.81,APC
Caregiver traing 1st 30 min,97550,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,68.81,,,,,,,fee schedule,39.32,68.81,APC
Caregiver traing ea addl 15,97551,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,20.79,,,,,,,fee schedule,20.79,36.38,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Caregiver traing ea addl 15,97551,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.83,,,,,,,fee schedule,20.79,36.38,APC
Caregiver traing ea addl 15,97551,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,21.62,,,,,,,fee schedule,20.79,36.38,APC
Caregiver traing ea addl 15,97551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,31.81,,,,,,,fee schedule,20.79,36.38,Radiology
Caregiver traing ea addl 15,97551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29.11,,,,,,,fee schedule,20.79,36.38,APC
Caregiver traing ea addl 15,97551,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,36.38,,,,,,,fee schedule,20.79,36.38,APC
Group caregiver training,97552,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.31,,,,,,,fee schedule,9.31,16.29,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Group caregiver training,97552,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.78,,,,,,,fee schedule,9.31,16.29,APC
Group caregiver training,97552,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9.68,,,,,,,fee schedule,9.31,16.29,APC
Group caregiver training,97552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.24,,,,,,,fee schedule,9.31,16.29,Radiology
Group caregiver training,97552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.03,,,,,,,fee schedule,9.31,16.29,APC
Group caregiver training,97552,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16.29,,,,,,,fee schedule,9.31,16.29,APC
Rmvl devital tis 20 cm/<,97597,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,427.97,,,,,,,fee schedule,198.62,881.22,
Rmvl devital tis 20 cm/<,97597,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,343.05,,,,,,,fee schedule,198.62,881.22,
Rmvl devital tis 20 cm/<,97597,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,374.75,,,,,,,fee schedule,198.62,881.22,
Rmvl devital tis 20 cm/<,97597,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,394,,,,,,,fee schedule,198.62,881.22,
Rmvl devital tis 20 cm/<,97597,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,881.22,,,,,,,fee schedule,198.62,881.22,APC 378
Rmvl devital tis 20 cm/<,97597,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.55,,,,,,,fee schedule,198.62,881.22,APC
Rmvl devital tis 20 cm/<,97597,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,206.57,,,,,,,fee schedule,198.62,881.22,APC
Rmvl devital tis 20 cm/<,97597,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.62,,,,,,,fee schedule,198.62,881.22,APC
Rmvl devital tis 20 cm/<,97597,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.89,,,,,,,fee schedule,198.62,881.22,Radiology
Rmvl devital tis 20 cm/<,97597,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,278.07,,,,,,,fee schedule,198.62,881.22,APC
Rmvl devital tis 20 cm/<,97597,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,347.59,,,,,,,fee schedule,198.62,881.22,APC
Rmvl devital tis addl 20cm/<,97598,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,326.16,,,,,,,fee schedule,261.45,326.16,
Rmvl devital tis addl 20cm/<,97598,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,261.45,,,,,,,fee schedule,261.45,326.16,
Rmvl devital tis addl 20cm/<,97598,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,285.61,,,,,,,fee schedule,261.45,326.16,
Rmvl devital tis addl 20cm/<,97598,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,300.28,,,,,,,fee schedule,261.45,326.16,
Wound(s) care non-selective,97602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,179.31,,,,,,,fee schedule,143.74,881.22,
Wound(s) care non-selective,97602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,143.74,,,,,,,fee schedule,143.74,881.22,
Wound(s) care non-selective,97602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,157.02,,,,,,,fee schedule,143.74,881.22,
Wound(s) care non-selective,97602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,165.08,,,,,,,fee schedule,143.74,881.22,
Wound(s) care non-selective,97602,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,881.22,,,,,,,fee schedule,143.74,881.22,APC 378
Wound(s) care non-selective,97602,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.55,,,,,,,fee schedule,143.74,881.22,APC
Wound(s) care non-selective,97602,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,206.57,,,,,,,fee schedule,143.74,881.22,APC
Wound(s) care non-selective,97602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.62,,,,,,,fee schedule,143.74,881.22,APC
Wound(s) care non-selective,97602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.89,,,,,,,fee schedule,143.74,881.22,Radiology
Wound(s) care non-selective,97602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,278.07,,,,,,,fee schedule,143.74,881.22,APC
Wound(s) care non-selective,97602,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,347.59,,,,,,,fee schedule,143.74,881.22,APC
Neg press wound tx <=50 cm,97605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,938.06,,,,,,,fee schedule,198.62,938.06,
Neg press wound tx <=50 cm,97605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,751.93,,,,,,,fee schedule,198.62,938.06,
Neg press wound tx <=50 cm,97605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,821.42,,,,,,,fee schedule,198.62,938.06,
Neg press wound tx <=50 cm,97605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,863.61,,,,,,,fee schedule,198.62,938.06,
Neg press wound tx <=50 cm,97605,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,881.22,,,,,,,fee schedule,198.62,938.06,APC 378
Neg press wound tx <=50 cm,97605,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.55,,,,,,,fee schedule,198.62,938.06,APC
Neg press wound tx <=50 cm,97605,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,206.57,,,,,,,fee schedule,198.62,938.06,APC
Neg press wound tx <=50 cm,97605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.62,,,,,,,fee schedule,198.62,938.06,APC
Neg press wound tx <=50 cm,97605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.89,,,,,,,fee schedule,198.62,938.06,Radiology
Neg press wound tx <=50 cm,97605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,278.07,,,,,,,fee schedule,198.62,938.06,APC
Neg press wound tx <=50 cm,97605,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,347.59,,,,,,,fee schedule,198.62,938.06,APC
Neg press wound tx >50 cm,97606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6253.46,,,,,,,fee schedule,402.44,6253.46,
Neg press wound tx >50 cm,97606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5012.69,,,,,,,fee schedule,402.44,6253.46,
Neg press wound tx >50 cm,97606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5475.91,,,,,,,fee schedule,402.44,6253.46,
Neg press wound tx >50 cm,97606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5757.15,,,,,,,fee schedule,402.44,6253.46,
Neg press wound tx >50 cm,97606,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1785.48,,,,,,,fee schedule,402.44,6253.46,APC 378
Neg press wound tx >50 cm,97606,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,422.56,,,,,,,fee schedule,402.44,6253.46,APC
Neg press wound tx >50 cm,97606,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,418.53,,,,,,,fee schedule,402.44,6253.46,APC
Neg press wound tx >50 cm,97606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,402.44,,,,,,,fee schedule,402.44,6253.46,APC
Neg press wound tx >50 cm,97606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,615.73,,,,,,,fee schedule,402.44,6253.46,Radiology
Neg press wound tx >50 cm,97606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,563.41,,,,,,,fee schedule,402.44,6253.46,APC
Neg press wound tx >50 cm,97606,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,704.26,,,,,,,fee schedule,402.44,6253.46,APC
Neg press wnd tx <=50 sq cm,97607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,391.18,,,,,,,fee schedule,313.56,1785.48,
Neg press wnd tx <=50 sq cm,97607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,313.56,,,,,,,fee schedule,313.56,1785.48,
Neg press wnd tx <=50 sq cm,97607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,342.54,,,,,,,fee schedule,313.56,1785.48,
Neg press wnd tx <=50 sq cm,97607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,360.13,,,,,,,fee schedule,313.56,1785.48,
Neg press wnd tx <=50 sq cm,97607,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1785.48,,,,,,,fee schedule,313.56,1785.48,APC 378
Neg press wnd tx <=50 sq cm,97607,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,422.56,,,,,,,fee schedule,313.56,1785.48,APC
Neg press wnd tx <=50 sq cm,97607,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,418.53,,,,,,,fee schedule,313.56,1785.48,APC
Neg press wnd tx <=50 sq cm,97607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,402.44,,,,,,,fee schedule,313.56,1785.48,APC
Neg press wnd tx <=50 sq cm,97607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,615.73,,,,,,,fee schedule,313.56,1785.48,Radiology
Neg press wnd tx <=50 sq cm,97607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,563.41,,,,,,,fee schedule,313.56,1785.48,APC
Neg press wnd tx <=50 sq cm,97607,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,704.26,,,,,,,fee schedule,313.56,1785.48,APC
Neg press wound tx >50 cm,97608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,552.41,,,,,,,fee schedule,402.44,1785.48,
Neg press wound tx >50 cm,97608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,442.8,,,,,,,fee schedule,402.44,1785.48,
Neg press wound tx >50 cm,97608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,483.72,,,,,,,fee schedule,402.44,1785.48,
Neg press wound tx >50 cm,97608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,508.57,,,,,,,fee schedule,402.44,1785.48,
Neg press wound tx >50 cm,97608,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1785.48,,,,,,,fee schedule,402.44,1785.48,APC 378
Neg press wound tx >50 cm,97608,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,422.56,,,,,,,fee schedule,402.44,1785.48,APC
Neg press wound tx >50 cm,97608,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,418.53,,,,,,,fee schedule,402.44,1785.48,APC
Neg press wound tx >50 cm,97608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,402.44,,,,,,,fee schedule,402.44,1785.48,APC
Neg press wound tx >50 cm,97608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,615.73,,,,,,,fee schedule,402.44,1785.48,Radiology
Neg press wound tx >50 cm,97608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,563.41,,,,,,,fee schedule,402.44,1785.48,APC
Neg press wound tx >50 cm,97608,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,704.26,,,,,,,fee schedule,402.44,1785.48,APC
Low frequency non-thermal us,97610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,552.41,,,,,,,fee schedule,198.62,881.22,
Low frequency non-thermal us,97610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,442.8,,,,,,,fee schedule,198.62,881.22,
Low frequency non-thermal us,97610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,483.72,,,,,,,fee schedule,198.62,881.22,
Low frequency non-thermal us,97610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,508.57,,,,,,,fee schedule,198.62,881.22,
Low frequency non-thermal us,97610,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,881.22,,,,,,,fee schedule,198.62,881.22,APC 378
Low frequency non-thermal us,97610,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.55,,,,,,,fee schedule,198.62,881.22,APC
Low frequency non-thermal us,97610,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,206.57,,,,,,,fee schedule,198.62,881.22,APC
Low frequency non-thermal us,97610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.62,,,,,,,fee schedule,198.62,881.22,APC
Low frequency non-thermal us,97610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.89,,,,,,,fee schedule,198.62,881.22,Radiology
Low frequency non-thermal us,97610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,278.07,,,,,,,fee schedule,198.62,881.22,APC
Low frequency non-thermal us,97610,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,347.59,,,,,,,fee schedule,198.62,881.22,APC
Physical performance test,97750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,140.01,,,,,,,fee schedule,32.28,140.01,
Physical performance test,97750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,112.23,,,,,,,fee schedule,32.28,140.01,
Physical performance test,97750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,122.6,,,,,,,fee schedule,32.28,140.01,
Physical performance test,97750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,128.9,,,,,,,fee schedule,32.28,140.01,
Physical performance test,97750,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,32.28,,,,,,,fee schedule,32.28,140.01,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Physical performance test,97750,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,33.89,,,,,,,fee schedule,32.28,140.01,APC
Physical performance test,97750,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,33.57,,,,,,,fee schedule,32.28,140.01,APC
Physical performance test,97750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49.39,,,,,,,fee schedule,32.28,140.01,Radiology
Physical performance test,97750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,45.19,,,,,,,fee schedule,32.28,140.01,APC
Physical performance test,97750,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,56.49,,,,,,,fee schedule,32.28,140.01,APC
Assistive technology assess,97755,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,121.49,,,,,,,fee schedule,36.42,121.49,
Assistive technology assess,97755,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,97.38,,,,,,,fee schedule,36.42,121.49,
Assistive technology assess,97755,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,106.38,,,,,,,fee schedule,36.42,121.49,
Assistive technology assess,97755,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,111.85,,,,,,,fee schedule,36.42,121.49,
Assistive technology assess,97755,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,36.42,,,,,,,fee schedule,36.42,121.49,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Assistive technology assess,97755,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.24,,,,,,,fee schedule,36.42,121.49,APC
Assistive technology assess,97755,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,37.88,,,,,,,fee schedule,36.42,121.49,APC
Assistive technology assess,97755,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,55.72,,,,,,,fee schedule,36.42,121.49,Radiology
Assistive technology assess,97755,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,50.99,,,,,,,fee schedule,36.42,121.49,APC
Assistive technology assess,97755,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,63.74,,,,,,,fee schedule,36.42,121.49,APC
Orthotic mgmt and training,97760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,148.45,,,,,,,fee schedule,43.75,148.45,
Orthotic mgmt and training,97760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,119,,,,,,,fee schedule,43.75,148.45,
Orthotic mgmt and training,97760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,129.99,,,,,,,fee schedule,43.75,148.45,
Orthotic mgmt and training,97760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,136.67,,,,,,,fee schedule,43.75,148.45,
Orthotic mgmt and training,97760,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,43.75,,,,,,,fee schedule,43.75,148.45,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Orthotic mgmt and training,97760,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,45.94,,,,,,,fee schedule,43.75,148.45,APC
Orthotic mgmt and training,97760,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,45.5,,,,,,,fee schedule,43.75,148.45,APC
Orthotic mgmt and training,97760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,66.94,,,,,,,fee schedule,43.75,148.45,Radiology
Orthotic mgmt and training,97760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,61.25,,,,,,,fee schedule,43.75,148.45,APC
Orthotic mgmt and training,97760,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,76.56,,,,,,,fee schedule,43.75,148.45,APC
Prosthetic training,97761,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,129.76,,,,,,,fee schedule,38.54,129.76,
Prosthetic training,97761,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,104.01,,,,,,,fee schedule,38.54,129.76,
Prosthetic training,97761,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,113.63,,,,,,,fee schedule,38.54,129.76,
Prosthetic training,97761,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,119.46,,,,,,,fee schedule,38.54,129.76,
Prosthetic training,97761,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,38.54,,,,,,,fee schedule,38.54,129.76,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Prosthetic training,97761,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,40.47,,,,,,,fee schedule,38.54,129.76,APC
Prosthetic training,97761,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,40.08,,,,,,,fee schedule,38.54,129.76,APC
Prosthetic training,97761,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,58.97,,,,,,,fee schedule,38.54,129.76,Radiology
Prosthetic training,97761,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,53.96,,,,,,,fee schedule,38.54,129.76,APC
Prosthetic training,97761,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,67.44,,,,,,,fee schedule,38.54,129.76,APC
Orthc/prostc mgmt sbsq enc,97763,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,47.37,,,,,,,fee schedule,47.37,82.9,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Orthc/prostc mgmt sbsq enc,97763,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,49.74,,,,,,,fee schedule,47.37,82.9,APC
Orthc/prostc mgmt sbsq enc,97763,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,49.26,,,,,,,fee schedule,47.37,82.9,APC
Orthc/prostc mgmt sbsq enc,97763,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,72.48,,,,,,,fee schedule,47.37,82.9,Radiology
Orthc/prostc mgmt sbsq enc,97763,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,66.32,,,,,,,fee schedule,47.37,82.9,APC
Orthc/prostc mgmt sbsq enc,97763,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,82.9,,,,,,,fee schedule,47.37,82.9,APC
Medical nutrition indiv in,97802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,100.43,,,,,,,fee schedule,25.76,100.43,
Medical nutrition indiv in,97802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,80.51,,,,,,,fee schedule,25.76,100.43,
Medical nutrition indiv in,97802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,87.95,,,,,,,fee schedule,25.76,100.43,
Medical nutrition indiv in,97802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,92.46,,,,,,,fee schedule,25.76,100.43,
Medical nutrition indiv in,97802,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25.76,,,,,,,fee schedule,25.76,100.43,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Medical nutrition indiv in,97802,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,27.05,,,,,,,fee schedule,25.76,100.43,APC
Medical nutrition indiv in,97802,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,26.79,,,,,,,fee schedule,25.76,100.43,APC
Medical nutrition indiv in,97802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,39.41,,,,,,,fee schedule,25.76,100.43,Radiology
Medical nutrition indiv in,97802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,36.06,,,,,,,fee schedule,25.76,100.43,APC
Medical nutrition indiv in,97802,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,45.08,,,,,,,fee schedule,25.76,100.43,APC
Med nutrition indiv subseq,97803,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,87.13,,,,,,,fee schedule,21.56,87.13,
Med nutrition indiv subseq,97803,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,69.84,,,,,,,fee schedule,21.56,87.13,
Med nutrition indiv subseq,97803,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,76.3,,,,,,,fee schedule,21.56,87.13,
Med nutrition indiv subseq,97803,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,80.21,,,,,,,fee schedule,21.56,87.13,
Med nutrition indiv subseq,97803,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21.56,,,,,,,fee schedule,21.56,87.13,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Med nutrition indiv subseq,97803,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,22.64,,,,,,,fee schedule,21.56,87.13,APC
Med nutrition indiv subseq,97803,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,22.42,,,,,,,fee schedule,21.56,87.13,APC
Med nutrition indiv subseq,97803,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,32.99,,,,,,,fee schedule,21.56,87.13,Radiology
Med nutrition indiv subseq,97803,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,30.18,,,,,,,fee schedule,21.56,87.13,APC
Med nutrition indiv subseq,97803,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,37.73,,,,,,,fee schedule,21.56,87.13,APC
Medical nutrition group,97804,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,47.7,,,,,,,fee schedule,12.12,47.7,
Medical nutrition group,97804,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38.24,,,,,,,fee schedule,12.12,47.7,
Medical nutrition group,97804,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,41.77,,,,,,,fee schedule,12.12,47.7,
Medical nutrition group,97804,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,43.92,,,,,,,fee schedule,12.12,47.7,
Medical nutrition group,97804,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.12,,,,,,,fee schedule,12.12,47.7,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Medical nutrition group,97804,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.73,,,,,,,fee schedule,12.12,47.7,APC
Medical nutrition group,97804,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.6,,,,,,,fee schedule,12.12,47.7,APC
Medical nutrition group,97804,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.54,,,,,,,fee schedule,12.12,47.7,Radiology
Medical nutrition group,97804,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.97,,,,,,,fee schedule,12.12,47.7,APC
Medical nutrition group,97804,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21.21,,,,,,,fee schedule,12.12,47.7,APC
Acupunct w/o stimul 15 min,97810,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,127.04,,,,,,,fee schedule,28.63,127.04,APC 378
Acupunct w/o stimul 15 min,97810,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.07,,,,,,,fee schedule,28.63,127.04,APC
Acupunct w/o stimul 15 min,97810,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,29.78,,,,,,,fee schedule,28.63,127.04,APC
Acupunct w/o stimul 15 min,97810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,28.63,,,,,,,fee schedule,28.63,127.04,APC
Acupunct w/o stimul 15 min,97810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43.81,,,,,,,fee schedule,28.63,127.04,Radiology
Acupunct w/o stimul 15 min,97810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40.09,,,,,,,fee schedule,28.63,127.04,APC
Acupunct w/o stimul 15 min,97810,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,50.11,,,,,,,fee schedule,28.63,127.04,APC
Acupunct w/stimul 15 min,97813,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,127.04,,,,,,,fee schedule,28.63,127.04,APC 378
Acupunct w/stimul 15 min,97813,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.07,,,,,,,fee schedule,28.63,127.04,APC
Acupunct w/stimul 15 min,97813,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,29.78,,,,,,,fee schedule,28.63,127.04,APC
Acupunct w/stimul 15 min,97813,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,28.63,,,,,,,fee schedule,28.63,127.04,APC
Acupunct w/stimul 15 min,97813,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43.81,,,,,,,fee schedule,28.63,127.04,Radiology
Acupunct w/stimul 15 min,97813,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40.09,,,,,,,fee schedule,28.63,127.04,APC
Acupunct w/stimul 15 min,97813,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,50.11,,,,,,,fee schedule,28.63,127.04,APC
Osteopath manj 1-2 regions,98925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30.34,,,,,,,fee schedule,21.38,94.84,
Osteopath manj 1-2 regions,98925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24.32,,,,,,,fee schedule,21.38,94.84,
Osteopath manj 1-2 regions,98925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26.57,,,,,,,fee schedule,21.38,94.84,
Osteopath manj 1-2 regions,98925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27.93,,,,,,,fee schedule,21.38,94.84,
Osteopath manj 1-2 regions,98925,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,94.84,,,,,,,fee schedule,21.38,94.84,APC 378
Osteopath manj 1-2 regions,98925,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,22.44,,,,,,,fee schedule,21.38,94.84,APC
Osteopath manj 1-2 regions,98925,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,22.23,,,,,,,fee schedule,21.38,94.84,APC
Osteopath manj 1-2 regions,98925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,21.38,,,,,,,fee schedule,21.38,94.84,APC
Osteopath manj 1-2 regions,98925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,32.7,,,,,,,fee schedule,21.38,94.84,Radiology
Osteopath manj 1-2 regions,98925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29.93,,,,,,,fee schedule,21.38,94.84,APC
Osteopath manj 1-2 regions,98925,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,37.41,,,,,,,fee schedule,21.38,94.84,APC
Osteopath manj 3-4 regions,98926,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,111.85,,,,,,,fee schedule,21.38,111.85,
Osteopath manj 3-4 regions,98926,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,89.66,,,,,,,fee schedule,21.38,111.85,
Osteopath manj 3-4 regions,98926,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,97.94,,,,,,,fee schedule,21.38,111.85,
Osteopath manj 3-4 regions,98926,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,102.97,,,,,,,fee schedule,21.38,111.85,
Osteopath manj 3-4 regions,98926,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,94.84,,,,,,,fee schedule,21.38,111.85,APC 378
Osteopath manj 3-4 regions,98926,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,22.44,,,,,,,fee schedule,21.38,111.85,APC
Osteopath manj 3-4 regions,98926,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,22.23,,,,,,,fee schedule,21.38,111.85,APC
Osteopath manj 3-4 regions,98926,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,21.38,,,,,,,fee schedule,21.38,111.85,APC
Osteopath manj 3-4 regions,98926,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,32.7,,,,,,,fee schedule,21.38,111.85,Radiology
Osteopath manj 3-4 regions,98926,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29.93,,,,,,,fee schedule,21.38,111.85,APC
Osteopath manj 3-4 regions,98926,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,37.41,,,,,,,fee schedule,21.38,111.85,APC
Osteopath manj 5-6 regions,98927,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,111.85,,,,,,,fee schedule,21.38,111.85,
Osteopath manj 5-6 regions,98927,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,89.66,,,,,,,fee schedule,21.38,111.85,
Osteopath manj 5-6 regions,98927,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,97.94,,,,,,,fee schedule,21.38,111.85,
Osteopath manj 5-6 regions,98927,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,102.97,,,,,,,fee schedule,21.38,111.85,
Osteopath manj 5-6 regions,98927,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,94.84,,,,,,,fee schedule,21.38,111.85,APC 378
Osteopath manj 5-6 regions,98927,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,22.44,,,,,,,fee schedule,21.38,111.85,APC
Osteopath manj 5-6 regions,98927,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,22.23,,,,,,,fee schedule,21.38,111.85,APC
Osteopath manj 5-6 regions,98927,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,21.38,,,,,,,fee schedule,21.38,111.85,APC
Osteopath manj 5-6 regions,98927,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,32.7,,,,,,,fee schedule,21.38,111.85,Radiology
Osteopath manj 5-6 regions,98927,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29.93,,,,,,,fee schedule,21.38,111.85,APC
Osteopath manj 5-6 regions,98927,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,37.41,,,,,,,fee schedule,21.38,111.85,APC
Osteopath manj 7-8 regions,98928,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,111.85,,,,,,,fee schedule,21.38,111.85,
Osteopath manj 7-8 regions,98928,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,89.66,,,,,,,fee schedule,21.38,111.85,
Osteopath manj 7-8 regions,98928,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,97.94,,,,,,,fee schedule,21.38,111.85,
Osteopath manj 7-8 regions,98928,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,102.97,,,,,,,fee schedule,21.38,111.85,
Osteopath manj 7-8 regions,98928,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,94.84,,,,,,,fee schedule,21.38,111.85,APC 378
Osteopath manj 7-8 regions,98928,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,22.44,,,,,,,fee schedule,21.38,111.85,APC
Osteopath manj 7-8 regions,98928,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,22.23,,,,,,,fee schedule,21.38,111.85,APC
Osteopath manj 7-8 regions,98928,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,21.38,,,,,,,fee schedule,21.38,111.85,APC
Osteopath manj 7-8 regions,98928,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,32.7,,,,,,,fee schedule,21.38,111.85,Radiology
Osteopath manj 7-8 regions,98928,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29.93,,,,,,,fee schedule,21.38,111.85,APC
Osteopath manj 7-8 regions,98928,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,37.41,,,,,,,fee schedule,21.38,111.85,APC
Osteopath manj 9-10 regions,98929,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,111.85,,,,,,,fee schedule,21.38,111.85,
Osteopath manj 9-10 regions,98929,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,89.66,,,,,,,fee schedule,21.38,111.85,
Osteopath manj 9-10 regions,98929,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,97.94,,,,,,,fee schedule,21.38,111.85,
Osteopath manj 9-10 regions,98929,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,102.97,,,,,,,fee schedule,21.38,111.85,
Osteopath manj 9-10 regions,98929,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,94.84,,,,,,,fee schedule,21.38,111.85,APC 378
Osteopath manj 9-10 regions,98929,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,22.44,,,,,,,fee schedule,21.38,111.85,APC
Osteopath manj 9-10 regions,98929,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,22.23,,,,,,,fee schedule,21.38,111.85,APC
Osteopath manj 9-10 regions,98929,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,21.38,,,,,,,fee schedule,21.38,111.85,APC
Osteopath manj 9-10 regions,98929,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,32.7,,,,,,,fee schedule,21.38,111.85,Radiology
Osteopath manj 9-10 regions,98929,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29.93,,,,,,,fee schedule,21.38,111.85,APC
Osteopath manj 9-10 regions,98929,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,37.41,,,,,,,fee schedule,21.38,111.85,APC
Chiropract manj 1-2 regions,98940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,111.85,,,,,,,fee schedule,21.38,111.85,
Chiropract manj 1-2 regions,98940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,89.66,,,,,,,fee schedule,21.38,111.85,
Chiropract manj 1-2 regions,98940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,97.94,,,,,,,fee schedule,21.38,111.85,
Chiropract manj 1-2 regions,98940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,102.97,,,,,,,fee schedule,21.38,111.85,
Chiropract manj 1-2 regions,98940,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,94.84,,,,,,,fee schedule,21.38,111.85,APC 378
Chiropract manj 1-2 regions,98940,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,22.44,,,,,,,fee schedule,21.38,111.85,APC
Chiropract manj 1-2 regions,98940,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,22.23,,,,,,,fee schedule,21.38,111.85,APC
Chiropract manj 1-2 regions,98940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,21.38,,,,,,,fee schedule,21.38,111.85,APC
Chiropract manj 1-2 regions,98940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,32.7,,,,,,,fee schedule,21.38,111.85,Radiology
Chiropract manj 1-2 regions,98940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29.93,,,,,,,fee schedule,21.38,111.85,APC
Chiropract manj 1-2 regions,98940,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,37.41,,,,,,,fee schedule,21.38,111.85,APC
Chiropract manj 3-4 regions,98941,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,111.85,,,,,,,fee schedule,21.38,111.85,
Chiropract manj 3-4 regions,98941,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,89.66,,,,,,,fee schedule,21.38,111.85,
Chiropract manj 3-4 regions,98941,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,97.94,,,,,,,fee schedule,21.38,111.85,
Chiropract manj 3-4 regions,98941,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,102.97,,,,,,,fee schedule,21.38,111.85,
Chiropract manj 3-4 regions,98941,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,94.84,,,,,,,fee schedule,21.38,111.85,APC 378
Chiropract manj 3-4 regions,98941,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,22.44,,,,,,,fee schedule,21.38,111.85,APC
Chiropract manj 3-4 regions,98941,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,22.23,,,,,,,fee schedule,21.38,111.85,APC
Chiropract manj 3-4 regions,98941,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,21.38,,,,,,,fee schedule,21.38,111.85,APC
Chiropract manj 3-4 regions,98941,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,32.7,,,,,,,fee schedule,21.38,111.85,Radiology
Chiropract manj 3-4 regions,98941,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29.93,,,,,,,fee schedule,21.38,111.85,APC
Chiropract manj 3-4 regions,98941,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,37.41,,,,,,,fee schedule,21.38,111.85,APC
Chiropractic manj 5 regions,98942,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,111.85,,,,,,,fee schedule,21.38,111.85,
Chiropractic manj 5 regions,98942,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,89.66,,,,,,,fee schedule,21.38,111.85,
Chiropractic manj 5 regions,98942,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,97.94,,,,,,,fee schedule,21.38,111.85,
Chiropractic manj 5 regions,98942,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,102.97,,,,,,,fee schedule,21.38,111.85,
Chiropractic manj 5 regions,98942,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,94.84,,,,,,,fee schedule,21.38,111.85,APC 378
Chiropractic manj 5 regions,98942,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,22.44,,,,,,,fee schedule,21.38,111.85,APC
Chiropractic manj 5 regions,98942,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,22.23,,,,,,,fee schedule,21.38,111.85,APC
Chiropractic manj 5 regions,98942,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,21.38,,,,,,,fee schedule,21.38,111.85,APC
Chiropractic manj 5 regions,98942,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,32.7,,,,,,,fee schedule,21.38,111.85,Radiology
Chiropractic manj 5 regions,98942,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29.93,,,,,,,fee schedule,21.38,111.85,APC
Chiropractic manj 5 regions,98942,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,37.41,,,,,,,fee schedule,21.38,111.85,APC
Hc pro phone call 5-10 min,98966,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.28,,,,,,,fee schedule,10.28,17.99,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Hc pro phone call 5-10 min,98966,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.79,,,,,,,fee schedule,10.28,17.99,APC
Hc pro phone call 5-10 min,98966,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10.69,,,,,,,fee schedule,10.28,17.99,APC
Hc pro phone call 5-10 min,98966,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15.73,,,,,,,fee schedule,10.28,17.99,Radiology
Hc pro phone call 5-10 min,98966,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.39,,,,,,,fee schedule,10.28,17.99,APC
Hc pro phone call 5-10 min,98966,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,17.99,,,,,,,fee schedule,10.28,17.99,APC
Hc pro phone call 11-20 min,98967,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,19.95,,,,,,,fee schedule,19.95,34.91,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Hc pro phone call 11-20 min,98967,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20.95,,,,,,,fee schedule,19.95,34.91,APC
Hc pro phone call 11-20 min,98967,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,20.75,,,,,,,fee schedule,19.95,34.91,APC
Hc pro phone call 11-20 min,98967,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,30.52,,,,,,,fee schedule,19.95,34.91,Radiology
Hc pro phone call 11-20 min,98967,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27.93,,,,,,,fee schedule,19.95,34.91,APC
Hc pro phone call 11-20 min,98967,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,34.91,,,,,,,fee schedule,19.95,34.91,APC
Hc pro phone call 21-30 min,98968,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,28.92,,,,,,,fee schedule,28.92,50.61,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Hc pro phone call 21-30 min,98968,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.37,,,,,,,fee schedule,28.92,50.61,APC
Hc pro phone call 21-30 min,98968,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,30.08,,,,,,,fee schedule,28.92,50.61,APC
Hc pro phone call 21-30 min,98968,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,44.25,,,,,,,fee schedule,28.92,50.61,Radiology
Hc pro phone call 21-30 min,98968,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40.49,,,,,,,fee schedule,28.92,50.61,APC
Hc pro phone call 21-30 min,98968,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,50.61,,,,,,,fee schedule,28.92,50.61,APC
Qnhp ol dig e/m svc 5-10min,98970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45.32,,,,,,,fee schedule,10.28,45.32,
Qnhp ol dig e/m svc 5-10min,98970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36.33,,,,,,,fee schedule,10.28,45.32,
Qnhp ol dig e/m svc 5-10min,98970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39.69,,,,,,,fee schedule,10.28,45.32,
Qnhp ol dig e/m svc 5-10min,98970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41.73,,,,,,,fee schedule,10.28,45.32,
Qnhp ol dig e/m svc 5-10min,98970,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.28,,,,,,,fee schedule,10.28,45.32,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Qnhp ol dig e/m svc 5-10min,98970,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.79,,,,,,,fee schedule,10.28,45.32,APC
Qnhp ol dig e/m svc 5-10min,98970,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10.69,,,,,,,fee schedule,10.28,45.32,APC
Qnhp ol dig e/m svc 5-10min,98970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15.73,,,,,,,fee schedule,10.28,45.32,Radiology
Qnhp ol dig e/m svc 5-10min,98970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.39,,,,,,,fee schedule,10.28,45.32,APC
Qnhp ol dig e/m svc 5-10min,98970,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,17.99,,,,,,,fee schedule,10.28,45.32,APC
Qnhp ol dig em svc 11-20min,98971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,80.06,,,,,,,fee schedule,18.87,80.06,
Qnhp ol dig em svc 11-20min,98971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,64.18,,,,,,,fee schedule,18.87,80.06,
Qnhp ol dig em svc 11-20min,98971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,70.11,,,,,,,fee schedule,18.87,80.06,
Qnhp ol dig em svc 11-20min,98971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,73.71,,,,,,,fee schedule,18.87,80.06,
Qnhp ol dig em svc 11-20min,98971,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.87,,,,,,,fee schedule,18.87,80.06,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Qnhp ol dig em svc 11-20min,98971,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.81,,,,,,,fee schedule,18.87,80.06,APC
Qnhp ol dig em svc 11-20min,98971,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,19.62,,,,,,,fee schedule,18.87,80.06,APC
Qnhp ol dig em svc 11-20min,98971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.87,,,,,,,fee schedule,18.87,80.06,Radiology
Qnhp ol dig em svc 11-20min,98971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26.42,,,,,,,fee schedule,18.87,80.06,APC
Qnhp ol dig em svc 11-20min,98971,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,33.02,,,,,,,fee schedule,18.87,80.06,APC
Qnhp ol dig e/m svc 21+ min,98972,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,124.14,,,,,,,fee schedule,28.84,124.14,
Qnhp ol dig e/m svc 21+ min,98972,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,99.51,,,,,,,fee schedule,28.84,124.14,
Qnhp ol dig e/m svc 21+ min,98972,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,108.7,,,,,,,fee schedule,28.84,124.14,
Qnhp ol dig e/m svc 21+ min,98972,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,114.28,,,,,,,fee schedule,28.84,124.14,
Qnhp ol dig e/m svc 21+ min,98972,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,28.84,,,,,,,fee schedule,28.84,124.14,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Qnhp ol dig e/m svc 21+ min,98972,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.28,,,,,,,fee schedule,28.84,124.14,APC
Qnhp ol dig e/m svc 21+ min,98972,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,29.99,,,,,,,fee schedule,28.84,124.14,APC
Qnhp ol dig e/m svc 21+ min,98972,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,44.13,,,,,,,fee schedule,28.84,124.14,Radiology
Qnhp ol dig e/m svc 21+ min,98972,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40.38,,,,,,,fee schedule,28.84,124.14,APC
Qnhp ol dig e/m svc 21+ min,98972,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,50.47,,,,,,,fee schedule,28.84,124.14,APC
Rem ther mntr 1st setup&edu,98975,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,458.7,,,,,,,fee schedule,131.8,584.75,
Rem ther mntr 1st setup&edu,98975,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,367.69,,,,,,,fee schedule,131.8,584.75,
Rem ther mntr 1st setup&edu,98975,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,401.67,,,,,,,fee schedule,131.8,584.75,
Rem ther mntr 1st setup&edu,98975,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,422.3,,,,,,,fee schedule,131.8,584.75,
Rem ther mntr 1st setup&edu,98975,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.75,,,,,,,fee schedule,131.8,584.75,APC 378
Rem ther mntr 1st setup&edu,98975,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.39,,,,,,,fee schedule,131.8,584.75,APC
Rem ther mntr 1st setup&edu,98975,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,137.07,,,,,,,fee schedule,131.8,584.75,APC
Rem ther mntr 1st setup&edu,98975,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.8,,,,,,,fee schedule,131.8,584.75,APC
Rem ther mntr 1st setup&edu,98975,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.66,,,,,,,fee schedule,131.8,584.75,Radiology
Rem ther mntr 1st setup&edu,98975,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.52,,,,,,,fee schedule,131.8,584.75,APC
Rem ther mntr 1st setup&edu,98975,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.65,,,,,,,fee schedule,131.8,584.75,APC
Rem ther mntr dev sply resp,98976,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,143.75,,,,,,,fee schedule,36.95,163.92,
Rem ther mntr dev sply resp,98976,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,115.23,,,,,,,fee schedule,36.95,163.92,
Rem ther mntr dev sply resp,98976,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,125.88,,,,,,,fee schedule,36.95,163.92,
Rem ther mntr dev sply resp,98976,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,132.34,,,,,,,fee schedule,36.95,163.92,
Rem ther mntr dev sply resp,98976,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,163.92,,,,,,,fee schedule,36.95,163.92,APC 378
Rem ther mntr dev sply resp,98976,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.79,,,,,,,fee schedule,36.95,163.92,APC
Rem ther mntr dev sply resp,98976,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.43,,,,,,,fee schedule,36.95,163.92,APC
Rem ther mntr dev sply resp,98976,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.95,,,,,,,fee schedule,36.95,163.92,APC
Rem ther mntr dev sply resp,98976,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.53,,,,,,,fee schedule,36.95,163.92,Radiology
Rem ther mntr dev sply resp,98976,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.73,,,,,,,fee schedule,36.95,163.92,APC
Rem ther mntr dev sply resp,98976,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.66,,,,,,,fee schedule,36.95,163.92,APC
Rem ther mntr dv sply mscskl,98977,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,143.75,,,,,,,fee schedule,36.95,163.92,
Rem ther mntr dv sply mscskl,98977,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,115.23,,,,,,,fee schedule,36.95,163.92,
Rem ther mntr dv sply mscskl,98977,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,125.88,,,,,,,fee schedule,36.95,163.92,
Rem ther mntr dv sply mscskl,98977,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,132.34,,,,,,,fee schedule,36.95,163.92,
Rem ther mntr dv sply mscskl,98977,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,163.92,,,,,,,fee schedule,36.95,163.92,APC 378
Rem ther mntr dv sply mscskl,98977,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.79,,,,,,,fee schedule,36.95,163.92,APC
Rem ther mntr dv sply mscskl,98977,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.43,,,,,,,fee schedule,36.95,163.92,APC
Rem ther mntr dv sply mscskl,98977,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.95,,,,,,,fee schedule,36.95,163.92,APC
Rem ther mntr dv sply mscskl,98977,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.53,,,,,,,fee schedule,36.95,163.92,Radiology
Rem ther mntr dv sply mscskl,98977,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.73,,,,,,,fee schedule,36.95,163.92,APC
Rem ther mntr dv sply mscskl,98977,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.66,,,,,,,fee schedule,36.95,163.92,APC
Rem ther mntr dev sply cbt,98978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,132.3,,,,,,,fee schedule,36.95,163.92,
Rem ther mntr dev sply cbt,98978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,106.05,,,,,,,fee schedule,36.95,163.92,
Rem ther mntr dev sply cbt,98978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,115.85,,,,,,,fee schedule,36.95,163.92,
Rem ther mntr dev sply cbt,98978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,121.8,,,,,,,fee schedule,36.95,163.92,
Rem ther mntr dev sply cbt,98978,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,163.92,,,,,,,fee schedule,36.95,163.92,APC 378
Rem ther mntr dev sply cbt,98978,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.79,,,,,,,fee schedule,36.95,163.92,APC
Rem ther mntr dev sply cbt,98978,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.43,,,,,,,fee schedule,36.95,163.92,APC
Rem ther mntr dev sply cbt,98978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.95,,,,,,,fee schedule,36.95,163.92,APC
Rem ther mntr dev sply cbt,98978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.53,,,,,,,fee schedule,36.95,163.92,Radiology
Rem ther mntr dev sply cbt,98978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.73,,,,,,,fee schedule,36.95,163.92,APC
Rem ther mntr dev sply cbt,98978,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.66,,,,,,,fee schedule,36.95,163.92,APC
Rtm tx mgmt 1st 10 min,98979,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.37,,,,,,,fee schedule,11.37,19.9,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Rtm tx mgmt 1st 10 min,98979,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.94,,,,,,,fee schedule,11.37,19.9,APC
Rtm tx mgmt 1st 10 min,98979,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11.82,,,,,,,fee schedule,11.37,19.9,APC
Rtm tx mgmt 1st 10 min,98979,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.4,,,,,,,fee schedule,11.37,19.9,Radiology
Rtm tx mgmt 1st 10 min,98979,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15.92,,,,,,,fee schedule,11.37,19.9,APC
Rtm tx mgmt 1st 10 min,98979,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19.9,,,,,,,fee schedule,11.37,19.9,APC
Rem ther mntr 1st 20 min,98980,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25.59,,,,,,,fee schedule,25.59,44.78,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Rem ther mntr 1st 20 min,98980,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,26.87,,,,,,,fee schedule,25.59,44.78,APC
Rem ther mntr 1st 20 min,98980,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,26.61,,,,,,,fee schedule,25.59,44.78,APC
Rem ther mntr 1st 20 min,98980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,39.15,,,,,,,fee schedule,25.59,44.78,Radiology
Rem ther mntr 1st 20 min,98980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,35.83,,,,,,,fee schedule,25.59,44.78,APC
Rem ther mntr 1st 20 min,98980,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,44.78,,,,,,,fee schedule,25.59,44.78,APC
Rem ther mntr ea addl 20 min,98981,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25.25,,,,,,,fee schedule,25.25,44.19,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Rem ther mntr ea addl 20 min,98981,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,26.51,,,,,,,fee schedule,25.25,44.19,APC
Rem ther mntr ea addl 20 min,98981,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,26.26,,,,,,,fee schedule,25.25,44.19,APC
Rem ther mntr ea addl 20 min,98981,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,38.63,,,,,,,fee schedule,25.25,44.19,Radiology
Rem ther mntr ea addl 20 min,98981,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,35.35,,,,,,,fee schedule,25.25,44.19,APC
Rem ther mntr ea addl 20 min,98981,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,44.19,,,,,,,fee schedule,25.25,44.19,APC
Device handling phys/qhp,99002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26.8,,,,,,,fee schedule,21.48,26.8,
Device handling phys/qhp,99002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21.48,,,,,,,fee schedule,21.48,26.8,
Device handling phys/qhp,99002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23.47,,,,,,,fee schedule,21.48,26.8,
Device handling phys/qhp,99002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24.67,,,,,,,fee schedule,21.48,26.8,
Medical services after hrs,99050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,71.52,,,,,,,fee schedule,57.33,71.52,
Medical services after hrs,99050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.33,,,,,,,fee schedule,57.33,71.52,
Medical services after hrs,99050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,62.63,,,,,,,fee schedule,57.33,71.52,
Medical services after hrs,99050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,65.84,,,,,,,fee schedule,57.33,71.52,
Med service out of office,99056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,68.95,,,,,,,fee schedule,55.27,68.95,
Med service out of office,99056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55.27,,,,,,,fee schedule,55.27,68.95,
Med service out of office,99056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,60.37,,,,,,,fee schedule,55.27,68.95,
Med service out of office,99056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,63.48,,,,,,,fee schedule,55.27,68.95,
Office emergency care,99058,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,84.11,,,,,,,fee schedule,67.42,84.11,
Office emergency care,99058,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,67.42,,,,,,,fee schedule,67.42,84.11,
Office emergency care,99058,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,73.65,,,,,,,fee schedule,67.42,84.11,
Office emergency care,99058,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,77.43,,,,,,,fee schedule,67.42,84.11,
Out of office emerg med serv,99060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,95.75,,,,,,,fee schedule,76.75,95.75,
Out of office emerg med serv,99060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,76.75,,,,,,,fee schedule,76.75,95.75,
Out of office emerg med serv,99060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,83.84,,,,,,,fee schedule,76.75,95.75,
Out of office emerg med serv,99060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,88.15,,,,,,,fee schedule,76.75,95.75,
Unusual physician travel,99082,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.25,,,,,,,fee schedule,2.61,3.25,
Unusual physician travel,99082,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.61,,,,,,,fee schedule,2.61,3.25,
Unusual physician travel,99082,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.85,,,,,,,fee schedule,2.61,3.25,
Unusual physician travel,99082,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.99,,,,,,,fee schedule,2.61,3.25,
Mod sed same phys/qhp <5 yrs,99151,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,232.97,,,,,,,fee schedule,186.75,232.97,
Mod sed same phys/qhp <5 yrs,99151,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,186.75,,,,,,,fee schedule,186.75,232.97,
Mod sed same phys/qhp <5 yrs,99151,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,204.01,,,,,,,fee schedule,186.75,232.97,
Mod sed same phys/qhp <5 yrs,99151,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,214.48,,,,,,,fee schedule,186.75,232.97,
Mod sed same phys/qhp 5/>yrs,99152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.03,,,,,,,fee schedule,353.52,441.03,
Mod sed same phys/qhp 5/>yrs,99152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.52,,,,,,,fee schedule,353.52,441.03,
Mod sed same phys/qhp 5/>yrs,99152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.19,,,,,,,fee schedule,353.52,441.03,
Mod sed same phys/qhp 5/>yrs,99152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.02,,,,,,,fee schedule,353.52,441.03,
Mod sed same phys/qhp ea,99153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,119.2,,,,,,,fee schedule,95.55,119.2,
Mod sed same phys/qhp ea,99153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,95.55,,,,,,,fee schedule,95.55,119.2,
Mod sed same phys/qhp ea,99153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,104.38,,,,,,,fee schedule,95.55,119.2,
Mod sed same phys/qhp ea,99153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,109.74,,,,,,,fee schedule,95.55,119.2,
Mod sed oth phys/qhp <5 yrs,99155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,355.41,,,,,,,fee schedule,284.89,355.41,
Mod sed oth phys/qhp <5 yrs,99155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,284.89,,,,,,,fee schedule,284.89,355.41,
Mod sed oth phys/qhp <5 yrs,99155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,311.22,,,,,,,fee schedule,284.89,355.41,
Mod sed oth phys/qhp <5 yrs,99155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,327.2,,,,,,,fee schedule,284.89,355.41,
Mod sed oth phys/qhp 5/>yrs,99156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,292.02,,,,,,,fee schedule,234.08,292.02,
Mod sed oth phys/qhp 5/>yrs,99156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,234.08,,,,,,,fee schedule,234.08,292.02,
Mod sed oth phys/qhp 5/>yrs,99156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,255.71,,,,,,,fee schedule,234.08,292.02,
Mod sed oth phys/qhp 5/>yrs,99156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,268.84,,,,,,,fee schedule,234.08,292.02,
Mod sed other phys/qhp ea,99157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,221.24,,,,,,,fee schedule,177.34,221.24,
Mod sed other phys/qhp ea,99157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,177.34,,,,,,,fee schedule,177.34,221.24,
Mod sed other phys/qhp ea,99157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,193.73,,,,,,,fee schedule,177.34,221.24,
Mod sed other phys/qhp ea,99157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,203.68,,,,,,,fee schedule,177.34,221.24,
Anogenital exam child w imag,99170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,32.7,,,,,,,fee schedule,26.21,887.97,
Anogenital exam child w imag,99170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26.21,,,,,,,fee schedule,26.21,887.97,
Anogenital exam child w imag,99170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28.63,,,,,,,fee schedule,26.21,887.97,
Anogenital exam child w imag,99170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30.1,,,,,,,fee schedule,26.21,887.97,
Anogenital exam child w imag,99170,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,887.97,,,,,,,fee schedule,26.21,887.97,APC 378
Anogenital exam child w imag,99170,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,210.15,,,,,,,fee schedule,26.21,887.97,APC
Anogenital exam child w imag,99170,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,208.15,,,,,,,fee schedule,26.21,887.97,APC
Anogenital exam child w imag,99170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,200.14,,,,,,,fee schedule,26.21,887.97,APC
Anogenital exam child w imag,99170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,306.22,,,,,,,fee schedule,26.21,887.97,Radiology
Anogenital exam child w imag,99170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,280.2,,,,,,,fee schedule,26.21,887.97,APC
Anogenital exam child w imag,99170,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,350.25,,,,,,,fee schedule,26.21,887.97,APC
Hyperbaric oxygen therapy,99183,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,420.56,,,,,,,fee schedule,337.12,420.56,
Hyperbaric oxygen therapy,99183,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,337.12,,,,,,,fee schedule,337.12,420.56,
Hyperbaric oxygen therapy,99183,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,368.27,,,,,,,fee schedule,337.12,420.56,
Hyperbaric oxygen therapy,99183,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,387.18,,,,,,,fee schedule,337.12,420.56,
Hypothermia ill neonate,99184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,884.6,,,,,,,fee schedule,709.08,884.6,
Hypothermia ill neonate,99184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,709.08,,,,,,,fee schedule,709.08,884.6,
Hypothermia ill neonate,99184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,774.61,,,,,,,fee schedule,709.08,884.6,
Hypothermia ill neonate,99184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,814.39,,,,,,,fee schedule,709.08,884.6,
Phlebotomy,99195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,341.65,,,,,,,fee schedule,131.71,584.37,
Phlebotomy,99195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,273.87,,,,,,,fee schedule,131.71,584.37,
Phlebotomy,99195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,299.17,,,,,,,fee schedule,131.71,584.37,
Phlebotomy,99195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,314.54,,,,,,,fee schedule,131.71,584.37,
Phlebotomy,99195,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,131.71,584.37,APC 378
Phlebotomy,99195,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,131.71,584.37,APC
Phlebotomy,99195,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,131.71,584.37,APC
Phlebotomy,99195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,131.71,584.37,APC
Phlebotomy,99195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,131.71,584.37,Radiology
Phlebotomy,99195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,131.71,584.37,APC
Phlebotomy,99195,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,131.71,584.37,APC
Initial hospital care,99221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,332.3,,,,,,,fee schedule,266.37,332.3,
Initial hospital care,99221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,266.37,,,,,,,fee schedule,266.37,332.3,
Initial hospital care,99221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,290.98,,,,,,,fee schedule,266.37,332.3,
Initial hospital care,99221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,305.93,,,,,,,fee schedule,266.37,332.3,
Initial hospital care,99222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,453.75,,,,,,,fee schedule,363.72,453.75,
Initial hospital care,99222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,363.72,,,,,,,fee schedule,363.72,453.75,
Initial hospital care,99222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,397.33,,,,,,,fee schedule,363.72,453.75,
Initial hospital care,99222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,417.74,,,,,,,fee schedule,363.72,453.75,
Initial hospital care,99223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,667.02,,,,,,,fee schedule,534.67,667.02,
Initial hospital care,99223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,534.67,,,,,,,fee schedule,534.67,667.02,
Initial hospital care,99223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,584.08,,,,,,,fee schedule,534.67,667.02,
Initial hospital care,99223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,614.08,,,,,,,fee schedule,534.67,667.02,
Subsequent hospital care,99231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,137.21,,,,,,,fee schedule,109.99,137.21,
Subsequent hospital care,99231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,109.99,,,,,,,fee schedule,109.99,137.21,
Subsequent hospital care,99231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,120.15,,,,,,,fee schedule,109.99,137.21,
Subsequent hospital care,99231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,126.32,,,,,,,fee schedule,109.99,137.21,
Subsequent hospital care,99232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,246.46,,,,,,,fee schedule,197.56,246.46,
Subsequent hospital care,99232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,197.56,,,,,,,fee schedule,197.56,246.46,
Subsequent hospital care,99232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,215.81,,,,,,,fee schedule,197.56,246.46,
Subsequent hospital care,99232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,226.9,,,,,,,fee schedule,197.56,246.46,
Subsequent hospital care,99233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,353.2,,,,,,,fee schedule,283.12,353.2,
Subsequent hospital care,99233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,283.12,,,,,,,fee schedule,283.12,353.2,
Subsequent hospital care,99233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,309.29,,,,,,,fee schedule,283.12,353.2,
Subsequent hospital care,99233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,325.17,,,,,,,fee schedule,283.12,353.2,
Observ/hosp same date,99234,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,470.35,,,,,,,fee schedule,377.02,470.35,
Observ/hosp same date,99234,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,377.02,,,,,,,fee schedule,377.02,470.35,
Observ/hosp same date,99234,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,411.86,,,,,,,fee schedule,377.02,470.35,
Observ/hosp same date,99234,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,433.02,,,,,,,fee schedule,377.02,470.35,
Observ/hosp same date,99235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,617.43,,,,,,,fee schedule,494.92,617.43,
Observ/hosp same date,99235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,494.92,,,,,,,fee schedule,494.92,617.43,
Observ/hosp same date,99235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,540.66,,,,,,,fee schedule,494.92,617.43,
Observ/hosp same date,99235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,568.42,,,,,,,fee schedule,494.92,617.43,
Observ/hosp same date,99236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,766.89,,,,,,,fee schedule,614.73,766.89,
Observ/hosp same date,99236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,614.73,,,,,,,fee schedule,614.73,766.89,
Observ/hosp same date,99236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,671.53,,,,,,,fee schedule,614.73,766.89,
Observ/hosp same date,99236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,706.02,,,,,,,fee schedule,614.73,766.89,
Hospital discharge day,99238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,243.85,,,,,,,fee schedule,195.47,243.85,
Hospital discharge day,99238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,195.47,,,,,,,fee schedule,195.47,243.85,
Hospital discharge day,99238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,213.53,,,,,,,fee schedule,195.47,243.85,
Hospital discharge day,99238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,224.49,,,,,,,fee schedule,195.47,243.85,
Hospital discharge day,99239,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,354.41,,,,,,,fee schedule,284.09,354.41,
Hospital discharge day,99239,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,284.09,,,,,,,fee schedule,284.09,354.41,
Hospital discharge day,99239,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,310.35,,,,,,,fee schedule,284.09,354.41,
Hospital discharge day,99239,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,326.28,,,,,,,fee schedule,284.09,354.41,
Office consultation,99242,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,258.29,,,,,,,fee schedule,207.04,258.29,
Office consultation,99242,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,207.04,,,,,,,fee schedule,207.04,258.29,
Office consultation,99242,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,226.17,,,,,,,fee schedule,207.04,258.29,
Office consultation,99242,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,237.79,,,,,,,fee schedule,207.04,258.29,
Office consultation,99243,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,359.44,,,,,,,fee schedule,288.12,359.44,
Office consultation,99243,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,288.12,,,,,,,fee schedule,288.12,359.44,
Office consultation,99243,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,314.75,,,,,,,fee schedule,288.12,359.44,
Office consultation,99243,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,330.91,,,,,,,fee schedule,288.12,359.44,
Office consultation,99244,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,567.87,,,,,,,fee schedule,455.2,567.87,
Office consultation,99244,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,455.2,,,,,,,fee schedule,455.2,567.87,
Office consultation,99244,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,497.26,,,,,,,fee schedule,455.2,567.87,
Office consultation,99244,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,522.8,,,,,,,fee schedule,455.2,567.87,
Office consultation,99245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,709.17,,,,,,,fee schedule,568.46,709.17,
Office consultation,99245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,568.46,,,,,,,fee schedule,568.46,709.17,
Office consultation,99245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,620.99,,,,,,,fee schedule,568.46,709.17,
Office consultation,99245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,652.88,,,,,,,fee schedule,568.46,709.17,
Emergency dept visit,99281,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,370.36,,,,,,,fee schedule,83.48,370.36,APC 378
Emergency dept visit,99281,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,87.65,,,,,,,fee schedule,83.48,370.36,APC
Emergency dept visit,99281,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,86.82,,,,,,,fee schedule,83.48,370.36,APC
Emergency dept visit,99281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,83.48,,,,,,,fee schedule,83.48,370.36,APC
Emergency dept visit,99281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,127.72,,,,,,,fee schedule,83.48,370.36,Radiology
Emergency dept visit,99281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,116.87,,,,,,,fee schedule,83.48,370.36,APC
Emergency dept visit,99281,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,146.09,,,,,,,fee schedule,83.48,370.36,APC
Emergency dept visit,99282,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,674.39,,,,,,,fee schedule,152,674.39,APC 378
Emergency dept visit,99282,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,159.6,,,,,,,fee schedule,152,674.39,APC
Emergency dept visit,99282,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,158.08,,,,,,,fee schedule,152,674.39,APC
Emergency dept visit,99282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,152,,,,,,,fee schedule,152,674.39,APC
Emergency dept visit,99282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,232.57,,,,,,,fee schedule,152,674.39,Radiology
Emergency dept visit,99282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,212.81,,,,,,,fee schedule,152,674.39,APC
Emergency dept visit,99282,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,266.01,,,,,,,fee schedule,152,674.39,APC
Emergency dept visit,99283,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1198.96,,,,,,,fee schedule,270.24,1198.96,APC 378
Emergency dept visit,99283,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,283.75,,,,,,,fee schedule,270.24,1198.96,APC
Emergency dept visit,99283,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,281.05,,,,,,,fee schedule,270.24,1198.96,APC
Emergency dept visit,99283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,270.24,,,,,,,fee schedule,270.24,1198.96,APC
Emergency dept visit,99283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,413.47,,,,,,,fee schedule,270.24,1198.96,Radiology
Emergency dept visit,99283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,378.33,,,,,,,fee schedule,270.24,1198.96,APC
Emergency dept visit,99283,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,472.92,,,,,,,fee schedule,270.24,1198.96,APC
Emergency dept visit,99284,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1832.68,,,,,,,fee schedule,413.08,1832.68,APC 378
Emergency dept visit,99284,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,433.73,,,,,,,fee schedule,413.08,1832.68,APC
Emergency dept visit,99284,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,429.6,,,,,,,fee schedule,413.08,1832.68,APC
Emergency dept visit,99284,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,413.08,,,,,,,fee schedule,413.08,1832.68,APC
Emergency dept visit,99284,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,632.01,,,,,,,fee schedule,413.08,1832.68,Radiology
Emergency dept visit,99284,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,578.31,,,,,,,fee schedule,413.08,1832.68,APC
Emergency dept visit,99284,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,722.88,,,,,,,fee schedule,413.08,1832.68,APC
Emergency dept visit,99285,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2615.66,,,,,,,fee schedule,589.56,2615.66,APC 378
Emergency dept visit,99285,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,619.03,,,,,,,fee schedule,589.56,2615.66,APC
Emergency dept visit,99285,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,613.14,,,,,,,fee schedule,589.56,2615.66,APC
Emergency dept visit,99285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,589.56,,,,,,,fee schedule,589.56,2615.66,APC
Emergency dept visit,99285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,902.02,,,,,,,fee schedule,589.56,2615.66,Radiology
Emergency dept visit,99285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,825.38,,,,,,,fee schedule,589.56,2615.66,APC
Emergency dept visit,99285,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1031.72,,,,,,,fee schedule,589.56,2615.66,APC
Critical care first hour,99291,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3628.04,,,,,,,fee schedule,817.74,3628.04,APC 378
Critical care first hour,99291,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,858.63,,,,,,,fee schedule,817.74,3628.04,APC
Critical care first hour,99291,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,850.45,,,,,,,fee schedule,817.74,3628.04,APC
Critical care first hour,99291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,817.74,,,,,,,fee schedule,817.74,3628.04,APC
Critical care first hour,99291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1251.14,,,,,,,fee schedule,817.74,3628.04,Radiology
Critical care first hour,99291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1144.84,,,,,,,fee schedule,817.74,3628.04,APC
Critical care first hour,99291,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1431.05,,,,,,,fee schedule,817.74,3628.04,APC
Nursing facility care init,99304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,294.92,,,,,,,fee schedule,236.4,294.92,
Nursing facility care init,99304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,236.4,,,,,,,fee schedule,236.4,294.92,
Nursing facility care init,99304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,258.25,,,,,,,fee schedule,236.4,294.92,
Nursing facility care init,99304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,271.51,,,,,,,fee schedule,236.4,294.92,
Nursing facility care init,99305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,412.59,,,,,,,fee schedule,330.72,412.59,
Nursing facility care init,99305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,330.72,,,,,,,fee schedule,330.72,412.59,
Nursing facility care init,99305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,361.29,,,,,,,fee schedule,330.72,412.59,
Nursing facility care init,99305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,379.84,,,,,,,fee schedule,330.72,412.59,
Nursing facility care init,99306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,530.45,,,,,,,fee schedule,425.2,530.45,
Nursing facility care init,99306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,425.2,,,,,,,fee schedule,425.2,530.45,
Nursing facility care init,99306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,464.49,,,,,,,fee schedule,425.2,530.45,
Nursing facility care init,99306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,488.35,,,,,,,fee schedule,425.2,530.45,
Nursing fac care subseq,99307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,145.72,,,,,,,fee schedule,116.81,145.72,
Nursing fac care subseq,99307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,116.81,,,,,,,fee schedule,116.81,145.72,
Nursing fac care subseq,99307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,127.6,,,,,,,fee schedule,116.81,145.72,
Nursing fac care subseq,99307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,134.15,,,,,,,fee schedule,116.81,145.72,
Nursing fac care subseq,99308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,222.38,,,,,,,fee schedule,178.25,222.38,
Nursing fac care subseq,99308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,178.25,,,,,,,fee schedule,178.25,222.38,
Nursing fac care subseq,99308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,194.73,,,,,,,fee schedule,178.25,222.38,
Nursing fac care subseq,99308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,204.73,,,,,,,fee schedule,178.25,222.38,
Nursing fac care subseq,99309,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,295.52,,,,,,,fee schedule,236.89,295.52,
Nursing fac care subseq,99309,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,236.89,,,,,,,fee schedule,236.89,295.52,
Nursing fac care subseq,99309,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,258.78,,,,,,,fee schedule,236.89,295.52,
Nursing fac care subseq,99309,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,272.07,,,,,,,fee schedule,236.89,295.52,
Nursing fac care subseq,99310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,436.67,,,,,,,fee schedule,350.03,436.67,
Nursing fac care subseq,99310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,350.03,,,,,,,fee schedule,350.03,436.67,
Nursing fac care subseq,99310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,382.37,,,,,,,fee schedule,350.03,436.67,
Nursing fac care subseq,99310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,402.01,,,,,,,fee schedule,350.03,436.67,
Nursing fac discharge day,99315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,213.68,,,,,,,fee schedule,171.29,213.68,
Nursing fac discharge day,99315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,171.29,,,,,,,fee schedule,171.29,213.68,
Nursing fac discharge day,99315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,187.11,,,,,,,fee schedule,171.29,213.68,
Nursing fac discharge day,99315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,196.72,,,,,,,fee schedule,171.29,213.68,
Nursing fac discharge day,99316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,279,,,,,,,fee schedule,223.64,279,
Nursing fac discharge day,99316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,223.64,,,,,,,fee schedule,223.64,279,
Nursing fac discharge day,99316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,244.31,,,,,,,fee schedule,223.64,279,
Nursing fac discharge day,99316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,256.86,,,,,,,fee schedule,223.64,279,
Home visit new patient,99341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,198.56,,,,,,,fee schedule,159.17,198.56,
Home visit new patient,99341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,159.17,,,,,,,fee schedule,159.17,198.56,
Home visit new patient,99341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,173.87,,,,,,,fee schedule,159.17,198.56,
Home visit new patient,99341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,182.8,,,,,,,fee schedule,159.17,198.56,
Home visit new patient,99342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,289.28,,,,,,,fee schedule,231.89,289.28,
Home visit new patient,99342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,231.89,,,,,,,fee schedule,231.89,289.28,
Home visit new patient,99342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,253.31,,,,,,,fee schedule,231.89,289.28,
Home visit new patient,99342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,266.32,,,,,,,fee schedule,231.89,289.28,
Home visit new patient,99344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,611.26,,,,,,,fee schedule,489.98,611.26,
Home visit new patient,99344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,489.98,,,,,,,fee schedule,489.98,611.26,
Home visit new patient,99344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,535.26,,,,,,,fee schedule,489.98,611.26,
Home visit new patient,99344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,562.75,,,,,,,fee schedule,489.98,611.26,
Home visit new patient,99345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,735.59,,,,,,,fee schedule,589.64,735.59,
Home visit new patient,99345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,589.64,,,,,,,fee schedule,589.64,735.59,
Home visit new patient,99345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,644.13,,,,,,,fee schedule,589.64,735.59,
Home visit new patient,99345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,677.21,,,,,,,fee schedule,589.64,735.59,
Home visit est patient,99347,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,193.27,,,,,,,fee schedule,154.92,193.27,
Home visit est patient,99347,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,154.92,,,,,,,fee schedule,154.92,193.27,
Home visit est patient,99347,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,169.24,,,,,,,fee schedule,154.92,193.27,
Home visit est patient,99347,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,177.93,,,,,,,fee schedule,154.92,193.27,
Home visit est patient,99348,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,292.01,,,,,,,fee schedule,234.07,292.01,
Home visit est patient,99348,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,234.07,,,,,,,fee schedule,234.07,292.01,
Home visit est patient,99348,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,255.7,,,,,,,fee schedule,234.07,292.01,
Home visit est patient,99348,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,268.83,,,,,,,fee schedule,234.07,292.01,
Home visit est patient,99349,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,425.74,,,,,,,fee schedule,341.27,425.74,
Home visit est patient,99349,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,341.27,,,,,,,fee schedule,341.27,425.74,
Home visit est patient,99349,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,372.81,,,,,,,fee schedule,341.27,425.74,
Home visit est patient,99349,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,391.95,,,,,,,fee schedule,341.27,425.74,
Home visit est patient,99350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,593.99,,,,,,,fee schedule,476.13,593.99,
Home visit est patient,99350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,476.13,,,,,,,fee schedule,476.13,593.99,
Home visit est patient,99350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,520.13,,,,,,,fee schedule,476.13,593.99,
Home visit est patient,99350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,546.85,,,,,,,fee schedule,476.13,593.99,
Physician standby services,99360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,219.62,,,,,,,fee schedule,176.04,219.62,
Physician standby services,99360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,176.04,,,,,,,fee schedule,176.04,219.62,
Physician standby services,99360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,192.31,,,,,,,fee schedule,176.04,219.62,
Physician standby services,99360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,202.19,,,,,,,fee schedule,176.04,219.62,
Home health care supervision,99374,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,203.55,,,,,,,fee schedule,163.17,203.55,
Home health care supervision,99374,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,163.17,,,,,,,fee schedule,163.17,203.55,
Home health care supervision,99374,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,178.24,,,,,,,fee schedule,163.17,203.55,
Home health care supervision,99374,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,187.4,,,,,,,fee schedule,163.17,203.55,
Hospice care supervision,99377,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,203.55,,,,,,,fee schedule,163.17,203.55,
Hospice care supervision,99377,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,163.17,,,,,,,fee schedule,163.17,203.55,
Hospice care supervision,99377,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,178.24,,,,,,,fee schedule,163.17,203.55,
Hospice care supervision,99377,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,187.4,,,,,,,fee schedule,163.17,203.55,
Nursing fac care supervision,99379,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,202.04,,,,,,,fee schedule,161.95,202.04,
Nursing fac care supervision,99379,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,161.95,,,,,,,fee schedule,161.95,202.04,
Nursing fac care supervision,99379,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,176.92,,,,,,,fee schedule,161.95,202.04,
Nursing fac care supervision,99379,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,186.01,,,,,,,fee schedule,161.95,202.04,
Nursing fac care supervision,99380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,317.63,,,,,,,fee schedule,254.61,317.63,
Nursing fac care supervision,99380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,254.61,,,,,,,fee schedule,254.61,317.63,
Nursing fac care supervision,99380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,278.14,,,,,,,fee schedule,254.61,317.63,
Nursing fac care supervision,99380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,292.42,,,,,,,fee schedule,254.61,317.63,
Prolong clincl staff svc,99415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,31.41,,,,,,,fee schedule,25.18,31.41,
Prolong clincl staff svc,99415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,25.18,,,,,,,fee schedule,25.18,31.41,
Prolong clincl staff svc,99415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,27.51,,,,,,,fee schedule,25.18,31.41,
Prolong clincl staff svc,99415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,28.92,,,,,,,fee schedule,25.18,31.41,
Prolong clincl staff svc add,99416,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17.73,,,,,,,fee schedule,14.21,17.73,
Prolong clincl staff svc add,99416,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14.21,,,,,,,fee schedule,14.21,17.73,
Prolong clincl staff svc add,99416,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15.52,,,,,,,fee schedule,14.21,17.73,
Prolong clincl staff svc add,99416,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16.32,,,,,,,fee schedule,14.21,17.73,
Ol dig e/m svc 5-10 min,99421,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,49.44,,,,,,,fee schedule,39.63,49.44,
Ol dig e/m svc 5-10 min,99421,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39.63,,,,,,,fee schedule,39.63,49.44,
Ol dig e/m svc 5-10 min,99421,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,43.29,,,,,,,fee schedule,39.63,49.44,
Ol dig e/m svc 5-10 min,99421,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45.52,,,,,,,fee schedule,39.63,49.44,
Ol dig e/m svc 11-20 min,99422,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,101.76,,,,,,,fee schedule,81.57,101.76,
Ol dig e/m svc 11-20 min,99422,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,81.57,,,,,,,fee schedule,81.57,101.76,
Ol dig e/m svc 11-20 min,99422,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,89.11,,,,,,,fee schedule,81.57,101.76,
Ol dig e/m svc 11-20 min,99422,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,93.68,,,,,,,fee schedule,81.57,101.76,
Ol dig e/m svc 21+ min,99423,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,162.09,,,,,,,fee schedule,129.93,162.09,
Ol dig e/m svc 21+ min,99423,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,129.93,,,,,,,fee schedule,129.93,162.09,
Ol dig e/m svc 21+ min,99423,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,141.93,,,,,,,fee schedule,129.93,162.09,
Ol dig e/m svc 21+ min,99423,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,149.22,,,,,,,fee schedule,129.93,162.09,
Prin care mgmt staff 1st 30,99426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,288.87,,,,,,,fee schedule,100.57,446.2,
Prin care mgmt staff 1st 30,99426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,231.55,,,,,,,fee schedule,100.57,446.2,
Prin care mgmt staff 1st 30,99426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,252.95,,,,,,,fee schedule,100.57,446.2,
Prin care mgmt staff 1st 30,99426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,265.94,,,,,,,fee schedule,100.57,446.2,
Prin care mgmt staff 1st 30,99426,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,446.2,,,,,,,fee schedule,100.57,446.2,APC 378
Prin care mgmt staff 1st 30,99426,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,105.6,,,,,,,fee schedule,100.57,446.2,APC
Prin care mgmt staff 1st 30,99426,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,104.59,,,,,,,fee schedule,100.57,446.2,APC
Prin care mgmt staff 1st 30,99426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,100.57,,,,,,,fee schedule,100.57,446.2,APC
Prin care mgmt staff 1st 30,99426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,153.87,,,,,,,fee schedule,100.57,446.2,Radiology
Prin care mgmt staff 1st 30,99426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,140.8,,,,,,,fee schedule,100.57,446.2,APC
Prin care mgmt staff 1st 30,99426,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,176,,,,,,,fee schedule,100.57,446.2,APC
Ntrprof ph1/ntrnet/ehr 5/>,99451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,138.69,,,,,,,fee schedule,111.17,138.69,
Ntrprof ph1/ntrnet/ehr 5/>,99451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,111.17,,,,,,,fee schedule,111.17,138.69,
Ntrprof ph1/ntrnet/ehr 5/>,99451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,121.44,,,,,,,fee schedule,111.17,138.69,
Ntrprof ph1/ntrnet/ehr 5/>,99451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,127.68,,,,,,,fee schedule,111.17,138.69,
Ntrprof ph1/ntrnet/ehr rfrl,99452,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,138.69,,,,,,,fee schedule,111.17,138.69,
Ntrprof ph1/ntrnet/ehr rfrl,99452,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,111.17,,,,,,,fee schedule,111.17,138.69,
Ntrprof ph1/ntrnet/ehr rfrl,99452,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,121.44,,,,,,,fee schedule,111.17,138.69,
Ntrprof ph1/ntrnet/ehr rfrl,99452,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,127.68,,,,,,,fee schedule,111.17,138.69,
Rem mntr physiol param setup,99453,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,437.91,,,,,,,fee schedule,131.8,584.75,
Rem mntr physiol param setup,99453,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,351.03,,,,,,,fee schedule,131.8,584.75,
Rem mntr physiol param setup,99453,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,383.46,,,,,,,fee schedule,131.8,584.75,
Rem mntr physiol param setup,99453,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,403.16,,,,,,,fee schedule,131.8,584.75,
Rem mntr physiol param setup,99453,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.75,,,,,,,fee schedule,131.8,584.75,APC 378
Rem mntr physiol param setup,99453,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.39,,,,,,,fee schedule,131.8,584.75,APC
Rem mntr physiol param setup,99453,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,137.07,,,,,,,fee schedule,131.8,584.75,APC
Rem mntr physiol param setup,99453,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.8,,,,,,,fee schedule,131.8,584.75,APC
Rem mntr physiol param setup,99453,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.66,,,,,,,fee schedule,131.8,584.75,Radiology
Rem mntr physiol param setup,99453,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.52,,,,,,,fee schedule,131.8,584.75,APC
Rem mntr physiol param setup,99453,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.65,,,,,,,fee schedule,131.8,584.75,APC
Rem mntr physiol param dev,99454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,140.46,,,,,,,fee schedule,36.95,163.92,
Rem mntr physiol param dev,99454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,112.59,,,,,,,fee schedule,36.95,163.92,
Rem mntr physiol param dev,99454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,123,,,,,,,fee schedule,36.95,163.92,
Rem mntr physiol param dev,99454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,129.32,,,,,,,fee schedule,36.95,163.92,
Rem mntr physiol param dev,99454,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,163.92,,,,,,,fee schedule,36.95,163.92,APC 378
Rem mntr physiol param dev,99454,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.79,,,,,,,fee schedule,36.95,163.92,APC
Rem mntr physiol param dev,99454,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.43,,,,,,,fee schedule,36.95,163.92,APC
Rem mntr physiol param dev,99454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.95,,,,,,,fee schedule,36.95,163.92,APC
Rem mntr physiol param dev,99454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.53,,,,,,,fee schedule,36.95,163.92,Radiology
Rem mntr physiol param dev,99454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.73,,,,,,,fee schedule,36.95,163.92,APC
Rem mntr physiol param dev,99454,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.66,,,,,,,fee schedule,36.95,163.92,APC
Rem physiol mntr 20 min mo,99457,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,121.56,,,,,,,fee schedule,97.44,121.56,
Rem physiol mntr 20 min mo,99457,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,97.44,,,,,,,fee schedule,97.44,121.56,
Rem physiol mntr 20 min mo,99457,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,106.45,,,,,,,fee schedule,97.44,121.56,
Rem physiol mntr 20 min mo,99457,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,111.92,,,,,,,fee schedule,97.44,121.56,
Rem physiol mntr ea addl 20,99458,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,121.56,,,,,,,fee schedule,97.44,121.56,
Rem physiol mntr ea addl 20,99458,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,97.44,,,,,,,fee schedule,97.44,121.56,
Rem physiol mntr ea addl 20,99458,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,106.45,,,,,,,fee schedule,97.44,121.56,
Rem physiol mntr ea addl 20,99458,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,111.92,,,,,,,fee schedule,97.44,121.56,
Init nb em per day hosp,99460,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.75,,,,,,,fee schedule,131.8,584.75,APC 378
Init nb em per day hosp,99460,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.39,,,,,,,fee schedule,131.8,584.75,APC
Init nb em per day hosp,99460,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,137.07,,,,,,,fee schedule,131.8,584.75,APC
Init nb em per day hosp,99460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.8,,,,,,,fee schedule,131.8,584.75,APC
Init nb em per day hosp,99460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.66,,,,,,,fee schedule,131.8,584.75,Radiology
Init nb em per day hosp,99460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.52,,,,,,,fee schedule,131.8,584.75,APC
Init nb em per day hosp,99460,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.65,,,,,,,fee schedule,131.8,584.75,APC
Init nb em per day non-fac,99461,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,233.19,,,,,,,fee schedule,186.92,233.19,
Init nb em per day non-fac,99461,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,186.92,,,,,,,fee schedule,186.92,233.19,
Init nb em per day non-fac,99461,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,204.19,,,,,,,fee schedule,186.92,233.19,
Init nb em per day non-fac,99461,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,214.68,,,,,,,fee schedule,186.92,233.19,
Sbsq nb em per day hosp,99462,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,110.57,,,,,,,fee schedule,88.63,110.57,
Sbsq nb em per day hosp,99462,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,88.63,,,,,,,fee schedule,88.63,110.57,
Sbsq nb em per day hosp,99462,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,96.82,,,,,,,fee schedule,88.63,110.57,
Sbsq nb em per day hosp,99462,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,101.79,,,,,,,fee schedule,88.63,110.57,
Same day nb discharge,99463,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.75,,,,,,,fee schedule,131.8,584.75,APC 378
Same day nb discharge,99463,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.39,,,,,,,fee schedule,131.8,584.75,APC
Same day nb discharge,99463,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,137.07,,,,,,,fee schedule,131.8,584.75,APC
Same day nb discharge,99463,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.8,,,,,,,fee schedule,131.8,584.75,APC
Same day nb discharge,99463,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.66,,,,,,,fee schedule,131.8,584.75,Radiology
Same day nb discharge,99463,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.52,,,,,,,fee schedule,131.8,584.75,APC
Same day nb discharge,99463,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.65,,,,,,,fee schedule,131.8,584.75,APC
Attendance at delivery,99464,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,261.99,,,,,,,fee schedule,210.01,261.99,
Attendance at delivery,99464,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,210.01,,,,,,,fee schedule,210.01,261.99,
Attendance at delivery,99464,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,229.42,,,,,,,fee schedule,210.01,261.99,
Attendance at delivery,99464,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,241.2,,,,,,,fee schedule,210.01,261.99,
Nb resuscitation,99465,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2902.97,,,,,,,fee schedule,654.31,2902.97,APC 378
Nb resuscitation,99465,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,687.03,,,,,,,fee schedule,654.31,2902.97,APC
Nb resuscitation,99465,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,680.49,,,,,,,fee schedule,654.31,2902.97,APC
Nb resuscitation,99465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,654.31,,,,,,,fee schedule,654.31,2902.97,APC
Nb resuscitation,99465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1001.1,,,,,,,fee schedule,654.31,2902.97,Radiology
Nb resuscitation,99465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,916.04,,,,,,,fee schedule,654.31,2902.97,APC
Nb resuscitation,99465,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1145.05,,,,,,,fee schedule,654.31,2902.97,APC
Ped crit care transport,99466,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,858.74,,,,,,,fee schedule,688.36,858.74,
Ped crit care transport,99466,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,688.36,,,,,,,fee schedule,688.36,858.74,
Ped crit care transport,99466,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,751.97,,,,,,,fee schedule,688.36,858.74,
Ped crit care transport,99466,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,790.59,,,,,,,fee schedule,688.36,858.74,
Ped crit care transport addl,99467,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,428.84,,,,,,,fee schedule,343.75,428.84,
Ped crit care transport addl,99467,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,343.75,,,,,,,fee schedule,343.75,428.84,
Ped crit care transport addl,99467,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,375.52,,,,,,,fee schedule,343.75,428.84,
Ped crit care transport addl,99467,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,394.81,,,,,,,fee schedule,343.75,428.84,
Neonate crit care initial,99468,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3238.44,,,,,,,fee schedule,2595.89,3238.44,
Neonate crit care initial,99468,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2595.89,,,,,,,fee schedule,2595.89,3238.44,
Neonate crit care initial,99468,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2835.78,,,,,,,fee schedule,2595.89,3238.44,
Neonate crit care initial,99468,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2981.42,,,,,,,fee schedule,2595.89,3238.44,
Neonate crit care subsq,99469,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1405.25,,,,,,,fee schedule,1126.43,1405.25,
Neonate crit care subsq,99469,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1126.43,,,,,,,fee schedule,1126.43,1405.25,
Neonate crit care subsq,99469,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1230.53,,,,,,,fee schedule,1126.43,1405.25,
Neonate crit care subsq,99469,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1293.72,,,,,,,fee schedule,1126.43,1405.25,
Ped critical care initial,99471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2888.3,,,,,,,fee schedule,2315.22,2888.3,
Ped critical care initial,99471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2315.22,,,,,,,fee schedule,2315.22,2888.3,
Ped critical care initial,99471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2529.17,,,,,,,fee schedule,2315.22,2888.3,
Ped critical care initial,99471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2659.07,,,,,,,fee schedule,2315.22,2888.3,
Ped critical care subsq,99472,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1424.68,,,,,,,fee schedule,1142.01,1424.68,
Ped critical care subsq,99472,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1142.01,,,,,,,fee schedule,1142.01,1424.68,
Ped critical care subsq,99472,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1247.54,,,,,,,fee schedule,1142.01,1424.68,
Ped critical care subsq,99472,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1311.61,,,,,,,fee schedule,1142.01,1424.68,
Self-meas bp pt educaj/train,99473,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,86.9,,,,,,,fee schedule,28.63,127.04,
Self-meas bp pt educaj/train,99473,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,69.66,,,,,,,fee schedule,28.63,127.04,
Self-meas bp pt educaj/train,99473,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,76.1,,,,,,,fee schedule,28.63,127.04,
Self-meas bp pt educaj/train,99473,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,80.01,,,,,,,fee schedule,28.63,127.04,
Self-meas bp pt educaj/train,99473,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,127.04,,,,,,,fee schedule,28.63,127.04,APC 378
Self-meas bp pt educaj/train,99473,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.07,,,,,,,fee schedule,28.63,127.04,APC
Self-meas bp pt educaj/train,99473,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,29.78,,,,,,,fee schedule,28.63,127.04,APC
Self-meas bp pt educaj/train,99473,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,28.63,,,,,,,fee schedule,28.63,127.04,APC
Self-meas bp pt educaj/train,99473,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43.81,,,,,,,fee schedule,28.63,127.04,Radiology
Self-meas bp pt educaj/train,99473,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40.09,,,,,,,fee schedule,28.63,127.04,APC
Self-meas bp pt educaj/train,99473,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,50.11,,,,,,,fee schedule,28.63,127.04,APC
Self-meas bp 2 readg bid 30d,99474,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33.38,,,,,,,fee schedule,26.75,33.38,
Self-meas bp 2 readg bid 30d,99474,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26.75,,,,,,,fee schedule,26.75,33.38,
Self-meas bp 2 readg bid 30d,99474,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29.23,,,,,,,fee schedule,26.75,33.38,
Self-meas bp 2 readg bid 30d,99474,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30.73,,,,,,,fee schedule,26.75,33.38,
Ped crit care age 2-5 init,99475,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1995.16,,,,,,,fee schedule,1599.29,1995.16,
Ped crit care age 2-5 init,99475,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1599.29,,,,,,,fee schedule,1599.29,1995.16,
Ped crit care age 2-5 init,99475,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1747.08,,,,,,,fee schedule,1599.29,1995.16,
Ped crit care age 2-5 init,99475,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1836.81,,,,,,,fee schedule,1599.29,1995.16,
Ped crit care age 2-5 subsq,99476,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1183.29,,,,,,,fee schedule,948.51,1183.29,
Ped crit care age 2-5 subsq,99476,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,948.51,,,,,,,fee schedule,948.51,1183.29,
Ped crit care age 2-5 subsq,99476,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1036.16,,,,,,,fee schedule,948.51,1183.29,
Ped crit care age 2-5 subsq,99476,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1089.38,,,,,,,fee schedule,948.51,1183.29,
Ic lbw inf < 1500 gm subsq,99478,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,510.72,,,,,,,fee schedule,409.38,510.72,
Ic lbw inf < 1500 gm subsq,99478,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,409.38,,,,,,,fee schedule,409.38,510.72,
Ic lbw inf < 1500 gm subsq,99478,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,447.21,,,,,,,fee schedule,409.38,510.72,
Ic lbw inf < 1500 gm subsq,99478,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,470.18,,,,,,,fee schedule,409.38,510.72,
Ic lbw inf 1500-2500 g subsq,99479,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,450.88,,,,,,,fee schedule,361.42,450.88,
Ic lbw inf 1500-2500 g subsq,99479,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,361.42,,,,,,,fee schedule,361.42,450.88,
Ic lbw inf 1500-2500 g subsq,99479,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,394.82,,,,,,,fee schedule,361.42,450.88,
Ic lbw inf 1500-2500 g subsq,99479,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,415.09,,,,,,,fee schedule,361.42,450.88,
Ic inf pbw 2501-5000 g subsq,99480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,433.34,,,,,,,fee schedule,347.36,433.34,
Ic inf pbw 2501-5000 g subsq,99480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,347.36,,,,,,,fee schedule,347.36,433.34,
Ic inf pbw 2501-5000 g subsq,99480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,379.46,,,,,,,fee schedule,347.36,433.34,
Ic inf pbw 2501-5000 g subsq,99480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,398.95,,,,,,,fee schedule,347.36,433.34,
Assmt & care pln pt cog imp,99483,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,288.75,,,,,,,fee schedule,100.57,446.2,
Assmt & care pln pt cog imp,99483,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,231.46,,,,,,,fee schedule,100.57,446.2,
Assmt & care pln pt cog imp,99483,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,252.85,,,,,,,fee schedule,100.57,446.2,
Assmt & care pln pt cog imp,99483,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,265.84,,,,,,,fee schedule,100.57,446.2,
Assmt & care pln pt cog imp,99483,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,446.2,,,,,,,fee schedule,100.57,446.2,APC 378
Assmt & care pln pt cog imp,99483,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,105.6,,,,,,,fee schedule,100.57,446.2,APC
Assmt & care pln pt cog imp,99483,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,104.59,,,,,,,fee schedule,100.57,446.2,APC
Assmt & care pln pt cog imp,99483,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,100.57,,,,,,,fee schedule,100.57,446.2,APC
Assmt & care pln pt cog imp,99483,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,153.87,,,,,,,fee schedule,100.57,446.2,Radiology
Assmt & care pln pt cog imp,99483,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,140.8,,,,,,,fee schedule,100.57,446.2,APC
Assmt & care pln pt cog imp,99483,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,176,,,,,,,fee schedule,100.57,446.2,APC
Care mgmt svc bhvl hlth cond,99484,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,126.18,,,,,,,fee schedule,37.09,164.57,
Care mgmt svc bhvl hlth cond,99484,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,101.14,,,,,,,fee schedule,37.09,164.57,
Care mgmt svc bhvl hlth cond,99484,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,110.49,,,,,,,fee schedule,37.09,164.57,
Care mgmt svc bhvl hlth cond,99484,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,116.16,,,,,,,fee schedule,37.09,164.57,
Care mgmt svc bhvl hlth cond,99484,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.57,,,,,,,fee schedule,37.09,164.57,APC 378
Care mgmt svc bhvl hlth cond,99484,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.95,,,,,,,fee schedule,37.09,164.57,APC
Care mgmt svc bhvl hlth cond,99484,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.58,,,,,,,fee schedule,37.09,164.57,APC
Care mgmt svc bhvl hlth cond,99484,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,37.09,,,,,,,fee schedule,37.09,164.57,APC
Care mgmt svc bhvl hlth cond,99484,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.75,,,,,,,fee schedule,37.09,164.57,Radiology
Care mgmt svc bhvl hlth cond,99484,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.93,,,,,,,fee schedule,37.09,164.57,APC
Care mgmt svc bhvl hlth cond,99484,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.91,,,,,,,fee schedule,37.09,164.57,APC
Suprv interfacilty transport,99485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,275.03,,,,,,,fee schedule,220.46,275.03,
Suprv interfacilty transport,99485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,220.46,,,,,,,fee schedule,220.46,275.03,
Suprv interfacilty transport,99485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,240.84,,,,,,,fee schedule,220.46,275.03,
Suprv interfacilty transport,99485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,253.2,,,,,,,fee schedule,220.46,275.03,
Suprv interfac trnsport addl,99486,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,239.88,,,,,,,fee schedule,192.28,239.88,
Suprv interfac trnsport addl,99486,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,192.28,,,,,,,fee schedule,192.28,239.88,
Suprv interfac trnsport addl,99486,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,210.05,,,,,,,fee schedule,192.28,239.88,
Suprv interfac trnsport addl,99486,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,220.84,,,,,,,fee schedule,192.28,239.88,
Cmplx chron care w/o pt vsit,99487,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,295.33,,,,,,,fee schedule,175.71,779.59,
Cmplx chron care w/o pt vsit,99487,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,236.73,,,,,,,fee schedule,175.71,779.59,
Cmplx chron care w/o pt vsit,99487,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,258.61,,,,,,,fee schedule,175.71,779.59,
Cmplx chron care w/o pt vsit,99487,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,271.89,,,,,,,fee schedule,175.71,779.59,
Cmplx chron care w/o pt vsit,99487,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,779.59,,,,,,,fee schedule,175.71,779.59,APC 378
Cmplx chron care w/o pt vsit,99487,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,184.5,,,,,,,fee schedule,175.71,779.59,APC
Cmplx chron care w/o pt vsit,99487,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,182.74,,,,,,,fee schedule,175.71,779.59,APC
Cmplx chron care w/o pt vsit,99487,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,175.71,,,,,,,fee schedule,175.71,779.59,APC
Cmplx chron care w/o pt vsit,99487,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,268.84,,,,,,,fee schedule,175.71,779.59,Radiology
Cmplx chron care w/o pt vsit,99487,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,246,,,,,,,fee schedule,175.71,779.59,APC
Cmplx chron care w/o pt vsit,99487,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,307.5,,,,,,,fee schedule,175.71,779.59,APC
Cmplx chron care addl 30 min,99489,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,148.25,,,,,,,fee schedule,118.84,148.25,
Cmplx chron care addl 30 min,99489,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,118.84,,,,,,,fee schedule,118.84,148.25,
Cmplx chron care addl 30 min,99489,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,129.82,,,,,,,fee schedule,118.84,148.25,
Cmplx chron care addl 30 min,99489,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,136.49,,,,,,,fee schedule,118.84,148.25,
Chron care mgmt srvc 20 min,99490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,203.06,,,,,,,fee schedule,100.57,446.2,
Chron care mgmt srvc 20 min,99490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,162.77,,,,,,,fee schedule,100.57,446.2,
Chron care mgmt srvc 20 min,99490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,177.81,,,,,,,fee schedule,100.57,446.2,
Chron care mgmt srvc 20 min,99490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,186.95,,,,,,,fee schedule,100.57,446.2,
Chron care mgmt srvc 20 min,99490,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,446.2,,,,,,,fee schedule,100.57,446.2,APC 378
Chron care mgmt srvc 20 min,99490,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,105.6,,,,,,,fee schedule,100.57,446.2,APC
Chron care mgmt srvc 20 min,99490,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,104.59,,,,,,,fee schedule,100.57,446.2,APC
Chron care mgmt srvc 20 min,99490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,100.57,,,,,,,fee schedule,100.57,446.2,APC
Chron care mgmt srvc 20 min,99490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,153.87,,,,,,,fee schedule,100.57,446.2,Radiology
Chron care mgmt srvc 20 min,99490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,140.8,,,,,,,fee schedule,100.57,446.2,APC
Chron care mgmt srvc 20 min,99490,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,176,,,,,,,fee schedule,100.57,446.2,APC
Chrnc care mgmt svc 30 min,99491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,308.49,,,,,,,fee schedule,247.28,308.49,
Chrnc care mgmt svc 30 min,99491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,247.28,,,,,,,fee schedule,247.28,308.49,
Chrnc care mgmt svc 30 min,99491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,270.13,,,,,,,fee schedule,247.28,308.49,
Chrnc care mgmt svc 30 min,99491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,284,,,,,,,fee schedule,247.28,308.49,
1st psyc collab care mgmt,99492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,288.75,,,,,,,fee schedule,100.57,446.2,
1st psyc collab care mgmt,99492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,231.46,,,,,,,fee schedule,100.57,446.2,
1st psyc collab care mgmt,99492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,252.85,,,,,,,fee schedule,100.57,446.2,
1st psyc collab care mgmt,99492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,265.84,,,,,,,fee schedule,100.57,446.2,
1st psyc collab care mgmt,99492,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,446.2,,,,,,,fee schedule,100.57,446.2,APC 378
1st psyc collab care mgmt,99492,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,105.6,,,,,,,fee schedule,100.57,446.2,APC
1st psyc collab care mgmt,99492,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,104.59,,,,,,,fee schedule,100.57,446.2,APC
1st psyc collab care mgmt,99492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,100.57,,,,,,,fee schedule,100.57,446.2,APC
1st psyc collab care mgmt,99492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,153.87,,,,,,,fee schedule,100.57,446.2,Radiology
1st psyc collab care mgmt,99492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,140.8,,,,,,,fee schedule,100.57,446.2,APC
1st psyc collab care mgmt,99492,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,176,,,,,,,fee schedule,100.57,446.2,APC
Sbsq psyc collab care mgmt,99493,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,288.75,,,,,,,fee schedule,100.57,446.2,
Sbsq psyc collab care mgmt,99493,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,231.46,,,,,,,fee schedule,100.57,446.2,
Sbsq psyc collab care mgmt,99493,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,252.85,,,,,,,fee schedule,100.57,446.2,
Sbsq psyc collab care mgmt,99493,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,265.84,,,,,,,fee schedule,100.57,446.2,
Sbsq psyc collab care mgmt,99493,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,446.2,,,,,,,fee schedule,100.57,446.2,APC 378
Sbsq psyc collab care mgmt,99493,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,105.6,,,,,,,fee schedule,100.57,446.2,APC
Sbsq psyc collab care mgmt,99493,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,104.59,,,,,,,fee schedule,100.57,446.2,APC
Sbsq psyc collab care mgmt,99493,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,100.57,,,,,,,fee schedule,100.57,446.2,APC
Sbsq psyc collab care mgmt,99493,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,153.87,,,,,,,fee schedule,100.57,446.2,Radiology
Sbsq psyc collab care mgmt,99493,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,140.8,,,,,,,fee schedule,100.57,446.2,APC
Sbsq psyc collab care mgmt,99493,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,176,,,,,,,fee schedule,100.57,446.2,APC
1st/sbsq psyc collab care,99494,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,159.86,,,,,,,fee schedule,128.14,159.86,
1st/sbsq psyc collab care,99494,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,128.14,,,,,,,fee schedule,128.14,159.86,
1st/sbsq psyc collab care,99494,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,139.98,,,,,,,fee schedule,128.14,159.86,
1st/sbsq psyc collab care,99494,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,147.17,,,,,,,fee schedule,128.14,159.86,
Trans care mgmt 14 day disch,99495,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,278.51,,,,,,,fee schedule,131.8,584.75,
Trans care mgmt 14 day disch,99495,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,223.25,,,,,,,fee schedule,131.8,584.75,
Trans care mgmt 14 day disch,99495,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,243.88,,,,,,,fee schedule,131.8,584.75,
Trans care mgmt 14 day disch,99495,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,256.41,,,,,,,fee schedule,131.8,584.75,
Trans care mgmt 14 day disch,99495,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.75,,,,,,,fee schedule,131.8,584.75,APC 378
Trans care mgmt 14 day disch,99495,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.39,,,,,,,fee schedule,131.8,584.75,APC
Trans care mgmt 14 day disch,99495,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,137.07,,,,,,,fee schedule,131.8,584.75,APC
Trans care mgmt 14 day disch,99495,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.8,,,,,,,fee schedule,131.8,584.75,APC
Trans care mgmt 14 day disch,99495,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.66,,,,,,,fee schedule,131.8,584.75,Radiology
Trans care mgmt 14 day disch,99495,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.52,,,,,,,fee schedule,131.8,584.75,APC
Trans care mgmt 14 day disch,99495,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.65,,,,,,,fee schedule,131.8,584.75,APC
Trans care mgmt 7 day disch,99496,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,366.51,,,,,,,fee schedule,131.8,584.75,
Trans care mgmt 7 day disch,99496,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,293.79,,,,,,,fee schedule,131.8,584.75,
Trans care mgmt 7 day disch,99496,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,320.94,,,,,,,fee schedule,131.8,584.75,
Trans care mgmt 7 day disch,99496,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,337.42,,,,,,,fee schedule,131.8,584.75,
Trans care mgmt 7 day disch,99496,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.75,,,,,,,fee schedule,131.8,584.75,APC 378
Trans care mgmt 7 day disch,99496,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.39,,,,,,,fee schedule,131.8,584.75,APC
Trans care mgmt 7 day disch,99496,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,137.07,,,,,,,fee schedule,131.8,584.75,APC
Trans care mgmt 7 day disch,99496,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.8,,,,,,,fee schedule,131.8,584.75,APC
Trans care mgmt 7 day disch,99496,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.66,,,,,,,fee schedule,131.8,584.75,Radiology
Trans care mgmt 7 day disch,99496,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.52,,,,,,,fee schedule,131.8,584.75,APC
Trans care mgmt 7 day disch,99496,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.65,,,,,,,fee schedule,131.8,584.75,APC
Advncd care plan 30 min,99497,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,265.58,,,,,,,fee schedule,100.57,446.2,
Advncd care plan 30 min,99497,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,212.89,,,,,,,fee schedule,100.57,446.2,
Advncd care plan 30 min,99497,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,232.56,,,,,,,fee schedule,100.57,446.2,
Advncd care plan 30 min,99497,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,244.5,,,,,,,fee schedule,100.57,446.2,
Advncd care plan 30 min,99497,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,446.2,,,,,,,fee schedule,100.57,446.2,APC 378
Advncd care plan 30 min,99497,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,105.6,,,,,,,fee schedule,100.57,446.2,APC
Advncd care plan 30 min,99497,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,104.59,,,,,,,fee schedule,100.57,446.2,APC
Advncd care plan 30 min,99497,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,100.57,,,,,,,fee schedule,100.57,446.2,APC
Advncd care plan 30 min,99497,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,153.87,,,,,,,fee schedule,100.57,446.2,Radiology
Advncd care plan 30 min,99497,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,140.8,,,,,,,fee schedule,100.57,446.2,APC
Advncd care plan 30 min,99497,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,176,,,,,,,fee schedule,100.57,446.2,APC
Basic support routine suppls,A0382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24.27,,,,,,,fee schedule,19.45,24.27,
Basic support routine suppls,A0382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19.45,,,,,,,fee schedule,19.45,24.27,
Basic support routine suppls,A0382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21.25,,,,,,,fee schedule,19.45,24.27,
Basic support routine suppls,A0382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22.34,,,,,,,fee schedule,19.45,24.27,
Bls defibrillation supplies,A0384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,118.92,,,,,,,fee schedule,95.32,118.92,
Bls defibrillation supplies,A0384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,95.32,,,,,,,fee schedule,95.32,118.92,
Bls defibrillation supplies,A0384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,104.13,,,,,,,fee schedule,95.32,118.92,
Bls defibrillation supplies,A0384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,109.48,,,,,,,fee schedule,95.32,118.92,
Als defibrillation supplies,A0392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,118.92,,,,,,,fee schedule,95.32,118.92,
Als defibrillation supplies,A0392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,95.32,,,,,,,fee schedule,95.32,118.92,
Als defibrillation supplies,A0392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,104.13,,,,,,,fee schedule,95.32,118.92,
Als defibrillation supplies,A0392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,109.48,,,,,,,fee schedule,95.32,118.92,
Als IV drug therapy supplies,A0394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,57.04,,,,,,,fee schedule,45.72,57.04,
Als IV drug therapy supplies,A0394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,45.72,,,,,,,fee schedule,45.72,57.04,
Als IV drug therapy supplies,A0394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,49.95,,,,,,,fee schedule,45.72,57.04,
Als IV drug therapy supplies,A0394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,52.51,,,,,,,fee schedule,45.72,57.04,
Als esophageal intub suppls,A0396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,94.65,,,,,,,fee schedule,75.87,94.65,
Als esophageal intub suppls,A0396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,75.87,,,,,,,fee schedule,75.87,94.65,
Als esophageal intub suppls,A0396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,82.88,,,,,,,fee schedule,75.87,94.65,
Als esophageal intub suppls,A0396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,87.14,,,,,,,fee schedule,75.87,94.65,
Als routine disposble suppls,A0398,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24.27,,,,,,,fee schedule,19.45,24.27,
Als routine disposble suppls,A0398,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19.45,,,,,,,fee schedule,19.45,24.27,
Als routine disposble suppls,A0398,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21.25,,,,,,,fee schedule,19.45,24.27,
Als routine disposble suppls,A0398,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22.34,,,,,,,fee schedule,19.45,24.27,
Ambulance 02 life sustaining,A0422,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,87.36,,,,,,,fee schedule,70.02,87.36,
Ambulance 02 life sustaining,A0422,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,70.02,,,,,,,fee schedule,70.02,87.36,
Ambulance 02 life sustaining,A0422,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,76.49,,,,,,,fee schedule,70.02,87.36,
Ambulance 02 life sustaining,A0422,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,80.42,,,,,,,fee schedule,70.02,87.36,
Ground mileage,A0425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13.82,,,,,,,fee schedule,9.42,16.48,
Ground mileage,A0425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11.08,,,,,,,fee schedule,9.42,16.48,
Ground mileage,A0425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12.1,,,,,,,fee schedule,9.42,16.48,
Ground mileage,A0425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12.72,,,,,,,fee schedule,9.42,16.48,
Ground mileage,A0425,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.42,,,,,,,fee schedule,9.42,16.48,Ambulance--Air
Ground mileage,A0425,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.89,,,,,,,fee schedule,9.42,16.48,APC
Ground mileage,A0425,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9.8,,,,,,,fee schedule,9.42,16.48,APC
Ground mileage,A0425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.41,,,,,,,fee schedule,9.42,16.48,Radiology
Ground mileage,A0425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.19,,,,,,,fee schedule,9.42,16.48,APC
Ground mileage,A0425,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16.48,,,,,,,fee schedule,9.42,16.48,APC
Als 1,A0426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,417.19,,,,,,,fee schedule,331.28,579.74,
Als 1,A0426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,334.41,,,,,,,fee schedule,331.28,579.74,
Als 1,A0426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,365.31,,,,,,,fee schedule,331.28,579.74,
Als 1,A0426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,384.08,,,,,,,fee schedule,331.28,579.74,
Als 1,A0426,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,331.28,,,,,,,fee schedule,331.28,579.74,Ambulance--Air
Als 1,A0426,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,347.84,,,,,,,fee schedule,331.28,579.74,APC
Als 1,A0426,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,344.53,,,,,,,fee schedule,331.28,579.74,APC
Als 1,A0426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,506.86,,,,,,,fee schedule,331.28,579.74,Radiology
Als 1,A0426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,463.79,,,,,,,fee schedule,331.28,579.74,APC
Als 1,A0426,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,579.74,,,,,,,fee schedule,331.28,579.74,APC
ALS1-emergency,A0427,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,657.75,,,,,,,fee schedule,524.53,917.93,
ALS1-emergency,A0427,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,527.24,,,,,,,fee schedule,524.53,917.93,
ALS1-emergency,A0427,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,575.96,,,,,,,fee schedule,524.53,917.93,
ALS1-emergency,A0427,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,605.54,,,,,,,fee schedule,524.53,917.93,
ALS1-emergency,A0427,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,524.53,,,,,,,fee schedule,524.53,917.93,Ambulance--Air
ALS1-emergency,A0427,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,550.76,,,,,,,fee schedule,524.53,917.93,APC
ALS1-emergency,A0427,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,545.51,,,,,,,fee schedule,524.53,917.93,APC
ALS1-emergency,A0427,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,802.53,,,,,,,fee schedule,524.53,917.93,Radiology
ALS1-emergency,A0427,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,734.34,,,,,,,fee schedule,524.53,917.93,APC
ALS1-emergency,A0427,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,917.93,,,,,,,fee schedule,524.53,917.93,APC
bls,A0428,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,384.68,,,,,,,fee schedule,276.07,483.12,
bls,A0428,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,308.35,,,,,,,fee schedule,276.07,483.12,
bls,A0428,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,336.85,,,,,,,fee schedule,276.07,483.12,
bls,A0428,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,354.15,,,,,,,fee schedule,276.07,483.12,
bls,A0428,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,276.07,,,,,,,fee schedule,276.07,483.12,Ambulance--Air
bls,A0428,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,289.87,,,,,,,fee schedule,276.07,483.12,APC
bls,A0428,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,287.11,,,,,,,fee schedule,276.07,483.12,APC
bls,A0428,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,422.39,,,,,,,fee schedule,276.07,483.12,Radiology
bls,A0428,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,386.5,,,,,,,fee schedule,276.07,483.12,APC
bls,A0428,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,483.12,,,,,,,fee schedule,276.07,483.12,APC
BLS-emergency,A0429,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,554.8,,,,,,,fee schedule,441.71,772.99,
BLS-emergency,A0429,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,444.72,,,,,,,fee schedule,441.71,772.99,
BLS-emergency,A0429,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,485.82,,,,,,,fee schedule,441.71,772.99,
BLS-emergency,A0429,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,510.77,,,,,,,fee schedule,441.71,772.99,
BLS-emergency,A0429,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,441.71,,,,,,,fee schedule,441.71,772.99,Ambulance--Air
BLS-emergency,A0429,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,463.8,,,,,,,fee schedule,441.71,772.99,APC
BLS-emergency,A0429,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,459.38,,,,,,,fee schedule,441.71,772.99,APC
BLS-emergency,A0429,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,675.82,,,,,,,fee schedule,441.71,772.99,Radiology
BLS-emergency,A0429,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,618.39,,,,,,,fee schedule,441.71,772.99,APC
BLS-emergency,A0429,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,772.99,,,,,,,fee schedule,441.71,772.99,APC
Fixed wing air transport,A0430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10163.13,,,,,,,fee schedule,5552.04,10163.13,
Fixed wing air transport,A0430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8146.64,,,,,,,fee schedule,5552.04,10163.13,
Fixed wing air transport,A0430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8899.46,,,,,,,fee schedule,5552.04,10163.13,
Fixed wing air transport,A0430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9356.54,,,,,,,fee schedule,5552.04,10163.13,
Fixed wing air transport,A0430,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5552.04,,,,,,,fee schedule,5552.04,10163.13,Ambulance--Air
Fixed wing air transport,A0430,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5829.64,,,,,,,fee schedule,5552.04,10163.13,APC
Fixed wing air transport,A0430,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5774.12,,,,,,,fee schedule,5552.04,10163.13,APC
Fixed wing air transport,A0430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8494.62,,,,,,,fee schedule,5552.04,10163.13,Radiology
Fixed wing air transport,A0430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7772.86,,,,,,,fee schedule,5552.04,10163.13,APC
Fixed wing air transport,A0430,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9716.07,,,,,,,fee schedule,5552.04,10163.13,APC
Rotary wing air transport,A0431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11816.13,,,,,,,fee schedule,6455.09,11816.13,
Rotary wing air transport,A0431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9471.66,,,,,,,fee schedule,6455.09,11816.13,
Rotary wing air transport,A0431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10346.93,,,,,,,fee schedule,6455.09,11816.13,
Rotary wing air transport,A0431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10878.34,,,,,,,fee schedule,6455.09,11816.13,
Rotary wing air transport,A0431,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6455.09,,,,,,,fee schedule,6455.09,11816.13,Ambulance--Air
Rotary wing air transport,A0431,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6777.84,,,,,,,fee schedule,6455.09,11816.13,APC
Rotary wing air transport,A0431,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6713.29,,,,,,,fee schedule,6455.09,11816.13,APC
Rotary wing air transport,A0431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9876.29,,,,,,,fee schedule,6455.09,11816.13,Radiology
Rotary wing air transport,A0431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9037.13,,,,,,,fee schedule,6455.09,11816.13,APC
Rotary wing air transport,A0431,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11296.41,,,,,,,fee schedule,6455.09,11816.13,APC
PI volunteer ambulance co,A0432,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1338.08,,,,,,,fee schedule,483.12,1338.08,
PI volunteer ambulance co,A0432,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1072.59,,,,,,,fee schedule,483.12,1338.08,
PI volunteer ambulance co,A0432,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1171.71,,,,,,,fee schedule,483.12,1338.08,
PI volunteer ambulance co,A0432,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1231.89,,,,,,,fee schedule,483.12,1338.08,
PI volunteer ambulance co,A0432,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,483.12,,,,,,,fee schedule,483.12,1338.08,Ambulance--Air
PI volunteer ambulance co,A0432,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,507.28,,,,,,,fee schedule,483.12,1338.08,APC
PI volunteer ambulance co,A0432,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,502.44,,,,,,,fee schedule,483.12,1338.08,APC
PI volunteer ambulance co,A0432,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,739.17,,,,,,,fee schedule,483.12,1338.08,Radiology
PI volunteer ambulance co,A0432,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,676.37,,,,,,,fee schedule,483.12,1338.08,APC
PI volunteer ambulance co,A0432,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,845.46,,,,,,,fee schedule,483.12,1338.08,APC
als 2,A0433,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,951.4,,,,,,,fee schedule,759.19,1328.58,
als 2,A0433,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,762.63,,,,,,,fee schedule,759.19,1328.58,
als 2,A0433,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,833.1,,,,,,,fee schedule,759.19,1328.58,
als 2,A0433,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,875.89,,,,,,,fee schedule,759.19,1328.58,
als 2,A0433,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,759.19,,,,,,,fee schedule,759.19,1328.58,Ambulance--Air
als 2,A0433,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,797.15,,,,,,,fee schedule,759.19,1328.58,APC
als 2,A0433,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,789.56,,,,,,,fee schedule,759.19,1328.58,APC
als 2,A0433,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1161.56,,,,,,,fee schedule,759.19,1328.58,Radiology
als 2,A0433,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1062.87,,,,,,,fee schedule,759.19,1328.58,APC
als 2,A0433,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1328.58,,,,,,,fee schedule,759.19,1328.58,APC
Specialty care transport,A0434,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2485.05,,,,,,,fee schedule,897.22,2485.05,
Specialty care transport,A0434,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1991.98,,,,,,,fee schedule,897.22,2485.05,
Specialty care transport,A0434,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2176.06,,,,,,,fee schedule,897.22,2485.05,
Specialty care transport,A0434,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2287.82,,,,,,,fee schedule,897.22,2485.05,
Specialty care transport,A0434,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,897.22,,,,,,,fee schedule,897.22,2485.05,Ambulance--Air
Specialty care transport,A0434,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,942.08,,,,,,,fee schedule,897.22,2485.05,APC
Specialty care transport,A0434,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,933.11,,,,,,,fee schedule,897.22,2485.05,APC
Specialty care transport,A0434,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1372.75,,,,,,,fee schedule,897.22,2485.05,Radiology
Specialty care transport,A0434,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1256.11,,,,,,,fee schedule,897.22,2485.05,APC
Specialty care transport,A0434,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1570.14,,,,,,,fee schedule,897.22,2485.05,APC
Fixed wing air mileage,A0435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30.5,,,,,,,fee schedule,16.44,30.5,
Fixed wing air mileage,A0435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24.45,,,,,,,fee schedule,16.44,30.5,
Fixed wing air mileage,A0435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26.71,,,,,,,fee schedule,16.44,30.5,
Fixed wing air mileage,A0435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,28.08,,,,,,,fee schedule,16.44,30.5,
Fixed wing air mileage,A0435,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.44,,,,,,,fee schedule,16.44,30.5,Ambulance--Air
Fixed wing air mileage,A0435,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.26,,,,,,,fee schedule,16.44,30.5,APC
Fixed wing air mileage,A0435,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,17.1,,,,,,,fee schedule,16.44,30.5,APC
Fixed wing air mileage,A0435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.15,,,,,,,fee schedule,16.44,30.5,Radiology
Fixed wing air mileage,A0435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.02,,,,,,,fee schedule,16.44,30.5,APC
Fixed wing air mileage,A0435,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,28.77,,,,,,,fee schedule,16.44,30.5,APC
Rotary wing air mileage,A0436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,81.38,,,,,,,fee schedule,43.85,81.38,
Rotary wing air mileage,A0436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,65.24,,,,,,,fee schedule,43.85,81.38,
Rotary wing air mileage,A0436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,71.26,,,,,,,fee schedule,43.85,81.38,
Rotary wing air mileage,A0436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,74.92,,,,,,,fee schedule,43.85,81.38,
Rotary wing air mileage,A0436,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,43.85,,,,,,,fee schedule,43.85,81.38,Ambulance--Air
Rotary wing air mileage,A0436,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,46.04,,,,,,,fee schedule,43.85,81.38,APC
Rotary wing air mileage,A0436,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,45.6,,,,,,,fee schedule,43.85,81.38,APC
Rotary wing air mileage,A0436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,67.09,,,,,,,fee schedule,43.85,81.38,Radiology
Rotary wing air mileage,A0436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,61.39,,,,,,,fee schedule,43.85,81.38,APC
Rotary wing air mileage,A0436,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,76.74,,,,,,,fee schedule,43.85,81.38,APC
Miscellaneous M <46.50 and A >=77.50,A2004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24.65,,,,,,,fee schedule,22.31,24.65,
Miscellaneous M <46.50 and A >=77.50,A2004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22.31,,,,,,,fee schedule,22.31,24.65,
"Symphony, per sq cm",A2009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,173.04,,,,,,,fee schedule,123.2,546.58,
"Symphony, per sq cm",A2009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,156.61,,,,,,,fee schedule,123.2,546.58,
"Symphony, per sq cm",A2009,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,546.58,APC 378
"Symphony, per sq cm",A2009,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,546.58,APC
"Symphony, per sq cm",A2009,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,546.58,APC
"Symphony, per sq cm",A2009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,546.58,APC
"Symphony, per sq cm",A2009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,546.58,Radiology
"Symphony, per sq cm",A2009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,546.58,APC
"Symphony, per sq cm",A2009,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,546.58,APC
Omeza collag per 100 mg,A2014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,112.58,,,,,,,fee schedule,101.89,112.58,
Omeza collag per 100 mg,A2014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,101.89,,,,,,,fee schedule,101.89,112.58,
"Phoenix wnd mtrx, per sq cm",A2015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2275.2,,,,,,,fee schedule,123.2,2275.2,
"Phoenix wnd mtrx, per sq cm",A2015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2059.2,,,,,,,fee schedule,123.2,2275.2,
"Phoenix wnd mtrx, per sq cm",A2015,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,2275.2,APC 378
"Phoenix wnd mtrx, per sq cm",A2015,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,2275.2,APC
"Phoenix wnd mtrx, per sq cm",A2015,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,2275.2,APC
"Phoenix wnd mtrx, per sq cm",A2015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,2275.2,APC
"Phoenix wnd mtrx, per sq cm",A2015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,2275.2,Radiology
"Phoenix wnd mtrx, per sq cm",A2015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,2275.2,APC
"Phoenix wnd mtrx, per sq cm",A2015,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,2275.2,APC
Kerecis marigen shld sq cm,A2019,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1073.14,,,,,,,fee schedule,123.2,1073.14,
Kerecis marigen shld sq cm,A2019,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,971.26,,,,,,,fee schedule,123.2,1073.14,
Kerecis marigen shld sq cm,A2019,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,1073.14,APC 378
Kerecis marigen shld sq cm,A2019,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,1073.14,APC
Kerecis marigen shld sq cm,A2019,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,1073.14,APC
Kerecis marigen shld sq cm,A2019,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,1073.14,APC
Kerecis marigen shld sq cm,A2019,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,1073.14,Radiology
Kerecis marigen shld sq cm,A2019,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,1073.14,APC
Kerecis marigen shld sq cm,A2019,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,1073.14,APC
"Sterile water/saline, 10 ml",A4216,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.78,,,,,,,fee schedule,1.42,1.78,
"Sterile water/saline, 10 ml",A4216,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.42,,,,,,,fee schedule,1.42,1.78,
"Sterile water/saline, 10 ml",A4216,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.56,,,,,,,fee schedule,1.42,1.78,
"Sterile water/saline, 10 ml",A4216,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.64,,,,,,,fee schedule,1.42,1.78,
"Sterile water/saline, 500 ml",A4217,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12.44,,,,,,,fee schedule,9.97,12.44,
"Sterile water/saline, 500 ml",A4217,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.97,,,,,,,fee schedule,9.97,12.44,
"Sterile water/saline, 500 ml",A4217,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10.89,,,,,,,fee schedule,9.97,12.44,
"Sterile water/saline, 500 ml",A4217,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11.45,,,,,,,fee schedule,9.97,12.44,
Supp non-insulin inf cath/wk,A4221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,89.85,,,,,,,fee schedule,72.02,89.85,
Supp non-insulin inf cath/wk,A4221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,72.02,,,,,,,fee schedule,72.02,89.85,
Supp non-insulin inf cath/wk,A4221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,78.68,,,,,,,fee schedule,72.02,89.85,
Supp non-insulin inf cath/wk,A4221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,82.72,,,,,,,fee schedule,72.02,89.85,
Infusion supplies with pump,A4222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,185.48,,,,,,,fee schedule,148.68,185.48,
Infusion supplies with pump,A4222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,148.68,,,,,,,fee schedule,148.68,185.48,
Infusion supplies with pump,A4222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,162.42,,,,,,,fee schedule,148.68,185.48,
Infusion supplies with pump,A4222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,170.76,,,,,,,fee schedule,148.68,185.48,
Supply insulin inf cath/wk,A4224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,73.33,,,,,,,fee schedule,58.78,73.33,
Supply insulin inf cath/wk,A4224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,58.78,,,,,,,fee schedule,58.78,73.33,
Supply insulin inf cath/wk,A4224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,64.21,,,,,,,fee schedule,58.78,73.33,
Supply insulin inf cath/wk,A4224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,67.51,,,,,,,fee schedule,58.78,73.33,
Sup/ext insulin inf pump syr,A4225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.83,,,,,,,fee schedule,7.88,9.83,
Sup/ext insulin inf pump syr,A4225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7.88,,,,,,,fee schedule,7.88,9.83,
Sup/ext insulin inf pump syr,A4225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.61,,,,,,,fee schedule,7.88,9.83,
Sup/ext insulin inf pump syr,A4225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.05,,,,,,,fee schedule,7.88,9.83,
Alkalin batt for glucose mon,A4233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.18,,,,,,,fee schedule,2.55,3.18,
Alkalin batt for glucose mon,A4233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.55,,,,,,,fee schedule,2.55,3.18,
Alkalin batt for glucose mon,A4233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.78,,,,,,,fee schedule,2.55,3.18,
Alkalin batt for glucose mon,A4233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.92,,,,,,,fee schedule,2.55,3.18,
J-cell batt for glucose mon,A4234,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14.4,,,,,,,fee schedule,11.54,14.4,
J-cell batt for glucose mon,A4234,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11.54,,,,,,,fee schedule,11.54,14.4,
J-cell batt for glucose mon,A4234,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12.61,,,,,,,fee schedule,11.54,14.4,
J-cell batt for glucose mon,A4234,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13.26,,,,,,,fee schedule,11.54,14.4,
Lithium batt for glucose mon,A4235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.3,,,,,,,fee schedule,7.45,9.3,
Lithium batt for glucose mon,A4235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7.45,,,,,,,fee schedule,7.45,9.3,
Lithium batt for glucose mon,A4235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.14,,,,,,,fee schedule,7.45,9.3,
Lithium batt for glucose mon,A4235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8.56,,,,,,,fee schedule,7.45,9.3,
Silvr oxide batt glucose mon,A4236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.65,,,,,,,fee schedule,5.33,6.65,
Silvr oxide batt glucose mon,A4236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.33,,,,,,,fee schedule,5.33,6.65,
Silvr oxide batt glucose mon,A4236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.83,,,,,,,fee schedule,5.33,6.65,
Silvr oxide batt glucose mon,A4236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.12,,,,,,,fee schedule,5.33,6.65,
Blood glucose/reagent strips,A4253,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,131.54,,,,,,,fee schedule,105.44,131.54,
Blood glucose/reagent strips,A4253,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,105.44,,,,,,,fee schedule,105.44,131.54,
Blood glucose/reagent strips,A4253,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,115.19,,,,,,,fee schedule,105.44,131.54,
Blood glucose/reagent strips,A4253,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,121.1,,,,,,,fee schedule,105.44,131.54,
Glucose monitor platforms,A4255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16.33,,,,,,,fee schedule,13.09,16.33,
Glucose monitor platforms,A4255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13.09,,,,,,,fee schedule,13.09,16.33,
Glucose monitor platforms,A4255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14.3,,,,,,,fee schedule,13.09,16.33,
Glucose monitor platforms,A4255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15.03,,,,,,,fee schedule,13.09,16.33,
Calibrator solution/chips,A4256,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,39.12,,,,,,,fee schedule,31.36,45.4,
Calibrator solution/chips,A4256,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45.4,,,,,,,fee schedule,31.36,45.4,
Calibrator solution/chips,A4256,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31.36,,,,,,,fee schedule,31.36,45.4,
Calibrator solution/chips,A4256,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36.39,,,,,,,fee schedule,31.36,45.4,
Calibrator solution/chips,A4256,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,34.26,,,,,,,fee schedule,31.36,45.4,
Calibrator solution/chips,A4256,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39.75,,,,,,,fee schedule,31.36,45.4,
Calibrator solution/chips,A4256,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,36.02,,,,,,,fee schedule,31.36,45.4,
Calibrator solution/chips,A4256,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41.79,,,,,,,fee schedule,31.36,45.4,
Replace lensshield cartridge,A4257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,50.61,,,,,,,fee schedule,40.57,50.61,
Replace lensshield cartridge,A4257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40.57,,,,,,,fee schedule,40.57,50.61,
Replace lensshield cartridge,A4257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,44.32,,,,,,,fee schedule,40.57,50.61,
Replace lensshield cartridge,A4257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46.6,,,,,,,fee schedule,40.57,50.61,
Lancet device each,A4258,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,61.77,,,,,,,fee schedule,49.51,71.63,
Lancet device each,A4258,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,71.63,,,,,,,fee schedule,49.51,71.63,
Lancet device each,A4258,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,49.51,,,,,,,fee schedule,49.51,71.63,
Lancet device each,A4258,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.42,,,,,,,fee schedule,49.51,71.63,
Lancet device each,A4258,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,54.09,,,,,,,fee schedule,49.51,71.63,
Lancet device each,A4258,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,62.72,,,,,,,fee schedule,49.51,71.63,
Lancet device each,A4258,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,56.86,,,,,,,fee schedule,49.51,71.63,
Lancet device each,A4258,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,65.95,,,,,,,fee schedule,49.51,71.63,
Lancets per box,A4259,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41.24,,,,,,,fee schedule,33.06,47.85,
Lancets per box,A4259,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,47.85,,,,,,,fee schedule,33.06,47.85,
Lancets per box,A4259,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,33.06,,,,,,,fee schedule,33.06,47.85,
Lancets per box,A4259,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38.36,,,,,,,fee schedule,33.06,47.85,
Lancets per box,A4259,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36.11,,,,,,,fee schedule,33.06,47.85,
Lancets per box,A4259,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,41.9,,,,,,,fee schedule,33.06,47.85,
Lancets per box,A4259,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37.97,,,,,,,fee schedule,33.06,47.85,
Lancets per box,A4259,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,44.06,,,,,,,fee schedule,33.06,47.85,
Paraffin,A4265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13.46,,,,,,,fee schedule,10.79,13.46,
Paraffin,A4265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10.79,,,,,,,fee schedule,10.79,13.46,
Paraffin,A4265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11.78,,,,,,,fee schedule,10.79,13.46,
Paraffin,A4265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12.39,,,,,,,fee schedule,10.79,13.46,
Brst prsths adhsv attchmnt,A4280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21.17,,,,,,,fee schedule,16.97,21.17,
Brst prsths adhsv attchmnt,A4280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.97,,,,,,,fee schedule,16.97,21.17,
Brst prsths adhsv attchmnt,A4280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18.54,,,,,,,fee schedule,16.97,21.17,
Brst prsths adhsv attchmnt,A4280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19.49,,,,,,,fee schedule,16.97,21.17,
Insert tray w/o bag/cath,A4310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30.66,,,,,,,fee schedule,24.57,30.66,
Insert tray w/o bag/cath,A4310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24.57,,,,,,,fee schedule,24.57,30.66,
Insert tray w/o bag/cath,A4310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26.84,,,,,,,fee schedule,24.57,30.66,
Insert tray w/o bag/cath,A4310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,28.22,,,,,,,fee schedule,24.57,30.66,
Catheter w/o bag 2-way latex,A4311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,58.89,,,,,,,fee schedule,47.21,58.89,
Catheter w/o bag 2-way latex,A4311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,47.21,,,,,,,fee schedule,47.21,58.89,
Catheter w/o bag 2-way latex,A4311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.57,,,,,,,fee schedule,47.21,58.89,
Catheter w/o bag 2-way latex,A4311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,54.22,,,,,,,fee schedule,47.21,58.89,
Cath w/o bag 2-way silicone,A4312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,71.59,,,,,,,fee schedule,57.39,71.59,
Cath w/o bag 2-way silicone,A4312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.39,,,,,,,fee schedule,57.39,71.59,
Cath w/o bag 2-way silicone,A4312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,62.69,,,,,,,fee schedule,57.39,71.59,
Cath w/o bag 2-way silicone,A4312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,65.91,,,,,,,fee schedule,57.39,71.59,
Catheter w/bag 3-way,A4313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,73.52,,,,,,,fee schedule,58.93,73.52,
Catheter w/bag 3-way,A4313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,58.93,,,,,,,fee schedule,58.93,73.52,
Catheter w/bag 3-way,A4313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,64.38,,,,,,,fee schedule,58.93,73.52,
Catheter w/bag 3-way,A4313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,67.69,,,,,,,fee schedule,58.93,73.52,
Cath w/drainage 2-way latex,A4314,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,93.33,,,,,,,fee schedule,74.81,93.33,
Cath w/drainage 2-way latex,A4314,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,74.81,,,,,,,fee schedule,74.81,93.33,
Cath w/drainage 2-way latex,A4314,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,81.72,,,,,,,fee schedule,74.81,93.33,
Cath w/drainage 2-way latex,A4314,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,85.92,,,,,,,fee schedule,74.81,93.33,
Cath w/drainage 2-way silcne,A4315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,93.33,,,,,,,fee schedule,74.81,93.33,
Cath w/drainage 2-way silcne,A4315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,74.81,,,,,,,fee schedule,74.81,93.33,
Cath w/drainage 2-way silcne,A4315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,81.72,,,,,,,fee schedule,74.81,93.33,
Cath w/drainage 2-way silcne,A4315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,85.92,,,,,,,fee schedule,74.81,93.33,
Cath w/drainage 3-way,A4316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,95.82,,,,,,,fee schedule,76.81,95.82,
Cath w/drainage 3-way,A4316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,76.81,,,,,,,fee schedule,76.81,95.82,
Cath w/drainage 3-way,A4316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,83.91,,,,,,,fee schedule,76.81,95.82,
Cath w/drainage 3-way,A4316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,88.22,,,,,,,fee schedule,76.81,95.82,
Irrigation tray,A4320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21.17,,,,,,,fee schedule,16.97,21.17,
Irrigation tray,A4320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.97,,,,,,,fee schedule,16.97,21.17,
Irrigation tray,A4320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18.54,,,,,,,fee schedule,16.97,21.17,
Irrigation tray,A4320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19.49,,,,,,,fee schedule,16.97,21.17,
Irrigation syringe,A4322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11.94,,,,,,,fee schedule,9.57,11.94,
Irrigation syringe,A4322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.57,,,,,,,fee schedule,9.57,11.94,
Irrigation syringe,A4322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10.46,,,,,,,fee schedule,9.57,11.94,
Irrigation syringe,A4322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11,,,,,,,fee schedule,9.57,11.94,
Male external catheter,A4326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42.83,,,,,,,fee schedule,34.33,42.83,
Male external catheter,A4326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,34.33,,,,,,,fee schedule,34.33,42.83,
Male external catheter,A4326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37.5,,,,,,,fee schedule,34.33,42.83,
Male external catheter,A4326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,39.43,,,,,,,fee schedule,34.33,42.83,
Fem urinary collect dev cup,A4327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,177.06,,,,,,,fee schedule,141.93,177.06,
Fem urinary collect dev cup,A4327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,141.93,,,,,,,fee schedule,141.93,177.06,
Fem urinary collect dev cup,A4327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,155.04,,,,,,,fee schedule,141.93,177.06,
Fem urinary collect dev cup,A4327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,163,,,,,,,fee schedule,141.93,177.06,
Fem urinary collect pouch,A4328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41.47,,,,,,,fee schedule,33.24,41.47,
Fem urinary collect pouch,A4328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,33.24,,,,,,,fee schedule,33.24,41.47,
Fem urinary collect pouch,A4328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36.31,,,,,,,fee schedule,33.24,41.47,
Fem urinary collect pouch,A4328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,38.18,,,,,,,fee schedule,33.24,41.47,
Stool collection pouch,A4330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24.12,,,,,,,fee schedule,19.33,24.12,
Stool collection pouch,A4330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19.33,,,,,,,fee schedule,19.33,24.12,
Stool collection pouch,A4330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21.12,,,,,,,fee schedule,19.33,24.12,
Stool collection pouch,A4330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22.2,,,,,,,fee schedule,19.33,24.12,
Extension drainage tubing,A4331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12.63,,,,,,,fee schedule,10.12,12.63,
Extension drainage tubing,A4331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10.12,,,,,,,fee schedule,10.12,12.63,
Extension drainage tubing,A4331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11.06,,,,,,,fee schedule,10.12,12.63,
Extension drainage tubing,A4331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11.62,,,,,,,fee schedule,10.12,12.63,
Lube sterile packet,A4332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.49,,,,,,,fee schedule,0.39,0.49,
Lube sterile packet,A4332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.39,,,,,,,fee schedule,0.39,0.49,
Lube sterile packet,A4332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.43,,,,,,,fee schedule,0.39,0.49,
Lube sterile packet,A4332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.45,,,,,,,fee schedule,0.39,0.49,
Urinary cath anchor device,A4333,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8.73,,,,,,,fee schedule,7,8.73,
Urinary cath anchor device,A4333,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7,,,,,,,fee schedule,7,8.73,
Urinary cath anchor device,A4333,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7.65,,,,,,,fee schedule,7,8.73,
Urinary cath anchor device,A4333,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8.04,,,,,,,fee schedule,7,8.73,
Urinary cath leg strap,A4334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19.58,,,,,,,fee schedule,15.7,19.58,
Urinary cath leg strap,A4334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15.7,,,,,,,fee schedule,15.7,19.58,
Urinary cath leg strap,A4334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17.15,,,,,,,fee schedule,15.7,19.58,
Urinary cath leg strap,A4334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18.03,,,,,,,fee schedule,15.7,19.58,
Urethral insert,A4336,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.9,,,,,,,fee schedule,4.73,5.9,
Urethral insert,A4336,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.73,,,,,,,fee schedule,4.73,5.9,
Urethral insert,A4336,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.16,,,,,,,fee schedule,4.73,5.9,
Urethral insert,A4336,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.43,,,,,,,fee schedule,4.73,5.9,
Indwelling catheter latex,A4338,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41.35,,,,,,,fee schedule,33.15,41.35,
Indwelling catheter latex,A4338,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,33.15,,,,,,,fee schedule,33.15,41.35,
Indwelling catheter latex,A4338,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36.21,,,,,,,fee schedule,33.15,41.35,
Indwelling catheter latex,A4338,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,38.07,,,,,,,fee schedule,33.15,41.35,
Indwelling catheter special,A4340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,114.95,,,,,,,fee schedule,92.14,114.95,
Indwelling catheter special,A4340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,92.14,,,,,,,fee schedule,92.14,114.95,
Indwelling catheter special,A4340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,100.66,,,,,,,fee schedule,92.14,114.95,
Indwelling catheter special,A4340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,105.83,,,,,,,fee schedule,92.14,114.95,
Cath indw foley 2 way silicn,A4344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,63.58,,,,,,,fee schedule,50.96,63.58,
Cath indw foley 2 way silicn,A4344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,50.96,,,,,,,fee schedule,50.96,63.58,
Cath indw foley 2 way silicn,A4344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55.67,,,,,,,fee schedule,50.96,63.58,
Cath indw foley 2 way silicn,A4344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,58.53,,,,,,,fee schedule,50.96,63.58,
Cath indw foley 3 way,A4346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,77.75,,,,,,,fee schedule,62.33,77.75,
Cath indw foley 3 way,A4346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,62.33,,,,,,,fee schedule,62.33,77.75,
Cath indw foley 3 way,A4346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,68.09,,,,,,,fee schedule,62.33,77.75,
Cath indw foley 3 way,A4346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,71.58,,,,,,,fee schedule,62.33,77.75,
Disposable male external cat,A4349,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8.01,,,,,,,fee schedule,6.42,8.01,
Disposable male external cat,A4349,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.42,,,,,,,fee schedule,6.42,8.01,
Disposable male external cat,A4349,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7.02,,,,,,,fee schedule,6.42,8.01,
Disposable male external cat,A4349,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7.38,,,,,,,fee schedule,6.42,8.01,
Straight tip urine catheter,A4351,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7.18,,,,,,,fee schedule,5.76,7.18,
Straight tip urine catheter,A4351,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.76,,,,,,,fee schedule,5.76,7.18,
Straight tip urine catheter,A4351,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.29,,,,,,,fee schedule,5.76,7.18,
Straight tip urine catheter,A4351,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.61,,,,,,,fee schedule,5.76,7.18,
Coude tip urinary catheter,A4352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21.74,,,,,,,fee schedule,17.42,21.74,
Coude tip urinary catheter,A4352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17.42,,,,,,,fee schedule,17.42,21.74,
Coude tip urinary catheter,A4352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19.03,,,,,,,fee schedule,17.42,21.74,
Coude tip urinary catheter,A4352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20.01,,,,,,,fee schedule,17.42,21.74,
Intermittent urinary cath,A4353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27.78,,,,,,,fee schedule,22.27,27.78,
Intermittent urinary cath,A4353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22.27,,,,,,,fee schedule,22.27,27.78,
Intermittent urinary cath,A4353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24.33,,,,,,,fee schedule,22.27,27.78,
Intermittent urinary cath,A4353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,25.58,,,,,,,fee schedule,22.27,27.78,
Cath insertion tray w/bag,A4354,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,43.02,,,,,,,fee schedule,34.48,43.02,
Cath insertion tray w/bag,A4354,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,34.48,,,,,,,fee schedule,34.48,43.02,
Cath insertion tray w/bag,A4354,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37.67,,,,,,,fee schedule,34.48,43.02,
Cath insertion tray w/bag,A4354,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,39.6,,,,,,,fee schedule,34.48,43.02,
Bladder irrigation tubing,A4355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30.09,,,,,,,fee schedule,24.12,30.09,
Bladder irrigation tubing,A4355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24.12,,,,,,,fee schedule,24.12,30.09,
Bladder irrigation tubing,A4355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26.35,,,,,,,fee schedule,24.12,30.09,
Bladder irrigation tubing,A4355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27.7,,,,,,,fee schedule,24.12,30.09,
Ext ureth clmp or compr dvc,A4356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,181.1,,,,,,,fee schedule,145.17,181.1,
Ext ureth clmp or compr dvc,A4356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,145.17,,,,,,,fee schedule,145.17,181.1,
Ext ureth clmp or compr dvc,A4356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,158.58,,,,,,,fee schedule,145.17,181.1,
Ext ureth clmp or compr dvc,A4356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,166.73,,,,,,,fee schedule,145.17,181.1,
Bedside drainage bag,A4357,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,32.73,,,,,,,fee schedule,26.24,32.73,
Bedside drainage bag,A4357,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26.24,,,,,,,fee schedule,26.24,32.73,
Bedside drainage bag,A4357,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28.66,,,,,,,fee schedule,26.24,32.73,
Bedside drainage bag,A4357,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30.14,,,,,,,fee schedule,26.24,32.73,
Urinary leg or abdomen bag,A4358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26.31,,,,,,,fee schedule,21.09,26.31,
Urinary leg or abdomen bag,A4358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21.09,,,,,,,fee schedule,21.09,26.31,
Urinary leg or abdomen bag,A4358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23.04,,,,,,,fee schedule,21.09,26.31,
Urinary leg or abdomen bag,A4358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24.22,,,,,,,fee schedule,21.09,26.31,
Disposable ext urethral dev,A4360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.97,,,,,,,fee schedule,1.58,1.97,
Disposable ext urethral dev,A4360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.58,,,,,,,fee schedule,1.58,1.97,
Disposable ext urethral dev,A4360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.72,,,,,,,fee schedule,1.58,1.97,
Disposable ext urethral dev,A4360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.81,,,,,,,fee schedule,1.58,1.97,
Ostomy face plate,A4361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,61.99,,,,,,,fee schedule,49.69,61.99,
Ostomy face plate,A4361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,49.69,,,,,,,fee schedule,49.69,61.99,
Ostomy face plate,A4361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,54.28,,,,,,,fee schedule,49.69,61.99,
Ostomy face plate,A4361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,57.07,,,,,,,fee schedule,49.69,61.99,
Solid skin barrier,A4362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11.68,,,,,,,fee schedule,9.36,11.68,
Solid skin barrier,A4362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.36,,,,,,,fee schedule,9.36,11.68,
Solid skin barrier,A4362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10.23,,,,,,,fee schedule,9.36,11.68,
Solid skin barrier,A4362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10.75,,,,,,,fee schedule,9.36,11.68,
"Ostomy clamp, replacement",A4363,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7.98,,,,,,,fee schedule,6.39,7.98,
"Ostomy clamp, replacement",A4363,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.39,,,,,,,fee schedule,6.39,7.98,
"Ostomy clamp, replacement",A4363,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.98,,,,,,,fee schedule,6.39,7.98,
"Ostomy clamp, replacement",A4363,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7.34,,,,,,,fee schedule,6.39,7.98,
"Adhesive, liquid or equal",A4364,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11.64,,,,,,,fee schedule,9.33,11.64,
"Adhesive, liquid or equal",A4364,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.33,,,,,,,fee schedule,9.33,11.64,
"Adhesive, liquid or equal",A4364,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10.19,,,,,,,fee schedule,9.33,11.64,
"Adhesive, liquid or equal",A4364,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10.72,,,,,,,fee schedule,9.33,11.64,
Ostomy vent,A4366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.18,,,,,,,fee schedule,4.15,5.18,
Ostomy vent,A4366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.15,,,,,,,fee schedule,4.15,5.18,
Ostomy vent,A4366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.53,,,,,,,fee schedule,4.15,5.18,
Ostomy vent,A4366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.77,,,,,,,fee schedule,4.15,5.18,
Ostomy belt,A4367,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,28.84,,,,,,,fee schedule,23.12,28.84,
Ostomy belt,A4367,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23.12,,,,,,,fee schedule,23.12,28.84,
Ostomy belt,A4367,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,25.26,,,,,,,fee schedule,23.12,28.84,
Ostomy belt,A4367,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26.55,,,,,,,fee schedule,23.12,28.84,
Ostomy filter,A4368,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.02,,,,,,,fee schedule,0.82,1.02,
Ostomy filter,A4368,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.82,,,,,,,fee schedule,0.82,1.02,
Ostomy filter,A4368,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.89,,,,,,,fee schedule,0.82,1.02,
Ostomy filter,A4368,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.94,,,,,,,fee schedule,0.82,1.02,
Skin barrier liquid per oz,A4369,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.6,,,,,,,fee schedule,7.7,9.6,
Skin barrier liquid per oz,A4369,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7.7,,,,,,,fee schedule,7.7,9.6,
Skin barrier liquid per oz,A4369,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.41,,,,,,,fee schedule,7.7,9.6,
Skin barrier liquid per oz,A4369,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8.84,,,,,,,fee schedule,7.7,9.6,
Skin barrier powder per oz,A4371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14.48,,,,,,,fee schedule,11.6,14.48,
Skin barrier powder per oz,A4371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11.6,,,,,,,fee schedule,11.6,14.48,
Skin barrier powder per oz,A4371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12.68,,,,,,,fee schedule,11.6,14.48,
Skin barrier powder per oz,A4371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13.33,,,,,,,fee schedule,11.6,14.48,
Skin barrier solid 4x4 equiv,A4372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16.59,,,,,,,fee schedule,13.3,16.59,
Skin barrier solid 4x4 equiv,A4372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13.3,,,,,,,fee schedule,13.3,16.59,
Skin barrier solid 4x4 equiv,A4372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14.53,,,,,,,fee schedule,13.3,16.59,
Skin barrier solid 4x4 equiv,A4372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15.28,,,,,,,fee schedule,13.3,16.59,
Skin barrier with flange,A4373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24.91,,,,,,,fee schedule,19.97,24.91,
Skin barrier with flange,A4373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19.97,,,,,,,fee schedule,19.97,24.91,
Skin barrier with flange,A4373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21.81,,,,,,,fee schedule,19.97,24.91,
Skin barrier with flange,A4373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22.93,,,,,,,fee schedule,19.97,24.91,
Drainable plastic pch w fcpl,A4375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,68.19,,,,,,,fee schedule,54.66,68.19,
Drainable plastic pch w fcpl,A4375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,54.66,,,,,,,fee schedule,54.66,68.19,
Drainable plastic pch w fcpl,A4375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,59.71,,,,,,,fee schedule,54.66,68.19,
Drainable plastic pch w fcpl,A4375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,62.78,,,,,,,fee schedule,54.66,68.19,
Drainable rubber pch w fcplt,A4376,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,188.85,,,,,,,fee schedule,151.38,188.85,
Drainable rubber pch w fcplt,A4376,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,151.38,,,,,,,fee schedule,151.38,188.85,
Drainable rubber pch w fcplt,A4376,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,165.37,,,,,,,fee schedule,151.38,188.85,
Drainable rubber pch w fcplt,A4376,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,173.86,,,,,,,fee schedule,151.38,188.85,
Drainable plstic pch w/o fp,A4377,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17.01,,,,,,,fee schedule,13.64,17.01,
Drainable plstic pch w/o fp,A4377,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13.64,,,,,,,fee schedule,13.64,17.01,
Drainable plstic pch w/o fp,A4377,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14.9,,,,,,,fee schedule,13.64,17.01,
Drainable plstic pch w/o fp,A4377,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15.66,,,,,,,fee schedule,13.64,17.01,
Drainable rubber pch w/o fp,A4378,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,122.06,,,,,,,fee schedule,97.84,122.06,
Drainable rubber pch w/o fp,A4378,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,97.84,,,,,,,fee schedule,97.84,122.06,
Drainable rubber pch w/o fp,A4378,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,106.88,,,,,,,fee schedule,97.84,122.06,
Drainable rubber pch w/o fp,A4378,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,112.37,,,,,,,fee schedule,97.84,122.06,
Urinary plastic pouch w fcpl,A4379,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59.61,,,,,,,fee schedule,47.78,59.61,
Urinary plastic pouch w fcpl,A4379,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,47.78,,,,,,,fee schedule,47.78,59.61,
Urinary plastic pouch w fcpl,A4379,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52.2,,,,,,,fee schedule,47.78,59.61,
Urinary plastic pouch w fcpl,A4379,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,54.88,,,,,,,fee schedule,47.78,59.61,
Urinary rubber pouch w fcplt,A4380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,148.18,,,,,,,fee schedule,118.78,148.18,
Urinary rubber pouch w fcplt,A4380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,118.78,,,,,,,fee schedule,118.78,148.18,
Urinary rubber pouch w fcplt,A4380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,129.75,,,,,,,fee schedule,118.78,148.18,
Urinary rubber pouch w fcplt,A4380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,136.42,,,,,,,fee schedule,118.78,148.18,
Urinary plastic pouch w/o fp,A4381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18.3,,,,,,,fee schedule,14.67,18.3,
Urinary plastic pouch w/o fp,A4381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14.67,,,,,,,fee schedule,14.67,18.3,
Urinary plastic pouch w/o fp,A4381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.02,,,,,,,fee schedule,14.67,18.3,
Urinary plastic pouch w/o fp,A4381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16.84,,,,,,,fee schedule,14.67,18.3,
Urinary hvy plstc pch w/o fp,A4382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,97.71,,,,,,,fee schedule,78.33,97.71,
Urinary hvy plstc pch w/o fp,A4382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,78.33,,,,,,,fee schedule,78.33,97.71,
Urinary hvy plstc pch w/o fp,A4382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,85.56,,,,,,,fee schedule,78.33,97.71,
Urinary hvy plstc pch w/o fp,A4382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,89.96,,,,,,,fee schedule,78.33,97.71,
Urinary rubber pouch w/o fp,A4383,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,111.89,,,,,,,fee schedule,89.69,111.89,
Urinary rubber pouch w/o fp,A4383,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,89.69,,,,,,,fee schedule,89.69,111.89,
Urinary rubber pouch w/o fp,A4383,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,97.98,,,,,,,fee schedule,89.69,111.89,
Urinary rubber pouch w/o fp,A4383,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,103.01,,,,,,,fee schedule,89.69,111.89,
Ostomy faceplt/silicone ring,A4384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,38.18,,,,,,,fee schedule,30.6,38.18,
Ostomy faceplt/silicone ring,A4384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,30.6,,,,,,,fee schedule,30.6,38.18,
Ostomy faceplt/silicone ring,A4384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,33.43,,,,,,,fee schedule,30.6,38.18,
Ostomy faceplt/silicone ring,A4384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,35.15,,,,,,,fee schedule,30.6,38.18,
Ost skn barrier sld ext wear,A4385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20.26,,,,,,,fee schedule,16.24,20.26,
Ost skn barrier sld ext wear,A4385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.24,,,,,,,fee schedule,16.24,20.26,
Ost skn barrier sld ext wear,A4385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17.74,,,,,,,fee schedule,16.24,20.26,
Ost skn barrier sld ext wear,A4385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18.65,,,,,,,fee schedule,16.24,20.26,
Drainable pch w ex wear barr,A4388,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17.31,,,,,,,fee schedule,13.88,17.31,
Drainable pch w ex wear barr,A4388,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13.88,,,,,,,fee schedule,13.88,17.31,
Drainable pch w ex wear barr,A4388,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15.16,,,,,,,fee schedule,13.88,17.31,
Drainable pch w ex wear barr,A4388,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15.94,,,,,,,fee schedule,13.88,17.31,
Drainable pch w st wear barr,A4389,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24.68,,,,,,,fee schedule,19.79,24.68,
Drainable pch w st wear barr,A4389,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19.79,,,,,,,fee schedule,19.79,24.68,
Drainable pch w st wear barr,A4389,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21.61,,,,,,,fee schedule,19.79,24.68,
Drainable pch w st wear barr,A4389,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22.72,,,,,,,fee schedule,19.79,24.68,
Drainable pch ex wear convex,A4390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,38.14,,,,,,,fee schedule,30.57,38.14,
Drainable pch ex wear convex,A4390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,30.57,,,,,,,fee schedule,30.57,38.14,
Drainable pch ex wear convex,A4390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,33.4,,,,,,,fee schedule,30.57,38.14,
Drainable pch ex wear convex,A4390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,35.11,,,,,,,fee schedule,30.57,38.14,
Urinary pouch w ex wear barr,A4391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,28.05,,,,,,,fee schedule,22.48,28.05,
Urinary pouch w ex wear barr,A4391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22.48,,,,,,,fee schedule,22.48,28.05,
Urinary pouch w ex wear barr,A4391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24.56,,,,,,,fee schedule,22.48,28.05,
Urinary pouch w ex wear barr,A4391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,25.82,,,,,,,fee schedule,22.48,28.05,
Urinary pouch w st wear barr,A4392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,32.47,,,,,,,fee schedule,26.03,32.47,
Urinary pouch w st wear barr,A4392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26.03,,,,,,,fee schedule,26.03,32.47,
Urinary pouch w st wear barr,A4392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28.43,,,,,,,fee schedule,26.03,32.47,
Urinary pouch w st wear barr,A4392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,29.89,,,,,,,fee schedule,26.03,32.47,
Urine pch w ex wear bar conv,A4393,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,35.87,,,,,,,fee schedule,28.75,35.87,
Urine pch w ex wear bar conv,A4393,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28.75,,,,,,,fee schedule,28.75,35.87,
Urine pch w ex wear bar conv,A4393,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31.41,,,,,,,fee schedule,28.75,35.87,
Urine pch w ex wear bar conv,A4393,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33.03,,,,,,,fee schedule,28.75,35.87,
Ostomy pouch liq deodorant,A4394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10.24,,,,,,,fee schedule,8.21,10.24,
Ostomy pouch liq deodorant,A4394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.21,,,,,,,fee schedule,8.21,10.24,
Ostomy pouch liq deodorant,A4394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.97,,,,,,,fee schedule,8.21,10.24,
Ostomy pouch liq deodorant,A4394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.43,,,,,,,fee schedule,8.21,10.24,
Ostomy pouch solid deodorant,A4395,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.19,,,,,,,fee schedule,0.15,0.19,
Ostomy pouch solid deodorant,A4395,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.15,,,,,,,fee schedule,0.15,0.19,
Ostomy pouch solid deodorant,A4395,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.17,,,,,,,fee schedule,0.15,0.19,
Ostomy pouch solid deodorant,A4395,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.17,,,,,,,fee schedule,0.15,0.19,
Peristomal hernia supprt blt,A4396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,160.65,,,,,,,fee schedule,128.78,160.65,
Peristomal hernia supprt blt,A4396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,128.78,,,,,,,fee schedule,128.78,160.65,
Peristomal hernia supprt blt,A4396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,140.68,,,,,,,fee schedule,128.78,160.65,
Peristomal hernia supprt blt,A4396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,147.9,,,,,,,fee schedule,128.78,160.65,
Ostomy irrigation bag,A4398,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,54.81,,,,,,,fee schedule,43.94,54.81,
Ostomy irrigation bag,A4398,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,43.94,,,,,,,fee schedule,43.94,54.81,
Ostomy irrigation bag,A4398,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48,,,,,,,fee schedule,43.94,54.81,
Ostomy irrigation bag,A4398,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,50.46,,,,,,,fee schedule,43.94,54.81,
Ostomy irrig cone/cath w brs,A4399,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,48.65,,,,,,,fee schedule,39,48.65,
Ostomy irrig cone/cath w brs,A4399,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39,,,,,,,fee schedule,39,48.65,
Ostomy irrig cone/cath w brs,A4399,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.6,,,,,,,fee schedule,39,48.65,
Ostomy irrig cone/cath w brs,A4399,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,44.79,,,,,,,fee schedule,39,48.65,
Ostomy irrigation set,A4400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,193.95,,,,,,,fee schedule,155.47,193.95,
Ostomy irrigation set,A4400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,155.47,,,,,,,fee schedule,155.47,193.95,
Ostomy irrigation set,A4400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,169.84,,,,,,,fee schedule,155.47,193.95,
Ostomy irrigation set,A4400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,178.56,,,,,,,fee schedule,155.47,193.95,
Lubricant per ounce,A4402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.52,,,,,,,fee schedule,4.42,5.52,
Lubricant per ounce,A4402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.42,,,,,,,fee schedule,4.42,5.52,
Lubricant per ounce,A4402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.83,,,,,,,fee schedule,4.42,5.52,
Lubricant per ounce,A4402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.08,,,,,,,fee schedule,4.42,5.52,
Ostomy ring each,A4404,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.69,,,,,,,fee schedule,5.36,6.69,
Ostomy ring each,A4404,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.36,,,,,,,fee schedule,5.36,6.69,
Ostomy ring each,A4404,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.86,,,,,,,fee schedule,5.36,6.69,
Ostomy ring each,A4404,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.16,,,,,,,fee schedule,5.36,6.69,
Nonpectin based ostomy paste,A4405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13.49,,,,,,,fee schedule,10.82,13.49,
Nonpectin based ostomy paste,A4405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10.82,,,,,,,fee schedule,10.82,13.49,
Nonpectin based ostomy paste,A4405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11.82,,,,,,,fee schedule,10.82,13.49,
Nonpectin based ostomy paste,A4405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12.42,,,,,,,fee schedule,10.82,13.49,
Pectin based ostomy paste,A4406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22.79,,,,,,,fee schedule,18.27,22.79,
Pectin based ostomy paste,A4406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18.27,,,,,,,fee schedule,18.27,22.79,
Pectin based ostomy paste,A4406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19.96,,,,,,,fee schedule,18.27,22.79,
Pectin based ostomy paste,A4406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20.98,,,,,,,fee schedule,18.27,22.79,
"Ext wear ost skn barr <=4sq""",A4407,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,34.78,,,,,,,fee schedule,27.88,34.78,
"Ext wear ost skn barr <=4sq""",A4407,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,27.88,,,,,,,fee schedule,27.88,34.78,
"Ext wear ost skn barr <=4sq""",A4407,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,30.45,,,,,,,fee schedule,27.88,34.78,
"Ext wear ost skn barr <=4sq""",A4407,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,32.02,,,,,,,fee schedule,27.88,34.78,
"Ext wear ost skn barr >4sq""",A4408,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,39.16,,,,,,,fee schedule,31.39,39.16,
"Ext wear ost skn barr >4sq""",A4408,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31.39,,,,,,,fee schedule,31.39,39.16,
"Ext wear ost skn barr >4sq""",A4408,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,34.29,,,,,,,fee schedule,31.39,39.16,
"Ext wear ost skn barr >4sq""",A4408,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,36.05,,,,,,,fee schedule,31.39,39.16,
Ost skn barr convex <=4 sq i,A4409,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24.68,,,,,,,fee schedule,19.79,24.68,
Ost skn barr convex <=4 sq i,A4409,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19.79,,,,,,,fee schedule,19.79,24.68,
Ost skn barr convex <=4 sq i,A4409,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21.61,,,,,,,fee schedule,19.79,24.68,
Ost skn barr convex <=4 sq i,A4409,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22.72,,,,,,,fee schedule,19.79,24.68,
Ost skn barr extnd >4 sq,A4410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,35.87,,,,,,,fee schedule,28.75,35.87,
Ost skn barr extnd >4 sq,A4410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28.75,,,,,,,fee schedule,28.75,35.87,
Ost skn barr extnd >4 sq,A4410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31.41,,,,,,,fee schedule,28.75,35.87,
Ost skn barr extnd >4 sq,A4410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33.03,,,,,,,fee schedule,28.75,35.87,
Ost skn barr extnd =4sq,A4411,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20.26,,,,,,,fee schedule,16.24,20.26,
Ost skn barr extnd =4sq,A4411,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.24,,,,,,,fee schedule,16.24,20.26,
Ost skn barr extnd =4sq,A4411,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17.74,,,,,,,fee schedule,16.24,20.26,
Ost skn barr extnd =4sq,A4411,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18.65,,,,,,,fee schedule,16.24,20.26,
Ost pouch drain high output,A4412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10.74,,,,,,,fee schedule,8.61,10.74,
Ost pouch drain high output,A4412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.61,,,,,,,fee schedule,8.61,10.74,
Ost pouch drain high output,A4412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.4,,,,,,,fee schedule,8.61,10.74,
Ost pouch drain high output,A4412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.88,,,,,,,fee schedule,8.61,10.74,
2 pc drainable ost pouch,A4413,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21.85,,,,,,,fee schedule,17.51,21.85,
2 pc drainable ost pouch,A4413,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17.51,,,,,,,fee schedule,17.51,21.85,
2 pc drainable ost pouch,A4413,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19.13,,,,,,,fee schedule,17.51,21.85,
2 pc drainable ost pouch,A4413,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20.11,,,,,,,fee schedule,17.51,21.85,
Ost sknbar w/o conv<=4 sq in,A4414,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19.58,,,,,,,fee schedule,15.7,19.58,
Ost sknbar w/o conv<=4 sq in,A4414,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15.7,,,,,,,fee schedule,15.7,19.58,
Ost sknbar w/o conv<=4 sq in,A4414,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17.15,,,,,,,fee schedule,15.7,19.58,
Ost sknbar w/o conv<=4 sq in,A4414,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18.03,,,,,,,fee schedule,15.7,19.58,
Ost skn barr w/o conv >4 sqi,A4415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23.81,,,,,,,fee schedule,19.09,23.81,
Ost skn barr w/o conv >4 sqi,A4415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19.09,,,,,,,fee schedule,19.09,23.81,
Ost skn barr w/o conv >4 sqi,A4415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20.85,,,,,,,fee schedule,19.09,23.81,
Ost skn barr w/o conv >4 sqi,A4415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21.92,,,,,,,fee schedule,19.09,23.81,
Ost pch clsd w barrier/filtr,A4416,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10.92,,,,,,,fee schedule,8.76,10.92,
Ost pch clsd w barrier/filtr,A4416,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.76,,,,,,,fee schedule,8.76,10.92,
Ost pch clsd w barrier/filtr,A4416,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.57,,,,,,,fee schedule,8.76,10.92,
Ost pch clsd w barrier/filtr,A4416,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10.06,,,,,,,fee schedule,8.76,10.92,
Ost pch w bar/bltinconv/fltr,A4417,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14.78,,,,,,,fee schedule,11.85,14.78,
Ost pch w bar/bltinconv/fltr,A4417,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11.85,,,,,,,fee schedule,11.85,14.78,
Ost pch w bar/bltinconv/fltr,A4417,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12.94,,,,,,,fee schedule,11.85,14.78,
Ost pch w bar/bltinconv/fltr,A4417,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13.61,,,,,,,fee schedule,11.85,14.78,
Ost pch clsd w/o bar w filtr,A4418,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7.18,,,,,,,fee schedule,5.76,7.18,
Ost pch clsd w/o bar w filtr,A4418,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.76,,,,,,,fee schedule,5.76,7.18,
Ost pch clsd w/o bar w filtr,A4418,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.29,,,,,,,fee schedule,5.76,7.18,
Ost pch clsd w/o bar w filtr,A4418,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.61,,,,,,,fee schedule,5.76,7.18,
Ost pch for bar w flange/flt,A4419,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.92,,,,,,,fee schedule,5.54,6.92,
Ost pch for bar w flange/flt,A4419,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.54,,,,,,,fee schedule,5.54,6.92,
Ost pch for bar w flange/flt,A4419,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.06,,,,,,,fee schedule,5.54,6.92,
Ost pch for bar w flange/flt,A4419,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.37,,,,,,,fee schedule,5.54,6.92,
Ost pouch absorbent material,A4422,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.49,,,,,,,fee schedule,0.39,0.49,
Ost pouch absorbent material,A4422,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.39,,,,,,,fee schedule,0.39,0.49,
Ost pouch absorbent material,A4422,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.43,,,,,,,fee schedule,0.39,0.49,
Ost pouch absorbent material,A4422,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.45,,,,,,,fee schedule,0.39,0.49,
Ost pch for bar w lk fl/fltr,A4423,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7.37,,,,,,,fee schedule,5.91,7.37,
Ost pch for bar w lk fl/fltr,A4423,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.91,,,,,,,fee schedule,5.91,7.37,
Ost pch for bar w lk fl/fltr,A4423,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.45,,,,,,,fee schedule,5.91,7.37,
Ost pch for bar w lk fl/fltr,A4423,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.79,,,,,,,fee schedule,5.91,7.37,
Ost pch drain w bar & filter,A4424,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18.86,,,,,,,fee schedule,15.12,18.86,
Ost pch drain w bar & filter,A4424,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15.12,,,,,,,fee schedule,15.12,18.86,
Ost pch drain w bar & filter,A4424,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.52,,,,,,,fee schedule,15.12,18.86,
Ost pch drain w bar & filter,A4424,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17.37,,,,,,,fee schedule,15.12,18.86,
Ost pch drain for barrier fl,A4425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14.21,,,,,,,fee schedule,11.39,14.21,
Ost pch drain for barrier fl,A4425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11.39,,,,,,,fee schedule,11.39,14.21,
Ost pch drain for barrier fl,A4425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12.45,,,,,,,fee schedule,11.39,14.21,
Ost pch drain for barrier fl,A4425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13.08,,,,,,,fee schedule,11.39,14.21,
Ost pch drain 2 piece system,A4426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10.85,,,,,,,fee schedule,8.7,10.85,
Ost pch drain 2 piece system,A4426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.7,,,,,,,fee schedule,8.7,10.85,
Ost pch drain 2 piece system,A4426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.5,,,,,,,fee schedule,8.7,10.85,
Ost pch drain 2 piece system,A4426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.99,,,,,,,fee schedule,8.7,10.85,
Ost pch drain/barr lk flng/f,A4427,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11.04,,,,,,,fee schedule,8.85,11.04,
Ost pch drain/barr lk flng/f,A4427,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.85,,,,,,,fee schedule,8.85,11.04,
Ost pch drain/barr lk flng/f,A4427,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.67,,,,,,,fee schedule,8.85,11.04,
Ost pch drain/barr lk flng/f,A4427,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10.16,,,,,,,fee schedule,8.85,11.04,
Urine ost pouch w faucet/tap,A4428,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,25.86,,,,,,,fee schedule,20.73,25.86,
Urine ost pouch w faucet/tap,A4428,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20.73,,,,,,,fee schedule,20.73,25.86,
Urine ost pouch w faucet/tap,A4428,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22.64,,,,,,,fee schedule,20.73,25.86,
Urine ost pouch w faucet/tap,A4428,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23.8,,,,,,,fee schedule,20.73,25.86,
Urine ost pouch w bltinconv,A4429,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,32.73,,,,,,,fee schedule,26.24,32.73,
Urine ost pouch w bltinconv,A4429,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26.24,,,,,,,fee schedule,26.24,32.73,
Urine ost pouch w bltinconv,A4429,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28.66,,,,,,,fee schedule,26.24,32.73,
Urine ost pouch w bltinconv,A4429,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30.14,,,,,,,fee schedule,26.24,32.73,
Ost urine pch w b/bltin conv,A4430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33.83,,,,,,,fee schedule,27.12,33.83,
Ost urine pch w b/bltin conv,A4430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,27.12,,,,,,,fee schedule,27.12,33.83,
Ost urine pch w b/bltin conv,A4430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29.62,,,,,,,fee schedule,27.12,33.83,
Ost urine pch w b/bltin conv,A4430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,31.15,,,,,,,fee schedule,27.12,33.83,
Ost pch urine w barrier/tapv,A4431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24.68,,,,,,,fee schedule,19.79,24.68,
Ost pch urine w barrier/tapv,A4431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19.79,,,,,,,fee schedule,19.79,24.68,
Ost pch urine w barrier/tapv,A4431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21.61,,,,,,,fee schedule,19.79,24.68,
Ost pch urine w barrier/tapv,A4431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22.72,,,,,,,fee schedule,19.79,24.68,
Os pch urine w bar/fange/tap,A4432,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14.25,,,,,,,fee schedule,11.42,14.25,
Os pch urine w bar/fange/tap,A4432,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11.42,,,,,,,fee schedule,11.42,14.25,
Os pch urine w bar/fange/tap,A4432,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12.48,,,,,,,fee schedule,11.42,14.25,
Os pch urine w bar/fange/tap,A4432,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13.12,,,,,,,fee schedule,11.42,14.25,
Urine ost pch bar w lock fln,A4433,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13.27,,,,,,,fee schedule,10.64,13.27,
Urine ost pch bar w lock fln,A4433,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10.64,,,,,,,fee schedule,10.64,13.27,
Urine ost pch bar w lock fln,A4433,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11.62,,,,,,,fee schedule,10.64,13.27,
Urine ost pch bar w lock fln,A4433,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12.21,,,,,,,fee schedule,10.64,13.27,
Ost pch urine w lock flng/ft,A4434,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14.93,,,,,,,fee schedule,11.97,14.93,
Ost pch urine w lock flng/ft,A4434,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11.97,,,,,,,fee schedule,11.97,14.93,
Ost pch urine w lock flng/ft,A4434,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13.07,,,,,,,fee schedule,11.97,14.93,
Ost pch urine w lock flng/ft,A4434,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13.75,,,,,,,fee schedule,11.97,14.93,
1pc ost pch drain hgh output,A4435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23.66,,,,,,,fee schedule,18.97,23.66,
1pc ost pch drain hgh output,A4435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18.97,,,,,,,fee schedule,18.97,23.66,
1pc ost pch drain hgh output,A4435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20.72,,,,,,,fee schedule,18.97,23.66,
1pc ost pch drain hgh output,A4435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21.78,,,,,,,fee schedule,18.97,23.66,
Non-waterproof tape,A4450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.34,,,,,,,fee schedule,0.27,0.45,
Non-waterproof tape,A4450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.45,,,,,,,fee schedule,0.27,0.45,
Non-waterproof tape,A4450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.27,,,,,,,fee schedule,0.27,0.45,
Non-waterproof tape,A4450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.36,,,,,,,fee schedule,0.27,0.45,
Non-waterproof tape,A4450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.3,,,,,,,fee schedule,0.27,0.45,
Non-waterproof tape,A4450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.4,,,,,,,fee schedule,0.27,0.45,
Non-waterproof tape,A4450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.31,,,,,,,fee schedule,0.27,0.45,
Non-waterproof tape,A4450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.42,,,,,,,fee schedule,0.27,0.45,
Waterproof tape,A4452,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.44,,,,,,,fee schedule,1.15,1.59,
Waterproof tape,A4452,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.59,,,,,,,fee schedule,1.15,1.59,
Waterproof tape,A4452,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.15,,,,,,,fee schedule,1.15,1.59,
Waterproof tape,A4452,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.27,,,,,,,fee schedule,1.15,1.59,
Waterproof tape,A4452,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.26,,,,,,,fee schedule,1.15,1.59,
Waterproof tape,A4452,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.39,,,,,,,fee schedule,1.15,1.59,
Waterproof tape,A4452,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.32,,,,,,,fee schedule,1.15,1.59,
Waterproof tape,A4452,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.46,,,,,,,fee schedule,1.15,1.59,
Adhesive remover per ounce,A4455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.84,,,,,,,fee schedule,3.88,4.84,
Adhesive remover per ounce,A4455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.88,,,,,,,fee schedule,3.88,4.84,
Adhesive remover per ounce,A4455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.24,,,,,,,fee schedule,3.88,4.84,
Adhesive remover per ounce,A4455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.45,,,,,,,fee schedule,3.88,4.84,
"Adhesive remover, wipes",A4456,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.02,,,,,,,fee schedule,0.82,1.02,
"Adhesive remover, wipes",A4456,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.82,,,,,,,fee schedule,0.82,1.02,
"Adhesive remover, wipes",A4456,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.89,,,,,,,fee schedule,0.82,1.02,
"Adhesive remover, wipes",A4456,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.94,,,,,,,fee schedule,0.82,1.02,
Surgicl dress hold non-reuse,A4461,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13.04,,,,,,,fee schedule,10.45,13.04,
Surgicl dress hold non-reuse,A4461,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10.45,,,,,,,fee schedule,10.45,13.04,
Surgicl dress hold non-reuse,A4461,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11.42,,,,,,,fee schedule,10.45,13.04,
Surgicl dress hold non-reuse,A4461,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12.01,,,,,,,fee schedule,10.45,13.04,
Surgical dress holder reuse,A4463,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,52.84,,,,,,,fee schedule,42.36,52.84,
Surgical dress holder reuse,A4463,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.36,,,,,,,fee schedule,42.36,52.84,
Surgical dress holder reuse,A4463,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.27,,,,,,,fee schedule,42.36,52.84,
Surgical dress holder reuse,A4463,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,48.65,,,,,,,fee schedule,42.36,52.84,
Tracheostoma filter,A4481,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.51,,,,,,,fee schedule,1.21,1.51,
Tracheostoma filter,A4481,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.21,,,,,,,fee schedule,1.21,1.51,
Tracheostoma filter,A4481,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.32,,,,,,,fee schedule,1.21,1.51,
Tracheostoma filter,A4481,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.39,,,,,,,fee schedule,1.21,1.51,
"Electrodes, pair",A4556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,48.2,,,,,,,fee schedule,38.63,48.2,
"Electrodes, pair",A4556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38.63,,,,,,,fee schedule,38.63,48.2,
"Electrodes, pair",A4556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.2,,,,,,,fee schedule,38.63,48.2,
"Electrodes, pair",A4556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,44.37,,,,,,,fee schedule,38.63,48.2,
"Lead wires, pair",A4557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83.31,,,,,,,fee schedule,66.78,83.31,
"Lead wires, pair",A4557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66.78,,,,,,,fee schedule,66.78,83.31,
"Lead wires, pair",A4557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,72.95,,,,,,,fee schedule,66.78,83.31,
"Lead wires, pair",A4557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,76.7,,,,,,,fee schedule,66.78,83.31,
Conductive gel or paste,A4558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18.37,,,,,,,fee schedule,14.73,18.37,
Conductive gel or paste,A4558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14.73,,,,,,,fee schedule,14.73,18.37,
Conductive gel or paste,A4558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.09,,,,,,,fee schedule,14.73,18.37,
Conductive gel or paste,A4558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16.91,,,,,,,fee schedule,14.73,18.37,
Coupling gel or paste,A4559,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.42,,,,,,,fee schedule,0.33,0.42,
Coupling gel or paste,A4559,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.33,,,,,,,fee schedule,0.33,0.42,
Coupling gel or paste,A4559,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.36,,,,,,,fee schedule,0.33,0.42,
Coupling gel or paste,A4559,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.38,,,,,,,fee schedule,0.33,0.42,
Vag inser rectal control sys,A4563,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,489.51,,,,,,,fee schedule,392.39,2956.71,
Vag inser rectal control sys,A4563,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,392.39,,,,,,,fee schedule,392.39,2956.71,
Vag inser rectal control sys,A4563,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,428.65,,,,,,,fee schedule,392.39,2956.71,
Vag inser rectal control sys,A4563,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,450.66,,,,,,,fee schedule,392.39,2956.71,
Vag inser rectal control sys,A4563,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1774.03,,,,,,,fee schedule,392.39,2956.71,APC
Vag inser rectal control sys,A4563,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1757.13,,,,,,,fee schedule,392.39,2956.71,APC
Vag inser rectal control sys,A4563,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1689.55,,,,,,,fee schedule,392.39,2956.71,APC
Vag inser rectal control sys,A4563,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2585.01,,,,,,,fee schedule,392.39,2956.71,Radiology
Vag inser rectal control sys,A4563,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2365.37,,,,,,,fee schedule,392.39,2956.71,APC
Vag inser rectal control sys,A4563,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2956.71,,,,,,,fee schedule,392.39,2956.71,APC
TENS suppl 2 lead per month,A4595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,114.35,,,,,,,fee schedule,91.66,114.35,
TENS suppl 2 lead per month,A4595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,91.66,,,,,,,fee schedule,91.66,114.35,
TENS suppl 2 lead per month,A4595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,100.13,,,,,,,fee schedule,91.66,114.35,
TENS suppl 2 lead per month,A4595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,105.27,,,,,,,fee schedule,91.66,114.35,
Tubing with heating element,A4604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,228.54,,,,,,,fee schedule,183.19,228.54,
Tubing with heating element,A4604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,183.19,,,,,,,fee schedule,183.19,228.54,
Tubing with heating element,A4604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,200.12,,,,,,,fee schedule,183.19,228.54,
Tubing with heating element,A4604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,210.4,,,,,,,fee schedule,183.19,228.54,
Trach suction cath close sys,A4605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,65.09,,,,,,,fee schedule,52.18,65.09,
Trach suction cath close sys,A4605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52.18,,,,,,,fee schedule,52.18,65.09,
Trach suction cath close sys,A4605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57,,,,,,,fee schedule,52.18,65.09,
Trach suction cath close sys,A4605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59.93,,,,,,,fee schedule,52.18,65.09,
Transtracheal oxygen cath,A4608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,198.94,,,,,,,fee schedule,159.47,198.94,
Transtracheal oxygen cath,A4608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,159.47,,,,,,,fee schedule,159.47,198.94,
Transtracheal oxygen cath,A4608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,174.21,,,,,,,fee schedule,159.47,198.94,
Transtracheal oxygen cath,A4608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,183.15,,,,,,,fee schedule,159.47,198.94,
Heavy duty battery,A4611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,662.75,,,,,,,fee schedule,55.09,662.75,
Heavy duty battery,A4611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,68.72,,,,,,,fee schedule,55.09,662.75,
Heavy duty battery,A4611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,497.07,,,,,,,fee schedule,55.09,662.75,
Heavy duty battery,A4611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,531.25,,,,,,,fee schedule,55.09,662.75,
Heavy duty battery,A4611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55.09,,,,,,,fee schedule,55.09,662.75,
Heavy duty battery,A4611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,398.45,,,,,,,fee schedule,55.09,662.75,
Heavy duty battery,A4611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,580.34,,,,,,,fee schedule,55.09,662.75,
Heavy duty battery,A4611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,60.18,,,,,,,fee schedule,55.09,662.75,
Heavy duty battery,A4611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,435.27,,,,,,,fee schedule,55.09,662.75,
Heavy duty battery,A4611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,610.15,,,,,,,fee schedule,55.09,662.75,
Heavy duty battery,A4611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,63.27,,,,,,,fee schedule,55.09,662.75,
Heavy duty battery,A4611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,457.62,,,,,,,fee schedule,55.09,662.75,
Battery cables,A4612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,317.26,,,,,,,fee schedule,25.91,317.26,
Battery cables,A4612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,32.32,,,,,,,fee schedule,25.91,317.26,
Battery cables,A4612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,241.92,,,,,,,fee schedule,25.91,317.26,
Battery cables,A4612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,254.31,,,,,,,fee schedule,25.91,317.26,
Battery cables,A4612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,25.91,,,,,,,fee schedule,25.91,317.26,
Battery cables,A4612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,193.92,,,,,,,fee schedule,25.91,317.26,
Battery cables,A4612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,277.81,,,,,,,fee schedule,25.91,317.26,
Battery cables,A4612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28.3,,,,,,,fee schedule,25.91,317.26,
Battery cables,A4612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,211.84,,,,,,,fee schedule,25.91,317.26,
Battery cables,A4612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,292.08,,,,,,,fee schedule,25.91,317.26,
Battery cables,A4612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,29.75,,,,,,,fee schedule,25.91,317.26,
Battery cables,A4612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,222.72,,,,,,,fee schedule,25.91,317.26,
Battery charger,A4613,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,551.92,,,,,,,fee schedule,44.3,551.92,
Battery charger,A4613,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55.26,,,,,,,fee schedule,44.3,551.92,
Battery charger,A4613,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,413.91,,,,,,,fee schedule,44.3,551.92,
Battery charger,A4613,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,442.41,,,,,,,fee schedule,44.3,551.92,
Battery charger,A4613,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,44.3,,,,,,,fee schedule,44.3,551.92,
Battery charger,A4613,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,331.79,,,,,,,fee schedule,44.3,551.92,
Battery charger,A4613,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,483.29,,,,,,,fee schedule,44.3,551.92,
Battery charger,A4613,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48.39,,,,,,,fee schedule,44.3,551.92,
Battery charger,A4613,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,362.45,,,,,,,fee schedule,44.3,551.92,
Battery charger,A4613,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,508.11,,,,,,,fee schedule,44.3,551.92,
Battery charger,A4613,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,50.88,,,,,,,fee schedule,44.3,551.92,
Battery charger,A4613,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,381.06,,,,,,,fee schedule,44.3,551.92,
Hand-held PEFR meter,A4614,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,94.39,,,,,,,fee schedule,75.66,94.39,
Hand-held PEFR meter,A4614,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,75.66,,,,,,,fee schedule,75.66,94.39,
Hand-held PEFR meter,A4614,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,82.65,,,,,,,fee schedule,75.66,94.39,
Hand-held PEFR meter,A4614,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,86.9,,,,,,,fee schedule,75.66,94.39,
Cannula nasal,A4615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.84,,,,,,,fee schedule,2.27,2.84,
Cannula nasal,A4615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.27,,,,,,,fee schedule,2.27,2.84,
Cannula nasal,A4615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.48,,,,,,,fee schedule,2.27,2.84,
Cannula nasal,A4615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.61,,,,,,,fee schedule,2.27,2.84,
Tubing (oxygen) per foot,A4616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.26,,,,,,,fee schedule,0.21,0.26,
Tubing (oxygen) per foot,A4616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.21,,,,,,,fee schedule,0.21,0.26,
Tubing (oxygen) per foot,A4616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.23,,,,,,,fee schedule,0.21,0.26,
Tubing (oxygen) per foot,A4616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.24,,,,,,,fee schedule,0.21,0.26,
Mouth piece,A4617,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12.29,,,,,,,fee schedule,9.85,12.29,
Mouth piece,A4617,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.85,,,,,,,fee schedule,9.85,12.29,
Mouth piece,A4617,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10.76,,,,,,,fee schedule,9.85,12.29,
Mouth piece,A4617,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11.31,,,,,,,fee schedule,9.85,12.29,
Breathing circuits,A4618,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,35.04,,,,,,,fee schedule,2.79,35.04,
Breathing circuits,A4618,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.48,,,,,,,fee schedule,2.79,35.04,
Breathing circuits,A4618,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26.27,,,,,,,fee schedule,2.79,35.04,
Breathing circuits,A4618,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28.09,,,,,,,fee schedule,2.79,35.04,
Breathing circuits,A4618,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.79,,,,,,,fee schedule,2.79,35.04,
Breathing circuits,A4618,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21.06,,,,,,,fee schedule,2.79,35.04,
Breathing circuits,A4618,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,30.68,,,,,,,fee schedule,2.79,35.04,
Breathing circuits,A4618,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.05,,,,,,,fee schedule,2.79,35.04,
Breathing circuits,A4618,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23,,,,,,,fee schedule,2.79,35.04,
Breathing circuits,A4618,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,32.26,,,,,,,fee schedule,2.79,35.04,
Breathing circuits,A4618,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.2,,,,,,,fee schedule,2.79,35.04,
Breathing circuits,A4618,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24.19,,,,,,,fee schedule,2.79,35.04,
Face tent,A4619,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.8,,,,,,,fee schedule,3.85,4.8,
Face tent,A4619,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.85,,,,,,,fee schedule,3.85,4.8,
Face tent,A4619,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.2,,,,,,,fee schedule,3.85,4.8,
Face tent,A4619,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.42,,,,,,,fee schedule,3.85,4.8,
Variable concentration mask,A4620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.46,,,,,,,fee schedule,1.97,2.46,
Variable concentration mask,A4620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.97,,,,,,,fee schedule,1.97,2.46,
Variable concentration mask,A4620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.15,,,,,,,fee schedule,1.97,2.46,
Variable concentration mask,A4620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.26,,,,,,,fee schedule,1.97,2.46,
Tracheostomy inner cannula,A4623,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22.11,,,,,,,fee schedule,17.73,22.11,
Tracheostomy inner cannula,A4623,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17.73,,,,,,,fee schedule,17.73,22.11,
Tracheostomy inner cannula,A4623,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19.36,,,,,,,fee schedule,17.73,22.11,
Tracheostomy inner cannula,A4623,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20.36,,,,,,,fee schedule,17.73,22.11,
Tracheal suction tube,A4624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8.88,,,,,,,fee schedule,7.12,8.88,
Tracheal suction tube,A4624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7.12,,,,,,,fee schedule,7.12,8.88,
Tracheal suction tube,A4624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7.78,,,,,,,fee schedule,7.12,8.88,
Tracheal suction tube,A4624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8.18,,,,,,,fee schedule,7.12,8.88,
Trach care kit for new trach,A4625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27.52,,,,,,,fee schedule,22.06,27.52,
Trach care kit for new trach,A4625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22.06,,,,,,,fee schedule,22.06,27.52,
Trach care kit for new trach,A4625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24.1,,,,,,,fee schedule,22.06,27.52,
Trach care kit for new trach,A4625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,25.33,,,,,,,fee schedule,22.06,27.52,
Tracheostomy cleaning brush,A4626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12.66,,,,,,,fee schedule,10.15,12.66,
Tracheostomy cleaning brush,A4626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10.15,,,,,,,fee schedule,10.15,12.66,
Tracheostomy cleaning brush,A4626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11.09,,,,,,,fee schedule,10.15,12.66,
Tracheostomy cleaning brush,A4626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11.66,,,,,,,fee schedule,10.15,12.66,
Oropharyngeal suction cath,A4628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14.86,,,,,,,fee schedule,11.91,14.86,
Oropharyngeal suction cath,A4628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11.91,,,,,,,fee schedule,11.91,14.86,
Oropharyngeal suction cath,A4628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13.01,,,,,,,fee schedule,11.91,14.86,
Oropharyngeal suction cath,A4628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13.68,,,,,,,fee schedule,11.91,14.86,
Tracheostomy care kit,A4629,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18.37,,,,,,,fee schedule,14.73,18.37,
Tracheostomy care kit,A4629,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14.73,,,,,,,fee schedule,14.73,18.37,
Tracheostomy care kit,A4629,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.09,,,,,,,fee schedule,14.73,18.37,
Tracheostomy care kit,A4629,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16.91,,,,,,,fee schedule,14.73,18.37,
Repl bat t.e.n.s. own by pt,A4630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21.09,,,,,,,fee schedule,16.91,21.09,
Repl bat t.e.n.s. own by pt,A4630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.91,,,,,,,fee schedule,16.91,21.09,
Repl bat t.e.n.s. own by pt,A4630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18.47,,,,,,,fee schedule,16.91,21.09,
Repl bat t.e.n.s. own by pt,A4630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19.42,,,,,,,fee schedule,16.91,21.09,
Uvl replacement bulb,A4633,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,162.88,,,,,,,fee schedule,130.56,162.88,
Uvl replacement bulb,A4633,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,130.56,,,,,,,fee schedule,130.56,162.88,
Uvl replacement bulb,A4633,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,142.63,,,,,,,fee schedule,130.56,162.88,
Uvl replacement bulb,A4633,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,149.95,,,,,,,fee schedule,130.56,162.88,
Underarm crutch pad,A4635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17.27,,,,,,,fee schedule,2.06,17.27,
Underarm crutch pad,A4635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.57,,,,,,,fee schedule,2.06,17.27,
Underarm crutch pad,A4635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11.45,,,,,,,fee schedule,2.06,17.27,
Underarm crutch pad,A4635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13.85,,,,,,,fee schedule,2.06,17.27,
Underarm crutch pad,A4635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.06,,,,,,,fee schedule,2.06,17.27,
Underarm crutch pad,A4635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.18,,,,,,,fee schedule,2.06,17.27,
Underarm crutch pad,A4635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15.13,,,,,,,fee schedule,2.06,17.27,
Underarm crutch pad,A4635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.25,,,,,,,fee schedule,2.06,17.27,
Underarm crutch pad,A4635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10.03,,,,,,,fee schedule,2.06,17.27,
Underarm crutch pad,A4635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15.9,,,,,,,fee schedule,2.06,17.27,
Underarm crutch pad,A4635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.37,,,,,,,fee schedule,2.06,17.27,
Underarm crutch pad,A4635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10.54,,,,,,,fee schedule,2.06,17.27,
Handgrip for cane etc,A4636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12.25,,,,,,,fee schedule,1,12.25,
Handgrip for cane etc,A4636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.25,,,,,,,fee schedule,1,12.25,
Handgrip for cane etc,A4636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8.92,,,,,,,fee schedule,1,12.25,
Handgrip for cane etc,A4636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.82,,,,,,,fee schedule,1,12.25,
Handgrip for cane etc,A4636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1,,,,,,,fee schedule,1,12.25,
Handgrip for cane etc,A4636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7.15,,,,,,,fee schedule,1,12.25,
Handgrip for cane etc,A4636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10.72,,,,,,,fee schedule,1,12.25,
Handgrip for cane etc,A4636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.09,,,,,,,fee schedule,1,12.25,
Handgrip for cane etc,A4636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7.81,,,,,,,fee schedule,1,12.25,
Handgrip for cane etc,A4636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11.28,,,,,,,fee schedule,1,12.25,
Handgrip for cane etc,A4636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.15,,,,,,,fee schedule,1,12.25,
Handgrip for cane etc,A4636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8.21,,,,,,,fee schedule,1,12.25,
Repl tip cane/crutch/walker,A4637,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.2,,,,,,,fee schedule,0.7,6.2,
Repl tip cane/crutch/walker,A4637,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.87,,,,,,,fee schedule,0.7,6.2,
Repl tip cane/crutch/walker,A4637,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.69,,,,,,,fee schedule,0.7,6.2,
Repl tip cane/crutch/walker,A4637,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.97,,,,,,,fee schedule,0.7,6.2,
Repl tip cane/crutch/walker,A4637,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.7,,,,,,,fee schedule,0.7,6.2,
Repl tip cane/crutch/walker,A4637,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.76,,,,,,,fee schedule,0.7,6.2,
Repl tip cane/crutch/walker,A4637,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.43,,,,,,,fee schedule,0.7,6.2,
Repl tip cane/crutch/walker,A4637,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.76,,,,,,,fee schedule,0.7,6.2,
Repl tip cane/crutch/walker,A4637,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.1,,,,,,,fee schedule,0.7,6.2,
Repl tip cane/crutch/walker,A4637,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.71,,,,,,,fee schedule,0.7,6.2,
Repl tip cane/crutch/walker,A4637,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.8,,,,,,,fee schedule,0.7,6.2,
Repl tip cane/crutch/walker,A4637,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.32,,,,,,,fee schedule,0.7,6.2,
Infrared ht sys replcmnt pad,A4639,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1139.93,,,,,,,fee schedule,913.76,1139.93,
Infrared ht sys replcmnt pad,A4639,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,913.76,,,,,,,fee schedule,913.76,1139.93,
Infrared ht sys replcmnt pad,A4639,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,998.2,,,,,,,fee schedule,913.76,1139.93,
Infrared ht sys replcmnt pad,A4639,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1049.46,,,,,,,fee schedule,913.76,1139.93,
Alternating pressure pad,A4640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,251.33,,,,,,,fee schedule,20.51,251.33,
Alternating pressure pad,A4640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,25.59,,,,,,,fee schedule,20.51,251.33,
Alternating pressure pad,A4640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,178.04,,,,,,,fee schedule,20.51,251.33,
Alternating pressure pad,A4640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,201.46,,,,,,,fee schedule,20.51,251.33,
Alternating pressure pad,A4640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20.51,,,,,,,fee schedule,20.51,251.33,
Alternating pressure pad,A4640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,142.71,,,,,,,fee schedule,20.51,251.33,
Alternating pressure pad,A4640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,220.08,,,,,,,fee schedule,20.51,251.33,
Alternating pressure pad,A4640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22.41,,,,,,,fee schedule,20.51,251.33,
Alternating pressure pad,A4640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,155.9,,,,,,,fee schedule,20.51,251.33,
Alternating pressure pad,A4640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,231.39,,,,,,,fee schedule,20.51,251.33,
Alternating pressure pad,A4640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23.56,,,,,,,fee schedule,20.51,251.33,
Alternating pressure pad,A4640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,163.91,,,,,,,fee schedule,20.51,251.33,
Pouch clsd w barr attached,A5051,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8.2,,,,,,,fee schedule,6.58,8.2,
Pouch clsd w barr attached,A5051,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.58,,,,,,,fee schedule,6.58,8.2,
Pouch clsd w barr attached,A5051,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7.18,,,,,,,fee schedule,6.58,8.2,
Pouch clsd w barr attached,A5051,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7.55,,,,,,,fee schedule,6.58,8.2,
Clsd ostomy pouch w/o barr,A5052,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.9,,,,,,,fee schedule,4.73,5.9,
Clsd ostomy pouch w/o barr,A5052,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.73,,,,,,,fee schedule,4.73,5.9,
Clsd ostomy pouch w/o barr,A5052,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.16,,,,,,,fee schedule,4.73,5.9,
Clsd ostomy pouch w/o barr,A5052,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.43,,,,,,,fee schedule,4.73,5.9,
Clsd ostomy pouch faceplate,A5053,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.9,,,,,,,fee schedule,4.73,5.9,
Clsd ostomy pouch faceplate,A5053,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.73,,,,,,,fee schedule,4.73,5.9,
Clsd ostomy pouch faceplate,A5053,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.16,,,,,,,fee schedule,4.73,5.9,
Clsd ostomy pouch faceplate,A5053,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.43,,,,,,,fee schedule,4.73,5.9,
Clsd ostomy pouch w/flange,A5054,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7.11,,,,,,,fee schedule,5.7,7.11,
Clsd ostomy pouch w/flange,A5054,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.7,,,,,,,fee schedule,5.7,7.11,
Clsd ostomy pouch w/flange,A5054,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.22,,,,,,,fee schedule,5.7,7.11,
Clsd ostomy pouch w/flange,A5054,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.54,,,,,,,fee schedule,5.7,7.11,
Stoma cap,A5055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.71,,,,,,,fee schedule,4.58,5.71,
Stoma cap,A5055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.58,,,,,,,fee schedule,4.58,5.71,
Stoma cap,A5055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5,,,,,,,fee schedule,4.58,5.71,
Stoma cap,A5055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.25,,,,,,,fee schedule,4.58,5.71,
1 pc ost pouch w filter,A5056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19.09,,,,,,,fee schedule,15.3,19.09,
1 pc ost pouch w filter,A5056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15.3,,,,,,,fee schedule,15.3,19.09,
1 pc ost pouch w filter,A5056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.72,,,,,,,fee schedule,15.3,19.09,
1 pc ost pouch w filter,A5056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17.57,,,,,,,fee schedule,15.3,19.09,
1 pc ost pou w built-in conv,A5057,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,39.31,,,,,,,fee schedule,31.51,39.31,
1 pc ost pou w built-in conv,A5057,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31.51,,,,,,,fee schedule,31.51,39.31,
1 pc ost pou w built-in conv,A5057,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,34.42,,,,,,,fee schedule,31.51,39.31,
1 pc ost pou w built-in conv,A5057,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,36.19,,,,,,,fee schedule,31.51,39.31,
Pouch drainable w barrier at,A5061,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13.99,,,,,,,fee schedule,11.21,13.99,
Pouch drainable w barrier at,A5061,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11.21,,,,,,,fee schedule,11.21,13.99,
Pouch drainable w barrier at,A5061,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12.25,,,,,,,fee schedule,11.21,13.99,
Pouch drainable w barrier at,A5061,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12.88,,,,,,,fee schedule,11.21,13.99,
Drnble ostomy pouch w/o barr,A5062,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8.81,,,,,,,fee schedule,7.06,8.81,
Drnble ostomy pouch w/o barr,A5062,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7.06,,,,,,,fee schedule,7.06,8.81,
Drnble ostomy pouch w/o barr,A5062,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7.71,,,,,,,fee schedule,7.06,8.81,
Drnble ostomy pouch w/o barr,A5062,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8.11,,,,,,,fee schedule,7.06,8.81,
Drain ostomy pouch w/flange,A5063,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10.74,,,,,,,fee schedule,8.61,10.74,
Drain ostomy pouch w/flange,A5063,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.61,,,,,,,fee schedule,8.61,10.74,
Drain ostomy pouch w/flange,A5063,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.4,,,,,,,fee schedule,8.61,10.74,
Drain ostomy pouch w/flange,A5063,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.88,,,,,,,fee schedule,8.61,10.74,
Urinary pouch w/barrier,A5071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23.85,,,,,,,fee schedule,19.12,23.85,
Urinary pouch w/barrier,A5071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19.12,,,,,,,fee schedule,19.12,23.85,
Urinary pouch w/barrier,A5071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20.89,,,,,,,fee schedule,19.12,23.85,
Urinary pouch w/barrier,A5071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21.96,,,,,,,fee schedule,19.12,23.85,
Urinary pouch w/o barrier,A5072,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13.99,,,,,,,fee schedule,11.21,13.99,
Urinary pouch w/o barrier,A5072,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11.21,,,,,,,fee schedule,11.21,13.99,
Urinary pouch w/o barrier,A5072,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12.25,,,,,,,fee schedule,11.21,13.99,
Urinary pouch w/o barrier,A5072,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12.88,,,,,,,fee schedule,11.21,13.99,
Urinary pouch on barr w/flng,A5073,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12.55,,,,,,,fee schedule,10.06,12.55,
Urinary pouch on barr w/flng,A5073,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10.06,,,,,,,fee schedule,10.06,12.55,
Urinary pouch on barr w/flng,A5073,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10.99,,,,,,,fee schedule,10.06,12.55,
Urinary pouch on barr w/flng,A5073,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11.55,,,,,,,fee schedule,10.06,12.55,
"Stoma plug or seal, any type",A5081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11.15,,,,,,,fee schedule,8.94,11.15,
"Stoma plug or seal, any type",A5081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.94,,,,,,,fee schedule,8.94,11.15,
"Stoma plug or seal, any type",A5081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.76,,,,,,,fee schedule,8.94,11.15,
"Stoma plug or seal, any type",A5081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10.27,,,,,,,fee schedule,8.94,11.15,
Continent stoma catheter,A5082,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,47.17,,,,,,,fee schedule,37.81,47.17,
Continent stoma catheter,A5082,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37.81,,,,,,,fee schedule,37.81,47.17,
Continent stoma catheter,A5082,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,41.31,,,,,,,fee schedule,37.81,47.17,
Continent stoma catheter,A5082,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,43.43,,,,,,,fee schedule,37.81,47.17,
Stoma absorptive cover,A5083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.49,,,,,,,fee schedule,2,2.49,
Stoma absorptive cover,A5083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2,,,,,,,fee schedule,2,2.49,
Stoma absorptive cover,A5083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.18,,,,,,,fee schedule,2,2.49,
Stoma absorptive cover,A5083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.3,,,,,,,fee schedule,2,2.49,
Ostomy accessory convex inse,A5093,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7.26,,,,,,,fee schedule,5.82,7.26,
Ostomy accessory convex inse,A5093,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.82,,,,,,,fee schedule,5.82,7.26,
Ostomy accessory convex inse,A5093,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.36,,,,,,,fee schedule,5.82,7.26,
Ostomy accessory convex inse,A5093,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.68,,,,,,,fee schedule,5.82,7.26,
"Expired, orthopedic, length of stay is 14 days or more",A5102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,89.62,,,,,,,fee schedule,71.84,89.62,
"Expired, orthopedic, length of stay is 14 days or more",A5102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,71.84,,,,,,,fee schedule,71.84,89.62,
"Expired, orthopedic, length of stay is 14 days or more",A5102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,78.48,,,,,,,fee schedule,71.84,89.62,
"Expired, orthopedic, length of stay is 14 days or more",A5102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,82.51,,,,,,,fee schedule,71.84,89.62,
Urinary suspensory,A5105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,151.77,,,,,,,fee schedule,121.65,151.77,
Urinary suspensory,A5105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,121.65,,,,,,,fee schedule,121.65,151.77,
Urinary suspensory,A5105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,132.9,,,,,,,fee schedule,121.65,151.77,
Urinary suspensory,A5105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,139.72,,,,,,,fee schedule,121.65,151.77,
Urinary leg bag,A5112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,128.41,,,,,,,fee schedule,102.93,128.41,
Urinary leg bag,A5112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,102.93,,,,,,,fee schedule,102.93,128.41,
Urinary leg bag,A5112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,112.44,,,,,,,fee schedule,102.93,128.41,
Urinary leg bag,A5112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,118.22,,,,,,,fee schedule,102.93,128.41,
Latex leg strap,A5113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15.88,,,,,,,fee schedule,12.73,15.88,
Latex leg strap,A5113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12.73,,,,,,,fee schedule,12.73,15.88,
Latex leg strap,A5113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13.9,,,,,,,fee schedule,12.73,15.88,
Latex leg strap,A5113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14.62,,,,,,,fee schedule,12.73,15.88,
Foam/fabric leg strap,A5114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,35.49,,,,,,,fee schedule,28.45,35.49,
Foam/fabric leg strap,A5114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28.45,,,,,,,fee schedule,28.45,35.49,
Foam/fabric leg strap,A5114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31.08,,,,,,,fee schedule,28.45,35.49,
Foam/fabric leg strap,A5114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,32.68,,,,,,,fee schedule,28.45,35.49,
"Skin barrier, wipe or swab",A5120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.95,,,,,,,fee schedule,0.76,0.95,
"Skin barrier, wipe or swab",A5120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.76,,,,,,,fee schedule,0.76,0.95,
"Skin barrier, wipe or swab",A5120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.83,,,,,,,fee schedule,0.76,0.95,
"Skin barrier, wipe or swab",A5120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.87,,,,,,,fee schedule,0.76,0.95,
Solid skin barrier 6x6,A5121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,29.6,,,,,,,fee schedule,23.72,29.6,
Solid skin barrier 6x6,A5121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23.72,,,,,,,fee schedule,23.72,29.6,
Solid skin barrier 6x6,A5121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,25.92,,,,,,,fee schedule,23.72,29.6,
Solid skin barrier 6x6,A5121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27.25,,,,,,,fee schedule,23.72,29.6,
Solid skin barrier 8x8,A5122,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,50.99,,,,,,,fee schedule,40.87,50.99,
Solid skin barrier 8x8,A5122,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40.87,,,,,,,fee schedule,40.87,50.99,
Solid skin barrier 8x8,A5122,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,44.65,,,,,,,fee schedule,40.87,50.99,
Solid skin barrier 8x8,A5122,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46.95,,,,,,,fee schedule,40.87,50.99,
Disk/foam pad +or- adhesive,A5126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.46,,,,,,,fee schedule,3.58,4.46,
Disk/foam pad +or- adhesive,A5126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.58,,,,,,,fee schedule,3.58,4.46,
Disk/foam pad +or- adhesive,A5126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.91,,,,,,,fee schedule,3.58,4.46,
Disk/foam pad +or- adhesive,A5126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.11,,,,,,,fee schedule,3.58,4.46,
Appliance cleaner,A5131,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,62.94,,,,,,,fee schedule,50.45,62.94,
Appliance cleaner,A5131,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,50.45,,,,,,,fee schedule,50.45,62.94,
Appliance cleaner,A5131,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55.11,,,,,,,fee schedule,50.45,62.94,
Appliance cleaner,A5131,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,57.94,,,,,,,fee schedule,50.45,62.94,
Percutaneous catheter anchor,A5200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,44.87,,,,,,,fee schedule,35.97,44.87,
Percutaneous catheter anchor,A5200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35.97,,,,,,,fee schedule,35.97,44.87,
Percutaneous catheter anchor,A5200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39.29,,,,,,,fee schedule,35.97,44.87,
Percutaneous catheter anchor,A5200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41.31,,,,,,,fee schedule,35.97,44.87,
Diab shoe for density insert,A5500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,252.35,,,,,,,fee schedule,202.28,252.35,
Diab shoe for density insert,A5500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,202.28,,,,,,,fee schedule,202.28,252.35,
Diab shoe for density insert,A5500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,220.98,,,,,,,fee schedule,202.28,252.35,
Diab shoe for density insert,A5500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,232.32,,,,,,,fee schedule,202.28,252.35,
Diabetic custom molded shoe,A5501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,756.95,,,,,,,fee schedule,606.76,756.95,
Diabetic custom molded shoe,A5501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,606.76,,,,,,,fee schedule,606.76,756.95,
Diabetic custom molded shoe,A5501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,662.83,,,,,,,fee schedule,606.76,756.95,
Diabetic custom molded shoe,A5501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,696.87,,,,,,,fee schedule,606.76,756.95,
Diabetic shoe w/roller/rockr,A5503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,112.23,,,,,,,fee schedule,89.96,112.23,
Diabetic shoe w/roller/rockr,A5503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,89.96,,,,,,,fee schedule,89.96,112.23,
Diabetic shoe w/roller/rockr,A5503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,98.27,,,,,,,fee schedule,89.96,112.23,
Diabetic shoe w/roller/rockr,A5503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,103.32,,,,,,,fee schedule,89.96,112.23,
Diabetic shoe with wedge,A5504,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,112.23,,,,,,,fee schedule,89.96,112.23,
Diabetic shoe with wedge,A5504,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,89.96,,,,,,,fee schedule,89.96,112.23,
Diabetic shoe with wedge,A5504,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,98.27,,,,,,,fee schedule,89.96,112.23,
Diabetic shoe with wedge,A5504,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,103.32,,,,,,,fee schedule,89.96,112.23,
Diab shoe w/metatarsal bar,A5505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,112.23,,,,,,,fee schedule,89.96,112.23,
Diab shoe w/metatarsal bar,A5505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,89.96,,,,,,,fee schedule,89.96,112.23,
Diab shoe w/metatarsal bar,A5505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,98.27,,,,,,,fee schedule,89.96,112.23,
Diab shoe w/metatarsal bar,A5505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,103.32,,,,,,,fee schedule,89.96,112.23,
Diabetic shoe w/off set heel,A5506,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,112.23,,,,,,,fee schedule,89.96,112.23,
Diabetic shoe w/off set heel,A5506,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,89.96,,,,,,,fee schedule,89.96,112.23,
Diabetic shoe w/off set heel,A5506,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,98.27,,,,,,,fee schedule,89.96,112.23,
Diabetic shoe w/off set heel,A5506,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,103.32,,,,,,,fee schedule,89.96,112.23,
Modification diabetic shoe,A5507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,112.23,,,,,,,fee schedule,89.96,112.23,
Modification diabetic shoe,A5507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,89.96,,,,,,,fee schedule,89.96,112.23,
Modification diabetic shoe,A5507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,98.27,,,,,,,fee schedule,89.96,112.23,
Modification diabetic shoe,A5507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,103.32,,,,,,,fee schedule,89.96,112.23,
Multi den insert direct form,A5512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,102.97,,,,,,,fee schedule,82.54,102.97,
Multi den insert direct form,A5512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,82.54,,,,,,,fee schedule,82.54,102.97,
Multi den insert direct form,A5512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,90.16,,,,,,,fee schedule,82.54,102.97,
Multi den insert direct form,A5512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,94.8,,,,,,,fee schedule,82.54,102.97,
Multi den insert custom mold,A5513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,153.66,,,,,,,fee schedule,123.17,153.66,
Multi den insert custom mold,A5513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,123.17,,,,,,,fee schedule,123.17,153.66,
Multi den insert custom mold,A5513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,134.55,,,,,,,fee schedule,123.17,153.66,
Multi den insert custom mold,A5513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,141.46,,,,,,,fee schedule,123.17,153.66,
Mult den insert dir carv/cam,A5514,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,169.95,,,,,,,fee schedule,136.23,169.95,
Mult den insert dir carv/cam,A5514,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,136.23,,,,,,,fee schedule,136.23,169.95,
Mult den insert dir carv/cam,A5514,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,148.82,,,,,,,fee schedule,136.23,169.95,
Mult den insert dir carv/cam,A5514,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,156.46,,,,,,,fee schedule,136.23,169.95,
Collagen based wound filler,A6010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,84.26,,,,,,,fee schedule,67.54,84.26,
Collagen based wound filler,A6010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,67.54,,,,,,,fee schedule,67.54,84.26,
Collagen based wound filler,A6010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,73.78,,,,,,,fee schedule,67.54,84.26,
Collagen based wound filler,A6010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,77.57,,,,,,,fee schedule,67.54,84.26,
Collagen gel/paste wound fil,A6011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10.89,,,,,,,fee schedule,8.73,10.89,
Collagen gel/paste wound fil,A6011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.73,,,,,,,fee schedule,8.73,10.89,
Collagen gel/paste wound fil,A6011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.53,,,,,,,fee schedule,8.73,10.89,
Collagen gel/paste wound fil,A6011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10.02,,,,,,,fee schedule,8.73,10.89,
Collagen dressing <=16 sq in,A6021,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83.42,,,,,,,fee schedule,66.87,83.42,
Collagen dressing <=16 sq in,A6021,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66.87,,,,,,,fee schedule,66.87,83.42,
Collagen dressing <=16 sq in,A6021,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,73.05,,,,,,,fee schedule,66.87,83.42,
Collagen dressing <=16 sq in,A6021,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,76.8,,,,,,,fee schedule,66.87,83.42,
Collagen drsg>16<=48 sq in,A6022,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83.42,,,,,,,fee schedule,66.87,83.42,
Collagen drsg>16<=48 sq in,A6022,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66.87,,,,,,,fee schedule,66.87,83.42,
Collagen drsg>16<=48 sq in,A6022,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,73.05,,,,,,,fee schedule,66.87,83.42,
Collagen drsg>16<=48 sq in,A6022,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,76.8,,,,,,,fee schedule,66.87,83.42,
Collagen dressing >48 sq in,A6023,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,755.32,,,,,,,fee schedule,605.45,755.32,
Collagen dressing >48 sq in,A6023,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,605.45,,,,,,,fee schedule,605.45,755.32,
Collagen dressing >48 sq in,A6023,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,661.4,,,,,,,fee schedule,605.45,755.32,
Collagen dressing >48 sq in,A6023,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,695.37,,,,,,,fee schedule,605.45,755.32,
Collagen dsg wound filler,A6024,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22.76,,,,,,,fee schedule,18.24,22.76,
Collagen dsg wound filler,A6024,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18.24,,,,,,,fee schedule,18.24,22.76,
Collagen dsg wound filler,A6024,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19.93,,,,,,,fee schedule,18.24,22.76,
Collagen dsg wound filler,A6024,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20.95,,,,,,,fee schedule,18.24,22.76,
Wound pouch each,A6154,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,57.08,,,,,,,fee schedule,45.75,57.08,
Wound pouch each,A6154,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,45.75,,,,,,,fee schedule,45.75,57.08,
Wound pouch each,A6154,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,49.98,,,,,,,fee schedule,45.75,57.08,
Wound pouch each,A6154,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,52.55,,,,,,,fee schedule,45.75,57.08,
Alginate dressing <=16 sq in,A6196,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42.26,,,,,,,fee schedule,33.88,42.26,
Alginate dressing <=16 sq in,A6196,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,33.88,,,,,,,fee schedule,33.88,42.26,
Alginate dressing <=16 sq in,A6196,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37.01,,,,,,,fee schedule,33.88,42.26,
Alginate dressing <=16 sq in,A6196,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,38.91,,,,,,,fee schedule,33.88,42.26,
Alginate drsg >16 <=48 sq in,A6197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,65.24,,,,,,,fee schedule,52.3,65.24,
Alginate drsg >16 <=48 sq in,A6197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52.3,,,,,,,fee schedule,52.3,65.24,
Alginate drsg >16 <=48 sq in,A6197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.13,,,,,,,fee schedule,52.3,65.24,
Alginate drsg >16 <=48 sq in,A6197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.06,,,,,,,fee schedule,52.3,65.24,
Alginate drsg wound filler,A6199,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20.98,,,,,,,fee schedule,16.82,20.98,
Alginate drsg wound filler,A6199,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.82,,,,,,,fee schedule,16.82,20.98,
Alginate drsg wound filler,A6199,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18.37,,,,,,,fee schedule,16.82,20.98,
Alginate drsg wound filler,A6199,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19.31,,,,,,,fee schedule,16.82,20.98,
Composite drsg <= 16 sq in,A6203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13.31,,,,,,,fee schedule,10.67,13.31,
Composite drsg <= 16 sq in,A6203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10.67,,,,,,,fee schedule,10.67,13.31,
Composite drsg <= 16 sq in,A6203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11.65,,,,,,,fee schedule,10.67,13.31,
Composite drsg <= 16 sq in,A6203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12.25,,,,,,,fee schedule,10.67,13.31,
Composite drsg >16<=48 sq in,A6204,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24.72,,,,,,,fee schedule,19.82,24.72,
Composite drsg >16<=48 sq in,A6204,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19.82,,,,,,,fee schedule,19.82,24.72,
Composite drsg >16<=48 sq in,A6204,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21.65,,,,,,,fee schedule,19.82,24.72,
Composite drsg >16<=48 sq in,A6204,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22.76,,,,,,,fee schedule,19.82,24.72,
Contact layer <= 16 sq in,A6206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11.65,,,,,,,fee schedule,9.34,11.65,
Contact layer <= 16 sq in,A6206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.34,,,,,,,fee schedule,9.34,11.65,
Contact layer <= 16 sq in,A6206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10.2,,,,,,,fee schedule,9.34,11.65,
Contact layer <= 16 sq in,A6206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10.72,,,,,,,fee schedule,9.34,11.65,
Contact layer >16<= 48 sq in,A6207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,29.14,,,,,,,fee schedule,23.36,29.14,
Contact layer >16<= 48 sq in,A6207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23.36,,,,,,,fee schedule,23.36,29.14,
Contact layer >16<= 48 sq in,A6207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,25.52,,,,,,,fee schedule,23.36,29.14,
Contact layer >16<= 48 sq in,A6207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26.83,,,,,,,fee schedule,23.36,29.14,
Foam drsg <=16 sq in w/o bdr,A6209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8.53,,,,,,,fee schedule,6.84,8.53,
Foam drsg <=16 sq in w/o bdr,A6209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.84,,,,,,,fee schedule,6.84,8.53,
Foam drsg <=16 sq in w/o bdr,A6209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7.47,,,,,,,fee schedule,6.84,8.53,
Foam drsg <=16 sq in w/o bdr,A6209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7.86,,,,,,,fee schedule,6.84,8.53,
Foam drg >16<=48 sq in w/o b,A6210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,43.15,,,,,,,fee schedule,34.58,43.15,
Foam drg >16<=48 sq in w/o b,A6210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,34.58,,,,,,,fee schedule,34.58,43.15,
Foam drg >16<=48 sq in w/o b,A6210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37.78,,,,,,,fee schedule,34.58,43.15,
Foam drg >16<=48 sq in w/o b,A6210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,39.72,,,,,,,fee schedule,34.58,43.15,
Foam drg > 48 sq in w/o brdr,A6211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,74.77,,,,,,,fee schedule,59.93,74.77,
Foam drg > 48 sq in w/o brdr,A6211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,59.93,,,,,,,fee schedule,59.93,74.77,
Foam drg > 48 sq in w/o brdr,A6211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,65.47,,,,,,,fee schedule,59.93,74.77,
Foam drg > 48 sq in w/o brdr,A6211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,68.83,,,,,,,fee schedule,59.93,74.77,
Foam drg <=16 sq in w/border,A6212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18.42,,,,,,,fee schedule,14.77,18.42,
Foam drg <=16 sq in w/border,A6212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14.77,,,,,,,fee schedule,14.77,18.42,
Foam drg <=16 sq in w/border,A6212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.13,,,,,,,fee schedule,14.77,18.42,
Foam drg <=16 sq in w/border,A6212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16.96,,,,,,,fee schedule,14.77,18.42,
Foam drg > 48 sq in w/border,A6214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,40.82,,,,,,,fee schedule,32.72,40.82,
Foam drg > 48 sq in w/border,A6214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32.72,,,,,,,fee schedule,32.72,40.82,
Foam drg > 48 sq in w/border,A6214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35.75,,,,,,,fee schedule,32.72,40.82,
Foam drg > 48 sq in w/border,A6214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37.58,,,,,,,fee schedule,32.72,40.82,
Non-sterile gauze<=16 sq in,A6216,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.19,,,,,,,fee schedule,0.15,0.19,
Non-sterile gauze<=16 sq in,A6216,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.15,,,,,,,fee schedule,0.15,0.19,
Non-sterile gauze<=16 sq in,A6216,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.17,,,,,,,fee schedule,0.15,0.19,
Non-sterile gauze<=16 sq in,A6216,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.17,,,,,,,fee schedule,0.15,0.19,
Gauze <= 16 sq in w/border,A6219,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.78,,,,,,,fee schedule,3.03,3.78,
Gauze <= 16 sq in w/border,A6219,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.03,,,,,,,fee schedule,3.03,3.78,
Gauze <= 16 sq in w/border,A6219,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.31,,,,,,,fee schedule,3.03,3.78,
Gauze <= 16 sq in w/border,A6219,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.48,,,,,,,fee schedule,3.03,3.78,
Gauze >16 <=48 sq in w/bordr,A6220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10.24,,,,,,,fee schedule,8.21,10.24,
Gauze >16 <=48 sq in w/bordr,A6220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.21,,,,,,,fee schedule,8.21,10.24,
Gauze >16 <=48 sq in w/bordr,A6220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.97,,,,,,,fee schedule,8.21,10.24,
Gauze >16 <=48 sq in w/bordr,A6220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.43,,,,,,,fee schedule,8.21,10.24,
Gauze <=16 in no w/sal w/o b,A6222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8.47,,,,,,,fee schedule,6.79,8.47,
Gauze <=16 in no w/sal w/o b,A6222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.79,,,,,,,fee schedule,6.79,8.47,
Gauze <=16 in no w/sal w/o b,A6222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7.41,,,,,,,fee schedule,6.79,8.47,
Gauze <=16 in no w/sal w/o b,A6222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7.8,,,,,,,fee schedule,6.79,8.47,
Gauze >16<=48 no w/sal w/o b,A6223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.6,,,,,,,fee schedule,7.7,9.6,
Gauze >16<=48 no w/sal w/o b,A6223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7.7,,,,,,,fee schedule,7.7,9.6,
Gauze >16<=48 no w/sal w/o b,A6223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.41,,,,,,,fee schedule,7.7,9.6,
Gauze >16<=48 no w/sal w/o b,A6223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8.84,,,,,,,fee schedule,7.7,9.6,
Gauze > 48 in no w/sal w/o b,A6224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14.33,,,,,,,fee schedule,11.48,14.33,
Gauze > 48 in no w/sal w/o b,A6224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11.48,,,,,,,fee schedule,11.48,14.33,
Gauze > 48 in no w/sal w/o b,A6224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12.54,,,,,,,fee schedule,11.48,14.33,
Gauze > 48 in no w/sal w/o b,A6224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13.19,,,,,,,fee schedule,11.48,14.33,
Gauze >16<=48 sq in watr/sal,A6229,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14.33,,,,,,,fee schedule,11.48,14.33,
Gauze >16<=48 sq in watr/sal,A6229,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11.48,,,,,,,fee schedule,11.48,14.33,
Gauze >16<=48 sq in watr/sal,A6229,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12.54,,,,,,,fee schedule,11.48,14.33,
Gauze >16<=48 sq in watr/sal,A6229,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13.19,,,,,,,fee schedule,11.48,14.33,
Hydrogel dsg<=16 sq in,A6231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18.56,,,,,,,fee schedule,14.88,18.56,
Hydrogel dsg<=16 sq in,A6231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14.88,,,,,,,fee schedule,14.88,18.56,
Hydrogel dsg<=16 sq in,A6231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.25,,,,,,,fee schedule,14.88,18.56,
Hydrogel dsg<=16 sq in,A6231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17.09,,,,,,,fee schedule,14.88,18.56,
Hydrogel dsg>16<=48 sq in,A6232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27.29,,,,,,,fee schedule,21.88,27.29,
Hydrogel dsg>16<=48 sq in,A6232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21.88,,,,,,,fee schedule,21.88,27.29,
Hydrogel dsg>16<=48 sq in,A6232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23.9,,,,,,,fee schedule,21.88,27.29,
Hydrogel dsg>16<=48 sq in,A6232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,25.13,,,,,,,fee schedule,21.88,27.29,
Hydrogel dressing >48 sq in,A6233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,76.17,,,,,,,fee schedule,61.05,76.17,
Hydrogel dressing >48 sq in,A6233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,61.05,,,,,,,fee schedule,61.05,76.17,
Hydrogel dressing >48 sq in,A6233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66.7,,,,,,,fee schedule,61.05,76.17,
Hydrogel dressing >48 sq in,A6233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,70.12,,,,,,,fee schedule,61.05,76.17,
Hydrocolld drg <=16 w/o bdr,A6234,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,40.09,,,,,,,fee schedule,32.14,40.09,
Hydrocolld drg <=16 w/o bdr,A6234,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32.14,,,,,,,fee schedule,32.14,40.09,
Hydrocolld drg <=16 w/o bdr,A6234,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35.11,,,,,,,fee schedule,32.14,40.09,
Hydrocolld drg <=16 w/o bdr,A6234,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,36.91,,,,,,,fee schedule,32.14,40.09,
Hydrocolld drg >16<=48 w/o b,A6235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46.59,,,,,,,fee schedule,37.35,46.59,
Hydrocolld drg >16<=48 w/o b,A6235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37.35,,,,,,,fee schedule,37.35,46.59,
Hydrocolld drg >16<=48 w/o b,A6235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40.8,,,,,,,fee schedule,37.35,46.59,
Hydrocolld drg >16<=48 w/o b,A6235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42.9,,,,,,,fee schedule,37.35,46.59,
Hydrocolld drg > 48 in w/o b,A6236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,108.15,,,,,,,fee schedule,86.69,108.15,
Hydrocolld drg > 48 in w/o b,A6236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,86.69,,,,,,,fee schedule,86.69,108.15,
Hydrocolld drg > 48 in w/o b,A6236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,94.7,,,,,,,fee schedule,86.69,108.15,
Hydrocolld drg > 48 in w/o b,A6236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,99.56,,,,,,,fee schedule,86.69,108.15,
Hydrocolld drg <=16 in w/bdr,A6237,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,31.41,,,,,,,fee schedule,25.18,31.41,
Hydrocolld drg <=16 in w/bdr,A6237,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,25.18,,,,,,,fee schedule,25.18,31.41,
Hydrocolld drg <=16 in w/bdr,A6237,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,27.51,,,,,,,fee schedule,25.18,31.41,
Hydrocolld drg <=16 in w/bdr,A6237,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,28.92,,,,,,,fee schedule,25.18,31.41,
Hydrocolld drg >16<=48 w/bdr,A6238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,90.46,,,,,,,fee schedule,72.51,90.46,
Hydrocolld drg >16<=48 w/bdr,A6238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,72.51,,,,,,,fee schedule,72.51,90.46,
Hydrocolld drg >16<=48 w/bdr,A6238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,79.21,,,,,,,fee schedule,72.51,90.46,
Hydrocolld drg >16<=48 w/bdr,A6238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83.28,,,,,,,fee schedule,72.51,90.46,
Hydrocolld drg filler paste,A6240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,48.57,,,,,,,fee schedule,38.94,48.57,
Hydrocolld drg filler paste,A6240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38.94,,,,,,,fee schedule,38.94,48.57,
Hydrocolld drg filler paste,A6240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.53,,,,,,,fee schedule,38.94,48.57,
Hydrocolld drg filler paste,A6240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,44.72,,,,,,,fee schedule,38.94,48.57,
Hydrocolloid drg filler dry,A6241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10.21,,,,,,,fee schedule,8.18,10.21,
Hydrocolloid drg filler dry,A6241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.18,,,,,,,fee schedule,8.18,10.21,
Hydrocolloid drg filler dry,A6241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.94,,,,,,,fee schedule,8.18,10.21,
Hydrocolloid drg filler dry,A6241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.4,,,,,,,fee schedule,8.18,10.21,
Hydrogel drg <=16 in w/o bdr,A6242,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24.08,,,,,,,fee schedule,19.3,24.08,
Hydrogel drg <=16 in w/o bdr,A6242,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19.3,,,,,,,fee schedule,19.3,24.08,
Hydrogel drg <=16 in w/o bdr,A6242,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21.08,,,,,,,fee schedule,19.3,24.08,
Hydrogel drg <=16 in w/o bdr,A6242,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22.17,,,,,,,fee schedule,19.3,24.08,
Hydrogel drg >16<=48 w/o bdr,A6243,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,48.88,,,,,,,fee schedule,39.18,48.88,
Hydrogel drg >16<=48 w/o bdr,A6243,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39.18,,,,,,,fee schedule,39.18,48.88,
Hydrogel drg >16<=48 w/o bdr,A6243,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.8,,,,,,,fee schedule,39.18,48.88,
Hydrogel drg >16<=48 w/o bdr,A6243,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45,,,,,,,fee schedule,39.18,48.88,
Hydrogel drg >48 in w/o bdr,A6244,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,155.89,,,,,,,fee schedule,124.96,155.89,
Hydrogel drg >48 in w/o bdr,A6244,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,124.96,,,,,,,fee schedule,124.96,155.89,
Hydrogel drg >48 in w/o bdr,A6244,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,136.5,,,,,,,fee schedule,124.96,155.89,
Hydrogel drg >48 in w/o bdr,A6244,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,143.52,,,,,,,fee schedule,124.96,155.89,
Hydrogel drg <= 16 in w/bdr,A6245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,28.84,,,,,,,fee schedule,23.12,28.84,
Hydrogel drg <= 16 in w/bdr,A6245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23.12,,,,,,,fee schedule,23.12,28.84,
Hydrogel drg <= 16 in w/bdr,A6245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,25.26,,,,,,,fee schedule,23.12,28.84,
Hydrogel drg <= 16 in w/bdr,A6245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26.55,,,,,,,fee schedule,23.12,28.84,
Hydrogel drg >16<=48 in w/b,A6246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,39.39,,,,,,,fee schedule,31.57,39.39,
Hydrogel drg >16<=48 in w/b,A6246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31.57,,,,,,,fee schedule,31.57,39.39,
Hydrogel drg >16<=48 in w/b,A6246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,34.49,,,,,,,fee schedule,31.57,39.39,
Hydrogel drg >16<=48 in w/b,A6246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,36.26,,,,,,,fee schedule,31.57,39.39,
Hydrogel drg > 48 sq in w/b,A6247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,94.39,,,,,,,fee schedule,75.66,94.39,
Hydrogel drg > 48 sq in w/b,A6247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,75.66,,,,,,,fee schedule,75.66,94.39,
Hydrogel drg > 48 sq in w/b,A6247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,82.65,,,,,,,fee schedule,75.66,94.39,
Hydrogel drg > 48 sq in w/b,A6247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,86.9,,,,,,,fee schedule,75.66,94.39,
Hydrogel drsg gel filler,A6248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,64.45,,,,,,,fee schedule,51.66,64.45,
Hydrogel drsg gel filler,A6248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.66,,,,,,,fee schedule,51.66,64.45,
Hydrogel drsg gel filler,A6248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56.44,,,,,,,fee schedule,51.66,64.45,
Hydrogel drsg gel filler,A6248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59.33,,,,,,,fee schedule,51.66,64.45,
Skin seal protect moisturizr,A6250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7.59,,,,,,,fee schedule,6.08,7.59,
Skin seal protect moisturizr,A6250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.08,,,,,,,fee schedule,6.08,7.59,
Skin seal protect moisturizr,A6250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.64,,,,,,,fee schedule,6.08,7.59,
Skin seal protect moisturizr,A6250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.98,,,,,,,fee schedule,6.08,7.59,
Absorpt drg <=16 sq in w/o b,A6251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7.9,,,,,,,fee schedule,6.33,7.9,
Absorpt drg <=16 sq in w/o b,A6251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.33,,,,,,,fee schedule,6.33,7.9,
Absorpt drg <=16 sq in w/o b,A6251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.92,,,,,,,fee schedule,6.33,7.9,
Absorpt drg <=16 sq in w/o b,A6251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7.27,,,,,,,fee schedule,6.33,7.9,
Absorpt drg >16 <=48 w/o bdr,A6252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12.89,,,,,,,fee schedule,10.33,12.89,
Absorpt drg >16 <=48 w/o bdr,A6252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10.33,,,,,,,fee schedule,10.33,12.89,
Absorpt drg >16 <=48 w/o bdr,A6252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11.29,,,,,,,fee schedule,10.33,12.89,
Absorpt drg >16 <=48 w/o bdr,A6252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11.87,,,,,,,fee schedule,10.33,12.89,
Absorpt drg > 48 sq in w/o b,A6253,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,25.17,,,,,,,fee schedule,20.18,25.17,
Absorpt drg > 48 sq in w/o b,A6253,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20.18,,,,,,,fee schedule,20.18,25.17,
Absorpt drg > 48 sq in w/o b,A6253,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22.04,,,,,,,fee schedule,20.18,25.17,
Absorpt drg > 48 sq in w/o b,A6253,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23.18,,,,,,,fee schedule,20.18,25.17,
Absorpt drg <=16 sq in w/bdr,A6254,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.8,,,,,,,fee schedule,3.85,4.8,
Absorpt drg <=16 sq in w/bdr,A6254,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.85,,,,,,,fee schedule,3.85,4.8,
Absorpt drg <=16 sq in w/bdr,A6254,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.2,,,,,,,fee schedule,3.85,4.8,
Absorpt drg <=16 sq in w/bdr,A6254,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.42,,,,,,,fee schedule,3.85,4.8,
Absorpt drg >16<=48 in w/bdr,A6255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12.02,,,,,,,fee schedule,9.64,12.02,
Absorpt drg >16<=48 in w/bdr,A6255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.64,,,,,,,fee schedule,9.64,12.02,
Absorpt drg >16<=48 in w/bdr,A6255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10.53,,,,,,,fee schedule,9.64,12.02,
Absorpt drg >16<=48 in w/bdr,A6255,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11.07,,,,,,,fee schedule,9.64,12.02,
Transparent film <= 16 sq in,A6257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.17,,,,,,,fee schedule,1.74,2.17,
Transparent film <= 16 sq in,A6257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.74,,,,,,,fee schedule,1.74,2.17,
Transparent film <= 16 sq in,A6257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.9,,,,,,,fee schedule,1.74,2.17,
Transparent film <= 16 sq in,A6257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2,,,,,,,fee schedule,1.74,2.17,
Transparent film >16<=48 in,A6258,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.67,,,,,,,fee schedule,5.35,6.67,
Transparent film >16<=48 in,A6258,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.35,,,,,,,fee schedule,5.35,6.67,
Transparent film >16<=48 in,A6258,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.84,,,,,,,fee schedule,5.35,6.67,
Transparent film >16<=48 in,A6258,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.14,,,,,,,fee schedule,5.35,6.67,
Transparent film > 48 sq in,A6259,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,43.43,,,,,,,fee schedule,34.81,43.43,
Transparent film > 48 sq in,A6259,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,34.81,,,,,,,fee schedule,34.81,43.43,
Transparent film > 48 sq in,A6259,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38.03,,,,,,,fee schedule,34.81,43.43,
Transparent film > 48 sq in,A6259,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,39.99,,,,,,,fee schedule,34.81,43.43,
Impreg gauze no h20/sal/yard,A6266,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7.64,,,,,,,fee schedule,6.12,7.64,
Impreg gauze no h20/sal/yard,A6266,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.12,,,,,,,fee schedule,6.12,7.64,
Impreg gauze no h20/sal/yard,A6266,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.69,,,,,,,fee schedule,6.12,7.64,
Impreg gauze no h20/sal/yard,A6266,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7.03,,,,,,,fee schedule,6.12,7.64,
Sterile gauze <= 16 sq in,A6402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.49,,,,,,,fee schedule,0.39,0.49,
Sterile gauze <= 16 sq in,A6402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.39,,,,,,,fee schedule,0.39,0.49,
Sterile gauze <= 16 sq in,A6402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.43,,,,,,,fee schedule,0.39,0.49,
Sterile gauze <= 16 sq in,A6402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.45,,,,,,,fee schedule,0.39,0.49,
Sterile gauze>16 <= 48 sq in,A6403,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.7,,,,,,,fee schedule,1.36,1.7,
Sterile gauze>16 <= 48 sq in,A6403,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.36,,,,,,,fee schedule,1.36,1.7,
Sterile gauze>16 <= 48 sq in,A6403,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.49,,,,,,,fee schedule,1.36,1.7,
Sterile gauze>16 <= 48 sq in,A6403,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.57,,,,,,,fee schedule,1.36,1.7,
"Packing strips, non-impreg",A6407,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7.45,,,,,,,fee schedule,5.97,7.45,
"Packing strips, non-impreg",A6407,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.97,,,,,,,fee schedule,5.97,7.45,
"Packing strips, non-impreg",A6407,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.52,,,,,,,fee schedule,5.97,7.45,
"Packing strips, non-impreg",A6407,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.86,,,,,,,fee schedule,5.97,7.45,
Sterile eye pad,A6410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.55,,,,,,,fee schedule,1.24,1.55,
Sterile eye pad,A6410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.24,,,,,,,fee schedule,1.24,1.55,
Sterile eye pad,A6410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.36,,,,,,,fee schedule,1.24,1.55,
Sterile eye pad,A6410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.43,,,,,,,fee schedule,1.24,1.55,
"Pad band w>=3"" <5""/yd",A6441,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.65,,,,,,,fee schedule,2.12,2.65,
"Pad band w>=3"" <5""/yd",A6441,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.12,,,,,,,fee schedule,2.12,2.65,
"Pad band w>=3"" <5""/yd",A6441,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.32,,,,,,,fee schedule,2.12,2.65,
"Pad band w>=3"" <5""/yd",A6441,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.44,,,,,,,fee schedule,2.12,2.65,
"Conform band n/s w<3""/yd",A6442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.68,,,,,,,fee schedule,0.55,0.68,
"Conform band n/s w<3""/yd",A6442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.55,,,,,,,fee schedule,0.55,0.68,
"Conform band n/s w<3""/yd",A6442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.6,,,,,,,fee schedule,0.55,0.68,
"Conform band n/s w<3""/yd",A6442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.63,,,,,,,fee schedule,0.55,0.68,
"Conform band n/s w>=3""<5""/yd",A6443,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.13,,,,,,,fee schedule,0.91,1.13,
"Conform band n/s w>=3""<5""/yd",A6443,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.91,,,,,,,fee schedule,0.91,1.13,
"Conform band n/s w>=3""<5""/yd",A6443,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.99,,,,,,,fee schedule,0.91,1.13,
"Conform band n/s w>=3""<5""/yd",A6443,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.04,,,,,,,fee schedule,0.91,1.13,
"Conform band n/s w>=5""/yd",A6444,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.23,,,,,,,fee schedule,1.79,2.23,
"Conform band n/s w>=5""/yd",A6444,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.79,,,,,,,fee schedule,1.79,2.23,
"Conform band n/s w>=5""/yd",A6444,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.95,,,,,,,fee schedule,1.79,2.23,
"Conform band n/s w>=5""/yd",A6444,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.05,,,,,,,fee schedule,1.79,2.23,
"Conform band s w <3""/yd",A6445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.29,,,,,,,fee schedule,1.03,1.29,
"Conform band s w <3""/yd",A6445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.03,,,,,,,fee schedule,1.03,1.29,
"Conform band s w <3""/yd",A6445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.13,,,,,,,fee schedule,1.03,1.29,
"Conform band s w <3""/yd",A6445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.18,,,,,,,fee schedule,1.03,1.29,
"Conform band s w>=3"" <5""/yd",A6446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.63,,,,,,,fee schedule,1.3,1.63,
"Conform band s w>=3"" <5""/yd",A6446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.3,,,,,,,fee schedule,1.3,1.63,
"Conform band s w>=3"" <5""/yd",A6446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.42,,,,,,,fee schedule,1.3,1.63,
"Conform band s w>=3"" <5""/yd",A6446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.5,,,,,,,fee schedule,1.3,1.63,
"Conform band s w >=5""/yd",A6447,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.65,,,,,,,fee schedule,2.12,2.65,
"Conform band s w >=5""/yd",A6447,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.12,,,,,,,fee schedule,2.12,2.65,
"Conform band s w >=5""/yd",A6447,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.32,,,,,,,fee schedule,2.12,2.65,
"Conform band s w >=5""/yd",A6447,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.44,,,,,,,fee schedule,2.12,2.65,
"Lt compres band <3""/yd",A6448,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.61,,,,,,,fee schedule,3.7,4.61,
"Lt compres band <3""/yd",A6448,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.7,,,,,,,fee schedule,3.7,4.61,
"Lt compres band <3""/yd",A6448,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.04,,,,,,,fee schedule,3.7,4.61,
"Lt compres band <3""/yd",A6448,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.25,,,,,,,fee schedule,3.7,4.61,
"Lt compres band >=3"" <5""/yd",A6449,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.96,,,,,,,fee schedule,5.58,6.96,
"Lt compres band >=3"" <5""/yd",A6449,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.58,,,,,,,fee schedule,5.58,6.96,
"Lt compres band >=3"" <5""/yd",A6449,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.09,,,,,,,fee schedule,5.58,6.96,
"Lt compres band >=3"" <5""/yd",A6449,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.4,,,,,,,fee schedule,5.58,6.96,
"High compres band w>=3""<5""yd",A6452,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23.47,,,,,,,fee schedule,18.82,23.47,
"High compres band w>=3""<5""yd",A6452,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18.82,,,,,,,fee schedule,18.82,23.47,
"High compres band w>=3""<5""yd",A6452,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20.56,,,,,,,fee schedule,18.82,23.47,
"High compres band w>=3""<5""yd",A6452,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21.61,,,,,,,fee schedule,18.82,23.47,
"Self-adher band w <3""/yd",A6453,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.42,,,,,,,fee schedule,1.94,2.42,
"Self-adher band w <3""/yd",A6453,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.94,,,,,,,fee schedule,1.94,2.42,
"Self-adher band w <3""/yd",A6453,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.12,,,,,,,fee schedule,1.94,2.42,
"Self-adher band w <3""/yd",A6453,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.23,,,,,,,fee schedule,1.94,2.42,
"Self-adher band w>=3"" <5""/yd",A6454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.06,,,,,,,fee schedule,2.45,3.06,
"Self-adher band w>=3"" <5""/yd",A6454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.45,,,,,,,fee schedule,2.45,3.06,
"Self-adher band w>=3"" <5""/yd",A6454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.68,,,,,,,fee schedule,2.45,3.06,
"Self-adher band w>=3"" <5""/yd",A6454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.82,,,,,,,fee schedule,2.45,3.06,
"Self-adher band >=5""/yd",A6455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.52,,,,,,,fee schedule,4.42,5.52,
"Self-adher band >=5""/yd",A6455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.42,,,,,,,fee schedule,4.42,5.52,
"Self-adher band >=5""/yd",A6455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.83,,,,,,,fee schedule,4.42,5.52,
"Self-adher band >=5""/yd",A6455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.08,,,,,,,fee schedule,4.42,5.52,
"Zinc paste band w >=3""<5""/yd",A6456,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.07,,,,,,,fee schedule,4.06,5.07,
"Zinc paste band w >=3""<5""/yd",A6456,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.06,,,,,,,fee schedule,4.06,5.07,
"Zinc paste band w >=3""<5""/yd",A6456,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.44,,,,,,,fee schedule,4.06,5.07,
"Zinc paste band w >=3""<5""/yd",A6456,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.66,,,,,,,fee schedule,4.06,5.07,
Tubular dressing,A6457,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.54,,,,,,,fee schedule,3.64,4.54,
Tubular dressing,A6457,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.64,,,,,,,fee schedule,3.64,4.54,
Tubular dressing,A6457,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.97,,,,,,,fee schedule,3.64,4.54,
Tubular dressing,A6457,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.18,,,,,,,fee schedule,3.64,4.54,
Compression stocking bk30-40,A6531,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,171.73,,,,,,,fee schedule,61.66,171.73,
Compression stocking bk30-40,A6531,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,137.65,,,,,,,fee schedule,61.66,171.73,
Compression stocking bk30-40,A6531,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,150.37,,,,,,,fee schedule,61.66,171.73,
Compression stocking bk30-40,A6531,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,158.1,,,,,,,fee schedule,61.66,171.73,
Compression stocking bk30-40,A6531,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,64.74,,,,,,,fee schedule,61.66,171.73,APC
Compression stocking bk30-40,A6531,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,64.13,,,,,,,fee schedule,61.66,171.73,APC
Compression stocking bk30-40,A6531,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,61.66,,,,,,,fee schedule,61.66,171.73,APC
Compression stocking bk30-40,A6531,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,94.34,,,,,,,fee schedule,61.66,171.73,Radiology
Compression stocking bk30-40,A6531,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,86.32,,,,,,,fee schedule,61.66,171.73,APC
Compression stocking bk30-40,A6531,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,107.9,,,,,,,fee schedule,61.66,171.73,APC
Compression stocking bk40-50,A6532,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,241.96,,,,,,,fee schedule,86.88,241.96,
Compression stocking bk40-50,A6532,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,193.95,,,,,,,fee schedule,86.88,241.96,
Compression stocking bk40-50,A6532,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,211.87,,,,,,,fee schedule,86.88,241.96,
Compression stocking bk40-50,A6532,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,222.75,,,,,,,fee schedule,86.88,241.96,
Compression stocking bk40-50,A6532,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.22,,,,,,,fee schedule,86.88,241.96,APC
Compression stocking bk40-50,A6532,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,90.36,,,,,,,fee schedule,86.88,241.96,APC
Compression stocking bk40-50,A6532,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.88,,,,,,,fee schedule,86.88,241.96,APC
Compression stocking bk40-50,A6532,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,132.93,,,,,,,fee schedule,86.88,241.96,Radiology
Compression stocking bk40-50,A6532,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,121.63,,,,,,,fee schedule,86.88,241.96,APC
Compression stocking bk40-50,A6532,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,152.04,,,,,,,fee schedule,86.88,241.96,APC
Grad comp non-elastic BK,A6545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,348.63,,,,,,,fee schedule,121.41,348.63,
Grad comp non-elastic BK,A6545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,279.46,,,,,,,fee schedule,121.41,348.63,
Grad comp non-elastic BK,A6545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,305.28,,,,,,,fee schedule,121.41,348.63,
Grad comp non-elastic BK,A6545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,320.96,,,,,,,fee schedule,121.41,348.63,
Grad comp non-elastic BK,A6545,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,127.48,,,,,,,fee schedule,121.41,348.63,APC
Grad comp non-elastic BK,A6545,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,126.27,,,,,,,fee schedule,121.41,348.63,APC
Grad comp non-elastic BK,A6545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,121.41,,,,,,,fee schedule,121.41,348.63,APC
Grad comp non-elastic BK,A6545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,185.76,,,,,,,fee schedule,121.41,348.63,Radiology
Grad comp non-elastic BK,A6545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,169.97,,,,,,,fee schedule,121.41,348.63,APC
Grad comp non-elastic BK,A6545,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,212.47,,,,,,,fee schedule,121.41,348.63,APC
Neg pres wound ther drsg set,A6550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,93.82,,,,,,,fee schedule,75.2,93.82,
Neg pres wound ther drsg set,A6550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,75.2,,,,,,,fee schedule,75.2,93.82,
Neg pres wound ther drsg set,A6550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,82.15,,,,,,,fee schedule,75.2,93.82,
Neg pres wound ther drsg set,A6550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,86.37,,,,,,,fee schedule,75.2,93.82,
Disposable canister for pump,A7000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,32.62,,,,,,,fee schedule,26.15,32.62,
Disposable canister for pump,A7000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26.15,,,,,,,fee schedule,26.15,32.62,
Disposable canister for pump,A7000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28.57,,,,,,,fee schedule,26.15,32.62,
Disposable canister for pump,A7000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30.03,,,,,,,fee schedule,26.15,32.62,
Nondisposable pump canister,A7001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,116.58,,,,,,,fee schedule,93.45,116.58,
Nondisposable pump canister,A7001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,93.45,,,,,,,fee schedule,93.45,116.58,
Nondisposable pump canister,A7001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,102.08,,,,,,,fee schedule,93.45,116.58,
Nondisposable pump canister,A7001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,107.32,,,,,,,fee schedule,93.45,116.58,
Tubing used w suction pump,A7002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12.93,,,,,,,fee schedule,10.36,12.93,
Tubing used w suction pump,A7002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10.36,,,,,,,fee schedule,10.36,12.93,
Tubing used w suction pump,A7002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11.32,,,,,,,fee schedule,10.36,12.93,
Tubing used w suction pump,A7002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11.9,,,,,,,fee schedule,10.36,12.93,
Nebulizer administration set,A7003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10.85,,,,,,,fee schedule,8.7,10.85,
Nebulizer administration set,A7003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.7,,,,,,,fee schedule,8.7,10.85,
Nebulizer administration set,A7003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.5,,,,,,,fee schedule,8.7,10.85,
Nebulizer administration set,A7003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.99,,,,,,,fee schedule,8.7,10.85,
Disposable nebulizer sml vol,A7004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.09,,,,,,,fee schedule,4.88,6.09,
Disposable nebulizer sml vol,A7004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.88,,,,,,,fee schedule,4.88,6.09,
Disposable nebulizer sml vol,A7004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.33,,,,,,,fee schedule,4.88,6.09,
Disposable nebulizer sml vol,A7004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.6,,,,,,,fee schedule,4.88,6.09,
Nondisposable nebulizer set,A7005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,103.99,,,,,,,fee schedule,83.36,103.99,
Nondisposable nebulizer set,A7005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,83.36,,,,,,,fee schedule,83.36,103.99,
Nondisposable nebulizer set,A7005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,91.06,,,,,,,fee schedule,83.36,103.99,
Nondisposable nebulizer set,A7005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,95.73,,,,,,,fee schedule,83.36,103.99,
Filtered nebulizer admin set,A7006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37.88,,,,,,,fee schedule,30.36,37.88,
Filtered nebulizer admin set,A7006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,30.36,,,,,,,fee schedule,30.36,37.88,
Filtered nebulizer admin set,A7006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,33.17,,,,,,,fee schedule,30.36,37.88,
Filtered nebulizer admin set,A7006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,34.87,,,,,,,fee schedule,30.36,37.88,
Lg vol nebulizer disposable,A7007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17.31,,,,,,,fee schedule,13.88,17.31,
Lg vol nebulizer disposable,A7007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13.88,,,,,,,fee schedule,13.88,17.31,
Lg vol nebulizer disposable,A7007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15.16,,,,,,,fee schedule,13.88,17.31,
Lg vol nebulizer disposable,A7007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15.94,,,,,,,fee schedule,13.88,17.31,
Disposable nebulizer prefill,A7008,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37.12,,,,,,,fee schedule,29.75,37.12,
Disposable nebulizer prefill,A7008,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29.75,,,,,,,fee schedule,29.75,37.12,
Disposable nebulizer prefill,A7008,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32.5,,,,,,,fee schedule,29.75,37.12,
Disposable nebulizer prefill,A7008,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,34.17,,,,,,,fee schedule,29.75,37.12,
Nebulizer reservoir bottle,A7009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,163.52,,,,,,,fee schedule,131.08,163.52,
Nebulizer reservoir bottle,A7009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,131.08,,,,,,,fee schedule,131.08,163.52,
Nebulizer reservoir bottle,A7009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,143.19,,,,,,,fee schedule,131.08,163.52,
Nebulizer reservoir bottle,A7009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,150.54,,,,,,,fee schedule,131.08,163.52,
Disposable corrugated tubing,A7010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,79.57,,,,,,,fee schedule,63.78,79.57,
Disposable corrugated tubing,A7010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,63.78,,,,,,,fee schedule,63.78,79.57,
Disposable corrugated tubing,A7010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,69.68,,,,,,,fee schedule,63.78,79.57,
Disposable corrugated tubing,A7010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,73.25,,,,,,,fee schedule,63.78,79.57,
Nebulizer water collec devic,A7012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15.01,,,,,,,fee schedule,12.03,15.01,
Nebulizer water collec devic,A7012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12.03,,,,,,,fee schedule,12.03,15.01,
Nebulizer water collec devic,A7012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13.14,,,,,,,fee schedule,12.03,15.01,
Nebulizer water collec devic,A7012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13.82,,,,,,,fee schedule,12.03,15.01,
Disposable compressor filter,A7013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.8,,,,,,,fee schedule,2.24,2.8,
Disposable compressor filter,A7013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.24,,,,,,,fee schedule,2.24,2.8,
Disposable compressor filter,A7013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.45,,,,,,,fee schedule,2.24,2.8,
Disposable compressor filter,A7013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.58,,,,,,,fee schedule,2.24,2.8,
Compressor nondispos filter,A7014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17.8,,,,,,,fee schedule,14.27,17.8,
Compressor nondispos filter,A7014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14.27,,,,,,,fee schedule,14.27,17.8,
Compressor nondispos filter,A7014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15.59,,,,,,,fee schedule,14.27,17.8,
Compressor nondispos filter,A7014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16.39,,,,,,,fee schedule,14.27,17.8,
Aerosol mask used w nebulize,A7015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7.45,,,,,,,fee schedule,5.97,7.45,
Aerosol mask used w nebulize,A7015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.97,,,,,,,fee schedule,5.97,7.45,
Aerosol mask used w nebulize,A7015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.52,,,,,,,fee schedule,5.97,7.45,
Aerosol mask used w nebulize,A7015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.86,,,,,,,fee schedule,5.97,7.45,
Nebulizer dome & mouthpiece,A7016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27.25,,,,,,,fee schedule,21.85,27.25,
Nebulizer dome & mouthpiece,A7016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21.85,,,,,,,fee schedule,21.85,27.25,
Nebulizer dome & mouthpiece,A7016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23.87,,,,,,,fee schedule,21.85,27.25,
Nebulizer dome & mouthpiece,A7016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,25.09,,,,,,,fee schedule,21.85,27.25,
Nebulizer not used w oxygen,A7017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,532,,,,,,,fee schedule,42.63,532,
Nebulizer not used w oxygen,A7017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,53.18,,,,,,,fee schedule,42.63,532,
Nebulizer not used w oxygen,A7017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,398.98,,,,,,,fee schedule,42.63,532,
Nebulizer not used w oxygen,A7017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,426.44,,,,,,,fee schedule,42.63,532,
Nebulizer not used w oxygen,A7017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.63,,,,,,,fee schedule,42.63,532,
Nebulizer not used w oxygen,A7017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,319.82,,,,,,,fee schedule,42.63,532,
Nebulizer not used w oxygen,A7017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,465.85,,,,,,,fee schedule,42.63,532,
Nebulizer not used w oxygen,A7017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.57,,,,,,,fee schedule,42.63,532,
Nebulizer not used w oxygen,A7017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,349.37,,,,,,,fee schedule,42.63,532,
Nebulizer not used w oxygen,A7017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,489.78,,,,,,,fee schedule,42.63,532,
Nebulizer not used w oxygen,A7017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,48.96,,,,,,,fee schedule,42.63,532,
Nebulizer not used w oxygen,A7017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,367.31,,,,,,,fee schedule,42.63,532,
Water distilled w/nebulizer,A7018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.29,,,,,,,fee schedule,1.03,1.29,
Water distilled w/nebulizer,A7018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.03,,,,,,,fee schedule,1.03,1.29,
Water distilled w/nebulizer,A7018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.13,,,,,,,fee schedule,1.03,1.29,
Water distilled w/nebulizer,A7018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.18,,,,,,,fee schedule,1.03,1.29,
Replace chest compress vest,A7025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1726.29,,,,,,,fee schedule,1383.77,1726.29,
Replace chest compress vest,A7025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1383.77,,,,,,,fee schedule,1383.77,1726.29,
Replace chest compress vest,A7025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1511.64,,,,,,,fee schedule,1383.77,1726.29,
Replace chest compress vest,A7025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1589.28,,,,,,,fee schedule,1383.77,1726.29,
Replace chst cmprss sys hose,A7026,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,114.12,,,,,,,fee schedule,91.48,114.12,
Replace chst cmprss sys hose,A7026,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,91.48,,,,,,,fee schedule,91.48,114.12,
Replace chst cmprss sys hose,A7026,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,99.93,,,,,,,fee schedule,91.48,114.12,
Replace chst cmprss sys hose,A7026,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,105.06,,,,,,,fee schedule,91.48,114.12,
Combination oral/nasal mask,A7027,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,740.31,,,,,,,fee schedule,593.43,740.31,
Combination oral/nasal mask,A7027,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,593.43,,,,,,,fee schedule,593.43,740.31,
Combination oral/nasal mask,A7027,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,648.26,,,,,,,fee schedule,593.43,740.31,
Combination oral/nasal mask,A7027,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,681.56,,,,,,,fee schedule,593.43,740.31,
Repl oral cushion combo mask,A7028,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,196.64,,,,,,,fee schedule,157.62,196.64,
Repl oral cushion combo mask,A7028,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,157.62,,,,,,,fee schedule,157.62,196.64,
Repl oral cushion combo mask,A7028,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,172.19,,,,,,,fee schedule,157.62,196.64,
Repl oral cushion combo mask,A7028,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,181.03,,,,,,,fee schedule,157.62,196.64,
Repl nasal pillow comb mask,A7029,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,80.33,,,,,,,fee schedule,64.39,80.33,
Repl nasal pillow comb mask,A7029,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,64.39,,,,,,,fee schedule,64.39,80.33,
Repl nasal pillow comb mask,A7029,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,70.34,,,,,,,fee schedule,64.39,80.33,
Repl nasal pillow comb mask,A7029,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,73.95,,,,,,,fee schedule,64.39,80.33,
CPAP full face mask,A7030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,645.32,,,,,,,fee schedule,517.28,645.32,
CPAP full face mask,A7030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,517.28,,,,,,,fee schedule,517.28,645.32,
CPAP full face mask,A7030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,565.08,,,,,,,fee schedule,517.28,645.32,
CPAP full face mask,A7030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,594.11,,,,,,,fee schedule,517.28,645.32,
Replacement facemask interfa,A7031,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,238.67,,,,,,,fee schedule,191.31,238.67,
Replacement facemask interfa,A7031,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,191.31,,,,,,,fee schedule,191.31,238.67,
Replacement facemask interfa,A7031,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,208.99,,,,,,,fee schedule,191.31,238.67,
Replacement facemask interfa,A7031,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,219.73,,,,,,,fee schedule,191.31,238.67,
Replacement nasal cushion,A7032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,138.65,,,,,,,fee schedule,111.14,138.65,
Replacement nasal cushion,A7032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,111.14,,,,,,,fee schedule,111.14,138.65,
Replacement nasal cushion,A7032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,121.41,,,,,,,fee schedule,111.14,138.65,
Replacement nasal cushion,A7032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,127.65,,,,,,,fee schedule,111.14,138.65,
Replacement nasal pillows,A7033,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,97.18,,,,,,,fee schedule,77.9,97.18,
Replacement nasal pillows,A7033,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,77.9,,,,,,,fee schedule,77.9,97.18,
Replacement nasal pillows,A7033,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,85.1,,,,,,,fee schedule,77.9,97.18,
Replacement nasal pillows,A7033,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,89.47,,,,,,,fee schedule,77.9,97.18,
Nasal application device,A7034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,402.42,,,,,,,fee schedule,322.57,402.42,
Nasal application device,A7034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,322.57,,,,,,,fee schedule,322.57,402.42,
Nasal application device,A7034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,352.38,,,,,,,fee schedule,322.57,402.42,
Nasal application device,A7034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,370.48,,,,,,,fee schedule,322.57,402.42,
Pos airway press headgear,A7035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,125.19,,,,,,,fee schedule,100.35,125.19,
Pos airway press headgear,A7035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,100.35,,,,,,,fee schedule,100.35,125.19,
Pos airway press headgear,A7035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,109.63,,,,,,,fee schedule,100.35,125.19,
Pos airway press headgear,A7035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,115.26,,,,,,,fee schedule,100.35,125.19,
Pos airway press chinstrap,A7036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,53.52,,,,,,,fee schedule,42.9,53.52,
Pos airway press chinstrap,A7036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.9,,,,,,,fee schedule,42.9,53.52,
Pos airway press chinstrap,A7036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.87,,,,,,,fee schedule,42.9,53.52,
Pos airway press chinstrap,A7036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,49.28,,,,,,,fee schedule,42.9,53.52,
Pos airway pressure tubing,A7037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,138.35,,,,,,,fee schedule,110.9,138.35,
Pos airway pressure tubing,A7037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,110.9,,,,,,,fee schedule,110.9,138.35,
Pos airway pressure tubing,A7037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,121.15,,,,,,,fee schedule,110.9,138.35,
Pos airway pressure tubing,A7037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,127.37,,,,,,,fee schedule,110.9,138.35,
Pos airway pressure filter,A7038,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18.45,,,,,,,fee schedule,14.79,18.45,
Pos airway pressure filter,A7038,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14.79,,,,,,,fee schedule,14.79,18.45,
Pos airway pressure filter,A7038,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.15,,,,,,,fee schedule,14.79,18.45,
Pos airway pressure filter,A7038,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16.98,,,,,,,fee schedule,14.79,18.45,
"Filter, non disposable w pap",A7039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,44.57,,,,,,,fee schedule,35.72,44.57,
"Filter, non disposable w pap",A7039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35.72,,,,,,,fee schedule,35.72,44.57,
"Filter, non disposable w pap",A7039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39.02,,,,,,,fee schedule,35.72,44.57,
"Filter, non disposable w pap",A7039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41.03,,,,,,,fee schedule,35.72,44.57,
One way chest drain valve,A7040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,161.44,,,,,,,fee schedule,129.41,161.44,
One way chest drain valve,A7040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,129.41,,,,,,,fee schedule,129.41,161.44,
One way chest drain valve,A7040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,141.37,,,,,,,fee schedule,129.41,161.44,
One way chest drain valve,A7040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,148.63,,,,,,,fee schedule,129.41,161.44,
Water seal drain container,A7041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,303.35,,,,,,,fee schedule,243.16,303.35,
Water seal drain container,A7041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,243.16,,,,,,,fee schedule,243.16,303.35,
Water seal drain container,A7041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,265.63,,,,,,,fee schedule,243.16,303.35,
Water seal drain container,A7041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,279.27,,,,,,,fee schedule,243.16,303.35,
PAP oral interface,A7044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,413.61,,,,,,,fee schedule,331.54,413.61,
PAP oral interface,A7044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,331.54,,,,,,,fee schedule,331.54,413.61,
PAP oral interface,A7044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,362.18,,,,,,,fee schedule,331.54,413.61,
PAP oral interface,A7044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,380.78,,,,,,,fee schedule,331.54,413.61,
Repl exhalation port for PAP,A7045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.6,,,,,,,fee schedule,5.33,66.6,
Repl exhalation port for PAP,A7045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.65,,,,,,,fee schedule,5.33,66.6,
Repl exhalation port for PAP,A7045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,49.93,,,,,,,fee schedule,5.33,66.6,
Repl exhalation port for PAP,A7045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.39,,,,,,,fee schedule,5.33,66.6,
Repl exhalation port for PAP,A7045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.33,,,,,,,fee schedule,5.33,66.6,
Repl exhalation port for PAP,A7045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40.03,,,,,,,fee schedule,5.33,66.6,
Repl exhalation port for PAP,A7045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,58.32,,,,,,,fee schedule,5.33,66.6,
Repl exhalation port for PAP,A7045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.83,,,,,,,fee schedule,5.33,66.6,
Repl exhalation port for PAP,A7045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,43.73,,,,,,,fee schedule,5.33,66.6,
Repl exhalation port for PAP,A7045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,61.32,,,,,,,fee schedule,5.33,66.6,
Repl exhalation port for PAP,A7045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.12,,,,,,,fee schedule,5.33,66.6,
Repl exhalation port for PAP,A7045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45.97,,,,,,,fee schedule,5.33,66.6,
"Repl water chamber, PAP dev",A7046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.75,,,,,,,fee schedule,53.51,66.75,
"Repl water chamber, PAP dev",A7046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.51,,,,,,,fee schedule,53.51,66.75,
"Repl water chamber, PAP dev",A7046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,58.45,,,,,,,fee schedule,53.51,66.75,
"Repl water chamber, PAP dev",A7046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,61.46,,,,,,,fee schedule,53.51,66.75,
Vacuum drain bottle/tube kit,A7048,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,178.45,,,,,,,fee schedule,143.05,178.45,
Vacuum drain bottle/tube kit,A7048,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,143.05,,,,,,,fee schedule,143.05,178.45,
Vacuum drain bottle/tube kit,A7048,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,156.27,,,,,,,fee schedule,143.05,178.45,
Vacuum drain bottle/tube kit,A7048,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,164.29,,,,,,,fee schedule,143.05,178.45,
Tracheostoma valve w diaphra,A7501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,416.86,,,,,,,fee schedule,334.15,416.86,
Tracheostoma valve w diaphra,A7501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,334.15,,,,,,,fee schedule,334.15,416.86,
Tracheostoma valve w diaphra,A7501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,365.03,,,,,,,fee schedule,334.15,416.86,
Tracheostoma valve w diaphra,A7501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,383.77,,,,,,,fee schedule,334.15,416.86,
Replacement diaphragm/fplate,A7502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,198.11,,,,,,,fee schedule,158.8,198.11,
Replacement diaphragm/fplate,A7502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,158.8,,,,,,,fee schedule,158.8,198.11,
Replacement diaphragm/fplate,A7502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,173.48,,,,,,,fee schedule,158.8,198.11,
Replacement diaphragm/fplate,A7502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,182.39,,,,,,,fee schedule,158.8,198.11,
HMES filter holder or cap,A7503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,44.98,,,,,,,fee schedule,36.06,44.98,
HMES filter holder or cap,A7503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36.06,,,,,,,fee schedule,36.06,44.98,
HMES filter holder or cap,A7503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39.39,,,,,,,fee schedule,36.06,44.98,
HMES filter holder or cap,A7503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41.41,,,,,,,fee schedule,36.06,44.98,
Tracheostoma HMES filter,A7504,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.65,,,,,,,fee schedule,2.12,2.65,
Tracheostoma HMES filter,A7504,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.12,,,,,,,fee schedule,2.12,2.65,
Tracheostoma HMES filter,A7504,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.32,,,,,,,fee schedule,2.12,2.65,
Tracheostoma HMES filter,A7504,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.44,,,,,,,fee schedule,2.12,2.65,
HMES or trach valve housing,A7505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18.56,,,,,,,fee schedule,14.88,18.56,
HMES or trach valve housing,A7505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14.88,,,,,,,fee schedule,14.88,18.56,
HMES or trach valve housing,A7505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.25,,,,,,,fee schedule,14.88,18.56,
HMES or trach valve housing,A7505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17.09,,,,,,,fee schedule,14.88,18.56,
HMES/trachvalve adhesivedisk,A7506,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.32,,,,,,,fee schedule,1.06,1.32,
HMES/trachvalve adhesivedisk,A7506,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.06,,,,,,,fee schedule,1.06,1.32,
HMES/trachvalve adhesivedisk,A7506,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.16,,,,,,,fee schedule,1.06,1.32,
HMES/trachvalve adhesivedisk,A7506,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.22,,,,,,,fee schedule,1.06,1.32,
Integrated filter & holder,A7507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.87,,,,,,,fee schedule,7.91,9.87,
Integrated filter & holder,A7507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7.91,,,,,,,fee schedule,7.91,9.87,
Integrated filter & holder,A7507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.64,,,,,,,fee schedule,7.91,9.87,
Integrated filter & holder,A7507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.08,,,,,,,fee schedule,7.91,9.87,
Housing & Integrated Adhesiv,A7508,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11.38,,,,,,,fee schedule,9.12,11.38,
Housing & Integrated Adhesiv,A7508,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.12,,,,,,,fee schedule,9.12,11.38,
Housing & Integrated Adhesiv,A7508,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.96,,,,,,,fee schedule,9.12,11.38,
Housing & Integrated Adhesiv,A7508,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10.47,,,,,,,fee schedule,9.12,11.38,
Heat & moisture exchange sys,A7509,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.59,,,,,,,fee schedule,4.48,5.59,
Heat & moisture exchange sys,A7509,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.48,,,,,,,fee schedule,4.48,5.59,
Heat & moisture exchange sys,A7509,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.9,,,,,,,fee schedule,4.48,5.59,
Heat & moisture exchange sys,A7509,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.15,,,,,,,fee schedule,4.48,5.59,
Trach/laryn tube non-cuffed,A7520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,188.43,,,,,,,fee schedule,151.05,188.43,
Trach/laryn tube non-cuffed,A7520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,151.05,,,,,,,fee schedule,151.05,188.43,
Trach/laryn tube non-cuffed,A7520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,165,,,,,,,fee schedule,151.05,188.43,
Trach/laryn tube non-cuffed,A7520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,173.48,,,,,,,fee schedule,151.05,188.43,
Trach/laryn tube cuffed,A7521,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,186.73,,,,,,,fee schedule,149.68,186.73,
Trach/laryn tube cuffed,A7521,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,149.68,,,,,,,fee schedule,149.68,186.73,
Trach/laryn tube cuffed,A7521,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,163.51,,,,,,,fee schedule,149.68,186.73,
Trach/laryn tube cuffed,A7521,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,171.91,,,,,,,fee schedule,149.68,186.73,
Trach/laryn tube stainless,A7522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,179.25,,,,,,,fee schedule,143.68,179.25,
Trach/laryn tube stainless,A7522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,143.68,,,,,,,fee schedule,143.68,179.25,
Trach/laryn tube stainless,A7522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,156.96,,,,,,,fee schedule,143.68,179.25,
Trach/laryn tube stainless,A7522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,165.02,,,,,,,fee schedule,143.68,179.25,
Tracheostoma stent/stud/bttn,A7524,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,307.2,,,,,,,fee schedule,246.25,307.2,
Tracheostoma stent/stud/bttn,A7524,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,246.25,,,,,,,fee schedule,246.25,307.2,
Tracheostoma stent/stud/bttn,A7524,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,269,,,,,,,fee schedule,246.25,307.2,
Tracheostoma stent/stud/bttn,A7524,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,282.82,,,,,,,fee schedule,246.25,307.2,
Tracheostomy mask,A7525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8.2,,,,,,,fee schedule,6.58,8.2,
Tracheostomy mask,A7525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.58,,,,,,,fee schedule,6.58,8.2,
Tracheostomy mask,A7525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7.18,,,,,,,fee schedule,6.58,8.2,
Tracheostomy mask,A7525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7.55,,,,,,,fee schedule,6.58,8.2,
Tracheostomy tube collar,A7526,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13.38,,,,,,,fee schedule,10.73,13.38,
Tracheostomy tube collar,A7526,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10.73,,,,,,,fee schedule,10.73,13.38,
Tracheostomy tube collar,A7526,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11.72,,,,,,,fee schedule,10.73,13.38,
Tracheostomy tube collar,A7526,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12.32,,,,,,,fee schedule,10.73,13.38,
Trach/laryn tube plug/stop,A7527,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14.21,,,,,,,fee schedule,11.39,14.21,
Trach/laryn tube plug/stop,A7527,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11.39,,,,,,,fee schedule,11.39,14.21,
Trach/laryn tube plug/stop,A7527,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12.45,,,,,,,fee schedule,11.39,14.21,
Trach/laryn tube plug/stop,A7527,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13.08,,,,,,,fee schedule,11.39,14.21,
Soft protect helmet prefab,A8000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,608.66,,,,,,,fee schedule,48.78,608.66,
Soft protect helmet prefab,A8000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.86,,,,,,,fee schedule,48.78,608.66,
Soft protect helmet prefab,A8000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,456.55,,,,,,,fee schedule,48.78,608.66,
Soft protect helmet prefab,A8000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,487.89,,,,,,,fee schedule,48.78,608.66,
Soft protect helmet prefab,A8000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48.78,,,,,,,fee schedule,48.78,608.66,
Soft protect helmet prefab,A8000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,365.96,,,,,,,fee schedule,48.78,608.66,
Soft protect helmet prefab,A8000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,532.98,,,,,,,fee schedule,48.78,608.66,
Soft protect helmet prefab,A8000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.29,,,,,,,fee schedule,48.78,608.66,
Soft protect helmet prefab,A8000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,399.78,,,,,,,fee schedule,48.78,608.66,
Soft protect helmet prefab,A8000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,560.35,,,,,,,fee schedule,48.78,608.66,
Soft protect helmet prefab,A8000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,56.03,,,,,,,fee schedule,48.78,608.66,
Soft protect helmet prefab,A8000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,420.31,,,,,,,fee schedule,48.78,608.66,
Hard protect helmet prefab,A8001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,608.66,,,,,,,fee schedule,48.78,608.66,
Hard protect helmet prefab,A8001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.86,,,,,,,fee schedule,48.78,608.66,
Hard protect helmet prefab,A8001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,456.55,,,,,,,fee schedule,48.78,608.66,
Hard protect helmet prefab,A8001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,487.89,,,,,,,fee schedule,48.78,608.66,
Hard protect helmet prefab,A8001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48.78,,,,,,,fee schedule,48.78,608.66,
Hard protect helmet prefab,A8001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,365.96,,,,,,,fee schedule,48.78,608.66,
Hard protect helmet prefab,A8001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,532.98,,,,,,,fee schedule,48.78,608.66,
Hard protect helmet prefab,A8001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.29,,,,,,,fee schedule,48.78,608.66,
Hard protect helmet prefab,A8001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,399.78,,,,,,,fee schedule,48.78,608.66,
Hard protect helmet prefab,A8001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,560.35,,,,,,,fee schedule,48.78,608.66,
Hard protect helmet prefab,A8001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,56.03,,,,,,,fee schedule,48.78,608.66,
Hard protect helmet prefab,A8001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,420.31,,,,,,,fee schedule,48.78,608.66,
Tc99m sestamibi,A9500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,711.92,,,,,,,fee schedule,644.33,711.92,
Tc99m sestamibi,A9500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,644.33,,,,,,,fee schedule,644.33,711.92,
Tc99m tetrofosmin,A9502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,153.59,,,,,,,fee schedule,139.01,153.59,
Tc99m tetrofosmin,A9502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,139.01,,,,,,,fee schedule,139.01,153.59,
Tc99m medronate,A9503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.64,,,,,,,fee schedule,54.88,60.64,
Tc99m medronate,A9503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,54.88,,,,,,,fee schedule,54.88,60.64,
Tl201 thallium,A9505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,211.31,,,,,,,fee schedule,191.25,211.31,
Tl201 thallium,A9505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,191.25,,,,,,,fee schedule,191.25,211.31,
Tc99m pertechnetate,A9512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.81,,,,,,,fee schedule,2.55,2.81,
Tc99m pertechnetate,A9512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.55,,,,,,,fee schedule,2.55,2.81,
Lutetium lu 177 dotatat ther,A9513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,951.62,,,,,,,fee schedule,319.94,1419.48,
Lutetium lu 177 dotatat ther,A9513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,762.8,,,,,,,fee schedule,319.94,1419.48,
Lutetium lu 177 dotatat ther,A9513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,833.29,,,,,,,fee schedule,319.94,1419.48,
Lutetium lu 177 dotatat ther,A9513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,876.09,,,,,,,fee schedule,319.94,1419.48,
Lutetium lu 177 dotatat ther,A9513,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1419.48,,,,,,,fee schedule,319.94,1419.48,APC 378
Lutetium lu 177 dotatat ther,A9513,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,335.94,,,,,,,fee schedule,319.94,1419.48,APC
Lutetium lu 177 dotatat ther,A9513,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,332.74,,,,,,,fee schedule,319.94,1419.48,APC
Lutetium lu 177 dotatat ther,A9513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,319.94,,,,,,,fee schedule,319.94,1419.48,APC
Lutetium lu 177 dotatat ther,A9513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,489.51,,,,,,,fee schedule,319.94,1419.48,Radiology
Lutetium lu 177 dotatat ther,A9513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,447.92,,,,,,,fee schedule,319.94,1419.48,APC
Lutetium lu 177 dotatat ther,A9513,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,559.9,,,,,,,fee schedule,319.94,1419.48,APC
Choline c-11,A9515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21546,,,,,,,fee schedule,2516.43,21546,
Choline c-11,A9515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9006,,,,,,,fee schedule,2516.43,21546,
Choline c-11,A9515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17271,,,,,,,fee schedule,2516.43,21546,
Choline c-11,A9515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18867,,,,,,,fee schedule,2516.43,21546,
Choline c-11,A9515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8151,,,,,,,fee schedule,2516.43,21546,
Choline c-11,A9515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19836,,,,,,,fee schedule,2516.43,21546,
Choline c-11,A9515,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11164.55,,,,,,,fee schedule,2516.43,21546,APC 378
Choline c-11,A9515,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2642.25,,,,,,,fee schedule,2516.43,21546,APC
Choline c-11,A9515,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2617.09,,,,,,,fee schedule,2516.43,21546,APC
Choline c-11,A9515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2516.43,,,,,,,fee schedule,2516.43,21546,APC
Choline c-11,A9515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3850.14,,,,,,,fee schedule,2516.43,21546,Radiology
Choline c-11,A9515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3523,,,,,,,fee schedule,2516.43,21546,APC
Choline c-11,A9515,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4403.75,,,,,,,fee schedule,2516.43,21546,APC
Iodine I-123 sod iodide mic,A9516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,205.43,,,,,,,fee schedule,185.93,205.43,
Iodine I-123 sod iodide mic,A9516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,185.93,,,,,,,fee schedule,185.93,205.43,
"I131 iodide cap, rx",A9517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11.65,,,,,,,fee schedule,9.34,106.79,
"I131 iodide cap, rx",A9517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,31.57,,,,,,,fee schedule,9.34,106.79,
"I131 iodide cap, rx",A9517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.34,,,,,,,fee schedule,9.34,106.79,
"I131 iodide cap, rx",A9517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10.21,,,,,,,fee schedule,9.34,106.79,
"I131 iodide cap, rx",A9517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28.57,,,,,,,fee schedule,9.34,106.79,
"I131 iodide cap, rx",A9517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10.73,,,,,,,fee schedule,9.34,106.79,
"I131 iodide cap, rx",A9517,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,106.79,,,,,,,fee schedule,9.34,106.79,APC 378
"I131 iodide cap, rx",A9517,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,25.27,,,,,,,fee schedule,9.34,106.79,APC
"I131 iodide cap, rx",A9517,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,25.03,,,,,,,fee schedule,9.34,106.79,APC
"I131 iodide cap, rx",A9517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,24.07,,,,,,,fee schedule,9.34,106.79,APC
"I131 iodide cap, rx",A9517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,36.83,,,,,,,fee schedule,9.34,106.79,Radiology
"I131 iodide cap, rx",A9517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,33.7,,,,,,,fee schedule,9.34,106.79,APC
"I131 iodide cap, rx",A9517,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,42.12,,,,,,,fee schedule,9.34,106.79,APC
Tc99 tilmanocept diag 0.5mci,A9520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,907.2,,,,,,,fee schedule,727.2,5225.06,
Tc99 tilmanocept diag 0.5mci,A9520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5225.06,,,,,,,fee schedule,727.2,5225.06,
Tc99 tilmanocept diag 0.5mci,A9520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,727.2,,,,,,,fee schedule,727.2,5225.06,
Tc99 tilmanocept diag 0.5mci,A9520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,794.4,,,,,,,fee schedule,727.2,5225.06,
Tc99 tilmanocept diag 0.5mci,A9520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4729.01,,,,,,,fee schedule,727.2,5225.06,
Tc99 tilmanocept diag 0.5mci,A9520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,835.2,,,,,,,fee schedule,727.2,5225.06,
Tc99m exametazime,A9521,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3087.19,,,,,,,fee schedule,2794.11,3087.19,
Tc99m exametazime,A9521,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2794.11,,,,,,,fee schedule,2794.11,3087.19,
Iodine I-125 sodium iodide,A9527,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,113.14,,,,,,,fee schedule,38.11,1758.34,
Iodine I-125 sodium iodide,A9527,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42.11,,,,,,,fee schedule,38.11,1758.34,
Iodine I-125 sodium iodide,A9527,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,90.69,,,,,,,fee schedule,38.11,1758.34,
Iodine I-125 sodium iodide,A9527,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,99.07,,,,,,,fee schedule,38.11,1758.34,
Iodine I-125 sodium iodide,A9527,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38.11,,,,,,,fee schedule,38.11,1758.34,
Iodine I-125 sodium iodide,A9527,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,104.16,,,,,,,fee schedule,38.11,1758.34,
Iodine I-125 sodium iodide,A9527,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1758.34,,,,,,,fee schedule,38.11,1758.34,APC 378
Iodine I-125 sodium iodide,A9527,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,416.14,,,,,,,fee schedule,38.11,1758.34,APC
Iodine I-125 sodium iodide,A9527,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,412.17,,,,,,,fee schedule,38.11,1758.34,APC
Iodine I-125 sodium iodide,A9527,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,396.32,,,,,,,fee schedule,38.11,1758.34,APC
Iodine I-125 sodium iodide,A9527,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,606.37,,,,,,,fee schedule,38.11,1758.34,Radiology
Iodine I-125 sodium iodide,A9527,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,554.85,,,,,,,fee schedule,38.11,1758.34,APC
Iodine I-125 sodium iodide,A9527,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,693.56,,,,,,,fee schedule,38.11,1758.34,APC
"Iodine i-131 iodide cap, dx",A9528,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,349.18,,,,,,,fee schedule,316.03,349.18,
"Iodine i-131 iodide cap, dx",A9528,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,316.03,,,,,,,fee schedule,316.03,349.18,
"I131 iodide sol, rx",A9530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,47.48,,,,,,,fee schedule,16.99,92.15,
"I131 iodide sol, rx",A9530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18.77,,,,,,,fee schedule,16.99,92.15,
"I131 iodide sol, rx",A9530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38.06,,,,,,,fee schedule,16.99,92.15,
"I131 iodide sol, rx",A9530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,41.57,,,,,,,fee schedule,16.99,92.15,
"I131 iodide sol, rx",A9530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.99,,,,,,,fee schedule,16.99,92.15,
"I131 iodide sol, rx",A9530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,43.71,,,,,,,fee schedule,16.99,92.15,
"I131 iodide sol, rx",A9530,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,92.15,,,,,,,fee schedule,16.99,92.15,APC 378
"I131 iodide sol, rx",A9530,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.81,,,,,,,fee schedule,16.99,92.15,APC
"I131 iodide sol, rx",A9530,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,21.6,,,,,,,fee schedule,16.99,92.15,APC
"I131 iodide sol, rx",A9530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,20.77,,,,,,,fee schedule,16.99,92.15,APC
"I131 iodide sol, rx",A9530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,31.78,,,,,,,fee schedule,16.99,92.15,Radiology
"I131 iodide sol, rx",A9530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29.08,,,,,,,fee schedule,16.99,92.15,APC
"I131 iodide sol, rx",A9530,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,36.35,,,,,,,fee schedule,16.99,92.15,APC
I131 max 100uci,A9531,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.72,,,,,,,fee schedule,5.18,5.72,
I131 max 100uci,A9531,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.18,,,,,,,fee schedule,5.18,5.72,
Tc99m mebrofenin,A9537,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,179.27,,,,,,,fee schedule,162.25,179.27,
Tc99m mebrofenin,A9537,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,162.25,,,,,,,fee schedule,162.25,179.27,
Tc99m pyrophosphate,A9538,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,115.37,,,,,,,fee schedule,104.42,115.37,
Tc99m pyrophosphate,A9538,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,104.42,,,,,,,fee schedule,104.42,115.37,
Tc99m pentetate,A9539,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,56.44,,,,,,,fee schedule,51.08,56.44,
Tc99m pentetate,A9539,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.08,,,,,,,fee schedule,51.08,56.44,
Tc99m maa,A9540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,54.04,,,,,,,fee schedule,48.91,54.04,
Tc99m maa,A9540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48.91,,,,,,,fee schedule,48.91,54.04,
Tc99m sulfur colloid,A9541,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,52.28,,,,,,,fee schedule,47.32,52.28,
Tc99m sulfur colloid,A9541,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,47.32,,,,,,,fee schedule,47.32,52.28,
"Y90 ibritumomab, rx",A9543,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,38142.72,,,,,,,fee schedule,30574.72,252111.29,
"Y90 ibritumomab, rx",A9543,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,75404.25,,,,,,,fee schedule,30574.72,252111.29,
"Y90 ibritumomab, rx",A9543,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,30574.72,,,,,,,fee schedule,30574.72,252111.29,
"Y90 ibritumomab, rx",A9543,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,33400.11,,,,,,,fee schedule,30574.72,252111.29,
"Y90 ibritumomab, rx",A9543,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,68245.62,,,,,,,fee schedule,30574.72,252111.29,
"Y90 ibritumomab, rx",A9543,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,35115.52,,,,,,,fee schedule,30574.72,252111.29,
"Y90 ibritumomab, rx",A9543,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,252111.29,,,,,,,fee schedule,30574.72,252111.29,APC 378
"Y90 ibritumomab, rx",A9543,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,59665.78,,,,,,,fee schedule,30574.72,252111.29,APC
"Y90 ibritumomab, rx",A9543,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,59097.53,,,,,,,fee schedule,30574.72,252111.29,APC
"Y90 ibritumomab, rx",A9543,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,56824.55,,,,,,,fee schedule,30574.72,252111.29,APC
"Y90 ibritumomab, rx",A9543,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,86941.56,,,,,,,fee schedule,30574.72,252111.29,Radiology
"Y90 ibritumomab, rx",A9543,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,79554.37,,,,,,,fee schedule,30574.72,252111.29,APC
"Y90 ibritumomab, rx",A9543,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,99442.96,,,,,,,fee schedule,30574.72,252111.29,APC
Tc99m succimer,A9551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,200.08,,,,,,,fee schedule,181.08,2927.89,
Tc99m succimer,A9551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,181.08,,,,,,,fee schedule,181.08,2927.89,
Tc99m succimer,A9551,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2927.89,,,,,,,fee schedule,181.08,2927.89,APC 378
Tc99m succimer,A9551,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,692.93,,,,,,,fee schedule,181.08,2927.89,APC
Tc99m succimer,A9551,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,686.33,,,,,,,fee schedule,181.08,2927.89,APC
Tc99m succimer,A9551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,659.93,,,,,,,fee schedule,181.08,2927.89,APC
Tc99m succimer,A9551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1009.69,,,,,,,fee schedule,181.08,2927.89,Radiology
Tc99m succimer,A9551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,923.9,,,,,,,fee schedule,181.08,2927.89,APC
Tc99m succimer,A9551,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1154.88,,,,,,,fee schedule,181.08,2927.89,APC
F18 fdg,A9552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,375.25,,,,,,,fee schedule,339.63,375.25,
F18 fdg,A9552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,339.63,,,,,,,fee schedule,339.63,375.25,
Rb82 rubidium,A9555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8227.85,,,,,,,fee schedule,7446.73,8227.85,
Rb82 rubidium,A9555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7446.73,,,,,,,fee schedule,7446.73,8227.85,
Ga67 gallium,A9556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,243.19,,,,,,,fee schedule,220.11,243.19,
Ga67 gallium,A9556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,220.11,,,,,,,fee schedule,220.11,243.19,
Tc99m bicisate,A9557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6411.45,,,,,,,fee schedule,775.52,6411.45,
Tc99m bicisate,A9557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5802.77,,,,,,,fee schedule,775.52,6411.45,
Tc99m bicisate,A9557,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3440.72,,,,,,,fee schedule,775.52,6411.45,APC 378
Tc99m bicisate,A9557,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,814.3,,,,,,,fee schedule,775.52,6411.45,APC
Tc99m bicisate,A9557,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,806.54,,,,,,,fee schedule,775.52,6411.45,APC
Tc99m bicisate,A9557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,775.52,,,,,,,fee schedule,775.52,6411.45,APC
Tc99m bicisate,A9557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1186.55,,,,,,,fee schedule,775.52,6411.45,Radiology
Tc99m bicisate,A9557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1085.73,,,,,,,fee schedule,775.52,6411.45,APC
Tc99m bicisate,A9557,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1357.16,,,,,,,fee schedule,775.52,6411.45,APC
Tc99m labeled rbc,A9560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,168.24,,,,,,,fee schedule,152.27,168.24,
Tc99m labeled rbc,A9560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,152.27,,,,,,,fee schedule,152.27,168.24,
Tc99m mertiatide,A9562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1395.52,,,,,,,fee schedule,1263.03,1395.52,
Tc99m mertiatide,A9562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1263.03,,,,,,,fee schedule,1263.03,1395.52,
P32 na phosphate,A9563,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,214.1,,,,,,,fee schedule,171.62,1234.46,
P32 na phosphate,A9563,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,404.48,,,,,,,fee schedule,171.62,1234.46,
P32 na phosphate,A9563,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,171.62,,,,,,,fee schedule,171.62,1234.46,
P32 na phosphate,A9563,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,187.48,,,,,,,fee schedule,171.62,1234.46,
P32 na phosphate,A9563,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,366.08,,,,,,,fee schedule,171.62,1234.46,
P32 na phosphate,A9563,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,197.11,,,,,,,fee schedule,171.62,1234.46,
P32 na phosphate,A9563,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1234.46,,,,,,,fee schedule,171.62,1234.46,APC 378
P32 na phosphate,A9563,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,292.15,,,,,,,fee schedule,171.62,1234.46,APC
P32 na phosphate,A9563,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,289.37,,,,,,,fee schedule,171.62,1234.46,APC
P32 na phosphate,A9563,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,278.24,,,,,,,fee schedule,171.62,1234.46,APC
P32 na phosphate,A9563,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,425.71,,,,,,,fee schedule,171.62,1234.46,Radiology
P32 na phosphate,A9563,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,389.54,,,,,,,fee schedule,171.62,1234.46,APC
P32 na phosphate,A9563,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,486.92,,,,,,,fee schedule,171.62,1234.46,APC
P32 chromic phosphate,A9564,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,268.91,,,,,,,fee schedule,215.55,268.91,
P32 chromic phosphate,A9564,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,215.55,,,,,,,fee schedule,215.55,268.91,
P32 chromic phosphate,A9564,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,235.47,,,,,,,fee schedule,215.55,268.91,
P32 chromic phosphate,A9564,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,247.57,,,,,,,fee schedule,215.55,268.91,
Technetium TC-99m auto WBC,A9569,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3087.19,,,,,,,fee schedule,934.13,4144.42,
Technetium TC-99m auto WBC,A9569,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2794.11,,,,,,,fee schedule,934.13,4144.42,
Technetium TC-99m auto WBC,A9569,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4144.42,,,,,,,fee schedule,934.13,4144.42,APC 378
Technetium TC-99m auto WBC,A9569,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,980.84,,,,,,,fee schedule,934.13,4144.42,APC
Technetium TC-99m auto WBC,A9569,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,971.5,,,,,,,fee schedule,934.13,4144.42,APC
Technetium TC-99m auto WBC,A9569,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,934.13,,,,,,,fee schedule,934.13,4144.42,APC
Technetium TC-99m auto WBC,A9569,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1429.22,,,,,,,fee schedule,934.13,4144.42,Radiology
Technetium TC-99m auto WBC,A9569,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1307.78,,,,,,,fee schedule,934.13,4144.42,APC
Technetium TC-99m auto WBC,A9569,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1634.73,,,,,,,fee schedule,934.13,4144.42,APC
Indium In-111 auto WBC,A9570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7582.97,,,,,,,fee schedule,1103.19,7582.97,
Indium In-111 auto WBC,A9570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6863.07,,,,,,,fee schedule,1103.19,7582.97,
Indium In-111 auto WBC,A9570,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4894.48,,,,,,,fee schedule,1103.19,7582.97,APC 378
Indium In-111 auto WBC,A9570,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1158.35,,,,,,,fee schedule,1103.19,7582.97,APC
Indium In-111 auto WBC,A9570,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1147.32,,,,,,,fee schedule,1103.19,7582.97,APC
Indium In-111 auto WBC,A9570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1103.19,,,,,,,fee schedule,1103.19,7582.97,APC
Indium In-111 auto WBC,A9570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1687.88,,,,,,,fee schedule,1103.19,7582.97,Radiology
Indium In-111 auto WBC,A9570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1544.47,,,,,,,fee schedule,1103.19,7582.97,APC
Indium In-111 auto WBC,A9570,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1930.58,,,,,,,fee schedule,1103.19,7582.97,APC
Indium In-111 pentetreotide,A9572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10223.61,,,,,,,fee schedule,2000.94,10223.61,
Indium In-111 pentetreotide,A9572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9253.02,,,,,,,fee schedule,2000.94,10223.61,
Indium In-111 pentetreotide,A9572,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8877.49,,,,,,,fee schedule,2000.94,10223.61,APC 378
Indium In-111 pentetreotide,A9572,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2100.99,,,,,,,fee schedule,2000.94,10223.61,APC
Indium In-111 pentetreotide,A9572,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2080.98,,,,,,,fee schedule,2000.94,10223.61,APC
Indium In-111 pentetreotide,A9572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2000.94,,,,,,,fee schedule,2000.94,10223.61,APC
Indium In-111 pentetreotide,A9572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3061.44,,,,,,,fee schedule,2000.94,10223.61,Radiology
Indium In-111 pentetreotide,A9572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2801.32,,,,,,,fee schedule,2000.94,10223.61,APC
Indium In-111 pentetreotide,A9572,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3501.64,,,,,,,fee schedule,2000.94,10223.61,APC
"Inj, gadopiclenol, 1 ml",A9573,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20.94,,,,,,,fee schedule,18.95,20.94,
"Inj, gadopiclenol, 1 ml",A9573,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18.95,,,,,,,fee schedule,18.95,20.94,
Inj gadoterate meglumi 0.1ml,A9575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.95,,,,,,,fee schedule,0.76,0.95,
Inj gadoterate meglumi 0.1ml,A9575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.76,,,,,,,fee schedule,0.76,0.95,
Inj gadoterate meglumi 0.1ml,A9575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.83,,,,,,,fee schedule,0.76,0.95,
Inj gadoterate meglumi 0.1ml,A9575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.87,,,,,,,fee schedule,0.76,0.95,
Sodium fluoride F-18,A9580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,309.68,,,,,,,fee schedule,280.28,309.68,
Sodium fluoride F-18,A9580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,280.28,,,,,,,fee schedule,280.28,309.68,
Gadoxetate disodium inj,A9581,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,50.27,,,,,,,fee schedule,40.3,50.27,
Gadoxetate disodium inj,A9581,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40.3,,,,,,,fee schedule,40.3,50.27,
Gadoxetate disodium inj,A9581,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,44.02,,,,,,,fee schedule,40.3,50.27,
Gadoxetate disodium inj,A9581,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46.28,,,,,,,fee schedule,40.3,50.27,
Gadofosveset trisodium inj,A9583,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,44.3,,,,,,,fee schedule,35.51,44.3,
Gadofosveset trisodium inj,A9583,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35.51,,,,,,,fee schedule,35.51,44.3,
Gadofosveset trisodium inj,A9583,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38.79,,,,,,,fee schedule,35.51,44.3,
Gadofosveset trisodium inj,A9583,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,40.79,,,,,,,fee schedule,35.51,44.3,
Iodine i-123 ioflupane,A9584,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6553.61,,,,,,,fee schedule,1387.74,6553.61,
Iodine i-123 ioflupane,A9584,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4445.36,,,,,,,fee schedule,1387.74,6553.61,
Iodine i-123 ioflupane,A9584,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5253.29,,,,,,,fee schedule,1387.74,6553.61,
Iodine i-123 ioflupane,A9584,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5738.75,,,,,,,fee schedule,1387.74,6553.61,
Iodine i-123 ioflupane,A9584,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4023.33,,,,,,,fee schedule,1387.74,6553.61,
Iodine i-123 ioflupane,A9584,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6033.48,,,,,,,fee schedule,1387.74,6553.61,
Iodine i-123 ioflupane,A9584,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6156.93,,,,,,,fee schedule,1387.74,6553.61,APC 378
Iodine i-123 ioflupane,A9584,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1457.13,,,,,,,fee schedule,1387.74,6553.61,APC
Iodine i-123 ioflupane,A9584,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1443.25,,,,,,,fee schedule,1387.74,6553.61,APC
Iodine i-123 ioflupane,A9584,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1387.74,,,,,,,fee schedule,1387.74,6553.61,APC
Iodine i-123 ioflupane,A9584,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2123.24,,,,,,,fee schedule,1387.74,6553.61,Radiology
Iodine i-123 ioflupane,A9584,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1942.84,,,,,,,fee schedule,1387.74,6553.61,APC
Iodine i-123 ioflupane,A9584,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2428.54,,,,,,,fee schedule,1387.74,6553.61,APC
Gadobutrol injection,A9585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.55,,,,,,,fee schedule,1.24,11.01,
Gadobutrol injection,A9585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11.01,,,,,,,fee schedule,1.24,11.01,
Gadobutrol injection,A9585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.24,,,,,,,fee schedule,1.24,11.01,
Gadobutrol injection,A9585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.36,,,,,,,fee schedule,1.24,11.01,
Gadobutrol injection,A9585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.97,,,,,,,fee schedule,1.24,11.01,
Gadobutrol injection,A9585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.43,,,,,,,fee schedule,1.24,11.01,
Florbetapir F18,A9586,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10417.68,,,,,,,fee schedule,1825.64,10417.68,
Florbetapir F18,A9586,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5146.76,,,,,,,fee schedule,1825.64,10417.68,
Florbetapir F18,A9586,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8350.68,,,,,,,fee schedule,1825.64,10417.68,
Florbetapir F18,A9586,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9122.36,,,,,,,fee schedule,1825.64,10417.68,
Florbetapir F18,A9586,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4658.14,,,,,,,fee schedule,1825.64,10417.68,
Florbetapir F18,A9586,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9590.88,,,,,,,fee schedule,1825.64,10417.68,
Florbetapir F18,A9586,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8099.75,,,,,,,fee schedule,1825.64,10417.68,APC 378
Florbetapir F18,A9586,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1916.92,,,,,,,fee schedule,1825.64,10417.68,APC
Florbetapir F18,A9586,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1898.67,,,,,,,fee schedule,1825.64,10417.68,APC
Florbetapir F18,A9586,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1825.64,,,,,,,fee schedule,1825.64,10417.68,APC
Florbetapir F18,A9586,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2793.23,,,,,,,fee schedule,1825.64,10417.68,Radiology
Florbetapir F18,A9586,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2555.9,,,,,,,fee schedule,1825.64,10417.68,APC
Florbetapir F18,A9586,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3194.87,,,,,,,fee schedule,1825.64,10417.68,APC
Gallium ga-68,A9587,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,252.28,,,,,,,fee schedule,49.63,252.28,
Gallium ga-68,A9587,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,95.07,,,,,,,fee schedule,49.63,252.28,
Gallium ga-68,A9587,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,202.22,,,,,,,fee schedule,49.63,252.28,
Gallium ga-68,A9587,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,220.91,,,,,,,fee schedule,49.63,252.28,
Gallium ga-68,A9587,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,86.04,,,,,,,fee schedule,49.63,252.28,
Gallium ga-68,A9587,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,232.26,,,,,,,fee schedule,49.63,252.28,
Gallium ga-68,A9587,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,220.19,,,,,,,fee schedule,49.63,252.28,APC 378
Gallium ga-68,A9587,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,52.11,,,,,,,fee schedule,49.63,252.28,APC
Gallium ga-68,A9587,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,51.62,,,,,,,fee schedule,49.63,252.28,APC
Gallium ga-68,A9587,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,49.63,,,,,,,fee schedule,49.63,252.28,APC
Gallium ga-68,A9587,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,75.93,,,,,,,fee schedule,49.63,252.28,Radiology
Gallium ga-68,A9587,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,69.48,,,,,,,fee schedule,49.63,252.28,APC
Gallium ga-68,A9587,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,86.85,,,,,,,fee schedule,49.63,252.28,APC
Fluciclovine f-18,A9588,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1472.5,,,,,,,fee schedule,322.27,1472.5,
Fluciclovine f-18,A9588,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,615.49,,,,,,,fee schedule,322.27,1472.5,
Fluciclovine f-18,A9588,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1180.34,,,,,,,fee schedule,322.27,1472.5,
Fluciclovine f-18,A9588,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1289.41,,,,,,,fee schedule,322.27,1472.5,
Fluciclovine f-18,A9588,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,557.06,,,,,,,fee schedule,322.27,1472.5,
Fluciclovine f-18,A9588,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1355.63,,,,,,,fee schedule,322.27,1472.5,
Fluciclovine f-18,A9588,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1429.8,,,,,,,fee schedule,322.27,1472.5,APC 378
Fluciclovine f-18,A9588,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,338.38,,,,,,,fee schedule,322.27,1472.5,APC
Fluciclovine f-18,A9588,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,335.16,,,,,,,fee schedule,322.27,1472.5,APC
Fluciclovine f-18,A9588,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,322.27,,,,,,,fee schedule,322.27,1472.5,APC
Fluciclovine f-18,A9588,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,493.07,,,,,,,fee schedule,322.27,1472.5,Radiology
Fluciclovine f-18,A9588,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,451.18,,,,,,,fee schedule,322.27,1472.5,APC
Fluciclovine f-18,A9588,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,563.97,,,,,,,fee schedule,322.27,1472.5,APC
Insti hexaminolevulinate hcl,A9589,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4328.7,,,,,,,fee schedule,3469.83,4328.7,
Insti hexaminolevulinate hcl,A9589,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3469.83,,,,,,,fee schedule,3469.83,4328.7,
Insti hexaminolevulinate hcl,A9589,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3790.48,,,,,,,fee schedule,3469.83,4328.7,
Insti hexaminolevulinate hcl,A9589,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3985.16,,,,,,,fee schedule,3469.83,4328.7,
Iodine i-131 iobenguane 1mci,A9590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1175.81,,,,,,,fee schedule,942.51,1175.81,
Iodine i-131 iobenguane 1mci,A9590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,942.51,,,,,,,fee schedule,942.51,1175.81,
Iodine i-131 iobenguane 1mci,A9590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1029.61,,,,,,,fee schedule,942.51,1175.81,
Iodine i-131 iobenguane 1mci,A9590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1082.49,,,,,,,fee schedule,942.51,1175.81,
Fluoroestradiol f 18,A9591,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.93,,,,,,,fee schedule,2.35,2042.73,
Fluoroestradiol f 18,A9591,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1320.88,,,,,,,fee schedule,2.35,2042.73,
Fluoroestradiol f 18,A9591,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.35,,,,,,,fee schedule,2.35,2042.73,
Fluoroestradiol f 18,A9591,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.56,,,,,,,fee schedule,2.35,2042.73,
Fluoroestradiol f 18,A9591,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1195.48,,,,,,,fee schedule,2.35,2042.73,
Fluoroestradiol f 18,A9591,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.69,,,,,,,fee schedule,2.35,2042.73,
Fluoroestradiol f 18,A9591,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2042.73,,,,,,,fee schedule,2.35,2042.73,APC 378
Fluoroestradiol f 18,A9591,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,483.44,,,,,,,fee schedule,2.35,2042.73,APC
Fluoroestradiol f 18,A9591,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,478.84,,,,,,,fee schedule,2.35,2042.73,APC
Fluoroestradiol f 18,A9591,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,460.42,,,,,,,fee schedule,2.35,2042.73,APC
Fluoroestradiol f 18,A9591,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,704.44,,,,,,,fee schedule,2.35,2042.73,Radiology
Fluoroestradiol f 18,A9591,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,644.59,,,,,,,fee schedule,2.35,2042.73,APC
Fluoroestradiol f 18,A9591,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,805.74,,,,,,,fee schedule,2.35,2042.73,APC
Copper cu 64 dotatate diag,A9592,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3472.02,,,,,,,fee schedule,594.28,3472.02,
Copper cu 64 dotatate diag,A9592,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2783.12,,,,,,,fee schedule,594.28,3472.02,
Copper cu 64 dotatate diag,A9592,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3040.31,,,,,,,fee schedule,594.28,3472.02,
Copper cu 64 dotatate diag,A9592,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3196.46,,,,,,,fee schedule,594.28,3472.02,
Copper cu 64 dotatate diag,A9592,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2636.62,,,,,,,fee schedule,594.28,3472.02,APC 378
Copper cu 64 dotatate diag,A9592,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,623.99,,,,,,,fee schedule,594.28,3472.02,APC
Copper cu 64 dotatate diag,A9592,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,618.05,,,,,,,fee schedule,594.28,3472.02,APC
Copper cu 64 dotatate diag,A9592,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,594.28,,,,,,,fee schedule,594.28,3472.02,APC
Copper cu 64 dotatate diag,A9592,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,909.25,,,,,,,fee schedule,594.28,3472.02,Radiology
Copper cu 64 dotatate diag,A9592,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,831.99,,,,,,,fee schedule,594.28,3472.02,APC
Copper cu 64 dotatate diag,A9592,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1039.99,,,,,,,fee schedule,594.28,3472.02,APC
Gallium ga-68 psma-11 ucsf,A9593,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2770.21,,,,,,,fee schedule,550.13,2770.21,
Gallium ga-68 psma-11 ucsf,A9593,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2220.56,,,,,,,fee schedule,550.13,2770.21,
Gallium ga-68 psma-11 ucsf,A9593,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2425.76,,,,,,,fee schedule,550.13,2770.21,
Gallium ga-68 psma-11 ucsf,A9593,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2550.35,,,,,,,fee schedule,550.13,2770.21,
Gallium ga-68 psma-11 ucsf,A9593,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2440.74,,,,,,,fee schedule,550.13,2770.21,APC 378
Gallium ga-68 psma-11 ucsf,A9593,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,577.64,,,,,,,fee schedule,550.13,2770.21,APC
Gallium ga-68 psma-11 ucsf,A9593,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,572.14,,,,,,,fee schedule,550.13,2770.21,APC
Gallium ga-68 psma-11 ucsf,A9593,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,550.13,,,,,,,fee schedule,550.13,2770.21,APC
Gallium ga-68 psma-11 ucsf,A9593,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,841.7,,,,,,,fee schedule,550.13,2770.21,Radiology
Gallium ga-68 psma-11 ucsf,A9593,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,770.18,,,,,,,fee schedule,550.13,2770.21,APC
Gallium ga-68 psma-11 ucsf,A9593,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,962.73,,,,,,,fee schedule,550.13,2770.21,APC
"Gallium ga-68 psma-11, ucla",A9594,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2712.32,,,,,,,fee schedule,363.5,2712.32,
"Gallium ga-68 psma-11, ucla",A9594,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2174.16,,,,,,,fee schedule,363.5,2712.32,
"Gallium ga-68 psma-11, ucla",A9594,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2375.07,,,,,,,fee schedule,363.5,2712.32,
"Gallium ga-68 psma-11, ucla",A9594,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2497.06,,,,,,,fee schedule,363.5,2712.32,
"Gallium ga-68 psma-11, ucla",A9594,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1612.73,,,,,,,fee schedule,363.5,2712.32,APC 378
"Gallium ga-68 psma-11, ucla",A9594,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,381.68,,,,,,,fee schedule,363.5,2712.32,APC
"Gallium ga-68 psma-11, ucla",A9594,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,378.04,,,,,,,fee schedule,363.5,2712.32,APC
"Gallium ga-68 psma-11, ucla",A9594,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,363.5,,,,,,,fee schedule,363.5,2712.32,APC
"Gallium ga-68 psma-11, ucla",A9594,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,556.16,,,,,,,fee schedule,363.5,2712.32,Radiology
"Gallium ga-68 psma-11, ucla",A9594,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,508.9,,,,,,,fee schedule,363.5,2712.32,APC
"Gallium ga-68 psma-11, ucla",A9594,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,636.12,,,,,,,fee schedule,363.5,2712.32,APC
"Piflu f-18, dia 1 millicurie",A9595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2047.92,,,,,,,fee schedule,346.49,2047.92,
"Piflu f-18, dia 1 millicurie",A9595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,992.97,,,,,,,fee schedule,346.49,2047.92,
"Piflu f-18, dia 1 millicurie",A9595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1641.59,,,,,,,fee schedule,346.49,2047.92,
"Piflu f-18, dia 1 millicurie",A9595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1793.29,,,,,,,fee schedule,346.49,2047.92,
"Piflu f-18, dia 1 millicurie",A9595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,898.7,,,,,,,fee schedule,346.49,2047.92,
"Piflu f-18, dia 1 millicurie",A9595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1885.39,,,,,,,fee schedule,346.49,2047.92,
"Piflu f-18, dia 1 millicurie",A9595,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1537.26,,,,,,,fee schedule,346.49,2047.92,APC 378
"Piflu f-18, dia 1 millicurie",A9595,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,363.81,,,,,,,fee schedule,346.49,2047.92,APC
"Piflu f-18, dia 1 millicurie",A9595,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,360.35,,,,,,,fee schedule,346.49,2047.92,APC
"Piflu f-18, dia 1 millicurie",A9595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,346.49,,,,,,,fee schedule,346.49,2047.92,APC
"Piflu f-18, dia 1 millicurie",A9595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,530.13,,,,,,,fee schedule,346.49,2047.92,Radiology
"Piflu f-18, dia 1 millicurie",A9595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,485.09,,,,,,,fee schedule,346.49,2047.92,APC
"Piflu f-18, dia 1 millicurie",A9595,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,606.36,,,,,,,fee schedule,346.49,2047.92,APC
Gallium illuccix 1 millicure,A9596,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3766.39,,,,,,,fee schedule,478.52,3766.39,
Gallium illuccix 1 millicure,A9596,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3019.09,,,,,,,fee schedule,478.52,3766.39,
Gallium illuccix 1 millicure,A9596,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3298.08,,,,,,,fee schedule,478.52,3766.39,
Gallium illuccix 1 millicure,A9596,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3467.47,,,,,,,fee schedule,478.52,3766.39,
Gallium illuccix 1 millicure,A9596,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2123.03,,,,,,,fee schedule,478.52,3766.39,APC 378
Gallium illuccix 1 millicure,A9596,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,502.45,,,,,,,fee schedule,478.52,3766.39,APC
Gallium illuccix 1 millicure,A9596,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,497.66,,,,,,,fee schedule,478.52,3766.39,APC
Gallium illuccix 1 millicure,A9596,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,478.52,,,,,,,fee schedule,478.52,3766.39,APC
Gallium illuccix 1 millicure,A9596,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,732.14,,,,,,,fee schedule,478.52,3766.39,Radiology
Gallium illuccix 1 millicure,A9596,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,669.93,,,,,,,fee schedule,478.52,3766.39,APC
Gallium illuccix 1 millicure,A9596,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,837.41,,,,,,,fee schedule,478.52,3766.39,APC
Sr89 strontium,A9600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3823.81,,,,,,,fee schedule,2011.99,18395.89,
Sr89 strontium,A9600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2223.04,,,,,,,fee schedule,2011.99,18395.89,
Sr89 strontium,A9600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3065.12,,,,,,,fee schedule,2011.99,18395.89,
Sr89 strontium,A9600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3348.36,,,,,,,fee schedule,2011.99,18395.89,
Sr89 strontium,A9600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2011.99,,,,,,,fee schedule,2011.99,18395.89,
Sr89 strontium,A9600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3520.33,,,,,,,fee schedule,2011.99,18395.89,
Sr89 strontium,A9600,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18395.89,,,,,,,fee schedule,2011.99,18395.89,APC 378
Sr89 strontium,A9600,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4353.65,,,,,,,fee schedule,2011.99,18395.89,APC
Sr89 strontium,A9600,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4312.19,,,,,,,fee schedule,2011.99,18395.89,APC
Sr89 strontium,A9600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4146.34,,,,,,,fee schedule,2011.99,18395.89,APC
Sr89 strontium,A9600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6343.89,,,,,,,fee schedule,2011.99,18395.89,Radiology
Sr89 strontium,A9600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5804.87,,,,,,,fee schedule,2011.99,18395.89,APC
Sr89 strontium,A9600,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7256.09,,,,,,,fee schedule,2011.99,18395.89,APC
Fluorodopa f-18 diag per mci,A9602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1998.86,,,,,,,fee schedule,855.55,3795.79,
Fluorodopa f-18 diag per mci,A9602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1602.26,,,,,,,fee schedule,855.55,3795.79,
Fluorodopa f-18 diag per mci,A9602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1750.33,,,,,,,fee schedule,855.55,3795.79,
Fluorodopa f-18 diag per mci,A9602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1840.22,,,,,,,fee schedule,855.55,3795.79,
Fluorodopa f-18 diag per mci,A9602,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3795.79,,,,,,,fee schedule,855.55,3795.79,APC 378
Fluorodopa f-18 diag per mci,A9602,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,898.33,,,,,,,fee schedule,855.55,3795.79,APC
Fluorodopa f-18 diag per mci,A9602,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,889.77,,,,,,,fee schedule,855.55,3795.79,APC
Fluorodopa f-18 diag per mci,A9602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,855.55,,,,,,,fee schedule,855.55,3795.79,APC
Fluorodopa f-18 diag per mci,A9602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1308.99,,,,,,,fee schedule,855.55,3795.79,Radiology
Fluorodopa f-18 diag per mci,A9602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1197.77,,,,,,,fee schedule,855.55,3795.79,APC
Fluorodopa f-18 diag per mci,A9602,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1497.21,,,,,,,fee schedule,855.55,3795.79,APC
Sm 153 lexidronam,A9604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,29934.8,,,,,,,fee schedule,3159.8,29934.8,
Sm 153 lexidronam,A9604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21115.21,,,,,,,fee schedule,3159.8,29934.8,
Sm 153 lexidronam,A9604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23995.36,,,,,,,fee schedule,3159.8,29934.8,
Sm 153 lexidronam,A9604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26212.75,,,,,,,fee schedule,3159.8,29934.8,
Sm 153 lexidronam,A9604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19110.6,,,,,,,fee schedule,3159.8,29934.8,
Sm 153 lexidronam,A9604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27559.02,,,,,,,fee schedule,3159.8,29934.8,
Sm 153 lexidronam,A9604,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14018.96,,,,,,,fee schedule,3159.8,29934.8,APC 378
Sm 153 lexidronam,A9604,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3317.79,,,,,,,fee schedule,3159.8,29934.8,APC
Sm 153 lexidronam,A9604,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3286.19,,,,,,,fee schedule,3159.8,29934.8,APC
Sm 153 lexidronam,A9604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3159.8,,,,,,,fee schedule,3159.8,29934.8,APC
Sm 153 lexidronam,A9604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4834.49,,,,,,,fee schedule,3159.8,29934.8,Radiology
Sm 153 lexidronam,A9604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4423.72,,,,,,,fee schedule,3159.8,29934.8,APC
Sm 153 lexidronam,A9604,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5529.65,,,,,,,fee schedule,3159.8,29934.8,APC
Radium ra223 dichloride ther,A9606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,456.06,,,,,,,fee schedule,171.09,456.06,
Radium ra223 dichloride ther,A9606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,272.61,,,,,,,fee schedule,171.09,456.06,
Radium ra223 dichloride ther,A9606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,365.57,,,,,,,fee schedule,171.09,456.06,
Radium ra223 dichloride ther,A9606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,399.35,,,,,,,fee schedule,171.09,456.06,
Radium ra223 dichloride ther,A9606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,246.73,,,,,,,fee schedule,171.09,456.06,
Radium ra223 dichloride ther,A9606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,419.86,,,,,,,fee schedule,171.09,456.06,
Radium ra223 dichloride ther,A9606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.46,,,,,,,fee schedule,171.09,456.06,OP High Cost Drugs
Radium ra223 dichloride ther,A9606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,171.09,,,,,,,fee schedule,171.09,456.06,Other Pharmacy
Radium ra223 dichloride ther,A9606,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,179.64,,,,,,,fee schedule,171.09,456.06,APC
Radium ra223 dichloride ther,A9606,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,177.93,,,,,,,fee schedule,171.09,456.06,APC
Radium ra223 dichloride ther,A9606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,261.77,,,,,,,fee schedule,171.09,456.06,Radiology
Radium ra223 dichloride ther,A9606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,239.53,,,,,,,fee schedule,171.09,456.06,APC
Radium ra223 dichloride ther,A9606,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,299.41,,,,,,,fee schedule,171.09,456.06,APC
Lutetium lu 177 vipivotide,A9607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,165469.5,,,,,,,fee schedule,259.6,165469.5,
Lutetium lu 177 vipivotide,A9607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.94,,,,,,,fee schedule,259.6,165469.5,
Lutetium lu 177 vipivotide,A9607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,132638.25,,,,,,,fee schedule,259.6,165469.5,
Lutetium lu 177 vipivotide,A9607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,144895.25,,,,,,,fee schedule,259.6,165469.5,
Lutetium lu 177 vipivotide,A9607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,368.31,,,,,,,fee schedule,259.6,165469.5,
Lutetium lu 177 vipivotide,A9607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,152337,,,,,,,fee schedule,259.6,165469.5,
Lutetium lu 177 vipivotide,A9607,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1151.74,,,,,,,fee schedule,259.6,165469.5,APC 378
Lutetium lu 177 vipivotide,A9607,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,272.58,,,,,,,fee schedule,259.6,165469.5,APC
Lutetium lu 177 vipivotide,A9607,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,269.98,,,,,,,fee schedule,259.6,165469.5,APC
Lutetium lu 177 vipivotide,A9607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,259.6,,,,,,,fee schedule,259.6,165469.5,APC
Lutetium lu 177 vipivotide,A9607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,397.18,,,,,,,fee schedule,259.6,165469.5,Radiology
Lutetium lu 177 vipivotide,A9607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,363.43,,,,,,,fee schedule,259.6,165469.5,APC
Lutetium lu 177 vipivotide,A9607,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,454.29,,,,,,,fee schedule,259.6,165469.5,APC
Flotufolastat f18 diag 1 mci,A9608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2323.87,,,,,,,fee schedule,671.22,2977.97,
Flotufolastat f18 diag 1 mci,A9608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1051.98,,,,,,,fee schedule,671.22,2977.97,
Flotufolastat f18 diag 1 mci,A9608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1862.79,,,,,,,fee schedule,671.22,2977.97,
Flotufolastat f18 diag 1 mci,A9608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2034.93,,,,,,,fee schedule,671.22,2977.97,
Flotufolastat f18 diag 1 mci,A9608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,952.11,,,,,,,fee schedule,671.22,2977.97,
Flotufolastat f18 diag 1 mci,A9608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2139.44,,,,,,,fee schedule,671.22,2977.97,
Flotufolastat f18 diag 1 mci,A9608,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2977.97,,,,,,,fee schedule,671.22,2977.97,APC 378
Flotufolastat f18 diag 1 mci,A9608,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,704.78,,,,,,,fee schedule,671.22,2977.97,APC
Flotufolastat f18 diag 1 mci,A9608,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,698.07,,,,,,,fee schedule,671.22,2977.97,APC
Flotufolastat f18 diag 1 mci,A9608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,671.22,,,,,,,fee schedule,671.22,2977.97,APC
Flotufolastat f18 diag 1 mci,A9608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1026.97,,,,,,,fee schedule,671.22,2977.97,Radiology
Flotufolastat f18 diag 1 mci,A9608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,939.71,,,,,,,fee schedule,671.22,2977.97,APC
Flotufolastat f18 diag 1 mci,A9608,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1174.63,,,,,,,fee schedule,671.22,2977.97,APC
Gallium locametz 1 millicuri,A9800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22438.08,,,,,,,fee schedule,362.5,22438.08,
Gallium locametz 1 millicuri,A9800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17986.08,,,,,,,fee schedule,362.5,22438.08,
Gallium locametz 1 millicuri,A9800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19648.16,,,,,,,fee schedule,362.5,22438.08,
Gallium locametz 1 millicuri,A9800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20657.28,,,,,,,fee schedule,362.5,22438.08,
Gallium locametz 1 millicuri,A9800,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1608.29,,,,,,,fee schedule,362.5,22438.08,APC 378
Gallium locametz 1 millicuri,A9800,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,380.62,,,,,,,fee schedule,362.5,22438.08,APC
Gallium locametz 1 millicuri,A9800,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,377,,,,,,,fee schedule,362.5,22438.08,APC
Gallium locametz 1 millicuri,A9800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,362.5,,,,,,,fee schedule,362.5,22438.08,APC
Gallium locametz 1 millicuri,A9800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,554.62,,,,,,,fee schedule,362.5,22438.08,Radiology
Gallium locametz 1 millicuri,A9800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,507.5,,,,,,,fee schedule,362.5,22438.08,APC
Gallium locametz 1 millicuri,A9800,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,634.38,,,,,,,fee schedule,362.5,22438.08,APC
Enter feed supkit syr by day,B4034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22.42,,,,,,,fee schedule,17.97,22.42,
Enter feed supkit syr by day,B4034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17.97,,,,,,,fee schedule,17.97,22.42,
Enter feed supkit syr by day,B4034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19.63,,,,,,,fee schedule,17.97,22.42,
Enter feed supkit syr by day,B4034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20.64,,,,,,,fee schedule,17.97,22.42,
Enteral feed supp pump per d,B4035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42.71,,,,,,,fee schedule,34.24,42.71,
Enteral feed supp pump per d,B4035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,34.24,,,,,,,fee schedule,34.24,42.71,
Enteral feed supp pump per d,B4035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37.4,,,,,,,fee schedule,34.24,42.71,
Enteral feed supp pump per d,B4035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,39.32,,,,,,,fee schedule,34.24,42.71,
Enteral feed sup kit grav by,B4036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,29.33,,,,,,,fee schedule,23.51,29.33,
Enteral feed sup kit grav by,B4036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23.51,,,,,,,fee schedule,23.51,29.33,
Enteral feed sup kit grav by,B4036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,25.69,,,,,,,fee schedule,23.51,29.33,
Enteral feed sup kit grav by,B4036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27,,,,,,,fee schedule,23.51,29.33,
Enteral ng tubing w/ stylet,B4081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,79.23,,,,,,,fee schedule,63.51,79.23,
Enteral ng tubing w/ stylet,B4081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,63.51,,,,,,,fee schedule,63.51,79.23,
Enteral ng tubing w/ stylet,B4081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,69.38,,,,,,,fee schedule,63.51,79.23,
Enteral ng tubing w/ stylet,B4081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,72.94,,,,,,,fee schedule,63.51,79.23,
Enteral ng tubing w/o stylet,B4082,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,58.93,,,,,,,fee schedule,47.24,58.93,
Enteral ng tubing w/o stylet,B4082,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,47.24,,,,,,,fee schedule,47.24,58.93,
Enteral ng tubing w/o stylet,B4082,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.6,,,,,,,fee schedule,47.24,58.93,
Enteral ng tubing w/o stylet,B4082,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,54.25,,,,,,,fee schedule,47.24,58.93,
Enteral stomach tube levine,B4083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.03,,,,,,,fee schedule,7.24,9.03,
Enteral stomach tube levine,B4083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7.24,,,,,,,fee schedule,7.24,9.03,
Enteral stomach tube levine,B4083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7.91,,,,,,,fee schedule,7.24,9.03,
Enteral stomach tube levine,B4083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8.32,,,,,,,fee schedule,7.24,9.03,
"Gastro/jejuno tube, std",B4087,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,130.75,,,,,,,fee schedule,104.81,130.75,
"Gastro/jejuno tube, std",B4087,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,104.81,,,,,,,fee schedule,104.81,130.75,
"Gastro/jejuno tube, std",B4087,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,114.49,,,,,,,fee schedule,104.81,130.75,
"Gastro/jejuno tube, std",B4087,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,120.37,,,,,,,fee schedule,104.81,130.75,
"Gastro/jejuno tube, low-pro",B4088,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,130.75,,,,,,,fee schedule,104.81,130.75,
"Gastro/jejuno tube, low-pro",B4088,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,104.81,,,,,,,fee schedule,104.81,130.75,
"Gastro/jejuno tube, low-pro",B4088,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,114.49,,,,,,,fee schedule,104.81,130.75,
"Gastro/jejuno tube, low-pro",B4088,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,120.37,,,,,,,fee schedule,104.81,130.75,
Enzyme cartridge enteral nut,B4105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,243.86,,,,,,,fee schedule,220.71,243.86,
Enzyme cartridge enteral nut,B4105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,220.71,,,,,,,fee schedule,220.71,243.86,
EF blenderized foods,B4149,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.75,,,,,,,fee schedule,4.61,5.75,
EF blenderized foods,B4149,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.61,,,,,,,fee schedule,4.61,5.75,
EF blenderized foods,B4149,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.03,,,,,,,fee schedule,4.61,5.75,
EF blenderized foods,B4149,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.29,,,,,,,fee schedule,4.61,5.75,
Ef complet w/intact nutrient,B4150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.46,,,,,,,fee schedule,1.97,2.46,
Ef complet w/intact nutrient,B4150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.97,,,,,,,fee schedule,1.97,2.46,
Ef complet w/intact nutrient,B4150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.15,,,,,,,fee schedule,1.97,2.46,
Ef complet w/intact nutrient,B4150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.26,,,,,,,fee schedule,1.97,2.46,
Ef calorie dense>/=1.5kcal,B4152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.04,,,,,,,fee schedule,1.64,2.04,
Ef calorie dense>/=1.5kcal,B4152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.64,,,,,,,fee schedule,1.64,2.04,
Ef calorie dense>/=1.5kcal,B4152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.79,,,,,,,fee schedule,1.64,2.04,
Ef calorie dense>/=1.5kcal,B4152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.88,,,,,,,fee schedule,1.64,2.04,
Ef hydrolyzed/amino acids,B4153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.99,,,,,,,fee schedule,5.61,6.99,
Ef hydrolyzed/amino acids,B4153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.61,,,,,,,fee schedule,5.61,6.99,
Ef hydrolyzed/amino acids,B4153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.12,,,,,,,fee schedule,5.61,6.99,
Ef hydrolyzed/amino acids,B4153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.44,,,,,,,fee schedule,5.61,6.99,
Ef spec metabolic noninherit,B4154,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.46,,,,,,,fee schedule,3.58,4.46,
Ef spec metabolic noninherit,B4154,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.58,,,,,,,fee schedule,3.58,4.46,
Ef spec metabolic noninherit,B4154,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.91,,,,,,,fee schedule,3.58,4.46,
Ef spec metabolic noninherit,B4154,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.11,,,,,,,fee schedule,3.58,4.46,
Ef incomplete/modular,B4155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.48,,,,,,,fee schedule,2.79,3.48,
Ef incomplete/modular,B4155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.79,,,,,,,fee schedule,2.79,3.48,
Ef incomplete/modular,B4155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.05,,,,,,,fee schedule,2.79,3.48,
Ef incomplete/modular,B4155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.2,,,,,,,fee schedule,2.79,3.48,
Parenteral 50% dextrose solu,B4164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,70.04,,,,,,,fee schedule,56.15,70.04,
Parenteral 50% dextrose solu,B4164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56.15,,,,,,,fee schedule,56.15,70.04,
Parenteral 50% dextrose solu,B4164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,61.33,,,,,,,fee schedule,56.15,70.04,
Parenteral 50% dextrose solu,B4164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,64.48,,,,,,,fee schedule,56.15,70.04,
Parenteral sol amino acid 3.,B4168,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,102.1,,,,,,,fee schedule,81.84,102.1,
Parenteral sol amino acid 3.,B4168,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,81.84,,,,,,,fee schedule,81.84,102.1,
Parenteral sol amino acid 3.,B4168,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,89.4,,,,,,,fee schedule,81.84,102.1,
Parenteral sol amino acid 3.,B4168,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,93.99,,,,,,,fee schedule,81.84,102.1,
Parenteral sol amino acid 7-,B4176,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,197.54,,,,,,,fee schedule,158.35,197.54,
Parenteral sol amino acid 7-,B4176,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,158.35,,,,,,,fee schedule,158.35,197.54,
Parenteral sol amino acid 7-,B4176,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,172.98,,,,,,,fee schedule,158.35,197.54,
Parenteral sol amino acid 7-,B4176,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,181.86,,,,,,,fee schedule,158.35,197.54,
Parenteral sol amino acid >,B4178,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,237.16,,,,,,,fee schedule,190.1,237.16,
Parenteral sol amino acid >,B4178,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,190.1,,,,,,,fee schedule,190.1,237.16,
Parenteral sol amino acid >,B4178,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,207.67,,,,,,,fee schedule,190.1,237.16,
Parenteral sol amino acid >,B4178,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,218.34,,,,,,,fee schedule,190.1,237.16,
Parenteral sol carb > 50%,B4180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,100.51,,,,,,,fee schedule,80.57,100.51,
Parenteral sol carb > 50%,B4180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,80.57,,,,,,,fee schedule,80.57,100.51,
Parenteral sol carb > 50%,B4180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,88.01,,,,,,,fee schedule,80.57,100.51,
Parenteral sol carb > 50%,B4180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,92.53,,,,,,,fee schedule,80.57,100.51,
Parenteral sol 10 gm lipids,B4185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46.31,,,,,,,fee schedule,37.12,46.31,
Parenteral sol 10 gm lipids,B4185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37.12,,,,,,,fee schedule,37.12,46.31,
Parenteral sol 10 gm lipids,B4185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40.55,,,,,,,fee schedule,37.12,46.31,
Parenteral sol 10 gm lipids,B4185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42.63,,,,,,,fee schedule,37.12,46.31,
Parenteral sol amino acid &,B4189,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,732.56,,,,,,,fee schedule,587.21,732.56,
Parenteral sol amino acid &,B4189,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,587.21,,,,,,,fee schedule,587.21,732.56,
Parenteral sol amino acid &,B4189,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,641.48,,,,,,,fee schedule,587.21,732.56,
Parenteral sol amino acid &,B4189,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,674.42,,,,,,,fee schedule,587.21,732.56,
Parenteral sol 52-73 gm prot,B4193,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,946.66,,,,,,,fee schedule,758.83,946.66,
Parenteral sol 52-73 gm prot,B4193,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,758.83,,,,,,,fee schedule,758.83,946.66,
Parenteral sol 52-73 gm prot,B4193,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,828.96,,,,,,,fee schedule,758.83,946.66,
Parenteral sol 52-73 gm prot,B4193,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,871.53,,,,,,,fee schedule,758.83,946.66,
Parenteral sol 74-100 gm pro,B4197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1152.48,,,,,,,fee schedule,923.82,1152.48,
Parenteral sol 74-100 gm pro,B4197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,923.82,,,,,,,fee schedule,923.82,1152.48,
Parenteral sol 74-100 gm pro,B4197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1009.19,,,,,,,fee schedule,923.82,1152.48,
Parenteral sol 74-100 gm pro,B4197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1061.02,,,,,,,fee schedule,923.82,1152.48,
Parenteral sol > 100gm prote,B4199,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1316.95,,,,,,,fee schedule,1055.65,1316.95,
Parenteral sol > 100gm prote,B4199,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1055.65,,,,,,,fee schedule,1055.65,1316.95,
Parenteral sol > 100gm prote,B4199,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1153.2,,,,,,,fee schedule,1055.65,1316.95,
Parenteral sol > 100gm prote,B4199,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1212.43,,,,,,,fee schedule,1055.65,1316.95,
Parenteral nutrition additiv,B4216,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,31.83,,,,,,,fee schedule,25.51,31.83,
Parenteral nutrition additiv,B4216,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,25.51,,,,,,,fee schedule,25.51,31.83,
Parenteral nutrition additiv,B4216,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,27.87,,,,,,,fee schedule,25.51,31.83,
Parenteral nutrition additiv,B4216,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,29.3,,,,,,,fee schedule,25.51,31.83,
Parenteral supply kit premix,B4220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33,,,,,,,fee schedule,26.45,33,
Parenteral supply kit premix,B4220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26.45,,,,,,,fee schedule,26.45,33,
Parenteral supply kit premix,B4220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28.9,,,,,,,fee schedule,26.45,33,
Parenteral supply kit premix,B4220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30.38,,,,,,,fee schedule,26.45,33,
Parenteral supply kit homemi,B4222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,40.67,,,,,,,fee schedule,32.6,40.67,
Parenteral supply kit homemi,B4222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32.6,,,,,,,fee schedule,32.6,40.67,
Parenteral supply kit homemi,B4222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35.62,,,,,,,fee schedule,32.6,40.67,
Parenteral supply kit homemi,B4222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37.44,,,,,,,fee schedule,32.6,40.67,
Parenteral administration ki,B4224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,103.08,,,,,,,fee schedule,82.63,103.08,
Parenteral administration ki,B4224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,82.63,,,,,,,fee schedule,82.63,103.08,
Parenteral administration ki,B4224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,90.26,,,,,,,fee schedule,82.63,103.08,
Parenteral administration ki,B4224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,94.9,,,,,,,fee schedule,82.63,103.08,
Parenteral sol renal-amirosy,B5000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,48.99,,,,,,,fee schedule,39.27,48.99,
Parenteral sol renal-amirosy,B5000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39.27,,,,,,,fee schedule,39.27,48.99,
Parenteral sol renal-amirosy,B5000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.9,,,,,,,fee schedule,39.27,48.99,
Parenteral sol renal-amirosy,B5000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45.1,,,,,,,fee schedule,39.27,48.99,
Parenteral solution hepatic,B5100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19.16,,,,,,,fee schedule,15.36,19.16,
Parenteral solution hepatic,B5100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15.36,,,,,,,fee schedule,15.36,19.16,
Parenteral solution hepatic,B5100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.78,,,,,,,fee schedule,15.36,19.16,
Parenteral solution hepatic,B5100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17.64,,,,,,,fee schedule,15.36,19.16,
Enter nutr inf pump any type,B9002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4493.44,,,,,,,fee schedule,348.84,4493.44,
Enter nutr inf pump any type,B9002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,435.19,,,,,,,fee schedule,348.84,4493.44,
Enter nutr inf pump any type,B9002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3370.06,,,,,,,fee schedule,348.84,4493.44,
Enter nutr inf pump any type,B9002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3601.88,,,,,,,fee schedule,348.84,4493.44,
Enter nutr inf pump any type,B9002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,348.84,,,,,,,fee schedule,348.84,4493.44,
Enter nutr inf pump any type,B9002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2701.4,,,,,,,fee schedule,348.84,4493.44,
Enter nutr inf pump any type,B9002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3934.73,,,,,,,fee schedule,348.84,4493.44,
Enter nutr inf pump any type,B9002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,381.08,,,,,,,fee schedule,348.84,4493.44,
Enter nutr inf pump any type,B9002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2951.03,,,,,,,fee schedule,348.84,4493.44,
Enter nutr inf pump any type,B9002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4136.82,,,,,,,fee schedule,348.84,4493.44,
Enter nutr inf pump any type,B9002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,400.65,,,,,,,fee schedule,348.84,4493.44,
Enter nutr inf pump any type,B9002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3102.59,,,,,,,fee schedule,348.84,4493.44,
Parenteral infus pump portab,B9004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10399.2,,,,,,,fee schedule,1319.63,10399.2,
Parenteral infus pump portab,B9004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1646.27,,,,,,,fee schedule,1319.63,10399.2,
Parenteral infus pump portab,B9004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7799.35,,,,,,,fee schedule,1319.63,10399.2,
Parenteral infus pump portab,B9004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8335.86,,,,,,,fee schedule,1319.63,10399.2,
Parenteral infus pump portab,B9004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1319.63,,,,,,,fee schedule,1319.63,10399.2,
Parenteral infus pump portab,B9004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6251.86,,,,,,,fee schedule,1319.63,10399.2,
Parenteral infus pump portab,B9004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9106.17,,,,,,,fee schedule,1319.63,10399.2,
Parenteral infus pump portab,B9004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1441.57,,,,,,,fee schedule,1319.63,10399.2,
Parenteral infus pump portab,B9004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6829.59,,,,,,,fee schedule,1319.63,10399.2,
Parenteral infus pump portab,B9004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9573.86,,,,,,,fee schedule,1319.63,10399.2,
Parenteral infus pump portab,B9004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1515.61,,,,,,,fee schedule,1319.63,10399.2,
Parenteral infus pump portab,B9004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7180.35,,,,,,,fee schedule,1319.63,10399.2,
Parenteral infus pump statio,B9006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10399.2,,,,,,,fee schedule,1319.63,10399.2,
Parenteral infus pump statio,B9006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1646.27,,,,,,,fee schedule,1319.63,10399.2,
Parenteral infus pump statio,B9006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7799.35,,,,,,,fee schedule,1319.63,10399.2,
Parenteral infus pump statio,B9006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8335.86,,,,,,,fee schedule,1319.63,10399.2,
Parenteral infus pump statio,B9006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1319.63,,,,,,,fee schedule,1319.63,10399.2,
Parenteral infus pump statio,B9006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6251.86,,,,,,,fee schedule,1319.63,10399.2,
Parenteral infus pump statio,B9006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9106.17,,,,,,,fee schedule,1319.63,10399.2,
Parenteral infus pump statio,B9006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1441.57,,,,,,,fee schedule,1319.63,10399.2,
Parenteral infus pump statio,B9006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6829.59,,,,,,,fee schedule,1319.63,10399.2,
Parenteral infus pump statio,B9006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9573.86,,,,,,,fee schedule,1319.63,10399.2,
Parenteral infus pump statio,B9006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1515.61,,,,,,,fee schedule,1319.63,10399.2,
Parenteral infus pump statio,B9006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7180.35,,,,,,,fee schedule,1319.63,10399.2,
"Brachytx, non-str, Gold-198",C1716,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,511.43,,,,,,,fee schedule,409.96,2278.54,
"Brachytx, non-str, Gold-198",C1716,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,409.96,,,,,,,fee schedule,409.96,2278.54,
"Brachytx, non-str, Gold-198",C1716,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,447.84,,,,,,,fee schedule,409.96,2278.54,
"Brachytx, non-str, Gold-198",C1716,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,470.84,,,,,,,fee schedule,409.96,2278.54,
"Brachytx, non-str, Gold-198",C1716,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2278.54,,,,,,,fee schedule,409.96,2278.54,APC 378
"Brachytx, non-str, Gold-198",C1716,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,539.25,,,,,,,fee schedule,409.96,2278.54,APC
"Brachytx, non-str, Gold-198",C1716,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,534.11,,,,,,,fee schedule,409.96,2278.54,APC
"Brachytx, non-str, Gold-198",C1716,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,513.57,,,,,,,fee schedule,409.96,2278.54,APC
"Brachytx, non-str, Gold-198",C1716,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,785.76,,,,,,,fee schedule,409.96,2278.54,Radiology
"Brachytx, non-str, Gold-198",C1716,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,719,,,,,,,fee schedule,409.96,2278.54,APC
"Brachytx, non-str, Gold-198",C1716,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,898.75,,,,,,,fee schedule,409.96,2278.54,APC
"Brachytx, non-str,hdr ir-192",C1717,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,667.5,,,,,,,fee schedule,357.49,1586.06,
"Brachytx, non-str,hdr ir-192",C1717,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,535.06,,,,,,,fee schedule,357.49,1586.06,
"Brachytx, non-str,hdr ir-192",C1717,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,584.5,,,,,,,fee schedule,357.49,1586.06,
"Brachytx, non-str,hdr ir-192",C1717,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,614.52,,,,,,,fee schedule,357.49,1586.06,
"Brachytx, non-str,hdr ir-192",C1717,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1586.06,,,,,,,fee schedule,357.49,1586.06,APC 378
"Brachytx, non-str,hdr ir-192",C1717,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,375.36,,,,,,,fee schedule,357.49,1586.06,APC
"Brachytx, non-str,hdr ir-192",C1717,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,371.79,,,,,,,fee schedule,357.49,1586.06,APC
"Brachytx, non-str,hdr ir-192",C1717,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,357.49,,,,,,,fee schedule,357.49,1586.06,APC
"Brachytx, non-str,hdr ir-192",C1717,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,546.96,,,,,,,fee schedule,357.49,1586.06,Radiology
"Brachytx, non-str,hdr ir-192",C1717,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,500.49,,,,,,,fee schedule,357.49,1586.06,APC
"Brachytx, non-str,hdr ir-192",C1717,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,625.61,,,,,,,fee schedule,357.49,1586.06,APC
"Brachytx, NS, Non-HDRIr-192",C1719,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,127.88,,,,,,,fee schedule,102.5,4031.59,
"Brachytx, NS, Non-HDRIr-192",C1719,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,102.5,,,,,,,fee schedule,102.5,4031.59,
"Brachytx, NS, Non-HDRIr-192",C1719,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,111.98,,,,,,,fee schedule,102.5,4031.59,
"Brachytx, NS, Non-HDRIr-192",C1719,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,117.73,,,,,,,fee schedule,102.5,4031.59,
"Brachytx, NS, Non-HDRIr-192",C1719,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4031.59,,,,,,,fee schedule,102.5,4031.59,APC 378
"Brachytx, NS, Non-HDRIr-192",C1719,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,954.14,,,,,,,fee schedule,102.5,4031.59,APC
"Brachytx, NS, Non-HDRIr-192",C1719,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,945.05,,,,,,,fee schedule,102.5,4031.59,APC
"Brachytx, NS, Non-HDRIr-192",C1719,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,908.7,,,,,,,fee schedule,102.5,4031.59,APC
"Brachytx, NS, Non-HDRIr-192",C1719,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1390.31,,,,,,,fee schedule,102.5,4031.59,Radiology
"Brachytx, NS, Non-HDRIr-192",C1719,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1272.18,,,,,,,fee schedule,102.5,4031.59,APC
"Brachytx, NS, Non-HDRIr-192",C1719,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1590.22,,,,,,,fee schedule,102.5,4031.59,APC
"Brachytx, non-str,Yttrium-90",C2616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,62399.22,,,,,,,fee schedule,17771.01,78843.96,
"Brachytx, non-str,Yttrium-90",C2616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,50018.42,,,,,,,fee schedule,17771.01,78843.96,
"Brachytx, non-str,Yttrium-90",C2616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,54640.59,,,,,,,fee schedule,17771.01,78843.96,
"Brachytx, non-str,Yttrium-90",C2616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,57446.9,,,,,,,fee schedule,17771.01,78843.96,
"Brachytx, non-str,Yttrium-90",C2616,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,78843.96,,,,,,,fee schedule,17771.01,78843.96,APC 378
"Brachytx, non-str,Yttrium-90",C2616,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18659.56,,,,,,,fee schedule,17771.01,78843.96,APC
"Brachytx, non-str,Yttrium-90",C2616,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18481.85,,,,,,,fee schedule,17771.01,78843.96,APC
"Brachytx, non-str,Yttrium-90",C2616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17771.01,,,,,,,fee schedule,17771.01,78843.96,APC
"Brachytx, non-str,Yttrium-90",C2616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27189.65,,,,,,,fee schedule,17771.01,78843.96,Radiology
"Brachytx, non-str,Yttrium-90",C2616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24879.41,,,,,,,fee schedule,17771.01,78843.96,APC
"Brachytx, non-str,Yttrium-90",C2616,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31099.27,,,,,,,fee schedule,17771.01,78843.96,APC
"Brachytx, non-str, HA, I-125",C2634,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,455.57,,,,,,,fee schedule,174.06,772.25,
"Brachytx, non-str, HA, I-125",C2634,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,365.18,,,,,,,fee schedule,174.06,772.25,
"Brachytx, non-str, HA, I-125",C2634,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,398.92,,,,,,,fee schedule,174.06,772.25,
"Brachytx, non-str, HA, I-125",C2634,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,419.41,,,,,,,fee schedule,174.06,772.25,
"Brachytx, non-str, HA, I-125",C2634,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,772.25,,,,,,,fee schedule,174.06,772.25,APC 378
"Brachytx, non-str, HA, I-125",C2634,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,182.76,,,,,,,fee schedule,174.06,772.25,APC
"Brachytx, non-str, HA, I-125",C2634,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,181.02,,,,,,,fee schedule,174.06,772.25,APC
"Brachytx, non-str, HA, I-125",C2634,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,174.06,,,,,,,fee schedule,174.06,772.25,APC
"Brachytx, non-str, HA, I-125",C2634,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,266.31,,,,,,,fee schedule,174.06,772.25,Radiology
"Brachytx, non-str, HA, I-125",C2634,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,243.68,,,,,,,fee schedule,174.06,772.25,APC
"Brachytx, non-str, HA, I-125",C2634,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,304.6,,,,,,,fee schedule,174.06,772.25,APC
"Brachytx, non-str, HA, P-103",C2635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,97.15,,,,,,,fee schedule,77.87,473.61,
"Brachytx, non-str, HA, P-103",C2635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,77.87,,,,,,,fee schedule,77.87,473.61,
"Brachytx, non-str, HA, P-103",C2635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,85.07,,,,,,,fee schedule,77.87,473.61,
"Brachytx, non-str, HA, P-103",C2635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,89.44,,,,,,,fee schedule,77.87,473.61,
"Brachytx, non-str, HA, P-103",C2635,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,473.61,,,,,,,fee schedule,77.87,473.61,APC 378
"Brachytx, non-str, HA, P-103",C2635,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,112.09,,,,,,,fee schedule,77.87,473.61,APC
"Brachytx, non-str, HA, P-103",C2635,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,111.02,,,,,,,fee schedule,77.87,473.61,APC
"Brachytx, non-str, HA, P-103",C2635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,106.75,,,,,,,fee schedule,77.87,473.61,APC
"Brachytx, non-str, HA, P-103",C2635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,163.33,,,,,,,fee schedule,77.87,473.61,Radiology
"Brachytx, non-str, HA, P-103",C2635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,149.45,,,,,,,fee schedule,77.87,473.61,APC
"Brachytx, non-str, HA, P-103",C2635,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,186.81,,,,,,,fee schedule,77.87,473.61,APC
"Brachy linear, non-str,P-103",C2636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,70.5,,,,,,,fee schedule,56.51,396.64,
"Brachy linear, non-str,P-103",C2636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56.51,,,,,,,fee schedule,56.51,396.64,
"Brachy linear, non-str,P-103",C2636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,61.73,,,,,,,fee schedule,56.51,396.64,
"Brachy linear, non-str,P-103",C2636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,64.9,,,,,,,fee schedule,56.51,396.64,
"Brachy linear, non-str,P-103",C2636,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,396.64,,,,,,,fee schedule,56.51,396.64,APC 378
"Brachy linear, non-str,P-103",C2636,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,93.87,,,,,,,fee schedule,56.51,396.64,APC
"Brachy linear, non-str,P-103",C2636,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,92.98,,,,,,,fee schedule,56.51,396.64,APC
"Brachy linear, non-str,P-103",C2636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,89.4,,,,,,,fee schedule,56.51,396.64,APC
"Brachy linear, non-str,P-103",C2636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,136.78,,,,,,,fee schedule,56.51,396.64,Radiology
"Brachy linear, non-str,P-103",C2636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,125.16,,,,,,,fee schedule,56.51,396.64,APC
"Brachy linear, non-str,P-103",C2636,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,156.45,,,,,,,fee schedule,56.51,396.64,APC
"Brachytx, stranded, I-125",C2638,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,143.53,,,,,,,fee schedule,35.26,156.44,
"Brachytx, stranded, I-125",C2638,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,115.05,,,,,,,fee schedule,35.26,156.44,
"Brachytx, stranded, I-125",C2638,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,125.68,,,,,,,fee schedule,35.26,156.44,
"Brachytx, stranded, I-125",C2638,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,132.14,,,,,,,fee schedule,35.26,156.44,
"Brachytx, stranded, I-125",C2638,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,156.44,,,,,,,fee schedule,35.26,156.44,APC 378
"Brachytx, stranded, I-125",C2638,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,37.02,,,,,,,fee schedule,35.26,156.44,APC
"Brachytx, stranded, I-125",C2638,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,36.67,,,,,,,fee schedule,35.26,156.44,APC
"Brachytx, stranded, I-125",C2638,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,35.26,,,,,,,fee schedule,35.26,156.44,APC
"Brachytx, stranded, I-125",C2638,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,53.95,,,,,,,fee schedule,35.26,156.44,Radiology
"Brachytx, stranded, I-125",C2638,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49.36,,,,,,,fee schedule,35.26,156.44,APC
"Brachytx, stranded, I-125",C2638,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,61.7,,,,,,,fee schedule,35.26,156.44,APC
"Brachytx, non-stranded,I-125",C2639,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,134.95,,,,,,,fee schedule,36.64,162.56,
"Brachytx, non-stranded,I-125",C2639,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,108.17,,,,,,,fee schedule,36.64,162.56,
"Brachytx, non-stranded,I-125",C2639,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,118.17,,,,,,,fee schedule,36.64,162.56,
"Brachytx, non-stranded,I-125",C2639,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,124.24,,,,,,,fee schedule,36.64,162.56,
"Brachytx, non-stranded,I-125",C2639,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,162.56,,,,,,,fee schedule,36.64,162.56,APC 378
"Brachytx, non-stranded,I-125",C2639,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.47,,,,,,,fee schedule,36.64,162.56,APC
"Brachytx, non-stranded,I-125",C2639,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.11,,,,,,,fee schedule,36.64,162.56,APC
"Brachytx, non-stranded,I-125",C2639,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.64,,,,,,,fee schedule,36.64,162.56,APC
"Brachytx, non-stranded,I-125",C2639,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.06,,,,,,,fee schedule,36.64,162.56,Radiology
"Brachytx, non-stranded,I-125",C2639,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.3,,,,,,,fee schedule,36.64,162.56,APC
"Brachytx, non-stranded,I-125",C2639,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.12,,,,,,,fee schedule,36.64,162.56,APC
"Brachytx, stranded, P-103",C2640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,276.77,,,,,,,fee schedule,88.26,391.58,
"Brachytx, stranded, P-103",C2640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,221.86,,,,,,,fee schedule,88.26,391.58,
"Brachytx, stranded, P-103",C2640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,242.36,,,,,,,fee schedule,88.26,391.58,
"Brachytx, stranded, P-103",C2640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,254.81,,,,,,,fee schedule,88.26,391.58,
"Brachytx, stranded, P-103",C2640,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,391.58,,,,,,,fee schedule,88.26,391.58,APC 378
"Brachytx, stranded, P-103",C2640,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,92.67,,,,,,,fee schedule,88.26,391.58,APC
"Brachytx, stranded, P-103",C2640,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,91.79,,,,,,,fee schedule,88.26,391.58,APC
"Brachytx, stranded, P-103",C2640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,88.26,,,,,,,fee schedule,88.26,391.58,APC
"Brachytx, stranded, P-103",C2640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,135.04,,,,,,,fee schedule,88.26,391.58,Radiology
"Brachytx, stranded, P-103",C2640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,123.56,,,,,,,fee schedule,88.26,391.58,APC
"Brachytx, stranded, P-103",C2640,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,154.46,,,,,,,fee schedule,88.26,391.58,APC
"Brachytx, non-stranded,P-103",C2641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,247.4,,,,,,,fee schedule,64.48,286.08,
"Brachytx, non-stranded,P-103",C2641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,198.31,,,,,,,fee schedule,64.48,286.08,
"Brachytx, non-stranded,P-103",C2641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,216.64,,,,,,,fee schedule,64.48,286.08,
"Brachytx, non-stranded,P-103",C2641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,227.77,,,,,,,fee schedule,64.48,286.08,
"Brachytx, non-stranded,P-103",C2641,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,286.08,,,,,,,fee schedule,64.48,286.08,APC 378
"Brachytx, non-stranded,P-103",C2641,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,67.7,,,,,,,fee schedule,64.48,286.08,APC
"Brachytx, non-stranded,P-103",C2641,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,67.06,,,,,,,fee schedule,64.48,286.08,APC
"Brachytx, non-stranded,P-103",C2641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,64.48,,,,,,,fee schedule,64.48,286.08,APC
"Brachytx, non-stranded,P-103",C2641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,98.65,,,,,,,fee schedule,64.48,286.08,Radiology
"Brachytx, non-stranded,P-103",C2641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,90.27,,,,,,,fee schedule,64.48,286.08,APC
"Brachytx, non-stranded,P-103",C2641,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,112.84,,,,,,,fee schedule,64.48,286.08,APC
"Brachytx, stranded, C-131",C2642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,331.17,,,,,,,fee schedule,119.11,528.45,
"Brachytx, stranded, C-131",C2642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,265.46,,,,,,,fee schedule,119.11,528.45,
"Brachytx, stranded, C-131",C2642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,289.99,,,,,,,fee schedule,119.11,528.45,
"Brachytx, stranded, C-131",C2642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,304.88,,,,,,,fee schedule,119.11,528.45,
"Brachytx, stranded, C-131",C2642,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,528.45,,,,,,,fee schedule,119.11,528.45,APC 378
"Brachytx, stranded, C-131",C2642,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,125.07,,,,,,,fee schedule,119.11,528.45,APC
"Brachytx, stranded, C-131",C2642,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,123.87,,,,,,,fee schedule,119.11,528.45,APC
"Brachytx, stranded, C-131",C2642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,119.11,,,,,,,fee schedule,119.11,528.45,APC
"Brachytx, stranded, C-131",C2642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,182.24,,,,,,,fee schedule,119.11,528.45,Radiology
"Brachytx, stranded, C-131",C2642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,166.75,,,,,,,fee schedule,119.11,528.45,APC
"Brachytx, stranded, C-131",C2642,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,208.44,,,,,,,fee schedule,119.11,528.45,APC
"Brachytx, non-stranded,C-131",C2643,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,223.74,,,,,,,fee schedule,99.8,442.78,
"Brachytx, non-stranded,C-131",C2643,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,179.35,,,,,,,fee schedule,99.8,442.78,
"Brachytx, non-stranded,C-131",C2643,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,195.92,,,,,,,fee schedule,99.8,442.78,
"Brachytx, non-stranded,C-131",C2643,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,205.98,,,,,,,fee schedule,99.8,442.78,
"Brachytx, non-stranded,C-131",C2643,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,442.78,,,,,,,fee schedule,99.8,442.78,APC 378
"Brachytx, non-stranded,C-131",C2643,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,104.79,,,,,,,fee schedule,99.8,442.78,APC
"Brachytx, non-stranded,C-131",C2643,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,103.79,,,,,,,fee schedule,99.8,442.78,APC
"Brachytx, non-stranded,C-131",C2643,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,99.8,,,,,,,fee schedule,99.8,442.78,APC
"Brachytx, non-stranded,C-131",C2643,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,152.69,,,,,,,fee schedule,99.8,442.78,Radiology
"Brachytx, non-stranded,C-131",C2643,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,139.72,,,,,,,fee schedule,99.8,442.78,APC
"Brachytx, non-stranded,C-131",C2643,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,174.65,,,,,,,fee schedule,99.8,442.78,APC
Brachytx cesium-131 chloride,C2644,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,50.09,,,,,,,fee schedule,40.15,50.09,
Brachytx cesium-131 chloride,C2644,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40.15,,,,,,,fee schedule,40.15,50.09,
Brachytx cesium-131 chloride,C2644,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,43.86,,,,,,,fee schedule,40.15,50.09,
Brachytx cesium-131 chloride,C2644,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46.11,,,,,,,fee schedule,40.15,50.09,
"Brachytx planar, p-103",C2645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17.73,,,,,,,fee schedule,4.69,20.81,
"Brachytx planar, p-103",C2645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14.21,,,,,,,fee schedule,4.69,20.81,
"Brachytx planar, p-103",C2645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15.52,,,,,,,fee schedule,4.69,20.81,
"Brachytx planar, p-103",C2645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16.32,,,,,,,fee schedule,4.69,20.81,
"Brachytx planar, p-103",C2645,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,20.81,,,,,,,fee schedule,4.69,20.81,APC 378
"Brachytx planar, p-103",C2645,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.92,,,,,,,fee schedule,4.69,20.81,APC
"Brachytx planar, p-103",C2645,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4.88,,,,,,,fee schedule,4.69,20.81,APC
"Brachytx planar, p-103",C2645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4.69,,,,,,,fee schedule,4.69,20.81,APC
"Brachytx planar, p-103",C2645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.18,,,,,,,fee schedule,4.69,20.81,Radiology
"Brachytx planar, p-103",C2645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.57,,,,,,,fee schedule,4.69,20.81,APC
"Brachytx planar, p-103",C2645,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8.21,,,,,,,fee schedule,4.69,20.81,APC
"Brachytx, stranded, NOS",C2698,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,143.53,,,,,,,fee schedule,35.26,156.44,
"Brachytx, stranded, NOS",C2698,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,115.05,,,,,,,fee schedule,35.26,156.44,
"Brachytx, stranded, NOS",C2698,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,125.68,,,,,,,fee schedule,35.26,156.44,
"Brachytx, stranded, NOS",C2698,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,132.14,,,,,,,fee schedule,35.26,156.44,
"Brachytx, stranded, NOS",C2698,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,156.44,,,,,,,fee schedule,35.26,156.44,APC 378
"Brachytx, stranded, NOS",C2698,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,37.02,,,,,,,fee schedule,35.26,156.44,APC
"Brachytx, stranded, NOS",C2698,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,36.67,,,,,,,fee schedule,35.26,156.44,APC
"Brachytx, stranded, NOS",C2698,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,35.26,,,,,,,fee schedule,35.26,156.44,APC
"Brachytx, stranded, NOS",C2698,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,53.95,,,,,,,fee schedule,35.26,156.44,Radiology
"Brachytx, stranded, NOS",C2698,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49.36,,,,,,,fee schedule,35.26,156.44,APC
"Brachytx, stranded, NOS",C2698,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,61.7,,,,,,,fee schedule,35.26,156.44,APC
"Brachytx, non-stranded, NOS",C2699,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,70.5,,,,,,,fee schedule,36.64,162.56,
"Brachytx, non-stranded, NOS",C2699,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56.51,,,,,,,fee schedule,36.64,162.56,
"Brachytx, non-stranded, NOS",C2699,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,61.73,,,,,,,fee schedule,36.64,162.56,
"Brachytx, non-stranded, NOS",C2699,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,64.9,,,,,,,fee schedule,36.64,162.56,
"Brachytx, non-stranded, NOS",C2699,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,162.56,,,,,,,fee schedule,36.64,162.56,APC 378
"Brachytx, non-stranded, NOS",C2699,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.47,,,,,,,fee schedule,36.64,162.56,APC
"Brachytx, non-stranded, NOS",C2699,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.11,,,,,,,fee schedule,36.64,162.56,APC
"Brachytx, non-stranded, NOS",C2699,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.64,,,,,,,fee schedule,36.64,162.56,APC
"Brachytx, non-stranded, NOS",C2699,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.06,,,,,,,fee schedule,36.64,162.56,Radiology
"Brachytx, non-stranded, NOS",C2699,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.3,,,,,,,fee schedule,36.64,162.56,APC
"Brachytx, non-stranded, NOS",C2699,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.12,,,,,,,fee schedule,36.64,162.56,APC
Low cost skin substitute app,C5271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1625.85,,,,,,,fee schedule,1303.26,1625.85,
Low cost skin substitute app,C5271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1303.26,,,,,,,fee schedule,1303.26,1625.85,
Low cost skin substitute app,C5271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1423.7,,,,,,,fee schedule,1303.26,1625.85,
Low cost skin substitute app,C5271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1496.82,,,,,,,fee schedule,1303.26,1625.85,
Low cost skin substitute app,C5273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5320.05,,,,,,,fee schedule,4264.48,5320.05,
Low cost skin substitute app,C5273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4264.48,,,,,,,fee schedule,4264.48,5320.05,
Low cost skin substitute app,C5273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4658.56,,,,,,,fee schedule,4264.48,5320.05,
Low cost skin substitute app,C5273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4897.82,,,,,,,fee schedule,4264.48,5320.05,
Low cost skin substitute app,C5275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1625.85,,,,,,,fee schedule,1303.26,1625.85,
Low cost skin substitute app,C5275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1303.26,,,,,,,fee schedule,1303.26,1625.85,
Low cost skin substitute app,C5275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1423.7,,,,,,,fee schedule,1303.26,1625.85,
Low cost skin substitute app,C5275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1496.82,,,,,,,fee schedule,1303.26,1625.85,
Low cost skin substitute app,C5277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1625.85,,,,,,,fee schedule,1303.26,1625.85,
Low cost skin substitute app,C5277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1303.26,,,,,,,fee schedule,1303.26,1625.85,
Low cost skin substitute app,C5277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1423.7,,,,,,,fee schedule,1303.26,1625.85,
Low cost skin substitute app,C5277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1496.82,,,,,,,fee schedule,1303.26,1625.85,
"Hopd mntl hlt, 15-29 min",C7900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,112.19,,,,,,,fee schedule,37.09,164.57,
"Hopd mntl hlt, 15-29 min",C7900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,89.93,,,,,,,fee schedule,37.09,164.57,
"Hopd mntl hlt, 15-29 min",C7900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,98.24,,,,,,,fee schedule,37.09,164.57,
"Hopd mntl hlt, 15-29 min",C7900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,103.29,,,,,,,fee schedule,37.09,164.57,
"Hopd mntl hlt, 15-29 min",C7900,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.57,,,,,,,fee schedule,37.09,164.57,APC 378
"Hopd mntl hlt, 15-29 min",C7900,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.95,,,,,,,fee schedule,37.09,164.57,APC
"Hopd mntl hlt, 15-29 min",C7900,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.58,,,,,,,fee schedule,37.09,164.57,APC
"Hopd mntl hlt, 15-29 min",C7900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,37.09,,,,,,,fee schedule,37.09,164.57,APC
"Hopd mntl hlt, 15-29 min",C7900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.75,,,,,,,fee schedule,37.09,164.57,Radiology
"Hopd mntl hlt, 15-29 min",C7900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.93,,,,,,,fee schedule,37.09,164.57,APC
"Hopd mntl hlt, 15-29 min",C7900,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.91,,,,,,,fee schedule,37.09,164.57,APC
"Hopd mntl hlt, 30-60 min",C7901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,286.71,,,,,,,fee schedule,100.57,446.2,
"Hopd mntl hlt, 30-60 min",C7901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,229.83,,,,,,,fee schedule,100.57,446.2,
"Hopd mntl hlt, 30-60 min",C7901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,251.06,,,,,,,fee schedule,100.57,446.2,
"Hopd mntl hlt, 30-60 min",C7901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,263.96,,,,,,,fee schedule,100.57,446.2,
"Hopd mntl hlt, 30-60 min",C7901,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,446.2,,,,,,,fee schedule,100.57,446.2,APC 378
"Hopd mntl hlt, 30-60 min",C7901,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,105.6,,,,,,,fee schedule,100.57,446.2,APC
"Hopd mntl hlt, 30-60 min",C7901,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,104.59,,,,,,,fee schedule,100.57,446.2,APC
"Hopd mntl hlt, 30-60 min",C7901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,100.57,,,,,,,fee schedule,100.57,446.2,APC
"Hopd mntl hlt, 30-60 min",C7901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,153.87,,,,,,,fee schedule,100.57,446.2,Radiology
"Hopd mntl hlt, 30-60 min",C7901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,140.8,,,,,,,fee schedule,100.57,446.2,APC
"Hopd mntl hlt, 30-60 min",C7901,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,176,,,,,,,fee schedule,100.57,446.2,APC
"Hopd mntl hlt, grp",C7903,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,103.5,,,,,,,fee schedule,37.09,164.57,
"Hopd mntl hlt, grp",C7903,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,82.96,,,,,,,fee schedule,37.09,164.57,
"Hopd mntl hlt, grp",C7903,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,90.63,,,,,,,fee schedule,37.09,164.57,
"Hopd mntl hlt, grp",C7903,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,95.28,,,,,,,fee schedule,37.09,164.57,
"Hopd mntl hlt, grp",C7903,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.57,,,,,,,fee schedule,37.09,164.57,APC 378
"Hopd mntl hlt, grp",C7903,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.95,,,,,,,fee schedule,37.09,164.57,APC
"Hopd mntl hlt, grp",C7903,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.58,,,,,,,fee schedule,37.09,164.57,APC
"Hopd mntl hlt, grp",C7903,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,37.09,,,,,,,fee schedule,37.09,164.57,APC
"Hopd mntl hlt, grp",C7903,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.75,,,,,,,fee schedule,37.09,164.57,Radiology
"Hopd mntl hlt, grp",C7903,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.93,,,,,,,fee schedule,37.09,164.57,APC
"Hopd mntl hlt, grp",C7903,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.91,,,,,,,fee schedule,37.09,164.57,APC
3d anat seg imaging preop,C8001,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,565.15,,,,,,,fee schedule,127.38,565.15,APC 378
3d anat seg imaging preop,C8001,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,133.75,,,,,,,fee schedule,127.38,565.15,APC
3d anat seg imaging preop,C8001,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,132.48,,,,,,,fee schedule,127.38,565.15,APC
3d anat seg imaging preop,C8001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,127.38,,,,,,,fee schedule,127.38,565.15,APC
3d anat seg imaging preop,C8001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,194.89,,,,,,,fee schedule,127.38,565.15,Radiology
3d anat seg imaging preop,C8001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,178.33,,,,,,,fee schedule,127.38,565.15,APC
3d anat seg imaging preop,C8001,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,222.92,,,,,,,fee schedule,127.38,565.15,APC
Imp extar knee shck absrb,C8003,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,77011.17,,,,,,,fee schedule,17357.91,77011.17,APC 378
Imp extar knee shck absrb,C8003,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18225.81,,,,,,,fee schedule,17357.91,77011.17,APC
Imp extar knee shck absrb,C8003,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18052.23,,,,,,,fee schedule,17357.91,77011.17,APC
Imp extar knee shck absrb,C8003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17357.91,,,,,,,fee schedule,17357.91,77011.17,APC
Imp extar knee shck absrb,C8003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26557.6,,,,,,,fee schedule,17357.91,77011.17,Radiology
Imp extar knee shck absrb,C8003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24301.07,,,,,,,fee schedule,17357.91,77011.17,APC
Imp extar knee shck absrb,C8003,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30376.34,,,,,,,fee schedule,17357.91,77011.17,APC
Sim ang w/prs cath rad emb,C8004,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,50703.82,,,,,,,fee schedule,11428.37,50703.82,APC 378
Sim ang w/prs cath rad emb,C8004,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11999.79,,,,,,,fee schedule,11428.37,50703.82,APC
Sim ang w/prs cath rad emb,C8004,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11885.51,,,,,,,fee schedule,11428.37,50703.82,APC
Sim ang w/prs cath rad emb,C8004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11428.37,,,,,,,fee schedule,11428.37,50703.82,APC
Sim ang w/prs cath rad emb,C8004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17485.41,,,,,,,fee schedule,11428.37,50703.82,Radiology
Sim ang w/prs cath rad emb,C8004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15999.72,,,,,,,fee schedule,11428.37,50703.82,APC
Sim ang w/prs cath rad emb,C8004,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19999.65,,,,,,,fee schedule,11428.37,50703.82,APC
Inst pleu-perit shnt w pump,C8006,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,28434,,,,,,,fee schedule,6408.87,28434,APC 378
Inst pleu-perit shnt w pump,C8006,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6729.32,,,,,,,fee schedule,6408.87,28434,APC
Inst pleu-perit shnt w pump,C8006,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6665.23,,,,,,,fee schedule,6408.87,28434,APC
Inst pleu-perit shnt w pump,C8006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6408.87,,,,,,,fee schedule,6408.87,28434,APC
Inst pleu-perit shnt w pump,C8006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9805.57,,,,,,,fee schedule,6408.87,28434,Radiology
Inst pleu-perit shnt w pump,C8006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8972.42,,,,,,,fee schedule,6408.87,28434,APC
Inst pleu-perit shnt w pump,C8006,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11215.53,,,,,,,fee schedule,6408.87,28434,APC
Opn mplnt hpgls ns ary ps gn,C8007,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,135531.68,,,,,,,fee schedule,30548.12,135531.68,APC 378
Opn mplnt hpgls ns ary ps gn,C8007,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,32075.53,,,,,,,fee schedule,30548.12,135531.68,APC
Opn mplnt hpgls ns ary ps gn,C8007,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,31770.05,,,,,,,fee schedule,30548.12,135531.68,APC
Opn mplnt hpgls ns ary ps gn,C8007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,30548.12,,,,,,,fee schedule,30548.12,135531.68,APC
Opn mplnt hpgls ns ary ps gn,C8007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,46738.63,,,,,,,fee schedule,30548.12,135531.68,Radiology
Opn mplnt hpgls ns ary ps gn,C8007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,42767.37,,,,,,,fee schedule,30548.12,135531.68,APC
Opn mplnt hpgls ns ary ps gn,C8007,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,53459.21,,,,,,,fee schedule,30548.12,135531.68,APC
Opn mplnt hpgls ns ary rec,C8011,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,135531.68,,,,,,,fee schedule,30548.12,135531.68,APC 378
Opn mplnt hpgls ns ary rec,C8011,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,32075.53,,,,,,,fee schedule,30548.12,135531.68,APC
Opn mplnt hpgls ns ary rec,C8011,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,31770.05,,,,,,,fee schedule,30548.12,135531.68,APC
Opn mplnt hpgls ns ary rec,C8011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,30548.12,,,,,,,fee schedule,30548.12,135531.68,APC
Opn mplnt hpgls ns ary rec,C8011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,46738.63,,,,,,,fee schedule,30548.12,135531.68,Radiology
Opn mplnt hpgls ns ary rec,C8011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,42767.37,,,,,,,fee schedule,30548.12,135531.68,APC
Opn mplnt hpgls ns ary rec,C8011,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,53459.21,,,,,,,fee schedule,30548.12,135531.68,APC
"Mra w/cont, abd",C8900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1556.07,,,,,,,fee schedule,345.37,1556.07,
"Mra w/cont, abd",C8900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1247.33,,,,,,,fee schedule,345.37,1556.07,
"Mra w/cont, abd",C8900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1362.59,,,,,,,fee schedule,345.37,1556.07,
"Mra w/cont, abd",C8900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1432.58,,,,,,,fee schedule,345.37,1556.07,
"Mra w/cont, abd",C8900,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1532.31,,,,,,,fee schedule,345.37,1556.07,APC 378
"Mra w/cont, abd",C8900,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,362.64,,,,,,,fee schedule,345.37,1556.07,APC
"Mra w/cont, abd",C8900,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,359.19,,,,,,,fee schedule,345.37,1556.07,APC
"Mra w/cont, abd",C8900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,345.37,,,,,,,fee schedule,345.37,1556.07,APC
"Mra w/cont, abd",C8900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,528.42,,,,,,,fee schedule,345.37,1556.07,Radiology
"Mra w/cont, abd",C8900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,483.52,,,,,,,fee schedule,345.37,1556.07,APC
"Mra w/cont, abd",C8900,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,604.4,,,,,,,fee schedule,345.37,1556.07,APC
"Mra w/o cont, abd",C8901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1346.02,,,,,,,fee schedule,236.21,1346.02,
"Mra w/o cont, abd",C8901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1078.95,,,,,,,fee schedule,236.21,1346.02,
"Mra w/o cont, abd",C8901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1178.66,,,,,,,fee schedule,236.21,1346.02,
"Mra w/o cont, abd",C8901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1239.19,,,,,,,fee schedule,236.21,1346.02,
"Mra w/o cont, abd",C8901,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,236.21,1346.02,APC 378
"Mra w/o cont, abd",C8901,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,236.21,1346.02,APC
"Mra w/o cont, abd",C8901,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,236.21,1346.02,APC
"Mra w/o cont, abd",C8901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,236.21,1346.02,APC
"Mra w/o cont, abd",C8901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,236.21,1346.02,Radiology
"Mra w/o cont, abd",C8901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,236.21,1346.02,APC
"Mra w/o cont, abd",C8901,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,236.21,1346.02,APC
"Mra w/o fol w/cont, abd",C8902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2058.06,,,,,,,fee schedule,345.37,2058.06,
"Mra w/o fol w/cont, abd",C8902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1649.71,,,,,,,fee schedule,345.37,2058.06,
"Mra w/o fol w/cont, abd",C8902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1802.16,,,,,,,fee schedule,345.37,2058.06,
"Mra w/o fol w/cont, abd",C8902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1894.72,,,,,,,fee schedule,345.37,2058.06,
"Mra w/o fol w/cont, abd",C8902,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1532.31,,,,,,,fee schedule,345.37,2058.06,APC 378
"Mra w/o fol w/cont, abd",C8902,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,362.64,,,,,,,fee schedule,345.37,2058.06,APC
"Mra w/o fol w/cont, abd",C8902,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,359.19,,,,,,,fee schedule,345.37,2058.06,APC
"Mra w/o fol w/cont, abd",C8902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,345.37,,,,,,,fee schedule,345.37,2058.06,APC
"Mra w/o fol w/cont, abd",C8902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,528.42,,,,,,,fee schedule,345.37,2058.06,Radiology
"Mra w/o fol w/cont, abd",C8902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,483.52,,,,,,,fee schedule,345.37,2058.06,APC
"Mra w/o fol w/cont, abd",C8902,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,604.4,,,,,,,fee schedule,345.37,2058.06,APC
"Mri w/cont, breast,  uni",C8903,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1556.07,,,,,,,fee schedule,173.64,1556.07,
"Mri w/cont, breast,  uni",C8903,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1247.33,,,,,,,fee schedule,173.64,1556.07,
"Mri w/cont, breast,  uni",C8903,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1362.59,,,,,,,fee schedule,173.64,1556.07,
"Mri w/cont, breast,  uni",C8903,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1432.58,,,,,,,fee schedule,173.64,1556.07,
"Mri w/cont, breast,  uni",C8903,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,770.39,,,,,,,fee schedule,173.64,1556.07,APC 378
"Mri w/cont, breast,  uni",C8903,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,182.32,,,,,,,fee schedule,173.64,1556.07,APC
"Mri w/cont, breast,  uni",C8903,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,180.59,,,,,,,fee schedule,173.64,1556.07,APC
"Mri w/cont, breast,  uni",C8903,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,173.64,,,,,,,fee schedule,173.64,1556.07,APC
"Mri w/cont, breast,  uni",C8903,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,265.67,,,,,,,fee schedule,173.64,1556.07,Radiology
"Mri w/cont, breast,  uni",C8903,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,243.1,,,,,,,fee schedule,173.64,1556.07,APC
"Mri w/cont, breast,  uni",C8903,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,303.87,,,,,,,fee schedule,173.64,1556.07,APC
"Mri w/o fol w/cont, brst, un",C8905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2058.06,,,,,,,fee schedule,345.37,2058.06,
"Mri w/o fol w/cont, brst, un",C8905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1649.71,,,,,,,fee schedule,345.37,2058.06,
"Mri w/o fol w/cont, brst, un",C8905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1802.16,,,,,,,fee schedule,345.37,2058.06,
"Mri w/o fol w/cont, brst, un",C8905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1894.72,,,,,,,fee schedule,345.37,2058.06,
"Mri w/o fol w/cont, brst, un",C8905,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1532.31,,,,,,,fee schedule,345.37,2058.06,APC 378
"Mri w/o fol w/cont, brst, un",C8905,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,362.64,,,,,,,fee schedule,345.37,2058.06,APC
"Mri w/o fol w/cont, brst, un",C8905,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,359.19,,,,,,,fee schedule,345.37,2058.06,APC
"Mri w/o fol w/cont, brst, un",C8905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,345.37,,,,,,,fee schedule,345.37,2058.06,APC
"Mri w/o fol w/cont, brst, un",C8905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,528.42,,,,,,,fee schedule,345.37,2058.06,Radiology
"Mri w/o fol w/cont, brst, un",C8905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,483.52,,,,,,,fee schedule,345.37,2058.06,APC
"Mri w/o fol w/cont, brst, un",C8905,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,604.4,,,,,,,fee schedule,345.37,2058.06,APC
"Mri w/cont, breast,  bi",C8906,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1556.07,,,,,,,fee schedule,345.37,1556.07,
"Mri w/cont, breast,  bi",C8906,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1247.33,,,,,,,fee schedule,345.37,1556.07,
"Mri w/cont, breast,  bi",C8906,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1362.59,,,,,,,fee schedule,345.37,1556.07,
"Mri w/cont, breast,  bi",C8906,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1432.58,,,,,,,fee schedule,345.37,1556.07,
"Mri w/cont, breast,  bi",C8906,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1532.31,,,,,,,fee schedule,345.37,1556.07,APC 378
"Mri w/cont, breast,  bi",C8906,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,362.64,,,,,,,fee schedule,345.37,1556.07,APC
"Mri w/cont, breast,  bi",C8906,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,359.19,,,,,,,fee schedule,345.37,1556.07,APC
"Mri w/cont, breast,  bi",C8906,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,345.37,,,,,,,fee schedule,345.37,1556.07,APC
"Mri w/cont, breast,  bi",C8906,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,528.42,,,,,,,fee schedule,345.37,1556.07,Radiology
"Mri w/cont, breast,  bi",C8906,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,483.52,,,,,,,fee schedule,345.37,1556.07,APC
"Mri w/cont, breast,  bi",C8906,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,604.4,,,,,,,fee schedule,345.37,1556.07,APC
"Mri w/o fol w/cont, breast,",C8908,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2058.06,,,,,,,fee schedule,345.37,2058.06,
"Mri w/o fol w/cont, breast,",C8908,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1649.71,,,,,,,fee schedule,345.37,2058.06,
"Mri w/o fol w/cont, breast,",C8908,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1802.16,,,,,,,fee schedule,345.37,2058.06,
"Mri w/o fol w/cont, breast,",C8908,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1894.72,,,,,,,fee schedule,345.37,2058.06,
"Mri w/o fol w/cont, breast,",C8908,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1532.31,,,,,,,fee schedule,345.37,2058.06,APC 378
"Mri w/o fol w/cont, breast,",C8908,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,362.64,,,,,,,fee schedule,345.37,2058.06,APC
"Mri w/o fol w/cont, breast,",C8908,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,359.19,,,,,,,fee schedule,345.37,2058.06,APC
"Mri w/o fol w/cont, breast,",C8908,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,345.37,,,,,,,fee schedule,345.37,2058.06,APC
"Mri w/o fol w/cont, breast,",C8908,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,528.42,,,,,,,fee schedule,345.37,2058.06,Radiology
"Mri w/o fol w/cont, breast,",C8908,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,483.52,,,,,,,fee schedule,345.37,2058.06,APC
"Mri w/o fol w/cont, breast,",C8908,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,604.4,,,,,,,fee schedule,345.37,2058.06,APC
"MRA w/cont, chest",C8909,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1556.07,,,,,,,fee schedule,345.37,1556.07,
"MRA w/cont, chest",C8909,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1247.33,,,,,,,fee schedule,345.37,1556.07,
"MRA w/cont, chest",C8909,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1362.59,,,,,,,fee schedule,345.37,1556.07,
"MRA w/cont, chest",C8909,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1432.58,,,,,,,fee schedule,345.37,1556.07,
"MRA w/cont, chest",C8909,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1532.31,,,,,,,fee schedule,345.37,1556.07,APC 378
"MRA w/cont, chest",C8909,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,362.64,,,,,,,fee schedule,345.37,1556.07,APC
"MRA w/cont, chest",C8909,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,359.19,,,,,,,fee schedule,345.37,1556.07,APC
"MRA w/cont, chest",C8909,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,345.37,,,,,,,fee schedule,345.37,1556.07,APC
"MRA w/cont, chest",C8909,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,528.42,,,,,,,fee schedule,345.37,1556.07,Radiology
"MRA w/cont, chest",C8909,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,483.52,,,,,,,fee schedule,345.37,1556.07,APC
"MRA w/cont, chest",C8909,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,604.4,,,,,,,fee schedule,345.37,1556.07,APC
"MRA w/o cont, chest",C8910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1346.02,,,,,,,fee schedule,236.21,1346.02,
"MRA w/o cont, chest",C8910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1078.95,,,,,,,fee schedule,236.21,1346.02,
"MRA w/o cont, chest",C8910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1178.66,,,,,,,fee schedule,236.21,1346.02,
"MRA w/o cont, chest",C8910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1239.19,,,,,,,fee schedule,236.21,1346.02,
"MRA w/o cont, chest",C8910,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,236.21,1346.02,APC 378
"MRA w/o cont, chest",C8910,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,236.21,1346.02,APC
"MRA w/o cont, chest",C8910,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,236.21,1346.02,APC
"MRA w/o cont, chest",C8910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,236.21,1346.02,APC
"MRA w/o cont, chest",C8910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,236.21,1346.02,Radiology
"MRA w/o cont, chest",C8910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,236.21,1346.02,APC
"MRA w/o cont, chest",C8910,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,236.21,1346.02,APC
"MRA w/o fol w/cont, chest",C8911,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2058.06,,,,,,,fee schedule,345.37,2058.06,
"MRA w/o fol w/cont, chest",C8911,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1649.71,,,,,,,fee schedule,345.37,2058.06,
"MRA w/o fol w/cont, chest",C8911,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1802.16,,,,,,,fee schedule,345.37,2058.06,
"MRA w/o fol w/cont, chest",C8911,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1894.72,,,,,,,fee schedule,345.37,2058.06,
"MRA w/o fol w/cont, chest",C8911,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1532.31,,,,,,,fee schedule,345.37,2058.06,APC 378
"MRA w/o fol w/cont, chest",C8911,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,362.64,,,,,,,fee schedule,345.37,2058.06,APC
"MRA w/o fol w/cont, chest",C8911,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,359.19,,,,,,,fee schedule,345.37,2058.06,APC
"MRA w/o fol w/cont, chest",C8911,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,345.37,,,,,,,fee schedule,345.37,2058.06,APC
"MRA w/o fol w/cont, chest",C8911,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,528.42,,,,,,,fee schedule,345.37,2058.06,Radiology
"MRA w/o fol w/cont, chest",C8911,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,483.52,,,,,,,fee schedule,345.37,2058.06,APC
"MRA w/o fol w/cont, chest",C8911,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,604.4,,,,,,,fee schedule,345.37,2058.06,APC
"Mra w/cont, lwr ext",C8912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1556.07,,,,,,,fee schedule,345.37,1556.07,
"Mra w/cont, lwr ext",C8912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1247.33,,,,,,,fee schedule,345.37,1556.07,
"Mra w/cont, lwr ext",C8912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1362.59,,,,,,,fee schedule,345.37,1556.07,
"Mra w/cont, lwr ext",C8912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1432.58,,,,,,,fee schedule,345.37,1556.07,
"Mra w/cont, lwr ext",C8912,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1532.31,,,,,,,fee schedule,345.37,1556.07,APC 378
"Mra w/cont, lwr ext",C8912,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,362.64,,,,,,,fee schedule,345.37,1556.07,APC
"Mra w/cont, lwr ext",C8912,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,359.19,,,,,,,fee schedule,345.37,1556.07,APC
"Mra w/cont, lwr ext",C8912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,345.37,,,,,,,fee schedule,345.37,1556.07,APC
"Mra w/cont, lwr ext",C8912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,528.42,,,,,,,fee schedule,345.37,1556.07,Radiology
"Mra w/cont, lwr ext",C8912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,483.52,,,,,,,fee schedule,345.37,1556.07,APC
"Mra w/cont, lwr ext",C8912,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,604.4,,,,,,,fee schedule,345.37,1556.07,APC
"Mra w/o cont, lwr ext",C8913,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1346.02,,,,,,,fee schedule,236.21,1346.02,
"Mra w/o cont, lwr ext",C8913,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1078.95,,,,,,,fee schedule,236.21,1346.02,
"Mra w/o cont, lwr ext",C8913,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1178.66,,,,,,,fee schedule,236.21,1346.02,
"Mra w/o cont, lwr ext",C8913,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1239.19,,,,,,,fee schedule,236.21,1346.02,
"Mra w/o cont, lwr ext",C8913,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,236.21,1346.02,APC 378
"Mra w/o cont, lwr ext",C8913,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,236.21,1346.02,APC
"Mra w/o cont, lwr ext",C8913,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,236.21,1346.02,APC
"Mra w/o cont, lwr ext",C8913,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,236.21,1346.02,APC
"Mra w/o cont, lwr ext",C8913,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,236.21,1346.02,Radiology
"Mra w/o cont, lwr ext",C8913,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,236.21,1346.02,APC
"Mra w/o cont, lwr ext",C8913,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,236.21,1346.02,APC
"Mra w/o fol w/cont, lwr ext",C8914,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2058.06,,,,,,,fee schedule,345.37,2058.06,
"Mra w/o fol w/cont, lwr ext",C8914,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1649.71,,,,,,,fee schedule,345.37,2058.06,
"Mra w/o fol w/cont, lwr ext",C8914,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1802.16,,,,,,,fee schedule,345.37,2058.06,
"Mra w/o fol w/cont, lwr ext",C8914,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1894.72,,,,,,,fee schedule,345.37,2058.06,
"Mra w/o fol w/cont, lwr ext",C8914,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1532.31,,,,,,,fee schedule,345.37,2058.06,APC 378
"Mra w/o fol w/cont, lwr ext",C8914,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,362.64,,,,,,,fee schedule,345.37,2058.06,APC
"Mra w/o fol w/cont, lwr ext",C8914,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,359.19,,,,,,,fee schedule,345.37,2058.06,APC
"Mra w/o fol w/cont, lwr ext",C8914,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,345.37,,,,,,,fee schedule,345.37,2058.06,APC
"Mra w/o fol w/cont, lwr ext",C8914,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,528.42,,,,,,,fee schedule,345.37,2058.06,Radiology
"Mra w/o fol w/cont, lwr ext",C8914,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,483.52,,,,,,,fee schedule,345.37,2058.06,APC
"Mra w/o fol w/cont, lwr ext",C8914,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,604.4,,,,,,,fee schedule,345.37,2058.06,APC
"MRA w/cont, pelvis",C8918,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1556.07,,,,,,,fee schedule,345.37,1556.07,
"MRA w/cont, pelvis",C8918,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1247.33,,,,,,,fee schedule,345.37,1556.07,
"MRA w/cont, pelvis",C8918,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1362.59,,,,,,,fee schedule,345.37,1556.07,
"MRA w/cont, pelvis",C8918,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1432.58,,,,,,,fee schedule,345.37,1556.07,
"MRA w/cont, pelvis",C8918,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1532.31,,,,,,,fee schedule,345.37,1556.07,APC 378
"MRA w/cont, pelvis",C8918,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,362.64,,,,,,,fee schedule,345.37,1556.07,APC
"MRA w/cont, pelvis",C8918,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,359.19,,,,,,,fee schedule,345.37,1556.07,APC
"MRA w/cont, pelvis",C8918,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,345.37,,,,,,,fee schedule,345.37,1556.07,APC
"MRA w/cont, pelvis",C8918,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,528.42,,,,,,,fee schedule,345.37,1556.07,Radiology
"MRA w/cont, pelvis",C8918,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,483.52,,,,,,,fee schedule,345.37,1556.07,APC
"MRA w/cont, pelvis",C8918,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,604.4,,,,,,,fee schedule,345.37,1556.07,APC
"MRA w/o cont, pelvis",C8919,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1346.02,,,,,,,fee schedule,236.21,1346.02,
"MRA w/o cont, pelvis",C8919,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1078.95,,,,,,,fee schedule,236.21,1346.02,
"MRA w/o cont, pelvis",C8919,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1178.66,,,,,,,fee schedule,236.21,1346.02,
"MRA w/o cont, pelvis",C8919,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1239.19,,,,,,,fee schedule,236.21,1346.02,
"MRA w/o cont, pelvis",C8919,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,236.21,1346.02,APC 378
"MRA w/o cont, pelvis",C8919,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,236.21,1346.02,APC
"MRA w/o cont, pelvis",C8919,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,236.21,1346.02,APC
"MRA w/o cont, pelvis",C8919,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,236.21,1346.02,APC
"MRA w/o cont, pelvis",C8919,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,236.21,1346.02,Radiology
"MRA w/o cont, pelvis",C8919,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,236.21,1346.02,APC
"MRA w/o cont, pelvis",C8919,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,236.21,1346.02,APC
"Mra w/o fol w/cont, pelvis",C8920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2058.06,,,,,,,fee schedule,345.37,2058.06,
"Mra w/o fol w/cont, pelvis",C8920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1649.71,,,,,,,fee schedule,345.37,2058.06,
"Mra w/o fol w/cont, pelvis",C8920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1802.16,,,,,,,fee schedule,345.37,2058.06,
"Mra w/o fol w/cont, pelvis",C8920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1894.72,,,,,,,fee schedule,345.37,2058.06,
"Mra w/o fol w/cont, pelvis",C8920,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1532.31,,,,,,,fee schedule,345.37,2058.06,APC 378
"Mra w/o fol w/cont, pelvis",C8920,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,362.64,,,,,,,fee schedule,345.37,2058.06,APC
"Mra w/o fol w/cont, pelvis",C8920,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,359.19,,,,,,,fee schedule,345.37,2058.06,APC
"Mra w/o fol w/cont, pelvis",C8920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,345.37,,,,,,,fee schedule,345.37,2058.06,APC
"Mra w/o fol w/cont, pelvis",C8920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,528.42,,,,,,,fee schedule,345.37,2058.06,Radiology
"Mra w/o fol w/cont, pelvis",C8920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,483.52,,,,,,,fee schedule,345.37,2058.06,APC
"Mra w/o fol w/cont, pelvis",C8920,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,604.4,,,,,,,fee schedule,345.37,2058.06,APC
"Tte w or w/o fol w/cont, com",C8921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2118.8,,,,,,,fee schedule,776.06,3443.1,
"Tte w or w/o fol w/cont, com",C8921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1698.41,,,,,,,fee schedule,776.06,3443.1,
"Tte w or w/o fol w/cont, com",C8921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1855.35,,,,,,,fee schedule,776.06,3443.1,
"Tte w or w/o fol w/cont, com",C8921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1950.64,,,,,,,fee schedule,776.06,3443.1,
"Tte w or w/o fol w/cont, com",C8921,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3443.1,,,,,,,fee schedule,776.06,3443.1,APC 378
"Tte w or w/o fol w/cont, com",C8921,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,814.86,,,,,,,fee schedule,776.06,3443.1,APC
"Tte w or w/o fol w/cont, com",C8921,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,807.1,,,,,,,fee schedule,776.06,3443.1,APC
"Tte w or w/o fol w/cont, com",C8921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,776.06,,,,,,,fee schedule,776.06,3443.1,APC
"Tte w or w/o fol w/cont, com",C8921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1187.37,,,,,,,fee schedule,776.06,3443.1,Radiology
"Tte w or w/o fol w/cont, com",C8921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1086.48,,,,,,,fee schedule,776.06,3443.1,APC
"Tte w or w/o fol w/cont, com",C8921,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1358.1,,,,,,,fee schedule,776.06,3443.1,APC
"Tte w or w/o fol w/cont, f/u",C8922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2118.8,,,,,,,fee schedule,776.06,3443.1,
"Tte w or w/o fol w/cont, f/u",C8922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1698.41,,,,,,,fee schedule,776.06,3443.1,
"Tte w or w/o fol w/cont, f/u",C8922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1855.35,,,,,,,fee schedule,776.06,3443.1,
"Tte w or w/o fol w/cont, f/u",C8922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1950.64,,,,,,,fee schedule,776.06,3443.1,
"Tte w or w/o fol w/cont, f/u",C8922,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3443.1,,,,,,,fee schedule,776.06,3443.1,APC 378
"Tte w or w/o fol w/cont, f/u",C8922,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,814.86,,,,,,,fee schedule,776.06,3443.1,APC
"Tte w or w/o fol w/cont, f/u",C8922,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,807.1,,,,,,,fee schedule,776.06,3443.1,APC
"Tte w or w/o fol w/cont, f/u",C8922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,776.06,,,,,,,fee schedule,776.06,3443.1,APC
"Tte w or w/o fol w/cont, f/u",C8922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1187.37,,,,,,,fee schedule,776.06,3443.1,Radiology
"Tte w or w/o fol w/cont, f/u",C8922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1086.48,,,,,,,fee schedule,776.06,3443.1,APC
"Tte w or w/o fol w/cont, f/u",C8922,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1358.1,,,,,,,fee schedule,776.06,3443.1,APC
"2d tte w or w/o fol w/con,co",C8923,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2118.8,,,,,,,fee schedule,776.06,3443.1,
"2d tte w or w/o fol w/con,co",C8923,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1698.41,,,,,,,fee schedule,776.06,3443.1,
"2d tte w or w/o fol w/con,co",C8923,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1855.35,,,,,,,fee schedule,776.06,3443.1,
"2d tte w or w/o fol w/con,co",C8923,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1950.64,,,,,,,fee schedule,776.06,3443.1,
"2d tte w or w/o fol w/con,co",C8923,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3443.1,,,,,,,fee schedule,776.06,3443.1,APC 378
"2d tte w or w/o fol w/con,co",C8923,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,814.86,,,,,,,fee schedule,776.06,3443.1,APC
"2d tte w or w/o fol w/con,co",C8923,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,807.1,,,,,,,fee schedule,776.06,3443.1,APC
"2d tte w or w/o fol w/con,co",C8923,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,776.06,,,,,,,fee schedule,776.06,3443.1,APC
"2d tte w or w/o fol w/con,co",C8923,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1187.37,,,,,,,fee schedule,776.06,3443.1,Radiology
"2d tte w or w/o fol w/con,co",C8923,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1086.48,,,,,,,fee schedule,776.06,3443.1,APC
"2d tte w or w/o fol w/con,co",C8923,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1358.1,,,,,,,fee schedule,776.06,3443.1,APC
"2d tte w or w/o fol w/con,fu",C8924,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2118.8,,,,,,,fee schedule,345.37,2118.8,
"2d tte w or w/o fol w/con,fu",C8924,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1698.41,,,,,,,fee schedule,345.37,2118.8,
"2d tte w or w/o fol w/con,fu",C8924,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1855.35,,,,,,,fee schedule,345.37,2118.8,
"2d tte w or w/o fol w/con,fu",C8924,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1950.64,,,,,,,fee schedule,345.37,2118.8,
"2d tte w or w/o fol w/con,fu",C8924,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1532.31,,,,,,,fee schedule,345.37,2118.8,APC 378
"2d tte w or w/o fol w/con,fu",C8924,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,362.64,,,,,,,fee schedule,345.37,2118.8,APC
"2d tte w or w/o fol w/con,fu",C8924,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,359.19,,,,,,,fee schedule,345.37,2118.8,APC
"2d tte w or w/o fol w/con,fu",C8924,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,345.37,,,,,,,fee schedule,345.37,2118.8,APC
"2d tte w or w/o fol w/con,fu",C8924,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,528.42,,,,,,,fee schedule,345.37,2118.8,Radiology
"2d tte w or w/o fol w/con,fu",C8924,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,483.52,,,,,,,fee schedule,345.37,2118.8,APC
"2d tte w or w/o fol w/con,fu",C8924,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,604.4,,,,,,,fee schedule,345.37,2118.8,APC
"2d tee w or w/o fol w/con,in",C8925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2118.8,,,,,,,fee schedule,776.06,3443.1,
"2d tee w or w/o fol w/con,in",C8925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1698.41,,,,,,,fee schedule,776.06,3443.1,
"2d tee w or w/o fol w/con,in",C8925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1855.35,,,,,,,fee schedule,776.06,3443.1,
"2d tee w or w/o fol w/con,in",C8925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1950.64,,,,,,,fee schedule,776.06,3443.1,
"2d tee w or w/o fol w/con,in",C8925,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3443.1,,,,,,,fee schedule,776.06,3443.1,APC 378
"2d tee w or w/o fol w/con,in",C8925,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,814.86,,,,,,,fee schedule,776.06,3443.1,APC
"2d tee w or w/o fol w/con,in",C8925,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,807.1,,,,,,,fee schedule,776.06,3443.1,APC
"2d tee w or w/o fol w/con,in",C8925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,776.06,,,,,,,fee schedule,776.06,3443.1,APC
"2d tee w or w/o fol w/con,in",C8925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1187.37,,,,,,,fee schedule,776.06,3443.1,Radiology
"2d tee w or w/o fol w/con,in",C8925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1086.48,,,,,,,fee schedule,776.06,3443.1,APC
"2d tee w or w/o fol w/con,in",C8925,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1358.1,,,,,,,fee schedule,776.06,3443.1,APC
"Tee w or w/o fol w/cont,cong",C8926,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2118.8,,,,,,,fee schedule,776.06,3443.1,
"Tee w or w/o fol w/cont,cong",C8926,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1698.41,,,,,,,fee schedule,776.06,3443.1,
"Tee w or w/o fol w/cont,cong",C8926,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1855.35,,,,,,,fee schedule,776.06,3443.1,
"Tee w or w/o fol w/cont,cong",C8926,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1950.64,,,,,,,fee schedule,776.06,3443.1,
"Tee w or w/o fol w/cont,cong",C8926,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3443.1,,,,,,,fee schedule,776.06,3443.1,APC 378
"Tee w or w/o fol w/cont,cong",C8926,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,814.86,,,,,,,fee schedule,776.06,3443.1,APC
"Tee w or w/o fol w/cont,cong",C8926,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,807.1,,,,,,,fee schedule,776.06,3443.1,APC
"Tee w or w/o fol w/cont,cong",C8926,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,776.06,,,,,,,fee schedule,776.06,3443.1,APC
"Tee w or w/o fol w/cont,cong",C8926,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1187.37,,,,,,,fee schedule,776.06,3443.1,Radiology
"Tee w or w/o fol w/cont,cong",C8926,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1086.48,,,,,,,fee schedule,776.06,3443.1,APC
"Tee w or w/o fol w/cont,cong",C8926,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1358.1,,,,,,,fee schedule,776.06,3443.1,APC
"TEE w or w/o fol w/cont, mon",C8927,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2118.8,,,,,,,fee schedule,776.06,3443.1,
"TEE w or w/o fol w/cont, mon",C8927,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1698.41,,,,,,,fee schedule,776.06,3443.1,
"TEE w or w/o fol w/cont, mon",C8927,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1855.35,,,,,,,fee schedule,776.06,3443.1,
"TEE w or w/o fol w/cont, mon",C8927,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1950.64,,,,,,,fee schedule,776.06,3443.1,
"TEE w or w/o fol w/cont, mon",C8927,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3443.1,,,,,,,fee schedule,776.06,3443.1,APC 378
"TEE w or w/o fol w/cont, mon",C8927,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,814.86,,,,,,,fee schedule,776.06,3443.1,APC
"TEE w or w/o fol w/cont, mon",C8927,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,807.1,,,,,,,fee schedule,776.06,3443.1,APC
"TEE w or w/o fol w/cont, mon",C8927,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,776.06,,,,,,,fee schedule,776.06,3443.1,APC
"TEE w or w/o fol w/cont, mon",C8927,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1187.37,,,,,,,fee schedule,776.06,3443.1,Radiology
"TEE w or w/o fol w/cont, mon",C8927,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1086.48,,,,,,,fee schedule,776.06,3443.1,APC
"TEE w or w/o fol w/cont, mon",C8927,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1358.1,,,,,,,fee schedule,776.06,3443.1,APC
"Tte w or w/o fol w/con,stres",C8928,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2118.8,,,,,,,fee schedule,776.06,3443.1,
"Tte w or w/o fol w/con,stres",C8928,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1698.41,,,,,,,fee schedule,776.06,3443.1,
"Tte w or w/o fol w/con,stres",C8928,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1855.35,,,,,,,fee schedule,776.06,3443.1,
"Tte w or w/o fol w/con,stres",C8928,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1950.64,,,,,,,fee schedule,776.06,3443.1,
"Tte w or w/o fol w/con,stres",C8928,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3443.1,,,,,,,fee schedule,776.06,3443.1,APC 378
"Tte w or w/o fol w/con,stres",C8928,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,814.86,,,,,,,fee schedule,776.06,3443.1,APC
"Tte w or w/o fol w/con,stres",C8928,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,807.1,,,,,,,fee schedule,776.06,3443.1,APC
"Tte w or w/o fol w/con,stres",C8928,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,776.06,,,,,,,fee schedule,776.06,3443.1,APC
"Tte w or w/o fol w/con,stres",C8928,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1187.37,,,,,,,fee schedule,776.06,3443.1,Radiology
"Tte w or w/o fol w/con,stres",C8928,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1086.48,,,,,,,fee schedule,776.06,3443.1,APC
"Tte w or w/o fol w/con,stres",C8928,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1358.1,,,,,,,fee schedule,776.06,3443.1,APC
"TTE w or wo fol wcon,Doppler",C8929,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2186.2,,,,,,,fee schedule,776.06,3443.1,
"TTE w or wo fol wcon,Doppler",C8929,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1752.43,,,,,,,fee schedule,776.06,3443.1,
"TTE w or wo fol wcon,Doppler",C8929,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1914.37,,,,,,,fee schedule,776.06,3443.1,
"TTE w or wo fol wcon,Doppler",C8929,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2012.69,,,,,,,fee schedule,776.06,3443.1,
"TTE w or wo fol wcon,Doppler",C8929,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3443.1,,,,,,,fee schedule,776.06,3443.1,APC 378
"TTE w or wo fol wcon,Doppler",C8929,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,814.86,,,,,,,fee schedule,776.06,3443.1,APC
"TTE w or wo fol wcon,Doppler",C8929,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,807.1,,,,,,,fee schedule,776.06,3443.1,APC
"TTE w or wo fol wcon,Doppler",C8929,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,776.06,,,,,,,fee schedule,776.06,3443.1,APC
"TTE w or wo fol wcon,Doppler",C8929,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1187.37,,,,,,,fee schedule,776.06,3443.1,Radiology
"TTE w or wo fol wcon,Doppler",C8929,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1086.48,,,,,,,fee schedule,776.06,3443.1,APC
"TTE w or wo fol wcon,Doppler",C8929,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1358.1,,,,,,,fee schedule,776.06,3443.1,APC
"TTE w or w/o contr, cont ECG",C8930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2186.2,,,,,,,fee schedule,776.06,3443.1,
"TTE w or w/o contr, cont ECG",C8930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1752.43,,,,,,,fee schedule,776.06,3443.1,
"TTE w or w/o contr, cont ECG",C8930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1914.37,,,,,,,fee schedule,776.06,3443.1,
"TTE w or w/o contr, cont ECG",C8930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2012.69,,,,,,,fee schedule,776.06,3443.1,
"TTE w or w/o contr, cont ECG",C8930,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3443.1,,,,,,,fee schedule,776.06,3443.1,APC 378
"TTE w or w/o contr, cont ECG",C8930,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,814.86,,,,,,,fee schedule,776.06,3443.1,APC
"TTE w or w/o contr, cont ECG",C8930,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,807.1,,,,,,,fee schedule,776.06,3443.1,APC
"TTE w or w/o contr, cont ECG",C8930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,776.06,,,,,,,fee schedule,776.06,3443.1,APC
"TTE w or w/o contr, cont ECG",C8930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1187.37,,,,,,,fee schedule,776.06,3443.1,Radiology
"TTE w or w/o contr, cont ECG",C8930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1086.48,,,,,,,fee schedule,776.06,3443.1,APC
"TTE w or w/o contr, cont ECG",C8930,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1358.1,,,,,,,fee schedule,776.06,3443.1,APC
"MRA, w/dye, spinal canal",C8931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1718.24,,,,,,,fee schedule,345.37,1718.24,
"MRA, w/dye, spinal canal",C8931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1377.32,,,,,,,fee schedule,345.37,1718.24,
"MRA, w/dye, spinal canal",C8931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1504.59,,,,,,,fee schedule,345.37,1718.24,
"MRA, w/dye, spinal canal",C8931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1581.87,,,,,,,fee schedule,345.37,1718.24,
"MRA, w/dye, spinal canal",C8931,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1532.31,,,,,,,fee schedule,345.37,1718.24,APC 378
"MRA, w/dye, spinal canal",C8931,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,362.64,,,,,,,fee schedule,345.37,1718.24,APC
"MRA, w/dye, spinal canal",C8931,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,359.19,,,,,,,fee schedule,345.37,1718.24,APC
"MRA, w/dye, spinal canal",C8931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,345.37,,,,,,,fee schedule,345.37,1718.24,APC
"MRA, w/dye, spinal canal",C8931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,528.42,,,,,,,fee schedule,345.37,1718.24,Radiology
"MRA, w/dye, spinal canal",C8931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,483.52,,,,,,,fee schedule,345.37,1718.24,APC
"MRA, w/dye, spinal canal",C8931,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,604.4,,,,,,,fee schedule,345.37,1718.24,APC
"MRA, w/o dye, spinal canal",C8932,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1279.49,,,,,,,fee schedule,236.21,1279.49,
"MRA, w/o dye, spinal canal",C8932,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1025.62,,,,,,,fee schedule,236.21,1279.49,
"MRA, w/o dye, spinal canal",C8932,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1120.4,,,,,,,fee schedule,236.21,1279.49,
"MRA, w/o dye, spinal canal",C8932,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1177.95,,,,,,,fee schedule,236.21,1279.49,
"MRA, w/o dye, spinal canal",C8932,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,236.21,1279.49,APC 378
"MRA, w/o dye, spinal canal",C8932,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,236.21,1279.49,APC
"MRA, w/o dye, spinal canal",C8932,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,236.21,1279.49,APC
"MRA, w/o dye, spinal canal",C8932,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,236.21,1279.49,APC
"MRA, w/o dye, spinal canal",C8932,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,236.21,1279.49,Radiology
"MRA, w/o dye, spinal canal",C8932,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,236.21,1279.49,APC
"MRA, w/o dye, spinal canal",C8932,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,236.21,1279.49,APC
"MRA, w/o&w/dye, spinal canal",C8933,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2077,,,,,,,fee schedule,345.37,2077,
"MRA, w/o&w/dye, spinal canal",C8933,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1664.89,,,,,,,fee schedule,345.37,2077,
"MRA, w/o&w/dye, spinal canal",C8933,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1818.75,,,,,,,fee schedule,345.37,2077,
"MRA, w/o&w/dye, spinal canal",C8933,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1912.16,,,,,,,fee schedule,345.37,2077,
"MRA, w/o&w/dye, spinal canal",C8933,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1532.31,,,,,,,fee schedule,345.37,2077,APC 378
"MRA, w/o&w/dye, spinal canal",C8933,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,362.64,,,,,,,fee schedule,345.37,2077,APC
"MRA, w/o&w/dye, spinal canal",C8933,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,359.19,,,,,,,fee schedule,345.37,2077,APC
"MRA, w/o&w/dye, spinal canal",C8933,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,345.37,,,,,,,fee schedule,345.37,2077,APC
"MRA, w/o&w/dye, spinal canal",C8933,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,528.42,,,,,,,fee schedule,345.37,2077,Radiology
"MRA, w/o&w/dye, spinal canal",C8933,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,483.52,,,,,,,fee schedule,345.37,2077,APC
"MRA, w/o&w/dye, spinal canal",C8933,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,604.4,,,,,,,fee schedule,345.37,2077,APC
"MRA, w/dye, upper extremity",C8934,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1718.24,,,,,,,fee schedule,345.37,1718.24,
"MRA, w/dye, upper extremity",C8934,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1377.32,,,,,,,fee schedule,345.37,1718.24,
"MRA, w/dye, upper extremity",C8934,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1504.59,,,,,,,fee schedule,345.37,1718.24,
"MRA, w/dye, upper extremity",C8934,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1581.87,,,,,,,fee schedule,345.37,1718.24,
"MRA, w/dye, upper extremity",C8934,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1532.31,,,,,,,fee schedule,345.37,1718.24,APC 378
"MRA, w/dye, upper extremity",C8934,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,362.64,,,,,,,fee schedule,345.37,1718.24,APC
"MRA, w/dye, upper extremity",C8934,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,359.19,,,,,,,fee schedule,345.37,1718.24,APC
"MRA, w/dye, upper extremity",C8934,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,345.37,,,,,,,fee schedule,345.37,1718.24,APC
"MRA, w/dye, upper extremity",C8934,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,528.42,,,,,,,fee schedule,345.37,1718.24,Radiology
"MRA, w/dye, upper extremity",C8934,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,483.52,,,,,,,fee schedule,345.37,1718.24,APC
"MRA, w/dye, upper extremity",C8934,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,604.4,,,,,,,fee schedule,345.37,1718.24,APC
"MRA, w/o dye, upper extr",C8935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1279.49,,,,,,,fee schedule,236.21,1279.49,
"MRA, w/o dye, upper extr",C8935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1025.62,,,,,,,fee schedule,236.21,1279.49,
"MRA, w/o dye, upper extr",C8935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1120.4,,,,,,,fee schedule,236.21,1279.49,
"MRA, w/o dye, upper extr",C8935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1177.95,,,,,,,fee schedule,236.21,1279.49,
"MRA, w/o dye, upper extr",C8935,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,236.21,1279.49,APC 378
"MRA, w/o dye, upper extr",C8935,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,236.21,1279.49,APC
"MRA, w/o dye, upper extr",C8935,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,236.21,1279.49,APC
"MRA, w/o dye, upper extr",C8935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,236.21,1279.49,APC
"MRA, w/o dye, upper extr",C8935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,236.21,1279.49,Radiology
"MRA, w/o dye, upper extr",C8935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,236.21,1279.49,APC
"MRA, w/o dye, upper extr",C8935,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,236.21,1279.49,APC
"MRA, w/o&w/dye, upper extr",C8936,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2077,,,,,,,fee schedule,345.37,2077,
"MRA, w/o&w/dye, upper extr",C8936,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1664.89,,,,,,,fee schedule,345.37,2077,
"MRA, w/o&w/dye, upper extr",C8936,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1818.75,,,,,,,fee schedule,345.37,2077,
"MRA, w/o&w/dye, upper extr",C8936,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1912.16,,,,,,,fee schedule,345.37,2077,
"MRA, w/o&w/dye, upper extr",C8936,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1532.31,,,,,,,fee schedule,345.37,2077,APC 378
"MRA, w/o&w/dye, upper extr",C8936,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,362.64,,,,,,,fee schedule,345.37,2077,APC
"MRA, w/o&w/dye, upper extr",C8936,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,359.19,,,,,,,fee schedule,345.37,2077,APC
"MRA, w/o&w/dye, upper extr",C8936,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,345.37,,,,,,,fee schedule,345.37,2077,APC
"MRA, w/o&w/dye, upper extr",C8936,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,528.42,,,,,,,fee schedule,345.37,2077,Radiology
"MRA, w/o&w/dye, upper extr",C8936,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,483.52,,,,,,,fee schedule,345.37,2077,APC
"MRA, w/o&w/dye, upper extr",C8936,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,604.4,,,,,,,fee schedule,345.37,2077,APC
"Prolonged iv inf, req pump",C8957,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,585.18,,,,,,,fee schedule,210.57,934.22,
"Prolonged iv inf, req pump",C8957,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,469.07,,,,,,,fee schedule,210.57,934.22,
"Prolonged iv inf, req pump",C8957,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,512.42,,,,,,,fee schedule,210.57,934.22,
"Prolonged iv inf, req pump",C8957,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,538.74,,,,,,,fee schedule,210.57,934.22,
"Prolonged iv inf, req pump",C8957,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,934.22,,,,,,,fee schedule,210.57,934.22,APC 378
"Prolonged iv inf, req pump",C8957,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,221.1,,,,,,,fee schedule,210.57,934.22,APC
"Prolonged iv inf, req pump",C8957,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,218.99,,,,,,,fee schedule,210.57,934.22,APC
"Prolonged iv inf, req pump",C8957,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,210.57,,,,,,,fee schedule,210.57,934.22,APC
"Prolonged iv inf, req pump",C8957,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,322.17,,,,,,,fee schedule,210.57,934.22,Radiology
"Prolonged iv inf, req pump",C8957,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,294.8,,,,,,,fee schedule,210.57,934.22,APC
"Prolonged iv inf, req pump",C8957,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,368.5,,,,,,,fee schedule,210.57,934.22,APC
Cocaine hcl nasal solution,C9046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.25,,,,,,,fee schedule,2.6,3.25,
Cocaine hcl nasal solution,C9046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.6,,,,,,,fee schedule,2.6,3.25,
Cocaine hcl nasal solution,C9046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.84,,,,,,,fee schedule,2.6,3.25,
Cocaine hcl nasal solution,C9046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.99,,,,,,,fee schedule,2.6,3.25,
"Injection, caplacizumab-yhdp",C9047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2583.8,,,,,,,fee schedule,801.26,3554.94,
"Injection, caplacizumab-yhdp",C9047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2071.14,,,,,,,fee schedule,801.26,3554.94,
"Injection, caplacizumab-yhdp",C9047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2262.53,,,,,,,fee schedule,801.26,3554.94,
"Injection, caplacizumab-yhdp",C9047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2378.74,,,,,,,fee schedule,801.26,3554.94,
"Injection, caplacizumab-yhdp",C9047,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3554.94,,,,,,,fee schedule,801.26,3554.94,APC 378
"Injection, caplacizumab-yhdp",C9047,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,841.33,,,,,,,fee schedule,801.26,3554.94,APC
"Injection, caplacizumab-yhdp",C9047,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,833.31,,,,,,,fee schedule,801.26,3554.94,APC
"Injection, caplacizumab-yhdp",C9047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,801.26,,,,,,,fee schedule,801.26,3554.94,APC
"Injection, caplacizumab-yhdp",C9047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1225.93,,,,,,,fee schedule,801.26,3554.94,Radiology
"Injection, caplacizumab-yhdp",C9047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1121.77,,,,,,,fee schedule,801.26,3554.94,APC
"Injection, caplacizumab-yhdp",C9047,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1402.21,,,,,,,fee schedule,801.26,3554.94,APC
Gallium ga-68 dotatoc,C9067,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,32.66,,,,,,,fee schedule,3.61,32.66,
Gallium ga-68 dotatoc,C9067,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26.18,,,,,,,fee schedule,3.61,32.66,
Gallium ga-68 dotatoc,C9067,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28.6,,,,,,,fee schedule,3.61,32.66,
Gallium ga-68 dotatoc,C9067,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30.07,,,,,,,fee schedule,3.61,32.66,
Gallium ga-68 dotatoc,C9067,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.02,,,,,,,fee schedule,3.61,32.66,APC 378
Gallium ga-68 dotatoc,C9067,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3.79,,,,,,,fee schedule,3.61,32.66,APC
Gallium ga-68 dotatoc,C9067,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3.75,,,,,,,fee schedule,3.61,32.66,APC
Gallium ga-68 dotatoc,C9067,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3.61,,,,,,,fee schedule,3.61,32.66,APC
Gallium ga-68 dotatoc,C9067,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.52,,,,,,,fee schedule,3.61,32.66,Radiology
Gallium ga-68 dotatoc,C9067,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.05,,,,,,,fee schedule,3.61,32.66,APC
Gallium ga-68 dotatoc,C9067,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6.32,,,,,,,fee schedule,3.61,32.66,APC
"Instill, bupivac and meloxic",C9088,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.65,,,,,,,fee schedule,2.12,2.65,
"Instill, bupivac and meloxic",C9088,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.12,,,,,,,fee schedule,2.12,2.65,
"Instill, bupivac and meloxic",C9088,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.32,,,,,,,fee schedule,2.12,2.65,
"Instill, bupivac and meloxic",C9088,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.44,,,,,,,fee schedule,2.12,2.65,
"Inj, oliceridine 0.1 mg",C9101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.47,,,,,,,fee schedule,1.18,1.47,
"Inj, oliceridine 0.1 mg",C9101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.18,,,,,,,fee schedule,1.18,1.47,
"Inj, oliceridine 0.1 mg",C9101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.29,,,,,,,fee schedule,1.18,1.47,
"Inj, oliceridine 0.1 mg",C9101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.36,,,,,,,fee schedule,1.18,1.47,
"Inj, aponvie, 1 mg",C9145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7.1,,,,,,,fee schedule,5.69,7.1,
"Inj, aponvie, 1 mg",C9145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.69,,,,,,,fee schedule,5.69,7.1,
"Inj, aponvie, 1 mg",C9145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.22,,,,,,,fee schedule,5.69,7.1,
"Inj, aponvie, 1 mg",C9145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.54,,,,,,,fee schedule,5.69,7.1,
"Inj, balfaxar, per i.u",C9159,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12.27,,,,,,,fee schedule,9.83,12.27,
"Inj, balfaxar, per i.u",C9159,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.83,,,,,,,fee schedule,9.83,12.27,
"Inj, balfaxar, per i.u",C9159,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10.74,,,,,,,fee schedule,9.83,12.27,
"Inj, balfaxar, per i.u",C9159,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11.29,,,,,,,fee schedule,9.83,12.27,
Inj daxibotulinumtoxina-lanm,C9160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20.19,,,,,,,fee schedule,16.19,20.19,
Inj daxibotulinumtoxina-lanm,C9160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.19,,,,,,,fee schedule,16.19,20.19,
Inj daxibotulinumtoxina-lanm,C9160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17.68,,,,,,,fee schedule,16.19,20.19,
Inj daxibotulinumtoxina-lanm,C9160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18.59,,,,,,,fee schedule,16.19,20.19,
"Inj, aflibercept hd, 1 mg",C9161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1277.52,,,,,,,fee schedule,566.28,1277.52,
"Inj, aflibercept hd, 1 mg",C9161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,625.68,,,,,,,fee schedule,566.28,1277.52,
"Inj, aflibercept hd, 1 mg",C9161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1024.05,,,,,,,fee schedule,566.28,1277.52,
"Inj, aflibercept hd, 1 mg",C9161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1118.68,,,,,,,fee schedule,566.28,1277.52,
"Inj, aflibercept hd, 1 mg",C9161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,566.28,,,,,,,fee schedule,566.28,1277.52,
"Inj, aflibercept hd, 1 mg",C9161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1176.13,,,,,,,fee schedule,566.28,1277.52,
"Inj, avacincaptad peg 0.1 mg",C9162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,408.81,,,,,,,fee schedule,327.69,408.81,
"Inj, avacincaptad peg 0.1 mg",C9162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,327.69,,,,,,,fee schedule,327.69,408.81,
"Inj, avacincaptad peg 0.1 mg",C9162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,357.98,,,,,,,fee schedule,327.69,408.81,
"Inj, avacincaptad peg 0.1 mg",C9162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,376.36,,,,,,,fee schedule,327.69,408.81,
Inj talquetamab-tgvs 0.25 mg,C9163,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,252.1,,,,,,,fee schedule,202.08,252.1,
Inj talquetamab-tgvs 0.25 mg,C9163,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,202.08,,,,,,,fee schedule,202.08,252.1,
Inj talquetamab-tgvs 0.25 mg,C9163,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,220.75,,,,,,,fee schedule,202.08,252.1,
Inj talquetamab-tgvs 0.25 mg,C9163,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,232.09,,,,,,,fee schedule,202.08,252.1,
"Cantharidin top, applicator",C9164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2666.98,,,,,,,fee schedule,2137.82,2666.98,
"Cantharidin top, applicator",C9164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2137.82,,,,,,,fee schedule,2137.82,2666.98,
"Cantharidin top, applicator",C9164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2335.37,,,,,,,fee schedule,2137.82,2666.98,
"Cantharidin top, applicator",C9164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2455.31,,,,,,,fee schedule,2137.82,2666.98,
"Inj, elranatamab-bcmm, 1 mg",C9165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,668.58,,,,,,,fee schedule,535.92,668.58,
"Inj, elranatamab-bcmm, 1 mg",C9165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,535.92,,,,,,,fee schedule,535.92,668.58,
"Inj, elranatamab-bcmm, 1 mg",C9165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,585.45,,,,,,,fee schedule,535.92,668.58,
"Inj, elranatamab-bcmm, 1 mg",C9165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,615.51,,,,,,,fee schedule,535.92,668.58,
"Inj, clevidipine butyrate",C9248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10.7,,,,,,,fee schedule,8.57,10.7,
"Inj, clevidipine butyrate",C9248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.57,,,,,,,fee schedule,8.57,10.7,
"Inj, clevidipine butyrate",C9248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.37,,,,,,,fee schedule,8.57,10.7,
"Inj, clevidipine butyrate",C9248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.85,,,,,,,fee schedule,8.57,10.7,
Artiss fibrin sealant,C9250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,128.18,,,,,,,fee schedule,102.75,637.55,
Artiss fibrin sealant,C9250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,102.75,,,,,,,fee schedule,102.75,637.55,
Artiss fibrin sealant,C9250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,112.24,,,,,,,fee schedule,102.75,637.55,
Artiss fibrin sealant,C9250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,118.01,,,,,,,fee schedule,102.75,637.55,
Artiss fibrin sealant,C9250,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,637.55,,,,,,,fee schedule,102.75,637.55,APC 378
Artiss fibrin sealant,C9250,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,150.88,,,,,,,fee schedule,102.75,637.55,APC
Artiss fibrin sealant,C9250,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,149.45,,,,,,,fee schedule,102.75,637.55,APC
Artiss fibrin sealant,C9250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,143.7,,,,,,,fee schedule,102.75,637.55,APC
Artiss fibrin sealant,C9250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,219.86,,,,,,,fee schedule,102.75,637.55,Radiology
Artiss fibrin sealant,C9250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.18,,,,,,,fee schedule,102.75,637.55,APC
Artiss fibrin sealant,C9250,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,251.47,,,,,,,fee schedule,102.75,637.55,APC
Bevacizumab injection,C9257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.12,,,,,,,fee schedule,1.86,8.25,
Bevacizumab injection,C9257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.91,,,,,,,fee schedule,1.86,8.25,
Bevacizumab injection,C9257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.36,,,,,,,fee schedule,1.86,8.25,
Bevacizumab injection,C9257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.64,,,,,,,fee schedule,1.86,8.25,
Bevacizumab injection,C9257,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.25,,,,,,,fee schedule,1.86,8.25,APC 378
Bevacizumab injection,C9257,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.95,,,,,,,fee schedule,1.86,8.25,APC
Bevacizumab injection,C9257,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1.93,,,,,,,fee schedule,1.86,8.25,APC
Bevacizumab injection,C9257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1.86,,,,,,,fee schedule,1.86,8.25,APC
Bevacizumab injection,C9257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2.84,,,,,,,fee schedule,1.86,8.25,Radiology
Bevacizumab injection,C9257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2.6,,,,,,,fee schedule,1.86,8.25,APC
Bevacizumab injection,C9257,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3.25,,,,,,,fee schedule,1.86,8.25,APC
"Patch, lidocaine/tetracaine",C9285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,49.78,,,,,,,fee schedule,39.91,49.78,
"Patch, lidocaine/tetracaine",C9285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39.91,,,,,,,fee schedule,39.91,49.78,
"Patch, lidocaine/tetracaine",C9285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,43.59,,,,,,,fee schedule,39.91,49.78,
"Patch, lidocaine/tetracaine",C9285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45.83,,,,,,,fee schedule,39.91,49.78,
"Inj, bupivacaine liposome",C9290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.08,,,,,,,fee schedule,3.27,4.08,
"Inj, bupivacaine liposome",C9290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.27,,,,,,,fee schedule,3.27,4.08,
"Inj, bupivacaine liposome",C9290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.57,,,,,,,fee schedule,3.27,4.08,
"Inj, bupivacaine liposome",C9290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.76,,,,,,,fee schedule,3.27,4.08,
"Injection, glucarpidase",C9293,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,883.5,,,,,,,fee schedule,449.1,1992.52,
"Injection, glucarpidase",C9293,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,708.2,,,,,,,fee schedule,449.1,1992.52,
"Injection, glucarpidase",C9293,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,773.65,,,,,,,fee schedule,449.1,1992.52,
"Injection, glucarpidase",C9293,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,813.38,,,,,,,fee schedule,449.1,1992.52,
"Injection, glucarpidase",C9293,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1992.52,,,,,,,fee schedule,449.1,1992.52,APC 378
"Injection, glucarpidase",C9293,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,471.56,,,,,,,fee schedule,449.1,1992.52,APC
"Injection, glucarpidase",C9293,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,467.07,,,,,,,fee schedule,449.1,1992.52,APC
"Injection, glucarpidase",C9293,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,449.1,,,,,,,fee schedule,449.1,1992.52,APC
"Injection, glucarpidase",C9293,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,687.13,,,,,,,fee schedule,449.1,1992.52,Radiology
"Injection, glucarpidase",C9293,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,628.75,,,,,,,fee schedule,449.1,1992.52,APC
"Injection, glucarpidase",C9293,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,785.93,,,,,,,fee schedule,449.1,1992.52,APC
"Neuragen nerve guide, per cm",C9352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1918.61,,,,,,,fee schedule,1537.94,1918.61,
"Neuragen nerve guide, per cm",C9352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1537.94,,,,,,,fee schedule,1537.94,1918.61,
"Neuragen nerve guide, per cm",C9352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1680.06,,,,,,,fee schedule,1537.94,1918.61,
"Neuragen nerve guide, per cm",C9352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1766.34,,,,,,,fee schedule,1537.94,1918.61,
"Neurawrap nerve protector,cm",C9353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1559.17,,,,,,,fee schedule,1249.81,1559.17,
"Neurawrap nerve protector,cm",C9353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1249.81,,,,,,,fee schedule,1249.81,1559.17,
"Neurawrap nerve protector,cm",C9353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1365.31,,,,,,,fee schedule,1249.81,1559.17,
"Neurawrap nerve protector,cm",C9353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1435.43,,,,,,,fee schedule,1249.81,1559.17,
"Veritas collagen matrix, cm2",C9354,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,43.81,,,,,,,fee schedule,35.12,43.81,
"Veritas collagen matrix, cm2",C9354,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35.12,,,,,,,fee schedule,35.12,43.81,
"Veritas collagen matrix, cm2",C9354,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38.36,,,,,,,fee schedule,35.12,43.81,
"Veritas collagen matrix, cm2",C9354,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,40.33,,,,,,,fee schedule,35.12,43.81,
"Neuromatrix nerve cuff, cm",C9355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,832.51,,,,,,,fee schedule,667.33,832.51,
"Neuromatrix nerve cuff, cm",C9355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,667.33,,,,,,,fee schedule,667.33,832.51,
"Neuromatrix nerve cuff, cm",C9355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,728.99,,,,,,,fee schedule,667.33,832.51,
"Neuromatrix nerve cuff, cm",C9355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,766.44,,,,,,,fee schedule,667.33,832.51,
"TenoGlide tendon prot, cm2",C9356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,110.98,,,,,,,fee schedule,88.96,110.98,
"TenoGlide tendon prot, cm2",C9356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,88.96,,,,,,,fee schedule,88.96,110.98,
"TenoGlide tendon prot, cm2",C9356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,97.18,,,,,,,fee schedule,88.96,110.98,
"TenoGlide tendon prot, cm2",C9356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,102.17,,,,,,,fee schedule,88.96,110.98,
"Surgimend, fetal",C9358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41.35,,,,,,,fee schedule,33.15,41.35,
"Surgimend, fetal",C9358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,33.15,,,,,,,fee schedule,33.15,41.35,
"Surgimend, fetal",C9358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36.21,,,,,,,fee schedule,33.15,41.35,
"Surgimend, fetal",C9358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,38.07,,,,,,,fee schedule,33.15,41.35,
"Implnt,bon void filler-putty",C9359,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,222.23,,,,,,,fee schedule,178.13,222.23,
"Implnt,bon void filler-putty",C9359,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,178.13,,,,,,,fee schedule,178.13,222.23,
"Implnt,bon void filler-putty",C9359,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,194.59,,,,,,,fee schedule,178.13,222.23,
"Implnt,bon void filler-putty",C9359,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,204.59,,,,,,,fee schedule,178.13,222.23,
"SurgiMend, neonatal",C9360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45.51,,,,,,,fee schedule,36.48,45.51,
"SurgiMend, neonatal",C9360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36.48,,,,,,,fee schedule,36.48,45.51,
"SurgiMend, neonatal",C9360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39.85,,,,,,,fee schedule,36.48,45.51,
"SurgiMend, neonatal",C9360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41.9,,,,,,,fee schedule,36.48,45.51,
Integra Meshed Bil Wound Mat,C9363,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,110.26,,,,,,,fee schedule,88.39,546.58,
Integra Meshed Bil Wound Mat,C9363,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,88.39,,,,,,,fee schedule,88.39,546.58,
Integra Meshed Bil Wound Mat,C9363,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,96.55,,,,,,,fee schedule,88.39,546.58,
Integra Meshed Bil Wound Mat,C9363,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,101.51,,,,,,,fee schedule,88.39,546.58,
Integra Meshed Bil Wound Mat,C9363,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,88.39,546.58,APC 378
Integra Meshed Bil Wound Mat,C9363,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,88.39,546.58,APC
Integra Meshed Bil Wound Mat,C9363,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,88.39,546.58,APC
Integra Meshed Bil Wound Mat,C9363,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,88.39,546.58,APC
Integra Meshed Bil Wound Mat,C9363,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,88.39,546.58,Radiology
Integra Meshed Bil Wound Mat,C9363,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,88.39,546.58,APC
Integra Meshed Bil Wound Mat,C9363,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,88.39,546.58,APC
"Injection, cangrelor",C9460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.03,,,,,,,fee schedule,20.02,88.83,
"Injection, cangrelor",C9460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48.12,,,,,,,fee schedule,20.02,88.83,
"Injection, cangrelor",C9460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52.56,,,,,,,fee schedule,20.02,88.83,
"Injection, cangrelor",C9460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55.26,,,,,,,fee schedule,20.02,88.83,
"Injection, cangrelor",C9460,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,88.83,,,,,,,fee schedule,20.02,88.83,APC 378
"Injection, cangrelor",C9460,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.02,,,,,,,fee schedule,20.02,88.83,APC
"Injection, cangrelor",C9460,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,20.82,,,,,,,fee schedule,20.02,88.83,APC
"Injection, cangrelor",C9460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,20.02,,,,,,,fee schedule,20.02,88.83,APC
"Injection, cangrelor",C9460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,30.63,,,,,,,fee schedule,20.02,88.83,Radiology
"Injection, cangrelor",C9460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.03,,,,,,,fee schedule,20.02,88.83,APC
"Injection, cangrelor",C9460,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,35.04,,,,,,,fee schedule,20.02,88.83,APC
"Injection, delafloxacin",C9462,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.74,,,,,,,fee schedule,1.39,1.74,
"Injection, delafloxacin",C9462,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.39,,,,,,,fee schedule,1.39,1.74,
"Injection, delafloxacin",C9462,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.52,,,,,,,fee schedule,1.39,1.74,
"Injection, delafloxacin",C9462,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.6,,,,,,,fee schedule,1.39,1.74,
Sotalol hydrochloride IV,C9482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37.76,,,,,,,fee schedule,30.27,37.76,
Sotalol hydrochloride IV,C9482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,30.27,,,,,,,fee schedule,30.27,37.76,
Sotalol hydrochloride IV,C9482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,33.07,,,,,,,fee schedule,30.27,37.76,
Sotalol hydrochloride IV,C9482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,34.77,,,,,,,fee schedule,30.27,37.76,
Conivaptan HCL,C9488,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,117.55,,,,,,,fee schedule,94.22,117.55,
Conivaptan HCL,C9488,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,94.22,,,,,,,fee schedule,94.22,117.55,
Conivaptan HCL,C9488,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,102.93,,,,,,,fee schedule,94.22,117.55,
Conivaptan HCL,C9488,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,108.22,,,,,,,fee schedule,94.22,117.55,
COVID-19 convalescent plasma,C9507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2836.89,,,,,,,fee schedule,680.03,3017.06,
COVID-19 convalescent plasma,C9507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2274.02,,,,,,,fee schedule,680.03,3017.06,
COVID-19 convalescent plasma,C9507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2484.16,,,,,,,fee schedule,680.03,3017.06,
COVID-19 convalescent plasma,C9507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2611.74,,,,,,,fee schedule,680.03,3017.06,
COVID-19 convalescent plasma,C9507,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3017.06,,,,,,,fee schedule,680.03,3017.06,APC 378
COVID-19 convalescent plasma,C9507,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,714.03,,,,,,,fee schedule,680.03,3017.06,APC
COVID-19 convalescent plasma,C9507,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,707.23,,,,,,,fee schedule,680.03,3017.06,APC
COVID-19 convalescent plasma,C9507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,680.03,,,,,,,fee schedule,680.03,3017.06,APC
COVID-19 convalescent plasma,C9507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1040.45,,,,,,,fee schedule,680.03,3017.06,Radiology
COVID-19 convalescent plasma,C9507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,952.04,,,,,,,fee schedule,680.03,3017.06,APC
COVID-19 convalescent plasma,C9507,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1190.05,,,,,,,fee schedule,680.03,3017.06,APC
Perc drug-el cor stent sing,C9600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11446.07,,,,,,,fee schedule,9175.02,50703.82,
Perc drug-el cor stent sing,C9600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9175.02,,,,,,,fee schedule,9175.02,50703.82,
Perc drug-el cor stent sing,C9600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10022.88,,,,,,,fee schedule,9175.02,50703.82,
Perc drug-el cor stent sing,C9600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10537.65,,,,,,,fee schedule,9175.02,50703.82,
Perc drug-el cor stent sing,C9600,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,50703.82,,,,,,,fee schedule,9175.02,50703.82,APC 378
Perc drug-el cor stent sing,C9600,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11999.79,,,,,,,fee schedule,9175.02,50703.82,APC
Perc drug-el cor stent sing,C9600,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11885.51,,,,,,,fee schedule,9175.02,50703.82,APC
Perc drug-el cor stent sing,C9600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11428.37,,,,,,,fee schedule,9175.02,50703.82,APC
Perc drug-el cor stent sing,C9600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17485.41,,,,,,,fee schedule,9175.02,50703.82,Radiology
Perc drug-el cor stent sing,C9600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15999.72,,,,,,,fee schedule,9175.02,50703.82,APC
Perc drug-el cor stent sing,C9600,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19999.65,,,,,,,fee schedule,9175.02,50703.82,APC
Perc drug-el cor stent bran,C9601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11446.07,,,,,,,fee schedule,9175.02,11446.07,
Perc drug-el cor stent bran,C9601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9175.02,,,,,,,fee schedule,9175.02,11446.07,
Perc drug-el cor stent bran,C9601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10022.88,,,,,,,fee schedule,9175.02,11446.07,
Perc drug-el cor stent bran,C9601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10537.65,,,,,,,fee schedule,9175.02,11446.07,
Perc d-e cor stent ather s,C9602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21752.19,,,,,,,fee schedule,17436.28,80515.32,
Perc d-e cor stent ather s,C9602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17436.28,,,,,,,fee schedule,17436.28,80515.32,
Perc d-e cor stent ather s,C9602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19047.55,,,,,,,fee schedule,17436.28,80515.32,
Perc d-e cor stent ather s,C9602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20025.82,,,,,,,fee schedule,17436.28,80515.32,
Perc d-e cor stent ather s,C9602,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,80515.32,,,,,,,fee schedule,17436.28,80515.32,APC 378
Perc d-e cor stent ather s,C9602,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19055.11,,,,,,,fee schedule,17436.28,80515.32,APC
Perc d-e cor stent ather s,C9602,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18873.64,,,,,,,fee schedule,17436.28,80515.32,APC
Perc d-e cor stent ather s,C9602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18147.73,,,,,,,fee schedule,17436.28,80515.32,APC
Perc d-e cor stent ather s,C9602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27766.02,,,,,,,fee schedule,17436.28,80515.32,Radiology
Perc d-e cor stent ather s,C9602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25406.82,,,,,,,fee schedule,17436.28,80515.32,APC
Perc d-e cor stent ather s,C9602,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31758.52,,,,,,,fee schedule,17436.28,80515.32,APC
Perc d-e cor stent ather br,C9603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,29344.82,,,,,,,fee schedule,23522.44,29344.82,
Perc d-e cor stent ather br,C9603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23522.44,,,,,,,fee schedule,23522.44,29344.82,
Perc d-e cor stent ather br,C9603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,25696.13,,,,,,,fee schedule,23522.44,29344.82,
Perc d-e cor stent ather br,C9603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27015.87,,,,,,,fee schedule,23522.44,29344.82,
Perc d-e cor revasc t cabg s,C9604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11446.07,,,,,,,fee schedule,9175.02,50703.82,
Perc d-e cor revasc t cabg s,C9604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9175.02,,,,,,,fee schedule,9175.02,50703.82,
Perc d-e cor revasc t cabg s,C9604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10022.88,,,,,,,fee schedule,9175.02,50703.82,
Perc d-e cor revasc t cabg s,C9604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10537.65,,,,,,,fee schedule,9175.02,50703.82,
Perc d-e cor revasc t cabg s,C9604,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,50703.82,,,,,,,fee schedule,9175.02,50703.82,APC 378
Perc d-e cor revasc t cabg s,C9604,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11999.79,,,,,,,fee schedule,9175.02,50703.82,APC
Perc d-e cor revasc t cabg s,C9604,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11885.51,,,,,,,fee schedule,9175.02,50703.82,APC
Perc d-e cor revasc t cabg s,C9604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11428.37,,,,,,,fee schedule,9175.02,50703.82,APC
Perc d-e cor revasc t cabg s,C9604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17485.41,,,,,,,fee schedule,9175.02,50703.82,Radiology
Perc d-e cor revasc t cabg s,C9604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15999.72,,,,,,,fee schedule,9175.02,50703.82,APC
Perc d-e cor revasc t cabg s,C9604,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19999.65,,,,,,,fee schedule,9175.02,50703.82,APC
Perc d-e cor revasc t cabg b,C9605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,29344.82,,,,,,,fee schedule,23522.44,29344.82,
Perc d-e cor revasc t cabg b,C9605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23522.44,,,,,,,fee schedule,23522.44,29344.82,
Perc d-e cor revasc t cabg b,C9605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,25696.13,,,,,,,fee schedule,23522.44,29344.82,
Perc d-e cor revasc t cabg b,C9605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27015.87,,,,,,,fee schedule,23522.44,29344.82,
Perc d-e cor revasc w AMI s,C9606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21752.19,,,,,,,fee schedule,17436.28,21752.19,
Perc d-e cor revasc w AMI s,C9606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17436.28,,,,,,,fee schedule,17436.28,21752.19,
Perc d-e cor revasc w AMI s,C9606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19047.55,,,,,,,fee schedule,17436.28,21752.19,
Perc d-e cor revasc w AMI s,C9606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20025.82,,,,,,,fee schedule,17436.28,21752.19,
Perc d-e cor revasc chro sin,C9607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21752.19,,,,,,,fee schedule,17436.28,80515.32,
Perc d-e cor revasc chro sin,C9607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17436.28,,,,,,,fee schedule,17436.28,80515.32,
Perc d-e cor revasc chro sin,C9607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19047.55,,,,,,,fee schedule,17436.28,80515.32,
Perc d-e cor revasc chro sin,C9607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20025.82,,,,,,,fee schedule,17436.28,80515.32,
Perc d-e cor revasc chro sin,C9607,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,80515.32,,,,,,,fee schedule,17436.28,80515.32,APC 378
Perc d-e cor revasc chro sin,C9607,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19055.11,,,,,,,fee schedule,17436.28,80515.32,APC
Perc d-e cor revasc chro sin,C9607,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18873.64,,,,,,,fee schedule,17436.28,80515.32,APC
Perc d-e cor revasc chro sin,C9607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18147.73,,,,,,,fee schedule,17436.28,80515.32,APC
Perc d-e cor revasc chro sin,C9607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27766.02,,,,,,,fee schedule,17436.28,80515.32,Radiology
Perc d-e cor revasc chro sin,C9607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25406.82,,,,,,,fee schedule,17436.28,80515.32,APC
Perc d-e cor revasc chro sin,C9607,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31758.52,,,,,,,fee schedule,17436.28,80515.32,APC
Perc d-e cor revasc chro add,C9608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,29344.82,,,,,,,fee schedule,23522.44,29344.82,
Perc d-e cor revasc chro add,C9608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23522.44,,,,,,,fee schedule,23522.44,29344.82,
Perc d-e cor revasc chro add,C9608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,25696.13,,,,,,,fee schedule,23522.44,29344.82,
Perc d-e cor revasc chro add,C9608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27015.87,,,,,,,fee schedule,23522.44,29344.82,
Place endorectal app,C9725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2155.09,,,,,,,fee schedule,920.63,4084.51,
Place endorectal app,C9725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1727.49,,,,,,,fee schedule,920.63,4084.51,
Place endorectal app,C9725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1887.13,,,,,,,fee schedule,920.63,4084.51,
Place endorectal app,C9725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1984.05,,,,,,,fee schedule,920.63,4084.51,
Place endorectal app,C9725,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4084.51,,,,,,,fee schedule,920.63,4084.51,APC 378
Place endorectal app,C9725,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,966.66,,,,,,,fee schedule,920.63,4084.51,APC
Place endorectal app,C9725,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,957.45,,,,,,,fee schedule,920.63,4084.51,APC
Place endorectal app,C9725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,920.63,,,,,,,fee schedule,920.63,4084.51,APC
Place endorectal app,C9725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1408.56,,,,,,,fee schedule,920.63,4084.51,Radiology
Place endorectal app,C9725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1288.88,,,,,,,fee schedule,920.63,4084.51,APC
Place endorectal app,C9725,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1611.1,,,,,,,fee schedule,920.63,4084.51,APC
Rxt breast appl place/remov,C9726,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2546.93,,,,,,,fee schedule,2041.58,2546.93,
Rxt breast appl place/remov,C9726,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2041.58,,,,,,,fee schedule,2041.58,2546.93,
Rxt breast appl place/remov,C9726,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2230.24,,,,,,,fee schedule,2041.58,2546.93,
Rxt breast appl place/remov,C9726,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2344.79,,,,,,,fee schedule,2041.58,2546.93,
Insert palate implants,C9727,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3330.6,,,,,,,fee schedule,1536.02,6814.79,
Insert palate implants,C9727,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2669.76,,,,,,,fee schedule,1536.02,6814.79,
Insert palate implants,C9727,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2916.47,,,,,,,fee schedule,1536.02,6814.79,
Insert palate implants,C9727,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3066.26,,,,,,,fee schedule,1536.02,6814.79,
Insert palate implants,C9727,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1536.02,6814.79,APC 378
Insert palate implants,C9727,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1536.02,6814.79,APC
Insert palate implants,C9727,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1536.02,6814.79,APC
Insert palate implants,C9727,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1536.02,6814.79,APC
Insert palate implants,C9727,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1536.02,6814.79,Radiology
Insert palate implants,C9727,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1536.02,6814.79,APC
Insert palate implants,C9727,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1536.02,6814.79,APC
"Place device/marker, non pro",C9728,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,760.42,,,,,,,fee schedule,609.55,6079.31,
"Place device/marker, non pro",C9728,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,609.55,,,,,,,fee schedule,609.55,6079.31,
"Place device/marker, non pro",C9728,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,665.87,,,,,,,fee schedule,609.55,6079.31,
"Place device/marker, non pro",C9728,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,700.07,,,,,,,fee schedule,609.55,6079.31,
"Place device/marker, non pro",C9728,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6079.31,,,,,,,fee schedule,609.55,6079.31,APC 378
"Place device/marker, non pro",C9728,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1438.76,,,,,,,fee schedule,609.55,6079.31,APC
"Place device/marker, non pro",C9728,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1425.05,,,,,,,fee schedule,609.55,6079.31,APC
"Place device/marker, non pro",C9728,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1370.24,,,,,,,fee schedule,609.55,6079.31,APC
"Place device/marker, non pro",C9728,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2096.47,,,,,,,fee schedule,609.55,6079.31,Radiology
"Place device/marker, non pro",C9728,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1918.34,,,,,,,fee schedule,609.55,6079.31,APC
"Place device/marker, non pro",C9728,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2397.93,,,,,,,fee schedule,609.55,6079.31,APC
Non-ophthalmic FVA,C9733,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1251.07,,,,,,,fee schedule,345.37,1532.31,
Non-ophthalmic FVA,C9733,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1002.84,,,,,,,fee schedule,345.37,1532.31,
Non-ophthalmic FVA,C9733,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1095.51,,,,,,,fee schedule,345.37,1532.31,
Non-ophthalmic FVA,C9733,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1151.78,,,,,,,fee schedule,345.37,1532.31,
Non-ophthalmic FVA,C9733,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1532.31,,,,,,,fee schedule,345.37,1532.31,APC 378
Non-ophthalmic FVA,C9733,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,362.64,,,,,,,fee schedule,345.37,1532.31,APC
Non-ophthalmic FVA,C9733,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,359.19,,,,,,,fee schedule,345.37,1532.31,APC
Non-ophthalmic FVA,C9733,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,345.37,,,,,,,fee schedule,345.37,1532.31,APC
Non-ophthalmic FVA,C9733,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,528.42,,,,,,,fee schedule,345.37,1532.31,Radiology
Non-ophthalmic FVA,C9733,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,483.52,,,,,,,fee schedule,345.37,1532.31,APC
Non-ophthalmic FVA,C9733,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,604.4,,,,,,,fee schedule,345.37,1532.31,APC
"U/s trtmt, not leiomyomata",C9734,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12476.42,,,,,,,fee schedule,10000.94,56389.43,
"U/s trtmt, not leiomyomata",C9734,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10000.94,,,,,,,fee schedule,10000.94,56389.43,
"U/s trtmt, not leiomyomata",C9734,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10925.12,,,,,,,fee schedule,10000.94,56389.43,
"U/s trtmt, not leiomyomata",C9734,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11486.23,,,,,,,fee schedule,10000.94,56389.43,
"U/s trtmt, not leiomyomata",C9734,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,10000.94,56389.43,APC 378
"U/s trtmt, not leiomyomata",C9734,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,10000.94,56389.43,APC
"U/s trtmt, not leiomyomata",C9734,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,10000.94,56389.43,APC
"U/s trtmt, not leiomyomata",C9734,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,10000.94,56389.43,APC
"U/s trtmt, not leiomyomata",C9734,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,10000.94,56389.43,Radiology
"U/s trtmt, not leiomyomata",C9734,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,10000.94,56389.43,APC
"U/s trtmt, not leiomyomata",C9734,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,10000.94,56389.43,APC
Cystoscopy prostatic imp 1-3,C9739,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7880.73,,,,,,,fee schedule,5308,23549.82,
Cystoscopy prostatic imp 1-3,C9739,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6317.1,,,,,,,fee schedule,5308,23549.82,
Cystoscopy prostatic imp 1-3,C9739,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6900.85,,,,,,,fee schedule,5308,23549.82,
Cystoscopy prostatic imp 1-3,C9739,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7255.28,,,,,,,fee schedule,5308,23549.82,
Cystoscopy prostatic imp 1-3,C9739,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23549.82,,,,,,,fee schedule,5308,23549.82,APC 378
Cystoscopy prostatic imp 1-3,C9739,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5573.4,,,,,,,fee schedule,5308,23549.82,APC
Cystoscopy prostatic imp 1-3,C9739,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5520.32,,,,,,,fee schedule,5308,23549.82,APC
Cystoscopy prostatic imp 1-3,C9739,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5308,,,,,,,fee schedule,5308,23549.82,APC
Cystoscopy prostatic imp 1-3,C9739,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8121.25,,,,,,,fee schedule,5308,23549.82,Radiology
Cystoscopy prostatic imp 1-3,C9739,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7431.21,,,,,,,fee schedule,5308,23549.82,APC
Cystoscopy prostatic imp 1-3,C9739,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9289.01,,,,,,,fee schedule,5308,23549.82,APC
Cysto impl 4 or more,C9740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17955,,,,,,,fee schedule,9371.49,41578.13,
Cysto impl 4 or more,C9740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14392.5,,,,,,,fee schedule,9371.49,41578.13,
Cysto impl 4 or more,C9740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15722.5,,,,,,,fee schedule,9371.49,41578.13,
Cysto impl 4 or more,C9740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16530,,,,,,,fee schedule,9371.49,41578.13,
Cysto impl 4 or more,C9740,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,41578.13,,,,,,,fee schedule,9371.49,41578.13,APC 378
Cysto impl 4 or more,C9740,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9840.06,,,,,,,fee schedule,9371.49,41578.13,APC
Cysto impl 4 or more,C9740,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9746.35,,,,,,,fee schedule,9371.49,41578.13,APC
Cysto impl 4 or more,C9740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9371.49,,,,,,,fee schedule,9371.49,41578.13,APC
Cysto impl 4 or more,C9740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14338.38,,,,,,,fee schedule,9371.49,41578.13,Radiology
Cysto impl 4 or more,C9740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13120.09,,,,,,,fee schedule,9371.49,41578.13,APC
Cysto impl 4 or more,C9740,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16400.11,,,,,,,fee schedule,9371.49,41578.13,APC
"Microwave bronch, 3d, ebus",C9751,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,31186.89,,,,,,,fee schedule,24999.02,31186.89,
"Microwave bronch, 3d, ebus",C9751,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24999.02,,,,,,,fee schedule,24999.02,31186.89,
"Microwave bronch, 3d, ebus",C9751,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,27309.16,,,,,,,fee schedule,24999.02,31186.89,
"Microwave bronch, 3d, ebus",C9751,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,28711.74,,,,,,,fee schedule,24999.02,31186.89,
Spine/lumbar disk surgery,C9757,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,44984.68,,,,,,,fee schedule,12709.88,56389.43,
Spine/lumbar disk surgery,C9757,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36059.15,,,,,,,fee schedule,12709.88,56389.43,
Spine/lumbar disk surgery,C9757,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39391.35,,,,,,,fee schedule,12709.88,56389.43,
Spine/lumbar disk surgery,C9757,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41414.47,,,,,,,fee schedule,12709.88,56389.43,
Spine/lumbar disk surgery,C9757,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,12709.88,56389.43,APC 378
Spine/lumbar disk surgery,C9757,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,12709.88,56389.43,APC
Spine/lumbar disk surgery,C9757,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,12709.88,56389.43,APC
Spine/lumbar disk surgery,C9757,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,12709.88,56389.43,APC
Spine/lumbar disk surgery,C9757,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,12709.88,56389.43,Radiology
Spine/lumbar disk surgery,C9757,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,12709.88,56389.43,APC
Spine/lumbar disk surgery,C9757,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,12709.88,56389.43,APC
Interatrial shunt IDE,C9758,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,47251.89,,,,,,,fee schedule,16957.63,75235.29,
Interatrial shunt IDE,C9758,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37876.52,,,,,,,fee schedule,16957.63,75235.29,
Interatrial shunt IDE,C9758,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,41376.66,,,,,,,fee schedule,16957.63,75235.29,
Interatrial shunt IDE,C9758,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,43501.74,,,,,,,fee schedule,16957.63,75235.29,
Interatrial shunt IDE,C9758,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,75235.29,,,,,,,fee schedule,16957.63,75235.29,APC 378
Interatrial shunt IDE,C9758,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17805.52,,,,,,,fee schedule,16957.63,75235.29,APC
Interatrial shunt IDE,C9758,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,17635.94,,,,,,,fee schedule,16957.63,75235.29,APC
Interatrial shunt IDE,C9758,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16957.63,,,,,,,fee schedule,16957.63,75235.29,APC
Interatrial shunt IDE,C9758,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25945.18,,,,,,,fee schedule,16957.63,75235.29,Radiology
Interatrial shunt IDE,C9758,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23740.69,,,,,,,fee schedule,16957.63,75235.29,APC
Interatrial shunt IDE,C9758,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,29675.86,,,,,,,fee schedule,16957.63,75235.29,APC
Non-blind interatrial shunt,C9760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,103951.89,,,,,,,fee schedule,26647.43,118225.65,
Non-blind interatrial shunt,C9760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,83326.52,,,,,,,fee schedule,26647.43,118225.65,
Non-blind interatrial shunt,C9760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,91026.66,,,,,,,fee schedule,26647.43,118225.65,
Non-blind interatrial shunt,C9760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,95701.74,,,,,,,fee schedule,26647.43,118225.65,
Non-blind interatrial shunt,C9760,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,118225.65,,,,,,,fee schedule,26647.43,118225.65,APC 378
Non-blind interatrial shunt,C9760,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,27979.81,,,,,,,fee schedule,26647.43,118225.65,APC
Non-blind interatrial shunt,C9760,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,27713.33,,,,,,,fee schedule,26647.43,118225.65,APC
Non-blind interatrial shunt,C9760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,26647.43,,,,,,,fee schedule,26647.43,118225.65,APC
Non-blind interatrial shunt,C9760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40770.57,,,,,,,fee schedule,26647.43,118225.65,Radiology
Non-blind interatrial shunt,C9760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,37306.41,,,,,,,fee schedule,26647.43,118225.65,APC
Non-blind interatrial shunt,C9760,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,46633.01,,,,,,,fee schedule,26647.43,118225.65,APC
"Cysto, litho, vacuum kidney",C9761,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16684.54,,,,,,,fee schedule,9371.49,41578.13,
"Cysto, litho, vacuum kidney",C9761,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13374.12,,,,,,,fee schedule,9371.49,41578.13,
"Cysto, litho, vacuum kidney",C9761,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14610.01,,,,,,,fee schedule,9371.49,41578.13,
"Cysto, litho, vacuum kidney",C9761,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15360.37,,,,,,,fee schedule,9371.49,41578.13,
"Cysto, litho, vacuum kidney",C9761,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,41578.13,,,,,,,fee schedule,9371.49,41578.13,APC 378
"Cysto, litho, vacuum kidney",C9761,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9840.06,,,,,,,fee schedule,9371.49,41578.13,APC
"Cysto, litho, vacuum kidney",C9761,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9746.35,,,,,,,fee schedule,9371.49,41578.13,APC
"Cysto, litho, vacuum kidney",C9761,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9371.49,,,,,,,fee schedule,9371.49,41578.13,APC
"Cysto, litho, vacuum kidney",C9761,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14338.38,,,,,,,fee schedule,9371.49,41578.13,Radiology
"Cysto, litho, vacuum kidney",C9761,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13120.09,,,,,,,fee schedule,9371.49,41578.13,APC
"Cysto, litho, vacuum kidney",C9761,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16400.11,,,,,,,fee schedule,9371.49,41578.13,APC
Cardiac MRI seg dys strain,C9762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1825.32,,,,,,,fee schedule,540.93,2399.94,
Cardiac MRI seg dys strain,C9762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1463.16,,,,,,,fee schedule,540.93,2399.94,
Cardiac MRI seg dys strain,C9762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1598.37,,,,,,,fee schedule,540.93,2399.94,
Cardiac MRI seg dys strain,C9762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1680.46,,,,,,,fee schedule,540.93,2399.94,
Cardiac MRI seg dys strain,C9762,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2399.94,,,,,,,fee schedule,540.93,2399.94,APC 378
Cardiac MRI seg dys strain,C9762,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,567.98,,,,,,,fee schedule,540.93,2399.94,APC
Cardiac MRI seg dys strain,C9762,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,562.57,,,,,,,fee schedule,540.93,2399.94,APC
Cardiac MRI seg dys strain,C9762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,540.93,,,,,,,fee schedule,540.93,2399.94,APC
Cardiac MRI seg dys strain,C9762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,827.63,,,,,,,fee schedule,540.93,2399.94,Radiology
Cardiac MRI seg dys strain,C9762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,757.31,,,,,,,fee schedule,540.93,2399.94,APC
Cardiac MRI seg dys strain,C9762,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,946.63,,,,,,,fee schedule,540.93,2399.94,APC
Cardiac MRI seg dys stress,C9763,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1825.32,,,,,,,fee schedule,540.93,2399.94,
Cardiac MRI seg dys stress,C9763,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1463.16,,,,,,,fee schedule,540.93,2399.94,
Cardiac MRI seg dys stress,C9763,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1598.37,,,,,,,fee schedule,540.93,2399.94,
Cardiac MRI seg dys stress,C9763,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1680.46,,,,,,,fee schedule,540.93,2399.94,
Cardiac MRI seg dys stress,C9763,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2399.94,,,,,,,fee schedule,540.93,2399.94,APC 378
Cardiac MRI seg dys stress,C9763,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,567.98,,,,,,,fee schedule,540.93,2399.94,APC
Cardiac MRI seg dys stress,C9763,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,562.57,,,,,,,fee schedule,540.93,2399.94,APC
Cardiac MRI seg dys stress,C9763,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,540.93,,,,,,,fee schedule,540.93,2399.94,APC
Cardiac MRI seg dys stress,C9763,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,827.63,,,,,,,fee schedule,540.93,2399.94,Radiology
Cardiac MRI seg dys stress,C9763,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,757.31,,,,,,,fee schedule,540.93,2399.94,APC
Cardiac MRI seg dys stress,C9763,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,946.63,,,,,,,fee schedule,540.93,2399.94,APC
Revasc intravasc lithotripsy,C9764,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18736.86,,,,,,,fee schedule,11428.37,50703.82,
Revasc intravasc lithotripsy,C9764,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15019.23,,,,,,,fee schedule,11428.37,50703.82,
Revasc intravasc lithotripsy,C9764,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16407.14,,,,,,,fee schedule,11428.37,50703.82,
Revasc intravasc lithotripsy,C9764,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17249.8,,,,,,,fee schedule,11428.37,50703.82,
Revasc intravasc lithotripsy,C9764,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,50703.82,,,,,,,fee schedule,11428.37,50703.82,APC 378
Revasc intravasc lithotripsy,C9764,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11999.79,,,,,,,fee schedule,11428.37,50703.82,APC
Revasc intravasc lithotripsy,C9764,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11885.51,,,,,,,fee schedule,11428.37,50703.82,APC
Revasc intravasc lithotripsy,C9764,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11428.37,,,,,,,fee schedule,11428.37,50703.82,APC
Revasc intravasc lithotripsy,C9764,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17485.41,,,,,,,fee schedule,11428.37,50703.82,Radiology
Revasc intravasc lithotripsy,C9764,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15999.72,,,,,,,fee schedule,11428.37,50703.82,APC
Revasc intravasc lithotripsy,C9764,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19999.65,,,,,,,fee schedule,11428.37,50703.82,APC
Revasc intra lithotrip-stent,C9765,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37962.31,,,,,,,fee schedule,18147.73,80515.32,
Revasc intra lithotrip-stent,C9765,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,30430.11,,,,,,,fee schedule,18147.73,80515.32,
Revasc intra lithotrip-stent,C9765,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,33242.13,,,,,,,fee schedule,18147.73,80515.32,
Revasc intra lithotrip-stent,C9765,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,34949.43,,,,,,,fee schedule,18147.73,80515.32,
Revasc intra lithotrip-stent,C9765,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,80515.32,,,,,,,fee schedule,18147.73,80515.32,APC 378
Revasc intra lithotrip-stent,C9765,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19055.11,,,,,,,fee schedule,18147.73,80515.32,APC
Revasc intra lithotrip-stent,C9765,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18873.64,,,,,,,fee schedule,18147.73,80515.32,APC
Revasc intra lithotrip-stent,C9765,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18147.73,,,,,,,fee schedule,18147.73,80515.32,APC
Revasc intra lithotrip-stent,C9765,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27766.02,,,,,,,fee schedule,18147.73,80515.32,Radiology
Revasc intra lithotrip-stent,C9765,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25406.82,,,,,,,fee schedule,18147.73,80515.32,APC
Revasc intra lithotrip-stent,C9765,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31758.52,,,,,,,fee schedule,18147.73,80515.32,APC
Revasc intra lithotrip-ather,C9766,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37962.31,,,,,,,fee schedule,18147.73,80515.32,
Revasc intra lithotrip-ather,C9766,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,30430.11,,,,,,,fee schedule,18147.73,80515.32,
Revasc intra lithotrip-ather,C9766,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,33242.13,,,,,,,fee schedule,18147.73,80515.32,
Revasc intra lithotrip-ather,C9766,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,34949.43,,,,,,,fee schedule,18147.73,80515.32,
Revasc intra lithotrip-ather,C9766,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,80515.32,,,,,,,fee schedule,18147.73,80515.32,APC 378
Revasc intra lithotrip-ather,C9766,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19055.11,,,,,,,fee schedule,18147.73,80515.32,APC
Revasc intra lithotrip-ather,C9766,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18873.64,,,,,,,fee schedule,18147.73,80515.32,APC
Revasc intra lithotrip-ather,C9766,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18147.73,,,,,,,fee schedule,18147.73,80515.32,APC
Revasc intra lithotrip-ather,C9766,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27766.02,,,,,,,fee schedule,18147.73,80515.32,Radiology
Revasc intra lithotrip-ather,C9766,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25406.82,,,,,,,fee schedule,18147.73,80515.32,APC
Revasc intra lithotrip-ather,C9766,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31758.52,,,,,,,fee schedule,18147.73,80515.32,APC
Revasc lithotrip-stent-ather,C9767,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60721.92,,,,,,,fee schedule,18147.73,80515.32,
Revasc lithotrip-stent-ather,C9767,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48673.92,,,,,,,fee schedule,18147.73,80515.32,
Revasc lithotrip-stent-ather,C9767,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53171.84,,,,,,,fee schedule,18147.73,80515.32,
Revasc lithotrip-stent-ather,C9767,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55902.72,,,,,,,fee schedule,18147.73,80515.32,
Revasc lithotrip-stent-ather,C9767,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,80515.32,,,,,,,fee schedule,18147.73,80515.32,APC 378
Revasc lithotrip-stent-ather,C9767,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19055.11,,,,,,,fee schedule,18147.73,80515.32,APC
Revasc lithotrip-stent-ather,C9767,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18873.64,,,,,,,fee schedule,18147.73,80515.32,APC
Revasc lithotrip-stent-ather,C9767,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18147.73,,,,,,,fee schedule,18147.73,80515.32,APC
Revasc lithotrip-stent-ather,C9767,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27766.02,,,,,,,fee schedule,18147.73,80515.32,Radiology
Revasc lithotrip-stent-ather,C9767,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25406.82,,,,,,,fee schedule,18147.73,80515.32,APC
Revasc lithotrip-stent-ather,C9767,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31758.52,,,,,,,fee schedule,18147.73,80515.32,APC
Cysto w/temp pros implant,C9769,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16684.54,,,,,,,fee schedule,13374.12,16684.54,
Cysto w/temp pros implant,C9769,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13374.12,,,,,,,fee schedule,13374.12,16684.54,
Cysto w/temp pros implant,C9769,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14610.01,,,,,,,fee schedule,13374.12,16684.54,
Cysto w/temp pros implant,C9769,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15360.37,,,,,,,fee schedule,13374.12,16684.54,
"Vitrec/mech pars, subret inj",C9770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12286.89,,,,,,,fee schedule,9849.02,12286.89,
"Vitrec/mech pars, subret inj",C9770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9849.02,,,,,,,fee schedule,9849.02,12286.89,
"Vitrec/mech pars, subret inj",C9770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10759.16,,,,,,,fee schedule,9849.02,12286.89,
"Vitrec/mech pars, subret inj",C9770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11311.74,,,,,,,fee schedule,9849.02,12286.89,
Nsl/sins cryo post nasal tis,C9771,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10343.55,,,,,,,fee schedule,8291.26,10343.55,
Nsl/sins cryo post nasal tis,C9771,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8291.26,,,,,,,fee schedule,8291.26,10343.55,
Nsl/sins cryo post nasal tis,C9771,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9057.45,,,,,,,fee schedule,8291.26,10343.55,
Nsl/sins cryo post nasal tis,C9771,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9522.64,,,,,,,fee schedule,8291.26,10343.55,
Revasc lithotrip tibi/perone,C9772,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37962.31,,,,,,,fee schedule,11428.37,50703.82,
Revasc lithotrip tibi/perone,C9772,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,30430.11,,,,,,,fee schedule,11428.37,50703.82,
Revasc lithotrip tibi/perone,C9772,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,33242.13,,,,,,,fee schedule,11428.37,50703.82,
Revasc lithotrip tibi/perone,C9772,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,34949.43,,,,,,,fee schedule,11428.37,50703.82,
Revasc lithotrip tibi/perone,C9772,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,50703.82,,,,,,,fee schedule,11428.37,50703.82,APC 378
Revasc lithotrip tibi/perone,C9772,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11999.79,,,,,,,fee schedule,11428.37,50703.82,APC
Revasc lithotrip tibi/perone,C9772,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11885.51,,,,,,,fee schedule,11428.37,50703.82,APC
Revasc lithotrip tibi/perone,C9772,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11428.37,,,,,,,fee schedule,11428.37,50703.82,APC
Revasc lithotrip tibi/perone,C9772,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17485.41,,,,,,,fee schedule,11428.37,50703.82,Radiology
Revasc lithotrip tibi/perone,C9772,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15999.72,,,,,,,fee schedule,11428.37,50703.82,APC
Revasc lithotrip tibi/perone,C9772,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19999.65,,,,,,,fee schedule,11428.37,50703.82,APC
Revasc lithotr-stent tib/per,C9773,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60721.92,,,,,,,fee schedule,18147.73,80515.32,
Revasc lithotr-stent tib/per,C9773,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48673.92,,,,,,,fee schedule,18147.73,80515.32,
Revasc lithotr-stent tib/per,C9773,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53171.84,,,,,,,fee schedule,18147.73,80515.32,
Revasc lithotr-stent tib/per,C9773,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55902.72,,,,,,,fee schedule,18147.73,80515.32,
Revasc lithotr-stent tib/per,C9773,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,80515.32,,,,,,,fee schedule,18147.73,80515.32,APC 378
Revasc lithotr-stent tib/per,C9773,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19055.11,,,,,,,fee schedule,18147.73,80515.32,APC
Revasc lithotr-stent tib/per,C9773,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18873.64,,,,,,,fee schedule,18147.73,80515.32,APC
Revasc lithotr-stent tib/per,C9773,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18147.73,,,,,,,fee schedule,18147.73,80515.32,APC
Revasc lithotr-stent tib/per,C9773,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27766.02,,,,,,,fee schedule,18147.73,80515.32,Radiology
Revasc lithotr-stent tib/per,C9773,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25406.82,,,,,,,fee schedule,18147.73,80515.32,APC
Revasc lithotr-stent tib/per,C9773,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31758.52,,,,,,,fee schedule,18147.73,80515.32,APC
Revasc lithotr-ather tib/per,C9774,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60721.92,,,,,,,fee schedule,18147.73,80515.32,
Revasc lithotr-ather tib/per,C9774,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48673.92,,,,,,,fee schedule,18147.73,80515.32,
Revasc lithotr-ather tib/per,C9774,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53171.84,,,,,,,fee schedule,18147.73,80515.32,
Revasc lithotr-ather tib/per,C9774,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55902.72,,,,,,,fee schedule,18147.73,80515.32,
Revasc lithotr-ather tib/per,C9774,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,80515.32,,,,,,,fee schedule,18147.73,80515.32,APC 378
Revasc lithotr-ather tib/per,C9774,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19055.11,,,,,,,fee schedule,18147.73,80515.32,APC
Revasc lithotr-ather tib/per,C9774,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18873.64,,,,,,,fee schedule,18147.73,80515.32,APC
Revasc lithotr-ather tib/per,C9774,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18147.73,,,,,,,fee schedule,18147.73,80515.32,APC
Revasc lithotr-ather tib/per,C9774,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27766.02,,,,,,,fee schedule,18147.73,80515.32,Radiology
Revasc lithotr-ather tib/per,C9774,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25406.82,,,,,,,fee schedule,18147.73,80515.32,APC
Revasc lithotr-ather tib/per,C9774,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31758.52,,,,,,,fee schedule,18147.73,80515.32,APC
Revasc lith-sten-ath tib/per,C9775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60721.92,,,,,,,fee schedule,18147.73,80515.32,
Revasc lith-sten-ath tib/per,C9775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48673.92,,,,,,,fee schedule,18147.73,80515.32,
Revasc lith-sten-ath tib/per,C9775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53171.84,,,,,,,fee schedule,18147.73,80515.32,
Revasc lith-sten-ath tib/per,C9775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55902.72,,,,,,,fee schedule,18147.73,80515.32,
Revasc lith-sten-ath tib/per,C9775,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,80515.32,,,,,,,fee schedule,18147.73,80515.32,APC 378
Revasc lith-sten-ath tib/per,C9775,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19055.11,,,,,,,fee schedule,18147.73,80515.32,APC
Revasc lith-sten-ath tib/per,C9775,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18873.64,,,,,,,fee schedule,18147.73,80515.32,APC
Revasc lith-sten-ath tib/per,C9775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18147.73,,,,,,,fee schedule,18147.73,80515.32,APC
Revasc lith-sten-ath tib/per,C9775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27766.02,,,,,,,fee schedule,18147.73,80515.32,Radiology
Revasc lith-sten-ath tib/per,C9775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25406.82,,,,,,,fee schedule,18147.73,80515.32,APC
Revasc lith-sten-ath tib/per,C9775,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31758.52,,,,,,,fee schedule,18147.73,80515.32,APC
Esophag mucosal integ add-on,C9777,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11853.7,,,,,,,fee schedule,3816.79,16933.82,
Esophag mucosal integ add-on,C9777,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9501.78,,,,,,,fee schedule,3816.79,16933.82,
Esophag mucosal integ add-on,C9777,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10379.83,,,,,,,fee schedule,3816.79,16933.82,
Esophag mucosal integ add-on,C9777,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10912.93,,,,,,,fee schedule,3816.79,16933.82,
Esophag mucosal integ add-on,C9777,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16933.82,,,,,,,fee schedule,3816.79,16933.82,APC 378
Esophag mucosal integ add-on,C9777,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4007.63,,,,,,,fee schedule,3816.79,16933.82,APC
Esophag mucosal integ add-on,C9777,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3969.46,,,,,,,fee schedule,3816.79,16933.82,APC
Esophag mucosal integ add-on,C9777,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3816.79,,,,,,,fee schedule,3816.79,16933.82,APC
Esophag mucosal integ add-on,C9777,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5839.69,,,,,,,fee schedule,3816.79,16933.82,Radiology
Esophag mucosal integ add-on,C9777,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5343.51,,,,,,,fee schedule,3816.79,16933.82,APC
Esophag mucosal integ add-on,C9777,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6679.39,,,,,,,fee schedule,3816.79,16933.82,APC
"Colpopexy, min/inv, ex-perit",C9778,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17023.19,,,,,,,fee schedule,4952.26,21971.51,
"Colpopexy, min/inv, ex-perit",C9778,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13645.57,,,,,,,fee schedule,4952.26,21971.51,
"Colpopexy, min/inv, ex-perit",C9778,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14906.55,,,,,,,fee schedule,4952.26,21971.51,
"Colpopexy, min/inv, ex-perit",C9778,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15672.15,,,,,,,fee schedule,4952.26,21971.51,
"Colpopexy, min/inv, ex-perit",C9778,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21971.51,,,,,,,fee schedule,4952.26,21971.51,APC 378
"Colpopexy, min/inv, ex-perit",C9778,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5199.88,,,,,,,fee schedule,4952.26,21971.51,APC
"Colpopexy, min/inv, ex-perit",C9778,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5150.35,,,,,,,fee schedule,4952.26,21971.51,APC
"Colpopexy, min/inv, ex-perit",C9778,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4952.26,,,,,,,fee schedule,4952.26,21971.51,APC
"Colpopexy, min/inv, ex-perit",C9778,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7576.96,,,,,,,fee schedule,4952.26,21971.51,Radiology
"Colpopexy, min/inv, ex-perit",C9778,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6933.17,,,,,,,fee schedule,4952.26,21971.51,APC
"Colpopexy, min/inv, ex-perit",C9778,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8666.46,,,,,,,fee schedule,4952.26,21971.51,APC
ESD endoscopy or colonoscopy,C9779,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9431.25,,,,,,,fee schedule,3816.79,16933.82,
ESD endoscopy or colonoscopy,C9779,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7559.97,,,,,,,fee schedule,3816.79,16933.82,
ESD endoscopy or colonoscopy,C9779,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8258.58,,,,,,,fee schedule,3816.79,16933.82,
ESD endoscopy or colonoscopy,C9779,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8682.74,,,,,,,fee schedule,3816.79,16933.82,
ESD endoscopy or colonoscopy,C9779,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16933.82,,,,,,,fee schedule,3816.79,16933.82,APC 378
ESD endoscopy or colonoscopy,C9779,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4007.63,,,,,,,fee schedule,3816.79,16933.82,APC
ESD endoscopy or colonoscopy,C9779,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3969.46,,,,,,,fee schedule,3816.79,16933.82,APC
ESD endoscopy or colonoscopy,C9779,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3816.79,,,,,,,fee schedule,3816.79,16933.82,APC
ESD endoscopy or colonoscopy,C9779,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5839.69,,,,,,,fee schedule,3816.79,16933.82,Radiology
ESD endoscopy or colonoscopy,C9779,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5343.51,,,,,,,fee schedule,3816.79,16933.82,APC
ESD endoscopy or colonoscopy,C9779,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6679.39,,,,,,,fee schedule,3816.79,16933.82,APC
Insert cv cath inf & sup app,C9780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,31186.89,,,,,,,fee schedule,7994.57,35469.2,
Insert cv cath inf & sup app,C9780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24999.02,,,,,,,fee schedule,7994.57,35469.2,
Insert cv cath inf & sup app,C9780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,27309.16,,,,,,,fee schedule,7994.57,35469.2,
Insert cv cath inf & sup app,C9780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,28711.74,,,,,,,fee schedule,7994.57,35469.2,
Insert cv cath inf & sup app,C9780,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,35469.2,,,,,,,fee schedule,7994.57,35469.2,APC 378
Insert cv cath inf & sup app,C9780,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8394.3,,,,,,,fee schedule,7994.57,35469.2,APC
Insert cv cath inf & sup app,C9780,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8314.35,,,,,,,fee schedule,7994.57,35469.2,APC
Insert cv cath inf & sup app,C9780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7994.57,,,,,,,fee schedule,7994.57,35469.2,APC
Insert cv cath inf & sup app,C9780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12231.69,,,,,,,fee schedule,7994.57,35469.2,Radiology
Insert cv cath inf & sup app,C9780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11192.4,,,,,,,fee schedule,7994.57,35469.2,APC
Insert cv cath inf & sup app,C9780,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,13990.5,,,,,,,fee schedule,7994.57,35469.2,APC
Arthro/shoul surg; w/spacer,C9781,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24180.85,,,,,,,fee schedule,12709.88,56389.43,
Arthro/shoul surg; w/spacer,C9781,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19383.06,,,,,,,fee schedule,12709.88,56389.43,
Arthro/shoul surg; w/spacer,C9781,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21174.24,,,,,,,fee schedule,12709.88,56389.43,
Arthro/shoul surg; w/spacer,C9781,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22261.73,,,,,,,fee schedule,12709.88,56389.43,
Arthro/shoul surg; w/spacer,C9781,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,56389.43,,,,,,,fee schedule,12709.88,56389.43,APC 378
Arthro/shoul surg; w/spacer,C9781,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13345.37,,,,,,,fee schedule,12709.88,56389.43,APC
Arthro/shoul surg; w/spacer,C9781,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13218.27,,,,,,,fee schedule,12709.88,56389.43,APC
Arthro/shoul surg; w/spacer,C9781,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12709.88,,,,,,,fee schedule,12709.88,56389.43,APC
Arthro/shoul surg; w/spacer,C9781,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19446.11,,,,,,,fee schedule,12709.88,56389.43,Radiology
Arthro/shoul surg; w/spacer,C9781,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17793.83,,,,,,,fee schedule,12709.88,56389.43,APC
Arthro/shoul surg; w/spacer,C9781,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22242.29,,,,,,,fee schedule,12709.88,56389.43,APC
Blind myocar trpl bon marrow,C9782,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,36856.89,,,,,,,fee schedule,16957.63,75235.29,
Blind myocar trpl bon marrow,C9782,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29544.02,,,,,,,fee schedule,16957.63,75235.29,
Blind myocar trpl bon marrow,C9782,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32274.16,,,,,,,fee schedule,16957.63,75235.29,
Blind myocar trpl bon marrow,C9782,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33931.74,,,,,,,fee schedule,16957.63,75235.29,
Blind myocar trpl bon marrow,C9782,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,75235.29,,,,,,,fee schedule,16957.63,75235.29,APC 378
Blind myocar trpl bon marrow,C9782,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17805.52,,,,,,,fee schedule,16957.63,75235.29,APC
Blind myocar trpl bon marrow,C9782,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,17635.94,,,,,,,fee schedule,16957.63,75235.29,APC
Blind myocar trpl bon marrow,C9782,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16957.63,,,,,,,fee schedule,16957.63,75235.29,APC
Blind myocar trpl bon marrow,C9782,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25945.18,,,,,,,fee schedule,16957.63,75235.29,Radiology
Blind myocar trpl bon marrow,C9782,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23740.69,,,,,,,fee schedule,16957.63,75235.29,APC
Blind myocar trpl bon marrow,C9782,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,29675.86,,,,,,,fee schedule,16957.63,75235.29,APC
Blind cor sinus reducer impl,C9783,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,38777.09,,,,,,,fee schedule,11428.37,50703.82,
Blind cor sinus reducer impl,C9783,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31083.22,,,,,,,fee schedule,11428.37,50703.82,
Blind cor sinus reducer impl,C9783,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,33955.6,,,,,,,fee schedule,11428.37,50703.82,
Blind cor sinus reducer impl,C9783,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,35699.55,,,,,,,fee schedule,11428.37,50703.82,
Blind cor sinus reducer impl,C9783,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,50703.82,,,,,,,fee schedule,11428.37,50703.82,APC 378
Blind cor sinus reducer impl,C9783,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11999.79,,,,,,,fee schedule,11428.37,50703.82,APC
Blind cor sinus reducer impl,C9783,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11885.51,,,,,,,fee schedule,11428.37,50703.82,APC
Blind cor sinus reducer impl,C9783,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11428.37,,,,,,,fee schedule,11428.37,50703.82,APC
Blind cor sinus reducer impl,C9783,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17485.41,,,,,,,fee schedule,11428.37,50703.82,Radiology
Blind cor sinus reducer impl,C9783,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15999.72,,,,,,,fee schedule,11428.37,50703.82,APC
Blind cor sinus reducer impl,C9783,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19999.65,,,,,,,fee schedule,11428.37,50703.82,APC
Endo sleeve gastro w/tube,C9784,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37111.93,,,,,,,fee schedule,29748.45,37111.93,
Endo sleeve gastro w/tube,C9784,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29748.45,,,,,,,fee schedule,29748.45,37111.93,
Endo sleeve gastro w/tube,C9784,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32497.48,,,,,,,fee schedule,29748.45,37111.93,
Endo sleeve gastro w/tube,C9784,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,34166.54,,,,,,,fee schedule,29748.45,37111.93,
Endo outlet restrict w/tube,C9785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37111.93,,,,,,,fee schedule,10523.19,46687.84,
Endo outlet restrict w/tube,C9785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29748.45,,,,,,,fee schedule,10523.19,46687.84,
Endo outlet restrict w/tube,C9785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32497.48,,,,,,,fee schedule,10523.19,46687.84,
Endo outlet restrict w/tube,C9785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,34166.54,,,,,,,fee schedule,10523.19,46687.84,
Endo outlet restrict w/tube,C9785,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46687.84,,,,,,,fee schedule,10523.19,46687.84,APC 378
Endo outlet restrict w/tube,C9785,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11049.35,,,,,,,fee schedule,10523.19,46687.84,APC
Endo outlet restrict w/tube,C9785,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10944.12,,,,,,,fee schedule,10523.19,46687.84,APC
Endo outlet restrict w/tube,C9785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10523.19,,,,,,,fee schedule,10523.19,46687.84,APC
Endo outlet restrict w/tube,C9785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16100.48,,,,,,,fee schedule,10523.19,46687.84,Radiology
Endo outlet restrict w/tube,C9785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14732.47,,,,,,,fee schedule,10523.19,46687.84,APC
Endo outlet restrict w/tube,C9785,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18415.58,,,,,,,fee schedule,10523.19,46687.84,APC
Echo cad for hf preserved ef,C9786,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1076.85,,,,,,,fee schedule,863.19,1076.85,
Echo cad for hf preserved ef,C9786,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,863.19,,,,,,,fee schedule,863.19,1076.85,
Echo cad for hf preserved ef,C9786,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,942.95,,,,,,,fee schedule,863.19,1076.85,
Echo cad for hf preserved ef,C9786,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,991.38,,,,,,,fee schedule,863.19,1076.85,
Gastric ep mapg simult pt sx,C9787,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1932.34,,,,,,,fee schedule,1548.94,1932.34,
Gastric ep mapg simult pt sx,C9787,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1548.94,,,,,,,fee schedule,1548.94,1932.34,
Gastric ep mapg simult pt sx,C9787,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1692.07,,,,,,,fee schedule,1548.94,1932.34,
Gastric ep mapg simult pt sx,C9787,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1778.98,,,,,,,fee schedule,1548.94,1932.34,
Instill pharm renal pelvis,C9789,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8506.89,,,,,,,fee schedule,1211.71,8506.89,
Instill pharm renal pelvis,C9789,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6819.02,,,,,,,fee schedule,1211.71,8506.89,
Instill pharm renal pelvis,C9789,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7449.16,,,,,,,fee schedule,1211.71,8506.89,
Instill pharm renal pelvis,C9789,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7831.74,,,,,,,fee schedule,1211.71,8506.89,
Instill pharm renal pelvis,C9789,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5375.94,,,,,,,fee schedule,1211.71,8506.89,APC 378
Instill pharm renal pelvis,C9789,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1272.29,,,,,,,fee schedule,1211.71,8506.89,APC
Instill pharm renal pelvis,C9789,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1260.18,,,,,,,fee schedule,1211.71,8506.89,APC
Instill pharm renal pelvis,C9789,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1211.71,,,,,,,fee schedule,1211.71,8506.89,APC
Instill pharm renal pelvis,C9789,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1853.92,,,,,,,fee schedule,1211.71,8506.89,Radiology
Instill pharm renal pelvis,C9789,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1696.39,,,,,,,fee schedule,1211.71,8506.89,APC
Instill pharm renal pelvis,C9789,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2120.49,,,,,,,fee schedule,1211.71,8506.89,APC
Kidney histotripsy w/image,C9790,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,47251.89,,,,,,,fee schedule,37876.52,47251.89,
Kidney histotripsy w/image,C9790,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37876.52,,,,,,,fee schedule,37876.52,47251.89,
Kidney histotripsy w/image,C9790,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,41376.66,,,,,,,fee schedule,37876.52,47251.89,
Kidney histotripsy w/image,C9790,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,43501.74,,,,,,,fee schedule,37876.52,47251.89,
Mri hyperpolarized xenon129,C9791,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4726.89,,,,,,,fee schedule,1211.71,5375.94,
Mri hyperpolarized xenon129,C9791,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3789.02,,,,,,,fee schedule,1211.71,5375.94,
Mri hyperpolarized xenon129,C9791,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4139.16,,,,,,,fee schedule,1211.71,5375.94,
Mri hyperpolarized xenon129,C9791,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4351.74,,,,,,,fee schedule,1211.71,5375.94,
Mri hyperpolarized xenon129,C9791,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5375.94,,,,,,,fee schedule,1211.71,5375.94,APC 378
Mri hyperpolarized xenon129,C9791,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1272.29,,,,,,,fee schedule,1211.71,5375.94,APC
Mri hyperpolarized xenon129,C9791,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1260.18,,,,,,,fee schedule,1211.71,5375.94,APC
Mri hyperpolarized xenon129,C9791,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1211.71,,,,,,,fee schedule,1211.71,5375.94,APC
Mri hyperpolarized xenon129,C9791,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1853.92,,,,,,,fee schedule,1211.71,5375.94,Radiology
Mri hyperpolarized xenon129,C9791,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1696.39,,,,,,,fee schedule,1211.71,5375.94,APC
Mri hyperpolarized xenon129,C9791,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2120.49,,,,,,,fee schedule,1211.71,5375.94,APC
Blind/nonblind trans atrial,C9792,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,36856.89,,,,,,,fee schedule,9448.04,41917.75,
Blind/nonblind trans atrial,C9792,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29544.02,,,,,,,fee schedule,9448.04,41917.75,
Blind/nonblind trans atrial,C9792,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32274.16,,,,,,,fee schedule,9448.04,41917.75,
Blind/nonblind trans atrial,C9792,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33931.74,,,,,,,fee schedule,9448.04,41917.75,
Blind/nonblind trans atrial,C9792,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,41917.75,,,,,,,fee schedule,9448.04,41917.75,APC 378
Blind/nonblind trans atrial,C9792,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9920.44,,,,,,,fee schedule,9448.04,41917.75,APC
Blind/nonblind trans atrial,C9792,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9825.96,,,,,,,fee schedule,9448.04,41917.75,APC
Blind/nonblind trans atrial,C9792,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9448.04,,,,,,,fee schedule,9448.04,41917.75,APC
Blind/nonblind trans atrial,C9792,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14455.5,,,,,,,fee schedule,9448.04,41917.75,Radiology
Blind/nonblind trans atrial,C9792,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13227.26,,,,,,,fee schedule,9448.04,41917.75,APC
Blind/nonblind trans atrial,C9792,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16534.07,,,,,,,fee schedule,9448.04,41917.75,APC
Pre-plan 3d model w/ccta,C9793,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3769.49,,,,,,,fee schedule,850.12,3771.72,
Pre-plan 3d model w/ccta,C9793,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3021.58,,,,,,,fee schedule,850.12,3771.72,
Pre-plan 3d model w/ccta,C9793,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3300.8,,,,,,,fee schedule,850.12,3771.72,
Pre-plan 3d model w/ccta,C9793,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3470.33,,,,,,,fee schedule,850.12,3771.72,
Pre-plan 3d model w/ccta,C9793,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3771.72,,,,,,,fee schedule,850.12,3771.72,APC 378
Pre-plan 3d model w/ccta,C9793,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,892.63,,,,,,,fee schedule,850.12,3771.72,APC
Pre-plan 3d model w/ccta,C9793,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,884.13,,,,,,,fee schedule,850.12,3771.72,APC
Pre-plan 3d model w/ccta,C9793,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,850.12,,,,,,,fee schedule,850.12,3771.72,APC
Pre-plan 3d model w/ccta,C9793,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1300.69,,,,,,,fee schedule,850.12,3771.72,Radiology
Pre-plan 3d model w/ccta,C9793,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1190.17,,,,,,,fee schedule,850.12,3771.72,APC
Pre-plan 3d model w/ccta,C9793,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1487.72,,,,,,,fee schedule,850.12,3771.72,APC
Complex simulation w/pet-ct,C9794,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7372.89,,,,,,,fee schedule,5910.02,7372.89,
Complex simulation w/pet-ct,C9794,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5910.02,,,,,,,fee schedule,5910.02,7372.89,
Complex simulation w/pet-ct,C9794,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6456.16,,,,,,,fee schedule,5910.02,7372.89,
Complex simulation w/pet-ct,C9794,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6787.74,,,,,,,fee schedule,5910.02,7372.89,
Sbrt w/positron emission del,C9795,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14176.89,,,,,,,fee schedule,11364.02,14176.89,
Sbrt w/positron emission del,C9795,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11364.02,,,,,,,fee schedule,11364.02,14176.89,
Sbrt w/positron emission del,C9795,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12414.16,,,,,,,fee schedule,11364.02,14176.89,
Sbrt w/positron emission del,C9795,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13051.74,,,,,,,fee schedule,11364.02,14176.89,
Rpr intst excl anrect fist,C9796,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12191.12,,,,,,,fee schedule,2747.81,12191.12,APC 378
Rpr intst excl anrect fist,C9796,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2885.2,,,,,,,fee schedule,2747.81,12191.12,APC
Rpr intst excl anrect fist,C9796,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2857.73,,,,,,,fee schedule,2747.81,12191.12,APC
Rpr intst excl anrect fist,C9796,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2747.81,,,,,,,fee schedule,2747.81,12191.12,APC
Rpr intst excl anrect fist,C9796,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4204.16,,,,,,,fee schedule,2747.81,12191.12,Radiology
Rpr intst excl anrect fist,C9796,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3846.94,,,,,,,fee schedule,2747.81,12191.12,APC
Rpr intst excl anrect fist,C9796,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4808.67,,,,,,,fee schedule,2747.81,12191.12,APC
Vasc emb/occ w/prs cath,C9797,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,80515.32,,,,,,,fee schedule,18147.73,80515.32,APC 378
Vasc emb/occ w/prs cath,C9797,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19055.11,,,,,,,fee schedule,18147.73,80515.32,APC
Vasc emb/occ w/prs cath,C9797,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18873.64,,,,,,,fee schedule,18147.73,80515.32,APC
Vasc emb/occ w/prs cath,C9797,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18147.73,,,,,,,fee schedule,18147.73,80515.32,APC
Vasc emb/occ w/prs cath,C9797,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27766.02,,,,,,,fee schedule,18147.73,80515.32,Radiology
Vasc emb/occ w/prs cath,C9797,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25406.82,,,,,,,fee schedule,18147.73,80515.32,APC
Vasc emb/occ w/prs cath,C9797,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31758.52,,,,,,,fee schedule,18147.73,80515.32,APC
HOPD covid-19 spec collect,C9803,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,93.25,,,,,,,fee schedule,74.75,93.25,
HOPD covid-19 spec collect,C9803,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,74.75,,,,,,,fee schedule,74.75,93.25,
HOPD covid-19 spec collect,C9803,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,81.66,,,,,,,fee schedule,74.75,93.25,
HOPD covid-19 spec collect,C9803,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,85.85,,,,,,,fee schedule,74.75,93.25,
Endo defect closure GI tract,C9901,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46687.84,,,,,,,fee schedule,10523.19,46687.84,APC 378
Endo defect closure GI tract,C9901,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11049.35,,,,,,,fee schedule,10523.19,46687.84,APC
Endo defect closure GI tract,C9901,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10944.12,,,,,,,fee schedule,10523.19,46687.84,APC
Endo defect closure GI tract,C9901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10523.19,,,,,,,fee schedule,10523.19,46687.84,APC
Endo defect closure GI tract,C9901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16100.48,,,,,,,fee schedule,10523.19,46687.84,Radiology
Endo defect closure GI tract,C9901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14732.47,,,,,,,fee schedule,10523.19,46687.84,APC
Endo defect closure GI tract,C9901,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18415.58,,,,,,,fee schedule,10523.19,46687.84,APC
Periodic oral evaluation,D0120,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.75,,,,,,,fee schedule,131.8,584.75,APC 378
Periodic oral evaluation,D0120,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.39,,,,,,,fee schedule,131.8,584.75,APC
Periodic oral evaluation,D0120,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,137.07,,,,,,,fee schedule,131.8,584.75,APC
Periodic oral evaluation,D0120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.8,,,,,,,fee schedule,131.8,584.75,APC
Periodic oral evaluation,D0120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.66,,,,,,,fee schedule,131.8,584.75,Radiology
Periodic oral evaluation,D0120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.52,,,,,,,fee schedule,131.8,584.75,APC
Periodic oral evaluation,D0120,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.65,,,,,,,fee schedule,131.8,584.75,APC
Limit oral eval problm focus,D0140,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.75,,,,,,,fee schedule,131.8,584.75,APC 378
Limit oral eval problm focus,D0140,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.39,,,,,,,fee schedule,131.8,584.75,APC
Limit oral eval problm focus,D0140,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,137.07,,,,,,,fee schedule,131.8,584.75,APC
Limit oral eval problm focus,D0140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.8,,,,,,,fee schedule,131.8,584.75,APC
Limit oral eval problm focus,D0140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.66,,,,,,,fee schedule,131.8,584.75,Radiology
Limit oral eval problm focus,D0140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.52,,,,,,,fee schedule,131.8,584.75,APC
Limit oral eval problm focus,D0140,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.65,,,,,,,fee schedule,131.8,584.75,APC
Comprehensve oral evaluation,D0150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2288.03,,,,,,,fee schedule,131.8,2288.03,
Comprehensve oral evaluation,D0150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1834.06,,,,,,,fee schedule,131.8,2288.03,
Comprehensve oral evaluation,D0150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2003.54,,,,,,,fee schedule,131.8,2288.03,
Comprehensve oral evaluation,D0150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2106.44,,,,,,,fee schedule,131.8,2288.03,
Comprehensve oral evaluation,D0150,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.75,,,,,,,fee schedule,131.8,2288.03,APC 378
Comprehensve oral evaluation,D0150,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.39,,,,,,,fee schedule,131.8,2288.03,APC
Comprehensve oral evaluation,D0150,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,137.07,,,,,,,fee schedule,131.8,2288.03,APC
Comprehensve oral evaluation,D0150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.8,,,,,,,fee schedule,131.8,2288.03,APC
Comprehensve oral evaluation,D0150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.66,,,,,,,fee schedule,131.8,2288.03,Radiology
Comprehensve oral evaluation,D0150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.52,,,,,,,fee schedule,131.8,2288.03,APC
Comprehensve oral evaluation,D0150,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.65,,,,,,,fee schedule,131.8,2288.03,APC
Extensv oral eval prob focus,D0160,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.75,,,,,,,fee schedule,131.8,584.75,APC 378
Extensv oral eval prob focus,D0160,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.39,,,,,,,fee schedule,131.8,584.75,APC
Extensv oral eval prob focus,D0160,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,137.07,,,,,,,fee schedule,131.8,584.75,APC
Extensv oral eval prob focus,D0160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.8,,,,,,,fee schedule,131.8,584.75,APC
Extensv oral eval prob focus,D0160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.66,,,,,,,fee schedule,131.8,584.75,Radiology
Extensv oral eval prob focus,D0160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.52,,,,,,,fee schedule,131.8,584.75,APC
Extensv oral eval prob focus,D0160,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.65,,,,,,,fee schedule,131.8,584.75,APC
"Re-eval,est pt,problem focus",D0170,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.75,,,,,,,fee schedule,131.8,584.75,APC 378
"Re-eval,est pt,problem focus",D0170,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.39,,,,,,,fee schedule,131.8,584.75,APC
"Re-eval,est pt,problem focus",D0170,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,137.07,,,,,,,fee schedule,131.8,584.75,APC
"Re-eval,est pt,problem focus",D0170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.8,,,,,,,fee schedule,131.8,584.75,APC
"Re-eval,est pt,problem focus",D0170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.66,,,,,,,fee schedule,131.8,584.75,Radiology
"Re-eval,est pt,problem focus",D0170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.52,,,,,,,fee schedule,131.8,584.75,APC
"Re-eval,est pt,problem focus",D0170,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.65,,,,,,,fee schedule,131.8,584.75,APC
Re-eval post-op visit,D0171,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.75,,,,,,,fee schedule,131.8,584.75,APC 378
Re-eval post-op visit,D0171,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.39,,,,,,,fee schedule,131.8,584.75,APC
Re-eval post-op visit,D0171,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,137.07,,,,,,,fee schedule,131.8,584.75,APC
Re-eval post-op visit,D0171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.8,,,,,,,fee schedule,131.8,584.75,APC
Re-eval post-op visit,D0171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.66,,,,,,,fee schedule,131.8,584.75,Radiology
Re-eval post-op visit,D0171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.52,,,,,,,fee schedule,131.8,584.75,APC
Re-eval post-op visit,D0171,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.65,,,,,,,fee schedule,131.8,584.75,APC
Comp periodontal evaluation,D0180,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.75,,,,,,,fee schedule,131.8,584.75,APC 378
Comp periodontal evaluation,D0180,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.39,,,,,,,fee schedule,131.8,584.75,APC
Comp periodontal evaluation,D0180,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,137.07,,,,,,,fee schedule,131.8,584.75,APC
Comp periodontal evaluation,D0180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.8,,,,,,,fee schedule,131.8,584.75,APC
Comp periodontal evaluation,D0180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.66,,,,,,,fee schedule,131.8,584.75,Radiology
Comp periodontal evaluation,D0180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.52,,,,,,,fee schedule,131.8,584.75,APC
Comp periodontal evaluation,D0180,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.65,,,,,,,fee schedule,131.8,584.75,APC
Assessment of a patient,D0191,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.75,,,,,,,fee schedule,131.8,584.75,APC 378
Assessment of a patient,D0191,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.39,,,,,,,fee schedule,131.8,584.75,APC
Assessment of a patient,D0191,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,137.07,,,,,,,fee schedule,131.8,584.75,APC
Assessment of a patient,D0191,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.8,,,,,,,fee schedule,131.8,584.75,APC
Assessment of a patient,D0191,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.66,,,,,,,fee schedule,131.8,584.75,Radiology
Assessment of a patient,D0191,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.52,,,,,,,fee schedule,131.8,584.75,APC
Assessment of a patient,D0191,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.65,,,,,,,fee schedule,131.8,584.75,APC
Intraor complete film series,D0210,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,236.21,1047.98,APC 378
Intraor complete film series,D0210,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,236.21,1047.98,APC
Intraor complete film series,D0210,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,236.21,1047.98,APC
Intraor complete film series,D0210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,236.21,1047.98,APC
Intraor complete film series,D0210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,236.21,1047.98,Radiology
Intraor complete film series,D0210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,236.21,1047.98,APC
Intraor complete film series,D0210,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,236.21,1047.98,APC
Intraoral periapical first,D0220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,476.63,,,,,,,fee schedule,86.15,476.63,
Intraoral periapical first,D0220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,382.06,,,,,,,fee schedule,86.15,476.63,
Intraoral periapical first,D0220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,417.37,,,,,,,fee schedule,86.15,476.63,
Intraoral periapical first,D0220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,438.8,,,,,,,fee schedule,86.15,476.63,
Intraoral periapical first,D0220,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,476.63,APC 378
Intraoral periapical first,D0220,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,476.63,APC
Intraoral periapical first,D0220,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,476.63,APC
Intraoral periapical first,D0220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,476.63,APC
Intraoral periapical first,D0220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,476.63,Radiology
Intraoral periapical first,D0220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,476.63,APC
Intraoral periapical first,D0220,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,476.63,APC
Intraoral periapical ea add,D0230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,413.92,,,,,,,fee schedule,331.8,413.92,
Intraoral periapical ea add,D0230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,331.8,,,,,,,fee schedule,331.8,413.92,
Intraoral periapical ea add,D0230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,362.46,,,,,,,fee schedule,331.8,413.92,
Intraoral periapical ea add,D0230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,381.07,,,,,,,fee schedule,331.8,413.92,
Intraoral occlusal film,D0240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,401.34,,,,,,,fee schedule,86.15,401.34,
Intraoral occlusal film,D0240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,321.71,,,,,,,fee schedule,86.15,401.34,
Intraoral occlusal film,D0240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,351.43,,,,,,,fee schedule,86.15,401.34,
Intraoral occlusal film,D0240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,369.48,,,,,,,fee schedule,86.15,401.34,
Intraoral occlusal film,D0240,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,401.34,APC 378
Intraoral occlusal film,D0240,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,401.34,APC
Intraoral occlusal film,D0240,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,401.34,APC
Intraoral occlusal film,D0240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,401.34,APC
Intraoral occlusal film,D0240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,401.34,Radiology
Intraoral occlusal film,D0240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,401.34,APC
Intraoral occlusal film,D0240,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,401.34,APC
Extraoral 2d project image,D0250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2288.03,,,,,,,fee schedule,86.15,2288.03,
Extraoral 2d project image,D0250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1834.06,,,,,,,fee schedule,86.15,2288.03,
Extraoral 2d project image,D0250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2003.54,,,,,,,fee schedule,86.15,2288.03,
Extraoral 2d project image,D0250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2106.44,,,,,,,fee schedule,86.15,2288.03,
Extraoral 2d project image,D0250,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,2288.03,APC 378
Extraoral 2d project image,D0250,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,2288.03,APC
Extraoral 2d project image,D0250,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,2288.03,APC
Extraoral 2d project image,D0250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,2288.03,APC
Extraoral 2d project image,D0250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,2288.03,Radiology
Extraoral 2d project image,D0250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,2288.03,APC
Extraoral 2d project image,D0250,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,2288.03,APC
Extraoral posterior image,D0251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,229.82,,,,,,,fee schedule,86.15,382.23,
Extraoral posterior image,D0251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,184.22,,,,,,,fee schedule,86.15,382.23,
Extraoral posterior image,D0251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,201.25,,,,,,,fee schedule,86.15,382.23,
Extraoral posterior image,D0251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,211.58,,,,,,,fee schedule,86.15,382.23,
Extraoral posterior image,D0251,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
Extraoral posterior image,D0251,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
Extraoral posterior image,D0251,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
Extraoral posterior image,D0251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
Extraoral posterior image,D0251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
Extraoral posterior image,D0251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
Extraoral posterior image,D0251,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
Dental bitewing single image,D0270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,370.65,,,,,,,fee schedule,86.15,382.23,
Dental bitewing single image,D0270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,297.1,,,,,,,fee schedule,86.15,382.23,
Dental bitewing single image,D0270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,324.56,,,,,,,fee schedule,86.15,382.23,
Dental bitewing single image,D0270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,341.23,,,,,,,fee schedule,86.15,382.23,
Dental bitewing single image,D0270,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
Dental bitewing single image,D0270,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
Dental bitewing single image,D0270,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
Dental bitewing single image,D0270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
Dental bitewing single image,D0270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
Dental bitewing single image,D0270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
Dental bitewing single image,D0270,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
Dental bitewings two images,D0272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,421.35,,,,,,,fee schedule,86.15,421.35,
Dental bitewings two images,D0272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,337.75,,,,,,,fee schedule,86.15,421.35,
Dental bitewings two images,D0272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,368.96,,,,,,,fee schedule,86.15,421.35,
Dental bitewings two images,D0272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,387.91,,,,,,,fee schedule,86.15,421.35,
Dental bitewings two images,D0272,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,421.35,APC 378
Dental bitewings two images,D0272,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,421.35,APC
Dental bitewings two images,D0272,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,421.35,APC
Dental bitewings two images,D0272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,421.35,APC
Dental bitewings two images,D0272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,421.35,Radiology
Dental bitewings two images,D0272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,421.35,APC
Dental bitewings two images,D0272,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,421.35,APC
Bitewings - three images,D0273,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,236.21,1047.98,APC 378
Bitewings - three images,D0273,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,236.21,1047.98,APC
Bitewings - three images,D0273,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,236.21,1047.98,APC
Bitewings - three images,D0273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,236.21,1047.98,APC
Bitewings - three images,D0273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,236.21,1047.98,Radiology
Bitewings - three images,D0273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,236.21,1047.98,APC
Bitewings - three images,D0273,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,236.21,1047.98,APC
Bitewings four images,D0274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1173.76,,,,,,,fee schedule,236.21,1173.76,
Bitewings four images,D0274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,940.87,,,,,,,fee schedule,236.21,1173.76,
Bitewings four images,D0274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1027.81,,,,,,,fee schedule,236.21,1173.76,
Bitewings four images,D0274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1080.6,,,,,,,fee schedule,236.21,1173.76,
Bitewings four images,D0274,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,236.21,1173.76,APC 378
Bitewings four images,D0274,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,236.21,1173.76,APC
Bitewings four images,D0274,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,236.21,1173.76,APC
Bitewings four images,D0274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,236.21,1173.76,APC
Bitewings four images,D0274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,236.21,1173.76,Radiology
Bitewings four images,D0274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,236.21,1173.76,APC
Bitewings four images,D0274,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,236.21,1173.76,APC
Vert bitewings 7 to 8 images,D0277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2288.03,,,,,,,fee schedule,236.21,2288.03,
Vert bitewings 7 to 8 images,D0277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1834.06,,,,,,,fee schedule,236.21,2288.03,
Vert bitewings 7 to 8 images,D0277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2003.54,,,,,,,fee schedule,236.21,2288.03,
Vert bitewings 7 to 8 images,D0277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2106.44,,,,,,,fee schedule,236.21,2288.03,
Vert bitewings 7 to 8 images,D0277,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,236.21,2288.03,APC 378
Vert bitewings 7 to 8 images,D0277,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,236.21,2288.03,APC
Vert bitewings 7 to 8 images,D0277,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,236.21,2288.03,APC
Vert bitewings 7 to 8 images,D0277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,236.21,2288.03,APC
Vert bitewings 7 to 8 images,D0277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,236.21,2288.03,Radiology
Vert bitewings 7 to 8 images,D0277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,236.21,2288.03,APC
Vert bitewings 7 to 8 images,D0277,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,236.21,2288.03,APC
Dental saliography,D0310,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,236.21,1047.98,APC 378
Dental saliography,D0310,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,236.21,1047.98,APC
Dental saliography,D0310,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,236.21,1047.98,APC
Dental saliography,D0310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,236.21,1047.98,APC
Dental saliography,D0310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,236.21,1047.98,Radiology
Dental saliography,D0310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,236.21,1047.98,APC
Dental saliography,D0310,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,236.21,1047.98,APC
Dental tmj arthrogram incl i,D0320,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,236.21,1047.98,APC 378
Dental tmj arthrogram incl i,D0320,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,236.21,1047.98,APC
Dental tmj arthrogram incl i,D0320,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,236.21,1047.98,APC
Dental tmj arthrogram incl i,D0320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,236.21,1047.98,APC
Dental tmj arthrogram incl i,D0320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,236.21,1047.98,Radiology
Dental tmj arthrogram incl i,D0320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,236.21,1047.98,APC
Dental tmj arthrogram incl i,D0320,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,236.21,1047.98,APC
Other tmj images by report,D0321,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
Other tmj images by report,D0321,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
Other tmj images by report,D0321,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
Other tmj images by report,D0321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
Other tmj images by report,D0321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
Other tmj images by report,D0321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
Other tmj images by report,D0321,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
Dental tomographic survey,D0322,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
Dental tomographic survey,D0322,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
Dental tomographic survey,D0322,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
Dental tomographic survey,D0322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
Dental tomographic survey,D0322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
Dental tomographic survey,D0322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
Dental tomographic survey,D0322,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Panoramic image,D0330,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1047.98,,,,,,,fee schedule,236.21,1047.98,APC 378
Panoramic image,D0330,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.02,,,,,,,fee schedule,236.21,1047.98,APC
Panoramic image,D0330,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.66,,,,,,,fee schedule,236.21,1047.98,APC
Panoramic image,D0330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.21,,,,,,,fee schedule,236.21,1047.98,APC
Panoramic image,D0330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.4,,,,,,,fee schedule,236.21,1047.98,Radiology
Panoramic image,D0330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.69,,,,,,,fee schedule,236.21,1047.98,APC
Panoramic image,D0330,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.36,,,,,,,fee schedule,236.21,1047.98,APC
2d cephalometric image,D0340,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
2d cephalometric image,D0340,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
2d cephalometric image,D0340,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
2d cephalometric image,D0340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
2d cephalometric image,D0340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
2d cephalometric image,D0340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
2d cephalometric image,D0340,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
Oral/facial photo images,D0350,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
Oral/facial photo images,D0350,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
Oral/facial photo images,D0350,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
Oral/facial photo images,D0350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
Oral/facial photo images,D0350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
Oral/facial photo images,D0350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
Oral/facial photo images,D0350,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
Cone beam ct capt & interp,D0364,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
Cone beam ct capt & interp,D0364,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
Cone beam ct capt & interp,D0364,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
Cone beam ct capt & interp,D0364,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
Cone beam ct capt & interp,D0364,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
Cone beam ct capt & interp,D0364,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
Cone beam ct capt & interp,D0364,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Cone beam ct interprete man,D0365,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
Cone beam ct interprete man,D0365,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
Cone beam ct interprete man,D0365,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
Cone beam ct interprete man,D0365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
Cone beam ct interprete man,D0365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
Cone beam ct interprete man,D0365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
Cone beam ct interprete man,D0365,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Cone beam ct interprete max,D0366,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
Cone beam ct interprete max,D0366,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
Cone beam ct interprete max,D0366,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
Cone beam ct interprete max,D0366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
Cone beam ct interprete max,D0366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
Cone beam ct interprete max,D0366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
Cone beam ct interprete max,D0366,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Cone beam ct interp both jaw,D0367,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
Cone beam ct interp both jaw,D0367,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
Cone beam ct interp both jaw,D0367,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
Cone beam ct interp both jaw,D0367,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
Cone beam ct interp both jaw,D0367,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
Cone beam ct interp both jaw,D0367,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
Cone beam ct interp both jaw,D0367,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Cone beam ct interprete TMJ,D0368,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
Cone beam ct interprete TMJ,D0368,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
Cone beam ct interprete TMJ,D0368,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
Cone beam ct interprete TMJ,D0368,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
Cone beam ct interprete TMJ,D0368,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
Cone beam ct interprete TMJ,D0368,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
Cone beam ct interprete TMJ,D0368,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Max MRI capture & interprete,D0369,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
Max MRI capture & interprete,D0369,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
Max MRI capture & interprete,D0369,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
Max MRI capture & interprete,D0369,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
Max MRI capture & interprete,D0369,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
Max MRI capture & interprete,D0369,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
Max MRI capture & interprete,D0369,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Max ultrasound capt & interp,D0370,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
Max ultrasound capt & interp,D0370,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
Max ultrasound capt & interp,D0370,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
Max ultrasound capt & interp,D0370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
Max ultrasound capt & interp,D0370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
Max ultrasound capt & interp,D0370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
Max ultrasound capt & interp,D0370,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Sialoendoscopy capt & interp,D0371,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
Sialoendoscopy capt & interp,D0371,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
Sialoendoscopy capt & interp,D0371,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
Sialoendoscopy capt & interp,D0371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
Sialoendoscopy capt & interp,D0371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
Sialoendoscopy capt & interp,D0371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
Sialoendoscopy capt & interp,D0371,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
Cone beam ct capture limited,D0380,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
Cone beam ct capture limited,D0380,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
Cone beam ct capture limited,D0380,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
Cone beam ct capture limited,D0380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
Cone beam ct capture limited,D0380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
Cone beam ct capture limited,D0380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
Cone beam ct capture limited,D0380,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Cone beam ct capt mandible,D0381,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
Cone beam ct capt mandible,D0381,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
Cone beam ct capt mandible,D0381,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
Cone beam ct capt mandible,D0381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
Cone beam ct capt mandible,D0381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
Cone beam ct capt mandible,D0381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
Cone beam ct capt mandible,D0381,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Cone beam ct capt maxilla,D0382,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
Cone beam ct capt maxilla,D0382,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
Cone beam ct capt maxilla,D0382,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
Cone beam ct capt maxilla,D0382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
Cone beam ct capt maxilla,D0382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
Cone beam ct capt maxilla,D0382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
Cone beam ct capt maxilla,D0382,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Cone beam ct both jaws,D0383,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
Cone beam ct both jaws,D0383,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
Cone beam ct both jaws,D0383,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
Cone beam ct both jaws,D0383,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
Cone beam ct both jaws,D0383,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
Cone beam ct both jaws,D0383,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
Cone beam ct both jaws,D0383,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Cone beam ct capture TMJ,D0384,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
Cone beam ct capture TMJ,D0384,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
Cone beam ct capture TMJ,D0384,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
Cone beam ct capture TMJ,D0384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
Cone beam ct capture TMJ,D0384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
Cone beam ct capture TMJ,D0384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
Cone beam ct capture TMJ,D0384,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Max MRI image capture,D0385,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
Max MRI image capture,D0385,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
Max MRI image capture,D0385,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
Max MRI image capture,D0385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
Max MRI image capture,D0385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
Max MRI image capture,D0385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
Max MRI image capture,D0385,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Max ultrasound image capture,D0386,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,103.5,459.18,APC 378
Max ultrasound image capture,D0386,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,103.5,459.18,APC
Max ultrasound image capture,D0386,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,103.5,459.18,APC
Max ultrasound image capture,D0386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,103.5,459.18,APC
Max ultrasound image capture,D0386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,103.5,459.18,Radiology
Max ultrasound image capture,D0386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,103.5,459.18,APC
Max ultrasound image capture,D0386,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,103.5,459.18,APC
Trtmnt simulation 3d image,D0393,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
Trtmnt simulation 3d image,D0393,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
Trtmnt simulation 3d image,D0393,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
Trtmnt simulation 3d image,D0393,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
Trtmnt simulation 3d image,D0393,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
Trtmnt simulation 3d image,D0393,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
Trtmnt simulation 3d image,D0393,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
Digital sub 2 or more images,D0394,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
Digital sub 2 or more images,D0394,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
Digital sub 2 or more images,D0394,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
Digital sub 2 or more images,D0394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
Digital sub 2 or more images,D0394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
Digital sub 2 or more images,D0394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
Digital sub 2 or more images,D0394,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
Fusion 2 or more 3d images,D0395,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
Fusion 2 or more 3d images,D0395,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
Fusion 2 or more 3d images,D0395,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
Fusion 2 or more 3d images,D0395,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
Fusion 2 or more 3d images,D0395,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
Fusion 2 or more 3d images,D0395,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
Fusion 2 or more 3d images,D0395,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
Viral culture,D0416,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,464.94,,,,,,,fee schedule,372.69,464.94,
Viral culture,D0416,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,372.69,,,,,,,fee schedule,372.69,464.94,
Viral culture,D0416,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,407.13,,,,,,,fee schedule,372.69,464.94,
Viral culture,D0416,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,428.04,,,,,,,fee schedule,372.69,464.94,
Diag tst detect mucos abnorm,D0431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,219.24,,,,,,,fee schedule,175.74,219.24,
Diag tst detect mucos abnorm,D0431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,175.74,,,,,,,fee schedule,175.74,219.24,
Diag tst detect mucos abnorm,D0431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,191.98,,,,,,,fee schedule,175.74,219.24,
Diag tst detect mucos abnorm,D0431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,201.84,,,,,,,fee schedule,175.74,219.24,
Pulp vitality test,D0460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2288.03,,,,,,,fee schedule,640,2839.47,
Pulp vitality test,D0460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1834.06,,,,,,,fee schedule,640,2839.47,
Pulp vitality test,D0460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2003.54,,,,,,,fee schedule,640,2839.47,
Pulp vitality test,D0460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2106.44,,,,,,,fee schedule,640,2839.47,
Pulp vitality test,D0460,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Pulp vitality test,D0460,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Pulp vitality test,D0460,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Pulp vitality test,D0460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Pulp vitality test,D0460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Pulp vitality test,D0460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Pulp vitality test,D0460,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
"Gross exam, prep & report",D0472,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,309.96,,,,,,,fee schedule,248.46,309.96,
"Gross exam, prep & report",D0472,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,248.46,,,,,,,fee schedule,248.46,309.96,
"Gross exam, prep & report",D0472,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,271.42,,,,,,,fee schedule,248.46,309.96,
"Gross exam, prep & report",D0472,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,285.36,,,,,,,fee schedule,248.46,309.96,
"Micro exam, prep & report",D0473,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,438.48,,,,,,,fee schedule,351.48,438.48,
"Micro exam, prep & report",D0473,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,351.48,,,,,,,fee schedule,351.48,438.48,
"Micro exam, prep & report",D0473,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,383.96,,,,,,,fee schedule,351.48,438.48,
"Micro exam, prep & report",D0473,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,403.68,,,,,,,fee schedule,351.48,438.48,
Micro w exam of surg margins,D0474,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,502.74,,,,,,,fee schedule,402.99,502.74,
Micro w exam of surg margins,D0474,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,402.99,,,,,,,fee schedule,402.99,502.74,
Micro w exam of surg margins,D0474,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,440.23,,,,,,,fee schedule,402.99,502.74,
Micro w exam of surg margins,D0474,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,462.84,,,,,,,fee schedule,402.99,502.74,
Decalcification procedure,D0475,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,544.32,,,,,,,fee schedule,436.32,544.32,
Decalcification procedure,D0475,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,436.32,,,,,,,fee schedule,436.32,544.32,
Decalcification procedure,D0475,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,476.64,,,,,,,fee schedule,436.32,544.32,
Decalcification procedure,D0475,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,501.12,,,,,,,fee schedule,436.32,544.32,
Spec stains for microorganis,D0476,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,839.16,,,,,,,fee schedule,672.66,839.16,
Spec stains for microorganis,D0476,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,672.66,,,,,,,fee schedule,672.66,839.16,
Spec stains for microorganis,D0476,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,734.82,,,,,,,fee schedule,672.66,839.16,
Spec stains for microorganis,D0476,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,772.56,,,,,,,fee schedule,672.66,839.16,
Spec stains not for microorg,D0477,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,854.28,,,,,,,fee schedule,684.78,854.28,
Spec stains not for microorg,D0477,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,684.78,,,,,,,fee schedule,684.78,854.28,
Spec stains not for microorg,D0477,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,748.06,,,,,,,fee schedule,684.78,854.28,
Spec stains not for microorg,D0477,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,786.48,,,,,,,fee schedule,684.78,854.28,
Immunohistochemical stains,D0478,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,480.06,,,,,,,fee schedule,384.81,480.06,
Immunohistochemical stains,D0478,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,384.81,,,,,,,fee schedule,384.81,480.06,
Immunohistochemical stains,D0478,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,420.37,,,,,,,fee schedule,384.81,480.06,
Immunohistochemical stains,D0478,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.96,,,,,,,fee schedule,384.81,480.06,
Tissue in-situ hybridization,D0479,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,627.48,,,,,,,fee schedule,502.98,627.48,
Tissue in-situ hybridization,D0479,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,502.98,,,,,,,fee schedule,502.98,627.48,
Tissue in-situ hybridization,D0479,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,549.46,,,,,,,fee schedule,502.98,627.48,
Tissue in-situ hybridization,D0479,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,577.68,,,,,,,fee schedule,502.98,627.48,
Cytopath smear prep & report,D0480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,472.5,,,,,,,fee schedule,378.75,472.5,
Cytopath smear prep & report,D0480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,378.75,,,,,,,fee schedule,378.75,472.5,
Cytopath smear prep & report,D0480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,413.75,,,,,,,fee schedule,378.75,472.5,
Cytopath smear prep & report,D0480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,435,,,,,,,fee schedule,378.75,472.5,
Electron microscopy,D0481,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,495.18,,,,,,,fee schedule,396.93,495.18,
Electron microscopy,D0481,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,396.93,,,,,,,fee schedule,396.93,495.18,
Electron microscopy,D0481,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,433.61,,,,,,,fee schedule,396.93,495.18,
Electron microscopy,D0481,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,455.88,,,,,,,fee schedule,396.93,495.18,
Direct immunofluorescence,D0482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,309.96,,,,,,,fee schedule,248.46,309.96,
Direct immunofluorescence,D0482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,248.46,,,,,,,fee schedule,248.46,309.96,
Direct immunofluorescence,D0482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,271.42,,,,,,,fee schedule,248.46,309.96,
Direct immunofluorescence,D0482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,285.36,,,,,,,fee schedule,248.46,309.96,
Indirect immunofluorescence,D0483,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,351.54,,,,,,,fee schedule,281.79,351.54,
Indirect immunofluorescence,D0483,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,281.79,,,,,,,fee schedule,281.79,351.54,
Indirect immunofluorescence,D0483,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,307.83,,,,,,,fee schedule,281.79,351.54,
Indirect immunofluorescence,D0483,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,323.64,,,,,,,fee schedule,281.79,351.54,
Consult slides prep elsewher,D0484,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,449.82,,,,,,,fee schedule,360.57,449.82,
Consult slides prep elsewher,D0484,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,360.57,,,,,,,fee schedule,360.57,449.82,
Consult slides prep elsewher,D0484,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,393.89,,,,,,,fee schedule,360.57,449.82,
Consult slides prep elsewher,D0484,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,414.12,,,,,,,fee schedule,360.57,449.82,
Consult inc prep of slides,D0485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,468.72,,,,,,,fee schedule,375.72,468.72,
Consult inc prep of slides,D0485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,375.72,,,,,,,fee schedule,375.72,468.72,
Consult inc prep of slides,D0485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,410.44,,,,,,,fee schedule,375.72,468.72,
Consult inc prep of slides,D0485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,431.52,,,,,,,fee schedule,375.72,468.72,
Non-traumatic spinal cord injury M >=53.50 and M <60.50,D0502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,487.62,,,,,,,fee schedule,390.87,487.62,
Non-traumatic spinal cord injury M >=53.50 and M <60.50,D0502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,390.87,,,,,,,fee schedule,390.87,487.62,
Non-traumatic spinal cord injury M >=53.50 and M <60.50,D0502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,426.99,,,,,,,fee schedule,390.87,487.62,
Non-traumatic spinal cord injury M >=53.50 and M <60.50,D0502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,448.92,,,,,,,fee schedule,390.87,487.62,
Non-ionizing diag proc,D0600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1939.4,,,,,,,fee schedule,640,2839.47,
Non-ionizing diag proc,D0600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1554.6,,,,,,,fee schedule,640,2839.47,
Non-ionizing diag proc,D0600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1698.26,,,,,,,fee schedule,640,2839.47,
Non-ionizing diag proc,D0600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1785.48,,,,,,,fee schedule,640,2839.47,
Non-ionizing diag proc,D0600,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Non-ionizing diag proc,D0600,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Non-ionizing diag proc,D0600,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Non-ionizing diag proc,D0600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Non-ionizing diag proc,D0600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Non-ionizing diag proc,D0600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Non-ionizing diag proc,D0600,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Fracture of lower extremity M >=61.50,D0701,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
Fracture of lower extremity M >=61.50,D0701,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
Fracture of lower extremity M >=61.50,D0701,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
Fracture of lower extremity M >=61.50,D0701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
Fracture of lower extremity M >=61.50,D0701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
Fracture of lower extremity M >=61.50,D0701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
Fracture of lower extremity M >=61.50,D0701,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
Fracture of lower extremity M >=52.50 and M <61.50,D0702,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
Fracture of lower extremity M >=52.50 and M <61.50,D0702,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
Fracture of lower extremity M >=52.50 and M <61.50,D0702,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
Fracture of lower extremity M >=52.50 and M <61.50,D0702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
Fracture of lower extremity M >=52.50 and M <61.50,D0702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
Fracture of lower extremity M >=52.50 and M <61.50,D0702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
Fracture of lower extremity M >=52.50 and M <61.50,D0702,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
Fracture of lower extremity M >=41.50 and M <52.50,D0703,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
Fracture of lower extremity M >=41.50 and M <52.50,D0703,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
Fracture of lower extremity M >=41.50 and M <52.50,D0703,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
Fracture of lower extremity M >=41.50 and M <52.50,D0703,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
Fracture of lower extremity M >=41.50 and M <52.50,D0703,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
Fracture of lower extremity M >=41.50 and M <52.50,D0703,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
Fracture of lower extremity M >=41.50 and M <52.50,D0703,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
Extra oral post radio image,D0705,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
Extra oral post radio image,D0705,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
Extra oral post radio image,D0705,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
Extra oral post radio image,D0705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
Extra oral post radio image,D0705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
Extra oral post radio image,D0705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
Extra oral post radio image,D0705,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
Intraoral occlus radio image,D0706,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
Intraoral occlus radio image,D0706,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
Intraoral occlus radio image,D0706,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
Intraoral occlus radio image,D0706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
Intraoral occlus radio image,D0706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
Intraoral occlus radio image,D0706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
Intraoral occlus radio image,D0706,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
Intraoral periap radio image,D0707,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
Intraoral periap radio image,D0707,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
Intraoral periap radio image,D0707,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
Intraoral periap radio image,D0707,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
Intraoral periap radio image,D0707,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
Intraoral periap radio image,D0707,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
Intraoral periap radio image,D0707,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
Intraoral bite radio image,D0708,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
Intraoral bite radio image,D0708,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
Intraoral bite radio image,D0708,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
Intraoral bite radio image,D0708,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
Intraoral bite radio image,D0708,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
Intraoral bite radio image,D0708,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
Intraoral bite radio image,D0708,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
Intraoral cmplt radio images,D0709,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
Intraoral cmplt radio images,D0709,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
Intraoral cmplt radio images,D0709,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
Intraoral cmplt radio images,D0709,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
Intraoral cmplt radio images,D0709,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
Intraoral cmplt radio images,D0709,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
Intraoral cmplt radio images,D0709,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
Dental prophylaxis adult,D1110,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.75,,,,,,,fee schedule,131.8,584.75,APC 378
Dental prophylaxis adult,D1110,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.39,,,,,,,fee schedule,131.8,584.75,APC
Dental prophylaxis adult,D1110,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,137.07,,,,,,,fee schedule,131.8,584.75,APC
Dental prophylaxis adult,D1110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.8,,,,,,,fee schedule,131.8,584.75,APC
Dental prophylaxis adult,D1110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.66,,,,,,,fee schedule,131.8,584.75,Radiology
Dental prophylaxis adult,D1110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.52,,,,,,,fee schedule,131.8,584.75,APC
Dental prophylaxis adult,D1110,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.65,,,,,,,fee schedule,131.8,584.75,APC
Dental prophylaxis child,D1120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,428.32,,,,,,,fee schedule,343.33,428.32,
Dental prophylaxis child,D1120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,343.33,,,,,,,fee schedule,343.33,428.32,
Dental prophylaxis child,D1120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,375.06,,,,,,,fee schedule,343.33,428.32,
Dental prophylaxis child,D1120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,394.33,,,,,,,fee schedule,343.33,428.32,
Topical app fluorid ex vrnsh,D1208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,510.14,,,,,,,fee schedule,408.92,510.14,
Topical app fluorid ex vrnsh,D1208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,408.92,,,,,,,fee schedule,408.92,510.14,
Topical app fluorid ex vrnsh,D1208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,446.71,,,,,,,fee schedule,408.92,510.14,
Topical app fluorid ex vrnsh,D1208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,469.65,,,,,,,fee schedule,408.92,510.14,
Dental sealant per tooth,D1351,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,326.59,,,,,,,fee schedule,261.79,326.59,
Dental sealant per tooth,D1351,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,261.79,,,,,,,fee schedule,261.79,326.59,
Dental sealant per tooth,D1351,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,285.99,,,,,,,fee schedule,261.79,326.59,
Dental sealant per tooth,D1351,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,300.67,,,,,,,fee schedule,261.79,326.59,
"Prev resin rest, perm tooth",D1352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,272.16,,,,,,,fee schedule,218.16,272.16,
"Prev resin rest, perm tooth",D1352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,218.16,,,,,,,fee schedule,218.16,272.16,
"Prev resin rest, perm tooth",D1352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,238.32,,,,,,,fee schedule,218.16,272.16,
"Prev resin rest, perm tooth",D1352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,250.56,,,,,,,fee schedule,218.16,272.16,
Space maintainer fxd unilat,D1510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,747.64,,,,,,,fee schedule,599.3,2839.47,
Space maintainer fxd unilat,D1510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,599.3,,,,,,,fee schedule,599.3,2839.47,
Space maintainer fxd unilat,D1510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,654.68,,,,,,,fee schedule,599.3,2839.47,
Space maintainer fxd unilat,D1510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,688.3,,,,,,,fee schedule,599.3,2839.47,
Space maintainer fxd unilat,D1510,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,599.3,2839.47,APC 378
Space maintainer fxd unilat,D1510,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,599.3,2839.47,APC
Space maintainer fxd unilat,D1510,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,599.3,2839.47,APC
Space maintainer fxd unilat,D1510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,599.3,2839.47,APC
Space maintainer fxd unilat,D1510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,599.3,2839.47,Radiology
Space maintainer fxd unilat,D1510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,599.3,2839.47,APC
Space maintainer fxd unilat,D1510,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,599.3,2839.47,APC
"Fixed bilat space maint, max",D1516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3398.9,,,,,,,fee schedule,640,3398.9,
"Fixed bilat space maint, max",D1516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2724.52,,,,,,,fee schedule,640,3398.9,
"Fixed bilat space maint, max",D1516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2976.29,,,,,,,fee schedule,640,3398.9,
"Fixed bilat space maint, max",D1516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3129.15,,,,,,,fee schedule,640,3398.9,
"Fixed bilat space maint, max",D1516,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,3398.9,APC 378
"Fixed bilat space maint, max",D1516,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,3398.9,APC
"Fixed bilat space maint, max",D1516,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,3398.9,APC
"Fixed bilat space maint, max",D1516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,3398.9,APC
"Fixed bilat space maint, max",D1516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,3398.9,Radiology
"Fixed bilat space maint, max",D1516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,3398.9,APC
"Fixed bilat space maint, max",D1516,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,3398.9,APC
"Fixed bilat space maint, man",D1517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3398.9,,,,,,,fee schedule,640,3398.9,
"Fixed bilat space maint, man",D1517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2724.52,,,,,,,fee schedule,640,3398.9,
"Fixed bilat space maint, man",D1517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2976.29,,,,,,,fee schedule,640,3398.9,
"Fixed bilat space maint, man",D1517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3129.15,,,,,,,fee schedule,640,3398.9,
"Fixed bilat space maint, man",D1517,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,3398.9,APC 378
"Fixed bilat space maint, man",D1517,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,3398.9,APC
"Fixed bilat space maint, man",D1517,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,3398.9,APC
"Fixed bilat space maint, man",D1517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,3398.9,APC
"Fixed bilat space maint, man",D1517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,3398.9,Radiology
"Fixed bilat space maint, man",D1517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,3398.9,APC
"Fixed bilat space maint, man",D1517,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,3398.9,APC
Remove unilat space maintain,D1520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2288.03,,,,,,,fee schedule,640,2839.47,
Remove unilat space maintain,D1520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1834.06,,,,,,,fee schedule,640,2839.47,
Remove unilat space maintain,D1520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2003.54,,,,,,,fee schedule,640,2839.47,
Remove unilat space maintain,D1520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2106.44,,,,,,,fee schedule,640,2839.47,
Remove unilat space maintain,D1520,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Remove unilat space maintain,D1520,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Remove unilat space maintain,D1520,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Remove unilat space maintain,D1520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Remove unilat space maintain,D1520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Remove unilat space maintain,D1520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Remove unilat space maintain,D1520,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
"Remove bilat space main, max",D1526,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3398.9,,,,,,,fee schedule,640,3398.9,
"Remove bilat space main, max",D1526,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2724.52,,,,,,,fee schedule,640,3398.9,
"Remove bilat space main, max",D1526,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2976.29,,,,,,,fee schedule,640,3398.9,
"Remove bilat space main, max",D1526,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3129.15,,,,,,,fee schedule,640,3398.9,
"Remove bilat space main, max",D1526,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,3398.9,APC 378
"Remove bilat space main, max",D1526,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,3398.9,APC
"Remove bilat space main, max",D1526,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,3398.9,APC
"Remove bilat space main, max",D1526,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,3398.9,APC
"Remove bilat space main, max",D1526,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,3398.9,Radiology
"Remove bilat space main, max",D1526,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,3398.9,APC
"Remove bilat space main, max",D1526,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,3398.9,APC
"Remove bilat space main, man",D1527,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3398.9,,,,,,,fee schedule,640,3398.9,
"Remove bilat space main, man",D1527,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2724.52,,,,,,,fee schedule,640,3398.9,
"Remove bilat space main, man",D1527,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2976.29,,,,,,,fee schedule,640,3398.9,
"Remove bilat space main, man",D1527,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3129.15,,,,,,,fee schedule,640,3398.9,
"Remove bilat space main, man",D1527,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,3398.9,APC 378
"Remove bilat space main, man",D1527,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,3398.9,APC
"Remove bilat space main, man",D1527,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,3398.9,APC
"Remove bilat space main, man",D1527,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,3398.9,APC
"Remove bilat space main, man",D1527,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,3398.9,Radiology
"Remove bilat space main, man",D1527,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,3398.9,APC
"Remove bilat space main, man",D1527,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,3398.9,APC
Recement space maint - max,D1551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3685.76,,,,,,,fee schedule,640,3685.76,
Recement space maint - max,D1551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2954.46,,,,,,,fee schedule,640,3685.76,
Recement space maint - max,D1551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3227.48,,,,,,,fee schedule,640,3685.76,
Recement space maint - max,D1551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3393.24,,,,,,,fee schedule,640,3685.76,
Recement space maint - max,D1551,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,3685.76,APC 378
Recement space maint - max,D1551,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,3685.76,APC
Recement space maint - max,D1551,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,3685.76,APC
Recement space maint - max,D1551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,3685.76,APC
Recement space maint - max,D1551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,3685.76,Radiology
Recement space maint - max,D1551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,3685.76,APC
Recement space maint - max,D1551,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,3685.76,APC
Recement space maint - man,D1552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3685.76,,,,,,,fee schedule,640,3685.76,
Recement space maint - man,D1552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2954.46,,,,,,,fee schedule,640,3685.76,
Recement space maint - man,D1552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3227.48,,,,,,,fee schedule,640,3685.76,
Recement space maint - man,D1552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3393.24,,,,,,,fee schedule,640,3685.76,
Recement space maint - man,D1552,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,3685.76,APC 378
Recement space maint - man,D1552,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,3685.76,APC
Recement space maint - man,D1552,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,3685.76,APC
Recement space maint - man,D1552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,3685.76,APC
Recement space maint - man,D1552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,3685.76,Radiology
Recement space maint - man,D1552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,3685.76,APC
Recement space maint - man,D1552,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,3685.76,APC
Recement unilat space maint,D1553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3685.76,,,,,,,fee schedule,640,3685.76,
Recement unilat space maint,D1553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2954.46,,,,,,,fee schedule,640,3685.76,
Recement unilat space maint,D1553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3227.48,,,,,,,fee schedule,640,3685.76,
Recement unilat space maint,D1553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3393.24,,,,,,,fee schedule,640,3685.76,
Recement unilat space maint,D1553,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,3685.76,APC 378
Recement unilat space maint,D1553,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,3685.76,APC
Recement unilat space maint,D1553,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,3685.76,APC
Recement unilat space maint,D1553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,3685.76,APC
Recement unilat space maint,D1553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,3685.76,Radiology
Recement unilat space maint,D1553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,3685.76,APC
Recement unilat space maint,D1553,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,3685.76,APC
"Dist space maint, fixed unil",D1575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1939.4,,,,,,,fee schedule,640,2839.47,
"Dist space maint, fixed unil",D1575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1554.6,,,,,,,fee schedule,640,2839.47,
"Dist space maint, fixed unil",D1575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1698.26,,,,,,,fee schedule,640,2839.47,
"Dist space maint, fixed unil",D1575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1785.48,,,,,,,fee schedule,640,2839.47,
"Dist space maint, fixed unil",D1575,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
"Dist space maint, fixed unil",D1575,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
"Dist space maint, fixed unil",D1575,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
"Dist space maint, fixed unil",D1575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
"Dist space maint, fixed unil",D1575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
"Dist space maint, fixed unil",D1575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
"Dist space maint, fixed unil",D1575,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Amalgam one surface permanen,D2140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,916.26,,,,,,,fee schedule,640,2839.47,
Amalgam one surface permanen,D2140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,734.46,,,,,,,fee schedule,640,2839.47,
Amalgam one surface permanen,D2140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,802.34,,,,,,,fee schedule,640,2839.47,
Amalgam one surface permanen,D2140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,843.54,,,,,,,fee schedule,640,2839.47,
Amalgam one surface permanen,D2140,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Amalgam one surface permanen,D2140,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Amalgam one surface permanen,D2140,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Amalgam one surface permanen,D2140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Amalgam one surface permanen,D2140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Amalgam one surface permanen,D2140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Amalgam one surface permanen,D2140,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Amalgam two surfaces permane,D2150,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Amalgam two surfaces permane,D2150,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Amalgam two surfaces permane,D2150,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Amalgam two surfaces permane,D2150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Amalgam two surfaces permane,D2150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Amalgam two surfaces permane,D2150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Amalgam two surfaces permane,D2150,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Amalgam three surfaces perma,D2160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,440.14,,,,,,,fee schedule,352.81,2839.47,
Amalgam three surfaces perma,D2160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,352.81,,,,,,,fee schedule,352.81,2839.47,
Amalgam three surfaces perma,D2160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,385.41,,,,,,,fee schedule,352.81,2839.47,
Amalgam three surfaces perma,D2160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,405.21,,,,,,,fee schedule,352.81,2839.47,
Amalgam three surfaces perma,D2160,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,352.81,2839.47,APC 378
Amalgam three surfaces perma,D2160,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,352.81,2839.47,APC
Amalgam three surfaces perma,D2160,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,352.81,2839.47,APC
Amalgam three surfaces perma,D2160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,352.81,2839.47,APC
Amalgam three surfaces perma,D2160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,352.81,2839.47,Radiology
Amalgam three surfaces perma,D2160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,352.81,2839.47,APC
Amalgam three surfaces perma,D2160,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,352.81,2839.47,APC
Amalgam 4 or > surfaces perm,D2161,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Amalgam 4 or > surfaces perm,D2161,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Amalgam 4 or > surfaces perm,D2161,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Amalgam 4 or > surfaces perm,D2161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Amalgam 4 or > surfaces perm,D2161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Amalgam 4 or > surfaces perm,D2161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Amalgam 4 or > surfaces perm,D2161,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Resin one surface-anterior,D2330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,513.69,,,,,,,fee schedule,411.77,2839.47,
Resin one surface-anterior,D2330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,411.77,,,,,,,fee schedule,411.77,2839.47,
Resin one surface-anterior,D2330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,449.82,,,,,,,fee schedule,411.77,2839.47,
Resin one surface-anterior,D2330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,472.92,,,,,,,fee schedule,411.77,2839.47,
Resin one surface-anterior,D2330,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,411.77,2839.47,APC 378
Resin one surface-anterior,D2330,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,411.77,2839.47,APC
Resin one surface-anterior,D2330,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,411.77,2839.47,APC
Resin one surface-anterior,D2330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,411.77,2839.47,APC
Resin one surface-anterior,D2330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,411.77,2839.47,Radiology
Resin one surface-anterior,D2330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,411.77,2839.47,APC
Resin one surface-anterior,D2330,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,411.77,2839.47,APC
Resin two surfaces-anterior,D2331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,503.6,,,,,,,fee schedule,403.68,2839.47,
Resin two surfaces-anterior,D2331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,403.68,,,,,,,fee schedule,403.68,2839.47,
Resin two surfaces-anterior,D2331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,440.98,,,,,,,fee schedule,403.68,2839.47,
Resin two surfaces-anterior,D2331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,463.63,,,,,,,fee schedule,403.68,2839.47,
Resin two surfaces-anterior,D2331,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,403.68,2839.47,APC 378
Resin two surfaces-anterior,D2331,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,403.68,2839.47,APC
Resin two surfaces-anterior,D2331,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,403.68,2839.47,APC
Resin two surfaces-anterior,D2331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,403.68,2839.47,APC
Resin two surfaces-anterior,D2331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,403.68,2839.47,Radiology
Resin two surfaces-anterior,D2331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,403.68,2839.47,APC
Resin two surfaces-anterior,D2331,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,403.68,2839.47,APC
Resin three surfaces-anterio,D2332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,394.56,,,,,,,fee schedule,316.27,2839.47,
Resin three surfaces-anterio,D2332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,316.27,,,,,,,fee schedule,316.27,2839.47,
Resin three surfaces-anterio,D2332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,345.5,,,,,,,fee schedule,316.27,2839.47,
Resin three surfaces-anterio,D2332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,363.25,,,,,,,fee schedule,316.27,2839.47,
Resin three surfaces-anterio,D2332,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,316.27,2839.47,APC 378
Resin three surfaces-anterio,D2332,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,316.27,2839.47,APC
Resin three surfaces-anterio,D2332,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,316.27,2839.47,APC
Resin three surfaces-anterio,D2332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,316.27,2839.47,APC
Resin three surfaces-anterio,D2332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,316.27,2839.47,Radiology
Resin three surfaces-anterio,D2332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,316.27,2839.47,APC
Resin three surfaces-anterio,D2332,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,316.27,2839.47,APC
Resin 4/> surf or w incis an,D2335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,442.95,,,,,,,fee schedule,355.06,2839.47,
Resin 4/> surf or w incis an,D2335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,355.06,,,,,,,fee schedule,355.06,2839.47,
Resin 4/> surf or w incis an,D2335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,387.88,,,,,,,fee schedule,355.06,2839.47,
Resin 4/> surf or w incis an,D2335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,407.8,,,,,,,fee schedule,355.06,2839.47,
Resin 4/> surf or w incis an,D2335,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,355.06,2839.47,APC 378
Resin 4/> surf or w incis an,D2335,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,355.06,2839.47,APC
Resin 4/> surf or w incis an,D2335,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,355.06,2839.47,APC
Resin 4/> surf or w incis an,D2335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,355.06,2839.47,APC
Resin 4/> surf or w incis an,D2335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,355.06,2839.47,Radiology
Resin 4/> surf or w incis an,D2335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,355.06,2839.47,APC
Resin 4/> surf or w incis an,D2335,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,355.06,2839.47,APC
Ant resin-based cmpst crown,D2390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,510.92,,,,,,,fee schedule,409.55,2839.47,
Ant resin-based cmpst crown,D2390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,409.55,,,,,,,fee schedule,409.55,2839.47,
Ant resin-based cmpst crown,D2390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,447.39,,,,,,,fee schedule,409.55,2839.47,
Ant resin-based cmpst crown,D2390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,470.37,,,,,,,fee schedule,409.55,2839.47,
Ant resin-based cmpst crown,D2390,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,409.55,2839.47,APC 378
Ant resin-based cmpst crown,D2390,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,409.55,2839.47,APC
Ant resin-based cmpst crown,D2390,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,409.55,2839.47,APC
Ant resin-based cmpst crown,D2390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,409.55,2839.47,APC
Ant resin-based cmpst crown,D2390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,409.55,2839.47,Radiology
Ant resin-based cmpst crown,D2390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,409.55,2839.47,APC
Ant resin-based cmpst crown,D2390,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,409.55,2839.47,APC
Post 1 srfc resinbased cmpst,D2391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,517.19,,,,,,,fee schedule,414.57,2839.47,
Post 1 srfc resinbased cmpst,D2391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,414.57,,,,,,,fee schedule,414.57,2839.47,
Post 1 srfc resinbased cmpst,D2391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,452.88,,,,,,,fee schedule,414.57,2839.47,
Post 1 srfc resinbased cmpst,D2391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,476.14,,,,,,,fee schedule,414.57,2839.47,
Post 1 srfc resinbased cmpst,D2391,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,414.57,2839.47,APC 378
Post 1 srfc resinbased cmpst,D2391,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,414.57,2839.47,APC
Post 1 srfc resinbased cmpst,D2391,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,414.57,2839.47,APC
Post 1 srfc resinbased cmpst,D2391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,414.57,2839.47,APC
Post 1 srfc resinbased cmpst,D2391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,414.57,2839.47,Radiology
Post 1 srfc resinbased cmpst,D2391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,414.57,2839.47,APC
Post 1 srfc resinbased cmpst,D2391,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,414.57,2839.47,APC
Post 2 srfc resinbased cmpst,D2392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,529.63,,,,,,,fee schedule,424.54,2839.47,
Post 2 srfc resinbased cmpst,D2392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,424.54,,,,,,,fee schedule,424.54,2839.47,
Post 2 srfc resinbased cmpst,D2392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,463.78,,,,,,,fee schedule,424.54,2839.47,
Post 2 srfc resinbased cmpst,D2392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,487.6,,,,,,,fee schedule,424.54,2839.47,
Post 2 srfc resinbased cmpst,D2392,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,424.54,2839.47,APC 378
Post 2 srfc resinbased cmpst,D2392,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,424.54,2839.47,APC
Post 2 srfc resinbased cmpst,D2392,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,424.54,2839.47,APC
Post 2 srfc resinbased cmpst,D2392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,424.54,2839.47,APC
Post 2 srfc resinbased cmpst,D2392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,424.54,2839.47,Radiology
Post 2 srfc resinbased cmpst,D2392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,424.54,2839.47,APC
Post 2 srfc resinbased cmpst,D2392,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,424.54,2839.47,APC
Post 3 srfc resinbased cmpst,D2393,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,480.58,,,,,,,fee schedule,385.22,2839.47,
Post 3 srfc resinbased cmpst,D2393,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,385.22,,,,,,,fee schedule,385.22,2839.47,
Post 3 srfc resinbased cmpst,D2393,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,420.82,,,,,,,fee schedule,385.22,2839.47,
Post 3 srfc resinbased cmpst,D2393,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,442.44,,,,,,,fee schedule,385.22,2839.47,
Post 3 srfc resinbased cmpst,D2393,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,385.22,2839.47,APC 378
Post 3 srfc resinbased cmpst,D2393,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,385.22,2839.47,APC
Post 3 srfc resinbased cmpst,D2393,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,385.22,2839.47,APC
Post 3 srfc resinbased cmpst,D2393,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,385.22,2839.47,APC
Post 3 srfc resinbased cmpst,D2393,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,385.22,2839.47,Radiology
Post 3 srfc resinbased cmpst,D2393,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,385.22,2839.47,APC
Post 3 srfc resinbased cmpst,D2393,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,385.22,2839.47,APC
Post >=4srfc resinbase cmpst,D2394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,335.34,,,,,,,fee schedule,268.81,2839.47,
Post >=4srfc resinbase cmpst,D2394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,268.81,,,,,,,fee schedule,268.81,2839.47,
Post >=4srfc resinbase cmpst,D2394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,293.65,,,,,,,fee schedule,268.81,2839.47,
Post >=4srfc resinbase cmpst,D2394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,308.73,,,,,,,fee schedule,268.81,2839.47,
Post >=4srfc resinbase cmpst,D2394,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,268.81,2839.47,APC 378
Post >=4srfc resinbase cmpst,D2394,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,268.81,2839.47,APC
Post >=4srfc resinbase cmpst,D2394,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,268.81,2839.47,APC
Post >=4srfc resinbase cmpst,D2394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,268.81,2839.47,APC
Post >=4srfc resinbase cmpst,D2394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,268.81,2839.47,Radiology
Post >=4srfc resinbase cmpst,D2394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,268.81,2839.47,APC
Post >=4srfc resinbase cmpst,D2394,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,268.81,2839.47,APC
Dental gold foil one surface,D2410,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Dental gold foil one surface,D2410,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Dental gold foil one surface,D2410,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Dental gold foil one surface,D2410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Dental gold foil one surface,D2410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Dental gold foil one surface,D2410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Dental gold foil one surface,D2410,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Dental gold foil two surface,D2420,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Dental gold foil two surface,D2420,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Dental gold foil two surface,D2420,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Dental gold foil two surface,D2420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Dental gold foil two surface,D2420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Dental gold foil two surface,D2420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Dental gold foil two surface,D2420,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Dental gold foil three surfa,D2430,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Dental gold foil three surfa,D2430,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Dental gold foil three surfa,D2430,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Dental gold foil three surfa,D2430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Dental gold foil three surfa,D2430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Dental gold foil three surfa,D2430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Dental gold foil three surfa,D2430,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Dental inlay metalic 1 surf,D2510,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Dental inlay metalic 1 surf,D2510,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Dental inlay metalic 1 surf,D2510,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Dental inlay metalic 1 surf,D2510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Dental inlay metalic 1 surf,D2510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Dental inlay metalic 1 surf,D2510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Dental inlay metalic 1 surf,D2510,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Dental inlay metallic 2 surf,D2520,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Dental inlay metallic 2 surf,D2520,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Dental inlay metallic 2 surf,D2520,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Dental inlay metallic 2 surf,D2520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Dental inlay metallic 2 surf,D2520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Dental inlay metallic 2 surf,D2520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Dental inlay metallic 2 surf,D2520,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Dental inlay metl 3/more sur,D2530,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Dental inlay metl 3/more sur,D2530,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Dental inlay metl 3/more sur,D2530,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Dental inlay metl 3/more sur,D2530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Dental inlay metl 3/more sur,D2530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Dental inlay metl 3/more sur,D2530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Dental inlay metl 3/more sur,D2530,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Dental onlay metallic 2 surf,D2542,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Dental onlay metallic 2 surf,D2542,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Dental onlay metallic 2 surf,D2542,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Dental onlay metallic 2 surf,D2542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Dental onlay metallic 2 surf,D2542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Dental onlay metallic 2 surf,D2542,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Dental onlay metallic 2 surf,D2542,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Dental onlay metallic 3 surf,D2543,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Dental onlay metallic 3 surf,D2543,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Dental onlay metallic 3 surf,D2543,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Dental onlay metallic 3 surf,D2543,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Dental onlay metallic 3 surf,D2543,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Dental onlay metallic 3 surf,D2543,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Dental onlay metallic 3 surf,D2543,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Dental onlay metl 4/more sur,D2544,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Dental onlay metl 4/more sur,D2544,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Dental onlay metl 4/more sur,D2544,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Dental onlay metl 4/more sur,D2544,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Dental onlay metl 4/more sur,D2544,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Dental onlay metl 4/more sur,D2544,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Dental onlay metl 4/more sur,D2544,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Inlay porcelain/ceramic 1 su,D2610,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Inlay porcelain/ceramic 1 su,D2610,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Inlay porcelain/ceramic 1 su,D2610,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Inlay porcelain/ceramic 1 su,D2610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Inlay porcelain/ceramic 1 su,D2610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Inlay porcelain/ceramic 1 su,D2610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Inlay porcelain/ceramic 1 su,D2610,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Inlay porcelain/ceramic 2 su,D2620,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Inlay porcelain/ceramic 2 su,D2620,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Inlay porcelain/ceramic 2 su,D2620,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Inlay porcelain/ceramic 2 su,D2620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Inlay porcelain/ceramic 2 su,D2620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Inlay porcelain/ceramic 2 su,D2620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Inlay porcelain/ceramic 2 su,D2620,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Dental onlay porc 3/more sur,D2630,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Dental onlay porc 3/more sur,D2630,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Dental onlay porc 3/more sur,D2630,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Dental onlay porc 3/more sur,D2630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Dental onlay porc 3/more sur,D2630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Dental onlay porc 3/more sur,D2630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Dental onlay porc 3/more sur,D2630,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Dental onlay porcelin 2 surf,D2642,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Dental onlay porcelin 2 surf,D2642,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Dental onlay porcelin 2 surf,D2642,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Dental onlay porcelin 2 surf,D2642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Dental onlay porcelin 2 surf,D2642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Dental onlay porcelin 2 surf,D2642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Dental onlay porcelin 2 surf,D2642,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Dental onlay porcelin 3 surf,D2643,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Dental onlay porcelin 3 surf,D2643,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Dental onlay porcelin 3 surf,D2643,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Dental onlay porcelin 3 surf,D2643,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Dental onlay porcelin 3 surf,D2643,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Dental onlay porcelin 3 surf,D2643,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Dental onlay porcelin 3 surf,D2643,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Dental onlay porc 4/more sur,D2644,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Dental onlay porc 4/more sur,D2644,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Dental onlay porc 4/more sur,D2644,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Dental onlay porc 4/more sur,D2644,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Dental onlay porc 4/more sur,D2644,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Dental onlay porc 4/more sur,D2644,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Dental onlay porc 4/more sur,D2644,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Inlay composite/resin one su,D2650,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Inlay composite/resin one su,D2650,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Inlay composite/resin one su,D2650,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Inlay composite/resin one su,D2650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Inlay composite/resin one su,D2650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Inlay composite/resin one su,D2650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Inlay composite/resin one su,D2650,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Inlay composite/resin two su,D2651,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Inlay composite/resin two su,D2651,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Inlay composite/resin two su,D2651,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Inlay composite/resin two su,D2651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Inlay composite/resin two su,D2651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Inlay composite/resin two su,D2651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Inlay composite/resin two su,D2651,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Dental inlay resin 3/mre sur,D2652,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Dental inlay resin 3/mre sur,D2652,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Dental inlay resin 3/mre sur,D2652,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Dental inlay resin 3/mre sur,D2652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Dental inlay resin 3/mre sur,D2652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Dental inlay resin 3/mre sur,D2652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Dental inlay resin 3/mre sur,D2652,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Dental onlay resin 2 surface,D2662,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Dental onlay resin 2 surface,D2662,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Dental onlay resin 2 surface,D2662,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Dental onlay resin 2 surface,D2662,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Dental onlay resin 2 surface,D2662,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Dental onlay resin 2 surface,D2662,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Dental onlay resin 2 surface,D2662,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Dental onlay resin 3 surface,D2663,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Dental onlay resin 3 surface,D2663,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Dental onlay resin 3 surface,D2663,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Dental onlay resin 3 surface,D2663,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Dental onlay resin 3 surface,D2663,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Dental onlay resin 3 surface,D2663,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Dental onlay resin 3 surface,D2663,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Dental onlay resin 4/mre sur,D2664,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Dental onlay resin 4/mre sur,D2664,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Dental onlay resin 4/mre sur,D2664,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Dental onlay resin 4/mre sur,D2664,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Dental onlay resin 4/mre sur,D2664,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Dental onlay resin 4/mre sur,D2664,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Dental onlay resin 4/mre sur,D2664,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Crown resin-based indirect,D2710,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Crown resin-based indirect,D2710,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Crown resin-based indirect,D2710,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Crown resin-based indirect,D2710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Crown resin-based indirect,D2710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Crown resin-based indirect,D2710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Crown resin-based indirect,D2710,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Crown 3/4 resin-based compos,D2712,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Crown 3/4 resin-based compos,D2712,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Crown 3/4 resin-based compos,D2712,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Crown 3/4 resin-based compos,D2712,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Crown 3/4 resin-based compos,D2712,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Crown 3/4 resin-based compos,D2712,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Crown 3/4 resin-based compos,D2712,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Crown resin w/ high noble me,D2720,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Crown resin w/ high noble me,D2720,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Crown resin w/ high noble me,D2720,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Crown resin w/ high noble me,D2720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Crown resin w/ high noble me,D2720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Crown resin w/ high noble me,D2720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Crown resin w/ high noble me,D2720,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Crown resin w/ base metal,D2721,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Crown resin w/ base metal,D2721,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Crown resin w/ base metal,D2721,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Crown resin w/ base metal,D2721,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Crown resin w/ base metal,D2721,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Crown resin w/ base metal,D2721,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Crown resin w/ base metal,D2721,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Crown resin w/ noble metal,D2722,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Crown resin w/ noble metal,D2722,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Crown resin w/ noble metal,D2722,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Crown resin w/ noble metal,D2722,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Crown resin w/ noble metal,D2722,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Crown resin w/ noble metal,D2722,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Crown resin w/ noble metal,D2722,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Crown porcelain/ceramic subs,D2740,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Crown porcelain/ceramic subs,D2740,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Crown porcelain/ceramic subs,D2740,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Crown porcelain/ceramic subs,D2740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Crown porcelain/ceramic subs,D2740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Crown porcelain/ceramic subs,D2740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Crown porcelain/ceramic subs,D2740,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Crown porcelain w/ h noble m,D2750,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Crown porcelain w/ h noble m,D2750,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Crown porcelain w/ h noble m,D2750,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Crown porcelain w/ h noble m,D2750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Crown porcelain w/ h noble m,D2750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Crown porcelain w/ h noble m,D2750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Crown porcelain w/ h noble m,D2750,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Crown porcelain fused base m,D2751,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Crown porcelain fused base m,D2751,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Crown porcelain fused base m,D2751,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Crown porcelain fused base m,D2751,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Crown porcelain fused base m,D2751,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Crown porcelain fused base m,D2751,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Crown porcelain fused base m,D2751,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Crown porcelain w/ noble met,D2752,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Crown porcelain w/ noble met,D2752,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Crown porcelain w/ noble met,D2752,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Crown porcelain w/ noble met,D2752,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Crown porcelain w/ noble met,D2752,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Crown porcelain w/ noble met,D2752,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Crown porcelain w/ noble met,D2752,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Crown porc fused to titanium,D2753,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Crown porc fused to titanium,D2753,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Crown porc fused to titanium,D2753,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Crown porc fused to titanium,D2753,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Crown porc fused to titanium,D2753,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Crown porc fused to titanium,D2753,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Crown porc fused to titanium,D2753,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Crown 3/4 cast hi noble met,D2780,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Crown 3/4 cast hi noble met,D2780,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Crown 3/4 cast hi noble met,D2780,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Crown 3/4 cast hi noble met,D2780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Crown 3/4 cast hi noble met,D2780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Crown 3/4 cast hi noble met,D2780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Crown 3/4 cast hi noble met,D2780,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Crown 3/4 cast base metal,D2781,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Crown 3/4 cast base metal,D2781,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Crown 3/4 cast base metal,D2781,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Crown 3/4 cast base metal,D2781,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Crown 3/4 cast base metal,D2781,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Crown 3/4 cast base metal,D2781,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Crown 3/4 cast base metal,D2781,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Crown 3/4 cast noble metal,D2782,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Crown 3/4 cast noble metal,D2782,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Crown 3/4 cast noble metal,D2782,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Crown 3/4 cast noble metal,D2782,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Crown 3/4 cast noble metal,D2782,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Crown 3/4 cast noble metal,D2782,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Crown 3/4 cast noble metal,D2782,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Crown 3/4 porcelain/ceramic,D2783,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Crown 3/4 porcelain/ceramic,D2783,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Crown 3/4 porcelain/ceramic,D2783,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Crown 3/4 porcelain/ceramic,D2783,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Crown 3/4 porcelain/ceramic,D2783,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Crown 3/4 porcelain/ceramic,D2783,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Crown 3/4 porcelain/ceramic,D2783,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Crown full cast high noble m,D2790,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Crown full cast high noble m,D2790,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Crown full cast high noble m,D2790,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Crown full cast high noble m,D2790,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Crown full cast high noble m,D2790,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Crown full cast high noble m,D2790,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Crown full cast high noble m,D2790,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Crown full cast base metal,D2791,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Crown full cast base metal,D2791,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Crown full cast base metal,D2791,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Crown full cast base metal,D2791,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Crown full cast base metal,D2791,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Crown full cast base metal,D2791,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Crown full cast base metal,D2791,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Crown full cast noble metal,D2792,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Crown full cast noble metal,D2792,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Crown full cast noble metal,D2792,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Crown full cast noble metal,D2792,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Crown full cast noble metal,D2792,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Crown full cast noble metal,D2792,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Crown full cast noble metal,D2792,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Crown-titanium,D2794,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Crown-titanium,D2794,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Crown-titanium,D2794,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Crown-titanium,D2794,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Crown-titanium,D2794,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Crown-titanium,D2794,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Crown-titanium,D2794,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Provisional crown,D2799,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Provisional crown,D2799,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Provisional crown,D2799,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Provisional crown,D2799,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Provisional crown,D2799,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Provisional crown,D2799,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Provisional crown,D2799,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Recement inlay onlay or part,D2910,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Recement inlay onlay or part,D2910,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Recement inlay onlay or part,D2910,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Recement inlay onlay or part,D2910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Recement inlay onlay or part,D2910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Recement inlay onlay or part,D2910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Recement inlay onlay or part,D2910,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Recement cast or prefab post,D2915,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Recement cast or prefab post,D2915,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Recement cast or prefab post,D2915,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Recement cast or prefab post,D2915,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Recement cast or prefab post,D2915,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Recement cast or prefab post,D2915,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Recement cast or prefab post,D2915,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Re-cement or re-bond crown,D2920,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Re-cement or re-bond crown,D2920,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Re-cement or re-bond crown,D2920,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Re-cement or re-bond crown,D2920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Re-cement or re-bond crown,D2920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Re-cement or re-bond crown,D2920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Re-cement or re-bond crown,D2920,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Reattach tooth fragment,D2921,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Reattach tooth fragment,D2921,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Reattach tooth fragment,D2921,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Reattach tooth fragment,D2921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Reattach tooth fragment,D2921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Reattach tooth fragment,D2921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Reattach tooth fragment,D2921,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Prefab porc/cer crown perm,D2928,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Prefab porc/cer crown perm,D2928,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Prefab porc/cer crown perm,D2928,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Prefab porc/cer crown perm,D2928,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Prefab porc/cer crown perm,D2928,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Prefab porc/cer crown perm,D2928,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Prefab porc/cer crown perm,D2928,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Prefab porc/ceram crown pri,D2929,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,756.65,,,,,,,fee schedule,606.52,2839.47,
Prefab porc/ceram crown pri,D2929,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,606.52,,,,,,,fee schedule,606.52,2839.47,
Prefab porc/ceram crown pri,D2929,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,662.57,,,,,,,fee schedule,606.52,2839.47,
Prefab porc/ceram crown pri,D2929,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,696.6,,,,,,,fee schedule,606.52,2839.47,
Prefab porc/ceram crown pri,D2929,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,606.52,2839.47,APC 378
Prefab porc/ceram crown pri,D2929,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,606.52,2839.47,APC
Prefab porc/ceram crown pri,D2929,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,606.52,2839.47,APC
Prefab porc/ceram crown pri,D2929,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,606.52,2839.47,APC
Prefab porc/ceram crown pri,D2929,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,606.52,2839.47,Radiology
Prefab porc/ceram crown pri,D2929,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,606.52,2839.47,APC
Prefab porc/ceram crown pri,D2929,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,606.52,2839.47,APC
Prefab stnlss steel crwn pri,D2930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,469.32,,,,,,,fee schedule,376.2,2839.47,
Prefab stnlss steel crwn pri,D2930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,376.2,,,,,,,fee schedule,376.2,2839.47,
Prefab stnlss steel crwn pri,D2930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,410.97,,,,,,,fee schedule,376.2,2839.47,
Prefab stnlss steel crwn pri,D2930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,432.07,,,,,,,fee schedule,376.2,2839.47,
Prefab stnlss steel crwn pri,D2930,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,376.2,2839.47,APC 378
Prefab stnlss steel crwn pri,D2930,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,376.2,2839.47,APC
Prefab stnlss steel crwn pri,D2930,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,376.2,2839.47,APC
Prefab stnlss steel crwn pri,D2930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,376.2,2839.47,APC
Prefab stnlss steel crwn pri,D2930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,376.2,2839.47,Radiology
Prefab stnlss steel crwn pri,D2930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,376.2,2839.47,APC
Prefab stnlss steel crwn pri,D2930,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,376.2,2839.47,APC
Prefab stnlss steel crown pe,D2931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,588.92,,,,,,,fee schedule,472.07,2839.47,
Prefab stnlss steel crown pe,D2931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,472.07,,,,,,,fee schedule,472.07,2839.47,
Prefab stnlss steel crown pe,D2931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,515.69,,,,,,,fee schedule,472.07,2839.47,
Prefab stnlss steel crown pe,D2931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,542.18,,,,,,,fee schedule,472.07,2839.47,
Prefab stnlss steel crown pe,D2931,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,472.07,2839.47,APC 378
Prefab stnlss steel crown pe,D2931,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,472.07,2839.47,APC
Prefab stnlss steel crown pe,D2931,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,472.07,2839.47,APC
Prefab stnlss steel crown pe,D2931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,472.07,2839.47,APC
Prefab stnlss steel crown pe,D2931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,472.07,2839.47,Radiology
Prefab stnlss steel crown pe,D2931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,472.07,2839.47,APC
Prefab stnlss steel crown pe,D2931,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,472.07,2839.47,APC
Prefabricated resin crown,D2932,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,479.35,,,,,,,fee schedule,384.24,2839.47,
Prefabricated resin crown,D2932,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,384.24,,,,,,,fee schedule,384.24,2839.47,
Prefabricated resin crown,D2932,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,419.75,,,,,,,fee schedule,384.24,2839.47,
Prefabricated resin crown,D2932,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.31,,,,,,,fee schedule,384.24,2839.47,
Prefabricated resin crown,D2932,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,384.24,2839.47,APC 378
Prefabricated resin crown,D2932,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,384.24,2839.47,APC
Prefabricated resin crown,D2932,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,384.24,2839.47,APC
Prefabricated resin crown,D2932,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,384.24,2839.47,APC
Prefabricated resin crown,D2932,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,384.24,2839.47,Radiology
Prefabricated resin crown,D2932,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,384.24,2839.47,APC
Prefabricated resin crown,D2932,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,384.24,2839.47,APC
Prefab stainless steel crown,D2933,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Prefab stainless steel crown,D2933,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Prefab stainless steel crown,D2933,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Prefab stainless steel crown,D2933,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Prefab stainless steel crown,D2933,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Prefab stainless steel crown,D2933,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Prefab stainless steel crown,D2933,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Prefab steel crown primary,D2934,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,402.56,,,,,,,fee schedule,322.69,2839.47,
Prefab steel crown primary,D2934,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,322.69,,,,,,,fee schedule,322.69,2839.47,
Prefab steel crown primary,D2934,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,352.51,,,,,,,fee schedule,322.69,2839.47,
Prefab steel crown primary,D2934,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,370.61,,,,,,,fee schedule,322.69,2839.47,
Prefab steel crown primary,D2934,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,322.69,2839.47,APC 378
Prefab steel crown primary,D2934,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,322.69,2839.47,APC
Prefab steel crown primary,D2934,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,322.69,2839.47,APC
Prefab steel crown primary,D2934,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,322.69,2839.47,APC
Prefab steel crown primary,D2934,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,322.69,2839.47,Radiology
Prefab steel crown primary,D2934,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,322.69,2839.47,APC
Prefab steel crown primary,D2934,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,322.69,2839.47,APC
Protective restoration,D2940,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Protective restoration,D2940,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Protective restoration,D2940,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Protective restoration,D2940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Protective restoration,D2940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Protective restoration,D2940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Protective restoration,D2940,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Restorative foundation,D2949,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Restorative foundation,D2949,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Restorative foundation,D2949,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Restorative foundation,D2949,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Restorative foundation,D2949,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Restorative foundation,D2949,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Restorative foundation,D2949,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Core build-up incl any pins,D2950,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Core build-up incl any pins,D2950,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Core build-up incl any pins,D2950,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Core build-up incl any pins,D2950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Core build-up incl any pins,D2950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Core build-up incl any pins,D2950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Core build-up incl any pins,D2950,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Tooth pin retention,D2951,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Tooth pin retention,D2951,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Tooth pin retention,D2951,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Tooth pin retention,D2951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Tooth pin retention,D2951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Tooth pin retention,D2951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Tooth pin retention,D2951,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Post and core cast + crown,D2952,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Post and core cast + crown,D2952,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Post and core cast + crown,D2952,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Post and core cast + crown,D2952,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Post and core cast + crown,D2952,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Post and core cast + crown,D2952,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Post and core cast + crown,D2952,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Prefab post/core + crown,D2954,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Prefab post/core + crown,D2954,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Prefab post/core + crown,D2954,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Prefab post/core + crown,D2954,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Prefab post/core + crown,D2954,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Prefab post/core + crown,D2954,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Prefab post/core + crown,D2954,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Each addtnl prefab post,D2957,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Each addtnl prefab post,D2957,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Each addtnl prefab post,D2957,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Each addtnl prefab post,D2957,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Each addtnl prefab post,D2957,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Each addtnl prefab post,D2957,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Each addtnl prefab post,D2957,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Laminate labial veneer,D2960,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Laminate labial veneer,D2960,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Laminate labial veneer,D2960,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Laminate labial veneer,D2960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Laminate labial veneer,D2960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Laminate labial veneer,D2960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Laminate labial veneer,D2960,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Lab labial veneer resin,D2961,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Lab labial veneer resin,D2961,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Lab labial veneer resin,D2961,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Lab labial veneer resin,D2961,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Lab labial veneer resin,D2961,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Lab labial veneer resin,D2961,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Lab labial veneer resin,D2961,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Lab labial veneer porcelain,D2962,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Lab labial veneer porcelain,D2962,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Lab labial veneer porcelain,D2962,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Lab labial veneer porcelain,D2962,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Lab labial veneer porcelain,D2962,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Lab labial veneer porcelain,D2962,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Lab labial veneer porcelain,D2962,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Add proc construct new crown,D2971,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Add proc construct new crown,D2971,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Add proc construct new crown,D2971,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Add proc construct new crown,D2971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Add proc construct new crown,D2971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Add proc construct new crown,D2971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Add proc construct new crown,D2971,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Coping,D2975,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Coping,D2975,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Coping,D2975,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Coping,D2975,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Coping,D2975,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Coping,D2975,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Coping,D2975,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Crown repair,D2980,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Crown repair,D2980,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Crown repair,D2980,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Crown repair,D2980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Crown repair,D2980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Crown repair,D2980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Crown repair,D2980,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Inlay repair,D2981,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Inlay repair,D2981,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Inlay repair,D2981,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Inlay repair,D2981,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Inlay repair,D2981,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Inlay repair,D2981,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Inlay repair,D2981,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Onlay repair,D2982,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Onlay repair,D2982,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Onlay repair,D2982,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Onlay repair,D2982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Onlay repair,D2982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Onlay repair,D2982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Onlay repair,D2982,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Veneer repair,D2983,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Veneer repair,D2983,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Veneer repair,D2983,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Veneer repair,D2983,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Veneer repair,D2983,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Veneer repair,D2983,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Veneer repair,D2983,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Resin infiltration of lesion,D2990,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Resin infiltration of lesion,D2990,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Resin infiltration of lesion,D2990,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Resin infiltration of lesion,D2990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Resin infiltration of lesion,D2990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Resin infiltration of lesion,D2990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Resin infiltration of lesion,D2990,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Dental unspec restorative pr,D2999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2288.03,,,,,,,fee schedule,640,2839.47,
Dental unspec restorative pr,D2999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1834.06,,,,,,,fee schedule,640,2839.47,
Dental unspec restorative pr,D2999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2003.54,,,,,,,fee schedule,640,2839.47,
Dental unspec restorative pr,D2999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2106.44,,,,,,,fee schedule,640,2839.47,
Dental unspec restorative pr,D2999,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Dental unspec restorative pr,D2999,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Dental unspec restorative pr,D2999,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Dental unspec restorative pr,D2999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Dental unspec restorative pr,D2999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Dental unspec restorative pr,D2999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Dental unspec restorative pr,D2999,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Pulp cap direct,D3110,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Pulp cap direct,D3110,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Pulp cap direct,D3110,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Pulp cap direct,D3110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Pulp cap direct,D3110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Pulp cap direct,D3110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Pulp cap direct,D3110,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Pulp cap indirect,D3120,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Pulp cap indirect,D3120,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Pulp cap indirect,D3120,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Pulp cap indirect,D3120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Pulp cap indirect,D3120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Pulp cap indirect,D3120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Pulp cap indirect,D3120,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Therapeutic pulpotomy,D3220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,421.09,,,,,,,fee schedule,337.54,2839.47,
Therapeutic pulpotomy,D3220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,337.54,,,,,,,fee schedule,337.54,2839.47,
Therapeutic pulpotomy,D3220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,368.73,,,,,,,fee schedule,337.54,2839.47,
Therapeutic pulpotomy,D3220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,387.67,,,,,,,fee schedule,337.54,2839.47,
Therapeutic pulpotomy,D3220,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,337.54,2839.47,APC 378
Therapeutic pulpotomy,D3220,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,337.54,2839.47,APC
Therapeutic pulpotomy,D3220,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,337.54,2839.47,APC
Therapeutic pulpotomy,D3220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,337.54,2839.47,APC
Therapeutic pulpotomy,D3220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,337.54,2839.47,Radiology
Therapeutic pulpotomy,D3220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,337.54,2839.47,APC
Therapeutic pulpotomy,D3220,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,337.54,2839.47,APC
Gross pulpal debridement,D3221,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Gross pulpal debridement,D3221,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Gross pulpal debridement,D3221,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Gross pulpal debridement,D3221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Gross pulpal debridement,D3221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Gross pulpal debridement,D3221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Gross pulpal debridement,D3221,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Part pulp for apexogenesis,D3222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,865.62,,,,,,,fee schedule,640,2839.47,
Part pulp for apexogenesis,D3222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,693.87,,,,,,,fee schedule,640,2839.47,
Part pulp for apexogenesis,D3222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,757.99,,,,,,,fee schedule,640,2839.47,
Part pulp for apexogenesis,D3222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,796.92,,,,,,,fee schedule,640,2839.47,
Part pulp for apexogenesis,D3222,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Part pulp for apexogenesis,D3222,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Part pulp for apexogenesis,D3222,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Part pulp for apexogenesis,D3222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Part pulp for apexogenesis,D3222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Part pulp for apexogenesis,D3222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Part pulp for apexogenesis,D3222,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Pulpal therapy anterior prim,D3230,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Pulpal therapy anterior prim,D3230,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Pulpal therapy anterior prim,D3230,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Pulpal therapy anterior prim,D3230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Pulpal therapy anterior prim,D3230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Pulpal therapy anterior prim,D3230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Pulpal therapy anterior prim,D3230,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Pulpal therapy posterior pri,D3240,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Pulpal therapy posterior pri,D3240,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Pulpal therapy posterior pri,D3240,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Pulpal therapy posterior pri,D3240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Pulpal therapy posterior pri,D3240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Pulpal therapy posterior pri,D3240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Pulpal therapy posterior pri,D3240,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
"End thxpy, anterior tooth",D3310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,308.14,,,,,,,fee schedule,247,2839.47,
"End thxpy, anterior tooth",D3310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,247,,,,,,,fee schedule,247,2839.47,
"End thxpy, anterior tooth",D3310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,269.83,,,,,,,fee schedule,247,2839.47,
"End thxpy, anterior tooth",D3310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,283.69,,,,,,,fee schedule,247,2839.47,
"End thxpy, anterior tooth",D3310,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,247,2839.47,APC 378
"End thxpy, anterior tooth",D3310,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,247,2839.47,APC
"End thxpy, anterior tooth",D3310,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,247,2839.47,APC
"End thxpy, anterior tooth",D3310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,247,2839.47,APC
"End thxpy, anterior tooth",D3310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,247,2839.47,Radiology
"End thxpy, anterior tooth",D3310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,247,2839.47,APC
"End thxpy, anterior tooth",D3310,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,247,2839.47,APC
"End thxpy, bicuspid tooth",D3320,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
"End thxpy, bicuspid tooth",D3320,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
"End thxpy, bicuspid tooth",D3320,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
"End thxpy, bicuspid tooth",D3320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
"End thxpy, bicuspid tooth",D3320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
"End thxpy, bicuspid tooth",D3320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
"End thxpy, bicuspid tooth",D3320,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
"End thxpy, molar",D3330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,423.93,,,,,,,fee schedule,339.82,2839.47,
"End thxpy, molar",D3330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,339.82,,,,,,,fee schedule,339.82,2839.47,
"End thxpy, molar",D3330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,371.22,,,,,,,fee schedule,339.82,2839.47,
"End thxpy, molar",D3330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,390.28,,,,,,,fee schedule,339.82,2839.47,
"End thxpy, molar",D3330,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,339.82,2839.47,APC 378
"End thxpy, molar",D3330,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,339.82,2839.47,APC
"End thxpy, molar",D3330,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,339.82,2839.47,APC
"End thxpy, molar",D3330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,339.82,2839.47,APC
"End thxpy, molar",D3330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,339.82,2839.47,Radiology
"End thxpy, molar",D3330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,339.82,2839.47,APC
"End thxpy, molar",D3330,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,339.82,2839.47,APC
Non-surg tx root canal obs,D3331,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Non-surg tx root canal obs,D3331,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Non-surg tx root canal obs,D3331,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Non-surg tx root canal obs,D3331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Non-surg tx root canal obs,D3331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Non-surg tx root canal obs,D3331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Non-surg tx root canal obs,D3331,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Incomplete endodontic tx,D3332,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Incomplete endodontic tx,D3332,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Incomplete endodontic tx,D3332,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Incomplete endodontic tx,D3332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Incomplete endodontic tx,D3332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Incomplete endodontic tx,D3332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Incomplete endodontic tx,D3332,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Internal root repair,D3333,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Internal root repair,D3333,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Internal root repair,D3333,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Internal root repair,D3333,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Internal root repair,D3333,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Internal root repair,D3333,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Internal root repair,D3333,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Retreat root canal anterior,D3346,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Retreat root canal anterior,D3346,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Retreat root canal anterior,D3346,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Retreat root canal anterior,D3346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Retreat root canal anterior,D3346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Retreat root canal anterior,D3346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Retreat root canal anterior,D3346,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Retreat root canal bicuspid,D3347,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Retreat root canal bicuspid,D3347,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Retreat root canal bicuspid,D3347,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Retreat root canal bicuspid,D3347,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Retreat root canal bicuspid,D3347,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Retreat root canal bicuspid,D3347,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Retreat root canal bicuspid,D3347,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Retreat root canal molar,D3348,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Retreat root canal molar,D3348,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Retreat root canal molar,D3348,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Retreat root canal molar,D3348,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Retreat root canal molar,D3348,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Retreat root canal molar,D3348,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Retreat root canal molar,D3348,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Apexification/recalc initial,D3351,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Apexification/recalc initial,D3351,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Apexification/recalc initial,D3351,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Apexification/recalc initial,D3351,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Apexification/recalc initial,D3351,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Apexification/recalc initial,D3351,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Apexification/recalc initial,D3351,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Apexification/recalc interim,D3352,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Apexification/recalc interim,D3352,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Apexification/recalc interim,D3352,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Apexification/recalc interim,D3352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Apexification/recalc interim,D3352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Apexification/recalc interim,D3352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Apexification/recalc interim,D3352,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Apexification/recalc final,D3353,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Apexification/recalc final,D3353,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Apexification/recalc final,D3353,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Apexification/recalc final,D3353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Apexification/recalc final,D3353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Apexification/recalc final,D3353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Apexification/recalc final,D3353,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Pulpal regeneration initial,D3355,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Pulpal regeneration initial,D3355,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Pulpal regeneration initial,D3355,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Pulpal regeneration initial,D3355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Pulpal regeneration initial,D3355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Pulpal regeneration initial,D3355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Pulpal regeneration initial,D3355,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Pulpal regeneration interim,D3356,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Pulpal regeneration interim,D3356,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Pulpal regeneration interim,D3356,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Pulpal regeneration interim,D3356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Pulpal regeneration interim,D3356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Pulpal regeneration interim,D3356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Pulpal regeneration interim,D3356,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Pulpal regeneration complete,D3357,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Pulpal regeneration complete,D3357,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Pulpal regeneration complete,D3357,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Pulpal regeneration complete,D3357,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Pulpal regeneration complete,D3357,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Pulpal regeneration complete,D3357,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Pulpal regeneration complete,D3357,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Apicoectomy - anterior,D3410,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Apicoectomy - anterior,D3410,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Apicoectomy - anterior,D3410,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Apicoectomy - anterior,D3410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Apicoectomy - anterior,D3410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Apicoectomy - anterior,D3410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Apicoectomy - anterior,D3410,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Root surgery bicuspid,D3421,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Root surgery bicuspid,D3421,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Root surgery bicuspid,D3421,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Root surgery bicuspid,D3421,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Root surgery bicuspid,D3421,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Root surgery bicuspid,D3421,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Root surgery bicuspid,D3421,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Root surgery molar,D3425,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Root surgery molar,D3425,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Root surgery molar,D3425,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Root surgery molar,D3425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Root surgery molar,D3425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Root surgery molar,D3425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Root surgery molar,D3425,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Bone graft peri per tooth,D3428,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Bone graft peri per tooth,D3428,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Bone graft peri per tooth,D3428,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Bone graft peri per tooth,D3428,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Bone graft peri per tooth,D3428,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Bone graft peri per tooth,D3428,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Bone graft peri per tooth,D3428,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Retrograde filling,D3430,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Retrograde filling,D3430,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Retrograde filling,D3430,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Retrograde filling,D3430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Retrograde filling,D3430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Retrograde filling,D3430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Retrograde filling,D3430,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Biological materials,D3431,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Biological materials,D3431,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Biological materials,D3431,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Biological materials,D3431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Biological materials,D3431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Biological materials,D3431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Biological materials,D3431,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Guided tissue regeneration,D3432,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Guided tissue regeneration,D3432,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Guided tissue regeneration,D3432,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Guided tissue regeneration,D3432,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Guided tissue regeneration,D3432,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Guided tissue regeneration,D3432,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Guided tissue regeneration,D3432,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Root amputation,D3450,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Root amputation,D3450,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Root amputation,D3450,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Root amputation,D3450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Root amputation,D3450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Root amputation,D3450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Root amputation,D3450,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Endodontic endosseous implan,D3460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2288.03,,,,,,,fee schedule,640,2839.47,
Endodontic endosseous implan,D3460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1834.06,,,,,,,fee schedule,640,2839.47,
Endodontic endosseous implan,D3460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2003.54,,,,,,,fee schedule,640,2839.47,
Endodontic endosseous implan,D3460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2106.44,,,,,,,fee schedule,640,2839.47,
Endodontic endosseous implan,D3460,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Endodontic endosseous implan,D3460,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Endodontic endosseous implan,D3460,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Endodontic endosseous implan,D3460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Endodontic endosseous implan,D3460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Endodontic endosseous implan,D3460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Endodontic endosseous implan,D3460,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Intentional replantation,D3470,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Intentional replantation,D3470,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Intentional replantation,D3470,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Intentional replantation,D3470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Intentional replantation,D3470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Intentional replantation,D3470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Intentional replantation,D3470,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Surg rep root res anterior,D3471,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Surg rep root res anterior,D3471,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Surg rep root res anterior,D3471,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Surg rep root res anterior,D3471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Surg rep root res anterior,D3471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Surg rep root res anterior,D3471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Surg rep root res anterior,D3471,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Surg rep root res premolar,D3472,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Surg rep root res premolar,D3472,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Surg rep root res premolar,D3472,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Surg rep root res premolar,D3472,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Surg rep root res premolar,D3472,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Surg rep root res premolar,D3472,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Surg rep root res premolar,D3472,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Surg rep root res molar,D3473,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Surg rep root res molar,D3473,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Surg rep root res molar,D3473,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Surg rep root res molar,D3473,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Surg rep root res molar,D3473,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Surg rep root res molar,D3473,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Surg rep root res molar,D3473,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Surg exp root surf anterior,D3501,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Surg exp root surf anterior,D3501,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Surg exp root surf anterior,D3501,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Surg exp root surf anterior,D3501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Surg exp root surf anterior,D3501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Surg exp root surf anterior,D3501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Surg exp root surf anterior,D3501,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Surg exp root surf premolar,D3502,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Surg exp root surf premolar,D3502,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Surg exp root surf premolar,D3502,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Surg exp root surf premolar,D3502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Surg exp root surf premolar,D3502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Surg exp root surf premolar,D3502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Surg exp root surf premolar,D3502,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Surg exp root surf molar,D3503,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Surg exp root surf molar,D3503,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Surg exp root surf molar,D3503,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Surg exp root surf molar,D3503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Surg exp root surf molar,D3503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Surg exp root surf molar,D3503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Surg exp root surf molar,D3503,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Isolation- tooth w rubb dam,D3910,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Isolation- tooth w rubb dam,D3910,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Isolation- tooth w rubb dam,D3910,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Isolation- tooth w rubb dam,D3910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Isolation- tooth w rubb dam,D3910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Isolation- tooth w rubb dam,D3910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Isolation- tooth w rubb dam,D3910,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Intraorifice barrier,D3911,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Intraorifice barrier,D3911,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Intraorifice barrier,D3911,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Intraorifice barrier,D3911,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Intraorifice barrier,D3911,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Intraorifice barrier,D3911,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Intraorifice barrier,D3911,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Tooth splitting,D3920,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Tooth splitting,D3920,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Tooth splitting,D3920,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Tooth splitting,D3920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Tooth splitting,D3920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Tooth splitting,D3920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Tooth splitting,D3920,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
D?cor or submerg erupt tooth,D3921,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
D?cor or submerg erupt tooth,D3921,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
D?cor or submerg erupt tooth,D3921,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
D?cor or submerg erupt tooth,D3921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
D?cor or submerg erupt tooth,D3921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
D?cor or submerg erupt tooth,D3921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
D?cor or submerg erupt tooth,D3921,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Canal prep/fitting of dowel,D3950,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Canal prep/fitting of dowel,D3950,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Canal prep/fitting of dowel,D3950,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Canal prep/fitting of dowel,D3950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Canal prep/fitting of dowel,D3950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Canal prep/fitting of dowel,D3950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Canal prep/fitting of dowel,D3950,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Endodontic procedure,D3999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2288.03,,,,,,,fee schedule,640,2839.47,
Endodontic procedure,D3999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1834.06,,,,,,,fee schedule,640,2839.47,
Endodontic procedure,D3999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2003.54,,,,,,,fee schedule,640,2839.47,
Endodontic procedure,D3999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2106.44,,,,,,,fee schedule,640,2839.47,
Endodontic procedure,D3999,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Endodontic procedure,D3999,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Endodontic procedure,D3999,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Endodontic procedure,D3999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Endodontic procedure,D3999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Endodontic procedure,D3999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Endodontic procedure,D3999,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Gingivectomy/plasty 4 or mor,D4210,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Gingivectomy/plasty 4 or mor,D4210,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Gingivectomy/plasty 4 or mor,D4210,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Gingivectomy/plasty 4 or mor,D4210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Gingivectomy/plasty 4 or mor,D4210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Gingivectomy/plasty 4 or mor,D4210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Gingivectomy/plasty 4 or mor,D4210,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Gingivectomy/plasty 1 to 3,D4211,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Gingivectomy/plasty 1 to 3,D4211,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Gingivectomy/plasty 1 to 3,D4211,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Gingivectomy/plasty 1 to 3,D4211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Gingivectomy/plasty 1 to 3,D4211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Gingivectomy/plasty 1 to 3,D4211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Gingivectomy/plasty 1 to 3,D4211,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Gingivectomy/plasty rest,D4212,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Gingivectomy/plasty rest,D4212,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Gingivectomy/plasty rest,D4212,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Gingivectomy/plasty rest,D4212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Gingivectomy/plasty rest,D4212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Gingivectomy/plasty rest,D4212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Gingivectomy/plasty rest,D4212,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Ana crown exp 4 or> per quad,D4230,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Ana crown exp 4 or> per quad,D4230,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Ana crown exp 4 or> per quad,D4230,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Ana crown exp 4 or> per quad,D4230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Ana crown exp 4 or> per quad,D4230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Ana crown exp 4 or> per quad,D4230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Ana crown exp 4 or> per quad,D4230,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Ana crown exp 1-3 per quad,D4231,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1536.02,6814.79,APC 378
Ana crown exp 1-3 per quad,D4231,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1536.02,6814.79,APC
Ana crown exp 1-3 per quad,D4231,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1536.02,6814.79,APC
Ana crown exp 1-3 per quad,D4231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1536.02,6814.79,APC
Ana crown exp 1-3 per quad,D4231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1536.02,6814.79,Radiology
Ana crown exp 1-3 per quad,D4231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1536.02,6814.79,APC
Ana crown exp 1-3 per quad,D4231,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1536.02,6814.79,APC
Gingival flap proc w/ planin,D4240,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Gingival flap proc w/ planin,D4240,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Gingival flap proc w/ planin,D4240,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Gingival flap proc w/ planin,D4240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Gingival flap proc w/ planin,D4240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Gingival flap proc w/ planin,D4240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Gingival flap proc w/ planin,D4240,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Gngvl flap w rootplan 1-3 th,D4241,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1536.02,6814.79,APC 378
Gngvl flap w rootplan 1-3 th,D4241,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1536.02,6814.79,APC
Gngvl flap w rootplan 1-3 th,D4241,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1536.02,6814.79,APC
Gngvl flap w rootplan 1-3 th,D4241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1536.02,6814.79,APC
Gngvl flap w rootplan 1-3 th,D4241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1536.02,6814.79,Radiology
Gngvl flap w rootplan 1-3 th,D4241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1536.02,6814.79,APC
Gngvl flap w rootplan 1-3 th,D4241,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1536.02,6814.79,APC
Apically positioned flap,D4245,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1536.02,6814.79,APC 378
Apically positioned flap,D4245,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1536.02,6814.79,APC
Apically positioned flap,D4245,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1536.02,6814.79,APC
Apically positioned flap,D4245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1536.02,6814.79,APC
Apically positioned flap,D4245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1536.02,6814.79,Radiology
Apically positioned flap,D4245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1536.02,6814.79,APC
Apically positioned flap,D4245,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1536.02,6814.79,APC
Crown lengthen hard tissue,D4249,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Crown lengthen hard tissue,D4249,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Crown lengthen hard tissue,D4249,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Crown lengthen hard tissue,D4249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Crown lengthen hard tissue,D4249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Crown lengthen hard tissue,D4249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Crown lengthen hard tissue,D4249,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Osseous surgery 4 or more,D4260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2288.03,,,,,,,fee schedule,1834.06,26000.79,
Osseous surgery 4 or more,D4260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1834.06,,,,,,,fee schedule,1834.06,26000.79,
Osseous surgery 4 or more,D4260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2003.54,,,,,,,fee schedule,1834.06,26000.79,
Osseous surgery 4 or more,D4260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2106.44,,,,,,,fee schedule,1834.06,26000.79,
Osseous surgery 4 or more,D4260,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,1834.06,26000.79,APC 378
Osseous surgery 4 or more,D4260,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,1834.06,26000.79,APC
Osseous surgery 4 or more,D4260,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,1834.06,26000.79,APC
Osseous surgery 4 or more,D4260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,1834.06,26000.79,APC
Osseous surgery 4 or more,D4260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,1834.06,26000.79,Radiology
Osseous surgery 4 or more,D4260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,1834.06,26000.79,APC
Osseous surgery 4 or more,D4260,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,1834.06,26000.79,APC
Osseous surg 1 to 3 teeth,D4261,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Osseous surg 1 to 3 teeth,D4261,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Osseous surg 1 to 3 teeth,D4261,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Osseous surg 1 to 3 teeth,D4261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Osseous surg 1 to 3 teeth,D4261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Osseous surg 1 to 3 teeth,D4261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Osseous surg 1 to 3 teeth,D4261,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Bone replce graft first site,D4263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2288.03,,,,,,,fee schedule,640,2839.47,
Bone replce graft first site,D4263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1834.06,,,,,,,fee schedule,640,2839.47,
Bone replce graft first site,D4263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2003.54,,,,,,,fee schedule,640,2839.47,
Bone replce graft first site,D4263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2106.44,,,,,,,fee schedule,640,2839.47,
Bone replce graft first site,D4263,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Bone replce graft first site,D4263,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Bone replce graft first site,D4263,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Bone replce graft first site,D4263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Bone replce graft first site,D4263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Bone replce graft first site,D4263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Bone replce graft first site,D4263,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Bone replce graft each add,D4264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2288.03,,,,,,,fee schedule,1834.06,2288.03,
Bone replce graft each add,D4264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1834.06,,,,,,,fee schedule,1834.06,2288.03,
Bone replce graft each add,D4264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2003.54,,,,,,,fee schedule,1834.06,2288.03,
Bone replce graft each add,D4264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2106.44,,,,,,,fee schedule,1834.06,2288.03,
Bio mtrls to aid soft/os reg,D4265,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Bio mtrls to aid soft/os reg,D4265,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Bio mtrls to aid soft/os reg,D4265,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Bio mtrls to aid soft/os reg,D4265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Bio mtrls to aid soft/os reg,D4265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Bio mtrls to aid soft/os reg,D4265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Bio mtrls to aid soft/os reg,D4265,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Guided tiss regen resorble,D4266,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1536.02,6814.79,APC 378
Guided tiss regen resorble,D4266,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1536.02,6814.79,APC
Guided tiss regen resorble,D4266,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1536.02,6814.79,APC
Guided tiss regen resorble,D4266,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1536.02,6814.79,APC
Guided tiss regen resorble,D4266,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1536.02,6814.79,Radiology
Guided tiss regen resorble,D4266,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1536.02,6814.79,APC
Guided tiss regen resorble,D4266,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1536.02,6814.79,APC
Guided tiss regen nonresorb,D4267,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1536.02,6814.79,APC 378
Guided tiss regen nonresorb,D4267,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1536.02,6814.79,APC
Guided tiss regen nonresorb,D4267,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1536.02,6814.79,APC
Guided tiss regen nonresorb,D4267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1536.02,6814.79,APC
Guided tiss regen nonresorb,D4267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1536.02,6814.79,Radiology
Guided tiss regen nonresorb,D4267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1536.02,6814.79,APC
Guided tiss regen nonresorb,D4267,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1536.02,6814.79,APC
Surgical revision procedure,D4268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2288.03,,,,,,,fee schedule,640,2839.47,
Surgical revision procedure,D4268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1834.06,,,,,,,fee schedule,640,2839.47,
Surgical revision procedure,D4268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2003.54,,,,,,,fee schedule,640,2839.47,
Surgical revision procedure,D4268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2106.44,,,,,,,fee schedule,640,2839.47,
Surgical revision procedure,D4268,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Surgical revision procedure,D4268,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Surgical revision procedure,D4268,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Surgical revision procedure,D4268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Surgical revision procedure,D4268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Surgical revision procedure,D4268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Surgical revision procedure,D4268,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Pedicle soft tissue graft pr,D4270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2288.03,,,,,,,fee schedule,1536.02,6814.79,
Pedicle soft tissue graft pr,D4270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1834.06,,,,,,,fee schedule,1536.02,6814.79,
Pedicle soft tissue graft pr,D4270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2003.54,,,,,,,fee schedule,1536.02,6814.79,
Pedicle soft tissue graft pr,D4270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2106.44,,,,,,,fee schedule,1536.02,6814.79,
Pedicle soft tissue graft pr,D4270,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1536.02,6814.79,APC 378
Pedicle soft tissue graft pr,D4270,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1536.02,6814.79,APC
Pedicle soft tissue graft pr,D4270,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1536.02,6814.79,APC
Pedicle soft tissue graft pr,D4270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1536.02,6814.79,APC
Pedicle soft tissue graft pr,D4270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1536.02,6814.79,Radiology
Pedicle soft tissue graft pr,D4270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1536.02,6814.79,APC
Pedicle soft tissue graft pr,D4270,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1536.02,6814.79,APC
Auto tissue graft 1st tooth,D4273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2288.03,,,,,,,fee schedule,1536.02,6814.79,
Auto tissue graft 1st tooth,D4273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1834.06,,,,,,,fee schedule,1536.02,6814.79,
Auto tissue graft 1st tooth,D4273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2003.54,,,,,,,fee schedule,1536.02,6814.79,
Auto tissue graft 1st tooth,D4273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2106.44,,,,,,,fee schedule,1536.02,6814.79,
Auto tissue graft 1st tooth,D4273,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1536.02,6814.79,APC 378
Auto tissue graft 1st tooth,D4273,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1536.02,6814.79,APC
Auto tissue graft 1st tooth,D4273,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1536.02,6814.79,APC
Auto tissue graft 1st tooth,D4273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1536.02,6814.79,APC
Auto tissue graft 1st tooth,D4273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1536.02,6814.79,Radiology
Auto tissue graft 1st tooth,D4273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1536.02,6814.79,APC
Auto tissue graft 1st tooth,D4273,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1536.02,6814.79,APC
Mesial/distal wedge proc,D4274,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Mesial/distal wedge proc,D4274,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Mesial/distal wedge proc,D4274,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Mesial/distal wedge proc,D4274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Mesial/distal wedge proc,D4274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Mesial/distal wedge proc,D4274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Mesial/distal wedge proc,D4274,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Non-auto graft 1st tooth,D4275,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1536.02,6814.79,APC 378
Non-auto graft 1st tooth,D4275,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1536.02,6814.79,APC
Non-auto graft 1st tooth,D4275,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1536.02,6814.79,APC
Non-auto graft 1st tooth,D4275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1536.02,6814.79,APC
Non-auto graft 1st tooth,D4275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1536.02,6814.79,Radiology
Non-auto graft 1st tooth,D4275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1536.02,6814.79,APC
Non-auto graft 1st tooth,D4275,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1536.02,6814.79,APC
Con tissue w dble ped graft,D4276,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1536.02,6814.79,APC 378
Con tissue w dble ped graft,D4276,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1536.02,6814.79,APC
Con tissue w dble ped graft,D4276,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1536.02,6814.79,APC
Con tissue w dble ped graft,D4276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1536.02,6814.79,APC
Con tissue w dble ped graft,D4276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1536.02,6814.79,Radiology
Con tissue w dble ped graft,D4276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1536.02,6814.79,APC
Con tissue w dble ped graft,D4276,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1536.02,6814.79,APC
Soft tissue graft firsttooth,D4277,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1536.02,6814.79,APC 378
Soft tissue graft firsttooth,D4277,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1536.02,6814.79,APC
Soft tissue graft firsttooth,D4277,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1536.02,6814.79,APC
Soft tissue graft firsttooth,D4277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1536.02,6814.79,APC
Soft tissue graft firsttooth,D4277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1536.02,6814.79,Radiology
Soft tissue graft firsttooth,D4277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1536.02,6814.79,APC
Soft tissue graft firsttooth,D4277,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1536.02,6814.79,APC
Splint intra-coronal,D4322,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Splint intra-coronal,D4322,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Splint intra-coronal,D4322,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Splint intra-coronal,D4322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Splint intra-coronal,D4322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Splint intra-coronal,D4322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Splint intra-coronal,D4322,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Splint extra-coronal,D4323,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Splint extra-coronal,D4323,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Splint extra-coronal,D4323,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Splint extra-coronal,D4323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Splint extra-coronal,D4323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Splint extra-coronal,D4323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Splint extra-coronal,D4323,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Periodontal scaling & root,D4341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,499.37,,,,,,,fee schedule,400.29,2839.47,
Periodontal scaling & root,D4341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,400.29,,,,,,,fee schedule,400.29,2839.47,
Periodontal scaling & root,D4341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,437.28,,,,,,,fee schedule,400.29,2839.47,
Periodontal scaling & root,D4341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,459.74,,,,,,,fee schedule,400.29,2839.47,
Periodontal scaling & root,D4341,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,400.29,2839.47,APC 378
Periodontal scaling & root,D4341,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,400.29,2839.47,APC
Periodontal scaling & root,D4341,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,400.29,2839.47,APC
Periodontal scaling & root,D4341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,400.29,2839.47,APC
Periodontal scaling & root,D4341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,400.29,2839.47,Radiology
Periodontal scaling & root,D4341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,400.29,2839.47,APC
Periodontal scaling & root,D4341,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,400.29,2839.47,APC
Periodontal scaling 1-3teeth,D4342,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Periodontal scaling 1-3teeth,D4342,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Periodontal scaling 1-3teeth,D4342,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Periodontal scaling 1-3teeth,D4342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Periodontal scaling 1-3teeth,D4342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Periodontal scaling 1-3teeth,D4342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Periodontal scaling 1-3teeth,D4342,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Scaling gingiv inflammation,D4346,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Scaling gingiv inflammation,D4346,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Scaling gingiv inflammation,D4346,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Scaling gingiv inflammation,D4346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Scaling gingiv inflammation,D4346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Scaling gingiv inflammation,D4346,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Scaling gingiv inflammation,D4346,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Full mouth debridement,D4355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2288.03,,,,,,,fee schedule,640,2839.47,
Full mouth debridement,D4355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1834.06,,,,,,,fee schedule,640,2839.47,
Full mouth debridement,D4355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2003.54,,,,,,,fee schedule,640,2839.47,
Full mouth debridement,D4355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2106.44,,,,,,,fee schedule,640,2839.47,
Full mouth debridement,D4355,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Full mouth debridement,D4355,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Full mouth debridement,D4355,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Full mouth debridement,D4355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Full mouth debridement,D4355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Full mouth debridement,D4355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Full mouth debridement,D4355,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Localized delivery antimicro,D4381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2288.03,,,,,,,fee schedule,640,2839.47,
Localized delivery antimicro,D4381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1834.06,,,,,,,fee schedule,640,2839.47,
Localized delivery antimicro,D4381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2003.54,,,,,,,fee schedule,640,2839.47,
Localized delivery antimicro,D4381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2106.44,,,,,,,fee schedule,640,2839.47,
Localized delivery antimicro,D4381,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Localized delivery antimicro,D4381,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Localized delivery antimicro,D4381,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Localized delivery antimicro,D4381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Localized delivery antimicro,D4381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Localized delivery antimicro,D4381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Localized delivery antimicro,D4381,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Periodontal maint procedures,D4910,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Periodontal maint procedures,D4910,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Periodontal maint procedures,D4910,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Periodontal maint procedures,D4910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Periodontal maint procedures,D4910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Periodontal maint procedures,D4910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Periodontal maint procedures,D4910,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Unscheduled dressing change,D4920,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Unscheduled dressing change,D4920,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Unscheduled dressing change,D4920,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Unscheduled dressing change,D4920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Unscheduled dressing change,D4920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Unscheduled dressing change,D4920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Unscheduled dressing change,D4920,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Gingival irrigation per quad,D4921,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.75,,,,,,,fee schedule,131.8,584.75,APC 378
Gingival irrigation per quad,D4921,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.39,,,,,,,fee schedule,131.8,584.75,APC
Gingival irrigation per quad,D4921,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,137.07,,,,,,,fee schedule,131.8,584.75,APC
Gingival irrigation per quad,D4921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.8,,,,,,,fee schedule,131.8,584.75,APC
Gingival irrigation per quad,D4921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.66,,,,,,,fee schedule,131.8,584.75,Radiology
Gingival irrigation per quad,D4921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.52,,,,,,,fee schedule,131.8,584.75,APC
Gingival irrigation per quad,D4921,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.65,,,,,,,fee schedule,131.8,584.75,APC
Unspecified periodontal proc,D4999,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1040.28,,,,,,,fee schedule,234.47,1040.28,APC 378
Unspecified periodontal proc,D4999,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,246.2,,,,,,,fee schedule,234.47,1040.28,APC
Unspecified periodontal proc,D4999,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,243.85,,,,,,,fee schedule,234.47,1040.28,APC
Unspecified periodontal proc,D4999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,234.47,,,,,,,fee schedule,234.47,1040.28,APC
Unspecified periodontal proc,D4999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,358.74,,,,,,,fee schedule,234.47,1040.28,Radiology
Unspecified periodontal proc,D4999,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,328.26,,,,,,,fee schedule,234.47,1040.28,APC
Unspecified periodontal proc,D4999,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,410.33,,,,,,,fee schedule,234.47,1040.28,APC
Facial moulage sectional,D5911,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2288.03,,,,,,,fee schedule,640,2839.47,
Facial moulage sectional,D5911,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1834.06,,,,,,,fee schedule,640,2839.47,
Facial moulage sectional,D5911,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2003.54,,,,,,,fee schedule,640,2839.47,
Facial moulage sectional,D5911,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2106.44,,,,,,,fee schedule,640,2839.47,
Facial moulage sectional,D5911,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Facial moulage sectional,D5911,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Facial moulage sectional,D5911,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Facial moulage sectional,D5911,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Facial moulage sectional,D5911,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Facial moulage sectional,D5911,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Facial moulage sectional,D5911,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Facial moulage complete,D5912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2288.03,,,,,,,fee schedule,640,2839.47,
Facial moulage complete,D5912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1834.06,,,,,,,fee schedule,640,2839.47,
Facial moulage complete,D5912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2003.54,,,,,,,fee schedule,640,2839.47,
Facial moulage complete,D5912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2106.44,,,,,,,fee schedule,640,2839.47,
Facial moulage complete,D5912,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Facial moulage complete,D5912,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Facial moulage complete,D5912,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Facial moulage complete,D5912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Facial moulage complete,D5912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Facial moulage complete,D5912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Facial moulage complete,D5912,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Radiation applicator,D5983,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2288.03,,,,,,,fee schedule,640,2839.47,
Radiation applicator,D5983,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1834.06,,,,,,,fee schedule,640,2839.47,
Radiation applicator,D5983,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2003.54,,,,,,,fee schedule,640,2839.47,
Radiation applicator,D5983,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2106.44,,,,,,,fee schedule,640,2839.47,
Radiation applicator,D5983,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Radiation applicator,D5983,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Radiation applicator,D5983,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Radiation applicator,D5983,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Radiation applicator,D5983,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Radiation applicator,D5983,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Radiation applicator,D5983,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Radiation shield,D5984,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2288.03,,,,,,,fee schedule,640,2839.47,
Radiation shield,D5984,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1834.06,,,,,,,fee schedule,640,2839.47,
Radiation shield,D5984,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2003.54,,,,,,,fee schedule,640,2839.47,
Radiation shield,D5984,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2106.44,,,,,,,fee schedule,640,2839.47,
Radiation shield,D5984,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Radiation shield,D5984,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Radiation shield,D5984,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Radiation shield,D5984,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Radiation shield,D5984,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Radiation shield,D5984,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Radiation shield,D5984,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Radiation cone locator,D5985,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2288.03,,,,,,,fee schedule,640,2839.47,
Radiation cone locator,D5985,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1834.06,,,,,,,fee schedule,640,2839.47,
Radiation cone locator,D5985,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2003.54,,,,,,,fee schedule,640,2839.47,
Radiation cone locator,D5985,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2106.44,,,,,,,fee schedule,640,2839.47,
Radiation cone locator,D5985,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Radiation cone locator,D5985,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Radiation cone locator,D5985,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Radiation cone locator,D5985,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Radiation cone locator,D5985,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Radiation cone locator,D5985,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Radiation cone locator,D5985,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Commissure splint,D5987,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2288.03,,,,,,,fee schedule,640,2839.47,
Commissure splint,D5987,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1834.06,,,,,,,fee schedule,640,2839.47,
Commissure splint,D5987,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2003.54,,,,,,,fee schedule,640,2839.47,
Commissure splint,D5987,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2106.44,,,,,,,fee schedule,640,2839.47,
Commissure splint,D5987,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Commissure splint,D5987,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Commissure splint,D5987,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Commissure splint,D5987,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Commissure splint,D5987,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Commissure splint,D5987,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Commissure splint,D5987,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Surgical splint,D5988,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Surgical splint,D5988,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Surgical splint,D5988,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Surgical splint,D5988,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Surgical splint,D5988,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Surgical splint,D5988,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Surgical splint,D5988,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Vesiculobullous disease carr,D5991,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,532.98,,,,,,,fee schedule,427.23,532.98,
Vesiculobullous disease carr,D5991,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,427.23,,,,,,,fee schedule,427.23,532.98,
Vesiculobullous disease carr,D5991,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,466.71,,,,,,,fee schedule,427.23,532.98,
Vesiculobullous disease carr,D5991,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,490.68,,,,,,,fee schedule,427.23,532.98,
Dental connector bar,D6920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2288.03,,,,,,,fee schedule,640,2839.47,
Dental connector bar,D6920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1834.06,,,,,,,fee schedule,640,2839.47,
Dental connector bar,D6920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2003.54,,,,,,,fee schedule,640,2839.47,
Dental connector bar,D6920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2106.44,,,,,,,fee schedule,640,2839.47,
Dental connector bar,D6920,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Dental connector bar,D6920,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Dental connector bar,D6920,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Dental connector bar,D6920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Dental connector bar,D6920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Dental connector bar,D6920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Dental connector bar,D6920,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Extraction coronal remnants,D7111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2288.03,,,,,,,fee schedule,640,2839.47,
Extraction coronal remnants,D7111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1834.06,,,,,,,fee schedule,640,2839.47,
Extraction coronal remnants,D7111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2003.54,,,,,,,fee schedule,640,2839.47,
Extraction coronal remnants,D7111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2106.44,,,,,,,fee schedule,640,2839.47,
Extraction coronal remnants,D7111,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Extraction coronal remnants,D7111,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Extraction coronal remnants,D7111,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Extraction coronal remnants,D7111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Extraction coronal remnants,D7111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Extraction coronal remnants,D7111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Extraction coronal remnants,D7111,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Extraction erupted tooth/exr,D7140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,513.03,,,,,,,fee schedule,411.24,2839.47,
Extraction erupted tooth/exr,D7140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,411.24,,,,,,,fee schedule,411.24,2839.47,
Extraction erupted tooth/exr,D7140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,449.24,,,,,,,fee schedule,411.24,2839.47,
Extraction erupted tooth/exr,D7140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,472.31,,,,,,,fee schedule,411.24,2839.47,
Extraction erupted tooth/exr,D7140,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,411.24,2839.47,APC 378
Extraction erupted tooth/exr,D7140,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,411.24,2839.47,APC
Extraction erupted tooth/exr,D7140,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,411.24,2839.47,APC
Extraction erupted tooth/exr,D7140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,411.24,2839.47,APC
Extraction erupted tooth/exr,D7140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,411.24,2839.47,Radiology
Extraction erupted tooth/exr,D7140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,411.24,2839.47,APC
Extraction erupted tooth/exr,D7140,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,411.24,2839.47,APC
Rem imp tooth w mucoper flp,D7210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2288.03,,,,,,,fee schedule,1536.02,6814.79,
Rem imp tooth w mucoper flp,D7210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1834.06,,,,,,,fee schedule,1536.02,6814.79,
Rem imp tooth w mucoper flp,D7210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2003.54,,,,,,,fee schedule,1536.02,6814.79,
Rem imp tooth w mucoper flp,D7210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2106.44,,,,,,,fee schedule,1536.02,6814.79,
Rem imp tooth w mucoper flp,D7210,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1536.02,6814.79,APC 378
Rem imp tooth w mucoper flp,D7210,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1536.02,6814.79,APC
Rem imp tooth w mucoper flp,D7210,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1536.02,6814.79,APC
Rem imp tooth w mucoper flp,D7210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1536.02,6814.79,APC
Rem imp tooth w mucoper flp,D7210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1536.02,6814.79,Radiology
Rem imp tooth w mucoper flp,D7210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1536.02,6814.79,APC
Rem imp tooth w mucoper flp,D7210,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1536.02,6814.79,APC
Impact tooth remov soft tiss,D7220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1563.36,,,,,,,fee schedule,640,2839.47,
Impact tooth remov soft tiss,D7220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1253.17,,,,,,,fee schedule,640,2839.47,
Impact tooth remov soft tiss,D7220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1368.98,,,,,,,fee schedule,640,2839.47,
Impact tooth remov soft tiss,D7220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1439.29,,,,,,,fee schedule,640,2839.47,
Impact tooth remov soft tiss,D7220,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Impact tooth remov soft tiss,D7220,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Impact tooth remov soft tiss,D7220,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Impact tooth remov soft tiss,D7220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Impact tooth remov soft tiss,D7220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Impact tooth remov soft tiss,D7220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Impact tooth remov soft tiss,D7220,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Impact tooth remov part bony,D7230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2288.03,,,,,,,fee schedule,640,2839.47,
Impact tooth remov part bony,D7230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1834.06,,,,,,,fee schedule,640,2839.47,
Impact tooth remov part bony,D7230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2003.54,,,,,,,fee schedule,640,2839.47,
Impact tooth remov part bony,D7230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2106.44,,,,,,,fee schedule,640,2839.47,
Impact tooth remov part bony,D7230,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Impact tooth remov part bony,D7230,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Impact tooth remov part bony,D7230,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Impact tooth remov part bony,D7230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Impact tooth remov part bony,D7230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Impact tooth remov part bony,D7230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Impact tooth remov part bony,D7230,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Impact tooth remov comp bony,D7240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3799.43,,,,,,,fee schedule,640,3799.43,
Impact tooth remov comp bony,D7240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3045.57,,,,,,,fee schedule,640,3799.43,
Impact tooth remov comp bony,D7240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3327.01,,,,,,,fee schedule,640,3799.43,
Impact tooth remov comp bony,D7240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3497.88,,,,,,,fee schedule,640,3799.43,
Impact tooth remov comp bony,D7240,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,3799.43,APC 378
Impact tooth remov comp bony,D7240,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,3799.43,APC
Impact tooth remov comp bony,D7240,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,3799.43,APC
Impact tooth remov comp bony,D7240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,3799.43,APC
Impact tooth remov comp bony,D7240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,3799.43,Radiology
Impact tooth remov comp bony,D7240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,3799.43,APC
Impact tooth remov comp bony,D7240,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,3799.43,APC
Impact tooth rem bony w/comp,D7241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2288.03,,,,,,,fee schedule,640,2839.47,
Impact tooth rem bony w/comp,D7241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1834.06,,,,,,,fee schedule,640,2839.47,
Impact tooth rem bony w/comp,D7241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2003.54,,,,,,,fee schedule,640,2839.47,
Impact tooth rem bony w/comp,D7241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2106.44,,,,,,,fee schedule,640,2839.47,
Impact tooth rem bony w/comp,D7241,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Impact tooth rem bony w/comp,D7241,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Impact tooth rem bony w/comp,D7241,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Impact tooth rem bony w/comp,D7241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Impact tooth rem bony w/comp,D7241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Impact tooth rem bony w/comp,D7241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Impact tooth rem bony w/comp,D7241,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Tooth root removal,D7250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2288.03,,,,,,,fee schedule,640,2839.47,
Tooth root removal,D7250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1834.06,,,,,,,fee schedule,640,2839.47,
Tooth root removal,D7250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2003.54,,,,,,,fee schedule,640,2839.47,
Tooth root removal,D7250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2106.44,,,,,,,fee schedule,640,2839.47,
Tooth root removal,D7250,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Tooth root removal,D7250,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Tooth root removal,D7250,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Tooth root removal,D7250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Tooth root removal,D7250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Tooth root removal,D7250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Tooth root removal,D7250,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Coronectomy,D7251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1205.82,,,,,,,fee schedule,966.57,6814.79,
Coronectomy,D7251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,966.57,,,,,,,fee schedule,966.57,6814.79,
Coronectomy,D7251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1055.89,,,,,,,fee schedule,966.57,6814.79,
Coronectomy,D7251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1110.12,,,,,,,fee schedule,966.57,6814.79,
Coronectomy,D7251,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,966.57,6814.79,APC 378
Coronectomy,D7251,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,966.57,6814.79,APC
Coronectomy,D7251,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,966.57,6814.79,APC
Coronectomy,D7251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,966.57,6814.79,APC
Coronectomy,D7251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,966.57,6814.79,Radiology
Coronectomy,D7251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,966.57,6814.79,APC
Coronectomy,D7251,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,966.57,6814.79,APC
Oral antral fistula closure,D7260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2288.03,,,,,,,fee schedule,640,2839.47,
Oral antral fistula closure,D7260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1834.06,,,,,,,fee schedule,640,2839.47,
Oral antral fistula closure,D7260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2003.54,,,,,,,fee schedule,640,2839.47,
Oral antral fistula closure,D7260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2106.44,,,,,,,fee schedule,640,2839.47,
Oral antral fistula closure,D7260,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Oral antral fistula closure,D7260,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Oral antral fistula closure,D7260,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Oral antral fistula closure,D7260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Oral antral fistula closure,D7260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Oral antral fistula closure,D7260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Oral antral fistula closure,D7260,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Primary closure sinus perf,D7261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2288.03,,,,,,,fee schedule,640,2839.47,
Primary closure sinus perf,D7261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1834.06,,,,,,,fee schedule,640,2839.47,
Primary closure sinus perf,D7261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2003.54,,,,,,,fee schedule,640,2839.47,
Primary closure sinus perf,D7261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2106.44,,,,,,,fee schedule,640,2839.47,
Primary closure sinus perf,D7261,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Primary closure sinus perf,D7261,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Primary closure sinus perf,D7261,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Primary closure sinus perf,D7261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Primary closure sinus perf,D7261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Primary closure sinus perf,D7261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Primary closure sinus perf,D7261,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Tooth reimplantation,D7270,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Tooth reimplantation,D7270,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Tooth reimplantation,D7270,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Tooth reimplantation,D7270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Tooth reimplantation,D7270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Tooth reimplantation,D7270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Tooth reimplantation,D7270,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Tooth transplantation,D7272,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Tooth transplantation,D7272,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Tooth transplantation,D7272,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Tooth transplantation,D7272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Tooth transplantation,D7272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Tooth transplantation,D7272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Tooth transplantation,D7272,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Exposure of unerupted tooth,D7280,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Exposure of unerupted tooth,D7280,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Exposure of unerupted tooth,D7280,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Exposure of unerupted tooth,D7280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Exposure of unerupted tooth,D7280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Exposure of unerupted tooth,D7280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Exposure of unerupted tooth,D7280,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Place device impacted tooth,D7283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1436.4,,,,,,,fee schedule,1151.4,1436.4,
Place device impacted tooth,D7283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1151.4,,,,,,,fee schedule,1151.4,1436.4,
Place device impacted tooth,D7283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1257.8,,,,,,,fee schedule,1151.4,1436.4,
Place device impacted tooth,D7283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1322.4,,,,,,,fee schedule,1151.4,1436.4,
Brush biopsy,D7288,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,517.86,,,,,,,fee schedule,415.11,517.86,
Brush biopsy,D7288,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,415.11,,,,,,,fee schedule,415.11,517.86,
Brush biopsy,D7288,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,453.47,,,,,,,fee schedule,415.11,517.86,
Brush biopsy,D7288,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,476.76,,,,,,,fee schedule,415.11,517.86,
Transseptal fiberotomy,D7291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2288.03,,,,,,,fee schedule,640,2839.47,
Transseptal fiberotomy,D7291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1834.06,,,,,,,fee schedule,640,2839.47,
Transseptal fiberotomy,D7291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2003.54,,,,,,,fee schedule,640,2839.47,
Transseptal fiberotomy,D7291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2106.44,,,,,,,fee schedule,640,2839.47,
Transseptal fiberotomy,D7291,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Transseptal fiberotomy,D7291,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Transseptal fiberotomy,D7291,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Transseptal fiberotomy,D7291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Transseptal fiberotomy,D7291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Transseptal fiberotomy,D7291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Transseptal fiberotomy,D7291,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Alveoplasty w/ extraction,D7310,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1536.02,6814.79,APC 378
Alveoplasty w/ extraction,D7310,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1536.02,6814.79,APC
Alveoplasty w/ extraction,D7310,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1536.02,6814.79,APC
Alveoplasty w/ extraction,D7310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1536.02,6814.79,APC
Alveoplasty w/ extraction,D7310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1536.02,6814.79,Radiology
Alveoplasty w/ extraction,D7310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1536.02,6814.79,APC
Alveoplasty w/ extraction,D7310,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1536.02,6814.79,APC
Alveoloplasty w/extract 1-3,D7311,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1536.02,6814.79,APC 378
Alveoloplasty w/extract 1-3,D7311,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1536.02,6814.79,APC
Alveoloplasty w/extract 1-3,D7311,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1536.02,6814.79,APC
Alveoloplasty w/extract 1-3,D7311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1536.02,6814.79,APC
Alveoloplasty w/extract 1-3,D7311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1536.02,6814.79,Radiology
Alveoloplasty w/extract 1-3,D7311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1536.02,6814.79,APC
Alveoloplasty w/extract 1-3,D7311,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1536.02,6814.79,APC
Alveoplasty w/o extraction,D7320,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1536.02,6814.79,APC 378
Alveoplasty w/o extraction,D7320,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1536.02,6814.79,APC
Alveoplasty w/o extraction,D7320,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1536.02,6814.79,APC
Alveoplasty w/o extraction,D7320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1536.02,6814.79,APC
Alveoplasty w/o extraction,D7320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1536.02,6814.79,Radiology
Alveoplasty w/o extraction,D7320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1536.02,6814.79,APC
Alveoplasty w/o extraction,D7320,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1536.02,6814.79,APC
Alveoloplasty not w/extracts,D7321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1198.26,,,,,,,fee schedule,960.51,6814.79,
Alveoloplasty not w/extracts,D7321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,960.51,,,,,,,fee schedule,960.51,6814.79,
Alveoloplasty not w/extracts,D7321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1049.27,,,,,,,fee schedule,960.51,6814.79,
Alveoloplasty not w/extracts,D7321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1103.16,,,,,,,fee schedule,960.51,6814.79,
Alveoloplasty not w/extracts,D7321,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,960.51,6814.79,APC 378
Alveoloplasty not w/extracts,D7321,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,960.51,6814.79,APC
Alveoloplasty not w/extracts,D7321,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,960.51,6814.79,APC
Alveoloplasty not w/extracts,D7321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,960.51,6814.79,APC
Alveoloplasty not w/extracts,D7321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,960.51,6814.79,Radiology
Alveoloplasty not w/extracts,D7321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,960.51,6814.79,APC
Alveoloplasty not w/extracts,D7321,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,960.51,6814.79,APC
Vestibuloplasty ridge extens,D7340,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Vestibuloplasty ridge extens,D7340,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Vestibuloplasty ridge extens,D7340,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Vestibuloplasty ridge extens,D7340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Vestibuloplasty ridge extens,D7340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Vestibuloplasty ridge extens,D7340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Vestibuloplasty ridge extens,D7340,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Vestibuloplasty exten graft,D7350,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Vestibuloplasty exten graft,D7350,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Vestibuloplasty exten graft,D7350,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Vestibuloplasty exten graft,D7350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Vestibuloplasty exten graft,D7350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Vestibuloplasty exten graft,D7350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Vestibuloplasty exten graft,D7350,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Rad exc lesion up to 1.25 cm,D7410,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1536.02,6814.79,APC 378
Rad exc lesion up to 1.25 cm,D7410,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1536.02,6814.79,APC
Rad exc lesion up to 1.25 cm,D7410,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1536.02,6814.79,APC
Rad exc lesion up to 1.25 cm,D7410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1536.02,6814.79,APC
Rad exc lesion up to 1.25 cm,D7410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1536.02,6814.79,Radiology
Rad exc lesion up to 1.25 cm,D7410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1536.02,6814.79,APC
Rad exc lesion up to 1.25 cm,D7410,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1536.02,6814.79,APC
Excision benign lesion>1.25c,D7411,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1536.02,6814.79,APC 378
Excision benign lesion>1.25c,D7411,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1536.02,6814.79,APC
Excision benign lesion>1.25c,D7411,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1536.02,6814.79,APC
Excision benign lesion>1.25c,D7411,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1536.02,6814.79,APC
Excision benign lesion>1.25c,D7411,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1536.02,6814.79,Radiology
Excision benign lesion>1.25c,D7411,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1536.02,6814.79,APC
Excision benign lesion>1.25c,D7411,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1536.02,6814.79,APC
Excision benign lesion compl,D7412,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1536.02,6814.79,APC 378
Excision benign lesion compl,D7412,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1536.02,6814.79,APC
Excision benign lesion compl,D7412,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1536.02,6814.79,APC
Excision benign lesion compl,D7412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1536.02,6814.79,APC
Excision benign lesion compl,D7412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1536.02,6814.79,Radiology
Excision benign lesion compl,D7412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1536.02,6814.79,APC
Excision benign lesion compl,D7412,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1536.02,6814.79,APC
Excision malig lesion<=1.25c,D7413,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1536.02,6814.79,APC 378
Excision malig lesion<=1.25c,D7413,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1536.02,6814.79,APC
Excision malig lesion<=1.25c,D7413,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1536.02,6814.79,APC
Excision malig lesion<=1.25c,D7413,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1536.02,6814.79,APC
Excision malig lesion<=1.25c,D7413,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1536.02,6814.79,Radiology
Excision malig lesion<=1.25c,D7413,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1536.02,6814.79,APC
Excision malig lesion<=1.25c,D7413,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1536.02,6814.79,APC
Excision malig lesion>1.25cm,D7414,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1536.02,6814.79,APC 378
Excision malig lesion>1.25cm,D7414,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1536.02,6814.79,APC
Excision malig lesion>1.25cm,D7414,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1536.02,6814.79,APC
Excision malig lesion>1.25cm,D7414,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1536.02,6814.79,APC
Excision malig lesion>1.25cm,D7414,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1536.02,6814.79,Radiology
Excision malig lesion>1.25cm,D7414,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1536.02,6814.79,APC
Excision malig lesion>1.25cm,D7414,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1536.02,6814.79,APC
Excision malig les complicat,D7415,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6814.79,,,,,,,fee schedule,1536.02,6814.79,APC 378
Excision malig les complicat,D7415,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1612.82,,,,,,,fee schedule,1536.02,6814.79,APC
Excision malig les complicat,D7415,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1597.46,,,,,,,fee schedule,1536.02,6814.79,APC
Excision malig les complicat,D7415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1536.02,,,,,,,fee schedule,1536.02,6814.79,APC
Excision malig les complicat,D7415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2350.11,,,,,,,fee schedule,1536.02,6814.79,Radiology
Excision malig les complicat,D7415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2150.42,,,,,,,fee schedule,1536.02,6814.79,APC
Excision malig les complicat,D7415,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2688.03,,,,,,,fee schedule,1536.02,6814.79,APC
Malig tumor exc to 1.25 cm,D7440,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Malig tumor exc to 1.25 cm,D7440,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Malig tumor exc to 1.25 cm,D7440,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Malig tumor exc to 1.25 cm,D7440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Malig tumor exc to 1.25 cm,D7440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Malig tumor exc to 1.25 cm,D7440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Malig tumor exc to 1.25 cm,D7440,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Malig tumor > 1.25 cm,D7441,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Malig tumor > 1.25 cm,D7441,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Malig tumor > 1.25 cm,D7441,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Malig tumor > 1.25 cm,D7441,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Malig tumor > 1.25 cm,D7441,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Malig tumor > 1.25 cm,D7441,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Malig tumor > 1.25 cm,D7441,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Rem odontogen cyst to 1.25cm,D7450,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Rem odontogen cyst to 1.25cm,D7450,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Rem odontogen cyst to 1.25cm,D7450,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Rem odontogen cyst to 1.25cm,D7450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Rem odontogen cyst to 1.25cm,D7450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Rem odontogen cyst to 1.25cm,D7450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Rem odontogen cyst to 1.25cm,D7450,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Rem odontogen cyst > 1.25 cm,D7451,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Rem odontogen cyst > 1.25 cm,D7451,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Rem odontogen cyst > 1.25 cm,D7451,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Rem odontogen cyst > 1.25 cm,D7451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Rem odontogen cyst > 1.25 cm,D7451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Rem odontogen cyst > 1.25 cm,D7451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Rem odontogen cyst > 1.25 cm,D7451,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Rem nonodonto cyst to 1.25cm,D7460,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Rem nonodonto cyst to 1.25cm,D7460,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Rem nonodonto cyst to 1.25cm,D7460,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Rem nonodonto cyst to 1.25cm,D7460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Rem nonodonto cyst to 1.25cm,D7460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Rem nonodonto cyst to 1.25cm,D7460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Rem nonodonto cyst to 1.25cm,D7460,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Rem nonodonto cyst > 1.25 cm,D7461,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Rem nonodonto cyst > 1.25 cm,D7461,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Rem nonodonto cyst > 1.25 cm,D7461,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Rem nonodonto cyst > 1.25 cm,D7461,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Rem nonodonto cyst > 1.25 cm,D7461,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Rem nonodonto cyst > 1.25 cm,D7461,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Rem nonodonto cyst > 1.25 cm,D7461,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Rem exostosis any site,D7471,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Rem exostosis any site,D7471,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Rem exostosis any site,D7471,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Rem exostosis any site,D7471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Rem exostosis any site,D7471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Rem exostosis any site,D7471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Rem exostosis any site,D7471,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Removal of torus palatinus,D7472,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Removal of torus palatinus,D7472,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Removal of torus palatinus,D7472,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Removal of torus palatinus,D7472,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Removal of torus palatinus,D7472,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Removal of torus palatinus,D7472,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Removal of torus palatinus,D7472,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Remove torus mandibularis,D7473,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Remove torus mandibularis,D7473,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Remove torus mandibularis,D7473,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Remove torus mandibularis,D7473,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Remove torus mandibularis,D7473,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Remove torus mandibularis,D7473,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Remove torus mandibularis,D7473,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Surg reduct osseoustuberosit,D7485,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Surg reduct osseoustuberosit,D7485,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Surg reduct osseoustuberosit,D7485,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Surg reduct osseoustuberosit,D7485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Surg reduct osseoustuberosit,D7485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Surg reduct osseoustuberosit,D7485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Surg reduct osseoustuberosit,D7485,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
I&d absc intraoral soft tiss,D7510,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3110.22,,,,,,,fee schedule,701.03,3110.22,APC 378
I&d absc intraoral soft tiss,D7510,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,736.08,,,,,,,fee schedule,701.03,3110.22,APC
I&d absc intraoral soft tiss,D7510,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,729.07,,,,,,,fee schedule,701.03,3110.22,APC
I&d absc intraoral soft tiss,D7510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,701.03,,,,,,,fee schedule,701.03,3110.22,APC
I&d absc intraoral soft tiss,D7510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1072.57,,,,,,,fee schedule,701.03,3110.22,Radiology
I&d absc intraoral soft tiss,D7510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,981.44,,,,,,,fee schedule,701.03,3110.22,APC
I&d absc intraoral soft tiss,D7510,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1226.8,,,,,,,fee schedule,701.03,3110.22,APC
Incision/drain abscess intra,D7511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,895.86,,,,,,,fee schedule,701.03,3110.22,
Incision/drain abscess intra,D7511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,718.11,,,,,,,fee schedule,701.03,3110.22,
Incision/drain abscess intra,D7511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,784.47,,,,,,,fee schedule,701.03,3110.22,
Incision/drain abscess intra,D7511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,824.76,,,,,,,fee schedule,701.03,3110.22,
Incision/drain abscess intra,D7511,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3110.22,,,,,,,fee schedule,701.03,3110.22,APC 378
Incision/drain abscess intra,D7511,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,736.08,,,,,,,fee schedule,701.03,3110.22,APC
Incision/drain abscess intra,D7511,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,729.07,,,,,,,fee schedule,701.03,3110.22,APC
Incision/drain abscess intra,D7511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,701.03,,,,,,,fee schedule,701.03,3110.22,APC
Incision/drain abscess intra,D7511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1072.57,,,,,,,fee schedule,701.03,3110.22,Radiology
Incision/drain abscess intra,D7511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,981.44,,,,,,,fee schedule,701.03,3110.22,APC
Incision/drain abscess intra,D7511,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1226.8,,,,,,,fee schedule,701.03,3110.22,APC
I&d abscess extraoral,D7520,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3110.22,,,,,,,fee schedule,701.03,3110.22,APC 378
I&d abscess extraoral,D7520,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,736.08,,,,,,,fee schedule,701.03,3110.22,APC
I&d abscess extraoral,D7520,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,729.07,,,,,,,fee schedule,701.03,3110.22,APC
I&d abscess extraoral,D7520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,701.03,,,,,,,fee schedule,701.03,3110.22,APC
I&d abscess extraoral,D7520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1072.57,,,,,,,fee schedule,701.03,3110.22,Radiology
I&d abscess extraoral,D7520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,981.44,,,,,,,fee schedule,701.03,3110.22,APC
I&d abscess extraoral,D7520,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1226.8,,,,,,,fee schedule,701.03,3110.22,APC
Incision/drain abscess extra,D7521,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1557.36,,,,,,,fee schedule,701.03,3110.22,
Incision/drain abscess extra,D7521,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1248.36,,,,,,,fee schedule,701.03,3110.22,
Incision/drain abscess extra,D7521,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1363.72,,,,,,,fee schedule,701.03,3110.22,
Incision/drain abscess extra,D7521,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1433.76,,,,,,,fee schedule,701.03,3110.22,
Incision/drain abscess extra,D7521,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3110.22,,,,,,,fee schedule,701.03,3110.22,APC 378
Incision/drain abscess extra,D7521,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,736.08,,,,,,,fee schedule,701.03,3110.22,APC
Incision/drain abscess extra,D7521,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,729.07,,,,,,,fee schedule,701.03,3110.22,APC
Incision/drain abscess extra,D7521,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,701.03,,,,,,,fee schedule,701.03,3110.22,APC
Incision/drain abscess extra,D7521,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1072.57,,,,,,,fee schedule,701.03,3110.22,Radiology
Incision/drain abscess extra,D7521,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,981.44,,,,,,,fee schedule,701.03,3110.22,APC
Incision/drain abscess extra,D7521,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1226.8,,,,,,,fee schedule,701.03,3110.22,APC
Removal fb skin/areolar tiss,D7530,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Removal fb skin/areolar tiss,D7530,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Removal fb skin/areolar tiss,D7530,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Removal fb skin/areolar tiss,D7530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Removal fb skin/areolar tiss,D7530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Removal fb skin/areolar tiss,D7530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Removal fb skin/areolar tiss,D7530,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Removal of fb reaction,D7540,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Removal of fb reaction,D7540,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Removal of fb reaction,D7540,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Removal of fb reaction,D7540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Removal of fb reaction,D7540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Removal of fb reaction,D7540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Removal of fb reaction,D7540,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Removal of sloughed off bone,D7550,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Removal of sloughed off bone,D7550,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Removal of sloughed off bone,D7550,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Removal of sloughed off bone,D7550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Removal of sloughed off bone,D7550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Removal of sloughed off bone,D7550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Removal of sloughed off bone,D7550,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Closd rductn splint alveolus,D7670,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Closd rductn splint alveolus,D7670,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Closd rductn splint alveolus,D7670,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Closd rductn splint alveolus,D7670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Closd rductn splint alveolus,D7670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Closd rductn splint alveolus,D7670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Closd rductn splint alveolus,D7670,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Alveolus open reduction,D7671,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Alveolus open reduction,D7671,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Alveolus open reduction,D7671,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Alveolus open reduction,D7671,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Alveolus open reduction,D7671,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Alveolus open reduction,D7671,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Alveolus open reduction,D7671,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Open reduc compd alveolus fx,D7770,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Open reduc compd alveolus fx,D7770,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Open reduc compd alveolus fx,D7770,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Open reduc compd alveolus fx,D7770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Open reduc compd alveolus fx,D7770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Open reduc compd alveolus fx,D7770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Open reduc compd alveolus fx,D7770,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Alveolus clsd reduc stblz te,D7771,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Alveolus clsd reduc stblz te,D7771,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Alveolus clsd reduc stblz te,D7771,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Alveolus clsd reduc stblz te,D7771,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Alveolus clsd reduc stblz te,D7771,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Alveolus clsd reduc stblz te,D7771,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Alveolus clsd reduc stblz te,D7771,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Tmj arthroscopy disc reposit,D7874,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Tmj arthroscopy disc reposit,D7874,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Tmj arthroscopy disc reposit,D7874,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Tmj arthroscopy disc reposit,D7874,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Tmj arthroscopy disc reposit,D7874,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Tmj arthroscopy disc reposit,D7874,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Tmj arthroscopy disc reposit,D7874,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
Place intra-socket bio dress,D7922,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Place intra-socket bio dress,D7922,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Place intra-socket bio dress,D7922,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Place intra-socket bio dress,D7922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Place intra-socket bio dress,D7922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Place intra-socket bio dress,D7922,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Place intra-socket bio dress,D7922,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Reshaping bone orthognathic,D7940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2288.03,,,,,,,fee schedule,640,2839.47,
Reshaping bone orthognathic,D7940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1834.06,,,,,,,fee schedule,640,2839.47,
Reshaping bone orthognathic,D7940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2003.54,,,,,,,fee schedule,640,2839.47,
Reshaping bone orthognathic,D7940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2106.44,,,,,,,fee schedule,640,2839.47,
Reshaping bone orthognathic,D7940,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Reshaping bone orthognathic,D7940,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Reshaping bone orthognathic,D7940,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Reshaping bone orthognathic,D7940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Reshaping bone orthognathic,D7940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Reshaping bone orthognathic,D7940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Reshaping bone orthognathic,D7940,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Mandible graft,D7950,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26000.79,,,,,,,fee schedule,5860.44,26000.79,APC 378
Mandible graft,D7950,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6153.46,,,,,,,fee schedule,5860.44,26000.79,APC
Mandible graft,D7950,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6094.86,,,,,,,fee schedule,5860.44,26000.79,APC
Mandible graft,D7950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5860.44,,,,,,,fee schedule,5860.44,26000.79,APC
Mandible graft,D7950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8966.47,,,,,,,fee schedule,5860.44,26000.79,Radiology
Mandible graft,D7950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8204.62,,,,,,,fee schedule,5860.44,26000.79,APC
Mandible graft,D7950,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10255.77,,,,,,,fee schedule,5860.44,26000.79,APC
Drugs/meds disp for home use,D9630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2288.03,,,,,,,fee schedule,1834.06,2288.03,
Drugs/meds disp for home use,D9630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1834.06,,,,,,,fee schedule,1834.06,2288.03,
Drugs/meds disp for home use,D9630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2003.54,,,,,,,fee schedule,1834.06,2288.03,
Drugs/meds disp for home use,D9630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2106.44,,,,,,,fee schedule,1834.06,2288.03,
Treatment of complications,D9930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2288.03,,,,,,,fee schedule,640,2839.47,
Treatment of complications,D9930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1834.06,,,,,,,fee schedule,640,2839.47,
Treatment of complications,D9930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2003.54,,,,,,,fee schedule,640,2839.47,
Treatment of complications,D9930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2106.44,,,,,,,fee schedule,640,2839.47,
Treatment of complications,D9930,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Treatment of complications,D9930,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Treatment of complications,D9930,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Treatment of complications,D9930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Treatment of complications,D9930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Treatment of complications,D9930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Treatment of complications,D9930,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
"Occ guard, hard, full arch",D9944,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3398.9,,,,,,,fee schedule,640,3398.9,
"Occ guard, hard, full arch",D9944,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2724.52,,,,,,,fee schedule,640,3398.9,
"Occ guard, hard, full arch",D9944,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2976.29,,,,,,,fee schedule,640,3398.9,
"Occ guard, hard, full arch",D9944,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3129.15,,,,,,,fee schedule,640,3398.9,
"Occ guard, hard, full arch",D9944,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,3398.9,APC 378
"Occ guard, hard, full arch",D9944,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,3398.9,APC
"Occ guard, hard, full arch",D9944,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,3398.9,APC
"Occ guard, hard, full arch",D9944,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,3398.9,APC
"Occ guard, hard, full arch",D9944,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,3398.9,Radiology
"Occ guard, hard, full arch",D9944,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,3398.9,APC
"Occ guard, hard, full arch",D9944,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,3398.9,APC
"Occ guard, soft, full arch",D9945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3398.9,,,,,,,fee schedule,640,3398.9,
"Occ guard, soft, full arch",D9945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2724.52,,,,,,,fee schedule,640,3398.9,
"Occ guard, soft, full arch",D9945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2976.29,,,,,,,fee schedule,640,3398.9,
"Occ guard, soft, full arch",D9945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3129.15,,,,,,,fee schedule,640,3398.9,
"Occ guard, soft, full arch",D9945,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,3398.9,APC 378
"Occ guard, soft, full arch",D9945,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,3398.9,APC
"Occ guard, soft, full arch",D9945,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,3398.9,APC
"Occ guard, soft, full arch",D9945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,3398.9,APC
"Occ guard, soft, full arch",D9945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,3398.9,Radiology
"Occ guard, soft, full arch",D9945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,3398.9,APC
"Occ guard, soft, full arch",D9945,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,3398.9,APC
"Occ guard, hard, part arch",D9946,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3398.9,,,,,,,fee schedule,640,3398.9,
"Occ guard, hard, part arch",D9946,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2724.52,,,,,,,fee schedule,640,3398.9,
"Occ guard, hard, part arch",D9946,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2976.29,,,,,,,fee schedule,640,3398.9,
"Occ guard, hard, part arch",D9946,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3129.15,,,,,,,fee schedule,640,3398.9,
"Occ guard, hard, part arch",D9946,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,3398.9,APC 378
"Occ guard, hard, part arch",D9946,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,3398.9,APC
"Occ guard, hard, part arch",D9946,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,3398.9,APC
"Occ guard, hard, part arch",D9946,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,3398.9,APC
"Occ guard, hard, part arch",D9946,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,3398.9,Radiology
"Occ guard, hard, part arch",D9946,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,3398.9,APC
"Occ guard, hard, part arch",D9946,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,3398.9,APC
Occlusion analysis,D9950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2288.03,,,,,,,fee schedule,640,2839.47,
Occlusion analysis,D9950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1834.06,,,,,,,fee schedule,640,2839.47,
Occlusion analysis,D9950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2003.54,,,,,,,fee schedule,640,2839.47,
Occlusion analysis,D9950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2106.44,,,,,,,fee schedule,640,2839.47,
Occlusion analysis,D9950,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Occlusion analysis,D9950,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Occlusion analysis,D9950,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Occlusion analysis,D9950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Occlusion analysis,D9950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Occlusion analysis,D9950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Occlusion analysis,D9950,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Limited occlusal adjustment,D9951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2288.03,,,,,,,fee schedule,640,2839.47,
Limited occlusal adjustment,D9951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1834.06,,,,,,,fee schedule,640,2839.47,
Limited occlusal adjustment,D9951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2003.54,,,,,,,fee schedule,640,2839.47,
Limited occlusal adjustment,D9951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2106.44,,,,,,,fee schedule,640,2839.47,
Limited occlusal adjustment,D9951,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Limited occlusal adjustment,D9951,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Limited occlusal adjustment,D9951,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Limited occlusal adjustment,D9951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Limited occlusal adjustment,D9951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Limited occlusal adjustment,D9951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Limited occlusal adjustment,D9951,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Complete occlusal adjustment,D9952,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2288.03,,,,,,,fee schedule,640,2839.47,
Complete occlusal adjustment,D9952,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1834.06,,,,,,,fee schedule,640,2839.47,
Complete occlusal adjustment,D9952,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2003.54,,,,,,,fee schedule,640,2839.47,
Complete occlusal adjustment,D9952,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2106.44,,,,,,,fee schedule,640,2839.47,
Complete occlusal adjustment,D9952,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2839.47,,,,,,,fee schedule,640,2839.47,APC 378
Complete occlusal adjustment,D9952,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,672,,,,,,,fee schedule,640,2839.47,APC
Complete occlusal adjustment,D9952,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,665.6,,,,,,,fee schedule,640,2839.47,APC
Complete occlusal adjustment,D9952,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,640,,,,,,,fee schedule,640,2839.47,APC
Complete occlusal adjustment,D9952,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,979.2,,,,,,,fee schedule,640,2839.47,Radiology
Complete occlusal adjustment,D9952,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,896,,,,,,,fee schedule,640,2839.47,APC
Complete occlusal adjustment,D9952,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1120,,,,,,,fee schedule,640,2839.47,APC
Cane adjust/fixed with tip,E0100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83.61,,,,,,,fee schedule,16.06,83.61,
Cane adjust/fixed with tip,E0100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20.03,,,,,,,fee schedule,16.06,83.61,
Cane adjust/fixed with tip,E0100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.68,,,,,,,fee schedule,16.06,83.61,
Cane adjust/fixed with tip,E0100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,67.02,,,,,,,fee schedule,16.06,83.61,
Cane adjust/fixed with tip,E0100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.06,,,,,,,fee schedule,16.06,83.61,
Cane adjust/fixed with tip,E0100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.45,,,,,,,fee schedule,16.06,83.61,
Cane adjust/fixed with tip,E0100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,73.22,,,,,,,fee schedule,16.06,83.61,
Cane adjust/fixed with tip,E0100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17.54,,,,,,,fee schedule,16.06,83.61,
Cane adjust/fixed with tip,E0100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,58.39,,,,,,,fee schedule,16.06,83.61,
Cane adjust/fixed with tip,E0100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,76.98,,,,,,,fee schedule,16.06,83.61,
Cane adjust/fixed with tip,E0100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18.44,,,,,,,fee schedule,16.06,83.61,
Cane adjust/fixed with tip,E0100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,61.39,,,,,,,fee schedule,16.06,83.61,
Cane adjust/fixed quad/3 pro,E0105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,194.93,,,,,,,fee schedule,23.97,194.93,
Cane adjust/fixed quad/3 pro,E0105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,29.9,,,,,,,fee schedule,23.97,194.93,
Cane adjust/fixed quad/3 pro,E0105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,150.26,,,,,,,fee schedule,23.97,194.93,
Cane adjust/fixed quad/3 pro,E0105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,156.26,,,,,,,fee schedule,23.97,194.93,
Cane adjust/fixed quad/3 pro,E0105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23.97,,,,,,,fee schedule,23.97,194.93,
Cane adjust/fixed quad/3 pro,E0105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,120.44,,,,,,,fee schedule,23.97,194.93,
Cane adjust/fixed quad/3 pro,E0105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,170.7,,,,,,,fee schedule,23.97,194.93,
Cane adjust/fixed quad/3 pro,E0105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26.18,,,,,,,fee schedule,23.97,194.93,
Cane adjust/fixed quad/3 pro,E0105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,131.57,,,,,,,fee schedule,23.97,194.93,
Cane adjust/fixed quad/3 pro,E0105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,179.46,,,,,,,fee schedule,23.97,194.93,
Cane adjust/fixed quad/3 pro,E0105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27.53,,,,,,,fee schedule,23.97,194.93,
Cane adjust/fixed quad/3 pro,E0105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,138.33,,,,,,,fee schedule,23.97,194.93,
Crutch forearm pair,E0110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,307.96,,,,,,,fee schedule,43.24,307.96,
Crutch forearm pair,E0110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,53.94,,,,,,,fee schedule,43.24,307.96,
Crutch forearm pair,E0110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,230.92,,,,,,,fee schedule,43.24,307.96,
Crutch forearm pair,E0110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,246.85,,,,,,,fee schedule,43.24,307.96,
Crutch forearm pair,E0110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,43.24,,,,,,,fee schedule,43.24,307.96,
Crutch forearm pair,E0110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,185.1,,,,,,,fee schedule,43.24,307.96,
Crutch forearm pair,E0110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,269.67,,,,,,,fee schedule,43.24,307.96,
Crutch forearm pair,E0110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,47.23,,,,,,,fee schedule,43.24,307.96,
Crutch forearm pair,E0110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,202.21,,,,,,,fee schedule,43.24,307.96,
Crutch forearm pair,E0110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,283.52,,,,,,,fee schedule,43.24,307.96,
Crutch forearm pair,E0110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,49.66,,,,,,,fee schedule,43.24,307.96,
Crutch forearm pair,E0110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,212.59,,,,,,,fee schedule,43.24,307.96,
Crutch forearm each,E0111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,211.38,,,,,,,fee schedule,22.79,211.38,
Crutch forearm each,E0111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,28.43,,,,,,,fee schedule,22.79,211.38,
Crutch forearm each,E0111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,159.97,,,,,,,fee schedule,22.79,211.38,
Crutch forearm each,E0111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,169.44,,,,,,,fee schedule,22.79,211.38,
Crutch forearm each,E0111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22.79,,,,,,,fee schedule,22.79,211.38,
Crutch forearm each,E0111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,128.23,,,,,,,fee schedule,22.79,211.38,
Crutch forearm each,E0111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,185.1,,,,,,,fee schedule,22.79,211.38,
Crutch forearm each,E0111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24.89,,,,,,,fee schedule,22.79,211.38,
Crutch forearm each,E0111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,140.08,,,,,,,fee schedule,22.79,211.38,
Crutch forearm each,E0111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,194.6,,,,,,,fee schedule,22.79,211.38,
Crutch forearm each,E0111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26.17,,,,,,,fee schedule,22.79,211.38,
Crutch forearm each,E0111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,147.27,,,,,,,fee schedule,22.79,211.38,
Crutch underarm pair wood,E0112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,124.82,,,,,,,fee schedule,26.88,124.82,
Crutch underarm pair wood,E0112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33.53,,,,,,,fee schedule,26.88,124.82,
Crutch underarm pair wood,E0112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,95.22,,,,,,,fee schedule,26.88,124.82,
Crutch underarm pair wood,E0112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,100.05,,,,,,,fee schedule,26.88,124.82,
Crutch underarm pair wood,E0112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26.88,,,,,,,fee schedule,26.88,124.82,
Crutch underarm pair wood,E0112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,76.33,,,,,,,fee schedule,26.88,124.82,
Crutch underarm pair wood,E0112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,109.3,,,,,,,fee schedule,26.88,124.82,
Crutch underarm pair wood,E0112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29.36,,,,,,,fee schedule,26.88,124.82,
Crutch underarm pair wood,E0112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,83.38,,,,,,,fee schedule,26.88,124.82,
Crutch underarm pair wood,E0112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,114.91,,,,,,,fee schedule,26.88,124.82,
Crutch underarm pair wood,E0112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30.87,,,,,,,fee schedule,26.88,124.82,
Crutch underarm pair wood,E0112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,87.66,,,,,,,fee schedule,26.88,124.82,
Crutch underarm each wood,E0113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83.88,,,,,,,fee schedule,13.94,83.88,
Crutch underarm each wood,E0113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17.39,,,,,,,fee schedule,13.94,83.88,
Crutch underarm each wood,E0113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,62.94,,,,,,,fee schedule,13.94,83.88,
Crutch underarm each wood,E0113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,67.24,,,,,,,fee schedule,13.94,83.88,
Crutch underarm each wood,E0113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13.94,,,,,,,fee schedule,13.94,83.88,
Crutch underarm each wood,E0113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,50.45,,,,,,,fee schedule,13.94,83.88,
Crutch underarm each wood,E0113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,73.45,,,,,,,fee schedule,13.94,83.88,
Crutch underarm each wood,E0113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15.23,,,,,,,fee schedule,13.94,83.88,
Crutch underarm each wood,E0113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55.11,,,,,,,fee schedule,13.94,83.88,
Crutch underarm each wood,E0113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,77.22,,,,,,,fee schedule,13.94,83.88,
Crutch underarm each wood,E0113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16.01,,,,,,,fee schedule,13.94,83.88,
Crutch underarm each wood,E0113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,57.94,,,,,,,fee schedule,13.94,83.88,
Crutch underarm pair no wood,E0114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,159.21,,,,,,,fee schedule,23.18,159.21,
Crutch underarm pair no wood,E0114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,28.92,,,,,,,fee schedule,23.18,159.21,
Crutch underarm pair no wood,E0114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,120.32,,,,,,,fee schedule,23.18,159.21,
Crutch underarm pair no wood,E0114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,127.62,,,,,,,fee schedule,23.18,159.21,
Crutch underarm pair no wood,E0114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23.18,,,,,,,fee schedule,23.18,159.21,
Crutch underarm pair no wood,E0114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,96.44,,,,,,,fee schedule,23.18,159.21,
Crutch underarm pair no wood,E0114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,139.42,,,,,,,fee schedule,23.18,159.21,
Crutch underarm pair no wood,E0114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,25.32,,,,,,,fee schedule,23.18,159.21,
Crutch underarm pair no wood,E0114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,105.36,,,,,,,fee schedule,23.18,159.21,
Crutch underarm pair no wood,E0114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,146.58,,,,,,,fee schedule,23.18,159.21,
Crutch underarm pair no wood,E0114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26.62,,,,,,,fee schedule,23.18,159.21,
Crutch underarm pair no wood,E0114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,110.77,,,,,,,fee schedule,23.18,159.21,
Crutch underarm each no wood,E0116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,110.11,,,,,,,fee schedule,14.6,110.11,
Crutch underarm each no wood,E0116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18.22,,,,,,,fee schedule,14.6,110.11,
Crutch underarm each no wood,E0116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,82.86,,,,,,,fee schedule,14.6,110.11,
Crutch underarm each no wood,E0116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,88.26,,,,,,,fee schedule,14.6,110.11,
Crutch underarm each no wood,E0116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14.6,,,,,,,fee schedule,14.6,110.11,
Crutch underarm each no wood,E0116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66.42,,,,,,,fee schedule,14.6,110.11,
Crutch underarm each no wood,E0116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,96.42,,,,,,,fee schedule,14.6,110.11,
Crutch underarm each no wood,E0116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15.95,,,,,,,fee schedule,14.6,110.11,
Crutch underarm each no wood,E0116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,72.56,,,,,,,fee schedule,14.6,110.11,
Crutch underarm each no wood,E0116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,101.37,,,,,,,fee schedule,14.6,110.11,
Crutch underarm each no wood,E0116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16.77,,,,,,,fee schedule,14.6,110.11,
Crutch underarm each no wood,E0116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,76.28,,,,,,,fee schedule,14.6,110.11,
Underarm springassist crutch,E0117,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,764.88,,,,,,,fee schedule,61.27,764.88,
Underarm springassist crutch,E0117,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,76.43,,,,,,,fee schedule,61.27,764.88,
Underarm springassist crutch,E0117,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,573.73,,,,,,,fee schedule,61.27,764.88,
Underarm springassist crutch,E0117,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,613.12,,,,,,,fee schedule,61.27,764.88,
Underarm springassist crutch,E0117,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,61.27,,,,,,,fee schedule,61.27,764.88,
Underarm springassist crutch,E0117,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,459.89,,,,,,,fee schedule,61.27,764.88,
Underarm springassist crutch,E0117,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,669.78,,,,,,,fee schedule,61.27,764.88,
Underarm springassist crutch,E0117,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66.93,,,,,,,fee schedule,61.27,764.88,
Underarm springassist crutch,E0117,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,502.39,,,,,,,fee schedule,61.27,764.88,
Underarm springassist crutch,E0117,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,704.18,,,,,,,fee schedule,61.27,764.88,
Underarm springassist crutch,E0117,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,70.37,,,,,,,fee schedule,61.27,764.88,
Underarm springassist crutch,E0117,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,528.19,,,,,,,fee schedule,61.27,764.88,
Walker rigid adjust/fixed ht,E0130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,240.26,,,,,,,fee schedule,39.21,240.26,
Walker rigid adjust/fixed ht,E0130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,48.91,,,,,,,fee schedule,39.21,240.26,
Walker rigid adjust/fixed ht,E0130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,187.22,,,,,,,fee schedule,39.21,240.26,
Walker rigid adjust/fixed ht,E0130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,192.59,,,,,,,fee schedule,39.21,240.26,
Walker rigid adjust/fixed ht,E0130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39.21,,,,,,,fee schedule,39.21,240.26,
Walker rigid adjust/fixed ht,E0130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,150.08,,,,,,,fee schedule,39.21,240.26,
Walker rigid adjust/fixed ht,E0130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,210.38,,,,,,,fee schedule,39.21,240.26,
Walker rigid adjust/fixed ht,E0130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.83,,,,,,,fee schedule,39.21,240.26,
Walker rigid adjust/fixed ht,E0130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,163.94,,,,,,,fee schedule,39.21,240.26,
Walker rigid adjust/fixed ht,E0130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,221.19,,,,,,,fee schedule,39.21,240.26,
Walker rigid adjust/fixed ht,E0130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45.03,,,,,,,fee schedule,39.21,240.26,
Walker rigid adjust/fixed ht,E0130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,172.36,,,,,,,fee schedule,39.21,240.26,
Walker folding adjust/fixed,E0135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,286.83,,,,,,,fee schedule,40.24,286.83,
Walker folding adjust/fixed,E0135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,50.2,,,,,,,fee schedule,40.24,286.83,
Walker folding adjust/fixed,E0135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,220.03,,,,,,,fee schedule,40.24,286.83,
Walker folding adjust/fixed,E0135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,229.92,,,,,,,fee schedule,40.24,286.83,
Walker folding adjust/fixed,E0135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40.24,,,,,,,fee schedule,40.24,286.83,
Walker folding adjust/fixed,E0135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,176.38,,,,,,,fee schedule,40.24,286.83,
Walker folding adjust/fixed,E0135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,251.16,,,,,,,fee schedule,40.24,286.83,
Walker folding adjust/fixed,E0135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,43.96,,,,,,,fee schedule,40.24,286.83,
Walker folding adjust/fixed,E0135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,192.68,,,,,,,fee schedule,40.24,286.83,
Walker folding adjust/fixed,E0135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,264.06,,,,,,,fee schedule,40.24,286.83,
Walker folding adjust/fixed,E0135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46.21,,,,,,,fee schedule,40.24,286.83,
Walker folding adjust/fixed,E0135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,202.57,,,,,,,fee schedule,40.24,286.83,
Walker w trunk support,E0140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1233.94,,,,,,,fee schedule,98.93,1233.94,
Walker w trunk support,E0140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,123.42,,,,,,,fee schedule,98.93,1233.94,
Walker w trunk support,E0140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,925.5,,,,,,,fee schedule,98.93,1233.94,
Walker w trunk support,E0140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,989.11,,,,,,,fee schedule,98.93,1233.94,
Walker w trunk support,E0140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,98.93,,,,,,,fee schedule,98.93,1233.94,
Walker w trunk support,E0140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,741.87,,,,,,,fee schedule,98.93,1233.94,
Walker w trunk support,E0140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1080.52,,,,,,,fee schedule,98.93,1233.94,
Walker w trunk support,E0140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,108.07,,,,,,,fee schedule,98.93,1233.94,
Walker w trunk support,E0140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,810.42,,,,,,,fee schedule,98.93,1233.94,
Walker w trunk support,E0140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1136.01,,,,,,,fee schedule,98.93,1233.94,
Walker w trunk support,E0140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,113.62,,,,,,,fee schedule,98.93,1233.94,
Walker w trunk support,E0140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,852.04,,,,,,,fee schedule,98.93,1233.94,
Rigid wheeled walker adj/fix,E0141,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,384.73,,,,,,,fee schedule,52.12,384.73,
Rigid wheeled walker adj/fix,E0141,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,65.02,,,,,,,fee schedule,52.12,384.73,
Rigid wheeled walker adj/fix,E0141,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,288.53,,,,,,,fee schedule,52.12,384.73,
Rigid wheeled walker adj/fix,E0141,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,308.39,,,,,,,fee schedule,52.12,384.73,
Rigid wheeled walker adj/fix,E0141,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52.12,,,,,,,fee schedule,52.12,384.73,
Rigid wheeled walker adj/fix,E0141,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,231.28,,,,,,,fee schedule,52.12,384.73,
Rigid wheeled walker adj/fix,E0141,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,336.89,,,,,,,fee schedule,52.12,384.73,
Rigid wheeled walker adj/fix,E0141,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56.93,,,,,,,fee schedule,52.12,384.73,
Rigid wheeled walker adj/fix,E0141,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,252.65,,,,,,,fee schedule,52.12,384.73,
Rigid wheeled walker adj/fix,E0141,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,354.19,,,,,,,fee schedule,52.12,384.73,
Rigid wheeled walker adj/fix,E0141,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59.86,,,,,,,fee schedule,52.12,384.73,
Rigid wheeled walker adj/fix,E0141,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,265.63,,,,,,,fee schedule,52.12,384.73,
Walker folding wheeled w/o s,E0143,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,411.19,,,,,,,fee schedule,50.33,411.19,
Walker folding wheeled w/o s,E0143,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,62.79,,,,,,,fee schedule,50.33,411.19,
Walker folding wheeled w/o s,E0143,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,307.81,,,,,,,fee schedule,50.33,411.19,
Walker folding wheeled w/o s,E0143,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,329.6,,,,,,,fee schedule,50.33,411.19,
Walker folding wheeled w/o s,E0143,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,50.33,,,,,,,fee schedule,50.33,411.19,
Walker folding wheeled w/o s,E0143,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,246.73,,,,,,,fee schedule,50.33,411.19,
Walker folding wheeled w/o s,E0143,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,360.06,,,,,,,fee schedule,50.33,411.19,
Walker folding wheeled w/o s,E0143,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,54.98,,,,,,,fee schedule,50.33,411.19,
Walker folding wheeled w/o s,E0143,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,269.53,,,,,,,fee schedule,50.33,411.19,
Walker folding wheeled w/o s,E0143,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,378.55,,,,,,,fee schedule,50.33,411.19,
Walker folding wheeled w/o s,E0143,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,57.8,,,,,,,fee schedule,50.33,411.19,
Walker folding wheeled w/o s,E0143,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,283.38,,,,,,,fee schedule,50.33,411.19,
Enclosed walker w rear seat,E0144,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1089.4,,,,,,,fee schedule,87.35,1089.4,
Enclosed walker w rear seat,E0144,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,108.98,,,,,,,fee schedule,87.35,1089.4,
Enclosed walker w rear seat,E0144,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,817.01,,,,,,,fee schedule,87.35,1089.4,
Enclosed walker w rear seat,E0144,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,873.25,,,,,,,fee schedule,87.35,1089.4,
Enclosed walker w rear seat,E0144,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,87.35,,,,,,,fee schedule,87.35,1089.4,
Enclosed walker w rear seat,E0144,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,654.9,,,,,,,fee schedule,87.35,1089.4,
Enclosed walker w rear seat,E0144,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,953.94,,,,,,,fee schedule,87.35,1089.4,
Enclosed walker w rear seat,E0144,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,95.43,,,,,,,fee schedule,87.35,1089.4,
Enclosed walker w rear seat,E0144,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,715.42,,,,,,,fee schedule,87.35,1089.4,
Enclosed walker w rear seat,E0144,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1002.94,,,,,,,fee schedule,87.35,1089.4,
Enclosed walker w rear seat,E0144,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,100.33,,,,,,,fee schedule,87.35,1089.4,
Enclosed walker w rear seat,E0144,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,752.17,,,,,,,fee schedule,87.35,1089.4,
Walker variable wheel resist,E0147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1966.36,,,,,,,fee schedule,157.62,1966.36,
Walker variable wheel resist,E0147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,196.64,,,,,,,fee schedule,157.62,1966.36,
Walker variable wheel resist,E0147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1474.84,,,,,,,fee schedule,157.62,1966.36,
Walker variable wheel resist,E0147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1576.21,,,,,,,fee schedule,157.62,1966.36,
Walker variable wheel resist,E0147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,157.62,,,,,,,fee schedule,157.62,1966.36,
Walker variable wheel resist,E0147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1182.22,,,,,,,fee schedule,157.62,1966.36,
Walker variable wheel resist,E0147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1721.86,,,,,,,fee schedule,157.62,1966.36,
Walker variable wheel resist,E0147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,172.19,,,,,,,fee schedule,157.62,1966.36,
Walker variable wheel resist,E0147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1291.46,,,,,,,fee schedule,157.62,1966.36,
Walker variable wheel resist,E0147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1810.3,,,,,,,fee schedule,157.62,1966.36,
Walker variable wheel resist,E0147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,181.03,,,,,,,fee schedule,157.62,1966.36,
Walker variable wheel resist,E0147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1357.79,,,,,,,fee schedule,157.62,1966.36,
Heavyduty walker no wheels,E0148,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,434.62,,,,,,,fee schedule,34.88,434.62,
Heavyduty walker no wheels,E0148,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,43.51,,,,,,,fee schedule,34.88,434.62,
Heavyduty walker no wheels,E0148,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,325.95,,,,,,,fee schedule,34.88,434.62,
Heavyduty walker no wheels,E0148,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,348.39,,,,,,,fee schedule,34.88,434.62,
Heavyduty walker no wheels,E0148,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,34.88,,,,,,,fee schedule,34.88,434.62,
Heavyduty walker no wheels,E0148,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,261.28,,,,,,,fee schedule,34.88,434.62,
Heavyduty walker no wheels,E0148,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,380.58,,,,,,,fee schedule,34.88,434.62,
Heavyduty walker no wheels,E0148,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38.1,,,,,,,fee schedule,34.88,434.62,
Heavyduty walker no wheels,E0148,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,285.42,,,,,,,fee schedule,34.88,434.62,
Heavyduty walker no wheels,E0148,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,400.13,,,,,,,fee schedule,34.88,434.62,
Heavyduty walker no wheels,E0148,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,40.05,,,,,,,fee schedule,34.88,434.62,
Heavyduty walker no wheels,E0148,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,300.08,,,,,,,fee schedule,34.88,434.62,
Heavy duty wheeled walker,E0149,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,763.56,,,,,,,fee schedule,61.21,763.56,
Heavy duty wheeled walker,E0149,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,76.36,,,,,,,fee schedule,61.21,763.56,
Heavy duty wheeled walker,E0149,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,572.63,,,,,,,fee schedule,61.21,763.56,
Heavy duty wheeled walker,E0149,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,612.06,,,,,,,fee schedule,61.21,763.56,
Heavy duty wheeled walker,E0149,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,61.21,,,,,,,fee schedule,61.21,763.56,
Heavy duty wheeled walker,E0149,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,459.01,,,,,,,fee schedule,61.21,763.56,
Heavy duty wheeled walker,E0149,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,668.62,,,,,,,fee schedule,61.21,763.56,
Heavy duty wheeled walker,E0149,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66.86,,,,,,,fee schedule,61.21,763.56,
Heavy duty wheeled walker,E0149,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,501.43,,,,,,,fee schedule,61.21,763.56,
Heavy duty wheeled walker,E0149,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,702.96,,,,,,,fee schedule,61.21,763.56,
Heavy duty wheeled walker,E0149,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,70.3,,,,,,,fee schedule,61.21,763.56,
Heavy duty wheeled walker,E0149,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,527.19,,,,,,,fee schedule,61.21,763.56,
Forearm crutch platform atta,E0153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,245.06,,,,,,,fee schedule,21.21,245.06,
Forearm crutch platform atta,E0153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26.46,,,,,,,fee schedule,21.21,245.06,
Forearm crutch platform atta,E0153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,183.82,,,,,,,fee schedule,21.21,245.06,
Forearm crutch platform atta,E0153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,196.43,,,,,,,fee schedule,21.21,245.06,
Forearm crutch platform atta,E0153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21.21,,,,,,,fee schedule,21.21,245.06,
Forearm crutch platform atta,E0153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,147.35,,,,,,,fee schedule,21.21,245.06,
Forearm crutch platform atta,E0153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,214.59,,,,,,,fee schedule,21.21,245.06,
Forearm crutch platform atta,E0153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23.17,,,,,,,fee schedule,21.21,245.06,
Forearm crutch platform atta,E0153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,160.97,,,,,,,fee schedule,21.21,245.06,
Forearm crutch platform atta,E0153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,225.61,,,,,,,fee schedule,21.21,245.06,
Forearm crutch platform atta,E0153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24.36,,,,,,,fee schedule,21.21,245.06,
Forearm crutch platform atta,E0153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,169.23,,,,,,,fee schedule,21.21,245.06,
Walker platform attachment,E0154,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,241.2,,,,,,,fee schedule,23.48,241.2,
Walker platform attachment,E0154,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,29.3,,,,,,,fee schedule,23.48,241.2,
Walker platform attachment,E0154,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,183.25,,,,,,,fee schedule,23.48,241.2,
Walker platform attachment,E0154,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,193.34,,,,,,,fee schedule,23.48,241.2,
Walker platform attachment,E0154,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23.48,,,,,,,fee schedule,23.48,241.2,
Walker platform attachment,E0154,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,146.89,,,,,,,fee schedule,23.48,241.2,
Walker platform attachment,E0154,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,211.21,,,,,,,fee schedule,23.48,241.2,
Walker platform attachment,E0154,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,25.65,,,,,,,fee schedule,23.48,241.2,
Walker platform attachment,E0154,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,160.47,,,,,,,fee schedule,23.48,241.2,
Walker platform attachment,E0154,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,222.06,,,,,,,fee schedule,23.48,241.2,
Walker platform attachment,E0154,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26.97,,,,,,,fee schedule,23.48,241.2,
Walker platform attachment,E0154,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,168.71,,,,,,,fee schedule,23.48,241.2,
"Walker wheel attachment,pair",E0155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,107.96,,,,,,,fee schedule,9.39,107.96,
"Walker wheel attachment,pair",E0155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11.72,,,,,,,fee schedule,9.39,107.96,
"Walker wheel attachment,pair",E0155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,82.29,,,,,,,fee schedule,9.39,107.96,
"Walker wheel attachment,pair",E0155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,86.54,,,,,,,fee schedule,9.39,107.96,
"Walker wheel attachment,pair",E0155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.39,,,,,,,fee schedule,9.39,107.96,
"Walker wheel attachment,pair",E0155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,65.96,,,,,,,fee schedule,9.39,107.96,
"Walker wheel attachment,pair",E0155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,94.53,,,,,,,fee schedule,9.39,107.96,
"Walker wheel attachment,pair",E0155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10.26,,,,,,,fee schedule,9.39,107.96,
"Walker wheel attachment,pair",E0155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,72.06,,,,,,,fee schedule,9.39,107.96,
"Walker wheel attachment,pair",E0155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,99.39,,,,,,,fee schedule,9.39,107.96,
"Walker wheel attachment,pair",E0155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10.79,,,,,,,fee schedule,9.39,107.96,
"Walker wheel attachment,pair",E0155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,75.76,,,,,,,fee schedule,9.39,107.96,
Walker seat attachment,E0156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,90.42,,,,,,,fee schedule,8.18,90.42,
Walker seat attachment,E0156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10.21,,,,,,,fee schedule,8.18,90.42,
Walker seat attachment,E0156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,67.89,,,,,,,fee schedule,8.18,90.42,
Walker seat attachment,E0156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,72.48,,,,,,,fee schedule,8.18,90.42,
Walker seat attachment,E0156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.18,,,,,,,fee schedule,8.18,90.42,
Walker seat attachment,E0156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,54.42,,,,,,,fee schedule,8.18,90.42,
Walker seat attachment,E0156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,79.18,,,,,,,fee schedule,8.18,90.42,
Walker seat attachment,E0156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.94,,,,,,,fee schedule,8.18,90.42,
Walker seat attachment,E0156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,59.45,,,,,,,fee schedule,8.18,90.42,
Walker seat attachment,E0156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83.24,,,,,,,fee schedule,8.18,90.42,
Walker seat attachment,E0156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.4,,,,,,,fee schedule,8.18,90.42,
Walker seat attachment,E0156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,62.5,,,,,,,fee schedule,8.18,90.42,
Walker crutch attachment,E0157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,280.25,,,,,,,fee schedule,24.66,280.25,
Walker crutch attachment,E0157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30.77,,,,,,,fee schedule,24.66,280.25,
Walker crutch attachment,E0157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,210.21,,,,,,,fee schedule,24.66,280.25,
Walker crutch attachment,E0157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,224.64,,,,,,,fee schedule,24.66,280.25,
Walker crutch attachment,E0157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24.66,,,,,,,fee schedule,24.66,280.25,
Walker crutch attachment,E0157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,168.5,,,,,,,fee schedule,24.66,280.25,
Walker crutch attachment,E0157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,245.4,,,,,,,fee schedule,24.66,280.25,
Walker crutch attachment,E0157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26.94,,,,,,,fee schedule,24.66,280.25,
Walker crutch attachment,E0157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,184.07,,,,,,,fee schedule,24.66,280.25,
Walker crutch attachment,E0157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,258.01,,,,,,,fee schedule,24.66,280.25,
Walker crutch attachment,E0157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,28.33,,,,,,,fee schedule,24.66,280.25,
Walker crutch attachment,E0157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,193.52,,,,,,,fee schedule,24.66,280.25,
Walker leg extenders set of4,E0158,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,110.07,,,,,,,fee schedule,9.61,110.07,
Walker leg extenders set of4,E0158,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11.98,,,,,,,fee schedule,9.61,110.07,
Walker leg extenders set of4,E0158,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83.08,,,,,,,fee schedule,9.61,110.07,
Walker leg extenders set of4,E0158,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,88.23,,,,,,,fee schedule,9.61,110.07,
Walker leg extenders set of4,E0158,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.61,,,,,,,fee schedule,9.61,110.07,
Walker leg extenders set of4,E0158,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66.6,,,,,,,fee schedule,9.61,110.07,
Walker leg extenders set of4,E0158,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,96.39,,,,,,,fee schedule,9.61,110.07,
Walker leg extenders set of4,E0158,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10.49,,,,,,,fee schedule,9.61,110.07,
Walker leg extenders set of4,E0158,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,72.75,,,,,,,fee schedule,9.61,110.07,
Walker leg extenders set of4,E0158,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,101.34,,,,,,,fee schedule,9.61,110.07,
Walker leg extenders set of4,E0158,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11.03,,,,,,,fee schedule,9.61,110.07,
Walker leg extenders set of4,E0158,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,76.49,,,,,,,fee schedule,9.61,110.07,
Brake for wheeled walker,E0159,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,61.12,,,,,,,fee schedule,5.06,61.12,
Brake for wheeled walker,E0159,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.31,,,,,,,fee schedule,5.06,61.12,
Brake for wheeled walker,E0159,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45.85,,,,,,,fee schedule,5.06,61.12,
Brake for wheeled walker,E0159,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,49,,,,,,,fee schedule,5.06,61.12,
Brake for wheeled walker,E0159,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.06,,,,,,,fee schedule,5.06,61.12,
Brake for wheeled walker,E0159,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36.75,,,,,,,fee schedule,5.06,61.12,
Brake for wheeled walker,E0159,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.52,,,,,,,fee schedule,5.06,61.12,
Brake for wheeled walker,E0159,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.53,,,,,,,fee schedule,5.06,61.12,
Brake for wheeled walker,E0159,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40.15,,,,,,,fee schedule,5.06,61.12,
Brake for wheeled walker,E0159,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,56.27,,,,,,,fee schedule,5.06,61.12,
Brake for wheeled walker,E0159,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.81,,,,,,,fee schedule,5.06,61.12,
Brake for wheeled walker,E0159,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42.21,,,,,,,fee schedule,5.06,61.12,
Sitz type bath or equipment,E0160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,111.51,,,,,,,fee schedule,11.73,111.51,
Sitz type bath or equipment,E0160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14.63,,,,,,,fee schedule,11.73,111.51,
Sitz type bath or equipment,E0160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83.58,,,,,,,fee schedule,11.73,111.51,
Sitz type bath or equipment,E0160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,89.39,,,,,,,fee schedule,11.73,111.51,
Sitz type bath or equipment,E0160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11.73,,,,,,,fee schedule,11.73,111.51,
Sitz type bath or equipment,E0160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66.99,,,,,,,fee schedule,11.73,111.51,
Sitz type bath or equipment,E0160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,97.65,,,,,,,fee schedule,11.73,111.51,
Sitz type bath or equipment,E0160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12.81,,,,,,,fee schedule,11.73,111.51,
Sitz type bath or equipment,E0160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,73.18,,,,,,,fee schedule,11.73,111.51,
Sitz type bath or equipment,E0160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,102.66,,,,,,,fee schedule,11.73,111.51,
Sitz type bath or equipment,E0160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13.47,,,,,,,fee schedule,11.73,111.51,
Sitz type bath or equipment,E0160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,76.94,,,,,,,fee schedule,11.73,111.51,
Sitz bath/equipment w/faucet,E0161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,88.49,,,,,,,fee schedule,9.67,88.49,
Sitz bath/equipment w/faucet,E0161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12.06,,,,,,,fee schedule,9.67,88.49,
Sitz bath/equipment w/faucet,E0161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.26,,,,,,,fee schedule,9.67,88.49,
Sitz bath/equipment w/faucet,E0161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,70.93,,,,,,,fee schedule,9.67,88.49,
Sitz bath/equipment w/faucet,E0161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.67,,,,,,,fee schedule,9.67,88.49,
Sitz bath/equipment w/faucet,E0161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.12,,,,,,,fee schedule,9.67,88.49,
Sitz bath/equipment w/faucet,E0161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,77.49,,,,,,,fee schedule,9.67,88.49,
Sitz bath/equipment w/faucet,E0161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10.56,,,,,,,fee schedule,9.67,88.49,
Sitz bath/equipment w/faucet,E0161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,58.02,,,,,,,fee schedule,9.67,88.49,
Sitz bath/equipment w/faucet,E0161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,81.47,,,,,,,fee schedule,9.67,88.49,
Sitz bath/equipment w/faucet,E0161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11.1,,,,,,,fee schedule,9.67,88.49,
Sitz bath/equipment w/faucet,E0161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,61,,,,,,,fee schedule,9.67,88.49,
Sitz bath chair,E0162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,491.55,,,,,,,fee schedule,41.33,491.55,
Sitz bath chair,E0162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,51.56,,,,,,,fee schedule,41.33,491.55,
Sitz bath chair,E0162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,381.21,,,,,,,fee schedule,41.33,491.55,
Sitz bath chair,E0162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,394.02,,,,,,,fee schedule,41.33,491.55,
Sitz bath chair,E0162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,41.33,,,,,,,fee schedule,41.33,491.55,
Sitz bath chair,E0162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,305.58,,,,,,,fee schedule,41.33,491.55,
Sitz bath chair,E0162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,430.43,,,,,,,fee schedule,41.33,491.55,
Sitz bath chair,E0162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,45.15,,,,,,,fee schedule,41.33,491.55,
Sitz bath chair,E0162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,333.81,,,,,,,fee schedule,41.33,491.55,
Sitz bath chair,E0162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,452.54,,,,,,,fee schedule,41.33,491.55,
Sitz bath chair,E0162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,47.47,,,,,,,fee schedule,41.33,491.55,
Sitz bath chair,E0162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,350.96,,,,,,,fee schedule,41.33,491.55,
Commode chair with fixed arm,E0163,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,437.72,,,,,,,fee schedule,66.05,437.72,
Commode chair with fixed arm,E0163,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,82.4,,,,,,,fee schedule,66.05,437.72,
Commode chair with fixed arm,E0163,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,329.96,,,,,,,fee schedule,66.05,437.72,
Commode chair with fixed arm,E0163,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,350.87,,,,,,,fee schedule,66.05,437.72,
Commode chair with fixed arm,E0163,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66.05,,,,,,,fee schedule,66.05,437.72,
Commode chair with fixed arm,E0163,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,264.49,,,,,,,fee schedule,66.05,437.72,
Commode chair with fixed arm,E0163,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,383.3,,,,,,,fee schedule,66.05,437.72,
Commode chair with fixed arm,E0163,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,72.16,,,,,,,fee schedule,66.05,437.72,
Commode chair with fixed arm,E0163,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,288.93,,,,,,,fee schedule,66.05,437.72,
Commode chair with fixed arm,E0163,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,402.98,,,,,,,fee schedule,66.05,437.72,
Commode chair with fixed arm,E0163,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,75.86,,,,,,,fee schedule,66.05,437.72,
Commode chair with fixed arm,E0163,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,303.77,,,,,,,fee schedule,66.05,437.72,
Commode chair with detacharm,E0165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,657.87,,,,,,,fee schedule,50.24,657.87,
Commode chair with detacharm,E0165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,62.67,,,,,,,fee schedule,50.24,657.87,
Commode chair with detacharm,E0165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,527.34,,,,,,,fee schedule,50.24,657.87,
Commode chair with detacharm,E0165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,50.24,,,,,,,fee schedule,50.24,657.87,
Commode chair with detacharm,E0165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,576.07,,,,,,,fee schedule,50.24,657.87,
Commode chair with detacharm,E0165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,54.88,,,,,,,fee schedule,50.24,657.87,
Commode chair with detacharm,E0165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,605.66,,,,,,,fee schedule,50.24,657.87,
Commode chair with detacharm,E0165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,57.7,,,,,,,fee schedule,50.24,657.87,
Commode chair pail or pan,E0167,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,43.85,,,,,,,fee schedule,4,47.63,
Commode chair pail or pan,E0167,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.59,,,,,,,fee schedule,4,47.63,
Commode chair pail or pan,E0167,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33.03,,,,,,,fee schedule,4,47.63,
Commode chair pail or pan,E0167,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,47.63,,,,,,,fee schedule,4,47.63,
Commode chair pail or pan,E0167,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.99,,,,,,,fee schedule,4,47.63,
Commode chair pail or pan,E0167,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,35.87,,,,,,,fee schedule,4,47.63,
Commode chair pail or pan,E0167,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38.18,,,,,,,fee schedule,4,47.63,
Commode chair pail or pan,E0167,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4,,,,,,,fee schedule,4,47.63,
Commode chair pail or pan,E0167,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28.75,,,,,,,fee schedule,4,47.63,
Commode chair pail or pan,E0167,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,41.71,,,,,,,fee schedule,4,47.63,
Commode chair pail or pan,E0167,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.37,,,,,,,fee schedule,4,47.63,
Commode chair pail or pan,E0167,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31.41,,,,,,,fee schedule,4,47.63,
Heavyduty/wide commode chair,E0168,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,551.48,,,,,,,fee schedule,48.27,599.02,
Heavyduty/wide commode chair,E0168,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55.44,,,,,,,fee schedule,48.27,599.02,
Heavyduty/wide commode chair,E0168,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,413.56,,,,,,,fee schedule,48.27,599.02,
Heavyduty/wide commode chair,E0168,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,599.02,,,,,,,fee schedule,48.27,599.02,
Heavyduty/wide commode chair,E0168,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.22,,,,,,,fee schedule,48.27,599.02,
Heavyduty/wide commode chair,E0168,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,449.22,,,,,,,fee schedule,48.27,599.02,
Heavyduty/wide commode chair,E0168,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,480.16,,,,,,,fee schedule,48.27,599.02,
Heavyduty/wide commode chair,E0168,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48.27,,,,,,,fee schedule,48.27,599.02,
Heavyduty/wide commode chair,E0168,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,360.09,,,,,,,fee schedule,48.27,599.02,
Heavyduty/wide commode chair,E0168,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,524.54,,,,,,,fee schedule,48.27,599.02,
Heavyduty/wide commode chair,E0168,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52.73,,,,,,,fee schedule,48.27,599.02,
Heavyduty/wide commode chair,E0168,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,393.36,,,,,,,fee schedule,48.27,599.02,
Commode chair electric,E0170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6166.49,,,,,,,fee schedule,511.34,6698.08,
Commode chair electric,E0170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,587.28,,,,,,,fee schedule,511.34,6698.08,
Commode chair electric,E0170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6698.08,,,,,,,fee schedule,511.34,6698.08,
Commode chair electric,E0170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,637.91,,,,,,,fee schedule,511.34,6698.08,
Commode chair electric,E0170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5369.1,,,,,,,fee schedule,511.34,6698.08,
Commode chair electric,E0170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,511.34,,,,,,,fee schedule,511.34,6698.08,
Commode chair electric,E0170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5865.25,,,,,,,fee schedule,511.34,6698.08,
Commode chair electric,E0170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,558.6,,,,,,,fee schedule,511.34,6698.08,
Commode chair non-electric,E0171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1109.74,,,,,,,fee schedule,92.02,1205.4,
Commode chair non-electric,E0171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,105.69,,,,,,,fee schedule,92.02,1205.4,
Commode chair non-electric,E0171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1205.4,,,,,,,fee schedule,92.02,1205.4,
Commode chair non-electric,E0171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,114.8,,,,,,,fee schedule,92.02,1205.4,
Commode chair non-electric,E0171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,966.24,,,,,,,fee schedule,92.02,1205.4,
Commode chair non-electric,E0171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,92.02,,,,,,,fee schedule,92.02,1205.4,
Commode chair non-electric,E0171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1055.53,,,,,,,fee schedule,92.02,1205.4,
Commode chair non-electric,E0171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,100.52,,,,,,,fee schedule,92.02,1205.4,
Commode chair foot rest,E0175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,242,,,,,,,fee schedule,21.06,262.86,
Commode chair foot rest,E0175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24.19,,,,,,,fee schedule,21.06,262.86,
Commode chair foot rest,E0175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,178.11,,,,,,,fee schedule,21.06,262.86,
Commode chair foot rest,E0175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,262.86,,,,,,,fee schedule,21.06,262.86,
Commode chair foot rest,E0175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26.27,,,,,,,fee schedule,21.06,262.86,
Commode chair foot rest,E0175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,193.46,,,,,,,fee schedule,21.06,262.86,
Commode chair foot rest,E0175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,210.71,,,,,,,fee schedule,21.06,262.86,
Commode chair foot rest,E0175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21.06,,,,,,,fee schedule,21.06,262.86,
Commode chair foot rest,E0175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,155.08,,,,,,,fee schedule,21.06,262.86,
Commode chair foot rest,E0175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,230.18,,,,,,,fee schedule,21.06,262.86,
Commode chair foot rest,E0175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23,,,,,,,fee schedule,21.06,262.86,
Commode chair foot rest,E0175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,169.41,,,,,,,fee schedule,21.06,262.86,
Press pad alternating w/ pum,E0181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,999.73,,,,,,,fee schedule,82.9,1085.92,
Press pad alternating w/ pum,E0181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,95.21,,,,,,,fee schedule,82.9,1085.92,
Press pad alternating w/ pum,E0181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1085.92,,,,,,,fee schedule,82.9,1085.92,
Press pad alternating w/ pum,E0181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,103.42,,,,,,,fee schedule,82.9,1085.92,
Press pad alternating w/ pum,E0181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,870.46,,,,,,,fee schedule,82.9,1085.92,
Press pad alternating w/ pum,E0181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,82.9,,,,,,,fee schedule,82.9,1085.92,
Press pad alternating w/ pum,E0181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,950.9,,,,,,,fee schedule,82.9,1085.92,
Press pad alternating w/ pum,E0181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,90.56,,,,,,,fee schedule,82.9,1085.92,
"Replace pump, alt press pad",E0182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,963.58,,,,,,,fee schedule,79.9,1046.64,
"Replace pump, alt press pad",E0182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,91.77,,,,,,,fee schedule,79.9,1046.64,
"Replace pump, alt press pad",E0182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1046.64,,,,,,,fee schedule,79.9,1046.64,
"Replace pump, alt press pad",E0182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,99.68,,,,,,,fee schedule,79.9,1046.64,
"Replace pump, alt press pad",E0182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,838.98,,,,,,,fee schedule,79.9,1046.64,
"Replace pump, alt press pad",E0182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,79.9,,,,,,,fee schedule,79.9,1046.64,
"Replace pump, alt press pad",E0182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,916.51,,,,,,,fee schedule,79.9,1046.64,
"Replace pump, alt press pad",E0182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,87.28,,,,,,,fee schedule,79.9,1046.64,
Dry pressure mattress,E0184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,604.72,,,,,,,fee schedule,66.45,656.85,
Dry pressure mattress,E0184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,76.32,,,,,,,fee schedule,66.45,656.85,
Dry pressure mattress,E0184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,463.78,,,,,,,fee schedule,66.45,656.85,
Dry pressure mattress,E0184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,656.85,,,,,,,fee schedule,66.45,656.85,
Dry pressure mattress,E0184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,82.9,,,,,,,fee schedule,66.45,656.85,
Dry pressure mattress,E0184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,503.76,,,,,,,fee schedule,66.45,656.85,
Dry pressure mattress,E0184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,526.52,,,,,,,fee schedule,66.45,656.85,
Dry pressure mattress,E0184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66.45,,,,,,,fee schedule,66.45,656.85,
Dry pressure mattress,E0184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,403.81,,,,,,,fee schedule,66.45,656.85,
Dry pressure mattress,E0184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,575.18,,,,,,,fee schedule,66.45,656.85,
Dry pressure mattress,E0184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,72.59,,,,,,,fee schedule,66.45,656.85,
Dry pressure mattress,E0184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,441.12,,,,,,,fee schedule,66.45,656.85,
Gel pressure mattress pad,E0185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1168.76,,,,,,,fee schedule,136.74,1269.51,
Gel pressure mattress pad,E0185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,157.05,,,,,,,fee schedule,136.74,1269.51,
Gel pressure mattress pad,E0185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,896.97,,,,,,,fee schedule,136.74,1269.51,
Gel pressure mattress pad,E0185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1269.51,,,,,,,fee schedule,136.74,1269.51,
Gel pressure mattress pad,E0185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,170.59,,,,,,,fee schedule,136.74,1269.51,
Gel pressure mattress pad,E0185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,974.3,,,,,,,fee schedule,136.74,1269.51,
Gel pressure mattress pad,E0185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1017.63,,,,,,,fee schedule,136.74,1269.51,
Gel pressure mattress pad,E0185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,136.74,,,,,,,fee schedule,136.74,1269.51,
Gel pressure mattress pad,E0185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,780.98,,,,,,,fee schedule,136.74,1269.51,
Gel pressure mattress pad,E0185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1111.66,,,,,,,fee schedule,136.74,1269.51,
Gel pressure mattress pad,E0185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,149.38,,,,,,,fee schedule,136.74,1269.51,
Gel pressure mattress pad,E0185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,853.15,,,,,,,fee schedule,136.74,1269.51,
Air pressure mattress,E0186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,662.1,,,,,,,fee schedule,54.9,719.18,
Air pressure mattress,E0186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,63.06,,,,,,,fee schedule,54.9,719.18,
Air pressure mattress,E0186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,719.18,,,,,,,fee schedule,54.9,719.18,
Air pressure mattress,E0186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,68.49,,,,,,,fee schedule,54.9,719.18,
Air pressure mattress,E0186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,576.49,,,,,,,fee schedule,54.9,719.18,
Air pressure mattress,E0186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,54.9,,,,,,,fee schedule,54.9,719.18,
Air pressure mattress,E0186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,629.76,,,,,,,fee schedule,54.9,719.18,
Air pressure mattress,E0186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,59.98,,,,,,,fee schedule,54.9,719.18,
Water pressure mattress,E0187,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,756.73,,,,,,,fee schedule,62.75,821.96,
Water pressure mattress,E0187,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,72.07,,,,,,,fee schedule,62.75,821.96,
Water pressure mattress,E0187,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,821.96,,,,,,,fee schedule,62.75,821.96,
Water pressure mattress,E0187,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,78.28,,,,,,,fee schedule,62.75,821.96,
Water pressure mattress,E0187,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,658.87,,,,,,,fee schedule,62.75,821.96,
Water pressure mattress,E0187,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,62.75,,,,,,,fee schedule,62.75,821.96,
Water pressure mattress,E0187,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,719.76,,,,,,,fee schedule,62.75,821.96,
Water pressure mattress,E0187,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,68.55,,,,,,,fee schedule,62.75,821.96,
Synthetic sheepskin pad,E0188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,82.09,,,,,,,fee schedule,8.39,89.17,
Synthetic sheepskin pad,E0188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.64,,,,,,,fee schedule,8.39,89.17,
Synthetic sheepskin pad,E0188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,61.63,,,,,,,fee schedule,8.39,89.17,
Synthetic sheepskin pad,E0188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,89.17,,,,,,,fee schedule,8.39,89.17,
Synthetic sheepskin pad,E0188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10.47,,,,,,,fee schedule,8.39,89.17,
Synthetic sheepskin pad,E0188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.94,,,,,,,fee schedule,8.39,89.17,
Synthetic sheepskin pad,E0188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,71.48,,,,,,,fee schedule,8.39,89.17,
Synthetic sheepskin pad,E0188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.39,,,,,,,fee schedule,8.39,89.17,
Synthetic sheepskin pad,E0188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.66,,,,,,,fee schedule,8.39,89.17,
Synthetic sheepskin pad,E0188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,78.08,,,,,,,fee schedule,8.39,89.17,
Synthetic sheepskin pad,E0188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.17,,,,,,,fee schedule,8.39,89.17,
Synthetic sheepskin pad,E0188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,58.62,,,,,,,fee schedule,8.39,89.17,
Lambswool sheepskin pad,E0189,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,189.87,,,,,,,fee schedule,17.91,206.24,
Lambswool sheepskin pad,E0189,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20.57,,,,,,,fee schedule,17.91,206.24,
Lambswool sheepskin pad,E0189,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,142.44,,,,,,,fee schedule,17.91,206.24,
Lambswool sheepskin pad,E0189,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,206.24,,,,,,,fee schedule,17.91,206.24,
Lambswool sheepskin pad,E0189,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22.34,,,,,,,fee schedule,17.91,206.24,
Lambswool sheepskin pad,E0189,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,154.72,,,,,,,fee schedule,17.91,206.24,
Lambswool sheepskin pad,E0189,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,165.32,,,,,,,fee schedule,17.91,206.24,
Lambswool sheepskin pad,E0189,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17.91,,,,,,,fee schedule,17.91,206.24,
Lambswool sheepskin pad,E0189,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,124.02,,,,,,,fee schedule,17.91,206.24,
Lambswool sheepskin pad,E0189,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,180.59,,,,,,,fee schedule,17.91,206.24,
Lambswool sheepskin pad,E0189,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19.56,,,,,,,fee schedule,17.91,206.24,
Lambswool sheepskin pad,E0189,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,135.48,,,,,,,fee schedule,17.91,206.24,
Protector heel or elbow,E0191,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,36.51,,,,,,,fee schedule,3.24,39.65,
Protector heel or elbow,E0191,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.72,,,,,,,fee schedule,3.24,39.65,
Protector heel or elbow,E0191,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27.25,,,,,,,fee schedule,3.24,39.65,
Protector heel or elbow,E0191,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,39.65,,,,,,,fee schedule,3.24,39.65,
Protector heel or elbow,E0191,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.04,,,,,,,fee schedule,3.24,39.65,
Protector heel or elbow,E0191,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,29.6,,,,,,,fee schedule,3.24,39.65,
Protector heel or elbow,E0191,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31.78,,,,,,,fee schedule,3.24,39.65,
Protector heel or elbow,E0191,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.24,,,,,,,fee schedule,3.24,39.65,
Protector heel or elbow,E0191,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23.72,,,,,,,fee schedule,3.24,39.65,
Protector heel or elbow,E0191,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,34.72,,,,,,,fee schedule,3.24,39.65,
Protector heel or elbow,E0191,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.54,,,,,,,fee schedule,3.24,39.65,
Protector heel or elbow,E0191,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,25.92,,,,,,,fee schedule,3.24,39.65,
Powered air flotation bed,E0193,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26425,,,,,,,fee schedule,2191.24,28703.01,
Powered air flotation bed,E0193,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2516.67,,,,,,,fee schedule,2191.24,28703.01,
Powered air flotation bed,E0193,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,28703.01,,,,,,,fee schedule,2191.24,28703.01,
Powered air flotation bed,E0193,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2733.62,,,,,,,fee schedule,2191.24,28703.01,
Powered air flotation bed,E0193,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23007.97,,,,,,,fee schedule,2191.24,28703.01,
Powered air flotation bed,E0193,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2191.24,,,,,,,fee schedule,2191.24,28703.01,
Powered air flotation bed,E0193,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,25134.12,,,,,,,fee schedule,2191.24,28703.01,
Powered air flotation bed,E0193,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2393.73,,,,,,,fee schedule,2191.24,28703.01,
Air fluidized bed,E0194,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,106130.43,,,,,,,fee schedule,8800.64,115279.61,
Air fluidized bed,E0194,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10107.66,,,,,,,fee schedule,8800.64,115279.61,
Air fluidized bed,E0194,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,115279.61,,,,,,,fee schedule,8800.64,115279.61,
Air fluidized bed,E0194,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10979.01,,,,,,,fee schedule,8800.64,115279.61,
Air fluidized bed,E0194,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,92406.67,,,,,,,fee schedule,8800.64,115279.61,
Air fluidized bed,E0194,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8800.64,,,,,,,fee schedule,8800.64,115279.61,
Air fluidized bed,E0194,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,100945.9,,,,,,,fee schedule,8800.64,115279.61,
Air fluidized bed,E0194,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9613.9,,,,,,,fee schedule,8800.64,115279.61,
Gel pressure mattress,E0196,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1128.7,,,,,,,fee schedule,93.6,1226.01,
Gel pressure mattress,E0196,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,107.5,,,,,,,fee schedule,93.6,1226.01,
Gel pressure mattress,E0196,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1226.01,,,,,,,fee schedule,93.6,1226.01,
Gel pressure mattress,E0196,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,116.76,,,,,,,fee schedule,93.6,1226.01,
Gel pressure mattress,E0196,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,982.75,,,,,,,fee schedule,93.6,1226.01,
Gel pressure mattress,E0196,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,93.6,,,,,,,fee schedule,93.6,1226.01,
Gel pressure mattress,E0196,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1073.57,,,,,,,fee schedule,93.6,1226.01,
Gel pressure mattress,E0196,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,102.25,,,,,,,fee schedule,93.6,1226.01,
Air pressure pad for mattres,E0197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,688.2,,,,,,,fee schedule,82.69,747.53,
Air pressure pad for mattres,E0197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,94.97,,,,,,,fee schedule,82.69,747.53,
Air pressure pad for mattres,E0197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,604.51,,,,,,,fee schedule,82.69,747.53,
Air pressure pad for mattres,E0197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,747.53,,,,,,,fee schedule,82.69,747.53,
Air pressure pad for mattres,E0197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,103.16,,,,,,,fee schedule,82.69,747.53,
Air pressure pad for mattres,E0197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,656.62,,,,,,,fee schedule,82.69,747.53,
Air pressure pad for mattres,E0197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,599.21,,,,,,,fee schedule,82.69,747.53,
Air pressure pad for mattres,E0197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,82.69,,,,,,,fee schedule,82.69,747.53,
Air pressure pad for mattres,E0197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,526.34,,,,,,,fee schedule,82.69,747.53,
Air pressure pad for mattres,E0197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,654.59,,,,,,,fee schedule,82.69,747.53,
Air pressure pad for mattres,E0197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,90.33,,,,,,,fee schedule,82.69,747.53,
Air pressure pad for mattres,E0197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,574.98,,,,,,,fee schedule,82.69,747.53,
Water pressure pad for mattr,E0198,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,688.2,,,,,,,fee schedule,62.08,747.53,
Water pressure pad for mattr,E0198,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,71.31,,,,,,,fee schedule,62.08,747.53,
Water pressure pad for mattr,E0198,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,522.24,,,,,,,fee schedule,62.08,747.53,
Water pressure pad for mattr,E0198,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,747.53,,,,,,,fee schedule,62.08,747.53,
Water pressure pad for mattr,E0198,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,77.45,,,,,,,fee schedule,62.08,747.53,
Water pressure pad for mattr,E0198,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,567.26,,,,,,,fee schedule,62.08,747.53,
Water pressure pad for mattr,E0198,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,599.21,,,,,,,fee schedule,62.08,747.53,
Water pressure pad for mattr,E0198,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,62.08,,,,,,,fee schedule,62.08,747.53,
Water pressure pad for mattr,E0198,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,454.71,,,,,,,fee schedule,62.08,747.53,
Water pressure pad for mattr,E0198,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,654.59,,,,,,,fee schedule,62.08,747.53,
Water pressure pad for mattr,E0198,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,67.82,,,,,,,fee schedule,62.08,747.53,
Water pressure pad for mattr,E0198,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,496.73,,,,,,,fee schedule,62.08,747.53,
Dry pressure pad for mattres,E0199,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,110.04,,,,,,,fee schedule,9.64,119.52,
Dry pressure pad for mattres,E0199,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11.07,,,,,,,fee schedule,9.64,119.52,
Dry pressure pad for mattres,E0199,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,82.58,,,,,,,fee schedule,9.64,119.52,
Dry pressure pad for mattres,E0199,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,119.52,,,,,,,fee schedule,9.64,119.52,
Dry pressure pad for mattres,E0199,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12.02,,,,,,,fee schedule,9.64,119.52,
Dry pressure pad for mattres,E0199,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,89.7,,,,,,,fee schedule,9.64,119.52,
Dry pressure pad for mattres,E0199,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,95.81,,,,,,,fee schedule,9.64,119.52,
Dry pressure pad for mattres,E0199,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.64,,,,,,,fee schedule,9.64,119.52,
Dry pressure pad for mattres,E0199,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,71.9,,,,,,,fee schedule,9.64,119.52,
Dry pressure pad for mattres,E0199,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,104.66,,,,,,,fee schedule,9.64,119.52,
Dry pressure pad for mattres,E0199,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10.53,,,,,,,fee schedule,9.64,119.52,
Dry pressure pad for mattres,E0199,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,78.55,,,,,,,fee schedule,9.64,119.52,
Heat lamp without stand,E0200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,275.89,,,,,,,fee schedule,29.12,299.68,
Heat lamp without stand,E0200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33.44,,,,,,,fee schedule,29.12,299.68,
Heat lamp without stand,E0200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,206.89,,,,,,,fee schedule,29.12,299.68,
Heat lamp without stand,E0200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,299.68,,,,,,,fee schedule,29.12,299.68,
Heat lamp without stand,E0200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,36.33,,,,,,,fee schedule,29.12,299.68,
Heat lamp without stand,E0200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,224.72,,,,,,,fee schedule,29.12,299.68,
Heat lamp without stand,E0200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,240.22,,,,,,,fee schedule,29.12,299.68,
Heat lamp without stand,E0200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29.12,,,,,,,fee schedule,29.12,299.68,
Heat lamp without stand,E0200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,180.13,,,,,,,fee schedule,29.12,299.68,
Heat lamp without stand,E0200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,262.42,,,,,,,fee schedule,29.12,299.68,
Heat lamp without stand,E0200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31.81,,,,,,,fee schedule,29.12,299.68,
Heat lamp without stand,E0200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,196.78,,,,,,,fee schedule,29.12,299.68,
Phototherapy light w/ photom,E0202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2402.14,,,,,,,fee schedule,199.19,2609.22,
Phototherapy light w/ photom,E0202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,228.78,,,,,,,fee schedule,199.19,2609.22,
Phototherapy light w/ photom,E0202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2609.22,,,,,,,fee schedule,199.19,2609.22,
Phototherapy light w/ photom,E0202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,248.5,,,,,,,fee schedule,199.19,2609.22,
Phototherapy light w/ photom,E0202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2091.52,,,,,,,fee schedule,199.19,2609.22,
Phototherapy light w/ photom,E0202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,199.19,,,,,,,fee schedule,199.19,2609.22,
Phototherapy light w/ photom,E0202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2284.79,,,,,,,fee schedule,199.19,2609.22,
Phototherapy light w/ photom,E0202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,217.6,,,,,,,fee schedule,199.19,2609.22,
Heat lamp with stand,E0205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,709.08,,,,,,,fee schedule,67.9,770.21,
Heat lamp with stand,E0205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,77.99,,,,,,,fee schedule,67.9,770.21,
Heat lamp with stand,E0205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,531.81,,,,,,,fee schedule,67.9,770.21,
Heat lamp with stand,E0205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,770.21,,,,,,,fee schedule,67.9,770.21,
Heat lamp with stand,E0205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,84.71,,,,,,,fee schedule,67.9,770.21,
Heat lamp with stand,E0205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,577.66,,,,,,,fee schedule,67.9,770.21,
Heat lamp with stand,E0205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,617.39,,,,,,,fee schedule,67.9,770.21,
Heat lamp with stand,E0205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,67.9,,,,,,,fee schedule,67.9,770.21,
Heat lamp with stand,E0205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,463.04,,,,,,,fee schedule,67.9,770.21,
Heat lamp with stand,E0205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,674.45,,,,,,,fee schedule,67.9,770.21,
Heat lamp with stand,E0205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,74.18,,,,,,,fee schedule,67.9,770.21,
Heat lamp with stand,E0205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,505.83,,,,,,,fee schedule,67.9,770.21,
Electric heat pad standard,E0210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,101.37,,,,,,,fee schedule,8.3,110.11,
Electric heat pad standard,E0210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.54,,,,,,,fee schedule,8.3,110.11,
Electric heat pad standard,E0210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,76.04,,,,,,,fee schedule,8.3,110.11,
Electric heat pad standard,E0210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,110.11,,,,,,,fee schedule,8.3,110.11,
Electric heat pad standard,E0210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10.36,,,,,,,fee schedule,8.3,110.11,
Electric heat pad standard,E0210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,82.59,,,,,,,fee schedule,8.3,110.11,
Electric heat pad standard,E0210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,88.26,,,,,,,fee schedule,8.3,110.11,
Electric heat pad standard,E0210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.3,,,,,,,fee schedule,8.3,110.11,
Electric heat pad standard,E0210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66.21,,,,,,,fee schedule,8.3,110.11,
Electric heat pad standard,E0210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,96.42,,,,,,,fee schedule,8.3,110.11,
Electric heat pad standard,E0210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.07,,,,,,,fee schedule,8.3,110.11,
Electric heat pad standard,E0210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,72.32,,,,,,,fee schedule,8.3,110.11,
Electric heat pad moist,E0215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,220.01,,,,,,,fee schedule,20.03,238.97,
Electric heat pad moist,E0215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23,,,,,,,fee schedule,20.03,238.97,
Electric heat pad moist,E0215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,165.06,,,,,,,fee schedule,20.03,238.97,
Electric heat pad moist,E0215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,238.97,,,,,,,fee schedule,20.03,238.97,
Electric heat pad moist,E0215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24.99,,,,,,,fee schedule,20.03,238.97,
Electric heat pad moist,E0215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,179.29,,,,,,,fee schedule,20.03,238.97,
Electric heat pad moist,E0215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,191.56,,,,,,,fee schedule,20.03,238.97,
Electric heat pad moist,E0215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20.03,,,,,,,fee schedule,20.03,238.97,
Electric heat pad moist,E0215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,143.71,,,,,,,fee schedule,20.03,238.97,
Electric heat pad moist,E0215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,209.26,,,,,,,fee schedule,20.03,238.97,
Electric heat pad moist,E0215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21.88,,,,,,,fee schedule,20.03,238.97,
Electric heat pad moist,E0215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,156.99,,,,,,,fee schedule,20.03,238.97,
Water circ heat pad w pump,E0217,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1814.09,,,,,,,fee schedule,157.92,1970.48,
Water circ heat pad w pump,E0217,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,181.38,,,,,,,fee schedule,157.92,1970.48,
Water circ heat pad w pump,E0217,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1360.47,,,,,,,fee schedule,157.92,1970.48,
Water circ heat pad w pump,E0217,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1970.48,,,,,,,fee schedule,157.92,1970.48,
Water circ heat pad w pump,E0217,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,197.01,,,,,,,fee schedule,157.92,1970.48,
Water circ heat pad w pump,E0217,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1477.75,,,,,,,fee schedule,157.92,1970.48,
Water circ heat pad w pump,E0217,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1579.51,,,,,,,fee schedule,157.92,1970.48,
Water circ heat pad w pump,E0217,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,157.92,,,,,,,fee schedule,157.92,1970.48,
Water circ heat pad w pump,E0217,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1184.55,,,,,,,fee schedule,157.92,1970.48,
Water circ heat pad w pump,E0217,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1725.47,,,,,,,fee schedule,157.92,1970.48,
Water circ heat pad w pump,E0217,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,172.52,,,,,,,fee schedule,157.92,1970.48,
Water circ heat pad w pump,E0217,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1294.01,,,,,,,fee schedule,157.92,1970.48,
Hydrocollator unit,E0225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1420.12,,,,,,,fee schedule,121.9,1542.54,
Hydrocollator unit,E0225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,140,,,,,,,fee schedule,121.9,1542.54,
Hydrocollator unit,E0225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1065.05,,,,,,,fee schedule,121.9,1542.54,
Hydrocollator unit,E0225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1542.54,,,,,,,fee schedule,121.9,1542.54,
Hydrocollator unit,E0225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,152.07,,,,,,,fee schedule,121.9,1542.54,
Hydrocollator unit,E0225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1156.87,,,,,,,fee schedule,121.9,1542.54,
Hydrocollator unit,E0225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1236.48,,,,,,,fee schedule,121.9,1542.54,
Hydrocollator unit,E0225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,121.9,,,,,,,fee schedule,121.9,1542.54,
Hydrocollator unit,E0225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,927.33,,,,,,,fee schedule,121.9,1542.54,
Hydrocollator unit,E0225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1350.74,,,,,,,fee schedule,121.9,1542.54,
Hydrocollator unit,E0225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,133.16,,,,,,,fee schedule,121.9,1542.54,
Hydrocollator unit,E0225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1013.03,,,,,,,fee schedule,121.9,1542.54,
Paraffin bath unit portable,E0235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,562.72,,,,,,,fee schedule,46.66,611.23,
Paraffin bath unit portable,E0235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,53.59,,,,,,,fee schedule,46.66,611.23,
Paraffin bath unit portable,E0235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,611.23,,,,,,,fee schedule,46.66,611.23,
Paraffin bath unit portable,E0235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,58.21,,,,,,,fee schedule,46.66,611.23,
Paraffin bath unit portable,E0235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,489.95,,,,,,,fee schedule,46.66,611.23,
Paraffin bath unit portable,E0235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.66,,,,,,,fee schedule,46.66,611.23,
Paraffin bath unit portable,E0235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,535.23,,,,,,,fee schedule,46.66,611.23,
Paraffin bath unit portable,E0235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,50.97,,,,,,,fee schedule,46.66,611.23,
Pump for water circulating p,E0236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1586.57,,,,,,,fee schedule,131.56,1723.34,
Pump for water circulating p,E0236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,151.1,,,,,,,fee schedule,131.56,1723.34,
Pump for water circulating p,E0236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1723.34,,,,,,,fee schedule,131.56,1723.34,
Pump for water circulating p,E0236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,164.13,,,,,,,fee schedule,131.56,1723.34,
Pump for water circulating p,E0236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1381.41,,,,,,,fee schedule,131.56,1723.34,
Pump for water circulating p,E0236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,131.56,,,,,,,fee schedule,131.56,1723.34,
Pump for water circulating p,E0236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1509.06,,,,,,,fee schedule,131.56,1723.34,
Pump for water circulating p,E0236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,143.72,,,,,,,fee schedule,131.56,1723.34,
Hydrocollator unit portable,E0239,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1400.53,,,,,,,fee schedule,121.96,1521.26,
Hydrocollator unit portable,E0239,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,140.07,,,,,,,fee schedule,121.96,1521.26,
Hydrocollator unit portable,E0239,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1050.54,,,,,,,fee schedule,121.96,1521.26,
Hydrocollator unit portable,E0239,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1521.26,,,,,,,fee schedule,121.96,1521.26,
Hydrocollator unit portable,E0239,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,152.15,,,,,,,fee schedule,121.96,1521.26,
Hydrocollator unit portable,E0239,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1141.11,,,,,,,fee schedule,121.96,1521.26,
Hydrocollator unit portable,E0239,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1219.42,,,,,,,fee schedule,121.96,1521.26,
Hydrocollator unit portable,E0239,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,121.96,,,,,,,fee schedule,121.96,1521.26,
Hydrocollator unit portable,E0239,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,914.7,,,,,,,fee schedule,121.96,1521.26,
Hydrocollator unit portable,E0239,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1332.11,,,,,,,fee schedule,121.96,1521.26,
Hydrocollator unit portable,E0239,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,133.23,,,,,,,fee schedule,121.96,1521.26,
Hydrocollator unit portable,E0239,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,999.22,,,,,,,fee schedule,121.96,1521.26,
Pad water circulating heat u,E0249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,309.34,,,,,,,fee schedule,29.63,336,
Pad water circulating heat u,E0249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,34.03,,,,,,,fee schedule,29.63,336,
Pad water circulating heat u,E0249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,232.01,,,,,,,fee schedule,29.63,336,
Pad water circulating heat u,E0249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,336,,,,,,,fee schedule,29.63,336,
Pad water circulating heat u,E0249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,36.97,,,,,,,fee schedule,29.63,336,
Pad water circulating heat u,E0249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,252.01,,,,,,,fee schedule,29.63,336,
Pad water circulating heat u,E0249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,269.34,,,,,,,fee schedule,29.63,336,
Pad water circulating heat u,E0249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29.63,,,,,,,fee schedule,29.63,336,
Pad water circulating heat u,E0249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,202.01,,,,,,,fee schedule,29.63,336,
Pad water circulating heat u,E0249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,294.23,,,,,,,fee schedule,29.63,336,
Pad water circulating heat u,E0249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32.37,,,,,,,fee schedule,29.63,336,
Pad water circulating heat u,E0249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,220.68,,,,,,,fee schedule,29.63,336,
Bed pan standard,E0275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55.96,,,,,,,fee schedule,5.09,60.78,
Bed pan standard,E0275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.85,,,,,,,fee schedule,5.09,60.78,
Bed pan standard,E0275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41.93,,,,,,,fee schedule,5.09,60.78,
Bed pan standard,E0275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.78,,,,,,,fee schedule,5.09,60.78,
Bed pan standard,E0275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.35,,,,,,,fee schedule,5.09,60.78,
Bed pan standard,E0275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45.55,,,,,,,fee schedule,5.09,60.78,
Bed pan standard,E0275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48.72,,,,,,,fee schedule,5.09,60.78,
Bed pan standard,E0275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.09,,,,,,,fee schedule,5.09,60.78,
Bed pan standard,E0275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36.51,,,,,,,fee schedule,5.09,60.78,
Bed pan standard,E0275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.22,,,,,,,fee schedule,5.09,60.78,
Bed pan standard,E0275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.56,,,,,,,fee schedule,5.09,60.78,
Bed pan standard,E0275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39.89,,,,,,,fee schedule,5.09,60.78,
Bed pan fracture,E0276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,48.62,,,,,,,fee schedule,5,52.81,
Bed pan fracture,E0276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.74,,,,,,,fee schedule,5,52.81,
Bed pan fracture,E0276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,38.45,,,,,,,fee schedule,5,52.81,
Bed pan fracture,E0276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,52.81,,,,,,,fee schedule,5,52.81,
Bed pan fracture,E0276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.24,,,,,,,fee schedule,5,52.81,
Bed pan fracture,E0276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41.77,,,,,,,fee schedule,5,52.81,
Bed pan fracture,E0276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.33,,,,,,,fee schedule,5,52.81,
Bed pan fracture,E0276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5,,,,,,,fee schedule,5,52.81,
Bed pan fracture,E0276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,33.48,,,,,,,fee schedule,5,52.81,
Bed pan fracture,E0276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.24,,,,,,,fee schedule,5,52.81,
Bed pan fracture,E0276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.46,,,,,,,fee schedule,5,52.81,
Bed pan fracture,E0276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36.58,,,,,,,fee schedule,5,52.81,
Powered pres-redu air mattrs,E0277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22197.67,,,,,,,fee schedule,1840.69,24111.26,
Powered pres-redu air mattrs,E0277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2114.07,,,,,,,fee schedule,1840.69,24111.26,
Powered pres-redu air mattrs,E0277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24111.26,,,,,,,fee schedule,1840.69,24111.26,
Powered pres-redu air mattrs,E0277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2296.31,,,,,,,fee schedule,1840.69,24111.26,
Powered pres-redu air mattrs,E0277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19327.28,,,,,,,fee schedule,1840.69,24111.26,
Powered pres-redu air mattrs,E0277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1840.69,,,,,,,fee schedule,1840.69,24111.26,
Powered pres-redu air mattrs,E0277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21113.3,,,,,,,fee schedule,1840.69,24111.26,
Powered pres-redu air mattrs,E0277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2010.79,,,,,,,fee schedule,1840.69,24111.26,
Bed cradle,E0280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,102.24,,,,,,,fee schedule,9.57,111.06,
Bed cradle,E0280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11,,,,,,,fee schedule,9.57,111.06,
Bed cradle,E0280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,76.7,,,,,,,fee schedule,9.57,111.06,
Bed cradle,E0280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,111.06,,,,,,,fee schedule,9.57,111.06,
Bed cradle,E0280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11.94,,,,,,,fee schedule,9.57,111.06,
Bed cradle,E0280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83.31,,,,,,,fee schedule,9.57,111.06,
Bed cradle,E0280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,89.02,,,,,,,fee schedule,9.57,111.06,
Bed cradle,E0280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.57,,,,,,,fee schedule,9.57,111.06,
Bed cradle,E0280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66.78,,,,,,,fee schedule,9.57,111.06,
Bed cradle,E0280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,97.25,,,,,,,fee schedule,9.57,111.06,
Bed cradle,E0280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10.46,,,,,,,fee schedule,9.57,111.06,
Bed cradle,E0280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,72.95,,,,,,,fee schedule,9.57,111.06,
Hosp bed fx ht w/o rail w/o,E0291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1526.29,,,,,,,fee schedule,126.56,1657.87,
Hosp bed fx ht w/o rail w/o,E0291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,145.36,,,,,,,fee schedule,126.56,1657.87,
Hosp bed fx ht w/o rail w/o,E0291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1657.87,,,,,,,fee schedule,126.56,1657.87,
Hosp bed fx ht w/o rail w/o,E0291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,157.89,,,,,,,fee schedule,126.56,1657.87,
Hosp bed fx ht w/o rail w/o,E0291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1328.93,,,,,,,fee schedule,126.56,1657.87,
Hosp bed fx ht w/o rail w/o,E0291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,126.56,,,,,,,fee schedule,126.56,1657.87,
Hosp bed fx ht w/o rail w/o,E0291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1451.73,,,,,,,fee schedule,126.56,1657.87,
Hosp bed fx ht w/o rail w/o,E0291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,138.26,,,,,,,fee schedule,126.56,1657.87,
Hosp bed var ht no sr no mat,E0293,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2352.79,,,,,,,fee schedule,195.1,2555.62,
Hosp bed var ht no sr no mat,E0293,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,224.08,,,,,,,fee schedule,195.1,2555.62,
Hosp bed var ht no sr no mat,E0293,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2555.62,,,,,,,fee schedule,195.1,2555.62,
Hosp bed var ht no sr no mat,E0293,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,243.39,,,,,,,fee schedule,195.1,2555.62,
Hosp bed var ht no sr no mat,E0293,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2048.55,,,,,,,fee schedule,195.1,2555.62,
Hosp bed var ht no sr no mat,E0293,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,195.1,,,,,,,fee schedule,195.1,2555.62,
Hosp bed var ht no sr no mat,E0293,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2237.86,,,,,,,fee schedule,195.1,2555.62,
Hosp bed var ht no sr no mat,E0293,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,213.13,,,,,,,fee schedule,195.1,2555.62,
Hosp bed semi-elect w/o matt,E0295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3593.69,,,,,,,fee schedule,298,3903.49,
Hosp bed semi-elect w/o matt,E0295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,342.26,,,,,,,fee schedule,298,3903.49,
Hosp bed semi-elect w/o matt,E0295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3903.49,,,,,,,fee schedule,298,3903.49,
Hosp bed semi-elect w/o matt,E0295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,371.76,,,,,,,fee schedule,298,3903.49,
Hosp bed semi-elect w/o matt,E0295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3128.99,,,,,,,fee schedule,298,3903.49,
Hosp bed semi-elect w/o matt,E0295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,298,,,,,,,fee schedule,298,3903.49,
Hosp bed semi-elect w/o matt,E0295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3418.14,,,,,,,fee schedule,298,3903.49,
Hosp bed semi-elect w/o matt,E0295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,325.54,,,,,,,fee schedule,298,3903.49,
Hosp bed total elect w/o mat,E0297,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4651.89,,,,,,,fee schedule,385.75,5052.92,
Hosp bed total elect w/o mat,E0297,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,443.04,,,,,,,fee schedule,385.75,5052.92,
Hosp bed total elect w/o mat,E0297,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5052.92,,,,,,,fee schedule,385.75,5052.92,
Hosp bed total elect w/o mat,E0297,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,481.23,,,,,,,fee schedule,385.75,5052.92,
Hosp bed total elect w/o mat,E0297,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4050.35,,,,,,,fee schedule,385.75,5052.92,
Hosp bed total elect w/o mat,E0297,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,385.75,,,,,,,fee schedule,385.75,5052.92,
Hosp bed total elect w/o mat,E0297,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4424.64,,,,,,,fee schedule,385.75,5052.92,
Hosp bed total elect w/o mat,E0297,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,421.4,,,,,,,fee schedule,385.75,5052.92,
Enclosed ped crib hosp grade,E0300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8939.95,,,,,,,fee schedule,778.38,9710.63,
Enclosed ped crib hosp grade,E0300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,893.98,,,,,,,fee schedule,778.38,9710.63,
Enclosed ped crib hosp grade,E0300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6704.95,,,,,,,fee schedule,778.38,9710.63,
Enclosed ped crib hosp grade,E0300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9710.63,,,,,,,fee schedule,778.38,9710.63,
Enclosed ped crib hosp grade,E0300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,971.04,,,,,,,fee schedule,778.38,9710.63,
Enclosed ped crib hosp grade,E0300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7282.96,,,,,,,fee schedule,778.38,9710.63,
Enclosed ped crib hosp grade,E0300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7783.92,,,,,,,fee schedule,778.38,9710.63,
Enclosed ped crib hosp grade,E0300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,778.38,,,,,,,fee schedule,778.38,9710.63,
Enclosed ped crib hosp grade,E0300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5837.93,,,,,,,fee schedule,778.38,9710.63,
Enclosed ped crib hosp grade,E0300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8503.22,,,,,,,fee schedule,778.38,9710.63,
Enclosed ped crib hosp grade,E0300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,850.31,,,,,,,fee schedule,778.38,9710.63,
Enclosed ped crib hosp grade,E0300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6377.41,,,,,,,fee schedule,778.38,9710.63,
"HD hosp bed, 350-600 lbs",E0301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7761.83,,,,,,,fee schedule,643.63,8430.95,
"HD hosp bed, 350-600 lbs",E0301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,739.22,,,,,,,fee schedule,643.63,8430.95,
"HD hosp bed, 350-600 lbs",E0301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8430.95,,,,,,,fee schedule,643.63,8430.95,
"HD hosp bed, 350-600 lbs",E0301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,802.95,,,,,,,fee schedule,643.63,8430.95,
"HD hosp bed, 350-600 lbs",E0301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6758.14,,,,,,,fee schedule,643.63,8430.95,
"HD hosp bed, 350-600 lbs",E0301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,643.63,,,,,,,fee schedule,643.63,8430.95,
"HD hosp bed, 350-600 lbs",E0301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7382.66,,,,,,,fee schedule,643.63,8430.95,
"HD hosp bed, 350-600 lbs",E0301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,703.11,,,,,,,fee schedule,643.63,8430.95,
Ex hd hosp bed > 600 lbs,E0302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23658.54,,,,,,,fee schedule,1961.83,25698.07,
Ex hd hosp bed > 600 lbs,E0302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2253.2,,,,,,,fee schedule,1961.83,25698.07,
Ex hd hosp bed > 600 lbs,E0302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,25698.07,,,,,,,fee schedule,1961.83,25698.07,
Ex hd hosp bed > 600 lbs,E0302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2447.44,,,,,,,fee schedule,1961.83,25698.07,
Ex hd hosp bed > 600 lbs,E0302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20599.24,,,,,,,fee schedule,1961.83,25698.07,
Ex hd hosp bed > 600 lbs,E0302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1961.83,,,,,,,fee schedule,1961.83,25698.07,
Ex hd hosp bed > 600 lbs,E0302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22502.8,,,,,,,fee schedule,1961.83,25698.07,
Ex hd hosp bed > 600 lbs,E0302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2143.13,,,,,,,fee schedule,1961.83,25698.07,
Bed safety enclosure,E0316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6298.77,,,,,,,fee schedule,522.31,6841.76,
Bed safety enclosure,E0316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,599.88,,,,,,,fee schedule,522.31,6841.76,
Bed safety enclosure,E0316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6841.76,,,,,,,fee schedule,522.31,6841.76,
Bed safety enclosure,E0316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,651.6,,,,,,,fee schedule,522.31,6841.76,
Bed safety enclosure,E0316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5484.27,,,,,,,fee schedule,522.31,6841.76,
Bed safety enclosure,E0316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,522.31,,,,,,,fee schedule,522.31,6841.76,
Bed safety enclosure,E0316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5991.07,,,,,,,fee schedule,522.31,6841.76,
Bed safety enclosure,E0316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,570.58,,,,,,,fee schedule,522.31,6841.76,
Urinal male jug-type,E0325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,36.96,,,,,,,fee schedule,4.09,40.14,
Urinal male jug-type,E0325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.7,,,,,,,fee schedule,4.09,40.14,
Urinal male jug-type,E0325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24.43,,,,,,,fee schedule,4.09,40.14,
Urinal male jug-type,E0325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,40.14,,,,,,,fee schedule,4.09,40.14,
Urinal male jug-type,E0325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.1,,,,,,,fee schedule,4.09,40.14,
Urinal male jug-type,E0325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26.54,,,,,,,fee schedule,4.09,40.14,
Urinal male jug-type,E0325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32.18,,,,,,,fee schedule,4.09,40.14,
Urinal male jug-type,E0325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.09,,,,,,,fee schedule,4.09,40.14,
Urinal male jug-type,E0325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21.27,,,,,,,fee schedule,4.09,40.14,
Urinal male jug-type,E0325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35.15,,,,,,,fee schedule,4.09,40.14,
Urinal male jug-type,E0325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.47,,,,,,,fee schedule,4.09,40.14,
Urinal male jug-type,E0325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23.24,,,,,,,fee schedule,4.09,40.14,
Urinal female jug-type,E0326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,32.64,,,,,,,fee schedule,3.21,35.46,
Urinal female jug-type,E0326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.69,,,,,,,fee schedule,3.21,35.46,
Urinal female jug-type,E0326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24.43,,,,,,,fee schedule,3.21,35.46,
Urinal female jug-type,E0326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,35.46,,,,,,,fee schedule,3.21,35.46,
Urinal female jug-type,E0326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.01,,,,,,,fee schedule,3.21,35.46,
Urinal female jug-type,E0326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26.54,,,,,,,fee schedule,3.21,35.46,
Urinal female jug-type,E0326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28.42,,,,,,,fee schedule,3.21,35.46,
Urinal female jug-type,E0326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.21,,,,,,,fee schedule,3.21,35.46,
Urinal female jug-type,E0326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21.27,,,,,,,fee schedule,3.21,35.46,
Urinal female jug-type,E0326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31.05,,,,,,,fee schedule,3.21,35.46,
Urinal female jug-type,E0326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.51,,,,,,,fee schedule,3.21,35.46,
Urinal female jug-type,E0326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23.24,,,,,,,fee schedule,3.21,35.46,
Nonpower mattress overlay,E0371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12992.55,,,,,,,fee schedule,1077.38,14112.59,
Nonpower mattress overlay,E0371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1237.38,,,,,,,fee schedule,1077.38,14112.59,
Nonpower mattress overlay,E0371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14112.59,,,,,,,fee schedule,1077.38,14112.59,
Nonpower mattress overlay,E0371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1344.05,,,,,,,fee schedule,1077.38,14112.59,
Nonpower mattress overlay,E0371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11312.47,,,,,,,fee schedule,1077.38,14112.59,
Nonpower mattress overlay,E0371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1077.38,,,,,,,fee schedule,1077.38,14112.59,
Nonpower mattress overlay,E0371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12357.85,,,,,,,fee schedule,1077.38,14112.59,
Nonpower mattress overlay,E0371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1176.94,,,,,,,fee schedule,1077.38,14112.59,
Powered air mattress overlay,E0372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15765.55,,,,,,,fee schedule,1307.32,17124.65,
Powered air mattress overlay,E0372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1501.48,,,,,,,fee schedule,1307.32,17124.65,
Powered air mattress overlay,E0372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17124.65,,,,,,,fee schedule,1307.32,17124.65,
Powered air mattress overlay,E0372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1630.92,,,,,,,fee schedule,1307.32,17124.65,
Powered air mattress overlay,E0372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13726.9,,,,,,,fee schedule,1307.32,17124.65,
Powered air mattress overlay,E0372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1307.32,,,,,,,fee schedule,1307.32,17124.65,
Powered air mattress overlay,E0372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14995.39,,,,,,,fee schedule,1307.32,17124.65,
Powered air mattress overlay,E0372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1428.13,,,,,,,fee schedule,1307.32,17124.65,
Nonpowered pressure mattress,E0373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18060.26,,,,,,,fee schedule,1497.61,19617.18,
Nonpowered pressure mattress,E0373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1720.02,,,,,,,fee schedule,1497.61,19617.18,
Nonpowered pressure mattress,E0373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19617.18,,,,,,,fee schedule,1497.61,19617.18,
Nonpowered pressure mattress,E0373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1868.3,,,,,,,fee schedule,1497.61,19617.18,
Nonpowered pressure mattress,E0373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15724.88,,,,,,,fee schedule,1497.61,19617.18,
Nonpowered pressure mattress,E0373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1497.61,,,,,,,fee schedule,1497.61,19617.18,
Nonpowered pressure mattress,E0373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17178.01,,,,,,,fee schedule,1497.61,19617.18,
Nonpowered pressure mattress,E0373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1636,,,,,,,fee schedule,1497.61,19617.18,
Stationary compressed gas 02,E0424,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,611.75,,,,,,,fee schedule,532.64,664.49,
Stationary compressed gas 02,E0424,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,664.49,,,,,,,fee schedule,532.64,664.49,
Stationary compressed gas 02,E0424,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,532.64,,,,,,,fee schedule,532.64,664.49,
Stationary compressed gas 02,E0424,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,581.86,,,,,,,fee schedule,532.64,664.49,
Portable gaseous 02,E0431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10.44,,,,,,,fee schedule,9.09,108.75,
Portable gaseous 02,E0431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,100.12,,,,,,,fee schedule,9.09,108.75,
Portable gaseous 02,E0431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11.34,,,,,,,fee schedule,9.09,108.75,
Portable gaseous 02,E0431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,108.75,,,,,,,fee schedule,9.09,108.75,
Portable gaseous 02,E0431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.09,,,,,,,fee schedule,9.09,108.75,
Portable gaseous 02,E0431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,87.17,,,,,,,fee schedule,9.09,108.75,
Portable gaseous 02,E0431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.93,,,,,,,fee schedule,9.09,108.75,
Portable gaseous 02,E0431,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,95.23,,,,,,,fee schedule,9.09,108.75,
Portable liquid 02,E0434,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,100.12,,,,,,,fee schedule,87.17,108.75,
Portable liquid 02,E0434,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,108.75,,,,,,,fee schedule,87.17,108.75,
Portable liquid 02,E0434,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,87.17,,,,,,,fee schedule,87.17,108.75,
Portable liquid 02,E0434,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,95.23,,,,,,,fee schedule,87.17,108.75,
Stationary liquid 02,E0439,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,611.75,,,,,,,fee schedule,532.64,664.49,
Stationary liquid 02,E0439,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,664.49,,,,,,,fee schedule,532.64,664.49,
Stationary liquid 02,E0439,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,532.64,,,,,,,fee schedule,532.64,664.49,
Stationary liquid 02,E0439,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,581.86,,,,,,,fee schedule,532.64,664.49,
"Stationary o2 contents, gas",E0441,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,269.53,,,,,,,fee schedule,234.67,292.76,
"Stationary o2 contents, gas",E0441,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,292.76,,,,,,,fee schedule,234.67,292.76,
"Stationary o2 contents, gas",E0441,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,234.67,,,,,,,fee schedule,234.67,292.76,
"Stationary o2 contents, gas",E0441,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,256.36,,,,,,,fee schedule,234.67,292.76,
"Stationary o2 contents, liq",E0442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,269.53,,,,,,,fee schedule,234.67,292.76,
"Stationary o2 contents, liq",E0442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,292.76,,,,,,,fee schedule,234.67,292.76,
"Stationary o2 contents, liq",E0442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,234.67,,,,,,,fee schedule,234.67,292.76,
"Stationary o2 contents, liq",E0442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,256.36,,,,,,,fee schedule,234.67,292.76,
"Portable 02 contents, gas",E0443,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,269.53,,,,,,,fee schedule,234.67,292.76,
"Portable 02 contents, gas",E0443,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,292.76,,,,,,,fee schedule,234.67,292.76,
"Portable 02 contents, gas",E0443,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,234.67,,,,,,,fee schedule,234.67,292.76,
"Portable 02 contents, gas",E0443,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,256.36,,,,,,,fee schedule,234.67,292.76,
"Portable 02 contents, liquid",E0444,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,269.53,,,,,,,fee schedule,234.67,292.76,
"Portable 02 contents, liquid",E0444,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,292.76,,,,,,,fee schedule,234.67,292.76,
"Portable 02 contents, liquid",E0444,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,234.67,,,,,,,fee schedule,234.67,292.76,
"Portable 02 contents, liquid",E0444,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,256.36,,,,,,,fee schedule,234.67,292.76,
"Port o2 cont, liq over 4 lpm",E0447,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,242.63,,,,,,,fee schedule,211.25,263.54,
"Port o2 cont, liq over 4 lpm",E0447,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,263.54,,,,,,,fee schedule,211.25,263.54,
"Port o2 cont, liq over 4 lpm",E0447,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,211.25,,,,,,,fee schedule,211.25,263.54,
"Port o2 cont, liq over 4 lpm",E0447,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,230.77,,,,,,,fee schedule,211.25,263.54,
Chest shell,E0457,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2245.44,,,,,,,fee schedule,195.5,2439.01,
Chest shell,E0457,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,224.53,,,,,,,fee schedule,195.5,2439.01,
Chest shell,E0457,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1683.94,,,,,,,fee schedule,195.5,2439.01,
Chest shell,E0457,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2439.01,,,,,,,fee schedule,195.5,2439.01,
Chest shell,E0457,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,243.89,,,,,,,fee schedule,195.5,2439.01,
Chest shell,E0457,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1829.1,,,,,,,fee schedule,195.5,2439.01,
Chest shell,E0457,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1955.08,,,,,,,fee schedule,195.5,2439.01,
Chest shell,E0457,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,195.5,,,,,,,fee schedule,195.5,2439.01,
Chest shell,E0457,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1466.19,,,,,,,fee schedule,195.5,2439.01,
Chest shell,E0457,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2135.74,,,,,,,fee schedule,195.5,2439.01,
Chest shell,E0457,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,213.56,,,,,,,fee schedule,195.5,2439.01,
Chest shell,E0457,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1601.68,,,,,,,fee schedule,195.5,2439.01,
Chest wrap,E0459,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1659.65,,,,,,,fee schedule,137.62,1802.72,
Chest wrap,E0459,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,158.06,,,,,,,fee schedule,137.62,1802.72,
Chest wrap,E0459,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1802.72,,,,,,,fee schedule,137.62,1802.72,
Chest wrap,E0459,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,171.69,,,,,,,fee schedule,137.62,1802.72,
Chest wrap,E0459,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1445.04,,,,,,,fee schedule,137.62,1802.72,
Chest wrap,E0459,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,137.62,,,,,,,fee schedule,137.62,1802.72,
Chest wrap,E0459,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1578.57,,,,,,,fee schedule,137.62,1802.72,
Chest wrap,E0459,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,150.34,,,,,,,fee schedule,137.62,1802.72,
Rocking bed w/ or w/o side r,E0462,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11180.16,,,,,,,fee schedule,927.09,12143.97,
Rocking bed w/ or w/o side r,E0462,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1064.78,,,,,,,fee schedule,927.09,12143.97,
Rocking bed w/ or w/o side r,E0462,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12143.97,,,,,,,fee schedule,927.09,12143.97,
Rocking bed w/ or w/o side r,E0462,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1156.57,,,,,,,fee schedule,927.09,12143.97,
Rocking bed w/ or w/o side r,E0462,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9734.45,,,,,,,fee schedule,927.09,12143.97,
Rocking bed w/ or w/o side r,E0462,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,927.09,,,,,,,fee schedule,927.09,12143.97,
Rocking bed w/ or w/o side r,E0462,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10634,,,,,,,fee schedule,927.09,12143.97,
Rocking bed w/ or w/o side r,E0462,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1012.76,,,,,,,fee schedule,927.09,12143.97,
RAD w/o backup non-inv intfc,E0470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8157.57,,,,,,,fee schedule,676.45,8860.81,
RAD w/o backup non-inv intfc,E0470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,776.91,,,,,,,fee schedule,676.45,8860.81,
RAD w/o backup non-inv intfc,E0470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8860.81,,,,,,,fee schedule,676.45,8860.81,
RAD w/o backup non-inv intfc,E0470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,843.89,,,,,,,fee schedule,676.45,8860.81,
RAD w/o backup non-inv intfc,E0470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7102.71,,,,,,,fee schedule,676.45,8860.81,
RAD w/o backup non-inv intfc,E0470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,676.45,,,,,,,fee schedule,676.45,8860.81,
RAD w/o backup non-inv intfc,E0470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7759.07,,,,,,,fee schedule,676.45,8860.81,
RAD w/o backup non-inv intfc,E0470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,738.96,,,,,,,fee schedule,676.45,8860.81,
RAD w/backup non inv intrfc,E0471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18050.38,,,,,,,fee schedule,1496.79,19606.44,
RAD w/backup non inv intrfc,E0471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1719.09,,,,,,,fee schedule,1496.79,19606.44,
RAD w/backup non inv intrfc,E0471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19606.44,,,,,,,fee schedule,1496.79,19606.44,
RAD w/backup non inv intrfc,E0471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1867.28,,,,,,,fee schedule,1496.79,19606.44,
RAD w/backup non inv intrfc,E0471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15716.28,,,,,,,fee schedule,1496.79,19606.44,
RAD w/backup non inv intrfc,E0471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1496.79,,,,,,,fee schedule,1496.79,19606.44,
RAD w/backup non inv intrfc,E0471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17168.61,,,,,,,fee schedule,1496.79,19606.44,
RAD w/backup non inv intrfc,E0471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1635.11,,,,,,,fee schedule,1496.79,19606.44,
RAD w backup invasive intrfc,E0472,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18050.38,,,,,,,fee schedule,1496.79,19606.44,
RAD w backup invasive intrfc,E0472,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1719.09,,,,,,,fee schedule,1496.79,19606.44,
RAD w backup invasive intrfc,E0472,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19606.44,,,,,,,fee schedule,1496.79,19606.44,
RAD w backup invasive intrfc,E0472,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1867.28,,,,,,,fee schedule,1496.79,19606.44,
RAD w backup invasive intrfc,E0472,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15716.28,,,,,,,fee schedule,1496.79,19606.44,
RAD w backup invasive intrfc,E0472,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1496.79,,,,,,,fee schedule,1496.79,19606.44,
RAD w backup invasive intrfc,E0472,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17168.61,,,,,,,fee schedule,1496.79,19606.44,
RAD w backup invasive intrfc,E0472,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1635.11,,,,,,,fee schedule,1496.79,19606.44,
Percussor elect/pneum home m,E0480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1685.96,,,,,,,fee schedule,139.8,1831.3,
Percussor elect/pneum home m,E0480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,160.57,,,,,,,fee schedule,139.8,1831.3,
Percussor elect/pneum home m,E0480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1831.3,,,,,,,fee schedule,139.8,1831.3,
Percussor elect/pneum home m,E0480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,174.41,,,,,,,fee schedule,139.8,1831.3,
Percussor elect/pneum home m,E0480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1467.94,,,,,,,fee schedule,139.8,1831.3,
Percussor elect/pneum home m,E0480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,139.8,,,,,,,fee schedule,139.8,1831.3,
Percussor elect/pneum home m,E0480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1603.6,,,,,,,fee schedule,139.8,1831.3,
Percussor elect/pneum home m,E0480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,152.72,,,,,,,fee schedule,139.8,1831.3,
Cough stimulating device,E0482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14584.58,,,,,,,fee schedule,1209.39,15841.87,
Cough stimulating device,E0482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1389.01,,,,,,,fee schedule,1209.39,15841.87,
Cough stimulating device,E0482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15841.87,,,,,,,fee schedule,1209.39,15841.87,
Cough stimulating device,E0482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1508.75,,,,,,,fee schedule,1209.39,15841.87,
Cough stimulating device,E0482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12698.64,,,,,,,fee schedule,1209.39,15841.87,
Cough stimulating device,E0482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1209.39,,,,,,,fee schedule,1209.39,15841.87,
Cough stimulating device,E0482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13872.11,,,,,,,fee schedule,1209.39,15841.87,
Cough stimulating device,E0482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1321.15,,,,,,,fee schedule,1209.39,15841.87,
Chest compression gen system,E0483,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,40789.25,,,,,,,fee schedule,3382.36,44305.57,
Chest compression gen system,E0483,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3884.69,,,,,,,fee schedule,3382.36,44305.57,
Chest compression gen system,E0483,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,44305.57,,,,,,,fee schedule,3382.36,44305.57,
Chest compression gen system,E0483,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4219.58,,,,,,,fee schedule,3382.36,44305.57,
Chest compression gen system,E0483,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35514.78,,,,,,,fee schedule,3382.36,44305.57,
Chest compression gen system,E0483,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3382.36,,,,,,,fee schedule,3382.36,44305.57,
Chest compression gen system,E0483,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38796.68,,,,,,,fee schedule,3382.36,44305.57,
Chest compression gen system,E0483,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3694.92,,,,,,,fee schedule,3382.36,44305.57,
Non-elec oscillatory pep dvc,E0484,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,134.92,,,,,,,fee schedule,11.73,146.55,
Non-elec oscillatory pep dvc,E0484,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13.47,,,,,,,fee schedule,11.73,146.55,
Non-elec oscillatory pep dvc,E0484,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,101.23,,,,,,,fee schedule,11.73,146.55,
Non-elec oscillatory pep dvc,E0484,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,146.55,,,,,,,fee schedule,11.73,146.55,
Non-elec oscillatory pep dvc,E0484,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14.63,,,,,,,fee schedule,11.73,146.55,
Non-elec oscillatory pep dvc,E0484,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,109.96,,,,,,,fee schedule,11.73,146.55,
Non-elec oscillatory pep dvc,E0484,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,117.47,,,,,,,fee schedule,11.73,146.55,
Non-elec oscillatory pep dvc,E0484,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11.73,,,,,,,fee schedule,11.73,146.55,
Non-elec oscillatory pep dvc,E0484,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,88.14,,,,,,,fee schedule,11.73,146.55,
Non-elec oscillatory pep dvc,E0484,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,128.33,,,,,,,fee schedule,11.73,146.55,
Non-elec oscillatory pep dvc,E0484,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12.81,,,,,,,fee schedule,11.73,146.55,
Non-elec oscillatory pep dvc,E0484,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,96.29,,,,,,,fee schedule,11.73,146.55,
Ippb all types,E0500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,401.1,,,,,,,fee schedule,349.24,435.68,
Ippb all types,E0500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,435.68,,,,,,,fee schedule,349.24,435.68,
Ippb all types,E0500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,349.24,,,,,,,fee schedule,349.24,435.68,
Ippb all types,E0500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,381.51,,,,,,,fee schedule,349.24,435.68,
Humidif extens supple w ippb,E0550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1634.8,,,,,,,fee schedule,135.56,1775.73,
Humidif extens supple w ippb,E0550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,155.7,,,,,,,fee schedule,135.56,1775.73,
Humidif extens supple w ippb,E0550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1775.73,,,,,,,fee schedule,135.56,1775.73,
Humidif extens supple w ippb,E0550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,169.12,,,,,,,fee schedule,135.56,1775.73,
Humidif extens supple w ippb,E0550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1423.4,,,,,,,fee schedule,135.56,1775.73,
Humidif extens supple w ippb,E0550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,135.56,,,,,,,fee schedule,135.56,1775.73,
Humidif extens supple w ippb,E0550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1554.94,,,,,,,fee schedule,135.56,1775.73,
Humidif extens supple w ippb,E0550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,148.09,,,,,,,fee schedule,135.56,1775.73,
Humidifier supplemental w/ i,E0560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,540.2,,,,,,,fee schedule,51.12,586.77,
Humidifier supplemental w/ i,E0560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,58.71,,,,,,,fee schedule,51.12,586.77,
Humidifier supplemental w/ i,E0560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,405.14,,,,,,,fee schedule,51.12,586.77,
Humidifier supplemental w/ i,E0560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,586.77,,,,,,,fee schedule,51.12,586.77,
Humidifier supplemental w/ i,E0560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,63.77,,,,,,,fee schedule,51.12,586.77,
Humidifier supplemental w/ i,E0560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,440.07,,,,,,,fee schedule,51.12,586.77,
Humidifier supplemental w/ i,E0560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,470.35,,,,,,,fee schedule,51.12,586.77,
Humidifier supplemental w/ i,E0560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.12,,,,,,,fee schedule,51.12,586.77,
Humidifier supplemental w/ i,E0560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,352.75,,,,,,,fee schedule,51.12,586.77,
Humidifier supplemental w/ i,E0560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,513.81,,,,,,,fee schedule,51.12,586.77,
Humidifier supplemental w/ i,E0560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55.84,,,,,,,fee schedule,51.12,586.77,
Humidifier supplemental w/ i,E0560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,385.35,,,,,,,fee schedule,51.12,586.77,
Humidifier nonheated w PAP,E0561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,337,,,,,,,fee schedule,29.3,366.06,
Humidifier nonheated w PAP,E0561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33.65,,,,,,,fee schedule,29.3,366.06,
Humidifier nonheated w PAP,E0561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,252.72,,,,,,,fee schedule,29.3,366.06,
Humidifier nonheated w PAP,E0561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,366.06,,,,,,,fee schedule,29.3,366.06,
Humidifier nonheated w PAP,E0561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,36.55,,,,,,,fee schedule,29.3,366.06,
Humidifier nonheated w PAP,E0561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,274.5,,,,,,,fee schedule,29.3,366.06,
Humidifier nonheated w PAP,E0561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,293.43,,,,,,,fee schedule,29.3,366.06,
Humidifier nonheated w PAP,E0561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29.3,,,,,,,fee schedule,29.3,366.06,
Humidifier nonheated w PAP,E0561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,220.04,,,,,,,fee schedule,29.3,366.06,
Humidifier nonheated w PAP,E0561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,320.54,,,,,,,fee schedule,29.3,366.06,
Humidifier nonheated w PAP,E0561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32.01,,,,,,,fee schedule,29.3,366.06,
Humidifier nonheated w PAP,E0561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,240.37,,,,,,,fee schedule,29.3,366.06,
Humidifier heated used w PAP,E0562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,948.65,,,,,,,fee schedule,82.57,1030.43,
Humidifier heated used w PAP,E0562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,94.83,,,,,,,fee schedule,82.57,1030.43,
Humidifier heated used w PAP,E0562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,711.49,,,,,,,fee schedule,82.57,1030.43,
Humidifier heated used w PAP,E0562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1030.43,,,,,,,fee schedule,82.57,1030.43,
Humidifier heated used w PAP,E0562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,103.01,,,,,,,fee schedule,82.57,1030.43,
Humidifier heated used w PAP,E0562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,772.82,,,,,,,fee schedule,82.57,1030.43,
Humidifier heated used w PAP,E0562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,825.98,,,,,,,fee schedule,82.57,1030.43,
Humidifier heated used w PAP,E0562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,82.57,,,,,,,fee schedule,82.57,1030.43,
Humidifier heated used w PAP,E0562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,619.48,,,,,,,fee schedule,82.57,1030.43,
Humidifier heated used w PAP,E0562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,902.31,,,,,,,fee schedule,82.57,1030.43,
Humidifier heated used w PAP,E0562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,90.2,,,,,,,fee schedule,82.57,1030.43,
Humidifier heated used w PAP,E0562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,676.73,,,,,,,fee schedule,82.57,1030.43,
Compressor air power source,E0565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2340.75,,,,,,,fee schedule,194.1,2542.54,
Compressor air power source,E0565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,222.93,,,,,,,fee schedule,194.1,2542.54,
Compressor air power source,E0565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2542.54,,,,,,,fee schedule,194.1,2542.54,
Compressor air power source,E0565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,242.15,,,,,,,fee schedule,194.1,2542.54,
Compressor air power source,E0565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2038.07,,,,,,,fee schedule,194.1,2542.54,
Compressor air power source,E0565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,194.1,,,,,,,fee schedule,194.1,2542.54,
Compressor air power source,E0565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2226.41,,,,,,,fee schedule,194.1,2542.54,
Compressor air power source,E0565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,212.04,,,,,,,fee schedule,194.1,2542.54,
Nebulizer with compression,E0570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,618.26,,,,,,,fee schedule,51.27,671.55,
Nebulizer with compression,E0570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,58.88,,,,,,,fee schedule,51.27,671.55,
Nebulizer with compression,E0570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,671.55,,,,,,,fee schedule,51.27,671.55,
Nebulizer with compression,E0570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,63.96,,,,,,,fee schedule,51.27,671.55,
Nebulizer with compression,E0570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,538.31,,,,,,,fee schedule,51.27,671.55,
Nebulizer with compression,E0570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.27,,,,,,,fee schedule,51.27,671.55,
Nebulizer with compression,E0570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,588.05,,,,,,,fee schedule,51.27,671.55,
Nebulizer with compression,E0570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56.01,,,,,,,fee schedule,51.27,671.55,
Aerosol compressor adjust pr,E0572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1298.25,,,,,,,fee schedule,107.66,1410.17,
Aerosol compressor adjust pr,E0572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,123.64,,,,,,,fee schedule,107.66,1410.17,
Aerosol compressor adjust pr,E0572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1410.17,,,,,,,fee schedule,107.66,1410.17,
Aerosol compressor adjust pr,E0572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,134.3,,,,,,,fee schedule,107.66,1410.17,
Aerosol compressor adjust pr,E0572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1130.37,,,,,,,fee schedule,107.66,1410.17,
Aerosol compressor adjust pr,E0572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,107.66,,,,,,,fee schedule,107.66,1410.17,
Aerosol compressor adjust pr,E0572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1234.83,,,,,,,fee schedule,107.66,1410.17,
Aerosol compressor adjust pr,E0572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,117.6,,,,,,,fee schedule,107.66,1410.17,
Ultrasonic generator w svneb,E0574,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1373.56,,,,,,,fee schedule,113.9,1491.97,
Ultrasonic generator w svneb,E0574,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,130.81,,,,,,,fee schedule,113.9,1491.97,
Ultrasonic generator w svneb,E0574,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1491.97,,,,,,,fee schedule,113.9,1491.97,
Ultrasonic generator w svneb,E0574,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,142.09,,,,,,,fee schedule,113.9,1491.97,
Ultrasonic generator w svneb,E0574,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1195.94,,,,,,,fee schedule,113.9,1491.97,
Ultrasonic generator w svneb,E0574,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,113.9,,,,,,,fee schedule,113.9,1491.97,
Ultrasonic generator w svneb,E0574,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1306.46,,,,,,,fee schedule,113.9,1491.97,
Ultrasonic generator w svneb,E0574,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,124.42,,,,,,,fee schedule,113.9,1491.97,
Nebulizer ultrasonic,E0575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,358.61,,,,,,,fee schedule,312.24,389.53,
Nebulizer ultrasonic,E0575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,389.53,,,,,,,fee schedule,312.24,389.53,
Nebulizer ultrasonic,E0575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,312.24,,,,,,,fee schedule,312.24,389.53,
Nebulizer ultrasonic,E0575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,341.1,,,,,,,fee schedule,312.24,389.53,
Nebulizer for use w/ regulat,E0580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,422.16,,,,,,,fee schedule,36.75,458.55,
Nebulizer for use w/ regulat,E0580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42.21,,,,,,,fee schedule,36.75,458.55,
Nebulizer for use w/ regulat,E0580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,316.58,,,,,,,fee schedule,36.75,458.55,
Nebulizer for use w/ regulat,E0580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,458.55,,,,,,,fee schedule,36.75,458.55,
Nebulizer for use w/ regulat,E0580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45.85,,,,,,,fee schedule,36.75,458.55,
Nebulizer for use w/ regulat,E0580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,343.87,,,,,,,fee schedule,36.75,458.55,
Nebulizer for use w/ regulat,E0580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,367.57,,,,,,,fee schedule,36.75,458.55,
Nebulizer for use w/ regulat,E0580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36.75,,,,,,,fee schedule,36.75,458.55,
Nebulizer for use w/ regulat,E0580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,275.64,,,,,,,fee schedule,36.75,458.55,
Nebulizer for use w/ regulat,E0580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,401.54,,,,,,,fee schedule,36.75,458.55,
Nebulizer for use w/ regulat,E0580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40.15,,,,,,,fee schedule,36.75,458.55,
Nebulizer for use w/ regulat,E0580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,301.11,,,,,,,fee schedule,36.75,458.55,
Nebulizer w/ compressor & he,E0585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1164.16,,,,,,,fee schedule,96.54,1264.52,
Nebulizer w/ compressor & he,E0585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,110.87,,,,,,,fee schedule,96.54,1264.52,
Nebulizer w/ compressor & he,E0585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1264.52,,,,,,,fee schedule,96.54,1264.52,
Nebulizer w/ compressor & he,E0585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,120.43,,,,,,,fee schedule,96.54,1264.52,
Nebulizer w/ compressor & he,E0585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1013.63,,,,,,,fee schedule,96.54,1264.52,
Nebulizer w/ compressor & he,E0585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,96.54,,,,,,,fee schedule,96.54,1264.52,
Nebulizer w/ compressor & he,E0585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1107.29,,,,,,,fee schedule,96.54,1264.52,
Nebulizer w/ compressor & he,E0585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,105.46,,,,,,,fee schedule,96.54,1264.52,
Suction pump portab hom modl,E0600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1675.72,,,,,,,fee schedule,138.96,1820.18,
Suction pump portab hom modl,E0600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,159.59,,,,,,,fee schedule,138.96,1820.18,
Suction pump portab hom modl,E0600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1820.18,,,,,,,fee schedule,138.96,1820.18,
Suction pump portab hom modl,E0600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,173.35,,,,,,,fee schedule,138.96,1820.18,
Suction pump portab hom modl,E0600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1459.04,,,,,,,fee schedule,138.96,1820.18,
Suction pump portab hom modl,E0600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,138.96,,,,,,,fee schedule,138.96,1820.18,
Suction pump portab hom modl,E0600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1593.86,,,,,,,fee schedule,138.96,1820.18,
Suction pump portab hom modl,E0600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,151.8,,,,,,,fee schedule,138.96,1820.18,
Cont airway pressure device,E0601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3694.19,,,,,,,fee schedule,306.33,4012.66,
Cont airway pressure device,E0601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,351.83,,,,,,,fee schedule,306.33,4012.66,
Cont airway pressure device,E0601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4012.66,,,,,,,fee schedule,306.33,4012.66,
Cont airway pressure device,E0601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,382.16,,,,,,,fee schedule,306.33,4012.66,
Cont airway pressure device,E0601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3216.5,,,,,,,fee schedule,306.33,4012.66,
Cont airway pressure device,E0601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,306.33,,,,,,,fee schedule,306.33,4012.66,
Cont airway pressure device,E0601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3513.73,,,,,,,fee schedule,306.33,4012.66,
Cont airway pressure device,E0601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,334.64,,,,,,,fee schedule,306.33,4012.66,
Manual breast pump,E0602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,107.88,,,,,,,fee schedule,9.42,117.18,
Manual breast pump,E0602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10.82,,,,,,,fee schedule,9.42,117.18,
Manual breast pump,E0602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,80.91,,,,,,,fee schedule,9.42,117.18,
Manual breast pump,E0602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,117.18,,,,,,,fee schedule,9.42,117.18,
Manual breast pump,E0602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11.76,,,,,,,fee schedule,9.42,117.18,
Manual breast pump,E0602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,87.89,,,,,,,fee schedule,9.42,117.18,
Manual breast pump,E0602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,93.93,,,,,,,fee schedule,9.42,117.18,
Manual breast pump,E0602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.42,,,,,,,fee schedule,9.42,117.18,
Manual breast pump,E0602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,70.45,,,,,,,fee schedule,9.42,117.18,
Manual breast pump,E0602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,102.61,,,,,,,fee schedule,9.42,117.18,
Manual breast pump,E0602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10.29,,,,,,,fee schedule,9.42,117.18,
Manual breast pump,E0602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,76.96,,,,,,,fee schedule,9.42,117.18,
Vaporizer room type,E0605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,82.09,,,,,,,fee schedule,8.3,89.17,
Vaporizer room type,E0605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.54,,,,,,,fee schedule,8.3,89.17,
Vaporizer room type,E0605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,67.62,,,,,,,fee schedule,8.3,89.17,
Vaporizer room type,E0605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,89.17,,,,,,,fee schedule,8.3,89.17,
Vaporizer room type,E0605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10.36,,,,,,,fee schedule,8.3,89.17,
Vaporizer room type,E0605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,73.45,,,,,,,fee schedule,8.3,89.17,
Vaporizer room type,E0605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,71.48,,,,,,,fee schedule,8.3,89.17,
Vaporizer room type,E0605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.3,,,,,,,fee schedule,8.3,89.17,
Vaporizer room type,E0605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,58.87,,,,,,,fee schedule,8.3,89.17,
Vaporizer room type,E0605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,78.08,,,,,,,fee schedule,8.3,89.17,
Vaporizer room type,E0605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.07,,,,,,,fee schedule,8.3,89.17,
Vaporizer room type,E0605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,64.31,,,,,,,fee schedule,8.3,89.17,
Drainage board postural,E0606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,876.96,,,,,,,fee schedule,72.72,952.56,
Drainage board postural,E0606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83.52,,,,,,,fee schedule,72.72,952.56,
Drainage board postural,E0606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,952.56,,,,,,,fee schedule,72.72,952.56,
Drainage board postural,E0606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,90.72,,,,,,,fee schedule,72.72,952.56,
Drainage board postural,E0606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,763.56,,,,,,,fee schedule,72.72,952.56,
Drainage board postural,E0606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,72.72,,,,,,,fee schedule,72.72,952.56,
Drainage board postural,E0606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,834.12,,,,,,,fee schedule,72.72,952.56,
Drainage board postural,E0606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,79.44,,,,,,,fee schedule,72.72,952.56,
Blood glucose monitor home,E0607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,244.16,,,,,,,fee schedule,21.24,265.2,
Blood glucose monitor home,E0607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24.39,,,,,,,fee schedule,21.24,265.2,
Blood glucose monitor home,E0607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,183.08,,,,,,,fee schedule,21.24,265.2,
Blood glucose monitor home,E0607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,265.2,,,,,,,fee schedule,21.24,265.2,
Blood glucose monitor home,E0607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26.5,,,,,,,fee schedule,21.24,265.2,
Blood glucose monitor home,E0607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,198.87,,,,,,,fee schedule,21.24,265.2,
Blood glucose monitor home,E0607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,212.58,,,,,,,fee schedule,21.24,265.2,
Blood glucose monitor home,E0607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21.24,,,,,,,fee schedule,21.24,265.2,
Blood glucose monitor home,E0607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,159.41,,,,,,,fee schedule,21.24,265.2,
Blood glucose monitor home,E0607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,232.23,,,,,,,fee schedule,21.24,265.2,
Blood glucose monitor home,E0607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23.2,,,,,,,fee schedule,21.24,265.2,
Blood glucose monitor home,E0607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,174.14,,,,,,,fee schedule,21.24,265.2,
Pacemaker monitr audible/vis,E0610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,764.07,,,,,,,fee schedule,67.84,829.94,
Pacemaker monitr audible/vis,E0610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,77.92,,,,,,,fee schedule,67.84,829.94,
Pacemaker monitr audible/vis,E0610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,573.12,,,,,,,fee schedule,67.84,829.94,
Pacemaker monitr audible/vis,E0610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,829.94,,,,,,,fee schedule,67.84,829.94,
Pacemaker monitr audible/vis,E0610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,84.63,,,,,,,fee schedule,67.84,829.94,
Pacemaker monitr audible/vis,E0610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,622.53,,,,,,,fee schedule,67.84,829.94,
Pacemaker monitr audible/vis,E0610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,665.27,,,,,,,fee schedule,67.84,829.94,
Pacemaker monitr audible/vis,E0610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,67.84,,,,,,,fee schedule,67.84,829.94,
Pacemaker monitr audible/vis,E0610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,499.01,,,,,,,fee schedule,67.84,829.94,
Pacemaker monitr audible/vis,E0610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,726.74,,,,,,,fee schedule,67.84,829.94,
Pacemaker monitr audible/vis,E0610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,74.11,,,,,,,fee schedule,67.84,829.94,
Pacemaker monitr audible/vis,E0610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,545.12,,,,,,,fee schedule,67.84,829.94,
Pacemaker monitr digital/vis,E0615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1487.18,,,,,,,fee schedule,158.23,1615.38,
Pacemaker monitr digital/vis,E0615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,181.73,,,,,,,fee schedule,158.23,1615.38,
Pacemaker monitr digital/vis,E0615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1115.41,,,,,,,fee schedule,158.23,1615.38,
Pacemaker monitr digital/vis,E0615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1615.38,,,,,,,fee schedule,158.23,1615.38,
Pacemaker monitr digital/vis,E0615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,197.39,,,,,,,fee schedule,158.23,1615.38,
Pacemaker monitr digital/vis,E0615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1211.57,,,,,,,fee schedule,158.23,1615.38,
Pacemaker monitr digital/vis,E0615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1294.87,,,,,,,fee schedule,158.23,1615.38,
Pacemaker monitr digital/vis,E0615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,158.23,,,,,,,fee schedule,158.23,1615.38,
Pacemaker monitr digital/vis,E0615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,971.18,,,,,,,fee schedule,158.23,1615.38,
Pacemaker monitr digital/vis,E0615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1414.53,,,,,,,fee schedule,158.23,1615.38,
Pacemaker monitr digital/vis,E0615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,172.85,,,,,,,fee schedule,158.23,1615.38,
Pacemaker monitr digital/vis,E0615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1060.92,,,,,,,fee schedule,158.23,1615.38,
Automatic ext defibrillator,E0617,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11665.41,,,,,,,fee schedule,967.33,12671.05,
Automatic ext defibrillator,E0617,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1110.99,,,,,,,fee schedule,967.33,12671.05,
Automatic ext defibrillator,E0617,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12671.05,,,,,,,fee schedule,967.33,12671.05,
Automatic ext defibrillator,E0617,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1206.77,,,,,,,fee schedule,967.33,12671.05,
Automatic ext defibrillator,E0617,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10156.95,,,,,,,fee schedule,967.33,12671.05,
Automatic ext defibrillator,E0617,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,967.33,,,,,,,fee schedule,967.33,12671.05,
Automatic ext defibrillator,E0617,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11095.55,,,,,,,fee schedule,967.33,12671.05,
Automatic ext defibrillator,E0617,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1056.72,,,,,,,fee schedule,967.33,12671.05,
Apnea monitor,E0618,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10756.26,,,,,,,fee schedule,891.94,11683.53,
Apnea monitor,E0618,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1024.41,,,,,,,fee schedule,891.94,11683.53,
Apnea monitor,E0618,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11683.53,,,,,,,fee schedule,891.94,11683.53,
Apnea monitor,E0618,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1112.72,,,,,,,fee schedule,891.94,11683.53,
Apnea monitor,E0618,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9365.37,,,,,,,fee schedule,891.94,11683.53,
Apnea monitor,E0618,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,891.94,,,,,,,fee schedule,891.94,11683.53,
Apnea monitor,E0618,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10230.81,,,,,,,fee schedule,891.94,11683.53,
Apnea monitor,E0618,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,974.36,,,,,,,fee schedule,891.94,11683.53,
Cap bld skin piercing laser,E0620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3195.02,,,,,,,fee schedule,278.15,3470.46,
Cap bld skin piercing laser,E0620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,319.46,,,,,,,fee schedule,278.15,3470.46,
Cap bld skin piercing laser,E0620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2396.26,,,,,,,fee schedule,278.15,3470.46,
Cap bld skin piercing laser,E0620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3470.46,,,,,,,fee schedule,278.15,3470.46,
Cap bld skin piercing laser,E0620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,347,,,,,,,fee schedule,278.15,3470.46,
Cap bld skin piercing laser,E0620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2602.83,,,,,,,fee schedule,278.15,3470.46,
Cap bld skin piercing laser,E0620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2781.87,,,,,,,fee schedule,278.15,3470.46,
Cap bld skin piercing laser,E0620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,278.15,,,,,,,fee schedule,278.15,3470.46,
Cap bld skin piercing laser,E0620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2086.4,,,,,,,fee schedule,278.15,3470.46,
Cap bld skin piercing laser,E0620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3038.94,,,,,,,fee schedule,278.15,3470.46,
Cap bld skin piercing laser,E0620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,303.86,,,,,,,fee schedule,278.15,3470.46,
Cap bld skin piercing laser,E0620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2279.2,,,,,,,fee schedule,278.15,3470.46,
Patient lift sling or seat,E0621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,350.75,,,,,,,fee schedule,29.42,380.99,
Patient lift sling or seat,E0621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33.79,,,,,,,fee schedule,29.42,380.99,
Patient lift sling or seat,E0621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,264.41,,,,,,,fee schedule,29.42,380.99,
Patient lift sling or seat,E0621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,380.99,,,,,,,fee schedule,29.42,380.99,
Patient lift sling or seat,E0621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,36.7,,,,,,,fee schedule,29.42,380.99,
Patient lift sling or seat,E0621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,287.2,,,,,,,fee schedule,29.42,380.99,
Patient lift sling or seat,E0621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,305.39,,,,,,,fee schedule,29.42,380.99,
Patient lift sling or seat,E0621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29.42,,,,,,,fee schedule,29.42,380.99,
Patient lift sling or seat,E0621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,230.22,,,,,,,fee schedule,29.42,380.99,
Patient lift sling or seat,E0621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,333.61,,,,,,,fee schedule,29.42,380.99,
Patient lift sling or seat,E0621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32.14,,,,,,,fee schedule,29.42,380.99,
Patient lift sling or seat,E0621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,251.49,,,,,,,fee schedule,29.42,380.99,
"Seat lift mech, electric any",E0627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1208.43,,,,,,,fee schedule,105.23,1312.61,
"Seat lift mech, electric any",E0627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,120.86,,,,,,,fee schedule,105.23,1312.61,
"Seat lift mech, electric any",E0627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,906.23,,,,,,,fee schedule,105.23,1312.61,
"Seat lift mech, electric any",E0627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1312.61,,,,,,,fee schedule,105.23,1312.61,
"Seat lift mech, electric any",E0627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,131.28,,,,,,,fee schedule,105.23,1312.61,
"Seat lift mech, electric any",E0627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,984.35,,,,,,,fee schedule,105.23,1312.61,
"Seat lift mech, electric any",E0627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1052.17,,,,,,,fee schedule,105.23,1312.61,
"Seat lift mech, electric any",E0627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,105.23,,,,,,,fee schedule,105.23,1312.61,
"Seat lift mech, electric any",E0627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,789.04,,,,,,,fee schedule,105.23,1312.61,
"Seat lift mech, electric any",E0627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1149.4,,,,,,,fee schedule,105.23,1312.61,
"Seat lift mech, electric any",E0627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,114.96,,,,,,,fee schedule,105.23,1312.61,
"Seat lift mech, electric any",E0627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,861.96,,,,,,,fee schedule,105.23,1312.61,
"Seat lift mech, non-electric",E0629,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1208.43,,,,,,,fee schedule,105.23,1312.61,
"Seat lift mech, non-electric",E0629,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,120.86,,,,,,,fee schedule,105.23,1312.61,
"Seat lift mech, non-electric",E0629,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,906.23,,,,,,,fee schedule,105.23,1312.61,
"Seat lift mech, non-electric",E0629,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1312.61,,,,,,,fee schedule,105.23,1312.61,
"Seat lift mech, non-electric",E0629,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,131.28,,,,,,,fee schedule,105.23,1312.61,
"Seat lift mech, non-electric",E0629,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,984.35,,,,,,,fee schedule,105.23,1312.61,
"Seat lift mech, non-electric",E0629,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1052.17,,,,,,,fee schedule,105.23,1312.61,
"Seat lift mech, non-electric",E0629,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,105.23,,,,,,,fee schedule,105.23,1312.61,
"Seat lift mech, non-electric",E0629,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,789.04,,,,,,,fee schedule,105.23,1312.61,
"Seat lift mech, non-electric",E0629,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1149.4,,,,,,,fee schedule,105.23,1312.61,
"Seat lift mech, non-electric",E0629,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,114.96,,,,,,,fee schedule,105.23,1312.61,
"Seat lift mech, non-electric",E0629,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,861.96,,,,,,,fee schedule,105.23,1312.61,
Patient lift hydraulic,E0630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3568.15,,,,,,,fee schedule,295.88,3875.75,
Patient lift hydraulic,E0630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,339.82,,,,,,,fee schedule,295.88,3875.75,
Patient lift hydraulic,E0630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3875.75,,,,,,,fee schedule,295.88,3875.75,
Patient lift hydraulic,E0630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,369.12,,,,,,,fee schedule,295.88,3875.75,
Patient lift hydraulic,E0630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3106.75,,,,,,,fee schedule,295.88,3875.75,
Patient lift hydraulic,E0630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,295.88,,,,,,,fee schedule,295.88,3875.75,
Patient lift hydraulic,E0630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3393.84,,,,,,,fee schedule,295.88,3875.75,
Patient lift hydraulic,E0630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,323.22,,,,,,,fee schedule,295.88,3875.75,
Patient lift electric,E0635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4694.66,,,,,,,fee schedule,389.29,5099.37,
Patient lift electric,E0635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,447.11,,,,,,,fee schedule,389.29,5099.37,
Patient lift electric,E0635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5099.37,,,,,,,fee schedule,389.29,5099.37,
Patient lift electric,E0635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,485.65,,,,,,,fee schedule,389.29,5099.37,
Patient lift electric,E0635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4087.59,,,,,,,fee schedule,389.29,5099.37,
Patient lift electric,E0635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,389.29,,,,,,,fee schedule,389.29,5099.37,
Patient lift electric,E0635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4465.32,,,,,,,fee schedule,389.29,5099.37,
Patient lift electric,E0635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,425.27,,,,,,,fee schedule,389.29,5099.37,
PT support & positioning sys,E0636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,40460.39,,,,,,,fee schedule,3355.09,43948.36,
PT support & positioning sys,E0636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3853.37,,,,,,,fee schedule,3355.09,43948.36,
PT support & positioning sys,E0636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,43948.36,,,,,,,fee schedule,3355.09,43948.36,
PT support & positioning sys,E0636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4185.56,,,,,,,fee schedule,3355.09,43948.36,
PT support & positioning sys,E0636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35228.45,,,,,,,fee schedule,3355.09,43948.36,
PT support & positioning sys,E0636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3355.09,,,,,,,fee schedule,3355.09,43948.36,
PT support & positioning sys,E0636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38483.88,,,,,,,fee schedule,3355.09,43948.36,
PT support & positioning sys,E0636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3665.13,,,,,,,fee schedule,3355.09,43948.36,
Pneuma compresor non-segment,E0650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2631.68,,,,,,,fee schedule,282.73,2858.55,
Pneuma compresor non-segment,E0650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,324.72,,,,,,,fee schedule,282.73,2858.55,
Pneuma compresor non-segment,E0650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1973.75,,,,,,,fee schedule,282.73,2858.55,
Pneuma compresor non-segment,E0650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2858.55,,,,,,,fee schedule,282.73,2858.55,
Pneuma compresor non-segment,E0650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,352.71,,,,,,,fee schedule,282.73,2858.55,
Pneuma compresor non-segment,E0650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2143.9,,,,,,,fee schedule,282.73,2858.55,
Pneuma compresor non-segment,E0650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2291.38,,,,,,,fee schedule,282.73,2858.55,
Pneuma compresor non-segment,E0650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,282.73,,,,,,,fee schedule,282.73,2858.55,
Pneuma compresor non-segment,E0650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1718.53,,,,,,,fee schedule,282.73,2858.55,
Pneuma compresor non-segment,E0650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2503.12,,,,,,,fee schedule,282.73,2858.55,
Pneuma compresor non-segment,E0650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,308.86,,,,,,,fee schedule,282.73,2858.55,
Pneuma compresor non-segment,E0650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1877.33,,,,,,,fee schedule,282.73,2858.55,
Pneum compressor segmental,E0651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3355.9,,,,,,,fee schedule,293.21,3645.21,
Pneum compressor segmental,E0651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,336.76,,,,,,,fee schedule,293.21,3645.21,
Pneum compressor segmental,E0651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2516.94,,,,,,,fee schedule,293.21,3645.21,
Pneum compressor segmental,E0651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3645.21,,,,,,,fee schedule,293.21,3645.21,
Pneum compressor segmental,E0651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,365.79,,,,,,,fee schedule,293.21,3645.21,
Pneum compressor segmental,E0651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2733.92,,,,,,,fee schedule,293.21,3645.21,
Pneum compressor segmental,E0651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2921.95,,,,,,,fee schedule,293.21,3645.21,
Pneum compressor segmental,E0651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,293.21,,,,,,,fee schedule,293.21,3645.21,
Pneum compressor segmental,E0651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2191.48,,,,,,,fee schedule,293.21,3645.21,
Pneum compressor segmental,E0651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3191.97,,,,,,,fee schedule,293.21,3645.21,
Pneum compressor segmental,E0651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,320.31,,,,,,,fee schedule,293.21,3645.21,
Pneum compressor segmental,E0651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2393.99,,,,,,,fee schedule,293.21,3645.21,
Pneum compres w/cal pressure,E0652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19371.49,,,,,,,fee schedule,1666.95,21041.45,
Pneum compres w/cal pressure,E0652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1914.52,,,,,,,fee schedule,1666.95,21041.45,
Pneum compres w/cal pressure,E0652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14515.64,,,,,,,fee schedule,1666.95,21041.45,
Pneum compres w/cal pressure,E0652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21041.45,,,,,,,fee schedule,1666.95,21041.45,
Pneum compres w/cal pressure,E0652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2079.57,,,,,,,fee schedule,1666.95,21041.45,
Pneum compres w/cal pressure,E0652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15766.98,,,,,,,fee schedule,1666.95,21041.45,
Pneum compres w/cal pressure,E0652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16866.56,,,,,,,fee schedule,1666.95,21041.45,
Pneum compres w/cal pressure,E0652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1666.95,,,,,,,fee schedule,1666.95,21041.45,
Pneum compres w/cal pressure,E0652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12638.61,,,,,,,fee schedule,1666.95,21041.45,
Pneum compres w/cal pressure,E0652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18425.18,,,,,,,fee schedule,1666.95,21041.45,
Pneum compres w/cal pressure,E0652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1821,,,,,,,fee schedule,1666.95,21041.45,
Pneum compres w/cal pressure,E0652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13806.54,,,,,,,fee schedule,1666.95,21041.45,
Pneumatic appliance half arm,E0655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,394.35,,,,,,,fee schedule,40.33,428.35,
Pneumatic appliance half arm,E0655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46.32,,,,,,,fee schedule,40.33,428.35,
Pneumatic appliance half arm,E0655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,296.15,,,,,,,fee schedule,40.33,428.35,
Pneumatic appliance half arm,E0655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,428.35,,,,,,,fee schedule,40.33,428.35,
Pneumatic appliance half arm,E0655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,50.31,,,,,,,fee schedule,40.33,428.35,
Pneumatic appliance half arm,E0655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,321.68,,,,,,,fee schedule,40.33,428.35,
Pneumatic appliance half arm,E0655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,343.36,,,,,,,fee schedule,40.33,428.35,
Pneumatic appliance half arm,E0655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40.33,,,,,,,fee schedule,40.33,428.35,
Pneumatic appliance half arm,E0655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,257.85,,,,,,,fee schedule,40.33,428.35,
Pneumatic appliance half arm,E0655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,375.09,,,,,,,fee schedule,40.33,428.35,
Pneumatic appliance half arm,E0655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,44.06,,,,,,,fee schedule,40.33,428.35,
Pneumatic appliance half arm,E0655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,281.68,,,,,,,fee schedule,40.33,428.35,
Pneumatic appliance full leg,E0660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,578.06,,,,,,,fee schedule,50.39,627.9,
Pneumatic appliance full leg,E0660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,57.87,,,,,,,fee schedule,50.39,627.9,
Pneumatic appliance full leg,E0660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,433.54,,,,,,,fee schedule,50.39,627.9,
Pneumatic appliance full leg,E0660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,627.9,,,,,,,fee schedule,50.39,627.9,
Pneumatic appliance full leg,E0660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,62.86,,,,,,,fee schedule,50.39,627.9,
Pneumatic appliance full leg,E0660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,470.91,,,,,,,fee schedule,50.39,627.9,
Pneumatic appliance full leg,E0660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,503.31,,,,,,,fee schedule,50.39,627.9,
Pneumatic appliance full leg,E0660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,50.39,,,,,,,fee schedule,50.39,627.9,
Pneumatic appliance full leg,E0660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,377.48,,,,,,,fee schedule,50.39,627.9,
Pneumatic appliance full leg,E0660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,549.82,,,,,,,fee schedule,50.39,627.9,
Pneumatic appliance full leg,E0660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55.05,,,,,,,fee schedule,50.39,627.9,
Pneumatic appliance full leg,E0660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,412.36,,,,,,,fee schedule,50.39,627.9,
Pneumatic appliance full arm,E0665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,500.56,,,,,,,fee schedule,44.75,543.72,
Pneumatic appliance full arm,E0665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,51.4,,,,,,,fee schedule,44.75,543.72,
Pneumatic appliance full arm,E0665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,375.91,,,,,,,fee schedule,44.75,543.72,
Pneumatic appliance full arm,E0665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,543.72,,,,,,,fee schedule,44.75,543.72,
Pneumatic appliance full arm,E0665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55.83,,,,,,,fee schedule,44.75,543.72,
Pneumatic appliance full arm,E0665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,408.32,,,,,,,fee schedule,44.75,543.72,
Pneumatic appliance full arm,E0665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,435.84,,,,,,,fee schedule,44.75,543.72,
Pneumatic appliance full arm,E0665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,44.75,,,,,,,fee schedule,44.75,543.72,
Pneumatic appliance full arm,E0665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,327.3,,,,,,,fee schedule,44.75,543.72,
Pneumatic appliance full arm,E0665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,476.11,,,,,,,fee schedule,44.75,543.72,
Pneumatic appliance full arm,E0665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48.89,,,,,,,fee schedule,44.75,543.72,
Pneumatic appliance full arm,E0665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,357.55,,,,,,,fee schedule,44.75,543.72,
Pneumatic appliance half leg,E0666,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,504.53,,,,,,,fee schedule,45.27,548.02,
Pneumatic appliance half leg,E0666,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,51.99,,,,,,,fee schedule,45.27,548.02,
Pneumatic appliance half leg,E0666,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,378.52,,,,,,,fee schedule,45.27,548.02,
Pneumatic appliance half leg,E0666,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,548.02,,,,,,,fee schedule,45.27,548.02,
Pneumatic appliance half leg,E0666,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,56.47,,,,,,,fee schedule,45.27,548.02,
Pneumatic appliance half leg,E0666,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,411.15,,,,,,,fee schedule,45.27,548.02,
Pneumatic appliance half leg,E0666,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,439.29,,,,,,,fee schedule,45.27,548.02,
Pneumatic appliance half leg,E0666,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,45.27,,,,,,,fee schedule,45.27,548.02,
Pneumatic appliance half leg,E0666,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,329.57,,,,,,,fee schedule,45.27,548.02,
Pneumatic appliance half leg,E0666,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,479.88,,,,,,,fee schedule,45.27,548.02,
Pneumatic appliance half leg,E0666,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,49.45,,,,,,,fee schedule,45.27,548.02,
Pneumatic appliance half leg,E0666,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,360.03,,,,,,,fee schedule,45.27,548.02,
Seg pneumatic appl full leg,E0667,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1183.06,,,,,,,fee schedule,107.96,1285.05,
Seg pneumatic appl full leg,E0667,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,123.99,,,,,,,fee schedule,107.96,1285.05,
Seg pneumatic appl full leg,E0667,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,887.3,,,,,,,fee schedule,107.96,1285.05,
Seg pneumatic appl full leg,E0667,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1285.05,,,,,,,fee schedule,107.96,1285.05,
Seg pneumatic appl full leg,E0667,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,134.68,,,,,,,fee schedule,107.96,1285.05,
Seg pneumatic appl full leg,E0667,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,963.79,,,,,,,fee schedule,107.96,1285.05,
Seg pneumatic appl full leg,E0667,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1030.08,,,,,,,fee schedule,107.96,1285.05,
Seg pneumatic appl full leg,E0667,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,107.96,,,,,,,fee schedule,107.96,1285.05,
Seg pneumatic appl full leg,E0667,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,772.56,,,,,,,fee schedule,107.96,1285.05,
Seg pneumatic appl full leg,E0667,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1125.27,,,,,,,fee schedule,107.96,1285.05,
Seg pneumatic appl full leg,E0667,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,117.94,,,,,,,fee schedule,107.96,1285.05,
Seg pneumatic appl full leg,E0667,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,843.95,,,,,,,fee schedule,107.96,1285.05,
Seg pneumatic appl full arm,E0668,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1614.62,,,,,,,fee schedule,138.74,1753.81,
Seg pneumatic appl full arm,E0668,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,159.35,,,,,,,fee schedule,138.74,1753.81,
Seg pneumatic appl full arm,E0668,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1211.01,,,,,,,fee schedule,138.74,1753.81,
Seg pneumatic appl full arm,E0668,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1753.81,,,,,,,fee schedule,138.74,1753.81,
Seg pneumatic appl full arm,E0668,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,173.09,,,,,,,fee schedule,138.74,1753.81,
Seg pneumatic appl full arm,E0668,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1315.4,,,,,,,fee schedule,138.74,1753.81,
Seg pneumatic appl full arm,E0668,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1405.83,,,,,,,fee schedule,138.74,1753.81,
Seg pneumatic appl full arm,E0668,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,138.74,,,,,,,fee schedule,138.74,1753.81,
Seg pneumatic appl full arm,E0668,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1054.41,,,,,,,fee schedule,138.74,1753.81,
Seg pneumatic appl full arm,E0668,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1535.74,,,,,,,fee schedule,138.74,1753.81,
Seg pneumatic appl full arm,E0668,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,151.56,,,,,,,fee schedule,138.74,1753.81,
Seg pneumatic appl full arm,E0668,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1151.85,,,,,,,fee schedule,138.74,1753.81,
Seg pneumatic appli half leg,E0669,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,669.83,,,,,,,fee schedule,58.36,727.57,
Seg pneumatic appli half leg,E0669,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,67.02,,,,,,,fee schedule,58.36,727.57,
Seg pneumatic appli half leg,E0669,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,502.48,,,,,,,fee schedule,58.36,727.57,
Seg pneumatic appli half leg,E0669,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,727.57,,,,,,,fee schedule,58.36,727.57,
Seg pneumatic appli half leg,E0669,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,72.8,,,,,,,fee schedule,58.36,727.57,
Seg pneumatic appli half leg,E0669,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,545.79,,,,,,,fee schedule,58.36,727.57,
Seg pneumatic appli half leg,E0669,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,583.21,,,,,,,fee schedule,58.36,727.57,
Seg pneumatic appli half leg,E0669,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,58.36,,,,,,,fee schedule,58.36,727.57,
Seg pneumatic appli half leg,E0669,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,437.5,,,,,,,fee schedule,58.36,727.57,
Seg pneumatic appli half leg,E0669,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,637.11,,,,,,,fee schedule,58.36,727.57,
Seg pneumatic appli half leg,E0669,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,63.75,,,,,,,fee schedule,58.36,727.57,
Seg pneumatic appli half leg,E0669,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,477.93,,,,,,,fee schedule,58.36,727.57,
Pressure pneum appl full leg,E0671,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1517.7,,,,,,,fee schedule,132.17,1648.53,
Pressure pneum appl full leg,E0671,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,151.8,,,,,,,fee schedule,132.17,1648.53,
Pressure pneum appl full leg,E0671,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1138.24,,,,,,,fee schedule,132.17,1648.53,
Pressure pneum appl full leg,E0671,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1648.53,,,,,,,fee schedule,132.17,1648.53,
Pressure pneum appl full leg,E0671,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,164.88,,,,,,,fee schedule,132.17,1648.53,
Pressure pneum appl full leg,E0671,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1236.36,,,,,,,fee schedule,132.17,1648.53,
Pressure pneum appl full leg,E0671,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1321.44,,,,,,,fee schedule,132.17,1648.53,
Pressure pneum appl full leg,E0671,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,132.17,,,,,,,fee schedule,132.17,1648.53,
Pressure pneum appl full leg,E0671,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,991.05,,,,,,,fee schedule,132.17,1648.53,
Pressure pneum appl full leg,E0671,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1443.56,,,,,,,fee schedule,132.17,1648.53,
Pressure pneum appl full leg,E0671,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,144.38,,,,,,,fee schedule,132.17,1648.53,
Pressure pneum appl full leg,E0671,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1082.63,,,,,,,fee schedule,132.17,1648.53,
Pressure pneum appl full arm,E0672,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1179.27,,,,,,,fee schedule,102.69,1280.93,
Pressure pneum appl full arm,E0672,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,117.94,,,,,,,fee schedule,102.69,1280.93,
Pressure pneum appl full arm,E0672,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,884.48,,,,,,,fee schedule,102.69,1280.93,
Pressure pneum appl full arm,E0672,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1280.93,,,,,,,fee schedule,102.69,1280.93,
Pressure pneum appl full arm,E0672,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,128.1,,,,,,,fee schedule,102.69,1280.93,
Pressure pneum appl full arm,E0672,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,960.72,,,,,,,fee schedule,102.69,1280.93,
Pressure pneum appl full arm,E0672,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1026.78,,,,,,,fee schedule,102.69,1280.93,
Pressure pneum appl full arm,E0672,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,102.69,,,,,,,fee schedule,102.69,1280.93,
Pressure pneum appl full arm,E0672,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,770.1,,,,,,,fee schedule,102.69,1280.93,
Pressure pneum appl full arm,E0672,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1121.66,,,,,,,fee schedule,102.69,1280.93,
Pressure pneum appl full arm,E0672,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,112.18,,,,,,,fee schedule,102.69,1280.93,
Pressure pneum appl full arm,E0672,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,841.27,,,,,,,fee schedule,102.69,1280.93,
Pressure pneum appl half leg,E0673,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,979.9,,,,,,,fee schedule,85.32,1064.37,
Pressure pneum appl half leg,E0673,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,98,,,,,,,fee schedule,85.32,1064.37,
Pressure pneum appl half leg,E0673,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,735.01,,,,,,,fee schedule,85.32,1064.37,
Pressure pneum appl half leg,E0673,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1064.37,,,,,,,fee schedule,85.32,1064.37,
Pressure pneum appl half leg,E0673,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,106.44,,,,,,,fee schedule,85.32,1064.37,
Pressure pneum appl half leg,E0673,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,798.37,,,,,,,fee schedule,85.32,1064.37,
Pressure pneum appl half leg,E0673,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,853.19,,,,,,,fee schedule,85.32,1064.37,
Pressure pneum appl half leg,E0673,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,85.32,,,,,,,fee schedule,85.32,1064.37,
Pressure pneum appl half leg,E0673,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,639.97,,,,,,,fee schedule,85.32,1064.37,
Pressure pneum appl half leg,E0673,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,932.03,,,,,,,fee schedule,85.32,1064.37,
Pressure pneum appl half leg,E0673,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,93.21,,,,,,,fee schedule,85.32,1064.37,
Pressure pneum appl half leg,E0673,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,699.11,,,,,,,fee schedule,85.32,1064.37,
Pneumatic compression device,E0675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14754.12,,,,,,,fee schedule,1223.45,16026.03,
Pneumatic compression device,E0675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1405.15,,,,,,,fee schedule,1223.45,16026.03,
Pneumatic compression device,E0675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16026.03,,,,,,,fee schedule,1223.45,16026.03,
Pneumatic compression device,E0675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1526.29,,,,,,,fee schedule,1223.45,16026.03,
Pneumatic compression device,E0675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12846.26,,,,,,,fee schedule,1223.45,16026.03,
Pneumatic compression device,E0675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1223.45,,,,,,,fee schedule,1223.45,16026.03,
Pneumatic compression device,E0675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14033.37,,,,,,,fee schedule,1223.45,16026.03,
Pneumatic compression device,E0675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1336.51,,,,,,,fee schedule,1223.45,16026.03,
Uvl pnl 2 sq ft or less,E0691,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3283.45,,,,,,,fee schedule,285.88,3566.51,
Uvl pnl 2 sq ft or less,E0691,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,328.34,,,,,,,fee schedule,285.88,3566.51,
Uvl pnl 2 sq ft or less,E0691,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2462.59,,,,,,,fee schedule,285.88,3566.51,
Uvl pnl 2 sq ft or less,E0691,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3566.51,,,,,,,fee schedule,285.88,3566.51,
Uvl pnl 2 sq ft or less,E0691,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,356.64,,,,,,,fee schedule,285.88,3566.51,
Uvl pnl 2 sq ft or less,E0691,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2674.88,,,,,,,fee schedule,285.88,3566.51,
Uvl pnl 2 sq ft or less,E0691,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2858.87,,,,,,,fee schedule,285.88,3566.51,
Uvl pnl 2 sq ft or less,E0691,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,285.88,,,,,,,fee schedule,285.88,3566.51,
Uvl pnl 2 sq ft or less,E0691,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2144.15,,,,,,,fee schedule,285.88,3566.51,
Uvl pnl 2 sq ft or less,E0691,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3123.05,,,,,,,fee schedule,285.88,3566.51,
Uvl pnl 2 sq ft or less,E0691,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,312.3,,,,,,,fee schedule,285.88,3566.51,
Uvl pnl 2 sq ft or less,E0691,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2342.29,,,,,,,fee schedule,285.88,3566.51,
Uvl sys panel 4 ft,E0692,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4123.07,,,,,,,fee schedule,358.96,4478.51,
Uvl sys panel 4 ft,E0692,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,412.28,,,,,,,fee schedule,358.96,4478.51,
Uvl sys panel 4 ft,E0692,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3092.33,,,,,,,fee schedule,358.96,4478.51,
Uvl sys panel 4 ft,E0692,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4478.51,,,,,,,fee schedule,358.96,4478.51,
Uvl sys panel 4 ft,E0692,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,447.82,,,,,,,fee schedule,358.96,4478.51,
Uvl sys panel 4 ft,E0692,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3358.91,,,,,,,fee schedule,358.96,4478.51,
Uvl sys panel 4 ft,E0692,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3589.91,,,,,,,fee schedule,358.96,4478.51,
Uvl sys panel 4 ft,E0692,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,358.96,,,,,,,fee schedule,358.96,4478.51,
Uvl sys panel 4 ft,E0692,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2692.46,,,,,,,fee schedule,358.96,4478.51,
Uvl sys panel 4 ft,E0692,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3921.65,,,,,,,fee schedule,358.96,4478.51,
Uvl sys panel 4 ft,E0692,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,392.14,,,,,,,fee schedule,358.96,4478.51,
Uvl sys panel 4 ft,E0692,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2941.27,,,,,,,fee schedule,358.96,4478.51,
Uvl sys panel 6 ft,E0693,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5082.64,,,,,,,fee schedule,442.56,5520.8,
Uvl sys panel 6 ft,E0693,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,508.29,,,,,,,fee schedule,442.56,5520.8,
Uvl sys panel 6 ft,E0693,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3811.99,,,,,,,fee schedule,442.56,5520.8,
Uvl sys panel 6 ft,E0693,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5520.8,,,,,,,fee schedule,442.56,5520.8,
Uvl sys panel 6 ft,E0693,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,552.11,,,,,,,fee schedule,442.56,5520.8,
Uvl sys panel 6 ft,E0693,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4140.61,,,,,,,fee schedule,442.56,5520.8,
Uvl sys panel 6 ft,E0693,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4425.41,,,,,,,fee schedule,442.56,5520.8,
Uvl sys panel 6 ft,E0693,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,442.56,,,,,,,fee schedule,442.56,5520.8,
Uvl sys panel 6 ft,E0693,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3319.06,,,,,,,fee schedule,442.56,5520.8,
Uvl sys panel 6 ft,E0693,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4834.35,,,,,,,fee schedule,442.56,5520.8,
Uvl sys panel 6 ft,E0693,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,483.46,,,,,,,fee schedule,442.56,5520.8,
Uvl sys panel 6 ft,E0693,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3625.77,,,,,,,fee schedule,442.56,5520.8,
Uvl md cabinet sys 6 ft,E0694,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16177.51,,,,,,,fee schedule,1408.56,17572.12,
Uvl md cabinet sys 6 ft,E0694,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1617.75,,,,,,,fee schedule,1408.56,17572.12,
Uvl md cabinet sys 6 ft,E0694,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12133.23,,,,,,,fee schedule,1408.56,17572.12,
Uvl md cabinet sys 6 ft,E0694,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17572.12,,,,,,,fee schedule,1408.56,17572.12,
Uvl md cabinet sys 6 ft,E0694,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1757.21,,,,,,,fee schedule,1408.56,17572.12,
Uvl md cabinet sys 6 ft,E0694,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13179.2,,,,,,,fee schedule,1408.56,17572.12,
Uvl md cabinet sys 6 ft,E0694,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14085.59,,,,,,,fee schedule,1408.56,17572.12,
Uvl md cabinet sys 6 ft,E0694,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1408.56,,,,,,,fee schedule,1408.56,17572.12,
Uvl md cabinet sys 6 ft,E0694,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10564.28,,,,,,,fee schedule,1408.56,17572.12,
Uvl md cabinet sys 6 ft,E0694,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15387.23,,,,,,,fee schedule,1408.56,17572.12,
Uvl md cabinet sys 6 ft,E0694,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1538.72,,,,,,,fee schedule,1408.56,17572.12,
Uvl md cabinet sys 6 ft,E0694,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11540.51,,,,,,,fee schedule,1408.56,17572.12,
Transfer device,E0705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,201.42,,,,,,,fee schedule,17.85,218.79,
Transfer device,E0705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20.5,,,,,,,fee schedule,17.85,218.79,
Transfer device,E0705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,147.48,,,,,,,fee schedule,17.85,218.79,
Transfer device,E0705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,218.79,,,,,,,fee schedule,17.85,218.79,
Transfer device,E0705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22.26,,,,,,,fee schedule,17.85,218.79,
Transfer device,E0705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,160.2,,,,,,,fee schedule,17.85,218.79,
Transfer device,E0705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,175.38,,,,,,,fee schedule,17.85,218.79,
Transfer device,E0705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17.85,,,,,,,fee schedule,17.85,218.79,
Transfer device,E0705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,128.41,,,,,,,fee schedule,17.85,218.79,
Transfer device,E0705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,191.58,,,,,,,fee schedule,17.85,218.79,
Transfer device,E0705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19.5,,,,,,,fee schedule,17.85,218.79,
Transfer device,E0705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,140.28,,,,,,,fee schedule,17.85,218.79,
Tens two lead,E0720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1343.14,,,,,,,fee schedule,1169.46,1458.93,
Tens two lead,E0720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1458.93,,,,,,,fee schedule,1169.46,1458.93,
Tens two lead,E0720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1169.46,,,,,,,fee schedule,1169.46,1458.93,
Tens two lead,E0720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1277.53,,,,,,,fee schedule,1169.46,1458.93,
Tens four lead,E0730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1354.03,,,,,,,fee schedule,1178.94,1470.76,
Tens four lead,E0730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1470.76,,,,,,,fee schedule,1178.94,1470.76,
Tens four lead,E0730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1178.94,,,,,,,fee schedule,1178.94,1470.76,
Tens four lead,E0730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1287.89,,,,,,,fee schedule,1178.94,1470.76,
Conductive garment for tens/,E0731,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1303.33,,,,,,,fee schedule,1134.8,1415.69,
Conductive garment for tens/,E0731,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1415.69,,,,,,,fee schedule,1134.8,1415.69,
Conductive garment for tens/,E0731,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1134.8,,,,,,,fee schedule,1134.8,1415.69,
Conductive garment for tens/,E0731,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1239.66,,,,,,,fee schedule,1134.8,1415.69,
Non-implant pelv flr e-stim,E0740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1910.55,,,,,,,fee schedule,166.35,2075.26,
Non-implant pelv flr e-stim,E0740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,191.05,,,,,,,fee schedule,166.35,2075.26,
Non-implant pelv flr e-stim,E0740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1433.03,,,,,,,fee schedule,166.35,2075.26,
Non-implant pelv flr e-stim,E0740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2075.26,,,,,,,fee schedule,166.35,2075.26,
Non-implant pelv flr e-stim,E0740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,207.52,,,,,,,fee schedule,166.35,2075.26,
Non-implant pelv flr e-stim,E0740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1556.57,,,,,,,fee schedule,166.35,2075.26,
Non-implant pelv flr e-stim,E0740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1663.5,,,,,,,fee schedule,166.35,2075.26,
Non-implant pelv flr e-stim,E0740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,166.35,,,,,,,fee schedule,166.35,2075.26,
Non-implant pelv flr e-stim,E0740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1247.72,,,,,,,fee schedule,166.35,2075.26,
Non-implant pelv flr e-stim,E0740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1817.22,,,,,,,fee schedule,166.35,2075.26,
Non-implant pelv flr e-stim,E0740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,181.72,,,,,,,fee schedule,166.35,2075.26,
Non-implant pelv flr e-stim,E0740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1363.02,,,,,,,fee schedule,166.35,2075.26,
Neuromuscular stim for scoli,E0744,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3465.45,,,,,,,fee schedule,287.37,3764.2,
Neuromuscular stim for scoli,E0744,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,330.04,,,,,,,fee schedule,287.37,3764.2,
Neuromuscular stim for scoli,E0744,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3764.2,,,,,,,fee schedule,287.37,3764.2,
Neuromuscular stim for scoli,E0744,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,358.5,,,,,,,fee schedule,287.37,3764.2,
Neuromuscular stim for scoli,E0744,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3017.33,,,,,,,fee schedule,287.37,3764.2,
Neuromuscular stim for scoli,E0744,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,287.37,,,,,,,fee schedule,287.37,3764.2,
Neuromuscular stim for scoli,E0744,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3296.16,,,,,,,fee schedule,287.37,3764.2,
Neuromuscular stim for scoli,E0744,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,313.92,,,,,,,fee schedule,287.37,3764.2,
Neuromuscular stim for shock,E0745,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3166.21,,,,,,,fee schedule,262.55,3439.16,
Neuromuscular stim for shock,E0745,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,301.54,,,,,,,fee schedule,262.55,3439.16,
Neuromuscular stim for shock,E0745,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3439.16,,,,,,,fee schedule,262.55,3439.16,
Neuromuscular stim for shock,E0745,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,327.54,,,,,,,fee schedule,262.55,3439.16,
Neuromuscular stim for shock,E0745,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2756.78,,,,,,,fee schedule,262.55,3439.16,
Neuromuscular stim for shock,E0745,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,262.55,,,,,,,fee schedule,262.55,3439.16,
Neuromuscular stim for shock,E0745,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3011.54,,,,,,,fee schedule,262.55,3439.16,
Neuromuscular stim for shock,E0745,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,286.81,,,,,,,fee schedule,262.55,3439.16,
Trans elec jt stim dev sys,E0762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4017.8,,,,,,,fee schedule,349.84,4364.16,
Trans elec jt stim dev sys,E0762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,401.8,,,,,,,fee schedule,349.84,4364.16,
Trans elec jt stim dev sys,E0762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3013.26,,,,,,,fee schedule,349.84,4364.16,
Trans elec jt stim dev sys,E0762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4364.16,,,,,,,fee schedule,349.84,4364.16,
Trans elec jt stim dev sys,E0762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,436.44,,,,,,,fee schedule,349.84,4364.16,
Trans elec jt stim dev sys,E0762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3273.03,,,,,,,fee schedule,349.84,4364.16,
Trans elec jt stim dev sys,E0762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3498.26,,,,,,,fee schedule,349.84,4364.16,
Trans elec jt stim dev sys,E0762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,349.84,,,,,,,fee schedule,349.84,4364.16,
Trans elec jt stim dev sys,E0762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2623.62,,,,,,,fee schedule,349.84,4364.16,
Trans elec jt stim dev sys,E0762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3821.53,,,,,,,fee schedule,349.84,4364.16,
Trans elec jt stim dev sys,E0762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,382.17,,,,,,,fee schedule,349.84,4364.16,
Trans elec jt stim dev sys,E0762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2866.06,,,,,,,fee schedule,349.84,4364.16,
Nerve stimulator for tx n&v,E0765,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,307.42,,,,,,,fee schedule,26.82,333.93,
Nerve stimulator for tx n&v,E0765,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30.8,,,,,,,fee schedule,26.82,333.93,
Nerve stimulator for tx n&v,E0765,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,230.65,,,,,,,fee schedule,26.82,333.93,
Nerve stimulator for tx n&v,E0765,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,333.93,,,,,,,fee schedule,26.82,333.93,
Nerve stimulator for tx n&v,E0765,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33.45,,,,,,,fee schedule,26.82,333.93,
Nerve stimulator for tx n&v,E0765,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,250.54,,,,,,,fee schedule,26.82,333.93,
Nerve stimulator for tx n&v,E0765,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,267.67,,,,,,,fee schedule,26.82,333.93,
Nerve stimulator for tx n&v,E0765,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26.82,,,,,,,fee schedule,26.82,333.93,
Nerve stimulator for tx n&v,E0765,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,200.83,,,,,,,fee schedule,26.82,333.93,
Nerve stimulator for tx n&v,E0765,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,292.41,,,,,,,fee schedule,26.82,333.93,
Nerve stimulator for tx n&v,E0765,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29.29,,,,,,,fee schedule,26.82,333.93,
Nerve stimulator for tx n&v,E0765,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,219.39,,,,,,,fee schedule,26.82,333.93,
Iv pole,E0776,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,512.33,,,,,,,fee schedule,50.42,556.49,
Iv pole,E0776,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,57.91,,,,,,,fee schedule,50.42,556.49,
Iv pole,E0776,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,384.23,,,,,,,fee schedule,50.42,556.49,
Iv pole,E0776,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,556.49,,,,,,,fee schedule,50.42,556.49,
Iv pole,E0776,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,62.9,,,,,,,fee schedule,50.42,556.49,
Iv pole,E0776,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,417.35,,,,,,,fee schedule,50.42,556.49,
Iv pole,E0776,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,446.08,,,,,,,fee schedule,50.42,556.49,
Iv pole,E0776,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,50.42,,,,,,,fee schedule,50.42,556.49,
Iv pole,E0776,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,334.54,,,,,,,fee schedule,50.42,556.49,
Iv pole,E0776,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,487.3,,,,,,,fee schedule,50.42,556.49,
Iv pole,E0776,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55.08,,,,,,,fee schedule,50.42,556.49,
Iv pole,E0776,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,365.46,,,,,,,fee schedule,50.42,556.49,
Amb infusion pump mechanical,E0779,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,570.02,,,,,,,fee schedule,47.27,619.16,
Amb infusion pump mechanical,E0779,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,54.29,,,,,,,fee schedule,47.27,619.16,
Amb infusion pump mechanical,E0779,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,619.16,,,,,,,fee schedule,47.27,619.16,
Amb infusion pump mechanical,E0779,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,58.97,,,,,,,fee schedule,47.27,619.16,
Amb infusion pump mechanical,E0779,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,496.31,,,,,,,fee schedule,47.27,619.16,
Amb infusion pump mechanical,E0779,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,47.27,,,,,,,fee schedule,47.27,619.16,
Amb infusion pump mechanical,E0779,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,542.18,,,,,,,fee schedule,47.27,619.16,
Amb infusion pump mechanical,E0779,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.64,,,,,,,fee schedule,47.27,619.16,
Mech amb infusion pump <8hrs,E0780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37.9,,,,,,,fee schedule,33,41.16,
Mech amb infusion pump <8hrs,E0780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41.16,,,,,,,fee schedule,33,41.16,
Mech amb infusion pump <8hrs,E0780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,33,,,,,,,fee schedule,33,41.16,
Mech amb infusion pump <8hrs,E0780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36.05,,,,,,,fee schedule,33,41.16,
External ambulatory infus pu,E0781,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8982.99,,,,,,,fee schedule,744.9,9757.39,
External ambulatory infus pu,E0781,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,855.52,,,,,,,fee schedule,744.9,9757.39,
External ambulatory infus pu,E0781,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9757.39,,,,,,,fee schedule,744.9,9757.39,
External ambulatory infus pu,E0781,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,929.28,,,,,,,fee schedule,744.9,9757.39,
External ambulatory infus pu,E0781,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7821.4,,,,,,,fee schedule,744.9,9757.39,
External ambulatory infus pu,E0781,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,744.9,,,,,,,fee schedule,744.9,9757.39,
External ambulatory infus pu,E0781,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8544.17,,,,,,,fee schedule,744.9,9757.39,
External ambulatory infus pu,E0781,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,813.73,,,,,,,fee schedule,744.9,9757.39,
Ext amb infusn pump insulin,E0784,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16020.98,,,,,,,fee schedule,1328.5,17402.1,
Ext amb infusn pump insulin,E0784,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1525.81,,,,,,,fee schedule,1328.5,17402.1,
Ext amb infusn pump insulin,E0784,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17402.1,,,,,,,fee schedule,1328.5,17402.1,
Ext amb infusn pump insulin,E0784,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1657.34,,,,,,,fee schedule,1328.5,17402.1,
Ext amb infusn pump insulin,E0784,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13949.3,,,,,,,fee schedule,1328.5,17402.1,
Ext amb infusn pump insulin,E0784,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1328.5,,,,,,,fee schedule,1328.5,17402.1,
Ext amb infusn pump insulin,E0784,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15238.35,,,,,,,fee schedule,1328.5,17402.1,
Ext amb infusn pump insulin,E0784,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1451.27,,,,,,,fee schedule,1328.5,17402.1,
Parenteral infusion pump sta,E0791,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12131.66,,,,,,,fee schedule,1005.99,13177.5,
Parenteral infusion pump sta,E0791,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1155.39,,,,,,,fee schedule,1005.99,13177.5,
Parenteral infusion pump sta,E0791,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13177.5,,,,,,,fee schedule,1005.99,13177.5,
Parenteral infusion pump sta,E0791,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1255,,,,,,,fee schedule,1005.99,13177.5,
Parenteral infusion pump sta,E0791,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10562.91,,,,,,,fee schedule,1005.99,13177.5,
Parenteral infusion pump sta,E0791,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1005.99,,,,,,,fee schedule,1005.99,13177.5,
Parenteral infusion pump sta,E0791,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11539.02,,,,,,,fee schedule,1005.99,13177.5,
Parenteral infusion pump sta,E0791,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1098.95,,,,,,,fee schedule,1005.99,13177.5,
Tract frame attach headboard,E0840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,249.03,,,,,,,fee schedule,44.15,270.5,
Tract frame attach headboard,E0840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,50.7,,,,,,,fee schedule,44.15,270.5,
Tract frame attach headboard,E0840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,186.81,,,,,,,fee schedule,44.15,270.5,
Tract frame attach headboard,E0840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,270.5,,,,,,,fee schedule,44.15,270.5,
Tract frame attach headboard,E0840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55.07,,,,,,,fee schedule,44.15,270.5,
Tract frame attach headboard,E0840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,202.91,,,,,,,fee schedule,44.15,270.5,
Tract frame attach headboard,E0840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,216.83,,,,,,,fee schedule,44.15,270.5,
Tract frame attach headboard,E0840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,44.15,,,,,,,fee schedule,44.15,270.5,
Tract frame attach headboard,E0840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,162.65,,,,,,,fee schedule,44.15,270.5,
Tract frame attach headboard,E0840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,236.86,,,,,,,fee schedule,44.15,270.5,
Tract frame attach headboard,E0840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48.23,,,,,,,fee schedule,44.15,270.5,
Tract frame attach headboard,E0840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,177.68,,,,,,,fee schedule,44.15,270.5,
Cervical pneum trac equip,E0849,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1882.96,,,,,,,fee schedule,163.95,2045.28,
Cervical pneum trac equip,E0849,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,188.3,,,,,,,fee schedule,163.95,2045.28,
Cervical pneum trac equip,E0849,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1412.11,,,,,,,fee schedule,163.95,2045.28,
Cervical pneum trac equip,E0849,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2045.28,,,,,,,fee schedule,163.95,2045.28,
Cervical pneum trac equip,E0849,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,204.54,,,,,,,fee schedule,163.95,2045.28,
Cervical pneum trac equip,E0849,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1533.85,,,,,,,fee schedule,163.95,2045.28,
Cervical pneum trac equip,E0849,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1639.47,,,,,,,fee schedule,163.95,2045.28,
Cervical pneum trac equip,E0849,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,163.95,,,,,,,fee schedule,163.95,2045.28,
Cervical pneum trac equip,E0849,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1229.51,,,,,,,fee schedule,163.95,2045.28,
Cervical pneum trac equip,E0849,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1790.97,,,,,,,fee schedule,163.95,2045.28,
Cervical pneum trac equip,E0849,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,179.1,,,,,,,fee schedule,163.95,2045.28,
Cervical pneum trac equip,E0849,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1343.13,,,,,,,fee schedule,163.95,2045.28,
Traction stand free standing,E0850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,326.28,,,,,,,fee schedule,39.03,354.41,
Traction stand free standing,E0850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,44.82,,,,,,,fee schedule,39.03,354.41,
Traction stand free standing,E0850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,244.75,,,,,,,fee schedule,39.03,354.41,
Traction stand free standing,E0850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,354.41,,,,,,,fee schedule,39.03,354.41,
Traction stand free standing,E0850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,48.69,,,,,,,fee schedule,39.03,354.41,
Traction stand free standing,E0850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,265.85,,,,,,,fee schedule,39.03,354.41,
Traction stand free standing,E0850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,284.09,,,,,,,fee schedule,39.03,354.41,
Traction stand free standing,E0850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39.03,,,,,,,fee schedule,39.03,354.41,
Traction stand free standing,E0850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,213.1,,,,,,,fee schedule,39.03,354.41,
Traction stand free standing,E0850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,310.35,,,,,,,fee schedule,39.03,354.41,
Traction stand free standing,E0850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.63,,,,,,,fee schedule,39.03,354.41,
Traction stand free standing,E0850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,232.79,,,,,,,fee schedule,39.03,354.41,
Cervical traction equipment,E0855,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1836.6,,,,,,,fee schedule,159.89,1994.93,
Cervical traction equipment,E0855,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,183.64,,,,,,,fee schedule,159.89,1994.93,
Cervical traction equipment,E0855,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1377.42,,,,,,,fee schedule,159.89,1994.93,
Cervical traction equipment,E0855,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1994.93,,,,,,,fee schedule,159.89,1994.93,
Cervical traction equipment,E0855,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,199.47,,,,,,,fee schedule,159.89,1994.93,
Cervical traction equipment,E0855,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1496.16,,,,,,,fee schedule,159.89,1994.93,
Cervical traction equipment,E0855,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1599.11,,,,,,,fee schedule,159.89,1994.93,
Cervical traction equipment,E0855,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,159.89,,,,,,,fee schedule,159.89,1994.93,
Cervical traction equipment,E0855,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1199.3,,,,,,,fee schedule,159.89,1994.93,
Cervical traction equipment,E0855,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1746.89,,,,,,,fee schedule,159.89,1994.93,
Cervical traction equipment,E0855,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,174.67,,,,,,,fee schedule,159.89,1994.93,
Cervical traction equipment,E0855,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1310.13,,,,,,,fee schedule,159.89,1994.93,
Cervic collar w air bladders,E0856,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,562.82,,,,,,,fee schedule,49.06,611.34,
Cervic collar w air bladders,E0856,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,56.34,,,,,,,fee schedule,49.06,611.34,
Cervic collar w air bladders,E0856,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,422.16,,,,,,,fee schedule,49.06,611.34,
Cervic collar w air bladders,E0856,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,611.34,,,,,,,fee schedule,49.06,611.34,
Cervic collar w air bladders,E0856,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,61.2,,,,,,,fee schedule,49.06,611.34,
Cervic collar w air bladders,E0856,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,458.55,,,,,,,fee schedule,49.06,611.34,
Cervic collar w air bladders,E0856,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,490.04,,,,,,,fee schedule,49.06,611.34,
Cervic collar w air bladders,E0856,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,49.06,,,,,,,fee schedule,49.06,611.34,
Cervic collar w air bladders,E0856,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,367.57,,,,,,,fee schedule,49.06,611.34,
Cervic collar w air bladders,E0856,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,535.33,,,,,,,fee schedule,49.06,611.34,
Cervic collar w air bladders,E0856,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.59,,,,,,,fee schedule,49.06,611.34,
Cervic collar w air bladders,E0856,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,401.54,,,,,,,fee schedule,49.06,611.34,
Tract equip cervical tract,E0860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,140.8,,,,,,,fee schedule,17.6,152.94,
Tract equip cervical tract,E0860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20.22,,,,,,,fee schedule,17.6,152.94,
Tract equip cervical tract,E0860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,106,,,,,,,fee schedule,17.6,152.94,
Tract equip cervical tract,E0860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,152.94,,,,,,,fee schedule,17.6,152.94,
Tract equip cervical tract,E0860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21.96,,,,,,,fee schedule,17.6,152.94,
Tract equip cervical tract,E0860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,115.14,,,,,,,fee schedule,17.6,152.94,
Tract equip cervical tract,E0860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,122.59,,,,,,,fee schedule,17.6,152.94,
Tract equip cervical tract,E0860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17.6,,,,,,,fee schedule,17.6,152.94,
Tract equip cervical tract,E0860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,92.29,,,,,,,fee schedule,17.6,152.94,
Tract equip cervical tract,E0860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,133.92,,,,,,,fee schedule,17.6,152.94,
Tract equip cervical tract,E0860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19.23,,,,,,,fee schedule,17.6,152.94,
Tract equip cervical tract,E0860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,100.82,,,,,,,fee schedule,17.6,152.94,
Tract frame attach footboard,E0870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,425.01,,,,,,,fee schedule,42.63,461.65,
Tract frame attach footboard,E0870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,48.96,,,,,,,fee schedule,42.63,461.65,
Tract frame attach footboard,E0870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,320.16,,,,,,,fee schedule,42.63,461.65,
Tract frame attach footboard,E0870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,461.65,,,,,,,fee schedule,42.63,461.65,
Tract frame attach footboard,E0870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,53.18,,,,,,,fee schedule,42.63,461.65,
Tract frame attach footboard,E0870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,347.76,,,,,,,fee schedule,42.63,461.65,
Tract frame attach footboard,E0870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,370.05,,,,,,,fee schedule,42.63,461.65,
Tract frame attach footboard,E0870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.63,,,,,,,fee schedule,42.63,461.65,
Tract frame attach footboard,E0870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,278.76,,,,,,,fee schedule,42.63,461.65,
Tract frame attach footboard,E0870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,404.25,,,,,,,fee schedule,42.63,461.65,
Tract frame attach footboard,E0870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.57,,,,,,,fee schedule,42.63,461.65,
Tract frame attach footboard,E0870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,304.52,,,,,,,fee schedule,42.63,461.65,
Trac stand free stand extrem,E0880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,389.93,,,,,,,fee schedule,53.33,423.55,
Trac stand free stand extrem,E0880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,61.25,,,,,,,fee schedule,53.33,423.55,
Trac stand free stand extrem,E0880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,295.1,,,,,,,fee schedule,53.33,423.55,
Trac stand free stand extrem,E0880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,423.55,,,,,,,fee schedule,53.33,423.55,
Trac stand free stand extrem,E0880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.53,,,,,,,fee schedule,53.33,423.55,
Trac stand free stand extrem,E0880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,320.54,,,,,,,fee schedule,53.33,423.55,
Trac stand free stand extrem,E0880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,339.51,,,,,,,fee schedule,53.33,423.55,
Trac stand free stand extrem,E0880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.33,,,,,,,fee schedule,53.33,423.55,
Trac stand free stand extrem,E0880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,256.94,,,,,,,fee schedule,53.33,423.55,
Trac stand free stand extrem,E0880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,370.89,,,,,,,fee schedule,53.33,423.55,
Trac stand free stand extrem,E0880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,58.26,,,,,,,fee schedule,53.33,423.55,
Trac stand free stand extrem,E0880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,280.69,,,,,,,fee schedule,53.33,423.55,
Traction frame attach pelvic,E0890,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,439.98,,,,,,,fee schedule,88.78,477.91,
Traction frame attach pelvic,E0890,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,101.96,,,,,,,fee schedule,88.78,477.91,
Traction frame attach pelvic,E0890,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,354.4,,,,,,,fee schedule,88.78,477.91,
Traction frame attach pelvic,E0890,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,477.91,,,,,,,fee schedule,88.78,477.91,
Traction frame attach pelvic,E0890,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,110.75,,,,,,,fee schedule,88.78,477.91,
Traction frame attach pelvic,E0890,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,384.96,,,,,,,fee schedule,88.78,477.91,
Traction frame attach pelvic,E0890,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,383.08,,,,,,,fee schedule,88.78,477.91,
Traction frame attach pelvic,E0890,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,88.78,,,,,,,fee schedule,88.78,477.91,
Traction frame attach pelvic,E0890,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,308.58,,,,,,,fee schedule,88.78,477.91,
Traction frame attach pelvic,E0890,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,418.48,,,,,,,fee schedule,88.78,477.91,
Traction frame attach pelvic,E0890,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,96.98,,,,,,,fee schedule,88.78,477.91,
Traction frame attach pelvic,E0890,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,337.09,,,,,,,fee schedule,88.78,477.91,
Trac stand free stand pelvic,E0900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,468.16,,,,,,,fee schedule,74.69,508.52,
Trac stand free stand pelvic,E0900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,85.78,,,,,,,fee schedule,74.69,508.52,
Trac stand free stand pelvic,E0900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,351.24,,,,,,,fee schedule,74.69,508.52,
Trac stand free stand pelvic,E0900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,508.52,,,,,,,fee schedule,74.69,508.52,
Trac stand free stand pelvic,E0900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,93.18,,,,,,,fee schedule,74.69,508.52,
Trac stand free stand pelvic,E0900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,381.52,,,,,,,fee schedule,74.69,508.52,
Trac stand free stand pelvic,E0900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,407.63,,,,,,,fee schedule,74.69,508.52,
Trac stand free stand pelvic,E0900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,74.69,,,,,,,fee schedule,74.69,508.52,
Trac stand free stand pelvic,E0900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,305.82,,,,,,,fee schedule,74.69,508.52,
Trac stand free stand pelvic,E0900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,445.29,,,,,,,fee schedule,74.69,508.52,
Trac stand free stand pelvic,E0900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,81.59,,,,,,,fee schedule,74.69,508.52,
Trac stand free stand pelvic,E0900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,334.08,,,,,,,fee schedule,74.69,508.52,
Trapeze bar attached to bed,E0910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,562.37,,,,,,,fee schedule,46.63,610.85,
Trapeze bar attached to bed,E0910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,53.56,,,,,,,fee schedule,46.63,610.85,
Trapeze bar attached to bed,E0910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,610.85,,,,,,,fee schedule,46.63,610.85,
Trapeze bar attached to bed,E0910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,58.17,,,,,,,fee schedule,46.63,610.85,
Trapeze bar attached to bed,E0910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,489.65,,,,,,,fee schedule,46.63,610.85,
Trapeze bar attached to bed,E0910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.63,,,,,,,fee schedule,46.63,610.85,
Trapeze bar attached to bed,E0910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,534.9,,,,,,,fee schedule,46.63,610.85,
Trapeze bar attached to bed,E0910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,50.94,,,,,,,fee schedule,46.63,610.85,
Hd trapeze bar attach to bed,E0911,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1648.34,,,,,,,fee schedule,136.68,1790.43,
Hd trapeze bar attach to bed,E0911,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,156.98,,,,,,,fee schedule,136.68,1790.43,
Hd trapeze bar attach to bed,E0911,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1790.43,,,,,,,fee schedule,136.68,1790.43,
Hd trapeze bar attach to bed,E0911,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,170.52,,,,,,,fee schedule,136.68,1790.43,
Hd trapeze bar attach to bed,E0911,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1435.19,,,,,,,fee schedule,136.68,1790.43,
Hd trapeze bar attach to bed,E0911,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,136.68,,,,,,,fee schedule,136.68,1790.43,
Hd trapeze bar attach to bed,E0911,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1567.81,,,,,,,fee schedule,136.68,1790.43,
Hd trapeze bar attach to bed,E0911,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,149.31,,,,,,,fee schedule,136.68,1790.43,
Hd trapeze bar free standing,E0912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3785.54,,,,,,,fee schedule,313.91,4111.88,
Hd trapeze bar free standing,E0912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,360.53,,,,,,,fee schedule,313.91,4111.88,
Hd trapeze bar free standing,E0912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4111.88,,,,,,,fee schedule,313.91,4111.88,
Hd trapeze bar free standing,E0912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,391.61,,,,,,,fee schedule,313.91,4111.88,
Hd trapeze bar free standing,E0912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3296.03,,,,,,,fee schedule,313.91,4111.88,
Hd trapeze bar free standing,E0912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,313.91,,,,,,,fee schedule,313.91,4111.88,
Hd trapeze bar free standing,E0912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3600.62,,,,,,,fee schedule,313.91,4111.88,
Hd trapeze bar free standing,E0912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,342.92,,,,,,,fee schedule,313.91,4111.88,
Fracture frame attached to b,E0920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1504.72,,,,,,,fee schedule,124.78,1634.43,
Fracture frame attached to b,E0920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,143.31,,,,,,,fee schedule,124.78,1634.43,
Fracture frame attached to b,E0920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1634.43,,,,,,,fee schedule,124.78,1634.43,
Fracture frame attached to b,E0920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,155.66,,,,,,,fee schedule,124.78,1634.43,
Fracture frame attached to b,E0920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1310.14,,,,,,,fee schedule,124.78,1634.43,
Fracture frame attached to b,E0920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,124.78,,,,,,,fee schedule,124.78,1634.43,
Fracture frame attached to b,E0920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1431.21,,,,,,,fee schedule,124.78,1634.43,
Fracture frame attached to b,E0920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,136.31,,,,,,,fee schedule,124.78,1634.43,
Fracture frame free standing,E0930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1541.99,,,,,,,fee schedule,127.87,1674.92,
Fracture frame free standing,E0930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,146.86,,,,,,,fee schedule,127.87,1674.92,
Fracture frame free standing,E0930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1674.92,,,,,,,fee schedule,127.87,1674.92,
Fracture frame free standing,E0930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,159.52,,,,,,,fee schedule,127.87,1674.92,
Fracture frame free standing,E0930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1342.59,,,,,,,fee schedule,127.87,1674.92,
Fracture frame free standing,E0930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,127.87,,,,,,,fee schedule,127.87,1674.92,
Fracture frame free standing,E0930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1466.66,,,,,,,fee schedule,127.87,1674.92,
Fracture frame free standing,E0930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,139.68,,,,,,,fee schedule,127.87,1674.92,
Cont pas motion exercise dev,E0935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,70.61,,,,,,,fee schedule,61.48,76.7,
Cont pas motion exercise dev,E0935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,76.7,,,,,,,fee schedule,61.48,76.7,
Cont pas motion exercise dev,E0935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,61.48,,,,,,,fee schedule,61.48,76.7,
Cont pas motion exercise dev,E0935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,67.16,,,,,,,fee schedule,61.48,76.7,
Trapeze bar free standing,E0940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,979.62,,,,,,,fee schedule,81.23,1064.07,
Trapeze bar free standing,E0940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,93.3,,,,,,,fee schedule,81.23,1064.07,
Trapeze bar free standing,E0940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1064.07,,,,,,,fee schedule,81.23,1064.07,
Trapeze bar free standing,E0940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,101.34,,,,,,,fee schedule,81.23,1064.07,
Trapeze bar free standing,E0940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,852.95,,,,,,,fee schedule,81.23,1064.07,
Trapeze bar free standing,E0940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,81.23,,,,,,,fee schedule,81.23,1064.07,
Trapeze bar free standing,E0940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,931.77,,,,,,,fee schedule,81.23,1064.07,
Trapeze bar free standing,E0940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,88.74,,,,,,,fee schedule,81.23,1064.07,
Gravity assisted traction de,E0941,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1665.49,,,,,,,fee schedule,138.11,1809.07,
Gravity assisted traction de,E0941,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,158.62,,,,,,,fee schedule,138.11,1809.07,
Gravity assisted traction de,E0941,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1809.07,,,,,,,fee schedule,138.11,1809.07,
Gravity assisted traction de,E0941,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,172.29,,,,,,,fee schedule,138.11,1809.07,
Gravity assisted traction de,E0941,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1450.13,,,,,,,fee schedule,138.11,1809.07,
Gravity assisted traction de,E0941,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,138.11,,,,,,,fee schedule,138.11,1809.07,
Gravity assisted traction de,E0941,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1584.13,,,,,,,fee schedule,138.11,1809.07,
Gravity assisted traction de,E0941,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,150.87,,,,,,,fee schedule,138.11,1809.07,
Cervical head harness/halter,E0942,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,61.63,,,,,,,fee schedule,6.33,66.94,
Cervical head harness/halter,E0942,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7.27,,,,,,,fee schedule,6.33,66.94,
Cervical head harness/halter,E0942,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46.21,,,,,,,fee schedule,6.33,66.94,
Cervical head harness/halter,E0942,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.94,,,,,,,fee schedule,6.33,66.94,
Cervical head harness/halter,E0942,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7.9,,,,,,,fee schedule,6.33,66.94,
Cervical head harness/halter,E0942,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,50.2,,,,,,,fee schedule,6.33,66.94,
Cervical head harness/halter,E0942,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.66,,,,,,,fee schedule,6.33,66.94,
Cervical head harness/halter,E0942,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.33,,,,,,,fee schedule,6.33,66.94,
Cervical head harness/halter,E0942,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40.24,,,,,,,fee schedule,6.33,66.94,
Cervical head harness/halter,E0942,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,58.62,,,,,,,fee schedule,6.33,66.94,
Cervical head harness/halter,E0942,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.92,,,,,,,fee schedule,6.33,66.94,
Cervical head harness/halter,E0942,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,43.96,,,,,,,fee schedule,6.33,66.94,
Pelvic belt/harness/boot,E0944,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,142.47,,,,,,,fee schedule,12.45,154.75,
Pelvic belt/harness/boot,E0944,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14.3,,,,,,,fee schedule,12.45,154.75,
Pelvic belt/harness/boot,E0944,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,106.84,,,,,,,fee schedule,12.45,154.75,
Pelvic belt/harness/boot,E0944,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,154.75,,,,,,,fee schedule,12.45,154.75,
Pelvic belt/harness/boot,E0944,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15.54,,,,,,,fee schedule,12.45,154.75,
Pelvic belt/harness/boot,E0944,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,116.05,,,,,,,fee schedule,12.45,154.75,
Pelvic belt/harness/boot,E0944,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,124.05,,,,,,,fee schedule,12.45,154.75,
Pelvic belt/harness/boot,E0944,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12.45,,,,,,,fee schedule,12.45,154.75,
Pelvic belt/harness/boot,E0944,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,93.02,,,,,,,fee schedule,12.45,154.75,
Pelvic belt/harness/boot,E0944,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,135.51,,,,,,,fee schedule,12.45,154.75,
Pelvic belt/harness/boot,E0944,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13.6,,,,,,,fee schedule,12.45,154.75,
Pelvic belt/harness/boot,E0944,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,101.62,,,,,,,fee schedule,12.45,154.75,
Belt/harness extremity,E0945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,137.67,,,,,,,fee schedule,12,149.54,
Belt/harness extremity,E0945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13.78,,,,,,,fee schedule,12,149.54,
Belt/harness extremity,E0945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,106.59,,,,,,,fee schedule,12,149.54,
Belt/harness extremity,E0945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,149.54,,,,,,,fee schedule,12,149.54,
Belt/harness extremity,E0945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14.97,,,,,,,fee schedule,12,149.54,
Belt/harness extremity,E0945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,115.78,,,,,,,fee schedule,12,149.54,
Belt/harness extremity,E0945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,119.87,,,,,,,fee schedule,12,149.54,
Belt/harness extremity,E0945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12,,,,,,,fee schedule,12,149.54,
Belt/harness extremity,E0945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,92.81,,,,,,,fee schedule,12,149.54,
Belt/harness extremity,E0945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,130.94,,,,,,,fee schedule,12,149.54,
Belt/harness extremity,E0945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13.11,,,,,,,fee schedule,12,149.54,
Belt/harness extremity,E0945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,101.39,,,,,,,fee schedule,12,149.54,
Fracture frame dual w cross,E0946,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1929.31,,,,,,,fee schedule,159.98,2095.63,
Fracture frame dual w cross,E0946,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,183.74,,,,,,,fee schedule,159.98,2095.63,
Fracture frame dual w cross,E0946,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2095.63,,,,,,,fee schedule,159.98,2095.63,
Fracture frame dual w cross,E0946,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,199.58,,,,,,,fee schedule,159.98,2095.63,
Fracture frame dual w cross,E0946,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1679.83,,,,,,,fee schedule,159.98,2095.63,
Fracture frame dual w cross,E0946,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,159.98,,,,,,,fee schedule,159.98,2095.63,
Fracture frame dual w cross,E0946,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1835.06,,,,,,,fee schedule,159.98,2095.63,
Fracture frame dual w cross,E0946,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,174.77,,,,,,,fee schedule,159.98,2095.63,
Fracture frame attachmnts pe,E0947,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2215.99,,,,,,,fee schedule,200.07,2407.03,
Fracture frame attachmnts pe,E0947,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,229.78,,,,,,,fee schedule,200.07,2407.03,
Fracture frame attachmnts pe,E0947,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1661.98,,,,,,,fee schedule,200.07,2407.03,
Fracture frame attachmnts pe,E0947,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2407.03,,,,,,,fee schedule,200.07,2407.03,
Fracture frame attachmnts pe,E0947,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,249.59,,,,,,,fee schedule,200.07,2407.03,
Fracture frame attachmnts pe,E0947,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1805.25,,,,,,,fee schedule,200.07,2407.03,
Fracture frame attachmnts pe,E0947,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1929.44,,,,,,,fee schedule,200.07,2407.03,
Fracture frame attachmnts pe,E0947,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,200.07,,,,,,,fee schedule,200.07,2407.03,
Fracture frame attachmnts pe,E0947,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1447.07,,,,,,,fee schedule,200.07,2407.03,
Fracture frame attachmnts pe,E0947,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2107.74,,,,,,,fee schedule,200.07,2407.03,
Fracture frame attachmnts pe,E0947,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,218.56,,,,,,,fee schedule,200.07,2407.03,
Fracture frame attachmnts pe,E0947,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1580.79,,,,,,,fee schedule,200.07,2407.03,
Fracture frame attachmnts ce,E0948,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1999.5,,,,,,,fee schedule,174.1,2171.87,
Fracture frame attachmnts ce,E0948,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,199.96,,,,,,,fee schedule,174.1,2171.87,
Fracture frame attachmnts ce,E0948,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1499.67,,,,,,,fee schedule,174.1,2171.87,
Fracture frame attachmnts ce,E0948,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2171.87,,,,,,,fee schedule,174.1,2171.87,
Fracture frame attachmnts ce,E0948,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,217.2,,,,,,,fee schedule,174.1,2171.87,
Fracture frame attachmnts ce,E0948,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1628.95,,,,,,,fee schedule,174.1,2171.87,
Fracture frame attachmnts ce,E0948,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1740.95,,,,,,,fee schedule,174.1,2171.87,
Fracture frame attachmnts ce,E0948,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,174.1,,,,,,,fee schedule,174.1,2171.87,
Fracture frame attachmnts ce,E0948,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1305.75,,,,,,,fee schedule,174.1,2171.87,
Fracture frame attachmnts ce,E0948,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1901.83,,,,,,,fee schedule,174.1,2171.87,
Fracture frame attachmnts ce,E0948,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,190.19,,,,,,,fee schedule,174.1,2171.87,
Fracture frame attachmnts ce,E0948,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1426.41,,,,,,,fee schedule,174.1,2171.87,
Tray,E0950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,327.36,,,,,,,fee schedule,28.54,355.58,
Tray,E0950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,32.78,,,,,,,fee schedule,28.54,355.58,
Tray,E0950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,245.55,,,,,,,fee schedule,28.54,355.58,
Tray,E0950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,355.58,,,,,,,fee schedule,28.54,355.58,
Tray,E0950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,35.61,,,,,,,fee schedule,28.54,355.58,
Tray,E0950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,266.72,,,,,,,fee schedule,28.54,355.58,
Tray,E0950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,285.03,,,,,,,fee schedule,28.54,355.58,
Tray,E0950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28.54,,,,,,,fee schedule,28.54,355.58,
Tray,E0950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,213.8,,,,,,,fee schedule,28.54,355.58,
Tray,E0950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,311.37,,,,,,,fee schedule,28.54,355.58,
Tray,E0950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31.18,,,,,,,fee schedule,28.54,355.58,
Tray,E0950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,233.55,,,,,,,fee schedule,28.54,355.58,
Loop heel,E0951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59.79,,,,,,,fee schedule,5.36,64.94,
Loop heel,E0951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.16,,,,,,,fee schedule,5.36,64.94,
Loop heel,E0951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,44.79,,,,,,,fee schedule,5.36,64.94,
Loop heel,E0951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,64.94,,,,,,,fee schedule,5.36,64.94,
Loop heel,E0951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.69,,,,,,,fee schedule,5.36,64.94,
Loop heel,E0951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,48.65,,,,,,,fee schedule,5.36,64.94,
Loop heel,E0951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52.06,,,,,,,fee schedule,5.36,64.94,
Loop heel,E0951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.36,,,,,,,fee schedule,5.36,64.94,
Loop heel,E0951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39,,,,,,,fee schedule,5.36,64.94,
Loop heel,E0951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56.87,,,,,,,fee schedule,5.36,64.94,
Loop heel,E0951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.86,,,,,,,fee schedule,5.36,64.94,
Loop heel,E0951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.6,,,,,,,fee schedule,5.36,64.94,
"Toe loop/holder, each",E0952,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59.3,,,,,,,fee schedule,5.36,64.41,
"Toe loop/holder, each",E0952,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.16,,,,,,,fee schedule,5.36,64.41,
"Toe loop/holder, each",E0952,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,44.51,,,,,,,fee schedule,5.36,64.41,
"Toe loop/holder, each",E0952,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,64.41,,,,,,,fee schedule,5.36,64.41,
"Toe loop/holder, each",E0952,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.69,,,,,,,fee schedule,5.36,64.41,
"Toe loop/holder, each",E0952,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,48.35,,,,,,,fee schedule,5.36,64.41,
"Toe loop/holder, each",E0952,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.63,,,,,,,fee schedule,5.36,64.41,
"Toe loop/holder, each",E0952,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.36,,,,,,,fee schedule,5.36,64.41,
"Toe loop/holder, each",E0952,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38.75,,,,,,,fee schedule,5.36,64.41,
"Toe loop/holder, each",E0952,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56.4,,,,,,,fee schedule,5.36,64.41,
"Toe loop/holder, each",E0952,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.86,,,,,,,fee schedule,5.36,64.41,
"Toe loop/holder, each",E0952,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.33,,,,,,,fee schedule,5.36,64.41,
Cushioned headrest,E0955,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,636.74,,,,,,,fee schedule,55.48,691.63,
Cushioned headrest,E0955,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,63.72,,,,,,,fee schedule,55.48,691.63,
Cushioned headrest,E0955,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,477.56,,,,,,,fee schedule,55.48,691.63,
Cushioned headrest,E0955,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,691.63,,,,,,,fee schedule,55.48,691.63,
Cushioned headrest,E0955,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,69.21,,,,,,,fee schedule,55.48,691.63,
Cushioned headrest,E0955,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,518.73,,,,,,,fee schedule,55.48,691.63,
Cushioned headrest,E0955,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,554.4,,,,,,,fee schedule,55.48,691.63,
Cushioned headrest,E0955,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55.48,,,,,,,fee schedule,55.48,691.63,
Cushioned headrest,E0955,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,415.81,,,,,,,fee schedule,55.48,691.63,
Cushioned headrest,E0955,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,605.63,,,,,,,fee schedule,55.48,691.63,
Cushioned headrest,E0955,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,60.61,,,,,,,fee schedule,55.48,691.63,
Cushioned headrest,E0955,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,454.23,,,,,,,fee schedule,55.48,691.63,
W/c lateral trunk/hip suppor,E0956,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,310.45,,,,,,,fee schedule,27.06,337.21,
W/c lateral trunk/hip suppor,E0956,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,31.08,,,,,,,fee schedule,27.06,337.21,
W/c lateral trunk/hip suppor,E0956,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,232.85,,,,,,,fee schedule,27.06,337.21,
W/c lateral trunk/hip suppor,E0956,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,337.21,,,,,,,fee schedule,27.06,337.21,
W/c lateral trunk/hip suppor,E0956,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33.76,,,,,,,fee schedule,27.06,337.21,
W/c lateral trunk/hip suppor,E0956,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,252.92,,,,,,,fee schedule,27.06,337.21,
W/c lateral trunk/hip suppor,E0956,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,270.31,,,,,,,fee schedule,27.06,337.21,
W/c lateral trunk/hip suppor,E0956,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,27.06,,,,,,,fee schedule,27.06,337.21,
W/c lateral trunk/hip suppor,E0956,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,202.74,,,,,,,fee schedule,27.06,337.21,
W/c lateral trunk/hip suppor,E0956,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,295.29,,,,,,,fee schedule,27.06,337.21,
W/c lateral trunk/hip suppor,E0956,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29.56,,,,,,,fee schedule,27.06,337.21,
W/c lateral trunk/hip suppor,E0956,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,221.47,,,,,,,fee schedule,27.06,337.21,
W/c medial thigh support,E0957,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,434.41,,,,,,,fee schedule,37.81,471.86,
W/c medial thigh support,E0957,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,43.43,,,,,,,fee schedule,37.81,471.86,
W/c medial thigh support,E0957,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,325.8,,,,,,,fee schedule,37.81,471.86,
W/c medial thigh support,E0957,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,471.86,,,,,,,fee schedule,37.81,471.86,
W/c medial thigh support,E0957,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,47.17,,,,,,,fee schedule,37.81,471.86,
W/c medial thigh support,E0957,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,353.88,,,,,,,fee schedule,37.81,471.86,
W/c medial thigh support,E0957,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,378.23,,,,,,,fee schedule,37.81,471.86,
W/c medial thigh support,E0957,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37.81,,,,,,,fee schedule,37.81,471.86,
W/c medial thigh support,E0957,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,283.67,,,,,,,fee schedule,37.81,471.86,
W/c medial thigh support,E0957,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,413.19,,,,,,,fee schedule,37.81,471.86,
W/c medial thigh support,E0957,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,41.31,,,,,,,fee schedule,37.81,471.86,
W/c medial thigh support,E0957,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,309.88,,,,,,,fee schedule,37.81,471.86,
Whlchr att- conv 1 arm drive,E0958,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1517.14,,,,,,,fee schedule,125.81,1647.93,
Whlchr att- conv 1 arm drive,E0958,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,144.49,,,,,,,fee schedule,125.81,1647.93,
Whlchr att- conv 1 arm drive,E0958,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1647.93,,,,,,,fee schedule,125.81,1647.93,
Whlchr att- conv 1 arm drive,E0958,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,156.95,,,,,,,fee schedule,125.81,1647.93,
Whlchr att- conv 1 arm drive,E0958,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1320.96,,,,,,,fee schedule,125.81,1647.93,
Whlchr att- conv 1 arm drive,E0958,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,125.81,,,,,,,fee schedule,125.81,1647.93,
Whlchr att- conv 1 arm drive,E0958,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1443.03,,,,,,,fee schedule,125.81,1647.93,
Whlchr att- conv 1 arm drive,E0958,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,137.43,,,,,,,fee schedule,125.81,1647.93,
Amputee adapter,E0959,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,161.54,,,,,,,fee schedule,14.15,175.47,
Amputee adapter,E0959,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16.25,,,,,,,fee schedule,14.15,175.47,
Amputee adapter,E0959,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,122.25,,,,,,,fee schedule,14.15,175.47,
Amputee adapter,E0959,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,175.47,,,,,,,fee schedule,14.15,175.47,
Amputee adapter,E0959,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17.65,,,,,,,fee schedule,14.15,175.47,
Amputee adapter,E0959,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,132.79,,,,,,,fee schedule,14.15,175.47,
Amputee adapter,E0959,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,140.65,,,,,,,fee schedule,14.15,175.47,
Amputee adapter,E0959,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14.15,,,,,,,fee schedule,14.15,175.47,
Amputee adapter,E0959,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,106.44,,,,,,,fee schedule,14.15,175.47,
Amputee adapter,E0959,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,153.65,,,,,,,fee schedule,14.15,175.47,
Amputee adapter,E0959,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15.46,,,,,,,fee schedule,14.15,175.47,
Amputee adapter,E0959,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,116.28,,,,,,,fee schedule,14.15,175.47,
W/c shoulder harness/straps,E0960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,286.54,,,,,,,fee schedule,24.97,311.25,
W/c shoulder harness/straps,E0960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,28.68,,,,,,,fee schedule,24.97,311.25,
W/c shoulder harness/straps,E0960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,214.92,,,,,,,fee schedule,24.97,311.25,
W/c shoulder harness/straps,E0960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,311.25,,,,,,,fee schedule,24.97,311.25,
W/c shoulder harness/straps,E0960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,31.15,,,,,,,fee schedule,24.97,311.25,
W/c shoulder harness/straps,E0960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,233.45,,,,,,,fee schedule,24.97,311.25,
W/c shoulder harness/straps,E0960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,249.49,,,,,,,fee schedule,24.97,311.25,
W/c shoulder harness/straps,E0960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24.97,,,,,,,fee schedule,24.97,311.25,
W/c shoulder harness/straps,E0960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,187.13,,,,,,,fee schedule,24.97,311.25,
W/c shoulder harness/straps,E0960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,272.55,,,,,,,fee schedule,24.97,311.25,
W/c shoulder harness/straps,E0960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,27.27,,,,,,,fee schedule,24.97,311.25,
W/c shoulder harness/straps,E0960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,204.43,,,,,,,fee schedule,24.97,311.25,
Wheelchair brake extension,E0961,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,92.39,,,,,,,fee schedule,8.39,100.36,
Wheelchair brake extension,E0961,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.64,,,,,,,fee schedule,8.39,100.36,
Wheelchair brake extension,E0961,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,47.75,,,,,,,fee schedule,8.39,100.36,
Wheelchair brake extension,E0961,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,100.36,,,,,,,fee schedule,8.39,100.36,
Wheelchair brake extension,E0961,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10.47,,,,,,,fee schedule,8.39,100.36,
Wheelchair brake extension,E0961,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,51.86,,,,,,,fee schedule,8.39,100.36,
Wheelchair brake extension,E0961,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,80.45,,,,,,,fee schedule,8.39,100.36,
Wheelchair brake extension,E0961,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.39,,,,,,,fee schedule,8.39,100.36,
Wheelchair brake extension,E0961,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,41.57,,,,,,,fee schedule,8.39,100.36,
Wheelchair brake extension,E0961,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,87.88,,,,,,,fee schedule,8.39,100.36,
Wheelchair brake extension,E0961,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.17,,,,,,,fee schedule,8.39,100.36,
Wheelchair brake extension,E0961,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,45.41,,,,,,,fee schedule,8.39,100.36,
Wheelchair head rest extensi,E0966,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,260.79,,,,,,,fee schedule,22.39,283.27,
Wheelchair head rest extensi,E0966,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,25.72,,,,,,,fee schedule,22.39,283.27,
Wheelchair head rest extensi,E0966,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,195.58,,,,,,,fee schedule,22.39,283.27,
Wheelchair head rest extensi,E0966,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,283.27,,,,,,,fee schedule,22.39,283.27,
Wheelchair head rest extensi,E0966,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27.93,,,,,,,fee schedule,22.39,283.27,
Wheelchair head rest extensi,E0966,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,212.44,,,,,,,fee schedule,22.39,283.27,
Wheelchair head rest extensi,E0966,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,227.07,,,,,,,fee schedule,22.39,283.27,
Wheelchair head rest extensi,E0966,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22.39,,,,,,,fee schedule,22.39,283.27,
Wheelchair head rest extensi,E0966,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,170.29,,,,,,,fee schedule,22.39,283.27,
Wheelchair head rest extensi,E0966,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,248.05,,,,,,,fee schedule,22.39,283.27,
Wheelchair head rest extensi,E0966,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24.46,,,,,,,fee schedule,22.39,283.27,
Wheelchair head rest extensi,E0966,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,186.02,,,,,,,fee schedule,22.39,283.27,
Man wc rim/projection rep ea,E0967,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,240.02,,,,,,,fee schedule,20.91,260.71,
Man wc rim/projection rep ea,E0967,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24.01,,,,,,,fee schedule,20.91,260.71,
Man wc rim/projection rep ea,E0967,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,179.95,,,,,,,fee schedule,20.91,260.71,
Man wc rim/projection rep ea,E0967,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,260.71,,,,,,,fee schedule,20.91,260.71,
Man wc rim/projection rep ea,E0967,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26.08,,,,,,,fee schedule,20.91,260.71,
Man wc rim/projection rep ea,E0967,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,195.46,,,,,,,fee schedule,20.91,260.71,
Man wc rim/projection rep ea,E0967,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,208.98,,,,,,,fee schedule,20.91,260.71,
Man wc rim/projection rep ea,E0967,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20.91,,,,,,,fee schedule,20.91,260.71,
Man wc rim/projection rep ea,E0967,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,156.68,,,,,,,fee schedule,20.91,260.71,
Man wc rim/projection rep ea,E0967,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,228.29,,,,,,,fee schedule,20.91,260.71,
Man wc rim/projection rep ea,E0967,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22.84,,,,,,,fee schedule,20.91,260.71,
Man wc rim/projection rep ea,E0967,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,171.16,,,,,,,fee schedule,20.91,260.71,
Wheelchair commode seat,E0968,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,678.18,,,,,,,fee schedule,56.24,736.65,
Wheelchair commode seat,E0968,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,64.59,,,,,,,fee schedule,56.24,736.65,
Wheelchair commode seat,E0968,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,736.65,,,,,,,fee schedule,56.24,736.65,
Wheelchair commode seat,E0968,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,70.16,,,,,,,fee schedule,56.24,736.65,
Wheelchair commode seat,E0968,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,590.49,,,,,,,fee schedule,56.24,736.65,
Wheelchair commode seat,E0968,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56.24,,,,,,,fee schedule,56.24,736.65,
Wheelchair commode seat,E0968,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,645.05,,,,,,,fee schedule,56.24,736.65,
Wheelchair commode seat,E0968,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,61.43,,,,,,,fee schedule,56.24,736.65,
Wheelchair narrowing device,E0969,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,572.32,,,,,,,fee schedule,49.36,621.66,
Wheelchair narrowing device,E0969,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,56.69,,,,,,,fee schedule,49.36,621.66,
Wheelchair narrowing device,E0969,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,429.26,,,,,,,fee schedule,49.36,621.66,
Wheelchair narrowing device,E0969,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,621.66,,,,,,,fee schedule,49.36,621.66,
Wheelchair narrowing device,E0969,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,61.58,,,,,,,fee schedule,49.36,621.66,
Wheelchair narrowing device,E0969,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,466.26,,,,,,,fee schedule,49.36,621.66,
Wheelchair narrowing device,E0969,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,498.31,,,,,,,fee schedule,49.36,621.66,
Wheelchair narrowing device,E0969,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,49.36,,,,,,,fee schedule,49.36,621.66,
Wheelchair narrowing device,E0969,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,373.75,,,,,,,fee schedule,49.36,621.66,
Wheelchair narrowing device,E0969,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,544.36,,,,,,,fee schedule,49.36,621.66,
Wheelchair narrowing device,E0969,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.92,,,,,,,fee schedule,49.36,621.66,
Wheelchair narrowing device,E0969,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,408.29,,,,,,,fee schedule,49.36,621.66,
Wheelchair anti-tipping devi,E0971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,158.55,,,,,,,fee schedule,13.82,172.22,
Wheelchair anti-tipping devi,E0971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15.87,,,,,,,fee schedule,13.82,172.22,
Wheelchair anti-tipping devi,E0971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,118.98,,,,,,,fee schedule,13.82,172.22,
Wheelchair anti-tipping devi,E0971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,172.22,,,,,,,fee schedule,13.82,172.22,
Wheelchair anti-tipping devi,E0971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17.24,,,,,,,fee schedule,13.82,172.22,
Wheelchair anti-tipping devi,E0971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,129.24,,,,,,,fee schedule,13.82,172.22,
Wheelchair anti-tipping devi,E0971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,138.05,,,,,,,fee schedule,13.82,172.22,
Wheelchair anti-tipping devi,E0971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13.82,,,,,,,fee schedule,13.82,172.22,
Wheelchair anti-tipping devi,E0971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,103.6,,,,,,,fee schedule,13.82,172.22,
Wheelchair anti-tipping devi,E0971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,150.8,,,,,,,fee schedule,13.82,172.22,
Wheelchair anti-tipping devi,E0971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15.09,,,,,,,fee schedule,13.82,172.22,
Wheelchair anti-tipping devi,E0971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,113.17,,,,,,,fee schedule,13.82,172.22,
W/ch access det adj armrest,E0973,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,307.77,,,,,,,fee schedule,25.51,334.3,
W/ch access det adj armrest,E0973,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,29.3,,,,,,,fee schedule,25.51,334.3,
W/ch access det adj armrest,E0973,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,230.83,,,,,,,fee schedule,25.51,334.3,
W/ch access det adj armrest,E0973,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,334.3,,,,,,,fee schedule,25.51,334.3,
W/ch access det adj armrest,E0973,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,31.83,,,,,,,fee schedule,25.51,334.3,
W/ch access det adj armrest,E0973,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,250.73,,,,,,,fee schedule,25.51,334.3,
W/ch access det adj armrest,E0973,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,267.97,,,,,,,fee schedule,25.51,334.3,
W/ch access det adj armrest,E0973,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,25.51,,,,,,,fee schedule,25.51,334.3,
W/ch access det adj armrest,E0973,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,200.98,,,,,,,fee schedule,25.51,334.3,
W/ch access det adj armrest,E0973,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,292.74,,,,,,,fee schedule,25.51,334.3,
W/ch access det adj armrest,E0973,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,27.87,,,,,,,fee schedule,25.51,334.3,
W/ch access det adj armrest,E0973,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,219.55,,,,,,,fee schedule,25.51,334.3,
W/ch access anti-rollback,E0974,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,286.51,,,,,,,fee schedule,26.45,311.21,
W/ch access anti-rollback,E0974,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30.38,,,,,,,fee schedule,26.45,311.21,
W/ch access anti-rollback,E0974,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,216.49,,,,,,,fee schedule,26.45,311.21,
W/ch access anti-rollback,E0974,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,311.21,,,,,,,fee schedule,26.45,311.21,
W/ch access anti-rollback,E0974,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33,,,,,,,fee schedule,26.45,311.21,
W/ch access anti-rollback,E0974,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,235.15,,,,,,,fee schedule,26.45,311.21,
W/ch access anti-rollback,E0974,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,249.46,,,,,,,fee schedule,26.45,311.21,
W/ch access anti-rollback,E0974,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26.45,,,,,,,fee schedule,26.45,311.21,
W/ch access anti-rollback,E0974,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,188.5,,,,,,,fee schedule,26.45,311.21,
W/ch access anti-rollback,E0974,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,272.51,,,,,,,fee schedule,26.45,311.21,
W/ch access anti-rollback,E0974,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28.9,,,,,,,fee schedule,26.45,311.21,
W/ch access anti-rollback,E0974,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,205.92,,,,,,,fee schedule,26.45,311.21,
"W/c acc,saf belt pelv strap",E0978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,114.28,,,,,,,fee schedule,9.97,124.14,
"W/c acc,saf belt pelv strap",E0978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11.45,,,,,,,fee schedule,9.97,124.14,
"W/c acc,saf belt pelv strap",E0978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,84.74,,,,,,,fee schedule,9.97,124.14,
"W/c acc,saf belt pelv strap",E0978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,124.14,,,,,,,fee schedule,9.97,124.14,
"W/c acc,saf belt pelv strap",E0978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12.44,,,,,,,fee schedule,9.97,124.14,
"W/c acc,saf belt pelv strap",E0978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,92.04,,,,,,,fee schedule,9.97,124.14,
"W/c acc,saf belt pelv strap",E0978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,99.51,,,,,,,fee schedule,9.97,124.14,
"W/c acc,saf belt pelv strap",E0978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.97,,,,,,,fee schedule,9.97,124.14,
"W/c acc,saf belt pelv strap",E0978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,73.78,,,,,,,fee schedule,9.97,124.14,
"W/c acc,saf belt pelv strap",E0978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,108.7,,,,,,,fee schedule,9.97,124.14,
"W/c acc,saf belt pelv strap",E0978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10.89,,,,,,,fee schedule,9.97,124.14,
"W/c acc,saf belt pelv strap",E0978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,80.6,,,,,,,fee schedule,9.97,124.14,
Wheelchair safety vest,E0980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,118.42,,,,,,,fee schedule,10.3,128.63,
Wheelchair safety vest,E0980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11.83,,,,,,,fee schedule,10.3,128.63,
Wheelchair safety vest,E0980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,88.81,,,,,,,fee schedule,10.3,128.63,
Wheelchair safety vest,E0980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,128.63,,,,,,,fee schedule,10.3,128.63,
Wheelchair safety vest,E0980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12.85,,,,,,,fee schedule,10.3,128.63,
Wheelchair safety vest,E0980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,96.47,,,,,,,fee schedule,10.3,128.63,
Wheelchair safety vest,E0980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,103.11,,,,,,,fee schedule,10.3,128.63,
Wheelchair safety vest,E0980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10.3,,,,,,,fee schedule,10.3,128.63,
Wheelchair safety vest,E0980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,77.33,,,,,,,fee schedule,10.3,128.63,
Wheelchair safety vest,E0980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,112.64,,,,,,,fee schedule,10.3,128.63,
Wheelchair safety vest,E0980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11.25,,,,,,,fee schedule,10.3,128.63,
Wheelchair safety vest,E0980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,84.47,,,,,,,fee schedule,10.3,128.63,
"Seat upholstery, replacement",E0981,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,126.22,,,,,,,fee schedule,11.18,137.1,
"Seat upholstery, replacement",E0981,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12.84,,,,,,,fee schedule,11.18,137.1,
"Seat upholstery, replacement",E0981,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,95.56,,,,,,,fee schedule,11.18,137.1,
"Seat upholstery, replacement",E0981,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,137.1,,,,,,,fee schedule,11.18,137.1,
"Seat upholstery, replacement",E0981,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13.95,,,,,,,fee schedule,11.18,137.1,
"Seat upholstery, replacement",E0981,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,103.8,,,,,,,fee schedule,11.18,137.1,
"Seat upholstery, replacement",E0981,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,109.9,,,,,,,fee schedule,11.18,137.1,
"Seat upholstery, replacement",E0981,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11.18,,,,,,,fee schedule,11.18,137.1,
"Seat upholstery, replacement",E0981,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,83.2,,,,,,,fee schedule,11.18,137.1,
"Seat upholstery, replacement",E0981,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,120.05,,,,,,,fee schedule,11.18,137.1,
"Seat upholstery, replacement",E0981,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12.21,,,,,,,fee schedule,11.18,137.1,
"Seat upholstery, replacement",E0981,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,90.89,,,,,,,fee schedule,11.18,137.1,
"Back upholstery, replacement",E0982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,137.95,,,,,,,fee schedule,12,149.84,
"Back upholstery, replacement",E0982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13.78,,,,,,,fee schedule,12,149.84,
"Back upholstery, replacement",E0982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,103.43,,,,,,,fee schedule,12,149.84,
"Back upholstery, replacement",E0982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,149.84,,,,,,,fee schedule,12,149.84,
"Back upholstery, replacement",E0982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14.97,,,,,,,fee schedule,12,149.84,
"Back upholstery, replacement",E0982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,112.34,,,,,,,fee schedule,12,149.84,
"Back upholstery, replacement",E0982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,120.11,,,,,,,fee schedule,12,149.84,
"Back upholstery, replacement",E0982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12,,,,,,,fee schedule,12,149.84,
"Back upholstery, replacement",E0982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,90.05,,,,,,,fee schedule,12,149.84,
"Back upholstery, replacement",E0982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,131.21,,,,,,,fee schedule,12,149.84,
"Back upholstery, replacement",E0982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13.11,,,,,,,fee schedule,12,149.84,
"Back upholstery, replacement",E0982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,98.37,,,,,,,fee schedule,12,149.84,
Add pwr joystick,E0983,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8453.55,,,,,,,fee schedule,700.99,9182.3,
Add pwr joystick,E0983,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,805.1,,,,,,,fee schedule,700.99,9182.3,
Add pwr joystick,E0983,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9182.3,,,,,,,fee schedule,700.99,9182.3,
Add pwr joystick,E0983,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,874.5,,,,,,,fee schedule,700.99,9182.3,
Add pwr joystick,E0983,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7360.42,,,,,,,fee schedule,700.99,9182.3,
Add pwr joystick,E0983,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,700.99,,,,,,,fee schedule,700.99,9182.3,
Add pwr joystick,E0983,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8040.59,,,,,,,fee schedule,700.99,9182.3,
Add pwr joystick,E0983,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,765.77,,,,,,,fee schedule,700.99,9182.3,
Add pwr tiller,E0984,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6981.26,,,,,,,fee schedule,565,7583.1,
Add pwr tiller,E0984,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,648.92,,,,,,,fee schedule,565,7583.1,
Add pwr tiller,E0984,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5386.97,,,,,,,fee schedule,565,7583.1,
Add pwr tiller,E0984,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7583.1,,,,,,,fee schedule,565,7583.1,
Add pwr tiller,E0984,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,704.86,,,,,,,fee schedule,565,7583.1,
Add pwr tiller,E0984,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5851.36,,,,,,,fee schedule,565,7583.1,
Add pwr tiller,E0984,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6078.51,,,,,,,fee schedule,565,7583.1,
Add pwr tiller,E0984,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,565,,,,,,,fee schedule,565,7583.1,
Add pwr tiller,E0984,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4690.38,,,,,,,fee schedule,565,7583.1,
Add pwr tiller,E0984,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6640.22,,,,,,,fee schedule,565,7583.1,
Add pwr tiller,E0984,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,617.22,,,,,,,fee schedule,565,7583.1,
Add pwr tiller,E0984,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5123.81,,,,,,,fee schedule,565,7583.1,
W/c seat lift mechanism,E0985,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,741.21,,,,,,,fee schedule,64.6,805.1,
W/c seat lift mechanism,E0985,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,74.19,,,,,,,fee schedule,64.6,805.1,
W/c seat lift mechanism,E0985,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,555.86,,,,,,,fee schedule,64.6,805.1,
W/c seat lift mechanism,E0985,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,805.1,,,,,,,fee schedule,64.6,805.1,
W/c seat lift mechanism,E0985,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,80.59,,,,,,,fee schedule,64.6,805.1,
W/c seat lift mechanism,E0985,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,603.78,,,,,,,fee schedule,64.6,805.1,
W/c seat lift mechanism,E0985,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,645.36,,,,,,,fee schedule,64.6,805.1,
W/c seat lift mechanism,E0985,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,64.6,,,,,,,fee schedule,64.6,805.1,
W/c seat lift mechanism,E0985,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,483.98,,,,,,,fee schedule,64.6,805.1,
W/c seat lift mechanism,E0985,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,705,,,,,,,fee schedule,64.6,805.1,
W/c seat lift mechanism,E0985,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,70.57,,,,,,,fee schedule,64.6,805.1,
W/c seat lift mechanism,E0985,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,528.71,,,,,,,fee schedule,64.6,805.1,
Man w/c push-rim powr system,E0986,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17773.93,,,,,,,fee schedule,1547.57,19306.16,
Man w/c push-rim powr system,E0986,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1777.41,,,,,,,fee schedule,1547.57,19306.16,
Man w/c push-rim powr system,E0986,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13330.52,,,,,,,fee schedule,1547.57,19306.16,
Man w/c push-rim powr system,E0986,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19306.16,,,,,,,fee schedule,1547.57,19306.16,
Man w/c push-rim powr system,E0986,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1930.64,,,,,,,fee schedule,1547.57,19306.16,
Man w/c push-rim powr system,E0986,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14479.71,,,,,,,fee schedule,1547.57,19306.16,
Man w/c push-rim powr system,E0986,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15475.57,,,,,,,fee schedule,1547.57,19306.16,
Man w/c push-rim powr system,E0986,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1547.57,,,,,,,fee schedule,1547.57,19306.16,
Man w/c push-rim powr system,E0986,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11606.75,,,,,,,fee schedule,1547.57,19306.16,
Man w/c push-rim powr system,E0986,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16905.66,,,,,,,fee schedule,1547.57,19306.16,
Man w/c push-rim powr system,E0986,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1690.58,,,,,,,fee schedule,1547.57,19306.16,
Man w/c push-rim powr system,E0986,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12679.32,,,,,,,fee schedule,1547.57,19306.16,
Lever-activated wheel drive,E0988,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14662.74,,,,,,,fee schedule,982.05,15926.77,
Lever-activated wheel drive,E0988,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1127.9,,,,,,,fee schedule,982.05,15926.77,
Lever-activated wheel drive,E0988,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15926.77,,,,,,,fee schedule,982.05,15926.77,
Lever-activated wheel drive,E0988,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1225.14,,,,,,,fee schedule,982.05,15926.77,
Lever-activated wheel drive,E0988,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12766.69,,,,,,,fee schedule,982.05,15926.77,
Lever-activated wheel drive,E0988,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,982.05,,,,,,,fee schedule,982.05,15926.77,
Lever-activated wheel drive,E0988,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13946.45,,,,,,,fee schedule,982.05,15926.77,
Lever-activated wheel drive,E0988,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1072.8,,,,,,,fee schedule,982.05,15926.77,
Wheelchair elevating leg res,E0990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,366.76,,,,,,,fee schedule,31.91,398.37,
Wheelchair elevating leg res,E0990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,36.64,,,,,,,fee schedule,31.91,398.37,
Wheelchair elevating leg res,E0990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,275.02,,,,,,,fee schedule,31.91,398.37,
Wheelchair elevating leg res,E0990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,398.37,,,,,,,fee schedule,31.91,398.37,
Wheelchair elevating leg res,E0990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,39.8,,,,,,,fee schedule,31.91,398.37,
Wheelchair elevating leg res,E0990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,298.73,,,,,,,fee schedule,31.91,398.37,
Wheelchair elevating leg res,E0990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,319.33,,,,,,,fee schedule,31.91,398.37,
Wheelchair elevating leg res,E0990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31.91,,,,,,,fee schedule,31.91,398.37,
Wheelchair elevating leg res,E0990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,239.46,,,,,,,fee schedule,31.91,398.37,
Wheelchair elevating leg res,E0990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,348.84,,,,,,,fee schedule,31.91,398.37,
Wheelchair elevating leg res,E0990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,34.85,,,,,,,fee schedule,31.91,398.37,
Wheelchair elevating leg res,E0990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,261.59,,,,,,,fee schedule,31.91,398.37,
Wheelchair solid seat insert,E0992,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,332.79,,,,,,,fee schedule,29,361.48,
Wheelchair solid seat insert,E0992,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33.3,,,,,,,fee schedule,29,361.48,
Wheelchair solid seat insert,E0992,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,249.69,,,,,,,fee schedule,29,361.48,
Wheelchair solid seat insert,E0992,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,361.48,,,,,,,fee schedule,29,361.48,
Wheelchair solid seat insert,E0992,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,36.17,,,,,,,fee schedule,29,361.48,
Wheelchair solid seat insert,E0992,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,271.22,,,,,,,fee schedule,29,361.48,
Wheelchair solid seat insert,E0992,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,289.76,,,,,,,fee schedule,29,361.48,
Wheelchair solid seat insert,E0992,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29,,,,,,,fee schedule,29,361.48,
Wheelchair solid seat insert,E0992,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,217.4,,,,,,,fee schedule,29,361.48,
Wheelchair solid seat insert,E0992,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,316.54,,,,,,,fee schedule,29,361.48,
Wheelchair solid seat insert,E0992,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31.68,,,,,,,fee schedule,29,361.48,
Wheelchair solid seat insert,E0992,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,237.49,,,,,,,fee schedule,29,361.48,
Wheelchair arm rest,E0994,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,64.41,,,,,,,fee schedule,5.67,69.97,
Wheelchair arm rest,E0994,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.51,,,,,,,fee schedule,5.67,69.97,
Wheelchair arm rest,E0994,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,48.34,,,,,,,fee schedule,5.67,69.97,
Wheelchair arm rest,E0994,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,69.97,,,,,,,fee schedule,5.67,69.97,
Wheelchair arm rest,E0994,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7.07,,,,,,,fee schedule,5.67,69.97,
Wheelchair arm rest,E0994,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,52.5,,,,,,,fee schedule,5.67,69.97,
Wheelchair arm rest,E0994,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56.09,,,,,,,fee schedule,5.67,69.97,
Wheelchair arm rest,E0994,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.67,,,,,,,fee schedule,5.67,69.97,
Wheelchair arm rest,E0994,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.09,,,,,,,fee schedule,5.67,69.97,
Wheelchair arm rest,E0994,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,61.27,,,,,,,fee schedule,5.67,69.97,
Wheelchair arm rest,E0994,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.19,,,,,,,fee schedule,5.67,69.97,
Wheelchair arm rest,E0994,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,45.98,,,,,,,fee schedule,5.67,69.97,
"Wc calf rest, pad replacemnt",E0995,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,95.73,,,,,,,fee schedule,8.36,103.99,
"Wc calf rest, pad replacemnt",E0995,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.6,,,,,,,fee schedule,8.36,103.99,
"Wc calf rest, pad replacemnt",E0995,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,71.76,,,,,,,fee schedule,8.36,103.99,
"Wc calf rest, pad replacemnt",E0995,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,103.99,,,,,,,fee schedule,8.36,103.99,
"Wc calf rest, pad replacemnt",E0995,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10.43,,,,,,,fee schedule,8.36,103.99,
"Wc calf rest, pad replacemnt",E0995,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,77.94,,,,,,,fee schedule,8.36,103.99,
"Wc calf rest, pad replacemnt",E0995,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,83.36,,,,,,,fee schedule,8.36,103.99,
"Wc calf rest, pad replacemnt",E0995,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.36,,,,,,,fee schedule,8.36,103.99,
"Wc calf rest, pad replacemnt",E0995,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,62.48,,,,,,,fee schedule,8.36,103.99,
"Wc calf rest, pad replacemnt",E0995,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,91.06,,,,,,,fee schedule,8.36,103.99,
"Wc calf rest, pad replacemnt",E0995,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.14,,,,,,,fee schedule,8.36,103.99,
"Wc calf rest, pad replacemnt",E0995,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,68.25,,,,,,,fee schedule,8.36,103.99,
Pwr seat tilt,E1002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12765.2,,,,,,,fee schedule,1111.43,13865.64,
Pwr seat tilt,E1002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1276.5,,,,,,,fee schedule,1111.43,13865.64,
Pwr seat tilt,E1002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9573.86,,,,,,,fee schedule,1111.43,13865.64,
Pwr seat tilt,E1002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13865.64,,,,,,,fee schedule,1111.43,13865.64,
Pwr seat tilt,E1002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1386.54,,,,,,,fee schedule,1111.43,13865.64,
Pwr seat tilt,E1002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10399.2,,,,,,,fee schedule,1111.43,13865.64,
Pwr seat tilt,E1002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11114.52,,,,,,,fee schedule,1111.43,13865.64,
Pwr seat tilt,E1002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1111.43,,,,,,,fee schedule,1111.43,13865.64,
Pwr seat tilt,E1002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8335.86,,,,,,,fee schedule,1111.43,13865.64,
Pwr seat tilt,E1002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12141.61,,,,,,,fee schedule,1111.43,13865.64,
Pwr seat tilt,E1002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1214.14,,,,,,,fee schedule,1111.43,13865.64,
Pwr seat tilt,E1002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9106.17,,,,,,,fee schedule,1111.43,13865.64,
Pwr seat recline,E1003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13829.97,,,,,,,fee schedule,1204.18,15022.21,
Pwr seat recline,E1003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1383.02,,,,,,,fee schedule,1204.18,15022.21,
Pwr seat recline,E1003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10372.49,,,,,,,fee schedule,1204.18,15022.21,
Pwr seat recline,E1003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15022.21,,,,,,,fee schedule,1204.18,15022.21,
Pwr seat recline,E1003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1502.25,,,,,,,fee schedule,1204.18,15022.21,
Pwr seat recline,E1003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11266.67,,,,,,,fee schedule,1204.18,15022.21,
Pwr seat recline,E1003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12041.61,,,,,,,fee schedule,1204.18,15022.21,
Pwr seat recline,E1003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1204.18,,,,,,,fee schedule,1204.18,15022.21,
Pwr seat recline,E1003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9031.22,,,,,,,fee schedule,1204.18,15022.21,
Pwr seat recline,E1003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13154.37,,,,,,,fee schedule,1204.18,15022.21,
Pwr seat recline,E1003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1315.46,,,,,,,fee schedule,1204.18,15022.21,
Pwr seat recline,E1003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9865.79,,,,,,,fee schedule,1204.18,15022.21,
Pwr seat recline mech,E1004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15334.59,,,,,,,fee schedule,1335.14,16656.53,
Pwr seat recline mech,E1004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1533.43,,,,,,,fee schedule,1335.14,16656.53,
Pwr seat recline mech,E1004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11500.88,,,,,,,fee schedule,1335.14,16656.53,
Pwr seat recline mech,E1004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16656.53,,,,,,,fee schedule,1335.14,16656.53,
Pwr seat recline mech,E1004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1665.62,,,,,,,fee schedule,1335.14,16656.53,
Pwr seat recline mech,E1004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12492.33,,,,,,,fee schedule,1335.14,16656.53,
Pwr seat recline mech,E1004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13351.66,,,,,,,fee schedule,1335.14,16656.53,
Pwr seat recline mech,E1004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1335.14,,,,,,,fee schedule,1335.14,16656.53,
Pwr seat recline mech,E1004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10013.7,,,,,,,fee schedule,1335.14,16656.53,
Pwr seat recline mech,E1004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14585.48,,,,,,,fee schedule,1335.14,16656.53,
Pwr seat recline mech,E1004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1458.52,,,,,,,fee schedule,1335.14,16656.53,
Pwr seat recline mech,E1004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10939.05,,,,,,,fee schedule,1335.14,16656.53,
Pwr seat recline pwr,E1005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16598.49,,,,,,,fee schedule,1445.19,18029.39,
Pwr seat recline pwr,E1005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1659.82,,,,,,,fee schedule,1445.19,18029.39,
Pwr seat recline pwr,E1005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12448.9,,,,,,,fee schedule,1445.19,18029.39,
Pwr seat recline pwr,E1005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18029.39,,,,,,,fee schedule,1445.19,18029.39,
Pwr seat recline pwr,E1005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1802.91,,,,,,,fee schedule,1445.19,18029.39,
Pwr seat recline pwr,E1005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13522.08,,,,,,,fee schedule,1445.19,18029.39,
Pwr seat recline pwr,E1005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14452.13,,,,,,,fee schedule,1445.19,18029.39,
Pwr seat recline pwr,E1005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1445.19,,,,,,,fee schedule,1445.19,18029.39,
Pwr seat recline pwr,E1005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10839.13,,,,,,,fee schedule,1445.19,18029.39,
Pwr seat recline pwr,E1005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15787.64,,,,,,,fee schedule,1445.19,18029.39,
Pwr seat recline pwr,E1005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1578.74,,,,,,,fee schedule,1445.19,18029.39,
Pwr seat recline pwr,E1005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11840.76,,,,,,,fee schedule,1445.19,18029.39,
Pwr seat combo w/o shear,E1006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20331.59,,,,,,,fee schedule,1770.19,22084.31,
Pwr seat combo w/o shear,E1006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2033.09,,,,,,,fee schedule,1770.19,22084.31,
Pwr seat combo w/o shear,E1006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15248.7,,,,,,,fee schedule,1770.19,22084.31,
Pwr seat combo w/o shear,E1006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22084.31,,,,,,,fee schedule,1770.19,22084.31,
Pwr seat combo w/o shear,E1006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2208.35,,,,,,,fee schedule,1770.19,22084.31,
Pwr seat combo w/o shear,E1006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16563.24,,,,,,,fee schedule,1770.19,22084.31,
Pwr seat combo w/o shear,E1006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17702.5,,,,,,,fee schedule,1770.19,22084.31,
Pwr seat combo w/o shear,E1006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1770.19,,,,,,,fee schedule,1770.19,22084.31,
Pwr seat combo w/o shear,E1006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13276.88,,,,,,,fee schedule,1770.19,22084.31,
Pwr seat combo w/o shear,E1006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19338.38,,,,,,,fee schedule,1770.19,22084.31,
Pwr seat combo w/o shear,E1006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1933.77,,,,,,,fee schedule,1770.19,22084.31,
Pwr seat combo w/o shear,E1006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14503.79,,,,,,,fee schedule,1770.19,22084.31,
Pwr seat combo w/shear,E1007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27529.76,,,,,,,fee schedule,2397,29903.01,
Pwr seat combo w/shear,E1007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2752.99,,,,,,,fee schedule,2397,29903.01,
Pwr seat combo w/shear,E1007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20647.29,,,,,,,fee schedule,2397,29903.01,
Pwr seat combo w/shear,E1007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,29903.01,,,,,,,fee schedule,2397,29903.01,
Pwr seat combo w/shear,E1007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2990.32,,,,,,,fee schedule,2397,29903.01,
Pwr seat combo w/shear,E1007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22427.23,,,,,,,fee schedule,2397,29903.01,
Pwr seat combo w/shear,E1007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23969.88,,,,,,,fee schedule,2397,29903.01,
Pwr seat combo w/shear,E1007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2397,,,,,,,fee schedule,2397,29903.01,
Pwr seat combo w/shear,E1007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17977.38,,,,,,,fee schedule,2397,29903.01,
Pwr seat combo w/shear,E1007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26184.91,,,,,,,fee schedule,2397,29903.01,
Pwr seat combo w/shear,E1007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2618.51,,,,,,,fee schedule,2397,29903.01,
Pwr seat combo w/shear,E1007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19638.66,,,,,,,fee schedule,2397,29903.01,
Pwr seat combo pwr shear,E1008,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27532.23,,,,,,,fee schedule,2397.18,29905.7,
Pwr seat combo pwr shear,E1008,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2753.2,,,,,,,fee schedule,2397.18,29905.7,
Pwr seat combo pwr shear,E1008,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20649.21,,,,,,,fee schedule,2397.18,29905.7,
Pwr seat combo pwr shear,E1008,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,29905.7,,,,,,,fee schedule,2397.18,29905.7,
Pwr seat combo pwr shear,E1008,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2990.55,,,,,,,fee schedule,2397.18,29905.7,
Pwr seat combo pwr shear,E1008,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22429.31,,,,,,,fee schedule,2397.18,29905.7,
Pwr seat combo pwr shear,E1008,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23972.03,,,,,,,fee schedule,2397.18,29905.7,
Pwr seat combo pwr shear,E1008,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2397.18,,,,,,,fee schedule,2397.18,29905.7,
Pwr seat combo pwr shear,E1008,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17979.05,,,,,,,fee schedule,2397.18,29905.7,
Pwr seat combo pwr shear,E1008,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26187.26,,,,,,,fee schedule,2397.18,29905.7,
Pwr seat combo pwr shear,E1008,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2618.71,,,,,,,fee schedule,2397.18,29905.7,
Pwr seat combo pwr shear,E1008,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19640.48,,,,,,,fee schedule,2397.18,29905.7,
Add pwr leg elevation,E1010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3602.25,,,,,,,fee schedule,313.64,3912.79,
Add pwr leg elevation,E1010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,360.21,,,,,,,fee schedule,313.64,3912.79,
Add pwr leg elevation,E1010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2701.73,,,,,,,fee schedule,313.64,3912.79,
Add pwr leg elevation,E1010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3912.79,,,,,,,fee schedule,313.64,3912.79,
Add pwr leg elevation,E1010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,391.27,,,,,,,fee schedule,313.64,3912.79,
Add pwr leg elevation,E1010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2934.64,,,,,,,fee schedule,313.64,3912.79,
Add pwr leg elevation,E1010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3136.44,,,,,,,fee schedule,313.64,3912.79,
Add pwr leg elevation,E1010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,313.64,,,,,,,fee schedule,313.64,3912.79,
Add pwr leg elevation,E1010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2352.37,,,,,,,fee schedule,313.64,3912.79,
Add pwr leg elevation,E1010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3426.28,,,,,,,fee schedule,313.64,3912.79,
Add pwr leg elevation,E1010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,342.62,,,,,,,fee schedule,313.64,3912.79,
Add pwr leg elevation,E1010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2569.75,,,,,,,fee schedule,313.64,3912.79,
Reclining back add ped w/c,E1014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1334.23,,,,,,,fee schedule,116.2,1449.25,
Reclining back add ped w/c,E1014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,133.46,,,,,,,fee schedule,116.2,1449.25,
Reclining back add ped w/c,E1014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1000.64,,,,,,,fee schedule,116.2,1449.25,
Reclining back add ped w/c,E1014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1449.25,,,,,,,fee schedule,116.2,1449.25,
Reclining back add ped w/c,E1014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,144.96,,,,,,,fee schedule,116.2,1449.25,
Reclining back add ped w/c,E1014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1086.9,,,,,,,fee schedule,116.2,1449.25,
Reclining back add ped w/c,E1014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1161.7,,,,,,,fee schedule,116.2,1449.25,
Reclining back add ped w/c,E1014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,116.2,,,,,,,fee schedule,116.2,1449.25,
Reclining back add ped w/c,E1014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,871.25,,,,,,,fee schedule,116.2,1449.25,
Reclining back add ped w/c,E1014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1269.05,,,,,,,fee schedule,116.2,1449.25,
Reclining back add ped w/c,E1014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,126.94,,,,,,,fee schedule,116.2,1449.25,
Reclining back add ped w/c,E1014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,951.76,,,,,,,fee schedule,116.2,1449.25,
Shock absorber for man w/c,E1015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,419.13,,,,,,,fee schedule,36.45,455.26,
Shock absorber for man w/c,E1015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41.86,,,,,,,fee schedule,36.45,455.26,
Shock absorber for man w/c,E1015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,314.31,,,,,,,fee schedule,36.45,455.26,
Shock absorber for man w/c,E1015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,455.26,,,,,,,fee schedule,36.45,455.26,
Shock absorber for man w/c,E1015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45.47,,,,,,,fee schedule,36.45,455.26,
Shock absorber for man w/c,E1015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,341.41,,,,,,,fee schedule,36.45,455.26,
Shock absorber for man w/c,E1015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,364.93,,,,,,,fee schedule,36.45,455.26,
Shock absorber for man w/c,E1015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36.45,,,,,,,fee schedule,36.45,455.26,
Shock absorber for man w/c,E1015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,273.67,,,,,,,fee schedule,36.45,455.26,
Shock absorber for man w/c,E1015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,398.66,,,,,,,fee schedule,36.45,455.26,
Shock absorber for man w/c,E1015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39.82,,,,,,,fee schedule,36.45,455.26,
Shock absorber for man w/c,E1015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,298.96,,,,,,,fee schedule,36.45,455.26,
Shock absorber for power w/c,E1016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,413.56,,,,,,,fee schedule,36.03,449.22,
Shock absorber for power w/c,E1016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41.38,,,,,,,fee schedule,36.03,449.22,
Shock absorber for power w/c,E1016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,310.14,,,,,,,fee schedule,36.03,449.22,
Shock absorber for power w/c,E1016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,449.22,,,,,,,fee schedule,36.03,449.22,
Shock absorber for power w/c,E1016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,44.94,,,,,,,fee schedule,36.03,449.22,
Shock absorber for power w/c,E1016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,336.87,,,,,,,fee schedule,36.03,449.22,
Shock absorber for power w/c,E1016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,360.09,,,,,,,fee schedule,36.03,449.22,
Shock absorber for power w/c,E1016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36.03,,,,,,,fee schedule,36.03,449.22,
Shock absorber for power w/c,E1016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,270.03,,,,,,,fee schedule,36.03,449.22,
Shock absorber for power w/c,E1016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,393.36,,,,,,,fee schedule,36.03,449.22,
Shock absorber for power w/c,E1016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39.36,,,,,,,fee schedule,36.03,449.22,
Shock absorber for power w/c,E1016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,294.99,,,,,,,fee schedule,36.03,449.22,
Residual limb support system,E1020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,766.61,,,,,,,fee schedule,66.69,832.7,
Residual limb support system,E1020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,76.59,,,,,,,fee schedule,66.69,832.7,
Residual limb support system,E1020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,574.93,,,,,,,fee schedule,66.69,832.7,
Residual limb support system,E1020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,832.7,,,,,,,fee schedule,66.69,832.7,
Residual limb support system,E1020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83.2,,,,,,,fee schedule,66.69,832.7,
Residual limb support system,E1020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,624.49,,,,,,,fee schedule,66.69,832.7,
Residual limb support system,E1020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,667.48,,,,,,,fee schedule,66.69,832.7,
Residual limb support system,E1020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66.69,,,,,,,fee schedule,66.69,832.7,
Residual limb support system,E1020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,500.59,,,,,,,fee schedule,66.69,832.7,
Residual limb support system,E1020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,729.16,,,,,,,fee schedule,66.69,832.7,
Residual limb support system,E1020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,72.85,,,,,,,fee schedule,66.69,832.7,
Residual limb support system,E1020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,546.85,,,,,,,fee schedule,66.69,832.7,
W/c manual swingaway,E1028,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,650.48,,,,,,,fee schedule,56.63,706.56,
W/c manual swingaway,E1028,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,65.04,,,,,,,fee schedule,56.63,706.56,
W/c manual swingaway,E1028,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,487.83,,,,,,,fee schedule,56.63,706.56,
W/c manual swingaway,E1028,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,706.56,,,,,,,fee schedule,56.63,706.56,
W/c manual swingaway,E1028,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,70.65,,,,,,,fee schedule,56.63,706.56,
W/c manual swingaway,E1028,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,529.88,,,,,,,fee schedule,56.63,706.56,
W/c manual swingaway,E1028,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,566.37,,,,,,,fee schedule,56.63,706.56,
W/c manual swingaway,E1028,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56.63,,,,,,,fee schedule,56.63,706.56,
W/c manual swingaway,E1028,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,424.75,,,,,,,fee schedule,56.63,706.56,
W/c manual swingaway,E1028,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,618.71,,,,,,,fee schedule,56.63,706.56,
W/c manual swingaway,E1028,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,61.86,,,,,,,fee schedule,56.63,706.56,
W/c manual swingaway,E1028,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,464,,,,,,,fee schedule,56.63,706.56,
W/c vent tray fixed,E1029,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1163.82,,,,,,,fee schedule,101.32,1264.15,
W/c vent tray fixed,E1029,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,116.37,,,,,,,fee schedule,101.32,1264.15,
W/c vent tray fixed,E1029,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,872.85,,,,,,,fee schedule,101.32,1264.15,
W/c vent tray fixed,E1029,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1264.15,,,,,,,fee schedule,101.32,1264.15,
W/c vent tray fixed,E1029,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,126.4,,,,,,,fee schedule,101.32,1264.15,
W/c vent tray fixed,E1029,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,948.1,,,,,,,fee schedule,101.32,1264.15,
W/c vent tray fixed,E1029,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1013.32,,,,,,,fee schedule,101.32,1264.15,
W/c vent tray fixed,E1029,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,101.32,,,,,,,fee schedule,101.32,1264.15,
W/c vent tray fixed,E1029,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,759.98,,,,,,,fee schedule,101.32,1264.15,
W/c vent tray fixed,E1029,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1106.96,,,,,,,fee schedule,101.32,1264.15,
W/c vent tray fixed,E1029,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,110.69,,,,,,,fee schedule,101.32,1264.15,
W/c vent tray fixed,E1029,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,830.21,,,,,,,fee schedule,101.32,1264.15,
W/c vent tray gimbaled,E1030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3669.9,,,,,,,fee schedule,319.54,3986.27,
W/c vent tray gimbaled,E1030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,367,,,,,,,fee schedule,319.54,3986.27,
W/c vent tray gimbaled,E1030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2752.44,,,,,,,fee schedule,319.54,3986.27,
W/c vent tray gimbaled,E1030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3986.27,,,,,,,fee schedule,319.54,3986.27,
W/c vent tray gimbaled,E1030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,398.64,,,,,,,fee schedule,319.54,3986.27,
W/c vent tray gimbaled,E1030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2989.72,,,,,,,fee schedule,319.54,3986.27,
W/c vent tray gimbaled,E1030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3195.35,,,,,,,fee schedule,319.54,3986.27,
W/c vent tray gimbaled,E1030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,319.54,,,,,,,fee schedule,319.54,3986.27,
W/c vent tray gimbaled,E1030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2396.52,,,,,,,fee schedule,319.54,3986.27,
W/c vent tray gimbaled,E1030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3490.63,,,,,,,fee schedule,319.54,3986.27,
W/c vent tray gimbaled,E1030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,349.07,,,,,,,fee schedule,319.54,3986.27,
W/c vent tray gimbaled,E1030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2617.98,,,,,,,fee schedule,319.54,3986.27,
Rollabout chair with casters,E1031,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1647.22,,,,,,,fee schedule,136.59,1789.23,
Rollabout chair with casters,E1031,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,156.88,,,,,,,fee schedule,136.59,1789.23,
Rollabout chair with casters,E1031,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1789.23,,,,,,,fee schedule,136.59,1789.23,
Rollabout chair with casters,E1031,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,170.4,,,,,,,fee schedule,136.59,1789.23,
Rollabout chair with casters,E1031,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1434.22,,,,,,,fee schedule,136.59,1789.23,
Rollabout chair with casters,E1031,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,136.59,,,,,,,fee schedule,136.59,1789.23,
Rollabout chair with casters,E1031,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1566.76,,,,,,,fee schedule,136.59,1789.23,
Rollabout chair with casters,E1031,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,149.21,,,,,,,fee schedule,136.59,1789.23,
Patient transfer system <300,E1035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23526.64,,,,,,,fee schedule,1950.9,25554.8,
Patient transfer system <300,E1035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2240.63,,,,,,,fee schedule,1950.9,25554.8,
Patient transfer system <300,E1035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,25554.8,,,,,,,fee schedule,1950.9,25554.8,
Patient transfer system <300,E1035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2433.79,,,,,,,fee schedule,1950.9,25554.8,
Patient transfer system <300,E1035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20484.41,,,,,,,fee schedule,1950.9,25554.8,
Patient transfer system <300,E1035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1950.9,,,,,,,fee schedule,1950.9,25554.8,
Patient transfer system <300,E1035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22377.35,,,,,,,fee schedule,1950.9,25554.8,
Patient transfer system <300,E1035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2131.18,,,,,,,fee schedule,1950.9,25554.8,
"Transport chair, ped size",E1037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4162.29,,,,,,,fee schedule,345.15,4521.11,
"Transport chair, ped size",E1037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,396.41,,,,,,,fee schedule,345.15,4521.11,
"Transport chair, ped size",E1037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4521.11,,,,,,,fee schedule,345.15,4521.11,
"Transport chair, ped size",E1037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,430.58,,,,,,,fee schedule,345.15,4521.11,
"Transport chair, ped size",E1037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3624.06,,,,,,,fee schedule,345.15,4521.11,
"Transport chair, ped size",E1037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,345.15,,,,,,,fee schedule,345.15,4521.11,
"Transport chair, ped size",E1037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3958.96,,,,,,,fee schedule,345.15,4521.11,
"Transport chair, ped size",E1037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,377.04,,,,,,,fee schedule,345.15,4521.11,
Transport chair pt wt<=300lb,E1038,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,691.72,,,,,,,fee schedule,57.36,751.35,
Transport chair pt wt<=300lb,E1038,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,65.88,,,,,,,fee schedule,57.36,751.35,
Transport chair pt wt<=300lb,E1038,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,751.35,,,,,,,fee schedule,57.36,751.35,
Transport chair pt wt<=300lb,E1038,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,71.56,,,,,,,fee schedule,57.36,751.35,
Transport chair pt wt<=300lb,E1038,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,602.27,,,,,,,fee schedule,57.36,751.35,
Transport chair pt wt<=300lb,E1038,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.36,,,,,,,fee schedule,57.36,751.35,
Transport chair pt wt<=300lb,E1038,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,657.93,,,,,,,fee schedule,57.36,751.35,
Transport chair pt wt<=300lb,E1038,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,62.66,,,,,,,fee schedule,57.36,751.35,
Transport chair pt wt >300lb,E1039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1312.13,,,,,,,fee schedule,108.81,1425.25,
Transport chair pt wt >300lb,E1039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,124.97,,,,,,,fee schedule,108.81,1425.25,
Transport chair pt wt >300lb,E1039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1425.25,,,,,,,fee schedule,108.81,1425.25,
Transport chair pt wt >300lb,E1039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,135.74,,,,,,,fee schedule,108.81,1425.25,
Transport chair pt wt >300lb,E1039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1142.46,,,,,,,fee schedule,108.81,1425.25,
Transport chair pt wt >300lb,E1039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,108.81,,,,,,,fee schedule,108.81,1425.25,
Transport chair pt wt >300lb,E1039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1248.04,,,,,,,fee schedule,108.81,1425.25,
Transport chair pt wt >300lb,E1039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,118.86,,,,,,,fee schedule,108.81,1425.25,
Whelchr fxd full length arms,E1050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3907.24,,,,,,,fee schedule,324,4244.07,
Whelchr fxd full length arms,E1050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,372.12,,,,,,,fee schedule,324,4244.07,
Whelchr fxd full length arms,E1050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4244.07,,,,,,,fee schedule,324,4244.07,
Whelchr fxd full length arms,E1050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,404.2,,,,,,,fee schedule,324,4244.07,
Whelchr fxd full length arms,E1050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3401.99,,,,,,,fee schedule,324,4244.07,
Whelchr fxd full length arms,E1050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,324,,,,,,,fee schedule,324,4244.07,
Whelchr fxd full length arms,E1050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3716.37,,,,,,,fee schedule,324,4244.07,
Whelchr fxd full length arms,E1050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.94,,,,,,,fee schedule,324,4244.07,
Wheelchair detachable arms,E1060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4836.78,,,,,,,fee schedule,401.08,5253.75,
Wheelchair detachable arms,E1060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,460.65,,,,,,,fee schedule,401.08,5253.75,
Wheelchair detachable arms,E1060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5253.75,,,,,,,fee schedule,401.08,5253.75,
Wheelchair detachable arms,E1060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,500.36,,,,,,,fee schedule,401.08,5253.75,
Wheelchair detachable arms,E1060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4211.34,,,,,,,fee schedule,401.08,5253.75,
Wheelchair detachable arms,E1060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,401.08,,,,,,,fee schedule,401.08,5253.75,
Wheelchair detachable arms,E1060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4600.5,,,,,,,fee schedule,401.08,5253.75,
Wheelchair detachable arms,E1060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,438.14,,,,,,,fee schedule,401.08,5253.75,
Wheelchair detachable foot r,E1070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4202.48,,,,,,,fee schedule,348.48,4564.77,
Wheelchair detachable foot r,E1070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,400.23,,,,,,,fee schedule,348.48,4564.77,
Wheelchair detachable foot r,E1070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4564.77,,,,,,,fee schedule,348.48,4564.77,
Wheelchair detachable foot r,E1070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,434.74,,,,,,,fee schedule,348.48,4564.77,
Wheelchair detachable foot r,E1070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3659.06,,,,,,,fee schedule,348.48,4564.77,
Wheelchair detachable foot r,E1070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,348.48,,,,,,,fee schedule,348.48,4564.77,
Wheelchair detachable foot r,E1070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3997.19,,,,,,,fee schedule,348.48,4564.77,
Wheelchair detachable foot r,E1070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,380.68,,,,,,,fee schedule,348.48,4564.77,
Hemi-wheelchair fixed arms,E1083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3021.13,,,,,,,fee schedule,250.52,3281.57,
Hemi-wheelchair fixed arms,E1083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,287.73,,,,,,,fee schedule,250.52,3281.57,
Hemi-wheelchair fixed arms,E1083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3281.57,,,,,,,fee schedule,250.52,3281.57,
Hemi-wheelchair fixed arms,E1083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,312.53,,,,,,,fee schedule,250.52,3281.57,
Hemi-wheelchair fixed arms,E1083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2630.46,,,,,,,fee schedule,250.52,3281.57,
Hemi-wheelchair fixed arms,E1083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,250.52,,,,,,,fee schedule,250.52,3281.57,
Hemi-wheelchair fixed arms,E1083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2873.54,,,,,,,fee schedule,250.52,3281.57,
Hemi-wheelchair fixed arms,E1083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,273.67,,,,,,,fee schedule,250.52,3281.57,
Hemi-wheelchair detachable a,E1084,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3764,,,,,,,fee schedule,312.12,4088.49,
Hemi-wheelchair detachable a,E1084,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,358.47,,,,,,,fee schedule,312.12,4088.49,
Hemi-wheelchair detachable a,E1084,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4088.49,,,,,,,fee schedule,312.12,4088.49,
Hemi-wheelchair detachable a,E1084,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,389.38,,,,,,,fee schedule,312.12,4088.49,
Hemi-wheelchair detachable a,E1084,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3277.28,,,,,,,fee schedule,312.12,4088.49,
Hemi-wheelchair detachable a,E1084,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,312.12,,,,,,,fee schedule,312.12,4088.49,
Hemi-wheelchair detachable a,E1084,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3580.13,,,,,,,fee schedule,312.12,4088.49,
Hemi-wheelchair detachable a,E1084,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,340.96,,,,,,,fee schedule,312.12,4088.49,
Wheelchair lightwt fixed arm,E1087,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4853.97,,,,,,,fee schedule,402.51,5272.42,
Wheelchair lightwt fixed arm,E1087,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,462.28,,,,,,,fee schedule,402.51,5272.42,
Wheelchair lightwt fixed arm,E1087,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5272.42,,,,,,,fee schedule,402.51,5272.42,
Wheelchair lightwt fixed arm,E1087,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,502.14,,,,,,,fee schedule,402.51,5272.42,
Wheelchair lightwt fixed arm,E1087,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4226.3,,,,,,,fee schedule,402.51,5272.42,
Wheelchair lightwt fixed arm,E1087,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,402.51,,,,,,,fee schedule,402.51,5272.42,
Wheelchair lightwt fixed arm,E1087,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4616.85,,,,,,,fee schedule,402.51,5272.42,
Wheelchair lightwt fixed arm,E1087,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,439.7,,,,,,,fee schedule,402.51,5272.42,
Wheelchair lightweight det a,E1088,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5784.63,,,,,,,fee schedule,479.68,6283.31,
Wheelchair lightweight det a,E1088,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,550.92,,,,,,,fee schedule,479.68,6283.31,
Wheelchair lightweight det a,E1088,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6283.31,,,,,,,fee schedule,479.68,6283.31,
Wheelchair lightweight det a,E1088,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,598.41,,,,,,,fee schedule,479.68,6283.31,
Wheelchair lightweight det a,E1088,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5036.62,,,,,,,fee schedule,479.68,6283.31,
Wheelchair lightweight det a,E1088,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,479.68,,,,,,,fee schedule,479.68,6283.31,
Wheelchair lightweight det a,E1088,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5502.05,,,,,,,fee schedule,479.68,6283.31,
Wheelchair lightweight det a,E1088,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,524.01,,,,,,,fee schedule,479.68,6283.31,
Wheelchair wide w/ leg rests,E1092,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4930.71,,,,,,,fee schedule,408.87,5355.77,
Wheelchair wide w/ leg rests,E1092,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,469.59,,,,,,,fee schedule,408.87,5355.77,
Wheelchair wide w/ leg rests,E1092,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5355.77,,,,,,,fee schedule,408.87,5355.77,
Wheelchair wide w/ leg rests,E1092,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,510.07,,,,,,,fee schedule,408.87,5355.77,
Wheelchair wide w/ leg rests,E1092,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4293.12,,,,,,,fee schedule,408.87,5355.77,
Wheelchair wide w/ leg rests,E1092,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,408.87,,,,,,,fee schedule,408.87,5355.77,
Wheelchair wide w/ leg rests,E1092,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4689.84,,,,,,,fee schedule,408.87,5355.77,
Wheelchair wide w/ leg rests,E1092,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,446.65,,,,,,,fee schedule,408.87,5355.77,
Wheelchair wide w/ foot rest,E1093,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4240.48,,,,,,,fee schedule,351.63,4606.04,
Wheelchair wide w/ foot rest,E1093,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,403.85,,,,,,,fee schedule,351.63,4606.04,
Wheelchair wide w/ foot rest,E1093,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4606.04,,,,,,,fee schedule,351.63,4606.04,
Wheelchair wide w/ foot rest,E1093,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,438.67,,,,,,,fee schedule,351.63,4606.04,
Wheelchair wide w/ foot rest,E1093,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3692.15,,,,,,,fee schedule,351.63,4606.04,
Wheelchair wide w/ foot rest,E1093,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,351.63,,,,,,,fee schedule,351.63,4606.04,
Wheelchair wide w/ foot rest,E1093,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4033.33,,,,,,,fee schedule,351.63,4606.04,
Wheelchair wide w/ foot rest,E1093,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,384.13,,,,,,,fee schedule,351.63,4606.04,
Whchr s-recl fxd arm leg res,E1100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3982.86,,,,,,,fee schedule,330.27,4326.21,
Whchr s-recl fxd arm leg res,E1100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,379.32,,,,,,,fee schedule,330.27,4326.21,
Whchr s-recl fxd arm leg res,E1100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4326.21,,,,,,,fee schedule,330.27,4326.21,
Whchr s-recl fxd arm leg res,E1100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,412.02,,,,,,,fee schedule,330.27,4326.21,
Whchr s-recl fxd arm leg res,E1100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3467.84,,,,,,,fee schedule,330.27,4326.21,
Whchr s-recl fxd arm leg res,E1100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,330.27,,,,,,,fee schedule,330.27,4326.21,
Whchr s-recl fxd arm leg res,E1100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3788.3,,,,,,,fee schedule,330.27,4326.21,
Whchr s-recl fxd arm leg res,E1100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,360.79,,,,,,,fee schedule,330.27,4326.21,
Wheelchair semi-recl detach,E1110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3900.28,,,,,,,fee schedule,323.42,4236.51,
Wheelchair semi-recl detach,E1110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,371.46,,,,,,,fee schedule,323.42,4236.51,
Wheelchair semi-recl detach,E1110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4236.51,,,,,,,fee schedule,323.42,4236.51,
Wheelchair semi-recl detach,E1110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,403.48,,,,,,,fee schedule,323.42,4236.51,
Wheelchair semi-recl detach,E1110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3395.93,,,,,,,fee schedule,323.42,4236.51,
Wheelchair semi-recl detach,E1110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,323.42,,,,,,,fee schedule,323.42,4236.51,
Wheelchair semi-recl detach,E1110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3709.75,,,,,,,fee schedule,323.42,4236.51,
Wheelchair semi-recl detach,E1110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.31,,,,,,,fee schedule,323.42,4236.51,
Wheelchair standard w/ leg r,E1150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2837.7,,,,,,,fee schedule,235.31,3082.33,
Wheelchair standard w/ leg r,E1150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,270.26,,,,,,,fee schedule,235.31,3082.33,
Wheelchair standard w/ leg r,E1150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3082.33,,,,,,,fee schedule,235.31,3082.33,
Wheelchair standard w/ leg r,E1150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,293.55,,,,,,,fee schedule,235.31,3082.33,
Wheelchair standard w/ leg r,E1150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2470.75,,,,,,,fee schedule,235.31,3082.33,
Wheelchair standard w/ leg r,E1150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,235.31,,,,,,,fee schedule,235.31,3082.33,
Wheelchair standard w/ leg r,E1150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2699.07,,,,,,,fee schedule,235.31,3082.33,
Wheelchair standard w/ leg r,E1150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,257.05,,,,,,,fee schedule,235.31,3082.33,
Wheelchair fixed arms,E1160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2217.25,,,,,,,fee schedule,183.86,2408.39,
Wheelchair fixed arms,E1160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,211.17,,,,,,,fee schedule,183.86,2408.39,
Wheelchair fixed arms,E1160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2408.39,,,,,,,fee schedule,183.86,2408.39,
Wheelchair fixed arms,E1160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,229.37,,,,,,,fee schedule,183.86,2408.39,
Wheelchair fixed arms,E1160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1930.53,,,,,,,fee schedule,183.86,2408.39,
Wheelchair fixed arms,E1160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,183.86,,,,,,,fee schedule,183.86,2408.39,
Wheelchair fixed arms,E1160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2108.93,,,,,,,fee schedule,183.86,2408.39,
Wheelchair fixed arms,E1160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,200.85,,,,,,,fee schedule,183.86,2408.39,
Manual adult wc w tiltinspac,E1161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8645.68,,,,,,,fee schedule,752.77,9390.99,
Manual adult wc w tiltinspac,E1161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,864.57,,,,,,,fee schedule,752.77,9390.99,
Manual adult wc w tiltinspac,E1161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6484.35,,,,,,,fee schedule,752.77,9390.99,
Manual adult wc w tiltinspac,E1161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9390.99,,,,,,,fee schedule,752.77,9390.99,
Manual adult wc w tiltinspac,E1161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,939.1,,,,,,,fee schedule,752.77,9390.99,
Manual adult wc w tiltinspac,E1161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7043.35,,,,,,,fee schedule,752.77,9390.99,
Manual adult wc w tiltinspac,E1161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7527.7,,,,,,,fee schedule,752.77,9390.99,
Manual adult wc w tiltinspac,E1161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,752.77,,,,,,,fee schedule,752.77,9390.99,
Manual adult wc w tiltinspac,E1161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5645.86,,,,,,,fee schedule,752.77,9390.99,
Manual adult wc w tiltinspac,E1161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8223.33,,,,,,,fee schedule,752.77,9390.99,
Manual adult wc w tiltinspac,E1161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,822.34,,,,,,,fee schedule,752.77,9390.99,
Manual adult wc w tiltinspac,E1161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6167.59,,,,,,,fee schedule,752.77,9390.99,
Whlchr ampu fxd arm leg rest,E1170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3426.72,,,,,,,fee schedule,284.15,3722.13,
Whlchr ampu fxd arm leg rest,E1170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,326.35,,,,,,,fee schedule,284.15,3722.13,
Whlchr ampu fxd arm leg rest,E1170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3722.13,,,,,,,fee schedule,284.15,3722.13,
Whlchr ampu fxd arm leg rest,E1170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,354.49,,,,,,,fee schedule,284.15,3722.13,
Whlchr ampu fxd arm leg rest,E1170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2983.61,,,,,,,fee schedule,284.15,3722.13,
Whlchr ampu fxd arm leg rest,E1170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,284.15,,,,,,,fee schedule,284.15,3722.13,
Whlchr ampu fxd arm leg rest,E1170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3259.32,,,,,,,fee schedule,284.15,3722.13,
Whlchr ampu fxd arm leg rest,E1170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,310.41,,,,,,,fee schedule,284.15,3722.13,
Wheelchair amputee w/o leg r,E1171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3075.21,,,,,,,fee schedule,255,3340.31,
Wheelchair amputee w/o leg r,E1171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,292.88,,,,,,,fee schedule,255,3340.31,
Wheelchair amputee w/o leg r,E1171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3340.31,,,,,,,fee schedule,255,3340.31,
Wheelchair amputee w/o leg r,E1171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,318.12,,,,,,,fee schedule,255,3340.31,
Wheelchair amputee w/o leg r,E1171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2677.55,,,,,,,fee schedule,255,3340.31,
Wheelchair amputee w/o leg r,E1171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,255,,,,,,,fee schedule,255,3340.31,
Wheelchair amputee w/o leg r,E1171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2924.98,,,,,,,fee schedule,255,3340.31,
Wheelchair amputee w/o leg r,E1171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,278.57,,,,,,,fee schedule,255,3340.31,
Wheelchair amputee detach ar,E1172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3758.12,,,,,,,fee schedule,311.64,4082.1,
Wheelchair amputee detach ar,E1172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,357.92,,,,,,,fee schedule,311.64,4082.1,
Wheelchair amputee detach ar,E1172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4082.1,,,,,,,fee schedule,311.64,4082.1,
Wheelchair amputee detach ar,E1172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,388.77,,,,,,,fee schedule,311.64,4082.1,
Wheelchair amputee detach ar,E1172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3272.16,,,,,,,fee schedule,311.64,4082.1,
Wheelchair amputee detach ar,E1172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,311.64,,,,,,,fee schedule,311.64,4082.1,
Wheelchair amputee detach ar,E1172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3574.54,,,,,,,fee schedule,311.64,4082.1,
Wheelchair amputee detach ar,E1172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,340.43,,,,,,,fee schedule,311.64,4082.1,
Wheelchair amputee w/ foot r,E1180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3888.24,,,,,,,fee schedule,322.42,4223.43,
Wheelchair amputee w/ foot r,E1180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,370.31,,,,,,,fee schedule,322.42,4223.43,
Wheelchair amputee w/ foot r,E1180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4223.43,,,,,,,fee schedule,322.42,4223.43,
Wheelchair amputee w/ foot r,E1180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,402.23,,,,,,,fee schedule,322.42,4223.43,
Wheelchair amputee w/ foot r,E1180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3385.45,,,,,,,fee schedule,322.42,4223.43,
Wheelchair amputee w/ foot r,E1180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,322.42,,,,,,,fee schedule,322.42,4223.43,
Wheelchair amputee w/ foot r,E1180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3698.3,,,,,,,fee schedule,322.42,4223.43,
Wheelchair amputee w/ foot r,E1180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,352.22,,,,,,,fee schedule,322.42,4223.43,
Wheelchair amputee w/ leg re,E1190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4491.5,,,,,,,fee schedule,372.45,4878.69,
Wheelchair amputee w/ leg re,E1190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,427.76,,,,,,,fee schedule,372.45,4878.69,
Wheelchair amputee w/ leg re,E1190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4878.69,,,,,,,fee schedule,372.45,4878.69,
Wheelchair amputee w/ leg re,E1190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,464.64,,,,,,,fee schedule,372.45,4878.69,
Wheelchair amputee w/ leg re,E1190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3910.7,,,,,,,fee schedule,372.45,4878.69,
Wheelchair amputee w/ leg re,E1190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,372.45,,,,,,,fee schedule,372.45,4878.69,
Wheelchair amputee w/ leg re,E1190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4272.08,,,,,,,fee schedule,372.45,4878.69,
Wheelchair amputee w/ leg re,E1190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,406.87,,,,,,,fee schedule,372.45,4878.69,
Wheelchair amputee heavy dut,E1195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4820.01,,,,,,,fee schedule,399.69,5235.53,
Wheelchair amputee heavy dut,E1195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,459.05,,,,,,,fee schedule,399.69,5235.53,
Wheelchair amputee heavy dut,E1195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5235.53,,,,,,,fee schedule,399.69,5235.53,
Wheelchair amputee heavy dut,E1195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,498.62,,,,,,,fee schedule,399.69,5235.53,
Wheelchair amputee heavy dut,E1195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4196.73,,,,,,,fee schedule,399.69,5235.53,
Wheelchair amputee heavy dut,E1195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,399.69,,,,,,,fee schedule,399.69,5235.53,
Wheelchair amputee heavy dut,E1195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4584.55,,,,,,,fee schedule,399.69,5235.53,
Wheelchair amputee heavy dut,E1195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,436.62,,,,,,,fee schedule,399.69,5235.53,
Wheelchair amputee fixed arm,E1200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3338.29,,,,,,,fee schedule,276.82,3626.08,
Wheelchair amputee fixed arm,E1200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,317.93,,,,,,,fee schedule,276.82,3626.08,
Wheelchair amputee fixed arm,E1200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3626.08,,,,,,,fee schedule,276.82,3626.08,
Wheelchair amputee fixed arm,E1200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,345.34,,,,,,,fee schedule,276.82,3626.08,
Wheelchair amputee fixed arm,E1200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2906.62,,,,,,,fee schedule,276.82,3626.08,
Wheelchair amputee fixed arm,E1200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,276.82,,,,,,,fee schedule,276.82,3626.08,
Wheelchair amputee fixed arm,E1200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3175.22,,,,,,,fee schedule,276.82,3626.08,
Wheelchair amputee fixed arm,E1200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,302.4,,,,,,,fee schedule,276.82,3626.08,
Wheelchair spec size w foot,E1221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1549.64,,,,,,,fee schedule,128.5,1683.23,
Wheelchair spec size w foot,E1221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,147.59,,,,,,,fee schedule,128.5,1683.23,
Wheelchair spec size w foot,E1221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1683.23,,,,,,,fee schedule,128.5,1683.23,
Wheelchair spec size w foot,E1221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,160.31,,,,,,,fee schedule,128.5,1683.23,
Wheelchair spec size w foot,E1221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1349.26,,,,,,,fee schedule,128.5,1683.23,
Wheelchair spec size w foot,E1221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,128.5,,,,,,,fee schedule,128.5,1683.23,
Wheelchair spec size w foot,E1221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1473.94,,,,,,,fee schedule,128.5,1683.23,
Wheelchair spec size w foot,E1221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,140.38,,,,,,,fee schedule,128.5,1683.23,
Wheelchair spec size w/ leg,E1222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2210.67,,,,,,,fee schedule,183.32,2401.25,
Wheelchair spec size w/ leg,E1222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,210.54,,,,,,,fee schedule,183.32,2401.25,
Wheelchair spec size w/ leg,E1222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2401.25,,,,,,,fee schedule,183.32,2401.25,
Wheelchair spec size w/ leg,E1222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,228.69,,,,,,,fee schedule,183.32,2401.25,
Wheelchair spec size w/ leg,E1222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1924.81,,,,,,,fee schedule,183.32,2401.25,
Wheelchair spec size w/ leg,E1222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,183.32,,,,,,,fee schedule,183.32,2401.25,
Wheelchair spec size w/ leg,E1222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2102.68,,,,,,,fee schedule,183.32,2401.25,
Wheelchair spec size w/ leg,E1222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,200.26,,,,,,,fee schedule,183.32,2401.25,
Wheelchair spec size w foot,E1223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2413.83,,,,,,,fee schedule,200.16,2621.92,
Wheelchair spec size w foot,E1223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,229.89,,,,,,,fee schedule,200.16,2621.92,
Wheelchair spec size w foot,E1223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2621.92,,,,,,,fee schedule,200.16,2621.92,
Wheelchair spec size w foot,E1223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,249.71,,,,,,,fee schedule,200.16,2621.92,
Wheelchair spec size w foot,E1223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2101.7,,,,,,,fee schedule,200.16,2621.92,
Wheelchair spec size w foot,E1223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,200.16,,,,,,,fee schedule,200.16,2621.92,
Wheelchair spec size w foot,E1223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2295.92,,,,,,,fee schedule,200.16,2621.92,
Wheelchair spec size w foot,E1223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,218.66,,,,,,,fee schedule,200.16,2621.92,
Wheelchair spec size w/ leg,E1224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2836.97,,,,,,,fee schedule,235.25,3081.53,
Wheelchair spec size w/ leg,E1224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,270.19,,,,,,,fee schedule,235.25,3081.53,
Wheelchair spec size w/ leg,E1224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3081.53,,,,,,,fee schedule,235.25,3081.53,
Wheelchair spec size w/ leg,E1224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,293.48,,,,,,,fee schedule,235.25,3081.53,
Wheelchair spec size w/ leg,E1224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2470.12,,,,,,,fee schedule,235.25,3081.53,
Wheelchair spec size w/ leg,E1224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,235.25,,,,,,,fee schedule,235.25,3081.53,
Wheelchair spec size w/ leg,E1224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2698.38,,,,,,,fee schedule,235.25,3081.53,
Wheelchair spec size w/ leg,E1224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,256.99,,,,,,,fee schedule,235.25,3081.53,
Manual semi-reclining back,E1225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1642.11,,,,,,,fee schedule,136.17,1783.67,
Manual semi-reclining back,E1225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,156.39,,,,,,,fee schedule,136.17,1783.67,
Manual semi-reclining back,E1225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1783.67,,,,,,,fee schedule,136.17,1783.67,
Manual semi-reclining back,E1225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,169.87,,,,,,,fee schedule,136.17,1783.67,
Manual semi-reclining back,E1225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1429.77,,,,,,,fee schedule,136.17,1783.67,
Manual semi-reclining back,E1225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,136.17,,,,,,,fee schedule,136.17,1783.67,
Manual semi-reclining back,E1225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1561.89,,,,,,,fee schedule,136.17,1783.67,
Manual semi-reclining back,E1225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,148.75,,,,,,,fee schedule,136.17,1783.67,
Manual fully reclining back,E1226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1993.8,,,,,,,fee schedule,178.68,2165.68,
Manual fully reclining back,E1226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,205.22,,,,,,,fee schedule,178.68,2165.68,
Manual fully reclining back,E1226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1495.22,,,,,,,fee schedule,178.68,2165.68,
Manual fully reclining back,E1226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2165.68,,,,,,,fee schedule,178.68,2165.68,
Manual fully reclining back,E1226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,222.91,,,,,,,fee schedule,178.68,2165.68,
Manual fully reclining back,E1226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1624.11,,,,,,,fee schedule,178.68,2165.68,
Manual fully reclining back,E1226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1735.98,,,,,,,fee schedule,178.68,2165.68,
Manual fully reclining back,E1226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,178.68,,,,,,,fee schedule,178.68,2165.68,
Manual fully reclining back,E1226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1301.87,,,,,,,fee schedule,178.68,2165.68,
Manual fully reclining back,E1226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1896.4,,,,,,,fee schedule,178.68,2165.68,
Manual fully reclining back,E1226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,195.19,,,,,,,fee schedule,178.68,2165.68,
Manual fully reclining back,E1226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1422.17,,,,,,,fee schedule,178.68,2165.68,
Wheelchair spec sz spec ht a,E1227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1014,,,,,,,fee schedule,88.29,1101.42,
Wheelchair spec sz spec ht a,E1227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,101.41,,,,,,,fee schedule,88.29,1101.42,
Wheelchair spec sz spec ht a,E1227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,760.59,,,,,,,fee schedule,88.29,1101.42,
Wheelchair spec sz spec ht a,E1227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1101.42,,,,,,,fee schedule,88.29,1101.42,
Wheelchair spec sz spec ht a,E1227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,110.15,,,,,,,fee schedule,88.29,1101.42,
Wheelchair spec sz spec ht a,E1227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,826.16,,,,,,,fee schedule,88.29,1101.42,
Wheelchair spec sz spec ht a,E1227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,882.88,,,,,,,fee schedule,88.29,1101.42,
Wheelchair spec sz spec ht a,E1227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,88.29,,,,,,,fee schedule,88.29,1101.42,
Wheelchair spec sz spec ht a,E1227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,662.24,,,,,,,fee schedule,88.29,1101.42,
Wheelchair spec sz spec ht a,E1227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,964.47,,,,,,,fee schedule,88.29,1101.42,
Wheelchair spec sz spec ht a,E1227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,96.45,,,,,,,fee schedule,88.29,1101.42,
Wheelchair spec sz spec ht a,E1227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,723.43,,,,,,,fee schedule,88.29,1101.42,
Wheelchair spec sz spec ht b,E1228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,913.88,,,,,,,fee schedule,75.78,992.67,
Wheelchair spec sz spec ht b,E1228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,87.03,,,,,,,fee schedule,75.78,992.67,
Wheelchair spec sz spec ht b,E1228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,992.67,,,,,,,fee schedule,75.78,992.67,
Wheelchair spec sz spec ht b,E1228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,94.54,,,,,,,fee schedule,75.78,992.67,
Wheelchair spec sz spec ht b,E1228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,795.71,,,,,,,fee schedule,75.78,992.67,
Wheelchair spec sz spec ht b,E1228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,75.78,,,,,,,fee schedule,75.78,992.67,
Wheelchair spec sz spec ht b,E1228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,869.24,,,,,,,fee schedule,75.78,992.67,
Wheelchair spec sz spec ht b,E1228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,82.78,,,,,,,fee schedule,75.78,992.67,
Power operated vehicle,E1230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8128.65,,,,,,,fee schedule,707.72,8829.4,
Power operated vehicle,E1230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,812.82,,,,,,,fee schedule,707.72,8829.4,
Power operated vehicle,E1230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6096.54,,,,,,,fee schedule,707.72,8829.4,
Power operated vehicle,E1230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8829.4,,,,,,,fee schedule,707.72,8829.4,
Power operated vehicle,E1230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,882.89,,,,,,,fee schedule,707.72,8829.4,
Power operated vehicle,E1230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6622.11,,,,,,,fee schedule,707.72,8829.4,
Power operated vehicle,E1230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7077.53,,,,,,,fee schedule,707.72,8829.4,
Power operated vehicle,E1230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,707.72,,,,,,,fee schedule,707.72,8829.4,
Power operated vehicle,E1230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5308.2,,,,,,,fee schedule,707.72,8829.4,
Power operated vehicle,E1230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7731.56,,,,,,,fee schedule,707.72,8829.4,
Power operated vehicle,E1230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,773.12,,,,,,,fee schedule,707.72,8829.4,
Power operated vehicle,E1230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5798.72,,,,,,,fee schedule,707.72,8829.4,
Folding ped wc tilt-in-space,E1232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7813.75,,,,,,,fee schedule,680.36,8487.35,
Folding ped wc tilt-in-space,E1232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,781.4,,,,,,,fee schedule,680.36,8487.35,
Folding ped wc tilt-in-space,E1232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5860.35,,,,,,,fee schedule,680.36,8487.35,
Folding ped wc tilt-in-space,E1232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8487.35,,,,,,,fee schedule,680.36,8487.35,
Folding ped wc tilt-in-space,E1232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,848.76,,,,,,,fee schedule,680.36,8487.35,
Folding ped wc tilt-in-space,E1232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6365.56,,,,,,,fee schedule,680.36,8487.35,
Folding ped wc tilt-in-space,E1232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6803.35,,,,,,,fee schedule,680.36,8487.35,
Folding ped wc tilt-in-space,E1232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,680.36,,,,,,,fee schedule,680.36,8487.35,
Folding ped wc tilt-in-space,E1232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5102.55,,,,,,,fee schedule,680.36,8487.35,
Folding ped wc tilt-in-space,E1232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7432.04,,,,,,,fee schedule,680.36,8487.35,
Folding ped wc tilt-in-space,E1232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,743.23,,,,,,,fee schedule,680.36,8487.35,
Folding ped wc tilt-in-space,E1232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5574.07,,,,,,,fee schedule,680.36,8487.35,
Rig ped wc tltnspc w/o seat,E1233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8096.29,,,,,,,fee schedule,704.93,8794.25,
Rig ped wc tltnspc w/o seat,E1233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,809.62,,,,,,,fee schedule,704.93,8794.25,
Rig ped wc tltnspc w/o seat,E1233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6072.18,,,,,,,fee schedule,704.93,8794.25,
Rig ped wc tltnspc w/o seat,E1233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8794.25,,,,,,,fee schedule,704.93,8794.25,
Rig ped wc tltnspc w/o seat,E1233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,879.42,,,,,,,fee schedule,704.93,8794.25,
Rig ped wc tltnspc w/o seat,E1233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6595.65,,,,,,,fee schedule,704.93,8794.25,
Rig ped wc tltnspc w/o seat,E1233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7049.36,,,,,,,fee schedule,704.93,8794.25,
Rig ped wc tltnspc w/o seat,E1233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,704.93,,,,,,,fee schedule,704.93,8794.25,
Rig ped wc tltnspc w/o seat,E1233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5286.99,,,,,,,fee schedule,704.93,8794.25,
Rig ped wc tltnspc w/o seat,E1233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7700.78,,,,,,,fee schedule,704.93,8794.25,
Rig ped wc tltnspc w/o seat,E1233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,770.07,,,,,,,fee schedule,704.93,8794.25,
Rig ped wc tltnspc w/o seat,E1233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5775.55,,,,,,,fee schedule,704.93,8794.25,
Fld ped wc tltnspc w/o seat,E1234,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7048.39,,,,,,,fee schedule,613.76,7656.01,
Fld ped wc tltnspc w/o seat,E1234,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,704.91,,,,,,,fee schedule,613.76,7656.01,
Fld ped wc tltnspc w/o seat,E1234,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5286.26,,,,,,,fee schedule,613.76,7656.01,
Fld ped wc tltnspc w/o seat,E1234,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7656.01,,,,,,,fee schedule,613.76,7656.01,
Fld ped wc tltnspc w/o seat,E1234,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,765.68,,,,,,,fee schedule,613.76,7656.01,
Fld ped wc tltnspc w/o seat,E1234,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5741.97,,,,,,,fee schedule,613.76,7656.01,
Fld ped wc tltnspc w/o seat,E1234,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6136.96,,,,,,,fee schedule,613.76,7656.01,
Fld ped wc tltnspc w/o seat,E1234,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,613.76,,,,,,,fee schedule,613.76,7656.01,
Fld ped wc tltnspc w/o seat,E1234,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4602.69,,,,,,,fee schedule,613.76,7656.01,
Fld ped wc tltnspc w/o seat,E1234,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6704.07,,,,,,,fee schedule,613.76,7656.01,
Fld ped wc tltnspc w/o seat,E1234,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,670.47,,,,,,,fee schedule,613.76,7656.01,
Fld ped wc tltnspc w/o seat,E1234,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5028.02,,,,,,,fee schedule,613.76,7656.01,
Rigid ped wc adjustable,E1235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6787.04,,,,,,,fee schedule,590.97,7372.13,
Rigid ped wc adjustable,E1235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,678.74,,,,,,,fee schedule,590.97,7372.13,
Rigid ped wc adjustable,E1235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5090.27,,,,,,,fee schedule,590.97,7372.13,
Rigid ped wc adjustable,E1235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7372.13,,,,,,,fee schedule,590.97,7372.13,
Rigid ped wc adjustable,E1235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,737.25,,,,,,,fee schedule,590.97,7372.13,
Rigid ped wc adjustable,E1235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5529.08,,,,,,,fee schedule,590.97,7372.13,
Rigid ped wc adjustable,E1235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5909.41,,,,,,,fee schedule,590.97,7372.13,
Rigid ped wc adjustable,E1235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,590.97,,,,,,,fee schedule,590.97,7372.13,
Rigid ped wc adjustable,E1235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4432.04,,,,,,,fee schedule,590.97,7372.13,
Rigid ped wc adjustable,E1235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6455.49,,,,,,,fee schedule,590.97,7372.13,
Rigid ped wc adjustable,E1235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,645.58,,,,,,,fee schedule,590.97,7372.13,
Rigid ped wc adjustable,E1235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4841.6,,,,,,,fee schedule,590.97,7372.13,
Folding ped wc adjustable,E1236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5987.93,,,,,,,fee schedule,521.34,6504.13,
Folding ped wc adjustable,E1236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,598.77,,,,,,,fee schedule,521.34,6504.13,
Folding ped wc adjustable,E1236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4490.94,,,,,,,fee schedule,521.34,6504.13,
Folding ped wc adjustable,E1236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6504.13,,,,,,,fee schedule,521.34,6504.13,
Folding ped wc adjustable,E1236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,650.39,,,,,,,fee schedule,521.34,6504.13,
Folding ped wc adjustable,E1236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4878.09,,,,,,,fee schedule,521.34,6504.13,
Folding ped wc adjustable,E1236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5213.63,,,,,,,fee schedule,521.34,6504.13,
Folding ped wc adjustable,E1236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,521.34,,,,,,,fee schedule,521.34,6504.13,
Folding ped wc adjustable,E1236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3910.22,,,,,,,fee schedule,521.34,6504.13,
Folding ped wc adjustable,E1236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5695.42,,,,,,,fee schedule,521.34,6504.13,
Folding ped wc adjustable,E1236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,569.52,,,,,,,fee schedule,521.34,6504.13,
Folding ped wc adjustable,E1236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4271.56,,,,,,,fee schedule,521.34,6504.13,
Rgd ped wc adjstabl w/o seat,E1237,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6040.24,,,,,,,fee schedule,525.92,6560.95,
Rgd ped wc adjstabl w/o seat,E1237,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,604.02,,,,,,,fee schedule,525.92,6560.95,
Rgd ped wc adjstabl w/o seat,E1237,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4530.23,,,,,,,fee schedule,525.92,6560.95,
Rgd ped wc adjstabl w/o seat,E1237,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6560.95,,,,,,,fee schedule,525.92,6560.95,
Rgd ped wc adjstabl w/o seat,E1237,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,656.09,,,,,,,fee schedule,525.92,6560.95,
Rgd ped wc adjstabl w/o seat,E1237,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4920.77,,,,,,,fee schedule,525.92,6560.95,
Rgd ped wc adjstabl w/o seat,E1237,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5259.17,,,,,,,fee schedule,525.92,6560.95,
Rgd ped wc adjstabl w/o seat,E1237,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,525.92,,,,,,,fee schedule,525.92,6560.95,
Rgd ped wc adjstabl w/o seat,E1237,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3944.42,,,,,,,fee schedule,525.92,6560.95,
Rgd ped wc adjstabl w/o seat,E1237,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5745.17,,,,,,,fee schedule,525.92,6560.95,
Rgd ped wc adjstabl w/o seat,E1237,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,574.52,,,,,,,fee schedule,525.92,6560.95,
Rgd ped wc adjstabl w/o seat,E1237,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4308.92,,,,,,,fee schedule,525.92,6560.95,
Fld ped wc adjstabl w/o seat,E1238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5987.93,,,,,,,fee schedule,521.34,6504.13,
Fld ped wc adjstabl w/o seat,E1238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,598.77,,,,,,,fee schedule,521.34,6504.13,
Fld ped wc adjstabl w/o seat,E1238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4490.94,,,,,,,fee schedule,521.34,6504.13,
Fld ped wc adjstabl w/o seat,E1238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6504.13,,,,,,,fee schedule,521.34,6504.13,
Fld ped wc adjstabl w/o seat,E1238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,650.39,,,,,,,fee schedule,521.34,6504.13,
Fld ped wc adjstabl w/o seat,E1238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4878.09,,,,,,,fee schedule,521.34,6504.13,
Fld ped wc adjstabl w/o seat,E1238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5213.63,,,,,,,fee schedule,521.34,6504.13,
Fld ped wc adjstabl w/o seat,E1238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,521.34,,,,,,,fee schedule,521.34,6504.13,
Fld ped wc adjstabl w/o seat,E1238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3910.22,,,,,,,fee schedule,521.34,6504.13,
Fld ped wc adjstabl w/o seat,E1238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5695.42,,,,,,,fee schedule,521.34,6504.13,
Fld ped wc adjstabl w/o seat,E1238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,569.52,,,,,,,fee schedule,521.34,6504.13,
Fld ped wc adjstabl w/o seat,E1238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4271.56,,,,,,,fee schedule,521.34,6504.13,
Whchr litwt det arm leg rest,E1240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3952.51,,,,,,,fee schedule,327.76,4293.25,
Whchr litwt det arm leg rest,E1240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,376.43,,,,,,,fee schedule,327.76,4293.25,
Whchr litwt det arm leg rest,E1240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4293.25,,,,,,,fee schedule,327.76,4293.25,
Whchr litwt det arm leg rest,E1240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,408.88,,,,,,,fee schedule,327.76,4293.25,
Whchr litwt det arm leg rest,E1240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3441.41,,,,,,,fee schedule,327.76,4293.25,
Whchr litwt det arm leg rest,E1240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,327.76,,,,,,,fee schedule,327.76,4293.25,
Whchr litwt det arm leg rest,E1240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3759.43,,,,,,,fee schedule,327.76,4293.25,
Whchr litwt det arm leg rest,E1240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,358.04,,,,,,,fee schedule,327.76,4293.25,
Wheelchair lightweight leg r,E1270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3028.78,,,,,,,fee schedule,251.16,3289.89,
Wheelchair lightweight leg r,E1270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,288.46,,,,,,,fee schedule,251.16,3289.89,
Wheelchair lightweight leg r,E1270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3289.89,,,,,,,fee schedule,251.16,3289.89,
Wheelchair lightweight leg r,E1270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,313.32,,,,,,,fee schedule,251.16,3289.89,
Wheelchair lightweight leg r,E1270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2637.13,,,,,,,fee schedule,251.16,3289.89,
Wheelchair lightweight leg r,E1270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,251.16,,,,,,,fee schedule,251.16,3289.89,
Wheelchair lightweight leg r,E1270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2880.83,,,,,,,fee schedule,251.16,3289.89,
Wheelchair lightweight leg r,E1270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,274.37,,,,,,,fee schedule,251.16,3289.89,
Whchr h-duty det arm leg res,E1280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5035.94,,,,,,,fee schedule,417.59,5470.08,
Whchr h-duty det arm leg res,E1280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,479.61,,,,,,,fee schedule,417.59,5470.08,
Whchr h-duty det arm leg res,E1280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5470.08,,,,,,,fee schedule,417.59,5470.08,
Whchr h-duty det arm leg res,E1280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,520.96,,,,,,,fee schedule,417.59,5470.08,
Whchr h-duty det arm leg res,E1280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4384.74,,,,,,,fee schedule,417.59,5470.08,
Whchr h-duty det arm leg res,E1280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,417.59,,,,,,,fee schedule,417.59,5470.08,
Whchr h-duty det arm leg res,E1280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4789.93,,,,,,,fee schedule,417.59,5470.08,
Whchr h-duty det arm leg res,E1280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,456.18,,,,,,,fee schedule,417.59,5470.08,
Wheelchair heavy duty fixed,E1295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4660.31,,,,,,,fee schedule,386.45,5062.06,
Wheelchair heavy duty fixed,E1295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,443.84,,,,,,,fee schedule,386.45,5062.06,
Wheelchair heavy duty fixed,E1295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5062.06,,,,,,,fee schedule,386.45,5062.06,
Wheelchair heavy duty fixed,E1295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,482.1,,,,,,,fee schedule,386.45,5062.06,
Wheelchair heavy duty fixed,E1295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4057.69,,,,,,,fee schedule,386.45,5062.06,
Wheelchair heavy duty fixed,E1295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.45,,,,,,,fee schedule,386.45,5062.06,
Wheelchair heavy duty fixed,E1295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4432.65,,,,,,,fee schedule,386.45,5062.06,
Wheelchair heavy duty fixed,E1295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,422.16,,,,,,,fee schedule,386.45,5062.06,
Wheelchair special seat heig,E1296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1796.55,,,,,,,fee schedule,158.89,1951.43,
Wheelchair special seat heig,E1296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,182.49,,,,,,,fee schedule,158.89,1951.43,
Wheelchair special seat heig,E1296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1347.42,,,,,,,fee schedule,158.89,1951.43,
Wheelchair special seat heig,E1296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1951.43,,,,,,,fee schedule,158.89,1951.43,
Wheelchair special seat heig,E1296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,198.22,,,,,,,fee schedule,158.89,1951.43,
Wheelchair special seat heig,E1296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1463.58,,,,,,,fee schedule,158.89,1951.43,
Wheelchair special seat heig,E1296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1564.24,,,,,,,fee schedule,158.89,1951.43,
Wheelchair special seat heig,E1296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,158.89,,,,,,,fee schedule,158.89,1951.43,
Wheelchair special seat heig,E1296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1173.19,,,,,,,fee schedule,158.89,1951.43,
Wheelchair special seat heig,E1296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1708.79,,,,,,,fee schedule,158.89,1951.43,
Wheelchair special seat heig,E1296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,173.58,,,,,,,fee schedule,158.89,1951.43,
Wheelchair special seat heig,E1296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1281.6,,,,,,,fee schedule,158.89,1951.43,
Wheelchair special seat dept,E1297,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,324.89,,,,,,,fee schedule,31.42,352.9,
Wheelchair special seat dept,E1297,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,36.09,,,,,,,fee schedule,31.42,352.9,
Wheelchair special seat dept,E1297,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,243.63,,,,,,,fee schedule,31.42,352.9,
Wheelchair special seat dept,E1297,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,352.9,,,,,,,fee schedule,31.42,352.9,
Wheelchair special seat dept,E1297,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,39.2,,,,,,,fee schedule,31.42,352.9,
Wheelchair special seat dept,E1297,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,264.64,,,,,,,fee schedule,31.42,352.9,
Wheelchair special seat dept,E1297,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,282.88,,,,,,,fee schedule,31.42,352.9,
Wheelchair special seat dept,E1297,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31.42,,,,,,,fee schedule,31.42,352.9,
Wheelchair special seat dept,E1297,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,212.13,,,,,,,fee schedule,31.42,352.9,
Wheelchair special seat dept,E1297,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,309.02,,,,,,,fee schedule,31.42,352.9,
Wheelchair special seat dept,E1297,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,34.32,,,,,,,fee schedule,31.42,352.9,
Wheelchair special seat dept,E1297,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,231.73,,,,,,,fee schedule,31.42,352.9,
Wheelchair spec seat depth/w,E1298,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1548.01,,,,,,,fee schedule,137.93,1681.46,
Wheelchair spec seat depth/w,E1298,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,158.41,,,,,,,fee schedule,137.93,1681.46,
Wheelchair spec seat depth/w,E1298,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1161,,,,,,,fee schedule,137.93,1681.46,
Wheelchair spec seat depth/w,E1298,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1681.46,,,,,,,fee schedule,137.93,1681.46,
Wheelchair spec seat depth/w,E1298,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,172.07,,,,,,,fee schedule,137.93,1681.46,
Wheelchair spec seat depth/w,E1298,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1261.08,,,,,,,fee schedule,137.93,1681.46,
Wheelchair spec seat depth/w,E1298,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1347.83,,,,,,,fee schedule,137.93,1681.46,
Wheelchair spec seat depth/w,E1298,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,137.93,,,,,,,fee schedule,137.93,1681.46,
Wheelchair spec seat depth/w,E1298,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1010.87,,,,,,,fee schedule,137.93,1681.46,
Wheelchair spec seat depth/w,E1298,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1472.39,,,,,,,fee schedule,137.93,1681.46,
Wheelchair spec seat depth/w,E1298,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,150.67,,,,,,,fee schedule,137.93,1681.46,
Wheelchair spec seat depth/w,E1298,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1104.28,,,,,,,fee schedule,137.93,1681.46,
Whirlpool non-portable,E1310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6669.59,,,,,,,fee schedule,576.25,7244.56,
Whirlpool non-portable,E1310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,661.83,,,,,,,fee schedule,576.25,7244.56,
Whirlpool non-portable,E1310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5002.22,,,,,,,fee schedule,576.25,7244.56,
Whirlpool non-portable,E1310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7244.56,,,,,,,fee schedule,576.25,7244.56,
Whirlpool non-portable,E1310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,718.88,,,,,,,fee schedule,576.25,7244.56,
Whirlpool non-portable,E1310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5433.45,,,,,,,fee schedule,576.25,7244.56,
Whirlpool non-portable,E1310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5807.15,,,,,,,fee schedule,576.25,7244.56,
Whirlpool non-portable,E1310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,576.25,,,,,,,fee schedule,576.25,7244.56,
Whirlpool non-portable,E1310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4355.38,,,,,,,fee schedule,576.25,7244.56,
Whirlpool non-portable,E1310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6343.78,,,,,,,fee schedule,576.25,7244.56,
Whirlpool non-portable,E1310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,629.5,,,,,,,fee schedule,576.25,7244.56,
Whirlpool non-portable,E1310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4757.86,,,,,,,fee schedule,576.25,7244.56,
Oxygen supplies regulator,E1353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,103.53,,,,,,,fee schedule,90.14,112.46,
Oxygen supplies regulator,E1353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,112.46,,,,,,,fee schedule,90.14,112.46,
Oxygen supplies regulator,E1353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,90.14,,,,,,,fee schedule,90.14,112.46,
Oxygen supplies regulator,E1353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,98.47,,,,,,,fee schedule,90.14,112.46,
Oxygen supplies stand/rack,E1355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,77.95,,,,,,,fee schedule,67.87,84.67,
Oxygen supplies stand/rack,E1355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,84.67,,,,,,,fee schedule,67.87,84.67,
Oxygen supplies stand/rack,E1355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,67.87,,,,,,,fee schedule,67.87,84.67,
Oxygen supplies stand/rack,E1355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,74.14,,,,,,,fee schedule,67.87,84.67,
Oxy suppl heater for nebuliz,E1372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,541.56,,,,,,,fee schedule,64.05,588.24,
Oxy suppl heater for nebuliz,E1372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,73.57,,,,,,,fee schedule,64.05,588.24,
Oxy suppl heater for nebuliz,E1372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.19,,,,,,,fee schedule,64.05,588.24,
Oxy suppl heater for nebuliz,E1372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,588.24,,,,,,,fee schedule,64.05,588.24,
Oxy suppl heater for nebuliz,E1372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,79.91,,,,,,,fee schedule,64.05,588.24,
Oxy suppl heater for nebuliz,E1372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.2,,,,,,,fee schedule,64.05,588.24,
Oxy suppl heater for nebuliz,E1372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,471.53,,,,,,,fee schedule,64.05,588.24,
Oxy suppl heater for nebuliz,E1372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,64.05,,,,,,,fee schedule,64.05,588.24,
Oxy suppl heater for nebuliz,E1372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.66,,,,,,,fee schedule,64.05,588.24,
Oxy suppl heater for nebuliz,E1372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,515.1,,,,,,,fee schedule,64.05,588.24,
Oxy suppl heater for nebuliz,E1372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,69.97,,,,,,,fee schedule,64.05,588.24,
Oxy suppl heater for nebuliz,E1372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.34,,,,,,,fee schedule,64.05,588.24,
Oxygen concentrator,E1390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,611.75,,,,,,,fee schedule,532.64,664.49,
Oxygen concentrator,E1390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,664.49,,,,,,,fee schedule,532.64,664.49,
Oxygen concentrator,E1390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,532.64,,,,,,,fee schedule,532.64,664.49,
Oxygen concentrator,E1390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,581.86,,,,,,,fee schedule,532.64,664.49,
"Oxygen concentrator, dual",E1391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,611.75,,,,,,,fee schedule,532.64,664.49,
"Oxygen concentrator, dual",E1391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,664.49,,,,,,,fee schedule,532.64,664.49,
"Oxygen concentrator, dual",E1391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,532.64,,,,,,,fee schedule,532.64,664.49,
"Oxygen concentrator, dual",E1391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,581.86,,,,,,,fee schedule,532.64,664.49,
Portable oxygen concentrator,E1392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,179.67,,,,,,,fee schedule,156.44,195.16,
Portable oxygen concentrator,E1392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,195.16,,,,,,,fee schedule,156.44,195.16,
Portable oxygen concentrator,E1392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,156.44,,,,,,,fee schedule,156.44,195.16,
Portable oxygen concentrator,E1392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,170.9,,,,,,,fee schedule,156.44,195.16,
O2/water vapor enrich w/heat,E1405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,722.62,,,,,,,fee schedule,629.18,784.92,
O2/water vapor enrich w/heat,E1405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,784.92,,,,,,,fee schedule,629.18,784.92,
O2/water vapor enrich w/heat,E1405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,629.18,,,,,,,fee schedule,629.18,784.92,
O2/water vapor enrich w/heat,E1405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,687.32,,,,,,,fee schedule,629.18,784.92,
O2/water vapor enrich w/o he,E1406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,670.63,,,,,,,fee schedule,583.91,728.44,
O2/water vapor enrich w/o he,E1406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,728.44,,,,,,,fee schedule,583.91,728.44,
O2/water vapor enrich w/o he,E1406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,583.91,,,,,,,fee schedule,583.91,728.44,
O2/water vapor enrich w/o he,E1406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,637.87,,,,,,,fee schedule,583.91,728.44,
Jaw motion rehab system,E1700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1260.04,,,,,,,fee schedule,107.6,1368.66,
Jaw motion rehab system,E1700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,123.57,,,,,,,fee schedule,107.6,1368.66,
Jaw motion rehab system,E1700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,945.03,,,,,,,fee schedule,107.6,1368.66,
Jaw motion rehab system,E1700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1368.66,,,,,,,fee schedule,107.6,1368.66,
Jaw motion rehab system,E1700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,134.23,,,,,,,fee schedule,107.6,1368.66,
Jaw motion rehab system,E1700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1026.5,,,,,,,fee schedule,107.6,1368.66,
Jaw motion rehab system,E1700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1097.1,,,,,,,fee schedule,107.6,1368.66,
Jaw motion rehab system,E1700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,107.6,,,,,,,fee schedule,107.6,1368.66,
Jaw motion rehab system,E1700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,822.83,,,,,,,fee schedule,107.6,1368.66,
Jaw motion rehab system,E1700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1198.48,,,,,,,fee schedule,107.6,1368.66,
Jaw motion rehab system,E1700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,117.54,,,,,,,fee schedule,107.6,1368.66,
Jaw motion rehab system,E1700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,898.86,,,,,,,fee schedule,107.6,1368.66,
Repl cushions for jaw motion,E1701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,38.77,,,,,,,fee schedule,33.75,42.11,
Repl cushions for jaw motion,E1701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42.11,,,,,,,fee schedule,33.75,42.11,
Repl cushions for jaw motion,E1701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,33.75,,,,,,,fee schedule,33.75,42.11,
Repl cushions for jaw motion,E1701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36.87,,,,,,,fee schedule,33.75,42.11,
Repl measr scales jaw motion,E1702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,78.23,,,,,,,fee schedule,68.11,84.97,
Repl measr scales jaw motion,E1702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,84.97,,,,,,,fee schedule,68.11,84.97,
Repl measr scales jaw motion,E1702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,68.11,,,,,,,fee schedule,68.11,84.97,
Repl measr scales jaw motion,E1702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,74.41,,,,,,,fee schedule,68.11,84.97,
Adjust elbow ext/flex device,E1800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3995.28,,,,,,,fee schedule,331.3,4339.7,
Adjust elbow ext/flex device,E1800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,380.5,,,,,,,fee schedule,331.3,4339.7,
Adjust elbow ext/flex device,E1800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4339.7,,,,,,,fee schedule,331.3,4339.7,
Adjust elbow ext/flex device,E1800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,413.31,,,,,,,fee schedule,331.3,4339.7,
Adjust elbow ext/flex device,E1800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3478.65,,,,,,,fee schedule,331.3,4339.7,
Adjust elbow ext/flex device,E1800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,331.3,,,,,,,fee schedule,331.3,4339.7,
Adjust elbow ext/flex device,E1800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3800.11,,,,,,,fee schedule,331.3,4339.7,
Adjust elbow ext/flex device,E1800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,361.92,,,,,,,fee schedule,331.3,4339.7,
Sps elbow device,E1801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4376.03,,,,,,,fee schedule,362.87,4753.27,
Sps elbow device,E1801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,416.76,,,,,,,fee schedule,362.87,4753.27,
Sps elbow device,E1801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4753.27,,,,,,,fee schedule,362.87,4753.27,
Sps elbow device,E1801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,452.69,,,,,,,fee schedule,362.87,4753.27,
Sps elbow device,E1801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3810.16,,,,,,,fee schedule,362.87,4753.27,
Sps elbow device,E1801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,362.87,,,,,,,fee schedule,362.87,4753.27,
Sps elbow device,E1801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4162.26,,,,,,,fee schedule,362.87,4753.27,
Sps elbow device,E1801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,396.41,,,,,,,fee schedule,362.87,4753.27,
Adjst forearm pro/sup device,E1802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12538.34,,,,,,,fee schedule,1039.71,13619.23,
Adjst forearm pro/sup device,E1802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1194.13,,,,,,,fee schedule,1039.71,13619.23,
Adjst forearm pro/sup device,E1802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13619.23,,,,,,,fee schedule,1039.71,13619.23,
Adjst forearm pro/sup device,E1802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1297.07,,,,,,,fee schedule,1039.71,13619.23,
Adjst forearm pro/sup device,E1802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10917,,,,,,,fee schedule,1039.71,13619.23,
Adjst forearm pro/sup device,E1802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1039.71,,,,,,,fee schedule,1039.71,13619.23,
Adjst forearm pro/sup device,E1802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11925.83,,,,,,,fee schedule,1039.71,13619.23,
Adjst forearm pro/sup device,E1802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1135.79,,,,,,,fee schedule,1039.71,13619.23,
Adjust wrist ext/flex device,E1805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4120.25,,,,,,,fee schedule,341.66,4475.44,
Adjust wrist ext/flex device,E1805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,392.4,,,,,,,fee schedule,341.66,4475.44,
Adjust wrist ext/flex device,E1805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4475.44,,,,,,,fee schedule,341.66,4475.44,
Adjust wrist ext/flex device,E1805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,426.23,,,,,,,fee schedule,341.66,4475.44,
Adjust wrist ext/flex device,E1805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3587.46,,,,,,,fee schedule,341.66,4475.44,
Adjust wrist ext/flex device,E1805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,341.66,,,,,,,fee schedule,341.66,4475.44,
Adjust wrist ext/flex device,E1805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3918.97,,,,,,,fee schedule,341.66,4475.44,
Adjust wrist ext/flex device,E1805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,373.24,,,,,,,fee schedule,341.66,4475.44,
Sps wrist device,E1806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3591.88,,,,,,,fee schedule,297.85,3901.53,
Sps wrist device,E1806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,342.08,,,,,,,fee schedule,297.85,3901.53,
Sps wrist device,E1806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3901.53,,,,,,,fee schedule,297.85,3901.53,
Sps wrist device,E1806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,371.57,,,,,,,fee schedule,297.85,3901.53,
Sps wrist device,E1806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3127.41,,,,,,,fee schedule,297.85,3901.53,
Sps wrist device,E1806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,297.85,,,,,,,fee schedule,297.85,3901.53,
Sps wrist device,E1806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3416.42,,,,,,,fee schedule,297.85,3901.53,
Sps wrist device,E1806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,325.37,,,,,,,fee schedule,297.85,3901.53,
Adjust knee ext/flex device,E1810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4062.9,,,,,,,fee schedule,336.91,4413.15,
Adjust knee ext/flex device,E1810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,386.94,,,,,,,fee schedule,336.91,4413.15,
Adjust knee ext/flex device,E1810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4413.15,,,,,,,fee schedule,336.91,4413.15,
Adjust knee ext/flex device,E1810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,420.3,,,,,,,fee schedule,336.91,4413.15,
Adjust knee ext/flex device,E1810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3537.53,,,,,,,fee schedule,336.91,4413.15,
Adjust knee ext/flex device,E1810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,336.91,,,,,,,fee schedule,336.91,4413.15,
Adjust knee ext/flex device,E1810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3864.43,,,,,,,fee schedule,336.91,4413.15,
Adjust knee ext/flex device,E1810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,368.04,,,,,,,fee schedule,336.91,4413.15,
Sps knee device,E1811,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4549.23,,,,,,,fee schedule,377.24,4941.41,
Sps knee device,E1811,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,433.26,,,,,,,fee schedule,377.24,4941.41,
Sps knee device,E1811,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4941.41,,,,,,,fee schedule,377.24,4941.41,
Sps knee device,E1811,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,470.61,,,,,,,fee schedule,377.24,4941.41,
Sps knee device,E1811,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3960.97,,,,,,,fee schedule,377.24,4941.41,
Sps knee device,E1811,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,377.24,,,,,,,fee schedule,377.24,4941.41,
Sps knee device,E1811,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4327,,,,,,,fee schedule,377.24,4941.41,
Sps knee device,E1811,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,412.1,,,,,,,fee schedule,377.24,4941.41,
Knee ext/flex w act res ctrl,E1812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3299.21,,,,,,,fee schedule,273.58,3583.63,
Knee ext/flex w act res ctrl,E1812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,314.21,,,,,,,fee schedule,273.58,3583.63,
Knee ext/flex w act res ctrl,E1812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3583.63,,,,,,,fee schedule,273.58,3583.63,
Knee ext/flex w act res ctrl,E1812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,341.3,,,,,,,fee schedule,273.58,3583.63,
Knee ext/flex w act res ctrl,E1812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2872.59,,,,,,,fee schedule,273.58,3583.63,
Knee ext/flex w act res ctrl,E1812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,273.58,,,,,,,fee schedule,273.58,3583.63,
Knee ext/flex w act res ctrl,E1812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3138.05,,,,,,,fee schedule,273.58,3583.63,
Knee ext/flex w act res ctrl,E1812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,298.86,,,,,,,fee schedule,273.58,3583.63,
Adjust ankle ext/flex device,E1815,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4120.25,,,,,,,fee schedule,341.66,4475.44,
Adjust ankle ext/flex device,E1815,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,392.4,,,,,,,fee schedule,341.66,4475.44,
Adjust ankle ext/flex device,E1815,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4475.44,,,,,,,fee schedule,341.66,4475.44,
Adjust ankle ext/flex device,E1815,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,426.23,,,,,,,fee schedule,341.66,4475.44,
Adjust ankle ext/flex device,E1815,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3587.46,,,,,,,fee schedule,341.66,4475.44,
Adjust ankle ext/flex device,E1815,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,341.66,,,,,,,fee schedule,341.66,4475.44,
Adjust ankle ext/flex device,E1815,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3918.97,,,,,,,fee schedule,341.66,4475.44,
Adjust ankle ext/flex device,E1815,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,373.24,,,,,,,fee schedule,341.66,4475.44,
Sps ankle device,E1816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4621.23,,,,,,,fee schedule,383.2,5019.61,
Sps ankle device,E1816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,440.12,,,,,,,fee schedule,383.2,5019.61,
Sps ankle device,E1816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5019.61,,,,,,,fee schedule,383.2,5019.61,
Sps ankle device,E1816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,478.06,,,,,,,fee schedule,383.2,5019.61,
Sps ankle device,E1816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4023.66,,,,,,,fee schedule,383.2,5019.61,
Sps ankle device,E1816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,383.2,,,,,,,fee schedule,383.2,5019.61,
Sps ankle device,E1816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4395.48,,,,,,,fee schedule,383.2,5019.61,
Sps ankle device,E1816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,418.62,,,,,,,fee schedule,383.2,5019.61,
Sps forearm device,E1818,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4716.93,,,,,,,fee schedule,391.14,5123.56,
Sps forearm device,E1818,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,449.23,,,,,,,fee schedule,391.14,5123.56,
Sps forearm device,E1818,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5123.56,,,,,,,fee schedule,391.14,5123.56,
Sps forearm device,E1818,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,487.96,,,,,,,fee schedule,391.14,5123.56,
Sps forearm device,E1818,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4106.98,,,,,,,fee schedule,391.14,5123.56,
Sps forearm device,E1818,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,391.14,,,,,,,fee schedule,391.14,5123.56,
Sps forearm device,E1818,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4486.51,,,,,,,fee schedule,391.14,5123.56,
Sps forearm device,E1818,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,427.29,,,,,,,fee schedule,391.14,5123.56,
Soft interface material,E1820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,298.69,,,,,,,fee schedule,26,324.44,
Soft interface material,E1820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,29.86,,,,,,,fee schedule,26,324.44,
Soft interface material,E1820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,224.04,,,,,,,fee schedule,26,324.44,
Soft interface material,E1820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,324.44,,,,,,,fee schedule,26,324.44,
Soft interface material,E1820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,32.43,,,,,,,fee schedule,26,324.44,
Soft interface material,E1820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,243.36,,,,,,,fee schedule,26,324.44,
Soft interface material,E1820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,260.06,,,,,,,fee schedule,26,324.44,
Soft interface material,E1820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26,,,,,,,fee schedule,26,324.44,
Soft interface material,E1820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,195.07,,,,,,,fee schedule,26,324.44,
Soft interface material,E1820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,284.1,,,,,,,fee schedule,26,324.44,
Soft interface material,E1820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28.4,,,,,,,fee schedule,26,324.44,
Soft interface material,E1820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,213.1,,,,,,,fee schedule,26,324.44,
Replacement interface spsd,E1821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,384.57,,,,,,,fee schedule,33.45,417.73,
Replacement interface spsd,E1821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,38.42,,,,,,,fee schedule,33.45,417.73,
Replacement interface spsd,E1821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,288.49,,,,,,,fee schedule,33.45,417.73,
Replacement interface spsd,E1821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,417.73,,,,,,,fee schedule,33.45,417.73,
Replacement interface spsd,E1821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41.73,,,,,,,fee schedule,33.45,417.73,
Replacement interface spsd,E1821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,313.36,,,,,,,fee schedule,33.45,417.73,
Replacement interface spsd,E1821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,334.85,,,,,,,fee schedule,33.45,417.73,
Replacement interface spsd,E1821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,33.45,,,,,,,fee schedule,33.45,417.73,
Replacement interface spsd,E1821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,251.19,,,,,,,fee schedule,33.45,417.73,
Replacement interface spsd,E1821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,365.79,,,,,,,fee schedule,33.45,417.73,
Replacement interface spsd,E1821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36.54,,,,,,,fee schedule,33.45,417.73,
Replacement interface spsd,E1821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,274.4,,,,,,,fee schedule,33.45,417.73,
Adjust finger ext/flex devc,E1825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4120.25,,,,,,,fee schedule,341.66,4475.44,
Adjust finger ext/flex devc,E1825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,392.4,,,,,,,fee schedule,341.66,4475.44,
Adjust finger ext/flex devc,E1825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4475.44,,,,,,,fee schedule,341.66,4475.44,
Adjust finger ext/flex devc,E1825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,426.23,,,,,,,fee schedule,341.66,4475.44,
Adjust finger ext/flex devc,E1825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3587.46,,,,,,,fee schedule,341.66,4475.44,
Adjust finger ext/flex devc,E1825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,341.66,,,,,,,fee schedule,341.66,4475.44,
Adjust finger ext/flex devc,E1825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3918.97,,,,,,,fee schedule,341.66,4475.44,
Adjust finger ext/flex devc,E1825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,373.24,,,,,,,fee schedule,341.66,4475.44,
Adjust toe ext/flex device,E1830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4120.25,,,,,,,fee schedule,341.66,4475.44,
Adjust toe ext/flex device,E1830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,392.4,,,,,,,fee schedule,341.66,4475.44,
Adjust toe ext/flex device,E1830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4475.44,,,,,,,fee schedule,341.66,4475.44,
Adjust toe ext/flex device,E1830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,426.23,,,,,,,fee schedule,341.66,4475.44,
Adjust toe ext/flex device,E1830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3587.46,,,,,,,fee schedule,341.66,4475.44,
Adjust toe ext/flex device,E1830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,341.66,,,,,,,fee schedule,341.66,4475.44,
Adjust toe ext/flex device,E1830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3918.97,,,,,,,fee schedule,341.66,4475.44,
Adjust toe ext/flex device,E1830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,373.24,,,,,,,fee schedule,341.66,4475.44,
Adj shoulder ext/flex device,E1840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12755.04,,,,,,,fee schedule,1057.68,13854.61,
Adj shoulder ext/flex device,E1840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1214.76,,,,,,,fee schedule,1057.68,13854.61,
Adj shoulder ext/flex device,E1840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13854.61,,,,,,,fee schedule,1057.68,13854.61,
Adj shoulder ext/flex device,E1840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1319.48,,,,,,,fee schedule,1057.68,13854.61,
Adj shoulder ext/flex device,E1840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11105.68,,,,,,,fee schedule,1057.68,13854.61,
Adj shoulder ext/flex device,E1840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1057.68,,,,,,,fee schedule,1057.68,13854.61,
Adj shoulder ext/flex device,E1840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12131.94,,,,,,,fee schedule,1057.68,13854.61,
Adj shoulder ext/flex device,E1840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1155.42,,,,,,,fee schedule,1057.68,13854.61,
Static str shldr dev rom adj,E1841,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17380.23,,,,,,,fee schedule,1441.22,18878.53,
Static str shldr dev rom adj,E1841,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1655.26,,,,,,,fee schedule,1441.22,18878.53,
Static str shldr dev rom adj,E1841,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18878.53,,,,,,,fee schedule,1441.22,18878.53,
Static str shldr dev rom adj,E1841,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1797.96,,,,,,,fee schedule,1441.22,18878.53,
Static str shldr dev rom adj,E1841,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15132.79,,,,,,,fee schedule,1441.22,18878.53,
Static str shldr dev rom adj,E1841,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1441.22,,,,,,,fee schedule,1441.22,18878.53,
Static str shldr dev rom adj,E1841,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16531.2,,,,,,,fee schedule,1441.22,18878.53,
Static str shldr dev rom adj,E1841,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1574.4,,,,,,,fee schedule,1441.22,18878.53,
Vr cbt therapy,E1905,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,708.51,,,,,,,fee schedule,674.77,1180.85,APC
Vr cbt therapy,E1905,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,701.76,,,,,,,fee schedule,674.77,1180.85,APC
Vr cbt therapy,E1905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,674.77,,,,,,,fee schedule,674.77,1180.85,APC
Vr cbt therapy,E1905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1032.4,,,,,,,fee schedule,674.77,1180.85,Radiology
Vr cbt therapy,E1905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,944.68,,,,,,,fee schedule,674.77,1180.85,APC
Vr cbt therapy,E1905,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1180.85,,,,,,,fee schedule,674.77,1180.85,APC
Gastric suction pump hme mdl,E2000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1757.23,,,,,,,fee schedule,145.71,1908.71,
Gastric suction pump hme mdl,E2000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,167.35,,,,,,,fee schedule,145.71,1908.71,
Gastric suction pump hme mdl,E2000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1908.71,,,,,,,fee schedule,145.71,1908.71,
Gastric suction pump hme mdl,E2000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,181.78,,,,,,,fee schedule,145.71,1908.71,
Gastric suction pump hme mdl,E2000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1530,,,,,,,fee schedule,145.71,1908.71,
Gastric suction pump hme mdl,E2000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,145.71,,,,,,,fee schedule,145.71,1908.71,
Gastric suction pump hme mdl,E2000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1671.38,,,,,,,fee schedule,145.71,1908.71,
Gastric suction pump hme mdl,E2000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,159.18,,,,,,,fee schedule,145.71,1908.71,
Bld glucose monitor w voice,E2100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2350.22,,,,,,,fee schedule,204.65,2552.82,
Bld glucose monitor w voice,E2100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,235.04,,,,,,,fee schedule,204.65,2552.82,
Bld glucose monitor w voice,E2100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1762.69,,,,,,,fee schedule,204.65,2552.82,
Bld glucose monitor w voice,E2100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2552.82,,,,,,,fee schedule,204.65,2552.82,
Bld glucose monitor w voice,E2100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,255.3,,,,,,,fee schedule,204.65,2552.82,
Bld glucose monitor w voice,E2100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1914.65,,,,,,,fee schedule,204.65,2552.82,
Bld glucose monitor w voice,E2100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2046.31,,,,,,,fee schedule,204.65,2552.82,
Bld glucose monitor w voice,E2100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,204.65,,,,,,,fee schedule,204.65,2552.82,
Bld glucose monitor w voice,E2100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1534.76,,,,,,,fee schedule,204.65,2552.82,
Bld glucose monitor w voice,E2100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2235.41,,,,,,,fee schedule,204.65,2552.82,
Bld glucose monitor w voice,E2100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,223.56,,,,,,,fee schedule,204.65,2552.82,
Bld glucose monitor w voice,E2100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1676.58,,,,,,,fee schedule,204.65,2552.82,
Bld glucose monitor w lance,E2101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,689.01,,,,,,,fee schedule,59.99,748.4,
Bld glucose monitor w lance,E2101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,68.9,,,,,,,fee schedule,59.99,748.4,
Bld glucose monitor w lance,E2101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,516.75,,,,,,,fee schedule,59.99,748.4,
Bld glucose monitor w lance,E2101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,748.4,,,,,,,fee schedule,59.99,748.4,
Bld glucose monitor w lance,E2101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,74.84,,,,,,,fee schedule,59.99,748.4,
Bld glucose monitor w lance,E2101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,561.29,,,,,,,fee schedule,59.99,748.4,
Bld glucose monitor w lance,E2101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,599.91,,,,,,,fee schedule,59.99,748.4,
Bld glucose monitor w lance,E2101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,59.99,,,,,,,fee schedule,59.99,748.4,
Bld glucose monitor w lance,E2101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,449.92,,,,,,,fee schedule,59.99,748.4,
Bld glucose monitor w lance,E2101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,655.35,,,,,,,fee schedule,59.99,748.4,
Bld glucose monitor w lance,E2101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,65.54,,,,,,,fee schedule,59.99,748.4,
Bld glucose monitor w lance,E2101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,491.5,,,,,,,fee schedule,59.99,748.4,
Pulse gen sys tx endolymp fl,E2120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10877.96,,,,,,,fee schedule,902.03,11815.71,
Pulse gen sys tx endolymp fl,E2120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1036,,,,,,,fee schedule,902.03,11815.71,
Pulse gen sys tx endolymp fl,E2120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11815.71,,,,,,,fee schedule,902.03,11815.71,
Pulse gen sys tx endolymp fl,E2120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1125.31,,,,,,,fee schedule,902.03,11815.71,
Pulse gen sys tx endolymp fl,E2120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9471.33,,,,,,,fee schedule,902.03,11815.71,
Pulse gen sys tx endolymp fl,E2120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,902.03,,,,,,,fee schedule,902.03,11815.71,
Pulse gen sys tx endolymp fl,E2120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10346.56,,,,,,,fee schedule,902.03,11815.71,
Pulse gen sys tx endolymp fl,E2120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,985.39,,,,,,,fee schedule,902.03,11815.71,
"Man w/ch acc seat w>=20""<24""",E2201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1363.32,,,,,,,fee schedule,118.72,1480.85,
"Man w/ch acc seat w>=20""<24""",E2201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,136.35,,,,,,,fee schedule,118.72,1480.85,
"Man w/ch acc seat w>=20""<24""",E2201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1022.49,,,,,,,fee schedule,118.72,1480.85,
"Man w/ch acc seat w>=20""<24""",E2201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1480.85,,,,,,,fee schedule,118.72,1480.85,
"Man w/ch acc seat w>=20""<24""",E2201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,148.1,,,,,,,fee schedule,118.72,1480.85,
"Man w/ch acc seat w>=20""<24""",E2201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1110.64,,,,,,,fee schedule,118.72,1480.85,
"Man w/ch acc seat w>=20""<24""",E2201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1187.03,,,,,,,fee schedule,118.72,1480.85,
"Man w/ch acc seat w>=20""<24""",E2201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,118.72,,,,,,,fee schedule,118.72,1480.85,
"Man w/ch acc seat w>=20""<24""",E2201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,890.27,,,,,,,fee schedule,118.72,1480.85,
"Man w/ch acc seat w>=20""<24""",E2201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1296.73,,,,,,,fee schedule,118.72,1480.85,
"Man w/ch acc seat w>=20""<24""",E2201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,129.69,,,,,,,fee schedule,118.72,1480.85,
"Man w/ch acc seat w>=20""<24""",E2201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,972.54,,,,,,,fee schedule,118.72,1480.85,
Seat width 24-27 in,E2202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1731.93,,,,,,,fee schedule,150.8,1881.23,
Seat width 24-27 in,E2202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,173.2,,,,,,,fee schedule,150.8,1881.23,
Seat width 24-27 in,E2202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1299.01,,,,,,,fee schedule,150.8,1881.23,
Seat width 24-27 in,E2202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1881.23,,,,,,,fee schedule,150.8,1881.23,
Seat width 24-27 in,E2202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,188.13,,,,,,,fee schedule,150.8,1881.23,
Seat width 24-27 in,E2202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1411,,,,,,,fee schedule,150.8,1881.23,
Seat width 24-27 in,E2202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1507.97,,,,,,,fee schedule,150.8,1881.23,
Seat width 24-27 in,E2202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,150.8,,,,,,,fee schedule,150.8,1881.23,
Seat width 24-27 in,E2202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1131.04,,,,,,,fee schedule,150.8,1881.23,
Seat width 24-27 in,E2202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1647.32,,,,,,,fee schedule,150.8,1881.23,
Seat width 24-27 in,E2202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,164.74,,,,,,,fee schedule,150.8,1881.23,
Seat width 24-27 in,E2202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1235.56,,,,,,,fee schedule,150.8,1881.23,
Frame depth less than 22 in,E2203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1750.44,,,,,,,fee schedule,152.35,1901.34,
Frame depth less than 22 in,E2203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,174.97,,,,,,,fee schedule,152.35,1901.34,
Frame depth less than 22 in,E2203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1312.8,,,,,,,fee schedule,152.35,1901.34,
Frame depth less than 22 in,E2203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1901.34,,,,,,,fee schedule,152.35,1901.34,
Frame depth less than 22 in,E2203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,190.06,,,,,,,fee schedule,152.35,1901.34,
Frame depth less than 22 in,E2203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1425.97,,,,,,,fee schedule,152.35,1901.34,
Frame depth less than 22 in,E2203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1524.09,,,,,,,fee schedule,152.35,1901.34,
Frame depth less than 22 in,E2203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,152.35,,,,,,,fee schedule,152.35,1901.34,
Frame depth less than 22 in,E2203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1143.04,,,,,,,fee schedule,152.35,1901.34,
Frame depth less than 22 in,E2203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1664.93,,,,,,,fee schedule,152.35,1901.34,
Frame depth less than 22 in,E2203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,166.43,,,,,,,fee schedule,152.35,1901.34,
Frame depth less than 22 in,E2203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1248.66,,,,,,,fee schedule,152.35,1901.34,
Frame depth 22 to 25 in,E2204,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2972.16,,,,,,,fee schedule,258.82,3228.38,
Frame depth 22 to 25 in,E2204,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,297.26,,,,,,,fee schedule,258.82,3228.38,
Frame depth 22 to 25 in,E2204,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2229.11,,,,,,,fee schedule,258.82,3228.38,
Frame depth 22 to 25 in,E2204,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3228.38,,,,,,,fee schedule,258.82,3228.38,
Frame depth 22 to 25 in,E2204,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,322.89,,,,,,,fee schedule,258.82,3228.38,
Frame depth 22 to 25 in,E2204,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2421.28,,,,,,,fee schedule,258.82,3228.38,
Frame depth 22 to 25 in,E2204,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2587.83,,,,,,,fee schedule,258.82,3228.38,
Frame depth 22 to 25 in,E2204,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,258.82,,,,,,,fee schedule,258.82,3228.38,
Frame depth 22 to 25 in,E2204,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1940.87,,,,,,,fee schedule,258.82,3228.38,
Frame depth 22 to 25 in,E2204,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2826.97,,,,,,,fee schedule,258.82,3228.38,
Frame depth 22 to 25 in,E2204,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,282.74,,,,,,,fee schedule,258.82,3228.38,
Frame depth 22 to 25 in,E2204,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2120.22,,,,,,,fee schedule,258.82,3228.38,
"Manual wc accessory, handrim",E2205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,119.36,,,,,,,fee schedule,10.33,129.65,
"Manual wc accessory, handrim",E2205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11.87,,,,,,,fee schedule,10.33,129.65,
"Manual wc accessory, handrim",E2205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,89.61,,,,,,,fee schedule,10.33,129.65,
"Manual wc accessory, handrim",E2205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,129.65,,,,,,,fee schedule,10.33,129.65,
"Manual wc accessory, handrim",E2205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12.89,,,,,,,fee schedule,10.33,129.65,
"Manual wc accessory, handrim",E2205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,97.34,,,,,,,fee schedule,10.33,129.65,
"Manual wc accessory, handrim",E2205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,103.93,,,,,,,fee schedule,10.33,129.65,
"Manual wc accessory, handrim",E2205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10.33,,,,,,,fee schedule,10.33,129.65,
"Manual wc accessory, handrim",E2205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,78.02,,,,,,,fee schedule,10.33,129.65,
"Manual wc accessory, handrim",E2205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,113.53,,,,,,,fee schedule,10.33,129.65,
"Manual wc accessory, handrim",E2205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11.29,,,,,,,fee schedule,10.33,129.65,
"Manual wc accessory, handrim",E2205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,85.23,,,,,,,fee schedule,10.33,129.65,
Man wc whl lock comp repl ea,E2206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,148.63,,,,,,,fee schedule,12.91,161.44,
Man wc whl lock comp repl ea,E2206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14.82,,,,,,,fee schedule,12.91,161.44,
Man wc whl lock comp repl ea,E2206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,111.46,,,,,,,fee schedule,12.91,161.44,
Man wc whl lock comp repl ea,E2206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,161.44,,,,,,,fee schedule,12.91,161.44,
Man wc whl lock comp repl ea,E2206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16.1,,,,,,,fee schedule,12.91,161.44,
Man wc whl lock comp repl ea,E2206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,121.07,,,,,,,fee schedule,12.91,161.44,
Man wc whl lock comp repl ea,E2206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,129.41,,,,,,,fee schedule,12.91,161.44,
Man wc whl lock comp repl ea,E2206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12.91,,,,,,,fee schedule,12.91,161.44,
Man wc whl lock comp repl ea,E2206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,97.05,,,,,,,fee schedule,12.91,161.44,
Man wc whl lock comp repl ea,E2206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,141.37,,,,,,,fee schedule,12.91,161.44,
Man wc whl lock comp repl ea,E2206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14.1,,,,,,,fee schedule,12.91,161.44,
Man wc whl lock comp repl ea,E2206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,106.02,,,,,,,fee schedule,12.91,161.44,
Crutch and cane holder,E2207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,158.41,,,,,,,fee schedule,13.82,172.07,
Crutch and cane holder,E2207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15.87,,,,,,,fee schedule,13.82,172.07,
Crutch and cane holder,E2207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,118.81,,,,,,,fee schedule,13.82,172.07,
Crutch and cane holder,E2207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,172.07,,,,,,,fee schedule,13.82,172.07,
Crutch and cane holder,E2207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17.24,,,,,,,fee schedule,13.82,172.07,
Crutch and cane holder,E2207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,129.05,,,,,,,fee schedule,13.82,172.07,
Crutch and cane holder,E2207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,137.93,,,,,,,fee schedule,13.82,172.07,
Crutch and cane holder,E2207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13.82,,,,,,,fee schedule,13.82,172.07,
Crutch and cane holder,E2207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,103.44,,,,,,,fee schedule,13.82,172.07,
Crutch and cane holder,E2207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,150.67,,,,,,,fee schedule,13.82,172.07,
Crutch and cane holder,E2207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15.09,,,,,,,fee schedule,13.82,172.07,
Crutch and cane holder,E2207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,113,,,,,,,fee schedule,13.82,172.07,
Cylinder tank carrier,E2208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,374.1,,,,,,,fee schedule,32.54,406.35,
Cylinder tank carrier,E2208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37.38,,,,,,,fee schedule,32.54,406.35,
Cylinder tank carrier,E2208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,280.59,,,,,,,fee schedule,32.54,406.35,
Cylinder tank carrier,E2208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.35,,,,,,,fee schedule,32.54,406.35,
Cylinder tank carrier,E2208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,40.6,,,,,,,fee schedule,32.54,406.35,
Cylinder tank carrier,E2208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,304.78,,,,,,,fee schedule,32.54,406.35,
Cylinder tank carrier,E2208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,325.73,,,,,,,fee schedule,32.54,406.35,
Cylinder tank carrier,E2208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32.54,,,,,,,fee schedule,32.54,406.35,
Cylinder tank carrier,E2208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,244.31,,,,,,,fee schedule,32.54,406.35,
Cylinder tank carrier,E2208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,355.83,,,,,,,fee schedule,32.54,406.35,
Cylinder tank carrier,E2208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35.55,,,,,,,fee schedule,32.54,406.35,
Cylinder tank carrier,E2208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,266.89,,,,,,,fee schedule,32.54,406.35,
Arm trough each,E2209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,337.49,,,,,,,fee schedule,29.45,366.58,
Arm trough each,E2209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33.83,,,,,,,fee schedule,29.45,366.58,
Arm trough each,E2209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,253.14,,,,,,,fee schedule,29.45,366.58,
Arm trough each,E2209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,366.58,,,,,,,fee schedule,29.45,366.58,
Arm trough each,E2209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,36.74,,,,,,,fee schedule,29.45,366.58,
Arm trough each,E2209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,274.96,,,,,,,fee schedule,29.45,366.58,
Arm trough each,E2209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,293.85,,,,,,,fee schedule,29.45,366.58,
Arm trough each,E2209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29.45,,,,,,,fee schedule,29.45,366.58,
Arm trough each,E2209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,220.4,,,,,,,fee schedule,29.45,366.58,
Arm trough each,E2209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,321,,,,,,,fee schedule,29.45,366.58,
Arm trough each,E2209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32.17,,,,,,,fee schedule,29.45,366.58,
Arm trough each,E2209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,240.77,,,,,,,fee schedule,29.45,366.58,
Wheelchair bearings,E2210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20.64,,,,,,,fee schedule,1.82,22.42,
Wheelchair bearings,E2210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.09,,,,,,,fee schedule,1.82,22.42,
Wheelchair bearings,E2210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15.49,,,,,,,fee schedule,1.82,22.42,
Wheelchair bearings,E2210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22.42,,,,,,,fee schedule,1.82,22.42,
Wheelchair bearings,E2210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.27,,,,,,,fee schedule,1.82,22.42,
Wheelchair bearings,E2210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16.82,,,,,,,fee schedule,1.82,22.42,
Wheelchair bearings,E2210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17.97,,,,,,,fee schedule,1.82,22.42,
Wheelchair bearings,E2210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.82,,,,,,,fee schedule,1.82,22.42,
Wheelchair bearings,E2210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13.48,,,,,,,fee schedule,1.82,22.42,
Wheelchair bearings,E2210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19.63,,,,,,,fee schedule,1.82,22.42,
Wheelchair bearings,E2210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.99,,,,,,,fee schedule,1.82,22.42,
Wheelchair bearings,E2210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14.73,,,,,,,fee schedule,1.82,22.42,
Pneumatic propulsion tire,E2211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,149.5,,,,,,,fee schedule,12.76,162.39,
Pneumatic propulsion tire,E2211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14.65,,,,,,,fee schedule,12.76,162.39,
Pneumatic propulsion tire,E2211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,107.08,,,,,,,fee schedule,12.76,162.39,
Pneumatic propulsion tire,E2211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,162.39,,,,,,,fee schedule,12.76,162.39,
Pneumatic propulsion tire,E2211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15.91,,,,,,,fee schedule,12.76,162.39,
Pneumatic propulsion tire,E2211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,116.31,,,,,,,fee schedule,12.76,162.39,
Pneumatic propulsion tire,E2211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,130.17,,,,,,,fee schedule,12.76,162.39,
Pneumatic propulsion tire,E2211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12.76,,,,,,,fee schedule,12.76,162.39,
Pneumatic propulsion tire,E2211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,93.23,,,,,,,fee schedule,12.76,162.39,
Pneumatic propulsion tire,E2211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,142.2,,,,,,,fee schedule,12.76,162.39,
Pneumatic propulsion tire,E2211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13.94,,,,,,,fee schedule,12.76,162.39,
Pneumatic propulsion tire,E2211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,101.85,,,,,,,fee schedule,12.76,162.39,
Pneumatic prop tire tube,E2212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21.47,,,,,,,fee schedule,1.94,23.32,
Pneumatic prop tire tube,E2212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.23,,,,,,,fee schedule,1.94,23.32,
Pneumatic prop tire tube,E2212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16.15,,,,,,,fee schedule,1.94,23.32,
Pneumatic prop tire tube,E2212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23.32,,,,,,,fee schedule,1.94,23.32,
Pneumatic prop tire tube,E2212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.42,,,,,,,fee schedule,1.94,23.32,
Pneumatic prop tire tube,E2212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17.54,,,,,,,fee schedule,1.94,23.32,
Pneumatic prop tire tube,E2212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18.7,,,,,,,fee schedule,1.94,23.32,
Pneumatic prop tire tube,E2212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.94,,,,,,,fee schedule,1.94,23.32,
Pneumatic prop tire tube,E2212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14.06,,,,,,,fee schedule,1.94,23.32,
Pneumatic prop tire tube,E2212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20.42,,,,,,,fee schedule,1.94,23.32,
Pneumatic prop tire tube,E2212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.12,,,,,,,fee schedule,1.94,23.32,
Pneumatic prop tire tube,E2212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15.36,,,,,,,fee schedule,1.94,23.32,
Pneumatic prop tire insert,E2213,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,111.12,,,,,,,fee schedule,9.7,120.7,
Pneumatic prop tire insert,E2213,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11.14,,,,,,,fee schedule,9.7,120.7,
Pneumatic prop tire insert,E2213,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83.28,,,,,,,fee schedule,9.7,120.7,
Pneumatic prop tire insert,E2213,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,120.7,,,,,,,fee schedule,9.7,120.7,
Pneumatic prop tire insert,E2213,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12.1,,,,,,,fee schedule,9.7,120.7,
Pneumatic prop tire insert,E2213,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,90.46,,,,,,,fee schedule,9.7,120.7,
Pneumatic prop tire insert,E2213,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,96.75,,,,,,,fee schedule,9.7,120.7,
Pneumatic prop tire insert,E2213,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.7,,,,,,,fee schedule,9.7,120.7,
Pneumatic prop tire insert,E2213,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,72.51,,,,,,,fee schedule,9.7,120.7,
Pneumatic prop tire insert,E2213,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,105.69,,,,,,,fee schedule,9.7,120.7,
Pneumatic prop tire insert,E2213,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10.59,,,,,,,fee schedule,9.7,120.7,
Pneumatic prop tire insert,E2213,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,79.21,,,,,,,fee schedule,9.7,120.7,
Pneumatic caster tire each,E2214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,131.54,,,,,,,fee schedule,12.6,142.88,
Pneumatic caster tire each,E2214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14.48,,,,,,,fee schedule,12.6,142.88,
Pneumatic caster tire each,E2214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,98.62,,,,,,,fee schedule,12.6,142.88,
Pneumatic caster tire each,E2214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,142.88,,,,,,,fee schedule,12.6,142.88,
Pneumatic caster tire each,E2214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15.72,,,,,,,fee schedule,12.6,142.88,
Pneumatic caster tire each,E2214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,107.13,,,,,,,fee schedule,12.6,142.88,
Pneumatic caster tire each,E2214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,114.53,,,,,,,fee schedule,12.6,142.88,
Pneumatic caster tire each,E2214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12.6,,,,,,,fee schedule,12.6,142.88,
Pneumatic caster tire each,E2214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,85.87,,,,,,,fee schedule,12.6,142.88,
Pneumatic caster tire each,E2214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,125.12,,,,,,,fee schedule,12.6,142.88,
Pneumatic caster tire each,E2214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13.77,,,,,,,fee schedule,12.6,142.88,
Pneumatic caster tire each,E2214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,93.81,,,,,,,fee schedule,12.6,142.88,
Pneumatic caster tire tube,E2215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,35.08,,,,,,,fee schedule,3.03,38.1,
Pneumatic caster tire tube,E2215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.48,,,,,,,fee schedule,3.03,38.1,
Pneumatic caster tire tube,E2215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26.24,,,,,,,fee schedule,3.03,38.1,
Pneumatic caster tire tube,E2215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,38.1,,,,,,,fee schedule,3.03,38.1,
Pneumatic caster tire tube,E2215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.78,,,,,,,fee schedule,3.03,38.1,
Pneumatic caster tire tube,E2215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,28.5,,,,,,,fee schedule,3.03,38.1,
Pneumatic caster tire tube,E2215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,30.54,,,,,,,fee schedule,3.03,38.1,
Pneumatic caster tire tube,E2215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.03,,,,,,,fee schedule,3.03,38.1,
Pneumatic caster tire tube,E2215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22.85,,,,,,,fee schedule,3.03,38.1,
Pneumatic caster tire tube,E2215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,33.36,,,,,,,fee schedule,3.03,38.1,
Pneumatic caster tire tube,E2215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.31,,,,,,,fee schedule,3.03,38.1,
Pneumatic caster tire tube,E2215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24.96,,,,,,,fee schedule,3.03,38.1,
Foam caster tire any size ea,E2219,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,129.98,,,,,,,fee schedule,12.79,141.18,
Foam caster tire any size ea,E2219,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14.69,,,,,,,fee schedule,12.79,141.18,
Foam caster tire any size ea,E2219,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,97.51,,,,,,,fee schedule,12.79,141.18,
Foam caster tire any size ea,E2219,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,141.18,,,,,,,fee schedule,12.79,141.18,
Foam caster tire any size ea,E2219,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15.95,,,,,,,fee schedule,12.79,141.18,
Foam caster tire any size ea,E2219,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,105.92,,,,,,,fee schedule,12.79,141.18,
Foam caster tire any size ea,E2219,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,113.17,,,,,,,fee schedule,12.79,141.18,
Foam caster tire any size ea,E2219,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12.79,,,,,,,fee schedule,12.79,141.18,
Foam caster tire any size ea,E2219,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,84.9,,,,,,,fee schedule,12.79,141.18,
Foam caster tire any size ea,E2219,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,123.63,,,,,,,fee schedule,12.79,141.18,
Foam caster tire any size ea,E2219,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13.97,,,,,,,fee schedule,12.79,141.18,
Foam caster tire any size ea,E2219,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,92.75,,,,,,,fee schedule,12.79,141.18,
"Solid propuls tire, repl, ea",E2220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,104.23,,,,,,,fee schedule,8.76,113.21,
"Solid propuls tire, repl, ea",E2220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10.06,,,,,,,fee schedule,8.76,113.21,
"Solid propuls tire, repl, ea",E2220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,79.69,,,,,,,fee schedule,8.76,113.21,
"Solid propuls tire, repl, ea",E2220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,113.21,,,,,,,fee schedule,8.76,113.21,
"Solid propuls tire, repl, ea",E2220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10.92,,,,,,,fee schedule,8.76,113.21,
"Solid propuls tire, repl, ea",E2220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,86.56,,,,,,,fee schedule,8.76,113.21,
"Solid propuls tire, repl, ea",E2220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,90.75,,,,,,,fee schedule,8.76,113.21,
"Solid propuls tire, repl, ea",E2220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.76,,,,,,,fee schedule,8.76,113.21,
"Solid propuls tire, repl, ea",E2220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,69.39,,,,,,,fee schedule,8.76,113.21,
"Solid propuls tire, repl, ea",E2220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,99.13,,,,,,,fee schedule,8.76,113.21,
"Solid propuls tire, repl, ea",E2220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.57,,,,,,,fee schedule,8.76,113.21,
"Solid propuls tire, repl, ea",E2220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,75.8,,,,,,,fee schedule,8.76,113.21,
"Solid caster tire repl, each",E2221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,93.37,,,,,,,fee schedule,8.21,101.42,
"Solid caster tire repl, each",E2221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.43,,,,,,,fee schedule,8.21,101.42,
"Solid caster tire repl, each",E2221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,70.09,,,,,,,fee schedule,8.21,101.42,
"Solid caster tire repl, each",E2221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,101.42,,,,,,,fee schedule,8.21,101.42,
"Solid caster tire repl, each",E2221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10.24,,,,,,,fee schedule,8.21,101.42,
"Solid caster tire repl, each",E2221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,76.13,,,,,,,fee schedule,8.21,101.42,
"Solid caster tire repl, each",E2221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,81.29,,,,,,,fee schedule,8.21,101.42,
"Solid caster tire repl, each",E2221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.21,,,,,,,fee schedule,8.21,101.42,
"Solid caster tire repl, each",E2221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,61.02,,,,,,,fee schedule,8.21,101.42,
"Solid caster tire repl, each",E2221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,88.81,,,,,,,fee schedule,8.21,101.42,
"Solid caster tire repl, each",E2221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.97,,,,,,,fee schedule,8.21,101.42,
"Solid caster tire repl, each",E2221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66.66,,,,,,,fee schedule,8.21,101.42,
"Solid caster integ whl, repl",E2222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,76.94,,,,,,,fee schedule,6.64,83.58,
"Solid caster integ whl, repl",E2222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7.62,,,,,,,fee schedule,6.64,83.58,
"Solid caster integ whl, repl",E2222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,57.77,,,,,,,fee schedule,6.64,83.58,
"Solid caster integ whl, repl",E2222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83.58,,,,,,,fee schedule,6.64,83.58,
"Solid caster integ whl, repl",E2222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8.28,,,,,,,fee schedule,6.64,83.58,
"Solid caster integ whl, repl",E2222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,62.75,,,,,,,fee schedule,6.64,83.58,
"Solid caster integ whl, repl",E2222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66.99,,,,,,,fee schedule,6.64,83.58,
"Solid caster integ whl, repl",E2222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.64,,,,,,,fee schedule,6.64,83.58,
"Solid caster integ whl, repl",E2222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,50.3,,,,,,,fee schedule,6.64,83.58,
"Solid caster integ whl, repl",E2222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,73.18,,,,,,,fee schedule,6.64,83.58,
"Solid caster integ whl, repl",E2222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7.25,,,,,,,fee schedule,6.64,83.58,
"Solid caster integ whl, repl",E2222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,54.95,,,,,,,fee schedule,6.64,83.58,
Propulsion whl excl tire rep,E2224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,358.3,,,,,,,fee schedule,31.27,389.19,
Propulsion whl excl tire rep,E2224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,35.91,,,,,,,fee schedule,31.27,389.19,
Propulsion whl excl tire rep,E2224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,268.76,,,,,,,fee schedule,31.27,389.19,
Propulsion whl excl tire rep,E2224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,389.19,,,,,,,fee schedule,31.27,389.19,
Propulsion whl excl tire rep,E2224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,39.01,,,,,,,fee schedule,31.27,389.19,
Propulsion whl excl tire rep,E2224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,291.93,,,,,,,fee schedule,31.27,389.19,
Propulsion whl excl tire rep,E2224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,311.97,,,,,,,fee schedule,31.27,389.19,
Propulsion whl excl tire rep,E2224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31.27,,,,,,,fee schedule,31.27,389.19,
Propulsion whl excl tire rep,E2224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,234.01,,,,,,,fee schedule,31.27,389.19,
Propulsion whl excl tire rep,E2224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,340.8,,,,,,,fee schedule,31.27,389.19,
Propulsion whl excl tire rep,E2224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,34.16,,,,,,,fee schedule,31.27,389.19,
Propulsion whl excl tire rep,E2224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,255.63,,,,,,,fee schedule,31.27,389.19,
Caster wheel excludes tire,E2225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,63.58,,,,,,,fee schedule,5.54,69.06,
Caster wheel excludes tire,E2225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.37,,,,,,,fee schedule,5.54,69.06,
Caster wheel excludes tire,E2225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,47.64,,,,,,,fee schedule,5.54,69.06,
Caster wheel excludes tire,E2225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,69.06,,,,,,,fee schedule,5.54,69.06,
Caster wheel excludes tire,E2225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.92,,,,,,,fee schedule,5.54,69.06,
Caster wheel excludes tire,E2225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,51.75,,,,,,,fee schedule,5.54,69.06,
Caster wheel excludes tire,E2225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55.36,,,,,,,fee schedule,5.54,69.06,
Caster wheel excludes tire,E2225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.54,,,,,,,fee schedule,5.54,69.06,
Caster wheel excludes tire,E2225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,41.48,,,,,,,fee schedule,5.54,69.06,
Caster wheel excludes tire,E2225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,60.47,,,,,,,fee schedule,5.54,69.06,
Caster wheel excludes tire,E2225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.06,,,,,,,fee schedule,5.54,69.06,
Caster wheel excludes tire,E2225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,45.31,,,,,,,fee schedule,5.54,69.06,
Caster fork replacement only,E2226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,138.64,,,,,,,fee schedule,12.06,150.6,
Caster fork replacement only,E2226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13.85,,,,,,,fee schedule,12.06,150.6,
Caster fork replacement only,E2226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,103.98,,,,,,,fee schedule,12.06,150.6,
Caster fork replacement only,E2226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,150.6,,,,,,,fee schedule,12.06,150.6,
Caster fork replacement only,E2226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15.04,,,,,,,fee schedule,12.06,150.6,
Caster fork replacement only,E2226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,112.95,,,,,,,fee schedule,12.06,150.6,
Caster fork replacement only,E2226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,120.72,,,,,,,fee schedule,12.06,150.6,
Caster fork replacement only,E2226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12.06,,,,,,,fee schedule,12.06,150.6,
Caster fork replacement only,E2226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,90.54,,,,,,,fee schedule,12.06,150.6,
Caster fork replacement only,E2226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,131.87,,,,,,,fee schedule,12.06,150.6,
Caster fork replacement only,E2226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13.17,,,,,,,fee schedule,12.06,150.6,
Caster fork replacement only,E2226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,98.9,,,,,,,fee schedule,12.06,150.6,
Gear reduction drive wheel,E2227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5733.61,,,,,,,fee schedule,499.28,6227.89,
Gear reduction drive wheel,E2227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,573.43,,,,,,,fee schedule,499.28,6227.89,
Gear reduction drive wheel,E2227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4300.1,,,,,,,fee schedule,499.28,6227.89,
Gear reduction drive wheel,E2227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6227.89,,,,,,,fee schedule,499.28,6227.89,
Gear reduction drive wheel,E2227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,622.87,,,,,,,fee schedule,499.28,6227.89,
Gear reduction drive wheel,E2227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4670.79,,,,,,,fee schedule,499.28,6227.89,
Gear reduction drive wheel,E2227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4992.2,,,,,,,fee schedule,499.28,6227.89,
Gear reduction drive wheel,E2227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,499.28,,,,,,,fee schedule,499.28,6227.89,
Gear reduction drive wheel,E2227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3744.05,,,,,,,fee schedule,499.28,6227.89,
Gear reduction drive wheel,E2227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5453.52,,,,,,,fee schedule,499.28,6227.89,
Gear reduction drive wheel,E2227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,545.42,,,,,,,fee schedule,499.28,6227.89,
Gear reduction drive wheel,E2227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4090.03,,,,,,,fee schedule,499.28,6227.89,
"Mwc acc, wheelchair brake",E2228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3421.08,,,,,,,fee schedule,297.85,3716,
"Mwc acc, wheelchair brake",E2228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,342.08,,,,,,,fee schedule,297.85,3716,
"Mwc acc, wheelchair brake",E2228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2565.91,,,,,,,fee schedule,297.85,3716,
"Mwc acc, wheelchair brake",E2228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3716,,,,,,,fee schedule,297.85,3716,
"Mwc acc, wheelchair brake",E2228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,371.57,,,,,,,fee schedule,297.85,3716,
"Mwc acc, wheelchair brake",E2228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2787.11,,,,,,,fee schedule,297.85,3716,
"Mwc acc, wheelchair brake",E2228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2978.7,,,,,,,fee schedule,297.85,3716,
"Mwc acc, wheelchair brake",E2228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,297.85,,,,,,,fee schedule,297.85,3716,
"Mwc acc, wheelchair brake",E2228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2234.11,,,,,,,fee schedule,297.85,3716,
"Mwc acc, wheelchair brake",E2228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3253.96,,,,,,,fee schedule,297.85,3716,
"Mwc acc, wheelchair brake",E2228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,325.37,,,,,,,fee schedule,297.85,3716,
"Mwc acc, wheelchair brake",E2228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2440.56,,,,,,,fee schedule,297.85,3716,
Solid seat support base,E2231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,561.53,,,,,,,fee schedule,48.9,609.94,
Solid seat support base,E2231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,56.17,,,,,,,fee schedule,48.9,609.94,
Solid seat support base,E2231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,421.11,,,,,,,fee schedule,48.9,609.94,
Solid seat support base,E2231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,609.94,,,,,,,fee schedule,48.9,609.94,
Solid seat support base,E2231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,61.01,,,,,,,fee schedule,48.9,609.94,
Solid seat support base,E2231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,457.42,,,,,,,fee schedule,48.9,609.94,
Solid seat support base,E2231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,488.92,,,,,,,fee schedule,48.9,609.94,
Solid seat support base,E2231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48.9,,,,,,,fee schedule,48.9,609.94,
Solid seat support base,E2231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,366.66,,,,,,,fee schedule,48.9,609.94,
Solid seat support base,E2231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,534.1,,,,,,,fee schedule,48.9,609.94,
Solid seat support base,E2231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.42,,,,,,,fee schedule,48.9,609.94,
Solid seat support base,E2231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,400.54,,,,,,,fee schedule,48.9,609.94,
Electro connect btw control,E2310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3685.56,,,,,,,fee schedule,320.88,4003.28,
Electro connect btw control,E2310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,368.53,,,,,,,fee schedule,320.88,4003.28,
Electro connect btw control,E2310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2764.16,,,,,,,fee schedule,320.88,4003.28,
Electro connect btw control,E2310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4003.28,,,,,,,fee schedule,320.88,4003.28,
Electro connect btw control,E2310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,400.3,,,,,,,fee schedule,320.88,4003.28,
Electro connect btw control,E2310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3002.45,,,,,,,fee schedule,320.88,4003.28,
Electro connect btw control,E2310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3208.98,,,,,,,fee schedule,320.88,4003.28,
Electro connect btw control,E2310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,320.88,,,,,,,fee schedule,320.88,4003.28,
Electro connect btw control,E2310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2406.73,,,,,,,fee schedule,320.88,4003.28,
Electro connect btw control,E2310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3505.52,,,,,,,fee schedule,320.88,4003.28,
Electro connect btw control,E2310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,350.53,,,,,,,fee schedule,320.88,4003.28,
Electro connect btw control,E2310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2629.13,,,,,,,fee schedule,320.88,4003.28,
Electro connect btw 2 sys,E2311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7461.57,,,,,,,fee schedule,649.69,8104.81,
Electro connect btw 2 sys,E2311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,746.18,,,,,,,fee schedule,649.69,8104.81,
Electro connect btw 2 sys,E2311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5596.15,,,,,,,fee schedule,649.69,8104.81,
Electro connect btw 2 sys,E2311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8104.81,,,,,,,fee schedule,649.69,8104.81,
Electro connect btw 2 sys,E2311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,810.51,,,,,,,fee schedule,649.69,8104.81,
Electro connect btw 2 sys,E2311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6078.58,,,,,,,fee schedule,649.69,8104.81,
Electro connect btw 2 sys,E2311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6496.71,,,,,,,fee schedule,649.69,8104.81,
Electro connect btw 2 sys,E2311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,649.69,,,,,,,fee schedule,649.69,8104.81,
Electro connect btw 2 sys,E2311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4872.51,,,,,,,fee schedule,649.69,8104.81,
Electro connect btw 2 sys,E2311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7097.07,,,,,,,fee schedule,649.69,8104.81,
Electro connect btw 2 sys,E2311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,709.73,,,,,,,fee schedule,649.69,8104.81,
Electro connect btw 2 sys,E2311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5322.78,,,,,,,fee schedule,649.69,8104.81,
Mini-prop remote joystick,E2312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7369.07,,,,,,,fee schedule,641.6,8004.34,
Mini-prop remote joystick,E2312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,736.89,,,,,,,fee schedule,641.6,8004.34,
Mini-prop remote joystick,E2312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5526.9,,,,,,,fee schedule,641.6,8004.34,
Mini-prop remote joystick,E2312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8004.34,,,,,,,fee schedule,641.6,8004.34,
Mini-prop remote joystick,E2312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,800.42,,,,,,,fee schedule,641.6,8004.34,
Mini-prop remote joystick,E2312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6003.36,,,,,,,fee schedule,641.6,8004.34,
Mini-prop remote joystick,E2312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6416.18,,,,,,,fee schedule,641.6,8004.34,
Mini-prop remote joystick,E2312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,641.6,,,,,,,fee schedule,641.6,8004.34,
Mini-prop remote joystick,E2312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4812.22,,,,,,,fee schedule,641.6,8004.34,
Mini-prop remote joystick,E2312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7009.09,,,,,,,fee schedule,641.6,8004.34,
Mini-prop remote joystick,E2312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,700.89,,,,,,,fee schedule,641.6,8004.34,
Mini-prop remote joystick,E2312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5256.91,,,,,,,fee schedule,641.6,8004.34,
"PWC harness, expand control",E2313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1170.22,,,,,,,fee schedule,101.9,1271.1,
"PWC harness, expand control",E2313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,117.03,,,,,,,fee schedule,101.9,1271.1,
"PWC harness, expand control",E2313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,877.66,,,,,,,fee schedule,101.9,1271.1,
"PWC harness, expand control",E2313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1271.1,,,,,,,fee schedule,101.9,1271.1,
"PWC harness, expand control",E2313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,127.12,,,,,,,fee schedule,101.9,1271.1,
"PWC harness, expand control",E2313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,953.32,,,,,,,fee schedule,101.9,1271.1,
"PWC harness, expand control",E2313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1018.9,,,,,,,fee schedule,101.9,1271.1,
"PWC harness, expand control",E2313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,101.9,,,,,,,fee schedule,101.9,1271.1,
"PWC harness, expand control",E2313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,764.17,,,,,,,fee schedule,101.9,1271.1,
"PWC harness, expand control",E2313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1113.05,,,,,,,fee schedule,101.9,1271.1,
"PWC harness, expand control",E2313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,111.32,,,,,,,fee schedule,101.9,1271.1,
"PWC harness, expand control",E2313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,834.78,,,,,,,fee schedule,101.9,1271.1,
Hand interface joystick,E2321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5004.73,,,,,,,fee schedule,435.77,5436.17,
Hand interface joystick,E2321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,500.49,,,,,,,fee schedule,435.77,5436.17,
Hand interface joystick,E2321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3753.6,,,,,,,fee schedule,435.77,5436.17,
Hand interface joystick,E2321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5436.17,,,,,,,fee schedule,435.77,5436.17,
Hand interface joystick,E2321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,543.64,,,,,,,fee schedule,435.77,5436.17,
Hand interface joystick,E2321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4077.18,,,,,,,fee schedule,435.77,5436.17,
Hand interface joystick,E2321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4357.56,,,,,,,fee schedule,435.77,5436.17,
Hand interface joystick,E2321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,435.77,,,,,,,fee schedule,435.77,5436.17,
Hand interface joystick,E2321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3268.22,,,,,,,fee schedule,435.77,5436.17,
Hand interface joystick,E2321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4760.24,,,,,,,fee schedule,435.77,5436.17,
Hand interface joystick,E2321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,476.04,,,,,,,fee schedule,435.77,5436.17,
Hand interface joystick,E2321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3570.23,,,,,,,fee schedule,435.77,5436.17,
Mult mech switches,E2322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4441.8,,,,,,,fee schedule,386.72,4824.72,
Mult mech switches,E2322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,444.15,,,,,,,fee schedule,386.72,4824.72,
Mult mech switches,E2322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3331.37,,,,,,,fee schedule,386.72,4824.72,
Mult mech switches,E2322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4824.72,,,,,,,fee schedule,386.72,4824.72,
Mult mech switches,E2322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,482.44,,,,,,,fee schedule,386.72,4824.72,
Mult mech switches,E2322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3618.56,,,,,,,fee schedule,386.72,4824.72,
Mult mech switches,E2322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3867.43,,,,,,,fee schedule,386.72,4824.72,
Mult mech switches,E2322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.72,,,,,,,fee schedule,386.72,4824.72,
Mult mech switches,E2322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2900.59,,,,,,,fee schedule,386.72,4824.72,
Mult mech switches,E2322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4224.82,,,,,,,fee schedule,386.72,4824.72,
Mult mech switches,E2322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,422.46,,,,,,,fee schedule,386.72,4824.72,
Mult mech switches,E2322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3168.63,,,,,,,fee schedule,386.72,4824.72,
Special joystick handle,E2323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,217.81,,,,,,,fee schedule,18.97,236.59,
Special joystick handle,E2323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21.78,,,,,,,fee schedule,18.97,236.59,
Special joystick handle,E2323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,163.35,,,,,,,fee schedule,18.97,236.59,
Special joystick handle,E2323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,236.59,,,,,,,fee schedule,18.97,236.59,
Special joystick handle,E2323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23.66,,,,,,,fee schedule,18.97,236.59,
Special joystick handle,E2323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,177.43,,,,,,,fee schedule,18.97,236.59,
Special joystick handle,E2323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,189.65,,,,,,,fee schedule,18.97,236.59,
Special joystick handle,E2323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18.97,,,,,,,fee schedule,18.97,236.59,
Special joystick handle,E2323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,142.23,,,,,,,fee schedule,18.97,236.59,
Special joystick handle,E2323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,207.17,,,,,,,fee schedule,18.97,236.59,
Special joystick handle,E2323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20.72,,,,,,,fee schedule,18.97,236.59,
Special joystick handle,E2323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,155.37,,,,,,,fee schedule,18.97,236.59,
Chin cup interface,E2324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,138.02,,,,,,,fee schedule,11.97,149.91,
Chin cup interface,E2324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13.75,,,,,,,fee schedule,11.97,149.91,
Chin cup interface,E2324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,103.53,,,,,,,fee schedule,11.97,149.91,
Chin cup interface,E2324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,149.91,,,,,,,fee schedule,11.97,149.91,
Chin cup interface,E2324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14.93,,,,,,,fee schedule,11.97,149.91,
Chin cup interface,E2324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,112.46,,,,,,,fee schedule,11.97,149.91,
Chin cup interface,E2324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,120.17,,,,,,,fee schedule,11.97,149.91,
Chin cup interface,E2324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11.97,,,,,,,fee schedule,11.97,149.91,
Chin cup interface,E2324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,90.14,,,,,,,fee schedule,11.97,149.91,
Chin cup interface,E2324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,131.27,,,,,,,fee schedule,11.97,149.91,
Chin cup interface,E2324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13.07,,,,,,,fee schedule,11.97,149.91,
Chin cup interface,E2324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,98.47,,,,,,,fee schedule,11.97,149.91,
Sip and puff interface,E2325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4241.7,,,,,,,fee schedule,369.36,4607.37,
Sip and puff interface,E2325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,424.21,,,,,,,fee schedule,369.36,4607.37,
Sip and puff interface,E2325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3181.31,,,,,,,fee schedule,369.36,4607.37,
Sip and puff interface,E2325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4607.37,,,,,,,fee schedule,369.36,4607.37,
Sip and puff interface,E2325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,460.78,,,,,,,fee schedule,369.36,4607.37,
Sip and puff interface,E2325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3455.56,,,,,,,fee schedule,369.36,4607.37,
Sip and puff interface,E2325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3693.21,,,,,,,fee schedule,369.36,4607.37,
Sip and puff interface,E2325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,369.36,,,,,,,fee schedule,369.36,4607.37,
Sip and puff interface,E2325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2769.94,,,,,,,fee schedule,369.36,4607.37,
Sip and puff interface,E2325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4034.49,,,,,,,fee schedule,369.36,4607.37,
Sip and puff interface,E2325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,403.49,,,,,,,fee schedule,369.36,4607.37,
Sip and puff interface,E2325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3025.9,,,,,,,fee schedule,369.36,4607.37,
Breath tube kit,E2326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1093.28,,,,,,,fee schedule,95.23,1187.52,
Breath tube kit,E2326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,109.38,,,,,,,fee schedule,95.23,1187.52,
Breath tube kit,E2326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,819.92,,,,,,,fee schedule,95.23,1187.52,
Breath tube kit,E2326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1187.52,,,,,,,fee schedule,95.23,1187.52,
Breath tube kit,E2326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,118.81,,,,,,,fee schedule,95.23,1187.52,
Breath tube kit,E2326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,890.61,,,,,,,fee schedule,95.23,1187.52,
Breath tube kit,E2326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,951.9,,,,,,,fee schedule,95.23,1187.52,
Breath tube kit,E2326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,95.23,,,,,,,fee schedule,95.23,1187.52,
Breath tube kit,E2326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,713.9,,,,,,,fee schedule,95.23,1187.52,
Breath tube kit,E2326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1039.87,,,,,,,fee schedule,95.23,1187.52,
Breath tube kit,E2326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,104.03,,,,,,,fee schedule,95.23,1187.52,
Breath tube kit,E2326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,779.87,,,,,,,fee schedule,95.23,1187.52,
Head control interface mech,E2327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8227.42,,,,,,,fee schedule,716.35,8936.68,
Head control interface mech,E2327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,822.74,,,,,,,fee schedule,716.35,8936.68,
Head control interface mech,E2327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6170.56,,,,,,,fee schedule,716.35,8936.68,
Head control interface mech,E2327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8936.68,,,,,,,fee schedule,716.35,8936.68,
Head control interface mech,E2327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,893.67,,,,,,,fee schedule,716.35,8936.68,
Head control interface mech,E2327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6702.51,,,,,,,fee schedule,716.35,8936.68,
Head control interface mech,E2327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7163.53,,,,,,,fee schedule,716.35,8936.68,
Head control interface mech,E2327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,716.35,,,,,,,fee schedule,716.35,8936.68,
Head control interface mech,E2327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5372.64,,,,,,,fee schedule,716.35,8936.68,
Head control interface mech,E2327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7825.5,,,,,,,fee schedule,716.35,8936.68,
Head control interface mech,E2327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,782.55,,,,,,,fee schedule,716.35,8936.68,
Head control interface mech,E2327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5869.13,,,,,,,fee schedule,716.35,8936.68,
Head/extremity control inter,E2328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15606.27,,,,,,,fee schedule,1358.8,16951.64,
Head/extremity control inter,E2328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1560.61,,,,,,,fee schedule,1358.8,16951.64,
Head/extremity control inter,E2328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11704.74,,,,,,,fee schedule,1358.8,16951.64,
Head/extremity control inter,E2328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16951.64,,,,,,,fee schedule,1358.8,16951.64,
Head/extremity control inter,E2328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1695.14,,,,,,,fee schedule,1358.8,16951.64,
Head/extremity control inter,E2328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12713.77,,,,,,,fee schedule,1358.8,16951.64,
Head/extremity control inter,E2328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13588.22,,,,,,,fee schedule,1358.8,16951.64,
Head/extremity control inter,E2328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1358.8,,,,,,,fee schedule,1358.8,16951.64,
Head/extremity control inter,E2328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10191.19,,,,,,,fee schedule,1358.8,16951.64,
Head/extremity control inter,E2328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14843.89,,,,,,,fee schedule,1358.8,16951.64,
Head/extremity control inter,E2328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1484.37,,,,,,,fee schedule,1358.8,16951.64,
Head/extremity control inter,E2328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11132.95,,,,,,,fee schedule,1358.8,16951.64,
Head control nonproportional,E2329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5562.26,,,,,,,fee schedule,484.28,6041.76,
Head control nonproportional,E2329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,556.21,,,,,,,fee schedule,484.28,6041.76,
Head control nonproportional,E2329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4171.68,,,,,,,fee schedule,484.28,6041.76,
Head control nonproportional,E2329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6041.76,,,,,,,fee schedule,484.28,6041.76,
Head control nonproportional,E2329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,604.16,,,,,,,fee schedule,484.28,6041.76,
Head control nonproportional,E2329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4531.31,,,,,,,fee schedule,484.28,6041.76,
Head control nonproportional,E2329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4843,,,,,,,fee schedule,484.28,6041.76,
Head control nonproportional,E2329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,484.28,,,,,,,fee schedule,484.28,6041.76,
Head control nonproportional,E2329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3632.24,,,,,,,fee schedule,484.28,6041.76,
Head control nonproportional,E2329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5290.54,,,,,,,fee schedule,484.28,6041.76,
Head control nonproportional,E2329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,529.04,,,,,,,fee schedule,484.28,6041.76,
Head control nonproportional,E2329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3967.9,,,,,,,fee schedule,484.28,6041.76,
Head control proximity switc,E2330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10777.53,,,,,,,fee schedule,938.36,11706.62,
Head control proximity switc,E2330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1077.72,,,,,,,fee schedule,938.36,11706.62,
Head control proximity switc,E2330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8083.17,,,,,,,fee schedule,938.36,11706.62,
Head control proximity switc,E2330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11706.62,,,,,,,fee schedule,938.36,11706.62,
Head control proximity switc,E2330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1170.63,,,,,,,fee schedule,938.36,11706.62,
Head control proximity switc,E2330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8780,,,,,,,fee schedule,938.36,11706.62,
Head control proximity switc,E2330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9383.88,,,,,,,fee schedule,938.36,11706.62,
Head control proximity switc,E2330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,938.36,,,,,,,fee schedule,938.36,11706.62,
Head control proximity switc,E2330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7037.93,,,,,,,fee schedule,938.36,11706.62,
Head control proximity switc,E2330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10251.04,,,,,,,fee schedule,938.36,11706.62,
Head control proximity switc,E2330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1025.07,,,,,,,fee schedule,938.36,11706.62,
Head control proximity switc,E2330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7688.3,,,,,,,fee schedule,938.36,11706.62,
W/c wdth 20-23 in seat frame,E2340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1309.45,,,,,,,fee schedule,114.05,1422.34,
W/c wdth 20-23 in seat frame,E2340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,130.99,,,,,,,fee schedule,114.05,1422.34,
W/c wdth 20-23 in seat frame,E2340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,982.16,,,,,,,fee schedule,114.05,1422.34,
W/c wdth 20-23 in seat frame,E2340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1422.34,,,,,,,fee schedule,114.05,1422.34,
W/c wdth 20-23 in seat frame,E2340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,142.28,,,,,,,fee schedule,114.05,1422.34,
W/c wdth 20-23 in seat frame,E2340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1066.83,,,,,,,fee schedule,114.05,1422.34,
W/c wdth 20-23 in seat frame,E2340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1140.13,,,,,,,fee schedule,114.05,1422.34,
W/c wdth 20-23 in seat frame,E2340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,114.05,,,,,,,fee schedule,114.05,1422.34,
W/c wdth 20-23 in seat frame,E2340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,855.16,,,,,,,fee schedule,114.05,1422.34,
W/c wdth 20-23 in seat frame,E2340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1245.49,,,,,,,fee schedule,114.05,1422.34,
W/c wdth 20-23 in seat frame,E2340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,124.59,,,,,,,fee schedule,114.05,1422.34,
W/c wdth 20-23 in seat frame,E2340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,934.18,,,,,,,fee schedule,114.05,1422.34,
W/c wdth 24-27 in seat frame,E2341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1964.32,,,,,,,fee schedule,171.04,2133.66,
W/c wdth 24-27 in seat frame,E2341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,196.45,,,,,,,fee schedule,171.04,2133.66,
W/c wdth 24-27 in seat frame,E2341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1473.26,,,,,,,fee schedule,171.04,2133.66,
W/c wdth 24-27 in seat frame,E2341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2133.66,,,,,,,fee schedule,171.04,2133.66,
W/c wdth 24-27 in seat frame,E2341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,213.38,,,,,,,fee schedule,171.04,2133.66,
W/c wdth 24-27 in seat frame,E2341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1600.26,,,,,,,fee schedule,171.04,2133.66,
W/c wdth 24-27 in seat frame,E2341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1710.31,,,,,,,fee schedule,171.04,2133.66,
W/c wdth 24-27 in seat frame,E2341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,171.04,,,,,,,fee schedule,171.04,2133.66,
W/c wdth 24-27 in seat frame,E2341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1282.75,,,,,,,fee schedule,171.04,2133.66,
W/c wdth 24-27 in seat frame,E2341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1868.36,,,,,,,fee schedule,171.04,2133.66,
W/c wdth 24-27 in seat frame,E2341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,186.85,,,,,,,fee schedule,171.04,2133.66,
W/c wdth 24-27 in seat frame,E2341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1401.29,,,,,,,fee schedule,171.04,2133.66,
W/c dpth 20-21 in seat frame,E2342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1636.92,,,,,,,fee schedule,142.53,1778.04,
W/c dpth 20-21 in seat frame,E2342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,163.7,,,,,,,fee schedule,142.53,1778.04,
W/c dpth 20-21 in seat frame,E2342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1227.71,,,,,,,fee schedule,142.53,1778.04,
W/c dpth 20-21 in seat frame,E2342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1778.04,,,,,,,fee schedule,142.53,1778.04,
W/c dpth 20-21 in seat frame,E2342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,177.81,,,,,,,fee schedule,142.53,1778.04,
W/c dpth 20-21 in seat frame,E2342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1333.55,,,,,,,fee schedule,142.53,1778.04,
W/c dpth 20-21 in seat frame,E2342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1425.25,,,,,,,fee schedule,142.53,1778.04,
W/c dpth 20-21 in seat frame,E2342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,142.53,,,,,,,fee schedule,142.53,1778.04,
W/c dpth 20-21 in seat frame,E2342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1068.95,,,,,,,fee schedule,142.53,1778.04,
W/c dpth 20-21 in seat frame,E2342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1556.96,,,,,,,fee schedule,142.53,1778.04,
W/c dpth 20-21 in seat frame,E2342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,155.7,,,,,,,fee schedule,142.53,1778.04,
W/c dpth 20-21 in seat frame,E2342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1167.73,,,,,,,fee schedule,142.53,1778.04,
W/c dpth 22-25 in seat frame,E2343,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2619.12,,,,,,,fee schedule,228.01,2844.9,
W/c dpth 22-25 in seat frame,E2343,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,261.87,,,,,,,fee schedule,228.01,2844.9,
W/c dpth 22-25 in seat frame,E2343,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1964.32,,,,,,,fee schedule,228.01,2844.9,
W/c dpth 22-25 in seat frame,E2343,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2844.9,,,,,,,fee schedule,228.01,2844.9,
W/c dpth 22-25 in seat frame,E2343,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,284.45,,,,,,,fee schedule,228.01,2844.9,
W/c dpth 22-25 in seat frame,E2343,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2133.66,,,,,,,fee schedule,228.01,2844.9,
W/c dpth 22-25 in seat frame,E2343,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2280.44,,,,,,,fee schedule,228.01,2844.9,
W/c dpth 22-25 in seat frame,E2343,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,228.01,,,,,,,fee schedule,228.01,2844.9,
W/c dpth 22-25 in seat frame,E2343,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1710.31,,,,,,,fee schedule,228.01,2844.9,
W/c dpth 22-25 in seat frame,E2343,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2491.17,,,,,,,fee schedule,228.01,2844.9,
W/c dpth 22-25 in seat frame,E2343,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,249.08,,,,,,,fee schedule,228.01,2844.9,
W/c dpth 22-25 in seat frame,E2343,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1868.36,,,,,,,fee schedule,228.01,2844.9,
Electronic SGD interface,E2351,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2200.26,,,,,,,fee schedule,191.62,2389.94,
Electronic SGD interface,E2351,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,220.08,,,,,,,fee schedule,191.62,2389.94,
Electronic SGD interface,E2351,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1650.15,,,,,,,fee schedule,191.62,2389.94,
Electronic SGD interface,E2351,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2389.94,,,,,,,fee schedule,191.62,2389.94,
Electronic SGD interface,E2351,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,239.05,,,,,,,fee schedule,191.62,2389.94,
Electronic SGD interface,E2351,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1792.4,,,,,,,fee schedule,191.62,2389.94,
Electronic SGD interface,E2351,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1915.75,,,,,,,fee schedule,191.62,2389.94,
Electronic SGD interface,E2351,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,191.62,,,,,,,fee schedule,191.62,2389.94,
Electronic SGD interface,E2351,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1436.77,,,,,,,fee schedule,191.62,2389.94,
Electronic SGD interface,E2351,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2092.78,,,,,,,fee schedule,191.62,2389.94,
Electronic SGD interface,E2351,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,209.32,,,,,,,fee schedule,191.62,2389.94,
Electronic SGD interface,E2351,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1569.54,,,,,,,fee schedule,191.62,2389.94,
Gr34 sealed leadacid battery,E2359,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,656.12,,,,,,,fee schedule,57.15,712.68,
Gr34 sealed leadacid battery,E2359,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,65.63,,,,,,,fee schedule,57.15,712.68,
Gr34 sealed leadacid battery,E2359,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,712.68,,,,,,,fee schedule,57.15,712.68,
Gr34 sealed leadacid battery,E2359,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,71.29,,,,,,,fee schedule,57.15,712.68,
Gr34 sealed leadacid battery,E2359,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,571.28,,,,,,,fee schedule,57.15,712.68,
Gr34 sealed leadacid battery,E2359,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.15,,,,,,,fee schedule,57.15,712.68,
Gr34 sealed leadacid battery,E2359,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,624.07,,,,,,,fee schedule,57.15,712.68,
Gr34 sealed leadacid battery,E2359,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,62.43,,,,,,,fee schedule,57.15,712.68,
22nf nonsealed leadacid,E2360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,410.5,,,,,,,fee schedule,35.91,445.89,
22nf nonsealed leadacid,E2360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41.24,,,,,,,fee schedule,35.91,445.89,
22nf nonsealed leadacid,E2360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,307.88,,,,,,,fee schedule,35.91,445.89,
22nf nonsealed leadacid,E2360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,445.89,,,,,,,fee schedule,35.91,445.89,
22nf nonsealed leadacid,E2360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,44.79,,,,,,,fee schedule,35.91,445.89,
22nf nonsealed leadacid,E2360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,334.42,,,,,,,fee schedule,35.91,445.89,
22nf nonsealed leadacid,E2360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,357.42,,,,,,,fee schedule,35.91,445.89,
22nf nonsealed leadacid,E2360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35.91,,,,,,,fee schedule,35.91,445.89,
22nf nonsealed leadacid,E2360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,268.06,,,,,,,fee schedule,35.91,445.89,
22nf nonsealed leadacid,E2360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,390.45,,,,,,,fee schedule,35.91,445.89,
22nf nonsealed leadacid,E2360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39.22,,,,,,,fee schedule,35.91,445.89,
22nf nonsealed leadacid,E2360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,292.84,,,,,,,fee schedule,35.91,445.89,
22nf sealed leadacid battery,E2361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,439.25,,,,,,,fee schedule,38.24,477.11,
22nf sealed leadacid battery,E2361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,43.92,,,,,,,fee schedule,38.24,477.11,
22nf sealed leadacid battery,E2361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,329.49,,,,,,,fee schedule,38.24,477.11,
22nf sealed leadacid battery,E2361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,477.11,,,,,,,fee schedule,38.24,477.11,
22nf sealed leadacid battery,E2361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,47.7,,,,,,,fee schedule,38.24,477.11,
22nf sealed leadacid battery,E2361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,357.89,,,,,,,fee schedule,38.24,477.11,
22nf sealed leadacid battery,E2361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,382.45,,,,,,,fee schedule,38.24,477.11,
22nf sealed leadacid battery,E2361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38.24,,,,,,,fee schedule,38.24,477.11,
22nf sealed leadacid battery,E2361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,286.88,,,,,,,fee schedule,38.24,477.11,
22nf sealed leadacid battery,E2361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,417.79,,,,,,,fee schedule,38.24,477.11,
22nf sealed leadacid battery,E2361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,41.77,,,,,,,fee schedule,38.24,477.11,
22nf sealed leadacid battery,E2361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,313.39,,,,,,,fee schedule,38.24,477.11,
Gr24 nonsealed leadacid,E2362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,336.1,,,,,,,fee schedule,29.27,365.07,
Gr24 nonsealed leadacid,E2362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33.62,,,,,,,fee schedule,29.27,365.07,
Gr24 nonsealed leadacid,E2362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,252.06,,,,,,,fee schedule,29.27,365.07,
Gr24 nonsealed leadacid,E2362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,365.07,,,,,,,fee schedule,29.27,365.07,
Gr24 nonsealed leadacid,E2362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,36.51,,,,,,,fee schedule,29.27,365.07,
Gr24 nonsealed leadacid,E2362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,273.79,,,,,,,fee schedule,29.27,365.07,
Gr24 nonsealed leadacid,E2362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,292.64,,,,,,,fee schedule,29.27,365.07,
Gr24 nonsealed leadacid,E2362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29.27,,,,,,,fee schedule,29.27,365.07,
Gr24 nonsealed leadacid,E2362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,219.46,,,,,,,fee schedule,29.27,365.07,
Gr24 nonsealed leadacid,E2362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,319.68,,,,,,,fee schedule,29.27,365.07,
Gr24 nonsealed leadacid,E2362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31.97,,,,,,,fee schedule,29.27,365.07,
Gr24 nonsealed leadacid,E2362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,239.74,,,,,,,fee schedule,29.27,365.07,
Gr24 sealed leadacid battery,E2363,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,585.79,,,,,,,fee schedule,51.03,636.29,
Gr24 sealed leadacid battery,E2363,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,58.6,,,,,,,fee schedule,51.03,636.29,
Gr24 sealed leadacid battery,E2363,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,439.35,,,,,,,fee schedule,51.03,636.29,
Gr24 sealed leadacid battery,E2363,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,636.29,,,,,,,fee schedule,51.03,636.29,
Gr24 sealed leadacid battery,E2363,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,63.66,,,,,,,fee schedule,51.03,636.29,
Gr24 sealed leadacid battery,E2363,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,477.23,,,,,,,fee schedule,51.03,636.29,
Gr24 sealed leadacid battery,E2363,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,510.04,,,,,,,fee schedule,51.03,636.29,
Gr24 sealed leadacid battery,E2363,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.03,,,,,,,fee schedule,51.03,636.29,
Gr24 sealed leadacid battery,E2363,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,382.54,,,,,,,fee schedule,51.03,636.29,
Gr24 sealed leadacid battery,E2363,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,557.17,,,,,,,fee schedule,51.03,636.29,
Gr24 sealed leadacid battery,E2363,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55.74,,,,,,,fee schedule,51.03,636.29,
Gr24 sealed leadacid battery,E2363,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,417.89,,,,,,,fee schedule,51.03,636.29,
U1nonsealed leadacid battery,E2364,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,410.5,,,,,,,fee schedule,35.91,445.89,
U1nonsealed leadacid battery,E2364,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41.24,,,,,,,fee schedule,35.91,445.89,
U1nonsealed leadacid battery,E2364,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,307.88,,,,,,,fee schedule,35.91,445.89,
U1nonsealed leadacid battery,E2364,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,445.89,,,,,,,fee schedule,35.91,445.89,
U1nonsealed leadacid battery,E2364,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,44.79,,,,,,,fee schedule,35.91,445.89,
U1nonsealed leadacid battery,E2364,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,334.42,,,,,,,fee schedule,35.91,445.89,
U1nonsealed leadacid battery,E2364,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,357.42,,,,,,,fee schedule,35.91,445.89,
U1nonsealed leadacid battery,E2364,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35.91,,,,,,,fee schedule,35.91,445.89,
U1nonsealed leadacid battery,E2364,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,268.06,,,,,,,fee schedule,35.91,445.89,
U1nonsealed leadacid battery,E2364,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,390.45,,,,,,,fee schedule,35.91,445.89,
U1nonsealed leadacid battery,E2364,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39.22,,,,,,,fee schedule,35.91,445.89,
U1nonsealed leadacid battery,E2364,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,292.84,,,,,,,fee schedule,35.91,445.89,
U1 sealed leadacid battery,E2365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,353.25,,,,,,,fee schedule,30.75,383.71,
U1 sealed leadacid battery,E2365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,35.32,,,,,,,fee schedule,30.75,383.71,
U1 sealed leadacid battery,E2365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,265.04,,,,,,,fee schedule,30.75,383.71,
U1 sealed leadacid battery,E2365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,383.71,,,,,,,fee schedule,30.75,383.71,
U1 sealed leadacid battery,E2365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,38.37,,,,,,,fee schedule,30.75,383.71,
U1 sealed leadacid battery,E2365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,287.88,,,,,,,fee schedule,30.75,383.71,
U1 sealed leadacid battery,E2365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,307.58,,,,,,,fee schedule,30.75,383.71,
U1 sealed leadacid battery,E2365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,30.75,,,,,,,fee schedule,30.75,383.71,
U1 sealed leadacid battery,E2365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,230.76,,,,,,,fee schedule,30.75,383.71,
U1 sealed leadacid battery,E2365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,336,,,,,,,fee schedule,30.75,383.71,
U1 sealed leadacid battery,E2365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,33.6,,,,,,,fee schedule,30.75,383.71,
U1 sealed leadacid battery,E2365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,252.09,,,,,,,fee schedule,30.75,383.71,
"Battery charger, single mode",E2366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,705.71,,,,,,,fee schedule,61.6,766.55,
"Battery charger, single mode",E2366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,70.75,,,,,,,fee schedule,61.6,766.55,
"Battery charger, single mode",E2366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,529.31,,,,,,,fee schedule,61.6,766.55,
"Battery charger, single mode",E2366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,766.55,,,,,,,fee schedule,61.6,766.55,
"Battery charger, single mode",E2366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,76.85,,,,,,,fee schedule,61.6,766.55,
"Battery charger, single mode",E2366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,574.94,,,,,,,fee schedule,61.6,766.55,
"Battery charger, single mode",E2366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,614.45,,,,,,,fee schedule,61.6,766.55,
"Battery charger, single mode",E2366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,61.6,,,,,,,fee schedule,61.6,766.55,
"Battery charger, single mode",E2366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,460.86,,,,,,,fee schedule,61.6,766.55,
"Battery charger, single mode",E2366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,671.23,,,,,,,fee schedule,61.6,766.55,
"Battery charger, single mode",E2366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,67.29,,,,,,,fee schedule,61.6,766.55,
"Battery charger, single mode",E2366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,503.45,,,,,,,fee schedule,61.6,766.55,
"Battery charger, dual mode",E2367,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1319.86,,,,,,,fee schedule,114.93,1433.64,
"Battery charger, dual mode",E2367,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,132,,,,,,,fee schedule,114.93,1433.64,
"Battery charger, dual mode",E2367,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,989.89,,,,,,,fee schedule,114.93,1433.64,
"Battery charger, dual mode",E2367,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1433.64,,,,,,,fee schedule,114.93,1433.64,
"Battery charger, dual mode",E2367,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,143.38,,,,,,,fee schedule,114.93,1433.64,
"Battery charger, dual mode",E2367,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1075.22,,,,,,,fee schedule,114.93,1433.64,
"Battery charger, dual mode",E2367,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1149.19,,,,,,,fee schedule,114.93,1433.64,
"Battery charger, dual mode",E2367,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,114.93,,,,,,,fee schedule,114.93,1433.64,
"Battery charger, dual mode",E2367,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,861.88,,,,,,,fee schedule,114.93,1433.64,
"Battery charger, dual mode",E2367,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1255.38,,,,,,,fee schedule,114.93,1433.64,
"Battery charger, dual mode",E2367,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,125.55,,,,,,,fee schedule,114.93,1433.64,
"Battery charger, dual mode",E2367,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,941.53,,,,,,,fee schedule,114.93,1433.64,
Pwr wc drivewheel motor repl,E2368,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1626.9,,,,,,,fee schedule,141.68,1767.15,
Pwr wc drivewheel motor repl,E2368,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,162.72,,,,,,,fee schedule,141.68,1767.15,
Pwr wc drivewheel motor repl,E2368,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1220.19,,,,,,,fee schedule,141.68,1767.15,
Pwr wc drivewheel motor repl,E2368,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1767.15,,,,,,,fee schedule,141.68,1767.15,
Pwr wc drivewheel motor repl,E2368,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,176.75,,,,,,,fee schedule,141.68,1767.15,
Pwr wc drivewheel motor repl,E2368,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1325.38,,,,,,,fee schedule,141.68,1767.15,
Pwr wc drivewheel motor repl,E2368,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1416.53,,,,,,,fee schedule,141.68,1767.15,
Pwr wc drivewheel motor repl,E2368,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,141.68,,,,,,,fee schedule,141.68,1767.15,
Pwr wc drivewheel motor repl,E2368,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1062.41,,,,,,,fee schedule,141.68,1767.15,
Pwr wc drivewheel motor repl,E2368,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1547.43,,,,,,,fee schedule,141.68,1767.15,
Pwr wc drivewheel motor repl,E2368,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,154.78,,,,,,,fee schedule,141.68,1767.15,
Pwr wc drivewheel motor repl,E2368,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1160.59,,,,,,,fee schedule,141.68,1767.15,
Pwr wc drivewheel gear repl,E2369,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1417.06,,,,,,,fee schedule,123.41,1539.22,
Pwr wc drivewheel gear repl,E2369,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,141.74,,,,,,,fee schedule,123.41,1539.22,
Pwr wc drivewheel gear repl,E2369,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1062.76,,,,,,,fee schedule,123.41,1539.22,
Pwr wc drivewheel gear repl,E2369,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1539.22,,,,,,,fee schedule,123.41,1539.22,
Pwr wc drivewheel gear repl,E2369,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,153.96,,,,,,,fee schedule,123.41,1539.22,
Pwr wc drivewheel gear repl,E2369,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1154.37,,,,,,,fee schedule,123.41,1539.22,
Pwr wc drivewheel gear repl,E2369,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1233.82,,,,,,,fee schedule,123.41,1539.22,
Pwr wc drivewheel gear repl,E2369,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,123.41,,,,,,,fee schedule,123.41,1539.22,
Pwr wc drivewheel gear repl,E2369,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,925.33,,,,,,,fee schedule,123.41,1539.22,
Pwr wc drivewheel gear repl,E2369,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1347.83,,,,,,,fee schedule,123.41,1539.22,
Pwr wc drivewheel gear repl,E2369,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,134.82,,,,,,,fee schedule,123.41,1539.22,
Pwr wc drivewheel gear repl,E2369,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1010.84,,,,,,,fee schedule,123.41,1539.22,
Pwr wc dr wh motor/gear comb,E2370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2528.46,,,,,,,fee schedule,220.16,2746.43,
Pwr wc dr wh motor/gear comb,E2370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,252.86,,,,,,,fee schedule,220.16,2746.43,
Pwr wc dr wh motor/gear comb,E2370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1896.32,,,,,,,fee schedule,220.16,2746.43,
Pwr wc dr wh motor/gear comb,E2370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2746.43,,,,,,,fee schedule,220.16,2746.43,
Pwr wc dr wh motor/gear comb,E2370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,274.65,,,,,,,fee schedule,220.16,2746.43,
Pwr wc dr wh motor/gear comb,E2370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2059.8,,,,,,,fee schedule,220.16,2746.43,
Pwr wc dr wh motor/gear comb,E2370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2201.51,,,,,,,fee schedule,220.16,2746.43,
Pwr wc dr wh motor/gear comb,E2370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,220.16,,,,,,,fee schedule,220.16,2746.43,
Pwr wc dr wh motor/gear comb,E2370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1651.11,,,,,,,fee schedule,220.16,2746.43,
Pwr wc dr wh motor/gear comb,E2370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2404.95,,,,,,,fee schedule,220.16,2746.43,
Pwr wc dr wh motor/gear comb,E2370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,240.5,,,,,,,fee schedule,220.16,2746.43,
Pwr wc dr wh motor/gear comb,E2370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1803.69,,,,,,,fee schedule,220.16,2746.43,
Gr27 sealed leadacid battery,E2371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,474.74,,,,,,,fee schedule,41.36,515.67,
Gr27 sealed leadacid battery,E2371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,47.5,,,,,,,fee schedule,41.36,515.67,
Gr27 sealed leadacid battery,E2371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,356.07,,,,,,,fee schedule,41.36,515.67,
Gr27 sealed leadacid battery,E2371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,515.67,,,,,,,fee schedule,41.36,515.67,
Gr27 sealed leadacid battery,E2371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,51.6,,,,,,,fee schedule,41.36,515.67,
Gr27 sealed leadacid battery,E2371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,386.77,,,,,,,fee schedule,41.36,515.67,
Gr27 sealed leadacid battery,E2371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,413.35,,,,,,,fee schedule,41.36,515.67,
Gr27 sealed leadacid battery,E2371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,41.36,,,,,,,fee schedule,41.36,515.67,
Gr27 sealed leadacid battery,E2371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,310.03,,,,,,,fee schedule,41.36,515.67,
Gr27 sealed leadacid battery,E2371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,451.55,,,,,,,fee schedule,41.36,515.67,
Gr27 sealed leadacid battery,E2371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,45.18,,,,,,,fee schedule,41.36,515.67,
Gr27 sealed leadacid battery,E2371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,338.68,,,,,,,fee schedule,41.36,515.67,
Hand/chin ctrl spec joystick,E2373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2568.69,,,,,,,fee schedule,223.61,2790.13,
Hand/chin ctrl spec joystick,E2373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,256.82,,,,,,,fee schedule,223.61,2790.13,
Hand/chin ctrl spec joystick,E2373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1926.53,,,,,,,fee schedule,223.61,2790.13,
Hand/chin ctrl spec joystick,E2373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2790.13,,,,,,,fee schedule,223.61,2790.13,
Hand/chin ctrl spec joystick,E2373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,278.96,,,,,,,fee schedule,223.61,2790.13,
Hand/chin ctrl spec joystick,E2373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2092.61,,,,,,,fee schedule,223.61,2790.13,
Hand/chin ctrl spec joystick,E2373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2236.53,,,,,,,fee schedule,223.61,2790.13,
Hand/chin ctrl spec joystick,E2373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,223.61,,,,,,,fee schedule,223.61,2790.13,
Hand/chin ctrl spec joystick,E2373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1677.41,,,,,,,fee schedule,223.61,2790.13,
Hand/chin ctrl spec joystick,E2373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2443.21,,,,,,,fee schedule,223.61,2790.13,
Hand/chin ctrl spec joystick,E2373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,244.28,,,,,,,fee schedule,223.61,2790.13,
Hand/chin ctrl spec joystick,E2373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1832.42,,,,,,,fee schedule,223.61,2790.13,
Hand/chin ctrl std joystick,E2374,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1681.85,,,,,,,fee schedule,146.44,1826.84,
Hand/chin ctrl std joystick,E2374,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,168.19,,,,,,,fee schedule,146.44,1826.84,
Hand/chin ctrl std joystick,E2374,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1261.43,,,,,,,fee schedule,146.44,1826.84,
Hand/chin ctrl std joystick,E2374,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1826.84,,,,,,,fee schedule,146.44,1826.84,
Hand/chin ctrl std joystick,E2374,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,182.69,,,,,,,fee schedule,146.44,1826.84,
Hand/chin ctrl std joystick,E2374,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1370.17,,,,,,,fee schedule,146.44,1826.84,
Hand/chin ctrl std joystick,E2374,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1464.37,,,,,,,fee schedule,146.44,1826.84,
Hand/chin ctrl std joystick,E2374,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,146.44,,,,,,,fee schedule,146.44,1826.84,
Hand/chin ctrl std joystick,E2374,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1098.31,,,,,,,fee schedule,146.44,1826.84,
Hand/chin ctrl std joystick,E2374,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1599.69,,,,,,,fee schedule,146.44,1826.84,
Hand/chin ctrl std joystick,E2374,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,159.97,,,,,,,fee schedule,146.44,1826.84,
Hand/chin ctrl std joystick,E2374,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1199.81,,,,,,,fee schedule,146.44,1826.84,
Non-expandable controller,E2375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2697.66,,,,,,,fee schedule,234.86,2930.22,
Non-expandable controller,E2375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,269.73,,,,,,,fee schedule,234.86,2930.22,
Non-expandable controller,E2375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2023.17,,,,,,,fee schedule,234.86,2930.22,
Non-expandable controller,E2375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2930.22,,,,,,,fee schedule,234.86,2930.22,
Non-expandable controller,E2375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,292.99,,,,,,,fee schedule,234.86,2930.22,
Non-expandable controller,E2375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2197.58,,,,,,,fee schedule,234.86,2930.22,
Non-expandable controller,E2375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2348.83,,,,,,,fee schedule,234.86,2930.22,
Non-expandable controller,E2375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,234.86,,,,,,,fee schedule,234.86,2930.22,
Non-expandable controller,E2375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1761.55,,,,,,,fee schedule,234.86,2930.22,
Non-expandable controller,E2375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2565.88,,,,,,,fee schedule,234.86,2930.22,
Non-expandable controller,E2375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,256.56,,,,,,,fee schedule,234.86,2930.22,
Non-expandable controller,E2375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1924.33,,,,,,,fee schedule,234.86,2930.22,
"Expandable controller, repl",E2376,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4227.33,,,,,,,fee schedule,368.08,4591.76,
"Expandable controller, repl",E2376,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,422.75,,,,,,,fee schedule,368.08,4591.76,
"Expandable controller, repl",E2376,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3170.56,,,,,,,fee schedule,368.08,4591.76,
"Expandable controller, repl",E2376,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4591.76,,,,,,,fee schedule,368.08,4591.76,
"Expandable controller, repl",E2376,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,459.19,,,,,,,fee schedule,368.08,4591.76,
"Expandable controller, repl",E2376,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3443.88,,,,,,,fee schedule,368.08,4591.76,
"Expandable controller, repl",E2376,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3680.69,,,,,,,fee schedule,368.08,4591.76,
"Expandable controller, repl",E2376,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,368.08,,,,,,,fee schedule,368.08,4591.76,
"Expandable controller, repl",E2376,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2760.57,,,,,,,fee schedule,368.08,4591.76,
"Expandable controller, repl",E2376,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4020.82,,,,,,,fee schedule,368.08,4591.76,
"Expandable controller, repl",E2376,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,402.1,,,,,,,fee schedule,368.08,4591.76,
"Expandable controller, repl",E2376,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3015.67,,,,,,,fee schedule,368.08,4591.76,
"Expandable controller, initl",E2377,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1529.7,,,,,,,fee schedule,133.17,1661.57,
"Expandable controller, initl",E2377,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,152.95,,,,,,,fee schedule,133.17,1661.57,
"Expandable controller, initl",E2377,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1147.32,,,,,,,fee schedule,133.17,1661.57,
"Expandable controller, initl",E2377,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1661.57,,,,,,,fee schedule,133.17,1661.57,
"Expandable controller, initl",E2377,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,166.13,,,,,,,fee schedule,133.17,1661.57,
"Expandable controller, initl",E2377,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1246.23,,,,,,,fee schedule,133.17,1661.57,
"Expandable controller, initl",E2377,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1331.9,,,,,,,fee schedule,133.17,1661.57,
"Expandable controller, initl",E2377,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,133.17,,,,,,,fee schedule,133.17,1661.57,
"Expandable controller, initl",E2377,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,998.96,,,,,,,fee schedule,133.17,1661.57,
"Expandable controller, initl",E2377,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1454.98,,,,,,,fee schedule,133.17,1661.57,
"Expandable controller, initl",E2377,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,145.47,,,,,,,fee schedule,133.17,1661.57,
"Expandable controller, initl",E2377,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1091.27,,,,,,,fee schedule,133.17,1661.57,
Pneum drive wheel tire,E2381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,239.91,,,,,,,fee schedule,20.94,260.59,
Pneum drive wheel tire,E2381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24.05,,,,,,,fee schedule,20.94,260.59,
Pneum drive wheel tire,E2381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,179.95,,,,,,,fee schedule,20.94,260.59,
Pneum drive wheel tire,E2381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,260.59,,,,,,,fee schedule,20.94,260.59,
Pneum drive wheel tire,E2381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26.12,,,,,,,fee schedule,20.94,260.59,
Pneum drive wheel tire,E2381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,195.46,,,,,,,fee schedule,20.94,260.59,
Pneum drive wheel tire,E2381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,208.89,,,,,,,fee schedule,20.94,260.59,
Pneum drive wheel tire,E2381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20.94,,,,,,,fee schedule,20.94,260.59,
Pneum drive wheel tire,E2381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,156.68,,,,,,,fee schedule,20.94,260.59,
Pneum drive wheel tire,E2381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,228.19,,,,,,,fee schedule,20.94,260.59,
Pneum drive wheel tire,E2381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22.87,,,,,,,fee schedule,20.94,260.59,
Pneum drive wheel tire,E2381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,171.16,,,,,,,fee schedule,20.94,260.59,
"Tube, pneum wheel drive tire",E2382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,65.42,,,,,,,fee schedule,5.67,71.06,
"Tube, pneum wheel drive tire",E2382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.51,,,,,,,fee schedule,5.67,71.06,
"Tube, pneum wheel drive tire",E2382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,49.03,,,,,,,fee schedule,5.67,71.06,
"Tube, pneum wheel drive tire",E2382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,71.06,,,,,,,fee schedule,5.67,71.06,
"Tube, pneum wheel drive tire",E2382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7.07,,,,,,,fee schedule,5.67,71.06,
"Tube, pneum wheel drive tire",E2382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,53.26,,,,,,,fee schedule,5.67,71.06,
"Tube, pneum wheel drive tire",E2382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56.96,,,,,,,fee schedule,5.67,71.06,
"Tube, pneum wheel drive tire",E2382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.67,,,,,,,fee schedule,5.67,71.06,
"Tube, pneum wheel drive tire",E2382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.69,,,,,,,fee schedule,5.67,71.06,
"Tube, pneum wheel drive tire",E2382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,62.23,,,,,,,fee schedule,5.67,71.06,
"Tube, pneum wheel drive tire",E2382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.19,,,,,,,fee schedule,5.67,71.06,
"Tube, pneum wheel drive tire",E2382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.64,,,,,,,fee schedule,5.67,71.06,
"Insert, pneum wheel drive",E2383,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,478.33,,,,,,,fee schedule,41.66,519.56,
"Insert, pneum wheel drive",E2383,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,47.85,,,,,,,fee schedule,41.66,519.56,
"Insert, pneum wheel drive",E2383,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,358.75,,,,,,,fee schedule,41.66,519.56,
"Insert, pneum wheel drive",E2383,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,519.56,,,,,,,fee schedule,41.66,519.56,
"Insert, pneum wheel drive",E2383,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,51.98,,,,,,,fee schedule,41.66,519.56,
"Insert, pneum wheel drive",E2383,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,389.68,,,,,,,fee schedule,41.66,519.56,
"Insert, pneum wheel drive",E2383,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,416.47,,,,,,,fee schedule,41.66,519.56,
"Insert, pneum wheel drive",E2383,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,41.66,,,,,,,fee schedule,41.66,519.56,
"Insert, pneum wheel drive",E2383,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,312.36,,,,,,,fee schedule,41.66,519.56,
"Insert, pneum wheel drive",E2383,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,454.96,,,,,,,fee schedule,41.66,519.56,
"Insert, pneum wheel drive",E2383,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,45.51,,,,,,,fee schedule,41.66,519.56,
"Insert, pneum wheel drive",E2383,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,341.23,,,,,,,fee schedule,41.66,519.56,
Pneumatic caster tire,E2384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,254.81,,,,,,,fee schedule,22.24,276.77,
Pneumatic caster tire,E2384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,25.54,,,,,,,fee schedule,22.24,276.77,
Pneumatic caster tire,E2384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,191.12,,,,,,,fee schedule,22.24,276.77,
Pneumatic caster tire,E2384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,276.77,,,,,,,fee schedule,22.24,276.77,
Pneumatic caster tire,E2384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27.75,,,,,,,fee schedule,22.24,276.77,
Pneumatic caster tire,E2384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,207.6,,,,,,,fee schedule,22.24,276.77,
Pneumatic caster tire,E2384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,221.86,,,,,,,fee schedule,22.24,276.77,
Pneumatic caster tire,E2384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22.24,,,,,,,fee schedule,22.24,276.77,
Pneumatic caster tire,E2384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,166.41,,,,,,,fee schedule,22.24,276.77,
Pneumatic caster tire,E2384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,242.36,,,,,,,fee schedule,22.24,276.77,
Pneumatic caster tire,E2384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24.3,,,,,,,fee schedule,22.24,276.77,
Pneumatic caster tire,E2384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,181.79,,,,,,,fee schedule,22.24,276.77,
"Tube, pneumatic caster tire",E2385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,155.9,,,,,,,fee schedule,13.6,169.34,
"Tube, pneumatic caster tire",E2385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15.63,,,,,,,fee schedule,13.6,169.34,
"Tube, pneumatic caster tire",E2385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,116.86,,,,,,,fee schedule,13.6,169.34,
"Tube, pneumatic caster tire",E2385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,169.34,,,,,,,fee schedule,13.6,169.34,
"Tube, pneumatic caster tire",E2385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16.97,,,,,,,fee schedule,13.6,169.34,
"Tube, pneumatic caster tire",E2385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,126.93,,,,,,,fee schedule,13.6,169.34,
"Tube, pneumatic caster tire",E2385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,135.74,,,,,,,fee schedule,13.6,169.34,
"Tube, pneumatic caster tire",E2385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13.6,,,,,,,fee schedule,13.6,169.34,
"Tube, pneumatic caster tire",E2385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,101.75,,,,,,,fee schedule,13.6,169.34,
"Tube, pneumatic caster tire",E2385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,148.29,,,,,,,fee schedule,13.6,169.34,
"Tube, pneumatic caster tire",E2385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14.86,,,,,,,fee schedule,13.6,169.34,
"Tube, pneumatic caster tire",E2385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,111.15,,,,,,,fee schedule,13.6,169.34,
Foam filled drive wheel tire,E2386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,474.01,,,,,,,fee schedule,41.27,514.87,
Foam filled drive wheel tire,E2386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,47.4,,,,,,,fee schedule,41.27,514.87,
Foam filled drive wheel tire,E2386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,355.48,,,,,,,fee schedule,41.27,514.87,
Foam filled drive wheel tire,E2386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,514.87,,,,,,,fee schedule,41.27,514.87,
Foam filled drive wheel tire,E2386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,51.48,,,,,,,fee schedule,41.27,514.87,
Foam filled drive wheel tire,E2386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,386.13,,,,,,,fee schedule,41.27,514.87,
Foam filled drive wheel tire,E2386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,412.72,,,,,,,fee schedule,41.27,514.87,
Foam filled drive wheel tire,E2386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,41.27,,,,,,,fee schedule,41.27,514.87,
Foam filled drive wheel tire,E2386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,309.51,,,,,,,fee schedule,41.27,514.87,
Foam filled drive wheel tire,E2386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,450.86,,,,,,,fee schedule,41.27,514.87,
Foam filled drive wheel tire,E2386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,45.08,,,,,,,fee schedule,41.27,514.87,
Foam filled drive wheel tire,E2386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,338.12,,,,,,,fee schedule,41.27,514.87,
Foam filled caster tire,E2387,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,212.56,,,,,,,fee schedule,18.51,230.88,
Foam filled caster tire,E2387,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21.26,,,,,,,fee schedule,18.51,230.88,
Foam filled caster tire,E2387,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,159.52,,,,,,,fee schedule,18.51,230.88,
Foam filled caster tire,E2387,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,230.88,,,,,,,fee schedule,18.51,230.88,
Foam filled caster tire,E2387,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23.1,,,,,,,fee schedule,18.51,230.88,
Foam filled caster tire,E2387,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,173.28,,,,,,,fee schedule,18.51,230.88,
Foam filled caster tire,E2387,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,185.07,,,,,,,fee schedule,18.51,230.88,
Foam filled caster tire,E2387,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18.51,,,,,,,fee schedule,18.51,230.88,
Foam filled caster tire,E2387,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,138.9,,,,,,,fee schedule,18.51,230.88,
Foam filled caster tire,E2387,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,202.17,,,,,,,fee schedule,18.51,230.88,
Foam filled caster tire,E2387,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20.22,,,,,,,fee schedule,18.51,230.88,
Foam filled caster tire,E2387,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,151.73,,,,,,,fee schedule,18.51,230.88,
Foam drive wheel tire,E2388,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,158.69,,,,,,,fee schedule,13.82,172.37,
Foam drive wheel tire,E2388,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15.87,,,,,,,fee schedule,13.82,172.37,
Foam drive wheel tire,E2388,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,119.05,,,,,,,fee schedule,13.82,172.37,
Foam drive wheel tire,E2388,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,172.37,,,,,,,fee schedule,13.82,172.37,
Foam drive wheel tire,E2388,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17.24,,,,,,,fee schedule,13.82,172.37,
Foam drive wheel tire,E2388,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,129.31,,,,,,,fee schedule,13.82,172.37,
Foam drive wheel tire,E2388,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,138.17,,,,,,,fee schedule,13.82,172.37,
Foam drive wheel tire,E2388,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13.82,,,,,,,fee schedule,13.82,172.37,
Foam drive wheel tire,E2388,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,103.66,,,,,,,fee schedule,13.82,172.37,
Foam drive wheel tire,E2388,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,150.94,,,,,,,fee schedule,13.82,172.37,
Foam drive wheel tire,E2388,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15.09,,,,,,,fee schedule,13.82,172.37,
Foam drive wheel tire,E2388,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,113.24,,,,,,,fee schedule,13.82,172.37,
Foam caster tire,E2389,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,86.16,,,,,,,fee schedule,7.51,93.59,
Foam caster tire,E2389,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8.63,,,,,,,fee schedule,7.51,93.59,
Foam caster tire,E2389,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,64.59,,,,,,,fee schedule,7.51,93.59,
Foam caster tire,E2389,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,93.59,,,,,,,fee schedule,7.51,93.59,
Foam caster tire,E2389,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.37,,,,,,,fee schedule,7.51,93.59,
Foam caster tire,E2389,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,70.16,,,,,,,fee schedule,7.51,93.59,
Foam caster tire,E2389,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,75.02,,,,,,,fee schedule,7.51,93.59,
Foam caster tire,E2389,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7.51,,,,,,,fee schedule,7.51,93.59,
Foam caster tire,E2389,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56.24,,,,,,,fee schedule,7.51,93.59,
Foam caster tire,E2389,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,81.96,,,,,,,fee schedule,7.51,93.59,
Foam caster tire,E2389,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.21,,,,,,,fee schedule,7.51,93.59,
Foam caster tire,E2389,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,61.43,,,,,,,fee schedule,7.51,93.59,
Solid drive wheel tire,E2390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,134.75,,,,,,,fee schedule,11.73,146.36,
Solid drive wheel tire,E2390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13.47,,,,,,,fee schedule,11.73,146.36,
Solid drive wheel tire,E2390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,100.99,,,,,,,fee schedule,11.73,146.36,
Solid drive wheel tire,E2390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,146.36,,,,,,,fee schedule,11.73,146.36,
Solid drive wheel tire,E2390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14.63,,,,,,,fee schedule,11.73,146.36,
Solid drive wheel tire,E2390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,109.7,,,,,,,fee schedule,11.73,146.36,
Solid drive wheel tire,E2390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,117.32,,,,,,,fee schedule,11.73,146.36,
Solid drive wheel tire,E2390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11.73,,,,,,,fee schedule,11.73,146.36,
Solid drive wheel tire,E2390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,87.93,,,,,,,fee schedule,11.73,146.36,
Solid drive wheel tire,E2390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,128.16,,,,,,,fee schedule,11.73,146.36,
Solid drive wheel tire,E2390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12.81,,,,,,,fee schedule,11.73,146.36,
Solid drive wheel tire,E2390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,96.06,,,,,,,fee schedule,11.73,146.36,
Solid caster tire,E2391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,64.55,,,,,,,fee schedule,5.64,70.12,
Solid caster tire,E2391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.47,,,,,,,fee schedule,5.64,70.12,
Solid caster tire,E2391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,48.44,,,,,,,fee schedule,5.64,70.12,
Solid caster tire,E2391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,70.12,,,,,,,fee schedule,5.64,70.12,
Solid caster tire,E2391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7.03,,,,,,,fee schedule,5.64,70.12,
Solid caster tire,E2391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,52.62,,,,,,,fee schedule,5.64,70.12,
Solid caster tire,E2391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56.21,,,,,,,fee schedule,5.64,70.12,
Solid caster tire,E2391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.64,,,,,,,fee schedule,5.64,70.12,
Solid caster tire,E2391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.18,,,,,,,fee schedule,5.64,70.12,
Solid caster tire,E2391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,61.4,,,,,,,fee schedule,5.64,70.12,
Solid caster tire,E2391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.16,,,,,,,fee schedule,5.64,70.12,
Solid caster tire,E2391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.08,,,,,,,fee schedule,5.64,70.12,
"Solid caster tire, integrate",E2392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,169.68,,,,,,,fee schedule,14.82,184.31,
"Solid caster tire, integrate",E2392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17.02,,,,,,,fee schedule,14.82,184.31,
"Solid caster tire, integrate",E2392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,127.26,,,,,,,fee schedule,14.82,184.31,
"Solid caster tire, integrate",E2392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,184.31,,,,,,,fee schedule,14.82,184.31,
"Solid caster tire, integrate",E2392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18.48,,,,,,,fee schedule,14.82,184.31,
"Solid caster tire, integrate",E2392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,138.23,,,,,,,fee schedule,14.82,184.31,
"Solid caster tire, integrate",E2392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,147.74,,,,,,,fee schedule,14.82,184.31,
"Solid caster tire, integrate",E2392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14.82,,,,,,,fee schedule,14.82,184.31,
"Solid caster tire, integrate",E2392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,110.81,,,,,,,fee schedule,14.82,184.31,
"Solid caster tire, integrate",E2392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,161.4,,,,,,,fee schedule,14.82,184.31,
"Solid caster tire, integrate",E2392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.19,,,,,,,fee schedule,14.82,184.31,
"Solid caster tire, integrate",E2392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,121.05,,,,,,,fee schedule,14.82,184.31,
Drive wheel excludes tire,E2394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,241.72,,,,,,,fee schedule,21.09,262.56,
Drive wheel excludes tire,E2394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24.22,,,,,,,fee schedule,21.09,262.56,
Drive wheel excludes tire,E2394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,181.31,,,,,,,fee schedule,21.09,262.56,
Drive wheel excludes tire,E2394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,262.56,,,,,,,fee schedule,21.09,262.56,
Drive wheel excludes tire,E2394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26.31,,,,,,,fee schedule,21.09,262.56,
Drive wheel excludes tire,E2394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,196.94,,,,,,,fee schedule,21.09,262.56,
Drive wheel excludes tire,E2394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,210.46,,,,,,,fee schedule,21.09,262.56,
Drive wheel excludes tire,E2394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21.09,,,,,,,fee schedule,21.09,262.56,
Drive wheel excludes tire,E2394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,157.86,,,,,,,fee schedule,21.09,262.56,
Drive wheel excludes tire,E2394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,229.91,,,,,,,fee schedule,21.09,262.56,
Drive wheel excludes tire,E2394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23.04,,,,,,,fee schedule,21.09,262.56,
Drive wheel excludes tire,E2394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,172.45,,,,,,,fee schedule,21.09,262.56,
Caster wheel excludes tire,E2395,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,171.81,,,,,,,fee schedule,14.97,186.62,
Caster wheel excludes tire,E2395,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17.19,,,,,,,fee schedule,14.97,186.62,
Caster wheel excludes tire,E2395,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,128.9,,,,,,,fee schedule,14.97,186.62,
Caster wheel excludes tire,E2395,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,186.62,,,,,,,fee schedule,14.97,186.62,
Caster wheel excludes tire,E2395,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18.67,,,,,,,fee schedule,14.97,186.62,
Caster wheel excludes tire,E2395,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,140.01,,,,,,,fee schedule,14.97,186.62,
Caster wheel excludes tire,E2395,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,149.59,,,,,,,fee schedule,14.97,186.62,
Caster wheel excludes tire,E2395,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14.97,,,,,,,fee schedule,14.97,186.62,
Caster wheel excludes tire,E2395,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,112.23,,,,,,,fee schedule,14.97,186.62,
Caster wheel excludes tire,E2395,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,163.41,,,,,,,fee schedule,14.97,186.62,
Caster wheel excludes tire,E2395,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.35,,,,,,,fee schedule,14.97,186.62,
Caster wheel excludes tire,E2395,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,122.6,,,,,,,fee schedule,14.97,186.62,
Caster fork,E2396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,178.04,,,,,,,fee schedule,16.6,193.38,
Caster fork,E2396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19.07,,,,,,,fee schedule,16.6,193.38,
Caster fork,E2396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,133.56,,,,,,,fee schedule,16.6,193.38,
Caster fork,E2396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,193.38,,,,,,,fee schedule,16.6,193.38,
Caster fork,E2396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20.71,,,,,,,fee schedule,16.6,193.38,
Caster fork,E2396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,145.08,,,,,,,fee schedule,16.6,193.38,
Caster fork,E2396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,155.01,,,,,,,fee schedule,16.6,193.38,
Caster fork,E2396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.6,,,,,,,fee schedule,16.6,193.38,
Caster fork,E2396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,116.29,,,,,,,fee schedule,16.6,193.38,
Caster fork,E2396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,169.34,,,,,,,fee schedule,16.6,193.38,
Caster fork,E2396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18.14,,,,,,,fee schedule,16.6,193.38,
Caster fork,E2396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,127.04,,,,,,,fee schedule,16.6,193.38,
"Pwc acc, lith-based battery",E2397,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1513.24,,,,,,,fee schedule,131.74,1643.7,
"Pwc acc, lith-based battery",E2397,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,151.31,,,,,,,fee schedule,131.74,1643.7,
"Pwc acc, lith-based battery",E2397,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1134.9,,,,,,,fee schedule,131.74,1643.7,
"Pwc acc, lith-based battery",E2397,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1643.7,,,,,,,fee schedule,131.74,1643.7,
"Pwc acc, lith-based battery",E2397,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,164.35,,,,,,,fee schedule,131.74,1643.7,
"Pwc acc, lith-based battery",E2397,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1232.73,,,,,,,fee schedule,131.74,1643.7,
"Pwc acc, lith-based battery",E2397,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1317.57,,,,,,,fee schedule,131.74,1643.7,
"Pwc acc, lith-based battery",E2397,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,131.74,,,,,,,fee schedule,131.74,1643.7,
"Pwc acc, lith-based battery",E2397,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,988.14,,,,,,,fee schedule,131.74,1643.7,
"Pwc acc, lith-based battery",E2397,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1439.32,,,,,,,fee schedule,131.74,1643.7,
"Pwc acc, lith-based battery",E2397,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,143.92,,,,,,,fee schedule,131.74,1643.7,
"Pwc acc, lith-based battery",E2397,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1079.46,,,,,,,fee schedule,131.74,1643.7,
Neg press wound therapy pump,E2402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,56761.24,,,,,,,fee schedule,4706.8,61654.45,
Neg press wound therapy pump,E2402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5405.83,,,,,,,fee schedule,4706.8,61654.45,
Neg press wound therapy pump,E2402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,61654.45,,,,,,,fee schedule,4706.8,61654.45,
Neg press wound therapy pump,E2402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5871.85,,,,,,,fee schedule,4706.8,61654.45,
Neg press wound therapy pump,E2402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,49421.42,,,,,,,fee schedule,4706.8,61654.45,
Neg press wound therapy pump,E2402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4706.8,,,,,,,fee schedule,4706.8,61654.45,
Neg press wound therapy pump,E2402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53988.42,,,,,,,fee schedule,4706.8,61654.45,
Neg press wound therapy pump,E2402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5141.75,,,,,,,fee schedule,4706.8,61654.45,
SGD digitized pre-rec <=8min,E2500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1428.92,,,,,,,fee schedule,124.44,1552.11,
SGD digitized pre-rec <=8min,E2500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,142.92,,,,,,,fee schedule,124.44,1552.11,
SGD digitized pre-rec <=8min,E2500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1071.67,,,,,,,fee schedule,124.44,1552.11,
SGD digitized pre-rec <=8min,E2500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1552.11,,,,,,,fee schedule,124.44,1552.11,
SGD digitized pre-rec <=8min,E2500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,155.24,,,,,,,fee schedule,124.44,1552.11,
SGD digitized pre-rec <=8min,E2500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1164.05,,,,,,,fee schedule,124.44,1552.11,
SGD digitized pre-rec <=8min,E2500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1244.15,,,,,,,fee schedule,124.44,1552.11,
SGD digitized pre-rec <=8min,E2500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,124.44,,,,,,,fee schedule,124.44,1552.11,
SGD digitized pre-rec <=8min,E2500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,933.09,,,,,,,fee schedule,124.44,1552.11,
SGD digitized pre-rec <=8min,E2500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1359.12,,,,,,,fee schedule,124.44,1552.11,
SGD digitized pre-rec <=8min,E2500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,135.94,,,,,,,fee schedule,124.44,1552.11,
SGD digitized pre-rec <=8min,E2500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1019.31,,,,,,,fee schedule,124.44,1552.11,
SGD prerec msg >8min <=20min,E2502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4369.45,,,,,,,fee schedule,380.48,4746.13,
SGD prerec msg >8min <=20min,E2502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,436.98,,,,,,,fee schedule,380.48,4746.13,
SGD prerec msg >8min <=20min,E2502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3277.12,,,,,,,fee schedule,380.48,4746.13,
SGD prerec msg >8min <=20min,E2502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4746.13,,,,,,,fee schedule,380.48,4746.13,
SGD prerec msg >8min <=20min,E2502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,474.65,,,,,,,fee schedule,380.48,4746.13,
SGD prerec msg >8min <=20min,E2502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3559.63,,,,,,,fee schedule,380.48,4746.13,
SGD prerec msg >8min <=20min,E2502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3804.44,,,,,,,fee schedule,380.48,4746.13,
SGD prerec msg >8min <=20min,E2502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,380.48,,,,,,,fee schedule,380.48,4746.13,
SGD prerec msg >8min <=20min,E2502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2853.35,,,,,,,fee schedule,380.48,4746.13,
SGD prerec msg >8min <=20min,E2502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4156,,,,,,,fee schedule,380.48,4746.13,
SGD prerec msg >8min <=20min,E2502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,415.64,,,,,,,fee schedule,380.48,4746.13,
SGD prerec msg >8min <=20min,E2502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3117.03,,,,,,,fee schedule,380.48,4746.13,
SGD prerec msg>20min <=40min,E2504,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5763.89,,,,,,,fee schedule,501.92,6260.78,
SGD prerec msg>20min <=40min,E2504,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,576.46,,,,,,,fee schedule,501.92,6260.78,
SGD prerec msg>20min <=40min,E2504,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4322.86,,,,,,,fee schedule,501.92,6260.78,
SGD prerec msg>20min <=40min,E2504,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6260.78,,,,,,,fee schedule,501.92,6260.78,
SGD prerec msg>20min <=40min,E2504,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,626.16,,,,,,,fee schedule,501.92,6260.78,
SGD prerec msg>20min <=40min,E2504,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4695.52,,,,,,,fee schedule,501.92,6260.78,
SGD prerec msg>20min <=40min,E2504,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5018.56,,,,,,,fee schedule,501.92,6260.78,
SGD prerec msg>20min <=40min,E2504,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,501.92,,,,,,,fee schedule,501.92,6260.78,
SGD prerec msg>20min <=40min,E2504,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3763.87,,,,,,,fee schedule,501.92,6260.78,
SGD prerec msg>20min <=40min,E2504,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5482.32,,,,,,,fee schedule,501.92,6260.78,
SGD prerec msg>20min <=40min,E2504,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,548.3,,,,,,,fee schedule,501.92,6260.78,
SGD prerec msg>20min <=40min,E2504,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4111.68,,,,,,,fee schedule,501.92,6260.78,
SGD prerec msg > 40 min,E2506,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8451.56,,,,,,,fee schedule,735.84,9180.15,
SGD prerec msg > 40 min,E2506,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,845.12,,,,,,,fee schedule,735.84,9180.15,
SGD prerec msg > 40 min,E2506,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6338.54,,,,,,,fee schedule,735.84,9180.15,
SGD prerec msg > 40 min,E2506,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9180.15,,,,,,,fee schedule,735.84,9180.15,
SGD prerec msg > 40 min,E2506,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,917.97,,,,,,,fee schedule,735.84,9180.15,
SGD prerec msg > 40 min,E2506,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6884.97,,,,,,,fee schedule,735.84,9180.15,
SGD prerec msg > 40 min,E2506,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7358.69,,,,,,,fee schedule,735.84,9180.15,
SGD prerec msg > 40 min,E2506,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,735.84,,,,,,,fee schedule,735.84,9180.15,
SGD prerec msg > 40 min,E2506,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5518.9,,,,,,,fee schedule,735.84,9180.15,
SGD prerec msg > 40 min,E2506,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8038.7,,,,,,,fee schedule,735.84,9180.15,
SGD prerec msg > 40 min,E2506,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,803.83,,,,,,,fee schedule,735.84,9180.15,
SGD prerec msg > 40 min,E2506,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6028.9,,,,,,,fee schedule,735.84,9180.15,
SGD spelling phys contact,E2508,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13068.93,,,,,,,fee schedule,1137.92,14195.56,
SGD spelling phys contact,E2508,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1306.91,,,,,,,fee schedule,1137.92,14195.56,
SGD spelling phys contact,E2508,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9801.73,,,,,,,fee schedule,1137.92,14195.56,
SGD spelling phys contact,E2508,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14195.56,,,,,,,fee schedule,1137.92,14195.56,
SGD spelling phys contact,E2508,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1419.58,,,,,,,fee schedule,1137.92,14195.56,
SGD spelling phys contact,E2508,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10646.71,,,,,,,fee schedule,1137.92,14195.56,
SGD spelling phys contact,E2508,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11378.98,,,,,,,fee schedule,1137.92,14195.56,
SGD spelling phys contact,E2508,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1137.92,,,,,,,fee schedule,1137.92,14195.56,
SGD spelling phys contact,E2508,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8534.27,,,,,,,fee schedule,1137.92,14195.56,
SGD spelling phys contact,E2508,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12430.51,,,,,,,fee schedule,1137.92,14195.56,
SGD spelling phys contact,E2508,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1243.07,,,,,,,fee schedule,1137.92,14195.56,
SGD spelling phys contact,E2508,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9322.91,,,,,,,fee schedule,1137.92,14195.56,
SGD w multi methods msg/accs,E2510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24731.18,,,,,,,fee schedule,2153.3,26863.17,
SGD w multi methods msg/accs,E2510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2473.1,,,,,,,fee schedule,2153.3,26863.17,
SGD w multi methods msg/accs,E2510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18548.37,,,,,,,fee schedule,2153.3,26863.17,
SGD w multi methods msg/accs,E2510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26863.17,,,,,,,fee schedule,2153.3,26863.17,
SGD w multi methods msg/accs,E2510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2686.29,,,,,,,fee schedule,2153.3,26863.17,
SGD w multi methods msg/accs,E2510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20147.36,,,,,,,fee schedule,2153.3,26863.17,
SGD w multi methods msg/accs,E2510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21533.18,,,,,,,fee schedule,2153.3,26863.17,
SGD w multi methods msg/accs,E2510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2153.3,,,,,,,fee schedule,2153.3,26863.17,
SGD w multi methods msg/accs,E2510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16149.87,,,,,,,fee schedule,2153.3,26863.17,
SGD w multi methods msg/accs,E2510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23523.04,,,,,,,fee schedule,2153.3,26863.17,
SGD w multi methods msg/accs,E2510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2352.28,,,,,,,fee schedule,2153.3,26863.17,
SGD w multi methods msg/accs,E2510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17642.27,,,,,,,fee schedule,2153.3,26863.17,
Gen w/c cushion wdth < 22 in,E2601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,192.62,,,,,,,fee schedule,16.82,209.22,
Gen w/c cushion wdth < 22 in,E2601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19.31,,,,,,,fee schedule,16.82,209.22,
Gen w/c cushion wdth < 22 in,E2601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,144.45,,,,,,,fee schedule,16.82,209.22,
Gen w/c cushion wdth < 22 in,E2601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,209.22,,,,,,,fee schedule,16.82,209.22,
Gen w/c cushion wdth < 22 in,E2601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20.98,,,,,,,fee schedule,16.82,209.22,
Gen w/c cushion wdth < 22 in,E2601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,156.91,,,,,,,fee schedule,16.82,209.22,
Gen w/c cushion wdth < 22 in,E2601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,167.71,,,,,,,fee schedule,16.82,209.22,
Gen w/c cushion wdth < 22 in,E2601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.82,,,,,,,fee schedule,16.82,209.22,
Gen w/c cushion wdth < 22 in,E2601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,125.78,,,,,,,fee schedule,16.82,209.22,
Gen w/c cushion wdth < 22 in,E2601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,183.21,,,,,,,fee schedule,16.82,209.22,
Gen w/c cushion wdth < 22 in,E2601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18.37,,,,,,,fee schedule,16.82,209.22,
Gen w/c cushion wdth < 22 in,E2601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,137.4,,,,,,,fee schedule,16.82,209.22,
Gen w/c cushion wdth >=22 in,E2602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,376.05,,,,,,,fee schedule,32.75,408.47,
Gen w/c cushion wdth >=22 in,E2602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37.62,,,,,,,fee schedule,32.75,408.47,
Gen w/c cushion wdth >=22 in,E2602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,282.02,,,,,,,fee schedule,32.75,408.47,
Gen w/c cushion wdth >=22 in,E2602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,408.47,,,,,,,fee schedule,32.75,408.47,
Gen w/c cushion wdth >=22 in,E2602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,40.86,,,,,,,fee schedule,32.75,408.47,
Gen w/c cushion wdth >=22 in,E2602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,306.33,,,,,,,fee schedule,32.75,408.47,
Gen w/c cushion wdth >=22 in,E2602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,327.42,,,,,,,fee schedule,32.75,408.47,
Gen w/c cushion wdth >=22 in,E2602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32.75,,,,,,,fee schedule,32.75,408.47,
Gen w/c cushion wdth >=22 in,E2602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,245.55,,,,,,,fee schedule,32.75,408.47,
Gen w/c cushion wdth >=22 in,E2602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,357.68,,,,,,,fee schedule,32.75,408.47,
Gen w/c cushion wdth >=22 in,E2602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35.78,,,,,,,fee schedule,32.75,408.47,
Gen w/c cushion wdth >=22 in,E2602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,268.24,,,,,,,fee schedule,32.75,408.47,
Skin protect wc cus wd <22in,E2603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,477.42,,,,,,,fee schedule,41.6,518.58,
Skin protect wc cus wd <22in,E2603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,47.78,,,,,,,fee schedule,41.6,518.58,
Skin protect wc cus wd <22in,E2603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,358.06,,,,,,,fee schedule,41.6,518.58,
Skin protect wc cus wd <22in,E2603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,518.58,,,,,,,fee schedule,41.6,518.58,
Skin protect wc cus wd <22in,E2603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,51.9,,,,,,,fee schedule,41.6,518.58,
Skin protect wc cus wd <22in,E2603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,388.92,,,,,,,fee schedule,41.6,518.58,
Skin protect wc cus wd <22in,E2603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,415.69,,,,,,,fee schedule,41.6,518.58,
Skin protect wc cus wd <22in,E2603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,41.6,,,,,,,fee schedule,41.6,518.58,
Skin protect wc cus wd <22in,E2603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,311.76,,,,,,,fee schedule,41.6,518.58,
Skin protect wc cus wd <22in,E2603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,454.1,,,,,,,fee schedule,41.6,518.58,
Skin protect wc cus wd <22in,E2603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,45.45,,,,,,,fee schedule,41.6,518.58,
Skin protect wc cus wd <22in,E2603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,340.57,,,,,,,fee schedule,41.6,518.58,
Skin protect wc cus wd>=22in,E2604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,593.37,,,,,,,fee schedule,51.63,644.53,
Skin protect wc cus wd>=22in,E2604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59.3,,,,,,,fee schedule,51.63,644.53,
Skin protect wc cus wd>=22in,E2604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,445.09,,,,,,,fee schedule,51.63,644.53,
Skin protect wc cus wd>=22in,E2604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,644.53,,,,,,,fee schedule,51.63,644.53,
Skin protect wc cus wd>=22in,E2604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,64.41,,,,,,,fee schedule,51.63,644.53,
Skin protect wc cus wd>=22in,E2604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,483.46,,,,,,,fee schedule,51.63,644.53,
Skin protect wc cus wd>=22in,E2604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,516.65,,,,,,,fee schedule,51.63,644.53,
Skin protect wc cus wd>=22in,E2604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.63,,,,,,,fee schedule,51.63,644.53,
Skin protect wc cus wd>=22in,E2604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,387.54,,,,,,,fee schedule,51.63,644.53,
Skin protect wc cus wd>=22in,E2604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,564.39,,,,,,,fee schedule,51.63,644.53,
Skin protect wc cus wd>=22in,E2604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56.4,,,,,,,fee schedule,51.63,644.53,
Skin protect wc cus wd>=22in,E2604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,423.35,,,,,,,fee schedule,51.63,644.53,
Position wc cush wdth <22 in,E2605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,847.73,,,,,,,fee schedule,73.84,920.81,
Position wc cush wdth <22 in,E2605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,84.81,,,,,,,fee schedule,73.84,920.81,
Position wc cush wdth <22 in,E2605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,635.9,,,,,,,fee schedule,73.84,920.81,
Position wc cush wdth <22 in,E2605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,920.81,,,,,,,fee schedule,73.84,920.81,
Position wc cush wdth <22 in,E2605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,92.12,,,,,,,fee schedule,73.84,920.81,
Position wc cush wdth <22 in,E2605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,690.72,,,,,,,fee schedule,73.84,920.81,
Position wc cush wdth <22 in,E2605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,738.11,,,,,,,fee schedule,73.84,920.81,
Position wc cush wdth <22 in,E2605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,73.84,,,,,,,fee schedule,73.84,920.81,
Position wc cush wdth <22 in,E2605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,553.67,,,,,,,fee schedule,73.84,920.81,
Position wc cush wdth <22 in,E2605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,806.32,,,,,,,fee schedule,73.84,920.81,
Position wc cush wdth <22 in,E2605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,80.66,,,,,,,fee schedule,73.84,920.81,
Position wc cush wdth <22 in,E2605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,604.84,,,,,,,fee schedule,73.84,920.81,
Position wc cush wdth>=22 in,E2606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1322.54,,,,,,,fee schedule,115.2,1436.55,
Position wc cush wdth>=22 in,E2606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,132.31,,,,,,,fee schedule,115.2,1436.55,
Position wc cush wdth>=22 in,E2606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,991.87,,,,,,,fee schedule,115.2,1436.55,
Position wc cush wdth>=22 in,E2606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1436.55,,,,,,,fee schedule,115.2,1436.55,
Position wc cush wdth>=22 in,E2606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,143.72,,,,,,,fee schedule,115.2,1436.55,
Position wc cush wdth>=22 in,E2606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1077.38,,,,,,,fee schedule,115.2,1436.55,
Position wc cush wdth>=22 in,E2606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1151.52,,,,,,,fee schedule,115.2,1436.55,
Position wc cush wdth>=22 in,E2606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,115.2,,,,,,,fee schedule,115.2,1436.55,
Position wc cush wdth>=22 in,E2606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,863.61,,,,,,,fee schedule,115.2,1436.55,
Position wc cush wdth>=22 in,E2606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1257.93,,,,,,,fee schedule,115.2,1436.55,
Position wc cush wdth>=22 in,E2606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,125.85,,,,,,,fee schedule,115.2,1436.55,
Position wc cush wdth>=22 in,E2606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,943.42,,,,,,,fee schedule,115.2,1436.55,
Skin pro/pos wc cus wd <22in,E2607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,912.84,,,,,,,fee schedule,79.51,991.53,
Skin pro/pos wc cus wd <22in,E2607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,91.32,,,,,,,fee schedule,79.51,991.53,
Skin pro/pos wc cus wd <22in,E2607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,684.66,,,,,,,fee schedule,79.51,991.53,
Skin pro/pos wc cus wd <22in,E2607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,991.53,,,,,,,fee schedule,79.51,991.53,
Skin pro/pos wc cus wd <22in,E2607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,99.19,,,,,,,fee schedule,79.51,991.53,
Skin pro/pos wc cus wd <22in,E2607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,743.68,,,,,,,fee schedule,79.51,991.53,
Skin pro/pos wc cus wd <22in,E2607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,794.8,,,,,,,fee schedule,79.51,991.53,
Skin pro/pos wc cus wd <22in,E2607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,79.51,,,,,,,fee schedule,79.51,991.53,
Skin pro/pos wc cus wd <22in,E2607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,596.12,,,,,,,fee schedule,79.51,991.53,
Skin pro/pos wc cus wd <22in,E2607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,868.25,,,,,,,fee schedule,79.51,991.53,
Skin pro/pos wc cus wd <22in,E2607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,86.85,,,,,,,fee schedule,79.51,991.53,
Skin pro/pos wc cus wd <22in,E2607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,651.21,,,,,,,fee schedule,79.51,991.53,
Skin pro/pos wc cus wd>=22in,E2608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1096.27,,,,,,,fee schedule,95.41,1190.78,
Skin pro/pos wc cus wd>=22in,E2608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,109.59,,,,,,,fee schedule,95.41,1190.78,
Skin pro/pos wc cus wd>=22in,E2608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,822.22,,,,,,,fee schedule,95.41,1190.78,
Skin pro/pos wc cus wd>=22in,E2608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1190.78,,,,,,,fee schedule,95.41,1190.78,
Skin pro/pos wc cus wd>=22in,E2608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,119.03,,,,,,,fee schedule,95.41,1190.78,
Skin pro/pos wc cus wd>=22in,E2608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,893.1,,,,,,,fee schedule,95.41,1190.78,
Skin pro/pos wc cus wd>=22in,E2608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,954.51,,,,,,,fee schedule,95.41,1190.78,
Skin pro/pos wc cus wd>=22in,E2608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,95.41,,,,,,,fee schedule,95.41,1190.78,
Skin pro/pos wc cus wd>=22in,E2608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,715.9,,,,,,,fee schedule,95.41,1190.78,
Skin pro/pos wc cus wd>=22in,E2608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1042.72,,,,,,,fee schedule,95.41,1190.78,
Skin pro/pos wc cus wd>=22in,E2608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,104.23,,,,,,,fee schedule,95.41,1190.78,
Skin pro/pos wc cus wd>=22in,E2608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,782.05,,,,,,,fee schedule,95.41,1190.78,
Gen use back cush wdth <22in,E2611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,983.73,,,,,,,fee schedule,85.63,1068.53,
Gen use back cush wdth <22in,E2611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,98.34,,,,,,,fee schedule,85.63,1068.53,
Gen use back cush wdth <22in,E2611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,737.86,,,,,,,fee schedule,85.63,1068.53,
Gen use back cush wdth <22in,E2611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1068.53,,,,,,,fee schedule,85.63,1068.53,
Gen use back cush wdth <22in,E2611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,106.82,,,,,,,fee schedule,85.63,1068.53,
Gen use back cush wdth <22in,E2611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,801.47,,,,,,,fee schedule,85.63,1068.53,
Gen use back cush wdth <22in,E2611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,856.52,,,,,,,fee schedule,85.63,1068.53,
Gen use back cush wdth <22in,E2611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,85.63,,,,,,,fee schedule,85.63,1068.53,
Gen use back cush wdth <22in,E2611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,642.45,,,,,,,fee schedule,85.63,1068.53,
Gen use back cush wdth <22in,E2611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,935.67,,,,,,,fee schedule,85.63,1068.53,
Gen use back cush wdth <22in,E2611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,93.54,,,,,,,fee schedule,85.63,1068.53,
Gen use back cush wdth <22in,E2611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,701.82,,,,,,,fee schedule,85.63,1068.53,
Gen use back cush wdth>=22in,E2612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1330.75,,,,,,,fee schedule,115.87,1445.47,
Gen use back cush wdth>=22in,E2612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,133.08,,,,,,,fee schedule,115.87,1445.47,
Gen use back cush wdth>=22in,E2612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,998.03,,,,,,,fee schedule,115.87,1445.47,
Gen use back cush wdth>=22in,E2612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1445.47,,,,,,,fee schedule,115.87,1445.47,
Gen use back cush wdth>=22in,E2612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,144.55,,,,,,,fee schedule,115.87,1445.47,
Gen use back cush wdth>=22in,E2612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1084.07,,,,,,,fee schedule,115.87,1445.47,
Gen use back cush wdth>=22in,E2612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1158.67,,,,,,,fee schedule,115.87,1445.47,
Gen use back cush wdth>=22in,E2612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,115.87,,,,,,,fee schedule,115.87,1445.47,
Gen use back cush wdth>=22in,E2612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,868.97,,,,,,,fee schedule,115.87,1445.47,
Gen use back cush wdth>=22in,E2612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1265.74,,,,,,,fee schedule,115.87,1445.47,
Gen use back cush wdth>=22in,E2612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,126.57,,,,,,,fee schedule,115.87,1445.47,
Gen use back cush wdth>=22in,E2612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,949.27,,,,,,,fee schedule,115.87,1445.47,
Position back cush wd <22in,E2613,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1237.84,,,,,,,fee schedule,107.81,1344.55,
Position back cush wd <22in,E2613,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,123.82,,,,,,,fee schedule,107.81,1344.55,
Position back cush wd <22in,E2613,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,928.39,,,,,,,fee schedule,107.81,1344.55,
Position back cush wd <22in,E2613,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1344.55,,,,,,,fee schedule,107.81,1344.55,
Position back cush wd <22in,E2613,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,134.49,,,,,,,fee schedule,107.81,1344.55,
Position back cush wd <22in,E2613,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1008.43,,,,,,,fee schedule,107.81,1344.55,
Position back cush wd <22in,E2613,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1077.77,,,,,,,fee schedule,107.81,1344.55,
Position back cush wd <22in,E2613,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,107.81,,,,,,,fee schedule,107.81,1344.55,
Position back cush wd <22in,E2613,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,808.34,,,,,,,fee schedule,107.81,1344.55,
Position back cush wd <22in,E2613,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1177.37,,,,,,,fee schedule,107.81,1344.55,
Position back cush wd <22in,E2613,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,117.77,,,,,,,fee schedule,107.81,1344.55,
Position back cush wd <22in,E2613,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,883.04,,,,,,,fee schedule,107.81,1344.55,
Position back cush wd>=22in,E2614,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1713.06,,,,,,,fee schedule,149.17,1860.74,
Position back cush wd>=22in,E2614,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,171.32,,,,,,,fee schedule,149.17,1860.74,
Position back cush wd>=22in,E2614,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1284.85,,,,,,,fee schedule,149.17,1860.74,
Position back cush wd>=22in,E2614,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1860.74,,,,,,,fee schedule,149.17,1860.74,
Position back cush wd>=22in,E2614,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,186.09,,,,,,,fee schedule,149.17,1860.74,
Position back cush wd>=22in,E2614,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1395.61,,,,,,,fee schedule,149.17,1860.74,
Position back cush wd>=22in,E2614,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1491.55,,,,,,,fee schedule,149.17,1860.74,
Position back cush wd>=22in,E2614,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,149.17,,,,,,,fee schedule,149.17,1860.74,
Position back cush wd>=22in,E2614,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1118.71,,,,,,,fee schedule,149.17,1860.74,
Position back cush wd>=22in,E2614,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1629.38,,,,,,,fee schedule,149.17,1860.74,
Position back cush wd>=22in,E2614,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,162.95,,,,,,,fee schedule,149.17,1860.74,
Position back cush wd>=22in,E2614,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1222.09,,,,,,,fee schedule,149.17,1860.74,
Pos back post/lat wdth <22in,E2615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1424.54,,,,,,,fee schedule,124.05,1547.34,
Pos back post/lat wdth <22in,E2615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,142.47,,,,,,,fee schedule,124.05,1547.34,
Pos back post/lat wdth <22in,E2615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1068.36,,,,,,,fee schedule,124.05,1547.34,
Pos back post/lat wdth <22in,E2615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1547.34,,,,,,,fee schedule,124.05,1547.34,
Pos back post/lat wdth <22in,E2615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,154.75,,,,,,,fee schedule,124.05,1547.34,
Pos back post/lat wdth <22in,E2615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1160.46,,,,,,,fee schedule,124.05,1547.34,
Pos back post/lat wdth <22in,E2615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1240.33,,,,,,,fee schedule,124.05,1547.34,
Pos back post/lat wdth <22in,E2615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,124.05,,,,,,,fee schedule,124.05,1547.34,
Pos back post/lat wdth <22in,E2615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,930.21,,,,,,,fee schedule,124.05,1547.34,
Pos back post/lat wdth <22in,E2615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1354.95,,,,,,,fee schedule,124.05,1547.34,
Pos back post/lat wdth <22in,E2615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,135.51,,,,,,,fee schedule,124.05,1547.34,
Pos back post/lat wdth <22in,E2615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1016.17,,,,,,,fee schedule,124.05,1547.34,
Pos back post/lat wdth>=22in,E2616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1916.64,,,,,,,fee schedule,166.89,2081.87,
Pos back post/lat wdth>=22in,E2616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,191.68,,,,,,,fee schedule,166.89,2081.87,
Pos back post/lat wdth>=22in,E2616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1437.55,,,,,,,fee schedule,166.89,2081.87,
Pos back post/lat wdth>=22in,E2616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2081.87,,,,,,,fee schedule,166.89,2081.87,
Pos back post/lat wdth>=22in,E2616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,208.2,,,,,,,fee schedule,166.89,2081.87,
Pos back post/lat wdth>=22in,E2616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1561.48,,,,,,,fee schedule,166.89,2081.87,
Pos back post/lat wdth>=22in,E2616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1668.8,,,,,,,fee schedule,166.89,2081.87,
Pos back post/lat wdth>=22in,E2616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,166.89,,,,,,,fee schedule,166.89,2081.87,
Pos back post/lat wdth>=22in,E2616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1251.66,,,,,,,fee schedule,166.89,2081.87,
Pos back post/lat wdth>=22in,E2616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1823.02,,,,,,,fee schedule,166.89,2081.87,
Pos back post/lat wdth>=22in,E2616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,182.31,,,,,,,fee schedule,166.89,2081.87,
Pos back post/lat wdth>=22in,E2616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1367.33,,,,,,,fee schedule,166.89,2081.87,
Replace cover w/c seat cush,E2619,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,161.61,,,,,,,fee schedule,14.06,175.54,
Replace cover w/c seat cush,E2619,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16.15,,,,,,,fee schedule,14.06,175.54,
Replace cover w/c seat cush,E2619,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,121.28,,,,,,,fee schedule,14.06,175.54,
Replace cover w/c seat cush,E2619,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,175.54,,,,,,,fee schedule,14.06,175.54,
Replace cover w/c seat cush,E2619,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17.54,,,,,,,fee schedule,14.06,175.54,
Replace cover w/c seat cush,E2619,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,131.73,,,,,,,fee schedule,14.06,175.54,
Replace cover w/c seat cush,E2619,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,140.71,,,,,,,fee schedule,14.06,175.54,
Replace cover w/c seat cush,E2619,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14.06,,,,,,,fee schedule,14.06,175.54,
Replace cover w/c seat cush,E2619,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,105.6,,,,,,,fee schedule,14.06,175.54,
Replace cover w/c seat cush,E2619,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,153.72,,,,,,,fee schedule,14.06,175.54,
Replace cover w/c seat cush,E2619,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15.36,,,,,,,fee schedule,14.06,175.54,
Replace cover w/c seat cush,E2619,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,115.35,,,,,,,fee schedule,14.06,175.54,
WC planar back cush wd <22in,E2620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1724.93,,,,,,,fee schedule,150.2,1873.63,
WC planar back cush wd <22in,E2620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,172.5,,,,,,,fee schedule,150.2,1873.63,
WC planar back cush wd <22in,E2620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1293.72,,,,,,,fee schedule,150.2,1873.63,
WC planar back cush wd <22in,E2620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1873.63,,,,,,,fee schedule,150.2,1873.63,
WC planar back cush wd <22in,E2620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,187.37,,,,,,,fee schedule,150.2,1873.63,
WC planar back cush wd <22in,E2620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1405.25,,,,,,,fee schedule,150.2,1873.63,
WC planar back cush wd <22in,E2620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1501.88,,,,,,,fee schedule,150.2,1873.63,
WC planar back cush wd <22in,E2620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,150.2,,,,,,,fee schedule,150.2,1873.63,
WC planar back cush wd <22in,E2620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1126.43,,,,,,,fee schedule,150.2,1873.63,
WC planar back cush wd <22in,E2620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1640.67,,,,,,,fee schedule,150.2,1873.63,
WC planar back cush wd <22in,E2620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,164.08,,,,,,,fee schedule,150.2,1873.63,
WC planar back cush wd <22in,E2620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1230.53,,,,,,,fee schedule,150.2,1873.63,
WC planar back cush wd>=22in,E2621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1810.16,,,,,,,fee schedule,157.59,1966.2,
WC planar back cush wd>=22in,E2621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,180.99,,,,,,,fee schedule,157.59,1966.2,
WC planar back cush wd>=22in,E2621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1357.65,,,,,,,fee schedule,157.59,1966.2,
WC planar back cush wd>=22in,E2621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1966.2,,,,,,,fee schedule,157.59,1966.2,
WC planar back cush wd>=22in,E2621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,196.6,,,,,,,fee schedule,157.59,1966.2,
WC planar back cush wd>=22in,E2621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1474.69,,,,,,,fee schedule,157.59,1966.2,
WC planar back cush wd>=22in,E2621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1576.08,,,,,,,fee schedule,157.59,1966.2,
WC planar back cush wd>=22in,E2621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,157.59,,,,,,,fee schedule,157.59,1966.2,
WC planar back cush wd>=22in,E2621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1182.09,,,,,,,fee schedule,157.59,1966.2,
WC planar back cush wd>=22in,E2621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1721.73,,,,,,,fee schedule,157.59,1966.2,
WC planar back cush wd>=22in,E2621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,172.15,,,,,,,fee schedule,157.59,1966.2,
WC planar back cush wd>=22in,E2621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1291.33,,,,,,,fee schedule,157.59,1966.2,
Seo mobile arm sup att to wc,E2626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2279.75,,,,,,,fee schedule,198.56,2476.28,
Seo mobile arm sup att to wc,E2626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,228.04,,,,,,,fee schedule,198.56,2476.28,
Seo mobile arm sup att to wc,E2626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2476.28,,,,,,,fee schedule,198.56,2476.28,
Seo mobile arm sup att to wc,E2626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,247.7,,,,,,,fee schedule,198.56,2476.28,
Seo mobile arm sup att to wc,E2626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1984.95,,,,,,,fee schedule,198.56,2476.28,
Seo mobile arm sup att to wc,E2626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,198.56,,,,,,,fee schedule,198.56,2476.28,
Seo mobile arm sup att to wc,E2626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2168.38,,,,,,,fee schedule,198.56,2476.28,
Seo mobile arm sup att to wc,E2626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,216.9,,,,,,,fee schedule,198.56,2476.28,
Arm supp att to wc rancho ty,E2627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3734.39,,,,,,,fee schedule,325.24,4056.32,
Arm supp att to wc rancho ty,E2627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,373.54,,,,,,,fee schedule,325.24,4056.32,
Arm supp att to wc rancho ty,E2627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4056.32,,,,,,,fee schedule,325.24,4056.32,
Arm supp att to wc rancho ty,E2627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,405.75,,,,,,,fee schedule,325.24,4056.32,
Arm supp att to wc rancho ty,E2627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3251.49,,,,,,,fee schedule,325.24,4056.32,
Arm supp att to wc rancho ty,E2627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,325.24,,,,,,,fee schedule,325.24,4056.32,
Arm supp att to wc rancho ty,E2627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3551.96,,,,,,,fee schedule,325.24,4056.32,
Arm supp att to wc rancho ty,E2627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,355.3,,,,,,,fee schedule,325.24,4056.32,
Mobile arm supports reclinin,E2628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2440,,,,,,,fee schedule,212.43,2650.35,
Mobile arm supports reclinin,E2628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,243.98,,,,,,,fee schedule,212.43,2650.35,
Mobile arm supports reclinin,E2628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2650.35,,,,,,,fee schedule,212.43,2650.35,
Mobile arm supports reclinin,E2628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,265.02,,,,,,,fee schedule,212.43,2650.35,
Mobile arm supports reclinin,E2628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2124.48,,,,,,,fee schedule,212.43,2650.35,
Mobile arm supports reclinin,E2628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,212.43,,,,,,,fee schedule,212.43,2650.35,
Mobile arm supports reclinin,E2628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2320.81,,,,,,,fee schedule,212.43,2650.35,
Mobile arm supports reclinin,E2628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,232.06,,,,,,,fee schedule,212.43,2650.35,
Friction dampening arm supp,E2629,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3298.94,,,,,,,fee schedule,287.21,3583.33,
Friction dampening arm supp,E2629,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,329.87,,,,,,,fee schedule,287.21,3583.33,
Friction dampening arm supp,E2629,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3583.33,,,,,,,fee schedule,287.21,3583.33,
Friction dampening arm supp,E2629,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,358.31,,,,,,,fee schedule,287.21,3583.33,
Friction dampening arm supp,E2629,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2872.35,,,,,,,fee schedule,287.21,3583.33,
Friction dampening arm supp,E2629,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,287.21,,,,,,,fee schedule,287.21,3583.33,
Friction dampening arm supp,E2629,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3137.78,,,,,,,fee schedule,287.21,3583.33,
Friction dampening arm supp,E2629,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,313.75,,,,,,,fee schedule,287.21,3583.33,
Monosuspension arm/hand supp,E2630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2489.59,,,,,,,fee schedule,216.77,2704.21,
Monosuspension arm/hand supp,E2630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,248.96,,,,,,,fee schedule,216.77,2704.21,
Monosuspension arm/hand supp,E2630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2704.21,,,,,,,fee schedule,216.77,2704.21,
Monosuspension arm/hand supp,E2630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,270.42,,,,,,,fee schedule,216.77,2704.21,
Monosuspension arm/hand supp,E2630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2167.66,,,,,,,fee schedule,216.77,2704.21,
Monosuspension arm/hand supp,E2630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,216.77,,,,,,,fee schedule,216.77,2704.21,
Monosuspension arm/hand supp,E2630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2367.97,,,,,,,fee schedule,216.77,2704.21,
Monosuspension arm/hand supp,E2630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,236.8,,,,,,,fee schedule,216.77,2704.21,
Elevat proximal arm support,E2631,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,853.68,,,,,,,fee schedule,74.36,927.27,
Elevat proximal arm support,E2631,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,85.4,,,,,,,fee schedule,74.36,927.27,
Elevat proximal arm support,E2631,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,927.27,,,,,,,fee schedule,74.36,927.27,
Elevat proximal arm support,E2631,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,92.76,,,,,,,fee schedule,74.36,927.27,
Elevat proximal arm support,E2631,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,743.29,,,,,,,fee schedule,74.36,927.27,
Elevat proximal arm support,E2631,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,74.36,,,,,,,fee schedule,74.36,927.27,
Elevat proximal arm support,E2631,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,811.98,,,,,,,fee schedule,74.36,927.27,
Elevat proximal arm support,E2631,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,81.23,,,,,,,fee schedule,74.36,927.27,
Offset/lat rocker arm w/ela,E2632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,538.25,,,,,,,fee schedule,46.84,584.65,
Offset/lat rocker arm w/ela,E2632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,53.8,,,,,,,fee schedule,46.84,584.65,
Offset/lat rocker arm w/ela,E2632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,584.65,,,,,,,fee schedule,46.84,584.65,
Offset/lat rocker arm w/ela,E2632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,58.44,,,,,,,fee schedule,46.84,584.65,
Offset/lat rocker arm w/ela,E2632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,468.65,,,,,,,fee schedule,46.84,584.65,
Offset/lat rocker arm w/ela,E2632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.84,,,,,,,fee schedule,46.84,584.65,
Offset/lat rocker arm w/ela,E2632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,511.96,,,,,,,fee schedule,46.84,584.65,
Offset/lat rocker arm w/ela,E2632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.17,,,,,,,fee schedule,46.84,584.65,
Mobile arm support supinator,E2633,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,525.34,,,,,,,fee schedule,45.78,570.63,
Mobile arm support supinator,E2633,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,52.58,,,,,,,fee schedule,45.78,570.63,
Mobile arm support supinator,E2633,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,570.63,,,,,,,fee schedule,45.78,570.63,
Mobile arm support supinator,E2633,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,57.12,,,,,,,fee schedule,45.78,570.63,
Mobile arm support supinator,E2633,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,457.41,,,,,,,fee schedule,45.78,570.63,
Mobile arm support supinator,E2633,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,45.78,,,,,,,fee schedule,45.78,570.63,
Mobile arm support supinator,E2633,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,499.68,,,,,,,fee schedule,45.78,570.63,
Mobile arm support supinator,E2633,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,50.01,,,,,,,fee schedule,45.78,570.63,
Admin influenza virus vac,G0008,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,40.9,,,,,,,fee schedule,35.61,205.67,
Admin influenza virus vac,G0008,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,44.43,,,,,,,fee schedule,35.61,205.67,
Admin influenza virus vac,G0008,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35.61,,,,,,,fee schedule,35.61,205.67,
Admin influenza virus vac,G0008,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38.9,,,,,,,fee schedule,35.61,205.67,
Admin influenza virus vac,G0008,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,205.67,,,,,,,fee schedule,35.61,205.67,APC 378
Admin influenza virus vac,G0008,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,48.67,,,,,,,fee schedule,35.61,205.67,APC
Admin influenza virus vac,G0008,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,48.21,,,,,,,fee schedule,35.61,205.67,APC
Admin influenza virus vac,G0008,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,46.36,,,,,,,fee schedule,35.61,205.67,APC
Admin influenza virus vac,G0008,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,70.92,,,,,,,fee schedule,35.61,205.67,Radiology
Admin influenza virus vac,G0008,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,64.9,,,,,,,fee schedule,35.61,205.67,APC
Admin influenza virus vac,G0008,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,81.12,,,,,,,fee schedule,35.61,205.67,APC
Admin pneumococcal vaccine,G0009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,90.65,,,,,,,fee schedule,46.36,205.67,
Admin pneumococcal vaccine,G0009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,98.47,,,,,,,fee schedule,46.36,205.67,
Admin pneumococcal vaccine,G0009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,78.93,,,,,,,fee schedule,46.36,205.67,
Admin pneumococcal vaccine,G0009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,86.23,,,,,,,fee schedule,46.36,205.67,
Admin pneumococcal vaccine,G0009,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,205.67,,,,,,,fee schedule,46.36,205.67,APC 378
Admin pneumococcal vaccine,G0009,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,48.67,,,,,,,fee schedule,46.36,205.67,APC
Admin pneumococcal vaccine,G0009,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,48.21,,,,,,,fee schedule,46.36,205.67,APC
Admin pneumococcal vaccine,G0009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,46.36,,,,,,,fee schedule,46.36,205.67,APC
Admin pneumococcal vaccine,G0009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,70.92,,,,,,,fee schedule,46.36,205.67,Radiology
Admin pneumococcal vaccine,G0009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,64.9,,,,,,,fee schedule,46.36,205.67,APC
Admin pneumococcal vaccine,G0009,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,81.12,,,,,,,fee schedule,46.36,205.67,APC
Admin hepatitis b vaccine,G0010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,67.41,,,,,,,fee schedule,46.36,205.67,
Admin hepatitis b vaccine,G0010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,73.22,,,,,,,fee schedule,46.36,205.67,
Admin hepatitis b vaccine,G0010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,58.69,,,,,,,fee schedule,46.36,205.67,
Admin hepatitis b vaccine,G0010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,64.11,,,,,,,fee schedule,46.36,205.67,
Admin hepatitis b vaccine,G0010,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,205.67,,,,,,,fee schedule,46.36,205.67,APC 378
Admin hepatitis b vaccine,G0010,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,48.67,,,,,,,fee schedule,46.36,205.67,APC
Admin hepatitis b vaccine,G0010,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,48.21,,,,,,,fee schedule,46.36,205.67,APC
Admin hepatitis b vaccine,G0010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,46.36,,,,,,,fee schedule,46.36,205.67,APC
Admin hepatitis b vaccine,G0010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,70.92,,,,,,,fee schedule,46.36,205.67,Radiology
Admin hepatitis b vaccine,G0010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,64.9,,,,,,,fee schedule,46.36,205.67,APC
Admin hepatitis b vaccine,G0010,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,81.12,,,,,,,fee schedule,46.36,205.67,APC
Injection of hiv prep drug,G0012,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,316.24,,,,,,,fee schedule,71.28,316.24,APC 378
Injection of hiv prep drug,G0012,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,74.84,,,,,,,fee schedule,71.28,316.24,APC
Injection of hiv prep drug,G0012,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,74.13,,,,,,,fee schedule,71.28,316.24,APC
Injection of hiv prep drug,G0012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,71.28,,,,,,,fee schedule,71.28,316.24,APC
Injection of hiv prep drug,G0012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,109.06,,,,,,,fee schedule,71.28,316.24,Radiology
Injection of hiv prep drug,G0012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,99.79,,,,,,,fee schedule,71.28,316.24,APC
Injection of hiv prep drug,G0012,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,124.74,,,,,,,fee schedule,71.28,316.24,APC
Comm hlth intg svs sdoh 60mn,G0019,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,295.83,,,,,,,fee schedule,100.57,446.2,
Comm hlth intg svs sdoh 60mn,G0019,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,321.34,,,,,,,fee schedule,100.57,446.2,
Comm hlth intg svs sdoh 60mn,G0019,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,257.58,,,,,,,fee schedule,100.57,446.2,
Comm hlth intg svs sdoh 60mn,G0019,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,281.38,,,,,,,fee schedule,100.57,446.2,
Comm hlth intg svs sdoh 60mn,G0019,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,446.2,,,,,,,fee schedule,100.57,446.2,APC 378
Comm hlth intg svs sdoh 60mn,G0019,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,105.6,,,,,,,fee schedule,100.57,446.2,APC
Comm hlth intg svs sdoh 60mn,G0019,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,104.59,,,,,,,fee schedule,100.57,446.2,APC
Comm hlth intg svs sdoh 60mn,G0019,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,100.57,,,,,,,fee schedule,100.57,446.2,APC
Comm hlth intg svs sdoh 60mn,G0019,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,153.87,,,,,,,fee schedule,100.57,446.2,Radiology
Comm hlth intg svs sdoh 60mn,G0019,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,140.8,,,,,,,fee schedule,100.57,446.2,APC
Comm hlth intg svs sdoh 60mn,G0019,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,176,,,,,,,fee schedule,100.57,446.2,APC
Pin service 60m per month,G0023,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,295.83,,,,,,,fee schedule,100.57,446.2,
Pin service 60m per month,G0023,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,321.34,,,,,,,fee schedule,100.57,446.2,
Pin service 60m per month,G0023,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,257.58,,,,,,,fee schedule,100.57,446.2,
Pin service 60m per month,G0023,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,281.38,,,,,,,fee schedule,100.57,446.2,
Pin service 60m per month,G0023,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,446.2,,,,,,,fee schedule,100.57,446.2,APC 378
Pin service 60m per month,G0023,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,105.6,,,,,,,fee schedule,100.57,446.2,APC
Pin service 60m per month,G0023,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,104.59,,,,,,,fee schedule,100.57,446.2,APC
Pin service 60m per month,G0023,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,100.57,,,,,,,fee schedule,100.57,446.2,APC
Pin service 60m per month,G0023,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,153.87,,,,,,,fee schedule,100.57,446.2,Radiology
Pin service 60m per month,G0023,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,140.8,,,,,,,fee schedule,100.57,446.2,APC
Pin service 60m per month,G0023,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,176,,,,,,,fee schedule,100.57,446.2,APC
Semen analysis,G0027,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33.03,,,,,,,fee schedule,5.85,35.87,
Semen analysis,G0027,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,35.87,,,,,,,fee schedule,5.85,35.87,
Semen analysis,G0027,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28.75,,,,,,,fee schedule,5.85,35.87,
Semen analysis,G0027,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31.41,,,,,,,fee schedule,5.85,35.87,
Semen analysis,G0027,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.85,,,,,,,fee schedule,5.85,35.87,Laboratory
Semen analysis,G0027,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.82,,,,,,,fee schedule,5.85,35.87,APC
Semen analysis,G0027,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6.76,,,,,,,fee schedule,5.85,35.87,APC
Semen analysis,G0027,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6.5,,,,,,,fee schedule,5.85,35.87,APC
Semen analysis,G0027,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.94,,,,,,,fee schedule,5.85,35.87,Radiology
Semen analysis,G0027,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.1,,,,,,,fee schedule,5.85,35.87,APC
Semen analysis,G0027,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11.38,,,,,,,fee schedule,5.85,35.87,APC
Care manag h vst new pt 20 m,G0076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,193.98,,,,,,,fee schedule,168.89,210.7,
Care manag h vst new pt 20 m,G0076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,210.7,,,,,,,fee schedule,168.89,210.7,
Care manag h vst new pt 20 m,G0076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,168.89,,,,,,,fee schedule,168.89,210.7,
Care manag h vst new pt 20 m,G0076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,184.5,,,,,,,fee schedule,168.89,210.7,
Care manag h vst new pt 30 m,G0077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,276.73,,,,,,,fee schedule,240.95,300.59,
Care manag h vst new pt 30 m,G0077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,300.59,,,,,,,fee schedule,240.95,300.59,
Care manag h vst new pt 30 m,G0077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,240.95,,,,,,,fee schedule,240.95,300.59,
Care manag h vst new pt 30 m,G0077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,263.21,,,,,,,fee schedule,240.95,300.59,
Care manag h vst new pt 45 m,G0078,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,457.03,,,,,,,fee schedule,397.93,496.43,
Care manag h vst new pt 45 m,G0078,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,496.43,,,,,,,fee schedule,397.93,496.43,
Care manag h vst new pt 45 m,G0078,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,397.93,,,,,,,fee schedule,397.93,496.43,
Care manag h vst new pt 45 m,G0078,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,434.7,,,,,,,fee schedule,397.93,496.43,
Care manag h vst new pt 60 m,G0079,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,637.95,,,,,,,fee schedule,555.46,692.95,
Care manag h vst new pt 60 m,G0079,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,692.95,,,,,,,fee schedule,555.46,692.95,
Care manag h vst new pt 60 m,G0079,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,555.46,,,,,,,fee schedule,555.46,692.95,
Care manag h vst new pt 60 m,G0079,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,606.79,,,,,,,fee schedule,555.46,692.95,
Care manag h vst new pt 75 m,G0080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,773.71,,,,,,,fee schedule,673.66,840.41,
Care manag h vst new pt 75 m,G0080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,840.41,,,,,,,fee schedule,673.66,840.41,
Care manag h vst new pt 75 m,G0080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,673.66,,,,,,,fee schedule,673.66,840.41,
Care manag h vst new pt 75 m,G0080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,735.91,,,,,,,fee schedule,673.66,840.41,
Care man h v ext pt 20 mi,G0081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,193.87,,,,,,,fee schedule,168.8,210.58,
Care man h v ext pt 20 mi,G0081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,210.58,,,,,,,fee schedule,168.8,210.58,
Care man h v ext pt 20 mi,G0081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,168.8,,,,,,,fee schedule,168.8,210.58,
Care man h v ext pt 20 mi,G0081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,184.4,,,,,,,fee schedule,168.8,210.58,
Care man h v ext pt 30 m,G0082,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,294.27,,,,,,,fee schedule,256.22,319.64,
Care man h v ext pt 30 m,G0082,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,319.64,,,,,,,fee schedule,256.22,319.64,
Care man h v ext pt 30 m,G0082,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,256.22,,,,,,,fee schedule,256.22,319.64,
Care man h v ext pt 30 m,G0082,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,279.89,,,,,,,fee schedule,256.22,319.64,
Care man h v ext pt 45 m,G0083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,450.42,,,,,,,fee schedule,392.17,489.25,
Care man h v ext pt 45 m,G0083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,489.25,,,,,,,fee schedule,392.17,489.25,
Care man h v ext pt 45 m,G0083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,392.17,,,,,,,fee schedule,392.17,489.25,
Care man h v ext pt 45 m,G0083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,428.41,,,,,,,fee schedule,392.17,489.25,
Care man h v ext pt 60 m,G0084,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,626.64,,,,,,,fee schedule,545.61,680.66,
Care man h v ext pt 60 m,G0084,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,680.66,,,,,,,fee schedule,545.61,680.66,
Care man h v ext pt 60 m,G0084,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,545.61,,,,,,,fee schedule,545.61,680.66,
Care man h v ext pt 60 m,G0084,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,596.03,,,,,,,fee schedule,545.61,680.66,
Care man h v ext pt 75 m,G0085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,773.71,,,,,,,fee schedule,673.66,840.41,
Care man h v ext pt 75 m,G0085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,840.41,,,,,,,fee schedule,673.66,840.41,
Care man h v ext pt 75 m,G0085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,673.66,,,,,,,fee schedule,673.66,840.41,
Care man h v ext pt 75 m,G0085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,735.91,,,,,,,fee schedule,673.66,840.41,
Care man home care plan 30 m,G0086,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,266.01,,,,,,,fee schedule,231.61,288.94,
Care man home care plan 30 m,G0086,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,288.94,,,,,,,fee schedule,231.61,288.94,
Care man home care plan 30 m,G0086,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,231.61,,,,,,,fee schedule,231.61,288.94,
Care man home care plan 30 m,G0086,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,253.02,,,,,,,fee schedule,231.61,288.94,
Care man home care plan 60 m,G0087,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,371.25,,,,,,,fee schedule,323.24,403.25,
Care man home care plan 60 m,G0087,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,403.25,,,,,,,fee schedule,323.24,403.25,
Care man home care plan 60 m,G0087,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,323.24,,,,,,,fee schedule,323.24,403.25,
Care man home care plan 60 m,G0087,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.11,,,,,,,fee schedule,323.24,403.25,
CA screen;pelvic/breast exam,G0101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,192.76,,,,,,,fee schedule,100.57,446.2,
CA screen;pelvic/breast exam,G0101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,209.37,,,,,,,fee schedule,100.57,446.2,
CA screen;pelvic/breast exam,G0101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,167.83,,,,,,,fee schedule,100.57,446.2,
CA screen;pelvic/breast exam,G0101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,183.34,,,,,,,fee schedule,100.57,446.2,
CA screen;pelvic/breast exam,G0101,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,446.2,,,,,,,fee schedule,100.57,446.2,APC 378
CA screen;pelvic/breast exam,G0101,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,105.6,,,,,,,fee schedule,100.57,446.2,APC
CA screen;pelvic/breast exam,G0101,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,104.59,,,,,,,fee schedule,100.57,446.2,APC
CA screen;pelvic/breast exam,G0101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,100.57,,,,,,,fee schedule,100.57,446.2,APC
CA screen;pelvic/breast exam,G0101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,153.87,,,,,,,fee schedule,100.57,446.2,Radiology
CA screen;pelvic/breast exam,G0101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,140.8,,,,,,,fee schedule,100.57,446.2,APC
CA screen;pelvic/breast exam,G0101,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,176,,,,,,,fee schedule,100.57,446.2,APC
PSA Screening,G0103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,68.83,,,,,,,fee schedule,17.38,74.77,
PSA Screening,G0103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,74.77,,,,,,,fee schedule,17.38,74.77,
PSA Screening,G0103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,59.93,,,,,,,fee schedule,17.38,74.77,
PSA Screening,G0103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,65.47,,,,,,,fee schedule,17.38,74.77,
PSA Screening,G0103,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.38,,,,,,,fee schedule,17.38,74.77,Laboratory
PSA Screening,G0103,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20.28,,,,,,,fee schedule,17.38,74.77,APC
PSA Screening,G0103,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,20.08,,,,,,,fee schedule,17.38,74.77,APC
PSA Screening,G0103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,19.31,,,,,,,fee schedule,17.38,74.77,APC
PSA Screening,G0103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29.54,,,,,,,fee schedule,17.38,74.77,Radiology
PSA Screening,G0103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27.03,,,,,,,fee schedule,17.38,74.77,APC
PSA Screening,G0103,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,33.79,,,,,,,fee schedule,17.38,74.77,APC
CA screen;flexi sigmoidscope,G0104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2424.17,,,,,,,fee schedule,920.63,4084.51,
CA screen;flexi sigmoidscope,G0104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2633.15,,,,,,,fee schedule,920.63,4084.51,
CA screen;flexi sigmoidscope,G0104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2110.7,,,,,,,fee schedule,920.63,4084.51,
CA screen;flexi sigmoidscope,G0104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2305.75,,,,,,,fee schedule,920.63,4084.51,
CA screen;flexi sigmoidscope,G0104,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4084.51,,,,,,,fee schedule,920.63,4084.51,APC 378
CA screen;flexi sigmoidscope,G0104,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,966.66,,,,,,,fee schedule,920.63,4084.51,APC
CA screen;flexi sigmoidscope,G0104,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,957.45,,,,,,,fee schedule,920.63,4084.51,APC
CA screen;flexi sigmoidscope,G0104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,920.63,,,,,,,fee schedule,920.63,4084.51,APC
CA screen;flexi sigmoidscope,G0104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1408.56,,,,,,,fee schedule,920.63,4084.51,Radiology
CA screen;flexi sigmoidscope,G0104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1288.88,,,,,,,fee schedule,920.63,4084.51,APC
CA screen;flexi sigmoidscope,G0104,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1611.1,,,,,,,fee schedule,920.63,4084.51,APC
Colorectal scrn; hi risk ind,G0105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,198.53,,,,,,,fee schedule,172.86,4084.51,
Colorectal scrn; hi risk ind,G0105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2595.49,,,,,,,fee schedule,172.86,4084.51,
Colorectal scrn; hi risk ind,G0105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,215.65,,,,,,,fee schedule,172.86,4084.51,
Colorectal scrn; hi risk ind,G0105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2819.24,,,,,,,fee schedule,172.86,4084.51,
Colorectal scrn; hi risk ind,G0105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,172.86,,,,,,,fee schedule,172.86,4084.51,
Colorectal scrn; hi risk ind,G0105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2259.87,,,,,,,fee schedule,172.86,4084.51,
Colorectal scrn; hi risk ind,G0105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,188.84,,,,,,,fee schedule,172.86,4084.51,
Colorectal scrn; hi risk ind,G0105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2468.7,,,,,,,fee schedule,172.86,4084.51,
Colorectal scrn; hi risk ind,G0105,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4084.51,,,,,,,fee schedule,172.86,4084.51,APC 378
Colorectal scrn; hi risk ind,G0105,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,966.66,,,,,,,fee schedule,172.86,4084.51,APC
Colorectal scrn; hi risk ind,G0105,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,957.45,,,,,,,fee schedule,172.86,4084.51,APC
Colorectal scrn; hi risk ind,G0105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,920.63,,,,,,,fee schedule,172.86,4084.51,APC
Colorectal scrn; hi risk ind,G0105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1408.56,,,,,,,fee schedule,172.86,4084.51,Radiology
Colorectal scrn; hi risk ind,G0105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1288.88,,,,,,,fee schedule,172.86,4084.51,APC
Colorectal scrn; hi risk ind,G0105,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1611.1,,,,,,,fee schedule,172.86,4084.51,APC
Colon CA screen;barium enema,G0106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,461.34,,,,,,,fee schedule,401.69,501.11,
Colon CA screen;barium enema,G0106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,501.11,,,,,,,fee schedule,401.69,501.11,
Colon CA screen;barium enema,G0106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,401.69,,,,,,,fee schedule,401.69,501.11,
Colon CA screen;barium enema,G0106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,438.81,,,,,,,fee schedule,401.69,501.11,
Diab manage trn  per indiv,G0108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,71.76,,,,,,,fee schedule,54.02,94.54,
Diab manage trn  per indiv,G0108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,77.94,,,,,,,fee schedule,54.02,94.54,
Diab manage trn  per indiv,G0108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,62.48,,,,,,,fee schedule,54.02,94.54,
Diab manage trn  per indiv,G0108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,68.25,,,,,,,fee schedule,54.02,94.54,
Diab manage trn  per indiv,G0108,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,54.02,,,,,,,fee schedule,54.02,94.54,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Diab manage trn  per indiv,G0108,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,56.72,,,,,,,fee schedule,54.02,94.54,APC
Diab manage trn  per indiv,G0108,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,56.18,,,,,,,fee schedule,54.02,94.54,APC
Diab manage trn  per indiv,G0108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,82.65,,,,,,,fee schedule,54.02,94.54,Radiology
Diab manage trn  per indiv,G0108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,75.63,,,,,,,fee schedule,54.02,94.54,APC
Diab manage trn  per indiv,G0108,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,94.54,,,,,,,fee schedule,54.02,94.54,APC
Diab manage trn ind/group,G0109,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,40.47,,,,,,,fee schedule,15.49,43.96,
Diab manage trn ind/group,G0109,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,43.96,,,,,,,fee schedule,15.49,43.96,
Diab manage trn ind/group,G0109,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35.24,,,,,,,fee schedule,15.49,43.96,
Diab manage trn ind/group,G0109,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38.5,,,,,,,fee schedule,15.49,43.96,
Diab manage trn ind/group,G0109,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.49,,,,,,,fee schedule,15.49,43.96,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Diab manage trn ind/group,G0109,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.26,,,,,,,fee schedule,15.49,43.96,APC
Diab manage trn ind/group,G0109,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,16.11,,,,,,,fee schedule,15.49,43.96,APC
Diab manage trn ind/group,G0109,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.7,,,,,,,fee schedule,15.49,43.96,Radiology
Diab manage trn ind/group,G0109,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21.69,,,,,,,fee schedule,15.49,43.96,APC
Diab manage trn ind/group,G0109,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,27.11,,,,,,,fee schedule,15.49,43.96,APC
Glaucoma scrn hgh risk direc,G0117,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,199.82,,,,,,,fee schedule,28.63,217.05,
Glaucoma scrn hgh risk direc,G0117,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,217.05,,,,,,,fee schedule,28.63,217.05,
Glaucoma scrn hgh risk direc,G0117,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,173.98,,,,,,,fee schedule,28.63,217.05,
Glaucoma scrn hgh risk direc,G0117,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,190.06,,,,,,,fee schedule,28.63,217.05,
Glaucoma scrn hgh risk direc,G0117,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,127.04,,,,,,,fee schedule,28.63,217.05,APC 378
Glaucoma scrn hgh risk direc,G0117,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.07,,,,,,,fee schedule,28.63,217.05,APC
Glaucoma scrn hgh risk direc,G0117,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,29.78,,,,,,,fee schedule,28.63,217.05,APC
Glaucoma scrn hgh risk direc,G0117,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,28.63,,,,,,,fee schedule,28.63,217.05,APC
Glaucoma scrn hgh risk direc,G0117,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43.81,,,,,,,fee schedule,28.63,217.05,Radiology
Glaucoma scrn hgh risk direc,G0117,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40.09,,,,,,,fee schedule,28.63,217.05,APC
Glaucoma scrn hgh risk direc,G0117,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,50.11,,,,,,,fee schedule,28.63,217.05,APC
Glaucoma scrn hgh risk direc,G0118,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,135.65,,,,,,,fee schedule,36.98,164.05,
Glaucoma scrn hgh risk direc,G0118,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,147.34,,,,,,,fee schedule,36.98,164.05,
Glaucoma scrn hgh risk direc,G0118,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,118.11,,,,,,,fee schedule,36.98,164.05,
Glaucoma scrn hgh risk direc,G0118,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,129.02,,,,,,,fee schedule,36.98,164.05,
Glaucoma scrn hgh risk direc,G0118,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.05,,,,,,,fee schedule,36.98,164.05,APC 378
Glaucoma scrn hgh risk direc,G0118,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.83,,,,,,,fee schedule,36.98,164.05,APC
Glaucoma scrn hgh risk direc,G0118,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.46,,,,,,,fee schedule,36.98,164.05,APC
Glaucoma scrn hgh risk direc,G0118,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.98,,,,,,,fee schedule,36.98,164.05,APC
Glaucoma scrn hgh risk direc,G0118,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.57,,,,,,,fee schedule,36.98,164.05,Radiology
Glaucoma scrn hgh risk direc,G0118,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.77,,,,,,,fee schedule,36.98,164.05,APC
Glaucoma scrn hgh risk direc,G0118,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.71,,,,,,,fee schedule,36.98,164.05,APC
Colon ca scrn; barium enema,G0120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,461.34,,,,,,,fee schedule,401.69,501.11,
Colon ca scrn; barium enema,G0120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,501.11,,,,,,,fee schedule,401.69,501.11,
Colon ca scrn; barium enema,G0120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,401.69,,,,,,,fee schedule,401.69,501.11,
Colon ca scrn; barium enema,G0120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,438.81,,,,,,,fee schedule,401.69,501.11,
Colon ca scrn not hi rsk ind,G0121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,198.53,,,,,,,fee schedule,172.86,4084.51,
Colon ca scrn not hi rsk ind,G0121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2637.36,,,,,,,fee schedule,172.86,4084.51,
Colon ca scrn not hi rsk ind,G0121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,215.65,,,,,,,fee schedule,172.86,4084.51,
Colon ca scrn not hi rsk ind,G0121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2864.72,,,,,,,fee schedule,172.86,4084.51,
Colon ca scrn not hi rsk ind,G0121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,172.86,,,,,,,fee schedule,172.86,4084.51,
Colon ca scrn not hi rsk ind,G0121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2296.33,,,,,,,fee schedule,172.86,4084.51,
Colon ca scrn not hi rsk ind,G0121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,188.84,,,,,,,fee schedule,172.86,4084.51,
Colon ca scrn not hi rsk ind,G0121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2508.53,,,,,,,fee schedule,172.86,4084.51,
Colon ca scrn not hi rsk ind,G0121,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4084.51,,,,,,,fee schedule,172.86,4084.51,APC 378
Colon ca scrn not hi rsk ind,G0121,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,966.66,,,,,,,fee schedule,172.86,4084.51,APC
Colon ca scrn not hi rsk ind,G0121,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,957.45,,,,,,,fee schedule,172.86,4084.51,APC
Colon ca scrn not hi rsk ind,G0121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,920.63,,,,,,,fee schedule,172.86,4084.51,APC
Colon ca scrn not hi rsk ind,G0121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1408.56,,,,,,,fee schedule,172.86,4084.51,Radiology
Colon ca scrn not hi rsk ind,G0121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1288.88,,,,,,,fee schedule,172.86,4084.51,APC
Colon ca scrn not hi rsk ind,G0121,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1611.1,,,,,,,fee schedule,172.86,4084.51,APC
Screen cerv/vag thin layer,G0123,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,76.73,,,,,,,fee schedule,18.23,83.35,
Screen cerv/vag thin layer,G0123,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83.35,,,,,,,fee schedule,18.23,83.35,
Screen cerv/vag thin layer,G0123,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66.81,,,,,,,fee schedule,18.23,83.35,
Screen cerv/vag thin layer,G0123,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,72.99,,,,,,,fee schedule,18.23,83.35,
Screen cerv/vag thin layer,G0123,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,18.23,,,,,,,fee schedule,18.23,83.35,Laboratory
Screen cerv/vag thin layer,G0123,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.27,,,,,,,fee schedule,18.23,83.35,APC
Screen cerv/vag thin layer,G0123,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,21.07,,,,,,,fee schedule,18.23,83.35,APC
Screen cerv/vag thin layer,G0123,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,20.26,,,,,,,fee schedule,18.23,83.35,APC
Screen cerv/vag thin layer,G0123,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,31,,,,,,,fee schedule,18.23,83.35,Radiology
Screen cerv/vag thin layer,G0123,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.36,,,,,,,fee schedule,18.23,83.35,APC
Screen cerv/vag thin layer,G0123,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,35.46,,,,,,,fee schedule,18.23,83.35,APC
Screen c/v thin layer by MD,G0124,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,90.1,,,,,,,fee schedule,78.45,97.86,
Screen c/v thin layer by MD,G0124,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,97.86,,,,,,,fee schedule,78.45,97.86,
Screen c/v thin layer by MD,G0124,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,78.45,,,,,,,fee schedule,78.45,97.86,
Screen c/v thin layer by MD,G0124,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,85.7,,,,,,,fee schedule,78.45,97.86,
Trim nail(s),G0127,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,182.21,,,,,,,fee schedule,58.4,259.1,
Trim nail(s),G0127,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,197.92,,,,,,,fee schedule,58.4,259.1,
Trim nail(s),G0127,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,158.65,,,,,,,fee schedule,58.4,259.1,
Trim nail(s),G0127,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,173.31,,,,,,,fee schedule,58.4,259.1,
Trim nail(s),G0127,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,58.4,259.1,APC 378
Trim nail(s),G0127,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,58.4,259.1,APC
Trim nail(s),G0127,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,58.4,259.1,APC
Trim nail(s),G0127,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,58.4,259.1,APC
Trim nail(s),G0127,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,58.4,259.1,Radiology
Trim nail(s),G0127,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,58.4,259.1,APC
Trim nail(s),G0127,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,58.4,259.1,APC
CORF skilled nursing service,G0128,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27.04,,,,,,,fee schedule,23.54,29.37,
CORF skilled nursing service,G0128,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,29.37,,,,,,,fee schedule,23.54,29.37,
CORF skilled nursing service,G0128,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23.54,,,,,,,fee schedule,23.54,29.37,
CORF skilled nursing service,G0128,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,25.72,,,,,,,fee schedule,23.54,29.37,
Single energy x-ray study,G0130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,69.43,,,,,,,fee schedule,60.45,459.18,
Single energy x-ray study,G0130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,75.41,,,,,,,fee schedule,60.45,459.18,
Single energy x-ray study,G0130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,60.45,,,,,,,fee schedule,60.45,459.18,
Single energy x-ray study,G0130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66.03,,,,,,,fee schedule,60.45,459.18,
Single energy x-ray study,G0130,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,459.18,,,,,,,fee schedule,60.45,459.18,APC 378
Single energy x-ray study,G0130,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.67,,,,,,,fee schedule,60.45,459.18,APC
Single energy x-ray study,G0130,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,60.45,459.18,APC
Single energy x-ray study,G0130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.5,,,,,,,fee schedule,60.45,459.18,APC
Single energy x-ray study,G0130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.35,,,,,,,fee schedule,60.45,459.18,Radiology
Single energy x-ray study,G0130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.9,,,,,,,fee schedule,60.45,459.18,APC
Single energy x-ray study,G0130,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181.12,,,,,,,fee schedule,60.45,459.18,APC
Adm of soc dtr assess 5-15 m,G0136,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,95.28,,,,,,,fee schedule,37.09,164.57,
Adm of soc dtr assess 5-15 m,G0136,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,103.5,,,,,,,fee schedule,37.09,164.57,
Adm of soc dtr assess 5-15 m,G0136,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,82.96,,,,,,,fee schedule,37.09,164.57,
Adm of soc dtr assess 5-15 m,G0136,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,90.63,,,,,,,fee schedule,37.09,164.57,
Adm of soc dtr assess 5-15 m,G0136,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.57,,,,,,,fee schedule,37.09,164.57,APC 378
Adm of soc dtr assess 5-15 m,G0136,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.95,,,,,,,fee schedule,37.09,164.57,APC
Adm of soc dtr assess 5-15 m,G0136,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.58,,,,,,,fee schedule,37.09,164.57,APC
Adm of soc dtr assess 5-15 m,G0136,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,37.09,,,,,,,fee schedule,37.09,164.57,APC
Adm of soc dtr assess 5-15 m,G0136,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.75,,,,,,,fee schedule,37.09,164.57,Radiology
Adm of soc dtr assess 5-15 m,G0136,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.93,,,,,,,fee schedule,37.09,164.57,APC
Adm of soc dtr assess 5-15 m,G0136,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.91,,,,,,,fee schedule,37.09,164.57,APC
Nav srv peer sup 60 min pr m,G0140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,295.83,,,,,,,fee schedule,100.57,446.2,
Nav srv peer sup 60 min pr m,G0140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,321.34,,,,,,,fee schedule,100.57,446.2,
Nav srv peer sup 60 min pr m,G0140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,257.58,,,,,,,fee schedule,100.57,446.2,
Nav srv peer sup 60 min pr m,G0140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,281.38,,,,,,,fee schedule,100.57,446.2,
Nav srv peer sup 60 min pr m,G0140,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,446.2,,,,,,,fee schedule,100.57,446.2,APC 378
Nav srv peer sup 60 min pr m,G0140,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,105.6,,,,,,,fee schedule,100.57,446.2,APC
Nav srv peer sup 60 min pr m,G0140,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,104.59,,,,,,,fee schedule,100.57,446.2,APC
Nav srv peer sup 60 min pr m,G0140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,100.57,,,,,,,fee schedule,100.57,446.2,APC
Nav srv peer sup 60 min pr m,G0140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,153.87,,,,,,,fee schedule,100.57,446.2,Radiology
Nav srv peer sup 60 min pr m,G0140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,140.8,,,,,,,fee schedule,100.57,446.2,APC
Nav srv peer sup 60 min pr m,G0140,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,176,,,,,,,fee schedule,100.57,446.2,APC
"Scr c/v cyto,autosys and md",G0141,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,90.1,,,,,,,fee schedule,78.45,97.86,
"Scr c/v cyto,autosys and md",G0141,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,97.86,,,,,,,fee schedule,78.45,97.86,
"Scr c/v cyto,autosys and md",G0141,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,78.45,,,,,,,fee schedule,78.45,97.86,
"Scr c/v cyto,autosys and md",G0141,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,85.7,,,,,,,fee schedule,78.45,97.86,
"Scr c/v cyto,thinlayer,rescr",G0143,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,69.84,,,,,,,fee schedule,24.34,75.86,
"Scr c/v cyto,thinlayer,rescr",G0143,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,75.86,,,,,,,fee schedule,24.34,75.86,
"Scr c/v cyto,thinlayer,rescr",G0143,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,60.81,,,,,,,fee schedule,24.34,75.86,
"Scr c/v cyto,thinlayer,rescr",G0143,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66.43,,,,,,,fee schedule,24.34,75.86,
"Scr c/v cyto,thinlayer,rescr",G0143,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24.35,,,,,,,fee schedule,24.34,75.86,Laboratory
"Scr c/v cyto,thinlayer,rescr",G0143,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,28.4,,,,,,,fee schedule,24.34,75.86,APC
"Scr c/v cyto,thinlayer,rescr",G0143,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,28.13,,,,,,,fee schedule,24.34,75.86,APC
"Scr c/v cyto,thinlayer,rescr",G0143,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,27.05,,,,,,,fee schedule,24.34,75.86,APC
"Scr c/v cyto,thinlayer,rescr",G0143,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,41.39,,,,,,,fee schedule,24.34,75.86,Radiology
"Scr c/v cyto,thinlayer,rescr",G0143,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,37.87,,,,,,,fee schedule,24.34,75.86,APC
"Scr c/v cyto,thinlayer,rescr",G0143,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,47.34,,,,,,,fee schedule,24.34,75.86,APC
"Scr c/v cyto,thinlayer,rescr",G0144,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,74.16,,,,,,,fee schedule,39.57,80.55,
"Scr c/v cyto,thinlayer,rescr",G0144,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,80.55,,,,,,,fee schedule,39.57,80.55,
"Scr c/v cyto,thinlayer,rescr",G0144,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,64.57,,,,,,,fee schedule,39.57,80.55,
"Scr c/v cyto,thinlayer,rescr",G0144,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,70.54,,,,,,,fee schedule,39.57,80.55,
"Scr c/v cyto,thinlayer,rescr",G0144,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,39.57,,,,,,,fee schedule,39.57,80.55,Laboratory
"Scr c/v cyto,thinlayer,rescr",G0144,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,46.17,,,,,,,fee schedule,39.57,80.55,APC
"Scr c/v cyto,thinlayer,rescr",G0144,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,45.73,,,,,,,fee schedule,39.57,80.55,APC
"Scr c/v cyto,thinlayer,rescr",G0144,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,43.97,,,,,,,fee schedule,39.57,80.55,APC
"Scr c/v cyto,thinlayer,rescr",G0144,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,67.27,,,,,,,fee schedule,39.57,80.55,Radiology
"Scr c/v cyto,thinlayer,rescr",G0144,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,61.56,,,,,,,fee schedule,39.57,80.55,APC
"Scr c/v cyto,thinlayer,rescr",G0144,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,76.95,,,,,,,fee schedule,39.57,80.55,APC
"Scr c/v cyto,thinlayer,rescr",G0145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,79.86,,,,,,,fee schedule,23.84,86.75,
"Scr c/v cyto,thinlayer,rescr",G0145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,86.75,,,,,,,fee schedule,23.84,86.75,
"Scr c/v cyto,thinlayer,rescr",G0145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,69.54,,,,,,,fee schedule,23.84,86.75,
"Scr c/v cyto,thinlayer,rescr",G0145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,75.96,,,,,,,fee schedule,23.84,86.75,
"Scr c/v cyto,thinlayer,rescr",G0145,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,23.84,,,,,,,fee schedule,23.84,86.75,Laboratory
"Scr c/v cyto,thinlayer,rescr",G0145,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,27.81,,,,,,,fee schedule,23.84,86.75,APC
"Scr c/v cyto,thinlayer,rescr",G0145,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,27.55,,,,,,,fee schedule,23.84,86.75,APC
"Scr c/v cyto,thinlayer,rescr",G0145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,26.49,,,,,,,fee schedule,23.84,86.75,APC
"Scr c/v cyto,thinlayer,rescr",G0145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40.53,,,,,,,fee schedule,23.84,86.75,Radiology
"Scr c/v cyto,thinlayer,rescr",G0145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,37.09,,,,,,,fee schedule,23.84,86.75,APC
"Scr c/v cyto,thinlayer,rescr",G0145,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,46.36,,,,,,,fee schedule,23.84,86.75,APC
"Scr c/v cyto, automated sys",G0147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,53.66,,,,,,,fee schedule,16.69,58.29,
"Scr c/v cyto, automated sys",G0147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,58.29,,,,,,,fee schedule,16.69,58.29,
"Scr c/v cyto, automated sys",G0147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.72,,,,,,,fee schedule,16.69,58.29,
"Scr c/v cyto, automated sys",G0147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.04,,,,,,,fee schedule,16.69,58.29,
"Scr c/v cyto, automated sys",G0147,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.69,,,,,,,fee schedule,16.69,58.29,Laboratory
"Scr c/v cyto, automated sys",G0147,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.47,,,,,,,fee schedule,16.69,58.29,APC
"Scr c/v cyto, automated sys",G0147,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,19.28,,,,,,,fee schedule,16.69,58.29,APC
"Scr c/v cyto, automated sys",G0147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18.54,,,,,,,fee schedule,16.69,58.29,APC
"Scr c/v cyto, automated sys",G0147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.37,,,,,,,fee schedule,16.69,58.29,Radiology
"Scr c/v cyto, automated sys",G0147,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.96,,,,,,,fee schedule,16.69,58.29,APC
"Scr c/v cyto, automated sys",G0147,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,32.44,,,,,,,fee schedule,16.69,58.29,APC
"Scr c/v cyto, autosys, rescr",G0148,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,53.66,,,,,,,fee schedule,28.75,58.29,
"Scr c/v cyto, autosys, rescr",G0148,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,58.29,,,,,,,fee schedule,28.75,58.29,
"Scr c/v cyto, autosys, rescr",G0148,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.72,,,,,,,fee schedule,28.75,58.29,
"Scr c/v cyto, autosys, rescr",G0148,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.04,,,,,,,fee schedule,28.75,58.29,
"Scr c/v cyto, autosys, rescr",G0148,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,28.75,,,,,,,fee schedule,28.75,58.29,Laboratory
"Scr c/v cyto, autosys, rescr",G0148,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,33.54,,,,,,,fee schedule,28.75,58.29,APC
"Scr c/v cyto, autosys, rescr",G0148,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,33.22,,,,,,,fee schedule,28.75,58.29,APC
"Scr c/v cyto, autosys, rescr",G0148,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,31.94,,,,,,,fee schedule,28.75,58.29,APC
"Scr c/v cyto, autosys, rescr",G0148,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,48.87,,,,,,,fee schedule,28.75,58.29,Radiology
"Scr c/v cyto, autosys, rescr",G0148,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,44.72,,,,,,,fee schedule,28.75,58.29,APC
"Scr c/v cyto, autosys, rescr",G0148,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,55.9,,,,,,,fee schedule,28.75,58.29,APC
"Extrnl counterpulse, per tx",G0166,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,394.91,,,,,,,fee schedule,131.71,584.37,
"Extrnl counterpulse, per tx",G0166,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,428.95,,,,,,,fee schedule,131.71,584.37,
"Extrnl counterpulse, per tx",G0166,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,343.84,,,,,,,fee schedule,131.71,584.37,
"Extrnl counterpulse, per tx",G0166,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,375.62,,,,,,,fee schedule,131.71,584.37,
"Extrnl counterpulse, per tx",G0166,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.37,,,,,,,fee schedule,131.71,584.37,APC 378
"Extrnl counterpulse, per tx",G0166,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.3,,,,,,,fee schedule,131.71,584.37,APC
"Extrnl counterpulse, per tx",G0166,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.98,,,,,,,fee schedule,131.71,584.37,APC
"Extrnl counterpulse, per tx",G0166,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.71,,,,,,,fee schedule,131.71,584.37,APC
"Extrnl counterpulse, per tx",G0166,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.52,,,,,,,fee schedule,131.71,584.37,Radiology
"Extrnl counterpulse, per tx",G0166,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.4,,,,,,,fee schedule,131.71,584.37,APC
"Extrnl counterpulse, per tx",G0166,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.5,,,,,,,fee schedule,131.71,584.37,APC
Wound closure by adhesive,G0168,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,84.08,,,,,,,fee schedule,73.2,91.32,
Wound closure by adhesive,G0168,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,91.32,,,,,,,fee schedule,73.2,91.32,
Wound closure by adhesive,G0168,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,73.2,,,,,,,fee schedule,73.2,91.32,
Wound closure by adhesive,G0168,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,79.97,,,,,,,fee schedule,73.2,91.32,
"Opps service,sched team conf",G0175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,499.52,,,,,,,fee schedule,413.08,1832.68,
"Opps service,sched team conf",G0175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,542.58,,,,,,,fee schedule,413.08,1832.68,
"Opps service,sched team conf",G0175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,434.93,,,,,,,fee schedule,413.08,1832.68,
"Opps service,sched team conf",G0175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,475.12,,,,,,,fee schedule,413.08,1832.68,
"Opps service,sched team conf",G0175,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1832.68,,,,,,,fee schedule,413.08,1832.68,APC 378
"Opps service,sched team conf",G0175,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,433.73,,,,,,,fee schedule,413.08,1832.68,APC
"Opps service,sched team conf",G0175,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,429.6,,,,,,,fee schedule,413.08,1832.68,APC
"Opps service,sched team conf",G0175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,413.08,,,,,,,fee schedule,413.08,1832.68,APC
"Opps service,sched team conf",G0175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,632.01,,,,,,,fee schedule,413.08,1832.68,Radiology
"Opps service,sched team conf",G0175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,578.31,,,,,,,fee schedule,413.08,1832.68,APC
"Opps service,sched team conf",G0175,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,722.88,,,,,,,fee schedule,413.08,1832.68,APC
Software meas of cardiac vol,G0183,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,382.23,,,,,,,fee schedule,86.15,382.23,APC 378
Software meas of cardiac vol,G0183,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.46,,,,,,,fee schedule,86.15,382.23,APC
Software meas of cardiac vol,G0183,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.6,,,,,,,fee schedule,86.15,382.23,APC
Software meas of cardiac vol,G0183,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.15,,,,,,,fee schedule,86.15,382.23,APC
Software meas of cardiac vol,G0183,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.81,,,,,,,fee schedule,86.15,382.23,Radiology
Software meas of cardiac vol,G0183,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.61,,,,,,,fee schedule,86.15,382.23,APC
Software meas of cardiac vol,G0183,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.77,,,,,,,fee schedule,86.15,382.23,APC
"Dstry eye lesn,fdr vssl tech",G0186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,949.62,,,,,,,fee schedule,544.48,2415.67,
"Dstry eye lesn,fdr vssl tech",G0186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1031.49,,,,,,,fee schedule,544.48,2415.67,
"Dstry eye lesn,fdr vssl tech",G0186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,826.83,,,,,,,fee schedule,544.48,2415.67,
"Dstry eye lesn,fdr vssl tech",G0186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,903.23,,,,,,,fee schedule,544.48,2415.67,
"Dstry eye lesn,fdr vssl tech",G0186,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2415.67,,,,,,,fee schedule,544.48,2415.67,APC 378
"Dstry eye lesn,fdr vssl tech",G0186,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,571.7,,,,,,,fee schedule,544.48,2415.67,APC
"Dstry eye lesn,fdr vssl tech",G0186,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,566.26,,,,,,,fee schedule,544.48,2415.67,APC
"Dstry eye lesn,fdr vssl tech",G0186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,544.48,,,,,,,fee schedule,544.48,2415.67,APC
"Dstry eye lesn,fdr vssl tech",G0186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,833.05,,,,,,,fee schedule,544.48,2415.67,Radiology
"Dstry eye lesn,fdr vssl tech",G0186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,762.27,,,,,,,fee schedule,544.48,2415.67,APC
"Dstry eye lesn,fdr vssl tech",G0186,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,952.84,,,,,,,fee schedule,544.48,2415.67,APC
PET not otherwise specified,G0235,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1755.86,,,,,,,fee schedule,395.76,1755.86,APC 378
PET not otherwise specified,G0235,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,415.55,,,,,,,fee schedule,395.76,1755.86,APC
PET not otherwise specified,G0235,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,411.59,,,,,,,fee schedule,395.76,1755.86,APC
PET not otherwise specified,G0235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,395.76,,,,,,,fee schedule,395.76,1755.86,APC
PET not otherwise specified,G0235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,605.51,,,,,,,fee schedule,395.76,1755.86,Radiology
PET not otherwise specified,G0235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,554.06,,,,,,,fee schedule,395.76,1755.86,APC
PET not otherwise specified,G0235,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,692.58,,,,,,,fee schedule,395.76,1755.86,APC
Therapeutic procd strg endur,G0237,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,89.05,,,,,,,fee schedule,28.63,127.04,
Therapeutic procd strg endur,G0237,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,96.73,,,,,,,fee schedule,28.63,127.04,
Therapeutic procd strg endur,G0237,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,77.54,,,,,,,fee schedule,28.63,127.04,
Therapeutic procd strg endur,G0237,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,84.7,,,,,,,fee schedule,28.63,127.04,
Therapeutic procd strg endur,G0237,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,127.04,,,,,,,fee schedule,28.63,127.04,APC 378
Therapeutic procd strg endur,G0237,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.07,,,,,,,fee schedule,28.63,127.04,APC
Therapeutic procd strg endur,G0237,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,29.78,,,,,,,fee schedule,28.63,127.04,APC
Therapeutic procd strg endur,G0237,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,28.63,,,,,,,fee schedule,28.63,127.04,APC
Therapeutic procd strg endur,G0237,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43.81,,,,,,,fee schedule,28.63,127.04,Radiology
Therapeutic procd strg endur,G0237,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40.09,,,,,,,fee schedule,28.63,127.04,APC
Therapeutic procd strg endur,G0237,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,50.11,,,,,,,fee schedule,28.63,127.04,APC
"Oth resp proc, indiv",G0238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,89.05,,,,,,,fee schedule,28.63,127.04,
"Oth resp proc, indiv",G0238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,96.73,,,,,,,fee schedule,28.63,127.04,
"Oth resp proc, indiv",G0238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,77.54,,,,,,,fee schedule,28.63,127.04,
"Oth resp proc, indiv",G0238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,84.7,,,,,,,fee schedule,28.63,127.04,
"Oth resp proc, indiv",G0238,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,127.04,,,,,,,fee schedule,28.63,127.04,APC 378
"Oth resp proc, indiv",G0238,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.07,,,,,,,fee schedule,28.63,127.04,APC
"Oth resp proc, indiv",G0238,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,29.78,,,,,,,fee schedule,28.63,127.04,APC
"Oth resp proc, indiv",G0238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,28.63,,,,,,,fee schedule,28.63,127.04,APC
"Oth resp proc, indiv",G0238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43.81,,,,,,,fee schedule,28.63,127.04,Radiology
"Oth resp proc, indiv",G0238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40.09,,,,,,,fee schedule,28.63,127.04,APC
"Oth resp proc, indiv",G0238,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,50.11,,,,,,,fee schedule,28.63,127.04,APC
"Oth resp proc, group",G0239,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,273.34,,,,,,,fee schedule,36.98,296.91,
"Oth resp proc, group",G0239,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,296.91,,,,,,,fee schedule,36.98,296.91,
"Oth resp proc, group",G0239,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,238,,,,,,,fee schedule,36.98,296.91,
"Oth resp proc, group",G0239,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,259.99,,,,,,,fee schedule,36.98,296.91,
"Oth resp proc, group",G0239,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.05,,,,,,,fee schedule,36.98,296.91,APC 378
"Oth resp proc, group",G0239,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.83,,,,,,,fee schedule,36.98,296.91,APC
"Oth resp proc, group",G0239,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.46,,,,,,,fee schedule,36.98,296.91,APC
"Oth resp proc, group",G0239,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.98,,,,,,,fee schedule,36.98,296.91,APC
"Oth resp proc, group",G0239,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.57,,,,,,,fee schedule,36.98,296.91,Radiology
"Oth resp proc, group",G0239,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.77,,,,,,,fee schedule,36.98,296.91,APC
"Oth resp proc, group",G0239,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.71,,,,,,,fee schedule,36.98,296.91,APC
Initial foot exam pt lops,G0245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,192.76,,,,,,,fee schedule,131.8,584.75,
Initial foot exam pt lops,G0245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,209.37,,,,,,,fee schedule,131.8,584.75,
Initial foot exam pt lops,G0245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,167.83,,,,,,,fee schedule,131.8,584.75,
Initial foot exam pt lops,G0245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,183.34,,,,,,,fee schedule,131.8,584.75,
Initial foot exam pt lops,G0245,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.75,,,,,,,fee schedule,131.8,584.75,APC 378
Initial foot exam pt lops,G0245,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.39,,,,,,,fee schedule,131.8,584.75,APC
Initial foot exam pt lops,G0245,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,137.07,,,,,,,fee schedule,131.8,584.75,APC
Initial foot exam pt lops,G0245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.8,,,,,,,fee schedule,131.8,584.75,APC
Initial foot exam pt lops,G0245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.66,,,,,,,fee schedule,131.8,584.75,Radiology
Initial foot exam pt lops,G0245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.52,,,,,,,fee schedule,131.8,584.75,APC
Initial foot exam pt lops,G0245,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.65,,,,,,,fee schedule,131.8,584.75,APC
Followup eval of foot pt lop,G0246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,228.91,,,,,,,fee schedule,131.8,584.75,
Followup eval of foot pt lop,G0246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,248.65,,,,,,,fee schedule,131.8,584.75,
Followup eval of foot pt lop,G0246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,199.31,,,,,,,fee schedule,131.8,584.75,
Followup eval of foot pt lop,G0246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,217.73,,,,,,,fee schedule,131.8,584.75,
Followup eval of foot pt lop,G0246,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.75,,,,,,,fee schedule,131.8,584.75,APC 378
Followup eval of foot pt lop,G0246,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.39,,,,,,,fee schedule,131.8,584.75,APC
Followup eval of foot pt lop,G0246,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,137.07,,,,,,,fee schedule,131.8,584.75,APC
Followup eval of foot pt lop,G0246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.8,,,,,,,fee schedule,131.8,584.75,APC
Followup eval of foot pt lop,G0246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.66,,,,,,,fee schedule,131.8,584.75,Radiology
Followup eval of foot pt lop,G0246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.52,,,,,,,fee schedule,131.8,584.75,APC
Followup eval of foot pt lop,G0246,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.65,,,,,,,fee schedule,131.8,584.75,APC
Routine footcare pt w lops,G0247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,182.21,,,,,,,fee schedule,158.65,881.22,
Routine footcare pt w lops,G0247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,197.92,,,,,,,fee schedule,158.65,881.22,
Routine footcare pt w lops,G0247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,158.65,,,,,,,fee schedule,158.65,881.22,
Routine footcare pt w lops,G0247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,173.31,,,,,,,fee schedule,158.65,881.22,
Routine footcare pt w lops,G0247,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,881.22,,,,,,,fee schedule,158.65,881.22,APC 378
Routine footcare pt w lops,G0247,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.55,,,,,,,fee schedule,158.65,881.22,APC
Routine footcare pt w lops,G0247,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,206.57,,,,,,,fee schedule,158.65,881.22,APC
Routine footcare pt w lops,G0247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.62,,,,,,,fee schedule,158.65,881.22,APC
Routine footcare pt w lops,G0247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.89,,,,,,,fee schedule,158.65,881.22,Radiology
Routine footcare pt w lops,G0247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,278.07,,,,,,,fee schedule,158.65,881.22,APC
Routine footcare pt w lops,G0247,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,347.59,,,,,,,fee schedule,158.65,881.22,APC
Demonstrate use home inr mon,G0248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,381.51,,,,,,,fee schedule,131.8,584.75,
Demonstrate use home inr mon,G0248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,414.4,,,,,,,fee schedule,131.8,584.75,
Demonstrate use home inr mon,G0248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,332.18,,,,,,,fee schedule,131.8,584.75,
Demonstrate use home inr mon,G0248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,362.88,,,,,,,fee schedule,131.8,584.75,
Demonstrate use home inr mon,G0248,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.75,,,,,,,fee schedule,131.8,584.75,APC 378
Demonstrate use home inr mon,G0248,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.39,,,,,,,fee schedule,131.8,584.75,APC
Demonstrate use home inr mon,G0248,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,137.07,,,,,,,fee schedule,131.8,584.75,APC
Demonstrate use home inr mon,G0248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.8,,,,,,,fee schedule,131.8,584.75,APC
Demonstrate use home inr mon,G0248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.66,,,,,,,fee schedule,131.8,584.75,Radiology
Demonstrate use home inr mon,G0248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.52,,,,,,,fee schedule,131.8,584.75,APC
Demonstrate use home inr mon,G0248,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.65,,,,,,,fee schedule,131.8,584.75,APC
Provide INR test mater/equip,G0249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,381.51,,,,,,,fee schedule,131.8,584.75,
Provide INR test mater/equip,G0249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,414.4,,,,,,,fee schedule,131.8,584.75,
Provide INR test mater/equip,G0249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,332.18,,,,,,,fee schedule,131.8,584.75,
Provide INR test mater/equip,G0249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,362.88,,,,,,,fee schedule,131.8,584.75,
Provide INR test mater/equip,G0249,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.75,,,,,,,fee schedule,131.8,584.75,APC 378
Provide INR test mater/equip,G0249,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.39,,,,,,,fee schedule,131.8,584.75,APC
Provide INR test mater/equip,G0249,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,137.07,,,,,,,fee schedule,131.8,584.75,APC
Provide INR test mater/equip,G0249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.8,,,,,,,fee schedule,131.8,584.75,APC
Provide INR test mater/equip,G0249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.66,,,,,,,fee schedule,131.8,584.75,Radiology
Provide INR test mater/equip,G0249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.52,,,,,,,fee schedule,131.8,584.75,APC
Provide INR test mater/equip,G0249,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.65,,,,,,,fee schedule,131.8,584.75,APC
Unsched dialysis ESRD pt hos,G0257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1502.28,,,,,,,fee schedule,679.43,3014.4,
Unsched dialysis ESRD pt hos,G0257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1631.79,,,,,,,fee schedule,679.43,3014.4,
Unsched dialysis ESRD pt hos,G0257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1308.02,,,,,,,fee schedule,679.43,3014.4,
Unsched dialysis ESRD pt hos,G0257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1428.89,,,,,,,fee schedule,679.43,3014.4,
Unsched dialysis ESRD pt hos,G0257,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3014.4,,,,,,,fee schedule,679.43,3014.4,APC 378
Unsched dialysis ESRD pt hos,G0257,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,713.4,,,,,,,fee schedule,679.43,3014.4,APC
Unsched dialysis ESRD pt hos,G0257,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,706.61,,,,,,,fee schedule,679.43,3014.4,APC
Unsched dialysis ESRD pt hos,G0257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,679.43,,,,,,,fee schedule,679.43,3014.4,APC
Unsched dialysis ESRD pt hos,G0257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1039.53,,,,,,,fee schedule,679.43,3014.4,Radiology
Unsched dialysis ESRD pt hos,G0257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,951.2,,,,,,,fee schedule,679.43,3014.4,APC
Unsched dialysis ESRD pt hos,G0257,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1189,,,,,,,fee schedule,679.43,3014.4,APC
Inj for sacroiliac jt anesth,G0260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,825.76,,,,,,,fee schedule,698.8,3100.34,
Inj for sacroiliac jt anesth,G0260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,896.95,,,,,,,fee schedule,698.8,3100.34,
Inj for sacroiliac jt anesth,G0260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,718.98,,,,,,,fee schedule,698.8,3100.34,
Inj for sacroiliac jt anesth,G0260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,785.42,,,,,,,fee schedule,698.8,3100.34,
Inj for sacroiliac jt anesth,G0260,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3100.34,,,,,,,fee schedule,698.8,3100.34,APC 378
Inj for sacroiliac jt anesth,G0260,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,733.74,,,,,,,fee schedule,698.8,3100.34,APC
Inj for sacroiliac jt anesth,G0260,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,726.75,,,,,,,fee schedule,698.8,3100.34,APC
Inj for sacroiliac jt anesth,G0260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,698.8,,,,,,,fee schedule,698.8,3100.34,APC
Inj for sacroiliac jt anesth,G0260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1069.16,,,,,,,fee schedule,698.8,3100.34,Radiology
Inj for sacroiliac jt anesth,G0260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,978.32,,,,,,,fee schedule,698.8,3100.34,APC
Inj for sacroiliac jt anesth,G0260,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1222.9,,,,,,,fee schedule,698.8,3100.34,APC
MNT subs tx for change dx,G0270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,70.16,,,,,,,fee schedule,21.56,76.2,
MNT subs tx for change dx,G0270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,76.2,,,,,,,fee schedule,21.56,76.2,
MNT subs tx for change dx,G0270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,61.08,,,,,,,fee schedule,21.56,76.2,
MNT subs tx for change dx,G0270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66.73,,,,,,,fee schedule,21.56,76.2,
MNT subs tx for change dx,G0270,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21.56,,,,,,,fee schedule,21.56,76.2,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
MNT subs tx for change dx,G0270,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,22.64,,,,,,,fee schedule,21.56,76.2,APC
MNT subs tx for change dx,G0270,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,22.42,,,,,,,fee schedule,21.56,76.2,APC
MNT subs tx for change dx,G0270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,32.99,,,,,,,fee schedule,21.56,76.2,Radiology
MNT subs tx for change dx,G0270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,30.18,,,,,,,fee schedule,21.56,76.2,APC
MNT subs tx for change dx,G0270,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,37.73,,,,,,,fee schedule,21.56,76.2,APC
Group MNT 2 or more 30 mins,G0271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,43.92,,,,,,,fee schedule,12.12,47.7,
Group MNT 2 or more 30 mins,G0271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,47.7,,,,,,,fee schedule,12.12,47.7,
Group MNT 2 or more 30 mins,G0271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38.24,,,,,,,fee schedule,12.12,47.7,
Group MNT 2 or more 30 mins,G0271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,41.77,,,,,,,fee schedule,12.12,47.7,
Group MNT 2 or more 30 mins,G0271,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.12,,,,,,,fee schedule,12.12,47.7,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Group MNT 2 or more 30 mins,G0271,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.73,,,,,,,fee schedule,12.12,47.7,APC
Group MNT 2 or more 30 mins,G0271,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.6,,,,,,,fee schedule,12.12,47.7,APC
Group MNT 2 or more 30 mins,G0271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.54,,,,,,,fee schedule,12.12,47.7,Radiology
Group MNT 2 or more 30 mins,G0271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.97,,,,,,,fee schedule,12.12,47.7,APC
Group MNT 2 or more 30 mins,G0271,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21.21,,,,,,,fee schedule,12.12,47.7,APC
Pild/placebo control clin tr,G0276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14313.83,,,,,,,fee schedule,7183.42,31870.39,
Pild/placebo control clin tr,G0276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15547.78,,,,,,,fee schedule,7183.42,31870.39,
Pild/placebo control clin tr,G0276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12462.91,,,,,,,fee schedule,7183.42,31870.39,
Pild/placebo control clin tr,G0276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13614.59,,,,,,,fee schedule,7183.42,31870.39,
Pild/placebo control clin tr,G0276,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,7183.42,31870.39,APC 378
Pild/placebo control clin tr,G0276,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,7183.42,31870.39,APC
Pild/placebo control clin tr,G0276,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,7183.42,31870.39,APC
Pild/placebo control clin tr,G0276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,7183.42,31870.39,APC
Pild/placebo control clin tr,G0276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,7183.42,31870.39,Radiology
Pild/placebo control clin tr,G0276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,7183.42,31870.39,APC
Pild/placebo control clin tr,G0276,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,7183.42,31870.39,APC
"Hbot, full body chamber, 30m",G0277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,783.12,,,,,,,fee schedule,136.23,850.63,
"Hbot, full body chamber, 30m",G0277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,850.63,,,,,,,fee schedule,136.23,850.63,
"Hbot, full body chamber, 30m",G0277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,681.85,,,,,,,fee schedule,136.23,850.63,
"Hbot, full body chamber, 30m",G0277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,744.86,,,,,,,fee schedule,136.23,850.63,
"Hbot, full body chamber, 30m",G0277,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,604.4,,,,,,,fee schedule,136.23,850.63,APC 378
"Hbot, full body chamber, 30m",G0277,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,143.04,,,,,,,fee schedule,136.23,850.63,APC
"Hbot, full body chamber, 30m",G0277,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,141.68,,,,,,,fee schedule,136.23,850.63,APC
"Hbot, full body chamber, 30m",G0277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,136.23,,,,,,,fee schedule,136.23,850.63,APC
"Hbot, full body chamber, 30m",G0277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,208.43,,,,,,,fee schedule,136.23,850.63,Radiology
"Hbot, full body chamber, 30m",G0277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,190.72,,,,,,,fee schedule,136.23,850.63,APC
"Hbot, full body chamber, 30m",G0277,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,238.4,,,,,,,fee schedule,136.23,850.63,APC
"Tomosynthesis, mammo",G0279,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,188.23,,,,,,,fee schedule,163.89,204.46,
"Tomosynthesis, mammo",G0279,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,204.46,,,,,,,fee schedule,163.89,204.46,
"Tomosynthesis, mammo",G0279,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,163.89,,,,,,,fee schedule,163.89,204.46,
"Tomosynthesis, mammo",G0279,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,179.04,,,,,,,fee schedule,163.89,204.46,
"Tomosynthesis, mammo",G0279,HCPCS,,,,,,,facility,outpatient,,,TC,,,Unitedhealthcare,All Commercial Plans,11.64,,,,,,,fee schedule,11.64,20.37,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
"Tomosynthesis, mammo",G0279,HCPCS,,,,,,,facility,outpatient,,,TC,,,Aetna,Medicare Managed Care Plan,12.22,,,,,,,fee schedule,11.64,20.37,APC
"Tomosynthesis, mammo",G0279,HCPCS,,,,,,,facility,outpatient,,,TC,,,Bcbs,Medicare Managed Care Plan,12.11,,,,,,,fee schedule,11.64,20.37,APC
"Tomosynthesis, mammo",G0279,HCPCS,,,,,,,facility,outpatient,,,TC,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.81,,,,,,,fee schedule,11.64,20.37,Radiology
"Tomosynthesis, mammo",G0279,HCPCS,,,,,,,facility,outpatient,,,TC,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.3,,,,,,,fee schedule,11.64,20.37,APC
"Tomosynthesis, mammo",G0279,HCPCS,,,,,,,facility,outpatient,,,TC,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20.37,,,,,,,fee schedule,11.64,20.37,APC
Elec stim unattend for press,G0281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,38.49,,,,,,,fee schedule,11.31,41.81,
Elec stim unattend for press,G0281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41.81,,,,,,,fee schedule,11.31,41.81,
Elec stim unattend for press,G0281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,33.51,,,,,,,fee schedule,11.31,41.81,
Elec stim unattend for press,G0281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36.61,,,,,,,fee schedule,11.31,41.81,
Elec stim unattend for press,G0281,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.31,,,,,,,fee schedule,11.31,41.81,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Elec stim unattend for press,G0281,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.88,,,,,,,fee schedule,11.31,41.81,APC
Elec stim unattend for press,G0281,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11.76,,,,,,,fee schedule,11.31,41.81,APC
Elec stim unattend for press,G0281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.3,,,,,,,fee schedule,11.31,41.81,Radiology
Elec stim unattend for press,G0281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15.83,,,,,,,fee schedule,11.31,41.81,APC
Elec stim unattend for press,G0281,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19.79,,,,,,,fee schedule,11.31,41.81,APC
Elec stim other than wound,G0283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,92.6,,,,,,,fee schedule,12.23,100.58,
Elec stim other than wound,G0283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,100.58,,,,,,,fee schedule,12.23,100.58,
Elec stim other than wound,G0283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,80.62,,,,,,,fee schedule,12.23,100.58,
Elec stim other than wound,G0283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,88.07,,,,,,,fee schedule,12.23,100.58,
Elec stim other than wound,G0283,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12.23,,,,,,,fee schedule,12.23,100.58,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Elec stim other than wound,G0283,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.84,,,,,,,fee schedule,12.23,100.58,APC
Elec stim other than wound,G0283,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.72,,,,,,,fee schedule,12.23,100.58,APC
Elec stim other than wound,G0283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.71,,,,,,,fee schedule,12.23,100.58,Radiology
Elec stim other than wound,G0283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.12,,,,,,,fee schedule,12.23,100.58,APC
Elec stim other than wound,G0283,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21.4,,,,,,,fee schedule,12.23,100.58,APC
"Arthro, loose body + chondro",G0289,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6612.77,,,,,,,fee schedule,5757.67,7182.83,
"Arthro, loose body + chondro",G0289,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7182.83,,,,,,,fee schedule,5757.67,7182.83,
"Arthro, loose body + chondro",G0289,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5757.67,,,,,,,fee schedule,5757.67,7182.83,
"Arthro, loose body + chondro",G0289,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6289.73,,,,,,,fee schedule,5757.67,7182.83,
"Non-cov surg proc,clin trial",G0293,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,144.98,,,,,,,fee schedule,36.98,164.05,
"Non-cov surg proc,clin trial",G0293,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,157.47,,,,,,,fee schedule,36.98,164.05,
"Non-cov surg proc,clin trial",G0293,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,126.23,,,,,,,fee schedule,36.98,164.05,
"Non-cov surg proc,clin trial",G0293,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,137.89,,,,,,,fee schedule,36.98,164.05,
"Non-cov surg proc,clin trial",G0293,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.05,,,,,,,fee schedule,36.98,164.05,APC 378
"Non-cov surg proc,clin trial",G0293,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.83,,,,,,,fee schedule,36.98,164.05,APC
"Non-cov surg proc,clin trial",G0293,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.46,,,,,,,fee schedule,36.98,164.05,APC
"Non-cov surg proc,clin trial",G0293,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.98,,,,,,,fee schedule,36.98,164.05,APC
"Non-cov surg proc,clin trial",G0293,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.57,,,,,,,fee schedule,36.98,164.05,Radiology
"Non-cov surg proc,clin trial",G0293,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.77,,,,,,,fee schedule,36.98,164.05,APC
"Non-cov surg proc,clin trial",G0293,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.71,,,,,,,fee schedule,36.98,164.05,APC
"Non-cov proc, clinical trial",G0294,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,144.98,,,,,,,fee schedule,36.98,164.05,
"Non-cov proc, clinical trial",G0294,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,157.47,,,,,,,fee schedule,36.98,164.05,
"Non-cov proc, clinical trial",G0294,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,126.23,,,,,,,fee schedule,36.98,164.05,
"Non-cov proc, clinical trial",G0294,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,137.89,,,,,,,fee schedule,36.98,164.05,
"Non-cov proc, clinical trial",G0294,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.05,,,,,,,fee schedule,36.98,164.05,APC 378
"Non-cov proc, clinical trial",G0294,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.83,,,,,,,fee schedule,36.98,164.05,APC
"Non-cov proc, clinical trial",G0294,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.46,,,,,,,fee schedule,36.98,164.05,APC
"Non-cov proc, clinical trial",G0294,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.98,,,,,,,fee schedule,36.98,164.05,APC
"Non-cov proc, clinical trial",G0294,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.57,,,,,,,fee schedule,36.98,164.05,Radiology
"Non-cov proc, clinical trial",G0294,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.77,,,,,,,fee schedule,36.98,164.05,APC
"Non-cov proc, clinical trial",G0294,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.71,,,,,,,fee schedule,36.98,164.05,APC
Visit to determ ldct elig,G0296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,242.38,,,,,,,fee schedule,100.57,446.2,
Visit to determ ldct elig,G0296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,263.28,,,,,,,fee schedule,100.57,446.2,
Visit to determ ldct elig,G0296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,211.04,,,,,,,fee schedule,100.57,446.2,
Visit to determ ldct elig,G0296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,230.54,,,,,,,fee schedule,100.57,446.2,
Visit to determ ldct elig,G0296,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,446.2,,,,,,,fee schedule,100.57,446.2,APC 378
Visit to determ ldct elig,G0296,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,105.6,,,,,,,fee schedule,100.57,446.2,APC
Visit to determ ldct elig,G0296,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,104.59,,,,,,,fee schedule,100.57,446.2,APC
Visit to determ ldct elig,G0296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,100.57,,,,,,,fee schedule,100.57,446.2,APC
Visit to determ ldct elig,G0296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,153.87,,,,,,,fee schedule,100.57,446.2,Radiology
Visit to determ ldct elig,G0296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,140.8,,,,,,,fee schedule,100.57,446.2,APC
Visit to determ ldct elig,G0296,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,176,,,,,,,fee schedule,100.57,446.2,APC
Pre-op service LVRS complete,G0302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2592.29,,,,,,,fee schedule,369.41,2815.76,
Pre-op service LVRS complete,G0302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2815.76,,,,,,,fee schedule,369.41,2815.76,
Pre-op service LVRS complete,G0302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2257.08,,,,,,,fee schedule,369.41,2815.76,
Pre-op service LVRS complete,G0302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2465.65,,,,,,,fee schedule,369.41,2815.76,
Pre-op service LVRS complete,G0302,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1638.96,,,,,,,fee schedule,369.41,2815.76,APC 378
Pre-op service LVRS complete,G0302,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,387.88,,,,,,,fee schedule,369.41,2815.76,APC
Pre-op service LVRS complete,G0302,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,384.19,,,,,,,fee schedule,369.41,2815.76,APC
Pre-op service LVRS complete,G0302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,369.41,,,,,,,fee schedule,369.41,2815.76,APC
Pre-op service LVRS complete,G0302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,565.2,,,,,,,fee schedule,369.41,2815.76,Radiology
Pre-op service LVRS complete,G0302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,517.18,,,,,,,fee schedule,369.41,2815.76,APC
Pre-op service LVRS complete,G0302,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,646.47,,,,,,,fee schedule,369.41,2815.76,APC
Pre-op service LVRS 10-15dos,G0303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2592.29,,,,,,,fee schedule,213.76,2815.76,
Pre-op service LVRS 10-15dos,G0303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2815.76,,,,,,,fee schedule,213.76,2815.76,
Pre-op service LVRS 10-15dos,G0303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2257.08,,,,,,,fee schedule,213.76,2815.76,
Pre-op service LVRS 10-15dos,G0303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2465.65,,,,,,,fee schedule,213.76,2815.76,
Pre-op service LVRS 10-15dos,G0303,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,213.76,2815.76,APC 378
Pre-op service LVRS 10-15dos,G0303,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,213.76,2815.76,APC
Pre-op service LVRS 10-15dos,G0303,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,213.76,2815.76,APC
Pre-op service LVRS 10-15dos,G0303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,213.76,2815.76,APC
Pre-op service LVRS 10-15dos,G0303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,213.76,2815.76,Radiology
Pre-op service LVRS 10-15dos,G0303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,213.76,2815.76,APC
Pre-op service LVRS 10-15dos,G0303,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,213.76,2815.76,APC
Pre-op service LVRS 1-9 dos,G0304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,528.02,,,,,,,fee schedule,369.41,1638.96,
Pre-op service LVRS 1-9 dos,G0304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,573.54,,,,,,,fee schedule,369.41,1638.96,
Pre-op service LVRS 1-9 dos,G0304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,459.74,,,,,,,fee schedule,369.41,1638.96,
Pre-op service LVRS 1-9 dos,G0304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,502.23,,,,,,,fee schedule,369.41,1638.96,
Pre-op service LVRS 1-9 dos,G0304,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1638.96,,,,,,,fee schedule,369.41,1638.96,APC 378
Pre-op service LVRS 1-9 dos,G0304,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,387.88,,,,,,,fee schedule,369.41,1638.96,APC
Pre-op service LVRS 1-9 dos,G0304,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,384.19,,,,,,,fee schedule,369.41,1638.96,APC
Pre-op service LVRS 1-9 dos,G0304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,369.41,,,,,,,fee schedule,369.41,1638.96,APC
Pre-op service LVRS 1-9 dos,G0304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,565.2,,,,,,,fee schedule,369.41,1638.96,Radiology
Pre-op service LVRS 1-9 dos,G0304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,517.18,,,,,,,fee schedule,369.41,1638.96,APC
Pre-op service LVRS 1-9 dos,G0304,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,646.47,,,,,,,fee schedule,369.41,1638.96,APC
Post op service LVRS min 6,G0305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,528.02,,,,,,,fee schedule,369.41,1638.96,
Post op service LVRS min 6,G0305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,573.54,,,,,,,fee schedule,369.41,1638.96,
Post op service LVRS min 6,G0305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,459.74,,,,,,,fee schedule,369.41,1638.96,
Post op service LVRS min 6,G0305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,502.23,,,,,,,fee schedule,369.41,1638.96,
Post op service LVRS min 6,G0305,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1638.96,,,,,,,fee schedule,369.41,1638.96,APC 378
Post op service LVRS min 6,G0305,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,387.88,,,,,,,fee schedule,369.41,1638.96,APC
Post op service LVRS min 6,G0305,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,384.19,,,,,,,fee schedule,369.41,1638.96,APC
Post op service LVRS min 6,G0305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,369.41,,,,,,,fee schedule,369.41,1638.96,APC
Post op service LVRS min 6,G0305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,565.2,,,,,,,fee schedule,369.41,1638.96,Radiology
Post op service LVRS min 6,G0305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,517.18,,,,,,,fee schedule,369.41,1638.96,APC
Post op service LVRS min 6,G0305,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,646.47,,,,,,,fee schedule,369.41,1638.96,APC
CBC/diffwbc w/o platelet,G0306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,39.5,,,,,,,fee schedule,6.99,42.9,
CBC/diffwbc w/o platelet,G0306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42.9,,,,,,,fee schedule,6.99,42.9,
CBC/diffwbc w/o platelet,G0306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,34.39,,,,,,,fee schedule,6.99,42.9,
CBC/diffwbc w/o platelet,G0306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37.57,,,,,,,fee schedule,6.99,42.9,
CBC/diffwbc w/o platelet,G0306,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,6.99,,,,,,,fee schedule,6.99,42.9,Laboratory
CBC/diffwbc w/o platelet,G0306,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.16,,,,,,,fee schedule,6.99,42.9,APC
CBC/diffwbc w/o platelet,G0306,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8.08,,,,,,,fee schedule,6.99,42.9,APC
CBC/diffwbc w/o platelet,G0306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7.77,,,,,,,fee schedule,6.99,42.9,APC
CBC/diffwbc w/o platelet,G0306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11.89,,,,,,,fee schedule,6.99,42.9,Radiology
CBC/diffwbc w/o platelet,G0306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10.88,,,,,,,fee schedule,6.99,42.9,APC
CBC/diffwbc w/o platelet,G0306,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,13.6,,,,,,,fee schedule,6.99,42.9,APC
CBC without platelet,G0307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,32.89,,,,,,,fee schedule,5.82,35.72,
CBC without platelet,G0307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,35.72,,,,,,,fee schedule,5.82,35.72,
CBC without platelet,G0307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28.63,,,,,,,fee schedule,5.82,35.72,
CBC without platelet,G0307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31.28,,,,,,,fee schedule,5.82,35.72,
CBC without platelet,G0307,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.82,,,,,,,fee schedule,5.82,35.72,Laboratory
CBC without platelet,G0307,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.79,,,,,,,fee schedule,5.82,35.72,APC
CBC without platelet,G0307,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6.73,,,,,,,fee schedule,5.82,35.72,APC
CBC without platelet,G0307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6.47,,,,,,,fee schedule,5.82,35.72,APC
CBC without platelet,G0307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.9,,,,,,,fee schedule,5.82,35.72,Radiology
CBC without platelet,G0307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.06,,,,,,,fee schedule,5.82,35.72,APC
CBC without platelet,G0307,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11.32,,,,,,,fee schedule,5.82,35.72,APC
Care manage beh svs 20mins,G0323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,103.29,,,,,,,fee schedule,37.09,164.57,
Care manage beh svs 20mins,G0323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,112.19,,,,,,,fee schedule,37.09,164.57,
Care manage beh svs 20mins,G0323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,89.93,,,,,,,fee schedule,37.09,164.57,
Care manage beh svs 20mins,G0323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,98.24,,,,,,,fee schedule,37.09,164.57,
Care manage beh svs 20mins,G0323,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.57,,,,,,,fee schedule,37.09,164.57,APC 378
Care manage beh svs 20mins,G0323,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.95,,,,,,,fee schedule,37.09,164.57,APC
Care manage beh svs 20mins,G0323,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.58,,,,,,,fee schedule,37.09,164.57,APC
Care manage beh svs 20mins,G0323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,37.09,,,,,,,fee schedule,37.09,164.57,APC
Care manage beh svs 20mins,G0323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.75,,,,,,,fee schedule,37.09,164.57,Radiology
Care manage beh svs 20mins,G0323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.93,,,,,,,fee schedule,37.09,164.57,APC
Care manage beh svs 20mins,G0323,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.91,,,,,,,fee schedule,37.09,164.57,APC
Fecal blood scrn immunoassay,G0328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37.51,,,,,,,fee schedule,16.24,40.74,
Fecal blood scrn immunoassay,G0328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,40.74,,,,,,,fee schedule,16.24,40.74,
Fecal blood scrn immunoassay,G0328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32.66,,,,,,,fee schedule,16.24,40.74,
Fecal blood scrn immunoassay,G0328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35.68,,,,,,,fee schedule,16.24,40.74,
Fecal blood scrn immunoassay,G0328,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.24,,,,,,,fee schedule,16.24,40.74,Laboratory
Fecal blood scrn immunoassay,G0328,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.95,,,,,,,fee schedule,16.24,40.74,APC
Fecal blood scrn immunoassay,G0328,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18.77,,,,,,,fee schedule,16.24,40.74,APC
Fecal blood scrn immunoassay,G0328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18.05,,,,,,,fee schedule,16.24,40.74,APC
Fecal blood scrn immunoassay,G0328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27.62,,,,,,,fee schedule,16.24,40.74,Radiology
Fecal blood scrn immunoassay,G0328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.27,,,,,,,fee schedule,16.24,40.74,APC
Fecal blood scrn immunoassay,G0328,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31.59,,,,,,,fee schedule,16.24,40.74,APC
Electromagntic tx for ulcers,G0329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,25.65,,,,,,,fee schedule,10.06,27.86,
Electromagntic tx for ulcers,G0329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27.86,,,,,,,fee schedule,10.06,27.86,
Electromagntic tx for ulcers,G0329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22.33,,,,,,,fee schedule,10.06,27.86,
Electromagntic tx for ulcers,G0329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24.39,,,,,,,fee schedule,10.06,27.86,
Electromagntic tx for ulcers,G0329,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.06,,,,,,,fee schedule,10.06,27.86,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Electromagntic tx for ulcers,G0329,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.56,,,,,,,fee schedule,10.06,27.86,APC
Electromagntic tx for ulcers,G0329,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10.46,,,,,,,fee schedule,10.06,27.86,APC
Electromagntic tx for ulcers,G0329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15.39,,,,,,,fee schedule,10.06,27.86,Radiology
Electromagntic tx for ulcers,G0329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.08,,,,,,,fee schedule,10.06,27.86,APC
Electromagntic tx for ulcers,G0329,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,17.6,,,,,,,fee schedule,10.06,27.86,APC
Facility svs dental rehab,G0330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5994.06,,,,,,,fee schedule,3282.2,14562,
Facility svs dental rehab,G0330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6510.79,,,,,,,fee schedule,3282.2,14562,
Facility svs dental rehab,G0330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5218.96,,,,,,,fee schedule,3282.2,14562,
Facility svs dental rehab,G0330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5701.24,,,,,,,fee schedule,3282.2,14562,
Facility svs dental rehab,G0330,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14562,,,,,,,fee schedule,3282.2,14562,APC 378
Facility svs dental rehab,G0330,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3446.31,,,,,,,fee schedule,3282.2,14562,APC
Facility svs dental rehab,G0330,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3413.48,,,,,,,fee schedule,3282.2,14562,APC
Facility svs dental rehab,G0330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3282.2,,,,,,,fee schedule,3282.2,14562,APC
Facility svs dental rehab,G0330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5021.76,,,,,,,fee schedule,3282.2,14562,Radiology
Facility svs dental rehab,G0330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4595.08,,,,,,,fee schedule,3282.2,14562,APC
Facility svs dental rehab,G0330,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5743.84,,,,,,,fee schedule,3282.2,14562,APC
Hospice evaluation preelecti,G0337,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,231.94,,,,,,,fee schedule,201.95,251.94,
Hospice evaluation preelecti,G0337,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,251.94,,,,,,,fee schedule,201.95,251.94,
Hospice evaluation preelecti,G0337,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,201.95,,,,,,,fee schedule,201.95,251.94,
Hospice evaluation preelecti,G0337,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,220.61,,,,,,,fee schedule,201.95,251.94,
"Robot lin-radsurg com, first",G0339,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14175.88,,,,,,,fee schedule,12342.8,15397.94,
"Robot lin-radsurg com, first",G0339,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15397.94,,,,,,,fee schedule,12342.8,15397.94,
"Robot lin-radsurg com, first",G0339,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12342.8,,,,,,,fee schedule,12342.8,15397.94,
"Robot lin-radsurg com, first",G0339,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13483.38,,,,,,,fee schedule,12342.8,15397.94,
Robt lin-radsurg fractx 2-5,G0340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10355.47,,,,,,,fee schedule,9016.4,11248.18,
Robt lin-radsurg fractx 2-5,G0340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11248.18,,,,,,,fee schedule,9016.4,11248.18,
Robt lin-radsurg fractx 2-5,G0340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9016.4,,,,,,,fee schedule,9016.4,11248.18,
Robt lin-radsurg fractx 2-5,G0340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9849.6,,,,,,,fee schedule,9016.4,11248.18,
Hospital observation per hr,G0378,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,97.02,,,,,,,fee schedule,84.47,105.38,
Hospital observation per hr,G0378,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,105.38,,,,,,,fee schedule,84.47,105.38,
Hospital observation per hr,G0378,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,84.47,,,,,,,fee schedule,84.47,105.38,
Hospital observation per hr,G0378,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,92.28,,,,,,,fee schedule,84.47,105.38,
Direct refer hospital observ,G0379,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.01,,,,,,,fee schedule,0.01,2615.66,
Direct refer hospital observ,G0379,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.01,,,,,,,fee schedule,0.01,2615.66,
Direct refer hospital observ,G0379,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2615.66,,,,,,,fee schedule,0.01,2615.66,APC 378
Direct refer hospital observ,G0379,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,619.03,,,,,,,fee schedule,0.01,2615.66,APC
Direct refer hospital observ,G0379,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,613.14,,,,,,,fee schedule,0.01,2615.66,APC
Direct refer hospital observ,G0379,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,589.56,,,,,,,fee schedule,0.01,2615.66,APC
Direct refer hospital observ,G0379,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,902.02,,,,,,,fee schedule,0.01,2615.66,Radiology
Direct refer hospital observ,G0379,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,825.38,,,,,,,fee schedule,0.01,2615.66,APC
Direct refer hospital observ,G0379,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1031.72,,,,,,,fee schedule,0.01,2615.66,APC
Lev 1 hosp type B ED visit,G0380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,192.76,,,,,,,fee schedule,73.58,326.47,
Lev 1 hosp type B ED visit,G0380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,209.37,,,,,,,fee schedule,73.58,326.47,
Lev 1 hosp type B ED visit,G0380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,167.83,,,,,,,fee schedule,73.58,326.47,
Lev 1 hosp type B ED visit,G0380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,183.34,,,,,,,fee schedule,73.58,326.47,
Lev 1 hosp type B ED visit,G0380,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,326.47,,,,,,,fee schedule,73.58,326.47,APC 378
Lev 1 hosp type B ED visit,G0380,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,77.26,,,,,,,fee schedule,73.58,326.47,APC
Lev 1 hosp type B ED visit,G0380,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,76.53,,,,,,,fee schedule,73.58,326.47,APC
Lev 1 hosp type B ED visit,G0380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,73.58,,,,,,,fee schedule,73.58,326.47,APC
Lev 1 hosp type B ED visit,G0380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,112.58,,,,,,,fee schedule,73.58,326.47,Radiology
Lev 1 hosp type B ED visit,G0380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,103.02,,,,,,,fee schedule,73.58,326.47,APC
Lev 1 hosp type B ED visit,G0380,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,128.77,,,,,,,fee schedule,73.58,326.47,APC
Lev 2 hosp type B ED visit,G0381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,228.91,,,,,,,fee schedule,91.96,407.98,
Lev 2 hosp type B ED visit,G0381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,248.65,,,,,,,fee schedule,91.96,407.98,
Lev 2 hosp type B ED visit,G0381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,199.31,,,,,,,fee schedule,91.96,407.98,
Lev 2 hosp type B ED visit,G0381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,217.73,,,,,,,fee schedule,91.96,407.98,
Lev 2 hosp type B ED visit,G0381,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,407.98,,,,,,,fee schedule,91.96,407.98,APC 378
Lev 2 hosp type B ED visit,G0381,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,96.55,,,,,,,fee schedule,91.96,407.98,APC
Lev 2 hosp type B ED visit,G0381,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,95.63,,,,,,,fee schedule,91.96,407.98,APC
Lev 2 hosp type B ED visit,G0381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,91.96,,,,,,,fee schedule,91.96,407.98,APC
Lev 2 hosp type B ED visit,G0381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,140.69,,,,,,,fee schedule,91.96,407.98,Radiology
Lev 2 hosp type B ED visit,G0381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,128.74,,,,,,,fee schedule,91.96,407.98,APC
Lev 2 hosp type B ED visit,G0381,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,160.92,,,,,,,fee schedule,91.96,407.98,APC
Lev 3 hosp type B ED visit,G0382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,303.87,,,,,,,fee schedule,170.16,754.95,
Lev 3 hosp type B ED visit,G0382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,330.07,,,,,,,fee schedule,170.16,754.95,
Lev 3 hosp type B ED visit,G0382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,264.58,,,,,,,fee schedule,170.16,754.95,
Lev 3 hosp type B ED visit,G0382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,289.03,,,,,,,fee schedule,170.16,754.95,
Lev 3 hosp type B ED visit,G0382,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,754.95,,,,,,,fee schedule,170.16,754.95,APC 378
Lev 3 hosp type B ED visit,G0382,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,178.67,,,,,,,fee schedule,170.16,754.95,APC
Lev 3 hosp type B ED visit,G0382,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,176.97,,,,,,,fee schedule,170.16,754.95,APC
Lev 3 hosp type B ED visit,G0382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,170.16,,,,,,,fee schedule,170.16,754.95,APC
Lev 3 hosp type B ED visit,G0382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,260.35,,,,,,,fee schedule,170.16,754.95,Radiology
Lev 3 hosp type B ED visit,G0382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,238.23,,,,,,,fee schedule,170.16,754.95,APC
Lev 3 hosp type B ED visit,G0382,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,297.78,,,,,,,fee schedule,170.16,754.95,APC
Lev 4 hosp type B ED visit,G0383,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,381.51,,,,,,,fee schedule,261.65,1160.87,
Lev 4 hosp type B ED visit,G0383,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,414.4,,,,,,,fee schedule,261.65,1160.87,
Lev 4 hosp type B ED visit,G0383,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,332.18,,,,,,,fee schedule,261.65,1160.87,
Lev 4 hosp type B ED visit,G0383,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,362.88,,,,,,,fee schedule,261.65,1160.87,
Lev 4 hosp type B ED visit,G0383,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1160.87,,,,,,,fee schedule,261.65,1160.87,APC 378
Lev 4 hosp type B ED visit,G0383,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,274.74,,,,,,,fee schedule,261.65,1160.87,APC
Lev 4 hosp type B ED visit,G0383,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,272.12,,,,,,,fee schedule,261.65,1160.87,APC
Lev 4 hosp type B ED visit,G0383,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,261.65,,,,,,,fee schedule,261.65,1160.87,APC
Lev 4 hosp type B ED visit,G0383,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,400.33,,,,,,,fee schedule,261.65,1160.87,Radiology
Lev 4 hosp type B ED visit,G0383,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,366.32,,,,,,,fee schedule,261.65,1160.87,APC
Lev 4 hosp type B ED visit,G0383,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,457.89,,,,,,,fee schedule,261.65,1160.87,APC
Lev 5 hosp type B ED visit,G0384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,499.52,,,,,,,fee schedule,406.6,1803.96,
Lev 5 hosp type B ED visit,G0384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,542.58,,,,,,,fee schedule,406.6,1803.96,
Lev 5 hosp type B ED visit,G0384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,434.93,,,,,,,fee schedule,406.6,1803.96,
Lev 5 hosp type B ED visit,G0384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,475.12,,,,,,,fee schedule,406.6,1803.96,
Lev 5 hosp type B ED visit,G0384,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1803.96,,,,,,,fee schedule,406.6,1803.96,APC 378
Lev 5 hosp type B ED visit,G0384,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,426.93,,,,,,,fee schedule,406.6,1803.96,APC
Lev 5 hosp type B ED visit,G0384,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,422.87,,,,,,,fee schedule,406.6,1803.96,APC
Lev 5 hosp type B ED visit,G0384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,406.6,,,,,,,fee schedule,406.6,1803.96,APC
Lev 5 hosp type B ED visit,G0384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,622.1,,,,,,,fee schedule,406.6,1803.96,Radiology
Lev 5 hosp type B ED visit,G0384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,569.24,,,,,,,fee schedule,406.6,1803.96,APC
Lev 5 hosp type B ED visit,G0384,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,711.56,,,,,,,fee schedule,406.6,1803.96,APC
Trauma Respons w/hosp criti,G0390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1191.45,,,,,,,fee schedule,1037.38,5854.34,
Trauma Respons w/hosp criti,G0390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1294.16,,,,,,,fee schedule,1037.38,5854.34,
Trauma Respons w/hosp criti,G0390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1037.38,,,,,,,fee schedule,1037.38,5854.34,
Trauma Respons w/hosp criti,G0390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1133.24,,,,,,,fee schedule,1037.38,5854.34,
Trauma Respons w/hosp criti,G0390,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5854.34,,,,,,,fee schedule,1037.38,5854.34,APC 378
Trauma Respons w/hosp criti,G0390,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1385.51,,,,,,,fee schedule,1037.38,5854.34,APC
Trauma Respons w/hosp criti,G0390,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1372.32,,,,,,,fee schedule,1037.38,5854.34,APC
Trauma Respons w/hosp criti,G0390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1319.54,,,,,,,fee schedule,1037.38,5854.34,APC
Trauma Respons w/hosp criti,G0390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2018.89,,,,,,,fee schedule,1037.38,5854.34,Radiology
Trauma Respons w/hosp criti,G0390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1847.35,,,,,,,fee schedule,1037.38,5854.34,APC
Trauma Respons w/hosp criti,G0390,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2309.19,,,,,,,fee schedule,1037.38,5854.34,APC
Alcohol/subs interv 15-30mn,G0396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,71.86,,,,,,,fee schedule,37.09,164.57,
Alcohol/subs interv 15-30mn,G0396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,78.06,,,,,,,fee schedule,37.09,164.57,
Alcohol/subs interv 15-30mn,G0396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,62.57,,,,,,,fee schedule,37.09,164.57,
Alcohol/subs interv 15-30mn,G0396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,68.35,,,,,,,fee schedule,37.09,164.57,
Alcohol/subs interv 15-30mn,G0396,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.57,,,,,,,fee schedule,37.09,164.57,APC 378
Alcohol/subs interv 15-30mn,G0396,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.95,,,,,,,fee schedule,37.09,164.57,APC
Alcohol/subs interv 15-30mn,G0396,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.58,,,,,,,fee schedule,37.09,164.57,APC
Alcohol/subs interv 15-30mn,G0396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,37.09,,,,,,,fee schedule,37.09,164.57,APC
Alcohol/subs interv 15-30mn,G0396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.75,,,,,,,fee schedule,37.09,164.57,Radiology
Alcohol/subs interv 15-30mn,G0396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.93,,,,,,,fee schedule,37.09,164.57,APC
Alcohol/subs interv 15-30mn,G0396,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.91,,,,,,,fee schedule,37.09,164.57,APC
Alcohol/subs interv >30 min,G0397,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,71.86,,,,,,,fee schedule,62.57,779.59,
Alcohol/subs interv >30 min,G0397,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,78.06,,,,,,,fee schedule,62.57,779.59,
Alcohol/subs interv >30 min,G0397,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,62.57,,,,,,,fee schedule,62.57,779.59,
Alcohol/subs interv >30 min,G0397,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,68.35,,,,,,,fee schedule,62.57,779.59,
Alcohol/subs interv >30 min,G0397,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,779.59,,,,,,,fee schedule,62.57,779.59,APC 378
Alcohol/subs interv >30 min,G0397,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,184.5,,,,,,,fee schedule,62.57,779.59,APC
Alcohol/subs interv >30 min,G0397,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,182.74,,,,,,,fee schedule,62.57,779.59,APC
Alcohol/subs interv >30 min,G0397,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,175.71,,,,,,,fee schedule,62.57,779.59,APC
Alcohol/subs interv >30 min,G0397,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,268.84,,,,,,,fee schedule,62.57,779.59,Radiology
Alcohol/subs interv >30 min,G0397,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,246,,,,,,,fee schedule,62.57,779.59,APC
Alcohol/subs interv >30 min,G0397,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,307.5,,,,,,,fee schedule,62.57,779.59,APC
Home sleep test/type 2 porta,G0398,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,175.91,,,,,,,fee schedule,153.17,948.37,
Home sleep test/type 2 porta,G0398,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,191.08,,,,,,,fee schedule,153.17,948.37,
Home sleep test/type 2 porta,G0398,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,153.17,,,,,,,fee schedule,153.17,948.37,
Home sleep test/type 2 porta,G0398,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,167.32,,,,,,,fee schedule,153.17,948.37,
Home sleep test/type 2 porta,G0398,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,153.17,948.37,APC 378
Home sleep test/type 2 porta,G0398,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,153.17,948.37,APC
Home sleep test/type 2 porta,G0398,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,153.17,948.37,APC
Home sleep test/type 2 porta,G0398,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,153.17,948.37,APC
Home sleep test/type 2 porta,G0398,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,153.17,948.37,Radiology
Home sleep test/type 2 porta,G0398,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,153.17,948.37,APC
Home sleep test/type 2 porta,G0398,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,153.17,948.37,APC
Home sleep test/type 3 porta,G0399,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,123.16,,,,,,,fee schedule,107.23,948.37,
Home sleep test/type 3 porta,G0399,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,133.77,,,,,,,fee schedule,107.23,948.37,
Home sleep test/type 3 porta,G0399,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,107.23,,,,,,,fee schedule,107.23,948.37,
Home sleep test/type 3 porta,G0399,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,117.14,,,,,,,fee schedule,107.23,948.37,
Home sleep test/type 3 porta,G0399,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,107.23,948.37,APC 378
Home sleep test/type 3 porta,G0399,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,107.23,948.37,APC
Home sleep test/type 3 porta,G0399,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,107.23,948.37,APC
Home sleep test/type 3 porta,G0399,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,107.23,948.37,APC
Home sleep test/type 3 porta,G0399,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,107.23,948.37,Radiology
Home sleep test/type 3 porta,G0399,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,107.23,948.37,APC
Home sleep test/type 3 porta,G0399,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,107.23,948.37,APC
Home sleep test/type 4 porta,G0400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,105.55,,,,,,,fee schedule,91.9,948.37,
Home sleep test/type 4 porta,G0400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,114.65,,,,,,,fee schedule,91.9,948.37,
Home sleep test/type 4 porta,G0400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,91.9,,,,,,,fee schedule,91.9,948.37,
Home sleep test/type 4 porta,G0400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,100.39,,,,,,,fee schedule,91.9,948.37,
Home sleep test/type 4 porta,G0400,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,948.37,,,,,,,fee schedule,91.9,948.37,APC 378
Home sleep test/type 4 porta,G0400,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.44,,,,,,,fee schedule,91.9,948.37,APC
Home sleep test/type 4 porta,G0400,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.31,,,,,,,fee schedule,91.9,948.37,APC
Home sleep test/type 4 porta,G0400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,213.76,,,,,,,fee schedule,91.9,948.37,APC
Home sleep test/type 4 porta,G0400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.05,,,,,,,fee schedule,91.9,948.37,Radiology
Home sleep test/type 4 porta,G0400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.26,,,,,,,fee schedule,91.9,948.37,APC
Home sleep test/type 4 porta,G0400,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.07,,,,,,,fee schedule,91.9,948.37,APC
Initial preventive exam,G0402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,308.15,,,,,,,fee schedule,131.8,584.75,
Initial preventive exam,G0402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,334.72,,,,,,,fee schedule,131.8,584.75,
Initial preventive exam,G0402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,268.31,,,,,,,fee schedule,131.8,584.75,
Initial preventive exam,G0402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,293.1,,,,,,,fee schedule,131.8,584.75,
Initial preventive exam,G0402,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.75,,,,,,,fee schedule,131.8,584.75,APC 378
Initial preventive exam,G0402,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.39,,,,,,,fee schedule,131.8,584.75,APC
Initial preventive exam,G0402,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,137.07,,,,,,,fee schedule,131.8,584.75,APC
Initial preventive exam,G0402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.8,,,,,,,fee schedule,131.8,584.75,APC
Initial preventive exam,G0402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.66,,,,,,,fee schedule,131.8,584.75,Radiology
Initial preventive exam,G0402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.52,,,,,,,fee schedule,131.8,584.75,APC
Initial preventive exam,G0402,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.65,,,,,,,fee schedule,131.8,584.75,APC
EKG for initial prevent exam,G0403,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,67.89,,,,,,,fee schedule,59.12,73.75,
EKG for initial prevent exam,G0403,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,73.75,,,,,,,fee schedule,59.12,73.75,
EKG for initial prevent exam,G0403,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,59.12,,,,,,,fee schedule,59.12,73.75,
EKG for initial prevent exam,G0403,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,64.58,,,,,,,fee schedule,59.12,73.75,
EKG tracing for initial prev,G0404,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42.98,,,,,,,fee schedule,28.63,127.04,
EKG tracing for initial prev,G0404,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46.68,,,,,,,fee schedule,28.63,127.04,
EKG tracing for initial prev,G0404,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37.42,,,,,,,fee schedule,28.63,127.04,
EKG tracing for initial prev,G0404,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40.88,,,,,,,fee schedule,28.63,127.04,
EKG tracing for initial prev,G0404,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,127.04,,,,,,,fee schedule,28.63,127.04,APC 378
EKG tracing for initial prev,G0404,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.07,,,,,,,fee schedule,28.63,127.04,APC
EKG tracing for initial prev,G0404,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,29.78,,,,,,,fee schedule,28.63,127.04,APC
EKG tracing for initial prev,G0404,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,28.63,,,,,,,fee schedule,28.63,127.04,APC
EKG tracing for initial prev,G0404,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43.81,,,,,,,fee schedule,28.63,127.04,Radiology
EKG tracing for initial prev,G0404,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40.09,,,,,,,fee schedule,28.63,127.04,APC
EKG tracing for initial prev,G0404,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,50.11,,,,,,,fee schedule,28.63,127.04,APC
EKG interpret & report preve,G0405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,28.29,,,,,,,fee schedule,24.63,30.73,
EKG interpret & report preve,G0405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30.73,,,,,,,fee schedule,24.63,30.73,
EKG interpret & report preve,G0405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24.63,,,,,,,fee schedule,24.63,30.73,
EKG interpret & report preve,G0405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26.91,,,,,,,fee schedule,24.63,30.73,
Inpt/tele follow up 15,G0406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,126.32,,,,,,,fee schedule,109.99,137.21,
Inpt/tele follow up 15,G0406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,137.21,,,,,,,fee schedule,109.99,137.21,
Inpt/tele follow up 15,G0406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,109.99,,,,,,,fee schedule,109.99,137.21,
Inpt/tele follow up 15,G0406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,120.15,,,,,,,fee schedule,109.99,137.21,
Inpt/tele follow up 25,G0407,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,226.9,,,,,,,fee schedule,197.56,246.46,
Inpt/tele follow up 25,G0407,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,246.46,,,,,,,fee schedule,197.56,246.46,
Inpt/tele follow up 25,G0407,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,197.56,,,,,,,fee schedule,197.56,246.46,
Inpt/tele follow up 25,G0407,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,215.81,,,,,,,fee schedule,197.56,246.46,
Inpt/tele follow up 35,G0408,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,325.17,,,,,,,fee schedule,283.12,353.2,
Inpt/tele follow up 35,G0408,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,353.2,,,,,,,fee schedule,283.12,353.2,
Inpt/tele follow up 35,G0408,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,283.12,,,,,,,fee schedule,283.12,353.2,
Inpt/tele follow up 35,G0408,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,309.29,,,,,,,fee schedule,283.12,353.2,
CORF related serv 15 mins ea,G0409,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27.07,,,,,,,fee schedule,23.57,29.41,
CORF related serv 15 mins ea,G0409,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,29.41,,,,,,,fee schedule,23.57,29.41,
CORF related serv 15 mins ea,G0409,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23.57,,,,,,,fee schedule,23.57,29.41,
CORF related serv 15 mins ea,G0409,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,25.75,,,,,,,fee schedule,23.57,29.41,
Open tx iliac spine uni/bil,G0412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2333.51,,,,,,,fee schedule,2031.77,31870.39,
Open tx iliac spine uni/bil,G0412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2534.68,,,,,,,fee schedule,2031.77,31870.39,
Open tx iliac spine uni/bil,G0412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2031.77,,,,,,,fee schedule,2031.77,31870.39,
Open tx iliac spine uni/bil,G0412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2219.52,,,,,,,fee schedule,2031.77,31870.39,
Open tx iliac spine uni/bil,G0412,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,2031.77,31870.39,APC 378
Open tx iliac spine uni/bil,G0412,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,2031.77,31870.39,APC
Open tx iliac spine uni/bil,G0412,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,2031.77,31870.39,APC
Open tx iliac spine uni/bil,G0412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,2031.77,31870.39,APC
Open tx iliac spine uni/bil,G0412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,2031.77,31870.39,Radiology
Open tx iliac spine uni/bil,G0412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,2031.77,31870.39,APC
Open tx iliac spine uni/bil,G0412,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,2031.77,31870.39,APC
Pelvic ring fracture uni/bil,G0413,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3402.01,,,,,,,fee schedule,2962.1,31870.39,
Pelvic ring fracture uni/bil,G0413,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3695.29,,,,,,,fee schedule,2962.1,31870.39,
Pelvic ring fracture uni/bil,G0413,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2962.1,,,,,,,fee schedule,2962.1,31870.39,
Pelvic ring fracture uni/bil,G0413,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3235.82,,,,,,,fee schedule,2962.1,31870.39,
Pelvic ring fracture uni/bil,G0413,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,2962.1,31870.39,APC 378
Pelvic ring fracture uni/bil,G0413,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,2962.1,31870.39,APC
Pelvic ring fracture uni/bil,G0413,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,2962.1,31870.39,APC
Pelvic ring fracture uni/bil,G0413,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,2962.1,31870.39,APC
Pelvic ring fracture uni/bil,G0413,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,2962.1,31870.39,Radiology
Pelvic ring fracture uni/bil,G0413,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,2962.1,31870.39,APC
Pelvic ring fracture uni/bil,G0413,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,2962.1,31870.39,APC
Pelvic ring fx treat int fix,G0414,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3211.62,,,,,,,fee schedule,2796.33,31870.39,
Pelvic ring fx treat int fix,G0414,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3488.49,,,,,,,fee schedule,2796.33,31870.39,
Pelvic ring fx treat int fix,G0414,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2796.33,,,,,,,fee schedule,2796.33,31870.39,
Pelvic ring fx treat int fix,G0414,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3054.73,,,,,,,fee schedule,2796.33,31870.39,
Pelvic ring fx treat int fix,G0414,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31870.39,,,,,,,fee schedule,2796.33,31870.39,APC 378
Pelvic ring fx treat int fix,G0414,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7542.59,,,,,,,fee schedule,2796.33,31870.39,APC
Pelvic ring fx treat int fix,G0414,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7470.75,,,,,,,fee schedule,2796.33,31870.39,APC
Pelvic ring fx treat int fix,G0414,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7183.42,,,,,,,fee schedule,2796.33,31870.39,APC
Pelvic ring fx treat int fix,G0414,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10990.63,,,,,,,fee schedule,2796.33,31870.39,Radiology
Pelvic ring fx treat int fix,G0414,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10056.78,,,,,,,fee schedule,2796.33,31870.39,APC
Pelvic ring fx treat int fix,G0414,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12570.98,,,,,,,fee schedule,2796.33,31870.39,APC
Open tx post pelvic fxcture,G0415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4411.77,,,,,,,fee schedule,3239.17,14371.12,
Open tx post pelvic fxcture,G0415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4792.1,,,,,,,fee schedule,3239.17,14371.12,
Open tx post pelvic fxcture,G0415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3841.28,,,,,,,fee schedule,3239.17,14371.12,
Open tx post pelvic fxcture,G0415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4196.25,,,,,,,fee schedule,3239.17,14371.12,
Open tx post pelvic fxcture,G0415,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14371.12,,,,,,,fee schedule,3239.17,14371.12,APC 378
Open tx post pelvic fxcture,G0415,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3401.13,,,,,,,fee schedule,3239.17,14371.12,APC
Open tx post pelvic fxcture,G0415,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3368.74,,,,,,,fee schedule,3239.17,14371.12,APC
Open tx post pelvic fxcture,G0415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3239.17,,,,,,,fee schedule,3239.17,14371.12,APC
Open tx post pelvic fxcture,G0415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4955.94,,,,,,,fee schedule,3239.17,14371.12,Radiology
Open tx post pelvic fxcture,G0415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4534.84,,,,,,,fee schedule,3239.17,14371.12,APC
Open tx post pelvic fxcture,G0415,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5668.55,,,,,,,fee schedule,3239.17,14371.12,APC
"Prostate biopsy, any mthd",G0416,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1397.36,,,,,,,fee schedule,354.85,1574.35,
"Prostate biopsy, any mthd",G0416,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1517.82,,,,,,,fee schedule,354.85,1574.35,
"Prostate biopsy, any mthd",G0416,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1216.67,,,,,,,fee schedule,354.85,1574.35,
"Prostate biopsy, any mthd",G0416,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1329.1,,,,,,,fee schedule,354.85,1574.35,
"Prostate biopsy, any mthd",G0416,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1574.35,,,,,,,fee schedule,354.85,1574.35,APC 378
"Prostate biopsy, any mthd",G0416,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,372.59,,,,,,,fee schedule,354.85,1574.35,APC
"Prostate biopsy, any mthd",G0416,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,369.04,,,,,,,fee schedule,354.85,1574.35,APC
"Prostate biopsy, any mthd",G0416,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,354.85,,,,,,,fee schedule,354.85,1574.35,APC
"Prostate biopsy, any mthd",G0416,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,542.92,,,,,,,fee schedule,354.85,1574.35,Radiology
"Prostate biopsy, any mthd",G0416,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,496.79,,,,,,,fee schedule,354.85,1574.35,APC
"Prostate biopsy, any mthd",G0416,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,620.99,,,,,,,fee schedule,354.85,1574.35,APC
Ed svc CKD ind per session,G0420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,361.61,,,,,,,fee schedule,111.25,392.78,
Ed svc CKD ind per session,G0420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,392.78,,,,,,,fee schedule,111.25,392.78,
Ed svc CKD ind per session,G0420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,314.85,,,,,,,fee schedule,111.25,392.78,
Ed svc CKD ind per session,G0420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,343.94,,,,,,,fee schedule,111.25,392.78,
Ed svc CKD ind per session,G0420,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,111.25,,,,,,,fee schedule,111.25,392.78,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Ed svc CKD ind per session,G0420,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,116.81,,,,,,,fee schedule,111.25,392.78,APC
Ed svc CKD ind per session,G0420,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,115.7,,,,,,,fee schedule,111.25,392.78,APC
Ed svc CKD ind per session,G0420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,170.21,,,,,,,fee schedule,111.25,392.78,Radiology
Ed svc CKD ind per session,G0420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,155.75,,,,,,,fee schedule,111.25,392.78,APC
Ed svc CKD ind per session,G0420,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,194.69,,,,,,,fee schedule,111.25,392.78,APC
Ed svc CKD grp per session,G0421,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,84.42,,,,,,,fee schedule,26.79,91.7,
Ed svc CKD grp per session,G0421,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,91.7,,,,,,,fee schedule,26.79,91.7,
Ed svc CKD grp per session,G0421,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,73.51,,,,,,,fee schedule,26.79,91.7,
Ed svc CKD grp per session,G0421,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,80.3,,,,,,,fee schedule,26.79,91.7,
Ed svc CKD grp per session,G0421,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,26.79,,,,,,,fee schedule,26.79,91.7,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Ed svc CKD grp per session,G0421,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,28.13,,,,,,,fee schedule,26.79,91.7,APC
Ed svc CKD grp per session,G0421,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,27.86,,,,,,,fee schedule,26.79,91.7,APC
Ed svc CKD grp per session,G0421,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40.99,,,,,,,fee schedule,26.79,91.7,Radiology
Ed svc CKD grp per session,G0421,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,37.51,,,,,,,fee schedule,26.79,91.7,APC
Ed svc CKD grp per session,G0421,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,46.88,,,,,,,fee schedule,26.79,91.7,APC
Intens cardiac rehab w/exerc,G0422,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,278.09,,,,,,,fee schedule,127.61,566.18,
Intens cardiac rehab w/exerc,G0422,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,302.06,,,,,,,fee schedule,127.61,566.18,
Intens cardiac rehab w/exerc,G0422,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,242.13,,,,,,,fee schedule,127.61,566.18,
Intens cardiac rehab w/exerc,G0422,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,264.5,,,,,,,fee schedule,127.61,566.18,
Intens cardiac rehab w/exerc,G0422,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,566.18,,,,,,,fee schedule,127.61,566.18,APC 378
Intens cardiac rehab w/exerc,G0422,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134,,,,,,,fee schedule,127.61,566.18,APC
Intens cardiac rehab w/exerc,G0422,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,132.72,,,,,,,fee schedule,127.61,566.18,APC
Intens cardiac rehab w/exerc,G0422,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,127.61,,,,,,,fee schedule,127.61,566.18,APC
Intens cardiac rehab w/exerc,G0422,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,195.25,,,,,,,fee schedule,127.61,566.18,Radiology
Intens cardiac rehab w/exerc,G0422,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,178.66,,,,,,,fee schedule,127.61,566.18,APC
Intens cardiac rehab w/exerc,G0422,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,223.33,,,,,,,fee schedule,127.61,566.18,APC
Intens cardiac rehab no exer,G0423,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,278.09,,,,,,,fee schedule,127.61,566.18,
Intens cardiac rehab no exer,G0423,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,302.06,,,,,,,fee schedule,127.61,566.18,
Intens cardiac rehab no exer,G0423,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,242.13,,,,,,,fee schedule,127.61,566.18,
Intens cardiac rehab no exer,G0423,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,264.5,,,,,,,fee schedule,127.61,566.18,
Intens cardiac rehab no exer,G0423,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,566.18,,,,,,,fee schedule,127.61,566.18,APC 378
Intens cardiac rehab no exer,G0423,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,134,,,,,,,fee schedule,127.61,566.18,APC
Intens cardiac rehab no exer,G0423,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,132.72,,,,,,,fee schedule,127.61,566.18,APC
Intens cardiac rehab no exer,G0423,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,127.61,,,,,,,fee schedule,127.61,566.18,APC
Intens cardiac rehab no exer,G0423,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,195.25,,,,,,,fee schedule,127.61,566.18,Radiology
Intens cardiac rehab no exer,G0423,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,178.66,,,,,,,fee schedule,127.61,566.18,APC
Intens cardiac rehab no exer,G0423,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,223.33,,,,,,,fee schedule,127.61,566.18,APC
Inpt/ed teleconsult30,G0425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,337.53,,,,,,,fee schedule,293.88,366.62,
Inpt/ed teleconsult30,G0425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,366.62,,,,,,,fee schedule,293.88,366.62,
Inpt/ed teleconsult30,G0425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,293.88,,,,,,,fee schedule,293.88,366.62,
Inpt/ed teleconsult30,G0425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,321.04,,,,,,,fee schedule,293.88,366.62,
Inpt/ed teleconsult50,G0426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,457.55,,,,,,,fee schedule,398.38,496.99,
Inpt/ed teleconsult50,G0426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,496.99,,,,,,,fee schedule,398.38,496.99,
Inpt/ed teleconsult50,G0426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,398.38,,,,,,,fee schedule,398.38,496.99,
Inpt/ed teleconsult50,G0426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,435.2,,,,,,,fee schedule,398.38,496.99,
Inpt/ed teleconsult70,G0427,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,672.37,,,,,,,fee schedule,585.43,730.33,
Inpt/ed teleconsult70,G0427,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,730.33,,,,,,,fee schedule,585.43,730.33,
Inpt/ed teleconsult70,G0427,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,585.43,,,,,,,fee schedule,585.43,730.33,
Inpt/ed teleconsult70,G0427,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,639.53,,,,,,,fee schedule,585.43,730.33,
Dermal filler injection(s),G0429,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,244.05,,,,,,,fee schedule,212.49,9062.24,
Dermal filler injection(s),G0429,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,265.09,,,,,,,fee schedule,212.49,9062.24,
Dermal filler injection(s),G0429,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,212.49,,,,,,,fee schedule,212.49,9062.24,
Dermal filler injection(s),G0429,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,232.13,,,,,,,fee schedule,212.49,9062.24,
Dermal filler injection(s),G0429,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,212.49,9062.24,APC 378
Dermal filler injection(s),G0429,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,212.49,9062.24,APC
Dermal filler injection(s),G0429,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,212.49,9062.24,APC
Dermal filler injection(s),G0429,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,212.49,9062.24,APC
Dermal filler injection(s),G0429,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,212.49,9062.24,Radiology
Dermal filler injection(s),G0429,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,212.49,9062.24,APC
Dermal filler injection(s),G0429,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,212.49,9062.24,APC
EIA HIV-1/HIV-2 screen,G0432,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,65.6,,,,,,,fee schedule,17.61,71.25,
EIA HIV-1/HIV-2 screen,G0432,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,71.25,,,,,,,fee schedule,17.61,71.25,
EIA HIV-1/HIV-2 screen,G0432,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.12,,,,,,,fee schedule,17.61,71.25,
EIA HIV-1/HIV-2 screen,G0432,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,62.39,,,,,,,fee schedule,17.61,71.25,
EIA HIV-1/HIV-2 screen,G0432,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,17.61,,,,,,,fee schedule,17.61,71.25,Laboratory
EIA HIV-1/HIV-2 screen,G0432,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20.55,,,,,,,fee schedule,17.61,71.25,APC
EIA HIV-1/HIV-2 screen,G0432,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,20.35,,,,,,,fee schedule,17.61,71.25,APC
EIA HIV-1/HIV-2 screen,G0432,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,19.57,,,,,,,fee schedule,17.61,71.25,APC
EIA HIV-1/HIV-2 screen,G0432,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29.94,,,,,,,fee schedule,17.61,71.25,Radiology
EIA HIV-1/HIV-2 screen,G0432,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27.4,,,,,,,fee schedule,17.61,71.25,APC
EIA HIV-1/HIV-2 screen,G0432,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,34.25,,,,,,,fee schedule,17.61,71.25,APC
ELISA HIV-1/HIV-2 screen,G0433,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,65.6,,,,,,,fee schedule,16.46,71.25,
ELISA HIV-1/HIV-2 screen,G0433,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,71.25,,,,,,,fee schedule,16.46,71.25,
ELISA HIV-1/HIV-2 screen,G0433,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.12,,,,,,,fee schedule,16.46,71.25,
ELISA HIV-1/HIV-2 screen,G0433,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,62.39,,,,,,,fee schedule,16.46,71.25,
ELISA HIV-1/HIV-2 screen,G0433,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.46,,,,,,,fee schedule,16.46,71.25,Laboratory
ELISA HIV-1/HIV-2 screen,G0433,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.2,,,,,,,fee schedule,16.46,71.25,APC
ELISA HIV-1/HIV-2 screen,G0433,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,19.02,,,,,,,fee schedule,16.46,71.25,APC
ELISA HIV-1/HIV-2 screen,G0433,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18.29,,,,,,,fee schedule,16.46,71.25,APC
ELISA HIV-1/HIV-2 screen,G0433,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27.98,,,,,,,fee schedule,16.46,71.25,Radiology
ELISA HIV-1/HIV-2 screen,G0433,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.61,,,,,,,fee schedule,16.46,71.25,APC
ELISA HIV-1/HIV-2 screen,G0433,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,32.01,,,,,,,fee schedule,16.46,71.25,APC
Oral hiv-1/hiv-2 screen,G0435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,57.39,,,,,,,fee schedule,10.78,62.33,
Oral hiv-1/hiv-2 screen,G0435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,62.33,,,,,,,fee schedule,10.78,62.33,
Oral hiv-1/hiv-2 screen,G0435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,49.96,,,,,,,fee schedule,10.78,62.33,
Oral hiv-1/hiv-2 screen,G0435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,54.58,,,,,,,fee schedule,10.78,62.33,
Oral hiv-1/hiv-2 screen,G0435,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.78,,,,,,,fee schedule,10.78,62.33,Laboratory
Oral hiv-1/hiv-2 screen,G0435,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.58,,,,,,,fee schedule,10.78,62.33,APC
Oral hiv-1/hiv-2 screen,G0435,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.46,,,,,,,fee schedule,10.78,62.33,APC
Oral hiv-1/hiv-2 screen,G0435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11.98,,,,,,,fee schedule,10.78,62.33,APC
Oral hiv-1/hiv-2 screen,G0435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.33,,,,,,,fee schedule,10.78,62.33,Radiology
Oral hiv-1/hiv-2 screen,G0435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.77,,,,,,,fee schedule,10.78,62.33,APC
Oral hiv-1/hiv-2 screen,G0435,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20.96,,,,,,,fee schedule,10.78,62.33,APC
"PPPS, initial visit",G0438,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,565.43,,,,,,,fee schedule,168.7,614.17,
"PPPS, initial visit",G0438,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,614.17,,,,,,,fee schedule,168.7,614.17,
"PPPS, initial visit",G0438,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,492.31,,,,,,,fee schedule,168.7,614.17,
"PPPS, initial visit",G0438,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,537.81,,,,,,,fee schedule,168.7,614.17,
"PPPS, initial visit",G0438,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,168.7,,,,,,,fee schedule,168.7,614.17,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
"PPPS, initial visit",G0438,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,177.14,,,,,,,fee schedule,168.7,614.17,APC
"PPPS, initial visit",G0438,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,175.45,,,,,,,fee schedule,168.7,614.17,APC
"PPPS, initial visit",G0438,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,258.11,,,,,,,fee schedule,168.7,614.17,Radiology
"PPPS, initial visit",G0438,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,236.18,,,,,,,fee schedule,168.7,614.17,APC
"PPPS, initial visit",G0438,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,295.22,,,,,,,fee schedule,168.7,614.17,APC
"PPPS, subseq visit",G0439,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,372.01,,,,,,,fee schedule,132.75,404.08,
"PPPS, subseq visit",G0439,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,404.08,,,,,,,fee schedule,132.75,404.08,
"PPPS, subseq visit",G0439,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,323.91,,,,,,,fee schedule,132.75,404.08,
"PPPS, subseq visit",G0439,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.84,,,,,,,fee schedule,132.75,404.08,
"PPPS, subseq visit",G0439,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,132.75,,,,,,,fee schedule,132.75,404.08,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
"PPPS, subseq visit",G0439,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.39,,,,,,,fee schedule,132.75,404.08,APC
"PPPS, subseq visit",G0439,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,138.06,,,,,,,fee schedule,132.75,404.08,APC
"PPPS, subseq visit",G0439,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,203.11,,,,,,,fee schedule,132.75,404.08,Radiology
"PPPS, subseq visit",G0439,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,185.85,,,,,,,fee schedule,132.75,404.08,APC
"PPPS, subseq visit",G0439,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,232.31,,,,,,,fee schedule,132.75,404.08,APC
Annual alcohol screen 15 min,G0442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,156.11,,,,,,,fee schedule,37.09,169.57,
Annual alcohol screen 15 min,G0442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,169.57,,,,,,,fee schedule,37.09,169.57,
Annual alcohol screen 15 min,G0442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,135.93,,,,,,,fee schedule,37.09,169.57,
Annual alcohol screen 15 min,G0442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,148.49,,,,,,,fee schedule,37.09,169.57,
Annual alcohol screen 15 min,G0442,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.57,,,,,,,fee schedule,37.09,169.57,APC 378
Annual alcohol screen 15 min,G0442,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.95,,,,,,,fee schedule,37.09,169.57,APC
Annual alcohol screen 15 min,G0442,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.58,,,,,,,fee schedule,37.09,169.57,APC
Annual alcohol screen 15 min,G0442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,37.09,,,,,,,fee schedule,37.09,169.57,APC
Annual alcohol screen 15 min,G0442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.75,,,,,,,fee schedule,37.09,169.57,Radiology
Annual alcohol screen 15 min,G0442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.93,,,,,,,fee schedule,37.09,169.57,APC
Annual alcohol screen 15 min,G0442,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.91,,,,,,,fee schedule,37.09,169.57,APC
Brief alcohol misuse counsel,G0443,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,156.11,,,,,,,fee schedule,100.57,446.2,
Brief alcohol misuse counsel,G0443,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,169.57,,,,,,,fee schedule,100.57,446.2,
Brief alcohol misuse counsel,G0443,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,135.93,,,,,,,fee schedule,100.57,446.2,
Brief alcohol misuse counsel,G0443,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,148.49,,,,,,,fee schedule,100.57,446.2,
Brief alcohol misuse counsel,G0443,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,446.2,,,,,,,fee schedule,100.57,446.2,APC 378
Brief alcohol misuse counsel,G0443,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,105.6,,,,,,,fee schedule,100.57,446.2,APC
Brief alcohol misuse counsel,G0443,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,104.59,,,,,,,fee schedule,100.57,446.2,APC
Brief alcohol misuse counsel,G0443,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,100.57,,,,,,,fee schedule,100.57,446.2,APC
Brief alcohol misuse counsel,G0443,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,153.87,,,,,,,fee schedule,100.57,446.2,Radiology
Brief alcohol misuse counsel,G0443,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,140.8,,,,,,,fee schedule,100.57,446.2,APC
Brief alcohol misuse counsel,G0443,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,176,,,,,,,fee schedule,100.57,446.2,APC
Depression Screen annual,G0444,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,156.11,,,,,,,fee schedule,37.09,169.57,
Depression Screen annual,G0444,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,169.57,,,,,,,fee schedule,37.09,169.57,
Depression Screen annual,G0444,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,135.93,,,,,,,fee schedule,37.09,169.57,
Depression Screen annual,G0444,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,148.49,,,,,,,fee schedule,37.09,169.57,
Depression Screen annual,G0444,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.57,,,,,,,fee schedule,37.09,169.57,APC 378
Depression Screen annual,G0444,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.95,,,,,,,fee schedule,37.09,169.57,APC
Depression Screen annual,G0444,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.58,,,,,,,fee schedule,37.09,169.57,APC
Depression Screen annual,G0444,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,37.09,,,,,,,fee schedule,37.09,169.57,APC
Depression Screen annual,G0444,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.75,,,,,,,fee schedule,37.09,169.57,Radiology
Depression Screen annual,G0444,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.93,,,,,,,fee schedule,37.09,169.57,APC
Depression Screen annual,G0444,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.91,,,,,,,fee schedule,37.09,169.57,APC
High inten beh couns STD 30m,G0445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,156.11,,,,,,,fee schedule,100.57,446.2,
High inten beh couns STD 30m,G0445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,169.57,,,,,,,fee schedule,100.57,446.2,
High inten beh couns STD 30m,G0445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,135.93,,,,,,,fee schedule,100.57,446.2,
High inten beh couns STD 30m,G0445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,148.49,,,,,,,fee schedule,100.57,446.2,
High inten beh couns STD 30m,G0445,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,446.2,,,,,,,fee schedule,100.57,446.2,APC 378
High inten beh couns STD 30m,G0445,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,105.6,,,,,,,fee schedule,100.57,446.2,APC
High inten beh couns STD 30m,G0445,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,104.59,,,,,,,fee schedule,100.57,446.2,APC
High inten beh couns STD 30m,G0445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,100.57,,,,,,,fee schedule,100.57,446.2,APC
High inten beh couns STD 30m,G0445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,153.87,,,,,,,fee schedule,100.57,446.2,Radiology
High inten beh couns STD 30m,G0445,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,140.8,,,,,,,fee schedule,100.57,446.2,APC
High inten beh couns STD 30m,G0445,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,176,,,,,,,fee schedule,100.57,446.2,APC
Intens behave ther cardio dx,G0446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,156.11,,,,,,,fee schedule,37.09,169.57,
Intens behave ther cardio dx,G0446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,169.57,,,,,,,fee schedule,37.09,169.57,
Intens behave ther cardio dx,G0446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,135.93,,,,,,,fee schedule,37.09,169.57,
Intens behave ther cardio dx,G0446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,148.49,,,,,,,fee schedule,37.09,169.57,
Intens behave ther cardio dx,G0446,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.57,,,,,,,fee schedule,37.09,169.57,APC 378
Intens behave ther cardio dx,G0446,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.95,,,,,,,fee schedule,37.09,169.57,APC
Intens behave ther cardio dx,G0446,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.58,,,,,,,fee schedule,37.09,169.57,APC
Intens behave ther cardio dx,G0446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,37.09,,,,,,,fee schedule,37.09,169.57,APC
Intens behave ther cardio dx,G0446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.75,,,,,,,fee schedule,37.09,169.57,Radiology
Intens behave ther cardio dx,G0446,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.93,,,,,,,fee schedule,37.09,169.57,APC
Intens behave ther cardio dx,G0446,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.91,,,,,,,fee schedule,37.09,169.57,APC
Behavior counsel obesity 15m,G0447,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,156.11,,,,,,,fee schedule,100.57,446.2,
Behavior counsel obesity 15m,G0447,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,169.57,,,,,,,fee schedule,100.57,446.2,
Behavior counsel obesity 15m,G0447,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,135.93,,,,,,,fee schedule,100.57,446.2,
Behavior counsel obesity 15m,G0447,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,148.49,,,,,,,fee schedule,100.57,446.2,
Behavior counsel obesity 15m,G0447,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,446.2,,,,,,,fee schedule,100.57,446.2,APC 378
Behavior counsel obesity 15m,G0447,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,105.6,,,,,,,fee schedule,100.57,446.2,APC
Behavior counsel obesity 15m,G0447,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,104.59,,,,,,,fee schedule,100.57,446.2,APC
Behavior counsel obesity 15m,G0447,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,100.57,,,,,,,fee schedule,100.57,446.2,APC
Behavior counsel obesity 15m,G0447,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,153.87,,,,,,,fee schedule,100.57,446.2,Radiology
Behavior counsel obesity 15m,G0447,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,140.8,,,,,,,fee schedule,100.57,446.2,APC
Behavior counsel obesity 15m,G0447,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,176,,,,,,,fee schedule,100.57,446.2,APC
Devlopment test interpt&rep,G0451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,156.11,,,,,,,fee schedule,100.57,446.2,
Devlopment test interpt&rep,G0451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,169.57,,,,,,,fee schedule,100.57,446.2,
Devlopment test interpt&rep,G0451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,135.93,,,,,,,fee schedule,100.57,446.2,
Devlopment test interpt&rep,G0451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,148.49,,,,,,,fee schedule,100.57,446.2,
Devlopment test interpt&rep,G0451,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,446.2,,,,,,,fee schedule,100.57,446.2,APC 378
Devlopment test interpt&rep,G0451,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,105.6,,,,,,,fee schedule,100.57,446.2,APC
Devlopment test interpt&rep,G0451,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,104.59,,,,,,,fee schedule,100.57,446.2,APC
Devlopment test interpt&rep,G0451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,100.57,,,,,,,fee schedule,100.57,446.2,APC
Devlopment test interpt&rep,G0451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,153.87,,,,,,,fee schedule,100.57,446.2,Radiology
Devlopment test interpt&rep,G0451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,140.8,,,,,,,fee schedule,100.57,446.2,APC
Devlopment test interpt&rep,G0451,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,176,,,,,,,fee schedule,100.57,446.2,APC
Molecular pathology interpr,G0452,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,63.61,,,,,,,fee schedule,55.39,69.1,
Molecular pathology interpr,G0452,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,69.1,,,,,,,fee schedule,55.39,69.1,
Molecular pathology interpr,G0452,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55.39,,,,,,,fee schedule,55.39,69.1,
Molecular pathology interpr,G0452,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,60.51,,,,,,,fee schedule,55.39,69.1,
Cont intraop neuro monitor,G0453,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,88.77,,,,,,,fee schedule,77.3,96.43,
Cont intraop neuro monitor,G0453,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,96.43,,,,,,,fee schedule,77.3,96.43,
Cont intraop neuro monitor,G0453,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,77.3,,,,,,,fee schedule,77.3,96.43,
Cont intraop neuro monitor,G0453,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,84.44,,,,,,,fee schedule,77.3,96.43,
MD document visit by NPP,G0454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30.07,,,,,,,fee schedule,26.18,32.66,
MD document visit by NPP,G0454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,32.66,,,,,,,fee schedule,26.18,32.66,
MD document visit by NPP,G0454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26.18,,,,,,,fee schedule,26.18,32.66,
MD document visit by NPP,G0454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28.6,,,,,,,fee schedule,26.18,32.66,
Fecal microbiota prep instil,G0455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,172.75,,,,,,,fee schedule,150.41,4084.51,
Fecal microbiota prep instil,G0455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,187.64,,,,,,,fee schedule,150.41,4084.51,
Fecal microbiota prep instil,G0455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,150.41,,,,,,,fee schedule,150.41,4084.51,
Fecal microbiota prep instil,G0455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,164.31,,,,,,,fee schedule,150.41,4084.51,
Fecal microbiota prep instil,G0455,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4084.51,,,,,,,fee schedule,150.41,4084.51,APC 378
Fecal microbiota prep instil,G0455,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,966.66,,,,,,,fee schedule,150.41,4084.51,APC
Fecal microbiota prep instil,G0455,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,957.45,,,,,,,fee schedule,150.41,4084.51,APC
Fecal microbiota prep instil,G0455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,920.63,,,,,,,fee schedule,150.41,4084.51,APC
Fecal microbiota prep instil,G0455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1408.56,,,,,,,fee schedule,150.41,4084.51,Radiology
Fecal microbiota prep instil,G0455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1288.88,,,,,,,fee schedule,150.41,4084.51,APC
Fecal microbiota prep instil,G0455,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1611.1,,,,,,,fee schedule,150.41,4084.51,APC
Telehealth inpt pharm mgmt,G0459,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,141.98,,,,,,,fee schedule,123.62,154.22,
Telehealth inpt pharm mgmt,G0459,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,154.22,,,,,,,fee schedule,123.62,154.22,
Telehealth inpt pharm mgmt,G0459,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,123.62,,,,,,,fee schedule,123.62,154.22,
Telehealth inpt pharm mgmt,G0459,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,135.05,,,,,,,fee schedule,123.62,154.22,
Autologous PRP for ulcers,G0460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,248.96,,,,,,,fee schedule,216.77,9062.24,
Autologous PRP for ulcers,G0460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,270.42,,,,,,,fee schedule,216.77,9062.24,
Autologous PRP for ulcers,G0460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,216.77,,,,,,,fee schedule,216.77,9062.24,
Autologous PRP for ulcers,G0460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,236.8,,,,,,,fee schedule,216.77,9062.24,
Autologous PRP for ulcers,G0460,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,216.77,9062.24,APC 378
Autologous PRP for ulcers,G0460,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,216.77,9062.24,APC
Autologous PRP for ulcers,G0460,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,216.77,9062.24,APC
Autologous PRP for ulcers,G0460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,216.77,9062.24,APC
Autologous PRP for ulcers,G0460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,216.77,9062.24,Radiology
Autologous PRP for ulcers,G0460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,216.77,9062.24,APC
Autologous PRP for ulcers,G0460,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,216.77,9062.24,APC
Hospital outpt clinic visit,G0463,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,223.12,,,,,,,fee schedule,131.8,584.75,
Hospital outpt clinic visit,G0463,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,242.35,,,,,,,fee schedule,131.8,584.75,
Hospital outpt clinic visit,G0463,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,194.27,,,,,,,fee schedule,131.8,584.75,
Hospital outpt clinic visit,G0463,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,212.22,,,,,,,fee schedule,131.8,584.75,
Hospital outpt clinic visit,G0463,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.75,,,,,,,fee schedule,131.8,584.75,APC 378
Hospital outpt clinic visit,G0463,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.39,,,,,,,fee schedule,131.8,584.75,APC
Hospital outpt clinic visit,G0463,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,137.07,,,,,,,fee schedule,131.8,584.75,APC
Hospital outpt clinic visit,G0463,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.8,,,,,,,fee schedule,131.8,584.75,APC
Hospital outpt clinic visit,G0463,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.66,,,,,,,fee schedule,131.8,584.75,Radiology
Hospital outpt clinic visit,G0463,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.52,,,,,,,fee schedule,131.8,584.75,APC
Hospital outpt clinic visit,G0463,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.65,,,,,,,fee schedule,131.8,584.75,APC
Autolog prp diab wound ulcer,G0465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6087.42,,,,,,,fee schedule,2042.58,9062.24,
Autolog prp diab wound ulcer,G0465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6612.2,,,,,,,fee schedule,2042.58,9062.24,
Autolog prp diab wound ulcer,G0465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5300.26,,,,,,,fee schedule,2042.58,9062.24,
Autolog prp diab wound ulcer,G0465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5790.05,,,,,,,fee schedule,2042.58,9062.24,
Autolog prp diab wound ulcer,G0465,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9062.24,,,,,,,fee schedule,2042.58,9062.24,APC 378
Autolog prp diab wound ulcer,G0465,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.71,,,,,,,fee schedule,2042.58,9062.24,APC
Autolog prp diab wound ulcer,G0465,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2124.28,,,,,,,fee schedule,2042.58,9062.24,APC
Autolog prp diab wound ulcer,G0465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.58,,,,,,,fee schedule,2042.58,9062.24,APC
Autolog prp diab wound ulcer,G0465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3125.15,,,,,,,fee schedule,2042.58,9062.24,Radiology
Autolog prp diab wound ulcer,G0465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859.61,,,,,,,fee schedule,2042.58,9062.24,APC
Autolog prp diab wound ulcer,G0465,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3574.52,,,,,,,fee schedule,2042.58,9062.24,APC
Ven blood coll snf/hha,G0471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17.4,,,,,,,fee schedule,10.21,19.84,
Ven blood coll snf/hha,G0471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18.9,,,,,,,fee schedule,10.21,19.84,
Ven blood coll snf/hha,G0471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15.15,,,,,,,fee schedule,10.21,19.84,
Ven blood coll snf/hha,G0471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.55,,,,,,,fee schedule,10.21,19.84,
Ven blood coll snf/hha,G0471,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.21,,,,,,,fee schedule,10.21,19.84,Laboratory
Ven blood coll snf/hha,G0471,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.91,,,,,,,fee schedule,10.21,19.84,APC
Ven blood coll snf/hha,G0471,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11.79,,,,,,,fee schedule,10.21,19.84,APC
Ven blood coll snf/hha,G0471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11.34,,,,,,,fee schedule,10.21,19.84,APC
Ven blood coll snf/hha,G0471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.35,,,,,,,fee schedule,10.21,19.84,Radiology
Ven blood coll snf/hha,G0471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15.88,,,,,,,fee schedule,10.21,19.84,APC
Ven blood coll snf/hha,G0471,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19.84,,,,,,,fee schedule,10.21,19.84,APC
Hep c screen high risk/other,G0472,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,41.72,,,,,,,fee schedule,41.72,81.11,Laboratory
Hep c screen high risk/other,G0472,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,48.67,,,,,,,fee schedule,41.72,81.11,APC
Hep c screen high risk/other,G0472,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,48.2,,,,,,,fee schedule,41.72,81.11,APC
Hep c screen high risk/other,G0472,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,46.35,,,,,,,fee schedule,41.72,81.11,APC
Hep c screen high risk/other,G0472,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,70.92,,,,,,,fee schedule,41.72,81.11,Radiology
Hep c screen high risk/other,G0472,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,64.89,,,,,,,fee schedule,41.72,81.11,APC
Hep c screen high risk/other,G0472,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,81.11,,,,,,,fee schedule,41.72,81.11,APC
Group behave couns 2-10,G0473,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,174.84,,,,,,,fee schedule,37.09,189.91,
Group behave couns 2-10,G0473,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,189.91,,,,,,,fee schedule,37.09,189.91,
Group behave couns 2-10,G0473,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,152.23,,,,,,,fee schedule,37.09,189.91,
Group behave couns 2-10,G0473,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,166.29,,,,,,,fee schedule,37.09,189.91,
Group behave couns 2-10,G0473,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.57,,,,,,,fee schedule,37.09,189.91,APC 378
Group behave couns 2-10,G0473,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.95,,,,,,,fee schedule,37.09,189.91,APC
Group behave couns 2-10,G0473,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.58,,,,,,,fee schedule,37.09,189.91,APC
Group behave couns 2-10,G0473,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,37.09,,,,,,,fee schedule,37.09,189.91,APC
Group behave couns 2-10,G0473,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.75,,,,,,,fee schedule,37.09,189.91,Radiology
Group behave couns 2-10,G0473,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.93,,,,,,,fee schedule,37.09,189.91,APC
Group behave couns 2-10,G0473,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.91,,,,,,,fee schedule,37.09,189.91,APC
Hiv combination assay,G0475,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,21.67,,,,,,,fee schedule,21.67,42.14,Laboratory
Hiv combination assay,G0475,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,25.28,,,,,,,fee schedule,21.67,42.14,APC
Hiv combination assay,G0475,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,25.04,,,,,,,fee schedule,21.67,42.14,APC
Hiv combination assay,G0475,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,24.08,,,,,,,fee schedule,21.67,42.14,APC
Hiv combination assay,G0475,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,36.84,,,,,,,fee schedule,21.67,42.14,Radiology
Hiv combination assay,G0475,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,33.71,,,,,,,fee schedule,21.67,42.14,APC
Hiv combination assay,G0475,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,42.14,,,,,,,fee schedule,21.67,42.14,APC
Hpv combo assay ca screen,G0476,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31.58,,,,,,,fee schedule,31.58,61.41,Laboratory
Hpv combo assay ca screen,G0476,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,31.58,61.41,APC
Hpv combo assay ca screen,G0476,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,36.49,,,,,,,fee schedule,31.58,61.41,APC
Hpv combo assay ca screen,G0476,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,35.09,,,,,,,fee schedule,31.58,61.41,APC
Hpv combo assay ca screen,G0476,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,53.69,,,,,,,fee schedule,31.58,61.41,Radiology
Hpv combo assay ca screen,G0476,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49.13,,,,,,,fee schedule,31.58,61.41,APC
Hpv combo assay ca screen,G0476,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,61.41,,,,,,,fee schedule,31.58,61.41,APC
Drug test def 1-7 classes,G0480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,245.06,,,,,,,fee schedule,102.99,266.19,
Drug test def 1-7 classes,G0480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,266.19,,,,,,,fee schedule,102.99,266.19,
Drug test def 1-7 classes,G0480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,213.37,,,,,,,fee schedule,102.99,266.19,
Drug test def 1-7 classes,G0480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,233.09,,,,,,,fee schedule,102.99,266.19,
Drug test def 1-7 classes,G0480,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,102.99,,,,,,,fee schedule,102.99,266.19,Laboratory
Drug test def 1-7 classes,G0480,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,120.15,,,,,,,fee schedule,102.99,266.19,APC
Drug test def 1-7 classes,G0480,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,119.01,,,,,,,fee schedule,102.99,266.19,APC
Drug test def 1-7 classes,G0480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,114.43,,,,,,,fee schedule,102.99,266.19,APC
Drug test def 1-7 classes,G0480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,175.08,,,,,,,fee schedule,102.99,266.19,Radiology
Drug test def 1-7 classes,G0480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,160.2,,,,,,,fee schedule,102.99,266.19,APC
Drug test def 1-7 classes,G0480,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,200.25,,,,,,,fee schedule,102.99,266.19,APC
Drug test def 8-14 classes,G0481,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,560.25,,,,,,,fee schedule,140.93,608.54,
Drug test def 8-14 classes,G0481,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,608.54,,,,,,,fee schedule,140.93,608.54,
Drug test def 8-14 classes,G0481,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,487.8,,,,,,,fee schedule,140.93,608.54,
Drug test def 8-14 classes,G0481,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,532.88,,,,,,,fee schedule,140.93,608.54,
Drug test def 8-14 classes,G0481,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,140.93,,,,,,,fee schedule,140.93,608.54,Laboratory
Drug test def 8-14 classes,G0481,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,164.42,,,,,,,fee schedule,140.93,608.54,APC
Drug test def 8-14 classes,G0481,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,162.85,,,,,,,fee schedule,140.93,608.54,APC
Drug test def 8-14 classes,G0481,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,156.59,,,,,,,fee schedule,140.93,608.54,APC
Drug test def 8-14 classes,G0481,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,239.58,,,,,,,fee schedule,140.93,608.54,Radiology
Drug test def 8-14 classes,G0481,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,219.23,,,,,,,fee schedule,140.93,608.54,APC
Drug test def 8-14 classes,G0481,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,274.03,,,,,,,fee schedule,140.93,608.54,APC
Drug test def 15-21 classes,G0482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,711.1,,,,,,,fee schedule,178.87,772.41,
Drug test def 15-21 classes,G0482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,772.41,,,,,,,fee schedule,178.87,772.41,
Drug test def 15-21 classes,G0482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,619.15,,,,,,,fee schedule,178.87,772.41,
Drug test def 15-21 classes,G0482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,676.37,,,,,,,fee schedule,178.87,772.41,
Drug test def 15-21 classes,G0482,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,178.87,,,,,,,fee schedule,178.87,772.41,Laboratory
Drug test def 15-21 classes,G0482,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.68,,,,,,,fee schedule,178.87,772.41,APC
Drug test def 15-21 classes,G0482,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,206.69,,,,,,,fee schedule,178.87,772.41,APC
Drug test def 15-21 classes,G0482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.74,,,,,,,fee schedule,178.87,772.41,APC
Drug test def 15-21 classes,G0482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,304.07,,,,,,,fee schedule,178.87,772.41,Radiology
Drug test def 15-21 classes,G0482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,278.24,,,,,,,fee schedule,178.87,772.41,APC
Drug test def 15-21 classes,G0482,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,347.8,,,,,,,fee schedule,178.87,772.41,APC
Drug test def 22+ classes,G0483,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,883.47,,,,,,,fee schedule,222.23,959.63,
Drug test def 22+ classes,G0483,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,959.63,,,,,,,fee schedule,222.23,959.63,
Drug test def 22+ classes,G0483,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,769.23,,,,,,,fee schedule,222.23,959.63,
Drug test def 22+ classes,G0483,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,840.31,,,,,,,fee schedule,222.23,959.63,
Drug test def 22+ classes,G0483,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,222.23,,,,,,,fee schedule,222.23,959.63,Laboratory
Drug test def 22+ classes,G0483,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,259.27,,,,,,,fee schedule,222.23,959.63,APC
Drug test def 22+ classes,G0483,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,256.8,,,,,,,fee schedule,222.23,959.63,APC
Drug test def 22+ classes,G0483,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,246.92,,,,,,,fee schedule,222.23,959.63,APC
Drug test def 22+ classes,G0483,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,377.79,,,,,,,fee schedule,222.23,959.63,Radiology
Drug test def 22+ classes,G0483,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,345.69,,,,,,,fee schedule,222.23,959.63,APC
Drug test def 22+ classes,G0483,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,432.11,,,,,,,fee schedule,222.23,959.63,APC
Chemo extend iv infus w/pump,G0498,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,972.49,,,,,,,fee schedule,326.99,1450.75,
Chemo extend iv infus w/pump,G0498,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1056.32,,,,,,,fee schedule,326.99,1450.75,
Chemo extend iv infus w/pump,G0498,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,846.73,,,,,,,fee schedule,326.99,1450.75,
Chemo extend iv infus w/pump,G0498,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,924.98,,,,,,,fee schedule,326.99,1450.75,
Chemo extend iv infus w/pump,G0498,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1450.75,,,,,,,fee schedule,326.99,1450.75,APC 378
Chemo extend iv infus w/pump,G0498,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,343.34,,,,,,,fee schedule,326.99,1450.75,APC
Chemo extend iv infus w/pump,G0498,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,340.07,,,,,,,fee schedule,326.99,1450.75,APC
Chemo extend iv infus w/pump,G0498,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,326.99,,,,,,,fee schedule,326.99,1450.75,APC
Chemo extend iv infus w/pump,G0498,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,500.3,,,,,,,fee schedule,326.99,1450.75,Radiology
Chemo extend iv infus w/pump,G0498,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,457.79,,,,,,,fee schedule,326.99,1450.75,APC
Chemo extend iv infus w/pump,G0498,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,572.24,,,,,,,fee schedule,326.99,1450.75,APC
Hepb screen high risk indiv,G0499,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,25.44,,,,,,,fee schedule,25.44,49.47,Laboratory
Hepb screen high risk indiv,G0499,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,29.68,,,,,,,fee schedule,25.44,49.47,APC
Hepb screen high risk indiv,G0499,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,29.4,,,,,,,fee schedule,25.44,49.47,APC
Hepb screen high risk indiv,G0499,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,28.27,,,,,,,fee schedule,25.44,49.47,APC
Hepb screen high risk indiv,G0499,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43.25,,,,,,,fee schedule,25.44,49.47,Radiology
Hepb screen high risk indiv,G0499,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,39.58,,,,,,,fee schedule,25.44,49.47,APC
Hepb screen high risk indiv,G0499,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,49.47,,,,,,,fee schedule,25.44,49.47,APC
Mod sedat endo service >5yrs,G0500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20.09,,,,,,,fee schedule,17.49,21.82,
Mod sedat endo service >5yrs,G0500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21.82,,,,,,,fee schedule,17.49,21.82,
Mod sedat endo service >5yrs,G0500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17.49,,,,,,,fee schedule,17.49,21.82,
Mod sedat endo service >5yrs,G0500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19.11,,,,,,,fee schedule,17.49,21.82,
Comp asses care plan ccm svc,G0506,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,159.04,,,,,,,fee schedule,138.48,172.75,
Comp asses care plan ccm svc,G0506,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,172.75,,,,,,,fee schedule,138.48,172.75,
Comp asses care plan ccm svc,G0506,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,138.48,,,,,,,fee schedule,138.48,172.75,
Comp asses care plan ccm svc,G0506,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,151.27,,,,,,,fee schedule,138.48,172.75,
Crit care telehea consult 60,G0508,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,694.14,,,,,,,fee schedule,604.38,753.98,
Crit care telehea consult 60,G0508,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,753.98,,,,,,,fee schedule,604.38,753.98,
Crit care telehea consult 60,G0508,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,604.38,,,,,,,fee schedule,604.38,753.98,
Crit care telehea consult 60,G0508,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,660.23,,,,,,,fee schedule,604.38,753.98,
Crit care telehea consult 50,G0509,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,669.4,,,,,,,fee schedule,582.84,727.11,
Crit care telehea consult 50,G0509,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,727.11,,,,,,,fee schedule,582.84,727.11,
Crit care telehea consult 50,G0509,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,582.84,,,,,,,fee schedule,582.84,727.11,
Crit care telehea consult 50,G0509,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,636.7,,,,,,,fee schedule,582.84,727.11,
"Prolong prev svcs, first 30m",G0513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,213.85,,,,,,,fee schedule,186.19,232.28,
"Prolong prev svcs, first 30m",G0513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,232.28,,,,,,,fee schedule,186.19,232.28,
"Prolong prev svcs, first 30m",G0513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,186.19,,,,,,,fee schedule,186.19,232.28,
"Prolong prev svcs, first 30m",G0513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,203.4,,,,,,,fee schedule,186.19,232.28,
"Prolong prev svcs, addl 30m",G0514,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,213.46,,,,,,,fee schedule,185.86,231.87,
"Prolong prev svcs, addl 30m",G0514,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,231.87,,,,,,,fee schedule,185.86,231.87,
"Prolong prev svcs, addl 30m",G0514,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,185.86,,,,,,,fee schedule,185.86,231.87,
"Prolong prev svcs, addl 30m",G0514,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,203.04,,,,,,,fee schedule,185.86,231.87,
"Insert drug del implant, >4",G0516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1211.6,,,,,,,fee schedule,442.24,1962.08,
"Insert drug del implant, >4",G0516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1316.04,,,,,,,fee schedule,442.24,1962.08,
"Insert drug del implant, >4",G0516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1054.92,,,,,,,fee schedule,442.24,1962.08,
"Insert drug del implant, >4",G0516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1152.41,,,,,,,fee schedule,442.24,1962.08,
"Insert drug del implant, >4",G0516,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1962.08,,,,,,,fee schedule,442.24,1962.08,APC 378
"Insert drug del implant, >4",G0516,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,464.35,,,,,,,fee schedule,442.24,1962.08,APC
"Insert drug del implant, >4",G0516,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,459.93,,,,,,,fee schedule,442.24,1962.08,APC
"Insert drug del implant, >4",G0516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,442.24,,,,,,,fee schedule,442.24,1962.08,APC
"Insert drug del implant, >4",G0516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,676.63,,,,,,,fee schedule,442.24,1962.08,Radiology
"Insert drug del implant, >4",G0516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,619.14,,,,,,,fee schedule,442.24,1962.08,APC
"Insert drug del implant, >4",G0516,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,773.92,,,,,,,fee schedule,442.24,1962.08,APC
Remove drug implant,G0517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1211.6,,,,,,,fee schedule,442.24,1962.08,
Remove drug implant,G0517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1316.04,,,,,,,fee schedule,442.24,1962.08,
Remove drug implant,G0517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1054.92,,,,,,,fee schedule,442.24,1962.08,
Remove drug implant,G0517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1152.41,,,,,,,fee schedule,442.24,1962.08,
Remove drug implant,G0517,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1962.08,,,,,,,fee schedule,442.24,1962.08,APC 378
Remove drug implant,G0517,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,464.35,,,,,,,fee schedule,442.24,1962.08,APC
Remove drug implant,G0517,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,459.93,,,,,,,fee schedule,442.24,1962.08,APC
Remove drug implant,G0517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,442.24,,,,,,,fee schedule,442.24,1962.08,APC
Remove drug implant,G0517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,676.63,,,,,,,fee schedule,442.24,1962.08,Radiology
Remove drug implant,G0517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,619.14,,,,,,,fee schedule,442.24,1962.08,APC
Remove drug implant,G0517,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,773.92,,,,,,,fee schedule,442.24,1962.08,APC
Remove w insert drug implant,G0518,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1211.6,,,,,,,fee schedule,442.24,1962.08,
Remove w insert drug implant,G0518,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1316.04,,,,,,,fee schedule,442.24,1962.08,
Remove w insert drug implant,G0518,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1054.92,,,,,,,fee schedule,442.24,1962.08,
Remove w insert drug implant,G0518,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1152.41,,,,,,,fee schedule,442.24,1962.08,
Remove w insert drug implant,G0518,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1962.08,,,,,,,fee schedule,442.24,1962.08,APC 378
Remove w insert drug implant,G0518,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,464.35,,,,,,,fee schedule,442.24,1962.08,APC
Remove w insert drug implant,G0518,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,459.93,,,,,,,fee schedule,442.24,1962.08,APC
Remove w insert drug implant,G0518,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,442.24,,,,,,,fee schedule,442.24,1962.08,APC
Remove w insert drug implant,G0518,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,676.63,,,,,,,fee schedule,442.24,1962.08,Radiology
Remove w insert drug implant,G0518,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,619.14,,,,,,,fee schedule,442.24,1962.08,APC
Remove w insert drug implant,G0518,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,773.92,,,,,,,fee schedule,442.24,1962.08,APC
Initial care training 30 m,G0539,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,39.32,,,,,,,fee schedule,39.32,68.81,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Initial care training 30 m,G0539,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,41.29,,,,,,,fee schedule,39.32,68.81,APC
Initial care training 30 m,G0539,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,40.89,,,,,,,fee schedule,39.32,68.81,APC
Initial care training 30 m,G0539,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,60.16,,,,,,,fee schedule,39.32,68.81,Radiology
Initial care training 30 m,G0539,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,55.05,,,,,,,fee schedule,39.32,68.81,APC
Initial care training 30 m,G0539,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,68.81,,,,,,,fee schedule,39.32,68.81,APC
Train for caregiver add 15,G0540,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,20.79,,,,,,,fee schedule,20.79,36.38,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Train for caregiver add 15,G0540,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.83,,,,,,,fee schedule,20.79,36.38,APC
Train for caregiver add 15,G0540,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,21.62,,,,,,,fee schedule,20.79,36.38,APC
Train for caregiver add 15,G0540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,31.81,,,,,,,fee schedule,20.79,36.38,Radiology
Train for caregiver add 15,G0540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29.11,,,,,,,fee schedule,20.79,36.38,APC
Train for caregiver add 15,G0540,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,36.38,,,,,,,fee schedule,20.79,36.38,APC
No pt prsnt train initial 30,G0541,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,127.04,,,,,,,fee schedule,28.63,127.04,APC 378
No pt prsnt train initial 30,G0541,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.07,,,,,,,fee schedule,28.63,127.04,APC
No pt prsnt train initial 30,G0541,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,29.78,,,,,,,fee schedule,28.63,127.04,APC
No pt prsnt train initial 30,G0541,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,28.63,,,,,,,fee schedule,28.63,127.04,APC
No pt prsnt train initial 30,G0541,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43.81,,,,,,,fee schedule,28.63,127.04,Radiology
No pt prsnt train initial 30,G0541,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40.09,,,,,,,fee schedule,28.63,127.04,APC
No pt prsnt train initial 30,G0541,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,50.11,,,,,,,fee schedule,28.63,127.04,APC
Group train w/o patient,G0543,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,127.04,,,,,,,fee schedule,28.63,127.04,APC 378
Group train w/o patient,G0543,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.07,,,,,,,fee schedule,28.63,127.04,APC
Group train w/o patient,G0543,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,29.78,,,,,,,fee schedule,28.63,127.04,APC
Group train w/o patient,G0543,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,28.63,,,,,,,fee schedule,28.63,127.04,APC
Group train w/o patient,G0543,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43.81,,,,,,,fee schedule,28.63,127.04,Radiology
Group train w/o patient,G0543,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40.09,,,,,,,fee schedule,28.63,127.04,APC
Group train w/o patient,G0543,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,50.11,,,,,,,fee schedule,28.63,127.04,APC
Supply of digital device,G0552,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.75,,,,,,,fee schedule,131.8,584.75,APC 378
Supply of digital device,G0552,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.39,,,,,,,fee schedule,131.8,584.75,APC
Supply of digital device,G0552,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,137.07,,,,,,,fee schedule,131.8,584.75,APC
Supply of digital device,G0552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.8,,,,,,,fee schedule,131.8,584.75,APC
Supply of digital device,G0552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.66,,,,,,,fee schedule,131.8,584.75,Radiology
Supply of digital device,G0552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.52,,,,,,,fee schedule,131.8,584.75,APC
Supply of digital device,G0552,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.65,,,,,,,fee schedule,131.8,584.75,APC
Monthly tx for dmht 20mins,G0553,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,584.75,,,,,,,fee schedule,131.8,584.75,APC 378
Monthly tx for dmht 20mins,G0553,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.39,,,,,,,fee schedule,131.8,584.75,APC
Monthly tx for dmht 20mins,G0553,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,137.07,,,,,,,fee schedule,131.8,584.75,APC
Monthly tx for dmht 20mins,G0553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.8,,,,,,,fee schedule,131.8,584.75,APC
Monthly tx for dmht 20mins,G0553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.66,,,,,,,fee schedule,131.8,584.75,Radiology
Monthly tx for dmht 20mins,G0553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.52,,,,,,,fee schedule,131.8,584.75,APC
Monthly tx for dmht 20mins,G0553,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.65,,,,,,,fee schedule,131.8,584.75,APC
Replacment pt electronic sys,G0555,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3771.72,,,,,,,fee schedule,850.12,3771.72,APC 378
Replacment pt electronic sys,G0555,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,892.63,,,,,,,fee schedule,850.12,3771.72,APC
Replacment pt electronic sys,G0555,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,884.13,,,,,,,fee schedule,850.12,3771.72,APC
Replacment pt electronic sys,G0555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,850.12,,,,,,,fee schedule,850.12,3771.72,APC
Replacment pt electronic sys,G0555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1300.69,,,,,,,fee schedule,850.12,3771.72,Radiology
Replacment pt electronic sys,G0555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1190.17,,,,,,,fee schedule,850.12,3771.72,APC
Replacment pt electronic sys,G0555,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1487.72,,,,,,,fee schedule,850.12,3771.72,APC
Safety plan interven,G0560,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,39.26,,,,,,,fee schedule,39.26,68.7,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
Safety plan interven,G0560,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,41.22,,,,,,,fee schedule,39.26,68.7,APC
Safety plan interven,G0560,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,40.83,,,,,,,fee schedule,39.26,68.7,APC
Safety plan interven,G0560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,60.07,,,,,,,fee schedule,39.26,68.7,Radiology
Safety plan interven,G0560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,54.96,,,,,,,fee schedule,39.26,68.7,APC
Safety plan interven,G0560,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,68.7,,,,,,,fee schedule,39.26,68.7,APC
3d bn img algor drvd fr mri,G0566,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,565.15,,,,,,,fee schedule,127.38,565.15,APC 378
3d bn img algor drvd fr mri,G0566,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,133.75,,,,,,,fee schedule,127.38,565.15,APC
3d bn img algor drvd fr mri,G0566,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,132.48,,,,,,,fee schedule,127.38,565.15,APC
3d bn img algor drvd fr mri,G0566,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,127.38,,,,,,,fee schedule,127.38,565.15,APC
3d bn img algor drvd fr mri,G0566,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,194.89,,,,,,,fee schedule,127.38,565.15,Radiology
3d bn img algor drvd fr mri,G0566,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,178.33,,,,,,,fee schedule,127.38,565.15,APC
3d bn img algor drvd fr mri,G0566,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,222.92,,,,,,,fee schedule,127.38,565.15,APC
Screening Hep C detect,G0567,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,31.58,,,,,,,fee schedule,31.58,61.41,Laboratory
Screening Hep C detect,G0567,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.84,,,,,,,fee schedule,31.58,61.41,APC
Screening Hep C detect,G0567,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,36.49,,,,,,,fee schedule,31.58,61.41,APC
Screening Hep C detect,G0567,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,35.09,,,,,,,fee schedule,31.58,61.41,APC
Screening Hep C detect,G0567,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,53.69,,,,,,,fee schedule,31.58,61.41,Radiology
Screening Hep C detect,G0567,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49.13,,,,,,,fee schedule,31.58,61.41,APC
Screening Hep C detect,G0567,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,61.41,,,,,,,fee schedule,31.58,61.41,APC
Drug test def simple all cl,G0659,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,55.93,,,,,,,fee schedule,55.93,108.74,Laboratory
Drug test def simple all cl,G0659,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,65.25,,,,,,,fee schedule,55.93,108.74,APC
Drug test def simple all cl,G0659,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,64.63,,,,,,,fee schedule,55.93,108.74,APC
Drug test def simple all cl,G0659,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,62.14,,,,,,,fee schedule,55.93,108.74,APC
Drug test def simple all cl,G0659,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,95.07,,,,,,,fee schedule,55.93,108.74,Radiology
Drug test def simple all cl,G0659,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,87,,,,,,,fee schedule,55.93,108.74,APC
Drug test def simple all cl,G0659,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,108.74,,,,,,,fee schedule,55.93,108.74,APC
Blinded conv. Tx MDD clin tr,G2000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1584.34,,,,,,,fee schedule,369.41,1720.92,
Blinded conv. Tx MDD clin tr,G2000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1720.92,,,,,,,fee schedule,369.41,1720.92,
Blinded conv. Tx MDD clin tr,G2000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1379.47,,,,,,,fee schedule,369.41,1720.92,
Blinded conv. Tx MDD clin tr,G2000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1506.94,,,,,,,fee schedule,369.41,1720.92,
Blinded conv. Tx MDD clin tr,G2000,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1638.96,,,,,,,fee schedule,369.41,1720.92,APC 378
Blinded conv. Tx MDD clin tr,G2000,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,387.88,,,,,,,fee schedule,369.41,1720.92,APC
Blinded conv. Tx MDD clin tr,G2000,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,384.19,,,,,,,fee schedule,369.41,1720.92,APC
Blinded conv. Tx MDD clin tr,G2000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,369.41,,,,,,,fee schedule,369.41,1720.92,APC
Blinded conv. Tx MDD clin tr,G2000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,565.2,,,,,,,fee schedule,369.41,1720.92,Radiology
Blinded conv. Tx MDD clin tr,G2000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,517.18,,,,,,,fee schedule,369.41,1720.92,APC
Blinded conv. Tx MDD clin tr,G2000,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,646.47,,,,,,,fee schedule,369.41,1720.92,APC
Post d/c h vst new pt 20 m,G2001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,193.98,,,,,,,fee schedule,168.89,210.7,
Post d/c h vst new pt 20 m,G2001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,210.7,,,,,,,fee schedule,168.89,210.7,
Post d/c h vst new pt 20 m,G2001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,168.89,,,,,,,fee schedule,168.89,210.7,
Post d/c h vst new pt 20 m,G2001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,184.5,,,,,,,fee schedule,168.89,210.7,
Post-d/c h vst new pt 30 m,G2002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,276.73,,,,,,,fee schedule,240.95,300.59,
Post-d/c h vst new pt 30 m,G2002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,300.59,,,,,,,fee schedule,240.95,300.59,
Post-d/c h vst new pt 30 m,G2002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,240.95,,,,,,,fee schedule,240.95,300.59,
Post-d/c h vst new pt 30 m,G2002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,263.21,,,,,,,fee schedule,240.95,300.59,
Post-d/c h vst new pt 45 m,G2003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,457.03,,,,,,,fee schedule,397.93,496.43,
Post-d/c h vst new pt 45 m,G2003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,496.43,,,,,,,fee schedule,397.93,496.43,
Post-d/c h vst new pt 45 m,G2003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,397.93,,,,,,,fee schedule,397.93,496.43,
Post-d/c h vst new pt 45 m,G2003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,434.7,,,,,,,fee schedule,397.93,496.43,
Post-d/c h vst new pt 60 m,G2004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,637.95,,,,,,,fee schedule,555.46,692.95,
Post-d/c h vst new pt 60 m,G2004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,692.95,,,,,,,fee schedule,555.46,692.95,
Post-d/c h vst new pt 60 m,G2004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,555.46,,,,,,,fee schedule,555.46,692.95,
Post-d/c h vst new pt 60 m,G2004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,606.79,,,,,,,fee schedule,555.46,692.95,
Post-d/c h vst new pt 75 m,G2005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,773.71,,,,,,,fee schedule,673.66,840.41,
Post-d/c h vst new pt 75 m,G2005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,840.41,,,,,,,fee schedule,673.66,840.41,
Post-d/c h vst new pt 75 m,G2005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,673.66,,,,,,,fee schedule,673.66,840.41,
Post-d/c h vst new pt 75 m,G2005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,735.91,,,,,,,fee schedule,673.66,840.41,
Post-d/c h vst ext pt 20 m,G2006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,193.87,,,,,,,fee schedule,168.8,210.58,
Post-d/c h vst ext pt 20 m,G2006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,210.58,,,,,,,fee schedule,168.8,210.58,
Post-d/c h vst ext pt 20 m,G2006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,168.8,,,,,,,fee schedule,168.8,210.58,
Post-d/c h vst ext pt 20 m,G2006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,184.4,,,,,,,fee schedule,168.8,210.58,
Post-d/c h vst ext pt 30 m,G2007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,294.27,,,,,,,fee schedule,256.22,319.64,
Post-d/c h vst ext pt 30 m,G2007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,319.64,,,,,,,fee schedule,256.22,319.64,
Post-d/c h vst ext pt 30 m,G2007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,256.22,,,,,,,fee schedule,256.22,319.64,
Post-d/c h vst ext pt 30 m,G2007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,279.89,,,,,,,fee schedule,256.22,319.64,
Post-d/c h vst ext pt 45 m,G2008,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,450.42,,,,,,,fee schedule,392.17,489.25,
Post-d/c h vst ext pt 45 m,G2008,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,489.25,,,,,,,fee schedule,392.17,489.25,
Post-d/c h vst ext pt 45 m,G2008,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,392.17,,,,,,,fee schedule,392.17,489.25,
Post-d/c h vst ext pt 45 m,G2008,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,428.41,,,,,,,fee schedule,392.17,489.25,
Post-d/c h vst ext pt 60 m,G2009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,626.64,,,,,,,fee schedule,545.61,680.66,
Post-d/c h vst ext pt 60 m,G2009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,680.66,,,,,,,fee schedule,545.61,680.66,
Post-d/c h vst ext pt 60 m,G2009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,545.61,,,,,,,fee schedule,545.61,680.66,
Post-d/c h vst ext pt 60 m,G2009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,596.03,,,,,,,fee schedule,545.61,680.66,
Remot image submit by pt,G2010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,31.88,,,,,,,fee schedule,27.75,34.62,
Remot image submit by pt,G2010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,34.62,,,,,,,fee schedule,27.75,34.62,
Remot image submit by pt,G2010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,27.75,,,,,,,fee schedule,27.75,34.62,
Remot image submit by pt,G2010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,30.32,,,,,,,fee schedule,27.75,34.62,
Alcohol/sub abuse assess,G2011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59.75,,,,,,,fee schedule,28.63,127.04,
Alcohol/sub abuse assess,G2011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,64.9,,,,,,,fee schedule,28.63,127.04,
Alcohol/sub abuse assess,G2011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52.03,,,,,,,fee schedule,28.63,127.04,
Alcohol/sub abuse assess,G2011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56.83,,,,,,,fee schedule,28.63,127.04,
Alcohol/sub abuse assess,G2011,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,127.04,,,,,,,fee schedule,28.63,127.04,APC 378
Alcohol/sub abuse assess,G2011,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.07,,,,,,,fee schedule,28.63,127.04,APC
Alcohol/sub abuse assess,G2011,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,29.78,,,,,,,fee schedule,28.63,127.04,APC
Alcohol/sub abuse assess,G2011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,28.63,,,,,,,fee schedule,28.63,127.04,APC
Alcohol/sub abuse assess,G2011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43.81,,,,,,,fee schedule,28.63,127.04,Radiology
Alcohol/sub abuse assess,G2011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40.09,,,,,,,fee schedule,28.63,127.04,APC
Alcohol/sub abuse assess,G2011,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,50.11,,,,,,,fee schedule,28.63,127.04,APC
Brief check in by MD/QHP,G2012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45.52,,,,,,,fee schedule,39.63,49.44,
Brief check in by MD/QHP,G2012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,49.44,,,,,,,fee schedule,39.63,49.44,
Brief check in by MD/QHP,G2012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39.63,,,,,,,fee schedule,39.63,49.44,
Brief check in by MD/QHP,G2012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,43.29,,,,,,,fee schedule,39.63,49.44,
Post-d/c h vst ext pt 75 m,G2013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,773.71,,,,,,,fee schedule,673.66,840.41,
Post-d/c h vst ext pt 75 m,G2013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,840.41,,,,,,,fee schedule,673.66,840.41,
Post-d/c h vst ext pt 75 m,G2013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,673.66,,,,,,,fee schedule,673.66,840.41,
Post-d/c h vst ext pt 75 m,G2013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,735.91,,,,,,,fee schedule,673.66,840.41,
Post-d/c care plan overs 30m,G2014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,266.01,,,,,,,fee schedule,231.61,288.94,
Post-d/c care plan overs 30m,G2014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,288.94,,,,,,,fee schedule,231.61,288.94,
Post-d/c care plan overs 30m,G2014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,231.61,,,,,,,fee schedule,231.61,288.94,
Post-d/c care plan overs 30m,G2014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,253.02,,,,,,,fee schedule,231.61,288.94,
Post-d/c care plan overs 60m,G2015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,371.25,,,,,,,fee schedule,323.24,403.25,
Post-d/c care plan overs 60m,G2015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,403.25,,,,,,,fee schedule,323.24,403.25,
Post-d/c care plan overs 60m,G2015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,323.24,,,,,,,fee schedule,323.24,403.25,
Post-d/c care plan overs 60m,G2015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.11,,,,,,,fee schedule,323.24,403.25,
Inter devc remote 30d,G2066,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,126.15,,,,,,,fee schedule,109.84,137.03,
Inter devc remote 30d,G2066,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,137.03,,,,,,,fee schedule,109.84,137.03,
Inter devc remote 30d,G2066,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,109.84,,,,,,,fee schedule,109.84,137.03,
Inter devc remote 30d,G2066,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,119.99,,,,,,,fee schedule,109.84,137.03,
Visit esketamine 56m or less,G2082,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2263.74,,,,,,,fee schedule,1017.91,4516.14,
Visit esketamine 56m or less,G2082,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2458.89,,,,,,,fee schedule,1017.91,4516.14,
Visit esketamine 56m or less,G2082,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1971.02,,,,,,,fee schedule,1017.91,4516.14,
Visit esketamine 56m or less,G2082,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2153.16,,,,,,,fee schedule,1017.91,4516.14,
Visit esketamine 56m or less,G2082,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4516.14,,,,,,,fee schedule,1017.91,4516.14,APC 378
Visit esketamine 56m or less,G2082,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1068.81,,,,,,,fee schedule,1017.91,4516.14,APC
Visit esketamine 56m or less,G2082,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1058.63,,,,,,,fee schedule,1017.91,4516.14,APC
Visit esketamine 56m or less,G2082,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1017.91,,,,,,,fee schedule,1017.91,4516.14,APC
Visit esketamine 56m or less,G2082,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1557.41,,,,,,,fee schedule,1017.91,4516.14,Radiology
Visit esketamine 56m or less,G2082,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1425.08,,,,,,,fee schedule,1017.91,4516.14,APC
Visit esketamine 56m or less,G2082,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1781.35,,,,,,,fee schedule,1017.91,4516.14,APC
"Visit esketamine, > 56m",G2083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3307.74,,,,,,,fee schedule,1599.3,7095.56,
"Visit esketamine, > 56m",G2083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3592.89,,,,,,,fee schedule,1599.3,7095.56,
"Visit esketamine, > 56m",G2083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2880.02,,,,,,,fee schedule,1599.3,7095.56,
"Visit esketamine, > 56m",G2083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3146.16,,,,,,,fee schedule,1599.3,7095.56,
"Visit esketamine, > 56m",G2083,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7095.56,,,,,,,fee schedule,1599.3,7095.56,APC 378
"Visit esketamine, > 56m",G2083,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1679.27,,,,,,,fee schedule,1599.3,7095.56,APC
"Visit esketamine, > 56m",G2083,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1663.27,,,,,,,fee schedule,1599.3,7095.56,APC
"Visit esketamine, > 56m",G2083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1599.3,,,,,,,fee schedule,1599.3,7095.56,APC
"Visit esketamine, > 56m",G2083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2446.93,,,,,,,fee schedule,1599.3,7095.56,Radiology
"Visit esketamine, > 56m",G2083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2239.02,,,,,,,fee schedule,1599.3,7095.56,APC
"Visit esketamine, > 56m",G2083,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2798.78,,,,,,,fee schedule,1599.3,7095.56,APC
Off base opioid tx 70min,G2086,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,457.13,,,,,,,fee schedule,175.71,779.59,
Off base opioid tx 70min,G2086,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,496.54,,,,,,,fee schedule,175.71,779.59,
Off base opioid tx 70min,G2086,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,398.02,,,,,,,fee schedule,175.71,779.59,
Off base opioid tx 70min,G2086,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,434.8,,,,,,,fee schedule,175.71,779.59,
Off base opioid tx 70min,G2086,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,779.59,,,,,,,fee schedule,175.71,779.59,APC 378
Off base opioid tx 70min,G2086,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,184.5,,,,,,,fee schedule,175.71,779.59,APC
Off base opioid tx 70min,G2086,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,182.74,,,,,,,fee schedule,175.71,779.59,APC
Off base opioid tx 70min,G2086,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,175.71,,,,,,,fee schedule,175.71,779.59,APC
Off base opioid tx 70min,G2086,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,268.84,,,,,,,fee schedule,175.71,779.59,Radiology
Off base opioid tx 70min,G2086,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,246,,,,,,,fee schedule,175.71,779.59,APC
Off base opioid tx 70min,G2086,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,307.5,,,,,,,fee schedule,175.71,779.59,APC
"Off base opioid tx, 60 m",G2087,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,457.13,,,,,,,fee schedule,175.71,779.59,
"Off base opioid tx, 60 m",G2087,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,496.54,,,,,,,fee schedule,175.71,779.59,
"Off base opioid tx, 60 m",G2087,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,398.02,,,,,,,fee schedule,175.71,779.59,
"Off base opioid tx, 60 m",G2087,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,434.8,,,,,,,fee schedule,175.71,779.59,
"Off base opioid tx, 60 m",G2087,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,779.59,,,,,,,fee schedule,175.71,779.59,APC 378
"Off base opioid tx, 60 m",G2087,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,184.5,,,,,,,fee schedule,175.71,779.59,APC
"Off base opioid tx, 60 m",G2087,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,182.74,,,,,,,fee schedule,175.71,779.59,APC
"Off base opioid tx, 60 m",G2087,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,175.71,,,,,,,fee schedule,175.71,779.59,APC
"Off base opioid tx, 60 m",G2087,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,268.84,,,,,,,fee schedule,175.71,779.59,Radiology
"Off base opioid tx, 60 m",G2087,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,246,,,,,,,fee schedule,175.71,779.59,APC
"Off base opioid tx, 60 m",G2087,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,307.5,,,,,,,fee schedule,175.71,779.59,APC
"Off base opioid tx, add30",G2088,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,120.2,,,,,,,fee schedule,104.66,130.56,
"Off base opioid tx, add30",G2088,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,130.56,,,,,,,fee schedule,104.66,130.56,
"Off base opioid tx, add30",G2088,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,104.66,,,,,,,fee schedule,104.66,130.56,
"Off base opioid tx, add30",G2088,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,114.33,,,,,,,fee schedule,104.66,130.56,
Init/sub psych care m 1st 30,G2214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,260.55,,,,,,,fee schedule,100.57,446.2,
Init/sub psych care m 1st 30,G2214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,283.01,,,,,,,fee schedule,100.57,446.2,
Init/sub psych care m 1st 30,G2214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,226.86,,,,,,,fee schedule,100.57,446.2,
Init/sub psych care m 1st 30,G2214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,247.82,,,,,,,fee schedule,100.57,446.2,
Init/sub psych care m 1st 30,G2214,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,446.2,,,,,,,fee schedule,100.57,446.2,APC 378
Init/sub psych care m 1st 30,G2214,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,105.6,,,,,,,fee schedule,100.57,446.2,APC
Init/sub psych care m 1st 30,G2214,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,104.59,,,,,,,fee schedule,100.57,446.2,APC
Init/sub psych care m 1st 30,G2214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,100.57,,,,,,,fee schedule,100.57,446.2,APC
Init/sub psych care m 1st 30,G2214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,153.87,,,,,,,fee schedule,100.57,446.2,Radiology
Init/sub psych care m 1st 30,G2214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,140.8,,,,,,,fee schedule,100.57,446.2,APC
Init/sub psych care m 1st 30,G2214,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,176,,,,,,,fee schedule,100.57,446.2,APC
"Remot img sub by pt, non e/m",G2250,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.94,,,,,,,fee schedule,7.94,13.9,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
"Remot img sub by pt, non e/m",G2250,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.34,,,,,,,fee schedule,7.94,13.9,APC
"Remot img sub by pt, non e/m",G2250,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8.26,,,,,,,fee schedule,7.94,13.9,APC
"Remot img sub by pt, non e/m",G2250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12.15,,,,,,,fee schedule,7.94,13.9,Radiology
"Remot img sub by pt, non e/m",G2250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11.12,,,,,,,fee schedule,7.94,13.9,APC
"Remot img sub by pt, non e/m",G2250,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,13.9,,,,,,,fee schedule,7.94,13.9,APC
"Brief chkin, 5-10, non-e/m",G2251,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.59,,,,,,,fee schedule,10.59,18.53,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
"Brief chkin, 5-10, non-e/m",G2251,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.12,,,,,,,fee schedule,10.59,18.53,APC
"Brief chkin, 5-10, non-e/m",G2251,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11.01,,,,,,,fee schedule,10.59,18.53,APC
"Brief chkin, 5-10, non-e/m",G2251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.2,,,,,,,fee schedule,10.59,18.53,Radiology
"Brief chkin, 5-10, non-e/m",G2251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.83,,,,,,,fee schedule,10.59,18.53,APC
"Brief chkin, 5-10, non-e/m",G2251,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18.53,,,,,,,fee schedule,10.59,18.53,APC
"Brief chkin by md/qhp, 11-20",G2252,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22.29,,,,,,,fee schedule,22.29,39.01,"Mammography-Diagnostic, Occupational Therapy, Physical Therapy, Speech Therapy"
"Brief chkin by md/qhp, 11-20",G2252,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,23.4,,,,,,,fee schedule,22.29,39.01,APC
"Brief chkin by md/qhp, 11-20",G2252,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,23.18,,,,,,,fee schedule,22.29,39.01,APC
"Brief chkin by md/qhp, 11-20",G2252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,34.1,,,,,,,fee schedule,22.29,39.01,Radiology
"Brief chkin by md/qhp, 11-20",G2252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,31.21,,,,,,,fee schedule,22.29,39.01,APC
"Brief chkin by md/qhp, 11-20",G2252,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,39.01,,,,,,,fee schedule,22.29,39.01,APC
Echo guidance radiotherapy,G6001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,171.42,,,,,,,fee schedule,149.26,186.2,
Echo guidance radiotherapy,G6001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,186.2,,,,,,,fee schedule,149.26,186.2,
Echo guidance radiotherapy,G6001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,149.26,,,,,,,fee schedule,149.26,186.2,
Echo guidance radiotherapy,G6001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,163.05,,,,,,,fee schedule,149.26,186.2,
Stereoscopic x-ray guidance,G6002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,244.96,,,,,,,fee schedule,213.28,266.07,
Stereoscopic x-ray guidance,G6002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,266.07,,,,,,,fee schedule,213.28,266.07,
Stereoscopic x-ray guidance,G6002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,213.28,,,,,,,fee schedule,213.28,266.07,
Stereoscopic x-ray guidance,G6002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,232.99,,,,,,,fee schedule,213.28,266.07,
Radiation treatment delivery,G6003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,517.16,,,,,,,fee schedule,450.29,561.75,
Radiation treatment delivery,G6003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,561.75,,,,,,,fee schedule,450.29,561.75,
Radiation treatment delivery,G6003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,450.29,,,,,,,fee schedule,450.29,561.75,
Radiation treatment delivery,G6003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,491.9,,,,,,,fee schedule,450.29,561.75,
Radiation treatment delivery,G6004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,400.51,,,,,,,fee schedule,348.72,435.04,
Radiation treatment delivery,G6004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,435.04,,,,,,,fee schedule,348.72,435.04,
Radiation treatment delivery,G6004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,348.72,,,,,,,fee schedule,348.72,435.04,
Radiation treatment delivery,G6004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,380.95,,,,,,,fee schedule,348.72,435.04,
Radiation treatment delivery,G6005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,447.39,,,,,,,fee schedule,389.54,485.96,
Radiation treatment delivery,G6005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,485.96,,,,,,,fee schedule,389.54,485.96,
Radiation treatment delivery,G6005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,389.54,,,,,,,fee schedule,389.54,485.96,
Radiation treatment delivery,G6005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,425.53,,,,,,,fee schedule,389.54,485.96,
Radiation treatment delivery,G6006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,445.13,,,,,,,fee schedule,387.57,483.5,
Radiation treatment delivery,G6006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,483.5,,,,,,,fee schedule,387.57,483.5,
Radiation treatment delivery,G6006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,387.57,,,,,,,fee schedule,387.57,483.5,
Radiation treatment delivery,G6006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,423.38,,,,,,,fee schedule,387.57,483.5,
Radiation treatment delivery,G6007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,822.46,,,,,,,fee schedule,716.11,893.37,
Radiation treatment delivery,G6007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,893.37,,,,,,,fee schedule,716.11,893.37,
Radiation treatment delivery,G6007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,716.11,,,,,,,fee schedule,716.11,893.37,
Radiation treatment delivery,G6007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,782.29,,,,,,,fee schedule,716.11,893.37,
Radiation treatment delivery,G6008,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,553.74,,,,,,,fee schedule,482.13,601.47,
Radiation treatment delivery,G6008,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,601.47,,,,,,,fee schedule,482.13,601.47,
Radiation treatment delivery,G6008,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,482.13,,,,,,,fee schedule,482.13,601.47,
Radiation treatment delivery,G6008,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,526.69,,,,,,,fee schedule,482.13,601.47,
Radiation treatment delivery,G6009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,613.21,,,,,,,fee schedule,533.92,666.07,
Radiation treatment delivery,G6009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,666.07,,,,,,,fee schedule,533.92,666.07,
Radiation treatment delivery,G6009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,533.92,,,,,,,fee schedule,533.92,666.07,
Radiation treatment delivery,G6009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,583.26,,,,,,,fee schedule,533.92,666.07,
Radiation treatment delivery,G6010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,613.21,,,,,,,fee schedule,533.92,666.07,
Radiation treatment delivery,G6010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,666.07,,,,,,,fee schedule,533.92,666.07,
Radiation treatment delivery,G6010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,533.92,,,,,,,fee schedule,533.92,666.07,
Radiation treatment delivery,G6010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,583.26,,,,,,,fee schedule,533.92,666.07,
Radiation treatment delivery,G6011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,879.64,,,,,,,fee schedule,765.89,955.47,
Radiation treatment delivery,G6011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,955.47,,,,,,,fee schedule,765.89,955.47,
Radiation treatment delivery,G6011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,765.89,,,,,,,fee schedule,765.89,955.47,
Radiation treatment delivery,G6011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,836.67,,,,,,,fee schedule,765.89,955.47,
Radiation treatment delivery,G6012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,728.71,,,,,,,fee schedule,634.48,791.53,
Radiation treatment delivery,G6012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,791.53,,,,,,,fee schedule,634.48,791.53,
Radiation treatment delivery,G6012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,634.48,,,,,,,fee schedule,634.48,791.53,
Radiation treatment delivery,G6012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,693.11,,,,,,,fee schedule,634.48,791.53,
Radiation treatment delivery,G6013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,820.17,,,,,,,fee schedule,714.11,890.87,
Radiation treatment delivery,G6013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,890.87,,,,,,,fee schedule,714.11,890.87,
Radiation treatment delivery,G6013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,714.11,,,,,,,fee schedule,714.11,890.87,
Radiation treatment delivery,G6013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,780.1,,,,,,,fee schedule,714.11,890.87,
Radiation treatment delivery,G6014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,820.17,,,,,,,fee schedule,714.11,890.87,
Radiation treatment delivery,G6014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,890.87,,,,,,,fee schedule,714.11,890.87,
Radiation treatment delivery,G6014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,714.11,,,,,,,fee schedule,714.11,890.87,
Radiation treatment delivery,G6014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,780.1,,,,,,,fee schedule,714.11,890.87,
Radiation tx delivery imrt,G6015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1280.74,,,,,,,fee schedule,1115.13,1391.15,
Radiation tx delivery imrt,G6015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1391.15,,,,,,,fee schedule,1115.13,1391.15,
Radiation tx delivery imrt,G6015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1115.13,,,,,,,fee schedule,1115.13,1391.15,
Radiation tx delivery imrt,G6015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1218.18,,,,,,,fee schedule,1115.13,1391.15,
Delivery comp imrt,G6016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1276.43,,,,,,,fee schedule,1111.37,1386.47,
Delivery comp imrt,G6016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1386.47,,,,,,,fee schedule,1111.37,1386.47,
Delivery comp imrt,G6016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1111.37,,,,,,,fee schedule,1111.37,1386.47,
Delivery comp imrt,G6016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1214.07,,,,,,,fee schedule,1111.37,1386.47,
Warfarin respon genetic test,G9143,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,577.44,,,,,,,fee schedule,502.77,627.22,
Warfarin respon genetic test,G9143,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,627.22,,,,,,,fee schedule,502.77,627.22,
Warfarin respon genetic test,G9143,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,502.77,,,,,,,fee schedule,502.77,627.22,
Warfarin respon genetic test,G9143,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,549.23,,,,,,,fee schedule,502.77,627.22,
Transesoph doppl cardiac mon,G9157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,346.82,,,,,,,fee schedule,301.97,376.71,
Transesoph doppl cardiac mon,G9157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,376.71,,,,,,,fee schedule,301.97,376.71,
Transesoph doppl cardiac mon,G9157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,301.97,,,,,,,fee schedule,301.97,376.71,
Transesoph doppl cardiac mon,G9157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,329.87,,,,,,,fee schedule,301.97,376.71,
BPCI home visit,G9187,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,161.65,,,,,,,fee schedule,140.74,175.58,
BPCI home visit,G9187,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,175.58,,,,,,,fee schedule,140.74,175.58,
BPCI home visit,G9187,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,140.74,,,,,,,fee schedule,140.74,175.58,
BPCI home visit,G9187,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,153.75,,,,,,,fee schedule,140.74,175.58,
Remote E/M new pt 10mins,G9481,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,67.47,,,,,,,fee schedule,58.74,73.28,
Remote E/M new pt 10mins,G9481,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,73.28,,,,,,,fee schedule,58.74,73.28,
Remote E/M new pt 10mins,G9481,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,58.74,,,,,,,fee schedule,58.74,73.28,
Remote E/M new pt 10mins,G9481,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,64.17,,,,,,,fee schedule,58.74,73.28,
Remote E/M new pt 20mins,G9482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,128.18,,,,,,,fee schedule,111.6,139.23,
Remote E/M new pt 20mins,G9482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,139.23,,,,,,,fee schedule,111.6,139.23,
Remote E/M new pt 20mins,G9482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,111.6,,,,,,,fee schedule,111.6,139.23,
Remote E/M new pt 20mins,G9482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,121.92,,,,,,,fee schedule,111.6,139.23,
Remote E/M new pt 30mins,G9483,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,199.9,,,,,,,fee schedule,174.05,217.14,
Remote E/M new pt 30mins,G9483,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,217.14,,,,,,,fee schedule,174.05,217.14,
Remote E/M new pt 30mins,G9483,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,174.05,,,,,,,fee schedule,174.05,217.14,
Remote E/M new pt 30mins,G9483,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,190.14,,,,,,,fee schedule,174.05,217.14,
Remote E/M new pt 45mins,G9484,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,336.57,,,,,,,fee schedule,293.05,365.59,
Remote E/M new pt 45mins,G9484,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,365.59,,,,,,,fee schedule,293.05,365.59,
Remote E/M new pt 45mins,G9484,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,293.05,,,,,,,fee schedule,293.05,365.59,
Remote E/M new pt 45mins,G9484,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,320.13,,,,,,,fee schedule,293.05,365.59,
Remote E/M new pt 60mins,G9485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,439.52,,,,,,,fee schedule,382.68,477.41,
Remote E/M new pt 60mins,G9485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,477.41,,,,,,,fee schedule,382.68,477.41,
Remote E/M new pt 60mins,G9485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,382.68,,,,,,,fee schedule,382.68,477.41,
Remote E/M new pt 60mins,G9485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,418.05,,,,,,,fee schedule,382.68,477.41,
Remote E/M est. pt 10mins,G9486,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,65.96,,,,,,,fee schedule,57.43,71.65,
Remote E/M est. pt 10mins,G9486,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,71.65,,,,,,,fee schedule,57.43,71.65,
Remote E/M est. pt 10mins,G9486,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.43,,,,,,,fee schedule,57.43,71.65,
Remote E/M est. pt 10mins,G9486,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,62.74,,,,,,,fee schedule,57.43,71.65,
Remote E/M est. pt 15mins,G9487,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,131.67,,,,,,,fee schedule,114.65,143.02,
Remote E/M est. pt 15mins,G9487,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,143.02,,,,,,,fee schedule,114.65,143.02,
Remote E/M est. pt 15mins,G9487,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,114.65,,,,,,,fee schedule,114.65,143.02,
Remote E/M est. pt 15mins,G9487,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,125.24,,,,,,,fee schedule,114.65,143.02,
Remote E/M est. pt 25mins,G9488,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,202.38,,,,,,,fee schedule,176.21,219.82,
Remote E/M est. pt 25mins,G9488,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,219.82,,,,,,,fee schedule,176.21,219.82,
Remote E/M est. pt 25mins,G9488,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,176.21,,,,,,,fee schedule,176.21,219.82,
Remote E/M est. pt 25mins,G9488,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,192.49,,,,,,,fee schedule,176.21,219.82,
Remote E/M est. pt 40mins,G9489,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,286.08,,,,,,,fee schedule,249.09,310.74,
Remote E/M est. pt 40mins,G9489,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,310.74,,,,,,,fee schedule,249.09,310.74,
Remote E/M est. pt 40mins,G9489,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,249.09,,,,,,,fee schedule,249.09,310.74,
Remote E/M est. pt 40mins,G9489,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,272.1,,,,,,,fee schedule,249.09,310.74,
Joint replac mod home visit,G9490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,147.64,,,,,,,fee schedule,128.55,160.37,
Joint replac mod home visit,G9490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,160.37,,,,,,,fee schedule,128.55,160.37,
Joint replac mod home visit,G9490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,128.55,,,,,,,fee schedule,128.55,160.37,
Joint replac mod home visit,G9490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,140.43,,,,,,,fee schedule,128.55,160.37,
Acute Nursing Facility Care,G9685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,707.24,,,,,,,fee schedule,615.78,768.21,
Acute Nursing Facility Care,G9685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,768.21,,,,,,,fee schedule,615.78,768.21,
Acute Nursing Facility Care,G9685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,615.78,,,,,,,fee schedule,615.78,768.21,
Acute Nursing Facility Care,G9685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,672.69,,,,,,,fee schedule,615.78,768.21,
Next Gen ACO model <10min,G9868,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,99.46,,,,,,,fee schedule,86.6,108.03,
Next Gen ACO model <10min,G9868,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,108.03,,,,,,,fee schedule,86.6,108.03,
Next Gen ACO model <10min,G9868,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,86.6,,,,,,,fee schedule,86.6,108.03,
Next Gen ACO model <10min,G9868,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,94.6,,,,,,,fee schedule,86.6,108.03,
Next Gen ACO model 10-20min,G9869,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,133.04,,,,,,,fee schedule,115.84,144.51,
Next Gen ACO model 10-20min,G9869,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,144.51,,,,,,,fee schedule,115.84,144.51,
Next Gen ACO model 10-20min,G9869,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,115.84,,,,,,,fee schedule,115.84,144.51,
Next Gen ACO model 10-20min,G9869,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,126.54,,,,,,,fee schedule,115.84,144.51,
Next Gen ACO model >20min,G9870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,166.62,,,,,,,fee schedule,145.08,180.99,
Next Gen ACO model >20min,G9870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,180.99,,,,,,,fee schedule,145.08,180.99,
Next Gen ACO model >20min,G9870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,145.08,,,,,,,fee schedule,145.08,180.99,
Next Gen ACO model >20min,G9870,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,158.48,,,,,,,fee schedule,145.08,180.99,
1 EM core session,G9873,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,78.68,,,,,,,fee schedule,68.51,85.47,
1 EM core session,G9873,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,85.47,,,,,,,fee schedule,68.51,85.47,
1 EM core session,G9873,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,68.51,,,,,,,fee schedule,68.51,85.47,
1 EM core session,G9873,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,74.84,,,,,,,fee schedule,68.51,85.47,
4 EM core sessions,G9874,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,158.51,,,,,,,fee schedule,138.02,172.18,
4 EM core sessions,G9874,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,172.18,,,,,,,fee schedule,138.02,172.18,
4 EM core sessions,G9874,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,138.02,,,,,,,fee schedule,138.02,172.18,
4 EM core sessions,G9874,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,150.77,,,,,,,fee schedule,138.02,172.18,
9 EM core sessions,G9875,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,285.08,,,,,,,fee schedule,248.22,309.66,
9 EM core sessions,G9875,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,309.66,,,,,,,fee schedule,248.22,309.66,
9 EM core sessions,G9875,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,248.22,,,,,,,fee schedule,248.22,309.66,
9 EM core sessions,G9875,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,271.16,,,,,,,fee schedule,248.22,309.66,
2 EM core MS mo 7-9 no WL,G9876,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,47.88,,,,,,,fee schedule,41.69,52.01,
2 EM core MS mo 7-9 no WL,G9876,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,52.01,,,,,,,fee schedule,41.69,52.01,
2 EM core MS mo 7-9 no WL,G9876,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,41.69,,,,,,,fee schedule,41.69,52.01,
2 EM core MS mo 7-9 no WL,G9876,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,45.55,,,,,,,fee schedule,41.69,52.01,
2 EM core MS mo 10-12 no WL,G9877,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,47.88,,,,,,,fee schedule,41.69,52.01,
2 EM core MS mo 10-12 no WL,G9877,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,52.01,,,,,,,fee schedule,41.69,52.01,
2 EM core MS mo 10-12 no WL,G9877,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,41.69,,,,,,,fee schedule,41.69,52.01,
2 EM core MS mo 10-12 no WL,G9877,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,45.55,,,,,,,fee schedule,41.69,52.01,
2 EM core MS mo 7-9  WL,G9878,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,190.43,,,,,,,fee schedule,165.8,206.84,
2 EM core MS mo 7-9  WL,G9878,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,206.84,,,,,,,fee schedule,165.8,206.84,
2 EM core MS mo 7-9  WL,G9878,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,165.8,,,,,,,fee schedule,165.8,206.84,
2 EM core MS mo 7-9  WL,G9878,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,181.12,,,,,,,fee schedule,165.8,206.84,
2 EM core MS mo 10-12 WL,G9879,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,190.43,,,,,,,fee schedule,165.8,206.84,
2 EM core MS mo 10-12 WL,G9879,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,206.84,,,,,,,fee schedule,165.8,206.84,
2 EM core MS mo 10-12 WL,G9879,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,165.8,,,,,,,fee schedule,165.8,206.84,
2 EM core MS mo 10-12 WL,G9879,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,181.12,,,,,,,fee schedule,165.8,206.84,
EM 5 percent WL,G9880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,506.34,,,,,,,fee schedule,440.87,549.99,
EM 5 percent WL,G9880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,549.99,,,,,,,fee schedule,440.87,549.99,
EM 5 percent WL,G9880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,440.87,,,,,,,fee schedule,440.87,549.99,
EM 5 percent WL,G9880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,481.61,,,,,,,fee schedule,440.87,549.99,
EM 9 percent WL,G9881,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,78.68,,,,,,,fee schedule,68.51,85.47,
EM 9 percent WL,G9881,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,85.47,,,,,,,fee schedule,68.51,85.47,
EM 9 percent WL,G9881,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,68.51,,,,,,,fee schedule,68.51,85.47,
EM 9 percent WL,G9881,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,74.84,,,,,,,fee schedule,68.51,85.47,
2 EM ongoing MS mo 13-15 WL,G9882,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,158.51,,,,,,,fee schedule,138.02,172.18,
2 EM ongoing MS mo 13-15 WL,G9882,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,172.18,,,,,,,fee schedule,138.02,172.18,
2 EM ongoing MS mo 13-15 WL,G9882,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,138.02,,,,,,,fee schedule,138.02,172.18,
2 EM ongoing MS mo 13-15 WL,G9882,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,150.77,,,,,,,fee schedule,138.02,172.18,
2 EM ongoing MS mo 16-18 WL,G9883,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,158.51,,,,,,,fee schedule,138.02,172.18,
2 EM ongoing MS mo 16-18 WL,G9883,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,172.18,,,,,,,fee schedule,138.02,172.18,
2 EM ongoing MS mo 16-18 WL,G9883,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,138.02,,,,,,,fee schedule,138.02,172.18,
2 EM ongoing MS mo 16-18 WL,G9883,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,150.77,,,,,,,fee schedule,138.02,172.18,
2 EM ongoing MS mo 19-21 WL,G9884,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,158.51,,,,,,,fee schedule,138.02,172.18,
2 EM ongoing MS mo 19-21 WL,G9884,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,172.18,,,,,,,fee schedule,138.02,172.18,
2 EM ongoing MS mo 19-21 WL,G9884,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,138.02,,,,,,,fee schedule,138.02,172.18,
2 EM ongoing MS mo 19-21 WL,G9884,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,150.77,,,,,,,fee schedule,138.02,172.18,
2 EM ongoing MS mo 22-24 WL,G9885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,158.51,,,,,,,fee schedule,138.02,172.18,
2 EM ongoing MS mo 22-24 WL,G9885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,172.18,,,,,,,fee schedule,138.02,172.18,
2 EM ongoing MS mo 22-24 WL,G9885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,138.02,,,,,,,fee schedule,138.02,172.18,
2 EM ongoing MS mo 22-24 WL,G9885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,150.77,,,,,,,fee schedule,138.02,172.18,
Mac exam perf,G9890,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,78.68,,,,,,,fee schedule,68.51,85.47,
Mac exam perf,G9890,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,85.47,,,,,,,fee schedule,68.51,85.47,
Mac exam perf,G9890,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,68.51,,,,,,,fee schedule,68.51,85.47,
Mac exam perf,G9890,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,74.84,,,,,,,fee schedule,68.51,85.47,
Remote E/M new pt 10mins,G9978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,92.36,,,,,,,fee schedule,80.42,100.32,
Remote E/M new pt 10mins,G9978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,100.32,,,,,,,fee schedule,80.42,100.32,
Remote E/M new pt 10mins,G9978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,80.42,,,,,,,fee schedule,80.42,100.32,
Remote E/M new pt 10mins,G9978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,87.85,,,,,,,fee schedule,80.42,100.32,
Remote E/M new pt 20mins,G9979,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,176.02,,,,,,,fee schedule,153.26,191.19,
Remote E/M new pt 20mins,G9979,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,191.19,,,,,,,fee schedule,153.26,191.19,
Remote E/M new pt 20mins,G9979,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,153.26,,,,,,,fee schedule,153.26,191.19,
Remote E/M new pt 20mins,G9979,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,167.42,,,,,,,fee schedule,153.26,191.19,
Remote E/M new pt 30 mins,G9980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,263.54,,,,,,,fee schedule,229.46,286.26,
Remote E/M new pt 30 mins,G9980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,286.26,,,,,,,fee schedule,229.46,286.26,
Remote E/M new pt 30 mins,G9980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,229.46,,,,,,,fee schedule,229.46,286.26,
Remote E/M new pt 30 mins,G9980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,250.67,,,,,,,fee schedule,229.46,286.26,
Remote E/M new pt 45mins,G9981,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,450.66,,,,,,,fee schedule,392.39,489.51,
Remote E/M new pt 45mins,G9981,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,489.51,,,,,,,fee schedule,392.39,489.51,
Remote E/M new pt 45mins,G9981,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,392.39,,,,,,,fee schedule,392.39,489.51,
Remote E/M new pt 45mins,G9981,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,428.65,,,,,,,fee schedule,392.39,489.51,
Remote E/M new pt 60mins,G9982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,588.26,,,,,,,fee schedule,512.19,638.97,
Remote E/M new pt 60mins,G9982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,638.97,,,,,,,fee schedule,512.19,638.97,
Remote E/M new pt 60mins,G9982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,512.19,,,,,,,fee schedule,512.19,638.97,
Remote E/M new pt 60mins,G9982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,559.52,,,,,,,fee schedule,512.19,638.97,
Remote E/M est. pt 10mins,G9983,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,90.06,,,,,,,fee schedule,78.42,97.83,
Remote E/M est. pt 10mins,G9983,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,97.83,,,,,,,fee schedule,78.42,97.83,
Remote E/M est. pt 10mins,G9983,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,78.42,,,,,,,fee schedule,78.42,97.83,
Remote E/M est. pt 10mins,G9983,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,85.66,,,,,,,fee schedule,78.42,97.83,
Remote E/M est. pt 15mins,G9984,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,178.35,,,,,,,fee schedule,155.29,193.73,
Remote E/M est. pt 15mins,G9984,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,193.73,,,,,,,fee schedule,155.29,193.73,
Remote E/M est. pt 15mins,G9984,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,155.29,,,,,,,fee schedule,155.29,193.73,
Remote E/M est. pt 15mins,G9984,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,169.64,,,,,,,fee schedule,155.29,193.73,
Remote E/M est. pt 25mins,G9985,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,273.88,,,,,,,fee schedule,238.46,297.49,
Remote E/M est. pt 25mins,G9985,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,297.49,,,,,,,fee schedule,238.46,297.49,
Remote E/M est. pt 25mins,G9985,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,238.46,,,,,,,fee schedule,238.46,297.49,
Remote E/M est. pt 25mins,G9985,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,260.5,,,,,,,fee schedule,238.46,297.49,
Remote E/M est. pt 40mins,G9986,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,386.59,,,,,,,fee schedule,336.6,419.92,
Remote E/M est. pt 40mins,G9986,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,419.92,,,,,,,fee schedule,336.6,419.92,
Remote E/M est. pt 40mins,G9986,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,336.6,,,,,,,fee schedule,336.6,419.92,
Remote E/M est. pt 40mins,G9986,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,367.71,,,,,,,fee schedule,336.6,419.92,
BPCI Advanced In home visit,G9987,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,142.85,,,,,,,fee schedule,124.38,155.17,
BPCI Advanced In home visit,G9987,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,155.17,,,,,,,fee schedule,124.38,155.17,
BPCI Advanced In home visit,G9987,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,124.38,,,,,,,fee schedule,124.38,155.17,
BPCI Advanced In home visit,G9987,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,135.88,,,,,,,fee schedule,124.38,155.17,
Tetracyclin injection,J0120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,25.37,,,,,,,fee schedule,22.09,27.56,
Tetracyclin injection,J0120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27.56,,,,,,,fee schedule,22.09,27.56,
Tetracyclin injection,J0120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22.09,,,,,,,fee schedule,22.09,27.56,
Tetracyclin injection,J0120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24.13,,,,,,,fee schedule,22.09,27.56,
"Inj., omadacycline, 1 mg",J0121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12.15,,,,,,,fee schedule,4.13,13.2,
"Inj., omadacycline, 1 mg",J0121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13.2,,,,,,,fee schedule,4.13,13.2,
"Inj., omadacycline, 1 mg",J0121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8.53,,,,,,,fee schedule,4.13,13.2,
"Inj., omadacycline, 1 mg",J0121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10.58,,,,,,,fee schedule,4.13,13.2,
"Inj., omadacycline, 1 mg",J0121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11.56,,,,,,,fee schedule,4.13,13.2,
"Inj., omadacycline, 1 mg",J0121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7.72,,,,,,,fee schedule,4.13,13.2,
"Inj., omadacycline, 1 mg",J0121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4.8,,,,,,,fee schedule,4.13,13.2,OP High Cost Drugs
"Inj., omadacycline, 1 mg",J0121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4.13,,,,,,,fee schedule,4.13,13.2,Other Pharmacy
"Inj., omadacycline, 1 mg",J0121,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.34,,,,,,,fee schedule,4.13,13.2,APC
"Inj., omadacycline, 1 mg",J0121,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4.3,,,,,,,fee schedule,4.13,13.2,APC
"Inj., omadacycline, 1 mg",J0121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.33,,,,,,,fee schedule,4.13,13.2,Radiology
"Inj., omadacycline, 1 mg",J0121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.79,,,,,,,fee schedule,4.13,13.2,APC
"Inj., omadacycline, 1 mg",J0121,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7.23,,,,,,,fee schedule,4.13,13.2,APC
"Inj., eravacycline, 1 mg",J0122,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.33,,,,,,,fee schedule,1.29,3.62,
"Inj., eravacycline, 1 mg",J0122,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.62,,,,,,,fee schedule,1.29,3.62,
"Inj., eravacycline, 1 mg",J0122,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.21,,,,,,,fee schedule,1.29,3.62,
"Inj., eravacycline, 1 mg",J0122,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.9,,,,,,,fee schedule,1.29,3.62,
"Inj., eravacycline, 1 mg",J0122,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.17,,,,,,,fee schedule,1.29,3.62,
"Inj., eravacycline, 1 mg",J0122,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2,,,,,,,fee schedule,1.29,3.62,
"Inj., eravacycline, 1 mg",J0122,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1.49,,,,,,,fee schedule,1.29,3.62,OP High Cost Drugs
"Inj., eravacycline, 1 mg",J0122,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1.29,,,,,,,fee schedule,1.29,3.62,Other Pharmacy
"Inj., eravacycline, 1 mg",J0122,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.35,,,,,,,fee schedule,1.29,3.62,APC
"Inj., eravacycline, 1 mg",J0122,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1.34,,,,,,,fee schedule,1.29,3.62,APC
"Inj., eravacycline, 1 mg",J0122,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1.97,,,,,,,fee schedule,1.29,3.62,Radiology
"Inj., eravacycline, 1 mg",J0122,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1.8,,,,,,,fee schedule,1.29,3.62,APC
"Inj., eravacycline, 1 mg",J0122,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2.25,,,,,,,fee schedule,1.29,3.62,APC
Abatacept injection,J0129,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,67.41,,,,,,,fee schedule,44.72,215.97,
Abatacept injection,J0129,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,73.22,,,,,,,fee schedule,44.72,215.97,
Abatacept injection,J0129,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,215.97,,,,,,,fee schedule,44.72,215.97,
Abatacept injection,J0129,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,58.69,,,,,,,fee schedule,44.72,215.97,
Abatacept injection,J0129,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,64.11,,,,,,,fee schedule,44.72,215.97,
Abatacept injection,J0129,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,195.47,,,,,,,fee schedule,44.72,215.97,
Abatacept injection,J0129,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,51.87,,,,,,,fee schedule,44.72,215.97,OP High Cost Drugs
Abatacept injection,J0129,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,44.72,,,,,,,fee schedule,44.72,215.97,Other Pharmacy
Abatacept injection,J0129,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,46.95,,,,,,,fee schedule,44.72,215.97,APC
Abatacept injection,J0129,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,46.51,,,,,,,fee schedule,44.72,215.97,APC
Abatacept injection,J0129,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,68.42,,,,,,,fee schedule,44.72,215.97,Radiology
Abatacept injection,J0129,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,62.61,,,,,,,fee schedule,44.72,215.97,APC
Abatacept injection,J0129,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,78.26,,,,,,,fee schedule,44.72,215.97,APC
Abciximab injection,J0130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1579.54,,,,,,,fee schedule,1375.29,2556.16,
Abciximab injection,J0130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1715.7,,,,,,,fee schedule,1375.29,2556.16,
Abciximab injection,J0130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2556.16,,,,,,,fee schedule,1375.29,2556.16,
Abciximab injection,J0130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1375.29,,,,,,,fee schedule,1375.29,2556.16,
Abciximab injection,J0130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1502.38,,,,,,,fee schedule,1375.29,2556.16,
Abciximab injection,J0130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2313.48,,,,,,,fee schedule,1375.29,2556.16,
Acetaminophen injection,J0131,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.45,,,,,,,fee schedule,0.19,0.49,
Acetaminophen injection,J0131,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.49,,,,,,,fee schedule,0.19,0.49,
Acetaminophen injection,J0131,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.21,,,,,,,fee schedule,0.19,0.49,
Acetaminophen injection,J0131,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.39,,,,,,,fee schedule,0.19,0.49,
Acetaminophen injection,J0131,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.43,,,,,,,fee schedule,0.19,0.49,
Acetaminophen injection,J0131,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.19,,,,,,,fee schedule,0.19,0.49,
Acetylcysteine injection,J0132,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.71,,,,,,,fee schedule,4.26,4.71,
Acetylcysteine injection,J0132,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.26,,,,,,,fee schedule,4.26,4.71,
Acyclovir injection,J0133,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.22,,,,,,,fee schedule,0.2,0.22,
Acyclovir injection,J0133,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.2,,,,,,,fee schedule,0.2,0.22,
Inj acetaminophen -fresenius,J0134,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.19,,,,,,,fee schedule,0.17,0.19,
Inj acetaminophen -fresenius,J0134,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.17,,,,,,,fee schedule,0.17,0.19,
Adalimumab injection,J0135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1232.96,,,,,,,fee schedule,1073.53,3281.33,
Adalimumab injection,J0135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1339.25,,,,,,,fee schedule,1073.53,3281.33,
Adalimumab injection,J0135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3281.33,,,,,,,fee schedule,1073.53,3281.33,
Adalimumab injection,J0135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1073.53,,,,,,,fee schedule,1073.53,3281.33,
Adalimumab injection,J0135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1172.73,,,,,,,fee schedule,1073.53,3281.33,
Adalimumab injection,J0135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2969.81,,,,,,,fee schedule,1073.53,3281.33,
"Inj, acetaminophen (b braun)",J0136,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.19,,,,,,,fee schedule,0.17,0.19,
"Inj, acetaminophen (b braun)",J0136,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.17,,,,,,,fee schedule,0.17,0.19,
"Inj, acetaminophen (hikma)",J0137,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.23,,,,,,,fee schedule,0.2,0.25,
"Inj, acetaminophen (hikma)",J0137,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.25,,,,,,,fee schedule,0.2,0.25,
"Inj, acetaminophen (hikma)",J0137,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.22,,,,,,,fee schedule,0.2,0.25,
"Inj, acetaminophen (hikma)",J0137,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.2,,,,,,,fee schedule,0.2,0.25,
"Inj, acetaminophen (hikma)",J0137,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.22,,,,,,,fee schedule,0.2,0.25,
"Injection, acetaminoph 10 mg",J0138,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.44,,,,,,,fee schedule,0.09,0.44,
"Injection, acetaminoph 10 mg",J0138,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.4,,,,,,,fee schedule,0.09,0.44,
"Injection, acetaminoph 10 mg",J0138,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,0.11,,,,,,,fee schedule,0.09,0.44,OP High Cost Drugs
"Injection, acetaminoph 10 mg",J0138,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,0.09,,,,,,,fee schedule,0.09,0.44,Other Pharmacy
"Injection, acetaminoph 10 mg",J0138,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,0.1,,,,,,,fee schedule,0.09,0.44,APC
"Injection, acetaminoph 10 mg",J0138,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,0.1,,,,,,,fee schedule,0.09,0.44,APC
"Injection, acetaminoph 10 mg",J0138,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,0.14,,,,,,,fee schedule,0.09,0.44,Radiology
"Injection, acetaminoph 10 mg",J0138,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,0.13,,,,,,,fee schedule,0.09,0.44,APC
"Injection, acetaminoph 10 mg",J0138,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,0.16,,,,,,,fee schedule,0.09,0.44,APC
Adenosine inj 1mg,J0153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.96,,,,,,,fee schedule,2.58,3.6,
Adenosine inj 1mg,J0153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.21,,,,,,,fee schedule,2.58,3.6,
Adenosine inj 1mg,J0153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.6,,,,,,,fee schedule,2.58,3.6,
Adenosine inj 1mg,J0153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.58,,,,,,,fee schedule,2.58,3.6,
Adenosine inj 1mg,J0153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.81,,,,,,,fee schedule,2.58,3.6,
Adenosine inj 1mg,J0153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.26,,,,,,,fee schedule,2.58,3.6,
Adrenalin epinephrine inject,J0171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.24,,,,,,,fee schedule,0.21,39.03,
Adrenalin epinephrine inject,J0171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.26,,,,,,,fee schedule,0.21,39.03,
Adrenalin epinephrine inject,J0171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,39.03,,,,,,,fee schedule,0.21,39.03,
Adrenalin epinephrine inject,J0171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.21,,,,,,,fee schedule,0.21,39.03,
Adrenalin epinephrine inject,J0171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.23,,,,,,,fee schedule,0.21,39.03,
Adrenalin epinephrine inject,J0171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35.32,,,,,,,fee schedule,0.21,39.03,
"Inj, aducanumab-avwa, 2 mg",J0172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41.31,,,,,,,fee schedule,9.68,44.88,
"Inj, aducanumab-avwa, 2 mg",J0172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,44.88,,,,,,,fee schedule,9.68,44.88,
"Inj, aducanumab-avwa, 2 mg",J0172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10.7,,,,,,,fee schedule,9.68,44.88,
"Inj, aducanumab-avwa, 2 mg",J0172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35.97,,,,,,,fee schedule,9.68,44.88,
"Inj, aducanumab-avwa, 2 mg",J0172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39.3,,,,,,,fee schedule,9.68,44.88,
"Inj, aducanumab-avwa, 2 mg",J0172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.68,,,,,,,fee schedule,9.68,44.88,
"Inj, epinephrine (belcher)",J0173,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,154.1,,,,,,,fee schedule,139.47,154.1,
"Inj, epinephrine (belcher)",J0173,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,139.47,,,,,,,fee schedule,139.47,154.1,
"Inj, lecanemab-irmb",J0174,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.7,,,,,,,fee schedule,1.34,5.1,
"Inj, lecanemab-irmb",J0174,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.1,,,,,,,fee schedule,1.34,5.1,
"Inj, lecanemab-irmb",J0174,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.42,,,,,,,fee schedule,1.34,5.1,
"Inj, lecanemab-irmb",J0174,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.09,,,,,,,fee schedule,1.34,5.1,
"Inj, lecanemab-irmb",J0174,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.47,,,,,,,fee schedule,1.34,5.1,
"Inj, lecanemab-irmb",J0174,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.19,,,,,,,fee schedule,1.34,5.1,
"Inj, lecanemab-irmb",J0174,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1.55,,,,,,,fee schedule,1.34,5.1,OP High Cost Drugs
"Inj, lecanemab-irmb",J0174,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1.34,,,,,,,fee schedule,1.34,5.1,Other Pharmacy
"Inj, lecanemab-irmb",J0174,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.4,,,,,,,fee schedule,1.34,5.1,APC
"Inj, lecanemab-irmb",J0174,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1.39,,,,,,,fee schedule,1.34,5.1,APC
"Inj, lecanemab-irmb",J0174,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2.04,,,,,,,fee schedule,1.34,5.1,Radiology
"Inj, lecanemab-irmb",J0174,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1.87,,,,,,,fee schedule,1.34,5.1,APC
"Inj, lecanemab-irmb",J0174,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2.34,,,,,,,fee schedule,1.34,5.1,APC
"Inj, donanemab-azbt, 2 mg",J0175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7.54,,,,,,,fee schedule,4.14,7.54,
"Inj, donanemab-azbt, 2 mg",J0175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.82,,,,,,,fee schedule,4.14,7.54,
"Inj, donanemab-azbt, 2 mg",J0175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4.8,,,,,,,fee schedule,4.14,7.54,OP High Cost Drugs
"Inj, donanemab-azbt, 2 mg",J0175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4.14,,,,,,,fee schedule,4.14,7.54,Other Pharmacy
"Inj, donanemab-azbt, 2 mg",J0175,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.35,,,,,,,fee schedule,4.14,7.54,APC
"Inj, donanemab-azbt, 2 mg",J0175,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4.31,,,,,,,fee schedule,4.14,7.54,APC
"Inj, donanemab-azbt, 2 mg",J0175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.33,,,,,,,fee schedule,4.14,7.54,Radiology
"Inj, donanemab-azbt, 2 mg",J0175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.8,,,,,,,fee schedule,4.14,7.54,APC
"Inj, donanemab-azbt, 2 mg",J0175,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7.24,,,,,,,fee schedule,4.14,7.54,APC
"Inj, aflibercept hd, 1 mg",J0177,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,625.68,,,,,,,fee schedule,301.18,625.68,
"Inj, aflibercept hd, 1 mg",J0177,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,566.28,,,,,,,fee schedule,301.18,625.68,
"Inj, aflibercept hd, 1 mg",J0177,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,349.37,,,,,,,fee schedule,301.18,625.68,OP High Cost Drugs
"Inj, aflibercept hd, 1 mg",J0177,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,301.18,,,,,,,fee schedule,301.18,625.68,Other Pharmacy
"Inj, aflibercept hd, 1 mg",J0177,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,316.24,,,,,,,fee schedule,301.18,625.68,APC
"Inj, aflibercept hd, 1 mg",J0177,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,313.22,,,,,,,fee schedule,301.18,625.68,APC
"Inj, aflibercept hd, 1 mg",J0177,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,460.8,,,,,,,fee schedule,301.18,625.68,Radiology
"Inj, aflibercept hd, 1 mg",J0177,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,421.65,,,,,,,fee schedule,301.18,625.68,APC
"Inj, aflibercept hd, 1 mg",J0177,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,527.06,,,,,,,fee schedule,301.18,625.68,APC
Aflibercept injection,J0178,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3412.14,,,,,,,fee schedule,731.88,3706.29,
Aflibercept injection,J0178,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3706.29,,,,,,,fee schedule,731.88,3706.29,
Aflibercept injection,J0178,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1753.8,,,,,,,fee schedule,731.88,3706.29,
Aflibercept injection,J0178,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2970.92,,,,,,,fee schedule,731.88,3706.29,
Aflibercept injection,J0178,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3245.46,,,,,,,fee schedule,731.88,3706.29,
Aflibercept injection,J0178,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1587.3,,,,,,,fee schedule,731.88,3706.29,
Aflibercept injection,J0178,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,848.99,,,,,,,fee schedule,731.88,3706.29,OP High Cost Drugs
Aflibercept injection,J0178,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,731.88,,,,,,,fee schedule,731.88,3706.29,Other Pharmacy
Aflibercept injection,J0178,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,768.48,,,,,,,fee schedule,731.88,3706.29,APC
Aflibercept injection,J0178,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,761.16,,,,,,,fee schedule,731.88,3706.29,APC
Aflibercept injection,J0178,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1119.78,,,,,,,fee schedule,731.88,3706.29,Radiology
Aflibercept injection,J0178,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1024.64,,,,,,,fee schedule,731.88,3706.29,APC
Aflibercept injection,J0178,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1280.8,,,,,,,fee schedule,731.88,3706.29,APC
"Inj, brolucizumab-dbll, 1 mg",J0179,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1105.19,,,,,,,fee schedule,353.07,1200.46,
"Inj, brolucizumab-dbll, 1 mg",J0179,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1200.46,,,,,,,fee schedule,353.07,1200.46,
"Inj, brolucizumab-dbll, 1 mg",J0179,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,630.26,,,,,,,fee schedule,353.07,1200.46,
"Inj, brolucizumab-dbll, 1 mg",J0179,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,962.28,,,,,,,fee schedule,353.07,1200.46,
"Inj, brolucizumab-dbll, 1 mg",J0179,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1051.2,,,,,,,fee schedule,353.07,1200.46,
"Inj, brolucizumab-dbll, 1 mg",J0179,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,570.43,,,,,,,fee schedule,353.07,1200.46,
"Inj, brolucizumab-dbll, 1 mg",J0179,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,409.56,,,,,,,fee schedule,353.07,1200.46,OP High Cost Drugs
"Inj, brolucizumab-dbll, 1 mg",J0179,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,353.07,,,,,,,fee schedule,353.07,1200.46,Other Pharmacy
"Inj, brolucizumab-dbll, 1 mg",J0179,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,370.72,,,,,,,fee schedule,353.07,1200.46,APC
"Inj, brolucizumab-dbll, 1 mg",J0179,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,367.19,,,,,,,fee schedule,353.07,1200.46,APC
"Inj, brolucizumab-dbll, 1 mg",J0179,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,540.2,,,,,,,fee schedule,353.07,1200.46,Radiology
"Inj, brolucizumab-dbll, 1 mg",J0179,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,494.3,,,,,,,fee schedule,353.07,1200.46,APC
"Inj, brolucizumab-dbll, 1 mg",J0179,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,617.87,,,,,,,fee schedule,353.07,1200.46,APC
Agalsidase beta injection,J0180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,463.08,,,,,,,fee schedule,227.58,503,
Agalsidase beta injection,J0180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,503,,,,,,,fee schedule,227.58,503,
Agalsidase beta injection,J0180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,403.3,,,,,,,fee schedule,227.58,503,
Agalsidase beta injection,J0180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,403.2,,,,,,,fee schedule,227.58,503,
Agalsidase beta injection,J0180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,440.46,,,,,,,fee schedule,227.58,503,
Agalsidase beta injection,J0180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,365.01,,,,,,,fee schedule,227.58,503,
Agalsidase beta injection,J0180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,263.99,,,,,,,fee schedule,227.58,503,OP High Cost Drugs
Agalsidase beta injection,J0180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,227.58,,,,,,,fee schedule,227.58,503,Other Pharmacy
Agalsidase beta injection,J0180,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,238.96,,,,,,,fee schedule,227.58,503,APC
Agalsidase beta injection,J0180,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,236.68,,,,,,,fee schedule,227.58,503,APC
Agalsidase beta injection,J0180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,348.2,,,,,,,fee schedule,227.58,503,Radiology
Agalsidase beta injection,J0180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,318.61,,,,,,,fee schedule,227.58,503,APC
Agalsidase beta injection,J0180,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,398.27,,,,,,,fee schedule,227.58,503,APC
"Inj, amisulpride, 1 mg",J0184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33.2,,,,,,,fee schedule,9.56,42.41,
"Inj, amisulpride, 1 mg",J0184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,36.06,,,,,,,fee schedule,9.56,42.41,
"Inj, amisulpride, 1 mg",J0184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17.06,,,,,,,fee schedule,9.56,42.41,
"Inj, amisulpride, 1 mg",J0184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28.91,,,,,,,fee schedule,9.56,42.41,
"Inj, amisulpride, 1 mg",J0184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31.58,,,,,,,fee schedule,9.56,42.41,
"Inj, amisulpride, 1 mg",J0184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15.44,,,,,,,fee schedule,9.56,42.41,
"Inj, amisulpride, 1 mg",J0184,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,42.41,,,,,,,fee schedule,9.56,42.41,APC 378
"Inj, amisulpride, 1 mg",J0184,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.04,,,,,,,fee schedule,9.56,42.41,APC
"Inj, amisulpride, 1 mg",J0184,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9.94,,,,,,,fee schedule,9.56,42.41,APC
"Inj, amisulpride, 1 mg",J0184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9.56,,,,,,,fee schedule,9.56,42.41,APC
"Inj, amisulpride, 1 mg",J0184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.63,,,,,,,fee schedule,9.56,42.41,Radiology
"Inj, amisulpride, 1 mg",J0184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.38,,,,,,,fee schedule,9.56,42.41,APC
"Inj, amisulpride, 1 mg",J0184,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16.73,,,,,,,fee schedule,9.56,42.41,APC
"Inj., aprepitant, 1 mg",J0185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7.32,,,,,,,fee schedule,1.69,7.95,
"Inj., aprepitant, 1 mg",J0185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7.95,,,,,,,fee schedule,1.69,7.95,
"Inj., aprepitant, 1 mg",J0185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.37,,,,,,,fee schedule,1.69,7.95,
"Inj., aprepitant, 1 mg",J0185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.38,,,,,,,fee schedule,1.69,7.95,
"Inj., aprepitant, 1 mg",J0185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.96,,,,,,,fee schedule,1.69,7.95,
"Inj., aprepitant, 1 mg",J0185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.76,,,,,,,fee schedule,1.69,7.95,
"Inj., aprepitant, 1 mg",J0185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1.96,,,,,,,fee schedule,1.69,7.95,OP High Cost Drugs
"Inj., aprepitant, 1 mg",J0185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1.69,,,,,,,fee schedule,1.69,7.95,Other Pharmacy
"Inj., aprepitant, 1 mg",J0185,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.78,,,,,,,fee schedule,1.69,7.95,APC
"Inj., aprepitant, 1 mg",J0185,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1.76,,,,,,,fee schedule,1.69,7.95,APC
"Inj., aprepitant, 1 mg",J0185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2.59,,,,,,,fee schedule,1.69,7.95,Radiology
"Inj., aprepitant, 1 mg",J0185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2.37,,,,,,,fee schedule,1.69,7.95,APC
"Inj., aprepitant, 1 mg",J0185,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2.96,,,,,,,fee schedule,1.69,7.95,APC
Inj biperiden lactate/5 mg,J0190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10.09,,,,,,,fee schedule,8.79,10.96,
Inj biperiden lactate/5 mg,J0190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10.96,,,,,,,fee schedule,8.79,10.96,
Inj biperiden lactate/5 mg,J0190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.79,,,,,,,fee schedule,8.79,10.96,
Inj biperiden lactate/5 mg,J0190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.6,,,,,,,fee schedule,8.79,10.96,
"Injection, alemtuzumab",J0202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6068.49,,,,,,,fee schedule,2440.42,6591.64,
"Injection, alemtuzumab",J0202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6591.64,,,,,,,fee schedule,2440.42,6591.64,
"Injection, alemtuzumab",J0202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4607,,,,,,,fee schedule,2440.42,6591.64,
"Injection, alemtuzumab",J0202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5283.77,,,,,,,fee schedule,2440.42,6591.64,
"Injection, alemtuzumab",J0202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5772.04,,,,,,,fee schedule,2440.42,6591.64,
"Injection, alemtuzumab",J0202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4169.62,,,,,,,fee schedule,2440.42,6591.64,
"Injection, alemtuzumab",J0202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2830.88,,,,,,,fee schedule,2440.42,6591.64,OP High Cost Drugs
"Injection, alemtuzumab",J0202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2440.42,,,,,,,fee schedule,2440.42,6591.64,Other Pharmacy
"Injection, alemtuzumab",J0202,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2562.44,,,,,,,fee schedule,2440.42,6591.64,APC
"Injection, alemtuzumab",J0202,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2538.03,,,,,,,fee schedule,2440.42,6591.64,APC
"Injection, alemtuzumab",J0202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3733.83,,,,,,,fee schedule,2440.42,6591.64,Radiology
"Injection, alemtuzumab",J0202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3416.58,,,,,,,fee schedule,2440.42,6591.64,APC
"Injection, alemtuzumab",J0202,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4270.73,,,,,,,fee schedule,2440.42,6591.64,APC
Alglucerase injection,J0205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,141.74,,,,,,,fee schedule,68.04,153.96,
Alglucerase injection,J0205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,153.96,,,,,,,fee schedule,68.04,153.96,
Alglucerase injection,J0205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,75.18,,,,,,,fee schedule,68.04,153.96,
Alglucerase injection,J0205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,123.41,,,,,,,fee schedule,68.04,153.96,
Alglucerase injection,J0205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,134.82,,,,,,,fee schedule,68.04,153.96,
Alglucerase injection,J0205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,68.04,,,,,,,fee schedule,68.04,153.96,
Inj allopurinol sodium 1 mg,J0206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19.61,,,,,,,fee schedule,3.81,21.3,
Inj allopurinol sodium 1 mg,J0206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21.3,,,,,,,fee schedule,3.81,21.3,
Inj allopurinol sodium 1 mg,J0206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14.79,,,,,,,fee schedule,3.81,21.3,
Inj allopurinol sodium 1 mg,J0206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17.07,,,,,,,fee schedule,3.81,21.3,
Inj allopurinol sodium 1 mg,J0206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18.65,,,,,,,fee schedule,3.81,21.3,
Inj allopurinol sodium 1 mg,J0206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13.38,,,,,,,fee schedule,3.81,21.3,
Inj allopurinol sodium 1 mg,J0206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4.42,,,,,,,fee schedule,3.81,21.3,OP High Cost Drugs
Inj allopurinol sodium 1 mg,J0206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3.81,,,,,,,fee schedule,3.81,21.3,Other Pharmacy
Inj allopurinol sodium 1 mg,J0206,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4,,,,,,,fee schedule,3.81,21.3,APC
Inj allopurinol sodium 1 mg,J0206,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3.96,,,,,,,fee schedule,3.81,21.3,APC
Inj allopurinol sodium 1 mg,J0206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.83,,,,,,,fee schedule,3.81,21.3,Radiology
Inj allopurinol sodium 1 mg,J0206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.33,,,,,,,fee schedule,3.81,21.3,APC
Inj allopurinol sodium 1 mg,J0206,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6.67,,,,,,,fee schedule,3.81,21.3,APC
Amifostine,J0207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1515.19,,,,,,,fee schedule,807.88,1645.81,
Amifostine,J0207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1645.81,,,,,,,fee schedule,807.88,1645.81,
Amifostine,J0207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,892.62,,,,,,,fee schedule,807.88,1645.81,
Amifostine,J0207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1319.26,,,,,,,fee schedule,807.88,1645.81,
Amifostine,J0207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1441.17,,,,,,,fee schedule,807.88,1645.81,
Amifostine,J0207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,807.88,,,,,,,fee schedule,807.88,1645.81,
Inj sodium thiosulfate 100mg,J0208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,334.73,,,,,,,fee schedule,95.45,423.47,
Inj sodium thiosulfate 100mg,J0208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,363.59,,,,,,,fee schedule,95.45,423.47,
Inj sodium thiosulfate 100mg,J0208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,173.17,,,,,,,fee schedule,95.45,423.47,
Inj sodium thiosulfate 100mg,J0208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,291.45,,,,,,,fee schedule,95.45,423.47,
Inj sodium thiosulfate 100mg,J0208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,318.38,,,,,,,fee schedule,95.45,423.47,
Inj sodium thiosulfate 100mg,J0208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,156.73,,,,,,,fee schedule,95.45,423.47,
Inj sodium thiosulfate 100mg,J0208,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,423.47,,,,,,,fee schedule,95.45,423.47,APC 378
Inj sodium thiosulfate 100mg,J0208,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,100.22,,,,,,,fee schedule,95.45,423.47,APC
Inj sodium thiosulfate 100mg,J0208,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,99.27,,,,,,,fee schedule,95.45,423.47,APC
Inj sodium thiosulfate 100mg,J0208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,95.45,,,,,,,fee schedule,95.45,423.47,APC
Inj sodium thiosulfate 100mg,J0208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,146.04,,,,,,,fee schedule,95.45,423.47,Radiology
Inj sodium thiosulfate 100mg,J0208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,133.63,,,,,,,fee schedule,95.45,423.47,APC
Inj sodium thiosulfate 100mg,J0208,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,167.04,,,,,,,fee schedule,95.45,423.47,APC
"Inj, sod thiosulfate (hope)",J0209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.47,,,,,,,fee schedule,0.88,3.91,
"Inj, sod thiosulfate (hope)",J0209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.33,,,,,,,fee schedule,0.88,3.91,
"Inj, sod thiosulfate (hope)",J0209,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.91,,,,,,,fee schedule,0.88,3.91,APC 378
"Inj, sod thiosulfate (hope)",J0209,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,0.93,,,,,,,fee schedule,0.88,3.91,APC
"Inj, sod thiosulfate (hope)",J0209,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,0.92,,,,,,,fee schedule,0.88,3.91,APC
"Inj, sod thiosulfate (hope)",J0209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,0.88,,,,,,,fee schedule,0.88,3.91,APC
"Inj, sod thiosulfate (hope)",J0209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1.35,,,,,,,fee schedule,0.88,3.91,Radiology
"Inj, sod thiosulfate (hope)",J0209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1.23,,,,,,,fee schedule,0.88,3.91,APC
"Inj, sod thiosulfate (hope)",J0209,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1.54,,,,,,,fee schedule,0.88,3.91,APC
Methyldopate hcl injection,J0210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45.14,,,,,,,fee schedule,39.3,79,
Methyldopate hcl injection,J0210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,49.03,,,,,,,fee schedule,39.3,79,
Methyldopate hcl injection,J0210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,79,,,,,,,fee schedule,39.3,79,
Methyldopate hcl injection,J0210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39.3,,,,,,,fee schedule,39.3,79,
Methyldopate hcl injection,J0210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.93,,,,,,,fee schedule,39.3,79,
Methyldopate hcl injection,J0210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,71.5,,,,,,,fee schedule,39.3,79,
"Inj, nithiodote, 3mg / 125mg",J0211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3,,,,,,,fee schedule,2.17,9.61,
"Inj, nithiodote, 3mg / 125mg",J0211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.72,,,,,,,fee schedule,2.17,9.61,
"Inj, nithiodote, 3mg / 125mg",J0211,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.61,,,,,,,fee schedule,2.17,9.61,APC 378
"Inj, nithiodote, 3mg / 125mg",J0211,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2.27,,,,,,,fee schedule,2.17,9.61,APC
"Inj, nithiodote, 3mg / 125mg",J0211,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2.25,,,,,,,fee schedule,2.17,9.61,APC
"Inj, nithiodote, 3mg / 125mg",J0211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2.17,,,,,,,fee schedule,2.17,9.61,APC
"Inj, nithiodote, 3mg / 125mg",J0211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3.31,,,,,,,fee schedule,2.17,9.61,Radiology
"Inj, nithiodote, 3mg / 125mg",J0211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3.03,,,,,,,fee schedule,2.17,9.61,APC
"Inj, nithiodote, 3mg / 125mg",J0211,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3.79,,,,,,,fee schedule,2.17,9.61,APC
Alefacept,J0215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,101.3,,,,,,,fee schedule,88.2,110.04,
Alefacept,J0215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,110.04,,,,,,,fee schedule,88.2,110.04,
Alefacept,J0215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,88.2,,,,,,,fee schedule,88.2,110.04,
Alefacept,J0215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,96.35,,,,,,,fee schedule,88.2,110.04,
"Inj, alfentanil hcl, 500mcg",J0216,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7.14,,,,,,,fee schedule,6.46,7.14,
"Inj, alfentanil hcl, 500mcg",J0216,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.46,,,,,,,fee schedule,6.46,7.14,
Inj velmanase alfa-tycv 1 mg,J0217,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1475.52,,,,,,,fee schedule,465.23,1602.72,
Inj velmanase alfa-tycv 1 mg,J0217,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1602.72,,,,,,,fee schedule,465.23,1602.72,
Inj velmanase alfa-tycv 1 mg,J0217,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,796.32,,,,,,,fee schedule,465.23,1602.72,
Inj velmanase alfa-tycv 1 mg,J0217,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1284.72,,,,,,,fee schedule,465.23,1602.72,
Inj velmanase alfa-tycv 1 mg,J0217,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1403.44,,,,,,,fee schedule,465.23,1602.72,
Inj velmanase alfa-tycv 1 mg,J0217,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,720.72,,,,,,,fee schedule,465.23,1602.72,
Inj velmanase alfa-tycv 1 mg,J0217,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,539.67,,,,,,,fee schedule,465.23,1602.72,OP High Cost Drugs
Inj velmanase alfa-tycv 1 mg,J0217,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,465.23,,,,,,,fee schedule,465.23,1602.72,Other Pharmacy
Inj velmanase alfa-tycv 1 mg,J0217,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,488.5,,,,,,,fee schedule,465.23,1602.72,APC
Inj velmanase alfa-tycv 1 mg,J0217,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,483.84,,,,,,,fee schedule,465.23,1602.72,APC
Inj velmanase alfa-tycv 1 mg,J0217,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,711.81,,,,,,,fee schedule,465.23,1602.72,Radiology
Inj velmanase alfa-tycv 1 mg,J0217,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,651.33,,,,,,,fee schedule,465.23,1602.72,APC
Inj velmanase alfa-tycv 1 mg,J0217,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,814.16,,,,,,,fee schedule,465.23,1602.72,APC
Inj olipudase alfa-rpcp 1mg,J0218,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1312.35,,,,,,,fee schedule,395.6,1425.49,
Inj olipudase alfa-rpcp 1mg,J0218,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1425.49,,,,,,,fee schedule,395.6,1425.49,
Inj olipudase alfa-rpcp 1mg,J0218,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,690.6,,,,,,,fee schedule,395.6,1425.49,
Inj olipudase alfa-rpcp 1mg,J0218,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1142.65,,,,,,,fee schedule,395.6,1425.49,
Inj olipudase alfa-rpcp 1mg,J0218,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1248.24,,,,,,,fee schedule,395.6,1425.49,
Inj olipudase alfa-rpcp 1mg,J0218,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,625.04,,,,,,,fee schedule,395.6,1425.49,
Inj olipudase alfa-rpcp 1mg,J0218,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,458.89,,,,,,,fee schedule,395.6,1425.49,OP High Cost Drugs
Inj olipudase alfa-rpcp 1mg,J0218,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,395.6,,,,,,,fee schedule,395.6,1425.49,Other Pharmacy
Inj olipudase alfa-rpcp 1mg,J0218,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,415.38,,,,,,,fee schedule,395.6,1425.49,APC
Inj olipudase alfa-rpcp 1mg,J0218,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,411.42,,,,,,,fee schedule,395.6,1425.49,APC
Inj olipudase alfa-rpcp 1mg,J0218,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,605.26,,,,,,,fee schedule,395.6,1425.49,Radiology
Inj olipudase alfa-rpcp 1mg,J0218,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,553.84,,,,,,,fee schedule,395.6,1425.49,APC
Inj olipudase alfa-rpcp 1mg,J0218,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,692.3,,,,,,,fee schedule,395.6,1425.49,APC
Inj aval alfa-nqpt 4mg,J0219,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,253.03,,,,,,,fee schedule,81.2,274.84,
Inj aval alfa-nqpt 4mg,J0219,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,274.84,,,,,,,fee schedule,81.2,274.84,
Inj aval alfa-nqpt 4mg,J0219,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,140.65,,,,,,,fee schedule,81.2,274.84,
Inj aval alfa-nqpt 4mg,J0219,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,220.31,,,,,,,fee schedule,81.2,274.84,
Inj aval alfa-nqpt 4mg,J0219,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,240.67,,,,,,,fee schedule,81.2,274.84,
Inj aval alfa-nqpt 4mg,J0219,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,127.3,,,,,,,fee schedule,81.2,274.84,
Inj aval alfa-nqpt 4mg,J0219,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,94.2,,,,,,,fee schedule,81.2,274.84,OP High Cost Drugs
Inj aval alfa-nqpt 4mg,J0219,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.2,,,,,,,fee schedule,81.2,274.84,Other Pharmacy
Inj aval alfa-nqpt 4mg,J0219,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,85.26,,,,,,,fee schedule,81.2,274.84,APC
Inj aval alfa-nqpt 4mg,J0219,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,84.45,,,,,,,fee schedule,81.2,274.84,APC
Inj aval alfa-nqpt 4mg,J0219,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,124.24,,,,,,,fee schedule,81.2,274.84,Radiology
Inj aval alfa-nqpt 4mg,J0219,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,113.69,,,,,,,fee schedule,81.2,274.84,APC
Inj aval alfa-nqpt 4mg,J0219,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,142.11,,,,,,,fee schedule,81.2,274.84,APC
Alglucosidase alfa injection,J0220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,454.52,,,,,,,fee schedule,334.62,493.71,
Alglucosidase alfa injection,J0220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,493.71,,,,,,,fee schedule,334.62,493.71,
Alglucosidase alfa injection,J0220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,369.72,,,,,,,fee schedule,334.62,493.71,
Alglucosidase alfa injection,J0220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,395.75,,,,,,,fee schedule,334.62,493.71,
Alglucosidase alfa injection,J0220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,432.32,,,,,,,fee schedule,334.62,493.71,
Alglucosidase alfa injection,J0220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,334.62,,,,,,,fee schedule,334.62,493.71,
Lumizyme injection,J0221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,534.6,,,,,,,fee schedule,207.51,580.68,
Lumizyme injection,J0221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,580.68,,,,,,,fee schedule,207.51,580.68,
Lumizyme injection,J0221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,365.71,,,,,,,fee schedule,207.51,580.68,
Lumizyme injection,J0221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,465.47,,,,,,,fee schedule,207.51,580.68,
Lumizyme injection,J0221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,508.48,,,,,,,fee schedule,207.51,580.68,
Lumizyme injection,J0221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,330.99,,,,,,,fee schedule,207.51,580.68,
Lumizyme injection,J0221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,240.71,,,,,,,fee schedule,207.51,580.68,OP High Cost Drugs
Lumizyme injection,J0221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,207.51,,,,,,,fee schedule,207.51,580.68,Other Pharmacy
Lumizyme injection,J0221,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,217.89,,,,,,,fee schedule,207.51,580.68,APC
Lumizyme injection,J0221,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,215.81,,,,,,,fee schedule,207.51,580.68,APC
Lumizyme injection,J0221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,317.49,,,,,,,fee schedule,207.51,580.68,Radiology
Lumizyme injection,J0221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,290.52,,,,,,,fee schedule,207.51,580.68,APC
Lumizyme injection,J0221,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,363.15,,,,,,,fee schedule,207.51,580.68,APC
"Inj., patisiran, 0.1 mg",J0222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,342.16,,,,,,,fee schedule,100.9,371.66,
"Inj., patisiran, 0.1 mg",J0222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,371.66,,,,,,,fee schedule,100.9,371.66,
"Inj., patisiran, 0.1 mg",J0222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,185.52,,,,,,,fee schedule,100.9,371.66,
"Inj., patisiran, 0.1 mg",J0222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,297.92,,,,,,,fee schedule,100.9,371.66,
"Inj., patisiran, 0.1 mg",J0222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,325.45,,,,,,,fee schedule,100.9,371.66,
"Inj., patisiran, 0.1 mg",J0222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,167.91,,,,,,,fee schedule,100.9,371.66,
"Inj., patisiran, 0.1 mg",J0222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,117.04,,,,,,,fee schedule,100.9,371.66,OP High Cost Drugs
"Inj., patisiran, 0.1 mg",J0222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,100.9,,,,,,,fee schedule,100.9,371.66,Other Pharmacy
"Inj., patisiran, 0.1 mg",J0222,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,105.94,,,,,,,fee schedule,100.9,371.66,APC
"Inj., patisiran, 0.1 mg",J0222,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,104.93,,,,,,,fee schedule,100.9,371.66,APC
"Inj., patisiran, 0.1 mg",J0222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,154.37,,,,,,,fee schedule,100.9,371.66,Radiology
"Inj., patisiran, 0.1 mg",J0222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,141.25,,,,,,,fee schedule,100.9,371.66,APC
"Inj., patisiran, 0.1 mg",J0222,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,176.57,,,,,,,fee schedule,100.9,371.66,APC
Inj givosiran 0.5 mg,J0223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,371.94,,,,,,,fee schedule,120.98,404.01,
Inj givosiran 0.5 mg,J0223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,404.01,,,,,,,fee schedule,120.98,404.01,
Inj givosiran 0.5 mg,J0223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,210.08,,,,,,,fee schedule,120.98,404.01,
Inj givosiran 0.5 mg,J0223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,323.85,,,,,,,fee schedule,120.98,404.01,
Inj givosiran 0.5 mg,J0223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.77,,,,,,,fee schedule,120.98,404.01,
Inj givosiran 0.5 mg,J0223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,190.13,,,,,,,fee schedule,120.98,404.01,
Inj givosiran 0.5 mg,J0223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,140.34,,,,,,,fee schedule,120.98,404.01,OP High Cost Drugs
Inj givosiran 0.5 mg,J0223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.98,,,,,,,fee schedule,120.98,404.01,Other Pharmacy
Inj givosiran 0.5 mg,J0223,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,127.03,,,,,,,fee schedule,120.98,404.01,APC
Inj givosiran 0.5 mg,J0223,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,125.82,,,,,,,fee schedule,120.98,404.01,APC
Inj givosiran 0.5 mg,J0223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,185.1,,,,,,,fee schedule,120.98,404.01,Radiology
Inj givosiran 0.5 mg,J0223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,169.38,,,,,,,fee schedule,120.98,404.01,APC
Inj givosiran 0.5 mg,J0223,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,211.72,,,,,,,fee schedule,120.98,404.01,APC
"Inj. lumasiran, 0.5 mg",J0224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1051.9,,,,,,,fee schedule,327.72,1142.58,
"Inj. lumasiran, 0.5 mg",J0224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1142.58,,,,,,,fee schedule,327.72,1142.58,
"Inj. lumasiran, 0.5 mg",J0224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,575.28,,,,,,,fee schedule,327.72,1142.58,
"Inj. lumasiran, 0.5 mg",J0224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,915.88,,,,,,,fee schedule,327.72,1142.58,
"Inj. lumasiran, 0.5 mg",J0224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1000.52,,,,,,,fee schedule,327.72,1142.58,
"Inj. lumasiran, 0.5 mg",J0224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,520.66,,,,,,,fee schedule,327.72,1142.58,
"Inj. lumasiran, 0.5 mg",J0224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,380.15,,,,,,,fee schedule,327.72,1142.58,OP High Cost Drugs
"Inj. lumasiran, 0.5 mg",J0224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.72,,,,,,,fee schedule,327.72,1142.58,Other Pharmacy
"Inj. lumasiran, 0.5 mg",J0224,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,344.1,,,,,,,fee schedule,327.72,1142.58,APC
"Inj. lumasiran, 0.5 mg",J0224,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,340.82,,,,,,,fee schedule,327.72,1142.58,APC
"Inj. lumasiran, 0.5 mg",J0224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,501.4,,,,,,,fee schedule,327.72,1142.58,Radiology
"Inj. lumasiran, 0.5 mg",J0224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,458.8,,,,,,,fee schedule,327.72,1142.58,APC
"Inj. lumasiran, 0.5 mg",J0224,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,573.5,,,,,,,fee schedule,327.72,1142.58,APC
"Inj, vutrisiran, 1 mg",J0225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16613.69,,,,,,,fee schedule,5019.27,18045.91,
"Inj, vutrisiran, 1 mg",J0225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18045.91,,,,,,,fee schedule,5019.27,18045.91,
"Inj, vutrisiran, 1 mg",J0225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9051.58,,,,,,,fee schedule,5019.27,18045.91,
"Inj, vutrisiran, 1 mg",J0225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14465.37,,,,,,,fee schedule,5019.27,18045.91,
"Inj, vutrisiran, 1 mg",J0225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15802.11,,,,,,,fee schedule,5019.27,18045.91,
"Inj, vutrisiran, 1 mg",J0225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8192.26,,,,,,,fee schedule,5019.27,18045.91,
"Inj, vutrisiran, 1 mg",J0225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5822.36,,,,,,,fee schedule,5019.27,18045.91,OP High Cost Drugs
"Inj, vutrisiran, 1 mg",J0225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5019.27,,,,,,,fee schedule,5019.27,18045.91,Other Pharmacy
"Inj, vutrisiran, 1 mg",J0225,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5270.24,,,,,,,fee schedule,5019.27,18045.91,APC
"Inj, vutrisiran, 1 mg",J0225,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5220.04,,,,,,,fee schedule,5019.27,18045.91,APC
"Inj, vutrisiran, 1 mg",J0225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7679.49,,,,,,,fee schedule,5019.27,18045.91,Radiology
"Inj, vutrisiran, 1 mg",J0225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7026.98,,,,,,,fee schedule,5019.27,18045.91,APC
"Inj, vutrisiran, 1 mg",J0225,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8783.73,,,,,,,fee schedule,5019.27,18045.91,APC
"Inj, remdesivir, 1 mg?",J0248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19.18,,,,,,,fee schedule,6.9,20.84,
"Inj, remdesivir, 1 mg?",J0248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20.84,,,,,,,fee schedule,6.9,20.84,
"Inj, remdesivir, 1 mg?",J0248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.86,,,,,,,fee schedule,6.9,20.84,
"Inj, remdesivir, 1 mg?",J0248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.7,,,,,,,fee schedule,6.9,20.84,
"Inj, remdesivir, 1 mg?",J0248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18.24,,,,,,,fee schedule,6.9,20.84,
"Inj, remdesivir, 1 mg?",J0248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.92,,,,,,,fee schedule,6.9,20.84,
"Inj, remdesivir, 1 mg?",J0248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8,,,,,,,fee schedule,6.9,20.84,OP High Cost Drugs
"Inj, remdesivir, 1 mg?",J0248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.9,,,,,,,fee schedule,6.9,20.84,Other Pharmacy
"Inj, remdesivir, 1 mg?",J0248,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.24,,,,,,,fee schedule,6.9,20.84,APC
"Inj, remdesivir, 1 mg?",J0248,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7.17,,,,,,,fee schedule,6.9,20.84,APC
"Inj, remdesivir, 1 mg?",J0248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10.55,,,,,,,fee schedule,6.9,20.84,Radiology
"Inj, remdesivir, 1 mg?",J0248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.66,,,,,,,fee schedule,6.9,20.84,APC
"Inj, remdesivir, 1 mg?",J0248,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12.07,,,,,,,fee schedule,6.9,20.84,APC
Alpha 1 proteinase inhibitor,J0256,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13.15,,,,,,,fee schedule,5.14,14.29,
Alpha 1 proteinase inhibitor,J0256,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14.29,,,,,,,fee schedule,5.14,14.29,
Alpha 1 proteinase inhibitor,J0256,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11.61,,,,,,,fee schedule,5.14,14.29,
Alpha 1 proteinase inhibitor,J0256,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11.45,,,,,,,fee schedule,5.14,14.29,
Alpha 1 proteinase inhibitor,J0256,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12.51,,,,,,,fee schedule,5.14,14.29,
Alpha 1 proteinase inhibitor,J0256,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10.51,,,,,,,fee schedule,5.14,14.29,
Alpha 1 proteinase inhibitor,J0256,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5.96,,,,,,,fee schedule,5.14,14.29,OP High Cost Drugs
Alpha 1 proteinase inhibitor,J0256,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.14,,,,,,,fee schedule,5.14,14.29,Other Pharmacy
Alpha 1 proteinase inhibitor,J0256,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.4,,,,,,,fee schedule,5.14,14.29,APC
Alpha 1 proteinase inhibitor,J0256,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5.35,,,,,,,fee schedule,5.14,14.29,APC
Alpha 1 proteinase inhibitor,J0256,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.87,,,,,,,fee schedule,5.14,14.29,Radiology
Alpha 1 proteinase inhibitor,J0256,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.2,,,,,,,fee schedule,5.14,14.29,APC
Alpha 1 proteinase inhibitor,J0256,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9,,,,,,,fee schedule,5.14,14.29,APC
Glassia injection,J0257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14.02,,,,,,,fee schedule,5.66,15.23,
Glassia injection,J0257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15.23,,,,,,,fee schedule,5.66,15.23,
Glassia injection,J0257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12.17,,,,,,,fee schedule,5.66,15.23,
Glassia injection,J0257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12.21,,,,,,,fee schedule,5.66,15.23,
Glassia injection,J0257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13.34,,,,,,,fee schedule,5.66,15.23,
Glassia injection,J0257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11.01,,,,,,,fee schedule,5.66,15.23,
Glassia injection,J0257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6.57,,,,,,,fee schedule,5.66,15.23,OP High Cost Drugs
Glassia injection,J0257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.66,,,,,,,fee schedule,5.66,15.23,Other Pharmacy
Glassia injection,J0257,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.94,,,,,,,fee schedule,5.66,15.23,APC
Glassia injection,J0257,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5.89,,,,,,,fee schedule,5.66,15.23,APC
Glassia injection,J0257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8.66,,,,,,,fee schedule,5.66,15.23,Radiology
Glassia injection,J0257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.92,,,,,,,fee schedule,5.66,15.23,APC
Glassia injection,J0257,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9.91,,,,,,,fee schedule,5.66,15.23,APC
Alprostadil for injection,J0270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.03,,,,,,,fee schedule,0.66,3.29,
Alprostadil for injection,J0270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.29,,,,,,,fee schedule,0.66,3.29,
Alprostadil for injection,J0270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.73,,,,,,,fee schedule,0.66,3.29,
Alprostadil for injection,J0270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.64,,,,,,,fee schedule,0.66,3.29,
Alprostadil for injection,J0270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.88,,,,,,,fee schedule,0.66,3.29,
Alprostadil for injection,J0270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.66,,,,,,,fee schedule,0.66,3.29,
Alprostadil urethral suppos,J0275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,85.09,,,,,,,fee schedule,70.37,92.42,
Alprostadil urethral suppos,J0275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,92.42,,,,,,,fee schedule,70.37,92.42,
Alprostadil urethral suppos,J0275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,77.75,,,,,,,fee schedule,70.37,92.42,
Alprostadil urethral suppos,J0275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,74.08,,,,,,,fee schedule,70.37,92.42,
Alprostadil urethral suppos,J0275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,80.93,,,,,,,fee schedule,70.37,92.42,
Alprostadil urethral suppos,J0275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,70.37,,,,,,,fee schedule,70.37,92.42,
Amikacin sulfate injection,J0278,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.99,,,,,,,fee schedule,2.7,2.99,
Amikacin sulfate injection,J0278,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.7,,,,,,,fee schedule,2.7,2.99,
Aminophyllin 250 MG inj,J0280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10.08,,,,,,,fee schedule,9.12,10.08,
Aminophyllin 250 MG inj,J0280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.12,,,,,,,fee schedule,9.12,10.08,
Amiodarone HCl,J0282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.92,,,,,,,fee schedule,0.83,0.92,
Amiodarone HCl,J0282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.83,,,,,,,fee schedule,0.83,0.92,
"Inj, amiodarone (nexterone)",J0283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10.22,,,,,,,fee schedule,9.25,10.22,
"Inj, amiodarone (nexterone)",J0283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.25,,,,,,,fee schedule,9.25,10.22,
Amphotericin B,J0285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,94.8,,,,,,,fee schedule,85.8,94.8,
Amphotericin B,J0285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,85.8,,,,,,,fee schedule,85.8,94.8,
Amphotericin b lipid complex,J0287,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,36.61,,,,,,,fee schedule,15.02,39.77,
Amphotericin b lipid complex,J0287,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,39.77,,,,,,,fee schedule,15.02,39.77,
Amphotericin b lipid complex,J0287,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16.59,,,,,,,fee schedule,15.02,39.77,
Amphotericin b lipid complex,J0287,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31.88,,,,,,,fee schedule,15.02,39.77,
Amphotericin b lipid complex,J0287,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,34.82,,,,,,,fee schedule,15.02,39.77,
Amphotericin b lipid complex,J0287,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15.02,,,,,,,fee schedule,15.02,39.77,
Ampho b cholesteryl sulfate,J0288,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42.91,,,,,,,fee schedule,37.36,46.61,
Ampho b cholesteryl sulfate,J0288,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46.61,,,,,,,fee schedule,37.36,46.61,
Ampho b cholesteryl sulfate,J0288,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37.36,,,,,,,fee schedule,37.36,46.61,
Ampho b cholesteryl sulfate,J0288,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40.81,,,,,,,fee schedule,37.36,46.61,
Amphotericin b liposome inj,J0289,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,57.59,,,,,,,fee schedule,22.81,96.6,
Amphotericin b liposome inj,J0289,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,62.56,,,,,,,fee schedule,22.81,96.6,
Amphotericin b liposome inj,J0289,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,96.6,,,,,,,fee schedule,22.81,96.6,
Amphotericin b liposome inj,J0289,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,50.15,,,,,,,fee schedule,22.81,96.6,
Amphotericin b liposome inj,J0289,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,54.78,,,,,,,fee schedule,22.81,96.6,
Amphotericin b liposome inj,J0289,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,87.43,,,,,,,fee schedule,22.81,96.6,
Amphotericin b liposome inj,J0289,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,26.46,,,,,,,fee schedule,22.81,96.6,OP High Cost Drugs
Amphotericin b liposome inj,J0289,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.81,,,,,,,fee schedule,22.81,96.6,Other Pharmacy
Amphotericin b liposome inj,J0289,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,23.95,,,,,,,fee schedule,22.81,96.6,APC
Amphotericin b liposome inj,J0289,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,23.72,,,,,,,fee schedule,22.81,96.6,APC
Amphotericin b liposome inj,J0289,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,34.89,,,,,,,fee schedule,22.81,96.6,Radiology
Amphotericin b liposome inj,J0289,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,31.93,,,,,,,fee schedule,22.81,96.6,APC
Amphotericin b liposome inj,J0289,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,39.91,,,,,,,fee schedule,22.81,96.6,APC
Ampicillin 500 MG inj,J0290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.27,,,,,,,fee schedule,5.68,6.27,
Ampicillin 500 MG inj,J0290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.68,,,,,,,fee schedule,5.68,6.27,
"Inj., plazomicin, 5 mg",J0291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11.2,,,,,,,fee schedule,3.51,12.17,
"Inj., plazomicin, 5 mg",J0291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12.17,,,,,,,fee schedule,3.51,12.17,
"Inj., plazomicin, 5 mg",J0291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.56,,,,,,,fee schedule,3.51,12.17,
"Inj., plazomicin, 5 mg",J0291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.75,,,,,,,fee schedule,3.51,12.17,
"Inj., plazomicin, 5 mg",J0291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10.65,,,,,,,fee schedule,3.51,12.17,
"Inj., plazomicin, 5 mg",J0291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.93,,,,,,,fee schedule,3.51,12.17,
"Inj., plazomicin, 5 mg",J0291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4.07,,,,,,,fee schedule,3.51,12.17,OP High Cost Drugs
"Inj., plazomicin, 5 mg",J0291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3.51,,,,,,,fee schedule,3.51,12.17,Other Pharmacy
"Inj., plazomicin, 5 mg",J0291,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3.68,,,,,,,fee schedule,3.51,12.17,APC
"Inj., plazomicin, 5 mg",J0291,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3.65,,,,,,,fee schedule,3.51,12.17,APC
"Inj., plazomicin, 5 mg",J0291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.37,,,,,,,fee schedule,3.51,12.17,Radiology
"Inj., plazomicin, 5 mg",J0291,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4.91,,,,,,,fee schedule,3.51,12.17,APC
"Inj., plazomicin, 5 mg",J0291,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6.14,,,,,,,fee schedule,3.51,12.17,APC
Ampicillin sodium per 1.5 gm,J0295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.48,,,,,,,fee schedule,8.58,9.48,
Ampicillin sodium per 1.5 gm,J0295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.58,,,,,,,fee schedule,8.58,9.48,
Amobarbital 125 MG inj,J0300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,676.02,,,,,,,fee schedule,588.61,734.3,
Amobarbital 125 MG inj,J0300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,734.3,,,,,,,fee schedule,588.61,734.3,
Amobarbital 125 MG inj,J0300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,588.61,,,,,,,fee schedule,588.61,734.3,
Amobarbital 125 MG inj,J0300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,643,,,,,,,fee schedule,588.61,734.3,
Succinycholine chloride inj,J0330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.98,,,,,,,fee schedule,1.79,1.98,
Succinycholine chloride inj,J0330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.79,,,,,,,fee schedule,1.79,1.98,
Anidulafungin injection,J0348,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.87,,,,,,,fee schedule,3.27,5.29,
Anidulafungin injection,J0348,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.29,,,,,,,fee schedule,3.27,5.29,
Anidulafungin injection,J0348,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.62,,,,,,,fee schedule,3.27,5.29,
Anidulafungin injection,J0348,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.24,,,,,,,fee schedule,3.27,5.29,
Anidulafungin injection,J0348,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.63,,,,,,,fee schedule,3.27,5.29,
Anidulafungin injection,J0348,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.27,,,,,,,fee schedule,3.27,5.29,
"Inj, rezafungin, 1 mg",J0349,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,34.95,,,,,,,fee schedule,10.79,37.96,
"Inj, rezafungin, 1 mg",J0349,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37.96,,,,,,,fee schedule,10.79,37.96,
"Inj, rezafungin, 1 mg",J0349,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19.04,,,,,,,fee schedule,10.79,37.96,
"Inj, rezafungin, 1 mg",J0349,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,30.43,,,,,,,fee schedule,10.79,37.96,
"Inj, rezafungin, 1 mg",J0349,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,33.24,,,,,,,fee schedule,10.79,37.96,
"Inj, rezafungin, 1 mg",J0349,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17.23,,,,,,,fee schedule,10.79,37.96,
"Inj, rezafungin, 1 mg",J0349,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.51,,,,,,,fee schedule,10.79,37.96,OP High Cost Drugs
"Inj, rezafungin, 1 mg",J0349,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10.79,,,,,,,fee schedule,10.79,37.96,Other Pharmacy
"Inj, rezafungin, 1 mg",J0349,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.33,,,,,,,fee schedule,10.79,37.96,APC
"Inj, rezafungin, 1 mg",J0349,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11.22,,,,,,,fee schedule,10.79,37.96,APC
"Inj, rezafungin, 1 mg",J0349,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.5,,,,,,,fee schedule,10.79,37.96,Radiology
"Inj, rezafungin, 1 mg",J0349,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15.1,,,,,,,fee schedule,10.79,37.96,APC
"Inj, rezafungin, 1 mg",J0349,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18.88,,,,,,,fee schedule,10.79,37.96,APC
Injection anistreplase 30 u,J0350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6154.31,,,,,,,fee schedule,5358.49,6684.85,
Injection anistreplase 30 u,J0350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6684.85,,,,,,,fee schedule,5358.49,6684.85,
Injection anistreplase 30 u,J0350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5358.49,,,,,,,fee schedule,5358.49,6684.85,
Injection anistreplase 30 u,J0350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5853.67,,,,,,,fee schedule,5358.49,6684.85,
Hydralazine hcl injection,J0360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,28.44,,,,,,,fee schedule,25.74,28.44,
Hydralazine hcl injection,J0360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,25.74,,,,,,,fee schedule,25.74,28.44,
Apomorphine hydrochloride,J0364,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83.77,,,,,,,fee schedule,75.82,83.77,
Apomorphine hydrochloride,J0364,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,75.82,,,,,,,fee schedule,75.82,83.77,
"Aprotonin, 10,000 kiu",J0365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.47,,,,,,,fee schedule,8.24,10.28,
"Aprotonin, 10,000 kiu",J0365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10.28,,,,,,,fee schedule,8.24,10.28,
"Aprotonin, 10,000 kiu",J0365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.24,,,,,,,fee schedule,8.24,10.28,
"Aprotonin, 10,000 kiu",J0365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9,,,,,,,fee schedule,8.24,10.28,
Chloroquine injection,J0390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,574.97,,,,,,,fee schedule,500.62,624.53,
Chloroquine injection,J0390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,624.53,,,,,,,fee schedule,500.62,624.53,
Chloroquine injection,J0390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,500.62,,,,,,,fee schedule,500.62,624.53,
Chloroquine injection,J0390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,546.88,,,,,,,fee schedule,500.62,624.53,
"Inj, artesunate, 1mg",J0391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,164.64,,,,,,,fee schedule,51.83,229.95,
"Inj, artesunate, 1mg",J0391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,178.83,,,,,,,fee schedule,51.83,229.95,
"Inj, artesunate, 1mg",J0391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,71.61,,,,,,,fee schedule,51.83,229.95,
"Inj, artesunate, 1mg",J0391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,143.35,,,,,,,fee schedule,51.83,229.95,
"Inj, artesunate, 1mg",J0391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,156.59,,,,,,,fee schedule,51.83,229.95,
"Inj, artesunate, 1mg",J0391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,64.81,,,,,,,fee schedule,51.83,229.95,
"Inj, artesunate, 1mg",J0391,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,229.95,,,,,,,fee schedule,51.83,229.95,APC 378
"Inj, artesunate, 1mg",J0391,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.42,,,,,,,fee schedule,51.83,229.95,APC
"Inj, artesunate, 1mg",J0391,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,53.9,,,,,,,fee schedule,51.83,229.95,APC
"Inj, artesunate, 1mg",J0391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,51.83,,,,,,,fee schedule,51.83,229.95,APC
"Inj, artesunate, 1mg",J0391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,79.3,,,,,,,fee schedule,51.83,229.95,Radiology
"Inj, artesunate, 1mg",J0391,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,72.56,,,,,,,fee schedule,51.83,229.95,APC
"Inj, artesunate, 1mg",J0391,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,90.7,,,,,,,fee schedule,51.83,229.95,APC
Aripiprazole injection,J0400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.04,,,,,,,fee schedule,0.91,1.34,
Aripiprazole injection,J0400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.13,,,,,,,fee schedule,0.91,1.34,
Aripiprazole injection,J0400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.34,,,,,,,fee schedule,0.91,1.34,
Aripiprazole injection,J0400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.91,,,,,,,fee schedule,0.91,1.34,
Aripiprazole injection,J0400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.99,,,,,,,fee schedule,0.91,1.34,
Aripiprazole injection,J0400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.22,,,,,,,fee schedule,0.91,1.34,
Inj aripiprazole ext rel 1mg,J0401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13.85,,,,,,,fee schedule,7.27,15.04,
Inj aripiprazole ext rel 1mg,J0401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15.04,,,,,,,fee schedule,7.27,15.04,
Inj aripiprazole ext rel 1mg,J0401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13.3,,,,,,,fee schedule,7.27,15.04,
Inj aripiprazole ext rel 1mg,J0401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12.06,,,,,,,fee schedule,7.27,15.04,
Inj aripiprazole ext rel 1mg,J0401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13.17,,,,,,,fee schedule,7.27,15.04,
Inj aripiprazole ext rel 1mg,J0401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12.04,,,,,,,fee schedule,7.27,15.04,
Inj aripiprazole ext rel 1mg,J0401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8.43,,,,,,,fee schedule,7.27,15.04,OP High Cost Drugs
Inj aripiprazole ext rel 1mg,J0401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.27,,,,,,,fee schedule,7.27,15.04,Other Pharmacy
Inj aripiprazole ext rel 1mg,J0401,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.63,,,,,,,fee schedule,7.27,15.04,APC
Inj aripiprazole ext rel 1mg,J0401,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7.56,,,,,,,fee schedule,7.27,15.04,APC
Inj aripiprazole ext rel 1mg,J0401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11.12,,,,,,,fee schedule,7.27,15.04,Radiology
Inj aripiprazole ext rel 1mg,J0401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10.18,,,,,,,fee schedule,7.27,15.04,APC
Inj aripiprazole ext rel 1mg,J0401,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12.72,,,,,,,fee schedule,7.27,15.04,APC
"Inj, abilify asimtufii, 1 mg",J0402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20.31,,,,,,,fee schedule,6.02,22.06,
"Inj, abilify asimtufii, 1 mg",J0402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22.06,,,,,,,fee schedule,6.02,22.06,
"Inj, abilify asimtufii, 1 mg",J0402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11.03,,,,,,,fee schedule,6.02,22.06,
"Inj, abilify asimtufii, 1 mg",J0402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17.68,,,,,,,fee schedule,6.02,22.06,
"Inj, abilify asimtufii, 1 mg",J0402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19.31,,,,,,,fee schedule,6.02,22.06,
"Inj, abilify asimtufii, 1 mg",J0402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.98,,,,,,,fee schedule,6.02,22.06,
"Inj, abilify asimtufii, 1 mg",J0402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6.99,,,,,,,fee schedule,6.02,22.06,OP High Cost Drugs
"Inj, abilify asimtufii, 1 mg",J0402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.02,,,,,,,fee schedule,6.02,22.06,Other Pharmacy
"Inj, abilify asimtufii, 1 mg",J0402,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.32,,,,,,,fee schedule,6.02,22.06,APC
"Inj, abilify asimtufii, 1 mg",J0402,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6.26,,,,,,,fee schedule,6.02,22.06,APC
"Inj, abilify asimtufii, 1 mg",J0402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.21,,,,,,,fee schedule,6.02,22.06,Radiology
"Inj, abilify asimtufii, 1 mg",J0402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8.43,,,,,,,fee schedule,6.02,22.06,APC
"Inj, abilify asimtufii, 1 mg",J0402,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10.54,,,,,,,fee schedule,6.02,22.06,APC
Azithromycin,J0456,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11.46,,,,,,,fee schedule,10.37,11.46,
Azithromycin,J0456,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10.37,,,,,,,fee schedule,10.37,11.46,
"Injection, aztreonam, 100 mg",J0457,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8.77,,,,,,,fee schedule,5.62,9.52,
"Injection, aztreonam, 100 mg",J0457,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.52,,,,,,,fee schedule,5.62,9.52,
"Injection, aztreonam, 100 mg",J0457,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.21,,,,,,,fee schedule,5.62,9.52,
"Injection, aztreonam, 100 mg",J0457,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7.63,,,,,,,fee schedule,5.62,9.52,
"Injection, aztreonam, 100 mg",J0457,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.34,,,,,,,fee schedule,5.62,9.52,
"Injection, aztreonam, 100 mg",J0457,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.62,,,,,,,fee schedule,5.62,9.52,
Atropine sulfate injection,J0461,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.1,,,,,,,fee schedule,0.09,0.19,
Atropine sulfate injection,J0461,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.11,,,,,,,fee schedule,0.09,0.19,
Atropine sulfate injection,J0461,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.19,,,,,,,fee schedule,0.09,0.19,
Atropine sulfate injection,J0461,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.09,,,,,,,fee schedule,0.09,0.19,
Atropine sulfate injection,J0461,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.1,,,,,,,fee schedule,0.09,0.19,
Atropine sulfate injection,J0461,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.17,,,,,,,fee schedule,0.09,0.19,
Dimecaprol injection,J0470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,131.58,,,,,,,fee schedule,91.78,142.92,
Dimecaprol injection,J0470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,142.92,,,,,,,fee schedule,91.78,142.92,
Dimecaprol injection,J0470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,101.4,,,,,,,fee schedule,91.78,142.92,
Dimecaprol injection,J0470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,114.56,,,,,,,fee schedule,91.78,142.92,
Dimecaprol injection,J0470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,125.15,,,,,,,fee schedule,91.78,142.92,
Dimecaprol injection,J0470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,91.78,,,,,,,fee schedule,91.78,142.92,
Baclofen 10 mg injection,J0475,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,671.15,,,,,,,fee schedule,178.05,729.01,
Baclofen 10 mg injection,J0475,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,729.01,,,,,,,fee schedule,178.05,729.01,
Baclofen 10 mg injection,J0475,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,447.99,,,,,,,fee schedule,178.05,729.01,
Baclofen 10 mg injection,J0475,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,584.37,,,,,,,fee schedule,178.05,729.01,
Baclofen 10 mg injection,J0475,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,638.37,,,,,,,fee schedule,178.05,729.01,
Baclofen 10 mg injection,J0475,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,405.46,,,,,,,fee schedule,178.05,729.01,
Baclofen 10 mg injection,J0475,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,206.54,,,,,,,fee schedule,178.05,729.01,OP High Cost Drugs
Baclofen 10 mg injection,J0475,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,178.05,,,,,,,fee schedule,178.05,729.01,Other Pharmacy
Baclofen 10 mg injection,J0475,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,186.95,,,,,,,fee schedule,178.05,729.01,APC
Baclofen 10 mg injection,J0475,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,185.17,,,,,,,fee schedule,178.05,729.01,APC
Baclofen 10 mg injection,J0475,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,272.42,,,,,,,fee schedule,178.05,729.01,Radiology
Baclofen 10 mg injection,J0475,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,249.27,,,,,,,fee schedule,178.05,729.01,APC
Baclofen 10 mg injection,J0475,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,311.59,,,,,,,fee schedule,178.05,729.01,APC
Baclofen intrathecal trial,J0476,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,248.19,,,,,,,fee schedule,75.5,269.59,
Baclofen intrathecal trial,J0476,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,269.59,,,,,,,fee schedule,75.5,269.59,
Baclofen intrathecal trial,J0476,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83.42,,,,,,,fee schedule,75.5,269.59,
Baclofen intrathecal trial,J0476,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,216.1,,,,,,,fee schedule,75.5,269.59,
Baclofen intrathecal trial,J0476,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,236.07,,,,,,,fee schedule,75.5,269.59,
Baclofen intrathecal trial,J0476,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,75.5,,,,,,,fee schedule,75.5,269.59,
Basiliximab,J0480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5701.7,,,,,,,fee schedule,4812.31,10694.26,
Basiliximab,J0480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6193.23,,,,,,,fee schedule,4812.31,10694.26,
Basiliximab,J0480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10694.26,,,,,,,fee schedule,4812.31,10694.26,
Basiliximab,J0480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4964.41,,,,,,,fee schedule,4812.31,10694.26,
Basiliximab,J0480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5423.17,,,,,,,fee schedule,4812.31,10694.26,
Basiliximab,J0480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9678.98,,,,,,,fee schedule,4812.31,10694.26,
Basiliximab,J0480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5582.28,,,,,,,fee schedule,4812.31,10694.26,OP High Cost Drugs
Basiliximab,J0480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4812.31,,,,,,,fee schedule,4812.31,10694.26,Other Pharmacy
Basiliximab,J0480,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5052.93,,,,,,,fee schedule,4812.31,10694.26,APC
Basiliximab,J0480,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5004.81,,,,,,,fee schedule,4812.31,10694.26,APC
Basiliximab,J0480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7362.84,,,,,,,fee schedule,4812.31,10694.26,Radiology
Basiliximab,J0480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6737.24,,,,,,,fee schedule,4812.31,10694.26,APC
Basiliximab,J0480,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8421.55,,,,,,,fee schedule,4812.31,10694.26,APC
Belatacept injection,J0485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13.22,,,,,,,fee schedule,3.89,14.36,
Belatacept injection,J0485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14.36,,,,,,,fee schedule,3.89,14.36,
Belatacept injection,J0485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7.36,,,,,,,fee schedule,3.89,14.36,
Belatacept injection,J0485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11.51,,,,,,,fee schedule,3.89,14.36,
Belatacept injection,J0485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12.58,,,,,,,fee schedule,3.89,14.36,
Belatacept injection,J0485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.66,,,,,,,fee schedule,3.89,14.36,
Belatacept injection,J0485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4.52,,,,,,,fee schedule,3.89,14.36,OP High Cost Drugs
Belatacept injection,J0485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3.89,,,,,,,fee schedule,3.89,14.36,Other Pharmacy
Belatacept injection,J0485,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.09,,,,,,,fee schedule,3.89,14.36,APC
Belatacept injection,J0485,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4.05,,,,,,,fee schedule,3.89,14.36,APC
Belatacept injection,J0485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.96,,,,,,,fee schedule,3.89,14.36,Radiology
Belatacept injection,J0485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.45,,,,,,,fee schedule,3.89,14.36,APC
Belatacept injection,J0485,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6.81,,,,,,,fee schedule,3.89,14.36,APC
Belimumab injection,J0490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,133.04,,,,,,,fee schedule,57.19,144.51,
Belimumab injection,J0490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,144.51,,,,,,,fee schedule,57.19,144.51,
Belimumab injection,J0490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,98.31,,,,,,,fee schedule,57.19,144.51,
Belimumab injection,J0490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,115.84,,,,,,,fee schedule,57.19,144.51,
Belimumab injection,J0490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,126.54,,,,,,,fee schedule,57.19,144.51,
Belimumab injection,J0490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,88.97,,,,,,,fee schedule,57.19,144.51,
Belimumab injection,J0490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,66.34,,,,,,,fee schedule,57.19,144.51,OP High Cost Drugs
Belimumab injection,J0490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,57.19,,,,,,,fee schedule,57.19,144.51,Other Pharmacy
Belimumab injection,J0490,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,60.05,,,,,,,fee schedule,57.19,144.51,APC
Belimumab injection,J0490,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,59.48,,,,,,,fee schedule,57.19,144.51,APC
Belimumab injection,J0490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,87.5,,,,,,,fee schedule,57.19,144.51,Radiology
Belimumab injection,J0490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,80.06,,,,,,,fee schedule,57.19,144.51,APC
Belimumab injection,J0490,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,100.08,,,,,,,fee schedule,57.19,144.51,APC
Inj anifrolumab-fnia 1mg,J0491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,56.41,,,,,,,fee schedule,18.31,61.27,
Inj anifrolumab-fnia 1mg,J0491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,61.27,,,,,,,fee schedule,18.31,61.27,
Inj anifrolumab-fnia 1mg,J0491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33.21,,,,,,,fee schedule,18.31,61.27,
Inj anifrolumab-fnia 1mg,J0491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,49.12,,,,,,,fee schedule,18.31,61.27,
Inj anifrolumab-fnia 1mg,J0491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.66,,,,,,,fee schedule,18.31,61.27,
Inj anifrolumab-fnia 1mg,J0491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,30.06,,,,,,,fee schedule,18.31,61.27,
Inj anifrolumab-fnia 1mg,J0491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,21.24,,,,,,,fee schedule,18.31,61.27,OP High Cost Drugs
Inj anifrolumab-fnia 1mg,J0491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.31,,,,,,,fee schedule,18.31,61.27,Other Pharmacy
Inj anifrolumab-fnia 1mg,J0491,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.22,,,,,,,fee schedule,18.31,61.27,APC
Inj anifrolumab-fnia 1mg,J0491,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,19.04,,,,,,,fee schedule,18.31,61.27,APC
Inj anifrolumab-fnia 1mg,J0491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.01,,,,,,,fee schedule,18.31,61.27,Radiology
Inj anifrolumab-fnia 1mg,J0491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.63,,,,,,,fee schedule,18.31,61.27,APC
Inj anifrolumab-fnia 1mg,J0491,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,32.04,,,,,,,fee schedule,18.31,61.27,APC
Dicyclomine injection,J0500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,75.49,,,,,,,fee schedule,68.33,75.49,
Dicyclomine injection,J0500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,68.33,,,,,,,fee schedule,68.33,75.49,
Inj benztropine mesylate,J0515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,49.28,,,,,,,fee schedule,44.6,49.28,
Inj benztropine mesylate,J0515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,44.6,,,,,,,fee schedule,44.6,49.28,
"Inj., benralizumab, 1 mg",J0517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,582.8,,,,,,,fee schedule,163.36,633.04,
"Inj., benralizumab, 1 mg",J0517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,633.04,,,,,,,fee schedule,163.36,633.04,
"Inj., benralizumab, 1 mg",J0517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,358.41,,,,,,,fee schedule,163.36,633.04,
"Inj., benralizumab, 1 mg",J0517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,507.44,,,,,,,fee schedule,163.36,633.04,
"Inj., benralizumab, 1 mg",J0517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,554.33,,,,,,,fee schedule,163.36,633.04,
"Inj., benralizumab, 1 mg",J0517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,324.38,,,,,,,fee schedule,163.36,633.04,
"Inj., benralizumab, 1 mg",J0517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,189.49,,,,,,,fee schedule,163.36,633.04,OP High Cost Drugs
"Inj., benralizumab, 1 mg",J0517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,163.36,,,,,,,fee schedule,163.36,633.04,Other Pharmacy
"Inj., benralizumab, 1 mg",J0517,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,171.52,,,,,,,fee schedule,163.36,633.04,APC
"Inj., benralizumab, 1 mg",J0517,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,169.89,,,,,,,fee schedule,163.36,633.04,APC
"Inj., benralizumab, 1 mg",J0517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,249.94,,,,,,,fee schedule,163.36,633.04,Radiology
"Inj., benralizumab, 1 mg",J0517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,228.7,,,,,,,fee schedule,163.36,633.04,APC
"Inj., benralizumab, 1 mg",J0517,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,285.87,,,,,,,fee schedule,163.36,633.04,APC
PenG benzathine/procaine inj,J0558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13.85,,,,,,,fee schedule,12.06,38.43,
PenG benzathine/procaine inj,J0558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15.04,,,,,,,fee schedule,12.06,38.43,
PenG benzathine/procaine inj,J0558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,38.43,,,,,,,fee schedule,12.06,38.43,
PenG benzathine/procaine inj,J0558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12.06,,,,,,,fee schedule,12.06,38.43,
PenG benzathine/procaine inj,J0558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13.17,,,,,,,fee schedule,12.06,38.43,
PenG benzathine/procaine inj,J0558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,34.78,,,,,,,fee schedule,12.06,38.43,
PenG benzathine/procaine inj,J0558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,22.65,,,,,,,fee schedule,12.06,38.43,OP High Cost Drugs
PenG benzathine/procaine inj,J0558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.52,,,,,,,fee schedule,12.06,38.43,Other Pharmacy
PenG benzathine/procaine inj,J0558,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20.5,,,,,,,fee schedule,12.06,38.43,APC
PenG benzathine/procaine inj,J0558,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,20.3,,,,,,,fee schedule,12.06,38.43,APC
PenG benzathine/procaine inj,J0558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29.87,,,,,,,fee schedule,12.06,38.43,Radiology
PenG benzathine/procaine inj,J0558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27.33,,,,,,,fee schedule,12.06,38.43,APC
PenG benzathine/procaine inj,J0558,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,34.17,,,,,,,fee schedule,12.06,38.43,APC
Penicillin g benzathine inj,J0561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17.75,,,,,,,fee schedule,15.45,55.06,
Penicillin g benzathine inj,J0561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19.28,,,,,,,fee schedule,15.45,55.06,
Penicillin g benzathine inj,J0561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,49.38,,,,,,,fee schedule,15.45,55.06,
Penicillin g benzathine inj,J0561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15.45,,,,,,,fee schedule,15.45,55.06,
Penicillin g benzathine inj,J0561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.88,,,,,,,fee schedule,15.45,55.06,
Penicillin g benzathine inj,J0561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,44.69,,,,,,,fee schedule,15.45,55.06,
Penicillin g benzathine inj,J0561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.5,,,,,,,fee schedule,15.45,55.06,OP High Cost Drugs
Penicillin g benzathine inj,J0561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,31.46,,,,,,,fee schedule,15.45,55.06,Other Pharmacy
Penicillin g benzathine inj,J0561,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,33.04,,,,,,,fee schedule,15.45,55.06,APC
Penicillin g benzathine inj,J0561,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,32.72,,,,,,,fee schedule,15.45,55.06,APC
Penicillin g benzathine inj,J0561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,48.14,,,,,,,fee schedule,15.45,55.06,Radiology
Penicillin g benzathine inj,J0561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,44.05,,,,,,,fee schedule,15.45,55.06,APC
Penicillin g benzathine inj,J0561,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,55.06,,,,,,,fee schedule,15.45,55.06,APC
"Inj, bezlotoxumab, 10 mg",J0565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,139.76,,,,,,,fee schedule,39.83,151.81,
"Inj, bezlotoxumab, 10 mg",J0565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,151.81,,,,,,,fee schedule,39.83,151.81,
"Inj, bezlotoxumab, 10 mg",J0565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,72.05,,,,,,,fee schedule,39.83,151.81,
"Inj, bezlotoxumab, 10 mg",J0565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,121.69,,,,,,,fee schedule,39.83,151.81,
"Inj, bezlotoxumab, 10 mg",J0565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,132.94,,,,,,,fee schedule,39.83,151.81,
"Inj, bezlotoxumab, 10 mg",J0565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,65.21,,,,,,,fee schedule,39.83,151.81,
"Inj, bezlotoxumab, 10 mg",J0565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,46.2,,,,,,,fee schedule,39.83,151.81,OP High Cost Drugs
"Inj, bezlotoxumab, 10 mg",J0565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,39.83,,,,,,,fee schedule,39.83,151.81,Other Pharmacy
"Inj, bezlotoxumab, 10 mg",J0565,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,41.82,,,,,,,fee schedule,39.83,151.81,APC
"Inj, bezlotoxumab, 10 mg",J0565,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,41.42,,,,,,,fee schedule,39.83,151.81,APC
"Inj, bezlotoxumab, 10 mg",J0565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,60.93,,,,,,,fee schedule,39.83,151.81,Radiology
"Inj, bezlotoxumab, 10 mg",J0565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,55.76,,,,,,,fee schedule,39.83,151.81,APC
"Inj, bezlotoxumab, 10 mg",J0565,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,69.69,,,,,,,fee schedule,39.83,151.81,APC
"Inj., cerliponase alfa 1 mg",J0567,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,331.99,,,,,,,fee schedule,121.17,537.59,
"Inj., cerliponase alfa 1 mg",J0567,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,360.61,,,,,,,fee schedule,121.17,537.59,
"Inj., cerliponase alfa 1 mg",J0567,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,208.09,,,,,,,fee schedule,121.17,537.59,
"Inj., cerliponase alfa 1 mg",J0567,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,289.06,,,,,,,fee schedule,121.17,537.59,
"Inj., cerliponase alfa 1 mg",J0567,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,315.77,,,,,,,fee schedule,121.17,537.59,
"Inj., cerliponase alfa 1 mg",J0567,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,188.33,,,,,,,fee schedule,121.17,537.59,
"Inj., cerliponase alfa 1 mg",J0567,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,537.59,,,,,,,fee schedule,121.17,537.59,APC 378
"Inj., cerliponase alfa 1 mg",J0567,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,127.23,,,,,,,fee schedule,121.17,537.59,APC
"Inj., cerliponase alfa 1 mg",J0567,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,126.02,,,,,,,fee schedule,121.17,537.59,APC
"Inj., cerliponase alfa 1 mg",J0567,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,121.17,,,,,,,fee schedule,121.17,537.59,APC
"Inj., cerliponase alfa 1 mg",J0567,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,185.39,,,,,,,fee schedule,121.17,537.59,Radiology
"Inj., cerliponase alfa 1 mg",J0567,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,169.64,,,,,,,fee schedule,121.17,537.59,APC
"Inj., cerliponase alfa 1 mg",J0567,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,212.05,,,,,,,fee schedule,121.17,537.59,APC
Buprenorphine implant 74.2mg,J0570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4456.21,,,,,,,fee schedule,2123.55,4840.37,
Buprenorphine implant 74.2mg,J0570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4840.37,,,,,,,fee schedule,2123.55,4840.37,
Buprenorphine implant 74.2mg,J0570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2346.3,,,,,,,fee schedule,2123.55,4840.37,
Buprenorphine implant 74.2mg,J0570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3879.98,,,,,,,fee schedule,2123.55,4840.37,
Buprenorphine implant 74.2mg,J0570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4238.52,,,,,,,fee schedule,2123.55,4840.37,
Buprenorphine implant 74.2mg,J0570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2123.55,,,,,,,fee schedule,2123.55,4840.37,
Buprenorphine oral 1mg,J0571,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.46,,,,,,,fee schedule,1.76,5.93,
Buprenorphine oral 1mg,J0571,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.93,,,,,,,fee schedule,1.76,5.93,
Buprenorphine oral 1mg,J0571,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.94,,,,,,,fee schedule,1.76,5.93,
Buprenorphine oral 1mg,J0571,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.76,,,,,,,fee schedule,1.76,5.93,
Buprenorphine oral 1mg,J0571,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.2,,,,,,,fee schedule,1.76,5.93,
Buprenorphine oral 1mg,J0571,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.76,,,,,,,fee schedule,1.76,5.93,
Bupren/nal up to 3mg bupreno,J0572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24.33,,,,,,,fee schedule,9.31,26.42,
Bupren/nal up to 3mg bupreno,J0572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26.42,,,,,,,fee schedule,9.31,26.42,
Bupren/nal up to 3mg bupreno,J0572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10.29,,,,,,,fee schedule,9.31,26.42,
Bupren/nal up to 3mg bupreno,J0572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21.18,,,,,,,fee schedule,9.31,26.42,
Bupren/nal up to 3mg bupreno,J0572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23.14,,,,,,,fee schedule,9.31,26.42,
Bupren/nal up to 3mg bupreno,J0572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.31,,,,,,,fee schedule,9.31,26.42,
Bupren/nal 3.1 to 6mg bupren,J0573,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,35.98,,,,,,,fee schedule,15.47,39.09,
Bupren/nal 3.1 to 6mg bupren,J0573,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,39.09,,,,,,,fee schedule,15.47,39.09,
Bupren/nal 3.1 to 6mg bupren,J0573,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17.1,,,,,,,fee schedule,15.47,39.09,
Bupren/nal 3.1 to 6mg bupren,J0573,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31.33,,,,,,,fee schedule,15.47,39.09,
Bupren/nal 3.1 to 6mg bupren,J0573,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,34.23,,,,,,,fee schedule,15.47,39.09,
Bupren/nal 3.1 to 6mg bupren,J0573,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15.47,,,,,,,fee schedule,15.47,39.09,
Bupren/nal 6.1 to 10mg bupre,J0574,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,36.26,,,,,,,fee schedule,14.9,39.39,
Bupren/nal 6.1 to 10mg bupre,J0574,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,39.39,,,,,,,fee schedule,14.9,39.39,
Bupren/nal 6.1 to 10mg bupre,J0574,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16.46,,,,,,,fee schedule,14.9,39.39,
Bupren/nal 6.1 to 10mg bupre,J0574,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31.57,,,,,,,fee schedule,14.9,39.39,
Bupren/nal 6.1 to 10mg bupre,J0574,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,34.49,,,,,,,fee schedule,14.9,39.39,
Bupren/nal 6.1 to 10mg bupre,J0574,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14.9,,,,,,,fee schedule,14.9,39.39,
Bupren/nal over 10mg bupreno,J0575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,39.18,,,,,,,fee schedule,25.17,42.56,
Bupren/nal over 10mg bupreno,J0575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42.56,,,,,,,fee schedule,25.17,42.56,
Bupren/nal over 10mg bupreno,J0575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27.81,,,,,,,fee schedule,25.17,42.56,
Bupren/nal over 10mg bupreno,J0575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,34.12,,,,,,,fee schedule,25.17,42.56,
Bupren/nal over 10mg bupreno,J0575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37.27,,,,,,,fee schedule,25.17,42.56,
Bupren/nal over 10mg bupreno,J0575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,25.17,,,,,,,fee schedule,25.17,42.56,
Inj buprenorph (brixadi) 1mg,J0576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,44.67,,,,,,,fee schedule,30.53,48.52,
Inj buprenorph (brixadi) 1mg,J0576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,48.52,,,,,,,fee schedule,30.53,48.52,
Inj buprenorph (brixadi) 1mg,J0576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33.73,,,,,,,fee schedule,30.53,48.52,
Inj buprenorph (brixadi) 1mg,J0576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38.89,,,,,,,fee schedule,30.53,48.52,
Inj buprenorph (brixadi) 1mg,J0576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.48,,,,,,,fee schedule,30.53,48.52,
Inj buprenorph (brixadi) 1mg,J0576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,30.53,,,,,,,fee schedule,30.53,48.52,
"Inj, brixadi, 7 days or less",J0577,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2108.32,,,,,,,fee schedule,417.21,2108.32,
"Inj, brixadi, 7 days or less",J0577,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1908.16,,,,,,,fee schedule,417.21,2108.32,
"Inj, brixadi, 7 days or less",J0577,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,483.96,,,,,,,fee schedule,417.21,2108.32,OP High Cost Drugs
"Inj, brixadi, 7 days or less",J0577,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,417.21,,,,,,,fee schedule,417.21,2108.32,Other Pharmacy
"Inj, brixadi, 7 days or less",J0577,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,438.07,,,,,,,fee schedule,417.21,2108.32,APC
"Inj, brixadi, 7 days or less",J0577,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,433.9,,,,,,,fee schedule,417.21,2108.32,APC
"Inj, brixadi, 7 days or less",J0577,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,638.33,,,,,,,fee schedule,417.21,2108.32,Radiology
"Inj, brixadi, 7 days or less",J0577,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,584.09,,,,,,,fee schedule,417.21,2108.32,APC
"Inj, brixadi, 7 days or less",J0577,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,730.12,,,,,,,fee schedule,417.21,2108.32,APC
"Inj brixadi, more than 7 day",J0578,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11993.95,,,,,,,fee schedule,1668.84,11993.95,
"Inj brixadi, more than 7 day",J0578,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10855.29,,,,,,,fee schedule,1668.84,11993.95,
"Inj brixadi, more than 7 day",J0578,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1935.86,,,,,,,fee schedule,1668.84,11993.95,OP High Cost Drugs
"Inj brixadi, more than 7 day",J0578,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1668.84,,,,,,,fee schedule,1668.84,11993.95,Other Pharmacy
"Inj brixadi, more than 7 day",J0578,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1752.28,,,,,,,fee schedule,1668.84,11993.95,APC
"Inj brixadi, more than 7 day",J0578,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1735.59,,,,,,,fee schedule,1668.84,11993.95,APC
"Inj brixadi, more than 7 day",J0578,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2553.33,,,,,,,fee schedule,1668.84,11993.95,Radiology
"Inj brixadi, more than 7 day",J0578,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2336.38,,,,,,,fee schedule,1668.84,11993.95,APC
"Inj brixadi, more than 7 day",J0578,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2920.47,,,,,,,fee schedule,1668.84,11993.95,APC
Bivalirudin,J0583,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8.35,,,,,,,fee schedule,3.02,9.07,
Bivalirudin,J0583,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.07,,,,,,,fee schedule,3.02,9.07,
Bivalirudin,J0583,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.33,,,,,,,fee schedule,3.02,9.07,
Bivalirudin,J0583,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7.27,,,,,,,fee schedule,3.02,9.07,
Bivalirudin,J0583,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7.94,,,,,,,fee schedule,3.02,9.07,
Bivalirudin,J0583,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.02,,,,,,,fee schedule,3.02,9.07,
"Injection, burosumab-twza 1m",J0584,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1254.19,,,,,,,fee schedule,498.72,1362.31,
"Injection, burosumab-twza 1m",J0584,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1362.31,,,,,,,fee schedule,498.72,1362.31,
"Injection, burosumab-twza 1m",J0584,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,843.99,,,,,,,fee schedule,498.72,1362.31,
"Injection, burosumab-twza 1m",J0584,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1092.01,,,,,,,fee schedule,498.72,1362.31,
"Injection, burosumab-twza 1m",J0584,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1192.92,,,,,,,fee schedule,498.72,1362.31,
"Injection, burosumab-twza 1m",J0584,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,763.86,,,,,,,fee schedule,498.72,1362.31,
"Injection, burosumab-twza 1m",J0584,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,578.51,,,,,,,fee schedule,498.72,1362.31,OP High Cost Drugs
"Injection, burosumab-twza 1m",J0584,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,498.72,,,,,,,fee schedule,498.72,1362.31,Other Pharmacy
"Injection, burosumab-twza 1m",J0584,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,523.65,,,,,,,fee schedule,498.72,1362.31,APC
"Injection, burosumab-twza 1m",J0584,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,518.66,,,,,,,fee schedule,498.72,1362.31,APC
"Injection, burosumab-twza 1m",J0584,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,763.04,,,,,,,fee schedule,498.72,1362.31,Radiology
"Injection, burosumab-twza 1m",J0584,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,698.2,,,,,,,fee schedule,498.72,1362.31,APC
"Injection, burosumab-twza 1m",J0584,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,872.75,,,,,,,fee schedule,498.72,1362.31,APC
"Injection,onabotulinumtoxina",J0585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19.31,,,,,,,fee schedule,6.51,20.98,
"Injection,onabotulinumtoxina",J0585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20.98,,,,,,,fee schedule,6.51,20.98,
"Injection,onabotulinumtoxina",J0585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12.34,,,,,,,fee schedule,6.51,20.98,
"Injection,onabotulinumtoxina",J0585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.82,,,,,,,fee schedule,6.51,20.98,
"Injection,onabotulinumtoxina",J0585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18.37,,,,,,,fee schedule,6.51,20.98,
"Injection,onabotulinumtoxina",J0585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11.17,,,,,,,fee schedule,6.51,20.98,
"Injection,onabotulinumtoxina",J0585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7.55,,,,,,,fee schedule,6.51,20.98,OP High Cost Drugs
"Injection,onabotulinumtoxina",J0585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.51,,,,,,,fee schedule,6.51,20.98,Other Pharmacy
"Injection,onabotulinumtoxina",J0585,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.84,,,,,,,fee schedule,6.51,20.98,APC
"Injection,onabotulinumtoxina",J0585,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6.77,,,,,,,fee schedule,6.51,20.98,APC
"Injection,onabotulinumtoxina",J0585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.96,,,,,,,fee schedule,6.51,20.98,Radiology
"Injection,onabotulinumtoxina",J0585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.12,,,,,,,fee schedule,6.51,20.98,APC
"Injection,onabotulinumtoxina",J0585,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11.4,,,,,,,fee schedule,6.51,20.98,APC
Abobotulinumtoxina,J0586,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24.22,,,,,,,fee schedule,8.9,26.31,
Abobotulinumtoxina,J0586,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26.31,,,,,,,fee schedule,8.9,26.31,
Abobotulinumtoxina,J0586,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16.32,,,,,,,fee schedule,8.9,26.31,
Abobotulinumtoxina,J0586,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21.09,,,,,,,fee schedule,8.9,26.31,
Abobotulinumtoxina,J0586,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23.04,,,,,,,fee schedule,8.9,26.31,
Abobotulinumtoxina,J0586,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14.77,,,,,,,fee schedule,8.9,26.31,
Abobotulinumtoxina,J0586,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10.33,,,,,,,fee schedule,8.9,26.31,OP High Cost Drugs
Abobotulinumtoxina,J0586,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8.9,,,,,,,fee schedule,8.9,26.31,Other Pharmacy
Abobotulinumtoxina,J0586,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.35,,,,,,,fee schedule,8.9,26.31,APC
Abobotulinumtoxina,J0586,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9.26,,,,,,,fee schedule,8.9,26.31,APC
Abobotulinumtoxina,J0586,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.62,,,,,,,fee schedule,8.9,26.31,Radiology
Abobotulinumtoxina,J0586,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12.46,,,,,,,fee schedule,8.9,26.31,APC
Abobotulinumtoxina,J0586,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15.58,,,,,,,fee schedule,8.9,26.31,APC
"Inj, rimabotulinumtoxinb",J0587,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,32.57,,,,,,,fee schedule,13.28,35.38,
"Inj, rimabotulinumtoxinb",J0587,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,35.38,,,,,,,fee schedule,13.28,35.38,
"Inj, rimabotulinumtoxinb",J0587,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23.61,,,,,,,fee schedule,13.28,35.38,
"Inj, rimabotulinumtoxinb",J0587,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28.36,,,,,,,fee schedule,13.28,35.38,
"Inj, rimabotulinumtoxinb",J0587,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,30.98,,,,,,,fee schedule,13.28,35.38,
"Inj, rimabotulinumtoxinb",J0587,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21.36,,,,,,,fee schedule,13.28,35.38,
"Inj, rimabotulinumtoxinb",J0587,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,15.41,,,,,,,fee schedule,13.28,35.38,OP High Cost Drugs
"Inj, rimabotulinumtoxinb",J0587,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.28,,,,,,,fee schedule,13.28,35.38,Other Pharmacy
"Inj, rimabotulinumtoxinb",J0587,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.95,,,,,,,fee schedule,13.28,35.38,APC
"Inj, rimabotulinumtoxinb",J0587,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.81,,,,,,,fee schedule,13.28,35.38,APC
"Inj, rimabotulinumtoxinb",J0587,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.32,,,,,,,fee schedule,13.28,35.38,Radiology
"Inj, rimabotulinumtoxinb",J0587,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.6,,,,,,,fee schedule,13.28,35.38,APC
"Inj, rimabotulinumtoxinb",J0587,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23.25,,,,,,,fee schedule,13.28,35.38,APC
Incobotulinumtoxin a,J0588,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15.59,,,,,,,fee schedule,5.29,16.93,
Incobotulinumtoxin a,J0588,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16.93,,,,,,,fee schedule,5.29,16.93,
Incobotulinumtoxin a,J0588,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.69,,,,,,,fee schedule,5.29,16.93,
Incobotulinumtoxin a,J0588,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13.57,,,,,,,fee schedule,5.29,16.93,
Incobotulinumtoxin a,J0588,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14.83,,,,,,,fee schedule,5.29,16.93,
Incobotulinumtoxin a,J0588,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.77,,,,,,,fee schedule,5.29,16.93,
Incobotulinumtoxin a,J0588,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6.14,,,,,,,fee schedule,5.29,16.93,OP High Cost Drugs
Incobotulinumtoxin a,J0588,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.29,,,,,,,fee schedule,5.29,16.93,Other Pharmacy
Incobotulinumtoxin a,J0588,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.55,,,,,,,fee schedule,5.29,16.93,APC
Incobotulinumtoxin a,J0588,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5.5,,,,,,,fee schedule,5.29,16.93,APC
Incobotulinumtoxin a,J0588,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8.09,,,,,,,fee schedule,5.29,16.93,Radiology
Incobotulinumtoxin a,J0588,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.4,,,,,,,fee schedule,5.29,16.93,APC
Incobotulinumtoxin a,J0588,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9.26,,,,,,,fee schedule,5.29,16.93,APC
Inj daxibotulinumtoxina-lanm,J0589,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7.96,,,,,,,fee schedule,3.09,7.96,
Inj daxibotulinumtoxina-lanm,J0589,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7.21,,,,,,,fee schedule,3.09,7.96,
Inj daxibotulinumtoxina-lanm,J0589,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3.59,,,,,,,fee schedule,3.09,7.96,OP High Cost Drugs
Inj daxibotulinumtoxina-lanm,J0589,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3.09,,,,,,,fee schedule,3.09,7.96,Other Pharmacy
Inj daxibotulinumtoxina-lanm,J0589,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3.25,,,,,,,fee schedule,3.09,7.96,APC
Inj daxibotulinumtoxina-lanm,J0589,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3.22,,,,,,,fee schedule,3.09,7.96,APC
Inj daxibotulinumtoxina-lanm,J0589,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4.73,,,,,,,fee schedule,3.09,7.96,Radiology
Inj daxibotulinumtoxina-lanm,J0589,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4.33,,,,,,,fee schedule,3.09,7.96,APC
Inj daxibotulinumtoxina-lanm,J0589,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5.41,,,,,,,fee schedule,3.09,7.96,APC
Buprenorphine hydrochloride,J0592,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8.61,,,,,,,fee schedule,7.79,8.61,
Buprenorphine hydrochloride,J0592,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7.79,,,,,,,fee schedule,7.79,8.61,
"Inj., lanadelumab-flyo, 1 mg",J0593,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,265.68,,,,,,,fee schedule,86.85,288.58,
"Inj., lanadelumab-flyo, 1 mg",J0593,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,288.58,,,,,,,fee schedule,86.85,288.58,
"Inj., lanadelumab-flyo, 1 mg",J0593,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,162.5,,,,,,,fee schedule,86.85,288.58,
"Inj., lanadelumab-flyo, 1 mg",J0593,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,231.32,,,,,,,fee schedule,86.85,288.58,
"Inj., lanadelumab-flyo, 1 mg",J0593,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,252.7,,,,,,,fee schedule,86.85,288.58,
"Inj., lanadelumab-flyo, 1 mg",J0593,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,147.08,,,,,,,fee schedule,86.85,288.58,
"Inj., lanadelumab-flyo, 1 mg",J0593,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,100.74,,,,,,,fee schedule,86.85,288.58,OP High Cost Drugs
"Inj., lanadelumab-flyo, 1 mg",J0593,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,86.85,,,,,,,fee schedule,86.85,288.58,Other Pharmacy
"Inj., lanadelumab-flyo, 1 mg",J0593,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.19,,,,,,,fee schedule,86.85,288.58,APC
"Inj., lanadelumab-flyo, 1 mg",J0593,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,90.32,,,,,,,fee schedule,86.85,288.58,APC
"Inj., lanadelumab-flyo, 1 mg",J0593,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,132.87,,,,,,,fee schedule,86.85,288.58,Radiology
"Inj., lanadelumab-flyo, 1 mg",J0593,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,121.58,,,,,,,fee schedule,86.85,288.58,APC
"Inj., lanadelumab-flyo, 1 mg",J0593,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,151.98,,,,,,,fee schedule,86.85,288.58,APC
Busulfan injection,J0594,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,43.43,,,,,,,fee schedule,0.68,47.17,
Busulfan injection,J0594,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,47.17,,,,,,,fee schedule,0.68,47.17,
Busulfan injection,J0594,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15.8,,,,,,,fee schedule,0.68,47.17,
Busulfan injection,J0594,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37.81,,,,,,,fee schedule,0.68,47.17,
Busulfan injection,J0594,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,41.31,,,,,,,fee schedule,0.68,47.17,
Busulfan injection,J0594,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14.3,,,,,,,fee schedule,0.68,47.17,
Busulfan injection,J0594,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,0.79,,,,,,,fee schedule,0.68,47.17,OP High Cost Drugs
Busulfan injection,J0594,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,0.68,,,,,,,fee schedule,0.68,47.17,Other Pharmacy
Busulfan injection,J0594,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,0.71,,,,,,,fee schedule,0.68,47.17,APC
Busulfan injection,J0594,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,0.7,,,,,,,fee schedule,0.68,47.17,APC
Busulfan injection,J0594,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1.04,,,,,,,fee schedule,0.68,47.17,Radiology
Busulfan injection,J0594,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,0.95,,,,,,,fee schedule,0.68,47.17,APC
Busulfan injection,J0594,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1.18,,,,,,,fee schedule,0.68,47.17,APC
Butorphanol tartrate 1 mg,J0595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.53,,,,,,,fee schedule,4.1,4.53,
Butorphanol tartrate 1 mg,J0595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.1,,,,,,,fee schedule,4.1,4.53,
"Injection, ruconest",J0596,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,89.09,,,,,,,fee schedule,36.67,96.77,
"Injection, ruconest",J0596,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,96.77,,,,,,,fee schedule,36.67,96.77,
"Injection, ruconest",J0596,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,69.39,,,,,,,fee schedule,36.67,96.77,
"Injection, ruconest",J0596,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,77.57,,,,,,,fee schedule,36.67,96.77,
"Injection, ruconest",J0596,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,84.74,,,,,,,fee schedule,36.67,96.77,
"Injection, ruconest",J0596,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,62.81,,,,,,,fee schedule,36.67,96.77,
"Injection, ruconest",J0596,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,42.54,,,,,,,fee schedule,36.67,96.77,OP High Cost Drugs
"Injection, ruconest",J0596,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,36.67,,,,,,,fee schedule,36.67,96.77,Other Pharmacy
"Injection, ruconest",J0596,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.51,,,,,,,fee schedule,36.67,96.77,APC
"Injection, ruconest",J0596,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.14,,,,,,,fee schedule,36.67,96.77,APC
"Injection, ruconest",J0596,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.11,,,,,,,fee schedule,36.67,96.77,Radiology
"Injection, ruconest",J0596,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.34,,,,,,,fee schedule,36.67,96.77,APC
"Injection, ruconest",J0596,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.18,,,,,,,fee schedule,36.67,96.77,APC
"C-1 esterase, berinert",J0597,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,108.37,,,,,,,fee schedule,76.05,154.27,
"C-1 esterase, berinert",J0597,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,117.71,,,,,,,fee schedule,76.05,154.27,
"C-1 esterase, berinert",J0597,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,154.27,,,,,,,fee schedule,76.05,154.27,
"C-1 esterase, berinert",J0597,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,94.35,,,,,,,fee schedule,76.05,154.27,
"C-1 esterase, berinert",J0597,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,103.07,,,,,,,fee schedule,76.05,154.27,
"C-1 esterase, berinert",J0597,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,139.63,,,,,,,fee schedule,76.05,154.27,
"C-1 esterase, berinert",J0597,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,88.22,,,,,,,fee schedule,76.05,154.27,OP High Cost Drugs
"C-1 esterase, berinert",J0597,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,76.05,,,,,,,fee schedule,76.05,154.27,Other Pharmacy
"C-1 esterase, berinert",J0597,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,79.85,,,,,,,fee schedule,76.05,154.27,APC
"C-1 esterase, berinert",J0597,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,79.09,,,,,,,fee schedule,76.05,154.27,APC
"C-1 esterase, berinert",J0597,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,116.36,,,,,,,fee schedule,76.05,154.27,Radiology
"C-1 esterase, berinert",J0597,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,106.47,,,,,,,fee schedule,76.05,154.27,APC
"C-1 esterase, berinert",J0597,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,133.09,,,,,,,fee schedule,76.05,154.27,APC
"C-1 esterase, cinryze",J0598,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,169.41,,,,,,,fee schedule,65.5,184.01,
"C-1 esterase, cinryze",J0598,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,184.01,,,,,,,fee schedule,65.5,184.01,
"C-1 esterase, cinryze",J0598,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,117.74,,,,,,,fee schedule,65.5,184.01,
"C-1 esterase, cinryze",J0598,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,147.5,,,,,,,fee schedule,65.5,184.01,
"C-1 esterase, cinryze",J0598,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,161.13,,,,,,,fee schedule,65.5,184.01,
"C-1 esterase, cinryze",J0598,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,106.56,,,,,,,fee schedule,65.5,184.01,
"C-1 esterase, cinryze",J0598,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,75.98,,,,,,,fee schedule,65.5,184.01,OP High Cost Drugs
"C-1 esterase, cinryze",J0598,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,65.5,,,,,,,fee schedule,65.5,184.01,Other Pharmacy
"C-1 esterase, cinryze",J0598,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,68.78,,,,,,,fee schedule,65.5,184.01,APC
"C-1 esterase, cinryze",J0598,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,68.12,,,,,,,fee schedule,65.5,184.01,APC
"C-1 esterase, cinryze",J0598,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,100.22,,,,,,,fee schedule,65.5,184.01,Radiology
"C-1 esterase, cinryze",J0598,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,91.7,,,,,,,fee schedule,65.5,184.01,APC
"C-1 esterase, cinryze",J0598,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,114.63,,,,,,,fee schedule,65.5,184.01,APC
"Inj., haegarda 10 units",J0599,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33.64,,,,,,,fee schedule,19.86,36.54,
"Inj., haegarda 10 units",J0599,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,36.54,,,,,,,fee schedule,19.86,36.54,
"Inj., haegarda 10 units",J0599,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21.95,,,,,,,fee schedule,19.86,36.54,
"Inj., haegarda 10 units",J0599,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29.29,,,,,,,fee schedule,19.86,36.54,
"Inj., haegarda 10 units",J0599,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32,,,,,,,fee schedule,19.86,36.54,
"Inj., haegarda 10 units",J0599,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19.86,,,,,,,fee schedule,19.86,36.54,
Edetate calcium disodium inj,J0600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,179.5,,,,,,,fee schedule,156.29,12313.81,
Edetate calcium disodium inj,J0600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,194.97,,,,,,,fee schedule,156.29,12313.81,
Edetate calcium disodium inj,J0600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12313.81,,,,,,,fee schedule,156.29,12313.81,
Edetate calcium disodium inj,J0600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,156.29,,,,,,,fee schedule,156.29,12313.81,
Edetate calcium disodium inj,J0600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,170.73,,,,,,,fee schedule,156.29,12313.81,
Edetate calcium disodium inj,J0600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11144.78,,,,,,,fee schedule,156.29,12313.81,
Edetate calcium disodium inj,J0600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7079.32,,,,,,,fee schedule,156.29,12313.81,OP High Cost Drugs
Edetate calcium disodium inj,J0600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6102.87,,,,,,,fee schedule,156.29,12313.81,Other Pharmacy
Edetate calcium disodium inj,J0600,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6408.01,,,,,,,fee schedule,156.29,12313.81,APC
Edetate calcium disodium inj,J0600,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6346.98,,,,,,,fee schedule,156.29,12313.81,APC
Edetate calcium disodium inj,J0600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9337.38,,,,,,,fee schedule,156.29,12313.81,Radiology
Edetate calcium disodium inj,J0600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8544.01,,,,,,,fee schedule,156.29,12313.81,APC
Edetate calcium disodium inj,J0600,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10680.02,,,,,,,fee schedule,156.29,12313.81,APC
"Cinacalcet, esrd on dialysis",J0604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.61,,,,,,,fee schedule,1.46,1.61,
"Cinacalcet, esrd on dialysis",J0604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.46,,,,,,,fee schedule,1.46,1.61,
"Inj, etelcalcetide, 0.1 mg",J0606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10.38,,,,,,,fee schedule,2.36,11.28,
"Inj, etelcalcetide, 0.1 mg",J0606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11.28,,,,,,,fee schedule,2.36,11.28,
"Inj, etelcalcetide, 0.1 mg",J0606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7.46,,,,,,,fee schedule,2.36,11.28,
"Inj, etelcalcetide, 0.1 mg",J0606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.04,,,,,,,fee schedule,2.36,11.28,
"Inj, etelcalcetide, 0.1 mg",J0606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.87,,,,,,,fee schedule,2.36,11.28,
"Inj, etelcalcetide, 0.1 mg",J0606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.75,,,,,,,fee schedule,2.36,11.28,
"Inj, etelcalcetide, 0.1 mg",J0606,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,10.45,,,,,,,fee schedule,2.36,11.28,APC 378
"Inj, etelcalcetide, 0.1 mg",J0606,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2.47,,,,,,,fee schedule,2.36,11.28,APC
"Inj, etelcalcetide, 0.1 mg",J0606,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2.45,,,,,,,fee schedule,2.36,11.28,APC
"Inj, etelcalcetide, 0.1 mg",J0606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2.36,,,,,,,fee schedule,2.36,11.28,APC
"Inj, etelcalcetide, 0.1 mg",J0606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3.6,,,,,,,fee schedule,2.36,11.28,Radiology
"Inj, etelcalcetide, 0.1 mg",J0606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3.3,,,,,,,fee schedule,2.36,11.28,APC
"Inj, etelcalcetide, 0.1 mg",J0606,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4.12,,,,,,,fee schedule,2.36,11.28,APC
Calcium glucon (fresenius),J0612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.18,,,,,,,fee schedule,0.09,0.19,
Calcium glucon (fresenius),J0612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.19,,,,,,,fee schedule,0.09,0.19,
Calcium glucon (fresenius),J0612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.09,,,,,,,fee schedule,0.09,0.19,
Calcium glucon (fresenius),J0612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.15,,,,,,,fee schedule,0.09,0.19,
Calcium glucon (fresenius),J0612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.17,,,,,,,fee schedule,0.09,0.19,
Calcium glucon (fresenius),J0612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.09,,,,,,,fee schedule,0.09,0.19,
Calcium glucon (wg critical),J0613,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.3,,,,,,,fee schedule,0.26,0.38,
Calcium glucon (wg critical),J0613,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.32,,,,,,,fee schedule,0.26,0.38,
Calcium glucon (wg critical),J0613,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.38,,,,,,,fee schedule,0.26,0.38,
Calcium glucon (wg critical),J0613,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.26,,,,,,,fee schedule,0.26,0.38,
Calcium glucon (wg critical),J0613,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.28,,,,,,,fee schedule,0.26,0.38,
Calcium glucon (wg critical),J0613,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.34,,,,,,,fee schedule,0.26,0.38,
Calcitonin salmon injection,J0630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8009.46,,,,,,,fee schedule,5374.68,8699.93,
Calcitonin salmon injection,J0630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8699.93,,,,,,,fee schedule,5374.68,8699.93,
Calcitonin salmon injection,J0630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5938.46,,,,,,,fee schedule,5374.68,8699.93,
Calcitonin salmon injection,J0630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6973.76,,,,,,,fee schedule,5374.68,8699.93,
Calcitonin salmon injection,J0630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7618.2,,,,,,,fee schedule,5374.68,8699.93,
Calcitonin salmon injection,J0630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5374.68,,,,,,,fee schedule,5374.68,8699.93,
Inj calcitriol per 0.1 mcg,J0636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.69,,,,,,,fee schedule,1.53,1.69,
Inj calcitriol per 0.1 mcg,J0636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.53,,,,,,,fee schedule,1.53,1.69,
Caspofungin acetate,J0637,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,52.69,,,,,,,fee schedule,16.47,57.23,
Caspofungin acetate,J0637,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,57.23,,,,,,,fee schedule,16.47,57.23,
Caspofungin acetate,J0637,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18.2,,,,,,,fee schedule,16.47,57.23,
Caspofungin acetate,J0637,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,45.87,,,,,,,fee schedule,16.47,57.23,
Caspofungin acetate,J0637,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,50.11,,,,,,,fee schedule,16.47,57.23,
Caspofungin acetate,J0637,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.47,,,,,,,fee schedule,16.47,57.23,
Canakinumab injection,J0638,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,316.47,,,,,,,fee schedule,149.57,343.75,
Canakinumab injection,J0638,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,343.75,,,,,,,fee schedule,149.57,343.75,
Canakinumab injection,J0638,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,247,,,,,,,fee schedule,149.57,343.75,
Canakinumab injection,J0638,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,275.55,,,,,,,fee schedule,149.57,343.75,
Canakinumab injection,J0638,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,301.01,,,,,,,fee schedule,149.57,343.75,
Canakinumab injection,J0638,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,223.55,,,,,,,fee schedule,149.57,343.75,
Canakinumab injection,J0638,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,173.51,,,,,,,fee schedule,149.57,343.75,OP High Cost Drugs
Canakinumab injection,J0638,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,149.57,,,,,,,fee schedule,149.57,343.75,Other Pharmacy
Canakinumab injection,J0638,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,157.05,,,,,,,fee schedule,149.57,343.75,APC
Canakinumab injection,J0638,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,155.56,,,,,,,fee schedule,149.57,343.75,APC
Canakinumab injection,J0638,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,228.85,,,,,,,fee schedule,149.57,343.75,Radiology
Canakinumab injection,J0638,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,209.4,,,,,,,fee schedule,149.57,343.75,APC
Canakinumab injection,J0638,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,261.75,,,,,,,fee schedule,149.57,343.75,APC
Leucovorin calcium injection,J0640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16.34,,,,,,,fee schedule,14.79,16.34,
Leucovorin calcium injection,J0640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14.79,,,,,,,fee schedule,14.79,16.34,
Levoleucovorin injection,J0641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.65,,,,,,,fee schedule,0.73,3.97,
Levoleucovorin injection,J0641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.97,,,,,,,fee schedule,0.73,3.97,
Levoleucovorin injection,J0641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.81,,,,,,,fee schedule,0.73,3.97,
Levoleucovorin injection,J0641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.18,,,,,,,fee schedule,0.73,3.97,
Levoleucovorin injection,J0641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.48,,,,,,,fee schedule,0.73,3.97,
Levoleucovorin injection,J0641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.73,,,,,,,fee schedule,0.73,3.97,
"Injection, khapzory, 0.5 mg",J0642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7.1,,,,,,,fee schedule,3.73,7.71,
"Injection, khapzory, 0.5 mg",J0642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7.71,,,,,,,fee schedule,3.73,7.71,
"Injection, khapzory, 0.5 mg",J0642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.12,,,,,,,fee schedule,3.73,7.71,
"Injection, khapzory, 0.5 mg",J0642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.18,,,,,,,fee schedule,3.73,7.71,
"Injection, khapzory, 0.5 mg",J0642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.75,,,,,,,fee schedule,3.73,7.71,
"Injection, khapzory, 0.5 mg",J0642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.73,,,,,,,fee schedule,3.73,7.71,
"Inj, levothyroxine nos 10mcg",J0650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19.47,,,,,,,fee schedule,17.62,19.47,
"Inj, levothyroxine nos 10mcg",J0650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17.62,,,,,,,fee schedule,17.62,19.47,
"Inj, levothyroxine, freskabi",J0651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21.01,,,,,,,fee schedule,6.96,21.01,
"Inj, levothyroxine, freskabi",J0651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19.02,,,,,,,fee schedule,6.96,21.01,
"Inj, levothyroxine, freskabi",J0651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8.07,,,,,,,fee schedule,6.96,21.01,OP High Cost Drugs
"Inj, levothyroxine, freskabi",J0651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.96,,,,,,,fee schedule,6.96,21.01,Other Pharmacy
"Inj, levothyroxine, freskabi",J0651,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.31,,,,,,,fee schedule,6.96,21.01,APC
"Inj, levothyroxine, freskabi",J0651,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7.24,,,,,,,fee schedule,6.96,21.01,APC
"Inj, levothyroxine, freskabi",J0651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10.65,,,,,,,fee schedule,6.96,21.01,Radiology
"Inj, levothyroxine, freskabi",J0651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.74,,,,,,,fee schedule,6.96,21.01,APC
"Inj, levothyroxine, freskabi",J0651,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12.18,,,,,,,fee schedule,6.96,21.01,APC
"Inj, levothyroxine, hikma",J0652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14.2,,,,,,,fee schedule,12.86,14.2,
"Inj, levothyroxine, hikma",J0652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12.86,,,,,,,fee schedule,12.86,14.2,
"Inj, bupivacaine, nos, 0.5mg",J0665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.06,,,,,,,fee schedule,0.04,0.06,
"Inj, bupivacaine, nos, 0.5mg",J0665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.05,,,,,,,fee schedule,0.04,0.06,
"Inj, bupivacaine, nos, 0.5mg",J0665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.05,,,,,,,fee schedule,0.04,0.06,
"Inj, bupivacaine, nos, 0.5mg",J0665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.04,,,,,,,fee schedule,0.04,0.06,
Inj mepivacaine HCL/10 ml,J0670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.75,,,,,,,fee schedule,6.11,6.75,
Inj mepivacaine HCL/10 ml,J0670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.11,,,,,,,fee schedule,6.11,6.75,
Inj cefazolin (wg crit care),J0687,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.31,,,,,,,fee schedule,2.09,2.31,
Inj cefazolin (wg crit care),J0687,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.09,,,,,,,fee schedule,2.09,2.31,
"Inj cefazolin sodium, hikma",J0688,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.78,,,,,,,fee schedule,2.52,2.78,
"Inj cefazolin sodium, hikma",J0688,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.52,,,,,,,fee schedule,2.52,2.78,
"Inj cefazolin sodium, baxter",J0689,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.08,,,,,,,fee schedule,0.07,0.08,
"Inj cefazolin sodium, baxter",J0689,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.07,,,,,,,fee schedule,0.07,0.08,
Cefazolin sodium injection,J0690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.07,,,,,,,fee schedule,1.87,2.07,
Cefazolin sodium injection,J0690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.87,,,,,,,fee schedule,1.87,2.07,
Inj lefamulin 1 mg,J0691,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.52,,,,,,,fee schedule,1.17,2.74,
Inj lefamulin 1 mg,J0691,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.74,,,,,,,fee schedule,1.17,2.74,
Inj lefamulin 1 mg,J0691,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.3,,,,,,,fee schedule,1.17,2.74,
Inj lefamulin 1 mg,J0691,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.19,,,,,,,fee schedule,1.17,2.74,
Inj lefamulin 1 mg,J0691,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.4,,,,,,,fee schedule,1.17,2.74,
Inj lefamulin 1 mg,J0691,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.17,,,,,,,fee schedule,1.17,2.74,
Cefepime hcl for injection,J0692,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.58,,,,,,,fee schedule,5.05,5.58,
Cefepime hcl for injection,J0692,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.05,,,,,,,fee schedule,5.05,5.58,
Cefoxitin sodium injection,J0694,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17.4,,,,,,,fee schedule,15.74,17.4,
Cefoxitin sodium injection,J0694,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15.74,,,,,,,fee schedule,15.74,17.4,
Inj ceftolozane tazobactam,J0695,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14.89,,,,,,,fee schedule,8.84,16.18,
Inj ceftolozane tazobactam,J0695,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16.18,,,,,,,fee schedule,8.84,16.18,
Inj ceftolozane tazobactam,J0695,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15.04,,,,,,,fee schedule,8.84,16.18,
Inj ceftolozane tazobactam,J0695,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12.97,,,,,,,fee schedule,8.84,16.18,
Inj ceftolozane tazobactam,J0695,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14.17,,,,,,,fee schedule,8.84,16.18,
Inj ceftolozane tazobactam,J0695,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13.61,,,,,,,fee schedule,8.84,16.18,
Inj ceftolozane tazobactam,J0695,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10.25,,,,,,,fee schedule,8.84,16.18,OP High Cost Drugs
Inj ceftolozane tazobactam,J0695,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8.84,,,,,,,fee schedule,8.84,16.18,Other Pharmacy
Inj ceftolozane tazobactam,J0695,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.28,,,,,,,fee schedule,8.84,16.18,APC
Inj ceftolozane tazobactam,J0695,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9.19,,,,,,,fee schedule,8.84,16.18,APC
Inj ceftolozane tazobactam,J0695,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.52,,,,,,,fee schedule,8.84,16.18,Radiology
Inj ceftolozane tazobactam,J0695,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12.37,,,,,,,fee schedule,8.84,16.18,APC
Inj ceftolozane tazobactam,J0695,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15.46,,,,,,,fee schedule,8.84,16.18,APC
Ceftriaxone sodium injection,J0696,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12.23,,,,,,,fee schedule,11.07,12.23,
Ceftriaxone sodium injection,J0696,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11.07,,,,,,,fee schedule,11.07,12.23,
Sterile cefuroxime injection,J0697,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.55,,,,,,,fee schedule,5.02,5.55,
Sterile cefuroxime injection,J0697,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.02,,,,,,,fee schedule,5.02,5.55,
Cefotaxime sodium injection,J0698,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.54,,,,,,,fee schedule,8.64,9.54,
Cefotaxime sodium injection,J0698,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.64,,,,,,,fee schedule,8.64,9.54,
"Inj, cefiderocol, 10 mg",J0699,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7,,,,,,,fee schedule,2.42,7.6,
"Inj, cefiderocol, 10 mg",J0699,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7.6,,,,,,,fee schedule,2.42,7.6,
"Inj, cefiderocol, 10 mg",J0699,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.17,,,,,,,fee schedule,2.42,7.6,
"Inj, cefiderocol, 10 mg",J0699,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.09,,,,,,,fee schedule,2.42,7.6,
"Inj, cefiderocol, 10 mg",J0699,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.66,,,,,,,fee schedule,2.42,7.6,
"Inj, cefiderocol, 10 mg",J0699,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.78,,,,,,,fee schedule,2.42,7.6,
"Inj, cefiderocol, 10 mg",J0699,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2.81,,,,,,,fee schedule,2.42,7.6,OP High Cost Drugs
"Inj, cefiderocol, 10 mg",J0699,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2.42,,,,,,,fee schedule,2.42,7.6,Other Pharmacy
"Inj, cefiderocol, 10 mg",J0699,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2.54,,,,,,,fee schedule,2.42,7.6,APC
"Inj, cefiderocol, 10 mg",J0699,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2.52,,,,,,,fee schedule,2.42,7.6,APC
"Inj, cefiderocol, 10 mg",J0699,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3.7,,,,,,,fee schedule,2.42,7.6,Radiology
"Inj, cefiderocol, 10 mg",J0699,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3.39,,,,,,,fee schedule,2.42,7.6,APC
"Inj, cefiderocol, 10 mg",J0699,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4.23,,,,,,,fee schedule,2.42,7.6,APC
Inj. cefepime hcl (baxter),J0701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22.88,,,,,,,fee schedule,20.71,22.88,
Inj. cefepime hcl (baxter),J0701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20.71,,,,,,,fee schedule,20.71,22.88,
Betamethasone acet&sod phosp,J0702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15.77,,,,,,,fee schedule,14.27,15.77,
Betamethasone acet&sod phosp,J0702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14.27,,,,,,,fee schedule,14.27,15.77,
"Inj, cefepime hcl (b braun)",J0703,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16.4,,,,,,,fee schedule,14.84,16.4,
"Inj, cefepime hcl (b braun)",J0703,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14.84,,,,,,,fee schedule,14.84,16.4,
Caffeine citrate injection,J0706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.14,,,,,,,fee schedule,2.85,3.14,
Caffeine citrate injection,J0706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.85,,,,,,,fee schedule,2.85,3.14,
Ceftaroline fosamil inj,J0712,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.85,,,,,,,fee schedule,2.48,9.69,
Ceftaroline fosamil inj,J0712,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.1,,,,,,,fee schedule,2.48,9.69,
Ceftaroline fosamil inj,J0712,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.69,,,,,,,fee schedule,2.48,9.69,
Ceftaroline fosamil inj,J0712,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.48,,,,,,,fee schedule,2.48,9.69,
Ceftaroline fosamil inj,J0712,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.71,,,,,,,fee schedule,2.48,9.69,
Ceftaroline fosamil inj,J0712,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.77,,,,,,,fee schedule,2.48,9.69,
Ceftaroline fosamil inj,J0712,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4.93,,,,,,,fee schedule,2.48,9.69,OP High Cost Drugs
Ceftaroline fosamil inj,J0712,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4.25,,,,,,,fee schedule,2.48,9.69,Other Pharmacy
Ceftaroline fosamil inj,J0712,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.47,,,,,,,fee schedule,2.48,9.69,APC
Ceftaroline fosamil inj,J0712,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4.42,,,,,,,fee schedule,2.48,9.69,APC
Ceftaroline fosamil inj,J0712,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.51,,,,,,,fee schedule,2.48,9.69,Radiology
Ceftaroline fosamil inj,J0712,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.96,,,,,,,fee schedule,2.48,9.69,APC
Ceftaroline fosamil inj,J0712,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7.44,,,,,,,fee schedule,2.48,9.69,APC
Inj ceftazidime per 500 mg,J0713,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7.88,,,,,,,fee schedule,7.14,7.88,
Inj ceftazidime per 500 mg,J0713,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7.14,,,,,,,fee schedule,7.14,7.88,
Ceftazidime and avibactam,J0714,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,257.07,,,,,,,fee schedule,104.75,279.23,
Ceftazidime and avibactam,J0714,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,279.23,,,,,,,fee schedule,104.75,279.23,
Ceftazidime and avibactam,J0714,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,187.51,,,,,,,fee schedule,104.75,279.23,
Ceftazidime and avibactam,J0714,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,223.83,,,,,,,fee schedule,104.75,279.23,
Ceftazidime and avibactam,J0714,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,244.51,,,,,,,fee schedule,104.75,279.23,
Ceftazidime and avibactam,J0714,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,169.71,,,,,,,fee schedule,104.75,279.23,
Ceftazidime and avibactam,J0714,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,121.51,,,,,,,fee schedule,104.75,279.23,OP High Cost Drugs
Ceftazidime and avibactam,J0714,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,104.75,,,,,,,fee schedule,104.75,279.23,Other Pharmacy
Ceftazidime and avibactam,J0714,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.99,,,,,,,fee schedule,104.75,279.23,APC
Ceftazidime and avibactam,J0714,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,108.94,,,,,,,fee schedule,104.75,279.23,APC
Ceftazidime and avibactam,J0714,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,160.27,,,,,,,fee schedule,104.75,279.23,Radiology
Ceftazidime and avibactam,J0714,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,146.65,,,,,,,fee schedule,104.75,279.23,APC
Ceftazidime and avibactam,J0714,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,183.31,,,,,,,fee schedule,104.75,279.23,APC
Centruroides immune f(ab),J0716,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12652.58,,,,,,,fee schedule,11016.47,13743.32,
Centruroides immune f(ab),J0716,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13743.32,,,,,,,fee schedule,11016.47,13743.32,
Centruroides immune f(ab),J0716,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11016.47,,,,,,,fee schedule,11016.47,13743.32,
Centruroides immune f(ab),J0716,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12034.5,,,,,,,fee schedule,11016.47,13743.32,
Certolizumab pegol inj 1mg,J0717,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22.97,,,,,,,fee schedule,3.79,27.11,
Certolizumab pegol inj 1mg,J0717,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24.95,,,,,,,fee schedule,3.79,27.11,
Certolizumab pegol inj 1mg,J0717,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27.11,,,,,,,fee schedule,3.79,27.11,
Certolizumab pegol inj 1mg,J0717,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20,,,,,,,fee schedule,3.79,27.11,
Certolizumab pegol inj 1mg,J0717,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21.85,,,,,,,fee schedule,3.79,27.11,
Certolizumab pegol inj 1mg,J0717,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24.54,,,,,,,fee schedule,3.79,27.11,
Certolizumab pegol inj 1mg,J0717,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4.4,,,,,,,fee schedule,3.79,27.11,OP High Cost Drugs
Certolizumab pegol inj 1mg,J0717,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3.79,,,,,,,fee schedule,3.79,27.11,Other Pharmacy
Certolizumab pegol inj 1mg,J0717,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3.98,,,,,,,fee schedule,3.79,27.11,APC
Certolizumab pegol inj 1mg,J0717,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3.94,,,,,,,fee schedule,3.79,27.11,APC
Certolizumab pegol inj 1mg,J0717,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.8,,,,,,,fee schedule,3.79,27.11,Radiology
Certolizumab pegol inj 1mg,J0717,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.31,,,,,,,fee schedule,3.79,27.11,APC
Certolizumab pegol inj 1mg,J0717,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6.63,,,,,,,fee schedule,3.79,27.11,APC
Chloramphenicol sodium injec,J0720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,92.24,,,,,,,fee schedule,83.48,92.24,
Chloramphenicol sodium injec,J0720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,83.48,,,,,,,fee schedule,83.48,92.24,
Chorionic gonadotropin/1000u,J0725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46.52,,,,,,,fee schedule,42.1,46.52,
Chorionic gonadotropin/1000u,J0725,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.1,,,,,,,fee schedule,42.1,46.52,
Clonidine hydrochloride,J0735,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,230.93,,,,,,,fee schedule,59.17,250.84,
Clonidine hydrochloride,J0735,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,250.84,,,,,,,fee schedule,59.17,250.84,
Clonidine hydrochloride,J0735,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,65.38,,,,,,,fee schedule,59.17,250.84,
Clonidine hydrochloride,J0735,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,201.07,,,,,,,fee schedule,59.17,250.84,
Clonidine hydrochloride,J0735,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,219.65,,,,,,,fee schedule,59.17,250.84,
Clonidine hydrochloride,J0735,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,59.17,,,,,,,fee schedule,59.17,250.84,
"Inj, clindamycin phosp 300mg",J0736,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7.57,,,,,,,fee schedule,3.02,8.22,
"Inj, clindamycin phosp 300mg",J0736,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8.22,,,,,,,fee schedule,3.02,8.22,
"Inj, clindamycin phosp 300mg",J0736,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.33,,,,,,,fee schedule,3.02,8.22,
"Inj, clindamycin phosp 300mg",J0736,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.59,,,,,,,fee schedule,3.02,8.22,
"Inj, clindamycin phosp 300mg",J0736,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7.2,,,,,,,fee schedule,3.02,8.22,
"Inj, clindamycin phosp 300mg",J0736,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.02,,,,,,,fee schedule,3.02,8.22,
"Inj, clindamycin (baxter)",J0737,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7.6,,,,,,,fee schedule,6.62,10.13,
"Inj, clindamycin (baxter)",J0737,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8.26,,,,,,,fee schedule,6.62,10.13,
"Inj, clindamycin (baxter)",J0737,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10.13,,,,,,,fee schedule,6.62,10.13,
"Inj, clindamycin (baxter)",J0737,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.62,,,,,,,fee schedule,6.62,10.13,
"Inj, clindamycin (baxter)",J0737,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7.23,,,,,,,fee schedule,6.62,10.13,
"Inj, clindamycin (baxter)",J0737,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.17,,,,,,,fee schedule,6.62,10.13,
"Injection, cabotegravir 1 mg",J0739,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12.4,,,,,,,fee schedule,7.14,12.5,
"Injection, cabotegravir 1 mg",J0739,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11.23,,,,,,,fee schedule,7.14,12.5,
"Injection, cabotegravir 1 mg",J0739,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8.29,,,,,,,fee schedule,7.14,12.5,OP High Cost Drugs
"Injection, cabotegravir 1 mg",J0739,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.14,,,,,,,fee schedule,7.14,12.5,Other Pharmacy
"Injection, cabotegravir 1 mg",J0739,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.5,,,,,,,fee schedule,7.14,12.5,APC
"Injection, cabotegravir 1 mg",J0739,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7.43,,,,,,,fee schedule,7.14,12.5,APC
"Injection, cabotegravir 1 mg",J0739,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10.93,,,,,,,fee schedule,7.14,12.5,Radiology
"Injection, cabotegravir 1 mg",J0739,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10,,,,,,,fee schedule,7.14,12.5,APC
"Injection, cabotegravir 1 mg",J0739,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12.5,,,,,,,fee schedule,7.14,12.5,APC
Cidofovir injection,J0740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2723.17,,,,,,,fee schedule,560.79,2957.93,
Cidofovir injection,J0740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2957.93,,,,,,,fee schedule,560.79,2957.93,
Cidofovir injection,J0740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1638.82,,,,,,,fee schedule,560.79,2957.93,
Cidofovir injection,J0740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2371.04,,,,,,,fee schedule,560.79,2957.93,
Cidofovir injection,J0740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2590.14,,,,,,,fee schedule,560.79,2957.93,
Cidofovir injection,J0740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1483.24,,,,,,,fee schedule,560.79,2957.93,
Cidofovir injection,J0740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,650.52,,,,,,,fee schedule,560.79,2957.93,OP High Cost Drugs
Cidofovir injection,J0740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,560.79,,,,,,,fee schedule,560.79,2957.93,Other Pharmacy
Cidofovir injection,J0740,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,588.83,,,,,,,fee schedule,560.79,2957.93,APC
Cidofovir injection,J0740,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,583.22,,,,,,,fee schedule,560.79,2957.93,APC
Cidofovir injection,J0740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,858.01,,,,,,,fee schedule,560.79,2957.93,Radiology
Cidofovir injection,J0740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,785.1,,,,,,,fee schedule,560.79,2957.93,APC
Cidofovir injection,J0740,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,981.38,,,,,,,fee schedule,560.79,2957.93,APC
"Inj, cabote rilpivir 2mg 3mg",J0741,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,71.53,,,,,,,fee schedule,24.18,77.7,
"Inj, cabote rilpivir 2mg 3mg",J0741,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,77.7,,,,,,,fee schedule,24.18,77.7,
"Inj, cabote rilpivir 2mg 3mg",J0741,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,62.28,,,,,,,fee schedule,24.18,77.7,
"Inj, cabote rilpivir 2mg 3mg",J0741,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,68.04,,,,,,,fee schedule,24.18,77.7,
"Inj, cabote rilpivir 2mg 3mg",J0741,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,28.05,,,,,,,fee schedule,24.18,77.7,OP High Cost Drugs
"Inj, cabote rilpivir 2mg 3mg",J0741,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24.18,,,,,,,fee schedule,24.18,77.7,Other Pharmacy
"Inj, cabote rilpivir 2mg 3mg",J0741,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,25.39,,,,,,,fee schedule,24.18,77.7,APC
"Inj, cabote rilpivir 2mg 3mg",J0741,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,25.15,,,,,,,fee schedule,24.18,77.7,APC
"Inj, cabote rilpivir 2mg 3mg",J0741,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,37,,,,,,,fee schedule,24.18,77.7,Radiology
"Inj, cabote rilpivir 2mg 3mg",J0741,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,33.85,,,,,,,fee schedule,24.18,77.7,APC
"Inj, cabote rilpivir 2mg 3mg",J0741,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,42.32,,,,,,,fee schedule,24.18,77.7,APC
Inj imip 4 cilas 4 releb 2mg,J0742,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7.85,,,,,,,fee schedule,4.22,8.53,
Inj imip 4 cilas 4 releb 2mg,J0742,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8.53,,,,,,,fee schedule,4.22,8.53,
Inj imip 4 cilas 4 releb 2mg,J0742,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.66,,,,,,,fee schedule,4.22,8.53,
Inj imip 4 cilas 4 releb 2mg,J0742,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.84,,,,,,,fee schedule,4.22,8.53,
Inj imip 4 cilas 4 releb 2mg,J0742,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7.47,,,,,,,fee schedule,4.22,8.53,
Inj imip 4 cilas 4 releb 2mg,J0742,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.22,,,,,,,fee schedule,4.22,8.53,
Cilastatin sodium injection,J0743,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27.18,,,,,,,fee schedule,24.6,27.18,
Cilastatin sodium injection,J0743,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24.6,,,,,,,fee schedule,24.6,27.18,
Ciprofloxacin iv,J0744,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.69,,,,,,,fee schedule,5.15,5.69,
Ciprofloxacin iv,J0744,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.15,,,,,,,fee schedule,5.15,5.69,
Inj codeine phosphate /30 MG,J0745,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,472.03,,,,,,,fee schedule,410.99,512.72,
Inj codeine phosphate /30 MG,J0745,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,512.72,,,,,,,fee schedule,410.99,512.72,
Inj codeine phosphate /30 MG,J0745,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,410.99,,,,,,,fee schedule,410.99,512.72,
Inj codeine phosphate /30 MG,J0745,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,448.97,,,,,,,fee schedule,410.99,512.72,
"Hiv prep, ftc/tdf 200/300mg",J0750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,110.62,,,,,,,fee schedule,0.49,110.62,
"Hiv prep, ftc/tdf 200/300mg",J0750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,100.11,,,,,,,fee schedule,0.49,110.62,
"Hiv prep, ftc/tdf 200/300mg",J0750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,0.57,,,,,,,fee schedule,0.49,110.62,OP High Cost Drugs
"Hiv prep, ftc/tdf 200/300mg",J0750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,0.49,,,,,,,fee schedule,0.49,110.62,Other Pharmacy
"Hiv prep, ftc/tdf 200/300mg",J0750,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,0.51,,,,,,,fee schedule,0.49,110.62,APC
"Hiv prep, ftc/tdf 200/300mg",J0750,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,0.51,,,,,,,fee schedule,0.49,110.62,APC
"Hiv prep, ftc/tdf 200/300mg",J0750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,0.75,,,,,,,fee schedule,0.49,110.62,Radiology
"Hiv prep, ftc/tdf 200/300mg",J0750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,0.68,,,,,,,fee schedule,0.49,110.62,APC
"Hiv prep, ftc/tdf 200/300mg",J0750,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,0.85,,,,,,,fee schedule,0.49,110.62,APC
"Hiv prep, ftc/taf 200/25mg",J0751,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,139.18,,,,,,,fee schedule,71.44,139.18,
"Hiv prep, ftc/taf 200/25mg",J0751,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,125.97,,,,,,,fee schedule,71.44,139.18,
"Hiv prep, ftc/taf 200/25mg",J0751,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,82.86,,,,,,,fee schedule,71.44,139.18,OP High Cost Drugs
"Hiv prep, ftc/taf 200/25mg",J0751,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,71.44,,,,,,,fee schedule,71.44,139.18,Other Pharmacy
"Hiv prep, ftc/taf 200/25mg",J0751,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,75.01,,,,,,,fee schedule,71.44,139.18,APC
"Hiv prep, ftc/taf 200/25mg",J0751,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,74.29,,,,,,,fee schedule,71.44,139.18,APC
"Hiv prep, ftc/taf 200/25mg",J0751,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,109.3,,,,,,,fee schedule,71.44,139.18,Radiology
"Hiv prep, ftc/taf 200/25mg",J0751,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,100.01,,,,,,,fee schedule,71.44,139.18,APC
"Hiv prep, ftc/taf 200/25mg",J0751,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,125.01,,,,,,,fee schedule,71.44,139.18,APC
Colistimethate sodium inj,J0770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,53.09,,,,,,,fee schedule,48.05,53.09,
Colistimethate sodium inj,J0770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48.05,,,,,,,fee schedule,48.05,53.09,
"Collagenase, clost hist inj",J0775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,134.64,,,,,,,fee schedule,78.35,146.25,
"Collagenase, clost hist inj",J0775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,146.25,,,,,,,fee schedule,78.35,146.25,
"Collagenase, clost hist inj",J0775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,138.57,,,,,,,fee schedule,78.35,146.25,
"Collagenase, clost hist inj",J0775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,117.23,,,,,,,fee schedule,78.35,146.25,
"Collagenase, clost hist inj",J0775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,128.06,,,,,,,fee schedule,78.35,146.25,
"Collagenase, clost hist inj",J0775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,125.41,,,,,,,fee schedule,78.35,146.25,
"Collagenase, clost hist inj",J0775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,90.89,,,,,,,fee schedule,78.35,146.25,OP High Cost Drugs
"Collagenase, clost hist inj",J0775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,78.35,,,,,,,fee schedule,78.35,146.25,Other Pharmacy
"Collagenase, clost hist inj",J0775,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,82.27,,,,,,,fee schedule,78.35,146.25,APC
"Collagenase, clost hist inj",J0775,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,81.49,,,,,,,fee schedule,78.35,146.25,APC
"Collagenase, clost hist inj",J0775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,119.88,,,,,,,fee schedule,78.35,146.25,Radiology
"Collagenase, clost hist inj",J0775,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,109.69,,,,,,,fee schedule,78.35,146.25,APC
"Collagenase, clost hist inj",J0775,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,137.12,,,,,,,fee schedule,78.35,146.25,APC
Prochlorperazine injection,J0780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11.44,,,,,,,fee schedule,10.35,11.44,
Prochlorperazine injection,J0780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10.35,,,,,,,fee schedule,10.35,11.44,
Inj crizanlizumab-tmca 5mg,J0791,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,426.04,,,,,,,fee schedule,129.94,462.77,
Inj crizanlizumab-tmca 5mg,J0791,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,462.77,,,,,,,fee schedule,129.94,462.77,
Inj crizanlizumab-tmca 5mg,J0791,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,232.54,,,,,,,fee schedule,129.94,462.77,
Inj crizanlizumab-tmca 5mg,J0791,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,370.95,,,,,,,fee schedule,129.94,462.77,
Inj crizanlizumab-tmca 5mg,J0791,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,405.23,,,,,,,fee schedule,129.94,462.77,
Inj crizanlizumab-tmca 5mg,J0791,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,210.47,,,,,,,fee schedule,129.94,462.77,
Inj crizanlizumab-tmca 5mg,J0791,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,150.74,,,,,,,fee schedule,129.94,462.77,OP High Cost Drugs
Inj crizanlizumab-tmca 5mg,J0791,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,129.94,,,,,,,fee schedule,129.94,462.77,Other Pharmacy
Inj crizanlizumab-tmca 5mg,J0791,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,136.44,,,,,,,fee schedule,129.94,462.77,APC
Inj crizanlizumab-tmca 5mg,J0791,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,135.14,,,,,,,fee schedule,129.94,462.77,APC
Inj crizanlizumab-tmca 5mg,J0791,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,198.81,,,,,,,fee schedule,129.94,462.77,Radiology
Inj crizanlizumab-tmca 5mg,J0791,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,181.92,,,,,,,fee schedule,129.94,462.77,APC
Inj crizanlizumab-tmca 5mg,J0791,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,227.4,,,,,,,fee schedule,129.94,462.77,APC
Corticorelin ovine triflutal,J0795,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15.69,,,,,,,fee schedule,13.67,17.3,
Corticorelin ovine triflutal,J0795,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17.05,,,,,,,fee schedule,13.67,17.3,
Corticorelin ovine triflutal,J0795,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17.3,,,,,,,fee schedule,13.67,17.3,
Corticorelin ovine triflutal,J0795,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13.67,,,,,,,fee schedule,13.67,17.3,
Corticorelin ovine triflutal,J0795,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14.93,,,,,,,fee schedule,13.67,17.3,
Corticorelin ovine triflutal,J0795,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15.66,,,,,,,fee schedule,13.67,17.3,
Corticotropin injection,J0800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8413.28,,,,,,,fee schedule,7325.36,9138.57,
Corticotropin injection,J0800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9138.57,,,,,,,fee schedule,7325.36,9138.57,
Corticotropin injection,J0800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7325.36,,,,,,,fee schedule,7325.36,9138.57,
Corticotropin injection,J0800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8002.29,,,,,,,fee schedule,7325.36,9138.57,
Inj. acthar gel to 40 units,J0801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14233.5,,,,,,,fee schedule,4094.26,15460.53,
Inj. acthar gel to 40 units,J0801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15460.53,,,,,,,fee schedule,4094.26,15460.53,
Inj. acthar gel to 40 units,J0801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8339.37,,,,,,,fee schedule,4094.26,15460.53,
Inj. acthar gel to 40 units,J0801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12392.96,,,,,,,fee schedule,4094.26,15460.53,
Inj. acthar gel to 40 units,J0801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13538.18,,,,,,,fee schedule,4094.26,15460.53,
Inj. acthar gel to 40 units,J0801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7547.65,,,,,,,fee schedule,4094.26,15460.53,
Inj. acthar gel to 40 units,J0801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4749.34,,,,,,,fee schedule,4094.26,15460.53,OP High Cost Drugs
Inj. acthar gel to 40 units,J0801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4094.26,,,,,,,fee schedule,4094.26,15460.53,Other Pharmacy
Inj. acthar gel to 40 units,J0801,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4298.97,,,,,,,fee schedule,4094.26,15460.53,APC
Inj. acthar gel to 40 units,J0801,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4258.03,,,,,,,fee schedule,4094.26,15460.53,APC
Inj. acthar gel to 40 units,J0801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6264.22,,,,,,,fee schedule,4094.26,15460.53,Radiology
Inj. acthar gel to 40 units,J0801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5731.96,,,,,,,fee schedule,4094.26,15460.53,APC
Inj. acthar gel to 40 units,J0801,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7164.95,,,,,,,fee schedule,4094.26,15460.53,APC
"Inj. (ani), up to 40 units",J0802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12101.85,,,,,,,fee schedule,3571.35,13145.11,
"Inj. (ani), up to 40 units",J0802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13145.11,,,,,,,fee schedule,3571.35,13145.11,
"Inj. (ani), up to 40 units",J0802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6618.48,,,,,,,fee schedule,3571.35,13145.11,
"Inj. (ani), up to 40 units",J0802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10536.95,,,,,,,fee schedule,3571.35,13145.11,
"Inj. (ani), up to 40 units",J0802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11510.66,,,,,,,fee schedule,3571.35,13145.11,
"Inj. (ani), up to 40 units",J0802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5990.14,,,,,,,fee schedule,3571.35,13145.11,
"Inj. (ani), up to 40 units",J0802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4142.77,,,,,,,fee schedule,3571.35,13145.11,OP High Cost Drugs
"Inj. (ani), up to 40 units",J0802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3571.35,,,,,,,fee schedule,3571.35,13145.11,Other Pharmacy
"Inj. (ani), up to 40 units",J0802,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3749.92,,,,,,,fee schedule,3571.35,13145.11,APC
"Inj. (ani), up to 40 units",J0802,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3714.21,,,,,,,fee schedule,3571.35,13145.11,APC
"Inj. (ani), up to 40 units",J0802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5464.17,,,,,,,fee schedule,3571.35,13145.11,Radiology
"Inj. (ani), up to 40 units",J0802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4999.89,,,,,,,fee schedule,3571.35,13145.11,APC
"Inj. (ani), up to 40 units",J0802,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6249.86,,,,,,,fee schedule,3571.35,13145.11,APC
Cosyntropin cortrosyn inj,J0834,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,230.76,,,,,,,fee schedule,151.31,250.65,
Cosyntropin cortrosyn inj,J0834,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,250.65,,,,,,,fee schedule,151.31,250.65,
Cosyntropin cortrosyn inj,J0834,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,167.18,,,,,,,fee schedule,151.31,250.65,
Cosyntropin cortrosyn inj,J0834,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,200.92,,,,,,,fee schedule,151.31,250.65,
Cosyntropin cortrosyn inj,J0834,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,219.49,,,,,,,fee schedule,151.31,250.65,
Cosyntropin cortrosyn inj,J0834,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,151.31,,,,,,,fee schedule,151.31,250.65,
Crotalidae poly immune fab,J0840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7714.46,,,,,,,fee schedule,1841.02,8379.5,
Crotalidae poly immune fab,J0840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8379.5,,,,,,,fee schedule,1841.02,8379.5,
Crotalidae poly immune fab,J0840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6063.41,,,,,,,fee schedule,1841.02,8379.5,
Crotalidae poly immune fab,J0840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6716.9,,,,,,,fee schedule,1841.02,8379.5,
Crotalidae poly immune fab,J0840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7337.61,,,,,,,fee schedule,1841.02,8379.5,
Crotalidae poly immune fab,J0840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5487.77,,,,,,,fee schedule,1841.02,8379.5,
Crotalidae poly immune fab,J0840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2135.58,,,,,,,fee schedule,1841.02,8379.5,OP High Cost Drugs
Crotalidae poly immune fab,J0840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1841.02,,,,,,,fee schedule,1841.02,8379.5,Other Pharmacy
Crotalidae poly immune fab,J0840,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1933.07,,,,,,,fee schedule,1841.02,8379.5,APC
Crotalidae poly immune fab,J0840,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1914.66,,,,,,,fee schedule,1841.02,8379.5,APC
Crotalidae poly immune fab,J0840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2816.76,,,,,,,fee schedule,1841.02,8379.5,Radiology
Crotalidae poly immune fab,J0840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2577.43,,,,,,,fee schedule,1841.02,8379.5,APC
Crotalidae poly immune fab,J0840,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3221.78,,,,,,,fee schedule,1841.02,8379.5,APC
Inj crotalidae im f(ab')2 eq,J0841,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4372.97,,,,,,,fee schedule,2265.12,4749.95,
Inj crotalidae im f(ab')2 eq,J0841,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4749.95,,,,,,,fee schedule,2265.12,4749.95,
Inj crotalidae im f(ab')2 eq,J0841,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2502.72,,,,,,,fee schedule,2265.12,4749.95,
Inj crotalidae im f(ab')2 eq,J0841,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3807.5,,,,,,,fee schedule,2265.12,4749.95,
Inj crotalidae im f(ab')2 eq,J0841,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4159.35,,,,,,,fee schedule,2265.12,4749.95,
Inj crotalidae im f(ab')2 eq,J0841,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2265.12,,,,,,,fee schedule,2265.12,4749.95,
Cytomegalovirus imm IV /vial,J0850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3140.32,,,,,,,fee schedule,1808.61,3411.03,
Cytomegalovirus imm IV /vial,J0850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3411.03,,,,,,,fee schedule,1808.61,3411.03,
Cytomegalovirus imm IV /vial,J0850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3330.99,,,,,,,fee schedule,1808.61,3411.03,
Cytomegalovirus imm IV /vial,J0850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2734.24,,,,,,,fee schedule,1808.61,3411.03,
Cytomegalovirus imm IV /vial,J0850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2986.91,,,,,,,fee schedule,1808.61,3411.03,
Cytomegalovirus imm IV /vial,J0850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3014.75,,,,,,,fee schedule,1808.61,3411.03,
Cytomegalovirus imm IV /vial,J0850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2097.98,,,,,,,fee schedule,1808.61,3411.03,OP High Cost Drugs
Cytomegalovirus imm IV /vial,J0850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1808.61,,,,,,,fee schedule,1808.61,3411.03,Other Pharmacy
Cytomegalovirus imm IV /vial,J0850,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1899.04,,,,,,,fee schedule,1808.61,3411.03,APC
Cytomegalovirus imm IV /vial,J0850,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1880.95,,,,,,,fee schedule,1808.61,3411.03,APC
Cytomegalovirus imm IV /vial,J0850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2767.17,,,,,,,fee schedule,1808.61,3411.03,Radiology
Cytomegalovirus imm IV /vial,J0850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2532.05,,,,,,,fee schedule,1808.61,3411.03,APC
Cytomegalovirus imm IV /vial,J0850,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3165.06,,,,,,,fee schedule,1808.61,3411.03,APC
Daptomycin (xellia) unrefrig,J0872,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.27,,,,,,,fee schedule,0.24,0.27,
Daptomycin (xellia) unrefrig,J0872,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.24,,,,,,,fee schedule,0.24,0.27,
"Inj, daptomycin (xellia)",J0873,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.22,,,,,,,fee schedule,0.2,0.22,
"Inj, daptomycin (xellia)",J0873,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.2,,,,,,,fee schedule,0.2,0.22,
"Inj, daptomycin (baxter)",J0874,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.16,,,,,,,fee schedule,0.14,0.16,
"Inj, daptomycin (baxter)",J0874,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.14,,,,,,,fee schedule,0.14,0.16,
"Injection, dalbavancin",J0875,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,50.74,,,,,,,fee schedule,15,55.11,
"Injection, dalbavancin",J0875,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55.11,,,,,,,fee schedule,15,55.11,
"Injection, dalbavancin",J0875,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33.73,,,,,,,fee schedule,15,55.11,
"Injection, dalbavancin",J0875,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,44.18,,,,,,,fee schedule,15,55.11,
"Injection, dalbavancin",J0875,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48.26,,,,,,,fee schedule,15,55.11,
"Injection, dalbavancin",J0875,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,30.53,,,,,,,fee schedule,15,55.11,
"Injection, dalbavancin",J0875,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17.4,,,,,,,fee schedule,15,55.11,OP High Cost Drugs
"Injection, dalbavancin",J0875,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15,,,,,,,fee schedule,15,55.11,Other Pharmacy
"Injection, dalbavancin",J0875,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.75,,,,,,,fee schedule,15,55.11,APC
"Injection, dalbavancin",J0875,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,15.6,,,,,,,fee schedule,15,55.11,APC
"Injection, dalbavancin",J0875,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.95,,,,,,,fee schedule,15,55.11,Radiology
"Injection, dalbavancin",J0875,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21,,,,,,,fee schedule,15,55.11,APC
"Injection, dalbavancin",J0875,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,26.26,,,,,,,fee schedule,15,55.11,APC
"Inj, daptomycin (hospira)",J0877,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.28,,,,,,,fee schedule,0.26,0.28,
"Inj, daptomycin (hospira)",J0877,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.26,,,,,,,fee schedule,0.26,0.28,
Daptomycin injection,J0878,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.25,,,,,,,fee schedule,1.09,1.52,
Daptomycin injection,J0878,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.36,,,,,,,fee schedule,1.09,1.52,
Daptomycin injection,J0878,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.52,,,,,,,fee schedule,1.09,1.52,
Daptomycin injection,J0878,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.09,,,,,,,fee schedule,1.09,1.52,
Daptomycin injection,J0878,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.19,,,,,,,fee schedule,1.09,1.52,
Daptomycin injection,J0878,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.37,,,,,,,fee schedule,1.09,1.52,
"Difelikefalin, esrd on dialy",J0879,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.84,,,,,,,fee schedule,0.4,0.91,
"Difelikefalin, esrd on dialy",J0879,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.91,,,,,,,fee schedule,0.4,0.91,
"Difelikefalin, esrd on dialy",J0879,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.44,,,,,,,fee schedule,0.4,0.91,
"Difelikefalin, esrd on dialy",J0879,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.73,,,,,,,fee schedule,0.4,0.91,
"Difelikefalin, esrd on dialy",J0879,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.79,,,,,,,fee schedule,0.4,0.91,
"Difelikefalin, esrd on dialy",J0879,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.4,,,,,,,fee schedule,0.4,0.91,
"Darbepoetin alfa, non-esrd",J0881,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10.61,,,,,,,fee schedule,3.07,14.68,
"Darbepoetin alfa, non-esrd",J0881,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11.53,,,,,,,fee schedule,3.07,14.68,
"Darbepoetin alfa, non-esrd",J0881,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14.68,,,,,,,fee schedule,3.07,14.68,
"Darbepoetin alfa, non-esrd",J0881,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.24,,,,,,,fee schedule,3.07,14.68,
"Darbepoetin alfa, non-esrd",J0881,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10.1,,,,,,,fee schedule,3.07,14.68,
"Darbepoetin alfa, non-esrd",J0881,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13.28,,,,,,,fee schedule,3.07,14.68,
"Darbepoetin alfa, non-esrd",J0881,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3.56,,,,,,,fee schedule,3.07,14.68,OP High Cost Drugs
"Darbepoetin alfa, non-esrd",J0881,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3.07,,,,,,,fee schedule,3.07,14.68,Other Pharmacy
"Darbepoetin alfa, non-esrd",J0881,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3.23,,,,,,,fee schedule,3.07,14.68,APC
"Darbepoetin alfa, non-esrd",J0881,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3.19,,,,,,,fee schedule,3.07,14.68,APC
"Darbepoetin alfa, non-esrd",J0881,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4.7,,,,,,,fee schedule,3.07,14.68,Radiology
"Darbepoetin alfa, non-esrd",J0881,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4.3,,,,,,,fee schedule,3.07,14.68,APC
"Darbepoetin alfa, non-esrd",J0881,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5.38,,,,,,,fee schedule,3.07,14.68,APC
"Darbepoetin alfa, esrd use",J0882,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10.65,,,,,,,fee schedule,3.07,14.68,
"Darbepoetin alfa, esrd use",J0882,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11.57,,,,,,,fee schedule,3.07,14.68,
"Darbepoetin alfa, esrd use",J0882,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14.68,,,,,,,fee schedule,3.07,14.68,
"Darbepoetin alfa, esrd use",J0882,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.27,,,,,,,fee schedule,3.07,14.68,
"Darbepoetin alfa, esrd use",J0882,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10.13,,,,,,,fee schedule,3.07,14.68,
"Darbepoetin alfa, esrd use",J0882,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13.28,,,,,,,fee schedule,3.07,14.68,
"Darbepoetin alfa, esrd use",J0882,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3.56,,,,,,,fee schedule,3.07,14.68,OP High Cost Drugs
"Darbepoetin alfa, esrd use",J0882,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3.07,,,,,,,fee schedule,3.07,14.68,Other Pharmacy
"Darbepoetin alfa, esrd use",J0882,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3.23,,,,,,,fee schedule,3.07,14.68,APC
"Darbepoetin alfa, esrd use",J0882,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3.19,,,,,,,fee schedule,3.07,14.68,APC
"Darbepoetin alfa, esrd use",J0882,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4.7,,,,,,,fee schedule,3.07,14.68,Radiology
"Darbepoetin alfa, esrd use",J0882,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4.3,,,,,,,fee schedule,3.07,14.68,APC
"Darbepoetin alfa, esrd use",J0882,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5.38,,,,,,,fee schedule,3.07,14.68,APC
Argatroban nonesrd use 1mg,J0883,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.47,,,,,,,fee schedule,1.01,7.03,
Argatroban nonesrd use 1mg,J0883,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7.03,,,,,,,fee schedule,1.01,7.03,
Argatroban nonesrd use 1mg,J0883,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.34,,,,,,,fee schedule,1.01,7.03,
Argatroban nonesrd use 1mg,J0883,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.64,,,,,,,fee schedule,1.01,7.03,
Argatroban nonesrd use 1mg,J0883,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.16,,,,,,,fee schedule,1.01,7.03,
Argatroban nonesrd use 1mg,J0883,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.73,,,,,,,fee schedule,1.01,7.03,
Argatroban nonesrd use 1mg,J0883,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1.18,,,,,,,fee schedule,1.01,7.03,OP High Cost Drugs
Argatroban nonesrd use 1mg,J0883,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1.01,,,,,,,fee schedule,1.01,7.03,Other Pharmacy
Argatroban nonesrd use 1mg,J0883,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.06,,,,,,,fee schedule,1.01,7.03,APC
Argatroban nonesrd use 1mg,J0883,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1.05,,,,,,,fee schedule,1.01,7.03,APC
Argatroban nonesrd use 1mg,J0883,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1.55,,,,,,,fee schedule,1.01,7.03,Radiology
Argatroban nonesrd use 1mg,J0883,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1.42,,,,,,,fee schedule,1.01,7.03,APC
Argatroban nonesrd use 1mg,J0883,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1.77,,,,,,,fee schedule,1.01,7.03,APC
Argatroban esrd dialysis 1mg,J0884,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19.04,,,,,,,fee schedule,5.73,20.68,
Argatroban esrd dialysis 1mg,J0884,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20.68,,,,,,,fee schedule,5.73,20.68,
Argatroban esrd dialysis 1mg,J0884,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.34,,,,,,,fee schedule,5.73,20.68,
Argatroban esrd dialysis 1mg,J0884,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.57,,,,,,,fee schedule,5.73,20.68,
Argatroban esrd dialysis 1mg,J0884,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18.11,,,,,,,fee schedule,5.73,20.68,
Argatroban esrd dialysis 1mg,J0884,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.73,,,,,,,fee schedule,5.73,20.68,
"Epoetin alfa, non-esrd",J0885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,32.5,,,,,,,fee schedule,7.3,35.31,
"Epoetin alfa, non-esrd",J0885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,35.31,,,,,,,fee schedule,7.3,35.31,
"Epoetin alfa, non-esrd",J0885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,31.44,,,,,,,fee schedule,7.3,35.31,
"Epoetin alfa, non-esrd",J0885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28.3,,,,,,,fee schedule,7.3,35.31,
"Epoetin alfa, non-esrd",J0885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,30.92,,,,,,,fee schedule,7.3,35.31,
"Epoetin alfa, non-esrd",J0885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28.46,,,,,,,fee schedule,7.3,35.31,
"Epoetin alfa, non-esrd",J0885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8.47,,,,,,,fee schedule,7.3,35.31,OP High Cost Drugs
"Epoetin alfa, non-esrd",J0885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.3,,,,,,,fee schedule,7.3,35.31,Other Pharmacy
"Epoetin alfa, non-esrd",J0885,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.67,,,,,,,fee schedule,7.3,35.31,APC
"Epoetin alfa, non-esrd",J0885,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7.6,,,,,,,fee schedule,7.3,35.31,APC
"Epoetin alfa, non-esrd",J0885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11.18,,,,,,,fee schedule,7.3,35.31,Radiology
"Epoetin alfa, non-esrd",J0885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10.23,,,,,,,fee schedule,7.3,35.31,APC
"Epoetin alfa, non-esrd",J0885,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12.78,,,,,,,fee schedule,7.3,35.31,APC
Epoetin beta esrd use,J0887,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5,,,,,,,fee schedule,4.35,5.47,
Epoetin beta esrd use,J0887,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.43,,,,,,,fee schedule,4.35,5.47,
Epoetin beta esrd use,J0887,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.47,,,,,,,fee schedule,4.35,5.47,
Epoetin beta esrd use,J0887,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.35,,,,,,,fee schedule,4.35,5.47,
Epoetin beta esrd use,J0887,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.75,,,,,,,fee schedule,4.35,5.47,
Epoetin beta esrd use,J0887,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.95,,,,,,,fee schedule,4.35,5.47,
Epoetin beta non esrd,J0888,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.21,,,,,,,fee schedule,4.53,5.65,
Epoetin beta non esrd,J0888,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.65,,,,,,,fee schedule,4.53,5.65,
Epoetin beta non esrd,J0888,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.47,,,,,,,fee schedule,4.53,5.65,
Epoetin beta non esrd,J0888,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.53,,,,,,,fee schedule,4.53,5.65,
Epoetin beta non esrd,J0888,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.95,,,,,,,fee schedule,4.53,5.65,
Daprodustat oral 1mg esrd,J0889,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7.41,,,,,,,fee schedule,6.71,7.41,
Daprodustat oral 1mg esrd,J0889,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.71,,,,,,,fee schedule,6.71,7.41,
Peginesatide injection,J0890,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,28.54,,,,,,,fee schedule,24.85,31,
Peginesatide injection,J0890,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,31,,,,,,,fee schedule,24.85,31,
Peginesatide injection,J0890,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24.85,,,,,,,fee schedule,24.85,31,
Peginesatide injection,J0890,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,27.14,,,,,,,fee schedule,24.85,31,
Argatroban nonesrd (accord),J0891,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.97,,,,,,,fee schedule,1.72,8.05,
Argatroban nonesrd (accord),J0891,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.14,,,,,,,fee schedule,1.72,8.05,
Argatroban nonesrd (accord),J0891,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7.51,,,,,,,fee schedule,1.72,8.05,
Argatroban nonesrd (accord),J0891,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.72,,,,,,,fee schedule,1.72,8.05,
Argatroban nonesrd (accord),J0891,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.88,,,,,,,fee schedule,1.72,8.05,
Argatroban nonesrd (accord),J0891,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.79,,,,,,,fee schedule,1.72,8.05,
Argatroban nonesrd (accord),J0891,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.05,,,,,,,fee schedule,1.72,8.05,APC 378
Argatroban nonesrd (accord),J0891,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.91,,,,,,,fee schedule,1.72,8.05,APC
Argatroban nonesrd (accord),J0891,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1.89,,,,,,,fee schedule,1.72,8.05,APC
Argatroban nonesrd (accord),J0891,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1.82,,,,,,,fee schedule,1.72,8.05,APC
Argatroban nonesrd (accord),J0891,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2.78,,,,,,,fee schedule,1.72,8.05,Radiology
Argatroban nonesrd (accord),J0891,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2.54,,,,,,,fee schedule,1.72,8.05,APC
Argatroban nonesrd (accord),J0891,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3.18,,,,,,,fee schedule,1.72,8.05,APC
Argatroban dialysis (accord),J0892,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.97,,,,,,,fee schedule,1.72,7.51,
Argatroban dialysis (accord),J0892,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.14,,,,,,,fee schedule,1.72,7.51,
Argatroban dialysis (accord),J0892,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7.51,,,,,,,fee schedule,1.72,7.51,
Argatroban dialysis (accord),J0892,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.72,,,,,,,fee schedule,1.72,7.51,
Argatroban dialysis (accord),J0892,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.88,,,,,,,fee schedule,1.72,7.51,
Argatroban dialysis (accord),J0892,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.79,,,,,,,fee schedule,1.72,7.51,
"Inj, decitabine (sun pharma)",J0893,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,58.33,,,,,,,fee schedule,52.8,58.33,
"Inj, decitabine (sun pharma)",J0893,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52.8,,,,,,,fee schedule,52.8,58.33,
Decitabine injection,J0894,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,95.53,,,,,,,fee schedule,14.09,103.76,
Decitabine injection,J0894,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,103.76,,,,,,,fee schedule,14.09,103.76,
Decitabine injection,J0894,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15.56,,,,,,,fee schedule,14.09,103.76,
Decitabine injection,J0894,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,83.17,,,,,,,fee schedule,14.09,103.76,
Decitabine injection,J0894,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,90.86,,,,,,,fee schedule,14.09,103.76,
Decitabine injection,J0894,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14.09,,,,,,,fee schedule,14.09,103.76,
Deferoxamine mesylate inj,J0895,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24.55,,,,,,,fee schedule,22.22,24.55,
Deferoxamine mesylate inj,J0895,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22.22,,,,,,,fee schedule,22.22,24.55,
Inj luspatercept-aamt 0.25mg,J0896,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,126.35,,,,,,,fee schedule,42.75,137.24,
Inj luspatercept-aamt 0.25mg,J0896,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,137.24,,,,,,,fee schedule,42.75,137.24,
Inj luspatercept-aamt 0.25mg,J0896,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,74.58,,,,,,,fee schedule,42.75,137.24,
Inj luspatercept-aamt 0.25mg,J0896,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,110.01,,,,,,,fee schedule,42.75,137.24,
Inj luspatercept-aamt 0.25mg,J0896,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,120.18,,,,,,,fee schedule,42.75,137.24,
Inj luspatercept-aamt 0.25mg,J0896,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,67.5,,,,,,,fee schedule,42.75,137.24,
Inj luspatercept-aamt 0.25mg,J0896,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,49.59,,,,,,,fee schedule,42.75,137.24,OP High Cost Drugs
Inj luspatercept-aamt 0.25mg,J0896,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,42.75,,,,,,,fee schedule,42.75,137.24,Other Pharmacy
Inj luspatercept-aamt 0.25mg,J0896,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,44.89,,,,,,,fee schedule,42.75,137.24,APC
Inj luspatercept-aamt 0.25mg,J0896,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,44.46,,,,,,,fee schedule,42.75,137.24,APC
Inj luspatercept-aamt 0.25mg,J0896,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,65.41,,,,,,,fee schedule,42.75,137.24,Radiology
Inj luspatercept-aamt 0.25mg,J0896,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,59.85,,,,,,,fee schedule,42.75,137.24,APC
Inj luspatercept-aamt 0.25mg,J0896,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,74.81,,,,,,,fee schedule,42.75,137.24,APC
Denosumab injection,J0897,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,49.28,,,,,,,fee schedule,29.51,56.55,
Denosumab injection,J0897,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,53.52,,,,,,,fee schedule,29.51,56.55,
Denosumab injection,J0897,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,56.55,,,,,,,fee schedule,29.51,56.55,
Denosumab injection,J0897,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.9,,,,,,,fee schedule,29.51,56.55,
Denosumab injection,J0897,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.87,,,,,,,fee schedule,29.51,56.55,
Denosumab injection,J0897,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.18,,,,,,,fee schedule,29.51,56.55,
Denosumab injection,J0897,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,34.23,,,,,,,fee schedule,29.51,56.55,OP High Cost Drugs
Denosumab injection,J0897,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29.51,,,,,,,fee schedule,29.51,56.55,Other Pharmacy
Denosumab injection,J0897,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.98,,,,,,,fee schedule,29.51,56.55,APC
Denosumab injection,J0897,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,30.69,,,,,,,fee schedule,29.51,56.55,APC
Denosumab injection,J0897,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,45.15,,,,,,,fee schedule,29.51,56.55,Radiology
Denosumab injection,J0897,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,41.31,,,,,,,fee schedule,29.51,56.55,APC
Denosumab injection,J0897,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,51.64,,,,,,,fee schedule,29.51,56.55,APC
Argatroban nonesrd (auromed),J0898,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7.3,,,,,,,fee schedule,6.36,8.33,
Argatroban nonesrd (auromed),J0898,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7.93,,,,,,,fee schedule,6.36,8.33,
Argatroban nonesrd (auromed),J0898,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8.33,,,,,,,fee schedule,6.36,8.33,
Argatroban nonesrd (auromed),J0898,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.36,,,,,,,fee schedule,6.36,8.33,
Argatroban nonesrd (auromed),J0898,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.95,,,,,,,fee schedule,6.36,8.33,
Argatroban nonesrd (auromed),J0898,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7.54,,,,,,,fee schedule,6.36,8.33,
"Argatroban dialysis, auromed",J0899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7.3,,,,,,,fee schedule,6.36,8.33,
"Argatroban dialysis, auromed",J0899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7.93,,,,,,,fee schedule,6.36,8.33,
"Argatroban dialysis, auromed",J0899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8.33,,,,,,,fee schedule,6.36,8.33,
"Argatroban dialysis, auromed",J0899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.36,,,,,,,fee schedule,6.36,8.33,
"Argatroban dialysis, auromed",J0899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.95,,,,,,,fee schedule,6.36,8.33,
"Argatroban dialysis, auromed",J0899,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7.54,,,,,,,fee schedule,6.36,8.33,
Inst tauro 1.35mg/hep 100u,J0911,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15.8,,,,,,,fee schedule,5.03,22.29,
Inst tauro 1.35mg/hep 100u,J0911,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14.3,,,,,,,fee schedule,5.03,22.29,
Inst tauro 1.35mg/hep 100u,J0911,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22.29,,,,,,,fee schedule,5.03,22.29,APC 378
Inst tauro 1.35mg/hep 100u,J0911,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.28,,,,,,,fee schedule,5.03,22.29,APC
Inst tauro 1.35mg/hep 100u,J0911,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5.23,,,,,,,fee schedule,5.03,22.29,APC
Inst tauro 1.35mg/hep 100u,J0911,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5.03,,,,,,,fee schedule,5.03,22.29,APC
Inst tauro 1.35mg/hep 100u,J0911,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.69,,,,,,,fee schedule,5.03,22.29,Radiology
Inst tauro 1.35mg/hep 100u,J0911,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.04,,,,,,,fee schedule,5.03,22.29,APC
Inst tauro 1.35mg/hep 100u,J0911,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8.79,,,,,,,fee schedule,5.03,22.29,APC
Depo-estradiol cypionate inj,J1000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,76.99,,,,,,,fee schedule,69.68,76.99,
Depo-estradiol cypionate inj,J1000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,69.68,,,,,,,fee schedule,69.68,76.99,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.35,,,,,,,fee schedule,0.31,0.35,
"Inj, methylpred acetate 1 mg",J1010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.31,,,,,,,fee schedule,0.31,0.35,
Medroxyprogesterone acetate,J1050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.77,,,,,,,fee schedule,0.67,0.88,
Medroxyprogesterone acetate,J1050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.83,,,,,,,fee schedule,0.67,0.88,
Medroxyprogesterone acetate,J1050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.88,,,,,,,fee schedule,0.67,0.88,
Medroxyprogesterone acetate,J1050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.67,,,,,,,fee schedule,0.67,0.88,
Medroxyprogesterone acetate,J1050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.73,,,,,,,fee schedule,0.67,0.88,
Medroxyprogesterone acetate,J1050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.8,,,,,,,fee schedule,0.67,0.88,
Inj testosterone cypionate,J1071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.1,,,,,,,fee schedule,0.09,0.16,
Inj testosterone cypionate,J1071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.11,,,,,,,fee schedule,0.09,0.16,
Inj testosterone cypionate,J1071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.16,,,,,,,fee schedule,0.09,0.16,
Inj testosterone cypionate,J1071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.09,,,,,,,fee schedule,0.09,0.16,
Inj testosterone cypionate,J1071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.1,,,,,,,fee schedule,0.09,0.16,
Inj testosterone cypionate,J1071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.14,,,,,,,fee schedule,0.09,0.16,
Inj dexamethasone acetate,J1094,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.19,,,,,,,fee schedule,1.07,1.19,
Inj dexamethasone acetate,J1094,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.07,,,,,,,fee schedule,1.07,1.19,
"Injection, dexamethasone 9%",J1095,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.12,,,,,,,fee schedule,3.59,4.48,
"Injection, dexamethasone 9%",J1095,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.48,,,,,,,fee schedule,3.59,4.48,
"Injection, dexamethasone 9%",J1095,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.28,,,,,,,fee schedule,3.59,4.48,
"Injection, dexamethasone 9%",J1095,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.59,,,,,,,fee schedule,3.59,4.48,
"Injection, dexamethasone 9%",J1095,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.92,,,,,,,fee schedule,3.59,4.48,
"Injection, dexamethasone 9%",J1095,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.88,,,,,,,fee schedule,3.59,4.48,
Dexametha opth insert 0.1 mg,J1096,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,526.91,,,,,,,fee schedule,92.55,572.33,
Dexametha opth insert 0.1 mg,J1096,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,572.33,,,,,,,fee schedule,92.55,572.33,
Dexametha opth insert 0.1 mg,J1096,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,286.77,,,,,,,fee schedule,92.55,572.33,
Dexametha opth insert 0.1 mg,J1096,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,458.77,,,,,,,fee schedule,92.55,572.33,
Dexametha opth insert 0.1 mg,J1096,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,501.17,,,,,,,fee schedule,92.55,572.33,
Dexametha opth insert 0.1 mg,J1096,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,259.55,,,,,,,fee schedule,92.55,572.33,
Dexametha opth insert 0.1 mg,J1096,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,107.35,,,,,,,fee schedule,92.55,572.33,OP High Cost Drugs
Dexametha opth insert 0.1 mg,J1096,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,92.55,,,,,,,fee schedule,92.55,572.33,Other Pharmacy
Dexametha opth insert 0.1 mg,J1096,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,97.17,,,,,,,fee schedule,92.55,572.33,APC
Dexametha opth insert 0.1 mg,J1096,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,96.25,,,,,,,fee schedule,92.55,572.33,APC
Dexametha opth insert 0.1 mg,J1096,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,141.6,,,,,,,fee schedule,92.55,572.33,Radiology
Dexametha opth insert 0.1 mg,J1096,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,129.57,,,,,,,fee schedule,92.55,572.33,APC
Dexametha opth insert 0.1 mg,J1096,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,161.96,,,,,,,fee schedule,92.55,572.33,APC
Phenylep ketorolac opth soln,J1097,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,390.99,,,,,,,fee schedule,96.61,428.63,
Phenylep ketorolac opth soln,J1097,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,424.69,,,,,,,fee schedule,96.61,428.63,
Phenylep ketorolac opth soln,J1097,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,223.73,,,,,,,fee schedule,96.61,428.63,
Phenylep ketorolac opth soln,J1097,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,340.43,,,,,,,fee schedule,96.61,428.63,
Phenylep ketorolac opth soln,J1097,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,371.89,,,,,,,fee schedule,96.61,428.63,
Phenylep ketorolac opth soln,J1097,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,202.49,,,,,,,fee schedule,96.61,428.63,
Phenylep ketorolac opth soln,J1097,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,428.63,,,,,,,fee schedule,96.61,428.63,APC 378
Phenylep ketorolac opth soln,J1097,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,101.44,,,,,,,fee schedule,96.61,428.63,APC
Phenylep ketorolac opth soln,J1097,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,100.47,,,,,,,fee schedule,96.61,428.63,APC
Phenylep ketorolac opth soln,J1097,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,96.61,,,,,,,fee schedule,96.61,428.63,APC
Phenylep ketorolac opth soln,J1097,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,147.81,,,,,,,fee schedule,96.61,428.63,Radiology
Phenylep ketorolac opth soln,J1097,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,135.25,,,,,,,fee schedule,96.61,428.63,APC
Phenylep ketorolac opth soln,J1097,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,169.07,,,,,,,fee schedule,96.61,428.63,APC
Dexamethasone sodium phos,J1100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.28,,,,,,,fee schedule,0.26,0.28,
Dexamethasone sodium phos,J1100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.26,,,,,,,fee schedule,0.26,0.28,
"Dexmedetomidine film, 1 mcg",J1105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.39,,,,,,,fee schedule,1.26,1.39,
"Dexmedetomidine film, 1 mcg",J1105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.26,,,,,,,fee schedule,1.26,1.39,
Inj dihydroergotamine mesylt,J1110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,266.25,,,,,,,fee schedule,240.97,266.25,
Inj dihydroergotamine mesylt,J1110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,240.97,,,,,,,fee schedule,240.97,266.25,
Acetazolamid sodium injectio,J1120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,75.56,,,,,,,fee schedule,68.38,75.56,
Acetazolamid sodium injectio,J1120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,68.38,,,,,,,fee schedule,68.38,75.56,
Inj diclofenac sodium 0.5mg,J1130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.87,,,,,,,fee schedule,0.36,0.95,
Inj diclofenac sodium 0.5mg,J1130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.95,,,,,,,fee schedule,0.36,0.95,
Inj diclofenac sodium 0.5mg,J1130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.4,,,,,,,fee schedule,0.36,0.95,
Inj diclofenac sodium 0.5mg,J1130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.76,,,,,,,fee schedule,0.36,0.95,
Inj diclofenac sodium 0.5mg,J1130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.83,,,,,,,fee schedule,0.36,0.95,
Inj diclofenac sodium 0.5mg,J1130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.36,,,,,,,fee schedule,0.36,0.95,
Digoxin injection,J1160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,266.34,,,,,,,fee schedule,241.06,266.34,
Digoxin injection,J1160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,241.06,,,,,,,fee schedule,241.06,266.34,
Digoxin immune fab (ovine),J1162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1765.06,,,,,,,fee schedule,1536.82,9042.23,
Digoxin immune fab (ovine),J1162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1917.22,,,,,,,fee schedule,1536.82,9042.23,
Digoxin immune fab (ovine),J1162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8719.7,,,,,,,fee schedule,1536.82,9042.23,
Digoxin immune fab (ovine),J1162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1536.82,,,,,,,fee schedule,1536.82,9042.23,
Digoxin immune fab (ovine),J1162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1678.83,,,,,,,fee schedule,1536.82,9042.23,
Digoxin immune fab (ovine),J1162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7891.88,,,,,,,fee schedule,1536.82,9042.23,
Digoxin immune fab (ovine),J1162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5993.71,,,,,,,fee schedule,1536.82,9042.23,OP High Cost Drugs
Digoxin immune fab (ovine),J1162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5166.99,,,,,,,fee schedule,1536.82,9042.23,Other Pharmacy
Digoxin immune fab (ovine),J1162,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5425.34,,,,,,,fee schedule,1536.82,9042.23,APC
Digoxin immune fab (ovine),J1162,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5373.67,,,,,,,fee schedule,1536.82,9042.23,APC
Digoxin immune fab (ovine),J1162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7905.5,,,,,,,fee schedule,1536.82,9042.23,Radiology
Digoxin immune fab (ovine),J1162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7233.79,,,,,,,fee schedule,1536.82,9042.23,APC
Digoxin immune fab (ovine),J1162,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9042.23,,,,,,,fee schedule,1536.82,9042.23,APC
Phenytoin sodium injection,J1165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.26,,,,,,,fee schedule,1.14,1.26,
Phenytoin sodium injection,J1165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.14,,,,,,,fee schedule,1.14,1.26,
Hydromorphone injection,J1170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18.04,,,,,,,fee schedule,16.33,18.04,
Hydromorphone injection,J1170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.33,,,,,,,fee schedule,16.33,18.04,
"Inj, hydromorphone, 0.1 mg",J1171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.14,,,,,,,fee schedule,0.13,0.14,
"Inj, hydromorphone, 0.1 mg",J1171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.13,,,,,,,fee schedule,0.13,0.14,
Dexrazoxane hcl injection,J1190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,960.69,,,,,,,fee schedule,49.74,1043.51,
Dexrazoxane hcl injection,J1190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1043.51,,,,,,,fee schedule,49.74,1043.51,
Dexrazoxane hcl injection,J1190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,519.99,,,,,,,fee schedule,49.74,1043.51,
Dexrazoxane hcl injection,J1190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,836.46,,,,,,,fee schedule,49.74,1043.51,
Dexrazoxane hcl injection,J1190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,913.76,,,,,,,fee schedule,49.74,1043.51,
Dexrazoxane hcl injection,J1190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,470.63,,,,,,,fee schedule,49.74,1043.51,
Dexrazoxane hcl injection,J1190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,57.7,,,,,,,fee schedule,49.74,1043.51,OP High Cost Drugs
Dexrazoxane hcl injection,J1190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49.74,,,,,,,fee schedule,49.74,1043.51,Other Pharmacy
Dexrazoxane hcl injection,J1190,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,52.22,,,,,,,fee schedule,49.74,1043.51,APC
Dexrazoxane hcl injection,J1190,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,51.73,,,,,,,fee schedule,49.74,1043.51,APC
Dexrazoxane hcl injection,J1190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,76.1,,,,,,,fee schedule,49.74,1043.51,Radiology
Dexrazoxane hcl injection,J1190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,69.63,,,,,,,fee schedule,49.74,1043.51,APC
Dexrazoxane hcl injection,J1190,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,87.04,,,,,,,fee schedule,49.74,1043.51,APC
Diphenhydramine hcl injectio,J1200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.65,,,,,,,fee schedule,2.4,2.65,
Diphenhydramine hcl injectio,J1200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.4,,,,,,,fee schedule,2.4,2.65,
Inj. cetirizine hcl 0.5mg,J1201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,53.56,,,,,,,fee schedule,16.92,58.18,
Inj. cetirizine hcl 0.5mg,J1201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,58.18,,,,,,,fee schedule,16.92,58.18,
Inj. cetirizine hcl 0.5mg,J1201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,31.77,,,,,,,fee schedule,16.92,58.18,
Inj. cetirizine hcl 0.5mg,J1201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.63,,,,,,,fee schedule,16.92,58.18,
Inj. cetirizine hcl 0.5mg,J1201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,50.94,,,,,,,fee schedule,16.92,58.18,
Inj. cetirizine hcl 0.5mg,J1201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28.76,,,,,,,fee schedule,16.92,58.18,
Inj. cetirizine hcl 0.5mg,J1201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,19.63,,,,,,,fee schedule,16.92,58.18,OP High Cost Drugs
Inj. cetirizine hcl 0.5mg,J1201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.92,,,,,,,fee schedule,16.92,58.18,Other Pharmacy
Inj. cetirizine hcl 0.5mg,J1201,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.77,,,,,,,fee schedule,16.92,58.18,APC
Inj. cetirizine hcl 0.5mg,J1201,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,17.6,,,,,,,fee schedule,16.92,58.18,APC
Inj. cetirizine hcl 0.5mg,J1201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.89,,,,,,,fee schedule,16.92,58.18,Radiology
Inj. cetirizine hcl 0.5mg,J1201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.69,,,,,,,fee schedule,16.92,58.18,APC
Inj. cetirizine hcl 0.5mg,J1201,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,29.61,,,,,,,fee schedule,16.92,58.18,APC
Miglustat oral 65 mg,J1202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,62.57,,,,,,,fee schedule,56.63,62.57,
Miglustat oral 65 mg,J1202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56.63,,,,,,,fee schedule,56.63,62.57,
"Inj, cipaglucosidase, 5 mg",J1203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,164.43,,,,,,,fee schedule,92.4,164.43,
"Inj, cipaglucosidase, 5 mg",J1203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,148.82,,,,,,,fee schedule,92.4,164.43,
"Inj, cipaglucosidase, 5 mg",J1203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,107.18,,,,,,,fee schedule,92.4,164.43,OP High Cost Drugs
"Inj, cipaglucosidase, 5 mg",J1203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,92.4,,,,,,,fee schedule,92.4,164.43,Other Pharmacy
"Inj, cipaglucosidase, 5 mg",J1203,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,97.02,,,,,,,fee schedule,92.4,164.43,APC
"Inj, cipaglucosidase, 5 mg",J1203,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,96.09,,,,,,,fee schedule,92.4,164.43,APC
"Inj, cipaglucosidase, 5 mg",J1203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,141.37,,,,,,,fee schedule,92.4,164.43,Radiology
"Inj, cipaglucosidase, 5 mg",J1203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,129.36,,,,,,,fee schedule,92.4,164.43,APC
"Inj, cipaglucosidase, 5 mg",J1203,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,161.7,,,,,,,fee schedule,92.4,164.43,APC
Chlorothiazide sodium inj,J1205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,690.47,,,,,,,fee schedule,286,749.99,
Chlorothiazide sodium inj,J1205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,749.99,,,,,,,fee schedule,286,749.99,
Chlorothiazide sodium inj,J1205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,316,,,,,,,fee schedule,286,749.99,
Chlorothiazide sodium inj,J1205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,601.18,,,,,,,fee schedule,286,749.99,
Chlorothiazide sodium inj,J1205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,656.74,,,,,,,fee schedule,286,749.99,
Chlorothiazide sodium inj,J1205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,286,,,,,,,fee schedule,286,749.99,
Dimethyl sulfoxide 50% 50 ML,J1212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1732.34,,,,,,,fee schedule,748.98,1881.68,
Dimethyl sulfoxide 50% 50 ML,J1212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1881.68,,,,,,,fee schedule,748.98,1881.68,
Dimethyl sulfoxide 50% 50 ML,J1212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1317.69,,,,,,,fee schedule,748.98,1881.68,
Dimethyl sulfoxide 50% 50 ML,J1212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1508.33,,,,,,,fee schedule,748.98,1881.68,
Dimethyl sulfoxide 50% 50 ML,J1212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1647.72,,,,,,,fee schedule,748.98,1881.68,
Dimethyl sulfoxide 50% 50 ML,J1212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1192.59,,,,,,,fee schedule,748.98,1881.68,
Dimethyl sulfoxide 50% 50 ML,J1212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,868.81,,,,,,,fee schedule,748.98,1881.68,OP High Cost Drugs
Dimethyl sulfoxide 50% 50 ML,J1212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,748.98,,,,,,,fee schedule,748.98,1881.68,Other Pharmacy
Dimethyl sulfoxide 50% 50 ML,J1212,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,786.42,,,,,,,fee schedule,748.98,1881.68,APC
Dimethyl sulfoxide 50% 50 ML,J1212,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,778.93,,,,,,,fee schedule,748.98,1881.68,APC
Dimethyl sulfoxide 50% 50 ML,J1212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1145.93,,,,,,,fee schedule,748.98,1881.68,Radiology
Dimethyl sulfoxide 50% 50 ML,J1212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1048.56,,,,,,,fee schedule,748.98,1881.68,APC
Dimethyl sulfoxide 50% 50 ML,J1212,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1310.71,,,,,,,fee schedule,748.98,1881.68,APC
Methadone injection,J1230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,35.03,,,,,,,fee schedule,31.7,35.03,
Methadone injection,J1230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31.7,,,,,,,fee schedule,31.7,35.03,
Dimenhydrinate injection,J1240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21.87,,,,,,,fee schedule,19.79,21.87,
Dimenhydrinate injection,J1240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19.79,,,,,,,fee schedule,19.79,21.87,
Dipyridamole injection,J1245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.04,,,,,,,fee schedule,4.56,5.04,
Dipyridamole injection,J1245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.56,,,,,,,fee schedule,4.56,5.04,
"Inj, dinutuximab, 0.1 mg",J1246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,325.96,,,,,,,fee schedule,283.81,354.06,
"Inj, dinutuximab, 0.1 mg",J1246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,354.06,,,,,,,fee schedule,283.81,354.06,
"Inj, dinutuximab, 0.1 mg",J1246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,283.81,,,,,,,fee schedule,283.81,354.06,
"Inj, dinutuximab, 0.1 mg",J1246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,310.04,,,,,,,fee schedule,283.81,354.06,
Inj dobutamine HCL/250 mg,J1250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13.86,,,,,,,fee schedule,12.54,13.86,
Inj dobutamine HCL/250 mg,J1250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12.54,,,,,,,fee schedule,12.54,13.86,
Dolasetron mesylate,J1260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16.46,,,,,,,fee schedule,14.33,17.88,
Dolasetron mesylate,J1260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17.88,,,,,,,fee schedule,14.33,17.88,
Dolasetron mesylate,J1260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14.33,,,,,,,fee schedule,14.33,17.88,
Dolasetron mesylate,J1260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15.66,,,,,,,fee schedule,14.33,17.88,
Dopamine injection,J1265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.11,,,,,,,fee schedule,1,1.11,
Dopamine injection,J1265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1,,,,,,,fee schedule,1,1.11,
Doripenem injection,J1267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.26,,,,,,,fee schedule,1.36,2.46,
Doripenem injection,J1267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.46,,,,,,,fee schedule,1.36,2.46,
Doripenem injection,J1267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.5,,,,,,,fee schedule,1.36,2.46,
Doripenem injection,J1267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.97,,,,,,,fee schedule,1.36,2.46,
Doripenem injection,J1267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.15,,,,,,,fee schedule,1.36,2.46,
Doripenem injection,J1267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.36,,,,,,,fee schedule,1.36,2.46,
"Injection, doxercalciferol",J1270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.13,,,,,,,fee schedule,1.93,2.13,
"Injection, doxercalciferol",J1270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.93,,,,,,,fee schedule,1.93,2.13,
Ecallantide injection,J1290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1101.59,,,,,,,fee schedule,578.75,1196.56,
Ecallantide injection,J1290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1196.56,,,,,,,fee schedule,578.75,1196.56,
Ecallantide injection,J1290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1050.45,,,,,,,fee schedule,578.75,1196.56,
Ecallantide injection,J1290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,959.15,,,,,,,fee schedule,578.75,1196.56,
Ecallantide injection,J1290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1047.78,,,,,,,fee schedule,578.75,1196.56,
Ecallantide injection,J1290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,950.72,,,,,,,fee schedule,578.75,1196.56,
Ecallantide injection,J1290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,671.35,,,,,,,fee schedule,578.75,1196.56,OP High Cost Drugs
Ecallantide injection,J1290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,578.75,,,,,,,fee schedule,578.75,1196.56,Other Pharmacy
Ecallantide injection,J1290,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,607.68,,,,,,,fee schedule,578.75,1196.56,APC
Ecallantide injection,J1290,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,601.9,,,,,,,fee schedule,578.75,1196.56,APC
Ecallantide injection,J1290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,885.48,,,,,,,fee schedule,578.75,1196.56,Radiology
Ecallantide injection,J1290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,810.25,,,,,,,fee schedule,578.75,1196.56,APC
Ecallantide injection,J1290,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1012.81,,,,,,,fee schedule,578.75,1196.56,APC
Eculizumab injection,J1300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,636.28,,,,,,,fee schedule,373.12,691.14,
Eculizumab injection,J1300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,691.14,,,,,,,fee schedule,373.12,691.14,
Eculizumab injection,J1300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,412.25,,,,,,,fee schedule,373.12,691.14,
Eculizumab injection,J1300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,554.01,,,,,,,fee schedule,373.12,691.14,
Eculizumab injection,J1300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,605.2,,,,,,,fee schedule,373.12,691.14,
Eculizumab injection,J1300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,373.12,,,,,,,fee schedule,373.12,691.14,
"Injection, edaravone, 1 mg",J1301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.74,,,,,,,fee schedule,15.18,72.5,
"Injection, edaravone, 1 mg",J1301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,72.5,,,,,,,fee schedule,15.18,72.5,
"Injection, edaravone, 1 mg",J1301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,40.21,,,,,,,fee schedule,15.18,72.5,
"Injection, edaravone, 1 mg",J1301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,58.11,,,,,,,fee schedule,15.18,72.5,
"Injection, edaravone, 1 mg",J1301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,63.48,,,,,,,fee schedule,15.18,72.5,
"Injection, edaravone, 1 mg",J1301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36.39,,,,,,,fee schedule,15.18,72.5,
"Injection, edaravone, 1 mg",J1301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17.61,,,,,,,fee schedule,15.18,72.5,OP High Cost Drugs
"Injection, edaravone, 1 mg",J1301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15.18,,,,,,,fee schedule,15.18,72.5,Other Pharmacy
"Injection, edaravone, 1 mg",J1301,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.94,,,,,,,fee schedule,15.18,72.5,APC
"Injection, edaravone, 1 mg",J1301,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,15.79,,,,,,,fee schedule,15.18,72.5,APC
"Injection, edaravone, 1 mg",J1301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.22,,,,,,,fee schedule,15.18,72.5,Radiology
"Injection, edaravone, 1 mg",J1301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21.25,,,,,,,fee schedule,15.18,72.5,APC
"Injection, edaravone, 1 mg",J1301,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,26.56,,,,,,,fee schedule,15.18,72.5,APC
"Inj, sutimlimab-jome, 10 mg",J1302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59.19,,,,,,,fee schedule,19.64,64.3,
"Inj, sutimlimab-jome, 10 mg",J1302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,64.3,,,,,,,fee schedule,19.64,64.3,
"Inj, sutimlimab-jome, 10 mg",J1302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33.05,,,,,,,fee schedule,19.64,64.3,
"Inj, sutimlimab-jome, 10 mg",J1302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.54,,,,,,,fee schedule,19.64,64.3,
"Inj, sutimlimab-jome, 10 mg",J1302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56.3,,,,,,,fee schedule,19.64,64.3,
"Inj, sutimlimab-jome, 10 mg",J1302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29.92,,,,,,,fee schedule,19.64,64.3,
"Inj, sutimlimab-jome, 10 mg",J1302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,22.78,,,,,,,fee schedule,19.64,64.3,OP High Cost Drugs
"Inj, sutimlimab-jome, 10 mg",J1302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.64,,,,,,,fee schedule,19.64,64.3,Other Pharmacy
"Inj, sutimlimab-jome, 10 mg",J1302,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20.62,,,,,,,fee schedule,19.64,64.3,APC
"Inj, sutimlimab-jome, 10 mg",J1302,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,20.43,,,,,,,fee schedule,19.64,64.3,APC
"Inj, sutimlimab-jome, 10 mg",J1302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,30.05,,,,,,,fee schedule,19.64,64.3,Radiology
"Inj, sutimlimab-jome, 10 mg",J1302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27.5,,,,,,,fee schedule,19.64,64.3,APC
"Inj, sutimlimab-jome, 10 mg",J1302,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,34.37,,,,,,,fee schedule,19.64,64.3,APC
"Inj., ravulizumab-cwvz 10 mg",J1303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,787.44,,,,,,,fee schedule,223.68,855.32,
"Inj., ravulizumab-cwvz 10 mg",J1303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,855.32,,,,,,,fee schedule,223.68,855.32,
"Inj., ravulizumab-cwvz 10 mg",J1303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,404.73,,,,,,,fee schedule,223.68,855.32,
"Inj., ravulizumab-cwvz 10 mg",J1303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,685.61,,,,,,,fee schedule,223.68,855.32,
"Inj., ravulizumab-cwvz 10 mg",J1303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,748.97,,,,,,,fee schedule,223.68,855.32,
"Inj., ravulizumab-cwvz 10 mg",J1303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,366.31,,,,,,,fee schedule,223.68,855.32,
"Inj., ravulizumab-cwvz 10 mg",J1303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,259.46,,,,,,,fee schedule,223.68,855.32,OP High Cost Drugs
"Inj., ravulizumab-cwvz 10 mg",J1303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,223.68,,,,,,,fee schedule,223.68,855.32,Other Pharmacy
"Inj., ravulizumab-cwvz 10 mg",J1303,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,234.86,,,,,,,fee schedule,223.68,855.32,APC
"Inj., ravulizumab-cwvz 10 mg",J1303,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,232.62,,,,,,,fee schedule,223.68,855.32,APC
"Inj., ravulizumab-cwvz 10 mg",J1303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,342.22,,,,,,,fee schedule,223.68,855.32,Radiology
"Inj., ravulizumab-cwvz 10 mg",J1303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,313.14,,,,,,,fee schedule,223.68,855.32,APC
"Inj., ravulizumab-cwvz 10 mg",J1303,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,391.43,,,,,,,fee schedule,223.68,855.32,APC
Inj tofersen intrathec 1 mg,J1304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,510.06,,,,,,,fee schedule,160.01,554.03,
Inj tofersen intrathec 1 mg,J1304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,554.03,,,,,,,fee schedule,160.01,554.03,
Inj tofersen intrathec 1 mg,J1304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,276.59,,,,,,,fee schedule,160.01,554.03,
Inj tofersen intrathec 1 mg,J1304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,444.1,,,,,,,fee schedule,160.01,554.03,
Inj tofersen intrathec 1 mg,J1304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,485.14,,,,,,,fee schedule,160.01,554.03,
Inj tofersen intrathec 1 mg,J1304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,250.34,,,,,,,fee schedule,160.01,554.03,
Inj tofersen intrathec 1 mg,J1304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,185.61,,,,,,,fee schedule,160.01,554.03,OP High Cost Drugs
Inj tofersen intrathec 1 mg,J1304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,160.01,,,,,,,fee schedule,160.01,554.03,Other Pharmacy
Inj tofersen intrathec 1 mg,J1304,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,168.01,,,,,,,fee schedule,160.01,554.03,APC
Inj tofersen intrathec 1 mg,J1304,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,166.41,,,,,,,fee schedule,160.01,554.03,APC
Inj tofersen intrathec 1 mg,J1304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,244.82,,,,,,,fee schedule,160.01,554.03,Radiology
Inj tofersen intrathec 1 mg,J1304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,224.01,,,,,,,fee schedule,160.01,554.03,APC
Inj tofersen intrathec 1 mg,J1304,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,280.02,,,,,,,fee schedule,160.01,554.03,APC
"Inj, evinacumab-dgnb, 5mg",J1305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,576.38,,,,,,,fee schedule,197.63,626.06,
"Inj, evinacumab-dgnb, 5mg",J1305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,626.06,,,,,,,fee schedule,197.63,626.06,
"Inj, evinacumab-dgnb, 5mg",J1305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,332.91,,,,,,,fee schedule,197.63,626.06,
"Inj, evinacumab-dgnb, 5mg",J1305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,501.84,,,,,,,fee schedule,197.63,626.06,
"Inj, evinacumab-dgnb, 5mg",J1305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,548.22,,,,,,,fee schedule,197.63,626.06,
"Inj, evinacumab-dgnb, 5mg",J1305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,301.3,,,,,,,fee schedule,197.63,626.06,
"Inj, evinacumab-dgnb, 5mg",J1305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,229.25,,,,,,,fee schedule,197.63,626.06,OP High Cost Drugs
"Inj, evinacumab-dgnb, 5mg",J1305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,197.63,,,,,,,fee schedule,197.63,626.06,Other Pharmacy
"Inj, evinacumab-dgnb, 5mg",J1305,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,207.51,,,,,,,fee schedule,197.63,626.06,APC
"Inj, evinacumab-dgnb, 5mg",J1305,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,205.54,,,,,,,fee schedule,197.63,626.06,APC
"Inj, evinacumab-dgnb, 5mg",J1305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,302.38,,,,,,,fee schedule,197.63,626.06,Radiology
"Inj, evinacumab-dgnb, 5mg",J1305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,276.69,,,,,,,fee schedule,197.63,626.06,APC
"Inj, evinacumab-dgnb, 5mg",J1305,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,345.86,,,,,,,fee schedule,197.63,626.06,APC
"Injection, inclisiran, 1 mg",J1306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41.03,,,,,,,fee schedule,12.61,44.57,
"Injection, inclisiran, 1 mg",J1306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,44.57,,,,,,,fee schedule,12.61,44.57,
"Injection, inclisiran, 1 mg",J1306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22.88,,,,,,,fee schedule,12.61,44.57,
"Injection, inclisiran, 1 mg",J1306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35.72,,,,,,,fee schedule,12.61,44.57,
"Injection, inclisiran, 1 mg",J1306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39.02,,,,,,,fee schedule,12.61,44.57,
"Injection, inclisiran, 1 mg",J1306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20.71,,,,,,,fee schedule,12.61,44.57,
"Injection, inclisiran, 1 mg",J1306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14.63,,,,,,,fee schedule,12.61,44.57,OP High Cost Drugs
"Injection, inclisiran, 1 mg",J1306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12.61,,,,,,,fee schedule,12.61,44.57,Other Pharmacy
"Injection, inclisiran, 1 mg",J1306,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.24,,,,,,,fee schedule,12.61,44.57,APC
"Injection, inclisiran, 1 mg",J1306,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.11,,,,,,,fee schedule,12.61,44.57,APC
"Injection, inclisiran, 1 mg",J1306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.29,,,,,,,fee schedule,12.61,44.57,Radiology
"Injection, inclisiran, 1 mg",J1306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.65,,,,,,,fee schedule,12.61,44.57,APC
"Injection, inclisiran, 1 mg",J1306,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22.07,,,,,,,fee schedule,12.61,44.57,APC
"Elosulfase alfa, injection",J1322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,771.52,,,,,,,fee schedule,311.95,838.03,
"Elosulfase alfa, injection",J1322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,838.03,,,,,,,fee schedule,311.95,838.03,
"Elosulfase alfa, injection",J1322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,538.84,,,,,,,fee schedule,311.95,838.03,
"Elosulfase alfa, injection",J1322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,671.75,,,,,,,fee schedule,311.95,838.03,
"Elosulfase alfa, injection",J1322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,733.83,,,,,,,fee schedule,311.95,838.03,
"Elosulfase alfa, injection",J1322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,487.69,,,,,,,fee schedule,311.95,838.03,
"Elosulfase alfa, injection",J1322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,361.86,,,,,,,fee schedule,311.95,838.03,OP High Cost Drugs
"Elosulfase alfa, injection",J1322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,311.95,,,,,,,fee schedule,311.95,838.03,Other Pharmacy
"Elosulfase alfa, injection",J1322,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,327.54,,,,,,,fee schedule,311.95,838.03,APC
"Elosulfase alfa, injection",J1322,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,324.42,,,,,,,fee schedule,311.95,838.03,APC
"Elosulfase alfa, injection",J1322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,477.28,,,,,,,fee schedule,311.95,838.03,Radiology
"Elosulfase alfa, injection",J1322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,436.72,,,,,,,fee schedule,311.95,838.03,APC
"Elosulfase alfa, injection",J1322,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,545.91,,,,,,,fee schedule,311.95,838.03,APC
"Inj, elranatamab-bcmm, 1 mg",J1323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,338.28,,,,,,,fee schedule,186.79,338.28,
"Inj, elranatamab-bcmm, 1 mg",J1323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,306.16,,,,,,,fee schedule,186.79,338.28,
"Inj, elranatamab-bcmm, 1 mg",J1323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,216.68,,,,,,,fee schedule,186.79,338.28,OP High Cost Drugs
"Inj, elranatamab-bcmm, 1 mg",J1323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,186.79,,,,,,,fee schedule,186.79,338.28,Other Pharmacy
"Inj, elranatamab-bcmm, 1 mg",J1323,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,196.13,,,,,,,fee schedule,186.79,338.28,APC
"Inj, elranatamab-bcmm, 1 mg",J1323,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,194.26,,,,,,,fee schedule,186.79,338.28,APC
"Inj, elranatamab-bcmm, 1 mg",J1323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,285.79,,,,,,,fee schedule,186.79,338.28,Radiology
"Inj, elranatamab-bcmm, 1 mg",J1323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,261.51,,,,,,,fee schedule,186.79,338.28,APC
"Inj, elranatamab-bcmm, 1 mg",J1323,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,326.88,,,,,,,fee schedule,186.79,338.28,APC
Enfuvirtide injection,J1324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.6,,,,,,,fee schedule,1.14,1.74,
Enfuvirtide injection,J1324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.74,,,,,,,fee schedule,1.14,1.74,
Enfuvirtide injection,J1324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.26,,,,,,,fee schedule,1.14,1.74,
Enfuvirtide injection,J1324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.39,,,,,,,fee schedule,1.14,1.74,
Enfuvirtide injection,J1324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.52,,,,,,,fee schedule,1.14,1.74,
Enfuvirtide injection,J1324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.14,,,,,,,fee schedule,1.14,1.74,
Epoprostenol injection,J1325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,32.61,,,,,,,fee schedule,29.52,32.61,
Epoprostenol injection,J1325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29.52,,,,,,,fee schedule,29.52,32.61,
Eptifibatide injection,J1327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,63.93,,,,,,,fee schedule,3.26,69.44,
Eptifibatide injection,J1327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,69.44,,,,,,,fee schedule,3.26,69.44,
Eptifibatide injection,J1327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,36.89,,,,,,,fee schedule,3.26,69.44,
Eptifibatide injection,J1327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55.66,,,,,,,fee schedule,3.26,69.44,
Eptifibatide injection,J1327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,60.8,,,,,,,fee schedule,3.26,69.44,
Eptifibatide injection,J1327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,33.39,,,,,,,fee schedule,3.26,69.44,
Eptifibatide injection,J1327,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14.47,,,,,,,fee schedule,3.26,69.44,APC 378
Eptifibatide injection,J1327,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3.42,,,,,,,fee schedule,3.26,69.44,APC
Eptifibatide injection,J1327,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3.39,,,,,,,fee schedule,3.26,69.44,APC
Eptifibatide injection,J1327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3.26,,,,,,,fee schedule,3.26,69.44,APC
Eptifibatide injection,J1327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4.99,,,,,,,fee schedule,3.26,69.44,Radiology
Eptifibatide injection,J1327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4.57,,,,,,,fee schedule,3.26,69.44,APC
Eptifibatide injection,J1327,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5.71,,,,,,,fee schedule,3.26,69.44,APC
Ertapenem injection,J1335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,102.89,,,,,,,fee schedule,93.12,102.89,
Ertapenem injection,J1335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,93.12,,,,,,,fee schedule,93.12,102.89,
Erythro lactobionate /500 MG,J1364,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,207.76,,,,,,,fee schedule,150.51,225.67,
Erythro lactobionate /500 MG,J1364,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,225.67,,,,,,,fee schedule,150.51,225.67,
Erythro lactobionate /500 MG,J1364,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,166.3,,,,,,,fee schedule,150.51,225.67,
Erythro lactobionate /500 MG,J1364,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,180.89,,,,,,,fee schedule,150.51,225.67,
Erythro lactobionate /500 MG,J1364,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,197.61,,,,,,,fee schedule,150.51,225.67,
Erythro lactobionate /500 MG,J1364,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,150.51,,,,,,,fee schedule,150.51,225.67,
Estradiol valerate 10 MG inj,J1380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45.25,,,,,,,fee schedule,40.96,45.25,
Estradiol valerate 10 MG inj,J1380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40.96,,,,,,,fee schedule,40.96,45.25,
Inj estrogen conjugate 25 MG,J1410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,270.12,,,,,,,fee schedule,235.19,697.82,
Inj estrogen conjugate 25 MG,J1410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,293.4,,,,,,,fee schedule,235.19,697.82,
Inj estrogen conjugate 25 MG,J1410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,697.82,,,,,,,fee schedule,235.19,697.82,
Inj estrogen conjugate 25 MG,J1410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,235.19,,,,,,,fee schedule,235.19,697.82,
Inj estrogen conjugate 25 MG,J1410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,256.92,,,,,,,fee schedule,235.19,697.82,
Inj estrogen conjugate 25 MG,J1410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,631.57,,,,,,,fee schedule,235.19,697.82,
Inj estrogen conjugate 25 MG,J1410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,454.39,,,,,,,fee schedule,235.19,697.82,OP High Cost Drugs
Inj estrogen conjugate 25 MG,J1410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,391.72,,,,,,,fee schedule,235.19,697.82,Other Pharmacy
Inj estrogen conjugate 25 MG,J1410,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,411.3,,,,,,,fee schedule,235.19,697.82,APC
Inj estrogen conjugate 25 MG,J1410,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,407.39,,,,,,,fee schedule,235.19,697.82,APC
Inj estrogen conjugate 25 MG,J1410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,599.33,,,,,,,fee schedule,235.19,697.82,Radiology
Inj estrogen conjugate 25 MG,J1410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,548.41,,,,,,,fee schedule,235.19,697.82,APC
Inj estrogen conjugate 25 MG,J1410,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,685.51,,,,,,,fee schedule,235.19,697.82,APC
"Inj, hemgenix, per tx dose",J1411,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12910800,,,,,,,fee schedule,3691450,16377714.39,
"Inj, hemgenix, per tx dose",J1411,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14023800,,,,,,,fee schedule,3691450,16377714.39,
"Inj, hemgenix, per tx dose",J1411,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6636000,,,,,,,fee schedule,3691450,16377714.39,
"Inj, hemgenix, per tx dose",J1411,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11241300,,,,,,,fee schedule,3691450,16377714.39,
"Inj, hemgenix, per tx dose",J1411,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12280100,,,,,,,fee schedule,3691450,16377714.39,
"Inj, hemgenix, per tx dose",J1411,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6006000,,,,,,,fee schedule,3691450,16377714.39,
"Inj, hemgenix, per tx dose",J1411,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16377714.39,,,,,,,fee schedule,3691450,16377714.39,APC 378
"Inj, hemgenix, per tx dose",J1411,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3876022.5,,,,,,,fee schedule,3691450,16377714.39,APC
"Inj, hemgenix, per tx dose",J1411,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3839108,,,,,,,fee schedule,3691450,16377714.39,APC
"Inj, hemgenix, per tx dose",J1411,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3691450,,,,,,,fee schedule,3691450,16377714.39,APC
"Inj, hemgenix, per tx dose",J1411,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5647918.5,,,,,,,fee schedule,3691450,16377714.39,Radiology
"Inj, hemgenix, per tx dose",J1411,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5168030,,,,,,,fee schedule,3691450,16377714.39,APC
"Inj, hemgenix, per tx dose",J1411,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6460037.5,,,,,,,fee schedule,3691450,16377714.39,APC
Inj roctavian ml 2x10^13vc g,J1412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41787.19,,,,,,,fee schedule,12553.71,171825,
Inj roctavian ml 2x10^13vc g,J1412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45389.53,,,,,,,fee schedule,12553.71,171825,
Inj roctavian ml 2x10^13vc g,J1412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,171825,,,,,,,fee schedule,12553.71,171825,
Inj roctavian ml 2x10^13vc g,J1412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36383.67,,,,,,,fee schedule,12553.71,171825,
Inj roctavian ml 2x10^13vc g,J1412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39745.86,,,,,,,fee schedule,12553.71,171825,
Inj roctavian ml 2x10^13vc g,J1412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,155512.5,,,,,,,fee schedule,12553.71,171825,
Inj roctavian ml 2x10^13vc g,J1412,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,55696.58,,,,,,,fee schedule,12553.71,171825,APC 378
Inj roctavian ml 2x10^13vc g,J1412,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13181.4,,,,,,,fee schedule,12553.71,171825,APC
Inj roctavian ml 2x10^13vc g,J1412,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13055.86,,,,,,,fee schedule,12553.71,171825,APC
Inj roctavian ml 2x10^13vc g,J1412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12553.71,,,,,,,fee schedule,12553.71,171825,APC
Inj roctavian ml 2x10^13vc g,J1412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19207.18,,,,,,,fee schedule,12553.71,171825,Radiology
Inj roctavian ml 2x10^13vc g,J1412,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17575.2,,,,,,,fee schedule,12553.71,171825,APC
Inj roctavian ml 2x10^13vc g,J1412,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21969,,,,,,,fee schedule,12553.71,171825,APC
Inj delandistrogene mox rokl,J1413,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11804160,,,,,,,fee schedule,3321376.38,14735822.97,
Inj delandistrogene mox rokl,J1413,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12821760,,,,,,,fee schedule,3321376.38,14735822.97,
Inj delandistrogene mox rokl,J1413,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6067200,,,,,,,fee schedule,3321376.38,14735822.97,
Inj delandistrogene mox rokl,J1413,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10277760,,,,,,,fee schedule,3321376.38,14735822.97,
Inj delandistrogene mox rokl,J1413,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11227520,,,,,,,fee schedule,3321376.38,14735822.97,
Inj delandistrogene mox rokl,J1413,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5491200,,,,,,,fee schedule,3321376.38,14735822.97,
Inj delandistrogene mox rokl,J1413,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14735822.97,,,,,,,fee schedule,3321376.38,14735822.97,APC 378
Inj delandistrogene mox rokl,J1413,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3487445.2,,,,,,,fee schedule,3321376.38,14735822.97,APC
Inj delandistrogene mox rokl,J1413,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3454231.43,,,,,,,fee schedule,3321376.38,14735822.97,APC
Inj delandistrogene mox rokl,J1413,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3321376.38,,,,,,,fee schedule,3321376.38,14735822.97,APC
Inj delandistrogene mox rokl,J1413,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5081705.86,,,,,,,fee schedule,3321376.38,14735822.97,Radiology
Inj delandistrogene mox rokl,J1413,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4649926.93,,,,,,,fee schedule,3321376.38,14735822.97,APC
Inj delandistrogene mox rokl,J1413,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5812408.66,,,,,,,fee schedule,3321376.38,14735822.97,APC
"Injection, casimersen, 10 mg",J1426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,579.38,,,,,,,fee schedule,166.2,737.37,
"Injection, casimersen, 10 mg",J1426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,629.32,,,,,,,fee schedule,166.2,737.37,
"Injection, casimersen, 10 mg",J1426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,303.36,,,,,,,fee schedule,166.2,737.37,
"Injection, casimersen, 10 mg",J1426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,504.46,,,,,,,fee schedule,166.2,737.37,
"Injection, casimersen, 10 mg",J1426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,551.08,,,,,,,fee schedule,166.2,737.37,
"Injection, casimersen, 10 mg",J1426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,274.56,,,,,,,fee schedule,166.2,737.37,
"Injection, casimersen, 10 mg",J1426,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,737.37,,,,,,,fee schedule,166.2,737.37,APC 378
"Injection, casimersen, 10 mg",J1426,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,174.51,,,,,,,fee schedule,166.2,737.37,APC
"Injection, casimersen, 10 mg",J1426,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,172.85,,,,,,,fee schedule,166.2,737.37,APC
"Injection, casimersen, 10 mg",J1426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,166.2,,,,,,,fee schedule,166.2,737.37,APC
"Injection, casimersen, 10 mg",J1426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,254.28,,,,,,,fee schedule,166.2,737.37,Radiology
"Injection, casimersen, 10 mg",J1426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,232.68,,,,,,,fee schedule,166.2,737.37,APC
"Injection, casimersen, 10 mg",J1426,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,290.85,,,,,,,fee schedule,166.2,737.37,APC
Inj. viltolarsen,J1427,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,205.16,,,,,,,fee schedule,96.78,222.84,
Inj. viltolarsen,J1427,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,222.84,,,,,,,fee schedule,96.78,222.84,
Inj. viltolarsen,J1427,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,106.93,,,,,,,fee schedule,96.78,222.84,
Inj. viltolarsen,J1427,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,178.63,,,,,,,fee schedule,96.78,222.84,
Inj. viltolarsen,J1427,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,195.13,,,,,,,fee schedule,96.78,222.84,
Inj. viltolarsen,J1427,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,96.78,,,,,,,fee schedule,96.78,222.84,
"Inj, eteplirsen, 10 mg",J1428,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,585.06,,,,,,,fee schedule,167.51,743.2,
"Inj, eteplirsen, 10 mg",J1428,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,635.5,,,,,,,fee schedule,167.51,743.2,
"Inj, eteplirsen, 10 mg",J1428,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,303.36,,,,,,,fee schedule,167.51,743.2,
"Inj, eteplirsen, 10 mg",J1428,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,509.41,,,,,,,fee schedule,167.51,743.2,
"Inj, eteplirsen, 10 mg",J1428,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,556.48,,,,,,,fee schedule,167.51,743.2,
"Inj, eteplirsen, 10 mg",J1428,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,274.56,,,,,,,fee schedule,167.51,743.2,
"Inj, eteplirsen, 10 mg",J1428,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,743.2,,,,,,,fee schedule,167.51,743.2,APC 378
"Inj, eteplirsen, 10 mg",J1428,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,175.89,,,,,,,fee schedule,167.51,743.2,APC
"Inj, eteplirsen, 10 mg",J1428,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,174.21,,,,,,,fee schedule,167.51,743.2,APC
"Inj, eteplirsen, 10 mg",J1428,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,167.51,,,,,,,fee schedule,167.51,743.2,APC
"Inj, eteplirsen, 10 mg",J1428,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,256.29,,,,,,,fee schedule,167.51,743.2,Radiology
"Inj, eteplirsen, 10 mg",J1428,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,234.52,,,,,,,fee schedule,167.51,743.2,APC
"Inj, eteplirsen, 10 mg",J1428,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,293.15,,,,,,,fee schedule,167.51,743.2,APC
Inj golodirsen 10 mg,J1429,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,578.34,,,,,,,fee schedule,274.56,628.2,
Inj golodirsen 10 mg,J1429,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,628.2,,,,,,,fee schedule,274.56,628.2,
Inj golodirsen 10 mg,J1429,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,303.36,,,,,,,fee schedule,274.56,628.2,
Inj golodirsen 10 mg,J1429,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,503.56,,,,,,,fee schedule,274.56,628.2,
Inj golodirsen 10 mg,J1429,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,550.09,,,,,,,fee schedule,274.56,628.2,
Inj golodirsen 10 mg,J1429,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,274.56,,,,,,,fee schedule,274.56,628.2,
Ethanolamine oleate 100 mg,J1430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,535.89,,,,,,,fee schedule,466.59,907.6,
Ethanolamine oleate 100 mg,J1430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,582.08,,,,,,,fee schedule,466.59,907.6,
Ethanolamine oleate 100 mg,J1430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,834.87,,,,,,,fee schedule,466.59,907.6,
Ethanolamine oleate 100 mg,J1430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,466.59,,,,,,,fee schedule,466.59,907.6,
Ethanolamine oleate 100 mg,J1430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,509.71,,,,,,,fee schedule,466.59,907.6,
Ethanolamine oleate 100 mg,J1430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,755.61,,,,,,,fee schedule,466.59,907.6,
Ethanolamine oleate 100 mg,J1430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,601.61,,,,,,,fee schedule,466.59,907.6,OP High Cost Drugs
Ethanolamine oleate 100 mg,J1430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,518.63,,,,,,,fee schedule,466.59,907.6,Other Pharmacy
Ethanolamine oleate 100 mg,J1430,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,544.56,,,,,,,fee schedule,466.59,907.6,APC
Ethanolamine oleate 100 mg,J1430,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,539.37,,,,,,,fee schedule,466.59,907.6,APC
Ethanolamine oleate 100 mg,J1430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,793.5,,,,,,,fee schedule,466.59,907.6,Radiology
Ethanolamine oleate 100 mg,J1430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,726.08,,,,,,,fee schedule,466.59,907.6,APC
Ethanolamine oleate 100 mg,J1430,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,907.6,,,,,,,fee schedule,466.59,907.6,APC
Injection estrone per 1 MG,J1435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.08,,,,,,,fee schedule,0.07,0.08,
Injection estrone per 1 MG,J1435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.07,,,,,,,fee schedule,0.07,0.08,
Etidronate disodium inj,J1436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,255.15,,,,,,,fee schedule,222.16,277.15,
Etidronate disodium inj,J1436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,277.15,,,,,,,fee schedule,222.16,277.15,
Etidronate disodium inj,J1436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,222.16,,,,,,,fee schedule,222.16,277.15,
Etidronate disodium inj,J1436,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,242.69,,,,,,,fee schedule,222.16,277.15,
Inj. fe derisomaltose 10 mg,J1437,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,88.33,,,,,,,fee schedule,21.93,95.94,
Inj. fe derisomaltose 10 mg,J1437,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,95.94,,,,,,,fee schedule,21.93,95.94,
Inj. fe derisomaltose 10 mg,J1437,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,64.02,,,,,,,fee schedule,21.93,95.94,
Inj. fe derisomaltose 10 mg,J1437,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,76.91,,,,,,,fee schedule,21.93,95.94,
Inj. fe derisomaltose 10 mg,J1437,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,84.01,,,,,,,fee schedule,21.93,95.94,
Inj. fe derisomaltose 10 mg,J1437,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.94,,,,,,,fee schedule,21.93,95.94,
Inj. fe derisomaltose 10 mg,J1437,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,25.44,,,,,,,fee schedule,21.93,95.94,OP High Cost Drugs
Inj. fe derisomaltose 10 mg,J1437,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21.93,,,,,,,fee schedule,21.93,95.94,Other Pharmacy
Inj. fe derisomaltose 10 mg,J1437,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,23.03,,,,,,,fee schedule,21.93,95.94,APC
Inj. fe derisomaltose 10 mg,J1437,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,22.81,,,,,,,fee schedule,21.93,95.94,APC
Inj. fe derisomaltose 10 mg,J1437,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,33.55,,,,,,,fee schedule,21.93,95.94,Radiology
Inj. fe derisomaltose 10 mg,J1437,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,30.7,,,,,,,fee schedule,21.93,95.94,APC
Inj. fe derisomaltose 10 mg,J1437,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,38.38,,,,,,,fee schedule,21.93,95.94,APC
Etanercept injection,J1438,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,621.28,,,,,,,fee schedule,540.95,1806.87,
Etanercept injection,J1438,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,674.84,,,,,,,fee schedule,540.95,1806.87,
Etanercept injection,J1438,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1806.87,,,,,,,fee schedule,540.95,1806.87,
Etanercept injection,J1438,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,540.95,,,,,,,fee schedule,540.95,1806.87,
Etanercept injection,J1438,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,590.93,,,,,,,fee schedule,540.95,1806.87,
Etanercept injection,J1438,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1635.33,,,,,,,fee schedule,540.95,1806.87,
Inj ferric carboxymaltos 1mg,J1439,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.69,,,,,,,fee schedule,1.1,4.01,
Inj ferric carboxymaltos 1mg,J1439,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.01,,,,,,,fee schedule,1.1,4.01,
Inj ferric carboxymaltos 1mg,J1439,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.76,,,,,,,fee schedule,1.1,4.01,
Inj ferric carboxymaltos 1mg,J1439,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.21,,,,,,,fee schedule,1.1,4.01,
Inj ferric carboxymaltos 1mg,J1439,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.51,,,,,,,fee schedule,1.1,4.01,
Inj ferric carboxymaltos 1mg,J1439,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.4,,,,,,,fee schedule,1.1,4.01,
Inj ferric carboxymaltos 1mg,J1439,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1.28,,,,,,,fee schedule,1.1,4.01,OP High Cost Drugs
Inj ferric carboxymaltos 1mg,J1439,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1.1,,,,,,,fee schedule,1.1,4.01,Other Pharmacy
Inj ferric carboxymaltos 1mg,J1439,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.16,,,,,,,fee schedule,1.1,4.01,APC
Inj ferric carboxymaltos 1mg,J1439,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1.15,,,,,,,fee schedule,1.1,4.01,APC
Inj ferric carboxymaltos 1mg,J1439,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1.69,,,,,,,fee schedule,1.1,4.01,Radiology
Inj ferric carboxymaltos 1mg,J1439,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1.54,,,,,,,fee schedule,1.1,4.01,APC
Inj ferric carboxymaltos 1mg,J1439,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1.93,,,,,,,fee schedule,1.1,4.01,APC
Fecal?microbiota jslm 1 ml,J1440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,217.23,,,,,,,fee schedule,64.32,235.96,
Fecal?microbiota jslm 1 ml,J1440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,235.96,,,,,,,fee schedule,64.32,235.96,
Fecal?microbiota jslm 1 ml,J1440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,115.47,,,,,,,fee schedule,64.32,235.96,
Fecal?microbiota jslm 1 ml,J1440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,189.14,,,,,,,fee schedule,64.32,235.96,
Fecal?microbiota jslm 1 ml,J1440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,206.62,,,,,,,fee schedule,64.32,235.96,
Fecal?microbiota jslm 1 ml,J1440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,104.5,,,,,,,fee schedule,64.32,235.96,
Fecal?microbiota jslm 1 ml,J1440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,74.61,,,,,,,fee schedule,64.32,235.96,OP High Cost Drugs
Fecal?microbiota jslm 1 ml,J1440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,64.32,,,,,,,fee schedule,64.32,235.96,Other Pharmacy
Fecal?microbiota jslm 1 ml,J1440,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,67.54,,,,,,,fee schedule,64.32,235.96,APC
Fecal?microbiota jslm 1 ml,J1440,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,66.89,,,,,,,fee schedule,64.32,235.96,APC
Fecal?microbiota jslm 1 ml,J1440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,98.41,,,,,,,fee schedule,64.32,235.96,Radiology
Fecal?microbiota jslm 1 ml,J1440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,90.05,,,,,,,fee schedule,64.32,235.96,APC
Fecal?microbiota jslm 1 ml,J1440,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,112.56,,,,,,,fee schedule,64.32,235.96,APC
Inj filgrastim excl biosimil,J1442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.48,,,,,,,fee schedule,1.02,3.78,
Inj filgrastim excl biosimil,J1442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.78,,,,,,,fee schedule,1.02,3.78,
Inj filgrastim excl biosimil,J1442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.15,,,,,,,fee schedule,1.02,3.78,
Inj filgrastim excl biosimil,J1442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.03,,,,,,,fee schedule,1.02,3.78,
Inj filgrastim excl biosimil,J1442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.31,,,,,,,fee schedule,1.02,3.78,
Inj filgrastim excl biosimil,J1442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.94,,,,,,,fee schedule,1.02,3.78,
Inj filgrastim excl biosimil,J1442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1.18,,,,,,,fee schedule,1.02,3.78,OP High Cost Drugs
Inj filgrastim excl biosimil,J1442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1.02,,,,,,,fee schedule,1.02,3.78,Other Pharmacy
Inj filgrastim excl biosimil,J1442,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.07,,,,,,,fee schedule,1.02,3.78,APC
Inj filgrastim excl biosimil,J1442,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1.06,,,,,,,fee schedule,1.02,3.78,APC
Inj filgrastim excl biosimil,J1442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1.55,,,,,,,fee schedule,1.02,3.78,Radiology
Inj filgrastim excl biosimil,J1442,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1.42,,,,,,,fee schedule,1.02,3.78,APC
Inj filgrastim excl biosimil,J1442,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1.78,,,,,,,fee schedule,1.02,3.78,APC
Inj ferric pyrophosphate cit,J1443,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.1,,,,,,,fee schedule,0.06,0.11,
Inj ferric pyrophosphate cit,J1443,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.11,,,,,,,fee schedule,0.06,0.11,
Inj ferric pyrophosphate cit,J1443,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.06,,,,,,,fee schedule,0.06,0.11,
Inj ferric pyrophosphate cit,J1443,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.09,,,,,,,fee schedule,0.06,0.11,
Inj ferric pyrophosphate cit,J1443,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.1,,,,,,,fee schedule,0.06,0.11,
Inj ferric pyrophosphate cit,J1443,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.06,,,,,,,fee schedule,0.06,0.11,
Fe pyro cit pow 0.1 mg iron,J1444,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.06,,,,,,,fee schedule,0.06,0.06,
Fe pyro cit pow 0.1 mg iron,J1444,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.06,,,,,,,fee schedule,0.06,0.06,
Inj tbo filgrastim 1 microg,J1447,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.68,,,,,,,fee schedule,0.25,2.91,
Inj tbo filgrastim 1 microg,J1447,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.91,,,,,,,fee schedule,0.25,2.91,
Inj tbo filgrastim 1 microg,J1447,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.61,,,,,,,fee schedule,0.25,2.91,
Inj tbo filgrastim 1 microg,J1447,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.33,,,,,,,fee schedule,0.25,2.91,
Inj tbo filgrastim 1 microg,J1447,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.55,,,,,,,fee schedule,0.25,2.91,
Inj tbo filgrastim 1 microg,J1447,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.46,,,,,,,fee schedule,0.25,2.91,
Inj tbo filgrastim 1 microg,J1447,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,0.29,,,,,,,fee schedule,0.25,2.91,OP High Cost Drugs
Inj tbo filgrastim 1 microg,J1447,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,0.25,,,,,,,fee schedule,0.25,2.91,Other Pharmacy
Inj tbo filgrastim 1 microg,J1447,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,0.26,,,,,,,fee schedule,0.25,2.91,APC
Inj tbo filgrastim 1 microg,J1447,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,0.26,,,,,,,fee schedule,0.25,2.91,APC
Inj tbo filgrastim 1 microg,J1447,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,0.38,,,,,,,fee schedule,0.25,2.91,Radiology
Inj tbo filgrastim 1 microg,J1447,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,0.34,,,,,,,fee schedule,0.25,2.91,APC
Inj tbo filgrastim 1 microg,J1447,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,0.43,,,,,,,fee schedule,0.25,2.91,APC
"Injection, trilaciclib, 1mg",J1448,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17.23,,,,,,,fee schedule,5.49,18.72,
"Injection, trilaciclib, 1mg",J1448,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18.72,,,,,,,fee schedule,5.49,18.72,
"Injection, trilaciclib, 1mg",J1448,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.78,,,,,,,fee schedule,5.49,18.72,
"Injection, trilaciclib, 1mg",J1448,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15,,,,,,,fee schedule,5.49,18.72,
"Injection, trilaciclib, 1mg",J1448,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.39,,,,,,,fee schedule,5.49,18.72,
"Injection, trilaciclib, 1mg",J1448,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.85,,,,,,,fee schedule,5.49,18.72,
"Injection, trilaciclib, 1mg",J1448,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6.37,,,,,,,fee schedule,5.49,18.72,OP High Cost Drugs
"Injection, trilaciclib, 1mg",J1448,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.49,,,,,,,fee schedule,5.49,18.72,Other Pharmacy
"Injection, trilaciclib, 1mg",J1448,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.76,,,,,,,fee schedule,5.49,18.72,APC
"Injection, trilaciclib, 1mg",J1448,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5.71,,,,,,,fee schedule,5.49,18.72,APC
"Injection, trilaciclib, 1mg",J1448,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8.4,,,,,,,fee schedule,5.49,18.72,Radiology
"Injection, trilaciclib, 1mg",J1448,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.68,,,,,,,fee schedule,5.49,18.72,APC
"Injection, trilaciclib, 1mg",J1448,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9.6,,,,,,,fee schedule,5.49,18.72,APC
Inj eflapegrastim-xnst 0.1mg,J1449,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,109.08,,,,,,,fee schedule,38.96,118.48,
Inj eflapegrastim-xnst 0.1mg,J1449,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,118.48,,,,,,,fee schedule,38.96,118.48,
Inj eflapegrastim-xnst 0.1mg,J1449,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,63.99,,,,,,,fee schedule,38.96,118.48,
Inj eflapegrastim-xnst 0.1mg,J1449,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,94.97,,,,,,,fee schedule,38.96,118.48,
Inj eflapegrastim-xnst 0.1mg,J1449,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,103.75,,,,,,,fee schedule,38.96,118.48,
Inj eflapegrastim-xnst 0.1mg,J1449,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.92,,,,,,,fee schedule,38.96,118.48,
Inj eflapegrastim-xnst 0.1mg,J1449,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,45.19,,,,,,,fee schedule,38.96,118.48,OP High Cost Drugs
Inj eflapegrastim-xnst 0.1mg,J1449,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,38.96,,,,,,,fee schedule,38.96,118.48,Other Pharmacy
Inj eflapegrastim-xnst 0.1mg,J1449,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,40.9,,,,,,,fee schedule,38.96,118.48,APC
Inj eflapegrastim-xnst 0.1mg,J1449,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,40.51,,,,,,,fee schedule,38.96,118.48,APC
Inj eflapegrastim-xnst 0.1mg,J1449,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,59.6,,,,,,,fee schedule,38.96,118.48,Radiology
Inj eflapegrastim-xnst 0.1mg,J1449,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,54.54,,,,,,,fee schedule,38.96,118.48,APC
Inj eflapegrastim-xnst 0.1mg,J1449,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,68.17,,,,,,,fee schedule,38.96,118.48,APC
Fluconazole,J1450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13.71,,,,,,,fee schedule,12.41,13.71,
Fluconazole,J1450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12.41,,,,,,,fee schedule,12.41,13.71,
"Fomepizole, 15 mg",J1451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42.35,,,,,,,fee schedule,6.54,46,
"Fomepizole, 15 mg",J1451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46,,,,,,,fee schedule,6.54,46,
"Fomepizole, 15 mg",J1451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21.57,,,,,,,fee schedule,6.54,46,
"Fomepizole, 15 mg",J1451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36.88,,,,,,,fee schedule,6.54,46,
"Fomepizole, 15 mg",J1451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40.28,,,,,,,fee schedule,6.54,46,
"Fomepizole, 15 mg",J1451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19.52,,,,,,,fee schedule,6.54,46,
"Fomepizole, 15 mg",J1451,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,29.01,,,,,,,fee schedule,6.54,46,APC 378
"Fomepizole, 15 mg",J1451,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.87,,,,,,,fee schedule,6.54,46,APC
"Fomepizole, 15 mg",J1451,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6.8,,,,,,,fee schedule,6.54,46,APC
"Fomepizole, 15 mg",J1451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6.54,,,,,,,fee schedule,6.54,46,APC
"Fomepizole, 15 mg",J1451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10,,,,,,,fee schedule,6.54,46,Radiology
"Fomepizole, 15 mg",J1451,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.15,,,,,,,fee schedule,6.54,46,APC
"Fomepizole, 15 mg",J1451,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11.44,,,,,,,fee schedule,6.54,46,APC
Fosaprepitant injection,J1453,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.46,,,,,,,fee schedule,3.07,5.93,
Fosaprepitant injection,J1453,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.93,,,,,,,fee schedule,3.07,5.93,
Fosaprepitant injection,J1453,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.4,,,,,,,fee schedule,3.07,5.93,
Fosaprepitant injection,J1453,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.76,,,,,,,fee schedule,3.07,5.93,
Fosaprepitant injection,J1453,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.2,,,,,,,fee schedule,3.07,5.93,
Fosaprepitant injection,J1453,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.07,,,,,,,fee schedule,3.07,5.93,
"Inj fosnetupitant, palonoset",J1454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1881.29,,,,,,,fee schedule,524.18,2043.47,
"Inj fosnetupitant, palonoset",J1454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2043.47,,,,,,,fee schedule,524.18,2043.47,
"Inj fosnetupitant, palonoset",J1454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,680.05,,,,,,,fee schedule,524.18,2043.47,
"Inj fosnetupitant, palonoset",J1454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1638.02,,,,,,,fee schedule,524.18,2043.47,
"Inj fosnetupitant, palonoset",J1454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1789.39,,,,,,,fee schedule,524.18,2043.47,
"Inj fosnetupitant, palonoset",J1454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,615.49,,,,,,,fee schedule,524.18,2043.47,
"Inj fosnetupitant, palonoset",J1454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,608.05,,,,,,,fee schedule,524.18,2043.47,OP High Cost Drugs
"Inj fosnetupitant, palonoset",J1454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,524.18,,,,,,,fee schedule,524.18,2043.47,Other Pharmacy
"Inj fosnetupitant, palonoset",J1454,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,550.39,,,,,,,fee schedule,524.18,2043.47,APC
"Inj fosnetupitant, palonoset",J1454,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,545.14,,,,,,,fee schedule,524.18,2043.47,APC
"Inj fosnetupitant, palonoset",J1454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,801.99,,,,,,,fee schedule,524.18,2043.47,Radiology
"Inj fosnetupitant, palonoset",J1454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,733.85,,,,,,,fee schedule,524.18,2043.47,APC
"Inj fosnetupitant, palonoset",J1454,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,917.31,,,,,,,fee schedule,524.18,2043.47,APC
Foscarnet sodium injection,J1455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,240.61,,,,,,,fee schedule,128.44,261.35,
Foscarnet sodium injection,J1455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,261.35,,,,,,,fee schedule,128.44,261.35,
Foscarnet sodium injection,J1455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,141.92,,,,,,,fee schedule,128.44,261.35,
Foscarnet sodium injection,J1455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,209.49,,,,,,,fee schedule,128.44,261.35,
Foscarnet sodium injection,J1455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,228.85,,,,,,,fee schedule,128.44,261.35,
Foscarnet sodium injection,J1455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,128.44,,,,,,,fee schedule,128.44,261.35,
"Inj, fosaprepitant (teva)",J1456,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.82,,,,,,,fee schedule,0.04,3.82,
"Inj, fosaprepitant (teva)",J1456,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.46,,,,,,,fee schedule,0.04,3.82,
"Inj, fosaprepitant (teva)",J1456,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,0.04,,,,,,,fee schedule,0.04,3.82,OP High Cost Drugs
"Inj, fosaprepitant (teva)",J1456,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,0.04,,,,,,,fee schedule,0.04,3.82,Other Pharmacy
"Inj, fosaprepitant (teva)",J1456,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,0.04,,,,,,,fee schedule,0.04,3.82,APC
"Inj, fosaprepitant (teva)",J1456,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,0.04,,,,,,,fee schedule,0.04,3.82,APC
"Inj, fosaprepitant (teva)",J1456,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,0.06,,,,,,,fee schedule,0.04,3.82,Radiology
"Inj, fosaprepitant (teva)",J1456,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,0.05,,,,,,,fee schedule,0.04,3.82,APC
"Inj, fosaprepitant (teva)",J1456,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,0.06,,,,,,,fee schedule,0.04,3.82,APC
Gallium nitrate injection,J1457,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.71,,,,,,,fee schedule,4.97,6.2,
Gallium nitrate injection,J1457,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.2,,,,,,,fee schedule,4.97,6.2,
Gallium nitrate injection,J1457,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.97,,,,,,,fee schedule,4.97,6.2,
Gallium nitrate injection,J1457,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.43,,,,,,,fee schedule,4.97,6.2,
Galsulfase injection,J1458,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1187.1,,,,,,,fee schedule,513.6,1289.43,
Galsulfase injection,J1458,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1289.43,,,,,,,fee schedule,513.6,1289.43,
Galsulfase injection,J1458,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,889.6,,,,,,,fee schedule,513.6,1289.43,
Galsulfase injection,J1458,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1033.59,,,,,,,fee schedule,513.6,1289.43,
Galsulfase injection,J1458,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1129.11,,,,,,,fee schedule,513.6,1289.43,
Galsulfase injection,J1458,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,805.15,,,,,,,fee schedule,513.6,1289.43,
Galsulfase injection,J1458,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,595.77,,,,,,,fee schedule,513.6,1289.43,OP High Cost Drugs
Galsulfase injection,J1458,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,513.6,,,,,,,fee schedule,513.6,1289.43,Other Pharmacy
Galsulfase injection,J1458,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,539.27,,,,,,,fee schedule,513.6,1289.43,APC
Galsulfase injection,J1458,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,534.14,,,,,,,fee schedule,513.6,1289.43,APC
Galsulfase injection,J1458,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,785.8,,,,,,,fee schedule,513.6,1289.43,Radiology
Galsulfase injection,J1458,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,719.03,,,,,,,fee schedule,513.6,1289.43,APC
Galsulfase injection,J1458,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,898.79,,,,,,,fee schedule,513.6,1289.43,APC
Inj IVIG privigen 500 mg,J1459,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,118.88,,,,,,,fee schedule,49.53,171.62,
Inj IVIG privigen 500 mg,J1459,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,129.12,,,,,,,fee schedule,49.53,171.62,
Inj IVIG privigen 500 mg,J1459,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,171.62,,,,,,,fee schedule,49.53,171.62,
Inj IVIG privigen 500 mg,J1459,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,103.5,,,,,,,fee schedule,49.53,171.62,
Inj IVIG privigen 500 mg,J1459,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,113.07,,,,,,,fee schedule,49.53,171.62,
Inj IVIG privigen 500 mg,J1459,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,155.33,,,,,,,fee schedule,49.53,171.62,
Inj IVIG privigen 500 mg,J1459,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,57.46,,,,,,,fee schedule,49.53,171.62,OP High Cost Drugs
Inj IVIG privigen 500 mg,J1459,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49.53,,,,,,,fee schedule,49.53,171.62,Other Pharmacy
Inj IVIG privigen 500 mg,J1459,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,52.01,,,,,,,fee schedule,49.53,171.62,APC
Inj IVIG privigen 500 mg,J1459,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,51.51,,,,,,,fee schedule,49.53,171.62,APC
Inj IVIG privigen 500 mg,J1459,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,75.79,,,,,,,fee schedule,49.53,171.62,Radiology
Inj IVIG privigen 500 mg,J1459,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,69.35,,,,,,,fee schedule,49.53,171.62,APC
Inj IVIG privigen 500 mg,J1459,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,86.68,,,,,,,fee schedule,49.53,171.62,APC
Gamma globulin 1 CC inj,J1460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,43.22,,,,,,,fee schedule,37.63,94.39,
Gamma globulin 1 CC inj,J1460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46.95,,,,,,,fee schedule,37.63,94.39,
Gamma globulin 1 CC inj,J1460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,94.39,,,,,,,fee schedule,37.63,94.39,
Gamma globulin 1 CC inj,J1460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37.63,,,,,,,fee schedule,37.63,94.39,
Gamma globulin 1 CC inj,J1460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,41.11,,,,,,,fee schedule,37.63,94.39,
Gamma globulin 1 CC inj,J1460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,85.43,,,,,,,fee schedule,37.63,94.39,
Gamma globulin 1 CC inj,J1460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,56.79,,,,,,,fee schedule,37.63,94.39,OP High Cost Drugs
Gamma globulin 1 CC inj,J1460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,48.95,,,,,,,fee schedule,37.63,94.39,Other Pharmacy
Gamma globulin 1 CC inj,J1460,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,51.4,,,,,,,fee schedule,37.63,94.39,APC
Gamma globulin 1 CC inj,J1460,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,50.91,,,,,,,fee schedule,37.63,94.39,APC
Gamma globulin 1 CC inj,J1460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,74.9,,,,,,,fee schedule,37.63,94.39,Radiology
Gamma globulin 1 CC inj,J1460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,68.53,,,,,,,fee schedule,37.63,94.39,APC
Gamma globulin 1 CC inj,J1460,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,85.67,,,,,,,fee schedule,37.63,94.39,APC
Inj cutaquig 100 mg,J1551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41.86,,,,,,,fee schedule,13.93,45.47,
Inj cutaquig 100 mg,J1551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45.47,,,,,,,fee schedule,13.93,45.47,
Inj cutaquig 100 mg,J1551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37.22,,,,,,,fee schedule,13.93,45.47,
Inj cutaquig 100 mg,J1551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36.45,,,,,,,fee schedule,13.93,45.47,
Inj cutaquig 100 mg,J1551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39.82,,,,,,,fee schedule,13.93,45.47,
Inj cutaquig 100 mg,J1551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,33.69,,,,,,,fee schedule,13.93,45.47,
Inj cutaquig 100 mg,J1551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16.16,,,,,,,fee schedule,13.93,45.47,OP High Cost Drugs
Inj cutaquig 100 mg,J1551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.93,,,,,,,fee schedule,13.93,45.47,Other Pharmacy
Inj cutaquig 100 mg,J1551,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.62,,,,,,,fee schedule,13.93,45.47,APC
Inj cutaquig 100 mg,J1551,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,14.48,,,,,,,fee schedule,13.93,45.47,APC
Inj cutaquig 100 mg,J1551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21.31,,,,,,,fee schedule,13.93,45.47,Radiology
Inj cutaquig 100 mg,J1551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.5,,,,,,,fee schedule,13.93,45.47,APC
Inj cutaquig 100 mg,J1551,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,24.37,,,,,,,fee schedule,13.93,45.47,APC
Inj. asceniv,J1554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1676.56,,,,,,,fee schedule,500.93,1821.09,
Inj. asceniv,J1554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1821.09,,,,,,,fee schedule,500.93,1821.09,
Inj. asceniv,J1554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,889.07,,,,,,,fee schedule,500.93,1821.09,
Inj. asceniv,J1554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1459.76,,,,,,,fee schedule,500.93,1821.09,
Inj. asceniv,J1554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1594.66,,,,,,,fee schedule,500.93,1821.09,
Inj. asceniv,J1554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,804.66,,,,,,,fee schedule,500.93,1821.09,
Inj. asceniv,J1554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,581.07,,,,,,,fee schedule,500.93,1821.09,OP High Cost Drugs
Inj. asceniv,J1554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,500.93,,,,,,,fee schedule,500.93,1821.09,Other Pharmacy
Inj. asceniv,J1554,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,525.97,,,,,,,fee schedule,500.93,1821.09,APC
Inj. asceniv,J1554,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,520.96,,,,,,,fee schedule,500.93,1821.09,APC
Inj. asceniv,J1554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,766.42,,,,,,,fee schedule,500.93,1821.09,Radiology
Inj. asceniv,J1554,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,701.3,,,,,,,fee schedule,500.93,1821.09,APC
Inj. asceniv,J1554,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,876.62,,,,,,,fee schedule,500.93,1821.09,APC
"Inj cuvitru, 100 mg",J1555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46.62,,,,,,,fee schedule,17.58,50.64,
"Inj cuvitru, 100 mg",J1555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,50.64,,,,,,,fee schedule,17.58,50.64,
"Inj cuvitru, 100 mg",J1555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42.57,,,,,,,fee schedule,17.58,50.64,
"Inj cuvitru, 100 mg",J1555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40.59,,,,,,,fee schedule,17.58,50.64,
"Inj cuvitru, 100 mg",J1555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,44.34,,,,,,,fee schedule,17.58,50.64,
"Inj cuvitru, 100 mg",J1555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38.52,,,,,,,fee schedule,17.58,50.64,
"Inj cuvitru, 100 mg",J1555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,20.39,,,,,,,fee schedule,17.58,50.64,OP High Cost Drugs
"Inj cuvitru, 100 mg",J1555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.58,,,,,,,fee schedule,17.58,50.64,Other Pharmacy
"Inj cuvitru, 100 mg",J1555,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.46,,,,,,,fee schedule,17.58,50.64,APC
"Inj cuvitru, 100 mg",J1555,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18.28,,,,,,,fee schedule,17.58,50.64,APC
"Inj cuvitru, 100 mg",J1555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26.9,,,,,,,fee schedule,17.58,50.64,Radiology
"Inj cuvitru, 100 mg",J1555,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24.61,,,,,,,fee schedule,17.58,50.64,APC
"Inj cuvitru, 100 mg",J1555,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30.76,,,,,,,fee schedule,17.58,50.64,APC
"Inj, imm glob bivigam, 500mg",J1556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,133.88,,,,,,,fee schedule,79.44,145.42,
"Inj, imm glob bivigam, 500mg",J1556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,145.42,,,,,,,fee schedule,79.44,145.42,
"Inj, imm glob bivigam, 500mg",J1556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,138.34,,,,,,,fee schedule,79.44,145.42,
"Inj, imm glob bivigam, 500mg",J1556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,116.56,,,,,,,fee schedule,79.44,145.42,
"Inj, imm glob bivigam, 500mg",J1556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,127.34,,,,,,,fee schedule,79.44,145.42,
"Inj, imm glob bivigam, 500mg",J1556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,125.21,,,,,,,fee schedule,79.44,145.42,
"Inj, imm glob bivigam, 500mg",J1556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,92.15,,,,,,,fee schedule,79.44,145.42,OP High Cost Drugs
"Inj, imm glob bivigam, 500mg",J1556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,79.44,,,,,,,fee schedule,79.44,145.42,Other Pharmacy
"Inj, imm glob bivigam, 500mg",J1556,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,83.41,,,,,,,fee schedule,79.44,145.42,APC
"Inj, imm glob bivigam, 500mg",J1556,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,82.62,,,,,,,fee schedule,79.44,145.42,APC
"Inj, imm glob bivigam, 500mg",J1556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,121.54,,,,,,,fee schedule,79.44,145.42,Radiology
"Inj, imm glob bivigam, 500mg",J1556,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,111.22,,,,,,,fee schedule,79.44,145.42,APC
"Inj, imm glob bivigam, 500mg",J1556,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,139.02,,,,,,,fee schedule,79.44,145.42,APC
Gammaplex injection,J1557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,128.55,,,,,,,fee schedule,64.65,202.54,
Gammaplex injection,J1557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,139.63,,,,,,,fee schedule,64.65,202.54,
Gammaplex injection,J1557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,202.54,,,,,,,fee schedule,64.65,202.54,
Gammaplex injection,J1557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,111.93,,,,,,,fee schedule,64.65,202.54,
Gammaplex injection,J1557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,122.27,,,,,,,fee schedule,64.65,202.54,
Gammaplex injection,J1557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,183.31,,,,,,,fee schedule,64.65,202.54,
Gammaplex injection,J1557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,74.99,,,,,,,fee schedule,64.65,202.54,OP High Cost Drugs
Gammaplex injection,J1557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,64.65,,,,,,,fee schedule,64.65,202.54,Other Pharmacy
Gammaplex injection,J1557,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,67.88,,,,,,,fee schedule,64.65,202.54,APC
Gammaplex injection,J1557,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,67.24,,,,,,,fee schedule,64.65,202.54,APC
Gammaplex injection,J1557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,98.91,,,,,,,fee schedule,64.65,202.54,Radiology
Gammaplex injection,J1557,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,90.51,,,,,,,fee schedule,64.65,202.54,APC
Gammaplex injection,J1557,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,113.14,,,,,,,fee schedule,64.65,202.54,APC
"Inj. xembify, 100 mg",J1558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,51.11,,,,,,,fee schedule,15.37,55.52,
"Inj. xembify, 100 mg",J1558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55.52,,,,,,,fee schedule,15.37,55.52,
"Inj. xembify, 100 mg",J1558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,34.59,,,,,,,fee schedule,15.37,55.52,
"Inj. xembify, 100 mg",J1558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,44.5,,,,,,,fee schedule,15.37,55.52,
"Inj. xembify, 100 mg",J1558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48.61,,,,,,,fee schedule,15.37,55.52,
"Inj. xembify, 100 mg",J1558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31.3,,,,,,,fee schedule,15.37,55.52,
"Inj. xembify, 100 mg",J1558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17.83,,,,,,,fee schedule,15.37,55.52,OP High Cost Drugs
"Inj. xembify, 100 mg",J1558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15.37,,,,,,,fee schedule,15.37,55.52,Other Pharmacy
"Inj. xembify, 100 mg",J1558,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.14,,,,,,,fee schedule,15.37,55.52,APC
"Inj. xembify, 100 mg",J1558,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,15.98,,,,,,,fee schedule,15.37,55.52,APC
"Inj. xembify, 100 mg",J1558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.51,,,,,,,fee schedule,15.37,55.52,Radiology
"Inj. xembify, 100 mg",J1558,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21.51,,,,,,,fee schedule,15.37,55.52,APC
"Inj. xembify, 100 mg",J1558,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,26.89,,,,,,,fee schedule,15.37,55.52,APC
Hizentra injection,J1559,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,25.37,,,,,,,fee schedule,14.52,43.12,
Hizentra injection,J1559,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27.56,,,,,,,fee schedule,14.52,43.12,
Hizentra injection,J1559,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,43.12,,,,,,,fee schedule,14.52,43.12,
Hizentra injection,J1559,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22.09,,,,,,,fee schedule,14.52,43.12,
Hizentra injection,J1559,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24.13,,,,,,,fee schedule,14.52,43.12,
Hizentra injection,J1559,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39.02,,,,,,,fee schedule,14.52,43.12,
Hizentra injection,J1559,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16.84,,,,,,,fee schedule,14.52,43.12,OP High Cost Drugs
Hizentra injection,J1559,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.52,,,,,,,fee schedule,14.52,43.12,Other Pharmacy
Hizentra injection,J1559,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.24,,,,,,,fee schedule,14.52,43.12,APC
Hizentra injection,J1559,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,15.1,,,,,,,fee schedule,14.52,43.12,APC
Hizentra injection,J1559,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.21,,,,,,,fee schedule,14.52,43.12,Radiology
Hizentra injection,J1559,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.32,,,,,,,fee schedule,14.52,43.12,APC
Hizentra injection,J1559,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,25.4,,,,,,,fee schedule,14.52,43.12,APC
Gamma globulin > 10 CC inj,J1560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,431.97,,,,,,,fee schedule,160.29,469.21,
Gamma globulin > 10 CC inj,J1560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,469.21,,,,,,,fee schedule,160.29,469.21,
Gamma globulin > 10 CC inj,J1560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,376.11,,,,,,,fee schedule,160.29,469.21,
Gamma globulin > 10 CC inj,J1560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,410.87,,,,,,,fee schedule,160.29,469.21,
Gamma globulin > 10 CC inj,J1560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,185.93,,,,,,,fee schedule,160.29,469.21,OP High Cost Drugs
Gamma globulin > 10 CC inj,J1560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,160.29,,,,,,,fee schedule,160.29,469.21,Other Pharmacy
Gamma globulin > 10 CC inj,J1560,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,168.3,,,,,,,fee schedule,160.29,469.21,APC
Gamma globulin > 10 CC inj,J1560,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,166.7,,,,,,,fee schedule,160.29,469.21,APC
Gamma globulin > 10 CC inj,J1560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,245.24,,,,,,,fee schedule,160.29,469.21,Radiology
Gamma globulin > 10 CC inj,J1560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,224.4,,,,,,,fee schedule,160.29,469.21,APC
Gamma globulin > 10 CC inj,J1560,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,280.5,,,,,,,fee schedule,160.29,469.21,APC
Gamunex-c/gammaked,J1561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,124.34,,,,,,,fee schedule,49.73,135.06,
Gamunex-c/gammaked,J1561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,135.06,,,,,,,fee schedule,49.73,135.06,
Gamunex-c/gammaked,J1561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,134.38,,,,,,,fee schedule,49.73,135.06,
Gamunex-c/gammaked,J1561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,108.26,,,,,,,fee schedule,49.73,135.06,
Gamunex-c/gammaked,J1561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,118.27,,,,,,,fee schedule,49.73,135.06,
Gamunex-c/gammaked,J1561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,121.62,,,,,,,fee schedule,49.73,135.06,
Gamunex-c/gammaked,J1561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,57.68,,,,,,,fee schedule,49.73,135.06,OP High Cost Drugs
Gamunex-c/gammaked,J1561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49.73,,,,,,,fee schedule,49.73,135.06,Other Pharmacy
Gamunex-c/gammaked,J1561,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,52.21,,,,,,,fee schedule,49.73,135.06,APC
Gamunex-c/gammaked,J1561,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,51.72,,,,,,,fee schedule,49.73,135.06,APC
Gamunex-c/gammaked,J1561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,76.08,,,,,,,fee schedule,49.73,135.06,Radiology
Gamunex-c/gammaked,J1561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,69.62,,,,,,,fee schedule,49.73,135.06,APC
Gamunex-c/gammaked,J1561,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,87.02,,,,,,,fee schedule,49.73,135.06,APC
"Vivaglobin, inj",J1562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,25.3,,,,,,,fee schedule,22.03,27.48,
"Vivaglobin, inj",J1562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27.48,,,,,,,fee schedule,22.03,27.48,
"Vivaglobin, inj",J1562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22.03,,,,,,,fee schedule,22.03,27.48,
"Vivaglobin, inj",J1562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24.06,,,,,,,fee schedule,22.03,27.48,
"Immune globulin, powder",J1566,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,104.47,,,,,,,fee schedule,80.4,212.6,
"Immune globulin, powder",J1566,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,113.48,,,,,,,fee schedule,80.4,212.6,
"Immune globulin, powder",J1566,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,212.6,,,,,,,fee schedule,80.4,212.6,
"Immune globulin, powder",J1566,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,90.96,,,,,,,fee schedule,80.4,212.6,
"Immune globulin, powder",J1566,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,99.37,,,,,,,fee schedule,80.4,212.6,
"Immune globulin, powder",J1566,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,192.42,,,,,,,fee schedule,80.4,212.6,
"Immune globulin, powder",J1566,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,93.26,,,,,,,fee schedule,80.4,212.6,OP High Cost Drugs
"Immune globulin, powder",J1566,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,80.4,,,,,,,fee schedule,80.4,212.6,Other Pharmacy
"Immune globulin, powder",J1566,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,84.41,,,,,,,fee schedule,80.4,212.6,APC
"Immune globulin, powder",J1566,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,83.61,,,,,,,fee schedule,80.4,212.6,APC
"Immune globulin, powder",J1566,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,123,,,,,,,fee schedule,80.4,212.6,Radiology
"Immune globulin, powder",J1566,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,112.55,,,,,,,fee schedule,80.4,212.6,APC
"Immune globulin, powder",J1566,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,140.69,,,,,,,fee schedule,80.4,212.6,APC
Octagam injection,J1568,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,128.13,,,,,,,fee schedule,47.04,184.15,
Octagam injection,J1568,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,139.18,,,,,,,fee schedule,47.04,184.15,
Octagam injection,J1568,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,184.15,,,,,,,fee schedule,47.04,184.15,
Octagam injection,J1568,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,111.56,,,,,,,fee schedule,47.04,184.15,
Octagam injection,J1568,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,121.87,,,,,,,fee schedule,47.04,184.15,
Octagam injection,J1568,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,166.67,,,,,,,fee schedule,47.04,184.15,
Octagam injection,J1568,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,54.56,,,,,,,fee schedule,47.04,184.15,OP High Cost Drugs
Octagam injection,J1568,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,47.04,,,,,,,fee schedule,47.04,184.15,Other Pharmacy
Octagam injection,J1568,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,49.39,,,,,,,fee schedule,47.04,184.15,APC
Octagam injection,J1568,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,48.92,,,,,,,fee schedule,47.04,184.15,APC
Octagam injection,J1568,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,71.96,,,,,,,fee schedule,47.04,184.15,Radiology
Octagam injection,J1568,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,65.85,,,,,,,fee schedule,47.04,184.15,APC
Octagam injection,J1568,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,82.31,,,,,,,fee schedule,47.04,184.15,APC
Gammagard liquid injection,J1569,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,125.11,,,,,,,fee schedule,49.08,160.7,
Gammagard liquid injection,J1569,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,135.89,,,,,,,fee schedule,49.08,160.7,
Gammagard liquid injection,J1569,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,160.7,,,,,,,fee schedule,49.08,160.7,
Gammagard liquid injection,J1569,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,108.93,,,,,,,fee schedule,49.08,160.7,
Gammagard liquid injection,J1569,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,118.99,,,,,,,fee schedule,49.08,160.7,
Gammagard liquid injection,J1569,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,145.45,,,,,,,fee schedule,49.08,160.7,
Gammagard liquid injection,J1569,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,56.93,,,,,,,fee schedule,49.08,160.7,OP High Cost Drugs
Gammagard liquid injection,J1569,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49.08,,,,,,,fee schedule,49.08,160.7,Other Pharmacy
Gammagard liquid injection,J1569,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,51.54,,,,,,,fee schedule,49.08,160.7,APC
Gammagard liquid injection,J1569,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,51.04,,,,,,,fee schedule,49.08,160.7,APC
Gammagard liquid injection,J1569,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,75.09,,,,,,,fee schedule,49.08,160.7,Radiology
Gammagard liquid injection,J1569,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,68.71,,,,,,,fee schedule,49.08,160.7,APC
Gammagard liquid injection,J1569,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,85.89,,,,,,,fee schedule,49.08,160.7,APC
Ganciclovir sodium injection,J1570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,121.72,,,,,,,fee schedule,110.17,121.72,
Ganciclovir sodium injection,J1570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,110.17,,,,,,,fee schedule,110.17,121.72,
HepaGam B IM injection,J1571,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,158.44,,,,,,,fee schedule,70.23,172.1,
HepaGam B IM injection,J1571,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,172.1,,,,,,,fee schedule,70.23,172.1,
HepaGam B IM injection,J1571,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,168.73,,,,,,,fee schedule,70.23,172.1,
HepaGam B IM injection,J1571,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,137.96,,,,,,,fee schedule,70.23,172.1,
HepaGam B IM injection,J1571,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,150.7,,,,,,,fee schedule,70.23,172.1,
HepaGam B IM injection,J1571,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,152.71,,,,,,,fee schedule,70.23,172.1,
HepaGam B IM injection,J1571,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,81.47,,,,,,,fee schedule,70.23,172.1,OP High Cost Drugs
HepaGam B IM injection,J1571,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,70.23,,,,,,,fee schedule,70.23,172.1,Other Pharmacy
HepaGam B IM injection,J1571,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,73.75,,,,,,,fee schedule,70.23,172.1,APC
HepaGam B IM injection,J1571,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,73.04,,,,,,,fee schedule,70.23,172.1,APC
HepaGam B IM injection,J1571,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,107.46,,,,,,,fee schedule,70.23,172.1,Radiology
HepaGam B IM injection,J1571,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,98.33,,,,,,,fee schedule,70.23,172.1,APC
HepaGam B IM injection,J1571,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,122.91,,,,,,,fee schedule,70.23,172.1,APC
Flebogamma injection,J1572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,127.54,,,,,,,fee schedule,90.74,402.58,
Flebogamma injection,J1572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,138.54,,,,,,,fee schedule,90.74,402.58,
Flebogamma injection,J1572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,100.38,,,,,,,fee schedule,90.74,402.58,
Flebogamma injection,J1572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,111.05,,,,,,,fee schedule,90.74,402.58,
Flebogamma injection,J1572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,121.31,,,,,,,fee schedule,90.74,402.58,
Flebogamma injection,J1572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,90.85,,,,,,,fee schedule,90.74,402.58,
Flebogamma injection,J1572,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,402.58,,,,,,,fee schedule,90.74,402.58,APC 378
Flebogamma injection,J1572,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,95.28,,,,,,,fee schedule,90.74,402.58,APC
Flebogamma injection,J1572,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,94.37,,,,,,,fee schedule,90.74,402.58,APC
Flebogamma injection,J1572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,90.74,,,,,,,fee schedule,90.74,402.58,APC
Flebogamma injection,J1572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,138.83,,,,,,,fee schedule,90.74,402.58,Radiology
Flebogamma injection,J1572,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,127.04,,,,,,,fee schedule,90.74,402.58,APC
Flebogamma injection,J1572,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,158.79,,,,,,,fee schedule,90.74,402.58,APC
"Hepagam B intravenous, inj",J1573,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,158.44,,,,,,,fee schedule,70.23,172.1,
"Hepagam B intravenous, inj",J1573,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,172.1,,,,,,,fee schedule,70.23,172.1,
"Hepagam B intravenous, inj",J1573,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,168.73,,,,,,,fee schedule,70.23,172.1,
"Hepagam B intravenous, inj",J1573,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,137.96,,,,,,,fee schedule,70.23,172.1,
"Hepagam B intravenous, inj",J1573,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,150.7,,,,,,,fee schedule,70.23,172.1,
"Hepagam B intravenous, inj",J1573,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,152.71,,,,,,,fee schedule,70.23,172.1,
"Hepagam B intravenous, inj",J1573,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,81.47,,,,,,,fee schedule,70.23,172.1,OP High Cost Drugs
"Hepagam B intravenous, inj",J1573,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,70.23,,,,,,,fee schedule,70.23,172.1,Other Pharmacy
"Hepagam B intravenous, inj",J1573,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,73.75,,,,,,,fee schedule,70.23,172.1,APC
"Hepagam B intravenous, inj",J1573,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,73.04,,,,,,,fee schedule,70.23,172.1,APC
"Hepagam B intravenous, inj",J1573,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,107.46,,,,,,,fee schedule,70.23,172.1,Radiology
"Hepagam B intravenous, inj",J1573,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,98.33,,,,,,,fee schedule,70.23,172.1,APC
"Hepagam B intravenous, inj",J1573,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,122.91,,,,,,,fee schedule,70.23,172.1,APC
"Inj, ganciclovir (exela)",J1574,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,94.8,,,,,,,fee schedule,85.8,94.8,
"Inj, ganciclovir (exela)",J1574,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,85.8,,,,,,,fee schedule,85.8,94.8,
Hyqvia 100mg immuneglobulin,J1575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37.69,,,,,,,fee schedule,18.8,44.24,
Hyqvia 100mg immuneglobulin,J1575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,40.94,,,,,,,fee schedule,18.8,44.24,
Hyqvia 100mg immuneglobulin,J1575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,44.24,,,,,,,fee schedule,18.8,44.24,
Hyqvia 100mg immuneglobulin,J1575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32.81,,,,,,,fee schedule,18.8,44.24,
Hyqvia 100mg immuneglobulin,J1575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35.85,,,,,,,fee schedule,18.8,44.24,
Hyqvia 100mg immuneglobulin,J1575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40.04,,,,,,,fee schedule,18.8,44.24,
Hyqvia 100mg immuneglobulin,J1575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,21.81,,,,,,,fee schedule,18.8,44.24,OP High Cost Drugs
Hyqvia 100mg immuneglobulin,J1575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.8,,,,,,,fee schedule,18.8,44.24,Other Pharmacy
Hyqvia 100mg immuneglobulin,J1575,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.74,,,,,,,fee schedule,18.8,44.24,APC
Hyqvia 100mg immuneglobulin,J1575,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,19.56,,,,,,,fee schedule,18.8,44.24,APC
Hyqvia 100mg immuneglobulin,J1575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.77,,,,,,,fee schedule,18.8,44.24,Radiology
Hyqvia 100mg immuneglobulin,J1575,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26.33,,,,,,,fee schedule,18.8,44.24,APC
Hyqvia 100mg immuneglobulin,J1575,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,32.91,,,,,,,fee schedule,18.8,44.24,APC
"Inj, panzyga, 500 mg",J1576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,228.65,,,,,,,fee schedule,73.83,248.36,
"Inj, panzyga, 500 mg",J1576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,248.36,,,,,,,fee schedule,73.83,248.36,
"Inj, panzyga, 500 mg",J1576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,203.82,,,,,,,fee schedule,73.83,248.36,
"Inj, panzyga, 500 mg",J1576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,199.08,,,,,,,fee schedule,73.83,248.36,
"Inj, panzyga, 500 mg",J1576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,217.48,,,,,,,fee schedule,73.83,248.36,
"Inj, panzyga, 500 mg",J1576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,184.47,,,,,,,fee schedule,73.83,248.36,
"Inj, panzyga, 500 mg",J1576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,85.64,,,,,,,fee schedule,73.83,248.36,OP High Cost Drugs
"Inj, panzyga, 500 mg",J1576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,73.83,,,,,,,fee schedule,73.83,248.36,Other Pharmacy
"Inj, panzyga, 500 mg",J1576,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,77.52,,,,,,,fee schedule,73.83,248.36,APC
"Inj, panzyga, 500 mg",J1576,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,76.78,,,,,,,fee schedule,73.83,248.36,APC
"Inj, panzyga, 500 mg",J1576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,112.96,,,,,,,fee schedule,73.83,248.36,Radiology
"Inj, panzyga, 500 mg",J1576,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,103.36,,,,,,,fee schedule,73.83,248.36,APC
"Inj, panzyga, 500 mg",J1576,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,129.2,,,,,,,fee schedule,73.83,248.36,APC
Garamycin gentamicin inj,J1580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.41,,,,,,,fee schedule,5.81,6.41,
Garamycin gentamicin inj,J1580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.81,,,,,,,fee schedule,5.81,6.41,
Injection glatiramer acetate,J1595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,231.11,,,,,,,fee schedule,201.22,414.2,
Injection glatiramer acetate,J1595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,251.03,,,,,,,fee schedule,201.22,414.2,
Injection glatiramer acetate,J1595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,414.2,,,,,,,fee schedule,201.22,414.2,
Injection glatiramer acetate,J1595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,201.22,,,,,,,fee schedule,201.22,414.2,
Injection glatiramer acetate,J1595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,219.82,,,,,,,fee schedule,201.22,414.2,
Injection glatiramer acetate,J1595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,374.87,,,,,,,fee schedule,201.22,414.2,
"Inj, glycopyrrolate, 0.1 mg",J1596,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.67,,,,,,,fee schedule,5.13,5.67,
"Inj, glycopyrrolate, 0.1 mg",J1596,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.13,,,,,,,fee schedule,5.13,5.67,
"Inj glycopyrrolate, glyrx-pf",J1597,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.1,,,,,,,fee schedule,2.8,3.1,
"Inj glycopyrrolate, glyrx-pf",J1597,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.8,,,,,,,fee schedule,2.8,3.1,
"Ivig non-lyophilized, NOS",J1599,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,209.98,,,,,,,fee schedule,150.15,228.09,
"Ivig non-lyophilized, NOS",J1599,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,228.09,,,,,,,fee schedule,150.15,228.09,
"Ivig non-lyophilized, NOS",J1599,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,165.9,,,,,,,fee schedule,150.15,228.09,
"Ivig non-lyophilized, NOS",J1599,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,182.83,,,,,,,fee schedule,150.15,228.09,
"Ivig non-lyophilized, NOS",J1599,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,199.73,,,,,,,fee schedule,150.15,228.09,
"Ivig non-lyophilized, NOS",J1599,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,150.15,,,,,,,fee schedule,150.15,228.09,
Golimumab for iv use 1mg,J1602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83.24,,,,,,,fee schedule,11.29,90.42,
Golimumab for iv use 1mg,J1602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,90.42,,,,,,,fee schedule,11.29,90.42,
Golimumab for iv use 1mg,J1602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,75.81,,,,,,,fee schedule,11.29,90.42,
Golimumab for iv use 1mg,J1602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,72.48,,,,,,,fee schedule,11.29,90.42,
Golimumab for iv use 1mg,J1602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,79.18,,,,,,,fee schedule,11.29,90.42,
Golimumab for iv use 1mg,J1602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,68.61,,,,,,,fee schedule,11.29,90.42,
Golimumab for iv use 1mg,J1602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.09,,,,,,,fee schedule,11.29,90.42,OP High Cost Drugs
Golimumab for iv use 1mg,J1602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11.29,,,,,,,fee schedule,11.29,90.42,Other Pharmacy
Golimumab for iv use 1mg,J1602,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.85,,,,,,,fee schedule,11.29,90.42,APC
Golimumab for iv use 1mg,J1602,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11.74,,,,,,,fee schedule,11.29,90.42,APC
Golimumab for iv use 1mg,J1602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.27,,,,,,,fee schedule,11.29,90.42,Radiology
Golimumab for iv use 1mg,J1602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15.8,,,,,,,fee schedule,11.29,90.42,APC
Golimumab for iv use 1mg,J1602,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19.75,,,,,,,fee schedule,11.29,90.42,APC
Glucagon hydrochloride/1 mg,J1610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,260.06,,,,,,,fee schedule,146.33,599.22,
Glucagon hydrochloride/1 mg,J1610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,282.48,,,,,,,fee schedule,146.33,599.22,
Glucagon hydrochloride/1 mg,J1610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,599.22,,,,,,,fee schedule,146.33,599.22,
Glucagon hydrochloride/1 mg,J1610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,226.43,,,,,,,fee schedule,146.33,599.22,
Glucagon hydrochloride/1 mg,J1610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,247.36,,,,,,,fee schedule,146.33,599.22,
Glucagon hydrochloride/1 mg,J1610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,542.33,,,,,,,fee schedule,146.33,599.22,
Glucagon hydrochloride/1 mg,J1610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,169.75,,,,,,,fee schedule,146.33,599.22,OP High Cost Drugs
Glucagon hydrochloride/1 mg,J1610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,146.33,,,,,,,fee schedule,146.33,599.22,Other Pharmacy
Glucagon hydrochloride/1 mg,J1610,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,153.65,,,,,,,fee schedule,146.33,599.22,APC
Glucagon hydrochloride/1 mg,J1610,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,152.19,,,,,,,fee schedule,146.33,599.22,APC
Glucagon hydrochloride/1 mg,J1610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,223.89,,,,,,,fee schedule,146.33,599.22,Radiology
Glucagon hydrochloride/1 mg,J1610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,204.86,,,,,,,fee schedule,146.33,599.22,APC
Glucagon hydrochloride/1 mg,J1610,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,256.08,,,,,,,fee schedule,146.33,599.22,APC
"Inj glucagon hcl, fresenius",J1611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,563.8,,,,,,,fee schedule,135,612.41,
"Inj glucagon hcl, fresenius",J1611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,612.41,,,,,,,fee schedule,135,612.41,
"Inj glucagon hcl, fresenius",J1611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,449.67,,,,,,,fee schedule,135,612.41,
"Inj glucagon hcl, fresenius",J1611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,490.9,,,,,,,fee schedule,135,612.41,
"Inj glucagon hcl, fresenius",J1611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,536.26,,,,,,,fee schedule,135,612.41,
"Inj glucagon hcl, fresenius",J1611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,406.98,,,,,,,fee schedule,135,612.41,
"Inj glucagon hcl, fresenius",J1611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,156.6,,,,,,,fee schedule,135,612.41,OP High Cost Drugs
"Inj glucagon hcl, fresenius",J1611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,135,,,,,,,fee schedule,135,612.41,Other Pharmacy
"Inj glucagon hcl, fresenius",J1611,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,141.75,,,,,,,fee schedule,135,612.41,APC
"Inj glucagon hcl, fresenius",J1611,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,140.4,,,,,,,fee schedule,135,612.41,APC
"Inj glucagon hcl, fresenius",J1611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,206.55,,,,,,,fee schedule,135,612.41,Radiology
"Inj glucagon hcl, fresenius",J1611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,189,,,,,,,fee schedule,135,612.41,APC
"Inj glucagon hcl, fresenius",J1611,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,236.25,,,,,,,fee schedule,135,612.41,APC
Gonadorelin hydroch/ 100 mcg,J1620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,644.25,,,,,,,fee schedule,560.94,699.79,
Gonadorelin hydroch/ 100 mcg,J1620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,699.79,,,,,,,fee schedule,560.94,699.79,
Gonadorelin hydroch/ 100 mcg,J1620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,560.94,,,,,,,fee schedule,560.94,699.79,
Gonadorelin hydroch/ 100 mcg,J1620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,612.78,,,,,,,fee schedule,560.94,699.79,
Granisetron hcl injection,J1626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15.49,,,,,,,fee schedule,3.1,16.82,
Granisetron hcl injection,J1626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16.82,,,,,,,fee schedule,3.1,16.82,
Granisetron hcl injection,J1626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.43,,,,,,,fee schedule,3.1,16.82,
Granisetron hcl injection,J1626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13.48,,,,,,,fee schedule,3.1,16.82,
Granisetron hcl injection,J1626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14.73,,,,,,,fee schedule,3.1,16.82,
Granisetron hcl injection,J1626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.1,,,,,,,fee schedule,3.1,16.82,
"Inj, granisetron, xr, 0.1 mg",J1627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12.44,,,,,,,fee schedule,3.88,14.63,
"Inj, granisetron, xr, 0.1 mg",J1627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13.52,,,,,,,fee schedule,3.88,14.63,
"Inj, granisetron, xr, 0.1 mg",J1627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14.63,,,,,,,fee schedule,3.88,14.63,
"Inj, granisetron, xr, 0.1 mg",J1627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10.84,,,,,,,fee schedule,3.88,14.63,
"Inj, granisetron, xr, 0.1 mg",J1627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11.84,,,,,,,fee schedule,3.88,14.63,
"Inj, granisetron, xr, 0.1 mg",J1627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13.24,,,,,,,fee schedule,3.88,14.63,
"Inj, granisetron, xr, 0.1 mg",J1627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4.5,,,,,,,fee schedule,3.88,14.63,OP High Cost Drugs
"Inj, granisetron, xr, 0.1 mg",J1627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3.88,,,,,,,fee schedule,3.88,14.63,Other Pharmacy
"Inj, granisetron, xr, 0.1 mg",J1627,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.07,,,,,,,fee schedule,3.88,14.63,APC
"Inj, granisetron, xr, 0.1 mg",J1627,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4.03,,,,,,,fee schedule,3.88,14.63,APC
"Inj, granisetron, xr, 0.1 mg",J1627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.93,,,,,,,fee schedule,3.88,14.63,Radiology
"Inj, granisetron, xr, 0.1 mg",J1627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.43,,,,,,,fee schedule,3.88,14.63,APC
"Inj, granisetron, xr, 0.1 mg",J1627,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6.78,,,,,,,fee schedule,3.88,14.63,APC
"Inj., guselkumab, 1 mg",J1628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,354.49,,,,,,,fee schedule,67.81,385.05,
"Inj., guselkumab, 1 mg",J1628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,385.05,,,,,,,fee schedule,67.81,385.05,
"Inj., guselkumab, 1 mg",J1628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,131.52,,,,,,,fee schedule,67.81,385.05,
"Inj., guselkumab, 1 mg",J1628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,308.65,,,,,,,fee schedule,67.81,385.05,
"Inj., guselkumab, 1 mg",J1628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,337.17,,,,,,,fee schedule,67.81,385.05,
"Inj., guselkumab, 1 mg",J1628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,119.03,,,,,,,fee schedule,67.81,385.05,
"Inj., guselkumab, 1 mg",J1628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,78.66,,,,,,,fee schedule,67.81,385.05,OP High Cost Drugs
"Inj., guselkumab, 1 mg",J1628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,67.81,,,,,,,fee schedule,67.81,385.05,Other Pharmacy
"Inj., guselkumab, 1 mg",J1628,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,71.2,,,,,,,fee schedule,67.81,385.05,APC
"Inj., guselkumab, 1 mg",J1628,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,70.53,,,,,,,fee schedule,67.81,385.05,APC
"Inj., guselkumab, 1 mg",J1628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,103.75,,,,,,,fee schedule,67.81,385.05,Radiology
"Inj., guselkumab, 1 mg",J1628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,94.94,,,,,,,fee schedule,67.81,385.05,APC
"Inj., guselkumab, 1 mg",J1628,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,118.67,,,,,,,fee schedule,67.81,385.05,APC
Haloperidol injection,J1630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.48,,,,,,,fee schedule,8.58,9.48,
Haloperidol injection,J1630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.58,,,,,,,fee schedule,8.58,9.48,
Haloperidol decanoate inj,J1631,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41.71,,,,,,,fee schedule,37.75,41.71,
Haloperidol decanoate inj,J1631,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37.75,,,,,,,fee schedule,37.75,41.71,
"Inj., brexanolone, 1 mg",J1632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,264.97,,,,,,,fee schedule,127.84,287.81,
"Inj., brexanolone, 1 mg",J1632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,287.81,,,,,,,fee schedule,127.84,287.81,
"Inj., brexanolone, 1 mg",J1632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,141.25,,,,,,,fee schedule,127.84,287.81,
"Inj., brexanolone, 1 mg",J1632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,230.71,,,,,,,fee schedule,127.84,287.81,
"Inj., brexanolone, 1 mg",J1632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,252.03,,,,,,,fee schedule,127.84,287.81,
"Inj., brexanolone, 1 mg",J1632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,127.84,,,,,,,fee schedule,127.84,287.81,
"Hemin, 1 mg",J1640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26.34,,,,,,,fee schedule,22.94,61.79,
"Hemin, 1 mg",J1640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,28.61,,,,,,,fee schedule,22.94,61.79,
"Hemin, 1 mg",J1640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,58.81,,,,,,,fee schedule,22.94,61.79,
"Hemin, 1 mg",J1640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22.94,,,,,,,fee schedule,22.94,61.79,
"Hemin, 1 mg",J1640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,25.06,,,,,,,fee schedule,22.94,61.79,
"Hemin, 1 mg",J1640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.22,,,,,,,fee schedule,22.94,61.79,
"Hemin, 1 mg",J1640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,40.96,,,,,,,fee schedule,22.94,61.79,OP High Cost Drugs
"Hemin, 1 mg",J1640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,35.31,,,,,,,fee schedule,22.94,61.79,Other Pharmacy
"Hemin, 1 mg",J1640,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,37.07,,,,,,,fee schedule,22.94,61.79,APC
"Hemin, 1 mg",J1640,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,36.72,,,,,,,fee schedule,22.94,61.79,APC
"Hemin, 1 mg",J1640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,54.02,,,,,,,fee schedule,22.94,61.79,Radiology
"Hemin, 1 mg",J1640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49.43,,,,,,,fee schedule,22.94,61.79,APC
"Hemin, 1 mg",J1640,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,61.79,,,,,,,fee schedule,22.94,61.79,APC
Inj heparin sodium per 10 u,J1642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.28,,,,,,,fee schedule,0.26,0.28,
Inj heparin sodium per 10 u,J1642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.26,,,,,,,fee schedule,0.26,0.28,
"Inj heparin, pfizer, 1000u",J1643,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.63,,,,,,,fee schedule,0.57,0.63,
"Inj heparin, pfizer, 1000u",J1643,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.57,,,,,,,fee schedule,0.57,0.63,
Inj heparin sodium per 1000u,J1644,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.98,,,,,,,fee schedule,0.89,0.98,
Inj heparin sodium per 1000u,J1644,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.89,,,,,,,fee schedule,0.89,0.98,
Dalteparin sodium,J1645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46.61,,,,,,,fee schedule,42.19,46.61,
Dalteparin sodium,J1645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.19,,,,,,,fee schedule,42.19,46.61,
Inj enoxaparin sodium,J1650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.78,,,,,,,fee schedule,3.42,3.78,
Inj enoxaparin sodium,J1650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.42,,,,,,,fee schedule,3.42,3.78,
Fondaparinux sodium,J1652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21.96,,,,,,,fee schedule,12.36,23.85,
Fondaparinux sodium,J1652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23.85,,,,,,,fee schedule,12.36,23.85,
Fondaparinux sodium,J1652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13.65,,,,,,,fee schedule,12.36,23.85,
Fondaparinux sodium,J1652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19.12,,,,,,,fee schedule,12.36,23.85,
Fondaparinux sodium,J1652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20.89,,,,,,,fee schedule,12.36,23.85,
Fondaparinux sodium,J1652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12.36,,,,,,,fee schedule,12.36,23.85,
Tetanus immune globulin inj,J1670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,491.52,,,,,,,fee schedule,427.96,1230.82,
Tetanus immune globulin inj,J1670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,533.89,,,,,,,fee schedule,427.96,1230.82,
Tetanus immune globulin inj,J1670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1230.82,,,,,,,fee schedule,427.96,1230.82,
Tetanus immune globulin inj,J1670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,427.96,,,,,,,fee schedule,427.96,1230.82,
Tetanus immune globulin inj,J1670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,467.5,,,,,,,fee schedule,427.96,1230.82,
Tetanus immune globulin inj,J1670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1113.97,,,,,,,fee schedule,427.96,1230.82,
Tetanus immune globulin inj,J1670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,647.42,,,,,,,fee schedule,427.96,1230.82,OP High Cost Drugs
Tetanus immune globulin inj,J1670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,558.12,,,,,,,fee schedule,427.96,1230.82,Other Pharmacy
Tetanus immune globulin inj,J1670,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,586.02,,,,,,,fee schedule,427.96,1230.82,APC
Tetanus immune globulin inj,J1670,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,580.44,,,,,,,fee schedule,427.96,1230.82,APC
Tetanus immune globulin inj,J1670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,853.92,,,,,,,fee schedule,427.96,1230.82,Radiology
Tetanus immune globulin inj,J1670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,781.37,,,,,,,fee schedule,427.96,1230.82,APC
Tetanus immune globulin inj,J1670,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,976.71,,,,,,,fee schedule,427.96,1230.82,APC
Hydrocortisone acetate inj,J1700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.57,,,,,,,fee schedule,0.51,0.57,
Hydrocortisone acetate inj,J1700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.51,,,,,,,fee schedule,0.51,0.57,
Hydrocortisone sodium succ i,J1720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,40.61,,,,,,,fee schedule,36.75,40.61,
Hydrocortisone sodium succ i,J1720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36.75,,,,,,,fee schedule,36.75,40.61,
"Makena, 10 mg",J1726,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,97.19,,,,,,,fee schedule,49.55,105.57,
"Makena, 10 mg",J1726,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,105.57,,,,,,,fee schedule,49.55,105.57,
"Makena, 10 mg",J1726,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,54.75,,,,,,,fee schedule,49.55,105.57,
"Makena, 10 mg",J1726,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,84.62,,,,,,,fee schedule,49.55,105.57,
"Makena, 10 mg",J1726,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,92.44,,,,,,,fee schedule,49.55,105.57,
"Makena, 10 mg",J1726,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,49.55,,,,,,,fee schedule,49.55,105.57,
Inj hydroxyprogst capoat nos,J1729,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37.62,,,,,,,fee schedule,32.75,53.93,
Inj hydroxyprogst capoat nos,J1729,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,40.86,,,,,,,fee schedule,32.75,53.93,
Inj hydroxyprogst capoat nos,J1729,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,53.93,,,,,,,fee schedule,32.75,53.93,
Inj hydroxyprogst capoat nos,J1729,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32.75,,,,,,,fee schedule,32.75,53.93,
Inj hydroxyprogst capoat nos,J1729,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35.78,,,,,,,fee schedule,32.75,53.93,
Inj hydroxyprogst capoat nos,J1729,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48.81,,,,,,,fee schedule,32.75,53.93,
Diazoxide injection,J1730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,408.48,,,,,,,fee schedule,355.66,443.7,
Diazoxide injection,J1730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,443.7,,,,,,,fee schedule,355.66,443.7,
Diazoxide injection,J1730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,355.66,,,,,,,fee schedule,355.66,443.7,
Diazoxide injection,J1730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,388.53,,,,,,,fee schedule,355.66,443.7,
Inj. meloxicam 1 mg,J1738,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11.33,,,,,,,fee schedule,5.38,12.3,
Inj. meloxicam 1 mg,J1738,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12.3,,,,,,,fee schedule,5.38,12.3,
Inj. meloxicam 1 mg,J1738,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.94,,,,,,,fee schedule,5.38,12.3,
Inj. meloxicam 1 mg,J1738,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.86,,,,,,,fee schedule,5.38,12.3,
Inj. meloxicam 1 mg,J1738,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10.77,,,,,,,fee schedule,5.38,12.3,
Inj. meloxicam 1 mg,J1738,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.38,,,,,,,fee schedule,5.38,12.3,
Ibandronate sodium injection,J1740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,501.33,,,,,,,fee schedule,240.81,544.55,
Ibandronate sodium injection,J1740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,544.55,,,,,,,fee schedule,240.81,544.55,
Ibandronate sodium injection,J1740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,266.07,,,,,,,fee schedule,240.81,544.55,
Ibandronate sodium injection,J1740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,436.5,,,,,,,fee schedule,240.81,544.55,
Ibandronate sodium injection,J1740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,476.84,,,,,,,fee schedule,240.81,544.55,
Ibandronate sodium injection,J1740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,240.81,,,,,,,fee schedule,240.81,544.55,
Ibuprofen injection,J1741,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.71,,,,,,,fee schedule,4.97,6.2,
Ibuprofen injection,J1741,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.2,,,,,,,fee schedule,4.97,6.2,
Ibuprofen injection,J1741,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.81,,,,,,,fee schedule,4.97,6.2,
Ibuprofen injection,J1741,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.97,,,,,,,fee schedule,4.97,6.2,
Ibuprofen injection,J1741,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.43,,,,,,,fee schedule,4.97,6.2,
Ibuprofen injection,J1741,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.26,,,,,,,fee schedule,4.97,6.2,
Ibutilide fumarate injection,J1742,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1326.09,,,,,,,fee schedule,219.22,1440.41,
Ibutilide fumarate injection,J1742,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1440.41,,,,,,,fee schedule,219.22,1440.41,
Ibutilide fumarate injection,J1742,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,589.15,,,,,,,fee schedule,219.22,1440.41,
Ibutilide fumarate injection,J1742,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1154.61,,,,,,,fee schedule,219.22,1440.41,
Ibutilide fumarate injection,J1742,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1261.31,,,,,,,fee schedule,219.22,1440.41,
Ibutilide fumarate injection,J1742,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,533.22,,,,,,,fee schedule,219.22,1440.41,
Ibutilide fumarate injection,J1742,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,972.58,,,,,,,fee schedule,219.22,1440.41,APC 378
Ibutilide fumarate injection,J1742,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,230.18,,,,,,,fee schedule,219.22,1440.41,APC
Ibutilide fumarate injection,J1742,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,227.98,,,,,,,fee schedule,219.22,1440.41,APC
Ibutilide fumarate injection,J1742,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,219.22,,,,,,,fee schedule,219.22,1440.41,APC
Ibutilide fumarate injection,J1742,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,335.4,,,,,,,fee schedule,219.22,1440.41,Radiology
Ibutilide fumarate injection,J1742,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,306.9,,,,,,,fee schedule,219.22,1440.41,APC
Ibutilide fumarate injection,J1742,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,383.63,,,,,,,fee schedule,219.22,1440.41,APC
Idursulfase injection,J1743,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1641.48,,,,,,,fee schedule,558.22,1782.99,
Idursulfase injection,J1743,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1782.99,,,,,,,fee schedule,558.22,1782.99,
Idursulfase injection,J1743,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,990.93,,,,,,,fee schedule,558.22,1782.99,
Idursulfase injection,J1743,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1429.22,,,,,,,fee schedule,558.22,1782.99,
Idursulfase injection,J1743,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1561.29,,,,,,,fee schedule,558.22,1782.99,
Idursulfase injection,J1743,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,896.85,,,,,,,fee schedule,558.22,1782.99,
Idursulfase injection,J1743,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,647.54,,,,,,,fee schedule,558.22,1782.99,OP High Cost Drugs
Idursulfase injection,J1743,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,558.22,,,,,,,fee schedule,558.22,1782.99,Other Pharmacy
Idursulfase injection,J1743,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,586.13,,,,,,,fee schedule,558.22,1782.99,APC
Idursulfase injection,J1743,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,580.55,,,,,,,fee schedule,558.22,1782.99,APC
Idursulfase injection,J1743,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,854.08,,,,,,,fee schedule,558.22,1782.99,Radiology
Idursulfase injection,J1743,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,781.51,,,,,,,fee schedule,558.22,1782.99,APC
Idursulfase injection,J1743,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,976.89,,,,,,,fee schedule,558.22,1782.99,APC
Icatibant injection,J1744,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,886.43,,,,,,,fee schedule,605.75,962.84,
Icatibant injection,J1744,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,962.84,,,,,,,fee schedule,605.75,962.84,
Icatibant injection,J1744,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,669.29,,,,,,,fee schedule,605.75,962.84,
Icatibant injection,J1744,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,771.8,,,,,,,fee schedule,605.75,962.84,
Icatibant injection,J1744,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,843.12,,,,,,,fee schedule,605.75,962.84,
Icatibant injection,J1744,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,605.75,,,,,,,fee schedule,605.75,962.84,
Infliximab not biosimil 10mg,J1745,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,203.96,,,,,,,fee schedule,31.04,221.55,
Infliximab not biosimil 10mg,J1745,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,221.55,,,,,,,fee schedule,31.04,221.55,
Infliximab not biosimil 10mg,J1745,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,155.74,,,,,,,fee schedule,31.04,221.55,
Infliximab not biosimil 10mg,J1745,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,177.59,,,,,,,fee schedule,31.04,221.55,
Infliximab not biosimil 10mg,J1745,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,194,,,,,,,fee schedule,31.04,221.55,
Infliximab not biosimil 10mg,J1745,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,140.96,,,,,,,fee schedule,31.04,221.55,
Infliximab not biosimil 10mg,J1745,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.01,,,,,,,fee schedule,31.04,221.55,OP High Cost Drugs
Infliximab not biosimil 10mg,J1745,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,31.04,,,,,,,fee schedule,31.04,221.55,Other Pharmacy
Infliximab not biosimil 10mg,J1745,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,32.59,,,,,,,fee schedule,31.04,221.55,APC
Infliximab not biosimil 10mg,J1745,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,32.28,,,,,,,fee schedule,31.04,221.55,APC
Infliximab not biosimil 10mg,J1745,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,47.49,,,,,,,fee schedule,31.04,221.55,Radiology
Infliximab not biosimil 10mg,J1745,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43.46,,,,,,,fee schedule,31.04,221.55,APC
Infliximab not biosimil 10mg,J1745,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,54.32,,,,,,,fee schedule,31.04,221.55,APC
"Inj., ibalizumab-uiyk, 10 mg",J1746,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,209.34,,,,,,,fee schedule,77.68,227.39,
"Inj., ibalizumab-uiyk, 10 mg",J1746,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,227.39,,,,,,,fee schedule,77.68,227.39,
"Inj., ibalizumab-uiyk, 10 mg",J1746,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,140.73,,,,,,,fee schedule,77.68,227.39,
"Inj., ibalizumab-uiyk, 10 mg",J1746,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,182.27,,,,,,,fee schedule,77.68,227.39,
"Inj., ibalizumab-uiyk, 10 mg",J1746,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,199.11,,,,,,,fee schedule,77.68,227.39,
"Inj., ibalizumab-uiyk, 10 mg",J1746,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,127.37,,,,,,,fee schedule,77.68,227.39,
"Inj., ibalizumab-uiyk, 10 mg",J1746,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,90.1,,,,,,,fee schedule,77.68,227.39,OP High Cost Drugs
"Inj., ibalizumab-uiyk, 10 mg",J1746,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,77.68,,,,,,,fee schedule,77.68,227.39,Other Pharmacy
"Inj., ibalizumab-uiyk, 10 mg",J1746,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,81.56,,,,,,,fee schedule,77.68,227.39,APC
"Inj., ibalizumab-uiyk, 10 mg",J1746,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,80.78,,,,,,,fee schedule,77.68,227.39,APC
"Inj., ibalizumab-uiyk, 10 mg",J1746,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,118.84,,,,,,,fee schedule,77.68,227.39,Radiology
"Inj., ibalizumab-uiyk, 10 mg",J1746,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,108.74,,,,,,,fee schedule,77.68,227.39,APC
"Inj., ibalizumab-uiyk, 10 mg",J1746,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,135.93,,,,,,,fee schedule,77.68,227.39,APC
"Inj, spesolimab-sbzo, 1 mg",J1747,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,209.58,,,,,,,fee schedule,65.73,227.64,
"Inj, spesolimab-sbzo, 1 mg",J1747,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,227.64,,,,,,,fee schedule,65.73,227.64,
"Inj, spesolimab-sbzo, 1 mg",J1747,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,110.09,,,,,,,fee schedule,65.73,227.64,
"Inj, spesolimab-sbzo, 1 mg",J1747,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,182.48,,,,,,,fee schedule,65.73,227.64,
"Inj, spesolimab-sbzo, 1 mg",J1747,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,199.34,,,,,,,fee schedule,65.73,227.64,
"Inj, spesolimab-sbzo, 1 mg",J1747,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,99.64,,,,,,,fee schedule,65.73,227.64,
"Inj, spesolimab-sbzo, 1 mg",J1747,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,76.24,,,,,,,fee schedule,65.73,227.64,OP High Cost Drugs
"Inj, spesolimab-sbzo, 1 mg",J1747,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,65.73,,,,,,,fee schedule,65.73,227.64,Other Pharmacy
"Inj, spesolimab-sbzo, 1 mg",J1747,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,69.01,,,,,,,fee schedule,65.73,227.64,APC
"Inj, spesolimab-sbzo, 1 mg",J1747,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,68.36,,,,,,,fee schedule,65.73,227.64,APC
"Inj, spesolimab-sbzo, 1 mg",J1747,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,100.56,,,,,,,fee schedule,65.73,227.64,Radiology
"Inj, spesolimab-sbzo, 1 mg",J1747,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,92.02,,,,,,,fee schedule,65.73,227.64,APC
"Inj, spesolimab-sbzo, 1 mg",J1747,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,115.02,,,,,,,fee schedule,65.73,227.64,APC
"Inj, zymfentra, 10 mg",J1748,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,976.22,,,,,,,fee schedule,883.54,976.22,
"Inj, zymfentra, 10 mg",J1748,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,883.54,,,,,,,fee schedule,883.54,976.22,
Inj iron dextran,J1750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,40.99,,,,,,,fee schedule,18.1,44.53,
Inj iron dextran,J1750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,44.53,,,,,,,fee schedule,18.1,44.53,
Inj iron dextran,J1750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33.67,,,,,,,fee schedule,18.1,44.53,
Inj iron dextran,J1750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35.69,,,,,,,fee schedule,18.1,44.53,
Inj iron dextran,J1750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38.99,,,,,,,fee schedule,18.1,44.53,
Inj iron dextran,J1750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,30.47,,,,,,,fee schedule,18.1,44.53,
Inj iron dextran,J1750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,21,,,,,,,fee schedule,18.1,44.53,OP High Cost Drugs
Inj iron dextran,J1750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.1,,,,,,,fee schedule,18.1,44.53,Other Pharmacy
Inj iron dextran,J1750,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.01,,,,,,,fee schedule,18.1,44.53,APC
Inj iron dextran,J1750,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18.83,,,,,,,fee schedule,18.1,44.53,APC
Inj iron dextran,J1750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27.7,,,,,,,fee schedule,18.1,44.53,Radiology
Inj iron dextran,J1750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.35,,,,,,,fee schedule,18.1,44.53,APC
Inj iron dextran,J1750,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31.68,,,,,,,fee schedule,18.1,44.53,APC
Iron sucrose injection,J1756,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.29,,,,,,,fee schedule,0.94,1.4,
Iron sucrose injection,J1756,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.4,,,,,,,fee schedule,0.94,1.4,
Iron sucrose injection,J1756,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.04,,,,,,,fee schedule,0.94,1.4,
Iron sucrose injection,J1756,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.12,,,,,,,fee schedule,0.94,1.4,
Iron sucrose injection,J1756,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.22,,,,,,,fee schedule,0.94,1.4,
Iron sucrose injection,J1756,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.94,,,,,,,fee schedule,0.94,1.4,
Imuglucerase injection,J1786,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,145.95,,,,,,,fee schedule,42.82,158.53,
Imuglucerase injection,J1786,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,158.53,,,,,,,fee schedule,42.82,158.53,
Imuglucerase injection,J1786,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,81.39,,,,,,,fee schedule,42.82,158.53,
Imuglucerase injection,J1786,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,127.08,,,,,,,fee schedule,42.82,158.53,
Imuglucerase injection,J1786,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,138.82,,,,,,,fee schedule,42.82,158.53,
Imuglucerase injection,J1786,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,73.66,,,,,,,fee schedule,42.82,158.53,
Imuglucerase injection,J1786,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,49.68,,,,,,,fee schedule,42.82,158.53,OP High Cost Drugs
Imuglucerase injection,J1786,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,42.82,,,,,,,fee schedule,42.82,158.53,Other Pharmacy
Imuglucerase injection,J1786,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,44.97,,,,,,,fee schedule,42.82,158.53,APC
Imuglucerase injection,J1786,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,44.54,,,,,,,fee schedule,42.82,158.53,APC
Imuglucerase injection,J1786,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,65.52,,,,,,,fee schedule,42.82,158.53,Radiology
Imuglucerase injection,J1786,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,59.96,,,,,,,fee schedule,42.82,158.53,APC
Imuglucerase injection,J1786,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,74.94,,,,,,,fee schedule,42.82,158.53,APC
Droperidol injection,J1790,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18.36,,,,,,,fee schedule,16.62,18.36,
Droperidol injection,J1790,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.62,,,,,,,fee schedule,16.62,18.36,
Propranolol injection,J1800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15.17,,,,,,,fee schedule,13.73,15.17,
Propranolol injection,J1800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13.73,,,,,,,fee schedule,13.73,15.17,
"Inj, esmolol hcl, 10mg",J1805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.85,,,,,,,fee schedule,0.74,1.86,
"Inj, esmolol hcl, 10mg",J1805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.93,,,,,,,fee schedule,0.74,1.86,
"Inj, esmolol hcl, 10mg",J1805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.86,,,,,,,fee schedule,0.74,1.86,
"Inj, esmolol hcl, 10mg",J1805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.74,,,,,,,fee schedule,0.74,1.86,
"Inj, esmolol hcl, 10mg",J1805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.81,,,,,,,fee schedule,0.74,1.86,
"Inj, esmolol hcl, 10mg",J1805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.69,,,,,,,fee schedule,0.74,1.86,
Inj esmolol hcl wg crit care,J1806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.63,,,,,,,fee schedule,0.97,1.77,
Inj esmolol hcl wg crit care,J1806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.77,,,,,,,fee schedule,0.97,1.77,
Inj esmolol hcl wg crit care,J1806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.07,,,,,,,fee schedule,0.97,1.77,
Inj esmolol hcl wg crit care,J1806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.42,,,,,,,fee schedule,0.97,1.77,
Inj esmolol hcl wg crit care,J1806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.55,,,,,,,fee schedule,0.97,1.77,
Inj esmolol hcl wg crit care,J1806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.97,,,,,,,fee schedule,0.97,1.77,
Fiasp for insulin pump use,J1811,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23.22,,,,,,,fee schedule,20.22,27.43,
Fiasp for insulin pump use,J1811,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,25.22,,,,,,,fee schedule,20.22,27.43,
Fiasp for insulin pump use,J1811,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27.43,,,,,,,fee schedule,20.22,27.43,
Fiasp for insulin pump use,J1811,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20.22,,,,,,,fee schedule,20.22,27.43,
Fiasp for insulin pump use,J1811,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22.09,,,,,,,fee schedule,20.22,27.43,
Fiasp for insulin pump use,J1811,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24.82,,,,,,,fee schedule,20.22,27.43,
Inj. Insulin (fiasp),J1812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.4,,,,,,,fee schedule,3.07,3.4,
Inj. Insulin (fiasp),J1812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.07,,,,,,,fee schedule,3.07,3.4,
Lyumjev for insulin pump use,J1813,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,54.55,,,,,,,fee schedule,23.57,59.25,
Lyumjev for insulin pump use,J1813,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59.25,,,,,,,fee schedule,23.57,59.25,
Lyumjev for insulin pump use,J1813,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26.04,,,,,,,fee schedule,23.57,59.25,
Lyumjev for insulin pump use,J1813,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,47.5,,,,,,,fee schedule,23.57,59.25,
Lyumjev for insulin pump use,J1813,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.88,,,,,,,fee schedule,23.57,59.25,
Lyumjev for insulin pump use,J1813,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23.57,,,,,,,fee schedule,23.57,59.25,
Inj. insulin (lyumjev),J1814,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.35,,,,,,,fee schedule,3.03,3.35,
Inj. insulin (lyumjev),J1814,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.03,,,,,,,fee schedule,3.03,3.35,
Insulin injection,J1815,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.82,,,,,,,fee schedule,0.74,0.82,
Insulin injection,J1815,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.74,,,,,,,fee schedule,0.74,0.82,
Insulin for insulin pump use,J1817,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.57,,,,,,,fee schedule,5.95,6.57,
Insulin for insulin pump use,J1817,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.95,,,,,,,fee schedule,5.95,6.57,
"Inj. inebilizumab-cdon, 1 mg",J1823,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1565.19,,,,,,,fee schedule,495.54,1700.12,
"Inj. inebilizumab-cdon, 1 mg",J1823,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1700.12,,,,,,,fee schedule,495.54,1700.12,
"Inj. inebilizumab-cdon, 1 mg",J1823,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,866.44,,,,,,,fee schedule,495.54,1700.12,
"Inj. inebilizumab-cdon, 1 mg",J1823,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1362.79,,,,,,,fee schedule,495.54,1700.12,
"Inj. inebilizumab-cdon, 1 mg",J1823,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1488.73,,,,,,,fee schedule,495.54,1700.12,
"Inj. inebilizumab-cdon, 1 mg",J1823,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,784.18,,,,,,,fee schedule,495.54,1700.12,
"Inj. inebilizumab-cdon, 1 mg",J1823,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,574.83,,,,,,,fee schedule,495.54,1700.12,OP High Cost Drugs
"Inj. inebilizumab-cdon, 1 mg",J1823,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,495.54,,,,,,,fee schedule,495.54,1700.12,Other Pharmacy
"Inj. inebilizumab-cdon, 1 mg",J1823,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,520.32,,,,,,,fee schedule,495.54,1700.12,APC
"Inj. inebilizumab-cdon, 1 mg",J1823,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,515.37,,,,,,,fee schedule,495.54,1700.12,APC
"Inj. inebilizumab-cdon, 1 mg",J1823,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,758.18,,,,,,,fee schedule,495.54,1700.12,Radiology
"Inj. inebilizumab-cdon, 1 mg",J1823,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,693.76,,,,,,,fee schedule,495.54,1700.12,APC
"Inj. inebilizumab-cdon, 1 mg",J1823,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,867.2,,,,,,,fee schedule,495.54,1700.12,APC
Interferon Beta-1A inj,J1826,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3714.8,,,,,,,fee schedule,3234.43,6503.9,
Interferon Beta-1A inj,J1826,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4035.04,,,,,,,fee schedule,3234.43,6503.9,
Interferon Beta-1A inj,J1826,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6503.9,,,,,,,fee schedule,3234.43,6503.9,
Interferon Beta-1A inj,J1826,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3234.43,,,,,,,fee schedule,3234.43,6503.9,
Interferon Beta-1A inj,J1826,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3533.33,,,,,,,fee schedule,3234.43,6503.9,
Interferon Beta-1A inj,J1826,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5886.44,,,,,,,fee schedule,3234.43,6503.9,
Interferon beta-1b / .25 MG,J1830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,393.07,,,,,,,fee schedule,342.24,836.58,
Interferon beta-1b / .25 MG,J1830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,426.95,,,,,,,fee schedule,342.24,836.58,
Interferon beta-1b / .25 MG,J1830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,836.58,,,,,,,fee schedule,342.24,836.58,
Interferon beta-1b / .25 MG,J1830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,342.24,,,,,,,fee schedule,342.24,836.58,
Interferon beta-1b / .25 MG,J1830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,373.86,,,,,,,fee schedule,342.24,836.58,
Interferon beta-1b / .25 MG,J1830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,757.16,,,,,,,fee schedule,342.24,836.58,
"Injection, isavuconazonium",J1833,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.19,,,,,,,fee schedule,1.01,4.47,
"Injection, isavuconazonium",J1833,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.38,,,,,,,fee schedule,1.01,4.47,
"Injection, isavuconazonium",J1833,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.96,,,,,,,fee schedule,1.01,4.47,
"Injection, isavuconazonium",J1833,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.91,,,,,,,fee schedule,1.01,4.47,
"Injection, isavuconazonium",J1833,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.09,,,,,,,fee schedule,1.01,4.47,
"Injection, isavuconazonium",J1833,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.77,,,,,,,fee schedule,1.01,4.47,
"Injection, isavuconazonium",J1833,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.47,,,,,,,fee schedule,1.01,4.47,APC 378
"Injection, isavuconazonium",J1833,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.06,,,,,,,fee schedule,1.01,4.47,APC
"Injection, isavuconazonium",J1833,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1.05,,,,,,,fee schedule,1.01,4.47,APC
"Injection, isavuconazonium",J1833,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1.01,,,,,,,fee schedule,1.01,4.47,APC
"Injection, isavuconazonium",J1833,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1.54,,,,,,,fee schedule,1.01,4.47,Radiology
"Injection, isavuconazonium",J1833,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1.41,,,,,,,fee schedule,1.01,4.47,APC
"Injection, isavuconazonium",J1833,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1.76,,,,,,,fee schedule,1.01,4.47,APC
Itraconazole injection,J1835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,134.15,,,,,,,fee schedule,116.81,145.72,
Itraconazole injection,J1835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,145.72,,,,,,,fee schedule,116.81,145.72,
Itraconazole injection,J1835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,116.81,,,,,,,fee schedule,116.81,145.72,
Itraconazole injection,J1835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,127.6,,,,,,,fee schedule,116.81,145.72,
"Inj, metronidazole, 10 mg",J1836,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.08,,,,,,,fee schedule,0.07,0.09,
"Inj, metronidazole, 10 mg",J1836,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.09,,,,,,,fee schedule,0.07,0.09,
"Inj, metronidazole, 10 mg",J1836,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.07,,,,,,,fee schedule,0.07,0.09,
"Inj, metronidazole, 10 mg",J1836,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.08,,,,,,,fee schedule,0.07,0.09,
"Inj, metronidazole, 10 mg",J1836,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.09,,,,,,,fee schedule,0.07,0.09,
Ketorolac tromethamine inj,J1885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.67,,,,,,,fee schedule,0.34,1.67,
Ketorolac tromethamine inj,J1885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.52,,,,,,,fee schedule,0.34,1.67,
Ketorolac tromethamine inj,J1885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,0.4,,,,,,,fee schedule,0.34,1.67,OP High Cost Drugs
Ketorolac tromethamine inj,J1885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,0.34,,,,,,,fee schedule,0.34,1.67,Other Pharmacy
Ketorolac tromethamine inj,J1885,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,0.36,,,,,,,fee schedule,0.34,1.67,APC
Ketorolac tromethamine inj,J1885,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,0.35,,,,,,,fee schedule,0.34,1.67,APC
Ketorolac tromethamine inj,J1885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,0.52,,,,,,,fee schedule,0.34,1.67,Radiology
Ketorolac tromethamine inj,J1885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,0.48,,,,,,,fee schedule,0.34,1.67,APC
Ketorolac tromethamine inj,J1885,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,0.6,,,,,,,fee schedule,0.34,1.67,APC
"Inj, labetalol hcl, 5mg",J1920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.64,,,,,,,fee schedule,0.39,0.69,
"Inj, labetalol hcl, 5mg",J1920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.69,,,,,,,fee schedule,0.39,0.69,
"Inj, labetalol hcl, 5mg",J1920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.43,,,,,,,fee schedule,0.39,0.69,
"Inj, labetalol hcl, 5mg",J1920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.55,,,,,,,fee schedule,0.39,0.69,
"Inj, labetalol hcl, 5mg",J1920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.61,,,,,,,fee schedule,0.39,0.69,
"Inj, labetalol hcl, 5mg",J1920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.39,,,,,,,fee schedule,0.39,0.69,
"Inj labetalol hcl hikma, 5mg",J1921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.47,,,,,,,fee schedule,0.6,10.29,
"Inj labetalol hcl hikma, 5mg",J1921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10.29,,,,,,,fee schedule,0.6,10.29,
"Inj labetalol hcl hikma, 5mg",J1921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.66,,,,,,,fee schedule,0.6,10.29,
"Inj labetalol hcl hikma, 5mg",J1921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.24,,,,,,,fee schedule,0.6,10.29,
"Inj labetalol hcl hikma, 5mg",J1921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.01,,,,,,,fee schedule,0.6,10.29,
"Inj labetalol hcl hikma, 5mg",J1921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.6,,,,,,,fee schedule,0.6,10.29,
Lanreotide injection,J1930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,93.44,,,,,,,fee schedule,35.72,152.28,
Lanreotide injection,J1930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,101.49,,,,,,,fee schedule,35.72,152.28,
Lanreotide injection,J1930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,152.28,,,,,,,fee schedule,35.72,152.28,
Lanreotide injection,J1930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,81.36,,,,,,,fee schedule,35.72,152.28,
Lanreotide injection,J1930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,88.87,,,,,,,fee schedule,35.72,152.28,
Lanreotide injection,J1930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,137.82,,,,,,,fee schedule,35.72,152.28,
Lanreotide injection,J1930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,41.44,,,,,,,fee schedule,35.72,152.28,OP High Cost Drugs
Lanreotide injection,J1930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,35.72,,,,,,,fee schedule,35.72,152.28,Other Pharmacy
Lanreotide injection,J1930,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,37.51,,,,,,,fee schedule,35.72,152.28,APC
Lanreotide injection,J1930,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,37.15,,,,,,,fee schedule,35.72,152.28,APC
Lanreotide injection,J1930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,54.65,,,,,,,fee schedule,35.72,152.28,Radiology
Lanreotide injection,J1930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,50.01,,,,,,,fee schedule,35.72,152.28,APC
Lanreotide injection,J1930,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,62.51,,,,,,,fee schedule,35.72,152.28,APC
Laronidase injection,J1931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,87,,,,,,,fee schedule,39.95,94.5,
Laronidase injection,J1931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,94.5,,,,,,,fee schedule,39.95,94.5,
Laronidase injection,J1931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,69.99,,,,,,,fee schedule,39.95,94.5,
Laronidase injection,J1931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,75.75,,,,,,,fee schedule,39.95,94.5,
Laronidase injection,J1931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,82.75,,,,,,,fee schedule,39.95,94.5,
Laronidase injection,J1931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,63.35,,,,,,,fee schedule,39.95,94.5,
Laronidase injection,J1931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,46.35,,,,,,,fee schedule,39.95,94.5,OP High Cost Drugs
Laronidase injection,J1931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,39.95,,,,,,,fee schedule,39.95,94.5,Other Pharmacy
Laronidase injection,J1931,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,41.95,,,,,,,fee schedule,39.95,94.5,APC
Laronidase injection,J1931,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,41.55,,,,,,,fee schedule,39.95,94.5,APC
Laronidase injection,J1931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,61.13,,,,,,,fee schedule,39.95,94.5,Radiology
Laronidase injection,J1931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,55.94,,,,,,,fee schedule,39.95,94.5,APC
Laronidase injection,J1931,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,69.92,,,,,,,fee schedule,39.95,94.5,APC
"Inj, lanreotide, (cipla) 1mg",J1932,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,211.9,,,,,,,fee schedule,32.19,230.16,
"Inj, lanreotide, (cipla) 1mg",J1932,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,230.16,,,,,,,fee schedule,32.19,230.16,
"Inj, lanreotide, (cipla) 1mg",J1932,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,141.63,,,,,,,fee schedule,32.19,230.16,
"Inj, lanreotide, (cipla) 1mg",J1932,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,184.5,,,,,,,fee schedule,32.19,230.16,
"Inj, lanreotide, (cipla) 1mg",J1932,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,201.55,,,,,,,fee schedule,32.19,230.16,
"Inj, lanreotide, (cipla) 1mg",J1932,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,128.19,,,,,,,fee schedule,32.19,230.16,
"Inj, lanreotide, (cipla) 1mg",J1932,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,37.34,,,,,,,fee schedule,32.19,230.16,OP High Cost Drugs
"Inj, lanreotide, (cipla) 1mg",J1932,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,32.19,,,,,,,fee schedule,32.19,230.16,Other Pharmacy
"Inj, lanreotide, (cipla) 1mg",J1932,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,33.8,,,,,,,fee schedule,32.19,230.16,APC
"Inj, lanreotide, (cipla) 1mg",J1932,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,33.48,,,,,,,fee schedule,32.19,230.16,APC
"Inj, lanreotide, (cipla) 1mg",J1932,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49.25,,,,,,,fee schedule,32.19,230.16,Radiology
"Inj, lanreotide, (cipla) 1mg",J1932,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,45.07,,,,,,,fee schedule,32.19,230.16,APC
"Inj, lanreotide, (cipla) 1mg",J1932,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,56.33,,,,,,,fee schedule,32.19,230.16,APC
"Inj, bumetanide, 0.5 mg",J1939,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.16,,,,,,,fee schedule,1.96,2.16,
"Inj, bumetanide, 0.5 mg",J1939,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.96,,,,,,,fee schedule,1.96,2.16,
Furosemide injection,J1940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.9,,,,,,,fee schedule,1.72,1.9,
Furosemide injection,J1940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.72,,,,,,,fee schedule,1.72,1.9,
"Inj, furoscix, 20 mg",J1941,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,449.08,,,,,,,fee schedule,406.45,449.08,
"Inj, furoscix, 20 mg",J1941,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,406.45,,,,,,,fee schedule,406.45,449.08,
"Inj., aristada initio, 1 mg",J1943,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.94,,,,,,,fee schedule,3.25,10.8,
"Inj., aristada initio, 1 mg",J1943,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10.8,,,,,,,fee schedule,3.25,10.8,
"Inj., aristada initio, 1 mg",J1943,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.73,,,,,,,fee schedule,3.25,10.8,
"Inj., aristada initio, 1 mg",J1943,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.65,,,,,,,fee schedule,3.25,10.8,
"Inj., aristada initio, 1 mg",J1943,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.45,,,,,,,fee schedule,3.25,10.8,
"Inj., aristada initio, 1 mg",J1943,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.09,,,,,,,fee schedule,3.25,10.8,
"Inj., aristada initio, 1 mg",J1943,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3.77,,,,,,,fee schedule,3.25,10.8,OP High Cost Drugs
"Inj., aristada initio, 1 mg",J1943,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3.25,,,,,,,fee schedule,3.25,10.8,Other Pharmacy
"Inj., aristada initio, 1 mg",J1943,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3.41,,,,,,,fee schedule,3.25,10.8,APC
"Inj., aristada initio, 1 mg",J1943,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3.38,,,,,,,fee schedule,3.25,10.8,APC
"Inj., aristada initio, 1 mg",J1943,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4.97,,,,,,,fee schedule,3.25,10.8,Radiology
"Inj., aristada initio, 1 mg",J1943,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4.55,,,,,,,fee schedule,3.25,10.8,APC
"Inj., aristada initio, 1 mg",J1943,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5.69,,,,,,,fee schedule,3.25,10.8,APC
Aripirazole lauroxil 1 mg,J1944,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.67,,,,,,,fee schedule,3.32,10.5,
Aripirazole lauroxil 1 mg,J1944,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10.5,,,,,,,fee schedule,3.32,10.5,
Aripirazole lauroxil 1 mg,J1944,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.59,,,,,,,fee schedule,3.32,10.5,
Aripirazole lauroxil 1 mg,J1944,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.42,,,,,,,fee schedule,3.32,10.5,
Aripirazole lauroxil 1 mg,J1944,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.2,,,,,,,fee schedule,3.32,10.5,
Aripirazole lauroxil 1 mg,J1944,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.96,,,,,,,fee schedule,3.32,10.5,
Aripirazole lauroxil 1 mg,J1944,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3.85,,,,,,,fee schedule,3.32,10.5,OP High Cost Drugs
Aripirazole lauroxil 1 mg,J1944,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3.32,,,,,,,fee schedule,3.32,10.5,Other Pharmacy
Aripirazole lauroxil 1 mg,J1944,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3.48,,,,,,,fee schedule,3.32,10.5,APC
Aripirazole lauroxil 1 mg,J1944,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3.45,,,,,,,fee schedule,3.32,10.5,APC
Aripirazole lauroxil 1 mg,J1944,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.07,,,,,,,fee schedule,3.32,10.5,Radiology
Aripirazole lauroxil 1 mg,J1944,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4.64,,,,,,,fee schedule,3.32,10.5,APC
Aripirazole lauroxil 1 mg,J1944,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5.8,,,,,,,fee schedule,3.32,10.5,APC
Lepirudin,J1945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,631.24,,,,,,,fee schedule,549.61,685.65,
Lepirudin,J1945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,685.65,,,,,,,fee schedule,549.61,685.65,
Lepirudin,J1945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,549.61,,,,,,,fee schedule,549.61,685.65,
Lepirudin,J1945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,600.4,,,,,,,fee schedule,549.61,685.65,
Leuprolide acetate /3.75 mg,J1950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1586.91,,,,,,,fee schedule,1381.71,3089.75,
Leuprolide acetate /3.75 mg,J1950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1723.72,,,,,,,fee schedule,1381.71,3089.75,
Leuprolide acetate /3.75 mg,J1950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2933.76,,,,,,,fee schedule,1381.71,3089.75,
Leuprolide acetate /3.75 mg,J1950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1381.71,,,,,,,fee schedule,1381.71,3089.75,
Leuprolide acetate /3.75 mg,J1950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1509.39,,,,,,,fee schedule,1381.71,3089.75,
Leuprolide acetate /3.75 mg,J1950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2655.24,,,,,,,fee schedule,1381.71,3089.75,
Leuprolide acetate /3.75 mg,J1950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2048.07,,,,,,,fee schedule,1381.71,3089.75,OP High Cost Drugs
Leuprolide acetate /3.75 mg,J1950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1765.57,,,,,,,fee schedule,1381.71,3089.75,Other Pharmacy
Leuprolide acetate /3.75 mg,J1950,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1853.85,,,,,,,fee schedule,1381.71,3089.75,APC
Leuprolide acetate /3.75 mg,J1950,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1836.2,,,,,,,fee schedule,1381.71,3089.75,APC
Leuprolide acetate /3.75 mg,J1950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2701.33,,,,,,,fee schedule,1381.71,3089.75,Radiology
Leuprolide acetate /3.75 mg,J1950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2471.8,,,,,,,fee schedule,1381.71,3089.75,APC
Leuprolide acetate /3.75 mg,J1950,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3089.75,,,,,,,fee schedule,1381.71,3089.75,APC
Inj fensolvi 0.25 mg,J1951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,442.12,,,,,,,fee schedule,140.71,480.23,
Inj fensolvi 0.25 mg,J1951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,480.23,,,,,,,fee schedule,140.71,480.23,
Inj fensolvi 0.25 mg,J1951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,277.51,,,,,,,fee schedule,140.71,480.23,
Inj fensolvi 0.25 mg,J1951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,384.95,,,,,,,fee schedule,140.71,480.23,
Inj fensolvi 0.25 mg,J1951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,420.52,,,,,,,fee schedule,140.71,480.23,
Inj fensolvi 0.25 mg,J1951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,251.17,,,,,,,fee schedule,140.71,480.23,
Inj fensolvi 0.25 mg,J1951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,163.22,,,,,,,fee schedule,140.71,480.23,OP High Cost Drugs
Inj fensolvi 0.25 mg,J1951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,140.71,,,,,,,fee schedule,140.71,480.23,Other Pharmacy
Inj fensolvi 0.25 mg,J1951,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,147.74,,,,,,,fee schedule,140.71,480.23,APC
Inj fensolvi 0.25 mg,J1951,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,146.34,,,,,,,fee schedule,140.71,480.23,APC
Inj fensolvi 0.25 mg,J1951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,215.28,,,,,,,fee schedule,140.71,480.23,Radiology
Inj fensolvi 0.25 mg,J1951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,196.99,,,,,,,fee schedule,140.71,480.23,APC
Inj fensolvi 0.25 mg,J1951,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,246.24,,,,,,,fee schedule,140.71,480.23,APC
"Leuprolide inj, camcevi, 1mg",J1952,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,332.83,,,,,,,fee schedule,39.95,361.52,
"Leuprolide inj, camcevi, 1mg",J1952,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,361.52,,,,,,,fee schedule,39.95,361.52,
"Leuprolide inj, camcevi, 1mg",J1952,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,192.68,,,,,,,fee schedule,39.95,361.52,
"Leuprolide inj, camcevi, 1mg",J1952,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,289.79,,,,,,,fee schedule,39.95,361.52,
"Leuprolide inj, camcevi, 1mg",J1952,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,316.57,,,,,,,fee schedule,39.95,361.52,
"Leuprolide inj, camcevi, 1mg",J1952,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,174.39,,,,,,,fee schedule,39.95,361.52,
"Leuprolide inj, camcevi, 1mg",J1952,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,46.34,,,,,,,fee schedule,39.95,361.52,OP High Cost Drugs
"Leuprolide inj, camcevi, 1mg",J1952,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,39.95,,,,,,,fee schedule,39.95,361.52,Other Pharmacy
"Leuprolide inj, camcevi, 1mg",J1952,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,41.94,,,,,,,fee schedule,39.95,361.52,APC
"Leuprolide inj, camcevi, 1mg",J1952,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,41.54,,,,,,,fee schedule,39.95,361.52,APC
"Leuprolide inj, camcevi, 1mg",J1952,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,61.12,,,,,,,fee schedule,39.95,361.52,Radiology
"Leuprolide inj, camcevi, 1mg",J1952,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,55.93,,,,,,,fee schedule,39.95,361.52,APC
"Leuprolide inj, camcevi, 1mg",J1952,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,69.91,,,,,,,fee schedule,39.95,361.52,APC
Levetiracetam injection,J1953,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.5,,,,,,,fee schedule,0.29,1.63,
Levetiracetam injection,J1953,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.63,,,,,,,fee schedule,0.29,1.63,
Levetiracetam injection,J1953,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.32,,,,,,,fee schedule,0.29,1.63,
Levetiracetam injection,J1953,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.3,,,,,,,fee schedule,0.29,1.63,
Levetiracetam injection,J1953,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.42,,,,,,,fee schedule,0.29,1.63,
Levetiracetam injection,J1953,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.29,,,,,,,fee schedule,0.29,1.63,
Leuprolide depot cipla 7.5mg,J1954,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1259.94,,,,,,,fee schedule,693.56,1368.56,
Leuprolide depot cipla 7.5mg,J1954,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1368.56,,,,,,,fee schedule,693.56,1368.56,
Leuprolide depot cipla 7.5mg,J1954,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,856.31,,,,,,,fee schedule,693.56,1368.56,
Leuprolide depot cipla 7.5mg,J1954,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1097.02,,,,,,,fee schedule,693.56,1368.56,
Leuprolide depot cipla 7.5mg,J1954,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1198.4,,,,,,,fee schedule,693.56,1368.56,
Leuprolide depot cipla 7.5mg,J1954,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,775.02,,,,,,,fee schedule,693.56,1368.56,
Leuprolide depot cipla 7.5mg,J1954,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,804.53,,,,,,,fee schedule,693.56,1368.56,OP High Cost Drugs
Leuprolide depot cipla 7.5mg,J1954,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,693.56,,,,,,,fee schedule,693.56,1368.56,Other Pharmacy
Leuprolide depot cipla 7.5mg,J1954,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,728.23,,,,,,,fee schedule,693.56,1368.56,APC
Leuprolide depot cipla 7.5mg,J1954,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,721.3,,,,,,,fee schedule,693.56,1368.56,APC
Leuprolide depot cipla 7.5mg,J1954,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1061.14,,,,,,,fee schedule,693.56,1368.56,Radiology
Leuprolide depot cipla 7.5mg,J1954,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,970.98,,,,,,,fee schedule,693.56,1368.56,APC
Leuprolide depot cipla 7.5mg,J1954,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1213.72,,,,,,,fee schedule,693.56,1368.56,APC
Inj levocarnitine per 1 gm,J1955,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23.35,,,,,,,fee schedule,20.33,67.62,
Inj levocarnitine per 1 gm,J1955,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,25.36,,,,,,,fee schedule,20.33,67.62,
Inj levocarnitine per 1 gm,J1955,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,67.62,,,,,,,fee schedule,20.33,67.62,
Inj levocarnitine per 1 gm,J1955,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20.33,,,,,,,fee schedule,20.33,67.62,
Inj levocarnitine per 1 gm,J1955,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22.21,,,,,,,fee schedule,20.33,67.62,
Inj levocarnitine per 1 gm,J1955,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,61.2,,,,,,,fee schedule,20.33,67.62,
Levofloxacin injection,J1956,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.88,,,,,,,fee schedule,8.94,9.88,
Levofloxacin injection,J1956,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.94,,,,,,,fee schedule,8.94,9.88,
"Inj, lenacapavir, 1 mg",J1961,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,75.84,,,,,,,fee schedule,22.3,82.38,
"Inj, lenacapavir, 1 mg",J1961,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,82.38,,,,,,,fee schedule,22.3,82.38,
"Inj, lenacapavir, 1 mg",J1961,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,39.44,,,,,,,fee schedule,22.3,82.38,
"Inj, lenacapavir, 1 mg",J1961,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66.03,,,,,,,fee schedule,22.3,82.38,
"Inj, lenacapavir, 1 mg",J1961,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,72.13,,,,,,,fee schedule,22.3,82.38,
"Inj, lenacapavir, 1 mg",J1961,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35.69,,,,,,,fee schedule,22.3,82.38,
"Inj, lenacapavir, 1 mg",J1961,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,25.87,,,,,,,fee schedule,22.3,82.38,OP High Cost Drugs
"Inj, lenacapavir, 1 mg",J1961,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.3,,,,,,,fee schedule,22.3,82.38,Other Pharmacy
"Inj, lenacapavir, 1 mg",J1961,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,23.41,,,,,,,fee schedule,22.3,82.38,APC
"Inj, lenacapavir, 1 mg",J1961,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,23.19,,,,,,,fee schedule,22.3,82.38,APC
"Inj, lenacapavir, 1 mg",J1961,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,34.12,,,,,,,fee schedule,22.3,82.38,Radiology
"Inj, lenacapavir, 1 mg",J1961,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,31.22,,,,,,,fee schedule,22.3,82.38,APC
"Inj, lenacapavir, 1 mg",J1961,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,39.02,,,,,,,fee schedule,22.3,82.38,APC
Lidocaine injection,J2001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.36,,,,,,,fee schedule,0.33,0.36,
Lidocaine injection,J2001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.33,,,,,,,fee schedule,0.33,0.36,
"Inj, lidocaine in d5w, 1 mg",J2002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.02,,,,,,,fee schedule,0.01,0.02,
"Inj, lidocaine in d5w, 1 mg",J2002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.01,,,,,,,fee schedule,0.01,0.02,
"Inj, lidocaine hcl, 1 mg",J2003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.06,,,,,,,fee schedule,0.06,0.06,
"Inj, lidocaine hcl, 1 mg",J2003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.06,,,,,,,fee schedule,0.06,0.06,
"Inj, lidocaine w epinephrine",J2004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.05,,,,,,,fee schedule,0.04,0.05,
"Inj, lidocaine w epinephrine",J2004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.04,,,,,,,fee schedule,0.04,0.05,
Lincomycin injection,J2010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21.55,,,,,,,fee schedule,19.51,21.55,
Lincomycin injection,J2010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19.51,,,,,,,fee schedule,19.51,21.55,
Linezolid injection,J2020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,102.63,,,,,,,fee schedule,37.24,111.47,
Linezolid injection,J2020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,111.47,,,,,,,fee schedule,37.24,111.47,
Linezolid injection,J2020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41.14,,,,,,,fee schedule,37.24,111.47,
Linezolid injection,J2020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,89.35,,,,,,,fee schedule,37.24,111.47,
Linezolid injection,J2020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,97.61,,,,,,,fee schedule,37.24,111.47,
Linezolid injection,J2020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37.24,,,,,,,fee schedule,37.24,111.47,
"Inj, linezolid (hospira)",J2021,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,44.1,,,,,,,fee schedule,39.91,44.1,
"Inj, linezolid (hospira)",J2021,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39.91,,,,,,,fee schedule,39.91,44.1,
Lorazepam injection,J2060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.45,,,,,,,fee schedule,2.22,2.45,
Lorazepam injection,J2060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.22,,,,,,,fee schedule,2.22,2.45,
Loxapine for inhalation 1 mg,J2062,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,524.79,,,,,,,fee schedule,25.74,570.03,
Loxapine for inhalation 1 mg,J2062,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,570.03,,,,,,,fee schedule,25.74,570.03,
Loxapine for inhalation 1 mg,J2062,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,28.44,,,,,,,fee schedule,25.74,570.03,
Loxapine for inhalation 1 mg,J2062,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,456.93,,,,,,,fee schedule,25.74,570.03,
Loxapine for inhalation 1 mg,J2062,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,499.15,,,,,,,fee schedule,25.74,570.03,
Loxapine for inhalation 1 mg,J2062,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,25.74,,,,,,,fee schedule,25.74,570.03,
Mannitol injection,J2150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8.53,,,,,,,fee schedule,7.72,8.53,
Mannitol injection,J2150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7.72,,,,,,,fee schedule,7.72,8.53,
Mecasermin injection,J2170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,64.8,,,,,,,fee schedule,56.42,266.81,
Mecasermin injection,J2170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,70.38,,,,,,,fee schedule,56.42,266.81,
Mecasermin injection,J2170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,266.81,,,,,,,fee schedule,56.42,266.81,
Mecasermin injection,J2170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56.42,,,,,,,fee schedule,56.42,266.81,
Mecasermin injection,J2170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,61.63,,,,,,,fee schedule,56.42,266.81,
Mecasermin injection,J2170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,241.48,,,,,,,fee schedule,56.42,266.81,
Meperidine hydrochl /100 MG,J2175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15.96,,,,,,,fee schedule,14.44,15.96,
Meperidine hydrochl /100 MG,J2175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14.44,,,,,,,fee schedule,14.44,15.96,
"Injection, mepolizumab, 1mg",J2182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,92.81,,,,,,,fee schedule,31.82,100.81,
"Injection, mepolizumab, 1mg",J2182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,100.81,,,,,,,fee schedule,31.82,100.81,
"Injection, mepolizumab, 1mg",J2182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,69.95,,,,,,,fee schedule,31.82,100.81,
"Injection, mepolizumab, 1mg",J2182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,80.81,,,,,,,fee schedule,31.82,100.81,
"Injection, mepolizumab, 1mg",J2182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,88.28,,,,,,,fee schedule,31.82,100.81,
"Injection, mepolizumab, 1mg",J2182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,63.31,,,,,,,fee schedule,31.82,100.81,
"Injection, mepolizumab, 1mg",J2182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.91,,,,,,,fee schedule,31.82,100.81,OP High Cost Drugs
"Injection, mepolizumab, 1mg",J2182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,31.82,,,,,,,fee schedule,31.82,100.81,Other Pharmacy
"Injection, mepolizumab, 1mg",J2182,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,33.41,,,,,,,fee schedule,31.82,100.81,APC
"Injection, mepolizumab, 1mg",J2182,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,33.1,,,,,,,fee schedule,31.82,100.81,APC
"Injection, mepolizumab, 1mg",J2182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,48.69,,,,,,,fee schedule,31.82,100.81,Radiology
"Injection, mepolizumab, 1mg",J2182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,44.55,,,,,,,fee schedule,31.82,100.81,APC
"Injection, mepolizumab, 1mg",J2182,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,55.69,,,,,,,fee schedule,31.82,100.81,APC
Inj meropenem (wg crit care),J2183,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.11,,,,,,,fee schedule,2.82,3.11,
Inj meropenem (wg crit care),J2183,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.82,,,,,,,fee schedule,2.82,3.11,
"Inj, meropenem (b. braun)",J2184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.72,,,,,,,fee schedule,6.08,6.72,
"Inj, meropenem (b. braun)",J2184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.08,,,,,,,fee schedule,6.08,6.72,
Meropenem,J2185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.28,,,,,,,fee schedule,2.06,2.28,
Meropenem,J2185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.06,,,,,,,fee schedule,2.06,2.28,
"Inj., meropenem, vaborbactam",J2186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.22,,,,,,,fee schedule,2.17,9.64,
"Inj., meropenem, vaborbactam",J2186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.76,,,,,,,fee schedule,2.17,9.64,
"Inj., meropenem, vaborbactam",J2186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.09,,,,,,,fee schedule,2.17,9.64,
"Inj., meropenem, vaborbactam",J2186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.42,,,,,,,fee schedule,2.17,9.64,
"Inj., meropenem, vaborbactam",J2186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.92,,,,,,,fee schedule,2.17,9.64,
"Inj., meropenem, vaborbactam",J2186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.7,,,,,,,fee schedule,2.17,9.64,
"Inj., meropenem, vaborbactam",J2186,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.64,,,,,,,fee schedule,2.17,9.64,APC 378
"Inj., meropenem, vaborbactam",J2186,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2.28,,,,,,,fee schedule,2.17,9.64,APC
"Inj., meropenem, vaborbactam",J2186,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2.26,,,,,,,fee schedule,2.17,9.64,APC
"Inj., meropenem, vaborbactam",J2186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2.17,,,,,,,fee schedule,2.17,9.64,APC
"Inj., meropenem, vaborbactam",J2186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3.32,,,,,,,fee schedule,2.17,9.64,Radiology
"Inj., meropenem, vaborbactam",J2186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3.04,,,,,,,fee schedule,2.17,9.64,APC
"Inj., meropenem, vaborbactam",J2186,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3.8,,,,,,,fee schedule,2.17,9.64,APC
Methylergonovin maleate inj,J2210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,56.74,,,,,,,fee schedule,51.35,56.74,
Methylergonovin maleate inj,J2210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.35,,,,,,,fee schedule,51.35,56.74,
Methylnaltrexone injection,J2212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.39,,,,,,,fee schedule,1.21,2.53,
Methylnaltrexone injection,J2212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.51,,,,,,,fee schedule,1.21,2.53,
Methylnaltrexone injection,J2212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.53,,,,,,,fee schedule,1.21,2.53,
Methylnaltrexone injection,J2212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.21,,,,,,,fee schedule,1.21,2.53,
Methylnaltrexone injection,J2212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.32,,,,,,,fee schedule,1.21,2.53,
Methylnaltrexone injection,J2212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.29,,,,,,,fee schedule,1.21,2.53,
"Inj, micafungin (baxter)",J2246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.71,,,,,,,fee schedule,1.54,1.71,
"Inj, micafungin (baxter)",J2246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.54,,,,,,,fee schedule,1.54,1.71,
"Inj, micafungin (par pharm)",J2247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.84,,,,,,,fee schedule,2.57,2.84,
"Inj, micafungin (par pharm)",J2247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.57,,,,,,,fee schedule,2.57,2.84,
Micafungin sodium injection,J2248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.52,,,,,,,fee schedule,3.2,4.91,
Micafungin sodium injection,J2248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.91,,,,,,,fee schedule,3.2,4.91,
Micafungin sodium injection,J2248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.54,,,,,,,fee schedule,3.2,4.91,
Micafungin sodium injection,J2248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.94,,,,,,,fee schedule,3.2,4.91,
Micafungin sodium injection,J2248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.3,,,,,,,fee schedule,3.2,4.91,
Micafungin sodium injection,J2248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.2,,,,,,,fee schedule,3.2,4.91,
"Inj, remimazolam, 1 mg",J2249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.92,,,,,,,fee schedule,3.55,3.92,
"Inj, remimazolam, 1 mg",J2249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.55,,,,,,,fee schedule,3.55,3.92,
Inj midazolam hydrochloride,J2250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.57,,,,,,,fee schedule,0.51,0.57,
Inj midazolam hydrochloride,J2250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.51,,,,,,,fee schedule,0.51,0.57,
Inj midazolam (wg crit care),J2251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.7,,,,,,,fee schedule,0.63,0.7,
Inj midazolam (wg crit care),J2251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.63,,,,,,,fee schedule,0.63,0.7,
Inj midazolam in 0.8% nacl,J2252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.13,,,,,,,fee schedule,0.11,0.13,
Inj midazolam in 0.8% nacl,J2252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.11,,,,,,,fee schedule,0.11,0.13,
Inj milrinone lactate / 5 mg,J2260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8.77,,,,,,,fee schedule,4.73,9.53,
Inj milrinone lactate / 5 mg,J2260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.53,,,,,,,fee schedule,4.73,9.53,
Inj milrinone lactate / 5 mg,J2260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.23,,,,,,,fee schedule,4.73,9.53,
Inj milrinone lactate / 5 mg,J2260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7.64,,,,,,,fee schedule,4.73,9.53,
Inj milrinone lactate / 5 mg,J2260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.34,,,,,,,fee schedule,4.73,9.53,
Inj milrinone lactate / 5 mg,J2260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.73,,,,,,,fee schedule,4.73,9.53,
Minocycline hydrochloride,J2265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.02,,,,,,,fee schedule,1.76,11.82,
Minocycline hydrochloride,J2265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.19,,,,,,,fee schedule,1.76,11.82,
Minocycline hydrochloride,J2265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.76,,,,,,,fee schedule,1.76,11.82,
Minocycline hydrochloride,J2265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.76,,,,,,,fee schedule,1.76,11.82,
Minocycline hydrochloride,J2265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.92,,,,,,,fee schedule,1.76,11.82,
Minocycline hydrochloride,J2265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.3,,,,,,,fee schedule,1.76,11.82,
Minocycline hydrochloride,J2265,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11.82,,,,,,,fee schedule,1.76,11.82,APC 378
Minocycline hydrochloride,J2265,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2.8,,,,,,,fee schedule,1.76,11.82,APC
Minocycline hydrochloride,J2265,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2.77,,,,,,,fee schedule,1.76,11.82,APC
Minocycline hydrochloride,J2265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2.66,,,,,,,fee schedule,1.76,11.82,APC
Minocycline hydrochloride,J2265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4.08,,,,,,,fee schedule,1.76,11.82,Radiology
Minocycline hydrochloride,J2265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3.73,,,,,,,fee schedule,1.76,11.82,APC
Minocycline hydrochloride,J2265,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4.66,,,,,,,fee schedule,1.76,11.82,APC
"Inj, mirikizumab-mrkz, 1 mg",J2267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,98.21,,,,,,,fee schedule,42.09,98.21,
"Inj, mirikizumab-mrkz, 1 mg",J2267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,88.89,,,,,,,fee schedule,42.09,98.21,
"Inj, mirikizumab-mrkz, 1 mg",J2267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,48.83,,,,,,,fee schedule,42.09,98.21,OP High Cost Drugs
"Inj, mirikizumab-mrkz, 1 mg",J2267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,42.09,,,,,,,fee schedule,42.09,98.21,Other Pharmacy
"Inj, mirikizumab-mrkz, 1 mg",J2267,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,44.2,,,,,,,fee schedule,42.09,98.21,APC
"Inj, mirikizumab-mrkz, 1 mg",J2267,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,43.78,,,,,,,fee schedule,42.09,98.21,APC
"Inj, mirikizumab-mrkz, 1 mg",J2267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,64.4,,,,,,,fee schedule,42.09,98.21,Radiology
"Inj, mirikizumab-mrkz, 1 mg",J2267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,58.93,,,,,,,fee schedule,42.09,98.21,APC
"Inj, mirikizumab-mrkz, 1 mg",J2267,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,73.66,,,,,,,fee schedule,42.09,98.21,APC
Morphine sulfate injection,J2270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.23,,,,,,,fee schedule,8.35,9.23,
Morphine sulfate injection,J2270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.35,,,,,,,fee schedule,8.35,9.23,
"Inj, morphine (fresenius)",J2272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10.89,,,,,,,fee schedule,9.85,10.89,
"Inj, morphine (fresenius)",J2272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.85,,,,,,,fee schedule,9.85,10.89,
In morphine preservativ free,J2274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,32.29,,,,,,,fee schedule,17.85,35.08,
In morphine preservativ free,J2274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,35.08,,,,,,,fee schedule,17.85,35.08,
In morphine preservativ free,J2274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19.72,,,,,,,fee schedule,17.85,35.08,
In morphine preservativ free,J2274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28.12,,,,,,,fee schedule,17.85,35.08,
In morphine preservativ free,J2274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,30.72,,,,,,,fee schedule,17.85,35.08,
In morphine preservativ free,J2274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17.85,,,,,,,fee schedule,17.85,35.08,
"Inj, motixafortide, 0.25 mg",J2277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,44.75,,,,,,,fee schedule,26.48,46.34,
"Inj, motixafortide, 0.25 mg",J2277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40.5,,,,,,,fee schedule,26.48,46.34,
"Inj, motixafortide, 0.25 mg",J2277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,30.72,,,,,,,fee schedule,26.48,46.34,OP High Cost Drugs
"Inj, motixafortide, 0.25 mg",J2277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26.48,,,,,,,fee schedule,26.48,46.34,Other Pharmacy
"Inj, motixafortide, 0.25 mg",J2277,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,27.8,,,,,,,fee schedule,26.48,46.34,APC
"Inj, motixafortide, 0.25 mg",J2277,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,27.54,,,,,,,fee schedule,26.48,46.34,APC
"Inj, motixafortide, 0.25 mg",J2277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40.51,,,,,,,fee schedule,26.48,46.34,Radiology
"Inj, motixafortide, 0.25 mg",J2277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,37.07,,,,,,,fee schedule,26.48,46.34,APC
"Inj, motixafortide, 0.25 mg",J2277,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,46.34,,,,,,,fee schedule,26.48,46.34,APC
Ziconotide injection,J2278,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23.21,,,,,,,fee schedule,10.46,25.21,
Ziconotide injection,J2278,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,25.21,,,,,,,fee schedule,10.46,25.21,
Ziconotide injection,J2278,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20.03,,,,,,,fee schedule,10.46,25.21,
Ziconotide injection,J2278,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20.21,,,,,,,fee schedule,10.46,25.21,
Ziconotide injection,J2278,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22.08,,,,,,,fee schedule,10.46,25.21,
Ziconotide injection,J2278,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18.13,,,,,,,fee schedule,10.46,25.21,
Ziconotide injection,J2278,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.14,,,,,,,fee schedule,10.46,25.21,OP High Cost Drugs
Ziconotide injection,J2278,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10.46,,,,,,,fee schedule,10.46,25.21,Other Pharmacy
Ziconotide injection,J2278,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.99,,,,,,,fee schedule,10.46,25.21,APC
Ziconotide injection,J2278,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10.88,,,,,,,fee schedule,10.46,25.21,APC
Ziconotide injection,J2278,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.01,,,,,,,fee schedule,10.46,25.21,Radiology
Ziconotide injection,J2278,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.65,,,,,,,fee schedule,10.46,25.21,APC
Ziconotide injection,J2278,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18.31,,,,,,,fee schedule,10.46,25.21,APC
"Inj, moxifloxacin 100 mg",J2280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24.21,,,,,,,fee schedule,21.91,24.21,
"Inj, moxifloxacin 100 mg",J2280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21.91,,,,,,,fee schedule,21.91,24.21,
Inj moxifloxacin (fres kabi),J2281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21.79,,,,,,,fee schedule,19.72,21.79,
Inj moxifloxacin (fres kabi),J2281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19.72,,,,,,,fee schedule,19.72,21.79,
Inj nalbuphine hydrochloride,J2300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8.25,,,,,,,fee schedule,7.46,8.25,
Inj nalbuphine hydrochloride,J2300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7.46,,,,,,,fee schedule,7.46,8.25,
"Inj, nitroglycerin, 5 mg",J2305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.5,,,,,,,fee schedule,2.77,4.89,
"Inj, nitroglycerin, 5 mg",J2305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.89,,,,,,,fee schedule,2.77,4.89,
"Inj, nitroglycerin, 5 mg",J2305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.07,,,,,,,fee schedule,2.77,4.89,
"Inj, nitroglycerin, 5 mg",J2305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.92,,,,,,,fee schedule,2.77,4.89,
"Inj, nitroglycerin, 5 mg",J2305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.28,,,,,,,fee schedule,2.77,4.89,
"Inj, nitroglycerin, 5 mg",J2305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.77,,,,,,,fee schedule,2.77,4.89,
Inj naloxone hydrochloride,J2310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,44.08,,,,,,,fee schedule,39.9,44.08,
Inj naloxone hydrochloride,J2310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39.9,,,,,,,fee schedule,39.9,44.08,
"Inj, naloxone hcl (zimhi)",J2311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23.7,,,,,,,fee schedule,21.45,23.7,
"Inj, naloxone hcl (zimhi)",J2311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21.45,,,,,,,fee schedule,21.45,23.7,
"Naltrexone, depot form",J2315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.75,,,,,,,fee schedule,4.25,8.09,
"Naltrexone, depot form",J2315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7.33,,,,,,,fee schedule,4.25,8.09,
"Naltrexone, depot form",J2315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8.09,,,,,,,fee schedule,4.25,8.09,
"Naltrexone, depot form",J2315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.88,,,,,,,fee schedule,4.25,8.09,
"Naltrexone, depot form",J2315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.42,,,,,,,fee schedule,4.25,8.09,
"Naltrexone, depot form",J2315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7.32,,,,,,,fee schedule,4.25,8.09,
"Naltrexone, depot form",J2315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4.93,,,,,,,fee schedule,4.25,8.09,OP High Cost Drugs
"Naltrexone, depot form",J2315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4.25,,,,,,,fee schedule,4.25,8.09,Other Pharmacy
"Naltrexone, depot form",J2315,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.46,,,,,,,fee schedule,4.25,8.09,APC
"Naltrexone, depot form",J2315,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4.42,,,,,,,fee schedule,4.25,8.09,APC
"Naltrexone, depot form",J2315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.5,,,,,,,fee schedule,4.25,8.09,Radiology
"Naltrexone, depot form",J2315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.94,,,,,,,fee schedule,4.25,8.09,APC
"Naltrexone, depot form",J2315,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7.43,,,,,,,fee schedule,4.25,8.09,APC
Nandrolone decanoate 50 MG,J2320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,464.09,,,,,,,fee schedule,404.08,504.1,
Nandrolone decanoate 50 MG,J2320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,504.1,,,,,,,fee schedule,404.08,504.1,
Nandrolone decanoate 50 MG,J2320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,404.08,,,,,,,fee schedule,404.08,504.1,
Nandrolone decanoate 50 MG,J2320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,441.42,,,,,,,fee schedule,404.08,504.1,
Natalizumab injection,J2323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27.18,,,,,,,fee schedule,23.66,51.89,
Natalizumab injection,J2323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,29.52,,,,,,,fee schedule,23.66,51.89,
Natalizumab injection,J2323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,51.89,,,,,,,fee schedule,23.66,51.89,
Natalizumab injection,J2323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23.66,,,,,,,fee schedule,23.66,51.89,
Natalizumab injection,J2323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,25.85,,,,,,,fee schedule,23.66,51.89,
Natalizumab injection,J2323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.96,,,,,,,fee schedule,23.66,51.89,
Natalizumab injection,J2323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,28.21,,,,,,,fee schedule,23.66,51.89,OP High Cost Drugs
Natalizumab injection,J2323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24.32,,,,,,,fee schedule,23.66,51.89,Other Pharmacy
Natalizumab injection,J2323,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,25.54,,,,,,,fee schedule,23.66,51.89,APC
Natalizumab injection,J2323,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,25.29,,,,,,,fee schedule,23.66,51.89,APC
Natalizumab injection,J2323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,37.21,,,,,,,fee schedule,23.66,51.89,Radiology
Natalizumab injection,J2323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,34.05,,,,,,,fee schedule,23.66,51.89,APC
Natalizumab injection,J2323,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,42.56,,,,,,,fee schedule,23.66,51.89,APC
Nesiritide injection,J2325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,123.51,,,,,,,fee schedule,107.53,134.15,
Nesiritide injection,J2325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,134.15,,,,,,,fee schedule,107.53,134.15,
Nesiritide injection,J2325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,133.86,,,,,,,fee schedule,107.53,134.15,
Nesiritide injection,J2325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,107.53,,,,,,,fee schedule,107.53,134.15,
Nesiritide injection,J2325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,117.47,,,,,,,fee schedule,107.53,134.15,
Nesiritide injection,J2325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,121.15,,,,,,,fee schedule,107.53,134.15,
"Inj, nusinersen, 0.1mg",J2326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3834.52,,,,,,,fee schedule,1285.78,5704.58,
"Inj, nusinersen, 0.1mg",J2326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4165.08,,,,,,,fee schedule,1285.78,5704.58,
"Inj, nusinersen, 0.1mg",J2326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2245.99,,,,,,,fee schedule,1285.78,5704.58,
"Inj, nusinersen, 0.1mg",J2326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3338.68,,,,,,,fee schedule,1285.78,5704.58,
"Inj, nusinersen, 0.1mg",J2326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3647.2,,,,,,,fee schedule,1285.78,5704.58,
"Inj, nusinersen, 0.1mg",J2326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2032.76,,,,,,,fee schedule,1285.78,5704.58,
"Inj, nusinersen, 0.1mg",J2326,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5704.58,,,,,,,fee schedule,1285.78,5704.58,APC 378
"Inj, nusinersen, 0.1mg",J2326,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1350.07,,,,,,,fee schedule,1285.78,5704.58,APC
"Inj, nusinersen, 0.1mg",J2326,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1337.21,,,,,,,fee schedule,1285.78,5704.58,APC
"Inj, nusinersen, 0.1mg",J2326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1285.78,,,,,,,fee schedule,1285.78,5704.58,APC
"Inj, nusinersen, 0.1mg",J2326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1967.25,,,,,,,fee schedule,1285.78,5704.58,Radiology
"Inj, nusinersen, 0.1mg",J2326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1800.09,,,,,,,fee schedule,1285.78,5704.58,APC
"Inj, nusinersen, 0.1mg",J2326,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2250.12,,,,,,,fee schedule,1285.78,5704.58,APC
Inj risankizumab-rzaa 1 mg,J2327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55.02,,,,,,,fee schedule,14.6,222.5,
Inj risankizumab-rzaa 1 mg,J2327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59.76,,,,,,,fee schedule,14.6,222.5,
Inj risankizumab-rzaa 1 mg,J2327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,222.5,,,,,,,fee schedule,14.6,222.5,
Inj risankizumab-rzaa 1 mg,J2327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,47.9,,,,,,,fee schedule,14.6,222.5,
Inj risankizumab-rzaa 1 mg,J2327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52.33,,,,,,,fee schedule,14.6,222.5,
Inj risankizumab-rzaa 1 mg,J2327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,201.37,,,,,,,fee schedule,14.6,222.5,
Inj risankizumab-rzaa 1 mg,J2327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16.93,,,,,,,fee schedule,14.6,222.5,OP High Cost Drugs
Inj risankizumab-rzaa 1 mg,J2327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.6,,,,,,,fee schedule,14.6,222.5,Other Pharmacy
Inj risankizumab-rzaa 1 mg,J2327,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.33,,,,,,,fee schedule,14.6,222.5,APC
Inj risankizumab-rzaa 1 mg,J2327,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,15.18,,,,,,,fee schedule,14.6,222.5,APC
Inj risankizumab-rzaa 1 mg,J2327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.34,,,,,,,fee schedule,14.6,222.5,Radiology
Inj risankizumab-rzaa 1 mg,J2327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.44,,,,,,,fee schedule,14.6,222.5,APC
Inj risankizumab-rzaa 1 mg,J2327,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,25.55,,,,,,,fee schedule,14.6,222.5,APC
"Inj ublituximab-xiiy, 1 mg",J2329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,233.43,,,,,,,fee schedule,68.75,253.55,
"Inj ublituximab-xiiy, 1 mg",J2329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,253.55,,,,,,,fee schedule,68.75,253.55,
"Inj ublituximab-xiiy, 1 mg",J2329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,132.37,,,,,,,fee schedule,68.75,253.55,
"Inj ublituximab-xiiy, 1 mg",J2329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,203.25,,,,,,,fee schedule,68.75,253.55,
"Inj ublituximab-xiiy, 1 mg",J2329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,222.03,,,,,,,fee schedule,68.75,253.55,
"Inj ublituximab-xiiy, 1 mg",J2329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,119.81,,,,,,,fee schedule,68.75,253.55,
"Inj ublituximab-xiiy, 1 mg",J2329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,79.75,,,,,,,fee schedule,68.75,253.55,OP High Cost Drugs
"Inj ublituximab-xiiy, 1 mg",J2329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,68.75,,,,,,,fee schedule,68.75,253.55,Other Pharmacy
"Inj ublituximab-xiiy, 1 mg",J2329,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,72.18,,,,,,,fee schedule,68.75,253.55,APC
"Inj ublituximab-xiiy, 1 mg",J2329,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,71.5,,,,,,,fee schedule,68.75,253.55,APC
"Inj ublituximab-xiiy, 1 mg",J2329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,105.18,,,,,,,fee schedule,68.75,253.55,Radiology
"Inj ublituximab-xiiy, 1 mg",J2329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,96.25,,,,,,,fee schedule,68.75,253.55,APC
"Inj ublituximab-xiiy, 1 mg",J2329,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,120.31,,,,,,,fee schedule,68.75,253.55,APC
"Injection, ocrelizumab, 1 mg",J2350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,199.56,,,,,,,fee schedule,59.6,216.76,
"Injection, ocrelizumab, 1 mg",J2350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,216.76,,,,,,,fee schedule,59.6,216.76,
"Injection, ocrelizumab, 1 mg",J2350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,124.47,,,,,,,fee schedule,59.6,216.76,
"Injection, ocrelizumab, 1 mg",J2350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,173.75,,,,,,,fee schedule,59.6,216.76,
"Injection, ocrelizumab, 1 mg",J2350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,189.81,,,,,,,fee schedule,59.6,216.76,
"Injection, ocrelizumab, 1 mg",J2350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,112.66,,,,,,,fee schedule,59.6,216.76,
"Injection, ocrelizumab, 1 mg",J2350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,69.13,,,,,,,fee schedule,59.6,216.76,OP High Cost Drugs
"Injection, ocrelizumab, 1 mg",J2350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,59.6,,,,,,,fee schedule,59.6,216.76,Other Pharmacy
"Injection, ocrelizumab, 1 mg",J2350,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,62.58,,,,,,,fee schedule,59.6,216.76,APC
"Injection, ocrelizumab, 1 mg",J2350,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,61.98,,,,,,,fee schedule,59.6,216.76,APC
"Injection, ocrelizumab, 1 mg",J2350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,91.18,,,,,,,fee schedule,59.6,216.76,Radiology
"Injection, ocrelizumab, 1 mg",J2350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,83.43,,,,,,,fee schedule,59.6,216.76,APC
"Injection, ocrelizumab, 1 mg",J2350,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,104.29,,,,,,,fee schedule,59.6,216.76,APC
"Octreotide injection, depot",J2353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,371.11,,,,,,,fee schedule,188.35,437.63,
"Octreotide injection, depot",J2353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,403.1,,,,,,,fee schedule,188.35,437.63,
"Octreotide injection, depot",J2353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,437.63,,,,,,,fee schedule,188.35,437.63,
"Octreotide injection, depot",J2353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,323.12,,,,,,,fee schedule,188.35,437.63,
"Octreotide injection, depot",J2353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,352.98,,,,,,,fee schedule,188.35,437.63,
"Octreotide injection, depot",J2353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,396.08,,,,,,,fee schedule,188.35,437.63,
"Octreotide injection, depot",J2353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,218.49,,,,,,,fee schedule,188.35,437.63,OP High Cost Drugs
"Octreotide injection, depot",J2353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.35,,,,,,,fee schedule,188.35,437.63,Other Pharmacy
"Octreotide injection, depot",J2353,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,197.77,,,,,,,fee schedule,188.35,437.63,APC
"Octreotide injection, depot",J2353,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,195.88,,,,,,,fee schedule,188.35,437.63,APC
"Octreotide injection, depot",J2353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,288.18,,,,,,,fee schedule,188.35,437.63,Radiology
"Octreotide injection, depot",J2353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,263.69,,,,,,,fee schedule,188.35,437.63,APC
"Octreotide injection, depot",J2353,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,329.61,,,,,,,fee schedule,188.35,437.63,APC
"Octreotide inj, non-depot",J2354,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.76,,,,,,,fee schedule,4.3,4.76,
"Octreotide inj, non-depot",J2354,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.3,,,,,,,fee schedule,4.3,4.76,
Oprelvekin injection,J2355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,881.38,,,,,,,fee schedule,691.12,957.36,
Oprelvekin injection,J2355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,957.36,,,,,,,fee schedule,691.12,957.36,
Oprelvekin injection,J2355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,763.61,,,,,,,fee schedule,691.12,957.36,
Oprelvekin injection,J2355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,767.41,,,,,,,fee schedule,691.12,957.36,
Oprelvekin injection,J2355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,838.32,,,,,,,fee schedule,691.12,957.36,
Oprelvekin injection,J2355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,691.12,,,,,,,fee schedule,691.12,957.36,
"Inj tezepelumab-ekko, 1mg",J2356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,62.01,,,,,,,fee schedule,17.58,67.36,
"Inj tezepelumab-ekko, 1mg",J2356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,67.36,,,,,,,fee schedule,17.58,67.36,
"Inj tezepelumab-ekko, 1mg",J2356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,38.9,,,,,,,fee schedule,17.58,67.36,
"Inj tezepelumab-ekko, 1mg",J2356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.99,,,,,,,fee schedule,17.58,67.36,
"Inj tezepelumab-ekko, 1mg",J2356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,58.98,,,,,,,fee schedule,17.58,67.36,
"Inj tezepelumab-ekko, 1mg",J2356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35.21,,,,,,,fee schedule,17.58,67.36,
"Inj tezepelumab-ekko, 1mg",J2356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,20.4,,,,,,,fee schedule,17.58,67.36,OP High Cost Drugs
"Inj tezepelumab-ekko, 1mg",J2356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.58,,,,,,,fee schedule,17.58,67.36,Other Pharmacy
"Inj tezepelumab-ekko, 1mg",J2356,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.46,,,,,,,fee schedule,17.58,67.36,APC
"Inj tezepelumab-ekko, 1mg",J2356,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18.29,,,,,,,fee schedule,17.58,67.36,APC
"Inj tezepelumab-ekko, 1mg",J2356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26.9,,,,,,,fee schedule,17.58,67.36,Radiology
"Inj tezepelumab-ekko, 1mg",J2356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24.62,,,,,,,fee schedule,17.58,67.36,APC
"Inj tezepelumab-ekko, 1mg",J2356,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30.77,,,,,,,fee schedule,17.58,67.36,APC
Omalizumab injection,J2357,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,64.8,,,,,,,fee schedule,41.82,87.44,
Omalizumab injection,J2357,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,70.38,,,,,,,fee schedule,41.82,87.44,
Omalizumab injection,J2357,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,87.44,,,,,,,fee schedule,41.82,87.44,
Omalizumab injection,J2357,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56.42,,,,,,,fee schedule,41.82,87.44,
Omalizumab injection,J2357,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,61.63,,,,,,,fee schedule,41.82,87.44,
Omalizumab injection,J2357,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,79.14,,,,,,,fee schedule,41.82,87.44,
Omalizumab injection,J2357,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,48.51,,,,,,,fee schedule,41.82,87.44,OP High Cost Drugs
Omalizumab injection,J2357,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,41.82,,,,,,,fee schedule,41.82,87.44,Other Pharmacy
Omalizumab injection,J2357,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,43.91,,,,,,,fee schedule,41.82,87.44,APC
Omalizumab injection,J2357,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,43.5,,,,,,,fee schedule,41.82,87.44,APC
Omalizumab injection,J2357,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,63.99,,,,,,,fee schedule,41.82,87.44,Radiology
Omalizumab injection,J2357,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,58.55,,,,,,,fee schedule,41.82,87.44,APC
Omalizumab injection,J2357,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,73.19,,,,,,,fee schedule,41.82,87.44,APC
Olanzapine long-acting inj,J2358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.57,,,,,,,fee schedule,4.86,10.4,
Olanzapine long-acting inj,J2358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10.4,,,,,,,fee schedule,4.86,10.4,
Olanzapine long-acting inj,J2358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.37,,,,,,,fee schedule,4.86,10.4,
Olanzapine long-acting inj,J2358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.33,,,,,,,fee schedule,4.86,10.4,
Olanzapine long-acting inj,J2358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.1,,,,,,,fee schedule,4.86,10.4,
Olanzapine long-acting inj,J2358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.86,,,,,,,fee schedule,4.86,10.4,
"Inj. olanzapine, 0.5mg",J2359,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.08,,,,,,,fee schedule,2.68,3.37,
"Inj. olanzapine, 0.5mg",J2359,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.35,,,,,,,fee schedule,2.68,3.37,
"Inj. olanzapine, 0.5mg",J2359,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.37,,,,,,,fee schedule,2.68,3.37,
"Inj. olanzapine, 0.5mg",J2359,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.68,,,,,,,fee schedule,2.68,3.37,
"Inj. olanzapine, 0.5mg",J2359,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.93,,,,,,,fee schedule,2.68,3.37,
"Inj. olanzapine, 0.5mg",J2359,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.05,,,,,,,fee schedule,2.68,3.37,
Orphenadrine injection,J2360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,29.58,,,,,,,fee schedule,26.77,29.58,
Orphenadrine injection,J2360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26.77,,,,,,,fee schedule,26.77,29.58,
Inj phenylephrine hcl 20 mcg,J2371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.02,,,,,,,fee schedule,0.01,0.02,
Inj phenylephrine hcl 20 mcg,J2371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.01,,,,,,,fee schedule,0.01,0.02,
"Inj, biorphen, 20 micrograms",J2372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.63,,,,,,,fee schedule,0.34,0.68,
"Inj, biorphen, 20 micrograms",J2372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.68,,,,,,,fee schedule,0.34,0.68,
"Inj, biorphen, 20 micrograms",J2372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.38,,,,,,,fee schedule,0.34,0.68,
"Inj, biorphen, 20 micrograms",J2372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.55,,,,,,,fee schedule,0.34,0.68,
"Inj, biorphen, 20 micrograms",J2372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.6,,,,,,,fee schedule,0.34,0.68,
"Inj, biorphen, 20 micrograms",J2372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.34,,,,,,,fee schedule,0.34,0.68,
"Inj, immphentiv, 20 mcg",J2373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.38,,,,,,,fee schedule,0.34,0.38,
"Inj, immphentiv, 20 mcg",J2373,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.34,,,,,,,fee schedule,0.34,0.38,
Chloroprocaine hcl injection,J2401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.08,,,,,,,fee schedule,0.07,0.08,
Chloroprocaine hcl injection,J2401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.07,,,,,,,fee schedule,0.07,0.08,
Chloroprocaine (clorotekal),J2402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.58,,,,,,,fee schedule,0.53,0.58,
Chloroprocaine (clorotekal),J2402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.53,,,,,,,fee schedule,0.53,0.58,
"Chloroprocaine opht gel, 1mg",J2403,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.46,,,,,,,fee schedule,1.22,2.67,
"Chloroprocaine opht gel, 1mg",J2403,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.67,,,,,,,fee schedule,1.22,2.67,
"Chloroprocaine opht gel, 1mg",J2403,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.34,,,,,,,fee schedule,1.22,2.67,
"Chloroprocaine opht gel, 1mg",J2403,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.14,,,,,,,fee schedule,1.22,2.67,
"Chloroprocaine opht gel, 1mg",J2403,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.34,,,,,,,fee schedule,1.22,2.67,
"Chloroprocaine opht gel, 1mg",J2403,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.22,,,,,,,fee schedule,1.22,2.67,
"Inj, nicardipine 0.1 mg",J2404,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.16,,,,,,,fee schedule,0.14,0.16,
"Inj, nicardipine 0.1 mg",J2404,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.14,,,,,,,fee schedule,0.14,0.16,
Ondansetron hcl injection,J2405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.7,,,,,,,fee schedule,0.34,0.76,
Ondansetron hcl injection,J2405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.76,,,,,,,fee schedule,0.34,0.76,
Ondansetron hcl injection,J2405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.38,,,,,,,fee schedule,0.34,0.76,
Ondansetron hcl injection,J2405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.61,,,,,,,fee schedule,0.34,0.76,
Ondansetron hcl injection,J2405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.66,,,,,,,fee schedule,0.34,0.76,
Ondansetron hcl injection,J2405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.34,,,,,,,fee schedule,0.34,0.76,
"Injection, oritavancin 10 mg",J2406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,145.89,,,,,,,fee schedule,43.72,158.46,
"Injection, oritavancin 10 mg",J2406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,158.46,,,,,,,fee schedule,43.72,158.46,
"Injection, oritavancin 10 mg",J2406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83.99,,,,,,,fee schedule,43.72,158.46,
"Injection, oritavancin 10 mg",J2406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,127.02,,,,,,,fee schedule,43.72,158.46,
"Injection, oritavancin 10 mg",J2406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,138.76,,,,,,,fee schedule,43.72,158.46,
"Injection, oritavancin 10 mg",J2406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,76.02,,,,,,,fee schedule,43.72,158.46,
"Injection, oritavancin 10 mg",J2406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,50.71,,,,,,,fee schedule,43.72,158.46,OP High Cost Drugs
"Injection, oritavancin 10 mg",J2406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43.72,,,,,,,fee schedule,43.72,158.46,Other Pharmacy
"Injection, oritavancin 10 mg",J2406,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,45.9,,,,,,,fee schedule,43.72,158.46,APC
"Injection, oritavancin 10 mg",J2406,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,45.47,,,,,,,fee schedule,43.72,158.46,APC
"Injection, oritavancin 10 mg",J2406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,66.89,,,,,,,fee schedule,43.72,158.46,Radiology
"Injection, oritavancin 10 mg",J2406,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,61.21,,,,,,,fee schedule,43.72,158.46,APC
"Injection, oritavancin 10 mg",J2406,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,76.51,,,,,,,fee schedule,43.72,158.46,APC
"Injection, oritavancin",J2407,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,89.16,,,,,,,fee schedule,28.57,96.84,
"Injection, oritavancin",J2407,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,96.84,,,,,,,fee schedule,28.57,96.84,
"Injection, oritavancin",J2407,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55.02,,,,,,,fee schedule,28.57,96.84,
"Injection, oritavancin",J2407,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,77.63,,,,,,,fee schedule,28.57,96.84,
"Injection, oritavancin",J2407,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,84.8,,,,,,,fee schedule,28.57,96.84,
"Injection, oritavancin",J2407,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,49.79,,,,,,,fee schedule,28.57,96.84,
"Injection, oritavancin",J2407,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,33.14,,,,,,,fee schedule,28.57,96.84,OP High Cost Drugs
"Injection, oritavancin",J2407,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.57,,,,,,,fee schedule,28.57,96.84,Other Pharmacy
"Injection, oritavancin",J2407,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30,,,,,,,fee schedule,28.57,96.84,APC
"Injection, oritavancin",J2407,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,29.71,,,,,,,fee schedule,28.57,96.84,APC
"Injection, oritavancin",J2407,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43.71,,,,,,,fee schedule,28.57,96.84,Radiology
"Injection, oritavancin",J2407,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,39.99,,,,,,,fee schedule,28.57,96.84,APC
"Injection, oritavancin",J2407,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,49.99,,,,,,,fee schedule,28.57,96.84,APC
Oxymorphone hcl injection,J2410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.93,,,,,,,fee schedule,5.36,5.93,
Oxymorphone hcl injection,J2410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.36,,,,,,,fee schedule,5.36,5.93,
Palifermin injection,J2425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,40.72,,,,,,,fee schedule,35.45,64.26,
Palifermin injection,J2425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,44.23,,,,,,,fee schedule,35.45,64.26,
Palifermin injection,J2425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.94,,,,,,,fee schedule,35.45,64.26,
Palifermin injection,J2425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35.45,,,,,,,fee schedule,35.45,64.26,
Palifermin injection,J2425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38.73,,,,,,,fee schedule,35.45,64.26,
Palifermin injection,J2425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55.16,,,,,,,fee schedule,35.45,64.26,
Palifermin injection,J2425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,42.59,,,,,,,fee schedule,35.45,64.26,OP High Cost Drugs
Palifermin injection,J2425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,36.72,,,,,,,fee schedule,35.45,64.26,Other Pharmacy
Palifermin injection,J2425,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.55,,,,,,,fee schedule,35.45,64.26,APC
Palifermin injection,J2425,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.19,,,,,,,fee schedule,35.45,64.26,APC
Palifermin injection,J2425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.18,,,,,,,fee schedule,35.45,64.26,Radiology
Palifermin injection,J2425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.41,,,,,,,fee schedule,35.45,64.26,APC
Palifermin injection,J2425,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.26,,,,,,,fee schedule,35.45,64.26,APC
Paliperidone palmitate inj,J2426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,25.82,,,,,,,fee schedule,15.08,28.14,
Paliperidone palmitate inj,J2426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,28.05,,,,,,,fee schedule,15.08,28.14,
Paliperidone palmitate inj,J2426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,28.14,,,,,,,fee schedule,15.08,28.14,
Paliperidone palmitate inj,J2426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22.48,,,,,,,fee schedule,15.08,28.14,
Paliperidone palmitate inj,J2426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24.56,,,,,,,fee schedule,15.08,28.14,
Paliperidone palmitate inj,J2426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,25.47,,,,,,,fee schedule,15.08,28.14,
Paliperidone palmitate inj,J2426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17.49,,,,,,,fee schedule,15.08,28.14,OP High Cost Drugs
Paliperidone palmitate inj,J2426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15.08,,,,,,,fee schedule,15.08,28.14,Other Pharmacy
Paliperidone palmitate inj,J2426,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.83,,,,,,,fee schedule,15.08,28.14,APC
Paliperidone palmitate inj,J2426,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,15.68,,,,,,,fee schedule,15.08,28.14,APC
Paliperidone palmitate inj,J2426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.07,,,,,,,fee schedule,15.08,28.14,Radiology
Paliperidone palmitate inj,J2426,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21.11,,,,,,,fee schedule,15.08,28.14,APC
Paliperidone palmitate inj,J2426,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,26.38,,,,,,,fee schedule,15.08,28.14,APC
"Inj, invega hafyera/trinza",J2427,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42.45,,,,,,,fee schedule,12.95,46.11,
"Inj, invega hafyera/trinza",J2427,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46.11,,,,,,,fee schedule,12.95,46.11,
"Inj, invega hafyera/trinza",J2427,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21.06,,,,,,,fee schedule,12.95,46.11,
"Inj, invega hafyera/trinza",J2427,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36.96,,,,,,,fee schedule,12.95,46.11,
"Inj, invega hafyera/trinza",J2427,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40.38,,,,,,,fee schedule,12.95,46.11,
"Inj, invega hafyera/trinza",J2427,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19.06,,,,,,,fee schedule,12.95,46.11,
"Inj, invega hafyera/trinza",J2427,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,15.02,,,,,,,fee schedule,12.95,46.11,OP High Cost Drugs
"Inj, invega hafyera/trinza",J2427,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12.95,,,,,,,fee schedule,12.95,46.11,Other Pharmacy
"Inj, invega hafyera/trinza",J2427,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.6,,,,,,,fee schedule,12.95,46.11,APC
"Inj, invega hafyera/trinza",J2427,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.47,,,,,,,fee schedule,12.95,46.11,APC
"Inj, invega hafyera/trinza",J2427,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.81,,,,,,,fee schedule,12.95,46.11,Radiology
"Inj, invega hafyera/trinza",J2427,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.13,,,,,,,fee schedule,12.95,46.11,APC
"Inj, invega hafyera/trinza",J2427,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22.66,,,,,,,fee schedule,12.95,46.11,APC
Pamidronate disodium /30 mg,J2430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,104.47,,,,,,,fee schedule,46.33,113.48,
Pamidronate disodium /30 mg,J2430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,113.48,,,,,,,fee schedule,46.33,113.48,
Pamidronate disodium /30 mg,J2430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,51.19,,,,,,,fee schedule,46.33,113.48,
Pamidronate disodium /30 mg,J2430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,90.96,,,,,,,fee schedule,46.33,113.48,
Pamidronate disodium /30 mg,J2430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,99.37,,,,,,,fee schedule,46.33,113.48,
Pamidronate disodium /30 mg,J2430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.33,,,,,,,fee schedule,46.33,113.48,
Papaverin hcl injection,J2440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,71.1,,,,,,,fee schedule,64.35,71.1,
Papaverin hcl injection,J2440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,64.35,,,,,,,fee schedule,64.35,71.1,
"Inj, palonosetron (avyxa)",J2468,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,109.97,,,,,,,fee schedule,55.29,109.97,
"Inj, palonosetron (avyxa)",J2468,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,99.53,,,,,,,fee schedule,55.29,109.97,
"Inj, palonosetron (avyxa)",J2468,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,64.14,,,,,,,fee schedule,55.29,109.97,OP High Cost Drugs
"Inj, palonosetron (avyxa)",J2468,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,55.29,,,,,,,fee schedule,55.29,109.97,Other Pharmacy
"Inj, palonosetron (avyxa)",J2468,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,58.05,,,,,,,fee schedule,55.29,109.97,APC
"Inj, palonosetron (avyxa)",J2468,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,57.5,,,,,,,fee schedule,55.29,109.97,APC
"Inj, palonosetron (avyxa)",J2468,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,84.59,,,,,,,fee schedule,55.29,109.97,Radiology
"Inj, palonosetron (avyxa)",J2468,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,77.4,,,,,,,fee schedule,55.29,109.97,APC
"Inj, palonosetron (avyxa)",J2468,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,96.76,,,,,,,fee schedule,55.29,109.97,APC
Palonosetron hcl,J2469,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,58.78,,,,,,,fee schedule,8.58,63.84,
Palonosetron hcl,J2469,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,63.84,,,,,,,fee schedule,8.58,63.84,
Palonosetron hcl,J2469,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.48,,,,,,,fee schedule,8.58,63.84,
Palonosetron hcl,J2469,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.18,,,,,,,fee schedule,8.58,63.84,
Palonosetron hcl,J2469,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55.91,,,,,,,fee schedule,8.58,63.84,
Palonosetron hcl,J2469,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.58,,,,,,,fee schedule,8.58,63.84,
Inj pantoprazole sodium 40mg,J2470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.48,,,,,,,fee schedule,8.58,9.48,
Inj pantoprazole sodium 40mg,J2470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.58,,,,,,,fee schedule,8.58,9.48,
Inj pantoprazole(hikma) 40mg,J2471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12.32,,,,,,,fee schedule,11.15,12.32,
Inj pantoprazole(hikma) 40mg,J2471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11.15,,,,,,,fee schedule,11.15,12.32,
Paricalcitol,J2501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.98,,,,,,,fee schedule,3.6,3.98,
Paricalcitol,J2501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.6,,,,,,,fee schedule,3.6,3.98,
"Inj, pasireotide long acting",J2502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,973.11,,,,,,,fee schedule,596.3,1203.87,
"Inj, pasireotide long acting",J2502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1057,,,,,,,fee schedule,596.3,1203.87,
"Inj, pasireotide long acting",J2502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1203.87,,,,,,,fee schedule,596.3,1203.87,
"Inj, pasireotide long acting",J2502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,847.28,,,,,,,fee schedule,596.3,1203.87,
"Inj, pasireotide long acting",J2502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,925.58,,,,,,,fee schedule,596.3,1203.87,
"Inj, pasireotide long acting",J2502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1089.57,,,,,,,fee schedule,596.3,1203.87,
"Inj, pasireotide long acting",J2502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,691.71,,,,,,,fee schedule,596.3,1203.87,OP High Cost Drugs
"Inj, pasireotide long acting",J2502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,596.3,,,,,,,fee schedule,596.3,1203.87,Other Pharmacy
"Inj, pasireotide long acting",J2502,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,626.12,,,,,,,fee schedule,596.3,1203.87,APC
"Inj, pasireotide long acting",J2502,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,620.15,,,,,,,fee schedule,596.3,1203.87,APC
"Inj, pasireotide long acting",J2502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,912.34,,,,,,,fee schedule,596.3,1203.87,Radiology
"Inj, pasireotide long acting",J2502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,834.82,,,,,,,fee schedule,596.3,1203.87,APC
"Inj, pasireotide long acting",J2502,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1043.53,,,,,,,fee schedule,596.3,1203.87,APC
Pegaptanib sodium injection,J2503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3652.09,,,,,,,fee schedule,1271.63,3966.92,
Pegaptanib sodium injection,J2503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3966.92,,,,,,,fee schedule,1271.63,3966.92,
Pegaptanib sodium injection,J2503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1405.02,,,,,,,fee schedule,1271.63,3966.92,
Pegaptanib sodium injection,J2503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3179.83,,,,,,,fee schedule,1271.63,3966.92,
Pegaptanib sodium injection,J2503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3473.68,,,,,,,fee schedule,1271.63,3966.92,
Pegaptanib sodium injection,J2503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1271.63,,,,,,,fee schedule,1271.63,3966.92,
"Pegademase bovine, 25 iu",J2504,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,808.06,,,,,,,fee schedule,595.68,877.72,
"Pegademase bovine, 25 iu",J2504,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,877.72,,,,,,,fee schedule,595.68,877.72,
"Pegademase bovine, 25 iu",J2504,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,658.16,,,,,,,fee schedule,595.68,877.72,
"Pegademase bovine, 25 iu",J2504,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,703.57,,,,,,,fee schedule,595.68,877.72,
"Pegademase bovine, 25 iu",J2504,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,768.58,,,,,,,fee schedule,595.68,877.72,
"Pegademase bovine, 25 iu",J2504,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,595.68,,,,,,,fee schedule,595.68,877.72,
Inj pegfilgrast ex bio 0.5mg,J2506,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,633.47,,,,,,,fee schedule,127.38,1014.04,
Inj pegfilgrast ex bio 0.5mg,J2506,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,688.08,,,,,,,fee schedule,127.38,1014.04,
Inj pegfilgrast ex bio 0.5mg,J2506,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1014.04,,,,,,,fee schedule,127.38,1014.04,
Inj pegfilgrast ex bio 0.5mg,J2506,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,551.56,,,,,,,fee schedule,127.38,1014.04,
Inj pegfilgrast ex bio 0.5mg,J2506,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,602.53,,,,,,,fee schedule,127.38,1014.04,
Inj pegfilgrast ex bio 0.5mg,J2506,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,917.77,,,,,,,fee schedule,127.38,1014.04,
Inj pegfilgrast ex bio 0.5mg,J2506,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,147.76,,,,,,,fee schedule,127.38,1014.04,OP High Cost Drugs
Inj pegfilgrast ex bio 0.5mg,J2506,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,127.38,,,,,,,fee schedule,127.38,1014.04,Other Pharmacy
Inj pegfilgrast ex bio 0.5mg,J2506,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,133.75,,,,,,,fee schedule,127.38,1014.04,APC
Inj pegfilgrast ex bio 0.5mg,J2506,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,132.47,,,,,,,fee schedule,127.38,1014.04,APC
Inj pegfilgrast ex bio 0.5mg,J2506,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,194.89,,,,,,,fee schedule,127.38,1014.04,Radiology
Inj pegfilgrast ex bio 0.5mg,J2506,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,178.33,,,,,,,fee schedule,127.38,1014.04,APC
Inj pegfilgrast ex bio 0.5mg,J2506,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,222.91,,,,,,,fee schedule,127.38,1014.04,APC
Pegloticase injection,J2507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1472.25,,,,,,,fee schedule,1281.87,6948.56,
Pegloticase injection,J2507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1599.17,,,,,,,fee schedule,1281.87,6948.56,
Pegloticase injection,J2507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6948.56,,,,,,,fee schedule,1281.87,6948.56,
Pegloticase injection,J2507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1281.87,,,,,,,fee schedule,1281.87,6948.56,
Pegloticase injection,J2507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1400.33,,,,,,,fee schedule,1281.87,6948.56,
Pegloticase injection,J2507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6288.88,,,,,,,fee schedule,1281.87,6948.56,
Pegloticase injection,J2507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4436.45,,,,,,,fee schedule,1281.87,6948.56,OP High Cost Drugs
Pegloticase injection,J2507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3824.52,,,,,,,fee schedule,1281.87,6948.56,Other Pharmacy
Pegloticase injection,J2507,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4015.75,,,,,,,fee schedule,1281.87,6948.56,APC
Pegloticase injection,J2507,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3977.5,,,,,,,fee schedule,1281.87,6948.56,APC
Pegloticase injection,J2507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5851.52,,,,,,,fee schedule,1281.87,6948.56,Radiology
Pegloticase injection,J2507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5354.33,,,,,,,fee schedule,1281.87,6948.56,APC
Pegloticase injection,J2507,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6692.92,,,,,,,fee schedule,1281.87,6948.56,APC
Pegunigalsidase alfa-iwxj,J2508,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,762.68,,,,,,,fee schedule,223.4,828.43,
Pegunigalsidase alfa-iwxj,J2508,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,828.43,,,,,,,fee schedule,223.4,828.43,
Pegunigalsidase alfa-iwxj,J2508,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,411.61,,,,,,,fee schedule,223.4,828.43,
Pegunigalsidase alfa-iwxj,J2508,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,664.06,,,,,,,fee schedule,223.4,828.43,
Pegunigalsidase alfa-iwxj,J2508,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,725.42,,,,,,,fee schedule,223.4,828.43,
Pegunigalsidase alfa-iwxj,J2508,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,372.53,,,,,,,fee schedule,223.4,828.43,
Pegunigalsidase alfa-iwxj,J2508,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,259.14,,,,,,,fee schedule,223.4,828.43,OP High Cost Drugs
Pegunigalsidase alfa-iwxj,J2508,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,223.4,,,,,,,fee schedule,223.4,828.43,Other Pharmacy
Pegunigalsidase alfa-iwxj,J2508,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,234.57,,,,,,,fee schedule,223.4,828.43,APC
Pegunigalsidase alfa-iwxj,J2508,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,232.34,,,,,,,fee schedule,223.4,828.43,APC
Pegunigalsidase alfa-iwxj,J2508,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.8,,,,,,,fee schedule,223.4,828.43,Radiology
Pegunigalsidase alfa-iwxj,J2508,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,312.76,,,,,,,fee schedule,223.4,828.43,APC
Pegunigalsidase alfa-iwxj,J2508,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,390.95,,,,,,,fee schedule,223.4,828.43,APC
Penicillin g procaine inj,J2510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,97.58,,,,,,,fee schedule,65.97,105.99,
Penicillin g procaine inj,J2510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,105.99,,,,,,,fee schedule,65.97,105.99,
Penicillin g procaine inj,J2510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,72.89,,,,,,,fee schedule,65.97,105.99,
Penicillin g procaine inj,J2510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,84.96,,,,,,,fee schedule,65.97,105.99,
Penicillin g procaine inj,J2510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,92.81,,,,,,,fee schedule,65.97,105.99,
Penicillin g procaine inj,J2510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,65.97,,,,,,,fee schedule,65.97,105.99,
Pentastarch 10% solution,J2513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,79.27,,,,,,,fee schedule,69.02,86.11,
Pentastarch 10% solution,J2513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,86.11,,,,,,,fee schedule,69.02,86.11,
Pentastarch 10% solution,J2513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,69.02,,,,,,,fee schedule,69.02,86.11,
Pentastarch 10% solution,J2513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,75.4,,,,,,,fee schedule,69.02,86.11,
Pentobarbital sodium inj,J2515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,172.05,,,,,,,fee schedule,36.84,186.88,
Pentobarbital sodium inj,J2515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,186.88,,,,,,,fee schedule,36.84,186.88,
Pentobarbital sodium inj,J2515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,104.33,,,,,,,fee schedule,36.84,186.88,
Pentobarbital sodium inj,J2515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,149.8,,,,,,,fee schedule,36.84,186.88,
Pentobarbital sodium inj,J2515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,163.65,,,,,,,fee schedule,36.84,186.88,
Pentobarbital sodium inj,J2515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,94.42,,,,,,,fee schedule,36.84,186.88,
Pentobarbital sodium inj,J2515,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,163.44,,,,,,,fee schedule,36.84,186.88,APC 378
Pentobarbital sodium inj,J2515,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.68,,,,,,,fee schedule,36.84,186.88,APC
Pentobarbital sodium inj,J2515,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.31,,,,,,,fee schedule,36.84,186.88,APC
Pentobarbital sodium inj,J2515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.84,,,,,,,fee schedule,36.84,186.88,APC
Pentobarbital sodium inj,J2515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.36,,,,,,,fee schedule,36.84,186.88,Radiology
Pentobarbital sodium inj,J2515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.57,,,,,,,fee schedule,36.84,186.88,APC
Pentobarbital sodium inj,J2515,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.47,,,,,,,fee schedule,36.84,186.88,APC
Piperacillin/tazobactam,J2543,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7.39,,,,,,,fee schedule,6.69,7.39,
Piperacillin/tazobactam,J2543,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.69,,,,,,,fee schedule,6.69,7.39,
Pentamidine non-comp unit,J2545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,171.46,,,,,,,fee schedule,149.29,285.19,
Pentamidine non-comp unit,J2545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,186.24,,,,,,,fee schedule,149.29,285.19,
Pentamidine non-comp unit,J2545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,285.19,,,,,,,fee schedule,149.29,285.19,
Pentamidine non-comp unit,J2545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,149.29,,,,,,,fee schedule,149.29,285.19,
Pentamidine non-comp unit,J2545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,163.08,,,,,,,fee schedule,149.29,285.19,
Pentamidine non-comp unit,J2545,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,258.12,,,,,,,fee schedule,149.29,285.19,
"Injection, peramivir",J2547,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.85,,,,,,,fee schedule,1.68,7.44,
"Injection, peramivir",J2547,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.35,,,,,,,fee schedule,1.68,7.44,
"Injection, peramivir",J2547,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3,,,,,,,fee schedule,1.68,7.44,
"Injection, peramivir",J2547,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.09,,,,,,,fee schedule,1.68,7.44,
"Injection, peramivir",J2547,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.56,,,,,,,fee schedule,1.68,7.44,
"Injection, peramivir",J2547,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.72,,,,,,,fee schedule,1.68,7.44,
"Injection, peramivir",J2547,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.44,,,,,,,fee schedule,1.68,7.44,APC 378
"Injection, peramivir",J2547,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.76,,,,,,,fee schedule,1.68,7.44,APC
"Injection, peramivir",J2547,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1.75,,,,,,,fee schedule,1.68,7.44,APC
"Injection, peramivir",J2547,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1.68,,,,,,,fee schedule,1.68,7.44,APC
"Injection, peramivir",J2547,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2.57,,,,,,,fee schedule,1.68,7.44,Radiology
"Injection, peramivir",J2547,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2.35,,,,,,,fee schedule,1.68,7.44,APC
"Injection, peramivir",J2547,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2.94,,,,,,,fee schedule,1.68,7.44,APC
Promethazine hcl injection,J2550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7.16,,,,,,,fee schedule,6.48,7.16,
Promethazine hcl injection,J2550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.48,,,,,,,fee schedule,6.48,7.16,
Phenobarbital sodium inj,J2560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,158.88,,,,,,,fee schedule,69.11,172.58,
Phenobarbital sodium inj,J2560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,172.58,,,,,,,fee schedule,69.11,172.58,
Phenobarbital sodium inj,J2560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,76.36,,,,,,,fee schedule,69.11,172.58,
Phenobarbital sodium inj,J2560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,138.34,,,,,,,fee schedule,69.11,172.58,
Phenobarbital sodium inj,J2560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,151.12,,,,,,,fee schedule,69.11,172.58,
Phenobarbital sodium inj,J2560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,69.11,,,,,,,fee schedule,69.11,172.58,
"Inj, sezaby, 1 mg",J2561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.53,,,,,,,fee schedule,1.13,5.03,
"Inj, sezaby, 1 mg",J2561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.29,,,,,,,fee schedule,1.13,5.03,
"Inj, sezaby, 1 mg",J2561,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.03,,,,,,,fee schedule,1.13,5.03,APC 378
"Inj, sezaby, 1 mg",J2561,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.19,,,,,,,fee schedule,1.13,5.03,APC
"Inj, sezaby, 1 mg",J2561,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1.18,,,,,,,fee schedule,1.13,5.03,APC
"Inj, sezaby, 1 mg",J2561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1.13,,,,,,,fee schedule,1.13,5.03,APC
"Inj, sezaby, 1 mg",J2561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1.74,,,,,,,fee schedule,1.13,5.03,Radiology
"Inj, sezaby, 1 mg",J2561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1.59,,,,,,,fee schedule,1.13,5.03,APC
"Inj, sezaby, 1 mg",J2561,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1.98,,,,,,,fee schedule,1.13,5.03,APC
Plerixafor injection,J2562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1032.38,,,,,,,fee schedule,32.74,1121.37,
Plerixafor injection,J2562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1121.37,,,,,,,fee schedule,32.74,1121.37,
Plerixafor injection,J2562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,85.07,,,,,,,fee schedule,32.74,1121.37,
Plerixafor injection,J2562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,898.88,,,,,,,fee schedule,32.74,1121.37,
Plerixafor injection,J2562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,981.94,,,,,,,fee schedule,32.74,1121.37,
Plerixafor injection,J2562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,76.99,,,,,,,fee schedule,32.74,1121.37,
Plerixafor injection,J2562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,37.98,,,,,,,fee schedule,32.74,1121.37,OP High Cost Drugs
Plerixafor injection,J2562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,32.74,,,,,,,fee schedule,32.74,1121.37,Other Pharmacy
Plerixafor injection,J2562,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,34.38,,,,,,,fee schedule,32.74,1121.37,APC
Plerixafor injection,J2562,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,34.05,,,,,,,fee schedule,32.74,1121.37,APC
Plerixafor injection,J2562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,50.1,,,,,,,fee schedule,32.74,1121.37,Radiology
Plerixafor injection,J2562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,45.84,,,,,,,fee schedule,32.74,1121.37,APC
Plerixafor injection,J2562,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,57.3,,,,,,,fee schedule,32.74,1121.37,APC
Oxytocin injection,J2590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.73,,,,,,,fee schedule,2.47,2.73,
Oxytocin injection,J2590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.47,,,,,,,fee schedule,2.47,2.73,
Inj desmopressin acetate,J2597,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46.49,,,,,,,fee schedule,22.21,50.5,
Inj desmopressin acetate,J2597,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,50.5,,,,,,,fee schedule,22.21,50.5,
Inj desmopressin acetate,J2597,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24.54,,,,,,,fee schedule,22.21,50.5,
Inj desmopressin acetate,J2597,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40.48,,,,,,,fee schedule,22.21,50.5,
Inj desmopressin acetate,J2597,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,44.22,,,,,,,fee schedule,22.21,50.5,
Inj desmopressin acetate,J2597,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22.21,,,,,,,fee schedule,22.21,50.5,
"Inj, vasopressin, 1 unit",J2598,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8.89,,,,,,,fee schedule,6.95,9.66,
"Inj, vasopressin, 1 unit",J2598,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.66,,,,,,,fee schedule,6.95,9.66,
"Inj, vasopressin, 1 unit",J2598,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7.68,,,,,,,fee schedule,6.95,9.66,
"Inj, vasopressin, 1 unit",J2598,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7.74,,,,,,,fee schedule,6.95,9.66,
"Inj, vasopressin, 1 unit",J2598,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.46,,,,,,,fee schedule,6.95,9.66,
"Inj, vasopressin, 1 unit",J2598,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.95,,,,,,,fee schedule,6.95,9.66,
Inj vasopressin (am reg) 1 u,J2599,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.95,,,,,,,fee schedule,1.7,10.76,
Inj vasopressin (am reg) 1 u,J2599,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.12,,,,,,,fee schedule,1.7,10.76,
Inj vasopressin (am reg) 1 u,J2599,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10.76,,,,,,,fee schedule,1.7,10.76,
Inj vasopressin (am reg) 1 u,J2599,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.7,,,,,,,fee schedule,1.7,10.76,
Inj vasopressin (am reg) 1 u,J2599,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.86,,,,,,,fee schedule,1.7,10.76,
Inj vasopressin (am reg) 1 u,J2599,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.74,,,,,,,fee schedule,1.7,10.76,
"Inj, vasopressin (baxter)",J2601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7.11,,,,,,,fee schedule,1.53,7.11,
"Inj, vasopressin (baxter)",J2601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.44,,,,,,,fee schedule,1.53,7.11,
"Inj, vasopressin (baxter)",J2601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1.78,,,,,,,fee schedule,1.53,7.11,OP High Cost Drugs
"Inj, vasopressin (baxter)",J2601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1.53,,,,,,,fee schedule,1.53,7.11,Other Pharmacy
"Inj, vasopressin (baxter)",J2601,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.61,,,,,,,fee schedule,1.53,7.11,APC
"Inj, vasopressin (baxter)",J2601,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1.59,,,,,,,fee schedule,1.53,7.11,APC
"Inj, vasopressin (baxter)",J2601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2.34,,,,,,,fee schedule,1.53,7.11,Radiology
"Inj, vasopressin (baxter)",J2601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2.14,,,,,,,fee schedule,1.53,7.11,APC
"Inj, vasopressin (baxter)",J2601,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2.68,,,,,,,fee schedule,1.53,7.11,APC
Totazoline hcl injection,J2670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5569.39,,,,,,,fee schedule,4849.21,6049.51,
Totazoline hcl injection,J2670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6049.51,,,,,,,fee schedule,4849.21,6049.51,
Totazoline hcl injection,J2670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4849.21,,,,,,,fee schedule,4849.21,6049.51,
Totazoline hcl injection,J2670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5297.32,,,,,,,fee schedule,4849.21,6049.51,
Inj progesterone per 50 MG,J2675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.15,,,,,,,fee schedule,5.56,6.15,
Inj progesterone per 50 MG,J2675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.56,,,,,,,fee schedule,5.56,6.15,
Inj fluphenazine hcl 1.25 mg,J2679,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18.2,,,,,,,fee schedule,16.47,18.2,
Inj fluphenazine hcl 1.25 mg,J2679,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.47,,,,,,,fee schedule,16.47,18.2,
Fluphenazine decanoate 25 MG,J2680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45.5,,,,,,,fee schedule,41.18,45.5,
Fluphenazine decanoate 25 MG,J2680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,41.18,,,,,,,fee schedule,41.18,45.5,
Procainamide hcl injection,J2690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,167.86,,,,,,,fee schedule,151.92,375.92,
Procainamide hcl injection,J2690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,151.92,,,,,,,fee schedule,151.92,375.92,
Procainamide hcl injection,J2690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,249.18,,,,,,,fee schedule,151.92,375.92,OP High Cost Drugs
Procainamide hcl injection,J2690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,214.81,,,,,,,fee schedule,151.92,375.92,Other Pharmacy
Procainamide hcl injection,J2690,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,225.55,,,,,,,fee schedule,151.92,375.92,APC
Procainamide hcl injection,J2690,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,223.4,,,,,,,fee schedule,151.92,375.92,APC
Procainamide hcl injection,J2690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,328.66,,,,,,,fee schedule,151.92,375.92,Radiology
Procainamide hcl injection,J2690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,300.74,,,,,,,fee schedule,151.92,375.92,APC
Procainamide hcl injection,J2690,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,375.92,,,,,,,fee schedule,151.92,375.92,APC
Oxacillin sodium injeciton,J2700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.59,,,,,,,fee schedule,5.06,5.59,
Oxacillin sodium injeciton,J2700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.06,,,,,,,fee schedule,5.06,5.59,
"Inj, propofol, 10 mg",J2704,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.45,,,,,,,fee schedule,0.37,0.49,
"Inj, propofol, 10 mg",J2704,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.49,,,,,,,fee schedule,0.37,0.49,
"Inj, propofol, 10 mg",J2704,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.41,,,,,,,fee schedule,0.37,0.49,
"Inj, propofol, 10 mg",J2704,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.39,,,,,,,fee schedule,0.37,0.49,
"Inj, propofol, 10 mg",J2704,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.43,,,,,,,fee schedule,0.37,0.49,
"Inj, propofol, 10 mg",J2704,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.37,,,,,,,fee schedule,0.37,0.49,
Neostigmine methylslfte inj,J2710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.46,,,,,,,fee schedule,2.23,2.46,
Neostigmine methylslfte inj,J2710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.23,,,,,,,fee schedule,2.23,2.46,
Inj protamine sulfate/10 MG,J2720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.95,,,,,,,fee schedule,4.48,4.95,
Inj protamine sulfate/10 MG,J2720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.48,,,,,,,fee schedule,4.48,4.95,
Protein C concentrate,J2724,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,43.57,,,,,,,fee schedule,15.05,47.33,
Protein C concentrate,J2724,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,47.33,,,,,,,fee schedule,15.05,47.33,
Protein C concentrate,J2724,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,28.44,,,,,,,fee schedule,15.05,47.33,
Protein C concentrate,J2724,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37.94,,,,,,,fee schedule,15.05,47.33,
Protein C concentrate,J2724,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,41.44,,,,,,,fee schedule,15.05,47.33,
Protein C concentrate,J2724,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,25.74,,,,,,,fee schedule,15.05,47.33,
Protein C concentrate,J2724,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17.46,,,,,,,fee schedule,15.05,47.33,OP High Cost Drugs
Protein C concentrate,J2724,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15.05,,,,,,,fee schedule,15.05,47.33,Other Pharmacy
Protein C concentrate,J2724,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15.8,,,,,,,fee schedule,15.05,47.33,APC
Protein C concentrate,J2724,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,15.65,,,,,,,fee schedule,15.05,47.33,APC
Protein C concentrate,J2724,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.02,,,,,,,fee schedule,15.05,47.33,Radiology
Protein C concentrate,J2724,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21.07,,,,,,,fee schedule,15.05,47.33,APC
Protein C concentrate,J2724,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,26.34,,,,,,,fee schedule,15.05,47.33,APC
Pralidoxime chloride inj,J2730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,304.29,,,,,,,fee schedule,148.78,330.52,
Pralidoxime chloride inj,J2730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,330.52,,,,,,,fee schedule,148.78,330.52,
Pralidoxime chloride inj,J2730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,164.38,,,,,,,fee schedule,148.78,330.52,
Pralidoxime chloride inj,J2730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,264.94,,,,,,,fee schedule,148.78,330.52,
Pralidoxime chloride inj,J2730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,289.43,,,,,,,fee schedule,148.78,330.52,
Pralidoxime chloride inj,J2730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,148.78,,,,,,,fee schedule,148.78,330.52,
Phentolaine mesylate inj,J2760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1386.15,,,,,,,fee schedule,257.45,1505.65,
Phentolaine mesylate inj,J2760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1505.65,,,,,,,fee schedule,257.45,1505.65,
Phentolaine mesylate inj,J2760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,795.94,,,,,,,fee schedule,257.45,1505.65,
Phentolaine mesylate inj,J2760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1206.91,,,,,,,fee schedule,257.45,1505.65,
Phentolaine mesylate inj,J2760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1318.44,,,,,,,fee schedule,257.45,1505.65,
Phentolaine mesylate inj,J2760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,720.38,,,,,,,fee schedule,257.45,1505.65,
Phentolaine mesylate inj,J2760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,298.64,,,,,,,fee schedule,257.45,1505.65,OP High Cost Drugs
Phentolaine mesylate inj,J2760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,257.45,,,,,,,fee schedule,257.45,1505.65,Other Pharmacy
Phentolaine mesylate inj,J2760,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,270.32,,,,,,,fee schedule,257.45,1505.65,APC
Phentolaine mesylate inj,J2760,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,267.75,,,,,,,fee schedule,257.45,1505.65,APC
Phentolaine mesylate inj,J2760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,393.9,,,,,,,fee schedule,257.45,1505.65,Radiology
Phentolaine mesylate inj,J2760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,360.43,,,,,,,fee schedule,257.45,1505.65,APC
Phentolaine mesylate inj,J2760,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,450.54,,,,,,,fee schedule,257.45,1505.65,APC
Metoclopramide hcl injection,J2765,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.04,,,,,,,fee schedule,4.56,5.04,
Metoclopramide hcl injection,J2765,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.56,,,,,,,fee schedule,4.56,5.04,
Quinupristin/dalfopristin,J2770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,499.48,,,,,,,fee schedule,434.9,542.54,
Quinupristin/dalfopristin,J2770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,542.54,,,,,,,fee schedule,434.9,542.54,
Quinupristin/dalfopristin,J2770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,434.9,,,,,,,fee schedule,434.9,542.54,
Quinupristin/dalfopristin,J2770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,475.08,,,,,,,fee schedule,434.9,542.54,
"Inj, faricimab-svoa, 0.1mg",J2777,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,132.45,,,,,,,fee schedule,32.87,143.87,
"Inj, faricimab-svoa, 0.1mg",J2777,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,143.87,,,,,,,fee schedule,32.87,143.87,
"Inj, faricimab-svoa, 0.1mg",J2777,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,67.77,,,,,,,fee schedule,32.87,143.87,
"Inj, faricimab-svoa, 0.1mg",J2777,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,115.32,,,,,,,fee schedule,32.87,143.87,
"Inj, faricimab-svoa, 0.1mg",J2777,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,125.98,,,,,,,fee schedule,32.87,143.87,
"Inj, faricimab-svoa, 0.1mg",J2777,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,61.33,,,,,,,fee schedule,32.87,143.87,
"Inj, faricimab-svoa, 0.1mg",J2777,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,38.12,,,,,,,fee schedule,32.87,143.87,OP High Cost Drugs
"Inj, faricimab-svoa, 0.1mg",J2777,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,32.87,,,,,,,fee schedule,32.87,143.87,Other Pharmacy
"Inj, faricimab-svoa, 0.1mg",J2777,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,34.51,,,,,,,fee schedule,32.87,143.87,APC
"Inj, faricimab-svoa, 0.1mg",J2777,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,34.18,,,,,,,fee schedule,32.87,143.87,APC
"Inj, faricimab-svoa, 0.1mg",J2777,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,50.28,,,,,,,fee schedule,32.87,143.87,Radiology
"Inj, faricimab-svoa, 0.1mg",J2777,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,46.01,,,,,,,fee schedule,32.87,143.87,APC
"Inj, faricimab-svoa, 0.1mg",J2777,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,57.52,,,,,,,fee schedule,32.87,143.87,APC
Ranibizumab injection,J2778,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1461.63,,,,,,,fee schedule,67.85,1587.64,
Ranibizumab injection,J2778,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1587.64,,,,,,,fee schedule,67.85,1587.64,
Ranibizumab injection,J2778,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,740.18,,,,,,,fee schedule,67.85,1587.64,
Ranibizumab injection,J2778,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1272.63,,,,,,,fee schedule,67.85,1587.64,
Ranibizumab injection,J2778,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1390.23,,,,,,,fee schedule,67.85,1587.64,
Ranibizumab injection,J2778,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,669.91,,,,,,,fee schedule,67.85,1587.64,
Ranibizumab injection,J2778,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,78.71,,,,,,,fee schedule,67.85,1587.64,OP High Cost Drugs
Ranibizumab injection,J2778,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,67.85,,,,,,,fee schedule,67.85,1587.64,Other Pharmacy
Ranibizumab injection,J2778,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,71.25,,,,,,,fee schedule,67.85,1587.64,APC
Ranibizumab injection,J2778,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,70.57,,,,,,,fee schedule,67.85,1587.64,APC
Ranibizumab injection,J2778,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,103.82,,,,,,,fee schedule,67.85,1587.64,Radiology
Ranibizumab injection,J2778,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,94.99,,,,,,,fee schedule,67.85,1587.64,APC
Ranibizumab injection,J2778,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,118.74,,,,,,,fee schedule,67.85,1587.64,APC
"Inj, susvimo 0.1 mg",J2779,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,289.64,,,,,,,fee schedule,76.2,314.61,
"Inj, susvimo 0.1 mg",J2779,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,314.61,,,,,,,fee schedule,76.2,314.61,
"Inj, susvimo 0.1 mg",J2779,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,151.68,,,,,,,fee schedule,76.2,314.61,
"Inj, susvimo 0.1 mg",J2779,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,252.19,,,,,,,fee schedule,76.2,314.61,
"Inj, susvimo 0.1 mg",J2779,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,275.49,,,,,,,fee schedule,76.2,314.61,
"Inj, susvimo 0.1 mg",J2779,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,137.28,,,,,,,fee schedule,76.2,314.61,
"Inj, susvimo 0.1 mg",J2779,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,88.39,,,,,,,fee schedule,76.2,314.61,OP High Cost Drugs
"Inj, susvimo 0.1 mg",J2779,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,76.2,,,,,,,fee schedule,76.2,314.61,Other Pharmacy
"Inj, susvimo 0.1 mg",J2779,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,80.01,,,,,,,fee schedule,76.2,314.61,APC
"Inj, susvimo 0.1 mg",J2779,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,79.25,,,,,,,fee schedule,76.2,314.61,APC
"Inj, susvimo 0.1 mg",J2779,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,116.58,,,,,,,fee schedule,76.2,314.61,Radiology
"Inj, susvimo 0.1 mg",J2779,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,106.68,,,,,,,fee schedule,76.2,314.61,APC
"Inj, susvimo 0.1 mg",J2779,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,133.35,,,,,,,fee schedule,76.2,314.61,APC
"Inj, pegcetacoplan, 1mg",J2781,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,534.25,,,,,,,fee schedule,147.81,580.31,
"Inj, pegcetacoplan, 1mg",J2781,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,580.31,,,,,,,fee schedule,147.81,580.31,
"Inj, pegcetacoplan, 1mg",J2781,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,278.21,,,,,,,fee schedule,147.81,580.31,
"Inj, pegcetacoplan, 1mg",J2781,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,465.17,,,,,,,fee schedule,147.81,580.31,
"Inj, pegcetacoplan, 1mg",J2781,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,508.15,,,,,,,fee schedule,147.81,580.31,
"Inj, pegcetacoplan, 1mg",J2781,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,251.79,,,,,,,fee schedule,147.81,580.31,
"Inj, pegcetacoplan, 1mg",J2781,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,171.46,,,,,,,fee schedule,147.81,580.31,OP High Cost Drugs
"Inj, pegcetacoplan, 1mg",J2781,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,147.81,,,,,,,fee schedule,147.81,580.31,Other Pharmacy
"Inj, pegcetacoplan, 1mg",J2781,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,155.2,,,,,,,fee schedule,147.81,580.31,APC
"Inj, pegcetacoplan, 1mg",J2781,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,153.72,,,,,,,fee schedule,147.81,580.31,APC
"Inj, pegcetacoplan, 1mg",J2781,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,226.14,,,,,,,fee schedule,147.81,580.31,Radiology
"Inj, pegcetacoplan, 1mg",J2781,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,206.93,,,,,,,fee schedule,147.81,580.31,APC
"Inj, pegcetacoplan, 1mg",J2781,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,258.66,,,,,,,fee schedule,147.81,580.31,APC
Inj avacincaptad pegol 0.1mg,J2782,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,199.08,,,,,,,fee schedule,103.4,199.08,
Inj avacincaptad pegol 0.1mg,J2782,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,180.18,,,,,,,fee schedule,103.4,199.08,
Inj avacincaptad pegol 0.1mg,J2782,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,119.95,,,,,,,fee schedule,103.4,199.08,OP High Cost Drugs
Inj avacincaptad pegol 0.1mg,J2782,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,103.4,,,,,,,fee schedule,103.4,199.08,Other Pharmacy
Inj avacincaptad pegol 0.1mg,J2782,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.57,,,,,,,fee schedule,103.4,199.08,APC
Inj avacincaptad pegol 0.1mg,J2782,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.54,,,,,,,fee schedule,103.4,199.08,APC
Inj avacincaptad pegol 0.1mg,J2782,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.2,,,,,,,fee schedule,103.4,199.08,Radiology
Inj avacincaptad pegol 0.1mg,J2782,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.76,,,,,,,fee schedule,103.4,199.08,APC
Inj avacincaptad pegol 0.1mg,J2782,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,180.95,,,,,,,fee schedule,103.4,199.08,APC
Rasburicase,J2783,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,554.82,,,,,,,fee schedule,382.19,672.31,
Rasburicase,J2783,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,602.65,,,,,,,fee schedule,382.19,672.31,
Rasburicase,J2783,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,672.31,,,,,,,fee schedule,382.19,672.31,
Rasburicase,J2783,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,483.07,,,,,,,fee schedule,382.19,672.31,
Rasburicase,J2783,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,527.71,,,,,,,fee schedule,382.19,672.31,
Rasburicase,J2783,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,608.48,,,,,,,fee schedule,382.19,672.31,
Rasburicase,J2783,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,443.34,,,,,,,fee schedule,382.19,672.31,OP High Cost Drugs
Rasburicase,J2783,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,382.19,,,,,,,fee schedule,382.19,672.31,Other Pharmacy
Rasburicase,J2783,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,401.3,,,,,,,fee schedule,382.19,672.31,APC
Rasburicase,J2783,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,397.47,,,,,,,fee schedule,382.19,672.31,APC
Rasburicase,J2783,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,584.75,,,,,,,fee schedule,382.19,672.31,Radiology
Rasburicase,J2783,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,535.06,,,,,,,fee schedule,382.19,672.31,APC
Rasburicase,J2783,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,668.83,,,,,,,fee schedule,382.19,672.31,APC
Regadenoson injection,J2785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,164.95,,,,,,,fee schedule,69.71,179.17,
Regadenoson injection,J2785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,179.17,,,,,,,fee schedule,69.71,179.17,
Regadenoson injection,J2785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,77.03,,,,,,,fee schedule,69.71,179.17,
Regadenoson injection,J2785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,143.62,,,,,,,fee schedule,69.71,179.17,
Regadenoson injection,J2785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,156.89,,,,,,,fee schedule,69.71,179.17,
Regadenoson injection,J2785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,69.71,,,,,,,fee schedule,69.71,179.17,
"Injection, reslizumab, 1mg",J2786,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30.8,,,,,,,fee schedule,11.53,33.45,
"Injection, reslizumab, 1mg",J2786,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33.45,,,,,,,fee schedule,11.53,33.45,
"Injection, reslizumab, 1mg",J2786,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20.7,,,,,,,fee schedule,11.53,33.45,
"Injection, reslizumab, 1mg",J2786,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26.82,,,,,,,fee schedule,11.53,33.45,
"Injection, reslizumab, 1mg",J2786,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29.29,,,,,,,fee schedule,11.53,33.45,
"Injection, reslizumab, 1mg",J2786,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18.73,,,,,,,fee schedule,11.53,33.45,
"Injection, reslizumab, 1mg",J2786,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.38,,,,,,,fee schedule,11.53,33.45,OP High Cost Drugs
"Injection, reslizumab, 1mg",J2786,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11.53,,,,,,,fee schedule,11.53,33.45,Other Pharmacy
"Injection, reslizumab, 1mg",J2786,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.11,,,,,,,fee schedule,11.53,33.45,APC
"Injection, reslizumab, 1mg",J2786,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11.99,,,,,,,fee schedule,11.53,33.45,APC
"Injection, reslizumab, 1mg",J2786,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.64,,,,,,,fee schedule,11.53,33.45,Radiology
"Injection, reslizumab, 1mg",J2786,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.14,,,,,,,fee schedule,11.53,33.45,APC
"Injection, reslizumab, 1mg",J2786,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20.18,,,,,,,fee schedule,11.53,33.45,APC
Riboflavin 5?phos opth<=3ml,J2787,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3934.2,,,,,,,fee schedule,3560.7,3934.2,
Riboflavin 5?phos opth<=3ml,J2787,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3560.7,,,,,,,fee schedule,3560.7,3934.2,
Rho d immune globulin 50 mcg,J2788,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,95.98,,,,,,,fee schedule,83.57,104.86,
Rho d immune globulin 50 mcg,J2788,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,104.25,,,,,,,fee schedule,83.57,104.86,
Rho d immune globulin 50 mcg,J2788,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,104.86,,,,,,,fee schedule,83.57,104.86,
Rho d immune globulin 50 mcg,J2788,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,83.57,,,,,,,fee schedule,83.57,104.86,
Rho d immune globulin 50 mcg,J2788,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,91.29,,,,,,,fee schedule,83.57,104.86,
Rho d immune globulin 50 mcg,J2788,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,94.91,,,,,,,fee schedule,83.57,104.86,
Rho d immune globulin inj,J2790,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,302.13,,,,,,,fee schedule,180.38,328.18,
Rho d immune globulin inj,J2790,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,328.18,,,,,,,fee schedule,180.38,328.18,
Rho d immune globulin inj,J2790,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,199.3,,,,,,,fee schedule,180.38,328.18,
Rho d immune globulin inj,J2790,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,263.06,,,,,,,fee schedule,180.38,328.18,
Rho d immune globulin inj,J2790,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,287.37,,,,,,,fee schedule,180.38,328.18,
Rho d immune globulin inj,J2790,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,180.38,,,,,,,fee schedule,180.38,328.18,
Rhophylac injection,J2791,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18.76,,,,,,,fee schedule,16.33,20.37,
Rhophylac injection,J2791,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20.37,,,,,,,fee schedule,16.33,20.37,
Rhophylac injection,J2791,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19.92,,,,,,,fee schedule,16.33,20.37,
Rhophylac injection,J2791,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.33,,,,,,,fee schedule,16.33,20.37,
Rhophylac injection,J2791,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17.84,,,,,,,fee schedule,16.33,20.37,
Rhophylac injection,J2791,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18.03,,,,,,,fee schedule,16.33,20.37,
"Rho(D) immune globulin h, sd",J2792,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.06,,,,,,,fee schedule,34.26,68.67,
"Rho(D) immune globulin h, sd",J2792,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,65.24,,,,,,,fee schedule,34.26,68.67,
"Rho(D) immune globulin h, sd",J2792,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,68.67,,,,,,,fee schedule,34.26,68.67,
"Rho(D) immune globulin h, sd",J2792,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52.3,,,,,,,fee schedule,34.26,68.67,
"Rho(D) immune globulin h, sd",J2792,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.13,,,,,,,fee schedule,34.26,68.67,
"Rho(D) immune globulin h, sd",J2792,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,62.15,,,,,,,fee schedule,34.26,68.67,
"Rho(D) immune globulin h, sd",J2792,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,39.74,,,,,,,fee schedule,34.26,68.67,OP High Cost Drugs
"Rho(D) immune globulin h, sd",J2792,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,34.26,,,,,,,fee schedule,34.26,68.67,Other Pharmacy
"Rho(D) immune globulin h, sd",J2792,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,35.97,,,,,,,fee schedule,34.26,68.67,APC
"Rho(D) immune globulin h, sd",J2792,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,35.63,,,,,,,fee schedule,34.26,68.67,APC
"Rho(D) immune globulin h, sd",J2792,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,52.41,,,,,,,fee schedule,34.26,68.67,Radiology
"Rho(D) immune globulin h, sd",J2792,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,47.96,,,,,,,fee schedule,34.26,68.67,APC
"Rho(D) immune globulin h, sd",J2792,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,59.95,,,,,,,fee schedule,34.26,68.67,APC
Rilonacept injection,J2793,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83.83,,,,,,,fee schedule,38.61,91.06,
Rilonacept injection,J2793,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,91.06,,,,,,,fee schedule,38.61,91.06,
Rilonacept injection,J2793,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42.66,,,,,,,fee schedule,38.61,91.06,
Rilonacept injection,J2793,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,72.99,,,,,,,fee schedule,38.61,91.06,
Rilonacept injection,J2793,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,79.74,,,,,,,fee schedule,38.61,91.06,
Rilonacept injection,J2793,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38.61,,,,,,,fee schedule,38.61,91.06,
"Risperidone, long acting",J2794,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17.71,,,,,,,fee schedule,10.8,23.31,
"Risperidone, long acting",J2794,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19.24,,,,,,,fee schedule,10.8,23.31,
"Risperidone, long acting",J2794,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23.31,,,,,,,fee schedule,10.8,23.31,
"Risperidone, long acting",J2794,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15.42,,,,,,,fee schedule,10.8,23.31,
"Risperidone, long acting",J2794,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.85,,,,,,,fee schedule,10.8,23.31,
"Risperidone, long acting",J2794,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21.09,,,,,,,fee schedule,10.8,23.31,
"Risperidone, long acting",J2794,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.52,,,,,,,fee schedule,10.8,23.31,OP High Cost Drugs
"Risperidone, long acting",J2794,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10.8,,,,,,,fee schedule,10.8,23.31,Other Pharmacy
"Risperidone, long acting",J2794,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.34,,,,,,,fee schedule,10.8,23.31,APC
"Risperidone, long acting",J2794,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11.23,,,,,,,fee schedule,10.8,23.31,APC
"Risperidone, long acting",J2794,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.52,,,,,,,fee schedule,10.8,23.31,Radiology
"Risperidone, long acting",J2794,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15.11,,,,,,,fee schedule,10.8,23.31,APC
"Risperidone, long acting",J2794,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18.89,,,,,,,fee schedule,10.8,23.31,APC
Ropivacaine HCl injection,J2795,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.28,,,,,,,fee schedule,0.26,0.28,
Ropivacaine HCl injection,J2795,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.26,,,,,,,fee schedule,0.26,0.28,
Romiplostim injection,J2796,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,177.24,,,,,,,fee schedule,154.32,198.84,
Romiplostim injection,J2796,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,192.52,,,,,,,fee schedule,154.32,198.84,
Romiplostim injection,J2796,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,198.84,,,,,,,fee schedule,154.32,198.84,
Romiplostim injection,J2796,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,154.32,,,,,,,fee schedule,154.32,198.84,
Romiplostim injection,J2796,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,168.58,,,,,,,fee schedule,154.32,198.84,
Romiplostim injection,J2796,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,179.97,,,,,,,fee schedule,154.32,198.84,
"Inj., rolapitant, 0.5 mg",J2797,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.27,,,,,,,fee schedule,2.85,3.55,
"Inj., rolapitant, 0.5 mg",J2797,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.55,,,,,,,fee schedule,2.85,3.55,
"Inj., rolapitant, 0.5 mg",J2797,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.85,,,,,,,fee schedule,2.85,3.55,
"Inj., rolapitant, 0.5 mg",J2797,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.11,,,,,,,fee schedule,2.85,3.55,
"Inj., perseris, 0.5 mg",J2798,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,34.33,,,,,,,fee schedule,12.17,37.29,
"Inj., perseris, 0.5 mg",J2798,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37.29,,,,,,,fee schedule,12.17,37.29,
"Inj., perseris, 0.5 mg",J2798,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23.08,,,,,,,fee schedule,12.17,37.29,
"Inj., perseris, 0.5 mg",J2798,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29.89,,,,,,,fee schedule,12.17,37.29,
"Inj., perseris, 0.5 mg",J2798,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32.66,,,,,,,fee schedule,12.17,37.29,
"Inj., perseris, 0.5 mg",J2798,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20.89,,,,,,,fee schedule,12.17,37.29,
"Inj., perseris, 0.5 mg",J2798,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14.12,,,,,,,fee schedule,12.17,37.29,OP High Cost Drugs
"Inj., perseris, 0.5 mg",J2798,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12.17,,,,,,,fee schedule,12.17,37.29,Other Pharmacy
"Inj., perseris, 0.5 mg",J2798,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.78,,,,,,,fee schedule,12.17,37.29,APC
"Inj., perseris, 0.5 mg",J2798,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.66,,,,,,,fee schedule,12.17,37.29,APC
"Inj., perseris, 0.5 mg",J2798,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.62,,,,,,,fee schedule,12.17,37.29,Radiology
"Inj., perseris, 0.5 mg",J2798,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.04,,,,,,,fee schedule,12.17,37.29,APC
"Inj., perseris, 0.5 mg",J2798,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21.3,,,,,,,fee schedule,12.17,37.29,APC
"Inj, uzedy, 1 mg",J2799,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,88.32,,,,,,,fee schedule,25.16,95.93,
"Inj, uzedy, 1 mg",J2799,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,95.93,,,,,,,fee schedule,25.16,95.93,
"Inj, uzedy, 1 mg",J2799,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,48.59,,,,,,,fee schedule,25.16,95.93,
"Inj, uzedy, 1 mg",J2799,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,76.9,,,,,,,fee schedule,25.16,95.93,
"Inj, uzedy, 1 mg",J2799,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,84,,,,,,,fee schedule,25.16,95.93,
"Inj, uzedy, 1 mg",J2799,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,43.97,,,,,,,fee schedule,25.16,95.93,
"Inj, uzedy, 1 mg",J2799,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,29.18,,,,,,,fee schedule,25.16,95.93,OP High Cost Drugs
"Inj, uzedy, 1 mg",J2799,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.16,,,,,,,fee schedule,25.16,95.93,Other Pharmacy
"Inj, uzedy, 1 mg",J2799,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,26.41,,,,,,,fee schedule,25.16,95.93,APC
"Inj, uzedy, 1 mg",J2799,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,26.16,,,,,,,fee schedule,25.16,95.93,APC
"Inj, uzedy, 1 mg",J2799,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,38.49,,,,,,,fee schedule,25.16,95.93,Radiology
"Inj, uzedy, 1 mg",J2799,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,35.22,,,,,,,fee schedule,25.16,95.93,APC
"Inj, uzedy, 1 mg",J2799,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,44.02,,,,,,,fee schedule,25.16,95.93,APC
Methocarbamol injection,J2800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18.96,,,,,,,fee schedule,17.16,18.96,
Methocarbamol injection,J2800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17.16,,,,,,,fee schedule,17.16,18.96,
"Inj, rykindo, 0.5 mg",J2801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23.31,,,,,,,fee schedule,13.03,57.81,
"Inj, rykindo, 0.5 mg",J2801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21.09,,,,,,,fee schedule,13.03,57.81,
"Inj, rykindo, 0.5 mg",J2801,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,57.81,,,,,,,fee schedule,13.03,57.81,APC 378
"Inj, rykindo, 0.5 mg",J2801,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.68,,,,,,,fee schedule,13.03,57.81,APC
"Inj, rykindo, 0.5 mg",J2801,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.55,,,,,,,fee schedule,13.03,57.81,APC
"Inj, rykindo, 0.5 mg",J2801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.03,,,,,,,fee schedule,13.03,57.81,APC
"Inj, rykindo, 0.5 mg",J2801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.94,,,,,,,fee schedule,13.03,57.81,Radiology
"Inj, rykindo, 0.5 mg",J2801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.24,,,,,,,fee schedule,13.03,57.81,APC
"Inj, rykindo, 0.5 mg",J2801,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22.8,,,,,,,fee schedule,13.03,57.81,APC
Sincalide injection,J2805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,235.36,,,,,,,fee schedule,213.01,235.36,
Sincalide injection,J2805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,213.01,,,,,,,fee schedule,213.01,235.36,
Inj theophylline per 40 MG,J2810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.5,,,,,,,fee schedule,1.36,1.5,
Inj theophylline per 40 MG,J2810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.36,,,,,,,fee schedule,1.36,1.5,
Sargramostim injection,J2820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,93.82,,,,,,,fee schedule,61.89,110.71,
Sargramostim injection,J2820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,101.91,,,,,,,fee schedule,61.89,110.71,
Sargramostim injection,J2820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,110.71,,,,,,,fee schedule,61.89,110.71,
Sargramostim injection,J2820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,81.69,,,,,,,fee schedule,61.89,110.71,
Sargramostim injection,J2820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,89.24,,,,,,,fee schedule,61.89,110.71,
Sargramostim injection,J2820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,100.2,,,,,,,fee schedule,61.89,110.71,
Sargramostim injection,J2820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,71.79,,,,,,,fee schedule,61.89,110.71,OP High Cost Drugs
Sargramostim injection,J2820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,61.89,,,,,,,fee schedule,61.89,110.71,Other Pharmacy
Sargramostim injection,J2820,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,64.98,,,,,,,fee schedule,61.89,110.71,APC
Sargramostim injection,J2820,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,64.36,,,,,,,fee schedule,61.89,110.71,APC
Sargramostim injection,J2820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,94.69,,,,,,,fee schedule,61.89,110.71,Radiology
Sargramostim injection,J2820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,86.64,,,,,,,fee schedule,61.89,110.71,APC
Sargramostim injection,J2820,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,108.3,,,,,,,fee schedule,61.89,110.71,APC
Inj sebelipase alfa 1 mg,J2840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1844.4,,,,,,,fee schedule,540.17,2396.57,
Inj sebelipase alfa 1 mg,J2840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2003.4,,,,,,,fee schedule,540.17,2396.57,
Inj sebelipase alfa 1 mg,J2840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,967.91,,,,,,,fee schedule,540.17,2396.57,
Inj sebelipase alfa 1 mg,J2840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1605.9,,,,,,,fee schedule,540.17,2396.57,
Inj sebelipase alfa 1 mg,J2840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1754.3,,,,,,,fee schedule,540.17,2396.57,
Inj sebelipase alfa 1 mg,J2840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,876.02,,,,,,,fee schedule,540.17,2396.57,
Inj sebelipase alfa 1 mg,J2840,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2396.57,,,,,,,fee schedule,540.17,2396.57,APC 378
Inj sebelipase alfa 1 mg,J2840,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,567.18,,,,,,,fee schedule,540.17,2396.57,APC
Inj sebelipase alfa 1 mg,J2840,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,561.78,,,,,,,fee schedule,540.17,2396.57,APC
Inj sebelipase alfa 1 mg,J2840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,540.17,,,,,,,fee schedule,540.17,2396.57,APC
Inj sebelipase alfa 1 mg,J2840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,826.47,,,,,,,fee schedule,540.17,2396.57,Radiology
Inj sebelipase alfa 1 mg,J2840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,756.24,,,,,,,fee schedule,540.17,2396.57,APC
Inj sebelipase alfa 1 mg,J2840,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,945.31,,,,,,,fee schedule,540.17,2396.57,APC
Inj secretin synthetic human,J2850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,72.59,,,,,,,fee schedule,40.23,178.48,
Inj secretin synthetic human,J2850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,78.85,,,,,,,fee schedule,40.23,178.48,
Inj secretin synthetic human,J2850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,62.22,,,,,,,fee schedule,40.23,178.48,
Inj secretin synthetic human,J2850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,63.21,,,,,,,fee schedule,40.23,178.48,
Inj secretin synthetic human,J2850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,69.05,,,,,,,fee schedule,40.23,178.48,
Inj secretin synthetic human,J2850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56.31,,,,,,,fee schedule,40.23,178.48,
Inj secretin synthetic human,J2850,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,178.48,,,,,,,fee schedule,40.23,178.48,APC 378
Inj secretin synthetic human,J2850,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,42.24,,,,,,,fee schedule,40.23,178.48,APC
Inj secretin synthetic human,J2850,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,41.84,,,,,,,fee schedule,40.23,178.48,APC
Inj secretin synthetic human,J2850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,40.23,,,,,,,fee schedule,40.23,178.48,APC
Inj secretin synthetic human,J2850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,61.55,,,,,,,fee schedule,40.23,178.48,Radiology
Inj secretin synthetic human,J2850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.32,,,,,,,fee schedule,40.23,178.48,APC
Inj secretin synthetic human,J2850,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,70.4,,,,,,,fee schedule,40.23,178.48,APC
"Injection, siltuximab",J2860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,31.32,,,,,,,fee schedule,27.27,304.63,
"Injection, siltuximab",J2860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,34.02,,,,,,,fee schedule,27.27,304.63,
"Injection, siltuximab",J2860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,253.56,,,,,,,fee schedule,27.27,304.63,
"Injection, siltuximab",J2860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,27.27,,,,,,,fee schedule,27.27,304.63,
"Injection, siltuximab",J2860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29.79,,,,,,,fee schedule,27.27,304.63,
"Injection, siltuximab",J2860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,229.49,,,,,,,fee schedule,27.27,304.63,
"Injection, siltuximab",J2860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,201.93,,,,,,,fee schedule,27.27,304.63,OP High Cost Drugs
"Injection, siltuximab",J2860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,174.08,,,,,,,fee schedule,27.27,304.63,Other Pharmacy
"Injection, siltuximab",J2860,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,182.78,,,,,,,fee schedule,27.27,304.63,APC
"Injection, siltuximab",J2860,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,181.04,,,,,,,fee schedule,27.27,304.63,APC
"Injection, siltuximab",J2860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,266.33,,,,,,,fee schedule,27.27,304.63,Radiology
"Injection, siltuximab",J2860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,243.7,,,,,,,fee schedule,27.27,304.63,APC
"Injection, siltuximab",J2860,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,304.63,,,,,,,fee schedule,27.27,304.63,APC
Na ferric gluconate complex,J2916,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12.06,,,,,,,fee schedule,10.91,12.06,
Na ferric gluconate complex,J2916,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10.91,,,,,,,fee schedule,10.91,12.06,
"Inj, methylpred sod succ 5mg",J2919,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.06,,,,,,,fee schedule,0.96,1.06,
"Inj, methylpred sod succ 5mg",J2919,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.96,,,,,,,fee schedule,0.96,1.06,
Somatrem injection,J2940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,153.99,,,,,,,fee schedule,134.08,167.27,
Somatrem injection,J2940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,167.27,,,,,,,fee schedule,134.08,167.27,
Somatrem injection,J2940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,134.08,,,,,,,fee schedule,134.08,167.27,
Somatrem injection,J2940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,146.47,,,,,,,fee schedule,134.08,167.27,
Somatropin injection,J2941,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,181.45,,,,,,,fee schedule,157.98,272.47,
Somatropin injection,J2941,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,197.09,,,,,,,fee schedule,157.98,272.47,
Somatropin injection,J2941,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,272.47,,,,,,,fee schedule,157.98,272.47,
Somatropin injection,J2941,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,157.98,,,,,,,fee schedule,157.98,272.47,
Somatropin injection,J2941,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,172.58,,,,,,,fee schedule,157.98,272.47,
Somatropin injection,J2941,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,246.6,,,,,,,fee schedule,157.98,272.47,
Reteplase injection,J2993,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3016.6,,,,,,,fee schedule,2626.53,12886.62,
Reteplase injection,J2993,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3276.66,,,,,,,fee schedule,2626.53,12886.62,
Reteplase injection,J2993,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2626.53,,,,,,,fee schedule,2626.53,12886.62,
Reteplase injection,J2993,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2869.24,,,,,,,fee schedule,2626.53,12886.62,
Reteplase injection,J2993,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,12886.62,,,,,,,fee schedule,2626.53,12886.62,APC 378
Reteplase injection,J2993,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3049.8,,,,,,,fee schedule,2626.53,12886.62,APC
Reteplase injection,J2993,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3020.76,,,,,,,fee schedule,2626.53,12886.62,APC
Reteplase injection,J2993,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2904.58,,,,,,,fee schedule,2626.53,12886.62,APC
Reteplase injection,J2993,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4444,,,,,,,fee schedule,2626.53,12886.62,Radiology
Reteplase injection,J2993,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4066.4,,,,,,,fee schedule,2626.53,12886.62,APC
Reteplase injection,J2993,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5083.01,,,,,,,fee schedule,2626.53,12886.62,APC
Inj streptokinase /250000 IU,J2995,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,75.34,,,,,,,fee schedule,65.6,81.84,
Inj streptokinase /250000 IU,J2995,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,81.84,,,,,,,fee schedule,65.6,81.84,
Inj streptokinase /250000 IU,J2995,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,65.6,,,,,,,fee schedule,65.6,81.84,
Inj streptokinase /250000 IU,J2995,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,71.66,,,,,,,fee schedule,65.6,81.84,
Alteplase recombinant,J2997,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,117.48,,,,,,,fee schedule,95.09,167.01,
Alteplase recombinant,J2997,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,127.61,,,,,,,fee schedule,95.09,167.01,
Alteplase recombinant,J2997,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,167.01,,,,,,,fee schedule,95.09,167.01,
Alteplase recombinant,J2997,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,102.29,,,,,,,fee schedule,95.09,167.01,
Alteplase recombinant,J2997,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,111.75,,,,,,,fee schedule,95.09,167.01,
Alteplase recombinant,J2997,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,151.15,,,,,,,fee schedule,95.09,167.01,
Alteplase recombinant,J2997,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,110.3,,,,,,,fee schedule,95.09,167.01,OP High Cost Drugs
Alteplase recombinant,J2997,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,95.09,,,,,,,fee schedule,95.09,167.01,Other Pharmacy
Alteplase recombinant,J2997,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,99.84,,,,,,,fee schedule,95.09,167.01,APC
Alteplase recombinant,J2997,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,98.89,,,,,,,fee schedule,95.09,167.01,APC
Alteplase recombinant,J2997,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,145.49,,,,,,,fee schedule,95.09,167.01,Radiology
Alteplase recombinant,J2997,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,133.13,,,,,,,fee schedule,95.09,167.01,APC
Alteplase recombinant,J2997,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,166.41,,,,,,,fee schedule,95.09,167.01,APC
Inj plasminogen tvmh 1mg,J2998,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,107.36,,,,,,,fee schedule,38.39,170.34,
Inj plasminogen tvmh 1mg,J2998,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,116.61,,,,,,,fee schedule,38.39,170.34,
Inj plasminogen tvmh 1mg,J2998,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,62.41,,,,,,,fee schedule,38.39,170.34,
Inj plasminogen tvmh 1mg,J2998,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,93.48,,,,,,,fee schedule,38.39,170.34,
Inj plasminogen tvmh 1mg,J2998,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,102.11,,,,,,,fee schedule,38.39,170.34,
Inj plasminogen tvmh 1mg,J2998,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56.49,,,,,,,fee schedule,38.39,170.34,
Inj plasminogen tvmh 1mg,J2998,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,170.34,,,,,,,fee schedule,38.39,170.34,APC 378
Inj plasminogen tvmh 1mg,J2998,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,40.31,,,,,,,fee schedule,38.39,170.34,APC
Inj plasminogen tvmh 1mg,J2998,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,39.93,,,,,,,fee schedule,38.39,170.34,APC
Inj plasminogen tvmh 1mg,J2998,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,38.39,,,,,,,fee schedule,38.39,170.34,APC
Inj plasminogen tvmh 1mg,J2998,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,58.74,,,,,,,fee schedule,38.39,170.34,Radiology
Inj plasminogen tvmh 1mg,J2998,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,53.75,,,,,,,fee schedule,38.39,170.34,APC
Inj plasminogen tvmh 1mg,J2998,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,67.19,,,,,,,fee schedule,38.39,170.34,APC
Streptomycin injection,J3000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,148.13,,,,,,,fee schedule,134.06,148.13,
Streptomycin injection,J3000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,134.06,,,,,,,fee schedule,134.06,148.13,
Fentanyl citrate injeciton,J3010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.1,,,,,,,fee schedule,1.9,2.1,
Fentanyl citrate injeciton,J3010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.9,,,,,,,fee schedule,1.9,2.1,
Sumatriptan succinate / 6 MG,J3030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,259.33,,,,,,,fee schedule,153.52,281.69,
Sumatriptan succinate / 6 MG,J3030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,281.69,,,,,,,fee schedule,153.52,281.69,
Sumatriptan succinate / 6 MG,J3030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,169.63,,,,,,,fee schedule,153.52,281.69,
Sumatriptan succinate / 6 MG,J3030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,225.8,,,,,,,fee schedule,153.52,281.69,
Sumatriptan succinate / 6 MG,J3030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,246.66,,,,,,,fee schedule,153.52,281.69,
Sumatriptan succinate / 6 MG,J3030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,153.52,,,,,,,fee schedule,153.52,281.69,
"Inj., fremanezumab-vfrm 1 mg",J3031,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8.72,,,,,,,fee schedule,5.62,9.47,
"Inj., fremanezumab-vfrm 1 mg",J3031,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.47,,,,,,,fee schedule,5.62,9.47,
"Inj., fremanezumab-vfrm 1 mg",J3031,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.21,,,,,,,fee schedule,5.62,9.47,
"Inj., fremanezumab-vfrm 1 mg",J3031,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7.59,,,,,,,fee schedule,5.62,9.47,
"Inj., fremanezumab-vfrm 1 mg",J3031,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.29,,,,,,,fee schedule,5.62,9.47,
"Inj., fremanezumab-vfrm 1 mg",J3031,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.62,,,,,,,fee schedule,5.62,9.47,
Inj. eptinezumab-jjmr 1 mg,J3032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,54.29,,,,,,,fee schedule,20.55,58.98,
Inj. eptinezumab-jjmr 1 mg,J3032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,58.98,,,,,,,fee schedule,20.55,58.98,
Inj. eptinezumab-jjmr 1 mg,J3032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,34.65,,,,,,,fee schedule,20.55,58.98,
Inj. eptinezumab-jjmr 1 mg,J3032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,47.27,,,,,,,fee schedule,20.55,58.98,
Inj. eptinezumab-jjmr 1 mg,J3032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.64,,,,,,,fee schedule,20.55,58.98,
Inj. eptinezumab-jjmr 1 mg,J3032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31.36,,,,,,,fee schedule,20.55,58.98,
Inj. eptinezumab-jjmr 1 mg,J3032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,23.83,,,,,,,fee schedule,20.55,58.98,OP High Cost Drugs
Inj. eptinezumab-jjmr 1 mg,J3032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.55,,,,,,,fee schedule,20.55,58.98,Other Pharmacy
Inj. eptinezumab-jjmr 1 mg,J3032,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.57,,,,,,,fee schedule,20.55,58.98,APC
Inj. eptinezumab-jjmr 1 mg,J3032,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,21.37,,,,,,,fee schedule,20.55,58.98,APC
Inj. eptinezumab-jjmr 1 mg,J3032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,31.44,,,,,,,fee schedule,20.55,58.98,Radiology
Inj. eptinezumab-jjmr 1 mg,J3032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.76,,,,,,,fee schedule,20.55,58.98,APC
Inj. eptinezumab-jjmr 1 mg,J3032,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,35.96,,,,,,,fee schedule,20.55,58.98,APC
Inj talquetamab-tgvs 0.25 mg,J3055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,127.82,,,,,,,fee schedule,74.88,131.03,
Inj talquetamab-tgvs 0.25 mg,J3055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,115.69,,,,,,,fee schedule,74.88,131.03,
Inj talquetamab-tgvs 0.25 mg,J3055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.86,,,,,,,fee schedule,74.88,131.03,OP High Cost Drugs
Inj talquetamab-tgvs 0.25 mg,J3055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,74.88,,,,,,,fee schedule,74.88,131.03,Other Pharmacy
Inj talquetamab-tgvs 0.25 mg,J3055,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,78.62,,,,,,,fee schedule,74.88,131.03,APC
Inj talquetamab-tgvs 0.25 mg,J3055,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,77.87,,,,,,,fee schedule,74.88,131.03,APC
Inj talquetamab-tgvs 0.25 mg,J3055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,114.56,,,,,,,fee schedule,74.88,131.03,Radiology
Inj talquetamab-tgvs 0.25 mg,J3055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,104.83,,,,,,,fee schedule,74.88,131.03,APC
Inj talquetamab-tgvs 0.25 mg,J3055,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,131.03,,,,,,,fee schedule,74.88,131.03,APC
"Inj, taliglucerace alfa 10 u",J3060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,122.6,,,,,,,fee schedule,40.66,133.17,
"Inj, taliglucerace alfa 10 u",J3060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,133.17,,,,,,,fee schedule,40.66,133.17,
"Inj, taliglucerace alfa 10 u",J3060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,82.73,,,,,,,fee schedule,40.66,133.17,
"Inj, taliglucerace alfa 10 u",J3060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,106.75,,,,,,,fee schedule,40.66,133.17,
"Inj, taliglucerace alfa 10 u",J3060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,116.61,,,,,,,fee schedule,40.66,133.17,
"Inj, taliglucerace alfa 10 u",J3060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,74.87,,,,,,,fee schedule,40.66,133.17,
"Inj, taliglucerace alfa 10 u",J3060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,47.16,,,,,,,fee schedule,40.66,133.17,OP High Cost Drugs
"Inj, taliglucerace alfa 10 u",J3060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40.66,,,,,,,fee schedule,40.66,133.17,Other Pharmacy
"Inj, taliglucerace alfa 10 u",J3060,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,42.69,,,,,,,fee schedule,40.66,133.17,APC
"Inj, taliglucerace alfa 10 u",J3060,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,42.28,,,,,,,fee schedule,40.66,133.17,APC
"Inj, taliglucerace alfa 10 u",J3060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,62.21,,,,,,,fee schedule,40.66,133.17,Radiology
"Inj, taliglucerace alfa 10 u",J3060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.92,,,,,,,fee schedule,40.66,133.17,APC
"Inj, taliglucerace alfa 10 u",J3060,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,71.15,,,,,,,fee schedule,40.66,133.17,APC
Pentazocine injection,J3070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,488.91,,,,,,,fee schedule,38.44,531.05,
Pentazocine injection,J3070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,531.05,,,,,,,fee schedule,38.44,531.05,
Pentazocine injection,J3070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42.47,,,,,,,fee schedule,38.44,531.05,
Pentazocine injection,J3070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,425.68,,,,,,,fee schedule,38.44,531.05,
Pentazocine injection,J3070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,465.02,,,,,,,fee schedule,38.44,531.05,
Pentazocine injection,J3070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38.44,,,,,,,fee schedule,38.44,531.05,
Inj tedizolid phosphate,J3090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.21,,,,,,,fee schedule,1.96,4.57,
Inj tedizolid phosphate,J3090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.57,,,,,,,fee schedule,1.96,4.57,
Inj tedizolid phosphate,J3090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.25,,,,,,,fee schedule,1.96,4.57,
Inj tedizolid phosphate,J3090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.67,,,,,,,fee schedule,1.96,4.57,
Inj tedizolid phosphate,J3090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.01,,,,,,,fee schedule,1.96,4.57,
Inj tedizolid phosphate,J3090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.95,,,,,,,fee schedule,1.96,4.57,
Inj tedizolid phosphate,J3090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2.28,,,,,,,fee schedule,1.96,4.57,OP High Cost Drugs
Inj tedizolid phosphate,J3090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1.96,,,,,,,fee schedule,1.96,4.57,Other Pharmacy
Inj tedizolid phosphate,J3090,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2.06,,,,,,,fee schedule,1.96,4.57,APC
Inj tedizolid phosphate,J3090,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2.04,,,,,,,fee schedule,1.96,4.57,APC
Inj tedizolid phosphate,J3090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3,,,,,,,fee schedule,1.96,4.57,Radiology
Inj tedizolid phosphate,J3090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2.75,,,,,,,fee schedule,1.96,4.57,APC
Inj tedizolid phosphate,J3090,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3.44,,,,,,,fee schedule,1.96,4.57,APC
Telavancin injection,J3095,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.22,,,,,,,fee schedule,7.03,16.43,
Telavancin injection,J3095,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10.02,,,,,,,fee schedule,7.03,16.43,
Telavancin injection,J3095,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16.43,,,,,,,fee schedule,7.03,16.43,
Telavancin injection,J3095,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.03,,,,,,,fee schedule,7.03,16.43,
Telavancin injection,J3095,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.77,,,,,,,fee schedule,7.03,16.43,
Telavancin injection,J3095,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14.87,,,,,,,fee schedule,7.03,16.43,
Telavancin injection,J3095,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8.16,,,,,,,fee schedule,7.03,16.43,OP High Cost Drugs
Telavancin injection,J3095,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.03,,,,,,,fee schedule,7.03,16.43,Other Pharmacy
Telavancin injection,J3095,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.38,,,,,,,fee schedule,7.03,16.43,APC
Telavancin injection,J3095,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7.31,,,,,,,fee schedule,7.03,16.43,APC
Telavancin injection,J3095,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10.76,,,,,,,fee schedule,7.03,16.43,Radiology
Telavancin injection,J3095,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.84,,,,,,,fee schedule,7.03,16.43,APC
Telavancin injection,J3095,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12.31,,,,,,,fee schedule,7.03,16.43,APC
Tenecteplase injection,J3101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,142.89,,,,,,,fee schedule,124.41,345.52,
Tenecteplase injection,J3101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,155.21,,,,,,,fee schedule,124.41,345.52,
Tenecteplase injection,J3101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,296.82,,,,,,,fee schedule,124.41,345.52,
Tenecteplase injection,J3101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,124.41,,,,,,,fee schedule,124.41,345.52,
Tenecteplase injection,J3101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,135.91,,,,,,,fee schedule,124.41,345.52,
Tenecteplase injection,J3101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,268.64,,,,,,,fee schedule,124.41,345.52,
Tenecteplase injection,J3101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,229.03,,,,,,,fee schedule,124.41,345.52,OP High Cost Drugs
Tenecteplase injection,J3101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,197.44,,,,,,,fee schedule,124.41,345.52,Other Pharmacy
Tenecteplase injection,J3101,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,207.31,,,,,,,fee schedule,124.41,345.52,APC
Tenecteplase injection,J3101,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,205.34,,,,,,,fee schedule,124.41,345.52,APC
Tenecteplase injection,J3101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,302.08,,,,,,,fee schedule,124.41,345.52,Radiology
Tenecteplase injection,J3101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,276.42,,,,,,,fee schedule,124.41,345.52,APC
Tenecteplase injection,J3101,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,345.52,,,,,,,fee schedule,124.41,345.52,APC
Terbutaline sulfate inj,J3105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7.58,,,,,,,fee schedule,6.86,7.58,
Terbutaline sulfate inj,J3105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.86,,,,,,,fee schedule,6.86,7.58,
Teriparatide injection,J3110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41.1,,,,,,,fee schedule,35.78,125.03,
Teriparatide injection,J3110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,44.64,,,,,,,fee schedule,35.78,125.03,
Teriparatide injection,J3110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,125.03,,,,,,,fee schedule,35.78,125.03,
Teriparatide injection,J3110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35.78,,,,,,,fee schedule,35.78,125.03,
Teriparatide injection,J3110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39.09,,,,,,,fee schedule,35.78,125.03,
Teriparatide injection,J3110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,113.16,,,,,,,fee schedule,35.78,125.03,
Inj. romosozumab-aqqg 1 mg,J3111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,31.15,,,,,,,fee schedule,12.19,33.83,
Inj. romosozumab-aqqg 1 mg,J3111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33.83,,,,,,,fee schedule,12.19,33.83,
Inj. romosozumab-aqqg 1 mg,J3111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22.52,,,,,,,fee schedule,12.19,33.83,
Inj. romosozumab-aqqg 1 mg,J3111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,27.12,,,,,,,fee schedule,12.19,33.83,
Inj. romosozumab-aqqg 1 mg,J3111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29.63,,,,,,,fee schedule,12.19,33.83,
Inj. romosozumab-aqqg 1 mg,J3111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20.38,,,,,,,fee schedule,12.19,33.83,
Inj. romosozumab-aqqg 1 mg,J3111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14.14,,,,,,,fee schedule,12.19,33.83,OP High Cost Drugs
Inj. romosozumab-aqqg 1 mg,J3111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12.19,,,,,,,fee schedule,12.19,33.83,Other Pharmacy
Inj. romosozumab-aqqg 1 mg,J3111,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.8,,,,,,,fee schedule,12.19,33.83,APC
Inj. romosozumab-aqqg 1 mg,J3111,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.67,,,,,,,fee schedule,12.19,33.83,APC
Inj. romosozumab-aqqg 1 mg,J3111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.65,,,,,,,fee schedule,12.19,33.83,Radiology
Inj. romosozumab-aqqg 1 mg,J3111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.06,,,,,,,fee schedule,12.19,33.83,APC
Inj. romosozumab-aqqg 1 mg,J3111,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21.33,,,,,,,fee schedule,12.19,33.83,APC
Inj testostero enanthate 1mg,J3121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.21,,,,,,,fee schedule,0.18,2.73,
Inj testostero enanthate 1mg,J3121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.23,,,,,,,fee schedule,0.18,2.73,
Inj testostero enanthate 1mg,J3121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.73,,,,,,,fee schedule,0.18,2.73,
Inj testostero enanthate 1mg,J3121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.18,,,,,,,fee schedule,0.18,2.73,
Inj testostero enanthate 1mg,J3121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.2,,,,,,,fee schedule,0.18,2.73,
Inj testostero enanthate 1mg,J3121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.47,,,,,,,fee schedule,0.18,2.73,
Testosterone undecanoate 1mg,J3145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.97,,,,,,,fee schedule,2.13,4.77,
Testosterone undecanoate 1mg,J3145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.31,,,,,,,fee schedule,2.13,4.77,
Testosterone undecanoate 1mg,J3145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.77,,,,,,,fee schedule,2.13,4.77,
Testosterone undecanoate 1mg,J3145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.45,,,,,,,fee schedule,2.13,4.77,
Testosterone undecanoate 1mg,J3145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.77,,,,,,,fee schedule,2.13,4.77,
Testosterone undecanoate 1mg,J3145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.32,,,,,,,fee schedule,2.13,4.77,
Testosterone undecanoate 1mg,J3145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2.47,,,,,,,fee schedule,2.13,4.77,OP High Cost Drugs
Testosterone undecanoate 1mg,J3145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2.13,,,,,,,fee schedule,2.13,4.77,Other Pharmacy
Testosterone undecanoate 1mg,J3145,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2.24,,,,,,,fee schedule,2.13,4.77,APC
Testosterone undecanoate 1mg,J3145,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2.22,,,,,,,fee schedule,2.13,4.77,APC
Testosterone undecanoate 1mg,J3145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3.26,,,,,,,fee schedule,2.13,4.77,Radiology
Testosterone undecanoate 1mg,J3145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2.98,,,,,,,fee schedule,2.13,4.77,APC
Testosterone undecanoate 1mg,J3145,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3.73,,,,,,,fee schedule,2.13,4.77,APC
Chlorpromazine hcl injection,J3230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,62.76,,,,,,,fee schedule,56.8,62.76,
Chlorpromazine hcl injection,J3230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56.8,,,,,,,fee schedule,56.8,62.76,
Thyrotropin injection,J3240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3501.12,,,,,,,fee schedule,2125.34,3802.94,
Thyrotropin injection,J3240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3802.94,,,,,,,fee schedule,2125.34,3802.94,
Thyrotropin injection,J3240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3748.85,,,,,,,fee schedule,2125.34,3802.94,
Thyrotropin injection,J3240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3048.39,,,,,,,fee schedule,2125.34,3802.94,
Thyrotropin injection,J3240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3330.09,,,,,,,fee schedule,2125.34,3802.94,
Thyrotropin injection,J3240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3392.95,,,,,,,fee schedule,2125.34,3802.94,
Thyrotropin injection,J3240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2465.39,,,,,,,fee schedule,2125.34,3802.94,OP High Cost Drugs
Thyrotropin injection,J3240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2125.34,,,,,,,fee schedule,2125.34,3802.94,Other Pharmacy
Thyrotropin injection,J3240,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2231.6,,,,,,,fee schedule,2125.34,3802.94,APC
Thyrotropin injection,J3240,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2210.35,,,,,,,fee schedule,2125.34,3802.94,APC
Thyrotropin injection,J3240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3251.77,,,,,,,fee schedule,2125.34,3802.94,Radiology
Thyrotropin injection,J3240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2975.47,,,,,,,fee schedule,2125.34,3802.94,APC
Thyrotropin injection,J3240,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3719.34,,,,,,,fee schedule,2125.34,3802.94,APC
Inj. teprotumumab-trbw 10 mg,J3241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1099.26,,,,,,,fee schedule,367.91,1194.03,
Inj. teprotumumab-trbw 10 mg,J3241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1194.03,,,,,,,fee schedule,367.91,1194.03,
Inj. teprotumumab-trbw 10 mg,J3241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,645.3,,,,,,,fee schedule,367.91,1194.03,
Inj. teprotumumab-trbw 10 mg,J3241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,957.12,,,,,,,fee schedule,367.91,1194.03,
Inj. teprotumumab-trbw 10 mg,J3241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1045.56,,,,,,,fee schedule,367.91,1194.03,
Inj. teprotumumab-trbw 10 mg,J3241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,584.04,,,,,,,fee schedule,367.91,1194.03,
Inj. teprotumumab-trbw 10 mg,J3241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,426.77,,,,,,,fee schedule,367.91,1194.03,OP High Cost Drugs
Inj. teprotumumab-trbw 10 mg,J3241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,367.91,,,,,,,fee schedule,367.91,1194.03,Other Pharmacy
Inj. teprotumumab-trbw 10 mg,J3241,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,386.3,,,,,,,fee schedule,367.91,1194.03,APC
Inj. teprotumumab-trbw 10 mg,J3241,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,382.62,,,,,,,fee schedule,367.91,1194.03,APC
Inj. teprotumumab-trbw 10 mg,J3241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,562.9,,,,,,,fee schedule,367.91,1194.03,Radiology
Inj. teprotumumab-trbw 10 mg,J3241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,515.07,,,,,,,fee schedule,367.91,1194.03,APC
Inj. teprotumumab-trbw 10 mg,J3241,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,643.84,,,,,,,fee schedule,367.91,1194.03,APC
Tigecycline injection,J3243,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.97,,,,,,,fee schedule,3.45,4.46,
Tigecycline injection,J3243,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.31,,,,,,,fee schedule,3.45,4.46,
Tigecycline injection,J3243,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.46,,,,,,,fee schedule,3.45,4.46,
Tigecycline injection,J3243,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.45,,,,,,,fee schedule,3.45,4.46,
Tigecycline injection,J3243,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.77,,,,,,,fee schedule,3.45,4.46,
Tigecycline injection,J3243,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.03,,,,,,,fee schedule,3.45,4.46,
Inj. tigecycline (accord),J3244,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.34,,,,,,,fee schedule,4.83,5.34,
Inj. tigecycline (accord),J3244,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.83,,,,,,,fee schedule,4.83,5.34,
"Inj., tildrakizumab, 1 mg",J3245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,474.98,,,,,,,fee schedule,118.2,515.93,
"Inj., tildrakizumab, 1 mg",J3245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,515.93,,,,,,,fee schedule,118.2,515.93,
"Inj., tildrakizumab, 1 mg",J3245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,326.82,,,,,,,fee schedule,118.2,515.93,
"Inj., tildrakizumab, 1 mg",J3245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,413.56,,,,,,,fee schedule,118.2,515.93,
"Inj., tildrakizumab, 1 mg",J3245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,451.78,,,,,,,fee schedule,118.2,515.93,
"Inj., tildrakizumab, 1 mg",J3245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,295.8,,,,,,,fee schedule,118.2,515.93,
"Inj., tildrakizumab, 1 mg",J3245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,137.11,,,,,,,fee schedule,118.2,515.93,OP High Cost Drugs
"Inj., tildrakizumab, 1 mg",J3245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,118.2,,,,,,,fee schedule,118.2,515.93,Other Pharmacy
"Inj., tildrakizumab, 1 mg",J3245,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,124.11,,,,,,,fee schedule,118.2,515.93,APC
"Inj., tildrakizumab, 1 mg",J3245,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,122.93,,,,,,,fee schedule,118.2,515.93,APC
"Inj., tildrakizumab, 1 mg",J3245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,180.84,,,,,,,fee schedule,118.2,515.93,Radiology
"Inj., tildrakizumab, 1 mg",J3245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,165.48,,,,,,,fee schedule,118.2,515.93,APC
"Inj., tildrakizumab, 1 mg",J3245,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,206.85,,,,,,,fee schedule,118.2,515.93,APC
Tirofiban hcl,J3246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26.17,,,,,,,fee schedule,7.49,28.43,
Tirofiban hcl,J3246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,28.43,,,,,,,fee schedule,7.49,28.43,
Tirofiban hcl,J3246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8.28,,,,,,,fee schedule,7.49,28.43,
Tirofiban hcl,J3246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22.79,,,,,,,fee schedule,7.49,28.43,
Tirofiban hcl,J3246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24.89,,,,,,,fee schedule,7.49,28.43,
Tirofiban hcl,J3246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7.49,,,,,,,fee schedule,7.49,28.43,
Inj secukinumab intrav 1mg,J3247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,32.41,,,,,,,fee schedule,18.04,32.41,
Inj secukinumab intrav 1mg,J3247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29.33,,,,,,,fee schedule,18.04,32.41,
Inj secukinumab intrav 1mg,J3247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,20.93,,,,,,,fee schedule,18.04,32.41,OP High Cost Drugs
Inj secukinumab intrav 1mg,J3247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.04,,,,,,,fee schedule,18.04,32.41,Other Pharmacy
Inj secukinumab intrav 1mg,J3247,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18.94,,,,,,,fee schedule,18.04,32.41,APC
Inj secukinumab intrav 1mg,J3247,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18.76,,,,,,,fee schedule,18.04,32.41,APC
Inj secukinumab intrav 1mg,J3247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27.6,,,,,,,fee schedule,18.04,32.41,Radiology
Inj secukinumab intrav 1mg,J3247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.26,,,,,,,fee schedule,18.04,32.41,APC
Inj secukinumab intrav 1mg,J3247,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31.57,,,,,,,fee schedule,18.04,32.41,APC
Trimethobenzamide hcl inj,J3250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,99.95,,,,,,,fee schedule,90.46,99.95,
Trimethobenzamide hcl inj,J3250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,90.46,,,,,,,fee schedule,90.46,99.95,
Tobramycin sulfate injection,J3260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.98,,,,,,,fee schedule,3.6,3.98,
Tobramycin sulfate injection,J3260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.6,,,,,,,fee schedule,3.6,3.98,
Tocilizumab injection,J3262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12.88,,,,,,,fee schedule,5.53,13.99,
Tocilizumab injection,J3262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13.99,,,,,,,fee schedule,5.53,13.99,
Tocilizumab injection,J3262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12.59,,,,,,,fee schedule,5.53,13.99,
Tocilizumab injection,J3262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11.21,,,,,,,fee schedule,5.53,13.99,
Tocilizumab injection,J3262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12.25,,,,,,,fee schedule,5.53,13.99,
Tocilizumab injection,J3262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11.4,,,,,,,fee schedule,5.53,13.99,
Tocilizumab injection,J3262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6.41,,,,,,,fee schedule,5.53,13.99,OP High Cost Drugs
Tocilizumab injection,J3262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.53,,,,,,,fee schedule,5.53,13.99,Other Pharmacy
Tocilizumab injection,J3262,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.81,,,,,,,fee schedule,5.53,13.99,APC
Tocilizumab injection,J3262,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5.75,,,,,,,fee schedule,5.53,13.99,APC
Tocilizumab injection,J3262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8.46,,,,,,,fee schedule,5.53,13.99,Radiology
Tocilizumab injection,J3262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.74,,,,,,,fee schedule,5.53,13.99,APC
Tocilizumab injection,J3262,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9.68,,,,,,,fee schedule,5.53,13.99,APC
"Inj, toripalimab-tpzi, 1 mg",J3263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,71.65,,,,,,,fee schedule,39.99,71.65,
"Inj, toripalimab-tpzi, 1 mg",J3263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,64.85,,,,,,,fee schedule,39.99,71.65,
"Inj, toripalimab-tpzi, 1 mg",J3263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,46.39,,,,,,,fee schedule,39.99,71.65,OP High Cost Drugs
"Inj, toripalimab-tpzi, 1 mg",J3263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,39.99,,,,,,,fee schedule,39.99,71.65,Other Pharmacy
"Inj, toripalimab-tpzi, 1 mg",J3263,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,41.99,,,,,,,fee schedule,39.99,71.65,APC
"Inj, toripalimab-tpzi, 1 mg",J3263,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,41.59,,,,,,,fee schedule,39.99,71.65,APC
"Inj, toripalimab-tpzi, 1 mg",J3263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,61.19,,,,,,,fee schedule,39.99,71.65,Radiology
"Inj, toripalimab-tpzi, 1 mg",J3263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,55.99,,,,,,,fee schedule,39.99,71.65,APC
"Inj, toripalimab-tpzi, 1 mg",J3263,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,69.99,,,,,,,fee schedule,39.99,71.65,APC
Injection torsemide 10 mg/ml,J3265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.64,,,,,,,fee schedule,5.11,5.64,
Injection torsemide 10 mg/ml,J3265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.11,,,,,,,fee schedule,5.11,5.64,
Treprostinil injection,J3285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,199.72,,,,,,,fee schedule,55.18,216.93,
Treprostinil injection,J3285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,216.93,,,,,,,fee schedule,55.18,216.93,
Treprostinil injection,J3285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,114.68,,,,,,,fee schedule,55.18,216.93,
Treprostinil injection,J3285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,173.89,,,,,,,fee schedule,55.18,216.93,
Treprostinil injection,J3285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,189.96,,,,,,,fee schedule,55.18,216.93,
Treprostinil injection,J3285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,103.79,,,,,,,fee schedule,55.18,216.93,
Treprostinil injection,J3285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,64.01,,,,,,,fee schedule,55.18,216.93,OP High Cost Drugs
Treprostinil injection,J3285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,55.18,,,,,,,fee schedule,55.18,216.93,Other Pharmacy
Treprostinil injection,J3285,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,57.94,,,,,,,fee schedule,55.18,216.93,APC
Treprostinil injection,J3285,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,57.39,,,,,,,fee schedule,55.18,216.93,APC
Treprostinil injection,J3285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,84.43,,,,,,,fee schedule,55.18,216.93,Radiology
Treprostinil injection,J3285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,77.26,,,,,,,fee schedule,55.18,216.93,APC
Treprostinil injection,J3285,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,96.57,,,,,,,fee schedule,55.18,216.93,APC
Inj xipere 1 mg,J3299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,149.12,,,,,,,fee schedule,47.78,161.97,
Inj xipere 1 mg,J3299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,161.97,,,,,,,fee schedule,47.78,161.97,
Inj xipere 1 mg,J3299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,86.9,,,,,,,fee schedule,47.78,161.97,
Inj xipere 1 mg,J3299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,129.84,,,,,,,fee schedule,47.78,161.97,
Inj xipere 1 mg,J3299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,141.83,,,,,,,fee schedule,47.78,161.97,
Inj xipere 1 mg,J3299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,78.65,,,,,,,fee schedule,47.78,161.97,
Inj xipere 1 mg,J3299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,55.42,,,,,,,fee schedule,47.78,161.97,OP High Cost Drugs
Inj xipere 1 mg,J3299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,47.78,,,,,,,fee schedule,47.78,161.97,Other Pharmacy
Inj xipere 1 mg,J3299,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,50.17,,,,,,,fee schedule,47.78,161.97,APC
Inj xipere 1 mg,J3299,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,49.69,,,,,,,fee schedule,47.78,161.97,APC
Inj xipere 1 mg,J3299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,73.1,,,,,,,fee schedule,47.78,161.97,Radiology
Inj xipere 1 mg,J3299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,66.89,,,,,,,fee schedule,47.78,161.97,APC
Inj xipere 1 mg,J3299,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,83.61,,,,,,,fee schedule,47.78,161.97,APC
Triamcinolone A inj PRS-free,J3300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11.31,,,,,,,fee schedule,9.85,44.75,
Triamcinolone A inj PRS-free,J3300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12.29,,,,,,,fee schedule,9.85,44.75,
Triamcinolone A inj PRS-free,J3300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,44.75,,,,,,,fee schedule,9.85,44.75,
Triamcinolone A inj PRS-free,J3300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.85,,,,,,,fee schedule,9.85,44.75,
Triamcinolone A inj PRS-free,J3300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10.76,,,,,,,fee schedule,9.85,44.75,
Triamcinolone A inj PRS-free,J3300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40.5,,,,,,,fee schedule,9.85,44.75,
Triamcinolone A inj PRS-free,J3300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,21.78,,,,,,,fee schedule,9.85,44.75,OP High Cost Drugs
Triamcinolone A inj PRS-free,J3300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.78,,,,,,,fee schedule,9.85,44.75,Other Pharmacy
Triamcinolone A inj PRS-free,J3300,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.72,,,,,,,fee schedule,9.85,44.75,APC
Triamcinolone A inj PRS-free,J3300,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,19.53,,,,,,,fee schedule,9.85,44.75,APC
Triamcinolone A inj PRS-free,J3300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.73,,,,,,,fee schedule,9.85,44.75,Radiology
Triamcinolone A inj PRS-free,J3300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26.29,,,,,,,fee schedule,9.85,44.75,APC
Triamcinolone A inj PRS-free,J3300,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,32.86,,,,,,,fee schedule,9.85,44.75,APC
Triamcinolone acet inj nos,J3301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.93,,,,,,,fee schedule,3.56,3.93,
Triamcinolone acet inj nos,J3301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.56,,,,,,,fee schedule,3.56,3.93,
Triamcinolone diacetate inj,J3302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.55,,,,,,,fee schedule,0.5,0.55,
Triamcinolone diacetate inj,J3302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.5,,,,,,,fee schedule,0.5,0.55,
Triamcinolone hexacetonl inj,J3303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15.41,,,,,,,fee schedule,13.94,15.41,
Triamcinolone hexacetonl inj,J3303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13.94,,,,,,,fee schedule,13.94,15.41,
Inj triamcinolone ace xr 1mg,J3304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,65.71,,,,,,,fee schedule,18.64,71.37,
Inj triamcinolone ace xr 1mg,J3304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,71.37,,,,,,,fee schedule,18.64,71.37,
Inj triamcinolone ace xr 1mg,J3304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,38.08,,,,,,,fee schedule,18.64,71.37,
Inj triamcinolone ace xr 1mg,J3304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.21,,,,,,,fee schedule,18.64,71.37,
Inj triamcinolone ace xr 1mg,J3304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,62.5,,,,,,,fee schedule,18.64,71.37,
Inj triamcinolone ace xr 1mg,J3304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,34.46,,,,,,,fee schedule,18.64,71.37,
Inj triamcinolone ace xr 1mg,J3304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,21.62,,,,,,,fee schedule,18.64,71.37,OP High Cost Drugs
Inj triamcinolone ace xr 1mg,J3304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.64,,,,,,,fee schedule,18.64,71.37,Other Pharmacy
Inj triamcinolone ace xr 1mg,J3304,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.57,,,,,,,fee schedule,18.64,71.37,APC
Inj triamcinolone ace xr 1mg,J3304,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,19.38,,,,,,,fee schedule,18.64,71.37,APC
Inj triamcinolone ace xr 1mg,J3304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.51,,,,,,,fee schedule,18.64,71.37,Radiology
Inj triamcinolone ace xr 1mg,J3304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26.09,,,,,,,fee schedule,18.64,71.37,APC
Inj triamcinolone ace xr 1mg,J3304,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,32.61,,,,,,,fee schedule,18.64,71.37,APC
Inj trimetrexate glucoronate,J3305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,534.98,,,,,,,fee schedule,465.8,581.1,
Inj trimetrexate glucoronate,J3305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,581.1,,,,,,,fee schedule,465.8,581.1,
Inj trimetrexate glucoronate,J3305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,465.8,,,,,,,fee schedule,465.8,581.1,
Inj trimetrexate glucoronate,J3305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,508.85,,,,,,,fee schedule,465.8,581.1,
Triptorelin pamoate,J3315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,544.9,,,,,,,fee schedule,469.38,1588.23,
Triptorelin pamoate,J3315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,591.87,,,,,,,fee schedule,469.38,1588.23,
Triptorelin pamoate,J3315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1588.23,,,,,,,fee schedule,469.38,1588.23,
Triptorelin pamoate,J3315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,474.44,,,,,,,fee schedule,469.38,1588.23,
Triptorelin pamoate,J3315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,518.28,,,,,,,fee schedule,469.38,1588.23,
Triptorelin pamoate,J3315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1437.45,,,,,,,fee schedule,469.38,1588.23,
Triptorelin pamoate,J3315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,544.48,,,,,,,fee schedule,469.38,1588.23,OP High Cost Drugs
Triptorelin pamoate,J3315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,469.38,,,,,,,fee schedule,469.38,1588.23,Other Pharmacy
Triptorelin pamoate,J3315,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,492.84,,,,,,,fee schedule,469.38,1588.23,APC
Triptorelin pamoate,J3315,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,488.15,,,,,,,fee schedule,469.38,1588.23,APC
Triptorelin pamoate,J3315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,718.15,,,,,,,fee schedule,469.38,1588.23,Radiology
Triptorelin pamoate,J3315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,657.13,,,,,,,fee schedule,469.38,1588.23,APC
Triptorelin pamoate,J3315,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,821.41,,,,,,,fee schedule,469.38,1588.23,APC
"Inj., triptorelin xr 3.75 mg",J3316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9836.8,,,,,,,fee schedule,3723.76,10684.8,
"Inj., triptorelin xr 3.75 mg",J3316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10684.8,,,,,,,fee schedule,3723.76,10684.8,
"Inj., triptorelin xr 3.75 mg",J3316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6465.57,,,,,,,fee schedule,3723.76,10684.8,
"Inj., triptorelin xr 3.75 mg",J3316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8564.8,,,,,,,fee schedule,3723.76,10684.8,
"Inj., triptorelin xr 3.75 mg",J3316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9356.27,,,,,,,fee schedule,3723.76,10684.8,
"Inj., triptorelin xr 3.75 mg",J3316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5851.75,,,,,,,fee schedule,3723.76,10684.8,
"Inj., triptorelin xr 3.75 mg",J3316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4319.56,,,,,,,fee schedule,3723.76,10684.8,OP High Cost Drugs
"Inj., triptorelin xr 3.75 mg",J3316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3723.76,,,,,,,fee schedule,3723.76,10684.8,Other Pharmacy
"Inj., triptorelin xr 3.75 mg",J3316,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3909.94,,,,,,,fee schedule,3723.76,10684.8,APC
"Inj., triptorelin xr 3.75 mg",J3316,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3872.71,,,,,,,fee schedule,3723.76,10684.8,APC
"Inj., triptorelin xr 3.75 mg",J3316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5697.35,,,,,,,fee schedule,3723.76,10684.8,Radiology
"Inj., triptorelin xr 3.75 mg",J3316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5213.26,,,,,,,fee schedule,3723.76,10684.8,APC
"Inj., triptorelin xr 3.75 mg",J3316,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6516.57,,,,,,,fee schedule,3723.76,10684.8,APC
Urea injection,J3350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83.8,,,,,,,fee schedule,72.96,91.02,
Urea injection,J3350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,91.02,,,,,,,fee schedule,72.96,91.02,
Urea injection,J3350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,72.96,,,,,,,fee schedule,72.96,91.02,
Urea injection,J3350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,79.7,,,,,,,fee schedule,72.96,91.02,
"Urofollitropin, 75 iu",J3355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,182.21,,,,,,,fee schedule,158.65,237.28,
"Urofollitropin, 75 iu",J3355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,197.92,,,,,,,fee schedule,158.65,237.28,
"Urofollitropin, 75 iu",J3355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,237.28,,,,,,,fee schedule,158.65,237.28,
"Urofollitropin, 75 iu",J3355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,158.65,,,,,,,fee schedule,158.65,237.28,
"Urofollitropin, 75 iu",J3355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,173.31,,,,,,,fee schedule,158.65,237.28,
"Urofollitropin, 75 iu",J3355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,214.76,,,,,,,fee schedule,158.65,237.28,
"Ustekinumab sub cu inj, 1 mg",J3357,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,481.25,,,,,,,fee schedule,419.02,585.97,
"Ustekinumab sub cu inj, 1 mg",J3357,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,522.74,,,,,,,fee schedule,419.02,585.97,
"Ustekinumab sub cu inj, 1 mg",J3357,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,585.97,,,,,,,fee schedule,419.02,585.97,
"Ustekinumab sub cu inj, 1 mg",J3357,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,419.02,,,,,,,fee schedule,419.02,585.97,
"Ustekinumab sub cu inj, 1 mg",J3357,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,457.74,,,,,,,fee schedule,419.02,585.97,
"Ustekinumab sub cu inj, 1 mg",J3357,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,530.34,,,,,,,fee schedule,419.02,585.97,
"Ustekinumab, iv inject, 1 mg",J3358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42.73,,,,,,,fee schedule,11.62,46.42,
"Ustekinumab, iv inject, 1 mg",J3358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46.42,,,,,,,fee schedule,11.62,46.42,
"Ustekinumab, iv inject, 1 mg",J3358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,29.53,,,,,,,fee schedule,11.62,46.42,
"Ustekinumab, iv inject, 1 mg",J3358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37.21,,,,,,,fee schedule,11.62,46.42,
"Ustekinumab, iv inject, 1 mg",J3358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40.65,,,,,,,fee schedule,11.62,46.42,
"Ustekinumab, iv inject, 1 mg",J3358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26.73,,,,,,,fee schedule,11.62,46.42,
"Ustekinumab, iv inject, 1 mg",J3358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.48,,,,,,,fee schedule,11.62,46.42,OP High Cost Drugs
"Ustekinumab, iv inject, 1 mg",J3358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11.62,,,,,,,fee schedule,11.62,46.42,Other Pharmacy
"Ustekinumab, iv inject, 1 mg",J3358,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.21,,,,,,,fee schedule,11.62,46.42,APC
"Ustekinumab, iv inject, 1 mg",J3358,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.09,,,,,,,fee schedule,11.62,46.42,APC
"Ustekinumab, iv inject, 1 mg",J3358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.78,,,,,,,fee schedule,11.62,46.42,Radiology
"Ustekinumab, iv inject, 1 mg",J3358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.27,,,,,,,fee schedule,11.62,46.42,APC
"Ustekinumab, iv inject, 1 mg",J3358,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20.34,,,,,,,fee schedule,11.62,46.42,APC
Diazepam injection,J3360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23.34,,,,,,,fee schedule,21.12,23.34,
Diazepam injection,J3360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21.12,,,,,,,fee schedule,21.12,23.34,
"Urokinase 250,000 IU inj",J3365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1635.6,,,,,,,fee schedule,1424.1,1776.6,
"Urokinase 250,000 IU inj",J3365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1776.6,,,,,,,fee schedule,1424.1,1776.6,
"Urokinase 250,000 IU inj",J3365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1424.1,,,,,,,fee schedule,1424.1,1776.6,
"Urokinase 250,000 IU inj",J3365,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1555.7,,,,,,,fee schedule,1424.1,1776.6,
Vancomycin hcl injection,J3370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13.07,,,,,,,fee schedule,11.83,13.07,
Vancomycin hcl injection,J3370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11.83,,,,,,,fee schedule,11.83,13.07,
"Inj, vancomycin hcl (mylan)",J3371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15.23,,,,,,,fee schedule,13.79,15.23,
"Inj, vancomycin hcl (mylan)",J3371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13.79,,,,,,,fee schedule,13.79,15.23,
"Inj, vancomycin hcl (xellia)",J3372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14.54,,,,,,,fee schedule,13.16,14.54,
"Inj, vancomycin hcl (xellia)",J3372,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13.16,,,,,,,fee schedule,13.16,14.54,
"Injection, vedolizumab",J3380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59.26,,,,,,,fee schedule,20.98,64.37,
"Injection, vedolizumab",J3380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,64.37,,,,,,,fee schedule,20.98,64.37,
"Injection, vedolizumab",J3380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,54.51,,,,,,,fee schedule,20.98,64.37,
"Injection, vedolizumab",J3380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.6,,,,,,,fee schedule,20.98,64.37,
"Injection, vedolizumab",J3380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56.37,,,,,,,fee schedule,20.98,64.37,
"Injection, vedolizumab",J3380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,49.34,,,,,,,fee schedule,20.98,64.37,
"Injection, vedolizumab",J3380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,24.34,,,,,,,fee schedule,20.98,64.37,OP High Cost Drugs
"Injection, vedolizumab",J3380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.98,,,,,,,fee schedule,20.98,64.37,Other Pharmacy
"Injection, vedolizumab",J3380,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,22.03,,,,,,,fee schedule,20.98,64.37,APC
"Injection, vedolizumab",J3380,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,21.82,,,,,,,fee schedule,20.98,64.37,APC
"Injection, vedolizumab",J3380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,32.1,,,,,,,fee schedule,20.98,64.37,Radiology
"Injection, vedolizumab",J3380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29.37,,,,,,,fee schedule,20.98,64.37,APC
"Injection, vedolizumab",J3380,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,36.72,,,,,,,fee schedule,20.98,64.37,APC
Velaglucerase alfa,J3385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1213.27,,,,,,,fee schedule,388.16,1317.86,
Velaglucerase alfa,J3385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1317.86,,,,,,,fee schedule,388.16,1317.86,
Velaglucerase alfa,J3385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,692.45,,,,,,,fee schedule,388.16,1317.86,
Velaglucerase alfa,J3385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1056.38,,,,,,,fee schedule,388.16,1317.86,
Velaglucerase alfa,J3385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1154,,,,,,,fee schedule,388.16,1317.86,
Velaglucerase alfa,J3385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,626.71,,,,,,,fee schedule,388.16,1317.86,
Velaglucerase alfa,J3385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,450.26,,,,,,,fee schedule,388.16,1317.86,OP High Cost Drugs
Velaglucerase alfa,J3385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,388.16,,,,,,,fee schedule,388.16,1317.86,Other Pharmacy
Velaglucerase alfa,J3385,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,407.56,,,,,,,fee schedule,388.16,1317.86,APC
Velaglucerase alfa,J3385,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,403.68,,,,,,,fee schedule,388.16,1317.86,APC
Velaglucerase alfa,J3385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,593.88,,,,,,,fee schedule,388.16,1317.86,Radiology
Velaglucerase alfa,J3385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,543.42,,,,,,,fee schedule,388.16,1317.86,APC
Velaglucerase alfa,J3385,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,679.27,,,,,,,fee schedule,388.16,1317.86,APC
"Inj, betibeglogene autotemce",J3393,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5308800,,,,,,,fee schedule,2938320,13036331.45,
"Inj, betibeglogene autotemce",J3393,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4804800,,,,,,,fee schedule,2938320,13036331.45,
"Inj, betibeglogene autotemce",J3393,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13036331.45,,,,,,,fee schedule,2938320,13036331.45,APC 378
"Inj, betibeglogene autotemce",J3393,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3085236,,,,,,,fee schedule,2938320,13036331.45,APC
"Inj, betibeglogene autotemce",J3393,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3055852.8,,,,,,,fee schedule,2938320,13036331.45,APC
"Inj, betibeglogene autotemce",J3393,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2938320,,,,,,,fee schedule,2938320,13036331.45,APC
"Inj, betibeglogene autotemce",J3393,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4495629.6,,,,,,,fee schedule,2938320,13036331.45,Radiology
"Inj, betibeglogene autotemce",J3393,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4113648,,,,,,,fee schedule,2938320,13036331.45,APC
"Inj, betibeglogene autotemce",J3393,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5142060,,,,,,,fee schedule,2938320,13036331.45,APC
"Inj, lovotibeglogene autotem",J3394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5877600,,,,,,,fee schedule,3245381.39,14398658.92,
"Inj, lovotibeglogene autotem",J3394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5319600,,,,,,,fee schedule,3245381.39,14398658.92,
"Inj, lovotibeglogene autotem",J3394,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14398658.92,,,,,,,fee schedule,3245381.39,14398658.92,APC 378
"Inj, lovotibeglogene autotem",J3394,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3407650.46,,,,,,,fee schedule,3245381.39,14398658.92,APC
"Inj, lovotibeglogene autotem",J3394,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3375196.64,,,,,,,fee schedule,3245381.39,14398658.92,APC
"Inj, lovotibeglogene autotem",J3394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3245381.39,,,,,,,fee schedule,3245381.39,14398658.92,APC
"Inj, lovotibeglogene autotem",J3394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4965433.53,,,,,,,fee schedule,3245381.39,14398658.92,Radiology
"Inj, lovotibeglogene autotem",J3394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4543533.94,,,,,,,fee schedule,3245381.39,14398658.92,APC
"Inj, lovotibeglogene autotem",J3394,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5679417.43,,,,,,,fee schedule,3245381.39,14398658.92,APC
Verteporfin injection,J3396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33.34,,,,,,,fee schedule,11.57,36.21,
Verteporfin injection,J3396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,36.21,,,,,,,fee schedule,11.57,36.21,
Verteporfin injection,J3396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21.73,,,,,,,fee schedule,11.57,36.21,
Verteporfin injection,J3396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29.03,,,,,,,fee schedule,11.57,36.21,
Verteporfin injection,J3396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31.71,,,,,,,fee schedule,11.57,36.21,
Verteporfin injection,J3396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19.66,,,,,,,fee schedule,11.57,36.21,
Verteporfin injection,J3396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.43,,,,,,,fee schedule,11.57,36.21,OP High Cost Drugs
Verteporfin injection,J3396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11.57,,,,,,,fee schedule,11.57,36.21,Other Pharmacy
Verteporfin injection,J3396,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12.15,,,,,,,fee schedule,11.57,36.21,APC
Verteporfin injection,J3396,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12.04,,,,,,,fee schedule,11.57,36.21,APC
Verteporfin injection,J3396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.71,,,,,,,fee schedule,11.57,36.21,Radiology
Verteporfin injection,J3396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.2,,,,,,,fee schedule,11.57,36.21,APC
Verteporfin injection,J3396,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20.25,,,,,,,fee schedule,11.57,36.21,APC
"Inj., vestronidase alfa-vjbk",J3397,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,764.49,,,,,,,fee schedule,280.15,1242.95,
"Inj., vestronidase alfa-vjbk",J3397,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,830.4,,,,,,,fee schedule,280.15,1242.95,
"Inj., vestronidase alfa-vjbk",J3397,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,499.98,,,,,,,fee schedule,280.15,1242.95,
"Inj., vestronidase alfa-vjbk",J3397,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,665.64,,,,,,,fee schedule,280.15,1242.95,
"Inj., vestronidase alfa-vjbk",J3397,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,727.15,,,,,,,fee schedule,280.15,1242.95,
"Inj., vestronidase alfa-vjbk",J3397,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,452.51,,,,,,,fee schedule,280.15,1242.95,
"Inj., vestronidase alfa-vjbk",J3397,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1242.95,,,,,,,fee schedule,280.15,1242.95,APC 378
"Inj., vestronidase alfa-vjbk",J3397,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,294.16,,,,,,,fee schedule,280.15,1242.95,APC
"Inj., vestronidase alfa-vjbk",J3397,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,291.36,,,,,,,fee schedule,280.15,1242.95,APC
"Inj., vestronidase alfa-vjbk",J3397,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,280.15,,,,,,,fee schedule,280.15,1242.95,APC
"Inj., vestronidase alfa-vjbk",J3397,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,428.64,,,,,,,fee schedule,280.15,1242.95,Radiology
"Inj., vestronidase alfa-vjbk",J3397,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,392.22,,,,,,,fee schedule,280.15,1242.95,APC
"Inj., vestronidase alfa-vjbk",J3397,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,490.27,,,,,,,fee schedule,280.15,1242.95,APC
Inj luxturna 1 billion vec g,J3398,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10312.25,,,,,,,fee schedule,3070.09,13620.95,
Inj luxturna 1 billion vec g,J3398,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11201.23,,,,,,,fee schedule,3070.09,13620.95,
Inj luxturna 1 billion vec g,J3398,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5890.4,,,,,,,fee schedule,3070.09,13620.95,
Inj luxturna 1 billion vec g,J3398,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8978.77,,,,,,,fee schedule,3070.09,13620.95,
Inj luxturna 1 billion vec g,J3398,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9808.49,,,,,,,fee schedule,3070.09,13620.95,
Inj luxturna 1 billion vec g,J3398,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5331.18,,,,,,,fee schedule,3070.09,13620.95,
Inj luxturna 1 billion vec g,J3398,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13620.95,,,,,,,fee schedule,3070.09,13620.95,APC 378
Inj luxturna 1 billion vec g,J3398,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3223.59,,,,,,,fee schedule,3070.09,13620.95,APC
Inj luxturna 1 billion vec g,J3398,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3192.89,,,,,,,fee schedule,3070.09,13620.95,APC
Inj luxturna 1 billion vec g,J3398,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3070.09,,,,,,,fee schedule,3070.09,13620.95,APC
Inj luxturna 1 billion vec g,J3398,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4697.24,,,,,,,fee schedule,3070.09,13620.95,Radiology
Inj luxturna 1 billion vec g,J3398,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4298.12,,,,,,,fee schedule,3070.09,13620.95,APC
Inj luxturna 1 billion vec g,J3398,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5372.66,,,,,,,fee schedule,3070.09,13620.95,APC
Inj onase abepar-xioi treat,J3399,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7679284.6,,,,,,,fee schedule,2587087.26,11478030.64,
Inj onase abepar-xioi treat,J3399,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8341291.9,,,,,,,fee schedule,2587087.26,11478030.64,
Inj onase abepar-xioi treat,J3399,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4402595.74,,,,,,,fee schedule,2587087.26,11478030.64,
Inj onase abepar-xioi treat,J3399,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6686273.66,,,,,,,fee schedule,2587087.26,11478030.64,
Inj onase abepar-xioi treat,J3399,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7304147.14,,,,,,,fee schedule,2587087.26,11478030.64,
Inj onase abepar-xioi treat,J3399,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3984627.79,,,,,,,fee schedule,2587087.26,11478030.64,
Inj onase abepar-xioi treat,J3399,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,11478030.64,,,,,,,fee schedule,2587087.26,11478030.64,APC 378
Inj onase abepar-xioi treat,J3399,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2716441.62,,,,,,,fee schedule,2587087.26,11478030.64,APC
Inj onase abepar-xioi treat,J3399,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2690570.75,,,,,,,fee schedule,2587087.26,11478030.64,APC
Inj onase abepar-xioi treat,J3399,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2587087.26,,,,,,,fee schedule,2587087.26,11478030.64,APC
Inj onase abepar-xioi treat,J3399,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3958243.5,,,,,,,fee schedule,2587087.26,11478030.64,Radiology
Inj onase abepar-xioi treat,J3399,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3621922.16,,,,,,,fee schedule,2587087.26,11478030.64,APC
Inj onase abepar-xioi treat,J3399,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4527402.7,,,,,,,fee schedule,2587087.26,11478030.64,APC
"Vyjuvek 5x10^9pfu/ml, 0.1 ml",J3401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8945.34,,,,,,,fee schedule,1004.58,9716.49,
"Vyjuvek 5x10^9pfu/ml, 0.1 ml",J3401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9716.49,,,,,,,fee schedule,1004.58,9716.49,
"Vyjuvek 5x10^9pfu/ml, 0.1 ml",J3401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1875.9,,,,,,,fee schedule,1004.58,9716.49,
"Vyjuvek 5x10^9pfu/ml, 0.1 ml",J3401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7788.62,,,,,,,fee schedule,1004.58,9716.49,
"Vyjuvek 5x10^9pfu/ml, 0.1 ml",J3401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8508.36,,,,,,,fee schedule,1004.58,9716.49,
"Vyjuvek 5x10^9pfu/ml, 0.1 ml",J3401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1697.81,,,,,,,fee schedule,1004.58,9716.49,
"Vyjuvek 5x10^9pfu/ml, 0.1 ml",J3401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1165.32,,,,,,,fee schedule,1004.58,9716.49,OP High Cost Drugs
"Vyjuvek 5x10^9pfu/ml, 0.1 ml",J3401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1004.58,,,,,,,fee schedule,1004.58,9716.49,Other Pharmacy
"Vyjuvek 5x10^9pfu/ml, 0.1 ml",J3401,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1054.81,,,,,,,fee schedule,1004.58,9716.49,APC
"Vyjuvek 5x10^9pfu/ml, 0.1 ml",J3401,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1044.77,,,,,,,fee schedule,1004.58,9716.49,APC
"Vyjuvek 5x10^9pfu/ml, 0.1 ml",J3401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1537.01,,,,,,,fee schedule,1004.58,9716.49,Radiology
"Vyjuvek 5x10^9pfu/ml, 0.1 ml",J3401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1406.41,,,,,,,fee schedule,1004.58,9716.49,APC
"Vyjuvek 5x10^9pfu/ml, 0.1 ml",J3401,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1758.02,,,,,,,fee schedule,1004.58,9716.49,APC
Hydroxyzine hcl injection,J3410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27.6,,,,,,,fee schedule,24.98,27.6,
Hydroxyzine hcl injection,J3410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24.98,,,,,,,fee schedule,24.98,27.6,
Thiamine hcl 100 mg,J3411,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8.67,,,,,,,fee schedule,7.85,8.67,
Thiamine hcl 100 mg,J3411,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7.85,,,,,,,fee schedule,7.85,8.67,
Pyridoxine hcl 100 mg,J3415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,35.01,,,,,,,fee schedule,31.69,35.01,
Pyridoxine hcl 100 mg,J3415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31.69,,,,,,,fee schedule,31.69,35.01,
Vitamin b12 injection,J3420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.57,,,,,,,fee schedule,5.95,6.57,
Vitamin b12 injection,J3420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.95,,,,,,,fee schedule,5.95,6.57,
Inj hydroxocobalamin iv 25mg,J3424,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.46,,,,,,,fee schedule,5.44,24.15,
Inj hydroxocobalamin iv 25mg,J3424,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.57,,,,,,,fee schedule,5.44,24.15,
Inj hydroxocobalamin iv 25mg,J3424,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24.15,,,,,,,fee schedule,5.44,24.15,APC 378
Inj hydroxocobalamin iv 25mg,J3424,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.72,,,,,,,fee schedule,5.44,24.15,APC
Inj hydroxocobalamin iv 25mg,J3424,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5.66,,,,,,,fee schedule,5.44,24.15,APC
Inj hydroxocobalamin iv 25mg,J3424,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5.44,,,,,,,fee schedule,5.44,24.15,APC
Inj hydroxocobalamin iv 25mg,J3424,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8.33,,,,,,,fee schedule,5.44,24.15,Radiology
Inj hydroxocobalamin iv 25mg,J3424,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.62,,,,,,,fee schedule,5.44,24.15,APC
Inj hydroxocobalamin iv 25mg,J3424,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9.53,,,,,,,fee schedule,5.44,24.15,APC
"Inj, hydroxocobalamin",J3425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.02,,,,,,,fee schedule,0.01,0.02,
"Inj, hydroxocobalamin",J3425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.01,,,,,,,fee schedule,0.01,0.02,
Vitamin k phytonadione inj,J3430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.15,,,,,,,fee schedule,8.28,9.15,
Vitamin k phytonadione inj,J3430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.28,,,,,,,fee schedule,8.28,9.15,
"Injection, voriconazole",J3465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18.9,,,,,,,fee schedule,5.18,20.53,
"Injection, voriconazole",J3465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20.53,,,,,,,fee schedule,5.18,20.53,
"Injection, voriconazole",J3465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.72,,,,,,,fee schedule,5.18,20.53,
"Injection, voriconazole",J3465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.45,,,,,,,fee schedule,5.18,20.53,
"Injection, voriconazole",J3465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17.97,,,,,,,fee schedule,5.18,20.53,
"Injection, voriconazole",J3465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.18,,,,,,,fee schedule,5.18,20.53,
Hyaluronidase injection,J3470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,105.8,,,,,,,fee schedule,95.75,105.8,
Hyaluronidase injection,J3470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,95.75,,,,,,,fee schedule,95.75,105.8,
"Ovine, up to 999 usp units",J3471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.58,,,,,,,fee schedule,0.53,0.58,
"Ovine, up to 999 usp units",J3471,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.53,,,,,,,fee schedule,0.53,0.58,
"Ovine, 1000 USP units",J3472,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,475.75,,,,,,,fee schedule,414.23,526.08,
"Ovine, 1000 USP units",J3472,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,516.76,,,,,,,fee schedule,414.23,526.08,
"Ovine, 1000 USP units",J3472,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,526.08,,,,,,,fee schedule,414.23,526.08,
"Ovine, 1000 USP units",J3472,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,414.23,,,,,,,fee schedule,414.23,526.08,
"Ovine, 1000 USP units",J3472,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,452.51,,,,,,,fee schedule,414.23,526.08,
"Ovine, 1000 USP units",J3472,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,476.13,,,,,,,fee schedule,414.23,526.08,
Hyaluronidase recombinant,J3473,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.74,,,,,,,fee schedule,0.64,1.89,
Hyaluronidase recombinant,J3473,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.89,,,,,,,fee schedule,0.64,1.89,
Hyaluronidase recombinant,J3473,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.71,,,,,,,fee schedule,0.64,1.89,
Hyaluronidase recombinant,J3473,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.52,,,,,,,fee schedule,0.64,1.89,
Hyaluronidase recombinant,J3473,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.66,,,,,,,fee schedule,0.64,1.89,
Hyaluronidase recombinant,J3473,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.64,,,,,,,fee schedule,0.64,1.89,
Inj magnesium sulfate,J3475,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.9,,,,,,,fee schedule,1.72,1.9,
Inj magnesium sulfate,J3475,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.72,,,,,,,fee schedule,1.72,1.9,
Inj potassium chloride,J3480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.07,,,,,,,fee schedule,0.97,1.07,
Inj potassium chloride,J3480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.97,,,,,,,fee schedule,0.97,1.07,
Zidovudine,J3485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.77,,,,,,,fee schedule,1.51,2.77,
Zidovudine,J3485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.5,,,,,,,fee schedule,1.51,2.77,
Zidovudine,J3485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1.76,,,,,,,fee schedule,1.51,2.77,OP High Cost Drugs
Zidovudine,J3485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1.51,,,,,,,fee schedule,1.51,2.77,Other Pharmacy
Zidovudine,J3485,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.59,,,,,,,fee schedule,1.51,2.77,APC
Zidovudine,J3485,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1.57,,,,,,,fee schedule,1.51,2.77,APC
Zidovudine,J3485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2.31,,,,,,,fee schedule,1.51,2.77,Radiology
Zidovudine,J3485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2.12,,,,,,,fee schedule,1.51,2.77,APC
Zidovudine,J3485,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2.65,,,,,,,fee schedule,1.51,2.77,APC
Ziprasidone mesylate,J3486,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,61.08,,,,,,,fee schedule,55.28,61.08,
Ziprasidone mesylate,J3486,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55.28,,,,,,,fee schedule,55.28,61.08,
Zoledronic acid 1mg,J3489,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,143.69,,,,,,,fee schedule,105.11,156.08,
Zoledronic acid 1mg,J3489,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,156.08,,,,,,,fee schedule,105.11,156.08,
Zoledronic acid 1mg,J3489,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,116.13,,,,,,,fee schedule,105.11,156.08,
Zoledronic acid 1mg,J3489,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,125.11,,,,,,,fee schedule,105.11,156.08,
Zoledronic acid 1mg,J3489,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,136.67,,,,,,,fee schedule,105.11,156.08,
Zoledronic acid 1mg,J3489,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,105.11,,,,,,,fee schedule,105.11,156.08,
Edetate disodium per 150 mg,J3520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.35,,,,,,,fee schedule,2.13,2.35,
Edetate disodium per 150 mg,J3520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.13,,,,,,,fee schedule,2.13,2.35,
Normal saline solution infus,J7030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10.92,,,,,,,fee schedule,9.88,10.92,
Normal saline solution infus,J7030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.88,,,,,,,fee schedule,9.88,10.92,
Normal saline solution infus,J7040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.95,,,,,,,fee schedule,9.01,9.95,
Normal saline solution infus,J7040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.01,,,,,,,fee schedule,9.01,9.95,
5% dextrose/normal saline,J7042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.59,,,,,,,fee schedule,5.96,6.59,
5% dextrose/normal saline,J7042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.96,,,,,,,fee schedule,5.96,6.59,
Normal saline solution infus,J7050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8.88,,,,,,,fee schedule,8.04,8.88,
Normal saline solution infus,J7050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.04,,,,,,,fee schedule,8.04,8.88,
5% dextrose/water,J7060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.95,,,,,,,fee schedule,9.01,9.95,
5% dextrose/water,J7060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.01,,,,,,,fee schedule,9.01,9.95,
D5w infusion,J7070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.05,,,,,,,fee schedule,8.19,9.05,
D5w infusion,J7070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.19,,,,,,,fee schedule,8.19,9.05,
Dextran 40 infusion,J7100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,74.02,,,,,,,fee schedule,67,74.02,
Dextran 40 infusion,J7100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,67,,,,,,,fee schedule,67,74.02,
Ringers lactate infusion,J7120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14,,,,,,,fee schedule,12.67,14,
Ringers lactate infusion,J7120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12.67,,,,,,,fee schedule,12.67,14,
5% dextrose in lac ringers,J7121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.72,,,,,,,fee schedule,8.79,9.72,
5% dextrose in lac ringers,J7121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.79,,,,,,,fee schedule,8.79,9.72,
Hypertonic saline sol,J7131,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.17,,,,,,,fee schedule,0.03,0.19,
Hypertonic saline sol,J7131,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.19,,,,,,,fee schedule,0.03,0.19,
Hypertonic saline sol,J7131,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.03,,,,,,,fee schedule,0.03,0.19,
Hypertonic saline sol,J7131,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.15,,,,,,,fee schedule,0.03,0.19,
Hypertonic saline sol,J7131,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.17,,,,,,,fee schedule,0.03,0.19,
Hypertonic saline sol,J7131,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.03,,,,,,,fee schedule,0.03,0.19,
"Inj, human-lans, per i.u",J7165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.97,,,,,,,fee schedule,1.72,7.61,
"Inj, human-lans, per i.u",J7165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.41,,,,,,,fee schedule,1.72,7.61,
"Inj, human-lans, per i.u",J7165,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7.61,,,,,,,fee schedule,1.72,7.61,APC 378
"Inj, human-lans, per i.u",J7165,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.8,,,,,,,fee schedule,1.72,7.61,APC
"Inj, human-lans, per i.u",J7165,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1.78,,,,,,,fee schedule,1.72,7.61,APC
"Inj, human-lans, per i.u",J7165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1.72,,,,,,,fee schedule,1.72,7.61,APC
"Inj, human-lans, per i.u",J7165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2.62,,,,,,,fee schedule,1.72,7.61,Radiology
"Inj, human-lans, per i.u",J7165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2.4,,,,,,,fee schedule,1.72,7.61,APC
"Inj, human-lans, per i.u",J7165,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3,,,,,,,fee schedule,1.72,7.61,APC
Prothrombin complex kcentra,J7168,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.92,,,,,,,fee schedule,2.05,9.11,
Prothrombin complex kcentra,J7168,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7.51,,,,,,,fee schedule,2.05,9.11,
Prothrombin complex kcentra,J7168,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.66,,,,,,,fee schedule,2.05,9.11,
Prothrombin complex kcentra,J7168,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.02,,,,,,,fee schedule,2.05,9.11,
Prothrombin complex kcentra,J7168,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.58,,,,,,,fee schedule,2.05,9.11,
Prothrombin complex kcentra,J7168,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.12,,,,,,,fee schedule,2.05,9.11,
Prothrombin complex kcentra,J7168,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.11,,,,,,,fee schedule,2.05,9.11,APC 378
Prothrombin complex kcentra,J7168,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2.16,,,,,,,fee schedule,2.05,9.11,APC
Prothrombin complex kcentra,J7168,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2.14,,,,,,,fee schedule,2.05,9.11,APC
Prothrombin complex kcentra,J7168,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2.05,,,,,,,fee schedule,2.05,9.11,APC
Prothrombin complex kcentra,J7168,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3.14,,,,,,,fee schedule,2.05,9.11,Radiology
Prothrombin complex kcentra,J7168,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2.87,,,,,,,fee schedule,2.05,9.11,APC
Prothrombin complex kcentra,J7168,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3.59,,,,,,,fee schedule,2.05,9.11,APC
"Inj andexxa, 10 mg",J7169,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1014.42,,,,,,,fee schedule,131.16,1101.87,
"Inj andexxa, 10 mg",J7169,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1101.87,,,,,,,fee schedule,131.16,1101.87,
"Inj andexxa, 10 mg",J7169,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,237,,,,,,,fee schedule,131.16,1101.87,
"Inj andexxa, 10 mg",J7169,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,883.25,,,,,,,fee schedule,131.16,1101.87,
"Inj andexxa, 10 mg",J7169,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,964.87,,,,,,,fee schedule,131.16,1101.87,
"Inj andexxa, 10 mg",J7169,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,214.5,,,,,,,fee schedule,131.16,1101.87,
"Inj andexxa, 10 mg",J7169,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,581.93,,,,,,,fee schedule,131.16,1101.87,APC 378
"Inj andexxa, 10 mg",J7169,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,137.72,,,,,,,fee schedule,131.16,1101.87,APC
"Inj andexxa, 10 mg",J7169,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.41,,,,,,,fee schedule,131.16,1101.87,APC
"Inj andexxa, 10 mg",J7169,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.16,,,,,,,fee schedule,131.16,1101.87,APC
"Inj andexxa, 10 mg",J7169,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,200.68,,,,,,,fee schedule,131.16,1101.87,Radiology
"Inj andexxa, 10 mg",J7169,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,183.63,,,,,,,fee schedule,131.16,1101.87,APC
"Inj andexxa, 10 mg",J7169,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,229.54,,,,,,,fee schedule,131.16,1101.87,APC
"Inj., emicizumab-kxwh 0.5 mg",J7170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,170.03,,,,,,,fee schedule,55.64,184.69,
"Inj., emicizumab-kxwh 0.5 mg",J7170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,184.69,,,,,,,fee schedule,55.64,184.69,
"Inj., emicizumab-kxwh 0.5 mg",J7170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,105.07,,,,,,,fee schedule,55.64,184.69,
"Inj., emicizumab-kxwh 0.5 mg",J7170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,148.05,,,,,,,fee schedule,55.64,184.69,
"Inj., emicizumab-kxwh 0.5 mg",J7170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,161.73,,,,,,,fee schedule,55.64,184.69,
"Inj., emicizumab-kxwh 0.5 mg",J7170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,95.1,,,,,,,fee schedule,55.64,184.69,
"Inj., emicizumab-kxwh 0.5 mg",J7170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,64.54,,,,,,,fee schedule,55.64,184.69,OP High Cost Drugs
"Inj., emicizumab-kxwh 0.5 mg",J7170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,55.64,,,,,,,fee schedule,55.64,184.69,Other Pharmacy
"Inj., emicizumab-kxwh 0.5 mg",J7170,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,58.42,,,,,,,fee schedule,55.64,184.69,APC
"Inj., emicizumab-kxwh 0.5 mg",J7170,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,57.87,,,,,,,fee schedule,55.64,184.69,APC
"Inj., emicizumab-kxwh 0.5 mg",J7170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,85.13,,,,,,,fee schedule,55.64,184.69,Radiology
"Inj., emicizumab-kxwh 0.5 mg",J7170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,77.9,,,,,,,fee schedule,55.64,184.69,APC
"Inj., emicizumab-kxwh 0.5 mg",J7170,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,97.37,,,,,,,fee schedule,55.64,184.69,APC
"Inj, adzynma, 10 iu",J7171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,62.25,,,,,,,fee schedule,35.58,62.26,
"Inj, adzynma, 10 iu",J7171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56.34,,,,,,,fee schedule,35.58,62.26,
"Inj, adzynma, 10 iu",J7171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,41.27,,,,,,,fee schedule,35.58,62.26,OP High Cost Drugs
"Inj, adzynma, 10 iu",J7171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,35.58,,,,,,,fee schedule,35.58,62.26,Other Pharmacy
"Inj, adzynma, 10 iu",J7171,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,37.35,,,,,,,fee schedule,35.58,62.26,APC
"Inj, adzynma, 10 iu",J7171,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,37,,,,,,,fee schedule,35.58,62.26,APC
"Inj, adzynma, 10 iu",J7171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,54.43,,,,,,,fee schedule,35.58,62.26,Radiology
"Inj, adzynma, 10 iu",J7171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49.81,,,,,,,fee schedule,35.58,62.26,APC
"Inj, adzynma, 10 iu",J7171,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,62.26,,,,,,,fee schedule,35.58,62.26,APC
"Inj, factor x, (human), 1iu",J7175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22.69,,,,,,,fee schedule,9.95,24.65,
"Inj, factor x, (human), 1iu",J7175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24.65,,,,,,,fee schedule,9.95,24.65,
"Inj, factor x, (human), 1iu",J7175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21.58,,,,,,,fee schedule,9.95,24.65,
"Inj, factor x, (human), 1iu",J7175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19.76,,,,,,,fee schedule,9.95,24.65,
"Inj, factor x, (human), 1iu",J7175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21.58,,,,,,,fee schedule,9.95,24.65,
"Inj, factor x, (human), 1iu",J7175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19.53,,,,,,,fee schedule,9.95,24.65,
"Inj, factor x, (human), 1iu",J7175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11.55,,,,,,,fee schedule,9.95,24.65,OP High Cost Drugs
"Inj, factor x, (human), 1iu",J7175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.95,,,,,,,fee schedule,9.95,24.65,Other Pharmacy
"Inj, factor x, (human), 1iu",J7175,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.45,,,,,,,fee schedule,9.95,24.65,APC
"Inj, factor x, (human), 1iu",J7175,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10.35,,,,,,,fee schedule,9.95,24.65,APC
"Inj, factor x, (human), 1iu",J7175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15.23,,,,,,,fee schedule,9.95,24.65,Radiology
"Inj, factor x, (human), 1iu",J7175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.93,,,,,,,fee schedule,9.95,24.65,APC
"Inj, factor x, (human), 1iu",J7175,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,17.42,,,,,,,fee schedule,9.95,24.65,APC
"Inj., fibryga, 1 mg",J7177,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.69,,,,,,,fee schedule,1.24,4.01,
"Inj., fibryga, 1 mg",J7177,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.01,,,,,,,fee schedule,1.24,4.01,
"Inj., fibryga, 1 mg",J7177,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.09,,,,,,,fee schedule,1.24,4.01,
"Inj., fibryga, 1 mg",J7177,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.21,,,,,,,fee schedule,1.24,4.01,
"Inj., fibryga, 1 mg",J7177,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.51,,,,,,,fee schedule,1.24,4.01,
"Inj., fibryga, 1 mg",J7177,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.89,,,,,,,fee schedule,1.24,4.01,
"Inj., fibryga, 1 mg",J7177,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1.43,,,,,,,fee schedule,1.24,4.01,OP High Cost Drugs
"Inj., fibryga, 1 mg",J7177,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1.24,,,,,,,fee schedule,1.24,4.01,Other Pharmacy
"Inj., fibryga, 1 mg",J7177,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.3,,,,,,,fee schedule,1.24,4.01,APC
"Inj., fibryga, 1 mg",J7177,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1.29,,,,,,,fee schedule,1.24,4.01,APC
"Inj., fibryga, 1 mg",J7177,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1.89,,,,,,,fee schedule,1.24,4.01,Radiology
"Inj., fibryga, 1 mg",J7177,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1.73,,,,,,,fee schedule,1.24,4.01,APC
"Inj., fibryga, 1 mg",J7177,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2.16,,,,,,,fee schedule,1.24,4.01,APC
Human fibrinogen conc inj,J7178,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.2,,,,,,,fee schedule,1.52,3.48,
Human fibrinogen conc inj,J7178,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.48,,,,,,,fee schedule,1.52,3.48,
Human fibrinogen conc inj,J7178,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.81,,,,,,,fee schedule,1.52,3.48,
Human fibrinogen conc inj,J7178,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.79,,,,,,,fee schedule,1.52,3.48,
Human fibrinogen conc inj,J7178,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.05,,,,,,,fee schedule,1.52,3.48,
Human fibrinogen conc inj,J7178,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.55,,,,,,,fee schedule,1.52,3.48,
Human fibrinogen conc inj,J7178,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1.77,,,,,,,fee schedule,1.52,3.48,OP High Cost Drugs
Human fibrinogen conc inj,J7178,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1.52,,,,,,,fee schedule,1.52,3.48,Other Pharmacy
Human fibrinogen conc inj,J7178,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.6,,,,,,,fee schedule,1.52,3.48,APC
Human fibrinogen conc inj,J7178,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1.58,,,,,,,fee schedule,1.52,3.48,APC
Human fibrinogen conc inj,J7178,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2.33,,,,,,,fee schedule,1.52,3.48,Radiology
Human fibrinogen conc inj,J7178,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2.13,,,,,,,fee schedule,1.52,3.48,APC
Human fibrinogen conc inj,J7178,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2.67,,,,,,,fee schedule,1.52,3.48,APC
Vonvendi inj 1 iu vwf:rco,J7179,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8.04,,,,,,,fee schedule,1.83,8.73,
Vonvendi inj 1 iu vwf:rco,J7179,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8.73,,,,,,,fee schedule,1.83,8.73,
Vonvendi inj 1 iu vwf:rco,J7179,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.76,,,,,,,fee schedule,1.83,8.73,
Vonvendi inj 1 iu vwf:rco,J7179,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7,,,,,,,fee schedule,1.83,8.73,
Vonvendi inj 1 iu vwf:rco,J7179,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7.65,,,,,,,fee schedule,1.83,8.73,
Vonvendi inj 1 iu vwf:rco,J7179,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.4,,,,,,,fee schedule,1.83,8.73,
Vonvendi inj 1 iu vwf:rco,J7179,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2.12,,,,,,,fee schedule,1.83,8.73,OP High Cost Drugs
Vonvendi inj 1 iu vwf:rco,J7179,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1.83,,,,,,,fee schedule,1.83,8.73,Other Pharmacy
Vonvendi inj 1 iu vwf:rco,J7179,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.92,,,,,,,fee schedule,1.83,8.73,APC
Vonvendi inj 1 iu vwf:rco,J7179,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1.9,,,,,,,fee schedule,1.83,8.73,APC
Vonvendi inj 1 iu vwf:rco,J7179,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2.8,,,,,,,fee schedule,1.83,8.73,Radiology
Vonvendi inj 1 iu vwf:rco,J7179,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2.56,,,,,,,fee schedule,1.83,8.73,APC
Vonvendi inj 1 iu vwf:rco,J7179,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3.2,,,,,,,fee schedule,1.83,8.73,APC
Factor XIII anti-hem factor,J7180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22.34,,,,,,,fee schedule,10.78,24.27,
Factor XIII anti-hem factor,J7180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24.27,,,,,,,fee schedule,10.78,24.27,
Factor XIII anti-hem factor,J7180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23.53,,,,,,,fee schedule,10.78,24.27,
Factor XIII anti-hem factor,J7180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19.45,,,,,,,fee schedule,10.78,24.27,
Factor XIII anti-hem factor,J7180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21.25,,,,,,,fee schedule,10.78,24.27,
Factor XIII anti-hem factor,J7180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21.29,,,,,,,fee schedule,10.78,24.27,
Factor XIII anti-hem factor,J7180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.5,,,,,,,fee schedule,10.78,24.27,OP High Cost Drugs
Factor XIII anti-hem factor,J7180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10.78,,,,,,,fee schedule,10.78,24.27,Other Pharmacy
Factor XIII anti-hem factor,J7180,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.32,,,,,,,fee schedule,10.78,24.27,APC
Factor XIII anti-hem factor,J7180,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11.21,,,,,,,fee schedule,10.78,24.27,APC
Factor XIII anti-hem factor,J7180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.49,,,,,,,fee schedule,10.78,24.27,Radiology
Factor XIII anti-hem factor,J7180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15.09,,,,,,,fee schedule,10.78,24.27,APC
Factor XIII anti-hem factor,J7180,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18.86,,,,,,,fee schedule,10.78,24.27,APC
Factor xiii recomb a-subunit,J7181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,48.06,,,,,,,fee schedule,18.33,52.2,
Factor xiii recomb a-subunit,J7181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,52.2,,,,,,,fee schedule,18.33,52.2,
Factor xiii recomb a-subunit,J7181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,34.22,,,,,,,fee schedule,18.33,52.2,
Factor xiii recomb a-subunit,J7181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,41.84,,,,,,,fee schedule,18.33,52.2,
Factor xiii recomb a-subunit,J7181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,45.71,,,,,,,fee schedule,18.33,52.2,
Factor xiii recomb a-subunit,J7181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,30.97,,,,,,,fee schedule,18.33,52.2,
Factor xiii recomb a-subunit,J7181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,21.26,,,,,,,fee schedule,18.33,52.2,OP High Cost Drugs
Factor xiii recomb a-subunit,J7181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.33,,,,,,,fee schedule,18.33,52.2,Other Pharmacy
Factor xiii recomb a-subunit,J7181,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.25,,,,,,,fee schedule,18.33,52.2,APC
Factor xiii recomb a-subunit,J7181,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,19.06,,,,,,,fee schedule,18.33,52.2,APC
Factor xiii recomb a-subunit,J7181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.05,,,,,,,fee schedule,18.33,52.2,Radiology
Factor xiii recomb a-subunit,J7181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.66,,,,,,,fee schedule,18.33,52.2,APC
Factor xiii recomb a-subunit,J7181,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,32.08,,,,,,,fee schedule,18.33,52.2,APC
Factor viii recomb novoeight,J7182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.49,,,,,,,fee schedule,1.41,4.88,
Factor viii recomb novoeight,J7182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.88,,,,,,,fee schedule,1.41,4.88,
Factor viii recomb novoeight,J7182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.09,,,,,,,fee schedule,1.41,4.88,
Factor viii recomb novoeight,J7182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.91,,,,,,,fee schedule,1.41,4.88,
Factor viii recomb novoeight,J7182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.27,,,,,,,fee schedule,1.41,4.88,
Factor viii recomb novoeight,J7182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.7,,,,,,,fee schedule,1.41,4.88,
Factor viii recomb novoeight,J7182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1.64,,,,,,,fee schedule,1.41,4.88,OP High Cost Drugs
Factor viii recomb novoeight,J7182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1.41,,,,,,,fee schedule,1.41,4.88,Other Pharmacy
Factor viii recomb novoeight,J7182,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.48,,,,,,,fee schedule,1.41,4.88,APC
Factor viii recomb novoeight,J7182,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1.47,,,,,,,fee schedule,1.41,4.88,APC
Factor viii recomb novoeight,J7182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2.16,,,,,,,fee schedule,1.41,4.88,Radiology
Factor viii recomb novoeight,J7182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1.97,,,,,,,fee schedule,1.41,4.88,APC
Factor viii recomb novoeight,J7182,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2.47,,,,,,,fee schedule,1.41,4.88,APC
Wilate injection,J7183,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.17,,,,,,,fee schedule,1.32,3.44,
Wilate injection,J7183,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.44,,,,,,,fee schedule,1.32,3.44,
Wilate injection,J7183,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.16,,,,,,,fee schedule,1.32,3.44,
Wilate injection,J7183,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.76,,,,,,,fee schedule,1.32,3.44,
Wilate injection,J7183,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.01,,,,,,,fee schedule,1.32,3.44,
Wilate injection,J7183,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.86,,,,,,,fee schedule,1.32,3.44,
Wilate injection,J7183,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1.53,,,,,,,fee schedule,1.32,3.44,OP High Cost Drugs
Wilate injection,J7183,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1.32,,,,,,,fee schedule,1.32,3.44,Other Pharmacy
Wilate injection,J7183,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.39,,,,,,,fee schedule,1.32,3.44,APC
Wilate injection,J7183,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1.37,,,,,,,fee schedule,1.32,3.44,APC
Wilate injection,J7183,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2.02,,,,,,,fee schedule,1.32,3.44,Radiology
Wilate injection,J7183,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1.85,,,,,,,fee schedule,1.32,3.44,APC
Wilate injection,J7183,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2.31,,,,,,,fee schedule,1.32,3.44,APC
Xyntha inj,J7185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.86,,,,,,,fee schedule,1.49,4.2,
Xyntha inj,J7185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.2,,,,,,,fee schedule,1.49,4.2,
Xyntha inj,J7185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.44,,,,,,,fee schedule,1.49,4.2,
Xyntha inj,J7185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.36,,,,,,,fee schedule,1.49,4.2,
Xyntha inj,J7185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.67,,,,,,,fee schedule,1.49,4.2,
Xyntha inj,J7185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.12,,,,,,,fee schedule,1.49,4.2,
Xyntha inj,J7185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1.73,,,,,,,fee schedule,1.49,4.2,OP High Cost Drugs
Xyntha inj,J7185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1.49,,,,,,,fee schedule,1.49,4.2,Other Pharmacy
Xyntha inj,J7185,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.57,,,,,,,fee schedule,1.49,4.2,APC
Xyntha inj,J7185,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1.55,,,,,,,fee schedule,1.49,4.2,APC
Xyntha inj,J7185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2.28,,,,,,,fee schedule,1.49,4.2,Radiology
Xyntha inj,J7185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2.09,,,,,,,fee schedule,1.49,4.2,APC
Xyntha inj,J7185,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2.61,,,,,,,fee schedule,1.49,4.2,APC
Antihemophilic viii/vwf comp,J7186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.99,,,,,,,fee schedule,1.25,3.25,
Antihemophilic viii/vwf comp,J7186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.25,,,,,,,fee schedule,1.25,3.25,
Antihemophilic viii/vwf comp,J7186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.54,,,,,,,fee schedule,1.25,3.25,
Antihemophilic viii/vwf comp,J7186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.61,,,,,,,fee schedule,1.25,3.25,
Antihemophilic viii/vwf comp,J7186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.85,,,,,,,fee schedule,1.25,3.25,
Antihemophilic viii/vwf comp,J7186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.3,,,,,,,fee schedule,1.25,3.25,
Antihemophilic viii/vwf comp,J7186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1.45,,,,,,,fee schedule,1.25,3.25,OP High Cost Drugs
Antihemophilic viii/vwf comp,J7186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1.25,,,,,,,fee schedule,1.25,3.25,Other Pharmacy
Antihemophilic viii/vwf comp,J7186,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.31,,,,,,,fee schedule,1.25,3.25,APC
Antihemophilic viii/vwf comp,J7186,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1.3,,,,,,,fee schedule,1.25,3.25,APC
Antihemophilic viii/vwf comp,J7186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1.92,,,,,,,fee schedule,1.25,3.25,Radiology
Antihemophilic viii/vwf comp,J7186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1.75,,,,,,,fee schedule,1.25,3.25,APC
Antihemophilic viii/vwf comp,J7186,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2.19,,,,,,,fee schedule,1.25,3.25,APC
"Humate-P, inj",J7187,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.17,,,,,,,fee schedule,1.49,3.44,
"Humate-P, inj",J7187,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.44,,,,,,,fee schedule,1.49,3.44,
"Humate-P, inj",J7187,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.03,,,,,,,fee schedule,1.49,3.44,
"Humate-P, inj",J7187,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.76,,,,,,,fee schedule,1.49,3.44,
"Humate-P, inj",J7187,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.01,,,,,,,fee schedule,1.49,3.44,
"Humate-P, inj",J7187,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.75,,,,,,,fee schedule,1.49,3.44,
"Humate-P, inj",J7187,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1.73,,,,,,,fee schedule,1.49,3.44,OP High Cost Drugs
"Humate-P, inj",J7187,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1.49,,,,,,,fee schedule,1.49,3.44,Other Pharmacy
"Humate-P, inj",J7187,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.57,,,,,,,fee schedule,1.49,3.44,APC
"Humate-P, inj",J7187,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1.55,,,,,,,fee schedule,1.49,3.44,APC
"Humate-P, inj",J7187,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2.29,,,,,,,fee schedule,1.49,3.44,Radiology
"Humate-P, inj",J7187,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2.09,,,,,,,fee schedule,1.49,3.44,APC
"Humate-P, inj",J7187,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2.61,,,,,,,fee schedule,1.49,3.44,APC
Factor viii recomb obizur,J7188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16.56,,,,,,,fee schedule,3.24,17.99,
Factor viii recomb obizur,J7188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17.99,,,,,,,fee schedule,3.24,17.99,
Factor viii recomb obizur,J7188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7.69,,,,,,,fee schedule,3.24,17.99,
Factor viii recomb obizur,J7188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14.42,,,,,,,fee schedule,3.24,17.99,
Factor viii recomb obizur,J7188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15.76,,,,,,,fee schedule,3.24,17.99,
Factor viii recomb obizur,J7188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.96,,,,,,,fee schedule,3.24,17.99,
Factor viii recomb obizur,J7188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3.75,,,,,,,fee schedule,3.24,17.99,OP High Cost Drugs
Factor viii recomb obizur,J7188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3.24,,,,,,,fee schedule,3.24,17.99,Other Pharmacy
Factor viii recomb obizur,J7188,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3.4,,,,,,,fee schedule,3.24,17.99,APC
Factor viii recomb obizur,J7188,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3.37,,,,,,,fee schedule,3.24,17.99,APC
Factor viii recomb obizur,J7188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4.95,,,,,,,fee schedule,3.24,17.99,Radiology
Factor viii recomb obizur,J7188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4.53,,,,,,,fee schedule,3.24,17.99,APC
Factor viii recomb obizur,J7188,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5.66,,,,,,,fee schedule,3.24,17.99,APC
Factor viia,J7189,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.38,,,,,,,fee schedule,2.64,5.09,
Factor viia,J7189,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.76,,,,,,,fee schedule,2.64,5.09,
Factor viia,J7189,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.09,,,,,,,fee schedule,2.64,5.09,
Factor viia,J7189,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.82,,,,,,,fee schedule,2.64,5.09,
Factor viia,J7189,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.17,,,,,,,fee schedule,2.64,5.09,
Factor viia,J7189,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.6,,,,,,,fee schedule,2.64,5.09,
Factor viia,J7189,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3.06,,,,,,,fee schedule,2.64,5.09,OP High Cost Drugs
Factor viia,J7189,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2.64,,,,,,,fee schedule,2.64,5.09,Other Pharmacy
Factor viia,J7189,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2.77,,,,,,,fee schedule,2.64,5.09,APC
Factor viia,J7189,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2.75,,,,,,,fee schedule,2.64,5.09,APC
Factor viia,J7189,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4.04,,,,,,,fee schedule,2.64,5.09,Radiology
Factor viia,J7189,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3.7,,,,,,,fee schedule,2.64,5.09,APC
Factor viia,J7189,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4.62,,,,,,,fee schedule,2.64,5.09,APC
Factor viii,J7190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.96,,,,,,,fee schedule,1.39,3.21,
Factor viii,J7190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.21,,,,,,,fee schedule,1.39,3.21,
Factor viii,J7190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.73,,,,,,,fee schedule,1.39,3.21,
Factor viii,J7190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.58,,,,,,,fee schedule,1.39,3.21,
Factor viii,J7190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.81,,,,,,,fee schedule,1.39,3.21,
Factor viii,J7190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.47,,,,,,,fee schedule,1.39,3.21,
Factor viii,J7190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1.62,,,,,,,fee schedule,1.39,3.21,OP High Cost Drugs
Factor viii,J7190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1.39,,,,,,,fee schedule,1.39,3.21,Other Pharmacy
Factor viii,J7190,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.46,,,,,,,fee schedule,1.39,3.21,APC
Factor viii,J7190,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1.45,,,,,,,fee schedule,1.39,3.21,APC
Factor viii,J7190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2.13,,,,,,,fee schedule,1.39,3.21,Radiology
Factor viii,J7190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1.95,,,,,,,fee schedule,1.39,3.21,APC
Factor viii,J7190,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2.44,,,,,,,fee schedule,1.39,3.21,APC
Factor viii (porcine),J7191,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.7,,,,,,,fee schedule,0.61,24.22,
Factor viii (porcine),J7191,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.76,,,,,,,fee schedule,0.61,24.22,
Factor viii (porcine),J7191,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.61,,,,,,,fee schedule,0.61,24.22,
Factor viii (porcine),J7191,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.66,,,,,,,fee schedule,0.61,24.22,
Factor viii (porcine),J7191,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,24.22,,,,,,,fee schedule,0.61,24.22,APC 378
Factor viii (porcine),J7191,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.73,,,,,,,fee schedule,0.61,24.22,APC
Factor viii (porcine),J7191,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5.68,,,,,,,fee schedule,0.61,24.22,APC
Factor viii (porcine),J7191,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5.46,,,,,,,fee schedule,0.61,24.22,APC
Factor viii (porcine),J7191,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8.35,,,,,,,fee schedule,0.61,24.22,Radiology
Factor viii (porcine),J7191,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.64,,,,,,,fee schedule,0.61,24.22,APC
Factor viii (porcine),J7191,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9.56,,,,,,,fee schedule,0.61,24.22,APC
Factor viii recombinant nos,J7192,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.86,,,,,,,fee schedule,1.57,4.2,
Factor viii recombinant nos,J7192,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.2,,,,,,,fee schedule,1.57,4.2,
Factor viii recombinant nos,J7192,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.6,,,,,,,fee schedule,1.57,4.2,
Factor viii recombinant nos,J7192,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.36,,,,,,,fee schedule,1.57,4.2,
Factor viii recombinant nos,J7192,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.67,,,,,,,fee schedule,1.57,4.2,
Factor viii recombinant nos,J7192,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.26,,,,,,,fee schedule,1.57,4.2,
Factor viii recombinant nos,J7192,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1.82,,,,,,,fee schedule,1.57,4.2,OP High Cost Drugs
Factor viii recombinant nos,J7192,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1.57,,,,,,,fee schedule,1.57,4.2,Other Pharmacy
Factor viii recombinant nos,J7192,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.65,,,,,,,fee schedule,1.57,4.2,APC
Factor viii recombinant nos,J7192,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1.63,,,,,,,fee schedule,1.57,4.2,APC
Factor viii recombinant nos,J7192,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2.4,,,,,,,fee schedule,1.57,4.2,Radiology
Factor viii recombinant nos,J7192,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2.2,,,,,,,fee schedule,1.57,4.2,APC
Factor viii recombinant nos,J7192,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2.74,,,,,,,fee schedule,1.57,4.2,APC
Factor ix non-recombinant,J7193,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.2,,,,,,,fee schedule,1.37,3.48,
Factor ix non-recombinant,J7193,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.48,,,,,,,fee schedule,1.37,3.48,
Factor ix non-recombinant,J7193,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.21,,,,,,,fee schedule,1.37,3.48,
Factor ix non-recombinant,J7193,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.79,,,,,,,fee schedule,1.37,3.48,
Factor ix non-recombinant,J7193,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.05,,,,,,,fee schedule,1.37,3.48,
Factor ix non-recombinant,J7193,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.9,,,,,,,fee schedule,1.37,3.48,
Factor ix non-recombinant,J7193,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1.59,,,,,,,fee schedule,1.37,3.48,OP High Cost Drugs
Factor ix non-recombinant,J7193,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1.37,,,,,,,fee schedule,1.37,3.48,Other Pharmacy
Factor ix non-recombinant,J7193,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.44,,,,,,,fee schedule,1.37,3.48,APC
Factor ix non-recombinant,J7193,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1.42,,,,,,,fee schedule,1.37,3.48,APC
Factor ix non-recombinant,J7193,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2.09,,,,,,,fee schedule,1.37,3.48,Radiology
Factor ix non-recombinant,J7193,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1.92,,,,,,,fee schedule,1.37,3.48,APC
Factor ix non-recombinant,J7193,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2.4,,,,,,,fee schedule,1.37,3.48,APC
Factor ix complex,J7194,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.92,,,,,,,fee schedule,1.7,3.18,
Factor ix complex,J7194,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.18,,,,,,,fee schedule,1.7,3.18,
Factor ix complex,J7194,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.81,,,,,,,fee schedule,1.7,3.18,
Factor ix complex,J7194,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.55,,,,,,,fee schedule,1.7,3.18,
Factor ix complex,J7194,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.78,,,,,,,fee schedule,1.7,3.18,
Factor ix complex,J7194,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1.98,,,,,,,fee schedule,1.7,3.18,OP High Cost Drugs
Factor ix complex,J7194,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1.7,,,,,,,fee schedule,1.7,3.18,Other Pharmacy
Factor ix complex,J7194,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.79,,,,,,,fee schedule,1.7,3.18,APC
Factor ix complex,J7194,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1.77,,,,,,,fee schedule,1.7,3.18,APC
Factor ix complex,J7194,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2.61,,,,,,,fee schedule,1.7,3.18,Radiology
Factor ix complex,J7194,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2.39,,,,,,,fee schedule,1.7,3.18,APC
Factor ix complex,J7194,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2.98,,,,,,,fee schedule,1.7,3.18,APC
Factor ix recombinant nos,J7195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.83,,,,,,,fee schedule,1.84,4.16,
Factor ix recombinant nos,J7195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.16,,,,,,,fee schedule,1.84,4.16,
Factor ix recombinant nos,J7195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.22,,,,,,,fee schedule,1.84,4.16,
Factor ix recombinant nos,J7195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.33,,,,,,,fee schedule,1.84,4.16,
Factor ix recombinant nos,J7195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.64,,,,,,,fee schedule,1.84,4.16,
Factor ix recombinant nos,J7195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.92,,,,,,,fee schedule,1.84,4.16,
Factor ix recombinant nos,J7195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2.13,,,,,,,fee schedule,1.84,4.16,OP High Cost Drugs
Factor ix recombinant nos,J7195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1.84,,,,,,,fee schedule,1.84,4.16,Other Pharmacy
Factor ix recombinant nos,J7195,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.93,,,,,,,fee schedule,1.84,4.16,APC
Factor ix recombinant nos,J7195,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1.91,,,,,,,fee schedule,1.84,4.16,APC
Factor ix recombinant nos,J7195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2.81,,,,,,,fee schedule,1.84,4.16,Radiology
Factor ix recombinant nos,J7195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2.57,,,,,,,fee schedule,1.84,4.16,APC
Factor ix recombinant nos,J7195,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3.21,,,,,,,fee schedule,1.84,4.16,APC
Antithrombin recombinant,J7196,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,359.66,,,,,,,fee schedule,167.31,390.66,
Antithrombin recombinant,J7196,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,390.66,,,,,,,fee schedule,167.31,390.66,
Antithrombin recombinant,J7196,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,184.86,,,,,,,fee schedule,167.31,390.66,
Antithrombin recombinant,J7196,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,313.15,,,,,,,fee schedule,167.31,390.66,
Antithrombin recombinant,J7196,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,342.09,,,,,,,fee schedule,167.31,390.66,
Antithrombin recombinant,J7196,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,167.31,,,,,,,fee schedule,167.31,390.66,
Antithrombin iii injection,J7197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7.86,,,,,,,fee schedule,4.1,8.54,
Antithrombin iii injection,J7197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8.54,,,,,,,fee schedule,4.1,8.54,
Antithrombin iii injection,J7197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8.22,,,,,,,fee schedule,4.1,8.54,
Antithrombin iii injection,J7197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.85,,,,,,,fee schedule,4.1,8.54,
Antithrombin iii injection,J7197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7.48,,,,,,,fee schedule,4.1,8.54,
Antithrombin iii injection,J7197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7.44,,,,,,,fee schedule,4.1,8.54,
Antithrombin iii injection,J7197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4.76,,,,,,,fee schedule,4.1,8.54,OP High Cost Drugs
Antithrombin iii injection,J7197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4.1,,,,,,,fee schedule,4.1,8.54,Other Pharmacy
Antithrombin iii injection,J7197,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.3,,,,,,,fee schedule,4.1,8.54,APC
Antithrombin iii injection,J7197,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4.26,,,,,,,fee schedule,4.1,8.54,APC
Antithrombin iii injection,J7197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.27,,,,,,,fee schedule,4.1,8.54,Radiology
Antithrombin iii injection,J7197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.74,,,,,,,fee schedule,4.1,8.54,APC
Antithrombin iii injection,J7197,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7.17,,,,,,,fee schedule,4.1,8.54,APC
Anti-inhibitor,J7198,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.29,,,,,,,fee schedule,2.42,5.75,
Anti-inhibitor,J7198,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.75,,,,,,,fee schedule,2.42,5.75,
Anti-inhibitor,J7198,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.27,,,,,,,fee schedule,2.42,5.75,
Anti-inhibitor,J7198,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.61,,,,,,,fee schedule,2.42,5.75,
Anti-inhibitor,J7198,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.03,,,,,,,fee schedule,2.42,5.75,
Anti-inhibitor,J7198,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.86,,,,,,,fee schedule,2.42,5.75,
Anti-inhibitor,J7198,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2.8,,,,,,,fee schedule,2.42,5.75,OP High Cost Drugs
Anti-inhibitor,J7198,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2.42,,,,,,,fee schedule,2.42,5.75,Other Pharmacy
Anti-inhibitor,J7198,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2.54,,,,,,,fee schedule,2.42,5.75,APC
Anti-inhibitor,J7198,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2.51,,,,,,,fee schedule,2.42,5.75,APC
Anti-inhibitor,J7198,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3.7,,,,,,,fee schedule,2.42,5.75,Radiology
Anti-inhibitor,J7198,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3.39,,,,,,,fee schedule,2.42,5.75,APC
Anti-inhibitor,J7198,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4.23,,,,,,,fee schedule,2.42,5.75,APC
Factor ix recombinan rixubis,J7200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.32,,,,,,,fee schedule,1.74,4.69,
Factor ix recombinan rixubis,J7200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.69,,,,,,,fee schedule,1.74,4.69,
Factor ix recombinan rixubis,J7200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.41,,,,,,,fee schedule,1.74,4.69,
Factor ix recombinan rixubis,J7200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.76,,,,,,,fee schedule,1.74,4.69,
Factor ix recombinan rixubis,J7200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.1,,,,,,,fee schedule,1.74,4.69,
Factor ix recombinan rixubis,J7200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.09,,,,,,,fee schedule,1.74,4.69,
Factor ix recombinan rixubis,J7200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2.02,,,,,,,fee schedule,1.74,4.69,OP High Cost Drugs
Factor ix recombinan rixubis,J7200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1.74,,,,,,,fee schedule,1.74,4.69,Other Pharmacy
Factor ix recombinan rixubis,J7200,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.83,,,,,,,fee schedule,1.74,4.69,APC
Factor ix recombinan rixubis,J7200,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1.81,,,,,,,fee schedule,1.74,4.69,APC
Factor ix recombinan rixubis,J7200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2.67,,,,,,,fee schedule,1.74,4.69,Radiology
Factor ix recombinan rixubis,J7200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2.44,,,,,,,fee schedule,1.74,4.69,APC
Factor ix recombinan rixubis,J7200,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3.05,,,,,,,fee schedule,1.74,4.69,APC
Factor ix alprolix recomb,J7201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.81,,,,,,,fee schedule,3.58,10.66,
Factor ix alprolix recomb,J7201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10.66,,,,,,,fee schedule,3.58,10.66,
Factor ix alprolix recomb,J7201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7.09,,,,,,,fee schedule,3.58,10.66,
Factor ix alprolix recomb,J7201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.54,,,,,,,fee schedule,3.58,10.66,
Factor ix alprolix recomb,J7201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.33,,,,,,,fee schedule,3.58,10.66,
Factor ix alprolix recomb,J7201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.42,,,,,,,fee schedule,3.58,10.66,
Factor ix alprolix recomb,J7201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4.15,,,,,,,fee schedule,3.58,10.66,OP High Cost Drugs
Factor ix alprolix recomb,J7201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3.58,,,,,,,fee schedule,3.58,10.66,Other Pharmacy
Factor ix alprolix recomb,J7201,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3.76,,,,,,,fee schedule,3.58,10.66,APC
Factor ix alprolix recomb,J7201,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3.72,,,,,,,fee schedule,3.58,10.66,APC
Factor ix alprolix recomb,J7201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.48,,,,,,,fee schedule,3.58,10.66,Radiology
Factor ix alprolix recomb,J7201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.01,,,,,,,fee schedule,3.58,10.66,APC
Factor ix alprolix recomb,J7201,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6.26,,,,,,,fee schedule,3.58,10.66,APC
Factor ix idelvion inj,J7202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14.41,,,,,,,fee schedule,5.32,15.65,
Factor ix idelvion inj,J7202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15.65,,,,,,,fee schedule,5.32,15.65,
Factor ix idelvion inj,J7202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10.21,,,,,,,fee schedule,5.32,15.65,
Factor ix idelvion inj,J7202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12.54,,,,,,,fee schedule,5.32,15.65,
Factor ix idelvion inj,J7202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13.7,,,,,,,fee schedule,5.32,15.65,
Factor ix idelvion inj,J7202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.24,,,,,,,fee schedule,5.32,15.65,
Factor ix idelvion inj,J7202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6.17,,,,,,,fee schedule,5.32,15.65,OP High Cost Drugs
Factor ix idelvion inj,J7202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.32,,,,,,,fee schedule,5.32,15.65,Other Pharmacy
Factor ix idelvion inj,J7202,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.58,,,,,,,fee schedule,5.32,15.65,APC
Factor ix idelvion inj,J7202,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5.53,,,,,,,fee schedule,5.32,15.65,APC
Factor ix idelvion inj,J7202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8.14,,,,,,,fee schedule,5.32,15.65,Radiology
Factor ix idelvion inj,J7202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.45,,,,,,,fee schedule,5.32,15.65,APC
Factor ix idelvion inj,J7202,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9.31,,,,,,,fee schedule,5.32,15.65,APC
Factor ix recomb gly rebinyn,J7203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13.51,,,,,,,fee schedule,4.5,14.68,
Factor ix recomb gly rebinyn,J7203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14.68,,,,,,,fee schedule,4.5,14.68,
Factor ix recomb gly rebinyn,J7203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.18,,,,,,,fee schedule,4.5,14.68,
Factor ix recomb gly rebinyn,J7203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11.77,,,,,,,fee schedule,4.5,14.68,
Factor ix recomb gly rebinyn,J7203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12.85,,,,,,,fee schedule,4.5,14.68,
Factor ix recomb gly rebinyn,J7203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.31,,,,,,,fee schedule,4.5,14.68,
Factor ix recomb gly rebinyn,J7203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5.22,,,,,,,fee schedule,4.5,14.68,OP High Cost Drugs
Factor ix recomb gly rebinyn,J7203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4.5,,,,,,,fee schedule,4.5,14.68,Other Pharmacy
Factor ix recomb gly rebinyn,J7203,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.72,,,,,,,fee schedule,4.5,14.68,APC
Factor ix recomb gly rebinyn,J7203,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4.68,,,,,,,fee schedule,4.5,14.68,APC
Factor ix recomb gly rebinyn,J7203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.88,,,,,,,fee schedule,4.5,14.68,Radiology
Factor ix recomb gly rebinyn,J7203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.29,,,,,,,fee schedule,4.5,14.68,APC
Factor ix recomb gly rebinyn,J7203,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7.87,,,,,,,fee schedule,4.5,14.68,APC
Inj recombin esperoct per iu,J7204,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7.82,,,,,,,fee schedule,2.22,8.5,
Inj recombin esperoct per iu,J7204,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8.5,,,,,,,fee schedule,2.22,8.5,
Inj recombin esperoct per iu,J7204,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.83,,,,,,,fee schedule,2.22,8.5,
Inj recombin esperoct per iu,J7204,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.81,,,,,,,fee schedule,2.22,8.5,
Inj recombin esperoct per iu,J7204,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7.44,,,,,,,fee schedule,2.22,8.5,
Inj recombin esperoct per iu,J7204,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.38,,,,,,,fee schedule,2.22,8.5,
Inj recombin esperoct per iu,J7204,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2.58,,,,,,,fee schedule,2.22,8.5,OP High Cost Drugs
Inj recombin esperoct per iu,J7204,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2.22,,,,,,,fee schedule,2.22,8.5,Other Pharmacy
Inj recombin esperoct per iu,J7204,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2.34,,,,,,,fee schedule,2.22,8.5,APC
Inj recombin esperoct per iu,J7204,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2.31,,,,,,,fee schedule,2.22,8.5,APC
Inj recombin esperoct per iu,J7204,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3.4,,,,,,,fee schedule,2.22,8.5,Radiology
Inj recombin esperoct per iu,J7204,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3.12,,,,,,,fee schedule,2.22,8.5,APC
Inj recombin esperoct per iu,J7204,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3.89,,,,,,,fee schedule,2.22,8.5,APC
Factor viii fc fusion recomb,J7205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.58,,,,,,,fee schedule,2.46,7.14,
Factor viii fc fusion recomb,J7205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7.14,,,,,,,fee schedule,2.46,7.14,
Factor viii fc fusion recomb,J7205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.9,,,,,,,fee schedule,2.46,7.14,
Factor viii fc fusion recomb,J7205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.73,,,,,,,fee schedule,2.46,7.14,
Factor viii fc fusion recomb,J7205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.26,,,,,,,fee schedule,2.46,7.14,
Factor viii fc fusion recomb,J7205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.43,,,,,,,fee schedule,2.46,7.14,
Factor viii fc fusion recomb,J7205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2.86,,,,,,,fee schedule,2.46,7.14,OP High Cost Drugs
Factor viii fc fusion recomb,J7205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2.46,,,,,,,fee schedule,2.46,7.14,Other Pharmacy
Factor viii fc fusion recomb,J7205,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2.59,,,,,,,fee schedule,2.46,7.14,APC
Factor viii fc fusion recomb,J7205,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2.56,,,,,,,fee schedule,2.46,7.14,APC
Factor viii fc fusion recomb,J7205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3.77,,,,,,,fee schedule,2.46,7.14,Radiology
Factor viii fc fusion recomb,J7205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3.45,,,,,,,fee schedule,2.46,7.14,APC
Factor viii fc fusion recomb,J7205,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4.31,,,,,,,fee schedule,2.46,7.14,APC
Factor viii pegylated recomb,J7207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.06,,,,,,,fee schedule,2.14,6.58,
Factor viii pegylated recomb,J7207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.58,,,,,,,fee schedule,2.14,6.58,
Factor viii pegylated recomb,J7207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.72,,,,,,,fee schedule,2.14,6.58,
Factor viii pegylated recomb,J7207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.27,,,,,,,fee schedule,2.14,6.58,
Factor viii pegylated recomb,J7207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.76,,,,,,,fee schedule,2.14,6.58,
Factor viii pegylated recomb,J7207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.28,,,,,,,fee schedule,2.14,6.58,
Factor viii pegylated recomb,J7207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2.48,,,,,,,fee schedule,2.14,6.58,OP High Cost Drugs
Factor viii pegylated recomb,J7207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2.14,,,,,,,fee schedule,2.14,6.58,Other Pharmacy
Factor viii pegylated recomb,J7207,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2.25,,,,,,,fee schedule,2.14,6.58,APC
Factor viii pegylated recomb,J7207,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2.23,,,,,,,fee schedule,2.14,6.58,APC
Factor viii pegylated recomb,J7207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3.28,,,,,,,fee schedule,2.14,6.58,Radiology
Factor viii pegylated recomb,J7207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3,,,,,,,fee schedule,2.14,6.58,APC
Factor viii pegylated recomb,J7207,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3.75,,,,,,,fee schedule,2.14,6.58,APC
Inj. jivi 1 iu,J7208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7.02,,,,,,,fee schedule,2.66,7.63,
Inj. jivi 1 iu,J7208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7.63,,,,,,,fee schedule,2.66,7.63,
Inj. jivi 1 iu,J7208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.23,,,,,,,fee schedule,2.66,7.63,
Inj. jivi 1 iu,J7208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.11,,,,,,,fee schedule,2.66,7.63,
Inj. jivi 1 iu,J7208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.68,,,,,,,fee schedule,2.66,7.63,
Inj. jivi 1 iu,J7208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.73,,,,,,,fee schedule,2.66,7.63,
Inj. jivi 1 iu,J7208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3.08,,,,,,,fee schedule,2.66,7.63,OP High Cost Drugs
Inj. jivi 1 iu,J7208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2.66,,,,,,,fee schedule,2.66,7.63,Other Pharmacy
Inj. jivi 1 iu,J7208,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2.79,,,,,,,fee schedule,2.66,7.63,APC
Inj. jivi 1 iu,J7208,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2.76,,,,,,,fee schedule,2.66,7.63,APC
Inj. jivi 1 iu,J7208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4.06,,,,,,,fee schedule,2.66,7.63,Radiology
Inj. jivi 1 iu,J7208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3.72,,,,,,,fee schedule,2.66,7.63,APC
Inj. jivi 1 iu,J7208,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4.65,,,,,,,fee schedule,2.66,7.63,APC
Factor viii nuwiq recomb 1iu,J7209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.92,,,,,,,fee schedule,1.18,6.43,
Factor viii nuwiq recomb 1iu,J7209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.43,,,,,,,fee schedule,1.18,6.43,
Factor viii nuwiq recomb 1iu,J7209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.6,,,,,,,fee schedule,1.18,6.43,
Factor viii nuwiq recomb 1iu,J7209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.15,,,,,,,fee schedule,1.18,6.43,
Factor viii nuwiq recomb 1iu,J7209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.63,,,,,,,fee schedule,1.18,6.43,
Factor viii nuwiq recomb 1iu,J7209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.26,,,,,,,fee schedule,1.18,6.43,
Factor viii nuwiq recomb 1iu,J7209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1.37,,,,,,,fee schedule,1.18,6.43,OP High Cost Drugs
Factor viii nuwiq recomb 1iu,J7209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1.18,,,,,,,fee schedule,1.18,6.43,Other Pharmacy
Factor viii nuwiq recomb 1iu,J7209,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.24,,,,,,,fee schedule,1.18,6.43,APC
Factor viii nuwiq recomb 1iu,J7209,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1.23,,,,,,,fee schedule,1.18,6.43,APC
Factor viii nuwiq recomb 1iu,J7209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1.81,,,,,,,fee schedule,1.18,6.43,Radiology
Factor viii nuwiq recomb 1iu,J7209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1.65,,,,,,,fee schedule,1.18,6.43,APC
Factor viii nuwiq recomb 1iu,J7209,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2.07,,,,,,,fee schedule,1.18,6.43,APC
"Inj, afstyla, 1 i.u.",J7210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.73,,,,,,,fee schedule,1.57,5.14,
"Inj, afstyla, 1 i.u.",J7210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.14,,,,,,,fee schedule,1.57,5.14,
"Inj, afstyla, 1 i.u.",J7210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.6,,,,,,,fee schedule,1.57,5.14,
"Inj, afstyla, 1 i.u.",J7210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.12,,,,,,,fee schedule,1.57,5.14,
"Inj, afstyla, 1 i.u.",J7210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.5,,,,,,,fee schedule,1.57,5.14,
"Inj, afstyla, 1 i.u.",J7210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.26,,,,,,,fee schedule,1.57,5.14,
"Inj, afstyla, 1 i.u.",J7210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1.82,,,,,,,fee schedule,1.57,5.14,OP High Cost Drugs
"Inj, afstyla, 1 i.u.",J7210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1.57,,,,,,,fee schedule,1.57,5.14,Other Pharmacy
"Inj, afstyla, 1 i.u.",J7210,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.65,,,,,,,fee schedule,1.57,5.14,APC
"Inj, afstyla, 1 i.u.",J7210,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1.63,,,,,,,fee schedule,1.57,5.14,APC
"Inj, afstyla, 1 i.u.",J7210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2.41,,,,,,,fee schedule,1.57,5.14,Radiology
"Inj, afstyla, 1 i.u.",J7210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2.2,,,,,,,fee schedule,1.57,5.14,APC
"Inj, afstyla, 1 i.u.",J7210,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2.75,,,,,,,fee schedule,1.57,5.14,APC
"Inj, kovaltry, 1 i.u.",J7211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.4,,,,,,,fee schedule,1.56,4.78,
"Inj, kovaltry, 1 i.u.",J7211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.78,,,,,,,fee schedule,1.56,4.78,
"Inj, kovaltry, 1 i.u.",J7211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.17,,,,,,,fee schedule,1.56,4.78,
"Inj, kovaltry, 1 i.u.",J7211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.83,,,,,,,fee schedule,1.56,4.78,
"Inj, kovaltry, 1 i.u.",J7211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.18,,,,,,,fee schedule,1.56,4.78,
"Inj, kovaltry, 1 i.u.",J7211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.78,,,,,,,fee schedule,1.56,4.78,
"Inj, kovaltry, 1 i.u.",J7211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1.81,,,,,,,fee schedule,1.56,4.78,OP High Cost Drugs
"Inj, kovaltry, 1 i.u.",J7211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1.56,,,,,,,fee schedule,1.56,4.78,Other Pharmacy
"Inj, kovaltry, 1 i.u.",J7211,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.64,,,,,,,fee schedule,1.56,4.78,APC
"Inj, kovaltry, 1 i.u.",J7211,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1.63,,,,,,,fee schedule,1.56,4.78,APC
"Inj, kovaltry, 1 i.u.",J7211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2.39,,,,,,,fee schedule,1.56,4.78,Radiology
"Inj, kovaltry, 1 i.u.",J7211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2.19,,,,,,,fee schedule,1.56,4.78,APC
"Inj, kovaltry, 1 i.u.",J7211,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2.74,,,,,,,fee schedule,1.56,4.78,APC
Factor viia recomb sevenfact,J7212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9,,,,,,,fee schedule,2.2,9.77,
Factor viia recomb sevenfact,J7212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.77,,,,,,,fee schedule,2.2,9.77,
Factor viia recomb sevenfact,J7212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.85,,,,,,,fee schedule,2.2,9.77,
Factor viia recomb sevenfact,J7212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7.83,,,,,,,fee schedule,2.2,9.77,
Factor viia recomb sevenfact,J7212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.56,,,,,,,fee schedule,2.2,9.77,
Factor viia recomb sevenfact,J7212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.39,,,,,,,fee schedule,2.2,9.77,
Factor viia recomb sevenfact,J7212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2.55,,,,,,,fee schedule,2.2,9.77,OP High Cost Drugs
Factor viia recomb sevenfact,J7212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2.2,,,,,,,fee schedule,2.2,9.77,Other Pharmacy
Factor viia recomb sevenfact,J7212,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2.31,,,,,,,fee schedule,2.2,9.77,APC
Factor viia recomb sevenfact,J7212,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2.29,,,,,,,fee schedule,2.2,9.77,APC
Factor viia recomb sevenfact,J7212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3.36,,,,,,,fee schedule,2.2,9.77,Radiology
Factor viia recomb sevenfact,J7212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3.08,,,,,,,fee schedule,2.2,9.77,APC
Factor viia recomb sevenfact,J7212,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3.85,,,,,,,fee schedule,2.2,9.77,APC
"Inj, ixinity, 1 i.u.",J7213,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.14,,,,,,,fee schedule,1.97,6.67,
"Inj, ixinity, 1 i.u.",J7213,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.67,,,,,,,fee schedule,1.97,6.67,
"Inj, ixinity, 1 i.u.",J7213,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.92,,,,,,,fee schedule,1.97,6.67,
"Inj, ixinity, 1 i.u.",J7213,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.34,,,,,,,fee schedule,1.97,6.67,
"Inj, ixinity, 1 i.u.",J7213,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.84,,,,,,,fee schedule,1.97,6.67,
"Inj, ixinity, 1 i.u.",J7213,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.55,,,,,,,fee schedule,1.97,6.67,
"Inj, ixinity, 1 i.u.",J7213,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2.29,,,,,,,fee schedule,1.97,6.67,OP High Cost Drugs
"Inj, ixinity, 1 i.u.",J7213,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1.97,,,,,,,fee schedule,1.97,6.67,Other Pharmacy
"Inj, ixinity, 1 i.u.",J7213,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2.07,,,,,,,fee schedule,1.97,6.67,APC
"Inj, ixinity, 1 i.u.",J7213,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2.05,,,,,,,fee schedule,1.97,6.67,APC
"Inj, ixinity, 1 i.u.",J7213,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3.02,,,,,,,fee schedule,1.97,6.67,Radiology
"Inj, ixinity, 1 i.u.",J7213,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2.76,,,,,,,fee schedule,1.97,6.67,APC
"Inj, ixinity, 1 i.u.",J7213,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3.45,,,,,,,fee schedule,1.97,6.67,APC
Altuviiio per factor viii iu,J7214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16.47,,,,,,,fee schedule,4.49,17.89,
Altuviiio per factor viii iu,J7214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17.89,,,,,,,fee schedule,4.49,17.89,
Altuviiio per factor viii iu,J7214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.97,,,,,,,fee schedule,4.49,17.89,
Altuviiio per factor viii iu,J7214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14.34,,,,,,,fee schedule,4.49,17.89,
Altuviiio per factor viii iu,J7214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15.67,,,,,,,fee schedule,4.49,17.89,
Altuviiio per factor viii iu,J7214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.02,,,,,,,fee schedule,4.49,17.89,
Altuviiio per factor viii iu,J7214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5.21,,,,,,,fee schedule,4.49,17.89,OP High Cost Drugs
Altuviiio per factor viii iu,J7214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4.49,,,,,,,fee schedule,4.49,17.89,Other Pharmacy
Altuviiio per factor viii iu,J7214,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.72,,,,,,,fee schedule,4.49,17.89,APC
Altuviiio per factor viii iu,J7214,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4.67,,,,,,,fee schedule,4.49,17.89,APC
Altuviiio per factor viii iu,J7214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.87,,,,,,,fee schedule,4.49,17.89,Radiology
Altuviiio per factor viii iu,J7214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.29,,,,,,,fee schedule,4.49,17.89,APC
Altuviiio per factor viii iu,J7214,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7.86,,,,,,,fee schedule,4.49,17.89,APC
Seg acet and eth estr yearly,J7294,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4589.36,,,,,,,fee schedule,4153.66,4589.36,
Seg acet and eth estr yearly,J7294,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4153.66,,,,,,,fee schedule,4153.66,4589.36,
Eth estr and eton monthly,J7295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,292.93,,,,,,,fee schedule,265.12,292.93,
Eth estr and eton monthly,J7295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,265.12,,,,,,,fee schedule,265.12,292.93,
"Kyleena, 19.5 mg",J7296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2193.28,,,,,,,fee schedule,1985.05,2193.28,
"Kyleena, 19.5 mg",J7296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1985.05,,,,,,,fee schedule,1985.05,2193.28,
"Liletta, 52 mg",J7297,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2610,,,,,,,fee schedule,1522.71,2835,
"Liletta, 52 mg",J7297,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2835,,,,,,,fee schedule,1522.71,2835,
"Liletta, 52 mg",J7297,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1682.43,,,,,,,fee schedule,1522.71,2835,
"Liletta, 52 mg",J7297,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2272.5,,,,,,,fee schedule,1522.71,2835,
"Liletta, 52 mg",J7297,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2482.5,,,,,,,fee schedule,1522.71,2835,
"Liletta, 52 mg",J7297,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1522.71,,,,,,,fee schedule,1522.71,2835,
"Mirena, 52 mg",J7298,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3384.68,,,,,,,fee schedule,1985.05,3676.47,
"Mirena, 52 mg",J7298,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3676.47,,,,,,,fee schedule,1985.05,3676.47,
"Mirena, 52 mg",J7298,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2193.28,,,,,,,fee schedule,1985.05,3676.47,
"Mirena, 52 mg",J7298,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2947.01,,,,,,,fee schedule,1985.05,3676.47,
"Mirena, 52 mg",J7298,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3219.34,,,,,,,fee schedule,1985.05,3676.47,
"Mirena, 52 mg",J7298,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1985.05,,,,,,,fee schedule,1985.05,3676.47,
Intraut copper contraceptive,J7300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2057.16,,,,,,,fee schedule,1861.86,2057.16,
Intraut copper contraceptive,J7300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1861.86,,,,,,,fee schedule,1861.86,2057.16,
"Skyla, 13.5 mg",J7301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2715.72,,,,,,,fee schedule,1652.88,2949.84,
"Skyla, 13.5 mg",J7301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2949.84,,,,,,,fee schedule,1652.88,2949.84,
"Skyla, 13.5 mg",J7301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1826.26,,,,,,,fee schedule,1652.88,2949.84,
"Skyla, 13.5 mg",J7301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2364.55,,,,,,,fee schedule,1652.88,2949.84,
"Skyla, 13.5 mg",J7301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2583.06,,,,,,,fee schedule,1652.88,2949.84,
"Skyla, 13.5 mg",J7301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1652.88,,,,,,,fee schedule,1652.88,2949.84,
Contraceptive hormone patch,J7304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,308.35,,,,,,,fee schedule,279.08,308.35,
Contraceptive hormone patch,J7304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,279.08,,,,,,,fee schedule,279.08,308.35,
Levonorgestrel implant sys,J7306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,308.35,,,,,,,fee schedule,279.08,308.35,
Levonorgestrel implant sys,J7306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,279.08,,,,,,,fee schedule,279.08,308.35,
Etonogestrel implant system,J7307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2192.31,,,,,,,fee schedule,1984.18,2192.31,
Etonogestrel implant system,J7307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1984.18,,,,,,,fee schedule,1984.18,2192.31,
Aminolevulinic acid hcl top,J7308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,419.9,,,,,,,fee schedule,365.6,745.54,
Aminolevulinic acid hcl top,J7308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,456.09,,,,,,,fee schedule,365.6,745.54,
Aminolevulinic acid hcl top,J7308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,745.54,,,,,,,fee schedule,365.6,745.54,
Aminolevulinic acid hcl top,J7308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,365.6,,,,,,,fee schedule,365.6,745.54,
Aminolevulinic acid hcl top,J7308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,399.38,,,,,,,fee schedule,365.6,745.54,
Aminolevulinic acid hcl top,J7308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,674.76,,,,,,,fee schedule,365.6,745.54,
Aminolevulinic acid hcl top,J7308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,452.42,,,,,,,fee schedule,365.6,745.54,OP High Cost Drugs
Aminolevulinic acid hcl top,J7308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,390.02,,,,,,,fee schedule,365.6,745.54,Other Pharmacy
Aminolevulinic acid hcl top,J7308,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,409.52,,,,,,,fee schedule,365.6,745.54,APC
Aminolevulinic acid hcl top,J7308,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,405.62,,,,,,,fee schedule,365.6,745.54,APC
Aminolevulinic acid hcl top,J7308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,596.72,,,,,,,fee schedule,365.6,745.54,Radiology
Aminolevulinic acid hcl top,J7308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,546.02,,,,,,,fee schedule,365.6,745.54,APC
Aminolevulinic acid hcl top,J7308,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,682.53,,,,,,,fee schedule,365.6,745.54,APC
"Methyl aminolevulinate, top",J7309,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,291.24,,,,,,,fee schedule,141.13,316.35,
"Methyl aminolevulinate, top",J7309,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,316.35,,,,,,,fee schedule,141.13,316.35,
"Methyl aminolevulinate, top",J7309,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,155.93,,,,,,,fee schedule,141.13,316.35,
"Methyl aminolevulinate, top",J7309,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,253.58,,,,,,,fee schedule,141.13,316.35,
"Methyl aminolevulinate, top",J7309,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,277.01,,,,,,,fee schedule,141.13,316.35,
"Methyl aminolevulinate, top",J7309,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,141.13,,,,,,,fee schedule,141.13,316.35,
Ganciclovir long act implant,J7310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60603.78,,,,,,,fee schedule,52767.09,65828.25,
Ganciclovir long act implant,J7310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,65828.25,,,,,,,fee schedule,52767.09,65828.25,
Ganciclovir long act implant,J7310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52767.09,,,,,,,fee schedule,52767.09,65828.25,
Ganciclovir long act implant,J7310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57643.25,,,,,,,fee schedule,52767.09,65828.25,
Fluocinolone acetonide implt,J7311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,69126.2,,,,,,,fee schedule,338.79,75085.35,
Fluocinolone acetonide implt,J7311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,75085.35,,,,,,,fee schedule,338.79,75085.35,
Fluocinolone acetonide implt,J7311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,635,,,,,,,fee schedule,338.79,75085.35,
Fluocinolone acetonide implt,J7311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,60187.47,,,,,,,fee schedule,338.79,75085.35,
Fluocinolone acetonide implt,J7311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,65749.34,,,,,,,fee schedule,338.79,75085.35,
Fluocinolone acetonide implt,J7311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,574.72,,,,,,,fee schedule,338.79,75085.35,
Fluocinolone acetonide implt,J7311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,393,,,,,,,fee schedule,338.79,75085.35,OP High Cost Drugs
Fluocinolone acetonide implt,J7311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,338.79,,,,,,,fee schedule,338.79,75085.35,Other Pharmacy
Fluocinolone acetonide implt,J7311,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,355.73,,,,,,,fee schedule,338.79,75085.35,APC
Fluocinolone acetonide implt,J7311,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,352.34,,,,,,,fee schedule,338.79,75085.35,APC
Fluocinolone acetonide implt,J7311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,518.35,,,,,,,fee schedule,338.79,75085.35,Radiology
Fluocinolone acetonide implt,J7311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,474.31,,,,,,,fee schedule,338.79,75085.35,APC
Fluocinolone acetonide implt,J7311,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,592.89,,,,,,,fee schedule,338.79,75085.35,APC
Dexamethasone intra implant,J7312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,681.7,,,,,,,fee schedule,203.79,740.46,
Dexamethasone intra implant,J7312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,740.46,,,,,,,fee schedule,203.79,740.46,
Dexamethasone intra implant,J7312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,372,,,,,,,fee schedule,203.79,740.46,
Dexamethasone intra implant,J7312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,593.55,,,,,,,fee schedule,203.79,740.46,
Dexamethasone intra implant,J7312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,648.4,,,,,,,fee schedule,203.79,740.46,
Dexamethasone intra implant,J7312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,336.68,,,,,,,fee schedule,203.79,740.46,
Dexamethasone intra implant,J7312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.4,,,,,,,fee schedule,203.79,740.46,OP High Cost Drugs
Dexamethasone intra implant,J7312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,203.79,,,,,,,fee schedule,203.79,740.46,Other Pharmacy
Dexamethasone intra implant,J7312,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,213.98,,,,,,,fee schedule,203.79,740.46,APC
Dexamethasone intra implant,J7312,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,211.94,,,,,,,fee schedule,203.79,740.46,APC
Dexamethasone intra implant,J7312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,311.8,,,,,,,fee schedule,203.79,740.46,Radiology
Dexamethasone intra implant,J7312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,285.31,,,,,,,fee schedule,203.79,740.46,APC
Dexamethasone intra implant,J7312,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,356.64,,,,,,,fee schedule,203.79,740.46,APC
Fluocinol acet intravit imp,J7313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1708.51,,,,,,,fee schedule,509.81,1855.79,
Fluocinol acet intravit imp,J7313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1855.79,,,,,,,fee schedule,509.81,1855.79,
Fluocinol acet intravit imp,J7313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,887.6,,,,,,,fee schedule,509.81,1855.79,
Fluocinol acet intravit imp,J7313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1487.58,,,,,,,fee schedule,509.81,1855.79,
Fluocinol acet intravit imp,J7313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1625.04,,,,,,,fee schedule,509.81,1855.79,
Fluocinol acet intravit imp,J7313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,803.33,,,,,,,fee schedule,509.81,1855.79,
Fluocinol acet intravit imp,J7313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,591.38,,,,,,,fee schedule,509.81,1855.79,OP High Cost Drugs
Fluocinol acet intravit imp,J7313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,509.81,,,,,,,fee schedule,509.81,1855.79,Other Pharmacy
Fluocinol acet intravit imp,J7313,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,535.3,,,,,,,fee schedule,509.81,1855.79,APC
Fluocinol acet intravit imp,J7313,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,530.2,,,,,,,fee schedule,509.81,1855.79,APC
Fluocinol acet intravit imp,J7313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,780.01,,,,,,,fee schedule,509.81,1855.79,Radiology
Fluocinol acet intravit imp,J7313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,713.73,,,,,,,fee schedule,509.81,1855.79,APC
Fluocinol acet intravit imp,J7313,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,892.17,,,,,,,fee schedule,509.81,1855.79,APC
"Inj., yutiq, 0.01 mg",J7314,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1709.14,,,,,,,fee schedule,529.89,1856.48,
"Inj., yutiq, 0.01 mg",J7314,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1856.48,,,,,,,fee schedule,529.89,1856.48,
"Inj., yutiq, 0.01 mg",J7314,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,948.33,,,,,,,fee schedule,529.89,1856.48,
"Inj., yutiq, 0.01 mg",J7314,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1488.13,,,,,,,fee schedule,529.89,1856.48,
"Inj., yutiq, 0.01 mg",J7314,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1625.65,,,,,,,fee schedule,529.89,1856.48,
"Inj., yutiq, 0.01 mg",J7314,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,858.3,,,,,,,fee schedule,529.89,1856.48,
"Inj., yutiq, 0.01 mg",J7314,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,614.67,,,,,,,fee schedule,529.89,1856.48,OP High Cost Drugs
"Inj., yutiq, 0.01 mg",J7314,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,529.89,,,,,,,fee schedule,529.89,1856.48,Other Pharmacy
"Inj., yutiq, 0.01 mg",J7314,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,556.38,,,,,,,fee schedule,529.89,1856.48,APC
"Inj., yutiq, 0.01 mg",J7314,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,551.08,,,,,,,fee schedule,529.89,1856.48,APC
"Inj., yutiq, 0.01 mg",J7314,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,810.73,,,,,,,fee schedule,529.89,1856.48,Radiology
"Inj., yutiq, 0.01 mg",J7314,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,741.84,,,,,,,fee schedule,529.89,1856.48,APC
"Inj., yutiq, 0.01 mg",J7314,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,927.31,,,,,,,fee schedule,529.89,1856.48,APC
Ophthalmic mitomycin,J7315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1319.76,,,,,,,fee schedule,1149.1,1433.53,
Ophthalmic mitomycin,J7315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1433.53,,,,,,,fee schedule,1149.1,1433.53,
Ophthalmic mitomycin,J7315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1149.1,,,,,,,fee schedule,1149.1,1433.53,
Ophthalmic mitomycin,J7315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1255.28,,,,,,,fee schedule,1149.1,1433.53,
"Inj, ocriplasmin, 0.125 mg",J7316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3642.69,,,,,,,fee schedule,1694.84,3956.72,
"Inj, ocriplasmin, 0.125 mg",J7316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3956.72,,,,,,,fee schedule,1694.84,3956.72,
"Inj, ocriplasmin, 0.125 mg",J7316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1872.62,,,,,,,fee schedule,1694.84,3956.72,
"Inj, ocriplasmin, 0.125 mg",J7316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3171.65,,,,,,,fee schedule,1694.84,3956.72,
"Inj, ocriplasmin, 0.125 mg",J7316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3464.74,,,,,,,fee schedule,1694.84,3956.72,
"Inj, ocriplasmin, 0.125 mg",J7316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1694.84,,,,,,,fee schedule,1694.84,3956.72,
"Inj, durolane 1 mg",J7318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3596.58,,,,,,,fee schedule,6.73,3906.63,
"Inj, durolane 1 mg",J7318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3906.63,,,,,,,fee schedule,6.73,3906.63,
"Inj, durolane 1 mg",J7318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33.97,,,,,,,fee schedule,6.73,3906.63,
"Inj, durolane 1 mg",J7318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3131.51,,,,,,,fee schedule,6.73,3906.63,
"Inj, durolane 1 mg",J7318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3420.89,,,,,,,fee schedule,6.73,3906.63,
"Inj, durolane 1 mg",J7318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,30.75,,,,,,,fee schedule,6.73,3906.63,
"Inj, durolane 1 mg",J7318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7.81,,,,,,,fee schedule,6.73,3906.63,OP High Cost Drugs
"Inj, durolane 1 mg",J7318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.73,,,,,,,fee schedule,6.73,3906.63,Other Pharmacy
"Inj, durolane 1 mg",J7318,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.07,,,,,,,fee schedule,6.73,3906.63,APC
"Inj, durolane 1 mg",J7318,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7,,,,,,,fee schedule,6.73,3906.63,APC
"Inj, durolane 1 mg",J7318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10.3,,,,,,,fee schedule,6.73,3906.63,Radiology
"Inj, durolane 1 mg",J7318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.42,,,,,,,fee schedule,6.73,3906.63,APC
"Inj, durolane 1 mg",J7318,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11.78,,,,,,,fee schedule,6.73,3906.63,APC
"Genvisc 850, inj, 1mg",J7320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27.84,,,,,,,fee schedule,3.68,30.26,
"Genvisc 850, inj, 1mg",J7320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30.24,,,,,,,fee schedule,3.68,30.26,
"Genvisc 850, inj, 1mg",J7320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30.26,,,,,,,fee schedule,3.68,30.26,
"Genvisc 850, inj, 1mg",J7320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24.24,,,,,,,fee schedule,3.68,30.26,
"Genvisc 850, inj, 1mg",J7320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26.48,,,,,,,fee schedule,3.68,30.26,
"Genvisc 850, inj, 1mg",J7320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,27.38,,,,,,,fee schedule,3.68,30.26,
"Genvisc 850, inj, 1mg",J7320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4.26,,,,,,,fee schedule,3.68,30.26,OP High Cost Drugs
"Genvisc 850, inj, 1mg",J7320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3.68,,,,,,,fee schedule,3.68,30.26,Other Pharmacy
"Genvisc 850, inj, 1mg",J7320,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3.86,,,,,,,fee schedule,3.68,30.26,APC
"Genvisc 850, inj, 1mg",J7320,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3.82,,,,,,,fee schedule,3.68,30.26,APC
"Genvisc 850, inj, 1mg",J7320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.62,,,,,,,fee schedule,3.68,30.26,Radiology
"Genvisc 850, inj, 1mg",J7320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.15,,,,,,,fee schedule,3.68,30.26,APC
"Genvisc 850, inj, 1mg",J7320,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6.43,,,,,,,fee schedule,3.68,30.26,APC
Hyalgan/supartz inj per dose,J7321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,353.32,,,,,,,fee schedule,307.64,383.78,
Hyalgan/supartz inj per dose,J7321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,383.78,,,,,,,fee schedule,307.64,383.78,
Hyalgan/supartz inj per dose,J7321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,360.24,,,,,,,fee schedule,307.64,383.78,
Hyalgan/supartz inj per dose,J7321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,307.64,,,,,,,fee schedule,307.64,383.78,
Hyalgan/supartz inj per dose,J7321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,336.06,,,,,,,fee schedule,307.64,383.78,
Hyalgan/supartz inj per dose,J7321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,326.04,,,,,,,fee schedule,307.64,383.78,
Hymovis injection 1 mg,J7322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,56.24,,,,,,,fee schedule,18.13,61.08,
Hymovis injection 1 mg,J7322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,61.08,,,,,,,fee schedule,18.13,61.08,
Hymovis injection 1 mg,J7322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,56.64,,,,,,,fee schedule,18.13,61.08,
Hymovis injection 1 mg,J7322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48.96,,,,,,,fee schedule,18.13,61.08,
Hymovis injection 1 mg,J7322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.49,,,,,,,fee schedule,18.13,61.08,
Hymovis injection 1 mg,J7322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.27,,,,,,,fee schedule,18.13,61.08,
Hymovis injection 1 mg,J7322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,21.04,,,,,,,fee schedule,18.13,61.08,OP High Cost Drugs
Hymovis injection 1 mg,J7322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.13,,,,,,,fee schedule,18.13,61.08,Other Pharmacy
Hymovis injection 1 mg,J7322,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.04,,,,,,,fee schedule,18.13,61.08,APC
Hymovis injection 1 mg,J7322,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18.86,,,,,,,fee schedule,18.13,61.08,APC
Hymovis injection 1 mg,J7322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27.75,,,,,,,fee schedule,18.13,61.08,Radiology
Hymovis injection 1 mg,J7322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.39,,,,,,,fee schedule,18.13,61.08,APC
Hymovis injection 1 mg,J7322,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31.73,,,,,,,fee schedule,18.13,61.08,APC
Euflexxa inj per dose,J7323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,391.64,,,,,,,fee schedule,105.58,683.75,
Euflexxa inj per dose,J7323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,425.4,,,,,,,fee schedule,105.58,683.75,
Euflexxa inj per dose,J7323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,683.75,,,,,,,fee schedule,105.58,683.75,
Euflexxa inj per dose,J7323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,341,,,,,,,fee schedule,105.58,683.75,
Euflexxa inj per dose,J7323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,372.51,,,,,,,fee schedule,105.58,683.75,
Euflexxa inj per dose,J7323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,618.83,,,,,,,fee schedule,105.58,683.75,
Euflexxa inj per dose,J7323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,122.47,,,,,,,fee schedule,105.58,683.75,OP High Cost Drugs
Euflexxa inj per dose,J7323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,105.58,,,,,,,fee schedule,105.58,683.75,Other Pharmacy
Euflexxa inj per dose,J7323,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,110.86,,,,,,,fee schedule,105.58,683.75,APC
Euflexxa inj per dose,J7323,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,109.8,,,,,,,fee schedule,105.58,683.75,APC
Euflexxa inj per dose,J7323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,161.54,,,,,,,fee schedule,105.58,683.75,Radiology
Euflexxa inj per dose,J7323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,147.81,,,,,,,fee schedule,105.58,683.75,APC
Euflexxa inj per dose,J7323,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,184.76,,,,,,,fee schedule,105.58,683.75,APC
Orthovisc inj per dose,J7324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,641.4,,,,,,,fee schedule,109.09,696.69,
Orthovisc inj per dose,J7324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,696.69,,,,,,,fee schedule,109.09,696.69,
Orthovisc inj per dose,J7324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,453.14,,,,,,,fee schedule,109.09,696.69,
Orthovisc inj per dose,J7324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,558.46,,,,,,,fee schedule,109.09,696.69,
Orthovisc inj per dose,J7324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,610.07,,,,,,,fee schedule,109.09,696.69,
Orthovisc inj per dose,J7324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,410.12,,,,,,,fee schedule,109.09,696.69,
Orthovisc inj per dose,J7324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,126.55,,,,,,,fee schedule,109.09,696.69,OP High Cost Drugs
Orthovisc inj per dose,J7324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,109.09,,,,,,,fee schedule,109.09,696.69,Other Pharmacy
Orthovisc inj per dose,J7324,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,114.55,,,,,,,fee schedule,109.09,696.69,APC
Orthovisc inj per dose,J7324,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,113.46,,,,,,,fee schedule,109.09,696.69,APC
Orthovisc inj per dose,J7324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,166.91,,,,,,,fee schedule,109.09,696.69,Radiology
Orthovisc inj per dose,J7324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,152.73,,,,,,,fee schedule,109.09,696.69,APC
Orthovisc inj per dose,J7324,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,190.91,,,,,,,fee schedule,109.09,696.69,APC
Synvisc or Synvisc-One,J7325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,43.74,,,,,,,fee schedule,6.96,54.1,
Synvisc or Synvisc-One,J7325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,47.51,,,,,,,fee schedule,6.96,54.1,
Synvisc or Synvisc-One,J7325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,54.1,,,,,,,fee schedule,6.96,54.1,
Synvisc or Synvisc-One,J7325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38.09,,,,,,,fee schedule,6.96,54.1,
Synvisc or Synvisc-One,J7325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,41.61,,,,,,,fee schedule,6.96,54.1,
Synvisc or Synvisc-One,J7325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48.96,,,,,,,fee schedule,6.96,54.1,
Synvisc or Synvisc-One,J7325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8.08,,,,,,,fee schedule,6.96,54.1,OP High Cost Drugs
Synvisc or Synvisc-One,J7325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.96,,,,,,,fee schedule,6.96,54.1,Other Pharmacy
Synvisc or Synvisc-One,J7325,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.31,,,,,,,fee schedule,6.96,54.1,APC
Synvisc or Synvisc-One,J7325,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7.24,,,,,,,fee schedule,6.96,54.1,APC
Synvisc or Synvisc-One,J7325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10.65,,,,,,,fee schedule,6.96,54.1,Radiology
Synvisc or Synvisc-One,J7325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.75,,,,,,,fee schedule,6.96,54.1,APC
Synvisc or Synvisc-One,J7325,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12.19,,,,,,,fee schedule,6.96,54.1,APC
Gel-one,J7326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2157.95,,,,,,,fee schedule,526.79,2343.98,
Gel-one,J7326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2343.98,,,,,,,fee schedule,526.79,2343.98,
Gel-one,J7326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2180.4,,,,,,,fee schedule,526.79,2343.98,
Gel-one,J7326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1878.9,,,,,,,fee schedule,526.79,2343.98,
Gel-one,J7326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2052.53,,,,,,,fee schedule,526.79,2343.98,
Gel-one,J7326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1973.4,,,,,,,fee schedule,526.79,2343.98,
Gel-one,J7326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,611.07,,,,,,,fee schedule,526.79,2343.98,OP High Cost Drugs
Gel-one,J7326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,526.79,,,,,,,fee schedule,526.79,2343.98,Other Pharmacy
Gel-one,J7326,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,553.13,,,,,,,fee schedule,526.79,2343.98,APC
Gel-one,J7326,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,547.86,,,,,,,fee schedule,526.79,2343.98,APC
Gel-one,J7326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,805.98,,,,,,,fee schedule,526.79,2343.98,Radiology
Gel-one,J7326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,737.5,,,,,,,fee schedule,526.79,2343.98,APC
Gel-one,J7326,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,921.88,,,,,,,fee schedule,526.79,2343.98,APC
Monovisc inj per dose,J7327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3439.56,,,,,,,fee schedule,655.34,3736.08,
Monovisc inj per dose,J7327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3736.08,,,,,,,fee schedule,655.34,3736.08,
Monovisc inj per dose,J7327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2844,,,,,,,fee schedule,655.34,3736.08,
Monovisc inj per dose,J7327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2994.79,,,,,,,fee schedule,655.34,3736.08,
Monovisc inj per dose,J7327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3271.54,,,,,,,fee schedule,655.34,3736.08,
Monovisc inj per dose,J7327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2574,,,,,,,fee schedule,655.34,3736.08,
Monovisc inj per dose,J7327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,760.19,,,,,,,fee schedule,655.34,3736.08,OP High Cost Drugs
Monovisc inj per dose,J7327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,655.34,,,,,,,fee schedule,655.34,3736.08,Other Pharmacy
Monovisc inj per dose,J7327,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,688.1,,,,,,,fee schedule,655.34,3736.08,APC
Monovisc inj per dose,J7327,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,681.55,,,,,,,fee schedule,655.34,3736.08,APC
Monovisc inj per dose,J7327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1002.67,,,,,,,fee schedule,655.34,3736.08,Radiology
Monovisc inj per dose,J7327,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,917.47,,,,,,,fee schedule,655.34,3736.08,APC
Monovisc inj per dose,J7327,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1146.84,,,,,,,fee schedule,655.34,3736.08,APC
Gel-syn injection 0.1 mg,J7328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.23,,,,,,,fee schedule,0.68,4.23,
Gel-syn injection 0.1 mg,J7328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.83,,,,,,,fee schedule,0.68,4.23,
Gel-syn injection 0.1 mg,J7328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,0.79,,,,,,,fee schedule,0.68,4.23,OP High Cost Drugs
Gel-syn injection 0.1 mg,J7328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,0.68,,,,,,,fee schedule,0.68,4.23,Other Pharmacy
Gel-syn injection 0.1 mg,J7328,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,0.71,,,,,,,fee schedule,0.68,4.23,APC
Gel-syn injection 0.1 mg,J7328,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,0.71,,,,,,,fee schedule,0.68,4.23,APC
Gel-syn injection 0.1 mg,J7328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1.04,,,,,,,fee schedule,0.68,4.23,Radiology
Gel-syn injection 0.1 mg,J7328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,0.95,,,,,,,fee schedule,0.68,4.23,APC
Gel-syn injection 0.1 mg,J7328,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1.19,,,,,,,fee schedule,0.68,4.23,APC
"Inj, trivisc 1 mg",J7329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,25.04,,,,,,,fee schedule,3.27,34.19,
"Inj, trivisc 1 mg",J7329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27.2,,,,,,,fee schedule,3.27,34.19,
"Inj, trivisc 1 mg",J7329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,34.19,,,,,,,fee schedule,3.27,34.19,
"Inj, trivisc 1 mg",J7329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21.8,,,,,,,fee schedule,3.27,34.19,
"Inj, trivisc 1 mg",J7329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23.82,,,,,,,fee schedule,3.27,34.19,
"Inj, trivisc 1 mg",J7329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,30.95,,,,,,,fee schedule,3.27,34.19,
"Inj, trivisc 1 mg",J7329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3.8,,,,,,,fee schedule,3.27,34.19,OP High Cost Drugs
"Inj, trivisc 1 mg",J7329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3.27,,,,,,,fee schedule,3.27,34.19,Other Pharmacy
"Inj, trivisc 1 mg",J7329,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3.44,,,,,,,fee schedule,3.27,34.19,APC
"Inj, trivisc 1 mg",J7329,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3.4,,,,,,,fee schedule,3.27,34.19,APC
"Inj, trivisc 1 mg",J7329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.01,,,,,,,fee schedule,3.27,34.19,Radiology
"Inj, trivisc 1 mg",J7329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4.58,,,,,,,fee schedule,3.27,34.19,APC
"Inj, trivisc 1 mg",J7329,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5.73,,,,,,,fee schedule,3.27,34.19,APC
Cultured chondrocytes implnt,J7330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,76931.32,,,,,,,fee schedule,66983.3,115020.84,
Cultured chondrocytes implnt,J7330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83563.33,,,,,,,fee schedule,66983.3,115020.84,
Cultured chondrocytes implnt,J7330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,115020.84,,,,,,,fee schedule,66983.3,115020.84,
Cultured chondrocytes implnt,J7330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66983.3,,,,,,,fee schedule,66983.3,115020.84,
Cultured chondrocytes implnt,J7330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,73173.18,,,,,,,fee schedule,66983.3,115020.84,
Cultured chondrocytes implnt,J7330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,104101.14,,,,,,,fee schedule,66983.3,115020.84,
"Synojoynt, inj., 1 mg",J7331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21.33,,,,,,,fee schedule,18.57,23.17,
"Synojoynt, inj., 1 mg",J7331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23.17,,,,,,,fee schedule,18.57,23.17,
"Synojoynt, inj., 1 mg",J7331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18.57,,,,,,,fee schedule,18.57,23.17,
"Synojoynt, inj., 1 mg",J7331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20.29,,,,,,,fee schedule,18.57,23.17,
"Inj., triluron, 1 mg",J7332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,87.64,,,,,,,fee schedule,10.54,95.2,
"Inj., triluron, 1 mg",J7332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,95.2,,,,,,,fee schedule,10.54,95.2,
"Inj., triluron, 1 mg",J7332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46.36,,,,,,,fee schedule,10.54,95.2,
"Inj., triluron, 1 mg",J7332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,76.31,,,,,,,fee schedule,10.54,95.2,
"Inj., triluron, 1 mg",J7332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,83.36,,,,,,,fee schedule,10.54,95.2,
"Inj., triluron, 1 mg",J7332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,41.96,,,,,,,fee schedule,10.54,95.2,
"Inj., triluron, 1 mg",J7332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.23,,,,,,,fee schedule,10.54,95.2,OP High Cost Drugs
"Inj., triluron, 1 mg",J7332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10.54,,,,,,,fee schedule,10.54,95.2,Other Pharmacy
"Inj., triluron, 1 mg",J7332,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.07,,,,,,,fee schedule,10.54,95.2,APC
"Inj., triluron, 1 mg",J7332,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10.97,,,,,,,fee schedule,10.54,95.2,APC
"Inj., triluron, 1 mg",J7332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.13,,,,,,,fee schedule,10.54,95.2,Radiology
"Inj., triluron, 1 mg",J7332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.76,,,,,,,fee schedule,10.54,95.2,APC
"Inj., triluron, 1 mg",J7332,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18.45,,,,,,,fee schedule,10.54,95.2,APC
Capsaicin 8% patch,J7336,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.5,,,,,,,fee schedule,3.42,10.32,
Capsaicin 8% patch,J7336,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10.32,,,,,,,fee schedule,3.42,10.32,
Capsaicin 8% patch,J7336,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.86,,,,,,,fee schedule,3.42,10.32,
Capsaicin 8% patch,J7336,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.27,,,,,,,fee schedule,3.42,10.32,
Capsaicin 8% patch,J7336,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.04,,,,,,,fee schedule,3.42,10.32,
Capsaicin 8% patch,J7336,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.31,,,,,,,fee schedule,3.42,10.32,
Capsaicin 8% patch,J7336,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3.97,,,,,,,fee schedule,3.42,10.32,OP High Cost Drugs
Capsaicin 8% patch,J7336,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3.42,,,,,,,fee schedule,3.42,10.32,Other Pharmacy
Capsaicin 8% patch,J7336,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3.59,,,,,,,fee schedule,3.42,10.32,APC
Capsaicin 8% patch,J7336,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3.56,,,,,,,fee schedule,3.42,10.32,APC
Capsaicin 8% patch,J7336,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.24,,,,,,,fee schedule,3.42,10.32,Radiology
Capsaicin 8% patch,J7336,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4.79,,,,,,,fee schedule,3.42,10.32,APC
Capsaicin 8% patch,J7336,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5.99,,,,,,,fee schedule,3.42,10.32,APC
Carbidopa levodopa ent 100ml,J7340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7.45,,,,,,,fee schedule,6.48,428.39,
Carbidopa levodopa ent 100ml,J7340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8.09,,,,,,,fee schedule,6.48,428.39,
Carbidopa levodopa ent 100ml,J7340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,428.39,,,,,,,fee schedule,6.48,428.39,
Carbidopa levodopa ent 100ml,J7340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.48,,,,,,,fee schedule,6.48,428.39,
Carbidopa levodopa ent 100ml,J7340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7.08,,,,,,,fee schedule,6.48,428.39,
Carbidopa levodopa ent 100ml,J7340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,387.72,,,,,,,fee schedule,6.48,428.39,
Carbidopa levodopa ent 100ml,J7340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,283.09,,,,,,,fee schedule,6.48,428.39,OP High Cost Drugs
Carbidopa levodopa ent 100ml,J7340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,244.04,,,,,,,fee schedule,6.48,428.39,Other Pharmacy
Carbidopa levodopa ent 100ml,J7340,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,256.24,,,,,,,fee schedule,6.48,428.39,APC
Carbidopa levodopa ent 100ml,J7340,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,253.8,,,,,,,fee schedule,6.48,428.39,APC
Carbidopa levodopa ent 100ml,J7340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,373.38,,,,,,,fee schedule,6.48,428.39,Radiology
Carbidopa levodopa ent 100ml,J7340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,341.66,,,,,,,fee schedule,6.48,428.39,APC
Carbidopa levodopa ent 100ml,J7340,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,427.07,,,,,,,fee schedule,6.48,428.39,APC
Ciprofloxacin otic susp 6 mg,J7342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,104.26,,,,,,,fee schedule,48.59,113.25,
Ciprofloxacin otic susp 6 mg,J7342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,113.25,,,,,,,fee schedule,48.59,113.25,
Ciprofloxacin otic susp 6 mg,J7342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,53.69,,,,,,,fee schedule,48.59,113.25,
Ciprofloxacin otic susp 6 mg,J7342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,90.78,,,,,,,fee schedule,48.59,113.25,
Ciprofloxacin otic susp 6 mg,J7342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,99.17,,,,,,,fee schedule,48.59,113.25,
Ciprofloxacin otic susp 6 mg,J7342,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48.59,,,,,,,fee schedule,48.59,113.25,
"Aminolevulinic acid, 10% gel",J7345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.82,,,,,,,fee schedule,1.77,5.23,
"Aminolevulinic acid, 10% gel",J7345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.23,,,,,,,fee schedule,1.77,5.23,
"Aminolevulinic acid, 10% gel",J7345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.44,,,,,,,fee schedule,1.77,5.23,
"Aminolevulinic acid, 10% gel",J7345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.19,,,,,,,fee schedule,1.77,5.23,
"Aminolevulinic acid, 10% gel",J7345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.58,,,,,,,fee schedule,1.77,5.23,
"Aminolevulinic acid, 10% gel",J7345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.12,,,,,,,fee schedule,1.77,5.23,
"Aminolevulinic acid, 10% gel",J7345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2.06,,,,,,,fee schedule,1.77,5.23,OP High Cost Drugs
"Aminolevulinic acid, 10% gel",J7345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1.77,,,,,,,fee schedule,1.77,5.23,Other Pharmacy
"Aminolevulinic acid, 10% gel",J7345,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.86,,,,,,,fee schedule,1.77,5.23,APC
"Aminolevulinic acid, 10% gel",J7345,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1.84,,,,,,,fee schedule,1.77,5.23,APC
"Aminolevulinic acid, 10% gel",J7345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2.71,,,,,,,fee schedule,1.77,5.23,Radiology
"Aminolevulinic acid, 10% gel",J7345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2.48,,,,,,,fee schedule,1.77,5.23,APC
"Aminolevulinic acid, 10% gel",J7345,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3.1,,,,,,,fee schedule,1.77,5.23,APC
Inj bimatoprost itc imp 1mcg,J7351,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,718.19,,,,,,,fee schedule,214.02,780.1,
Inj bimatoprost itc imp 1mcg,J7351,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,780.1,,,,,,,fee schedule,214.02,780.1,
Inj bimatoprost itc imp 1mcg,J7351,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,376.74,,,,,,,fee schedule,214.02,780.1,
Inj bimatoprost itc imp 1mcg,J7351,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,625.32,,,,,,,fee schedule,214.02,780.1,
Inj bimatoprost itc imp 1mcg,J7351,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,683.1,,,,,,,fee schedule,214.02,780.1,
Inj bimatoprost itc imp 1mcg,J7351,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,340.97,,,,,,,fee schedule,214.02,780.1,
Inj bimatoprost itc imp 1mcg,J7351,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,248.26,,,,,,,fee schedule,214.02,780.1,OP High Cost Drugs
Inj bimatoprost itc imp 1mcg,J7351,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,214.02,,,,,,,fee schedule,214.02,780.1,Other Pharmacy
Inj bimatoprost itc imp 1mcg,J7351,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.72,,,,,,,fee schedule,214.02,780.1,APC
Inj bimatoprost itc imp 1mcg,J7351,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.58,,,,,,,fee schedule,214.02,780.1,APC
Inj bimatoprost itc imp 1mcg,J7351,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.45,,,,,,,fee schedule,214.02,780.1,Radiology
Inj bimatoprost itc imp 1mcg,J7351,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.63,,,,,,,fee schedule,214.02,780.1,APC
Inj bimatoprost itc imp 1mcg,J7351,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.54,,,,,,,fee schedule,214.02,780.1,APC
"Afamelanotide implant, 1 mg",J7352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11201.76,,,,,,,fee schedule,2943.42,13058.96,
"Afamelanotide implant, 1 mg",J7352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12167.43,,,,,,,fee schedule,2943.42,13058.96,
"Afamelanotide implant, 1 mg",J7352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9753.26,,,,,,,fee schedule,2943.42,13058.96,
"Afamelanotide implant, 1 mg",J7352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10654.55,,,,,,,fee schedule,2943.42,13058.96,
"Afamelanotide implant, 1 mg",J7352,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,13058.96,,,,,,,fee schedule,2943.42,13058.96,APC 378
"Afamelanotide implant, 1 mg",J7352,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3090.59,,,,,,,fee schedule,2943.42,13058.96,APC
"Afamelanotide implant, 1 mg",J7352,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3061.16,,,,,,,fee schedule,2943.42,13058.96,APC
"Afamelanotide implant, 1 mg",J7352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2943.42,,,,,,,fee schedule,2943.42,13058.96,APC
"Afamelanotide implant, 1 mg",J7352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4503.43,,,,,,,fee schedule,2943.42,13058.96,Radiology
"Afamelanotide implant, 1 mg",J7352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4120.79,,,,,,,fee schedule,2943.42,13058.96,APC
"Afamelanotide implant, 1 mg",J7352,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5150.99,,,,,,,fee schedule,2943.42,13058.96,APC
Anacaulase-bcdb 8.8% gel 1 g,J7353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,108.59,,,,,,,fee schedule,98.28,108.59,
Anacaulase-bcdb 8.8% gel 1 g,J7353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,98.28,,,,,,,fee schedule,98.28,108.59,
"Cantharidin top, applicator",J7354,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1298.76,,,,,,,fee schedule,667.07,1298.76,
"Cantharidin top, applicator",J7354,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1175.46,,,,,,,fee schedule,667.07,1298.76,
"Cantharidin top, applicator",J7354,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,773.8,,,,,,,fee schedule,667.07,1298.76,OP High Cost Drugs
"Cantharidin top, applicator",J7354,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,667.07,,,,,,,fee schedule,667.07,1298.76,Other Pharmacy
"Cantharidin top, applicator",J7354,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,700.43,,,,,,,fee schedule,667.07,1298.76,APC
"Cantharidin top, applicator",J7354,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,693.76,,,,,,,fee schedule,667.07,1298.76,APC
"Cantharidin top, applicator",J7354,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1020.62,,,,,,,fee schedule,667.07,1298.76,Radiology
"Cantharidin top, applicator",J7354,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,933.9,,,,,,,fee schedule,667.07,1298.76,APC
"Cantharidin top, applicator",J7354,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1167.38,,,,,,,fee schedule,667.07,1298.76,APC
Inj travoprost intra impl,J7355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,351.77,,,,,,,fee schedule,196.88,351.77,
Inj travoprost intra impl,J7355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,318.38,,,,,,,fee schedule,196.88,351.77,
Inj travoprost intra impl,J7355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,228.38,,,,,,,fee schedule,196.88,351.77,OP High Cost Drugs
Inj travoprost intra impl,J7355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,196.88,,,,,,,fee schedule,196.88,351.77,Other Pharmacy
Inj travoprost intra impl,J7355,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,206.72,,,,,,,fee schedule,196.88,351.77,APC
Inj travoprost intra impl,J7355,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,204.75,,,,,,,fee schedule,196.88,351.77,APC
Inj travoprost intra impl,J7355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,301.22,,,,,,,fee schedule,196.88,351.77,Radiology
Inj travoprost intra impl,J7355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,275.63,,,,,,,fee schedule,196.88,351.77,APC
Inj travoprost intra impl,J7355,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,344.54,,,,,,,fee schedule,196.88,351.77,APC
Mometasone sinus sinuva,J7402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,36.75,,,,,,,fee schedule,11.34,39.92,
Mometasone sinus sinuva,J7402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,39.92,,,,,,,fee schedule,11.34,39.92,
Mometasone sinus sinuva,J7402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20.68,,,,,,,fee schedule,11.34,39.92,
Mometasone sinus sinuva,J7402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32,,,,,,,fee schedule,11.34,39.92,
Mometasone sinus sinuva,J7402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,34.95,,,,,,,fee schedule,11.34,39.92,
Mometasone sinus sinuva,J7402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18.72,,,,,,,fee schedule,11.34,39.92,
Mometasone sinus sinuva,J7402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.16,,,,,,,fee schedule,11.34,39.92,OP High Cost Drugs
Mometasone sinus sinuva,J7402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11.34,,,,,,,fee schedule,11.34,39.92,Other Pharmacy
Mometasone sinus sinuva,J7402,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.91,,,,,,,fee schedule,11.34,39.92,APC
Mometasone sinus sinuva,J7402,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11.8,,,,,,,fee schedule,11.34,39.92,APC
Mometasone sinus sinuva,J7402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.36,,,,,,,fee schedule,11.34,39.92,Radiology
Mometasone sinus sinuva,J7402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15.88,,,,,,,fee schedule,11.34,39.92,APC
Mometasone sinus sinuva,J7402,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19.85,,,,,,,fee schedule,11.34,39.92,APC
Azathioprine oral 50mg,J7500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.71,,,,,,,fee schedule,3.36,3.71,
Azathioprine oral 50mg,J7500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.36,,,,,,,fee schedule,3.36,3.71,
Azathioprine parenteral,J7501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,325.14,,,,,,,fee schedule,254.76,1130.28,
Azathioprine parenteral,J7501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,353.17,,,,,,,fee schedule,254.76,1130.28,
Azathioprine parenteral,J7501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,474,,,,,,,fee schedule,254.76,1130.28,
Azathioprine parenteral,J7501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,283.09,,,,,,,fee schedule,254.76,1130.28,
Azathioprine parenteral,J7501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,309.25,,,,,,,fee schedule,254.76,1130.28,
Azathioprine parenteral,J7501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,429,,,,,,,fee schedule,254.76,1130.28,
Azathioprine parenteral,J7501,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1130.28,,,,,,,fee schedule,254.76,1130.28,APC 378
Azathioprine parenteral,J7501,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,267.5,,,,,,,fee schedule,254.76,1130.28,APC
Azathioprine parenteral,J7501,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,264.95,,,,,,,fee schedule,254.76,1130.28,APC
Azathioprine parenteral,J7501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,254.76,,,,,,,fee schedule,254.76,1130.28,APC
Azathioprine parenteral,J7501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,389.78,,,,,,,fee schedule,254.76,1130.28,Radiology
Azathioprine parenteral,J7501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,356.66,,,,,,,fee schedule,254.76,1130.28,APC
Azathioprine parenteral,J7501,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,445.83,,,,,,,fee schedule,254.76,1130.28,APC
Cyclosporine oral 100 mg,J7502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13.12,,,,,,,fee schedule,11.42,20.29,
Cyclosporine oral 100 mg,J7502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14.25,,,,,,,fee schedule,11.42,20.29,
Cyclosporine oral 100 mg,J7502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20.29,,,,,,,fee schedule,11.42,20.29,
Cyclosporine oral 100 mg,J7502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11.42,,,,,,,fee schedule,11.42,20.29,
Cyclosporine oral 100 mg,J7502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12.48,,,,,,,fee schedule,11.42,20.29,
Cyclosporine oral 100 mg,J7502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18.36,,,,,,,fee schedule,11.42,20.29,
Tacrol envarsus ex rel oral,J7503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.07,,,,,,,fee schedule,2.93,4.42,
Tacrol envarsus ex rel oral,J7503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.42,,,,,,,fee schedule,2.93,4.42,
Tacrol envarsus ex rel oral,J7503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.24,,,,,,,fee schedule,2.93,4.42,
Tacrol envarsus ex rel oral,J7503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.55,,,,,,,fee schedule,2.93,4.42,
Tacrol envarsus ex rel oral,J7503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.87,,,,,,,fee schedule,2.93,4.42,
Tacrol envarsus ex rel oral,J7503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.93,,,,,,,fee schedule,2.93,4.42,
Lymphocyte immune globulin,J7504,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1570.38,,,,,,,fee schedule,1367.32,9261.76,
Lymphocyte immune globulin,J7504,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1705.76,,,,,,,fee schedule,1367.32,9261.76,
Lymphocyte immune globulin,J7504,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7947.19,,,,,,,fee schedule,1367.32,9261.76,
Lymphocyte immune globulin,J7504,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1367.32,,,,,,,fee schedule,1367.32,9261.76,
Lymphocyte immune globulin,J7504,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1493.67,,,,,,,fee schedule,1367.32,9261.76,
Lymphocyte immune globulin,J7504,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7192.71,,,,,,,fee schedule,1367.32,9261.76,
Lymphocyte immune globulin,J7504,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6139.22,,,,,,,fee schedule,1367.32,9261.76,OP High Cost Drugs
Lymphocyte immune globulin,J7504,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5292.43,,,,,,,fee schedule,1367.32,9261.76,Other Pharmacy
Lymphocyte immune globulin,J7504,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5557.05,,,,,,,fee schedule,1367.32,9261.76,APC
Lymphocyte immune globulin,J7504,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5504.13,,,,,,,fee schedule,1367.32,9261.76,APC
Lymphocyte immune globulin,J7504,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8097.42,,,,,,,fee schedule,1367.32,9261.76,Radiology
Lymphocyte immune globulin,J7504,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7409.4,,,,,,,fee schedule,1367.32,9261.76,APC
Lymphocyte immune globulin,J7504,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9261.76,,,,,,,fee schedule,1367.32,9261.76,APC
Monoclonal antibodies,J7505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3945.59,,,,,,,fee schedule,3435.38,4285.73,
Monoclonal antibodies,J7505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4285.73,,,,,,,fee schedule,3435.38,4285.73,
Monoclonal antibodies,J7505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3435.38,,,,,,,fee schedule,3435.38,4285.73,
Monoclonal antibodies,J7505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3752.84,,,,,,,fee schedule,3435.38,4285.73,
Tacrolimus imme rel oral 1mg,J7507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13.92,,,,,,,fee schedule,6.38,15.12,
Tacrolimus imme rel oral 1mg,J7507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15.12,,,,,,,fee schedule,6.38,15.12,
Tacrolimus imme rel oral 1mg,J7507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7.05,,,,,,,fee schedule,6.38,15.12,
Tacrolimus imme rel oral 1mg,J7507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12.12,,,,,,,fee schedule,6.38,15.12,
Tacrolimus imme rel oral 1mg,J7507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13.24,,,,,,,fee schedule,6.38,15.12,
Tacrolimus imme rel oral 1mg,J7507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.38,,,,,,,fee schedule,6.38,15.12,
Tacrol astagraf ex rel oral,J7508,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.36,,,,,,,fee schedule,0.96,1.47,
Tacrol astagraf ex rel oral,J7508,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.47,,,,,,,fee schedule,0.96,1.47,
Tacrol astagraf ex rel oral,J7508,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.06,,,,,,,fee schedule,0.96,1.47,
Tacrol astagraf ex rel oral,J7508,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.18,,,,,,,fee schedule,0.96,1.47,
Tacrol astagraf ex rel oral,J7508,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.29,,,,,,,fee schedule,0.96,1.47,
Tacrol astagraf ex rel oral,J7508,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.96,,,,,,,fee schedule,0.96,1.47,
Methylprednisolone oral,J7509,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.69,,,,,,,fee schedule,1.53,1.69,
Methylprednisolone oral,J7509,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.53,,,,,,,fee schedule,1.53,1.69,
Prednisolone oral per 5 mg,J7510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.82,,,,,,,fee schedule,4.36,4.82,
Prednisolone oral per 5 mg,J7510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.36,,,,,,,fee schedule,4.36,4.82,
Antithymocyte globuln rabbit,J7511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1330.47,,,,,,,fee schedule,1023.12,2021.44,
Antithymocyte globuln rabbit,J7511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1445.17,,,,,,,fee schedule,1023.12,2021.44,
Antithymocyte globuln rabbit,J7511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2021.44,,,,,,,fee schedule,1023.12,2021.44,
Antithymocyte globuln rabbit,J7511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1158.43,,,,,,,fee schedule,1023.12,2021.44,
Antithymocyte globuln rabbit,J7511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1265.48,,,,,,,fee schedule,1023.12,2021.44,
Antithymocyte globuln rabbit,J7511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1829.53,,,,,,,fee schedule,1023.12,2021.44,
Antithymocyte globuln rabbit,J7511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1186.82,,,,,,,fee schedule,1023.12,2021.44,OP High Cost Drugs
Antithymocyte globuln rabbit,J7511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1023.12,,,,,,,fee schedule,1023.12,2021.44,Other Pharmacy
Antithymocyte globuln rabbit,J7511,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1074.28,,,,,,,fee schedule,1023.12,2021.44,APC
Antithymocyte globuln rabbit,J7511,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1064.05,,,,,,,fee schedule,1023.12,2021.44,APC
Antithymocyte globuln rabbit,J7511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1565.38,,,,,,,fee schedule,1023.12,2021.44,Radiology
Antithymocyte globuln rabbit,J7511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1432.37,,,,,,,fee schedule,1023.12,2021.44,APC
Antithymocyte globuln rabbit,J7511,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1790.47,,,,,,,fee schedule,1023.12,2021.44,APC
Prednisone ir or dr oral 1mg,J7512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.1,,,,,,,fee schedule,0.06,0.11,
Prednisone ir or dr oral 1mg,J7512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.11,,,,,,,fee schedule,0.06,0.11,
Prednisone ir or dr oral 1mg,J7512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.06,,,,,,,fee schedule,0.06,0.11,
Prednisone ir or dr oral 1mg,J7512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.09,,,,,,,fee schedule,0.06,0.11,
Prednisone ir or dr oral 1mg,J7512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.1,,,,,,,fee schedule,0.06,0.11,
Prednisone ir or dr oral 1mg,J7512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.06,,,,,,,fee schedule,0.06,0.11,
"Daclizumab, parenteral",J7513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1231.19,,,,,,,fee schedule,1071.98,1337.33,
"Daclizumab, parenteral",J7513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1337.33,,,,,,,fee schedule,1071.98,1337.33,
"Daclizumab, parenteral",J7513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1071.98,,,,,,,fee schedule,1071.98,1337.33,
"Daclizumab, parenteral",J7513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1171.04,,,,,,,fee schedule,1071.98,1337.33,
Cyclosporine oral 25 mg,J7515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.07,,,,,,,fee schedule,4.59,5.07,
Cyclosporine oral 25 mg,J7515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.59,,,,,,,fee schedule,4.59,5.07,
Cyclosporin parenteral 250mg,J7516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,129.72,,,,,,,fee schedule,117.4,129.72,
Cyclosporin parenteral 250mg,J7516,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,117.4,,,,,,,fee schedule,117.4,129.72,
Mycophenolate mofetil oral,J7517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11.24,,,,,,,fee schedule,5.68,12.21,
Mycophenolate mofetil oral,J7517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12.21,,,,,,,fee schedule,5.68,12.21,
Mycophenolate mofetil oral,J7517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.27,,,,,,,fee schedule,5.68,12.21,
Mycophenolate mofetil oral,J7517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.79,,,,,,,fee schedule,5.68,12.21,
Mycophenolate mofetil oral,J7517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10.69,,,,,,,fee schedule,5.68,12.21,
Mycophenolate mofetil oral,J7517,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.68,,,,,,,fee schedule,5.68,12.21,
Mycophenolic acid,J7518,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.29,,,,,,,fee schedule,6.54,10.09,
Mycophenolic acid,J7518,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10.09,,,,,,,fee schedule,6.54,10.09,
Mycophenolic acid,J7518,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7.22,,,,,,,fee schedule,6.54,10.09,
Mycophenolic acid,J7518,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.09,,,,,,,fee schedule,6.54,10.09,
Mycophenolic acid,J7518,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.84,,,,,,,fee schedule,6.54,10.09,
Mycophenolic acid,J7518,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.54,,,,,,,fee schedule,6.54,10.09,
Inj. mycophenolate mofetil,J7519,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.58,,,,,,,fee schedule,2.25,2.8,
Inj. mycophenolate mofetil,J7519,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.8,,,,,,,fee schedule,2.25,2.8,
Inj. mycophenolate mofetil,J7519,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.75,,,,,,,fee schedule,2.25,2.8,
Inj. mycophenolate mofetil,J7519,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.25,,,,,,,fee schedule,2.25,2.8,
Inj. mycophenolate mofetil,J7519,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.45,,,,,,,fee schedule,2.25,2.8,
Inj. mycophenolate mofetil,J7519,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.49,,,,,,,fee schedule,2.25,2.8,
"Sirolimus, oral",J7520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30,,,,,,,fee schedule,24.31,32.58,
"Sirolimus, oral",J7520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,32.58,,,,,,,fee schedule,24.31,32.58,
"Sirolimus, oral",J7520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26.86,,,,,,,fee schedule,24.31,32.58,
"Sirolimus, oral",J7520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26.12,,,,,,,fee schedule,24.31,32.58,
"Sirolimus, oral",J7520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28.53,,,,,,,fee schedule,24.31,32.58,
"Sirolimus, oral",J7520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24.31,,,,,,,fee schedule,24.31,32.58,
Tacrolimus injection,J7525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,498.86,,,,,,,fee schedule,259.96,541.86,
Tacrolimus injection,J7525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,541.86,,,,,,,fee schedule,259.96,541.86,
Tacrolimus injection,J7525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,469.45,,,,,,,fee schedule,259.96,541.86,
Tacrolimus injection,J7525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,434.35,,,,,,,fee schedule,259.96,541.86,
Tacrolimus injection,J7525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,474.49,,,,,,,fee schedule,259.96,541.86,
Tacrolimus injection,J7525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,424.88,,,,,,,fee schedule,259.96,541.86,
Tacrolimus injection,J7525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,301.55,,,,,,,fee schedule,259.96,541.86,OP High Cost Drugs
Tacrolimus injection,J7525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,259.96,,,,,,,fee schedule,259.96,541.86,Other Pharmacy
Tacrolimus injection,J7525,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,272.95,,,,,,,fee schedule,259.96,541.86,APC
Tacrolimus injection,J7525,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,270.35,,,,,,,fee schedule,259.96,541.86,APC
Tacrolimus injection,J7525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,397.73,,,,,,,fee schedule,259.96,541.86,Radiology
Tacrolimus injection,J7525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,363.94,,,,,,,fee schedule,259.96,541.86,APC
Tacrolimus injection,J7525,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,454.92,,,,,,,fee schedule,259.96,541.86,APC
Oral everolimus,J7527,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22.48,,,,,,,fee schedule,19.57,31.87,
Oral everolimus,J7527,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24.42,,,,,,,fee schedule,19.57,31.87,
Oral everolimus,J7527,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,31.87,,,,,,,fee schedule,19.57,31.87,
Oral everolimus,J7527,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19.57,,,,,,,fee schedule,19.57,31.87,
Oral everolimus,J7527,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21.38,,,,,,,fee schedule,19.57,31.87,
Oral everolimus,J7527,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28.84,,,,,,,fee schedule,19.57,31.87,
Arformoterol non-comp unit,J7605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,35.57,,,,,,,fee schedule,32.19,35.57,
Arformoterol non-comp unit,J7605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32.19,,,,,,,fee schedule,32.19,35.57,
"Formoterol fumarate, inh",J7606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14.55,,,,,,,fee schedule,12.67,33.48,
"Formoterol fumarate, inh",J7606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15.8,,,,,,,fee schedule,12.67,33.48,
"Formoterol fumarate, inh",J7606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33.48,,,,,,,fee schedule,12.67,33.48,
"Formoterol fumarate, inh",J7606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12.67,,,,,,,fee schedule,12.67,33.48,
"Formoterol fumarate, inh",J7606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13.84,,,,,,,fee schedule,12.67,33.48,
"Formoterol fumarate, inh",J7606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,30.3,,,,,,,fee schedule,12.67,33.48,
Levalbuterol comp con,J7607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8.47,,,,,,,fee schedule,7.66,8.47,
Levalbuterol comp con,J7607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7.66,,,,,,,fee schedule,7.66,8.47,
Acetylcysteine non-comp unit,J7608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,28.74,,,,,,,fee schedule,26.01,28.74,
Acetylcysteine non-comp unit,J7608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26.01,,,,,,,fee schedule,26.01,28.74,
Albuterol non-comp con,J7611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.92,,,,,,,fee schedule,0.83,0.92,
Albuterol non-comp con,J7611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.83,,,,,,,fee schedule,0.83,0.92,
Levalbuterol non-comp con,J7612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.12,,,,,,,fee schedule,1.92,2.12,
Levalbuterol non-comp con,J7612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.92,,,,,,,fee schedule,1.92,2.12,
Albuterol non-comp unit,J7613,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.88,,,,,,,fee schedule,0.8,0.88,
Albuterol non-comp unit,J7613,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.8,,,,,,,fee schedule,0.8,0.88,
Levalbuterol non-comp unit,J7614,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7.51,,,,,,,fee schedule,6.79,7.51,
Levalbuterol non-comp unit,J7614,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.79,,,,,,,fee schedule,6.79,7.51,
Albuterol ipratrop non-comp,J7620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.88,,,,,,,fee schedule,2.6,2.88,
Albuterol ipratrop non-comp,J7620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.6,,,,,,,fee schedule,2.6,2.88,
Budesonide non-comp unit,J7626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17.65,,,,,,,fee schedule,15.97,17.65,
Budesonide non-comp unit,J7626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15.97,,,,,,,fee schedule,15.97,17.65,
Cromolyn sodium noncomp unit,J7631,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.32,,,,,,,fee schedule,4.82,5.32,
Cromolyn sodium noncomp unit,J7631,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.82,,,,,,,fee schedule,4.82,5.32,
Dornase alfa non-comp unit,J7639,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,98.5,,,,,,,fee schedule,89.15,98.5,
Dornase alfa non-comp unit,J7639,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,89.15,,,,,,,fee schedule,89.15,98.5,
Glycopyrrolate comp unit,J7643,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1431.86,,,,,,,fee schedule,1295.92,1431.86,
Glycopyrrolate comp unit,J7643,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1295.92,,,,,,,fee schedule,1295.92,1431.86,
Ipratropium bromide non-comp,J7644,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.17,,,,,,,fee schedule,3.78,4.17,
Ipratropium bromide non-comp,J7644,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.78,,,,,,,fee schedule,3.78,4.17,
Mannitol for inhaler,J7665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.33,,,,,,,fee schedule,1.69,2.53,
Mannitol for inhaler,J7665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.53,,,,,,,fee schedule,1.69,2.53,
Mannitol for inhaler,J7665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.86,,,,,,,fee schedule,1.69,2.53,
Mannitol for inhaler,J7665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.03,,,,,,,fee schedule,1.69,2.53,
Mannitol for inhaler,J7665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.22,,,,,,,fee schedule,1.69,2.53,
Mannitol for inhaler,J7665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.69,,,,,,,fee schedule,1.69,2.53,
"Methacholine chloride, neb",J7674,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.58,,,,,,,fee schedule,1.43,1.58,
"Methacholine chloride, neb",J7674,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.43,,,,,,,fee schedule,1.43,1.58,
Revefenacin inh non-com 1mcg,J7677,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.54,,,,,,,fee schedule,0.49,0.54,
Revefenacin inh non-com 1mcg,J7677,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.49,,,,,,,fee schedule,0.49,0.54,
Tobramycin non-comp unit,J7682,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,203.46,,,,,,,fee schedule,184.14,203.46,
Tobramycin non-comp unit,J7682,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,184.14,,,,,,,fee schedule,184.14,203.46,
"Treprostinil, non-comp unit",J7686,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1602.33,,,,,,,fee schedule,1355.28,1740.46,
"Treprostinil, non-comp unit",J7686,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1740.46,,,,,,,fee schedule,1355.28,1740.46,
"Treprostinil, non-comp unit",J7686,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1497.45,,,,,,,fee schedule,1355.28,1740.46,
"Treprostinil, non-comp unit",J7686,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1395.13,,,,,,,fee schedule,1355.28,1740.46,
"Treprostinil, non-comp unit",J7686,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1524.06,,,,,,,fee schedule,1355.28,1740.46,
"Treprostinil, non-comp unit",J7686,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1355.28,,,,,,,fee schedule,1355.28,1740.46,
Oral aprepitant,J8501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19.07,,,,,,,fee schedule,16.6,20.71,
Oral aprepitant,J8501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20.71,,,,,,,fee schedule,16.6,20.71,
Oral aprepitant,J8501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20.13,,,,,,,fee schedule,16.6,20.71,
Oral aprepitant,J8501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.6,,,,,,,fee schedule,16.6,20.71,
Oral aprepitant,J8501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18.14,,,,,,,fee schedule,16.6,20.71,
Oral aprepitant,J8501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18.22,,,,,,,fee schedule,16.6,20.71,
Oral busulfan,J8510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.99,,,,,,,fee schedule,8.7,547.56,
Oral busulfan,J8510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10.85,,,,,,,fee schedule,8.7,547.56,
Oral busulfan,J8510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,547.56,,,,,,,fee schedule,8.7,547.56,
Oral busulfan,J8510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.7,,,,,,,fee schedule,8.7,547.56,
Oral busulfan,J8510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.5,,,,,,,fee schedule,8.7,547.56,
Oral busulfan,J8510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,495.58,,,,,,,fee schedule,8.7,547.56,
Oral busulfan,J8510,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,44.9,,,,,,,fee schedule,8.7,547.56,APC 378
Oral busulfan,J8510,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.63,,,,,,,fee schedule,8.7,547.56,APC
Oral busulfan,J8510,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10.52,,,,,,,fee schedule,8.7,547.56,APC
Oral busulfan,J8510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10.12,,,,,,,fee schedule,8.7,547.56,APC
Oral busulfan,J8510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15.48,,,,,,,fee schedule,8.7,547.56,Radiology
Oral busulfan,J8510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.17,,,,,,,fee schedule,8.7,547.56,APC
Oral busulfan,J8510,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,17.71,,,,,,,fee schedule,8.7,547.56,APC
"Cabergoline, oral 0.25mg",J8515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,28.96,,,,,,,fee schedule,26.21,28.96,
"Cabergoline, oral 0.25mg",J8515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26.21,,,,,,,fee schedule,26.21,28.96,
"Capecitabine, oral, 150 mg",J8520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17.57,,,,,,,fee schedule,15.3,19.09,
"Capecitabine, oral, 150 mg",J8520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19.09,,,,,,,fee schedule,15.3,19.09,
"Capecitabine, oral, 150 mg",J8520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18.55,,,,,,,fee schedule,15.3,19.09,
"Capecitabine, oral, 150 mg",J8520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15.3,,,,,,,fee schedule,15.3,19.09,
"Capecitabine, oral, 150 mg",J8520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.72,,,,,,,fee schedule,15.3,19.09,
"Capecitabine, oral, 150 mg",J8520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.79,,,,,,,fee schedule,15.3,19.09,
"Capecitabine, oral, 500 mg",J8521,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,58.39,,,,,,,fee schedule,50.84,63.43,
"Capecitabine, oral, 500 mg",J8521,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,63.43,,,,,,,fee schedule,50.84,63.43,
"Capecitabine, oral, 500 mg",J8521,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,61.81,,,,,,,fee schedule,50.84,63.43,
"Capecitabine, oral, 500 mg",J8521,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,50.84,,,,,,,fee schedule,50.84,63.43,
"Capecitabine, oral, 500 mg",J8521,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55.54,,,,,,,fee schedule,50.84,63.43,
"Capecitabine, oral, 500 mg",J8521,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55.94,,,,,,,fee schedule,50.84,63.43,
"Capecitabine, oral, 50 mg",J8522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.18,,,,,,,fee schedule,0.03,6.18,
"Capecitabine, oral, 50 mg",J8522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.59,,,,,,,fee schedule,0.03,6.18,
"Capecitabine, oral, 50 mg",J8522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,0.03,,,,,,,fee schedule,0.03,6.18,OP High Cost Drugs
"Capecitabine, oral, 50 mg",J8522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,0.03,,,,,,,fee schedule,0.03,6.18,Other Pharmacy
"Capecitabine, oral, 50 mg",J8522,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,0.03,,,,,,,fee schedule,0.03,6.18,APC
"Capecitabine, oral, 50 mg",J8522,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,0.03,,,,,,,fee schedule,0.03,6.18,APC
"Capecitabine, oral, 50 mg",J8522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,0.05,,,,,,,fee schedule,0.03,6.18,Radiology
"Capecitabine, oral, 50 mg",J8522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,0.04,,,,,,,fee schedule,0.03,6.18,APC
"Capecitabine, oral, 50 mg",J8522,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,0.05,,,,,,,fee schedule,0.03,6.18,APC
Cyclophosphamide oral 25 MG,J8530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14.11,,,,,,,fee schedule,12.77,14.11,
Cyclophosphamide oral 25 MG,J8530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12.77,,,,,,,fee schedule,12.77,14.11,
Oral dexamethasone,J8540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.14,,,,,,,fee schedule,0.13,0.14,
Oral dexamethasone,J8540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.13,,,,,,,fee schedule,0.13,0.14,
"Oral, hemady, 0.25 mg",J8541,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.65,,,,,,,fee schedule,0.59,0.65,
"Oral, hemady, 0.25 mg",J8541,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.59,,,,,,,fee schedule,0.59,0.65,
Etoposide oral 50 mg,J8560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,104.85,,,,,,,fee schedule,86.84,158.7,
Etoposide oral 50 mg,J8560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,113.89,,,,,,,fee schedule,86.84,158.7,
Etoposide oral 50 mg,J8560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,158.7,,,,,,,fee schedule,86.84,158.7,
Etoposide oral 50 mg,J8560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,91.29,,,,,,,fee schedule,86.84,158.7,
Etoposide oral 50 mg,J8560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,99.73,,,,,,,fee schedule,86.84,158.7,
Etoposide oral 50 mg,J8560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,143.63,,,,,,,fee schedule,86.84,158.7,
Etoposide oral 50 mg,J8560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,100.73,,,,,,,fee schedule,86.84,158.7,OP High Cost Drugs
Etoposide oral 50 mg,J8560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,86.84,,,,,,,fee schedule,86.84,158.7,Other Pharmacy
Etoposide oral 50 mg,J8560,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.18,,,,,,,fee schedule,86.84,158.7,APC
Etoposide oral 50 mg,J8560,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,90.31,,,,,,,fee schedule,86.84,158.7,APC
Etoposide oral 50 mg,J8560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,132.87,,,,,,,fee schedule,86.84,158.7,Radiology
Etoposide oral 50 mg,J8560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,121.58,,,,,,,fee schedule,86.84,158.7,APC
Etoposide oral 50 mg,J8560,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,151.97,,,,,,,fee schedule,86.84,158.7,APC
Oral fludarabine phosphate,J8562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,284.56,,,,,,,fee schedule,247.76,309.09,
Oral fludarabine phosphate,J8562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,309.09,,,,,,,fee schedule,247.76,309.09,
Oral fludarabine phosphate,J8562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,247.76,,,,,,,fee schedule,247.76,309.09,
Oral fludarabine phosphate,J8562,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,270.66,,,,,,,fee schedule,247.76,309.09,
Gefitinib oral,J8565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,467.65,,,,,,,fee schedule,423.25,467.65,
Gefitinib oral,J8565,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,423.25,,,,,,,fee schedule,423.25,467.65,
Melphalan oral 2 MG,J8600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16.7,,,,,,,fee schedule,14.54,20.38,
Melphalan oral 2 MG,J8600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18.14,,,,,,,fee schedule,14.54,20.38,
Melphalan oral 2 MG,J8600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20.38,,,,,,,fee schedule,14.54,20.38,
Melphalan oral 2 MG,J8600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14.54,,,,,,,fee schedule,14.54,20.38,
Melphalan oral 2 MG,J8600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15.89,,,,,,,fee schedule,14.54,20.38,
Melphalan oral 2 MG,J8600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18.45,,,,,,,fee schedule,14.54,20.38,
Methotrexate oral 2.5 MG,J8610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.4,,,,,,,fee schedule,5.79,6.4,
Methotrexate oral 2.5 MG,J8610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.79,,,,,,,fee schedule,5.79,6.4,
Oral methotrexate (jylamvo),J8611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,34.62,,,,,,,fee schedule,18.71,34.62,
Oral methotrexate (jylamvo),J8611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31.33,,,,,,,fee schedule,18.71,34.62,
Oral methotrexate (jylamvo),J8611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,21.7,,,,,,,fee schedule,18.71,34.62,OP High Cost Drugs
Oral methotrexate (jylamvo),J8611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.71,,,,,,,fee schedule,18.71,34.62,Other Pharmacy
Oral methotrexate (jylamvo),J8611,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.65,,,,,,,fee schedule,18.71,34.62,APC
Oral methotrexate (jylamvo),J8611,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,19.46,,,,,,,fee schedule,18.71,34.62,APC
Oral methotrexate (jylamvo),J8611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.63,,,,,,,fee schedule,18.71,34.62,Radiology
Oral methotrexate (jylamvo),J8611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26.19,,,,,,,fee schedule,18.71,34.62,APC
Oral methotrexate (jylamvo),J8611,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,32.74,,,,,,,fee schedule,18.71,34.62,APC
Oral methotrexate (xatmep),J8612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37.16,,,,,,,fee schedule,22.3,39.02,
Oral methotrexate (xatmep),J8612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,33.63,,,,,,,fee schedule,22.3,39.02,
Oral methotrexate (xatmep),J8612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,25.86,,,,,,,fee schedule,22.3,39.02,OP High Cost Drugs
Oral methotrexate (xatmep),J8612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.3,,,,,,,fee schedule,22.3,39.02,Other Pharmacy
Oral methotrexate (xatmep),J8612,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,23.41,,,,,,,fee schedule,22.3,39.02,APC
Oral methotrexate (xatmep),J8612,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,23.19,,,,,,,fee schedule,22.3,39.02,APC
Oral methotrexate (xatmep),J8612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,34.11,,,,,,,fee schedule,22.3,39.02,Radiology
Oral methotrexate (xatmep),J8612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,31.21,,,,,,,fee schedule,22.3,39.02,APC
Oral methotrexate (xatmep),J8612,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,39.02,,,,,,,fee schedule,22.3,39.02,APC
Nabilone oral,J8650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.59,,,,,,,fee schedule,52.75,74.32,
Nabilone oral,J8650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,65.81,,,,,,,fee schedule,52.75,74.32,
Nabilone oral,J8650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,74.32,,,,,,,fee schedule,52.75,74.32,
Nabilone oral,J8650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52.75,,,,,,,fee schedule,52.75,74.32,
Nabilone oral,J8650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.63,,,,,,,fee schedule,52.75,74.32,
Nabilone oral,J8650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,67.27,,,,,,,fee schedule,52.75,74.32,
Netupitant palonosetron oral,J8655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1719.4,,,,,,,fee schedule,397.79,1867.62,
Netupitant palonosetron oral,J8655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1867.62,,,,,,,fee schedule,397.79,1867.62,
Netupitant palonosetron oral,J8655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1308.43,,,,,,,fee schedule,397.79,1867.62,
Netupitant palonosetron oral,J8655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1497.06,,,,,,,fee schedule,397.79,1867.62,
Netupitant palonosetron oral,J8655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1635.4,,,,,,,fee schedule,397.79,1867.62,
Netupitant palonosetron oral,J8655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1184.21,,,,,,,fee schedule,397.79,1867.62,
Netupitant palonosetron oral,J8655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,461.44,,,,,,,fee schedule,397.79,1867.62,OP High Cost Drugs
Netupitant palonosetron oral,J8655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,397.79,,,,,,,fee schedule,397.79,1867.62,Other Pharmacy
Netupitant palonosetron oral,J8655,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,417.68,,,,,,,fee schedule,397.79,1867.62,APC
Netupitant palonosetron oral,J8655,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,413.7,,,,,,,fee schedule,397.79,1867.62,APC
Netupitant palonosetron oral,J8655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,608.62,,,,,,,fee schedule,397.79,1867.62,Radiology
Netupitant palonosetron oral,J8655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,556.91,,,,,,,fee schedule,397.79,1867.62,APC
Netupitant palonosetron oral,J8655,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,696.14,,,,,,,fee schedule,397.79,1867.62,APC
"Rolapitant, oral, 1mg",J8670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8.53,,,,,,,fee schedule,6.31,9.26,
"Rolapitant, oral, 1mg",J8670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.26,,,,,,,fee schedule,6.31,9.26,
"Rolapitant, oral, 1mg",J8670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.97,,,,,,,fee schedule,6.31,9.26,
"Rolapitant, oral, 1mg",J8670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7.42,,,,,,,fee schedule,6.31,9.26,
"Rolapitant, oral, 1mg",J8670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.11,,,,,,,fee schedule,6.31,9.26,
"Rolapitant, oral, 1mg",J8670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.31,,,,,,,fee schedule,6.31,9.26,
Temozolomide,J8700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,29.48,,,,,,,fee schedule,20.19,32.02,
Temozolomide,J8700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,32.02,,,,,,,fee schedule,20.19,32.02,
Temozolomide,J8700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22.31,,,,,,,fee schedule,20.19,32.02,
Temozolomide,J8700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,25.66,,,,,,,fee schedule,20.19,32.02,
Temozolomide,J8700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28.04,,,,,,,fee schedule,20.19,32.02,
Temozolomide,J8700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20.19,,,,,,,fee schedule,20.19,32.02,
Topotecan oral,J8705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,243.22,,,,,,,fee schedule,125.22,264.18,
Topotecan oral,J8705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,264.18,,,,,,,fee schedule,125.22,264.18,
Topotecan oral,J8705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,230.13,,,,,,,fee schedule,125.22,264.18,
Topotecan oral,J8705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,211.77,,,,,,,fee schedule,125.22,264.18,
Topotecan oral,J8705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,231.34,,,,,,,fee schedule,125.22,264.18,
Topotecan oral,J8705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,208.28,,,,,,,fee schedule,125.22,264.18,
Topotecan oral,J8705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,145.26,,,,,,,fee schedule,125.22,264.18,OP High Cost Drugs
Topotecan oral,J8705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,125.22,,,,,,,fee schedule,125.22,264.18,Other Pharmacy
Topotecan oral,J8705,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,131.49,,,,,,,fee schedule,125.22,264.18,APC
Topotecan oral,J8705,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,130.23,,,,,,,fee schedule,125.22,264.18,APC
Topotecan oral,J8705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,191.59,,,,,,,fee schedule,125.22,264.18,Radiology
Topotecan oral,J8705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,175.31,,,,,,,fee schedule,125.22,264.18,APC
Topotecan oral,J8705,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,219.14,,,,,,,fee schedule,125.22,264.18,APC
Doxorubicin hcl injection,J9000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14.22,,,,,,,fee schedule,12.87,14.22,
Doxorubicin hcl injection,J9000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12.87,,,,,,,fee schedule,12.87,14.22,
Aldesleukin injection,J9015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2887.29,,,,,,,fee schedule,2513.93,14813.44,
Aldesleukin injection,J9015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3136.19,,,,,,,fee schedule,2513.93,14813.44,
Aldesleukin injection,J9015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10525.58,,,,,,,fee schedule,2513.93,14813.44,
Aldesleukin injection,J9015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2513.93,,,,,,,fee schedule,2513.93,14813.44,
Aldesleukin injection,J9015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2746.24,,,,,,,fee schedule,2513.93,14813.44,
Aldesleukin injection,J9015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9526.32,,,,,,,fee schedule,2513.93,14813.44,
Aldesleukin injection,J9015,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,14813.44,,,,,,,fee schedule,2513.93,14813.44,APC 378
Aldesleukin injection,J9015,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3505.81,,,,,,,fee schedule,2513.93,14813.44,APC
Aldesleukin injection,J9015,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3472.42,,,,,,,fee schedule,2513.93,14813.44,APC
Aldesleukin injection,J9015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3338.87,,,,,,,fee schedule,2513.93,14813.44,APC
Aldesleukin injection,J9015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5108.47,,,,,,,fee schedule,2513.93,14813.44,Radiology
Aldesleukin injection,J9015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4674.42,,,,,,,fee schedule,2513.93,14813.44,APC
Aldesleukin injection,J9015,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5843.02,,,,,,,fee schedule,2513.93,14813.44,APC
Arsenic trioxide injection,J9017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,123.4,,,,,,,fee schedule,65.05,134.04,
Arsenic trioxide injection,J9017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,134.04,,,,,,,fee schedule,65.05,134.04,
Arsenic trioxide injection,J9017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,71.87,,,,,,,fee schedule,65.05,134.04,
Arsenic trioxide injection,J9017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,107.44,,,,,,,fee schedule,65.05,134.04,
Arsenic trioxide injection,J9017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,117.37,,,,,,,fee schedule,65.05,134.04,
Arsenic trioxide injection,J9017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,65.05,,,,,,,fee schedule,65.05,134.04,
Erwinaze injection,J9019,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1192.74,,,,,,,fee schedule,691.69,1295.56,
Erwinaze injection,J9019,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1295.56,,,,,,,fee schedule,691.69,1295.56,
Erwinaze injection,J9019,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,764.25,,,,,,,fee schedule,691.69,1295.56,
Erwinaze injection,J9019,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1038.5,,,,,,,fee schedule,691.69,1295.56,
Erwinaze injection,J9019,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1134.47,,,,,,,fee schedule,691.69,1295.56,
Erwinaze injection,J9019,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,691.69,,,,,,,fee schedule,691.69,1295.56,
"Asparaginase, nos",J9020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,207.51,,,,,,,fee schedule,104.52,225.4,
"Asparaginase, nos",J9020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,225.4,,,,,,,fee schedule,104.52,225.4,
"Asparaginase, nos",J9020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,115.48,,,,,,,fee schedule,104.52,225.4,
"Asparaginase, nos",J9020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,180.68,,,,,,,fee schedule,104.52,225.4,
"Asparaginase, nos",J9020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,197.38,,,,,,,fee schedule,104.52,225.4,
"Asparaginase, nos",J9020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,104.52,,,,,,,fee schedule,104.52,225.4,
"Inj, aspara, rylaze, 0.1 mg",J9021,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,157.36,,,,,,,fee schedule,56.29,170.92,
"Inj, aspara, rylaze, 0.1 mg",J9021,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,170.92,,,,,,,fee schedule,56.29,170.92,
"Inj, aspara, rylaze, 0.1 mg",J9021,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,97.26,,,,,,,fee schedule,56.29,170.92,
"Inj, aspara, rylaze, 0.1 mg",J9021,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,137.01,,,,,,,fee schedule,56.29,170.92,
"Inj, aspara, rylaze, 0.1 mg",J9021,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,149.67,,,,,,,fee schedule,56.29,170.92,
"Inj, aspara, rylaze, 0.1 mg",J9021,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,88.03,,,,,,,fee schedule,56.29,170.92,
"Inj, aspara, rylaze, 0.1 mg",J9021,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,65.29,,,,,,,fee schedule,56.29,170.92,OP High Cost Drugs
"Inj, aspara, rylaze, 0.1 mg",J9021,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.29,,,,,,,fee schedule,56.29,170.92,Other Pharmacy
"Inj, aspara, rylaze, 0.1 mg",J9021,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,59.1,,,,,,,fee schedule,56.29,170.92,APC
"Inj, aspara, rylaze, 0.1 mg",J9021,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,58.54,,,,,,,fee schedule,56.29,170.92,APC
"Inj, aspara, rylaze, 0.1 mg",J9021,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,86.12,,,,,,,fee schedule,56.29,170.92,Radiology
"Inj, aspara, rylaze, 0.1 mg",J9021,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,78.8,,,,,,,fee schedule,56.29,170.92,APC
"Inj, aspara, rylaze, 0.1 mg",J9021,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,98.5,,,,,,,fee schedule,56.29,170.92,APC
"Inj, atezolizumab,10 mg",J9022,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,267.65,,,,,,,fee schedule,94,290.73,
"Inj, atezolizumab,10 mg",J9022,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,290.73,,,,,,,fee schedule,94,290.73,
"Inj, atezolizumab,10 mg",J9022,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,172.63,,,,,,,fee schedule,94,290.73,
"Inj, atezolizumab,10 mg",J9022,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,233.04,,,,,,,fee schedule,94,290.73,
"Inj, atezolizumab,10 mg",J9022,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,254.58,,,,,,,fee schedule,94,290.73,
"Inj, atezolizumab,10 mg",J9022,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,156.24,,,,,,,fee schedule,94,290.73,
"Inj, atezolizumab,10 mg",J9022,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,109.04,,,,,,,fee schedule,94,290.73,OP High Cost Drugs
"Inj, atezolizumab,10 mg",J9022,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,94,,,,,,,fee schedule,94,290.73,Other Pharmacy
"Inj, atezolizumab,10 mg",J9022,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,98.7,,,,,,,fee schedule,94,290.73,APC
"Inj, atezolizumab,10 mg",J9022,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,97.76,,,,,,,fee schedule,94,290.73,APC
"Inj, atezolizumab,10 mg",J9022,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,143.82,,,,,,,fee schedule,94,290.73,Radiology
"Inj, atezolizumab,10 mg",J9022,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.6,,,,,,,fee schedule,94,290.73,APC
"Inj, atezolizumab,10 mg",J9022,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,164.49,,,,,,,fee schedule,94,290.73,APC
"Injection, avelumab, 10 mg",J9023,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,284.73,,,,,,,fee schedule,105.54,309.28,
"Injection, avelumab, 10 mg",J9023,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,309.28,,,,,,,fee schedule,105.54,309.28,
"Injection, avelumab, 10 mg",J9023,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,183.53,,,,,,,fee schedule,105.54,309.28,
"Injection, avelumab, 10 mg",J9023,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,247.91,,,,,,,fee schedule,105.54,309.28,
"Injection, avelumab, 10 mg",J9023,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,270.82,,,,,,,fee schedule,105.54,309.28,
"Injection, avelumab, 10 mg",J9023,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,166.11,,,,,,,fee schedule,105.54,309.28,
"Injection, avelumab, 10 mg",J9023,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,122.43,,,,,,,fee schedule,105.54,309.28,OP High Cost Drugs
"Injection, avelumab, 10 mg",J9023,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,105.54,,,,,,,fee schedule,105.54,309.28,Other Pharmacy
"Injection, avelumab, 10 mg",J9023,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,110.82,,,,,,,fee schedule,105.54,309.28,APC
"Injection, avelumab, 10 mg",J9023,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,109.77,,,,,,,fee schedule,105.54,309.28,APC
"Injection, avelumab, 10 mg",J9023,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,161.48,,,,,,,fee schedule,105.54,309.28,Radiology
"Injection, avelumab, 10 mg",J9023,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,147.76,,,,,,,fee schedule,105.54,309.28,APC
"Injection, avelumab, 10 mg",J9023,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,184.7,,,,,,,fee schedule,105.54,309.28,APC
Azacitidine injection,J9025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16.39,,,,,,,fee schedule,8.84,17.8,
Azacitidine injection,J9025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17.8,,,,,,,fee schedule,8.84,17.8,
Azacitidine injection,J9025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.76,,,,,,,fee schedule,8.84,17.8,
Azacitidine injection,J9025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14.27,,,,,,,fee schedule,8.84,17.8,
Azacitidine injection,J9025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15.59,,,,,,,fee schedule,8.84,17.8,
Azacitidine injection,J9025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.84,,,,,,,fee schedule,8.84,17.8,
Clofarabine injection,J9027,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,413.77,,,,,,,fee schedule,10.94,449.44,
Clofarabine injection,J9027,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,449.44,,,,,,,fee schedule,10.94,449.44,
Clofarabine injection,J9027,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,185.11,,,,,,,fee schedule,10.94,449.44,
Clofarabine injection,J9027,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,360.27,,,,,,,fee schedule,10.94,449.44,
Clofarabine injection,J9027,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,393.56,,,,,,,fee schedule,10.94,449.44,
Clofarabine injection,J9027,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,167.54,,,,,,,fee schedule,10.94,449.44,
Clofarabine injection,J9027,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.69,,,,,,,fee schedule,10.94,449.44,OP High Cost Drugs
Clofarabine injection,J9027,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10.94,,,,,,,fee schedule,10.94,449.44,Other Pharmacy
Clofarabine injection,J9027,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.48,,,,,,,fee schedule,10.94,449.44,APC
Clofarabine injection,J9027,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11.37,,,,,,,fee schedule,10.94,449.44,APC
Clofarabine injection,J9027,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.73,,,,,,,fee schedule,10.94,449.44,Radiology
Clofarabine injection,J9027,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15.31,,,,,,,fee schedule,10.94,449.44,APC
Clofarabine injection,J9027,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19.14,,,,,,,fee schedule,10.94,449.44,APC
"Inj, adstiladrin, per tx dos",J9029,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,215064,,,,,,,fee schedule,25740,233604,
"Inj, adstiladrin, per tx dos",J9029,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,233604,,,,,,,fee schedule,25740,233604,
"Inj, adstiladrin, per tx dos",J9029,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,28440,,,,,,,fee schedule,25740,233604,
"Inj, adstiladrin, per tx dos",J9029,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,187254,,,,,,,fee schedule,25740,233604,
"Inj, adstiladrin, per tx dos",J9029,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,204558,,,,,,,fee schedule,25740,233604,
"Inj, adstiladrin, per tx dos",J9029,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,25740,,,,,,,fee schedule,25740,233604,
"Inj, adstiladrin, per tx dos",J9029,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,74567.47,,,,,,,fee schedule,25740,233604,OP High Cost Drugs
"Inj, adstiladrin, per tx dos",J9029,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,64282.3,,,,,,,fee schedule,25740,233604,Other Pharmacy
"Inj, adstiladrin, per tx dos",J9029,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,67496.41,,,,,,,fee schedule,25740,233604,APC
"Inj, adstiladrin, per tx dos",J9029,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,66853.59,,,,,,,fee schedule,25740,233604,APC
"Inj, adstiladrin, per tx dos",J9029,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,98351.92,,,,,,,fee schedule,25740,233604,Radiology
"Inj, adstiladrin, per tx dos",J9029,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89995.22,,,,,,,fee schedule,25740,233604,APC
"Inj, adstiladrin, per tx dos",J9029,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,112494.02,,,,,,,fee schedule,25740,233604,APC
Bcg live intravesical 1mg,J9030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.82,,,,,,,fee schedule,3.39,10.66,
Bcg live intravesical 1mg,J9030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10.66,,,,,,,fee schedule,3.39,10.66,
Bcg live intravesical 1mg,J9030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.45,,,,,,,fee schedule,3.39,10.66,
Bcg live intravesical 1mg,J9030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.55,,,,,,,fee schedule,3.39,10.66,
Bcg live intravesical 1mg,J9030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.34,,,,,,,fee schedule,3.39,10.66,
Bcg live intravesical 1mg,J9030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.83,,,,,,,fee schedule,3.39,10.66,
Bcg live intravesical 1mg,J9030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3.93,,,,,,,fee schedule,3.39,10.66,OP High Cost Drugs
Bcg live intravesical 1mg,J9030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3.39,,,,,,,fee schedule,3.39,10.66,Other Pharmacy
Bcg live intravesical 1mg,J9030,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3.56,,,,,,,fee schedule,3.39,10.66,APC
Bcg live intravesical 1mg,J9030,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3.53,,,,,,,fee schedule,3.39,10.66,APC
Bcg live intravesical 1mg,J9030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.19,,,,,,,fee schedule,3.39,10.66,Radiology
Bcg live intravesical 1mg,J9030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4.75,,,,,,,fee schedule,3.39,10.66,APC
Bcg live intravesical 1mg,J9030,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5.93,,,,,,,fee schedule,3.39,10.66,APC
"Injection, belinostat, 10mg",J9032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,113.1,,,,,,,fee schedule,53.11,122.85,
"Injection, belinostat, 10mg",J9032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,122.85,,,,,,,fee schedule,53.11,122.85,
"Injection, belinostat, 10mg",J9032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,91.07,,,,,,,fee schedule,53.11,122.85,
"Injection, belinostat, 10mg",J9032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,98.48,,,,,,,fee schedule,53.11,122.85,
"Injection, belinostat, 10mg",J9032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,107.58,,,,,,,fee schedule,53.11,122.85,
"Injection, belinostat, 10mg",J9032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,82.43,,,,,,,fee schedule,53.11,122.85,
"Injection, belinostat, 10mg",J9032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,61.61,,,,,,,fee schedule,53.11,122.85,OP High Cost Drugs
"Injection, belinostat, 10mg",J9032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,53.11,,,,,,,fee schedule,53.11,122.85,Other Pharmacy
"Injection, belinostat, 10mg",J9032,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,55.77,,,,,,,fee schedule,53.11,122.85,APC
"Injection, belinostat, 10mg",J9032,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,55.24,,,,,,,fee schedule,53.11,122.85,APC
"Injection, belinostat, 10mg",J9032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.26,,,,,,,fee schedule,53.11,122.85,Radiology
"Injection, belinostat, 10mg",J9032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,74.36,,,,,,,fee schedule,53.11,122.85,APC
"Injection, belinostat, 10mg",J9032,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,92.94,,,,,,,fee schedule,53.11,122.85,APC
"Inj., treanda 1 mg",J9033,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,64.76,,,,,,,fee schedule,2.16,70.35,
"Inj., treanda 1 mg",J9033,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,70.35,,,,,,,fee schedule,2.16,70.35,
"Inj., treanda 1 mg",J9033,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30.34,,,,,,,fee schedule,2.16,70.35,
"Inj., treanda 1 mg",J9033,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56.39,,,,,,,fee schedule,2.16,70.35,
"Inj., treanda 1 mg",J9033,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,61.6,,,,,,,fee schedule,2.16,70.35,
"Inj., treanda 1 mg",J9033,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,27.46,,,,,,,fee schedule,2.16,70.35,
"Inj., treanda 1 mg",J9033,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2.5,,,,,,,fee schedule,2.16,70.35,OP High Cost Drugs
"Inj., treanda 1 mg",J9033,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2.16,,,,,,,fee schedule,2.16,70.35,Other Pharmacy
"Inj., treanda 1 mg",J9033,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2.27,,,,,,,fee schedule,2.16,70.35,APC
"Inj., treanda 1 mg",J9033,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2.25,,,,,,,fee schedule,2.16,70.35,APC
"Inj., treanda 1 mg",J9033,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3.3,,,,,,,fee schedule,2.16,70.35,Radiology
"Inj., treanda 1 mg",J9033,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3.02,,,,,,,fee schedule,2.16,70.35,APC
"Inj., treanda 1 mg",J9033,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3.78,,,,,,,fee schedule,2.16,70.35,APC
"Inj., bendeka 1 mg",J9034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,82.44,,,,,,,fee schedule,12.9,89.55,
"Inj., bendeka 1 mg",J9034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,89.55,,,,,,,fee schedule,12.9,89.55,
"Inj., bendeka 1 mg",J9034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46.91,,,,,,,fee schedule,12.9,89.55,
"Inj., bendeka 1 mg",J9034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,71.78,,,,,,,fee schedule,12.9,89.55,
"Inj., bendeka 1 mg",J9034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,78.41,,,,,,,fee schedule,12.9,89.55,
"Inj., bendeka 1 mg",J9034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.46,,,,,,,fee schedule,12.9,89.55,
"Inj., bendeka 1 mg",J9034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14.97,,,,,,,fee schedule,12.9,89.55,OP High Cost Drugs
"Inj., bendeka 1 mg",J9034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12.9,,,,,,,fee schedule,12.9,89.55,Other Pharmacy
"Inj., bendeka 1 mg",J9034,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.55,,,,,,,fee schedule,12.9,89.55,APC
"Inj., bendeka 1 mg",J9034,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.42,,,,,,,fee schedule,12.9,89.55,APC
"Inj., bendeka 1 mg",J9034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.74,,,,,,,fee schedule,12.9,89.55,Radiology
"Inj., bendeka 1 mg",J9034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.06,,,,,,,fee schedule,12.9,89.55,APC
"Inj., bendeka 1 mg",J9034,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22.58,,,,,,,fee schedule,12.9,89.55,APC
Bevacizumab injection,J9035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,205.01,,,,,,,fee schedule,74.36,222.68,
Bevacizumab injection,J9035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,222.68,,,,,,,fee schedule,74.36,222.68,
Bevacizumab injection,J9035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,151.1,,,,,,,fee schedule,74.36,222.68,
Bevacizumab injection,J9035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,178.5,,,,,,,fee schedule,74.36,222.68,
Bevacizumab injection,J9035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,194.99,,,,,,,fee schedule,74.36,222.68,
Bevacizumab injection,J9035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,136.75,,,,,,,fee schedule,74.36,222.68,
Bevacizumab injection,J9035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.25,,,,,,,fee schedule,74.36,222.68,OP High Cost Drugs
Bevacizumab injection,J9035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,74.36,,,,,,,fee schedule,74.36,222.68,Other Pharmacy
Bevacizumab injection,J9035,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,78.07,,,,,,,fee schedule,74.36,222.68,APC
Bevacizumab injection,J9035,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,77.33,,,,,,,fee schedule,74.36,222.68,APC
Bevacizumab injection,J9035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,113.76,,,,,,,fee schedule,74.36,222.68,Radiology
Bevacizumab injection,J9035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,104.1,,,,,,,fee schedule,74.36,222.68,APC
Bevacizumab injection,J9035,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,130.12,,,,,,,fee schedule,74.36,222.68,APC
Inj. belrapzo/bendamustine,J9036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,84.76,,,,,,,fee schedule,13.94,92.06,
Inj. belrapzo/bendamustine,J9036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,92.06,,,,,,,fee schedule,13.94,92.06,
Inj. belrapzo/bendamustine,J9036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,47.19,,,,,,,fee schedule,13.94,92.06,
Inj. belrapzo/bendamustine,J9036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,73.8,,,,,,,fee schedule,13.94,92.06,
Inj. belrapzo/bendamustine,J9036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,80.62,,,,,,,fee schedule,13.94,92.06,
Inj. belrapzo/bendamustine,J9036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.71,,,,,,,fee schedule,13.94,92.06,
Inj. belrapzo/bendamustine,J9036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16.17,,,,,,,fee schedule,13.94,92.06,OP High Cost Drugs
Inj. belrapzo/bendamustine,J9036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.94,,,,,,,fee schedule,13.94,92.06,Other Pharmacy
Inj. belrapzo/bendamustine,J9036,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.64,,,,,,,fee schedule,13.94,92.06,APC
Inj. belrapzo/bendamustine,J9036,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,14.5,,,,,,,fee schedule,13.94,92.06,APC
Inj. belrapzo/bendamustine,J9036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21.33,,,,,,,fee schedule,13.94,92.06,Radiology
Inj. belrapzo/bendamustine,J9036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.52,,,,,,,fee schedule,13.94,92.06,APC
Inj. belrapzo/bendamustine,J9036,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,24.4,,,,,,,fee schedule,13.94,92.06,APC
Inj belantamab mafodont blmf,J9037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,150.64,,,,,,,fee schedule,75.73,163.63,
Inj belantamab mafodont blmf,J9037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,163.63,,,,,,,fee schedule,75.73,163.63,
Inj belantamab mafodont blmf,J9037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83.68,,,,,,,fee schedule,75.73,163.63,
Inj belantamab mafodont blmf,J9037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,131.16,,,,,,,fee schedule,75.73,163.63,
Inj belantamab mafodont blmf,J9037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,143.28,,,,,,,fee schedule,75.73,163.63,
Inj belantamab mafodont blmf,J9037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,75.73,,,,,,,fee schedule,75.73,163.63,
"Injection, blinatumomab",J9039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,332.03,,,,,,,fee schedule,163.96,360.65,
"Injection, blinatumomab",J9039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,360.65,,,,,,,fee schedule,163.96,360.65,
"Injection, blinatumomab",J9039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,279,,,,,,,fee schedule,163.96,360.65,
"Injection, blinatumomab",J9039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,289.09,,,,,,,fee schedule,163.96,360.65,
"Injection, blinatumomab",J9039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,315.81,,,,,,,fee schedule,163.96,360.65,
"Injection, blinatumomab",J9039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,252.51,,,,,,,fee schedule,163.96,360.65,
"Injection, blinatumomab",J9039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,190.19,,,,,,,fee schedule,163.96,360.65,OP High Cost Drugs
"Injection, blinatumomab",J9039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,163.96,,,,,,,fee schedule,163.96,360.65,Other Pharmacy
"Injection, blinatumomab",J9039,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,172.16,,,,,,,fee schedule,163.96,360.65,APC
"Injection, blinatumomab",J9039,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,170.52,,,,,,,fee schedule,163.96,360.65,APC
"Injection, blinatumomab",J9039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,250.86,,,,,,,fee schedule,163.96,360.65,Radiology
"Injection, blinatumomab",J9039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,229.54,,,,,,,fee schedule,163.96,360.65,APC
"Injection, blinatumomab",J9039,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,286.93,,,,,,,fee schedule,163.96,360.65,APC
Bleomycin sulfate injection,J9040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,124.44,,,,,,,fee schedule,68,135.17,
Bleomycin sulfate injection,J9040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,135.17,,,,,,,fee schedule,68,135.17,
Bleomycin sulfate injection,J9040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,75.13,,,,,,,fee schedule,68,135.17,
Bleomycin sulfate injection,J9040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,108.35,,,,,,,fee schedule,68,135.17,
Bleomycin sulfate injection,J9040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,118.37,,,,,,,fee schedule,68,135.17,
Bleomycin sulfate injection,J9040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,68,,,,,,,fee schedule,68,135.17,
Bortezomib injection,J9041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,126.29,,,,,,,fee schedule,12.27,137.18,
Bortezomib injection,J9041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,137.18,,,,,,,fee schedule,12.27,137.18,
Bortezomib injection,J9041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13.56,,,,,,,fee schedule,12.27,137.18,
Bortezomib injection,J9041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,109.96,,,,,,,fee schedule,12.27,137.18,
Bortezomib injection,J9041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,120.12,,,,,,,fee schedule,12.27,137.18,
Bortezomib injection,J9041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12.27,,,,,,,fee schedule,12.27,137.18,
Brentuximab vedotin inj,J9042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,357.54,,,,,,,fee schedule,268.73,470.27,
Brentuximab vedotin inj,J9042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,388.36,,,,,,,fee schedule,268.73,470.27,
Brentuximab vedotin inj,J9042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,445.26,,,,,,,fee schedule,268.73,470.27,
Brentuximab vedotin inj,J9042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,311.3,,,,,,,fee schedule,268.73,470.27,
Brentuximab vedotin inj,J9042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,340.07,,,,,,,fee schedule,268.73,470.27,
Brentuximab vedotin inj,J9042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,402.99,,,,,,,fee schedule,268.73,470.27,
Brentuximab vedotin inj,J9042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,311.72,,,,,,,fee schedule,268.73,470.27,OP High Cost Drugs
Brentuximab vedotin inj,J9042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,268.73,,,,,,,fee schedule,268.73,470.27,Other Pharmacy
Brentuximab vedotin inj,J9042,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,282.16,,,,,,,fee schedule,268.73,470.27,APC
Brentuximab vedotin inj,J9042,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,279.48,,,,,,,fee schedule,268.73,470.27,APC
Brentuximab vedotin inj,J9042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,411.15,,,,,,,fee schedule,268.73,470.27,Radiology
Brentuximab vedotin inj,J9042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,376.22,,,,,,,fee schedule,268.73,470.27,APC
Brentuximab vedotin inj,J9042,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,470.27,,,,,,,fee schedule,268.73,470.27,APC
Cabazitaxel injection,J9043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,486.26,,,,,,,fee schedule,231.05,528.18,
Cabazitaxel injection,J9043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,528.18,,,,,,,fee schedule,231.05,528.18,
Cabazitaxel injection,J9043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,447.03,,,,,,,fee schedule,231.05,528.18,
Cabazitaxel injection,J9043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,423.38,,,,,,,fee schedule,231.05,528.18,
Cabazitaxel injection,J9043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,462.51,,,,,,,fee schedule,231.05,528.18,
Cabazitaxel injection,J9043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,404.59,,,,,,,fee schedule,231.05,528.18,
Cabazitaxel injection,J9043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,268.02,,,,,,,fee schedule,231.05,528.18,OP High Cost Drugs
Cabazitaxel injection,J9043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,231.05,,,,,,,fee schedule,231.05,528.18,Other Pharmacy
Cabazitaxel injection,J9043,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,242.6,,,,,,,fee schedule,231.05,528.18,APC
Cabazitaxel injection,J9043,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,240.29,,,,,,,fee schedule,231.05,528.18,APC
Cabazitaxel injection,J9043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,353.5,,,,,,,fee schedule,231.05,528.18,Radiology
Cabazitaxel injection,J9043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,323.47,,,,,,,fee schedule,231.05,528.18,APC
Cabazitaxel injection,J9043,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,404.33,,,,,,,fee schedule,231.05,528.18,APC
Carboplatin injection,J9045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,34.35,,,,,,,fee schedule,14.87,37.31,
Carboplatin injection,J9045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37.31,,,,,,,fee schedule,14.87,37.31,
Carboplatin injection,J9045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16.43,,,,,,,fee schedule,14.87,37.31,
Carboplatin injection,J9045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29.91,,,,,,,fee schedule,14.87,37.31,
Carboplatin injection,J9045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32.67,,,,,,,fee schedule,14.87,37.31,
Carboplatin injection,J9045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14.87,,,,,,,fee schedule,14.87,37.31,
"Inj, bortezomib, dr. reddy's",J9046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,38.14,,,,,,,fee schedule,3.46,86.92,
"Inj, bortezomib, dr. reddy's",J9046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41.43,,,,,,,fee schedule,3.46,86.92,
"Inj, bortezomib, dr. reddy's",J9046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,86.92,,,,,,,fee schedule,3.46,86.92,
"Inj, bortezomib, dr. reddy's",J9046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,33.21,,,,,,,fee schedule,3.46,86.92,
"Inj, bortezomib, dr. reddy's",J9046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36.27,,,,,,,fee schedule,3.46,86.92,
"Inj, bortezomib, dr. reddy's",J9046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,78.66,,,,,,,fee schedule,3.46,86.92,
"Inj, bortezomib, dr. reddy's",J9046,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,15.35,,,,,,,fee schedule,3.46,86.92,APC 378
"Inj, bortezomib, dr. reddy's",J9046,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3.63,,,,,,,fee schedule,3.46,86.92,APC
"Inj, bortezomib, dr. reddy's",J9046,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3.6,,,,,,,fee schedule,3.46,86.92,APC
"Inj, bortezomib, dr. reddy's",J9046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3.46,,,,,,,fee schedule,3.46,86.92,APC
"Inj, bortezomib, dr. reddy's",J9046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.29,,,,,,,fee schedule,3.46,86.92,Radiology
"Inj, bortezomib, dr. reddy's",J9046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4.84,,,,,,,fee schedule,3.46,86.92,APC
"Inj, bortezomib, dr. reddy's",J9046,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6.06,,,,,,,fee schedule,3.46,86.92,APC
"Injection, carfilzomib, 1 mg",J9047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,104.5,,,,,,,fee schedule,56.24,113.51,
"Injection, carfilzomib, 1 mg",J9047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,113.51,,,,,,,fee schedule,56.24,113.51,
"Injection, carfilzomib, 1 mg",J9047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,103.49,,,,,,,fee schedule,56.24,113.51,
"Injection, carfilzomib, 1 mg",J9047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,90.99,,,,,,,fee schedule,56.24,113.51,
"Injection, carfilzomib, 1 mg",J9047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,99.4,,,,,,,fee schedule,56.24,113.51,
"Injection, carfilzomib, 1 mg",J9047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,93.67,,,,,,,fee schedule,56.24,113.51,
"Injection, carfilzomib, 1 mg",J9047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,65.24,,,,,,,fee schedule,56.24,113.51,OP High Cost Drugs
"Injection, carfilzomib, 1 mg",J9047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.24,,,,,,,fee schedule,56.24,113.51,Other Pharmacy
"Injection, carfilzomib, 1 mg",J9047,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,59.05,,,,,,,fee schedule,56.24,113.51,APC
"Injection, carfilzomib, 1 mg",J9047,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,58.49,,,,,,,fee schedule,56.24,113.51,APC
"Injection, carfilzomib, 1 mg",J9047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,86.05,,,,,,,fee schedule,56.24,113.51,Radiology
"Injection, carfilzomib, 1 mg",J9047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,78.73,,,,,,,fee schedule,56.24,113.51,APC
"Injection, carfilzomib, 1 mg",J9047,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,98.42,,,,,,,fee schedule,56.24,113.51,APC
"Inj, bortezomib freseniuskab",J9048,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.32,,,,,,,fee schedule,6.97,51.6,
"Inj, bortezomib freseniuskab",J9048,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10.12,,,,,,,fee schedule,6.97,51.6,
"Inj, bortezomib freseniuskab",J9048,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,51.6,,,,,,,fee schedule,6.97,51.6,
"Inj, bortezomib freseniuskab",J9048,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.11,,,,,,,fee schedule,6.97,51.6,
"Inj, bortezomib freseniuskab",J9048,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.86,,,,,,,fee schedule,6.97,51.6,
"Inj, bortezomib freseniuskab",J9048,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.7,,,,,,,fee schedule,6.97,51.6,
"Inj, bortezomib freseniuskab",J9048,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,30.92,,,,,,,fee schedule,6.97,51.6,APC 378
"Inj, bortezomib freseniuskab",J9048,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7.32,,,,,,,fee schedule,6.97,51.6,APC
"Inj, bortezomib freseniuskab",J9048,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7.25,,,,,,,fee schedule,6.97,51.6,APC
"Inj, bortezomib freseniuskab",J9048,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6.97,,,,,,,fee schedule,6.97,51.6,APC
"Inj, bortezomib freseniuskab",J9048,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10.66,,,,,,,fee schedule,6.97,51.6,Radiology
"Inj, bortezomib freseniuskab",J9048,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.76,,,,,,,fee schedule,6.97,51.6,APC
"Inj, bortezomib freseniuskab",J9048,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12.2,,,,,,,fee schedule,6.97,51.6,APC
"Inj, bortezomib, hospira",J9049,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24.81,,,,,,,fee schedule,13.18,26.95,
"Inj, bortezomib, hospira",J9049,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26.95,,,,,,,fee schedule,13.18,26.95,
"Inj, bortezomib, hospira",J9049,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14.57,,,,,,,fee schedule,13.18,26.95,
"Inj, bortezomib, hospira",J9049,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21.6,,,,,,,fee schedule,13.18,26.95,
"Inj, bortezomib, hospira",J9049,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23.6,,,,,,,fee schedule,13.18,26.95,
"Inj, bortezomib, hospira",J9049,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13.18,,,,,,,fee schedule,13.18,26.95,
Carmustine injection,J9050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,587.53,,,,,,,fee schedule,241.8,2830.48,
Carmustine injection,J9050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,638.18,,,,,,,fee schedule,241.8,2830.48,
Carmustine injection,J9050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2830.48,,,,,,,fee schedule,241.8,2830.48,
Carmustine injection,J9050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,511.55,,,,,,,fee schedule,241.8,2830.48,
Carmustine injection,J9050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,558.83,,,,,,,fee schedule,241.8,2830.48,
Carmustine injection,J9050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2561.76,,,,,,,fee schedule,241.8,2830.48,
Carmustine injection,J9050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,280.49,,,,,,,fee schedule,241.8,2830.48,OP High Cost Drugs
Carmustine injection,J9050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,241.8,,,,,,,fee schedule,241.8,2830.48,Other Pharmacy
Carmustine injection,J9050,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,253.89,,,,,,,fee schedule,241.8,2830.48,APC
Carmustine injection,J9050,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,251.48,,,,,,,fee schedule,241.8,2830.48,APC
Carmustine injection,J9050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,369.96,,,,,,,fee schedule,241.8,2830.48,Radiology
Carmustine injection,J9050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,338.52,,,,,,,fee schedule,241.8,2830.48,APC
Carmustine injection,J9050,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,423.16,,,,,,,fee schedule,241.8,2830.48,APC
"Inj, carmustine (accord)",J9052,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2067.41,,,,,,,fee schedule,1800.07,3562.55,
"Inj, carmustine (accord)",J9052,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2245.63,,,,,,,fee schedule,1800.07,3562.55,
"Inj, carmustine (accord)",J9052,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3562.55,,,,,,,fee schedule,1800.07,3562.55,
"Inj, carmustine (accord)",J9052,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1800.07,,,,,,,fee schedule,1800.07,3562.55,
"Inj, carmustine (accord)",J9052,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1966.41,,,,,,,fee schedule,1800.07,3562.55,
"Inj, carmustine (accord)",J9052,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3224.34,,,,,,,fee schedule,1800.07,3562.55,
Cetuximab injection,J9055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,177.79,,,,,,,fee schedule,80.46,193.12,
Cetuximab injection,J9055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,193.12,,,,,,,fee schedule,80.46,193.12,
Cetuximab injection,J9055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,152.45,,,,,,,fee schedule,80.46,193.12,
Cetuximab injection,J9055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,154.8,,,,,,,fee schedule,80.46,193.12,
Cetuximab injection,J9055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,169.11,,,,,,,fee schedule,80.46,193.12,
Cetuximab injection,J9055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,137.98,,,,,,,fee schedule,80.46,193.12,
Cetuximab injection,J9055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,93.33,,,,,,,fee schedule,80.46,193.12,OP High Cost Drugs
Cetuximab injection,J9055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,80.46,,,,,,,fee schedule,80.46,193.12,Other Pharmacy
Cetuximab injection,J9055,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,84.48,,,,,,,fee schedule,80.46,193.12,APC
Cetuximab injection,J9055,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,83.68,,,,,,,fee schedule,80.46,193.12,APC
Cetuximab injection,J9055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,123.1,,,,,,,fee schedule,80.46,193.12,Radiology
Cetuximab injection,J9055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,112.64,,,,,,,fee schedule,80.46,193.12,APC
Cetuximab injection,J9055,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,140.8,,,,,,,fee schedule,80.46,193.12,APC
"Inj, bendamustine, 1 mg",J9056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,115.48,,,,,,,fee schedule,31.74,125.43,
"Inj, bendamustine, 1 mg",J9056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,125.43,,,,,,,fee schedule,31.74,125.43,
"Inj, bendamustine, 1 mg",J9056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,62.06,,,,,,,fee schedule,31.74,125.43,
"Inj, bendamustine, 1 mg",J9056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,100.54,,,,,,,fee schedule,31.74,125.43,
"Inj, bendamustine, 1 mg",J9056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,109.84,,,,,,,fee schedule,31.74,125.43,
"Inj, bendamustine, 1 mg",J9056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56.17,,,,,,,fee schedule,31.74,125.43,
"Inj, bendamustine, 1 mg",J9056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.81,,,,,,,fee schedule,31.74,125.43,OP High Cost Drugs
"Inj, bendamustine, 1 mg",J9056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,31.74,,,,,,,fee schedule,31.74,125.43,Other Pharmacy
"Inj, bendamustine, 1 mg",J9056,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,33.32,,,,,,,fee schedule,31.74,125.43,APC
"Inj, bendamustine, 1 mg",J9056,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,33.01,,,,,,,fee schedule,31.74,125.43,APC
"Inj, bendamustine, 1 mg",J9056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,48.56,,,,,,,fee schedule,31.74,125.43,Radiology
"Inj, bendamustine, 1 mg",J9056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,44.43,,,,,,,fee schedule,31.74,125.43,APC
"Inj, bendamustine, 1 mg",J9056,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,55.54,,,,,,,fee schedule,31.74,125.43,APC
"Inj., copanlisib, 1 mg",J9057,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,271.1,,,,,,,fee schedule,150.55,294.47,
"Inj., copanlisib, 1 mg",J9057,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,294.47,,,,,,,fee schedule,150.55,294.47,
"Inj., copanlisib, 1 mg",J9057,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,166.34,,,,,,,fee schedule,150.55,294.47,
"Inj., copanlisib, 1 mg",J9057,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,236.04,,,,,,,fee schedule,150.55,294.47,
"Inj., copanlisib, 1 mg",J9057,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,257.86,,,,,,,fee schedule,150.55,294.47,
"Inj., copanlisib, 1 mg",J9057,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,150.55,,,,,,,fee schedule,150.55,294.47,
Inj apotex/bendamustine 1 mg,J9058,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,115.04,,,,,,,fee schedule,55.9,124.96,
Inj apotex/bendamustine 1 mg,J9058,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,124.96,,,,,,,fee schedule,55.9,124.96,
Inj apotex/bendamustine 1 mg,J9058,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,61.76,,,,,,,fee schedule,55.9,124.96,
Inj apotex/bendamustine 1 mg,J9058,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,100.17,,,,,,,fee schedule,55.9,124.96,
Inj apotex/bendamustine 1 mg,J9058,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,109.42,,,,,,,fee schedule,55.9,124.96,
Inj apotex/bendamustine 1 mg,J9058,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55.9,,,,,,,fee schedule,55.9,124.96,
"Inj bendamustine, baxter 1mg",J9059,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,80.49,,,,,,,fee schedule,40.15,87.43,
"Inj bendamustine, baxter 1mg",J9059,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,87.43,,,,,,,fee schedule,40.15,87.43,
"Inj bendamustine, baxter 1mg",J9059,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,44.37,,,,,,,fee schedule,40.15,87.43,
"Inj bendamustine, baxter 1mg",J9059,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,70.08,,,,,,,fee schedule,40.15,87.43,
"Inj bendamustine, baxter 1mg",J9059,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,76.56,,,,,,,fee schedule,40.15,87.43,
"Inj bendamustine, baxter 1mg",J9059,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40.15,,,,,,,fee schedule,40.15,87.43,
Cisplatin 10 mg injection,J9060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7.65,,,,,,,fee schedule,6.92,7.65,
Cisplatin 10 mg injection,J9060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.92,,,,,,,fee schedule,6.92,7.65,
"Inj, amivantamab-vmjw",J9061,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,62.31,,,,,,,fee schedule,22.63,67.68,
"Inj, amivantamab-vmjw",J9061,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,67.68,,,,,,,fee schedule,22.63,67.68,
"Inj, amivantamab-vmjw",J9061,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,39.5,,,,,,,fee schedule,22.63,67.68,
"Inj, amivantamab-vmjw",J9061,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,54.25,,,,,,,fee schedule,22.63,67.68,
"Inj, amivantamab-vmjw",J9061,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,59.27,,,,,,,fee schedule,22.63,67.68,
"Inj, amivantamab-vmjw",J9061,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35.75,,,,,,,fee schedule,22.63,67.68,
"Inj, amivantamab-vmjw",J9061,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,26.25,,,,,,,fee schedule,22.63,67.68,OP High Cost Drugs
"Inj, amivantamab-vmjw",J9061,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.63,,,,,,,fee schedule,22.63,67.68,Other Pharmacy
"Inj, amivantamab-vmjw",J9061,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,23.76,,,,,,,fee schedule,22.63,67.68,APC
"Inj, amivantamab-vmjw",J9061,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,23.54,,,,,,,fee schedule,22.63,67.68,APC
"Inj, amivantamab-vmjw",J9061,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,34.63,,,,,,,fee schedule,22.63,67.68,Radiology
"Inj, amivantamab-vmjw",J9061,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,31.68,,,,,,,fee schedule,22.63,67.68,APC
"Inj, amivantamab-vmjw",J9061,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,39.6,,,,,,,fee schedule,22.63,67.68,APC
"Inj, elahere, 1 mg",J9063,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,228.82,,,,,,,fee schedule,71.13,248.55,
"Inj, elahere, 1 mg",J9063,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,248.55,,,,,,,fee schedule,71.13,248.55,
"Inj, elahere, 1 mg",J9063,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,123,,,,,,,fee schedule,71.13,248.55,
"Inj, elahere, 1 mg",J9063,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,199.23,,,,,,,fee schedule,71.13,248.55,
"Inj, elahere, 1 mg",J9063,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,217.65,,,,,,,fee schedule,71.13,248.55,
"Inj, elahere, 1 mg",J9063,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,111.33,,,,,,,fee schedule,71.13,248.55,
"Inj, elahere, 1 mg",J9063,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,82.51,,,,,,,fee schedule,71.13,248.55,OP High Cost Drugs
"Inj, elahere, 1 mg",J9063,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,71.13,,,,,,,fee schedule,71.13,248.55,Other Pharmacy
"Inj, elahere, 1 mg",J9063,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,74.68,,,,,,,fee schedule,71.13,248.55,APC
"Inj, elahere, 1 mg",J9063,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,73.97,,,,,,,fee schedule,71.13,248.55,APC
"Inj, elahere, 1 mg",J9063,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,108.83,,,,,,,fee schedule,71.13,248.55,Radiology
"Inj, elahere, 1 mg",J9063,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,99.58,,,,,,,fee schedule,71.13,248.55,APC
"Inj, elahere, 1 mg",J9063,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,124.47,,,,,,,fee schedule,71.13,248.55,APC
Inj cladribine per 1 mg,J9065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,104.85,,,,,,,fee schedule,8.73,113.89,
Inj cladribine per 1 mg,J9065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,113.89,,,,,,,fee schedule,8.73,113.89,
Inj cladribine per 1 mg,J9065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.36,,,,,,,fee schedule,8.73,113.89,
Inj cladribine per 1 mg,J9065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,91.29,,,,,,,fee schedule,8.73,113.89,
Inj cladribine per 1 mg,J9065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,99.73,,,,,,,fee schedule,8.73,113.89,
Inj cladribine per 1 mg,J9065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,60.06,,,,,,,fee schedule,8.73,113.89,
Inj cladribine per 1 mg,J9065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10.12,,,,,,,fee schedule,8.73,113.89,OP High Cost Drugs
Inj cladribine per 1 mg,J9065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8.73,,,,,,,fee schedule,8.73,113.89,Other Pharmacy
Inj cladribine per 1 mg,J9065,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.16,,,,,,,fee schedule,8.73,113.89,APC
Inj cladribine per 1 mg,J9065,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9.08,,,,,,,fee schedule,8.73,113.89,APC
Inj cladribine per 1 mg,J9065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.35,,,,,,,fee schedule,8.73,113.89,Radiology
Inj cladribine per 1 mg,J9065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12.22,,,,,,,fee schedule,8.73,113.89,APC
Inj cladribine per 1 mg,J9065,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15.27,,,,,,,fee schedule,8.73,113.89,APC
Cyclophosphamide 100 mg inj,J9070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,147.24,,,,,,,fee schedule,128.2,159.93,
Cyclophosphamide 100 mg inj,J9070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,159.93,,,,,,,fee schedule,128.2,159.93,
Cyclophosphamide 100 mg inj,J9070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,128.2,,,,,,,fee schedule,128.2,159.93,
Cyclophosphamide 100 mg inj,J9070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,140.05,,,,,,,fee schedule,128.2,159.93,
Inj cyclophosphamd auromedic,J9071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13.08,,,,,,,fee schedule,0.52,14.21,
Inj cyclophosphamd auromedic,J9071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14.21,,,,,,,fee schedule,0.52,14.21,
Inj cyclophosphamd auromedic,J9071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.84,,,,,,,fee schedule,0.52,14.21,
Inj cyclophosphamd auromedic,J9071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11.39,,,,,,,fee schedule,0.52,14.21,
Inj cyclophosphamd auromedic,J9071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12.45,,,,,,,fee schedule,0.52,14.21,
Inj cyclophosphamd auromedic,J9071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.57,,,,,,,fee schedule,0.52,14.21,
Inj cyclophosphamd auromedic,J9071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,0.6,,,,,,,fee schedule,0.52,14.21,OP High Cost Drugs
Inj cyclophosphamd auromedic,J9071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,0.52,,,,,,,fee schedule,0.52,14.21,Other Pharmacy
Inj cyclophosphamd auromedic,J9071,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,0.54,,,,,,,fee schedule,0.52,14.21,APC
Inj cyclophosphamd auromedic,J9071,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,0.54,,,,,,,fee schedule,0.52,14.21,APC
Inj cyclophosphamd auromedic,J9071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,0.79,,,,,,,fee schedule,0.52,14.21,Radiology
Inj cyclophosphamd auromedic,J9071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,0.73,,,,,,,fee schedule,0.52,14.21,APC
Inj cyclophosphamd auromedic,J9071,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,0.91,,,,,,,fee schedule,0.52,14.21,APC
Inj cyclophos dr.reddy's 5mg,J9072,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13.08,,,,,,,fee schedule,9.1,16.59,
Inj cyclophos dr.reddy's 5mg,J9072,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14.21,,,,,,,fee schedule,9.1,16.59,
Inj cyclophos dr.reddy's 5mg,J9072,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16.59,,,,,,,fee schedule,9.1,16.59,
Inj cyclophos dr.reddy's 5mg,J9072,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11.39,,,,,,,fee schedule,9.1,16.59,
Inj cyclophos dr.reddy's 5mg,J9072,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12.45,,,,,,,fee schedule,9.1,16.59,
Inj cyclophos dr.reddy's 5mg,J9072,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15.02,,,,,,,fee schedule,9.1,16.59,
Inj cyclophos dr.reddy's 5mg,J9072,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10.56,,,,,,,fee schedule,9.1,16.59,OP High Cost Drugs
Inj cyclophos dr.reddy's 5mg,J9072,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.1,,,,,,,fee schedule,9.1,16.59,Other Pharmacy
Inj cyclophos dr.reddy's 5mg,J9072,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.56,,,,,,,fee schedule,9.1,16.59,APC
Inj cyclophos dr.reddy's 5mg,J9072,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9.47,,,,,,,fee schedule,9.1,16.59,APC
Inj cyclophos dr.reddy's 5mg,J9072,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.93,,,,,,,fee schedule,9.1,16.59,Radiology
Inj cyclophos dr.reddy's 5mg,J9072,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12.74,,,,,,,fee schedule,9.1,16.59,APC
Inj cyclophos dr.reddy's 5mg,J9072,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15.93,,,,,,,fee schedule,9.1,16.59,APC
Inj cyclophosphamd (ingenus),J9073,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.95,,,,,,,fee schedule,0.5,6.95,
Inj cyclophosphamd (ingenus),J9073,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.29,,,,,,,fee schedule,0.5,6.95,
Inj cyclophosphamd (ingenus),J9073,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,0.58,,,,,,,fee schedule,0.5,6.95,OP High Cost Drugs
Inj cyclophosphamd (ingenus),J9073,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,0.5,,,,,,,fee schedule,0.5,6.95,Other Pharmacy
Inj cyclophosphamd (ingenus),J9073,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,0.53,,,,,,,fee schedule,0.5,6.95,APC
Inj cyclophosphamd (ingenus),J9073,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,0.52,,,,,,,fee schedule,0.5,6.95,APC
Inj cyclophosphamd (ingenus),J9073,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,0.77,,,,,,,fee schedule,0.5,6.95,Radiology
Inj cyclophosphamd (ingenus),J9073,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,0.7,,,,,,,fee schedule,0.5,6.95,APC
Inj cyclophosphamd (ingenus),J9073,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,0.88,,,,,,,fee schedule,0.5,6.95,APC
"Inj, cyclophosphamd, sandoz",J9074,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8.31,,,,,,,fee schedule,3.65,8.31,
"Inj, cyclophosphamd, sandoz",J9074,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7.52,,,,,,,fee schedule,3.65,8.31,
"Inj, cyclophosphamd, sandoz",J9074,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4.24,,,,,,,fee schedule,3.65,8.31,OP High Cost Drugs
"Inj, cyclophosphamd, sandoz",J9074,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3.65,,,,,,,fee schedule,3.65,8.31,Other Pharmacy
"Inj, cyclophosphamd, sandoz",J9074,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3.84,,,,,,,fee schedule,3.65,8.31,APC
"Inj, cyclophosphamd, sandoz",J9074,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3.8,,,,,,,fee schedule,3.65,8.31,APC
"Inj, cyclophosphamd, sandoz",J9074,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.59,,,,,,,fee schedule,3.65,8.31,Radiology
"Inj, cyclophosphamd, sandoz",J9074,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.11,,,,,,,fee schedule,3.65,8.31,APC
"Inj, cyclophosphamd, sandoz",J9074,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6.39,,,,,,,fee schedule,3.65,8.31,APC
"Inj, cyclophosphamide, nos",J9075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.26,,,,,,,fee schedule,0.77,6.26,
"Inj, cyclophosphamide, nos",J9075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.66,,,,,,,fee schedule,0.77,6.26,
"Inj, cyclophosphamide, nos",J9075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,0.9,,,,,,,fee schedule,0.77,6.26,OP High Cost Drugs
"Inj, cyclophosphamide, nos",J9075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,0.77,,,,,,,fee schedule,0.77,6.26,Other Pharmacy
"Inj, cyclophosphamide, nos",J9075,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,0.81,,,,,,,fee schedule,0.77,6.26,APC
"Inj, cyclophosphamide, nos",J9075,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,0.8,,,,,,,fee schedule,0.77,6.26,APC
"Inj, cyclophosphamide, nos",J9075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1.18,,,,,,,fee schedule,0.77,6.26,Radiology
"Inj, cyclophosphamide, nos",J9075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1.08,,,,,,,fee schedule,0.77,6.26,APC
"Inj, cyclophosphamide, nos",J9075,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1.35,,,,,,,fee schedule,0.77,6.26,APC
Cytarabine liposome inj,J9098,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1601.46,,,,,,,fee schedule,1017.24,1739.52,
Cytarabine liposome inj,J9098,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1739.52,,,,,,,fee schedule,1017.24,1739.52,
Cytarabine liposome inj,J9098,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1123.95,,,,,,,fee schedule,1017.24,1739.52,
Cytarabine liposome inj,J9098,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1394.38,,,,,,,fee schedule,1017.24,1739.52,
Cytarabine liposome inj,J9098,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1523.23,,,,,,,fee schedule,1017.24,1739.52,
Cytarabine liposome inj,J9098,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1017.24,,,,,,,fee schedule,1017.24,1739.52,
Cytarabine hcl 100 mg inj,J9100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.17,,,,,,,fee schedule,3.78,4.17,
Cytarabine hcl 100 mg inj,J9100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.78,,,,,,,fee schedule,3.78,4.17,
Inj. calaspargase pegol-mknl,J9118,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,136.54,,,,,,,fee schedule,82.08,143.63,
Inj. calaspargase pegol-mknl,J9118,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,123.58,,,,,,,fee schedule,82.08,143.63,
Inj. calaspargase pegol-mknl,J9118,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,95.21,,,,,,,fee schedule,82.08,143.63,OP High Cost Drugs
Inj. calaspargase pegol-mknl,J9118,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,82.08,,,,,,,fee schedule,82.08,143.63,Other Pharmacy
Inj. calaspargase pegol-mknl,J9118,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,86.18,,,,,,,fee schedule,82.08,143.63,APC
Inj. calaspargase pegol-mknl,J9118,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,85.36,,,,,,,fee schedule,82.08,143.63,APC
Inj. calaspargase pegol-mknl,J9118,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,125.57,,,,,,,fee schedule,82.08,143.63,Radiology
Inj. calaspargase pegol-mknl,J9118,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,114.9,,,,,,,fee schedule,82.08,143.63,APC
Inj. calaspargase pegol-mknl,J9118,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,143.63,,,,,,,fee schedule,82.08,143.63,APC
"Inj., cemiplimab-rwlc, 1 mg",J9119,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,95.52,,,,,,,fee schedule,29.76,103.75,
"Inj., cemiplimab-rwlc, 1 mg",J9119,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,103.75,,,,,,,fee schedule,29.76,103.75,
"Inj., cemiplimab-rwlc, 1 mg",J9119,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55.79,,,,,,,fee schedule,29.76,103.75,
"Inj., cemiplimab-rwlc, 1 mg",J9119,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,83.16,,,,,,,fee schedule,29.76,103.75,
"Inj., cemiplimab-rwlc, 1 mg",J9119,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,90.85,,,,,,,fee schedule,29.76,103.75,
"Inj., cemiplimab-rwlc, 1 mg",J9119,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,50.49,,,,,,,fee schedule,29.76,103.75,
"Inj., cemiplimab-rwlc, 1 mg",J9119,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,34.52,,,,,,,fee schedule,29.76,103.75,OP High Cost Drugs
"Inj., cemiplimab-rwlc, 1 mg",J9119,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29.76,,,,,,,fee schedule,29.76,103.75,Other Pharmacy
"Inj., cemiplimab-rwlc, 1 mg",J9119,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,31.25,,,,,,,fee schedule,29.76,103.75,APC
"Inj., cemiplimab-rwlc, 1 mg",J9119,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,30.95,,,,,,,fee schedule,29.76,103.75,APC
"Inj., cemiplimab-rwlc, 1 mg",J9119,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,45.54,,,,,,,fee schedule,29.76,103.75,Radiology
"Inj., cemiplimab-rwlc, 1 mg",J9119,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,41.67,,,,,,,fee schedule,29.76,103.75,APC
"Inj., cemiplimab-rwlc, 1 mg",J9119,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,52.08,,,,,,,fee schedule,29.76,103.75,APC
Dactinomycin injection,J9120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1771.01,,,,,,,fee schedule,337.67,2879.69,
Dactinomycin injection,J9120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1923.68,,,,,,,fee schedule,337.67,2879.69,
Dactinomycin injection,J9120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2879.69,,,,,,,fee schedule,337.67,2879.69,
Dactinomycin injection,J9120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1542,,,,,,,fee schedule,337.67,2879.69,
Dactinomycin injection,J9120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1684.49,,,,,,,fee schedule,337.67,2879.69,
Dactinomycin injection,J9120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2606.3,,,,,,,fee schedule,337.67,2879.69,
Dactinomycin injection,J9120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,391.7,,,,,,,fee schedule,337.67,2879.69,OP High Cost Drugs
Dactinomycin injection,J9120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,337.67,,,,,,,fee schedule,337.67,2879.69,Other Pharmacy
Dactinomycin injection,J9120,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,354.55,,,,,,,fee schedule,337.67,2879.69,APC
Dactinomycin injection,J9120,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,351.18,,,,,,,fee schedule,337.67,2879.69,APC
Dactinomycin injection,J9120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,516.63,,,,,,,fee schedule,337.67,2879.69,Radiology
Dactinomycin injection,J9120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,472.74,,,,,,,fee schedule,337.67,2879.69,APC
Dactinomycin injection,J9120,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,590.92,,,,,,,fee schedule,337.67,2879.69,APC
Dacarbazine 100 mg inj,J9130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11.38,,,,,,,fee schedule,10.3,11.38,
Dacarbazine 100 mg inj,J9130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10.3,,,,,,,fee schedule,10.3,11.38,
"Daratumumab, hyaluronidase",J9144,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,152.6,,,,,,,fee schedule,55.03,165.76,
"Daratumumab, hyaluronidase",J9144,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,165.76,,,,,,,fee schedule,55.03,165.76,
"Daratumumab, hyaluronidase",J9144,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,105.53,,,,,,,fee schedule,55.03,165.76,
"Daratumumab, hyaluronidase",J9144,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,132.87,,,,,,,fee schedule,55.03,165.76,
"Daratumumab, hyaluronidase",J9144,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,145.15,,,,,,,fee schedule,55.03,165.76,
"Daratumumab, hyaluronidase",J9144,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,95.51,,,,,,,fee schedule,55.03,165.76,
"Daratumumab, hyaluronidase",J9144,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,63.84,,,,,,,fee schedule,55.03,165.76,OP High Cost Drugs
"Daratumumab, hyaluronidase",J9144,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,55.03,,,,,,,fee schedule,55.03,165.76,Other Pharmacy
"Daratumumab, hyaluronidase",J9144,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,57.78,,,,,,,fee schedule,55.03,165.76,APC
"Daratumumab, hyaluronidase",J9144,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,57.23,,,,,,,fee schedule,55.03,165.76,APC
"Daratumumab, hyaluronidase",J9144,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,84.2,,,,,,,fee schedule,55.03,165.76,Radiology
"Daratumumab, hyaluronidase",J9144,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,77.04,,,,,,,fee schedule,55.03,165.76,APC
"Daratumumab, hyaluronidase",J9144,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,96.31,,,,,,,fee schedule,55.03,165.76,APC
"Injection, daratumumab 10 mg",J9145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,163.28,,,,,,,fee schedule,70.77,177.36,
"Injection, daratumumab 10 mg",J9145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,177.36,,,,,,,fee schedule,70.77,177.36,
"Injection, daratumumab 10 mg",J9145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,139.42,,,,,,,fee schedule,70.77,177.36,
"Injection, daratumumab 10 mg",J9145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,142.17,,,,,,,fee schedule,70.77,177.36,
"Injection, daratumumab 10 mg",J9145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,155.31,,,,,,,fee schedule,70.77,177.36,
"Injection, daratumumab 10 mg",J9145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,126.18,,,,,,,fee schedule,70.77,177.36,
"Injection, daratumumab 10 mg",J9145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,82.1,,,,,,,fee schedule,70.77,177.36,OP High Cost Drugs
"Injection, daratumumab 10 mg",J9145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,70.77,,,,,,,fee schedule,70.77,177.36,Other Pharmacy
"Injection, daratumumab 10 mg",J9145,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,74.31,,,,,,,fee schedule,70.77,177.36,APC
"Injection, daratumumab 10 mg",J9145,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,73.6,,,,,,,fee schedule,70.77,177.36,APC
"Injection, daratumumab 10 mg",J9145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,108.28,,,,,,,fee schedule,70.77,177.36,Radiology
"Injection, daratumumab 10 mg",J9145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,99.08,,,,,,,fee schedule,70.77,177.36,APC
"Injection, daratumumab 10 mg",J9145,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,123.85,,,,,,,fee schedule,70.77,177.36,APC
Daunorubicin injection,J9150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.38,,,,,,,fee schedule,52.57,127.17,
Daunorubicin injection,J9150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,65.58,,,,,,,fee schedule,52.57,127.17,
Daunorubicin injection,J9150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,127.17,,,,,,,fee schedule,52.57,127.17,
Daunorubicin injection,J9150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52.57,,,,,,,fee schedule,52.57,127.17,
Daunorubicin injection,J9150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.43,,,,,,,fee schedule,52.57,127.17,
Daunorubicin injection,J9150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,115.1,,,,,,,fee schedule,52.57,127.17,
Daunorubicin citrate inj,J9151,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,200.45,,,,,,,fee schedule,174.53,218.04,
Daunorubicin citrate inj,J9151,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,217.73,,,,,,,fee schedule,174.53,218.04,
Daunorubicin citrate inj,J9151,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,218.04,,,,,,,fee schedule,174.53,218.04,
Daunorubicin citrate inj,J9151,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,174.53,,,,,,,fee schedule,174.53,218.04,
Daunorubicin citrate inj,J9151,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,190.66,,,,,,,fee schedule,174.53,218.04,
Daunorubicin citrate inj,J9151,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,197.34,,,,,,,fee schedule,174.53,218.04,
"Inj daunorubicin, cytarabine",J9153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,649.73,,,,,,,fee schedule,261.2,705.74,
"Inj daunorubicin, cytarabine",J9153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,705.74,,,,,,,fee schedule,261.2,705.74,
"Inj daunorubicin, cytarabine",J9153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,449.97,,,,,,,fee schedule,261.2,705.74,
"Inj daunorubicin, cytarabine",J9153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,565.71,,,,,,,fee schedule,261.2,705.74,
"Inj daunorubicin, cytarabine",J9153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,617.99,,,,,,,fee schedule,261.2,705.74,
"Inj daunorubicin, cytarabine",J9153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,407.25,,,,,,,fee schedule,261.2,705.74,
"Inj daunorubicin, cytarabine",J9153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,302.99,,,,,,,fee schedule,261.2,705.74,OP High Cost Drugs
"Inj daunorubicin, cytarabine",J9153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,261.2,,,,,,,fee schedule,261.2,705.74,Other Pharmacy
"Inj daunorubicin, cytarabine",J9153,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,274.25,,,,,,,fee schedule,261.2,705.74,APC
"Inj daunorubicin, cytarabine",J9153,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,271.64,,,,,,,fee schedule,261.2,705.74,APC
"Inj daunorubicin, cytarabine",J9153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,399.63,,,,,,,fee schedule,261.2,705.74,Radiology
"Inj daunorubicin, cytarabine",J9153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,365.67,,,,,,,fee schedule,261.2,705.74,APC
"Inj daunorubicin, cytarabine",J9153,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,457.09,,,,,,,fee schedule,261.2,705.74,APC
Degarelix injection,J9155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10.61,,,,,,,fee schedule,4.46,11.79,
Degarelix injection,J9155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11.53,,,,,,,fee schedule,4.46,11.79,
Degarelix injection,J9155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11.79,,,,,,,fee schedule,4.46,11.79,
Degarelix injection,J9155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.24,,,,,,,fee schedule,4.46,11.79,
Degarelix injection,J9155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10.1,,,,,,,fee schedule,4.46,11.79,
Degarelix injection,J9155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10.67,,,,,,,fee schedule,4.46,11.79,
Degarelix injection,J9155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5.17,,,,,,,fee schedule,4.46,11.79,OP High Cost Drugs
Degarelix injection,J9155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4.46,,,,,,,fee schedule,4.46,11.79,Other Pharmacy
Degarelix injection,J9155,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.68,,,,,,,fee schedule,4.46,11.79,APC
Degarelix injection,J9155,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4.64,,,,,,,fee schedule,4.46,11.79,APC
Degarelix injection,J9155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.82,,,,,,,fee schedule,4.46,11.79,Radiology
Degarelix injection,J9155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.24,,,,,,,fee schedule,4.46,11.79,APC
Degarelix injection,J9155,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7.8,,,,,,,fee schedule,4.46,11.79,APC
Denileukin diftitox inj,J9160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5118.07,,,,,,,fee schedule,197.34,5559.28,
Denileukin diftitox inj,J9160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5559.28,,,,,,,fee schedule,197.34,5559.28,
Denileukin diftitox inj,J9160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,218.04,,,,,,,fee schedule,197.34,5559.28,
Denileukin diftitox inj,J9160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4456.25,,,,,,,fee schedule,197.34,5559.28,
Denileukin diftitox inj,J9160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4868.05,,,,,,,fee schedule,197.34,5559.28,
Denileukin diftitox inj,J9160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,197.34,,,,,,,fee schedule,197.34,5559.28,
Diethylstilbestrol injection,J9165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,218.04,,,,,,,fee schedule,197.34,218.04,
Diethylstilbestrol injection,J9165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,197.34,,,,,,,fee schedule,197.34,218.04,
Docetaxel injection,J9171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16.56,,,,,,,fee schedule,5.99,17.99,
Docetaxel injection,J9171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17.99,,,,,,,fee schedule,5.99,17.99,
Docetaxel injection,J9171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.62,,,,,,,fee schedule,5.99,17.99,
Docetaxel injection,J9171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14.42,,,,,,,fee schedule,5.99,17.99,
Docetaxel injection,J9171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15.76,,,,,,,fee schedule,5.99,17.99,
Docetaxel injection,J9171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.99,,,,,,,fee schedule,5.99,17.99,
"Docetaxel (ingenus), 1 mg",J9172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,93.85,,,,,,,fee schedule,50.61,93.85,
"Docetaxel (ingenus), 1 mg",J9172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,84.94,,,,,,,fee schedule,50.61,93.85,
"Docetaxel (ingenus), 1 mg",J9172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.7,,,,,,,fee schedule,50.61,93.85,OP High Cost Drugs
"Docetaxel (ingenus), 1 mg",J9172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,50.61,,,,,,,fee schedule,50.61,93.85,Other Pharmacy
"Docetaxel (ingenus), 1 mg",J9172,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,53.14,,,,,,,fee schedule,50.61,93.85,APC
"Docetaxel (ingenus), 1 mg",J9172,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,52.63,,,,,,,fee schedule,50.61,93.85,APC
"Docetaxel (ingenus), 1 mg",J9172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,77.43,,,,,,,fee schedule,50.61,93.85,Radiology
"Docetaxel (ingenus), 1 mg",J9172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,70.85,,,,,,,fee schedule,50.61,93.85,APC
"Docetaxel (ingenus), 1 mg",J9172,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,88.56,,,,,,,fee schedule,50.61,93.85,APC
"Inj., durvalumab, 10 mg",J9173,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,257.42,,,,,,,fee schedule,86.15,279.61,
"Inj., durvalumab, 10 mg",J9173,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,279.61,,,,,,,fee schedule,86.15,279.61,
"Inj., durvalumab, 10 mg",J9173,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,156.53,,,,,,,fee schedule,86.15,279.61,
"Inj., durvalumab, 10 mg",J9173,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,224.13,,,,,,,fee schedule,86.15,279.61,
"Inj., durvalumab, 10 mg",J9173,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,244.84,,,,,,,fee schedule,86.15,279.61,
"Inj., durvalumab, 10 mg",J9173,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,141.67,,,,,,,fee schedule,86.15,279.61,
"Inj., durvalumab, 10 mg",J9173,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,99.93,,,,,,,fee schedule,86.15,279.61,OP High Cost Drugs
"Inj., durvalumab, 10 mg",J9173,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,86.15,,,,,,,fee schedule,86.15,279.61,Other Pharmacy
"Inj., durvalumab, 10 mg",J9173,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.45,,,,,,,fee schedule,86.15,279.61,APC
"Inj., durvalumab, 10 mg",J9173,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.59,,,,,,,fee schedule,86.15,279.61,APC
"Inj., durvalumab, 10 mg",J9173,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.8,,,,,,,fee schedule,86.15,279.61,Radiology
"Inj., durvalumab, 10 mg",J9173,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.6,,,,,,,fee schedule,86.15,279.61,APC
"Inj., durvalumab, 10 mg",J9173,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.76,,,,,,,fee schedule,86.15,279.61,APC
Elliotts b solution per ml,J9175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18.23,,,,,,,fee schedule,16.5,18.23,
Elliotts b solution per ml,J9175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.5,,,,,,,fee schedule,16.5,18.23,
"Injection, elotuzumab, 1mg",J9176,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21.68,,,,,,,fee schedule,8.04,23.55,
"Injection, elotuzumab, 1mg",J9176,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23.55,,,,,,,fee schedule,8.04,23.55,
"Injection, elotuzumab, 1mg",J9176,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14.03,,,,,,,fee schedule,8.04,23.55,
"Injection, elotuzumab, 1mg",J9176,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18.88,,,,,,,fee schedule,8.04,23.55,
"Injection, elotuzumab, 1mg",J9176,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20.62,,,,,,,fee schedule,8.04,23.55,
"Injection, elotuzumab, 1mg",J9176,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12.7,,,,,,,fee schedule,8.04,23.55,
"Injection, elotuzumab, 1mg",J9176,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9.33,,,,,,,fee schedule,8.04,23.55,OP High Cost Drugs
"Injection, elotuzumab, 1mg",J9176,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8.04,,,,,,,fee schedule,8.04,23.55,Other Pharmacy
"Injection, elotuzumab, 1mg",J9176,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.44,,,,,,,fee schedule,8.04,23.55,APC
"Injection, elotuzumab, 1mg",J9176,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8.36,,,,,,,fee schedule,8.04,23.55,APC
"Injection, elotuzumab, 1mg",J9176,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12.3,,,,,,,fee schedule,8.04,23.55,Radiology
"Injection, elotuzumab, 1mg",J9176,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11.26,,,,,,,fee schedule,8.04,23.55,APC
"Injection, elotuzumab, 1mg",J9176,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14.07,,,,,,,fee schedule,8.04,23.55,APC
Inj enfort vedo-ejfv 0.25mg,J9177,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,97.29,,,,,,,fee schedule,36.71,105.68,
Inj enfort vedo-ejfv 0.25mg,J9177,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,105.68,,,,,,,fee schedule,36.71,105.68,
Inj enfort vedo-ejfv 0.25mg,J9177,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.44,,,,,,,fee schedule,36.71,105.68,
Inj enfort vedo-ejfv 0.25mg,J9177,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,84.71,,,,,,,fee schedule,36.71,105.68,
Inj enfort vedo-ejfv 0.25mg,J9177,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,92.54,,,,,,,fee schedule,36.71,105.68,
Inj enfort vedo-ejfv 0.25mg,J9177,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,60.13,,,,,,,fee schedule,36.71,105.68,
Inj enfort vedo-ejfv 0.25mg,J9177,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,42.58,,,,,,,fee schedule,36.71,105.68,OP High Cost Drugs
Inj enfort vedo-ejfv 0.25mg,J9177,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,36.71,,,,,,,fee schedule,36.71,105.68,Other Pharmacy
Inj enfort vedo-ejfv 0.25mg,J9177,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.54,,,,,,,fee schedule,36.71,105.68,APC
Inj enfort vedo-ejfv 0.25mg,J9177,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.18,,,,,,,fee schedule,36.71,105.68,APC
Inj enfort vedo-ejfv 0.25mg,J9177,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.16,,,,,,,fee schedule,36.71,105.68,Radiology
Inj enfort vedo-ejfv 0.25mg,J9177,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.39,,,,,,,fee schedule,36.71,105.68,APC
Inj enfort vedo-ejfv 0.25mg,J9177,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.24,,,,,,,fee schedule,36.71,105.68,APC
"Inj, epirubicin hcl, 2 mg",J9178,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19.45,,,,,,,fee schedule,4.15,21.13,
"Inj, epirubicin hcl, 2 mg",J9178,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21.13,,,,,,,fee schedule,4.15,21.13,
"Inj, epirubicin hcl, 2 mg",J9178,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.58,,,,,,,fee schedule,4.15,21.13,
"Inj, epirubicin hcl, 2 mg",J9178,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.94,,,,,,,fee schedule,4.15,21.13,
"Inj, epirubicin hcl, 2 mg",J9178,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18.5,,,,,,,fee schedule,4.15,21.13,
"Inj, epirubicin hcl, 2 mg",J9178,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.15,,,,,,,fee schedule,4.15,21.13,
Eribulin mesylate injection,J9179,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,340.76,,,,,,,fee schedule,76.76,370.14,
Eribulin mesylate injection,J9179,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,370.14,,,,,,,fee schedule,76.76,370.14,
Eribulin mesylate injection,J9179,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,253.97,,,,,,,fee schedule,76.76,370.14,
Eribulin mesylate injection,J9179,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,296.7,,,,,,,fee schedule,76.76,370.14,
Eribulin mesylate injection,J9179,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,324.12,,,,,,,fee schedule,76.76,370.14,
Eribulin mesylate injection,J9179,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,229.86,,,,,,,fee schedule,76.76,370.14,
Eribulin mesylate injection,J9179,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,89.04,,,,,,,fee schedule,76.76,370.14,OP High Cost Drugs
Eribulin mesylate injection,J9179,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,76.76,,,,,,,fee schedule,76.76,370.14,Other Pharmacy
Eribulin mesylate injection,J9179,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,80.59,,,,,,,fee schedule,76.76,370.14,APC
Eribulin mesylate injection,J9179,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,79.83,,,,,,,fee schedule,76.76,370.14,APC
Eribulin mesylate injection,J9179,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,117.44,,,,,,,fee schedule,76.76,370.14,Radiology
Eribulin mesylate injection,J9179,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,107.46,,,,,,,fee schedule,76.76,370.14,APC
Eribulin mesylate injection,J9179,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,134.32,,,,,,,fee schedule,76.76,370.14,APC
Etoposide injection,J9181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.8,,,,,,,fee schedule,1.63,1.8,
Etoposide injection,J9181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.63,,,,,,,fee schedule,1.63,1.8,
Fludarabine phosphate inj,J9185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,790.45,,,,,,,fee schedule,373.23,858.59,
Fludarabine phosphate inj,J9185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,858.59,,,,,,,fee schedule,373.23,858.59,
Fludarabine phosphate inj,J9185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,412.38,,,,,,,fee schedule,373.23,858.59,
Fludarabine phosphate inj,J9185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,688.23,,,,,,,fee schedule,373.23,858.59,
Fludarabine phosphate inj,J9185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,751.83,,,,,,,fee schedule,373.23,858.59,
Fludarabine phosphate inj,J9185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,373.23,,,,,,,fee schedule,373.23,858.59,
Fluorouracil injection,J9190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10.87,,,,,,,fee schedule,9.84,10.87,
Fluorouracil injection,J9190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.84,,,,,,,fee schedule,9.84,10.87,
Inj gemcitabine hcl (accord),J9196,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12.84,,,,,,,fee schedule,11.18,23.64,
Inj gemcitabine hcl (accord),J9196,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13.94,,,,,,,fee schedule,11.18,23.64,
Inj gemcitabine hcl (accord),J9196,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23.64,,,,,,,fee schedule,11.18,23.64,
Inj gemcitabine hcl (accord),J9196,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11.18,,,,,,,fee schedule,11.18,23.64,
Inj gemcitabine hcl (accord),J9196,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12.21,,,,,,,fee schedule,11.18,23.64,
Inj gemcitabine hcl (accord),J9196,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21.39,,,,,,,fee schedule,11.18,23.64,
"Inj. infugem, 100 mg",J9198,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,136.21,,,,,,,fee schedule,65.21,147.95,
"Inj. infugem, 100 mg",J9198,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,147.95,,,,,,,fee schedule,65.21,147.95,
"Inj. infugem, 100 mg",J9198,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,72.05,,,,,,,fee schedule,65.21,147.95,
"Inj. infugem, 100 mg",J9198,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,118.59,,,,,,,fee schedule,65.21,147.95,
"Inj. infugem, 100 mg",J9198,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,129.55,,,,,,,fee schedule,65.21,147.95,
"Inj. infugem, 100 mg",J9198,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,65.21,,,,,,,fee schedule,65.21,147.95,
Floxuridine injection,J9200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,180.58,,,,,,,fee schedule,157.23,7439.19,
Floxuridine injection,J9200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,196.14,,,,,,,fee schedule,157.23,7439.19,
Floxuridine injection,J9200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6902.59,,,,,,,fee schedule,157.23,7439.19,
Floxuridine injection,J9200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,157.23,,,,,,,fee schedule,157.23,7439.19,
Floxuridine injection,J9200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,171.76,,,,,,,fee schedule,157.23,7439.19,
Floxuridine injection,J9200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6247.28,,,,,,,fee schedule,157.23,7439.19,
Floxuridine injection,J9200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4931.12,,,,,,,fee schedule,157.23,7439.19,OP High Cost Drugs
Floxuridine injection,J9200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4250.97,,,,,,,fee schedule,157.23,7439.19,Other Pharmacy
Floxuridine injection,J9200,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4463.52,,,,,,,fee schedule,157.23,7439.19,APC
Floxuridine injection,J9200,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4421.01,,,,,,,fee schedule,157.23,7439.19,APC
Floxuridine injection,J9200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6503.98,,,,,,,fee schedule,157.23,7439.19,Radiology
Floxuridine injection,J9200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5951.35,,,,,,,fee schedule,157.23,7439.19,APC
Floxuridine injection,J9200,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7439.19,,,,,,,fee schedule,157.23,7439.19,APC
Gemcitabine hcl injection,J9201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,482.71,,,,,,,fee schedule,15.77,524.32,
Gemcitabine hcl injection,J9201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,524.32,,,,,,,fee schedule,15.77,524.32,
Gemcitabine hcl injection,J9201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17.43,,,,,,,fee schedule,15.77,524.32,
Gemcitabine hcl injection,J9201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,420.29,,,,,,,fee schedule,15.77,524.32,
Gemcitabine hcl injection,J9201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,459.13,,,,,,,fee schedule,15.77,524.32,
Gemcitabine hcl injection,J9201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15.77,,,,,,,fee schedule,15.77,524.32,
Goserelin acetate implant,J9202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,676.96,,,,,,,fee schedule,589.43,1820.73,
Goserelin acetate implant,J9202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,735.32,,,,,,,fee schedule,589.43,1820.73,
Goserelin acetate implant,J9202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1820.73,,,,,,,fee schedule,589.43,1820.73,
Goserelin acetate implant,J9202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,589.43,,,,,,,fee schedule,589.43,1820.73,
Goserelin acetate implant,J9202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,643.89,,,,,,,fee schedule,589.43,1820.73,
Goserelin acetate implant,J9202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1647.87,,,,,,,fee schedule,589.43,1820.73,
Gemtuzumab ozogamicin 0.1 mg,J9203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,672.18,,,,,,,fee schedule,240.16,730.13,
Gemtuzumab ozogamicin 0.1 mg,J9203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,730.13,,,,,,,fee schedule,240.16,730.13,
Gemtuzumab ozogamicin 0.1 mg,J9203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,416.55,,,,,,,fee schedule,240.16,730.13,
Gemtuzumab ozogamicin 0.1 mg,J9203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,585.26,,,,,,,fee schedule,240.16,730.13,
Gemtuzumab ozogamicin 0.1 mg,J9203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,639.35,,,,,,,fee schedule,240.16,730.13,
Gemtuzumab ozogamicin 0.1 mg,J9203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,377.01,,,,,,,fee schedule,240.16,730.13,
Gemtuzumab ozogamicin 0.1 mg,J9203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,278.59,,,,,,,fee schedule,240.16,730.13,OP High Cost Drugs
Gemtuzumab ozogamicin 0.1 mg,J9203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,240.16,,,,,,,fee schedule,240.16,730.13,Other Pharmacy
Gemtuzumab ozogamicin 0.1 mg,J9203,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,252.17,,,,,,,fee schedule,240.16,730.13,APC
Gemtuzumab ozogamicin 0.1 mg,J9203,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,249.77,,,,,,,fee schedule,240.16,730.13,APC
Gemtuzumab ozogamicin 0.1 mg,J9203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,367.45,,,,,,,fee schedule,240.16,730.13,Radiology
Gemtuzumab ozogamicin 0.1 mg,J9203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,336.23,,,,,,,fee schedule,240.16,730.13,APC
Gemtuzumab ozogamicin 0.1 mg,J9203,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,420.29,,,,,,,fee schedule,240.16,730.13,APC
"Inj mogamulizumab-kpkc, 1 mg",J9204,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,699.03,,,,,,,fee schedule,253.47,759.29,
"Inj mogamulizumab-kpkc, 1 mg",J9204,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,759.29,,,,,,,fee schedule,253.47,759.29,
"Inj mogamulizumab-kpkc, 1 mg",J9204,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,435.76,,,,,,,fee schedule,253.47,759.29,
"Inj mogamulizumab-kpkc, 1 mg",J9204,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,608.64,,,,,,,fee schedule,253.47,759.29,
"Inj mogamulizumab-kpkc, 1 mg",J9204,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,664.88,,,,,,,fee schedule,253.47,759.29,
"Inj mogamulizumab-kpkc, 1 mg",J9204,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,394.39,,,,,,,fee schedule,253.47,759.29,
"Inj mogamulizumab-kpkc, 1 mg",J9204,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,294.02,,,,,,,fee schedule,253.47,759.29,OP High Cost Drugs
"Inj mogamulizumab-kpkc, 1 mg",J9204,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,253.47,,,,,,,fee schedule,253.47,759.29,Other Pharmacy
"Inj mogamulizumab-kpkc, 1 mg",J9204,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,266.14,,,,,,,fee schedule,253.47,759.29,APC
"Inj mogamulizumab-kpkc, 1 mg",J9204,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,263.61,,,,,,,fee schedule,253.47,759.29,APC
"Inj mogamulizumab-kpkc, 1 mg",J9204,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,387.8,,,,,,,fee schedule,253.47,759.29,Radiology
"Inj mogamulizumab-kpkc, 1 mg",J9204,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,354.85,,,,,,,fee schedule,253.47,759.29,APC
"Inj mogamulizumab-kpkc, 1 mg",J9204,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,443.57,,,,,,,fee schedule,253.47,759.29,APC
Inj irinotecan liposome 1 mg,J9205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,137.49,,,,,,,fee schedule,66.37,149.35,
Inj irinotecan liposome 1 mg,J9205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,149.35,,,,,,,fee schedule,66.37,149.35,
Inj irinotecan liposome 1 mg,J9205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,125.03,,,,,,,fee schedule,66.37,149.35,
Inj irinotecan liposome 1 mg,J9205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,119.72,,,,,,,fee schedule,66.37,149.35,
Inj irinotecan liposome 1 mg,J9205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,130.78,,,,,,,fee schedule,66.37,149.35,
Inj irinotecan liposome 1 mg,J9205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,113.16,,,,,,,fee schedule,66.37,149.35,
Inj irinotecan liposome 1 mg,J9205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,76.99,,,,,,,fee schedule,66.37,149.35,OP High Cost Drugs
Inj irinotecan liposome 1 mg,J9205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,66.37,,,,,,,fee schedule,66.37,149.35,Other Pharmacy
Inj irinotecan liposome 1 mg,J9205,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,69.69,,,,,,,fee schedule,66.37,149.35,APC
Inj irinotecan liposome 1 mg,J9205,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,69.03,,,,,,,fee schedule,66.37,149.35,APC
Inj irinotecan liposome 1 mg,J9205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,101.55,,,,,,,fee schedule,66.37,149.35,Radiology
Inj irinotecan liposome 1 mg,J9205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,92.92,,,,,,,fee schedule,66.37,149.35,APC
Inj irinotecan liposome 1 mg,J9205,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,116.15,,,,,,,fee schedule,66.37,149.35,APC
Irinotecan injection,J9206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,132.21,,,,,,,fee schedule,12.87,143.6,
Irinotecan injection,J9206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,143.6,,,,,,,fee schedule,12.87,143.6,
Irinotecan injection,J9206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14.22,,,,,,,fee schedule,12.87,143.6,
Irinotecan injection,J9206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,115.11,,,,,,,fee schedule,12.87,143.6,
Irinotecan injection,J9206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,125.75,,,,,,,fee schedule,12.87,143.6,
Irinotecan injection,J9206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12.87,,,,,,,fee schedule,12.87,143.6,
Ixabepilone injection,J9207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,221.82,,,,,,,fee schedule,139.75,244.56,
Ixabepilone injection,J9207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,240.94,,,,,,,fee schedule,139.75,244.56,
Ixabepilone injection,J9207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,233.26,,,,,,,fee schedule,139.75,244.56,
Ixabepilone injection,J9207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,193.13,,,,,,,fee schedule,139.75,244.56,
Ixabepilone injection,J9207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,210.98,,,,,,,fee schedule,139.75,244.56,
Ixabepilone injection,J9207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,211.11,,,,,,,fee schedule,139.75,244.56,
Ixabepilone injection,J9207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,162.11,,,,,,,fee schedule,139.75,244.56,OP High Cost Drugs
Ixabepilone injection,J9207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,139.75,,,,,,,fee schedule,139.75,244.56,Other Pharmacy
Ixabepilone injection,J9207,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,146.74,,,,,,,fee schedule,139.75,244.56,APC
Ixabepilone injection,J9207,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,145.34,,,,,,,fee schedule,139.75,244.56,APC
Ixabepilone injection,J9207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,213.82,,,,,,,fee schedule,139.75,244.56,Radiology
Ixabepilone injection,J9207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,195.65,,,,,,,fee schedule,139.75,244.56,APC
Ixabepilone injection,J9207,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,244.56,,,,,,,fee schedule,139.75,244.56,APC
Ifosfamide injection,J9208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,120.79,,,,,,,fee schedule,63.05,131.2,
Ifosfamide injection,J9208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,131.2,,,,,,,fee schedule,63.05,131.2,
Ifosfamide injection,J9208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,69.66,,,,,,,fee schedule,63.05,131.2,
Ifosfamide injection,J9208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,105.17,,,,,,,fee schedule,63.05,131.2,
Ifosfamide injection,J9208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,114.89,,,,,,,fee schedule,63.05,131.2,
Ifosfamide injection,J9208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,63.05,,,,,,,fee schedule,63.05,131.2,
Mesna injection,J9209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24.88,,,,,,,fee schedule,8.58,27.03,
Mesna injection,J9209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27.03,,,,,,,fee schedule,8.58,27.03,
Mesna injection,J9209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.48,,,,,,,fee schedule,8.58,27.03,
Mesna injection,J9209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21.66,,,,,,,fee schedule,8.58,27.03,
Mesna injection,J9209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23.67,,,,,,,fee schedule,8.58,27.03,
Mesna injection,J9209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.58,,,,,,,fee schedule,8.58,27.03,
"Inj., emapalumab-lzsg, 1 mg",J9210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2714.56,,,,,,,fee schedule,384.14,2948.58,
"Inj., emapalumab-lzsg, 1 mg",J9210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2948.58,,,,,,,fee schedule,384.14,2948.58,
"Inj., emapalumab-lzsg, 1 mg",J9210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,640.28,,,,,,,fee schedule,384.14,2948.58,
"Inj., emapalumab-lzsg, 1 mg",J9210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2363.54,,,,,,,fee schedule,384.14,2948.58,
"Inj., emapalumab-lzsg, 1 mg",J9210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2581.96,,,,,,,fee schedule,384.14,2948.58,
"Inj., emapalumab-lzsg, 1 mg",J9210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,579.49,,,,,,,fee schedule,384.14,2948.58,
"Inj., emapalumab-lzsg, 1 mg",J9210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,445.6,,,,,,,fee schedule,384.14,2948.58,OP High Cost Drugs
"Inj., emapalumab-lzsg, 1 mg",J9210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,384.14,,,,,,,fee schedule,384.14,2948.58,Other Pharmacy
"Inj., emapalumab-lzsg, 1 mg",J9210,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,403.34,,,,,,,fee schedule,384.14,2948.58,APC
"Inj., emapalumab-lzsg, 1 mg",J9210,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,399.5,,,,,,,fee schedule,384.14,2948.58,APC
"Inj., emapalumab-lzsg, 1 mg",J9210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,587.73,,,,,,,fee schedule,384.14,2948.58,Radiology
"Inj., emapalumab-lzsg, 1 mg",J9210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,537.79,,,,,,,fee schedule,384.14,2948.58,APC
"Inj., emapalumab-lzsg, 1 mg",J9210,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,672.24,,,,,,,fee schedule,384.14,2948.58,APC
Idarubicin hcl injection,J9211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,837.98,,,,,,,fee schedule,95.51,910.22,
Idarubicin hcl injection,J9211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,910.22,,,,,,,fee schedule,95.51,910.22,
Idarubicin hcl injection,J9211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,105.53,,,,,,,fee schedule,95.51,910.22,
Idarubicin hcl injection,J9211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,729.62,,,,,,,fee schedule,95.51,910.22,
Idarubicin hcl injection,J9211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,797.05,,,,,,,fee schedule,95.51,910.22,
Idarubicin hcl injection,J9211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,95.51,,,,,,,fee schedule,95.51,910.22,
Interferon alfacon-1 inj,J9212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17.68,,,,,,,fee schedule,15.39,24.38,
Interferon alfacon-1 inj,J9212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19.2,,,,,,,fee schedule,15.39,24.38,
Interferon alfacon-1 inj,J9212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24.38,,,,,,,fee schedule,15.39,24.38,
Interferon alfacon-1 inj,J9212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15.39,,,,,,,fee schedule,15.39,24.38,
Interferon alfacon-1 inj,J9212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.81,,,,,,,fee schedule,15.39,24.38,
Interferon alfacon-1 inj,J9212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22.06,,,,,,,fee schedule,15.39,24.38,
Interferon alfa-2a inj,J9213,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,144.8,,,,,,,fee schedule,126.08,157.29,
Interferon alfa-2a inj,J9213,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,157.29,,,,,,,fee schedule,126.08,157.29,
Interferon alfa-2a inj,J9213,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,126.08,,,,,,,fee schedule,126.08,157.29,
Interferon alfa-2a inj,J9213,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,137.73,,,,,,,fee schedule,126.08,157.29,
Interferon alfa-2b inj,J9214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,52.62,,,,,,,fee schedule,45.81,58.27,
Interferon alfa-2b inj,J9214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,57.15,,,,,,,fee schedule,45.81,58.27,
Interferon alfa-2b inj,J9214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,58.27,,,,,,,fee schedule,45.81,58.27,
Interferon alfa-2b inj,J9214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,45.81,,,,,,,fee schedule,45.81,58.27,
Interferon alfa-2b inj,J9214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,50.05,,,,,,,fee schedule,45.81,58.27,
Interferon alfa-2b inj,J9214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52.74,,,,,,,fee schedule,45.81,58.27,
Interferon alfa-n3 inj,J9215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,65.15,,,,,,,fee schedule,51.68,70.76,
Interferon alfa-n3 inj,J9215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,70.76,,,,,,,fee schedule,51.68,70.76,
Interferon alfa-n3 inj,J9215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,57.1,,,,,,,fee schedule,51.68,70.76,
Interferon alfa-n3 inj,J9215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56.72,,,,,,,fee schedule,51.68,70.76,
Interferon alfa-n3 inj,J9215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,61.96,,,,,,,fee schedule,51.68,70.76,
Interferon alfa-n3 inj,J9215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.68,,,,,,,fee schedule,51.68,70.76,
Interferon gamma 1-b inj,J9216,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1257.05,,,,,,,fee schedule,1094.5,15437.42,
Interferon gamma 1-b inj,J9216,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1365.41,,,,,,,fee schedule,1094.5,15437.42,
Interferon gamma 1-b inj,J9216,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15437.42,,,,,,,fee schedule,1094.5,15437.42,
Interferon gamma 1-b inj,J9216,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1094.5,,,,,,,fee schedule,1094.5,15437.42,
Interferon gamma 1-b inj,J9216,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1195.64,,,,,,,fee schedule,1094.5,15437.42,
Interferon gamma 1-b inj,J9216,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13971.84,,,,,,,fee schedule,1094.5,15437.42,
Leuprolide acetate suspnsion,J9217,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,617.98,,,,,,,fee schedule,176.2,856.58,
Leuprolide acetate suspnsion,J9217,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,671.25,,,,,,,fee schedule,176.2,856.58,
Leuprolide acetate suspnsion,J9217,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,856.58,,,,,,,fee schedule,176.2,856.58,
Leuprolide acetate suspnsion,J9217,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,538.07,,,,,,,fee schedule,176.2,856.58,
Leuprolide acetate suspnsion,J9217,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,587.79,,,,,,,fee schedule,176.2,856.58,
Leuprolide acetate suspnsion,J9217,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,775.26,,,,,,,fee schedule,176.2,856.58,
Leuprolide acetate suspnsion,J9217,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,204.39,,,,,,,fee schedule,176.2,856.58,OP High Cost Drugs
Leuprolide acetate suspnsion,J9217,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,176.2,,,,,,,fee schedule,176.2,856.58,Other Pharmacy
Leuprolide acetate suspnsion,J9217,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,185.01,,,,,,,fee schedule,176.2,856.58,APC
Leuprolide acetate suspnsion,J9217,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,183.25,,,,,,,fee schedule,176.2,856.58,APC
Leuprolide acetate suspnsion,J9217,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,269.59,,,,,,,fee schedule,176.2,856.58,Radiology
Leuprolide acetate suspnsion,J9217,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,246.68,,,,,,,fee schedule,176.2,856.58,APC
Leuprolide acetate suspnsion,J9217,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,308.35,,,,,,,fee schedule,176.2,856.58,APC
Leuprolide acetate injeciton,J9218,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23.87,,,,,,,fee schedule,20.79,275.93,
Leuprolide acetate injeciton,J9218,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,25.93,,,,,,,fee schedule,20.79,275.93,
Leuprolide acetate injeciton,J9218,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,275.93,,,,,,,fee schedule,20.79,275.93,
Leuprolide acetate injeciton,J9218,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20.79,,,,,,,fee schedule,20.79,275.93,
Leuprolide acetate injeciton,J9218,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22.71,,,,,,,fee schedule,20.79,275.93,
Leuprolide acetate injeciton,J9218,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,249.74,,,,,,,fee schedule,20.79,275.93,
Leuprolide acetate implant,J9219,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6051.09,,,,,,,fee schedule,5268.62,8980.72,
Leuprolide acetate implant,J9219,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6572.74,,,,,,,fee schedule,5268.62,8980.72,
Leuprolide acetate implant,J9219,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8980.72,,,,,,,fee schedule,5268.62,8980.72,
Leuprolide acetate implant,J9219,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5268.62,,,,,,,fee schedule,5268.62,8980.72,
Leuprolide acetate implant,J9219,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5755.49,,,,,,,fee schedule,5268.62,8980.72,
Leuprolide acetate implant,J9219,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8128.12,,,,,,,fee schedule,5268.62,8980.72,
"Inj. lurbinectedin, 0.1 mg",J9223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,594.38,,,,,,,fee schedule,212.1,645.62,
"Inj. lurbinectedin, 0.1 mg",J9223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,645.62,,,,,,,fee schedule,212.1,645.62,
"Inj. lurbinectedin, 0.1 mg",J9223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,380.62,,,,,,,fee schedule,212.1,645.62,
"Inj. lurbinectedin, 0.1 mg",J9223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,517.52,,,,,,,fee schedule,212.1,645.62,
"Inj. lurbinectedin, 0.1 mg",J9223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,565.35,,,,,,,fee schedule,212.1,645.62,
"Inj. lurbinectedin, 0.1 mg",J9223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,344.49,,,,,,,fee schedule,212.1,645.62,
"Inj. lurbinectedin, 0.1 mg",J9223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,246.03,,,,,,,fee schedule,212.1,645.62,OP High Cost Drugs
"Inj. lurbinectedin, 0.1 mg",J9223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,212.1,,,,,,,fee schedule,212.1,645.62,Other Pharmacy
"Inj. lurbinectedin, 0.1 mg",J9223,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,222.7,,,,,,,fee schedule,212.1,645.62,APC
"Inj. lurbinectedin, 0.1 mg",J9223,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,220.58,,,,,,,fee schedule,212.1,645.62,APC
"Inj. lurbinectedin, 0.1 mg",J9223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,324.51,,,,,,,fee schedule,212.1,645.62,Radiology
"Inj. lurbinectedin, 0.1 mg",J9223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,296.94,,,,,,,fee schedule,212.1,645.62,APC
"Inj. lurbinectedin, 0.1 mg",J9223,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,371.17,,,,,,,fee schedule,212.1,645.62,APC
Vantas implant,J9225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5159.97,,,,,,,fee schedule,4492.73,9240.84,
Vantas implant,J9225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5604.8,,,,,,,fee schedule,4492.73,9240.84,
Vantas implant,J9225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9240.84,,,,,,,fee schedule,4492.73,9240.84,
Vantas implant,J9225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4492.73,,,,,,,fee schedule,4492.73,9240.84,
Vantas implant,J9225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4907.9,,,,,,,fee schedule,4492.73,9240.84,
Vantas implant,J9225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8363.54,,,,,,,fee schedule,4492.73,9240.84,
Supprelin LA implant,J9226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,52700.84,,,,,,,fee schedule,41173.43,92462.93,
Supprelin LA implant,J9226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,57244.02,,,,,,,fee schedule,41173.43,92462.93,
Supprelin LA implant,J9226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,92462.93,,,,,,,fee schedule,41173.43,92462.93,
Supprelin LA implant,J9226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,45886.08,,,,,,,fee schedule,41173.43,92462.93,
Supprelin LA implant,J9226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,50126.38,,,,,,,fee schedule,41173.43,92462.93,
Supprelin LA implant,J9226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,83684.8,,,,,,,fee schedule,41173.43,92462.93,
Supprelin LA implant,J9226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,47761.18,,,,,,,fee schedule,41173.43,92462.93,OP High Cost Drugs
Supprelin LA implant,J9226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,41173.43,,,,,,,fee schedule,41173.43,92462.93,Other Pharmacy
Supprelin LA implant,J9226,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,43232.1,,,,,,,fee schedule,41173.43,92462.93,APC
Supprelin LA implant,J9226,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,42820.36,,,,,,,fee schedule,41173.43,92462.93,APC
Supprelin LA implant,J9226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,62995.34,,,,,,,fee schedule,41173.43,92462.93,Radiology
Supprelin LA implant,J9226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,57642.8,,,,,,,fee schedule,41173.43,92462.93,APC
Supprelin LA implant,J9226,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,72053.5,,,,,,,fee schedule,41173.43,92462.93,APC
Inj. isatuximab-irfc 10 mg,J9227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,230.97,,,,,,,fee schedule,83.58,250.89,
Inj. isatuximab-irfc 10 mg,J9227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,250.89,,,,,,,fee schedule,83.58,250.89,
Inj. isatuximab-irfc 10 mg,J9227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,150.07,,,,,,,fee schedule,83.58,250.89,
Inj. isatuximab-irfc 10 mg,J9227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,201.11,,,,,,,fee schedule,83.58,250.89,
Inj. isatuximab-irfc 10 mg,J9227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,219.69,,,,,,,fee schedule,83.58,250.89,
Inj. isatuximab-irfc 10 mg,J9227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,135.82,,,,,,,fee schedule,83.58,250.89,
Inj. isatuximab-irfc 10 mg,J9227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,96.95,,,,,,,fee schedule,83.58,250.89,OP High Cost Drugs
Inj. isatuximab-irfc 10 mg,J9227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,83.58,,,,,,,fee schedule,83.58,250.89,Other Pharmacy
Inj. isatuximab-irfc 10 mg,J9227,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,87.76,,,,,,,fee schedule,83.58,250.89,APC
Inj. isatuximab-irfc 10 mg,J9227,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,86.92,,,,,,,fee schedule,83.58,250.89,APC
Inj. isatuximab-irfc 10 mg,J9227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,127.87,,,,,,,fee schedule,83.58,250.89,Radiology
Inj. isatuximab-irfc 10 mg,J9227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,117.01,,,,,,,fee schedule,83.58,250.89,APC
Inj. isatuximab-irfc 10 mg,J9227,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,146.26,,,,,,,fee schedule,83.58,250.89,APC
Ipilimumab injection,J9228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,442.13,,,,,,,fee schedule,187.17,480.25,
Ipilimumab injection,J9228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,480.25,,,,,,,fee schedule,187.17,480.25,
Ipilimumab injection,J9228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,330.03,,,,,,,fee schedule,187.17,480.25,
Ipilimumab injection,J9228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,384.96,,,,,,,fee schedule,187.17,480.25,
Ipilimumab injection,J9228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,420.54,,,,,,,fee schedule,187.17,480.25,
Ipilimumab injection,J9228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,298.7,,,,,,,fee schedule,187.17,480.25,
Ipilimumab injection,J9228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,217.11,,,,,,,fee schedule,187.17,480.25,OP High Cost Drugs
Ipilimumab injection,J9228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,187.17,,,,,,,fee schedule,187.17,480.25,Other Pharmacy
Ipilimumab injection,J9228,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,196.52,,,,,,,fee schedule,187.17,480.25,APC
Ipilimumab injection,J9228,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,194.65,,,,,,,fee schedule,187.17,480.25,APC
Ipilimumab injection,J9228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,286.36,,,,,,,fee schedule,187.17,480.25,Radiology
Ipilimumab injection,J9228,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,262.03,,,,,,,fee schedule,187.17,480.25,APC
Ipilimumab injection,J9228,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,327.54,,,,,,,fee schedule,187.17,480.25,APC
Inj inotuzumab ozogam 0.1 mg,J9229,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7664.51,,,,,,,fee schedule,2816.77,8325.24,
Inj inotuzumab ozogam 0.1 mg,J9229,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8325.24,,,,,,,fee schedule,2816.77,8325.24,
Inj inotuzumab ozogam 0.1 mg,J9229,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4754.06,,,,,,,fee schedule,2816.77,8325.24,
Inj inotuzumab ozogam 0.1 mg,J9229,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6673.41,,,,,,,fee schedule,2816.77,8325.24,
Inj inotuzumab ozogam 0.1 mg,J9229,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7290.09,,,,,,,fee schedule,2816.77,8325.24,
Inj inotuzumab ozogam 0.1 mg,J9229,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4302.73,,,,,,,fee schedule,2816.77,8325.24,
Inj inotuzumab ozogam 0.1 mg,J9229,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3267.45,,,,,,,fee schedule,2816.77,8325.24,OP High Cost Drugs
Inj inotuzumab ozogam 0.1 mg,J9229,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2816.77,,,,,,,fee schedule,2816.77,8325.24,Other Pharmacy
Inj inotuzumab ozogam 0.1 mg,J9229,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2957.61,,,,,,,fee schedule,2816.77,8325.24,APC
Inj inotuzumab ozogam 0.1 mg,J9229,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2929.44,,,,,,,fee schedule,2816.77,8325.24,APC
Inj inotuzumab ozogam 0.1 mg,J9229,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4309.65,,,,,,,fee schedule,2816.77,8325.24,Radiology
Inj inotuzumab ozogam 0.1 mg,J9229,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3943.47,,,,,,,fee schedule,2816.77,8325.24,APC
Inj inotuzumab ozogam 0.1 mg,J9229,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4929.34,,,,,,,fee schedule,2816.77,8325.24,APC
Mechlorethamine hcl inj,J9230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,517.02,,,,,,,fee schedule,450.17,561.59,
Mechlorethamine hcl inj,J9230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,561.59,,,,,,,fee schedule,450.17,561.59,
Mechlorethamine hcl inj,J9230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,450.17,,,,,,,fee schedule,450.17,561.59,
Mechlorethamine hcl inj,J9230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,491.77,,,,,,,fee schedule,450.17,561.59,
Inj melphalan hydrochl 50 MG,J9245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5805.23,,,,,,,fee schedule,120.67,6305.68,
Inj melphalan hydrochl 50 MG,J9245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6305.68,,,,,,,fee schedule,120.67,6305.68,
Inj melphalan hydrochl 50 MG,J9245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,559.32,,,,,,,fee schedule,120.67,6305.68,
Inj melphalan hydrochl 50 MG,J9245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5054.56,,,,,,,fee schedule,120.67,6305.68,
Inj melphalan hydrochl 50 MG,J9245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5521.64,,,,,,,fee schedule,120.67,6305.68,
Inj melphalan hydrochl 50 MG,J9245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,506.22,,,,,,,fee schedule,120.67,6305.68,
Inj melphalan hydrochl 50 MG,J9245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,139.97,,,,,,,fee schedule,120.67,6305.68,OP High Cost Drugs
Inj melphalan hydrochl 50 MG,J9245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.67,,,,,,,fee schedule,120.67,6305.68,Other Pharmacy
Inj melphalan hydrochl 50 MG,J9245,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,126.7,,,,,,,fee schedule,120.67,6305.68,APC
Inj melphalan hydrochl 50 MG,J9245,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,125.49,,,,,,,fee schedule,120.67,6305.68,APC
Inj melphalan hydrochl 50 MG,J9245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.62,,,,,,,fee schedule,120.67,6305.68,Radiology
Inj melphalan hydrochl 50 MG,J9245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,168.94,,,,,,,fee schedule,120.67,6305.68,APC
Inj melphalan hydrochl 50 MG,J9245,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,211.17,,,,,,,fee schedule,120.67,6305.68,APC
"Inj., evomela, 1 mg",J9246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,82.13,,,,,,,fee schedule,19.43,89.21,
"Inj., evomela, 1 mg",J9246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,89.21,,,,,,,fee schedule,19.43,89.21,
"Inj., evomela, 1 mg",J9246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,68.24,,,,,,,fee schedule,19.43,89.21,
"Inj., evomela, 1 mg",J9246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,71.51,,,,,,,fee schedule,19.43,89.21,
"Inj., evomela, 1 mg",J9246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,78.12,,,,,,,fee schedule,19.43,89.21,
"Inj., evomela, 1 mg",J9246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,61.76,,,,,,,fee schedule,19.43,89.21,
"Inj., evomela, 1 mg",J9246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,22.54,,,,,,,fee schedule,19.43,89.21,OP High Cost Drugs
"Inj., evomela, 1 mg",J9246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.43,,,,,,,fee schedule,19.43,89.21,Other Pharmacy
"Inj., evomela, 1 mg",J9246,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20.4,,,,,,,fee schedule,19.43,89.21,APC
"Inj., evomela, 1 mg",J9246,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,20.21,,,,,,,fee schedule,19.43,89.21,APC
"Inj., evomela, 1 mg",J9246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29.73,,,,,,,fee schedule,19.43,89.21,Radiology
"Inj., evomela, 1 mg",J9246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27.2,,,,,,,fee schedule,19.43,89.21,APC
"Inj., evomela, 1 mg",J9246,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,34,,,,,,,fee schedule,19.43,89.21,APC
"Inj, melphalan flufenami 1mg",J9247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1731.07,,,,,,,fee schedule,815.1,1880.3,
"Inj, melphalan flufenami 1mg",J9247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1880.3,,,,,,,fee schedule,815.1,1880.3,
"Inj, melphalan flufenami 1mg",J9247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,900.6,,,,,,,fee schedule,815.1,1880.3,
"Inj, melphalan flufenami 1mg",J9247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1507.23,,,,,,,fee schedule,815.1,1880.3,
"Inj, melphalan flufenami 1mg",J9247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1646.51,,,,,,,fee schedule,815.1,1880.3,
"Inj, melphalan flufenami 1mg",J9247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,815.1,,,,,,,fee schedule,815.1,1880.3,
Inj melphalan (hepzato) 1 mg,J9248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1384.08,,,,,,,fee schedule,795,1391.25,
Inj melphalan (hepzato) 1 mg,J9248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1252.68,,,,,,,fee schedule,795,1391.25,
Inj melphalan (hepzato) 1 mg,J9248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,922.2,,,,,,,fee schedule,795,1391.25,OP High Cost Drugs
Inj melphalan (hepzato) 1 mg,J9248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,795,,,,,,,fee schedule,795,1391.25,Other Pharmacy
Inj melphalan (hepzato) 1 mg,J9248,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,834.75,,,,,,,fee schedule,795,1391.25,APC
Inj melphalan (hepzato) 1 mg,J9248,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,826.8,,,,,,,fee schedule,795,1391.25,APC
Inj melphalan (hepzato) 1 mg,J9248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1216.35,,,,,,,fee schedule,795,1391.25,Radiology
Inj melphalan (hepzato) 1 mg,J9248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1113,,,,,,,fee schedule,795,1391.25,APC
Inj melphalan (hepzato) 1 mg,J9248,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1391.25,,,,,,,fee schedule,795,1391.25,APC
Paclitaxel (american regent),J9259,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,56.47,,,,,,,fee schedule,28.13,61.33,
Paclitaxel (american regent),J9259,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,61.33,,,,,,,fee schedule,28.13,61.33,
Paclitaxel (american regent),J9259,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,31.08,,,,,,,fee schedule,28.13,61.33,
Paclitaxel (american regent),J9259,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,49.16,,,,,,,fee schedule,28.13,61.33,
Paclitaxel (american regent),J9259,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.71,,,,,,,fee schedule,28.13,61.33,
Paclitaxel (american regent),J9259,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28.13,,,,,,,fee schedule,28.13,61.33,
Methotrexate sodium inj,J9260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.27,,,,,,,fee schedule,3.86,4.27,
Methotrexate sodium inj,J9260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.86,,,,,,,fee schedule,3.86,4.27,
Nelarabine injection,J9261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,346.64,,,,,,,fee schedule,52.71,376.53,
Nelarabine injection,J9261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,376.53,,,,,,,fee schedule,52.71,376.53,
Nelarabine injection,J9261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,250.65,,,,,,,fee schedule,52.71,376.53,
Nelarabine injection,J9261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,301.82,,,,,,,fee schedule,52.71,376.53,
Nelarabine injection,J9261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,329.71,,,,,,,fee schedule,52.71,376.53,
Nelarabine injection,J9261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,226.86,,,,,,,fee schedule,52.71,376.53,
Nelarabine injection,J9261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,61.14,,,,,,,fee schedule,52.71,376.53,OP High Cost Drugs
Nelarabine injection,J9261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,52.71,,,,,,,fee schedule,52.71,376.53,Other Pharmacy
Nelarabine injection,J9261,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,55.34,,,,,,,fee schedule,52.71,376.53,APC
Nelarabine injection,J9261,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,54.82,,,,,,,fee schedule,52.71,376.53,APC
Nelarabine injection,J9261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,80.64,,,,,,,fee schedule,52.71,376.53,Radiology
Nelarabine injection,J9261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,73.79,,,,,,,fee schedule,52.71,376.53,APC
Nelarabine injection,J9261,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,92.24,,,,,,,fee schedule,52.71,376.53,APC
"Inj, omacetaxine mep, 0.01mg",J9262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8.63,,,,,,,fee schedule,7.51,9.37,
"Inj, omacetaxine mep, 0.01mg",J9262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.37,,,,,,,fee schedule,7.51,9.37,
"Inj, omacetaxine mep, 0.01mg",J9262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7.51,,,,,,,fee schedule,7.51,9.37,
"Inj, omacetaxine mep, 0.01mg",J9262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.21,,,,,,,fee schedule,7.51,9.37,
Oxaliplatin,J9263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,34.17,,,,,,,fee schedule,1.72,37.12,
Oxaliplatin,J9263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37.12,,,,,,,fee schedule,1.72,37.12,
Oxaliplatin,J9263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.9,,,,,,,fee schedule,1.72,37.12,
Oxaliplatin,J9263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29.75,,,,,,,fee schedule,1.72,37.12,
Oxaliplatin,J9263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32.5,,,,,,,fee schedule,1.72,37.12,
Oxaliplatin,J9263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.72,,,,,,,fee schedule,1.72,37.12,
Paclitaxel protein bound,J9264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,31.63,,,,,,,fee schedule,6.02,34.36,
Paclitaxel protein bound,J9264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,34.36,,,,,,,fee schedule,6.02,34.36,
Paclitaxel protein bound,J9264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,29.21,,,,,,,fee schedule,6.02,34.36,
Paclitaxel protein bound,J9264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,27.54,,,,,,,fee schedule,6.02,34.36,
Paclitaxel protein bound,J9264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,30.09,,,,,,,fee schedule,6.02,34.36,
Paclitaxel protein bound,J9264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26.44,,,,,,,fee schedule,6.02,34.36,
Paclitaxel protein bound,J9264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6.98,,,,,,,fee schedule,6.02,34.36,OP High Cost Drugs
Paclitaxel protein bound,J9264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.02,,,,,,,fee schedule,6.02,34.36,Other Pharmacy
Paclitaxel protein bound,J9264,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.32,,,,,,,fee schedule,6.02,34.36,APC
Paclitaxel protein bound,J9264,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6.26,,,,,,,fee schedule,6.02,34.36,APC
Paclitaxel protein bound,J9264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.21,,,,,,,fee schedule,6.02,34.36,Radiology
Paclitaxel protein bound,J9264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8.43,,,,,,,fee schedule,6.02,34.36,APC
Paclitaxel protein bound,J9264,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10.54,,,,,,,fee schedule,6.02,34.36,APC
Pegaspargase injection,J9266,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9356.88,,,,,,,fee schedule,8146.94,49742.1,
Pegaspargase injection,J9266,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10163.51,,,,,,,fee schedule,8146.94,49742.1,
Pegaspargase injection,J9266,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,48420.51,,,,,,,fee schedule,8146.94,49742.1,
Pegaspargase injection,J9266,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8146.94,,,,,,,fee schedule,8146.94,49742.1,
Pegaspargase injection,J9266,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8899.8,,,,,,,fee schedule,8146.94,49742.1,
Pegaspargase injection,J9266,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,43823.62,,,,,,,fee schedule,8146.94,49742.1,
Pegaspargase injection,J9266,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,32971.91,,,,,,,fee schedule,8146.94,49742.1,OP High Cost Drugs
Pegaspargase injection,J9266,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28424.06,,,,,,,fee schedule,8146.94,49742.1,Other Pharmacy
Pegaspargase injection,J9266,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,29845.26,,,,,,,fee schedule,8146.94,49742.1,APC
Pegaspargase injection,J9266,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,29561.02,,,,,,,fee schedule,8146.94,49742.1,APC
Pegaspargase injection,J9266,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43488.81,,,,,,,fee schedule,8146.94,49742.1,Radiology
Pegaspargase injection,J9266,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,39793.68,,,,,,,fee schedule,8146.94,49742.1,APC
Pegaspargase injection,J9266,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,49742.1,,,,,,,fee schedule,8146.94,49742.1,APC
Paclitaxel injection,J9267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.56,,,,,,,fee schedule,0.48,0.63,
Paclitaxel injection,J9267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.6,,,,,,,fee schedule,0.48,0.63,
Paclitaxel injection,J9267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.63,,,,,,,fee schedule,0.48,0.63,
Paclitaxel injection,J9267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.48,,,,,,,fee schedule,0.48,0.63,
Paclitaxel injection,J9267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.53,,,,,,,fee schedule,0.48,0.63,
Paclitaxel injection,J9267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.57,,,,,,,fee schedule,0.48,0.63,
Pentostatin injection,J9268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5798.27,,,,,,,fee schedule,2626.33,6298.12,
Pentostatin injection,J9268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6298.12,,,,,,,fee schedule,2626.33,6298.12,
Pentostatin injection,J9268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5595.63,,,,,,,fee schedule,2626.33,6298.12,
Pentostatin injection,J9268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5048.5,,,,,,,fee schedule,2626.33,6298.12,
Pentostatin injection,J9268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5515.02,,,,,,,fee schedule,2626.33,6298.12,
Pentostatin injection,J9268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5064.4,,,,,,,fee schedule,2626.33,6298.12,
Pentostatin injection,J9268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3046.54,,,,,,,fee schedule,2626.33,6298.12,OP High Cost Drugs
Pentostatin injection,J9268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2626.33,,,,,,,fee schedule,2626.33,6298.12,Other Pharmacy
Pentostatin injection,J9268,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2757.64,,,,,,,fee schedule,2626.33,6298.12,APC
Pentostatin injection,J9268,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2731.38,,,,,,,fee schedule,2626.33,6298.12,APC
Pentostatin injection,J9268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4018.28,,,,,,,fee schedule,2626.33,6298.12,Radiology
Pentostatin injection,J9268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3676.86,,,,,,,fee schedule,2626.33,6298.12,APC
Pentostatin injection,J9268,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4596.07,,,,,,,fee schedule,2626.33,6298.12,APC
Inj. tagraxofusp-erzs 10 mcg,J9269,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,901.17,,,,,,,fee schedule,357.28,978.86,
Inj. tagraxofusp-erzs 10 mcg,J9269,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,978.86,,,,,,,fee schedule,357.28,978.86,
Inj. tagraxofusp-erzs 10 mcg,J9269,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,609.55,,,,,,,fee schedule,357.28,978.86,
Inj. tagraxofusp-erzs 10 mcg,J9269,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,784.64,,,,,,,fee schedule,357.28,978.86,
Inj. tagraxofusp-erzs 10 mcg,J9269,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,857.15,,,,,,,fee schedule,357.28,978.86,
Inj. tagraxofusp-erzs 10 mcg,J9269,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,551.68,,,,,,,fee schedule,357.28,978.86,
Inj. tagraxofusp-erzs 10 mcg,J9269,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,414.44,,,,,,,fee schedule,357.28,978.86,OP High Cost Drugs
Inj. tagraxofusp-erzs 10 mcg,J9269,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,357.28,,,,,,,fee schedule,357.28,978.86,Other Pharmacy
Inj. tagraxofusp-erzs 10 mcg,J9269,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,375.14,,,,,,,fee schedule,357.28,978.86,APC
Inj. tagraxofusp-erzs 10 mcg,J9269,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,371.57,,,,,,,fee schedule,357.28,978.86,APC
Inj. tagraxofusp-erzs 10 mcg,J9269,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,546.64,,,,,,,fee schedule,357.28,978.86,Radiology
Inj. tagraxofusp-erzs 10 mcg,J9269,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,500.19,,,,,,,fee schedule,357.28,978.86,APC
Inj. tagraxofusp-erzs 10 mcg,J9269,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,625.24,,,,,,,fee schedule,357.28,978.86,APC
Plicamycin (mithramycin) inj,J9270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,71.48,,,,,,,fee schedule,62.24,77.64,
Plicamycin (mithramycin) inj,J9270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,77.64,,,,,,,fee schedule,62.24,77.64,
Plicamycin (mithramycin) inj,J9270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,62.24,,,,,,,fee schedule,62.24,77.64,
Plicamycin (mithramycin) inj,J9270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,67.99,,,,,,,fee schedule,62.24,77.64,
Inj pembrolizumab,J9271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,159.04,,,,,,,fee schedule,61.25,172.75,
Inj pembrolizumab,J9271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,172.75,,,,,,,fee schedule,61.25,172.75,
Inj pembrolizumab,J9271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,109.62,,,,,,,fee schedule,61.25,172.75,
Inj pembrolizumab,J9271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,138.47,,,,,,,fee schedule,61.25,172.75,
Inj pembrolizumab,J9271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,151.27,,,,,,,fee schedule,61.25,172.75,
Inj pembrolizumab,J9271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,99.21,,,,,,,fee schedule,61.25,172.75,
Inj pembrolizumab,J9271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,71.05,,,,,,,fee schedule,61.25,172.75,OP High Cost Drugs
Inj pembrolizumab,J9271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,61.25,,,,,,,fee schedule,61.25,172.75,Other Pharmacy
Inj pembrolizumab,J9271,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,64.31,,,,,,,fee schedule,61.25,172.75,APC
Inj pembrolizumab,J9271,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,63.7,,,,,,,fee schedule,61.25,172.75,APC
Inj pembrolizumab,J9271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,93.71,,,,,,,fee schedule,61.25,172.75,Radiology
Inj pembrolizumab,J9271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,85.75,,,,,,,fee schedule,61.25,172.75,APC
Inj pembrolizumab,J9271,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,107.19,,,,,,,fee schedule,61.25,172.75,APC
"Inj, dostarlimab-gxly, 10 mg",J9272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,748.6,,,,,,,fee schedule,247.08,813.14,
"Inj, dostarlimab-gxly, 10 mg",J9272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,813.14,,,,,,,fee schedule,247.08,813.14,
"Inj, dostarlimab-gxly, 10 mg",J9272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,438.47,,,,,,,fee schedule,247.08,813.14,
"Inj, dostarlimab-gxly, 10 mg",J9272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,651.8,,,,,,,fee schedule,247.08,813.14,
"Inj, dostarlimab-gxly, 10 mg",J9272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,712.03,,,,,,,fee schedule,247.08,813.14,
"Inj, dostarlimab-gxly, 10 mg",J9272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,396.84,,,,,,,fee schedule,247.08,813.14,
"Inj, dostarlimab-gxly, 10 mg",J9272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,286.62,,,,,,,fee schedule,247.08,813.14,OP High Cost Drugs
"Inj, dostarlimab-gxly, 10 mg",J9272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,247.08,,,,,,,fee schedule,247.08,813.14,Other Pharmacy
"Inj, dostarlimab-gxly, 10 mg",J9272,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,259.44,,,,,,,fee schedule,247.08,813.14,APC
"Inj, dostarlimab-gxly, 10 mg",J9272,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,256.97,,,,,,,fee schedule,247.08,813.14,APC
"Inj, dostarlimab-gxly, 10 mg",J9272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,378.04,,,,,,,fee schedule,247.08,813.14,Radiology
"Inj, dostarlimab-gxly, 10 mg",J9272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,345.92,,,,,,,fee schedule,247.08,813.14,APC
"Inj, dostarlimab-gxly, 10 mg",J9272,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,432.4,,,,,,,fee schedule,247.08,813.14,APC
"Inj tisotu vedotin-tftv, 1mg",J9273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,542.71,,,,,,,fee schedule,196.12,589.49,
"Inj tisotu vedotin-tftv, 1mg",J9273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,589.49,,,,,,,fee schedule,196.12,589.49,
"Inj tisotu vedotin-tftv, 1mg",J9273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,337.63,,,,,,,fee schedule,196.12,589.49,
"Inj tisotu vedotin-tftv, 1mg",J9273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,472.53,,,,,,,fee schedule,196.12,589.49,
"Inj tisotu vedotin-tftv, 1mg",J9273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,516.19,,,,,,,fee schedule,196.12,589.49,
"Inj tisotu vedotin-tftv, 1mg",J9273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,305.58,,,,,,,fee schedule,196.12,589.49,
"Inj tisotu vedotin-tftv, 1mg",J9273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,227.5,,,,,,,fee schedule,196.12,589.49,OP High Cost Drugs
"Inj tisotu vedotin-tftv, 1mg",J9273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,196.12,,,,,,,fee schedule,196.12,589.49,Other Pharmacy
"Inj tisotu vedotin-tftv, 1mg",J9273,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,205.93,,,,,,,fee schedule,196.12,589.49,APC
"Inj tisotu vedotin-tftv, 1mg",J9273,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,203.97,,,,,,,fee schedule,196.12,589.49,APC
"Inj tisotu vedotin-tftv, 1mg",J9273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,300.07,,,,,,,fee schedule,196.12,589.49,Radiology
"Inj tisotu vedotin-tftv, 1mg",J9273,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,274.57,,,,,,,fee schedule,196.12,589.49,APC
"Inj tisotu vedotin-tftv, 1mg",J9273,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,343.21,,,,,,,fee schedule,196.12,589.49,APC
"Inj, tebentafusp-tebn, 1 mcg",J9274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,692.03,,,,,,,fee schedule,222.49,751.69,
"Inj, tebentafusp-tebn, 1 mcg",J9274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,751.69,,,,,,,fee schedule,222.49,751.69,
"Inj, tebentafusp-tebn, 1 mcg",J9274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,384.13,,,,,,,fee schedule,222.49,751.69,
"Inj, tebentafusp-tebn, 1 mcg",J9274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,602.55,,,,,,,fee schedule,222.49,751.69,
"Inj, tebentafusp-tebn, 1 mcg",J9274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,658.23,,,,,,,fee schedule,222.49,751.69,
"Inj, tebentafusp-tebn, 1 mcg",J9274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,347.66,,,,,,,fee schedule,222.49,751.69,
"Inj, tebentafusp-tebn, 1 mcg",J9274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,258.09,,,,,,,fee schedule,222.49,751.69,OP High Cost Drugs
"Inj, tebentafusp-tebn, 1 mcg",J9274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,222.49,,,,,,,fee schedule,222.49,751.69,Other Pharmacy
"Inj, tebentafusp-tebn, 1 mcg",J9274,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,233.62,,,,,,,fee schedule,222.49,751.69,APC
"Inj, tebentafusp-tebn, 1 mcg",J9274,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,231.39,,,,,,,fee schedule,222.49,751.69,APC
"Inj, tebentafusp-tebn, 1 mcg",J9274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,340.42,,,,,,,fee schedule,222.49,751.69,Radiology
"Inj, tebentafusp-tebn, 1 mcg",J9274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,311.49,,,,,,,fee schedule,222.49,751.69,APC
"Inj, tebentafusp-tebn, 1 mcg",J9274,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,389.36,,,,,,,fee schedule,222.49,751.69,APC
Mitomycin injection,J9280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,56.65,,,,,,,fee schedule,28.46,299.55,
Mitomycin injection,J9280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,61.54,,,,,,,fee schedule,28.46,299.55,
Mitomycin injection,J9280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,299.55,,,,,,,fee schedule,28.46,299.55,
Mitomycin injection,J9280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,49.33,,,,,,,fee schedule,28.46,299.55,
Mitomycin injection,J9280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.89,,,,,,,fee schedule,28.46,299.55,
Mitomycin injection,J9280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,271.11,,,,,,,fee schedule,28.46,299.55,
Mitomycin injection,J9280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,33.01,,,,,,,fee schedule,28.46,299.55,OP High Cost Drugs
Mitomycin injection,J9280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.46,,,,,,,fee schedule,28.46,299.55,Other Pharmacy
Mitomycin injection,J9280,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,29.88,,,,,,,fee schedule,28.46,299.55,APC
Mitomycin injection,J9280,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,29.6,,,,,,,fee schedule,28.46,299.55,APC
Mitomycin injection,J9280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43.54,,,,,,,fee schedule,28.46,299.55,Radiology
Mitomycin injection,J9280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,39.84,,,,,,,fee schedule,28.46,299.55,APC
Mitomycin injection,J9280,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,49.8,,,,,,,fee schedule,28.46,299.55,APC
Mitomycin instillation,J9281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,981.96,,,,,,,fee schedule,323.17,1066.61,
Mitomycin instillation,J9281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1066.61,,,,,,,fee schedule,323.17,1066.61,
Mitomycin instillation,J9281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,569.4,,,,,,,fee schedule,323.17,1066.61,
Mitomycin instillation,J9281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,854.98,,,,,,,fee schedule,323.17,1066.61,
Mitomycin instillation,J9281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,933.99,,,,,,,fee schedule,323.17,1066.61,
Mitomycin instillation,J9281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,515.34,,,,,,,fee schedule,323.17,1066.61,
Mitomycin instillation,J9281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,374.88,,,,,,,fee schedule,323.17,1066.61,OP High Cost Drugs
Mitomycin instillation,J9281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,323.17,,,,,,,fee schedule,323.17,1066.61,Other Pharmacy
Mitomycin instillation,J9281,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,339.33,,,,,,,fee schedule,323.17,1066.61,APC
Mitomycin instillation,J9281,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,336.1,,,,,,,fee schedule,323.17,1066.61,APC
Mitomycin instillation,J9281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,494.45,,,,,,,fee schedule,323.17,1066.61,Radiology
Mitomycin instillation,J9281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,452.44,,,,,,,fee schedule,323.17,1066.61,APC
Mitomycin instillation,J9281,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,565.55,,,,,,,fee schedule,323.17,1066.61,APC
"Inj, olaratumab, 10 mg",J9285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,177.62,,,,,,,fee schedule,84.28,192.93,
"Inj, olaratumab, 10 mg",J9285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,192.93,,,,,,,fee schedule,84.28,192.93,
"Inj, olaratumab, 10 mg",J9285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,93.13,,,,,,,fee schedule,84.28,192.93,
"Inj, olaratumab, 10 mg",J9285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,154.65,,,,,,,fee schedule,84.28,192.93,
"Inj, olaratumab, 10 mg",J9285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,168.94,,,,,,,fee schedule,84.28,192.93,
"Inj, olaratumab, 10 mg",J9285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,84.28,,,,,,,fee schedule,84.28,192.93,
"Inj glofitamab gxbm, 2.5 mg",J9286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9157.21,,,,,,,fee schedule,2840.68,9946.62,
"Inj glofitamab gxbm, 2.5 mg",J9286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9946.62,,,,,,,fee schedule,2840.68,9946.62,
"Inj glofitamab gxbm, 2.5 mg",J9286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4989.1,,,,,,,fee schedule,2840.68,9946.62,
"Inj glofitamab gxbm, 2.5 mg",J9286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7973.09,,,,,,,fee schedule,2840.68,9946.62,
"Inj glofitamab gxbm, 2.5 mg",J9286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8709.87,,,,,,,fee schedule,2840.68,9946.62,
"Inj glofitamab gxbm, 2.5 mg",J9286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4515.45,,,,,,,fee schedule,2840.68,9946.62,
"Inj glofitamab gxbm, 2.5 mg",J9286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3295.19,,,,,,,fee schedule,2840.68,9946.62,OP High Cost Drugs
"Inj glofitamab gxbm, 2.5 mg",J9286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2840.68,,,,,,,fee schedule,2840.68,9946.62,Other Pharmacy
"Inj glofitamab gxbm, 2.5 mg",J9286,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2982.71,,,,,,,fee schedule,2840.68,9946.62,APC
"Inj glofitamab gxbm, 2.5 mg",J9286,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2954.3,,,,,,,fee schedule,2840.68,9946.62,APC
"Inj glofitamab gxbm, 2.5 mg",J9286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4346.24,,,,,,,fee schedule,2840.68,9946.62,Radiology
"Inj glofitamab gxbm, 2.5 mg",J9286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3976.95,,,,,,,fee schedule,2840.68,9946.62,APC
"Inj glofitamab gxbm, 2.5 mg",J9286,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4971.18,,,,,,,fee schedule,2840.68,9946.62,APC
Mitoxantrone hydrochl / 5 MG,J9293,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,311.56,,,,,,,fee schedule,38.61,338.42,
Mitoxantrone hydrochl / 5 MG,J9293,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,338.42,,,,,,,fee schedule,38.61,338.42,
Mitoxantrone hydrochl / 5 MG,J9293,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,137.51,,,,,,,fee schedule,38.61,338.42,
Mitoxantrone hydrochl / 5 MG,J9293,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,271.28,,,,,,,fee schedule,38.61,338.42,
Mitoxantrone hydrochl / 5 MG,J9293,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,296.34,,,,,,,fee schedule,38.61,338.42,
Mitoxantrone hydrochl / 5 MG,J9293,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,124.45,,,,,,,fee schedule,38.61,338.42,
Mitoxantrone hydrochl / 5 MG,J9293,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,44.79,,,,,,,fee schedule,38.61,338.42,OP High Cost Drugs
Mitoxantrone hydrochl / 5 MG,J9293,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,38.61,,,,,,,fee schedule,38.61,338.42,Other Pharmacy
Mitoxantrone hydrochl / 5 MG,J9293,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,40.54,,,,,,,fee schedule,38.61,338.42,APC
Mitoxantrone hydrochl / 5 MG,J9293,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,40.16,,,,,,,fee schedule,38.61,338.42,APC
Mitoxantrone hydrochl / 5 MG,J9293,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,59.08,,,,,,,fee schedule,38.61,338.42,Radiology
Mitoxantrone hydrochl / 5 MG,J9293,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,54.06,,,,,,,fee schedule,38.61,338.42,APC
Mitoxantrone hydrochl / 5 MG,J9293,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,67.57,,,,,,,fee schedule,38.61,338.42,APC
"Inj pemetrexed, hospira 10mg",J9294,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17.32,,,,,,,fee schedule,5.2,18.88,
"Inj pemetrexed, hospira 10mg",J9294,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18.82,,,,,,,fee schedule,5.2,18.88,
"Inj pemetrexed, hospira 10mg",J9294,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18.88,,,,,,,fee schedule,5.2,18.88,
"Inj pemetrexed, hospira 10mg",J9294,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15.08,,,,,,,fee schedule,5.2,18.88,
"Inj pemetrexed, hospira 10mg",J9294,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.48,,,,,,,fee schedule,5.2,18.88,
"Inj pemetrexed, hospira 10mg",J9294,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17.09,,,,,,,fee schedule,5.2,18.88,
"Inj pemetrexed, hospira 10mg",J9294,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6.03,,,,,,,fee schedule,5.2,18.88,OP High Cost Drugs
"Inj pemetrexed, hospira 10mg",J9294,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.2,,,,,,,fee schedule,5.2,18.88,Other Pharmacy
"Inj pemetrexed, hospira 10mg",J9294,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.46,,,,,,,fee schedule,5.2,18.88,APC
"Inj pemetrexed, hospira 10mg",J9294,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5.41,,,,,,,fee schedule,5.2,18.88,APC
"Inj pemetrexed, hospira 10mg",J9294,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.95,,,,,,,fee schedule,5.2,18.88,Radiology
"Inj pemetrexed, hospira 10mg",J9294,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.28,,,,,,,fee schedule,5.2,18.88,APC
"Inj pemetrexed, hospira 10mg",J9294,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9.1,,,,,,,fee schedule,5.2,18.88,APC
"Injection, necitumumab, 1 mg",J9295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18.3,,,,,,,fee schedule,5.73,19.88,
"Injection, necitumumab, 1 mg",J9295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19.88,,,,,,,fee schedule,5.73,19.88,
"Injection, necitumumab, 1 mg",J9295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10.25,,,,,,,fee schedule,5.73,19.88,
"Injection, necitumumab, 1 mg",J9295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15.94,,,,,,,fee schedule,5.73,19.88,
"Injection, necitumumab, 1 mg",J9295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17.41,,,,,,,fee schedule,5.73,19.88,
"Injection, necitumumab, 1 mg",J9295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.28,,,,,,,fee schedule,5.73,19.88,
"Injection, necitumumab, 1 mg",J9295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6.65,,,,,,,fee schedule,5.73,19.88,OP High Cost Drugs
"Injection, necitumumab, 1 mg",J9295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.73,,,,,,,fee schedule,5.73,19.88,Other Pharmacy
"Injection, necitumumab, 1 mg",J9295,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.02,,,,,,,fee schedule,5.73,19.88,APC
"Injection, necitumumab, 1 mg",J9295,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5.96,,,,,,,fee schedule,5.73,19.88,APC
"Injection, necitumumab, 1 mg",J9295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8.77,,,,,,,fee schedule,5.73,19.88,Radiology
"Injection, necitumumab, 1 mg",J9295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8.02,,,,,,,fee schedule,5.73,19.88,APC
"Injection, necitumumab, 1 mg",J9295,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10.03,,,,,,,fee schedule,5.73,19.88,APC
Inj pemetrexed (accord) 10mg,J9296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33.6,,,,,,,fee schedule,9.66,36.5,
Inj pemetrexed (accord) 10mg,J9296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,36.5,,,,,,,fee schedule,9.66,36.5,
Inj pemetrexed (accord) 10mg,J9296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29.26,,,,,,,fee schedule,9.66,36.5,
Inj pemetrexed (accord) 10mg,J9296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31.96,,,,,,,fee schedule,9.66,36.5,
Inj pemetrexed (accord) 10mg,J9296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11.2,,,,,,,fee schedule,9.66,36.5,OP High Cost Drugs
Inj pemetrexed (accord) 10mg,J9296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.66,,,,,,,fee schedule,9.66,36.5,Other Pharmacy
Inj pemetrexed (accord) 10mg,J9296,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.14,,,,,,,fee schedule,9.66,36.5,APC
Inj pemetrexed (accord) 10mg,J9296,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10.04,,,,,,,fee schedule,9.66,36.5,APC
Inj pemetrexed (accord) 10mg,J9296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.77,,,,,,,fee schedule,9.66,36.5,Radiology
Inj pemetrexed (accord) 10mg,J9296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.52,,,,,,,fee schedule,9.66,36.5,APC
Inj pemetrexed (accord) 10mg,J9296,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16.9,,,,,,,fee schedule,9.66,36.5,APC
Inj pemetrexed (sandoz) 10mg,J9297,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7.95,,,,,,,fee schedule,6.92,133.08,
Inj pemetrexed (sandoz) 10mg,J9297,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8.64,,,,,,,fee schedule,6.92,133.08,
Inj pemetrexed (sandoz) 10mg,J9297,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,133.08,,,,,,,fee schedule,6.92,133.08,
Inj pemetrexed (sandoz) 10mg,J9297,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.92,,,,,,,fee schedule,6.92,133.08,
Inj pemetrexed (sandoz) 10mg,J9297,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7.56,,,,,,,fee schedule,6.92,133.08,
Inj pemetrexed (sandoz) 10mg,J9297,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,120.45,,,,,,,fee schedule,6.92,133.08,
Inj nivol relatlimab 3mg/1mg,J9298,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,628.63,,,,,,,fee schedule,201.76,682.82,
Inj nivol relatlimab 3mg/1mg,J9298,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,682.82,,,,,,,fee schedule,201.76,682.82,
Inj nivol relatlimab 3mg/1mg,J9298,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,351.31,,,,,,,fee schedule,201.76,682.82,
Inj nivol relatlimab 3mg/1mg,J9298,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,547.34,,,,,,,fee schedule,201.76,682.82,
Inj nivol relatlimab 3mg/1mg,J9298,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,597.92,,,,,,,fee schedule,201.76,682.82,
Inj nivol relatlimab 3mg/1mg,J9298,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,317.96,,,,,,,fee schedule,201.76,682.82,
Inj nivol relatlimab 3mg/1mg,J9298,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,234.04,,,,,,,fee schedule,201.76,682.82,OP High Cost Drugs
Inj nivol relatlimab 3mg/1mg,J9298,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.76,,,,,,,fee schedule,201.76,682.82,Other Pharmacy
Inj nivol relatlimab 3mg/1mg,J9298,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,211.84,,,,,,,fee schedule,201.76,682.82,APC
Inj nivol relatlimab 3mg/1mg,J9298,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,209.83,,,,,,,fee schedule,201.76,682.82,APC
Inj nivol relatlimab 3mg/1mg,J9298,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,308.69,,,,,,,fee schedule,201.76,682.82,Radiology
Inj nivol relatlimab 3mg/1mg,J9298,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,282.46,,,,,,,fee schedule,201.76,682.82,APC
Inj nivol relatlimab 3mg/1mg,J9298,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,353.07,,,,,,,fee schedule,201.76,682.82,APC
"Injection, nivolumab",J9299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,88.29,,,,,,,fee schedule,33.62,95.9,
"Injection, nivolumab",J9299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,95.9,,,,,,,fee schedule,33.62,95.9,
"Injection, nivolumab",J9299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.31,,,,,,,fee schedule,33.62,95.9,
"Injection, nivolumab",J9299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,76.87,,,,,,,fee schedule,33.62,95.9,
"Injection, nivolumab",J9299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,83.97,,,,,,,fee schedule,33.62,95.9,
"Injection, nivolumab",J9299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,54.58,,,,,,,fee schedule,33.62,95.9,
"Injection, nivolumab",J9299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,39,,,,,,,fee schedule,33.62,95.9,OP High Cost Drugs
"Injection, nivolumab",J9299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,33.62,,,,,,,fee schedule,33.62,95.9,Other Pharmacy
"Injection, nivolumab",J9299,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,35.31,,,,,,,fee schedule,33.62,95.9,APC
"Injection, nivolumab",J9299,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,34.97,,,,,,,fee schedule,33.62,95.9,APC
"Injection, nivolumab",J9299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.44,,,,,,,fee schedule,33.62,95.9,Radiology
"Injection, nivolumab",J9299,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,47.07,,,,,,,fee schedule,33.62,95.9,APC
"Injection, nivolumab",J9299,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,58.84,,,,,,,fee schedule,33.62,95.9,APC
Obinutuzumab inj,J9301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,188.76,,,,,,,fee schedule,81.81,205.03,
Obinutuzumab inj,J9301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,205.03,,,,,,,fee schedule,81.81,205.03,
Obinutuzumab inj,J9301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,156.26,,,,,,,fee schedule,81.81,205.03,
Obinutuzumab inj,J9301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,164.35,,,,,,,fee schedule,81.81,205.03,
Obinutuzumab inj,J9301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,179.53,,,,,,,fee schedule,81.81,205.03,
Obinutuzumab inj,J9301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,141.43,,,,,,,fee schedule,81.81,205.03,
Obinutuzumab inj,J9301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,94.89,,,,,,,fee schedule,81.81,205.03,OP High Cost Drugs
Obinutuzumab inj,J9301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.81,,,,,,,fee schedule,81.81,205.03,Other Pharmacy
Obinutuzumab inj,J9301,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,85.9,,,,,,,fee schedule,81.81,205.03,APC
Obinutuzumab inj,J9301,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,85.08,,,,,,,fee schedule,81.81,205.03,APC
Obinutuzumab inj,J9301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,125.16,,,,,,,fee schedule,81.81,205.03,Radiology
Obinutuzumab inj,J9301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,114.53,,,,,,,fee schedule,81.81,205.03,APC
Obinutuzumab inj,J9301,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,143.16,,,,,,,fee schedule,81.81,205.03,APC
Ofatumumab injection,J9302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,161.82,,,,,,,fee schedule,62.23,276.11,
Ofatumumab injection,J9302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,175.77,,,,,,,fee schedule,62.23,276.11,
Ofatumumab injection,J9302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,140.9,,,,,,,fee schedule,62.23,276.11,
Ofatumumab injection,J9302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,153.92,,,,,,,fee schedule,62.23,276.11,
Ofatumumab injection,J9302,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,276.11,,,,,,,fee schedule,62.23,276.11,APC 378
Ofatumumab injection,J9302,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,65.35,,,,,,,fee schedule,62.23,276.11,APC
Ofatumumab injection,J9302,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,64.72,,,,,,,fee schedule,62.23,276.11,APC
Ofatumumab injection,J9302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,62.23,,,,,,,fee schedule,62.23,276.11,APC
Ofatumumab injection,J9302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,95.22,,,,,,,fee schedule,62.23,276.11,Radiology
Ofatumumab injection,J9302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,87.13,,,,,,,fee schedule,62.23,276.11,APC
Ofatumumab injection,J9302,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,108.91,,,,,,,fee schedule,62.23,276.11,APC
Panitumumab injection,J9303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,296.74,,,,,,,fee schedule,174.39,327.14,
Panitumumab injection,J9303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,322.32,,,,,,,fee schedule,174.39,327.14,
Panitumumab injection,J9303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,327.14,,,,,,,fee schedule,174.39,327.14,
Panitumumab injection,J9303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,258.37,,,,,,,fee schedule,174.39,327.14,
Panitumumab injection,J9303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,282.24,,,,,,,fee schedule,174.39,327.14,
Panitumumab injection,J9303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,296.08,,,,,,,fee schedule,174.39,327.14,
Panitumumab injection,J9303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,202.29,,,,,,,fee schedule,174.39,327.14,OP High Cost Drugs
Panitumumab injection,J9303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,174.39,,,,,,,fee schedule,174.39,327.14,Other Pharmacy
Panitumumab injection,J9303,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,183.11,,,,,,,fee schedule,174.39,327.14,APC
Panitumumab injection,J9303,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,181.36,,,,,,,fee schedule,174.39,327.14,APC
Panitumumab injection,J9303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,266.81,,,,,,,fee schedule,174.39,327.14,Radiology
Panitumumab injection,J9303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,244.14,,,,,,,fee schedule,174.39,327.14,APC
Panitumumab injection,J9303,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,305.18,,,,,,,fee schedule,174.39,327.14,APC
"Inj. pemetrexed, 10 mg",J9304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,275.79,,,,,,,fee schedule,7.99,299.57,
"Inj. pemetrexed, 10 mg",J9304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,299.57,,,,,,,fee schedule,7.99,299.57,
"Inj. pemetrexed, 10 mg",J9304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,161.81,,,,,,,fee schedule,7.99,299.57,
"Inj. pemetrexed, 10 mg",J9304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,240.13,,,,,,,fee schedule,7.99,299.57,
"Inj. pemetrexed, 10 mg",J9304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,262.32,,,,,,,fee schedule,7.99,299.57,
"Inj. pemetrexed, 10 mg",J9304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,146.45,,,,,,,fee schedule,7.99,299.57,
"Inj. pemetrexed, 10 mg",J9304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9.27,,,,,,,fee schedule,7.99,299.57,OP High Cost Drugs
"Inj. pemetrexed, 10 mg",J9304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.99,,,,,,,fee schedule,7.99,299.57,Other Pharmacy
"Inj. pemetrexed, 10 mg",J9304,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.39,,,,,,,fee schedule,7.99,299.57,APC
"Inj. pemetrexed, 10 mg",J9304,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8.31,,,,,,,fee schedule,7.99,299.57,APC
"Inj. pemetrexed, 10 mg",J9304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12.23,,,,,,,fee schedule,7.99,299.57,Radiology
"Inj. pemetrexed, 10 mg",J9304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11.19,,,,,,,fee schedule,7.99,299.57,APC
"Inj. pemetrexed, 10 mg",J9304,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,13.99,,,,,,,fee schedule,7.99,299.57,APC
Pemetrexed injection,J9305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,168.99,,,,,,,fee schedule,4.04,183.56,
Pemetrexed injection,J9305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,183.56,,,,,,,fee schedule,4.04,183.56,
Pemetrexed injection,J9305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30.15,,,,,,,fee schedule,4.04,183.56,
Pemetrexed injection,J9305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,147.14,,,,,,,fee schedule,4.04,183.56,
Pemetrexed injection,J9305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,160.73,,,,,,,fee schedule,4.04,183.56,
Pemetrexed injection,J9305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,27.28,,,,,,,fee schedule,4.04,183.56,
Pemetrexed injection,J9305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4.68,,,,,,,fee schedule,4.04,183.56,OP High Cost Drugs
Pemetrexed injection,J9305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4.04,,,,,,,fee schedule,4.04,183.56,Other Pharmacy
Pemetrexed injection,J9305,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.24,,,,,,,fee schedule,4.04,183.56,APC
Pemetrexed injection,J9305,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4.2,,,,,,,fee schedule,4.04,183.56,APC
Pemetrexed injection,J9305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.18,,,,,,,fee schedule,4.04,183.56,Radiology
Pemetrexed injection,J9305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.65,,,,,,,fee schedule,4.04,183.56,APC
Pemetrexed injection,J9305,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7.07,,,,,,,fee schedule,4.04,183.56,APC
"Injection, pertuzumab, 1 mg",J9306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,35.57,,,,,,,fee schedule,17.02,38.63,
"Injection, pertuzumab, 1 mg",J9306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,38.63,,,,,,,fee schedule,17.02,38.63,
"Injection, pertuzumab, 1 mg",J9306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,29.44,,,,,,,fee schedule,17.02,38.63,
"Injection, pertuzumab, 1 mg",J9306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,30.97,,,,,,,fee schedule,17.02,38.63,
"Injection, pertuzumab, 1 mg",J9306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,33.83,,,,,,,fee schedule,17.02,38.63,
"Injection, pertuzumab, 1 mg",J9306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26.64,,,,,,,fee schedule,17.02,38.63,
"Injection, pertuzumab, 1 mg",J9306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,19.74,,,,,,,fee schedule,17.02,38.63,OP High Cost Drugs
"Injection, pertuzumab, 1 mg",J9306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17.02,,,,,,,fee schedule,17.02,38.63,Other Pharmacy
"Injection, pertuzumab, 1 mg",J9306,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.87,,,,,,,fee schedule,17.02,38.63,APC
"Injection, pertuzumab, 1 mg",J9306,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,17.7,,,,,,,fee schedule,17.02,38.63,APC
"Injection, pertuzumab, 1 mg",J9306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26.03,,,,,,,fee schedule,17.02,38.63,Radiology
"Injection, pertuzumab, 1 mg",J9306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.82,,,,,,,fee schedule,17.02,38.63,APC
"Injection, pertuzumab, 1 mg",J9306,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,29.78,,,,,,,fee schedule,17.02,38.63,APC
Pralatrexate injection,J9307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,635.38,,,,,,,fee schedule,392.72,690.15,
Pralatrexate injection,J9307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,690.15,,,,,,,fee schedule,392.72,690.15,
Pralatrexate injection,J9307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,643.46,,,,,,,fee schedule,392.72,690.15,
Pralatrexate injection,J9307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,553.22,,,,,,,fee schedule,392.72,690.15,
Pralatrexate injection,J9307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,604.34,,,,,,,fee schedule,392.72,690.15,
Pralatrexate injection,J9307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,582.37,,,,,,,fee schedule,392.72,690.15,
Pralatrexate injection,J9307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,455.55,,,,,,,fee schedule,392.72,690.15,OP High Cost Drugs
Pralatrexate injection,J9307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,392.72,,,,,,,fee schedule,392.72,690.15,Other Pharmacy
Pralatrexate injection,J9307,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,412.35,,,,,,,fee schedule,392.72,690.15,APC
Pralatrexate injection,J9307,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,408.43,,,,,,,fee schedule,392.72,690.15,APC
Pralatrexate injection,J9307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,600.86,,,,,,,fee schedule,392.72,690.15,Radiology
Pralatrexate injection,J9307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,549.81,,,,,,,fee schedule,392.72,690.15,APC
Pralatrexate injection,J9307,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,687.26,,,,,,,fee schedule,392.72,690.15,APC
"Injection, ramucirumab",J9308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,187.99,,,,,,,fee schedule,75.47,204.2,
"Injection, ramucirumab",J9308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,204.2,,,,,,,fee schedule,75.47,204.2,
"Injection, ramucirumab",J9308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,138.11,,,,,,,fee schedule,75.47,204.2,
"Injection, ramucirumab",J9308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,163.68,,,,,,,fee schedule,75.47,204.2,
"Injection, ramucirumab",J9308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,178.81,,,,,,,fee schedule,75.47,204.2,
"Injection, ramucirumab",J9308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,125,,,,,,,fee schedule,75.47,204.2,
"Injection, ramucirumab",J9308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,87.55,,,,,,,fee schedule,75.47,204.2,OP High Cost Drugs
"Injection, ramucirumab",J9308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,75.47,,,,,,,fee schedule,75.47,204.2,Other Pharmacy
"Injection, ramucirumab",J9308,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,79.25,,,,,,,fee schedule,75.47,204.2,APC
"Injection, ramucirumab",J9308,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,78.49,,,,,,,fee schedule,75.47,204.2,APC
"Injection, ramucirumab",J9308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,115.47,,,,,,,fee schedule,75.47,204.2,Radiology
"Injection, ramucirumab",J9308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,105.66,,,,,,,fee schedule,75.47,204.2,APC
"Injection, ramucirumab",J9308,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,132.08,,,,,,,fee schedule,75.47,204.2,APC
"Inj, polatuzumab vedotin 1mg",J9309,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,384.04,,,,,,,fee schedule,137.23,417.15,
"Inj, polatuzumab vedotin 1mg",J9309,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,417.15,,,,,,,fee schedule,137.23,417.15,
"Inj, polatuzumab vedotin 1mg",J9309,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,243.86,,,,,,,fee schedule,137.23,417.15,
"Inj, polatuzumab vedotin 1mg",J9309,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,334.38,,,,,,,fee schedule,137.23,417.15,
"Inj, polatuzumab vedotin 1mg",J9309,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,365.28,,,,,,,fee schedule,137.23,417.15,
"Inj, polatuzumab vedotin 1mg",J9309,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,220.71,,,,,,,fee schedule,137.23,417.15,
"Inj, polatuzumab vedotin 1mg",J9309,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,159.18,,,,,,,fee schedule,137.23,417.15,OP High Cost Drugs
"Inj, polatuzumab vedotin 1mg",J9309,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,137.23,,,,,,,fee schedule,137.23,417.15,Other Pharmacy
"Inj, polatuzumab vedotin 1mg",J9309,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,144.09,,,,,,,fee schedule,137.23,417.15,APC
"Inj, polatuzumab vedotin 1mg",J9309,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,142.72,,,,,,,fee schedule,137.23,417.15,APC
"Inj, polatuzumab vedotin 1mg",J9309,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,209.96,,,,,,,fee schedule,137.23,417.15,Radiology
"Inj, polatuzumab vedotin 1mg",J9309,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,192.12,,,,,,,fee schedule,137.23,417.15,APC
"Inj, polatuzumab vedotin 1mg",J9309,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,240.15,,,,,,,fee schedule,137.23,417.15,APC
"Inj rituximab, hyaluronidase",J9311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,159.11,,,,,,,fee schedule,36.28,172.83,
"Inj rituximab, hyaluronidase",J9311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,172.83,,,,,,,fee schedule,36.28,172.83,
"Inj rituximab, hyaluronidase",J9311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,88.69,,,,,,,fee schedule,36.28,172.83,
"Inj rituximab, hyaluronidase",J9311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,138.54,,,,,,,fee schedule,36.28,172.83,
"Inj rituximab, hyaluronidase",J9311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,151.34,,,,,,,fee schedule,36.28,172.83,
"Inj rituximab, hyaluronidase",J9311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,80.27,,,,,,,fee schedule,36.28,172.83,
"Inj rituximab, hyaluronidase",J9311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,42.09,,,,,,,fee schedule,36.28,172.83,OP High Cost Drugs
"Inj rituximab, hyaluronidase",J9311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,36.28,,,,,,,fee schedule,36.28,172.83,Other Pharmacy
"Inj rituximab, hyaluronidase",J9311,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.1,,,,,,,fee schedule,36.28,172.83,APC
"Inj rituximab, hyaluronidase",J9311,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,37.73,,,,,,,fee schedule,36.28,172.83,APC
"Inj rituximab, hyaluronidase",J9311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,55.51,,,,,,,fee schedule,36.28,172.83,Radiology
"Inj rituximab, hyaluronidase",J9311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,50.79,,,,,,,fee schedule,36.28,172.83,APC
"Inj rituximab, hyaluronidase",J9311,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,63.49,,,,,,,fee schedule,36.28,172.83,APC
"Inj., rituximab, 10 mg",J9312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,320.11,,,,,,,fee schedule,74.16,347.7,
"Inj., rituximab, 10 mg",J9312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,347.7,,,,,,,fee schedule,74.16,347.7,
"Inj., rituximab, 10 mg",J9312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,178.13,,,,,,,fee schedule,74.16,347.7,
"Inj., rituximab, 10 mg",J9312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,278.71,,,,,,,fee schedule,74.16,347.7,
"Inj., rituximab, 10 mg",J9312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,304.47,,,,,,,fee schedule,74.16,347.7,
"Inj., rituximab, 10 mg",J9312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,161.22,,,,,,,fee schedule,74.16,347.7,
"Inj., rituximab, 10 mg",J9312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.02,,,,,,,fee schedule,74.16,347.7,OP High Cost Drugs
"Inj., rituximab, 10 mg",J9312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,74.16,,,,,,,fee schedule,74.16,347.7,Other Pharmacy
"Inj., rituximab, 10 mg",J9312,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,77.87,,,,,,,fee schedule,74.16,347.7,APC
"Inj., rituximab, 10 mg",J9312,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,77.12,,,,,,,fee schedule,74.16,347.7,APC
"Inj., rituximab, 10 mg",J9312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,113.46,,,,,,,fee schedule,74.16,347.7,Radiology
"Inj., rituximab, 10 mg",J9312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,103.82,,,,,,,fee schedule,74.16,347.7,APC
"Inj., rituximab, 10 mg",J9312,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,129.78,,,,,,,fee schedule,74.16,347.7,APC
"Inj., lumoxiti, 0.01 mg",J9313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,76.85,,,,,,,fee schedule,23.39,103.79,
"Inj., lumoxiti, 0.01 mg",J9313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83.47,,,,,,,fee schedule,23.39,103.79,
"Inj., lumoxiti, 0.01 mg",J9313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41.84,,,,,,,fee schedule,23.39,103.79,
"Inj., lumoxiti, 0.01 mg",J9313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66.91,,,,,,,fee schedule,23.39,103.79,
"Inj., lumoxiti, 0.01 mg",J9313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,73.09,,,,,,,fee schedule,23.39,103.79,
"Inj., lumoxiti, 0.01 mg",J9313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37.87,,,,,,,fee schedule,23.39,103.79,
"Inj., lumoxiti, 0.01 mg",J9313,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,103.79,,,,,,,fee schedule,23.39,103.79,APC 378
"Inj., lumoxiti, 0.01 mg",J9313,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,24.56,,,,,,,fee schedule,23.39,103.79,APC
"Inj., lumoxiti, 0.01 mg",J9313,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,24.33,,,,,,,fee schedule,23.39,103.79,APC
"Inj., lumoxiti, 0.01 mg",J9313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,23.39,,,,,,,fee schedule,23.39,103.79,APC
"Inj., lumoxiti, 0.01 mg",J9313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,35.79,,,,,,,fee schedule,23.39,103.79,Radiology
"Inj., lumoxiti, 0.01 mg",J9313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,32.75,,,,,,,fee schedule,23.39,103.79,APC
"Inj., lumoxiti, 0.01 mg",J9313,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,40.94,,,,,,,fee schedule,23.39,103.79,APC
Inj pemetrexed (teva) 10mg,J9314,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46.24,,,,,,,fee schedule,10.99,50.22,
Inj pemetrexed (teva) 10mg,J9314,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,50.22,,,,,,,fee schedule,10.99,50.22,
Inj pemetrexed (teva) 10mg,J9314,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37.57,,,,,,,fee schedule,10.99,50.22,
Inj pemetrexed (teva) 10mg,J9314,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40.26,,,,,,,fee schedule,10.99,50.22,
Inj pemetrexed (teva) 10mg,J9314,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,43.98,,,,,,,fee schedule,10.99,50.22,
Inj pemetrexed (teva) 10mg,J9314,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,34.01,,,,,,,fee schedule,10.99,50.22,
Inj pemetrexed (teva) 10mg,J9314,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.74,,,,,,,fee schedule,10.99,50.22,OP High Cost Drugs
Inj pemetrexed (teva) 10mg,J9314,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10.99,,,,,,,fee schedule,10.99,50.22,Other Pharmacy
Inj pemetrexed (teva) 10mg,J9314,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.54,,,,,,,fee schedule,10.99,50.22,APC
Inj pemetrexed (teva) 10mg,J9314,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11.43,,,,,,,fee schedule,10.99,50.22,APC
Inj pemetrexed (teva) 10mg,J9314,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.81,,,,,,,fee schedule,10.99,50.22,Radiology
Inj pemetrexed (teva) 10mg,J9314,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15.38,,,,,,,fee schedule,10.99,50.22,APC
Inj pemetrexed (teva) 10mg,J9314,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19.23,,,,,,,fee schedule,10.99,50.22,APC
"Pertuzu, trastuzu, 10 mg",J9316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,253.03,,,,,,,fee schedule,60.22,274.84,
"Pertuzu, trastuzu, 10 mg",J9316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,274.84,,,,,,,fee schedule,60.22,274.84,
"Pertuzu, trastuzu, 10 mg",J9316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,140.21,,,,,,,fee schedule,60.22,274.84,
"Pertuzu, trastuzu, 10 mg",J9316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,220.31,,,,,,,fee schedule,60.22,274.84,
"Pertuzu, trastuzu, 10 mg",J9316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,240.67,,,,,,,fee schedule,60.22,274.84,
"Pertuzu, trastuzu, 10 mg",J9316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,126.9,,,,,,,fee schedule,60.22,274.84,
"Pertuzu, trastuzu, 10 mg",J9316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,69.86,,,,,,,fee schedule,60.22,274.84,OP High Cost Drugs
"Pertuzu, trastuzu, 10 mg",J9316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,60.22,,,,,,,fee schedule,60.22,274.84,Other Pharmacy
"Pertuzu, trastuzu, 10 mg",J9316,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,63.24,,,,,,,fee schedule,60.22,274.84,APC
"Pertuzu, trastuzu, 10 mg",J9316,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,62.63,,,,,,,fee schedule,60.22,274.84,APC
"Pertuzu, trastuzu, 10 mg",J9316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,92.14,,,,,,,fee schedule,60.22,274.84,Radiology
"Pertuzu, trastuzu, 10 mg",J9316,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,84.32,,,,,,,fee schedule,60.22,274.84,APC
"Pertuzu, trastuzu, 10 mg",J9316,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,105.39,,,,,,,fee schedule,60.22,274.84,APC
Sacituzumab govitecan-hziy,J9317,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,102.68,,,,,,,fee schedule,36.8,111.53,
Sacituzumab govitecan-hziy,J9317,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,111.53,,,,,,,fee schedule,36.8,111.53,
Sacituzumab govitecan-hziy,J9317,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,64.94,,,,,,,fee schedule,36.8,111.53,
Sacituzumab govitecan-hziy,J9317,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,89.4,,,,,,,fee schedule,36.8,111.53,
Sacituzumab govitecan-hziy,J9317,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,97.66,,,,,,,fee schedule,36.8,111.53,
Sacituzumab govitecan-hziy,J9317,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,58.77,,,,,,,fee schedule,36.8,111.53,
Sacituzumab govitecan-hziy,J9317,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,42.68,,,,,,,fee schedule,36.8,111.53,OP High Cost Drugs
Sacituzumab govitecan-hziy,J9317,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,36.8,,,,,,,fee schedule,36.8,111.53,Other Pharmacy
Sacituzumab govitecan-hziy,J9317,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.64,,,,,,,fee schedule,36.8,111.53,APC
Sacituzumab govitecan-hziy,J9317,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.27,,,,,,,fee schedule,36.8,111.53,APC
Sacituzumab govitecan-hziy,J9317,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.3,,,,,,,fee schedule,36.8,111.53,Radiology
Sacituzumab govitecan-hziy,J9317,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.52,,,,,,,fee schedule,36.8,111.53,APC
Sacituzumab govitecan-hziy,J9317,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.39,,,,,,,fee schedule,36.8,111.53,APC
Inj romidepsin non-lyo 0.1mg,J9318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,117.99,,,,,,,fee schedule,28.52,128.16,
Inj romidepsin non-lyo 0.1mg,J9318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,128.16,,,,,,,fee schedule,28.52,128.16,
Inj romidepsin non-lyo 0.1mg,J9318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.64,,,,,,,fee schedule,28.52,128.16,
Inj romidepsin non-lyo 0.1mg,J9318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,102.73,,,,,,,fee schedule,28.52,128.16,
Inj romidepsin non-lyo 0.1mg,J9318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,112.23,,,,,,,fee schedule,28.52,128.16,
Inj romidepsin non-lyo 0.1mg,J9318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,54.88,,,,,,,fee schedule,28.52,128.16,
Inj romidepsin non-lyo 0.1mg,J9318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,33.08,,,,,,,fee schedule,28.52,128.16,OP High Cost Drugs
Inj romidepsin non-lyo 0.1mg,J9318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.52,,,,,,,fee schedule,28.52,128.16,Other Pharmacy
Inj romidepsin non-lyo 0.1mg,J9318,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,29.94,,,,,,,fee schedule,28.52,128.16,APC
Inj romidepsin non-lyo 0.1mg,J9318,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,29.66,,,,,,,fee schedule,28.52,128.16,APC
Inj romidepsin non-lyo 0.1mg,J9318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43.63,,,,,,,fee schedule,28.52,128.16,Radiology
Inj romidepsin non-lyo 0.1mg,J9318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,39.92,,,,,,,fee schedule,28.52,128.16,APC
Inj romidepsin non-lyo 0.1mg,J9318,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,49.9,,,,,,,fee schedule,28.52,128.16,APC
Inj romidepsin lyophil 0.1mg,J9319,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,115.63,,,,,,,fee schedule,30.8,125.6,
Inj romidepsin lyophil 0.1mg,J9319,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,125.6,,,,,,,fee schedule,30.8,125.6,
Inj romidepsin lyophil 0.1mg,J9319,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.36,,,,,,,fee schedule,30.8,125.6,
Inj romidepsin lyophil 0.1mg,J9319,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,100.68,,,,,,,fee schedule,30.8,125.6,
Inj romidepsin lyophil 0.1mg,J9319,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,109.98,,,,,,,fee schedule,30.8,125.6,
Inj romidepsin lyophil 0.1mg,J9319,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,54.63,,,,,,,fee schedule,30.8,125.6,
Inj romidepsin lyophil 0.1mg,J9319,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,35.72,,,,,,,fee schedule,30.8,125.6,OP High Cost Drugs
Inj romidepsin lyophil 0.1mg,J9319,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,30.8,,,,,,,fee schedule,30.8,125.6,Other Pharmacy
Inj romidepsin lyophil 0.1mg,J9319,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,32.34,,,,,,,fee schedule,30.8,125.6,APC
Inj romidepsin lyophil 0.1mg,J9319,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,32.03,,,,,,,fee schedule,30.8,125.6,APC
Inj romidepsin lyophil 0.1mg,J9319,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,47.12,,,,,,,fee schedule,30.8,125.6,Radiology
Inj romidepsin lyophil 0.1mg,J9319,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43.11,,,,,,,fee schedule,30.8,125.6,APC
Inj romidepsin lyophil 0.1mg,J9319,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,53.89,,,,,,,fee schedule,30.8,125.6,APC
Streptozocin injection,J9320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,702.93,,,,,,,fee schedule,599.28,763.52,
Streptozocin injection,J9320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,763.52,,,,,,,fee schedule,599.28,763.52,
Streptozocin injection,J9320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,662.15,,,,,,,fee schedule,599.28,763.52,
Streptozocin injection,J9320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,612.03,,,,,,,fee schedule,599.28,763.52,
Streptozocin injection,J9320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,668.59,,,,,,,fee schedule,599.28,763.52,
Streptozocin injection,J9320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,599.28,,,,,,,fee schedule,599.28,763.52,
Inj epcoritamab-bysp 0.16 mg,J9321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,181.91,,,,,,,fee schedule,56.92,197.6,
Inj epcoritamab-bysp 0.16 mg,J9321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,197.6,,,,,,,fee schedule,56.92,197.6,
Inj epcoritamab-bysp 0.16 mg,J9321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,100.74,,,,,,,fee schedule,56.92,197.6,
Inj epcoritamab-bysp 0.16 mg,J9321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,158.39,,,,,,,fee schedule,56.92,197.6,
Inj epcoritamab-bysp 0.16 mg,J9321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,173.03,,,,,,,fee schedule,56.92,197.6,
Inj epcoritamab-bysp 0.16 mg,J9321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,91.18,,,,,,,fee schedule,56.92,197.6,
Inj epcoritamab-bysp 0.16 mg,J9321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,66.02,,,,,,,fee schedule,56.92,197.6,OP High Cost Drugs
Inj epcoritamab-bysp 0.16 mg,J9321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.92,,,,,,,fee schedule,56.92,197.6,Other Pharmacy
Inj epcoritamab-bysp 0.16 mg,J9321,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,59.76,,,,,,,fee schedule,56.92,197.6,APC
Inj epcoritamab-bysp 0.16 mg,J9321,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,59.19,,,,,,,fee schedule,56.92,197.6,APC
Inj epcoritamab-bysp 0.16 mg,J9321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,87.08,,,,,,,fee schedule,56.92,197.6,Radiology
Inj epcoritamab-bysp 0.16 mg,J9321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,79.68,,,,,,,fee schedule,56.92,197.6,APC
Inj epcoritamab-bysp 0.16 mg,J9321,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,99.6,,,,,,,fee schedule,56.92,197.6,APC
Inj pemetrexed ditromethamin,J9323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24.63,,,,,,,fee schedule,17.98,26.75,
Inj pemetrexed ditromethamin,J9323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26.75,,,,,,,fee schedule,17.98,26.75,
Inj pemetrexed ditromethamin,J9323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19.86,,,,,,,fee schedule,17.98,26.75,
Inj pemetrexed ditromethamin,J9323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21.45,,,,,,,fee schedule,17.98,26.75,
Inj pemetrexed ditromethamin,J9323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23.43,,,,,,,fee schedule,17.98,26.75,
Inj pemetrexed ditromethamin,J9323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17.98,,,,,,,fee schedule,17.98,26.75,
"Inj, pemrydi rtu, 10 mg",J9324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,151.49,,,,,,,fee schedule,70.48,151.49,
"Inj, pemrydi rtu, 10 mg",J9324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,137.11,,,,,,,fee schedule,70.48,151.49,
"Inj, pemrydi rtu, 10 mg",J9324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,81.75,,,,,,,fee schedule,70.48,151.49,OP High Cost Drugs
"Inj, pemrydi rtu, 10 mg",J9324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,70.48,,,,,,,fee schedule,70.48,151.49,Other Pharmacy
"Inj, pemrydi rtu, 10 mg",J9324,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,74,,,,,,,fee schedule,70.48,151.49,APC
"Inj, pemrydi rtu, 10 mg",J9324,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,73.3,,,,,,,fee schedule,70.48,151.49,APC
"Inj, pemrydi rtu, 10 mg",J9324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,107.83,,,,,,,fee schedule,70.48,151.49,Radiology
"Inj, pemrydi rtu, 10 mg",J9324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,98.67,,,,,,,fee schedule,70.48,151.49,APC
"Inj, pemrydi rtu, 10 mg",J9324,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,123.33,,,,,,,fee schedule,70.48,151.49,APC
Inj talimogene laherparepvec,J9325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,160.53,,,,,,,fee schedule,73.94,174.37,
Inj talimogene laherparepvec,J9325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,174.37,,,,,,,fee schedule,73.94,174.37,
Inj talimogene laherparepvec,J9325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,126.15,,,,,,,fee schedule,73.94,174.37,
Inj talimogene laherparepvec,J9325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,139.77,,,,,,,fee schedule,73.94,174.37,
Inj talimogene laherparepvec,J9325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,152.69,,,,,,,fee schedule,73.94,174.37,
Inj talimogene laherparepvec,J9325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,114.17,,,,,,,fee schedule,73.94,174.37,
Inj talimogene laherparepvec,J9325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,85.77,,,,,,,fee schedule,73.94,174.37,OP High Cost Drugs
Inj talimogene laherparepvec,J9325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,73.94,,,,,,,fee schedule,73.94,174.37,Other Pharmacy
Inj talimogene laherparepvec,J9325,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,77.64,,,,,,,fee schedule,73.94,174.37,APC
Inj talimogene laherparepvec,J9325,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,76.9,,,,,,,fee schedule,73.94,174.37,APC
Inj talimogene laherparepvec,J9325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,113.13,,,,,,,fee schedule,73.94,174.37,Radiology
Inj talimogene laherparepvec,J9325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,103.52,,,,,,,fee schedule,73.94,174.37,APC
Inj talimogene laherparepvec,J9325,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,129.4,,,,,,,fee schedule,73.94,174.37,APC
Temozolomide injection,J9328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16.84,,,,,,,fee schedule,10.4,19.02,
Temozolomide injection,J9328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18.3,,,,,,,fee schedule,10.4,19.02,
Temozolomide injection,J9328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19.02,,,,,,,fee schedule,10.4,19.02,
Temozolomide injection,J9328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14.67,,,,,,,fee schedule,10.4,19.02,
Temozolomide injection,J9328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.02,,,,,,,fee schedule,10.4,19.02,
Temozolomide injection,J9328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17.22,,,,,,,fee schedule,10.4,19.02,
Temozolomide injection,J9328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.06,,,,,,,fee schedule,10.4,19.02,OP High Cost Drugs
Temozolomide injection,J9328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10.4,,,,,,,fee schedule,10.4,19.02,Other Pharmacy
Temozolomide injection,J9328,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.92,,,,,,,fee schedule,10.4,19.02,APC
Temozolomide injection,J9328,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10.81,,,,,,,fee schedule,10.4,19.02,APC
Temozolomide injection,J9328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15.91,,,,,,,fee schedule,10.4,19.02,Radiology
Temozolomide injection,J9328,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.56,,,,,,,fee schedule,10.4,19.02,APC
Temozolomide injection,J9328,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18.2,,,,,,,fee schedule,10.4,19.02,APC
"Inj, tislelizumab-jsgr",J9329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,98.67,,,,,,,fee schedule,58.27,101.97,
"Inj, tislelizumab-jsgr",J9329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,89.3,,,,,,,fee schedule,58.27,101.97,
"Inj, tislelizumab-jsgr",J9329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,67.59,,,,,,,fee schedule,58.27,101.97,OP High Cost Drugs
"Inj, tislelizumab-jsgr",J9329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,58.27,,,,,,,fee schedule,58.27,101.97,Other Pharmacy
"Inj, tislelizumab-jsgr",J9329,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.18,,,,,,,fee schedule,58.27,101.97,APC
"Inj, tislelizumab-jsgr",J9329,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.6,,,,,,,fee schedule,58.27,101.97,APC
"Inj, tislelizumab-jsgr",J9329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.15,,,,,,,fee schedule,58.27,101.97,Radiology
"Inj, tislelizumab-jsgr",J9329,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.58,,,,,,,fee schedule,58.27,101.97,APC
"Inj, tislelizumab-jsgr",J9329,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,101.97,,,,,,,fee schedule,58.27,101.97,APC
Temsirolimus injection,J9330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,166.73,,,,,,,fee schedule,30.08,181.1,
Temsirolimus injection,J9330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,181.1,,,,,,,fee schedule,30.08,181.1,
Temsirolimus injection,J9330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,109.3,,,,,,,fee schedule,30.08,181.1,
Temsirolimus injection,J9330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,145.17,,,,,,,fee schedule,30.08,181.1,
Temsirolimus injection,J9330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,158.58,,,,,,,fee schedule,30.08,181.1,
Temsirolimus injection,J9330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,98.93,,,,,,,fee schedule,30.08,181.1,
Temsirolimus injection,J9330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,34.89,,,,,,,fee schedule,30.08,181.1,OP High Cost Drugs
Temsirolimus injection,J9330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,30.08,,,,,,,fee schedule,30.08,181.1,Other Pharmacy
Temsirolimus injection,J9330,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,31.58,,,,,,,fee schedule,30.08,181.1,APC
Temsirolimus injection,J9330,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,31.28,,,,,,,fee schedule,30.08,181.1,APC
Temsirolimus injection,J9330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,46.02,,,,,,,fee schedule,30.08,181.1,Radiology
Temsirolimus injection,J9330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,42.11,,,,,,,fee schedule,30.08,181.1,APC
Temsirolimus injection,J9330,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,52.64,,,,,,,fee schedule,30.08,181.1,APC
Inj sirolimus prot part 1 mg,J9331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,353.5,,,,,,,fee schedule,87.11,383.97,
Inj sirolimus prot part 1 mg,J9331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,383.97,,,,,,,fee schedule,87.11,383.97,
Inj sirolimus prot part 1 mg,J9331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,144.76,,,,,,,fee schedule,87.11,383.97,
Inj sirolimus prot part 1 mg,J9331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,307.79,,,,,,,fee schedule,87.11,383.97,
Inj sirolimus prot part 1 mg,J9331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,336.23,,,,,,,fee schedule,87.11,383.97,
Inj sirolimus prot part 1 mg,J9331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,131.02,,,,,,,fee schedule,87.11,383.97,
Inj sirolimus prot part 1 mg,J9331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,101.05,,,,,,,fee schedule,87.11,383.97,OP High Cost Drugs
Inj sirolimus prot part 1 mg,J9331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,87.11,,,,,,,fee schedule,87.11,383.97,Other Pharmacy
Inj sirolimus prot part 1 mg,J9331,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.47,,,,,,,fee schedule,87.11,383.97,APC
Inj sirolimus prot part 1 mg,J9331,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,90.59,,,,,,,fee schedule,87.11,383.97,APC
Inj sirolimus prot part 1 mg,J9331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,133.28,,,,,,,fee schedule,87.11,383.97,Radiology
Inj sirolimus prot part 1 mg,J9331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,121.95,,,,,,,fee schedule,87.11,383.97,APC
Inj sirolimus prot part 1 mg,J9331,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,152.44,,,,,,,fee schedule,87.11,383.97,APC
Inj efgartigimod 2mg,J9332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,109.72,,,,,,,fee schedule,32.61,119.18,
Inj efgartigimod 2mg,J9332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,119.18,,,,,,,fee schedule,32.61,119.18,
Inj efgartigimod 2mg,J9332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,58.68,,,,,,,fee schedule,32.61,119.18,
Inj efgartigimod 2mg,J9332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,95.54,,,,,,,fee schedule,32.61,119.18,
Inj efgartigimod 2mg,J9332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,104.36,,,,,,,fee schedule,32.61,119.18,
Inj efgartigimod 2mg,J9332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.11,,,,,,,fee schedule,32.61,119.18,
Inj efgartigimod 2mg,J9332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,37.83,,,,,,,fee schedule,32.61,119.18,OP High Cost Drugs
Inj efgartigimod 2mg,J9332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,32.61,,,,,,,fee schedule,32.61,119.18,Other Pharmacy
Inj efgartigimod 2mg,J9332,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,34.24,,,,,,,fee schedule,32.61,119.18,APC
Inj efgartigimod 2mg,J9332,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,33.91,,,,,,,fee schedule,32.61,119.18,APC
Inj efgartigimod 2mg,J9332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49.89,,,,,,,fee schedule,32.61,119.18,Radiology
Inj efgartigimod 2mg,J9332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,45.65,,,,,,,fee schedule,32.61,119.18,APC
Inj efgartigimod 2mg,J9332,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,57.06,,,,,,,fee schedule,32.61,119.18,APC
Inj ronzanolixizum-noli 1 mg,J9333,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,79.71,,,,,,,fee schedule,23.4,86.58,
Inj ronzanolixizum-noli 1 mg,J9333,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,86.58,,,,,,,fee schedule,23.4,86.58,
Inj ronzanolixizum-noli 1 mg,J9333,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,40.72,,,,,,,fee schedule,23.4,86.58,
Inj ronzanolixizum-noli 1 mg,J9333,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,69.4,,,,,,,fee schedule,23.4,86.58,
Inj ronzanolixizum-noli 1 mg,J9333,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,75.81,,,,,,,fee schedule,23.4,86.58,
Inj ronzanolixizum-noli 1 mg,J9333,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36.85,,,,,,,fee schedule,23.4,86.58,
Inj ronzanolixizum-noli 1 mg,J9333,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,27.14,,,,,,,fee schedule,23.4,86.58,OP High Cost Drugs
Inj ronzanolixizum-noli 1 mg,J9333,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.4,,,,,,,fee schedule,23.4,86.58,Other Pharmacy
Inj ronzanolixizum-noli 1 mg,J9333,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,24.57,,,,,,,fee schedule,23.4,86.58,APC
Inj ronzanolixizum-noli 1 mg,J9333,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,24.33,,,,,,,fee schedule,23.4,86.58,APC
Inj ronzanolixizum-noli 1 mg,J9333,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,35.8,,,,,,,fee schedule,23.4,86.58,Radiology
Inj ronzanolixizum-noli 1 mg,J9333,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,32.75,,,,,,,fee schedule,23.4,86.58,APC
Inj ronzanolixizum-noli 1 mg,J9333,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,40.94,,,,,,,fee schedule,23.4,86.58,APC
Inj efgart-alfa 2mg hya-qvfc,J9334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,115.44,,,,,,,fee schedule,34.33,125.39,
Inj efgart-alfa 2mg hya-qvfc,J9334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,125.39,,,,,,,fee schedule,34.33,125.39,
Inj efgart-alfa 2mg hya-qvfc,J9334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59.28,,,,,,,fee schedule,34.33,125.39,
Inj efgart-alfa 2mg hya-qvfc,J9334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,100.51,,,,,,,fee schedule,34.33,125.39,
Inj efgart-alfa 2mg hya-qvfc,J9334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,109.8,,,,,,,fee schedule,34.33,125.39,
Inj efgart-alfa 2mg hya-qvfc,J9334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.65,,,,,,,fee schedule,34.33,125.39,
Inj efgart-alfa 2mg hya-qvfc,J9334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,39.82,,,,,,,fee schedule,34.33,125.39,OP High Cost Drugs
Inj efgart-alfa 2mg hya-qvfc,J9334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,34.33,,,,,,,fee schedule,34.33,125.39,Other Pharmacy
Inj efgart-alfa 2mg hya-qvfc,J9334,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.04,,,,,,,fee schedule,34.33,125.39,APC
Inj efgart-alfa 2mg hya-qvfc,J9334,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,35.7,,,,,,,fee schedule,34.33,125.39,APC
Inj efgart-alfa 2mg hya-qvfc,J9334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,52.52,,,,,,,fee schedule,34.33,125.39,Radiology
Inj efgart-alfa 2mg hya-qvfc,J9334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,48.06,,,,,,,fee schedule,34.33,125.39,APC
Inj efgart-alfa 2mg hya-qvfc,J9334,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,60.07,,,,,,,fee schedule,34.33,125.39,APC
Thiotepa injection,J9340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,337.84,,,,,,,fee schedule,294.15,1336.68,
Thiotepa injection,J9340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,366.96,,,,,,,fee schedule,294.15,1336.68,
Thiotepa injection,J9340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1336.68,,,,,,,fee schedule,294.15,1336.68,
Thiotepa injection,J9340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,294.15,,,,,,,fee schedule,294.15,1336.68,
Thiotepa injection,J9340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,321.33,,,,,,,fee schedule,294.15,1336.68,
Thiotepa injection,J9340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1209.78,,,,,,,fee schedule,294.15,1336.68,
"Inj, retifanlimab-dlwr, 1 mg",J9345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,102.08,,,,,,,fee schedule,30.4,110.88,
"Inj, retifanlimab-dlwr, 1 mg",J9345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,110.88,,,,,,,fee schedule,30.4,110.88,
"Inj, retifanlimab-dlwr, 1 mg",J9345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,54,,,,,,,fee schedule,30.4,110.88,
"Inj, retifanlimab-dlwr, 1 mg",J9345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,88.88,,,,,,,fee schedule,30.4,110.88,
"Inj, retifanlimab-dlwr, 1 mg",J9345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,97.1,,,,,,,fee schedule,30.4,110.88,
"Inj, retifanlimab-dlwr, 1 mg",J9345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48.88,,,,,,,fee schedule,30.4,110.88,
"Inj, retifanlimab-dlwr, 1 mg",J9345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,35.27,,,,,,,fee schedule,30.4,110.88,OP High Cost Drugs
"Inj, retifanlimab-dlwr, 1 mg",J9345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,30.4,,,,,,,fee schedule,30.4,110.88,Other Pharmacy
"Inj, retifanlimab-dlwr, 1 mg",J9345,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,31.92,,,,,,,fee schedule,30.4,110.88,APC
"Inj, retifanlimab-dlwr, 1 mg",J9345,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,31.62,,,,,,,fee schedule,30.4,110.88,APC
"Inj, retifanlimab-dlwr, 1 mg",J9345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,46.52,,,,,,,fee schedule,30.4,110.88,Radiology
"Inj, retifanlimab-dlwr, 1 mg",J9345,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,42.56,,,,,,,fee schedule,30.4,110.88,APC
"Inj, retifanlimab-dlwr, 1 mg",J9345,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,53.21,,,,,,,fee schedule,30.4,110.88,APC
"Inj, tremelimumab-actl, 1 mg",J9347,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,474.34,,,,,,,fee schedule,143.23,515.24,
"Inj, tremelimumab-actl, 1 mg",J9347,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,515.24,,,,,,,fee schedule,143.23,515.24,
"Inj, tremelimumab-actl, 1 mg",J9347,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,251.41,,,,,,,fee schedule,143.23,515.24,
"Inj, tremelimumab-actl, 1 mg",J9347,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,413.01,,,,,,,fee schedule,143.23,515.24,
"Inj, tremelimumab-actl, 1 mg",J9347,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,451.17,,,,,,,fee schedule,143.23,515.24,
"Inj, tremelimumab-actl, 1 mg",J9347,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,227.54,,,,,,,fee schedule,143.23,515.24,
"Inj, tremelimumab-actl, 1 mg",J9347,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,166.14,,,,,,,fee schedule,143.23,515.24,OP High Cost Drugs
"Inj, tremelimumab-actl, 1 mg",J9347,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,143.23,,,,,,,fee schedule,143.23,515.24,Other Pharmacy
"Inj, tremelimumab-actl, 1 mg",J9347,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,150.39,,,,,,,fee schedule,143.23,515.24,APC
"Inj, tremelimumab-actl, 1 mg",J9347,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,148.96,,,,,,,fee schedule,143.23,515.24,APC
"Inj, tremelimumab-actl, 1 mg",J9347,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,219.14,,,,,,,fee schedule,143.23,515.24,Radiology
"Inj, tremelimumab-actl, 1 mg",J9347,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,200.52,,,,,,,fee schedule,143.23,515.24,APC
"Inj, tremelimumab-actl, 1 mg",J9347,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,250.65,,,,,,,fee schedule,143.23,515.24,APC
"Inj. naxitamab-gqgk, 1 mg",J9348,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1875.31,,,,,,,fee schedule,686.09,2036.98,
"Inj. naxitamab-gqgk, 1 mg",J9348,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2036.98,,,,,,,fee schedule,686.09,2036.98,
"Inj. naxitamab-gqgk, 1 mg",J9348,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1154.7,,,,,,,fee schedule,686.09,2036.98,
"Inj. naxitamab-gqgk, 1 mg",J9348,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1632.82,,,,,,,fee schedule,686.09,2036.98,
"Inj. naxitamab-gqgk, 1 mg",J9348,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1783.7,,,,,,,fee schedule,686.09,2036.98,
"Inj. naxitamab-gqgk, 1 mg",J9348,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1045.07,,,,,,,fee schedule,686.09,2036.98,
"Inj. naxitamab-gqgk, 1 mg",J9348,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,795.87,,,,,,,fee schedule,686.09,2036.98,OP High Cost Drugs
"Inj. naxitamab-gqgk, 1 mg",J9348,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,686.09,,,,,,,fee schedule,686.09,2036.98,Other Pharmacy
"Inj. naxitamab-gqgk, 1 mg",J9348,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,720.4,,,,,,,fee schedule,686.09,2036.98,APC
"Inj. naxitamab-gqgk, 1 mg",J9348,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,713.54,,,,,,,fee schedule,686.09,2036.98,APC
"Inj. naxitamab-gqgk, 1 mg",J9348,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1049.72,,,,,,,fee schedule,686.09,2036.98,Radiology
"Inj. naxitamab-gqgk, 1 mg",J9348,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,960.53,,,,,,,fee schedule,686.09,2036.98,APC
"Inj. naxitamab-gqgk, 1 mg",J9348,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1200.66,,,,,,,fee schedule,686.09,2036.98,APC
"Inj., tafasitamab-cxix",J9349,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,44.54,,,,,,,fee schedule,14.17,48.38,
"Inj., tafasitamab-cxix",J9349,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,48.38,,,,,,,fee schedule,14.17,48.38,
"Inj., tafasitamab-cxix",J9349,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,25.56,,,,,,,fee schedule,14.17,48.38,
"Inj., tafasitamab-cxix",J9349,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38.78,,,,,,,fee schedule,14.17,48.38,
"Inj., tafasitamab-cxix",J9349,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.37,,,,,,,fee schedule,14.17,48.38,
"Inj., tafasitamab-cxix",J9349,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23.14,,,,,,,fee schedule,14.17,48.38,
"Inj., tafasitamab-cxix",J9349,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16.43,,,,,,,fee schedule,14.17,48.38,OP High Cost Drugs
"Inj., tafasitamab-cxix",J9349,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.17,,,,,,,fee schedule,14.17,48.38,Other Pharmacy
"Inj., tafasitamab-cxix",J9349,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.87,,,,,,,fee schedule,14.17,48.38,APC
"Inj., tafasitamab-cxix",J9349,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,14.73,,,,,,,fee schedule,14.17,48.38,APC
"Inj., tafasitamab-cxix",J9349,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21.67,,,,,,,fee schedule,14.17,48.38,Radiology
"Inj., tafasitamab-cxix",J9349,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.83,,,,,,,fee schedule,14.17,48.38,APC
"Inj., tafasitamab-cxix",J9349,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,24.79,,,,,,,fee schedule,14.17,48.38,APC
"Inj mosunetuzumab-axgb, 1 mg",J9350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2191.37,,,,,,,fee schedule,654.54,2380.28,
"Inj mosunetuzumab-axgb, 1 mg",J9350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2380.28,,,,,,,fee schedule,654.54,2380.28,
"Inj mosunetuzumab-axgb, 1 mg",J9350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1160.37,,,,,,,fee schedule,654.54,2380.28,
"Inj mosunetuzumab-axgb, 1 mg",J9350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1908,,,,,,,fee schedule,654.54,2380.28,
"Inj mosunetuzumab-axgb, 1 mg",J9350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2084.32,,,,,,,fee schedule,654.54,2380.28,
"Inj mosunetuzumab-axgb, 1 mg",J9350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1050.21,,,,,,,fee schedule,654.54,2380.28,
"Inj mosunetuzumab-axgb, 1 mg",J9350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,759.27,,,,,,,fee schedule,654.54,2380.28,OP High Cost Drugs
"Inj mosunetuzumab-axgb, 1 mg",J9350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,654.54,,,,,,,fee schedule,654.54,2380.28,Other Pharmacy
"Inj mosunetuzumab-axgb, 1 mg",J9350,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,687.27,,,,,,,fee schedule,654.54,2380.28,APC
"Inj mosunetuzumab-axgb, 1 mg",J9350,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,680.72,,,,,,,fee schedule,654.54,2380.28,APC
"Inj mosunetuzumab-axgb, 1 mg",J9350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1001.45,,,,,,,fee schedule,654.54,2380.28,Radiology
"Inj mosunetuzumab-axgb, 1 mg",J9350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,916.36,,,,,,,fee schedule,654.54,2380.28,APC
"Inj mosunetuzumab-axgb, 1 mg",J9350,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1145.45,,,,,,,fee schedule,654.54,2380.28,APC
Topotecan injection,J9351,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7.41,,,,,,,fee schedule,6.45,11.14,
Topotecan injection,J9351,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8.05,,,,,,,fee schedule,6.45,11.14,
Topotecan injection,J9351,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11.14,,,,,,,fee schedule,6.45,11.14,
Topotecan injection,J9351,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.45,,,,,,,fee schedule,6.45,11.14,
Topotecan injection,J9351,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7.05,,,,,,,fee schedule,6.45,11.14,
Topotecan injection,J9351,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10.08,,,,,,,fee schedule,6.45,11.14,
Injection trabectedin 0.1mg,J9352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,986.02,,,,,,,fee schedule,391.07,1071.03,
Injection trabectedin 0.1mg,J9352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1071.03,,,,,,,fee schedule,391.07,1071.03,
Injection trabectedin 0.1mg,J9352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,653.74,,,,,,,fee schedule,391.07,1071.03,
Injection trabectedin 0.1mg,J9352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,858.52,,,,,,,fee schedule,391.07,1071.03,
Injection trabectedin 0.1mg,J9352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,937.86,,,,,,,fee schedule,391.07,1071.03,
Injection trabectedin 0.1mg,J9352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,591.68,,,,,,,fee schedule,391.07,1071.03,
Injection trabectedin 0.1mg,J9352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,453.64,,,,,,,fee schedule,391.07,1071.03,OP High Cost Drugs
Injection trabectedin 0.1mg,J9352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,391.07,,,,,,,fee schedule,391.07,1071.03,Other Pharmacy
Injection trabectedin 0.1mg,J9352,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,410.62,,,,,,,fee schedule,391.07,1071.03,APC
Injection trabectedin 0.1mg,J9352,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,406.71,,,,,,,fee schedule,391.07,1071.03,APC
Injection trabectedin 0.1mg,J9352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,598.34,,,,,,,fee schedule,391.07,1071.03,Radiology
Injection trabectedin 0.1mg,J9352,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,547.5,,,,,,,fee schedule,391.07,1071.03,APC
Injection trabectedin 0.1mg,J9352,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,684.37,,,,,,,fee schedule,391.07,1071.03,APC
"Inj. margetuximab-cmkb, 5 mg",J9353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,152.27,,,,,,,fee schedule,53.27,165.4,
"Inj. margetuximab-cmkb, 5 mg",J9353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,165.4,,,,,,,fee schedule,53.27,165.4,
"Inj. margetuximab-cmkb, 5 mg",J9353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,89.57,,,,,,,fee schedule,53.27,165.4,
"Inj. margetuximab-cmkb, 5 mg",J9353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,132.58,,,,,,,fee schedule,53.27,165.4,
"Inj. margetuximab-cmkb, 5 mg",J9353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,144.84,,,,,,,fee schedule,53.27,165.4,
"Inj. margetuximab-cmkb, 5 mg",J9353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,81.07,,,,,,,fee schedule,53.27,165.4,
"Inj. margetuximab-cmkb, 5 mg",J9353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,61.8,,,,,,,fee schedule,53.27,165.4,OP High Cost Drugs
"Inj. margetuximab-cmkb, 5 mg",J9353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,53.27,,,,,,,fee schedule,53.27,165.4,Other Pharmacy
"Inj. margetuximab-cmkb, 5 mg",J9353,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,55.94,,,,,,,fee schedule,53.27,165.4,APC
"Inj. margetuximab-cmkb, 5 mg",J9353,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,55.4,,,,,,,fee schedule,53.27,165.4,APC
"Inj. margetuximab-cmkb, 5 mg",J9353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.51,,,,,,,fee schedule,53.27,165.4,Radiology
"Inj. margetuximab-cmkb, 5 mg",J9353,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,74.58,,,,,,,fee schedule,53.27,165.4,APC
"Inj. margetuximab-cmkb, 5 mg",J9353,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,93.23,,,,,,,fee schedule,53.27,165.4,APC
"Inj, ado-trastuzumab emt 1mg",J9354,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,101.51,,,,,,,fee schedule,42.2,110.26,
"Inj, ado-trastuzumab emt 1mg",J9354,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,110.26,,,,,,,fee schedule,42.2,110.26,
"Inj, ado-trastuzumab emt 1mg",J9354,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,74.23,,,,,,,fee schedule,42.2,110.26,
"Inj, ado-trastuzumab emt 1mg",J9354,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,88.39,,,,,,,fee schedule,42.2,110.26,
"Inj, ado-trastuzumab emt 1mg",J9354,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,96.55,,,,,,,fee schedule,42.2,110.26,
"Inj, ado-trastuzumab emt 1mg",J9354,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,67.18,,,,,,,fee schedule,42.2,110.26,
"Inj, ado-trastuzumab emt 1mg",J9354,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,48.95,,,,,,,fee schedule,42.2,110.26,OP High Cost Drugs
"Inj, ado-trastuzumab emt 1mg",J9354,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,42.2,,,,,,,fee schedule,42.2,110.26,Other Pharmacy
"Inj, ado-trastuzumab emt 1mg",J9354,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,44.31,,,,,,,fee schedule,42.2,110.26,APC
"Inj, ado-trastuzumab emt 1mg",J9354,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,43.89,,,,,,,fee schedule,42.2,110.26,APC
"Inj, ado-trastuzumab emt 1mg",J9354,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,64.56,,,,,,,fee schedule,42.2,110.26,Radiology
"Inj, ado-trastuzumab emt 1mg",J9354,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,59.08,,,,,,,fee schedule,42.2,110.26,APC
"Inj, ado-trastuzumab emt 1mg",J9354,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,73.85,,,,,,,fee schedule,42.2,110.26,APC
Trastuzumab injection,J9355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,219.73,,,,,,,fee schedule,73.42,238.67,
Trastuzumab injection,J9355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,238.67,,,,,,,fee schedule,73.42,238.67,
Trastuzumab injection,J9355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,197.09,,,,,,,fee schedule,73.42,238.67,
Trastuzumab injection,J9355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,191.31,,,,,,,fee schedule,73.42,238.67,
Trastuzumab injection,J9355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,208.99,,,,,,,fee schedule,73.42,238.67,
Trastuzumab injection,J9355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,178.38,,,,,,,fee schedule,73.42,238.67,
Trastuzumab injection,J9355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,85.17,,,,,,,fee schedule,73.42,238.67,OP High Cost Drugs
Trastuzumab injection,J9355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,73.42,,,,,,,fee schedule,73.42,238.67,Other Pharmacy
Trastuzumab injection,J9355,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,77.1,,,,,,,fee schedule,73.42,238.67,APC
Trastuzumab injection,J9355,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,76.36,,,,,,,fee schedule,73.42,238.67,APC
Trastuzumab injection,J9355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,112.34,,,,,,,fee schedule,73.42,238.67,Radiology
Trastuzumab injection,J9355,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,102.79,,,,,,,fee schedule,73.42,238.67,APC
Trastuzumab injection,J9355,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,128.49,,,,,,,fee schedule,73.42,238.67,APC
"Inj. herceptin hylecta, 10mg",J9356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,279.3,,,,,,,fee schedule,59.91,303.38,
"Inj. herceptin hylecta, 10mg",J9356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,303.38,,,,,,,fee schedule,59.91,303.38,
"Inj. herceptin hylecta, 10mg",J9356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,147.68,,,,,,,fee schedule,59.91,303.38,
"Inj. herceptin hylecta, 10mg",J9356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,243.18,,,,,,,fee schedule,59.91,303.38,
"Inj. herceptin hylecta, 10mg",J9356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,265.65,,,,,,,fee schedule,59.91,303.38,
"Inj. herceptin hylecta, 10mg",J9356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,133.66,,,,,,,fee schedule,59.91,303.38,
"Inj. herceptin hylecta, 10mg",J9356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,69.49,,,,,,,fee schedule,59.91,303.38,OP High Cost Drugs
"Inj. herceptin hylecta, 10mg",J9356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,59.91,,,,,,,fee schedule,59.91,303.38,Other Pharmacy
"Inj. herceptin hylecta, 10mg",J9356,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,62.9,,,,,,,fee schedule,59.91,303.38,APC
"Inj. herceptin hylecta, 10mg",J9356,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,62.31,,,,,,,fee schedule,59.91,303.38,APC
"Inj. herceptin hylecta, 10mg",J9356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,91.66,,,,,,,fee schedule,59.91,303.38,Radiology
"Inj. herceptin hylecta, 10mg",J9356,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,83.87,,,,,,,fee schedule,59.91,303.38,APC
"Inj. herceptin hylecta, 10mg",J9356,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,104.84,,,,,,,fee schedule,59.91,303.38,APC
Valrubicin injection,J9357,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,791.42,,,,,,,fee schedule,689.08,4330.95,
Valrubicin injection,J9357,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,859.65,,,,,,,fee schedule,689.08,4330.95,
Valrubicin injection,J9357,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4330.95,,,,,,,fee schedule,689.08,4330.95,
Valrubicin injection,J9357,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,689.08,,,,,,,fee schedule,689.08,4330.95,
Valrubicin injection,J9357,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,752.76,,,,,,,fee schedule,689.08,4330.95,
Valrubicin injection,J9357,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3919.79,,,,,,,fee schedule,689.08,4330.95,
Valrubicin injection,J9357,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1473.81,,,,,,,fee schedule,689.08,4330.95,OP High Cost Drugs
Valrubicin injection,J9357,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1270.52,,,,,,,fee schedule,689.08,4330.95,Other Pharmacy
Valrubicin injection,J9357,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1334.05,,,,,,,fee schedule,689.08,4330.95,APC
Valrubicin injection,J9357,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1321.34,,,,,,,fee schedule,689.08,4330.95,APC
Valrubicin injection,J9357,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1943.9,,,,,,,fee schedule,689.08,4330.95,Radiology
Valrubicin injection,J9357,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1778.73,,,,,,,fee schedule,689.08,4330.95,APC
Valrubicin injection,J9357,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2223.42,,,,,,,fee schedule,689.08,4330.95,APC
Inj fam-trastu deru-nxki 1mg,J9358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,85.68,,,,,,,fee schedule,31.26,93.06,
Inj fam-trastu deru-nxki 1mg,J9358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,93.06,,,,,,,fee schedule,31.26,93.06,
Inj fam-trastu deru-nxki 1mg,J9358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,53.25,,,,,,,fee schedule,31.26,93.06,
Inj fam-trastu deru-nxki 1mg,J9358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,74.6,,,,,,,fee schedule,31.26,93.06,
Inj fam-trastu deru-nxki 1mg,J9358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,81.49,,,,,,,fee schedule,31.26,93.06,
Inj fam-trastu deru-nxki 1mg,J9358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48.19,,,,,,,fee schedule,31.26,93.06,
Inj fam-trastu deru-nxki 1mg,J9358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.26,,,,,,,fee schedule,31.26,93.06,OP High Cost Drugs
Inj fam-trastu deru-nxki 1mg,J9358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,31.26,,,,,,,fee schedule,31.26,93.06,Other Pharmacy
Inj fam-trastu deru-nxki 1mg,J9358,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,32.83,,,,,,,fee schedule,31.26,93.06,APC
Inj fam-trastu deru-nxki 1mg,J9358,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,32.51,,,,,,,fee schedule,31.26,93.06,APC
Inj fam-trastu deru-nxki 1mg,J9358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,47.83,,,,,,,fee schedule,31.26,93.06,Radiology
Inj fam-trastu deru-nxki 1mg,J9358,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43.77,,,,,,,fee schedule,31.26,93.06,APC
Inj fam-trastu deru-nxki 1mg,J9358,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,54.71,,,,,,,fee schedule,31.26,93.06,APC
Inj lon tesirin-lpyl 0.075mg,J9359,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,650.17,,,,,,,fee schedule,221.49,706.22,
Inj lon tesirin-lpyl 0.075mg,J9359,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,706.22,,,,,,,fee schedule,221.49,706.22,
Inj lon tesirin-lpyl 0.075mg,J9359,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,384.27,,,,,,,fee schedule,221.49,706.22,
Inj lon tesirin-lpyl 0.075mg,J9359,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,566.09,,,,,,,fee schedule,221.49,706.22,
Inj lon tesirin-lpyl 0.075mg,J9359,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,618.41,,,,,,,fee schedule,221.49,706.22,
Inj lon tesirin-lpyl 0.075mg,J9359,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,347.79,,,,,,,fee schedule,221.49,706.22,
Inj lon tesirin-lpyl 0.075mg,J9359,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,256.93,,,,,,,fee schedule,221.49,706.22,OP High Cost Drugs
Inj lon tesirin-lpyl 0.075mg,J9359,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,221.49,,,,,,,fee schedule,221.49,706.22,Other Pharmacy
Inj lon tesirin-lpyl 0.075mg,J9359,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,232.57,,,,,,,fee schedule,221.49,706.22,APC
Inj lon tesirin-lpyl 0.075mg,J9359,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,230.35,,,,,,,fee schedule,221.49,706.22,APC
Inj lon tesirin-lpyl 0.075mg,J9359,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,338.88,,,,,,,fee schedule,221.49,706.22,Radiology
Inj lon tesirin-lpyl 0.075mg,J9359,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,310.09,,,,,,,fee schedule,221.49,706.22,APC
Inj lon tesirin-lpyl 0.075mg,J9359,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,387.61,,,,,,,fee schedule,221.49,706.22,APC
Vinblastine sulfate inj,J9360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10.19,,,,,,,fee schedule,9.22,10.19,
Vinblastine sulfate inj,J9360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.22,,,,,,,fee schedule,9.22,10.19,
Vincristine sulfate 1 MG inj,J9370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22.77,,,,,,,fee schedule,20.61,22.77,
Vincristine sulfate 1 MG inj,J9370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20.61,,,,,,,fee schedule,20.61,22.77,
"Inj, vincristine sul lip 1mg",J9371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7456.25,,,,,,,fee schedule,5901.91,8099.03,
"Inj, vincristine sul lip 1mg",J9371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8099.03,,,,,,,fee schedule,5901.91,8099.03,
"Inj, vincristine sul lip 1mg",J9371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6520.99,,,,,,,fee schedule,5901.91,8099.03,
"Inj, vincristine sul lip 1mg",J9371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6492.08,,,,,,,fee schedule,5901.91,8099.03,
"Inj, vincristine sul lip 1mg",J9371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7092.01,,,,,,,fee schedule,5901.91,8099.03,
"Inj, vincristine sul lip 1mg",J9371,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5901.91,,,,,,,fee schedule,5901.91,8099.03,
"Inj pozelimab-bbfg, 1 mg",J9376,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,164.08,,,,,,,fee schedule,91.73,406.97,
"Inj pozelimab-bbfg, 1 mg",J9376,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,148.51,,,,,,,fee schedule,91.73,406.97,
"Inj pozelimab-bbfg, 1 mg",J9376,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,406.97,,,,,,,fee schedule,91.73,406.97,APC 378
"Inj pozelimab-bbfg, 1 mg",J9376,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,96.32,,,,,,,fee schedule,91.73,406.97,APC
"Inj pozelimab-bbfg, 1 mg",J9376,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,95.4,,,,,,,fee schedule,91.73,406.97,APC
"Inj pozelimab-bbfg, 1 mg",J9376,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,91.73,,,,,,,fee schedule,91.73,406.97,APC
"Inj pozelimab-bbfg, 1 mg",J9376,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,140.35,,,,,,,fee schedule,91.73,406.97,Radiology
"Inj pozelimab-bbfg, 1 mg",J9376,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,128.42,,,,,,,fee schedule,91.73,406.97,APC
"Inj pozelimab-bbfg, 1 mg",J9376,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,160.53,,,,,,,fee schedule,91.73,406.97,APC
Inj teclistamab cqyv 0.5 mg,J9380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,107.53,,,,,,,fee schedule,34.5,116.8,
Inj teclistamab cqyv 0.5 mg,J9380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,116.8,,,,,,,fee schedule,34.5,116.8,
Inj teclistamab cqyv 0.5 mg,J9380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.44,,,,,,,fee schedule,34.5,116.8,
Inj teclistamab cqyv 0.5 mg,J9380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,93.62,,,,,,,fee schedule,34.5,116.8,
Inj teclistamab cqyv 0.5 mg,J9380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,102.28,,,,,,,fee schedule,34.5,116.8,
Inj teclistamab cqyv 0.5 mg,J9380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,54.7,,,,,,,fee schedule,34.5,116.8,
Inj teclistamab cqyv 0.5 mg,J9380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,40.02,,,,,,,fee schedule,34.5,116.8,OP High Cost Drugs
Inj teclistamab cqyv 0.5 mg,J9380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,34.5,,,,,,,fee schedule,34.5,116.8,Other Pharmacy
Inj teclistamab cqyv 0.5 mg,J9380,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.23,,,,,,,fee schedule,34.5,116.8,APC
Inj teclistamab cqyv 0.5 mg,J9380,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,35.88,,,,,,,fee schedule,34.5,116.8,APC
Inj teclistamab cqyv 0.5 mg,J9380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,52.79,,,,,,,fee schedule,34.5,116.8,Radiology
Inj teclistamab cqyv 0.5 mg,J9380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,48.3,,,,,,,fee schedule,34.5,116.8,APC
Inj teclistamab cqyv 0.5 mg,J9380,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,60.38,,,,,,,fee schedule,34.5,116.8,APC
Inj teplizumab mzwv 5 mcg,J9381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,126.08,,,,,,,fee schedule,38.39,136.95,
Inj teplizumab mzwv 5 mcg,J9381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,136.95,,,,,,,fee schedule,38.39,136.95,
Inj teplizumab mzwv 5 mcg,J9381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,67.62,,,,,,,fee schedule,38.39,136.95,
Inj teplizumab mzwv 5 mcg,J9381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,109.78,,,,,,,fee schedule,38.39,136.95,
Inj teplizumab mzwv 5 mcg,J9381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,119.92,,,,,,,fee schedule,38.39,136.95,
Inj teplizumab mzwv 5 mcg,J9381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,61.2,,,,,,,fee schedule,38.39,136.95,
Inj teplizumab mzwv 5 mcg,J9381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,44.54,,,,,,,fee schedule,38.39,136.95,OP High Cost Drugs
Inj teplizumab mzwv 5 mcg,J9381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,38.39,,,,,,,fee schedule,38.39,136.95,Other Pharmacy
Inj teplizumab mzwv 5 mcg,J9381,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,40.31,,,,,,,fee schedule,38.39,136.95,APC
Inj teplizumab mzwv 5 mcg,J9381,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,39.93,,,,,,,fee schedule,38.39,136.95,APC
Inj teplizumab mzwv 5 mcg,J9381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,58.74,,,,,,,fee schedule,38.39,136.95,Radiology
Inj teplizumab mzwv 5 mcg,J9381,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,53.75,,,,,,,fee schedule,38.39,136.95,APC
Inj teplizumab mzwv 5 mcg,J9381,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,67.19,,,,,,,fee schedule,38.39,136.95,APC
Vinorelbine tartrate inj,J9390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59.23,,,,,,,fee schedule,36.89,64.34,
Vinorelbine tartrate inj,J9390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,64.34,,,,,,,fee schedule,36.89,64.34,
Vinorelbine tartrate inj,J9390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,40.76,,,,,,,fee schedule,36.89,64.34,
Vinorelbine tartrate inj,J9390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.57,,,,,,,fee schedule,36.89,64.34,
Vinorelbine tartrate inj,J9390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56.34,,,,,,,fee schedule,36.89,64.34,
Vinorelbine tartrate inj,J9390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36.89,,,,,,,fee schedule,36.89,64.34,
"Inj, fulvestrant (teva)",J9393,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,53.74,,,,,,,fee schedule,41.67,184.88,
"Inj, fulvestrant (teva)",J9393,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,58.37,,,,,,,fee schedule,41.67,184.88,
"Inj, fulvestrant (teva)",J9393,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.79,,,,,,,fee schedule,41.67,184.88,
"Inj, fulvestrant (teva)",J9393,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.12,,,,,,,fee schedule,41.67,184.88,
"Inj, fulvestrant (teva)",J9393,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,184.88,,,,,,,fee schedule,41.67,184.88,APC 378
"Inj, fulvestrant (teva)",J9393,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,43.75,,,,,,,fee schedule,41.67,184.88,APC
"Inj, fulvestrant (teva)",J9393,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,43.34,,,,,,,fee schedule,41.67,184.88,APC
"Inj, fulvestrant (teva)",J9393,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,41.67,,,,,,,fee schedule,41.67,184.88,APC
"Inj, fulvestrant (teva)",J9393,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,63.76,,,,,,,fee schedule,41.67,184.88,Radiology
"Inj, fulvestrant (teva)",J9393,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,58.34,,,,,,,fee schedule,41.67,184.88,APC
"Inj, fulvestrant (teva)",J9393,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,72.92,,,,,,,fee schedule,41.67,184.88,APC
"Inj, fulvestrant (fresenius)",J9394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27.3,,,,,,,fee schedule,23.77,94.8,
"Inj, fulvestrant (fresenius)",J9394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,29.65,,,,,,,fee schedule,23.77,94.8,
"Inj, fulvestrant (fresenius)",J9394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,94.8,,,,,,,fee schedule,23.77,94.8,
"Inj, fulvestrant (fresenius)",J9394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23.77,,,,,,,fee schedule,23.77,94.8,
"Inj, fulvestrant (fresenius)",J9394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,25.97,,,,,,,fee schedule,23.77,94.8,
"Inj, fulvestrant (fresenius)",J9394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,85.8,,,,,,,fee schedule,23.77,94.8,
"Inj, fulvestrant (fresenius)",J9394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,31.45,,,,,,,fee schedule,23.77,94.8,OP High Cost Drugs
"Inj, fulvestrant (fresenius)",J9394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27.11,,,,,,,fee schedule,23.77,94.8,Other Pharmacy
"Inj, fulvestrant (fresenius)",J9394,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,28.47,,,,,,,fee schedule,23.77,94.8,APC
"Inj, fulvestrant (fresenius)",J9394,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,28.2,,,,,,,fee schedule,23.77,94.8,APC
"Inj, fulvestrant (fresenius)",J9394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,41.48,,,,,,,fee schedule,23.77,94.8,Radiology
"Inj, fulvestrant (fresenius)",J9394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,37.96,,,,,,,fee schedule,23.77,94.8,APC
"Inj, fulvestrant (fresenius)",J9394,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,47.45,,,,,,,fee schedule,23.77,94.8,APC
"Injection, Fulvestrant",J9395,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,290.3,,,,,,,fee schedule,133.46,315.33,
"Injection, Fulvestrant",J9395,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,315.33,,,,,,,fee schedule,133.46,315.33,
"Injection, Fulvestrant",J9395,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,147.46,,,,,,,fee schedule,133.46,315.33,
"Injection, Fulvestrant",J9395,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,252.76,,,,,,,fee schedule,133.46,315.33,
"Injection, Fulvestrant",J9395,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,276.12,,,,,,,fee schedule,133.46,315.33,
"Injection, Fulvestrant",J9395,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,133.46,,,,,,,fee schedule,133.46,315.33,
"Inj, ziv-aflibercept, 1mg",J9400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26.52,,,,,,,fee schedule,8.61,30.34,
"Inj, ziv-aflibercept, 1mg",J9400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,28.8,,,,,,,fee schedule,8.61,30.34,
"Inj, ziv-aflibercept, 1mg",J9400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30.34,,,,,,,fee schedule,8.61,30.34,
"Inj, ziv-aflibercept, 1mg",J9400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23.09,,,,,,,fee schedule,8.61,30.34,
"Inj, ziv-aflibercept, 1mg",J9400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,25.22,,,,,,,fee schedule,8.61,30.34,
"Inj, ziv-aflibercept, 1mg",J9400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,27.46,,,,,,,fee schedule,8.61,30.34,
"Inj, ziv-aflibercept, 1mg",J9400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9.99,,,,,,,fee schedule,8.61,30.34,OP High Cost Drugs
"Inj, ziv-aflibercept, 1mg",J9400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8.61,,,,,,,fee schedule,8.61,30.34,Other Pharmacy
"Inj, ziv-aflibercept, 1mg",J9400,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.04,,,,,,,fee schedule,8.61,30.34,APC
"Inj, ziv-aflibercept, 1mg",J9400,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8.95,,,,,,,fee schedule,8.61,30.34,APC
"Inj, ziv-aflibercept, 1mg",J9400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.17,,,,,,,fee schedule,8.61,30.34,Radiology
"Inj, ziv-aflibercept, 1mg",J9400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12.05,,,,,,,fee schedule,8.61,30.34,APC
"Inj, ziv-aflibercept, 1mg",J9400,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15.06,,,,,,,fee schedule,8.61,30.34,APC
Porfimer sodium injection,J9600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9070.65,,,,,,,fee schedule,7897.73,44220.41,
Porfimer sodium injection,J9600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9852.61,,,,,,,fee schedule,7897.73,44220.41,
Porfimer sodium injection,J9600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,44220.41,,,,,,,fee schedule,7897.73,44220.41,
Porfimer sodium injection,J9600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7897.73,,,,,,,fee schedule,7897.73,44220.41,
Porfimer sodium injection,J9600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8627.55,,,,,,,fee schedule,7897.73,44220.41,
Porfimer sodium injection,J9600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40022.27,,,,,,,fee schedule,7897.73,44220.41,
Standard wheelchair,K0001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1843.08,,,,,,,fee schedule,152.83,2001.96,
Standard wheelchair,K0001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,175.53,,,,,,,fee schedule,152.83,2001.96,
Standard wheelchair,K0001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2001.96,,,,,,,fee schedule,152.83,2001.96,
Standard wheelchair,K0001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,190.66,,,,,,,fee schedule,152.83,2001.96,
Standard wheelchair,K0001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1604.75,,,,,,,fee schedule,152.83,2001.96,
Standard wheelchair,K0001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,152.83,,,,,,,fee schedule,152.83,2001.96,
Standard wheelchair,K0001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1753.04,,,,,,,fee schedule,152.83,2001.96,
Standard wheelchair,K0001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,166.96,,,,,,,fee schedule,152.83,2001.96,
Stnd hemi (low seat) whlchr,K0002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3139.52,,,,,,,fee schedule,260.34,3410.16,
Stnd hemi (low seat) whlchr,K0002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,299,,,,,,,fee schedule,260.34,3410.16,
Stnd hemi (low seat) whlchr,K0002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3410.16,,,,,,,fee schedule,260.34,3410.16,
Stnd hemi (low seat) whlchr,K0002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,324.78,,,,,,,fee schedule,260.34,3410.16,
Stnd hemi (low seat) whlchr,K0002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2733.54,,,,,,,fee schedule,260.34,3410.16,
Stnd hemi (low seat) whlchr,K0002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,260.34,,,,,,,fee schedule,260.34,3410.16,
Stnd hemi (low seat) whlchr,K0002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2986.15,,,,,,,fee schedule,260.34,3410.16,
Stnd hemi (low seat) whlchr,K0002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,284.4,,,,,,,fee schedule,260.34,3410.16,
Lightweight wheelchair,K0003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3437.3,,,,,,,fee schedule,285.03,3733.62,
Lightweight wheelchair,K0003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,327.36,,,,,,,fee schedule,285.03,3733.62,
Lightweight wheelchair,K0003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3733.62,,,,,,,fee schedule,285.03,3733.62,
Lightweight wheelchair,K0003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,355.58,,,,,,,fee schedule,285.03,3733.62,
Lightweight wheelchair,K0003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2992.82,,,,,,,fee schedule,285.03,3733.62,
Lightweight wheelchair,K0003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,285.03,,,,,,,fee schedule,285.03,3733.62,
Lightweight wheelchair,K0003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3269.39,,,,,,,fee schedule,285.03,3733.62,
Lightweight wheelchair,K0003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,311.37,,,,,,,fee schedule,285.03,3733.62,
High strength ltwt whlchr,K0004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5127.29,,,,,,,fee schedule,425.17,5569.3,
High strength ltwt whlchr,K0004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,488.31,,,,,,,fee schedule,425.17,5569.3,
High strength ltwt whlchr,K0004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5569.3,,,,,,,fee schedule,425.17,5569.3,
High strength ltwt whlchr,K0004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,530.41,,,,,,,fee schedule,425.17,5569.3,
High strength ltwt whlchr,K0004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4464.28,,,,,,,fee schedule,425.17,5569.3,
High strength ltwt whlchr,K0004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,425.17,,,,,,,fee schedule,425.17,5569.3,
High strength ltwt whlchr,K0004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4876.82,,,,,,,fee schedule,425.17,5569.3,
High strength ltwt whlchr,K0004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,464.46,,,,,,,fee schedule,425.17,5569.3,
Ultralightweight wheelchair,K0005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6755.38,,,,,,,fee schedule,588.12,7337.74,
Ultralightweight wheelchair,K0005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,675.47,,,,,,,fee schedule,588.12,7337.74,
Ultralightweight wheelchair,K0005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5066.46,,,,,,,fee schedule,588.12,7337.74,
Ultralightweight wheelchair,K0005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7337.74,,,,,,,fee schedule,588.12,7337.74,
Ultralightweight wheelchair,K0005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,733.7,,,,,,,fee schedule,588.12,7337.74,
Ultralightweight wheelchair,K0005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5503.23,,,,,,,fee schedule,588.12,7337.74,
Ultralightweight wheelchair,K0005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5881.84,,,,,,,fee schedule,588.12,7337.74,
Ultralightweight wheelchair,K0005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,588.12,,,,,,,fee schedule,588.12,7337.74,
Ultralightweight wheelchair,K0005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4411.32,,,,,,,fee schedule,588.12,7337.74,
Ultralightweight wheelchair,K0005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6425.37,,,,,,,fee schedule,588.12,7337.74,
Ultralightweight wheelchair,K0005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,642.47,,,,,,,fee schedule,588.12,7337.74,
Ultralightweight wheelchair,K0005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4818.96,,,,,,,fee schedule,588.12,7337.74,
Heavy duty wheelchair,K0006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4811.59,,,,,,,fee schedule,398.99,5226.38,
Heavy duty wheelchair,K0006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,458.25,,,,,,,fee schedule,398.99,5226.38,
Heavy duty wheelchair,K0006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5226.38,,,,,,,fee schedule,398.99,5226.38,
Heavy duty wheelchair,K0006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,497.75,,,,,,,fee schedule,398.99,5226.38,
Heavy duty wheelchair,K0006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4189.4,,,,,,,fee schedule,398.99,5226.38,
Heavy duty wheelchair,K0006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,398.99,,,,,,,fee schedule,398.99,5226.38,
Heavy duty wheelchair,K0006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4576.54,,,,,,,fee schedule,398.99,5226.38,
Heavy duty wheelchair,K0006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,435.86,,,,,,,fee schedule,398.99,5226.38,
Extra heavy duty wheelchair,K0007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6135.8,,,,,,,fee schedule,508.8,6664.74,
Extra heavy duty wheelchair,K0007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,584.36,,,,,,,fee schedule,508.8,6664.74,
Extra heavy duty wheelchair,K0007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6664.74,,,,,,,fee schedule,508.8,6664.74,
Extra heavy duty wheelchair,K0007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,634.74,,,,,,,fee schedule,508.8,6664.74,
Extra heavy duty wheelchair,K0007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5342.37,,,,,,,fee schedule,508.8,6664.74,
Extra heavy duty wheelchair,K0007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,508.8,,,,,,,fee schedule,508.8,6664.74,
Extra heavy duty wheelchair,K0007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5836.06,,,,,,,fee schedule,508.8,6664.74,
Extra heavy duty wheelchair,K0007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,555.82,,,,,,,fee schedule,508.8,6664.74,
Stnd wt frame power whlchr,K0010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16343.99,,,,,,,fee schedule,1355.29,17752.96,
Stnd wt frame power whlchr,K0010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1556.57,,,,,,,fee schedule,1355.29,17752.96,
Stnd wt frame power whlchr,K0010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17752.96,,,,,,,fee schedule,1355.29,17752.96,
Stnd wt frame power whlchr,K0010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1690.76,,,,,,,fee schedule,1355.29,17752.96,
Stnd wt frame power whlchr,K0010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14230.55,,,,,,,fee schedule,1355.29,17752.96,
Stnd wt frame power whlchr,K0010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1355.29,,,,,,,fee schedule,1355.29,17752.96,
Stnd wt frame power whlchr,K0010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15545.58,,,,,,,fee schedule,1355.29,17752.96,
Stnd wt frame power whlchr,K0010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1480.53,,,,,,,fee schedule,1355.29,17752.96,
Stnd wt pwr whlchr w control,K0011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17963.79,,,,,,,fee schedule,1489.61,19512.4,
Stnd wt pwr whlchr w control,K0011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1710.84,,,,,,,fee schedule,1489.61,19512.4,
Stnd wt pwr whlchr w control,K0011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19512.4,,,,,,,fee schedule,1489.61,19512.4,
Stnd wt pwr whlchr w control,K0011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1858.32,,,,,,,fee schedule,1489.61,19512.4,
Stnd wt pwr whlchr w control,K0011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15640.89,,,,,,,fee schedule,1489.61,19512.4,
Stnd wt pwr whlchr w control,K0011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1489.61,,,,,,,fee schedule,1489.61,19512.4,
Stnd wt pwr whlchr w control,K0011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17086.25,,,,,,,fee schedule,1489.61,19512.4,
Stnd wt pwr whlchr w control,K0011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1627.26,,,,,,,fee schedule,1489.61,19512.4,
Ltwt portbl power whlchr,K0012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11019.39,,,,,,,fee schedule,913.76,11969.33,
Ltwt portbl power whlchr,K0012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1049.46,,,,,,,fee schedule,913.76,11969.33,
Ltwt portbl power whlchr,K0012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11969.33,,,,,,,fee schedule,913.76,11969.33,
Ltwt portbl power whlchr,K0012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1139.93,,,,,,,fee schedule,913.76,11969.33,
Ltwt portbl power whlchr,K0012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9594.46,,,,,,,fee schedule,913.76,11969.33,
Ltwt portbl power whlchr,K0012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,913.76,,,,,,,fee schedule,913.76,11969.33,
Ltwt portbl power whlchr,K0012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10481.08,,,,,,,fee schedule,913.76,11969.33,
Ltwt portbl power whlchr,K0012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,998.2,,,,,,,fee schedule,913.76,11969.33,
Detach non-adj ht armrst rep,K0015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,572.25,,,,,,,fee schedule,49.84,621.58,
Detach non-adj ht armrst rep,K0015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,57.25,,,,,,,fee schedule,49.84,621.58,
Detach non-adj ht armrst rep,K0015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,429.15,,,,,,,fee schedule,49.84,621.58,
Detach non-adj ht armrst rep,K0015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,621.58,,,,,,,fee schedule,49.84,621.58,
Detach non-adj ht armrst rep,K0015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,62.18,,,,,,,fee schedule,49.84,621.58,
Detach non-adj ht armrst rep,K0015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,466.15,,,,,,,fee schedule,49.84,621.58,
Detach non-adj ht armrst rep,K0015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,498.25,,,,,,,fee schedule,49.84,621.58,
Detach non-adj ht armrst rep,K0015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,49.84,,,,,,,fee schedule,49.84,621.58,
Detach non-adj ht armrst rep,K0015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,373.66,,,,,,,fee schedule,49.84,621.58,
Detach non-adj ht armrst rep,K0015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,544.3,,,,,,,fee schedule,49.84,621.58,
Detach non-adj ht armrst rep,K0015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,54.45,,,,,,,fee schedule,49.84,621.58,
Detach non-adj ht armrst rep,K0015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,408.19,,,,,,,fee schedule,49.84,621.58,
Detach adjust armrest base,K0017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,160.95,,,,,,,fee schedule,14,174.83,
Detach adjust armrest base,K0017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16.08,,,,,,,fee schedule,14,174.83,
Detach adjust armrest base,K0017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,120.72,,,,,,,fee schedule,14,174.83,
Detach adjust armrest base,K0017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,174.83,,,,,,,fee schedule,14,174.83,
Detach adjust armrest base,K0017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17.46,,,,,,,fee schedule,14,174.83,
Detach adjust armrest base,K0017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,131.13,,,,,,,fee schedule,14,174.83,
Detach adjust armrest base,K0017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,140.14,,,,,,,fee schedule,14,174.83,
Detach adjust armrest base,K0017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14,,,,,,,fee schedule,14,174.83,
Detach adjust armrest base,K0017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,105.11,,,,,,,fee schedule,14,174.83,
Detach adjust armrest base,K0017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,153.09,,,,,,,fee schedule,14,174.83,
Detach adjust armrest base,K0017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15.29,,,,,,,fee schedule,14,174.83,
Detach adjust armrest base,K0017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,114.82,,,,,,,fee schedule,14,174.83,
Detach adjust armrst upper,K0018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,89.92,,,,,,,fee schedule,7.79,97.68,
Detach adjust armrst upper,K0018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8.94,,,,,,,fee schedule,7.79,97.68,
Detach adjust armrst upper,K0018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,67.48,,,,,,,fee schedule,7.79,97.68,
Detach adjust armrst upper,K0018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,97.68,,,,,,,fee schedule,7.79,97.68,
Detach adjust armrst upper,K0018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.71,,,,,,,fee schedule,7.79,97.68,
Detach adjust armrst upper,K0018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,73.29,,,,,,,fee schedule,7.79,97.68,
Detach adjust armrst upper,K0018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,78.3,,,,,,,fee schedule,7.79,97.68,
Detach adjust armrst upper,K0018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7.79,,,,,,,fee schedule,7.79,97.68,
Detach adjust armrst upper,K0018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,58.75,,,,,,,fee schedule,7.79,97.68,
Detach adjust armrst upper,K0018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,85.53,,,,,,,fee schedule,7.79,97.68,
Detach adjust armrst upper,K0018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.51,,,,,,,fee schedule,7.79,97.68,
Detach adjust armrst upper,K0018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,64.18,,,,,,,fee schedule,7.79,97.68,
"Arm pad repl, each",K0019,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,54.29,,,,,,,fee schedule,4.73,58.97,
"Arm pad repl, each",K0019,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.43,,,,,,,fee schedule,4.73,58.97,
"Arm pad repl, each",K0019,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,40.72,,,,,,,fee schedule,4.73,58.97,
"Arm pad repl, each",K0019,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,58.97,,,,,,,fee schedule,4.73,58.97,
"Arm pad repl, each",K0019,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.9,,,,,,,fee schedule,4.73,58.97,
"Arm pad repl, each",K0019,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,44.23,,,,,,,fee schedule,4.73,58.97,
"Arm pad repl, each",K0019,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,47.27,,,,,,,fee schedule,4.73,58.97,
"Arm pad repl, each",K0019,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.73,,,,,,,fee schedule,4.73,58.97,
"Arm pad repl, each",K0019,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35.45,,,,,,,fee schedule,4.73,58.97,
"Arm pad repl, each",K0019,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.64,,,,,,,fee schedule,4.73,58.97,
"Arm pad repl, each",K0019,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.16,,,,,,,fee schedule,4.73,58.97,
"Arm pad repl, each",K0019,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38.73,,,,,,,fee schedule,4.73,58.97,
Fixed adjust armrest pair,K0020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,146.33,,,,,,,fee schedule,12.76,158.95,
Fixed adjust armrest pair,K0020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14.65,,,,,,,fee schedule,12.76,158.95,
Fixed adjust armrest pair,K0020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,109.69,,,,,,,fee schedule,12.76,158.95,
Fixed adjust armrest pair,K0020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,158.95,,,,,,,fee schedule,12.76,158.95,
Fixed adjust armrest pair,K0020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15.91,,,,,,,fee schedule,12.76,158.95,
Fixed adjust armrest pair,K0020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,119.15,,,,,,,fee schedule,12.76,158.95,
Fixed adjust armrest pair,K0020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,127.41,,,,,,,fee schedule,12.76,158.95,
Fixed adjust armrest pair,K0020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12.76,,,,,,,fee schedule,12.76,158.95,
Fixed adjust armrest pair,K0020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,95.51,,,,,,,fee schedule,12.76,158.95,
Fixed adjust armrest pair,K0020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,139.19,,,,,,,fee schedule,12.76,158.95,
Fixed adjust armrest pair,K0020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13.94,,,,,,,fee schedule,12.76,158.95,
Fixed adjust armrest pair,K0020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,104.33,,,,,,,fee schedule,12.76,158.95,
Hi mount flip-up ftrest repl,K0037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,131.79,,,,,,,fee schedule,11.48,143.15,
Hi mount flip-up ftrest repl,K0037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13.19,,,,,,,fee schedule,11.48,143.15,
Hi mount flip-up ftrest repl,K0037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,98.76,,,,,,,fee schedule,11.48,143.15,
Hi mount flip-up ftrest repl,K0037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,143.15,,,,,,,fee schedule,11.48,143.15,
Hi mount flip-up ftrest repl,K0037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14.33,,,,,,,fee schedule,11.48,143.15,
Hi mount flip-up ftrest repl,K0037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,107.28,,,,,,,fee schedule,11.48,143.15,
Hi mount flip-up ftrest repl,K0037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,114.75,,,,,,,fee schedule,11.48,143.15,
Hi mount flip-up ftrest repl,K0037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11.48,,,,,,,fee schedule,11.48,143.15,
Hi mount flip-up ftrest repl,K0037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,85.99,,,,,,,fee schedule,11.48,143.15,
Hi mount flip-up ftrest repl,K0037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,125.35,,,,,,,fee schedule,11.48,143.15,
Hi mount flip-up ftrest repl,K0037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12.54,,,,,,,fee schedule,11.48,143.15,
Hi mount flip-up ftrest repl,K0037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,93.94,,,,,,,fee schedule,11.48,143.15,
Leg strap each,K0038,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,76.42,,,,,,,fee schedule,6.67,83.01,
Leg strap each,K0038,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7.66,,,,,,,fee schedule,6.67,83.01,
Leg strap each,K0038,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,57.32,,,,,,,fee schedule,6.67,83.01,
Leg strap each,K0038,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83.01,,,,,,,fee schedule,6.67,83.01,
Leg strap each,K0038,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8.32,,,,,,,fee schedule,6.67,83.01,
Leg strap each,K0038,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,62.26,,,,,,,fee schedule,6.67,83.01,
Leg strap each,K0038,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66.54,,,,,,,fee schedule,6.67,83.01,
Leg strap each,K0038,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.67,,,,,,,fee schedule,6.67,83.01,
Leg strap each,K0038,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,49.9,,,,,,,fee schedule,6.67,83.01,
Leg strap each,K0038,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,72.69,,,,,,,fee schedule,6.67,83.01,
Leg strap each,K0038,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7.28,,,,,,,fee schedule,6.67,83.01,
Leg strap each,K0038,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,54.52,,,,,,,fee schedule,6.67,83.01,
Leg strap h style each,K0039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,169.68,,,,,,,fee schedule,14.82,184.31,
Leg strap h style each,K0039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17.02,,,,,,,fee schedule,14.82,184.31,
Leg strap h style each,K0039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,127.26,,,,,,,fee schedule,14.82,184.31,
Leg strap h style each,K0039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,184.31,,,,,,,fee schedule,14.82,184.31,
Leg strap h style each,K0039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18.48,,,,,,,fee schedule,14.82,184.31,
Leg strap h style each,K0039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,138.23,,,,,,,fee schedule,14.82,184.31,
Leg strap h style each,K0039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,147.74,,,,,,,fee schedule,14.82,184.31,
Leg strap h style each,K0039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14.82,,,,,,,fee schedule,14.82,184.31,
Leg strap h style each,K0039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,110.81,,,,,,,fee schedule,14.82,184.31,
Leg strap h style each,K0039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,161.4,,,,,,,fee schedule,14.82,184.31,
Leg strap h style each,K0039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.19,,,,,,,fee schedule,14.82,184.31,
Leg strap h style each,K0039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,121.05,,,,,,,fee schedule,14.82,184.31,
Adjustable angle footplate,K0040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,235.18,,,,,,,fee schedule,20.42,255.45,
Adjustable angle footplate,K0040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23.46,,,,,,,fee schedule,20.42,255.45,
Adjustable angle footplate,K0040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,176.33,,,,,,,fee schedule,20.42,255.45,
Adjustable angle footplate,K0040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,255.45,,,,,,,fee schedule,20.42,255.45,
Adjustable angle footplate,K0040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,25.48,,,,,,,fee schedule,20.42,255.45,
Adjustable angle footplate,K0040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,191.53,,,,,,,fee schedule,20.42,255.45,
Adjustable angle footplate,K0040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,204.77,,,,,,,fee schedule,20.42,255.45,
Adjustable angle footplate,K0040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20.42,,,,,,,fee schedule,20.42,255.45,
Adjustable angle footplate,K0040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,153.53,,,,,,,fee schedule,20.42,255.45,
Adjustable angle footplate,K0040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,223.69,,,,,,,fee schedule,20.42,255.45,
Adjustable angle footplate,K0040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22.31,,,,,,,fee schedule,20.42,255.45,
Adjustable angle footplate,K0040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,167.72,,,,,,,fee schedule,20.42,255.45,
Large size footplate each,K0041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,166.66,,,,,,,fee schedule,14.57,181.02,
Large size footplate each,K0041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16.74,,,,,,,fee schedule,14.57,181.02,
Large size footplate each,K0041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,125,,,,,,,fee schedule,14.57,181.02,
Large size footplate each,K0041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,181.02,,,,,,,fee schedule,14.57,181.02,
Large size footplate each,K0041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18.18,,,,,,,fee schedule,14.57,181.02,
Large size footplate each,K0041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,135.78,,,,,,,fee schedule,14.57,181.02,
Large size footplate each,K0041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,145.11,,,,,,,fee schedule,14.57,181.02,
Large size footplate each,K0041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14.57,,,,,,,fee schedule,14.57,181.02,
Large size footplate each,K0041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,108.84,,,,,,,fee schedule,14.57,181.02,
Large size footplate each,K0041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,158.52,,,,,,,fee schedule,14.57,181.02,
Large size footplate each,K0041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15.92,,,,,,,fee schedule,14.57,181.02,
Large size footplate each,K0041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,118.9,,,,,,,fee schedule,14.57,181.02,
Standard size ftplate rep ea,K0042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,114.74,,,,,,,fee schedule,9.97,124.63,
Standard size ftplate rep ea,K0042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11.45,,,,,,,fee schedule,9.97,124.63,
Standard size ftplate rep ea,K0042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,86.03,,,,,,,fee schedule,9.97,124.63,
Standard size ftplate rep ea,K0042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,124.63,,,,,,,fee schedule,9.97,124.63,
Standard size ftplate rep ea,K0042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12.44,,,,,,,fee schedule,9.97,124.63,
Standard size ftplate rep ea,K0042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,93.44,,,,,,,fee schedule,9.97,124.63,
Standard size ftplate rep ea,K0042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,99.9,,,,,,,fee schedule,9.97,124.63,
Standard size ftplate rep ea,K0042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.97,,,,,,,fee schedule,9.97,124.63,
Standard size ftplate rep ea,K0042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,74.9,,,,,,,fee schedule,9.97,124.63,
Standard size ftplate rep ea,K0042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,109.13,,,,,,,fee schedule,9.97,124.63,
Standard size ftplate rep ea,K0042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10.89,,,,,,,fee schedule,9.97,124.63,
Standard size ftplate rep ea,K0042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,81.82,,,,,,,fee schedule,9.97,124.63,
Ftrst lowr exten tube rep ea,K0043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,61.49,,,,,,,fee schedule,5.33,66.79,
Ftrst lowr exten tube rep ea,K0043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.12,,,,,,,fee schedule,5.33,66.79,
Ftrst lowr exten tube rep ea,K0043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46.18,,,,,,,fee schedule,5.33,66.79,
Ftrst lowr exten tube rep ea,K0043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.79,,,,,,,fee schedule,5.33,66.79,
Ftrst lowr exten tube rep ea,K0043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.65,,,,,,,fee schedule,5.33,66.79,
Ftrst lowr exten tube rep ea,K0043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,50.16,,,,,,,fee schedule,5.33,66.79,
Ftrst lowr exten tube rep ea,K0043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.54,,,,,,,fee schedule,5.33,66.79,
Ftrst lowr exten tube rep ea,K0043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.33,,,,,,,fee schedule,5.33,66.79,
Ftrst lowr exten tube rep ea,K0043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40.21,,,,,,,fee schedule,5.33,66.79,
Ftrst lowr exten tube rep ea,K0043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,58.49,,,,,,,fee schedule,5.33,66.79,
Ftrst lowr exten tube rep ea,K0043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.83,,,,,,,fee schedule,5.33,66.79,
Ftrst lowr exten tube rep ea,K0043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,43.92,,,,,,,fee schedule,5.33,66.79,
Ftrst upr hanger brac rep ea,K0044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,52.41,,,,,,,fee schedule,4.58,56.93,
Ftrst upr hanger brac rep ea,K0044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.25,,,,,,,fee schedule,4.58,56.93,
Ftrst upr hanger brac rep ea,K0044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,39.29,,,,,,,fee schedule,4.58,56.93,
Ftrst upr hanger brac rep ea,K0044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,56.93,,,,,,,fee schedule,4.58,56.93,
Ftrst upr hanger brac rep ea,K0044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.71,,,,,,,fee schedule,4.58,56.93,
Ftrst upr hanger brac rep ea,K0044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42.68,,,,,,,fee schedule,4.58,56.93,
Ftrst upr hanger brac rep ea,K0044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,45.63,,,,,,,fee schedule,4.58,56.93,
Ftrst upr hanger brac rep ea,K0044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.58,,,,,,,fee schedule,4.58,56.93,
Ftrst upr hanger brac rep ea,K0044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,34.21,,,,,,,fee schedule,4.58,56.93,
Ftrst upr hanger brac rep ea,K0044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,49.85,,,,,,,fee schedule,4.58,56.93,
Ftrst upr hanger brac rep ea,K0044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5,,,,,,,fee schedule,4.58,56.93,
Ftrst upr hanger brac rep ea,K0044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37.37,,,,,,,fee schedule,4.58,56.93,
Ftrst compl assembly repl ea,K0045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,178.32,,,,,,,fee schedule,16.03,193.69,
Ftrst compl assembly repl ea,K0045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18.41,,,,,,,fee schedule,16.03,193.69,
Ftrst compl assembly repl ea,K0045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,133.77,,,,,,,fee schedule,16.03,193.69,
Ftrst compl assembly repl ea,K0045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,193.69,,,,,,,fee schedule,16.03,193.69,
Ftrst compl assembly repl ea,K0045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20,,,,,,,fee schedule,16.03,193.69,
Ftrst compl assembly repl ea,K0045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,145.3,,,,,,,fee schedule,16.03,193.69,
Ftrst compl assembly repl ea,K0045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,155.26,,,,,,,fee schedule,16.03,193.69,
Ftrst compl assembly repl ea,K0045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.03,,,,,,,fee schedule,16.03,193.69,
Ftrst compl assembly repl ea,K0045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,116.47,,,,,,,fee schedule,16.03,193.69,
Ftrst compl assembly repl ea,K0045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,169.6,,,,,,,fee schedule,16.03,193.69,
Ftrst compl assembly repl ea,K0045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17.51,,,,,,,fee schedule,16.03,193.69,
Ftrst compl assembly repl ea,K0045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,127.24,,,,,,,fee schedule,16.03,193.69,
Elev lgrst lwr exten repl ea,K0046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,61.49,,,,,,,fee schedule,5.33,66.79,
Elev lgrst lwr exten repl ea,K0046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.12,,,,,,,fee schedule,5.33,66.79,
Elev lgrst lwr exten repl ea,K0046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46.18,,,,,,,fee schedule,5.33,66.79,
Elev lgrst lwr exten repl ea,K0046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.79,,,,,,,fee schedule,5.33,66.79,
Elev lgrst lwr exten repl ea,K0046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.65,,,,,,,fee schedule,5.33,66.79,
Elev lgrst lwr exten repl ea,K0046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,50.16,,,,,,,fee schedule,5.33,66.79,
Elev lgrst lwr exten repl ea,K0046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.54,,,,,,,fee schedule,5.33,66.79,
Elev lgrst lwr exten repl ea,K0046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.33,,,,,,,fee schedule,5.33,66.79,
Elev lgrst lwr exten repl ea,K0046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40.21,,,,,,,fee schedule,5.33,66.79,
Elev lgrst lwr exten repl ea,K0046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,58.49,,,,,,,fee schedule,5.33,66.79,
Elev lgrst lwr exten repl ea,K0046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.83,,,,,,,fee schedule,5.33,66.79,
Elev lgrst lwr exten repl ea,K0046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,43.92,,,,,,,fee schedule,5.33,66.79,
Elev legrst upr hangr rep ea,K0047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,240.85,,,,,,,fee schedule,21.03,261.61,
Elev legrst upr hangr rep ea,K0047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24.15,,,,,,,fee schedule,21.03,261.61,
Elev legrst upr hangr rep ea,K0047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,180.58,,,,,,,fee schedule,21.03,261.61,
Elev legrst upr hangr rep ea,K0047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,261.61,,,,,,,fee schedule,21.03,261.61,
Elev legrst upr hangr rep ea,K0047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26.23,,,,,,,fee schedule,21.03,261.61,
Elev legrst upr hangr rep ea,K0047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,196.14,,,,,,,fee schedule,21.03,261.61,
Elev legrst upr hangr rep ea,K0047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,209.71,,,,,,,fee schedule,21.03,261.61,
Elev legrst upr hangr rep ea,K0047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21.03,,,,,,,fee schedule,21.03,261.61,
Elev legrst upr hangr rep ea,K0047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,157.23,,,,,,,fee schedule,21.03,261.61,
Elev legrst upr hangr rep ea,K0047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,229.09,,,,,,,fee schedule,21.03,261.61,
Elev legrst upr hangr rep ea,K0047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22.97,,,,,,,fee schedule,21.03,261.61,
Elev legrst upr hangr rep ea,K0047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,171.76,,,,,,,fee schedule,21.03,261.61,
Ratchet assembly replacement,K0050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,102.35,,,,,,,fee schedule,8.88,111.17,
Ratchet assembly replacement,K0050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10.2,,,,,,,fee schedule,8.88,111.17,
Ratchet assembly replacement,K0050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,76.8,,,,,,,fee schedule,8.88,111.17,
Ratchet assembly replacement,K0050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,111.17,,,,,,,fee schedule,8.88,111.17,
Ratchet assembly replacement,K0050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11.08,,,,,,,fee schedule,8.88,111.17,
Ratchet assembly replacement,K0050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83.42,,,,,,,fee schedule,8.88,111.17,
Ratchet assembly replacement,K0050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,89.11,,,,,,,fee schedule,8.88,111.17,
Ratchet assembly replacement,K0050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.88,,,,,,,fee schedule,8.88,111.17,
Ratchet assembly replacement,K0050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66.87,,,,,,,fee schedule,8.88,111.17,
Ratchet assembly replacement,K0050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,97.35,,,,,,,fee schedule,8.88,111.17,
Ratchet assembly replacement,K0050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.7,,,,,,,fee schedule,8.88,111.17,
Ratchet assembly replacement,K0050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,73.05,,,,,,,fee schedule,8.88,111.17,
Cam rel asm ft/legrst rep ea,K0051,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,165.68,,,,,,,fee schedule,14.51,179.97,
Cam rel asm ft/legrst rep ea,K0051,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16.67,,,,,,,fee schedule,14.51,179.97,
Cam rel asm ft/legrst rep ea,K0051,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,124.2,,,,,,,fee schedule,14.51,179.97,
Cam rel asm ft/legrst rep ea,K0051,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,179.97,,,,,,,fee schedule,14.51,179.97,
Cam rel asm ft/legrst rep ea,K0051,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18.11,,,,,,,fee schedule,14.51,179.97,
Cam rel asm ft/legrst rep ea,K0051,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,134.91,,,,,,,fee schedule,14.51,179.97,
Cam rel asm ft/legrst rep ea,K0051,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,144.26,,,,,,,fee schedule,14.51,179.97,
Cam rel asm ft/legrst rep ea,K0051,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14.51,,,,,,,fee schedule,14.51,179.97,
Cam rel asm ft/legrst rep ea,K0051,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,108.14,,,,,,,fee schedule,14.51,179.97,
Cam rel asm ft/legrst rep ea,K0051,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,157.59,,,,,,,fee schedule,14.51,179.97,
Cam rel asm ft/legrst rep ea,K0051,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15.85,,,,,,,fee schedule,14.51,179.97,
Cam rel asm ft/legrst rep ea,K0051,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,118.13,,,,,,,fee schedule,14.51,179.97,
Swingaway detach ftrest repl,K0052,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,291.14,,,,,,,fee schedule,25.33,316.23,
Swingaway detach ftrest repl,K0052,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,29.09,,,,,,,fee schedule,25.33,316.23,
Swingaway detach ftrest repl,K0052,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,218.3,,,,,,,fee schedule,25.33,316.23,
Swingaway detach ftrest repl,K0052,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,316.23,,,,,,,fee schedule,25.33,316.23,
Swingaway detach ftrest repl,K0052,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,31.6,,,,,,,fee schedule,25.33,316.23,
Swingaway detach ftrest repl,K0052,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,237.12,,,,,,,fee schedule,25.33,316.23,
Swingaway detach ftrest repl,K0052,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,253.49,,,,,,,fee schedule,25.33,316.23,
Swingaway detach ftrest repl,K0052,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,25.33,,,,,,,fee schedule,25.33,316.23,
Swingaway detach ftrest repl,K0052,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,190.07,,,,,,,fee schedule,25.33,316.23,
Swingaway detach ftrest repl,K0052,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,276.91,,,,,,,fee schedule,25.33,316.23,
Swingaway detach ftrest repl,K0052,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,27.67,,,,,,,fee schedule,25.33,316.23,
Swingaway detach ftrest repl,K0052,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,207.64,,,,,,,fee schedule,25.33,316.23,
Elevate footrest articulate,K0053,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,321.27,,,,,,,fee schedule,27.94,348.97,
Elevate footrest articulate,K0053,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,32.09,,,,,,,fee schedule,27.94,348.97,
Elevate footrest articulate,K0053,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,240.96,,,,,,,fee schedule,27.94,348.97,
Elevate footrest articulate,K0053,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,348.97,,,,,,,fee schedule,27.94,348.97,
Elevate footrest articulate,K0053,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,34.85,,,,,,,fee schedule,27.94,348.97,
Elevate footrest articulate,K0053,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,261.73,,,,,,,fee schedule,27.94,348.97,
Elevate footrest articulate,K0053,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,279.73,,,,,,,fee schedule,27.94,348.97,
Elevate footrest articulate,K0053,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,27.94,,,,,,,fee schedule,27.94,348.97,
Elevate footrest articulate,K0053,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,209.8,,,,,,,fee schedule,27.94,348.97,
Elevate footrest articulate,K0053,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,305.58,,,,,,,fee schedule,27.94,348.97,
Elevate footrest articulate,K0053,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,30.52,,,,,,,fee schedule,27.94,348.97,
Elevate footrest articulate,K0053,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,229.18,,,,,,,fee schedule,27.94,348.97,
Seat ht <17 or >=21 ltwt wc,K0056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,347.51,,,,,,,fee schedule,30.27,377.47,
Seat ht <17 or >=21 ltwt wc,K0056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,34.77,,,,,,,fee schedule,30.27,377.47,
Seat ht <17 or >=21 ltwt wc,K0056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,260.69,,,,,,,fee schedule,30.27,377.47,
Seat ht <17 or >=21 ltwt wc,K0056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,377.47,,,,,,,fee schedule,30.27,377.47,
Seat ht <17 or >=21 ltwt wc,K0056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37.76,,,,,,,fee schedule,30.27,377.47,
Seat ht <17 or >=21 ltwt wc,K0056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,283.16,,,,,,,fee schedule,30.27,377.47,
Seat ht <17 or >=21 ltwt wc,K0056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,302.58,,,,,,,fee schedule,30.27,377.47,
Seat ht <17 or >=21 ltwt wc,K0056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,30.27,,,,,,,fee schedule,30.27,377.47,
Seat ht <17 or >=21 ltwt wc,K0056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,226.98,,,,,,,fee schedule,30.27,377.47,
Seat ht <17 or >=21 ltwt wc,K0056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,330.54,,,,,,,fee schedule,30.27,377.47,
Seat ht <17 or >=21 ltwt wc,K0056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,33.07,,,,,,,fee schedule,30.27,377.47,
Seat ht <17 or >=21 ltwt wc,K0056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,247.95,,,,,,,fee schedule,30.27,377.47,
Spoke protectors,K0065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,162.45,,,,,,,fee schedule,14.15,176.45,
Spoke protectors,K0065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16.25,,,,,,,fee schedule,14.15,176.45,
Spoke protectors,K0065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,121.83,,,,,,,fee schedule,14.15,176.45,
Spoke protectors,K0065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,176.45,,,,,,,fee schedule,14.15,176.45,
Spoke protectors,K0065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17.65,,,,,,,fee schedule,14.15,176.45,
Spoke protectors,K0065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,132.34,,,,,,,fee schedule,14.15,176.45,
Spoke protectors,K0065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,141.44,,,,,,,fee schedule,14.15,176.45,
Spoke protectors,K0065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14.15,,,,,,,fee schedule,14.15,176.45,
Spoke protectors,K0065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,106.08,,,,,,,fee schedule,14.15,176.45,
Spoke protectors,K0065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,154.51,,,,,,,fee schedule,14.15,176.45,
Spoke protectors,K0065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15.46,,,,,,,fee schedule,14.15,176.45,
Spoke protectors,K0065,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,115.88,,,,,,,fee schedule,14.15,176.45,
Rr whl compl sol tire rep ea,K0069,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,365.12,,,,,,,fee schedule,33.12,396.6,
Rr whl compl sol tire rep ea,K0069,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,38.04,,,,,,,fee schedule,33.12,396.6,
Rr whl compl sol tire rep ea,K0069,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,273.84,,,,,,,fee schedule,33.12,396.6,
Rr whl compl sol tire rep ea,K0069,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,396.6,,,,,,,fee schedule,33.12,396.6,
Rr whl compl sol tire rep ea,K0069,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41.32,,,,,,,fee schedule,33.12,396.6,
Rr whl compl sol tire rep ea,K0069,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,297.45,,,,,,,fee schedule,33.12,396.6,
Rr whl compl sol tire rep ea,K0069,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,317.91,,,,,,,fee schedule,33.12,396.6,
Rr whl compl sol tire rep ea,K0069,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,33.12,,,,,,,fee schedule,33.12,396.6,
Rr whl compl sol tire rep ea,K0069,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,238.43,,,,,,,fee schedule,33.12,396.6,
Rr whl compl sol tire rep ea,K0069,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,347.29,,,,,,,fee schedule,33.12,396.6,
Rr whl compl sol tire rep ea,K0069,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36.18,,,,,,,fee schedule,33.12,396.6,
Rr whl compl sol tire rep ea,K0069,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,260.46,,,,,,,fee schedule,33.12,396.6,
Rr whl compl pne tire rep ea,K0070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,669.27,,,,,,,fee schedule,58.33,726.97,
Rr whl compl pne tire rep ea,K0070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.99,,,,,,,fee schedule,58.33,726.97,
Rr whl compl pne tire rep ea,K0070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,501.96,,,,,,,fee schedule,58.33,726.97,
Rr whl compl pne tire rep ea,K0070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,726.97,,,,,,,fee schedule,58.33,726.97,
Rr whl compl pne tire rep ea,K0070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,72.77,,,,,,,fee schedule,58.33,726.97,
Rr whl compl pne tire rep ea,K0070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,545.23,,,,,,,fee schedule,58.33,726.97,
Rr whl compl pne tire rep ea,K0070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,582.73,,,,,,,fee schedule,58.33,726.97,
Rr whl compl pne tire rep ea,K0070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,58.33,,,,,,,fee schedule,58.33,726.97,
Rr whl compl pne tire rep ea,K0070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,437.05,,,,,,,fee schedule,58.33,726.97,
Rr whl compl pne tire rep ea,K0070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,636.58,,,,,,,fee schedule,58.33,726.97,
Rr whl compl pne tire rep ea,K0070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,63.72,,,,,,,fee schedule,58.33,726.97,
Rr whl compl pne tire rep ea,K0070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,477.43,,,,,,,fee schedule,58.33,726.97,
Fr cstr comp pne tire rep ea,K0071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,399.19,,,,,,,fee schedule,34.78,433.6,
Fr cstr comp pne tire rep ea,K0071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,39.95,,,,,,,fee schedule,34.78,433.6,
Fr cstr comp pne tire rep ea,K0071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,299.35,,,,,,,fee schedule,34.78,433.6,
Fr cstr comp pne tire rep ea,K0071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,433.6,,,,,,,fee schedule,34.78,433.6,
Fr cstr comp pne tire rep ea,K0071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,43.39,,,,,,,fee schedule,34.78,433.6,
Fr cstr comp pne tire rep ea,K0071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,325.16,,,,,,,fee schedule,34.78,433.6,
Fr cstr comp pne tire rep ea,K0071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,347.57,,,,,,,fee schedule,34.78,433.6,
Fr cstr comp pne tire rep ea,K0071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,34.78,,,,,,,fee schedule,34.78,433.6,
Fr cstr comp pne tire rep ea,K0071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,260.64,,,,,,,fee schedule,34.78,433.6,
Fr cstr comp pne tire rep ea,K0071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,379.69,,,,,,,fee schedule,34.78,433.6,
Fr cstr comp pne tire rep ea,K0071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38,,,,,,,fee schedule,34.78,433.6,
Fr cstr comp pne tire rep ea,K0071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,284.73,,,,,,,fee schedule,34.78,433.6,
Fr cstr semi-pne tire rep ea,K0072,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,240.29,,,,,,,fee schedule,20.91,261.01,
Fr cstr semi-pne tire rep ea,K0072,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24.01,,,,,,,fee schedule,20.91,261.01,
Fr cstr semi-pne tire rep ea,K0072,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,180.23,,,,,,,fee schedule,20.91,261.01,
Fr cstr semi-pne tire rep ea,K0072,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,261.01,,,,,,,fee schedule,20.91,261.01,
Fr cstr semi-pne tire rep ea,K0072,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26.08,,,,,,,fee schedule,20.91,261.01,
Fr cstr semi-pne tire rep ea,K0072,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,195.77,,,,,,,fee schedule,20.91,261.01,
Fr cstr semi-pne tire rep ea,K0072,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,209.22,,,,,,,fee schedule,20.91,261.01,
Fr cstr semi-pne tire rep ea,K0072,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20.91,,,,,,,fee schedule,20.91,261.01,
Fr cstr semi-pne tire rep ea,K0072,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,156.92,,,,,,,fee schedule,20.91,261.01,
Fr cstr semi-pne tire rep ea,K0072,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,228.56,,,,,,,fee schedule,20.91,261.01,
Fr cstr semi-pne tire rep ea,K0072,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22.84,,,,,,,fee schedule,20.91,261.01,
Fr cstr semi-pne tire rep ea,K0072,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,171.42,,,,,,,fee schedule,20.91,261.01,
Caster pin lock each,K0073,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,127.16,,,,,,,fee schedule,11.06,138.12,
Caster pin lock each,K0073,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12.7,,,,,,,fee schedule,11.06,138.12,
Caster pin lock each,K0073,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,95.39,,,,,,,fee schedule,11.06,138.12,
Caster pin lock each,K0073,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,138.12,,,,,,,fee schedule,11.06,138.12,
Caster pin lock each,K0073,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13.8,,,,,,,fee schedule,11.06,138.12,
Caster pin lock each,K0073,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,103.61,,,,,,,fee schedule,11.06,138.12,
Caster pin lock each,K0073,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,110.72,,,,,,,fee schedule,11.06,138.12,
Caster pin lock each,K0073,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11.06,,,,,,,fee schedule,11.06,138.12,
Caster pin lock each,K0073,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,83.05,,,,,,,fee schedule,11.06,138.12,
Caster pin lock each,K0073,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,120.95,,,,,,,fee schedule,11.06,138.12,
Caster pin lock each,K0073,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12.08,,,,,,,fee schedule,11.06,138.12,
Caster pin lock each,K0073,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,90.73,,,,,,,fee schedule,11.06,138.12,
Fr cstr asmb sol tire rep ea,K0077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,215.03,,,,,,,fee schedule,18.7,233.57,
Fr cstr asmb sol tire rep ea,K0077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21.47,,,,,,,fee schedule,18.7,233.57,
Fr cstr asmb sol tire rep ea,K0077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,161.26,,,,,,,fee schedule,18.7,233.57,
Fr cstr asmb sol tire rep ea,K0077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,233.57,,,,,,,fee schedule,18.7,233.57,
Fr cstr asmb sol tire rep ea,K0077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23.32,,,,,,,fee schedule,18.7,233.57,
Fr cstr asmb sol tire rep ea,K0077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,175.17,,,,,,,fee schedule,18.7,233.57,
Fr cstr asmb sol tire rep ea,K0077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,187.22,,,,,,,fee schedule,18.7,233.57,
Fr cstr asmb sol tire rep ea,K0077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18.7,,,,,,,fee schedule,18.7,233.57,
Fr cstr asmb sol tire rep ea,K0077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,140.41,,,,,,,fee schedule,18.7,233.57,
Fr cstr asmb sol tire rep ea,K0077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,204.52,,,,,,,fee schedule,18.7,233.57,
Fr cstr asmb sol tire rep ea,K0077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20.42,,,,,,,fee schedule,18.7,233.57,
Fr cstr asmb sol tire rep ea,K0077,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,153.39,,,,,,,fee schedule,18.7,233.57,
"Drive belt for pwc, repl",K0098,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,85.71,,,,,,,fee schedule,7.45,93.1,
"Drive belt for pwc, repl",K0098,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8.56,,,,,,,fee schedule,7.45,93.1,
"Drive belt for pwc, repl",K0098,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,64.21,,,,,,,fee schedule,7.45,93.1,
"Drive belt for pwc, repl",K0098,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,93.1,,,,,,,fee schedule,7.45,93.1,
"Drive belt for pwc, repl",K0098,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.3,,,,,,,fee schedule,7.45,93.1,
"Drive belt for pwc, repl",K0098,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,69.74,,,,,,,fee schedule,7.45,93.1,
"Drive belt for pwc, repl",K0098,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,74.63,,,,,,,fee schedule,7.45,93.1,
"Drive belt for pwc, repl",K0098,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7.45,,,,,,,fee schedule,7.45,93.1,
"Drive belt for pwc, repl",K0098,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55.9,,,,,,,fee schedule,7.45,93.1,
"Drive belt for pwc, repl",K0098,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,81.53,,,,,,,fee schedule,7.45,93.1,
"Drive belt for pwc, repl",K0098,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.14,,,,,,,fee schedule,7.45,93.1,
"Drive belt for pwc, repl",K0098,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,61.07,,,,,,,fee schedule,7.45,93.1,
Iv hanger,K0105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,363.31,,,,,,,fee schedule,31.6,394.63,
Iv hanger,K0105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,36.3,,,,,,,fee schedule,31.6,394.63,
Iv hanger,K0105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,272.48,,,,,,,fee schedule,31.6,394.63,
Iv hanger,K0105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,394.63,,,,,,,fee schedule,31.6,394.63,
Iv hanger,K0105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,39.43,,,,,,,fee schedule,31.6,394.63,
Iv hanger,K0105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,295.97,,,,,,,fee schedule,31.6,394.63,
Iv hanger,K0105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,316.33,,,,,,,fee schedule,31.6,394.63,
Iv hanger,K0105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31.6,,,,,,,fee schedule,31.6,394.63,
Iv hanger,K0105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,237.25,,,,,,,fee schedule,31.6,394.63,
Iv hanger,K0105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,345.56,,,,,,,fee schedule,31.6,394.63,
Iv hanger,K0105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,34.52,,,,,,,fee schedule,31.6,394.63,
Iv hanger,K0105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,259.17,,,,,,,fee schedule,31.6,394.63,
Elevating whlchair leg rests,K0195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,629.57,,,,,,,fee schedule,52.21,683.84,
Elevating whlchair leg rests,K0195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59.96,,,,,,,fee schedule,52.21,683.84,
Elevating whlchair leg rests,K0195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,683.84,,,,,,,fee schedule,52.21,683.84,
Elevating whlchair leg rests,K0195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,65.13,,,,,,,fee schedule,52.21,683.84,
Elevating whlchair leg rests,K0195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,548.16,,,,,,,fee schedule,52.21,683.84,
Elevating whlchair leg rests,K0195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52.21,,,,,,,fee schedule,52.21,683.84,
Elevating whlchair leg rests,K0195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,598.81,,,,,,,fee schedule,52.21,683.84,
Elevating whlchair leg rests,K0195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.03,,,,,,,fee schedule,52.21,683.84,
Pump uninterrupted infusion,K0455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,855.52,,,,,,,fee schedule,744.9,929.28,
Pump uninterrupted infusion,K0455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,929.28,,,,,,,fee schedule,744.9,929.28,
Pump uninterrupted infusion,K0455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,744.9,,,,,,,fee schedule,744.9,929.28,
Pump uninterrupted infusion,K0455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,813.73,,,,,,,fee schedule,744.9,929.28,
Sup/ext non-ins inf pump syr,K0552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.67,,,,,,,fee schedule,8.42,10.51,
Sup/ext non-ins inf pump syr,K0552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10.51,,,,,,,fee schedule,8.42,10.51,
Sup/ext non-ins inf pump syr,K0552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.42,,,,,,,fee schedule,8.42,10.51,
Sup/ext non-ins inf pump syr,K0552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.2,,,,,,,fee schedule,8.42,10.51,
Repl batt silver oxide 1.5 v,K0601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.04,,,,,,,fee schedule,3.51,4.38,
Repl batt silver oxide 1.5 v,K0601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.38,,,,,,,fee schedule,3.51,4.38,
Repl batt silver oxide 1.5 v,K0601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.51,,,,,,,fee schedule,3.51,4.38,
Repl batt silver oxide 1.5 v,K0601,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.84,,,,,,,fee schedule,3.51,4.38,
Repl batt silver oxide 3 v,K0602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23.25,,,,,,,fee schedule,20.24,25.25,
Repl batt silver oxide 3 v,K0602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,25.25,,,,,,,fee schedule,20.24,25.25,
Repl batt silver oxide 3 v,K0602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20.24,,,,,,,fee schedule,20.24,25.25,
Repl batt silver oxide 3 v,K0602,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22.11,,,,,,,fee schedule,20.24,25.25,
Repl batt alkaline 1.5 v,K0603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.09,,,,,,,fee schedule,1.82,2.27,
Repl batt alkaline 1.5 v,K0603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.27,,,,,,,fee schedule,1.82,2.27,
Repl batt alkaline 1.5 v,K0603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.82,,,,,,,fee schedule,1.82,2.27,
Repl batt alkaline 1.5 v,K0603,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.99,,,,,,,fee schedule,1.82,2.27,
Repl batt lithium 3.6 v,K0604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22.24,,,,,,,fee schedule,19.36,24.15,
Repl batt lithium 3.6 v,K0604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24.15,,,,,,,fee schedule,19.36,24.15,
Repl batt lithium 3.6 v,K0604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19.36,,,,,,,fee schedule,19.36,24.15,
Repl batt lithium 3.6 v,K0604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21.15,,,,,,,fee schedule,19.36,24.15,
Repl batt lithium 4.5 v,K0605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,53.35,,,,,,,fee schedule,46.45,57.95,
Repl batt lithium 4.5 v,K0605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,57.95,,,,,,,fee schedule,46.45,57.95,
Repl batt lithium 4.5 v,K0605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.45,,,,,,,fee schedule,46.45,57.95,
Repl batt lithium 4.5 v,K0605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,50.74,,,,,,,fee schedule,46.45,57.95,
Aed garment w elec analysis,K0606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,87024.05,,,,,,,fee schedule,7216.28,94526.12,
Aed garment w elec analysis,K0606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8288,,,,,,,fee schedule,7216.28,94526.12,
Aed garment w elec analysis,K0606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,94526.12,,,,,,,fee schedule,7216.28,94526.12,
Aed garment w elec analysis,K0606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9002.49,,,,,,,fee schedule,7216.28,94526.12,
Aed garment w elec analysis,K0606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,75770.94,,,,,,,fee schedule,7216.28,94526.12,
Aed garment w elec analysis,K0606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7216.28,,,,,,,fee schedule,7216.28,94526.12,
Aed garment w elec analysis,K0606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,82772.87,,,,,,,fee schedule,7216.28,94526.12,
Aed garment w elec analysis,K0606,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7883.13,,,,,,,fee schedule,7216.28,94526.12,
Repl batt for aed,K0607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,709.71,,,,,,,fee schedule,61.81,770.89,
Repl batt for aed,K0607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,70.99,,,,,,,fee schedule,61.81,770.89,
Repl batt for aed,K0607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,532.27,,,,,,,fee schedule,61.81,770.89,
Repl batt for aed,K0607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,770.89,,,,,,,fee schedule,61.81,770.89,
Repl batt for aed,K0607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,77.11,,,,,,,fee schedule,61.81,770.89,
Repl batt for aed,K0607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,578.15,,,,,,,fee schedule,61.81,770.89,
Repl batt for aed,K0607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,617.94,,,,,,,fee schedule,61.81,770.89,
Repl batt for aed,K0607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,61.81,,,,,,,fee schedule,61.81,770.89,
Repl batt for aed,K0607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,463.44,,,,,,,fee schedule,61.81,770.89,
Repl batt for aed,K0607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,675.04,,,,,,,fee schedule,61.81,770.89,
Repl batt for aed,K0607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,67.52,,,,,,,fee schedule,61.81,770.89,
Repl batt for aed,K0607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,506.26,,,,,,,fee schedule,61.81,770.89,
Repl garment for AED,K0608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,442.9,,,,,,,fee schedule,38.63,481.08,
Repl garment for AED,K0608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,44.37,,,,,,,fee schedule,38.63,481.08,
Repl garment for AED,K0608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,332.2,,,,,,,fee schedule,38.63,481.08,
Repl garment for AED,K0608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,481.08,,,,,,,fee schedule,38.63,481.08,
Repl garment for AED,K0608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,48.2,,,,,,,fee schedule,38.63,481.08,
Repl garment for AED,K0608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,360.84,,,,,,,fee schedule,38.63,481.08,
Repl garment for AED,K0608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,385.63,,,,,,,fee schedule,38.63,481.08,
Repl garment for AED,K0608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38.63,,,,,,,fee schedule,38.63,481.08,
Repl garment for AED,K0608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,289.24,,,,,,,fee schedule,38.63,481.08,
Repl garment for AED,K0608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,421.26,,,,,,,fee schedule,38.63,481.08,
Repl garment for AED,K0608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.2,,,,,,,fee schedule,38.63,481.08,
Repl garment for AED,K0608,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,315.97,,,,,,,fee schedule,38.63,481.08,
Repl electrode for AED,K0609,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3270.19,,,,,,,fee schedule,2564.56,3552.1,
Repl electrode for AED,K0609,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2945.44,,,,,,,fee schedule,2564.56,3552.1,
Repl electrode for AED,K0609,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3552.1,,,,,,,fee schedule,2564.56,3552.1,
Repl electrode for AED,K0609,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3199.35,,,,,,,fee schedule,2564.56,3552.1,
Repl electrode for AED,K0609,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2847.32,,,,,,,fee schedule,2564.56,3552.1,
Repl electrode for AED,K0609,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2564.56,,,,,,,fee schedule,2564.56,3552.1,
Repl electrode for AED,K0609,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3110.44,,,,,,,fee schedule,2564.56,3552.1,
Repl electrode for AED,K0609,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2801.55,,,,,,,fee schedule,2564.56,3552.1,
Removable soft interface le,K0672,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,268.62,,,,,,,fee schedule,104.75,291.78,
Removable soft interface le,K0672,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,291.78,,,,,,,fee schedule,104.75,291.78,
Removable soft interface le,K0672,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,233.89,,,,,,,fee schedule,104.75,291.78,
Removable soft interface le,K0672,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,255.5,,,,,,,fee schedule,104.75,291.78,
Removable soft interface le,K0672,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,109.99,,,,,,,fee schedule,104.75,291.78,APC
Removable soft interface le,K0672,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,108.94,,,,,,,fee schedule,104.75,291.78,APC
Removable soft interface le,K0672,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,104.75,,,,,,,fee schedule,104.75,291.78,APC
Removable soft interface le,K0672,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,160.27,,,,,,,fee schedule,104.75,291.78,Radiology
Removable soft interface le,K0672,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,146.65,,,,,,,fee schedule,104.75,291.78,APC
Removable soft interface le,K0672,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,183.31,,,,,,,fee schedule,104.75,291.78,APC
Ctrl dose inh drug deliv sys,K0730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6299.57,,,,,,,fee schedule,548.49,6842.63,
Ctrl dose inh drug deliv sys,K0730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,629.95,,,,,,,fee schedule,548.49,6842.63,
Ctrl dose inh drug deliv sys,K0730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4724.66,,,,,,,fee schedule,548.49,6842.63,
Ctrl dose inh drug deliv sys,K0730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6842.63,,,,,,,fee schedule,548.49,6842.63,
Ctrl dose inh drug deliv sys,K0730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,684.26,,,,,,,fee schedule,548.49,6842.63,
Ctrl dose inh drug deliv sys,K0730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5131.95,,,,,,,fee schedule,548.49,6842.63,
Ctrl dose inh drug deliv sys,K0730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5484.97,,,,,,,fee schedule,548.49,6842.63,
Ctrl dose inh drug deliv sys,K0730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,548.49,,,,,,,fee schedule,548.49,6842.63,
Ctrl dose inh drug deliv sys,K0730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4113.71,,,,,,,fee schedule,548.49,6842.63,
Ctrl dose inh drug deliv sys,K0730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5991.83,,,,,,,fee schedule,548.49,6842.63,
Ctrl dose inh drug deliv sys,K0730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,599.18,,,,,,,fee schedule,548.49,6842.63,
Ctrl dose inh drug deliv sys,K0730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4493.85,,,,,,,fee schedule,548.49,6842.63,
12-24hr sealed lead acid,K0733,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,95.14,,,,,,,fee schedule,8.33,103.35,
12-24hr sealed lead acid,K0733,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.57,,,,,,,fee schedule,8.33,103.35,
12-24hr sealed lead acid,K0733,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,71.41,,,,,,,fee schedule,8.33,103.35,
12-24hr sealed lead acid,K0733,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,103.35,,,,,,,fee schedule,8.33,103.35,
12-24hr sealed lead acid,K0733,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10.4,,,,,,,fee schedule,8.33,103.35,
12-24hr sealed lead acid,K0733,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,77.57,,,,,,,fee schedule,8.33,103.35,
12-24hr sealed lead acid,K0733,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,82.84,,,,,,,fee schedule,8.33,103.35,
12-24hr sealed lead acid,K0733,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.33,,,,,,,fee schedule,8.33,103.35,
12-24hr sealed lead acid,K0733,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,62.18,,,,,,,fee schedule,8.33,103.35,
12-24hr sealed lead acid,K0733,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,90.5,,,,,,,fee schedule,8.33,103.35,
12-24hr sealed lead acid,K0733,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.1,,,,,,,fee schedule,8.33,103.35,
12-24hr sealed lead acid,K0733,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,67.92,,,,,,,fee schedule,8.33,103.35,
Portable gas oxygen system,K0738,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,179.67,,,,,,,fee schedule,156.44,195.16,
Portable gas oxygen system,K0738,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,195.16,,,,,,,fee schedule,156.44,195.16,
Portable gas oxygen system,K0738,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,156.44,,,,,,,fee schedule,156.44,195.16,
Portable gas oxygen system,K0738,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,170.9,,,,,,,fee schedule,156.44,195.16,
Pov group 1 std up to 300lbs,K0800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4071.46,,,,,,,fee schedule,354.51,4422.45,
Pov group 1 std up to 300lbs,K0800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,407.16,,,,,,,fee schedule,354.51,4422.45,
Pov group 1 std up to 300lbs,K0800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3053.6,,,,,,,fee schedule,354.51,4422.45,
Pov group 1 std up to 300lbs,K0800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4422.45,,,,,,,fee schedule,354.51,4422.45,
Pov group 1 std up to 300lbs,K0800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,442.26,,,,,,,fee schedule,354.51,4422.45,
Pov group 1 std up to 300lbs,K0800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3316.84,,,,,,,fee schedule,354.51,4422.45,
Pov group 1 std up to 300lbs,K0800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3544.98,,,,,,,fee schedule,354.51,4422.45,
Pov group 1 std up to 300lbs,K0800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,354.51,,,,,,,fee schedule,354.51,4422.45,
Pov group 1 std up to 300lbs,K0800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2658.73,,,,,,,fee schedule,354.51,4422.45,
Pov group 1 std up to 300lbs,K0800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3872.57,,,,,,,fee schedule,354.51,4422.45,
Pov group 1 std up to 300lbs,K0800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,387.27,,,,,,,fee schedule,354.51,4422.45,
Pov group 1 std up to 300lbs,K0800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2904.43,,,,,,,fee schedule,354.51,4422.45,
POV group 1 hd 301-450 lbs,K0801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6564.05,,,,,,,fee schedule,571.46,7129.91,
POV group 1 hd 301-450 lbs,K0801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,656.33,,,,,,,fee schedule,571.46,7129.91,
POV group 1 hd 301-450 lbs,K0801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4922.98,,,,,,,fee schedule,571.46,7129.91,
POV group 1 hd 301-450 lbs,K0801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7129.91,,,,,,,fee schedule,571.46,7129.91,
POV group 1 hd 301-450 lbs,K0801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,712.91,,,,,,,fee schedule,571.46,7129.91,
POV group 1 hd 301-450 lbs,K0801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5347.38,,,,,,,fee schedule,571.46,7129.91,
POV group 1 hd 301-450 lbs,K0801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5715.25,,,,,,,fee schedule,571.46,7129.91,
POV group 1 hd 301-450 lbs,K0801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,571.46,,,,,,,fee schedule,571.46,7129.91,
POV group 1 hd 301-450 lbs,K0801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4286.39,,,,,,,fee schedule,571.46,7129.91,
POV group 1 hd 301-450 lbs,K0801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6243.39,,,,,,,fee schedule,571.46,7129.91,
POV group 1 hd 301-450 lbs,K0801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,624.27,,,,,,,fee schedule,571.46,7129.91,
POV group 1 hd 301-450 lbs,K0801,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4682.49,,,,,,,fee schedule,571.46,7129.91,
POV group 1 vhd 451-600 lbs,K0802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7428.37,,,,,,,fee schedule,646.75,8068.75,
POV group 1 vhd 451-600 lbs,K0802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,742.81,,,,,,,fee schedule,646.75,8068.75,
POV group 1 vhd 451-600 lbs,K0802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5571.31,,,,,,,fee schedule,646.75,8068.75,
POV group 1 vhd 451-600 lbs,K0802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8068.75,,,,,,,fee schedule,646.75,8068.75,
POV group 1 vhd 451-600 lbs,K0802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,806.84,,,,,,,fee schedule,646.75,8068.75,
POV group 1 vhd 451-600 lbs,K0802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6051.59,,,,,,,fee schedule,646.75,8068.75,
POV group 1 vhd 451-600 lbs,K0802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6467.81,,,,,,,fee schedule,646.75,8068.75,
POV group 1 vhd 451-600 lbs,K0802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,646.75,,,,,,,fee schedule,646.75,8068.75,
POV group 1 vhd 451-600 lbs,K0802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4850.88,,,,,,,fee schedule,646.75,8068.75,
POV group 1 vhd 451-600 lbs,K0802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7065.49,,,,,,,fee schedule,646.75,8068.75,
POV group 1 vhd 451-600 lbs,K0802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,706.52,,,,,,,fee schedule,646.75,8068.75,
POV group 1 vhd 451-600 lbs,K0802,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5299.14,,,,,,,fee schedule,646.75,8068.75,
POV group 2 std up to 300lbs,K0806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4925.38,,,,,,,fee schedule,428.84,5349.99,
POV group 2 std up to 300lbs,K0806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,492.52,,,,,,,fee schedule,428.84,5349.99,
POV group 2 std up to 300lbs,K0806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3694.02,,,,,,,fee schedule,428.84,5349.99,
POV group 2 std up to 300lbs,K0806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5349.99,,,,,,,fee schedule,428.84,5349.99,
POV group 2 std up to 300lbs,K0806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,534.98,,,,,,,fee schedule,428.84,5349.99,
POV group 2 std up to 300lbs,K0806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4012.47,,,,,,,fee schedule,428.84,5349.99,
POV group 2 std up to 300lbs,K0806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4288.48,,,,,,,fee schedule,428.84,5349.99,
POV group 2 std up to 300lbs,K0806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,428.84,,,,,,,fee schedule,428.84,5349.99,
POV group 2 std up to 300lbs,K0806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3216.35,,,,,,,fee schedule,428.84,5349.99,
POV group 2 std up to 300lbs,K0806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4684.78,,,,,,,fee schedule,428.84,5349.99,
POV group 2 std up to 300lbs,K0806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,468.46,,,,,,,fee schedule,428.84,5349.99,
POV group 2 std up to 300lbs,K0806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3513.57,,,,,,,fee schedule,428.84,5349.99,
POV group 2 hd 301-450 lbs,K0807,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7473.68,,,,,,,fee schedule,650.72,8117.97,
POV group 2 hd 301-450 lbs,K0807,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,747.36,,,,,,,fee schedule,650.72,8117.97,
POV group 2 hd 301-450 lbs,K0807,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5605.31,,,,,,,fee schedule,650.72,8117.97,
POV group 2 hd 301-450 lbs,K0807,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8117.97,,,,,,,fee schedule,650.72,8117.97,
POV group 2 hd 301-450 lbs,K0807,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,811.79,,,,,,,fee schedule,650.72,8117.97,
POV group 2 hd 301-450 lbs,K0807,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6088.52,,,,,,,fee schedule,650.72,8117.97,
POV group 2 hd 301-450 lbs,K0807,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6507.26,,,,,,,fee schedule,650.72,8117.97,
POV group 2 hd 301-450 lbs,K0807,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,650.72,,,,,,,fee schedule,650.72,8117.97,
POV group 2 hd 301-450 lbs,K0807,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4880.48,,,,,,,fee schedule,650.72,8117.97,
POV group 2 hd 301-450 lbs,K0807,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7108.59,,,,,,,fee schedule,650.72,8117.97,
POV group 2 hd 301-450 lbs,K0807,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,710.86,,,,,,,fee schedule,650.72,8117.97,
POV group 2 hd 301-450 lbs,K0807,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5331.48,,,,,,,fee schedule,650.72,8117.97,
POV group 2 vhd 451-600 lbs,K0808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11563.34,,,,,,,fee schedule,1006.78,12560.18,
POV group 2 vhd 451-600 lbs,K0808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1156.3,,,,,,,fee schedule,1006.78,12560.18,
POV group 2 vhd 451-600 lbs,K0808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8672.47,,,,,,,fee schedule,1006.78,12560.18,
POV group 2 vhd 451-600 lbs,K0808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12560.18,,,,,,,fee schedule,1006.78,12560.18,
POV group 2 vhd 451-600 lbs,K0808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1255.98,,,,,,,fee schedule,1006.78,12560.18,
POV group 2 vhd 451-600 lbs,K0808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9420.1,,,,,,,fee schedule,1006.78,12560.18,
POV group 2 vhd 451-600 lbs,K0808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10068.08,,,,,,,fee schedule,1006.78,12560.18,
POV group 2 vhd 451-600 lbs,K0808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1006.78,,,,,,,fee schedule,1006.78,12560.18,
POV group 2 vhd 451-600 lbs,K0808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7551.03,,,,,,,fee schedule,1006.78,12560.18,
POV group 2 vhd 451-600 lbs,K0808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10998.47,,,,,,,fee schedule,1006.78,12560.18,
POV group 2 vhd 451-600 lbs,K0808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1099.81,,,,,,,fee schedule,1006.78,12560.18,
POV group 2 vhd 451-600 lbs,K0808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8248.82,,,,,,,fee schedule,1006.78,12560.18,
PWC gp 1 std port seat/back,K0813,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7977.41,,,,,,,fee schedule,661.51,8665.12,
PWC gp 1 std port seat/back,K0813,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,759.75,,,,,,,fee schedule,661.51,8665.12,
PWC gp 1 std port seat/back,K0813,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8665.12,,,,,,,fee schedule,661.51,8665.12,
PWC gp 1 std port seat/back,K0813,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,825.25,,,,,,,fee schedule,661.51,8665.12,
PWC gp 1 std port seat/back,K0813,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6945.85,,,,,,,fee schedule,661.51,8665.12,
PWC gp 1 std port seat/back,K0813,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,661.51,,,,,,,fee schedule,661.51,8665.12,
PWC gp 1 std port seat/back,K0813,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7587.71,,,,,,,fee schedule,661.51,8665.12,
PWC gp 1 std port seat/back,K0813,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,722.64,,,,,,,fee schedule,661.51,8665.12,
PWC gp 1 std port cap chair,K0814,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10211.12,,,,,,,fee schedule,846.73,11091.39,
PWC gp 1 std port cap chair,K0814,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,972.49,,,,,,,fee schedule,846.73,11091.39,
PWC gp 1 std port cap chair,K0814,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11091.39,,,,,,,fee schedule,846.73,11091.39,
PWC gp 1 std port cap chair,K0814,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1056.32,,,,,,,fee schedule,846.73,11091.39,
PWC gp 1 std port cap chair,K0814,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8890.72,,,,,,,fee schedule,846.73,11091.39,
PWC gp 1 std port cap chair,K0814,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,846.73,,,,,,,fee schedule,846.73,11091.39,
PWC gp 1 std port cap chair,K0814,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9712.3,,,,,,,fee schedule,846.73,11091.39,
PWC gp 1 std port cap chair,K0814,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,924.98,,,,,,,fee schedule,846.73,11091.39,
PWC gp 1 std seat/back,K0815,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11628.14,,,,,,,fee schedule,964.24,12630.57,
PWC gp 1 std seat/back,K0815,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1107.44,,,,,,,fee schedule,964.24,12630.57,
PWC gp 1 std seat/back,K0815,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12630.57,,,,,,,fee schedule,964.24,12630.57,
PWC gp 1 std seat/back,K0815,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1202.91,,,,,,,fee schedule,964.24,12630.57,
PWC gp 1 std seat/back,K0815,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10124.5,,,,,,,fee schedule,964.24,12630.57,
PWC gp 1 std seat/back,K0815,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,964.24,,,,,,,fee schedule,964.24,12630.57,
PWC gp 1 std seat/back,K0815,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11060.1,,,,,,,fee schedule,964.24,12630.57,
PWC gp 1 std seat/back,K0815,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1053.34,,,,,,,fee schedule,964.24,12630.57,
PWC gp 1 std cap chair,K0816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11135.58,,,,,,,fee schedule,923.39,12095.55,
PWC gp 1 std cap chair,K0816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1060.53,,,,,,,fee schedule,923.39,12095.55,
PWC gp 1 std cap chair,K0816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12095.55,,,,,,,fee schedule,923.39,12095.55,
PWC gp 1 std cap chair,K0816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1151.96,,,,,,,fee schedule,923.39,12095.55,
PWC gp 1 std cap chair,K0816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9695.64,,,,,,,fee schedule,923.39,12095.55,
PWC gp 1 std cap chair,K0816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,923.39,,,,,,,fee schedule,923.39,12095.55,
PWC gp 1 std cap chair,K0816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10591.6,,,,,,,fee schedule,923.39,12095.55,
PWC gp 1 std cap chair,K0816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1008.72,,,,,,,fee schedule,923.39,12095.55,
PWC gp 2 std port seat/back,K0820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8520.4,,,,,,,fee schedule,706.54,9254.91,
PWC gp 2 std port seat/back,K0820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,811.47,,,,,,,fee schedule,706.54,9254.91,
PWC gp 2 std port seat/back,K0820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9254.91,,,,,,,fee schedule,706.54,9254.91,
PWC gp 2 std port seat/back,K0820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,881.42,,,,,,,fee schedule,706.54,9254.91,
PWC gp 2 std port seat/back,K0820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7418.62,,,,,,,fee schedule,706.54,9254.91,
PWC gp 2 std port seat/back,K0820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,706.54,,,,,,,fee schedule,706.54,9254.91,
PWC gp 2 std port seat/back,K0820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8104.17,,,,,,,fee schedule,706.54,9254.91,
PWC gp 2 std port seat/back,K0820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,771.83,,,,,,,fee schedule,706.54,9254.91,
PWC gp 2 std port cap chair,K0821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10938.27,,,,,,,fee schedule,907.03,11881.22,
PWC gp 2 std port cap chair,K0821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1041.74,,,,,,,fee schedule,907.03,11881.22,
PWC gp 2 std port cap chair,K0821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11881.22,,,,,,,fee schedule,907.03,11881.22,
PWC gp 2 std port cap chair,K0821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1131.54,,,,,,,fee schedule,907.03,11881.22,
PWC gp 2 std port cap chair,K0821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9523.84,,,,,,,fee schedule,907.03,11881.22,
PWC gp 2 std port cap chair,K0821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,907.03,,,,,,,fee schedule,907.03,11881.22,
PWC gp 2 std port cap chair,K0821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10403.93,,,,,,,fee schedule,907.03,11881.22,
PWC gp 2 std port cap chair,K0821,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,990.85,,,,,,,fee schedule,907.03,11881.22,
PWC gp 2 std seat/back,K0822,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13219.06,,,,,,,fee schedule,1096.16,14358.63,
PWC gp 2 std seat/back,K0822,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1258.96,,,,,,,fee schedule,1096.16,14358.63,
PWC gp 2 std seat/back,K0822,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14358.63,,,,,,,fee schedule,1096.16,14358.63,
PWC gp 2 std seat/back,K0822,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1367.49,,,,,,,fee schedule,1096.16,14358.63,
PWC gp 2 std seat/back,K0822,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11509.7,,,,,,,fee schedule,1096.16,14358.63,
PWC gp 2 std seat/back,K0822,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1096.16,,,,,,,fee schedule,1096.16,14358.63,
PWC gp 2 std seat/back,K0822,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12573.3,,,,,,,fee schedule,1096.16,14358.63,
PWC gp 2 std seat/back,K0822,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1197.46,,,,,,,fee schedule,1096.16,14358.63,
PWC gp 2 std cap chair,K0823,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13305.68,,,,,,,fee schedule,1103.34,14452.72,
PWC gp 2 std cap chair,K0823,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1267.21,,,,,,,fee schedule,1103.34,14452.72,
PWC gp 2 std cap chair,K0823,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14452.72,,,,,,,fee schedule,1103.34,14452.72,
PWC gp 2 std cap chair,K0823,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1376.45,,,,,,,fee schedule,1103.34,14452.72,
PWC gp 2 std cap chair,K0823,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11585.11,,,,,,,fee schedule,1103.34,14452.72,
PWC gp 2 std cap chair,K0823,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1103.34,,,,,,,fee schedule,1103.34,14452.72,
PWC gp 2 std cap chair,K0823,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12655.69,,,,,,,fee schedule,1103.34,14452.72,
PWC gp 2 std cap chair,K0823,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1205.3,,,,,,,fee schedule,1103.34,14452.72,
PWC gp 2 hd seat/back,K0824,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16014.02,,,,,,,fee schedule,1327.93,17394.54,
PWC gp 2 hd seat/back,K0824,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1525.14,,,,,,,fee schedule,1327.93,17394.54,
PWC gp 2 hd seat/back,K0824,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17394.54,,,,,,,fee schedule,1327.93,17394.54,
PWC gp 2 hd seat/back,K0824,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1656.62,,,,,,,fee schedule,1327.93,17394.54,
PWC gp 2 hd seat/back,K0824,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13943.24,,,,,,,fee schedule,1327.93,17394.54,
PWC gp 2 hd seat/back,K0824,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1327.93,,,,,,,fee schedule,1327.93,17394.54,
PWC gp 2 hd seat/back,K0824,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15231.73,,,,,,,fee schedule,1327.93,17394.54,
PWC gp 2 hd seat/back,K0824,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1450.64,,,,,,,fee schedule,1327.93,17394.54,
PWC gp 2 hd cap chair,K0825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14659.85,,,,,,,fee schedule,1215.64,15923.63,
PWC gp 2 hd cap chair,K0825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1396.18,,,,,,,fee schedule,1215.64,15923.63,
PWC gp 2 hd cap chair,K0825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15923.63,,,,,,,fee schedule,1215.64,15923.63,
PWC gp 2 hd cap chair,K0825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1516.54,,,,,,,fee schedule,1215.64,15923.63,
PWC gp 2 hd cap chair,K0825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12764.18,,,,,,,fee schedule,1215.64,15923.63,
PWC gp 2 hd cap chair,K0825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1215.64,,,,,,,fee schedule,1215.64,15923.63,
PWC gp 2 hd cap chair,K0825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13943.71,,,,,,,fee schedule,1215.64,15923.63,
PWC gp 2 hd cap chair,K0825,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1327.97,,,,,,,fee schedule,1215.64,15923.63,
Pwc gp 2 vhd seat/back,K0826,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20731.68,,,,,,,fee schedule,1719.13,22518.9,
Pwc gp 2 vhd seat/back,K0826,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1974.45,,,,,,,fee schedule,1719.13,22518.9,
Pwc gp 2 vhd seat/back,K0826,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22518.9,,,,,,,fee schedule,1719.13,22518.9,
Pwc gp 2 vhd seat/back,K0826,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2144.66,,,,,,,fee schedule,1719.13,22518.9,
Pwc gp 2 vhd seat/back,K0826,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18050.86,,,,,,,fee schedule,1719.13,22518.9,
Pwc gp 2 vhd seat/back,K0826,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1719.13,,,,,,,fee schedule,1719.13,22518.9,
Pwc gp 2 vhd seat/back,K0826,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19718.93,,,,,,,fee schedule,1719.13,22518.9,
Pwc gp 2 vhd seat/back,K0826,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1877.99,,,,,,,fee schedule,1719.13,22518.9,
Pwc gp vhd cap chair,K0827,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17628.74,,,,,,,fee schedule,1461.82,19148.46,
Pwc gp vhd cap chair,K0827,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1678.93,,,,,,,fee schedule,1461.82,19148.46,
Pwc gp vhd cap chair,K0827,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19148.46,,,,,,,fee schedule,1461.82,19148.46,
Pwc gp vhd cap chair,K0827,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1823.66,,,,,,,fee schedule,1461.82,19148.46,
Pwc gp vhd cap chair,K0827,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15349.16,,,,,,,fee schedule,1461.82,19148.46,
Pwc gp vhd cap chair,K0827,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1461.82,,,,,,,fee schedule,1461.82,19148.46,
Pwc gp vhd cap chair,K0827,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16767.57,,,,,,,fee schedule,1461.82,19148.46,
Pwc gp vhd cap chair,K0827,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1596.91,,,,,,,fee schedule,1461.82,19148.46,
PWC gp 2 xtra hd seat/back,K0828,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22844.46,,,,,,,fee schedule,1894.33,24813.81,
PWC gp 2 xtra hd seat/back,K0828,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2175.66,,,,,,,fee schedule,1894.33,24813.81,
PWC gp 2 xtra hd seat/back,K0828,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24813.81,,,,,,,fee schedule,1894.33,24813.81,
PWC gp 2 xtra hd seat/back,K0828,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2363.22,,,,,,,fee schedule,1894.33,24813.81,
PWC gp 2 xtra hd seat/back,K0828,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19890.44,,,,,,,fee schedule,1894.33,24813.81,
PWC gp 2 xtra hd seat/back,K0828,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1894.33,,,,,,,fee schedule,1894.33,24813.81,
PWC gp 2 xtra hd seat/back,K0828,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21728.5,,,,,,,fee schedule,1894.33,24813.81,
PWC gp 2 xtra hd seat/back,K0828,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2069.38,,,,,,,fee schedule,1894.33,24813.81,
PWC gp 2 xtra hd cap chair,K0829,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20977.61,,,,,,,fee schedule,1739.52,22786.03,
PWC gp 2 xtra hd cap chair,K0829,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1997.87,,,,,,,fee schedule,1739.52,22786.03,
PWC gp 2 xtra hd cap chair,K0829,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22786.03,,,,,,,fee schedule,1739.52,22786.03,
PWC gp 2 xtra hd cap chair,K0829,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2170.1,,,,,,,fee schedule,1739.52,22786.03,
PWC gp 2 xtra hd cap chair,K0829,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18264.99,,,,,,,fee schedule,1739.52,22786.03,
PWC gp 2 xtra hd cap chair,K0829,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1739.52,,,,,,,fee schedule,1739.52,22786.03,
PWC gp 2 xtra hd cap chair,K0829,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19952.85,,,,,,,fee schedule,1739.52,22786.03,
PWC gp 2 xtra hd cap chair,K0829,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1900.27,,,,,,,fee schedule,1739.52,22786.03,
PWC gp2 std sing pow opt s/b,K0835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13417.14,,,,,,,fee schedule,1112.59,14573.79,
PWC gp2 std sing pow opt s/b,K0835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1277.82,,,,,,,fee schedule,1112.59,14573.79,
PWC gp2 std sing pow opt s/b,K0835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14573.79,,,,,,,fee schedule,1112.59,14573.79,
PWC gp2 std sing pow opt s/b,K0835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1387.98,,,,,,,fee schedule,1112.59,14573.79,
PWC gp2 std sing pow opt s/b,K0835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11682.17,,,,,,,fee schedule,1112.59,14573.79,
PWC gp2 std sing pow opt s/b,K0835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1112.59,,,,,,,fee schedule,1112.59,14573.79,
PWC gp2 std sing pow opt s/b,K0835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12761.71,,,,,,,fee schedule,1112.59,14573.79,
PWC gp2 std sing pow opt s/b,K0835,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1215.4,,,,,,,fee schedule,1112.59,14573.79,
PWC gp2 std sing pow opt cap,K0836,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13913.7,,,,,,,fee schedule,1153.76,15113.16,
PWC gp2 std sing pow opt cap,K0836,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1325.11,,,,,,,fee schedule,1153.76,15113.16,
PWC gp2 std sing pow opt cap,K0836,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15113.16,,,,,,,fee schedule,1153.76,15113.16,
PWC gp2 std sing pow opt cap,K0836,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1439.35,,,,,,,fee schedule,1153.76,15113.16,
PWC gp2 std sing pow opt cap,K0836,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12114.52,,,,,,,fee schedule,1153.76,15113.16,
PWC gp2 std sing pow opt cap,K0836,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1153.76,,,,,,,fee schedule,1153.76,15113.16,
PWC gp2 std sing pow opt cap,K0836,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13234.01,,,,,,,fee schedule,1153.76,15113.16,
PWC gp2 std sing pow opt cap,K0836,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1260.38,,,,,,,fee schedule,1153.76,15113.16,
PWC gp 2 hd sing pow opt s/b,K0837,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16014.02,,,,,,,fee schedule,1327.93,17394.54,
PWC gp 2 hd sing pow opt s/b,K0837,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1525.14,,,,,,,fee schedule,1327.93,17394.54,
PWC gp 2 hd sing pow opt s/b,K0837,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17394.54,,,,,,,fee schedule,1327.93,17394.54,
PWC gp 2 hd sing pow opt s/b,K0837,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1656.62,,,,,,,fee schedule,1327.93,17394.54,
PWC gp 2 hd sing pow opt s/b,K0837,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13943.24,,,,,,,fee schedule,1327.93,17394.54,
PWC gp 2 hd sing pow opt s/b,K0837,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1327.93,,,,,,,fee schedule,1327.93,17394.54,
PWC gp 2 hd sing pow opt s/b,K0837,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15231.73,,,,,,,fee schedule,1327.93,17394.54,
PWC gp 2 hd sing pow opt s/b,K0837,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1450.64,,,,,,,fee schedule,1327.93,17394.54,
PWC gp 2 hd sing pow opt cap,K0838,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14326.26,,,,,,,fee schedule,1187.97,15561.28,
PWC gp 2 hd sing pow opt cap,K0838,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1364.4,,,,,,,fee schedule,1187.97,15561.28,
PWC gp 2 hd sing pow opt cap,K0838,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15561.28,,,,,,,fee schedule,1187.97,15561.28,
PWC gp 2 hd sing pow opt cap,K0838,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1482.02,,,,,,,fee schedule,1187.97,15561.28,
PWC gp 2 hd sing pow opt cap,K0838,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12473.72,,,,,,,fee schedule,1187.97,15561.28,
PWC gp 2 hd sing pow opt cap,K0838,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1187.97,,,,,,,fee schedule,1187.97,15561.28,
PWC gp 2 hd sing pow opt cap,K0838,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13626.41,,,,,,,fee schedule,1187.97,15561.28,
PWC gp 2 hd sing pow opt cap,K0838,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1297.75,,,,,,,fee schedule,1187.97,15561.28,
PWC gp2 vhd sing pow opt s/b,K0839,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20731.68,,,,,,,fee schedule,1719.13,22518.9,
PWC gp2 vhd sing pow opt s/b,K0839,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1974.45,,,,,,,fee schedule,1719.13,22518.9,
PWC gp2 vhd sing pow opt s/b,K0839,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22518.9,,,,,,,fee schedule,1719.13,22518.9,
PWC gp2 vhd sing pow opt s/b,K0839,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2144.66,,,,,,,fee schedule,1719.13,22518.9,
PWC gp2 vhd sing pow opt s/b,K0839,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18050.86,,,,,,,fee schedule,1719.13,22518.9,
PWC gp2 vhd sing pow opt s/b,K0839,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1719.13,,,,,,,fee schedule,1719.13,22518.9,
PWC gp2 vhd sing pow opt s/b,K0839,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19718.93,,,,,,,fee schedule,1719.13,22518.9,
PWC gp2 vhd sing pow opt s/b,K0839,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1877.99,,,,,,,fee schedule,1719.13,22518.9,
PWC gp2 xhd sing pow opt s/b,K0840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,31409.78,,,,,,,fee schedule,2604.59,34117.52,
PWC gp2 xhd sing pow opt s/b,K0840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2991.41,,,,,,,fee schedule,2604.59,34117.52,
PWC gp2 xhd sing pow opt s/b,K0840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,34117.52,,,,,,,fee schedule,2604.59,34117.52,
PWC gp2 xhd sing pow opt s/b,K0840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3249.29,,,,,,,fee schedule,2604.59,34117.52,
PWC gp2 xhd sing pow opt s/b,K0840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,27348.17,,,,,,,fee schedule,2604.59,34117.52,
PWC gp2 xhd sing pow opt s/b,K0840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2604.59,,,,,,,fee schedule,2604.59,34117.52,
PWC gp2 xhd sing pow opt s/b,K0840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29875.4,,,,,,,fee schedule,2604.59,34117.52,
PWC gp2 xhd sing pow opt s/b,K0840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2845.28,,,,,,,fee schedule,2604.59,34117.52,
PWC gp2 std mult pow opt s/b,K0841,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14280.91,,,,,,,fee schedule,1184.21,15512.02,
PWC gp2 std mult pow opt s/b,K0841,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1360.09,,,,,,,fee schedule,1184.21,15512.02,
PWC gp2 std mult pow opt s/b,K0841,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15512.02,,,,,,,fee schedule,1184.21,15512.02,
PWC gp2 std mult pow opt s/b,K0841,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1477.34,,,,,,,fee schedule,1184.21,15512.02,
PWC gp2 std mult pow opt s/b,K0841,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12434.24,,,,,,,fee schedule,1184.21,15512.02,
PWC gp2 std mult pow opt s/b,K0841,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1184.21,,,,,,,fee schedule,1184.21,15512.02,
PWC gp2 std mult pow opt s/b,K0841,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13583.28,,,,,,,fee schedule,1184.21,15512.02,
PWC gp2 std mult pow opt s/b,K0841,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1293.65,,,,,,,fee schedule,1184.21,15512.02,
PWC gp2 std mult pow opt cap,K0842,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14280.91,,,,,,,fee schedule,1184.21,15512.02,
PWC gp2 std mult pow opt cap,K0842,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1360.09,,,,,,,fee schedule,1184.21,15512.02,
PWC gp2 std mult pow opt cap,K0842,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15512.02,,,,,,,fee schedule,1184.21,15512.02,
PWC gp2 std mult pow opt cap,K0842,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1477.34,,,,,,,fee schedule,1184.21,15512.02,
PWC gp2 std mult pow opt cap,K0842,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12434.24,,,,,,,fee schedule,1184.21,15512.02,
PWC gp2 std mult pow opt cap,K0842,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1184.21,,,,,,,fee schedule,1184.21,15512.02,
PWC gp2 std mult pow opt cap,K0842,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13583.28,,,,,,,fee schedule,1184.21,15512.02,
PWC gp2 std mult pow opt cap,K0842,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1293.65,,,,,,,fee schedule,1184.21,15512.02,
PWC gp2 hd mult pow opt s/b,K0843,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17194.26,,,,,,,fee schedule,1425.8,18676.53,
PWC gp2 hd mult pow opt s/b,K0843,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1637.55,,,,,,,fee schedule,1425.8,18676.53,
PWC gp2 hd mult pow opt s/b,K0843,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18676.53,,,,,,,fee schedule,1425.8,18676.53,
PWC gp2 hd mult pow opt s/b,K0843,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1778.72,,,,,,,fee schedule,1425.8,18676.53,
PWC gp2 hd mult pow opt s/b,K0843,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14970.87,,,,,,,fee schedule,1425.8,18676.53,
PWC gp2 hd mult pow opt s/b,K0843,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1425.8,,,,,,,fee schedule,1425.8,18676.53,
PWC gp2 hd mult pow opt s/b,K0843,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16354.31,,,,,,,fee schedule,1425.8,18676.53,
PWC gp2 hd mult pow opt s/b,K0843,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1557.55,,,,,,,fee schedule,1425.8,18676.53,
PWC gp 3 std seat/back,K0848,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17474.89,,,,,,,fee schedule,1449.07,18981.35,
PWC gp 3 std seat/back,K0848,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1664.28,,,,,,,fee schedule,1449.07,18981.35,
PWC gp 3 std seat/back,K0848,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18981.35,,,,,,,fee schedule,1449.07,18981.35,
PWC gp 3 std seat/back,K0848,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1807.75,,,,,,,fee schedule,1449.07,18981.35,
PWC gp 3 std seat/back,K0848,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15215.21,,,,,,,fee schedule,1449.07,18981.35,
PWC gp 3 std seat/back,K0848,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1449.07,,,,,,,fee schedule,1449.07,18981.35,
PWC gp 3 std seat/back,K0848,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16621.23,,,,,,,fee schedule,1449.07,18981.35,
PWC gp 3 std seat/back,K0848,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1582.97,,,,,,,fee schedule,1449.07,18981.35,
PWC gp 3 std cap chair,K0849,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16801.09,,,,,,,fee schedule,1393.19,18249.46,
PWC gp 3 std cap chair,K0849,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1600.1,,,,,,,fee schedule,1393.19,18249.46,
PWC gp 3 std cap chair,K0849,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18249.46,,,,,,,fee schedule,1393.19,18249.46,
PWC gp 3 std cap chair,K0849,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1738.04,,,,,,,fee schedule,1393.19,18249.46,
PWC gp 3 std cap chair,K0849,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14628.54,,,,,,,fee schedule,1393.19,18249.46,
PWC gp 3 std cap chair,K0849,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1393.19,,,,,,,fee schedule,1393.19,18249.46,
PWC gp 3 std cap chair,K0849,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15980.35,,,,,,,fee schedule,1393.19,18249.46,
PWC gp 3 std cap chair,K0849,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1521.94,,,,,,,fee schedule,1393.19,18249.46,
PWC gp 3 hd seat/back,K0850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20270.58,,,,,,,fee schedule,1680.89,22018.05,
PWC gp 3 hd seat/back,K0850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1930.53,,,,,,,fee schedule,1680.89,22018.05,
PWC gp 3 hd seat/back,K0850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22018.05,,,,,,,fee schedule,1680.89,22018.05,
PWC gp 3 hd seat/back,K0850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2096.96,,,,,,,fee schedule,1680.89,22018.05,
PWC gp 3 hd seat/back,K0850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17649.39,,,,,,,fee schedule,1680.89,22018.05,
PWC gp 3 hd seat/back,K0850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1680.89,,,,,,,fee schedule,1680.89,22018.05,
PWC gp 3 hd seat/back,K0850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19280.35,,,,,,,fee schedule,1680.89,22018.05,
PWC gp 3 hd seat/back,K0850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1836.22,,,,,,,fee schedule,1680.89,22018.05,
PWC gp 3 hd cap chair,K0851,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19489.71,,,,,,,fee schedule,1616.14,21169.85,
PWC gp 3 hd cap chair,K0851,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1856.16,,,,,,,fee schedule,1616.14,21169.85,
PWC gp 3 hd cap chair,K0851,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21169.85,,,,,,,fee schedule,1616.14,21169.85,
PWC gp 3 hd cap chair,K0851,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2016.18,,,,,,,fee schedule,1616.14,21169.85,
PWC gp 3 hd cap chair,K0851,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16969.48,,,,,,,fee schedule,1616.14,21169.85,
PWC gp 3 hd cap chair,K0851,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1616.14,,,,,,,fee schedule,1616.14,21169.85,
PWC gp 3 hd cap chair,K0851,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18537.62,,,,,,,fee schedule,1616.14,21169.85,
PWC gp 3 hd cap chair,K0851,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1765.49,,,,,,,fee schedule,1616.14,21169.85,
PWC gp 3 vhd seat/back,K0852,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23421.41,,,,,,,fee schedule,1942.17,25440.5,
PWC gp 3 vhd seat/back,K0852,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2230.61,,,,,,,fee schedule,1942.17,25440.5,
PWC gp 3 vhd seat/back,K0852,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,25440.5,,,,,,,fee schedule,1942.17,25440.5,
PWC gp 3 vhd seat/back,K0852,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2422.9,,,,,,,fee schedule,1942.17,25440.5,
PWC gp 3 vhd seat/back,K0852,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20392.78,,,,,,,fee schedule,1942.17,25440.5,
PWC gp 3 vhd seat/back,K0852,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1942.17,,,,,,,fee schedule,1942.17,25440.5,
PWC gp 3 vhd seat/back,K0852,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22277.26,,,,,,,fee schedule,1942.17,25440.5,
PWC gp 3 vhd seat/back,K0852,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2121.64,,,,,,,fee schedule,1942.17,25440.5,
PWC gp 3 vhd cap chair,K0853,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24059.4,,,,,,,fee schedule,1995.07,26133.48,
PWC gp 3 vhd cap chair,K0853,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2291.37,,,,,,,fee schedule,1995.07,26133.48,
PWC gp 3 vhd cap chair,K0853,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26133.48,,,,,,,fee schedule,1995.07,26133.48,
PWC gp 3 vhd cap chair,K0853,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2488.9,,,,,,,fee schedule,1995.07,26133.48,
PWC gp 3 vhd cap chair,K0853,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20948.27,,,,,,,fee schedule,1995.07,26133.48,
PWC gp 3 vhd cap chair,K0853,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1995.07,,,,,,,fee schedule,1995.07,26133.48,
PWC gp 3 vhd cap chair,K0853,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22884.08,,,,,,,fee schedule,1995.07,26133.48,
PWC gp 3 vhd cap chair,K0853,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2179.44,,,,,,,fee schedule,1995.07,26133.48,
PWC gp 3 xhd seat/back,K0854,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,31873.46,,,,,,,fee schedule,2643.04,34621.17,
PWC gp 3 xhd seat/back,K0854,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3035.57,,,,,,,fee schedule,2643.04,34621.17,
PWC gp 3 xhd seat/back,K0854,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,34621.17,,,,,,,fee schedule,2643.04,34621.17,
PWC gp 3 xhd seat/back,K0854,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3297.26,,,,,,,fee schedule,2643.04,34621.17,
PWC gp 3 xhd seat/back,K0854,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,27751.89,,,,,,,fee schedule,2643.04,34621.17,
PWC gp 3 xhd seat/back,K0854,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2643.04,,,,,,,fee schedule,2643.04,34621.17,
PWC gp 3 xhd seat/back,K0854,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,30316.42,,,,,,,fee schedule,2643.04,34621.17,
PWC gp 3 xhd seat/back,K0854,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2887.28,,,,,,,fee schedule,2643.04,34621.17,
PWC gp 3 xhd cap chair,K0855,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30109.34,,,,,,,fee schedule,2496.75,32704.98,
PWC gp 3 xhd cap chair,K0855,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2867.55,,,,,,,fee schedule,2496.75,32704.98,
PWC gp 3 xhd cap chair,K0855,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,32704.98,,,,,,,fee schedule,2496.75,32704.98,
PWC gp 3 xhd cap chair,K0855,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3114.76,,,,,,,fee schedule,2496.75,32704.98,
PWC gp 3 xhd cap chair,K0855,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26215.89,,,,,,,fee schedule,2496.75,32704.98,
PWC gp 3 xhd cap chair,K0855,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2496.75,,,,,,,fee schedule,2496.75,32704.98,
PWC gp 3 xhd cap chair,K0855,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28638.48,,,,,,,fee schedule,2496.75,32704.98,
PWC gp 3 xhd cap chair,K0855,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2727.47,,,,,,,fee schedule,2496.75,32704.98,
PWC gp3 std sing pow opt s/b,K0856,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18757.44,,,,,,,fee schedule,1555.42,20374.46,
PWC gp3 std sing pow opt s/b,K0856,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1786.42,,,,,,,fee schedule,1555.42,20374.46,
PWC gp3 std sing pow opt s/b,K0856,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20374.46,,,,,,,fee schedule,1555.42,20374.46,
PWC gp3 std sing pow opt s/b,K0856,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1940.43,,,,,,,fee schedule,1555.42,20374.46,
PWC gp3 std sing pow opt s/b,K0856,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16331.91,,,,,,,fee schedule,1555.42,20374.46,
PWC gp3 std sing pow opt s/b,K0856,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1555.42,,,,,,,fee schedule,1555.42,20374.46,
PWC gp3 std sing pow opt s/b,K0856,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17841.13,,,,,,,fee schedule,1555.42,20374.46,
PWC gp3 std sing pow opt s/b,K0856,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1699.16,,,,,,,fee schedule,1555.42,20374.46,
PWC gp3 std sing pow opt cap,K0857,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19133.46,,,,,,,fee schedule,1586.6,20782.89,
PWC gp3 std sing pow opt cap,K0857,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1822.23,,,,,,,fee schedule,1586.6,20782.89,
PWC gp3 std sing pow opt cap,K0857,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20782.89,,,,,,,fee schedule,1586.6,20782.89,
PWC gp3 std sing pow opt cap,K0857,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1979.32,,,,,,,fee schedule,1586.6,20782.89,
PWC gp3 std sing pow opt cap,K0857,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16659.3,,,,,,,fee schedule,1586.6,20782.89,
PWC gp3 std sing pow opt cap,K0857,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1586.6,,,,,,,fee schedule,1586.6,20782.89,
PWC gp3 std sing pow opt cap,K0857,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18198.78,,,,,,,fee schedule,1586.6,20782.89,
PWC gp3 std sing pow opt cap,K0857,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1733.22,,,,,,,fee schedule,1586.6,20782.89,
PWC gp3 hd sing pow opt s/b,K0858,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23272.33,,,,,,,fee schedule,1929.81,25278.56,
PWC gp3 hd sing pow opt s/b,K0858,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2216.41,,,,,,,fee schedule,1929.81,25278.56,
PWC gp3 hd sing pow opt s/b,K0858,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,25278.56,,,,,,,fee schedule,1929.81,25278.56,
PWC gp3 hd sing pow opt s/b,K0858,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2407.48,,,,,,,fee schedule,1929.81,25278.56,
PWC gp3 hd sing pow opt s/b,K0858,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20262.97,,,,,,,fee schedule,1929.81,25278.56,
PWC gp3 hd sing pow opt s/b,K0858,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1929.81,,,,,,,fee schedule,1929.81,25278.56,
PWC gp3 hd sing pow opt s/b,K0858,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22135.46,,,,,,,fee schedule,1929.81,25278.56,
PWC gp3 hd sing pow opt s/b,K0858,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2108.14,,,,,,,fee schedule,1929.81,25278.56,
PWC gp3 hd sing pow opt cap,K0859,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22194.74,,,,,,,fee schedule,1840.45,24108.08,
PWC gp3 hd sing pow opt cap,K0859,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2113.79,,,,,,,fee schedule,1840.45,24108.08,
PWC gp3 hd sing pow opt cap,K0859,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24108.08,,,,,,,fee schedule,1840.45,24108.08,
PWC gp3 hd sing pow opt cap,K0859,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2296.01,,,,,,,fee schedule,1840.45,24108.08,
PWC gp3 hd sing pow opt cap,K0859,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19324.73,,,,,,,fee schedule,1840.45,24108.08,
PWC gp3 hd sing pow opt cap,K0859,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1840.45,,,,,,,fee schedule,1840.45,24108.08,
PWC gp3 hd sing pow opt cap,K0859,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21110.52,,,,,,,fee schedule,1840.45,24108.08,
PWC gp3 hd sing pow opt cap,K0859,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2010.53,,,,,,,fee schedule,1840.45,24108.08,
PWC gp3 vhd sing pow opt s/b,K0860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33247.75,,,,,,,fee schedule,2757,36113.93,
PWC gp3 vhd sing pow opt s/b,K0860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3166.45,,,,,,,fee schedule,2757,36113.93,
PWC gp3 vhd sing pow opt s/b,K0860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,36113.93,,,,,,,fee schedule,2757,36113.93,
PWC gp3 vhd sing pow opt s/b,K0860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3439.42,,,,,,,fee schedule,2757,36113.93,
PWC gp3 vhd sing pow opt s/b,K0860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28948.47,,,,,,,fee schedule,2757,36113.93,
PWC gp3 vhd sing pow opt s/b,K0860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2757,,,,,,,fee schedule,2757,36113.93,
PWC gp3 vhd sing pow opt s/b,K0860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31623.57,,,,,,,fee schedule,2757,36113.93,
PWC gp3 vhd sing pow opt s/b,K0860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3011.77,,,,,,,fee schedule,2757,36113.93,
PWC gp3 std mult pow opt s/b,K0861,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18787.75,,,,,,,fee schedule,1557.94,20407.39,
PWC gp3 std mult pow opt s/b,K0861,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1789.31,,,,,,,fee schedule,1557.94,20407.39,
PWC gp3 std mult pow opt s/b,K0861,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20407.39,,,,,,,fee schedule,1557.94,20407.39,
PWC gp3 std mult pow opt s/b,K0861,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1943.56,,,,,,,fee schedule,1557.94,20407.39,
PWC gp3 std mult pow opt s/b,K0861,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16358.3,,,,,,,fee schedule,1557.94,20407.39,
PWC gp3 std mult pow opt s/b,K0861,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1557.94,,,,,,,fee schedule,1557.94,20407.39,
PWC gp3 std mult pow opt s/b,K0861,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17869.96,,,,,,,fee schedule,1557.94,20407.39,
PWC gp3 std mult pow opt s/b,K0861,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1701.9,,,,,,,fee schedule,1557.94,20407.39,
PWC gp3 hd mult pow opt s/b,K0862,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23272.33,,,,,,,fee schedule,1929.81,25278.56,
PWC gp3 hd mult pow opt s/b,K0862,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2216.41,,,,,,,fee schedule,1929.81,25278.56,
PWC gp3 hd mult pow opt s/b,K0862,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,25278.56,,,,,,,fee schedule,1929.81,25278.56,
PWC gp3 hd mult pow opt s/b,K0862,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2407.48,,,,,,,fee schedule,1929.81,25278.56,
PWC gp3 hd mult pow opt s/b,K0862,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20262.97,,,,,,,fee schedule,1929.81,25278.56,
PWC gp3 hd mult pow opt s/b,K0862,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1929.81,,,,,,,fee schedule,1929.81,25278.56,
PWC gp3 hd mult pow opt s/b,K0862,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22135.46,,,,,,,fee schedule,1929.81,25278.56,
PWC gp3 hd mult pow opt s/b,K0862,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2108.14,,,,,,,fee schedule,1929.81,25278.56,
PWC gp3 vhd mult pow opt s/b,K0863,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,34639.75,,,,,,,fee schedule,2757,37625.93,
PWC gp3 vhd mult pow opt s/b,K0863,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3166.45,,,,,,,fee schedule,2757,37625.93,
PWC gp3 vhd mult pow opt s/b,K0863,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37625.93,,,,,,,fee schedule,2757,37625.93,
PWC gp3 vhd mult pow opt s/b,K0863,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3439.42,,,,,,,fee schedule,2757,37625.93,
PWC gp3 vhd mult pow opt s/b,K0863,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,30160.47,,,,,,,fee schedule,2757,37625.93,
PWC gp3 vhd mult pow opt s/b,K0863,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2757,,,,,,,fee schedule,2757,37625.93,
PWC gp3 vhd mult pow opt s/b,K0863,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32947.57,,,,,,,fee schedule,2757,37625.93,
PWC gp3 vhd mult pow opt s/b,K0863,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3011.77,,,,,,,fee schedule,2757,37625.93,
PWC gp3 xhd mult pow opt s/b,K0864,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,39565.16,,,,,,,fee schedule,3280.85,42975.95,
PWC gp3 xhd mult pow opt s/b,K0864,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3768.11,,,,,,,fee schedule,3280.85,42975.95,
PWC gp3 xhd mult pow opt s/b,K0864,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42975.95,,,,,,,fee schedule,3280.85,42975.95,
PWC gp3 xhd mult pow opt s/b,K0864,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4092.95,,,,,,,fee schedule,3280.85,42975.95,
PWC gp3 xhd mult pow opt s/b,K0864,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,34448.98,,,,,,,fee schedule,3280.85,42975.95,
PWC gp3 xhd mult pow opt s/b,K0864,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3280.85,,,,,,,fee schedule,3280.85,42975.95,
PWC gp3 xhd mult pow opt s/b,K0864,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37632.38,,,,,,,fee schedule,3280.85,42975.95,
PWC gp3 xhd mult pow opt s/b,K0864,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3584.03,,,,,,,fee schedule,3280.85,42975.95,
Cranial cervical orthosis,L0112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4433.69,,,,,,,fee schedule,1729.24,4815.91,
Cranial cervical orthosis,L0112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4815.91,,,,,,,fee schedule,1729.24,4815.91,
Cranial cervical orthosis,L0112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3860.37,,,,,,,fee schedule,1729.24,4815.91,
Cranial cervical orthosis,L0112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4217.11,,,,,,,fee schedule,1729.24,4815.91,
Cranial cervical orthosis,L0112,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1815.7,,,,,,,fee schedule,1729.24,4815.91,APC
Cranial cervical orthosis,L0112,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1798.41,,,,,,,fee schedule,1729.24,4815.91,APC
Cranial cervical orthosis,L0112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1729.24,,,,,,,fee schedule,1729.24,4815.91,APC
Cranial cervical orthosis,L0112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2645.74,,,,,,,fee schedule,1729.24,4815.91,Radiology
Cranial cervical orthosis,L0112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2420.94,,,,,,,fee schedule,1729.24,4815.91,APC
Cranial cervical orthosis,L0112,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3026.17,,,,,,,fee schedule,1729.24,4815.91,APC
Cranial cervical torticollis,L0113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,931.56,,,,,,,fee schedule,352.36,1011.87,
Cranial cervical torticollis,L0113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1011.87,,,,,,,fee schedule,352.36,1011.87,
Cranial cervical torticollis,L0113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,811.1,,,,,,,fee schedule,352.36,1011.87,
Cranial cervical torticollis,L0113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,886.05,,,,,,,fee schedule,352.36,1011.87,
Cranial cervical torticollis,L0113,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,369.98,,,,,,,fee schedule,352.36,1011.87,APC
Cranial cervical torticollis,L0113,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,366.45,,,,,,,fee schedule,352.36,1011.87,APC
Cranial cervical torticollis,L0113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,352.36,,,,,,,fee schedule,352.36,1011.87,APC
Cranial cervical torticollis,L0113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,539.11,,,,,,,fee schedule,352.36,1011.87,Radiology
Cranial cervical torticollis,L0113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,493.3,,,,,,,fee schedule,352.36,1011.87,APC
Cranial cervical torticollis,L0113,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,616.63,,,,,,,fee schedule,352.36,1011.87,APC
Cerv flex n/adj foam pre ots,L0120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,78.16,,,,,,,fee schedule,30.5,84.9,
Cerv flex n/adj foam pre ots,L0120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,84.9,,,,,,,fee schedule,30.5,84.9,
Cerv flex n/adj foam pre ots,L0120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,68.05,,,,,,,fee schedule,30.5,84.9,
Cerv flex n/adj foam pre ots,L0120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,74.34,,,,,,,fee schedule,30.5,84.9,
Cerv flex n/adj foam pre ots,L0120,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,32.02,,,,,,,fee schedule,30.5,84.9,APC
Cerv flex n/adj foam pre ots,L0120,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,31.72,,,,,,,fee schedule,30.5,84.9,APC
Cerv flex n/adj foam pre ots,L0120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,30.5,,,,,,,fee schedule,30.5,84.9,APC
Cerv flex n/adj foam pre ots,L0120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,46.66,,,,,,,fee schedule,30.5,84.9,Radiology
Cerv flex n/adj foam pre ots,L0120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,42.7,,,,,,,fee schedule,30.5,84.9,APC
Cerv flex n/adj foam pre ots,L0120,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,53.38,,,,,,,fee schedule,30.5,84.9,APC
Flex thermoplastic collar mo,L0130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,480.69,,,,,,,fee schedule,187.48,522.13,
Flex thermoplastic collar mo,L0130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,522.13,,,,,,,fee schedule,187.48,522.13,
Flex thermoplastic collar mo,L0130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,418.53,,,,,,,fee schedule,187.48,522.13,
Flex thermoplastic collar mo,L0130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,457.21,,,,,,,fee schedule,187.48,522.13,
Flex thermoplastic collar mo,L0130,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,196.85,,,,,,,fee schedule,187.48,522.13,APC
Flex thermoplastic collar mo,L0130,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,194.98,,,,,,,fee schedule,187.48,522.13,APC
Flex thermoplastic collar mo,L0130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,187.48,,,,,,,fee schedule,187.48,522.13,APC
Flex thermoplastic collar mo,L0130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,286.84,,,,,,,fee schedule,187.48,522.13,Radiology
Flex thermoplastic collar mo,L0130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,262.47,,,,,,,fee schedule,187.48,522.13,APC
Flex thermoplastic collar mo,L0130,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,328.09,,,,,,,fee schedule,187.48,522.13,APC
Cervical semi-rigid adjustab,L0140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,192.44,,,,,,,fee schedule,75.05,209.03,
Cervical semi-rigid adjustab,L0140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,209.03,,,,,,,fee schedule,75.05,209.03,
Cervical semi-rigid adjustab,L0140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,167.56,,,,,,,fee schedule,75.05,209.03,
Cervical semi-rigid adjustab,L0140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,183.04,,,,,,,fee schedule,75.05,209.03,
Cervical semi-rigid adjustab,L0140,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,78.8,,,,,,,fee schedule,75.05,209.03,APC
Cervical semi-rigid adjustab,L0140,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,78.05,,,,,,,fee schedule,75.05,209.03,APC
Cervical semi-rigid adjustab,L0140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,75.05,,,,,,,fee schedule,75.05,209.03,APC
Cervical semi-rigid adjustab,L0140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,114.83,,,,,,,fee schedule,75.05,209.03,Radiology
Cervical semi-rigid adjustab,L0140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,105.07,,,,,,,fee schedule,75.05,209.03,APC
Cervical semi-rigid adjustab,L0140,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,131.34,,,,,,,fee schedule,75.05,209.03,APC
Cerv semi-rig adj molded chn,L0150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,318.39,,,,,,,fee schedule,124.18,345.83,
Cerv semi-rig adj molded chn,L0150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,345.83,,,,,,,fee schedule,124.18,345.83,
Cerv semi-rig adj molded chn,L0150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,277.21,,,,,,,fee schedule,124.18,345.83,
Cerv semi-rig adj molded chn,L0150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,302.83,,,,,,,fee schedule,124.18,345.83,
Cerv semi-rig adj molded chn,L0150,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.39,,,,,,,fee schedule,124.18,345.83,APC
Cerv semi-rig adj molded chn,L0150,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,129.15,,,,,,,fee schedule,124.18,345.83,APC
Cerv semi-rig adj molded chn,L0150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,124.18,,,,,,,fee schedule,124.18,345.83,APC
Cerv semi-rig adj molded chn,L0150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,190,,,,,,,fee schedule,124.18,345.83,Radiology
Cerv semi-rig adj molded chn,L0150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,173.85,,,,,,,fee schedule,124.18,345.83,APC
Cerv semi-rig adj molded chn,L0150,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,217.32,,,,,,,fee schedule,124.18,345.83,APC
Cerv sr wire occ/man pre ots,L0160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,615.26,,,,,,,fee schedule,239.97,668.3,
Cerv sr wire occ/man pre ots,L0160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,668.3,,,,,,,fee schedule,239.97,668.3,
Cerv sr wire occ/man pre ots,L0160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,535.7,,,,,,,fee schedule,239.97,668.3,
Cerv sr wire occ/man pre ots,L0160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,585.21,,,,,,,fee schedule,239.97,668.3,
Cerv sr wire occ/man pre ots,L0160,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,251.97,,,,,,,fee schedule,239.97,668.3,APC
Cerv sr wire occ/man pre ots,L0160,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,249.57,,,,,,,fee schedule,239.97,668.3,APC
Cerv sr wire occ/man pre ots,L0160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,239.97,,,,,,,fee schedule,239.97,668.3,APC
Cerv sr wire occ/man pre ots,L0160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,367.15,,,,,,,fee schedule,239.97,668.3,Radiology
Cerv sr wire occ/man pre ots,L0160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,335.96,,,,,,,fee schedule,239.97,668.3,APC
Cerv sr wire occ/man pre ots,L0160,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,419.95,,,,,,,fee schedule,239.97,668.3,APC
Cervical collar molded to pt,L0170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2015.34,,,,,,,fee schedule,786.01,2189.07,
Cervical collar molded to pt,L0170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2189.07,,,,,,,fee schedule,786.01,2189.07,
Cervical collar molded to pt,L0170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1754.73,,,,,,,fee schedule,786.01,2189.07,
Cervical collar molded to pt,L0170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1916.89,,,,,,,fee schedule,786.01,2189.07,
Cervical collar molded to pt,L0170,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,825.31,,,,,,,fee schedule,786.01,2189.07,APC
Cervical collar molded to pt,L0170,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,817.45,,,,,,,fee schedule,786.01,2189.07,APC
Cervical collar molded to pt,L0170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,786.01,,,,,,,fee schedule,786.01,2189.07,APC
Cervical collar molded to pt,L0170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1202.6,,,,,,,fee schedule,786.01,2189.07,Radiology
Cervical collar molded to pt,L0170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1100.41,,,,,,,fee schedule,786.01,2189.07,APC
Cervical collar molded to pt,L0170,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1375.52,,,,,,,fee schedule,786.01,2189.07,APC
Cerv col sr foam 2pc pre ots,L0172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,415.23,,,,,,,fee schedule,161.96,451.03,
Cerv col sr foam 2pc pre ots,L0172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,451.03,,,,,,,fee schedule,161.96,451.03,
Cerv col sr foam 2pc pre ots,L0172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,361.54,,,,,,,fee schedule,161.96,451.03,
Cerv col sr foam 2pc pre ots,L0172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,394.95,,,,,,,fee schedule,161.96,451.03,
Cerv col sr foam 2pc pre ots,L0172,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,170.06,,,,,,,fee schedule,161.96,451.03,APC
Cerv col sr foam 2pc pre ots,L0172,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,168.44,,,,,,,fee schedule,161.96,451.03,APC
Cerv col sr foam 2pc pre ots,L0172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,161.96,,,,,,,fee schedule,161.96,451.03,APC
Cerv col sr foam 2pc pre ots,L0172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,247.8,,,,,,,fee schedule,161.96,451.03,Radiology
Cerv col sr foam 2pc pre ots,L0172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,226.74,,,,,,,fee schedule,161.96,451.03,APC
Cerv col sr foam 2pc pre ots,L0172,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,283.43,,,,,,,fee schedule,161.96,451.03,APC
Cerv sr 2pc thor ext pre ots,L0174,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,809.38,,,,,,,fee schedule,315.67,879.15,
Cerv sr 2pc thor ext pre ots,L0174,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,879.15,,,,,,,fee schedule,315.67,879.15,
Cerv sr 2pc thor ext pre ots,L0174,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,704.72,,,,,,,fee schedule,315.67,879.15,
Cerv sr 2pc thor ext pre ots,L0174,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,769.84,,,,,,,fee schedule,315.67,879.15,
Cerv sr 2pc thor ext pre ots,L0174,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,331.45,,,,,,,fee schedule,315.67,879.15,APC
Cerv sr 2pc thor ext pre ots,L0174,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,328.3,,,,,,,fee schedule,315.67,879.15,APC
Cerv sr 2pc thor ext pre ots,L0174,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,315.67,,,,,,,fee schedule,315.67,879.15,APC
Cerv sr 2pc thor ext pre ots,L0174,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,482.98,,,,,,,fee schedule,315.67,879.15,Radiology
Cerv sr 2pc thor ext pre ots,L0174,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,441.94,,,,,,,fee schedule,315.67,879.15,APC
Cerv sr 2pc thor ext pre ots,L0174,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,552.42,,,,,,,fee schedule,315.67,879.15,APC
Cer post col occ/man sup adj,L0180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1212.78,,,,,,,fee schedule,473,1317.33,
Cer post col occ/man sup adj,L0180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1317.33,,,,,,,fee schedule,473,1317.33,
Cer post col occ/man sup adj,L0180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1055.96,,,,,,,fee schedule,473,1317.33,
Cer post col occ/man sup adj,L0180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1153.54,,,,,,,fee schedule,473,1317.33,
Cer post col occ/man sup adj,L0180,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,496.65,,,,,,,fee schedule,473,1317.33,APC
Cer post col occ/man sup adj,L0180,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,491.92,,,,,,,fee schedule,473,1317.33,APC
Cer post col occ/man sup adj,L0180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,473,,,,,,,fee schedule,473,1317.33,APC
Cer post col occ/man sup adj,L0180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,723.69,,,,,,,fee schedule,473,1317.33,Radiology
Cer post col occ/man sup adj,L0180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,662.2,,,,,,,fee schedule,473,1317.33,APC
Cer post col occ/man sup adj,L0180,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,827.75,,,,,,,fee schedule,473,1317.33,APC
Cerv collar supp adj cerv ba,L0190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1570.45,,,,,,,fee schedule,612.51,1705.84,
Cerv collar supp adj cerv ba,L0190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1705.84,,,,,,,fee schedule,612.51,1705.84,
Cerv collar supp adj cerv ba,L0190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1367.38,,,,,,,fee schedule,612.51,1705.84,
Cerv collar supp adj cerv ba,L0190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1493.74,,,,,,,fee schedule,612.51,1705.84,
Cerv collar supp adj cerv ba,L0190,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,643.14,,,,,,,fee schedule,612.51,1705.84,APC
Cerv collar supp adj cerv ba,L0190,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,637.01,,,,,,,fee schedule,612.51,1705.84,APC
Cerv collar supp adj cerv ba,L0190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,612.51,,,,,,,fee schedule,612.51,1705.84,APC
Cerv collar supp adj cerv ba,L0190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,937.14,,,,,,,fee schedule,612.51,1705.84,Radiology
Cerv collar supp adj cerv ba,L0190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,857.51,,,,,,,fee schedule,612.51,1705.84,APC
Cerv collar supp adj cerv ba,L0190,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1071.89,,,,,,,fee schedule,612.51,1705.84,APC
Cerv col supp adj bar & thor,L0200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1754.76,,,,,,,fee schedule,684.43,1906.03,
Cerv col supp adj bar & thor,L0200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1906.03,,,,,,,fee schedule,684.43,1906.03,
Cerv col supp adj bar & thor,L0200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1527.85,,,,,,,fee schedule,684.43,1906.03,
Cerv col supp adj bar & thor,L0200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1669.03,,,,,,,fee schedule,684.43,1906.03,
Cerv col supp adj bar & thor,L0200,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,718.65,,,,,,,fee schedule,684.43,1906.03,APC
Cerv col supp adj bar & thor,L0200,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,711.81,,,,,,,fee schedule,684.43,1906.03,APC
Cerv col supp adj bar & thor,L0200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,684.43,,,,,,,fee schedule,684.43,1906.03,APC
Cerv col supp adj bar & thor,L0200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1047.18,,,,,,,fee schedule,684.43,1906.03,Radiology
Cerv col supp adj bar & thor,L0200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,958.2,,,,,,,fee schedule,684.43,1906.03,APC
Cerv col supp adj bar & thor,L0200,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1197.75,,,,,,,fee schedule,684.43,1906.03,APC
Thor rib belt custom fabrica,L0220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,481.11,,,,,,,fee schedule,187.65,522.59,
Thor rib belt custom fabrica,L0220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,522.59,,,,,,,fee schedule,187.65,522.59,
Thor rib belt custom fabrica,L0220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,418.9,,,,,,,fee schedule,187.65,522.59,
Thor rib belt custom fabrica,L0220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,457.61,,,,,,,fee schedule,187.65,522.59,
Thor rib belt custom fabrica,L0220,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,197.03,,,,,,,fee schedule,187.65,522.59,APC
Thor rib belt custom fabrica,L0220,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,195.16,,,,,,,fee schedule,187.65,522.59,APC
Thor rib belt custom fabrica,L0220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,187.65,,,,,,,fee schedule,187.65,522.59,APC
Thor rib belt custom fabrica,L0220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,287.1,,,,,,,fee schedule,187.65,522.59,Radiology
Thor rib belt custom fabrica,L0220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,262.71,,,,,,,fee schedule,187.65,522.59,APC
Thor rib belt custom fabrica,L0220,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,328.39,,,,,,,fee schedule,187.65,522.59,APC
Tlso flex trunk/thor pre ots,L0450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,512.05,,,,,,,fee schedule,136.83,556.19,
Tlso flex trunk/thor pre ots,L0450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,556.19,,,,,,,fee schedule,136.83,556.19,
Tlso flex trunk/thor pre ots,L0450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,445.83,,,,,,,fee schedule,136.83,556.19,
Tlso flex trunk/thor pre ots,L0450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,487.03,,,,,,,fee schedule,136.83,556.19,
Tlso flex trunk/thor pre ots,L0450,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,143.67,,,,,,,fee schedule,136.83,556.19,APC
Tlso flex trunk/thor pre ots,L0450,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,142.3,,,,,,,fee schedule,136.83,556.19,APC
Tlso flex trunk/thor pre ots,L0450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,136.83,,,,,,,fee schedule,136.83,556.19,APC
Tlso flex trunk/thor pre ots,L0450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,209.35,,,,,,,fee schedule,136.83,556.19,Radiology
Tlso flex trunk/thor pre ots,L0450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,191.56,,,,,,,fee schedule,136.83,556.19,APC
Tlso flex trunk/thor pre ots,L0450,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,239.45,,,,,,,fee schedule,136.83,556.19,APC
Tlso trnk sj-t9 pre cst,L0454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1098.64,,,,,,,fee schedule,428.5,1193.35,
Tlso trnk sj-t9 pre cst,L0454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1193.35,,,,,,,fee schedule,428.5,1193.35,
Tlso trnk sj-t9 pre cst,L0454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,956.57,,,,,,,fee schedule,428.5,1193.35,
Tlso trnk sj-t9 pre cst,L0454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1044.97,,,,,,,fee schedule,428.5,1193.35,
Tlso trnk sj-t9 pre cst,L0454,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,449.92,,,,,,,fee schedule,428.5,1193.35,APC
Tlso trnk sj-t9 pre cst,L0454,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,445.64,,,,,,,fee schedule,428.5,1193.35,APC
Tlso trnk sj-t9 pre cst,L0454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,428.5,,,,,,,fee schedule,428.5,1193.35,APC
Tlso trnk sj-t9 pre cst,L0454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,655.6,,,,,,,fee schedule,428.5,1193.35,Radiology
Tlso trnk sj-t9 pre cst,L0454,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,599.9,,,,,,,fee schedule,428.5,1193.35,APC
Tlso trnk sj-t9 pre cst,L0454,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,749.88,,,,,,,fee schedule,428.5,1193.35,APC
Tlso flex trnk sj-t9 pre ots,L0455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1161.35,,,,,,,fee schedule,254.02,1261.46,
Tlso flex trnk sj-t9 pre ots,L0455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1261.46,,,,,,,fee schedule,254.02,1261.46,
Tlso flex trnk sj-t9 pre ots,L0455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1011.17,,,,,,,fee schedule,254.02,1261.46,
Tlso flex trnk sj-t9 pre ots,L0455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1104.61,,,,,,,fee schedule,254.02,1261.46,
Tlso flex trnk sj-t9 pre ots,L0455,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,266.72,,,,,,,fee schedule,254.02,1261.46,APC
Tlso flex trnk sj-t9 pre ots,L0455,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,264.18,,,,,,,fee schedule,254.02,1261.46,APC
Tlso flex trnk sj-t9 pre ots,L0455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,254.02,,,,,,,fee schedule,254.02,1261.46,APC
Tlso flex trnk sj-t9 pre ots,L0455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,388.65,,,,,,,fee schedule,254.02,1261.46,Radiology
Tlso flex trnk sj-t9 pre ots,L0455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,355.63,,,,,,,fee schedule,254.02,1261.46,APC
Tlso flex trnk sj-t9 pre ots,L0455,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,444.54,,,,,,,fee schedule,254.02,1261.46,APC
Tlso flex trnk sj-ss pre cst,L0456,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3150.62,,,,,,,fee schedule,1228.79,3422.22,
Tlso flex trnk sj-ss pre cst,L0456,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3422.22,,,,,,,fee schedule,1228.79,3422.22,
Tlso flex trnk sj-ss pre cst,L0456,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2743.21,,,,,,,fee schedule,1228.79,3422.22,
Tlso flex trnk sj-ss pre cst,L0456,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2996.71,,,,,,,fee schedule,1228.79,3422.22,
Tlso flex trnk sj-ss pre cst,L0456,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1290.23,,,,,,,fee schedule,1228.79,3422.22,APC
Tlso flex trnk sj-ss pre cst,L0456,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1277.94,,,,,,,fee schedule,1228.79,3422.22,APC
Tlso flex trnk sj-ss pre cst,L0456,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1228.79,,,,,,,fee schedule,1228.79,3422.22,APC
Tlso flex trnk sj-ss pre cst,L0456,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1880.05,,,,,,,fee schedule,1228.79,3422.22,Radiology
Tlso flex trnk sj-ss pre cst,L0456,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1720.31,,,,,,,fee schedule,1228.79,3422.22,APC
Tlso flex trnk sj-ss pre cst,L0456,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2150.38,,,,,,,fee schedule,1228.79,3422.22,APC
Tlso flex trnk sj-ss pre ots,L0457,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3330.5,,,,,,,fee schedule,728.43,3617.61,
Tlso flex trnk sj-ss pre ots,L0457,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3617.61,,,,,,,fee schedule,728.43,3617.61,
Tlso flex trnk sj-ss pre ots,L0457,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2899.83,,,,,,,fee schedule,728.43,3617.61,
Tlso flex trnk sj-ss pre ots,L0457,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3167.8,,,,,,,fee schedule,728.43,3617.61,
Tlso flex trnk sj-ss pre ots,L0457,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,764.85,,,,,,,fee schedule,728.43,3617.61,APC
Tlso flex trnk sj-ss pre ots,L0457,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,757.57,,,,,,,fee schedule,728.43,3617.61,APC
Tlso flex trnk sj-ss pre ots,L0457,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,728.43,,,,,,,fee schedule,728.43,3617.61,APC
Tlso flex trnk sj-ss pre ots,L0457,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1114.5,,,,,,,fee schedule,728.43,3617.61,Radiology
Tlso flex trnk sj-ss pre ots,L0457,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1019.8,,,,,,,fee schedule,728.43,3617.61,APC
Tlso flex trnk sj-ss pre ots,L0457,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1274.75,,,,,,,fee schedule,728.43,3617.61,APC
TLSO 2Mod symphis-xipho pre,L0458,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2825.2,,,,,,,fee schedule,1101.88,3068.76,
TLSO 2Mod symphis-xipho pre,L0458,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3068.76,,,,,,,fee schedule,1101.88,3068.76,
TLSO 2Mod symphis-xipho pre,L0458,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2459.88,,,,,,,fee schedule,1101.88,3068.76,
TLSO 2Mod symphis-xipho pre,L0458,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2687.19,,,,,,,fee schedule,1101.88,3068.76,
TLSO 2Mod symphis-xipho pre,L0458,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1156.97,,,,,,,fee schedule,1101.88,3068.76,APC
TLSO 2Mod symphis-xipho pre,L0458,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1145.96,,,,,,,fee schedule,1101.88,3068.76,APC
TLSO 2Mod symphis-xipho pre,L0458,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1101.88,,,,,,,fee schedule,1101.88,3068.76,APC
TLSO 2Mod symphis-xipho pre,L0458,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1685.88,,,,,,,fee schedule,1101.88,3068.76,Radiology
TLSO 2Mod symphis-xipho pre,L0458,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1542.63,,,,,,,fee schedule,1101.88,3068.76,APC
TLSO 2Mod symphis-xipho pre,L0458,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1928.29,,,,,,,fee schedule,1101.88,3068.76,APC
Tlso 2 shl symphys-stern cst,L0460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3179.95,,,,,,,fee schedule,1240.27,3454.09,
Tlso 2 shl symphys-stern cst,L0460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3454.09,,,,,,,fee schedule,1240.27,3454.09,
Tlso 2 shl symphys-stern cst,L0460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2768.75,,,,,,,fee schedule,1240.27,3454.09,
Tlso 2 shl symphys-stern cst,L0460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3024.61,,,,,,,fee schedule,1240.27,3454.09,
Tlso 2 shl symphys-stern cst,L0460,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1302.28,,,,,,,fee schedule,1240.27,3454.09,APC
Tlso 2 shl symphys-stern cst,L0460,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1289.88,,,,,,,fee schedule,1240.27,3454.09,APC
Tlso 2 shl symphys-stern cst,L0460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1240.27,,,,,,,fee schedule,1240.27,3454.09,APC
Tlso 2 shl symphys-stern cst,L0460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1897.61,,,,,,,fee schedule,1240.27,3454.09,Radiology
Tlso 2 shl symphys-stern cst,L0460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1736.38,,,,,,,fee schedule,1240.27,3454.09,APC
Tlso 2 shl symphys-stern cst,L0460,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2170.47,,,,,,,fee schedule,1240.27,3454.09,APC
TLSO 3Mod sacro-scap pre,L0462,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3955.23,,,,,,,fee schedule,1542.64,4296.2,
TLSO 3Mod sacro-scap pre,L0462,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4296.2,,,,,,,fee schedule,1542.64,4296.2,
TLSO 3Mod sacro-scap pre,L0462,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3443.78,,,,,,,fee schedule,1542.64,4296.2,
TLSO 3Mod sacro-scap pre,L0462,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3762.01,,,,,,,fee schedule,1542.64,4296.2,
TLSO 3Mod sacro-scap pre,L0462,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1619.77,,,,,,,fee schedule,1542.64,4296.2,APC
TLSO 3Mod sacro-scap pre,L0462,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1604.35,,,,,,,fee schedule,1542.64,4296.2,APC
TLSO 3Mod sacro-scap pre,L0462,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1542.64,,,,,,,fee schedule,1542.64,4296.2,APC
TLSO 3Mod sacro-scap pre,L0462,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2360.24,,,,,,,fee schedule,1542.64,4296.2,Radiology
TLSO 3Mod sacro-scap pre,L0462,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2159.7,,,,,,,fee schedule,1542.64,4296.2,APC
TLSO 3Mod sacro-scap pre,L0462,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2699.62,,,,,,,fee schedule,1542.64,4296.2,APC
TLSO 4Mod sacro-scap pre,L0464,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4708.68,,,,,,,fee schedule,1836.48,5114.6,
TLSO 4Mod sacro-scap pre,L0464,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5114.6,,,,,,,fee schedule,1836.48,5114.6,
TLSO 4Mod sacro-scap pre,L0464,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4099.8,,,,,,,fee schedule,1836.48,5114.6,
TLSO 4Mod sacro-scap pre,L0464,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4478.66,,,,,,,fee schedule,1836.48,5114.6,
TLSO 4Mod sacro-scap pre,L0464,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1928.3,,,,,,,fee schedule,1836.48,5114.6,APC
TLSO 4Mod sacro-scap pre,L0464,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1909.94,,,,,,,fee schedule,1836.48,5114.6,APC
TLSO 4Mod sacro-scap pre,L0464,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1836.48,,,,,,,fee schedule,1836.48,5114.6,APC
TLSO 4Mod sacro-scap pre,L0464,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2809.81,,,,,,,fee schedule,1836.48,5114.6,Radiology
TLSO 4Mod sacro-scap pre,L0464,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2571.07,,,,,,,fee schedule,1836.48,5114.6,APC
TLSO 4Mod sacro-scap pre,L0464,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3213.84,,,,,,,fee schedule,1836.48,5114.6,APC
Tlso r fram soft ant pre cst,L0466,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1261.22,,,,,,,fee schedule,491.93,1369.95,
Tlso r fram soft ant pre cst,L0466,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1369.95,,,,,,,fee schedule,491.93,1369.95,
Tlso r fram soft ant pre cst,L0466,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1098.13,,,,,,,fee schedule,491.93,1369.95,
Tlso r fram soft ant pre cst,L0466,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1199.61,,,,,,,fee schedule,491.93,1369.95,
Tlso r fram soft ant pre cst,L0466,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,516.53,,,,,,,fee schedule,491.93,1369.95,APC
Tlso r fram soft ant pre cst,L0466,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,511.61,,,,,,,fee schedule,491.93,1369.95,APC
Tlso r fram soft ant pre cst,L0466,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,491.93,,,,,,,fee schedule,491.93,1369.95,APC
Tlso r fram soft ant pre cst,L0466,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,752.65,,,,,,,fee schedule,491.93,1369.95,Radiology
Tlso r fram soft ant pre cst,L0466,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,688.7,,,,,,,fee schedule,491.93,1369.95,APC
Tlso r fram soft ant pre cst,L0466,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,860.88,,,,,,,fee schedule,491.93,1369.95,APC
Tlso r fram soft pre ots,L0467,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1333.26,,,,,,,fee schedule,284.88,1448.19,
Tlso r fram soft pre ots,L0467,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1448.19,,,,,,,fee schedule,284.88,1448.19,
Tlso r fram soft pre ots,L0467,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1160.85,,,,,,,fee schedule,284.88,1448.19,
Tlso r fram soft pre ots,L0467,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1268.13,,,,,,,fee schedule,284.88,1448.19,
Tlso r fram soft pre ots,L0467,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,299.12,,,,,,,fee schedule,284.88,1448.19,APC
Tlso r fram soft pre ots,L0467,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,296.28,,,,,,,fee schedule,284.88,1448.19,APC
Tlso r fram soft pre ots,L0467,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,284.88,,,,,,,fee schedule,284.88,1448.19,APC
Tlso r fram soft pre ots,L0467,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,435.87,,,,,,,fee schedule,284.88,1448.19,Radiology
Tlso r fram soft pre ots,L0467,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,398.83,,,,,,,fee schedule,284.88,1448.19,APC
Tlso r fram soft pre ots,L0467,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,498.54,,,,,,,fee schedule,284.88,1448.19,APC
Tlso rig fram pelvic pre cst,L0468,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1460.21,,,,,,,fee schedule,569.51,1586.09,
Tlso rig fram pelvic pre cst,L0468,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1586.09,,,,,,,fee schedule,569.51,1586.09,
Tlso rig fram pelvic pre cst,L0468,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1271.39,,,,,,,fee schedule,569.51,1586.09,
Tlso rig fram pelvic pre cst,L0468,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1388.88,,,,,,,fee schedule,569.51,1586.09,
Tlso rig fram pelvic pre cst,L0468,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,597.99,,,,,,,fee schedule,569.51,1586.09,APC
Tlso rig fram pelvic pre cst,L0468,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,592.29,,,,,,,fee schedule,569.51,1586.09,APC
Tlso rig fram pelvic pre cst,L0468,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,569.51,,,,,,,fee schedule,569.51,1586.09,APC
Tlso rig fram pelvic pre cst,L0468,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,871.35,,,,,,,fee schedule,569.51,1586.09,Radiology
Tlso rig fram pelvic pre cst,L0468,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,797.31,,,,,,,fee schedule,569.51,1586.09,APC
Tlso rig fram pelvic pre cst,L0468,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,996.64,,,,,,,fee schedule,569.51,1586.09,APC
Tlso rig fram pelvic pre ots,L0469,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1543.59,,,,,,,fee schedule,362.99,1676.66,
Tlso rig fram pelvic pre ots,L0469,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1676.66,,,,,,,fee schedule,362.99,1676.66,
Tlso rig fram pelvic pre ots,L0469,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1343.99,,,,,,,fee schedule,362.99,1676.66,
Tlso rig fram pelvic pre ots,L0469,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1468.18,,,,,,,fee schedule,362.99,1676.66,
Tlso rig fram pelvic pre ots,L0469,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,381.14,,,,,,,fee schedule,362.99,1676.66,APC
Tlso rig fram pelvic pre ots,L0469,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,377.51,,,,,,,fee schedule,362.99,1676.66,APC
Tlso rig fram pelvic pre ots,L0469,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,362.99,,,,,,,fee schedule,362.99,1676.66,APC
Tlso rig fram pelvic pre ots,L0469,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,555.37,,,,,,,fee schedule,362.99,1676.66,Radiology
Tlso rig fram pelvic pre ots,L0469,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,508.19,,,,,,,fee schedule,362.99,1676.66,APC
Tlso rig fram pelvic pre ots,L0469,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,635.23,,,,,,,fee schedule,362.99,1676.66,APC
TLSO rigid frame pre subclav,L0470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1878.43,,,,,,,fee schedule,732.62,2040.37,
TLSO rigid frame pre subclav,L0470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2040.37,,,,,,,fee schedule,732.62,2040.37,
TLSO rigid frame pre subclav,L0470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1635.53,,,,,,,fee schedule,732.62,2040.37,
TLSO rigid frame pre subclav,L0470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1786.67,,,,,,,fee schedule,732.62,2040.37,
TLSO rigid frame pre subclav,L0470,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,769.25,,,,,,,fee schedule,732.62,2040.37,APC
TLSO rigid frame pre subclav,L0470,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,761.92,,,,,,,fee schedule,732.62,2040.37,APC
TLSO rigid frame pre subclav,L0470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,732.62,,,,,,,fee schedule,732.62,2040.37,APC
TLSO rigid frame pre subclav,L0470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1120.91,,,,,,,fee schedule,732.62,2040.37,Radiology
TLSO rigid frame pre subclav,L0470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1025.67,,,,,,,fee schedule,732.62,2040.37,APC
TLSO rigid frame pre subclav,L0470,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1282.08,,,,,,,fee schedule,732.62,2040.37,APC
TLSO rigid frame hyperex pre,L0472,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1311.19,,,,,,,fee schedule,511.39,1424.23,
TLSO rigid frame hyperex pre,L0472,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1424.23,,,,,,,fee schedule,511.39,1424.23,
TLSO rigid frame hyperex pre,L0472,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1141.64,,,,,,,fee schedule,511.39,1424.23,
TLSO rigid frame hyperex pre,L0472,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1247.14,,,,,,,fee schedule,511.39,1424.23,
TLSO rigid frame hyperex pre,L0472,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,536.96,,,,,,,fee schedule,511.39,1424.23,APC
TLSO rigid frame hyperex pre,L0472,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,531.85,,,,,,,fee schedule,511.39,1424.23,APC
TLSO rigid frame hyperex pre,L0472,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,511.39,,,,,,,fee schedule,511.39,1424.23,APC
TLSO rigid frame hyperex pre,L0472,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,782.43,,,,,,,fee schedule,511.39,1424.23,Radiology
TLSO rigid frame hyperex pre,L0472,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,715.95,,,,,,,fee schedule,511.39,1424.23,APC
TLSO rigid frame hyperex pre,L0472,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,894.93,,,,,,,fee schedule,511.39,1424.23,APC
TLSO rigid plastic custom fa,L0480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4517.88,,,,,,,fee schedule,1762.06,4907.35,
TLSO rigid plastic custom fa,L0480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4907.35,,,,,,,fee schedule,1762.06,4907.35,
TLSO rigid plastic custom fa,L0480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3933.67,,,,,,,fee schedule,1762.06,4907.35,
TLSO rigid plastic custom fa,L0480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4297.17,,,,,,,fee schedule,1762.06,4907.35,
TLSO rigid plastic custom fa,L0480,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1850.16,,,,,,,fee schedule,1762.06,4907.35,APC
TLSO rigid plastic custom fa,L0480,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1832.54,,,,,,,fee schedule,1762.06,4907.35,APC
TLSO rigid plastic custom fa,L0480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1762.06,,,,,,,fee schedule,1762.06,4907.35,APC
TLSO rigid plastic custom fa,L0480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2695.95,,,,,,,fee schedule,1762.06,4907.35,Radiology
TLSO rigid plastic custom fa,L0480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2466.88,,,,,,,fee schedule,1762.06,4907.35,APC
TLSO rigid plastic custom fa,L0480,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3083.6,,,,,,,fee schedule,1762.06,4907.35,APC
TLSO rigid lined custom fab,L0482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4568.89,,,,,,,fee schedule,1781.97,4962.76,
TLSO rigid lined custom fab,L0482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4962.76,,,,,,,fee schedule,1781.97,4962.76,
TLSO rigid lined custom fab,L0482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3978.09,,,,,,,fee schedule,1781.97,4962.76,
TLSO rigid lined custom fab,L0482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4345.7,,,,,,,fee schedule,1781.97,4962.76,
TLSO rigid lined custom fab,L0482,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1871.07,,,,,,,fee schedule,1781.97,4962.76,APC
TLSO rigid lined custom fab,L0482,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1853.25,,,,,,,fee schedule,1781.97,4962.76,APC
TLSO rigid lined custom fab,L0482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1781.97,,,,,,,fee schedule,1781.97,4962.76,APC
TLSO rigid lined custom fab,L0482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2726.41,,,,,,,fee schedule,1781.97,4962.76,Radiology
TLSO rigid lined custom fab,L0482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2494.76,,,,,,,fee schedule,1781.97,4962.76,APC
TLSO rigid lined custom fab,L0482,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3118.45,,,,,,,fee schedule,1781.97,4962.76,APC
TLSO rigid plastic cust fab,L0484,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5235.97,,,,,,,fee schedule,2042.14,5687.35,
TLSO rigid plastic cust fab,L0484,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5687.35,,,,,,,fee schedule,2042.14,5687.35,
TLSO rigid plastic cust fab,L0484,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4558.91,,,,,,,fee schedule,2042.14,5687.35,
TLSO rigid plastic cust fab,L0484,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4980.19,,,,,,,fee schedule,2042.14,5687.35,
TLSO rigid plastic cust fab,L0484,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2144.25,,,,,,,fee schedule,2042.14,5687.35,APC
TLSO rigid plastic cust fab,L0484,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2123.83,,,,,,,fee schedule,2042.14,5687.35,APC
TLSO rigid plastic cust fab,L0484,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2042.14,,,,,,,fee schedule,2042.14,5687.35,APC
TLSO rigid plastic cust fab,L0484,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3124.47,,,,,,,fee schedule,2042.14,5687.35,Radiology
TLSO rigid plastic cust fab,L0484,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2859,,,,,,,fee schedule,2042.14,5687.35,APC
TLSO rigid plastic cust fab,L0484,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3573.75,,,,,,,fee schedule,2042.14,5687.35,APC
TLSO rigidlined cust fab two,L0486,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5649.95,,,,,,,fee schedule,2203.61,6137.02,
TLSO rigidlined cust fab two,L0486,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6137.02,,,,,,,fee schedule,2203.61,6137.02,
TLSO rigidlined cust fab two,L0486,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4919.36,,,,,,,fee schedule,2203.61,6137.02,
TLSO rigidlined cust fab two,L0486,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5373.95,,,,,,,fee schedule,2203.61,6137.02,
TLSO rigidlined cust fab two,L0486,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2313.79,,,,,,,fee schedule,2203.61,6137.02,APC
TLSO rigidlined cust fab two,L0486,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2291.75,,,,,,,fee schedule,2203.61,6137.02,APC
TLSO rigidlined cust fab two,L0486,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2203.61,,,,,,,fee schedule,2203.61,6137.02,APC
TLSO rigidlined cust fab two,L0486,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3371.52,,,,,,,fee schedule,2203.61,6137.02,Radiology
TLSO rigidlined cust fab two,L0486,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3085.05,,,,,,,fee schedule,2203.61,6137.02,APC
TLSO rigidlined cust fab two,L0486,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3856.32,,,,,,,fee schedule,2203.61,6137.02,APC
TLSO rigid lined pre one pie,L0488,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3179.95,,,,,,,fee schedule,1240.27,3454.09,
TLSO rigid lined pre one pie,L0488,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3454.09,,,,,,,fee schedule,1240.27,3454.09,
TLSO rigid lined pre one pie,L0488,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2768.75,,,,,,,fee schedule,1240.27,3454.09,
TLSO rigid lined pre one pie,L0488,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3024.61,,,,,,,fee schedule,1240.27,3454.09,
TLSO rigid lined pre one pie,L0488,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1302.28,,,,,,,fee schedule,1240.27,3454.09,APC
TLSO rigid lined pre one pie,L0488,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1289.88,,,,,,,fee schedule,1240.27,3454.09,APC
TLSO rigid lined pre one pie,L0488,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1240.27,,,,,,,fee schedule,1240.27,3454.09,APC
TLSO rigid lined pre one pie,L0488,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1897.61,,,,,,,fee schedule,1240.27,3454.09,Radiology
TLSO rigid lined pre one pie,L0488,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1736.38,,,,,,,fee schedule,1240.27,3454.09,APC
TLSO rigid lined pre one pie,L0488,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2170.47,,,,,,,fee schedule,1240.27,3454.09,APC
TLSO rigid plastic pre one,L0490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,896.07,,,,,,,fee schedule,349.48,973.31,
TLSO rigid plastic pre one,L0490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,973.31,,,,,,,fee schedule,349.48,973.31,
TLSO rigid plastic pre one,L0490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,780.19,,,,,,,fee schedule,349.48,973.31,
TLSO rigid plastic pre one,L0490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,852.29,,,,,,,fee schedule,349.48,973.31,
TLSO rigid plastic pre one,L0490,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,366.95,,,,,,,fee schedule,349.48,973.31,APC
TLSO rigid plastic pre one,L0490,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,363.46,,,,,,,fee schedule,349.48,973.31,APC
TLSO rigid plastic pre one,L0490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,349.48,,,,,,,fee schedule,349.48,973.31,APC
TLSO rigid plastic pre one,L0490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,534.7,,,,,,,fee schedule,349.48,973.31,Radiology
TLSO rigid plastic pre one,L0490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,489.27,,,,,,,fee schedule,349.48,973.31,APC
TLSO rigid plastic pre one,L0490,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,611.59,,,,,,,fee schedule,349.48,973.31,APC
TLSO 2 piece rigid shell,L0491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2432.87,,,,,,,fee schedule,948.87,2642.6,
TLSO 2 piece rigid shell,L0491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2642.6,,,,,,,fee schedule,948.87,2642.6,
TLSO 2 piece rigid shell,L0491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2118.27,,,,,,,fee schedule,948.87,2642.6,
TLSO 2 piece rigid shell,L0491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2314.02,,,,,,,fee schedule,948.87,2642.6,
TLSO 2 piece rigid shell,L0491,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,996.31,,,,,,,fee schedule,948.87,2642.6,APC
TLSO 2 piece rigid shell,L0491,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,986.82,,,,,,,fee schedule,948.87,2642.6,APC
TLSO 2 piece rigid shell,L0491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,948.87,,,,,,,fee schedule,948.87,2642.6,APC
TLSO 2 piece rigid shell,L0491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1451.77,,,,,,,fee schedule,948.87,2642.6,Radiology
TLSO 2 piece rigid shell,L0491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1328.42,,,,,,,fee schedule,948.87,2642.6,APC
TLSO 2 piece rigid shell,L0491,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1660.52,,,,,,,fee schedule,948.87,2642.6,APC
TLSO 3 piece rigid shell,L0492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1576.75,,,,,,,fee schedule,614.96,1712.68,
TLSO 3 piece rigid shell,L0492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1712.68,,,,,,,fee schedule,614.96,1712.68,
TLSO 3 piece rigid shell,L0492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1372.86,,,,,,,fee schedule,614.96,1712.68,
TLSO 3 piece rigid shell,L0492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1499.73,,,,,,,fee schedule,614.96,1712.68,
TLSO 3 piece rigid shell,L0492,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,645.71,,,,,,,fee schedule,614.96,1712.68,APC
TLSO 3 piece rigid shell,L0492,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,639.56,,,,,,,fee schedule,614.96,1712.68,APC
TLSO 3 piece rigid shell,L0492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,614.96,,,,,,,fee schedule,614.96,1712.68,APC
TLSO 3 piece rigid shell,L0492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,940.89,,,,,,,fee schedule,614.96,1712.68,Radiology
TLSO 3 piece rigid shell,L0492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,860.94,,,,,,,fee schedule,614.96,1712.68,APC
TLSO 3 piece rigid shell,L0492,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1076.18,,,,,,,fee schedule,614.96,1712.68,APC
Sio flex pelvic/sacr pre ots,L0621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,294.3,,,,,,,fee schedule,72.14,319.67,
Sio flex pelvic/sacr pre ots,L0621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,319.67,,,,,,,fee schedule,72.14,319.67,
Sio flex pelvic/sacr pre ots,L0621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,256.25,,,,,,,fee schedule,72.14,319.67,
Sio flex pelvic/sacr pre ots,L0621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,279.93,,,,,,,fee schedule,72.14,319.67,
Sio flex pelvic/sacr pre ots,L0621,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,75.75,,,,,,,fee schedule,72.14,319.67,APC
Sio flex pelvic/sacr pre ots,L0621,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,75.03,,,,,,,fee schedule,72.14,319.67,APC
Sio flex pelvic/sacr pre ots,L0621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,72.14,,,,,,,fee schedule,72.14,319.67,APC
Sio flex pelvic/sacr pre ots,L0621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,110.37,,,,,,,fee schedule,72.14,319.67,Radiology
Sio flex pelvic/sacr pre ots,L0621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,101,,,,,,,fee schedule,72.14,319.67,APC
Sio flex pelvic/sacr pre ots,L0621,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,126.24,,,,,,,fee schedule,72.14,319.67,APC
Sio flex pelvisacral custom,L0622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,761.15,,,,,,,fee schedule,296.87,826.76,
Sio flex pelvisacral custom,L0622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,826.76,,,,,,,fee schedule,296.87,826.76,
Sio flex pelvisacral custom,L0622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,662.72,,,,,,,fee schedule,296.87,826.76,
Sio flex pelvisacral custom,L0622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,723.96,,,,,,,fee schedule,296.87,826.76,
Sio flex pelvisacral custom,L0622,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,311.71,,,,,,,fee schedule,296.87,826.76,APC
Sio flex pelvisacral custom,L0622,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,308.74,,,,,,,fee schedule,296.87,826.76,APC
Sio flex pelvisacral custom,L0622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,296.87,,,,,,,fee schedule,296.87,826.76,APC
Sio flex pelvisacral custom,L0622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,454.21,,,,,,,fee schedule,296.87,826.76,Radiology
Sio flex pelvisacral custom,L0622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,415.62,,,,,,,fee schedule,296.87,826.76,APC
Sio flex pelvisacral custom,L0622,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,519.52,,,,,,,fee schedule,296.87,826.76,APC
Lo flex l1-below l5 pre ots,L0625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,174.56,,,,,,,fee schedule,40.36,189.6,
Lo flex l1-below l5 pre ots,L0625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,189.6,,,,,,,fee schedule,40.36,189.6,
Lo flex l1-below l5 pre ots,L0625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,151.98,,,,,,,fee schedule,40.36,189.6,
Lo flex l1-below l5 pre ots,L0625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,166.03,,,,,,,fee schedule,40.36,189.6,
Lo flex l1-below l5 pre ots,L0625,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,42.38,,,,,,,fee schedule,40.36,189.6,APC
Lo flex l1-below l5 pre ots,L0625,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,41.97,,,,,,,fee schedule,40.36,189.6,APC
Lo flex l1-below l5 pre ots,L0625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,40.36,,,,,,,fee schedule,40.36,189.6,APC
Lo flex l1-below l5 pre ots,L0625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,61.75,,,,,,,fee schedule,40.36,189.6,Radiology
Lo flex l1-below l5 pre ots,L0625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.5,,,,,,,fee schedule,40.36,189.6,APC
Lo flex l1-below l5 pre ots,L0625,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,70.63,,,,,,,fee schedule,40.36,189.6,APC
Lo sag rig pnl stays pre cst,L0626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,246.94,,,,,,,fee schedule,96.31,268.23,
Lo sag rig pnl stays pre cst,L0626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,268.23,,,,,,,fee schedule,96.31,268.23,
Lo sag rig pnl stays pre cst,L0626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,215.01,,,,,,,fee schedule,96.31,268.23,
Lo sag rig pnl stays pre cst,L0626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,234.88,,,,,,,fee schedule,96.31,268.23,
Lo sag rig pnl stays pre cst,L0626,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,101.13,,,,,,,fee schedule,96.31,268.23,APC
Lo sag rig pnl stays pre cst,L0626,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,100.16,,,,,,,fee schedule,96.31,268.23,APC
Lo sag rig pnl stays pre cst,L0626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,96.31,,,,,,,fee schedule,96.31,268.23,APC
Lo sag rig pnl stays pre cst,L0626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,147.35,,,,,,,fee schedule,96.31,268.23,Radiology
Lo sag rig pnl stays pre cst,L0626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,134.83,,,,,,,fee schedule,96.31,268.23,APC
Lo sag rig pnl stays pre cst,L0626,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,168.54,,,,,,,fee schedule,96.31,268.23,APC
Lo sag ri an/pos pnl pre cst,L0627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1302.15,,,,,,,fee schedule,507.88,1414.4,
Lo sag ri an/pos pnl pre cst,L0627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1414.4,,,,,,,fee schedule,507.88,1414.4,
Lo sag ri an/pos pnl pre cst,L0627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1133.77,,,,,,,fee schedule,507.88,1414.4,
Lo sag ri an/pos pnl pre cst,L0627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1238.54,,,,,,,fee schedule,507.88,1414.4,
Lo sag ri an/pos pnl pre cst,L0627,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,533.27,,,,,,,fee schedule,507.88,1414.4,APC
Lo sag ri an/pos pnl pre cst,L0627,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,528.2,,,,,,,fee schedule,507.88,1414.4,APC
Lo sag ri an/pos pnl pre cst,L0627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,507.88,,,,,,,fee schedule,507.88,1414.4,APC
Lo sag ri an/pos pnl pre cst,L0627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,777.06,,,,,,,fee schedule,507.88,1414.4,Radiology
Lo sag ri an/pos pnl pre cst,L0627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,711.03,,,,,,,fee schedule,507.88,1414.4,APC
Lo sag ri an/pos pnl pre cst,L0627,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,888.79,,,,,,,fee schedule,507.88,1414.4,APC
Lso flex no ri stays pre ots,L0628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,265.73,,,,,,,fee schedule,61.45,288.64,
Lso flex no ri stays pre ots,L0628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,288.64,,,,,,,fee schedule,61.45,288.64,
Lso flex no ri stays pre ots,L0628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,231.37,,,,,,,fee schedule,61.45,288.64,
Lso flex no ri stays pre ots,L0628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,252.75,,,,,,,fee schedule,61.45,288.64,
Lso flex no ri stays pre ots,L0628,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,64.52,,,,,,,fee schedule,61.45,288.64,APC
Lso flex no ri stays pre ots,L0628,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,63.91,,,,,,,fee schedule,61.45,288.64,APC
Lso flex no ri stays pre ots,L0628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,61.45,,,,,,,fee schedule,61.45,288.64,APC
Lso flex no ri stays pre ots,L0628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,94.02,,,,,,,fee schedule,61.45,288.64,Radiology
Lso flex no ri stays pre ots,L0628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,86.03,,,,,,,fee schedule,61.45,288.64,APC
Lso flex no ri stays pre ots,L0628,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,107.54,,,,,,,fee schedule,61.45,288.64,APC
Lso r post pnl sj-t9 pre cst,L0630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,512.99,,,,,,,fee schedule,200.06,557.21,
Lso r post pnl sj-t9 pre cst,L0630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,557.21,,,,,,,fee schedule,200.06,557.21,
Lso r post pnl sj-t9 pre cst,L0630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,446.65,,,,,,,fee schedule,200.06,557.21,
Lso r post pnl sj-t9 pre cst,L0630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,487.93,,,,,,,fee schedule,200.06,557.21,
Lso r post pnl sj-t9 pre cst,L0630,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,210.06,,,,,,,fee schedule,200.06,557.21,APC
Lso r post pnl sj-t9 pre cst,L0630,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,208.06,,,,,,,fee schedule,200.06,557.21,APC
Lso r post pnl sj-t9 pre cst,L0630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,200.06,,,,,,,fee schedule,200.06,557.21,APC
Lso r post pnl sj-t9 pre cst,L0630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,306.09,,,,,,,fee schedule,200.06,557.21,Radiology
Lso r post pnl sj-t9 pre cst,L0630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,280.08,,,,,,,fee schedule,200.06,557.21,APC
Lso r post pnl sj-t9 pre cst,L0630,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,350.1,,,,,,,fee schedule,200.06,557.21,APC
Lso sag r an/pos pnl pre cst,L0631,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3251.99,,,,,,,fee schedule,1268.37,3532.33,
Lso sag r an/pos pnl pre cst,L0631,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3532.33,,,,,,,fee schedule,1268.37,3532.33,
Lso sag r an/pos pnl pre cst,L0631,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2831.47,,,,,,,fee schedule,1268.37,3532.33,
Lso sag r an/pos pnl pre cst,L0631,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3093.13,,,,,,,fee schedule,1268.37,3532.33,
Lso sag r an/pos pnl pre cst,L0631,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1331.79,,,,,,,fee schedule,1268.37,3532.33,APC
Lso sag r an/pos pnl pre cst,L0631,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1319.1,,,,,,,fee schedule,1268.37,3532.33,APC
Lso sag r an/pos pnl pre cst,L0631,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1268.37,,,,,,,fee schedule,1268.37,3532.33,APC
Lso sag r an/pos pnl pre cst,L0631,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1940.61,,,,,,,fee schedule,1268.37,3532.33,Radiology
Lso sag r an/pos pnl pre cst,L0631,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1775.72,,,,,,,fee schedule,1268.37,3532.33,APC
Lso sag r an/pos pnl pre cst,L0631,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2219.65,,,,,,,fee schedule,1268.37,3532.33,APC
Lso sc r pos/lat pnl pre cst,L0633,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,908.38,,,,,,,fee schedule,354.31,986.69,
Lso sc r pos/lat pnl pre cst,L0633,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,986.69,,,,,,,fee schedule,354.31,986.69,
Lso sc r pos/lat pnl pre cst,L0633,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,790.92,,,,,,,fee schedule,354.31,986.69,
Lso sc r pos/lat pnl pre cst,L0633,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,864.01,,,,,,,fee schedule,354.31,986.69,
Lso sc r pos/lat pnl pre cst,L0633,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,372.03,,,,,,,fee schedule,354.31,986.69,APC
Lso sc r pos/lat pnl pre cst,L0633,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,368.48,,,,,,,fee schedule,354.31,986.69,APC
Lso sc r pos/lat pnl pre cst,L0633,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,354.31,,,,,,,fee schedule,354.31,986.69,APC
Lso sc r pos/lat pnl pre cst,L0633,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,542.09,,,,,,,fee schedule,354.31,986.69,Radiology
Lso sc r pos/lat pnl pre cst,L0633,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,496.03,,,,,,,fee schedule,354.31,986.69,APC
Lso sc r pos/lat pnl pre cst,L0633,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,620.04,,,,,,,fee schedule,354.31,986.69,APC
Lso sagit rigid panel prefab,L0635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3134.33,,,,,,,fee schedule,1222.44,3404.53,
Lso sagit rigid panel prefab,L0635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3404.53,,,,,,,fee schedule,1222.44,3404.53,
Lso sagit rigid panel prefab,L0635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2729.03,,,,,,,fee schedule,1222.44,3404.53,
Lso sagit rigid panel prefab,L0635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2981.22,,,,,,,fee schedule,1222.44,3404.53,
Lso sagit rigid panel prefab,L0635,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1283.56,,,,,,,fee schedule,1222.44,3404.53,APC
Lso sagit rigid panel prefab,L0635,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1271.34,,,,,,,fee schedule,1222.44,3404.53,APC
Lso sagit rigid panel prefab,L0635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1222.44,,,,,,,fee schedule,1222.44,3404.53,APC
Lso sagit rigid panel prefab,L0635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1870.33,,,,,,,fee schedule,1222.44,3404.53,Radiology
Lso sagit rigid panel prefab,L0635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1711.42,,,,,,,fee schedule,1222.44,3404.53,APC
Lso sagit rigid panel prefab,L0635,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2139.27,,,,,,,fee schedule,1222.44,3404.53,APC
Lso sagittal rigid panel cus,L0636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4249.01,,,,,,,fee schedule,1657.19,4615.3,
Lso sagittal rigid panel cus,L0636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4615.3,,,,,,,fee schedule,1657.19,4615.3,
Lso sagittal rigid panel cus,L0636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3699.57,,,,,,,fee schedule,1657.19,4615.3,
Lso sagittal rigid panel cus,L0636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4041.44,,,,,,,fee schedule,1657.19,4615.3,
Lso sagittal rigid panel cus,L0636,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1740.05,,,,,,,fee schedule,1657.19,4615.3,APC
Lso sagittal rigid panel cus,L0636,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1723.48,,,,,,,fee schedule,1657.19,4615.3,APC
Lso sagittal rigid panel cus,L0636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1657.19,,,,,,,fee schedule,1657.19,4615.3,APC
Lso sagittal rigid panel cus,L0636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2535.5,,,,,,,fee schedule,1657.19,4615.3,Radiology
Lso sagittal rigid panel cus,L0636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2320.07,,,,,,,fee schedule,1657.19,4615.3,APC
Lso sagittal rigid panel cus,L0636,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2900.08,,,,,,,fee schedule,1657.19,4615.3,APC
Lso sc r ant/pos pnl pre cst,L0637,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3848.57,,,,,,,fee schedule,1501.02,4180.34,
Lso sc r ant/pos pnl pre cst,L0637,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4180.34,,,,,,,fee schedule,1501.02,4180.34,
Lso sc r ant/pos pnl pre cst,L0637,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3350.91,,,,,,,fee schedule,1501.02,4180.34,
Lso sc r ant/pos pnl pre cst,L0637,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3660.56,,,,,,,fee schedule,1501.02,4180.34,
Lso sc r ant/pos pnl pre cst,L0637,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1576.07,,,,,,,fee schedule,1501.02,4180.34,APC
Lso sc r ant/pos pnl pre cst,L0637,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1561.06,,,,,,,fee schedule,1501.02,4180.34,APC
Lso sc r ant/pos pnl pre cst,L0637,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1501.02,,,,,,,fee schedule,1501.02,4180.34,APC
Lso sc r ant/pos pnl pre cst,L0637,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2296.56,,,,,,,fee schedule,1501.02,4180.34,Radiology
Lso sc r ant/pos pnl pre cst,L0637,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2101.43,,,,,,,fee schedule,1501.02,4180.34,APC
Lso sc r ant/pos pnl pre cst,L0637,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2626.78,,,,,,,fee schedule,1501.02,4180.34,APC
Lso sag-coronal panel custom,L0638,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4177.98,,,,,,,fee schedule,1629.51,4538.15,
Lso sag-coronal panel custom,L0638,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4538.15,,,,,,,fee schedule,1629.51,4538.15,
Lso sag-coronal panel custom,L0638,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3637.73,,,,,,,fee schedule,1629.51,4538.15,
Lso sag-coronal panel custom,L0638,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3973.89,,,,,,,fee schedule,1629.51,4538.15,
Lso sag-coronal panel custom,L0638,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1710.99,,,,,,,fee schedule,1629.51,4538.15,APC
Lso sag-coronal panel custom,L0638,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1694.69,,,,,,,fee schedule,1629.51,4538.15,APC
Lso sag-coronal panel custom,L0638,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1629.51,,,,,,,fee schedule,1629.51,4538.15,APC
Lso sag-coronal panel custom,L0638,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2493.15,,,,,,,fee schedule,1629.51,4538.15,Radiology
Lso sag-coronal panel custom,L0638,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2281.31,,,,,,,fee schedule,1629.51,4538.15,APC
Lso sag-coronal panel custom,L0638,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2851.64,,,,,,,fee schedule,1629.51,4538.15,APC
Lso s/c shell/panel prefab,L0639,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3848.57,,,,,,,fee schedule,1501.02,4180.34,
Lso s/c shell/panel prefab,L0639,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4180.34,,,,,,,fee schedule,1501.02,4180.34,
Lso s/c shell/panel prefab,L0639,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3350.91,,,,,,,fee schedule,1501.02,4180.34,
Lso s/c shell/panel prefab,L0639,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3660.56,,,,,,,fee schedule,1501.02,4180.34,
Lso s/c shell/panel prefab,L0639,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1576.07,,,,,,,fee schedule,1501.02,4180.34,APC
Lso s/c shell/panel prefab,L0639,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1561.06,,,,,,,fee schedule,1501.02,4180.34,APC
Lso s/c shell/panel prefab,L0639,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1501.02,,,,,,,fee schedule,1501.02,4180.34,APC
Lso s/c shell/panel prefab,L0639,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2296.56,,,,,,,fee schedule,1501.02,4180.34,Radiology
Lso s/c shell/panel prefab,L0639,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2101.43,,,,,,,fee schedule,1501.02,4180.34,APC
Lso s/c shell/panel prefab,L0639,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2626.78,,,,,,,fee schedule,1501.02,4180.34,APC
Lso s/c shell/panel custom,L0640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3314.63,,,,,,,fee schedule,1292.78,3600.37,
Lso s/c shell/panel custom,L0640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3600.37,,,,,,,fee schedule,1292.78,3600.37,
Lso s/c shell/panel custom,L0640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2886.01,,,,,,,fee schedule,1292.78,3600.37,
Lso s/c shell/panel custom,L0640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3152.71,,,,,,,fee schedule,1292.78,3600.37,
Lso s/c shell/panel custom,L0640,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1357.42,,,,,,,fee schedule,1292.78,3600.37,APC
Lso s/c shell/panel custom,L0640,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1344.49,,,,,,,fee schedule,1292.78,3600.37,APC
Lso s/c shell/panel custom,L0640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1292.78,,,,,,,fee schedule,1292.78,3600.37,APC
Lso s/c shell/panel custom,L0640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1977.95,,,,,,,fee schedule,1292.78,3600.37,Radiology
Lso s/c shell/panel custom,L0640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1809.89,,,,,,,fee schedule,1292.78,3600.37,APC
Lso s/c shell/panel custom,L0640,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2262.36,,,,,,,fee schedule,1292.78,3600.37,APC
Lo rig pos pnl l1-l5 pre ots,L0641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,261.03,,,,,,,fee schedule,57.1,283.54,
Lo rig pos pnl l1-l5 pre ots,L0641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,283.54,,,,,,,fee schedule,57.1,283.54,
Lo rig pos pnl l1-l5 pre ots,L0641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,227.28,,,,,,,fee schedule,57.1,283.54,
Lo rig pos pnl l1-l5 pre ots,L0641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,248.28,,,,,,,fee schedule,57.1,283.54,
Lo rig pos pnl l1-l5 pre ots,L0641,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,59.96,,,,,,,fee schedule,57.1,283.54,APC
Lo rig pos pnl l1-l5 pre ots,L0641,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,59.38,,,,,,,fee schedule,57.1,283.54,APC
Lo rig pos pnl l1-l5 pre ots,L0641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,57.1,,,,,,,fee schedule,57.1,283.54,APC
Lo rig pos pnl l1-l5 pre ots,L0641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,87.36,,,,,,,fee schedule,57.1,283.54,Radiology
Lo rig pos pnl l1-l5 pre ots,L0641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,79.94,,,,,,,fee schedule,57.1,283.54,APC
Lo rig pos pnl l1-l5 pre ots,L0641,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,99.92,,,,,,,fee schedule,57.1,283.54,APC
Lo sag ri an/pos pnl pre ots,L0642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1376.51,,,,,,,fee schedule,301.13,1495.18,
Lo sag ri an/pos pnl pre ots,L0642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1495.18,,,,,,,fee schedule,301.13,1495.18,
Lo sag ri an/pos pnl pre ots,L0642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1198.52,,,,,,,fee schedule,301.13,1495.18,
Lo sag ri an/pos pnl pre ots,L0642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1309.27,,,,,,,fee schedule,301.13,1495.18,
Lo sag ri an/pos pnl pre ots,L0642,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,316.19,,,,,,,fee schedule,301.13,1495.18,APC
Lo sag ri an/pos pnl pre ots,L0642,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,313.18,,,,,,,fee schedule,301.13,1495.18,APC
Lo sag ri an/pos pnl pre ots,L0642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,301.13,,,,,,,fee schedule,301.13,1495.18,APC
Lo sag ri an/pos pnl pre ots,L0642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,460.73,,,,,,,fee schedule,301.13,1495.18,Radiology
Lo sag ri an/pos pnl pre ots,L0642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,421.58,,,,,,,fee schedule,301.13,1495.18,APC
Lo sag ri an/pos pnl pre ots,L0642,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,526.98,,,,,,,fee schedule,301.13,1495.18,APC
Lso sag ctr rigi pos pre ots,L0643,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,542.25,,,,,,,fee schedule,118.63,589,
Lso sag ctr rigi pos pre ots,L0643,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,589,,,,,,,fee schedule,118.63,589,
Lso sag ctr rigi pos pre ots,L0643,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,472.13,,,,,,,fee schedule,118.63,589,
Lso sag ctr rigi pos pre ots,L0643,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,515.76,,,,,,,fee schedule,118.63,589,
Lso sag ctr rigi pos pre ots,L0643,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,124.56,,,,,,,fee schedule,118.63,589,APC
Lso sag ctr rigi pos pre ots,L0643,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,123.38,,,,,,,fee schedule,118.63,589,APC
Lso sag ctr rigi pos pre ots,L0643,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,118.63,,,,,,,fee schedule,118.63,589,APC
Lso sag ctr rigi pos pre ots,L0643,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,181.5,,,,,,,fee schedule,118.63,589,Radiology
Lso sag ctr rigi pos pre ots,L0643,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,166.08,,,,,,,fee schedule,118.63,589,APC
Lso sag ctr rigi pos pre ots,L0643,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,207.6,,,,,,,fee schedule,118.63,589,APC
Lso sag r an/pos pnl pre ots,L0648,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3437.72,,,,,,,fee schedule,752.04,3734.07,
Lso sag r an/pos pnl pre ots,L0648,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3734.07,,,,,,,fee schedule,752.04,3734.07,
Lso sag r an/pos pnl pre ots,L0648,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2993.19,,,,,,,fee schedule,752.04,3734.07,
Lso sag r an/pos pnl pre ots,L0648,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3269.78,,,,,,,fee schedule,752.04,3734.07,
Lso sag r an/pos pnl pre ots,L0648,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,789.64,,,,,,,fee schedule,752.04,3734.07,APC
Lso sag r an/pos pnl pre ots,L0648,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,782.12,,,,,,,fee schedule,752.04,3734.07,APC
Lso sag r an/pos pnl pre ots,L0648,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,752.04,,,,,,,fee schedule,752.04,3734.07,APC
Lso sag r an/pos pnl pre ots,L0648,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1150.62,,,,,,,fee schedule,752.04,3734.07,Radiology
Lso sag r an/pos pnl pre ots,L0648,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1052.86,,,,,,,fee schedule,752.04,3734.07,APC
Lso sag r an/pos pnl pre ots,L0648,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1316.07,,,,,,,fee schedule,752.04,3734.07,APC
Lso sc r pos/lat pnl pre ots,L0649,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,960.27,,,,,,,fee schedule,210.07,1043.05,
Lso sc r pos/lat pnl pre ots,L0649,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1043.05,,,,,,,fee schedule,210.07,1043.05,
Lso sc r pos/lat pnl pre ots,L0649,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,836.1,,,,,,,fee schedule,210.07,1043.05,
Lso sc r pos/lat pnl pre ots,L0649,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,913.36,,,,,,,fee schedule,210.07,1043.05,
Lso sc r pos/lat pnl pre ots,L0649,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,220.57,,,,,,,fee schedule,210.07,1043.05,APC
Lso sc r pos/lat pnl pre ots,L0649,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,218.47,,,,,,,fee schedule,210.07,1043.05,APC
Lso sc r pos/lat pnl pre ots,L0649,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,210.07,,,,,,,fee schedule,210.07,1043.05,APC
Lso sc r pos/lat pnl pre ots,L0649,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,321.41,,,,,,,fee schedule,210.07,1043.05,Radiology
Lso sc r pos/lat pnl pre ots,L0649,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,294.1,,,,,,,fee schedule,210.07,1043.05,APC
Lso sc r pos/lat pnl pre ots,L0649,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,367.62,,,,,,,fee schedule,210.07,1043.05,APC
Lso sc r ant/pos pnl pre ots,L0650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4068.29,,,,,,,fee schedule,870.15,4419.01,
Lso sc r ant/pos pnl pre ots,L0650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4419.01,,,,,,,fee schedule,870.15,4419.01,
Lso sc r ant/pos pnl pre ots,L0650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3542.22,,,,,,,fee schedule,870.15,4419.01,
Lso sc r ant/pos pnl pre ots,L0650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3869.56,,,,,,,fee schedule,870.15,4419.01,
Lso sc r ant/pos pnl pre ots,L0650,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,913.66,,,,,,,fee schedule,870.15,4419.01,APC
Lso sc r ant/pos pnl pre ots,L0650,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,904.96,,,,,,,fee schedule,870.15,4419.01,APC
Lso sc r ant/pos pnl pre ots,L0650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,870.15,,,,,,,fee schedule,870.15,4419.01,APC
Lso sc r ant/pos pnl pre ots,L0650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1331.33,,,,,,,fee schedule,870.15,4419.01,Radiology
Lso sc r ant/pos pnl pre ots,L0650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1218.21,,,,,,,fee schedule,870.15,4419.01,APC
Lso sc r ant/pos pnl pre ots,L0650,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1522.76,,,,,,,fee schedule,870.15,4419.01,APC
LSO sag-co shell pnl pre ots,L0651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4068.29,,,,,,,fee schedule,870.15,4419.01,
LSO sag-co shell pnl pre ots,L0651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4419.01,,,,,,,fee schedule,870.15,4419.01,
LSO sag-co shell pnl pre ots,L0651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3542.22,,,,,,,fee schedule,870.15,4419.01,
LSO sag-co shell pnl pre ots,L0651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3869.56,,,,,,,fee schedule,870.15,4419.01,
LSO sag-co shell pnl pre ots,L0651,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,913.66,,,,,,,fee schedule,870.15,4419.01,APC
LSO sag-co shell pnl pre ots,L0651,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,904.96,,,,,,,fee schedule,870.15,4419.01,APC
LSO sag-co shell pnl pre ots,L0651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,870.15,,,,,,,fee schedule,870.15,4419.01,APC
LSO sag-co shell pnl pre ots,L0651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1331.33,,,,,,,fee schedule,870.15,4419.01,Radiology
LSO sag-co shell pnl pre ots,L0651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1218.21,,,,,,,fee schedule,870.15,4419.01,APC
LSO sag-co shell pnl pre ots,L0651,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1522.76,,,,,,,fee schedule,870.15,4419.01,APC
Ctlso a-p-l control molded,L0700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6046.19,,,,,,,fee schedule,2358.12,6567.41,
Ctlso a-p-l control molded,L0700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6567.41,,,,,,,fee schedule,2358.12,6567.41,
Ctlso a-p-l control molded,L0700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5264.35,,,,,,,fee schedule,2358.12,6567.41,
Ctlso a-p-l control molded,L0700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5750.83,,,,,,,fee schedule,2358.12,6567.41,
Ctlso a-p-l control molded,L0700,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2476.03,,,,,,,fee schedule,2358.12,6567.41,APC
Ctlso a-p-l control molded,L0700,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2452.44,,,,,,,fee schedule,2358.12,6567.41,APC
Ctlso a-p-l control molded,L0700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2358.12,,,,,,,fee schedule,2358.12,6567.41,APC
Ctlso a-p-l control molded,L0700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3607.92,,,,,,,fee schedule,2358.12,6567.41,Radiology
Ctlso a-p-l control molded,L0700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3301.37,,,,,,,fee schedule,2358.12,6567.41,APC
Ctlso a-p-l control molded,L0700,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4126.71,,,,,,,fee schedule,2358.12,6567.41,APC
Ctlso a-p-l control w/ inter,L0710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6513.27,,,,,,,fee schedule,2540.31,7074.76,
Ctlso a-p-l control w/ inter,L0710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7074.76,,,,,,,fee schedule,2540.31,7074.76,
Ctlso a-p-l control w/ inter,L0710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5671.04,,,,,,,fee schedule,2540.31,7074.76,
Ctlso a-p-l control w/ inter,L0710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6195.1,,,,,,,fee schedule,2540.31,7074.76,
Ctlso a-p-l control w/ inter,L0710,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2667.33,,,,,,,fee schedule,2540.31,7074.76,APC
Ctlso a-p-l control w/ inter,L0710,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2641.92,,,,,,,fee schedule,2540.31,7074.76,APC
Ctlso a-p-l control w/ inter,L0710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2540.31,,,,,,,fee schedule,2540.31,7074.76,APC
Ctlso a-p-l control w/ inter,L0710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3886.67,,,,,,,fee schedule,2540.31,7074.76,Radiology
Ctlso a-p-l control w/ inter,L0710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3556.43,,,,,,,fee schedule,2540.31,7074.76,APC
Ctlso a-p-l control w/ inter,L0710,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4445.54,,,,,,,fee schedule,2540.31,7074.76,APC
Halo cervical into jckt vest,L0810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8069.15,,,,,,,fee schedule,3147.13,8764.76,
Halo cervical into jckt vest,L0810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8764.76,,,,,,,fee schedule,3147.13,8764.76,
Halo cervical into jckt vest,L0810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7025.72,,,,,,,fee schedule,3147.13,8764.76,
Halo cervical into jckt vest,L0810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7674.96,,,,,,,fee schedule,3147.13,8764.76,
Halo cervical into jckt vest,L0810,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3304.49,,,,,,,fee schedule,3147.13,8764.76,APC
Halo cervical into jckt vest,L0810,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3273.02,,,,,,,fee schedule,3147.13,8764.76,APC
Halo cervical into jckt vest,L0810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3147.13,,,,,,,fee schedule,3147.13,8764.76,APC
Halo cervical into jckt vest,L0810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4815.11,,,,,,,fee schedule,3147.13,8764.76,Radiology
Halo cervical into jckt vest,L0810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4405.98,,,,,,,fee schedule,3147.13,8764.76,APC
Halo cervical into jckt vest,L0810,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5507.48,,,,,,,fee schedule,3147.13,8764.76,APC
Halo cervical into body jack,L0820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6806.78,,,,,,,fee schedule,2654.79,7393.57,
Halo cervical into body jack,L0820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7393.57,,,,,,,fee schedule,2654.79,7393.57,
Halo cervical into body jack,L0820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5926.59,,,,,,,fee schedule,2654.79,7393.57,
Halo cervical into body jack,L0820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6474.26,,,,,,,fee schedule,2654.79,7393.57,
Halo cervical into body jack,L0820,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2787.53,,,,,,,fee schedule,2654.79,7393.57,APC
Halo cervical into body jack,L0820,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2760.98,,,,,,,fee schedule,2654.79,7393.57,APC
Halo cervical into body jack,L0820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2654.79,,,,,,,fee schedule,2654.79,7393.57,APC
Halo cervical into body jack,L0820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4061.83,,,,,,,fee schedule,2654.79,7393.57,Radiology
Halo cervical into body jack,L0820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3716.71,,,,,,,fee schedule,2654.79,7393.57,APC
Halo cervical into body jack,L0820,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4645.88,,,,,,,fee schedule,2654.79,7393.57,APC
Halo cerv into milwaukee typ,L0830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10906.04,,,,,,,fee schedule,4253.6,11846.22,
Halo cerv into milwaukee typ,L0830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11846.22,,,,,,,fee schedule,4253.6,11846.22,
Halo cerv into milwaukee typ,L0830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9495.78,,,,,,,fee schedule,4253.6,11846.22,
Halo cerv into milwaukee typ,L0830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10373.28,,,,,,,fee schedule,4253.6,11846.22,
Halo cerv into milwaukee typ,L0830,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4466.28,,,,,,,fee schedule,4253.6,11846.22,APC
Halo cerv into milwaukee typ,L0830,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4423.74,,,,,,,fee schedule,4253.6,11846.22,APC
Halo cerv into milwaukee typ,L0830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4253.6,,,,,,,fee schedule,4253.6,11846.22,APC
Halo cerv into milwaukee typ,L0830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6508.01,,,,,,,fee schedule,4253.6,11846.22,Radiology
Halo cerv into milwaukee typ,L0830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5955.04,,,,,,,fee schedule,4253.6,11846.22,APC
Halo cerv into milwaukee typ,L0830,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7443.8,,,,,,,fee schedule,4253.6,11846.22,APC
MRI compatible system,L0859,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4785.73,,,,,,,fee schedule,1866.53,5198.29,
MRI compatible system,L0859,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5198.29,,,,,,,fee schedule,1866.53,5198.29,
MRI compatible system,L0859,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4166.89,,,,,,,fee schedule,1866.53,5198.29,
MRI compatible system,L0859,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4551.95,,,,,,,fee schedule,1866.53,5198.29,
MRI compatible system,L0859,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1959.86,,,,,,,fee schedule,1866.53,5198.29,APC
MRI compatible system,L0859,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1941.19,,,,,,,fee schedule,1866.53,5198.29,APC
MRI compatible system,L0859,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1866.53,,,,,,,fee schedule,1866.53,5198.29,APC
MRI compatible system,L0859,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2855.79,,,,,,,fee schedule,1866.53,5198.29,Radiology
MRI compatible system,L0859,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2613.14,,,,,,,fee schedule,1866.53,5198.29,APC
MRI compatible system,L0859,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3266.43,,,,,,,fee schedule,1866.53,5198.29,APC
Halo repl liner/interface,L0861,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,682.81,,,,,,,fee schedule,266.31,741.67,
Halo repl liner/interface,L0861,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,741.67,,,,,,,fee schedule,266.31,741.67,
Halo repl liner/interface,L0861,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,594.52,,,,,,,fee schedule,266.31,741.67,
Halo repl liner/interface,L0861,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,649.46,,,,,,,fee schedule,266.31,741.67,
Halo repl liner/interface,L0861,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,279.63,,,,,,,fee schedule,266.31,741.67,APC
Halo repl liner/interface,L0861,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,276.96,,,,,,,fee schedule,266.31,741.67,APC
Halo repl liner/interface,L0861,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,266.31,,,,,,,fee schedule,266.31,741.67,APC
Halo repl liner/interface,L0861,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,407.45,,,,,,,fee schedule,266.31,741.67,Radiology
Halo repl liner/interface,L0861,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,372.83,,,,,,,fee schedule,266.31,741.67,APC
Halo repl liner/interface,L0861,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,466.04,,,,,,,fee schedule,266.31,741.67,APC
Tlso corset front,L0970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,428.35,,,,,,,fee schedule,167.07,465.28,
Tlso corset front,L0970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,465.28,,,,,,,fee schedule,167.07,465.28,
Tlso corset front,L0970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,372.96,,,,,,,fee schedule,167.07,465.28,
Tlso corset front,L0970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,407.43,,,,,,,fee schedule,167.07,465.28,
Tlso corset front,L0970,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,175.42,,,,,,,fee schedule,167.07,465.28,APC
Tlso corset front,L0970,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,173.75,,,,,,,fee schedule,167.07,465.28,APC
Tlso corset front,L0970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,167.07,,,,,,,fee schedule,167.07,465.28,APC
Tlso corset front,L0970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,255.62,,,,,,,fee schedule,167.07,465.28,Radiology
Tlso corset front,L0970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,233.9,,,,,,,fee schedule,167.07,465.28,APC
Tlso corset front,L0970,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,292.37,,,,,,,fee schedule,167.07,465.28,APC
Lso corset front,L0972,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,391.71,,,,,,,fee schedule,152.77,425.48,
Lso corset front,L0972,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,425.48,,,,,,,fee schedule,152.77,425.48,
Lso corset front,L0972,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,341.06,,,,,,,fee schedule,152.77,425.48,
Lso corset front,L0972,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,372.57,,,,,,,fee schedule,152.77,425.48,
Lso corset front,L0972,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,160.41,,,,,,,fee schedule,152.77,425.48,APC
Lso corset front,L0972,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,158.88,,,,,,,fee schedule,152.77,425.48,APC
Lso corset front,L0972,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,152.77,,,,,,,fee schedule,152.77,425.48,APC
Lso corset front,L0972,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,233.74,,,,,,,fee schedule,152.77,425.48,Radiology
Lso corset front,L0972,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,213.88,,,,,,,fee schedule,152.77,425.48,APC
Lso corset front,L0972,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,267.35,,,,,,,fee schedule,152.77,425.48,APC
Tlso full corset,L0974,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,592.16,,,,,,,fee schedule,230.94,643.2,
Tlso full corset,L0974,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,643.2,,,,,,,fee schedule,230.94,643.2,
Tlso full corset,L0974,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,515.58,,,,,,,fee schedule,230.94,643.2,
Tlso full corset,L0974,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,563.23,,,,,,,fee schedule,230.94,643.2,
Tlso full corset,L0974,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,242.49,,,,,,,fee schedule,230.94,643.2,APC
Tlso full corset,L0974,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,240.18,,,,,,,fee schedule,230.94,643.2,APC
Tlso full corset,L0974,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,230.94,,,,,,,fee schedule,230.94,643.2,APC
Tlso full corset,L0974,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,353.34,,,,,,,fee schedule,230.94,643.2,Radiology
Tlso full corset,L0974,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,323.32,,,,,,,fee schedule,230.94,643.2,APC
Tlso full corset,L0974,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,404.14,,,,,,,fee schedule,230.94,643.2,APC
Lso full corset,L0976,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,554.5,,,,,,,fee schedule,216.26,602.31,
Lso full corset,L0976,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,602.31,,,,,,,fee schedule,216.26,602.31,
Lso full corset,L0976,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,482.8,,,,,,,fee schedule,216.26,602.31,
Lso full corset,L0976,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,527.42,,,,,,,fee schedule,216.26,602.31,
Lso full corset,L0976,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,227.07,,,,,,,fee schedule,216.26,602.31,APC
Lso full corset,L0976,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,224.91,,,,,,,fee schedule,216.26,602.31,APC
Lso full corset,L0976,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,216.26,,,,,,,fee schedule,216.26,602.31,APC
Lso full corset,L0976,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.88,,,,,,,fee schedule,216.26,602.31,Radiology
Lso full corset,L0976,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,302.76,,,,,,,fee schedule,216.26,602.31,APC
Lso full corset,L0976,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,378.46,,,,,,,fee schedule,216.26,602.31,APC
Axillary crutch extension,L0978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,580.92,,,,,,,fee schedule,226.58,631,
Axillary crutch extension,L0978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,631,,,,,,,fee schedule,226.58,631,
Axillary crutch extension,L0978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,505.8,,,,,,,fee schedule,226.58,631,
Axillary crutch extension,L0978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,552.54,,,,,,,fee schedule,226.58,631,
Axillary crutch extension,L0978,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,237.91,,,,,,,fee schedule,226.58,631,APC
Axillary crutch extension,L0978,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,235.64,,,,,,,fee schedule,226.58,631,APC
Axillary crutch extension,L0978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,226.58,,,,,,,fee schedule,226.58,631,APC
Axillary crutch extension,L0978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,346.67,,,,,,,fee schedule,226.58,631,Radiology
Axillary crutch extension,L0978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,317.21,,,,,,,fee schedule,226.58,631,APC
Axillary crutch extension,L0978,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,396.52,,,,,,,fee schedule,226.58,631,APC
Peroneal straps pair pre ots,L0980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,68.59,,,,,,,fee schedule,26.75,74.5,
Peroneal straps pair pre ots,L0980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,74.5,,,,,,,fee schedule,26.75,74.5,
Peroneal straps pair pre ots,L0980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,59.72,,,,,,,fee schedule,26.75,74.5,
Peroneal straps pair pre ots,L0980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,65.24,,,,,,,fee schedule,26.75,74.5,
Peroneal straps pair pre ots,L0980,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,28.09,,,,,,,fee schedule,26.75,74.5,APC
Peroneal straps pair pre ots,L0980,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,27.82,,,,,,,fee schedule,26.75,74.5,APC
Peroneal straps pair pre ots,L0980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,26.75,,,,,,,fee schedule,26.75,74.5,APC
Peroneal straps pair pre ots,L0980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40.93,,,,,,,fee schedule,26.75,74.5,Radiology
Peroneal straps pair pre ots,L0980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,37.45,,,,,,,fee schedule,26.75,74.5,APC
Peroneal straps pair pre ots,L0980,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,46.81,,,,,,,fee schedule,26.75,74.5,APC
Stocking sup grips 4 pre ots,L0982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,63.96,,,,,,,fee schedule,24.95,69.48,
Stocking sup grips 4 pre ots,L0982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,69.48,,,,,,,fee schedule,24.95,69.48,
Stocking sup grips 4 pre ots,L0982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55.69,,,,,,,fee schedule,24.95,69.48,
Stocking sup grips 4 pre ots,L0982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,60.84,,,,,,,fee schedule,24.95,69.48,
Stocking sup grips 4 pre ots,L0982,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,26.2,,,,,,,fee schedule,24.95,69.48,APC
Stocking sup grips 4 pre ots,L0982,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,25.95,,,,,,,fee schedule,24.95,69.48,APC
Stocking sup grips 4 pre ots,L0982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,24.95,,,,,,,fee schedule,24.95,69.48,APC
Stocking sup grips 4 pre ots,L0982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,38.17,,,,,,,fee schedule,24.95,69.48,Radiology
Stocking sup grips 4 pre ots,L0982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,34.93,,,,,,,fee schedule,24.95,69.48,APC
Stocking sup grips 4 pre ots,L0982,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,43.66,,,,,,,fee schedule,24.95,69.48,APC
Protect body sock ea pre ots,L0984,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,178.91,,,,,,,fee schedule,69.77,194.33,
Protect body sock ea pre ots,L0984,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,194.33,,,,,,,fee schedule,69.77,194.33,
Protect body sock ea pre ots,L0984,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,155.77,,,,,,,fee schedule,69.77,194.33,
Protect body sock ea pre ots,L0984,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,170.17,,,,,,,fee schedule,69.77,194.33,
Protect body sock ea pre ots,L0984,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,73.26,,,,,,,fee schedule,69.77,194.33,APC
Protect body sock ea pre ots,L0984,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,72.56,,,,,,,fee schedule,69.77,194.33,APC
Protect body sock ea pre ots,L0984,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,69.77,,,,,,,fee schedule,69.77,194.33,APC
Protect body sock ea pre ots,L0984,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,106.75,,,,,,,fee schedule,69.77,194.33,Radiology
Protect body sock ea pre ots,L0984,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,97.68,,,,,,,fee schedule,69.77,194.33,APC
Protect body sock ea pre ots,L0984,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,122.1,,,,,,,fee schedule,69.77,194.33,APC
Ctlso milwauke initial model,L1000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6503.25,,,,,,,fee schedule,2536.39,7063.88,
Ctlso milwauke initial model,L1000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7063.88,,,,,,,fee schedule,2536.39,7063.88,
Ctlso milwauke initial model,L1000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5662.31,,,,,,,fee schedule,2536.39,7063.88,
Ctlso milwauke initial model,L1000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6185.56,,,,,,,fee schedule,2536.39,7063.88,
Ctlso milwauke initial model,L1000,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2663.21,,,,,,,fee schedule,2536.39,7063.88,APC
Ctlso milwauke initial model,L1000,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2637.85,,,,,,,fee schedule,2536.39,7063.88,APC
Ctlso milwauke initial model,L1000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2536.39,,,,,,,fee schedule,2536.39,7063.88,APC
Ctlso milwauke initial model,L1000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3880.68,,,,,,,fee schedule,2536.39,7063.88,Radiology
Ctlso milwauke initial model,L1000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3550.95,,,,,,,fee schedule,2536.39,7063.88,APC
Ctlso milwauke initial model,L1000,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4438.68,,,,,,,fee schedule,2536.39,7063.88,APC
Tension based scoliosis orth,L1005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10138.91,,,,,,,fee schedule,3954.38,11012.95,
Tension based scoliosis orth,L1005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11012.95,,,,,,,fee schedule,3954.38,11012.95,
Tension based scoliosis orth,L1005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8827.84,,,,,,,fee schedule,3954.38,11012.95,
Tension based scoliosis orth,L1005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9643.62,,,,,,,fee schedule,3954.38,11012.95,
Tension based scoliosis orth,L1005,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4152.1,,,,,,,fee schedule,3954.38,11012.95,APC
Tension based scoliosis orth,L1005,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4112.56,,,,,,,fee schedule,3954.38,11012.95,APC
Tension based scoliosis orth,L1005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3954.38,,,,,,,fee schedule,3954.38,11012.95,APC
Tension based scoliosis orth,L1005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6050.2,,,,,,,fee schedule,3954.38,11012.95,Radiology
Tension based scoliosis orth,L1005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5536.13,,,,,,,fee schedule,3954.38,11012.95,APC
Tension based scoliosis orth,L1005,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6920.16,,,,,,,fee schedule,3954.38,11012.95,APC
Ctlso axilla sling,L1010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,233.02,,,,,,,fee schedule,90.9,253.11,
Ctlso axilla sling,L1010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,253.11,,,,,,,fee schedule,90.9,253.11,
Ctlso axilla sling,L1010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,202.89,,,,,,,fee schedule,90.9,253.11,
Ctlso axilla sling,L1010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,221.64,,,,,,,fee schedule,90.9,253.11,
Ctlso axilla sling,L1010,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,95.44,,,,,,,fee schedule,90.9,253.11,APC
Ctlso axilla sling,L1010,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,94.54,,,,,,,fee schedule,90.9,253.11,APC
Ctlso axilla sling,L1010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,90.9,,,,,,,fee schedule,90.9,253.11,APC
Ctlso axilla sling,L1010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,139.08,,,,,,,fee schedule,90.9,253.11,Radiology
Ctlso axilla sling,L1010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,127.26,,,,,,,fee schedule,90.9,253.11,APC
Ctlso axilla sling,L1010,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,159.08,,,,,,,fee schedule,90.9,253.11,APC
Kyphosis pad,L1020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,322.87,,,,,,,fee schedule,125.95,350.71,
Kyphosis pad,L1020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,350.71,,,,,,,fee schedule,125.95,350.71,
Kyphosis pad,L1020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,281.12,,,,,,,fee schedule,125.95,350.71,
Kyphosis pad,L1020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,307.1,,,,,,,fee schedule,125.95,350.71,
Kyphosis pad,L1020,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,132.25,,,,,,,fee schedule,125.95,350.71,APC
Kyphosis pad,L1020,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,130.99,,,,,,,fee schedule,125.95,350.71,APC
Kyphosis pad,L1020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,125.95,,,,,,,fee schedule,125.95,350.71,APC
Kyphosis pad,L1020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,192.7,,,,,,,fee schedule,125.95,350.71,Radiology
Kyphosis pad,L1020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,176.33,,,,,,,fee schedule,125.95,350.71,APC
Kyphosis pad,L1020,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,220.41,,,,,,,fee schedule,125.95,350.71,APC
Kyphosis pad floating,L1025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,367.38,,,,,,,fee schedule,143.3,399.05,
Kyphosis pad floating,L1025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,399.05,,,,,,,fee schedule,143.3,399.05,
Kyphosis pad floating,L1025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,319.88,,,,,,,fee schedule,143.3,399.05,
Kyphosis pad floating,L1025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,349.44,,,,,,,fee schedule,143.3,399.05,
Kyphosis pad floating,L1025,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,150.47,,,,,,,fee schedule,143.3,399.05,APC
Kyphosis pad floating,L1025,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,149.03,,,,,,,fee schedule,143.3,399.05,APC
Kyphosis pad floating,L1025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,143.3,,,,,,,fee schedule,143.3,399.05,APC
Kyphosis pad floating,L1025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,219.25,,,,,,,fee schedule,143.3,399.05,Radiology
Kyphosis pad floating,L1025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,200.62,,,,,,,fee schedule,143.3,399.05,APC
Kyphosis pad floating,L1025,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,250.78,,,,,,,fee schedule,143.3,399.05,APC
Lumbar bolster pad,L1030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,249.9,,,,,,,fee schedule,97.47,271.44,
Lumbar bolster pad,L1030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,271.44,,,,,,,fee schedule,97.47,271.44,
Lumbar bolster pad,L1030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,217.58,,,,,,,fee schedule,97.47,271.44,
Lumbar bolster pad,L1030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,237.69,,,,,,,fee schedule,97.47,271.44,
Lumbar bolster pad,L1030,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,102.34,,,,,,,fee schedule,97.47,271.44,APC
Lumbar bolster pad,L1030,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,101.37,,,,,,,fee schedule,97.47,271.44,APC
Lumbar bolster pad,L1030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,97.47,,,,,,,fee schedule,97.47,271.44,APC
Lumbar bolster pad,L1030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,149.13,,,,,,,fee schedule,97.47,271.44,Radiology
Lumbar bolster pad,L1030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,136.46,,,,,,,fee schedule,97.47,271.44,APC
Lumbar bolster pad,L1030,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,170.57,,,,,,,fee schedule,97.47,271.44,APC
Lumbar or lumbar rib pad,L1040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,261.31,,,,,,,fee schedule,101.89,283.84,
Lumbar or lumbar rib pad,L1040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,283.84,,,,,,,fee schedule,101.89,283.84,
Lumbar or lumbar rib pad,L1040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,227.52,,,,,,,fee schedule,101.89,283.84,
Lumbar or lumbar rib pad,L1040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,248.55,,,,,,,fee schedule,101.89,283.84,
Lumbar or lumbar rib pad,L1040,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,106.98,,,,,,,fee schedule,101.89,283.84,APC
Lumbar or lumbar rib pad,L1040,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,105.97,,,,,,,fee schedule,101.89,283.84,APC
Lumbar or lumbar rib pad,L1040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,101.89,,,,,,,fee schedule,101.89,283.84,APC
Lumbar or lumbar rib pad,L1040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,155.89,,,,,,,fee schedule,101.89,283.84,Radiology
Lumbar or lumbar rib pad,L1040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,142.65,,,,,,,fee schedule,101.89,283.84,APC
Lumbar or lumbar rib pad,L1040,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,178.31,,,,,,,fee schedule,101.89,283.84,APC
Sternal pad,L1050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,316.23,,,,,,,fee schedule,123.34,343.49,
Sternal pad,L1050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,343.49,,,,,,,fee schedule,123.34,343.49,
Sternal pad,L1050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,275.34,,,,,,,fee schedule,123.34,343.49,
Sternal pad,L1050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,300.78,,,,,,,fee schedule,123.34,343.49,
Sternal pad,L1050,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.51,,,,,,,fee schedule,123.34,343.49,APC
Sternal pad,L1050,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.27,,,,,,,fee schedule,123.34,343.49,APC
Sternal pad,L1050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.34,,,,,,,fee schedule,123.34,343.49,APC
Sternal pad,L1050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.71,,,,,,,fee schedule,123.34,343.49,Radiology
Sternal pad,L1050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.68,,,,,,,fee schedule,123.34,343.49,APC
Sternal pad,L1050,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.84,,,,,,,fee schedule,123.34,343.49,APC
Thoracic pad,L1060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,306.9,,,,,,,fee schedule,119.7,333.36,
Thoracic pad,L1060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,333.36,,,,,,,fee schedule,119.7,333.36,
Thoracic pad,L1060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,267.22,,,,,,,fee schedule,119.7,333.36,
Thoracic pad,L1060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,291.91,,,,,,,fee schedule,119.7,333.36,
Thoracic pad,L1060,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,125.68,,,,,,,fee schedule,119.7,333.36,APC
Thoracic pad,L1060,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,124.49,,,,,,,fee schedule,119.7,333.36,APC
Thoracic pad,L1060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,119.7,,,,,,,fee schedule,119.7,333.36,APC
Thoracic pad,L1060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,183.14,,,,,,,fee schedule,119.7,333.36,Radiology
Thoracic pad,L1060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,167.58,,,,,,,fee schedule,119.7,333.36,APC
Thoracic pad,L1060,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,209.48,,,,,,,fee schedule,119.7,333.36,APC
Trapezius sling,L1070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,300.15,,,,,,,fee schedule,117.1,326.03,
Trapezius sling,L1070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,326.03,,,,,,,fee schedule,117.1,326.03,
Trapezius sling,L1070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,261.34,,,,,,,fee schedule,117.1,326.03,
Trapezius sling,L1070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,285.49,,,,,,,fee schedule,117.1,326.03,
Trapezius sling,L1070,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,122.96,,,,,,,fee schedule,117.1,326.03,APC
Trapezius sling,L1070,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,121.78,,,,,,,fee schedule,117.1,326.03,APC
Trapezius sling,L1070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,117.1,,,,,,,fee schedule,117.1,326.03,APC
Trapezius sling,L1070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,179.16,,,,,,,fee schedule,117.1,326.03,Radiology
Trapezius sling,L1070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,163.94,,,,,,,fee schedule,117.1,326.03,APC
Trapezius sling,L1070,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,204.92,,,,,,,fee schedule,117.1,326.03,APC
Outrigger,L1080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,168.88,,,,,,,fee schedule,65.87,183.44,
Outrigger,L1080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,183.44,,,,,,,fee schedule,65.87,183.44,
Outrigger,L1080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,147.05,,,,,,,fee schedule,65.87,183.44,
Outrigger,L1080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,160.63,,,,,,,fee schedule,65.87,183.44,
Outrigger,L1080,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,69.16,,,,,,,fee schedule,65.87,183.44,APC
Outrigger,L1080,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,68.5,,,,,,,fee schedule,65.87,183.44,APC
Outrigger,L1080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,65.87,,,,,,,fee schedule,65.87,183.44,APC
Outrigger,L1080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,100.78,,,,,,,fee schedule,65.87,183.44,Radiology
Outrigger,L1080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,92.22,,,,,,,fee schedule,65.87,183.44,APC
Outrigger,L1080,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,115.27,,,,,,,fee schedule,65.87,183.44,APC
Outrigger bil w/ vert extens,L1085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,509.99,,,,,,,fee schedule,198.91,553.96,
Outrigger bil w/ vert extens,L1085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,553.96,,,,,,,fee schedule,198.91,553.96,
Outrigger bil w/ vert extens,L1085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,444.05,,,,,,,fee schedule,198.91,553.96,
Outrigger bil w/ vert extens,L1085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,485.08,,,,,,,fee schedule,198.91,553.96,
Outrigger bil w/ vert extens,L1085,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.86,,,,,,,fee schedule,198.91,553.96,APC
Outrigger bil w/ vert extens,L1085,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,206.87,,,,,,,fee schedule,198.91,553.96,APC
Outrigger bil w/ vert extens,L1085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.91,,,,,,,fee schedule,198.91,553.96,APC
Outrigger bil w/ vert extens,L1085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,304.33,,,,,,,fee schedule,198.91,553.96,Radiology
Outrigger bil w/ vert extens,L1085,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,278.47,,,,,,,fee schedule,198.91,553.96,APC
Outrigger bil w/ vert extens,L1085,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,348.09,,,,,,,fee schedule,198.91,553.96,APC
Lumbar sling,L1090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,302.03,,,,,,,fee schedule,117.8,328.07,
Lumbar sling,L1090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,328.07,,,,,,,fee schedule,117.8,328.07,
Lumbar sling,L1090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,262.97,,,,,,,fee schedule,117.8,328.07,
Lumbar sling,L1090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,287.27,,,,,,,fee schedule,117.8,328.07,
Lumbar sling,L1090,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,123.69,,,,,,,fee schedule,117.8,328.07,APC
Lumbar sling,L1090,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,122.51,,,,,,,fee schedule,117.8,328.07,APC
Lumbar sling,L1090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,117.8,,,,,,,fee schedule,117.8,328.07,APC
Lumbar sling,L1090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,180.23,,,,,,,fee schedule,117.8,328.07,Radiology
Lumbar sling,L1090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,164.92,,,,,,,fee schedule,117.8,328.07,APC
Lumbar sling,L1090,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,206.15,,,,,,,fee schedule,117.8,328.07,APC
Ring flange plastic/leather,L1100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,520.54,,,,,,,fee schedule,203.03,565.41,
Ring flange plastic/leather,L1100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,565.41,,,,,,,fee schedule,203.03,565.41,
Ring flange plastic/leather,L1100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,453.23,,,,,,,fee schedule,203.03,565.41,
Ring flange plastic/leather,L1100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,495.11,,,,,,,fee schedule,203.03,565.41,
Ring flange plastic/leather,L1100,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,213.18,,,,,,,fee schedule,203.03,565.41,APC
Ring flange plastic/leather,L1100,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,211.15,,,,,,,fee schedule,203.03,565.41,APC
Ring flange plastic/leather,L1100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,203.03,,,,,,,fee schedule,203.03,565.41,APC
Ring flange plastic/leather,L1100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,310.64,,,,,,,fee schedule,203.03,565.41,Radiology
Ring flange plastic/leather,L1100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,284.24,,,,,,,fee schedule,203.03,565.41,APC
Ring flange plastic/leather,L1100,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,355.3,,,,,,,fee schedule,203.03,565.41,APC
Ring flange plas/leather mol,L1110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,759.16,,,,,,,fee schedule,296.08,824.61,
Ring flange plas/leather mol,L1110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,824.61,,,,,,,fee schedule,296.08,824.61,
Ring flange plas/leather mol,L1110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,660.99,,,,,,,fee schedule,296.08,824.61,
Ring flange plas/leather mol,L1110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,722.08,,,,,,,fee schedule,296.08,824.61,
Ring flange plas/leather mol,L1110,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,310.88,,,,,,,fee schedule,296.08,824.61,APC
Ring flange plas/leather mol,L1110,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,307.92,,,,,,,fee schedule,296.08,824.61,APC
Ring flange plas/leather mol,L1110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,296.08,,,,,,,fee schedule,296.08,824.61,APC
Ring flange plas/leather mol,L1110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,453,,,,,,,fee schedule,296.08,824.61,Radiology
Ring flange plas/leather mol,L1110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,414.51,,,,,,,fee schedule,296.08,824.61,APC
Ring flange plas/leather mol,L1110,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,518.14,,,,,,,fee schedule,296.08,824.61,APC
Covers for upright each,L1120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,137.6,,,,,,,fee schedule,53.66,149.46,
Covers for upright each,L1120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,149.46,,,,,,,fee schedule,53.66,149.46,
Covers for upright each,L1120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,119.81,,,,,,,fee schedule,53.66,149.46,
Covers for upright each,L1120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,130.88,,,,,,,fee schedule,53.66,149.46,
Covers for upright each,L1120,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,56.34,,,,,,,fee schedule,53.66,149.46,APC
Covers for upright each,L1120,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,55.81,,,,,,,fee schedule,53.66,149.46,APC
Covers for upright each,L1120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,53.66,,,,,,,fee schedule,53.66,149.46,APC
Covers for upright each,L1120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,82.1,,,,,,,fee schedule,53.66,149.46,Radiology
Covers for upright each,L1120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,75.12,,,,,,,fee schedule,53.66,149.46,APC
Covers for upright each,L1120,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,93.9,,,,,,,fee schedule,53.66,149.46,APC
Furnsh initial orthosis only,L1200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5309.23,,,,,,,fee schedule,2070.7,5766.92,
Furnsh initial orthosis only,L1200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5766.92,,,,,,,fee schedule,2070.7,5766.92,
Furnsh initial orthosis only,L1200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4622.69,,,,,,,fee schedule,2070.7,5766.92,
Furnsh initial orthosis only,L1200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5049.87,,,,,,,fee schedule,2070.7,5766.92,
Furnsh initial orthosis only,L1200,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2174.24,,,,,,,fee schedule,2070.7,5766.92,APC
Furnsh initial orthosis only,L1200,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2153.53,,,,,,,fee schedule,2070.7,5766.92,APC
Furnsh initial orthosis only,L1200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2070.7,,,,,,,fee schedule,2070.7,5766.92,APC
Furnsh initial orthosis only,L1200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3168.17,,,,,,,fee schedule,2070.7,5766.92,Radiology
Furnsh initial orthosis only,L1200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2898.98,,,,,,,fee schedule,2070.7,5766.92,APC
Furnsh initial orthosis only,L1200,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3623.72,,,,,,,fee schedule,2070.7,5766.92,APC
Lateral thoracic extension,L1210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,770.92,,,,,,,fee schedule,300.68,837.38,
Lateral thoracic extension,L1210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,837.38,,,,,,,fee schedule,300.68,837.38,
Lateral thoracic extension,L1210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,671.24,,,,,,,fee schedule,300.68,837.38,
Lateral thoracic extension,L1210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,733.26,,,,,,,fee schedule,300.68,837.38,
Lateral thoracic extension,L1210,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,315.71,,,,,,,fee schedule,300.68,837.38,APC
Lateral thoracic extension,L1210,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,312.71,,,,,,,fee schedule,300.68,837.38,APC
Lateral thoracic extension,L1210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,300.68,,,,,,,fee schedule,300.68,837.38,APC
Lateral thoracic extension,L1210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,460.04,,,,,,,fee schedule,300.68,837.38,Radiology
Lateral thoracic extension,L1210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,420.95,,,,,,,fee schedule,300.68,837.38,APC
Lateral thoracic extension,L1210,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,526.19,,,,,,,fee schedule,300.68,837.38,APC
Anterior thoracic extension,L1220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,746.08,,,,,,,fee schedule,290.99,810.39,
Anterior thoracic extension,L1220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,810.39,,,,,,,fee schedule,290.99,810.39,
Anterior thoracic extension,L1220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,649.6,,,,,,,fee schedule,290.99,810.39,
Anterior thoracic extension,L1220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,709.63,,,,,,,fee schedule,290.99,810.39,
Anterior thoracic extension,L1220,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,305.54,,,,,,,fee schedule,290.99,810.39,APC
Anterior thoracic extension,L1220,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,302.63,,,,,,,fee schedule,290.99,810.39,APC
Anterior thoracic extension,L1220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,290.99,,,,,,,fee schedule,290.99,810.39,APC
Anterior thoracic extension,L1220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,445.21,,,,,,,fee schedule,290.99,810.39,Radiology
Anterior thoracic extension,L1220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,407.39,,,,,,,fee schedule,290.99,810.39,APC
Anterior thoracic extension,L1220,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,509.23,,,,,,,fee schedule,290.99,810.39,APC
Milwaukee type superstructur,L1230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1674.82,,,,,,,fee schedule,653.22,1819.2,
Milwaukee type superstructur,L1230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1819.2,,,,,,,fee schedule,653.22,1819.2,
Milwaukee type superstructur,L1230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1458.25,,,,,,,fee schedule,653.22,1819.2,
Milwaukee type superstructur,L1230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1593,,,,,,,fee schedule,653.22,1819.2,
Milwaukee type superstructur,L1230,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,685.88,,,,,,,fee schedule,653.22,1819.2,APC
Milwaukee type superstructur,L1230,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,679.35,,,,,,,fee schedule,653.22,1819.2,APC
Milwaukee type superstructur,L1230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,653.22,,,,,,,fee schedule,653.22,1819.2,APC
Milwaukee type superstructur,L1230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,999.43,,,,,,,fee schedule,653.22,1819.2,Radiology
Milwaukee type superstructur,L1230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,914.51,,,,,,,fee schedule,653.22,1819.2,APC
Milwaukee type superstructur,L1230,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1143.14,,,,,,,fee schedule,653.22,1819.2,APC
Lumbar derotation pad,L1240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,247.05,,,,,,,fee schedule,96.35,268.34,
Lumbar derotation pad,L1240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,268.34,,,,,,,fee schedule,96.35,268.34,
Lumbar derotation pad,L1240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,215.1,,,,,,,fee schedule,96.35,268.34,
Lumbar derotation pad,L1240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,234.98,,,,,,,fee schedule,96.35,268.34,
Lumbar derotation pad,L1240,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,101.17,,,,,,,fee schedule,96.35,268.34,APC
Lumbar derotation pad,L1240,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,100.2,,,,,,,fee schedule,96.35,268.34,APC
Lumbar derotation pad,L1240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,96.35,,,,,,,fee schedule,96.35,268.34,APC
Lumbar derotation pad,L1240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,147.42,,,,,,,fee schedule,96.35,268.34,Radiology
Lumbar derotation pad,L1240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,134.89,,,,,,,fee schedule,96.35,268.34,APC
Lumbar derotation pad,L1240,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,168.61,,,,,,,fee schedule,96.35,268.34,APC
Anterior asis pad,L1250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,239.67,,,,,,,fee schedule,93.47,260.33,
Anterior asis pad,L1250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,260.33,,,,,,,fee schedule,93.47,260.33,
Anterior asis pad,L1250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,208.68,,,,,,,fee schedule,93.47,260.33,
Anterior asis pad,L1250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,227.96,,,,,,,fee schedule,93.47,260.33,
Anterior asis pad,L1250,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,98.14,,,,,,,fee schedule,93.47,260.33,APC
Anterior asis pad,L1250,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,97.21,,,,,,,fee schedule,93.47,260.33,APC
Anterior asis pad,L1250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,93.47,,,,,,,fee schedule,93.47,260.33,APC
Anterior asis pad,L1250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,143.01,,,,,,,fee schedule,93.47,260.33,Radiology
Anterior asis pad,L1250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,130.86,,,,,,,fee schedule,93.47,260.33,APC
Anterior asis pad,L1250,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,163.57,,,,,,,fee schedule,93.47,260.33,APC
Anterior thoracic derotation,L1260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,241.16,,,,,,,fee schedule,94.04,261.95,
Anterior thoracic derotation,L1260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,261.95,,,,,,,fee schedule,94.04,261.95,
Anterior thoracic derotation,L1260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,209.98,,,,,,,fee schedule,94.04,261.95,
Anterior thoracic derotation,L1260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,229.38,,,,,,,fee schedule,94.04,261.95,
Anterior thoracic derotation,L1260,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,98.74,,,,,,,fee schedule,94.04,261.95,APC
Anterior thoracic derotation,L1260,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,97.8,,,,,,,fee schedule,94.04,261.95,APC
Anterior thoracic derotation,L1260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,94.04,,,,,,,fee schedule,94.04,261.95,APC
Anterior thoracic derotation,L1260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,143.88,,,,,,,fee schedule,94.04,261.95,Radiology
Anterior thoracic derotation,L1260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.66,,,,,,,fee schedule,94.04,261.95,APC
Anterior thoracic derotation,L1260,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,164.57,,,,,,,fee schedule,94.04,261.95,APC
Abdominal pad,L1270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,231.84,,,,,,,fee schedule,90.43,251.82,
Abdominal pad,L1270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,251.82,,,,,,,fee schedule,90.43,251.82,
Abdominal pad,L1270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,201.86,,,,,,,fee schedule,90.43,251.82,
Abdominal pad,L1270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,220.51,,,,,,,fee schedule,90.43,251.82,
Abdominal pad,L1270,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,94.95,,,,,,,fee schedule,90.43,251.82,APC
Abdominal pad,L1270,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,94.05,,,,,,,fee schedule,90.43,251.82,APC
Abdominal pad,L1270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,90.43,,,,,,,fee schedule,90.43,251.82,APC
Abdominal pad,L1270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,138.36,,,,,,,fee schedule,90.43,251.82,Radiology
Abdominal pad,L1270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,126.6,,,,,,,fee schedule,90.43,251.82,APC
Abdominal pad,L1270,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,158.25,,,,,,,fee schedule,90.43,251.82,APC
Rib gusset (elastic) each,L1280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,254.14,,,,,,,fee schedule,99.14,276.05,
Rib gusset (elastic) each,L1280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,276.05,,,,,,,fee schedule,99.14,276.05,
Rib gusset (elastic) each,L1280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,221.28,,,,,,,fee schedule,99.14,276.05,
Rib gusset (elastic) each,L1280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,241.73,,,,,,,fee schedule,99.14,276.05,
Rib gusset (elastic) each,L1280,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,104.1,,,,,,,fee schedule,99.14,276.05,APC
Rib gusset (elastic) each,L1280,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,103.11,,,,,,,fee schedule,99.14,276.05,APC
Rib gusset (elastic) each,L1280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,99.14,,,,,,,fee schedule,99.14,276.05,APC
Rib gusset (elastic) each,L1280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,151.68,,,,,,,fee schedule,99.14,276.05,Radiology
Rib gusset (elastic) each,L1280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,138.8,,,,,,,fee schedule,99.14,276.05,APC
Rib gusset (elastic) each,L1280,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,173.5,,,,,,,fee schedule,99.14,276.05,APC
Lateral trochanteric pad,L1290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,231.56,,,,,,,fee schedule,90.32,251.52,
Lateral trochanteric pad,L1290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,251.52,,,,,,,fee schedule,90.32,251.52,
Lateral trochanteric pad,L1290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,201.62,,,,,,,fee schedule,90.32,251.52,
Lateral trochanteric pad,L1290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,220.25,,,,,,,fee schedule,90.32,251.52,
Lateral trochanteric pad,L1290,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,94.84,,,,,,,fee schedule,90.32,251.52,APC
Lateral trochanteric pad,L1290,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,93.93,,,,,,,fee schedule,90.32,251.52,APC
Lateral trochanteric pad,L1290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,90.32,,,,,,,fee schedule,90.32,251.52,APC
Lateral trochanteric pad,L1290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,138.19,,,,,,,fee schedule,90.32,251.52,Radiology
Lateral trochanteric pad,L1290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,126.45,,,,,,,fee schedule,90.32,251.52,APC
Lateral trochanteric pad,L1290,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,158.06,,,,,,,fee schedule,90.32,251.52,APC
Body jacket mold to patient,L1300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5672.99,,,,,,,fee schedule,2212.58,6162.04,
Body jacket mold to patient,L1300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6162.04,,,,,,,fee schedule,2212.58,6162.04,
Body jacket mold to patient,L1300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4939.42,,,,,,,fee schedule,2212.58,6162.04,
Body jacket mold to patient,L1300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5395.86,,,,,,,fee schedule,2212.58,6162.04,
Body jacket mold to patient,L1300,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2323.21,,,,,,,fee schedule,2212.58,6162.04,APC
Body jacket mold to patient,L1300,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2301.08,,,,,,,fee schedule,2212.58,6162.04,APC
Body jacket mold to patient,L1300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2212.58,,,,,,,fee schedule,2212.58,6162.04,APC
Body jacket mold to patient,L1300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3385.25,,,,,,,fee schedule,2212.58,6162.04,Radiology
Body jacket mold to patient,L1300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3097.61,,,,,,,fee schedule,2212.58,6162.04,APC
Body jacket mold to patient,L1300,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3872.02,,,,,,,fee schedule,2212.58,6162.04,APC
Post-operative body jacket,L1310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5464.89,,,,,,,fee schedule,2131.4,5936,
Post-operative body jacket,L1310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5936,,,,,,,fee schedule,2131.4,5936,
Post-operative body jacket,L1310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4758.22,,,,,,,fee schedule,2131.4,5936,
Post-operative body jacket,L1310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5197.92,,,,,,,fee schedule,2131.4,5936,
Post-operative body jacket,L1310,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2237.97,,,,,,,fee schedule,2131.4,5936,APC
Post-operative body jacket,L1310,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2216.66,,,,,,,fee schedule,2131.4,5936,APC
Post-operative body jacket,L1310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2131.4,,,,,,,fee schedule,2131.4,5936,APC
Post-operative body jacket,L1310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3261.04,,,,,,,fee schedule,2131.4,5936,Radiology
Post-operative body jacket,L1310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2983.96,,,,,,,fee schedule,2131.4,5936,APC
Post-operative body jacket,L1310,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3729.95,,,,,,,fee schedule,2131.4,5936,APC
Ho flex frejka w/cov pre cst,L1600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,506.2,,,,,,,fee schedule,197.44,549.84,
Ho flex frejka w/cov pre cst,L1600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,549.84,,,,,,,fee schedule,197.44,549.84,
Ho flex frejka w/cov pre cst,L1600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,440.74,,,,,,,fee schedule,197.44,549.84,
Ho flex frejka w/cov pre cst,L1600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,481.47,,,,,,,fee schedule,197.44,549.84,
Ho flex frejka w/cov pre cst,L1600,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,207.31,,,,,,,fee schedule,197.44,549.84,APC
Ho flex frejka w/cov pre cst,L1600,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,205.34,,,,,,,fee schedule,197.44,549.84,APC
Ho flex frejka w/cov pre cst,L1600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,197.44,,,,,,,fee schedule,197.44,549.84,APC
Ho flex frejka w/cov pre cst,L1600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,302.08,,,,,,,fee schedule,197.44,549.84,Radiology
Ho flex frejka w/cov pre cst,L1600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,276.42,,,,,,,fee schedule,197.44,549.84,APC
Ho flex frejka w/cov pre cst,L1600,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,345.52,,,,,,,fee schedule,197.44,549.84,APC
Ho frejka cov only pre cst,L1610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,134.12,,,,,,,fee schedule,52.32,145.68,
Ho frejka cov only pre cst,L1610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,145.68,,,,,,,fee schedule,52.32,145.68,
Ho frejka cov only pre cst,L1610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,116.78,,,,,,,fee schedule,52.32,145.68,
Ho frejka cov only pre cst,L1610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,127.57,,,,,,,fee schedule,52.32,145.68,
Ho frejka cov only pre cst,L1610,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.94,,,,,,,fee schedule,52.32,145.68,APC
Ho frejka cov only pre cst,L1610,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,54.41,,,,,,,fee schedule,52.32,145.68,APC
Ho frejka cov only pre cst,L1610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,52.32,,,,,,,fee schedule,52.32,145.68,APC
Ho frejka cov only pre cst,L1610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,80.05,,,,,,,fee schedule,52.32,145.68,Radiology
Ho frejka cov only pre cst,L1610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,73.25,,,,,,,fee schedule,52.32,145.68,APC
Ho frejka cov only pre cst,L1610,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,91.56,,,,,,,fee schedule,52.32,145.68,APC
Ho flex pavlik harns pre cst,L1620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,394.74,,,,,,,fee schedule,153.96,428.77,
Ho flex pavlik harns pre cst,L1620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,428.77,,,,,,,fee schedule,153.96,428.77,
Ho flex pavlik harns pre cst,L1620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,343.69,,,,,,,fee schedule,153.96,428.77,
Ho flex pavlik harns pre cst,L1620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,375.45,,,,,,,fee schedule,153.96,428.77,
Ho flex pavlik harns pre cst,L1620,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,161.66,,,,,,,fee schedule,153.96,428.77,APC
Ho flex pavlik harns pre cst,L1620,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,160.12,,,,,,,fee schedule,153.96,428.77,APC
Ho flex pavlik harns pre cst,L1620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,153.96,,,,,,,fee schedule,153.96,428.77,APC
Ho flex pavlik harns pre cst,L1620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,235.56,,,,,,,fee schedule,153.96,428.77,Radiology
Ho flex pavlik harns pre cst,L1620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,215.54,,,,,,,fee schedule,153.96,428.77,APC
Ho flex pavlik harns pre cst,L1620,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,269.43,,,,,,,fee schedule,153.96,428.77,APC
Abduct control hip semi-flex,L1630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,499.24,,,,,,,fee schedule,194.72,542.28,
Abduct control hip semi-flex,L1630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,542.28,,,,,,,fee schedule,194.72,542.28,
Abduct control hip semi-flex,L1630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,434.68,,,,,,,fee schedule,194.72,542.28,
Abduct control hip semi-flex,L1630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,474.85,,,,,,,fee schedule,194.72,542.28,
Abduct control hip semi-flex,L1630,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,204.46,,,,,,,fee schedule,194.72,542.28,APC
Abduct control hip semi-flex,L1630,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,202.51,,,,,,,fee schedule,194.72,542.28,APC
Abduct control hip semi-flex,L1630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,194.72,,,,,,,fee schedule,194.72,542.28,APC
Abduct control hip semi-flex,L1630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,297.92,,,,,,,fee schedule,194.72,542.28,Radiology
Abduct control hip semi-flex,L1630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,272.61,,,,,,,fee schedule,194.72,542.28,APC
Abduct control hip semi-flex,L1630,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,340.76,,,,,,,fee schedule,194.72,542.28,APC
Pelv band/spread bar thigh c,L1640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1565.51,,,,,,,fee schedule,610.6,1700.47,
Pelv band/spread bar thigh c,L1640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1700.47,,,,,,,fee schedule,610.6,1700.47,
Pelv band/spread bar thigh c,L1640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1363.08,,,,,,,fee schedule,610.6,1700.47,
Pelv band/spread bar thigh c,L1640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1489.04,,,,,,,fee schedule,610.6,1700.47,
Pelv band/spread bar thigh c,L1640,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,641.13,,,,,,,fee schedule,610.6,1700.47,APC
Pelv band/spread bar thigh c,L1640,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,635.02,,,,,,,fee schedule,610.6,1700.47,APC
Pelv band/spread bar thigh c,L1640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,610.6,,,,,,,fee schedule,610.6,1700.47,APC
Pelv band/spread bar thigh c,L1640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,934.22,,,,,,,fee schedule,610.6,1700.47,Radiology
Pelv band/spread bar thigh c,L1640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,854.84,,,,,,,fee schedule,610.6,1700.47,APC
Pelv band/spread bar thigh c,L1640,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1068.55,,,,,,,fee schedule,610.6,1700.47,APC
HO abduction hip adjustable,L1650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,718.97,,,,,,,fee schedule,280.4,780.95,
HO abduction hip adjustable,L1650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,780.95,,,,,,,fee schedule,280.4,780.95,
HO abduction hip adjustable,L1650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,626,,,,,,,fee schedule,280.4,780.95,
HO abduction hip adjustable,L1650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,683.85,,,,,,,fee schedule,280.4,780.95,
HO abduction hip adjustable,L1650,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,294.42,,,,,,,fee schedule,280.4,780.95,APC
HO abduction hip adjustable,L1650,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,291.62,,,,,,,fee schedule,280.4,780.95,APC
HO abduction hip adjustable,L1650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,280.4,,,,,,,fee schedule,280.4,780.95,APC
HO abduction hip adjustable,L1650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,429.01,,,,,,,fee schedule,280.4,780.95,Radiology
HO abduction hip adjustable,L1650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,392.56,,,,,,,fee schedule,280.4,780.95,APC
HO abduction hip adjustable,L1650,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,490.7,,,,,,,fee schedule,280.4,780.95,APC
HO bi thighcuffs w sprdr bar,L1652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1129.23,,,,,,,fee schedule,440.44,1226.57,
HO bi thighcuffs w sprdr bar,L1652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1226.57,,,,,,,fee schedule,440.44,1226.57,
HO bi thighcuffs w sprdr bar,L1652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,983.2,,,,,,,fee schedule,440.44,1226.57,
HO bi thighcuffs w sprdr bar,L1652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1074.06,,,,,,,fee schedule,440.44,1226.57,
HO bi thighcuffs w sprdr bar,L1652,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,462.46,,,,,,,fee schedule,440.44,1226.57,APC
HO bi thighcuffs w sprdr bar,L1652,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,458.06,,,,,,,fee schedule,440.44,1226.57,APC
HO bi thighcuffs w sprdr bar,L1652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,440.44,,,,,,,fee schedule,440.44,1226.57,APC
HO bi thighcuffs w sprdr bar,L1652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,673.87,,,,,,,fee schedule,440.44,1226.57,Radiology
HO bi thighcuffs w sprdr bar,L1652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,616.62,,,,,,,fee schedule,440.44,1226.57,APC
HO bi thighcuffs w sprdr bar,L1652,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,770.77,,,,,,,fee schedule,440.44,1226.57,APC
HO abduction static plastic,L1660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,672.3,,,,,,,fee schedule,262.21,730.26,
HO abduction static plastic,L1660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,730.26,,,,,,,fee schedule,262.21,730.26,
HO abduction static plastic,L1660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,585.37,,,,,,,fee schedule,262.21,730.26,
HO abduction static plastic,L1660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,639.46,,,,,,,fee schedule,262.21,730.26,
HO abduction static plastic,L1660,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,275.32,,,,,,,fee schedule,262.21,730.26,APC
HO abduction static plastic,L1660,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,272.7,,,,,,,fee schedule,262.21,730.26,APC
HO abduction static plastic,L1660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,262.21,,,,,,,fee schedule,262.21,730.26,APC
HO abduction static plastic,L1660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,401.18,,,,,,,fee schedule,262.21,730.26,Radiology
HO abduction static plastic,L1660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,367.09,,,,,,,fee schedule,262.21,730.26,APC
HO abduction static plastic,L1660,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,458.87,,,,,,,fee schedule,262.21,730.26,APC
Pelvic & hip control thigh c,L1680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4243.79,,,,,,,fee schedule,1655.15,4609.63,
Pelvic & hip control thigh c,L1680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4609.63,,,,,,,fee schedule,1655.15,4609.63,
Pelvic & hip control thigh c,L1680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3695.02,,,,,,,fee schedule,1655.15,4609.63,
Pelvic & hip control thigh c,L1680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4036.48,,,,,,,fee schedule,1655.15,4609.63,
Pelvic & hip control thigh c,L1680,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1737.91,,,,,,,fee schedule,1655.15,4609.63,APC
Pelvic & hip control thigh c,L1680,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1721.36,,,,,,,fee schedule,1655.15,4609.63,APC
Pelvic & hip control thigh c,L1680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1655.15,,,,,,,fee schedule,1655.15,4609.63,APC
Pelvic & hip control thigh c,L1680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2532.38,,,,,,,fee schedule,1655.15,4609.63,Radiology
Pelvic & hip control thigh c,L1680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2317.21,,,,,,,fee schedule,1655.15,4609.63,APC
Pelvic & hip control thigh c,L1680,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2896.51,,,,,,,fee schedule,1655.15,4609.63,APC
Post-op hip abduct custom fa,L1685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3504.57,,,,,,,fee schedule,1366.86,3806.69,
Post-op hip abduct custom fa,L1685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3806.69,,,,,,,fee schedule,1366.86,3806.69,
Post-op hip abduct custom fa,L1685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3051.39,,,,,,,fee schedule,1366.86,3806.69,
Post-op hip abduct custom fa,L1685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3333.37,,,,,,,fee schedule,1366.86,3806.69,
Post-op hip abduct custom fa,L1685,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1435.2,,,,,,,fee schedule,1366.86,3806.69,APC
Post-op hip abduct custom fa,L1685,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1421.53,,,,,,,fee schedule,1366.86,3806.69,APC
Post-op hip abduct custom fa,L1685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1366.86,,,,,,,fee schedule,1366.86,3806.69,APC
Post-op hip abduct custom fa,L1685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2091.3,,,,,,,fee schedule,1366.86,3806.69,Radiology
Post-op hip abduct custom fa,L1685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1913.6,,,,,,,fee schedule,1366.86,3806.69,APC
Post-op hip abduct custom fa,L1685,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2392,,,,,,,fee schedule,1366.86,3806.69,APC
HO post-op hip abduction,L1686,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2687.6,,,,,,,fee schedule,1048.22,2919.29,
HO post-op hip abduction,L1686,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2919.29,,,,,,,fee schedule,1048.22,2919.29,
HO post-op hip abduction,L1686,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2340.07,,,,,,,fee schedule,1048.22,2919.29,
HO post-op hip abduction,L1686,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2556.31,,,,,,,fee schedule,1048.22,2919.29,
HO post-op hip abduction,L1686,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1100.63,,,,,,,fee schedule,1048.22,2919.29,APC
HO post-op hip abduction,L1686,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1090.15,,,,,,,fee schedule,1048.22,2919.29,APC
HO post-op hip abduction,L1686,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1048.22,,,,,,,fee schedule,1048.22,2919.29,APC
HO post-op hip abduction,L1686,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1603.78,,,,,,,fee schedule,1048.22,2919.29,Radiology
HO post-op hip abduction,L1686,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1467.51,,,,,,,fee schedule,1048.22,2919.29,APC
HO post-op hip abduction,L1686,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1834.38,,,,,,,fee schedule,1048.22,2919.29,APC
Combination bilateral HO,L1690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6125.67,,,,,,,fee schedule,2389.17,6653.75,
Combination bilateral HO,L1690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6653.75,,,,,,,fee schedule,2389.17,6653.75,
Combination bilateral HO,L1690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5333.56,,,,,,,fee schedule,2389.17,6653.75,
Combination bilateral HO,L1690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5826.43,,,,,,,fee schedule,2389.17,6653.75,
Combination bilateral HO,L1690,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2508.63,,,,,,,fee schedule,2389.17,6653.75,APC
Combination bilateral HO,L1690,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2484.74,,,,,,,fee schedule,2389.17,6653.75,APC
Combination bilateral HO,L1690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2389.17,,,,,,,fee schedule,2389.17,6653.75,APC
Combination bilateral HO,L1690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3655.43,,,,,,,fee schedule,2389.17,6653.75,Radiology
Combination bilateral HO,L1690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3344.84,,,,,,,fee schedule,2389.17,6653.75,APC
Combination bilateral HO,L1690,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4181.05,,,,,,,fee schedule,2389.17,6653.75,APC
Leg perthes orth toronto typ,L1700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5053.9,,,,,,,fee schedule,1971.13,5489.58,
Leg perthes orth toronto typ,L1700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5489.58,,,,,,,fee schedule,1971.13,5489.58,
Leg perthes orth toronto typ,L1700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4400.38,,,,,,,fee schedule,1971.13,5489.58,
Leg perthes orth toronto typ,L1700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4807.01,,,,,,,fee schedule,1971.13,5489.58,
Leg perthes orth toronto typ,L1700,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2069.69,,,,,,,fee schedule,1971.13,5489.58,APC
Leg perthes orth toronto typ,L1700,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2049.98,,,,,,,fee schedule,1971.13,5489.58,APC
Leg perthes orth toronto typ,L1700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1971.13,,,,,,,fee schedule,1971.13,5489.58,APC
Leg perthes orth toronto typ,L1700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3015.83,,,,,,,fee schedule,1971.13,5489.58,Radiology
Leg perthes orth toronto typ,L1700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2759.58,,,,,,,fee schedule,1971.13,5489.58,APC
Leg perthes orth toronto typ,L1700,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3449.48,,,,,,,fee schedule,1971.13,5489.58,APC
Legg perthes orth newington,L1710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6498.87,,,,,,,fee schedule,2534.68,7059.11,
Legg perthes orth newington,L1710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7059.11,,,,,,,fee schedule,2534.68,7059.11,
Legg perthes orth newington,L1710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5658.49,,,,,,,fee schedule,2534.68,7059.11,
Legg perthes orth newington,L1710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6181.39,,,,,,,fee schedule,2534.68,7059.11,
Legg perthes orth newington,L1710,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2661.41,,,,,,,fee schedule,2534.68,7059.11,APC
Legg perthes orth newington,L1710,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2636.07,,,,,,,fee schedule,2534.68,7059.11,APC
Legg perthes orth newington,L1710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2534.68,,,,,,,fee schedule,2534.68,7059.11,APC
Legg perthes orth newington,L1710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3878.06,,,,,,,fee schedule,2534.68,7059.11,Radiology
Legg perthes orth newington,L1710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3548.55,,,,,,,fee schedule,2534.68,7059.11,APC
Legg perthes orth newington,L1710,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4435.69,,,,,,,fee schedule,2534.68,7059.11,APC
Legg perthes orthosis trilat,L1720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4821.16,,,,,,,fee schedule,1880.37,5236.77,
Legg perthes orthosis trilat,L1720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5236.77,,,,,,,fee schedule,1880.37,5236.77,
Legg perthes orthosis trilat,L1720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4197.73,,,,,,,fee schedule,1880.37,5236.77,
Legg perthes orthosis trilat,L1720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4585.64,,,,,,,fee schedule,1880.37,5236.77,
Legg perthes orthosis trilat,L1720,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1974.39,,,,,,,fee schedule,1880.37,5236.77,APC
Legg perthes orthosis trilat,L1720,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1955.58,,,,,,,fee schedule,1880.37,5236.77,APC
Legg perthes orthosis trilat,L1720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1880.37,,,,,,,fee schedule,1880.37,5236.77,APC
Legg perthes orthosis trilat,L1720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2876.97,,,,,,,fee schedule,1880.37,5236.77,Radiology
Legg perthes orthosis trilat,L1720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2632.52,,,,,,,fee schedule,1880.37,5236.77,APC
Legg perthes orthosis trilat,L1720,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3290.65,,,,,,,fee schedule,1880.37,5236.77,APC
Legg perthes orth scottish r,L1730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3816.34,,,,,,,fee schedule,1488.44,4145.34,
Legg perthes orth scottish r,L1730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4145.34,,,,,,,fee schedule,1488.44,4145.34,
Legg perthes orth scottish r,L1730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3322.85,,,,,,,fee schedule,1488.44,4145.34,
Legg perthes orth scottish r,L1730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3629.91,,,,,,,fee schedule,1488.44,4145.34,
Legg perthes orth scottish r,L1730,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1562.86,,,,,,,fee schedule,1488.44,4145.34,APC
Legg perthes orth scottish r,L1730,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1547.98,,,,,,,fee schedule,1488.44,4145.34,APC
Legg perthes orth scottish r,L1730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1488.44,,,,,,,fee schedule,1488.44,4145.34,APC
Legg perthes orth scottish r,L1730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2277.31,,,,,,,fee schedule,1488.44,4145.34,Radiology
Legg perthes orth scottish r,L1730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2083.82,,,,,,,fee schedule,1488.44,4145.34,APC
Legg perthes orth scottish r,L1730,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2604.77,,,,,,,fee schedule,1488.44,4145.34,APC
Legg perthes patten bottom t,L1755,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4664.7,,,,,,,fee schedule,1819.35,5066.83,
Legg perthes patten bottom t,L1755,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5066.83,,,,,,,fee schedule,1819.35,5066.83,
Legg perthes patten bottom t,L1755,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4061.5,,,,,,,fee schedule,1819.35,5066.83,
Legg perthes patten bottom t,L1755,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4436.82,,,,,,,fee schedule,1819.35,5066.83,
Legg perthes patten bottom t,L1755,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1910.32,,,,,,,fee schedule,1819.35,5066.83,APC
Legg perthes patten bottom t,L1755,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1892.12,,,,,,,fee schedule,1819.35,5066.83,APC
Legg perthes patten bottom t,L1755,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1819.35,,,,,,,fee schedule,1819.35,5066.83,APC
Legg perthes patten bottom t,L1755,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2783.61,,,,,,,fee schedule,1819.35,5066.83,Radiology
Legg perthes patten bottom t,L1755,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2547.09,,,,,,,fee schedule,1819.35,5066.83,APC
Legg perthes patten bottom t,L1755,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3183.86,,,,,,,fee schedule,1819.35,5066.83,APC
Ko elastic with joints,L1810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,315.15,,,,,,,fee schedule,122.9,342.32,
Ko elastic with joints,L1810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,342.32,,,,,,,fee schedule,122.9,342.32,
Ko elastic with joints,L1810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,274.4,,,,,,,fee schedule,122.9,342.32,
Ko elastic with joints,L1810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,299.75,,,,,,,fee schedule,122.9,342.32,
Ko elastic with joints,L1810,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.05,,,,,,,fee schedule,122.9,342.32,APC
Ko elastic with joints,L1810,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,127.82,,,,,,,fee schedule,122.9,342.32,APC
Ko elastic with joints,L1810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,122.9,,,,,,,fee schedule,122.9,342.32,APC
Ko elastic with joints,L1810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.04,,,,,,,fee schedule,122.9,342.32,Radiology
Ko elastic with joints,L1810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.06,,,,,,,fee schedule,122.9,342.32,APC
Ko elastic with joints,L1810,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.08,,,,,,,fee schedule,122.9,342.32,APC
Ko elastic w/joints pre ots,L1812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,333.11,,,,,,,fee schedule,70.12,361.82,
Ko elastic w/joints pre ots,L1812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,361.82,,,,,,,fee schedule,70.12,361.82,
Ko elastic w/joints pre ots,L1812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,290.03,,,,,,,fee schedule,70.12,361.82,
Ko elastic w/joints pre ots,L1812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,316.83,,,,,,,fee schedule,70.12,361.82,
Ko elastic w/joints pre ots,L1812,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,73.63,,,,,,,fee schedule,70.12,361.82,APC
Ko elastic w/joints pre ots,L1812,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,72.92,,,,,,,fee schedule,70.12,361.82,APC
Ko elastic w/joints pre ots,L1812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,70.12,,,,,,,fee schedule,70.12,361.82,APC
Ko elastic w/joints pre ots,L1812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,107.28,,,,,,,fee schedule,70.12,361.82,Radiology
Ko elastic w/joints pre ots,L1812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,98.17,,,,,,,fee schedule,70.12,361.82,APC
Ko elastic w/joints pre ots,L1812,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,122.71,,,,,,,fee schedule,70.12,361.82,APC
Ko elas w/ condyle pads & jo,L1820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,423.9,,,,,,,fee schedule,165.33,460.44,
Ko elas w/ condyle pads & jo,L1820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,460.44,,,,,,,fee schedule,165.33,460.44,
Ko elas w/ condyle pads & jo,L1820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,369.08,,,,,,,fee schedule,165.33,460.44,
Ko elas w/ condyle pads & jo,L1820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,403.19,,,,,,,fee schedule,165.33,460.44,
Ko elas w/ condyle pads & jo,L1820,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,173.6,,,,,,,fee schedule,165.33,460.44,APC
Ko elas w/ condyle pads & jo,L1820,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,171.94,,,,,,,fee schedule,165.33,460.44,APC
Ko elas w/ condyle pads & jo,L1820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,165.33,,,,,,,fee schedule,165.33,460.44,APC
Ko elas w/ condyle pads & jo,L1820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,252.95,,,,,,,fee schedule,165.33,460.44,Radiology
Ko elas w/ condyle pads & jo,L1820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,231.46,,,,,,,fee schedule,165.33,460.44,APC
Ko elas w/ condyle pads & jo,L1820,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,289.33,,,,,,,fee schedule,165.33,460.44,APC
Ko immob canvas long pre ots,L1830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,257.73,,,,,,,fee schedule,63.18,279.95,
Ko immob canvas long pre ots,L1830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,279.95,,,,,,,fee schedule,63.18,279.95,
Ko immob canvas long pre ots,L1830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,224.4,,,,,,,fee schedule,63.18,279.95,
Ko immob canvas long pre ots,L1830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,245.14,,,,,,,fee schedule,63.18,279.95,
Ko immob canvas long pre ots,L1830,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,66.34,,,,,,,fee schedule,63.18,279.95,APC
Ko immob canvas long pre ots,L1830,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,65.71,,,,,,,fee schedule,63.18,279.95,APC
Ko immob canvas long pre ots,L1830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,63.18,,,,,,,fee schedule,63.18,279.95,APC
Ko immob canvas long pre ots,L1830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,96.67,,,,,,,fee schedule,63.18,279.95,Radiology
Ko immob canvas long pre ots,L1830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,88.45,,,,,,,fee schedule,63.18,279.95,APC
Ko immob canvas long pre ots,L1830,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,110.56,,,,,,,fee schedule,63.18,279.95,APC
Knee orth pos locking joint,L1831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,932.36,,,,,,,fee schedule,363.62,1012.74,
Knee orth pos locking joint,L1831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1012.74,,,,,,,fee schedule,363.62,1012.74,
Knee orth pos locking joint,L1831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,811.8,,,,,,,fee schedule,363.62,1012.74,
Knee orth pos locking joint,L1831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,886.82,,,,,,,fee schedule,363.62,1012.74,
Knee orth pos locking joint,L1831,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,381.8,,,,,,,fee schedule,363.62,1012.74,APC
Knee orth pos locking joint,L1831,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,378.16,,,,,,,fee schedule,363.62,1012.74,APC
Knee orth pos locking joint,L1831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,363.62,,,,,,,fee schedule,363.62,1012.74,APC
Knee orth pos locking joint,L1831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,556.34,,,,,,,fee schedule,363.62,1012.74,Radiology
Knee orth pos locking joint,L1831,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,509.07,,,,,,,fee schedule,363.62,1012.74,APC
Knee orth pos locking joint,L1831,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,636.34,,,,,,,fee schedule,363.62,1012.74,APC
Ko adj jnt pos r sup pre cst,L1832,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1791.26,,,,,,,fee schedule,698.63,1945.68,
Ko adj jnt pos r sup pre cst,L1832,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1945.68,,,,,,,fee schedule,698.63,1945.68,
Ko adj jnt pos r sup pre cst,L1832,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1559.63,,,,,,,fee schedule,698.63,1945.68,
Ko adj jnt pos r sup pre cst,L1832,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1703.76,,,,,,,fee schedule,698.63,1945.68,
Ko adj jnt pos r sup pre cst,L1832,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,733.56,,,,,,,fee schedule,698.63,1945.68,APC
Ko adj jnt pos r sup pre cst,L1832,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,726.58,,,,,,,fee schedule,698.63,1945.68,APC
Ko adj jnt pos r sup pre cst,L1832,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,698.63,,,,,,,fee schedule,698.63,1945.68,APC
Ko adj jnt pos r sup pre cst,L1832,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1068.9,,,,,,,fee schedule,698.63,1945.68,Radiology
Ko adj jnt pos r sup pre cst,L1832,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,978.08,,,,,,,fee schedule,698.63,1945.68,APC
Ko adj jnt pos r sup pre cst,L1832,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1222.6,,,,,,,fee schedule,698.63,1945.68,APC
Ko adj jnt pos r sup pre ots,L1833,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1893.54,,,,,,,fee schedule,455.16,2056.77,
Ko adj jnt pos r sup pre ots,L1833,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2056.77,,,,,,,fee schedule,455.16,2056.77,
Ko adj jnt pos r sup pre ots,L1833,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1648.68,,,,,,,fee schedule,455.16,2056.77,
Ko adj jnt pos r sup pre ots,L1833,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1801.04,,,,,,,fee schedule,455.16,2056.77,
Ko adj jnt pos r sup pre ots,L1833,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,477.92,,,,,,,fee schedule,455.16,2056.77,APC
Ko adj jnt pos r sup pre ots,L1833,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,473.37,,,,,,,fee schedule,455.16,2056.77,APC
Ko adj jnt pos r sup pre ots,L1833,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,455.16,,,,,,,fee schedule,455.16,2056.77,APC
Ko adj jnt pos r sup pre ots,L1833,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,696.39,,,,,,,fee schedule,455.16,2056.77,Radiology
Ko adj jnt pos r sup pre ots,L1833,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,637.22,,,,,,,fee schedule,455.16,2056.77,APC
Ko adj jnt pos r sup pre ots,L1833,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,796.53,,,,,,,fee schedule,455.16,2056.77,APC
Ko w/0 joint rigid molded to,L1834,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2287.09,,,,,,,fee schedule,892.02,2484.25,
Ko w/0 joint rigid molded to,L1834,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2484.25,,,,,,,fee schedule,892.02,2484.25,
Ko w/0 joint rigid molded to,L1834,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1991.35,,,,,,,fee schedule,892.02,2484.25,
Ko w/0 joint rigid molded to,L1834,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2175.37,,,,,,,fee schedule,892.02,2484.25,
Ko w/0 joint rigid molded to,L1834,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,936.62,,,,,,,fee schedule,892.02,2484.25,APC
Ko w/0 joint rigid molded to,L1834,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,927.7,,,,,,,fee schedule,892.02,2484.25,APC
Ko w/0 joint rigid molded to,L1834,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,892.02,,,,,,,fee schedule,892.02,2484.25,APC
Ko w/0 joint rigid molded to,L1834,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1364.79,,,,,,,fee schedule,892.02,2484.25,Radiology
Ko w/0 joint rigid molded to,L1834,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1248.83,,,,,,,fee schedule,892.02,2484.25,APC
Ko w/0 joint rigid molded to,L1834,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1561.04,,,,,,,fee schedule,892.02,2484.25,APC
Ko rigid w/o joints pre ots,L1836,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,422.61,,,,,,,fee schedule,89.34,459.04,
Ko rigid w/o joints pre ots,L1836,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,459.04,,,,,,,fee schedule,89.34,459.04,
Ko rigid w/o joints pre ots,L1836,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,367.96,,,,,,,fee schedule,89.34,459.04,
Ko rigid w/o joints pre ots,L1836,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,401.97,,,,,,,fee schedule,89.34,459.04,
Ko rigid w/o joints pre ots,L1836,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,93.81,,,,,,,fee schedule,89.34,459.04,APC
Ko rigid w/o joints pre ots,L1836,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,92.91,,,,,,,fee schedule,89.34,459.04,APC
Ko rigid w/o joints pre ots,L1836,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,89.34,,,,,,,fee schedule,89.34,459.04,APC
Ko rigid w/o joints pre ots,L1836,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,136.69,,,,,,,fee schedule,89.34,459.04,Radiology
Ko rigid w/o joints pre ots,L1836,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,125.08,,,,,,,fee schedule,89.34,459.04,APC
Ko rigid w/o joints pre ots,L1836,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,156.34,,,,,,,fee schedule,89.34,459.04,APC
Ko derot ant cruciate custom,L1840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3328.76,,,,,,,fee schedule,1298.28,3615.72,
Ko derot ant cruciate custom,L1840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3615.72,,,,,,,fee schedule,1298.28,3615.72,
Ko derot ant cruciate custom,L1840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2898.32,,,,,,,fee schedule,1298.28,3615.72,
Ko derot ant cruciate custom,L1840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3166.15,,,,,,,fee schedule,1298.28,3615.72,
Ko derot ant cruciate custom,L1840,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1363.19,,,,,,,fee schedule,1298.28,3615.72,APC
Ko derot ant cruciate custom,L1840,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1350.21,,,,,,,fee schedule,1298.28,3615.72,APC
Ko derot ant cruciate custom,L1840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1298.28,,,,,,,fee schedule,1298.28,3615.72,APC
Ko derot ant cruciate custom,L1840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1986.37,,,,,,,fee schedule,1298.28,3615.72,Radiology
Ko derot ant cruciate custom,L1840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1817.59,,,,,,,fee schedule,1298.28,3615.72,APC
Ko derot ant cruciate custom,L1840,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2271.99,,,,,,,fee schedule,1298.28,3615.72,APC
Ko single upright pre cst,L1843,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2842.32,,,,,,,fee schedule,1108.58,3087.35,
Ko single upright pre cst,L1843,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3087.35,,,,,,,fee schedule,1108.58,3087.35,
Ko single upright pre cst,L1843,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2474.78,,,,,,,fee schedule,1108.58,3087.35,
Ko single upright pre cst,L1843,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2703.48,,,,,,,fee schedule,1108.58,3087.35,
Ko single upright pre cst,L1843,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1164.01,,,,,,,fee schedule,1108.58,3087.35,APC
Ko single upright pre cst,L1843,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1152.92,,,,,,,fee schedule,1108.58,3087.35,APC
Ko single upright pre cst,L1843,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1108.58,,,,,,,fee schedule,1108.58,3087.35,APC
Ko single upright pre cst,L1843,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1696.13,,,,,,,fee schedule,1108.58,3087.35,Radiology
Ko single upright pre cst,L1843,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1552.01,,,,,,,fee schedule,1108.58,3087.35,APC
Ko single upright pre cst,L1843,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1940.02,,,,,,,fee schedule,1108.58,3087.35,APC
Ko w/adj jt rot cntrl molded,L1844,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4916.93,,,,,,,fee schedule,1917.72,5340.8,
Ko w/adj jt rot cntrl molded,L1844,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5340.8,,,,,,,fee schedule,1917.72,5340.8,
Ko w/adj jt rot cntrl molded,L1844,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4281.12,,,,,,,fee schedule,1917.72,5340.8,
Ko w/adj jt rot cntrl molded,L1844,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4676.73,,,,,,,fee schedule,1917.72,5340.8,
Ko w/adj jt rot cntrl molded,L1844,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2013.61,,,,,,,fee schedule,1917.72,5340.8,APC
Ko w/adj jt rot cntrl molded,L1844,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1994.43,,,,,,,fee schedule,1917.72,5340.8,APC
Ko w/adj jt rot cntrl molded,L1844,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1917.72,,,,,,,fee schedule,1917.72,5340.8,APC
Ko w/adj jt rot cntrl molded,L1844,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2934.11,,,,,,,fee schedule,1917.72,5340.8,Radiology
Ko w/adj jt rot cntrl molded,L1844,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2684.81,,,,,,,fee schedule,1917.72,5340.8,APC
Ko w/adj jt rot cntrl molded,L1844,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3356.01,,,,,,,fee schedule,1917.72,5340.8,APC
Ko double upright pre cst,L1845,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2759.64,,,,,,,fee schedule,1076.32,2997.54,
Ko double upright pre cst,L1845,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2997.54,,,,,,,fee schedule,1076.32,2997.54,
Ko double upright pre cst,L1845,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2402.79,,,,,,,fee schedule,1076.32,2997.54,
Ko double upright pre cst,L1845,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2624.83,,,,,,,fee schedule,1076.32,2997.54,
Ko double upright pre cst,L1845,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1130.14,,,,,,,fee schedule,1076.32,2997.54,APC
Ko double upright pre cst,L1845,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1119.37,,,,,,,fee schedule,1076.32,2997.54,APC
Ko double upright pre cst,L1845,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1076.32,,,,,,,fee schedule,1076.32,2997.54,APC
Ko double upright pre cst,L1845,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1646.77,,,,,,,fee schedule,1076.32,2997.54,Radiology
Ko double upright pre cst,L1845,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1506.85,,,,,,,fee schedule,1076.32,2997.54,APC
Ko double upright pre cst,L1845,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1883.56,,,,,,,fee schedule,1076.32,2997.54,APC
Ko w adj flex/ext rotat mold,L1846,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3458.22,,,,,,,fee schedule,1348.79,3756.34,
Ko w adj flex/ext rotat mold,L1846,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3756.34,,,,,,,fee schedule,1348.79,3756.34,
Ko w adj flex/ext rotat mold,L1846,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3011.03,,,,,,,fee schedule,1348.79,3756.34,
Ko w adj flex/ext rotat mold,L1846,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3289.28,,,,,,,fee schedule,1348.79,3756.34,
Ko w adj flex/ext rotat mold,L1846,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1416.23,,,,,,,fee schedule,1348.79,3756.34,APC
Ko w adj flex/ext rotat mold,L1846,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1402.74,,,,,,,fee schedule,1348.79,3756.34,APC
Ko w adj flex/ext rotat mold,L1846,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1348.79,,,,,,,fee schedule,1348.79,3756.34,APC
Ko w adj flex/ext rotat mold,L1846,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2063.65,,,,,,,fee schedule,1348.79,3756.34,Radiology
Ko w adj flex/ext rotat mold,L1846,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1888.31,,,,,,,fee schedule,1348.79,3756.34,APC
Ko w adj flex/ext rotat mold,L1846,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2360.38,,,,,,,fee schedule,1348.79,3756.34,APC
Ko dbl upright w/air pre cst,L1847,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1822.02,,,,,,,fee schedule,710.64,1979.09,
Ko dbl upright w/air pre cst,L1847,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1979.09,,,,,,,fee schedule,710.64,1979.09,
Ko dbl upright w/air pre cst,L1847,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1586.42,,,,,,,fee schedule,710.64,1979.09,
Ko dbl upright w/air pre cst,L1847,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1733.02,,,,,,,fee schedule,710.64,1979.09,
Ko dbl upright w/air pre cst,L1847,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,746.17,,,,,,,fee schedule,710.64,1979.09,APC
Ko dbl upright w/air pre cst,L1847,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,739.07,,,,,,,fee schedule,710.64,1979.09,APC
Ko dbl upright w/air pre cst,L1847,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,710.64,,,,,,,fee schedule,710.64,1979.09,APC
Ko dbl upright w/air pre cst,L1847,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1087.28,,,,,,,fee schedule,710.64,1979.09,Radiology
Ko dbl upright w/air pre cst,L1847,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,994.9,,,,,,,fee schedule,710.64,1979.09,APC
Ko dbl upright w/air pre cst,L1847,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1243.62,,,,,,,fee schedule,710.64,1979.09,APC
Ko dbl upright w/air pre ots,L1848,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1926.04,,,,,,,fee schedule,710.64,2092.08,
Ko dbl upright w/air pre ots,L1848,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2092.08,,,,,,,fee schedule,710.64,2092.08,
Ko dbl upright w/air pre ots,L1848,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1676.98,,,,,,,fee schedule,710.64,2092.08,
Ko dbl upright w/air pre ots,L1848,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1831.95,,,,,,,fee schedule,710.64,2092.08,
Ko dbl upright w/air pre ots,L1848,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,746.17,,,,,,,fee schedule,710.64,2092.08,APC
Ko dbl upright w/air pre ots,L1848,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,739.07,,,,,,,fee schedule,710.64,2092.08,APC
Ko dbl upright w/air pre ots,L1848,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,710.64,,,,,,,fee schedule,710.64,2092.08,APC
Ko dbl upright w/air pre ots,L1848,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1087.28,,,,,,,fee schedule,710.64,2092.08,Radiology
Ko dbl upright w/air pre ots,L1848,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,994.9,,,,,,,fee schedule,710.64,2092.08,APC
Ko dbl upright w/air pre ots,L1848,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1243.62,,,,,,,fee schedule,710.64,2092.08,APC
Ko swedish type pre ots,L1850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,980.66,,,,,,,fee schedule,205.78,1065.2,
Ko swedish type pre ots,L1850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1065.2,,,,,,,fee schedule,205.78,1065.2,
Ko swedish type pre ots,L1850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,853.85,,,,,,,fee schedule,205.78,1065.2,
Ko swedish type pre ots,L1850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,932.76,,,,,,,fee schedule,205.78,1065.2,
Ko swedish type pre ots,L1850,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,216.07,,,,,,,fee schedule,205.78,1065.2,APC
Ko swedish type pre ots,L1850,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,214.01,,,,,,,fee schedule,205.78,1065.2,APC
Ko swedish type pre ots,L1850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,205.78,,,,,,,fee schedule,205.78,1065.2,APC
Ko swedish type pre ots,L1850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,314.84,,,,,,,fee schedule,205.78,1065.2,Radiology
Ko swedish type pre ots,L1850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,288.09,,,,,,,fee schedule,205.78,1065.2,APC
Ko swedish type pre ots,L1850,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,360.12,,,,,,,fee schedule,205.78,1065.2,APC
Ko single upright prefab ots,L1851,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3013.51,,,,,,,fee schedule,600.78,3273.29,
Ko single upright prefab ots,L1851,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3273.29,,,,,,,fee schedule,600.78,3273.29,
Ko single upright prefab ots,L1851,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2623.83,,,,,,,fee schedule,600.78,3273.29,
Ko single upright prefab ots,L1851,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2866.29,,,,,,,fee schedule,600.78,3273.29,
Ko single upright prefab ots,L1851,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,630.82,,,,,,,fee schedule,600.78,3273.29,APC
Ko single upright prefab ots,L1851,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,624.81,,,,,,,fee schedule,600.78,3273.29,APC
Ko single upright prefab ots,L1851,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,600.78,,,,,,,fee schedule,600.78,3273.29,APC
Ko single upright prefab ots,L1851,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,919.19,,,,,,,fee schedule,600.78,3273.29,Radiology
Ko single upright prefab ots,L1851,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,841.09,,,,,,,fee schedule,600.78,3273.29,APC
Ko single upright prefab ots,L1851,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1051.36,,,,,,,fee schedule,600.78,3273.29,APC
Ko double upright prefab ots,L1852,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2925.88,,,,,,,fee schedule,573.13,3178.11,
Ko double upright prefab ots,L1852,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3178.11,,,,,,,fee schedule,573.13,3178.11,
Ko double upright prefab ots,L1852,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2547.53,,,,,,,fee schedule,573.13,3178.11,
Ko double upright prefab ots,L1852,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2782.95,,,,,,,fee schedule,573.13,3178.11,
Ko double upright prefab ots,L1852,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,601.79,,,,,,,fee schedule,573.13,3178.11,APC
Ko double upright prefab ots,L1852,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,596.06,,,,,,,fee schedule,573.13,3178.11,APC
Ko double upright prefab ots,L1852,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,573.13,,,,,,,fee schedule,573.13,3178.11,APC
Ko double upright prefab ots,L1852,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,876.89,,,,,,,fee schedule,573.13,3178.11,Radiology
Ko double upright prefab ots,L1852,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,802.38,,,,,,,fee schedule,573.13,3178.11,APC
Ko double upright prefab ots,L1852,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1002.98,,,,,,,fee schedule,573.13,3178.11,APC
Ko supracondylar socket mold,L1860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3222.2,,,,,,,fee schedule,1256.72,3499.98,
Ko supracondylar socket mold,L1860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3499.98,,,,,,,fee schedule,1256.72,3499.98,
Ko supracondylar socket mold,L1860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2805.54,,,,,,,fee schedule,1256.72,3499.98,
Ko supracondylar socket mold,L1860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3064.8,,,,,,,fee schedule,1256.72,3499.98,
Ko supracondylar socket mold,L1860,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1319.56,,,,,,,fee schedule,1256.72,3499.98,APC
Ko supracondylar socket mold,L1860,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1306.99,,,,,,,fee schedule,1256.72,3499.98,APC
Ko supracondylar socket mold,L1860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1256.72,,,,,,,fee schedule,1256.72,3499.98,APC
Ko supracondylar socket mold,L1860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1922.78,,,,,,,fee schedule,1256.72,3499.98,Radiology
Ko supracondylar socket mold,L1860,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1759.41,,,,,,,fee schedule,1256.72,3499.98,APC
Ko supracondylar socket mold,L1860,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2199.26,,,,,,,fee schedule,1256.72,3499.98,APC
Afo sprng wir drsflx calf bd,L1900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1020.72,,,,,,,fee schedule,398.09,1108.71,
Afo sprng wir drsflx calf bd,L1900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1108.71,,,,,,,fee schedule,398.09,1108.71,
Afo sprng wir drsflx calf bd,L1900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,888.73,,,,,,,fee schedule,398.09,1108.71,
Afo sprng wir drsflx calf bd,L1900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,970.86,,,,,,,fee schedule,398.09,1108.71,
Afo sprng wir drsflx calf bd,L1900,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,417.99,,,,,,,fee schedule,398.09,1108.71,APC
Afo sprng wir drsflx calf bd,L1900,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,414.01,,,,,,,fee schedule,398.09,1108.71,APC
Afo sprng wir drsflx calf bd,L1900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,398.09,,,,,,,fee schedule,398.09,1108.71,APC
Afo sprng wir drsflx calf bd,L1900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,609.08,,,,,,,fee schedule,398.09,1108.71,Radiology
Afo sprng wir drsflx calf bd,L1900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,557.33,,,,,,,fee schedule,398.09,1108.71,APC
Afo sprng wir drsflx calf bd,L1900,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,696.66,,,,,,,fee schedule,398.09,1108.71,APC
Afo ankle gauntlet pre ots,L1902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,313.58,,,,,,,fee schedule,122.31,340.62,
Afo ankle gauntlet pre ots,L1902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,340.62,,,,,,,fee schedule,122.31,340.62,
Afo ankle gauntlet pre ots,L1902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,273.03,,,,,,,fee schedule,122.31,340.62,
Afo ankle gauntlet pre ots,L1902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,298.26,,,,,,,fee schedule,122.31,340.62,
Afo ankle gauntlet pre ots,L1902,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,128.43,,,,,,,fee schedule,122.31,340.62,APC
Afo ankle gauntlet pre ots,L1902,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,127.2,,,,,,,fee schedule,122.31,340.62,APC
Afo ankle gauntlet pre ots,L1902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,122.31,,,,,,,fee schedule,122.31,340.62,APC
Afo ankle gauntlet pre ots,L1902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,187.13,,,,,,,fee schedule,122.31,340.62,Radiology
Afo ankle gauntlet pre ots,L1902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,171.23,,,,,,,fee schedule,122.31,340.62,APC
Afo ankle gauntlet pre ots,L1902,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,214.04,,,,,,,fee schedule,122.31,340.62,APC
Afo molded ankle gauntlet,L1904,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1385.49,,,,,,,fee schedule,540.36,1504.93,
Afo molded ankle gauntlet,L1904,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1504.93,,,,,,,fee schedule,540.36,1504.93,
Afo molded ankle gauntlet,L1904,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1206.33,,,,,,,fee schedule,540.36,1504.93,
Afo molded ankle gauntlet,L1904,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1317.81,,,,,,,fee schedule,540.36,1504.93,
Afo molded ankle gauntlet,L1904,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,567.38,,,,,,,fee schedule,540.36,1504.93,APC
Afo molded ankle gauntlet,L1904,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,561.97,,,,,,,fee schedule,540.36,1504.93,APC
Afo molded ankle gauntlet,L1904,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,540.36,,,,,,,fee schedule,540.36,1504.93,APC
Afo molded ankle gauntlet,L1904,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,826.75,,,,,,,fee schedule,540.36,1504.93,Radiology
Afo molded ankle gauntlet,L1904,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,756.5,,,,,,,fee schedule,540.36,1504.93,APC
Afo molded ankle gauntlet,L1904,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,945.63,,,,,,,fee schedule,540.36,1504.93,APC
Afo multilig ank sup pre ots,L1906,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,354.33,,,,,,,fee schedule,138.2,384.88,
Afo multilig ank sup pre ots,L1906,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,384.88,,,,,,,fee schedule,138.2,384.88,
Afo multilig ank sup pre ots,L1906,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,308.51,,,,,,,fee schedule,138.2,384.88,
Afo multilig ank sup pre ots,L1906,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,337.02,,,,,,,fee schedule,138.2,384.88,
Afo multilig ank sup pre ots,L1906,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,145.11,,,,,,,fee schedule,138.2,384.88,APC
Afo multilig ank sup pre ots,L1906,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,143.73,,,,,,,fee schedule,138.2,384.88,APC
Afo multilig ank sup pre ots,L1906,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,138.2,,,,,,,fee schedule,138.2,384.88,APC
Afo multilig ank sup pre ots,L1906,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,211.45,,,,,,,fee schedule,138.2,384.88,Radiology
Afo multilig ank sup pre ots,L1906,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,193.48,,,,,,,fee schedule,138.2,384.88,APC
Afo multilig ank sup pre ots,L1906,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,241.85,,,,,,,fee schedule,138.2,384.88,APC
AFO supramalleolar custom,L1907,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1782.53,,,,,,,fee schedule,695.21,1936.19,
AFO supramalleolar custom,L1907,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1936.19,,,,,,,fee schedule,695.21,1936.19,
AFO supramalleolar custom,L1907,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1552.03,,,,,,,fee schedule,695.21,1936.19,
AFO supramalleolar custom,L1907,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1695.45,,,,,,,fee schedule,695.21,1936.19,
AFO supramalleolar custom,L1907,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,729.97,,,,,,,fee schedule,695.21,1936.19,APC
AFO supramalleolar custom,L1907,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,723.02,,,,,,,fee schedule,695.21,1936.19,APC
AFO supramalleolar custom,L1907,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,695.21,,,,,,,fee schedule,695.21,1936.19,APC
AFO supramalleolar custom,L1907,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1063.67,,,,,,,fee schedule,695.21,1936.19,Radiology
AFO supramalleolar custom,L1907,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,973.29,,,,,,,fee schedule,695.21,1936.19,APC
AFO supramalleolar custom,L1907,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1216.62,,,,,,,fee schedule,695.21,1936.19,APC
Afo sing bar clasp attach sh,L1910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,887.68,,,,,,,fee schedule,346.21,964.2,
Afo sing bar clasp attach sh,L1910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,964.2,,,,,,,fee schedule,346.21,964.2,
Afo sing bar clasp attach sh,L1910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,772.89,,,,,,,fee schedule,346.21,964.2,
Afo sing bar clasp attach sh,L1910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,844.31,,,,,,,fee schedule,346.21,964.2,
Afo sing bar clasp attach sh,L1910,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,363.52,,,,,,,fee schedule,346.21,964.2,APC
Afo sing bar clasp attach sh,L1910,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,360.06,,,,,,,fee schedule,346.21,964.2,APC
Afo sing bar clasp attach sh,L1910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,346.21,,,,,,,fee schedule,346.21,964.2,APC
Afo sing bar clasp attach sh,L1910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,529.7,,,,,,,fee schedule,346.21,964.2,Radiology
Afo sing bar clasp attach sh,L1910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,484.69,,,,,,,fee schedule,346.21,964.2,APC
Afo sing bar clasp attach sh,L1910,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,605.87,,,,,,,fee schedule,346.21,964.2,APC
Afo sing upright w/ adjust s,L1920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1066.48,,,,,,,fee schedule,415.96,1158.42,
Afo sing upright w/ adjust s,L1920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1158.42,,,,,,,fee schedule,415.96,1158.42,
Afo sing upright w/ adjust s,L1920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,928.57,,,,,,,fee schedule,415.96,1158.42,
Afo sing upright w/ adjust s,L1920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1014.38,,,,,,,fee schedule,415.96,1158.42,
Afo sing upright w/ adjust s,L1920,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,436.76,,,,,,,fee schedule,415.96,1158.42,APC
Afo sing upright w/ adjust s,L1920,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,432.6,,,,,,,fee schedule,415.96,1158.42,APC
Afo sing upright w/ adjust s,L1920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,415.96,,,,,,,fee schedule,415.96,1158.42,APC
Afo sing upright w/ adjust s,L1920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,636.42,,,,,,,fee schedule,415.96,1158.42,Radiology
Afo sing upright w/ adjust s,L1920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,582.34,,,,,,,fee schedule,415.96,1158.42,APC
Afo sing upright w/ adjust s,L1920,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,727.93,,,,,,,fee schedule,415.96,1158.42,APC
Afo plastic,L1930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,929.33,,,,,,,fee schedule,362.45,1009.45,
Afo plastic,L1930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1009.45,,,,,,,fee schedule,362.45,1009.45,
Afo plastic,L1930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,809.16,,,,,,,fee schedule,362.45,1009.45,
Afo plastic,L1930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,883.94,,,,,,,fee schedule,362.45,1009.45,
Afo plastic,L1930,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,380.57,,,,,,,fee schedule,362.45,1009.45,APC
Afo plastic,L1930,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,376.95,,,,,,,fee schedule,362.45,1009.45,APC
Afo plastic,L1930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,362.45,,,,,,,fee schedule,362.45,1009.45,APC
Afo plastic,L1930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,554.55,,,,,,,fee schedule,362.45,1009.45,Radiology
Afo plastic,L1930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,507.43,,,,,,,fee schedule,362.45,1009.45,APC
Afo plastic,L1930,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,634.29,,,,,,,fee schedule,362.45,1009.45,APC
Afo rig ant tib prefab TCF/=,L1932,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2826.8,,,,,,,fee schedule,1102.55,3070.49,
Afo rig ant tib prefab TCF/=,L1932,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3070.49,,,,,,,fee schedule,1102.55,3070.49,
Afo rig ant tib prefab TCF/=,L1932,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2461.27,,,,,,,fee schedule,1102.55,3070.49,
Afo rig ant tib prefab TCF/=,L1932,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2688.71,,,,,,,fee schedule,1102.55,3070.49,
Afo rig ant tib prefab TCF/=,L1932,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1157.68,,,,,,,fee schedule,1102.55,3070.49,APC
Afo rig ant tib prefab TCF/=,L1932,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1146.65,,,,,,,fee schedule,1102.55,3070.49,APC
Afo rig ant tib prefab TCF/=,L1932,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1102.55,,,,,,,fee schedule,1102.55,3070.49,APC
Afo rig ant tib prefab TCF/=,L1932,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1686.9,,,,,,,fee schedule,1102.55,3070.49,Radiology
Afo rig ant tib prefab TCF/=,L1932,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1543.57,,,,,,,fee schedule,1102.55,3070.49,APC
Afo rig ant tib prefab TCF/=,L1932,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1929.46,,,,,,,fee schedule,1102.55,3070.49,APC
Afo molded to patient plasti,L1940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1491.88,,,,,,,fee schedule,581.88,1620.49,
Afo molded to patient plasti,L1940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1620.49,,,,,,,fee schedule,581.88,1620.49,
Afo molded to patient plasti,L1940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1298.96,,,,,,,fee schedule,581.88,1620.49,
Afo molded to patient plasti,L1940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1419,,,,,,,fee schedule,581.88,1620.49,
Afo molded to patient plasti,L1940,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,610.97,,,,,,,fee schedule,581.88,1620.49,APC
Afo molded to patient plasti,L1940,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,605.16,,,,,,,fee schedule,581.88,1620.49,APC
Afo molded to patient plasti,L1940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,581.88,,,,,,,fee schedule,581.88,1620.49,APC
Afo molded to patient plasti,L1940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,890.28,,,,,,,fee schedule,581.88,1620.49,Radiology
Afo molded to patient plasti,L1940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,814.63,,,,,,,fee schedule,581.88,1620.49,APC
Afo molded to patient plasti,L1940,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1018.29,,,,,,,fee schedule,581.88,1620.49,APC
Afo molded plas rig ant tib,L1945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2727.38,,,,,,,fee schedule,1063.73,2962.5,
Afo molded plas rig ant tib,L1945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2962.5,,,,,,,fee schedule,1063.73,2962.5,
Afo molded plas rig ant tib,L1945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2374.7,,,,,,,fee schedule,1063.73,2962.5,
Afo molded plas rig ant tib,L1945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2594.15,,,,,,,fee schedule,1063.73,2962.5,
Afo molded plas rig ant tib,L1945,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1116.92,,,,,,,fee schedule,1063.73,2962.5,APC
Afo molded plas rig ant tib,L1945,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1106.28,,,,,,,fee schedule,1063.73,2962.5,APC
Afo molded plas rig ant tib,L1945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1063.73,,,,,,,fee schedule,1063.73,2962.5,APC
Afo molded plas rig ant tib,L1945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1627.51,,,,,,,fee schedule,1063.73,2962.5,Radiology
Afo molded plas rig ant tib,L1945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1489.22,,,,,,,fee schedule,1063.73,2962.5,APC
Afo molded plas rig ant tib,L1945,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1861.53,,,,,,,fee schedule,1063.73,2962.5,APC
Afo spiral molded to pt plas,L1950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2202.04,,,,,,,fee schedule,858.83,2391.87,
Afo spiral molded to pt plas,L1950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2391.87,,,,,,,fee schedule,858.83,2391.87,
Afo spiral molded to pt plas,L1950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1917.29,,,,,,,fee schedule,858.83,2391.87,
Afo spiral molded to pt plas,L1950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2094.47,,,,,,,fee schedule,858.83,2391.87,
Afo spiral molded to pt plas,L1950,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,901.77,,,,,,,fee schedule,858.83,2391.87,APC
Afo spiral molded to pt plas,L1950,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,893.18,,,,,,,fee schedule,858.83,2391.87,APC
Afo spiral molded to pt plas,L1950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,858.83,,,,,,,fee schedule,858.83,2391.87,APC
Afo spiral molded to pt plas,L1950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1314.01,,,,,,,fee schedule,858.83,2391.87,Radiology
Afo spiral molded to pt plas,L1950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1202.36,,,,,,,fee schedule,858.83,2391.87,APC
Afo spiral molded to pt plas,L1950,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1502.95,,,,,,,fee schedule,858.83,2391.87,APC
AFO spiral prefabricated,L1951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2660.39,,,,,,,fee schedule,1037.61,2889.73,
AFO spiral prefabricated,L1951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2889.73,,,,,,,fee schedule,1037.61,2889.73,
AFO spiral prefabricated,L1951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2316.37,,,,,,,fee schedule,1037.61,2889.73,
AFO spiral prefabricated,L1951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2530.43,,,,,,,fee schedule,1037.61,2889.73,
AFO spiral prefabricated,L1951,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1089.49,,,,,,,fee schedule,1037.61,2889.73,APC
AFO spiral prefabricated,L1951,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1079.11,,,,,,,fee schedule,1037.61,2889.73,APC
AFO spiral prefabricated,L1951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1037.61,,,,,,,fee schedule,1037.61,2889.73,APC
AFO spiral prefabricated,L1951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1587.54,,,,,,,fee schedule,1037.61,2889.73,Radiology
AFO spiral prefabricated,L1951,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1452.65,,,,,,,fee schedule,1037.61,2889.73,APC
AFO spiral prefabricated,L1951,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1815.82,,,,,,,fee schedule,1037.61,2889.73,APC
Afo pos solid ank plastic mo,L1960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1633.09,,,,,,,fee schedule,636.95,1773.88,
Afo pos solid ank plastic mo,L1960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1773.88,,,,,,,fee schedule,636.95,1773.88,
Afo pos solid ank plastic mo,L1960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1421.92,,,,,,,fee schedule,636.95,1773.88,
Afo pos solid ank plastic mo,L1960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1553.32,,,,,,,fee schedule,636.95,1773.88,
Afo pos solid ank plastic mo,L1960,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,668.8,,,,,,,fee schedule,636.95,1773.88,APC
Afo pos solid ank plastic mo,L1960,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,662.43,,,,,,,fee schedule,636.95,1773.88,APC
Afo pos solid ank plastic mo,L1960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,636.95,,,,,,,fee schedule,636.95,1773.88,APC
Afo pos solid ank plastic mo,L1960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,974.53,,,,,,,fee schedule,636.95,1773.88,Radiology
Afo pos solid ank plastic mo,L1960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,891.73,,,,,,,fee schedule,636.95,1773.88,APC
Afo pos solid ank plastic mo,L1960,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1114.66,,,,,,,fee schedule,636.95,1773.88,APC
Afo plastic molded w/ankle j,L1970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2096.49,,,,,,,fee schedule,817.68,2277.22,
Afo plastic molded w/ankle j,L1970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2277.22,,,,,,,fee schedule,817.68,2277.22,
Afo plastic molded w/ankle j,L1970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1825.39,,,,,,,fee schedule,817.68,2277.22,
Afo plastic molded w/ankle j,L1970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1994.08,,,,,,,fee schedule,817.68,2277.22,
Afo plastic molded w/ankle j,L1970,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,858.56,,,,,,,fee schedule,817.68,2277.22,APC
Afo plastic molded w/ankle j,L1970,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,850.39,,,,,,,fee schedule,817.68,2277.22,APC
Afo plastic molded w/ankle j,L1970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,817.68,,,,,,,fee schedule,817.68,2277.22,APC
Afo plastic molded w/ankle j,L1970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1251.05,,,,,,,fee schedule,817.68,2277.22,Radiology
Afo plastic molded w/ankle j,L1970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1144.75,,,,,,,fee schedule,817.68,2277.22,APC
Afo plastic molded w/ankle j,L1970,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1430.94,,,,,,,fee schedule,817.68,2277.22,APC
"AFO w/ankle joint, prefab",L1971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1484.81,,,,,,,fee schedule,579.11,1612.81,
"AFO w/ankle joint, prefab",L1971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1612.81,,,,,,,fee schedule,579.11,1612.81,
"AFO w/ankle joint, prefab",L1971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1292.81,,,,,,,fee schedule,579.11,1612.81,
"AFO w/ankle joint, prefab",L1971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1412.28,,,,,,,fee schedule,579.11,1612.81,
"AFO w/ankle joint, prefab",L1971,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,608.07,,,,,,,fee schedule,579.11,1612.81,APC
"AFO w/ankle joint, prefab",L1971,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,602.27,,,,,,,fee schedule,579.11,1612.81,APC
"AFO w/ankle joint, prefab",L1971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,579.11,,,,,,,fee schedule,579.11,1612.81,APC
"AFO w/ankle joint, prefab",L1971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,886.04,,,,,,,fee schedule,579.11,1612.81,Radiology
"AFO w/ankle joint, prefab",L1971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,810.75,,,,,,,fee schedule,579.11,1612.81,APC
"AFO w/ankle joint, prefab",L1971,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1013.44,,,,,,,fee schedule,579.11,1612.81,APC
Afo sing solid stirrup calf,L1980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1130.3,,,,,,,fee schedule,440.87,1227.74,
Afo sing solid stirrup calf,L1980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1227.74,,,,,,,fee schedule,440.87,1227.74,
Afo sing solid stirrup calf,L1980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,984.14,,,,,,,fee schedule,440.87,1227.74,
Afo sing solid stirrup calf,L1980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1075.09,,,,,,,fee schedule,440.87,1227.74,
Afo sing solid stirrup calf,L1980,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,462.91,,,,,,,fee schedule,440.87,1227.74,APC
Afo sing solid stirrup calf,L1980,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,458.5,,,,,,,fee schedule,440.87,1227.74,APC
Afo sing solid stirrup calf,L1980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,440.87,,,,,,,fee schedule,440.87,1227.74,APC
Afo sing solid stirrup calf,L1980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,674.53,,,,,,,fee schedule,440.87,1227.74,Radiology
Afo sing solid stirrup calf,L1980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,617.22,,,,,,,fee schedule,440.87,1227.74,APC
Afo sing solid stirrup calf,L1980,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,771.52,,,,,,,fee schedule,440.87,1227.74,APC
Afo doub solid stirrup calf,L1990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1313.32,,,,,,,fee schedule,512.22,1426.53,
Afo doub solid stirrup calf,L1990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1426.53,,,,,,,fee schedule,512.22,1426.53,
Afo doub solid stirrup calf,L1990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1143.49,,,,,,,fee schedule,512.22,1426.53,
Afo doub solid stirrup calf,L1990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1249.16,,,,,,,fee schedule,512.22,1426.53,
Afo doub solid stirrup calf,L1990,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,537.83,,,,,,,fee schedule,512.22,1426.53,APC
Afo doub solid stirrup calf,L1990,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,532.71,,,,,,,fee schedule,512.22,1426.53,APC
Afo doub solid stirrup calf,L1990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,512.22,,,,,,,fee schedule,512.22,1426.53,APC
Afo doub solid stirrup calf,L1990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,783.7,,,,,,,fee schedule,512.22,1426.53,Radiology
Afo doub solid stirrup calf,L1990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,717.11,,,,,,,fee schedule,512.22,1426.53,APC
Afo doub solid stirrup calf,L1990,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,896.38,,,,,,,fee schedule,512.22,1426.53,APC
Kafo sing fre stirr thi/calf,L2000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2988.42,,,,,,,fee schedule,1165.54,3246.04,
Kafo sing fre stirr thi/calf,L2000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3246.04,,,,,,,fee schedule,1165.54,3246.04,
Kafo sing fre stirr thi/calf,L2000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2601.98,,,,,,,fee schedule,1165.54,3246.04,
Kafo sing fre stirr thi/calf,L2000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2842.43,,,,,,,fee schedule,1165.54,3246.04,
Kafo sing fre stirr thi/calf,L2000,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1223.82,,,,,,,fee schedule,1165.54,3246.04,APC
Kafo sing fre stirr thi/calf,L2000,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1212.16,,,,,,,fee schedule,1165.54,3246.04,APC
Kafo sing fre stirr thi/calf,L2000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1165.54,,,,,,,fee schedule,1165.54,3246.04,APC
Kafo sing fre stirr thi/calf,L2000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1783.28,,,,,,,fee schedule,1165.54,3246.04,Radiology
Kafo sing fre stirr thi/calf,L2000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1631.76,,,,,,,fee schedule,1165.54,3246.04,APC
Kafo sing fre stirr thi/calf,L2000,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2039.7,,,,,,,fee schedule,1165.54,3246.04,APC
KAFO sng/dbl mechanical act,L2005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12980.61,,,,,,,fee schedule,5062.71,14099.63,
KAFO sng/dbl mechanical act,L2005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14099.63,,,,,,,fee schedule,5062.71,14099.63,
KAFO sng/dbl mechanical act,L2005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11302.08,,,,,,,fee schedule,5062.71,14099.63,
KAFO sng/dbl mechanical act,L2005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12346.5,,,,,,,fee schedule,5062.71,14099.63,
KAFO sng/dbl mechanical act,L2005,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5315.85,,,,,,,fee schedule,5062.71,14099.63,APC
KAFO sng/dbl mechanical act,L2005,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5265.22,,,,,,,fee schedule,5062.71,14099.63,APC
KAFO sng/dbl mechanical act,L2005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5062.71,,,,,,,fee schedule,5062.71,14099.63,APC
KAFO sng/dbl mechanical act,L2005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7745.95,,,,,,,fee schedule,5062.71,14099.63,Radiology
KAFO sng/dbl mechanical act,L2005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7087.79,,,,,,,fee schedule,5062.71,14099.63,APC
KAFO sng/dbl mechanical act,L2005,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8859.74,,,,,,,fee schedule,5062.71,14099.63,APC
Kafo sng solid stirrup w/o j,L2010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2918.26,,,,,,,fee schedule,1138.18,3169.83,
Kafo sng solid stirrup w/o j,L2010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3169.83,,,,,,,fee schedule,1138.18,3169.83,
Kafo sng solid stirrup w/o j,L2010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2540.9,,,,,,,fee schedule,1138.18,3169.83,
Kafo sng solid stirrup w/o j,L2010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2775.7,,,,,,,fee schedule,1138.18,3169.83,
Kafo sng solid stirrup w/o j,L2010,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1195.09,,,,,,,fee schedule,1138.18,3169.83,APC
Kafo sng solid stirrup w/o j,L2010,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1183.71,,,,,,,fee schedule,1138.18,3169.83,APC
Kafo sng solid stirrup w/o j,L2010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1138.18,,,,,,,fee schedule,1138.18,3169.83,APC
Kafo sng solid stirrup w/o j,L2010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1741.42,,,,,,,fee schedule,1138.18,3169.83,Radiology
Kafo sng solid stirrup w/o j,L2010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1593.45,,,,,,,fee schedule,1138.18,3169.83,APC
Kafo sng solid stirrup w/o j,L2010,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1991.82,,,,,,,fee schedule,1138.18,3169.83,APC
Kafo dbl solid stirrup band/,L2020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3440.26,,,,,,,fee schedule,1341.77,3736.83,
Kafo dbl solid stirrup band/,L2020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3736.83,,,,,,,fee schedule,1341.77,3736.83,
Kafo dbl solid stirrup band/,L2020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2995.4,,,,,,,fee schedule,1341.77,3736.83,
Kafo dbl solid stirrup band/,L2020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3272.2,,,,,,,fee schedule,1341.77,3736.83,
Kafo dbl solid stirrup band/,L2020,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1408.86,,,,,,,fee schedule,1341.77,3736.83,APC
Kafo dbl solid stirrup band/,L2020,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1395.44,,,,,,,fee schedule,1341.77,3736.83,APC
Kafo dbl solid stirrup band/,L2020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1341.77,,,,,,,fee schedule,1341.77,3736.83,APC
Kafo dbl solid stirrup band/,L2020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2052.91,,,,,,,fee schedule,1341.77,3736.83,Radiology
Kafo dbl solid stirrup band/,L2020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1878.48,,,,,,,fee schedule,1341.77,3736.83,APC
Kafo dbl solid stirrup band/,L2020,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2348.1,,,,,,,fee schedule,1341.77,3736.83,APC
Kafo dbl solid stirrup w/o j,L2030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3017.61,,,,,,,fee schedule,1176.93,3277.75,
Kafo dbl solid stirrup w/o j,L2030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3277.75,,,,,,,fee schedule,1176.93,3277.75,
Kafo dbl solid stirrup w/o j,L2030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2627.4,,,,,,,fee schedule,1176.93,3277.75,
Kafo dbl solid stirrup w/o j,L2030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2870.2,,,,,,,fee schedule,1176.93,3277.75,
Kafo dbl solid stirrup w/o j,L2030,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1235.78,,,,,,,fee schedule,1176.93,3277.75,APC
Kafo dbl solid stirrup w/o j,L2030,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1224.01,,,,,,,fee schedule,1176.93,3277.75,APC
Kafo dbl solid stirrup w/o j,L2030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1176.93,,,,,,,fee schedule,1176.93,3277.75,APC
Kafo dbl solid stirrup w/o j,L2030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1800.7,,,,,,,fee schedule,1176.93,3277.75,Radiology
Kafo dbl solid stirrup w/o j,L2030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1647.7,,,,,,,fee schedule,1176.93,3277.75,APC
Kafo dbl solid stirrup w/o j,L2030,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2059.63,,,,,,,fee schedule,1176.93,3277.75,APC
Kafo pla sin up w/wo k/a cus,L2034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6652.26,,,,,,,fee schedule,2594.53,7225.73,
Kafo pla sin up w/wo k/a cus,L2034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7225.73,,,,,,,fee schedule,2594.53,7225.73,
Kafo pla sin up w/wo k/a cus,L2034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5792.06,,,,,,,fee schedule,2594.53,7225.73,
Kafo pla sin up w/wo k/a cus,L2034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6327.3,,,,,,,fee schedule,2594.53,7225.73,
Kafo pla sin up w/wo k/a cus,L2034,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2724.26,,,,,,,fee schedule,2594.53,7225.73,APC
Kafo pla sin up w/wo k/a cus,L2034,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2698.31,,,,,,,fee schedule,2594.53,7225.73,APC
Kafo pla sin up w/wo k/a cus,L2034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2594.53,,,,,,,fee schedule,2594.53,7225.73,APC
Kafo pla sin up w/wo k/a cus,L2034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3969.63,,,,,,,fee schedule,2594.53,7225.73,Radiology
Kafo pla sin up w/wo k/a cus,L2034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3632.34,,,,,,,fee schedule,2594.53,7225.73,APC
Kafo pla sin up w/wo k/a cus,L2034,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4540.43,,,,,,,fee schedule,2594.53,7225.73,APC
KAFO plastic pediatric size,L2035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,548.8,,,,,,,fee schedule,214.05,596.11,
KAFO plastic pediatric size,L2035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,596.11,,,,,,,fee schedule,214.05,596.11,
KAFO plastic pediatric size,L2035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,477.83,,,,,,,fee schedule,214.05,596.11,
KAFO plastic pediatric size,L2035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,521.99,,,,,,,fee schedule,214.05,596.11,
KAFO plastic pediatric size,L2035,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,224.75,,,,,,,fee schedule,214.05,596.11,APC
KAFO plastic pediatric size,L2035,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,222.61,,,,,,,fee schedule,214.05,596.11,APC
KAFO plastic pediatric size,L2035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,214.05,,,,,,,fee schedule,214.05,596.11,APC
KAFO plastic pediatric size,L2035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,327.5,,,,,,,fee schedule,214.05,596.11,Radiology
KAFO plastic pediatric size,L2035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.67,,,,,,,fee schedule,214.05,596.11,APC
KAFO plastic pediatric size,L2035,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,374.59,,,,,,,fee schedule,214.05,596.11,APC
Kafo plas doub free knee mol,L2036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5743.95,,,,,,,fee schedule,2240.26,6239.12,
Kafo plas doub free knee mol,L2036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6239.12,,,,,,,fee schedule,2240.26,6239.12,
Kafo plas doub free knee mol,L2036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5001.2,,,,,,,fee schedule,2240.26,6239.12,
Kafo plas doub free knee mol,L2036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5463.35,,,,,,,fee schedule,2240.26,6239.12,
Kafo plas doub free knee mol,L2036,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2352.27,,,,,,,fee schedule,2240.26,6239.12,APC
Kafo plas doub free knee mol,L2036,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2329.87,,,,,,,fee schedule,2240.26,6239.12,APC
Kafo plas doub free knee mol,L2036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2240.26,,,,,,,fee schedule,2240.26,6239.12,APC
Kafo plas doub free knee mol,L2036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3427.6,,,,,,,fee schedule,2240.26,6239.12,Radiology
Kafo plas doub free knee mol,L2036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3136.36,,,,,,,fee schedule,2240.26,6239.12,APC
Kafo plas doub free knee mol,L2036,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3920.46,,,,,,,fee schedule,2240.26,6239.12,APC
Kafo plas sing free knee mol,L2037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4907.36,,,,,,,fee schedule,1913.97,5330.4,
Kafo plas sing free knee mol,L2037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5330.4,,,,,,,fee schedule,1913.97,5330.4,
Kafo plas sing free knee mol,L2037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4272.78,,,,,,,fee schedule,1913.97,5330.4,
Kafo plas sing free knee mol,L2037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4667.63,,,,,,,fee schedule,1913.97,5330.4,
Kafo plas sing free knee mol,L2037,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2009.67,,,,,,,fee schedule,1913.97,5330.4,APC
Kafo plas sing free knee mol,L2037,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1990.53,,,,,,,fee schedule,1913.97,5330.4,APC
Kafo plas sing free knee mol,L2037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1913.97,,,,,,,fee schedule,1913.97,5330.4,APC
Kafo plas sing free knee mol,L2037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2928.37,,,,,,,fee schedule,1913.97,5330.4,Radiology
Kafo plas sing free knee mol,L2037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2679.56,,,,,,,fee schedule,1913.97,5330.4,APC
Kafo plas sing free knee mol,L2037,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3349.45,,,,,,,fee schedule,1913.97,5330.4,APC
Kafo w/o joint multi-axis an,L2038,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4212.44,,,,,,,fee schedule,1642.94,4575.58,
Kafo w/o joint multi-axis an,L2038,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4575.58,,,,,,,fee schedule,1642.94,4575.58,
Kafo w/o joint multi-axis an,L2038,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3667.72,,,,,,,fee schedule,1642.94,4575.58,
Kafo w/o joint multi-axis an,L2038,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4006.66,,,,,,,fee schedule,1642.94,4575.58,
Kafo w/o joint multi-axis an,L2038,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1725.09,,,,,,,fee schedule,1642.94,4575.58,APC
Kafo w/o joint multi-axis an,L2038,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1708.66,,,,,,,fee schedule,1642.94,4575.58,APC
Kafo w/o joint multi-axis an,L2038,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1642.94,,,,,,,fee schedule,1642.94,4575.58,APC
Kafo w/o joint multi-axis an,L2038,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2513.7,,,,,,,fee schedule,1642.94,4575.58,Radiology
Kafo w/o joint multi-axis an,L2038,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2300.12,,,,,,,fee schedule,1642.94,4575.58,APC
Kafo w/o joint multi-axis an,L2038,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2875.14,,,,,,,fee schedule,1642.94,4575.58,APC
Hkafo torsion bil rot straps,L2040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,523.08,,,,,,,fee schedule,204.02,568.17,
Hkafo torsion bil rot straps,L2040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,568.17,,,,,,,fee schedule,204.02,568.17,
Hkafo torsion bil rot straps,L2040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,455.44,,,,,,,fee schedule,204.02,568.17,
Hkafo torsion bil rot straps,L2040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,497.53,,,,,,,fee schedule,204.02,568.17,
Hkafo torsion bil rot straps,L2040,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,214.22,,,,,,,fee schedule,204.02,568.17,APC
Hkafo torsion bil rot straps,L2040,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,212.18,,,,,,,fee schedule,204.02,568.17,APC
Hkafo torsion bil rot straps,L2040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,204.02,,,,,,,fee schedule,204.02,568.17,APC
Hkafo torsion bil rot straps,L2040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,312.15,,,,,,,fee schedule,204.02,568.17,Radiology
Hkafo torsion bil rot straps,L2040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,285.63,,,,,,,fee schedule,204.02,568.17,APC
Hkafo torsion bil rot straps,L2040,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,357.04,,,,,,,fee schedule,204.02,568.17,APC
Hkafo torsion cable hip pelv,L2050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1664.87,,,,,,,fee schedule,649.33,1808.39,
Hkafo torsion cable hip pelv,L2050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1808.39,,,,,,,fee schedule,649.33,1808.39,
Hkafo torsion cable hip pelv,L2050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1449.58,,,,,,,fee schedule,649.33,1808.39,
Hkafo torsion cable hip pelv,L2050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1583.54,,,,,,,fee schedule,649.33,1808.39,
Hkafo torsion cable hip pelv,L2050,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,681.8,,,,,,,fee schedule,649.33,1808.39,APC
Hkafo torsion cable hip pelv,L2050,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,675.3,,,,,,,fee schedule,649.33,1808.39,APC
Hkafo torsion cable hip pelv,L2050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,649.33,,,,,,,fee schedule,649.33,1808.39,APC
Hkafo torsion cable hip pelv,L2050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,993.47,,,,,,,fee schedule,649.33,1808.39,Radiology
Hkafo torsion cable hip pelv,L2050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,909.06,,,,,,,fee schedule,649.33,1808.39,APC
Hkafo torsion cable hip pelv,L2050,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1136.33,,,,,,,fee schedule,649.33,1808.39,APC
Hkafo torsion ball bearing j,L2060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1926.21,,,,,,,fee schedule,751.28,2092.27,
Hkafo torsion ball bearing j,L2060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2092.27,,,,,,,fee schedule,751.28,2092.27,
Hkafo torsion ball bearing j,L2060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1677.14,,,,,,,fee schedule,751.28,2092.27,
Hkafo torsion ball bearing j,L2060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1832.12,,,,,,,fee schedule,751.28,2092.27,
Hkafo torsion ball bearing j,L2060,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,788.84,,,,,,,fee schedule,751.28,2092.27,APC
Hkafo torsion ball bearing j,L2060,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,781.33,,,,,,,fee schedule,751.28,2092.27,APC
Hkafo torsion ball bearing j,L2060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,751.28,,,,,,,fee schedule,751.28,2092.27,APC
Hkafo torsion ball bearing j,L2060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1149.46,,,,,,,fee schedule,751.28,2092.27,Radiology
Hkafo torsion ball bearing j,L2060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1051.79,,,,,,,fee schedule,751.28,2092.27,APC
Hkafo torsion ball bearing j,L2060,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1314.74,,,,,,,fee schedule,751.28,2092.27,APC
Hkafo torsion unilat rot str,L2070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,399.16,,,,,,,fee schedule,155.7,433.57,
Hkafo torsion unilat rot str,L2070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,433.57,,,,,,,fee schedule,155.7,433.57,
Hkafo torsion unilat rot str,L2070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,347.54,,,,,,,fee schedule,155.7,433.57,
Hkafo torsion unilat rot str,L2070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,379.66,,,,,,,fee schedule,155.7,433.57,
Hkafo torsion unilat rot str,L2070,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,163.48,,,,,,,fee schedule,155.7,433.57,APC
Hkafo torsion unilat rot str,L2070,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,161.93,,,,,,,fee schedule,155.7,433.57,APC
Hkafo torsion unilat rot str,L2070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,155.7,,,,,,,fee schedule,155.7,433.57,APC
Hkafo torsion unilat rot str,L2070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,238.22,,,,,,,fee schedule,155.7,433.57,Radiology
Hkafo torsion unilat rot str,L2070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,217.98,,,,,,,fee schedule,155.7,433.57,APC
Hkafo torsion unilat rot str,L2070,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,272.47,,,,,,,fee schedule,155.7,433.57,APC
Hkafo unilat torsion cable,L2080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1132.32,,,,,,,fee schedule,441.61,1229.94,
Hkafo unilat torsion cable,L2080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1229.94,,,,,,,fee schedule,441.61,1229.94,
Hkafo unilat torsion cable,L2080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,985.9,,,,,,,fee schedule,441.61,1229.94,
Hkafo unilat torsion cable,L2080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1077.01,,,,,,,fee schedule,441.61,1229.94,
Hkafo unilat torsion cable,L2080,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,463.69,,,,,,,fee schedule,441.61,1229.94,APC
Hkafo unilat torsion cable,L2080,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,459.27,,,,,,,fee schedule,441.61,1229.94,APC
Hkafo unilat torsion cable,L2080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,441.61,,,,,,,fee schedule,441.61,1229.94,APC
Hkafo unilat torsion cable,L2080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,675.66,,,,,,,fee schedule,441.61,1229.94,Radiology
Hkafo unilat torsion cable,L2080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,618.25,,,,,,,fee schedule,441.61,1229.94,APC
Hkafo unilat torsion cable,L2080,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,772.82,,,,,,,fee schedule,441.61,1229.94,APC
Hkafo unilat torsion ball br,L2090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1372.27,,,,,,,fee schedule,535.22,1490.57,
Hkafo unilat torsion ball br,L2090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1490.57,,,,,,,fee schedule,535.22,1490.57,
Hkafo unilat torsion ball br,L2090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1194.82,,,,,,,fee schedule,535.22,1490.57,
Hkafo unilat torsion ball br,L2090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1305.23,,,,,,,fee schedule,535.22,1490.57,
Hkafo unilat torsion ball br,L2090,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,561.98,,,,,,,fee schedule,535.22,1490.57,APC
Hkafo unilat torsion ball br,L2090,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,556.63,,,,,,,fee schedule,535.22,1490.57,APC
Hkafo unilat torsion ball br,L2090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,535.22,,,,,,,fee schedule,535.22,1490.57,APC
Hkafo unilat torsion ball br,L2090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,818.89,,,,,,,fee schedule,535.22,1490.57,Radiology
Hkafo unilat torsion ball br,L2090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,749.31,,,,,,,fee schedule,535.22,1490.57,APC
Hkafo unilat torsion ball br,L2090,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,936.64,,,,,,,fee schedule,535.22,1490.57,APC
Afo tib fx cast plaster mold,L2106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2465.48,,,,,,,fee schedule,961.61,2678.02,
Afo tib fx cast plaster mold,L2106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2678.02,,,,,,,fee schedule,961.61,2678.02,
Afo tib fx cast plaster mold,L2106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2146.66,,,,,,,fee schedule,961.61,2678.02,
Afo tib fx cast plaster mold,L2106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2345.04,,,,,,,fee schedule,961.61,2678.02,
Afo tib fx cast plaster mold,L2106,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1009.69,,,,,,,fee schedule,961.61,2678.02,APC
Afo tib fx cast plaster mold,L2106,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1000.07,,,,,,,fee schedule,961.61,2678.02,APC
Afo tib fx cast plaster mold,L2106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,961.61,,,,,,,fee schedule,961.61,2678.02,APC
Afo tib fx cast plaster mold,L2106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1471.26,,,,,,,fee schedule,961.61,2678.02,Radiology
Afo tib fx cast plaster mold,L2106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1346.25,,,,,,,fee schedule,961.61,2678.02,APC
Afo tib fx cast plaster mold,L2106,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1682.82,,,,,,,fee schedule,961.61,2678.02,APC
Afo tib fx cast molded to pt,L2108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3425.22,,,,,,,fee schedule,1335.93,3720.5,
Afo tib fx cast molded to pt,L2108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3720.5,,,,,,,fee schedule,1335.93,3720.5,
Afo tib fx cast molded to pt,L2108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2982.31,,,,,,,fee schedule,1335.93,3720.5,
Afo tib fx cast molded to pt,L2108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3257.9,,,,,,,fee schedule,1335.93,3720.5,
Afo tib fx cast molded to pt,L2108,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1402.73,,,,,,,fee schedule,1335.93,3720.5,APC
Afo tib fx cast molded to pt,L2108,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1389.37,,,,,,,fee schedule,1335.93,3720.5,APC
Afo tib fx cast molded to pt,L2108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1335.93,,,,,,,fee schedule,1335.93,3720.5,APC
Afo tib fx cast molded to pt,L2108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2043.97,,,,,,,fee schedule,1335.93,3720.5,Radiology
Afo tib fx cast molded to pt,L2108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1870.3,,,,,,,fee schedule,1335.93,3720.5,APC
Afo tib fx cast molded to pt,L2108,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2337.88,,,,,,,fee schedule,1335.93,3720.5,APC
Afo tibial fracture soft,L2112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1668.87,,,,,,,fee schedule,650.87,1812.74,
Afo tibial fracture soft,L2112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1812.74,,,,,,,fee schedule,650.87,1812.74,
Afo tibial fracture soft,L2112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1453.07,,,,,,,fee schedule,650.87,1812.74,
Afo tibial fracture soft,L2112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1587.34,,,,,,,fee schedule,650.87,1812.74,
Afo tibial fracture soft,L2112,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,683.41,,,,,,,fee schedule,650.87,1812.74,APC
Afo tibial fracture soft,L2112,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,676.9,,,,,,,fee schedule,650.87,1812.74,APC
Afo tibial fracture soft,L2112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,650.87,,,,,,,fee schedule,650.87,1812.74,APC
Afo tibial fracture soft,L2112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,995.83,,,,,,,fee schedule,650.87,1812.74,Radiology
Afo tibial fracture soft,L2112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,911.22,,,,,,,fee schedule,650.87,1812.74,APC
Afo tibial fracture soft,L2112,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1139.02,,,,,,,fee schedule,650.87,1812.74,APC
Afo tib fx semi-rigid,L2114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1931.92,,,,,,,fee schedule,753.46,2098.47,
Afo tib fx semi-rigid,L2114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2098.47,,,,,,,fee schedule,753.46,2098.47,
Afo tib fx semi-rigid,L2114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1682.1,,,,,,,fee schedule,753.46,2098.47,
Afo tib fx semi-rigid,L2114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1837.55,,,,,,,fee schedule,753.46,2098.47,
Afo tib fx semi-rigid,L2114,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,791.13,,,,,,,fee schedule,753.46,2098.47,APC
Afo tib fx semi-rigid,L2114,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,783.6,,,,,,,fee schedule,753.46,2098.47,APC
Afo tib fx semi-rigid,L2114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,753.46,,,,,,,fee schedule,753.46,2098.47,APC
Afo tib fx semi-rigid,L2114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1152.79,,,,,,,fee schedule,753.46,2098.47,Radiology
Afo tib fx semi-rigid,L2114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1054.84,,,,,,,fee schedule,753.46,2098.47,APC
Afo tib fx semi-rigid,L2114,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1318.56,,,,,,,fee schedule,753.46,2098.47,APC
Afo tibial fracture rigid,L2116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2314.48,,,,,,,fee schedule,902.69,2514,
Afo tibial fracture rigid,L2116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2514,,,,,,,fee schedule,902.69,2514,
Afo tibial fracture rigid,L2116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2015.19,,,,,,,fee schedule,902.69,2514,
Afo tibial fracture rigid,L2116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2201.41,,,,,,,fee schedule,902.69,2514,
Afo tibial fracture rigid,L2116,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,947.82,,,,,,,fee schedule,902.69,2514,APC
Afo tibial fracture rigid,L2116,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,938.8,,,,,,,fee schedule,902.69,2514,APC
Afo tibial fracture rigid,L2116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,902.69,,,,,,,fee schedule,902.69,2514,APC
Afo tibial fracture rigid,L2116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1381.12,,,,,,,fee schedule,902.69,2514,Radiology
Afo tibial fracture rigid,L2116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1263.77,,,,,,,fee schedule,902.69,2514,APC
Afo tibial fracture rigid,L2116,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1579.71,,,,,,,fee schedule,902.69,2514,APC
Kafo fem fx cast thermoplas,L2126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3528.06,,,,,,,fee schedule,1376.03,3832.2,
Kafo fem fx cast thermoplas,L2126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3832.2,,,,,,,fee schedule,1376.03,3832.2,
Kafo fem fx cast thermoplas,L2126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3071.84,,,,,,,fee schedule,1376.03,3832.2,
Kafo fem fx cast thermoplas,L2126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3355.71,,,,,,,fee schedule,1376.03,3832.2,
Kafo fem fx cast thermoplas,L2126,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1444.83,,,,,,,fee schedule,1376.03,3832.2,APC
Kafo fem fx cast thermoplas,L2126,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1431.07,,,,,,,fee schedule,1376.03,3832.2,APC
Kafo fem fx cast thermoplas,L2126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1376.03,,,,,,,fee schedule,1376.03,3832.2,APC
Kafo fem fx cast thermoplas,L2126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2105.33,,,,,,,fee schedule,1376.03,3832.2,Radiology
Kafo fem fx cast thermoplas,L2126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1926.44,,,,,,,fee schedule,1376.03,3832.2,APC
Kafo fem fx cast thermoplas,L2126,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2408.05,,,,,,,fee schedule,1376.03,3832.2,APC
Kafo fem fx cast molded to p,L2128,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5052.12,,,,,,,fee schedule,1970.44,5487.65,
Kafo fem fx cast molded to p,L2128,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5487.65,,,,,,,fee schedule,1970.44,5487.65,
Kafo fem fx cast molded to p,L2128,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4398.83,,,,,,,fee schedule,1970.44,5487.65,
Kafo fem fx cast molded to p,L2128,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4805.33,,,,,,,fee schedule,1970.44,5487.65,
Kafo fem fx cast molded to p,L2128,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2068.96,,,,,,,fee schedule,1970.44,5487.65,APC
Kafo fem fx cast molded to p,L2128,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2049.26,,,,,,,fee schedule,1970.44,5487.65,APC
Kafo fem fx cast molded to p,L2128,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1970.44,,,,,,,fee schedule,1970.44,5487.65,APC
Kafo fem fx cast molded to p,L2128,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3014.77,,,,,,,fee schedule,1970.44,5487.65,Radiology
Kafo fem fx cast molded to p,L2128,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2758.62,,,,,,,fee schedule,1970.44,5487.65,APC
Kafo fem fx cast molded to p,L2128,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3448.27,,,,,,,fee schedule,1970.44,5487.65,APC
Kafo femoral fx cast soft,L2132,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2681.24,,,,,,,fee schedule,1045.73,2912.38,
Kafo femoral fx cast soft,L2132,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2912.38,,,,,,,fee schedule,1045.73,2912.38,
Kafo femoral fx cast soft,L2132,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2334.52,,,,,,,fee schedule,1045.73,2912.38,
Kafo femoral fx cast soft,L2132,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2550.26,,,,,,,fee schedule,1045.73,2912.38,
Kafo femoral fx cast soft,L2132,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1098.02,,,,,,,fee schedule,1045.73,2912.38,APC
Kafo femoral fx cast soft,L2132,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1087.56,,,,,,,fee schedule,1045.73,2912.38,APC
Kafo femoral fx cast soft,L2132,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1045.73,,,,,,,fee schedule,1045.73,2912.38,APC
Kafo femoral fx cast soft,L2132,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1599.97,,,,,,,fee schedule,1045.73,2912.38,Radiology
Kafo femoral fx cast soft,L2132,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1464.02,,,,,,,fee schedule,1045.73,2912.38,APC
Kafo femoral fx cast soft,L2132,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1830.03,,,,,,,fee schedule,1045.73,2912.38,APC
Kafo fem fx cast semi-rigid,L2134,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3353.47,,,,,,,fee schedule,1307.92,3642.56,
Kafo fem fx cast semi-rigid,L2134,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3642.56,,,,,,,fee schedule,1307.92,3642.56,
Kafo fem fx cast semi-rigid,L2134,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2919.83,,,,,,,fee schedule,1307.92,3642.56,
Kafo fem fx cast semi-rigid,L2134,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3189.65,,,,,,,fee schedule,1307.92,3642.56,
Kafo fem fx cast semi-rigid,L2134,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1373.32,,,,,,,fee schedule,1307.92,3642.56,APC
Kafo fem fx cast semi-rigid,L2134,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1360.24,,,,,,,fee schedule,1307.92,3642.56,APC
Kafo fem fx cast semi-rigid,L2134,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1307.92,,,,,,,fee schedule,1307.92,3642.56,APC
Kafo fem fx cast semi-rigid,L2134,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2001.12,,,,,,,fee schedule,1307.92,3642.56,Radiology
Kafo fem fx cast semi-rigid,L2134,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1831.09,,,,,,,fee schedule,1307.92,3642.56,APC
Kafo fem fx cast semi-rigid,L2134,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2288.86,,,,,,,fee schedule,1307.92,3642.56,APC
Kafo femoral fx cast rigid,L2136,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3796.65,,,,,,,fee schedule,1480.79,4123.94,
Kafo femoral fx cast rigid,L2136,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4123.94,,,,,,,fee schedule,1480.79,4123.94,
Kafo femoral fx cast rigid,L2136,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3305.7,,,,,,,fee schedule,1480.79,4123.94,
Kafo femoral fx cast rigid,L2136,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3611.18,,,,,,,fee schedule,1480.79,4123.94,
Kafo femoral fx cast rigid,L2136,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1554.83,,,,,,,fee schedule,1480.79,4123.94,APC
Kafo femoral fx cast rigid,L2136,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1540.02,,,,,,,fee schedule,1480.79,4123.94,APC
Kafo femoral fx cast rigid,L2136,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1480.79,,,,,,,fee schedule,1480.79,4123.94,APC
Kafo femoral fx cast rigid,L2136,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2265.61,,,,,,,fee schedule,1480.79,4123.94,Radiology
Kafo femoral fx cast rigid,L2136,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2073.11,,,,,,,fee schedule,1480.79,4123.94,APC
Kafo femoral fx cast rigid,L2136,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2591.38,,,,,,,fee schedule,1480.79,4123.94,APC
Plas shoe insert w ank joint,L2180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,460.06,,,,,,,fee schedule,179.43,499.72,
Plas shoe insert w ank joint,L2180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,499.72,,,,,,,fee schedule,179.43,499.72,
Plas shoe insert w ank joint,L2180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,400.57,,,,,,,fee schedule,179.43,499.72,
Plas shoe insert w ank joint,L2180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,437.58,,,,,,,fee schedule,179.43,499.72,
Plas shoe insert w ank joint,L2180,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,188.4,,,,,,,fee schedule,179.43,499.72,APC
Plas shoe insert w ank joint,L2180,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,186.61,,,,,,,fee schedule,179.43,499.72,APC
Plas shoe insert w ank joint,L2180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,179.43,,,,,,,fee schedule,179.43,499.72,APC
Plas shoe insert w ank joint,L2180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,274.53,,,,,,,fee schedule,179.43,499.72,Radiology
Plas shoe insert w ank joint,L2180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,251.2,,,,,,,fee schedule,179.43,499.72,APC
Plas shoe insert w ank joint,L2180,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,314,,,,,,,fee schedule,179.43,499.72,APC
Drop lock knee,L2182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,338.01,,,,,,,fee schedule,131.81,367.15,
Drop lock knee,L2182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,367.15,,,,,,,fee schedule,131.81,367.15,
Drop lock knee,L2182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,294.3,,,,,,,fee schedule,131.81,367.15,
Drop lock knee,L2182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,321.5,,,,,,,fee schedule,131.81,367.15,
Drop lock knee,L2182,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.4,,,,,,,fee schedule,131.81,367.15,APC
Drop lock knee,L2182,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,137.08,,,,,,,fee schedule,131.81,367.15,APC
Drop lock knee,L2182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.81,,,,,,,fee schedule,131.81,367.15,APC
Drop lock knee,L2182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.67,,,,,,,fee schedule,131.81,367.15,Radiology
Drop lock knee,L2182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.53,,,,,,,fee schedule,131.81,367.15,APC
Drop lock knee,L2182,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.67,,,,,,,fee schedule,131.81,367.15,APC
Limited motion knee joint,L2184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,439.14,,,,,,,fee schedule,171.28,477,
Limited motion knee joint,L2184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,477,,,,,,,fee schedule,171.28,477,
Limited motion knee joint,L2184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,382.36,,,,,,,fee schedule,171.28,477,
Limited motion knee joint,L2184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,417.69,,,,,,,fee schedule,171.28,477,
Limited motion knee joint,L2184,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,179.84,,,,,,,fee schedule,171.28,477,APC
Limited motion knee joint,L2184,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,178.13,,,,,,,fee schedule,171.28,477,APC
Limited motion knee joint,L2184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,171.28,,,,,,,fee schedule,171.28,477,APC
Limited motion knee joint,L2184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,262.06,,,,,,,fee schedule,171.28,477,Radiology
Limited motion knee joint,L2184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,239.79,,,,,,,fee schedule,171.28,477,APC
Limited motion knee joint,L2184,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,299.74,,,,,,,fee schedule,171.28,477,APC
Adj motion knee jnt lerman t,L2186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,443.56,,,,,,,fee schedule,173,481.8,
Adj motion knee jnt lerman t,L2186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,481.8,,,,,,,fee schedule,173,481.8,
Adj motion knee jnt lerman t,L2186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.2,,,,,,,fee schedule,173,481.8,
Adj motion knee jnt lerman t,L2186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,421.89,,,,,,,fee schedule,173,481.8,
Adj motion knee jnt lerman t,L2186,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,181.65,,,,,,,fee schedule,173,481.8,APC
Adj motion knee jnt lerman t,L2186,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,179.92,,,,,,,fee schedule,173,481.8,APC
Adj motion knee jnt lerman t,L2186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,173,,,,,,,fee schedule,173,481.8,APC
Adj motion knee jnt lerman t,L2186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,264.69,,,,,,,fee schedule,173,481.8,Radiology
Adj motion knee jnt lerman t,L2186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,242.2,,,,,,,fee schedule,173,481.8,APC
Adj motion knee jnt lerman t,L2186,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,302.75,,,,,,,fee schedule,173,481.8,APC
Quadrilateral brim,L2188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1032.13,,,,,,,fee schedule,402.57,1121.11,
Quadrilateral brim,L2188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1121.11,,,,,,,fee schedule,402.57,1121.11,
Quadrilateral brim,L2188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,898.67,,,,,,,fee schedule,402.57,1121.11,
Quadrilateral brim,L2188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,981.71,,,,,,,fee schedule,402.57,1121.11,
Quadrilateral brim,L2188,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,422.7,,,,,,,fee schedule,402.57,1121.11,APC
Quadrilateral brim,L2188,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,418.67,,,,,,,fee schedule,402.57,1121.11,APC
Quadrilateral brim,L2188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,402.57,,,,,,,fee schedule,402.57,1121.11,APC
Quadrilateral brim,L2188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,615.93,,,,,,,fee schedule,402.57,1121.11,Radiology
Quadrilateral brim,L2188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,563.6,,,,,,,fee schedule,402.57,1121.11,APC
Quadrilateral brim,L2188,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,704.5,,,,,,,fee schedule,402.57,1121.11,APC
Waist belt,L2190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,295,,,,,,,fee schedule,115.04,320.43,
Waist belt,L2190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,320.43,,,,,,,fee schedule,115.04,320.43,
Waist belt,L2190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,256.85,,,,,,,fee schedule,115.04,320.43,
Waist belt,L2190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,280.59,,,,,,,fee schedule,115.04,320.43,
Waist belt,L2190,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,120.79,,,,,,,fee schedule,115.04,320.43,APC
Waist belt,L2190,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,119.64,,,,,,,fee schedule,115.04,320.43,APC
Waist belt,L2190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,115.04,,,,,,,fee schedule,115.04,320.43,APC
Waist belt,L2190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,176.01,,,,,,,fee schedule,115.04,320.43,Radiology
Waist belt,L2190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,161.06,,,,,,,fee schedule,115.04,320.43,APC
Waist belt,L2190,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,201.32,,,,,,,fee schedule,115.04,320.43,APC
Pelvic band & belt thigh fla,L2192,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1162.04,,,,,,,fee schedule,453.23,1262.22,
Pelvic band & belt thigh fla,L2192,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1262.22,,,,,,,fee schedule,453.23,1262.22,
Pelvic band & belt thigh fla,L2192,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1011.78,,,,,,,fee schedule,453.23,1262.22,
Pelvic band & belt thigh fla,L2192,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1105.28,,,,,,,fee schedule,453.23,1262.22,
Pelvic band & belt thigh fla,L2192,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,475.89,,,,,,,fee schedule,453.23,1262.22,APC
Pelvic band & belt thigh fla,L2192,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,471.36,,,,,,,fee schedule,453.23,1262.22,APC
Pelvic band & belt thigh fla,L2192,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,453.23,,,,,,,fee schedule,453.23,1262.22,APC
Pelvic band & belt thigh fla,L2192,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,693.44,,,,,,,fee schedule,453.23,1262.22,Radiology
Pelvic band & belt thigh fla,L2192,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,634.52,,,,,,,fee schedule,453.23,1262.22,APC
Pelvic band & belt thigh fla,L2192,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,793.15,,,,,,,fee schedule,453.23,1262.22,APC
Limited ankle motion ea jnt,L2200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,186.77,,,,,,,fee schedule,72.84,202.87,
Limited ankle motion ea jnt,L2200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,202.87,,,,,,,fee schedule,72.84,202.87,
Limited ankle motion ea jnt,L2200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,162.62,,,,,,,fee schedule,72.84,202.87,
Limited ankle motion ea jnt,L2200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,177.65,,,,,,,fee schedule,72.84,202.87,
Limited ankle motion ea jnt,L2200,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,76.48,,,,,,,fee schedule,72.84,202.87,APC
Limited ankle motion ea jnt,L2200,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,75.75,,,,,,,fee schedule,72.84,202.87,APC
Limited ankle motion ea jnt,L2200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,72.84,,,,,,,fee schedule,72.84,202.87,APC
Limited ankle motion ea jnt,L2200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,111.45,,,,,,,fee schedule,72.84,202.87,Radiology
Limited ankle motion ea jnt,L2200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,101.98,,,,,,,fee schedule,72.84,202.87,APC
Limited ankle motion ea jnt,L2200,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,127.47,,,,,,,fee schedule,72.84,202.87,APC
Dorsiflexion assist each joi,L2210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,198.05,,,,,,,fee schedule,77.24,215.12,
Dorsiflexion assist each joi,L2210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,215.12,,,,,,,fee schedule,77.24,215.12,
Dorsiflexion assist each joi,L2210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,172.44,,,,,,,fee schedule,77.24,215.12,
Dorsiflexion assist each joi,L2210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,188.37,,,,,,,fee schedule,77.24,215.12,
Dorsiflexion assist each joi,L2210,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,81.1,,,,,,,fee schedule,77.24,215.12,APC
Dorsiflexion assist each joi,L2210,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,80.33,,,,,,,fee schedule,77.24,215.12,APC
Dorsiflexion assist each joi,L2210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,77.24,,,,,,,fee schedule,77.24,215.12,APC
Dorsiflexion assist each joi,L2210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,118.18,,,,,,,fee schedule,77.24,215.12,Radiology
Dorsiflexion assist each joi,L2210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,108.14,,,,,,,fee schedule,77.24,215.12,APC
Dorsiflexion assist each joi,L2210,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,135.17,,,,,,,fee schedule,77.24,215.12,APC
Dorsi & plantar flex ass/res,L2220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,257.38,,,,,,,fee schedule,100.4,279.57,
Dorsi & plantar flex ass/res,L2220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,279.57,,,,,,,fee schedule,100.4,279.57,
Dorsi & plantar flex ass/res,L2220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,224.1,,,,,,,fee schedule,100.4,279.57,
Dorsi & plantar flex ass/res,L2220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,244.81,,,,,,,fee schedule,100.4,279.57,
Dorsi & plantar flex ass/res,L2220,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,105.42,,,,,,,fee schedule,100.4,279.57,APC
Dorsi & plantar flex ass/res,L2220,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,104.42,,,,,,,fee schedule,100.4,279.57,APC
Dorsi & plantar flex ass/res,L2220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,100.4,,,,,,,fee schedule,100.4,279.57,APC
Dorsi & plantar flex ass/res,L2220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,153.61,,,,,,,fee schedule,100.4,279.57,Radiology
Dorsi & plantar flex ass/res,L2220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,140.56,,,,,,,fee schedule,100.4,279.57,APC
Dorsi & plantar flex ass/res,L2220,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,175.7,,,,,,,fee schedule,100.4,279.57,APC
Split flat caliper stirr & p,L2230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,237.89,,,,,,,fee schedule,92.77,258.4,
Split flat caliper stirr & p,L2230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,258.4,,,,,,,fee schedule,92.77,258.4,
Split flat caliper stirr & p,L2230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,207.13,,,,,,,fee schedule,92.77,258.4,
Split flat caliper stirr & p,L2230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,226.27,,,,,,,fee schedule,92.77,258.4,
Split flat caliper stirr & p,L2230,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,97.41,,,,,,,fee schedule,92.77,258.4,APC
Split flat caliper stirr & p,L2230,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,96.48,,,,,,,fee schedule,92.77,258.4,APC
Split flat caliper stirr & p,L2230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,92.77,,,,,,,fee schedule,92.77,258.4,APC
Split flat caliper stirr & p,L2230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,141.94,,,,,,,fee schedule,92.77,258.4,Radiology
Split flat caliper stirr & p,L2230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,129.88,,,,,,,fee schedule,92.77,258.4,APC
Split flat caliper stirr & p,L2230,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,162.35,,,,,,,fee schedule,92.77,258.4,APC
"Rocker bottom, contact AFO",L2232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,306.07,,,,,,,fee schedule,119.38,332.45,
"Rocker bottom, contact AFO",L2232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,332.45,,,,,,,fee schedule,119.38,332.45,
"Rocker bottom, contact AFO",L2232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,266.49,,,,,,,fee schedule,119.38,332.45,
"Rocker bottom, contact AFO",L2232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,291.11,,,,,,,fee schedule,119.38,332.45,
"Rocker bottom, contact AFO",L2232,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,125.35,,,,,,,fee schedule,119.38,332.45,APC
"Rocker bottom, contact AFO",L2232,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,124.16,,,,,,,fee schedule,119.38,332.45,APC
"Rocker bottom, contact AFO",L2232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,119.38,,,,,,,fee schedule,119.38,332.45,APC
"Rocker bottom, contact AFO",L2232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,182.65,,,,,,,fee schedule,119.38,332.45,Radiology
"Rocker bottom, contact AFO",L2232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,167.13,,,,,,,fee schedule,119.38,332.45,APC
"Rocker bottom, contact AFO",L2232,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,208.92,,,,,,,fee schedule,119.38,332.45,APC
Round caliper and plate atta,L2240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,246.38,,,,,,,fee schedule,96.11,267.62,
Round caliper and plate atta,L2240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,267.62,,,,,,,fee schedule,96.11,267.62,
Round caliper and plate atta,L2240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,214.52,,,,,,,fee schedule,96.11,267.62,
Round caliper and plate atta,L2240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,234.35,,,,,,,fee schedule,96.11,267.62,
Round caliper and plate atta,L2240,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,100.92,,,,,,,fee schedule,96.11,267.62,APC
Round caliper and plate atta,L2240,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,99.95,,,,,,,fee schedule,96.11,267.62,APC
Round caliper and plate atta,L2240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,96.11,,,,,,,fee schedule,96.11,267.62,APC
Round caliper and plate atta,L2240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,147.05,,,,,,,fee schedule,96.11,267.62,Radiology
Round caliper and plate atta,L2240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,134.55,,,,,,,fee schedule,96.11,267.62,APC
Round caliper and plate atta,L2240,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,168.19,,,,,,,fee schedule,96.11,267.62,APC
Foot plate molded stirrup at,L2250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1046.92,,,,,,,fee schedule,408.31,1137.18,
Foot plate molded stirrup at,L2250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1137.18,,,,,,,fee schedule,408.31,1137.18,
Foot plate molded stirrup at,L2250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,911.55,,,,,,,fee schedule,408.31,1137.18,
Foot plate molded stirrup at,L2250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,995.78,,,,,,,fee schedule,408.31,1137.18,
Foot plate molded stirrup at,L2250,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,428.73,,,,,,,fee schedule,408.31,1137.18,APC
Foot plate molded stirrup at,L2250,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,424.64,,,,,,,fee schedule,408.31,1137.18,APC
Foot plate molded stirrup at,L2250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,408.31,,,,,,,fee schedule,408.31,1137.18,APC
Foot plate molded stirrup at,L2250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,624.71,,,,,,,fee schedule,408.31,1137.18,Radiology
Foot plate molded stirrup at,L2250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,571.63,,,,,,,fee schedule,408.31,1137.18,APC
Foot plate molded stirrup at,L2250,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,714.54,,,,,,,fee schedule,408.31,1137.18,APC
Reinforced solid stirrup,L2260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,609.52,,,,,,,fee schedule,237.72,662.07,
Reinforced solid stirrup,L2260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,662.07,,,,,,,fee schedule,237.72,662.07,
Reinforced solid stirrup,L2260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,530.7,,,,,,,fee schedule,237.72,662.07,
Reinforced solid stirrup,L2260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,579.75,,,,,,,fee schedule,237.72,662.07,
Reinforced solid stirrup,L2260,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.61,,,,,,,fee schedule,237.72,662.07,APC
Reinforced solid stirrup,L2260,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,247.23,,,,,,,fee schedule,237.72,662.07,APC
Reinforced solid stirrup,L2260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,237.72,,,,,,,fee schedule,237.72,662.07,APC
Reinforced solid stirrup,L2260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,363.71,,,,,,,fee schedule,237.72,662.07,Radiology
Reinforced solid stirrup,L2260,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,332.81,,,,,,,fee schedule,237.72,662.07,APC
Reinforced solid stirrup,L2260,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,416.01,,,,,,,fee schedule,237.72,662.07,APC
Long tongue stirrup,L2265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,462.63,,,,,,,fee schedule,180.44,502.51,
Long tongue stirrup,L2265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,502.51,,,,,,,fee schedule,180.44,502.51,
Long tongue stirrup,L2265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,402.81,,,,,,,fee schedule,180.44,502.51,
Long tongue stirrup,L2265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,440.03,,,,,,,fee schedule,180.44,502.51,
Long tongue stirrup,L2265,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,189.46,,,,,,,fee schedule,180.44,502.51,APC
Long tongue stirrup,L2265,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,187.66,,,,,,,fee schedule,180.44,502.51,APC
Long tongue stirrup,L2265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,180.44,,,,,,,fee schedule,180.44,502.51,APC
Long tongue stirrup,L2265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,276.07,,,,,,,fee schedule,180.44,502.51,Radiology
Long tongue stirrup,L2265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,252.62,,,,,,,fee schedule,180.44,502.51,APC
Long tongue stirrup,L2265,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,315.77,,,,,,,fee schedule,180.44,502.51,APC
Varus/valgus strap padded/li,L2270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,158.24,,,,,,,fee schedule,61.71,171.88,
Varus/valgus strap padded/li,L2270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,171.88,,,,,,,fee schedule,61.71,171.88,
Varus/valgus strap padded/li,L2270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,137.77,,,,,,,fee schedule,61.71,171.88,
Varus/valgus strap padded/li,L2270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,150.51,,,,,,,fee schedule,61.71,171.88,
Varus/valgus strap padded/li,L2270,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,64.8,,,,,,,fee schedule,61.71,171.88,APC
Varus/valgus strap padded/li,L2270,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,64.18,,,,,,,fee schedule,61.71,171.88,APC
Varus/valgus strap padded/li,L2270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,61.71,,,,,,,fee schedule,61.71,171.88,APC
Varus/valgus strap padded/li,L2270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,94.42,,,,,,,fee schedule,61.71,171.88,Radiology
Varus/valgus strap padded/li,L2270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,86.39,,,,,,,fee schedule,61.71,171.88,APC
Varus/valgus strap padded/li,L2270,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,107.99,,,,,,,fee schedule,61.71,171.88,APC
Plastic mod low ext pad/line,L2275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,384.96,,,,,,,fee schedule,150.13,418.14,
Plastic mod low ext pad/line,L2275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,418.14,,,,,,,fee schedule,150.13,418.14,
Plastic mod low ext pad/line,L2275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,335.18,,,,,,,fee schedule,150.13,418.14,
Plastic mod low ext pad/line,L2275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,366.15,,,,,,,fee schedule,150.13,418.14,
Plastic mod low ext pad/line,L2275,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,157.64,,,,,,,fee schedule,150.13,418.14,APC
Plastic mod low ext pad/line,L2275,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,156.14,,,,,,,fee schedule,150.13,418.14,APC
Plastic mod low ext pad/line,L2275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,150.13,,,,,,,fee schedule,150.13,418.14,APC
Plastic mod low ext pad/line,L2275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,229.7,,,,,,,fee schedule,150.13,418.14,Radiology
Plastic mod low ext pad/line,L2275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,210.18,,,,,,,fee schedule,150.13,418.14,APC
Plastic mod low ext pad/line,L2275,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,262.73,,,,,,,fee schedule,150.13,418.14,APC
Molded inner boot,L2280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1334.13,,,,,,,fee schedule,520.33,1449.14,
Molded inner boot,L2280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1449.14,,,,,,,fee schedule,520.33,1449.14,
Molded inner boot,L2280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1161.61,,,,,,,fee schedule,520.33,1449.14,
Molded inner boot,L2280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1268.95,,,,,,,fee schedule,520.33,1449.14,
Molded inner boot,L2280,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,546.35,,,,,,,fee schedule,520.33,1449.14,APC
Molded inner boot,L2280,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,541.14,,,,,,,fee schedule,520.33,1449.14,APC
Molded inner boot,L2280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,520.33,,,,,,,fee schedule,520.33,1449.14,APC
Molded inner boot,L2280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,796.1,,,,,,,fee schedule,520.33,1449.14,Radiology
Molded inner boot,L2280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,728.46,,,,,,,fee schedule,520.33,1449.14,APC
Molded inner boot,L2280,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,910.58,,,,,,,fee schedule,520.33,1449.14,APC
Abduction bar jointed adjust,L2300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1057.68,,,,,,,fee schedule,412.52,1148.86,
Abduction bar jointed adjust,L2300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1148.86,,,,,,,fee schedule,412.52,1148.86,
Abduction bar jointed adjust,L2300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,920.91,,,,,,,fee schedule,412.52,1148.86,
Abduction bar jointed adjust,L2300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1006.01,,,,,,,fee schedule,412.52,1148.86,
Abduction bar jointed adjust,L2300,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,433.15,,,,,,,fee schedule,412.52,1148.86,APC
Abduction bar jointed adjust,L2300,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,429.02,,,,,,,fee schedule,412.52,1148.86,APC
Abduction bar jointed adjust,L2300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,412.52,,,,,,,fee schedule,412.52,1148.86,APC
Abduction bar jointed adjust,L2300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,631.16,,,,,,,fee schedule,412.52,1148.86,Radiology
Abduction bar jointed adjust,L2300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,577.53,,,,,,,fee schedule,412.52,1148.86,APC
Abduction bar jointed adjust,L2300,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,721.91,,,,,,,fee schedule,412.52,1148.86,APC
Abduction bar-straight,L2310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,483.27,,,,,,,fee schedule,188.49,524.93,
Abduction bar-straight,L2310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,524.93,,,,,,,fee schedule,188.49,524.93,
Abduction bar-straight,L2310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,420.78,,,,,,,fee schedule,188.49,524.93,
Abduction bar-straight,L2310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,459.66,,,,,,,fee schedule,188.49,524.93,
Abduction bar-straight,L2310,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,197.91,,,,,,,fee schedule,188.49,524.93,APC
Abduction bar-straight,L2310,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,196.03,,,,,,,fee schedule,188.49,524.93,APC
Abduction bar-straight,L2310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,188.49,,,,,,,fee schedule,188.49,524.93,APC
Abduction bar-straight,L2310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,288.39,,,,,,,fee schedule,188.49,524.93,Radiology
Abduction bar-straight,L2310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,263.89,,,,,,,fee schedule,188.49,524.93,APC
Abduction bar-straight,L2310,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,329.86,,,,,,,fee schedule,188.49,524.93,APC
Non-molded lacer,L2320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,661.34,,,,,,,fee schedule,257.98,718.35,
Non-molded lacer,L2320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,718.35,,,,,,,fee schedule,257.98,718.35,
Non-molded lacer,L2320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,575.82,,,,,,,fee schedule,257.98,718.35,
Non-molded lacer,L2320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,629.03,,,,,,,fee schedule,257.98,718.35,
Non-molded lacer,L2320,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,270.88,,,,,,,fee schedule,257.98,718.35,APC
Non-molded lacer,L2320,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,268.3,,,,,,,fee schedule,257.98,718.35,APC
Non-molded lacer,L2320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,257.98,,,,,,,fee schedule,257.98,718.35,APC
Non-molded lacer,L2320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,394.71,,,,,,,fee schedule,257.98,718.35,Radiology
Non-molded lacer,L2320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.17,,,,,,,fee schedule,257.98,718.35,APC
Non-molded lacer,L2320,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,451.46,,,,,,,fee schedule,257.98,718.35,APC
Lacer molded to patient mode,L2330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1226.14,,,,,,,fee schedule,478.23,1331.85,
Lacer molded to patient mode,L2330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1331.85,,,,,,,fee schedule,478.23,1331.85,
Lacer molded to patient mode,L2330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1067.59,,,,,,,fee schedule,478.23,1331.85,
Lacer molded to patient mode,L2330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1166.25,,,,,,,fee schedule,478.23,1331.85,
Lacer molded to patient mode,L2330,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,502.14,,,,,,,fee schedule,478.23,1331.85,APC
Lacer molded to patient mode,L2330,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,497.36,,,,,,,fee schedule,478.23,1331.85,APC
Lacer molded to patient mode,L2330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,478.23,,,,,,,fee schedule,478.23,1331.85,APC
Lacer molded to patient mode,L2330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,731.69,,,,,,,fee schedule,478.23,1331.85,Radiology
Lacer molded to patient mode,L2330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,669.52,,,,,,,fee schedule,478.23,1331.85,APC
Lacer molded to patient mode,L2330,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,836.9,,,,,,,fee schedule,478.23,1331.85,APC
Anterior swing band,L2335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,669.31,,,,,,,fee schedule,261.05,727.01,
Anterior swing band,L2335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,727.01,,,,,,,fee schedule,261.05,727.01,
Anterior swing band,L2335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,582.76,,,,,,,fee schedule,261.05,727.01,
Anterior swing band,L2335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,636.61,,,,,,,fee schedule,261.05,727.01,
Anterior swing band,L2335,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,274.1,,,,,,,fee schedule,261.05,727.01,APC
Anterior swing band,L2335,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,271.49,,,,,,,fee schedule,261.05,727.01,APC
Anterior swing band,L2335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,261.05,,,,,,,fee schedule,261.05,727.01,APC
Anterior swing band,L2335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,399.41,,,,,,,fee schedule,261.05,727.01,Radiology
Anterior swing band,L2335,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,365.47,,,,,,,fee schedule,261.05,727.01,APC
Anterior swing band,L2335,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,456.84,,,,,,,fee schedule,261.05,727.01,APC
Pre-tibial shell molded to p,L2340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1632.89,,,,,,,fee schedule,636.87,1773.65,
Pre-tibial shell molded to p,L2340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1773.65,,,,,,,fee schedule,636.87,1773.65,
Pre-tibial shell molded to p,L2340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1421.74,,,,,,,fee schedule,636.87,1773.65,
Pre-tibial shell molded to p,L2340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1553.12,,,,,,,fee schedule,636.87,1773.65,
Pre-tibial shell molded to p,L2340,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,668.71,,,,,,,fee schedule,636.87,1773.65,APC
Pre-tibial shell molded to p,L2340,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,662.34,,,,,,,fee schedule,636.87,1773.65,APC
Pre-tibial shell molded to p,L2340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,636.87,,,,,,,fee schedule,636.87,1773.65,APC
Pre-tibial shell molded to p,L2340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,974.41,,,,,,,fee schedule,636.87,1773.65,Radiology
Pre-tibial shell molded to p,L2340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,891.62,,,,,,,fee schedule,636.87,1773.65,APC
Pre-tibial shell molded to p,L2340,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1114.52,,,,,,,fee schedule,636.87,1773.65,APC
Prosthetic type socket molde,L2350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2797.5,,,,,,,fee schedule,1091.08,3038.67,
Prosthetic type socket molde,L2350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3038.67,,,,,,,fee schedule,1091.08,3038.67,
Prosthetic type socket molde,L2350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2435.76,,,,,,,fee schedule,1091.08,3038.67,
Prosthetic type socket molde,L2350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2660.84,,,,,,,fee schedule,1091.08,3038.67,
Prosthetic type socket molde,L2350,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1145.63,,,,,,,fee schedule,1091.08,3038.67,APC
Prosthetic type socket molde,L2350,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1134.72,,,,,,,fee schedule,1091.08,3038.67,APC
Prosthetic type socket molde,L2350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1091.08,,,,,,,fee schedule,1091.08,3038.67,APC
Prosthetic type socket molde,L2350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1669.35,,,,,,,fee schedule,1091.08,3038.67,Radiology
Prosthetic type socket molde,L2350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1527.51,,,,,,,fee schedule,1091.08,3038.67,APC
Prosthetic type socket molde,L2350,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1909.39,,,,,,,fee schedule,1091.08,3038.67,APC
Extended steel shank,L2360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,203.27,,,,,,,fee schedule,79.27,220.79,
Extended steel shank,L2360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,220.79,,,,,,,fee schedule,79.27,220.79,
Extended steel shank,L2360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,176.98,,,,,,,fee schedule,79.27,220.79,
Extended steel shank,L2360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,193.34,,,,,,,fee schedule,79.27,220.79,
Extended steel shank,L2360,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,83.23,,,,,,,fee schedule,79.27,220.79,APC
Extended steel shank,L2360,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,82.44,,,,,,,fee schedule,79.27,220.79,APC
Extended steel shank,L2360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,79.27,,,,,,,fee schedule,79.27,220.79,APC
Extended steel shank,L2360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,121.28,,,,,,,fee schedule,79.27,220.79,Radiology
Extended steel shank,L2360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,110.98,,,,,,,fee schedule,79.27,220.79,APC
Extended steel shank,L2360,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,138.72,,,,,,,fee schedule,79.27,220.79,APC
Patten bottom,L2370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,864.64,,,,,,,fee schedule,337.23,939.18,
Patten bottom,L2370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,939.18,,,,,,,fee schedule,337.23,939.18,
Patten bottom,L2370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,752.83,,,,,,,fee schedule,337.23,939.18,
Patten bottom,L2370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,822.4,,,,,,,fee schedule,337.23,939.18,
Patten bottom,L2370,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,354.09,,,,,,,fee schedule,337.23,939.18,APC
Patten bottom,L2370,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,350.72,,,,,,,fee schedule,337.23,939.18,APC
Patten bottom,L2370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,337.23,,,,,,,fee schedule,337.23,939.18,APC
Patten bottom,L2370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,515.96,,,,,,,fee schedule,337.23,939.18,Radiology
Patten bottom,L2370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,472.12,,,,,,,fee schedule,337.23,939.18,APC
Patten bottom,L2370,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,590.15,,,,,,,fee schedule,337.23,939.18,APC
Torsion ank & half solid sti,L2375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,443.87,,,,,,,fee schedule,173.12,482.14,
Torsion ank & half solid sti,L2375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,482.14,,,,,,,fee schedule,173.12,482.14,
Torsion ank & half solid sti,L2375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.48,,,,,,,fee schedule,173.12,482.14,
Torsion ank & half solid sti,L2375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,422.19,,,,,,,fee schedule,173.12,482.14,
Torsion ank & half solid sti,L2375,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,181.78,,,,,,,fee schedule,173.12,482.14,APC
Torsion ank & half solid sti,L2375,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,180.04,,,,,,,fee schedule,173.12,482.14,APC
Torsion ank & half solid sti,L2375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,173.12,,,,,,,fee schedule,173.12,482.14,APC
Torsion ank & half solid sti,L2375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,264.87,,,,,,,fee schedule,173.12,482.14,Radiology
Torsion ank & half solid sti,L2375,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,242.37,,,,,,,fee schedule,173.12,482.14,APC
Torsion ank & half solid sti,L2375,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,302.96,,,,,,,fee schedule,173.12,482.14,APC
Torsion straight knee joint,L2380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,483.62,,,,,,,fee schedule,188.63,525.31,
Torsion straight knee joint,L2380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,525.31,,,,,,,fee schedule,188.63,525.31,
Torsion straight knee joint,L2380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,421.08,,,,,,,fee schedule,188.63,525.31,
Torsion straight knee joint,L2380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,459.99,,,,,,,fee schedule,188.63,525.31,
Torsion straight knee joint,L2380,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,198.06,,,,,,,fee schedule,188.63,525.31,APC
Torsion straight knee joint,L2380,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,196.18,,,,,,,fee schedule,188.63,525.31,APC
Torsion straight knee joint,L2380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,188.63,,,,,,,fee schedule,188.63,525.31,APC
Torsion straight knee joint,L2380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,288.6,,,,,,,fee schedule,188.63,525.31,Radiology
Torsion straight knee joint,L2380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,264.08,,,,,,,fee schedule,188.63,525.31,APC
Torsion straight knee joint,L2380,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,330.1,,,,,,,fee schedule,188.63,525.31,APC
Straight knee joint heavy du,L2385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,509.51,,,,,,,fee schedule,198.72,553.43,
Straight knee joint heavy du,L2385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,553.43,,,,,,,fee schedule,198.72,553.43,
Straight knee joint heavy du,L2385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,443.62,,,,,,,fee schedule,198.72,553.43,
Straight knee joint heavy du,L2385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,484.62,,,,,,,fee schedule,198.72,553.43,
Straight knee joint heavy du,L2385,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,208.66,,,,,,,fee schedule,198.72,553.43,APC
Straight knee joint heavy du,L2385,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,206.67,,,,,,,fee schedule,198.72,553.43,APC
Straight knee joint heavy du,L2385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,198.72,,,,,,,fee schedule,198.72,553.43,APC
Straight knee joint heavy du,L2385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,304.04,,,,,,,fee schedule,198.72,553.43,Radiology
Straight knee joint heavy du,L2385,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,278.21,,,,,,,fee schedule,198.72,553.43,APC
Straight knee joint heavy du,L2385,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,347.76,,,,,,,fee schedule,198.72,553.43,APC
Add le poly knee custom kafo,L2387,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,487.62,,,,,,,fee schedule,190.18,529.65,
Add le poly knee custom kafo,L2387,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,529.65,,,,,,,fee schedule,190.18,529.65,
Add le poly knee custom kafo,L2387,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,424.56,,,,,,,fee schedule,190.18,529.65,
Add le poly knee custom kafo,L2387,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,463.8,,,,,,,fee schedule,190.18,529.65,
Add le poly knee custom kafo,L2387,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,199.69,,,,,,,fee schedule,190.18,529.65,APC
Add le poly knee custom kafo,L2387,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,197.79,,,,,,,fee schedule,190.18,529.65,APC
Add le poly knee custom kafo,L2387,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,190.18,,,,,,,fee schedule,190.18,529.65,APC
Add le poly knee custom kafo,L2387,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,290.98,,,,,,,fee schedule,190.18,529.65,Radiology
Add le poly knee custom kafo,L2387,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,266.25,,,,,,,fee schedule,190.18,529.65,APC
Add le poly knee custom kafo,L2387,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,332.82,,,,,,,fee schedule,190.18,529.65,APC
Offset knee joint each,L2390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,322.53,,,,,,,fee schedule,125.79,350.33,
Offset knee joint each,L2390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,350.33,,,,,,,fee schedule,125.79,350.33,
Offset knee joint each,L2390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,280.82,,,,,,,fee schedule,125.79,350.33,
Offset knee joint each,L2390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,306.77,,,,,,,fee schedule,125.79,350.33,
Offset knee joint each,L2390,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,132.08,,,,,,,fee schedule,125.79,350.33,APC
Offset knee joint each,L2390,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,130.82,,,,,,,fee schedule,125.79,350.33,APC
Offset knee joint each,L2390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,125.79,,,,,,,fee schedule,125.79,350.33,APC
Offset knee joint each,L2390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,192.46,,,,,,,fee schedule,125.79,350.33,Radiology
Offset knee joint each,L2390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,176.11,,,,,,,fee schedule,125.79,350.33,APC
Offset knee joint each,L2390,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,220.13,,,,,,,fee schedule,125.79,350.33,APC
Offset knee joint heavy duty,L2395,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,614.64,,,,,,,fee schedule,239.73,667.62,
Offset knee joint heavy duty,L2395,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,667.62,,,,,,,fee schedule,239.73,667.62,
Offset knee joint heavy duty,L2395,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,535.16,,,,,,,fee schedule,239.73,667.62,
Offset knee joint heavy duty,L2395,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,584.61,,,,,,,fee schedule,239.73,667.62,
Offset knee joint heavy duty,L2395,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,251.72,,,,,,,fee schedule,239.73,667.62,APC
Offset knee joint heavy duty,L2395,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,249.32,,,,,,,fee schedule,239.73,667.62,APC
Offset knee joint heavy duty,L2395,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,239.73,,,,,,,fee schedule,239.73,667.62,APC
Offset knee joint heavy duty,L2395,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,366.79,,,,,,,fee schedule,239.73,667.62,Radiology
Offset knee joint heavy duty,L2395,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,335.62,,,,,,,fee schedule,239.73,667.62,APC
Offset knee joint heavy duty,L2395,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,419.53,,,,,,,fee schedule,239.73,667.62,APC
Suspension sleeve lower ext,L2397,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,345.32,,,,,,,fee schedule,134.68,375.09,
Suspension sleeve lower ext,L2397,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,375.09,,,,,,,fee schedule,134.68,375.09,
Suspension sleeve lower ext,L2397,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,300.67,,,,,,,fee schedule,134.68,375.09,
Suspension sleeve lower ext,L2397,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,328.45,,,,,,,fee schedule,134.68,375.09,
Suspension sleeve lower ext,L2397,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,141.41,,,,,,,fee schedule,134.68,375.09,APC
Suspension sleeve lower ext,L2397,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,140.07,,,,,,,fee schedule,134.68,375.09,APC
Suspension sleeve lower ext,L2397,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,134.68,,,,,,,fee schedule,134.68,375.09,APC
Suspension sleeve lower ext,L2397,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,206.06,,,,,,,fee schedule,134.68,375.09,Radiology
Suspension sleeve lower ext,L2397,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.55,,,,,,,fee schedule,134.68,375.09,APC
Suspension sleeve lower ext,L2397,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,235.69,,,,,,,fee schedule,134.68,375.09,APC
Knee joint drop lock ea jnt,L2405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,276.21,,,,,,,fee schedule,107.73,300.02,
Knee joint drop lock ea jnt,L2405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,300.02,,,,,,,fee schedule,107.73,300.02,
Knee joint drop lock ea jnt,L2405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,240.49,,,,,,,fee schedule,107.73,300.02,
Knee joint drop lock ea jnt,L2405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,262.71,,,,,,,fee schedule,107.73,300.02,
Knee joint drop lock ea jnt,L2405,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,113.12,,,,,,,fee schedule,107.73,300.02,APC
Knee joint drop lock ea jnt,L2405,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,112.04,,,,,,,fee schedule,107.73,300.02,APC
Knee joint drop lock ea jnt,L2405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,107.73,,,,,,,fee schedule,107.73,300.02,APC
Knee joint drop lock ea jnt,L2405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,164.83,,,,,,,fee schedule,107.73,300.02,Radiology
Knee joint drop lock ea jnt,L2405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,150.82,,,,,,,fee schedule,107.73,300.02,APC
Knee joint drop lock ea jnt,L2405,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,188.53,,,,,,,fee schedule,107.73,300.02,APC
Knee joint cam lock each joi,L2415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,384.82,,,,,,,fee schedule,150.07,417.99,
Knee joint cam lock each joi,L2415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,417.99,,,,,,,fee schedule,150.07,417.99,
Knee joint cam lock each joi,L2415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,335.06,,,,,,,fee schedule,150.07,417.99,
Knee joint cam lock each joi,L2415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,366.02,,,,,,,fee schedule,150.07,417.99,
Knee joint cam lock each joi,L2415,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,157.57,,,,,,,fee schedule,150.07,417.99,APC
Knee joint cam lock each joi,L2415,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,156.07,,,,,,,fee schedule,150.07,417.99,APC
Knee joint cam lock each joi,L2415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,150.07,,,,,,,fee schedule,150.07,417.99,APC
Knee joint cam lock each joi,L2415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,229.61,,,,,,,fee schedule,150.07,417.99,Radiology
Knee joint cam lock each joi,L2415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,210.1,,,,,,,fee schedule,150.07,417.99,APC
Knee joint cam lock each joi,L2415,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,262.62,,,,,,,fee schedule,150.07,417.99,APC
Knee disc/dial lock/adj flex,L2425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,454.04,,,,,,,fee schedule,177.11,493.18,
Knee disc/dial lock/adj flex,L2425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,493.18,,,,,,,fee schedule,177.11,493.18,
Knee disc/dial lock/adj flex,L2425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,395.32,,,,,,,fee schedule,177.11,493.18,
Knee disc/dial lock/adj flex,L2425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,431.86,,,,,,,fee schedule,177.11,493.18,
Knee disc/dial lock/adj flex,L2425,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,185.97,,,,,,,fee schedule,177.11,493.18,APC
Knee disc/dial lock/adj flex,L2425,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,184.19,,,,,,,fee schedule,177.11,493.18,APC
Knee disc/dial lock/adj flex,L2425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,177.11,,,,,,,fee schedule,177.11,493.18,APC
Knee disc/dial lock/adj flex,L2425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,270.98,,,,,,,fee schedule,177.11,493.18,Radiology
Knee disc/dial lock/adj flex,L2425,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,247.95,,,,,,,fee schedule,177.11,493.18,APC
Knee disc/dial lock/adj flex,L2425,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,309.94,,,,,,,fee schedule,177.11,493.18,APC
Knee jnt ratchet lock ea jnt,L2430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,454.04,,,,,,,fee schedule,177.11,493.18,
Knee jnt ratchet lock ea jnt,L2430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,493.18,,,,,,,fee schedule,177.11,493.18,
Knee jnt ratchet lock ea jnt,L2430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,395.32,,,,,,,fee schedule,177.11,493.18,
Knee jnt ratchet lock ea jnt,L2430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,431.86,,,,,,,fee schedule,177.11,493.18,
Knee jnt ratchet lock ea jnt,L2430,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,185.97,,,,,,,fee schedule,177.11,493.18,APC
Knee jnt ratchet lock ea jnt,L2430,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,184.19,,,,,,,fee schedule,177.11,493.18,APC
Knee jnt ratchet lock ea jnt,L2430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,177.11,,,,,,,fee schedule,177.11,493.18,APC
Knee jnt ratchet lock ea jnt,L2430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,270.98,,,,,,,fee schedule,177.11,493.18,Radiology
Knee jnt ratchet lock ea jnt,L2430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,247.95,,,,,,,fee schedule,177.11,493.18,APC
Knee jnt ratchet lock ea jnt,L2430,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,309.94,,,,,,,fee schedule,177.11,493.18,APC
Knee lift loop drop lock rin,L2492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,335.37,,,,,,,fee schedule,130.79,364.28,
Knee lift loop drop lock rin,L2492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,364.28,,,,,,,fee schedule,130.79,364.28,
Knee lift loop drop lock rin,L2492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,292,,,,,,,fee schedule,130.79,364.28,
Knee lift loop drop lock rin,L2492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,318.98,,,,,,,fee schedule,130.79,364.28,
Knee lift loop drop lock rin,L2492,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,137.33,,,,,,,fee schedule,130.79,364.28,APC
Knee lift loop drop lock rin,L2492,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.02,,,,,,,fee schedule,130.79,364.28,APC
Knee lift loop drop lock rin,L2492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,130.79,,,,,,,fee schedule,130.79,364.28,APC
Knee lift loop drop lock rin,L2492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,200.11,,,,,,,fee schedule,130.79,364.28,Radiology
Knee lift loop drop lock rin,L2492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,183.11,,,,,,,fee schedule,130.79,364.28,APC
Knee lift loop drop lock rin,L2492,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,228.88,,,,,,,fee schedule,130.79,364.28,APC
Thi/glut/ischia wgt bearing,L2500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1083.85,,,,,,,fee schedule,422.73,1177.28,
Thi/glut/ischia wgt bearing,L2500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1177.28,,,,,,,fee schedule,422.73,1177.28,
Thi/glut/ischia wgt bearing,L2500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,943.69,,,,,,,fee schedule,422.73,1177.28,
Thi/glut/ischia wgt bearing,L2500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1030.9,,,,,,,fee schedule,422.73,1177.28,
Thi/glut/ischia wgt bearing,L2500,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,443.87,,,,,,,fee schedule,422.73,1177.28,APC
Thi/glut/ischia wgt bearing,L2500,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,439.64,,,,,,,fee schedule,422.73,1177.28,APC
Thi/glut/ischia wgt bearing,L2500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,422.73,,,,,,,fee schedule,422.73,1177.28,APC
Thi/glut/ischia wgt bearing,L2500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,646.78,,,,,,,fee schedule,422.73,1177.28,Radiology
Thi/glut/ischia wgt bearing,L2500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,591.82,,,,,,,fee schedule,422.73,1177.28,APC
Thi/glut/ischia wgt bearing,L2500,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,739.78,,,,,,,fee schedule,422.73,1177.28,APC
Th/wght bear quad-lat brim m,L2510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2458.31,,,,,,,fee schedule,958.79,2670.23,
Th/wght bear quad-lat brim m,L2510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2670.23,,,,,,,fee schedule,958.79,2670.23,
Th/wght bear quad-lat brim m,L2510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2140.42,,,,,,,fee schedule,958.79,2670.23,
Th/wght bear quad-lat brim m,L2510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2338.22,,,,,,,fee schedule,958.79,2670.23,
Th/wght bear quad-lat brim m,L2510,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1006.73,,,,,,,fee schedule,958.79,2670.23,APC
Th/wght bear quad-lat brim m,L2510,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,997.14,,,,,,,fee schedule,958.79,2670.23,APC
Th/wght bear quad-lat brim m,L2510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,958.79,,,,,,,fee schedule,958.79,2670.23,APC
Th/wght bear quad-lat brim m,L2510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1466.95,,,,,,,fee schedule,958.79,2670.23,Radiology
Th/wght bear quad-lat brim m,L2510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1342.31,,,,,,,fee schedule,958.79,2670.23,APC
Th/wght bear quad-lat brim m,L2510,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1677.88,,,,,,,fee schedule,958.79,2670.23,APC
Th/wght bear quad-lat brim c,L2520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1551.91,,,,,,,fee schedule,605.28,1685.69,
Th/wght bear quad-lat brim c,L2520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1685.69,,,,,,,fee schedule,605.28,1685.69,
Th/wght bear quad-lat brim c,L2520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1351.23,,,,,,,fee schedule,605.28,1685.69,
Th/wght bear quad-lat brim c,L2520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1476.09,,,,,,,fee schedule,605.28,1685.69,
Th/wght bear quad-lat brim c,L2520,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,635.54,,,,,,,fee schedule,605.28,1685.69,APC
Th/wght bear quad-lat brim c,L2520,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,629.49,,,,,,,fee schedule,605.28,1685.69,APC
Th/wght bear quad-lat brim c,L2520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,605.28,,,,,,,fee schedule,605.28,1685.69,APC
Th/wght bear quad-lat brim c,L2520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,926.08,,,,,,,fee schedule,605.28,1685.69,Radiology
Th/wght bear quad-lat brim c,L2520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,847.39,,,,,,,fee schedule,605.28,1685.69,APC
Th/wght bear quad-lat brim c,L2520,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1059.24,,,,,,,fee schedule,605.28,1685.69,APC
Th/wght bear nar m-l brim mo,L2525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3591.53,,,,,,,fee schedule,1400.77,3901.15,
Th/wght bear nar m-l brim mo,L2525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3901.15,,,,,,,fee schedule,1400.77,3901.15,
Th/wght bear nar m-l brim mo,L2525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3127.11,,,,,,,fee schedule,1400.77,3901.15,
Th/wght bear nar m-l brim mo,L2525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3416.09,,,,,,,fee schedule,1400.77,3901.15,
Th/wght bear nar m-l brim mo,L2525,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1470.81,,,,,,,fee schedule,1400.77,3901.15,APC
Th/wght bear nar m-l brim mo,L2525,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1456.8,,,,,,,fee schedule,1400.77,3901.15,APC
Th/wght bear nar m-l brim mo,L2525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1400.77,,,,,,,fee schedule,1400.77,3901.15,APC
Th/wght bear nar m-l brim mo,L2525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2143.18,,,,,,,fee schedule,1400.77,3901.15,Radiology
Th/wght bear nar m-l brim mo,L2525,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1961.08,,,,,,,fee schedule,1400.77,3901.15,APC
Th/wght bear nar m-l brim mo,L2525,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2451.35,,,,,,,fee schedule,1400.77,3901.15,APC
Th/wght bear nar m-l brim cu,L2526,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2018.05,,,,,,,fee schedule,787.09,2192.02,
Th/wght bear nar m-l brim cu,L2526,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2192.02,,,,,,,fee schedule,787.09,2192.02,
Th/wght bear nar m-l brim cu,L2526,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1757.1,,,,,,,fee schedule,787.09,2192.02,
Th/wght bear nar m-l brim cu,L2526,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1919.47,,,,,,,fee schedule,787.09,2192.02,
Th/wght bear nar m-l brim cu,L2526,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,826.44,,,,,,,fee schedule,787.09,2192.02,APC
Th/wght bear nar m-l brim cu,L2526,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,818.57,,,,,,,fee schedule,787.09,2192.02,APC
Th/wght bear nar m-l brim cu,L2526,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,787.09,,,,,,,fee schedule,787.09,2192.02,APC
Th/wght bear nar m-l brim cu,L2526,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1204.25,,,,,,,fee schedule,787.09,2192.02,Radiology
Th/wght bear nar m-l brim cu,L2526,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1101.93,,,,,,,fee schedule,787.09,2192.02,APC
Th/wght bear nar m-l brim cu,L2526,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1377.41,,,,,,,fee schedule,787.09,2192.02,APC
Thigh/wght bear lacer non-mo,L2530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,697.95,,,,,,,fee schedule,272.2,758.12,
Thigh/wght bear lacer non-mo,L2530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,758.12,,,,,,,fee schedule,272.2,758.12,
Thigh/wght bear lacer non-mo,L2530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,607.7,,,,,,,fee schedule,272.2,758.12,
Thigh/wght bear lacer non-mo,L2530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,663.85,,,,,,,fee schedule,272.2,758.12,
Thigh/wght bear lacer non-mo,L2530,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,285.81,,,,,,,fee schedule,272.2,758.12,APC
Thigh/wght bear lacer non-mo,L2530,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,283.09,,,,,,,fee schedule,272.2,758.12,APC
Thigh/wght bear lacer non-mo,L2530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,272.2,,,,,,,fee schedule,272.2,758.12,APC
Thigh/wght bear lacer non-mo,L2530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,416.47,,,,,,,fee schedule,272.2,758.12,Radiology
Thigh/wght bear lacer non-mo,L2530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,381.08,,,,,,,fee schedule,272.2,758.12,APC
Thigh/wght bear lacer non-mo,L2530,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,476.35,,,,,,,fee schedule,272.2,758.12,APC
Thigh/wght bear lacer molded,L2540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1324.98,,,,,,,fee schedule,516.79,1439.2,
Thigh/wght bear lacer molded,L2540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1439.2,,,,,,,fee schedule,516.79,1439.2,
Thigh/wght bear lacer molded,L2540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1153.64,,,,,,,fee schedule,516.79,1439.2,
Thigh/wght bear lacer molded,L2540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1260.25,,,,,,,fee schedule,516.79,1439.2,
Thigh/wght bear lacer molded,L2540,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,542.63,,,,,,,fee schedule,516.79,1439.2,APC
Thigh/wght bear lacer molded,L2540,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,537.46,,,,,,,fee schedule,516.79,1439.2,APC
Thigh/wght bear lacer molded,L2540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,516.79,,,,,,,fee schedule,516.79,1439.2,APC
Thigh/wght bear lacer molded,L2540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,790.69,,,,,,,fee schedule,516.79,1439.2,Radiology
Thigh/wght bear lacer molded,L2540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,723.51,,,,,,,fee schedule,516.79,1439.2,APC
Thigh/wght bear lacer molded,L2540,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,904.38,,,,,,,fee schedule,516.79,1439.2,APC
Thigh/wght bear high roll cu,L2550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,846.2,,,,,,,fee schedule,330.04,919.14,
Thigh/wght bear high roll cu,L2550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,919.14,,,,,,,fee schedule,330.04,919.14,
Thigh/wght bear high roll cu,L2550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,736.77,,,,,,,fee schedule,330.04,919.14,
Thigh/wght bear high roll cu,L2550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,804.86,,,,,,,fee schedule,330.04,919.14,
Thigh/wght bear high roll cu,L2550,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,346.54,,,,,,,fee schedule,330.04,919.14,APC
Thigh/wght bear high roll cu,L2550,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,343.24,,,,,,,fee schedule,330.04,919.14,APC
Thigh/wght bear high roll cu,L2550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,330.04,,,,,,,fee schedule,330.04,919.14,APC
Thigh/wght bear high roll cu,L2550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,504.96,,,,,,,fee schedule,330.04,919.14,Radiology
Thigh/wght bear high roll cu,L2550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,462.06,,,,,,,fee schedule,330.04,919.14,APC
Thigh/wght bear high roll cu,L2550,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,577.57,,,,,,,fee schedule,330.04,919.14,APC
Hip clevis type 2 posit jnt,L2570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1871.13,,,,,,,fee schedule,729.78,2032.43,
Hip clevis type 2 posit jnt,L2570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2032.43,,,,,,,fee schedule,729.78,2032.43,
Hip clevis type 2 posit jnt,L2570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1629.17,,,,,,,fee schedule,729.78,2032.43,
Hip clevis type 2 posit jnt,L2570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1779.72,,,,,,,fee schedule,729.78,2032.43,
Hip clevis type 2 posit jnt,L2570,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,766.27,,,,,,,fee schedule,729.78,2032.43,APC
Hip clevis type 2 posit jnt,L2570,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,758.97,,,,,,,fee schedule,729.78,2032.43,APC
Hip clevis type 2 posit jnt,L2570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,729.78,,,,,,,fee schedule,729.78,2032.43,APC
Hip clevis type 2 posit jnt,L2570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1116.56,,,,,,,fee schedule,729.78,2032.43,Radiology
Hip clevis type 2 posit jnt,L2570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1021.69,,,,,,,fee schedule,729.78,2032.43,APC
Hip clevis type 2 posit jnt,L2570,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1277.12,,,,,,,fee schedule,729.78,2032.43,APC
Pelvic control pelvic sling,L2580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1367.4,,,,,,,fee schedule,533.32,1485.28,
Pelvic control pelvic sling,L2580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1485.28,,,,,,,fee schedule,533.32,1485.28,
Pelvic control pelvic sling,L2580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1190.58,,,,,,,fee schedule,533.32,1485.28,
Pelvic control pelvic sling,L2580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1300.6,,,,,,,fee schedule,533.32,1485.28,
Pelvic control pelvic sling,L2580,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,559.99,,,,,,,fee schedule,533.32,1485.28,APC
Pelvic control pelvic sling,L2580,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,554.65,,,,,,,fee schedule,533.32,1485.28,APC
Pelvic control pelvic sling,L2580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,533.32,,,,,,,fee schedule,533.32,1485.28,APC
Pelvic control pelvic sling,L2580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,815.98,,,,,,,fee schedule,533.32,1485.28,Radiology
Pelvic control pelvic sling,L2580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,746.65,,,,,,,fee schedule,533.32,1485.28,APC
Pelvic control pelvic sling,L2580,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,933.31,,,,,,,fee schedule,533.32,1485.28,APC
Hip clevis/thrust bearing fr,L2600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,806.8,,,,,,,fee schedule,314.68,876.36,
Hip clevis/thrust bearing fr,L2600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,876.36,,,,,,,fee schedule,314.68,876.36,
Hip clevis/thrust bearing fr,L2600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,702.48,,,,,,,fee schedule,314.68,876.36,
Hip clevis/thrust bearing fr,L2600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,767.39,,,,,,,fee schedule,314.68,876.36,
Hip clevis/thrust bearing fr,L2600,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,330.41,,,,,,,fee schedule,314.68,876.36,APC
Hip clevis/thrust bearing fr,L2600,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,327.27,,,,,,,fee schedule,314.68,876.36,APC
Hip clevis/thrust bearing fr,L2600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,314.68,,,,,,,fee schedule,314.68,876.36,APC
Hip clevis/thrust bearing fr,L2600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,481.46,,,,,,,fee schedule,314.68,876.36,Radiology
Hip clevis/thrust bearing fr,L2600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,440.55,,,,,,,fee schedule,314.68,876.36,APC
Hip clevis/thrust bearing fr,L2600,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,550.69,,,,,,,fee schedule,314.68,876.36,APC
Hip clevis/thrust bearing lo,L2610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,954.01,,,,,,,fee schedule,372.09,1036.25,
Hip clevis/thrust bearing lo,L2610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1036.25,,,,,,,fee schedule,372.09,1036.25,
Hip clevis/thrust bearing lo,L2610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,830.64,,,,,,,fee schedule,372.09,1036.25,
Hip clevis/thrust bearing lo,L2610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,907.4,,,,,,,fee schedule,372.09,1036.25,
Hip clevis/thrust bearing lo,L2610,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,390.69,,,,,,,fee schedule,372.09,1036.25,APC
Hip clevis/thrust bearing lo,L2610,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,386.97,,,,,,,fee schedule,372.09,1036.25,APC
Hip clevis/thrust bearing lo,L2610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,372.09,,,,,,,fee schedule,372.09,1036.25,APC
Hip clevis/thrust bearing lo,L2610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,569.3,,,,,,,fee schedule,372.09,1036.25,Radiology
Hip clevis/thrust bearing lo,L2610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,520.93,,,,,,,fee schedule,372.09,1036.25,APC
Hip clevis/thrust bearing lo,L2610,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,651.16,,,,,,,fee schedule,372.09,1036.25,APC
Pelvic control hip heavy dut,L2620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,921.78,,,,,,,fee schedule,359.52,1001.25,
Pelvic control hip heavy dut,L2620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1001.25,,,,,,,fee schedule,359.52,1001.25,
Pelvic control hip heavy dut,L2620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,802.59,,,,,,,fee schedule,359.52,1001.25,
Pelvic control hip heavy dut,L2620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,876.75,,,,,,,fee schedule,359.52,1001.25,
Pelvic control hip heavy dut,L2620,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,377.5,,,,,,,fee schedule,359.52,1001.25,APC
Pelvic control hip heavy dut,L2620,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,373.9,,,,,,,fee schedule,359.52,1001.25,APC
Pelvic control hip heavy dut,L2620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,359.52,,,,,,,fee schedule,359.52,1001.25,APC
Pelvic control hip heavy dut,L2620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,550.07,,,,,,,fee schedule,359.52,1001.25,Radiology
Pelvic control hip heavy dut,L2620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,503.33,,,,,,,fee schedule,359.52,1001.25,APC
Pelvic control hip heavy dut,L2620,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,629.16,,,,,,,fee schedule,359.52,1001.25,APC
Hip joint adjustable flexion,L2622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1204.67,,,,,,,fee schedule,469.85,1308.52,
Hip joint adjustable flexion,L2622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1308.52,,,,,,,fee schedule,469.85,1308.52,
Hip joint adjustable flexion,L2622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1048.9,,,,,,,fee schedule,469.85,1308.52,
Hip joint adjustable flexion,L2622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1145.82,,,,,,,fee schedule,469.85,1308.52,
Hip joint adjustable flexion,L2622,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,493.34,,,,,,,fee schedule,469.85,1308.52,APC
Hip joint adjustable flexion,L2622,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,488.64,,,,,,,fee schedule,469.85,1308.52,APC
Hip joint adjustable flexion,L2622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,469.85,,,,,,,fee schedule,469.85,1308.52,APC
Hip joint adjustable flexion,L2622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,718.87,,,,,,,fee schedule,469.85,1308.52,Radiology
Hip joint adjustable flexion,L2622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,657.79,,,,,,,fee schedule,469.85,1308.52,APC
Hip joint adjustable flexion,L2622,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,822.24,,,,,,,fee schedule,469.85,1308.52,APC
Hip adj flex ext abduct cont,L2624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1047.62,,,,,,,fee schedule,408.59,1137.93,
Hip adj flex ext abduct cont,L2624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1137.93,,,,,,,fee schedule,408.59,1137.93,
Hip adj flex ext abduct cont,L2624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,912.15,,,,,,,fee schedule,408.59,1137.93,
Hip adj flex ext abduct cont,L2624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,996.44,,,,,,,fee schedule,408.59,1137.93,
Hip adj flex ext abduct cont,L2624,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,429.02,,,,,,,fee schedule,408.59,1137.93,APC
Hip adj flex ext abduct cont,L2624,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,424.93,,,,,,,fee schedule,408.59,1137.93,APC
Hip adj flex ext abduct cont,L2624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,408.59,,,,,,,fee schedule,408.59,1137.93,APC
Hip adj flex ext abduct cont,L2624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,625.14,,,,,,,fee schedule,408.59,1137.93,Radiology
Hip adj flex ext abduct cont,L2624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,572.03,,,,,,,fee schedule,408.59,1137.93,APC
Hip adj flex ext abduct cont,L2624,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,715.03,,,,,,,fee schedule,408.59,1137.93,APC
Plastic mold recipro hip & c,L2627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5050.84,,,,,,,fee schedule,1969.94,5486.25,
Plastic mold recipro hip & c,L2627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5486.25,,,,,,,fee schedule,1969.94,5486.25,
Plastic mold recipro hip & c,L2627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4397.71,,,,,,,fee schedule,1969.94,5486.25,
Plastic mold recipro hip & c,L2627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4804.1,,,,,,,fee schedule,1969.94,5486.25,
Plastic mold recipro hip & c,L2627,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2068.44,,,,,,,fee schedule,1969.94,5486.25,APC
Plastic mold recipro hip & c,L2627,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2048.74,,,,,,,fee schedule,1969.94,5486.25,APC
Plastic mold recipro hip & c,L2627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1969.94,,,,,,,fee schedule,1969.94,5486.25,APC
Plastic mold recipro hip & c,L2627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3014.01,,,,,,,fee schedule,1969.94,5486.25,Radiology
Plastic mold recipro hip & c,L2627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2757.92,,,,,,,fee schedule,1969.94,5486.25,APC
Plastic mold recipro hip & c,L2627,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3447.4,,,,,,,fee schedule,1969.94,5486.25,APC
Metal frame recipro hip & ca,L2628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4936.21,,,,,,,fee schedule,1925.23,5361.74,
Metal frame recipro hip & ca,L2628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5361.74,,,,,,,fee schedule,1925.23,5361.74,
Metal frame recipro hip & ca,L2628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4297.9,,,,,,,fee schedule,1925.23,5361.74,
Metal frame recipro hip & ca,L2628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4695.07,,,,,,,fee schedule,1925.23,5361.74,
Metal frame recipro hip & ca,L2628,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2021.49,,,,,,,fee schedule,1925.23,5361.74,APC
Metal frame recipro hip & ca,L2628,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2002.24,,,,,,,fee schedule,1925.23,5361.74,APC
Metal frame recipro hip & ca,L2628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1925.23,,,,,,,fee schedule,1925.23,5361.74,APC
Metal frame recipro hip & ca,L2628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2945.6,,,,,,,fee schedule,1925.23,5361.74,Radiology
Metal frame recipro hip & ca,L2628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2695.32,,,,,,,fee schedule,1925.23,5361.74,APC
Metal frame recipro hip & ca,L2628,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3369.15,,,,,,,fee schedule,1925.23,5361.74,APC
Pelvic control band & belt u,L2630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,862.73,,,,,,,fee schedule,336.48,937.1,
Pelvic control band & belt u,L2630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,937.1,,,,,,,fee schedule,336.48,937.1,
Pelvic control band & belt u,L2630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,751.17,,,,,,,fee schedule,336.48,937.1,
Pelvic control band & belt u,L2630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,820.58,,,,,,,fee schedule,336.48,937.1,
Pelvic control band & belt u,L2630,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,353.3,,,,,,,fee schedule,336.48,937.1,APC
Pelvic control band & belt u,L2630,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,349.94,,,,,,,fee schedule,336.48,937.1,APC
Pelvic control band & belt u,L2630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,336.48,,,,,,,fee schedule,336.48,937.1,APC
Pelvic control band & belt u,L2630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,514.81,,,,,,,fee schedule,336.48,937.1,Radiology
Pelvic control band & belt u,L2630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,471.07,,,,,,,fee schedule,336.48,937.1,APC
Pelvic control band & belt u,L2630,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,588.84,,,,,,,fee schedule,336.48,937.1,APC
Pelvic control band & belt b,L2640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1134.17,,,,,,,fee schedule,442.33,1231.94,
Pelvic control band & belt b,L2640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1231.94,,,,,,,fee schedule,442.33,1231.94,
Pelvic control band & belt b,L2640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,987.51,,,,,,,fee schedule,442.33,1231.94,
Pelvic control band & belt b,L2640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1078.76,,,,,,,fee schedule,442.33,1231.94,
Pelvic control band & belt b,L2640,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,464.45,,,,,,,fee schedule,442.33,1231.94,APC
Pelvic control band & belt b,L2640,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,460.02,,,,,,,fee schedule,442.33,1231.94,APC
Pelvic control band & belt b,L2640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,442.33,,,,,,,fee schedule,442.33,1231.94,APC
Pelvic control band & belt b,L2640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,676.76,,,,,,,fee schedule,442.33,1231.94,Radiology
Pelvic control band & belt b,L2640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,619.26,,,,,,,fee schedule,442.33,1231.94,APC
Pelvic control band & belt b,L2640,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,774.08,,,,,,,fee schedule,442.33,1231.94,APC
Pelv & thor control gluteal,L2650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,425.95,,,,,,,fee schedule,166.13,462.67,
Pelv & thor control gluteal,L2650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,462.67,,,,,,,fee schedule,166.13,462.67,
Pelv & thor control gluteal,L2650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,370.87,,,,,,,fee schedule,166.13,462.67,
Pelv & thor control gluteal,L2650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,405.14,,,,,,,fee schedule,166.13,462.67,
Pelv & thor control gluteal,L2650,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,174.44,,,,,,,fee schedule,166.13,462.67,APC
Pelv & thor control gluteal,L2650,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,172.78,,,,,,,fee schedule,166.13,462.67,APC
Pelv & thor control gluteal,L2650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,166.13,,,,,,,fee schedule,166.13,462.67,APC
Pelv & thor control gluteal,L2650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,254.18,,,,,,,fee schedule,166.13,462.67,Radiology
Pelv & thor control gluteal,L2650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,232.58,,,,,,,fee schedule,166.13,462.67,APC
Pelv & thor control gluteal,L2650,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,290.73,,,,,,,fee schedule,166.13,462.67,APC
Thoracic control thoracic ba,L2660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,663.25,,,,,,,fee schedule,258.68,720.43,
Thoracic control thoracic ba,L2660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,720.43,,,,,,,fee schedule,258.68,720.43,
Thoracic control thoracic ba,L2660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,577.49,,,,,,,fee schedule,258.68,720.43,
Thoracic control thoracic ba,L2660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,630.85,,,,,,,fee schedule,258.68,720.43,
Thoracic control thoracic ba,L2660,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,271.61,,,,,,,fee schedule,258.68,720.43,APC
Thoracic control thoracic ba,L2660,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,269.03,,,,,,,fee schedule,258.68,720.43,APC
Thoracic control thoracic ba,L2660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,258.68,,,,,,,fee schedule,258.68,720.43,APC
Thoracic control thoracic ba,L2660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,395.78,,,,,,,fee schedule,258.68,720.43,Radiology
Thoracic control thoracic ba,L2660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,362.15,,,,,,,fee schedule,258.68,720.43,APC
Thoracic control thoracic ba,L2660,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,452.69,,,,,,,fee schedule,258.68,720.43,APC
Thorac cont paraspinal uprig,L2670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,670.11,,,,,,,fee schedule,261.36,727.88,
Thorac cont paraspinal uprig,L2670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,727.88,,,,,,,fee schedule,261.36,727.88,
Thorac cont paraspinal uprig,L2670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,583.46,,,,,,,fee schedule,261.36,727.88,
Thorac cont paraspinal uprig,L2670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,637.37,,,,,,,fee schedule,261.36,727.88,
Thorac cont paraspinal uprig,L2670,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,274.43,,,,,,,fee schedule,261.36,727.88,APC
Thorac cont paraspinal uprig,L2670,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,271.81,,,,,,,fee schedule,261.36,727.88,APC
Thorac cont paraspinal uprig,L2670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,261.36,,,,,,,fee schedule,261.36,727.88,APC
Thorac cont paraspinal uprig,L2670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,399.88,,,,,,,fee schedule,261.36,727.88,Radiology
Thorac cont paraspinal uprig,L2670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,365.9,,,,,,,fee schedule,261.36,727.88,APC
Thorac cont paraspinal uprig,L2670,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,457.38,,,,,,,fee schedule,261.36,727.88,APC
Thorac cont lat support upri,L2680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,614.74,,,,,,,fee schedule,239.76,667.74,
Thorac cont lat support upri,L2680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,667.74,,,,,,,fee schedule,239.76,667.74,
Thorac cont lat support upri,L2680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,535.25,,,,,,,fee schedule,239.76,667.74,
Thorac cont lat support upri,L2680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,584.71,,,,,,,fee schedule,239.76,667.74,
Thorac cont lat support upri,L2680,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,251.75,,,,,,,fee schedule,239.76,667.74,APC
Thorac cont lat support upri,L2680,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,249.35,,,,,,,fee schedule,239.76,667.74,APC
Thorac cont lat support upri,L2680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,239.76,,,,,,,fee schedule,239.76,667.74,APC
Thorac cont lat support upri,L2680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,366.83,,,,,,,fee schedule,239.76,667.74,Radiology
Thorac cont lat support upri,L2680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,335.66,,,,,,,fee schedule,239.76,667.74,APC
Thorac cont lat support upri,L2680,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,419.58,,,,,,,fee schedule,239.76,667.74,APC
Plating chrome/nickel pr bar,L2750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,323.81,,,,,,,fee schedule,126.3,351.73,
Plating chrome/nickel pr bar,L2750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,351.73,,,,,,,fee schedule,126.3,351.73,
Plating chrome/nickel pr bar,L2750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,281.94,,,,,,,fee schedule,126.3,351.73,
Plating chrome/nickel pr bar,L2750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,308,,,,,,,fee schedule,126.3,351.73,
Plating chrome/nickel pr bar,L2750,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,132.62,,,,,,,fee schedule,126.3,351.73,APC
Plating chrome/nickel pr bar,L2750,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,131.35,,,,,,,fee schedule,126.3,351.73,APC
Plating chrome/nickel pr bar,L2750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,126.3,,,,,,,fee schedule,126.3,351.73,APC
Plating chrome/nickel pr bar,L2750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,193.24,,,,,,,fee schedule,126.3,351.73,Radiology
Plating chrome/nickel pr bar,L2750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,176.82,,,,,,,fee schedule,126.3,351.73,APC
Plating chrome/nickel pr bar,L2750,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,221.02,,,,,,,fee schedule,126.3,351.73,APC
Carbon graphite lamination,L2755,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,414.02,,,,,,,fee schedule,161.48,449.71,
Carbon graphite lamination,L2755,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,449.71,,,,,,,fee schedule,161.48,449.71,
Carbon graphite lamination,L2755,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,360.48,,,,,,,fee schedule,161.48,449.71,
Carbon graphite lamination,L2755,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,393.79,,,,,,,fee schedule,161.48,449.71,
Carbon graphite lamination,L2755,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,169.55,,,,,,,fee schedule,161.48,449.71,APC
Carbon graphite lamination,L2755,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,167.94,,,,,,,fee schedule,161.48,449.71,APC
Carbon graphite lamination,L2755,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,161.48,,,,,,,fee schedule,161.48,449.71,APC
Carbon graphite lamination,L2755,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,247.06,,,,,,,fee schedule,161.48,449.71,Radiology
Carbon graphite lamination,L2755,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,226.07,,,,,,,fee schedule,161.48,449.71,APC
Carbon graphite lamination,L2755,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,282.59,,,,,,,fee schedule,161.48,449.71,APC
Extension per extension per,L2760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,238.69,,,,,,,fee schedule,93.09,259.27,
Extension per extension per,L2760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,259.27,,,,,,,fee schedule,93.09,259.27,
Extension per extension per,L2760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,207.83,,,,,,,fee schedule,93.09,259.27,
Extension per extension per,L2760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,227.03,,,,,,,fee schedule,93.09,259.27,
Extension per extension per,L2760,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,97.74,,,,,,,fee schedule,93.09,259.27,APC
Extension per extension per,L2760,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,96.81,,,,,,,fee schedule,93.09,259.27,APC
Extension per extension per,L2760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,93.09,,,,,,,fee schedule,93.09,259.27,APC
Extension per extension per,L2760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,142.43,,,,,,,fee schedule,93.09,259.27,Radiology
Extension per extension per,L2760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,130.33,,,,,,,fee schedule,93.09,259.27,APC
Extension per extension per,L2760,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,162.91,,,,,,,fee schedule,93.09,259.27,APC
Ortho sidebar disconnect,L2768,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,412.73,,,,,,,fee schedule,160.94,448.31,
Ortho sidebar disconnect,L2768,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,448.31,,,,,,,fee schedule,160.94,448.31,
Ortho sidebar disconnect,L2768,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,359.36,,,,,,,fee schedule,160.94,448.31,
Ortho sidebar disconnect,L2768,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,392.57,,,,,,,fee schedule,160.94,448.31,
Ortho sidebar disconnect,L2768,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,168.99,,,,,,,fee schedule,160.94,448.31,APC
Ortho sidebar disconnect,L2768,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,167.38,,,,,,,fee schedule,160.94,448.31,APC
Ortho sidebar disconnect,L2768,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,160.94,,,,,,,fee schedule,160.94,448.31,APC
Ortho sidebar disconnect,L2768,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,246.24,,,,,,,fee schedule,160.94,448.31,Radiology
Ortho sidebar disconnect,L2768,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,225.32,,,,,,,fee schedule,160.94,448.31,APC
Ortho sidebar disconnect,L2768,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,281.64,,,,,,,fee schedule,160.94,448.31,APC
Non-corrosive finish,L2780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,199.4,,,,,,,fee schedule,77.77,216.59,
Non-corrosive finish,L2780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,216.59,,,,,,,fee schedule,77.77,216.59,
Non-corrosive finish,L2780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,173.62,,,,,,,fee schedule,77.77,216.59,
Non-corrosive finish,L2780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,189.66,,,,,,,fee schedule,77.77,216.59,
Non-corrosive finish,L2780,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,81.66,,,,,,,fee schedule,77.77,216.59,APC
Non-corrosive finish,L2780,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,80.88,,,,,,,fee schedule,77.77,216.59,APC
Non-corrosive finish,L2780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,77.77,,,,,,,fee schedule,77.77,216.59,APC
Non-corrosive finish,L2780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,118.99,,,,,,,fee schedule,77.77,216.59,Radiology
Non-corrosive finish,L2780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,108.88,,,,,,,fee schedule,77.77,216.59,APC
Non-corrosive finish,L2780,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,136.1,,,,,,,fee schedule,77.77,216.59,APC
Drop lock retainer each,L2785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,93.37,,,,,,,fee schedule,36.42,101.42,
Drop lock retainer each,L2785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,101.42,,,,,,,fee schedule,36.42,101.42,
Drop lock retainer each,L2785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,81.29,,,,,,,fee schedule,36.42,101.42,
Drop lock retainer each,L2785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,88.81,,,,,,,fee schedule,36.42,101.42,
Drop lock retainer each,L2785,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.24,,,,,,,fee schedule,36.42,101.42,APC
Drop lock retainer each,L2785,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,37.88,,,,,,,fee schedule,36.42,101.42,APC
Drop lock retainer each,L2785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.42,,,,,,,fee schedule,36.42,101.42,APC
Drop lock retainer each,L2785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,55.72,,,,,,,fee schedule,36.42,101.42,Radiology
Drop lock retainer each,L2785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,50.99,,,,,,,fee schedule,36.42,101.42,APC
Drop lock retainer each,L2785,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,63.74,,,,,,,fee schedule,36.42,101.42,APC
Knee control full kneecap,L2795,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,288.53,,,,,,,fee schedule,112.56,313.4,
Knee control full kneecap,L2795,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,313.4,,,,,,,fee schedule,112.56,313.4,
Knee control full kneecap,L2795,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,251.22,,,,,,,fee schedule,112.56,313.4,
Knee control full kneecap,L2795,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,274.43,,,,,,,fee schedule,112.56,313.4,
Knee control full kneecap,L2795,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,118.19,,,,,,,fee schedule,112.56,313.4,APC
Knee control full kneecap,L2795,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,117.06,,,,,,,fee schedule,112.56,313.4,APC
Knee control full kneecap,L2795,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,112.56,,,,,,,fee schedule,112.56,313.4,APC
Knee control full kneecap,L2795,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.22,,,,,,,fee schedule,112.56,313.4,Radiology
Knee control full kneecap,L2795,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,157.58,,,,,,,fee schedule,112.56,313.4,APC
Knee control full kneecap,L2795,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,196.98,,,,,,,fee schedule,112.56,313.4,APC
Knee cap medial or lateral p,L2800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,314.28,,,,,,,fee schedule,122.57,341.37,
Knee cap medial or lateral p,L2800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,341.37,,,,,,,fee schedule,122.57,341.37,
Knee cap medial or lateral p,L2800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,273.64,,,,,,,fee schedule,122.57,341.37,
Knee cap medial or lateral p,L2800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,298.93,,,,,,,fee schedule,122.57,341.37,
Knee cap medial or lateral p,L2800,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,128.7,,,,,,,fee schedule,122.57,341.37,APC
Knee cap medial or lateral p,L2800,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,127.47,,,,,,,fee schedule,122.57,341.37,APC
Knee cap medial or lateral p,L2800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,122.57,,,,,,,fee schedule,122.57,341.37,APC
Knee cap medial or lateral p,L2800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,187.53,,,,,,,fee schedule,122.57,341.37,Radiology
Knee cap medial or lateral p,L2800,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,171.6,,,,,,,fee schedule,122.57,341.37,APC
Knee cap medial or lateral p,L2800,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,214.5,,,,,,,fee schedule,122.57,341.37,APC
Knee control condylar pad,L2810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,256.16,,,,,,,fee schedule,99.9,278.25,
Knee control condylar pad,L2810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,278.25,,,,,,,fee schedule,99.9,278.25,
Knee control condylar pad,L2810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,223.04,,,,,,,fee schedule,99.9,278.25,
Knee control condylar pad,L2810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,243.65,,,,,,,fee schedule,99.9,278.25,
Knee control condylar pad,L2810,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,104.9,,,,,,,fee schedule,99.9,278.25,APC
Knee control condylar pad,L2810,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,103.9,,,,,,,fee schedule,99.9,278.25,APC
Knee control condylar pad,L2810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,99.9,,,,,,,fee schedule,99.9,278.25,APC
Knee control condylar pad,L2810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,152.85,,,,,,,fee schedule,99.9,278.25,Radiology
Knee control condylar pad,L2810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,139.86,,,,,,,fee schedule,99.9,278.25,APC
Knee control condylar pad,L2810,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,174.82,,,,,,,fee schedule,99.9,278.25,APC
Soft interface below knee se,L2820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,255.85,,,,,,,fee schedule,99.79,277.91,
Soft interface below knee se,L2820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,277.91,,,,,,,fee schedule,99.79,277.91,
Soft interface below knee se,L2820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,222.77,,,,,,,fee schedule,99.79,277.91,
Soft interface below knee se,L2820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,243.35,,,,,,,fee schedule,99.79,277.91,
Soft interface below knee se,L2820,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,104.78,,,,,,,fee schedule,99.79,277.91,APC
Soft interface below knee se,L2820,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,103.78,,,,,,,fee schedule,99.79,277.91,APC
Soft interface below knee se,L2820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,99.79,,,,,,,fee schedule,99.79,277.91,APC
Soft interface below knee se,L2820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,152.68,,,,,,,fee schedule,99.79,277.91,Radiology
Soft interface below knee se,L2820,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,139.71,,,,,,,fee schedule,99.79,277.91,APC
Soft interface below knee se,L2820,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,174.63,,,,,,,fee schedule,99.79,277.91,APC
Soft interface above knee se,L2830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,276.8,,,,,,,fee schedule,107.96,300.66,
Soft interface above knee se,L2830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,300.66,,,,,,,fee schedule,107.96,300.66,
Soft interface above knee se,L2830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,241.01,,,,,,,fee schedule,107.96,300.66,
Soft interface above knee se,L2830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,263.28,,,,,,,fee schedule,107.96,300.66,
Soft interface above knee se,L2830,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,113.36,,,,,,,fee schedule,107.96,300.66,APC
Soft interface above knee se,L2830,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,112.28,,,,,,,fee schedule,107.96,300.66,APC
Soft interface above knee se,L2830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,107.96,,,,,,,fee schedule,107.96,300.66,APC
Soft interface above knee se,L2830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,165.18,,,,,,,fee schedule,107.96,300.66,Radiology
Soft interface above knee se,L2830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,151.14,,,,,,,fee schedule,107.96,300.66,APC
Soft interface above knee se,L2830,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,188.93,,,,,,,fee schedule,107.96,300.66,APC
Tibial length sock fx or equ,L2840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,171.63,,,,,,,fee schedule,66.94,186.43,
Tibial length sock fx or equ,L2840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,186.43,,,,,,,fee schedule,66.94,186.43,
Tibial length sock fx or equ,L2840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,149.44,,,,,,,fee schedule,66.94,186.43,
Tibial length sock fx or equ,L2840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,163.25,,,,,,,fee schedule,66.94,186.43,
Tibial length sock fx or equ,L2840,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,70.29,,,,,,,fee schedule,66.94,186.43,APC
Tibial length sock fx or equ,L2840,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,69.62,,,,,,,fee schedule,66.94,186.43,APC
Tibial length sock fx or equ,L2840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,66.94,,,,,,,fee schedule,66.94,186.43,APC
Tibial length sock fx or equ,L2840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,102.42,,,,,,,fee schedule,66.94,186.43,Radiology
Tibial length sock fx or equ,L2840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,93.72,,,,,,,fee schedule,66.94,186.43,APC
Tibial length sock fx or equ,L2840,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,117.14,,,,,,,fee schedule,66.94,186.43,APC
Femoral lgth sock fx or equa,L2850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,196.31,,,,,,,fee schedule,76.56,213.23,
Femoral lgth sock fx or equa,L2850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,213.23,,,,,,,fee schedule,76.56,213.23,
Femoral lgth sock fx or equa,L2850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,170.92,,,,,,,fee schedule,76.56,213.23,
Femoral lgth sock fx or equa,L2850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,186.72,,,,,,,fee schedule,76.56,213.23,
Femoral lgth sock fx or equa,L2850,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,80.39,,,,,,,fee schedule,76.56,213.23,APC
Femoral lgth sock fx or equa,L2850,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,79.62,,,,,,,fee schedule,76.56,213.23,APC
Femoral lgth sock fx or equa,L2850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,76.56,,,,,,,fee schedule,76.56,213.23,APC
Femoral lgth sock fx or equa,L2850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,117.14,,,,,,,fee schedule,76.56,213.23,Radiology
Femoral lgth sock fx or equa,L2850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,107.18,,,,,,,fee schedule,76.56,213.23,APC
Femoral lgth sock fx or equa,L2850,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,133.98,,,,,,,fee schedule,76.56,213.23,APC
Ft insert ucb berkeley shell,L3000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,995.11,,,,,,,fee schedule,388.12,1080.89,
Ft insert ucb berkeley shell,L3000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1080.89,,,,,,,fee schedule,388.12,1080.89,
Ft insert ucb berkeley shell,L3000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,866.43,,,,,,,fee schedule,388.12,1080.89,
Ft insert ucb berkeley shell,L3000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,946.49,,,,,,,fee schedule,388.12,1080.89,
Ft insert ucb berkeley shell,L3000,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,407.53,,,,,,,fee schedule,388.12,1080.89,APC
Ft insert ucb berkeley shell,L3000,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,403.64,,,,,,,fee schedule,388.12,1080.89,APC
Ft insert ucb berkeley shell,L3000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,388.12,,,,,,,fee schedule,388.12,1080.89,APC
Ft insert ucb berkeley shell,L3000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,593.82,,,,,,,fee schedule,388.12,1080.89,Radiology
Ft insert ucb berkeley shell,L3000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,543.37,,,,,,,fee schedule,388.12,1080.89,APC
Ft insert ucb berkeley shell,L3000,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,679.21,,,,,,,fee schedule,388.12,1080.89,APC
Foot insert remov molded spe,L3001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,418.92,,,,,,,fee schedule,163.39,455.04,
Foot insert remov molded spe,L3001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,455.04,,,,,,,fee schedule,163.39,455.04,
Foot insert remov molded spe,L3001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,364.75,,,,,,,fee schedule,163.39,455.04,
Foot insert remov molded spe,L3001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,398.46,,,,,,,fee schedule,163.39,455.04,
Foot insert remov molded spe,L3001,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,171.56,,,,,,,fee schedule,163.39,455.04,APC
Foot insert remov molded spe,L3001,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,169.93,,,,,,,fee schedule,163.39,455.04,APC
Foot insert remov molded spe,L3001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,163.39,,,,,,,fee schedule,163.39,455.04,APC
Foot insert remov molded spe,L3001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,249.99,,,,,,,fee schedule,163.39,455.04,Radiology
Foot insert remov molded spe,L3001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,228.75,,,,,,,fee schedule,163.39,455.04,APC
Foot insert remov molded spe,L3001,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,285.93,,,,,,,fee schedule,163.39,455.04,APC
Foot insert plastazote or eq,L3002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,511.59,,,,,,,fee schedule,199.51,555.7,
Foot insert plastazote or eq,L3002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,555.7,,,,,,,fee schedule,199.51,555.7,
Foot insert plastazote or eq,L3002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,445.44,,,,,,,fee schedule,199.51,555.7,
Foot insert plastazote or eq,L3002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,486.6,,,,,,,fee schedule,199.51,555.7,
Foot insert plastazote or eq,L3002,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,209.49,,,,,,,fee schedule,199.51,555.7,APC
Foot insert plastazote or eq,L3002,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,207.49,,,,,,,fee schedule,199.51,555.7,APC
Foot insert plastazote or eq,L3002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,199.51,,,,,,,fee schedule,199.51,555.7,APC
Foot insert plastazote or eq,L3002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,305.25,,,,,,,fee schedule,199.51,555.7,Radiology
Foot insert plastazote or eq,L3002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,279.31,,,,,,,fee schedule,199.51,555.7,APC
Foot insert plastazote or eq,L3002,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,349.14,,,,,,,fee schedule,199.51,555.7,APC
Foot insert silicone gel eac,L3003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,551.93,,,,,,,fee schedule,215.28,599.51,
Foot insert silicone gel eac,L3003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,599.51,,,,,,,fee schedule,215.28,599.51,
Foot insert silicone gel eac,L3003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,480.56,,,,,,,fee schedule,215.28,599.51,
Foot insert silicone gel eac,L3003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,524.97,,,,,,,fee schedule,215.28,599.51,
Foot insert silicone gel eac,L3003,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,226.04,,,,,,,fee schedule,215.28,599.51,APC
Foot insert silicone gel eac,L3003,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,223.89,,,,,,,fee schedule,215.28,599.51,APC
Foot insert silicone gel eac,L3003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,215.28,,,,,,,fee schedule,215.28,599.51,APC
Foot insert silicone gel eac,L3003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,329.38,,,,,,,fee schedule,215.28,599.51,Radiology
Foot insert silicone gel eac,L3003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,301.39,,,,,,,fee schedule,215.28,599.51,APC
Foot insert silicone gel eac,L3003,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,376.74,,,,,,,fee schedule,215.28,599.51,APC
Foot longitudinal arch suppo,L3010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,551.93,,,,,,,fee schedule,215.28,599.51,
Foot longitudinal arch suppo,L3010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,599.51,,,,,,,fee schedule,215.28,599.51,
Foot longitudinal arch suppo,L3010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,480.56,,,,,,,fee schedule,215.28,599.51,
Foot longitudinal arch suppo,L3010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,524.97,,,,,,,fee schedule,215.28,599.51,
Foot longitudinal arch suppo,L3010,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,226.04,,,,,,,fee schedule,215.28,599.51,APC
Foot longitudinal arch suppo,L3010,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,223.89,,,,,,,fee schedule,215.28,599.51,APC
Foot longitudinal arch suppo,L3010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,215.28,,,,,,,fee schedule,215.28,599.51,APC
Foot longitudinal arch suppo,L3010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,329.38,,,,,,,fee schedule,215.28,599.51,Radiology
Foot longitudinal arch suppo,L3010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,301.39,,,,,,,fee schedule,215.28,599.51,APC
Foot longitudinal arch suppo,L3010,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,376.74,,,,,,,fee schedule,215.28,599.51,APC
Foot longitud/metatarsal sup,L3020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,628.45,,,,,,,fee schedule,245.12,682.63,
Foot longitud/metatarsal sup,L3020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,682.63,,,,,,,fee schedule,245.12,682.63,
Foot longitud/metatarsal sup,L3020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,547.19,,,,,,,fee schedule,245.12,682.63,
Foot longitud/metatarsal sup,L3020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,597.75,,,,,,,fee schedule,245.12,682.63,
Foot longitud/metatarsal sup,L3020,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,257.38,,,,,,,fee schedule,245.12,682.63,APC
Foot longitud/metatarsal sup,L3020,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,254.92,,,,,,,fee schedule,245.12,682.63,APC
Foot longitud/metatarsal sup,L3020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,245.12,,,,,,,fee schedule,245.12,682.63,APC
Foot longitud/metatarsal sup,L3020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,375.03,,,,,,,fee schedule,245.12,682.63,Radiology
Foot longitud/metatarsal sup,L3020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,343.17,,,,,,,fee schedule,245.12,682.63,APC
Foot longitud/metatarsal sup,L3020,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,428.96,,,,,,,fee schedule,245.12,682.63,APC
Foot arch support remov prem,L3030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,241.72,,,,,,,fee schedule,94.3,262.56,
Foot arch support remov prem,L3030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,262.56,,,,,,,fee schedule,94.3,262.56,
Foot arch support remov prem,L3030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,210.46,,,,,,,fee schedule,94.3,262.56,
Foot arch support remov prem,L3030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,229.91,,,,,,,fee schedule,94.3,262.56,
Foot arch support remov prem,L3030,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,99.02,,,,,,,fee schedule,94.3,262.56,APC
Foot arch support remov prem,L3030,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,98.07,,,,,,,fee schedule,94.3,262.56,APC
Foot arch support remov prem,L3030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,94.3,,,,,,,fee schedule,94.3,262.56,APC
Foot arch support remov prem,L3030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.28,,,,,,,fee schedule,94.3,262.56,Radiology
Foot arch support remov prem,L3030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,132.02,,,,,,,fee schedule,94.3,262.56,APC
Foot arch support remov prem,L3030,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,165.02,,,,,,,fee schedule,94.3,262.56,APC
Ft arch suprt premold longit,L3040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,149.05,,,,,,,fee schedule,58.14,161.9,
Ft arch suprt premold longit,L3040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,161.9,,,,,,,fee schedule,58.14,161.9,
Ft arch suprt premold longit,L3040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,129.77,,,,,,,fee schedule,58.14,161.9,
Ft arch suprt premold longit,L3040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,141.77,,,,,,,fee schedule,58.14,161.9,
Ft arch suprt premold longit,L3040,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.05,,,,,,,fee schedule,58.14,161.9,APC
Ft arch suprt premold longit,L3040,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.47,,,,,,,fee schedule,58.14,161.9,APC
Ft arch suprt premold longit,L3040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.14,,,,,,,fee schedule,58.14,161.9,APC
Ft arch suprt premold longit,L3040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,88.95,,,,,,,fee schedule,58.14,161.9,Radiology
Ft arch suprt premold longit,L3040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.4,,,,,,,fee schedule,58.14,161.9,APC
Ft arch suprt premold longit,L3040,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,101.74,,,,,,,fee schedule,58.14,161.9,APC
Foot arch supp premold metat,L3050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,149.05,,,,,,,fee schedule,58.14,161.9,
Foot arch supp premold metat,L3050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,161.9,,,,,,,fee schedule,58.14,161.9,
Foot arch supp premold metat,L3050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,129.77,,,,,,,fee schedule,58.14,161.9,
Foot arch supp premold metat,L3050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,141.77,,,,,,,fee schedule,58.14,161.9,
Foot arch supp premold metat,L3050,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.05,,,,,,,fee schedule,58.14,161.9,APC
Foot arch supp premold metat,L3050,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.47,,,,,,,fee schedule,58.14,161.9,APC
Foot arch supp premold metat,L3050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.14,,,,,,,fee schedule,58.14,161.9,APC
Foot arch supp premold metat,L3050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,88.95,,,,,,,fee schedule,58.14,161.9,Radiology
Foot arch supp premold metat,L3050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.4,,,,,,,fee schedule,58.14,161.9,APC
Foot arch supp premold metat,L3050,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,101.74,,,,,,,fee schedule,58.14,161.9,APC
Foot arch supp longitud/meta,L3060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,233.65,,,,,,,fee schedule,91.13,253.79,
Foot arch supp longitud/meta,L3060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,253.79,,,,,,,fee schedule,91.13,253.79,
Foot arch supp longitud/meta,L3060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,203.43,,,,,,,fee schedule,91.13,253.79,
Foot arch supp longitud/meta,L3060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,222.23,,,,,,,fee schedule,91.13,253.79,
Foot arch supp longitud/meta,L3060,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,95.69,,,,,,,fee schedule,91.13,253.79,APC
Foot arch supp longitud/meta,L3060,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,94.78,,,,,,,fee schedule,91.13,253.79,APC
Foot arch supp longitud/meta,L3060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,91.13,,,,,,,fee schedule,91.13,253.79,APC
Foot arch supp longitud/meta,L3060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,139.43,,,,,,,fee schedule,91.13,253.79,Radiology
Foot arch supp longitud/meta,L3060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,127.58,,,,,,,fee schedule,91.13,253.79,APC
Foot arch supp longitud/meta,L3060,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,159.48,,,,,,,fee schedule,91.13,253.79,APC
Arch suprt att to sho longit,L3070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,100.71,,,,,,,fee schedule,39.27,109.39,
Arch suprt att to sho longit,L3070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,109.39,,,,,,,fee schedule,39.27,109.39,
Arch suprt att to sho longit,L3070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,87.69,,,,,,,fee schedule,39.27,109.39,
Arch suprt att to sho longit,L3070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,95.79,,,,,,,fee schedule,39.27,109.39,
Arch suprt att to sho longit,L3070,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,41.23,,,,,,,fee schedule,39.27,109.39,APC
Arch suprt att to sho longit,L3070,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,40.84,,,,,,,fee schedule,39.27,109.39,APC
Arch suprt att to sho longit,L3070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,39.27,,,,,,,fee schedule,39.27,109.39,APC
Arch suprt att to sho longit,L3070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,60.08,,,,,,,fee schedule,39.27,109.39,Radiology
Arch suprt att to sho longit,L3070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,54.98,,,,,,,fee schedule,39.27,109.39,APC
Arch suprt att to sho longit,L3070,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,68.72,,,,,,,fee schedule,39.27,109.39,APC
Arch supp att to shoe metata,L3080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,100.71,,,,,,,fee schedule,39.27,109.39,
Arch supp att to shoe metata,L3080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,109.39,,,,,,,fee schedule,39.27,109.39,
Arch supp att to shoe metata,L3080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,87.69,,,,,,,fee schedule,39.27,109.39,
Arch supp att to shoe metata,L3080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,95.79,,,,,,,fee schedule,39.27,109.39,
Arch supp att to shoe metata,L3080,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,41.23,,,,,,,fee schedule,39.27,109.39,APC
Arch supp att to shoe metata,L3080,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,40.84,,,,,,,fee schedule,39.27,109.39,APC
Arch supp att to shoe metata,L3080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,39.27,,,,,,,fee schedule,39.27,109.39,APC
Arch supp att to shoe metata,L3080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,60.08,,,,,,,fee schedule,39.27,109.39,Radiology
Arch supp att to shoe metata,L3080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,54.98,,,,,,,fee schedule,39.27,109.39,APC
Arch supp att to shoe metata,L3080,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,68.72,,,,,,,fee schedule,39.27,109.39,APC
Arch supp att to shoe long/m,L3090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,129,,,,,,,fee schedule,50.31,140.12,
Arch supp att to shoe long/m,L3090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,140.12,,,,,,,fee schedule,50.31,140.12,
Arch supp att to shoe long/m,L3090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,112.32,,,,,,,fee schedule,50.31,140.12,
Arch supp att to shoe long/m,L3090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,122.7,,,,,,,fee schedule,50.31,140.12,
Arch supp att to shoe long/m,L3090,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,52.83,,,,,,,fee schedule,50.31,140.12,APC
Arch supp att to shoe long/m,L3090,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,52.32,,,,,,,fee schedule,50.31,140.12,APC
Arch supp att to shoe long/m,L3090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,50.31,,,,,,,fee schedule,50.31,140.12,APC
Arch supp att to shoe long/m,L3090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,76.97,,,,,,,fee schedule,50.31,140.12,Radiology
Arch supp att to shoe long/m,L3090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,70.43,,,,,,,fee schedule,50.31,140.12,APC
Arch supp att to shoe long/m,L3090,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,88.04,,,,,,,fee schedule,50.31,140.12,APC
Hallus-valgus nt dyn pre ots,L3100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,136.94,,,,,,,fee schedule,53.41,148.74,
Hallus-valgus nt dyn pre ots,L3100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,148.74,,,,,,,fee schedule,53.41,148.74,
Hallus-valgus nt dyn pre ots,L3100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,119.23,,,,,,,fee schedule,53.41,148.74,
Hallus-valgus nt dyn pre ots,L3100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,130.25,,,,,,,fee schedule,53.41,148.74,
Hallus-valgus nt dyn pre ots,L3100,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,56.08,,,,,,,fee schedule,53.41,148.74,APC
Hallus-valgus nt dyn pre ots,L3100,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,55.55,,,,,,,fee schedule,53.41,148.74,APC
Hallus-valgus nt dyn pre ots,L3100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,53.41,,,,,,,fee schedule,53.41,148.74,APC
Hallus-valgus nt dyn pre ots,L3100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.72,,,,,,,fee schedule,53.41,148.74,Radiology
Hallus-valgus nt dyn pre ots,L3100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,74.77,,,,,,,fee schedule,53.41,148.74,APC
Hallus-valgus nt dyn pre ots,L3100,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,93.47,,,,,,,fee schedule,53.41,148.74,APC
Abduction rotation bar shoe,L3140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,282.05,,,,,,,fee schedule,110.03,306.37,
Abduction rotation bar shoe,L3140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,306.37,,,,,,,fee schedule,110.03,306.37,
Abduction rotation bar shoe,L3140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,245.58,,,,,,,fee schedule,110.03,306.37,
Abduction rotation bar shoe,L3140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,268.28,,,,,,,fee schedule,110.03,306.37,
Abduction rotation bar shoe,L3140,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,115.53,,,,,,,fee schedule,110.03,306.37,APC
Abduction rotation bar shoe,L3140,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,114.43,,,,,,,fee schedule,110.03,306.37,APC
Abduction rotation bar shoe,L3140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,110.03,,,,,,,fee schedule,110.03,306.37,APC
Abduction rotation bar shoe,L3140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,168.35,,,,,,,fee schedule,110.03,306.37,Radiology
Abduction rotation bar shoe,L3140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,154.04,,,,,,,fee schedule,110.03,306.37,APC
Abduction rotation bar shoe,L3140,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,192.55,,,,,,,fee schedule,110.03,306.37,APC
Abduct rotation bar w/o shoe,L3150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,257.8,,,,,,,fee schedule,100.56,280.02,
Abduct rotation bar w/o shoe,L3150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,280.02,,,,,,,fee schedule,100.56,280.02,
Abduct rotation bar w/o shoe,L3150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,224.46,,,,,,,fee schedule,100.56,280.02,
Abduct rotation bar w/o shoe,L3150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,245.2,,,,,,,fee schedule,100.56,280.02,
Abduct rotation bar w/o shoe,L3150,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,105.59,,,,,,,fee schedule,100.56,280.02,APC
Abduct rotation bar w/o shoe,L3150,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,104.58,,,,,,,fee schedule,100.56,280.02,APC
Abduct rotation bar w/o shoe,L3150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,100.56,,,,,,,fee schedule,100.56,280.02,APC
Abduct rotation bar w/o shoe,L3150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,153.86,,,,,,,fee schedule,100.56,280.02,Radiology
Abduct rotation bar w/o shoe,L3150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,140.78,,,,,,,fee schedule,100.56,280.02,APC
Abduct rotation bar w/o shoe,L3150,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,175.98,,,,,,,fee schedule,100.56,280.02,APC
Foot plas heel stabi pre ots,L3170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,161.19,,,,,,,fee schedule,62.84,175.09,
Foot plas heel stabi pre ots,L3170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,175.09,,,,,,,fee schedule,62.84,175.09,
Foot plas heel stabi pre ots,L3170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,140.35,,,,,,,fee schedule,62.84,175.09,
Foot plas heel stabi pre ots,L3170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,153.32,,,,,,,fee schedule,62.84,175.09,
Foot plas heel stabi pre ots,L3170,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,65.98,,,,,,,fee schedule,62.84,175.09,APC
Foot plas heel stabi pre ots,L3170,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,65.35,,,,,,,fee schedule,62.84,175.09,APC
Foot plas heel stabi pre ots,L3170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,62.84,,,,,,,fee schedule,62.84,175.09,APC
Foot plas heel stabi pre ots,L3170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,96.15,,,,,,,fee schedule,62.84,175.09,Radiology
Foot plas heel stabi pre ots,L3170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,87.98,,,,,,,fee schedule,62.84,175.09,APC
Foot plas heel stabi pre ots,L3170,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,109.97,,,,,,,fee schedule,62.84,175.09,APC
Woman's shoe oxford brace,L3224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,173.27,,,,,,,fee schedule,67.57,188.21,
Woman's shoe oxford brace,L3224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,188.21,,,,,,,fee schedule,67.57,188.21,
Woman's shoe oxford brace,L3224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,150.86,,,,,,,fee schedule,67.57,188.21,
Woman's shoe oxford brace,L3224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,164.8,,,,,,,fee schedule,67.57,188.21,
Woman's shoe oxford brace,L3224,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,70.95,,,,,,,fee schedule,67.57,188.21,APC
Woman's shoe oxford brace,L3224,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,70.27,,,,,,,fee schedule,67.57,188.21,APC
Woman's shoe oxford brace,L3224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,67.57,,,,,,,fee schedule,67.57,188.21,APC
Woman's shoe oxford brace,L3224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,103.38,,,,,,,fee schedule,67.57,188.21,Radiology
Woman's shoe oxford brace,L3224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,94.6,,,,,,,fee schedule,67.57,188.21,APC
Woman's shoe oxford brace,L3224,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,118.25,,,,,,,fee schedule,67.57,188.21,APC
Man's shoe oxford brace,L3225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,203.13,,,,,,,fee schedule,79.22,220.64,
Man's shoe oxford brace,L3225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,220.64,,,,,,,fee schedule,79.22,220.64,
Man's shoe oxford brace,L3225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,176.86,,,,,,,fee schedule,79.22,220.64,
Man's shoe oxford brace,L3225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,193.2,,,,,,,fee schedule,79.22,220.64,
Man's shoe oxford brace,L3225,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,83.18,,,,,,,fee schedule,79.22,220.64,APC
Man's shoe oxford brace,L3225,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,82.39,,,,,,,fee schedule,79.22,220.64,APC
Man's shoe oxford brace,L3225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,79.22,,,,,,,fee schedule,79.22,220.64,APC
Man's shoe oxford brace,L3225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,121.21,,,,,,,fee schedule,79.22,220.64,Radiology
Man's shoe oxford brace,L3225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,110.91,,,,,,,fee schedule,79.22,220.64,APC
Man's shoe oxford brace,L3225,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,138.64,,,,,,,fee schedule,79.22,220.64,APC
Sho lift taper to metatarsal,L3300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,165.16,,,,,,,fee schedule,64.41,179.4,
Sho lift taper to metatarsal,L3300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,179.4,,,,,,,fee schedule,64.41,179.4,
Sho lift taper to metatarsal,L3300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,143.8,,,,,,,fee schedule,64.41,179.4,
Sho lift taper to metatarsal,L3300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,157.09,,,,,,,fee schedule,64.41,179.4,
Sho lift taper to metatarsal,L3300,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,67.63,,,,,,,fee schedule,64.41,179.4,APC
Sho lift taper to metatarsal,L3300,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,66.99,,,,,,,fee schedule,64.41,179.4,APC
Sho lift taper to metatarsal,L3300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,64.41,,,,,,,fee schedule,64.41,179.4,APC
Sho lift taper to metatarsal,L3300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,98.55,,,,,,,fee schedule,64.41,179.4,Radiology
Sho lift taper to metatarsal,L3300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,90.17,,,,,,,fee schedule,64.41,179.4,APC
Sho lift taper to metatarsal,L3300,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,112.72,,,,,,,fee schedule,64.41,179.4,APC
Shoe lift elev heel/sole neo,L3310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,257.8,,,,,,,fee schedule,100.56,280.02,
Shoe lift elev heel/sole neo,L3310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,280.02,,,,,,,fee schedule,100.56,280.02,
Shoe lift elev heel/sole neo,L3310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,224.46,,,,,,,fee schedule,100.56,280.02,
Shoe lift elev heel/sole neo,L3310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,245.2,,,,,,,fee schedule,100.56,280.02,
Shoe lift elev heel/sole neo,L3310,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,105.59,,,,,,,fee schedule,100.56,280.02,APC
Shoe lift elev heel/sole neo,L3310,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,104.58,,,,,,,fee schedule,100.56,280.02,APC
Shoe lift elev heel/sole neo,L3310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,100.56,,,,,,,fee schedule,100.56,280.02,APC
Shoe lift elev heel/sole neo,L3310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,153.86,,,,,,,fee schedule,100.56,280.02,Radiology
Shoe lift elev heel/sole neo,L3310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,140.78,,,,,,,fee schedule,100.56,280.02,APC
Shoe lift elev heel/sole neo,L3310,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,175.98,,,,,,,fee schedule,100.56,280.02,APC
Lifts elevation metal extens,L3330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1792.83,,,,,,,fee schedule,699.23,1947.38,
Lifts elevation metal extens,L3330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1947.38,,,,,,,fee schedule,699.23,1947.38,
Lifts elevation metal extens,L3330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1561,,,,,,,fee schedule,699.23,1947.38,
Lifts elevation metal extens,L3330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1705.25,,,,,,,fee schedule,699.23,1947.38,
Lifts elevation metal extens,L3330,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,734.19,,,,,,,fee schedule,699.23,1947.38,APC
Lifts elevation metal extens,L3330,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,727.2,,,,,,,fee schedule,699.23,1947.38,APC
Lifts elevation metal extens,L3330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,699.23,,,,,,,fee schedule,699.23,1947.38,APC
Lifts elevation metal extens,L3330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1069.82,,,,,,,fee schedule,699.23,1947.38,Radiology
Lifts elevation metal extens,L3330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,978.92,,,,,,,fee schedule,699.23,1947.38,APC
Lifts elevation metal extens,L3330,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1223.65,,,,,,,fee schedule,699.23,1947.38,APC
Shoe lifts tapered to one-ha,L3332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,233.65,,,,,,,fee schedule,91.13,253.79,
Shoe lifts tapered to one-ha,L3332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,253.79,,,,,,,fee schedule,91.13,253.79,
Shoe lifts tapered to one-ha,L3332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,203.43,,,,,,,fee schedule,91.13,253.79,
Shoe lifts tapered to one-ha,L3332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,222.23,,,,,,,fee schedule,91.13,253.79,
Shoe lifts tapered to one-ha,L3332,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,95.69,,,,,,,fee schedule,91.13,253.79,APC
Shoe lifts tapered to one-ha,L3332,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,94.78,,,,,,,fee schedule,91.13,253.79,APC
Shoe lifts tapered to one-ha,L3332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,91.13,,,,,,,fee schedule,91.13,253.79,APC
Shoe lifts tapered to one-ha,L3332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,139.43,,,,,,,fee schedule,91.13,253.79,Radiology
Shoe lifts tapered to one-ha,L3332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,127.58,,,,,,,fee schedule,91.13,253.79,APC
Shoe lifts tapered to one-ha,L3332,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,159.48,,,,,,,fee schedule,91.13,253.79,APC
Shoe lifts elevation heel /i,L3334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,120.86,,,,,,,fee schedule,47.13,131.28,
Shoe lifts elevation heel /i,L3334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,131.28,,,,,,,fee schedule,47.13,131.28,
Shoe lifts elevation heel /i,L3334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,105.23,,,,,,,fee schedule,47.13,131.28,
Shoe lifts elevation heel /i,L3334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,114.96,,,,,,,fee schedule,47.13,131.28,
Shoe lifts elevation heel /i,L3334,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,49.49,,,,,,,fee schedule,47.13,131.28,APC
Shoe lifts elevation heel /i,L3334,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,49.02,,,,,,,fee schedule,47.13,131.28,APC
Shoe lifts elevation heel /i,L3334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,47.13,,,,,,,fee schedule,47.13,131.28,APC
Shoe lifts elevation heel /i,L3334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,72.11,,,,,,,fee schedule,47.13,131.28,Radiology
Shoe lifts elevation heel /i,L3334,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,65.98,,,,,,,fee schedule,47.13,131.28,APC
Shoe lifts elevation heel /i,L3334,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,82.48,,,,,,,fee schedule,47.13,131.28,APC
Shoe wedge sach,L3340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,269.94,,,,,,,fee schedule,105.25,293.21,
Shoe wedge sach,L3340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,293.21,,,,,,,fee schedule,105.25,293.21,
Shoe wedge sach,L3340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,235.04,,,,,,,fee schedule,105.25,293.21,
Shoe wedge sach,L3340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,256.76,,,,,,,fee schedule,105.25,293.21,
Shoe wedge sach,L3340,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,110.51,,,,,,,fee schedule,105.25,293.21,APC
Shoe wedge sach,L3340,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,109.46,,,,,,,fee schedule,105.25,293.21,APC
Shoe wedge sach,L3340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,105.25,,,,,,,fee schedule,105.25,293.21,APC
Shoe wedge sach,L3340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,161.03,,,,,,,fee schedule,105.25,293.21,Radiology
Shoe wedge sach,L3340,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,147.35,,,,,,,fee schedule,105.25,293.21,APC
Shoe wedge sach,L3340,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,184.19,,,,,,,fee schedule,105.25,293.21,APC
Shoe heel wedge,L3350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,72.45,,,,,,,fee schedule,28.26,78.7,
Shoe heel wedge,L3350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,78.7,,,,,,,fee schedule,28.26,78.7,
Shoe heel wedge,L3350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,63.08,,,,,,,fee schedule,28.26,78.7,
Shoe heel wedge,L3350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,68.91,,,,,,,fee schedule,28.26,78.7,
Shoe heel wedge,L3350,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,29.67,,,,,,,fee schedule,28.26,78.7,APC
Shoe heel wedge,L3350,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,29.39,,,,,,,fee schedule,28.26,78.7,APC
Shoe heel wedge,L3350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,28.26,,,,,,,fee schedule,28.26,78.7,APC
Shoe heel wedge,L3350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43.24,,,,,,,fee schedule,28.26,78.7,Radiology
Shoe heel wedge,L3350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,39.56,,,,,,,fee schedule,28.26,78.7,APC
Shoe heel wedge,L3350,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,49.46,,,,,,,fee schedule,28.26,78.7,APC
Shoe sole wedge outside sole,L3360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,112.79,,,,,,,fee schedule,44,122.51,
Shoe sole wedge outside sole,L3360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,122.51,,,,,,,fee schedule,44,122.51,
Shoe sole wedge outside sole,L3360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,98.2,,,,,,,fee schedule,44,122.51,
Shoe sole wedge outside sole,L3360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,107.28,,,,,,,fee schedule,44,122.51,
Shoe sole wedge outside sole,L3360,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,46.2,,,,,,,fee schedule,44,122.51,APC
Shoe sole wedge outside sole,L3360,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,45.76,,,,,,,fee schedule,44,122.51,APC
Shoe sole wedge outside sole,L3360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,44,,,,,,,fee schedule,44,122.51,APC
Shoe sole wedge outside sole,L3360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,67.32,,,,,,,fee schedule,44,122.51,Radiology
Shoe sole wedge outside sole,L3360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,61.6,,,,,,,fee schedule,44,122.51,APC
Shoe sole wedge outside sole,L3360,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,77,,,,,,,fee schedule,44,122.51,APC
Shoe sole wedge between sole,L3370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,157.09,,,,,,,fee schedule,61.28,170.63,
Shoe sole wedge between sole,L3370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,170.63,,,,,,,fee schedule,61.28,170.63,
Shoe sole wedge between sole,L3370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,136.77,,,,,,,fee schedule,61.28,170.63,
Shoe sole wedge between sole,L3370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,149.41,,,,,,,fee schedule,61.28,170.63,
Shoe sole wedge between sole,L3370,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,64.34,,,,,,,fee schedule,61.28,170.63,APC
Shoe sole wedge between sole,L3370,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,63.73,,,,,,,fee schedule,61.28,170.63,APC
Shoe sole wedge between sole,L3370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,61.28,,,,,,,fee schedule,61.28,170.63,APC
Shoe sole wedge between sole,L3370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,93.76,,,,,,,fee schedule,61.28,170.63,Radiology
Shoe sole wedge between sole,L3370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,85.79,,,,,,,fee schedule,61.28,170.63,APC
Shoe sole wedge between sole,L3370,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,107.24,,,,,,,fee schedule,61.28,170.63,APC
Shoe clubfoot wedge,L3380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,157.09,,,,,,,fee schedule,61.28,170.63,
Shoe clubfoot wedge,L3380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,170.63,,,,,,,fee schedule,61.28,170.63,
Shoe clubfoot wedge,L3380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,136.77,,,,,,,fee schedule,61.28,170.63,
Shoe clubfoot wedge,L3380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,149.41,,,,,,,fee schedule,61.28,170.63,
Shoe clubfoot wedge,L3380,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,64.34,,,,,,,fee schedule,61.28,170.63,APC
Shoe clubfoot wedge,L3380,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,63.73,,,,,,,fee schedule,61.28,170.63,APC
Shoe clubfoot wedge,L3380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,61.28,,,,,,,fee schedule,61.28,170.63,APC
Shoe clubfoot wedge,L3380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,93.76,,,,,,,fee schedule,61.28,170.63,Radiology
Shoe clubfoot wedge,L3380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,85.79,,,,,,,fee schedule,61.28,170.63,APC
Shoe clubfoot wedge,L3380,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,107.24,,,,,,,fee schedule,61.28,170.63,APC
Shoe outflare wedge,L3390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,157.09,,,,,,,fee schedule,61.28,170.63,
Shoe outflare wedge,L3390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,170.63,,,,,,,fee schedule,61.28,170.63,
Shoe outflare wedge,L3390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,136.77,,,,,,,fee schedule,61.28,170.63,
Shoe outflare wedge,L3390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,149.41,,,,,,,fee schedule,61.28,170.63,
Shoe outflare wedge,L3390,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,64.34,,,,,,,fee schedule,61.28,170.63,APC
Shoe outflare wedge,L3390,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,63.73,,,,,,,fee schedule,61.28,170.63,APC
Shoe outflare wedge,L3390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,61.28,,,,,,,fee schedule,61.28,170.63,APC
Shoe outflare wedge,L3390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,93.76,,,,,,,fee schedule,61.28,170.63,Radiology
Shoe outflare wedge,L3390,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,85.79,,,,,,,fee schedule,61.28,170.63,APC
Shoe outflare wedge,L3390,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,107.24,,,,,,,fee schedule,61.28,170.63,APC
Shoe metatarsal bar wedge ro,L3400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,129,,,,,,,fee schedule,50.31,140.12,
Shoe metatarsal bar wedge ro,L3400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,140.12,,,,,,,fee schedule,50.31,140.12,
Shoe metatarsal bar wedge ro,L3400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,112.32,,,,,,,fee schedule,50.31,140.12,
Shoe metatarsal bar wedge ro,L3400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,122.7,,,,,,,fee schedule,50.31,140.12,
Shoe metatarsal bar wedge ro,L3400,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,52.83,,,,,,,fee schedule,50.31,140.12,APC
Shoe metatarsal bar wedge ro,L3400,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,52.32,,,,,,,fee schedule,50.31,140.12,APC
Shoe metatarsal bar wedge ro,L3400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,50.31,,,,,,,fee schedule,50.31,140.12,APC
Shoe metatarsal bar wedge ro,L3400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,76.97,,,,,,,fee schedule,50.31,140.12,Radiology
Shoe metatarsal bar wedge ro,L3400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,70.43,,,,,,,fee schedule,50.31,140.12,APC
Shoe metatarsal bar wedge ro,L3400,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,88.04,,,,,,,fee schedule,50.31,140.12,APC
Shoe metatarsal bar between,L3410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,294.2,,,,,,,fee schedule,114.74,319.56,
Shoe metatarsal bar between,L3410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,319.56,,,,,,,fee schedule,114.74,319.56,
Shoe metatarsal bar between,L3410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,256.16,,,,,,,fee schedule,114.74,319.56,
Shoe metatarsal bar between,L3410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,279.83,,,,,,,fee schedule,114.74,319.56,
Shoe metatarsal bar between,L3410,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,120.48,,,,,,,fee schedule,114.74,319.56,APC
Shoe metatarsal bar between,L3410,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,119.33,,,,,,,fee schedule,114.74,319.56,APC
Shoe metatarsal bar between,L3410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,114.74,,,,,,,fee schedule,114.74,319.56,APC
Shoe metatarsal bar between,L3410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,175.55,,,,,,,fee schedule,114.74,319.56,Radiology
Shoe metatarsal bar between,L3410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,160.64,,,,,,,fee schedule,114.74,319.56,APC
Shoe metatarsal bar between,L3410,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,200.8,,,,,,,fee schedule,114.74,319.56,APC
Full sole/heel wedge btween,L3420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,173.2,,,,,,,fee schedule,67.55,188.13,
Full sole/heel wedge btween,L3420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,188.13,,,,,,,fee schedule,67.55,188.13,
Full sole/heel wedge btween,L3420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,150.8,,,,,,,fee schedule,67.55,188.13,
Full sole/heel wedge btween,L3420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,164.74,,,,,,,fee schedule,67.55,188.13,
Full sole/heel wedge btween,L3420,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,70.93,,,,,,,fee schedule,67.55,188.13,APC
Full sole/heel wedge btween,L3420,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,70.25,,,,,,,fee schedule,67.55,188.13,APC
Full sole/heel wedge btween,L3420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,67.55,,,,,,,fee schedule,67.55,188.13,APC
Full sole/heel wedge btween,L3420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,103.35,,,,,,,fee schedule,67.55,188.13,Radiology
Full sole/heel wedge btween,L3420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,94.57,,,,,,,fee schedule,67.55,188.13,APC
Full sole/heel wedge btween,L3420,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,118.21,,,,,,,fee schedule,67.55,188.13,APC
Sho heel count plast reinfor,L3430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,507.66,,,,,,,fee schedule,197.99,551.43,
Sho heel count plast reinfor,L3430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,551.43,,,,,,,fee schedule,197.99,551.43,
Sho heel count plast reinfor,L3430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,442.02,,,,,,,fee schedule,197.99,551.43,
Sho heel count plast reinfor,L3430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,482.86,,,,,,,fee schedule,197.99,551.43,
Sho heel count plast reinfor,L3430,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,207.89,,,,,,,fee schedule,197.99,551.43,APC
Sho heel count plast reinfor,L3430,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,205.91,,,,,,,fee schedule,197.99,551.43,APC
Sho heel count plast reinfor,L3430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,197.99,,,,,,,fee schedule,197.99,551.43,APC
Sho heel count plast reinfor,L3430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,302.92,,,,,,,fee schedule,197.99,551.43,Radiology
Sho heel count plast reinfor,L3430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,277.19,,,,,,,fee schedule,197.99,551.43,APC
Sho heel count plast reinfor,L3430,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,346.48,,,,,,,fee schedule,197.99,551.43,APC
Heel leather reinforced,L3440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,241.72,,,,,,,fee schedule,94.3,262.56,
Heel leather reinforced,L3440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,262.56,,,,,,,fee schedule,94.3,262.56,
Heel leather reinforced,L3440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,210.46,,,,,,,fee schedule,94.3,262.56,
Heel leather reinforced,L3440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,229.91,,,,,,,fee schedule,94.3,262.56,
Heel leather reinforced,L3440,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,99.02,,,,,,,fee schedule,94.3,262.56,APC
Heel leather reinforced,L3440,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,98.07,,,,,,,fee schedule,94.3,262.56,APC
Heel leather reinforced,L3440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,94.3,,,,,,,fee schedule,94.3,262.56,APC
Heel leather reinforced,L3440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.28,,,,,,,fee schedule,94.3,262.56,Radiology
Heel leather reinforced,L3440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,132.02,,,,,,,fee schedule,94.3,262.56,APC
Heel leather reinforced,L3440,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,165.02,,,,,,,fee schedule,94.3,262.56,APC
Shoe heel sach cushion type,L3450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,334.36,,,,,,,fee schedule,130.4,363.18,
Shoe heel sach cushion type,L3450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,363.18,,,,,,,fee schedule,130.4,363.18,
Shoe heel sach cushion type,L3450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,291.12,,,,,,,fee schedule,130.4,363.18,
Shoe heel sach cushion type,L3450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,318.02,,,,,,,fee schedule,130.4,363.18,
Shoe heel sach cushion type,L3450,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,136.92,,,,,,,fee schedule,130.4,363.18,APC
Shoe heel sach cushion type,L3450,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,135.62,,,,,,,fee schedule,130.4,363.18,APC
Shoe heel sach cushion type,L3450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,130.4,,,,,,,fee schedule,130.4,363.18,APC
Shoe heel sach cushion type,L3450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,199.51,,,,,,,fee schedule,130.4,363.18,Radiology
Shoe heel sach cushion type,L3450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,182.56,,,,,,,fee schedule,130.4,363.18,APC
Shoe heel sach cushion type,L3450,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,228.2,,,,,,,fee schedule,130.4,363.18,APC
Shoe heel new leather standa,L3455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,129,,,,,,,fee schedule,50.31,140.12,
Shoe heel new leather standa,L3455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,140.12,,,,,,,fee schedule,50.31,140.12,
Shoe heel new leather standa,L3455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,112.32,,,,,,,fee schedule,50.31,140.12,
Shoe heel new leather standa,L3455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,122.7,,,,,,,fee schedule,50.31,140.12,
Shoe heel new leather standa,L3455,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,52.83,,,,,,,fee schedule,50.31,140.12,APC
Shoe heel new leather standa,L3455,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,52.32,,,,,,,fee schedule,50.31,140.12,APC
Shoe heel new leather standa,L3455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,50.31,,,,,,,fee schedule,50.31,140.12,APC
Shoe heel new leather standa,L3455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,76.97,,,,,,,fee schedule,50.31,140.12,Radiology
Shoe heel new leather standa,L3455,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,70.43,,,,,,,fee schedule,50.31,140.12,APC
Shoe heel new leather standa,L3455,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,88.04,,,,,,,fee schedule,50.31,140.12,APC
Shoe heel new rubber standar,L3460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,108.72,,,,,,,fee schedule,42.41,118.09,
Shoe heel new rubber standar,L3460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,118.09,,,,,,,fee schedule,42.41,118.09,
Shoe heel new rubber standar,L3460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,94.66,,,,,,,fee schedule,42.41,118.09,
Shoe heel new rubber standar,L3460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,103.4,,,,,,,fee schedule,42.41,118.09,
Shoe heel new rubber standar,L3460,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,44.53,,,,,,,fee schedule,42.41,118.09,APC
Shoe heel new rubber standar,L3460,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,44.11,,,,,,,fee schedule,42.41,118.09,APC
Shoe heel new rubber standar,L3460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,42.41,,,,,,,fee schedule,42.41,118.09,APC
Shoe heel new rubber standar,L3460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,64.89,,,,,,,fee schedule,42.41,118.09,Radiology
Shoe heel new rubber standar,L3460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,59.37,,,,,,,fee schedule,42.41,118.09,APC
Shoe heel new rubber standar,L3460,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,74.22,,,,,,,fee schedule,42.41,118.09,APC
Shoe heel thomas with wedge,L3465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,185.31,,,,,,,fee schedule,72.28,201.29,
Shoe heel thomas with wedge,L3465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,201.29,,,,,,,fee schedule,72.28,201.29,
Shoe heel thomas with wedge,L3465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,161.35,,,,,,,fee schedule,72.28,201.29,
Shoe heel thomas with wedge,L3465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,176.26,,,,,,,fee schedule,72.28,201.29,
Shoe heel thomas with wedge,L3465,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,75.89,,,,,,,fee schedule,72.28,201.29,APC
Shoe heel thomas with wedge,L3465,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,75.17,,,,,,,fee schedule,72.28,201.29,APC
Shoe heel thomas with wedge,L3465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,72.28,,,,,,,fee schedule,72.28,201.29,APC
Shoe heel thomas with wedge,L3465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,110.59,,,,,,,fee schedule,72.28,201.29,Radiology
Shoe heel thomas with wedge,L3465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,101.19,,,,,,,fee schedule,72.28,201.29,APC
Shoe heel thomas with wedge,L3465,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,126.49,,,,,,,fee schedule,72.28,201.29,APC
Shoe heel thomas extend to b,L3470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,197.39,,,,,,,fee schedule,76.99,214.4,
Shoe heel thomas extend to b,L3470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,214.4,,,,,,,fee schedule,76.99,214.4,
Shoe heel thomas extend to b,L3470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,171.86,,,,,,,fee schedule,76.99,214.4,
Shoe heel thomas extend to b,L3470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,187.74,,,,,,,fee schedule,76.99,214.4,
Shoe heel thomas extend to b,L3470,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,80.84,,,,,,,fee schedule,76.99,214.4,APC
Shoe heel thomas extend to b,L3470,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,80.07,,,,,,,fee schedule,76.99,214.4,APC
Shoe heel thomas extend to b,L3470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,76.99,,,,,,,fee schedule,76.99,214.4,APC
Shoe heel thomas extend to b,L3470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,117.79,,,,,,,fee schedule,76.99,214.4,Radiology
Shoe heel thomas extend to b,L3470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,107.79,,,,,,,fee schedule,76.99,214.4,APC
Shoe heel thomas extend to b,L3470,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,134.73,,,,,,,fee schedule,76.99,214.4,APC
Shoe heel pad & depress for,L3480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,197.39,,,,,,,fee schedule,76.99,214.4,
Shoe heel pad & depress for,L3480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,214.4,,,,,,,fee schedule,76.99,214.4,
Shoe heel pad & depress for,L3480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,171.86,,,,,,,fee schedule,76.99,214.4,
Shoe heel pad & depress for,L3480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,187.74,,,,,,,fee schedule,76.99,214.4,
Shoe heel pad & depress for,L3480,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,80.84,,,,,,,fee schedule,76.99,214.4,APC
Shoe heel pad & depress for,L3480,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,80.07,,,,,,,fee schedule,76.99,214.4,APC
Shoe heel pad & depress for,L3480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,76.99,,,,,,,fee schedule,76.99,214.4,APC
Shoe heel pad & depress for,L3480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,117.79,,,,,,,fee schedule,76.99,214.4,Radiology
Shoe heel pad & depress for,L3480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,107.79,,,,,,,fee schedule,76.99,214.4,APC
Shoe heel pad & depress for,L3480,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,134.73,,,,,,,fee schedule,76.99,214.4,APC
Ortho shoe add leather insol,L3500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,92.74,,,,,,,fee schedule,36.18,100.74,
Ortho shoe add leather insol,L3500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,100.74,,,,,,,fee schedule,36.18,100.74,
Ortho shoe add leather insol,L3500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,80.75,,,,,,,fee schedule,36.18,100.74,
Ortho shoe add leather insol,L3500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,88.21,,,,,,,fee schedule,36.18,100.74,
Ortho shoe add leather insol,L3500,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,37.99,,,,,,,fee schedule,36.18,100.74,APC
Ortho shoe add leather insol,L3500,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,37.63,,,,,,,fee schedule,36.18,100.74,APC
Ortho shoe add leather insol,L3500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.18,,,,,,,fee schedule,36.18,100.74,APC
Ortho shoe add leather insol,L3500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,55.36,,,,,,,fee schedule,36.18,100.74,Radiology
Ortho shoe add leather insol,L3500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,50.65,,,,,,,fee schedule,36.18,100.74,APC
Ortho shoe add leather insol,L3500,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,63.32,,,,,,,fee schedule,36.18,100.74,APC
Orthopedic shoe add rub insl,L3510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,92.74,,,,,,,fee schedule,36.18,100.74,
Orthopedic shoe add rub insl,L3510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,100.74,,,,,,,fee schedule,36.18,100.74,
Orthopedic shoe add rub insl,L3510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,80.75,,,,,,,fee schedule,36.18,100.74,
Orthopedic shoe add rub insl,L3510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,88.21,,,,,,,fee schedule,36.18,100.74,
Orthopedic shoe add rub insl,L3510,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,37.99,,,,,,,fee schedule,36.18,100.74,APC
Orthopedic shoe add rub insl,L3510,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,37.63,,,,,,,fee schedule,36.18,100.74,APC
Orthopedic shoe add rub insl,L3510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.18,,,,,,,fee schedule,36.18,100.74,APC
Orthopedic shoe add rub insl,L3510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,55.36,,,,,,,fee schedule,36.18,100.74,Radiology
Orthopedic shoe add rub insl,L3510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,50.65,,,,,,,fee schedule,36.18,100.74,APC
Orthopedic shoe add rub insl,L3510,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,63.32,,,,,,,fee schedule,36.18,100.74,APC
O shoe add felt w leath insl,L3520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,100.71,,,,,,,fee schedule,39.27,109.39,
O shoe add felt w leath insl,L3520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,109.39,,,,,,,fee schedule,39.27,109.39,
O shoe add felt w leath insl,L3520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,87.69,,,,,,,fee schedule,39.27,109.39,
O shoe add felt w leath insl,L3520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,95.79,,,,,,,fee schedule,39.27,109.39,
O shoe add felt w leath insl,L3520,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,41.23,,,,,,,fee schedule,39.27,109.39,APC
O shoe add felt w leath insl,L3520,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,40.84,,,,,,,fee schedule,39.27,109.39,APC
O shoe add felt w leath insl,L3520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,39.27,,,,,,,fee schedule,39.27,109.39,APC
O shoe add felt w leath insl,L3520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,60.08,,,,,,,fee schedule,39.27,109.39,Radiology
O shoe add felt w leath insl,L3520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,54.98,,,,,,,fee schedule,39.27,109.39,APC
O shoe add felt w leath insl,L3520,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,68.72,,,,,,,fee schedule,39.27,109.39,APC
Ortho shoe add half sole,L3530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,100.71,,,,,,,fee schedule,39.27,109.39,
Ortho shoe add half sole,L3530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,109.39,,,,,,,fee schedule,39.27,109.39,
Ortho shoe add half sole,L3530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,87.69,,,,,,,fee schedule,39.27,109.39,
Ortho shoe add half sole,L3530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,95.79,,,,,,,fee schedule,39.27,109.39,
Ortho shoe add half sole,L3530,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,41.23,,,,,,,fee schedule,39.27,109.39,APC
Ortho shoe add half sole,L3530,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,40.84,,,,,,,fee schedule,39.27,109.39,APC
Ortho shoe add half sole,L3530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,39.27,,,,,,,fee schedule,39.27,109.39,APC
Ortho shoe add half sole,L3530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,60.08,,,,,,,fee schedule,39.27,109.39,Radiology
Ortho shoe add half sole,L3530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,54.98,,,,,,,fee schedule,39.27,109.39,APC
Ortho shoe add half sole,L3530,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,68.72,,,,,,,fee schedule,39.27,109.39,APC
Ortho shoe add full sole,L3540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,161.19,,,,,,,fee schedule,62.84,175.09,
Ortho shoe add full sole,L3540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,175.09,,,,,,,fee schedule,62.84,175.09,
Ortho shoe add full sole,L3540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,140.35,,,,,,,fee schedule,62.84,175.09,
Ortho shoe add full sole,L3540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,153.32,,,,,,,fee schedule,62.84,175.09,
Ortho shoe add full sole,L3540,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,65.98,,,,,,,fee schedule,62.84,175.09,APC
Ortho shoe add full sole,L3540,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,65.35,,,,,,,fee schedule,62.84,175.09,APC
Ortho shoe add full sole,L3540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,62.84,,,,,,,fee schedule,62.84,175.09,APC
Ortho shoe add full sole,L3540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,96.15,,,,,,,fee schedule,62.84,175.09,Radiology
Ortho shoe add full sole,L3540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,87.98,,,,,,,fee schedule,62.84,175.09,APC
Ortho shoe add full sole,L3540,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,109.97,,,,,,,fee schedule,62.84,175.09,APC
O shoe add standard toe tap,L3550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,28.26,,,,,,,fee schedule,11.02,30.69,
O shoe add standard toe tap,L3550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30.69,,,,,,,fee schedule,11.02,30.69,
O shoe add standard toe tap,L3550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24.6,,,,,,,fee schedule,11.02,30.69,
O shoe add standard toe tap,L3550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26.88,,,,,,,fee schedule,11.02,30.69,
O shoe add standard toe tap,L3550,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.57,,,,,,,fee schedule,11.02,30.69,APC
O shoe add standard toe tap,L3550,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11.46,,,,,,,fee schedule,11.02,30.69,APC
O shoe add standard toe tap,L3550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11.02,,,,,,,fee schedule,11.02,30.69,APC
O shoe add standard toe tap,L3550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.86,,,,,,,fee schedule,11.02,30.69,Radiology
O shoe add standard toe tap,L3550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15.43,,,,,,,fee schedule,11.02,30.69,APC
O shoe add standard toe tap,L3550,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19.28,,,,,,,fee schedule,11.02,30.69,APC
O shoe add horseshoe toe tap,L3560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,72.45,,,,,,,fee schedule,28.26,78.7,
O shoe add horseshoe toe tap,L3560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,78.7,,,,,,,fee schedule,28.26,78.7,
O shoe add horseshoe toe tap,L3560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,63.08,,,,,,,fee schedule,28.26,78.7,
O shoe add horseshoe toe tap,L3560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,68.91,,,,,,,fee schedule,28.26,78.7,
O shoe add horseshoe toe tap,L3560,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,29.67,,,,,,,fee schedule,28.26,78.7,APC
O shoe add horseshoe toe tap,L3560,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,29.39,,,,,,,fee schedule,28.26,78.7,APC
O shoe add horseshoe toe tap,L3560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,28.26,,,,,,,fee schedule,28.26,78.7,APC
O shoe add horseshoe toe tap,L3560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43.24,,,,,,,fee schedule,28.26,78.7,Radiology
O shoe add horseshoe toe tap,L3560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,39.56,,,,,,,fee schedule,28.26,78.7,APC
O shoe add horseshoe toe tap,L3560,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,49.46,,,,,,,fee schedule,28.26,78.7,APC
O shoe add instep extension,L3570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,269.94,,,,,,,fee schedule,105.25,293.21,
O shoe add instep extension,L3570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,293.21,,,,,,,fee schedule,105.25,293.21,
O shoe add instep extension,L3570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,235.04,,,,,,,fee schedule,105.25,293.21,
O shoe add instep extension,L3570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,256.76,,,,,,,fee schedule,105.25,293.21,
O shoe add instep extension,L3570,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,110.51,,,,,,,fee schedule,105.25,293.21,APC
O shoe add instep extension,L3570,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,109.46,,,,,,,fee schedule,105.25,293.21,APC
O shoe add instep extension,L3570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,105.25,,,,,,,fee schedule,105.25,293.21,APC
O shoe add instep extension,L3570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,161.03,,,,,,,fee schedule,105.25,293.21,Radiology
O shoe add instep extension,L3570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,147.35,,,,,,,fee schedule,105.25,293.21,APC
O shoe add instep extension,L3570,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,184.19,,,,,,,fee schedule,105.25,293.21,APC
O shoe add instep velcro clo,L3580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,205.46,,,,,,,fee schedule,80.14,223.17,
O shoe add instep velcro clo,L3580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,223.17,,,,,,,fee schedule,80.14,223.17,
O shoe add instep velcro clo,L3580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,178.89,,,,,,,fee schedule,80.14,223.17,
O shoe add instep velcro clo,L3580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,195.42,,,,,,,fee schedule,80.14,223.17,
O shoe add instep velcro clo,L3580,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,84.15,,,,,,,fee schedule,80.14,223.17,APC
O shoe add instep velcro clo,L3580,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,83.35,,,,,,,fee schedule,80.14,223.17,APC
O shoe add instep velcro clo,L3580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,80.14,,,,,,,fee schedule,80.14,223.17,APC
O shoe add instep velcro clo,L3580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,122.61,,,,,,,fee schedule,80.14,223.17,Radiology
O shoe add instep velcro clo,L3580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,112.2,,,,,,,fee schedule,80.14,223.17,APC
O shoe add instep velcro clo,L3580,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,140.24,,,,,,,fee schedule,80.14,223.17,APC
O shoe convert to sof counte,L3590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,169.23,,,,,,,fee schedule,66.01,183.82,
O shoe convert to sof counte,L3590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,183.82,,,,,,,fee schedule,66.01,183.82,
O shoe convert to sof counte,L3590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,147.35,,,,,,,fee schedule,66.01,183.82,
O shoe convert to sof counte,L3590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,160.97,,,,,,,fee schedule,66.01,183.82,
O shoe convert to sof counte,L3590,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,69.31,,,,,,,fee schedule,66.01,183.82,APC
O shoe convert to sof counte,L3590,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,68.65,,,,,,,fee schedule,66.01,183.82,APC
O shoe convert to sof counte,L3590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,66.01,,,,,,,fee schedule,66.01,183.82,APC
O shoe convert to sof counte,L3590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,101,,,,,,,fee schedule,66.01,183.82,Radiology
O shoe convert to sof counte,L3590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,92.41,,,,,,,fee schedule,66.01,183.82,APC
O shoe convert to sof counte,L3590,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,115.52,,,,,,,fee schedule,66.01,183.82,APC
Ortho shoe add march bar,L3595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,132.9,,,,,,,fee schedule,51.84,144.36,
Ortho shoe add march bar,L3595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,144.36,,,,,,,fee schedule,51.84,144.36,
Ortho shoe add march bar,L3595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,115.72,,,,,,,fee schedule,51.84,144.36,
Ortho shoe add march bar,L3595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,126.41,,,,,,,fee schedule,51.84,144.36,
Ortho shoe add march bar,L3595,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.43,,,,,,,fee schedule,51.84,144.36,APC
Ortho shoe add march bar,L3595,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,53.91,,,,,,,fee schedule,51.84,144.36,APC
Ortho shoe add march bar,L3595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,51.84,,,,,,,fee schedule,51.84,144.36,APC
Ortho shoe add march bar,L3595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,79.32,,,,,,,fee schedule,51.84,144.36,Radiology
Ortho shoe add march bar,L3595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,72.58,,,,,,,fee schedule,51.84,144.36,APC
Ortho shoe add march bar,L3595,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,90.72,,,,,,,fee schedule,51.84,144.36,APC
Trans shoe calip plate exist,L3600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,241.72,,,,,,,fee schedule,94.3,262.56,
Trans shoe calip plate exist,L3600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,262.56,,,,,,,fee schedule,94.3,262.56,
Trans shoe calip plate exist,L3600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,210.46,,,,,,,fee schedule,94.3,262.56,
Trans shoe calip plate exist,L3600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,229.91,,,,,,,fee schedule,94.3,262.56,
Trans shoe calip plate exist,L3600,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,99.02,,,,,,,fee schedule,94.3,262.56,APC
Trans shoe calip plate exist,L3600,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,98.07,,,,,,,fee schedule,94.3,262.56,APC
Trans shoe calip plate exist,L3600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,94.3,,,,,,,fee schedule,94.3,262.56,APC
Trans shoe calip plate exist,L3600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.28,,,,,,,fee schedule,94.3,262.56,Radiology
Trans shoe calip plate exist,L3600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,132.02,,,,,,,fee schedule,94.3,262.56,APC
Trans shoe calip plate exist,L3600,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,165.02,,,,,,,fee schedule,94.3,262.56,APC
Trans shoe caliper plate new,L3610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,318.32,,,,,,,fee schedule,124.12,345.76,
Trans shoe caliper plate new,L3610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,345.76,,,,,,,fee schedule,124.12,345.76,
Trans shoe caliper plate new,L3610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,277.15,,,,,,,fee schedule,124.12,345.76,
Trans shoe caliper plate new,L3610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,302.77,,,,,,,fee schedule,124.12,345.76,
Trans shoe caliper plate new,L3610,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.33,,,,,,,fee schedule,124.12,345.76,APC
Trans shoe caliper plate new,L3610,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,129.08,,,,,,,fee schedule,124.12,345.76,APC
Trans shoe caliper plate new,L3610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,124.12,,,,,,,fee schedule,124.12,345.76,APC
Trans shoe caliper plate new,L3610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,189.9,,,,,,,fee schedule,124.12,345.76,Radiology
Trans shoe caliper plate new,L3610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,173.77,,,,,,,fee schedule,124.12,345.76,APC
Trans shoe caliper plate new,L3610,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,217.21,,,,,,,fee schedule,124.12,345.76,APC
Trans shoe solid stirrup exi,L3620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,241.72,,,,,,,fee schedule,94.3,262.56,
Trans shoe solid stirrup exi,L3620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,262.56,,,,,,,fee schedule,94.3,262.56,
Trans shoe solid stirrup exi,L3620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,210.46,,,,,,,fee schedule,94.3,262.56,
Trans shoe solid stirrup exi,L3620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,229.91,,,,,,,fee schedule,94.3,262.56,
Trans shoe solid stirrup exi,L3620,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,99.02,,,,,,,fee schedule,94.3,262.56,APC
Trans shoe solid stirrup exi,L3620,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,98.07,,,,,,,fee schedule,94.3,262.56,APC
Trans shoe solid stirrup exi,L3620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,94.3,,,,,,,fee schedule,94.3,262.56,APC
Trans shoe solid stirrup exi,L3620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.28,,,,,,,fee schedule,94.3,262.56,Radiology
Trans shoe solid stirrup exi,L3620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,132.02,,,,,,,fee schedule,94.3,262.56,APC
Trans shoe solid stirrup exi,L3620,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,165.02,,,,,,,fee schedule,94.3,262.56,APC
Trans shoe solid stirrup new,L3630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,318.32,,,,,,,fee schedule,124.12,345.76,
Trans shoe solid stirrup new,L3630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,345.76,,,,,,,fee schedule,124.12,345.76,
Trans shoe solid stirrup new,L3630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,277.15,,,,,,,fee schedule,124.12,345.76,
Trans shoe solid stirrup new,L3630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,302.77,,,,,,,fee schedule,124.12,345.76,
Trans shoe solid stirrup new,L3630,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.33,,,,,,,fee schedule,124.12,345.76,APC
Trans shoe solid stirrup new,L3630,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,129.08,,,,,,,fee schedule,124.12,345.76,APC
Trans shoe solid stirrup new,L3630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,124.12,,,,,,,fee schedule,124.12,345.76,APC
Trans shoe solid stirrup new,L3630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,189.9,,,,,,,fee schedule,124.12,345.76,Radiology
Trans shoe solid stirrup new,L3630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,173.77,,,,,,,fee schedule,124.12,345.76,APC
Trans shoe solid stirrup new,L3630,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,217.21,,,,,,,fee schedule,124.12,345.76,APC
Shoe dennis browne splint bo,L3640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,136.94,,,,,,,fee schedule,53.41,148.74,
Shoe dennis browne splint bo,L3640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,148.74,,,,,,,fee schedule,53.41,148.74,
Shoe dennis browne splint bo,L3640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,119.23,,,,,,,fee schedule,53.41,148.74,
Shoe dennis browne splint bo,L3640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,130.25,,,,,,,fee schedule,53.41,148.74,
Shoe dennis browne splint bo,L3640,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,56.08,,,,,,,fee schedule,53.41,148.74,APC
Shoe dennis browne splint bo,L3640,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,55.55,,,,,,,fee schedule,53.41,148.74,APC
Shoe dennis browne splint bo,L3640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,53.41,,,,,,,fee schedule,53.41,148.74,APC
Shoe dennis browne splint bo,L3640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.72,,,,,,,fee schedule,53.41,148.74,Radiology
Shoe dennis browne splint bo,L3640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,74.77,,,,,,,fee schedule,53.41,148.74,APC
Shoe dennis browne splint bo,L3640,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,93.47,,,,,,,fee schedule,53.41,148.74,APC
So 8 abd restraint pre ots,L3650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,187.36,,,,,,,fee schedule,73.08,203.52,
So 8 abd restraint pre ots,L3650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,203.52,,,,,,,fee schedule,73.08,203.52,
So 8 abd restraint pre ots,L3650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,163.14,,,,,,,fee schedule,73.08,203.52,
So 8 abd restraint pre ots,L3650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,178.21,,,,,,,fee schedule,73.08,203.52,
So 8 abd restraint pre ots,L3650,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,76.73,,,,,,,fee schedule,73.08,203.52,APC
So 8 abd restraint pre ots,L3650,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,76,,,,,,,fee schedule,73.08,203.52,APC
So 8 abd restraint pre ots,L3650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,73.08,,,,,,,fee schedule,73.08,203.52,APC
So 8 abd restraint pre ots,L3650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,111.81,,,,,,,fee schedule,73.08,203.52,Radiology
So 8 abd restraint pre ots,L3650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,102.31,,,,,,,fee schedule,73.08,203.52,APC
So 8 abd restraint pre ots,L3650,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,127.89,,,,,,,fee schedule,73.08,203.52,APC
So 8 ab rstr can/web pre ots,L3660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,296.32,,,,,,,fee schedule,115.57,321.87,
So 8 ab rstr can/web pre ots,L3660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,321.87,,,,,,,fee schedule,115.57,321.87,
So 8 ab rstr can/web pre ots,L3660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,258,,,,,,,fee schedule,115.57,321.87,
So 8 ab rstr can/web pre ots,L3660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,281.85,,,,,,,fee schedule,115.57,321.87,
So 8 ab rstr can/web pre ots,L3660,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,121.35,,,,,,,fee schedule,115.57,321.87,APC
So 8 ab rstr can/web pre ots,L3660,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,120.19,,,,,,,fee schedule,115.57,321.87,APC
So 8 ab rstr can/web pre ots,L3660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,115.57,,,,,,,fee schedule,115.57,321.87,APC
So 8 ab rstr can/web pre ots,L3660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,176.82,,,,,,,fee schedule,115.57,321.87,Radiology
So 8 ab rstr can/web pre ots,L3660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,161.8,,,,,,,fee schedule,115.57,321.87,APC
So 8 ab rstr can/web pre ots,L3660,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,202.25,,,,,,,fee schedule,115.57,321.87,APC
So acro/clav can web pre ots,L3670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,57.55,,,,,,,fee schedule,50.11,231.04,
So acro/clav can web pre ots,L3670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,62.51,,,,,,,fee schedule,50.11,231.04,
So acro/clav can web pre ots,L3670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,50.11,,,,,,,fee schedule,50.11,231.04,
So acro/clav can web pre ots,L3670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,54.74,,,,,,,fee schedule,50.11,231.04,
So acro/clav can web pre ots,L3670,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.62,,,,,,,fee schedule,50.11,231.04,APC
So acro/clav can web pre ots,L3670,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,137.3,,,,,,,fee schedule,50.11,231.04,APC
So acro/clav can web pre ots,L3670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,132.02,,,,,,,fee schedule,50.11,231.04,APC
So acro/clav can web pre ots,L3670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.99,,,,,,,fee schedule,50.11,231.04,Radiology
So acro/clav can web pre ots,L3670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.83,,,,,,,fee schedule,50.11,231.04,APC
So acro/clav can web pre ots,L3670,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,231.04,,,,,,,fee schedule,50.11,231.04,APC
SO cap design w/o jnts CF,L3671,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2597.75,,,,,,,fee schedule,1013.18,2821.69,
SO cap design w/o jnts CF,L3671,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2821.69,,,,,,,fee schedule,1013.18,2821.69,
SO cap design w/o jnts CF,L3671,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2261.83,,,,,,,fee schedule,1013.18,2821.69,
SO cap design w/o jnts CF,L3671,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2470.85,,,,,,,fee schedule,1013.18,2821.69,
SO cap design w/o jnts CF,L3671,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1063.84,,,,,,,fee schedule,1013.18,2821.69,APC
SO cap design w/o jnts CF,L3671,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1053.71,,,,,,,fee schedule,1013.18,2821.69,APC
SO cap design w/o jnts CF,L3671,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1013.18,,,,,,,fee schedule,1013.18,2821.69,APC
SO cap design w/o jnts CF,L3671,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1550.17,,,,,,,fee schedule,1013.18,2821.69,Radiology
SO cap design w/o jnts CF,L3671,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1418.45,,,,,,,fee schedule,1013.18,2821.69,APC
SO cap design w/o jnts CF,L3671,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1773.06,,,,,,,fee schedule,1013.18,2821.69,APC
SO airplane w/wo joint CF,L3674,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3513.96,,,,,,,fee schedule,1329.12,3816.89,
SO airplane w/wo joint CF,L3674,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3816.89,,,,,,,fee schedule,1329.12,3816.89,
SO airplane w/wo joint CF,L3674,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3059.57,,,,,,,fee schedule,1329.12,3816.89,
SO airplane w/wo joint CF,L3674,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3342.31,,,,,,,fee schedule,1329.12,3816.89,
SO airplane w/wo joint CF,L3674,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1395.58,,,,,,,fee schedule,1329.12,3816.89,APC
SO airplane w/wo joint CF,L3674,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1382.28,,,,,,,fee schedule,1329.12,3816.89,APC
SO airplane w/wo joint CF,L3674,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1329.12,,,,,,,fee schedule,1329.12,3816.89,APC
SO airplane w/wo joint CF,L3674,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2033.55,,,,,,,fee schedule,1329.12,3816.89,Radiology
SO airplane w/wo joint CF,L3674,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1860.77,,,,,,,fee schedule,1329.12,3816.89,APC
SO airplane w/wo joint CF,L3674,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2325.96,,,,,,,fee schedule,1329.12,3816.89,APC
So vest canvas/web pre ots,L3675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,505.96,,,,,,,fee schedule,197.33,549.57,
So vest canvas/web pre ots,L3675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,549.57,,,,,,,fee schedule,197.33,549.57,
So vest canvas/web pre ots,L3675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,440.53,,,,,,,fee schedule,197.33,549.57,
So vest canvas/web pre ots,L3675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,481.24,,,,,,,fee schedule,197.33,549.57,
So vest canvas/web pre ots,L3675,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,207.2,,,,,,,fee schedule,197.33,549.57,APC
So vest canvas/web pre ots,L3675,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,205.22,,,,,,,fee schedule,197.33,549.57,APC
So vest canvas/web pre ots,L3675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,197.33,,,,,,,fee schedule,197.33,549.57,APC
So vest canvas/web pre ots,L3675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,301.91,,,,,,,fee schedule,197.33,549.57,Radiology
So vest canvas/web pre ots,L3675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,276.26,,,,,,,fee schedule,197.33,549.57,APC
So vest canvas/web pre ots,L3675,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,345.33,,,,,,,fee schedule,197.33,549.57,APC
EO w/o joints CF,L3702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,832.49,,,,,,,fee schedule,324.71,904.25,
EO w/o joints CF,L3702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,904.25,,,,,,,fee schedule,324.71,904.25,
EO w/o joints CF,L3702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,724.84,,,,,,,fee schedule,324.71,904.25,
EO w/o joints CF,L3702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,791.82,,,,,,,fee schedule,324.71,904.25,
EO w/o joints CF,L3702,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,340.95,,,,,,,fee schedule,324.71,904.25,APC
EO w/o joints CF,L3702,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,337.7,,,,,,,fee schedule,324.71,904.25,APC
EO w/o joints CF,L3702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,324.71,,,,,,,fee schedule,324.71,904.25,APC
EO w/o joints CF,L3702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,496.81,,,,,,,fee schedule,324.71,904.25,Radiology
EO w/o joints CF,L3702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,454.59,,,,,,,fee schedule,324.71,904.25,APC
EO w/o joints CF,L3702,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,568.24,,,,,,,fee schedule,324.71,904.25,APC
Eo elas w/metal jnts pre ots,L3710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,428.28,,,,,,,fee schedule,167.05,465.2,
Eo elas w/metal jnts pre ots,L3710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,465.2,,,,,,,fee schedule,167.05,465.2,
Eo elas w/metal jnts pre ots,L3710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,372.9,,,,,,,fee schedule,167.05,465.2,
Eo elas w/metal jnts pre ots,L3710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,407.36,,,,,,,fee schedule,167.05,465.2,
Eo elas w/metal jnts pre ots,L3710,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,175.4,,,,,,,fee schedule,167.05,465.2,APC
Eo elas w/metal jnts pre ots,L3710,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,173.73,,,,,,,fee schedule,167.05,465.2,APC
Eo elas w/metal jnts pre ots,L3710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,167.05,,,,,,,fee schedule,167.05,465.2,APC
Eo elas w/metal jnts pre ots,L3710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,255.59,,,,,,,fee schedule,167.05,465.2,Radiology
Eo elas w/metal jnts pre ots,L3710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,233.87,,,,,,,fee schedule,167.05,465.2,APC
Eo elas w/metal jnts pre ots,L3710,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,292.34,,,,,,,fee schedule,167.05,465.2,APC
Forearm/arm cuffs free motio,L3720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2187.49,,,,,,,fee schedule,853.15,2376.07,
Forearm/arm cuffs free motio,L3720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2376.07,,,,,,,fee schedule,853.15,2376.07,
Forearm/arm cuffs free motio,L3720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1904.63,,,,,,,fee schedule,853.15,2376.07,
Forearm/arm cuffs free motio,L3720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2080.63,,,,,,,fee schedule,853.15,2376.07,
Forearm/arm cuffs free motio,L3720,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,895.81,,,,,,,fee schedule,853.15,2376.07,APC
Forearm/arm cuffs free motio,L3720,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,887.28,,,,,,,fee schedule,853.15,2376.07,APC
Forearm/arm cuffs free motio,L3720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,853.15,,,,,,,fee schedule,853.15,2376.07,APC
Forearm/arm cuffs free motio,L3720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1305.32,,,,,,,fee schedule,853.15,2376.07,Radiology
Forearm/arm cuffs free motio,L3720,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1194.41,,,,,,,fee schedule,853.15,2376.07,APC
Forearm/arm cuffs free motio,L3720,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1493.01,,,,,,,fee schedule,853.15,2376.07,APC
Forearm/arm cuffs ext/flex a,L3730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3199.58,,,,,,,fee schedule,1247.88,3475.41,
Forearm/arm cuffs ext/flex a,L3730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3475.41,,,,,,,fee schedule,1247.88,3475.41,
Forearm/arm cuffs ext/flex a,L3730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2785.84,,,,,,,fee schedule,1247.88,3475.41,
Forearm/arm cuffs ext/flex a,L3730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3043.28,,,,,,,fee schedule,1247.88,3475.41,
Forearm/arm cuffs ext/flex a,L3730,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1310.27,,,,,,,fee schedule,1247.88,3475.41,APC
Forearm/arm cuffs ext/flex a,L3730,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1297.8,,,,,,,fee schedule,1247.88,3475.41,APC
Forearm/arm cuffs ext/flex a,L3730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1247.88,,,,,,,fee schedule,1247.88,3475.41,APC
Forearm/arm cuffs ext/flex a,L3730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1909.26,,,,,,,fee schedule,1247.88,3475.41,Radiology
Forearm/arm cuffs ext/flex a,L3730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1747.03,,,,,,,fee schedule,1247.88,3475.41,APC
Forearm/arm cuffs ext/flex a,L3730,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2183.79,,,,,,,fee schedule,1247.88,3475.41,APC
Cuffs adj lock w/ active con,L3740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4108.42,,,,,,,fee schedule,1602.37,4462.59,
Cuffs adj lock w/ active con,L3740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4462.59,,,,,,,fee schedule,1602.37,4462.59,
Cuffs adj lock w/ active con,L3740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3577.16,,,,,,,fee schedule,1602.37,4462.59,
Cuffs adj lock w/ active con,L3740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3907.72,,,,,,,fee schedule,1602.37,4462.59,
Cuffs adj lock w/ active con,L3740,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1682.49,,,,,,,fee schedule,1602.37,4462.59,APC
Cuffs adj lock w/ active con,L3740,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1666.46,,,,,,,fee schedule,1602.37,4462.59,APC
Cuffs adj lock w/ active con,L3740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1602.37,,,,,,,fee schedule,1602.37,4462.59,APC
Cuffs adj lock w/ active con,L3740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2451.63,,,,,,,fee schedule,1602.37,4462.59,Radiology
Cuffs adj lock w/ active con,L3740,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2243.32,,,,,,,fee schedule,1602.37,4462.59,APC
Cuffs adj lock w/ active con,L3740,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2804.15,,,,,,,fee schedule,1602.37,4462.59,APC
"EO withjoint, Prefabricated",L3760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1441.76,,,,,,,fee schedule,562.31,1566.05,
"EO withjoint, Prefabricated",L3760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1566.05,,,,,,,fee schedule,562.31,1566.05,
"EO withjoint, Prefabricated",L3760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1255.33,,,,,,,fee schedule,562.31,1566.05,
"EO withjoint, Prefabricated",L3760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1371.33,,,,,,,fee schedule,562.31,1566.05,
"EO withjoint, Prefabricated",L3760,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,590.43,,,,,,,fee schedule,562.31,1566.05,APC
"EO withjoint, Prefabricated",L3760,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,584.8,,,,,,,fee schedule,562.31,1566.05,APC
"EO withjoint, Prefabricated",L3760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,562.31,,,,,,,fee schedule,562.31,1566.05,APC
"EO withjoint, Prefabricated",L3760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,860.33,,,,,,,fee schedule,562.31,1566.05,Radiology
"EO withjoint, Prefabricated",L3760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,787.23,,,,,,,fee schedule,562.31,1566.05,APC
"EO withjoint, Prefabricated",L3760,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,984.04,,,,,,,fee schedule,562.31,1566.05,APC
Eo rigid w/o joints pre ots,L3762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,310.03,,,,,,,fee schedule,120.93,336.76,
Eo rigid w/o joints pre ots,L3762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,336.76,,,,,,,fee schedule,120.93,336.76,
Eo rigid w/o joints pre ots,L3762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,269.94,,,,,,,fee schedule,120.93,336.76,
Eo rigid w/o joints pre ots,L3762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,294.89,,,,,,,fee schedule,120.93,336.76,
Eo rigid w/o joints pre ots,L3762,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,126.98,,,,,,,fee schedule,120.93,336.76,APC
Eo rigid w/o joints pre ots,L3762,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,125.77,,,,,,,fee schedule,120.93,336.76,APC
Eo rigid w/o joints pre ots,L3762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,120.93,,,,,,,fee schedule,120.93,336.76,APC
Eo rigid w/o joints pre ots,L3762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,185.02,,,,,,,fee schedule,120.93,336.76,Radiology
Eo rigid w/o joints pre ots,L3762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,169.3,,,,,,,fee schedule,120.93,336.76,APC
Eo rigid w/o joints pre ots,L3762,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,211.63,,,,,,,fee schedule,120.93,336.76,APC
EWHO rigid w/o jnts CF,L3763,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2018.4,,,,,,,fee schedule,787.21,2192.4,
EWHO rigid w/o jnts CF,L3763,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2192.4,,,,,,,fee schedule,787.21,2192.4,
EWHO rigid w/o jnts CF,L3763,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1757.4,,,,,,,fee schedule,787.21,2192.4,
EWHO rigid w/o jnts CF,L3763,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1919.8,,,,,,,fee schedule,787.21,2192.4,
EWHO rigid w/o jnts CF,L3763,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,826.57,,,,,,,fee schedule,787.21,2192.4,APC
EWHO rigid w/o jnts CF,L3763,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,818.7,,,,,,,fee schedule,787.21,2192.4,APC
EWHO rigid w/o jnts CF,L3763,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,787.21,,,,,,,fee schedule,787.21,2192.4,APC
EWHO rigid w/o jnts CF,L3763,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1204.43,,,,,,,fee schedule,787.21,2192.4,Radiology
EWHO rigid w/o jnts CF,L3763,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1102.09,,,,,,,fee schedule,787.21,2192.4,APC
EWHO rigid w/o jnts CF,L3763,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1377.62,,,,,,,fee schedule,787.21,2192.4,APC
EWHO w/joint(s) CF,L3764,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2193.1,,,,,,,fee schedule,855.35,2382.16,
EWHO w/joint(s) CF,L3764,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2382.16,,,,,,,fee schedule,855.35,2382.16,
EWHO w/joint(s) CF,L3764,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1909.51,,,,,,,fee schedule,855.35,2382.16,
EWHO w/joint(s) CF,L3764,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2085.96,,,,,,,fee schedule,855.35,2382.16,
EWHO w/joint(s) CF,L3764,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,898.12,,,,,,,fee schedule,855.35,2382.16,APC
EWHO w/joint(s) CF,L3764,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,889.56,,,,,,,fee schedule,855.35,2382.16,APC
EWHO w/joint(s) CF,L3764,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,855.35,,,,,,,fee schedule,855.35,2382.16,APC
EWHO w/joint(s) CF,L3764,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1308.69,,,,,,,fee schedule,855.35,2382.16,Radiology
EWHO w/joint(s) CF,L3764,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1197.49,,,,,,,fee schedule,855.35,2382.16,APC
EWHO w/joint(s) CF,L3764,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1496.86,,,,,,,fee schedule,855.35,2382.16,APC
EWHFO rigid w/o jnts CF,L3765,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3696.66,,,,,,,fee schedule,1441.77,4015.34,
EWHFO rigid w/o jnts CF,L3765,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4015.34,,,,,,,fee schedule,1441.77,4015.34,
EWHFO rigid w/o jnts CF,L3765,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3218.65,,,,,,,fee schedule,1441.77,4015.34,
EWHFO rigid w/o jnts CF,L3765,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3516.08,,,,,,,fee schedule,1441.77,4015.34,
EWHFO rigid w/o jnts CF,L3765,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1513.86,,,,,,,fee schedule,1441.77,4015.34,APC
EWHFO rigid w/o jnts CF,L3765,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1499.44,,,,,,,fee schedule,1441.77,4015.34,APC
EWHFO rigid w/o jnts CF,L3765,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1441.77,,,,,,,fee schedule,1441.77,4015.34,APC
EWHFO rigid w/o jnts CF,L3765,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2205.91,,,,,,,fee schedule,1441.77,4015.34,Radiology
EWHFO rigid w/o jnts CF,L3765,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2018.48,,,,,,,fee schedule,1441.77,4015.34,APC
EWHFO rigid w/o jnts CF,L3765,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2523.1,,,,,,,fee schedule,1441.77,4015.34,APC
EWHFO w/joint(s) CF,L3766,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3914.48,,,,,,,fee schedule,1526.74,4251.93,
EWHFO w/joint(s) CF,L3766,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4251.93,,,,,,,fee schedule,1526.74,4251.93,
EWHFO w/joint(s) CF,L3766,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3408.3,,,,,,,fee schedule,1526.74,4251.93,
EWHFO w/joint(s) CF,L3766,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3723.25,,,,,,,fee schedule,1526.74,4251.93,
EWHFO w/joint(s) CF,L3766,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1603.08,,,,,,,fee schedule,1526.74,4251.93,APC
EWHFO w/joint(s) CF,L3766,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1587.81,,,,,,,fee schedule,1526.74,4251.93,APC
EWHFO w/joint(s) CF,L3766,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1526.74,,,,,,,fee schedule,1526.74,4251.93,APC
EWHFO w/joint(s) CF,L3766,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2335.91,,,,,,,fee schedule,1526.74,4251.93,Radiology
EWHFO w/joint(s) CF,L3766,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2137.44,,,,,,,fee schedule,1526.74,4251.93,APC
EWHFO w/joint(s) CF,L3766,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2671.8,,,,,,,fee schedule,1526.74,4251.93,APC
WHFO w/joint(s) custom fab,L3806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1309.59,,,,,,,fee schedule,510.77,1422.49,
WHFO w/joint(s) custom fab,L3806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1422.49,,,,,,,fee schedule,510.77,1422.49,
WHFO w/joint(s) custom fab,L3806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1140.25,,,,,,,fee schedule,510.77,1422.49,
WHFO w/joint(s) custom fab,L3806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1245.62,,,,,,,fee schedule,510.77,1422.49,
WHFO w/joint(s) custom fab,L3806,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,536.31,,,,,,,fee schedule,510.77,1422.49,APC
WHFO w/joint(s) custom fab,L3806,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,531.2,,,,,,,fee schedule,510.77,1422.49,APC
WHFO w/joint(s) custom fab,L3806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,510.77,,,,,,,fee schedule,510.77,1422.49,APC
WHFO w/joint(s) custom fab,L3806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,781.48,,,,,,,fee schedule,510.77,1422.49,Radiology
WHFO w/joint(s) custom fab,L3806,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,715.08,,,,,,,fee schedule,510.77,1422.49,APC
WHFO w/joint(s) custom fab,L3806,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,893.85,,,,,,,fee schedule,510.77,1422.49,APC
Whfo w/o joints pre cst,L3807,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,720.88,,,,,,,fee schedule,281.17,783.03,
Whfo w/o joints pre cst,L3807,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,783.03,,,,,,,fee schedule,281.17,783.03,
Whfo w/o joints pre cst,L3807,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,627.66,,,,,,,fee schedule,281.17,783.03,
Whfo w/o joints pre cst,L3807,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,685.67,,,,,,,fee schedule,281.17,783.03,
Whfo w/o joints pre cst,L3807,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,295.23,,,,,,,fee schedule,281.17,783.03,APC
Whfo w/o joints pre cst,L3807,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,292.42,,,,,,,fee schedule,281.17,783.03,APC
Whfo w/o joints pre cst,L3807,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,281.17,,,,,,,fee schedule,281.17,783.03,APC
Whfo w/o joints pre cst,L3807,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,430.19,,,,,,,fee schedule,281.17,783.03,Radiology
Whfo w/o joints pre cst,L3807,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,393.64,,,,,,,fee schedule,281.17,783.03,APC
Whfo w/o joints pre cst,L3807,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,492.05,,,,,,,fee schedule,281.17,783.03,APC
"WHFO, rigid w/o joints",L3808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,963.44,,,,,,,fee schedule,375.75,1046.49,
"WHFO, rigid w/o joints",L3808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1046.49,,,,,,,fee schedule,375.75,1046.49,
"WHFO, rigid w/o joints",L3808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,838.86,,,,,,,fee schedule,375.75,1046.49,
"WHFO, rigid w/o joints",L3808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,916.37,,,,,,,fee schedule,375.75,1046.49,
"WHFO, rigid w/o joints",L3808,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,394.54,,,,,,,fee schedule,375.75,1046.49,APC
"WHFO, rigid w/o joints",L3808,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,390.78,,,,,,,fee schedule,375.75,1046.49,APC
"WHFO, rigid w/o joints",L3808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,375.75,,,,,,,fee schedule,375.75,1046.49,APC
"WHFO, rigid w/o joints",L3808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,574.9,,,,,,,fee schedule,375.75,1046.49,Radiology
"WHFO, rigid w/o joints",L3808,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,526.05,,,,,,,fee schedule,375.75,1046.49,APC
"WHFO, rigid w/o joints",L3808,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,657.56,,,,,,,fee schedule,375.75,1046.49,APC
Whfo w/o joints pre ots,L3809,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,762.09,,,,,,,fee schedule,281.17,827.78,
Whfo w/o joints pre ots,L3809,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,827.78,,,,,,,fee schedule,281.17,827.78,
Whfo w/o joints pre ots,L3809,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,663.54,,,,,,,fee schedule,281.17,827.78,
Whfo w/o joints pre ots,L3809,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,724.86,,,,,,,fee schedule,281.17,827.78,
Whfo w/o joints pre ots,L3809,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,295.23,,,,,,,fee schedule,281.17,827.78,APC
Whfo w/o joints pre ots,L3809,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,292.42,,,,,,,fee schedule,281.17,827.78,APC
Whfo w/o joints pre ots,L3809,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,281.17,,,,,,,fee schedule,281.17,827.78,APC
Whfo w/o joints pre ots,L3809,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,430.19,,,,,,,fee schedule,281.17,827.78,Radiology
Whfo w/o joints pre ots,L3809,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,393.64,,,,,,,fee schedule,281.17,827.78,APC
Whfo w/o joints pre ots,L3809,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,492.05,,,,,,,fee schedule,281.17,827.78,APC
Hinge extension/flex wrist/f,L3900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3768.6,,,,,,,fee schedule,1469.84,4093.48,
Hinge extension/flex wrist/f,L3900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4093.48,,,,,,,fee schedule,1469.84,4093.48,
Hinge extension/flex wrist/f,L3900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3281.28,,,,,,,fee schedule,1469.84,4093.48,
Hinge extension/flex wrist/f,L3900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3584.5,,,,,,,fee schedule,1469.84,4093.48,
Hinge extension/flex wrist/f,L3900,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1543.33,,,,,,,fee schedule,1469.84,4093.48,APC
Hinge extension/flex wrist/f,L3900,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1528.63,,,,,,,fee schedule,1469.84,4093.48,APC
Hinge extension/flex wrist/f,L3900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1469.84,,,,,,,fee schedule,1469.84,4093.48,APC
Hinge extension/flex wrist/f,L3900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2248.86,,,,,,,fee schedule,1469.84,4093.48,Radiology
Hinge extension/flex wrist/f,L3900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2057.78,,,,,,,fee schedule,1469.84,4093.48,APC
Hinge extension/flex wrist/f,L3900,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2572.22,,,,,,,fee schedule,1469.84,4093.48,APC
Hinge ext/flex wrist finger,L3901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4633.2,,,,,,,fee schedule,1807.05,5032.62,
Hinge ext/flex wrist finger,L3901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5032.62,,,,,,,fee schedule,1807.05,5032.62,
Hinge ext/flex wrist finger,L3901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4034.08,,,,,,,fee schedule,1807.05,5032.62,
Hinge ext/flex wrist finger,L3901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4406.87,,,,,,,fee schedule,1807.05,5032.62,
Hinge ext/flex wrist finger,L3901,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1897.4,,,,,,,fee schedule,1807.05,5032.62,APC
Hinge ext/flex wrist finger,L3901,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1879.33,,,,,,,fee schedule,1807.05,5032.62,APC
Hinge ext/flex wrist finger,L3901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1807.05,,,,,,,fee schedule,1807.05,5032.62,APC
Hinge ext/flex wrist finger,L3901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2764.79,,,,,,,fee schedule,1807.05,5032.62,Radiology
Hinge ext/flex wrist finger,L3901,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2529.87,,,,,,,fee schedule,1807.05,5032.62,APC
Hinge ext/flex wrist finger,L3901,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3162.34,,,,,,,fee schedule,1807.05,5032.62,APC
Whfo electric custom fitted,L3904,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8443.04,,,,,,,fee schedule,3292.96,9170.88,
Whfo electric custom fitted,L3904,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9170.88,,,,,,,fee schedule,3292.96,9170.88,
Whfo electric custom fitted,L3904,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7351.26,,,,,,,fee schedule,3292.96,9170.88,
Whfo electric custom fitted,L3904,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8030.59,,,,,,,fee schedule,3292.96,9170.88,
Whfo electric custom fitted,L3904,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3457.61,,,,,,,fee schedule,3292.96,9170.88,APC
Whfo electric custom fitted,L3904,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3424.68,,,,,,,fee schedule,3292.96,9170.88,APC
Whfo electric custom fitted,L3904,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3292.96,,,,,,,fee schedule,3292.96,9170.88,APC
Whfo electric custom fitted,L3904,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5038.23,,,,,,,fee schedule,3292.96,9170.88,Radiology
Whfo electric custom fitted,L3904,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4610.14,,,,,,,fee schedule,3292.96,9170.88,APC
Whfo electric custom fitted,L3904,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5762.68,,,,,,,fee schedule,3292.96,9170.88,APC
Who w/nontorsion jnt(s) cf,L3905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2858.99,,,,,,,fee schedule,1115.05,3105.46,
Who w/nontorsion jnt(s) cf,L3905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3105.46,,,,,,,fee schedule,1115.05,3105.46,
Who w/nontorsion jnt(s) cf,L3905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2489.3,,,,,,,fee schedule,1115.05,3105.46,
Who w/nontorsion jnt(s) cf,L3905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2719.33,,,,,,,fee schedule,1115.05,3105.46,
Who w/nontorsion jnt(s) cf,L3905,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1170.8,,,,,,,fee schedule,1115.05,3105.46,APC
Who w/nontorsion jnt(s) cf,L3905,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1159.65,,,,,,,fee schedule,1115.05,3105.46,APC
Who w/nontorsion jnt(s) cf,L3905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1115.05,,,,,,,fee schedule,1115.05,3105.46,APC
Who w/nontorsion jnt(s) cf,L3905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1706.03,,,,,,,fee schedule,1115.05,3105.46,Radiology
Who w/nontorsion jnt(s) cf,L3905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1561.07,,,,,,,fee schedule,1115.05,3105.46,APC
Who w/nontorsion jnt(s) cf,L3905,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1951.34,,,,,,,fee schedule,1115.05,3105.46,APC
Who w/o joints cf,L3906,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1139.21,,,,,,,fee schedule,444.32,1237.42,
Who w/o joints cf,L3906,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1237.42,,,,,,,fee schedule,444.32,1237.42,
Who w/o joints cf,L3906,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,991.9,,,,,,,fee schedule,444.32,1237.42,
Who w/o joints cf,L3906,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1083.56,,,,,,,fee schedule,444.32,1237.42,
Who w/o joints cf,L3906,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,466.54,,,,,,,fee schedule,444.32,1237.42,APC
Who w/o joints cf,L3906,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,462.09,,,,,,,fee schedule,444.32,1237.42,APC
Who w/o joints cf,L3906,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,444.32,,,,,,,fee schedule,444.32,1237.42,APC
Who w/o joints cf,L3906,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,679.81,,,,,,,fee schedule,444.32,1237.42,Radiology
Who w/o joints cf,L3906,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,622.05,,,,,,,fee schedule,444.32,1237.42,APC
Who w/o joints cf,L3906,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,777.56,,,,,,,fee schedule,444.32,1237.42,APC
Who cock-up nonmolde pre ots,L3908,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,172.75,,,,,,,fee schedule,67.37,187.64,
Who cock-up nonmolde pre ots,L3908,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,187.64,,,,,,,fee schedule,67.37,187.64,
Who cock-up nonmolde pre ots,L3908,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,150.41,,,,,,,fee schedule,67.37,187.64,
Who cock-up nonmolde pre ots,L3908,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,164.31,,,,,,,fee schedule,67.37,187.64,
Who cock-up nonmolde pre ots,L3908,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,70.74,,,,,,,fee schedule,67.37,187.64,APC
Who cock-up nonmolde pre ots,L3908,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,70.06,,,,,,,fee schedule,67.37,187.64,APC
Who cock-up nonmolde pre ots,L3908,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,67.37,,,,,,,fee schedule,67.37,187.64,APC
Who cock-up nonmolde pre ots,L3908,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,103.08,,,,,,,fee schedule,67.37,187.64,Radiology
Who cock-up nonmolde pre ots,L3908,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,94.32,,,,,,,fee schedule,67.37,187.64,APC
Who cock-up nonmolde pre ots,L3908,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,117.9,,,,,,,fee schedule,67.37,187.64,APC
Hfo flexion glove pre ots,L3912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,359.41,,,,,,,fee schedule,140.19,390.4,
Hfo flexion glove pre ots,L3912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,390.4,,,,,,,fee schedule,140.19,390.4,
Hfo flexion glove pre ots,L3912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,312.94,,,,,,,fee schedule,140.19,390.4,
Hfo flexion glove pre ots,L3912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,341.86,,,,,,,fee schedule,140.19,390.4,
Hfo flexion glove pre ots,L3912,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,147.2,,,,,,,fee schedule,140.19,390.4,APC
Hfo flexion glove pre ots,L3912,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,145.8,,,,,,,fee schedule,140.19,390.4,APC
Hfo flexion glove pre ots,L3912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,140.19,,,,,,,fee schedule,140.19,390.4,APC
Hfo flexion glove pre ots,L3912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,214.49,,,,,,,fee schedule,140.19,390.4,Radiology
Hfo flexion glove pre ots,L3912,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,196.27,,,,,,,fee schedule,140.19,390.4,APC
Hfo flexion glove pre ots,L3912,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,245.33,,,,,,,fee schedule,140.19,390.4,APC
HFO w/o joints CF,L3913,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,780.81,,,,,,,fee schedule,304.55,848.12,
HFO w/o joints CF,L3913,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,848.12,,,,,,,fee schedule,304.55,848.12,
HFO w/o joints CF,L3913,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,679.84,,,,,,,fee schedule,304.55,848.12,
HFO w/o joints CF,L3913,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,742.66,,,,,,,fee schedule,304.55,848.12,
HFO w/o joints CF,L3913,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,319.78,,,,,,,fee schedule,304.55,848.12,APC
HFO w/o joints CF,L3913,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,316.73,,,,,,,fee schedule,304.55,848.12,APC
HFO w/o joints CF,L3913,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,304.55,,,,,,,fee schedule,304.55,848.12,APC
HFO w/o joints CF,L3913,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,465.96,,,,,,,fee schedule,304.55,848.12,Radiology
HFO w/o joints CF,L3913,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,426.37,,,,,,,fee schedule,304.55,848.12,APC
HFO w/o joints CF,L3913,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,532.96,,,,,,,fee schedule,304.55,848.12,APC
Who nontorsion jnts pre cst,L3915,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1532.52,,,,,,,fee schedule,597.72,1664.64,
Who nontorsion jnts pre cst,L3915,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1664.64,,,,,,,fee schedule,597.72,1664.64,
Who nontorsion jnts pre cst,L3915,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1334.35,,,,,,,fee schedule,597.72,1664.64,
Who nontorsion jnts pre cst,L3915,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1457.66,,,,,,,fee schedule,597.72,1664.64,
Who nontorsion jnts pre cst,L3915,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,627.61,,,,,,,fee schedule,597.72,1664.64,APC
Who nontorsion jnts pre cst,L3915,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,621.63,,,,,,,fee schedule,597.72,1664.64,APC
Who nontorsion jnts pre cst,L3915,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,597.72,,,,,,,fee schedule,597.72,1664.64,APC
Who nontorsion jnts pre cst,L3915,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,914.51,,,,,,,fee schedule,597.72,1664.64,Radiology
Who nontorsion jnts pre cst,L3915,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,836.81,,,,,,,fee schedule,597.72,1664.64,APC
Who nontorsion jnts pre cst,L3915,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1046.01,,,,,,,fee schedule,597.72,1664.64,APC
Who nontorsion jnts pre ots,L3916,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1620.01,,,,,,,fee schedule,597.72,1759.67,
Who nontorsion jnts pre ots,L3916,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1759.67,,,,,,,fee schedule,597.72,1759.67,
Who nontorsion jnts pre ots,L3916,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1410.53,,,,,,,fee schedule,597.72,1759.67,
Who nontorsion jnts pre ots,L3916,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1540.87,,,,,,,fee schedule,597.72,1759.67,
Who nontorsion jnts pre ots,L3916,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,627.61,,,,,,,fee schedule,597.72,1759.67,APC
Who nontorsion jnts pre ots,L3916,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,621.63,,,,,,,fee schedule,597.72,1759.67,APC
Who nontorsion jnts pre ots,L3916,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,597.72,,,,,,,fee schedule,597.72,1759.67,APC
Who nontorsion jnts pre ots,L3916,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,914.51,,,,,,,fee schedule,597.72,1759.67,Radiology
Who nontorsion jnts pre ots,L3916,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,836.81,,,,,,,fee schedule,597.72,1759.67,APC
Who nontorsion jnts pre ots,L3916,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1046.01,,,,,,,fee schedule,597.72,1759.67,APC
Metacarp fx orthosis pre cst,L3917,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,304.47,,,,,,,fee schedule,118.75,330.71,
Metacarp fx orthosis pre cst,L3917,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,330.71,,,,,,,fee schedule,118.75,330.71,
Metacarp fx orthosis pre cst,L3917,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,265.09,,,,,,,fee schedule,118.75,330.71,
Metacarp fx orthosis pre cst,L3917,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,289.59,,,,,,,fee schedule,118.75,330.71,
Metacarp fx orthosis pre cst,L3917,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,124.69,,,,,,,fee schedule,118.75,330.71,APC
Metacarp fx orthosis pre cst,L3917,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,123.5,,,,,,,fee schedule,118.75,330.71,APC
Metacarp fx orthosis pre cst,L3917,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,118.75,,,,,,,fee schedule,118.75,330.71,APC
Metacarp fx orthosis pre cst,L3917,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,181.69,,,,,,,fee schedule,118.75,330.71,Radiology
Metacarp fx orthosis pre cst,L3917,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,166.25,,,,,,,fee schedule,118.75,330.71,APC
Metacarp fx orthosis pre cst,L3917,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,207.81,,,,,,,fee schedule,118.75,330.71,APC
Metacarp fx orthosis pre ots,L3918,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,321.87,,,,,,,fee schedule,118.75,349.61,
Metacarp fx orthosis pre ots,L3918,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,349.61,,,,,,,fee schedule,118.75,349.61,
Metacarp fx orthosis pre ots,L3918,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,280.24,,,,,,,fee schedule,118.75,349.61,
Metacarp fx orthosis pre ots,L3918,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,306.14,,,,,,,fee schedule,118.75,349.61,
Metacarp fx orthosis pre ots,L3918,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,124.69,,,,,,,fee schedule,118.75,349.61,APC
Metacarp fx orthosis pre ots,L3918,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,123.5,,,,,,,fee schedule,118.75,349.61,APC
Metacarp fx orthosis pre ots,L3918,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,118.75,,,,,,,fee schedule,118.75,349.61,APC
Metacarp fx orthosis pre ots,L3918,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,181.69,,,,,,,fee schedule,118.75,349.61,Radiology
Metacarp fx orthosis pre ots,L3918,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,166.25,,,,,,,fee schedule,118.75,349.61,APC
Metacarp fx orthosis pre ots,L3918,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,207.81,,,,,,,fee schedule,118.75,349.61,APC
HO w/o joints CF,L3919,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,780.81,,,,,,,fee schedule,304.55,848.12,
HO w/o joints CF,L3919,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,848.12,,,,,,,fee schedule,304.55,848.12,
HO w/o joints CF,L3919,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,679.84,,,,,,,fee schedule,304.55,848.12,
HO w/o joints CF,L3919,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,742.66,,,,,,,fee schedule,304.55,848.12,
HO w/o joints CF,L3919,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,319.78,,,,,,,fee schedule,304.55,848.12,APC
HO w/o joints CF,L3919,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,316.73,,,,,,,fee schedule,304.55,848.12,APC
HO w/o joints CF,L3919,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,304.55,,,,,,,fee schedule,304.55,848.12,APC
HO w/o joints CF,L3919,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,465.96,,,,,,,fee schedule,304.55,848.12,Radiology
HO w/o joints CF,L3919,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,426.37,,,,,,,fee schedule,304.55,848.12,APC
HO w/o joints CF,L3919,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,532.96,,,,,,,fee schedule,304.55,848.12,APC
HFO w/joint(s) CF,L3921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,925.99,,,,,,,fee schedule,361.14,1005.82,
HFO w/joint(s) CF,L3921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1005.82,,,,,,,fee schedule,361.14,1005.82,
HFO w/joint(s) CF,L3921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,806.25,,,,,,,fee schedule,361.14,1005.82,
HFO w/joint(s) CF,L3921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,880.76,,,,,,,fee schedule,361.14,1005.82,
HFO w/joint(s) CF,L3921,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,379.2,,,,,,,fee schedule,361.14,1005.82,APC
HFO w/joint(s) CF,L3921,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,375.59,,,,,,,fee schedule,361.14,1005.82,APC
HFO w/joint(s) CF,L3921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,361.14,,,,,,,fee schedule,361.14,1005.82,APC
HFO w/joint(s) CF,L3921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,552.54,,,,,,,fee schedule,361.14,1005.82,Radiology
HFO w/joint(s) CF,L3921,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,505.6,,,,,,,fee schedule,361.14,1005.82,APC
HFO w/joint(s) CF,L3921,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,632,,,,,,,fee schedule,361.14,1005.82,APC
Hfo without joints pre cst,L3923,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,250.8,,,,,,,fee schedule,97.81,272.42,
Hfo without joints pre cst,L3923,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,272.42,,,,,,,fee schedule,97.81,272.42,
Hfo without joints pre cst,L3923,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,218.37,,,,,,,fee schedule,97.81,272.42,
Hfo without joints pre cst,L3923,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,238.55,,,,,,,fee schedule,97.81,272.42,
Hfo without joints pre cst,L3923,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,102.7,,,,,,,fee schedule,97.81,272.42,APC
Hfo without joints pre cst,L3923,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,101.72,,,,,,,fee schedule,97.81,272.42,APC
Hfo without joints pre cst,L3923,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,97.81,,,,,,,fee schedule,97.81,272.42,APC
Hfo without joints pre cst,L3923,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,149.65,,,,,,,fee schedule,97.81,272.42,Radiology
Hfo without joints pre cst,L3923,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,136.93,,,,,,,fee schedule,97.81,272.42,APC
Hfo without joints pre cst,L3923,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,171.17,,,,,,,fee schedule,97.81,272.42,APC
Hfo without joints pre ots,L3924,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,265.11,,,,,,,fee schedule,97.81,287.96,
Hfo without joints pre ots,L3924,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,287.96,,,,,,,fee schedule,97.81,287.96,
Hfo without joints pre ots,L3924,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,230.83,,,,,,,fee schedule,97.81,287.96,
Hfo without joints pre ots,L3924,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,252.16,,,,,,,fee schedule,97.81,287.96,
Hfo without joints pre ots,L3924,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,102.7,,,,,,,fee schedule,97.81,287.96,APC
Hfo without joints pre ots,L3924,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,101.72,,,,,,,fee schedule,97.81,287.96,APC
Hfo without joints pre ots,L3924,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,97.81,,,,,,,fee schedule,97.81,287.96,APC
Hfo without joints pre ots,L3924,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,149.65,,,,,,,fee schedule,97.81,287.96,Radiology
Hfo without joints pre ots,L3924,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,136.93,,,,,,,fee schedule,97.81,287.96,APC
Hfo without joints pre ots,L3924,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,171.17,,,,,,,fee schedule,97.81,287.96,APC
Fo pip dip jnt/sprng pre ots,L3925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,154.86,,,,,,,fee schedule,60.42,168.21,
Fo pip dip jnt/sprng pre ots,L3925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,168.21,,,,,,,fee schedule,60.42,168.21,
Fo pip dip jnt/sprng pre ots,L3925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,134.84,,,,,,,fee schedule,60.42,168.21,
Fo pip dip jnt/sprng pre ots,L3925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,147.3,,,,,,,fee schedule,60.42,168.21,
Fo pip dip jnt/sprng pre ots,L3925,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,63.44,,,,,,,fee schedule,60.42,168.21,APC
Fo pip dip jnt/sprng pre ots,L3925,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,62.84,,,,,,,fee schedule,60.42,168.21,APC
Fo pip dip jnt/sprng pre ots,L3925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,60.42,,,,,,,fee schedule,60.42,168.21,APC
Fo pip dip jnt/sprng pre ots,L3925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,92.44,,,,,,,fee schedule,60.42,168.21,Radiology
Fo pip dip jnt/sprng pre ots,L3925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,84.59,,,,,,,fee schedule,60.42,168.21,APC
Fo pip dip jnt/sprng pre ots,L3925,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,105.74,,,,,,,fee schedule,60.42,168.21,APC
Fo pip dip no jt spr pre ots,L3927,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,100.89,,,,,,,fee schedule,39.34,109.58,
Fo pip dip no jt spr pre ots,L3927,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,109.58,,,,,,,fee schedule,39.34,109.58,
Fo pip dip no jt spr pre ots,L3927,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,87.84,,,,,,,fee schedule,39.34,109.58,
Fo pip dip no jt spr pre ots,L3927,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,95.96,,,,,,,fee schedule,39.34,109.58,
Fo pip dip no jt spr pre ots,L3927,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,41.31,,,,,,,fee schedule,39.34,109.58,APC
Fo pip dip no jt spr pre ots,L3927,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,40.91,,,,,,,fee schedule,39.34,109.58,APC
Fo pip dip no jt spr pre ots,L3927,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,39.34,,,,,,,fee schedule,39.34,109.58,APC
Fo pip dip no jt spr pre ots,L3927,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,60.19,,,,,,,fee schedule,39.34,109.58,Radiology
Fo pip dip no jt spr pre ots,L3927,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,55.08,,,,,,,fee schedule,39.34,109.58,APC
Fo pip dip no jt spr pre ots,L3927,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,68.84,,,,,,,fee schedule,39.34,109.58,APC
Hfo nontorsion jnts pre cst,L3929,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,265.18,,,,,,,fee schedule,103.43,288.04,
Hfo nontorsion jnts pre cst,L3929,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,288.04,,,,,,,fee schedule,103.43,288.04,
Hfo nontorsion jnts pre cst,L3929,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,230.89,,,,,,,fee schedule,103.43,288.04,
Hfo nontorsion jnts pre cst,L3929,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,252.22,,,,,,,fee schedule,103.43,288.04,
Hfo nontorsion jnts pre cst,L3929,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.6,,,,,,,fee schedule,103.43,288.04,APC
Hfo nontorsion jnts pre cst,L3929,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.57,,,,,,,fee schedule,103.43,288.04,APC
Hfo nontorsion jnts pre cst,L3929,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.43,,,,,,,fee schedule,103.43,288.04,APC
Hfo nontorsion jnts pre cst,L3929,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.25,,,,,,,fee schedule,103.43,288.04,Radiology
Hfo nontorsion jnts pre cst,L3929,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.8,,,,,,,fee schedule,103.43,288.04,APC
Hfo nontorsion jnts pre cst,L3929,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181,,,,,,,fee schedule,103.43,288.04,APC
Hfo nontorsion jnts pre ots,L3930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,280.31,,,,,,,fee schedule,103.43,304.48,
Hfo nontorsion jnts pre ots,L3930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,304.48,,,,,,,fee schedule,103.43,304.48,
Hfo nontorsion jnts pre ots,L3930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,244.07,,,,,,,fee schedule,103.43,304.48,
Hfo nontorsion jnts pre ots,L3930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,266.62,,,,,,,fee schedule,103.43,304.48,
Hfo nontorsion jnts pre ots,L3930,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.6,,,,,,,fee schedule,103.43,304.48,APC
Hfo nontorsion jnts pre ots,L3930,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.57,,,,,,,fee schedule,103.43,304.48,APC
Hfo nontorsion jnts pre ots,L3930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.43,,,,,,,fee schedule,103.43,304.48,APC
Hfo nontorsion jnts pre ots,L3930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.25,,,,,,,fee schedule,103.43,304.48,Radiology
Hfo nontorsion jnts pre ots,L3930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.8,,,,,,,fee schedule,103.43,304.48,APC
Hfo nontorsion jnts pre ots,L3930,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,181,,,,,,,fee schedule,103.43,304.48,APC
WHFO nontorsion joint prefab,L3931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,592.26,,,,,,,fee schedule,230.98,643.32,
WHFO nontorsion joint prefab,L3931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,643.32,,,,,,,fee schedule,230.98,643.32,
WHFO nontorsion joint prefab,L3931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,515.68,,,,,,,fee schedule,230.98,643.32,
WHFO nontorsion joint prefab,L3931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,563.33,,,,,,,fee schedule,230.98,643.32,
WHFO nontorsion joint prefab,L3931,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,242.53,,,,,,,fee schedule,230.98,643.32,APC
WHFO nontorsion joint prefab,L3931,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,240.22,,,,,,,fee schedule,230.98,643.32,APC
WHFO nontorsion joint prefab,L3931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,230.98,,,,,,,fee schedule,230.98,643.32,APC
WHFO nontorsion joint prefab,L3931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,353.4,,,,,,,fee schedule,230.98,643.32,Radiology
WHFO nontorsion joint prefab,L3931,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,323.37,,,,,,,fee schedule,230.98,643.32,APC
WHFO nontorsion joint prefab,L3931,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,404.22,,,,,,,fee schedule,230.98,643.32,APC
FO w/o joints CF,L3933,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,615.19,,,,,,,fee schedule,239.91,668.23,
FO w/o joints CF,L3933,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,668.23,,,,,,,fee schedule,239.91,668.23,
FO w/o joints CF,L3933,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,535.64,,,,,,,fee schedule,239.91,668.23,
FO w/o joints CF,L3933,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,585.14,,,,,,,fee schedule,239.91,668.23,
FO w/o joints CF,L3933,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,251.91,,,,,,,fee schedule,239.91,668.23,APC
FO w/o joints CF,L3933,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,249.51,,,,,,,fee schedule,239.91,668.23,APC
FO w/o joints CF,L3933,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,239.91,,,,,,,fee schedule,239.91,668.23,APC
FO w/o joints CF,L3933,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,367.06,,,,,,,fee schedule,239.91,668.23,Radiology
FO w/o joints CF,L3933,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,335.87,,,,,,,fee schedule,239.91,668.23,APC
FO w/o joints CF,L3933,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,419.84,,,,,,,fee schedule,239.91,668.23,APC
FO nontorsion joint CF,L3935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,636.98,,,,,,,fee schedule,248.46,691.89,
FO nontorsion joint CF,L3935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,691.89,,,,,,,fee schedule,248.46,691.89,
FO nontorsion joint CF,L3935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,554.61,,,,,,,fee schedule,248.46,691.89,
FO nontorsion joint CF,L3935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,605.86,,,,,,,fee schedule,248.46,691.89,
FO nontorsion joint CF,L3935,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,260.88,,,,,,,fee schedule,248.46,691.89,APC
FO nontorsion joint CF,L3935,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,258.4,,,,,,,fee schedule,248.46,691.89,APC
FO nontorsion joint CF,L3935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,248.46,,,,,,,fee schedule,248.46,691.89,APC
FO nontorsion joint CF,L3935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,380.14,,,,,,,fee schedule,248.46,691.89,Radiology
FO nontorsion joint CF,L3935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,347.84,,,,,,,fee schedule,248.46,691.89,APC
FO nontorsion joint CF,L3935,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,434.8,,,,,,,fee schedule,248.46,691.89,APC
Sewho airplan desig abdu pos,L3960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2583.45,,,,,,,fee schedule,1007.62,2806.16,
Sewho airplan desig abdu pos,L3960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2806.16,,,,,,,fee schedule,1007.62,2806.16,
Sewho airplan desig abdu pos,L3960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2249.38,,,,,,,fee schedule,1007.62,2806.16,
Sewho airplan desig abdu pos,L3960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2457.24,,,,,,,fee schedule,1007.62,2806.16,
Sewho airplan desig abdu pos,L3960,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1058,,,,,,,fee schedule,1007.62,2806.16,APC
Sewho airplan desig abdu pos,L3960,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1047.92,,,,,,,fee schedule,1007.62,2806.16,APC
Sewho airplan desig abdu pos,L3960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1007.62,,,,,,,fee schedule,1007.62,2806.16,APC
Sewho airplan desig abdu pos,L3960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1541.66,,,,,,,fee schedule,1007.62,2806.16,Radiology
Sewho airplan desig abdu pos,L3960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1410.67,,,,,,,fee schedule,1007.62,2806.16,APC
Sewho airplan desig abdu pos,L3960,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1763.34,,,,,,,fee schedule,1007.62,2806.16,APC
Sewho cap design w/o jnts cf,L3961,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4843.74,,,,,,,fee schedule,1889.14,5261.31,
Sewho cap design w/o jnts cf,L3961,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5261.31,,,,,,,fee schedule,1889.14,5261.31,
Sewho cap design w/o jnts cf,L3961,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4217.4,,,,,,,fee schedule,1889.14,5261.31,
Sewho cap design w/o jnts cf,L3961,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4607.12,,,,,,,fee schedule,1889.14,5261.31,
Sewho cap design w/o jnts cf,L3961,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1983.6,,,,,,,fee schedule,1889.14,5261.31,APC
Sewho cap design w/o jnts cf,L3961,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1964.71,,,,,,,fee schedule,1889.14,5261.31,APC
Sewho cap design w/o jnts cf,L3961,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1889.14,,,,,,,fee schedule,1889.14,5261.31,APC
Sewho cap design w/o jnts cf,L3961,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2890.38,,,,,,,fee schedule,1889.14,5261.31,Radiology
Sewho cap design w/o jnts cf,L3961,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2644.8,,,,,,,fee schedule,1889.14,5261.31,APC
Sewho cap design w/o jnts cf,L3961,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3306,,,,,,,fee schedule,1889.14,5261.31,APC
Sewho erbs palsey design abd,L3962,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2068.62,,,,,,,fee schedule,806.8,2246.95,
Sewho erbs palsey design abd,L3962,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2246.95,,,,,,,fee schedule,806.8,2246.95,
Sewho erbs palsey design abd,L3962,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1801.12,,,,,,,fee schedule,806.8,2246.95,
Sewho erbs palsey design abd,L3962,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1967.56,,,,,,,fee schedule,806.8,2246.95,
Sewho erbs palsey design abd,L3962,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,847.14,,,,,,,fee schedule,806.8,2246.95,APC
Sewho erbs palsey design abd,L3962,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,839.07,,,,,,,fee schedule,806.8,2246.95,APC
Sewho erbs palsey design abd,L3962,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,806.8,,,,,,,fee schedule,806.8,2246.95,APC
Sewho erbs palsey design abd,L3962,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1234.4,,,,,,,fee schedule,806.8,2246.95,Radiology
Sewho erbs palsey design abd,L3962,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1129.52,,,,,,,fee schedule,806.8,2246.95,APC
Sewho erbs palsey design abd,L3962,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1411.9,,,,,,,fee schedule,806.8,2246.95,APC
Sewho airplane w/o jnts cf,L3967,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5718.89,,,,,,,fee schedule,2230.51,6211.9,
Sewho airplane w/o jnts cf,L3967,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6211.9,,,,,,,fee schedule,2230.51,6211.9,
Sewho airplane w/o jnts cf,L3967,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4979.38,,,,,,,fee schedule,2230.51,6211.9,
Sewho airplane w/o jnts cf,L3967,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5439.52,,,,,,,fee schedule,2230.51,6211.9,
Sewho airplane w/o jnts cf,L3967,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2342.04,,,,,,,fee schedule,2230.51,6211.9,APC
Sewho airplane w/o jnts cf,L3967,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2319.73,,,,,,,fee schedule,2230.51,6211.9,APC
Sewho airplane w/o jnts cf,L3967,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2230.51,,,,,,,fee schedule,2230.51,6211.9,APC
Sewho airplane w/o jnts cf,L3967,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3412.68,,,,,,,fee schedule,2230.51,6211.9,Radiology
Sewho airplane w/o jnts cf,L3967,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3122.71,,,,,,,fee schedule,2230.51,6211.9,APC
Sewho airplane w/o jnts cf,L3967,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3903.39,,,,,,,fee schedule,2230.51,6211.9,APC
Sewho cap design w/jnt(s) cf,L3971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5428.42,,,,,,,fee schedule,2117.21,5896.38,
Sewho cap design w/jnt(s) cf,L3971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5896.38,,,,,,,fee schedule,2117.21,5896.38,
Sewho cap design w/jnt(s) cf,L3971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4726.47,,,,,,,fee schedule,2117.21,5896.38,
Sewho cap design w/jnt(s) cf,L3971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5163.24,,,,,,,fee schedule,2117.21,5896.38,
Sewho cap design w/jnt(s) cf,L3971,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2223.07,,,,,,,fee schedule,2117.21,5896.38,APC
Sewho cap design w/jnt(s) cf,L3971,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2201.9,,,,,,,fee schedule,2117.21,5896.38,APC
Sewho cap design w/jnt(s) cf,L3971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2117.21,,,,,,,fee schedule,2117.21,5896.38,APC
Sewho cap design w/jnt(s) cf,L3971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3239.33,,,,,,,fee schedule,2117.21,5896.38,Radiology
Sewho cap design w/jnt(s) cf,L3971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2964.09,,,,,,,fee schedule,2117.21,5896.38,APC
Sewho cap design w/jnt(s) cf,L3971,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3705.12,,,,,,,fee schedule,2117.21,5896.38,APC
Sewho airplane w/jnt(s) cf,L3973,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5718.89,,,,,,,fee schedule,2230.51,6211.9,
Sewho airplane w/jnt(s) cf,L3973,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6211.9,,,,,,,fee schedule,2230.51,6211.9,
Sewho airplane w/jnt(s) cf,L3973,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4979.38,,,,,,,fee schedule,2230.51,6211.9,
Sewho airplane w/jnt(s) cf,L3973,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5439.52,,,,,,,fee schedule,2230.51,6211.9,
Sewho airplane w/jnt(s) cf,L3973,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2342.04,,,,,,,fee schedule,2230.51,6211.9,APC
Sewho airplane w/jnt(s) cf,L3973,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2319.73,,,,,,,fee schedule,2230.51,6211.9,APC
Sewho airplane w/jnt(s) cf,L3973,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2230.51,,,,,,,fee schedule,2230.51,6211.9,APC
Sewho airplane w/jnt(s) cf,L3973,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3412.68,,,,,,,fee schedule,2230.51,6211.9,Radiology
Sewho airplane w/jnt(s) cf,L3973,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3122.71,,,,,,,fee schedule,2230.51,6211.9,APC
Sewho airplane w/jnt(s) cf,L3973,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3903.39,,,,,,,fee schedule,2230.51,6211.9,APC
Sewhfo cap design w/o jnt cf,L3975,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4843.74,,,,,,,fee schedule,1889.14,5261.31,
Sewhfo cap design w/o jnt cf,L3975,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5261.31,,,,,,,fee schedule,1889.14,5261.31,
Sewhfo cap design w/o jnt cf,L3975,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4217.4,,,,,,,fee schedule,1889.14,5261.31,
Sewhfo cap design w/o jnt cf,L3975,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4607.12,,,,,,,fee schedule,1889.14,5261.31,
Sewhfo cap design w/o jnt cf,L3975,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1983.6,,,,,,,fee schedule,1889.14,5261.31,APC
Sewhfo cap design w/o jnt cf,L3975,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1964.71,,,,,,,fee schedule,1889.14,5261.31,APC
Sewhfo cap design w/o jnt cf,L3975,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1889.14,,,,,,,fee schedule,1889.14,5261.31,APC
Sewhfo cap design w/o jnt cf,L3975,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2890.38,,,,,,,fee schedule,1889.14,5261.31,Radiology
Sewhfo cap design w/o jnt cf,L3975,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2644.8,,,,,,,fee schedule,1889.14,5261.31,APC
Sewhfo cap design w/o jnt cf,L3975,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3306,,,,,,,fee schedule,1889.14,5261.31,APC
Sewhfo airplane w/o jnts cf,L3976,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4843.74,,,,,,,fee schedule,1889.14,5261.31,
Sewhfo airplane w/o jnts cf,L3976,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5261.31,,,,,,,fee schedule,1889.14,5261.31,
Sewhfo airplane w/o jnts cf,L3976,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4217.4,,,,,,,fee schedule,1889.14,5261.31,
Sewhfo airplane w/o jnts cf,L3976,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4607.12,,,,,,,fee schedule,1889.14,5261.31,
Sewhfo airplane w/o jnts cf,L3976,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1983.6,,,,,,,fee schedule,1889.14,5261.31,APC
Sewhfo airplane w/o jnts cf,L3976,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1964.71,,,,,,,fee schedule,1889.14,5261.31,APC
Sewhfo airplane w/o jnts cf,L3976,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1889.14,,,,,,,fee schedule,1889.14,5261.31,APC
Sewhfo airplane w/o jnts cf,L3976,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2890.38,,,,,,,fee schedule,1889.14,5261.31,Radiology
Sewhfo airplane w/o jnts cf,L3976,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2644.8,,,,,,,fee schedule,1889.14,5261.31,APC
Sewhfo airplane w/o jnts cf,L3976,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3306,,,,,,,fee schedule,1889.14,5261.31,APC
Sewhfo cap desgn w/jnt(s) cf,L3977,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5428.42,,,,,,,fee schedule,2117.21,5896.38,
Sewhfo cap desgn w/jnt(s) cf,L3977,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5896.38,,,,,,,fee schedule,2117.21,5896.38,
Sewhfo cap desgn w/jnt(s) cf,L3977,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4726.47,,,,,,,fee schedule,2117.21,5896.38,
Sewhfo cap desgn w/jnt(s) cf,L3977,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5163.24,,,,,,,fee schedule,2117.21,5896.38,
Sewhfo cap desgn w/jnt(s) cf,L3977,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2223.07,,,,,,,fee schedule,2117.21,5896.38,APC
Sewhfo cap desgn w/jnt(s) cf,L3977,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2201.9,,,,,,,fee schedule,2117.21,5896.38,APC
Sewhfo cap desgn w/jnt(s) cf,L3977,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2117.21,,,,,,,fee schedule,2117.21,5896.38,APC
Sewhfo cap desgn w/jnt(s) cf,L3977,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3239.33,,,,,,,fee schedule,2117.21,5896.38,Radiology
Sewhfo cap desgn w/jnt(s) cf,L3977,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2964.09,,,,,,,fee schedule,2117.21,5896.38,APC
Sewhfo cap desgn w/jnt(s) cf,L3977,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3705.12,,,,,,,fee schedule,2117.21,5896.38,APC
Sewhfo airplane w/jnt(s) cf,L3978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5718.89,,,,,,,fee schedule,2230.51,6211.9,
Sewhfo airplane w/jnt(s) cf,L3978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6211.9,,,,,,,fee schedule,2230.51,6211.9,
Sewhfo airplane w/jnt(s) cf,L3978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4979.38,,,,,,,fee schedule,2230.51,6211.9,
Sewhfo airplane w/jnt(s) cf,L3978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5439.52,,,,,,,fee schedule,2230.51,6211.9,
Sewhfo airplane w/jnt(s) cf,L3978,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2342.04,,,,,,,fee schedule,2230.51,6211.9,APC
Sewhfo airplane w/jnt(s) cf,L3978,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2319.73,,,,,,,fee schedule,2230.51,6211.9,APC
Sewhfo airplane w/jnt(s) cf,L3978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2230.51,,,,,,,fee schedule,2230.51,6211.9,APC
Sewhfo airplane w/jnt(s) cf,L3978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3412.68,,,,,,,fee schedule,2230.51,6211.9,Radiology
Sewhfo airplane w/jnt(s) cf,L3978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3122.71,,,,,,,fee schedule,2230.51,6211.9,APC
Sewhfo airplane w/jnt(s) cf,L3978,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3903.39,,,,,,,fee schedule,2230.51,6211.9,APC
Up ext fx orthos humeral nos,L3980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1061.33,,,,,,,fee schedule,413.94,1152.82,
Up ext fx orthos humeral nos,L3980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1152.82,,,,,,,fee schedule,413.94,1152.82,
Up ext fx orthos humeral nos,L3980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,924.09,,,,,,,fee schedule,413.94,1152.82,
Up ext fx orthos humeral nos,L3980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1009.48,,,,,,,fee schedule,413.94,1152.82,
Up ext fx orthos humeral nos,L3980,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,434.64,,,,,,,fee schedule,413.94,1152.82,APC
Up ext fx orthos humeral nos,L3980,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,430.5,,,,,,,fee schedule,413.94,1152.82,APC
Up ext fx orthos humeral nos,L3980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,413.94,,,,,,,fee schedule,413.94,1152.82,APC
Up ext fx orthos humeral nos,L3980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,633.33,,,,,,,fee schedule,413.94,1152.82,Radiology
Up ext fx orthos humeral nos,L3980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,579.52,,,,,,,fee schedule,413.94,1152.82,APC
Up ext fx orthos humeral nos,L3980,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,724.4,,,,,,,fee schedule,413.94,1152.82,APC
Ue fx orth shoul cap forearm,L3981,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3067.59,,,,,,,fee schedule,1131.82,3332.03,
Ue fx orth shoul cap forearm,L3981,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3332.03,,,,,,,fee schedule,1131.82,3332.03,
Ue fx orth shoul cap forearm,L3981,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2670.91,,,,,,,fee schedule,1131.82,3332.03,
Ue fx orth shoul cap forearm,L3981,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2917.73,,,,,,,fee schedule,1131.82,3332.03,
Ue fx orth shoul cap forearm,L3981,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1188.41,,,,,,,fee schedule,1131.82,3332.03,APC
Ue fx orth shoul cap forearm,L3981,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1177.09,,,,,,,fee schedule,1131.82,3332.03,APC
Ue fx orth shoul cap forearm,L3981,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1131.82,,,,,,,fee schedule,1131.82,3332.03,APC
Ue fx orth shoul cap forearm,L3981,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1731.68,,,,,,,fee schedule,1131.82,3332.03,Radiology
Ue fx orth shoul cap forearm,L3981,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1584.55,,,,,,,fee schedule,1131.82,3332.03,APC
Ue fx orth shoul cap forearm,L3981,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1980.68,,,,,,,fee schedule,1131.82,3332.03,APC
Upper ext fx orthosis rad/ul,L3982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1197.68,,,,,,,fee schedule,467.12,1300.92,
Upper ext fx orthosis rad/ul,L3982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1300.92,,,,,,,fee schedule,467.12,1300.92,
Upper ext fx orthosis rad/ul,L3982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1042.8,,,,,,,fee schedule,467.12,1300.92,
Upper ext fx orthosis rad/ul,L3982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1139.17,,,,,,,fee schedule,467.12,1300.92,
Upper ext fx orthosis rad/ul,L3982,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,490.48,,,,,,,fee schedule,467.12,1300.92,APC
Upper ext fx orthosis rad/ul,L3982,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,485.8,,,,,,,fee schedule,467.12,1300.92,APC
Upper ext fx orthosis rad/ul,L3982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,467.12,,,,,,,fee schedule,467.12,1300.92,APC
Upper ext fx orthosis rad/ul,L3982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,714.69,,,,,,,fee schedule,467.12,1300.92,Radiology
Upper ext fx orthosis rad/ul,L3982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,653.97,,,,,,,fee schedule,467.12,1300.92,APC
Upper ext fx orthosis rad/ul,L3982,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,817.46,,,,,,,fee schedule,467.12,1300.92,APC
Upper ext fx orthosis wrist,L3984,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1041.98,,,,,,,fee schedule,406.39,1131.81,
Upper ext fx orthosis wrist,L3984,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1131.81,,,,,,,fee schedule,406.39,1131.81,
Upper ext fx orthosis wrist,L3984,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,907.24,,,,,,,fee schedule,406.39,1131.81,
Upper ext fx orthosis wrist,L3984,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,991.08,,,,,,,fee schedule,406.39,1131.81,
Upper ext fx orthosis wrist,L3984,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,426.71,,,,,,,fee schedule,406.39,1131.81,APC
Upper ext fx orthosis wrist,L3984,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,422.65,,,,,,,fee schedule,406.39,1131.81,APC
Upper ext fx orthosis wrist,L3984,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,406.39,,,,,,,fee schedule,406.39,1131.81,APC
Upper ext fx orthosis wrist,L3984,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,621.78,,,,,,,fee schedule,406.39,1131.81,Radiology
Upper ext fx orthosis wrist,L3984,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,568.95,,,,,,,fee schedule,406.39,1131.81,APC
Upper ext fx orthosis wrist,L3984,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,711.18,,,,,,,fee schedule,406.39,1131.81,APC
Sock fracture or equal each,L3995,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,122.95,,,,,,,fee schedule,47.94,133.55,
Sock fracture or equal each,L3995,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,133.55,,,,,,,fee schedule,47.94,133.55,
Sock fracture or equal each,L3995,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,107.05,,,,,,,fee schedule,47.94,133.55,
Sock fracture or equal each,L3995,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,116.94,,,,,,,fee schedule,47.94,133.55,
Sock fracture or equal each,L3995,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,50.34,,,,,,,fee schedule,47.94,133.55,APC
Sock fracture or equal each,L3995,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,49.86,,,,,,,fee schedule,47.94,133.55,APC
Sock fracture or equal each,L3995,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,47.94,,,,,,,fee schedule,47.94,133.55,APC
Sock fracture or equal each,L3995,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,73.35,,,,,,,fee schedule,47.94,133.55,Radiology
Sock fracture or equal each,L3995,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,67.12,,,,,,,fee schedule,47.94,133.55,APC
Sock fracture or equal each,L3995,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,83.9,,,,,,,fee schedule,47.94,133.55,APC
Repl girdle milwaukee orth,L4000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3970.02,,,,,,,fee schedule,1548.39,4312.26,
Repl girdle milwaukee orth,L4000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4312.26,,,,,,,fee schedule,1548.39,4312.26,
Repl girdle milwaukee orth,L4000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3456.65,,,,,,,fee schedule,1548.39,4312.26,
Repl girdle milwaukee orth,L4000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3776.08,,,,,,,fee schedule,1548.39,4312.26,
Repl girdle milwaukee orth,L4000,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1625.81,,,,,,,fee schedule,1548.39,4312.26,APC
Repl girdle milwaukee orth,L4000,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1610.33,,,,,,,fee schedule,1548.39,4312.26,APC
Repl girdle milwaukee orth,L4000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1548.39,,,,,,,fee schedule,1548.39,4312.26,APC
Repl girdle milwaukee orth,L4000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2369.04,,,,,,,fee schedule,1548.39,4312.26,Radiology
Repl girdle milwaukee orth,L4000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2167.75,,,,,,,fee schedule,1548.39,4312.26,APC
Repl girdle milwaukee orth,L4000,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2709.68,,,,,,,fee schedule,1548.39,4312.26,APC
Replace trilateral socket br,L4010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2028.94,,,,,,,fee schedule,791.32,2203.85,
Replace trilateral socket br,L4010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2203.85,,,,,,,fee schedule,791.32,2203.85,
Replace trilateral socket br,L4010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1766.58,,,,,,,fee schedule,791.32,2203.85,
Replace trilateral socket br,L4010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1929.83,,,,,,,fee schedule,791.32,2203.85,
Replace trilateral socket br,L4010,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,830.89,,,,,,,fee schedule,791.32,2203.85,APC
Replace trilateral socket br,L4010,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,822.97,,,,,,,fee schedule,791.32,2203.85,APC
Replace trilateral socket br,L4010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,791.32,,,,,,,fee schedule,791.32,2203.85,APC
Replace trilateral socket br,L4010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1210.72,,,,,,,fee schedule,791.32,2203.85,Radiology
Replace trilateral socket br,L4010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1107.85,,,,,,,fee schedule,791.32,2203.85,APC
Replace trilateral socket br,L4010,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1384.81,,,,,,,fee schedule,791.32,2203.85,APC
Replace quadlat socket brim,L4020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2967.05,,,,,,,fee schedule,1157.21,3222.83,
Replace quadlat socket brim,L4020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3222.83,,,,,,,fee schedule,1157.21,3222.83,
Replace quadlat socket brim,L4020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2583.38,,,,,,,fee schedule,1157.21,3222.83,
Replace quadlat socket brim,L4020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2822.11,,,,,,,fee schedule,1157.21,3222.83,
Replace quadlat socket brim,L4020,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1215.07,,,,,,,fee schedule,1157.21,3222.83,APC
Replace quadlat socket brim,L4020,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1203.5,,,,,,,fee schedule,1157.21,3222.83,APC
Replace quadlat socket brim,L4020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1157.21,,,,,,,fee schedule,1157.21,3222.83,APC
Replace quadlat socket brim,L4020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1770.53,,,,,,,fee schedule,1157.21,3222.83,Radiology
Replace quadlat socket brim,L4020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1620.09,,,,,,,fee schedule,1157.21,3222.83,APC
Replace quadlat socket brim,L4020,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2025.12,,,,,,,fee schedule,1157.21,3222.83,APC
Replace socket brim cust fit,L4030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1940.31,,,,,,,fee schedule,756.75,2107.58,
Replace socket brim cust fit,L4030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2107.58,,,,,,,fee schedule,756.75,2107.58,
Replace socket brim cust fit,L4030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1689.41,,,,,,,fee schedule,756.75,2107.58,
Replace socket brim cust fit,L4030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1845.52,,,,,,,fee schedule,756.75,2107.58,
Replace socket brim cust fit,L4030,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,794.59,,,,,,,fee schedule,756.75,2107.58,APC
Replace socket brim cust fit,L4030,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,787.02,,,,,,,fee schedule,756.75,2107.58,APC
Replace socket brim cust fit,L4030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,756.75,,,,,,,fee schedule,756.75,2107.58,APC
Replace socket brim cust fit,L4030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1157.83,,,,,,,fee schedule,756.75,2107.58,Radiology
Replace socket brim cust fit,L4030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1059.45,,,,,,,fee schedule,756.75,2107.58,APC
Replace socket brim cust fit,L4030,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1324.31,,,,,,,fee schedule,756.75,2107.58,APC
Replace molded thigh lacer,L4040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1264.6,,,,,,,fee schedule,493.23,1373.61,
Replace molded thigh lacer,L4040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1373.61,,,,,,,fee schedule,493.23,1373.61,
Replace molded thigh lacer,L4040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1101.07,,,,,,,fee schedule,493.23,1373.61,
Replace molded thigh lacer,L4040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1202.82,,,,,,,fee schedule,493.23,1373.61,
Replace molded thigh lacer,L4040,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,517.89,,,,,,,fee schedule,493.23,1373.61,APC
Replace molded thigh lacer,L4040,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,512.96,,,,,,,fee schedule,493.23,1373.61,APC
Replace molded thigh lacer,L4040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,493.23,,,,,,,fee schedule,493.23,1373.61,APC
Replace molded thigh lacer,L4040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,754.64,,,,,,,fee schedule,493.23,1373.61,Radiology
Replace molded thigh lacer,L4040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,690.52,,,,,,,fee schedule,493.23,1373.61,APC
Replace molded thigh lacer,L4040,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,863.15,,,,,,,fee schedule,493.23,1373.61,APC
Replace non-molded thigh lac,L4045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,966.47,,,,,,,fee schedule,376.94,1049.78,
Replace non-molded thigh lac,L4045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1049.78,,,,,,,fee schedule,376.94,1049.78,
Replace non-molded thigh lac,L4045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,841.49,,,,,,,fee schedule,376.94,1049.78,
Replace non-molded thigh lac,L4045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,919.25,,,,,,,fee schedule,376.94,1049.78,
Replace non-molded thigh lac,L4045,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,395.79,,,,,,,fee schedule,376.94,1049.78,APC
Replace non-molded thigh lac,L4045,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,392.02,,,,,,,fee schedule,376.94,1049.78,APC
Replace non-molded thigh lac,L4045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,376.94,,,,,,,fee schedule,376.94,1049.78,APC
Replace non-molded thigh lac,L4045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,576.72,,,,,,,fee schedule,376.94,1049.78,Radiology
Replace non-molded thigh lac,L4045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,527.72,,,,,,,fee schedule,376.94,1049.78,APC
Replace non-molded thigh lac,L4045,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,659.64,,,,,,,fee schedule,376.94,1049.78,APC
Replace molded calf lacer,L4050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1216.36,,,,,,,fee schedule,474.4,1321.22,
Replace molded calf lacer,L4050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1321.22,,,,,,,fee schedule,474.4,1321.22,
Replace molded calf lacer,L4050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1059.08,,,,,,,fee schedule,474.4,1321.22,
Replace molded calf lacer,L4050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1156.94,,,,,,,fee schedule,474.4,1321.22,
Replace molded calf lacer,L4050,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,498.12,,,,,,,fee schedule,474.4,1321.22,APC
Replace molded calf lacer,L4050,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,493.38,,,,,,,fee schedule,474.4,1321.22,APC
Replace molded calf lacer,L4050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,474.4,,,,,,,fee schedule,474.4,1321.22,APC
Replace molded calf lacer,L4050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,725.83,,,,,,,fee schedule,474.4,1321.22,Radiology
Replace molded calf lacer,L4050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,664.16,,,,,,,fee schedule,474.4,1321.22,APC
Replace molded calf lacer,L4050,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,830.2,,,,,,,fee schedule,474.4,1321.22,APC
Replace non-molded calf lace,L4055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,802.31,,,,,,,fee schedule,312.94,871.48,
Replace non-molded calf lace,L4055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,871.48,,,,,,,fee schedule,312.94,871.48,
Replace non-molded calf lace,L4055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,698.57,,,,,,,fee schedule,312.94,871.48,
Replace non-molded calf lace,L4055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,763.12,,,,,,,fee schedule,312.94,871.48,
Replace non-molded calf lace,L4055,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,328.59,,,,,,,fee schedule,312.94,871.48,APC
Replace non-molded calf lace,L4055,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,325.46,,,,,,,fee schedule,312.94,871.48,APC
Replace non-molded calf lace,L4055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,312.94,,,,,,,fee schedule,312.94,871.48,APC
Replace non-molded calf lace,L4055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,478.8,,,,,,,fee schedule,312.94,871.48,Radiology
Replace non-molded calf lace,L4055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,438.12,,,,,,,fee schedule,312.94,871.48,APC
Replace non-molded calf lace,L4055,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,547.64,,,,,,,fee schedule,312.94,871.48,APC
Replace high roll cuff,L4060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,936.33,,,,,,,fee schedule,365.19,1017.05,
Replace high roll cuff,L4060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1017.05,,,,,,,fee schedule,365.19,1017.05,
Replace high roll cuff,L4060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,815.25,,,,,,,fee schedule,365.19,1017.05,
Replace high roll cuff,L4060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,890.59,,,,,,,fee schedule,365.19,1017.05,
Replace high roll cuff,L4060,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,383.45,,,,,,,fee schedule,365.19,1017.05,APC
Replace high roll cuff,L4060,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,379.8,,,,,,,fee schedule,365.19,1017.05,APC
Replace high roll cuff,L4060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,365.19,,,,,,,fee schedule,365.19,1017.05,APC
Replace high roll cuff,L4060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,558.74,,,,,,,fee schedule,365.19,1017.05,Radiology
Replace high roll cuff,L4060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,511.27,,,,,,,fee schedule,365.19,1017.05,APC
Replace high roll cuff,L4060,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,639.08,,,,,,,fee schedule,365.19,1017.05,APC
Replace prox & dist upright,L4070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1043.79,,,,,,,fee schedule,407.08,1133.77,
Replace prox & dist upright,L4070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1133.77,,,,,,,fee schedule,407.08,1133.77,
Replace prox & dist upright,L4070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,908.82,,,,,,,fee schedule,407.08,1133.77,
Replace prox & dist upright,L4070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,992.8,,,,,,,fee schedule,407.08,1133.77,
Replace prox & dist upright,L4070,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,427.43,,,,,,,fee schedule,407.08,1133.77,APC
Replace prox & dist upright,L4070,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,423.36,,,,,,,fee schedule,407.08,1133.77,APC
Replace prox & dist upright,L4070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,407.08,,,,,,,fee schedule,407.08,1133.77,APC
Replace prox & dist upright,L4070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,622.83,,,,,,,fee schedule,407.08,1133.77,Radiology
Replace prox & dist upright,L4070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,569.91,,,,,,,fee schedule,407.08,1133.77,APC
Replace prox & dist upright,L4070,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,712.39,,,,,,,fee schedule,407.08,1133.77,APC
Repl met band kafo-afo prox,L4080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,297.99,,,,,,,fee schedule,116.23,323.68,
Repl met band kafo-afo prox,L4080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,323.68,,,,,,,fee schedule,116.23,323.68,
Repl met band kafo-afo prox,L4080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,259.46,,,,,,,fee schedule,116.23,323.68,
Repl met band kafo-afo prox,L4080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,283.44,,,,,,,fee schedule,116.23,323.68,
Repl met band kafo-afo prox,L4080,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,122.04,,,,,,,fee schedule,116.23,323.68,APC
Repl met band kafo-afo prox,L4080,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,120.88,,,,,,,fee schedule,116.23,323.68,APC
Repl met band kafo-afo prox,L4080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,116.23,,,,,,,fee schedule,116.23,323.68,APC
Repl met band kafo-afo prox,L4080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,177.83,,,,,,,fee schedule,116.23,323.68,Radiology
Repl met band kafo-afo prox,L4080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,162.72,,,,,,,fee schedule,116.23,323.68,APC
Repl met band kafo-afo prox,L4080,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,203.4,,,,,,,fee schedule,116.23,323.68,APC
Repl met band kafo-afo calf/,L4090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,336.66,,,,,,,fee schedule,131.28,365.68,
Repl met band kafo-afo calf/,L4090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,365.68,,,,,,,fee schedule,131.28,365.68,
Repl met band kafo-afo calf/,L4090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,293.12,,,,,,,fee schedule,131.28,365.68,
Repl met band kafo-afo calf/,L4090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,320.21,,,,,,,fee schedule,131.28,365.68,
Repl met band kafo-afo calf/,L4090,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,137.84,,,,,,,fee schedule,131.28,365.68,APC
Repl met band kafo-afo calf/,L4090,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.53,,,,,,,fee schedule,131.28,365.68,APC
Repl met band kafo-afo calf/,L4090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.28,,,,,,,fee schedule,131.28,365.68,APC
Repl met band kafo-afo calf/,L4090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,200.86,,,,,,,fee schedule,131.28,365.68,Radiology
Repl met band kafo-afo calf/,L4090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,183.79,,,,,,,fee schedule,131.28,365.68,APC
Repl met band kafo-afo calf/,L4090,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,229.74,,,,,,,fee schedule,131.28,365.68,APC
Repl leath cuff kafo prox th,L4100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,345.67,,,,,,,fee schedule,134.81,375.47,
Repl leath cuff kafo prox th,L4100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,375.47,,,,,,,fee schedule,134.81,375.47,
Repl leath cuff kafo prox th,L4100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,300.97,,,,,,,fee schedule,134.81,375.47,
Repl leath cuff kafo prox th,L4100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,328.78,,,,,,,fee schedule,134.81,375.47,
Repl leath cuff kafo prox th,L4100,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,141.55,,,,,,,fee schedule,134.81,375.47,APC
Repl leath cuff kafo prox th,L4100,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,140.2,,,,,,,fee schedule,134.81,375.47,APC
Repl leath cuff kafo prox th,L4100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,134.81,,,,,,,fee schedule,134.81,375.47,APC
Repl leath cuff kafo prox th,L4100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,206.26,,,,,,,fee schedule,134.81,375.47,Radiology
Repl leath cuff kafo prox th,L4100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.73,,,,,,,fee schedule,134.81,375.47,APC
Repl leath cuff kafo prox th,L4100,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,235.92,,,,,,,fee schedule,134.81,375.47,APC
Repl leath cuff kafo-afo cal,L4110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,276.49,,,,,,,fee schedule,107.83,300.32,
Repl leath cuff kafo-afo cal,L4110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,300.32,,,,,,,fee schedule,107.83,300.32,
Repl leath cuff kafo-afo cal,L4110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,240.73,,,,,,,fee schedule,107.83,300.32,
Repl leath cuff kafo-afo cal,L4110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,262.98,,,,,,,fee schedule,107.83,300.32,
Repl leath cuff kafo-afo cal,L4110,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,113.22,,,,,,,fee schedule,107.83,300.32,APC
Repl leath cuff kafo-afo cal,L4110,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,112.14,,,,,,,fee schedule,107.83,300.32,APC
Repl leath cuff kafo-afo cal,L4110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,107.83,,,,,,,fee schedule,107.83,300.32,APC
Repl leath cuff kafo-afo cal,L4110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,164.98,,,,,,,fee schedule,107.83,300.32,Radiology
Repl leath cuff kafo-afo cal,L4110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,150.96,,,,,,,fee schedule,107.83,300.32,APC
Repl leath cuff kafo-afo cal,L4110,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,188.7,,,,,,,fee schedule,107.83,300.32,APC
Replace pretibial shell,L4130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1703.63,,,,,,,fee schedule,664.47,1850.5,
Replace pretibial shell,L4130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1850.5,,,,,,,fee schedule,664.47,1850.5,
Replace pretibial shell,L4130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1483.34,,,,,,,fee schedule,664.47,1850.5,
Replace pretibial shell,L4130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1620.41,,,,,,,fee schedule,664.47,1850.5,
Replace pretibial shell,L4130,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,697.69,,,,,,,fee schedule,664.47,1850.5,APC
Replace pretibial shell,L4130,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,691.05,,,,,,,fee schedule,664.47,1850.5,APC
Replace pretibial shell,L4130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,664.47,,,,,,,fee schedule,664.47,1850.5,APC
Replace pretibial shell,L4130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1016.64,,,,,,,fee schedule,664.47,1850.5,Radiology
Replace pretibial shell,L4130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,930.26,,,,,,,fee schedule,664.47,1850.5,APC
Replace pretibial shell,L4130,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1162.82,,,,,,,fee schedule,664.47,1850.5,APC
Ankle control ortho pre ots,L4350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,270.85,,,,,,,fee schedule,105.64,294.2,
Ankle control ortho pre ots,L4350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,294.2,,,,,,,fee schedule,105.64,294.2,
Ankle control ortho pre ots,L4350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,235.82,,,,,,,fee schedule,105.64,294.2,
Ankle control ortho pre ots,L4350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,257.62,,,,,,,fee schedule,105.64,294.2,
Ankle control ortho pre ots,L4350,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,110.92,,,,,,,fee schedule,105.64,294.2,APC
Ankle control ortho pre ots,L4350,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,109.87,,,,,,,fee schedule,105.64,294.2,APC
Ankle control ortho pre ots,L4350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,105.64,,,,,,,fee schedule,105.64,294.2,APC
Ankle control ortho pre ots,L4350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,161.63,,,,,,,fee schedule,105.64,294.2,Radiology
Ankle control ortho pre ots,L4350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,147.9,,,,,,,fee schedule,105.64,294.2,APC
Ankle control ortho pre ots,L4350,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,184.87,,,,,,,fee schedule,105.64,294.2,APC
Pneumat walking boot pre cst,L4360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,815.78,,,,,,,fee schedule,318.18,886.11,
Pneumat walking boot pre cst,L4360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,886.11,,,,,,,fee schedule,318.18,886.11,
Pneumat walking boot pre cst,L4360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,710.29,,,,,,,fee schedule,318.18,886.11,
Pneumat walking boot pre cst,L4360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,775.93,,,,,,,fee schedule,318.18,886.11,
Pneumat walking boot pre cst,L4360,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,334.09,,,,,,,fee schedule,318.18,886.11,APC
Pneumat walking boot pre cst,L4360,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,330.91,,,,,,,fee schedule,318.18,886.11,APC
Pneumat walking boot pre cst,L4360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,318.18,,,,,,,fee schedule,318.18,886.11,APC
Pneumat walking boot pre cst,L4360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,486.82,,,,,,,fee schedule,318.18,886.11,Radiology
Pneumat walking boot pre cst,L4360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,445.45,,,,,,,fee schedule,318.18,886.11,APC
Pneumat walking boot pre cst,L4360,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,556.82,,,,,,,fee schedule,318.18,886.11,APC
Pneuma/vac walk boot pre ots,L4361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,862.38,,,,,,,fee schedule,318.18,936.72,
Pneuma/vac walk boot pre ots,L4361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,936.72,,,,,,,fee schedule,318.18,936.72,
Pneuma/vac walk boot pre ots,L4361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,750.86,,,,,,,fee schedule,318.18,936.72,
Pneuma/vac walk boot pre ots,L4361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,820.25,,,,,,,fee schedule,318.18,936.72,
Pneuma/vac walk boot pre ots,L4361,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,334.09,,,,,,,fee schedule,318.18,936.72,APC
Pneuma/vac walk boot pre ots,L4361,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,330.91,,,,,,,fee schedule,318.18,936.72,APC
Pneuma/vac walk boot pre ots,L4361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,318.18,,,,,,,fee schedule,318.18,936.72,APC
Pneuma/vac walk boot pre ots,L4361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,486.82,,,,,,,fee schedule,318.18,936.72,Radiology
Pneuma/vac walk boot pre ots,L4361,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,445.45,,,,,,,fee schedule,318.18,936.72,APC
Pneuma/vac walk boot pre ots,L4361,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,556.82,,,,,,,fee schedule,318.18,936.72,APC
Pneum full leg splnt pre ots,L4370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,556.21,,,,,,,fee schedule,216.94,604.16,
Pneum full leg splnt pre ots,L4370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,604.16,,,,,,,fee schedule,216.94,604.16,
Pneum full leg splnt pre ots,L4370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,484.28,,,,,,,fee schedule,216.94,604.16,
Pneum full leg splnt pre ots,L4370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,529.04,,,,,,,fee schedule,216.94,604.16,
Pneum full leg splnt pre ots,L4370,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,227.79,,,,,,,fee schedule,216.94,604.16,APC
Pneum full leg splnt pre ots,L4370,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,225.62,,,,,,,fee schedule,216.94,604.16,APC
Pneum full leg splnt pre ots,L4370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,216.94,,,,,,,fee schedule,216.94,604.16,APC
Pneum full leg splnt pre ots,L4370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,331.92,,,,,,,fee schedule,216.94,604.16,Radiology
Pneum full leg splnt pre ots,L4370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.72,,,,,,,fee schedule,216.94,604.16,APC
Pneum full leg splnt pre ots,L4370,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,379.64,,,,,,,fee schedule,216.94,604.16,APC
Non-pneum walk boot pre cst,L4386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,502.27,,,,,,,fee schedule,195.88,545.57,
Non-pneum walk boot pre cst,L4386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,545.57,,,,,,,fee schedule,195.88,545.57,
Non-pneum walk boot pre cst,L4386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,437.32,,,,,,,fee schedule,195.88,545.57,
Non-pneum walk boot pre cst,L4386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,477.73,,,,,,,fee schedule,195.88,545.57,
Non-pneum walk boot pre cst,L4386,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,205.67,,,,,,,fee schedule,195.88,545.57,APC
Non-pneum walk boot pre cst,L4386,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,203.72,,,,,,,fee schedule,195.88,545.57,APC
Non-pneum walk boot pre cst,L4386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,195.88,,,,,,,fee schedule,195.88,545.57,APC
Non-pneum walk boot pre cst,L4386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.7,,,,,,,fee schedule,195.88,545.57,Radiology
Non-pneum walk boot pre cst,L4386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,274.23,,,,,,,fee schedule,195.88,545.57,APC
Non-pneum walk boot pre cst,L4386,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,342.79,,,,,,,fee schedule,195.88,545.57,APC
Non-pneum walk boot pre ots,L4387,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,530.94,,,,,,,fee schedule,195.88,576.71,
Non-pneum walk boot pre ots,L4387,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,576.71,,,,,,,fee schedule,195.88,576.71,
Non-pneum walk boot pre ots,L4387,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,462.29,,,,,,,fee schedule,195.88,576.71,
Non-pneum walk boot pre ots,L4387,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,505.01,,,,,,,fee schedule,195.88,576.71,
Non-pneum walk boot pre ots,L4387,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,205.67,,,,,,,fee schedule,195.88,576.71,APC
Non-pneum walk boot pre ots,L4387,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,203.72,,,,,,,fee schedule,195.88,576.71,APC
Non-pneum walk boot pre ots,L4387,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,195.88,,,,,,,fee schedule,195.88,576.71,APC
Non-pneum walk boot pre ots,L4387,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,299.7,,,,,,,fee schedule,195.88,576.71,Radiology
Non-pneum walk boot pre ots,L4387,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,274.23,,,,,,,fee schedule,195.88,576.71,APC
Non-pneum walk boot pre ots,L4387,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,342.79,,,,,,,fee schedule,195.88,576.71,APC
Replace AFO soft interface,L4392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,74.61,,,,,,,fee schedule,29.1,81.04,
Replace AFO soft interface,L4392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,81.04,,,,,,,fee schedule,29.1,81.04,
Replace AFO soft interface,L4392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,64.96,,,,,,,fee schedule,29.1,81.04,
Replace AFO soft interface,L4392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,70.97,,,,,,,fee schedule,29.1,81.04,
Replace AFO soft interface,L4392,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.56,,,,,,,fee schedule,29.1,81.04,APC
Replace AFO soft interface,L4392,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,30.26,,,,,,,fee schedule,29.1,81.04,APC
Replace AFO soft interface,L4392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,29.1,,,,,,,fee schedule,29.1,81.04,APC
Replace AFO soft interface,L4392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,44.52,,,,,,,fee schedule,29.1,81.04,Radiology
Replace AFO soft interface,L4392,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40.74,,,,,,,fee schedule,29.1,81.04,APC
Replace AFO soft interface,L4392,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,50.92,,,,,,,fee schedule,29.1,81.04,APC
Replace foot drop spint,L4394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,54.46,,,,,,,fee schedule,21.24,59.16,
Replace foot drop spint,L4394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59.16,,,,,,,fee schedule,21.24,59.16,
Replace foot drop spint,L4394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,47.42,,,,,,,fee schedule,21.24,59.16,
Replace foot drop spint,L4394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.8,,,,,,,fee schedule,21.24,59.16,
Replace foot drop spint,L4394,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,22.3,,,,,,,fee schedule,21.24,59.16,APC
Replace foot drop spint,L4394,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,22.09,,,,,,,fee schedule,21.24,59.16,APC
Replace foot drop spint,L4394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,21.24,,,,,,,fee schedule,21.24,59.16,APC
Replace foot drop spint,L4394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,32.5,,,,,,,fee schedule,21.24,59.16,Radiology
Replace foot drop spint,L4394,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29.74,,,,,,,fee schedule,21.24,59.16,APC
Replace foot drop spint,L4394,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,37.17,,,,,,,fee schedule,21.24,59.16,APC
Static or dynami afo pre cst,L4396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,531.71,,,,,,,fee schedule,207.4,577.55,
Static or dynami afo pre cst,L4396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,577.55,,,,,,,fee schedule,207.4,577.55,
Static or dynami afo pre cst,L4396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,462.95,,,,,,,fee schedule,207.4,577.55,
Static or dynami afo pre cst,L4396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,505.73,,,,,,,fee schedule,207.4,577.55,
Static or dynami afo pre cst,L4396,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,217.77,,,,,,,fee schedule,207.4,577.55,APC
Static or dynami afo pre cst,L4396,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,215.7,,,,,,,fee schedule,207.4,577.55,APC
Static or dynami afo pre cst,L4396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,207.4,,,,,,,fee schedule,207.4,577.55,APC
Static or dynami afo pre cst,L4396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,317.32,,,,,,,fee schedule,207.4,577.55,Radiology
Static or dynami afo pre cst,L4396,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,290.36,,,,,,,fee schedule,207.4,577.55,APC
Static or dynami afo pre cst,L4396,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,362.95,,,,,,,fee schedule,207.4,577.55,APC
Static or dynami afo pre ots,L4397,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,562.09,,,,,,,fee schedule,207.4,610.55,
Static or dynami afo pre ots,L4397,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,610.55,,,,,,,fee schedule,207.4,610.55,
Static or dynami afo pre ots,L4397,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,489.41,,,,,,,fee schedule,207.4,610.55,
Static or dynami afo pre ots,L4397,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,534.63,,,,,,,fee schedule,207.4,610.55,
Static or dynami afo pre ots,L4397,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,217.77,,,,,,,fee schedule,207.4,610.55,APC
Static or dynami afo pre ots,L4397,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,215.7,,,,,,,fee schedule,207.4,610.55,APC
Static or dynami afo pre ots,L4397,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,207.4,,,,,,,fee schedule,207.4,610.55,APC
Static or dynami afo pre ots,L4397,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,317.32,,,,,,,fee schedule,207.4,610.55,Radiology
Static or dynami afo pre ots,L4397,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,290.36,,,,,,,fee schedule,207.4,610.55,APC
Static or dynami afo pre ots,L4397,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,362.95,,,,,,,fee schedule,207.4,610.55,APC
Foot drop splint pre ots,L4398,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,244.68,,,,,,,fee schedule,95.45,265.77,
Foot drop splint pre ots,L4398,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,265.77,,,,,,,fee schedule,95.45,265.77,
Foot drop splint pre ots,L4398,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,213.04,,,,,,,fee schedule,95.45,265.77,
Foot drop splint pre ots,L4398,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,232.73,,,,,,,fee schedule,95.45,265.77,
Foot drop splint pre ots,L4398,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,100.22,,,,,,,fee schedule,95.45,265.77,APC
Foot drop splint pre ots,L4398,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,99.27,,,,,,,fee schedule,95.45,265.77,APC
Foot drop splint pre ots,L4398,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,95.45,,,,,,,fee schedule,95.45,265.77,APC
Foot drop splint pre ots,L4398,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,146.04,,,,,,,fee schedule,95.45,265.77,Radiology
Foot drop splint pre ots,L4398,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,133.63,,,,,,,fee schedule,95.45,265.77,APC
Foot drop splint pre ots,L4398,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,167.04,,,,,,,fee schedule,95.45,265.77,APC
"Afo, walk boot type, cus fab",L4631,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4831.7,,,,,,,fee schedule,1827.5,5248.23,
"Afo, walk boot type, cus fab",L4631,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5248.23,,,,,,,fee schedule,1827.5,5248.23,
"Afo, walk boot type, cus fab",L4631,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4206.91,,,,,,,fee schedule,1827.5,5248.23,
"Afo, walk boot type, cus fab",L4631,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4595.67,,,,,,,fee schedule,1827.5,5248.23,
"Afo, walk boot type, cus fab",L4631,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1918.88,,,,,,,fee schedule,1827.5,5248.23,APC
"Afo, walk boot type, cus fab",L4631,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1900.6,,,,,,,fee schedule,1827.5,5248.23,APC
"Afo, walk boot type, cus fab",L4631,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1827.5,,,,,,,fee schedule,1827.5,5248.23,APC
"Afo, walk boot type, cus fab",L4631,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2796.08,,,,,,,fee schedule,1827.5,5248.23,Radiology
"Afo, walk boot type, cus fab",L4631,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2558.5,,,,,,,fee schedule,1827.5,5248.23,APC
"Afo, walk boot type, cus fab",L4631,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3198.12,,,,,,,fee schedule,1827.5,5248.23,APC
Sho insert w arch toe filler,L5000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2114.62,,,,,,,fee schedule,824.75,2296.92,
Sho insert w arch toe filler,L5000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2296.92,,,,,,,fee schedule,824.75,2296.92,
Sho insert w arch toe filler,L5000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1841.18,,,,,,,fee schedule,824.75,2296.92,
Sho insert w arch toe filler,L5000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2011.32,,,,,,,fee schedule,824.75,2296.92,
Sho insert w arch toe filler,L5000,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,865.99,,,,,,,fee schedule,824.75,2296.92,APC
Sho insert w arch toe filler,L5000,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,857.74,,,,,,,fee schedule,824.75,2296.92,APC
Sho insert w arch toe filler,L5000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,824.75,,,,,,,fee schedule,824.75,2296.92,APC
Sho insert w arch toe filler,L5000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1261.87,,,,,,,fee schedule,824.75,2296.92,Radiology
Sho insert w arch toe filler,L5000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1154.65,,,,,,,fee schedule,824.75,2296.92,APC
Sho insert w arch toe filler,L5000,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1443.31,,,,,,,fee schedule,824.75,2296.92,APC
Mold socket ank hgt w/ toe f,L5010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4801.53,,,,,,,fee schedule,1872.71,5215.46,
Mold socket ank hgt w/ toe f,L5010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5215.46,,,,,,,fee schedule,1872.71,5215.46,
Mold socket ank hgt w/ toe f,L5010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4180.64,,,,,,,fee schedule,1872.71,5215.46,
Mold socket ank hgt w/ toe f,L5010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4566.97,,,,,,,fee schedule,1872.71,5215.46,
Mold socket ank hgt w/ toe f,L5010,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1966.35,,,,,,,fee schedule,1872.71,5215.46,APC
Mold socket ank hgt w/ toe f,L5010,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1947.62,,,,,,,fee schedule,1872.71,5215.46,APC
Mold socket ank hgt w/ toe f,L5010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1872.71,,,,,,,fee schedule,1872.71,5215.46,APC
Mold socket ank hgt w/ toe f,L5010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2865.25,,,,,,,fee schedule,1872.71,5215.46,Radiology
Mold socket ank hgt w/ toe f,L5010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2621.79,,,,,,,fee schedule,1872.71,5215.46,APC
Mold socket ank hgt w/ toe f,L5010,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3277.24,,,,,,,fee schedule,1872.71,5215.46,APC
Tibial tubercle hgt w/ toe f,L5020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7213.1,,,,,,,fee schedule,2813.27,7834.92,
Tibial tubercle hgt w/ toe f,L5020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7834.92,,,,,,,fee schedule,2813.27,7834.92,
Tibial tubercle hgt w/ toe f,L5020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6280.37,,,,,,,fee schedule,2813.27,7834.92,
Tibial tubercle hgt w/ toe f,L5020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6860.74,,,,,,,fee schedule,2813.27,7834.92,
Tibial tubercle hgt w/ toe f,L5020,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2953.93,,,,,,,fee schedule,2813.27,7834.92,APC
Tibial tubercle hgt w/ toe f,L5020,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2925.8,,,,,,,fee schedule,2813.27,7834.92,APC
Tibial tubercle hgt w/ toe f,L5020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2813.27,,,,,,,fee schedule,2813.27,7834.92,APC
Tibial tubercle hgt w/ toe f,L5020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4304.3,,,,,,,fee schedule,2813.27,7834.92,Radiology
Tibial tubercle hgt w/ toe f,L5020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3938.58,,,,,,,fee schedule,2813.27,7834.92,APC
Tibial tubercle hgt w/ toe f,L5020,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4923.22,,,,,,,fee schedule,2813.27,7834.92,APC
Ank symes mold sckt sach ft,L5050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9080.22,,,,,,,fee schedule,3541.48,9863,
Ank symes mold sckt sach ft,L5050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9863,,,,,,,fee schedule,3541.48,9863,
Ank symes mold sckt sach ft,L5050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7906.06,,,,,,,fee schedule,3541.48,9863,
Ank symes mold sckt sach ft,L5050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8636.65,,,,,,,fee schedule,3541.48,9863,
Ank symes mold sckt sach ft,L5050,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3718.55,,,,,,,fee schedule,3541.48,9863,APC
Ank symes mold sckt sach ft,L5050,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3683.14,,,,,,,fee schedule,3541.48,9863,APC
Ank symes mold sckt sach ft,L5050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3541.48,,,,,,,fee schedule,3541.48,9863,APC
Ank symes mold sckt sach ft,L5050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5418.46,,,,,,,fee schedule,3541.48,9863,Radiology
Ank symes mold sckt sach ft,L5050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4958.07,,,,,,,fee schedule,3541.48,9863,APC
Ank symes mold sckt sach ft,L5050,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6197.59,,,,,,,fee schedule,3541.48,9863,APC
Symes met fr leath socket ar,L5060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10260.19,,,,,,,fee schedule,4001.69,11144.69,
Symes met fr leath socket ar,L5060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11144.69,,,,,,,fee schedule,4001.69,11144.69,
Symes met fr leath socket ar,L5060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8933.44,,,,,,,fee schedule,4001.69,11144.69,
Symes met fr leath socket ar,L5060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9758.97,,,,,,,fee schedule,4001.69,11144.69,
Symes met fr leath socket ar,L5060,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4201.77,,,,,,,fee schedule,4001.69,11144.69,APC
Symes met fr leath socket ar,L5060,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4161.76,,,,,,,fee schedule,4001.69,11144.69,APC
Symes met fr leath socket ar,L5060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4001.69,,,,,,,fee schedule,4001.69,11144.69,APC
Symes met fr leath socket ar,L5060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6122.59,,,,,,,fee schedule,4001.69,11144.69,Radiology
Symes met fr leath socket ar,L5060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5602.37,,,,,,,fee schedule,4001.69,11144.69,APC
Symes met fr leath socket ar,L5060,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7002.96,,,,,,,fee schedule,4001.69,11144.69,APC
Molded socket shin sach foot,L5100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8922.79,,,,,,,fee schedule,3480.09,9692,
Molded socket shin sach foot,L5100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9692,,,,,,,fee schedule,3480.09,9692,
Molded socket shin sach foot,L5100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7768.98,,,,,,,fee schedule,3480.09,9692,
Molded socket shin sach foot,L5100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8486.91,,,,,,,fee schedule,3480.09,9692,
Molded socket shin sach foot,L5100,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3654.09,,,,,,,fee schedule,3480.09,9692,APC
Molded socket shin sach foot,L5100,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3619.29,,,,,,,fee schedule,3480.09,9692,APC
Molded socket shin sach foot,L5100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3480.09,,,,,,,fee schedule,3480.09,9692,APC
Molded socket shin sach foot,L5100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5324.54,,,,,,,fee schedule,3480.09,9692,Radiology
Molded socket shin sach foot,L5100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4872.13,,,,,,,fee schedule,3480.09,9692,APC
Molded socket shin sach foot,L5100,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6090.16,,,,,,,fee schedule,3480.09,9692,APC
Plast socket jts/thgh lacer,L5105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10904.48,,,,,,,fee schedule,4252.97,11844.52,
Plast socket jts/thgh lacer,L5105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11844.52,,,,,,,fee schedule,4252.97,11844.52,
Plast socket jts/thgh lacer,L5105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9494.41,,,,,,,fee schedule,4252.97,11844.52,
Plast socket jts/thgh lacer,L5105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10371.79,,,,,,,fee schedule,4252.97,11844.52,
Plast socket jts/thgh lacer,L5105,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4465.62,,,,,,,fee schedule,4252.97,11844.52,APC
Plast socket jts/thgh lacer,L5105,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4423.09,,,,,,,fee schedule,4252.97,11844.52,APC
Plast socket jts/thgh lacer,L5105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4252.97,,,,,,,fee schedule,4252.97,11844.52,APC
Plast socket jts/thgh lacer,L5105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6507.04,,,,,,,fee schedule,4252.97,11844.52,Radiology
Plast socket jts/thgh lacer,L5105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5954.16,,,,,,,fee schedule,4252.97,11844.52,APC
Plast socket jts/thgh lacer,L5105,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7442.7,,,,,,,fee schedule,4252.97,11844.52,APC
Mold sckt ext knee shin sach,L5150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12997.9,,,,,,,fee schedule,5069.47,14118.41,
Mold sckt ext knee shin sach,L5150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14118.41,,,,,,,fee schedule,5069.47,14118.41,
Mold sckt ext knee shin sach,L5150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11317.14,,,,,,,fee schedule,5069.47,14118.41,
Mold sckt ext knee shin sach,L5150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12362.95,,,,,,,fee schedule,5069.47,14118.41,
Mold sckt ext knee shin sach,L5150,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5322.94,,,,,,,fee schedule,5069.47,14118.41,APC
Mold sckt ext knee shin sach,L5150,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5272.25,,,,,,,fee schedule,5069.47,14118.41,APC
Mold sckt ext knee shin sach,L5150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5069.47,,,,,,,fee schedule,5069.47,14118.41,APC
Mold sckt ext knee shin sach,L5150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7756.29,,,,,,,fee schedule,5069.47,14118.41,Radiology
Mold sckt ext knee shin sach,L5150,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7097.26,,,,,,,fee schedule,5069.47,14118.41,APC
Mold sckt ext knee shin sach,L5150,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8871.57,,,,,,,fee schedule,5069.47,14118.41,APC
Mold socket bent knee shin s,L5160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13675.36,,,,,,,fee schedule,5333.68,14854.27,
Mold socket bent knee shin s,L5160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14854.27,,,,,,,fee schedule,5333.68,14854.27,
Mold socket bent knee shin s,L5160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11906.99,,,,,,,fee schedule,5333.68,14854.27,
Mold socket bent knee shin s,L5160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13007.31,,,,,,,fee schedule,5333.68,14854.27,
Mold socket bent knee shin s,L5160,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5600.36,,,,,,,fee schedule,5333.68,14854.27,APC
Mold socket bent knee shin s,L5160,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5547.03,,,,,,,fee schedule,5333.68,14854.27,APC
Mold socket bent knee shin s,L5160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5333.68,,,,,,,fee schedule,5333.68,14854.27,APC
Mold socket bent knee shin s,L5160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8160.53,,,,,,,fee schedule,5333.68,14854.27,Radiology
Mold socket bent knee shin s,L5160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7467.15,,,,,,,fee schedule,5333.68,14854.27,APC
Mold socket bent knee shin s,L5160,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9333.94,,,,,,,fee schedule,5333.68,14854.27,APC
Kne sing axis fric shin sach,L5200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11884.93,,,,,,,fee schedule,4635.37,12909.49,
Kne sing axis fric shin sach,L5200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12909.49,,,,,,,fee schedule,4635.37,12909.49,
Kne sing axis fric shin sach,L5200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10348.09,,,,,,,fee schedule,4635.37,12909.49,
Kne sing axis fric shin sach,L5200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11304.35,,,,,,,fee schedule,4635.37,12909.49,
Kne sing axis fric shin sach,L5200,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4867.14,,,,,,,fee schedule,4635.37,12909.49,APC
Kne sing axis fric shin sach,L5200,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4820.78,,,,,,,fee schedule,4635.37,12909.49,APC
Kne sing axis fric shin sach,L5200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4635.37,,,,,,,fee schedule,4635.37,12909.49,APC
Kne sing axis fric shin sach,L5200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7092.12,,,,,,,fee schedule,4635.37,12909.49,Radiology
Kne sing axis fric shin sach,L5200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6489.52,,,,,,,fee schedule,4635.37,12909.49,APC
Kne sing axis fric shin sach,L5200,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8111.9,,,,,,,fee schedule,4635.37,12909.49,APC
No knee/ankle joints w/ ft b,L5210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8784.88,,,,,,,fee schedule,3426.3,9542.19,
No knee/ankle joints w/ ft b,L5210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9542.19,,,,,,,fee schedule,3426.3,9542.19,
No knee/ankle joints w/ ft b,L5210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7648.9,,,,,,,fee schedule,3426.3,9542.19,
No knee/ankle joints w/ ft b,L5210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8355.73,,,,,,,fee schedule,3426.3,9542.19,
No knee/ankle joints w/ ft b,L5210,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3597.62,,,,,,,fee schedule,3426.3,9542.19,APC
No knee/ankle joints w/ ft b,L5210,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3563.35,,,,,,,fee schedule,3426.3,9542.19,APC
No knee/ankle joints w/ ft b,L5210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3426.3,,,,,,,fee schedule,3426.3,9542.19,APC
No knee/ankle joints w/ ft b,L5210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5242.24,,,,,,,fee schedule,3426.3,9542.19,Radiology
No knee/ankle joints w/ ft b,L5210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4796.82,,,,,,,fee schedule,3426.3,9542.19,APC
No knee/ankle joints w/ ft b,L5210,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5996.02,,,,,,,fee schedule,3426.3,9542.19,APC
No knee joint with artic ali,L5220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11036.47,,,,,,,fee schedule,4304.46,11987.89,
No knee joint with artic ali,L5220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11987.89,,,,,,,fee schedule,4304.46,11987.89,
No knee joint with artic ali,L5220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9609.34,,,,,,,fee schedule,4304.46,11987.89,
No knee joint with artic ali,L5220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10497.33,,,,,,,fee schedule,4304.46,11987.89,
No knee joint with artic ali,L5220,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4519.68,,,,,,,fee schedule,4304.46,11987.89,APC
No knee joint with artic ali,L5220,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4476.64,,,,,,,fee schedule,4304.46,11987.89,APC
No knee joint with artic ali,L5220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4304.46,,,,,,,fee schedule,4304.46,11987.89,APC
No knee joint with artic ali,L5220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6585.82,,,,,,,fee schedule,4304.46,11987.89,Radiology
No knee joint with artic ali,L5220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6026.24,,,,,,,fee schedule,4304.46,11987.89,APC
No knee joint with artic ali,L5220,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7532.8,,,,,,,fee schedule,4304.46,11987.89,APC
Fem focal defic constant fri,L5230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13081.29,,,,,,,fee schedule,5101.97,14208.98,
Fem focal defic constant fri,L5230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14208.98,,,,,,,fee schedule,5101.97,14208.98,
Fem focal defic constant fri,L5230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11389.74,,,,,,,fee schedule,5101.97,14208.98,
Fem focal defic constant fri,L5230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12442.26,,,,,,,fee schedule,5101.97,14208.98,
Fem focal defic constant fri,L5230,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5357.07,,,,,,,fee schedule,5101.97,14208.98,APC
Fem focal defic constant fri,L5230,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5306.05,,,,,,,fee schedule,5101.97,14208.98,APC
Fem focal defic constant fri,L5230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5101.97,,,,,,,fee schedule,5101.97,14208.98,APC
Fem focal defic constant fri,L5230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7806.01,,,,,,,fee schedule,5101.97,14208.98,Radiology
Fem focal defic constant fri,L5230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7142.76,,,,,,,fee schedule,5101.97,14208.98,APC
Fem focal defic constant fri,L5230,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8928.45,,,,,,,fee schedule,5101.97,14208.98,APC
Hip canad sing axi cons fric,L5250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17709.58,,,,,,,fee schedule,6907.11,19236.27,
Hip canad sing axi cons fric,L5250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19236.27,,,,,,,fee schedule,6907.11,19236.27,
Hip canad sing axi cons fric,L5250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15419.55,,,,,,,fee schedule,6907.11,19236.27,
Hip canad sing axi cons fric,L5250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16844.46,,,,,,,fee schedule,6907.11,19236.27,
Hip canad sing axi cons fric,L5250,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7252.47,,,,,,,fee schedule,6907.11,19236.27,APC
Hip canad sing axi cons fric,L5250,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7183.39,,,,,,,fee schedule,6907.11,19236.27,APC
Hip canad sing axi cons fric,L5250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6907.11,,,,,,,fee schedule,6907.11,19236.27,APC
Hip canad sing axi cons fric,L5250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10567.88,,,,,,,fee schedule,6907.11,19236.27,Radiology
Hip canad sing axi cons fric,L5250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9669.95,,,,,,,fee schedule,6907.11,19236.27,APC
Hip canad sing axi cons fric,L5250,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12087.44,,,,,,,fee schedule,6907.11,19236.27,APC
Tilt table locking hip sing,L5270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16827.68,,,,,,,fee schedule,6563.13,18278.34,
Tilt table locking hip sing,L5270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18278.34,,,,,,,fee schedule,6563.13,18278.34,
Tilt table locking hip sing,L5270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14651.69,,,,,,,fee schedule,6563.13,18278.34,
Tilt table locking hip sing,L5270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16005.64,,,,,,,fee schedule,6563.13,18278.34,
Tilt table locking hip sing,L5270,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6891.29,,,,,,,fee schedule,6563.13,18278.34,APC
Tilt table locking hip sing,L5270,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6825.66,,,,,,,fee schedule,6563.13,18278.34,APC
Tilt table locking hip sing,L5270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6563.13,,,,,,,fee schedule,6563.13,18278.34,APC
Tilt table locking hip sing,L5270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10041.59,,,,,,,fee schedule,6563.13,18278.34,Radiology
Tilt table locking hip sing,L5270,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9188.38,,,,,,,fee schedule,6563.13,18278.34,APC
Tilt table locking hip sing,L5270,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11485.48,,,,,,,fee schedule,6563.13,18278.34,APC
Hemipelvect canad sing axis,L5280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18317.92,,,,,,,fee schedule,7144.39,19897.05,
Hemipelvect canad sing axis,L5280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19897.05,,,,,,,fee schedule,7144.39,19897.05,
Hemipelvect canad sing axis,L5280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15949.22,,,,,,,fee schedule,7144.39,19897.05,
Hemipelvect canad sing axis,L5280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17423.08,,,,,,,fee schedule,7144.39,19897.05,
Hemipelvect canad sing axis,L5280,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7501.61,,,,,,,fee schedule,7144.39,19897.05,APC
Hemipelvect canad sing axis,L5280,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7430.17,,,,,,,fee schedule,7144.39,19897.05,APC
Hemipelvect canad sing axis,L5280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7144.39,,,,,,,fee schedule,7144.39,19897.05,APC
Hemipelvect canad sing axis,L5280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10930.92,,,,,,,fee schedule,7144.39,19897.05,Radiology
Hemipelvect canad sing axis,L5280,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10002.15,,,,,,,fee schedule,7144.39,19897.05,APC
Hemipelvect canad sing axis,L5280,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12502.68,,,,,,,fee schedule,7144.39,19897.05,APC
Bk mold socket sach ft endo,L5301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8656.92,,,,,,,fee schedule,3376.36,9403.2,
Bk mold socket sach ft endo,L5301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9403.2,,,,,,,fee schedule,3376.36,9403.2,
Bk mold socket sach ft endo,L5301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7537.49,,,,,,,fee schedule,3376.36,9403.2,
Bk mold socket sach ft endo,L5301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8234.02,,,,,,,fee schedule,3376.36,9403.2,
Bk mold socket sach ft endo,L5301,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3545.18,,,,,,,fee schedule,3376.36,9403.2,APC
Bk mold socket sach ft endo,L5301,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3511.41,,,,,,,fee schedule,3376.36,9403.2,APC
Bk mold socket sach ft endo,L5301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3376.36,,,,,,,fee schedule,3376.36,9403.2,APC
Bk mold socket sach ft endo,L5301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5165.83,,,,,,,fee schedule,3376.36,9403.2,Radiology
Bk mold socket sach ft endo,L5301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4726.9,,,,,,,fee schedule,3376.36,9403.2,APC
Bk mold socket sach ft endo,L5301,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5908.63,,,,,,,fee schedule,3376.36,9403.2,APC
"Knee disart, SACH ft, endo",L5312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11914.44,,,,,,,fee schedule,4506.48,12941.55,
"Knee disart, SACH ft, endo",L5312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12941.55,,,,,,,fee schedule,4506.48,12941.55,
"Knee disart, SACH ft, endo",L5312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10373.78,,,,,,,fee schedule,4506.48,12941.55,
"Knee disart, SACH ft, endo",L5312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11332.41,,,,,,,fee schedule,4506.48,12941.55,
"Knee disart, SACH ft, endo",L5312,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4731.8,,,,,,,fee schedule,4506.48,12941.55,APC
"Knee disart, SACH ft, endo",L5312,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4686.74,,,,,,,fee schedule,4506.48,12941.55,APC
"Knee disart, SACH ft, endo",L5312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4506.48,,,,,,,fee schedule,4506.48,12941.55,APC
"Knee disart, SACH ft, endo",L5312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6894.91,,,,,,,fee schedule,4506.48,12941.55,Radiology
"Knee disart, SACH ft, endo",L5312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6309.07,,,,,,,fee schedule,4506.48,12941.55,APC
"Knee disart, SACH ft, endo",L5312,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7886.34,,,,,,,fee schedule,4506.48,12941.55,APC
Ak open end sach,L5321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12077.58,,,,,,,fee schedule,4710.53,13118.75,
Ak open end sach,L5321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13118.75,,,,,,,fee schedule,4710.53,13118.75,
Ak open end sach,L5321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10515.83,,,,,,,fee schedule,4710.53,13118.75,
Ak open end sach,L5321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11487.59,,,,,,,fee schedule,4710.53,13118.75,
Ak open end sach,L5321,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4946.06,,,,,,,fee schedule,4710.53,13118.75,APC
Ak open end sach,L5321,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4898.95,,,,,,,fee schedule,4710.53,13118.75,APC
Ak open end sach,L5321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4710.53,,,,,,,fee schedule,4710.53,13118.75,APC
Ak open end sach,L5321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7207.11,,,,,,,fee schedule,4710.53,13118.75,Radiology
Ak open end sach,L5321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6594.74,,,,,,,fee schedule,4710.53,13118.75,APC
Ak open end sach,L5321,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8243.43,,,,,,,fee schedule,4710.53,13118.75,APC
Hip disart canadian sach ft,L5331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18182.37,,,,,,,fee schedule,7091.52,19749.82,
Hip disart canadian sach ft,L5331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19749.82,,,,,,,fee schedule,7091.52,19749.82,
Hip disart canadian sach ft,L5331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15831.2,,,,,,,fee schedule,7091.52,19749.82,
Hip disart canadian sach ft,L5331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17294.15,,,,,,,fee schedule,7091.52,19749.82,
Hip disart canadian sach ft,L5331,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7446.1,,,,,,,fee schedule,7091.52,19749.82,APC
Hip disart canadian sach ft,L5331,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7375.18,,,,,,,fee schedule,7091.52,19749.82,APC
Hip disart canadian sach ft,L5331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7091.52,,,,,,,fee schedule,7091.52,19749.82,APC
Hip disart canadian sach ft,L5331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10850.03,,,,,,,fee schedule,7091.52,19749.82,Radiology
Hip disart canadian sach ft,L5331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9928.13,,,,,,,fee schedule,7091.52,19749.82,APC
Hip disart canadian sach ft,L5331,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12410.16,,,,,,,fee schedule,7091.52,19749.82,APC
Hemipelvectomy canadian sach,L5341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18974.42,,,,,,,fee schedule,7400.44,20610.15,
Hemipelvectomy canadian sach,L5341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20610.15,,,,,,,fee schedule,7400.44,20610.15,
Hemipelvectomy canadian sach,L5341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16520.83,,,,,,,fee schedule,7400.44,20610.15,
Hemipelvectomy canadian sach,L5341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18047.51,,,,,,,fee schedule,7400.44,20610.15,
Hemipelvectomy canadian sach,L5341,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,7770.46,,,,,,,fee schedule,7400.44,20610.15,APC
Hemipelvectomy canadian sach,L5341,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,7696.46,,,,,,,fee schedule,7400.44,20610.15,APC
Hemipelvectomy canadian sach,L5341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7400.44,,,,,,,fee schedule,7400.44,20610.15,APC
Hemipelvectomy canadian sach,L5341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11322.67,,,,,,,fee schedule,7400.44,20610.15,Radiology
Hemipelvectomy canadian sach,L5341,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10360.62,,,,,,,fee schedule,7400.44,20610.15,APC
Hemipelvectomy canadian sach,L5341,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12950.77,,,,,,,fee schedule,7400.44,20610.15,APC
Postop dress & 1 cast chg bk,L5400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4476.6,,,,,,,fee schedule,1745.96,4862.52,
Postop dress & 1 cast chg bk,L5400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4862.52,,,,,,,fee schedule,1745.96,4862.52,
Postop dress & 1 cast chg bk,L5400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3897.73,,,,,,,fee schedule,1745.96,4862.52,
Postop dress & 1 cast chg bk,L5400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4257.92,,,,,,,fee schedule,1745.96,4862.52,
Postop dress & 1 cast chg bk,L5400,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1833.26,,,,,,,fee schedule,1745.96,4862.52,APC
Postop dress & 1 cast chg bk,L5400,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1815.8,,,,,,,fee schedule,1745.96,4862.52,APC
Postop dress & 1 cast chg bk,L5400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1745.96,,,,,,,fee schedule,1745.96,4862.52,APC
Postop dress & 1 cast chg bk,L5400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2671.32,,,,,,,fee schedule,1745.96,4862.52,Radiology
Postop dress & 1 cast chg bk,L5400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2444.34,,,,,,,fee schedule,1745.96,4862.52,APC
Postop dress & 1 cast chg bk,L5400,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3055.43,,,,,,,fee schedule,1745.96,4862.52,APC
Postop dsg bk ea add cast ch,L5410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1748.67,,,,,,,fee schedule,682.01,1899.41,
Postop dsg bk ea add cast ch,L5410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1899.41,,,,,,,fee schedule,682.01,1899.41,
Postop dsg bk ea add cast ch,L5410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1522.54,,,,,,,fee schedule,682.01,1899.41,
Postop dsg bk ea add cast ch,L5410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1663.24,,,,,,,fee schedule,682.01,1899.41,
Postop dsg bk ea add cast ch,L5410,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,716.11,,,,,,,fee schedule,682.01,1899.41,APC
Postop dsg bk ea add cast ch,L5410,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,709.29,,,,,,,fee schedule,682.01,1899.41,APC
Postop dsg bk ea add cast ch,L5410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,682.01,,,,,,,fee schedule,682.01,1899.41,APC
Postop dsg bk ea add cast ch,L5410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1043.48,,,,,,,fee schedule,682.01,1899.41,Radiology
Postop dsg bk ea add cast ch,L5410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,954.81,,,,,,,fee schedule,682.01,1899.41,APC
Postop dsg bk ea add cast ch,L5410,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1193.52,,,,,,,fee schedule,682.01,1899.41,APC
Postop dsg & 1 cast chg ak/d,L5420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5732.92,,,,,,,fee schedule,2235.96,6227.13,
Postop dsg & 1 cast chg ak/d,L5420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6227.13,,,,,,,fee schedule,2235.96,6227.13,
Postop dsg & 1 cast chg ak/d,L5420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4991.59,,,,,,,fee schedule,2235.96,6227.13,
Postop dsg & 1 cast chg ak/d,L5420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5452.86,,,,,,,fee schedule,2235.96,6227.13,
Postop dsg & 1 cast chg ak/d,L5420,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2347.76,,,,,,,fee schedule,2235.96,6227.13,APC
Postop dsg & 1 cast chg ak/d,L5420,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2325.4,,,,,,,fee schedule,2235.96,6227.13,APC
Postop dsg & 1 cast chg ak/d,L5420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2235.96,,,,,,,fee schedule,2235.96,6227.13,APC
Postop dsg & 1 cast chg ak/d,L5420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3421.02,,,,,,,fee schedule,2235.96,6227.13,Radiology
Postop dsg & 1 cast chg ak/d,L5420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3130.34,,,,,,,fee schedule,2235.96,6227.13,APC
Postop dsg & 1 cast chg ak/d,L5420,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3912.93,,,,,,,fee schedule,2235.96,6227.13,APC
Postop dsg ak ea add cast ch,L5430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2106.06,,,,,,,fee schedule,821.42,2287.62,
Postop dsg ak ea add cast ch,L5430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2287.62,,,,,,,fee schedule,821.42,2287.62,
Postop dsg ak ea add cast ch,L5430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1833.73,,,,,,,fee schedule,821.42,2287.62,
Postop dsg ak ea add cast ch,L5430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2003.18,,,,,,,fee schedule,821.42,2287.62,
Postop dsg ak ea add cast ch,L5430,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,862.49,,,,,,,fee schedule,821.42,2287.62,APC
Postop dsg ak ea add cast ch,L5430,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,854.28,,,,,,,fee schedule,821.42,2287.62,APC
Postop dsg ak ea add cast ch,L5430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,821.42,,,,,,,fee schedule,821.42,2287.62,APC
Postop dsg ak ea add cast ch,L5430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1256.77,,,,,,,fee schedule,821.42,2287.62,Radiology
Postop dsg ak ea add cast ch,L5430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1149.99,,,,,,,fee schedule,821.42,2287.62,APC
Postop dsg ak ea add cast ch,L5430,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1437.48,,,,,,,fee schedule,821.42,2287.62,APC
Postop app non-wgt bear dsg,L5450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1705.1,,,,,,,fee schedule,665.02,1852.09,
Postop app non-wgt bear dsg,L5450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1852.09,,,,,,,fee schedule,665.02,1852.09,
Postop app non-wgt bear dsg,L5450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1484.61,,,,,,,fee schedule,665.02,1852.09,
Postop app non-wgt bear dsg,L5450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1621.8,,,,,,,fee schedule,665.02,1852.09,
Postop app non-wgt bear dsg,L5450,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,698.27,,,,,,,fee schedule,665.02,1852.09,APC
Postop app non-wgt bear dsg,L5450,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,691.62,,,,,,,fee schedule,665.02,1852.09,APC
Postop app non-wgt bear dsg,L5450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,665.02,,,,,,,fee schedule,665.02,1852.09,APC
Postop app non-wgt bear dsg,L5450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1017.48,,,,,,,fee schedule,665.02,1852.09,Radiology
Postop app non-wgt bear dsg,L5450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,931.03,,,,,,,fee schedule,665.02,1852.09,APC
Postop app non-wgt bear dsg,L5450,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1163.78,,,,,,,fee schedule,665.02,1852.09,APC
Postop app non-wgt bear dsg,L5460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2282.11,,,,,,,fee schedule,890.08,2478.85,
Postop app non-wgt bear dsg,L5460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2478.85,,,,,,,fee schedule,890.08,2478.85,
Postop app non-wgt bear dsg,L5460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1987.01,,,,,,,fee schedule,890.08,2478.85,
Postop app non-wgt bear dsg,L5460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2170.63,,,,,,,fee schedule,890.08,2478.85,
Postop app non-wgt bear dsg,L5460,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,934.58,,,,,,,fee schedule,890.08,2478.85,APC
Postop app non-wgt bear dsg,L5460,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,925.68,,,,,,,fee schedule,890.08,2478.85,APC
Postop app non-wgt bear dsg,L5460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,890.08,,,,,,,fee schedule,890.08,2478.85,APC
Postop app non-wgt bear dsg,L5460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1361.82,,,,,,,fee schedule,890.08,2478.85,Radiology
Postop app non-wgt bear dsg,L5460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1246.11,,,,,,,fee schedule,890.08,2478.85,APC
Postop app non-wgt bear dsg,L5460,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1557.64,,,,,,,fee schedule,890.08,2478.85,APC
Init bk ptb plaster direct,L5500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4504.48,,,,,,,fee schedule,1756.84,4892.79,
Init bk ptb plaster direct,L5500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4892.79,,,,,,,fee schedule,1756.84,4892.79,
Init bk ptb plaster direct,L5500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3922,,,,,,,fee schedule,1756.84,4892.79,
Init bk ptb plaster direct,L5500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4284.43,,,,,,,fee schedule,1756.84,4892.79,
Init bk ptb plaster direct,L5500,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1844.68,,,,,,,fee schedule,1756.84,4892.79,APC
Init bk ptb plaster direct,L5500,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1827.11,,,,,,,fee schedule,1756.84,4892.79,APC
Init bk ptb plaster direct,L5500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1756.84,,,,,,,fee schedule,1756.84,4892.79,APC
Init bk ptb plaster direct,L5500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2687.97,,,,,,,fee schedule,1756.84,4892.79,Radiology
Init bk ptb plaster direct,L5500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2459.58,,,,,,,fee schedule,1756.84,4892.79,APC
Init bk ptb plaster direct,L5500,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3074.47,,,,,,,fee schedule,1756.84,4892.79,APC
Init ak ischal plstr direct,L5505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7279.46,,,,,,,fee schedule,2839.14,7907,
Init ak ischal plstr direct,L5505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7907,,,,,,,fee schedule,2839.14,7907,
Init ak ischal plstr direct,L5505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6338.15,,,,,,,fee schedule,2839.14,7907,
Init ak ischal plstr direct,L5505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6923.86,,,,,,,fee schedule,2839.14,7907,
Init ak ischal plstr direct,L5505,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2981.1,,,,,,,fee schedule,2839.14,7907,APC
Init ak ischal plstr direct,L5505,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2952.71,,,,,,,fee schedule,2839.14,7907,APC
Init ak ischal plstr direct,L5505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2839.14,,,,,,,fee schedule,2839.14,7907,APC
Init ak ischal plstr direct,L5505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4343.88,,,,,,,fee schedule,2839.14,7907,Radiology
Init ak ischal plstr direct,L5505,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3974.8,,,,,,,fee schedule,2839.14,7907,APC
Init ak ischal plstr direct,L5505,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4968.5,,,,,,,fee schedule,2839.14,7907,APC
Prep BK ptb plaster molded,L5510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5355.2,,,,,,,fee schedule,2088.64,5816.85,
Prep BK ptb plaster molded,L5510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5816.85,,,,,,,fee schedule,2088.64,5816.85,
Prep BK ptb plaster molded,L5510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4662.72,,,,,,,fee schedule,2088.64,5816.85,
Prep BK ptb plaster molded,L5510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5093.59,,,,,,,fee schedule,2088.64,5816.85,
Prep BK ptb plaster molded,L5510,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2193.07,,,,,,,fee schedule,2088.64,5816.85,APC
Prep BK ptb plaster molded,L5510,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2172.19,,,,,,,fee schedule,2088.64,5816.85,APC
Prep BK ptb plaster molded,L5510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2088.64,,,,,,,fee schedule,2088.64,5816.85,APC
Prep BK ptb plaster molded,L5510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3195.62,,,,,,,fee schedule,2088.64,5816.85,Radiology
Prep BK ptb plaster molded,L5510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2924.1,,,,,,,fee schedule,2088.64,5816.85,APC
Prep BK ptb plaster molded,L5510,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3655.12,,,,,,,fee schedule,2088.64,5816.85,APC
Perp BK ptb thermopls direct,L5520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6018.59,,,,,,,fee schedule,2347.37,6537.43,
Perp BK ptb thermopls direct,L5520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6537.43,,,,,,,fee schedule,2347.37,6537.43,
Perp BK ptb thermopls direct,L5520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5240.32,,,,,,,fee schedule,2347.37,6537.43,
Perp BK ptb thermopls direct,L5520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5724.58,,,,,,,fee schedule,2347.37,6537.43,
Perp BK ptb thermopls direct,L5520,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2464.74,,,,,,,fee schedule,2347.37,6537.43,APC
Perp BK ptb thermopls direct,L5520,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2441.26,,,,,,,fee schedule,2347.37,6537.43,APC
Perp BK ptb thermopls direct,L5520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2347.37,,,,,,,fee schedule,2347.37,6537.43,APC
Perp BK ptb thermopls direct,L5520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3591.48,,,,,,,fee schedule,2347.37,6537.43,Radiology
Perp BK ptb thermopls direct,L5520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3286.32,,,,,,,fee schedule,2347.37,6537.43,APC
Perp BK ptb thermopls direct,L5520,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4107.9,,,,,,,fee schedule,2347.37,6537.43,APC
Prep BK ptb thermopls molded,L5530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6219.91,,,,,,,fee schedule,2425.89,6756.11,
Prep BK ptb thermopls molded,L5530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6756.11,,,,,,,fee schedule,2425.89,6756.11,
Prep BK ptb thermopls molded,L5530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5415.61,,,,,,,fee schedule,2425.89,6756.11,
Prep BK ptb thermopls molded,L5530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5916.06,,,,,,,fee schedule,2425.89,6756.11,
Prep BK ptb thermopls molded,L5530,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2547.18,,,,,,,fee schedule,2425.89,6756.11,APC
Prep BK ptb thermopls molded,L5530,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2522.93,,,,,,,fee schedule,2425.89,6756.11,APC
Prep BK ptb thermopls molded,L5530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2425.89,,,,,,,fee schedule,2425.89,6756.11,APC
Prep BK ptb thermopls molded,L5530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3711.61,,,,,,,fee schedule,2425.89,6756.11,Radiology
Prep BK ptb thermopls molded,L5530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3396.25,,,,,,,fee schedule,2425.89,6756.11,APC
Prep BK ptb thermopls molded,L5530,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4245.31,,,,,,,fee schedule,2425.89,6756.11,APC
Prep BK ptb open end socket,L5535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6232.05,,,,,,,fee schedule,2430.65,6769.3,
Prep BK ptb open end socket,L5535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6769.3,,,,,,,fee schedule,2430.65,6769.3,
Prep BK ptb open end socket,L5535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5426.18,,,,,,,fee schedule,2430.65,6769.3,
Prep BK ptb open end socket,L5535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5927.61,,,,,,,fee schedule,2430.65,6769.3,
Prep BK ptb open end socket,L5535,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2552.18,,,,,,,fee schedule,2430.65,6769.3,APC
Prep BK ptb open end socket,L5535,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2527.88,,,,,,,fee schedule,2430.65,6769.3,APC
Prep BK ptb open end socket,L5535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2430.65,,,,,,,fee schedule,2430.65,6769.3,APC
Prep BK ptb open end socket,L5535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3718.89,,,,,,,fee schedule,2430.65,6769.3,Radiology
Prep BK ptb open end socket,L5535,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3402.91,,,,,,,fee schedule,2430.65,6769.3,APC
Prep BK ptb open end socket,L5535,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4253.64,,,,,,,fee schedule,2430.65,6769.3,APC
Prep BK ptb laminated socket,L5540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6681.95,,,,,,,fee schedule,2606.1,7257.98,
Prep BK ptb laminated socket,L5540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7257.98,,,,,,,fee schedule,2606.1,7257.98,
Prep BK ptb laminated socket,L5540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5817.9,,,,,,,fee schedule,2606.1,7257.98,
Prep BK ptb laminated socket,L5540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6355.53,,,,,,,fee schedule,2606.1,7257.98,
Prep BK ptb laminated socket,L5540,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2736.4,,,,,,,fee schedule,2606.1,7257.98,APC
Prep BK ptb laminated socket,L5540,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2710.34,,,,,,,fee schedule,2606.1,7257.98,APC
Prep BK ptb laminated socket,L5540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2606.1,,,,,,,fee schedule,2606.1,7257.98,APC
Prep BK ptb laminated socket,L5540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3987.33,,,,,,,fee schedule,2606.1,7257.98,Radiology
Prep BK ptb laminated socket,L5540,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3648.54,,,,,,,fee schedule,2606.1,7257.98,APC
Prep BK ptb laminated socket,L5540,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4560.68,,,,,,,fee schedule,2606.1,7257.98,APC
Prep AK ischial plast molded,L5560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8036.16,,,,,,,fee schedule,3134.29,8728.93,
Prep AK ischial plast molded,L5560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8728.93,,,,,,,fee schedule,3134.29,8728.93,
Prep AK ischial plast molded,L5560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6997,,,,,,,fee schedule,3134.29,8728.93,
Prep AK ischial plast molded,L5560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7643.58,,,,,,,fee schedule,3134.29,8728.93,
Prep AK ischial plast molded,L5560,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3291,,,,,,,fee schedule,3134.29,8728.93,APC
Prep AK ischial plast molded,L5560,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3259.66,,,,,,,fee schedule,3134.29,8728.93,APC
Prep AK ischial plast molded,L5560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3134.29,,,,,,,fee schedule,3134.29,8728.93,APC
Prep AK ischial plast molded,L5560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4795.46,,,,,,,fee schedule,3134.29,8728.93,Radiology
Prep AK ischial plast molded,L5560,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4388.01,,,,,,,fee schedule,3134.29,8728.93,APC
Prep AK ischial plast molded,L5560,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5485.01,,,,,,,fee schedule,3134.29,8728.93,APC
Prep AK ischial direct form,L5570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7934.33,,,,,,,fee schedule,3094.56,8618.32,
Prep AK ischial direct form,L5570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8618.32,,,,,,,fee schedule,3094.56,8618.32,
Prep AK ischial direct form,L5570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6908.34,,,,,,,fee schedule,3094.56,8618.32,
Prep AK ischial direct form,L5570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7546.73,,,,,,,fee schedule,3094.56,8618.32,
Prep AK ischial direct form,L5570,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3249.29,,,,,,,fee schedule,3094.56,8618.32,APC
Prep AK ischial direct form,L5570,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3218.34,,,,,,,fee schedule,3094.56,8618.32,APC
Prep AK ischial direct form,L5570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3094.56,,,,,,,fee schedule,3094.56,8618.32,APC
Prep AK ischial direct form,L5570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4734.68,,,,,,,fee schedule,3094.56,8618.32,Radiology
Prep AK ischial direct form,L5570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4332.38,,,,,,,fee schedule,3094.56,8618.32,APC
Prep AK ischial direct form,L5570,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5415.48,,,,,,,fee schedule,3094.56,8618.32,APC
Prep AK ischial thermo mold,L5580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8859.28,,,,,,,fee schedule,3455.29,9623.01,
Prep AK ischial thermo mold,L5580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9623.01,,,,,,,fee schedule,3455.29,9623.01,
Prep AK ischial thermo mold,L5580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7713.68,,,,,,,fee schedule,3455.29,9623.01,
Prep AK ischial thermo mold,L5580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8426.5,,,,,,,fee schedule,3455.29,9623.01,
Prep AK ischial thermo mold,L5580,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3628.05,,,,,,,fee schedule,3455.29,9623.01,APC
Prep AK ischial thermo mold,L5580,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3593.5,,,,,,,fee schedule,3455.29,9623.01,APC
Prep AK ischial thermo mold,L5580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3455.29,,,,,,,fee schedule,3455.29,9623.01,APC
Prep AK ischial thermo mold,L5580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5286.59,,,,,,,fee schedule,3455.29,9623.01,Radiology
Prep AK ischial thermo mold,L5580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4837.41,,,,,,,fee schedule,3455.29,9623.01,APC
Prep AK ischial thermo mold,L5580,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6046.76,,,,,,,fee schedule,3455.29,9623.01,APC
Prep AK ischial open end,L5585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8888.44,,,,,,,fee schedule,3466.68,9654.69,
Prep AK ischial open end,L5585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9654.69,,,,,,,fee schedule,3466.68,9654.69,
Prep AK ischial open end,L5585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7739.07,,,,,,,fee schedule,3466.68,9654.69,
Prep AK ischial open end,L5585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8454.24,,,,,,,fee schedule,3466.68,9654.69,
Prep AK ischial open end,L5585,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3640.01,,,,,,,fee schedule,3466.68,9654.69,APC
Prep AK ischial open end,L5585,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3605.35,,,,,,,fee schedule,3466.68,9654.69,APC
Prep AK ischial open end,L5585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3466.68,,,,,,,fee schedule,3466.68,9654.69,APC
Prep AK ischial open end,L5585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5304.02,,,,,,,fee schedule,3466.68,9654.69,Radiology
Prep AK ischial open end,L5585,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4853.35,,,,,,,fee schedule,3466.68,9654.69,APC
Prep AK ischial open end,L5585,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6066.69,,,,,,,fee schedule,3466.68,9654.69,APC
Prep AK ischial laminated,L5590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8696.66,,,,,,,fee schedule,3391.89,9446.37,
Prep AK ischial laminated,L5590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9446.37,,,,,,,fee schedule,3391.89,9446.37,
Prep AK ischial laminated,L5590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7572.09,,,,,,,fee schedule,3391.89,9446.37,
Prep AK ischial laminated,L5590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8271.82,,,,,,,fee schedule,3391.89,9446.37,
Prep AK ischial laminated,L5590,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3561.48,,,,,,,fee schedule,3391.89,9446.37,APC
Prep AK ischial laminated,L5590,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3527.57,,,,,,,fee schedule,3391.89,9446.37,APC
Prep AK ischial laminated,L5590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3391.89,,,,,,,fee schedule,3391.89,9446.37,APC
Prep AK ischial laminated,L5590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5189.59,,,,,,,fee schedule,3391.89,9446.37,Radiology
Prep AK ischial laminated,L5590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4748.65,,,,,,,fee schedule,3391.89,9446.37,APC
Prep AK ischial laminated,L5590,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5935.81,,,,,,,fee schedule,3391.89,9446.37,APC
Hip disartic sach thermopls,L5595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12638.87,,,,,,,fee schedule,4929.43,13728.43,
Hip disartic sach thermopls,L5595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13728.43,,,,,,,fee schedule,4929.43,13728.43,
Hip disartic sach thermopls,L5595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11004.54,,,,,,,fee schedule,4929.43,13728.43,
Hip disartic sach thermopls,L5595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12021.46,,,,,,,fee schedule,4929.43,13728.43,
Hip disartic sach thermopls,L5595,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5175.9,,,,,,,fee schedule,4929.43,13728.43,APC
Hip disartic sach thermopls,L5595,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5126.61,,,,,,,fee schedule,4929.43,13728.43,APC
Hip disartic sach thermopls,L5595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4929.43,,,,,,,fee schedule,4929.43,13728.43,APC
Hip disartic sach thermopls,L5595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7542.03,,,,,,,fee schedule,4929.43,13728.43,Radiology
Hip disartic sach thermopls,L5595,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6901.2,,,,,,,fee schedule,4929.43,13728.43,APC
Hip disartic sach thermopls,L5595,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8626.5,,,,,,,fee schedule,4929.43,13728.43,APC
Hip disart sach laminat mold,L5600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13957.1,,,,,,,fee schedule,5443.57,15160.29,
Hip disart sach laminat mold,L5600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15160.29,,,,,,,fee schedule,5443.57,15160.29,
Hip disart sach laminat mold,L5600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12152.3,,,,,,,fee schedule,5443.57,15160.29,
Hip disart sach laminat mold,L5600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13275.28,,,,,,,fee schedule,5443.57,15160.29,
Hip disart sach laminat mold,L5600,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5715.75,,,,,,,fee schedule,5443.57,15160.29,APC
Hip disart sach laminat mold,L5600,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5661.31,,,,,,,fee schedule,5443.57,15160.29,APC
Hip disart sach laminat mold,L5600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5443.57,,,,,,,fee schedule,5443.57,15160.29,APC
Hip disart sach laminat mold,L5600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8328.66,,,,,,,fee schedule,5443.57,15160.29,Radiology
Hip disart sach laminat mold,L5600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7621,,,,,,,fee schedule,5443.57,15160.29,APC
Hip disart sach laminat mold,L5600,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9526.25,,,,,,,fee schedule,5443.57,15160.29,APC
Above knee hydracadence,L5610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7532.01,,,,,,,fee schedule,2937.63,8181.32,
Above knee hydracadence,L5610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8181.32,,,,,,,fee schedule,2937.63,8181.32,
Above knee hydracadence,L5610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6558.04,,,,,,,fee schedule,2937.63,8181.32,
Above knee hydracadence,L5610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7164.06,,,,,,,fee schedule,2937.63,8181.32,
Above knee hydracadence,L5610,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3084.51,,,,,,,fee schedule,2937.63,8181.32,APC
Above knee hydracadence,L5610,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3055.14,,,,,,,fee schedule,2937.63,8181.32,APC
Above knee hydracadence,L5610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2937.63,,,,,,,fee schedule,2937.63,8181.32,APC
Above knee hydracadence,L5610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4494.57,,,,,,,fee schedule,2937.63,8181.32,Radiology
Above knee hydracadence,L5610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4112.68,,,,,,,fee schedule,2937.63,8181.32,APC
Above knee hydracadence,L5610,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5140.85,,,,,,,fee schedule,2937.63,8181.32,APC
Ak 4 bar link w/fric swing,L5611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5057.34,,,,,,,fee schedule,1972.47,5493.32,
Ak 4 bar link w/fric swing,L5611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5493.32,,,,,,,fee schedule,1972.47,5493.32,
Ak 4 bar link w/fric swing,L5611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4403.38,,,,,,,fee schedule,1972.47,5493.32,
Ak 4 bar link w/fric swing,L5611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4810.29,,,,,,,fee schedule,1972.47,5493.32,
Ak 4 bar link w/fric swing,L5611,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2071.09,,,,,,,fee schedule,1972.47,5493.32,APC
Ak 4 bar link w/fric swing,L5611,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2051.37,,,,,,,fee schedule,1972.47,5493.32,APC
Ak 4 bar link w/fric swing,L5611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1972.47,,,,,,,fee schedule,1972.47,5493.32,APC
Ak 4 bar link w/fric swing,L5611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3017.88,,,,,,,fee schedule,1972.47,5493.32,Radiology
Ak 4 bar link w/fric swing,L5611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2761.46,,,,,,,fee schedule,1972.47,5493.32,APC
Ak 4 bar link w/fric swing,L5611,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3451.82,,,,,,,fee schedule,1972.47,5493.32,APC
Ak 4 bar ling w/hydraul swig,L5613,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7789.84,,,,,,,fee schedule,3038.19,8461.38,
Ak 4 bar ling w/hydraul swig,L5613,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8461.38,,,,,,,fee schedule,3038.19,8461.38,
Ak 4 bar ling w/hydraul swig,L5613,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6782.53,,,,,,,fee schedule,3038.19,8461.38,
Ak 4 bar ling w/hydraul swig,L5613,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7409.3,,,,,,,fee schedule,3038.19,8461.38,
Ak 4 bar ling w/hydraul swig,L5613,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3190.1,,,,,,,fee schedule,3038.19,8461.38,APC
Ak 4 bar ling w/hydraul swig,L5613,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3159.72,,,,,,,fee schedule,3038.19,8461.38,APC
Ak 4 bar ling w/hydraul swig,L5613,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3038.19,,,,,,,fee schedule,3038.19,8461.38,APC
Ak 4 bar ling w/hydraul swig,L5613,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4648.43,,,,,,,fee schedule,3038.19,8461.38,Radiology
Ak 4 bar ling w/hydraul swig,L5613,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4253.47,,,,,,,fee schedule,3038.19,8461.38,APC
Ak 4 bar ling w/hydraul swig,L5613,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5316.83,,,,,,,fee schedule,3038.19,8461.38,APC
4-bar link above knee w/swng,L5614,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5355.86,,,,,,,fee schedule,2088.9,5817.57,
4-bar link above knee w/swng,L5614,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5817.57,,,,,,,fee schedule,2088.9,5817.57,
4-bar link above knee w/swng,L5614,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4663.29,,,,,,,fee schedule,2088.9,5817.57,
4-bar link above knee w/swng,L5614,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5094.22,,,,,,,fee schedule,2088.9,5817.57,
4-bar link above knee w/swng,L5614,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2193.35,,,,,,,fee schedule,2088.9,5817.57,APC
4-bar link above knee w/swng,L5614,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2172.46,,,,,,,fee schedule,2088.9,5817.57,APC
4-bar link above knee w/swng,L5614,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2088.9,,,,,,,fee schedule,2088.9,5817.57,APC
4-bar link above knee w/swng,L5614,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3196.02,,,,,,,fee schedule,2088.9,5817.57,Radiology
4-bar link above knee w/swng,L5614,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2924.46,,,,,,,fee schedule,2088.9,5817.57,APC
4-bar link above knee w/swng,L5614,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3655.58,,,,,,,fee schedule,2088.9,5817.57,APC
Ak univ multiplex sys frict,L5616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5684.2,,,,,,,fee schedule,2216.96,6174.21,
Ak univ multiplex sys frict,L5616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6174.21,,,,,,,fee schedule,2216.96,6174.21,
Ak univ multiplex sys frict,L5616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4949.17,,,,,,,fee schedule,2216.96,6174.21,
Ak univ multiplex sys frict,L5616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5406.52,,,,,,,fee schedule,2216.96,6174.21,
Ak univ multiplex sys frict,L5616,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2327.81,,,,,,,fee schedule,2216.96,6174.21,APC
Ak univ multiplex sys frict,L5616,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2305.64,,,,,,,fee schedule,2216.96,6174.21,APC
Ak univ multiplex sys frict,L5616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2216.96,,,,,,,fee schedule,2216.96,6174.21,APC
Ak univ multiplex sys frict,L5616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3391.95,,,,,,,fee schedule,2216.96,6174.21,Radiology
Ak univ multiplex sys frict,L5616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3103.74,,,,,,,fee schedule,2216.96,6174.21,APC
Ak univ multiplex sys frict,L5616,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3879.68,,,,,,,fee schedule,2216.96,6174.21,APC
AK/BK self-aligning unit ea,L5617,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1775.84,,,,,,,fee schedule,692.6,1928.93,
AK/BK self-aligning unit ea,L5617,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1928.93,,,,,,,fee schedule,692.6,1928.93,
AK/BK self-aligning unit ea,L5617,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1546.21,,,,,,,fee schedule,692.6,1928.93,
AK/BK self-aligning unit ea,L5617,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1689.09,,,,,,,fee schedule,692.6,1928.93,
AK/BK self-aligning unit ea,L5617,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,727.23,,,,,,,fee schedule,692.6,1928.93,APC
AK/BK self-aligning unit ea,L5617,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,720.3,,,,,,,fee schedule,692.6,1928.93,APC
AK/BK self-aligning unit ea,L5617,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,692.6,,,,,,,fee schedule,692.6,1928.93,APC
AK/BK self-aligning unit ea,L5617,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1059.68,,,,,,,fee schedule,692.6,1928.93,Radiology
AK/BK self-aligning unit ea,L5617,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,969.64,,,,,,,fee schedule,692.6,1928.93,APC
AK/BK self-aligning unit ea,L5617,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1212.05,,,,,,,fee schedule,692.6,1928.93,APC
Test socket symes,L5618,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,948.27,,,,,,,fee schedule,369.85,1030.01,
Test socket symes,L5618,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1030.01,,,,,,,fee schedule,369.85,1030.01,
Test socket symes,L5618,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,825.64,,,,,,,fee schedule,369.85,1030.01,
Test socket symes,L5618,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,901.94,,,,,,,fee schedule,369.85,1030.01,
Test socket symes,L5618,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,388.34,,,,,,,fee schedule,369.85,1030.01,APC
Test socket symes,L5618,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,384.64,,,,,,,fee schedule,369.85,1030.01,APC
Test socket symes,L5618,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,369.85,,,,,,,fee schedule,369.85,1030.01,APC
Test socket symes,L5618,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,565.87,,,,,,,fee schedule,369.85,1030.01,Radiology
Test socket symes,L5618,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,517.79,,,,,,,fee schedule,369.85,1030.01,APC
Test socket symes,L5618,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,647.24,,,,,,,fee schedule,369.85,1030.01,APC
Test socket below knee,L5620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1163.57,,,,,,,fee schedule,453.81,1263.88,
Test socket below knee,L5620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1263.88,,,,,,,fee schedule,453.81,1263.88,
Test socket below knee,L5620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1013.11,,,,,,,fee schedule,453.81,1263.88,
Test socket below knee,L5620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1106.73,,,,,,,fee schedule,453.81,1263.88,
Test socket below knee,L5620,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,476.5,,,,,,,fee schedule,453.81,1263.88,APC
Test socket below knee,L5620,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,471.96,,,,,,,fee schedule,453.81,1263.88,APC
Test socket below knee,L5620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,453.81,,,,,,,fee schedule,453.81,1263.88,APC
Test socket below knee,L5620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,694.33,,,,,,,fee schedule,453.81,1263.88,Radiology
Test socket below knee,L5620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,635.33,,,,,,,fee schedule,453.81,1263.88,APC
Test socket below knee,L5620,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,794.17,,,,,,,fee schedule,453.81,1263.88,APC
Test socket knee disarticula,L5622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1517.25,,,,,,,fee schedule,591.76,1648.04,
Test socket knee disarticula,L5622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1648.04,,,,,,,fee schedule,591.76,1648.04,
Test socket knee disarticula,L5622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1321.05,,,,,,,fee schedule,591.76,1648.04,
Test socket knee disarticula,L5622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1443.13,,,,,,,fee schedule,591.76,1648.04,
Test socket knee disarticula,L5622,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,621.35,,,,,,,fee schedule,591.76,1648.04,APC
Test socket knee disarticula,L5622,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,615.43,,,,,,,fee schedule,591.76,1648.04,APC
Test socket knee disarticula,L5622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,591.76,,,,,,,fee schedule,591.76,1648.04,APC
Test socket knee disarticula,L5622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,905.39,,,,,,,fee schedule,591.76,1648.04,Radiology
Test socket knee disarticula,L5622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,828.46,,,,,,,fee schedule,591.76,1648.04,APC
Test socket knee disarticula,L5622,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1035.58,,,,,,,fee schedule,591.76,1648.04,APC
Test socket above knee,L5624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1521.6,,,,,,,fee schedule,593.44,1652.77,
Test socket above knee,L5624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1652.77,,,,,,,fee schedule,593.44,1652.77,
Test socket above knee,L5624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1324.84,,,,,,,fee schedule,593.44,1652.77,
Test socket above knee,L5624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1447.26,,,,,,,fee schedule,593.44,1652.77,
Test socket above knee,L5624,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,623.11,,,,,,,fee schedule,593.44,1652.77,APC
Test socket above knee,L5624,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,617.18,,,,,,,fee schedule,593.44,1652.77,APC
Test socket above knee,L5624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,593.44,,,,,,,fee schedule,593.44,1652.77,APC
Test socket above knee,L5624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,907.96,,,,,,,fee schedule,593.44,1652.77,Radiology
Test socket above knee,L5624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,830.82,,,,,,,fee schedule,593.44,1652.77,APC
Test socket above knee,L5624,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1038.52,,,,,,,fee schedule,593.44,1652.77,APC
Test socket hip disarticulat,L5626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1670.92,,,,,,,fee schedule,651.69,1814.97,
Test socket hip disarticulat,L5626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1814.97,,,,,,,fee schedule,651.69,1814.97,
Test socket hip disarticulat,L5626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1454.85,,,,,,,fee schedule,651.69,1814.97,
Test socket hip disarticulat,L5626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1589.3,,,,,,,fee schedule,651.69,1814.97,
Test socket hip disarticulat,L5626,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,684.27,,,,,,,fee schedule,651.69,1814.97,APC
Test socket hip disarticulat,L5626,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,677.76,,,,,,,fee schedule,651.69,1814.97,APC
Test socket hip disarticulat,L5626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,651.69,,,,,,,fee schedule,651.69,1814.97,APC
Test socket hip disarticulat,L5626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,997.09,,,,,,,fee schedule,651.69,1814.97,Radiology
Test socket hip disarticulat,L5626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,912.37,,,,,,,fee schedule,651.69,1814.97,APC
Test socket hip disarticulat,L5626,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1140.46,,,,,,,fee schedule,651.69,1814.97,APC
Test socket hemipelvectomy,L5628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1803.3,,,,,,,fee schedule,703.32,1958.76,
Test socket hemipelvectomy,L5628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1958.76,,,,,,,fee schedule,703.32,1958.76,
Test socket hemipelvectomy,L5628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1570.12,,,,,,,fee schedule,703.32,1958.76,
Test socket hemipelvectomy,L5628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1715.21,,,,,,,fee schedule,703.32,1958.76,
Test socket hemipelvectomy,L5628,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,738.49,,,,,,,fee schedule,703.32,1958.76,APC
Test socket hemipelvectomy,L5628,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,731.45,,,,,,,fee schedule,703.32,1958.76,APC
Test socket hemipelvectomy,L5628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,703.32,,,,,,,fee schedule,703.32,1958.76,APC
Test socket hemipelvectomy,L5628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1076.08,,,,,,,fee schedule,703.32,1958.76,Radiology
Test socket hemipelvectomy,L5628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,984.65,,,,,,,fee schedule,703.32,1958.76,APC
Test socket hemipelvectomy,L5628,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1230.81,,,,,,,fee schedule,703.32,1958.76,APC
Below knee acrylic socket,L5629,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1330.06,,,,,,,fee schedule,518.74,1444.72,
Below knee acrylic socket,L5629,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1444.72,,,,,,,fee schedule,518.74,1444.72,
Below knee acrylic socket,L5629,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1158.07,,,,,,,fee schedule,518.74,1444.72,
Below knee acrylic socket,L5629,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1265.08,,,,,,,fee schedule,518.74,1444.72,
Below knee acrylic socket,L5629,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,544.68,,,,,,,fee schedule,518.74,1444.72,APC
Below knee acrylic socket,L5629,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,539.49,,,,,,,fee schedule,518.74,1444.72,APC
Below knee acrylic socket,L5629,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,518.74,,,,,,,fee schedule,518.74,1444.72,APC
Below knee acrylic socket,L5629,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,793.67,,,,,,,fee schedule,518.74,1444.72,Radiology
Below knee acrylic socket,L5629,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,726.24,,,,,,,fee schedule,518.74,1444.72,APC
Below knee acrylic socket,L5629,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,907.8,,,,,,,fee schedule,518.74,1444.72,APC
Syme typ expandabl wall sckt,L5630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1623.66,,,,,,,fee schedule,633.26,1763.63,
Syme typ expandabl wall sckt,L5630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1763.63,,,,,,,fee schedule,633.26,1763.63,
Syme typ expandabl wall sckt,L5630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1413.71,,,,,,,fee schedule,633.26,1763.63,
Syme typ expandabl wall sckt,L5630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1544.35,,,,,,,fee schedule,633.26,1763.63,
Syme typ expandabl wall sckt,L5630,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,664.92,,,,,,,fee schedule,633.26,1763.63,APC
Syme typ expandabl wall sckt,L5630,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,658.59,,,,,,,fee schedule,633.26,1763.63,APC
Syme typ expandabl wall sckt,L5630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,633.26,,,,,,,fee schedule,633.26,1763.63,APC
Syme typ expandabl wall sckt,L5630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,968.89,,,,,,,fee schedule,633.26,1763.63,Radiology
Syme typ expandabl wall sckt,L5630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,886.56,,,,,,,fee schedule,633.26,1763.63,APC
Syme typ expandabl wall sckt,L5630,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1108.2,,,,,,,fee schedule,633.26,1763.63,APC
Ak/knee disartic acrylic soc,L5631,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1838.9,,,,,,,fee schedule,717.21,1997.43,
Ak/knee disartic acrylic soc,L5631,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1997.43,,,,,,,fee schedule,717.21,1997.43,
Ak/knee disartic acrylic soc,L5631,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1601.11,,,,,,,fee schedule,717.21,1997.43,
Ak/knee disartic acrylic soc,L5631,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1749.07,,,,,,,fee schedule,717.21,1997.43,
Ak/knee disartic acrylic soc,L5631,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,753.07,,,,,,,fee schedule,717.21,1997.43,APC
Ak/knee disartic acrylic soc,L5631,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,745.9,,,,,,,fee schedule,717.21,1997.43,APC
Ak/knee disartic acrylic soc,L5631,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,717.21,,,,,,,fee schedule,717.21,1997.43,APC
Ak/knee disartic acrylic soc,L5631,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1097.33,,,,,,,fee schedule,717.21,1997.43,Radiology
Ak/knee disartic acrylic soc,L5631,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1004.09,,,,,,,fee schedule,717.21,1997.43,APC
Ak/knee disartic acrylic soc,L5631,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1255.12,,,,,,,fee schedule,717.21,1997.43,APC
Symes type ptb brim design s,L5632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,696.97,,,,,,,fee schedule,271.83,757.06,
Symes type ptb brim design s,L5632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,757.06,,,,,,,fee schedule,271.83,757.06,
Symes type ptb brim design s,L5632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,606.85,,,,,,,fee schedule,271.83,757.06,
Symes type ptb brim design s,L5632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,662.93,,,,,,,fee schedule,271.83,757.06,
Symes type ptb brim design s,L5632,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,285.42,,,,,,,fee schedule,271.83,757.06,APC
Symes type ptb brim design s,L5632,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,282.7,,,,,,,fee schedule,271.83,757.06,APC
Symes type ptb brim design s,L5632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,271.83,,,,,,,fee schedule,271.83,757.06,APC
Symes type ptb brim design s,L5632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,415.9,,,,,,,fee schedule,271.83,757.06,Radiology
Symes type ptb brim design s,L5632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,380.56,,,,,,,fee schedule,271.83,757.06,APC
Symes type ptb brim design s,L5632,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,475.7,,,,,,,fee schedule,271.83,757.06,APC
Symes type poster opening so,L5634,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,954.84,,,,,,,fee schedule,372.4,1037.16,
Symes type poster opening so,L5634,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1037.16,,,,,,,fee schedule,372.4,1037.16,
Symes type poster opening so,L5634,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,831.37,,,,,,,fee schedule,372.4,1037.16,
Symes type poster opening so,L5634,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,908.2,,,,,,,fee schedule,372.4,1037.16,
Symes type poster opening so,L5634,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,391.02,,,,,,,fee schedule,372.4,1037.16,APC
Symes type poster opening so,L5634,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,387.3,,,,,,,fee schedule,372.4,1037.16,APC
Symes type poster opening so,L5634,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,372.4,,,,,,,fee schedule,372.4,1037.16,APC
Symes type poster opening so,L5634,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,569.77,,,,,,,fee schedule,372.4,1037.16,Radiology
Symes type poster opening so,L5634,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,521.36,,,,,,,fee schedule,372.4,1037.16,APC
Symes type poster opening so,L5634,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,651.7,,,,,,,fee schedule,372.4,1037.16,APC
Symes type medial opening so,L5636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,799.81,,,,,,,fee schedule,311.94,868.76,
Symes type medial opening so,L5636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,868.76,,,,,,,fee schedule,311.94,868.76,
Symes type medial opening so,L5636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,696.38,,,,,,,fee schedule,311.94,868.76,
Symes type medial opening so,L5636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,760.74,,,,,,,fee schedule,311.94,868.76,
Symes type medial opening so,L5636,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,327.54,,,,,,,fee schedule,311.94,868.76,APC
Symes type medial opening so,L5636,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,324.42,,,,,,,fee schedule,311.94,868.76,APC
Symes type medial opening so,L5636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,311.94,,,,,,,fee schedule,311.94,868.76,APC
Symes type medial opening so,L5636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,477.27,,,,,,,fee schedule,311.94,868.76,Radiology
Symes type medial opening so,L5636,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,436.72,,,,,,,fee schedule,311.94,868.76,APC
Symes type medial opening so,L5636,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,545.9,,,,,,,fee schedule,311.94,868.76,APC
Below knee total contact,L5637,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1209.06,,,,,,,fee schedule,471.56,1313.29,
Below knee total contact,L5637,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1313.29,,,,,,,fee schedule,471.56,1313.29,
Below knee total contact,L5637,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1052.71,,,,,,,fee schedule,471.56,1313.29,
Below knee total contact,L5637,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1149.99,,,,,,,fee schedule,471.56,1313.29,
Below knee total contact,L5637,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,495.14,,,,,,,fee schedule,471.56,1313.29,APC
Below knee total contact,L5637,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,490.42,,,,,,,fee schedule,471.56,1313.29,APC
Below knee total contact,L5637,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,471.56,,,,,,,fee schedule,471.56,1313.29,APC
Below knee total contact,L5637,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,721.49,,,,,,,fee schedule,471.56,1313.29,Radiology
Below knee total contact,L5637,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,660.18,,,,,,,fee schedule,471.56,1313.29,APC
Below knee total contact,L5637,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,825.23,,,,,,,fee schedule,471.56,1313.29,APC
Below knee leather socket,L5638,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1584.44,,,,,,,fee schedule,617.95,1721.03,
Below knee leather socket,L5638,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1721.03,,,,,,,fee schedule,617.95,1721.03,
Below knee leather socket,L5638,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1379.56,,,,,,,fee schedule,617.95,1721.03,
Below knee leather socket,L5638,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1507.04,,,,,,,fee schedule,617.95,1721.03,
Below knee leather socket,L5638,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,648.85,,,,,,,fee schedule,617.95,1721.03,APC
Below knee leather socket,L5638,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,642.67,,,,,,,fee schedule,617.95,1721.03,APC
Below knee leather socket,L5638,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,617.95,,,,,,,fee schedule,617.95,1721.03,APC
Below knee leather socket,L5638,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,945.46,,,,,,,fee schedule,617.95,1721.03,Radiology
Below knee leather socket,L5638,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,865.13,,,,,,,fee schedule,617.95,1721.03,APC
Below knee leather socket,L5638,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1081.41,,,,,,,fee schedule,617.95,1721.03,APC
Below knee wood socket,L5639,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3519.29,,,,,,,fee schedule,1372.6,3822.68,
Below knee wood socket,L5639,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3822.68,,,,,,,fee schedule,1372.6,3822.68,
Below knee wood socket,L5639,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3064.21,,,,,,,fee schedule,1372.6,3822.68,
Below knee wood socket,L5639,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3347.37,,,,,,,fee schedule,1372.6,3822.68,
Below knee wood socket,L5639,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1441.23,,,,,,,fee schedule,1372.6,3822.68,APC
Below knee wood socket,L5639,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1427.5,,,,,,,fee schedule,1372.6,3822.68,APC
Below knee wood socket,L5639,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1372.6,,,,,,,fee schedule,1372.6,3822.68,APC
Below knee wood socket,L5639,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2100.08,,,,,,,fee schedule,1372.6,3822.68,Radiology
Below knee wood socket,L5639,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1921.64,,,,,,,fee schedule,1372.6,3822.68,APC
Below knee wood socket,L5639,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2402.05,,,,,,,fee schedule,1372.6,3822.68,APC
Knee disarticulat leather so,L5640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2007.12,,,,,,,fee schedule,782.83,2180.15,
Knee disarticulat leather so,L5640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2180.15,,,,,,,fee schedule,782.83,2180.15,
Knee disarticulat leather so,L5640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1747.58,,,,,,,fee schedule,782.83,2180.15,
Knee disarticulat leather so,L5640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1909.08,,,,,,,fee schedule,782.83,2180.15,
Knee disarticulat leather so,L5640,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,821.97,,,,,,,fee schedule,782.83,2180.15,APC
Knee disarticulat leather so,L5640,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,814.14,,,,,,,fee schedule,782.83,2180.15,APC
Knee disarticulat leather so,L5640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,782.83,,,,,,,fee schedule,782.83,2180.15,APC
Knee disarticulat leather so,L5640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1197.73,,,,,,,fee schedule,782.83,2180.15,Radiology
Knee disarticulat leather so,L5640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1095.96,,,,,,,fee schedule,782.83,2180.15,APC
Knee disarticulat leather so,L5640,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1369.95,,,,,,,fee schedule,782.83,2180.15,APC
Above knee leather socket,L5642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2005.77,,,,,,,fee schedule,782.3,2178.68,
Above knee leather socket,L5642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2178.68,,,,,,,fee schedule,782.3,2178.68,
Above knee leather socket,L5642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1746.4,,,,,,,fee schedule,782.3,2178.68,
Above knee leather socket,L5642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1907.78,,,,,,,fee schedule,782.3,2178.68,
Above knee leather socket,L5642,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,821.42,,,,,,,fee schedule,782.3,2178.68,APC
Above knee leather socket,L5642,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,813.59,,,,,,,fee schedule,782.3,2178.68,APC
Above knee leather socket,L5642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,782.3,,,,,,,fee schedule,782.3,2178.68,APC
Above knee leather socket,L5642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1196.92,,,,,,,fee schedule,782.3,2178.68,Radiology
Above knee leather socket,L5642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1095.22,,,,,,,fee schedule,782.3,2178.68,APC
Above knee leather socket,L5642,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1369.02,,,,,,,fee schedule,782.3,2178.68,APC
Hip flex inner socket ext fr,L5643,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5254.56,,,,,,,fee schedule,2049.39,5707.54,
Hip flex inner socket ext fr,L5643,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5707.54,,,,,,,fee schedule,2049.39,5707.54,
Hip flex inner socket ext fr,L5643,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4575.09,,,,,,,fee schedule,2049.39,5707.54,
Hip flex inner socket ext fr,L5643,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4997.87,,,,,,,fee schedule,2049.39,5707.54,
Hip flex inner socket ext fr,L5643,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2151.86,,,,,,,fee schedule,2049.39,5707.54,APC
Hip flex inner socket ext fr,L5643,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2131.37,,,,,,,fee schedule,2049.39,5707.54,APC
Hip flex inner socket ext fr,L5643,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2049.39,,,,,,,fee schedule,2049.39,5707.54,APC
Hip flex inner socket ext fr,L5643,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3135.57,,,,,,,fee schedule,2049.39,5707.54,Radiology
Hip flex inner socket ext fr,L5643,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2869.15,,,,,,,fee schedule,2049.39,5707.54,APC
Hip flex inner socket ext fr,L5643,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3586.43,,,,,,,fee schedule,2049.39,5707.54,APC
Above knee wood socket,L5644,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2211.71,,,,,,,fee schedule,862.59,2402.38,
Above knee wood socket,L5644,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2402.38,,,,,,,fee schedule,862.59,2402.38,
Above knee wood socket,L5644,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1925.72,,,,,,,fee schedule,862.59,2402.38,
Above knee wood socket,L5644,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2103.67,,,,,,,fee schedule,862.59,2402.38,
Above knee wood socket,L5644,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,905.72,,,,,,,fee schedule,862.59,2402.38,APC
Above knee wood socket,L5644,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,897.09,,,,,,,fee schedule,862.59,2402.38,APC
Above knee wood socket,L5644,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,862.59,,,,,,,fee schedule,862.59,2402.38,APC
Above knee wood socket,L5644,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1319.76,,,,,,,fee schedule,862.59,2402.38,Radiology
Above knee wood socket,L5644,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1207.63,,,,,,,fee schedule,862.59,2402.38,APC
Above knee wood socket,L5644,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1509.53,,,,,,,fee schedule,862.59,2402.38,APC
Bk flex inner socket ext fra,L5645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2509.6,,,,,,,fee schedule,978.8,2725.95,
Bk flex inner socket ext fra,L5645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2725.95,,,,,,,fee schedule,978.8,2725.95,
Bk flex inner socket ext fra,L5645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2185.08,,,,,,,fee schedule,978.8,2725.95,
Bk flex inner socket ext fra,L5645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2387.01,,,,,,,fee schedule,978.8,2725.95,
Bk flex inner socket ext fra,L5645,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1027.74,,,,,,,fee schedule,978.8,2725.95,APC
Bk flex inner socket ext fra,L5645,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1017.95,,,,,,,fee schedule,978.8,2725.95,APC
Bk flex inner socket ext fra,L5645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,978.8,,,,,,,fee schedule,978.8,2725.95,APC
Bk flex inner socket ext fra,L5645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1497.56,,,,,,,fee schedule,978.8,2725.95,Radiology
Bk flex inner socket ext fra,L5645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1370.32,,,,,,,fee schedule,978.8,2725.95,APC
Bk flex inner socket ext fra,L5645,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1712.9,,,,,,,fee schedule,978.8,2725.95,APC
Below knee cushion socket,L5646,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2232.49,,,,,,,fee schedule,870.73,2424.95,
Below knee cushion socket,L5646,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2424.95,,,,,,,fee schedule,870.73,2424.95,
Below knee cushion socket,L5646,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1943.81,,,,,,,fee schedule,870.73,2424.95,
Below knee cushion socket,L5646,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2123.43,,,,,,,fee schedule,870.73,2424.95,
Below knee cushion socket,L5646,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,914.27,,,,,,,fee schedule,870.73,2424.95,APC
Below knee cushion socket,L5646,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,905.56,,,,,,,fee schedule,870.73,2424.95,APC
Below knee cushion socket,L5646,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,870.73,,,,,,,fee schedule,870.73,2424.95,APC
Below knee cushion socket,L5646,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1332.22,,,,,,,fee schedule,870.73,2424.95,Radiology
Below knee cushion socket,L5646,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1219.02,,,,,,,fee schedule,870.73,2424.95,APC
Below knee cushion socket,L5646,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1523.78,,,,,,,fee schedule,870.73,2424.95,APC
Below knee suction socket,L5647,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2496.87,,,,,,,fee schedule,973.84,2712.11,
Below knee suction socket,L5647,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2712.11,,,,,,,fee schedule,973.84,2712.11,
Below knee suction socket,L5647,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2173.99,,,,,,,fee schedule,973.84,2712.11,
Below knee suction socket,L5647,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2374.89,,,,,,,fee schedule,973.84,2712.11,
Below knee suction socket,L5647,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1022.53,,,,,,,fee schedule,973.84,2712.11,APC
Below knee suction socket,L5647,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1012.79,,,,,,,fee schedule,973.84,2712.11,APC
Below knee suction socket,L5647,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,973.84,,,,,,,fee schedule,973.84,2712.11,APC
Below knee suction socket,L5647,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1489.98,,,,,,,fee schedule,973.84,2712.11,Radiology
Below knee suction socket,L5647,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1363.38,,,,,,,fee schedule,973.84,2712.11,APC
Below knee suction socket,L5647,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1704.22,,,,,,,fee schedule,973.84,2712.11,APC
Above knee cushion socket,L5648,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2435.13,,,,,,,fee schedule,949.75,2645.06,
Above knee cushion socket,L5648,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2645.06,,,,,,,fee schedule,949.75,2645.06,
Above knee cushion socket,L5648,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2120.24,,,,,,,fee schedule,949.75,2645.06,
Above knee cushion socket,L5648,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2316.17,,,,,,,fee schedule,949.75,2645.06,
Above knee cushion socket,L5648,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,997.24,,,,,,,fee schedule,949.75,2645.06,APC
Above knee cushion socket,L5648,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,987.74,,,,,,,fee schedule,949.75,2645.06,APC
Above knee cushion socket,L5648,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,949.75,,,,,,,fee schedule,949.75,2645.06,APC
Above knee cushion socket,L5648,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1453.12,,,,,,,fee schedule,949.75,2645.06,Radiology
Above knee cushion socket,L5648,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1329.65,,,,,,,fee schedule,949.75,2645.06,APC
Above knee cushion socket,L5648,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1662.06,,,,,,,fee schedule,949.75,2645.06,APC
Isch containmt/narrow m-l so,L5649,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7626.66,,,,,,,fee schedule,2974.58,8284.13,
Isch containmt/narrow m-l so,L5649,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8284.13,,,,,,,fee schedule,2974.58,8284.13,
Isch containmt/narrow m-l so,L5649,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6640.46,,,,,,,fee schedule,2974.58,8284.13,
Isch containmt/narrow m-l so,L5649,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7254.1,,,,,,,fee schedule,2974.58,8284.13,
Isch containmt/narrow m-l so,L5649,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3123.31,,,,,,,fee schedule,2974.58,8284.13,APC
Isch containmt/narrow m-l so,L5649,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3093.56,,,,,,,fee schedule,2974.58,8284.13,APC
Isch containmt/narrow m-l so,L5649,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2974.58,,,,,,,fee schedule,2974.58,8284.13,APC
Isch containmt/narrow m-l so,L5649,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4551.11,,,,,,,fee schedule,2974.58,8284.13,Radiology
Isch containmt/narrow m-l so,L5649,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4164.41,,,,,,,fee schedule,2974.58,8284.13,APC
Isch containmt/narrow m-l so,L5649,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5205.51,,,,,,,fee schedule,2974.58,8284.13,APC
Tot contact ak/knee disart s,L5650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1798.15,,,,,,,fee schedule,701.34,1953.16,
Tot contact ak/knee disart s,L5650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1953.16,,,,,,,fee schedule,701.34,1953.16,
Tot contact ak/knee disart s,L5650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1565.63,,,,,,,fee schedule,701.34,1953.16,
Tot contact ak/knee disart s,L5650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1710.31,,,,,,,fee schedule,701.34,1953.16,
Tot contact ak/knee disart s,L5650,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,736.41,,,,,,,fee schedule,701.34,1953.16,APC
Tot contact ak/knee disart s,L5650,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,729.39,,,,,,,fee schedule,701.34,1953.16,APC
Tot contact ak/knee disart s,L5650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,701.34,,,,,,,fee schedule,701.34,1953.16,APC
Tot contact ak/knee disart s,L5650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1073.05,,,,,,,fee schedule,701.34,1953.16,Radiology
Tot contact ak/knee disart s,L5650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,981.88,,,,,,,fee schedule,701.34,1953.16,APC
Tot contact ak/knee disart s,L5650,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1227.34,,,,,,,fee schedule,701.34,1953.16,APC
Ak flex inner socket ext fra,L5651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5026.09,,,,,,,fee schedule,1960.29,5459.38,
Ak flex inner socket ext fra,L5651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5459.38,,,,,,,fee schedule,1960.29,5459.38,
Ak flex inner socket ext fra,L5651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4376.17,,,,,,,fee schedule,1960.29,5459.38,
Ak flex inner socket ext fra,L5651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4780.57,,,,,,,fee schedule,1960.29,5459.38,
Ak flex inner socket ext fra,L5651,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2058.3,,,,,,,fee schedule,1960.29,5459.38,APC
Ak flex inner socket ext fra,L5651,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2038.7,,,,,,,fee schedule,1960.29,5459.38,APC
Ak flex inner socket ext fra,L5651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1960.29,,,,,,,fee schedule,1960.29,5459.38,APC
Ak flex inner socket ext fra,L5651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2999.24,,,,,,,fee schedule,1960.29,5459.38,Radiology
Ak flex inner socket ext fra,L5651,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2744.41,,,,,,,fee schedule,1960.29,5459.38,APC
Ak flex inner socket ext fra,L5651,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3430.51,,,,,,,fee schedule,1960.29,5459.38,APC
Suction susp ak/knee disart,L5652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1596.59,,,,,,,fee schedule,622.71,1734.23,
Suction susp ak/knee disart,L5652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1734.23,,,,,,,fee schedule,622.71,1734.23,
Suction susp ak/knee disart,L5652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1390.13,,,,,,,fee schedule,622.71,1734.23,
Suction susp ak/knee disart,L5652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1518.59,,,,,,,fee schedule,622.71,1734.23,
Suction susp ak/knee disart,L5652,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,653.85,,,,,,,fee schedule,622.71,1734.23,APC
Suction susp ak/knee disart,L5652,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,647.62,,,,,,,fee schedule,622.71,1734.23,APC
Suction susp ak/knee disart,L5652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,622.71,,,,,,,fee schedule,622.71,1734.23,APC
Suction susp ak/knee disart,L5652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,952.75,,,,,,,fee schedule,622.71,1734.23,Radiology
Suction susp ak/knee disart,L5652,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,871.79,,,,,,,fee schedule,622.71,1734.23,APC
Suction susp ak/knee disart,L5652,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1089.74,,,,,,,fee schedule,622.71,1734.23,APC
Knee disart expand wall sock,L5653,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1870.01,,,,,,,fee schedule,729.34,2031.22,
Knee disart expand wall sock,L5653,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2031.22,,,,,,,fee schedule,729.34,2031.22,
Knee disart expand wall sock,L5653,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1628.2,,,,,,,fee schedule,729.34,2031.22,
Knee disart expand wall sock,L5653,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1778.66,,,,,,,fee schedule,729.34,2031.22,
Knee disart expand wall sock,L5653,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,765.81,,,,,,,fee schedule,729.34,2031.22,APC
Knee disart expand wall sock,L5653,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,758.51,,,,,,,fee schedule,729.34,2031.22,APC
Knee disart expand wall sock,L5653,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,729.34,,,,,,,fee schedule,729.34,2031.22,APC
Knee disart expand wall sock,L5653,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1115.89,,,,,,,fee schedule,729.34,2031.22,Radiology
Knee disart expand wall sock,L5653,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1021.08,,,,,,,fee schedule,729.34,2031.22,APC
Knee disart expand wall sock,L5653,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1276.34,,,,,,,fee schedule,729.34,2031.22,APC
Socket insert symes,L5654,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1237.38,,,,,,,fee schedule,482.61,1344.05,
Socket insert symes,L5654,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1344.05,,,,,,,fee schedule,482.61,1344.05,
Socket insert symes,L5654,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1077.38,,,,,,,fee schedule,482.61,1344.05,
Socket insert symes,L5654,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1176.94,,,,,,,fee schedule,482.61,1344.05,
Socket insert symes,L5654,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,506.74,,,,,,,fee schedule,482.61,1344.05,APC
Socket insert symes,L5654,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,501.91,,,,,,,fee schedule,482.61,1344.05,APC
Socket insert symes,L5654,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,482.61,,,,,,,fee schedule,482.61,1344.05,APC
Socket insert symes,L5654,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,738.39,,,,,,,fee schedule,482.61,1344.05,Radiology
Socket insert symes,L5654,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,675.65,,,,,,,fee schedule,482.61,1344.05,APC
Socket insert symes,L5654,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,844.57,,,,,,,fee schedule,482.61,1344.05,APC
Socket insert below knee,L5655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,962.67,,,,,,,fee schedule,375.45,1045.66,
Socket insert below knee,L5655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1045.66,,,,,,,fee schedule,375.45,1045.66,
Socket insert below knee,L5655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,838.19,,,,,,,fee schedule,375.45,1045.66,
Socket insert below knee,L5655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,915.65,,,,,,,fee schedule,375.45,1045.66,
Socket insert below knee,L5655,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,394.22,,,,,,,fee schedule,375.45,1045.66,APC
Socket insert below knee,L5655,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,390.47,,,,,,,fee schedule,375.45,1045.66,APC
Socket insert below knee,L5655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,375.45,,,,,,,fee schedule,375.45,1045.66,APC
Socket insert below knee,L5655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,574.44,,,,,,,fee schedule,375.45,1045.66,Radiology
Socket insert below knee,L5655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,525.63,,,,,,,fee schedule,375.45,1045.66,APC
Socket insert below knee,L5655,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,657.04,,,,,,,fee schedule,375.45,1045.66,APC
Socket insert knee articulat,L5656,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1193.12,,,,,,,fee schedule,465.36,1295.97,
Socket insert knee articulat,L5656,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1295.97,,,,,,,fee schedule,465.36,1295.97,
Socket insert knee articulat,L5656,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1038.84,,,,,,,fee schedule,465.36,1295.97,
Socket insert knee articulat,L5656,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1134.83,,,,,,,fee schedule,465.36,1295.97,
Socket insert knee articulat,L5656,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,488.63,,,,,,,fee schedule,465.36,1295.97,APC
Socket insert knee articulat,L5656,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,483.97,,,,,,,fee schedule,465.36,1295.97,APC
Socket insert knee articulat,L5656,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,465.36,,,,,,,fee schedule,465.36,1295.97,APC
Socket insert knee articulat,L5656,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,712,,,,,,,fee schedule,465.36,1295.97,Radiology
Socket insert knee articulat,L5656,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,651.5,,,,,,,fee schedule,465.36,1295.97,APC
Socket insert knee articulat,L5656,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,814.38,,,,,,,fee schedule,465.36,1295.97,APC
Socket insert above knee,L5658,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1141.3,,,,,,,fee schedule,445.13,1239.69,
Socket insert above knee,L5658,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1239.69,,,,,,,fee schedule,445.13,1239.69,
Socket insert above knee,L5658,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,993.72,,,,,,,fee schedule,445.13,1239.69,
Socket insert above knee,L5658,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1085.55,,,,,,,fee schedule,445.13,1239.69,
Socket insert above knee,L5658,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,467.39,,,,,,,fee schedule,445.13,1239.69,APC
Socket insert above knee,L5658,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,462.94,,,,,,,fee schedule,445.13,1239.69,APC
Socket insert above knee,L5658,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,445.13,,,,,,,fee schedule,445.13,1239.69,APC
Socket insert above knee,L5658,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,681.05,,,,,,,fee schedule,445.13,1239.69,Radiology
Socket insert above knee,L5658,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,623.18,,,,,,,fee schedule,445.13,1239.69,APC
Socket insert above knee,L5658,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,778.98,,,,,,,fee schedule,445.13,1239.69,APC
Multi-durometer symes,L5661,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1910.17,,,,,,,fee schedule,745.01,2074.84,
Multi-durometer symes,L5661,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2074.84,,,,,,,fee schedule,745.01,2074.84,
Multi-durometer symes,L5661,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1663.17,,,,,,,fee schedule,745.01,2074.84,
Multi-durometer symes,L5661,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1816.86,,,,,,,fee schedule,745.01,2074.84,
Multi-durometer symes,L5661,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,782.26,,,,,,,fee schedule,745.01,2074.84,APC
Multi-durometer symes,L5661,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,774.81,,,,,,,fee schedule,745.01,2074.84,APC
Multi-durometer symes,L5661,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,745.01,,,,,,,fee schedule,745.01,2074.84,APC
Multi-durometer symes,L5661,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1139.87,,,,,,,fee schedule,745.01,2074.84,Radiology
Multi-durometer symes,L5661,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1043.01,,,,,,,fee schedule,745.01,2074.84,APC
Multi-durometer symes,L5661,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1303.77,,,,,,,fee schedule,745.01,2074.84,APC
Multi-durometer below knee,L5665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1717.66,,,,,,,fee schedule,669.92,1865.73,
Multi-durometer below knee,L5665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1865.73,,,,,,,fee schedule,669.92,1865.73,
Multi-durometer below knee,L5665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1495.55,,,,,,,fee schedule,669.92,1865.73,
Multi-durometer below knee,L5665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1633.75,,,,,,,fee schedule,669.92,1865.73,
Multi-durometer below knee,L5665,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,703.42,,,,,,,fee schedule,669.92,1865.73,APC
Multi-durometer below knee,L5665,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,696.72,,,,,,,fee schedule,669.92,1865.73,APC
Multi-durometer below knee,L5665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,669.92,,,,,,,fee schedule,669.92,1865.73,APC
Multi-durometer below knee,L5665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1024.98,,,,,,,fee schedule,669.92,1865.73,Radiology
Multi-durometer below knee,L5665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,937.89,,,,,,,fee schedule,669.92,1865.73,APC
Multi-durometer below knee,L5665,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1172.36,,,,,,,fee schedule,669.92,1865.73,APC
Below knee cuff suspension,L5666,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,292.98,,,,,,,fee schedule,114.26,318.24,
Below knee cuff suspension,L5666,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,318.24,,,,,,,fee schedule,114.26,318.24,
Below knee cuff suspension,L5666,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,255.1,,,,,,,fee schedule,114.26,318.24,
Below knee cuff suspension,L5666,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,278.67,,,,,,,fee schedule,114.26,318.24,
Below knee cuff suspension,L5666,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,119.97,,,,,,,fee schedule,114.26,318.24,APC
Below knee cuff suspension,L5666,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,118.83,,,,,,,fee schedule,114.26,318.24,APC
Below knee cuff suspension,L5666,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,114.26,,,,,,,fee schedule,114.26,318.24,APC
Below knee cuff suspension,L5666,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,174.82,,,,,,,fee schedule,114.26,318.24,Radiology
Below knee cuff suspension,L5666,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,159.96,,,,,,,fee schedule,114.26,318.24,APC
Below knee cuff suspension,L5666,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,199.96,,,,,,,fee schedule,114.26,318.24,APC
Bk molded distal cushion,L5668,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,422.61,,,,,,,fee schedule,164.84,459.04,
Bk molded distal cushion,L5668,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,459.04,,,,,,,fee schedule,164.84,459.04,
Bk molded distal cushion,L5668,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,367.96,,,,,,,fee schedule,164.84,459.04,
Bk molded distal cushion,L5668,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,401.97,,,,,,,fee schedule,164.84,459.04,
Bk molded distal cushion,L5668,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,173.08,,,,,,,fee schedule,164.84,459.04,APC
Bk molded distal cushion,L5668,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,171.43,,,,,,,fee schedule,164.84,459.04,APC
Bk molded distal cushion,L5668,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,164.84,,,,,,,fee schedule,164.84,459.04,APC
Bk molded distal cushion,L5668,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,252.21,,,,,,,fee schedule,164.84,459.04,Radiology
Bk molded distal cushion,L5668,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,230.78,,,,,,,fee schedule,164.84,459.04,APC
Bk molded distal cushion,L5668,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,288.47,,,,,,,fee schedule,164.84,459.04,APC
Bk molded supracondylar susp,L5670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1135.66,,,,,,,fee schedule,442.94,1233.57,
Bk molded supracondylar susp,L5670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1233.57,,,,,,,fee schedule,442.94,1233.57,
Bk molded supracondylar susp,L5670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,988.81,,,,,,,fee schedule,442.94,1233.57,
Bk molded supracondylar susp,L5670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1080.19,,,,,,,fee schedule,442.94,1233.57,
Bk molded supracondylar susp,L5670,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,465.09,,,,,,,fee schedule,442.94,1233.57,APC
Bk molded supracondylar susp,L5670,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,460.66,,,,,,,fee schedule,442.94,1233.57,APC
Bk molded supracondylar susp,L5670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,442.94,,,,,,,fee schedule,442.94,1233.57,APC
Bk molded supracondylar susp,L5670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,677.7,,,,,,,fee schedule,442.94,1233.57,Radiology
Bk molded supracondylar susp,L5670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,620.12,,,,,,,fee schedule,442.94,1233.57,APC
Bk molded supracondylar susp,L5670,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,775.14,,,,,,,fee schedule,442.94,1233.57,APC
Bk/ak locking mechanism,L5671,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1804.73,,,,,,,fee schedule,703.88,1960.31,
Bk/ak locking mechanism,L5671,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1960.31,,,,,,,fee schedule,703.88,1960.31,
Bk/ak locking mechanism,L5671,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1571.36,,,,,,,fee schedule,703.88,1960.31,
Bk/ak locking mechanism,L5671,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1716.57,,,,,,,fee schedule,703.88,1960.31,
Bk/ak locking mechanism,L5671,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,739.07,,,,,,,fee schedule,703.88,1960.31,APC
Bk/ak locking mechanism,L5671,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,732.04,,,,,,,fee schedule,703.88,1960.31,APC
Bk/ak locking mechanism,L5671,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,703.88,,,,,,,fee schedule,703.88,1960.31,APC
Bk/ak locking mechanism,L5671,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1076.94,,,,,,,fee schedule,703.88,1960.31,Radiology
Bk/ak locking mechanism,L5671,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,985.43,,,,,,,fee schedule,703.88,1960.31,APC
Bk/ak locking mechanism,L5671,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1231.79,,,,,,,fee schedule,703.88,1960.31,APC
Bk removable medial brim sus,L5672,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,935.98,,,,,,,fee schedule,365.06,1016.67,
Bk removable medial brim sus,L5672,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1016.67,,,,,,,fee schedule,365.06,1016.67,
Bk removable medial brim sus,L5672,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,814.95,,,,,,,fee schedule,365.06,1016.67,
Bk removable medial brim sus,L5672,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,890.26,,,,,,,fee schedule,365.06,1016.67,
Bk removable medial brim sus,L5672,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,383.31,,,,,,,fee schedule,365.06,1016.67,APC
Bk removable medial brim sus,L5672,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,379.66,,,,,,,fee schedule,365.06,1016.67,APC
Bk removable medial brim sus,L5672,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,365.06,,,,,,,fee schedule,365.06,1016.67,APC
Bk removable medial brim sus,L5672,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,558.54,,,,,,,fee schedule,365.06,1016.67,Radiology
Bk removable medial brim sus,L5672,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,511.08,,,,,,,fee schedule,365.06,1016.67,APC
Bk removable medial brim sus,L5672,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,638.86,,,,,,,fee schedule,365.06,1016.67,APC
Socket insert w lock mech,L5673,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2299.62,,,,,,,fee schedule,896.9,2497.86,
Socket insert w lock mech,L5673,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2497.86,,,,,,,fee schedule,896.9,2497.86,
Socket insert w lock mech,L5673,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2002.25,,,,,,,fee schedule,896.9,2497.86,
Socket insert w lock mech,L5673,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2187.28,,,,,,,fee schedule,896.9,2497.86,
Socket insert w lock mech,L5673,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,941.74,,,,,,,fee schedule,896.9,2497.86,APC
Socket insert w lock mech,L5673,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,932.78,,,,,,,fee schedule,896.9,2497.86,APC
Socket insert w lock mech,L5673,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,896.9,,,,,,,fee schedule,896.9,2497.86,APC
Socket insert w lock mech,L5673,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1372.26,,,,,,,fee schedule,896.9,2497.86,Radiology
Socket insert w lock mech,L5673,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1255.66,,,,,,,fee schedule,896.9,2497.86,APC
Socket insert w lock mech,L5673,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1569.58,,,,,,,fee schedule,896.9,2497.86,APC
Bk knee joints single axis p,L5676,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1481.37,,,,,,,fee schedule,577.76,1609.07,
Bk knee joints single axis p,L5676,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1609.07,,,,,,,fee schedule,577.76,1609.07,
Bk knee joints single axis p,L5676,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1289.81,,,,,,,fee schedule,577.76,1609.07,
Bk knee joints single axis p,L5676,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1409,,,,,,,fee schedule,577.76,1609.07,
Bk knee joints single axis p,L5676,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,606.65,,,,,,,fee schedule,577.76,1609.07,APC
Bk knee joints single axis p,L5676,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,600.87,,,,,,,fee schedule,577.76,1609.07,APC
Bk knee joints single axis p,L5676,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,577.76,,,,,,,fee schedule,577.76,1609.07,APC
Bk knee joints single axis p,L5676,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,883.97,,,,,,,fee schedule,577.76,1609.07,Radiology
Bk knee joints single axis p,L5676,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,808.86,,,,,,,fee schedule,577.76,1609.07,APC
Bk knee joints single axis p,L5676,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1011.08,,,,,,,fee schedule,577.76,1609.07,APC
Bk knee joints polycentric p,L5677,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2063.57,,,,,,,fee schedule,804.82,2241.46,
Bk knee joints polycentric p,L5677,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2241.46,,,,,,,fee schedule,804.82,2241.46,
Bk knee joints polycentric p,L5677,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1796.73,,,,,,,fee schedule,804.82,2241.46,
Bk knee joints polycentric p,L5677,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1962.76,,,,,,,fee schedule,804.82,2241.46,
Bk knee joints polycentric p,L5677,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,845.06,,,,,,,fee schedule,804.82,2241.46,APC
Bk knee joints polycentric p,L5677,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,837.01,,,,,,,fee schedule,804.82,2241.46,APC
Bk knee joints polycentric p,L5677,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,804.82,,,,,,,fee schedule,804.82,2241.46,APC
Bk knee joints polycentric p,L5677,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1231.37,,,,,,,fee schedule,804.82,2241.46,Radiology
Bk knee joints polycentric p,L5677,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1126.75,,,,,,,fee schedule,804.82,2241.46,APC
Bk knee joints polycentric p,L5677,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1408.44,,,,,,,fee schedule,804.82,2241.46,APC
Bk joint covers pair,L5678,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,166.17,,,,,,,fee schedule,64.81,180.5,
Bk joint covers pair,L5678,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,180.5,,,,,,,fee schedule,64.81,180.5,
Bk joint covers pair,L5678,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,144.68,,,,,,,fee schedule,64.81,180.5,
Bk joint covers pair,L5678,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,158.05,,,,,,,fee schedule,64.81,180.5,
Bk joint covers pair,L5678,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,68.05,,,,,,,fee schedule,64.81,180.5,APC
Bk joint covers pair,L5678,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,67.4,,,,,,,fee schedule,64.81,180.5,APC
Bk joint covers pair,L5678,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,64.81,,,,,,,fee schedule,64.81,180.5,APC
Bk joint covers pair,L5678,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,99.16,,,,,,,fee schedule,64.81,180.5,Radiology
Bk joint covers pair,L5678,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,90.73,,,,,,,fee schedule,64.81,180.5,APC
Bk joint covers pair,L5678,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,113.42,,,,,,,fee schedule,64.81,180.5,APC
Socket insert w/o lock mech,L5679,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1916.26,,,,,,,fee schedule,747.37,2081.46,
Socket insert w/o lock mech,L5679,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2081.46,,,,,,,fee schedule,747.37,2081.46,
Socket insert w/o lock mech,L5679,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1668.47,,,,,,,fee schedule,747.37,2081.46,
Socket insert w/o lock mech,L5679,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1822.65,,,,,,,fee schedule,747.37,2081.46,
Socket insert w/o lock mech,L5679,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,784.74,,,,,,,fee schedule,747.37,2081.46,APC
Socket insert w/o lock mech,L5679,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,777.26,,,,,,,fee schedule,747.37,2081.46,APC
Socket insert w/o lock mech,L5679,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,747.37,,,,,,,fee schedule,747.37,2081.46,APC
Socket insert w/o lock mech,L5679,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1143.48,,,,,,,fee schedule,747.37,2081.46,Radiology
Socket insert w/o lock mech,L5679,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1046.32,,,,,,,fee schedule,747.37,2081.46,APC
Socket insert w/o lock mech,L5679,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1307.9,,,,,,,fee schedule,747.37,2081.46,APC
Bk thigh lacer non-molded,L5680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1024.58,,,,,,,fee schedule,399.64,1112.91,
Bk thigh lacer non-molded,L5680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1112.91,,,,,,,fee schedule,399.64,1112.91,
Bk thigh lacer non-molded,L5680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,892.09,,,,,,,fee schedule,399.64,1112.91,
Bk thigh lacer non-molded,L5680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,974.53,,,,,,,fee schedule,399.64,1112.91,
Bk thigh lacer non-molded,L5680,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,419.62,,,,,,,fee schedule,399.64,1112.91,APC
Bk thigh lacer non-molded,L5680,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,415.63,,,,,,,fee schedule,399.64,1112.91,APC
Bk thigh lacer non-molded,L5680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,399.64,,,,,,,fee schedule,399.64,1112.91,APC
Bk thigh lacer non-molded,L5680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,611.45,,,,,,,fee schedule,399.64,1112.91,Radiology
Bk thigh lacer non-molded,L5680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,559.5,,,,,,,fee schedule,399.64,1112.91,APC
Bk thigh lacer non-molded,L5680,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,699.37,,,,,,,fee schedule,399.64,1112.91,APC
Intl custm cong/latyp insert,L5681,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4175.03,,,,,,,fee schedule,1628.34,4534.94,
Intl custm cong/latyp insert,L5681,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4534.94,,,,,,,fee schedule,1628.34,4534.94,
Intl custm cong/latyp insert,L5681,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3635.15,,,,,,,fee schedule,1628.34,4534.94,
Intl custm cong/latyp insert,L5681,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3971.07,,,,,,,fee schedule,1628.34,4534.94,
Intl custm cong/latyp insert,L5681,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1709.76,,,,,,,fee schedule,1628.34,4534.94,APC
Intl custm cong/latyp insert,L5681,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1693.47,,,,,,,fee schedule,1628.34,4534.94,APC
Intl custm cong/latyp insert,L5681,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1628.34,,,,,,,fee schedule,1628.34,4534.94,APC
Intl custm cong/latyp insert,L5681,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2491.36,,,,,,,fee schedule,1628.34,4534.94,Radiology
Intl custm cong/latyp insert,L5681,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2279.68,,,,,,,fee schedule,1628.34,4534.94,APC
Intl custm cong/latyp insert,L5681,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2849.6,,,,,,,fee schedule,1628.34,4534.94,APC
Bk thigh lacer glut/ischia m,L5682,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2002.88,,,,,,,fee schedule,781.15,2175.54,
Bk thigh lacer glut/ischia m,L5682,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2175.54,,,,,,,fee schedule,781.15,2175.54,
Bk thigh lacer glut/ischia m,L5682,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1743.89,,,,,,,fee schedule,781.15,2175.54,
Bk thigh lacer glut/ischia m,L5682,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1905.04,,,,,,,fee schedule,781.15,2175.54,
Bk thigh lacer glut/ischia m,L5682,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,820.21,,,,,,,fee schedule,781.15,2175.54,APC
Bk thigh lacer glut/ischia m,L5682,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,812.4,,,,,,,fee schedule,781.15,2175.54,APC
Bk thigh lacer glut/ischia m,L5682,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,781.15,,,,,,,fee schedule,781.15,2175.54,APC
Bk thigh lacer glut/ischia m,L5682,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1195.16,,,,,,,fee schedule,781.15,2175.54,Radiology
Bk thigh lacer glut/ischia m,L5682,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1093.61,,,,,,,fee schedule,781.15,2175.54,APC
Bk thigh lacer glut/ischia m,L5682,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1367.01,,,,,,,fee schedule,781.15,2175.54,APC
Initial custom socket insert,L5683,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4175.03,,,,,,,fee schedule,1628.34,4534.94,
Initial custom socket insert,L5683,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4534.94,,,,,,,fee schedule,1628.34,4534.94,
Initial custom socket insert,L5683,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3635.15,,,,,,,fee schedule,1628.34,4534.94,
Initial custom socket insert,L5683,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3971.07,,,,,,,fee schedule,1628.34,4534.94,
Initial custom socket insert,L5683,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1709.76,,,,,,,fee schedule,1628.34,4534.94,APC
Initial custom socket insert,L5683,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1693.47,,,,,,,fee schedule,1628.34,4534.94,APC
Initial custom socket insert,L5683,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1628.34,,,,,,,fee schedule,1628.34,4534.94,APC
Initial custom socket insert,L5683,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2491.36,,,,,,,fee schedule,1628.34,4534.94,Radiology
Initial custom socket insert,L5683,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2279.68,,,,,,,fee schedule,1628.34,4534.94,APC
Initial custom socket insert,L5683,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2849.6,,,,,,,fee schedule,1628.34,4534.94,APC
Bk fork strap,L5684,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,168.95,,,,,,,fee schedule,65.9,183.52,
Bk fork strap,L5684,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,183.52,,,,,,,fee schedule,65.9,183.52,
Bk fork strap,L5684,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,147.11,,,,,,,fee schedule,65.9,183.52,
Bk fork strap,L5684,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,160.7,,,,,,,fee schedule,65.9,183.52,
Bk fork strap,L5684,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,69.2,,,,,,,fee schedule,65.9,183.52,APC
Bk fork strap,L5684,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,68.54,,,,,,,fee schedule,65.9,183.52,APC
Bk fork strap,L5684,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,65.9,,,,,,,fee schedule,65.9,183.52,APC
Bk fork strap,L5684,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,100.83,,,,,,,fee schedule,65.9,183.52,Radiology
Bk fork strap,L5684,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,92.26,,,,,,,fee schedule,65.9,183.52,APC
Bk fork strap,L5684,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,115.33,,,,,,,fee schedule,65.9,183.52,APC
Below knee sus/seal sleeve,L5685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.5,,,,,,,fee schedule,158.53,441.54,
Below knee sus/seal sleeve,L5685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.54,,,,,,,fee schedule,158.53,441.54,
Below knee sus/seal sleeve,L5685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,353.93,,,,,,,fee schedule,158.53,441.54,
Below knee sus/seal sleeve,L5685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.64,,,,,,,fee schedule,158.53,441.54,
Below knee sus/seal sleeve,L5685,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,166.46,,,,,,,fee schedule,158.53,441.54,APC
Below knee sus/seal sleeve,L5685,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,164.87,,,,,,,fee schedule,158.53,441.54,APC
Below knee sus/seal sleeve,L5685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,158.53,,,,,,,fee schedule,158.53,441.54,APC
Below knee sus/seal sleeve,L5685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,242.55,,,,,,,fee schedule,158.53,441.54,Radiology
Below knee sus/seal sleeve,L5685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,221.94,,,,,,,fee schedule,158.53,441.54,APC
Below knee sus/seal sleeve,L5685,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,277.43,,,,,,,fee schedule,158.53,441.54,APC
Bk back check,L5686,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,169.58,,,,,,,fee schedule,66.14,184.2,
Bk back check,L5686,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,184.2,,,,,,,fee schedule,66.14,184.2,
Bk back check,L5686,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,147.65,,,,,,,fee schedule,66.14,184.2,
Bk back check,L5686,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,161.3,,,,,,,fee schedule,66.14,184.2,
Bk back check,L5686,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,69.45,,,,,,,fee schedule,66.14,184.2,APC
Bk back check,L5686,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,68.79,,,,,,,fee schedule,66.14,184.2,APC
Bk back check,L5686,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,66.14,,,,,,,fee schedule,66.14,184.2,APC
Bk back check,L5686,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,101.19,,,,,,,fee schedule,66.14,184.2,Radiology
Bk back check,L5686,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,92.6,,,,,,,fee schedule,66.14,184.2,APC
Bk back check,L5686,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,115.74,,,,,,,fee schedule,66.14,184.2,APC
Bk waist belt webbing,L5688,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,241.06,,,,,,,fee schedule,94.01,261.84,
Bk waist belt webbing,L5688,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,261.84,,,,,,,fee schedule,94.01,261.84,
Bk waist belt webbing,L5688,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,209.89,,,,,,,fee schedule,94.01,261.84,
Bk waist belt webbing,L5688,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,229.28,,,,,,,fee schedule,94.01,261.84,
Bk waist belt webbing,L5688,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,98.71,,,,,,,fee schedule,94.01,261.84,APC
Bk waist belt webbing,L5688,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,97.77,,,,,,,fee schedule,94.01,261.84,APC
Bk waist belt webbing,L5688,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,94.01,,,,,,,fee schedule,94.01,261.84,APC
Bk waist belt webbing,L5688,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,143.84,,,,,,,fee schedule,94.01,261.84,Radiology
Bk waist belt webbing,L5688,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.61,,,,,,,fee schedule,94.01,261.84,APC
Bk waist belt webbing,L5688,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,164.52,,,,,,,fee schedule,94.01,261.84,APC
Bk waist belt padded and lin,L5690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,338.67,,,,,,,fee schedule,132.07,367.87,
Bk waist belt padded and lin,L5690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,367.87,,,,,,,fee schedule,132.07,367.87,
Bk waist belt padded and lin,L5690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,294.88,,,,,,,fee schedule,132.07,367.87,
Bk waist belt padded and lin,L5690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,322.13,,,,,,,fee schedule,132.07,367.87,
Bk waist belt padded and lin,L5690,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.67,,,,,,,fee schedule,132.07,367.87,APC
Bk waist belt padded and lin,L5690,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,137.35,,,,,,,fee schedule,132.07,367.87,APC
Bk waist belt padded and lin,L5690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,132.07,,,,,,,fee schedule,132.07,367.87,APC
Bk waist belt padded and lin,L5690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,202.07,,,,,,,fee schedule,132.07,367.87,Radiology
Bk waist belt padded and lin,L5690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.9,,,,,,,fee schedule,132.07,367.87,APC
Bk waist belt padded and lin,L5690,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,231.12,,,,,,,fee schedule,132.07,367.87,APC
Ak pelvic control belt light,L5692,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,556.14,,,,,,,fee schedule,216.9,604.08,
Ak pelvic control belt light,L5692,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,604.08,,,,,,,fee schedule,216.9,604.08,
Ak pelvic control belt light,L5692,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,484.22,,,,,,,fee schedule,216.9,604.08,
Ak pelvic control belt light,L5692,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,528.97,,,,,,,fee schedule,216.9,604.08,
Ak pelvic control belt light,L5692,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,227.74,,,,,,,fee schedule,216.9,604.08,APC
Ak pelvic control belt light,L5692,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,225.58,,,,,,,fee schedule,216.9,604.08,APC
Ak pelvic control belt light,L5692,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,216.9,,,,,,,fee schedule,216.9,604.08,APC
Ak pelvic control belt light,L5692,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,331.86,,,,,,,fee schedule,216.9,604.08,Radiology
Ak pelvic control belt light,L5692,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,303.66,,,,,,,fee schedule,216.9,604.08,APC
Ak pelvic control belt light,L5692,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,379.58,,,,,,,fee schedule,216.9,604.08,APC
Ak pelvic control belt pad/l,L5694,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,759.27,,,,,,,fee schedule,296.13,824.72,
Ak pelvic control belt pad/l,L5694,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,824.72,,,,,,,fee schedule,296.13,824.72,
Ak pelvic control belt pad/l,L5694,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,661.09,,,,,,,fee schedule,296.13,824.72,
Ak pelvic control belt pad/l,L5694,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,722.18,,,,,,,fee schedule,296.13,824.72,
Ak pelvic control belt pad/l,L5694,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,310.94,,,,,,,fee schedule,296.13,824.72,APC
Ak pelvic control belt pad/l,L5694,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,307.98,,,,,,,fee schedule,296.13,824.72,APC
Ak pelvic control belt pad/l,L5694,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,296.13,,,,,,,fee schedule,296.13,824.72,APC
Ak pelvic control belt pad/l,L5694,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,453.08,,,,,,,fee schedule,296.13,824.72,Radiology
Ak pelvic control belt pad/l,L5694,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,414.58,,,,,,,fee schedule,296.13,824.72,APC
Ak pelvic control belt pad/l,L5694,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,518.23,,,,,,,fee schedule,296.13,824.72,APC
Ak sleeve susp neoprene/equa,L5695,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,682.53,,,,,,,fee schedule,266.2,741.37,
Ak sleeve susp neoprene/equa,L5695,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,741.37,,,,,,,fee schedule,266.2,741.37,
Ak sleeve susp neoprene/equa,L5695,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,594.27,,,,,,,fee schedule,266.2,741.37,
Ak sleeve susp neoprene/equa,L5695,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,649.19,,,,,,,fee schedule,266.2,741.37,
Ak sleeve susp neoprene/equa,L5695,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,279.51,,,,,,,fee schedule,266.2,741.37,APC
Ak sleeve susp neoprene/equa,L5695,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,276.85,,,,,,,fee schedule,266.2,741.37,APC
Ak sleeve susp neoprene/equa,L5695,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,266.2,,,,,,,fee schedule,266.2,741.37,APC
Ak sleeve susp neoprene/equa,L5695,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,407.29,,,,,,,fee schedule,266.2,741.37,Radiology
Ak sleeve susp neoprene/equa,L5695,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,372.68,,,,,,,fee schedule,266.2,741.37,APC
Ak sleeve susp neoprene/equa,L5695,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,465.85,,,,,,,fee schedule,266.2,741.37,APC
Ak/knee disartic pelvic join,L5696,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,696.73,,,,,,,fee schedule,271.74,756.79,
Ak/knee disartic pelvic join,L5696,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,756.79,,,,,,,fee schedule,271.74,756.79,
Ak/knee disartic pelvic join,L5696,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,606.64,,,,,,,fee schedule,271.74,756.79,
Ak/knee disartic pelvic join,L5696,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,662.7,,,,,,,fee schedule,271.74,756.79,
Ak/knee disartic pelvic join,L5696,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,285.33,,,,,,,fee schedule,271.74,756.79,APC
Ak/knee disartic pelvic join,L5696,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,282.61,,,,,,,fee schedule,271.74,756.79,APC
Ak/knee disartic pelvic join,L5696,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,271.74,,,,,,,fee schedule,271.74,756.79,APC
Ak/knee disartic pelvic join,L5696,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,415.76,,,,,,,fee schedule,271.74,756.79,Radiology
Ak/knee disartic pelvic join,L5696,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,380.44,,,,,,,fee schedule,271.74,756.79,APC
Ak/knee disartic pelvic join,L5696,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,475.54,,,,,,,fee schedule,271.74,756.79,APC
Ak/knee disartic pelvic band,L5697,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,251.99,,,,,,,fee schedule,98.28,273.71,
Ak/knee disartic pelvic band,L5697,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,273.71,,,,,,,fee schedule,98.28,273.71,
Ak/knee disartic pelvic band,L5697,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,219.4,,,,,,,fee schedule,98.28,273.71,
Ak/knee disartic pelvic band,L5697,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,239.68,,,,,,,fee schedule,98.28,273.71,
Ak/knee disartic pelvic band,L5697,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,103.19,,,,,,,fee schedule,98.28,273.71,APC
Ak/knee disartic pelvic band,L5697,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,102.21,,,,,,,fee schedule,98.28,273.71,APC
Ak/knee disartic pelvic band,L5697,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,98.28,,,,,,,fee schedule,98.28,273.71,APC
Ak/knee disartic pelvic band,L5697,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,150.37,,,,,,,fee schedule,98.28,273.71,Radiology
Ak/knee disartic pelvic band,L5697,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,137.59,,,,,,,fee schedule,98.28,273.71,APC
Ak/knee disartic pelvic band,L5697,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,171.99,,,,,,,fee schedule,98.28,273.71,APC
Ak/knee disartic silesian ba,L5698,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,375.67,,,,,,,fee schedule,146.51,408.05,
Ak/knee disartic silesian ba,L5698,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,408.05,,,,,,,fee schedule,146.51,408.05,
Ak/knee disartic silesian ba,L5698,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,327.09,,,,,,,fee schedule,146.51,408.05,
Ak/knee disartic silesian ba,L5698,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,357.31,,,,,,,fee schedule,146.51,408.05,
Ak/knee disartic silesian ba,L5698,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,153.84,,,,,,,fee schedule,146.51,408.05,APC
Ak/knee disartic silesian ba,L5698,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,152.37,,,,,,,fee schedule,146.51,408.05,APC
Ak/knee disartic silesian ba,L5698,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,146.51,,,,,,,fee schedule,146.51,408.05,APC
Ak/knee disartic silesian ba,L5698,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,224.16,,,,,,,fee schedule,146.51,408.05,Radiology
Ak/knee disartic silesian ba,L5698,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,205.11,,,,,,,fee schedule,146.51,408.05,APC
Ak/knee disartic silesian ba,L5698,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,256.39,,,,,,,fee schedule,146.51,408.05,APC
Shoulder harness,L5699,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,585.27,,,,,,,fee schedule,228.26,635.72,
Shoulder harness,L5699,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,635.72,,,,,,,fee schedule,228.26,635.72,
Shoulder harness,L5699,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,509.59,,,,,,,fee schedule,228.26,635.72,
Shoulder harness,L5699,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,556.68,,,,,,,fee schedule,228.26,635.72,
Shoulder harness,L5699,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,239.67,,,,,,,fee schedule,228.26,635.72,APC
Shoulder harness,L5699,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,237.39,,,,,,,fee schedule,228.26,635.72,APC
Shoulder harness,L5699,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,228.26,,,,,,,fee schedule,228.26,635.72,APC
Shoulder harness,L5699,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,349.24,,,,,,,fee schedule,228.26,635.72,Radiology
Shoulder harness,L5699,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,319.56,,,,,,,fee schedule,228.26,635.72,APC
Shoulder harness,L5699,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,399.46,,,,,,,fee schedule,228.26,635.72,APC
Replace socket below knee,L5700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8992.74,,,,,,,fee schedule,3507.38,9767.97,
Replace socket below knee,L5700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9767.97,,,,,,,fee schedule,3507.38,9767.97,
Replace socket below knee,L5700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7829.88,,,,,,,fee schedule,3507.38,9767.97,
Replace socket below knee,L5700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8553.44,,,,,,,fee schedule,3507.38,9767.97,
Replace socket below knee,L5700,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3682.75,,,,,,,fee schedule,3507.38,9767.97,APC
Replace socket below knee,L5700,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3647.68,,,,,,,fee schedule,3507.38,9767.97,APC
Replace socket below knee,L5700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3507.38,,,,,,,fee schedule,3507.38,9767.97,APC
Replace socket below knee,L5700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5366.29,,,,,,,fee schedule,3507.38,9767.97,Radiology
Replace socket below knee,L5700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4910.33,,,,,,,fee schedule,3507.38,9767.97,APC
Replace socket below knee,L5700,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6137.92,,,,,,,fee schedule,3507.38,9767.97,APC
Replace socket above knee,L5701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10799.66,,,,,,,fee schedule,4212.11,11730.66,
Replace socket above knee,L5701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11730.66,,,,,,,fee schedule,4212.11,11730.66,
Replace socket above knee,L5701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9403.15,,,,,,,fee schedule,4212.11,11730.66,
Replace socket above knee,L5701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10272.09,,,,,,,fee schedule,4212.11,11730.66,
Replace socket above knee,L5701,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4422.72,,,,,,,fee schedule,4212.11,11730.66,APC
Replace socket above knee,L5701,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4380.59,,,,,,,fee schedule,4212.11,11730.66,APC
Replace socket above knee,L5701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4212.11,,,,,,,fee schedule,4212.11,11730.66,APC
Replace socket above knee,L5701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6444.53,,,,,,,fee schedule,4212.11,11730.66,Radiology
Replace socket above knee,L5701,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5896.95,,,,,,,fee schedule,4212.11,11730.66,APC
Replace socket above knee,L5701,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7371.19,,,,,,,fee schedule,4212.11,11730.66,APC
Replace socket hip,L5702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13663.21,,,,,,,fee schedule,5328.96,14841.07,
Replace socket hip,L5702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14841.07,,,,,,,fee schedule,5328.96,14841.07,
Replace socket hip,L5702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11896.42,,,,,,,fee schedule,5328.96,14841.07,
Replace socket hip,L5702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12995.76,,,,,,,fee schedule,5328.96,14841.07,
Replace socket hip,L5702,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5595.41,,,,,,,fee schedule,5328.96,14841.07,APC
Replace socket hip,L5702,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5542.12,,,,,,,fee schedule,5328.96,14841.07,APC
Replace socket hip,L5702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5328.96,,,,,,,fee schedule,5328.96,14841.07,APC
Replace socket hip,L5702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8153.31,,,,,,,fee schedule,5328.96,14841.07,Radiology
Replace socket hip,L5702,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7460.54,,,,,,,fee schedule,5328.96,14841.07,APC
Replace socket hip,L5702,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9325.68,,,,,,,fee schedule,5328.96,14841.07,APC
Symes ankle w/o (sach) foot,L5703,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8365.85,,,,,,,fee schedule,3262.87,9087.04,
Symes ankle w/o (sach) foot,L5703,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9087.04,,,,,,,fee schedule,3262.87,9087.04,
Symes ankle w/o (sach) foot,L5703,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7284.06,,,,,,,fee schedule,3262.87,9087.04,
Symes ankle w/o (sach) foot,L5703,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7957.17,,,,,,,fee schedule,3262.87,9087.04,
Symes ankle w/o (sach) foot,L5703,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3426.01,,,,,,,fee schedule,3262.87,9087.04,APC
Symes ankle w/o (sach) foot,L5703,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3393.38,,,,,,,fee schedule,3262.87,9087.04,APC
Symes ankle w/o (sach) foot,L5703,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3262.87,,,,,,,fee schedule,3262.87,9087.04,APC
Symes ankle w/o (sach) foot,L5703,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4992.19,,,,,,,fee schedule,3262.87,9087.04,Radiology
Symes ankle w/o (sach) foot,L5703,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4568.02,,,,,,,fee schedule,3262.87,9087.04,APC
Symes ankle w/o (sach) foot,L5703,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5710.02,,,,,,,fee schedule,3262.87,9087.04,APC
Custom shape cover bk,L5704,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1682.34,,,,,,,fee schedule,656.17,1827.37,
Custom shape cover bk,L5704,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1827.37,,,,,,,fee schedule,656.17,1827.37,
Custom shape cover bk,L5704,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1464.79,,,,,,,fee schedule,656.17,1827.37,
Custom shape cover bk,L5704,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1600.15,,,,,,,fee schedule,656.17,1827.37,
Custom shape cover bk,L5704,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,688.98,,,,,,,fee schedule,656.17,1827.37,APC
Custom shape cover bk,L5704,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,682.42,,,,,,,fee schedule,656.17,1827.37,APC
Custom shape cover bk,L5704,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,656.17,,,,,,,fee schedule,656.17,1827.37,APC
Custom shape cover bk,L5704,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1003.94,,,,,,,fee schedule,656.17,1827.37,Radiology
Custom shape cover bk,L5704,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,918.64,,,,,,,fee schedule,656.17,1827.37,APC
Custom shape cover bk,L5704,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1148.3,,,,,,,fee schedule,656.17,1827.37,APC
Custom shape cover ak,L5705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3005.99,,,,,,,fee schedule,1172.4,3265.13,
Custom shape cover ak,L5705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3265.13,,,,,,,fee schedule,1172.4,3265.13,
Custom shape cover ak,L5705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2617.28,,,,,,,fee schedule,1172.4,3265.13,
Custom shape cover ak,L5705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2859.14,,,,,,,fee schedule,1172.4,3265.13,
Custom shape cover ak,L5705,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1231.02,,,,,,,fee schedule,1172.4,3265.13,APC
Custom shape cover ak,L5705,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1219.3,,,,,,,fee schedule,1172.4,3265.13,APC
Custom shape cover ak,L5705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1172.4,,,,,,,fee schedule,1172.4,3265.13,APC
Custom shape cover ak,L5705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1793.77,,,,,,,fee schedule,1172.4,3265.13,Radiology
Custom shape cover ak,L5705,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1641.36,,,,,,,fee schedule,1172.4,3265.13,APC
Custom shape cover ak,L5705,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2051.7,,,,,,,fee schedule,1172.4,3265.13,APC
Custom shape cvr knee disart,L5706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2946.72,,,,,,,fee schedule,1149.3,3200.75,
Custom shape cvr knee disart,L5706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3200.75,,,,,,,fee schedule,1149.3,3200.75,
Custom shape cvr knee disart,L5706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2565.68,,,,,,,fee schedule,1149.3,3200.75,
Custom shape cvr knee disart,L5706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2802.78,,,,,,,fee schedule,1149.3,3200.75,
Custom shape cvr knee disart,L5706,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1206.77,,,,,,,fee schedule,1149.3,3200.75,APC
Custom shape cvr knee disart,L5706,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1195.27,,,,,,,fee schedule,1149.3,3200.75,APC
Custom shape cvr knee disart,L5706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1149.3,,,,,,,fee schedule,1149.3,3200.75,APC
Custom shape cvr knee disart,L5706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1758.43,,,,,,,fee schedule,1149.3,3200.75,Radiology
Custom shape cvr knee disart,L5706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1609.02,,,,,,,fee schedule,1149.3,3200.75,APC
Custom shape cvr knee disart,L5706,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2011.28,,,,,,,fee schedule,1149.3,3200.75,APC
Custom shape cvr hip disart,L5707,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3884.9,,,,,,,fee schedule,1515.21,4219.8,
Custom shape cvr hip disart,L5707,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4219.8,,,,,,,fee schedule,1515.21,4219.8,
Custom shape cvr hip disart,L5707,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3382.54,,,,,,,fee schedule,1515.21,4219.8,
Custom shape cvr hip disart,L5707,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3695.12,,,,,,,fee schedule,1515.21,4219.8,
Custom shape cvr hip disart,L5707,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1590.97,,,,,,,fee schedule,1515.21,4219.8,APC
Custom shape cvr hip disart,L5707,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1575.82,,,,,,,fee schedule,1515.21,4219.8,APC
Custom shape cvr hip disart,L5707,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1515.21,,,,,,,fee schedule,1515.21,4219.8,APC
Custom shape cvr hip disart,L5707,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2318.27,,,,,,,fee schedule,1515.21,4219.8,Radiology
Custom shape cvr hip disart,L5707,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2121.29,,,,,,,fee schedule,1515.21,4219.8,APC
Custom shape cvr hip disart,L5707,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2651.62,,,,,,,fee schedule,1515.21,4219.8,APC
Kne-shin exo sng axi mnl loc,L5710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1343.49,,,,,,,fee schedule,523.99,1459.31,
Kne-shin exo sng axi mnl loc,L5710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1459.31,,,,,,,fee schedule,523.99,1459.31,
Kne-shin exo sng axi mnl loc,L5710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1169.76,,,,,,,fee schedule,523.99,1459.31,
Kne-shin exo sng axi mnl loc,L5710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1277.86,,,,,,,fee schedule,523.99,1459.31,
Kne-shin exo sng axi mnl loc,L5710,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,550.19,,,,,,,fee schedule,523.99,1459.31,APC
Kne-shin exo sng axi mnl loc,L5710,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,544.95,,,,,,,fee schedule,523.99,1459.31,APC
Kne-shin exo sng axi mnl loc,L5710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,523.99,,,,,,,fee schedule,523.99,1459.31,APC
Kne-shin exo sng axi mnl loc,L5710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,801.7,,,,,,,fee schedule,523.99,1459.31,Radiology
Kne-shin exo sng axi mnl loc,L5710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,733.59,,,,,,,fee schedule,523.99,1459.31,APC
Kne-shin exo sng axi mnl loc,L5710,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,916.98,,,,,,,fee schedule,523.99,1459.31,APC
Knee-shin exo mnl lock ultra,L5711,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1701.79,,,,,,,fee schedule,663.71,1848.5,
Knee-shin exo mnl lock ultra,L5711,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1848.5,,,,,,,fee schedule,663.71,1848.5,
Knee-shin exo mnl lock ultra,L5711,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1481.73,,,,,,,fee schedule,663.71,1848.5,
Knee-shin exo mnl lock ultra,L5711,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1618.66,,,,,,,fee schedule,663.71,1848.5,
Knee-shin exo mnl lock ultra,L5711,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,696.9,,,,,,,fee schedule,663.71,1848.5,APC
Knee-shin exo mnl lock ultra,L5711,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,690.26,,,,,,,fee schedule,663.71,1848.5,APC
Knee-shin exo mnl lock ultra,L5711,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,663.71,,,,,,,fee schedule,663.71,1848.5,APC
Knee-shin exo mnl lock ultra,L5711,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1015.48,,,,,,,fee schedule,663.71,1848.5,Radiology
Knee-shin exo mnl lock ultra,L5711,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,929.19,,,,,,,fee schedule,663.71,1848.5,APC
Knee-shin exo mnl lock ultra,L5711,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1161.49,,,,,,,fee schedule,663.71,1848.5,APC
Knee-shin exo frict swg & st,L5712,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1783.4,,,,,,,fee schedule,695.57,1937.14,
Knee-shin exo frict swg & st,L5712,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1937.14,,,,,,,fee schedule,695.57,1937.14,
Knee-shin exo frict swg & st,L5712,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1552.78,,,,,,,fee schedule,695.57,1937.14,
Knee-shin exo frict swg & st,L5712,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1696.28,,,,,,,fee schedule,695.57,1937.14,
Knee-shin exo frict swg & st,L5712,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,730.35,,,,,,,fee schedule,695.57,1937.14,APC
Knee-shin exo frict swg & st,L5712,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,723.39,,,,,,,fee schedule,695.57,1937.14,APC
Knee-shin exo frict swg & st,L5712,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,695.57,,,,,,,fee schedule,695.57,1937.14,APC
Knee-shin exo frict swg & st,L5712,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1064.22,,,,,,,fee schedule,695.57,1937.14,Radiology
Knee-shin exo frict swg & st,L5712,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,973.8,,,,,,,fee schedule,695.57,1937.14,APC
Knee-shin exo frict swg & st,L5712,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1217.25,,,,,,,fee schedule,695.57,1937.14,APC
Knee-shin exo variable frict,L5714,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1506.74,,,,,,,fee schedule,587.64,1636.63,
Knee-shin exo variable frict,L5714,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1636.63,,,,,,,fee schedule,587.64,1636.63,
Knee-shin exo variable frict,L5714,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1311.9,,,,,,,fee schedule,587.64,1636.63,
Knee-shin exo variable frict,L5714,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1433.13,,,,,,,fee schedule,587.64,1636.63,
Knee-shin exo variable frict,L5714,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,617.02,,,,,,,fee schedule,587.64,1636.63,APC
Knee-shin exo variable frict,L5714,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,611.15,,,,,,,fee schedule,587.64,1636.63,APC
Knee-shin exo variable frict,L5714,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,587.64,,,,,,,fee schedule,587.64,1636.63,APC
Knee-shin exo variable frict,L5714,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,899.09,,,,,,,fee schedule,587.64,1636.63,Radiology
Knee-shin exo variable frict,L5714,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,822.7,,,,,,,fee schedule,587.64,1636.63,APC
Knee-shin exo variable frict,L5714,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1028.37,,,,,,,fee schedule,587.64,1636.63,APC
Knee-shin exo mech stance ph,L5716,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2663.28,,,,,,,fee schedule,1038.73,2892.87,
Knee-shin exo mech stance ph,L5716,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2892.87,,,,,,,fee schedule,1038.73,2892.87,
Knee-shin exo mech stance ph,L5716,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2318.89,,,,,,,fee schedule,1038.73,2892.87,
Knee-shin exo mech stance ph,L5716,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2533.18,,,,,,,fee schedule,1038.73,2892.87,
Knee-shin exo mech stance ph,L5716,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1090.67,,,,,,,fee schedule,1038.73,2892.87,APC
Knee-shin exo mech stance ph,L5716,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1080.28,,,,,,,fee schedule,1038.73,2892.87,APC
Knee-shin exo mech stance ph,L5716,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1038.73,,,,,,,fee schedule,1038.73,2892.87,APC
Knee-shin exo mech stance ph,L5716,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1589.26,,,,,,,fee schedule,1038.73,2892.87,Radiology
Knee-shin exo mech stance ph,L5716,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1454.22,,,,,,,fee schedule,1038.73,2892.87,APC
Knee-shin exo mech stance ph,L5716,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1817.78,,,,,,,fee schedule,1038.73,2892.87,APC
Knee-shin exo frct swg & sta,L5718,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2938.27,,,,,,,fee schedule,1145.99,3191.57,
Knee-shin exo frct swg & sta,L5718,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3191.57,,,,,,,fee schedule,1145.99,3191.57,
Knee-shin exo frct swg & sta,L5718,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2558.32,,,,,,,fee schedule,1145.99,3191.57,
Knee-shin exo frct swg & sta,L5718,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2794.73,,,,,,,fee schedule,1145.99,3191.57,
Knee-shin exo frct swg & sta,L5718,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1203.29,,,,,,,fee schedule,1145.99,3191.57,APC
Knee-shin exo frct swg & sta,L5718,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1191.83,,,,,,,fee schedule,1145.99,3191.57,APC
Knee-shin exo frct swg & sta,L5718,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1145.99,,,,,,,fee schedule,1145.99,3191.57,APC
Knee-shin exo frct swg & sta,L5718,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1753.36,,,,,,,fee schedule,1145.99,3191.57,Radiology
Knee-shin exo frct swg & sta,L5718,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1604.39,,,,,,,fee schedule,1145.99,3191.57,APC
Knee-shin exo frct swg & sta,L5718,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2005.48,,,,,,,fee schedule,1145.99,3191.57,APC
Knee-shin pneum swg frct exo,L5722,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2856.38,,,,,,,fee schedule,1114.06,3102.62,
Knee-shin pneum swg frct exo,L5722,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3102.62,,,,,,,fee schedule,1114.06,3102.62,
Knee-shin pneum swg frct exo,L5722,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2487.02,,,,,,,fee schedule,1114.06,3102.62,
Knee-shin pneum swg frct exo,L5722,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2716.85,,,,,,,fee schedule,1114.06,3102.62,
Knee-shin pneum swg frct exo,L5722,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1169.76,,,,,,,fee schedule,1114.06,3102.62,APC
Knee-shin pneum swg frct exo,L5722,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1158.62,,,,,,,fee schedule,1114.06,3102.62,APC
Knee-shin pneum swg frct exo,L5722,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1114.06,,,,,,,fee schedule,1114.06,3102.62,APC
Knee-shin pneum swg frct exo,L5722,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1704.51,,,,,,,fee schedule,1114.06,3102.62,Radiology
Knee-shin pneum swg frct exo,L5722,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1559.68,,,,,,,fee schedule,1114.06,3102.62,APC
Knee-shin pneum swg frct exo,L5722,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1949.6,,,,,,,fee schedule,1114.06,3102.62,APC
Knee-shin exo fluid swing ph,L5724,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6317.24,,,,,,,fee schedule,2463.86,6861.83,
Knee-shin exo fluid swing ph,L5724,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6861.83,,,,,,,fee schedule,2463.86,6861.83,
Knee-shin exo fluid swing ph,L5724,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5500.36,,,,,,,fee schedule,2463.86,6861.83,
Knee-shin exo fluid swing ph,L5724,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6008.64,,,,,,,fee schedule,2463.86,6861.83,
Knee-shin exo fluid swing ph,L5724,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2587.05,,,,,,,fee schedule,2463.86,6861.83,APC
Knee-shin exo fluid swing ph,L5724,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2562.41,,,,,,,fee schedule,2463.86,6861.83,APC
Knee-shin exo fluid swing ph,L5724,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2463.86,,,,,,,fee schedule,2463.86,6861.83,APC
Knee-shin exo fluid swing ph,L5724,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3769.71,,,,,,,fee schedule,2463.86,6861.83,Radiology
Knee-shin exo fluid swing ph,L5724,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3449.4,,,,,,,fee schedule,2463.86,6861.83,APC
Knee-shin exo fluid swing ph,L5724,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4311.76,,,,,,,fee schedule,2463.86,6861.83,APC
Knee-shin ext jnts fld swg e,L5726,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7280.51,,,,,,,fee schedule,2839.54,7908.14,
Knee-shin ext jnts fld swg e,L5726,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7908.14,,,,,,,fee schedule,2839.54,7908.14,
Knee-shin ext jnts fld swg e,L5726,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6339.06,,,,,,,fee schedule,2839.54,7908.14,
Knee-shin ext jnts fld swg e,L5726,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6924.85,,,,,,,fee schedule,2839.54,7908.14,
Knee-shin ext jnts fld swg e,L5726,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2981.52,,,,,,,fee schedule,2839.54,7908.14,APC
Knee-shin ext jnts fld swg e,L5726,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2953.12,,,,,,,fee schedule,2839.54,7908.14,APC
Knee-shin ext jnts fld swg e,L5726,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2839.54,,,,,,,fee schedule,2839.54,7908.14,APC
Knee-shin ext jnts fld swg e,L5726,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4344.5,,,,,,,fee schedule,2839.54,7908.14,Radiology
Knee-shin ext jnts fld swg e,L5726,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3975.36,,,,,,,fee schedule,2839.54,7908.14,APC
Knee-shin ext jnts fld swg e,L5726,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4969.2,,,,,,,fee schedule,2839.54,7908.14,APC
Knee-shin fluid swg & stance,L5728,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7778.29,,,,,,,fee schedule,3033.7,8448.83,
Knee-shin fluid swg & stance,L5728,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8448.83,,,,,,,fee schedule,3033.7,8448.83,
Knee-shin fluid swg & stance,L5728,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6772.47,,,,,,,fee schedule,3033.7,8448.83,
Knee-shin fluid swg & stance,L5728,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7398.31,,,,,,,fee schedule,3033.7,8448.83,
Knee-shin fluid swg & stance,L5728,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3185.38,,,,,,,fee schedule,3033.7,8448.83,APC
Knee-shin fluid swg & stance,L5728,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3155.05,,,,,,,fee schedule,3033.7,8448.83,APC
Knee-shin fluid swg & stance,L5728,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3033.7,,,,,,,fee schedule,3033.7,8448.83,APC
Knee-shin fluid swg & stance,L5728,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4641.56,,,,,,,fee schedule,3033.7,8448.83,Radiology
Knee-shin fluid swg & stance,L5728,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4247.18,,,,,,,fee schedule,3033.7,8448.83,APC
Knee-shin fluid swg & stance,L5728,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5308.98,,,,,,,fee schedule,3033.7,8448.83,APC
Knee-shin pneum/hydra pneum,L5780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4140.64,,,,,,,fee schedule,1614.94,4497.6,
Knee-shin pneum/hydra pneum,L5780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4497.6,,,,,,,fee schedule,1614.94,4497.6,
Knee-shin pneum/hydra pneum,L5780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3605.22,,,,,,,fee schedule,1614.94,4497.6,
Knee-shin pneum/hydra pneum,L5780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3938.37,,,,,,,fee schedule,1614.94,4497.6,
Knee-shin pneum/hydra pneum,L5780,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1695.69,,,,,,,fee schedule,1614.94,4497.6,APC
Knee-shin pneum/hydra pneum,L5780,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1679.54,,,,,,,fee schedule,1614.94,4497.6,APC
Knee-shin pneum/hydra pneum,L5780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1614.94,,,,,,,fee schedule,1614.94,4497.6,APC
Knee-shin pneum/hydra pneum,L5780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2470.86,,,,,,,fee schedule,1614.94,4497.6,Radiology
Knee-shin pneum/hydra pneum,L5780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2260.92,,,,,,,fee schedule,1614.94,4497.6,APC
Knee-shin pneum/hydra pneum,L5780,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2826.14,,,,,,,fee schedule,1614.94,4497.6,APC
Lower limb pros vacuum pump,L5781,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12699.63,,,,,,,fee schedule,4953.14,13794.43,
Lower limb pros vacuum pump,L5781,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13794.43,,,,,,,fee schedule,4953.14,13794.43,
Lower limb pros vacuum pump,L5781,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11057.44,,,,,,,fee schedule,4953.14,13794.43,
Lower limb pros vacuum pump,L5781,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12079.25,,,,,,,fee schedule,4953.14,13794.43,
Lower limb pros vacuum pump,L5781,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5200.8,,,,,,,fee schedule,4953.14,13794.43,APC
Lower limb pros vacuum pump,L5781,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5151.27,,,,,,,fee schedule,4953.14,13794.43,APC
Lower limb pros vacuum pump,L5781,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4953.14,,,,,,,fee schedule,4953.14,13794.43,APC
Lower limb pros vacuum pump,L5781,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7578.3,,,,,,,fee schedule,4953.14,13794.43,Radiology
Lower limb pros vacuum pump,L5781,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6934.4,,,,,,,fee schedule,4953.14,13794.43,APC
Lower limb pros vacuum pump,L5781,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8668,,,,,,,fee schedule,4953.14,13794.43,APC
HD low limb pros vacuum pump,L5782,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13388.22,,,,,,,fee schedule,5221.68,14542.38,
HD low limb pros vacuum pump,L5782,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14542.38,,,,,,,fee schedule,5221.68,14542.38,
HD low limb pros vacuum pump,L5782,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11656.99,,,,,,,fee schedule,5221.68,14542.38,
HD low limb pros vacuum pump,L5782,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12734.2,,,,,,,fee schedule,5221.68,14542.38,
HD low limb pros vacuum pump,L5782,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5482.76,,,,,,,fee schedule,5221.68,14542.38,APC
HD low limb pros vacuum pump,L5782,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5430.55,,,,,,,fee schedule,5221.68,14542.38,APC
HD low limb pros vacuum pump,L5782,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5221.68,,,,,,,fee schedule,5221.68,14542.38,APC
HD low limb pros vacuum pump,L5782,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7989.17,,,,,,,fee schedule,5221.68,14542.38,Radiology
HD low limb pros vacuum pump,L5782,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7310.35,,,,,,,fee schedule,5221.68,14542.38,APC
HD low limb pros vacuum pump,L5782,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9137.94,,,,,,,fee schedule,5221.68,14542.38,APC
Exoskeletal bk ultralt mater,L5785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1818.27,,,,,,,fee schedule,709.19,1975.01,
Exoskeletal bk ultralt mater,L5785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1975.01,,,,,,,fee schedule,709.19,1975.01,
Exoskeletal bk ultralt mater,L5785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1583.14,,,,,,,fee schedule,709.19,1975.01,
Exoskeletal bk ultralt mater,L5785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1729.44,,,,,,,fee schedule,709.19,1975.01,
Exoskeletal bk ultralt mater,L5785,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,744.65,,,,,,,fee schedule,709.19,1975.01,APC
Exoskeletal bk ultralt mater,L5785,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,737.56,,,,,,,fee schedule,709.19,1975.01,APC
Exoskeletal bk ultralt mater,L5785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,709.19,,,,,,,fee schedule,709.19,1975.01,APC
Exoskeletal bk ultralt mater,L5785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1085.06,,,,,,,fee schedule,709.19,1975.01,Radiology
Exoskeletal bk ultralt mater,L5785,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,992.87,,,,,,,fee schedule,709.19,1975.01,APC
Exoskeletal bk ultralt mater,L5785,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1241.08,,,,,,,fee schedule,709.19,1975.01,APC
Exoskeletal ak ultra-light m,L5790,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3009.26,,,,,,,fee schedule,1173.68,3268.68,
Exoskeletal ak ultra-light m,L5790,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3268.68,,,,,,,fee schedule,1173.68,3268.68,
Exoskeletal ak ultra-light m,L5790,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2620.13,,,,,,,fee schedule,1173.68,3268.68,
Exoskeletal ak ultra-light m,L5790,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2862.26,,,,,,,fee schedule,1173.68,3268.68,
Exoskeletal ak ultra-light m,L5790,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1232.36,,,,,,,fee schedule,1173.68,3268.68,APC
Exoskeletal ak ultra-light m,L5790,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1220.63,,,,,,,fee schedule,1173.68,3268.68,APC
Exoskeletal ak ultra-light m,L5790,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1173.68,,,,,,,fee schedule,1173.68,3268.68,APC
Exoskeletal ak ultra-light m,L5790,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1795.73,,,,,,,fee schedule,1173.68,3268.68,Radiology
Exoskeletal ak ultra-light m,L5790,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1643.15,,,,,,,fee schedule,1173.68,3268.68,APC
Exoskeletal ak ultra-light m,L5790,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2053.94,,,,,,,fee schedule,1173.68,3268.68,APC
Exoskel hip ultra-light mate,L5795,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4493.65,,,,,,,fee schedule,1752.61,4881.04,
Exoskel hip ultra-light mate,L5795,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4881.04,,,,,,,fee schedule,1752.61,4881.04,
Exoskel hip ultra-light mate,L5795,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3912.58,,,,,,,fee schedule,1752.61,4881.04,
Exoskel hip ultra-light mate,L5795,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4274.14,,,,,,,fee schedule,1752.61,4881.04,
Exoskel hip ultra-light mate,L5795,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1840.24,,,,,,,fee schedule,1752.61,4881.04,APC
Exoskel hip ultra-light mate,L5795,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1822.71,,,,,,,fee schedule,1752.61,4881.04,APC
Exoskel hip ultra-light mate,L5795,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1752.61,,,,,,,fee schedule,1752.61,4881.04,APC
Exoskel hip ultra-light mate,L5795,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2681.49,,,,,,,fee schedule,1752.61,4881.04,Radiology
Exoskel hip ultra-light mate,L5795,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2453.65,,,,,,,fee schedule,1752.61,4881.04,APC
Exoskel hip ultra-light mate,L5795,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3067.07,,,,,,,fee schedule,1752.61,4881.04,APC
Endoskel knee-shin mnl lock,L5810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1687.31,,,,,,,fee schedule,658.08,1832.77,
Endoskel knee-shin mnl lock,L5810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1832.77,,,,,,,fee schedule,658.08,1832.77,
Endoskel knee-shin mnl lock,L5810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1469.13,,,,,,,fee schedule,658.08,1832.77,
Endoskel knee-shin mnl lock,L5810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1604.89,,,,,,,fee schedule,658.08,1832.77,
Endoskel knee-shin mnl lock,L5810,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,690.98,,,,,,,fee schedule,658.08,1832.77,APC
Endoskel knee-shin mnl lock,L5810,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,684.4,,,,,,,fee schedule,658.08,1832.77,APC
Endoskel knee-shin mnl lock,L5810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,658.08,,,,,,,fee schedule,658.08,1832.77,APC
Endoskel knee-shin mnl lock,L5810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1006.86,,,,,,,fee schedule,658.08,1832.77,Radiology
Endoskel knee-shin mnl lock,L5810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,921.31,,,,,,,fee schedule,658.08,1832.77,APC
Endoskel knee-shin mnl lock,L5810,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1151.64,,,,,,,fee schedule,658.08,1832.77,APC
Endo knee-shin mnl lck ultra,L5811,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2499.41,,,,,,,fee schedule,974.83,2714.87,
Endo knee-shin mnl lck ultra,L5811,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2714.87,,,,,,,fee schedule,974.83,2714.87,
Endo knee-shin mnl lck ultra,L5811,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2176.21,,,,,,,fee schedule,974.83,2714.87,
Endo knee-shin mnl lck ultra,L5811,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2377.31,,,,,,,fee schedule,974.83,2714.87,
Endo knee-shin mnl lck ultra,L5811,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1023.57,,,,,,,fee schedule,974.83,2714.87,APC
Endo knee-shin mnl lck ultra,L5811,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1013.82,,,,,,,fee schedule,974.83,2714.87,APC
Endo knee-shin mnl lck ultra,L5811,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,974.83,,,,,,,fee schedule,974.83,2714.87,APC
Endo knee-shin mnl lck ultra,L5811,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1491.49,,,,,,,fee schedule,974.83,2714.87,Radiology
Endo knee-shin mnl lck ultra,L5811,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1364.76,,,,,,,fee schedule,974.83,2714.87,APC
Endo knee-shin mnl lck ultra,L5811,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1705.95,,,,,,,fee schedule,974.83,2714.87,APC
Endo knee-shin frct swg & st,L5812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1891.35,,,,,,,fee schedule,737.66,2054.39,
Endo knee-shin frct swg & st,L5812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2054.39,,,,,,,fee schedule,737.66,2054.39,
Endo knee-shin frct swg & st,L5812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1646.77,,,,,,,fee schedule,737.66,2054.39,
Endo knee-shin frct swg & st,L5812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1798.95,,,,,,,fee schedule,737.66,2054.39,
Endo knee-shin frct swg & st,L5812,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,774.54,,,,,,,fee schedule,737.66,2054.39,APC
Endo knee-shin frct swg & st,L5812,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,767.17,,,,,,,fee schedule,737.66,2054.39,APC
Endo knee-shin frct swg & st,L5812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,737.66,,,,,,,fee schedule,737.66,2054.39,APC
Endo knee-shin frct swg & st,L5812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1128.62,,,,,,,fee schedule,737.66,2054.39,Radiology
Endo knee-shin frct swg & st,L5812,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1032.72,,,,,,,fee schedule,737.66,2054.39,APC
Endo knee-shin frct swg & st,L5812,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1290.9,,,,,,,fee schedule,737.66,2054.39,APC
Endo knee-shin hydral swg ph,L5814,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11787.7,,,,,,,fee schedule,4597.46,12803.88,
Endo knee-shin hydral swg ph,L5814,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12803.88,,,,,,,fee schedule,4597.46,12803.88,
Endo knee-shin hydral swg ph,L5814,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10263.43,,,,,,,fee schedule,4597.46,12803.88,
Endo knee-shin hydral swg ph,L5814,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11211.86,,,,,,,fee schedule,4597.46,12803.88,
Endo knee-shin hydral swg ph,L5814,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4827.33,,,,,,,fee schedule,4597.46,12803.88,APC
Endo knee-shin hydral swg ph,L5814,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4781.36,,,,,,,fee schedule,4597.46,12803.88,APC
Endo knee-shin hydral swg ph,L5814,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4597.46,,,,,,,fee schedule,4597.46,12803.88,APC
Endo knee-shin hydral swg ph,L5814,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7034.11,,,,,,,fee schedule,4597.46,12803.88,Radiology
Endo knee-shin hydral swg ph,L5814,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6436.44,,,,,,,fee schedule,4597.46,12803.88,APC
Endo knee-shin hydral swg ph,L5814,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8045.56,,,,,,,fee schedule,4597.46,12803.88,APC
Endo knee-shin polyc mch sta,L5816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3042.32,,,,,,,fee schedule,1186.56,3304.59,
Endo knee-shin polyc mch sta,L5816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3304.59,,,,,,,fee schedule,1186.56,3304.59,
Endo knee-shin polyc mch sta,L5816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2648.92,,,,,,,fee schedule,1186.56,3304.59,
Endo knee-shin polyc mch sta,L5816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2893.7,,,,,,,fee schedule,1186.56,3304.59,
Endo knee-shin polyc mch sta,L5816,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1245.89,,,,,,,fee schedule,1186.56,3304.59,APC
Endo knee-shin polyc mch sta,L5816,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1234.02,,,,,,,fee schedule,1186.56,3304.59,APC
Endo knee-shin polyc mch sta,L5816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1186.56,,,,,,,fee schedule,1186.56,3304.59,APC
Endo knee-shin polyc mch sta,L5816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1815.44,,,,,,,fee schedule,1186.56,3304.59,Radiology
Endo knee-shin polyc mch sta,L5816,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1661.18,,,,,,,fee schedule,1186.56,3304.59,APC
Endo knee-shin polyc mch sta,L5816,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2076.48,,,,,,,fee schedule,1186.56,3304.59,APC
Endo knee-shin frct swg & st,L5818,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3050.46,,,,,,,fee schedule,1189.74,3313.43,
Endo knee-shin frct swg & st,L5818,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3313.43,,,,,,,fee schedule,1189.74,3313.43,
Endo knee-shin frct swg & st,L5818,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2656.01,,,,,,,fee schedule,1189.74,3313.43,
Endo knee-shin frct swg & st,L5818,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2901.45,,,,,,,fee schedule,1189.74,3313.43,
Endo knee-shin frct swg & st,L5818,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1249.23,,,,,,,fee schedule,1189.74,3313.43,APC
Endo knee-shin frct swg & st,L5818,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1237.33,,,,,,,fee schedule,1189.74,3313.43,APC
Endo knee-shin frct swg & st,L5818,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1189.74,,,,,,,fee schedule,1189.74,3313.43,APC
Endo knee-shin frct swg & st,L5818,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1820.3,,,,,,,fee schedule,1189.74,3313.43,Radiology
Endo knee-shin frct swg & st,L5818,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1665.64,,,,,,,fee schedule,1189.74,3313.43,APC
Endo knee-shin frct swg & st,L5818,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2082.04,,,,,,,fee schedule,1189.74,3313.43,APC
Endo knee-shin pneum swg frc,L5822,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5345.28,,,,,,,fee schedule,2084.77,5806.08,
Endo knee-shin pneum swg frc,L5822,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5806.08,,,,,,,fee schedule,2084.77,5806.08,
Endo knee-shin pneum swg frc,L5822,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4654.08,,,,,,,fee schedule,2084.77,5806.08,
Endo knee-shin pneum swg frc,L5822,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5084.16,,,,,,,fee schedule,2084.77,5806.08,
Endo knee-shin pneum swg frc,L5822,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2189.01,,,,,,,fee schedule,2084.77,5806.08,APC
Endo knee-shin pneum swg frc,L5822,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2168.16,,,,,,,fee schedule,2084.77,5806.08,APC
Endo knee-shin pneum swg frc,L5822,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2084.77,,,,,,,fee schedule,2084.77,5806.08,APC
Endo knee-shin pneum swg frc,L5822,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3189.7,,,,,,,fee schedule,2084.77,5806.08,Radiology
Endo knee-shin pneum swg frc,L5822,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2918.68,,,,,,,fee schedule,2084.77,5806.08,APC
Endo knee-shin pneum swg frc,L5822,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3648.35,,,,,,,fee schedule,2084.77,5806.08,APC
Endo knee-shin fluid swing p,L5824,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5734.34,,,,,,,fee schedule,2236.51,6228.68,
Endo knee-shin fluid swing p,L5824,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6228.68,,,,,,,fee schedule,2236.51,6228.68,
Endo knee-shin fluid swing p,L5824,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4992.83,,,,,,,fee schedule,2236.51,6228.68,
Endo knee-shin fluid swing p,L5824,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5454.22,,,,,,,fee schedule,2236.51,6228.68,
Endo knee-shin fluid swing p,L5824,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2348.34,,,,,,,fee schedule,2236.51,6228.68,APC
Endo knee-shin fluid swing p,L5824,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2325.97,,,,,,,fee schedule,2236.51,6228.68,APC
Endo knee-shin fluid swing p,L5824,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2236.51,,,,,,,fee schedule,2236.51,6228.68,APC
Endo knee-shin fluid swing p,L5824,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3421.86,,,,,,,fee schedule,2236.51,6228.68,Radiology
Endo knee-shin fluid swing p,L5824,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3131.11,,,,,,,fee schedule,2236.51,6228.68,APC
Endo knee-shin fluid swing p,L5824,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3913.89,,,,,,,fee schedule,2236.51,6228.68,APC
Miniature knee joint,L5826,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9911.94,,,,,,,fee schedule,3865.87,10766.42,
Miniature knee joint,L5826,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10766.42,,,,,,,fee schedule,3865.87,10766.42,
Miniature knee joint,L5826,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8630.23,,,,,,,fee schedule,3865.87,10766.42,
Miniature knee joint,L5826,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9427.74,,,,,,,fee schedule,3865.87,10766.42,
Miniature knee joint,L5826,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4059.16,,,,,,,fee schedule,3865.87,10766.42,APC
Miniature knee joint,L5826,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4020.5,,,,,,,fee schedule,3865.87,10766.42,APC
Miniature knee joint,L5826,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3865.87,,,,,,,fee schedule,3865.87,10766.42,APC
Miniature knee joint,L5826,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5914.78,,,,,,,fee schedule,3865.87,10766.42,Radiology
Miniature knee joint,L5826,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5412.22,,,,,,,fee schedule,3865.87,10766.42,APC
Miniature knee joint,L5826,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6765.27,,,,,,,fee schedule,3865.87,10766.42,APC
Endo knee-shin fluid swg/sta,L5828,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8864.12,,,,,,,fee schedule,3457.19,9628.26,
Endo knee-shin fluid swg/sta,L5828,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9628.26,,,,,,,fee schedule,3457.19,9628.26,
Endo knee-shin fluid swg/sta,L5828,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7717.89,,,,,,,fee schedule,3457.19,9628.26,
Endo knee-shin fluid swg/sta,L5828,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8431.1,,,,,,,fee schedule,3457.19,9628.26,
Endo knee-shin fluid swg/sta,L5828,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3630.05,,,,,,,fee schedule,3457.19,9628.26,APC
Endo knee-shin fluid swg/sta,L5828,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3595.48,,,,,,,fee schedule,3457.19,9628.26,APC
Endo knee-shin fluid swg/sta,L5828,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3457.19,,,,,,,fee schedule,3457.19,9628.26,APC
Endo knee-shin fluid swg/sta,L5828,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5289.5,,,,,,,fee schedule,3457.19,9628.26,Radiology
Endo knee-shin fluid swg/sta,L5828,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4840.07,,,,,,,fee schedule,3457.19,9628.26,APC
Endo knee-shin fluid swg/sta,L5828,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6050.08,,,,,,,fee schedule,3457.19,9628.26,APC
Endo knee-shin pneum/swg pha,L5830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6537.11,,,,,,,fee schedule,2549.61,7100.65,
Endo knee-shin pneum/swg pha,L5830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7100.65,,,,,,,fee schedule,2549.61,7100.65,
Endo knee-shin pneum/swg pha,L5830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5691.79,,,,,,,fee schedule,2549.61,7100.65,
Endo knee-shin pneum/swg pha,L5830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6217.77,,,,,,,fee schedule,2549.61,7100.65,
Endo knee-shin pneum/swg pha,L5830,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2677.09,,,,,,,fee schedule,2549.61,7100.65,APC
Endo knee-shin pneum/swg pha,L5830,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2651.59,,,,,,,fee schedule,2549.61,7100.65,APC
Endo knee-shin pneum/swg pha,L5830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2549.61,,,,,,,fee schedule,2549.61,7100.65,APC
Endo knee-shin pneum/swg pha,L5830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3900.9,,,,,,,fee schedule,2549.61,7100.65,Radiology
Endo knee-shin pneum/swg pha,L5830,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3569.45,,,,,,,fee schedule,2549.61,7100.65,APC
Endo knee-shin pneum/swg pha,L5830,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4461.82,,,,,,,fee schedule,2549.61,7100.65,APC
Multi-axial knee/shin system,L5840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11012.01,,,,,,,fee schedule,4294.9,11961.32,
Multi-axial knee/shin system,L5840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11961.32,,,,,,,fee schedule,4294.9,11961.32,
Multi-axial knee/shin system,L5840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9588.04,,,,,,,fee schedule,4294.9,11961.32,
Multi-axial knee/shin system,L5840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10474.06,,,,,,,fee schedule,4294.9,11961.32,
Multi-axial knee/shin system,L5840,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4509.64,,,,,,,fee schedule,4294.9,11961.32,APC
Multi-axial knee/shin system,L5840,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4466.7,,,,,,,fee schedule,4294.9,11961.32,APC
Multi-axial knee/shin system,L5840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4294.9,,,,,,,fee schedule,4294.9,11961.32,APC
Multi-axial knee/shin system,L5840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6571.2,,,,,,,fee schedule,4294.9,11961.32,Radiology
Multi-axial knee/shin system,L5840,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6012.86,,,,,,,fee schedule,4294.9,11961.32,APC
Multi-axial knee/shin system,L5840,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7516.07,,,,,,,fee schedule,4294.9,11961.32,APC
Knee-shin sys stance flexion,L5845,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5688.93,,,,,,,fee schedule,2218.82,6179.36,
Knee-shin sys stance flexion,L5845,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6179.36,,,,,,,fee schedule,2218.82,6179.36,
Knee-shin sys stance flexion,L5845,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4953.29,,,,,,,fee schedule,2218.82,6179.36,
Knee-shin sys stance flexion,L5845,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5411.02,,,,,,,fee schedule,2218.82,6179.36,
Knee-shin sys stance flexion,L5845,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2329.76,,,,,,,fee schedule,2218.82,6179.36,APC
Knee-shin sys stance flexion,L5845,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2307.57,,,,,,,fee schedule,2218.82,6179.36,APC
Knee-shin sys stance flexion,L5845,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2218.82,,,,,,,fee schedule,2218.82,6179.36,APC
Knee-shin sys stance flexion,L5845,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3394.79,,,,,,,fee schedule,2218.82,6179.36,Radiology
Knee-shin sys stance flexion,L5845,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3106.35,,,,,,,fee schedule,2218.82,6179.36,APC
Knee-shin sys stance flexion,L5845,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3882.94,,,,,,,fee schedule,2218.82,6179.36,APC
Knee-shin sys hydraul stance,L5848,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3413.01,,,,,,,fee schedule,1331.15,3707.24,
Knee-shin sys hydraul stance,L5848,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3707.24,,,,,,,fee schedule,1331.15,3707.24,
Knee-shin sys hydraul stance,L5848,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2971.67,,,,,,,fee schedule,1331.15,3707.24,
Knee-shin sys hydraul stance,L5848,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3246.28,,,,,,,fee schedule,1331.15,3707.24,
Knee-shin sys hydraul stance,L5848,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1397.71,,,,,,,fee schedule,1331.15,3707.24,APC
Knee-shin sys hydraul stance,L5848,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1384.4,,,,,,,fee schedule,1331.15,3707.24,APC
Knee-shin sys hydraul stance,L5848,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1331.15,,,,,,,fee schedule,1331.15,3707.24,APC
Knee-shin sys hydraul stance,L5848,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2036.66,,,,,,,fee schedule,1331.15,3707.24,Radiology
Knee-shin sys hydraul stance,L5848,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1863.61,,,,,,,fee schedule,1331.15,3707.24,APC
Knee-shin sys hydraul stance,L5848,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2329.51,,,,,,,fee schedule,1331.15,3707.24,APC
Endo ak/hip knee extens assi,L5850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,535.4,,,,,,,fee schedule,208.81,581.55,
Endo ak/hip knee extens assi,L5850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,581.55,,,,,,,fee schedule,208.81,581.55,
Endo ak/hip knee extens assi,L5850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,466.17,,,,,,,fee schedule,208.81,581.55,
Endo ak/hip knee extens assi,L5850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,509.24,,,,,,,fee schedule,208.81,581.55,
Endo ak/hip knee extens assi,L5850,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,219.25,,,,,,,fee schedule,208.81,581.55,APC
Endo ak/hip knee extens assi,L5850,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,217.16,,,,,,,fee schedule,208.81,581.55,APC
Endo ak/hip knee extens assi,L5850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,208.81,,,,,,,fee schedule,208.81,581.55,APC
Endo ak/hip knee extens assi,L5850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,319.48,,,,,,,fee schedule,208.81,581.55,Radiology
Endo ak/hip knee extens assi,L5850,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,292.33,,,,,,,fee schedule,208.81,581.55,APC
Endo ak/hip knee extens assi,L5850,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,365.42,,,,,,,fee schedule,208.81,581.55,APC
Mech hip extension assist,L5855,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1078.87,,,,,,,fee schedule,420.79,1171.88,
Mech hip extension assist,L5855,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1171.88,,,,,,,fee schedule,420.79,1171.88,
Mech hip extension assist,L5855,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,939.36,,,,,,,fee schedule,420.79,1171.88,
Mech hip extension assist,L5855,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1026.17,,,,,,,fee schedule,420.79,1171.88,
Mech hip extension assist,L5855,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,441.83,,,,,,,fee schedule,420.79,1171.88,APC
Mech hip extension assist,L5855,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,437.62,,,,,,,fee schedule,420.79,1171.88,APC
Mech hip extension assist,L5855,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,420.79,,,,,,,fee schedule,420.79,1171.88,APC
Mech hip extension assist,L5855,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,643.81,,,,,,,fee schedule,420.79,1171.88,Radiology
Mech hip extension assist,L5855,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,589.11,,,,,,,fee schedule,420.79,1171.88,APC
Mech hip extension assist,L5855,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,736.38,,,,,,,fee schedule,420.79,1171.88,APC
Elec knee-shin swing/stance,L5856,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,76193.73,,,,,,,fee schedule,29717.2,82762.16,
Elec knee-shin swing/stance,L5856,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,82762.16,,,,,,,fee schedule,29717.2,82762.16,
Elec knee-shin swing/stance,L5856,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66341.09,,,,,,,fee schedule,29717.2,82762.16,
Elec knee-shin swing/stance,L5856,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,72471.62,,,,,,,fee schedule,29717.2,82762.16,
Elec knee-shin swing/stance,L5856,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,31203.06,,,,,,,fee schedule,29717.2,82762.16,APC
Elec knee-shin swing/stance,L5856,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,30905.89,,,,,,,fee schedule,29717.2,82762.16,APC
Elec knee-shin swing/stance,L5856,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,29717.2,,,,,,,fee schedule,29717.2,82762.16,APC
Elec knee-shin swing/stance,L5856,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,45467.32,,,,,,,fee schedule,29717.2,82762.16,Radiology
Elec knee-shin swing/stance,L5856,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,41604.08,,,,,,,fee schedule,29717.2,82762.16,APC
Elec knee-shin swing/stance,L5856,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,52005.1,,,,,,,fee schedule,29717.2,82762.16,APC
Elec knee-shin swing only,L5857,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27036.47,,,,,,,fee schedule,10544.8,29367.2,
Elec knee-shin swing only,L5857,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,29367.2,,,,,,,fee schedule,10544.8,29367.2,
Elec knee-shin swing only,L5857,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23540.37,,,,,,,fee schedule,10544.8,29367.2,
Elec knee-shin swing only,L5857,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,25715.72,,,,,,,fee schedule,10544.8,29367.2,
Elec knee-shin swing only,L5857,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11072.04,,,,,,,fee schedule,10544.8,29367.2,APC
Elec knee-shin swing only,L5857,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10966.59,,,,,,,fee schedule,10544.8,29367.2,APC
Elec knee-shin swing only,L5857,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10544.8,,,,,,,fee schedule,10544.8,29367.2,APC
Elec knee-shin swing only,L5857,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16133.54,,,,,,,fee schedule,10544.8,29367.2,Radiology
Elec knee-shin swing only,L5857,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14762.72,,,,,,,fee schedule,10544.8,29367.2,APC
Elec knee-shin swing only,L5857,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18453.4,,,,,,,fee schedule,10544.8,29367.2,APC
Stance phase only,L5858,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,58988.82,,,,,,,fee schedule,23006.91,64074.06,
Stance phase only,L5858,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,64074.06,,,,,,,fee schedule,23006.91,64074.06,
Stance phase only,L5858,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51360.95,,,,,,,fee schedule,23006.91,64074.06,
Stance phase only,L5858,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56107.18,,,,,,,fee schedule,23006.91,64074.06,
Stance phase only,L5858,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,24157.26,,,,,,,fee schedule,23006.91,64074.06,APC
Stance phase only,L5858,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,23927.19,,,,,,,fee schedule,23006.91,64074.06,APC
Stance phase only,L5858,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,23006.91,,,,,,,fee schedule,23006.91,64074.06,APC
Stance phase only,L5858,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,35200.57,,,,,,,fee schedule,23006.91,64074.06,Radiology
Stance phase only,L5858,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,32209.67,,,,,,,fee schedule,23006.91,64074.06,APC
Stance phase only,L5858,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,40262.09,,,,,,,fee schedule,23006.91,64074.06,APC
Knee-shin pro flex/ext cont,L5859,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,48681.34,,,,,,,fee schedule,17961.29,52878,
Knee-shin pro flex/ext cont,L5859,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,52878,,,,,,,fee schedule,17961.29,52878,
Knee-shin pro flex/ext cont,L5859,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42386.34,,,,,,,fee schedule,17961.29,52878,
Knee-shin pro flex/ext cont,L5859,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46303.23,,,,,,,fee schedule,17961.29,52878,
Knee-shin pro flex/ext cont,L5859,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18859.35,,,,,,,fee schedule,17961.29,52878,APC
Knee-shin pro flex/ext cont,L5859,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18679.74,,,,,,,fee schedule,17961.29,52878,APC
Knee-shin pro flex/ext cont,L5859,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17961.29,,,,,,,fee schedule,17961.29,52878,APC
Knee-shin pro flex/ext cont,L5859,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27480.77,,,,,,,fee schedule,17961.29,52878,Radiology
Knee-shin pro flex/ext cont,L5859,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25145.81,,,,,,,fee schedule,17961.29,52878,APC
Knee-shin pro flex/ext cont,L5859,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31432.26,,,,,,,fee schedule,17961.29,52878,APC
Endo below knee alignable sy,L5910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1515.78,,,,,,,fee schedule,591.19,1646.45,
Endo below knee alignable sy,L5910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1646.45,,,,,,,fee schedule,591.19,1646.45,
Endo below knee alignable sy,L5910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1319.78,,,,,,,fee schedule,591.19,1646.45,
Endo below knee alignable sy,L5910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1441.74,,,,,,,fee schedule,591.19,1646.45,
Endo below knee alignable sy,L5910,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,620.75,,,,,,,fee schedule,591.19,1646.45,APC
Endo below knee alignable sy,L5910,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,614.84,,,,,,,fee schedule,591.19,1646.45,APC
Endo below knee alignable sy,L5910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,591.19,,,,,,,fee schedule,591.19,1646.45,APC
Endo below knee alignable sy,L5910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,904.52,,,,,,,fee schedule,591.19,1646.45,Radiology
Endo below knee alignable sy,L5910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,827.67,,,,,,,fee schedule,591.19,1646.45,APC
Endo below knee alignable sy,L5910,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1034.58,,,,,,,fee schedule,591.19,1646.45,APC
Endo ak/hip alignable system,L5920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2220.62,,,,,,,fee schedule,866.11,2412.06,
Endo ak/hip alignable system,L5920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2412.06,,,,,,,fee schedule,866.11,2412.06,
Endo ak/hip alignable system,L5920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1933.47,,,,,,,fee schedule,866.11,2412.06,
Endo ak/hip alignable system,L5920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2112.14,,,,,,,fee schedule,866.11,2412.06,
Endo ak/hip alignable system,L5920,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,909.42,,,,,,,fee schedule,866.11,2412.06,APC
Endo ak/hip alignable system,L5920,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,900.75,,,,,,,fee schedule,866.11,2412.06,APC
Endo ak/hip alignable system,L5920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,866.11,,,,,,,fee schedule,866.11,2412.06,APC
Endo ak/hip alignable system,L5920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1325.15,,,,,,,fee schedule,866.11,2412.06,Radiology
Endo ak/hip alignable system,L5920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1212.55,,,,,,,fee schedule,866.11,2412.06,APC
Endo ak/hip alignable system,L5920,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1515.69,,,,,,,fee schedule,866.11,2412.06,APC
Above knee manual lock,L5925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1406.27,,,,,,,fee schedule,548.48,1527.5,
Above knee manual lock,L5925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1527.5,,,,,,,fee schedule,548.48,1527.5,
Above knee manual lock,L5925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1224.42,,,,,,,fee schedule,548.48,1527.5,
Above knee manual lock,L5925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1337.57,,,,,,,fee schedule,548.48,1527.5,
Above knee manual lock,L5925,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,575.9,,,,,,,fee schedule,548.48,1527.5,APC
Above knee manual lock,L5925,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,570.42,,,,,,,fee schedule,548.48,1527.5,APC
Above knee manual lock,L5925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,548.48,,,,,,,fee schedule,548.48,1527.5,APC
Above knee manual lock,L5925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,839.17,,,,,,,fee schedule,548.48,1527.5,Radiology
Above knee manual lock,L5925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,767.87,,,,,,,fee schedule,548.48,1527.5,APC
Above knee manual lock,L5925,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,959.84,,,,,,,fee schedule,548.48,1527.5,APC
High activity knee frame,L5930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10683.25,,,,,,,fee schedule,4166.69,11604.22,
High activity knee frame,L5930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11604.22,,,,,,,fee schedule,4166.69,11604.22,
High activity knee frame,L5930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9301.8,,,,,,,fee schedule,4166.69,11604.22,
High activity knee frame,L5930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10161.37,,,,,,,fee schedule,4166.69,11604.22,
High activity knee frame,L5930,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4375.02,,,,,,,fee schedule,4166.69,11604.22,APC
High activity knee frame,L5930,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4333.36,,,,,,,fee schedule,4166.69,11604.22,APC
High activity knee frame,L5930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4166.69,,,,,,,fee schedule,4166.69,11604.22,APC
High activity knee frame,L5930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6375.04,,,,,,,fee schedule,4166.69,11604.22,Radiology
High activity knee frame,L5930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5833.37,,,,,,,fee schedule,4166.69,11604.22,APC
High activity knee frame,L5930,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7291.71,,,,,,,fee schedule,4166.69,11604.22,APC
Endo bk ultra-light material,L5940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2099.34,,,,,,,fee schedule,818.79,2280.32,
Endo bk ultra-light material,L5940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2280.32,,,,,,,fee schedule,818.79,2280.32,
Endo bk ultra-light material,L5940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1827.88,,,,,,,fee schedule,818.79,2280.32,
Endo bk ultra-light material,L5940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1996.79,,,,,,,fee schedule,818.79,2280.32,
Endo bk ultra-light material,L5940,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,859.73,,,,,,,fee schedule,818.79,2280.32,APC
Endo bk ultra-light material,L5940,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,851.54,,,,,,,fee schedule,818.79,2280.32,APC
Endo bk ultra-light material,L5940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,818.79,,,,,,,fee schedule,818.79,2280.32,APC
Endo bk ultra-light material,L5940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1252.75,,,,,,,fee schedule,818.79,2280.32,Radiology
Endo bk ultra-light material,L5940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1146.31,,,,,,,fee schedule,818.79,2280.32,APC
Endo bk ultra-light material,L5940,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1432.88,,,,,,,fee schedule,818.79,2280.32,APC
Endo ak ultra-light material,L5950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3256.13,,,,,,,fee schedule,1269.97,3536.83,
Endo ak ultra-light material,L5950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3536.83,,,,,,,fee schedule,1269.97,3536.83,
Endo ak ultra-light material,L5950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2835.08,,,,,,,fee schedule,1269.97,3536.83,
Endo ak ultra-light material,L5950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3097.07,,,,,,,fee schedule,1269.97,3536.83,
Endo ak ultra-light material,L5950,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1333.47,,,,,,,fee schedule,1269.97,3536.83,APC
Endo ak ultra-light material,L5950,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1320.77,,,,,,,fee schedule,1269.97,3536.83,APC
Endo ak ultra-light material,L5950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1269.97,,,,,,,fee schedule,1269.97,3536.83,APC
Endo ak ultra-light material,L5950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1943.05,,,,,,,fee schedule,1269.97,3536.83,Radiology
Endo ak ultra-light material,L5950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1777.96,,,,,,,fee schedule,1269.97,3536.83,APC
Endo ak ultra-light material,L5950,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2222.45,,,,,,,fee schedule,1269.97,3536.83,APC
Endo hip ultra-light materia,L5960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4034.75,,,,,,,fee schedule,1573.63,4382.57,
Endo hip ultra-light materia,L5960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4382.57,,,,,,,fee schedule,1573.63,4382.57,
Endo hip ultra-light materia,L5960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3513.01,,,,,,,fee schedule,1573.63,4382.57,
Endo hip ultra-light materia,L5960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3837.65,,,,,,,fee schedule,1573.63,4382.57,
Endo hip ultra-light materia,L5960,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1652.31,,,,,,,fee schedule,1573.63,4382.57,APC
Endo hip ultra-light materia,L5960,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1636.58,,,,,,,fee schedule,1573.63,4382.57,APC
Endo hip ultra-light materia,L5960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1573.63,,,,,,,fee schedule,1573.63,4382.57,APC
Endo hip ultra-light materia,L5960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2407.65,,,,,,,fee schedule,1573.63,4382.57,Radiology
Endo hip ultra-light materia,L5960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2203.08,,,,,,,fee schedule,1573.63,4382.57,APC
Endo hip ultra-light materia,L5960,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2753.85,,,,,,,fee schedule,1573.63,4382.57,APC
"Endo poly hip, pneu/hyd/rot",L5961,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15432.69,,,,,,,fee schedule,5837.22,16763.09,
"Endo poly hip, pneu/hyd/rot",L5961,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16763.09,,,,,,,fee schedule,5837.22,16763.09,
"Endo poly hip, pneu/hyd/rot",L5961,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13437.08,,,,,,,fee schedule,5837.22,16763.09,
"Endo poly hip, pneu/hyd/rot",L5961,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14678.79,,,,,,,fee schedule,5837.22,16763.09,
"Endo poly hip, pneu/hyd/rot",L5961,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6129.08,,,,,,,fee schedule,5837.22,16763.09,APC
"Endo poly hip, pneu/hyd/rot",L5961,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6070.71,,,,,,,fee schedule,5837.22,16763.09,APC
"Endo poly hip, pneu/hyd/rot",L5961,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5837.22,,,,,,,fee schedule,5837.22,16763.09,APC
"Endo poly hip, pneu/hyd/rot",L5961,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8930.95,,,,,,,fee schedule,5837.22,16763.09,Radiology
"Endo poly hip, pneu/hyd/rot",L5961,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8172.11,,,,,,,fee schedule,5837.22,16763.09,APC
"Endo poly hip, pneu/hyd/rot",L5961,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10215.14,,,,,,,fee schedule,5837.22,16763.09,APC
Below knee flex cover system,L5962,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1991.33,,,,,,,fee schedule,776.67,2162.99,
Below knee flex cover system,L5962,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2162.99,,,,,,,fee schedule,776.67,2162.99,
Below knee flex cover system,L5962,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1733.83,,,,,,,fee schedule,776.67,2162.99,
Below knee flex cover system,L5962,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1894.05,,,,,,,fee schedule,776.67,2162.99,
Below knee flex cover system,L5962,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,815.5,,,,,,,fee schedule,776.67,2162.99,APC
Below knee flex cover system,L5962,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,807.74,,,,,,,fee schedule,776.67,2162.99,APC
Below knee flex cover system,L5962,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,776.67,,,,,,,fee schedule,776.67,2162.99,APC
Below knee flex cover system,L5962,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1188.31,,,,,,,fee schedule,776.67,2162.99,Radiology
Below knee flex cover system,L5962,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1087.34,,,,,,,fee schedule,776.67,2162.99,APC
Below knee flex cover system,L5962,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1359.17,,,,,,,fee schedule,776.67,2162.99,APC
Above knee flex cover system,L5964,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2939.7,,,,,,,fee schedule,1146.54,3193.12,
Above knee flex cover system,L5964,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3193.12,,,,,,,fee schedule,1146.54,3193.12,
Above knee flex cover system,L5964,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2559.56,,,,,,,fee schedule,1146.54,3193.12,
Above knee flex cover system,L5964,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2796.09,,,,,,,fee schedule,1146.54,3193.12,
Above knee flex cover system,L5964,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1203.87,,,,,,,fee schedule,1146.54,3193.12,APC
Above knee flex cover system,L5964,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1192.4,,,,,,,fee schedule,1146.54,3193.12,APC
Above knee flex cover system,L5964,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1146.54,,,,,,,fee schedule,1146.54,3193.12,APC
Above knee flex cover system,L5964,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1754.21,,,,,,,fee schedule,1146.54,3193.12,Radiology
Above knee flex cover system,L5964,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1605.16,,,,,,,fee schedule,1146.54,3193.12,APC
Above knee flex cover system,L5964,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2006.44,,,,,,,fee schedule,1146.54,3193.12,APC
Hip flexible cover system,L5966,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3745.87,,,,,,,fee schedule,1460.97,4068.79,
Hip flexible cover system,L5966,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4068.79,,,,,,,fee schedule,1460.97,4068.79,
Hip flexible cover system,L5966,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3261.49,,,,,,,fee schedule,1460.97,4068.79,
Hip flexible cover system,L5966,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3562.88,,,,,,,fee schedule,1460.97,4068.79,
Hip flexible cover system,L5966,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1534.02,,,,,,,fee schedule,1460.97,4068.79,APC
Hip flexible cover system,L5966,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1519.41,,,,,,,fee schedule,1460.97,4068.79,APC
Hip flexible cover system,L5966,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1460.97,,,,,,,fee schedule,1460.97,4068.79,APC
Hip flexible cover system,L5966,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2235.28,,,,,,,fee schedule,1460.97,4068.79,Radiology
Hip flexible cover system,L5966,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2045.36,,,,,,,fee schedule,1460.97,4068.79,APC
Hip flexible cover system,L5966,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2556.7,,,,,,,fee schedule,1460.97,4068.79,APC
Multiaxial ankle w dorsiflex,L5968,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11533.9,,,,,,,fee schedule,4498.47,12528.21,
Multiaxial ankle w dorsiflex,L5968,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12528.21,,,,,,,fee schedule,4498.47,12528.21,
Multiaxial ankle w dorsiflex,L5968,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10042.45,,,,,,,fee schedule,4498.47,12528.21,
Multiaxial ankle w dorsiflex,L5968,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10970.47,,,,,,,fee schedule,4498.47,12528.21,
Multiaxial ankle w dorsiflex,L5968,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4723.39,,,,,,,fee schedule,4498.47,12528.21,APC
Multiaxial ankle w dorsiflex,L5968,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4678.41,,,,,,,fee schedule,4498.47,12528.21,APC
Multiaxial ankle w dorsiflex,L5968,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4498.47,,,,,,,fee schedule,4498.47,12528.21,APC
Multiaxial ankle w dorsiflex,L5968,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6882.66,,,,,,,fee schedule,4498.47,12528.21,Radiology
Multiaxial ankle w dorsiflex,L5968,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6297.86,,,,,,,fee schedule,4498.47,12528.21,APC
Multiaxial ankle w dorsiflex,L5968,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7872.32,,,,,,,fee schedule,4498.47,12528.21,APC
Ak/ft power asst incl motors,L5969,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,47961.92,,,,,,,fee schedule,41759.94,52096.56,
Ak/ft power asst incl motors,L5969,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,52096.56,,,,,,,fee schedule,41759.94,52096.56,
Ak/ft power asst incl motors,L5969,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,41759.94,,,,,,,fee schedule,41759.94,52096.56,
Ak/ft power asst incl motors,L5969,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,45618.95,,,,,,,fee schedule,41759.94,52096.56,
Foot external keel sach foot,L5970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,714.48,,,,,,,fee schedule,278.64,776.07,
Foot external keel sach foot,L5970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,776.07,,,,,,,fee schedule,278.64,776.07,
Foot external keel sach foot,L5970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,622.09,,,,,,,fee schedule,278.64,776.07,
Foot external keel sach foot,L5970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,679.58,,,,,,,fee schedule,278.64,776.07,
Foot external keel sach foot,L5970,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,292.57,,,,,,,fee schedule,278.64,776.07,APC
Foot external keel sach foot,L5970,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,289.79,,,,,,,fee schedule,278.64,776.07,APC
Foot external keel sach foot,L5970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,278.64,,,,,,,fee schedule,278.64,776.07,APC
Foot external keel sach foot,L5970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,426.32,,,,,,,fee schedule,278.64,776.07,Radiology
Foot external keel sach foot,L5970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,390.1,,,,,,,fee schedule,278.64,776.07,APC
Foot external keel sach foot,L5970,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,487.62,,,,,,,fee schedule,278.64,776.07,APC
"SACH foot, replacement",L5971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,714.48,,,,,,,fee schedule,278.64,776.07,
"SACH foot, replacement",L5971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,776.07,,,,,,,fee schedule,278.64,776.07,
"SACH foot, replacement",L5971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,622.09,,,,,,,fee schedule,278.64,776.07,
"SACH foot, replacement",L5971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,679.58,,,,,,,fee schedule,278.64,776.07,
"SACH foot, replacement",L5971,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,292.57,,,,,,,fee schedule,278.64,776.07,APC
"SACH foot, replacement",L5971,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,289.79,,,,,,,fee schedule,278.64,776.07,APC
"SACH foot, replacement",L5971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,278.64,,,,,,,fee schedule,278.64,776.07,APC
"SACH foot, replacement",L5971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,426.32,,,,,,,fee schedule,278.64,776.07,Radiology
"SACH foot, replacement",L5971,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,390.1,,,,,,,fee schedule,278.64,776.07,APC
"SACH foot, replacement",L5971,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,487.62,,,,,,,fee schedule,278.64,776.07,APC
Flexible keel foot,L5972,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1344.92,,,,,,,fee schedule,524.57,1460.86,
Flexible keel foot,L5972,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1460.86,,,,,,,fee schedule,524.57,1460.86,
Flexible keel foot,L5972,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1171,,,,,,,fee schedule,524.57,1460.86,
Flexible keel foot,L5972,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1279.22,,,,,,,fee schedule,524.57,1460.86,
Flexible keel foot,L5972,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,550.8,,,,,,,fee schedule,524.57,1460.86,APC
Flexible keel foot,L5972,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,545.55,,,,,,,fee schedule,524.57,1460.86,APC
Flexible keel foot,L5972,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,524.57,,,,,,,fee schedule,524.57,1460.86,APC
Flexible keel foot,L5972,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,802.59,,,,,,,fee schedule,524.57,1460.86,Radiology
Flexible keel foot,L5972,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,734.4,,,,,,,fee schedule,524.57,1460.86,APC
Flexible keel foot,L5972,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,918,,,,,,,fee schedule,524.57,1460.86,APC
Ank-foot sys dors-plant flex,L5973,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,56308.66,,,,,,,fee schedule,21297.95,61162.86,
Ank-foot sys dors-plant flex,L5973,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,61162.86,,,,,,,fee schedule,21297.95,61162.86,
Ank-foot sys dors-plant flex,L5973,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,49027.37,,,,,,,fee schedule,21297.95,61162.86,
Ank-foot sys dors-plant flex,L5973,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53557.95,,,,,,,fee schedule,21297.95,61162.86,
Ank-foot sys dors-plant flex,L5973,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,22362.85,,,,,,,fee schedule,21297.95,61162.86,APC
Ank-foot sys dors-plant flex,L5973,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,22149.87,,,,,,,fee schedule,21297.95,61162.86,APC
Ank-foot sys dors-plant flex,L5973,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,21297.95,,,,,,,fee schedule,21297.95,61162.86,APC
Ank-foot sys dors-plant flex,L5973,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,32585.86,,,,,,,fee schedule,21297.95,61162.86,Radiology
Ank-foot sys dors-plant flex,L5973,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29817.13,,,,,,,fee schedule,21297.95,61162.86,APC
Ank-foot sys dors-plant flex,L5973,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,37271.41,,,,,,,fee schedule,21297.95,61162.86,APC
Foot single axis ankle/foot,L5974,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,832.03,,,,,,,fee schedule,324.52,903.76,
Foot single axis ankle/foot,L5974,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,903.76,,,,,,,fee schedule,324.52,903.76,
Foot single axis ankle/foot,L5974,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,724.44,,,,,,,fee schedule,324.52,903.76,
Foot single axis ankle/foot,L5974,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,791.39,,,,,,,fee schedule,324.52,903.76,
Foot single axis ankle/foot,L5974,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,340.75,,,,,,,fee schedule,324.52,903.76,APC
Foot single axis ankle/foot,L5974,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,337.5,,,,,,,fee schedule,324.52,903.76,APC
Foot single axis ankle/foot,L5974,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,324.52,,,,,,,fee schedule,324.52,903.76,APC
Foot single axis ankle/foot,L5974,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,496.52,,,,,,,fee schedule,324.52,903.76,Radiology
Foot single axis ankle/foot,L5974,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,454.33,,,,,,,fee schedule,324.52,903.76,APC
Foot single axis ankle/foot,L5974,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,567.91,,,,,,,fee schedule,324.52,903.76,APC
Combo ankle/foot prosthesis,L5975,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1471.52,,,,,,,fee schedule,573.92,1598.37,
Combo ankle/foot prosthesis,L5975,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1598.37,,,,,,,fee schedule,573.92,1598.37,
Combo ankle/foot prosthesis,L5975,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1281.24,,,,,,,fee schedule,573.92,1598.37,
Combo ankle/foot prosthesis,L5975,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1399.63,,,,,,,fee schedule,573.92,1598.37,
Combo ankle/foot prosthesis,L5975,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,602.62,,,,,,,fee schedule,573.92,1598.37,APC
Combo ankle/foot prosthesis,L5975,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,596.88,,,,,,,fee schedule,573.92,1598.37,APC
Combo ankle/foot prosthesis,L5975,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,573.92,,,,,,,fee schedule,573.92,1598.37,APC
Combo ankle/foot prosthesis,L5975,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,878.1,,,,,,,fee schedule,573.92,1598.37,Radiology
Combo ankle/foot prosthesis,L5975,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,803.49,,,,,,,fee schedule,573.92,1598.37,APC
Combo ankle/foot prosthesis,L5975,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1004.36,,,,,,,fee schedule,573.92,1598.37,APC
Energy storing foot,L5976,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1905.37,,,,,,,fee schedule,743.14,2069.63,
Energy storing foot,L5976,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2069.63,,,,,,,fee schedule,743.14,2069.63,
Energy storing foot,L5976,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1658.99,,,,,,,fee schedule,743.14,2069.63,
Energy storing foot,L5976,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1812.29,,,,,,,fee schedule,743.14,2069.63,
Energy storing foot,L5976,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,780.3,,,,,,,fee schedule,743.14,2069.63,APC
Energy storing foot,L5976,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,772.87,,,,,,,fee schedule,743.14,2069.63,APC
Energy storing foot,L5976,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,743.14,,,,,,,fee schedule,743.14,2069.63,APC
Energy storing foot,L5976,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1137,,,,,,,fee schedule,743.14,2069.63,Radiology
Energy storing foot,L5976,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1040.4,,,,,,,fee schedule,743.14,2069.63,APC
Energy storing foot,L5976,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1300.49,,,,,,,fee schedule,743.14,2069.63,APC
Ft prosth multiaxial ankl/ft,L5978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1068.29,,,,,,,fee schedule,416.66,1160.38,
Ft prosth multiaxial ankl/ft,L5978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1160.38,,,,,,,fee schedule,416.66,1160.38,
Ft prosth multiaxial ankl/ft,L5978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,930.15,,,,,,,fee schedule,416.66,1160.38,
Ft prosth multiaxial ankl/ft,L5978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1016.1,,,,,,,fee schedule,416.66,1160.38,
Ft prosth multiaxial ankl/ft,L5978,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,437.49,,,,,,,fee schedule,416.66,1160.38,APC
Ft prosth multiaxial ankl/ft,L5978,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,433.33,,,,,,,fee schedule,416.66,1160.38,APC
Ft prosth multiaxial ankl/ft,L5978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,416.66,,,,,,,fee schedule,416.66,1160.38,APC
Ft prosth multiaxial ankl/ft,L5978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,637.49,,,,,,,fee schedule,416.66,1160.38,Radiology
Ft prosth multiaxial ankl/ft,L5978,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,583.32,,,,,,,fee schedule,416.66,1160.38,APC
Ft prosth multiaxial ankl/ft,L5978,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,729.16,,,,,,,fee schedule,416.66,1160.38,APC
Multi-axial ankle/ft prosth,L5979,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7162.26,,,,,,,fee schedule,2793.44,7779.69,
Multi-axial ankle/ft prosth,L5979,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7779.69,,,,,,,fee schedule,2793.44,7779.69,
Multi-axial ankle/ft prosth,L5979,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6236.1,,,,,,,fee schedule,2793.44,7779.69,
Multi-axial ankle/ft prosth,L5979,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6812.38,,,,,,,fee schedule,2793.44,7779.69,
Multi-axial ankle/ft prosth,L5979,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2933.11,,,,,,,fee schedule,2793.44,7779.69,APC
Multi-axial ankle/ft prosth,L5979,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2905.18,,,,,,,fee schedule,2793.44,7779.69,APC
Multi-axial ankle/ft prosth,L5979,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2793.44,,,,,,,fee schedule,2793.44,7779.69,APC
Multi-axial ankle/ft prosth,L5979,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4273.96,,,,,,,fee schedule,2793.44,7779.69,Radiology
Multi-axial ankle/ft prosth,L5979,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3910.82,,,,,,,fee schedule,2793.44,7779.69,APC
Multi-axial ankle/ft prosth,L5979,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4888.52,,,,,,,fee schedule,2793.44,7779.69,APC
Flex foot system,L5980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12310.12,,,,,,,fee schedule,4801.22,13371.33,
Flex foot system,L5980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13371.33,,,,,,,fee schedule,4801.22,13371.33,
Flex foot system,L5980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10718.29,,,,,,,fee schedule,4801.22,13371.33,
Flex foot system,L5980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11708.76,,,,,,,fee schedule,4801.22,13371.33,
Flex foot system,L5980,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5041.28,,,,,,,fee schedule,4801.22,13371.33,APC
Flex foot system,L5980,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4993.27,,,,,,,fee schedule,4801.22,13371.33,APC
Flex foot system,L5980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4801.22,,,,,,,fee schedule,4801.22,13371.33,APC
Flex foot system,L5980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7345.87,,,,,,,fee schedule,4801.22,13371.33,Radiology
Flex foot system,L5980,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6721.71,,,,,,,fee schedule,4801.22,13371.33,APC
Flex foot system,L5980,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8402.14,,,,,,,fee schedule,4801.22,13371.33,APC
Flex-walk sys low ext prosth,L5981,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9401.19,,,,,,,fee schedule,3666.67,10211.63,
Flex-walk sys low ext prosth,L5981,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10211.63,,,,,,,fee schedule,3666.67,10211.63,
Flex-walk sys low ext prosth,L5981,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8185.51,,,,,,,fee schedule,3666.67,10211.63,
Flex-walk sys low ext prosth,L5981,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8941.93,,,,,,,fee schedule,3666.67,10211.63,
Flex-walk sys low ext prosth,L5981,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3850,,,,,,,fee schedule,3666.67,10211.63,APC
Flex-walk sys low ext prosth,L5981,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3813.34,,,,,,,fee schedule,3666.67,10211.63,APC
Flex-walk sys low ext prosth,L5981,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3666.67,,,,,,,fee schedule,3666.67,10211.63,APC
Flex-walk sys low ext prosth,L5981,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5610.01,,,,,,,fee schedule,3666.67,10211.63,Radiology
Flex-walk sys low ext prosth,L5981,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5133.34,,,,,,,fee schedule,3666.67,10211.63,APC
Flex-walk sys low ext prosth,L5981,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6416.67,,,,,,,fee schedule,3666.67,10211.63,APC
Exoskeletal axial rotation u,L5982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1964.67,,,,,,,fee schedule,766.26,2134.04,
Exoskeletal axial rotation u,L5982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2134.04,,,,,,,fee schedule,766.26,2134.04,
Exoskeletal axial rotation u,L5982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1710.62,,,,,,,fee schedule,766.26,2134.04,
Exoskeletal axial rotation u,L5982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1868.69,,,,,,,fee schedule,766.26,2134.04,
Exoskeletal axial rotation u,L5982,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,804.57,,,,,,,fee schedule,766.26,2134.04,APC
Exoskeletal axial rotation u,L5982,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,796.91,,,,,,,fee schedule,766.26,2134.04,APC
Exoskeletal axial rotation u,L5982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,766.26,,,,,,,fee schedule,766.26,2134.04,APC
Exoskeletal axial rotation u,L5982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1172.38,,,,,,,fee schedule,766.26,2134.04,Radiology
Exoskeletal axial rotation u,L5982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1072.76,,,,,,,fee schedule,766.26,2134.04,APC
Exoskeletal axial rotation u,L5982,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1340.96,,,,,,,fee schedule,766.26,2134.04,APC
Endoskeletal axial rotation,L5984,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2110.34,,,,,,,fee schedule,823.06,2292.27,
Endoskeletal axial rotation,L5984,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2292.27,,,,,,,fee schedule,823.06,2292.27,
Endoskeletal axial rotation,L5984,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1837.45,,,,,,,fee schedule,823.06,2292.27,
Endoskeletal axial rotation,L5984,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2007.25,,,,,,,fee schedule,823.06,2292.27,
Endoskeletal axial rotation,L5984,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,864.21,,,,,,,fee schedule,823.06,2292.27,APC
Endoskeletal axial rotation,L5984,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,855.98,,,,,,,fee schedule,823.06,2292.27,APC
Endoskeletal axial rotation,L5984,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,823.06,,,,,,,fee schedule,823.06,2292.27,APC
Endoskeletal axial rotation,L5984,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1259.28,,,,,,,fee schedule,823.06,2292.27,Radiology
Endoskeletal axial rotation,L5984,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1152.28,,,,,,,fee schedule,823.06,2292.27,APC
Endoskeletal axial rotation,L5984,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1440.36,,,,,,,fee schedule,823.06,2292.27,APC
Lwr ext dynamic prosth pylon,L5985,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,896.24,,,,,,,fee schedule,349.54,973.5,
Lwr ext dynamic prosth pylon,L5985,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,973.5,,,,,,,fee schedule,349.54,973.5,
Lwr ext dynamic prosth pylon,L5985,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,780.35,,,,,,,fee schedule,349.54,973.5,
Lwr ext dynamic prosth pylon,L5985,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,852.46,,,,,,,fee schedule,349.54,973.5,
Lwr ext dynamic prosth pylon,L5985,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,367.02,,,,,,,fee schedule,349.54,973.5,APC
Lwr ext dynamic prosth pylon,L5985,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,363.52,,,,,,,fee schedule,349.54,973.5,APC
Lwr ext dynamic prosth pylon,L5985,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,349.54,,,,,,,fee schedule,349.54,973.5,APC
Lwr ext dynamic prosth pylon,L5985,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,534.8,,,,,,,fee schedule,349.54,973.5,Radiology
Lwr ext dynamic prosth pylon,L5985,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,489.36,,,,,,,fee schedule,349.54,973.5,APC
Lwr ext dynamic prosth pylon,L5985,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,611.7,,,,,,,fee schedule,349.54,973.5,APC
Multi-axial rotation unit,L5986,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2099.76,,,,,,,fee schedule,818.99,2280.78,
Multi-axial rotation unit,L5986,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2280.78,,,,,,,fee schedule,818.99,2280.78,
Multi-axial rotation unit,L5986,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1828.24,,,,,,,fee schedule,818.99,2280.78,
Multi-axial rotation unit,L5986,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1997.19,,,,,,,fee schedule,818.99,2280.78,
Multi-axial rotation unit,L5986,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,859.94,,,,,,,fee schedule,818.99,2280.78,APC
Multi-axial rotation unit,L5986,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,851.75,,,,,,,fee schedule,818.99,2280.78,APC
Multi-axial rotation unit,L5986,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,818.99,,,,,,,fee schedule,818.99,2280.78,APC
Multi-axial rotation unit,L5986,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1253.05,,,,,,,fee schedule,818.99,2280.78,Radiology
Multi-axial rotation unit,L5986,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1146.59,,,,,,,fee schedule,818.99,2280.78,APC
Multi-axial rotation unit,L5986,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1433.23,,,,,,,fee schedule,818.99,2280.78,APC
Shank ft w vert load pylon,L5987,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22832.7,,,,,,,fee schedule,8905.25,24801.03,
Shank ft w vert load pylon,L5987,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24801.03,,,,,,,fee schedule,8905.25,24801.03,
Shank ft w vert load pylon,L5987,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19880.19,,,,,,,fee schedule,8905.25,24801.03,
Shank ft w vert load pylon,L5987,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21717.31,,,,,,,fee schedule,8905.25,24801.03,
Shank ft w vert load pylon,L5987,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9350.51,,,,,,,fee schedule,8905.25,24801.03,APC
Shank ft w vert load pylon,L5987,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9261.46,,,,,,,fee schedule,8905.25,24801.03,APC
Shank ft w vert load pylon,L5987,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8905.25,,,,,,,fee schedule,8905.25,24801.03,APC
Shank ft w vert load pylon,L5987,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13625.03,,,,,,,fee schedule,8905.25,24801.03,Radiology
Shank ft w vert load pylon,L5987,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12467.35,,,,,,,fee schedule,8905.25,24801.03,APC
Shank ft w vert load pylon,L5987,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15584.19,,,,,,,fee schedule,8905.25,24801.03,APC
Vertical shock reducing pylo,L5988,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6340.63,,,,,,,fee schedule,2472.98,6887.24,
Vertical shock reducing pylo,L5988,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6887.24,,,,,,,fee schedule,2472.98,6887.24,
Vertical shock reducing pylo,L5988,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5520.72,,,,,,,fee schedule,2472.98,6887.24,
Vertical shock reducing pylo,L5988,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6030.89,,,,,,,fee schedule,2472.98,6887.24,
Vertical shock reducing pylo,L5988,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2596.63,,,,,,,fee schedule,2472.98,6887.24,APC
Vertical shock reducing pylo,L5988,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2571.9,,,,,,,fee schedule,2472.98,6887.24,APC
Vertical shock reducing pylo,L5988,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2472.98,,,,,,,fee schedule,2472.98,6887.24,APC
Vertical shock reducing pylo,L5988,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3783.66,,,,,,,fee schedule,2472.98,6887.24,Radiology
Vertical shock reducing pylo,L5988,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3462.17,,,,,,,fee schedule,2472.98,6887.24,APC
Vertical shock reducing pylo,L5988,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4327.72,,,,,,,fee schedule,2472.98,6887.24,APC
User adjustable heel height,L5990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5758.22,,,,,,,fee schedule,2245.81,6254.61,
User adjustable heel height,L5990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6254.61,,,,,,,fee schedule,2245.81,6254.61,
User adjustable heel height,L5990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5013.62,,,,,,,fee schedule,2245.81,6254.61,
User adjustable heel height,L5990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5476.92,,,,,,,fee schedule,2245.81,6254.61,
User adjustable heel height,L5990,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2358.1,,,,,,,fee schedule,2245.81,6254.61,APC
User adjustable heel height,L5990,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2335.64,,,,,,,fee schedule,2245.81,6254.61,APC
User adjustable heel height,L5990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2245.81,,,,,,,fee schedule,2245.81,6254.61,APC
User adjustable heel height,L5990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3436.09,,,,,,,fee schedule,2245.81,6254.61,Radiology
User adjustable heel height,L5990,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3144.13,,,,,,,fee schedule,2245.81,6254.61,APC
User adjustable heel height,L5990,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3930.17,,,,,,,fee schedule,2245.81,6254.61,APC
Part hand thumb rem,L6000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4698.21,,,,,,,fee schedule,4090.68,5103.23,
Part hand thumb rem,L6000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5103.23,,,,,,,fee schedule,4090.68,5103.23,
Part hand thumb rem,L6000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4090.68,,,,,,,fee schedule,4090.68,5103.23,
Part hand thumb rem,L6000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4468.7,,,,,,,fee schedule,4090.68,5103.23,
Part hand little/ring,L6010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4726.88,,,,,,,fee schedule,4115.65,5134.37,
Part hand little/ring,L6010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5134.37,,,,,,,fee schedule,4115.65,5134.37,
Part hand little/ring,L6010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4115.65,,,,,,,fee schedule,4115.65,5134.37,
Part hand little/ring,L6010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4495.97,,,,,,,fee schedule,4115.65,5134.37,
Part hand no fingers,L6020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4701.86,,,,,,,fee schedule,4093.86,5107.2,
Part hand no fingers,L6020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5107.2,,,,,,,fee schedule,4093.86,5107.2,
Part hand no fingers,L6020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4093.86,,,,,,,fee schedule,4093.86,5107.2,
Part hand no fingers,L6020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4472.17,,,,,,,fee schedule,4093.86,5107.2,
Part hand myo exclu term dev,L6026,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12440.34,,,,,,,fee schedule,4589.94,13512.78,
Part hand myo exclu term dev,L6026,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13512.78,,,,,,,fee schedule,4589.94,13512.78,
Part hand myo exclu term dev,L6026,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10831.67,,,,,,,fee schedule,4589.94,13512.78,
Part hand myo exclu term dev,L6026,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11832.62,,,,,,,fee schedule,4589.94,13512.78,
Part hand myo exclu term dev,L6026,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4819.44,,,,,,,fee schedule,4589.94,13512.78,APC
Part hand myo exclu term dev,L6026,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4773.54,,,,,,,fee schedule,4589.94,13512.78,APC
Part hand myo exclu term dev,L6026,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4589.94,,,,,,,fee schedule,4589.94,13512.78,APC
Part hand myo exclu term dev,L6026,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7022.61,,,,,,,fee schedule,4589.94,13512.78,Radiology
Part hand myo exclu term dev,L6026,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6425.92,,,,,,,fee schedule,4589.94,13512.78,APC
Part hand myo exclu term dev,L6026,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8032.4,,,,,,,fee schedule,4589.94,13512.78,APC
Wrst MLd sck flx hng tri pad,L6050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7223.12,,,,,,,fee schedule,2817.16,7845.81,
Wrst MLd sck flx hng tri pad,L6050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7845.81,,,,,,,fee schedule,2817.16,7845.81,
Wrst MLd sck flx hng tri pad,L6050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6289.1,,,,,,,fee schedule,2817.16,7845.81,
Wrst MLd sck flx hng tri pad,L6050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6870.27,,,,,,,fee schedule,2817.16,7845.81,
Wrst MLd sck flx hng tri pad,L6050,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2958.02,,,,,,,fee schedule,2817.16,7845.81,APC
Wrst MLd sck flx hng tri pad,L6050,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2929.85,,,,,,,fee schedule,2817.16,7845.81,APC
Wrst MLd sck flx hng tri pad,L6050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2817.16,,,,,,,fee schedule,2817.16,7845.81,APC
Wrst MLd sck flx hng tri pad,L6050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4310.25,,,,,,,fee schedule,2817.16,7845.81,Radiology
Wrst MLd sck flx hng tri pad,L6050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3944.02,,,,,,,fee schedule,2817.16,7845.81,APC
Wrst MLd sck flx hng tri pad,L6050,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4930.03,,,,,,,fee schedule,2817.16,7845.81,APC
Wrst mold sock w/exp interfa,L6055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8910.3,,,,,,,fee schedule,3475.2,9678.43,
Wrst mold sock w/exp interfa,L6055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9678.43,,,,,,,fee schedule,3475.2,9678.43,
Wrst mold sock w/exp interfa,L6055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7758.1,,,,,,,fee schedule,3475.2,9678.43,
Wrst mold sock w/exp interfa,L6055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8475.02,,,,,,,fee schedule,3475.2,9678.43,
Wrst mold sock w/exp interfa,L6055,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3648.96,,,,,,,fee schedule,3475.2,9678.43,APC
Wrst mold sock w/exp interfa,L6055,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3614.21,,,,,,,fee schedule,3475.2,9678.43,APC
Wrst mold sock w/exp interfa,L6055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3475.2,,,,,,,fee schedule,3475.2,9678.43,APC
Wrst mold sock w/exp interfa,L6055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5317.06,,,,,,,fee schedule,3475.2,9678.43,Radiology
Wrst mold sock w/exp interfa,L6055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4865.28,,,,,,,fee schedule,3475.2,9678.43,APC
Wrst mold sock w/exp interfa,L6055,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6081.6,,,,,,,fee schedule,3475.2,9678.43,APC
Elb mold sock flex hinge pad,L6100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7410.69,,,,,,,fee schedule,2890.34,8049.55,
Elb mold sock flex hinge pad,L6100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8049.55,,,,,,,fee schedule,2890.34,8049.55,
Elb mold sock flex hinge pad,L6100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6452.42,,,,,,,fee schedule,2890.34,8049.55,
Elb mold sock flex hinge pad,L6100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7048.68,,,,,,,fee schedule,2890.34,8049.55,
Elb mold sock flex hinge pad,L6100,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3034.86,,,,,,,fee schedule,2890.34,8049.55,APC
Elb mold sock flex hinge pad,L6100,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3005.95,,,,,,,fee schedule,2890.34,8049.55,APC
Elb mold sock flex hinge pad,L6100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2890.34,,,,,,,fee schedule,2890.34,8049.55,APC
Elb mold sock flex hinge pad,L6100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4422.22,,,,,,,fee schedule,2890.34,8049.55,Radiology
Elb mold sock flex hinge pad,L6100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4046.48,,,,,,,fee schedule,2890.34,8049.55,APC
Elb mold sock flex hinge pad,L6100,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5058.1,,,,,,,fee schedule,2890.34,8049.55,APC
Elbow mold sock suspension t,L6110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7866.61,,,,,,,fee schedule,3068.14,8544.77,
Elbow mold sock suspension t,L6110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8544.77,,,,,,,fee schedule,3068.14,8544.77,
Elbow mold sock suspension t,L6110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6849.38,,,,,,,fee schedule,3068.14,8544.77,
Elbow mold sock suspension t,L6110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7482.32,,,,,,,fee schedule,3068.14,8544.77,
Elbow mold sock suspension t,L6110,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3221.55,,,,,,,fee schedule,3068.14,8544.77,APC
Elbow mold sock suspension t,L6110,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3190.87,,,,,,,fee schedule,3068.14,8544.77,APC
Elbow mold sock suspension t,L6110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3068.14,,,,,,,fee schedule,3068.14,8544.77,APC
Elbow mold sock suspension t,L6110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4694.25,,,,,,,fee schedule,3068.14,8544.77,Radiology
Elbow mold sock suspension t,L6110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4295.4,,,,,,,fee schedule,3068.14,8544.77,APC
Elbow mold sock suspension t,L6110,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5369.24,,,,,,,fee schedule,3068.14,8544.77,APC
Elbow mold doub splt soc ste,L6120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8869.62,,,,,,,fee schedule,3459.34,9634.24,
Elbow mold doub splt soc ste,L6120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9634.24,,,,,,,fee schedule,3459.34,9634.24,
Elbow mold doub splt soc ste,L6120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7722.68,,,,,,,fee schedule,3459.34,9634.24,
Elbow mold doub splt soc ste,L6120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8436.33,,,,,,,fee schedule,3459.34,9634.24,
Elbow mold doub splt soc ste,L6120,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3632.31,,,,,,,fee schedule,3459.34,9634.24,APC
Elbow mold doub splt soc ste,L6120,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3597.71,,,,,,,fee schedule,3459.34,9634.24,APC
Elbow mold doub splt soc ste,L6120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3459.34,,,,,,,fee schedule,3459.34,9634.24,APC
Elbow mold doub splt soc ste,L6120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5292.79,,,,,,,fee schedule,3459.34,9634.24,Radiology
Elbow mold doub splt soc ste,L6120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4843.08,,,,,,,fee schedule,3459.34,9634.24,APC
Elbow mold doub splt soc ste,L6120,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6053.84,,,,,,,fee schedule,3459.34,9634.24,APC
Elbow stump activated lock h,L6130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8218.79,,,,,,,fee schedule,3205.49,8927.3,
Elbow stump activated lock h,L6130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8927.3,,,,,,,fee schedule,3205.49,8927.3,
Elbow stump activated lock h,L6130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7156.01,,,,,,,fee schedule,3205.49,8927.3,
Elbow stump activated lock h,L6130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7817.29,,,,,,,fee schedule,3205.49,8927.3,
Elbow stump activated lock h,L6130,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3365.76,,,,,,,fee schedule,3205.49,8927.3,APC
Elbow stump activated lock h,L6130,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3333.71,,,,,,,fee schedule,3205.49,8927.3,APC
Elbow stump activated lock h,L6130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3205.49,,,,,,,fee schedule,3205.49,8927.3,APC
Elbow stump activated lock h,L6130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4904.4,,,,,,,fee schedule,3205.49,8927.3,Radiology
Elbow stump activated lock h,L6130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4487.69,,,,,,,fee schedule,3205.49,8927.3,APC
Elbow stump activated lock h,L6130,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5609.61,,,,,,,fee schedule,3205.49,8927.3,APC
Elbow mold outsid lock hinge,L6200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9999.68,,,,,,,fee schedule,3900.09,10861.72,
Elbow mold outsid lock hinge,L6200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10861.72,,,,,,,fee schedule,3900.09,10861.72,
Elbow mold outsid lock hinge,L6200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8706.61,,,,,,,fee schedule,3900.09,10861.72,
Elbow mold outsid lock hinge,L6200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9511.19,,,,,,,fee schedule,3900.09,10861.72,
Elbow mold outsid lock hinge,L6200,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4095.09,,,,,,,fee schedule,3900.09,10861.72,APC
Elbow mold outsid lock hinge,L6200,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4056.09,,,,,,,fee schedule,3900.09,10861.72,APC
Elbow mold outsid lock hinge,L6200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3900.09,,,,,,,fee schedule,3900.09,10861.72,APC
Elbow mold outsid lock hinge,L6200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5967.14,,,,,,,fee schedule,3900.09,10861.72,Radiology
Elbow mold outsid lock hinge,L6200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5460.13,,,,,,,fee schedule,3900.09,10861.72,APC
Elbow mold outsid lock hinge,L6200,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6825.16,,,,,,,fee schedule,3900.09,10861.72,APC
Elbow molded w/ expand inter,L6205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11430.58,,,,,,,fee schedule,4458.17,12415.98,
Elbow molded w/ expand inter,L6205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12415.98,,,,,,,fee schedule,4458.17,12415.98,
Elbow molded w/ expand inter,L6205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9952.49,,,,,,,fee schedule,4458.17,12415.98,
Elbow molded w/ expand inter,L6205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10872.19,,,,,,,fee schedule,4458.17,12415.98,
Elbow molded w/ expand inter,L6205,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4681.08,,,,,,,fee schedule,4458.17,12415.98,APC
Elbow molded w/ expand inter,L6205,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4636.5,,,,,,,fee schedule,4458.17,12415.98,APC
Elbow molded w/ expand inter,L6205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4458.17,,,,,,,fee schedule,4458.17,12415.98,APC
Elbow molded w/ expand inter,L6205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6821,,,,,,,fee schedule,4458.17,12415.98,Radiology
Elbow molded w/ expand inter,L6205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6241.44,,,,,,,fee schedule,4458.17,12415.98,APC
Elbow molded w/ expand inter,L6205,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7801.8,,,,,,,fee schedule,4458.17,12415.98,APC
Elbow inter loc elbow forarm,L6250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10369.77,,,,,,,fee schedule,4044.42,11263.72,
Elbow inter loc elbow forarm,L6250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11263.72,,,,,,,fee schedule,4044.42,11263.72,
Elbow inter loc elbow forarm,L6250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9028.85,,,,,,,fee schedule,4044.42,11263.72,
Elbow inter loc elbow forarm,L6250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9863.2,,,,,,,fee schedule,4044.42,11263.72,
Elbow inter loc elbow forarm,L6250,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4246.64,,,,,,,fee schedule,4044.42,11263.72,APC
Elbow inter loc elbow forarm,L6250,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4206.2,,,,,,,fee schedule,4044.42,11263.72,APC
Elbow inter loc elbow forarm,L6250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4044.42,,,,,,,fee schedule,4044.42,11263.72,APC
Elbow inter loc elbow forarm,L6250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6187.96,,,,,,,fee schedule,4044.42,11263.72,Radiology
Elbow inter loc elbow forarm,L6250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5662.19,,,,,,,fee schedule,4044.42,11263.72,APC
Elbow inter loc elbow forarm,L6250,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7077.74,,,,,,,fee schedule,4044.42,11263.72,APC
Shlder disart int lock elbow,L6300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12487.28,,,,,,,fee schedule,4870.31,13563.77,
Shlder disart int lock elbow,L6300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13563.77,,,,,,,fee schedule,4870.31,13563.77,
Shlder disart int lock elbow,L6300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10872.55,,,,,,,fee schedule,4870.31,13563.77,
Shlder disart int lock elbow,L6300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11877.27,,,,,,,fee schedule,4870.31,13563.77,
Shlder disart int lock elbow,L6300,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5113.83,,,,,,,fee schedule,4870.31,13563.77,APC
Shlder disart int lock elbow,L6300,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5065.12,,,,,,,fee schedule,4870.31,13563.77,APC
Shlder disart int lock elbow,L6300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4870.31,,,,,,,fee schedule,4870.31,13563.77,APC
Shlder disart int lock elbow,L6300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7451.57,,,,,,,fee schedule,4870.31,13563.77,Radiology
Shlder disart int lock elbow,L6300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6818.43,,,,,,,fee schedule,4870.31,13563.77,APC
Shlder disart int lock elbow,L6300,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8523.04,,,,,,,fee schedule,4870.31,13563.77,APC
Shoulder passive restor comp,L6310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10026.23,,,,,,,fee schedule,3910.46,10890.56,
Shoulder passive restor comp,L6310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10890.56,,,,,,,fee schedule,3910.46,10890.56,
Shoulder passive restor comp,L6310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8729.73,,,,,,,fee schedule,3910.46,10890.56,
Shoulder passive restor comp,L6310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9536.44,,,,,,,fee schedule,3910.46,10890.56,
Shoulder passive restor comp,L6310,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4105.98,,,,,,,fee schedule,3910.46,10890.56,APC
Shoulder passive restor comp,L6310,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4066.88,,,,,,,fee schedule,3910.46,10890.56,APC
Shoulder passive restor comp,L6310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3910.46,,,,,,,fee schedule,3910.46,10890.56,APC
Shoulder passive restor comp,L6310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5983,,,,,,,fee schedule,3910.46,10890.56,Radiology
Shoulder passive restor comp,L6310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5474.64,,,,,,,fee schedule,3910.46,10890.56,APC
Shoulder passive restor comp,L6310,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6843.3,,,,,,,fee schedule,3910.46,10890.56,APC
Shoulder passive restor cap,L6320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6031.95,,,,,,,fee schedule,2352.61,6551.95,
Shoulder passive restor cap,L6320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6551.95,,,,,,,fee schedule,2352.61,6551.95,
Shoulder passive restor cap,L6320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5251.96,,,,,,,fee schedule,2352.61,6551.95,
Shoulder passive restor cap,L6320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5737.29,,,,,,,fee schedule,2352.61,6551.95,
Shoulder passive restor cap,L6320,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2470.24,,,,,,,fee schedule,2352.61,6551.95,APC
Shoulder passive restor cap,L6320,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2446.71,,,,,,,fee schedule,2352.61,6551.95,APC
Shoulder passive restor cap,L6320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2352.61,,,,,,,fee schedule,2352.61,6551.95,APC
Shoulder passive restor cap,L6320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3599.49,,,,,,,fee schedule,2352.61,6551.95,Radiology
Shoulder passive restor cap,L6320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3293.65,,,,,,,fee schedule,2352.61,6551.95,APC
Shoulder passive restor cap,L6320,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4117.07,,,,,,,fee schedule,2352.61,6551.95,APC
Thoracic intern lock elbow,L6350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12294.94,,,,,,,fee schedule,4795.29,13354.85,
Thoracic intern lock elbow,L6350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13354.85,,,,,,,fee schedule,4795.29,13354.85,
Thoracic intern lock elbow,L6350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10705.08,,,,,,,fee schedule,4795.29,13354.85,
Thoracic intern lock elbow,L6350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11694.33,,,,,,,fee schedule,4795.29,13354.85,
Thoracic intern lock elbow,L6350,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5035.05,,,,,,,fee schedule,4795.29,13354.85,APC
Thoracic intern lock elbow,L6350,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4987.1,,,,,,,fee schedule,4795.29,13354.85,APC
Thoracic intern lock elbow,L6350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4795.29,,,,,,,fee schedule,4795.29,13354.85,APC
Thoracic intern lock elbow,L6350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7336.79,,,,,,,fee schedule,4795.29,13354.85,Radiology
Thoracic intern lock elbow,L6350,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6713.41,,,,,,,fee schedule,4795.29,13354.85,APC
Thoracic intern lock elbow,L6350,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8391.76,,,,,,,fee schedule,4795.29,13354.85,APC
Thoracic passive restor comp,L6360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9998.04,,,,,,,fee schedule,3899.44,10859.94,
Thoracic passive restor comp,L6360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10859.94,,,,,,,fee schedule,3899.44,10859.94,
Thoracic passive restor comp,L6360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8705.19,,,,,,,fee schedule,3899.44,10859.94,
Thoracic passive restor comp,L6360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9509.63,,,,,,,fee schedule,3899.44,10859.94,
Thoracic passive restor comp,L6360,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4094.41,,,,,,,fee schedule,3899.44,10859.94,APC
Thoracic passive restor comp,L6360,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4055.42,,,,,,,fee schedule,3899.44,10859.94,APC
Thoracic passive restor comp,L6360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3899.44,,,,,,,fee schedule,3899.44,10859.94,APC
Thoracic passive restor comp,L6360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5966.14,,,,,,,fee schedule,3899.44,10859.94,Radiology
Thoracic passive restor comp,L6360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5459.22,,,,,,,fee schedule,3899.44,10859.94,APC
Thoracic passive restor comp,L6360,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6824.02,,,,,,,fee schedule,3899.44,10859.94,APC
Thoracic passive restor cap,L6370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6970.44,,,,,,,fee schedule,2718.61,7571.34,
Thoracic passive restor cap,L6370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7571.34,,,,,,,fee schedule,2718.61,7571.34,
Thoracic passive restor cap,L6370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6069.09,,,,,,,fee schedule,2718.61,7571.34,
Thoracic passive restor cap,L6370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6629.93,,,,,,,fee schedule,2718.61,7571.34,
Thoracic passive restor cap,L6370,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2854.54,,,,,,,fee schedule,2718.61,7571.34,APC
Thoracic passive restor cap,L6370,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2827.35,,,,,,,fee schedule,2718.61,7571.34,APC
Thoracic passive restor cap,L6370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2718.61,,,,,,,fee schedule,2718.61,7571.34,APC
Thoracic passive restor cap,L6370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4159.47,,,,,,,fee schedule,2718.61,7571.34,Radiology
Thoracic passive restor cap,L6370,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3806.05,,,,,,,fee schedule,2718.61,7571.34,APC
Thoracic passive restor cap,L6370,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4757.57,,,,,,,fee schedule,2718.61,7571.34,APC
Postop dsg cast chg wrst/elb,L6380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4120.46,,,,,,,fee schedule,1607.09,4475.67,
Postop dsg cast chg wrst/elb,L6380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4475.67,,,,,,,fee schedule,1607.09,4475.67,
Postop dsg cast chg wrst/elb,L6380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3587.64,,,,,,,fee schedule,1607.09,4475.67,
Postop dsg cast chg wrst/elb,L6380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3919.17,,,,,,,fee schedule,1607.09,4475.67,
Postop dsg cast chg wrst/elb,L6380,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1687.44,,,,,,,fee schedule,1607.09,4475.67,APC
Postop dsg cast chg wrst/elb,L6380,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1671.37,,,,,,,fee schedule,1607.09,4475.67,APC
Postop dsg cast chg wrst/elb,L6380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1607.09,,,,,,,fee schedule,1607.09,4475.67,APC
Postop dsg cast chg wrst/elb,L6380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2458.85,,,,,,,fee schedule,1607.09,4475.67,Radiology
Postop dsg cast chg wrst/elb,L6380,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2249.93,,,,,,,fee schedule,1607.09,4475.67,APC
Postop dsg cast chg wrst/elb,L6380,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2812.41,,,,,,,fee schedule,1607.09,4475.67,APC
Postop dsg cast chg elb dis/,L6382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4888.36,,,,,,,fee schedule,1906.55,5309.77,
Postop dsg cast chg elb dis/,L6382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5309.77,,,,,,,fee schedule,1906.55,5309.77,
Postop dsg cast chg elb dis/,L6382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4256.24,,,,,,,fee schedule,1906.55,5309.77,
Postop dsg cast chg elb dis/,L6382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4649.56,,,,,,,fee schedule,1906.55,5309.77,
Postop dsg cast chg elb dis/,L6382,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2001.88,,,,,,,fee schedule,1906.55,5309.77,APC
Postop dsg cast chg elb dis/,L6382,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1982.81,,,,,,,fee schedule,1906.55,5309.77,APC
Postop dsg cast chg elb dis/,L6382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1906.55,,,,,,,fee schedule,1906.55,5309.77,APC
Postop dsg cast chg elb dis/,L6382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2917.02,,,,,,,fee schedule,1906.55,5309.77,Radiology
Postop dsg cast chg elb dis/,L6382,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2669.17,,,,,,,fee schedule,1906.55,5309.77,APC
Postop dsg cast chg elb dis/,L6382,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3336.46,,,,,,,fee schedule,1906.55,5309.77,APC
Postop dsg cast chg shlder/t,L6384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6059.93,,,,,,,fee schedule,2363.5,6582.34,
Postop dsg cast chg shlder/t,L6384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6582.34,,,,,,,fee schedule,2363.5,6582.34,
Postop dsg cast chg shlder/t,L6384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5276.32,,,,,,,fee schedule,2363.5,6582.34,
Postop dsg cast chg shlder/t,L6384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5763.9,,,,,,,fee schedule,2363.5,6582.34,
Postop dsg cast chg shlder/t,L6384,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2481.68,,,,,,,fee schedule,2363.5,6582.34,APC
Postop dsg cast chg shlder/t,L6384,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2458.04,,,,,,,fee schedule,2363.5,6582.34,APC
Postop dsg cast chg shlder/t,L6384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2363.5,,,,,,,fee schedule,2363.5,6582.34,APC
Postop dsg cast chg shlder/t,L6384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3616.16,,,,,,,fee schedule,2363.5,6582.34,Radiology
Postop dsg cast chg shlder/t,L6384,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3308.9,,,,,,,fee schedule,2363.5,6582.34,APC
Postop dsg cast chg shlder/t,L6384,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4136.12,,,,,,,fee schedule,2363.5,6582.34,APC
Postop ea cast chg & realign,L6386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1403.24,,,,,,,fee schedule,547.3,1524.21,
Postop ea cast chg & realign,L6386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1524.21,,,,,,,fee schedule,547.3,1524.21,
Postop ea cast chg & realign,L6386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1221.79,,,,,,,fee schedule,547.3,1524.21,
Postop ea cast chg & realign,L6386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1334.69,,,,,,,fee schedule,547.3,1524.21,
Postop ea cast chg & realign,L6386,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,574.66,,,,,,,fee schedule,547.3,1524.21,APC
Postop ea cast chg & realign,L6386,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,569.19,,,,,,,fee schedule,547.3,1524.21,APC
Postop ea cast chg & realign,L6386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,547.3,,,,,,,fee schedule,547.3,1524.21,APC
Postop ea cast chg & realign,L6386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,837.37,,,,,,,fee schedule,547.3,1524.21,Radiology
Postop ea cast chg & realign,L6386,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,766.22,,,,,,,fee schedule,547.3,1524.21,APC
Postop ea cast chg & realign,L6386,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,957.77,,,,,,,fee schedule,547.3,1524.21,APC
Postop applicat rigid dsg on,L6388,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1568.23,,,,,,,fee schedule,611.64,1703.42,
Postop applicat rigid dsg on,L6388,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1703.42,,,,,,,fee schedule,611.64,1703.42,
Postop applicat rigid dsg on,L6388,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1365.44,,,,,,,fee schedule,611.64,1703.42,
Postop applicat rigid dsg on,L6388,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1491.62,,,,,,,fee schedule,611.64,1703.42,
Postop applicat rigid dsg on,L6388,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,642.22,,,,,,,fee schedule,611.64,1703.42,APC
Postop applicat rigid dsg on,L6388,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,636.11,,,,,,,fee schedule,611.64,1703.42,APC
Postop applicat rigid dsg on,L6388,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,611.64,,,,,,,fee schedule,611.64,1703.42,APC
Postop applicat rigid dsg on,L6388,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,935.81,,,,,,,fee schedule,611.64,1703.42,Radiology
Postop applicat rigid dsg on,L6388,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,856.3,,,,,,,fee schedule,611.64,1703.42,APC
Postop applicat rigid dsg on,L6388,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1070.37,,,,,,,fee schedule,611.64,1703.42,APC
Below elbow prosth tiss shap,L6400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7873.08,,,,,,,fee schedule,3070.68,8551.8,
Below elbow prosth tiss shap,L6400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8551.8,,,,,,,fee schedule,3070.68,8551.8,
Below elbow prosth tiss shap,L6400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6855.01,,,,,,,fee schedule,3070.68,8551.8,
Below elbow prosth tiss shap,L6400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7488.48,,,,,,,fee schedule,3070.68,8551.8,
Below elbow prosth tiss shap,L6400,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3224.21,,,,,,,fee schedule,3070.68,8551.8,APC
Below elbow prosth tiss shap,L6400,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3193.51,,,,,,,fee schedule,3070.68,8551.8,APC
Below elbow prosth tiss shap,L6400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3070.68,,,,,,,fee schedule,3070.68,8551.8,APC
Below elbow prosth tiss shap,L6400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4698.14,,,,,,,fee schedule,3070.68,8551.8,Radiology
Below elbow prosth tiss shap,L6400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4298.95,,,,,,,fee schedule,3070.68,8551.8,APC
Below elbow prosth tiss shap,L6400,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5373.69,,,,,,,fee schedule,3070.68,8551.8,APC
Elb disart prosth tiss shap,L6450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9677.57,,,,,,,fee schedule,3774.46,10511.84,
Elb disart prosth tiss shap,L6450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10511.84,,,,,,,fee schedule,3774.46,10511.84,
Elb disart prosth tiss shap,L6450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8426.16,,,,,,,fee schedule,3774.46,10511.84,
Elb disart prosth tiss shap,L6450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9204.81,,,,,,,fee schedule,3774.46,10511.84,
Elb disart prosth tiss shap,L6450,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3963.18,,,,,,,fee schedule,3774.46,10511.84,APC
Elb disart prosth tiss shap,L6450,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3925.44,,,,,,,fee schedule,3774.46,10511.84,APC
Elb disart prosth tiss shap,L6450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3774.46,,,,,,,fee schedule,3774.46,10511.84,APC
Elb disart prosth tiss shap,L6450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5774.92,,,,,,,fee schedule,3774.46,10511.84,Radiology
Elb disart prosth tiss shap,L6450,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5284.24,,,,,,,fee schedule,3774.46,10511.84,APC
Elb disart prosth tiss shap,L6450,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6605.3,,,,,,,fee schedule,3774.46,10511.84,APC
Above elbow prosth tiss shap,L6500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9764.81,,,,,,,fee schedule,3808.49,10606.6,
Above elbow prosth tiss shap,L6500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10606.6,,,,,,,fee schedule,3808.49,10606.6,
Above elbow prosth tiss shap,L6500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8502.12,,,,,,,fee schedule,3808.49,10606.6,
Above elbow prosth tiss shap,L6500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9287.79,,,,,,,fee schedule,3808.49,10606.6,
Above elbow prosth tiss shap,L6500,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3998.91,,,,,,,fee schedule,3808.49,10606.6,APC
Above elbow prosth tiss shap,L6500,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3960.83,,,,,,,fee schedule,3808.49,10606.6,APC
Above elbow prosth tiss shap,L6500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3808.49,,,,,,,fee schedule,3808.49,10606.6,APC
Above elbow prosth tiss shap,L6500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5826.99,,,,,,,fee schedule,3808.49,10606.6,Radiology
Above elbow prosth tiss shap,L6500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5331.89,,,,,,,fee schedule,3808.49,10606.6,APC
Above elbow prosth tiss shap,L6500,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6664.86,,,,,,,fee schedule,3808.49,10606.6,APC
Shldr disar prosth tiss shap,L6550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11969.49,,,,,,,fee schedule,4668.36,13001.35,
Shldr disar prosth tiss shap,L6550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13001.35,,,,,,,fee schedule,4668.36,13001.35,
Shldr disar prosth tiss shap,L6550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10421.72,,,,,,,fee schedule,4668.36,13001.35,
Shldr disar prosth tiss shap,L6550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11384.78,,,,,,,fee schedule,4668.36,13001.35,
Shldr disar prosth tiss shap,L6550,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4901.78,,,,,,,fee schedule,4668.36,13001.35,APC
Shldr disar prosth tiss shap,L6550,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4855.09,,,,,,,fee schedule,4668.36,13001.35,APC
Shldr disar prosth tiss shap,L6550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4668.36,,,,,,,fee schedule,4668.36,13001.35,APC
Shldr disar prosth tiss shap,L6550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7142.59,,,,,,,fee schedule,4668.36,13001.35,Radiology
Shldr disar prosth tiss shap,L6550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6535.7,,,,,,,fee schedule,4668.36,13001.35,APC
Shldr disar prosth tiss shap,L6550,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8169.63,,,,,,,fee schedule,4668.36,13001.35,APC
Scap thorac prosth tiss shap,L6570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13738.66,,,,,,,fee schedule,5358.37,14923.02,
Scap thorac prosth tiss shap,L6570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14923.02,,,,,,,fee schedule,5358.37,14923.02,
Scap thorac prosth tiss shap,L6570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11962.11,,,,,,,fee schedule,5358.37,14923.02,
Scap thorac prosth tiss shap,L6570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13067.52,,,,,,,fee schedule,5358.37,14923.02,
Scap thorac prosth tiss shap,L6570,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5626.29,,,,,,,fee schedule,5358.37,14923.02,APC
Scap thorac prosth tiss shap,L6570,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5572.7,,,,,,,fee schedule,5358.37,14923.02,APC
Scap thorac prosth tiss shap,L6570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5358.37,,,,,,,fee schedule,5358.37,14923.02,APC
Scap thorac prosth tiss shap,L6570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8198.31,,,,,,,fee schedule,5358.37,14923.02,Radiology
Scap thorac prosth tiss shap,L6570,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7501.72,,,,,,,fee schedule,5358.37,14923.02,APC
Scap thorac prosth tiss shap,L6570,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9377.15,,,,,,,fee schedule,5358.37,14923.02,APC
Wrist/elbow bowden cable mol,L6580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5158.02,,,,,,,fee schedule,2011.74,5602.68,
Wrist/elbow bowden cable mol,L6580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5602.68,,,,,,,fee schedule,2011.74,5602.68,
Wrist/elbow bowden cable mol,L6580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4491.04,,,,,,,fee schedule,2011.74,5602.68,
Wrist/elbow bowden cable mol,L6580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4906.05,,,,,,,fee schedule,2011.74,5602.68,
Wrist/elbow bowden cable mol,L6580,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2112.33,,,,,,,fee schedule,2011.74,5602.68,APC
Wrist/elbow bowden cable mol,L6580,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2092.21,,,,,,,fee schedule,2011.74,5602.68,APC
Wrist/elbow bowden cable mol,L6580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2011.74,,,,,,,fee schedule,2011.74,5602.68,APC
Wrist/elbow bowden cable mol,L6580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3077.96,,,,,,,fee schedule,2011.74,5602.68,Radiology
Wrist/elbow bowden cable mol,L6580,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2816.44,,,,,,,fee schedule,2011.74,5602.68,APC
Wrist/elbow bowden cable mol,L6580,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3520.54,,,,,,,fee schedule,2011.74,5602.68,APC
Wrist/elbow bowden cbl dir f,L6582,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4783.54,,,,,,,fee schedule,1865.69,5195.91,
Wrist/elbow bowden cbl dir f,L6582,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5195.91,,,,,,,fee schedule,1865.69,5195.91,
Wrist/elbow bowden cbl dir f,L6582,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4164.98,,,,,,,fee schedule,1865.69,5195.91,
Wrist/elbow bowden cbl dir f,L6582,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4549.86,,,,,,,fee schedule,1865.69,5195.91,
Wrist/elbow bowden cbl dir f,L6582,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1958.97,,,,,,,fee schedule,1865.69,5195.91,APC
Wrist/elbow bowden cbl dir f,L6582,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1940.32,,,,,,,fee schedule,1865.69,5195.91,APC
Wrist/elbow bowden cbl dir f,L6582,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1865.69,,,,,,,fee schedule,1865.69,5195.91,APC
Wrist/elbow bowden cbl dir f,L6582,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2854.51,,,,,,,fee schedule,1865.69,5195.91,Radiology
Wrist/elbow bowden cbl dir f,L6582,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2611.97,,,,,,,fee schedule,1865.69,5195.91,APC
Wrist/elbow bowden cbl dir f,L6582,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3264.96,,,,,,,fee schedule,1865.69,5195.91,APC
Elbow fair lead cable molded,L6584,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6988.15,,,,,,,fee schedule,2725.54,7590.58,
Elbow fair lead cable molded,L6584,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7590.58,,,,,,,fee schedule,2725.54,7590.58,
Elbow fair lead cable molded,L6584,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6084.51,,,,,,,fee schedule,2725.54,7590.58,
Elbow fair lead cable molded,L6584,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6646.78,,,,,,,fee schedule,2725.54,7590.58,
Elbow fair lead cable molded,L6584,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2861.82,,,,,,,fee schedule,2725.54,7590.58,APC
Elbow fair lead cable molded,L6584,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2834.56,,,,,,,fee schedule,2725.54,7590.58,APC
Elbow fair lead cable molded,L6584,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2725.54,,,,,,,fee schedule,2725.54,7590.58,APC
Elbow fair lead cable molded,L6584,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4170.08,,,,,,,fee schedule,2725.54,7590.58,Radiology
Elbow fair lead cable molded,L6584,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3815.76,,,,,,,fee schedule,2725.54,7590.58,APC
Elbow fair lead cable molded,L6584,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4769.7,,,,,,,fee schedule,2725.54,7590.58,APC
Elbow fair lead cable dir fo,L6586,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6875.54,,,,,,,fee schedule,2681.6,7468.26,
Elbow fair lead cable dir fo,L6586,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7468.26,,,,,,,fee schedule,2681.6,7468.26,
Elbow fair lead cable dir fo,L6586,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5986.46,,,,,,,fee schedule,2681.6,7468.26,
Elbow fair lead cable dir fo,L6586,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6539.67,,,,,,,fee schedule,2681.6,7468.26,
Elbow fair lead cable dir fo,L6586,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2815.68,,,,,,,fee schedule,2681.6,7468.26,APC
Elbow fair lead cable dir fo,L6586,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2788.86,,,,,,,fee schedule,2681.6,7468.26,APC
Elbow fair lead cable dir fo,L6586,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2681.6,,,,,,,fee schedule,2681.6,7468.26,APC
Elbow fair lead cable dir fo,L6586,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4102.85,,,,,,,fee schedule,2681.6,7468.26,Radiology
Elbow fair lead cable dir fo,L6586,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3754.24,,,,,,,fee schedule,2681.6,7468.26,APC
Elbow fair lead cable dir fo,L6586,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4692.8,,,,,,,fee schedule,2681.6,7468.26,APC
Shdr fair lead cable molded,L6588,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9465.95,,,,,,,fee schedule,3691.92,10281.98,
Shdr fair lead cable molded,L6588,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10281.98,,,,,,,fee schedule,3691.92,10281.98,
Shdr fair lead cable molded,L6588,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8241.9,,,,,,,fee schedule,3691.92,10281.98,
Shdr fair lead cable molded,L6588,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9003.53,,,,,,,fee schedule,3691.92,10281.98,
Shdr fair lead cable molded,L6588,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3876.52,,,,,,,fee schedule,3691.92,10281.98,APC
Shdr fair lead cable molded,L6588,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3839.6,,,,,,,fee schedule,3691.92,10281.98,APC
Shdr fair lead cable molded,L6588,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3691.92,,,,,,,fee schedule,3691.92,10281.98,APC
Shdr fair lead cable molded,L6588,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5648.64,,,,,,,fee schedule,3691.92,10281.98,Radiology
Shdr fair lead cable molded,L6588,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5168.69,,,,,,,fee schedule,3691.92,10281.98,APC
Shdr fair lead cable molded,L6588,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6460.86,,,,,,,fee schedule,3691.92,10281.98,APC
Shdr fair lead cable direct,L6590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9283.49,,,,,,,fee schedule,3620.76,10083.79,
Shdr fair lead cable direct,L6590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10083.79,,,,,,,fee schedule,3620.76,10083.79,
Shdr fair lead cable direct,L6590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8083.04,,,,,,,fee schedule,3620.76,10083.79,
Shdr fair lead cable direct,L6590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8829.99,,,,,,,fee schedule,3620.76,10083.79,
Shdr fair lead cable direct,L6590,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3801.8,,,,,,,fee schedule,3620.76,10083.79,APC
Shdr fair lead cable direct,L6590,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3765.59,,,,,,,fee schedule,3620.76,10083.79,APC
Shdr fair lead cable direct,L6590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3620.76,,,,,,,fee schedule,3620.76,10083.79,APC
Shdr fair lead cable direct,L6590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5539.76,,,,,,,fee schedule,3620.76,10083.79,Radiology
Shdr fair lead cable direct,L6590,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5069.06,,,,,,,fee schedule,3620.76,10083.79,APC
Shdr fair lead cable direct,L6590,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6336.33,,,,,,,fee schedule,3620.76,10083.79,APC
Polycentric hinge pair,L6600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,785.05,,,,,,,fee schedule,306.19,852.73,
Polycentric hinge pair,L6600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,852.73,,,,,,,fee schedule,306.19,852.73,
Polycentric hinge pair,L6600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,683.54,,,,,,,fee schedule,306.19,852.73,
Polycentric hinge pair,L6600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,746.7,,,,,,,fee schedule,306.19,852.73,
Polycentric hinge pair,L6600,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,321.5,,,,,,,fee schedule,306.19,852.73,APC
Polycentric hinge pair,L6600,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,318.44,,,,,,,fee schedule,306.19,852.73,APC
Polycentric hinge pair,L6600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,306.19,,,,,,,fee schedule,306.19,852.73,APC
Polycentric hinge pair,L6600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,468.47,,,,,,,fee schedule,306.19,852.73,Radiology
Polycentric hinge pair,L6600,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,428.67,,,,,,,fee schedule,306.19,852.73,APC
Polycentric hinge pair,L6600,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,535.83,,,,,,,fee schedule,306.19,852.73,APC
Single pivot hinge pair,L6605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,775.17,,,,,,,fee schedule,302.33,842,
Single pivot hinge pair,L6605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,842,,,,,,,fee schedule,302.33,842,
Single pivot hinge pair,L6605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,674.93,,,,,,,fee schedule,302.33,842,
Single pivot hinge pair,L6605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,737.3,,,,,,,fee schedule,302.33,842,
Single pivot hinge pair,L6605,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,317.45,,,,,,,fee schedule,302.33,842,APC
Single pivot hinge pair,L6605,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,314.42,,,,,,,fee schedule,302.33,842,APC
Single pivot hinge pair,L6605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,302.33,,,,,,,fee schedule,302.33,842,APC
Single pivot hinge pair,L6605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,462.56,,,,,,,fee schedule,302.33,842,Radiology
Single pivot hinge pair,L6605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,423.26,,,,,,,fee schedule,302.33,842,APC
Single pivot hinge pair,L6605,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,529.08,,,,,,,fee schedule,302.33,842,APC
Flexible metal hinge pair,L6610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,634.86,,,,,,,fee schedule,247.59,689.59,
Flexible metal hinge pair,L6610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,689.59,,,,,,,fee schedule,247.59,689.59,
Flexible metal hinge pair,L6610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,552.76,,,,,,,fee schedule,247.59,689.59,
Flexible metal hinge pair,L6610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,603.84,,,,,,,fee schedule,247.59,689.59,
Flexible metal hinge pair,L6610,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,259.97,,,,,,,fee schedule,247.59,689.59,APC
Flexible metal hinge pair,L6610,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,257.49,,,,,,,fee schedule,247.59,689.59,APC
Flexible metal hinge pair,L6610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,247.59,,,,,,,fee schedule,247.59,689.59,APC
Flexible metal hinge pair,L6610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,378.81,,,,,,,fee schedule,247.59,689.59,Radiology
Flexible metal hinge pair,L6610,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,346.63,,,,,,,fee schedule,247.59,689.59,APC
Flexible metal hinge pair,L6610,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,433.28,,,,,,,fee schedule,247.59,689.59,APC
"Additional switch, ext power",L6611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1306.81,,,,,,,fee schedule,509.68,1419.47,
"Additional switch, ext power",L6611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1419.47,,,,,,,fee schedule,509.68,1419.47,
"Additional switch, ext power",L6611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1137.83,,,,,,,fee schedule,509.68,1419.47,
"Additional switch, ext power",L6611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1242.97,,,,,,,fee schedule,509.68,1419.47,
"Additional switch, ext power",L6611,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,535.16,,,,,,,fee schedule,509.68,1419.47,APC
"Additional switch, ext power",L6611,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,530.07,,,,,,,fee schedule,509.68,1419.47,APC
"Additional switch, ext power",L6611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,509.68,,,,,,,fee schedule,509.68,1419.47,APC
"Additional switch, ext power",L6611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,779.81,,,,,,,fee schedule,509.68,1419.47,Radiology
"Additional switch, ext power",L6611,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,713.55,,,,,,,fee schedule,509.68,1419.47,APC
"Additional switch, ext power",L6611,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,891.94,,,,,,,fee schedule,509.68,1419.47,APC
Disconnect locking wrist uni,L6615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,609.42,,,,,,,fee schedule,237.69,661.95,
Disconnect locking wrist uni,L6615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,661.95,,,,,,,fee schedule,237.69,661.95,
Disconnect locking wrist uni,L6615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,530.61,,,,,,,fee schedule,237.69,661.95,
Disconnect locking wrist uni,L6615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,579.65,,,,,,,fee schedule,237.69,661.95,
Disconnect locking wrist uni,L6615,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,249.57,,,,,,,fee schedule,237.69,661.95,APC
Disconnect locking wrist uni,L6615,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,247.2,,,,,,,fee schedule,237.69,661.95,APC
Disconnect locking wrist uni,L6615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,237.69,,,,,,,fee schedule,237.69,661.95,APC
Disconnect locking wrist uni,L6615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,363.67,,,,,,,fee schedule,237.69,661.95,Radiology
Disconnect locking wrist uni,L6615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,332.77,,,,,,,fee schedule,237.69,661.95,APC
Disconnect locking wrist uni,L6615,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,415.96,,,,,,,fee schedule,237.69,661.95,APC
Disconnect insert locking wr,L6616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,259.02,,,,,,,fee schedule,101.03,281.35,
Disconnect insert locking wr,L6616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,281.35,,,,,,,fee schedule,101.03,281.35,
Disconnect insert locking wr,L6616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,225.52,,,,,,,fee schedule,101.03,281.35,
Disconnect insert locking wr,L6616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,246.36,,,,,,,fee schedule,101.03,281.35,
Disconnect insert locking wr,L6616,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,106.08,,,,,,,fee schedule,101.03,281.35,APC
Disconnect insert locking wr,L6616,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,105.07,,,,,,,fee schedule,101.03,281.35,APC
Disconnect insert locking wr,L6616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,101.03,,,,,,,fee schedule,101.03,281.35,APC
Disconnect insert locking wr,L6616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,154.58,,,,,,,fee schedule,101.03,281.35,Radiology
Disconnect insert locking wr,L6616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,141.44,,,,,,,fee schedule,101.03,281.35,APC
Disconnect insert locking wr,L6616,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,176.8,,,,,,,fee schedule,101.03,281.35,APC
Flexion/extension wrist unit,L6620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1053.01,,,,,,,fee schedule,410.7,1143.79,
Flexion/extension wrist unit,L6620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1143.79,,,,,,,fee schedule,410.7,1143.79,
Flexion/extension wrist unit,L6620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,916.85,,,,,,,fee schedule,410.7,1143.79,
Flexion/extension wrist unit,L6620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1001.57,,,,,,,fee schedule,410.7,1143.79,
Flexion/extension wrist unit,L6620,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,431.24,,,,,,,fee schedule,410.7,1143.79,APC
Flexion/extension wrist unit,L6620,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,427.13,,,,,,,fee schedule,410.7,1143.79,APC
Flexion/extension wrist unit,L6620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,410.7,,,,,,,fee schedule,410.7,1143.79,APC
Flexion/extension wrist unit,L6620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,628.37,,,,,,,fee schedule,410.7,1143.79,Radiology
Flexion/extension wrist unit,L6620,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,574.98,,,,,,,fee schedule,410.7,1143.79,APC
Flexion/extension wrist unit,L6620,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,718.72,,,,,,,fee schedule,410.7,1143.79,APC
Flex/ext wrist w/wo friction,L6621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7259.8,,,,,,,fee schedule,2831.48,7885.65,
Flex/ext wrist w/wo friction,L6621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7885.65,,,,,,,fee schedule,2831.48,7885.65,
Flex/ext wrist w/wo friction,L6621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6321.03,,,,,,,fee schedule,2831.48,7885.65,
Flex/ext wrist w/wo friction,L6621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6905.16,,,,,,,fee schedule,2831.48,7885.65,
Flex/ext wrist w/wo friction,L6621,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2973.05,,,,,,,fee schedule,2831.48,7885.65,APC
Flex/ext wrist w/wo friction,L6621,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2944.74,,,,,,,fee schedule,2831.48,7885.65,APC
Flex/ext wrist w/wo friction,L6621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2831.48,,,,,,,fee schedule,2831.48,7885.65,APC
Flex/ext wrist w/wo friction,L6621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4332.16,,,,,,,fee schedule,2831.48,7885.65,Radiology
Flex/ext wrist w/wo friction,L6621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3964.07,,,,,,,fee schedule,2831.48,7885.65,APC
Flex/ext wrist w/wo friction,L6621,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4955.09,,,,,,,fee schedule,2831.48,7885.65,APC
Spring-ass rot wrst w/ latch,L6623,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2114.34,,,,,,,fee schedule,824.65,2296.61,
Spring-ass rot wrst w/ latch,L6623,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2296.61,,,,,,,fee schedule,824.65,2296.61,
Spring-ass rot wrst w/ latch,L6623,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1840.94,,,,,,,fee schedule,824.65,2296.61,
Spring-ass rot wrst w/ latch,L6623,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2011.06,,,,,,,fee schedule,824.65,2296.61,
Spring-ass rot wrst w/ latch,L6623,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,865.88,,,,,,,fee schedule,824.65,2296.61,APC
Spring-ass rot wrst w/ latch,L6623,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,857.64,,,,,,,fee schedule,824.65,2296.61,APC
Spring-ass rot wrst w/ latch,L6623,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,824.65,,,,,,,fee schedule,824.65,2296.61,APC
Spring-ass rot wrst w/ latch,L6623,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1261.71,,,,,,,fee schedule,824.65,2296.61,Radiology
Spring-ass rot wrst w/ latch,L6623,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1154.51,,,,,,,fee schedule,824.65,2296.61,APC
Spring-ass rot wrst w/ latch,L6623,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1443.14,,,,,,,fee schedule,824.65,2296.61,APC
Flex/ext/rotation wrist unit,L6624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11953.42,,,,,,,fee schedule,4662.11,12983.88,
Flex/ext/rotation wrist unit,L6624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12983.88,,,,,,,fee schedule,4662.11,12983.88,
Flex/ext/rotation wrist unit,L6624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10407.72,,,,,,,fee schedule,4662.11,12983.88,
Flex/ext/rotation wrist unit,L6624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11369.49,,,,,,,fee schedule,4662.11,12983.88,
Flex/ext/rotation wrist unit,L6624,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4895.22,,,,,,,fee schedule,4662.11,12983.88,APC
Flex/ext/rotation wrist unit,L6624,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4848.59,,,,,,,fee schedule,4662.11,12983.88,APC
Flex/ext/rotation wrist unit,L6624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4662.11,,,,,,,fee schedule,4662.11,12983.88,APC
Flex/ext/rotation wrist unit,L6624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7133.03,,,,,,,fee schedule,4662.11,12983.88,Radiology
Flex/ext/rotation wrist unit,L6624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6526.95,,,,,,,fee schedule,4662.11,12983.88,APC
Flex/ext/rotation wrist unit,L6624,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8158.69,,,,,,,fee schedule,4662.11,12983.88,APC
Rotation wrst w/ cable lock,L6625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2225.91,,,,,,,fee schedule,868.15,2417.8,
Rotation wrst w/ cable lock,L6625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2417.8,,,,,,,fee schedule,868.15,2417.8,
Rotation wrst w/ cable lock,L6625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1938.08,,,,,,,fee schedule,868.15,2417.8,
Rotation wrst w/ cable lock,L6625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2117.18,,,,,,,fee schedule,868.15,2417.8,
Rotation wrst w/ cable lock,L6625,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,911.56,,,,,,,fee schedule,868.15,2417.8,APC
Rotation wrst w/ cable lock,L6625,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,902.88,,,,,,,fee schedule,868.15,2417.8,APC
Rotation wrst w/ cable lock,L6625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,868.15,,,,,,,fee schedule,868.15,2417.8,APC
Rotation wrst w/ cable lock,L6625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1328.27,,,,,,,fee schedule,868.15,2417.8,Radiology
Rotation wrst w/ cable lock,L6625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1215.41,,,,,,,fee schedule,868.15,2417.8,APC
Rotation wrst w/ cable lock,L6625,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1519.26,,,,,,,fee schedule,868.15,2417.8,APC
Quick disconn hook adapter o,L6628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1620.32,,,,,,,fee schedule,631.93,1760.01,
Quick disconn hook adapter o,L6628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1760.01,,,,,,,fee schedule,631.93,1760.01,
Quick disconn hook adapter o,L6628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1410.8,,,,,,,fee schedule,631.93,1760.01,
Quick disconn hook adapter o,L6628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1541.17,,,,,,,fee schedule,631.93,1760.01,
Quick disconn hook adapter o,L6628,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,663.53,,,,,,,fee schedule,631.93,1760.01,APC
Quick disconn hook adapter o,L6628,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,657.21,,,,,,,fee schedule,631.93,1760.01,APC
Quick disconn hook adapter o,L6628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,631.93,,,,,,,fee schedule,631.93,1760.01,APC
Quick disconn hook adapter o,L6628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,966.85,,,,,,,fee schedule,631.93,1760.01,Radiology
Quick disconn hook adapter o,L6628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,884.7,,,,,,,fee schedule,631.93,1760.01,APC
Quick disconn hook adapter o,L6628,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1105.88,,,,,,,fee schedule,631.93,1760.01,APC
Lamination collar w/ couplin,L6629,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,557.11,,,,,,,fee schedule,217.28,605.14,
Lamination collar w/ couplin,L6629,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,605.14,,,,,,,fee schedule,217.28,605.14,
Lamination collar w/ couplin,L6629,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,485.07,,,,,,,fee schedule,217.28,605.14,
Lamination collar w/ couplin,L6629,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,529.9,,,,,,,fee schedule,217.28,605.14,
Lamination collar w/ couplin,L6629,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,228.14,,,,,,,fee schedule,217.28,605.14,APC
Lamination collar w/ couplin,L6629,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,225.97,,,,,,,fee schedule,217.28,605.14,APC
Lamination collar w/ couplin,L6629,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,217.28,,,,,,,fee schedule,217.28,605.14,APC
Lamination collar w/ couplin,L6629,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,332.44,,,,,,,fee schedule,217.28,605.14,Radiology
Lamination collar w/ couplin,L6629,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,304.19,,,,,,,fee schedule,217.28,605.14,APC
Lamination collar w/ couplin,L6629,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,380.24,,,,,,,fee schedule,217.28,605.14,APC
Stainless steel any wrist,L6630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,902.02,,,,,,,fee schedule,351.8,979.78,
Stainless steel any wrist,L6630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,979.78,,,,,,,fee schedule,351.8,979.78,
Stainless steel any wrist,L6630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,785.38,,,,,,,fee schedule,351.8,979.78,
Stainless steel any wrist,L6630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,857.95,,,,,,,fee schedule,351.8,979.78,
Stainless steel any wrist,L6630,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,369.39,,,,,,,fee schedule,351.8,979.78,APC
Stainless steel any wrist,L6630,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,365.87,,,,,,,fee schedule,351.8,979.78,APC
Stainless steel any wrist,L6630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,351.8,,,,,,,fee schedule,351.8,979.78,APC
Stainless steel any wrist,L6630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,538.25,,,,,,,fee schedule,351.8,979.78,Radiology
Stainless steel any wrist,L6630,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,492.52,,,,,,,fee schedule,351.8,979.78,APC
Stainless steel any wrist,L6630,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,615.65,,,,,,,fee schedule,351.8,979.78,APC
Latex suspension sleeve each,L6632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,203.93,,,,,,,fee schedule,79.54,221.51,
Latex suspension sleeve each,L6632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,221.51,,,,,,,fee schedule,79.54,221.51,
Latex suspension sleeve each,L6632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,177.56,,,,,,,fee schedule,79.54,221.51,
Latex suspension sleeve each,L6632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,193.97,,,,,,,fee schedule,79.54,221.51,
Latex suspension sleeve each,L6632,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,83.52,,,,,,,fee schedule,79.54,221.51,APC
Latex suspension sleeve each,L6632,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,82.72,,,,,,,fee schedule,79.54,221.51,APC
Latex suspension sleeve each,L6632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,79.54,,,,,,,fee schedule,79.54,221.51,APC
Latex suspension sleeve each,L6632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,121.7,,,,,,,fee schedule,79.54,221.51,Radiology
Latex suspension sleeve each,L6632,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,111.36,,,,,,,fee schedule,79.54,221.51,APC
Latex suspension sleeve each,L6632,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,139.2,,,,,,,fee schedule,79.54,221.51,APC
Lift assist for elbow,L6635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,694.47,,,,,,,fee schedule,270.85,754.34,
Lift assist for elbow,L6635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,754.34,,,,,,,fee schedule,270.85,754.34,
Lift assist for elbow,L6635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,604.67,,,,,,,fee schedule,270.85,754.34,
Lift assist for elbow,L6635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,660.54,,,,,,,fee schedule,270.85,754.34,
Lift assist for elbow,L6635,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,284.39,,,,,,,fee schedule,270.85,754.34,APC
Lift assist for elbow,L6635,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,281.68,,,,,,,fee schedule,270.85,754.34,APC
Lift assist for elbow,L6635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,270.85,,,,,,,fee schedule,270.85,754.34,APC
Lift assist for elbow,L6635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,414.4,,,,,,,fee schedule,270.85,754.34,Radiology
Lift assist for elbow,L6635,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,379.19,,,,,,,fee schedule,270.85,754.34,APC
Lift assist for elbow,L6635,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,473.99,,,,,,,fee schedule,270.85,754.34,APC
Nudge control elbow lock,L6637,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1353.23,,,,,,,fee schedule,527.81,1469.89,
Nudge control elbow lock,L6637,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1469.89,,,,,,,fee schedule,527.81,1469.89,
Nudge control elbow lock,L6637,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1178.25,,,,,,,fee schedule,527.81,1469.89,
Nudge control elbow lock,L6637,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1287.13,,,,,,,fee schedule,527.81,1469.89,
Nudge control elbow lock,L6637,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,554.2,,,,,,,fee schedule,527.81,1469.89,APC
Nudge control elbow lock,L6637,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,548.92,,,,,,,fee schedule,527.81,1469.89,APC
Nudge control elbow lock,L6637,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,527.81,,,,,,,fee schedule,527.81,1469.89,APC
Nudge control elbow lock,L6637,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,807.55,,,,,,,fee schedule,527.81,1469.89,Radiology
Nudge control elbow lock,L6637,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,738.93,,,,,,,fee schedule,527.81,1469.89,APC
Nudge control elbow lock,L6637,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,923.67,,,,,,,fee schedule,527.81,1469.89,APC
Elec lock on manual pw elbow,L6638,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7937.18,,,,,,,fee schedule,3095.69,8621.42,
Elec lock on manual pw elbow,L6638,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8621.42,,,,,,,fee schedule,3095.69,8621.42,
Elec lock on manual pw elbow,L6638,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6910.82,,,,,,,fee schedule,3095.69,8621.42,
Elec lock on manual pw elbow,L6638,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7549.45,,,,,,,fee schedule,3095.69,8621.42,
Elec lock on manual pw elbow,L6638,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3250.47,,,,,,,fee schedule,3095.69,8621.42,APC
Elec lock on manual pw elbow,L6638,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3219.52,,,,,,,fee schedule,3095.69,8621.42,APC
Elec lock on manual pw elbow,L6638,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3095.69,,,,,,,fee schedule,3095.69,8621.42,APC
Elec lock on manual pw elbow,L6638,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4736.41,,,,,,,fee schedule,3095.69,8621.42,Radiology
Elec lock on manual pw elbow,L6638,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4333.97,,,,,,,fee schedule,3095.69,8621.42,APC
Elec lock on manual pw elbow,L6638,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5417.46,,,,,,,fee schedule,3095.69,8621.42,APC
Shoulder abduction joint pai,L6640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1132.25,,,,,,,fee schedule,441.57,1229.86,
Shoulder abduction joint pai,L6640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1229.86,,,,,,,fee schedule,441.57,1229.86,
Shoulder abduction joint pai,L6640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,985.84,,,,,,,fee schedule,441.57,1229.86,
Shoulder abduction joint pai,L6640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1076.94,,,,,,,fee schedule,441.57,1229.86,
Shoulder abduction joint pai,L6640,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,463.65,,,,,,,fee schedule,441.57,1229.86,APC
Shoulder abduction joint pai,L6640,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,459.23,,,,,,,fee schedule,441.57,1229.86,APC
Shoulder abduction joint pai,L6640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,441.57,,,,,,,fee schedule,441.57,1229.86,APC
Shoulder abduction joint pai,L6640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,675.6,,,,,,,fee schedule,441.57,1229.86,Radiology
Shoulder abduction joint pai,L6640,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,618.2,,,,,,,fee schedule,441.57,1229.86,APC
Shoulder abduction joint pai,L6640,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,772.75,,,,,,,fee schedule,441.57,1229.86,APC
Excursion amplifier pulley t,L6641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,612.27,,,,,,,fee schedule,238.81,665.05,
Excursion amplifier pulley t,L6641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,665.05,,,,,,,fee schedule,238.81,665.05,
Excursion amplifier pulley t,L6641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,533.1,,,,,,,fee schedule,238.81,665.05,
Excursion amplifier pulley t,L6641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,582.36,,,,,,,fee schedule,238.81,665.05,
Excursion amplifier pulley t,L6641,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,250.75,,,,,,,fee schedule,238.81,665.05,APC
Excursion amplifier pulley t,L6641,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,248.36,,,,,,,fee schedule,238.81,665.05,APC
Excursion amplifier pulley t,L6641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,238.81,,,,,,,fee schedule,238.81,665.05,APC
Excursion amplifier pulley t,L6641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,365.38,,,,,,,fee schedule,238.81,665.05,Radiology
Excursion amplifier pulley t,L6641,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,334.33,,,,,,,fee schedule,238.81,665.05,APC
Excursion amplifier pulley t,L6641,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,417.92,,,,,,,fee schedule,238.81,665.05,APC
Excursion amplifier lever ty,L6642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,729.03,,,,,,,fee schedule,284.29,791.87,
Excursion amplifier lever ty,L6642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,791.87,,,,,,,fee schedule,284.29,791.87,
Excursion amplifier lever ty,L6642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,634.75,,,,,,,fee schedule,284.29,791.87,
Excursion amplifier lever ty,L6642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,693.41,,,,,,,fee schedule,284.29,791.87,
Excursion amplifier lever ty,L6642,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,298.5,,,,,,,fee schedule,284.29,791.87,APC
Excursion amplifier lever ty,L6642,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,295.66,,,,,,,fee schedule,284.29,791.87,APC
Excursion amplifier lever ty,L6642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,284.29,,,,,,,fee schedule,284.29,791.87,APC
Excursion amplifier lever ty,L6642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,434.96,,,,,,,fee schedule,284.29,791.87,Radiology
Excursion amplifier lever ty,L6642,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,398.01,,,,,,,fee schedule,284.29,791.87,APC
Excursion amplifier lever ty,L6642,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,497.51,,,,,,,fee schedule,284.29,791.87,APC
Shoulder flexion-abduction j,L6645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1264.25,,,,,,,fee schedule,493.1,1373.24,
Shoulder flexion-abduction j,L6645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1373.24,,,,,,,fee schedule,493.1,1373.24,
Shoulder flexion-abduction j,L6645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1100.77,,,,,,,fee schedule,493.1,1373.24,
Shoulder flexion-abduction j,L6645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1202.49,,,,,,,fee schedule,493.1,1373.24,
Shoulder flexion-abduction j,L6645,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,517.76,,,,,,,fee schedule,493.1,1373.24,APC
Shoulder flexion-abduction j,L6645,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,512.82,,,,,,,fee schedule,493.1,1373.24,APC
Shoulder flexion-abduction j,L6645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,493.1,,,,,,,fee schedule,493.1,1373.24,APC
Shoulder flexion-abduction j,L6645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,754.44,,,,,,,fee schedule,493.1,1373.24,Radiology
Shoulder flexion-abduction j,L6645,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,690.34,,,,,,,fee schedule,493.1,1373.24,APC
Shoulder flexion-abduction j,L6645,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,862.92,,,,,,,fee schedule,493.1,1373.24,APC
Multipo locking shoulder jnt,L6646,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10010.6,,,,,,,fee schedule,3904.35,10873.59,
Multipo locking shoulder jnt,L6646,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10873.59,,,,,,,fee schedule,3904.35,10873.59,
Multipo locking shoulder jnt,L6646,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8716.13,,,,,,,fee schedule,3904.35,10873.59,
Multipo locking shoulder jnt,L6646,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9521.58,,,,,,,fee schedule,3904.35,10873.59,
Multipo locking shoulder jnt,L6646,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4099.57,,,,,,,fee schedule,3904.35,10873.59,APC
Multipo locking shoulder jnt,L6646,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4060.52,,,,,,,fee schedule,3904.35,10873.59,APC
Multipo locking shoulder jnt,L6646,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3904.35,,,,,,,fee schedule,3904.35,10873.59,APC
Multipo locking shoulder jnt,L6646,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5973.66,,,,,,,fee schedule,3904.35,10873.59,Radiology
Multipo locking shoulder jnt,L6646,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5466.09,,,,,,,fee schedule,3904.35,10873.59,APC
Multipo locking shoulder jnt,L6646,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6832.61,,,,,,,fee schedule,3904.35,10873.59,APC
Shoulder lock actuator,L6647,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1648.06,,,,,,,fee schedule,642.79,1790.13,
Shoulder lock actuator,L6647,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1790.13,,,,,,,fee schedule,642.79,1790.13,
Shoulder lock actuator,L6647,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1434.95,,,,,,,fee schedule,642.79,1790.13,
Shoulder lock actuator,L6647,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1567.55,,,,,,,fee schedule,642.79,1790.13,
Shoulder lock actuator,L6647,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,674.93,,,,,,,fee schedule,642.79,1790.13,APC
Shoulder lock actuator,L6647,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,668.5,,,,,,,fee schedule,642.79,1790.13,APC
Shoulder lock actuator,L6647,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,642.79,,,,,,,fee schedule,642.79,1790.13,APC
Shoulder lock actuator,L6647,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,983.47,,,,,,,fee schedule,642.79,1790.13,Radiology
Shoulder lock actuator,L6647,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,899.91,,,,,,,fee schedule,642.79,1790.13,APC
Shoulder lock actuator,L6647,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1124.88,,,,,,,fee schedule,642.79,1790.13,APC
Ext pwrd shlder lock/unlock,L6648,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10324.57,,,,,,,fee schedule,4026.82,11214.62,
Ext pwrd shlder lock/unlock,L6648,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11214.62,,,,,,,fee schedule,4026.82,11214.62,
Ext pwrd shlder lock/unlock,L6648,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8989.49,,,,,,,fee schedule,4026.82,11214.62,
Ext pwrd shlder lock/unlock,L6648,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9820.21,,,,,,,fee schedule,4026.82,11214.62,
Ext pwrd shlder lock/unlock,L6648,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4228.16,,,,,,,fee schedule,4026.82,11214.62,APC
Ext pwrd shlder lock/unlock,L6648,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4187.89,,,,,,,fee schedule,4026.82,11214.62,APC
Ext pwrd shlder lock/unlock,L6648,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4026.82,,,,,,,fee schedule,4026.82,11214.62,APC
Ext pwrd shlder lock/unlock,L6648,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6161.03,,,,,,,fee schedule,4026.82,11214.62,Radiology
Ext pwrd shlder lock/unlock,L6648,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5637.55,,,,,,,fee schedule,4026.82,11214.62,APC
Ext pwrd shlder lock/unlock,L6648,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7046.94,,,,,,,fee schedule,4026.82,11214.62,APC
Shoulder universal joint,L6650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1327.45,,,,,,,fee schedule,517.73,1441.88,
Shoulder universal joint,L6650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1441.88,,,,,,,fee schedule,517.73,1441.88,
Shoulder universal joint,L6650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1155.79,,,,,,,fee schedule,517.73,1441.88,
Shoulder universal joint,L6650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1262.6,,,,,,,fee schedule,517.73,1441.88,
Shoulder universal joint,L6650,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,543.62,,,,,,,fee schedule,517.73,1441.88,APC
Shoulder universal joint,L6650,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,538.44,,,,,,,fee schedule,517.73,1441.88,APC
Shoulder universal joint,L6650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,517.73,,,,,,,fee schedule,517.73,1441.88,APC
Shoulder universal joint,L6650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,792.13,,,,,,,fee schedule,517.73,1441.88,Radiology
Shoulder universal joint,L6650,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,724.82,,,,,,,fee schedule,517.73,1441.88,APC
Shoulder universal joint,L6650,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,906.03,,,,,,,fee schedule,517.73,1441.88,APC
Standard control cable extra,L6655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,290.65,,,,,,,fee schedule,113.34,315.71,
Standard control cable extra,L6655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,315.71,,,,,,,fee schedule,113.34,315.71,
Standard control cable extra,L6655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,253.07,,,,,,,fee schedule,113.34,315.71,
Standard control cable extra,L6655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,276.45,,,,,,,fee schedule,113.34,315.71,
Standard control cable extra,L6655,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,119.01,,,,,,,fee schedule,113.34,315.71,APC
Standard control cable extra,L6655,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,117.87,,,,,,,fee schedule,113.34,315.71,APC
Standard control cable extra,L6655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,113.34,,,,,,,fee schedule,113.34,315.71,APC
Standard control cable extra,L6655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,173.41,,,,,,,fee schedule,113.34,315.71,Radiology
Standard control cable extra,L6655,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.68,,,,,,,fee schedule,113.34,315.71,APC
Standard control cable extra,L6655,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,198.34,,,,,,,fee schedule,113.34,315.71,APC
Heavy duty control cable,L6660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,323.99,,,,,,,fee schedule,126.38,351.92,
Heavy duty control cable,L6660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,351.92,,,,,,,fee schedule,126.38,351.92,
Heavy duty control cable,L6660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,282.09,,,,,,,fee schedule,126.38,351.92,
Heavy duty control cable,L6660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,308.16,,,,,,,fee schedule,126.38,351.92,
Heavy duty control cable,L6660,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,132.7,,,,,,,fee schedule,126.38,351.92,APC
Heavy duty control cable,L6660,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,131.44,,,,,,,fee schedule,126.38,351.92,APC
Heavy duty control cable,L6660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,126.38,,,,,,,fee schedule,126.38,351.92,APC
Heavy duty control cable,L6660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,193.36,,,,,,,fee schedule,126.38,351.92,Radiology
Heavy duty control cable,L6660,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,176.93,,,,,,,fee schedule,126.38,351.92,APC
Heavy duty control cable,L6660,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,221.16,,,,,,,fee schedule,126.38,351.92,APC
Teflon or equal cable lining,L6665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,192.76,,,,,,,fee schedule,75.17,209.37,
Teflon or equal cable lining,L6665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,209.37,,,,,,,fee schedule,75.17,209.37,
Teflon or equal cable lining,L6665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,167.83,,,,,,,fee schedule,75.17,209.37,
Teflon or equal cable lining,L6665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,183.34,,,,,,,fee schedule,75.17,209.37,
Teflon or equal cable lining,L6665,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,78.93,,,,,,,fee schedule,75.17,209.37,APC
Teflon or equal cable lining,L6665,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,78.18,,,,,,,fee schedule,75.17,209.37,APC
Teflon or equal cable lining,L6665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,75.17,,,,,,,fee schedule,75.17,209.37,APC
Teflon or equal cable lining,L6665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,115.01,,,,,,,fee schedule,75.17,209.37,Radiology
Teflon or equal cable lining,L6665,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,105.24,,,,,,,fee schedule,75.17,209.37,APC
Teflon or equal cable lining,L6665,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,131.55,,,,,,,fee schedule,75.17,209.37,APC
Hook to hand cable adapter,L6670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,200.69,,,,,,,fee schedule,78.28,217.99,
Hook to hand cable adapter,L6670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,217.99,,,,,,,fee schedule,78.28,217.99,
Hook to hand cable adapter,L6670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,174.74,,,,,,,fee schedule,78.28,217.99,
Hook to hand cable adapter,L6670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,190.89,,,,,,,fee schedule,78.28,217.99,
Hook to hand cable adapter,L6670,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,82.19,,,,,,,fee schedule,78.28,217.99,APC
Hook to hand cable adapter,L6670,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,81.41,,,,,,,fee schedule,78.28,217.99,APC
Hook to hand cable adapter,L6670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,78.28,,,,,,,fee schedule,78.28,217.99,APC
Hook to hand cable adapter,L6670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,119.77,,,,,,,fee schedule,78.28,217.99,Radiology
Hook to hand cable adapter,L6670,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,109.59,,,,,,,fee schedule,78.28,217.99,APC
Hook to hand cable adapter,L6670,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,136.99,,,,,,,fee schedule,78.28,217.99,APC
Harness chest/shlder saddle,L6672,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,558.51,,,,,,,fee schedule,217.81,606.65,
Harness chest/shlder saddle,L6672,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,606.65,,,,,,,fee schedule,217.81,606.65,
Harness chest/shlder saddle,L6672,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,486.28,,,,,,,fee schedule,217.81,606.65,
Harness chest/shlder saddle,L6672,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,531.22,,,,,,,fee schedule,217.81,606.65,
Harness chest/shlder saddle,L6672,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,228.7,,,,,,,fee schedule,217.81,606.65,APC
Harness chest/shlder saddle,L6672,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,226.52,,,,,,,fee schedule,217.81,606.65,APC
Harness chest/shlder saddle,L6672,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,217.81,,,,,,,fee schedule,217.81,606.65,APC
Harness chest/shlder saddle,L6672,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,333.25,,,,,,,fee schedule,217.81,606.65,Radiology
Harness chest/shlder saddle,L6672,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,304.93,,,,,,,fee schedule,217.81,606.65,APC
Harness chest/shlder saddle,L6672,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,381.17,,,,,,,fee schedule,217.81,606.65,APC
Harness figure of 8 sing con,L6675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,391.64,,,,,,,fee schedule,152.75,425.4,
Harness figure of 8 sing con,L6675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,425.4,,,,,,,fee schedule,152.75,425.4,
Harness figure of 8 sing con,L6675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,341,,,,,,,fee schedule,152.75,425.4,
Harness figure of 8 sing con,L6675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,372.51,,,,,,,fee schedule,152.75,425.4,
Harness figure of 8 sing con,L6675,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,160.39,,,,,,,fee schedule,152.75,425.4,APC
Harness figure of 8 sing con,L6675,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,158.86,,,,,,,fee schedule,152.75,425.4,APC
Harness figure of 8 sing con,L6675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,152.75,,,,,,,fee schedule,152.75,425.4,APC
Harness figure of 8 sing con,L6675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,233.71,,,,,,,fee schedule,152.75,425.4,Radiology
Harness figure of 8 sing con,L6675,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,213.85,,,,,,,fee schedule,152.75,425.4,APC
Harness figure of 8 sing con,L6675,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,267.31,,,,,,,fee schedule,152.75,425.4,APC
Harness figure of 8 dual con,L6676,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,411.68,,,,,,,fee schedule,160.58,447.17,
Harness figure of 8 dual con,L6676,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,447.17,,,,,,,fee schedule,160.58,447.17,
Harness figure of 8 dual con,L6676,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,358.45,,,,,,,fee schedule,160.58,447.17,
Harness figure of 8 dual con,L6676,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,391.57,,,,,,,fee schedule,160.58,447.17,
Harness figure of 8 dual con,L6676,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,168.61,,,,,,,fee schedule,160.58,447.17,APC
Harness figure of 8 dual con,L6676,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,167,,,,,,,fee schedule,160.58,447.17,APC
Harness figure of 8 dual con,L6676,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,160.58,,,,,,,fee schedule,160.58,447.17,APC
Harness figure of 8 dual con,L6676,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,245.69,,,,,,,fee schedule,160.58,447.17,Radiology
Harness figure of 8 dual con,L6676,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,224.81,,,,,,,fee schedule,160.58,447.17,APC
Harness figure of 8 dual con,L6676,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,281.02,,,,,,,fee schedule,160.58,447.17,APC
UE triple control harness,L6677,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,941.58,,,,,,,fee schedule,367.25,1022.75,
UE triple control harness,L6677,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1022.75,,,,,,,fee schedule,367.25,1022.75,
UE triple control harness,L6677,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,819.83,,,,,,,fee schedule,367.25,1022.75,
UE triple control harness,L6677,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,895.59,,,,,,,fee schedule,367.25,1022.75,
UE triple control harness,L6677,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,385.61,,,,,,,fee schedule,367.25,1022.75,APC
UE triple control harness,L6677,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,381.94,,,,,,,fee schedule,367.25,1022.75,APC
UE triple control harness,L6677,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,367.25,,,,,,,fee schedule,367.25,1022.75,APC
UE triple control harness,L6677,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,561.89,,,,,,,fee schedule,367.25,1022.75,Radiology
UE triple control harness,L6677,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,514.15,,,,,,,fee schedule,367.25,1022.75,APC
UE triple control harness,L6677,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,642.69,,,,,,,fee schedule,367.25,1022.75,APC
Test sock wrist disart/bel e,L6680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,971.02,,,,,,,fee schedule,378.71,1054.73,
Test sock wrist disart/bel e,L6680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1054.73,,,,,,,fee schedule,378.71,1054.73,
Test sock wrist disart/bel e,L6680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,845.46,,,,,,,fee schedule,378.71,1054.73,
Test sock wrist disart/bel e,L6680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,923.59,,,,,,,fee schedule,378.71,1054.73,
Test sock wrist disart/bel e,L6680,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,397.65,,,,,,,fee schedule,378.71,1054.73,APC
Test sock wrist disart/bel e,L6680,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,393.86,,,,,,,fee schedule,378.71,1054.73,APC
Test sock wrist disart/bel e,L6680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,378.71,,,,,,,fee schedule,378.71,1054.73,APC
Test sock wrist disart/bel e,L6680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,579.43,,,,,,,fee schedule,378.71,1054.73,Radiology
Test sock wrist disart/bel e,L6680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,530.19,,,,,,,fee schedule,378.71,1054.73,APC
Test sock wrist disart/bel e,L6680,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,662.74,,,,,,,fee schedule,378.71,1054.73,APC
Test sock elbw disart/above,L6682,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,950.77,,,,,,,fee schedule,370.84,1032.73,
Test sock elbw disart/above,L6682,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1032.73,,,,,,,fee schedule,370.84,1032.73,
Test sock elbw disart/above,L6682,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,827.83,,,,,,,fee schedule,370.84,1032.73,
Test sock elbw disart/above,L6682,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,904.33,,,,,,,fee schedule,370.84,1032.73,
Test sock elbw disart/above,L6682,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,389.38,,,,,,,fee schedule,370.84,1032.73,APC
Test sock elbw disart/above,L6682,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,385.67,,,,,,,fee schedule,370.84,1032.73,APC
Test sock elbw disart/above,L6682,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,370.84,,,,,,,fee schedule,370.84,1032.73,APC
Test sock elbw disart/above,L6682,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,567.39,,,,,,,fee schedule,370.84,1032.73,Radiology
Test sock elbw disart/above,L6682,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,519.18,,,,,,,fee schedule,370.84,1032.73,APC
Test sock elbw disart/above,L6682,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,648.97,,,,,,,fee schedule,370.84,1032.73,APC
Test socket shldr disart/tho,L6684,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1094.15,,,,,,,fee schedule,426.74,1188.47,
Test socket shldr disart/tho,L6684,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1188.47,,,,,,,fee schedule,426.74,1188.47,
Test socket shldr disart/tho,L6684,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,952.66,,,,,,,fee schedule,426.74,1188.47,
Test socket shldr disart/tho,L6684,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1040.7,,,,,,,fee schedule,426.74,1188.47,
Test socket shldr disart/tho,L6684,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,448.08,,,,,,,fee schedule,426.74,1188.47,APC
Test socket shldr disart/tho,L6684,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,443.81,,,,,,,fee schedule,426.74,1188.47,APC
Test socket shldr disart/tho,L6684,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,426.74,,,,,,,fee schedule,426.74,1188.47,APC
Test socket shldr disart/tho,L6684,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,652.91,,,,,,,fee schedule,426.74,1188.47,Radiology
Test socket shldr disart/tho,L6684,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,597.44,,,,,,,fee schedule,426.74,1188.47,APC
Test socket shldr disart/tho,L6684,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,746.8,,,,,,,fee schedule,426.74,1188.47,APC
Suction socket,L6686,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2034.27,,,,,,,fee schedule,793.42,2209.64,
Suction socket,L6686,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2209.64,,,,,,,fee schedule,793.42,2209.64,
Suction socket,L6686,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1771.22,,,,,,,fee schedule,793.42,2209.64,
Suction socket,L6686,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1934.89,,,,,,,fee schedule,793.42,2209.64,
Suction socket,L6686,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,833.09,,,,,,,fee schedule,793.42,2209.64,APC
Suction socket,L6686,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,825.16,,,,,,,fee schedule,793.42,2209.64,APC
Suction socket,L6686,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,793.42,,,,,,,fee schedule,793.42,2209.64,APC
Suction socket,L6686,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1213.93,,,,,,,fee schedule,793.42,2209.64,Radiology
Suction socket,L6686,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1110.79,,,,,,,fee schedule,793.42,2209.64,APC
Suction socket,L6686,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1388.48,,,,,,,fee schedule,793.42,2209.64,APC
Frame typ socket bel elbow/w,L6687,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1810.57,,,,,,,fee schedule,706.16,1966.66,
Frame typ socket bel elbow/w,L6687,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1966.66,,,,,,,fee schedule,706.16,1966.66,
Frame typ socket bel elbow/w,L6687,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1576.45,,,,,,,fee schedule,706.16,1966.66,
Frame typ socket bel elbow/w,L6687,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1722.13,,,,,,,fee schedule,706.16,1966.66,
Frame typ socket bel elbow/w,L6687,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,741.47,,,,,,,fee schedule,706.16,1966.66,APC
Frame typ socket bel elbow/w,L6687,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,734.41,,,,,,,fee schedule,706.16,1966.66,APC
Frame typ socket bel elbow/w,L6687,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,706.16,,,,,,,fee schedule,706.16,1966.66,APC
Frame typ socket bel elbow/w,L6687,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1080.42,,,,,,,fee schedule,706.16,1966.66,Radiology
Frame typ socket bel elbow/w,L6687,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,988.62,,,,,,,fee schedule,706.16,1966.66,APC
Frame typ socket bel elbow/w,L6687,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1235.78,,,,,,,fee schedule,706.16,1966.66,APC
Frame typ sock above elb/dis,L6688,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2139.92,,,,,,,fee schedule,834.62,2324.4,
Frame typ sock above elb/dis,L6688,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2324.4,,,,,,,fee schedule,834.62,2324.4,
Frame typ sock above elb/dis,L6688,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1863.21,,,,,,,fee schedule,834.62,2324.4,
Frame typ sock above elb/dis,L6688,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2035.39,,,,,,,fee schedule,834.62,2324.4,
Frame typ sock above elb/dis,L6688,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,876.35,,,,,,,fee schedule,834.62,2324.4,APC
Frame typ sock above elb/dis,L6688,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,868,,,,,,,fee schedule,834.62,2324.4,APC
Frame typ sock above elb/dis,L6688,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,834.62,,,,,,,fee schedule,834.62,2324.4,APC
Frame typ sock above elb/dis,L6688,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1276.97,,,,,,,fee schedule,834.62,2324.4,Radiology
Frame typ sock above elb/dis,L6688,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1168.47,,,,,,,fee schedule,834.62,2324.4,APC
Frame typ sock above elb/dis,L6688,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1460.58,,,,,,,fee schedule,834.62,2324.4,APC
Frame typ socket shoulder di,L6689,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2239.24,,,,,,,fee schedule,873.35,2432.28,
Frame typ socket shoulder di,L6689,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2432.28,,,,,,,fee schedule,873.35,2432.28,
Frame typ socket shoulder di,L6689,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1949.68,,,,,,,fee schedule,873.35,2432.28,
Frame typ socket shoulder di,L6689,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2129.85,,,,,,,fee schedule,873.35,2432.28,
Frame typ socket shoulder di,L6689,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,917.02,,,,,,,fee schedule,873.35,2432.28,APC
Frame typ socket shoulder di,L6689,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,908.28,,,,,,,fee schedule,873.35,2432.28,APC
Frame typ socket shoulder di,L6689,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,873.35,,,,,,,fee schedule,873.35,2432.28,APC
Frame typ socket shoulder di,L6689,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1336.23,,,,,,,fee schedule,873.35,2432.28,Radiology
Frame typ socket shoulder di,L6689,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1222.69,,,,,,,fee schedule,873.35,2432.28,APC
Frame typ socket shoulder di,L6689,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1528.36,,,,,,,fee schedule,873.35,2432.28,APC
Frame typ sock interscap-tho,L6690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2429.67,,,,,,,fee schedule,947.61,2639.12,
Frame typ sock interscap-tho,L6690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2639.12,,,,,,,fee schedule,947.61,2639.12,
Frame typ sock interscap-tho,L6690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2115.49,,,,,,,fee schedule,947.61,2639.12,
Frame typ sock interscap-tho,L6690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2310.98,,,,,,,fee schedule,947.61,2639.12,
Frame typ sock interscap-tho,L6690,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,994.99,,,,,,,fee schedule,947.61,2639.12,APC
Frame typ sock interscap-tho,L6690,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,985.51,,,,,,,fee schedule,947.61,2639.12,APC
Frame typ sock interscap-tho,L6690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,947.61,,,,,,,fee schedule,947.61,2639.12,APC
Frame typ sock interscap-tho,L6690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1449.84,,,,,,,fee schedule,947.61,2639.12,Radiology
Frame typ sock interscap-tho,L6690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1326.65,,,,,,,fee schedule,947.61,2639.12,APC
Frame typ sock interscap-tho,L6690,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1658.32,,,,,,,fee schedule,947.61,2639.12,APC
Removable insert each,L6691,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1083.53,,,,,,,fee schedule,422.6,1176.94,
Removable insert each,L6691,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1176.94,,,,,,,fee schedule,422.6,1176.94,
Removable insert each,L6691,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,943.42,,,,,,,fee schedule,422.6,1176.94,
Removable insert each,L6691,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1030.6,,,,,,,fee schedule,422.6,1176.94,
Removable insert each,L6691,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,443.73,,,,,,,fee schedule,422.6,1176.94,APC
Removable insert each,L6691,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,439.5,,,,,,,fee schedule,422.6,1176.94,APC
Removable insert each,L6691,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,422.6,,,,,,,fee schedule,422.6,1176.94,APC
Removable insert each,L6691,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,646.58,,,,,,,fee schedule,422.6,1176.94,Radiology
Removable insert each,L6691,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,591.64,,,,,,,fee schedule,422.6,1176.94,APC
Removable insert each,L6691,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,739.55,,,,,,,fee schedule,422.6,1176.94,APC
Silicone gel insert or equal,L6692,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2233.43,,,,,,,fee schedule,871.1,2425.97,
Silicone gel insert or equal,L6692,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2425.97,,,,,,,fee schedule,871.1,2425.97,
Silicone gel insert or equal,L6692,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1944.62,,,,,,,fee schedule,871.1,2425.97,
Silicone gel insert or equal,L6692,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2124.32,,,,,,,fee schedule,871.1,2425.97,
Silicone gel insert or equal,L6692,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,914.66,,,,,,,fee schedule,871.1,2425.97,APC
Silicone gel insert or equal,L6692,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,905.94,,,,,,,fee schedule,871.1,2425.97,APC
Silicone gel insert or equal,L6692,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,871.1,,,,,,,fee schedule,871.1,2425.97,APC
Silicone gel insert or equal,L6692,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1332.78,,,,,,,fee schedule,871.1,2425.97,Radiology
Silicone gel insert or equal,L6692,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1219.54,,,,,,,fee schedule,871.1,2425.97,APC
Silicone gel insert or equal,L6692,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1524.42,,,,,,,fee schedule,871.1,2425.97,APC
Lockingelbow forearm cntrbal,L6693,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9010.83,,,,,,,fee schedule,3514.41,9787.63,
Lockingelbow forearm cntrbal,L6693,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9787.63,,,,,,,fee schedule,3514.41,9787.63,
Lockingelbow forearm cntrbal,L6693,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7845.64,,,,,,,fee schedule,3514.41,9787.63,
Lockingelbow forearm cntrbal,L6693,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8570.65,,,,,,,fee schedule,3514.41,9787.63,
Lockingelbow forearm cntrbal,L6693,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3690.13,,,,,,,fee schedule,3514.41,9787.63,APC
Lockingelbow forearm cntrbal,L6693,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3654.99,,,,,,,fee schedule,3514.41,9787.63,APC
Lockingelbow forearm cntrbal,L6693,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3514.41,,,,,,,fee schedule,3514.41,9787.63,APC
Lockingelbow forearm cntrbal,L6693,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5377.05,,,,,,,fee schedule,3514.41,9787.63,Radiology
Lockingelbow forearm cntrbal,L6693,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4920.17,,,,,,,fee schedule,3514.41,9787.63,APC
Lockingelbow forearm cntrbal,L6693,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6150.22,,,,,,,fee schedule,3514.41,9787.63,APC
Elbow socket ins use w/lock,L6694,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2299.62,,,,,,,fee schedule,896.9,2497.86,
Elbow socket ins use w/lock,L6694,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2497.86,,,,,,,fee schedule,896.9,2497.86,
Elbow socket ins use w/lock,L6694,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2002.25,,,,,,,fee schedule,896.9,2497.86,
Elbow socket ins use w/lock,L6694,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2187.28,,,,,,,fee schedule,896.9,2497.86,
Elbow socket ins use w/lock,L6694,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,941.74,,,,,,,fee schedule,896.9,2497.86,APC
Elbow socket ins use w/lock,L6694,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,932.78,,,,,,,fee schedule,896.9,2497.86,APC
Elbow socket ins use w/lock,L6694,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,896.9,,,,,,,fee schedule,896.9,2497.86,APC
Elbow socket ins use w/lock,L6694,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1372.26,,,,,,,fee schedule,896.9,2497.86,Radiology
Elbow socket ins use w/lock,L6694,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1255.66,,,,,,,fee schedule,896.9,2497.86,APC
Elbow socket ins use w/lock,L6694,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1569.58,,,,,,,fee schedule,896.9,2497.86,APC
Elbow socket ins use w/o lck,L6695,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1916.26,,,,,,,fee schedule,747.37,2081.46,
Elbow socket ins use w/o lck,L6695,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2081.46,,,,,,,fee schedule,747.37,2081.46,
Elbow socket ins use w/o lck,L6695,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1668.47,,,,,,,fee schedule,747.37,2081.46,
Elbow socket ins use w/o lck,L6695,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1822.65,,,,,,,fee schedule,747.37,2081.46,
Elbow socket ins use w/o lck,L6695,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,784.74,,,,,,,fee schedule,747.37,2081.46,APC
Elbow socket ins use w/o lck,L6695,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,777.26,,,,,,,fee schedule,747.37,2081.46,APC
Elbow socket ins use w/o lck,L6695,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,747.37,,,,,,,fee schedule,747.37,2081.46,APC
Elbow socket ins use w/o lck,L6695,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1143.48,,,,,,,fee schedule,747.37,2081.46,Radiology
Elbow socket ins use w/o lck,L6695,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1046.32,,,,,,,fee schedule,747.37,2081.46,APC
Elbow socket ins use w/o lck,L6695,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1307.9,,,,,,,fee schedule,747.37,2081.46,APC
Cus elbo skt in for con/atyp,L6696,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4175.03,,,,,,,fee schedule,1628.34,4534.94,
Cus elbo skt in for con/atyp,L6696,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4534.94,,,,,,,fee schedule,1628.34,4534.94,
Cus elbo skt in for con/atyp,L6696,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3635.15,,,,,,,fee schedule,1628.34,4534.94,
Cus elbo skt in for con/atyp,L6696,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3971.07,,,,,,,fee schedule,1628.34,4534.94,
Cus elbo skt in for con/atyp,L6696,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1709.76,,,,,,,fee schedule,1628.34,4534.94,APC
Cus elbo skt in for con/atyp,L6696,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1693.47,,,,,,,fee schedule,1628.34,4534.94,APC
Cus elbo skt in for con/atyp,L6696,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1628.34,,,,,,,fee schedule,1628.34,4534.94,APC
Cus elbo skt in for con/atyp,L6696,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2491.36,,,,,,,fee schedule,1628.34,4534.94,Radiology
Cus elbo skt in for con/atyp,L6696,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2279.68,,,,,,,fee schedule,1628.34,4534.94,APC
Cus elbo skt in for con/atyp,L6696,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2849.6,,,,,,,fee schedule,1628.34,4534.94,APC
Cus elbo skt in not con/atyp,L6697,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4175.03,,,,,,,fee schedule,1628.34,4534.94,
Cus elbo skt in not con/atyp,L6697,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4534.94,,,,,,,fee schedule,1628.34,4534.94,
Cus elbo skt in not con/atyp,L6697,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3635.15,,,,,,,fee schedule,1628.34,4534.94,
Cus elbo skt in not con/atyp,L6697,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3971.07,,,,,,,fee schedule,1628.34,4534.94,
Cus elbo skt in not con/atyp,L6697,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1709.76,,,,,,,fee schedule,1628.34,4534.94,APC
Cus elbo skt in not con/atyp,L6697,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1693.47,,,,,,,fee schedule,1628.34,4534.94,APC
Cus elbo skt in not con/atyp,L6697,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1628.34,,,,,,,fee schedule,1628.34,4534.94,APC
Cus elbo skt in not con/atyp,L6697,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2491.36,,,,,,,fee schedule,1628.34,4534.94,Radiology
Cus elbo skt in not con/atyp,L6697,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2279.68,,,,,,,fee schedule,1628.34,4534.94,APC
Cus elbo skt in not con/atyp,L6697,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2849.6,,,,,,,fee schedule,1628.34,4534.94,APC
Below/above elbow lock mech,L6698,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1804.73,,,,,,,fee schedule,703.88,1960.31,
Below/above elbow lock mech,L6698,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1960.31,,,,,,,fee schedule,703.88,1960.31,
Below/above elbow lock mech,L6698,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1571.36,,,,,,,fee schedule,703.88,1960.31,
Below/above elbow lock mech,L6698,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1716.57,,,,,,,fee schedule,703.88,1960.31,
Below/above elbow lock mech,L6698,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,739.07,,,,,,,fee schedule,703.88,1960.31,APC
Below/above elbow lock mech,L6698,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,732.04,,,,,,,fee schedule,703.88,1960.31,APC
Below/above elbow lock mech,L6698,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,703.88,,,,,,,fee schedule,703.88,1960.31,APC
Below/above elbow lock mech,L6698,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1076.94,,,,,,,fee schedule,703.88,1960.31,Radiology
Below/above elbow lock mech,L6698,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,985.43,,,,,,,fee schedule,703.88,1960.31,APC
Below/above elbow lock mech,L6698,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1231.79,,,,,,,fee schedule,703.88,1960.31,APC
"Term dev, passive hand mitt",L6703,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1038.12,,,,,,,fee schedule,404.88,1127.61,
"Term dev, passive hand mitt",L6703,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1127.61,,,,,,,fee schedule,404.88,1127.61,
"Term dev, passive hand mitt",L6703,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,903.88,,,,,,,fee schedule,404.88,1127.61,
"Term dev, passive hand mitt",L6703,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,987.41,,,,,,,fee schedule,404.88,1127.61,
"Term dev, passive hand mitt",L6703,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,425.12,,,,,,,fee schedule,404.88,1127.61,APC
"Term dev, passive hand mitt",L6703,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,421.08,,,,,,,fee schedule,404.88,1127.61,APC
"Term dev, passive hand mitt",L6703,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,404.88,,,,,,,fee schedule,404.88,1127.61,APC
"Term dev, passive hand mitt",L6703,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,619.47,,,,,,,fee schedule,404.88,1127.61,Radiology
"Term dev, passive hand mitt",L6703,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,566.83,,,,,,,fee schedule,404.88,1127.61,APC
"Term dev, passive hand mitt",L6703,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,708.54,,,,,,,fee schedule,404.88,1127.61,APC
"Term dev, sport/rec/work att",L6704,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2434.47,,,,,,,fee schedule,949.5,2644.34,
"Term dev, sport/rec/work att",L6704,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2644.34,,,,,,,fee schedule,949.5,2644.34,
"Term dev, sport/rec/work att",L6704,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2119.67,,,,,,,fee schedule,949.5,2644.34,
"Term dev, sport/rec/work att",L6704,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2315.54,,,,,,,fee schedule,949.5,2644.34,
"Term dev, sport/rec/work att",L6704,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,996.98,,,,,,,fee schedule,949.5,2644.34,APC
"Term dev, sport/rec/work att",L6704,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,987.48,,,,,,,fee schedule,949.5,2644.34,APC
"Term dev, sport/rec/work att",L6704,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,949.5,,,,,,,fee schedule,949.5,2644.34,APC
"Term dev, sport/rec/work att",L6704,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1452.74,,,,,,,fee schedule,949.5,2644.34,Radiology
"Term dev, sport/rec/work att",L6704,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1329.3,,,,,,,fee schedule,949.5,2644.34,APC
"Term dev, sport/rec/work att",L6704,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1661.62,,,,,,,fee schedule,949.5,2644.34,APC
Term dev mech hook vol open,L6706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1263,,,,,,,fee schedule,492.59,1371.88,
Term dev mech hook vol open,L6706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1371.88,,,,,,,fee schedule,492.59,1371.88,
Term dev mech hook vol open,L6706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1099.68,,,,,,,fee schedule,492.59,1371.88,
Term dev mech hook vol open,L6706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1201.3,,,,,,,fee schedule,492.59,1371.88,
Term dev mech hook vol open,L6706,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,517.22,,,,,,,fee schedule,492.59,1371.88,APC
Term dev mech hook vol open,L6706,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,512.29,,,,,,,fee schedule,492.59,1371.88,APC
Term dev mech hook vol open,L6706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,492.59,,,,,,,fee schedule,492.59,1371.88,APC
Term dev mech hook vol open,L6706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,753.66,,,,,,,fee schedule,492.59,1371.88,Radiology
Term dev mech hook vol open,L6706,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,689.63,,,,,,,fee schedule,492.59,1371.88,APC
Term dev mech hook vol open,L6706,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,862.03,,,,,,,fee schedule,492.59,1371.88,APC
Term dev mech hook vol close,L6707,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4494.07,,,,,,,fee schedule,1752.8,4881.49,
Term dev mech hook vol close,L6707,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4881.49,,,,,,,fee schedule,1752.8,4881.49,
Term dev mech hook vol close,L6707,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3912.94,,,,,,,fee schedule,1752.8,4881.49,
Term dev mech hook vol close,L6707,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4274.53,,,,,,,fee schedule,1752.8,4881.49,
Term dev mech hook vol close,L6707,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1840.44,,,,,,,fee schedule,1752.8,4881.49,APC
Term dev mech hook vol close,L6707,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1822.91,,,,,,,fee schedule,1752.8,4881.49,APC
Term dev mech hook vol close,L6707,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1752.8,,,,,,,fee schedule,1752.8,4881.49,APC
Term dev mech hook vol close,L6707,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2681.78,,,,,,,fee schedule,1752.8,4881.49,Radiology
Term dev mech hook vol close,L6707,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2453.92,,,,,,,fee schedule,1752.8,4881.49,APC
Term dev mech hook vol close,L6707,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3067.4,,,,,,,fee schedule,1752.8,4881.49,APC
Term dev mech hand vol open,L6708,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3020.4,,,,,,,fee schedule,1178.02,3280.78,
Term dev mech hand vol open,L6708,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3280.78,,,,,,,fee schedule,1178.02,3280.78,
Term dev mech hand vol open,L6708,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2629.83,,,,,,,fee schedule,1178.02,3280.78,
Term dev mech hand vol open,L6708,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2872.85,,,,,,,fee schedule,1178.02,3280.78,
Term dev mech hand vol open,L6708,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1236.92,,,,,,,fee schedule,1178.02,3280.78,APC
Term dev mech hand vol open,L6708,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1225.14,,,,,,,fee schedule,1178.02,3280.78,APC
Term dev mech hand vol open,L6708,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1178.02,,,,,,,fee schedule,1178.02,3280.78,APC
Term dev mech hand vol open,L6708,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1802.37,,,,,,,fee schedule,1178.02,3280.78,Radiology
Term dev mech hand vol open,L6708,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1649.23,,,,,,,fee schedule,1178.02,3280.78,APC
Term dev mech hand vol open,L6708,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2061.54,,,,,,,fee schedule,1178.02,3280.78,APC
Term dev mech hand vol close,L6709,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4431.5,,,,,,,fee schedule,1728.38,4813.53,
Term dev mech hand vol close,L6709,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4813.53,,,,,,,fee schedule,1728.38,4813.53,
Term dev mech hand vol close,L6709,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3858.46,,,,,,,fee schedule,1728.38,4813.53,
Term dev mech hand vol close,L6709,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4215.02,,,,,,,fee schedule,1728.38,4813.53,
Term dev mech hand vol close,L6709,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1814.8,,,,,,,fee schedule,1728.38,4813.53,APC
Term dev mech hand vol close,L6709,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1797.52,,,,,,,fee schedule,1728.38,4813.53,APC
Term dev mech hand vol close,L6709,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1728.38,,,,,,,fee schedule,1728.38,4813.53,APC
Term dev mech hand vol close,L6709,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2644.42,,,,,,,fee schedule,1728.38,4813.53,Radiology
Term dev mech hand vol close,L6709,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2419.73,,,,,,,fee schedule,1728.38,4813.53,APC
Term dev mech hand vol close,L6709,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3024.66,,,,,,,fee schedule,1728.38,4813.53,APC
"Ped term dev, hook, vol open",L6711,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2133.9,,,,,,,fee schedule,832.27,2317.86,
"Ped term dev, hook, vol open",L6711,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2317.86,,,,,,,fee schedule,832.27,2317.86,
"Ped term dev, hook, vol open",L6711,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1857.97,,,,,,,fee schedule,832.27,2317.86,
"Ped term dev, hook, vol open",L6711,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2029.66,,,,,,,fee schedule,832.27,2317.86,
"Ped term dev, hook, vol open",L6711,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,873.88,,,,,,,fee schedule,832.27,2317.86,APC
"Ped term dev, hook, vol open",L6711,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,865.56,,,,,,,fee schedule,832.27,2317.86,APC
"Ped term dev, hook, vol open",L6711,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,832.27,,,,,,,fee schedule,832.27,2317.86,APC
"Ped term dev, hook, vol open",L6711,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1273.37,,,,,,,fee schedule,832.27,2317.86,Radiology
"Ped term dev, hook, vol open",L6711,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1165.18,,,,,,,fee schedule,832.27,2317.86,APC
"Ped term dev, hook, vol open",L6711,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1456.47,,,,,,,fee schedule,832.27,2317.86,APC
"Ped term dev, hook, vol clos",L6712,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3928.99,,,,,,,fee schedule,1532.4,4267.7,
"Ped term dev, hook, vol clos",L6712,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4267.7,,,,,,,fee schedule,1532.4,4267.7,
"Ped term dev, hook, vol clos",L6712,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3420.93,,,,,,,fee schedule,1532.4,4267.7,
"Ped term dev, hook, vol clos",L6712,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3737.06,,,,,,,fee schedule,1532.4,4267.7,
"Ped term dev, hook, vol clos",L6712,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1609.02,,,,,,,fee schedule,1532.4,4267.7,APC
"Ped term dev, hook, vol clos",L6712,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1593.7,,,,,,,fee schedule,1532.4,4267.7,APC
"Ped term dev, hook, vol clos",L6712,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1532.4,,,,,,,fee schedule,1532.4,4267.7,APC
"Ped term dev, hook, vol clos",L6712,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2344.57,,,,,,,fee schedule,1532.4,4267.7,Radiology
"Ped term dev, hook, vol clos",L6712,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2145.36,,,,,,,fee schedule,1532.4,4267.7,APC
"Ped term dev, hook, vol clos",L6712,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2681.7,,,,,,,fee schedule,1532.4,4267.7,APC
"Ped term dev, hand, vol open",L6713,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4958.72,,,,,,,fee schedule,1933.98,5386.2,
"Ped term dev, hand, vol open",L6713,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5386.2,,,,,,,fee schedule,1933.98,5386.2,
"Ped term dev, hand, vol open",L6713,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4317.51,,,,,,,fee schedule,1933.98,5386.2,
"Ped term dev, hand, vol open",L6713,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4716.49,,,,,,,fee schedule,1933.98,5386.2,
"Ped term dev, hand, vol open",L6713,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2030.68,,,,,,,fee schedule,1933.98,5386.2,APC
"Ped term dev, hand, vol open",L6713,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2011.34,,,,,,,fee schedule,1933.98,5386.2,APC
"Ped term dev, hand, vol open",L6713,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1933.98,,,,,,,fee schedule,1933.98,5386.2,APC
"Ped term dev, hand, vol open",L6713,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2958.99,,,,,,,fee schedule,1933.98,5386.2,Radiology
"Ped term dev, hand, vol open",L6713,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2707.57,,,,,,,fee schedule,1933.98,5386.2,APC
"Ped term dev, hand, vol open",L6713,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3384.46,,,,,,,fee schedule,1933.98,5386.2,APC
"Ped term dev, hand, vol clos",L6714,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4200.01,,,,,,,fee schedule,1638.09,4562.08,
"Ped term dev, hand, vol clos",L6714,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4562.08,,,,,,,fee schedule,1638.09,4562.08,
"Ped term dev, hand, vol clos",L6714,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3656.91,,,,,,,fee schedule,1638.09,4562.08,
"Ped term dev, hand, vol clos",L6714,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3994.84,,,,,,,fee schedule,1638.09,4562.08,
"Ped term dev, hand, vol clos",L6714,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1719.99,,,,,,,fee schedule,1638.09,4562.08,APC
"Ped term dev, hand, vol clos",L6714,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1703.61,,,,,,,fee schedule,1638.09,4562.08,APC
"Ped term dev, hand, vol clos",L6714,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1638.09,,,,,,,fee schedule,1638.09,4562.08,APC
"Ped term dev, hand, vol clos",L6714,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2506.28,,,,,,,fee schedule,1638.09,4562.08,Radiology
"Ped term dev, hand, vol clos",L6714,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2293.33,,,,,,,fee schedule,1638.09,4562.08,APC
"Ped term dev, hand, vol clos",L6714,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2866.66,,,,,,,fee schedule,1638.09,4562.08,APC
"Term device, multi art digit",L6715,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10332.96,,,,,,,fee schedule,3908.27,11223.73,
"Term device, multi art digit",L6715,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11223.73,,,,,,,fee schedule,3908.27,11223.73,
"Term device, multi art digit",L6715,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8996.8,,,,,,,fee schedule,3908.27,11223.73,
"Term device, multi art digit",L6715,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9828.18,,,,,,,fee schedule,3908.27,11223.73,
"Term device, multi art digit",L6715,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4103.68,,,,,,,fee schedule,3908.27,11223.73,APC
"Term device, multi art digit",L6715,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4064.6,,,,,,,fee schedule,3908.27,11223.73,APC
"Term device, multi art digit",L6715,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3908.27,,,,,,,fee schedule,3908.27,11223.73,APC
"Term device, multi art digit",L6715,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5979.65,,,,,,,fee schedule,3908.27,11223.73,Radiology
"Term device, multi art digit",L6715,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5471.58,,,,,,,fee schedule,3908.27,11223.73,APC
"Term device, multi art digit",L6715,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6839.47,,,,,,,fee schedule,3908.27,11223.73,APC
"Hook/hand, hvy dty, vol open",L6721,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7465.05,,,,,,,fee schedule,2911.54,8108.59,
"Hook/hand, hvy dty, vol open",L6721,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8108.59,,,,,,,fee schedule,2911.54,8108.59,
"Hook/hand, hvy dty, vol open",L6721,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6499.74,,,,,,,fee schedule,2911.54,8108.59,
"Hook/hand, hvy dty, vol open",L6721,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7100.38,,,,,,,fee schedule,2911.54,8108.59,
"Hook/hand, hvy dty, vol open",L6721,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3057.12,,,,,,,fee schedule,2911.54,8108.59,APC
"Hook/hand, hvy dty, vol open",L6721,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3028,,,,,,,fee schedule,2911.54,8108.59,APC
"Hook/hand, hvy dty, vol open",L6721,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2911.54,,,,,,,fee schedule,2911.54,8108.59,APC
"Hook/hand, hvy dty, vol open",L6721,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4454.66,,,,,,,fee schedule,2911.54,8108.59,Radiology
"Hook/hand, hvy dty, vol open",L6721,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4076.16,,,,,,,fee schedule,2911.54,8108.59,APC
"Hook/hand, hvy dty, vol open",L6721,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5095.2,,,,,,,fee schedule,2911.54,8108.59,APC
"Hook/hand, hvy dty, vol clos",L6722,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6435.39,,,,,,,fee schedule,2509.94,6990.17,
"Hook/hand, hvy dty, vol clos",L6722,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6990.17,,,,,,,fee schedule,2509.94,6990.17,
"Hook/hand, hvy dty, vol clos",L6722,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5603.23,,,,,,,fee schedule,2509.94,6990.17,
"Hook/hand, hvy dty, vol clos",L6722,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6121.02,,,,,,,fee schedule,2509.94,6990.17,
"Hook/hand, hvy dty, vol clos",L6722,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2635.44,,,,,,,fee schedule,2509.94,6990.17,APC
"Hook/hand, hvy dty, vol clos",L6722,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2610.34,,,,,,,fee schedule,2509.94,6990.17,APC
"Hook/hand, hvy dty, vol clos",L6722,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2509.94,,,,,,,fee schedule,2509.94,6990.17,APC
"Hook/hand, hvy dty, vol clos",L6722,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3840.21,,,,,,,fee schedule,2509.94,6990.17,Radiology
"Hook/hand, hvy dty, vol clos",L6722,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3513.92,,,,,,,fee schedule,2509.94,6990.17,APC
"Hook/hand, hvy dty, vol clos",L6722,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4392.4,,,,,,,fee schedule,2509.94,6990.17,APC
Term dev modifier wrist unit,L6805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1335.69,,,,,,,fee schedule,520.97,1450.84,
Term dev modifier wrist unit,L6805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1450.84,,,,,,,fee schedule,520.97,1450.84,
Term dev modifier wrist unit,L6805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1162.97,,,,,,,fee schedule,520.97,1450.84,
Term dev modifier wrist unit,L6805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1270.44,,,,,,,fee schedule,520.97,1450.84,
Term dev modifier wrist unit,L6805,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,547.02,,,,,,,fee schedule,520.97,1450.84,APC
Term dev modifier wrist unit,L6805,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,541.81,,,,,,,fee schedule,520.97,1450.84,APC
Term dev modifier wrist unit,L6805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,520.97,,,,,,,fee schedule,520.97,1450.84,APC
Term dev modifier wrist unit,L6805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,797.08,,,,,,,fee schedule,520.97,1450.84,Radiology
Term dev modifier wrist unit,L6805,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,729.36,,,,,,,fee schedule,520.97,1450.84,APC
Term dev modifier wrist unit,L6805,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,911.7,,,,,,,fee schedule,520.97,1450.84,APC
Term dev precision pinch dev,L6810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,780.7,,,,,,,fee schedule,304.48,848.01,
Term dev precision pinch dev,L6810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,848.01,,,,,,,fee schedule,304.48,848.01,
Term dev precision pinch dev,L6810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,679.75,,,,,,,fee schedule,304.48,848.01,
Term dev precision pinch dev,L6810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,742.57,,,,,,,fee schedule,304.48,848.01,
Term dev precision pinch dev,L6810,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,319.7,,,,,,,fee schedule,304.48,848.01,APC
Term dev precision pinch dev,L6810,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,316.66,,,,,,,fee schedule,304.48,848.01,APC
Term dev precision pinch dev,L6810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,304.48,,,,,,,fee schedule,304.48,848.01,APC
Term dev precision pinch dev,L6810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,465.85,,,,,,,fee schedule,304.48,848.01,Radiology
Term dev precision pinch dev,L6810,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,426.27,,,,,,,fee schedule,304.48,848.01,APC
Term dev precision pinch dev,L6810,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,532.84,,,,,,,fee schedule,304.48,848.01,APC
Elec hand ind art digits,L6880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,78196.89,,,,,,,fee schedule,29576.84,84938,
Elec hand ind art digits,L6880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,84938,,,,,,,fee schedule,29576.84,84938,
Elec hand ind art digits,L6880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,68085.22,,,,,,,fee schedule,29576.84,84938,
Elec hand ind art digits,L6880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,74376.92,,,,,,,fee schedule,29576.84,84938,
Elec hand ind art digits,L6880,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,31055.68,,,,,,,fee schedule,29576.84,84938,APC
Elec hand ind art digits,L6880,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,30759.91,,,,,,,fee schedule,29576.84,84938,APC
Elec hand ind art digits,L6880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,29576.84,,,,,,,fee schedule,29576.84,84938,APC
Elec hand ind art digits,L6880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,45252.57,,,,,,,fee schedule,29576.84,84938,Radiology
Elec hand ind art digits,L6880,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,41407.58,,,,,,,fee schedule,29576.84,84938,APC
Elec hand ind art digits,L6880,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,51759.47,,,,,,,fee schedule,29576.84,84938,APC
Term dev auto grasp feature,L6881,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12975.95,,,,,,,fee schedule,5060.9,14094.56,
Term dev auto grasp feature,L6881,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14094.56,,,,,,,fee schedule,5060.9,14094.56,
Term dev auto grasp feature,L6881,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11298.02,,,,,,,fee schedule,5060.9,14094.56,
Term dev auto grasp feature,L6881,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12342.06,,,,,,,fee schedule,5060.9,14094.56,
Term dev auto grasp feature,L6881,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5313.94,,,,,,,fee schedule,5060.9,14094.56,APC
Term dev auto grasp feature,L6881,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5263.34,,,,,,,fee schedule,5060.9,14094.56,APC
Term dev auto grasp feature,L6881,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5060.9,,,,,,,fee schedule,5060.9,14094.56,APC
Term dev auto grasp feature,L6881,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7743.18,,,,,,,fee schedule,5060.9,14094.56,Radiology
Term dev auto grasp feature,L6881,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7085.26,,,,,,,fee schedule,5060.9,14094.56,APC
Term dev auto grasp feature,L6881,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8856.57,,,,,,,fee schedule,5060.9,14094.56,APC
Microprocessor control uplmb,L6882,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9842.9,,,,,,,fee schedule,3838.95,10691.43,
Microprocessor control uplmb,L6882,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10691.43,,,,,,,fee schedule,3838.95,10691.43,
Microprocessor control uplmb,L6882,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8570.11,,,,,,,fee schedule,3838.95,10691.43,
Microprocessor control uplmb,L6882,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9362.07,,,,,,,fee schedule,3838.95,10691.43,
Microprocessor control uplmb,L6882,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4030.9,,,,,,,fee schedule,3838.95,10691.43,APC
Microprocessor control uplmb,L6882,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3992.51,,,,,,,fee schedule,3838.95,10691.43,APC
Microprocessor control uplmb,L6882,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3838.95,,,,,,,fee schedule,3838.95,10691.43,APC
Microprocessor control uplmb,L6882,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5873.59,,,,,,,fee schedule,3838.95,10691.43,Radiology
Microprocessor control uplmb,L6882,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5374.53,,,,,,,fee schedule,3838.95,10691.43,APC
Microprocessor control uplmb,L6882,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6718.16,,,,,,,fee schedule,3838.95,10691.43,APC
Replc sockt below e/w disa,L6883,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5857.19,,,,,,,fee schedule,2284.39,6362.12,
Replc sockt below e/w disa,L6883,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6362.12,,,,,,,fee schedule,2284.39,6362.12,
Replc sockt below e/w disa,L6883,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5099.79,,,,,,,fee schedule,2284.39,6362.12,
Replc sockt below e/w disa,L6883,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5571.06,,,,,,,fee schedule,2284.39,6362.12,
Replc sockt below e/w disa,L6883,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2398.61,,,,,,,fee schedule,2284.39,6362.12,APC
Replc sockt below e/w disa,L6883,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2375.77,,,,,,,fee schedule,2284.39,6362.12,APC
Replc sockt below e/w disa,L6883,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2284.39,,,,,,,fee schedule,2284.39,6362.12,APC
Replc sockt below e/w disa,L6883,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3495.12,,,,,,,fee schedule,2284.39,6362.12,Radiology
Replc sockt below e/w disa,L6883,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3198.15,,,,,,,fee schedule,2284.39,6362.12,APC
Replc sockt below e/w disa,L6883,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3997.68,,,,,,,fee schedule,2284.39,6362.12,APC
Replc sockt above elbow disa,L6884,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8790.45,,,,,,,fee schedule,3428.45,9548.24,
Replc sockt above elbow disa,L6884,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9548.24,,,,,,,fee schedule,3428.45,9548.24,
Replc sockt above elbow disa,L6884,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7653.75,,,,,,,fee schedule,3428.45,9548.24,
Replc sockt above elbow disa,L6884,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8361.03,,,,,,,fee schedule,3428.45,9548.24,
Replc sockt above elbow disa,L6884,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3599.87,,,,,,,fee schedule,3428.45,9548.24,APC
Replc sockt above elbow disa,L6884,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3565.59,,,,,,,fee schedule,3428.45,9548.24,APC
Replc sockt above elbow disa,L6884,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3428.45,,,,,,,fee schedule,3428.45,9548.24,APC
Replc sockt above elbow disa,L6884,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5245.53,,,,,,,fee schedule,3428.45,9548.24,Radiology
Replc sockt above elbow disa,L6884,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4799.83,,,,,,,fee schedule,3428.45,9548.24,APC
Replc sockt above elbow disa,L6884,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5999.79,,,,,,,fee schedule,3428.45,9548.24,APC
Replc sockt shldr dis/interc,L6885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9998.04,,,,,,,fee schedule,3899.44,10859.94,
Replc sockt shldr dis/interc,L6885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10859.94,,,,,,,fee schedule,3899.44,10859.94,
Replc sockt shldr dis/interc,L6885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8705.19,,,,,,,fee schedule,3899.44,10859.94,
Replc sockt shldr dis/interc,L6885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9509.63,,,,,,,fee schedule,3899.44,10859.94,
Replc sockt shldr dis/interc,L6885,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4094.41,,,,,,,fee schedule,3899.44,10859.94,APC
Replc sockt shldr dis/interc,L6885,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4055.42,,,,,,,fee schedule,3899.44,10859.94,APC
Replc sockt shldr dis/interc,L6885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3899.44,,,,,,,fee schedule,3899.44,10859.94,APC
Replc sockt shldr dis/interc,L6885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5966.14,,,,,,,fee schedule,3899.44,10859.94,Radiology
Replc sockt shldr dis/interc,L6885,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5459.22,,,,,,,fee schedule,3899.44,10859.94,APC
Replc sockt shldr dis/interc,L6885,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6824.02,,,,,,,fee schedule,3899.44,10859.94,APC
Prefab glove for term device,L6890,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,578.65,,,,,,,fee schedule,225.71,628.54,
Prefab glove for term device,L6890,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,628.54,,,,,,,fee schedule,225.71,628.54,
Prefab glove for term device,L6890,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,503.83,,,,,,,fee schedule,225.71,628.54,
Prefab glove for term device,L6890,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,550.39,,,,,,,fee schedule,225.71,628.54,
Prefab glove for term device,L6890,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,237,,,,,,,fee schedule,225.71,628.54,APC
Prefab glove for term device,L6890,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,234.74,,,,,,,fee schedule,225.71,628.54,APC
Prefab glove for term device,L6890,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,225.71,,,,,,,fee schedule,225.71,628.54,APC
Prefab glove for term device,L6890,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,345.34,,,,,,,fee schedule,225.71,628.54,Radiology
Prefab glove for term device,L6890,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,315.99,,,,,,,fee schedule,225.71,628.54,APC
Prefab glove for term device,L6890,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,394.99,,,,,,,fee schedule,225.71,628.54,APC
Custom glove for term device,L6895,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1752.74,,,,,,,fee schedule,683.61,1903.83,
Custom glove for term device,L6895,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1903.83,,,,,,,fee schedule,683.61,1903.83,
Custom glove for term device,L6895,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1526.09,,,,,,,fee schedule,683.61,1903.83,
Custom glove for term device,L6895,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1667.11,,,,,,,fee schedule,683.61,1903.83,
Custom glove for term device,L6895,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,717.79,,,,,,,fee schedule,683.61,1903.83,APC
Custom glove for term device,L6895,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,710.95,,,,,,,fee schedule,683.61,1903.83,APC
Custom glove for term device,L6895,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,683.61,,,,,,,fee schedule,683.61,1903.83,APC
Custom glove for term device,L6895,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1045.92,,,,,,,fee schedule,683.61,1903.83,Radiology
Custom glove for term device,L6895,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,957.05,,,,,,,fee schedule,683.61,1903.83,APC
Custom glove for term device,L6895,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1196.32,,,,,,,fee schedule,683.61,1903.83,APC
Hand restorat thumb/1 finger,L6900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4853.28,,,,,,,fee schedule,1892.87,5271.66,
Hand restorat thumb/1 finger,L6900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5271.66,,,,,,,fee schedule,1892.87,5271.66,
Hand restorat thumb/1 finger,L6900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4225.7,,,,,,,fee schedule,1892.87,5271.66,
Hand restorat thumb/1 finger,L6900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4616.19,,,,,,,fee schedule,1892.87,5271.66,
Hand restorat thumb/1 finger,L6900,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1987.51,,,,,,,fee schedule,1892.87,5271.66,APC
Hand restorat thumb/1 finger,L6900,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1968.58,,,,,,,fee schedule,1892.87,5271.66,APC
Hand restorat thumb/1 finger,L6900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1892.87,,,,,,,fee schedule,1892.87,5271.66,APC
Hand restorat thumb/1 finger,L6900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2896.09,,,,,,,fee schedule,1892.87,5271.66,Radiology
Hand restorat thumb/1 finger,L6900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2650.02,,,,,,,fee schedule,1892.87,5271.66,APC
Hand restorat thumb/1 finger,L6900,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3312.52,,,,,,,fee schedule,1892.87,5271.66,APC
Hand restoration multiple fi,L6905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4608.6,,,,,,,fee schedule,1797.45,5005.89,
Hand restoration multiple fi,L6905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5005.89,,,,,,,fee schedule,1797.45,5005.89,
Hand restoration multiple fi,L6905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4012.66,,,,,,,fee schedule,1797.45,5005.89,
Hand restoration multiple fi,L6905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4383.47,,,,,,,fee schedule,1797.45,5005.89,
Hand restoration multiple fi,L6905,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1887.32,,,,,,,fee schedule,1797.45,5005.89,APC
Hand restoration multiple fi,L6905,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1869.35,,,,,,,fee schedule,1797.45,5005.89,APC
Hand restoration multiple fi,L6905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1797.45,,,,,,,fee schedule,1797.45,5005.89,APC
Hand restoration multiple fi,L6905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2750.1,,,,,,,fee schedule,1797.45,5005.89,Radiology
Hand restoration multiple fi,L6905,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2516.43,,,,,,,fee schedule,1797.45,5005.89,APC
Hand restoration multiple fi,L6905,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3145.54,,,,,,,fee schedule,1797.45,5005.89,APC
Hand restoration no fingers,L6910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4541.37,,,,,,,fee schedule,1771.25,4932.86,
Hand restoration no fingers,L6910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4932.86,,,,,,,fee schedule,1771.25,4932.86,
Hand restoration no fingers,L6910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3954.12,,,,,,,fee schedule,1771.25,4932.86,
Hand restoration no fingers,L6910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4319.52,,,,,,,fee schedule,1771.25,4932.86,
Hand restoration no fingers,L6910,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1859.81,,,,,,,fee schedule,1771.25,4932.86,APC
Hand restoration no fingers,L6910,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1842.1,,,,,,,fee schedule,1771.25,4932.86,APC
Hand restoration no fingers,L6910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1771.25,,,,,,,fee schedule,1771.25,4932.86,APC
Hand restoration no fingers,L6910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2710.01,,,,,,,fee schedule,1771.25,4932.86,Radiology
Hand restoration no fingers,L6910,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2479.75,,,,,,,fee schedule,1771.25,4932.86,APC
Hand restoration no fingers,L6910,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3099.69,,,,,,,fee schedule,1771.25,4932.86,APC
Hand restoration replacmnt g,L6915,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1965.05,,,,,,,fee schedule,766.41,2134.45,
Hand restoration replacmnt g,L6915,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2134.45,,,,,,,fee schedule,766.41,2134.45,
Hand restoration replacmnt g,L6915,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1710.95,,,,,,,fee schedule,766.41,2134.45,
Hand restoration replacmnt g,L6915,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1869.06,,,,,,,fee schedule,766.41,2134.45,
Hand restoration replacmnt g,L6915,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,804.73,,,,,,,fee schedule,766.41,2134.45,APC
Hand restoration replacmnt g,L6915,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,797.07,,,,,,,fee schedule,766.41,2134.45,APC
Hand restoration replacmnt g,L6915,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,766.41,,,,,,,fee schedule,766.41,2134.45,APC
Hand restoration replacmnt g,L6915,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1172.61,,,,,,,fee schedule,766.41,2134.45,Radiology
Hand restoration replacmnt g,L6915,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1072.97,,,,,,,fee schedule,766.41,2134.45,APC
Hand restoration replacmnt g,L6915,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1341.22,,,,,,,fee schedule,766.41,2134.45,APC
Wrist disarticul switch ctrl,L6920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23002.31,,,,,,,fee schedule,8971.39,24985.27,
Wrist disarticul switch ctrl,L6920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24985.27,,,,,,,fee schedule,8971.39,24985.27,
Wrist disarticul switch ctrl,L6920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20027.88,,,,,,,fee schedule,8971.39,24985.27,
Wrist disarticul switch ctrl,L6920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21878.64,,,,,,,fee schedule,8971.39,24985.27,
Wrist disarticul switch ctrl,L6920,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9419.96,,,,,,,fee schedule,8971.39,24985.27,APC
Wrist disarticul switch ctrl,L6920,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9330.25,,,,,,,fee schedule,8971.39,24985.27,APC
Wrist disarticul switch ctrl,L6920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8971.39,,,,,,,fee schedule,8971.39,24985.27,APC
Wrist disarticul switch ctrl,L6920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13726.23,,,,,,,fee schedule,8971.39,24985.27,Radiology
Wrist disarticul switch ctrl,L6920,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12559.95,,,,,,,fee schedule,8971.39,24985.27,APC
Wrist disarticul switch ctrl,L6920,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15699.93,,,,,,,fee schedule,8971.39,24985.27,APC
Wrist disart myoelectronic c,L6925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24288.45,,,,,,,fee schedule,9473.02,26382.28,
Wrist disart myoelectronic c,L6925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26382.28,,,,,,,fee schedule,9473.02,26382.28,
Wrist disart myoelectronic c,L6925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21147.7,,,,,,,fee schedule,9473.02,26382.28,
Wrist disart myoelectronic c,L6925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23101.95,,,,,,,fee schedule,9473.02,26382.28,
Wrist disart myoelectronic c,L6925,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9946.67,,,,,,,fee schedule,9473.02,26382.28,APC
Wrist disart myoelectronic c,L6925,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9851.94,,,,,,,fee schedule,9473.02,26382.28,APC
Wrist disart myoelectronic c,L6925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9473.02,,,,,,,fee schedule,9473.02,26382.28,APC
Wrist disart myoelectronic c,L6925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14493.72,,,,,,,fee schedule,9473.02,26382.28,Radiology
Wrist disart myoelectronic c,L6925,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13262.23,,,,,,,fee schedule,9473.02,26382.28,APC
Wrist disart myoelectronic c,L6925,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16577.78,,,,,,,fee schedule,9473.02,26382.28,APC
Below elbow switch control,L6930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24695.68,,,,,,,fee schedule,9631.82,26824.62,
Below elbow switch control,L6930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26824.62,,,,,,,fee schedule,9631.82,26824.62,
Below elbow switch control,L6930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21502.27,,,,,,,fee schedule,9631.82,26824.62,
Below elbow switch control,L6930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23489.28,,,,,,,fee schedule,9631.82,26824.62,
Below elbow switch control,L6930,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10113.41,,,,,,,fee schedule,9631.82,26824.62,APC
Below elbow switch control,L6930,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10017.09,,,,,,,fee schedule,9631.82,26824.62,APC
Below elbow switch control,L6930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9631.82,,,,,,,fee schedule,9631.82,26824.62,APC
Below elbow switch control,L6930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14736.68,,,,,,,fee schedule,9631.82,26824.62,Radiology
Below elbow switch control,L6930,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13484.55,,,,,,,fee schedule,9631.82,26824.62,APC
Below elbow switch control,L6930,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16855.68,,,,,,,fee schedule,9631.82,26824.62,APC
Below elbow myoelectronic ct,L6935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27164.98,,,,,,,fee schedule,10594.92,29506.79,
Below elbow myoelectronic ct,L6935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,29506.79,,,,,,,fee schedule,10594.92,29506.79,
Below elbow myoelectronic ct,L6935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23652.27,,,,,,,fee schedule,10594.92,29506.79,
Below elbow myoelectronic ct,L6935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,25837.96,,,,,,,fee schedule,10594.92,29506.79,
Below elbow myoelectronic ct,L6935,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11124.67,,,,,,,fee schedule,10594.92,29506.79,APC
Below elbow myoelectronic ct,L6935,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11018.72,,,,,,,fee schedule,10594.92,29506.79,APC
Below elbow myoelectronic ct,L6935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10594.92,,,,,,,fee schedule,10594.92,29506.79,APC
Below elbow myoelectronic ct,L6935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16210.23,,,,,,,fee schedule,10594.92,29506.79,Radiology
Below elbow myoelectronic ct,L6935,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14832.89,,,,,,,fee schedule,10594.92,29506.79,APC
Below elbow myoelectronic ct,L6935,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18541.11,,,,,,,fee schedule,10594.92,29506.79,APC
Elbow disarticulation switch,L6940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30864.26,,,,,,,fee schedule,12037.72,33524.97,
Elbow disarticulation switch,L6940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33524.97,,,,,,,fee schedule,12037.72,33524.97,
Elbow disarticulation switch,L6940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26873.19,,,,,,,fee schedule,12037.72,33524.97,
Elbow disarticulation switch,L6940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29356.52,,,,,,,fee schedule,12037.72,33524.97,
Elbow disarticulation switch,L6940,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12639.61,,,,,,,fee schedule,12037.72,33524.97,APC
Elbow disarticulation switch,L6940,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12519.23,,,,,,,fee schedule,12037.72,33524.97,APC
Elbow disarticulation switch,L6940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12037.72,,,,,,,fee schedule,12037.72,33524.97,APC
Elbow disarticulation switch,L6940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18417.71,,,,,,,fee schedule,12037.72,33524.97,Radiology
Elbow disarticulation switch,L6940,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16852.81,,,,,,,fee schedule,12037.72,33524.97,APC
Elbow disarticulation switch,L6940,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21066.01,,,,,,,fee schedule,12037.72,33524.97,APC
Elbow disart myoelectronic c,L6945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,34914.67,,,,,,,fee schedule,13617.48,37924.55,
Elbow disart myoelectronic c,L6945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37924.55,,,,,,,fee schedule,13617.48,37924.55,
Elbow disart myoelectronic c,L6945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,30399.84,,,,,,,fee schedule,13617.48,37924.55,
Elbow disart myoelectronic c,L6945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,33209.06,,,,,,,fee schedule,13617.48,37924.55,
Elbow disart myoelectronic c,L6945,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14298.35,,,,,,,fee schedule,13617.48,37924.55,APC
Elbow disart myoelectronic c,L6945,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,14162.18,,,,,,,fee schedule,13617.48,37924.55,APC
Elbow disart myoelectronic c,L6945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13617.48,,,,,,,fee schedule,13617.48,37924.55,APC
Elbow disart myoelectronic c,L6945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20834.74,,,,,,,fee schedule,13617.48,37924.55,Radiology
Elbow disart myoelectronic c,L6945,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19064.47,,,,,,,fee schedule,13617.48,37924.55,APC
Elbow disart myoelectronic c,L6945,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23830.59,,,,,,,fee schedule,13617.48,37924.55,APC
Above elbow switch control,L6950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,32814.63,,,,,,,fee schedule,12798.41,35643.47,
Above elbow switch control,L6950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,35643.47,,,,,,,fee schedule,12798.41,35643.47,
Above elbow switch control,L6950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28571.35,,,,,,,fee schedule,12798.41,35643.47,
Above elbow switch control,L6950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31211.61,,,,,,,fee schedule,12798.41,35643.47,
Above elbow switch control,L6950,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13438.33,,,,,,,fee schedule,12798.41,35643.47,APC
Above elbow switch control,L6950,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13310.35,,,,,,,fee schedule,12798.41,35643.47,APC
Above elbow switch control,L6950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12798.41,,,,,,,fee schedule,12798.41,35643.47,APC
Above elbow switch control,L6950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19581.57,,,,,,,fee schedule,12798.41,35643.47,Radiology
Above elbow switch control,L6950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17917.77,,,,,,,fee schedule,12798.41,35643.47,APC
Above elbow switch control,L6950,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22397.22,,,,,,,fee schedule,12798.41,35643.47,APC
Above elbow myoelectronic ct,L6955,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41177.76,,,,,,,fee schedule,16060.21,44727.57,
Above elbow myoelectronic ct,L6955,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,44727.57,,,,,,,fee schedule,16060.21,44727.57,
Above elbow myoelectronic ct,L6955,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35853.05,,,,,,,fee schedule,16060.21,44727.57,
Above elbow myoelectronic ct,L6955,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39166.2,,,,,,,fee schedule,16060.21,44727.57,
Above elbow myoelectronic ct,L6955,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16863.22,,,,,,,fee schedule,16060.21,44727.57,APC
Above elbow myoelectronic ct,L6955,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,16702.62,,,,,,,fee schedule,16060.21,44727.57,APC
Above elbow myoelectronic ct,L6955,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16060.21,,,,,,,fee schedule,16060.21,44727.57,APC
Above elbow myoelectronic ct,L6955,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24572.12,,,,,,,fee schedule,16060.21,44727.57,Radiology
Above elbow myoelectronic ct,L6955,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22484.29,,,,,,,fee schedule,16060.21,44727.57,APC
Above elbow myoelectronic ct,L6955,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,28105.37,,,,,,,fee schedule,16060.21,44727.57,APC
Shldr disartic switch contro,L6960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,40603.35,,,,,,,fee schedule,15836.16,44103.64,
Shldr disartic switch contro,L6960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,44103.64,,,,,,,fee schedule,15836.16,44103.64,
Shldr disartic switch contro,L6960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35352.92,,,,,,,fee schedule,15836.16,44103.64,
Shldr disartic switch contro,L6960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38619.86,,,,,,,fee schedule,15836.16,44103.64,
Shldr disartic switch contro,L6960,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16627.97,,,,,,,fee schedule,15836.16,44103.64,APC
Shldr disartic switch contro,L6960,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,16469.61,,,,,,,fee schedule,15836.16,44103.64,APC
Shldr disartic switch contro,L6960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,15836.16,,,,,,,fee schedule,15836.16,44103.64,APC
Shldr disartic switch contro,L6960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24229.32,,,,,,,fee schedule,15836.16,44103.64,Radiology
Shldr disartic switch contro,L6960,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22170.62,,,,,,,fee schedule,15836.16,44103.64,APC
Shldr disartic switch contro,L6960,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,27713.28,,,,,,,fee schedule,15836.16,44103.64,APC
Shldr disartic myoelectronic,L6965,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59315.66,,,,,,,fee schedule,23134.38,64429.08,
Shldr disartic myoelectronic,L6965,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,64429.08,,,,,,,fee schedule,23134.38,64429.08,
Shldr disartic myoelectronic,L6965,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51645.53,,,,,,,fee schedule,23134.38,64429.08,
Shldr disartic myoelectronic,L6965,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56418.06,,,,,,,fee schedule,23134.38,64429.08,
Shldr disartic myoelectronic,L6965,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,24291.1,,,,,,,fee schedule,23134.38,64429.08,APC
Shldr disartic myoelectronic,L6965,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,24059.76,,,,,,,fee schedule,23134.38,64429.08,APC
Shldr disartic myoelectronic,L6965,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,23134.38,,,,,,,fee schedule,23134.38,64429.08,APC
Shldr disartic myoelectronic,L6965,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,35395.6,,,,,,,fee schedule,23134.38,64429.08,Radiology
Shldr disartic myoelectronic,L6965,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,32388.13,,,,,,,fee schedule,23134.38,64429.08,APC
Shldr disartic myoelectronic,L6965,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,40485.16,,,,,,,fee schedule,23134.38,64429.08,APC
Interscapular-thor switch ct,L6970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60290.34,,,,,,,fee schedule,23514.53,65487.78,
Interscapular-thor switch ct,L6970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,65487.78,,,,,,,fee schedule,23514.53,65487.78,
Interscapular-thor switch ct,L6970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52494.17,,,,,,,fee schedule,23514.53,65487.78,
Interscapular-thor switch ct,L6970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57345.12,,,,,,,fee schedule,23514.53,65487.78,
Interscapular-thor switch ct,L6970,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,24690.26,,,,,,,fee schedule,23514.53,65487.78,APC
Interscapular-thor switch ct,L6970,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,24455.11,,,,,,,fee schedule,23514.53,65487.78,APC
Interscapular-thor switch ct,L6970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,23514.53,,,,,,,fee schedule,23514.53,65487.78,APC
Interscapular-thor switch ct,L6970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,35977.23,,,,,,,fee schedule,23514.53,65487.78,Radiology
Interscapular-thor switch ct,L6970,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,32920.34,,,,,,,fee schedule,23514.53,65487.78,APC
Interscapular-thor switch ct,L6970,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,41150.43,,,,,,,fee schedule,23514.53,65487.78,APC
Interscap-thor myoelectronic,L6975,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60613.94,,,,,,,fee schedule,23640.73,65839.28,
Interscap-thor myoelectronic,L6975,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,65839.28,,,,,,,fee schedule,23640.73,65839.28,
Interscap-thor myoelectronic,L6975,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52775.93,,,,,,,fee schedule,23640.73,65839.28,
Interscap-thor myoelectronic,L6975,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57652.92,,,,,,,fee schedule,23640.73,65839.28,
Interscap-thor myoelectronic,L6975,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,24822.77,,,,,,,fee schedule,23640.73,65839.28,APC
Interscap-thor myoelectronic,L6975,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,24586.36,,,,,,,fee schedule,23640.73,65839.28,APC
Interscap-thor myoelectronic,L6975,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,23640.73,,,,,,,fee schedule,23640.73,65839.28,APC
Interscap-thor myoelectronic,L6975,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,36170.32,,,,,,,fee schedule,23640.73,65839.28,Radiology
Interscap-thor myoelectronic,L6975,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,33097.02,,,,,,,fee schedule,23640.73,65839.28,APC
Interscap-thor myoelectronic,L6975,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,41371.28,,,,,,,fee schedule,23640.73,65839.28,APC
Adult electric hand,L7007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14401.67,,,,,,,fee schedule,5616.95,15643.19,
Adult electric hand,L7007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15643.19,,,,,,,fee schedule,5616.95,15643.19,
Adult electric hand,L7007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12539.38,,,,,,,fee schedule,5616.95,15643.19,
Adult electric hand,L7007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13698.14,,,,,,,fee schedule,5616.95,15643.19,
Adult electric hand,L7007,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5897.8,,,,,,,fee schedule,5616.95,15643.19,APC
Adult electric hand,L7007,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5841.63,,,,,,,fee schedule,5616.95,15643.19,APC
Adult electric hand,L7007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5616.95,,,,,,,fee schedule,5616.95,15643.19,APC
Adult electric hand,L7007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8593.93,,,,,,,fee schedule,5616.95,15643.19,Radiology
Adult electric hand,L7007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7863.73,,,,,,,fee schedule,5616.95,15643.19,APC
Adult electric hand,L7007,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9829.66,,,,,,,fee schedule,5616.95,15643.19,APC
Pediatric electric hand,L7008,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22666.67,,,,,,,fee schedule,8840.49,24620.69,
Pediatric electric hand,L7008,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24620.69,,,,,,,fee schedule,8840.49,24620.69,
Pediatric electric hand,L7008,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19735.63,,,,,,,fee schedule,8840.49,24620.69,
Pediatric electric hand,L7008,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21559.39,,,,,,,fee schedule,8840.49,24620.69,
Pediatric electric hand,L7008,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9282.51,,,,,,,fee schedule,8840.49,24620.69,APC
Pediatric electric hand,L7008,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9194.11,,,,,,,fee schedule,8840.49,24620.69,APC
Pediatric electric hand,L7008,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8840.49,,,,,,,fee schedule,8840.49,24620.69,APC
Pediatric electric hand,L7008,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13525.95,,,,,,,fee schedule,8840.49,24620.69,Radiology
Pediatric electric hand,L7008,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12376.69,,,,,,,fee schedule,8840.49,24620.69,APC
Pediatric electric hand,L7008,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15470.86,,,,,,,fee schedule,8840.49,24620.69,APC
Adult electric hook,L7009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14694.23,,,,,,,fee schedule,5731.07,15960.97,
Adult electric hook,L7009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15960.97,,,,,,,fee schedule,5731.07,15960.97,
Adult electric hook,L7009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12794.11,,,,,,,fee schedule,5731.07,15960.97,
Adult electric hook,L7009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13976.41,,,,,,,fee schedule,5731.07,15960.97,
Adult electric hook,L7009,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6017.62,,,,,,,fee schedule,5731.07,15960.97,APC
Adult electric hook,L7009,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5960.31,,,,,,,fee schedule,5731.07,15960.97,APC
Adult electric hook,L7009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5731.07,,,,,,,fee schedule,5731.07,15960.97,APC
Adult electric hook,L7009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8768.54,,,,,,,fee schedule,5731.07,15960.97,Radiology
Adult electric hook,L7009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8023.5,,,,,,,fee schedule,5731.07,15960.97,APC
Adult electric hook,L7009,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10029.37,,,,,,,fee schedule,5731.07,15960.97,APC
Prehensile actuator,L7040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11798.91,,,,,,,fee schedule,4601.82,12816.05,
Prehensile actuator,L7040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12816.05,,,,,,,fee schedule,4601.82,12816.05,
Prehensile actuator,L7040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10273.18,,,,,,,fee schedule,4601.82,12816.05,
Prehensile actuator,L7040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11222.52,,,,,,,fee schedule,4601.82,12816.05,
Prehensile actuator,L7040,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4831.91,,,,,,,fee schedule,4601.82,12816.05,APC
Prehensile actuator,L7040,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4785.89,,,,,,,fee schedule,4601.82,12816.05,APC
Prehensile actuator,L7040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4601.82,,,,,,,fee schedule,4601.82,12816.05,APC
Prehensile actuator,L7040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7040.78,,,,,,,fee schedule,4601.82,12816.05,Radiology
Prehensile actuator,L7040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6442.55,,,,,,,fee schedule,4601.82,12816.05,APC
Prehensile actuator,L7040,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8053.18,,,,,,,fee schedule,4601.82,12816.05,APC
Pediatric electric hook,L7045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6764.74,,,,,,,fee schedule,2638.38,7347.9,
Pediatric electric hook,L7045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7347.9,,,,,,,fee schedule,2638.38,7347.9,
Pediatric electric hook,L7045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5889.99,,,,,,,fee schedule,2638.38,7347.9,
Pediatric electric hook,L7045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6434.28,,,,,,,fee schedule,2638.38,7347.9,
Pediatric electric hook,L7045,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2770.3,,,,,,,fee schedule,2638.38,7347.9,APC
Pediatric electric hook,L7045,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2743.92,,,,,,,fee schedule,2638.38,7347.9,APC
Pediatric electric hook,L7045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2638.38,,,,,,,fee schedule,2638.38,7347.9,APC
Pediatric electric hook,L7045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4036.72,,,,,,,fee schedule,2638.38,7347.9,Radiology
Pediatric electric hook,L7045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3693.73,,,,,,,fee schedule,2638.38,7347.9,APC
Pediatric electric hook,L7045,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4617.16,,,,,,,fee schedule,2638.38,7347.9,APC
Electronic elbow hosmer swit,L7170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24540.12,,,,,,,fee schedule,9571.18,26655.65,
Electronic elbow hosmer swit,L7170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26655.65,,,,,,,fee schedule,9571.18,26655.65,
Electronic elbow hosmer swit,L7170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21366.83,,,,,,,fee schedule,9571.18,26655.65,
Electronic elbow hosmer swit,L7170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23341.33,,,,,,,fee schedule,9571.18,26655.65,
Electronic elbow hosmer swit,L7170,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10049.74,,,,,,,fee schedule,9571.18,26655.65,APC
Electronic elbow hosmer swit,L7170,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9954.03,,,,,,,fee schedule,9571.18,26655.65,APC
Electronic elbow hosmer swit,L7170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9571.18,,,,,,,fee schedule,9571.18,26655.65,APC
Electronic elbow hosmer swit,L7170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14643.91,,,,,,,fee schedule,9571.18,26655.65,Radiology
Electronic elbow hosmer swit,L7170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13399.65,,,,,,,fee schedule,9571.18,26655.65,APC
Electronic elbow hosmer swit,L7170,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16749.57,,,,,,,fee schedule,9571.18,26655.65,APC
Electronic elbow sequential,L7180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,128216.46,,,,,,,fee schedule,50007.15,139269.6,
Electronic elbow sequential,L7180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,139269.6,,,,,,,fee schedule,50007.15,139269.6,
Electronic elbow sequential,L7180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,111636.74,,,,,,,fee schedule,50007.15,139269.6,
Electronic elbow sequential,L7180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,121953.01,,,,,,,fee schedule,50007.15,139269.6,
Electronic elbow sequential,L7180,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,52507.51,,,,,,,fee schedule,50007.15,139269.6,APC
Electronic elbow sequential,L7180,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,52007.44,,,,,,,fee schedule,50007.15,139269.6,APC
Electronic elbow sequential,L7180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,50007.15,,,,,,,fee schedule,50007.15,139269.6,APC
Electronic elbow sequential,L7180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,76510.94,,,,,,,fee schedule,50007.15,139269.6,Radiology
Electronic elbow sequential,L7180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,70010.01,,,,,,,fee schedule,50007.15,139269.6,APC
Electronic elbow sequential,L7180,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,87512.51,,,,,,,fee schedule,50007.15,139269.6,APC
Electronic elbo simultaneous,L7181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,127174.69,,,,,,,fee schedule,49600.83,138138.02,
Electronic elbo simultaneous,L7181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,138138.02,,,,,,,fee schedule,49600.83,138138.02,
Electronic elbo simultaneous,L7181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,110729.68,,,,,,,fee schedule,49600.83,138138.02,
Electronic elbo simultaneous,L7181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,120962.13,,,,,,,fee schedule,49600.83,138138.02,
Electronic elbo simultaneous,L7181,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,52080.87,,,,,,,fee schedule,49600.83,138138.02,APC
Electronic elbo simultaneous,L7181,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,51584.86,,,,,,,fee schedule,49600.83,138138.02,APC
Electronic elbo simultaneous,L7181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,49600.83,,,,,,,fee schedule,49600.83,138138.02,APC
Electronic elbo simultaneous,L7181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,75889.27,,,,,,,fee schedule,49600.83,138138.02,Radiology
Electronic elbo simultaneous,L7181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,69441.16,,,,,,,fee schedule,49600.83,138138.02,APC
Electronic elbo simultaneous,L7181,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,86801.45,,,,,,,fee schedule,49600.83,138138.02,APC
Electron elbow adolescent sw,L7185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24850.16,,,,,,,fee schedule,9692.1,26992.41,
Electron elbow adolescent sw,L7185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26992.41,,,,,,,fee schedule,9692.1,26992.41,
Electron elbow adolescent sw,L7185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21636.78,,,,,,,fee schedule,9692.1,26992.41,
Electron elbow adolescent sw,L7185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23636.21,,,,,,,fee schedule,9692.1,26992.41,
Electron elbow adolescent sw,L7185,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10176.7,,,,,,,fee schedule,9692.1,26992.41,APC
Electron elbow adolescent sw,L7185,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10079.78,,,,,,,fee schedule,9692.1,26992.41,APC
Electron elbow adolescent sw,L7185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9692.1,,,,,,,fee schedule,9692.1,26992.41,APC
Electron elbow adolescent sw,L7185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14828.91,,,,,,,fee schedule,9692.1,26992.41,Radiology
Electron elbow adolescent sw,L7185,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13568.94,,,,,,,fee schedule,9692.1,26992.41,APC
Electron elbow adolescent sw,L7185,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16961.18,,,,,,,fee schedule,9692.1,26992.41,APC
Electron elbow child switch,L7186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,35864.85,,,,,,,fee schedule,13988.06,38956.64,
Electron elbow child switch,L7186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,38956.64,,,,,,,fee schedule,13988.06,38956.64,
Electron elbow child switch,L7186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31227.15,,,,,,,fee schedule,13988.06,38956.64,
Electron elbow child switch,L7186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,34112.83,,,,,,,fee schedule,13988.06,38956.64,
Electron elbow child switch,L7186,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14687.46,,,,,,,fee schedule,13988.06,38956.64,APC
Electron elbow child switch,L7186,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,14547.58,,,,,,,fee schedule,13988.06,38956.64,APC
Electron elbow child switch,L7186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13988.06,,,,,,,fee schedule,13988.06,38956.64,APC
Electron elbow child switch,L7186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21401.73,,,,,,,fee schedule,13988.06,38956.64,Radiology
Electron elbow child switch,L7186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19583.28,,,,,,,fee schedule,13988.06,38956.64,APC
Electron elbow child switch,L7186,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,24479.1,,,,,,,fee schedule,13988.06,38956.64,APC
Elbow adolescent myoelectron,L7190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,31617.12,,,,,,,fee schedule,12331.36,34342.74,
Elbow adolescent myoelectron,L7190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,34342.74,,,,,,,fee schedule,12331.36,34342.74,
Elbow adolescent myoelectron,L7190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,27528.7,,,,,,,fee schedule,12331.36,34342.74,
Elbow adolescent myoelectron,L7190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,30072.61,,,,,,,fee schedule,12331.36,34342.74,
Elbow adolescent myoelectron,L7190,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,12947.93,,,,,,,fee schedule,12331.36,34342.74,APC
Elbow adolescent myoelectron,L7190,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,12824.61,,,,,,,fee schedule,12331.36,34342.74,APC
Elbow adolescent myoelectron,L7190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12331.36,,,,,,,fee schedule,12331.36,34342.74,APC
Elbow adolescent myoelectron,L7190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18866.98,,,,,,,fee schedule,12331.36,34342.74,Radiology
Elbow adolescent myoelectron,L7190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17263.9,,,,,,,fee schedule,12331.36,34342.74,APC
Elbow adolescent myoelectron,L7190,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21579.88,,,,,,,fee schedule,12331.36,34342.74,APC
Elbow child myoelectronic ct,L7191,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,38123.19,,,,,,,fee schedule,14868.87,41409.67,
Elbow child myoelectronic ct,L7191,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41409.67,,,,,,,fee schedule,14868.87,41409.67,
Elbow child myoelectronic ct,L7191,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,33193.47,,,,,,,fee schedule,14868.87,41409.67,
Elbow child myoelectronic ct,L7191,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36260.85,,,,,,,fee schedule,14868.87,41409.67,
Elbow child myoelectronic ct,L7191,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15612.31,,,,,,,fee schedule,14868.87,41409.67,APC
Elbow child myoelectronic ct,L7191,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,15463.62,,,,,,,fee schedule,14868.87,41409.67,APC
Elbow child myoelectronic ct,L7191,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14868.87,,,,,,,fee schedule,14868.87,41409.67,APC
Elbow child myoelectronic ct,L7191,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22749.37,,,,,,,fee schedule,14868.87,41409.67,Radiology
Elbow child myoelectronic ct,L7191,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20816.42,,,,,,,fee schedule,14868.87,41409.67,APC
Elbow child myoelectronic ct,L7191,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,26020.52,,,,,,,fee schedule,14868.87,41409.67,APC
Electronic wrist rotator any,L7259,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12740.73,,,,,,,fee schedule,4700.78,13839.07,
Electronic wrist rotator any,L7259,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13839.07,,,,,,,fee schedule,4700.78,13839.07,
Electronic wrist rotator any,L7259,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11093.22,,,,,,,fee schedule,4700.78,13839.07,
Electronic wrist rotator any,L7259,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12118.34,,,,,,,fee schedule,4700.78,13839.07,
Electronic wrist rotator any,L7259,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4935.82,,,,,,,fee schedule,4700.78,13839.07,APC
Electronic wrist rotator any,L7259,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4888.81,,,,,,,fee schedule,4700.78,13839.07,APC
Electronic wrist rotator any,L7259,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4700.78,,,,,,,fee schedule,4700.78,13839.07,APC
Electronic wrist rotator any,L7259,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7192.19,,,,,,,fee schedule,4700.78,13839.07,Radiology
Electronic wrist rotator any,L7259,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6581.09,,,,,,,fee schedule,4700.78,13839.07,APC
Electronic wrist rotator any,L7259,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8226.36,,,,,,,fee schedule,4700.78,13839.07,APC
Six volt bat otto bock/eq ea,L7360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,755.86,,,,,,,fee schedule,294.78,821.02,
Six volt bat otto bock/eq ea,L7360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,821.02,,,,,,,fee schedule,294.78,821.02,
Six volt bat otto bock/eq ea,L7360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,658.12,,,,,,,fee schedule,294.78,821.02,
Six volt bat otto bock/eq ea,L7360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,718.93,,,,,,,fee schedule,294.78,821.02,
Six volt bat otto bock/eq ea,L7360,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,309.52,,,,,,,fee schedule,294.78,821.02,APC
Six volt bat otto bock/eq ea,L7360,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,306.57,,,,,,,fee schedule,294.78,821.02,APC
Six volt bat otto bock/eq ea,L7360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,294.78,,,,,,,fee schedule,294.78,821.02,APC
Six volt bat otto bock/eq ea,L7360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,451.01,,,,,,,fee schedule,294.78,821.02,Radiology
Six volt bat otto bock/eq ea,L7360,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,412.69,,,,,,,fee schedule,294.78,821.02,APC
Six volt bat otto bock/eq ea,L7360,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,515.86,,,,,,,fee schedule,294.78,821.02,APC
Battery chrgr six volt otto,L7362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,909.05,,,,,,,fee schedule,354.56,987.41,
Battery chrgr six volt otto,L7362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,987.41,,,,,,,fee schedule,354.56,987.41,
Battery chrgr six volt otto,L7362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,791.5,,,,,,,fee schedule,354.56,987.41,
Battery chrgr six volt otto,L7362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,864.64,,,,,,,fee schedule,354.56,987.41,
Battery chrgr six volt otto,L7362,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,372.29,,,,,,,fee schedule,354.56,987.41,APC
Battery chrgr six volt otto,L7362,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,368.74,,,,,,,fee schedule,354.56,987.41,APC
Battery chrgr six volt otto,L7362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,354.56,,,,,,,fee schedule,354.56,987.41,APC
Battery chrgr six volt otto,L7362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,542.48,,,,,,,fee schedule,354.56,987.41,Radiology
Battery chrgr six volt otto,L7362,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,496.38,,,,,,,fee schedule,354.56,987.41,APC
Battery chrgr six volt otto,L7362,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,620.48,,,,,,,fee schedule,354.56,987.41,APC
Twelve volt battery utah/equ,L7364,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1655.96,,,,,,,fee schedule,645.85,1798.71,
Twelve volt battery utah/equ,L7364,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1798.71,,,,,,,fee schedule,645.85,1798.71,
Twelve volt battery utah/equ,L7364,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1441.83,,,,,,,fee schedule,645.85,1798.71,
Twelve volt battery utah/equ,L7364,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1575.06,,,,,,,fee schedule,645.85,1798.71,
Twelve volt battery utah/equ,L7364,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,678.14,,,,,,,fee schedule,645.85,1798.71,APC
Twelve volt battery utah/equ,L7364,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,671.68,,,,,,,fee schedule,645.85,1798.71,APC
Twelve volt battery utah/equ,L7364,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,645.85,,,,,,,fee schedule,645.85,1798.71,APC
Twelve volt battery utah/equ,L7364,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,988.15,,,,,,,fee schedule,645.85,1798.71,Radiology
Twelve volt battery utah/equ,L7364,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,904.19,,,,,,,fee schedule,645.85,1798.71,APC
Twelve volt battery utah/equ,L7364,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1130.24,,,,,,,fee schedule,645.85,1798.71,APC
Battery chrgr 12 volt utah/e,L7366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2246.48,,,,,,,fee schedule,876.17,2440.14,
Battery chrgr 12 volt utah/e,L7366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2440.14,,,,,,,fee schedule,876.17,2440.14,
Battery chrgr 12 volt utah/e,L7366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1955.99,,,,,,,fee schedule,876.17,2440.14,
Battery chrgr 12 volt utah/e,L7366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2136.74,,,,,,,fee schedule,876.17,2440.14,
Battery chrgr 12 volt utah/e,L7366,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,919.98,,,,,,,fee schedule,876.17,2440.14,APC
Battery chrgr 12 volt utah/e,L7366,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,911.22,,,,,,,fee schedule,876.17,2440.14,APC
Battery chrgr 12 volt utah/e,L7366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,876.17,,,,,,,fee schedule,876.17,2440.14,APC
Battery chrgr 12 volt utah/e,L7366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1340.54,,,,,,,fee schedule,876.17,2440.14,Radiology
Battery chrgr 12 volt utah/e,L7366,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1226.64,,,,,,,fee schedule,876.17,2440.14,APC
Battery chrgr 12 volt utah/e,L7366,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1533.3,,,,,,,fee schedule,876.17,2440.14,APC
Replacemnt lithium ionbatter,L7367,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1235.68,,,,,,,fee schedule,481.93,1342.2,
Replacemnt lithium ionbatter,L7367,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1342.2,,,,,,,fee schedule,481.93,1342.2,
Replacemnt lithium ionbatter,L7367,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1075.89,,,,,,,fee schedule,481.93,1342.2,
Replacemnt lithium ionbatter,L7367,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1175.31,,,,,,,fee schedule,481.93,1342.2,
Replacemnt lithium ionbatter,L7367,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,506.03,,,,,,,fee schedule,481.93,1342.2,APC
Replacemnt lithium ionbatter,L7367,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,501.21,,,,,,,fee schedule,481.93,1342.2,APC
Replacemnt lithium ionbatter,L7367,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,481.93,,,,,,,fee schedule,481.93,1342.2,APC
Replacemnt lithium ionbatter,L7367,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,737.35,,,,,,,fee schedule,481.93,1342.2,Radiology
Replacemnt lithium ionbatter,L7367,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,674.7,,,,,,,fee schedule,481.93,1342.2,APC
Replacemnt lithium ionbatter,L7367,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,843.38,,,,,,,fee schedule,481.93,1342.2,APC
Lithium ion battery charger,L7368,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1601.91,,,,,,,fee schedule,624.79,1740.01,
Lithium ion battery charger,L7368,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1740.01,,,,,,,fee schedule,624.79,1740.01,
Lithium ion battery charger,L7368,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1394.77,,,,,,,fee schedule,624.79,1740.01,
Lithium ion battery charger,L7368,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1523.66,,,,,,,fee schedule,624.79,1740.01,
Lithium ion battery charger,L7368,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,656.03,,,,,,,fee schedule,624.79,1740.01,APC
Lithium ion battery charger,L7368,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,649.78,,,,,,,fee schedule,624.79,1740.01,APC
Lithium ion battery charger,L7368,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,624.79,,,,,,,fee schedule,624.79,1740.01,APC
Lithium ion battery charger,L7368,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,955.93,,,,,,,fee schedule,624.79,1740.01,Radiology
Lithium ion battery charger,L7368,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,874.71,,,,,,,fee schedule,624.79,1740.01,APC
Lithium ion battery charger,L7368,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1093.38,,,,,,,fee schedule,624.79,1740.01,APC
"Add ue prost be/wd, ultlite",L7400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,972.76,,,,,,,fee schedule,379.41,1056.62,
"Add ue prost be/wd, ultlite",L7400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1056.62,,,,,,,fee schedule,379.41,1056.62,
"Add ue prost be/wd, ultlite",L7400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,846.98,,,,,,,fee schedule,379.41,1056.62,
"Add ue prost be/wd, ultlite",L7400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,925.24,,,,,,,fee schedule,379.41,1056.62,
"Add ue prost be/wd, ultlite",L7400,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,398.38,,,,,,,fee schedule,379.41,1056.62,APC
"Add ue prost be/wd, ultlite",L7400,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,394.59,,,,,,,fee schedule,379.41,1056.62,APC
"Add ue prost be/wd, ultlite",L7400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,379.41,,,,,,,fee schedule,379.41,1056.62,APC
"Add ue prost be/wd, ultlite",L7400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,580.5,,,,,,,fee schedule,379.41,1056.62,Radiology
"Add ue prost be/wd, ultlite",L7400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,531.17,,,,,,,fee schedule,379.41,1056.62,APC
"Add ue prost be/wd, ultlite",L7400,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,663.97,,,,,,,fee schedule,379.41,1056.62,APC
Add ue prost a/e ultlite mat,L7401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1089,,,,,,,fee schedule,424.75,1182.88,
Add ue prost a/e ultlite mat,L7401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1182.88,,,,,,,fee schedule,424.75,1182.88,
Add ue prost a/e ultlite mat,L7401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,948.18,,,,,,,fee schedule,424.75,1182.88,
Add ue prost a/e ultlite mat,L7401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1035.8,,,,,,,fee schedule,424.75,1182.88,
Add ue prost a/e ultlite mat,L7401,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,445.99,,,,,,,fee schedule,424.75,1182.88,APC
Add ue prost a/e ultlite mat,L7401,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,441.74,,,,,,,fee schedule,424.75,1182.88,APC
Add ue prost a/e ultlite mat,L7401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,424.75,,,,,,,fee schedule,424.75,1182.88,APC
Add ue prost a/e ultlite mat,L7401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,649.87,,,,,,,fee schedule,424.75,1182.88,Radiology
Add ue prost a/e ultlite mat,L7401,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,594.65,,,,,,,fee schedule,424.75,1182.88,APC
Add ue prost a/e ultlite mat,L7401,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,743.31,,,,,,,fee schedule,424.75,1182.88,APC
Add ue prost s/d ultlite mat,L7402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1176.03,,,,,,,fee schedule,458.68,1277.41,
Add ue prost s/d ultlite mat,L7402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1277.41,,,,,,,fee schedule,458.68,1277.41,
Add ue prost s/d ultlite mat,L7402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1023.96,,,,,,,fee schedule,458.68,1277.41,
Add ue prost s/d ultlite mat,L7402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1118.58,,,,,,,fee schedule,458.68,1277.41,
Add ue prost s/d ultlite mat,L7402,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,481.61,,,,,,,fee schedule,458.68,1277.41,APC
Add ue prost s/d ultlite mat,L7402,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,477.03,,,,,,,fee schedule,458.68,1277.41,APC
Add ue prost s/d ultlite mat,L7402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,458.68,,,,,,,fee schedule,458.68,1277.41,APC
Add ue prost s/d ultlite mat,L7402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,701.78,,,,,,,fee schedule,458.68,1277.41,Radiology
Add ue prost s/d ultlite mat,L7402,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,642.15,,,,,,,fee schedule,458.68,1277.41,APC
Add ue prost s/d ultlite mat,L7402,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,802.69,,,,,,,fee schedule,458.68,1277.41,APC
Add UE prost b/e acrylic,L7403,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1168.86,,,,,,,fee schedule,455.88,1269.63,
Add UE prost b/e acrylic,L7403,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1269.63,,,,,,,fee schedule,455.88,1269.63,
Add UE prost b/e acrylic,L7403,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1017.72,,,,,,,fee schedule,455.88,1269.63,
Add UE prost b/e acrylic,L7403,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1111.76,,,,,,,fee schedule,455.88,1269.63,
Add UE prost b/e acrylic,L7403,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,478.67,,,,,,,fee schedule,455.88,1269.63,APC
Add UE prost b/e acrylic,L7403,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,474.12,,,,,,,fee schedule,455.88,1269.63,APC
Add UE prost b/e acrylic,L7403,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,455.88,,,,,,,fee schedule,455.88,1269.63,APC
Add UE prost b/e acrylic,L7403,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,697.5,,,,,,,fee schedule,455.88,1269.63,Radiology
Add UE prost b/e acrylic,L7403,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,638.23,,,,,,,fee schedule,455.88,1269.63,APC
Add UE prost b/e acrylic,L7403,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,797.79,,,,,,,fee schedule,455.88,1269.63,APC
Add UE prost a/e acrylic,L7404,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1764.08,,,,,,,fee schedule,688.03,1916.16,
Add UE prost a/e acrylic,L7404,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1916.16,,,,,,,fee schedule,688.03,1916.16,
Add UE prost a/e acrylic,L7404,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1535.97,,,,,,,fee schedule,688.03,1916.16,
Add UE prost a/e acrylic,L7404,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1677.91,,,,,,,fee schedule,688.03,1916.16,
Add UE prost a/e acrylic,L7404,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,722.43,,,,,,,fee schedule,688.03,1916.16,APC
Add UE prost a/e acrylic,L7404,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,715.55,,,,,,,fee schedule,688.03,1916.16,APC
Add UE prost a/e acrylic,L7404,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,688.03,,,,,,,fee schedule,688.03,1916.16,APC
Add UE prost a/e acrylic,L7404,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1052.69,,,,,,,fee schedule,688.03,1916.16,Radiology
Add UE prost a/e acrylic,L7404,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,963.24,,,,,,,fee schedule,688.03,1916.16,APC
Add UE prost a/e acrylic,L7404,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1204.05,,,,,,,fee schedule,688.03,1916.16,APC
Add UE prost s/d acrylic,L7405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2307.17,,,,,,,fee schedule,899.88,2506.06,
Add UE prost s/d acrylic,L7405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2506.06,,,,,,,fee schedule,899.88,2506.06,
Add UE prost s/d acrylic,L7405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2008.83,,,,,,,fee schedule,899.88,2506.06,
Add UE prost s/d acrylic,L7405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2194.46,,,,,,,fee schedule,899.88,2506.06,
Add UE prost s/d acrylic,L7405,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,944.87,,,,,,,fee schedule,899.88,2506.06,APC
Add UE prost s/d acrylic,L7405,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,935.88,,,,,,,fee schedule,899.88,2506.06,APC
Add UE prost s/d acrylic,L7405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,899.88,,,,,,,fee schedule,899.88,2506.06,APC
Add UE prost s/d acrylic,L7405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1376.82,,,,,,,fee schedule,899.88,2506.06,Radiology
Add UE prost s/d acrylic,L7405,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1259.83,,,,,,,fee schedule,899.88,2506.06,APC
Add UE prost s/d acrylic,L7405,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1574.79,,,,,,,fee schedule,899.88,2506.06,APC
Male vacuum erection system,L7900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1717.83,,,,,,,fee schedule,1495.7,1865.92,
Male vacuum erection system,L7900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1865.92,,,,,,,fee schedule,1495.7,1865.92,
Male vacuum erection system,L7900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1495.7,,,,,,,fee schedule,1495.7,1865.92,
Male vacuum erection system,L7900,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1633.92,,,,,,,fee schedule,1495.7,1865.92,
"Tension ring, vac erect dev",L7902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,63.13,,,,,,,fee schedule,54.96,68.57,
"Tension ring, vac erect dev",L7902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,68.57,,,,,,,fee schedule,54.96,68.57,
"Tension ring, vac erect dev",L7902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,54.96,,,,,,,fee schedule,54.96,68.57,
"Tension ring, vac erect dev",L7902,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,60.04,,,,,,,fee schedule,54.96,68.57,
Mastectomy bra,L8000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,117.76,,,,,,,fee schedule,45.92,127.92,
Mastectomy bra,L8000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,127.92,,,,,,,fee schedule,45.92,127.92,
Mastectomy bra,L8000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,102.54,,,,,,,fee schedule,45.92,127.92,
Mastectomy bra,L8000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,112.01,,,,,,,fee schedule,45.92,127.92,
Mastectomy bra,L8000,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,48.22,,,,,,,fee schedule,45.92,127.92,APC
Mastectomy bra,L8000,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,47.76,,,,,,,fee schedule,45.92,127.92,APC
Mastectomy bra,L8000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,45.92,,,,,,,fee schedule,45.92,127.92,APC
Mastectomy bra,L8000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,70.26,,,,,,,fee schedule,45.92,127.92,Radiology
Mastectomy bra,L8000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,64.29,,,,,,,fee schedule,45.92,127.92,APC
Mastectomy bra,L8000,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,80.36,,,,,,,fee schedule,45.92,127.92,APC
Breast prosthesis bra & form,L8001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,398.08,,,,,,,fee schedule,155.27,432.39,
Breast prosthesis bra & form,L8001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,432.39,,,,,,,fee schedule,155.27,432.39,
Breast prosthesis bra & form,L8001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,346.6,,,,,,,fee schedule,155.27,432.39,
Breast prosthesis bra & form,L8001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,378.63,,,,,,,fee schedule,155.27,432.39,
Breast prosthesis bra & form,L8001,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,163.03,,,,,,,fee schedule,155.27,432.39,APC
Breast prosthesis bra & form,L8001,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,161.48,,,,,,,fee schedule,155.27,432.39,APC
Breast prosthesis bra & form,L8001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,155.27,,,,,,,fee schedule,155.27,432.39,APC
Breast prosthesis bra & form,L8001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,237.56,,,,,,,fee schedule,155.27,432.39,Radiology
Breast prosthesis bra & form,L8001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,217.38,,,,,,,fee schedule,155.27,432.39,APC
Breast prosthesis bra & form,L8001,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,271.72,,,,,,,fee schedule,155.27,432.39,APC
Brst prsth bra & bilat form,L8002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,523.67,,,,,,,fee schedule,204.23,568.81,
Brst prsth bra & bilat form,L8002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,568.81,,,,,,,fee schedule,204.23,568.81,
Brst prsth bra & bilat form,L8002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,455.95,,,,,,,fee schedule,204.23,568.81,
Brst prsth bra & bilat form,L8002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,498.09,,,,,,,fee schedule,204.23,568.81,
Brst prsth bra & bilat form,L8002,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,214.44,,,,,,,fee schedule,204.23,568.81,APC
Brst prsth bra & bilat form,L8002,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,212.4,,,,,,,fee schedule,204.23,568.81,APC
Brst prsth bra & bilat form,L8002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,204.23,,,,,,,fee schedule,204.23,568.81,APC
Brst prsth bra & bilat form,L8002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,312.47,,,,,,,fee schedule,204.23,568.81,Radiology
Brst prsth bra & bilat form,L8002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,285.92,,,,,,,fee schedule,204.23,568.81,APC
Brst prsth bra & bilat form,L8002,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,357.4,,,,,,,fee schedule,204.23,568.81,APC
Ext breastprosthesis garment,L8015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,190.25,,,,,,,fee schedule,74.19,206.65,
Ext breastprosthesis garment,L8015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,206.65,,,,,,,fee schedule,74.19,206.65,
Ext breastprosthesis garment,L8015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,165.65,,,,,,,fee schedule,74.19,206.65,
Ext breastprosthesis garment,L8015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,180.96,,,,,,,fee schedule,74.19,206.65,
Ext breastprosthesis garment,L8015,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,77.9,,,,,,,fee schedule,74.19,206.65,APC
Ext breastprosthesis garment,L8015,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,77.16,,,,,,,fee schedule,74.19,206.65,APC
Ext breastprosthesis garment,L8015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,74.19,,,,,,,fee schedule,74.19,206.65,APC
Ext breastprosthesis garment,L8015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,113.51,,,,,,,fee schedule,74.19,206.65,Radiology
Ext breastprosthesis garment,L8015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,103.87,,,,,,,fee schedule,74.19,206.65,APC
Ext breastprosthesis garment,L8015,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,129.83,,,,,,,fee schedule,74.19,206.65,APC
Mastectomy form,L8020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,713.19,,,,,,,fee schedule,278.14,774.67,
Mastectomy form,L8020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,774.67,,,,,,,fee schedule,278.14,774.67,
Mastectomy form,L8020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,620.97,,,,,,,fee schedule,278.14,774.67,
Mastectomy form,L8020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,678.35,,,,,,,fee schedule,278.14,774.67,
Mastectomy form,L8020,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,292.05,,,,,,,fee schedule,278.14,774.67,APC
Mastectomy form,L8020,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,289.27,,,,,,,fee schedule,278.14,774.67,APC
Mastectomy form,L8020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,278.14,,,,,,,fee schedule,278.14,774.67,APC
Mastectomy form,L8020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,425.55,,,,,,,fee schedule,278.14,774.67,Radiology
Mastectomy form,L8020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,389.4,,,,,,,fee schedule,278.14,774.67,APC
Mastectomy form,L8020,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,486.74,,,,,,,fee schedule,278.14,774.67,APC
Breast prosthes w/o adhesive,L8030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1047.06,,,,,,,fee schedule,408.38,1137.33,
Breast prosthes w/o adhesive,L8030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1137.33,,,,,,,fee schedule,408.38,1137.33,
Breast prosthes w/o adhesive,L8030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,911.67,,,,,,,fee schedule,408.38,1137.33,
Breast prosthes w/o adhesive,L8030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,995.91,,,,,,,fee schedule,408.38,1137.33,
Breast prosthes w/o adhesive,L8030,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,428.8,,,,,,,fee schedule,408.38,1137.33,APC
Breast prosthes w/o adhesive,L8030,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,424.72,,,,,,,fee schedule,408.38,1137.33,APC
Breast prosthes w/o adhesive,L8030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,408.38,,,,,,,fee schedule,408.38,1137.33,APC
Breast prosthes w/o adhesive,L8030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,624.82,,,,,,,fee schedule,408.38,1137.33,Radiology
Breast prosthes w/o adhesive,L8030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,571.73,,,,,,,fee schedule,408.38,1137.33,APC
Breast prosthes w/o adhesive,L8030,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,714.66,,,,,,,fee schedule,408.38,1137.33,APC
Breast prosthesis w adhesive,L8031,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1079.67,,,,,,,fee schedule,408.38,1172.75,
Breast prosthesis w adhesive,L8031,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1172.75,,,,,,,fee schedule,408.38,1172.75,
Breast prosthesis w adhesive,L8031,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,940.06,,,,,,,fee schedule,408.38,1172.75,
Breast prosthesis w adhesive,L8031,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1026.93,,,,,,,fee schedule,408.38,1172.75,
Breast prosthesis w adhesive,L8031,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,428.8,,,,,,,fee schedule,408.38,1172.75,APC
Breast prosthesis w adhesive,L8031,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,424.72,,,,,,,fee schedule,408.38,1172.75,APC
Breast prosthesis w adhesive,L8031,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,408.38,,,,,,,fee schedule,408.38,1172.75,APC
Breast prosthesis w adhesive,L8031,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,624.82,,,,,,,fee schedule,408.38,1172.75,Radiology
Breast prosthesis w adhesive,L8031,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,571.73,,,,,,,fee schedule,408.38,1172.75,APC
Breast prosthesis w adhesive,L8031,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,714.66,,,,,,,fee schedule,408.38,1172.75,APC
Reusable nipple prosthesis,L8032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,128.2,,,,,,,fee schedule,48.49,139.26,
Reusable nipple prosthesis,L8032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,139.26,,,,,,,fee schedule,48.49,139.26,
Reusable nipple prosthesis,L8032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,111.63,,,,,,,fee schedule,48.49,139.26,
Reusable nipple prosthesis,L8032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,121.94,,,,,,,fee schedule,48.49,139.26,
Reusable nipple prosthesis,L8032,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,50.91,,,,,,,fee schedule,48.49,139.26,APC
Reusable nipple prosthesis,L8032,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,50.43,,,,,,,fee schedule,48.49,139.26,APC
Reusable nipple prosthesis,L8032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,48.49,,,,,,,fee schedule,48.49,139.26,APC
Reusable nipple prosthesis,L8032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,74.19,,,,,,,fee schedule,48.49,139.26,Radiology
Reusable nipple prosthesis,L8032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,67.89,,,,,,,fee schedule,48.49,139.26,APC
Reusable nipple prosthesis,L8032,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,84.86,,,,,,,fee schedule,48.49,139.26,APC
Custom breast prosthesis,L8035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11628.18,,,,,,,fee schedule,4535.25,12630.61,
Custom breast prosthesis,L8035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12630.61,,,,,,,fee schedule,4535.25,12630.61,
Custom breast prosthesis,L8035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10124.53,,,,,,,fee schedule,4535.25,12630.61,
Custom breast prosthesis,L8035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11060.13,,,,,,,fee schedule,4535.25,12630.61,
Custom breast prosthesis,L8035,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4762.01,,,,,,,fee schedule,4535.25,12630.61,APC
Custom breast prosthesis,L8035,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4716.66,,,,,,,fee schedule,4535.25,12630.61,APC
Custom breast prosthesis,L8035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4535.25,,,,,,,fee schedule,4535.25,12630.61,APC
Custom breast prosthesis,L8035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6938.93,,,,,,,fee schedule,4535.25,12630.61,Radiology
Custom breast prosthesis,L8035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6349.35,,,,,,,fee schedule,4535.25,12630.61,APC
Custom breast prosthesis,L8035,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7936.69,,,,,,,fee schedule,4535.25,12630.61,APC
Nasal prosthesis,L8040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7186.93,,,,,,,fee schedule,2634.71,8217.38,
Nasal prosthesis,L8040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3026,,,,,,,fee schedule,2634.71,8217.38,
Nasal prosthesis,L8040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7565.21,,,,,,,fee schedule,2634.71,8217.38,
Nasal prosthesis,L8040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7806.49,,,,,,,fee schedule,2634.71,8217.38,
Nasal prosthesis,L8040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3286.86,,,,,,,fee schedule,2634.71,8217.38,
Nasal prosthesis,L8040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8217.38,,,,,,,fee schedule,2634.71,8217.38,
Nasal prosthesis,L8040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6257.59,,,,,,,fee schedule,2634.71,8217.38,
Nasal prosthesis,L8040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2634.71,,,,,,,fee schedule,2634.71,8217.38,
Nasal prosthesis,L8040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6586.95,,,,,,,fee schedule,2634.71,8217.38,
Nasal prosthesis,L8040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6835.85,,,,,,,fee schedule,2634.71,8217.38,
Nasal prosthesis,L8040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2878.18,,,,,,,fee schedule,2634.71,8217.38,
Nasal prosthesis,L8040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7195.64,,,,,,,fee schedule,2634.71,8217.38,
Nasal prosthesis,L8040,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3098.11,,,,,,,fee schedule,2634.71,8217.38,APC
Nasal prosthesis,L8040,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3068.6,,,,,,,fee schedule,2634.71,8217.38,APC
Nasal prosthesis,L8040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2950.58,,,,,,,fee schedule,2634.71,8217.38,APC
Nasal prosthesis,L8040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4514.39,,,,,,,fee schedule,2634.71,8217.38,Radiology
Nasal prosthesis,L8040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4130.81,,,,,,,fee schedule,2634.71,8217.38,APC
Nasal prosthesis,L8040,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5163.51,,,,,,,fee schedule,2634.71,8217.38,APC
Midfacial prosthesis,L8041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8662.66,,,,,,,fee schedule,3175.77,9904.73,
Midfacial prosthesis,L8041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3647.42,,,,,,,fee schedule,3175.77,9904.73,
Midfacial prosthesis,L8041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9118.64,,,,,,,fee schedule,3175.77,9904.73,
Midfacial prosthesis,L8041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9409.44,,,,,,,fee schedule,3175.77,9904.73,
Midfacial prosthesis,L8041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3961.86,,,,,,,fee schedule,3175.77,9904.73,
Midfacial prosthesis,L8041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9904.73,,,,,,,fee schedule,3175.77,9904.73,
Midfacial prosthesis,L8041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7542.49,,,,,,,fee schedule,3175.77,9904.73,
Midfacial prosthesis,L8041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3175.77,,,,,,,fee schedule,3175.77,9904.73,
Midfacial prosthesis,L8041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7939.51,,,,,,,fee schedule,3175.77,9904.73,
Midfacial prosthesis,L8041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8239.48,,,,,,,fee schedule,3175.77,9904.73,
Midfacial prosthesis,L8041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3469.24,,,,,,,fee schedule,3175.77,9904.73,
Midfacial prosthesis,L8041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8673.19,,,,,,,fee schedule,3175.77,9904.73,
Midfacial prosthesis,L8041,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3734.27,,,,,,,fee schedule,3175.77,9904.73,APC
Midfacial prosthesis,L8041,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3698.71,,,,,,,fee schedule,3175.77,9904.73,APC
Midfacial prosthesis,L8041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3556.45,,,,,,,fee schedule,3175.77,9904.73,APC
Midfacial prosthesis,L8041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5441.37,,,,,,,fee schedule,3175.77,9904.73,Radiology
Midfacial prosthesis,L8041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4979.03,,,,,,,fee schedule,3175.77,9904.73,APC
Midfacial prosthesis,L8041,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6223.79,,,,,,,fee schedule,3175.77,9904.73,APC
Orbital prosthesis,L8042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9733.32,,,,,,,fee schedule,3568.31,11128.89,
Orbital prosthesis,L8042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4098.26,,,,,,,fee schedule,3568.31,11128.89,
Orbital prosthesis,L8042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10245.64,,,,,,,fee schedule,3568.31,11128.89,
Orbital prosthesis,L8042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10572.4,,,,,,,fee schedule,3568.31,11128.89,
Orbital prosthesis,L8042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4451.55,,,,,,,fee schedule,3568.31,11128.89,
Orbital prosthesis,L8042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11128.89,,,,,,,fee schedule,3568.31,11128.89,
Orbital prosthesis,L8042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8474.7,,,,,,,fee schedule,3568.31,11128.89,
Orbital prosthesis,L8042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3568.31,,,,,,,fee schedule,3568.31,11128.89,
Orbital prosthesis,L8042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8920.77,,,,,,,fee schedule,3568.31,11128.89,
Orbital prosthesis,L8042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9257.84,,,,,,,fee schedule,3568.31,11128.89,
Orbital prosthesis,L8042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3898.05,,,,,,,fee schedule,3568.31,11128.89,
Orbital prosthesis,L8042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9745.14,,,,,,,fee schedule,3568.31,11128.89,
Orbital prosthesis,L8042,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4195.81,,,,,,,fee schedule,3568.31,11128.89,APC
Orbital prosthesis,L8042,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4155.85,,,,,,,fee schedule,3568.31,11128.89,APC
Orbital prosthesis,L8042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3996.01,,,,,,,fee schedule,3568.31,11128.89,APC
Orbital prosthesis,L8042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6113.9,,,,,,,fee schedule,3568.31,11128.89,Radiology
Orbital prosthesis,L8042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5594.41,,,,,,,fee schedule,3568.31,11128.89,APC
Orbital prosthesis,L8042,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,6993.02,,,,,,,fee schedule,3568.31,11128.89,APC
Upper facial prosthesis,L8043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10901.31,,,,,,,fee schedule,3996.54,12464.29,
Upper facial prosthesis,L8043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4590.09,,,,,,,fee schedule,3996.54,12464.29,
Upper facial prosthesis,L8043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11475.06,,,,,,,fee schedule,3996.54,12464.29,
Upper facial prosthesis,L8043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11841.08,,,,,,,fee schedule,3996.54,12464.29,
Upper facial prosthesis,L8043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4985.78,,,,,,,fee schedule,3996.54,12464.29,
Upper facial prosthesis,L8043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12464.29,,,,,,,fee schedule,3996.54,12464.29,
Upper facial prosthesis,L8043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9491.66,,,,,,,fee schedule,3996.54,12464.29,
Upper facial prosthesis,L8043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3996.54,,,,,,,fee schedule,3996.54,12464.29,
Upper facial prosthesis,L8043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9991.21,,,,,,,fee schedule,3996.54,12464.29,
Upper facial prosthesis,L8043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10368.77,,,,,,,fee schedule,3996.54,12464.29,
Upper facial prosthesis,L8043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4365.86,,,,,,,fee schedule,3996.54,12464.29,
Upper facial prosthesis,L8043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10914.49,,,,,,,fee schedule,3996.54,12464.29,
Upper facial prosthesis,L8043,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4699.3,,,,,,,fee schedule,3996.54,12464.29,APC
Upper facial prosthesis,L8043,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4654.54,,,,,,,fee schedule,3996.54,12464.29,APC
Upper facial prosthesis,L8043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4475.52,,,,,,,fee schedule,3996.54,12464.29,APC
Upper facial prosthesis,L8043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6847.55,,,,,,,fee schedule,3996.54,12464.29,Radiology
Upper facial prosthesis,L8043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6265.73,,,,,,,fee schedule,3996.54,12464.29,APC
Upper facial prosthesis,L8043,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7832.16,,,,,,,fee schedule,3996.54,12464.29,APC
Hemi-facial prosthesis,L8044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12069.34,,,,,,,fee schedule,4424.74,13799.76,
Hemi-facial prosthesis,L8044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5081.88,,,,,,,fee schedule,4424.74,13799.76,
Hemi-facial prosthesis,L8044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12704.54,,,,,,,fee schedule,4424.74,13799.76,
Hemi-facial prosthesis,L8044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13109.8,,,,,,,fee schedule,4424.74,13799.76,
Hemi-facial prosthesis,L8044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5519.97,,,,,,,fee schedule,4424.74,13799.76,
Hemi-facial prosthesis,L8044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13799.76,,,,,,,fee schedule,4424.74,13799.76,
Hemi-facial prosthesis,L8044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10508.65,,,,,,,fee schedule,4424.74,13799.76,
Hemi-facial prosthesis,L8044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4424.74,,,,,,,fee schedule,4424.74,13799.76,
Hemi-facial prosthesis,L8044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11061.71,,,,,,,fee schedule,4424.74,13799.76,
Hemi-facial prosthesis,L8044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11479.74,,,,,,,fee schedule,4424.74,13799.76,
Hemi-facial prosthesis,L8044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4833.63,,,,,,,fee schedule,4424.74,13799.76,
Hemi-facial prosthesis,L8044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12083.92,,,,,,,fee schedule,4424.74,13799.76,
Hemi-facial prosthesis,L8044,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5202.79,,,,,,,fee schedule,4424.74,13799.76,APC
Hemi-facial prosthesis,L8044,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5153.24,,,,,,,fee schedule,4424.74,13799.76,APC
Hemi-facial prosthesis,L8044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4955.04,,,,,,,fee schedule,4424.74,13799.76,APC
Hemi-facial prosthesis,L8044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7581.21,,,,,,,fee schedule,4424.74,13799.76,Radiology
Hemi-facial prosthesis,L8044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6937.06,,,,,,,fee schedule,4424.74,13799.76,APC
Hemi-facial prosthesis,L8044,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8671.32,,,,,,,fee schedule,4424.74,13799.76,APC
Auricular prosthesis,L8045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7557.79,,,,,,,fee schedule,2770.72,8641.38,
Auricular prosthesis,L8045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3182.22,,,,,,,fee schedule,2770.72,8641.38,
Auricular prosthesis,L8045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7955.56,,,,,,,fee schedule,2770.72,8641.38,
Auricular prosthesis,L8045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8209.33,,,,,,,fee schedule,2770.72,8641.38,
Auricular prosthesis,L8045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3456.55,,,,,,,fee schedule,2770.72,8641.38,
Auricular prosthesis,L8045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8641.38,,,,,,,fee schedule,2770.72,8641.38,
Auricular prosthesis,L8045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6580.49,,,,,,,fee schedule,2770.72,8641.38,
Auricular prosthesis,L8045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2770.72,,,,,,,fee schedule,2770.72,8641.38,
Auricular prosthesis,L8045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6926.82,,,,,,,fee schedule,2770.72,8641.38,
Auricular prosthesis,L8045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7188.59,,,,,,,fee schedule,2770.72,8641.38,
Auricular prosthesis,L8045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3026.76,,,,,,,fee schedule,2770.72,8641.38,
Auricular prosthesis,L8045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7566.92,,,,,,,fee schedule,2770.72,8641.38,
Auricular prosthesis,L8045,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3257.96,,,,,,,fee schedule,2770.72,8641.38,APC
Auricular prosthesis,L8045,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3226.93,,,,,,,fee schedule,2770.72,8641.38,APC
Auricular prosthesis,L8045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3102.82,,,,,,,fee schedule,2770.72,8641.38,APC
Auricular prosthesis,L8045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4747.31,,,,,,,fee schedule,2770.72,8641.38,Radiology
Auricular prosthesis,L8045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4343.95,,,,,,,fee schedule,2770.72,8641.38,APC
Auricular prosthesis,L8045,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5429.94,,,,,,,fee schedule,2770.72,8641.38,APC
Partial facial prosthesis,L8046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7786.64,,,,,,,fee schedule,2854.62,8903.03,
Partial facial prosthesis,L8046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3278.58,,,,,,,fee schedule,2854.62,8903.03,
Partial facial prosthesis,L8046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8196.44,,,,,,,fee schedule,2854.62,8903.03,
Partial facial prosthesis,L8046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8457.9,,,,,,,fee schedule,2854.62,8903.03,
Partial facial prosthesis,L8046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3561.21,,,,,,,fee schedule,2854.62,8903.03,
Partial facial prosthesis,L8046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8903.03,,,,,,,fee schedule,2854.62,8903.03,
Partial facial prosthesis,L8046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6779.75,,,,,,,fee schedule,2854.62,8903.03,
Partial facial prosthesis,L8046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2854.62,,,,,,,fee schedule,2854.62,8903.03,
Partial facial prosthesis,L8046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7136.56,,,,,,,fee schedule,2854.62,8903.03,
Partial facial prosthesis,L8046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7406.26,,,,,,,fee schedule,2854.62,8903.03,
Partial facial prosthesis,L8046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3118.42,,,,,,,fee schedule,2854.62,8903.03,
Partial facial prosthesis,L8046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7796.04,,,,,,,fee schedule,2854.62,8903.03,
Partial facial prosthesis,L8046,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,3356.63,,,,,,,fee schedule,2854.62,8903.03,APC
Partial facial prosthesis,L8046,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,3324.66,,,,,,,fee schedule,2854.62,8903.03,APC
Partial facial prosthesis,L8046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3196.79,,,,,,,fee schedule,2854.62,8903.03,APC
Partial facial prosthesis,L8046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4891.09,,,,,,,fee schedule,2854.62,8903.03,Radiology
Partial facial prosthesis,L8046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4475.51,,,,,,,fee schedule,2854.62,8903.03,APC
Partial facial prosthesis,L8046,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,5594.38,,,,,,,fee schedule,2854.62,8903.03,APC
Nasal septal prosthesis,L8047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3990.69,,,,,,,fee schedule,1462.97,4562.84,
Nasal septal prosthesis,L8047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1680.25,,,,,,,fee schedule,1462.97,4562.84,
Nasal septal prosthesis,L8047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4200.71,,,,,,,fee schedule,1462.97,4562.84,
Nasal septal prosthesis,L8047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4334.72,,,,,,,fee schedule,1462.97,4562.84,
Nasal septal prosthesis,L8047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1825.1,,,,,,,fee schedule,1462.97,4562.84,
Nasal septal prosthesis,L8047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4562.84,,,,,,,fee schedule,1462.97,4562.84,
Nasal septal prosthesis,L8047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3474.65,,,,,,,fee schedule,1462.97,4562.84,
Nasal septal prosthesis,L8047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1462.97,,,,,,,fee schedule,1462.97,4562.84,
Nasal septal prosthesis,L8047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3657.51,,,,,,,fee schedule,1462.97,4562.84,
Nasal septal prosthesis,L8047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3795.74,,,,,,,fee schedule,1462.97,4562.84,
Nasal septal prosthesis,L8047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1598.17,,,,,,,fee schedule,1462.97,4562.84,
Nasal septal prosthesis,L8047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3995.5,,,,,,,fee schedule,1462.97,4562.84,
Nasal septal prosthesis,L8047,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1720.3,,,,,,,fee schedule,1462.97,4562.84,APC
Nasal septal prosthesis,L8047,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1703.92,,,,,,,fee schedule,1462.97,4562.84,APC
Nasal septal prosthesis,L8047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1638.38,,,,,,,fee schedule,1462.97,4562.84,APC
Nasal septal prosthesis,L8047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2506.72,,,,,,,fee schedule,1462.97,4562.84,Radiology
Nasal septal prosthesis,L8047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2293.73,,,,,,,fee schedule,1462.97,4562.84,APC
Nasal septal prosthesis,L8047,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2867.16,,,,,,,fee schedule,1462.97,4562.84,APC
Truss single w/ standard pad,L8300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,264.76,,,,,,,fee schedule,103.28,287.58,
Truss single w/ standard pad,L8300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,287.58,,,,,,,fee schedule,103.28,287.58,
Truss single w/ standard pad,L8300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,230.52,,,,,,,fee schedule,103.28,287.58,
Truss single w/ standard pad,L8300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,251.82,,,,,,,fee schedule,103.28,287.58,
Truss single w/ standard pad,L8300,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,108.44,,,,,,,fee schedule,103.28,287.58,APC
Truss single w/ standard pad,L8300,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,107.41,,,,,,,fee schedule,103.28,287.58,APC
Truss single w/ standard pad,L8300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,103.28,,,,,,,fee schedule,103.28,287.58,APC
Truss single w/ standard pad,L8300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.02,,,,,,,fee schedule,103.28,287.58,Radiology
Truss single w/ standard pad,L8300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.59,,,,,,,fee schedule,103.28,287.58,APC
Truss single w/ standard pad,L8300,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,180.74,,,,,,,fee schedule,103.28,287.58,APC
Truss double w/ standard pad,L8310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,418.05,,,,,,,fee schedule,163.05,454.09,
Truss double w/ standard pad,L8310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,454.09,,,,,,,fee schedule,163.05,454.09,
Truss double w/ standard pad,L8310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,363.99,,,,,,,fee schedule,163.05,454.09,
Truss double w/ standard pad,L8310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,397.63,,,,,,,fee schedule,163.05,454.09,
Truss double w/ standard pad,L8310,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,171.2,,,,,,,fee schedule,163.05,454.09,APC
Truss double w/ standard pad,L8310,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,169.57,,,,,,,fee schedule,163.05,454.09,APC
Truss double w/ standard pad,L8310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,163.05,,,,,,,fee schedule,163.05,454.09,APC
Truss double w/ standard pad,L8310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,249.47,,,,,,,fee schedule,163.05,454.09,Radiology
Truss double w/ standard pad,L8310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,228.27,,,,,,,fee schedule,163.05,454.09,APC
Truss double w/ standard pad,L8310,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,285.34,,,,,,,fee schedule,163.05,454.09,APC
Truss addition to std pad wa,L8320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,193,,,,,,,fee schedule,75.29,209.64,
Truss addition to std pad wa,L8320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,209.64,,,,,,,fee schedule,75.29,209.64,
Truss addition to std pad wa,L8320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,168.04,,,,,,,fee schedule,75.29,209.64,
Truss addition to std pad wa,L8320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,183.57,,,,,,,fee schedule,75.29,209.64,
Truss addition to std pad wa,L8320,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,79.05,,,,,,,fee schedule,75.29,209.64,APC
Truss addition to std pad wa,L8320,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,78.3,,,,,,,fee schedule,75.29,209.64,APC
Truss addition to std pad wa,L8320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,75.29,,,,,,,fee schedule,75.29,209.64,APC
Truss addition to std pad wa,L8320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,115.19,,,,,,,fee schedule,75.29,209.64,Radiology
Truss addition to std pad wa,L8320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,105.41,,,,,,,fee schedule,75.29,209.64,APC
Truss addition to std pad wa,L8320,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,131.76,,,,,,,fee schedule,75.29,209.64,APC
Truss add to std pad scrotal,L8330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,206.64,,,,,,,fee schedule,80.58,224.46,
Truss add to std pad scrotal,L8330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,224.46,,,,,,,fee schedule,80.58,224.46,
Truss add to std pad scrotal,L8330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,179.92,,,,,,,fee schedule,80.58,224.46,
Truss add to std pad scrotal,L8330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,196.55,,,,,,,fee schedule,80.58,224.46,
Truss add to std pad scrotal,L8330,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,84.61,,,,,,,fee schedule,80.58,224.46,APC
Truss add to std pad scrotal,L8330,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,83.8,,,,,,,fee schedule,80.58,224.46,APC
Truss add to std pad scrotal,L8330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,80.58,,,,,,,fee schedule,80.58,224.46,APC
Truss add to std pad scrotal,L8330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,123.29,,,,,,,fee schedule,80.58,224.46,Radiology
Truss add to std pad scrotal,L8330,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,112.81,,,,,,,fee schedule,80.58,224.46,APC
Truss add to std pad scrotal,L8330,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,141.01,,,,,,,fee schedule,80.58,224.46,APC
Sheath below knee,L8400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,49.42,,,,,,,fee schedule,19.27,53.68,
Sheath below knee,L8400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,53.68,,,,,,,fee schedule,19.27,53.68,
Sheath below knee,L8400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,43.03,,,,,,,fee schedule,19.27,53.68,
Sheath below knee,L8400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,47,,,,,,,fee schedule,19.27,53.68,
Sheath below knee,L8400,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,20.23,,,,,,,fee schedule,19.27,53.68,APC
Sheath below knee,L8400,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,20.04,,,,,,,fee schedule,19.27,53.68,APC
Sheath below knee,L8400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,19.27,,,,,,,fee schedule,19.27,53.68,APC
Sheath below knee,L8400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29.48,,,,,,,fee schedule,19.27,53.68,Radiology
Sheath below knee,L8400,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26.98,,,,,,,fee schedule,19.27,53.68,APC
Sheath below knee,L8400,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,33.72,,,,,,,fee schedule,19.27,53.68,APC
Sheath above knee,L8410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,72.28,,,,,,,fee schedule,28.16,78.51,
Sheath above knee,L8410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,78.51,,,,,,,fee schedule,28.16,78.51,
Sheath above knee,L8410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,62.93,,,,,,,fee schedule,28.16,78.51,
Sheath above knee,L8410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,68.75,,,,,,,fee schedule,28.16,78.51,
Sheath above knee,L8410,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,29.57,,,,,,,fee schedule,28.16,78.51,APC
Sheath above knee,L8410,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,29.29,,,,,,,fee schedule,28.16,78.51,APC
Sheath above knee,L8410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,28.16,,,,,,,fee schedule,28.16,78.51,APC
Sheath above knee,L8410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43.08,,,,,,,fee schedule,28.16,78.51,Radiology
Sheath above knee,L8410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,39.42,,,,,,,fee schedule,28.16,78.51,APC
Sheath above knee,L8410,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,49.28,,,,,,,fee schedule,28.16,78.51,APC
Sheath upper limb,L8415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,73.39,,,,,,,fee schedule,28.64,79.72,
Sheath upper limb,L8415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,79.72,,,,,,,fee schedule,28.64,79.72,
Sheath upper limb,L8415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,63.9,,,,,,,fee schedule,28.64,79.72,
Sheath upper limb,L8415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,69.81,,,,,,,fee schedule,28.64,79.72,
Sheath upper limb,L8415,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.07,,,,,,,fee schedule,28.64,79.72,APC
Sheath upper limb,L8415,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,29.79,,,,,,,fee schedule,28.64,79.72,APC
Sheath upper limb,L8415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,28.64,,,,,,,fee schedule,28.64,79.72,APC
Sheath upper limb,L8415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43.82,,,,,,,fee schedule,28.64,79.72,Radiology
Sheath upper limb,L8415,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40.1,,,,,,,fee schedule,28.64,79.72,APC
Sheath upper limb,L8415,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,50.12,,,,,,,fee schedule,28.64,79.72,APC
Pros sheath/sock w gel cushn,L8417,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,238.66,,,,,,,fee schedule,93.09,259.23,
Pros sheath/sock w gel cushn,L8417,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,259.23,,,,,,,fee schedule,93.09,259.23,
Pros sheath/sock w gel cushn,L8417,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,207.8,,,,,,,fee schedule,93.09,259.23,
Pros sheath/sock w gel cushn,L8417,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,227,,,,,,,fee schedule,93.09,259.23,
Pros sheath/sock w gel cushn,L8417,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,97.74,,,,,,,fee schedule,93.09,259.23,APC
Pros sheath/sock w gel cushn,L8417,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,96.81,,,,,,,fee schedule,93.09,259.23,APC
Pros sheath/sock w gel cushn,L8417,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,93.09,,,,,,,fee schedule,93.09,259.23,APC
Pros sheath/sock w gel cushn,L8417,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,142.43,,,,,,,fee schedule,93.09,259.23,Radiology
Pros sheath/sock w gel cushn,L8417,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,130.33,,,,,,,fee schedule,93.09,259.23,APC
Pros sheath/sock w gel cushn,L8417,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,162.91,,,,,,,fee schedule,93.09,259.23,APC
Prosthetic sock multi ply BK,L8420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,65.28,,,,,,,fee schedule,25.45,70.91,
Prosthetic sock multi ply BK,L8420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,70.91,,,,,,,fee schedule,25.45,70.91,
Prosthetic sock multi ply BK,L8420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56.84,,,,,,,fee schedule,25.45,70.91,
Prosthetic sock multi ply BK,L8420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,62.1,,,,,,,fee schedule,25.45,70.91,
Prosthetic sock multi ply BK,L8420,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,26.72,,,,,,,fee schedule,25.45,70.91,APC
Prosthetic sock multi ply BK,L8420,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,26.47,,,,,,,fee schedule,25.45,70.91,APC
Prosthetic sock multi ply BK,L8420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,25.45,,,,,,,fee schedule,25.45,70.91,APC
Prosthetic sock multi ply BK,L8420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,38.94,,,,,,,fee schedule,25.45,70.91,Radiology
Prosthetic sock multi ply BK,L8420,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,35.63,,,,,,,fee schedule,25.45,70.91,APC
Prosthetic sock multi ply BK,L8420,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,44.54,,,,,,,fee schedule,25.45,70.91,APC
Prosthetic sock multi ply AK,L8430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,71.69,,,,,,,fee schedule,27.95,77.87,
Prosthetic sock multi ply AK,L8430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,77.87,,,,,,,fee schedule,27.95,77.87,
Prosthetic sock multi ply AK,L8430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,62.42,,,,,,,fee schedule,27.95,77.87,
Prosthetic sock multi ply AK,L8430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,68.19,,,,,,,fee schedule,27.95,77.87,
Prosthetic sock multi ply AK,L8430,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,29.35,,,,,,,fee schedule,27.95,77.87,APC
Prosthetic sock multi ply AK,L8430,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,29.07,,,,,,,fee schedule,27.95,77.87,APC
Prosthetic sock multi ply AK,L8430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,27.95,,,,,,,fee schedule,27.95,77.87,APC
Prosthetic sock multi ply AK,L8430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,42.76,,,,,,,fee schedule,27.95,77.87,Radiology
Prosthetic sock multi ply AK,L8430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,39.13,,,,,,,fee schedule,27.95,77.87,APC
Prosthetic sock multi ply AK,L8430,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,48.91,,,,,,,fee schedule,27.95,77.87,APC
Pros sock multi ply upper lm,L8435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,75.69,,,,,,,fee schedule,29.52,82.22,
Pros sock multi ply upper lm,L8435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,82.22,,,,,,,fee schedule,29.52,82.22,
Pros sock multi ply upper lm,L8435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,65.9,,,,,,,fee schedule,29.52,82.22,
Pros sock multi ply upper lm,L8435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,71.99,,,,,,,fee schedule,29.52,82.22,
Pros sock multi ply upper lm,L8435,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,31,,,,,,,fee schedule,29.52,82.22,APC
Pros sock multi ply upper lm,L8435,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,30.7,,,,,,,fee schedule,29.52,82.22,APC
Pros sock multi ply upper lm,L8435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,29.52,,,,,,,fee schedule,29.52,82.22,APC
Pros sock multi ply upper lm,L8435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,45.17,,,,,,,fee schedule,29.52,82.22,Radiology
Pros sock multi ply upper lm,L8435,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,41.33,,,,,,,fee schedule,29.52,82.22,APC
Pros sock multi ply upper lm,L8435,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,51.66,,,,,,,fee schedule,29.52,82.22,APC
Shrinker below knee,L8440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,138.68,,,,,,,fee schedule,54.07,150.63,
Shrinker below knee,L8440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,150.63,,,,,,,fee schedule,54.07,150.63,
Shrinker below knee,L8440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,120.75,,,,,,,fee schedule,54.07,150.63,
Shrinker below knee,L8440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,131.9,,,,,,,fee schedule,54.07,150.63,
Shrinker below knee,L8440,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,56.77,,,,,,,fee schedule,54.07,150.63,APC
Shrinker below knee,L8440,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,56.23,,,,,,,fee schedule,54.07,150.63,APC
Shrinker below knee,L8440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,54.07,,,,,,,fee schedule,54.07,150.63,APC
Shrinker below knee,L8440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,82.73,,,,,,,fee schedule,54.07,150.63,Radiology
Shrinker below knee,L8440,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,75.7,,,,,,,fee schedule,54.07,150.63,APC
Shrinker below knee,L8440,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,94.62,,,,,,,fee schedule,54.07,150.63,APC
Shrinker above knee,L8460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,241.27,,,,,,,fee schedule,94.08,262.07,
Shrinker above knee,L8460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,262.07,,,,,,,fee schedule,94.08,262.07,
Shrinker above knee,L8460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,210.07,,,,,,,fee schedule,94.08,262.07,
Shrinker above knee,L8460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,229.48,,,,,,,fee schedule,94.08,262.07,
Shrinker above knee,L8460,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,98.78,,,,,,,fee schedule,94.08,262.07,APC
Shrinker above knee,L8460,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,97.84,,,,,,,fee schedule,94.08,262.07,APC
Shrinker above knee,L8460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,94.08,,,,,,,fee schedule,94.08,262.07,APC
Shrinker above knee,L8460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,143.94,,,,,,,fee schedule,94.08,262.07,Radiology
Shrinker above knee,L8460,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.71,,,,,,,fee schedule,94.08,262.07,APC
Shrinker above knee,L8460,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,164.64,,,,,,,fee schedule,94.08,262.07,APC
Shrinker upper limb,L8465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,171.91,,,,,,,fee schedule,67.04,186.73,
Shrinker upper limb,L8465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,186.73,,,,,,,fee schedule,67.04,186.73,
Shrinker upper limb,L8465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,149.68,,,,,,,fee schedule,67.04,186.73,
Shrinker upper limb,L8465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,163.51,,,,,,,fee schedule,67.04,186.73,
Shrinker upper limb,L8465,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,70.39,,,,,,,fee schedule,67.04,186.73,APC
Shrinker upper limb,L8465,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,69.72,,,,,,,fee schedule,67.04,186.73,APC
Shrinker upper limb,L8465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,67.04,,,,,,,fee schedule,67.04,186.73,APC
Shrinker upper limb,L8465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,102.57,,,,,,,fee schedule,67.04,186.73,Radiology
Shrinker upper limb,L8465,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,93.86,,,,,,,fee schedule,67.04,186.73,APC
Shrinker upper limb,L8465,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,117.32,,,,,,,fee schedule,67.04,186.73,APC
Pros sock single ply BK,L8470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,25.16,,,,,,,fee schedule,9.8,27.33,
Pros sock single ply BK,L8470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27.33,,,,,,,fee schedule,9.8,27.33,
Pros sock single ply BK,L8470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21.91,,,,,,,fee schedule,9.8,27.33,
Pros sock single ply BK,L8470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23.93,,,,,,,fee schedule,9.8,27.33,
Pros sock single ply BK,L8470,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.29,,,,,,,fee schedule,9.8,27.33,APC
Pros sock single ply BK,L8470,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10.19,,,,,,,fee schedule,9.8,27.33,APC
Pros sock single ply BK,L8470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9.8,,,,,,,fee schedule,9.8,27.33,APC
Pros sock single ply BK,L8470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.99,,,,,,,fee schedule,9.8,27.33,Radiology
Pros sock single ply BK,L8470,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.72,,,,,,,fee schedule,9.8,27.33,APC
Pros sock single ply BK,L8470,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,17.15,,,,,,,fee schedule,9.8,27.33,APC
Pros sock single ply AK,L8480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,32.99,,,,,,,fee schedule,12.87,35.83,
Pros sock single ply AK,L8480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,35.83,,,,,,,fee schedule,12.87,35.83,
Pros sock single ply AK,L8480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28.72,,,,,,,fee schedule,12.87,35.83,
Pros sock single ply AK,L8480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31.38,,,,,,,fee schedule,12.87,35.83,
Pros sock single ply AK,L8480,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,13.51,,,,,,,fee schedule,12.87,35.83,APC
Pros sock single ply AK,L8480,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,13.38,,,,,,,fee schedule,12.87,35.83,APC
Pros sock single ply AK,L8480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.87,,,,,,,fee schedule,12.87,35.83,APC
Pros sock single ply AK,L8480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.69,,,,,,,fee schedule,12.87,35.83,Radiology
Pros sock single ply AK,L8480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18.02,,,,,,,fee schedule,12.87,35.83,APC
Pros sock single ply AK,L8480,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22.52,,,,,,,fee schedule,12.87,35.83,APC
Pros sock single ply upper l,L8485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,34.9,,,,,,,fee schedule,13.62,37.91,
Pros sock single ply upper l,L8485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37.91,,,,,,,fee schedule,13.62,37.91,
Pros sock single ply upper l,L8485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,30.39,,,,,,,fee schedule,13.62,37.91,
Pros sock single ply upper l,L8485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,33.2,,,,,,,fee schedule,13.62,37.91,
Pros sock single ply upper l,L8485,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.3,,,,,,,fee schedule,13.62,37.91,APC
Pros sock single ply upper l,L8485,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,14.16,,,,,,,fee schedule,13.62,37.91,APC
Pros sock single ply upper l,L8485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13.62,,,,,,,fee schedule,13.62,37.91,APC
Pros sock single ply upper l,L8485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.84,,,,,,,fee schedule,13.62,37.91,Radiology
Pros sock single ply upper l,L8485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.07,,,,,,,fee schedule,13.62,37.91,APC
Pros sock single ply upper l,L8485,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23.83,,,,,,,fee schedule,13.62,37.91,APC
Artificial larynx,L8500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2440.32,,,,,,,fee schedule,951.76,2650.69,
Artificial larynx,L8500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2650.69,,,,,,,fee schedule,951.76,2650.69,
Artificial larynx,L8500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2124.76,,,,,,,fee schedule,951.76,2650.69,
Artificial larynx,L8500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2321.1,,,,,,,fee schedule,951.76,2650.69,
Artificial larynx,L8500,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,999.35,,,,,,,fee schedule,951.76,2650.69,APC
Artificial larynx,L8500,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,989.83,,,,,,,fee schedule,951.76,2650.69,APC
Artificial larynx,L8500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,951.76,,,,,,,fee schedule,951.76,2650.69,APC
Artificial larynx,L8500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1456.19,,,,,,,fee schedule,951.76,2650.69,Radiology
Artificial larynx,L8500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1332.46,,,,,,,fee schedule,951.76,2650.69,APC
Artificial larynx,L8500,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1665.58,,,,,,,fee schedule,951.76,2650.69,APC
Tracheostomy speaking valve,L8501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,379.18,,,,,,,fee schedule,147.88,411.87,
Tracheostomy speaking valve,L8501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,411.87,,,,,,,fee schedule,147.88,411.87,
Tracheostomy speaking valve,L8501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,330.15,,,,,,,fee schedule,147.88,411.87,
Tracheostomy speaking valve,L8501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,360.66,,,,,,,fee schedule,147.88,411.87,
Tracheostomy speaking valve,L8501,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,155.27,,,,,,,fee schedule,147.88,411.87,APC
Tracheostomy speaking valve,L8501,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,153.8,,,,,,,fee schedule,147.88,411.87,APC
Tracheostomy speaking valve,L8501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,147.88,,,,,,,fee schedule,147.88,411.87,APC
Tracheostomy speaking valve,L8501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,226.26,,,,,,,fee schedule,147.88,411.87,Radiology
Tracheostomy speaking valve,L8501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,207.03,,,,,,,fee schedule,147.88,411.87,APC
Tracheostomy speaking valve,L8501,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,258.79,,,,,,,fee schedule,147.88,411.87,APC
Trach-esoph voice pros pt in,L8507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,132.94,,,,,,,fee schedule,51.85,144.4,
Trach-esoph voice pros pt in,L8507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,144.4,,,,,,,fee schedule,51.85,144.4,
Trach-esoph voice pros pt in,L8507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,115.75,,,,,,,fee schedule,51.85,144.4,
Trach-esoph voice pros pt in,L8507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,126.44,,,,,,,fee schedule,51.85,144.4,
Trach-esoph voice pros pt in,L8507,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.44,,,,,,,fee schedule,51.85,144.4,APC
Trach-esoph voice pros pt in,L8507,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,53.92,,,,,,,fee schedule,51.85,144.4,APC
Trach-esoph voice pros pt in,L8507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,51.85,,,,,,,fee schedule,51.85,144.4,APC
Trach-esoph voice pros pt in,L8507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,79.33,,,,,,,fee schedule,51.85,144.4,Radiology
Trach-esoph voice pros pt in,L8507,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,72.59,,,,,,,fee schedule,51.85,144.4,APC
Trach-esoph voice pros pt in,L8507,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,90.74,,,,,,,fee schedule,51.85,144.4,APC
Trach-esoph voice pros md in,L8509,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,346.61,,,,,,,fee schedule,135.2,376.49,
Trach-esoph voice pros md in,L8509,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,376.49,,,,,,,fee schedule,135.2,376.49,
Trach-esoph voice pros md in,L8509,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,301.79,,,,,,,fee schedule,135.2,376.49,
Trach-esoph voice pros md in,L8509,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,329.68,,,,,,,fee schedule,135.2,376.49,
Trach-esoph voice pros md in,L8509,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,141.96,,,,,,,fee schedule,135.2,376.49,APC
Trach-esoph voice pros md in,L8509,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,140.61,,,,,,,fee schedule,135.2,376.49,APC
Trach-esoph voice pros md in,L8509,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,135.2,,,,,,,fee schedule,135.2,376.49,APC
Trach-esoph voice pros md in,L8509,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,206.86,,,,,,,fee schedule,135.2,376.49,Radiology
Trach-esoph voice pros md in,L8509,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,189.28,,,,,,,fee schedule,135.2,376.49,APC
Trach-esoph voice pros md in,L8509,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,236.6,,,,,,,fee schedule,135.2,376.49,APC
Voice amplifier,L8510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,802.07,,,,,,,fee schedule,312.83,871.21,
Voice amplifier,L8510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,871.21,,,,,,,fee schedule,312.83,871.21,
Voice amplifier,L8510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,698.35,,,,,,,fee schedule,312.83,871.21,
Voice amplifier,L8510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,762.89,,,,,,,fee schedule,312.83,871.21,
Voice amplifier,L8510,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,328.47,,,,,,,fee schedule,312.83,871.21,APC
Voice amplifier,L8510,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,325.34,,,,,,,fee schedule,312.83,871.21,APC
Voice amplifier,L8510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,312.83,,,,,,,fee schedule,312.83,871.21,APC
Voice amplifier,L8510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,478.63,,,,,,,fee schedule,312.83,871.21,Radiology
Voice amplifier,L8510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,437.96,,,,,,,fee schedule,312.83,871.21,APC
Voice amplifier,L8510,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,547.45,,,,,,,fee schedule,312.83,871.21,APC
Indwelling trach insert,L8511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,230.86,,,,,,,fee schedule,90.03,250.77,
Indwelling trach insert,L8511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,250.77,,,,,,,fee schedule,90.03,250.77,
Indwelling trach insert,L8511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,201.01,,,,,,,fee schedule,90.03,250.77,
Indwelling trach insert,L8511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,219.59,,,,,,,fee schedule,90.03,250.77,
Indwelling trach insert,L8511,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,94.53,,,,,,,fee schedule,90.03,250.77,APC
Indwelling trach insert,L8511,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,93.63,,,,,,,fee schedule,90.03,250.77,APC
Indwelling trach insert,L8511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,90.03,,,,,,,fee schedule,90.03,250.77,APC
Indwelling trach insert,L8511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,137.75,,,,,,,fee schedule,90.03,250.77,Radiology
Indwelling trach insert,L8511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,126.04,,,,,,,fee schedule,90.03,250.77,APC
Indwelling trach insert,L8511,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,157.55,,,,,,,fee schedule,90.03,250.77,APC
Gel cap for trach voice pros,L8512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.96,,,,,,,fee schedule,2.7,7.56,
Gel cap for trach voice pros,L8512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7.56,,,,,,,fee schedule,2.7,7.56,
Gel cap for trach voice pros,L8512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.06,,,,,,,fee schedule,2.7,7.56,
Gel cap for trach voice pros,L8512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.62,,,,,,,fee schedule,2.7,7.56,
Gel cap for trach voice pros,L8512,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2.84,,,,,,,fee schedule,2.7,7.56,APC
Gel cap for trach voice pros,L8512,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2.81,,,,,,,fee schedule,2.7,7.56,APC
Gel cap for trach voice pros,L8512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2.7,,,,,,,fee schedule,2.7,7.56,APC
Gel cap for trach voice pros,L8512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4.13,,,,,,,fee schedule,2.7,7.56,Radiology
Gel cap for trach voice pros,L8512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3.78,,,,,,,fee schedule,2.7,7.56,APC
Gel cap for trach voice pros,L8512,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4.73,,,,,,,fee schedule,2.7,7.56,APC
Trach pros cleaning device,L8513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16.53,,,,,,,fee schedule,6.47,17.96,
Trach pros cleaning device,L8513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17.96,,,,,,,fee schedule,6.47,17.96,
Trach pros cleaning device,L8513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14.39,,,,,,,fee schedule,6.47,17.96,
Trach pros cleaning device,L8513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15.72,,,,,,,fee schedule,6.47,17.96,
Trach pros cleaning device,L8513,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.79,,,,,,,fee schedule,6.47,17.96,APC
Trach pros cleaning device,L8513,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6.73,,,,,,,fee schedule,6.47,17.96,APC
Trach pros cleaning device,L8513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6.47,,,,,,,fee schedule,6.47,17.96,APC
Trach pros cleaning device,L8513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.9,,,,,,,fee schedule,6.47,17.96,Radiology
Trach pros cleaning device,L8513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9.06,,,,,,,fee schedule,6.47,17.96,APC
Trach pros cleaning device,L8513,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11.32,,,,,,,fee schedule,6.47,17.96,APC
Repl trach puncture dilator,L8514,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,299.35,,,,,,,fee schedule,116.73,325.16,
Repl trach puncture dilator,L8514,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,325.16,,,,,,,fee schedule,116.73,325.16,
Repl trach puncture dilator,L8514,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,260.64,,,,,,,fee schedule,116.73,325.16,
Repl trach puncture dilator,L8514,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,284.73,,,,,,,fee schedule,116.73,325.16,
Repl trach puncture dilator,L8514,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,122.57,,,,,,,fee schedule,116.73,325.16,APC
Repl trach puncture dilator,L8514,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,121.4,,,,,,,fee schedule,116.73,325.16,APC
Repl trach puncture dilator,L8514,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,116.73,,,,,,,fee schedule,116.73,325.16,APC
Repl trach puncture dilator,L8514,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,178.6,,,,,,,fee schedule,116.73,325.16,Radiology
Repl trach puncture dilator,L8514,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,163.42,,,,,,,fee schedule,116.73,325.16,APC
Repl trach puncture dilator,L8514,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,204.28,,,,,,,fee schedule,116.73,325.16,APC
Gel cap app device for trach,L8515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,200.34,,,,,,,fee schedule,78.14,217.61,
Gel cap app device for trach,L8515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,217.61,,,,,,,fee schedule,78.14,217.61,
Gel cap app device for trach,L8515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,174.44,,,,,,,fee schedule,78.14,217.61,
Gel cap app device for trach,L8515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,190.56,,,,,,,fee schedule,78.14,217.61,
Gel cap app device for trach,L8515,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,82.05,,,,,,,fee schedule,78.14,217.61,APC
Gel cap app device for trach,L8515,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,81.27,,,,,,,fee schedule,78.14,217.61,APC
Gel cap app device for trach,L8515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,78.14,,,,,,,fee schedule,78.14,217.61,APC
Gel cap app device for trach,L8515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,119.55,,,,,,,fee schedule,78.14,217.61,Radiology
Gel cap app device for trach,L8515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,109.4,,,,,,,fee schedule,78.14,217.61,APC
Gel cap app device for trach,L8515,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,136.74,,,,,,,fee schedule,78.14,217.61,APC
Inj bulking agent anal canal,L8605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2344.09,,,,,,,fee schedule,2040.98,2546.17,
Inj bulking agent anal canal,L8605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2546.17,,,,,,,fee schedule,2040.98,2546.17,
Inj bulking agent anal canal,L8605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2040.98,,,,,,,fee schedule,2040.98,2546.17,
Inj bulking agent anal canal,L8605,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2229.58,,,,,,,fee schedule,2040.98,2546.17,
Inj vocal cord bulking agent,L8607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,143.34,,,,,,,fee schedule,124.81,155.7,
Inj vocal cord bulking agent,L8607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,155.7,,,,,,,fee schedule,124.81,155.7,
Inj vocal cord bulking agent,L8607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,124.81,,,,,,,fee schedule,124.81,155.7,
Inj vocal cord bulking agent,L8607,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,136.34,,,,,,,fee schedule,124.81,155.7,
Coch implant headset replace,L8615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1431.53,,,,,,,fee schedule,558.34,1554.94,
Coch implant headset replace,L8615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1554.94,,,,,,,fee schedule,558.34,1554.94,
Coch implant headset replace,L8615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1246.42,,,,,,,fee schedule,558.34,1554.94,
Coch implant headset replace,L8615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1361.6,,,,,,,fee schedule,558.34,1554.94,
Coch implant headset replace,L8615,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,586.26,,,,,,,fee schedule,558.34,1554.94,APC
Coch implant headset replace,L8615,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,580.67,,,,,,,fee schedule,558.34,1554.94,APC
Coch implant headset replace,L8615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,558.34,,,,,,,fee schedule,558.34,1554.94,APC
Coch implant headset replace,L8615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,854.26,,,,,,,fee schedule,558.34,1554.94,Radiology
Coch implant headset replace,L8615,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,781.68,,,,,,,fee schedule,558.34,1554.94,APC
Coch implant headset replace,L8615,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,977.1,,,,,,,fee schedule,558.34,1554.94,APC
Coch implant microphone repl,L8616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,333.42,,,,,,,fee schedule,130.05,362.16,
Coch implant microphone repl,L8616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,362.16,,,,,,,fee schedule,130.05,362.16,
Coch implant microphone repl,L8616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,290.3,,,,,,,fee schedule,130.05,362.16,
Coch implant microphone repl,L8616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,317.13,,,,,,,fee schedule,130.05,362.16,
Coch implant microphone repl,L8616,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,136.55,,,,,,,fee schedule,130.05,362.16,APC
Coch implant microphone repl,L8616,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,135.25,,,,,,,fee schedule,130.05,362.16,APC
Coch implant microphone repl,L8616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,130.05,,,,,,,fee schedule,130.05,362.16,APC
Coch implant microphone repl,L8616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,198.98,,,,,,,fee schedule,130.05,362.16,Radiology
Coch implant microphone repl,L8616,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,182.07,,,,,,,fee schedule,130.05,362.16,APC
Coch implant microphone repl,L8616,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,227.59,,,,,,,fee schedule,130.05,362.16,APC
Coch implant trans coil repl,L8617,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,291.24,,,,,,,fee schedule,113.62,316.35,
Coch implant trans coil repl,L8617,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,316.35,,,,,,,fee schedule,113.62,316.35,
Coch implant trans coil repl,L8617,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,253.58,,,,,,,fee schedule,113.62,316.35,
Coch implant trans coil repl,L8617,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,277.01,,,,,,,fee schedule,113.62,316.35,
Coch implant trans coil repl,L8617,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,119.3,,,,,,,fee schedule,113.62,316.35,APC
Coch implant trans coil repl,L8617,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,118.16,,,,,,,fee schedule,113.62,316.35,APC
Coch implant trans coil repl,L8617,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,113.62,,,,,,,fee schedule,113.62,316.35,APC
Coch implant trans coil repl,L8617,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,173.84,,,,,,,fee schedule,113.62,316.35,Radiology
Coch implant trans coil repl,L8617,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,159.07,,,,,,,fee schedule,113.62,316.35,APC
Coch implant trans coil repl,L8617,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,198.84,,,,,,,fee schedule,113.62,316.35,APC
Coch implant tran cable repl,L8618,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83.17,,,,,,,fee schedule,32.46,90.34,
Coch implant tran cable repl,L8618,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,90.34,,,,,,,fee schedule,32.46,90.34,
Coch implant tran cable repl,L8618,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,72.42,,,,,,,fee schedule,32.46,90.34,
Coch implant tran cable repl,L8618,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,79.11,,,,,,,fee schedule,32.46,90.34,
Coch implant tran cable repl,L8618,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,34.08,,,,,,,fee schedule,32.46,90.34,APC
Coch implant tran cable repl,L8618,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,33.76,,,,,,,fee schedule,32.46,90.34,APC
Coch implant tran cable repl,L8618,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,32.46,,,,,,,fee schedule,32.46,90.34,APC
Coch implant tran cable repl,L8618,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49.66,,,,,,,fee schedule,32.46,90.34,Radiology
Coch implant tran cable repl,L8618,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,45.44,,,,,,,fee schedule,32.46,90.34,APC
Coch implant tran cable repl,L8618,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,56.8,,,,,,,fee schedule,32.46,90.34,APC
Coch imp ext proc/contr rplc,L8619,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26081.35,,,,,,,fee schedule,10172.28,28329.74,
Coch imp ext proc/contr rplc,L8619,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,28329.74,,,,,,,fee schedule,10172.28,28329.74,
Coch imp ext proc/contr rplc,L8619,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22708.76,,,,,,,fee schedule,10172.28,28329.74,
Coch imp ext proc/contr rplc,L8619,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24807.26,,,,,,,fee schedule,10172.28,28329.74,
Coch imp ext proc/contr rplc,L8619,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10680.89,,,,,,,fee schedule,10172.28,28329.74,APC
Coch imp ext proc/contr rplc,L8619,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10579.17,,,,,,,fee schedule,10172.28,28329.74,APC
Coch imp ext proc/contr rplc,L8619,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10172.28,,,,,,,fee schedule,10172.28,28329.74,APC
Coch imp ext proc/contr rplc,L8619,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15563.59,,,,,,,fee schedule,10172.28,28329.74,Radiology
Coch imp ext proc/contr rplc,L8619,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14241.19,,,,,,,fee schedule,10172.28,28329.74,APC
Coch imp ext proc/contr rplc,L8619,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,17801.49,,,,,,,fee schedule,10172.28,28329.74,APC
Repl zinc air battery,L8621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.95,,,,,,,fee schedule,0.77,2.12,
Repl zinc air battery,L8621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.12,,,,,,,fee schedule,0.77,2.12,
Repl zinc air battery,L8621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.7,,,,,,,fee schedule,0.77,2.12,
Repl zinc air battery,L8621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.85,,,,,,,fee schedule,0.77,2.12,
Repl zinc air battery,L8621,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,0.81,,,,,,,fee schedule,0.77,2.12,APC
Repl zinc air battery,L8621,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,0.8,,,,,,,fee schedule,0.77,2.12,APC
Repl zinc air battery,L8621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,0.77,,,,,,,fee schedule,0.77,2.12,APC
Repl zinc air battery,L8621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1.18,,,,,,,fee schedule,0.77,2.12,Radiology
Repl zinc air battery,L8621,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1.08,,,,,,,fee schedule,0.77,2.12,APC
Repl zinc air battery,L8621,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1.35,,,,,,,fee schedule,0.77,2.12,APC
Repl alkaline battery,L8622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.04,,,,,,,fee schedule,0.4,1.13,
Repl alkaline battery,L8622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.13,,,,,,,fee schedule,0.4,1.13,
Repl alkaline battery,L8622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.91,,,,,,,fee schedule,0.4,1.13,
Repl alkaline battery,L8622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.99,,,,,,,fee schedule,0.4,1.13,
Repl alkaline battery,L8622,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,0.42,,,,,,,fee schedule,0.4,1.13,APC
Repl alkaline battery,L8622,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,0.42,,,,,,,fee schedule,0.4,1.13,APC
Repl alkaline battery,L8622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,0.4,,,,,,,fee schedule,0.4,1.13,APC
Repl alkaline battery,L8622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,0.61,,,,,,,fee schedule,0.4,1.13,Radiology
Repl alkaline battery,L8622,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,0.56,,,,,,,fee schedule,0.4,1.13,APC
Repl alkaline battery,L8622,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,0.7,,,,,,,fee schedule,0.4,1.13,APC
"Lith ion batt cid,non-earlvl",L8623,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,205.32,,,,,,,fee schedule,80.05,223.02,
"Lith ion batt cid,non-earlvl",L8623,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,223.02,,,,,,,fee schedule,80.05,223.02,
"Lith ion batt cid,non-earlvl",L8623,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,178.77,,,,,,,fee schedule,80.05,223.02,
"Lith ion batt cid,non-earlvl",L8623,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,195.29,,,,,,,fee schedule,80.05,223.02,
"Lith ion batt cid,non-earlvl",L8623,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,84.05,,,,,,,fee schedule,80.05,223.02,APC
"Lith ion batt cid,non-earlvl",L8623,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,83.25,,,,,,,fee schedule,80.05,223.02,APC
"Lith ion batt cid,non-earlvl",L8623,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,80.05,,,,,,,fee schedule,80.05,223.02,APC
"Lith ion batt cid,non-earlvl",L8623,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,122.48,,,,,,,fee schedule,80.05,223.02,Radiology
"Lith ion batt cid,non-earlvl",L8623,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,112.07,,,,,,,fee schedule,80.05,223.02,APC
"Lith ion batt cid,non-earlvl",L8623,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,140.09,,,,,,,fee schedule,80.05,223.02,APC
"Lith ion batt cid, ear level",L8624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,511.73,,,,,,,fee schedule,199.61,555.85,
"Lith ion batt cid, ear level",L8624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,555.85,,,,,,,fee schedule,199.61,555.85,
"Lith ion batt cid, ear level",L8624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,445.56,,,,,,,fee schedule,199.61,555.85,
"Lith ion batt cid, ear level",L8624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,486.74,,,,,,,fee schedule,199.61,555.85,
"Lith ion batt cid, ear level",L8624,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,209.59,,,,,,,fee schedule,199.61,555.85,APC
"Lith ion batt cid, ear level",L8624,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,207.59,,,,,,,fee schedule,199.61,555.85,APC
"Lith ion batt cid, ear level",L8624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,199.61,,,,,,,fee schedule,199.61,555.85,APC
"Lith ion batt cid, ear level",L8624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,305.4,,,,,,,fee schedule,199.61,555.85,Radiology
"Lith ion batt cid, ear level",L8624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,279.45,,,,,,,fee schedule,199.61,555.85,APC
"Lith ion batt cid, ear level",L8624,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,349.32,,,,,,,fee schedule,199.61,555.85,APC
CID ext speech process repl,L8627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22845.19,,,,,,,fee schedule,8640.87,24814.6,
CID ext speech process repl,L8627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24814.6,,,,,,,fee schedule,8640.87,24814.6,
CID ext speech process repl,L8627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19891.07,,,,,,,fee schedule,8640.87,24814.6,
CID ext speech process repl,L8627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21729.19,,,,,,,fee schedule,8640.87,24814.6,
CID ext speech process repl,L8627,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9072.91,,,,,,,fee schedule,8640.87,24814.6,APC
CID ext speech process repl,L8627,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8986.5,,,,,,,fee schedule,8640.87,24814.6,APC
CID ext speech process repl,L8627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8640.87,,,,,,,fee schedule,8640.87,24814.6,APC
CID ext speech process repl,L8627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13220.53,,,,,,,fee schedule,8640.87,24814.6,Radiology
CID ext speech process repl,L8627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12097.22,,,,,,,fee schedule,8640.87,24814.6,APC
CID ext speech process repl,L8627,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15121.52,,,,,,,fee schedule,8640.87,24814.6,APC
CID ext controller repl,L8628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4048.81,,,,,,,fee schedule,1531.43,4397.84,
CID ext controller repl,L8628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4397.84,,,,,,,fee schedule,1531.43,4397.84,
CID ext controller repl,L8628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3525.25,,,,,,,fee schedule,1531.43,4397.84,
CID ext controller repl,L8628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3851.02,,,,,,,fee schedule,1531.43,4397.84,
CID ext controller repl,L8628,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1608,,,,,,,fee schedule,1531.43,4397.84,APC
CID ext controller repl,L8628,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1592.69,,,,,,,fee schedule,1531.43,4397.84,APC
CID ext controller repl,L8628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1531.43,,,,,,,fee schedule,1531.43,4397.84,APC
CID ext controller repl,L8628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2343.09,,,,,,,fee schedule,1531.43,4397.84,Radiology
CID ext controller repl,L8628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2144,,,,,,,fee schedule,1531.43,4397.84,APC
CID ext controller repl,L8628,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2680,,,,,,,fee schedule,1531.43,4397.84,APC
CID transmit coil and cable,L8629,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,586.07,,,,,,,fee schedule,221.65,636.59,
CID transmit coil and cable,L8629,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,636.59,,,,,,,fee schedule,221.65,636.59,
CID transmit coil and cable,L8629,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,510.28,,,,,,,fee schedule,221.65,636.59,
CID transmit coil and cable,L8629,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,557.44,,,,,,,fee schedule,221.65,636.59,
CID transmit coil and cable,L8629,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,232.73,,,,,,,fee schedule,221.65,636.59,APC
CID transmit coil and cable,L8629,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,230.52,,,,,,,fee schedule,221.65,636.59,APC
CID transmit coil and cable,L8629,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,221.65,,,,,,,fee schedule,221.65,636.59,APC
CID transmit coil and cable,L8629,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,339.12,,,,,,,fee schedule,221.65,636.59,Radiology
CID transmit coil and cable,L8629,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,310.31,,,,,,,fee schedule,221.65,636.59,APC
CID transmit coil and cable,L8629,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,387.89,,,,,,,fee schedule,221.65,636.59,APC
Imp neurosti pls gn any type,L8679,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27995.7,,,,,,,fee schedule,24375.56,30409.12,
Imp neurosti pls gn any type,L8679,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30409.12,,,,,,,fee schedule,24375.56,30409.12,
Imp neurosti pls gn any type,L8679,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24375.56,,,,,,,fee schedule,24375.56,30409.12,
Imp neurosti pls gn any type,L8679,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26628.09,,,,,,,fee schedule,24375.56,30409.12,
Implt neurostim elctr each,L8680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1457.95,,,,,,,fee schedule,1269.42,1583.63,
Implt neurostim elctr each,L8680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1583.63,,,,,,,fee schedule,1269.42,1583.63,
Implt neurostim elctr each,L8680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1269.42,,,,,,,fee schedule,1269.42,1583.63,
Implt neurostim elctr each,L8680,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1386.72,,,,,,,fee schedule,1269.42,1583.63,
Pt prgrm for implt neurostim,L8681,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3386.25,,,,,,,fee schedule,1320.72,3678.17,
Pt prgrm for implt neurostim,L8681,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3678.17,,,,,,,fee schedule,1320.72,3678.17,
Pt prgrm for implt neurostim,L8681,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2948.37,,,,,,,fee schedule,1320.72,3678.17,
Pt prgrm for implt neurostim,L8681,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3220.83,,,,,,,fee schedule,1320.72,3678.17,
Pt prgrm for implt neurostim,L8681,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1386.76,,,,,,,fee schedule,1320.72,3678.17,APC
Pt prgrm for implt neurostim,L8681,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1373.55,,,,,,,fee schedule,1320.72,3678.17,APC
Pt prgrm for implt neurostim,L8681,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1320.72,,,,,,,fee schedule,1320.72,3678.17,APC
Pt prgrm for implt neurostim,L8681,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2020.7,,,,,,,fee schedule,1320.72,3678.17,Radiology
Pt prgrm for implt neurostim,L8681,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1849.01,,,,,,,fee schedule,1320.72,3678.17,APC
Pt prgrm for implt neurostim,L8681,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2311.26,,,,,,,fee schedule,1320.72,3678.17,APC
Radiofq trsmtr for implt neu,L8683,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16655.77,,,,,,,fee schedule,6496.09,18091.61,
Radiofq trsmtr for implt neu,L8683,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18091.61,,,,,,,fee schedule,6496.09,18091.61,
Radiofq trsmtr for implt neu,L8683,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14502,,,,,,,fee schedule,6496.09,18091.61,
Radiofq trsmtr for implt neu,L8683,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15842.12,,,,,,,fee schedule,6496.09,18091.61,
Radiofq trsmtr for implt neu,L8683,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6820.89,,,,,,,fee schedule,6496.09,18091.61,APC
Radiofq trsmtr for implt neu,L8683,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6755.93,,,,,,,fee schedule,6496.09,18091.61,APC
Radiofq trsmtr for implt neu,L8683,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6496.09,,,,,,,fee schedule,6496.09,18091.61,APC
Radiofq trsmtr for implt neu,L8683,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9939.02,,,,,,,fee schedule,6496.09,18091.61,Radiology
Radiofq trsmtr for implt neu,L8683,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9094.53,,,,,,,fee schedule,6496.09,18091.61,APC
Radiofq trsmtr for implt neu,L8683,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11368.16,,,,,,,fee schedule,6496.09,18091.61,APC
Radiof trsmtr implt scrl neu,L8684,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2450.51,,,,,,,fee schedule,955.74,2661.76,
Radiof trsmtr implt scrl neu,L8684,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2661.76,,,,,,,fee schedule,955.74,2661.76,
Radiof trsmtr implt scrl neu,L8684,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2133.64,,,,,,,fee schedule,955.74,2661.76,
Radiof trsmtr implt scrl neu,L8684,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2330.8,,,,,,,fee schedule,955.74,2661.76,
Radiof trsmtr implt scrl neu,L8684,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1003.53,,,,,,,fee schedule,955.74,2661.76,APC
Radiof trsmtr implt scrl neu,L8684,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,993.97,,,,,,,fee schedule,955.74,2661.76,APC
Radiof trsmtr implt scrl neu,L8684,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,955.74,,,,,,,fee schedule,955.74,2661.76,APC
Radiof trsmtr implt scrl neu,L8684,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1462.28,,,,,,,fee schedule,955.74,2661.76,Radiology
Radiof trsmtr implt scrl neu,L8684,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1338.04,,,,,,,fee schedule,955.74,2661.76,APC
Radiof trsmtr implt scrl neu,L8684,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1672.54,,,,,,,fee schedule,955.74,2661.76,APC
Implt nrostm pls gen sng rec,L8685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41505.3,,,,,,,fee schedule,36138.23,45083.34,
Implt nrostm pls gen sng rec,L8685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45083.34,,,,,,,fee schedule,36138.23,45083.34,
Implt nrostm pls gen sng rec,L8685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36138.23,,,,,,,fee schedule,36138.23,45083.34,
Implt nrostm pls gen sng rec,L8685,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39477.74,,,,,,,fee schedule,36138.23,45083.34,
Implt nrostm pls gen sng non,L8686,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26483.67,,,,,,,fee schedule,23059.06,28766.75,
Implt nrostm pls gen sng non,L8686,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,28766.75,,,,,,,fee schedule,23059.06,28766.75,
Implt nrostm pls gen sng non,L8686,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23059.06,,,,,,,fee schedule,23059.06,28766.75,
Implt nrostm pls gen sng non,L8686,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,25189.93,,,,,,,fee schedule,23059.06,28766.75,
Implt nrostm pls gen dua rec,L8687,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,54015.03,,,,,,,fee schedule,47030.33,58671.5,
Implt nrostm pls gen dua rec,L8687,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,58671.5,,,,,,,fee schedule,47030.33,58671.5,
Implt nrostm pls gen dua rec,L8687,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,47030.33,,,,,,,fee schedule,47030.33,58671.5,
Implt nrostm pls gen dua rec,L8687,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51376.36,,,,,,,fee schedule,47030.33,58671.5,
Implt nrostm pls gen dua non,L8688,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,34465.89,,,,,,,fee schedule,30009.09,37437.08,
Implt nrostm pls gen dua non,L8688,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37437.08,,,,,,,fee schedule,30009.09,37437.08,
Implt nrostm pls gen dua non,L8688,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,30009.09,,,,,,,fee schedule,30009.09,37437.08,
Implt nrostm pls gen dua non,L8688,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32782.21,,,,,,,fee schedule,30009.09,37437.08,
External recharg sys intern,L8689,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5474.94,,,,,,,fee schedule,2135.37,5946.92,
External recharg sys intern,L8689,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5946.92,,,,,,,fee schedule,2135.37,5946.92,
External recharg sys intern,L8689,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4766.98,,,,,,,fee schedule,2135.37,5946.92,
External recharg sys intern,L8689,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5207.49,,,,,,,fee schedule,2135.37,5946.92,
External recharg sys intern,L8689,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2242.14,,,,,,,fee schedule,2135.37,5946.92,APC
External recharg sys intern,L8689,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2220.78,,,,,,,fee schedule,2135.37,5946.92,APC
External recharg sys intern,L8689,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2135.37,,,,,,,fee schedule,2135.37,5946.92,APC
External recharg sys intern,L8689,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3267.12,,,,,,,fee schedule,2135.37,5946.92,Radiology
External recharg sys intern,L8689,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2989.52,,,,,,,fee schedule,2135.37,5946.92,APC
External recharg sys intern,L8689,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3736.9,,,,,,,fee schedule,2135.37,5946.92,APC
"Aud osseo dev, int/ext comp",L8690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15099.02,,,,,,,fee schedule,13146.56,16400.66,
"Aud osseo dev, int/ext comp",L8690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16400.66,,,,,,,fee schedule,13146.56,16400.66,
"Aud osseo dev, int/ext comp",L8690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13146.56,,,,,,,fee schedule,13146.56,16400.66,
"Aud osseo dev, int/ext comp",L8690,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14361.43,,,,,,,fee schedule,13146.56,16400.66,
Osseointegrated snd proc rpl,L8691,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8463.53,,,,,,,fee schedule,2131.89,9193.15,
Osseointegrated snd proc rpl,L8691,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9193.15,,,,,,,fee schedule,2131.89,9193.15,
Osseointegrated snd proc rpl,L8691,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7369.11,,,,,,,fee schedule,2131.89,9193.15,
Osseointegrated snd proc rpl,L8691,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8050.09,,,,,,,fee schedule,2131.89,9193.15,
Osseointegrated snd proc rpl,L8691,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2238.48,,,,,,,fee schedule,2131.89,9193.15,APC
Osseointegrated snd proc rpl,L8691,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2217.17,,,,,,,fee schedule,2131.89,9193.15,APC
Osseointegrated snd proc rpl,L8691,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2131.89,,,,,,,fee schedule,2131.89,9193.15,APC
Osseointegrated snd proc rpl,L8691,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3261.79,,,,,,,fee schedule,2131.89,9193.15,Radiology
Osseointegrated snd proc rpl,L8691,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2984.65,,,,,,,fee schedule,2131.89,9193.15,APC
Osseointegrated snd proc rpl,L8691,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3730.81,,,,,,,fee schedule,2131.89,9193.15,APC
"Aud osseo dev, abutment",L8693,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4962.79,,,,,,,fee schedule,1877.12,5390.62,
"Aud osseo dev, abutment",L8693,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5390.62,,,,,,,fee schedule,1877.12,5390.62,
"Aud osseo dev, abutment",L8693,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4321.05,,,,,,,fee schedule,1877.12,5390.62,
"Aud osseo dev, abutment",L8693,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4720.36,,,,,,,fee schedule,1877.12,5390.62,
"Aud osseo dev, abutment",L8693,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1970.98,,,,,,,fee schedule,1877.12,5390.62,APC
"Aud osseo dev, abutment",L8693,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1952.2,,,,,,,fee schedule,1877.12,5390.62,APC
"Aud osseo dev, abutment",L8693,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1877.12,,,,,,,fee schedule,1877.12,5390.62,APC
"Aud osseo dev, abutment",L8693,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2871.99,,,,,,,fee schedule,1877.12,5390.62,Radiology
"Aud osseo dev, abutment",L8693,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2627.97,,,,,,,fee schedule,1877.12,5390.62,APC
"Aud osseo dev, abutment",L8693,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3284.96,,,,,,,fee schedule,1877.12,5390.62,APC
External recharg sys extern,L8695,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,52.9,,,,,,,fee schedule,20.61,57.46,
External recharg sys extern,L8695,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,57.46,,,,,,,fee schedule,20.61,57.46,
External recharg sys extern,L8695,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.06,,,,,,,fee schedule,20.61,57.46,
External recharg sys extern,L8695,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,50.31,,,,,,,fee schedule,20.61,57.46,
External recharg sys extern,L8695,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.64,,,,,,,fee schedule,20.61,57.46,APC
External recharg sys extern,L8695,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,21.43,,,,,,,fee schedule,20.61,57.46,APC
External recharg sys extern,L8695,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,20.61,,,,,,,fee schedule,20.61,57.46,APC
External recharg sys extern,L8695,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,31.53,,,,,,,fee schedule,20.61,57.46,Radiology
External recharg sys extern,L8695,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.85,,,,,,,fee schedule,20.61,57.46,APC
External recharg sys extern,L8695,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,36.07,,,,,,,fee schedule,20.61,57.46,APC
Ext antenna phren nerve stim,L8696,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,727.18,,,,,,,fee schedule,268.31,789.87,
Ext antenna phren nerve stim,L8696,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,789.87,,,,,,,fee schedule,268.31,789.87,
Ext antenna phren nerve stim,L8696,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,633.15,,,,,,,fee schedule,268.31,789.87,
Ext antenna phren nerve stim,L8696,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,691.66,,,,,,,fee schedule,268.31,789.87,
Ext antenna phren nerve stim,L8696,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,281.73,,,,,,,fee schedule,268.31,789.87,APC
Ext antenna phren nerve stim,L8696,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,279.04,,,,,,,fee schedule,268.31,789.87,APC
Ext antenna phren nerve stim,L8696,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,268.31,,,,,,,fee schedule,268.31,789.87,APC
Ext antenna phren nerve stim,L8696,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,410.51,,,,,,,fee schedule,268.31,789.87,Radiology
Ext antenna phren nerve stim,L8696,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,375.63,,,,,,,fee schedule,268.31,789.87,APC
Ext antenna phren nerve stim,L8696,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,469.54,,,,,,,fee schedule,268.31,789.87,APC
Covid-19 vaccine home admin,M0201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,123.54,,,,,,,fee schedule,35.71,158.42,
Covid-19 vaccine home admin,M0201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,134.19,,,,,,,fee schedule,35.71,158.42,
Covid-19 vaccine home admin,M0201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,107.57,,,,,,,fee schedule,35.71,158.42,
Covid-19 vaccine home admin,M0201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,117.51,,,,,,,fee schedule,35.71,158.42,
Covid-19 vaccine home admin,M0201,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,158.42,,,,,,,fee schedule,35.71,158.42,APC 378
Covid-19 vaccine home admin,M0201,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,37.49,,,,,,,fee schedule,35.71,158.42,APC
Covid-19 vaccine home admin,M0201,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,37.14,,,,,,,fee schedule,35.71,158.42,APC
Covid-19 vaccine home admin,M0201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,35.71,,,,,,,fee schedule,35.71,158.42,APC
Covid-19 vaccine home admin,M0201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,54.63,,,,,,,fee schedule,35.71,158.42,Radiology
Covid-19 vaccine home admin,M0201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49.99,,,,,,,fee schedule,35.71,158.42,APC
Covid-19 vaccine home admin,M0201,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,62.49,,,,,,,fee schedule,35.71,158.42,APC
Tixagev and cilgav inj,M0220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,523.74,,,,,,,fee schedule,456.02,568.89,
Tixagev and cilgav inj,M0220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,568.89,,,,,,,fee schedule,456.02,568.89,
Tixagev and cilgav inj,M0220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,456.02,,,,,,,fee schedule,456.02,568.89,
Tixagev and cilgav inj,M0220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,498.16,,,,,,,fee schedule,456.02,568.89,
Tixagev and cilgav inj hm,M0221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,871.74,,,,,,,fee schedule,759.02,946.89,
Tixagev and cilgav inj hm,M0221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,946.89,,,,,,,fee schedule,759.02,946.89,
Tixagev and cilgav inj hm,M0221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,759.02,,,,,,,fee schedule,759.02,946.89,
Tixagev and cilgav inj hm,M0221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,829.16,,,,,,,fee schedule,759.02,946.89,
Bebtelovimab injection,M0222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1219.74,,,,,,,fee schedule,1062.02,1324.89,
Bebtelovimab injection,M0222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1324.89,,,,,,,fee schedule,1062.02,1324.89,
Bebtelovimab injection,M0222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1062.02,,,,,,,fee schedule,1062.02,1324.89,
Bebtelovimab injection,M0222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1160.16,,,,,,,fee schedule,1062.02,1324.89,
Bebtelovimab injection home,M0223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1915.74,,,,,,,fee schedule,1668.02,2080.89,
Bebtelovimab injection home,M0223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2080.89,,,,,,,fee schedule,1668.02,2080.89,
Bebtelovimab injection home,M0223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1668.02,,,,,,,fee schedule,1668.02,2080.89,
Bebtelovimab injection home,M0223,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1822.16,,,,,,,fee schedule,1668.02,2080.89,
Pemivibart infusion,M0224,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1936.72,,,,,,,fee schedule,436.53,1936.72,APC 378
Pemivibart infusion,M0224,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,458.35,,,,,,,fee schedule,436.53,1936.72,APC
Pemivibart infusion,M0224,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,453.99,,,,,,,fee schedule,436.53,1936.72,APC
Pemivibart infusion,M0224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,436.53,,,,,,,fee schedule,436.53,1936.72,APC
Pemivibart infusion,M0224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,667.88,,,,,,,fee schedule,436.53,1936.72,Radiology
Pemivibart infusion,M0224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,611.14,,,,,,,fee schedule,436.53,1936.72,APC
Pemivibart infusion,M0224,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,763.92,,,,,,,fee schedule,436.53,1936.72,APC
"Intra inf, toci, first dose",M0233,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1936.72,,,,,,,fee schedule,436.53,1936.72,APC 378
"Intra inf, toci, first dose",M0233,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,458.35,,,,,,,fee schedule,436.53,1936.72,APC
"Intra inf, toci, first dose",M0233,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,453.99,,,,,,,fee schedule,436.53,1936.72,APC
"Intra inf, toci, first dose",M0233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,436.53,,,,,,,fee schedule,436.53,1936.72,APC
"Intra inf, toci, first dose",M0233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,667.88,,,,,,,fee schedule,436.53,1936.72,Radiology
"Intra inf, toci, first dose",M0233,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,611.14,,,,,,,fee schedule,436.53,1936.72,APC
"Intra inf, toci, first dose",M0233,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,763.92,,,,,,,fee schedule,436.53,1936.72,APC
"Intra inf, toci, second dos",M0234,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1936.72,,,,,,,fee schedule,436.53,1936.72,APC 378
"Intra inf, toci, second dos",M0234,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,458.35,,,,,,,fee schedule,436.53,1936.72,APC
"Intra inf, toci, second dos",M0234,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,453.99,,,,,,,fee schedule,436.53,1936.72,APC
"Intra inf, toci, second dos",M0234,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,436.53,,,,,,,fee schedule,436.53,1936.72,APC
"Intra inf, toci, second dos",M0234,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,667.88,,,,,,,fee schedule,436.53,1936.72,Radiology
"Intra inf, toci, second dos",M0234,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,611.14,,,,,,,fee schedule,436.53,1936.72,APC
"Intra inf, toci, second dos",M0234,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,763.92,,,,,,,fee schedule,436.53,1936.72,APC
"Intrav inf, mon anti, fir do",M0235,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1936.72,,,,,,,fee schedule,436.53,1936.72,APC 378
"Intrav inf, mon anti, fir do",M0235,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,458.35,,,,,,,fee schedule,436.53,1936.72,APC
"Intrav inf, mon anti, fir do",M0235,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,453.99,,,,,,,fee schedule,436.53,1936.72,APC
"Intrav inf, mon anti, fir do",M0235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,436.53,,,,,,,fee schedule,436.53,1936.72,APC
"Intrav inf, mon anti, fir do",M0235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,667.88,,,,,,,fee schedule,436.53,1936.72,Radiology
"Intrav inf, mon anti, fir do",M0235,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,611.14,,,,,,,fee schedule,436.53,1936.72,APC
"Intrav inf, mon anti, fir do",M0235,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,763.92,,,,,,,fee schedule,436.53,1936.72,APC
"Intrav inf, mon anti, sec do",M0236,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1936.72,,,,,,,fee schedule,436.53,1936.72,APC 378
"Intrav inf, mon anti, sec do",M0236,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,458.35,,,,,,,fee schedule,436.53,1936.72,APC
"Intrav inf, mon anti, sec do",M0236,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,453.99,,,,,,,fee schedule,436.53,1936.72,APC
"Intrav inf, mon anti, sec do",M0236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,436.53,,,,,,,fee schedule,436.53,1936.72,APC
"Intrav inf, mon anti, sec do",M0236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,667.88,,,,,,,fee schedule,436.53,1936.72,Radiology
"Intrav inf, mon anti, sec do",M0236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,611.14,,,,,,,fee schedule,436.53,1936.72,APC
"Intrav inf, mon anti, sec do",M0236,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,763.92,,,,,,,fee schedule,436.53,1936.72,APC
"Intrav inf, toci, first dose",M0237,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1936.72,,,,,,,fee schedule,436.53,1936.72,APC 378
"Intrav inf, toci, first dose",M0237,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,458.35,,,,,,,fee schedule,436.53,1936.72,APC
"Intrav inf, toci, first dose",M0237,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,453.99,,,,,,,fee schedule,436.53,1936.72,APC
"Intrav inf, toci, first dose",M0237,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,436.53,,,,,,,fee schedule,436.53,1936.72,APC
"Intrav inf, toci, first dose",M0237,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,667.88,,,,,,,fee schedule,436.53,1936.72,Radiology
"Intrav inf, toci, first dose",M0237,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,611.14,,,,,,,fee schedule,436.53,1936.72,APC
"Intrav inf, toci, first dose",M0237,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,763.92,,,,,,,fee schedule,436.53,1936.72,APC
"Intrav inf, toci, second dos",M0238,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1936.72,,,,,,,fee schedule,436.53,1936.72,APC 378
"Intrav inf, toci, second dos",M0238,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,458.35,,,,,,,fee schedule,436.53,1936.72,APC
"Intrav inf, toci, second dos",M0238,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,453.99,,,,,,,fee schedule,436.53,1936.72,APC
"Intrav inf, toci, second dos",M0238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,436.53,,,,,,,fee schedule,436.53,1936.72,APC
"Intrav inf, toci, second dos",M0238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,667.88,,,,,,,fee schedule,436.53,1936.72,Radiology
"Intrav inf, toci, second dos",M0238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,611.14,,,,,,,fee schedule,436.53,1936.72,APC
"Intrav inf, toci, second dos",M0238,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,763.92,,,,,,,fee schedule,436.53,1936.72,APC
Casiri and imdev repeat,M0240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1567.74,,,,,,,fee schedule,1365.02,1702.89,
Casiri and imdev repeat,M0240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1702.89,,,,,,,fee schedule,1365.02,1702.89,
Casiri and imdev repeat,M0240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1365.02,,,,,,,fee schedule,1365.02,1702.89,
Casiri and imdev repeat,M0240,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1491.16,,,,,,,fee schedule,1365.02,1702.89,
Casiri and imdev repeat hm,M0241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2611.74,,,,,,,fee schedule,2274.02,2836.89,
Casiri and imdev repeat hm,M0241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2836.89,,,,,,,fee schedule,2274.02,2836.89,
Casiri and imdev repeat hm,M0241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2274.02,,,,,,,fee schedule,2274.02,2836.89,
Casiri and imdev repeat hm,M0241,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2484.16,,,,,,,fee schedule,2274.02,2836.89,
Casirivi and imdevi infusion,M0243,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1566,,,,,,,fee schedule,1363.5,1701,
Casirivi and imdevi infusion,M0243,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1701,,,,,,,fee schedule,1363.5,1701,
Casirivi and imdevi infusion,M0243,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1363.5,,,,,,,fee schedule,1363.5,1701,
Casirivi and imdevi infusion,M0243,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1489.5,,,,,,,fee schedule,1363.5,1701,
Casirivi and imdevi infus hm,M0244,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2611.74,,,,,,,fee schedule,2274.02,2836.89,
Casirivi and imdevi infus hm,M0244,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2836.89,,,,,,,fee schedule,2274.02,2836.89,
Casirivi and imdevi infus hm,M0244,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2274.02,,,,,,,fee schedule,2274.02,2836.89,
Casirivi and imdevi infus hm,M0244,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2484.16,,,,,,,fee schedule,2274.02,2836.89,
Bamlan and etesev infusion,M0245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1567.74,,,,,,,fee schedule,1365.02,1702.89,
Bamlan and etesev infusion,M0245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1702.89,,,,,,,fee schedule,1365.02,1702.89,
Bamlan and etesev infusion,M0245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1365.02,,,,,,,fee schedule,1365.02,1702.89,
Bamlan and etesev infusion,M0245,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1491.16,,,,,,,fee schedule,1365.02,1702.89,
Bamlan and etesev infus home,M0246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2611.74,,,,,,,fee schedule,2274.02,2836.89,
Bamlan and etesev infus home,M0246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2836.89,,,,,,,fee schedule,2274.02,2836.89,
Bamlan and etesev infus home,M0246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2274.02,,,,,,,fee schedule,2274.02,2836.89,
Bamlan and etesev infus home,M0246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2484.16,,,,,,,fee schedule,2274.02,2836.89,
Sotrovimab infusion,M0247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1567.74,,,,,,,fee schedule,1365.02,1702.89,
Sotrovimab infusion,M0247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1702.89,,,,,,,fee schedule,1365.02,1702.89,
Sotrovimab infusion,M0247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1365.02,,,,,,,fee schedule,1365.02,1702.89,
Sotrovimab infusion,M0247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1491.16,,,,,,,fee schedule,1365.02,1702.89,
"Sotrovimab inf, home admin",M0248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2611.74,,,,,,,fee schedule,2274.02,2836.89,
"Sotrovimab inf, home admin",M0248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2836.89,,,,,,,fee schedule,2274.02,2836.89,
"Sotrovimab inf, home admin",M0248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2274.02,,,,,,,fee schedule,2274.02,2836.89,
"Sotrovimab inf, home admin",M0248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2484.16,,,,,,,fee schedule,2274.02,2836.89,
Adm tocilizu covid-19 1st,M0249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1567.74,,,,,,,fee schedule,436.53,1936.72,
Adm tocilizu covid-19 1st,M0249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1702.89,,,,,,,fee schedule,436.53,1936.72,
Adm tocilizu covid-19 1st,M0249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1365.02,,,,,,,fee schedule,436.53,1936.72,
Adm tocilizu covid-19 1st,M0249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1491.16,,,,,,,fee schedule,436.53,1936.72,
Adm tocilizu covid-19 1st,M0249,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1936.72,,,,,,,fee schedule,436.53,1936.72,APC 378
Adm tocilizu covid-19 1st,M0249,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,458.35,,,,,,,fee schedule,436.53,1936.72,APC
Adm tocilizu covid-19 1st,M0249,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,453.99,,,,,,,fee schedule,436.53,1936.72,APC
Adm tocilizu covid-19 1st,M0249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,436.53,,,,,,,fee schedule,436.53,1936.72,APC
Adm tocilizu covid-19 1st,M0249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,667.88,,,,,,,fee schedule,436.53,1936.72,Radiology
Adm tocilizu covid-19 1st,M0249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,611.14,,,,,,,fee schedule,436.53,1936.72,APC
Adm tocilizu covid-19 1st,M0249,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,763.92,,,,,,,fee schedule,436.53,1936.72,APC
Adm tocilizu covid-19 2nd,M0250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1567.74,,,,,,,fee schedule,436.53,1936.72,
Adm tocilizu covid-19 2nd,M0250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1702.89,,,,,,,fee schedule,436.53,1936.72,
Adm tocilizu covid-19 2nd,M0250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1365.02,,,,,,,fee schedule,436.53,1936.72,
Adm tocilizu covid-19 2nd,M0250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1491.16,,,,,,,fee schedule,436.53,1936.72,
Adm tocilizu covid-19 2nd,M0250,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1936.72,,,,,,,fee schedule,436.53,1936.72,APC 378
Adm tocilizu covid-19 2nd,M0250,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,458.35,,,,,,,fee schedule,436.53,1936.72,APC
Adm tocilizu covid-19 2nd,M0250,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,453.99,,,,,,,fee schedule,436.53,1936.72,APC
Adm tocilizu covid-19 2nd,M0250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,436.53,,,,,,,fee schedule,436.53,1936.72,APC
Adm tocilizu covid-19 2nd,M0250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,667.88,,,,,,,fee schedule,436.53,1936.72,Radiology
Adm tocilizu covid-19 2nd,M0250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,611.14,,,,,,,fee schedule,436.53,1936.72,APC
Adm tocilizu covid-19 2nd,M0250,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,763.92,,,,,,,fee schedule,436.53,1936.72,APC
Cephalin floculation test,P2028,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.46,,,,,,,fee schedule,4.46,8.66,Laboratory
Cephalin floculation test,P2028,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.2,,,,,,,fee schedule,4.46,8.66,APC
Cephalin floculation test,P2028,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5.15,,,,,,,fee schedule,4.46,8.66,APC
Cephalin floculation test,P2028,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4.95,,,,,,,fee schedule,4.46,8.66,APC
Cephalin floculation test,P2028,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.57,,,,,,,fee schedule,4.46,8.66,Radiology
Cephalin floculation test,P2028,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.93,,,,,,,fee schedule,4.46,8.66,APC
Cephalin floculation test,P2028,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8.66,,,,,,,fee schedule,4.46,8.66,APC
Congo red blood test,P2029,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.46,,,,,,,fee schedule,4.46,8.66,Laboratory
Congo red blood test,P2029,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.2,,,,,,,fee schedule,4.46,8.66,APC
Congo red blood test,P2029,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5.15,,,,,,,fee schedule,4.46,8.66,APC
Congo red blood test,P2029,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4.95,,,,,,,fee schedule,4.46,8.66,APC
Congo red blood test,P2029,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.57,,,,,,,fee schedule,4.46,8.66,Radiology
Congo red blood test,P2029,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.93,,,,,,,fee schedule,4.46,8.66,APC
Congo red blood test,P2029,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8.66,,,,,,,fee schedule,4.46,8.66,APC
Blood thymol turbidity,P2033,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.46,,,,,,,fee schedule,4.46,8.66,Laboratory
Blood thymol turbidity,P2033,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.2,,,,,,,fee schedule,4.46,8.66,APC
Blood thymol turbidity,P2033,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5.15,,,,,,,fee schedule,4.46,8.66,APC
Blood thymol turbidity,P2033,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4.95,,,,,,,fee schedule,4.46,8.66,APC
Blood thymol turbidity,P2033,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.57,,,,,,,fee schedule,4.46,8.66,Radiology
Blood thymol turbidity,P2033,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.93,,,,,,,fee schedule,4.46,8.66,APC
Blood thymol turbidity,P2033,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8.66,,,,,,,fee schedule,4.46,8.66,APC
Blood mucoprotein,P2038,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,25.54,,,,,,,fee schedule,4.46,27.75,
Blood mucoprotein,P2038,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27.75,,,,,,,fee schedule,4.46,27.75,
Blood mucoprotein,P2038,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22.24,,,,,,,fee schedule,4.46,27.75,
Blood mucoprotein,P2038,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24.3,,,,,,,fee schedule,4.46,27.75,
Blood mucoprotein,P2038,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4.46,,,,,,,fee schedule,4.46,27.75,Laboratory
Blood mucoprotein,P2038,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.2,,,,,,,fee schedule,4.46,27.75,APC
Blood mucoprotein,P2038,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5.15,,,,,,,fee schedule,4.46,27.75,APC
Blood mucoprotein,P2038,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4.95,,,,,,,fee schedule,4.46,27.75,APC
Blood mucoprotein,P2038,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.57,,,,,,,fee schedule,4.46,27.75,Radiology
Blood mucoprotein,P2038,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.93,,,,,,,fee schedule,4.46,27.75,APC
Blood mucoprotein,P2038,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8.66,,,,,,,fee schedule,4.46,27.75,APC
Screen pap by tech w md supv,P3000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,53.66,,,,,,,fee schedule,16.69,58.29,
Screen pap by tech w md supv,P3000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,58.29,,,,,,,fee schedule,16.69,58.29,
Screen pap by tech w md supv,P3000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.72,,,,,,,fee schedule,16.69,58.29,
Screen pap by tech w md supv,P3000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.04,,,,,,,fee schedule,16.69,58.29,
Screen pap by tech w md supv,P3000,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.69,,,,,,,fee schedule,16.69,58.29,Laboratory
Screen pap by tech w md supv,P3000,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.47,,,,,,,fee schedule,16.69,58.29,APC
Screen pap by tech w md supv,P3000,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,19.28,,,,,,,fee schedule,16.69,58.29,APC
Screen pap by tech w md supv,P3000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18.54,,,,,,,fee schedule,16.69,58.29,APC
Screen pap by tech w md supv,P3000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.37,,,,,,,fee schedule,16.69,58.29,Radiology
Screen pap by tech w md supv,P3000,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.96,,,,,,,fee schedule,16.69,58.29,APC
Screen pap by tech w md supv,P3000,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,32.44,,,,,,,fee schedule,16.69,58.29,APC
Screening pap smear by phys,P3001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,90.1,,,,,,,fee schedule,78.45,97.86,
Screening pap smear by phys,P3001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,97.86,,,,,,,fee schedule,78.45,97.86,
Screening pap smear by phys,P3001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,78.45,,,,,,,fee schedule,78.45,97.86,
Screening pap smear by phys,P3001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,85.7,,,,,,,fee schedule,78.45,97.86,
Whole blood for transfusion,P9010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,919.35,,,,,,,fee schedule,189.84,998.6,
Whole blood for transfusion,P9010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,998.6,,,,,,,fee schedule,189.84,998.6,
Whole blood for transfusion,P9010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,800.47,,,,,,,fee schedule,189.84,998.6,
Whole blood for transfusion,P9010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,874.44,,,,,,,fee schedule,189.84,998.6,
Whole blood for transfusion,P9010,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,842.26,,,,,,,fee schedule,189.84,998.6,APC 378
Whole blood for transfusion,P9010,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,199.33,,,,,,,fee schedule,189.84,998.6,APC
Whole blood for transfusion,P9010,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,197.43,,,,,,,fee schedule,189.84,998.6,APC
Whole blood for transfusion,P9010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,189.84,,,,,,,fee schedule,189.84,998.6,APC
Whole blood for transfusion,P9010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,290.46,,,,,,,fee schedule,189.84,998.6,Radiology
Whole blood for transfusion,P9010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,265.78,,,,,,,fee schedule,189.84,998.6,APC
Whole blood for transfusion,P9010,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,332.22,,,,,,,fee schedule,189.84,998.6,APC
Blood split unit,P9011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,537.87,,,,,,,fee schedule,155.84,691.41,
Blood split unit,P9011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,584.24,,,,,,,fee schedule,155.84,691.41,
Blood split unit,P9011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,468.32,,,,,,,fee schedule,155.84,691.41,
Blood split unit,P9011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,511.59,,,,,,,fee schedule,155.84,691.41,
Blood split unit,P9011,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,691.41,,,,,,,fee schedule,155.84,691.41,APC 378
Blood split unit,P9011,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,163.63,,,,,,,fee schedule,155.84,691.41,APC
Blood split unit,P9011,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,162.07,,,,,,,fee schedule,155.84,691.41,APC
Blood split unit,P9011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,155.84,,,,,,,fee schedule,155.84,691.41,APC
Blood split unit,P9011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,238.44,,,,,,,fee schedule,155.84,691.41,Radiology
Blood split unit,P9011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,218.18,,,,,,,fee schedule,155.84,691.41,APC
Blood split unit,P9011,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,272.72,,,,,,,fee schedule,155.84,691.41,APC
Cryoprecipitate each unit,P9012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,148.77,,,,,,,fee schedule,71.95,319.22,
Cryoprecipitate each unit,P9012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,161.6,,,,,,,fee schedule,71.95,319.22,
Cryoprecipitate each unit,P9012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,129.53,,,,,,,fee schedule,71.95,319.22,
Cryoprecipitate each unit,P9012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,141.5,,,,,,,fee schedule,71.95,319.22,
Cryoprecipitate each unit,P9012,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,319.22,,,,,,,fee schedule,71.95,319.22,APC 378
Cryoprecipitate each unit,P9012,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,75.55,,,,,,,fee schedule,71.95,319.22,APC
Cryoprecipitate each unit,P9012,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,74.83,,,,,,,fee schedule,71.95,319.22,APC
Cryoprecipitate each unit,P9012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,71.95,,,,,,,fee schedule,71.95,319.22,APC
Cryoprecipitate each unit,P9012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,110.08,,,,,,,fee schedule,71.95,319.22,Radiology
Cryoprecipitate each unit,P9012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,100.73,,,,,,,fee schedule,71.95,319.22,APC
Cryoprecipitate each unit,P9012,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,125.91,,,,,,,fee schedule,71.95,319.22,APC
Rbc leukocytes reduced,P9016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,332.96,,,,,,,fee schedule,184.91,820.38,
Rbc leukocytes reduced,P9016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,361.67,,,,,,,fee schedule,184.91,820.38,
Rbc leukocytes reduced,P9016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,289.91,,,,,,,fee schedule,184.91,820.38,
Rbc leukocytes reduced,P9016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,316.7,,,,,,,fee schedule,184.91,820.38,
Rbc leukocytes reduced,P9016,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,820.38,,,,,,,fee schedule,184.91,820.38,APC 378
Rbc leukocytes reduced,P9016,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,194.16,,,,,,,fee schedule,184.91,820.38,APC
Rbc leukocytes reduced,P9016,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,192.31,,,,,,,fee schedule,184.91,820.38,APC
Rbc leukocytes reduced,P9016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,184.91,,,,,,,fee schedule,184.91,820.38,APC
Rbc leukocytes reduced,P9016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,282.91,,,,,,,fee schedule,184.91,820.38,Radiology
Rbc leukocytes reduced,P9016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,258.87,,,,,,,fee schedule,184.91,820.38,APC
Rbc leukocytes reduced,P9016,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,323.59,,,,,,,fee schedule,184.91,820.38,APC
Plasma 1 donor frz w/in 8 hr,P9017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,237.43,,,,,,,fee schedule,85.98,381.46,
Plasma 1 donor frz w/in 8 hr,P9017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,257.9,,,,,,,fee schedule,85.98,381.46,
Plasma 1 donor frz w/in 8 hr,P9017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,206.73,,,,,,,fee schedule,85.98,381.46,
Plasma 1 donor frz w/in 8 hr,P9017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,225.83,,,,,,,fee schedule,85.98,381.46,
Plasma 1 donor frz w/in 8 hr,P9017,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,381.46,,,,,,,fee schedule,85.98,381.46,APC 378
Plasma 1 donor frz w/in 8 hr,P9017,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,90.28,,,,,,,fee schedule,85.98,381.46,APC
Plasma 1 donor frz w/in 8 hr,P9017,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,89.42,,,,,,,fee schedule,85.98,381.46,APC
Plasma 1 donor frz w/in 8 hr,P9017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,85.98,,,,,,,fee schedule,85.98,381.46,APC
Plasma 1 donor frz w/in 8 hr,P9017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,131.55,,,,,,,fee schedule,85.98,381.46,Radiology
Plasma 1 donor frz w/in 8 hr,P9017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.37,,,,,,,fee schedule,85.98,381.46,APC
Plasma 1 donor frz w/in 8 hr,P9017,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,150.46,,,,,,,fee schedule,85.98,381.46,APC
"Platelets, each unit",P9019,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,250.7,,,,,,,fee schedule,53.17,272.31,
"Platelets, each unit",P9019,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,272.31,,,,,,,fee schedule,53.17,272.31,
"Platelets, each unit",P9019,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,218.28,,,,,,,fee schedule,53.17,272.31,
"Platelets, each unit",P9019,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,238.45,,,,,,,fee schedule,53.17,272.31,
"Platelets, each unit",P9019,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,235.9,,,,,,,fee schedule,53.17,272.31,APC 378
"Platelets, each unit",P9019,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,55.83,,,,,,,fee schedule,53.17,272.31,APC
"Platelets, each unit",P9019,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,55.3,,,,,,,fee schedule,53.17,272.31,APC
"Platelets, each unit",P9019,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,53.17,,,,,,,fee schedule,53.17,272.31,APC
"Platelets, each unit",P9019,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.35,,,,,,,fee schedule,53.17,272.31,Radiology
"Platelets, each unit",P9019,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,74.44,,,,,,,fee schedule,53.17,272.31,APC
"Platelets, each unit",P9019,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,93.05,,,,,,,fee schedule,53.17,272.31,APC
Plaelet rich plasma unit,P9020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1311.26,,,,,,,fee schedule,559.79,2483.6,
Plaelet rich plasma unit,P9020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1424.3,,,,,,,fee schedule,559.79,2483.6,
Plaelet rich plasma unit,P9020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1141.7,,,,,,,fee schedule,559.79,2483.6,
Plaelet rich plasma unit,P9020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1247.21,,,,,,,fee schedule,559.79,2483.6,
Plaelet rich plasma unit,P9020,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2483.6,,,,,,,fee schedule,559.79,2483.6,APC 378
Plaelet rich plasma unit,P9020,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,587.78,,,,,,,fee schedule,559.79,2483.6,APC
Plaelet rich plasma unit,P9020,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,582.18,,,,,,,fee schedule,559.79,2483.6,APC
Plaelet rich plasma unit,P9020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,559.79,,,,,,,fee schedule,559.79,2483.6,APC
Plaelet rich plasma unit,P9020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,856.48,,,,,,,fee schedule,559.79,2483.6,Radiology
Plaelet rich plasma unit,P9020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,783.71,,,,,,,fee schedule,559.79,2483.6,APC
Plaelet rich plasma unit,P9020,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,979.63,,,,,,,fee schedule,559.79,2483.6,APC
Red blood cells unit,P9021,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,467.75,,,,,,,fee schedule,150.57,668.03,
Red blood cells unit,P9021,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,508.07,,,,,,,fee schedule,150.57,668.03,
Red blood cells unit,P9021,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,407.26,,,,,,,fee schedule,150.57,668.03,
Red blood cells unit,P9021,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,444.9,,,,,,,fee schedule,150.57,668.03,
Red blood cells unit,P9021,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,668.03,,,,,,,fee schedule,150.57,668.03,APC 378
Red blood cells unit,P9021,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,158.1,,,,,,,fee schedule,150.57,668.03,APC
Red blood cells unit,P9021,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,156.59,,,,,,,fee schedule,150.57,668.03,APC
Red blood cells unit,P9021,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,150.57,,,,,,,fee schedule,150.57,668.03,APC
Red blood cells unit,P9021,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,230.37,,,,,,,fee schedule,150.57,668.03,Radiology
Red blood cells unit,P9021,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,210.8,,,,,,,fee schedule,150.57,668.03,APC
Red blood cells unit,P9021,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,263.5,,,,,,,fee schedule,150.57,668.03,APC
Washed red blood cells unit,P9022,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,999.35,,,,,,,fee schedule,368.58,1635.26,
Washed red blood cells unit,P9022,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1085.5,,,,,,,fee schedule,368.58,1635.26,
Washed red blood cells unit,P9022,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,870.13,,,,,,,fee schedule,368.58,1635.26,
Washed red blood cells unit,P9022,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,950.53,,,,,,,fee schedule,368.58,1635.26,
Washed red blood cells unit,P9022,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1635.26,,,,,,,fee schedule,368.58,1635.26,APC 378
Washed red blood cells unit,P9022,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,387.01,,,,,,,fee schedule,368.58,1635.26,APC
Washed red blood cells unit,P9022,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,383.32,,,,,,,fee schedule,368.58,1635.26,APC
Washed red blood cells unit,P9022,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,368.58,,,,,,,fee schedule,368.58,1635.26,APC
Washed red blood cells unit,P9022,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,563.93,,,,,,,fee schedule,368.58,1635.26,Radiology
Washed red blood cells unit,P9022,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,516.01,,,,,,,fee schedule,368.58,1635.26,APC
Washed red blood cells unit,P9022,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,645.02,,,,,,,fee schedule,368.58,1635.26,APC
"Frozen plasma, pooled, sd",P9023,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,266.46,,,,,,,fee schedule,55.96,289.43,
"Frozen plasma, pooled, sd",P9023,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,289.43,,,,,,,fee schedule,55.96,289.43,
"Frozen plasma, pooled, sd",P9023,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,232.01,,,,,,,fee schedule,55.96,289.43,
"Frozen plasma, pooled, sd",P9023,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,253.45,,,,,,,fee schedule,55.96,289.43,
"Frozen plasma, pooled, sd",P9023,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,248.28,,,,,,,fee schedule,55.96,289.43,APC 378
"Frozen plasma, pooled, sd",P9023,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,58.76,,,,,,,fee schedule,55.96,289.43,APC
"Frozen plasma, pooled, sd",P9023,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,58.2,,,,,,,fee schedule,55.96,289.43,APC
"Frozen plasma, pooled, sd",P9023,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,55.96,,,,,,,fee schedule,55.96,289.43,APC
"Frozen plasma, pooled, sd",P9023,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,85.62,,,,,,,fee schedule,55.96,289.43,Radiology
"Frozen plasma, pooled, sd",P9023,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,78.34,,,,,,,fee schedule,55.96,289.43,APC
"Frozen plasma, pooled, sd",P9023,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,97.93,,,,,,,fee schedule,55.96,289.43,APC
Plasma cryo redu path each,P9025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,233.44,,,,,,,fee schedule,133.76,593.45,
Plasma cryo redu path each,P9025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,253.56,,,,,,,fee schedule,133.76,593.45,
Plasma cryo redu path each,P9025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,203.25,,,,,,,fee schedule,133.76,593.45,
Plasma cryo redu path each,P9025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,222.03,,,,,,,fee schedule,133.76,593.45,
Plasma cryo redu path each,P9025,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,593.45,,,,,,,fee schedule,133.76,593.45,APC 378
Plasma cryo redu path each,P9025,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,140.45,,,,,,,fee schedule,133.76,593.45,APC
Plasma cryo redu path each,P9025,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,139.11,,,,,,,fee schedule,133.76,593.45,APC
Plasma cryo redu path each,P9025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,133.76,,,,,,,fee schedule,133.76,593.45,APC
Plasma cryo redu path each,P9025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,204.65,,,,,,,fee schedule,133.76,593.45,Radiology
Plasma cryo redu path each,P9025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,187.26,,,,,,,fee schedule,133.76,593.45,APC
Plasma cryo redu path each,P9025,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,234.08,,,,,,,fee schedule,133.76,593.45,APC
Cryo fib comp path redu each,P9026,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,283.72,,,,,,,fee schedule,247.04,2436.97,
Cryo fib comp path redu each,P9026,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,308.18,,,,,,,fee schedule,247.04,2436.97,
Cryo fib comp path redu each,P9026,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,247.04,,,,,,,fee schedule,247.04,2436.97,
Cryo fib comp path redu each,P9026,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,269.86,,,,,,,fee schedule,247.04,2436.97,
Cryo fib comp path redu each,P9026,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2436.97,,,,,,,fee schedule,247.04,2436.97,APC 378
Cryo fib comp path redu each,P9026,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,576.74,,,,,,,fee schedule,247.04,2436.97,APC
Cryo fib comp path redu each,P9026,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,571.25,,,,,,,fee schedule,247.04,2436.97,APC
Cryo fib comp path redu each,P9026,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,549.28,,,,,,,fee schedule,247.04,2436.97,APC
Cryo fib comp path redu each,P9026,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,840.4,,,,,,,fee schedule,247.04,2436.97,Radiology
Cryo fib comp path redu each,P9026,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,768.99,,,,,,,fee schedule,247.04,2436.97,APC
Cryo fib comp path redu each,P9026,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,961.24,,,,,,,fee schedule,247.04,2436.97,APC
Platelets leukocytes reduced,P9031,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,387.81,,,,,,,fee schedule,144.26,640.03,
Platelets leukocytes reduced,P9031,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,421.24,,,,,,,fee schedule,144.26,640.03,
Platelets leukocytes reduced,P9031,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,337.66,,,,,,,fee schedule,144.26,640.03,
Platelets leukocytes reduced,P9031,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,368.87,,,,,,,fee schedule,144.26,640.03,
Platelets leukocytes reduced,P9031,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,640.03,,,,,,,fee schedule,144.26,640.03,APC 378
Platelets leukocytes reduced,P9031,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,151.47,,,,,,,fee schedule,144.26,640.03,APC
Platelets leukocytes reduced,P9031,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,150.03,,,,,,,fee schedule,144.26,640.03,APC
Platelets leukocytes reduced,P9031,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,144.26,,,,,,,fee schedule,144.26,640.03,APC
Platelets leukocytes reduced,P9031,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,220.72,,,,,,,fee schedule,144.26,640.03,Radiology
Platelets leukocytes reduced,P9031,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.96,,,,,,,fee schedule,144.26,640.03,APC
Platelets leukocytes reduced,P9031,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,252.46,,,,,,,fee schedule,144.26,640.03,APC
"Platelets, irradiated",P9032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,439.07,,,,,,,fee schedule,382.3,1743.47,
"Platelets, irradiated",P9032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,476.92,,,,,,,fee schedule,382.3,1743.47,
"Platelets, irradiated",P9032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,382.3,,,,,,,fee schedule,382.3,1743.47,
"Platelets, irradiated",P9032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,417.62,,,,,,,fee schedule,382.3,1743.47,
"Platelets, irradiated",P9032,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1743.47,,,,,,,fee schedule,382.3,1743.47,APC 378
"Platelets, irradiated",P9032,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,412.62,,,,,,,fee schedule,382.3,1743.47,APC
"Platelets, irradiated",P9032,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,408.69,,,,,,,fee schedule,382.3,1743.47,APC
"Platelets, irradiated",P9032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,392.97,,,,,,,fee schedule,382.3,1743.47,APC
"Platelets, irradiated",P9032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,601.24,,,,,,,fee schedule,382.3,1743.47,Radiology
"Platelets, irradiated",P9032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,550.16,,,,,,,fee schedule,382.3,1743.47,APC
"Platelets, irradiated",P9032,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,687.7,,,,,,,fee schedule,382.3,1743.47,APC
Platelets leukoreduced irrad,P9033,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,504.81,,,,,,,fee schedule,189.59,841.15,
Platelets leukoreduced irrad,P9033,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,548.33,,,,,,,fee schedule,189.59,841.15,
Platelets leukoreduced irrad,P9033,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,439.53,,,,,,,fee schedule,189.59,841.15,
Platelets leukoreduced irrad,P9033,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,480.15,,,,,,,fee schedule,189.59,841.15,
Platelets leukoreduced irrad,P9033,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,841.15,,,,,,,fee schedule,189.59,841.15,APC 378
Platelets leukoreduced irrad,P9033,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,199.07,,,,,,,fee schedule,189.59,841.15,APC
Platelets leukoreduced irrad,P9033,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,197.17,,,,,,,fee schedule,189.59,841.15,APC
Platelets leukoreduced irrad,P9033,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,189.59,,,,,,,fee schedule,189.59,841.15,APC
Platelets leukoreduced irrad,P9033,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,290.07,,,,,,,fee schedule,189.59,841.15,Radiology
Platelets leukoreduced irrad,P9033,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,265.43,,,,,,,fee schedule,189.59,841.15,APC
Platelets leukoreduced irrad,P9033,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,331.78,,,,,,,fee schedule,189.59,841.15,APC
"Platelets, pheresis",P9034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1590.95,,,,,,,fee schedule,308.96,1728.1,
"Platelets, pheresis",P9034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1728.1,,,,,,,fee schedule,308.96,1728.1,
"Platelets, pheresis",P9034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1385.23,,,,,,,fee schedule,308.96,1728.1,
"Platelets, pheresis",P9034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1513.23,,,,,,,fee schedule,308.96,1728.1,
"Platelets, pheresis",P9034,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1370.75,,,,,,,fee schedule,308.96,1728.1,APC 378
"Platelets, pheresis",P9034,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,324.41,,,,,,,fee schedule,308.96,1728.1,APC
"Platelets, pheresis",P9034,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,321.32,,,,,,,fee schedule,308.96,1728.1,APC
"Platelets, pheresis",P9034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,308.96,,,,,,,fee schedule,308.96,1728.1,APC
"Platelets, pheresis",P9034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,472.71,,,,,,,fee schedule,308.96,1728.1,Radiology
"Platelets, pheresis",P9034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,432.54,,,,,,,fee schedule,308.96,1728.1,APC
"Platelets, pheresis",P9034,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,540.68,,,,,,,fee schedule,308.96,1728.1,APC
Platelet pheres leukoreduced,P9035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,792.09,,,,,,,fee schedule,511.59,2269.75,
Platelet pheres leukoreduced,P9035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,860.38,,,,,,,fee schedule,511.59,2269.75,
Platelet pheres leukoreduced,P9035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,689.67,,,,,,,fee schedule,511.59,2269.75,
Platelet pheres leukoreduced,P9035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,753.4,,,,,,,fee schedule,511.59,2269.75,
Platelet pheres leukoreduced,P9035,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2269.75,,,,,,,fee schedule,511.59,2269.75,APC 378
Platelet pheres leukoreduced,P9035,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,537.17,,,,,,,fee schedule,511.59,2269.75,APC
Platelet pheres leukoreduced,P9035,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,532.05,,,,,,,fee schedule,511.59,2269.75,APC
Platelet pheres leukoreduced,P9035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,511.59,,,,,,,fee schedule,511.59,2269.75,APC
Platelet pheres leukoreduced,P9035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,782.73,,,,,,,fee schedule,511.59,2269.75,Radiology
Platelet pheres leukoreduced,P9035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,716.23,,,,,,,fee schedule,511.59,2269.75,APC
Platelet pheres leukoreduced,P9035,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,895.28,,,,,,,fee schedule,511.59,2269.75,APC
Platelet pheresis irradiated,P9036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1506.84,,,,,,,fee schedule,949.13,4210.97,
Platelet pheresis irradiated,P9036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1636.74,,,,,,,fee schedule,949.13,4210.97,
Platelet pheresis irradiated,P9036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1311.99,,,,,,,fee schedule,949.13,4210.97,
Platelet pheresis irradiated,P9036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1433.23,,,,,,,fee schedule,949.13,4210.97,
Platelet pheresis irradiated,P9036,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,4210.97,,,,,,,fee schedule,949.13,4210.97,APC 378
Platelet pheresis irradiated,P9036,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,996.59,,,,,,,fee schedule,949.13,4210.97,APC
Platelet pheresis irradiated,P9036,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,987.1,,,,,,,fee schedule,949.13,4210.97,APC
Platelet pheresis irradiated,P9036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,949.13,,,,,,,fee schedule,949.13,4210.97,APC
Platelet pheresis irradiated,P9036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1452.17,,,,,,,fee schedule,949.13,4210.97,Radiology
Platelet pheresis irradiated,P9036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1328.78,,,,,,,fee schedule,949.13,4210.97,APC
Platelet pheresis irradiated,P9036,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1660.98,,,,,,,fee schedule,949.13,4210.97,APC
Plate pheres leukoredu irrad,P9037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,907.82,,,,,,,fee schedule,680.61,3019.64,
Plate pheres leukoredu irrad,P9037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,986.08,,,,,,,fee schedule,680.61,3019.64,
Plate pheres leukoredu irrad,P9037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,790.43,,,,,,,fee schedule,680.61,3019.64,
Plate pheres leukoredu irrad,P9037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,863.47,,,,,,,fee schedule,680.61,3019.64,
Plate pheres leukoredu irrad,P9037,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3019.64,,,,,,,fee schedule,680.61,3019.64,APC 378
Plate pheres leukoredu irrad,P9037,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,714.64,,,,,,,fee schedule,680.61,3019.64,APC
Plate pheres leukoredu irrad,P9037,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,707.83,,,,,,,fee schedule,680.61,3019.64,APC
Plate pheres leukoredu irrad,P9037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,680.61,,,,,,,fee schedule,680.61,3019.64,APC
Plate pheres leukoredu irrad,P9037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1041.33,,,,,,,fee schedule,680.61,3019.64,Radiology
Plate pheres leukoredu irrad,P9037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,952.85,,,,,,,fee schedule,680.61,3019.64,APC
Plate pheres leukoredu irrad,P9037,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1191.07,,,,,,,fee schedule,680.61,3019.64,APC
RBC irradiated,P9038,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,704.07,,,,,,,fee schedule,145.22,764.77,
RBC irradiated,P9038,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,764.77,,,,,,,fee schedule,145.22,764.77,
RBC irradiated,P9038,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,613.03,,,,,,,fee schedule,145.22,764.77,
RBC irradiated,P9038,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,669.68,,,,,,,fee schedule,145.22,764.77,
RBC irradiated,P9038,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,644.29,,,,,,,fee schedule,145.22,764.77,APC 378
RBC irradiated,P9038,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,152.48,,,,,,,fee schedule,145.22,764.77,APC
RBC irradiated,P9038,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,151.03,,,,,,,fee schedule,145.22,764.77,APC
RBC irradiated,P9038,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,145.22,,,,,,,fee schedule,145.22,764.77,APC
RBC irradiated,P9038,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,222.19,,,,,,,fee schedule,145.22,764.77,Radiology
RBC irradiated,P9038,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,203.31,,,,,,,fee schedule,145.22,764.77,APC
RBC irradiated,P9038,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,254.14,,,,,,,fee schedule,145.22,764.77,APC
RBC deglycerolized,P9039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1252.59,,,,,,,fee schedule,313,1388.68,
RBC deglycerolized,P9039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1360.57,,,,,,,fee schedule,313,1388.68,
RBC deglycerolized,P9039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1090.62,,,,,,,fee schedule,313,1388.68,
RBC deglycerolized,P9039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1191.4,,,,,,,fee schedule,313,1388.68,
RBC deglycerolized,P9039,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1388.68,,,,,,,fee schedule,313,1388.68,APC 378
RBC deglycerolized,P9039,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,328.65,,,,,,,fee schedule,313,1388.68,APC
RBC deglycerolized,P9039,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,325.52,,,,,,,fee schedule,313,1388.68,APC
RBC deglycerolized,P9039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,313,,,,,,,fee schedule,313,1388.68,APC
RBC deglycerolized,P9039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,478.89,,,,,,,fee schedule,313,1388.68,Radiology
RBC deglycerolized,P9039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,438.2,,,,,,,fee schedule,313,1388.68,APC
RBC deglycerolized,P9039,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,547.75,,,,,,,fee schedule,313,1388.68,APC
RBC leukoreduced irradiated,P9040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,451.91,,,,,,,fee schedule,265.41,1177.53,
RBC leukoreduced irradiated,P9040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,490.87,,,,,,,fee schedule,265.41,1177.53,
RBC leukoreduced irradiated,P9040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,393.48,,,,,,,fee schedule,265.41,1177.53,
RBC leukoreduced irradiated,P9040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,429.84,,,,,,,fee schedule,265.41,1177.53,
RBC leukoreduced irradiated,P9040,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1177.53,,,,,,,fee schedule,265.41,1177.53,APC 378
RBC leukoreduced irradiated,P9040,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,278.68,,,,,,,fee schedule,265.41,1177.53,APC
RBC leukoreduced irradiated,P9040,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,276.03,,,,,,,fee schedule,265.41,1177.53,APC
RBC leukoreduced irradiated,P9040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,265.41,,,,,,,fee schedule,265.41,1177.53,APC
RBC leukoreduced irradiated,P9040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,406.08,,,,,,,fee schedule,265.41,1177.53,Radiology
RBC leukoreduced irradiated,P9040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,371.57,,,,,,,fee schedule,265.41,1177.53,APC
RBC leukoreduced irradiated,P9040,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,464.47,,,,,,,fee schedule,265.41,1177.53,APC
"Albumin (human),5%, 50ml",P9041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,78.44,,,,,,,fee schedule,10.62,85.2,
"Albumin (human),5%, 50ml",P9041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,85.2,,,,,,,fee schedule,10.62,85.2,
"Albumin (human),5%, 50ml",P9041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,68.3,,,,,,,fee schedule,10.62,85.2,
"Albumin (human),5%, 50ml",P9041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,74.61,,,,,,,fee schedule,10.62,85.2,
"Albumin (human),5%, 50ml",P9041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.31,,,,,,,fee schedule,10.62,85.2,OP High Cost Drugs
"Albumin (human),5%, 50ml",P9041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10.62,,,,,,,fee schedule,10.62,85.2,Other Pharmacy
"Albumin (human),5%, 50ml",P9041,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,11.15,,,,,,,fee schedule,10.62,85.2,APC
"Albumin (human),5%, 50ml",P9041,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,11.04,,,,,,,fee schedule,10.62,85.2,APC
"Albumin (human),5%, 50ml",P9041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16.24,,,,,,,fee schedule,10.62,85.2,Radiology
"Albumin (human),5%, 50ml",P9041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.86,,,,,,,fee schedule,10.62,85.2,APC
"Albumin (human),5%, 50ml",P9041,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18.58,,,,,,,fee schedule,10.62,85.2,APC
"Plasma protein fract,5%,50ml",P9043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,338.67,,,,,,,fee schedule,8.11,367.87,
"Plasma protein fract,5%,50ml",P9043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,367.87,,,,,,,fee schedule,8.11,367.87,
"Plasma protein fract,5%,50ml",P9043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,294.88,,,,,,,fee schedule,8.11,367.87,
"Plasma protein fract,5%,50ml",P9043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,322.13,,,,,,,fee schedule,8.11,367.87,
"Plasma protein fract,5%,50ml",P9043,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,35.98,,,,,,,fee schedule,8.11,367.87,APC 378
"Plasma protein fract,5%,50ml",P9043,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.52,,,,,,,fee schedule,8.11,367.87,APC
"Plasma protein fract,5%,50ml",P9043,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8.43,,,,,,,fee schedule,8.11,367.87,APC
"Plasma protein fract,5%,50ml",P9043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8.11,,,,,,,fee schedule,8.11,367.87,APC
"Plasma protein fract,5%,50ml",P9043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12.41,,,,,,,fee schedule,8.11,367.87,Radiology
"Plasma protein fract,5%,50ml",P9043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11.35,,,,,,,fee schedule,8.11,367.87,APC
"Plasma protein fract,5%,50ml",P9043,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14.19,,,,,,,fee schedule,8.11,367.87,APC
Cryoprecipitatereducedplasma,P9044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,301.89,,,,,,,fee schedule,132.05,585.86,
Cryoprecipitatereducedplasma,P9044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,327.92,,,,,,,fee schedule,132.05,585.86,
Cryoprecipitatereducedplasma,P9044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,262.85,,,,,,,fee schedule,132.05,585.86,
Cryoprecipitatereducedplasma,P9044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,287.14,,,,,,,fee schedule,132.05,585.86,
Cryoprecipitatereducedplasma,P9044,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,585.86,,,,,,,fee schedule,132.05,585.86,APC 378
Cryoprecipitatereducedplasma,P9044,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.65,,,,,,,fee schedule,132.05,585.86,APC
Cryoprecipitatereducedplasma,P9044,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,137.33,,,,,,,fee schedule,132.05,585.86,APC
Cryoprecipitatereducedplasma,P9044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,132.05,,,,,,,fee schedule,132.05,585.86,APC
Cryoprecipitatereducedplasma,P9044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,202.04,,,,,,,fee schedule,132.05,585.86,Radiology
Cryoprecipitatereducedplasma,P9044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.87,,,,,,,fee schedule,132.05,585.86,APC
Cryoprecipitatereducedplasma,P9044,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,231.09,,,,,,,fee schedule,132.05,585.86,APC
"Albumin (human), 5%, 250 ml",P9045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,252.44,,,,,,,fee schedule,53.08,274.2,
"Albumin (human), 5%, 250 ml",P9045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,274.2,,,,,,,fee schedule,53.08,274.2,
"Albumin (human), 5%, 250 ml",P9045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,219.8,,,,,,,fee schedule,53.08,274.2,
"Albumin (human), 5%, 250 ml",P9045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,240.11,,,,,,,fee schedule,53.08,274.2,
"Albumin (human), 5%, 250 ml",P9045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,61.57,,,,,,,fee schedule,53.08,274.2,OP High Cost Drugs
"Albumin (human), 5%, 250 ml",P9045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,53.08,,,,,,,fee schedule,53.08,274.2,Other Pharmacy
"Albumin (human), 5%, 250 ml",P9045,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,55.73,,,,,,,fee schedule,53.08,274.2,APC
"Albumin (human), 5%, 250 ml",P9045,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,55.2,,,,,,,fee schedule,53.08,274.2,APC
"Albumin (human), 5%, 250 ml",P9045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.21,,,,,,,fee schedule,53.08,274.2,Radiology
"Albumin (human), 5%, 250 ml",P9045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,74.31,,,,,,,fee schedule,53.08,274.2,APC
"Albumin (human), 5%, 250 ml",P9045,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,92.88,,,,,,,fee schedule,53.08,274.2,APC
"Albumin (human), 25%, 20 ml",P9046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,94.62,,,,,,,fee schedule,21.23,102.78,
"Albumin (human), 25%, 20 ml",P9046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,102.78,,,,,,,fee schedule,21.23,102.78,
"Albumin (human), 25%, 20 ml",P9046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,82.39,,,,,,,fee schedule,21.23,102.78,
"Albumin (human), 25%, 20 ml",P9046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,90,,,,,,,fee schedule,21.23,102.78,
"Albumin (human), 25%, 20 ml",P9046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,24.63,,,,,,,fee schedule,21.23,102.78,OP High Cost Drugs
"Albumin (human), 25%, 20 ml",P9046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21.23,,,,,,,fee schedule,21.23,102.78,Other Pharmacy
"Albumin (human), 25%, 20 ml",P9046,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,22.29,,,,,,,fee schedule,21.23,102.78,APC
"Albumin (human), 25%, 20 ml",P9046,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,22.08,,,,,,,fee schedule,21.23,102.78,APC
"Albumin (human), 25%, 20 ml",P9046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,32.48,,,,,,,fee schedule,21.23,102.78,Radiology
"Albumin (human), 25%, 20 ml",P9046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29.72,,,,,,,fee schedule,21.23,102.78,APC
"Albumin (human), 25%, 20 ml",P9046,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,37.15,,,,,,,fee schedule,21.23,102.78,APC
"Albumin (human), 25%, 50ml",P9047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,261.07,,,,,,,fee schedule,53.08,283.58,
"Albumin (human), 25%, 50ml",P9047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,283.58,,,,,,,fee schedule,53.08,283.58,
"Albumin (human), 25%, 50ml",P9047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,227.31,,,,,,,fee schedule,53.08,283.58,
"Albumin (human), 25%, 50ml",P9047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,248.32,,,,,,,fee schedule,53.08,283.58,
"Albumin (human), 25%, 50ml",P9047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,61.57,,,,,,,fee schedule,53.08,283.58,OP High Cost Drugs
"Albumin (human), 25%, 50ml",P9047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,53.08,,,,,,,fee schedule,53.08,283.58,Other Pharmacy
"Albumin (human), 25%, 50ml",P9047,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,55.73,,,,,,,fee schedule,53.08,283.58,APC
"Albumin (human), 25%, 50ml",P9047,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,55.2,,,,,,,fee schedule,53.08,283.58,APC
"Albumin (human), 25%, 50ml",P9047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.21,,,,,,,fee schedule,53.08,283.58,Radiology
"Albumin (human), 25%, 50ml",P9047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,74.31,,,,,,,fee schedule,53.08,283.58,APC
"Albumin (human), 25%, 50ml",P9047,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,92.88,,,,,,,fee schedule,53.08,283.58,APC
"Plasmaprotein fract,5%,250ml",P9048,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,776.42,,,,,,,fee schedule,35.32,843.36,
"Plasmaprotein fract,5%,250ml",P9048,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,843.36,,,,,,,fee schedule,35.32,843.36,
"Plasmaprotein fract,5%,250ml",P9048,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,676.02,,,,,,,fee schedule,35.32,843.36,
"Plasmaprotein fract,5%,250ml",P9048,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,738.49,,,,,,,fee schedule,35.32,843.36,
"Plasmaprotein fract,5%,250ml",P9048,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,156.7,,,,,,,fee schedule,35.32,843.36,APC 378
"Plasmaprotein fract,5%,250ml",P9048,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,37.09,,,,,,,fee schedule,35.32,843.36,APC
"Plasmaprotein fract,5%,250ml",P9048,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,36.73,,,,,,,fee schedule,35.32,843.36,APC
"Plasmaprotein fract,5%,250ml",P9048,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,35.32,,,,,,,fee schedule,35.32,843.36,APC
"Plasmaprotein fract,5%,250ml",P9048,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,54.04,,,,,,,fee schedule,35.32,843.36,Radiology
"Plasmaprotein fract,5%,250ml",P9048,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49.45,,,,,,,fee schedule,35.32,843.36,APC
"Plasmaprotein fract,5%,250ml",P9048,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,61.81,,,,,,,fee schedule,35.32,843.36,APC
"Granulocytes, pheresis unit",P9050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5005.39,,,,,,,fee schedule,4358.14,5436.89,
"Granulocytes, pheresis unit",P9050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5436.89,,,,,,,fee schedule,4358.14,5436.89,
"Granulocytes, pheresis unit",P9050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4358.14,,,,,,,fee schedule,4358.14,5436.89,
"Granulocytes, pheresis unit",P9050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4760.87,,,,,,,fee schedule,4358.14,5436.89,
"Blood, l/r, cmv-neg",P9051,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,533.52,,,,,,,fee schedule,151.58,672.51,
"Blood, l/r, cmv-neg",P9051,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,579.51,,,,,,,fee schedule,151.58,672.51,
"Blood, l/r, cmv-neg",P9051,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,464.53,,,,,,,fee schedule,151.58,672.51,
"Blood, l/r, cmv-neg",P9051,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,507.46,,,,,,,fee schedule,151.58,672.51,
"Blood, l/r, cmv-neg",P9051,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,672.51,,,,,,,fee schedule,151.58,672.51,APC 378
"Blood, l/r, cmv-neg",P9051,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,159.16,,,,,,,fee schedule,151.58,672.51,APC
"Blood, l/r, cmv-neg",P9051,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,157.64,,,,,,,fee schedule,151.58,672.51,APC
"Blood, l/r, cmv-neg",P9051,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,151.58,,,,,,,fee schedule,151.58,672.51,APC
"Blood, l/r, cmv-neg",P9051,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,231.92,,,,,,,fee schedule,151.58,672.51,Radiology
"Blood, l/r, cmv-neg",P9051,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,212.21,,,,,,,fee schedule,151.58,672.51,APC
"Blood, l/r, cmv-neg",P9051,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,265.27,,,,,,,fee schedule,151.58,672.51,APC
"Platelets, hla-m, l/r, unit",P9052,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2330.14,,,,,,,fee schedule,708.06,3141.42,
"Platelets, hla-m, l/r, unit",P9052,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2531.01,,,,,,,fee schedule,708.06,3141.42,
"Platelets, hla-m, l/r, unit",P9052,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2028.83,,,,,,,fee schedule,708.06,3141.42,
"Platelets, hla-m, l/r, unit",P9052,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2216.31,,,,,,,fee schedule,708.06,3141.42,
"Platelets, hla-m, l/r, unit",P9052,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3141.42,,,,,,,fee schedule,708.06,3141.42,APC 378
"Platelets, hla-m, l/r, unit",P9052,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,743.46,,,,,,,fee schedule,708.06,3141.42,APC
"Platelets, hla-m, l/r, unit",P9052,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,736.38,,,,,,,fee schedule,708.06,3141.42,APC
"Platelets, hla-m, l/r, unit",P9052,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,708.06,,,,,,,fee schedule,708.06,3141.42,APC
"Platelets, hla-m, l/r, unit",P9052,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1083.33,,,,,,,fee schedule,708.06,3141.42,Radiology
"Platelets, hla-m, l/r, unit",P9052,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,991.28,,,,,,,fee schedule,708.06,3141.42,APC
"Platelets, hla-m, l/r, unit",P9052,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1239.1,,,,,,,fee schedule,708.06,3141.42,APC
"Plt, pher, l/r cmv-neg, irr",P9053,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2476.61,,,,,,,fee schedule,503.45,2690.11,
"Plt, pher, l/r cmv-neg, irr",P9053,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2690.11,,,,,,,fee schedule,503.45,2690.11,
"Plt, pher, l/r cmv-neg, irr",P9053,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2156.36,,,,,,,fee schedule,503.45,2690.11,
"Plt, pher, l/r cmv-neg, irr",P9053,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2355.63,,,,,,,fee schedule,503.45,2690.11,
"Plt, pher, l/r cmv-neg, irr",P9053,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2233.64,,,,,,,fee schedule,503.45,2690.11,APC 378
"Plt, pher, l/r cmv-neg, irr",P9053,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,528.62,,,,,,,fee schedule,503.45,2690.11,APC
"Plt, pher, l/r cmv-neg, irr",P9053,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,523.59,,,,,,,fee schedule,503.45,2690.11,APC
"Plt, pher, l/r cmv-neg, irr",P9053,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,503.45,,,,,,,fee schedule,503.45,2690.11,APC
"Plt, pher, l/r cmv-neg, irr",P9053,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,770.28,,,,,,,fee schedule,503.45,2690.11,Radiology
"Plt, pher, l/r cmv-neg, irr",P9053,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,704.83,,,,,,,fee schedule,503.45,2690.11,APC
"Plt, pher, l/r cmv-neg, irr",P9053,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,881.04,,,,,,,fee schedule,503.45,2690.11,APC
"Blood, l/r, froz/degly/wash",P9054,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,789.33,,,,,,,fee schedule,265.19,1176.56,
"Blood, l/r, froz/degly/wash",P9054,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,857.38,,,,,,,fee schedule,265.19,1176.56,
"Blood, l/r, froz/degly/wash",P9054,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,687.26,,,,,,,fee schedule,265.19,1176.56,
"Blood, l/r, froz/degly/wash",P9054,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,750.77,,,,,,,fee schedule,265.19,1176.56,
"Blood, l/r, froz/degly/wash",P9054,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1176.56,,,,,,,fee schedule,265.19,1176.56,APC 378
"Blood, l/r, froz/degly/wash",P9054,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,278.45,,,,,,,fee schedule,265.19,1176.56,APC
"Blood, l/r, froz/degly/wash",P9054,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,275.8,,,,,,,fee schedule,265.19,1176.56,APC
"Blood, l/r, froz/degly/wash",P9054,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,265.19,,,,,,,fee schedule,265.19,1176.56,APC
"Blood, l/r, froz/degly/wash",P9054,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,405.74,,,,,,,fee schedule,265.19,1176.56,Radiology
"Blood, l/r, froz/degly/wash",P9054,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,371.27,,,,,,,fee schedule,265.19,1176.56,APC
"Blood, l/r, froz/degly/wash",P9054,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,464.08,,,,,,,fee schedule,265.19,1176.56,APC
"Plt, aph/pher, l/r, cmv-neg",P9055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1763.07,,,,,,,fee schedule,250.49,1915.06,
"Plt, aph/pher, l/r, cmv-neg",P9055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1915.06,,,,,,,fee schedule,250.49,1915.06,
"Plt, aph/pher, l/r, cmv-neg",P9055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1535.09,,,,,,,fee schedule,250.49,1915.06,
"Plt, aph/pher, l/r, cmv-neg",P9055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1676.95,,,,,,,fee schedule,250.49,1915.06,
"Plt, aph/pher, l/r, cmv-neg",P9055,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1111.34,,,,,,,fee schedule,250.49,1915.06,APC 378
"Plt, aph/pher, l/r, cmv-neg",P9055,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,263.01,,,,,,,fee schedule,250.49,1915.06,APC
"Plt, aph/pher, l/r, cmv-neg",P9055,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,260.51,,,,,,,fee schedule,250.49,1915.06,APC
"Plt, aph/pher, l/r, cmv-neg",P9055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,250.49,,,,,,,fee schedule,250.49,1915.06,APC
"Plt, aph/pher, l/r, cmv-neg",P9055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,383.25,,,,,,,fee schedule,250.49,1915.06,Radiology
"Plt, aph/pher, l/r, cmv-neg",P9055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,350.69,,,,,,,fee schedule,250.49,1915.06,APC
"Plt, aph/pher, l/r, cmv-neg",P9055,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,438.36,,,,,,,fee schedule,250.49,1915.06,APC
"Blood, l/r, irradiated",P9056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,530.73,,,,,,,fee schedule,84.55,576.49,
"Blood, l/r, irradiated",P9056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,576.49,,,,,,,fee schedule,84.55,576.49,
"Blood, l/r, irradiated",P9056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,462.11,,,,,,,fee schedule,84.55,576.49,
"Blood, l/r, irradiated",P9056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,504.81,,,,,,,fee schedule,84.55,576.49,
"Blood, l/r, irradiated",P9056,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,375.12,,,,,,,fee schedule,84.55,576.49,APC 378
"Blood, l/r, irradiated",P9056,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,88.78,,,,,,,fee schedule,84.55,576.49,APC
"Blood, l/r, irradiated",P9056,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,87.93,,,,,,,fee schedule,84.55,576.49,APC
"Blood, l/r, irradiated",P9056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,84.55,,,,,,,fee schedule,84.55,576.49,APC
"Blood, l/r, irradiated",P9056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,129.36,,,,,,,fee schedule,84.55,576.49,Radiology
"Blood, l/r, irradiated",P9056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,118.37,,,,,,,fee schedule,84.55,576.49,APC
"Blood, l/r, irradiated",P9056,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,147.96,,,,,,,fee schedule,84.55,576.49,APC
"RBC, frz/deg/wsh, l/r, irrad",P9057,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1349.13,,,,,,,fee schedule,422.69,1875.33,
"RBC, frz/deg/wsh, l/r, irrad",P9057,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1465.43,,,,,,,fee schedule,422.69,1875.33,
"RBC, frz/deg/wsh, l/r, irrad",P9057,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1174.67,,,,,,,fee schedule,422.69,1875.33,
"RBC, frz/deg/wsh, l/r, irrad",P9057,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1283.22,,,,,,,fee schedule,422.69,1875.33,
"RBC, frz/deg/wsh, l/r, irrad",P9057,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1875.33,,,,,,,fee schedule,422.69,1875.33,APC 378
"RBC, frz/deg/wsh, l/r, irrad",P9057,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,443.82,,,,,,,fee schedule,422.69,1875.33,APC
"RBC, frz/deg/wsh, l/r, irrad",P9057,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,439.6,,,,,,,fee schedule,422.69,1875.33,APC
"RBC, frz/deg/wsh, l/r, irrad",P9057,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,422.69,,,,,,,fee schedule,422.69,1875.33,APC
"RBC, frz/deg/wsh, l/r, irrad",P9057,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,646.72,,,,,,,fee schedule,422.69,1875.33,Radiology
"RBC, frz/deg/wsh, l/r, irrad",P9057,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,591.77,,,,,,,fee schedule,422.69,1875.33,APC
"RBC, frz/deg/wsh, l/r, irrad",P9057,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,739.71,,,,,,,fee schedule,422.69,1875.33,APC
"RBC, l/r, cmv-neg, irrad",P9058,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,950.39,,,,,,,fee schedule,249.4,1106.5,
"RBC, l/r, cmv-neg, irrad",P9058,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1032.32,,,,,,,fee schedule,249.4,1106.5,
"RBC, l/r, cmv-neg, irrad",P9058,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,827.49,,,,,,,fee schedule,249.4,1106.5,
"RBC, l/r, cmv-neg, irrad",P9058,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,903.96,,,,,,,fee schedule,249.4,1106.5,
"RBC, l/r, cmv-neg, irrad",P9058,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1106.5,,,,,,,fee schedule,249.4,1106.5,APC 378
"RBC, l/r, cmv-neg, irrad",P9058,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,261.87,,,,,,,fee schedule,249.4,1106.5,APC
"RBC, l/r, cmv-neg, irrad",P9058,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,259.38,,,,,,,fee schedule,249.4,1106.5,APC
"RBC, l/r, cmv-neg, irrad",P9058,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,249.4,,,,,,,fee schedule,249.4,1106.5,APC
"RBC, l/r, cmv-neg, irrad",P9058,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,381.58,,,,,,,fee schedule,249.4,1106.5,Radiology
"RBC, l/r, cmv-neg, irrad",P9058,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,349.16,,,,,,,fee schedule,249.4,1106.5,APC
"RBC, l/r, cmv-neg, irrad",P9058,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,436.45,,,,,,,fee schedule,249.4,1106.5,APC
"Plasma, frz between 8-24hour",P9059,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,163.61,,,,,,,fee schedule,73.77,327.29,
"Plasma, frz between 8-24hour",P9059,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,177.71,,,,,,,fee schedule,73.77,327.29,
"Plasma, frz between 8-24hour",P9059,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,142.45,,,,,,,fee schedule,73.77,327.29,
"Plasma, frz between 8-24hour",P9059,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,155.61,,,,,,,fee schedule,73.77,327.29,
"Plasma, frz between 8-24hour",P9059,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,327.29,,,,,,,fee schedule,73.77,327.29,APC 378
"Plasma, frz between 8-24hour",P9059,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,77.46,,,,,,,fee schedule,73.77,327.29,APC
"Plasma, frz between 8-24hour",P9059,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,76.72,,,,,,,fee schedule,73.77,327.29,APC
"Plasma, frz between 8-24hour",P9059,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,73.77,,,,,,,fee schedule,73.77,327.29,APC
"Plasma, frz between 8-24hour",P9059,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,112.87,,,,,,,fee schedule,73.77,327.29,Radiology
"Plasma, frz between 8-24hour",P9059,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,103.28,,,,,,,fee schedule,73.77,327.29,APC
"Plasma, frz between 8-24hour",P9059,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,129.1,,,,,,,fee schedule,73.77,327.29,APC
Fr frz plasma donor retested,P9060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,189.9,,,,,,,fee schedule,53.25,236.25,
Fr frz plasma donor retested,P9060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,206.27,,,,,,,fee schedule,53.25,236.25,
Fr frz plasma donor retested,P9060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,165.35,,,,,,,fee schedule,53.25,236.25,
Fr frz plasma donor retested,P9060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,180.63,,,,,,,fee schedule,53.25,236.25,
Fr frz plasma donor retested,P9060,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,236.25,,,,,,,fee schedule,53.25,236.25,APC 378
Fr frz plasma donor retested,P9060,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,55.91,,,,,,,fee schedule,53.25,236.25,APC
Fr frz plasma donor retested,P9060,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,55.38,,,,,,,fee schedule,53.25,236.25,APC
Fr frz plasma donor retested,P9060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,53.25,,,,,,,fee schedule,53.25,236.25,APC
Fr frz plasma donor retested,P9060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.47,,,,,,,fee schedule,53.25,236.25,Radiology
Fr frz plasma donor retested,P9060,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,74.55,,,,,,,fee schedule,53.25,236.25,APC
Fr frz plasma donor retested,P9060,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,93.19,,,,,,,fee schedule,53.25,236.25,APC
Pathogen reduced plasma pool,P9070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,254.32,,,,,,,fee schedule,55.78,276.24,
Pathogen reduced plasma pool,P9070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,276.24,,,,,,,fee schedule,55.78,276.24,
Pathogen reduced plasma pool,P9070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,221.43,,,,,,,fee schedule,55.78,276.24,
Pathogen reduced plasma pool,P9070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,241.89,,,,,,,fee schedule,55.78,276.24,
Pathogen reduced plasma pool,P9070,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,247.48,,,,,,,fee schedule,55.78,276.24,APC 378
Pathogen reduced plasma pool,P9070,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,58.57,,,,,,,fee schedule,55.78,276.24,APC
Pathogen reduced plasma pool,P9070,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,58.01,,,,,,,fee schedule,55.78,276.24,APC
Pathogen reduced plasma pool,P9070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,55.78,,,,,,,fee schedule,55.78,276.24,APC
Pathogen reduced plasma pool,P9070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,85.34,,,,,,,fee schedule,55.78,276.24,Radiology
Pathogen reduced plasma pool,P9070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,78.09,,,,,,,fee schedule,55.78,276.24,APC
Pathogen reduced plasma pool,P9070,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,97.62,,,,,,,fee schedule,55.78,276.24,APC
Pathogen reduced plasma sing,P9071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,252.51,,,,,,,fee schedule,219.86,1306.51,
Pathogen reduced plasma sing,P9071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,274.28,,,,,,,fee schedule,219.86,1306.51,
Pathogen reduced plasma sing,P9071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,219.86,,,,,,,fee schedule,219.86,1306.51,
Pathogen reduced plasma sing,P9071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,240.17,,,,,,,fee schedule,219.86,1306.51,
Pathogen reduced plasma sing,P9071,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1306.51,,,,,,,fee schedule,219.86,1306.51,APC 378
Pathogen reduced plasma sing,P9071,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,309.2,,,,,,,fee schedule,219.86,1306.51,APC
Pathogen reduced plasma sing,P9071,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,306.26,,,,,,,fee schedule,219.86,1306.51,APC
Pathogen reduced plasma sing,P9071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,294.48,,,,,,,fee schedule,219.86,1306.51,APC
Pathogen reduced plasma sing,P9071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,450.55,,,,,,,fee schedule,219.86,1306.51,Radiology
Pathogen reduced plasma sing,P9071,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,412.27,,,,,,,fee schedule,219.86,1306.51,APC
Pathogen reduced plasma sing,P9071,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,515.34,,,,,,,fee schedule,219.86,1306.51,APC
"Platelets, pathogen reduced",P9073,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2174.76,,,,,,,fee schedule,607.43,2694.96,
"Platelets, pathogen reduced",P9073,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2362.24,,,,,,,fee schedule,607.43,2694.96,
"Platelets, pathogen reduced",P9073,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1893.54,,,,,,,fee schedule,607.43,2694.96,
"Platelets, pathogen reduced",P9073,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2068.52,,,,,,,fee schedule,607.43,2694.96,
"Platelets, pathogen reduced",P9073,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,2694.96,,,,,,,fee schedule,607.43,2694.96,APC 378
"Platelets, pathogen reduced",P9073,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,637.8,,,,,,,fee schedule,607.43,2694.96,APC
"Platelets, pathogen reduced",P9073,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,631.73,,,,,,,fee schedule,607.43,2694.96,APC
"Platelets, pathogen reduced",P9073,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,607.43,,,,,,,fee schedule,607.43,2694.96,APC
"Platelets, pathogen reduced",P9073,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,929.37,,,,,,,fee schedule,607.43,2694.96,Radiology
"Platelets, pathogen reduced",P9073,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,850.4,,,,,,,fee schedule,607.43,2694.96,APC
"Platelets, pathogen reduced",P9073,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1063,,,,,,,fee schedule,607.43,2694.96,APC
Pathogen test for platelets,P9100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,88.74,,,,,,,fee schedule,58.4,259.1,
Pathogen test for platelets,P9100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,96.39,,,,,,,fee schedule,58.4,259.1,
Pathogen test for platelets,P9100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,77.27,,,,,,,fee schedule,58.4,259.1,
Pathogen test for platelets,P9100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,84.41,,,,,,,fee schedule,58.4,259.1,
Pathogen test for platelets,P9100,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,259.1,,,,,,,fee schedule,58.4,259.1,APC 378
Pathogen test for platelets,P9100,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.32,,,,,,,fee schedule,58.4,259.1,APC
Pathogen test for platelets,P9100,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.74,,,,,,,fee schedule,58.4,259.1,APC
Pathogen test for platelets,P9100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.4,,,,,,,fee schedule,58.4,259.1,APC
Pathogen test for platelets,P9100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.35,,,,,,,fee schedule,58.4,259.1,Radiology
Pathogen test for platelets,P9100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.76,,,,,,,fee schedule,58.4,259.1,APC
Pathogen test for platelets,P9100,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.2,,,,,,,fee schedule,58.4,259.1,APC
One-way allow prorated trip,P9604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8.94,,,,,,,fee schedule,7.79,9.71,
One-way allow prorated trip,P9604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.71,,,,,,,fee schedule,7.79,9.71,
One-way allow prorated trip,P9604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7.79,,,,,,,fee schedule,7.79,9.71,
One-way allow prorated trip,P9604,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.51,,,,,,,fee schedule,7.79,9.71,
Catheterize for urine spec,P9612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10.44,,,,,,,fee schedule,8.41,16.34,
Catheterize for urine spec,P9612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11.34,,,,,,,fee schedule,8.41,16.34,
Catheterize for urine spec,P9612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.09,,,,,,,fee schedule,8.41,16.34,
Catheterize for urine spec,P9612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.93,,,,,,,fee schedule,8.41,16.34,
Catheterize for urine spec,P9612,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.41,,,,,,,fee schedule,8.41,16.34,Laboratory
Catheterize for urine spec,P9612,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,9.81,,,,,,,fee schedule,8.41,16.34,APC
Catheterize for urine spec,P9612,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,9.71,,,,,,,fee schedule,8.41,16.34,APC
Catheterize for urine spec,P9612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9.34,,,,,,,fee schedule,8.41,16.34,APC
Catheterize for urine spec,P9612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.29,,,,,,,fee schedule,8.41,16.34,Radiology
Catheterize for urine spec,P9612,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.08,,,,,,,fee schedule,8.41,16.34,APC
Catheterize for urine spec,P9612,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16.34,,,,,,,fee schedule,8.41,16.34,APC
Cardiokymography,Q0035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,34.03,,,,,,,fee schedule,29.63,164.05,
Cardiokymography,Q0035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,36.97,,,,,,,fee schedule,29.63,164.05,
Cardiokymography,Q0035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29.63,,,,,,,fee schedule,29.63,164.05,
Cardiokymography,Q0035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32.37,,,,,,,fee schedule,29.63,164.05,
Cardiokymography,Q0035,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,164.05,,,,,,,fee schedule,29.63,164.05,APC 378
Cardiokymography,Q0035,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,38.83,,,,,,,fee schedule,29.63,164.05,APC
Cardiokymography,Q0035,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,38.46,,,,,,,fee schedule,29.63,164.05,APC
Cardiokymography,Q0035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.98,,,,,,,fee schedule,29.63,164.05,APC
Cardiokymography,Q0035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.57,,,,,,,fee schedule,29.63,164.05,Radiology
Cardiokymography,Q0035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.77,,,,,,,fee schedule,29.63,164.05,APC
Cardiokymography,Q0035,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64.71,,,,,,,fee schedule,29.63,164.05,APC
Infusion ther other than che,Q0081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,80.42,,,,,,,fee schedule,70.02,87.36,
Infusion ther other than che,Q0081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,87.36,,,,,,,fee schedule,70.02,87.36,
Infusion ther other than che,Q0081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,70.02,,,,,,,fee schedule,70.02,87.36,
Infusion ther other than che,Q0081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,76.49,,,,,,,fee schedule,70.02,87.36,
Chemo by other than infusion,Q0083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,148.56,,,,,,,fee schedule,129.35,161.37,
Chemo by other than infusion,Q0083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,161.37,,,,,,,fee schedule,129.35,161.37,
Chemo by other than infusion,Q0083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,129.35,,,,,,,fee schedule,129.35,161.37,
Chemo by other than infusion,Q0083,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,141.3,,,,,,,fee schedule,129.35,161.37,
Chemotherapy by infusion,Q0084,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,252.44,,,,,,,fee schedule,219.8,274.2,
Chemotherapy by infusion,Q0084,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,274.2,,,,,,,fee schedule,219.8,274.2,
Chemotherapy by infusion,Q0084,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,219.8,,,,,,,fee schedule,219.8,274.2,
Chemotherapy by infusion,Q0084,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,240.11,,,,,,,fee schedule,219.8,274.2,
Obtaining screen pap smear,Q0091,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30.1,,,,,,,fee schedule,26.21,127.04,
Obtaining screen pap smear,Q0091,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,32.7,,,,,,,fee schedule,26.21,127.04,
Obtaining screen pap smear,Q0091,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26.21,,,,,,,fee schedule,26.21,127.04,
Obtaining screen pap smear,Q0091,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28.63,,,,,,,fee schedule,26.21,127.04,
Obtaining screen pap smear,Q0091,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,127.04,,,,,,,fee schedule,26.21,127.04,APC 378
Obtaining screen pap smear,Q0091,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,30.07,,,,,,,fee schedule,26.21,127.04,APC
Obtaining screen pap smear,Q0091,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,29.78,,,,,,,fee schedule,26.21,127.04,APC
Obtaining screen pap smear,Q0091,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,28.63,,,,,,,fee schedule,26.21,127.04,APC
Obtaining screen pap smear,Q0091,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43.81,,,,,,,fee schedule,26.21,127.04,Radiology
Obtaining screen pap smear,Q0091,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40.09,,,,,,,fee schedule,26.21,127.04,APC
Obtaining screen pap smear,Q0091,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,50.11,,,,,,,fee schedule,26.21,127.04,APC
Wet mounts/ w preparations,Q0111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21.68,,,,,,,fee schedule,16.69,32.44,
Wet mounts/ w preparations,Q0111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23.55,,,,,,,fee schedule,16.69,32.44,
Wet mounts/ w preparations,Q0111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18.88,,,,,,,fee schedule,16.69,32.44,
Wet mounts/ w preparations,Q0111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20.62,,,,,,,fee schedule,16.69,32.44,
Wet mounts/ w preparations,Q0111,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,16.69,,,,,,,fee schedule,16.69,32.44,Laboratory
Wet mounts/ w preparations,Q0111,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,19.47,,,,,,,fee schedule,16.69,32.44,APC
Wet mounts/ w preparations,Q0111,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,19.28,,,,,,,fee schedule,16.69,32.44,APC
Wet mounts/ w preparations,Q0111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18.54,,,,,,,fee schedule,16.69,32.44,APC
Wet mounts/ w preparations,Q0111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.37,,,,,,,fee schedule,16.69,32.44,Radiology
Wet mounts/ w preparations,Q0111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.96,,,,,,,fee schedule,16.69,32.44,APC
Wet mounts/ w preparations,Q0111,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,32.44,,,,,,,fee schedule,16.69,32.44,APC
Potassium hydroxide preps,Q0112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21.68,,,,,,,fee schedule,5.25,23.55,
Potassium hydroxide preps,Q0112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23.55,,,,,,,fee schedule,5.25,23.55,
Potassium hydroxide preps,Q0112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18.88,,,,,,,fee schedule,5.25,23.55,
Potassium hydroxide preps,Q0112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20.62,,,,,,,fee schedule,5.25,23.55,
Potassium hydroxide preps,Q0112,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.25,,,,,,,fee schedule,5.25,23.55,Laboratory
Potassium hydroxide preps,Q0112,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,6.12,,,,,,,fee schedule,5.25,23.55,APC
Potassium hydroxide preps,Q0112,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,6.06,,,,,,,fee schedule,5.25,23.55,APC
Potassium hydroxide preps,Q0112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5.83,,,,,,,fee schedule,5.25,23.55,APC
Potassium hydroxide preps,Q0112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8.92,,,,,,,fee schedule,5.25,23.55,Radiology
Potassium hydroxide preps,Q0112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8.16,,,,,,,fee schedule,5.25,23.55,APC
Potassium hydroxide preps,Q0112,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10.2,,,,,,,fee schedule,5.25,23.55,APC
Pinworm examinations,Q0113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27.49,,,,,,,fee schedule,3.84,29.86,
Pinworm examinations,Q0113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,29.86,,,,,,,fee schedule,3.84,29.86,
Pinworm examinations,Q0113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23.94,,,,,,,fee schedule,3.84,29.86,
Pinworm examinations,Q0113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26.15,,,,,,,fee schedule,3.84,29.86,
Pinworm examinations,Q0113,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,3.84,,,,,,,fee schedule,3.84,29.86,Laboratory
Pinworm examinations,Q0113,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.48,,,,,,,fee schedule,3.84,29.86,APC
Pinworm examinations,Q0113,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4.44,,,,,,,fee schedule,3.84,29.86,APC
Pinworm examinations,Q0113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4.27,,,,,,,fee schedule,3.84,29.86,APC
Pinworm examinations,Q0113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.53,,,,,,,fee schedule,3.84,29.86,Radiology
Pinworm examinations,Q0113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.98,,,,,,,fee schedule,3.84,29.86,APC
Pinworm examinations,Q0113,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7.47,,,,,,,fee schedule,3.84,29.86,APC
Fern test,Q0114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,36.33,,,,,,,fee schedule,8.77,39.46,
Fern test,Q0114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,39.46,,,,,,,fee schedule,8.77,39.46,
Fern test,Q0114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31.63,,,,,,,fee schedule,8.77,39.46,
Fern test,Q0114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,34.56,,,,,,,fee schedule,8.77,39.46,
Fern test,Q0114,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8.77,,,,,,,fee schedule,8.77,39.46,Laboratory
Fern test,Q0114,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.23,,,,,,,fee schedule,8.77,39.46,APC
Fern test,Q0114,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10.13,,,,,,,fee schedule,8.77,39.46,APC
Fern test,Q0114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9.74,,,,,,,fee schedule,8.77,39.46,APC
Fern test,Q0114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.9,,,,,,,fee schedule,8.77,39.46,Radiology
Fern test,Q0114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.64,,,,,,,fee schedule,8.77,39.46,APC
Fern test,Q0114,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,17.05,,,,,,,fee schedule,8.77,39.46,APC
Post-coital mucous exam,Q0115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,50.29,,,,,,,fee schedule,22.5,54.62,
Post-coital mucous exam,Q0115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,54.62,,,,,,,fee schedule,22.5,54.62,
Post-coital mucous exam,Q0115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,43.78,,,,,,,fee schedule,22.5,54.62,
Post-coital mucous exam,Q0115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,47.83,,,,,,,fee schedule,22.5,54.62,
Post-coital mucous exam,Q0115,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,22.5,,,,,,,fee schedule,22.5,54.62,Laboratory
Post-coital mucous exam,Q0115,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,26.25,,,,,,,fee schedule,22.5,54.62,APC
Post-coital mucous exam,Q0115,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,26,,,,,,,fee schedule,22.5,54.62,APC
Post-coital mucous exam,Q0115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,25,,,,,,,fee schedule,22.5,54.62,APC
Post-coital mucous exam,Q0115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,38.25,,,,,,,fee schedule,22.5,54.62,Radiology
Post-coital mucous exam,Q0115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,35,,,,,,,fee schedule,22.5,54.62,APC
Post-coital mucous exam,Q0115,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,43.75,,,,,,,fee schedule,22.5,54.62,APC
"Ferumoxytol, non-esrd",Q0138,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.23,,,,,,,fee schedule,0.23,3.9,
"Ferumoxytol, non-esrd",Q0138,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.42,,,,,,,fee schedule,0.23,3.9,
"Ferumoxytol, non-esrd",Q0138,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.9,,,,,,,fee schedule,0.23,3.9,
"Ferumoxytol, non-esrd",Q0138,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.94,,,,,,,fee schedule,0.23,3.9,
"Ferumoxytol, non-esrd",Q0138,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.12,,,,,,,fee schedule,0.23,3.9,
"Ferumoxytol, non-esrd",Q0138,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.53,,,,,,,fee schedule,0.23,3.9,
"Ferumoxytol, non-esrd",Q0138,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,0.27,,,,,,,fee schedule,0.23,3.9,OP High Cost Drugs
"Ferumoxytol, non-esrd",Q0138,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,0.23,,,,,,,fee schedule,0.23,3.9,Other Pharmacy
"Ferumoxytol, non-esrd",Q0138,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,0.24,,,,,,,fee schedule,0.23,3.9,APC
"Ferumoxytol, non-esrd",Q0138,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,0.24,,,,,,,fee schedule,0.23,3.9,APC
"Ferumoxytol, non-esrd",Q0138,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,0.35,,,,,,,fee schedule,0.23,3.9,Radiology
"Ferumoxytol, non-esrd",Q0138,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,0.32,,,,,,,fee schedule,0.23,3.9,APC
"Ferumoxytol, non-esrd",Q0138,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,0.4,,,,,,,fee schedule,0.23,3.9,APC
"Ferumoxytol, esrd use",Q0139,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.33,,,,,,,fee schedule,0.23,3.9,
"Ferumoxytol, esrd use",Q0139,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.53,,,,,,,fee schedule,0.23,3.9,
"Ferumoxytol, esrd use",Q0139,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.9,,,,,,,fee schedule,0.23,3.9,
"Ferumoxytol, esrd use",Q0139,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.03,,,,,,,fee schedule,0.23,3.9,
"Ferumoxytol, esrd use",Q0139,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.22,,,,,,,fee schedule,0.23,3.9,
"Ferumoxytol, esrd use",Q0139,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.53,,,,,,,fee schedule,0.23,3.9,
"Ferumoxytol, esrd use",Q0139,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,0.27,,,,,,,fee schedule,0.23,3.9,OP High Cost Drugs
"Ferumoxytol, esrd use",Q0139,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,0.23,,,,,,,fee schedule,0.23,3.9,Other Pharmacy
"Ferumoxytol, esrd use",Q0139,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,0.24,,,,,,,fee schedule,0.23,3.9,APC
"Ferumoxytol, esrd use",Q0139,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,0.24,,,,,,,fee schedule,0.23,3.9,APC
"Ferumoxytol, esrd use",Q0139,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,0.35,,,,,,,fee schedule,0.23,3.9,Radiology
"Ferumoxytol, esrd use",Q0139,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,0.32,,,,,,,fee schedule,0.23,3.9,APC
"Ferumoxytol, esrd use",Q0139,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,0.4,,,,,,,fee schedule,0.23,3.9,APC
Ondansetron oral,Q0162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.14,,,,,,,fee schedule,0.12,8.17,
Ondansetron oral,Q0162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.15,,,,,,,fee schedule,0.12,8.17,
Ondansetron oral,Q0162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8.17,,,,,,,fee schedule,0.12,8.17,
Ondansetron oral,Q0162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.12,,,,,,,fee schedule,0.12,8.17,
Ondansetron oral,Q0162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.13,,,,,,,fee schedule,0.12,8.17,
Ondansetron oral,Q0162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7.39,,,,,,,fee schedule,0.12,8.17,
Diphenhydramine HCl 50mg,Q0163,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.24,,,,,,,fee schedule,0.21,0.24,
Diphenhydramine HCl 50mg,Q0163,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.21,,,,,,,fee schedule,0.21,0.24,
Prochlorperazine maleate 5mg,Q0164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.93,,,,,,,fee schedule,0.84,0.93,
Prochlorperazine maleate 5mg,Q0164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.84,,,,,,,fee schedule,0.84,0.93,
Granisetron HCl 1 mg oral,Q0166,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,63.89,,,,,,,fee schedule,55.63,93.25,
Granisetron HCl 1 mg oral,Q0166,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,69.4,,,,,,,fee schedule,55.63,93.25,
Granisetron HCl 1 mg oral,Q0166,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,93.25,,,,,,,fee schedule,55.63,93.25,
Granisetron HCl 1 mg oral,Q0166,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55.63,,,,,,,fee schedule,55.63,93.25,
Granisetron HCl 1 mg oral,Q0166,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,60.77,,,,,,,fee schedule,55.63,93.25,
Granisetron HCl 1 mg oral,Q0166,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,84.4,,,,,,,fee schedule,55.63,93.25,
Dronabinol 2.5mg oral,Q0167,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.31,,,,,,,fee schedule,8.42,9.31,
Dronabinol 2.5mg oral,Q0167,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.42,,,,,,,fee schedule,8.42,9.31,
Promethazine HCl 12.5mg oral,Q0169,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.4,,,,,,,fee schedule,0.36,0.4,
Promethazine HCl 12.5mg oral,Q0169,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.36,,,,,,,fee schedule,0.36,0.4,
Dolasetron mesylate oral,Q0180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,203.96,,,,,,,fee schedule,177.59,227.16,
Dolasetron mesylate oral,Q0180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,221.55,,,,,,,fee schedule,177.59,227.16,
Dolasetron mesylate oral,Q0180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,227.16,,,,,,,fee schedule,177.59,227.16,
Dolasetron mesylate oral,Q0180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,177.59,,,,,,,fee schedule,177.59,227.16,
Dolasetron mesylate oral,Q0180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,194,,,,,,,fee schedule,177.59,227.16,
Dolasetron mesylate oral,Q0180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,205.59,,,,,,,fee schedule,177.59,227.16,
Bebtelovimab 175 mg,Q0222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8331.12,,,,,,,fee schedule,3603.6,9049.32,
Bebtelovimab 175 mg,Q0222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9049.32,,,,,,,fee schedule,3603.6,9049.32,
Bebtelovimab 175 mg,Q0222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3981.6,,,,,,,fee schedule,3603.6,9049.32,
Bebtelovimab 175 mg,Q0222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7253.82,,,,,,,fee schedule,3603.6,9049.32,
Bebtelovimab 175 mg,Q0222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7924.14,,,,,,,fee schedule,3603.6,9049.32,
Bebtelovimab 175 mg,Q0222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3603.6,,,,,,,fee schedule,3603.6,9049.32,
"Inj, pemivibart, 4500 mg",Q0224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10949.4,,,,,,,fee schedule,9909.9,10949.4,
"Inj, pemivibart, 4500 mg",Q0224,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9909.9,,,,,,,fee schedule,9909.9,10949.4,
Sotrovimab,Q0247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3981.6,,,,,,,fee schedule,3603.6,3981.6,
Sotrovimab,Q0247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3603.6,,,,,,,fee schedule,3603.6,3981.6,
Tocilizumab for covid-19,Q0249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12.59,,,,,,,fee schedule,11.4,12.59,
Tocilizumab for covid-19,Q0249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11.4,,,,,,,fee schedule,11.4,12.59,
"Power adapter, combo vad",Q0478,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,601.45,,,,,,,fee schedule,227.49,653.3,
"Power adapter, combo vad",Q0478,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,653.3,,,,,,,fee schedule,227.49,653.3,
"Power adapter, combo vad",Q0478,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,523.67,,,,,,,fee schedule,227.49,653.3,
"Power adapter, combo vad",Q0478,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,572.07,,,,,,,fee schedule,227.49,653.3,
"Power adapter, combo vad",Q0478,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,238.86,,,,,,,fee schedule,227.49,653.3,APC
"Power adapter, combo vad",Q0478,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,236.59,,,,,,,fee schedule,227.49,653.3,APC
"Power adapter, combo vad",Q0478,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,227.49,,,,,,,fee schedule,227.49,653.3,APC
"Power adapter, combo vad",Q0478,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,348.06,,,,,,,fee schedule,227.49,653.3,Radiology
"Power adapter, combo vad",Q0478,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,318.49,,,,,,,fee schedule,227.49,653.3,APC
"Power adapter, combo vad",Q0478,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,398.11,,,,,,,fee schedule,227.49,653.3,APC
"Power module combo vad, rep",Q0479,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,39528.76,,,,,,,fee schedule,14823.51,42936.42,
"Power module combo vad, rep",Q0479,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42936.42,,,,,,,fee schedule,14823.51,42936.42,
"Power module combo vad, rep",Q0479,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,34417.29,,,,,,,fee schedule,14823.51,42936.42,
"Power module combo vad, rep",Q0479,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37597.76,,,,,,,fee schedule,14823.51,42936.42,
"Power module combo vad, rep",Q0479,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,15564.69,,,,,,,fee schedule,14823.51,42936.42,APC
"Power module combo vad, rep",Q0479,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,15416.45,,,,,,,fee schedule,14823.51,42936.42,APC
"Power module combo vad, rep",Q0479,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14823.51,,,,,,,fee schedule,14823.51,42936.42,APC
"Power module combo vad, rep",Q0479,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22679.97,,,,,,,fee schedule,14823.51,42936.42,Radiology
"Power module combo vad, rep",Q0479,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20752.91,,,,,,,fee schedule,14823.51,42936.42,APC
"Power module combo vad, rep",Q0479,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,25941.14,,,,,,,fee schedule,14823.51,42936.42,APC
"driver pneumatic vad, rep",Q0480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,285861.71,,,,,,,fee schedule,111492.17,310504.96,
"driver pneumatic vad, rep",Q0480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,310504.96,,,,,,,fee schedule,111492.17,310504.96,
"driver pneumatic vad, rep",Q0480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,248896.84,,,,,,,fee schedule,111492.17,310504.96,
"driver pneumatic vad, rep",Q0480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,271897.2,,,,,,,fee schedule,111492.17,310504.96,
"driver pneumatic vad, rep",Q0480,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,117066.78,,,,,,,fee schedule,111492.17,310504.96,APC
"driver pneumatic vad, rep",Q0480,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,115951.86,,,,,,,fee schedule,111492.17,310504.96,APC
"driver pneumatic vad, rep",Q0480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,111492.17,,,,,,,fee schedule,111492.17,310504.96,APC
"driver pneumatic vad, rep",Q0480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,170583.02,,,,,,,fee schedule,111492.17,310504.96,Radiology
"driver pneumatic vad, rep",Q0480,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,156089.04,,,,,,,fee schedule,111492.17,310504.96,APC
"driver pneumatic vad, rep",Q0480,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,195111.3,,,,,,,fee schedule,111492.17,310504.96,APC
"microprcsr cu elec vad, rep",Q0481,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46120.51,,,,,,,fee schedule,17987.99,50096.42,
"microprcsr cu elec vad, rep",Q0481,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,50096.42,,,,,,,fee schedule,17987.99,50096.42,
"microprcsr cu elec vad, rep",Q0481,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40156.65,,,,,,,fee schedule,17987.99,50096.42,
"microprcsr cu elec vad, rep",Q0481,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,43867.5,,,,,,,fee schedule,17987.99,50096.42,
"microprcsr cu elec vad, rep",Q0481,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,18887.39,,,,,,,fee schedule,17987.99,50096.42,APC
"microprcsr cu elec vad, rep",Q0481,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,18707.51,,,,,,,fee schedule,17987.99,50096.42,APC
"microprcsr cu elec vad, rep",Q0481,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17987.99,,,,,,,fee schedule,17987.99,50096.42,APC
"microprcsr cu elec vad, rep",Q0481,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27521.62,,,,,,,fee schedule,17987.99,50096.42,Radiology
"microprcsr cu elec vad, rep",Q0481,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25183.19,,,,,,,fee schedule,17987.99,50096.42,APC
"microprcsr cu elec vad, rep",Q0481,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31478.98,,,,,,,fee schedule,17987.99,50096.42,APC
"microprcsr cu combo vad, rep",Q0482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14445.76,,,,,,,fee schedule,5634.16,15691.08,
"microprcsr cu combo vad, rep",Q0482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15691.08,,,,,,,fee schedule,5634.16,15691.08,
"microprcsr cu combo vad, rep",Q0482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12577.77,,,,,,,fee schedule,5634.16,15691.08,
"microprcsr cu combo vad, rep",Q0482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13740.07,,,,,,,fee schedule,5634.16,15691.08,
"microprcsr cu combo vad, rep",Q0482,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5915.87,,,,,,,fee schedule,5634.16,15691.08,APC
"microprcsr cu combo vad, rep",Q0482,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5859.53,,,,,,,fee schedule,5634.16,15691.08,APC
"microprcsr cu combo vad, rep",Q0482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5634.16,,,,,,,fee schedule,5634.16,15691.08,APC
"microprcsr cu combo vad, rep",Q0482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8620.26,,,,,,,fee schedule,5634.16,15691.08,Radiology
"microprcsr cu combo vad, rep",Q0482,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7887.82,,,,,,,fee schedule,5634.16,15691.08,APC
"microprcsr cu combo vad, rep",Q0482,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9859.78,,,,,,,fee schedule,5634.16,15691.08,APC
"monitor elec vad, rep",Q0483,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59510.19,,,,,,,fee schedule,23210.23,64640.38,
"monitor elec vad, rep",Q0483,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,64640.38,,,,,,,fee schedule,23210.23,64640.38,
"monitor elec vad, rep",Q0483,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51814.91,,,,,,,fee schedule,23210.23,64640.38,
"monitor elec vad, rep",Q0483,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56603.09,,,,,,,fee schedule,23210.23,64640.38,
"monitor elec vad, rep",Q0483,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,24370.74,,,,,,,fee schedule,23210.23,64640.38,APC
"monitor elec vad, rep",Q0483,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,24138.64,,,,,,,fee schedule,23210.23,64640.38,APC
"monitor elec vad, rep",Q0483,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,23210.23,,,,,,,fee schedule,23210.23,64640.38,APC
"monitor elec vad, rep",Q0483,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,35511.65,,,,,,,fee schedule,23210.23,64640.38,Radiology
"monitor elec vad, rep",Q0483,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,32494.32,,,,,,,fee schedule,23210.23,64640.38,APC
"monitor elec vad, rep",Q0483,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,40617.9,,,,,,,fee schedule,23210.23,64640.38,APC
monitor elec or comb vad rep,Q0484,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11556.66,,,,,,,fee schedule,4507.35,12552.93,
monitor elec or comb vad rep,Q0484,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12552.93,,,,,,,fee schedule,4507.35,12552.93,
monitor elec or comb vad rep,Q0484,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10062.27,,,,,,,fee schedule,4507.35,12552.93,
monitor elec or comb vad rep,Q0484,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10992.11,,,,,,,fee schedule,4507.35,12552.93,
monitor elec or comb vad rep,Q0484,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4732.72,,,,,,,fee schedule,4507.35,12552.93,APC
monitor elec or comb vad rep,Q0484,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4687.64,,,,,,,fee schedule,4507.35,12552.93,APC
monitor elec or comb vad rep,Q0484,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4507.35,,,,,,,fee schedule,4507.35,12552.93,APC
monitor elec or comb vad rep,Q0484,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6896.25,,,,,,,fee schedule,4507.35,12552.93,Radiology
monitor elec or comb vad rep,Q0484,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6310.29,,,,,,,fee schedule,4507.35,12552.93,APC
monitor elec or comb vad rep,Q0484,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7887.86,,,,,,,fee schedule,4507.35,12552.93,APC
"monitor cable elec vad, rep",Q0485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1115.83,,,,,,,fee schedule,435.18,1212.02,
"monitor cable elec vad, rep",Q0485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1212.02,,,,,,,fee schedule,435.18,1212.02,
"monitor cable elec vad, rep",Q0485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,971.54,,,,,,,fee schedule,435.18,1212.02,
"monitor cable elec vad, rep",Q0485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1061.32,,,,,,,fee schedule,435.18,1212.02,
"monitor cable elec vad, rep",Q0485,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,456.94,,,,,,,fee schedule,435.18,1212.02,APC
"monitor cable elec vad, rep",Q0485,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,452.59,,,,,,,fee schedule,435.18,1212.02,APC
"monitor cable elec vad, rep",Q0485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,435.18,,,,,,,fee schedule,435.18,1212.02,APC
"monitor cable elec vad, rep",Q0485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,665.83,,,,,,,fee schedule,435.18,1212.02,Radiology
"monitor cable elec vad, rep",Q0485,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,609.25,,,,,,,fee schedule,435.18,1212.02,APC
"monitor cable elec vad, rep",Q0485,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,761.56,,,,,,,fee schedule,435.18,1212.02,APC
mon cable elec/pneum vad rep,Q0486,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,928.64,,,,,,,fee schedule,362.18,1008.69,
mon cable elec/pneum vad rep,Q0486,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1008.69,,,,,,,fee schedule,362.18,1008.69,
mon cable elec/pneum vad rep,Q0486,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,808.56,,,,,,,fee schedule,362.18,1008.69,
mon cable elec/pneum vad rep,Q0486,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,883.27,,,,,,,fee schedule,362.18,1008.69,
mon cable elec/pneum vad rep,Q0486,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,380.29,,,,,,,fee schedule,362.18,1008.69,APC
mon cable elec/pneum vad rep,Q0486,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,376.67,,,,,,,fee schedule,362.18,1008.69,APC
mon cable elec/pneum vad rep,Q0486,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,362.18,,,,,,,fee schedule,362.18,1008.69,APC
mon cable elec/pneum vad rep,Q0486,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,554.14,,,,,,,fee schedule,362.18,1008.69,Radiology
mon cable elec/pneum vad rep,Q0486,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,507.05,,,,,,,fee schedule,362.18,1008.69,APC
mon cable elec/pneum vad rep,Q0486,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,633.82,,,,,,,fee schedule,362.18,1008.69,APC
"leads any type vad, rep only",Q0487,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1083.46,,,,,,,fee schedule,422.56,1176.87,
"leads any type vad, rep only",Q0487,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1176.87,,,,,,,fee schedule,422.56,1176.87,
"leads any type vad, rep only",Q0487,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,943.36,,,,,,,fee schedule,422.56,1176.87,
"leads any type vad, rep only",Q0487,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1030.54,,,,,,,fee schedule,422.56,1176.87,
"leads any type vad, rep only",Q0487,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,443.69,,,,,,,fee schedule,422.56,1176.87,APC
"leads any type vad, rep only",Q0487,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,439.46,,,,,,,fee schedule,422.56,1176.87,APC
"leads any type vad, rep only",Q0487,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,422.56,,,,,,,fee schedule,422.56,1176.87,APC
"leads any type vad, rep only",Q0487,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,646.52,,,,,,,fee schedule,422.56,1176.87,Radiology
"leads any type vad, rep only",Q0487,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,591.58,,,,,,,fee schedule,422.56,1176.87,APC
"leads any type vad, rep only",Q0487,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,739.48,,,,,,,fee schedule,422.56,1176.87,APC
"pwr pck base combo vad, rep",Q0489,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,51592.18,,,,,,,fee schedule,20122.03,56039.79,
"pwr pck base combo vad, rep",Q0489,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,56039.79,,,,,,,fee schedule,20122.03,56039.79,
"pwr pck base combo vad, rep",Q0489,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,44920.78,,,,,,,fee schedule,20122.03,56039.79,
"pwr pck base combo vad, rep",Q0489,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,49071.88,,,,,,,fee schedule,20122.03,56039.79,
"pwr pck base combo vad, rep",Q0489,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21128.13,,,,,,,fee schedule,20122.03,56039.79,APC
"pwr pck base combo vad, rep",Q0489,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,20926.91,,,,,,,fee schedule,20122.03,56039.79,APC
"pwr pck base combo vad, rep",Q0489,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,20122.03,,,,,,,fee schedule,20122.03,56039.79,APC
"pwr pck base combo vad, rep",Q0489,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,30786.71,,,,,,,fee schedule,20122.03,56039.79,Radiology
"pwr pck base combo vad, rep",Q0489,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28170.84,,,,,,,fee schedule,20122.03,56039.79,APC
"pwr pck base combo vad, rep",Q0489,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,35213.55,,,,,,,fee schedule,20122.03,56039.79,APC
"emr pwr source elec vad, rep",Q0490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2231.65,,,,,,,fee schedule,870.42,2424.04,
"emr pwr source elec vad, rep",Q0490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2424.04,,,,,,,fee schedule,870.42,2424.04,
"emr pwr source elec vad, rep",Q0490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1943.08,,,,,,,fee schedule,870.42,2424.04,
"emr pwr source elec vad, rep",Q0490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2122.64,,,,,,,fee schedule,870.42,2424.04,
"emr pwr source elec vad, rep",Q0490,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,913.94,,,,,,,fee schedule,870.42,2424.04,APC
"emr pwr source elec vad, rep",Q0490,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,905.24,,,,,,,fee schedule,870.42,2424.04,APC
"emr pwr source elec vad, rep",Q0490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,870.42,,,,,,,fee schedule,870.42,2424.04,APC
"emr pwr source elec vad, rep",Q0490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1331.74,,,,,,,fee schedule,870.42,2424.04,Radiology
"emr pwr source elec vad, rep",Q0490,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1218.59,,,,,,,fee schedule,870.42,2424.04,APC
"emr pwr source elec vad, rep",Q0490,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1523.24,,,,,,,fee schedule,870.42,2424.04,APC
emr pwr source combo vad rep,Q0491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3508.33,,,,,,,fee schedule,1368.33,3810.77,
emr pwr source combo vad rep,Q0491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3810.77,,,,,,,fee schedule,1368.33,3810.77,
emr pwr source combo vad rep,Q0491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3054.66,,,,,,,fee schedule,1368.33,3810.77,
emr pwr source combo vad rep,Q0491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3336.94,,,,,,,fee schedule,1368.33,3810.77,
emr pwr source combo vad rep,Q0491,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1436.75,,,,,,,fee schedule,1368.33,3810.77,APC
emr pwr source combo vad rep,Q0491,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1423.06,,,,,,,fee schedule,1368.33,3810.77,APC
emr pwr source combo vad rep,Q0491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1368.33,,,,,,,fee schedule,1368.33,3810.77,APC
emr pwr source combo vad rep,Q0491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2093.54,,,,,,,fee schedule,1368.33,3810.77,Radiology
emr pwr source combo vad rep,Q0491,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1915.66,,,,,,,fee schedule,1368.33,3810.77,APC
emr pwr source combo vad rep,Q0491,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2394.58,,,,,,,fee schedule,1368.33,3810.77,APC
"emr pwr cbl elec vad, rep",Q0492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,282.72,,,,,,,fee schedule,110.27,307.09,
"emr pwr cbl elec vad, rep",Q0492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,307.09,,,,,,,fee schedule,110.27,307.09,
"emr pwr cbl elec vad, rep",Q0492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,246.16,,,,,,,fee schedule,110.27,307.09,
"emr pwr cbl elec vad, rep",Q0492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,268.9,,,,,,,fee schedule,110.27,307.09,
"emr pwr cbl elec vad, rep",Q0492,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,115.78,,,,,,,fee schedule,110.27,307.09,APC
"emr pwr cbl elec vad, rep",Q0492,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,114.68,,,,,,,fee schedule,110.27,307.09,APC
"emr pwr cbl elec vad, rep",Q0492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,110.27,,,,,,,fee schedule,110.27,307.09,APC
"emr pwr cbl elec vad, rep",Q0492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,168.71,,,,,,,fee schedule,110.27,307.09,Radiology
"emr pwr cbl elec vad, rep",Q0492,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,154.38,,,,,,,fee schedule,110.27,307.09,APC
"emr pwr cbl elec vad, rep",Q0492,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,192.97,,,,,,,fee schedule,110.27,307.09,APC
"emr pwr cbl combo vad, rep",Q0493,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,804.75,,,,,,,fee schedule,313.83,874.13,
"emr pwr cbl combo vad, rep",Q0493,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,874.13,,,,,,,fee schedule,313.83,874.13,
"emr pwr cbl combo vad, rep",Q0493,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,700.69,,,,,,,fee schedule,313.83,874.13,
"emr pwr cbl combo vad, rep",Q0493,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,765.44,,,,,,,fee schedule,313.83,874.13,
"emr pwr cbl combo vad, rep",Q0493,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,329.52,,,,,,,fee schedule,313.83,874.13,APC
"emr pwr cbl combo vad, rep",Q0493,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,326.38,,,,,,,fee schedule,313.83,874.13,APC
"emr pwr cbl combo vad, rep",Q0493,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,313.83,,,,,,,fee schedule,313.83,874.13,APC
"emr pwr cbl combo vad, rep",Q0493,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,480.16,,,,,,,fee schedule,313.83,874.13,Radiology
"emr pwr cbl combo vad, rep",Q0493,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,439.36,,,,,,,fee schedule,313.83,874.13,APC
"emr pwr cbl combo vad, rep",Q0493,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,549.2,,,,,,,fee schedule,313.83,874.13,APC
"emr hd pmp elec/combo, rep",Q0494,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,680.97,,,,,,,fee schedule,265.56,739.67,
"emr hd pmp elec/combo, rep",Q0494,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,739.67,,,,,,,fee schedule,265.56,739.67,
"emr hd pmp elec/combo, rep",Q0494,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,592.91,,,,,,,fee schedule,265.56,739.67,
"emr hd pmp elec/combo, rep",Q0494,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,647.7,,,,,,,fee schedule,265.56,739.67,
"emr hd pmp elec/combo, rep",Q0494,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,278.84,,,,,,,fee schedule,265.56,739.67,APC
"emr hd pmp elec/combo, rep",Q0494,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,276.18,,,,,,,fee schedule,265.56,739.67,APC
"emr hd pmp elec/combo, rep",Q0494,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,265.56,,,,,,,fee schedule,265.56,739.67,APC
"emr hd pmp elec/combo, rep",Q0494,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,406.31,,,,,,,fee schedule,265.56,739.67,Radiology
"emr hd pmp elec/combo, rep",Q0494,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,371.78,,,,,,,fee schedule,265.56,739.67,APC
"emr hd pmp elec/combo, rep",Q0494,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,464.73,,,,,,,fee schedule,265.56,739.67,APC
"charger elec/combo vad, rep",Q0495,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13257.9,,,,,,,fee schedule,5170.85,14400.82,
"charger elec/combo vad, rep",Q0495,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14400.82,,,,,,,fee schedule,5170.85,14400.82,
"charger elec/combo vad, rep",Q0495,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11543.51,,,,,,,fee schedule,5170.85,14400.82,
"charger elec/combo vad, rep",Q0495,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12610.24,,,,,,,fee schedule,5170.85,14400.82,
"charger elec/combo vad, rep",Q0495,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5429.39,,,,,,,fee schedule,5170.85,14400.82,APC
"charger elec/combo vad, rep",Q0495,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5377.68,,,,,,,fee schedule,5170.85,14400.82,APC
"charger elec/combo vad, rep",Q0495,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5170.85,,,,,,,fee schedule,5170.85,14400.82,APC
"charger elec/combo vad, rep",Q0495,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7911.4,,,,,,,fee schedule,5170.85,14400.82,Radiology
"charger elec/combo vad, rep",Q0495,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7239.19,,,,,,,fee schedule,5170.85,14400.82,APC
"charger elec/combo vad, rep",Q0495,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9048.99,,,,,,,fee schedule,5170.85,14400.82,APC
"battery elec/combo vad, rep",Q0496,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4758.41,,,,,,,fee schedule,1855.88,5168.62,
"battery elec/combo vad, rep",Q0496,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5168.62,,,,,,,fee schedule,1855.88,5168.62,
"battery elec/combo vad, rep",Q0496,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4143.1,,,,,,,fee schedule,1855.88,5168.62,
"battery elec/combo vad, rep",Q0496,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4525.96,,,,,,,fee schedule,1855.88,5168.62,
"battery elec/combo vad, rep",Q0496,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1948.67,,,,,,,fee schedule,1855.88,5168.62,APC
"battery elec/combo vad, rep",Q0496,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1930.12,,,,,,,fee schedule,1855.88,5168.62,APC
"battery elec/combo vad, rep",Q0496,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1855.88,,,,,,,fee schedule,1855.88,5168.62,APC
"battery elec/combo vad, rep",Q0496,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2839.5,,,,,,,fee schedule,1855.88,5168.62,Radiology
"battery elec/combo vad, rep",Q0496,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2598.23,,,,,,,fee schedule,1855.88,5168.62,APC
"battery elec/combo vad, rep",Q0496,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3247.79,,,,,,,fee schedule,1855.88,5168.62,APC
"bat clps elec/comb vad, rep",Q0497,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1485.82,,,,,,,fee schedule,579.49,1613.91,
"bat clps elec/comb vad, rep",Q0497,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1613.91,,,,,,,fee schedule,579.49,1613.91,
"bat clps elec/comb vad, rep",Q0497,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1293.69,,,,,,,fee schedule,579.49,1613.91,
"bat clps elec/comb vad, rep",Q0497,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1413.24,,,,,,,fee schedule,579.49,1613.91,
"bat clps elec/comb vad, rep",Q0497,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,608.46,,,,,,,fee schedule,579.49,1613.91,APC
"bat clps elec/comb vad, rep",Q0497,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,602.67,,,,,,,fee schedule,579.49,1613.91,APC
"bat clps elec/comb vad, rep",Q0497,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,579.49,,,,,,,fee schedule,579.49,1613.91,APC
"bat clps elec/comb vad, rep",Q0497,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,886.62,,,,,,,fee schedule,579.49,1613.91,Radiology
"bat clps elec/comb vad, rep",Q0497,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,811.29,,,,,,,fee schedule,579.49,1613.91,APC
"bat clps elec/comb vad, rep",Q0497,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1014.11,,,,,,,fee schedule,579.49,1613.91,APC
"holster elec/combo vad, rep",Q0498,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1630.28,,,,,,,fee schedule,635.84,1770.82,
"holster elec/combo vad, rep",Q0498,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1770.82,,,,,,,fee schedule,635.84,1770.82,
"holster elec/combo vad, rep",Q0498,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1419.46,,,,,,,fee schedule,635.84,1770.82,
"holster elec/combo vad, rep",Q0498,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1550.64,,,,,,,fee schedule,635.84,1770.82,
"holster elec/combo vad, rep",Q0498,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,667.63,,,,,,,fee schedule,635.84,1770.82,APC
"holster elec/combo vad, rep",Q0498,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,661.27,,,,,,,fee schedule,635.84,1770.82,APC
"holster elec/combo vad, rep",Q0498,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,635.84,,,,,,,fee schedule,635.84,1770.82,APC
"holster elec/combo vad, rep",Q0498,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,972.84,,,,,,,fee schedule,635.84,1770.82,Radiology
"holster elec/combo vad, rep",Q0498,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,890.18,,,,,,,fee schedule,635.84,1770.82,APC
"holster elec/combo vad, rep",Q0498,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1112.72,,,,,,,fee schedule,635.84,1770.82,APC
belt/vest elec/combo vad rep,Q0499,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,529.69,,,,,,,fee schedule,206.61,575.35,
belt/vest elec/combo vad rep,Q0499,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,575.35,,,,,,,fee schedule,206.61,575.35,
belt/vest elec/combo vad rep,Q0499,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,461.2,,,,,,,fee schedule,206.61,575.35,
belt/vest elec/combo vad rep,Q0499,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,503.82,,,,,,,fee schedule,206.61,575.35,
belt/vest elec/combo vad rep,Q0499,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,216.94,,,,,,,fee schedule,206.61,575.35,APC
belt/vest elec/combo vad rep,Q0499,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,214.87,,,,,,,fee schedule,206.61,575.35,APC
belt/vest elec/combo vad rep,Q0499,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,206.61,,,,,,,fee schedule,206.61,575.35,APC
belt/vest elec/combo vad rep,Q0499,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,316.11,,,,,,,fee schedule,206.61,575.35,Radiology
belt/vest elec/combo vad rep,Q0499,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,289.25,,,,,,,fee schedule,206.61,575.35,APC
belt/vest elec/combo vad rep,Q0499,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,361.57,,,,,,,fee schedule,206.61,575.35,APC
"filters elec/combo vad, rep",Q0500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,96.92,,,,,,,fee schedule,37.8,105.27,
"filters elec/combo vad, rep",Q0500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,105.27,,,,,,,fee schedule,37.8,105.27,
"filters elec/combo vad, rep",Q0500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,84.39,,,,,,,fee schedule,37.8,105.27,
"filters elec/combo vad, rep",Q0500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,92.18,,,,,,,fee schedule,37.8,105.27,
"filters elec/combo vad, rep",Q0500,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,39.69,,,,,,,fee schedule,37.8,105.27,APC
"filters elec/combo vad, rep",Q0500,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,39.31,,,,,,,fee schedule,37.8,105.27,APC
"filters elec/combo vad, rep",Q0500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,37.8,,,,,,,fee schedule,37.8,105.27,APC
"filters elec/combo vad, rep",Q0500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,57.83,,,,,,,fee schedule,37.8,105.27,Radiology
"filters elec/combo vad, rep",Q0500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,52.92,,,,,,,fee schedule,37.8,105.27,APC
"filters elec/combo vad, rep",Q0500,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,66.15,,,,,,,fee schedule,37.8,105.27,APC
"shwr cov elec/combo vad, rep",Q0501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1620.98,,,,,,,fee schedule,632.22,1760.72,
"shwr cov elec/combo vad, rep",Q0501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1760.72,,,,,,,fee schedule,632.22,1760.72,
"shwr cov elec/combo vad, rep",Q0501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1411.37,,,,,,,fee schedule,632.22,1760.72,
"shwr cov elec/combo vad, rep",Q0501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1541.8,,,,,,,fee schedule,632.22,1760.72,
"shwr cov elec/combo vad, rep",Q0501,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,663.83,,,,,,,fee schedule,632.22,1760.72,APC
"shwr cov elec/combo vad, rep",Q0501,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,657.51,,,,,,,fee schedule,632.22,1760.72,APC
"shwr cov elec/combo vad, rep",Q0501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,632.22,,,,,,,fee schedule,632.22,1760.72,APC
"shwr cov elec/combo vad, rep",Q0501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,967.3,,,,,,,fee schedule,632.22,1760.72,Radiology
"shwr cov elec/combo vad, rep",Q0501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,885.11,,,,,,,fee schedule,632.22,1760.72,APC
"shwr cov elec/combo vad, rep",Q0501,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1106.38,,,,,,,fee schedule,632.22,1760.72,APC
"mobility cart pneum vad, rep",Q0502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2063.61,,,,,,,fee schedule,804.84,2241.5,
"mobility cart pneum vad, rep",Q0502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2241.5,,,,,,,fee schedule,804.84,2241.5,
"mobility cart pneum vad, rep",Q0502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1796.76,,,,,,,fee schedule,804.84,2241.5,
"mobility cart pneum vad, rep",Q0502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1962.8,,,,,,,fee schedule,804.84,2241.5,
"mobility cart pneum vad, rep",Q0502,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,845.08,,,,,,,fee schedule,804.84,2241.5,APC
"mobility cart pneum vad, rep",Q0502,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,837.03,,,,,,,fee schedule,804.84,2241.5,APC
"mobility cart pneum vad, rep",Q0502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,804.84,,,,,,,fee schedule,804.84,2241.5,APC
"mobility cart pneum vad, rep",Q0502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1231.41,,,,,,,fee schedule,804.84,2241.5,Radiology
"mobility cart pneum vad, rep",Q0502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1126.78,,,,,,,fee schedule,804.84,2241.5,APC
"mobility cart pneum vad, rep",Q0502,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1408.47,,,,,,,fee schedule,804.84,2241.5,APC
battery pneum vad replacemnt,Q0503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4127.42,,,,,,,fee schedule,1609.77,4483.23,
battery pneum vad replacemnt,Q0503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4483.23,,,,,,,fee schedule,1609.77,4483.23,
battery pneum vad replacemnt,Q0503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3593.7,,,,,,,fee schedule,1609.77,4483.23,
battery pneum vad replacemnt,Q0503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3925.79,,,,,,,fee schedule,1609.77,4483.23,
battery pneum vad replacemnt,Q0503,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1690.26,,,,,,,fee schedule,1609.77,4483.23,APC
battery pneum vad replacemnt,Q0503,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1674.16,,,,,,,fee schedule,1609.77,4483.23,APC
battery pneum vad replacemnt,Q0503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1609.77,,,,,,,fee schedule,1609.77,4483.23,APC
battery pneum vad replacemnt,Q0503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2462.95,,,,,,,fee schedule,1609.77,4483.23,Radiology
battery pneum vad replacemnt,Q0503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2253.68,,,,,,,fee schedule,1609.77,4483.23,APC
battery pneum vad replacemnt,Q0503,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2817.1,,,,,,,fee schedule,1609.77,4483.23,APC
"pwr adpt pneum vad, rep veh",Q0504,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2177.89,,,,,,,fee schedule,849.41,2365.64,
"pwr adpt pneum vad, rep veh",Q0504,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2365.64,,,,,,,fee schedule,849.41,2365.64,
"pwr adpt pneum vad, rep veh",Q0504,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1896.26,,,,,,,fee schedule,849.41,2365.64,
"pwr adpt pneum vad, rep veh",Q0504,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2071.5,,,,,,,fee schedule,849.41,2365.64,
"pwr adpt pneum vad, rep veh",Q0504,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,891.88,,,,,,,fee schedule,849.41,2365.64,APC
"pwr adpt pneum vad, rep veh",Q0504,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,883.39,,,,,,,fee schedule,849.41,2365.64,APC
"pwr adpt pneum vad, rep veh",Q0504,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,849.41,,,,,,,fee schedule,849.41,2365.64,APC
"pwr adpt pneum vad, rep veh",Q0504,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1299.6,,,,,,,fee schedule,849.41,2365.64,Radiology
"pwr adpt pneum vad, rep veh",Q0504,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1189.17,,,,,,,fee schedule,849.41,2365.64,APC
"pwr adpt pneum vad, rep veh",Q0504,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1486.47,,,,,,,fee schedule,849.41,2365.64,APC
Lith-ion batt elec/pneum VAD,Q0506,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2795.41,,,,,,,fee schedule,1057.34,3036.4,
Lith-ion batt elec/pneum VAD,Q0506,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3036.4,,,,,,,fee schedule,1057.34,3036.4,
Lith-ion batt elec/pneum VAD,Q0506,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2433.94,,,,,,,fee schedule,1057.34,3036.4,
Lith-ion batt elec/pneum VAD,Q0506,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2658.86,,,,,,,fee schedule,1057.34,3036.4,
Lith-ion batt elec/pneum VAD,Q0506,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1110.21,,,,,,,fee schedule,1057.34,3036.4,APC
Lith-ion batt elec/pneum VAD,Q0506,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1099.63,,,,,,,fee schedule,1057.34,3036.4,APC
Lith-ion batt elec/pneum VAD,Q0506,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1057.34,,,,,,,fee schedule,1057.34,3036.4,APC
Lith-ion batt elec/pneum VAD,Q0506,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1617.73,,,,,,,fee schedule,1057.34,3036.4,Radiology
Lith-ion batt elec/pneum VAD,Q0506,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1480.28,,,,,,,fee schedule,1057.34,3036.4,APC
Lith-ion batt elec/pneum VAD,Q0506,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1850.34,,,,,,,fee schedule,1057.34,3036.4,APC
Sermorelin acetate injection,Q0515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.23,,,,,,,fee schedule,5.42,6.77,
Sermorelin acetate injection,Q0515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.77,,,,,,,fee schedule,5.42,6.77,
Sermorelin acetate injection,Q0515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.42,,,,,,,fee schedule,5.42,6.77,
Sermorelin acetate injection,Q0515,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.92,,,,,,,fee schedule,5.42,6.77,
Fosphenytoin inj pe,Q2009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.61,,,,,,,fee schedule,1.33,11.57,
Fosphenytoin inj pe,Q2009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.84,,,,,,,fee schedule,1.33,11.57,
Fosphenytoin inj pe,Q2009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11.57,,,,,,,fee schedule,1.33,11.57,
Fosphenytoin inj pe,Q2009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.27,,,,,,,fee schedule,1.33,11.57,
Fosphenytoin inj pe,Q2009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.48,,,,,,,fee schedule,1.33,11.57,
Fosphenytoin inj pe,Q2009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10.47,,,,,,,fee schedule,1.33,11.57,
Fosphenytoin inj pe,Q2009,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,5.91,,,,,,,fee schedule,1.33,11.57,APC 378
Fosphenytoin inj pe,Q2009,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1.4,,,,,,,fee schedule,1.33,11.57,APC
Fosphenytoin inj pe,Q2009,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1.39,,,,,,,fee schedule,1.33,11.57,APC
Fosphenytoin inj pe,Q2009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1.33,,,,,,,fee schedule,1.33,11.57,APC
Fosphenytoin inj pe,Q2009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2.04,,,,,,,fee schedule,1.33,11.57,Radiology
Fosphenytoin inj pe,Q2009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1.86,,,,,,,fee schedule,1.33,11.57,APC
Fosphenytoin inj pe,Q2009,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2.33,,,,,,,fee schedule,1.33,11.57,APC
"Teniposide, 50 mg",Q2017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1081.76,,,,,,,fee schedule,941.88,4732.32,
"Teniposide, 50 mg",Q2017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1175.01,,,,,,,fee schedule,941.88,4732.32,
"Teniposide, 50 mg",Q2017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4732.32,,,,,,,fee schedule,941.88,4732.32,
"Teniposide, 50 mg",Q2017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,941.88,,,,,,,fee schedule,941.88,4732.32,
"Teniposide, 50 mg",Q2017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1028.91,,,,,,,fee schedule,941.88,4732.32,
"Teniposide, 50 mg",Q2017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4283.05,,,,,,,fee schedule,941.88,4732.32,
Radiesse injection,Q2026,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,895.65,,,,,,,fee schedule,349.19,1549.24,
Radiesse injection,Q2026,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,972.86,,,,,,,fee schedule,349.19,1549.24,
Radiesse injection,Q2026,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,779.83,,,,,,,fee schedule,349.19,1549.24,
Radiesse injection,Q2026,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,851.89,,,,,,,fee schedule,349.19,1549.24,
Radiesse injection,Q2026,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1549.24,,,,,,,fee schedule,349.19,1549.24,APC 378
Radiesse injection,Q2026,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,366.65,,,,,,,fee schedule,349.19,1549.24,APC
Radiesse injection,Q2026,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,363.16,,,,,,,fee schedule,349.19,1549.24,APC
Radiesse injection,Q2026,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,349.19,,,,,,,fee schedule,349.19,1549.24,APC
Radiesse injection,Q2026,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,534.26,,,,,,,fee schedule,349.19,1549.24,Radiology
Radiesse injection,Q2026,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,488.87,,,,,,,fee schedule,349.19,1549.24,APC
Radiesse injection,Q2026,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,611.08,,,,,,,fee schedule,349.19,1549.24,APC
"Inj, sculptra, 0.5mg",Q2028,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8.67,,,,,,,fee schedule,2.16,9.58,
"Inj, sculptra, 0.5mg",Q2028,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.41,,,,,,,fee schedule,2.16,9.58,
"Inj, sculptra, 0.5mg",Q2028,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7.54,,,,,,,fee schedule,2.16,9.58,
"Inj, sculptra, 0.5mg",Q2028,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.24,,,,,,,fee schedule,2.16,9.58,
"Inj, sculptra, 0.5mg",Q2028,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,9.58,,,,,,,fee schedule,2.16,9.58,APC 378
"Inj, sculptra, 0.5mg",Q2028,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2.27,,,,,,,fee schedule,2.16,9.58,APC
"Inj, sculptra, 0.5mg",Q2028,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2.25,,,,,,,fee schedule,2.16,9.58,APC
"Inj, sculptra, 0.5mg",Q2028,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2.16,,,,,,,fee schedule,2.16,9.58,APC
"Inj, sculptra, 0.5mg",Q2028,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3.3,,,,,,,fee schedule,2.16,9.58,Radiology
"Inj, sculptra, 0.5mg",Q2028,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3.02,,,,,,,fee schedule,2.16,9.58,APC
"Inj, sculptra, 0.5mg",Q2028,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3.78,,,,,,,fee schedule,2.16,9.58,APC
Agriflu vaccine,Q2034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,54.81,,,,,,,fee schedule,47.72,59.54,
Agriflu vaccine,Q2034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59.54,,,,,,,fee schedule,47.72,59.54,
Agriflu vaccine,Q2034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,47.72,,,,,,,fee schedule,47.72,59.54,
Agriflu vaccine,Q2034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52.13,,,,,,,fee schedule,47.72,59.54,
"Afluria vacc, 3 yrs & >, im",Q2035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,40.16,,,,,,,fee schedule,34.97,43.62,
"Afluria vacc, 3 yrs & >, im",Q2035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,43.62,,,,,,,fee schedule,34.97,43.62,
"Afluria vacc, 3 yrs & >, im",Q2035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,39.15,,,,,,,fee schedule,34.97,43.62,
"Afluria vacc, 3 yrs & >, im",Q2035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,34.97,,,,,,,fee schedule,34.97,43.62,
"Afluria vacc, 3 yrs & >, im",Q2035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38.2,,,,,,,fee schedule,34.97,43.62,
"Afluria vacc, 3 yrs & >, im",Q2035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35.44,,,,,,,fee schedule,34.97,43.62,
"Flulaval vacc, 3 yrs & >, im",Q2036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,34.21,,,,,,,fee schedule,26.84,37.16,
"Flulaval vacc, 3 yrs & >, im",Q2036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37.16,,,,,,,fee schedule,26.84,37.16,
"Flulaval vacc, 3 yrs & >, im",Q2036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,29.66,,,,,,,fee schedule,26.84,37.16,
"Flulaval vacc, 3 yrs & >, im",Q2036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29.78,,,,,,,fee schedule,26.84,37.16,
"Flulaval vacc, 3 yrs & >, im",Q2036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32.54,,,,,,,fee schedule,26.84,37.16,
"Flulaval vacc, 3 yrs & >, im",Q2036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26.84,,,,,,,fee schedule,26.84,37.16,
"Fluvirin vacc, 3 yrs & >, im",Q2037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,48.89,,,,,,,fee schedule,26.63,53.11,
"Fluvirin vacc, 3 yrs & >, im",Q2037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,53.11,,,,,,,fee schedule,26.63,53.11,
"Fluvirin vacc, 3 yrs & >, im",Q2037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,29.42,,,,,,,fee schedule,26.63,53.11,
"Fluvirin vacc, 3 yrs & >, im",Q2037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.57,,,,,,,fee schedule,26.63,53.11,
"Fluvirin vacc, 3 yrs & >, im",Q2037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.51,,,,,,,fee schedule,26.63,53.11,
"Fluvirin vacc, 3 yrs & >, im",Q2037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26.63,,,,,,,fee schedule,26.63,53.11,
"Fluzone vacc, 3 yrs & >, im",Q2038,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41.93,,,,,,,fee schedule,35.28,45.55,
"Fluzone vacc, 3 yrs & >, im",Q2038,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45.55,,,,,,,fee schedule,35.28,45.55,
"Fluzone vacc, 3 yrs & >, im",Q2038,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,38.98,,,,,,,fee schedule,35.28,45.55,
"Fluzone vacc, 3 yrs & >, im",Q2038,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36.51,,,,,,,fee schedule,35.28,45.55,
"Fluzone vacc, 3 yrs & >, im",Q2038,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39.89,,,,,,,fee schedule,35.28,45.55,
"Fluzone vacc, 3 yrs & >, im",Q2038,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35.28,,,,,,,fee schedule,35.28,45.55,
"Influenza virus vaccine, nos",Q2039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,79.34,,,,,,,fee schedule,26.84,86.18,
"Influenza virus vaccine, nos",Q2039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,86.18,,,,,,,fee schedule,26.84,86.18,
"Influenza virus vaccine, nos",Q2039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,29.66,,,,,,,fee schedule,26.84,86.18,
"Influenza virus vaccine, nos",Q2039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,69.08,,,,,,,fee schedule,26.84,86.18,
"Influenza virus vaccine, nos",Q2039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,75.47,,,,,,,fee schedule,26.84,86.18,
"Influenza virus vaccine, nos",Q2039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26.84,,,,,,,fee schedule,26.84,86.18,
Axicabtagene ciloleucel car+,Q2041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1375922.4,,,,,,,fee schedule,531849.12,1494536.4,
Axicabtagene ciloleucel car+,Q2041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1494536.4,,,,,,,fee schedule,531849.12,1494536.4,
Axicabtagene ciloleucel car+,Q2041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,875952,,,,,,,fee schedule,531849.12,1494536.4,
Axicabtagene ciloleucel car+,Q2041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1198001.4,,,,,,,fee schedule,531849.12,1494536.4,
Axicabtagene ciloleucel car+,Q2041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1308707.8,,,,,,,fee schedule,531849.12,1494536.4,
Axicabtagene ciloleucel car+,Q2041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,792792,,,,,,,fee schedule,531849.12,1494536.4,
Axicabtagene ciloleucel car+,Q2041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,616944.98,,,,,,,fee schedule,531849.12,1494536.4,OP High Cost Drugs
Axicabtagene ciloleucel car+,Q2041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,531849.12,,,,,,,fee schedule,531849.12,1494536.4,Other Pharmacy
Axicabtagene ciloleucel car+,Q2041,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,558441.57,,,,,,,fee schedule,531849.12,1494536.4,APC
Axicabtagene ciloleucel car+,Q2041,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,553123.08,,,,,,,fee schedule,531849.12,1494536.4,APC
Axicabtagene ciloleucel car+,Q2041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,813729.15,,,,,,,fee schedule,531849.12,1494536.4,Radiology
Axicabtagene ciloleucel car+,Q2041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,744588.77,,,,,,,fee schedule,531849.12,1494536.4,APC
Axicabtagene ciloleucel car+,Q2041,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,930735.96,,,,,,,fee schedule,531849.12,1494536.4,APC
Tisagenlecleucel car-pos t,Q2042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1704379.16,,,,,,,fee schedule,614180.81,1851308.39,
Tisagenlecleucel car-pos t,Q2042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1851308.39,,,,,,,fee schedule,614180.81,1851308.39,
Tisagenlecleucel car-pos t,Q2042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,984816.97,,,,,,,fee schedule,614180.81,1851308.39,
Tisagenlecleucel car-pos t,Q2042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1483985.3,,,,,,,fee schedule,614180.81,1851308.39,
Tisagenlecleucel car-pos t,Q2042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1621119.25,,,,,,,fee schedule,614180.81,1851308.39,
Tisagenlecleucel car-pos t,Q2042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,891321.69,,,,,,,fee schedule,614180.81,1851308.39,
Tisagenlecleucel car-pos t,Q2042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,712449.74,,,,,,,fee schedule,614180.81,1851308.39,OP High Cost Drugs
Tisagenlecleucel car-pos t,Q2042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,614180.81,,,,,,,fee schedule,614180.81,1851308.39,Other Pharmacy
Tisagenlecleucel car-pos t,Q2042,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,644889.85,,,,,,,fee schedule,614180.81,1851308.39,APC
Tisagenlecleucel car-pos t,Q2042,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,638748.04,,,,,,,fee schedule,614180.81,1851308.39,APC
Tisagenlecleucel car-pos t,Q2042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,939696.64,,,,,,,fee schedule,614180.81,1851308.39,Radiology
Tisagenlecleucel car-pos t,Q2042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,859853.13,,,,,,,fee schedule,614180.81,1851308.39,APC
Tisagenlecleucel car-pos t,Q2042,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1074816.41,,,,,,,fee schedule,614180.81,1851308.39,APC
Sipuleucel-t auto cd54+,Q2043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,114299.21,,,,,,,fee schedule,56269.19,124152.59,
Sipuleucel-t auto cd54+,Q2043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,124152.59,,,,,,,fee schedule,56269.19,124152.59,
Sipuleucel-t auto cd54+,Q2043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,122955.6,,,,,,,fee schedule,56269.19,124152.59,
Sipuleucel-t auto cd54+,Q2043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,99519.14,,,,,,,fee schedule,56269.19,124152.59,
Sipuleucel-t auto cd54+,Q2043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,108715.63,,,,,,,fee schedule,56269.19,124152.59,
Sipuleucel-t auto cd54+,Q2043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,111282.6,,,,,,,fee schedule,56269.19,124152.59,
Sipuleucel-t auto cd54+,Q2043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,65272.26,,,,,,,fee schedule,56269.19,124152.59,OP High Cost Drugs
Sipuleucel-t auto cd54+,Q2043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56269.19,,,,,,,fee schedule,56269.19,124152.59,Other Pharmacy
Sipuleucel-t auto cd54+,Q2043,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,59082.65,,,,,,,fee schedule,56269.19,124152.59,APC
Sipuleucel-t auto cd54+,Q2043,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,58519.96,,,,,,,fee schedule,56269.19,124152.59,APC
Sipuleucel-t auto cd54+,Q2043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,86091.86,,,,,,,fee schedule,56269.19,124152.59,Radiology
Sipuleucel-t auto cd54+,Q2043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,78776.87,,,,,,,fee schedule,56269.19,124152.59,APC
Sipuleucel-t auto cd54+,Q2043,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,98471.09,,,,,,,fee schedule,56269.19,124152.59,APC
Imported Lipodox inj,Q2049,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1733.94,,,,,,,fee schedule,298.74,1883.42,
Imported Lipodox inj,Q2049,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1883.42,,,,,,,fee schedule,298.74,1883.42,
Imported Lipodox inj,Q2049,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,909.45,,,,,,,fee schedule,298.74,1883.42,
Imported Lipodox inj,Q2049,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1509.73,,,,,,,fee schedule,298.74,1883.42,
Imported Lipodox inj,Q2049,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1649.24,,,,,,,fee schedule,298.74,1883.42,
Imported Lipodox inj,Q2049,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,823.11,,,,,,,fee schedule,298.74,1883.42,
Imported Lipodox inj,Q2049,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,1325.41,,,,,,,fee schedule,298.74,1883.42,APC 378
Imported Lipodox inj,Q2049,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,313.68,,,,,,,fee schedule,298.74,1883.42,APC
Imported Lipodox inj,Q2049,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,310.69,,,,,,,fee schedule,298.74,1883.42,APC
Imported Lipodox inj,Q2049,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,298.74,,,,,,,fee schedule,298.74,1883.42,APC
Imported Lipodox inj,Q2049,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,457.07,,,,,,,fee schedule,298.74,1883.42,Radiology
Imported Lipodox inj,Q2049,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,418.24,,,,,,,fee schedule,298.74,1883.42,APC
Imported Lipodox inj,Q2049,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,522.8,,,,,,,fee schedule,298.74,1883.42,APC
Doxorubicin inj 10mg,Q2050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1898.13,,,,,,,fee schedule,71.86,2061.76,
Doxorubicin inj 10mg,Q2050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2061.76,,,,,,,fee schedule,71.86,2061.76,
Doxorubicin inj 10mg,Q2050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,826.66,,,,,,,fee schedule,71.86,2061.76,
Doxorubicin inj 10mg,Q2050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1652.68,,,,,,,fee schedule,71.86,2061.76,
Doxorubicin inj 10mg,Q2050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1805.41,,,,,,,fee schedule,71.86,2061.76,
Doxorubicin inj 10mg,Q2050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,748.18,,,,,,,fee schedule,71.86,2061.76,
Doxorubicin inj 10mg,Q2050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,83.36,,,,,,,fee schedule,71.86,2061.76,OP High Cost Drugs
Doxorubicin inj 10mg,Q2050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,71.86,,,,,,,fee schedule,71.86,2061.76,Other Pharmacy
Doxorubicin inj 10mg,Q2050,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,75.45,,,,,,,fee schedule,71.86,2061.76,APC
Doxorubicin inj 10mg,Q2050,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,74.74,,,,,,,fee schedule,71.86,2061.76,APC
Doxorubicin inj 10mg,Q2050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,109.95,,,,,,,fee schedule,71.86,2061.76,Radiology
Doxorubicin inj 10mg,Q2050,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,100.61,,,,,,,fee schedule,71.86,2061.76,APC
Doxorubicin inj 10mg,Q2050,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,125.76,,,,,,,fee schedule,71.86,2061.76,APC
Brexucabtagene car pos t,Q2053,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1423876.8,,,,,,,fee schedule,489290.6,1546624.8,
Brexucabtagene car pos t,Q2053,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1546624.8,,,,,,,fee schedule,489290.6,1546624.8,
Brexucabtagene car pos t,Q2053,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,875952,,,,,,,fee schedule,489290.6,1546624.8,
Brexucabtagene car pos t,Q2053,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1239754.8,,,,,,,fee schedule,489290.6,1546624.8,
Brexucabtagene car pos t,Q2053,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1354319.6,,,,,,,fee schedule,489290.6,1546624.8,
Brexucabtagene car pos t,Q2053,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,792792,,,,,,,fee schedule,489290.6,1546624.8,
Brexucabtagene car pos t,Q2053,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,567577.1,,,,,,,fee schedule,489290.6,1546624.8,OP High Cost Drugs
Brexucabtagene car pos t,Q2053,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,489290.6,,,,,,,fee schedule,489290.6,1546624.8,Other Pharmacy
Brexucabtagene car pos t,Q2053,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,513755.13,,,,,,,fee schedule,489290.6,1546624.8,APC
Brexucabtagene car pos t,Q2053,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,508862.23,,,,,,,fee schedule,489290.6,1546624.8,APC
Brexucabtagene car pos t,Q2053,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,748614.62,,,,,,,fee schedule,489290.6,1546624.8,Radiology
Brexucabtagene car pos t,Q2053,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,685006.84,,,,,,,fee schedule,489290.6,1546624.8,APC
Brexucabtagene car pos t,Q2053,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,856258.55,,,,,,,fee schedule,489290.6,1546624.8,APC
Lisocabtagene mara car pos t,Q2054,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1513514.64,,,,,,,fee schedule,562260.84,1643990.04,
Lisocabtagene mara car pos t,Q2054,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1643990.04,,,,,,,fee schedule,562260.84,1643990.04,
Lisocabtagene mara car pos t,Q2054,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,924257.25,,,,,,,fee schedule,562260.84,1643990.04,
Lisocabtagene mara car pos t,Q2054,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1317801.54,,,,,,,fee schedule,562260.84,1643990.04,
Lisocabtagene mara car pos t,Q2054,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1439578.58,,,,,,,fee schedule,562260.84,1643990.04,
Lisocabtagene mara car pos t,Q2054,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,836511.3,,,,,,,fee schedule,562260.84,1643990.04,
Lisocabtagene mara car pos t,Q2054,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,652222.57,,,,,,,fee schedule,562260.84,1643990.04,OP High Cost Drugs
Lisocabtagene mara car pos t,Q2054,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,562260.84,,,,,,,fee schedule,562260.84,1643990.04,Other Pharmacy
Lisocabtagene mara car pos t,Q2054,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,590373.88,,,,,,,fee schedule,562260.84,1643990.04,APC
Lisocabtagene mara car pos t,Q2054,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,584751.27,,,,,,,fee schedule,562260.84,1643990.04,APC
Lisocabtagene mara car pos t,Q2054,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,860259.08,,,,,,,fee schedule,562260.84,1643990.04,Radiology
Lisocabtagene mara car pos t,Q2054,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,787165.17,,,,,,,fee schedule,562260.84,1643990.04,APC
Lisocabtagene mara car pos t,Q2054,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,983956.46,,,,,,,fee schedule,562260.84,1643990.04,APC
Idecabtagene vicleucel car,Q2055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1547451.6,,,,,,,fee schedule,559781.08,1680852.6,
Idecabtagene vicleucel car,Q2055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1680852.6,,,,,,,fee schedule,559781.08,1680852.6,
Idecabtagene vicleucel car,Q2055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,944981.41,,,,,,,fee schedule,559781.08,1680852.6,
Idecabtagene vicleucel car,Q2055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1347350.1,,,,,,,fee schedule,559781.08,1680852.6,
Idecabtagene vicleucel car,Q2055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1471857.7,,,,,,,fee schedule,559781.08,1680852.6,
Idecabtagene vicleucel car,Q2055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,855267.99,,,,,,,fee schedule,559781.08,1680852.6,
Idecabtagene vicleucel car,Q2055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,649346.05,,,,,,,fee schedule,559781.08,1680852.6,OP High Cost Drugs
Idecabtagene vicleucel car,Q2055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,559781.08,,,,,,,fee schedule,559781.08,1680852.6,Other Pharmacy
Idecabtagene vicleucel car,Q2055,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,587770.14,,,,,,,fee schedule,559781.08,1680852.6,APC
Idecabtagene vicleucel car,Q2055,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,582172.32,,,,,,,fee schedule,559781.08,1680852.6,APC
Idecabtagene vicleucel car,Q2055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,856465.05,,,,,,,fee schedule,559781.08,1680852.6,Radiology
Idecabtagene vicleucel car,Q2055,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,783693.51,,,,,,,fee schedule,559781.08,1680852.6,APC
Idecabtagene vicleucel car,Q2055,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,979616.89,,,,,,,fee schedule,559781.08,1680852.6,APC
Ciltacabtagene car-pos t,Q2056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1666746,,,,,,,fee schedule,588494.81,1810431,
Ciltacabtagene car-pos t,Q2056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1810431,,,,,,,fee schedule,588494.81,1810431,
Ciltacabtagene car-pos t,Q2056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,989817.28,,,,,,,fee schedule,588494.81,1810431,
Ciltacabtagene car-pos t,Q2056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1451218.5,,,,,,,fee schedule,588494.81,1810431,
Ciltacabtagene car-pos t,Q2056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1585324.5,,,,,,,fee schedule,588494.81,1810431,
Ciltacabtagene car-pos t,Q2056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,895847.28,,,,,,,fee schedule,588494.81,1810431,
Ciltacabtagene car-pos t,Q2056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,682653.98,,,,,,,fee schedule,588494.81,1810431,OP High Cost Drugs
Ciltacabtagene car-pos t,Q2056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,588494.81,,,,,,,fee schedule,588494.81,1810431,Other Pharmacy
Ciltacabtagene car-pos t,Q2056,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,617919.55,,,,,,,fee schedule,588494.81,1810431,APC
Ciltacabtagene car-pos t,Q2056,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,612034.6,,,,,,,fee schedule,588494.81,1810431,APC
Ciltacabtagene car-pos t,Q2056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,900397.06,,,,,,,fee schedule,588494.81,1810431,Radiology
Ciltacabtagene car-pos t,Q2056,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,823892.73,,,,,,,fee schedule,588494.81,1810431,APC
Ciltacabtagene car-pos t,Q2056,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1029865.91,,,,,,,fee schedule,588494.81,1810431,APC
Inj beta interferon im 1 mcg,Q3027,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,127.68,,,,,,,fee schedule,111.17,261.73,
Inj beta interferon im 1 mcg,Q3027,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,138.69,,,,,,,fee schedule,111.17,261.73,
Inj beta interferon im 1 mcg,Q3027,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,261.73,,,,,,,fee schedule,111.17,261.73,
Inj beta interferon im 1 mcg,Q3027,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,111.17,,,,,,,fee schedule,111.17,261.73,
Inj beta interferon im 1 mcg,Q3027,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,121.44,,,,,,,fee schedule,111.17,261.73,
Inj beta interferon im 1 mcg,Q3027,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,236.88,,,,,,,fee schedule,111.17,261.73,
Inj beta interferon sq 1 mcg,Q3028,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,81.75,,,,,,,fee schedule,68.6,88.79,
Inj beta interferon sq 1 mcg,Q3028,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,88.79,,,,,,,fee schedule,68.6,88.79,
Inj beta interferon sq 1 mcg,Q3028,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,75.79,,,,,,,fee schedule,68.6,88.79,
Inj beta interferon sq 1 mcg,Q3028,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,71.17,,,,,,,fee schedule,68.6,88.79,
Inj beta interferon sq 1 mcg,Q3028,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,77.75,,,,,,,fee schedule,68.6,88.79,
Inj beta interferon sq 1 mcg,Q3028,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,68.6,,,,,,,fee schedule,68.6,88.79,
Cast sup body cast plaster,Q4001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,146.19,,,,,,,fee schedule,127.29,158.8,
Cast sup body cast plaster,Q4001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,158.8,,,,,,,fee schedule,127.29,158.8,
Cast sup body cast plaster,Q4001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,127.29,,,,,,,fee schedule,127.29,158.8,
Cast sup body cast plaster,Q4001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,139.05,,,,,,,fee schedule,127.29,158.8,
Cast sup body cast fiberglas,Q4002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,552.66,,,,,,,fee schedule,481.19,600.3,
Cast sup body cast fiberglas,Q4002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,600.3,,,,,,,fee schedule,481.19,600.3,
Cast sup body cast fiberglas,Q4002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,481.19,,,,,,,fee schedule,481.19,600.3,
Cast sup body cast fiberglas,Q4002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,525.66,,,,,,,fee schedule,481.19,600.3,
Cast sup shoulder cast plstr,Q4003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,105.03,,,,,,,fee schedule,91.45,114.08,
Cast sup shoulder cast plstr,Q4003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,114.08,,,,,,,fee schedule,91.45,114.08,
Cast sup shoulder cast plstr,Q4003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,91.45,,,,,,,fee schedule,91.45,114.08,
Cast sup shoulder cast plstr,Q4003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,99.9,,,,,,,fee schedule,91.45,114.08,
Cast sup shoulder cast fbrgl,Q4004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,363.63,,,,,,,fee schedule,316.6,394.97,
Cast sup shoulder cast fbrgl,Q4004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,394.97,,,,,,,fee schedule,316.6,394.97,
Cast sup shoulder cast fbrgl,Q4004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,316.6,,,,,,,fee schedule,316.6,394.97,
Cast sup shoulder cast fbrgl,Q4004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,345.86,,,,,,,fee schedule,316.6,394.97,
Cast sup long arm adult plst,Q4005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,38.7,,,,,,,fee schedule,33.69,42.03,
Cast sup long arm adult plst,Q4005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42.03,,,,,,,fee schedule,33.69,42.03,
Cast sup long arm adult plst,Q4005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,33.69,,,,,,,fee schedule,33.69,42.03,
Cast sup long arm adult plst,Q4005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36.81,,,,,,,fee schedule,33.69,42.03,
Cast sup long arm adult fbrg,Q4006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,87.28,,,,,,,fee schedule,75.99,94.8,
Cast sup long arm adult fbrg,Q4006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,94.8,,,,,,,fee schedule,75.99,94.8,
Cast sup long arm adult fbrg,Q4006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,75.99,,,,,,,fee schedule,75.99,94.8,
Cast sup long arm adult fbrg,Q4006,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,83.01,,,,,,,fee schedule,75.99,94.8,
Cast sup long arm ped plster,Q4007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19.42,,,,,,,fee schedule,16.91,21.09,
Cast sup long arm ped plster,Q4007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21.09,,,,,,,fee schedule,16.91,21.09,
Cast sup long arm ped plster,Q4007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.91,,,,,,,fee schedule,16.91,21.09,
Cast sup long arm ped plster,Q4007,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18.47,,,,,,,fee schedule,16.91,21.09,
Cast sup long arm ped fbrgls,Q4008,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,43.64,,,,,,,fee schedule,38,47.4,
Cast sup long arm ped fbrgls,Q4008,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,47.4,,,,,,,fee schedule,38,47.4,
Cast sup long arm ped fbrgls,Q4008,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38,,,,,,,fee schedule,38,47.4,
Cast sup long arm ped fbrgls,Q4008,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,41.51,,,,,,,fee schedule,38,47.4,
Cast sup sht arm adult plstr,Q4009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,25.86,,,,,,,fee schedule,22.51,28.09,
Cast sup sht arm adult plstr,Q4009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,28.09,,,,,,,fee schedule,22.51,28.09,
Cast sup sht arm adult plstr,Q4009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22.51,,,,,,,fee schedule,22.51,28.09,
Cast sup sht arm adult plstr,Q4009,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24.59,,,,,,,fee schedule,22.51,28.09,
Cast sup sht arm adult fbrgl,Q4010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,58.19,,,,,,,fee schedule,50.66,63.2,
Cast sup sht arm adult fbrgl,Q4010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,63.2,,,,,,,fee schedule,50.66,63.2,
Cast sup sht arm adult fbrgl,Q4010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,50.66,,,,,,,fee schedule,50.66,63.2,
Cast sup sht arm adult fbrgl,Q4010,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55.34,,,,,,,fee schedule,50.66,63.2,
Cast sup sht arm ped plaster,Q4011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12.91,,,,,,,fee schedule,11.24,14.02,
Cast sup sht arm ped plaster,Q4011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14.02,,,,,,,fee schedule,11.24,14.02,
Cast sup sht arm ped plaster,Q4011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11.24,,,,,,,fee schedule,11.24,14.02,
Cast sup sht arm ped plaster,Q4011,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12.28,,,,,,,fee schedule,11.24,14.02,
Cast sup sht arm ped fbrglas,Q4012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,29.09,,,,,,,fee schedule,25.33,31.6,
Cast sup sht arm ped fbrglas,Q4012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,31.6,,,,,,,fee schedule,25.33,31.6,
Cast sup sht arm ped fbrglas,Q4012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,25.33,,,,,,,fee schedule,25.33,31.6,
Cast sup sht arm ped fbrglas,Q4012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,27.67,,,,,,,fee schedule,25.33,31.6,
Cast sup gauntlet plaster,Q4013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,47.05,,,,,,,fee schedule,40.97,51.11,
Cast sup gauntlet plaster,Q4013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,51.11,,,,,,,fee schedule,40.97,51.11,
Cast sup gauntlet plaster,Q4013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40.97,,,,,,,fee schedule,40.97,51.11,
Cast sup gauntlet plaster,Q4013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,44.75,,,,,,,fee schedule,40.97,51.11,
Cast sup gauntlet fiberglass,Q4014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,79.38,,,,,,,fee schedule,69.11,86.22,
Cast sup gauntlet fiberglass,Q4014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,86.22,,,,,,,fee schedule,69.11,86.22,
Cast sup gauntlet fiberglass,Q4014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,69.11,,,,,,,fee schedule,69.11,86.22,
Cast sup gauntlet fiberglass,Q4014,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,75.5,,,,,,,fee schedule,69.11,86.22,
Cast sup gauntlet ped plster,Q4015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23.52,,,,,,,fee schedule,20.48,25.55,
Cast sup gauntlet ped plster,Q4015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,25.55,,,,,,,fee schedule,20.48,25.55,
Cast sup gauntlet ped plster,Q4015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20.48,,,,,,,fee schedule,20.48,25.55,
Cast sup gauntlet ped plster,Q4015,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22.38,,,,,,,fee schedule,20.48,25.55,
Cast sup gauntlet ped fbrgls,Q4016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,39.67,,,,,,,fee schedule,34.54,43.09,
Cast sup gauntlet ped fbrgls,Q4016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,43.09,,,,,,,fee schedule,34.54,43.09,
Cast sup gauntlet ped fbrgls,Q4016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,34.54,,,,,,,fee schedule,34.54,43.09,
Cast sup gauntlet ped fbrgls,Q4016,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37.73,,,,,,,fee schedule,34.54,43.09,
Cast sup lng arm splint plst,Q4017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27.21,,,,,,,fee schedule,23.69,29.56,
Cast sup lng arm splint plst,Q4017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,29.56,,,,,,,fee schedule,23.69,29.56,
Cast sup lng arm splint plst,Q4017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23.69,,,,,,,fee schedule,23.69,29.56,
Cast sup lng arm splint plst,Q4017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,25.88,,,,,,,fee schedule,23.69,29.56,
Cast sup lng arm splint fbrg,Q4018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,43.4,,,,,,,fee schedule,37.78,47.14,
Cast sup lng arm splint fbrg,Q4018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,47.14,,,,,,,fee schedule,37.78,47.14,
Cast sup lng arm splint fbrg,Q4018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37.78,,,,,,,fee schedule,37.78,47.14,
Cast sup lng arm splint fbrg,Q4018,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,41.28,,,,,,,fee schedule,37.78,47.14,
Cast sup lng arm splnt ped p,Q4019,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13.61,,,,,,,fee schedule,11.85,14.78,
Cast sup lng arm splnt ped p,Q4019,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14.78,,,,,,,fee schedule,11.85,14.78,
Cast sup lng arm splnt ped p,Q4019,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11.85,,,,,,,fee schedule,11.85,14.78,
Cast sup lng arm splnt ped p,Q4019,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12.94,,,,,,,fee schedule,11.85,14.78,
Cast sup lng arm splnt ped f,Q4020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21.72,,,,,,,fee schedule,18.91,23.59,
Cast sup lng arm splnt ped f,Q4020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23.59,,,,,,,fee schedule,18.91,23.59,
Cast sup lng arm splnt ped f,Q4020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18.91,,,,,,,fee schedule,18.91,23.59,
Cast sup lng arm splnt ped f,Q4020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20.65,,,,,,,fee schedule,18.91,23.59,
Cast sup sht arm splint plst,Q4021,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20.11,,,,,,,fee schedule,17.51,21.85,
Cast sup sht arm splint plst,Q4021,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21.85,,,,,,,fee schedule,17.51,21.85,
Cast sup sht arm splint plst,Q4021,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17.51,,,,,,,fee schedule,17.51,21.85,
Cast sup sht arm splint plst,Q4021,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19.13,,,,,,,fee schedule,17.51,21.85,
Cast sup sht arm splint fbrg,Q4022,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,36.33,,,,,,,fee schedule,31.63,39.46,
Cast sup sht arm splint fbrg,Q4022,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,39.46,,,,,,,fee schedule,31.63,39.46,
Cast sup sht arm splint fbrg,Q4022,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31.63,,,,,,,fee schedule,31.63,39.46,
Cast sup sht arm splint fbrg,Q4022,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,34.56,,,,,,,fee schedule,31.63,39.46,
Cast sup sht arm splnt ped p,Q4023,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10.13,,,,,,,fee schedule,8.82,11,
Cast sup sht arm splnt ped p,Q4023,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11,,,,,,,fee schedule,8.82,11,
Cast sup sht arm splnt ped p,Q4023,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.82,,,,,,,fee schedule,8.82,11,
Cast sup sht arm splnt ped p,Q4023,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.63,,,,,,,fee schedule,8.82,11,
Cast sup sht arm splnt ped f,Q4024,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18.17,,,,,,,fee schedule,15.82,19.73,
Cast sup sht arm splnt ped f,Q4024,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19.73,,,,,,,fee schedule,15.82,19.73,
Cast sup sht arm splnt ped f,Q4024,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15.82,,,,,,,fee schedule,15.82,19.73,
Cast sup sht arm splnt ped f,Q4024,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17.28,,,,,,,fee schedule,15.82,19.73,
Cast sup hip spica plaster,Q4025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,112.93,,,,,,,fee schedule,98.32,122.66,
Cast sup hip spica plaster,Q4025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,122.66,,,,,,,fee schedule,98.32,122.66,
Cast sup hip spica plaster,Q4025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,98.32,,,,,,,fee schedule,98.32,122.66,
Cast sup hip spica plaster,Q4025,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,107.41,,,,,,,fee schedule,98.32,122.66,
Cast sup hip spica fiberglas,Q4026,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,352.52,,,,,,,fee schedule,306.94,382.91,
Cast sup hip spica fiberglas,Q4026,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,382.91,,,,,,,fee schedule,306.94,382.91,
Cast sup hip spica fiberglas,Q4026,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,306.94,,,,,,,fee schedule,306.94,382.91,
Cast sup hip spica fiberglas,Q4026,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,335.3,,,,,,,fee schedule,306.94,382.91,
Cast sup hip spica ped plstr,Q4027,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,56.48,,,,,,,fee schedule,49.18,61.35,
Cast sup hip spica ped plstr,Q4027,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,61.35,,,,,,,fee schedule,49.18,61.35,
Cast sup hip spica ped plstr,Q4027,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,49.18,,,,,,,fee schedule,49.18,61.35,
Cast sup hip spica ped plstr,Q4027,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.72,,,,,,,fee schedule,49.18,61.35,
Cast sup hip spica ped fbrgl,Q4028,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,176.3,,,,,,,fee schedule,153.5,191.49,
Cast sup hip spica ped fbrgl,Q4028,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,191.49,,,,,,,fee schedule,153.5,191.49,
Cast sup hip spica ped fbrgl,Q4028,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,153.5,,,,,,,fee schedule,153.5,191.49,
Cast sup hip spica ped fbrgl,Q4028,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,167.68,,,,,,,fee schedule,153.5,191.49,
Cast sup long leg plaster,Q4029,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,86.34,,,,,,,fee schedule,75.17,93.78,
Cast sup long leg plaster,Q4029,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,93.78,,,,,,,fee schedule,75.17,93.78,
Cast sup long leg plaster,Q4029,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,75.17,,,,,,,fee schedule,75.17,93.78,
Cast sup long leg plaster,Q4029,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,82.12,,,,,,,fee schedule,75.17,93.78,
Cast sup long leg fiberglass,Q4030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,227.28,,,,,,,fee schedule,197.89,246.87,
Cast sup long leg fiberglass,Q4030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,246.87,,,,,,,fee schedule,197.89,246.87,
Cast sup long leg fiberglass,Q4030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,197.89,,,,,,,fee schedule,197.89,246.87,
Cast sup long leg fiberglass,Q4030,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,216.18,,,,,,,fee schedule,197.89,246.87,
Cast sup lng leg ped plaster,Q4031,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,43.19,,,,,,,fee schedule,37.6,46.91,
Cast sup lng leg ped plaster,Q4031,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46.91,,,,,,,fee schedule,37.6,46.91,
Cast sup lng leg ped plaster,Q4031,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37.6,,,,,,,fee schedule,37.6,46.91,
Cast sup lng leg ped plaster,Q4031,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,41.08,,,,,,,fee schedule,37.6,46.91,
Cast sup lng leg ped fbrgls,Q4032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,113.62,,,,,,,fee schedule,98.93,123.42,
Cast sup lng leg ped fbrgls,Q4032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,123.42,,,,,,,fee schedule,98.93,123.42,
Cast sup lng leg ped fbrgls,Q4032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,98.93,,,,,,,fee schedule,98.93,123.42,
Cast sup lng leg ped fbrgls,Q4032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,108.07,,,,,,,fee schedule,98.93,123.42,
Cast sup lng leg cylinder pl,Q4033,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,80.53,,,,,,,fee schedule,70.11,87.47,
Cast sup lng leg cylinder pl,Q4033,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,87.47,,,,,,,fee schedule,70.11,87.47,
Cast sup lng leg cylinder pl,Q4033,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,70.11,,,,,,,fee schedule,70.11,87.47,
Cast sup lng leg cylinder pl,Q4033,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,76.59,,,,,,,fee schedule,70.11,87.47,
Cast sup lng leg cylinder fb,Q4034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,200.31,,,,,,,fee schedule,174.41,217.58,
Cast sup lng leg cylinder fb,Q4034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,217.58,,,,,,,fee schedule,174.41,217.58,
Cast sup lng leg cylinder fb,Q4034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,174.41,,,,,,,fee schedule,174.41,217.58,
Cast sup lng leg cylinder fb,Q4034,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,190.52,,,,,,,fee schedule,174.41,217.58,
Cast sup lngleg cylndr ped p,Q4035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,40.26,,,,,,,fee schedule,35.06,43.73,
Cast sup lngleg cylndr ped p,Q4035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,43.73,,,,,,,fee schedule,35.06,43.73,
Cast sup lngleg cylndr ped p,Q4035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35.06,,,,,,,fee schedule,35.06,43.73,
Cast sup lngleg cylndr ped p,Q4035,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38.3,,,,,,,fee schedule,35.06,43.73,
Cast sup lngleg cylndr ped f,Q4036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,100.19,,,,,,,fee schedule,87.23,108.83,
Cast sup lngleg cylndr ped f,Q4036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,108.83,,,,,,,fee schedule,87.23,108.83,
Cast sup lngleg cylndr ped f,Q4036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,87.23,,,,,,,fee schedule,87.23,108.83,
Cast sup lngleg cylndr ped f,Q4036,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,95.29,,,,,,,fee schedule,87.23,108.83,
Cast sup shrt leg plaster,Q4037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,49.14,,,,,,,fee schedule,42.78,53.37,
Cast sup shrt leg plaster,Q4037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,53.37,,,,,,,fee schedule,42.78,53.37,
Cast sup shrt leg plaster,Q4037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42.78,,,,,,,fee schedule,42.78,53.37,
Cast sup shrt leg plaster,Q4037,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46.74,,,,,,,fee schedule,42.78,53.37,
Cast sup shrt leg fiberglass,Q4038,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,123.09,,,,,,,fee schedule,107.17,133.7,
Cast sup shrt leg fiberglass,Q4038,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,133.7,,,,,,,fee schedule,107.17,133.7,
Cast sup shrt leg fiberglass,Q4038,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,107.17,,,,,,,fee schedule,107.17,133.7,
Cast sup shrt leg fiberglass,Q4038,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,117.07,,,,,,,fee schedule,107.17,133.7,
Cast sup shrt leg ped plster,Q4039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24.64,,,,,,,fee schedule,21.45,26.76,
Cast sup shrt leg ped plster,Q4039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26.76,,,,,,,fee schedule,21.45,26.76,
Cast sup shrt leg ped plster,Q4039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21.45,,,,,,,fee schedule,21.45,26.76,
Cast sup shrt leg ped plster,Q4039,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23.43,,,,,,,fee schedule,21.45,26.76,
Cast sup shrt leg ped fbrgls,Q4040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,61.53,,,,,,,fee schedule,53.57,66.83,
Cast sup shrt leg ped fbrgls,Q4040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,66.83,,,,,,,fee schedule,53.57,66.83,
Cast sup shrt leg ped fbrgls,Q4040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.57,,,,,,,fee schedule,53.57,66.83,
Cast sup shrt leg ped fbrgls,Q4040,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,58.52,,,,,,,fee schedule,53.57,66.83,
Cast sup lng leg splnt plstr,Q4041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59.72,,,,,,,fee schedule,51.99,64.86,
Cast sup lng leg splnt plstr,Q4041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,64.86,,,,,,,fee schedule,51.99,64.86,
Cast sup lng leg splnt plstr,Q4041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.99,,,,,,,fee schedule,51.99,64.86,
Cast sup lng leg splnt plstr,Q4041,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56.8,,,,,,,fee schedule,51.99,64.86,
Cast sup lng leg splnt fbrgl,Q4042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,101.96,,,,,,,fee schedule,88.78,110.75,
Cast sup lng leg splnt fbrgl,Q4042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,110.75,,,,,,,fee schedule,88.78,110.75,
Cast sup lng leg splnt fbrgl,Q4042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,88.78,,,,,,,fee schedule,88.78,110.75,
Cast sup lng leg splnt fbrgl,Q4042,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,96.98,,,,,,,fee schedule,88.78,110.75,
Cast sup lng leg splnt ped p,Q4043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,29.89,,,,,,,fee schedule,26.03,32.47,
Cast sup lng leg splnt ped p,Q4043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,32.47,,,,,,,fee schedule,26.03,32.47,
Cast sup lng leg splnt ped p,Q4043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26.03,,,,,,,fee schedule,26.03,32.47,
Cast sup lng leg splnt ped p,Q4043,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28.43,,,,,,,fee schedule,26.03,32.47,
Cast sup lng leg splnt ped f,Q4044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,51.02,,,,,,,fee schedule,44.42,55.41,
Cast sup lng leg splnt ped f,Q4044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55.41,,,,,,,fee schedule,44.42,55.41,
Cast sup lng leg splnt ped f,Q4044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,44.42,,,,,,,fee schedule,44.42,55.41,
Cast sup lng leg splnt ped f,Q4044,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48.52,,,,,,,fee schedule,44.42,55.41,
Cast sup sht leg splnt plstr,Q4045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,34.66,,,,,,,fee schedule,30.18,37.65,
Cast sup sht leg splnt plstr,Q4045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37.65,,,,,,,fee schedule,30.18,37.65,
Cast sup sht leg splnt plstr,Q4045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,30.18,,,,,,,fee schedule,30.18,37.65,
Cast sup sht leg splnt plstr,Q4045,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32.97,,,,,,,fee schedule,30.18,37.65,
Cast sup sht leg splnt fbrgl,Q4046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55.78,,,,,,,fee schedule,48.57,60.59,
Cast sup sht leg splnt fbrgl,Q4046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.59,,,,,,,fee schedule,48.57,60.59,
Cast sup sht leg splnt fbrgl,Q4046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48.57,,,,,,,fee schedule,48.57,60.59,
Cast sup sht leg splnt fbrgl,Q4046,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53.06,,,,,,,fee schedule,48.57,60.59,
Cast sup sht leg splnt ped p,Q4047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17.3,,,,,,,fee schedule,15.06,18.79,
Cast sup sht leg splnt ped p,Q4047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18.79,,,,,,,fee schedule,15.06,18.79,
Cast sup sht leg splnt ped p,Q4047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15.06,,,,,,,fee schedule,15.06,18.79,
Cast sup sht leg splnt ped p,Q4047,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.45,,,,,,,fee schedule,15.06,18.79,
Cast sup sht leg splnt ped f,Q4048,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27.91,,,,,,,fee schedule,24.3,30.32,
Cast sup sht leg splnt ped f,Q4048,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30.32,,,,,,,fee schedule,24.3,30.32,
Cast sup sht leg splnt ped f,Q4048,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24.3,,,,,,,fee schedule,24.3,30.32,
Cast sup sht leg splnt ped f,Q4048,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26.55,,,,,,,fee schedule,24.3,30.32,
"Finger splint, static",Q4049,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.33,,,,,,,fee schedule,5.51,6.88,
"Finger splint, static",Q4049,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6.88,,,,,,,fee schedule,5.51,6.88,
"Finger splint, static",Q4049,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5.51,,,,,,,fee schedule,5.51,6.88,
"Finger splint, static",Q4049,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6.02,,,,,,,fee schedule,5.51,6.88,
Iloprost non-comp unit dose,Q4074,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,267.23,,,,,,,fee schedule,232.67,402.25,
Iloprost non-comp unit dose,Q4074,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,290.27,,,,,,,fee schedule,232.67,402.25,
Iloprost non-comp unit dose,Q4074,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,402.25,,,,,,,fee schedule,232.67,402.25,
Iloprost non-comp unit dose,Q4074,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,232.67,,,,,,,fee schedule,232.67,402.25,
Iloprost non-comp unit dose,Q4074,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,254.17,,,,,,,fee schedule,232.67,402.25,
Iloprost non-comp unit dose,Q4074,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,364.06,,,,,,,fee schedule,232.67,402.25,
"Epoetin alfa, 100 units ESRD",Q4081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.2,,,,,,,fee schedule,2.79,3.48,
"Epoetin alfa, 100 units ESRD",Q4081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.48,,,,,,,fee schedule,2.79,3.48,
"Epoetin alfa, 100 units ESRD",Q4081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.14,,,,,,,fee schedule,2.79,3.48,
"Epoetin alfa, 100 units ESRD",Q4081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.79,,,,,,,fee schedule,2.79,3.48,
"Epoetin alfa, 100 units ESRD",Q4081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.05,,,,,,,fee schedule,2.79,3.48,
"Epoetin alfa, 100 units ESRD",Q4081,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.85,,,,,,,fee schedule,2.79,3.48,
Apligraf,Q4101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,109.24,,,,,,,fee schedule,77.36,546.58,
Apligraf,Q4101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,118.65,,,,,,,fee schedule,77.36,546.58,
Apligraf,Q4101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,85.48,,,,,,,fee schedule,77.36,546.58,
Apligraf,Q4101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,95.11,,,,,,,fee schedule,77.36,546.58,
Apligraf,Q4101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,103.9,,,,,,,fee schedule,77.36,546.58,
Apligraf,Q4101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,77.36,,,,,,,fee schedule,77.36,546.58,
Apligraf,Q4101,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,77.36,546.58,APC 378
Apligraf,Q4101,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,77.36,546.58,APC
Apligraf,Q4101,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,77.36,546.58,APC
Apligraf,Q4101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,77.36,546.58,APC
Apligraf,Q4101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,77.36,546.58,Radiology
Apligraf,Q4101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,77.36,546.58,APC
Apligraf,Q4101,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,77.36,546.58,APC
Oasis wound matrix,Q4102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15.14,,,,,,,fee schedule,13.18,546.58,
Oasis wound matrix,Q4102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16.44,,,,,,,fee schedule,13.18,546.58,
Oasis wound matrix,Q4102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21.31,,,,,,,fee schedule,13.18,546.58,
Oasis wound matrix,Q4102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13.18,,,,,,,fee schedule,13.18,546.58,
Oasis wound matrix,Q4102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14.4,,,,,,,fee schedule,13.18,546.58,
Oasis wound matrix,Q4102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19.29,,,,,,,fee schedule,13.18,546.58,
Oasis wound matrix,Q4102,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,13.18,546.58,APC 378
Oasis wound matrix,Q4102,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,13.18,546.58,APC
Oasis wound matrix,Q4102,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,13.18,546.58,APC
Oasis wound matrix,Q4102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,13.18,546.58,APC
Oasis wound matrix,Q4102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,13.18,546.58,Radiology
Oasis wound matrix,Q4102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,13.18,546.58,APC
Oasis wound matrix,Q4102,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,13.18,546.58,APC
Oasis burn matrix,Q4103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15.14,,,,,,,fee schedule,13.18,546.58,
Oasis burn matrix,Q4103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16.44,,,,,,,fee schedule,13.18,546.58,
Oasis burn matrix,Q4103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23.73,,,,,,,fee schedule,13.18,546.58,
Oasis burn matrix,Q4103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13.18,,,,,,,fee schedule,13.18,546.58,
Oasis burn matrix,Q4103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14.4,,,,,,,fee schedule,13.18,546.58,
Oasis burn matrix,Q4103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21.48,,,,,,,fee schedule,13.18,546.58,
Oasis burn matrix,Q4103,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,13.18,546.58,APC 378
Oasis burn matrix,Q4103,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,13.18,546.58,APC
Oasis burn matrix,Q4103,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,13.18,546.58,APC
Oasis burn matrix,Q4103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,13.18,546.58,APC
Oasis burn matrix,Q4103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,13.18,546.58,Radiology
Oasis burn matrix,Q4103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,13.18,546.58,APC
Oasis burn matrix,Q4103,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,13.18,546.58,APC
Integra bmwd,Q4104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41.31,,,,,,,fee schedule,35.97,546.58,
Integra bmwd,Q4104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,44.87,,,,,,,fee schedule,35.97,546.58,
Integra bmwd,Q4104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,112.2,,,,,,,fee schedule,35.97,546.58,
Integra bmwd,Q4104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35.97,,,,,,,fee schedule,35.97,546.58,
Integra bmwd,Q4104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39.29,,,,,,,fee schedule,35.97,546.58,
Integra bmwd,Q4104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,101.54,,,,,,,fee schedule,35.97,546.58,
Integra bmwd,Q4104,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,35.97,546.58,APC 378
Integra bmwd,Q4104,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,35.97,546.58,APC
Integra bmwd,Q4104,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,35.97,546.58,APC
Integra bmwd,Q4104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,35.97,546.58,APC
Integra bmwd,Q4104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,35.97,546.58,Radiology
Integra bmwd,Q4104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,35.97,546.58,APC
Integra bmwd,Q4104,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,35.97,546.58,APC
Integra drt or omnigraft,Q4105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41.31,,,,,,,fee schedule,35.97,546.58,
Integra drt or omnigraft,Q4105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,44.87,,,,,,,fee schedule,35.97,546.58,
Integra drt or omnigraft,Q4105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,88.84,,,,,,,fee schedule,35.97,546.58,
Integra drt or omnigraft,Q4105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35.97,,,,,,,fee schedule,35.97,546.58,
Integra drt or omnigraft,Q4105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39.29,,,,,,,fee schedule,35.97,546.58,
Integra drt or omnigraft,Q4105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,80.41,,,,,,,fee schedule,35.97,546.58,
Integra drt or omnigraft,Q4105,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,35.97,546.58,APC 378
Integra drt or omnigraft,Q4105,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,35.97,546.58,APC
Integra drt or omnigraft,Q4105,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,35.97,546.58,APC
Integra drt or omnigraft,Q4105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,35.97,546.58,APC
Integra drt or omnigraft,Q4105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,35.97,546.58,Radiology
Integra drt or omnigraft,Q4105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,35.97,546.58,APC
Integra drt or omnigraft,Q4105,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,35.97,546.58,APC
Dermagraft,Q4106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,133.81,,,,,,,fee schedule,72.84,145.34,
Dermagraft,Q4106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,145.34,,,,,,,fee schedule,72.84,145.34,
Dermagraft,Q4106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,80.49,,,,,,,fee schedule,72.84,145.34,
Dermagraft,Q4106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,116.5,,,,,,,fee schedule,72.84,145.34,
Dermagraft,Q4106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,127.27,,,,,,,fee schedule,72.84,145.34,
Dermagraft,Q4106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,72.84,,,,,,,fee schedule,72.84,145.34,
Graftjacket,Q4107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,309.62,,,,,,,fee schedule,123.2,546.58,
Graftjacket,Q4107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,336.31,,,,,,,fee schedule,123.2,546.58,
Graftjacket,Q4107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,244.9,,,,,,,fee schedule,123.2,546.58,
Graftjacket,Q4107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,269.58,,,,,,,fee schedule,123.2,546.58,
Graftjacket,Q4107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,294.49,,,,,,,fee schedule,123.2,546.58,
Graftjacket,Q4107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,221.65,,,,,,,fee schedule,123.2,546.58,
Graftjacket,Q4107,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,546.58,APC 378
Graftjacket,Q4107,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,546.58,APC
Graftjacket,Q4107,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,546.58,APC
Graftjacket,Q4107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,546.58,APC
Graftjacket,Q4107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,546.58,Radiology
Graftjacket,Q4107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,546.58,APC
Graftjacket,Q4107,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,546.58,APC
Integra matrix,Q4108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,65.6,,,,,,,fee schedule,57.12,546.58,
Integra matrix,Q4108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,71.25,,,,,,,fee schedule,57.12,546.58,
Integra matrix,Q4108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,99.95,,,,,,,fee schedule,57.12,546.58,
Integra matrix,Q4108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.12,,,,,,,fee schedule,57.12,546.58,
Integra matrix,Q4108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,62.39,,,,,,,fee schedule,57.12,546.58,
Integra matrix,Q4108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,90.46,,,,,,,fee schedule,57.12,546.58,
Integra matrix,Q4108,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,57.12,546.58,APC 378
Integra matrix,Q4108,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,57.12,546.58,APC
Integra matrix,Q4108,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,57.12,546.58,APC
Integra matrix,Q4108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,57.12,546.58,APC
Integra matrix,Q4108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,57.12,546.58,Radiology
Integra matrix,Q4108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,57.12,546.58,APC
Integra matrix,Q4108,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,57.12,546.58,APC
Primatrix,Q4110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,119.26,,,,,,,fee schedule,103.84,546.58,
Primatrix,Q4110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,129.54,,,,,,,fee schedule,103.84,546.58,
Primatrix,Q4110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,149.77,,,,,,,fee schedule,103.84,546.58,
Primatrix,Q4110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,103.84,,,,,,,fee schedule,103.84,546.58,
Primatrix,Q4110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,113.43,,,,,,,fee schedule,103.84,546.58,
Primatrix,Q4110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,135.55,,,,,,,fee schedule,103.84,546.58,
Primatrix,Q4110,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,103.84,546.58,APC 378
Primatrix,Q4110,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,103.84,546.58,APC
Primatrix,Q4110,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,103.84,546.58,APC
Primatrix,Q4110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,103.84,546.58,APC
Primatrix,Q4110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,103.84,546.58,Radiology
Primatrix,Q4110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,103.84,546.58,APC
Primatrix,Q4110,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,103.84,546.58,APC
Gammagraft,Q4111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26.31,,,,,,,fee schedule,22.91,546.58,
Gammagraft,Q4111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,28.58,,,,,,,fee schedule,22.91,546.58,
Gammagraft,Q4111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22.91,,,,,,,fee schedule,22.91,546.58,
Gammagraft,Q4111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,25.02,,,,,,,fee schedule,22.91,546.58,
Gammagraft,Q4111,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,22.91,546.58,APC 378
Gammagraft,Q4111,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,22.91,546.58,APC
Gammagraft,Q4111,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,22.91,546.58,APC
Gammagraft,Q4111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,22.91,546.58,APC
Gammagraft,Q4111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,22.91,546.58,Radiology
Gammagraft,Q4111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,22.91,546.58,APC
Gammagraft,Q4111,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,22.91,546.58,APC
Cymetra injectable,Q4112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1083.53,,,,,,,fee schedule,943.42,1176.94,
Cymetra injectable,Q4112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1176.94,,,,,,,fee schedule,943.42,1176.94,
Cymetra injectable,Q4112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,943.42,,,,,,,fee schedule,943.42,1176.94,
Cymetra injectable,Q4112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1030.6,,,,,,,fee schedule,943.42,1176.94,
Graftjacket xpress,Q4113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1083.53,,,,,,,fee schedule,943.42,3156.05,
Graftjacket xpress,Q4113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1176.94,,,,,,,fee schedule,943.42,3156.05,
Graftjacket xpress,Q4113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3156.05,,,,,,,fee schedule,943.42,3156.05,
Graftjacket xpress,Q4113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,943.42,,,,,,,fee schedule,943.42,3156.05,
Graftjacket xpress,Q4113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1030.6,,,,,,,fee schedule,943.42,3156.05,
Graftjacket xpress,Q4113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2856.43,,,,,,,fee schedule,943.42,3156.05,
Integra flowable wound matri,Q4114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3121.94,,,,,,,fee schedule,2718.24,4472.22,
Integra flowable wound matri,Q4114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3391.08,,,,,,,fee schedule,2718.24,4472.22,
Integra flowable wound matri,Q4114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4472.22,,,,,,,fee schedule,2718.24,4472.22,
Integra flowable wound matri,Q4114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2718.24,,,,,,,fee schedule,2718.24,4472.22,
Integra flowable wound matri,Q4114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2969.43,,,,,,,fee schedule,2718.24,4472.22,
Integra flowable wound matri,Q4114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4047.64,,,,,,,fee schedule,2718.24,4472.22,
Alloskin,Q4115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,31.25,,,,,,,fee schedule,27.21,546.58,
Alloskin,Q4115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33.94,,,,,,,fee schedule,27.21,546.58,
Alloskin,Q4115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,27.21,,,,,,,fee schedule,27.21,546.58,
Alloskin,Q4115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29.72,,,,,,,fee schedule,27.21,546.58,
Alloskin,Q4115,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,27.21,546.58,APC 378
Alloskin,Q4115,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,27.21,546.58,APC
Alloskin,Q4115,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,27.21,546.58,APC
Alloskin,Q4115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,27.21,546.58,APC
Alloskin,Q4115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,27.21,546.58,Radiology
Alloskin,Q4115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,27.21,546.58,APC
Alloskin,Q4115,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,27.21,546.58,APC
Alloderm,Q4116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,112.06,,,,,,,fee schedule,97.57,546.58,
Alloderm,Q4116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,121.72,,,,,,,fee schedule,97.57,546.58,
Alloderm,Q4116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,97.57,,,,,,,fee schedule,97.57,546.58,
Alloderm,Q4116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,106.58,,,,,,,fee schedule,97.57,546.58,
Alloderm,Q4116,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,97.57,546.58,APC 378
Alloderm,Q4116,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,97.57,546.58,APC
Alloderm,Q4116,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,97.57,546.58,APC
Alloderm,Q4116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,97.57,546.58,APC
Alloderm,Q4116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,97.57,546.58,Radiology
Alloderm,Q4116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,97.57,546.58,APC
Alloderm,Q4116,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,97.57,546.58,APC
Hyalomatrix,Q4117,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46.14,,,,,,,fee schedule,41.76,546.58,
Hyalomatrix,Q4117,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,41.76,,,,,,,fee schedule,41.76,546.58,
Hyalomatrix,Q4117,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,41.76,546.58,APC 378
Hyalomatrix,Q4117,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,41.76,546.58,APC
Hyalomatrix,Q4117,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,41.76,546.58,APC
Hyalomatrix,Q4117,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,41.76,546.58,APC
Hyalomatrix,Q4117,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,41.76,546.58,Radiology
Hyalomatrix,Q4117,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,41.76,546.58,APC
Hyalomatrix,Q4117,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,41.76,546.58,APC
Matristem micromatrix,Q4118,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.74,,,,,,,fee schedule,8.48,10.58,
Matristem micromatrix,Q4118,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10.58,,,,,,,fee schedule,8.48,10.58,
Matristem micromatrix,Q4118,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.86,,,,,,,fee schedule,8.48,10.58,
Matristem micromatrix,Q4118,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.48,,,,,,,fee schedule,8.48,10.58,
Matristem micromatrix,Q4118,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.27,,,,,,,fee schedule,8.48,10.58,
Matristem micromatrix,Q4118,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.92,,,,,,,fee schedule,8.48,10.58,
Theraskin,Q4121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,81.26,,,,,,,fee schedule,70.75,546.58,
Theraskin,Q4121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,88.26,,,,,,,fee schedule,70.75,546.58,
Theraskin,Q4121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,70.75,,,,,,,fee schedule,70.75,546.58,
Theraskin,Q4121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,77.29,,,,,,,fee schedule,70.75,546.58,
Theraskin,Q4121,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,70.75,546.58,APC 378
Theraskin,Q4121,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,70.75,546.58,APC
Theraskin,Q4121,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,70.75,546.58,APC
Theraskin,Q4121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,70.75,546.58,APC
Theraskin,Q4121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,70.75,546.58,Radiology
Theraskin,Q4121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,70.75,546.58,APC
Theraskin,Q4121,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,70.75,546.58,APC
Dermacell,Q4122,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,191.18,,,,,,,fee schedule,123.2,546.58,
Dermacell,Q4122,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,173.03,,,,,,,fee schedule,123.2,546.58,
Dermacell,Q4122,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,546.58,APC 378
Dermacell,Q4122,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,546.58,APC
Dermacell,Q4122,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,546.58,APC
Dermacell,Q4122,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,546.58,APC
Dermacell,Q4122,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,546.58,Radiology
Dermacell,Q4122,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,546.58,APC
Dermacell,Q4122,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,546.58,APC
Alloskin,Q4123,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,54.84,,,,,,,fee schedule,47.75,546.58,
Alloskin,Q4123,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59.57,,,,,,,fee schedule,47.75,546.58,
Alloskin,Q4123,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,126.05,,,,,,,fee schedule,47.75,546.58,
Alloskin,Q4123,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,47.75,,,,,,,fee schedule,47.75,546.58,
Alloskin,Q4123,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52.17,,,,,,,fee schedule,47.75,546.58,
Alloskin,Q4123,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,114.09,,,,,,,fee schedule,47.75,546.58,
Alloskin,Q4123,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,47.75,546.58,APC 378
Alloskin,Q4123,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,47.75,546.58,APC
Alloskin,Q4123,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,47.75,546.58,APC
Alloskin,Q4123,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,47.75,546.58,APC
Alloskin,Q4123,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,47.75,546.58,Radiology
Alloskin,Q4123,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,47.75,546.58,APC
Alloskin,Q4123,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,47.75,546.58,APC
Oasis tri-layer wound matrix,Q4124,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45.55,,,,,,,fee schedule,21.48,546.58,
Oasis tri-layer wound matrix,Q4124,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,49.48,,,,,,,fee schedule,21.48,546.58,
Oasis tri-layer wound matrix,Q4124,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23.73,,,,,,,fee schedule,21.48,546.58,
Oasis tri-layer wound matrix,Q4124,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39.66,,,,,,,fee schedule,21.48,546.58,
Oasis tri-layer wound matrix,Q4124,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,43.33,,,,,,,fee schedule,21.48,546.58,
Oasis tri-layer wound matrix,Q4124,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21.48,,,,,,,fee schedule,21.48,546.58,
Oasis tri-layer wound matrix,Q4124,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,21.48,546.58,APC 378
Oasis tri-layer wound matrix,Q4124,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,21.48,546.58,APC
Oasis tri-layer wound matrix,Q4124,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,21.48,546.58,APC
Oasis tri-layer wound matrix,Q4124,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,21.48,546.58,APC
Oasis tri-layer wound matrix,Q4124,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,21.48,546.58,Radiology
Oasis tri-layer wound matrix,Q4124,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,21.48,546.58,APC
Oasis tri-layer wound matrix,Q4124,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,21.48,546.58,APC
Memoderm/derma/tranz/integup,Q4126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,339.86,,,,,,,fee schedule,123.2,546.58,
Memoderm/derma/tranz/integup,Q4126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,369.15,,,,,,,fee schedule,123.2,546.58,
Memoderm/derma/tranz/integup,Q4126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,154.3,,,,,,,fee schedule,123.2,546.58,
Memoderm/derma/tranz/integup,Q4126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,295.91,,,,,,,fee schedule,123.2,546.58,
Memoderm/derma/tranz/integup,Q4126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,323.25,,,,,,,fee schedule,123.2,546.58,
Memoderm/derma/tranz/integup,Q4126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,139.65,,,,,,,fee schedule,123.2,546.58,
Memoderm/derma/tranz/integup,Q4126,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,546.58,APC 378
Memoderm/derma/tranz/integup,Q4126,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,546.58,APC
Memoderm/derma/tranz/integup,Q4126,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,546.58,APC
Memoderm/derma/tranz/integup,Q4126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,546.58,APC
Memoderm/derma/tranz/integup,Q4126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,546.58,Radiology
Memoderm/derma/tranz/integup,Q4126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,546.58,APC
Memoderm/derma/tranz/integup,Q4126,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,546.58,APC
Talymed,Q4127,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,94.8,,,,,,,fee schedule,85.8,546.58,
Talymed,Q4127,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,85.8,,,,,,,fee schedule,85.8,546.58,
Talymed,Q4127,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,85.8,546.58,APC 378
Talymed,Q4127,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,85.8,546.58,APC
Talymed,Q4127,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,85.8,546.58,APC
Talymed,Q4127,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,85.8,546.58,APC
Talymed,Q4127,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,85.8,546.58,Radiology
Talymed,Q4127,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,85.8,546.58,APC
Talymed,Q4127,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,85.8,546.58,APC
Grafix core,Q4132,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,451.88,,,,,,,fee schedule,123.2,891.07,
Grafix core,Q4132,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,490.83,,,,,,,fee schedule,123.2,891.07,
Grafix core,Q4132,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,891.07,,,,,,,fee schedule,123.2,891.07,
Grafix core,Q4132,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,393.45,,,,,,,fee schedule,123.2,891.07,
Grafix core,Q4132,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,429.8,,,,,,,fee schedule,123.2,891.07,
Grafix core,Q4132,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,806.48,,,,,,,fee schedule,123.2,891.07,
Grafix core,Q4132,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,891.07,APC 378
Grafix core,Q4132,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,891.07,APC
Grafix core,Q4132,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,891.07,APC
Grafix core,Q4132,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,891.07,APC
Grafix core,Q4132,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,891.07,Radiology
Grafix core,Q4132,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,891.07,APC
Grafix core,Q4132,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,891.07,APC
Grafix prime,Q4133,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,442.17,,,,,,,fee schedule,123.2,546.58,
Grafix prime,Q4133,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,480.29,,,,,,,fee schedule,123.2,546.58,
Grafix prime,Q4133,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,400.48,,,,,,,fee schedule,123.2,546.58,
Grafix prime,Q4133,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,384.99,,,,,,,fee schedule,123.2,546.58,
Grafix prime,Q4133,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,420.57,,,,,,,fee schedule,123.2,546.58,
Grafix prime,Q4133,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,362.46,,,,,,,fee schedule,123.2,546.58,
Grafix prime,Q4133,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,546.58,APC 378
Grafix prime,Q4133,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,546.58,APC
Grafix prime,Q4133,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,546.58,APC
Grafix prime,Q4133,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,546.58,APC
Grafix prime,Q4133,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,546.58,Radiology
Grafix prime,Q4133,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,546.58,APC
Grafix prime,Q4133,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,546.58,APC
hMatrix,Q4134,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,123.37,,,,,,,fee schedule,107.41,546.58,
hMatrix,Q4134,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,134,,,,,,,fee schedule,107.41,546.58,
hMatrix,Q4134,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,107.41,,,,,,,fee schedule,107.41,546.58,
hMatrix,Q4134,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,117.34,,,,,,,fee schedule,107.41,546.58,
hMatrix,Q4134,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,107.41,546.58,APC 378
hMatrix,Q4134,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,107.41,546.58,APC
hMatrix,Q4134,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,107.41,546.58,APC
hMatrix,Q4134,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,107.41,546.58,APC
hMatrix,Q4134,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,107.41,546.58,Radiology
hMatrix,Q4134,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,107.41,546.58,APC
hMatrix,Q4134,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,107.41,546.58,APC
"Amnioexcel or biodexcel, 1cm",Q4137,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,443.76,,,,,,,fee schedule,123.2,546.58,
"Amnioexcel or biodexcel, 1cm",Q4137,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,401.63,,,,,,,fee schedule,123.2,546.58,
"Amnioexcel or biodexcel, 1cm",Q4137,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,546.58,APC 378
"Amnioexcel or biodexcel, 1cm",Q4137,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,546.58,APC
"Amnioexcel or biodexcel, 1cm",Q4137,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,546.58,APC
"Amnioexcel or biodexcel, 1cm",Q4137,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,546.58,APC
"Amnioexcel or biodexcel, 1cm",Q4137,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,546.58,Radiology
"Amnioexcel or biodexcel, 1cm",Q4137,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,546.58,APC
"Amnioexcel or biodexcel, 1cm",Q4137,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,546.58,APC
"Alloskin ac, 1 cm",Q4141,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,184.48,,,,,,,fee schedule,123.2,546.58,
"Alloskin ac, 1 cm",Q4141,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,166.97,,,,,,,fee schedule,123.2,546.58,
"Alloskin ac, 1 cm",Q4141,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,546.58,APC 378
"Alloskin ac, 1 cm",Q4141,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,546.58,APC
"Alloskin ac, 1 cm",Q4141,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,546.58,APC
"Alloskin ac, 1 cm",Q4141,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,546.58,APC
"Alloskin ac, 1 cm",Q4141,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,546.58,Radiology
"Alloskin ac, 1 cm",Q4141,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,546.58,APC
"Alloskin ac, 1 cm",Q4141,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,546.58,APC
"Neox 1k, 1cm",Q4148,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,426.95,,,,,,,fee schedule,123.2,546.58,
"Neox 1k, 1cm",Q4148,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,386.41,,,,,,,fee schedule,123.2,546.58,
"Neox 1k, 1cm",Q4148,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,546.58,APC 378
"Neox 1k, 1cm",Q4148,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,546.58,APC
"Neox 1k, 1cm",Q4148,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,546.58,APC
"Neox 1k, 1cm",Q4148,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,546.58,APC
"Neox 1k, 1cm",Q4148,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,546.58,Radiology
"Neox 1k, 1cm",Q4148,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,546.58,APC
"Neox 1k, 1cm",Q4148,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,546.58,APC
"Excellagen, 0.1 cc",Q4149,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,125.28,,,,,,,fee schedule,109.08,274.92,
"Excellagen, 0.1 cc",Q4149,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,136.08,,,,,,,fee schedule,109.08,274.92,
"Excellagen, 0.1 cc",Q4149,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,274.92,,,,,,,fee schedule,109.08,274.92,
"Excellagen, 0.1 cc",Q4149,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,109.08,,,,,,,fee schedule,109.08,274.92,
"Excellagen, 0.1 cc",Q4149,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,119.16,,,,,,,fee schedule,109.08,274.92,
"Excellagen, 0.1 cc",Q4149,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,248.82,,,,,,,fee schedule,109.08,274.92,
Dermapure 1 square cm,Q4152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,400.03,,,,,,,fee schedule,123.2,546.58,
Dermapure 1 square cm,Q4152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,434.51,,,,,,,fee schedule,123.2,546.58,
Dermapure 1 square cm,Q4152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,181.62,,,,,,,fee schedule,123.2,546.58,
Dermapure 1 square cm,Q4152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,348.3,,,,,,,fee schedule,123.2,546.58,
Dermapure 1 square cm,Q4152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,380.48,,,,,,,fee schedule,123.2,546.58,
Dermapure 1 square cm,Q4152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,164.38,,,,,,,fee schedule,123.2,546.58,
Dermapure 1 square cm,Q4152,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,546.58,APC 378
Dermapure 1 square cm,Q4152,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,546.58,APC
Dermapure 1 square cm,Q4152,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,546.58,APC
Dermapure 1 square cm,Q4152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,546.58,APC
Dermapure 1 square cm,Q4152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,546.58,Radiology
Dermapure 1 square cm,Q4152,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,546.58,APC
Dermapure 1 square cm,Q4152,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,546.58,APC
"Dermavest, plurivest sq cm",Q4153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,411.13,,,,,,,fee schedule,123.2,546.58,
"Dermavest, plurivest sq cm",Q4153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,372.1,,,,,,,fee schedule,123.2,546.58,
"Dermavest, plurivest sq cm",Q4153,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,546.58,APC 378
"Dermavest, plurivest sq cm",Q4153,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,546.58,APC
"Dermavest, plurivest sq cm",Q4153,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,546.58,APC
"Dermavest, plurivest sq cm",Q4153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,546.58,APC
"Dermavest, plurivest sq cm",Q4153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,546.58,Radiology
"Dermavest, plurivest sq cm",Q4153,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,546.58,APC
"Dermavest, plurivest sq cm",Q4153,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,546.58,APC
Biovance 1 square cm,Q4154,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,711,,,,,,,fee schedule,123.2,711,
Biovance 1 square cm,Q4154,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,643.5,,,,,,,fee schedule,123.2,711,
Biovance 1 square cm,Q4154,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,711,APC 378
Biovance 1 square cm,Q4154,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,711,APC
Biovance 1 square cm,Q4154,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,711,APC
Biovance 1 square cm,Q4154,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,711,APC
Biovance 1 square cm,Q4154,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,711,Radiology
Biovance 1 square cm,Q4154,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,711,APC
Biovance 1 square cm,Q4154,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,711,APC
Neoxflo or clarixflo 1 mg,Q4155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.67,,,,,,,fee schedule,54.91,60.67,
Neoxflo or clarixflo 1 mg,Q4155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,54.91,,,,,,,fee schedule,54.91,60.67,
Neox 100 1 square cm,Q4156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,621.18,,,,,,,fee schedule,123.2,674.73,
Neox 100 1 square cm,Q4156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,674.73,,,,,,,fee schedule,123.2,674.73,
Neox 100 1 square cm,Q4156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,284.4,,,,,,,fee schedule,123.2,674.73,
Neox 100 1 square cm,Q4156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,540.86,,,,,,,fee schedule,123.2,674.73,
Neox 100 1 square cm,Q4156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,590.84,,,,,,,fee schedule,123.2,674.73,
Neox 100 1 square cm,Q4156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,257.4,,,,,,,fee schedule,123.2,674.73,
Neox 100 1 square cm,Q4156,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,674.73,APC 378
Neox 100 1 square cm,Q4156,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,674.73,APC
Neox 100 1 square cm,Q4156,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,674.73,APC
Neox 100 1 square cm,Q4156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,674.73,APC
Neox 100 1 square cm,Q4156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,674.73,Radiology
Neox 100 1 square cm,Q4156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,674.73,APC
Neox 100 1 square cm,Q4156,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,674.73,APC
Revitalon 1 square cm,Q4157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,331.1,,,,,,,fee schedule,123.2,546.58,
Revitalon 1 square cm,Q4157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,299.67,,,,,,,fee schedule,123.2,546.58,
Revitalon 1 square cm,Q4157,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,546.58,APC 378
Revitalon 1 square cm,Q4157,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,546.58,APC
Revitalon 1 square cm,Q4157,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,546.58,APC
Revitalon 1 square cm,Q4157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,546.58,APC
Revitalon 1 square cm,Q4157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,546.58,Radiology
Revitalon 1 square cm,Q4157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,546.58,APC
Revitalon 1 square cm,Q4157,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,546.58,APC
Marigen 1 square cm,Q4158,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,322.18,,,,,,,fee schedule,123.2,546.58,
Marigen 1 square cm,Q4158,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,291.59,,,,,,,fee schedule,123.2,546.58,
Marigen 1 square cm,Q4158,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,546.58,APC 378
Marigen 1 square cm,Q4158,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,546.58,APC
Marigen 1 square cm,Q4158,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,546.58,APC
Marigen 1 square cm,Q4158,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,546.58,APC
Marigen 1 square cm,Q4158,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,546.58,Radiology
Marigen 1 square cm,Q4158,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,546.58,APC
Marigen 1 square cm,Q4158,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,546.58,APC
Affinity1 square cm,Q4159,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2539.01,,,,,,,fee schedule,123.2,2757.89,
Affinity1 square cm,Q4159,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2757.89,,,,,,,fee schedule,123.2,2757.89,
Affinity1 square cm,Q4159,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2001.23,,,,,,,fee schedule,123.2,2757.89,
Affinity1 square cm,Q4159,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2210.69,,,,,,,fee schedule,123.2,2757.89,
Affinity1 square cm,Q4159,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2414.98,,,,,,,fee schedule,123.2,2757.89,
Affinity1 square cm,Q4159,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1811.24,,,,,,,fee schedule,123.2,2757.89,
Affinity1 square cm,Q4159,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,2757.89,APC 378
Affinity1 square cm,Q4159,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,2757.89,APC
Affinity1 square cm,Q4159,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,2757.89,APC
Affinity1 square cm,Q4159,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,2757.89,APC
Affinity1 square cm,Q4159,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,2757.89,Radiology
Affinity1 square cm,Q4159,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,2757.89,APC
Affinity1 square cm,Q4159,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,2757.89,APC
Nushield 1 square cm,Q4160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,835.86,,,,,,,fee schedule,123.2,907.92,
Nushield 1 square cm,Q4160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,907.92,,,,,,,fee schedule,123.2,907.92,
Nushield 1 square cm,Q4160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,395.32,,,,,,,fee schedule,123.2,907.92,
Nushield 1 square cm,Q4160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,727.78,,,,,,,fee schedule,123.2,907.92,
Nushield 1 square cm,Q4160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,795.03,,,,,,,fee schedule,123.2,907.92,
Nushield 1 square cm,Q4160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,357.79,,,,,,,fee schedule,123.2,907.92,
Nushield 1 square cm,Q4160,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,907.92,APC 378
Nushield 1 square cm,Q4160,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,907.92,APC
Nushield 1 square cm,Q4160,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,907.92,APC
Nushield 1 square cm,Q4160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,907.92,APC
Nushield 1 square cm,Q4160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,907.92,Radiology
Nushield 1 square cm,Q4160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,907.92,APC
Nushield 1 square cm,Q4160,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,907.92,APC
Bio-connekt per square cm,Q4161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4739.53,,,,,,,fee schedule,123.2,4739.53,
Bio-connekt per square cm,Q4161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4289.57,,,,,,,fee schedule,123.2,4739.53,
Bio-connekt per square cm,Q4161,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,4739.53,APC 378
Bio-connekt per square cm,Q4161,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,4739.53,APC
Bio-connekt per square cm,Q4161,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,4739.53,APC
Bio-connekt per square cm,Q4161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,4739.53,APC
Bio-connekt per square cm,Q4161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,4739.53,Radiology
Bio-connekt per square cm,Q4161,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,4739.53,APC
Bio-connekt per square cm,Q4161,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,4739.53,APC
Amnio bio and woundex flow,Q4162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3476,,,,,,,fee schedule,3146,3476,
Amnio bio and woundex flow,Q4162,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3146,,,,,,,fee schedule,3146,3476,
Amnio bio and woundex sq cm,Q4163,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,793.48,,,,,,,fee schedule,123.2,793.48,
Amnio bio and woundex sq cm,Q4163,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,718.15,,,,,,,fee schedule,123.2,793.48,
Amnio bio and woundex sq cm,Q4163,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,793.48,APC 378
Amnio bio and woundex sq cm,Q4163,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,793.48,APC
Amnio bio and woundex sq cm,Q4163,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,793.48,APC
Amnio bio and woundex sq cm,Q4163,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,793.48,APC
Amnio bio and woundex sq cm,Q4163,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,793.48,Radiology
Amnio bio and woundex sq cm,Q4163,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,793.48,APC
Amnio bio and woundex sq cm,Q4163,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,793.48,APC
"Helicoll, per square cm",Q4164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2464.8,,,,,,,fee schedule,123.2,2464.8,
"Helicoll, per square cm",Q4164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2230.8,,,,,,,fee schedule,123.2,2464.8,
"Helicoll, per square cm",Q4164,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,2464.8,APC 378
"Helicoll, per square cm",Q4164,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,2464.8,APC
"Helicoll, per square cm",Q4164,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,2464.8,APC
"Helicoll, per square cm",Q4164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,2464.8,APC
"Helicoll, per square cm",Q4164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,2464.8,Radiology
"Helicoll, per square cm",Q4164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,2464.8,APC
"Helicoll, per square cm",Q4164,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,2464.8,APC
"Keramatrix, per square cm",Q4165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,56.85,,,,,,,fee schedule,51.45,546.58,
"Keramatrix, per square cm",Q4165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.45,,,,,,,fee schedule,51.45,546.58,
"Keramatrix, per square cm",Q4165,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,51.45,546.58,APC 378
"Keramatrix, per square cm",Q4165,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,51.45,546.58,APC
"Keramatrix, per square cm",Q4165,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,51.45,546.58,APC
"Keramatrix, per square cm",Q4165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,51.45,546.58,APC
"Keramatrix, per square cm",Q4165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,51.45,546.58,Radiology
"Keramatrix, per square cm",Q4165,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,51.45,546.58,APC
"Keramatrix, per square cm",Q4165,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,51.45,546.58,APC
"Cytal, per square centimeter",Q4166,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,40.91,,,,,,,fee schedule,37.02,546.58,
"Cytal, per square centimeter",Q4166,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37.02,,,,,,,fee schedule,37.02,546.58,
"Cytal, per square centimeter",Q4166,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,37.02,546.58,APC 378
"Cytal, per square centimeter",Q4166,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,37.02,546.58,APC
"Cytal, per square centimeter",Q4166,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,37.02,546.58,APC
"Cytal, per square centimeter",Q4166,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,37.02,546.58,APC
"Cytal, per square centimeter",Q4166,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,37.02,546.58,Radiology
"Cytal, per square centimeter",Q4166,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,37.02,546.58,APC
"Cytal, per square centimeter",Q4166,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,37.02,546.58,APC
"Truskin, per sq centimeter",Q4167,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,191.21,,,,,,,fee schedule,123.2,546.58,
"Truskin, per sq centimeter",Q4167,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,173.06,,,,,,,fee schedule,123.2,546.58,
"Truskin, per sq centimeter",Q4167,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,546.58,APC 378
"Truskin, per sq centimeter",Q4167,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,546.58,APC
"Truskin, per sq centimeter",Q4167,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,546.58,APC
"Truskin, per sq centimeter",Q4167,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,546.58,APC
"Truskin, per sq centimeter",Q4167,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,546.58,Radiology
"Truskin, per sq centimeter",Q4167,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,546.58,APC
"Truskin, per sq centimeter",Q4167,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,546.58,APC
"Artacent wound, per sq cm",Q4169,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5256.12,,,,,,,fee schedule,123.2,5256.12,
"Artacent wound, per sq cm",Q4169,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4757.12,,,,,,,fee schedule,123.2,5256.12,
"Artacent wound, per sq cm",Q4169,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,5256.12,APC 378
"Artacent wound, per sq cm",Q4169,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,5256.12,APC
"Artacent wound, per sq cm",Q4169,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,5256.12,APC
"Artacent wound, per sq cm",Q4169,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,5256.12,APC
"Artacent wound, per sq cm",Q4169,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,5256.12,Radiology
"Artacent wound, per sq cm",Q4169,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,5256.12,APC
"Artacent wound, per sq cm",Q4169,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,5256.12,APC
"Cygnus, per sq cm",Q4170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1184.94,,,,,,,fee schedule,123.2,1184.94,
"Cygnus, per sq cm",Q4170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1072.44,,,,,,,fee schedule,123.2,1184.94,
"Cygnus, per sq cm",Q4170,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,1184.94,APC 378
"Cygnus, per sq cm",Q4170,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,1184.94,APC
"Cygnus, per sq cm",Q4170,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,1184.94,APC
"Cygnus, per sq cm",Q4170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,1184.94,APC
"Cygnus, per sq cm",Q4170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,1184.94,Radiology
"Cygnus, per sq cm",Q4170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,1184.94,APC
"Cygnus, per sq cm",Q4170,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,1184.94,APC
"Interfyl, 1 mg",Q4171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,61.62,,,,,,,fee schedule,55.77,61.62,
"Interfyl, 1 mg",Q4171,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55.77,,,,,,,fee schedule,55.77,61.62,
Palingen or palingen xplus,Q4173,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1801.2,,,,,,,fee schedule,123.2,1801.2,
Palingen or palingen xplus,Q4173,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1630.2,,,,,,,fee schedule,123.2,1801.2,
Palingen or palingen xplus,Q4173,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,1801.2,APC 378
Palingen or palingen xplus,Q4173,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,1801.2,APC
Palingen or palingen xplus,Q4173,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,1801.2,APC
Palingen or palingen xplus,Q4173,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,1801.2,APC
Palingen or palingen xplus,Q4173,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,1801.2,Radiology
Palingen or palingen xplus,Q4173,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,1801.2,APC
Palingen or palingen xplus,Q4173,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,1801.2,APC
Palingen or promatrx,Q4174,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1469.4,,,,,,,fee schedule,1329.9,1469.4,
Palingen or promatrx,Q4174,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1329.9,,,,,,,fee schedule,1329.9,1469.4,
Miroderm,Q4175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,245.22,,,,,,,fee schedule,123.2,546.58,
Miroderm,Q4175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,221.94,,,,,,,fee schedule,123.2,546.58,
Miroderm,Q4175,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,546.58,APC 378
Miroderm,Q4175,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,546.58,APC
Miroderm,Q4175,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,546.58,APC
Miroderm,Q4175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,546.58,APC
Miroderm,Q4175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,546.58,Radiology
Miroderm,Q4175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,546.58,APC
Miroderm,Q4175,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,546.58,APC
"Neopatch, per sq centimeter",Q4176,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,299.9,,,,,,,fee schedule,123.2,546.58,
"Neopatch, per sq centimeter",Q4176,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,271.43,,,,,,,fee schedule,123.2,546.58,
"Neopatch, per sq centimeter",Q4176,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,546.58,APC 378
"Neopatch, per sq centimeter",Q4176,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,546.58,APC
"Neopatch, per sq centimeter",Q4176,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,546.58,APC
"Neopatch, per sq centimeter",Q4176,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,546.58,APC
"Neopatch, per sq centimeter",Q4176,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,546.58,Radiology
"Neopatch, per sq centimeter",Q4176,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,546.58,APC
"Neopatch, per sq centimeter",Q4176,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,546.58,APC
"Floweramnioflo, 0.1 cc",Q4177,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,284.4,,,,,,,fee schedule,257.4,284.4,
"Floweramnioflo, 0.1 cc",Q4177,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,257.4,,,,,,,fee schedule,257.4,284.4,
"Floweramniopatch, per sq cm",Q4178,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,355.5,,,,,,,fee schedule,123.2,546.58,
"Floweramniopatch, per sq cm",Q4178,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,321.75,,,,,,,fee schedule,123.2,546.58,
"Floweramniopatch, per sq cm",Q4178,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,546.58,APC 378
"Floweramniopatch, per sq cm",Q4178,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,546.58,APC
"Floweramniopatch, per sq cm",Q4178,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,546.58,APC
"Floweramniopatch, per sq cm",Q4178,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,546.58,APC
"Floweramniopatch, per sq cm",Q4178,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,546.58,Radiology
"Floweramniopatch, per sq cm",Q4178,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,546.58,APC
"Floweramniopatch, per sq cm",Q4178,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,546.58,APC
"Revita, per sq cm",Q4180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1501.16,,,,,,,fee schedule,123.2,1501.16,
"Revita, per sq cm",Q4180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1358.64,,,,,,,fee schedule,123.2,1501.16,
"Revita, per sq cm",Q4180,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,1501.16,APC 378
"Revita, per sq cm",Q4180,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,1501.16,APC
"Revita, per sq cm",Q4180,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,1501.16,APC
"Revita, per sq cm",Q4180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,1501.16,APC
"Revita, per sq cm",Q4180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,1501.16,Radiology
"Revita, per sq cm",Q4180,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,1501.16,APC
"Revita, per sq cm",Q4180,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,1501.16,APC
"Amnio wound, per square cm",Q4181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,289.84,,,,,,,fee schedule,123.2,546.58,
"Amnio wound, per square cm",Q4181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,262.32,,,,,,,fee schedule,123.2,546.58,
"Amnio wound, per square cm",Q4181,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,546.58,APC 378
"Amnio wound, per square cm",Q4181,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,546.58,APC
"Amnio wound, per square cm",Q4181,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,546.58,APC
"Amnio wound, per square cm",Q4181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,546.58,APC
"Amnio wound, per square cm",Q4181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,546.58,Radiology
"Amnio wound, per square cm",Q4181,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,546.58,APC
"Amnio wound, per square cm",Q4181,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,546.58,APC
"Surgigraft, 1 sq cm",Q4183,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,158,,,,,,,fee schedule,123.2,546.58,
"Surgigraft, 1 sq cm",Q4183,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,143,,,,,,,fee schedule,123.2,546.58,
"Surgigraft, 1 sq cm",Q4183,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,546.58,APC 378
"Surgigraft, 1 sq cm",Q4183,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,546.58,APC
"Surgigraft, 1 sq cm",Q4183,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,546.58,APC
"Surgigraft, 1 sq cm",Q4183,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,546.58,APC
"Surgigraft, 1 sq cm",Q4183,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,546.58,Radiology
"Surgigraft, 1 sq cm",Q4183,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,546.58,APC
"Surgigraft, 1 sq cm",Q4183,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,546.58,APC
"Cellesta, 1 sq cm",Q4184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,930.62,,,,,,,fee schedule,123.2,930.62,
"Cellesta, 1 sq cm",Q4184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,842.27,,,,,,,fee schedule,123.2,930.62,
"Cellesta, 1 sq cm",Q4184,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,930.62,APC 378
"Cellesta, 1 sq cm",Q4184,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,930.62,APC
"Cellesta, 1 sq cm",Q4184,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,930.62,APC
"Cellesta, 1 sq cm",Q4184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,930.62,APC
"Cellesta, 1 sq cm",Q4184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,930.62,Radiology
"Cellesta, 1 sq cm",Q4184,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,930.62,APC
"Cellesta, 1 sq cm",Q4184,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,930.62,APC
Epifix 1 sq cm,Q4186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,568.46,,,,,,,fee schedule,123.2,633.26,
Epifix 1 sq cm,Q4186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,617.46,,,,,,,fee schedule,123.2,633.26,
Epifix 1 sq cm,Q4186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,633.26,,,,,,,fee schedule,123.2,633.26,
Epifix 1 sq cm,Q4186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,494.95,,,,,,,fee schedule,123.2,633.26,
Epifix 1 sq cm,Q4186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,540.69,,,,,,,fee schedule,123.2,633.26,
Epifix 1 sq cm,Q4186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,573.14,,,,,,,fee schedule,123.2,633.26,
Epifix 1 sq cm,Q4186,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,633.26,APC 378
Epifix 1 sq cm,Q4186,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,633.26,APC
Epifix 1 sq cm,Q4186,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,633.26,APC
Epifix 1 sq cm,Q4186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,633.26,APC
Epifix 1 sq cm,Q4186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,633.26,Radiology
Epifix 1 sq cm,Q4186,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,633.26,APC
Epifix 1 sq cm,Q4186,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,633.26,APC
Epicord 1 sq cm,Q4187,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,773.46,,,,,,,fee schedule,123.2,773.46,
Epicord 1 sq cm,Q4187,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,700.03,,,,,,,fee schedule,123.2,773.46,
Epicord 1 sq cm,Q4187,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,773.46,APC 378
Epicord 1 sq cm,Q4187,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,773.46,APC
Epicord 1 sq cm,Q4187,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,773.46,APC
Epicord 1 sq cm,Q4187,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,773.46,APC
Epicord 1 sq cm,Q4187,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,773.46,Radiology
Epicord 1 sq cm,Q4187,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,773.46,APC
Epicord 1 sq cm,Q4187,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,773.46,APC
Amnioarmor 1 sq cm,Q4188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1548.4,,,,,,,fee schedule,123.2,1548.4,
Amnioarmor 1 sq cm,Q4188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1401.4,,,,,,,fee schedule,123.2,1548.4,
Amnioarmor 1 sq cm,Q4188,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,1548.4,APC 378
Amnioarmor 1 sq cm,Q4188,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,1548.4,APC
Amnioarmor 1 sq cm,Q4188,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,1548.4,APC
Amnioarmor 1 sq cm,Q4188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,1548.4,APC
Amnioarmor 1 sq cm,Q4188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,1548.4,Radiology
Amnioarmor 1 sq cm,Q4188,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,1548.4,APC
Amnioarmor 1 sq cm,Q4188,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,1548.4,APC
Artacent ac 1 sq cm,Q4190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1536.06,,,,,,,fee schedule,123.2,1536.06,
Artacent ac 1 sq cm,Q4190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1390.23,,,,,,,fee schedule,123.2,1536.06,
Artacent ac 1 sq cm,Q4190,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,1536.06,APC 378
Artacent ac 1 sq cm,Q4190,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,1536.06,APC
Artacent ac 1 sq cm,Q4190,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,1536.06,APC
Artacent ac 1 sq cm,Q4190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,1536.06,APC
Artacent ac 1 sq cm,Q4190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,1536.06,Radiology
Artacent ac 1 sq cm,Q4190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,1536.06,APC
Artacent ac 1 sq cm,Q4190,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,1536.06,APC
Restorigin 1 sq cm,Q4191,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2765,,,,,,,fee schedule,123.2,2765,
Restorigin 1 sq cm,Q4191,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2502.5,,,,,,,fee schedule,123.2,2765,
Restorigin 1 sq cm,Q4191,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,2765,APC 378
Restorigin 1 sq cm,Q4191,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,2765,APC
Restorigin 1 sq cm,Q4191,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,2765,APC
Restorigin 1 sq cm,Q4191,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,2765,APC
Restorigin 1 sq cm,Q4191,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,2765,Radiology
Restorigin 1 sq cm,Q4191,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,2765,APC
Restorigin 1 sq cm,Q4191,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,2765,APC
Coll-e-derm 1 sq cm,Q4193,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3697.56,,,,,,,fee schedule,123.2,3697.56,
Coll-e-derm 1 sq cm,Q4193,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3346.53,,,,,,,fee schedule,123.2,3697.56,
Coll-e-derm 1 sq cm,Q4193,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,3697.56,APC 378
Coll-e-derm 1 sq cm,Q4193,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,3697.56,APC
Coll-e-derm 1 sq cm,Q4193,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,3697.56,APC
Coll-e-derm 1 sq cm,Q4193,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,3697.56,APC
Coll-e-derm 1 sq cm,Q4193,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,3697.56,Radiology
Coll-e-derm 1 sq cm,Q4193,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,3697.56,APC
Coll-e-derm 1 sq cm,Q4193,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,3697.56,APC
Novachor 1 sq cm,Q4194,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1579.84,,,,,,,fee schedule,123.2,1579.84,
Novachor 1 sq cm,Q4194,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1429.86,,,,,,,fee schedule,123.2,1579.84,
Novachor 1 sq cm,Q4194,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,1579.84,APC 378
Novachor 1 sq cm,Q4194,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,1579.84,APC
Novachor 1 sq cm,Q4194,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,1579.84,APC
Novachor 1 sq cm,Q4194,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,1579.84,APC
Novachor 1 sq cm,Q4194,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,1579.84,Radiology
Novachor 1 sq cm,Q4194,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,1579.84,APC
Novachor 1 sq cm,Q4194,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,1579.84,APC
Puraply 1 sq cm,Q4195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,247.77,,,,,,,fee schedule,123.2,546.58,
Puraply 1 sq cm,Q4195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,269.13,,,,,,,fee schedule,123.2,546.58,
Puraply 1 sq cm,Q4195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,326.11,,,,,,,fee schedule,123.2,546.58,
Puraply 1 sq cm,Q4195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,215.73,,,,,,,fee schedule,123.2,546.58,
Puraply 1 sq cm,Q4195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,235.67,,,,,,,fee schedule,123.2,546.58,
Puraply 1 sq cm,Q4195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,295.15,,,,,,,fee schedule,123.2,546.58,
Puraply 1 sq cm,Q4195,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,546.58,APC 378
Puraply 1 sq cm,Q4195,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,546.58,APC
Puraply 1 sq cm,Q4195,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,546.58,APC
Puraply 1 sq cm,Q4195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,546.58,APC
Puraply 1 sq cm,Q4195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,546.58,Radiology
Puraply 1 sq cm,Q4195,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,546.58,APC
Puraply 1 sq cm,Q4195,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,546.58,APC
Puraply am 1 sq cm,Q4196,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,239.98,,,,,,,fee schedule,123.2,546.58,
Puraply am 1 sq cm,Q4196,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,260.67,,,,,,,fee schedule,123.2,546.58,
Puraply am 1 sq cm,Q4196,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,325.92,,,,,,,fee schedule,123.2,546.58,
Puraply am 1 sq cm,Q4196,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,208.95,,,,,,,fee schedule,123.2,546.58,
Puraply am 1 sq cm,Q4196,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,228.26,,,,,,,fee schedule,123.2,546.58,
Puraply am 1 sq cm,Q4196,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,294.98,,,,,,,fee schedule,123.2,546.58,
Puraply am 1 sq cm,Q4196,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,546.58,APC 378
Puraply am 1 sq cm,Q4196,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,546.58,APC
Puraply am 1 sq cm,Q4196,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,546.58,APC
Puraply am 1 sq cm,Q4196,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,546.58,APC
Puraply am 1 sq cm,Q4196,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,546.58,Radiology
Puraply am 1 sq cm,Q4196,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,546.58,APC
Puraply am 1 sq cm,Q4196,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,546.58,APC
Puraply xt 1 sq cm,Q4197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,474,,,,,,,fee schedule,123.2,546.58,
Puraply xt 1 sq cm,Q4197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,429,,,,,,,fee schedule,123.2,546.58,
Puraply xt 1 sq cm,Q4197,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,546.58,APC 378
Puraply xt 1 sq cm,Q4197,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,546.58,APC
Puraply xt 1 sq cm,Q4197,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,546.58,APC
Puraply xt 1 sq cm,Q4197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,546.58,APC
Puraply xt 1 sq cm,Q4197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,546.58,Radiology
Puraply xt 1 sq cm,Q4197,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,546.58,APC
Puraply xt 1 sq cm,Q4197,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,546.58,APC
"Cygnus matrix, per sq cm",Q4199,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,748.92,,,,,,,fee schedule,123.2,748.92,
"Cygnus matrix, per sq cm",Q4199,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,677.82,,,,,,,fee schedule,123.2,748.92,
"Cygnus matrix, per sq cm",Q4199,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,748.92,APC 378
"Cygnus matrix, per sq cm",Q4199,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,748.92,APC
"Cygnus matrix, per sq cm",Q4199,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,748.92,APC
"Cygnus matrix, per sq cm",Q4199,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,748.92,APC
"Cygnus matrix, per sq cm",Q4199,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,748.92,Radiology
"Cygnus matrix, per sq cm",Q4199,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,748.92,APC
"Cygnus matrix, per sq cm",Q4199,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,748.92,APC
Matrion 1 sq cm,Q4201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,529.88,,,,,,,fee schedule,123.2,546.58,
Matrion 1 sq cm,Q4201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,479.58,,,,,,,fee schedule,123.2,546.58,
Matrion 1 sq cm,Q4201,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,546.58,APC 378
Matrion 1 sq cm,Q4201,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,546.58,APC
Matrion 1 sq cm,Q4201,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,546.58,APC
Matrion 1 sq cm,Q4201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,546.58,APC
Matrion 1 sq cm,Q4201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,546.58,Radiology
Matrion 1 sq cm,Q4201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,546.58,APC
Matrion 1 sq cm,Q4201,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,546.58,APC
"Derma-gide, 1 sq cm",Q4203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,536.93,,,,,,,fee schedule,123.2,546.58,
"Derma-gide, 1 sq cm",Q4203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,485.96,,,,,,,fee schedule,123.2,546.58,
"Derma-gide, 1 sq cm",Q4203,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,546.58,APC 378
"Derma-gide, 1 sq cm",Q4203,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,546.58,APC
"Derma-gide, 1 sq cm",Q4203,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,546.58,APC
"Derma-gide, 1 sq cm",Q4203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,546.58,APC
"Derma-gide, 1 sq cm",Q4203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,546.58,Radiology
"Derma-gide, 1 sq cm",Q4203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,546.58,APC
"Derma-gide, 1 sq cm",Q4203,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,546.58,APC
Xwrap 1 sq cm,Q4204,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5403.6,,,,,,,fee schedule,123.2,5403.6,
Xwrap 1 sq cm,Q4204,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4890.6,,,,,,,fee schedule,123.2,5403.6,
Xwrap 1 sq cm,Q4204,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,5403.6,APC 378
Xwrap 1 sq cm,Q4204,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,5403.6,APC
Xwrap 1 sq cm,Q4204,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,5403.6,APC
Xwrap 1 sq cm,Q4204,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,5403.6,APC
Xwrap 1 sq cm,Q4204,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,5403.6,Radiology
Xwrap 1 sq cm,Q4204,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,5403.6,APC
Xwrap 1 sq cm,Q4204,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,5403.6,APC
Membrane graft or wrap sq cm,Q4205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2654.4,,,,,,,fee schedule,123.2,2654.4,
Membrane graft or wrap sq cm,Q4205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2402.4,,,,,,,fee schedule,123.2,2654.4,
Membrane graft or wrap sq cm,Q4205,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,2654.4,APC 378
Membrane graft or wrap sq cm,Q4205,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,2654.4,APC
Membrane graft or wrap sq cm,Q4205,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,2654.4,APC
Membrane graft or wrap sq cm,Q4205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,2654.4,APC
Membrane graft or wrap sq cm,Q4205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,2654.4,Radiology
Membrane graft or wrap sq cm,Q4205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,2654.4,APC
Membrane graft or wrap sq cm,Q4205,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,2654.4,APC
Fluid flow or fluid gf 1 cc,Q4206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4550.4,,,,,,,fee schedule,4118.4,4550.4,
Fluid flow or fluid gf 1 cc,Q4206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4118.4,,,,,,,fee schedule,4118.4,4550.4,
Axolotl graf dualgraf sq cm,Q4210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3209.38,,,,,,,fee schedule,2904.69,3209.38,
Axolotl graf dualgraf sq cm,Q4210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2904.69,,,,,,,fee schedule,2904.69,3209.38,
"Ascent, 0.5 mg",Q4213,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,108.99,,,,,,,fee schedule,98.64,108.99,
"Ascent, 0.5 mg",Q4213,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,98.64,,,,,,,fee schedule,98.64,108.99,
Woundfix biowound plus xplus,Q4217,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2291,,,,,,,fee schedule,123.2,2291,
Woundfix biowound plus xplus,Q4217,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2073.5,,,,,,,fee schedule,123.2,2291,
Woundfix biowound plus xplus,Q4217,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,2291,APC 378
Woundfix biowound plus xplus,Q4217,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,2291,APC
Woundfix biowound plus xplus,Q4217,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,2291,APC
Woundfix biowound plus xplus,Q4217,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,2291,APC
Woundfix biowound plus xplus,Q4217,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,2291,Radiology
Woundfix biowound plus xplus,Q4217,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,2291,APC
Woundfix biowound plus xplus,Q4217,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,2291,APC
Surgigraft dual per sq cm,Q4219,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1896,,,,,,,fee schedule,123.2,1896,
Surgigraft dual per sq cm,Q4219,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1716,,,,,,,fee schedule,123.2,1896,
Surgigraft dual per sq cm,Q4219,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,1896,APC 378
Surgigraft dual per sq cm,Q4219,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,1896,APC
Surgigraft dual per sq cm,Q4219,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,1896,APC
Surgigraft dual per sq cm,Q4219,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,1896,APC
Surgigraft dual per sq cm,Q4219,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,1896,Radiology
Surgigraft dual per sq cm,Q4219,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,1896,APC
Surgigraft dual per sq cm,Q4219,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,1896,APC
Amniowrap2 per sq cm,Q4221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3033.6,,,,,,,fee schedule,123.2,3033.6,
Amniowrap2 per sq cm,Q4221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2745.6,,,,,,,fee schedule,123.2,3033.6,
Amniowrap2 per sq cm,Q4221,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,3033.6,APC 378
Amniowrap2 per sq cm,Q4221,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,3033.6,APC
Amniowrap2 per sq cm,Q4221,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,3033.6,APC
Amniowrap2 per sq cm,Q4221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,3033.6,APC
Amniowrap2 per sq cm,Q4221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,3033.6,Radiology
Amniowrap2 per sq cm,Q4221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,3033.6,APC
Amniowrap2 per sq cm,Q4221,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,3033.6,APC
"Progenamatrix, per sq cm",Q4222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,341.28,,,,,,,fee schedule,123.2,546.58,
"Progenamatrix, per sq cm",Q4222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,308.88,,,,,,,fee schedule,123.2,546.58,
"Progenamatrix, per sq cm",Q4222,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,546.58,APC 378
"Progenamatrix, per sq cm",Q4222,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,546.58,APC
"Progenamatrix, per sq cm",Q4222,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,546.58,APC
"Progenamatrix, per sq cm",Q4222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,546.58,APC
"Progenamatrix, per sq cm",Q4222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,546.58,Radiology
"Progenamatrix, per sq cm",Q4222,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,546.58,APC
"Progenamatrix, per sq cm",Q4222,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,546.58,APC
"Amniobind, per sq cm",Q4225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2749.2,,,,,,,fee schedule,123.2,2749.2,
"Amniobind, per sq cm",Q4225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2488.2,,,,,,,fee schedule,123.2,2749.2,
"Amniobind, per sq cm",Q4225,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,2749.2,APC 378
"Amniobind, per sq cm",Q4225,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,2749.2,APC
"Amniobind, per sq cm",Q4225,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,2749.2,APC
"Amniobind, per sq cm",Q4225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,2749.2,APC
"Amniobind, per sq cm",Q4225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,2749.2,Radiology
"Amniobind, per sq cm",Q4225,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,2749.2,APC
"Amniobind, per sq cm",Q4225,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,2749.2,APC
Myown harv prep proc sq cm,Q4226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2275.2,,,,,,,fee schedule,2059.2,2275.2,
Myown harv prep proc sq cm,Q4226,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2059.2,,,,,,,fee schedule,2059.2,2275.2,
Amniocore per sq cm,Q4227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2038.2,,,,,,,fee schedule,123.2,2038.2,
Amniocore per sq cm,Q4227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1844.7,,,,,,,fee schedule,123.2,2038.2,
Amniocore per sq cm,Q4227,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,2038.2,APC 378
Amniocore per sq cm,Q4227,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,2038.2,APC
Amniocore per sq cm,Q4227,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,2038.2,APC
Amniocore per sq cm,Q4227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,2038.2,APC
Amniocore per sq cm,Q4227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,2038.2,Radiology
Amniocore per sq cm,Q4227,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,2038.2,APC
Amniocore per sq cm,Q4227,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,2038.2,APC
Cogenex amnio memb per sq cm,Q4229,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1501,,,,,,,fee schedule,123.2,1501,
Cogenex amnio memb per sq cm,Q4229,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1358.5,,,,,,,fee schedule,123.2,1501,
Cogenex amnio memb per sq cm,Q4229,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,1501,APC 378
Cogenex amnio memb per sq cm,Q4229,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,1501,APC
Cogenex amnio memb per sq cm,Q4229,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,1501,APC
Cogenex amnio memb per sq cm,Q4229,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,1501,APC
Cogenex amnio memb per sq cm,Q4229,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,1501,Radiology
Cogenex amnio memb per sq cm,Q4229,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,1501,APC
Cogenex amnio memb per sq cm,Q4229,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,1501,APC
Cogenex flow amnion 0.5 cc,Q4230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1580,,,,,,,fee schedule,1430,1580,
Cogenex flow amnion 0.5 cc,Q4230,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1430,,,,,,,fee schedule,1430,1580,
"Corplex p, per cc",Q4231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5767,,,,,,,fee schedule,5219.5,5767,
"Corplex p, per cc",Q4231,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5219.5,,,,,,,fee schedule,5219.5,5767,
"Corplex, per sq cm",Q4232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1106.11,,,,,,,fee schedule,123.2,1106.11,
"Corplex, per sq cm",Q4232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1001.1,,,,,,,fee schedule,123.2,1106.11,
"Corplex, per sq cm",Q4232,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,1106.11,APC 378
"Corplex, per sq cm",Q4232,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,1106.11,APC
"Corplex, per sq cm",Q4232,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,1106.11,APC
"Corplex, per sq cm",Q4232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,1106.11,APC
"Corplex, per sq cm",Q4232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,1106.11,Radiology
"Corplex, per sq cm",Q4232,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,1106.11,APC
"Corplex, per sq cm",Q4232,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,1106.11,APC
"Xcellerate, per sq cm",Q4234,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1975,,,,,,,fee schedule,123.2,1975,
"Xcellerate, per sq cm",Q4234,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1787.5,,,,,,,fee schedule,123.2,1975,
"Xcellerate, per sq cm",Q4234,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,1975,APC 378
"Xcellerate, per sq cm",Q4234,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,1975,APC
"Xcellerate, per sq cm",Q4234,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,1975,APC
"Xcellerate, per sq cm",Q4234,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,1975,APC
"Xcellerate, per sq cm",Q4234,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,1975,Radiology
"Xcellerate, per sq cm",Q4234,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,1975,APC
"Xcellerate, per sq cm",Q4234,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,1975,APC
Carepatch per sq cm,Q4236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2464.8,,,,,,,fee schedule,123.2,2464.8,
Carepatch per sq cm,Q4236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2230.8,,,,,,,fee schedule,123.2,2464.8,
Carepatch per sq cm,Q4236,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,2464.8,APC 378
Carepatch per sq cm,Q4236,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,2464.8,APC
Carepatch per sq cm,Q4236,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,2464.8,APC
Carepatch per sq cm,Q4236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,2464.8,APC
Carepatch per sq cm,Q4236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,2464.8,Radiology
Carepatch per sq cm,Q4236,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,2464.8,APC
Carepatch per sq cm,Q4236,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,2464.8,APC
"cryo-cord, per sq cm",Q4237,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,789.02,,,,,,,fee schedule,123.2,789.02,
"cryo-cord, per sq cm",Q4237,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,714.11,,,,,,,fee schedule,123.2,789.02,
"cryo-cord, per sq cm",Q4237,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,789.02,APC 378
"cryo-cord, per sq cm",Q4237,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,789.02,APC
"cryo-cord, per sq cm",Q4237,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,789.02,APC
"cryo-cord, per sq cm",Q4237,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,789.02,APC
"cryo-cord, per sq cm",Q4237,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,789.02,Radiology
"cryo-cord, per sq cm",Q4237,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,789.02,APC
"cryo-cord, per sq cm",Q4237,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,789.02,APC
"Derm-maxx, per sq cm",Q4238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2844,,,,,,,fee schedule,123.2,2844,
"Derm-maxx, per sq cm",Q4238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2574,,,,,,,fee schedule,123.2,2844,
"Derm-maxx, per sq cm",Q4238,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,2844,APC 378
"Derm-maxx, per sq cm",Q4238,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,2844,APC
"Derm-maxx, per sq cm",Q4238,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,2844,APC
"Derm-maxx, per sq cm",Q4238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,2844,APC
"Derm-maxx, per sq cm",Q4238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,2844,Radiology
"Derm-maxx, per sq cm",Q4238,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,2844,APC
"Derm-maxx, per sq cm",Q4238,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,2844,APC
Amnio-maxx or lite per sq cm,Q4239,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4266.85,,,,,,,fee schedule,123.2,4266.85,
Amnio-maxx or lite per sq cm,Q4239,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3861.77,,,,,,,fee schedule,123.2,4266.85,
Amnio-maxx or lite per sq cm,Q4239,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,4266.85,APC 378
Amnio-maxx or lite per sq cm,Q4239,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,4266.85,APC
Amnio-maxx or lite per sq cm,Q4239,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,4266.85,APC
Amnio-maxx or lite per sq cm,Q4239,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,4266.85,APC
Amnio-maxx or lite per sq cm,Q4239,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,4266.85,Radiology
Amnio-maxx or lite per sq cm,Q4239,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,4266.85,APC
Amnio-maxx or lite per sq cm,Q4239,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,4266.85,APC
"Coretext or protext, per cc",Q4246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5087.6,,,,,,,fee schedule,4604.6,5087.6,
"Coretext or protext, per cc",Q4246,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4604.6,,,,,,,fee schedule,4604.6,5087.6,
"Amniotext patch, per sq cm",Q4247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3597.66,,,,,,,fee schedule,123.2,3597.66,
"Amniotext patch, per sq cm",Q4247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3256.11,,,,,,,fee schedule,123.2,3597.66,
"Amniotext patch, per sq cm",Q4247,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,3597.66,APC 378
"Amniotext patch, per sq cm",Q4247,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,3597.66,APC
"Amniotext patch, per sq cm",Q4247,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,3597.66,APC
"Amniotext patch, per sq cm",Q4247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,3597.66,APC
"Amniotext patch, per sq cm",Q4247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,3597.66,Radiology
"Amniotext patch, per sq cm",Q4247,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,3597.66,APC
"Amniotext patch, per sq cm",Q4247,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,3597.66,APC
Dermacyte Amn mem allo sq cm,Q4248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2472.95,,,,,,,fee schedule,123.2,2472.95,
Dermacyte Amn mem allo sq cm,Q4248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2238.18,,,,,,,fee schedule,123.2,2472.95,
Dermacyte Amn mem allo sq cm,Q4248,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,2472.95,APC 378
Dermacyte Amn mem allo sq cm,Q4248,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,2472.95,APC
Dermacyte Amn mem allo sq cm,Q4248,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,2472.95,APC
Dermacyte Amn mem allo sq cm,Q4248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,2472.95,APC
Dermacyte Amn mem allo sq cm,Q4248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,2472.95,Radiology
Dermacyte Amn mem allo sq cm,Q4248,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,2472.95,APC
Dermacyte Amn mem allo sq cm,Q4248,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,2472.95,APC
"Amniply, per sq cm",Q4249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2696.11,,,,,,,fee schedule,123.2,2696.11,
"Amniply, per sq cm",Q4249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2440.15,,,,,,,fee schedule,123.2,2696.11,
"Amniply, per sq cm",Q4249,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,2696.11,APC 378
"Amniply, per sq cm",Q4249,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,2696.11,APC
"Amniply, per sq cm",Q4249,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,2696.11,APC
"Amniply, per sq cm",Q4249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,2696.11,APC
"Amniply, per sq cm",Q4249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,2696.11,Radiology
"Amniply, per sq cm",Q4249,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,2696.11,APC
"Amniply, per sq cm",Q4249,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,2696.11,APC
AmnioAMP-MP per sq cm,Q4250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4503.9,,,,,,,fee schedule,123.2,4503.9,
AmnioAMP-MP per sq cm,Q4250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4076.32,,,,,,,fee schedule,123.2,4503.9,
AmnioAMP-MP per sq cm,Q4250,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,4503.9,APC 378
AmnioAMP-MP per sq cm,Q4250,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,4503.9,APC
AmnioAMP-MP per sq cm,Q4250,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,4503.9,APC
AmnioAMP-MP per sq cm,Q4250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,4503.9,APC
AmnioAMP-MP per sq cm,Q4250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,4503.9,Radiology
AmnioAMP-MP per sq cm,Q4250,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,4503.9,APC
AmnioAMP-MP per sq cm,Q4250,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,4503.9,APC
"Vim, per square centimeter",Q4251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,284.4,,,,,,,fee schedule,123.2,546.58,
"Vim, per square centimeter",Q4251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,257.4,,,,,,,fee schedule,123.2,546.58,
"Vim, per square centimeter",Q4251,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,546.58,APC 378
"Vim, per square centimeter",Q4251,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,546.58,APC
"Vim, per square centimeter",Q4251,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,546.58,APC
"Vim, per square centimeter",Q4251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,546.58,APC
"Vim, per square centimeter",Q4251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,546.58,Radiology
"Vim, per square centimeter",Q4251,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,546.58,APC
"Vim, per square centimeter",Q4251,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,546.58,APC
"Vendaje, per square centimet",Q4252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1801.2,,,,,,,fee schedule,123.2,1801.2,
"Vendaje, per square centimet",Q4252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1630.2,,,,,,,fee schedule,123.2,1801.2,
"Vendaje, per square centimet",Q4252,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,1801.2,APC 378
"Vendaje, per square centimet",Q4252,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,1801.2,APC
"Vendaje, per square centimet",Q4252,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,1801.2,APC
"Vendaje, per square centimet",Q4252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,1801.2,APC
"Vendaje, per square centimet",Q4252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,1801.2,Radiology
"Vendaje, per square centimet",Q4252,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,1801.2,APC
"Vendaje, per square centimet",Q4252,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,1801.2,APC
Zenith amniotic membrane psc,Q4253,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1801.2,,,,,,,fee schedule,123.2,1801.2,
Zenith amniotic membrane psc,Q4253,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1630.2,,,,,,,fee schedule,123.2,1801.2,
Zenith amniotic membrane psc,Q4253,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,1801.2,APC 378
Zenith amniotic membrane psc,Q4253,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,1801.2,APC
Zenith amniotic membrane psc,Q4253,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,1801.2,APC
Zenith amniotic membrane psc,Q4253,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,1801.2,APC
Zenith amniotic membrane psc,Q4253,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,1801.2,Radiology
Zenith amniotic membrane psc,Q4253,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,1801.2,APC
Zenith amniotic membrane psc,Q4253,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,1801.2,APC
"Mlg complet, per sq cm",Q4256,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3507.6,,,,,,,fee schedule,123.2,3507.6,
"Mlg complet, per sq cm",Q4256,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3174.6,,,,,,,fee schedule,123.2,3507.6,
"Mlg complet, per sq cm",Q4256,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,3507.6,APC 378
"Mlg complet, per sq cm",Q4256,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,3507.6,APC
"Mlg complet, per sq cm",Q4256,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,3507.6,APC
"Mlg complet, per sq cm",Q4256,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,3507.6,APC
"Mlg complet, per sq cm",Q4256,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,3507.6,Radiology
"Mlg complet, per sq cm",Q4256,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,3507.6,APC
"Mlg complet, per sq cm",Q4256,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,3507.6,APC
"Relese, per sq cm",Q4257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1501,,,,,,,fee schedule,123.2,1501,
"Relese, per sq cm",Q4257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1358.5,,,,,,,fee schedule,123.2,1501,
"Relese, per sq cm",Q4257,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,1501,APC 378
"Relese, per sq cm",Q4257,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,1501,APC
"Relese, per sq cm",Q4257,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,1501,APC
"Relese, per sq cm",Q4257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,1501,APC
"Relese, per sq cm",Q4257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,1501,Radiology
"Relese, per sq cm",Q4257,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,1501,APC
"Relese, per sq cm",Q4257,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,1501,APC
"Enverse, per sq cm",Q4258,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1105.97,,,,,,,fee schedule,123.2,1105.97,
"Enverse, per sq cm",Q4258,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1000.97,,,,,,,fee schedule,123.2,1105.97,
"Enverse, per sq cm",Q4258,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,1105.97,APC 378
"Enverse, per sq cm",Q4258,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,1105.97,APC
"Enverse, per sq cm",Q4258,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,1105.97,APC
"Enverse, per sq cm",Q4258,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,1105.97,APC
"Enverse, per sq cm",Q4258,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,1105.97,Radiology
"Enverse, per sq cm",Q4258,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,1105.97,APC
"Enverse, per sq cm",Q4258,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,1105.97,APC
Celera per sq cm,Q4259,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2512.2,,,,,,,fee schedule,123.2,2512.2,
Celera per sq cm,Q4259,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2273.7,,,,,,,fee schedule,123.2,2512.2,
Celera per sq cm,Q4259,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,2512.2,APC 378
Celera per sq cm,Q4259,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,2512.2,APC
Celera per sq cm,Q4259,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,2512.2,APC
Celera per sq cm,Q4259,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,2512.2,APC
Celera per sq cm,Q4259,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,2512.2,Radiology
Celera per sq cm,Q4259,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,2512.2,APC
Celera per sq cm,Q4259,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,2512.2,APC
"Tag, per square centimeter",Q4261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1144.27,,,,,,,fee schedule,123.2,1144.27,
"Tag, per square centimeter",Q4261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1035.63,,,,,,,fee schedule,123.2,1144.27,
"Tag, per square centimeter",Q4261,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,1144.27,APC 378
"Tag, per square centimeter",Q4261,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,1144.27,APC
"Tag, per square centimeter",Q4261,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,1144.27,APC
"Tag, per square centimeter",Q4261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,1144.27,APC
"Tag, per square centimeter",Q4261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,1144.27,Radiology
"Tag, per square centimeter",Q4261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,1144.27,APC
"Tag, per square centimeter",Q4261,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,1144.27,APC
"Dual layer impax, per sq cm",Q4262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2559.85,,,,,,,fee schedule,123.2,2559.85,
"Dual layer impax, per sq cm",Q4262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2316.83,,,,,,,fee schedule,123.2,2559.85,
"Dual layer impax, per sq cm",Q4262,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,2559.85,APC 378
"Dual layer impax, per sq cm",Q4262,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,2559.85,APC
"Dual layer impax, per sq cm",Q4262,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,2559.85,APC
"Dual layer impax, per sq cm",Q4262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,2559.85,APC
"Dual layer impax, per sq cm",Q4262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,2559.85,Radiology
"Dual layer impax, per sq cm",Q4262,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,2559.85,APC
"Dual layer impax, per sq cm",Q4262,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,2559.85,APC
"Surgraft tl, per sq cm",Q4263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1886.9,,,,,,,fee schedule,123.2,1886.9,
"Surgraft tl, per sq cm",Q4263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1707.76,,,,,,,fee schedule,123.2,1886.9,
"Surgraft tl, per sq cm",Q4263,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,1886.9,APC 378
"Surgraft tl, per sq cm",Q4263,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,1886.9,APC
"Surgraft tl, per sq cm",Q4263,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,1886.9,APC
"Surgraft tl, per sq cm",Q4263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,1886.9,APC
"Surgraft tl, per sq cm",Q4263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,1886.9,Radiology
"Surgraft tl, per sq cm",Q4263,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,1886.9,APC
"Surgraft tl, per sq cm",Q4263,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,1886.9,APC
"Cocoon membrane, per sq cm",Q4264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5119.2,,,,,,,fee schedule,123.2,5119.2,
"Cocoon membrane, per sq cm",Q4264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4633.2,,,,,,,fee schedule,123.2,5119.2,
"Cocoon membrane, per sq cm",Q4264,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,5119.2,APC 378
"Cocoon membrane, per sq cm",Q4264,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,5119.2,APC
"Cocoon membrane, per sq cm",Q4264,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,5119.2,APC
"Cocoon membrane, per sq cm",Q4264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,5119.2,APC
"Cocoon membrane, per sq cm",Q4264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,5119.2,Radiology
"Cocoon membrane, per sq cm",Q4264,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,5119.2,APC
"Cocoon membrane, per sq cm",Q4264,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,5119.2,APC
Neostim tl per sq cm,Q4265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3152.1,,,,,,,fee schedule,123.2,3152.1,
Neostim tl per sq cm,Q4265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2852.85,,,,,,,fee schedule,123.2,3152.1,
Neostim tl per sq cm,Q4265,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,3152.1,APC 378
Neostim tl per sq cm,Q4265,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,3152.1,APC
Neostim tl per sq cm,Q4265,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,3152.1,APC
Neostim tl per sq cm,Q4265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,3152.1,APC
Neostim tl per sq cm,Q4265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,3152.1,Radiology
Neostim tl per sq cm,Q4265,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,3152.1,APC
Neostim tl per sq cm,Q4265,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,3152.1,APC
Neostim per sq cm,Q4266,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2362.57,,,,,,,fee schedule,123.2,2362.57,
Neostim per sq cm,Q4266,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2138.28,,,,,,,fee schedule,123.2,2362.57,
Neostim per sq cm,Q4266,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,2362.57,APC 378
Neostim per sq cm,Q4266,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,2362.57,APC
Neostim per sq cm,Q4266,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,2362.57,APC
Neostim per sq cm,Q4266,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,2362.57,APC
Neostim per sq cm,Q4266,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,2362.57,Radiology
Neostim per sq cm,Q4266,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,2362.57,APC
Neostim per sq cm,Q4266,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,2362.57,APC
Neostim dl per sq cm,Q4267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1303.77,,,,,,,fee schedule,123.2,1303.77,
Neostim dl per sq cm,Q4267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1179.99,,,,,,,fee schedule,123.2,1303.77,
Neostim dl per sq cm,Q4267,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,1303.77,APC 378
Neostim dl per sq cm,Q4267,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,1303.77,APC
Neostim dl per sq cm,Q4267,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,1303.77,APC
Neostim dl per sq cm,Q4267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,1303.77,APC
Neostim dl per sq cm,Q4267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,1303.77,Radiology
Neostim dl per sq cm,Q4267,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,1303.77,APC
Neostim dl per sq cm,Q4267,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,1303.77,APC
Surgraft ft per sq cm,Q4268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2726.86,,,,,,,fee schedule,123.2,2726.86,
Surgraft ft per sq cm,Q4268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2467.98,,,,,,,fee schedule,123.2,2726.86,
Surgraft ft per sq cm,Q4268,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,2726.86,APC 378
Surgraft ft per sq cm,Q4268,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,2726.86,APC
Surgraft ft per sq cm,Q4268,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,2726.86,APC
Surgraft ft per sq cm,Q4268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,2726.86,APC
Surgraft ft per sq cm,Q4268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,2726.86,Radiology
Surgraft ft per sq cm,Q4268,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,2726.86,APC
Surgraft ft per sq cm,Q4268,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,2726.86,APC
Surgraft xt per sq cm,Q4269,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1422,,,,,,,fee schedule,123.2,1422,
Surgraft xt per sq cm,Q4269,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1287,,,,,,,fee schedule,123.2,1422,
Surgraft xt per sq cm,Q4269,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,1422,APC 378
Surgraft xt per sq cm,Q4269,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,1422,APC
Surgraft xt per sq cm,Q4269,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,1422,APC
Surgraft xt per sq cm,Q4269,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,1422,APC
Surgraft xt per sq cm,Q4269,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,1422,Radiology
Surgraft xt per sq cm,Q4269,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,1422,APC
Surgraft xt per sq cm,Q4269,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,1422,APC
Complete ft per sq cm,Q4271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3128.4,,,,,,,fee schedule,123.2,3128.4,
Complete ft per sq cm,Q4271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2831.4,,,,,,,fee schedule,123.2,3128.4,
Complete ft per sq cm,Q4271,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,3128.4,APC 378
Complete ft per sq cm,Q4271,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,3128.4,APC
Complete ft per sq cm,Q4271,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,3128.4,APC
Complete ft per sq cm,Q4271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,3128.4,APC
Complete ft per sq cm,Q4271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,3128.4,Radiology
Complete ft per sq cm,Q4271,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,3128.4,APC
Complete ft per sq cm,Q4271,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,3128.4,APC
"Esano a, per sq cm",Q4272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,553,,,,,,,fee schedule,123.2,553,
"Esano a, per sq cm",Q4272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,500.5,,,,,,,fee schedule,123.2,553,
"Esano a, per sq cm",Q4272,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,553,APC 378
"Esano a, per sq cm",Q4272,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,553,APC
"Esano a, per sq cm",Q4272,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,553,APC
"Esano a, per sq cm",Q4272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,553,APC
"Esano a, per sq cm",Q4272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,553,Radiology
"Esano a, per sq cm",Q4272,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,553,APC
"Esano a, per sq cm",Q4272,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,553,APC
"Esano ac, per sq cm",Q4274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2330.5,,,,,,,fee schedule,123.2,2330.5,
"Esano ac, per sq cm",Q4274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2109.25,,,,,,,fee schedule,123.2,2330.5,
"Esano ac, per sq cm",Q4274,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,2330.5,APC 378
"Esano ac, per sq cm",Q4274,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,2330.5,APC
"Esano ac, per sq cm",Q4274,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,2330.5,APC
"Esano ac, per sq cm",Q4274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,2330.5,APC
"Esano ac, per sq cm",Q4274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,2330.5,Radiology
"Esano ac, per sq cm",Q4274,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,2330.5,APC
"Esano ac, per sq cm",Q4274,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,2330.5,APC
"Esano aca, per sq cm",Q4275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4068.5,,,,,,,fee schedule,123.2,4068.5,
"Esano aca, per sq cm",Q4275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3682.25,,,,,,,fee schedule,123.2,4068.5,
"Esano aca, per sq cm",Q4275,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,4068.5,APC 378
"Esano aca, per sq cm",Q4275,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,4068.5,APC
"Esano aca, per sq cm",Q4275,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,4068.5,APC
"Esano aca, per sq cm",Q4275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,4068.5,APC
"Esano aca, per sq cm",Q4275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,4068.5,Radiology
"Esano aca, per sq cm",Q4275,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,4068.5,APC
"Esano aca, per sq cm",Q4275,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,4068.5,APC
"Orion, per sq cm",Q4276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2749.2,,,,,,,fee schedule,123.2,2749.2,
"Orion, per sq cm",Q4276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2488.2,,,,,,,fee schedule,123.2,2749.2,
"Orion, per sq cm",Q4276,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,2749.2,APC 378
"Orion, per sq cm",Q4276,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,2749.2,APC
"Orion, per sq cm",Q4276,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,2749.2,APC
"Orion, per sq cm",Q4276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,2749.2,APC
"Orion, per sq cm",Q4276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,2749.2,Radiology
"Orion, per sq cm",Q4276,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,2749.2,APC
"Orion, per sq cm",Q4276,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,2749.2,APC
"Woundplus e-grat, per sq cm",Q4277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2709.7,,,,,,,fee schedule,2452.45,2709.7,
"Woundplus e-grat, per sq cm",Q4277,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2452.45,,,,,,,fee schedule,2452.45,2709.7,
"Epieffect, per sq cm",Q4278,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,948,,,,,,,fee schedule,123.2,948,
"Epieffect, per sq cm",Q4278,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,858,,,,,,,fee schedule,123.2,948,
"Epieffect, per sq cm",Q4278,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,948,APC 378
"Epieffect, per sq cm",Q4278,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,948,APC
"Epieffect, per sq cm",Q4278,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,948,APC
"Epieffect, per sq cm",Q4278,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,948,APC
"Epieffect, per sq cm",Q4278,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,948,Radiology
"Epieffect, per sq cm",Q4278,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,948,APC
"Epieffect, per sq cm",Q4278,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,948,APC
"Vendaje ac, per sq cm",Q4279,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4266,,,,,,,fee schedule,123.2,4266,
"Vendaje ac, per sq cm",Q4279,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3861,,,,,,,fee schedule,123.2,4266,
"Vendaje ac, per sq cm",Q4279,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,4266,APC 378
"Vendaje ac, per sq cm",Q4279,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,4266,APC
"Vendaje ac, per sq cm",Q4279,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,4266,APC
"Vendaje ac, per sq cm",Q4279,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,4266,APC
"Vendaje ac, per sq cm",Q4279,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,4266,Radiology
"Vendaje ac, per sq cm",Q4279,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,4266,APC
"Vendaje ac, per sq cm",Q4279,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,4266,APC
Barrera slor dl per sq cm,Q4281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2938.8,,,,,,,fee schedule,123.2,2938.8,
Barrera slor dl per sq cm,Q4281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2659.8,,,,,,,fee schedule,123.2,2938.8,
Barrera slor dl per sq cm,Q4281,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,2938.8,APC 378
Barrera slor dl per sq cm,Q4281,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,2938.8,APC
Barrera slor dl per sq cm,Q4281,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,2938.8,APC
Barrera slor dl per sq cm,Q4281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,2938.8,APC
Barrera slor dl per sq cm,Q4281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,2938.8,Radiology
Barrera slor dl per sq cm,Q4281,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,2938.8,APC
Barrera slor dl per sq cm,Q4281,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,2938.8,APC
Cygnus dual per sq cm,Q4282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2559.85,,,,,,,fee schedule,123.2,2559.85,
Cygnus dual per sq cm,Q4282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2316.83,,,,,,,fee schedule,123.2,2559.85,
Cygnus dual per sq cm,Q4282,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,2559.85,APC 378
Cygnus dual per sq cm,Q4282,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,2559.85,APC
Cygnus dual per sq cm,Q4282,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,2559.85,APC
Cygnus dual per sq cm,Q4282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,2559.85,APC
Cygnus dual per sq cm,Q4282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,2559.85,Radiology
Cygnus dual per sq cm,Q4282,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,2559.85,APC
Cygnus dual per sq cm,Q4282,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,2559.85,APC
"Biovance tri or 3l, sq cm",Q4283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2844,,,,,,,fee schedule,123.2,2844,
"Biovance tri or 3l, sq cm",Q4283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2574,,,,,,,fee schedule,123.2,2844,
"Biovance tri or 3l, sq cm",Q4283,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,2844,APC 378
"Biovance tri or 3l, sq cm",Q4283,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,2844,APC
"Biovance tri or 3l, sq cm",Q4283,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,2844,APC
"Biovance tri or 3l, sq cm",Q4283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,2844,APC
"Biovance tri or 3l, sq cm",Q4283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,2844,Radiology
"Biovance tri or 3l, sq cm",Q4283,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,2844,APC
"Biovance tri or 3l, sq cm",Q4283,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,2844,APC
Nudyn dl or dl mesh pr sq cm,Q4285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,316.38,,,,,,,fee schedule,123.2,546.58,
Nudyn dl or dl mesh pr sq cm,Q4285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,286.34,,,,,,,fee schedule,123.2,546.58,
Nudyn dl or dl mesh pr sq cm,Q4285,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,546.58,APC 378
Nudyn dl or dl mesh pr sq cm,Q4285,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,546.58,APC
Nudyn dl or dl mesh pr sq cm,Q4285,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,546.58,APC
Nudyn dl or dl mesh pr sq cm,Q4285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,546.58,APC
Nudyn dl or dl mesh pr sq cm,Q4285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,546.58,Radiology
Nudyn dl or dl mesh pr sq cm,Q4285,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,546.58,APC
Nudyn dl or dl mesh pr sq cm,Q4285,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,546.58,APC
"Nudyn sl or slw, per sq cm",Q4286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,338.2,,,,,,,fee schedule,123.2,546.58,
"Nudyn sl or slw, per sq cm",Q4286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,306.09,,,,,,,fee schedule,123.2,546.58,
"Nudyn sl or slw, per sq cm",Q4286,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,546.58,APC 378
"Nudyn sl or slw, per sq cm",Q4286,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,546.58,APC
"Nudyn sl or slw, per sq cm",Q4286,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,546.58,APC
"Nudyn sl or slw, per sq cm",Q4286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,546.58,APC
"Nudyn sl or slw, per sq cm",Q4286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,546.58,Radiology
"Nudyn sl or slw, per sq cm",Q4286,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,546.58,APC
"Nudyn sl or slw, per sq cm",Q4286,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,546.58,APC
"Revoshield+ amnio, per sq cm",Q4289,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3507.6,,,,,,,fee schedule,123.2,3507.6,
"Revoshield+ amnio, per sq cm",Q4289,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3174.6,,,,,,,fee schedule,123.2,3507.6,
"Revoshield+ amnio, per sq cm",Q4289,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,3507.6,APC 378
"Revoshield+ amnio, per sq cm",Q4289,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,3507.6,APC
"Revoshield+ amnio, per sq cm",Q4289,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,3507.6,APC
"Revoshield+ amnio, per sq cm",Q4289,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,3507.6,APC
"Revoshield+ amnio, per sq cm",Q4289,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,3507.6,Radiology
"Revoshield+ amnio, per sq cm",Q4289,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,3507.6,APC
"Revoshield+ amnio, per sq cm",Q4289,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,3507.6,APC
Membrane wrap hydr per sq cm,Q4290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3507.6,,,,,,,fee schedule,123.2,3507.6,
Membrane wrap hydr per sq cm,Q4290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3174.6,,,,,,,fee schedule,123.2,3507.6,
Membrane wrap hydr per sq cm,Q4290,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,3507.6,APC 378
Membrane wrap hydr per sq cm,Q4290,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,3507.6,APC
Membrane wrap hydr per sq cm,Q4290,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,3507.6,APC
Membrane wrap hydr per sq cm,Q4290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,3507.6,APC
Membrane wrap hydr per sq cm,Q4290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,3507.6,Radiology
Membrane wrap hydr per sq cm,Q4290,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,3507.6,APC
Membrane wrap hydr per sq cm,Q4290,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,3507.6,APC
"Lamellas, per sq cm",Q4292,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2324.42,,,,,,,fee schedule,123.2,2324.42,
"Lamellas, per sq cm",Q4292,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2103.74,,,,,,,fee schedule,123.2,2324.42,
"Lamellas, per sq cm",Q4292,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,2324.42,APC 378
"Lamellas, per sq cm",Q4292,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,2324.42,APC
"Lamellas, per sq cm",Q4292,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,2324.42,APC
"Lamellas, per sq cm",Q4292,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,2324.42,APC
"Lamellas, per sq cm",Q4292,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,2324.42,Radiology
"Lamellas, per sq cm",Q4292,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,2324.42,APC
"Lamellas, per sq cm",Q4292,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,2324.42,APC
"Acesso dl, per sq cm",Q4293,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2362.34,,,,,,,fee schedule,123.2,2362.34,
"Acesso dl, per sq cm",Q4293,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2138.06,,,,,,,fee schedule,123.2,2362.34,
"Acesso dl, per sq cm",Q4293,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,2362.34,APC 378
"Acesso dl, per sq cm",Q4293,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,2362.34,APC
"Acesso dl, per sq cm",Q4293,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,2362.34,APC
"Acesso dl, per sq cm",Q4293,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,2362.34,APC
"Acesso dl, per sq cm",Q4293,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,2362.34,Radiology
"Acesso dl, per sq cm",Q4293,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,2362.34,APC
"Acesso dl, per sq cm",Q4293,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,2362.34,APC
"Amnio quad-core, per sq cm",Q4294,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4503,,,,,,,fee schedule,123.2,4503,
"Amnio quad-core, per sq cm",Q4294,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4075.5,,,,,,,fee schedule,123.2,4503,
"Amnio quad-core, per sq cm",Q4294,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,4503,APC 378
"Amnio quad-core, per sq cm",Q4294,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,4503,APC
"Amnio quad-core, per sq cm",Q4294,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,4503,APC
"Amnio quad-core, per sq cm",Q4294,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,4503,APC
"Amnio quad-core, per sq cm",Q4294,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,4503,Radiology
"Amnio quad-core, per sq cm",Q4294,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,4503,APC
"Amnio quad-core, per sq cm",Q4294,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,4503,APC
"Amnio tri-core, per sq cm",Q4295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3981.6,,,,,,,fee schedule,123.2,3981.6,
"Amnio tri-core, per sq cm",Q4295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3603.6,,,,,,,fee schedule,123.2,3981.6,
"Amnio tri-core, per sq cm",Q4295,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,3981.6,APC 378
"Amnio tri-core, per sq cm",Q4295,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,3981.6,APC
"Amnio tri-core, per sq cm",Q4295,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,3981.6,APC
"Amnio tri-core, per sq cm",Q4295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,3981.6,APC
"Amnio tri-core, per sq cm",Q4295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,3981.6,Radiology
"Amnio tri-core, per sq cm",Q4295,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,3981.6,APC
"Amnio tri-core, per sq cm",Q4295,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,3981.6,APC
"Rebound matrix, per sq cm",Q4296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4266,,,,,,,fee schedule,123.2,4266,
"Rebound matrix, per sq cm",Q4296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3861,,,,,,,fee schedule,123.2,4266,
"Rebound matrix, per sq cm",Q4296,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,4266,APC 378
"Rebound matrix, per sq cm",Q4296,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,4266,APC
"Rebound matrix, per sq cm",Q4296,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,4266,APC
"Rebound matrix, per sq cm",Q4296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,4266,APC
"Rebound matrix, per sq cm",Q4296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,4266,Radiology
"Rebound matrix, per sq cm",Q4296,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,4266,APC
"Rebound matrix, per sq cm",Q4296,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,4266,APC
"Emerge matrix, per sq cm",Q4297,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4076.4,,,,,,,fee schedule,123.2,4076.4,
"Emerge matrix, per sq cm",Q4297,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3689.4,,,,,,,fee schedule,123.2,4076.4,
"Emerge matrix, per sq cm",Q4297,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,4076.4,APC 378
"Emerge matrix, per sq cm",Q4297,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,4076.4,APC
"Emerge matrix, per sq cm",Q4297,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,4076.4,APC
"Emerge matrix, per sq cm",Q4297,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,4076.4,APC
"Emerge matrix, per sq cm",Q4297,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,4076.4,Radiology
"Emerge matrix, per sq cm",Q4297,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,4076.4,APC
"Emerge matrix, per sq cm",Q4297,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,4076.4,APC
"Acesso tl, per sq cm",Q4300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3152.42,,,,,,,fee schedule,123.2,3152.42,
"Acesso tl, per sq cm",Q4300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2853.14,,,,,,,fee schedule,123.2,3152.42,
"Acesso tl, per sq cm",Q4300,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,3152.42,APC 378
"Acesso tl, per sq cm",Q4300,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,3152.42,APC
"Acesso tl, per sq cm",Q4300,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,3152.42,APC
"Acesso tl, per sq cm",Q4300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,3152.42,APC
"Acesso tl, per sq cm",Q4300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,3152.42,Radiology
"Acesso tl, per sq cm",Q4300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,3152.42,APC
"Acesso tl, per sq cm",Q4300,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,3152.42,APC
"Activate matrix, per sq cm",Q4301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5100.24,,,,,,,fee schedule,123.2,5100.24,
"Activate matrix, per sq cm",Q4301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4616.04,,,,,,,fee schedule,123.2,5100.24,
"Activate matrix, per sq cm",Q4301,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,5100.24,APC 378
"Activate matrix, per sq cm",Q4301,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,5100.24,APC
"Activate matrix, per sq cm",Q4301,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,5100.24,APC
"Activate matrix, per sq cm",Q4301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,5100.24,APC
"Activate matrix, per sq cm",Q4301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,5100.24,Radiology
"Activate matrix, per sq cm",Q4301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,5100.24,APC
"Activate matrix, per sq cm",Q4301,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,5100.24,APC
"Complete aca, per sq cm",Q4302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2995.6,,,,,,,fee schedule,123.2,2995.6,
"Complete aca, per sq cm",Q4302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2711.21,,,,,,,fee schedule,123.2,2995.6,
"Complete aca, per sq cm",Q4302,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,2995.6,APC 378
"Complete aca, per sq cm",Q4302,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,2995.6,APC
"Complete aca, per sq cm",Q4302,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,2995.6,APC
"Complete aca, per sq cm",Q4302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,2995.6,APC
"Complete aca, per sq cm",Q4302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,2995.6,Radiology
"Complete aca, per sq cm",Q4302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,2995.6,APC
"Complete aca, per sq cm",Q4302,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,2995.6,APC
"Complete aa, per sq cm",Q4303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6259.93,,,,,,,fee schedule,123.2,6259.93,
"Complete aa, per sq cm",Q4303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5665.63,,,,,,,fee schedule,123.2,6259.93,
"Complete aa, per sq cm",Q4303,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,6259.93,APC 378
"Complete aa, per sq cm",Q4303,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,6259.93,APC
"Complete aa, per sq cm",Q4303,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,6259.93,APC
"Complete aa, per sq cm",Q4303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,6259.93,APC
"Complete aa, per sq cm",Q4303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,6259.93,Radiology
"Complete aa, per sq cm",Q4303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,6259.93,APC
"Complete aa, per sq cm",Q4303,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,6259.93,APC
"Grafix plus, per sq cm",Q4304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2558.57,,,,,,,fee schedule,123.2,2558.57,
"Grafix plus, per sq cm",Q4304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2315.67,,,,,,,fee schedule,123.2,2558.57,
"Grafix plus, per sq cm",Q4304,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,2558.57,APC 378
"Grafix plus, per sq cm",Q4304,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,2558.57,APC
"Grafix plus, per sq cm",Q4304,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,2558.57,APC
"Grafix plus, per sq cm",Q4304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,2558.57,APC
"Grafix plus, per sq cm",Q4304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,2558.57,Radiology
"Grafix plus, per sq cm",Q4304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,2558.57,APC
"Grafix plus, per sq cm",Q4304,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,2558.57,APC
"Via matrix, per sq cm",Q4309,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3319.66,,,,,,,fee schedule,123.2,3319.66,
"Via matrix, per sq cm",Q4309,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3004.5,,,,,,,fee schedule,123.2,3319.66,
"Via matrix, per sq cm",Q4309,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,3319.66,APC 378
"Via matrix, per sq cm",Q4309,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,3319.66,APC
"Via matrix, per sq cm",Q4309,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,3319.66,APC
"Via matrix, per sq cm",Q4309,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,3319.66,APC
"Via matrix, per sq cm",Q4309,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,3319.66,Radiology
"Via matrix, per sq cm",Q4309,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,3319.66,APC
"Via matrix, per sq cm",Q4309,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,3319.66,APC
"Procenta, per 100 mg",Q4310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9385.2,,,,,,,fee schedule,8494.2,9385.2,
"Procenta, per 100 mg",Q4310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8494.2,,,,,,,fee schedule,8494.2,9385.2,
"Dermabind fm, per sq cm",Q4313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5451,,,,,,,fee schedule,123.2,5451,
"Dermabind fm, per sq cm",Q4313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4933.5,,,,,,,fee schedule,123.2,5451,
"Dermabind fm, per sq cm",Q4313,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,5451,APC 378
"Dermabind fm, per sq cm",Q4313,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,5451,APC
"Dermabind fm, per sq cm",Q4313,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,5451,APC
"Dermabind fm, per sq cm",Q4313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,5451,APC
"Dermabind fm, per sq cm",Q4313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,5451,Radiology
"Dermabind fm, per sq cm",Q4313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,5451,APC
"Dermabind fm, per sq cm",Q4313,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,5451,APC
"Sanograft, per sq cm",Q4319,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1185.13,,,,,,,fee schedule,123.2,1185.13,
"Sanograft, per sq cm",Q4319,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1072.61,,,,,,,fee schedule,123.2,1185.13,
"Sanograft, per sq cm",Q4319,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,1185.13,APC 378
"Sanograft, per sq cm",Q4319,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,1185.13,APC
"Sanograft, per sq cm",Q4319,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,1185.13,APC
"Sanograft, per sq cm",Q4319,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,1185.13,APC
"Sanograft, per sq cm",Q4319,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,1185.13,Radiology
"Sanograft, per sq cm",Q4319,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,1185.13,APC
"Sanograft, per sq cm",Q4319,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,1185.13,APC
"Pellograft, per sq cm",Q4320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1422.14,,,,,,,fee schedule,123.2,1422.14,
"Pellograft, per sq cm",Q4320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1287.13,,,,,,,fee schedule,123.2,1422.14,
"Pellograft, per sq cm",Q4320,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,1422.14,APC 378
"Pellograft, per sq cm",Q4320,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,1422.14,APC
"Pellograft, per sq cm",Q4320,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,1422.14,APC
"Pellograft, per sq cm",Q4320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,1422.14,APC
"Pellograft, per sq cm",Q4320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,1422.14,Radiology
"Pellograft, per sq cm",Q4320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,1422.14,APC
"Pellograft, per sq cm",Q4320,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,1422.14,APC
"Caregraft, per sq cm",Q4322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3412.8,,,,,,,fee schedule,123.2,3412.8,
"Caregraft, per sq cm",Q4322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3088.8,,,,,,,fee schedule,123.2,3412.8,
"Caregraft, per sq cm",Q4322,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,3412.8,APC 378
"Caregraft, per sq cm",Q4322,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,3412.8,APC
"Caregraft, per sq cm",Q4322,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,3412.8,APC
"Caregraft, per sq cm",Q4322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,3412.8,APC
"Caregraft, per sq cm",Q4322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,3412.8,Radiology
"Caregraft, per sq cm",Q4322,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,3412.8,APC
"Caregraft, per sq cm",Q4322,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,3412.8,APC
"Alloply, per sq cm",Q4323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2607,,,,,,,fee schedule,123.2,2607,
"Alloply, per sq cm",Q4323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2359.5,,,,,,,fee schedule,123.2,2607,
"Alloply, per sq cm",Q4323,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,2607,APC 378
"Alloply, per sq cm",Q4323,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,2607,APC
"Alloply, per sq cm",Q4323,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,2607,APC
"Alloply, per sq cm",Q4323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,2607,APC
"Alloply, per sq cm",Q4323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,2607,Radiology
"Alloply, per sq cm",Q4323,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,2607,APC
"Alloply, per sq cm",Q4323,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,2607,APC
"Amniotx, per sq cm",Q4324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2607,,,,,,,fee schedule,123.2,2607,
"Amniotx, per sq cm",Q4324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2359.5,,,,,,,fee schedule,123.2,2607,
"Amniotx, per sq cm",Q4324,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,2607,APC 378
"Amniotx, per sq cm",Q4324,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,2607,APC
"Amniotx, per sq cm",Q4324,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,2607,APC
"Amniotx, per sq cm",Q4324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,2607,APC
"Amniotx, per sq cm",Q4324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,2607,Radiology
"Amniotx, per sq cm",Q4324,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,2607,APC
"Amniotx, per sq cm",Q4324,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,2607,APC
"Acapatch, per sq cm",Q4325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3886.8,,,,,,,fee schedule,123.2,3886.8,
"Acapatch, per sq cm",Q4325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3517.8,,,,,,,fee schedule,123.2,3886.8,
"Acapatch, per sq cm",Q4325,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,3886.8,APC 378
"Acapatch, per sq cm",Q4325,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,3886.8,APC
"Acapatch, per sq cm",Q4325,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,3886.8,APC
"Acapatch, per sq cm",Q4325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,3886.8,APC
"Acapatch, per sq cm",Q4325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,3886.8,Radiology
"Acapatch, per sq cm",Q4325,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,3886.8,APC
"Acapatch, per sq cm",Q4325,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,3886.8,APC
"Woundplus, per sq cm",Q4326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2962.5,,,,,,,fee schedule,123.2,2962.5,
"Woundplus, per sq cm",Q4326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2681.25,,,,,,,fee schedule,123.2,2962.5,
"Woundplus, per sq cm",Q4326,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,2962.5,APC 378
"Woundplus, per sq cm",Q4326,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,2962.5,APC
"Woundplus, per sq cm",Q4326,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,2962.5,APC
"Woundplus, per sq cm",Q4326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,2962.5,APC
"Woundplus, per sq cm",Q4326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,2962.5,Radiology
"Woundplus, per sq cm",Q4326,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,2962.5,APC
"Woundplus, per sq cm",Q4326,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,2962.5,APC
"Axolotl graft, per sq cm",Q4331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3209.38,,,,,,,fee schedule,123.2,3209.38,
"Axolotl graft, per sq cm",Q4331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2904.69,,,,,,,fee schedule,123.2,3209.38,
"Axolotl graft, per sq cm",Q4331,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,3209.38,APC 378
"Axolotl graft, per sq cm",Q4331,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,3209.38,APC
"Axolotl graft, per sq cm",Q4331,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,3209.38,APC
"Axolotl graft, per sq cm",Q4331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,3209.38,APC
"Axolotl graft, per sq cm",Q4331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,3209.38,Radiology
"Axolotl graft, per sq cm",Q4331,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,3209.38,APC
"Axolotl graft, per sq cm",Q4331,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,3209.38,APC
"Axolotl dualgraft, per sq cm",Q4332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3209.38,,,,,,,fee schedule,123.2,3209.38,
"Axolotl dualgraft, per sq cm",Q4332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2904.69,,,,,,,fee schedule,123.2,3209.38,
"Axolotl dualgraft, per sq cm",Q4332,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,3209.38,APC 378
"Axolotl dualgraft, per sq cm",Q4332,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,3209.38,APC
"Axolotl dualgraft, per sq cm",Q4332,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,3209.38,APC
"Axolotl dualgraft, per sq cm",Q4332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,3209.38,APC
"Axolotl dualgraft, per sq cm",Q4332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,3209.38,Radiology
"Axolotl dualgraft, per sq cm",Q4332,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,3209.38,APC
"Axolotl dualgraft, per sq cm",Q4332,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,3209.38,APC
"Ardeograft, per sq cm",Q4333,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1422,,,,,,,fee schedule,123.2,1422,
"Ardeograft, per sq cm",Q4333,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1287,,,,,,,fee schedule,123.2,1422,
"Ardeograft, per sq cm",Q4333,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,1422,APC 378
"Ardeograft, per sq cm",Q4333,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,1422,APC
"Ardeograft, per sq cm",Q4333,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,1422,APC
"Ardeograft, per sq cm",Q4333,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,1422,APC
"Ardeograft, per sq cm",Q4333,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,1422,Radiology
"Ardeograft, per sq cm",Q4333,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,1422,APC
"Ardeograft, per sq cm",Q4333,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,1422,APC
"Artacent vericlen, per sq cm",Q4339,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4380.11,,,,,,,fee schedule,123.2,4380.11,
"Artacent vericlen, per sq cm",Q4339,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3964.27,,,,,,,fee schedule,123.2,4380.11,
"Artacent vericlen, per sq cm",Q4339,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,4380.11,APC 378
"Artacent vericlen, per sq cm",Q4339,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,4380.11,APC
"Artacent vericlen, per sq cm",Q4339,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,4380.11,APC
"Artacent vericlen, per sq cm",Q4339,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,4380.11,APC
"Artacent vericlen, per sq cm",Q4339,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,4380.11,Radiology
"Artacent vericlen, per sq cm",Q4339,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,4380.11,APC
"Artacent vericlen, per sq cm",Q4339,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,4380.11,APC
Dermacyte ac matrx per sq cm,Q4343,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4399.86,,,,,,,fee schedule,123.2,4399.86,
Dermacyte ac matrx per sq cm,Q4343,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3982.15,,,,,,,fee schedule,123.2,4399.86,
Dermacyte ac matrx per sq cm,Q4343,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,4399.86,APC 378
Dermacyte ac matrx per sq cm,Q4343,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,4399.86,APC
Dermacyte ac matrx per sq cm,Q4343,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,4399.86,APC
Dermacyte ac matrx per sq cm,Q4343,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,4399.86,APC
Dermacyte ac matrx per sq cm,Q4343,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,4399.86,Radiology
Dermacyte ac matrx per sq cm,Q4343,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,4399.86,APC
Dermacyte ac matrx per sq cm,Q4343,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,4399.86,APC
"Tri membrane wrap, per sq cm",Q4344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4834.8,,,,,,,fee schedule,123.2,4834.8,
"Tri membrane wrap, per sq cm",Q4344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4375.8,,,,,,,fee schedule,123.2,4834.8,
"Tri membrane wrap, per sq cm",Q4344,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,546.58,,,,,,,fee schedule,123.2,4834.8,APC 378
"Tri membrane wrap, per sq cm",Q4344,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.36,,,,,,,fee schedule,123.2,4834.8,APC
"Tri membrane wrap, per sq cm",Q4344,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.12,,,,,,,fee schedule,123.2,4834.8,APC
"Tri membrane wrap, per sq cm",Q4344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.2,,,,,,,fee schedule,123.2,4834.8,APC
"Tri membrane wrap, per sq cm",Q4344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.49,,,,,,,fee schedule,123.2,4834.8,Radiology
"Tri membrane wrap, per sq cm",Q4344,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.47,,,,,,,fee schedule,123.2,4834.8,APC
"Tri membrane wrap, per sq cm",Q4344,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.59,,,,,,,fee schedule,123.2,4834.8,APC
Inj filgrastim gcsf biosimil,Q5101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.38,,,,,,,fee schedule,0.35,3.67,
Inj filgrastim gcsf biosimil,Q5101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.67,,,,,,,fee schedule,0.35,3.67,
Inj filgrastim gcsf biosimil,Q5101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.77,,,,,,,fee schedule,0.35,3.67,
Inj filgrastim gcsf biosimil,Q5101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.94,,,,,,,fee schedule,0.35,3.67,
Inj filgrastim gcsf biosimil,Q5101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.21,,,,,,,fee schedule,0.35,3.67,
Inj filgrastim gcsf biosimil,Q5101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.6,,,,,,,fee schedule,0.35,3.67,
Inj filgrastim gcsf biosimil,Q5101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,0.41,,,,,,,fee schedule,0.35,3.67,OP High Cost Drugs
Inj filgrastim gcsf biosimil,Q5101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,0.35,,,,,,,fee schedule,0.35,3.67,Other Pharmacy
Inj filgrastim gcsf biosimil,Q5101,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,0.37,,,,,,,fee schedule,0.35,3.67,APC
Inj filgrastim gcsf biosimil,Q5101,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,0.37,,,,,,,fee schedule,0.35,3.67,APC
Inj filgrastim gcsf biosimil,Q5101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,0.54,,,,,,,fee schedule,0.35,3.67,Radiology
Inj filgrastim gcsf biosimil,Q5101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,0.5,,,,,,,fee schedule,0.35,3.67,APC
Inj filgrastim gcsf biosimil,Q5101,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,0.62,,,,,,,fee schedule,0.35,3.67,APC
"Injection, inflectra",Q5103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,213.54,,,,,,,fee schedule,26.04,231.95,
"Injection, inflectra",Q5103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,231.95,,,,,,,fee schedule,26.04,231.95,
"Injection, inflectra",Q5103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,179.41,,,,,,,fee schedule,26.04,231.95,
"Injection, inflectra",Q5103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,185.93,,,,,,,fee schedule,26.04,231.95,
"Injection, inflectra",Q5103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,203.11,,,,,,,fee schedule,26.04,231.95,
"Injection, inflectra",Q5103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,162.38,,,,,,,fee schedule,26.04,231.95,
"Injection, inflectra",Q5103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,30.2,,,,,,,fee schedule,26.04,231.95,OP High Cost Drugs
"Injection, inflectra",Q5103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26.04,,,,,,,fee schedule,26.04,231.95,Other Pharmacy
"Injection, inflectra",Q5103,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,27.34,,,,,,,fee schedule,26.04,231.95,APC
"Injection, inflectra",Q5103,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,27.08,,,,,,,fee schedule,26.04,231.95,APC
"Injection, inflectra",Q5103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,39.83,,,,,,,fee schedule,26.04,231.95,Radiology
"Injection, inflectra",Q5103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,36.45,,,,,,,fee schedule,26.04,231.95,APC
"Injection, inflectra",Q5103,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,45.56,,,,,,,fee schedule,26.04,231.95,APC
"Injection, renflexis",Q5104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,224.05,,,,,,,fee schedule,26.8,243.36,
"Injection, renflexis",Q5104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,243.36,,,,,,,fee schedule,26.8,243.36,
"Injection, renflexis",Q5104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,142.85,,,,,,,fee schedule,26.8,243.36,
"Injection, renflexis",Q5104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,195.08,,,,,,,fee schedule,26.8,243.36,
"Injection, renflexis",Q5104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,213.1,,,,,,,fee schedule,26.8,243.36,
"Injection, renflexis",Q5104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,129.29,,,,,,,fee schedule,26.8,243.36,
"Injection, renflexis",Q5104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,31.09,,,,,,,fee schedule,26.8,243.36,OP High Cost Drugs
"Injection, renflexis",Q5104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26.8,,,,,,,fee schedule,26.8,243.36,Other Pharmacy
"Injection, renflexis",Q5104,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,28.14,,,,,,,fee schedule,26.8,243.36,APC
"Injection, renflexis",Q5104,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,27.88,,,,,,,fee schedule,26.8,243.36,APC
"Injection, renflexis",Q5104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,41.01,,,,,,,fee schedule,26.8,243.36,Radiology
"Injection, renflexis",Q5104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,37.52,,,,,,,fee schedule,26.8,243.36,APC
"Injection, renflexis",Q5104,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,46.91,,,,,,,fee schedule,26.8,243.36,APC
Inj Retacrit esrd on dialysi,Q5105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.07,,,,,,,fee schedule,1.89,4.42,
Inj Retacrit esrd on dialysi,Q5105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.42,,,,,,,fee schedule,1.89,4.42,
Inj Retacrit esrd on dialysi,Q5105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.09,,,,,,,fee schedule,1.89,4.42,
Inj Retacrit esrd on dialysi,Q5105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.54,,,,,,,fee schedule,1.89,4.42,
Inj Retacrit esrd on dialysi,Q5105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3.87,,,,,,,fee schedule,1.89,4.42,
Inj Retacrit esrd on dialysi,Q5105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.89,,,,,,,fee schedule,1.89,4.42,
Inj Retacrit non-esrd use,Q5106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,40.69,,,,,,,fee schedule,7.88,44.2,
Inj Retacrit non-esrd use,Q5106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,44.2,,,,,,,fee schedule,7.88,44.2,
Inj Retacrit non-esrd use,Q5106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20.92,,,,,,,fee schedule,7.88,44.2,
Inj Retacrit non-esrd use,Q5106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35.43,,,,,,,fee schedule,7.88,44.2,
Inj Retacrit non-esrd use,Q5106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38.7,,,,,,,fee schedule,7.88,44.2,
Inj Retacrit non-esrd use,Q5106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18.93,,,,,,,fee schedule,7.88,44.2,
Inj Retacrit non-esrd use,Q5106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9.14,,,,,,,fee schedule,7.88,44.2,OP High Cost Drugs
Inj Retacrit non-esrd use,Q5106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.88,,,,,,,fee schedule,7.88,44.2,Other Pharmacy
Inj Retacrit non-esrd use,Q5106,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,8.28,,,,,,,fee schedule,7.88,44.2,APC
Inj Retacrit non-esrd use,Q5106,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,8.2,,,,,,,fee schedule,7.88,44.2,APC
Inj Retacrit non-esrd use,Q5106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12.06,,,,,,,fee schedule,7.88,44.2,Radiology
Inj Retacrit non-esrd use,Q5106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11.04,,,,,,,fee schedule,7.88,44.2,APC
Inj Retacrit non-esrd use,Q5106,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,13.8,,,,,,,fee schedule,7.88,44.2,APC
Inj mvasi 10 mg,Q5107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,242.81,,,,,,,fee schedule,23.74,263.74,
Inj mvasi 10 mg,Q5107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,263.74,,,,,,,fee schedule,23.74,263.74,
Inj mvasi 10 mg,Q5107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,211.41,,,,,,,fee schedule,23.74,263.74,
Inj mvasi 10 mg,Q5107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,230.95,,,,,,,fee schedule,23.74,263.74,
Inj mvasi 10 mg,Q5107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,27.53,,,,,,,fee schedule,23.74,263.74,OP High Cost Drugs
Inj mvasi 10 mg,Q5107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.74,,,,,,,fee schedule,23.74,263.74,Other Pharmacy
Inj mvasi 10 mg,Q5107,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,24.92,,,,,,,fee schedule,23.74,263.74,APC
Inj mvasi 10 mg,Q5107,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,24.68,,,,,,,fee schedule,23.74,263.74,APC
Inj mvasi 10 mg,Q5107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,36.31,,,,,,,fee schedule,23.74,263.74,Radiology
Inj mvasi 10 mg,Q5107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,33.23,,,,,,,fee schedule,23.74,263.74,APC
Inj mvasi 10 mg,Q5107,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,41.54,,,,,,,fee schedule,23.74,263.74,APC
"Injection, fulphila",Q5108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1283.4,,,,,,,fee schedule,79.5,1394.03,
"Injection, fulphila",Q5108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1394.03,,,,,,,fee schedule,79.5,1394.03,
"Injection, fulphila",Q5108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,494.75,,,,,,,fee schedule,79.5,1394.03,
"Injection, fulphila",Q5108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1117.44,,,,,,,fee schedule,79.5,1394.03,
"Injection, fulphila",Q5108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1220.7,,,,,,,fee schedule,79.5,1394.03,
"Injection, fulphila",Q5108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,447.78,,,,,,,fee schedule,79.5,1394.03,
"Injection, fulphila",Q5108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,92.22,,,,,,,fee schedule,79.5,1394.03,OP High Cost Drugs
"Injection, fulphila",Q5108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,79.5,,,,,,,fee schedule,79.5,1394.03,Other Pharmacy
"Injection, fulphila",Q5108,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,83.47,,,,,,,fee schedule,79.5,1394.03,APC
"Injection, fulphila",Q5108,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,82.68,,,,,,,fee schedule,79.5,1394.03,APC
"Injection, fulphila",Q5108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,121.63,,,,,,,fee schedule,79.5,1394.03,Radiology
"Injection, fulphila",Q5108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,111.3,,,,,,,fee schedule,79.5,1394.03,APC
"Injection, fulphila",Q5108,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,139.12,,,,,,,fee schedule,79.5,1394.03,APC
Nivestym,Q5110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.69,,,,,,,fee schedule,0.28,2.93,
Nivestym,Q5110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.93,,,,,,,fee schedule,0.28,2.93,
Nivestym,Q5110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.41,,,,,,,fee schedule,0.28,2.93,
Nivestym,Q5110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.35,,,,,,,fee schedule,0.28,2.93,
Nivestym,Q5110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.56,,,,,,,fee schedule,0.28,2.93,
Nivestym,Q5110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.27,,,,,,,fee schedule,0.28,2.93,
Nivestym,Q5110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,0.33,,,,,,,fee schedule,0.28,2.93,OP High Cost Drugs
Nivestym,Q5110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,0.28,,,,,,,fee schedule,0.28,2.93,Other Pharmacy
Nivestym,Q5110,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,0.3,,,,,,,fee schedule,0.28,2.93,APC
Nivestym,Q5110,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,0.3,,,,,,,fee schedule,0.28,2.93,APC
Nivestym,Q5110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,0.43,,,,,,,fee schedule,0.28,2.93,Radiology
Nivestym,Q5110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,0.4,,,,,,,fee schedule,0.28,2.93,APC
Nivestym,Q5110,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,0.5,,,,,,,fee schedule,0.28,2.93,APC
"Injection, udenyca 0.5 mg",Q5111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1207.75,,,,,,,fee schedule,135.89,1311.87,
"Injection, udenyca 0.5 mg",Q5111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1311.87,,,,,,,fee schedule,135.89,1311.87,
"Injection, udenyca 0.5 mg",Q5111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,659.65,,,,,,,fee schedule,135.89,1311.87,
"Injection, udenyca 0.5 mg",Q5111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1051.58,,,,,,,fee schedule,135.89,1311.87,
"Injection, udenyca 0.5 mg",Q5111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1148.76,,,,,,,fee schedule,135.89,1311.87,
"Injection, udenyca 0.5 mg",Q5111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,597.03,,,,,,,fee schedule,135.89,1311.87,
"Injection, udenyca 0.5 mg",Q5111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,157.63,,,,,,,fee schedule,135.89,1311.87,OP High Cost Drugs
"Injection, udenyca 0.5 mg",Q5111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,135.89,,,,,,,fee schedule,135.89,1311.87,Other Pharmacy
"Injection, udenyca 0.5 mg",Q5111,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,142.68,,,,,,,fee schedule,135.89,1311.87,APC
"Injection, udenyca 0.5 mg",Q5111,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,141.32,,,,,,,fee schedule,135.89,1311.87,APC
"Injection, udenyca 0.5 mg",Q5111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,207.91,,,,,,,fee schedule,135.89,1311.87,Radiology
"Injection, udenyca 0.5 mg",Q5111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,190.24,,,,,,,fee schedule,135.89,1311.87,APC
"Injection, udenyca 0.5 mg",Q5111,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,237.81,,,,,,,fee schedule,135.89,1311.87,APC
Inj ontruzant 10 mg,Q5112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,167.45,,,,,,,fee schedule,29.81,167.45,
Inj ontruzant 10 mg,Q5112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,151.55,,,,,,,fee schedule,29.81,167.45,
Inj ontruzant 10 mg,Q5112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,34.58,,,,,,,fee schedule,29.81,167.45,OP High Cost Drugs
Inj ontruzant 10 mg,Q5112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29.81,,,,,,,fee schedule,29.81,167.45,Other Pharmacy
Inj ontruzant 10 mg,Q5112,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,31.3,,,,,,,fee schedule,29.81,167.45,APC
Inj ontruzant 10 mg,Q5112,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,31,,,,,,,fee schedule,29.81,167.45,APC
Inj ontruzant 10 mg,Q5112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,45.61,,,,,,,fee schedule,29.81,167.45,Radiology
Inj ontruzant 10 mg,Q5112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,41.73,,,,,,,fee schedule,29.81,167.45,APC
Inj ontruzant 10 mg,Q5112,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,52.16,,,,,,,fee schedule,29.81,167.45,APC
Inj herzuma 10 mg,Q5113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,177.29,,,,,,,fee schedule,56.02,177.29,
Inj herzuma 10 mg,Q5113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,160.46,,,,,,,fee schedule,56.02,177.29,
Inj herzuma 10 mg,Q5113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,64.98,,,,,,,fee schedule,56.02,177.29,OP High Cost Drugs
Inj herzuma 10 mg,Q5113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.02,,,,,,,fee schedule,56.02,177.29,Other Pharmacy
Inj herzuma 10 mg,Q5113,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,58.82,,,,,,,fee schedule,56.02,177.29,APC
Inj herzuma 10 mg,Q5113,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,58.26,,,,,,,fee schedule,56.02,177.29,APC
Inj herzuma 10 mg,Q5113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,85.71,,,,,,,fee schedule,56.02,177.29,Radiology
Inj herzuma 10 mg,Q5113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,78.43,,,,,,,fee schedule,56.02,177.29,APC
Inj herzuma 10 mg,Q5113,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,98.03,,,,,,,fee schedule,56.02,177.29,APC
Inj  ogivri 10 mg,Q5114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,113.07,,,,,,,fee schedule,35.78,142.9,
Inj  ogivri 10 mg,Q5114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,122.81,,,,,,,fee schedule,35.78,142.9,
Inj  ogivri 10 mg,Q5114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,142.9,,,,,,,fee schedule,35.78,142.9,
Inj  ogivri 10 mg,Q5114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,98.44,,,,,,,fee schedule,35.78,142.9,
Inj  ogivri 10 mg,Q5114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,107.54,,,,,,,fee schedule,35.78,142.9,
Inj  ogivri 10 mg,Q5114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,129.33,,,,,,,fee schedule,35.78,142.9,
Inj  ogivri 10 mg,Q5114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,41.51,,,,,,,fee schedule,35.78,142.9,OP High Cost Drugs
Inj  ogivri 10 mg,Q5114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,35.78,,,,,,,fee schedule,35.78,142.9,Other Pharmacy
Inj  ogivri 10 mg,Q5114,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,37.57,,,,,,,fee schedule,35.78,142.9,APC
Inj  ogivri 10 mg,Q5114,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,37.21,,,,,,,fee schedule,35.78,142.9,APC
Inj  ogivri 10 mg,Q5114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,54.75,,,,,,,fee schedule,35.78,142.9,Radiology
Inj  ogivri 10 mg,Q5114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,50.1,,,,,,,fee schedule,35.78,142.9,APC
Inj  ogivri 10 mg,Q5114,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,62.62,,,,,,,fee schedule,35.78,142.9,APC
Inj truxima 10 mg,Q5115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,303.07,,,,,,,fee schedule,31.28,329.2,
Inj truxima 10 mg,Q5115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,329.2,,,,,,,fee schedule,31.28,329.2,
Inj truxima 10 mg,Q5115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,160.32,,,,,,,fee schedule,31.28,329.2,
Inj truxima 10 mg,Q5115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,263.88,,,,,,,fee schedule,31.28,329.2,
Inj truxima 10 mg,Q5115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,288.27,,,,,,,fee schedule,31.28,329.2,
Inj truxima 10 mg,Q5115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,145.1,,,,,,,fee schedule,31.28,329.2,
Inj truxima 10 mg,Q5115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36.28,,,,,,,fee schedule,31.28,329.2,OP High Cost Drugs
Inj truxima 10 mg,Q5115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,31.28,,,,,,,fee schedule,31.28,329.2,Other Pharmacy
Inj truxima 10 mg,Q5115,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,32.84,,,,,,,fee schedule,31.28,329.2,APC
Inj truxima 10 mg,Q5115,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,32.53,,,,,,,fee schedule,31.28,329.2,APC
Inj truxima 10 mg,Q5115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,47.86,,,,,,,fee schedule,31.28,329.2,Radiology
Inj truxima 10 mg,Q5115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43.79,,,,,,,fee schedule,31.28,329.2,APC
Inj truxima 10 mg,Q5115,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,54.74,,,,,,,fee schedule,31.28,329.2,APC
"Inj., trazimera, 10 mg",Q5116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,153.09,,,,,,,fee schedule,10.42,153.09,
"Inj., trazimera, 10 mg",Q5116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,138.55,,,,,,,fee schedule,10.42,153.09,
"Inj., trazimera, 10 mg",Q5116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12.09,,,,,,,fee schedule,10.42,153.09,OP High Cost Drugs
"Inj., trazimera, 10 mg",Q5116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10.42,,,,,,,fee schedule,10.42,153.09,Other Pharmacy
"Inj., trazimera, 10 mg",Q5116,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.95,,,,,,,fee schedule,10.42,153.09,APC
"Inj., trazimera, 10 mg",Q5116,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10.84,,,,,,,fee schedule,10.42,153.09,APC
"Inj., trazimera, 10 mg",Q5116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15.95,,,,,,,fee schedule,10.42,153.09,Radiology
"Inj., trazimera, 10 mg",Q5116,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.6,,,,,,,fee schedule,10.42,153.09,APC
"Inj., trazimera, 10 mg",Q5116,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18.24,,,,,,,fee schedule,10.42,153.09,APC
"Inj., kanjinti, 10 mg",Q5117,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,315.54,,,,,,,fee schedule,56.38,342.74,
"Inj., kanjinti, 10 mg",Q5117,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,342.74,,,,,,,fee schedule,56.38,342.74,
"Inj., kanjinti, 10 mg",Q5117,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,171.84,,,,,,,fee schedule,56.38,342.74,
"Inj., kanjinti, 10 mg",Q5117,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,274.73,,,,,,,fee schedule,56.38,342.74,
"Inj., kanjinti, 10 mg",Q5117,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,300.12,,,,,,,fee schedule,56.38,342.74,
"Inj., kanjinti, 10 mg",Q5117,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,155.53,,,,,,,fee schedule,56.38,342.74,
"Inj., kanjinti, 10 mg",Q5117,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,65.4,,,,,,,fee schedule,56.38,342.74,OP High Cost Drugs
"Inj., kanjinti, 10 mg",Q5117,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56.38,,,,,,,fee schedule,56.38,342.74,Other Pharmacy
"Inj., kanjinti, 10 mg",Q5117,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,59.2,,,,,,,fee schedule,56.38,342.74,APC
"Inj., kanjinti, 10 mg",Q5117,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,58.63,,,,,,,fee schedule,56.38,342.74,APC
"Inj., kanjinti, 10 mg",Q5117,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,86.26,,,,,,,fee schedule,56.38,342.74,Radiology
"Inj., kanjinti, 10 mg",Q5117,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,78.93,,,,,,,fee schedule,56.38,342.74,APC
"Inj., kanjinti, 10 mg",Q5117,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,98.66,,,,,,,fee schedule,56.38,342.74,APC
"Inj., zirabev, 10 mg",Q5118,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,98.01,,,,,,,fee schedule,25.85,98.01,
"Inj., zirabev, 10 mg",Q5118,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,88.7,,,,,,,fee schedule,25.85,98.01,
"Inj., zirabev, 10 mg",Q5118,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,29.99,,,,,,,fee schedule,25.85,98.01,OP High Cost Drugs
"Inj., zirabev, 10 mg",Q5118,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.85,,,,,,,fee schedule,25.85,98.01,Other Pharmacy
"Inj., zirabev, 10 mg",Q5118,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,27.15,,,,,,,fee schedule,25.85,98.01,APC
"Inj., zirabev, 10 mg",Q5118,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,26.89,,,,,,,fee schedule,25.85,98.01,APC
"Inj., zirabev, 10 mg",Q5118,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,39.56,,,,,,,fee schedule,25.85,98.01,Radiology
"Inj., zirabev, 10 mg",Q5118,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,36.2,,,,,,,fee schedule,25.85,98.01,APC
"Inj., zirabev, 10 mg",Q5118,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,45.24,,,,,,,fee schedule,25.85,98.01,APC
"Inj ruxience, 10 mg",Q5119,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,234.28,,,,,,,fee schedule,13.69,254.48,
"Inj ruxience, 10 mg",Q5119,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,254.48,,,,,,,fee schedule,13.69,254.48,
"Inj ruxience, 10 mg",Q5119,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,135.91,,,,,,,fee schedule,13.69,254.48,
"Inj ruxience, 10 mg",Q5119,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,203.99,,,,,,,fee schedule,13.69,254.48,
"Inj ruxience, 10 mg",Q5119,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,222.84,,,,,,,fee schedule,13.69,254.48,
"Inj ruxience, 10 mg",Q5119,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,123.01,,,,,,,fee schedule,13.69,254.48,
"Inj ruxience, 10 mg",Q5119,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,15.88,,,,,,,fee schedule,13.69,254.48,OP High Cost Drugs
"Inj ruxience, 10 mg",Q5119,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13.69,,,,,,,fee schedule,13.69,254.48,Other Pharmacy
"Inj ruxience, 10 mg",Q5119,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,14.37,,,,,,,fee schedule,13.69,254.48,APC
"Inj ruxience, 10 mg",Q5119,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,14.23,,,,,,,fee schedule,13.69,254.48,APC
"Inj ruxience, 10 mg",Q5119,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.94,,,,,,,fee schedule,13.69,254.48,Radiology
"Inj ruxience, 10 mg",Q5119,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19.16,,,,,,,fee schedule,13.69,254.48,APC
"Inj ruxience, 10 mg",Q5119,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23.95,,,,,,,fee schedule,13.69,254.48,APC
Inj pegfilgrastim-bmez 0.5mg,Q5120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1036.91,,,,,,,fee schedule,119.64,1126.3,
Inj pegfilgrastim-bmez 0.5mg,Q5120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1126.3,,,,,,,fee schedule,119.64,1126.3,
Inj pegfilgrastim-bmez 0.5mg,Q5120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,620.23,,,,,,,fee schedule,119.64,1126.3,
Inj pegfilgrastim-bmez 0.5mg,Q5120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,902.82,,,,,,,fee schedule,119.64,1126.3,
Inj pegfilgrastim-bmez 0.5mg,Q5120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,986.25,,,,,,,fee schedule,119.64,1126.3,
Inj pegfilgrastim-bmez 0.5mg,Q5120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,561.35,,,,,,,fee schedule,119.64,1126.3,
Inj pegfilgrastim-bmez 0.5mg,Q5120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,138.78,,,,,,,fee schedule,119.64,1126.3,OP High Cost Drugs
Inj pegfilgrastim-bmez 0.5mg,Q5120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,119.64,,,,,,,fee schedule,119.64,1126.3,Other Pharmacy
Inj pegfilgrastim-bmez 0.5mg,Q5120,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,125.62,,,,,,,fee schedule,119.64,1126.3,APC
Inj pegfilgrastim-bmez 0.5mg,Q5120,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,124.42,,,,,,,fee schedule,119.64,1126.3,APC
Inj pegfilgrastim-bmez 0.5mg,Q5120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,183.04,,,,,,,fee schedule,119.64,1126.3,Radiology
Inj pegfilgrastim-bmez 0.5mg,Q5120,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,167.49,,,,,,,fee schedule,119.64,1126.3,APC
Inj pegfilgrastim-bmez 0.5mg,Q5120,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,209.36,,,,,,,fee schedule,119.64,1126.3,APC
"Inj. avsola, 10 mg",Q5121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,179.22,,,,,,,fee schedule,28.04,194.67,
"Inj. avsola, 10 mg",Q5121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,194.67,,,,,,,fee schedule,28.04,194.67,
"Inj. avsola, 10 mg",Q5121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,94.8,,,,,,,fee schedule,28.04,194.67,
"Inj. avsola, 10 mg",Q5121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,156.05,,,,,,,fee schedule,28.04,194.67,
"Inj. avsola, 10 mg",Q5121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,170.47,,,,,,,fee schedule,28.04,194.67,
"Inj. avsola, 10 mg",Q5121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,85.8,,,,,,,fee schedule,28.04,194.67,
"Inj. avsola, 10 mg",Q5121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,32.53,,,,,,,fee schedule,28.04,194.67,OP High Cost Drugs
"Inj. avsola, 10 mg",Q5121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.04,,,,,,,fee schedule,28.04,194.67,Other Pharmacy
"Inj. avsola, 10 mg",Q5121,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,29.44,,,,,,,fee schedule,28.04,194.67,APC
"Inj. avsola, 10 mg",Q5121,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,29.16,,,,,,,fee schedule,28.04,194.67,APC
"Inj. avsola, 10 mg",Q5121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,42.9,,,,,,,fee schedule,28.04,194.67,Radiology
"Inj. avsola, 10 mg",Q5121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,39.26,,,,,,,fee schedule,28.04,194.67,APC
"Inj. avsola, 10 mg",Q5121,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,49.07,,,,,,,fee schedule,28.04,194.67,APC
"Inj, nyvepria",Q5122,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,936.61,,,,,,,fee schedule,133.31,1017.35,
"Inj, nyvepria",Q5122,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1017.35,,,,,,,fee schedule,133.31,1017.35,
"Inj, nyvepria",Q5122,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,620.15,,,,,,,fee schedule,133.31,1017.35,
"Inj, nyvepria",Q5122,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,815.5,,,,,,,fee schedule,133.31,1017.35,
"Inj, nyvepria",Q5122,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,890.86,,,,,,,fee schedule,133.31,1017.35,
"Inj, nyvepria",Q5122,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,561.28,,,,,,,fee schedule,133.31,1017.35,
"Inj, nyvepria",Q5122,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,154.64,,,,,,,fee schedule,133.31,1017.35,OP High Cost Drugs
"Inj, nyvepria",Q5122,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,133.31,,,,,,,fee schedule,133.31,1017.35,Other Pharmacy
"Inj, nyvepria",Q5122,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,139.98,,,,,,,fee schedule,133.31,1017.35,APC
"Inj, nyvepria",Q5122,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,138.64,,,,,,,fee schedule,133.31,1017.35,APC
"Inj, nyvepria",Q5122,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,203.97,,,,,,,fee schedule,133.31,1017.35,Radiology
"Inj, nyvepria",Q5122,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,186.64,,,,,,,fee schedule,133.31,1017.35,APC
"Inj, nyvepria",Q5122,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,233.29,,,,,,,fee schedule,133.31,1017.35,APC
"Inj. riabni, 10 mg",Q5123,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,223.86,,,,,,,fee schedule,20.26,243.16,
"Inj. riabni, 10 mg",Q5123,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,243.16,,,,,,,fee schedule,20.26,243.16,
"Inj. riabni, 10 mg",Q5123,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,135.91,,,,,,,fee schedule,20.26,243.16,
"Inj. riabni, 10 mg",Q5123,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,194.92,,,,,,,fee schedule,20.26,243.16,
"Inj. riabni, 10 mg",Q5123,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,212.93,,,,,,,fee schedule,20.26,243.16,
"Inj. riabni, 10 mg",Q5123,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,123.01,,,,,,,fee schedule,20.26,243.16,
"Inj. riabni, 10 mg",Q5123,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,23.5,,,,,,,fee schedule,20.26,243.16,OP High Cost Drugs
"Inj. riabni, 10 mg",Q5123,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20.26,,,,,,,fee schedule,20.26,243.16,Other Pharmacy
"Inj. riabni, 10 mg",Q5123,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,21.27,,,,,,,fee schedule,20.26,243.16,APC
"Inj. riabni, 10 mg",Q5123,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,21.07,,,,,,,fee schedule,20.26,243.16,APC
"Inj. riabni, 10 mg",Q5123,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,30.99,,,,,,,fee schedule,20.26,243.16,Radiology
"Inj. riabni, 10 mg",Q5123,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28.36,,,,,,,fee schedule,20.26,243.16,APC
"Inj. riabni, 10 mg",Q5123,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,35.45,,,,,,,fee schedule,20.26,243.16,APC
"Inj. byooviz, 0.1 mg",Q5124,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,821.11,,,,,,,fee schedule,70.9,891.89,
"Inj. byooviz, 0.1 mg",Q5124,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,891.89,,,,,,,fee schedule,70.9,891.89,
"Inj. byooviz, 0.1 mg",Q5124,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,441.36,,,,,,,fee schedule,70.9,891.89,
"Inj. byooviz, 0.1 mg",Q5124,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,714.93,,,,,,,fee schedule,70.9,891.89,
"Inj. byooviz, 0.1 mg",Q5124,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,780.99,,,,,,,fee schedule,70.9,891.89,
"Inj. byooviz, 0.1 mg",Q5124,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,399.46,,,,,,,fee schedule,70.9,891.89,
"Inj. byooviz, 0.1 mg",Q5124,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,82.25,,,,,,,fee schedule,70.9,891.89,OP High Cost Drugs
"Inj. byooviz, 0.1 mg",Q5124,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,70.9,,,,,,,fee schedule,70.9,891.89,Other Pharmacy
"Inj. byooviz, 0.1 mg",Q5124,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,74.45,,,,,,,fee schedule,70.9,891.89,APC
"Inj. byooviz, 0.1 mg",Q5124,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,73.74,,,,,,,fee schedule,70.9,891.89,APC
"Inj. byooviz, 0.1 mg",Q5124,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,108.48,,,,,,,fee schedule,70.9,891.89,Radiology
"Inj. byooviz, 0.1 mg",Q5124,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,99.27,,,,,,,fee schedule,70.9,891.89,APC
"Inj. byooviz, 0.1 mg",Q5124,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,124.08,,,,,,,fee schedule,70.9,891.89,APC
"Inj, releuko 1 mcg",Q5125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.82,,,,,,,fee schedule,0.32,3.06,
"Inj, releuko 1 mcg",Q5125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.06,,,,,,,fee schedule,0.32,3.06,
"Inj, releuko 1 mcg",Q5125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.03,,,,,,,fee schedule,0.32,3.06,
"Inj, releuko 1 mcg",Q5125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.45,,,,,,,fee schedule,0.32,3.06,
"Inj, releuko 1 mcg",Q5125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.68,,,,,,,fee schedule,0.32,3.06,
"Inj, releuko 1 mcg",Q5125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.93,,,,,,,fee schedule,0.32,3.06,
"Inj, releuko 1 mcg",Q5125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,0.37,,,,,,,fee schedule,0.32,3.06,OP High Cost Drugs
"Inj, releuko 1 mcg",Q5125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,0.32,,,,,,,fee schedule,0.32,3.06,Other Pharmacy
"Inj, releuko 1 mcg",Q5125,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,0.34,,,,,,,fee schedule,0.32,3.06,APC
"Inj, releuko 1 mcg",Q5125,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,0.33,,,,,,,fee schedule,0.32,3.06,APC
"Inj, releuko 1 mcg",Q5125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,0.49,,,,,,,fee schedule,0.32,3.06,Radiology
"Inj, releuko 1 mcg",Q5125,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,0.45,,,,,,,fee schedule,0.32,3.06,APC
"Inj, releuko 1 mcg",Q5125,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,0.56,,,,,,,fee schedule,0.32,3.06,APC
Inj alymsys 10 mg,Q5126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,265.08,,,,,,,fee schedule,51.59,287.93,
Inj alymsys 10 mg,Q5126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,287.93,,,,,,,fee schedule,51.59,287.93,
Inj alymsys 10 mg,Q5126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,136.24,,,,,,,fee schedule,51.59,287.93,
Inj alymsys 10 mg,Q5126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,230.8,,,,,,,fee schedule,51.59,287.93,
Inj alymsys 10 mg,Q5126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,252.13,,,,,,,fee schedule,51.59,287.93,
Inj alymsys 10 mg,Q5126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,123.31,,,,,,,fee schedule,51.59,287.93,
Inj alymsys 10 mg,Q5126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,59.84,,,,,,,fee schedule,51.59,287.93,OP High Cost Drugs
Inj alymsys 10 mg,Q5126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51.59,,,,,,,fee schedule,51.59,287.93,Other Pharmacy
Inj alymsys 10 mg,Q5126,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.17,,,,,,,fee schedule,51.59,287.93,APC
Inj alymsys 10 mg,Q5126,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,53.65,,,,,,,fee schedule,51.59,287.93,APC
Inj alymsys 10 mg,Q5126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,78.93,,,,,,,fee schedule,51.59,287.93,Radiology
Inj alymsys 10 mg,Q5126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,72.22,,,,,,,fee schedule,51.59,287.93,APC
Inj alymsys 10 mg,Q5126,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,90.28,,,,,,,fee schedule,51.59,287.93,APC
"Inj, stimufend, 0.5 mg",Q5127,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1215.01,,,,,,,fee schedule,158.26,1319.75,
"Inj, stimufend, 0.5 mg",Q5127,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1319.75,,,,,,,fee schedule,158.26,1319.75,
"Inj, stimufend, 0.5 mg",Q5127,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,679.43,,,,,,,fee schedule,158.26,1319.75,
"Inj, stimufend, 0.5 mg",Q5127,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1057.89,,,,,,,fee schedule,158.26,1319.75,
"Inj, stimufend, 0.5 mg",Q5127,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1155.65,,,,,,,fee schedule,158.26,1319.75,
"Inj, stimufend, 0.5 mg",Q5127,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,614.93,,,,,,,fee schedule,158.26,1319.75,
"Inj, stimufend, 0.5 mg",Q5127,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,183.58,,,,,,,fee schedule,158.26,1319.75,OP High Cost Drugs
"Inj, stimufend, 0.5 mg",Q5127,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,158.26,,,,,,,fee schedule,158.26,1319.75,Other Pharmacy
"Inj, stimufend, 0.5 mg",Q5127,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,166.17,,,,,,,fee schedule,158.26,1319.75,APC
"Inj, stimufend, 0.5 mg",Q5127,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,164.59,,,,,,,fee schedule,158.26,1319.75,APC
"Inj, stimufend, 0.5 mg",Q5127,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,242.13,,,,,,,fee schedule,158.26,1319.75,Radiology
"Inj, stimufend, 0.5 mg",Q5127,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,221.56,,,,,,,fee schedule,158.26,1319.75,APC
"Inj, stimufend, 0.5 mg",Q5127,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,276.95,,,,,,,fee schedule,158.26,1319.75,APC
"Inj, cimerli, 0.1 mg",Q5128,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,950.96,,,,,,,fee schedule,83.48,1032.94,
"Inj, cimerli, 0.1 mg",Q5128,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1032.94,,,,,,,fee schedule,83.48,1032.94,
"Inj, cimerli, 0.1 mg",Q5128,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,516.23,,,,,,,fee schedule,83.48,1032.94,
"Inj, cimerli, 0.1 mg",Q5128,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,827.99,,,,,,,fee schedule,83.48,1032.94,
"Inj, cimerli, 0.1 mg",Q5128,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,904.5,,,,,,,fee schedule,83.48,1032.94,
"Inj, cimerli, 0.1 mg",Q5128,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,467.22,,,,,,,fee schedule,83.48,1032.94,
"Inj, cimerli, 0.1 mg",Q5128,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,96.83,,,,,,,fee schedule,83.48,1032.94,OP High Cost Drugs
"Inj, cimerli, 0.1 mg",Q5128,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,83.48,,,,,,,fee schedule,83.48,1032.94,Other Pharmacy
"Inj, cimerli, 0.1 mg",Q5128,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,87.65,,,,,,,fee schedule,83.48,1032.94,APC
"Inj, cimerli, 0.1 mg",Q5128,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,86.82,,,,,,,fee schedule,83.48,1032.94,APC
"Inj, cimerli, 0.1 mg",Q5128,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,127.72,,,,,,,fee schedule,83.48,1032.94,Radiology
"Inj, cimerli, 0.1 mg",Q5128,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,116.87,,,,,,,fee schedule,83.48,1032.94,APC
"Inj, cimerli, 0.1 mg",Q5128,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,146.08,,,,,,,fee schedule,83.48,1032.94,APC
"Inj, vegzelma, 10 mg",Q5129,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,242.81,,,,,,,fee schedule,34.65,263.74,
"Inj, vegzelma, 10 mg",Q5129,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,263.74,,,,,,,fee schedule,34.65,263.74,
"Inj, vegzelma, 10 mg",Q5129,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,128.44,,,,,,,fee schedule,34.65,263.74,
"Inj, vegzelma, 10 mg",Q5129,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,211.41,,,,,,,fee schedule,34.65,263.74,
"Inj, vegzelma, 10 mg",Q5129,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,230.95,,,,,,,fee schedule,34.65,263.74,
"Inj, vegzelma, 10 mg",Q5129,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,116.24,,,,,,,fee schedule,34.65,263.74,
"Inj, vegzelma, 10 mg",Q5129,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,40.2,,,,,,,fee schedule,34.65,263.74,OP High Cost Drugs
"Inj, vegzelma, 10 mg",Q5129,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,34.65,,,,,,,fee schedule,34.65,263.74,Other Pharmacy
"Inj, vegzelma, 10 mg",Q5129,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.39,,,,,,,fee schedule,34.65,263.74,APC
"Inj, vegzelma, 10 mg",Q5129,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,36.04,,,,,,,fee schedule,34.65,263.74,APC
"Inj, vegzelma, 10 mg",Q5129,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,53.02,,,,,,,fee schedule,34.65,263.74,Radiology
"Inj, vegzelma, 10 mg",Q5129,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,48.52,,,,,,,fee schedule,34.65,263.74,APC
"Inj, vegzelma, 10 mg",Q5129,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,60.64,,,,,,,fee schedule,34.65,263.74,APC
"Inj, fylnetra, 0.5 mg",Q5130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,726.61,,,,,,,fee schedule,112.13,789.25,
"Inj, fylnetra, 0.5 mg",Q5130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,789.25,,,,,,,fee schedule,112.13,789.25,
"Inj, fylnetra, 0.5 mg",Q5130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,395,,,,,,,fee schedule,112.13,789.25,
"Inj, fylnetra, 0.5 mg",Q5130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,632.65,,,,,,,fee schedule,112.13,789.25,
"Inj, fylnetra, 0.5 mg",Q5130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,691.11,,,,,,,fee schedule,112.13,789.25,
"Inj, fylnetra, 0.5 mg",Q5130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,357.5,,,,,,,fee schedule,112.13,789.25,
"Inj, fylnetra, 0.5 mg",Q5130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,130.07,,,,,,,fee schedule,112.13,789.25,OP High Cost Drugs
"Inj, fylnetra, 0.5 mg",Q5130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,112.13,,,,,,,fee schedule,112.13,789.25,Other Pharmacy
"Inj, fylnetra, 0.5 mg",Q5130,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,117.74,,,,,,,fee schedule,112.13,789.25,APC
"Inj, fylnetra, 0.5 mg",Q5130,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,116.62,,,,,,,fee schedule,112.13,789.25,APC
"Inj, fylnetra, 0.5 mg",Q5130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,171.56,,,,,,,fee schedule,112.13,789.25,Radiology
"Inj, fylnetra, 0.5 mg",Q5130,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,156.99,,,,,,,fee schedule,112.13,789.25,APC
"Inj, fylnetra, 0.5 mg",Q5130,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,196.23,,,,,,,fee schedule,112.13,789.25,APC
"Inj, abrilada, 10 mg",Q5132,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1246.9,,,,,,,fee schedule,1128.53,1246.9,
"Inj, abrilada, 10 mg",Q5132,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1128.53,,,,,,,fee schedule,1128.53,1246.9,
"Inj, tofidence, 1 mg",Q5133,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10.52,,,,,,,fee schedule,5.26,10.52,
"Inj, tofidence, 1 mg",Q5133,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9.52,,,,,,,fee schedule,5.26,10.52,
"Inj, tofidence, 1 mg",Q5133,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6.1,,,,,,,fee schedule,5.26,10.52,OP High Cost Drugs
"Inj, tofidence, 1 mg",Q5133,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5.26,,,,,,,fee schedule,5.26,10.52,Other Pharmacy
"Inj, tofidence, 1 mg",Q5133,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,5.52,,,,,,,fee schedule,5.26,10.52,APC
"Inj, tofidence, 1 mg",Q5133,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,5.47,,,,,,,fee schedule,5.26,10.52,APC
"Inj, tofidence, 1 mg",Q5133,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8.05,,,,,,,fee schedule,5.26,10.52,Radiology
"Inj, tofidence, 1 mg",Q5133,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7.36,,,,,,,fee schedule,5.26,10.52,APC
"Inj, tofidence, 1 mg",Q5133,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9.2,,,,,,,fee schedule,5.26,10.52,APC
"Inj, tyenne, 1 mg",Q5135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.29,,,,,,,fee schedule,4.44,9.29,
"Inj, tyenne, 1 mg",Q5135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.41,,,,,,,fee schedule,4.44,9.29,
"Inj, tyenne, 1 mg",Q5135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5.15,,,,,,,fee schedule,4.44,9.29,OP High Cost Drugs
"Inj, tyenne, 1 mg",Q5135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4.44,,,,,,,fee schedule,4.44,9.29,Other Pharmacy
"Inj, tyenne, 1 mg",Q5135,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,4.66,,,,,,,fee schedule,4.44,9.29,APC
"Inj, tyenne, 1 mg",Q5135,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,4.61,,,,,,,fee schedule,4.44,9.29,APC
"Inj, tyenne, 1 mg",Q5135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.79,,,,,,,fee schedule,4.44,9.29,Radiology
"Inj, tyenne, 1 mg",Q5135,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6.21,,,,,,,fee schedule,4.44,9.29,APC
"Inj, tyenne, 1 mg",Q5135,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7.76,,,,,,,fee schedule,4.44,9.29,APC
Inj sulf hexa lipid microsph,Q9950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,115.05,,,,,,,fee schedule,49.81,124.97,
Inj sulf hexa lipid microsph,Q9950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,124.97,,,,,,,fee schedule,49.81,124.97,
Inj sulf hexa lipid microsph,Q9950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55.03,,,,,,,fee schedule,49.81,124.97,
Inj sulf hexa lipid microsph,Q9950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,100.17,,,,,,,fee schedule,49.81,124.97,
Inj sulf hexa lipid microsph,Q9950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,109.43,,,,,,,fee schedule,49.81,124.97,
Inj sulf hexa lipid microsph,Q9950,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,49.81,,,,,,,fee schedule,49.81,124.97,
"Inj perflutren lip micros,ml",Q9957,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,311.31,,,,,,,fee schedule,281.75,311.31,
"Inj perflutren lip micros,ml",Q9957,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,281.75,,,,,,,fee schedule,281.75,311.31,
"LOCM 200-299mg/ml iodine,1ml",Q9966,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.39,,,,,,,fee schedule,1.26,1.39,
"LOCM 200-299mg/ml iodine,1ml",Q9966,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.26,,,,,,,fee schedule,1.26,1.39,
"LOCM 300-399mg/ml iodine,1ml",Q9967,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.82,,,,,,,fee schedule,1.64,1.82,
"LOCM 300-399mg/ml iodine,1ml",Q9967,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.64,,,,,,,fee schedule,1.64,1.82,
Visualization adjunct,Q9968,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.98,,,,,,,fee schedule,4.33,45.64,
Visualization adjunct,Q9968,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5.41,,,,,,,fee schedule,4.33,45.64,
Visualization adjunct,Q9968,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.33,,,,,,,fee schedule,4.33,45.64,
Visualization adjunct,Q9968,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.73,,,,,,,fee schedule,4.33,45.64,
Visualization adjunct,Q9968,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,45.64,,,,,,,fee schedule,4.33,45.64,APC 378
Visualization adjunct,Q9968,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,10.8,,,,,,,fee schedule,4.33,45.64,APC
Visualization adjunct,Q9968,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,10.7,,,,,,,fee schedule,4.33,45.64,APC
Visualization adjunct,Q9968,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10.29,,,,,,,fee schedule,4.33,45.64,APC
Visualization adjunct,Q9968,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15.74,,,,,,,fee schedule,4.33,45.64,Radiology
Visualization adjunct,Q9968,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14.4,,,,,,,fee schedule,4.33,45.64,APC
Visualization adjunct,Q9968,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18,,,,,,,fee schedule,4.33,45.64,APC
Non-HEU TC-99M add-on/dose,Q9969,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,34.8,,,,,,,fee schedule,30.3,37.8,
Non-HEU TC-99M add-on/dose,Q9969,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37.8,,,,,,,fee schedule,30.3,37.8,
Non-HEU TC-99M add-on/dose,Q9969,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,30.3,,,,,,,fee schedule,30.3,37.8,
Non-HEU TC-99M add-on/dose,Q9969,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,33.1,,,,,,,fee schedule,30.3,37.8,
flutemetamol f18 diagnostic,Q9982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12173.04,,,,,,,fee schedule,1944.01,13222.44,
flutemetamol f18 diagnostic,Q9982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13222.44,,,,,,,fee schedule,1944.01,13222.44,
flutemetamol f18 diagnostic,Q9982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6067.2,,,,,,,fee schedule,1944.01,13222.44,
flutemetamol f18 diagnostic,Q9982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10598.94,,,,,,,fee schedule,1944.01,13222.44,
flutemetamol f18 diagnostic,Q9982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11578.38,,,,,,,fee schedule,1944.01,13222.44,
flutemetamol f18 diagnostic,Q9982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5491.2,,,,,,,fee schedule,1944.01,13222.44,
flutemetamol f18 diagnostic,Q9982,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,8624.91,,,,,,,fee schedule,1944.01,13222.44,APC 378
flutemetamol f18 diagnostic,Q9982,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2041.21,,,,,,,fee schedule,1944.01,13222.44,APC
flutemetamol f18 diagnostic,Q9982,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2021.77,,,,,,,fee schedule,1944.01,13222.44,APC
flutemetamol f18 diagnostic,Q9982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1944.01,,,,,,,fee schedule,1944.01,13222.44,APC
flutemetamol f18 diagnostic,Q9982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2974.34,,,,,,,fee schedule,1944.01,13222.44,Radiology
flutemetamol f18 diagnostic,Q9982,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2721.61,,,,,,,fee schedule,1944.01,13222.44,APC
flutemetamol f18 diagnostic,Q9982,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3402.02,,,,,,,fee schedule,1944.01,13222.44,APC
florbetaben f18 diagnostic,Q9983,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10328.64,,,,,,,fee schedule,1584.67,11219.04,
florbetaben f18 diagnostic,Q9983,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11219.04,,,,,,,fee schedule,1584.67,11219.04,
florbetaben f18 diagnostic,Q9983,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6446.4,,,,,,,fee schedule,1584.67,11219.04,
florbetaben f18 diagnostic,Q9983,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8993.04,,,,,,,fee schedule,1584.67,11219.04,
florbetaben f18 diagnostic,Q9983,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9824.08,,,,,,,fee schedule,1584.67,11219.04,
florbetaben f18 diagnostic,Q9983,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5834.4,,,,,,,fee schedule,1584.67,11219.04,
florbetaben f18 diagnostic,Q9983,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,7030.64,,,,,,,fee schedule,1584.67,11219.04,APC 378
florbetaben f18 diagnostic,Q9983,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1663.9,,,,,,,fee schedule,1584.67,11219.04,APC
florbetaben f18 diagnostic,Q9983,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1648.06,,,,,,,fee schedule,1584.67,11219.04,APC
florbetaben f18 diagnostic,Q9983,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1584.67,,,,,,,fee schedule,1584.67,11219.04,APC
florbetaben f18 diagnostic,Q9983,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2424.55,,,,,,,fee schedule,1584.67,11219.04,Radiology
florbetaben f18 diagnostic,Q9983,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2218.54,,,,,,,fee schedule,1584.67,11219.04,APC
florbetaben f18 diagnostic,Q9983,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2773.17,,,,,,,fee schedule,1584.67,11219.04,APC
Buprenorph xr 100 mg or less,Q9991,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5828.3,,,,,,,fee schedule,1996.56,6330.74,
Buprenorph xr 100 mg or less,Q9991,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6330.74,,,,,,,fee schedule,1996.56,6330.74,
Buprenorph xr 100 mg or less,Q9991,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3823.32,,,,,,,fee schedule,1996.56,6330.74,
Buprenorph xr 100 mg or less,Q9991,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5074.64,,,,,,,fee schedule,1996.56,6330.74,
Buprenorph xr 100 mg or less,Q9991,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5543.59,,,,,,,fee schedule,1996.56,6330.74,
Buprenorph xr 100 mg or less,Q9991,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3460.34,,,,,,,fee schedule,1996.56,6330.74,
Buprenorph xr 100 mg or less,Q9991,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2316.01,,,,,,,fee schedule,1996.56,6330.74,OP High Cost Drugs
Buprenorph xr 100 mg or less,Q9991,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1996.56,,,,,,,fee schedule,1996.56,6330.74,Other Pharmacy
Buprenorph xr 100 mg or less,Q9991,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2096.38,,,,,,,fee schedule,1996.56,6330.74,APC
Buprenorph xr 100 mg or less,Q9991,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2076.42,,,,,,,fee schedule,1996.56,6330.74,APC
Buprenorph xr 100 mg or less,Q9991,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3054.73,,,,,,,fee schedule,1996.56,6330.74,Radiology
Buprenorph xr 100 mg or less,Q9991,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2795.18,,,,,,,fee schedule,1996.56,6330.74,APC
Buprenorph xr 100 mg or less,Q9991,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3493.97,,,,,,,fee schedule,1996.56,6330.74,APC
Buprenorphine xr over 100 mg,Q9992,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5828.3,,,,,,,fee schedule,1996.56,6330.74,
Buprenorphine xr over 100 mg,Q9992,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6330.74,,,,,,,fee schedule,1996.56,6330.74,
Buprenorphine xr over 100 mg,Q9992,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3823.32,,,,,,,fee schedule,1996.56,6330.74,
Buprenorphine xr over 100 mg,Q9992,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5074.64,,,,,,,fee schedule,1996.56,6330.74,
Buprenorphine xr over 100 mg,Q9992,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5543.59,,,,,,,fee schedule,1996.56,6330.74,
Buprenorphine xr over 100 mg,Q9992,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3460.34,,,,,,,fee schedule,1996.56,6330.74,
Buprenorphine xr over 100 mg,Q9992,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,2316.01,,,,,,,fee schedule,1996.56,6330.74,OP High Cost Drugs
Buprenorphine xr over 100 mg,Q9992,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1996.56,,,,,,,fee schedule,1996.56,6330.74,Other Pharmacy
Buprenorphine xr over 100 mg,Q9992,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,2096.38,,,,,,,fee schedule,1996.56,6330.74,APC
Buprenorphine xr over 100 mg,Q9992,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,2076.42,,,,,,,fee schedule,1996.56,6330.74,APC
Buprenorphine xr over 100 mg,Q9992,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,3054.73,,,,,,,fee schedule,1996.56,6330.74,Radiology
Buprenorphine xr over 100 mg,Q9992,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2795.18,,,,,,,fee schedule,1996.56,6330.74,APC
Buprenorphine xr over 100 mg,Q9992,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3493.97,,,,,,,fee schedule,1996.56,6330.74,APC
Transport portable x-ray,R0070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,834.78,,,,,,,fee schedule,726.84,906.75,
Transport portable x-ray,R0070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,906.75,,,,,,,fee schedule,726.84,906.75,
Transport portable x-ray,R0070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,726.84,,,,,,,fee schedule,726.84,906.75,
Transport portable x-ray,R0070,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,794,,,,,,,fee schedule,726.84,906.75,
Transport port x-ray multipl,R0075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,834.78,,,,,,,fee schedule,726.84,906.75,
Transport port x-ray multipl,R0075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,906.75,,,,,,,fee schedule,726.84,906.75,
Transport port x-ray multipl,R0075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,726.84,,,,,,,fee schedule,726.84,906.75,
Transport port x-ray multipl,R0075,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,794,,,,,,,fee schedule,726.84,906.75,
Transport portable EKG,R0076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,82.65,,,,,,,fee schedule,71.96,89.78,
Transport portable EKG,R0076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,89.78,,,,,,,fee schedule,71.96,89.78,
Transport portable EKG,R0076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,71.96,,,,,,,fee schedule,71.96,89.78,
Transport portable EKG,R0076,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,78.61,,,,,,,fee schedule,71.96,89.78,
Description Not Available,S0013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26.15,,,,,,,fee schedule,23.67,26.15,
Description Not Available,S0013,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23.67,,,,,,,fee schedule,23.67,26.15,
"Injection, aminocaproic acid, 5mg",S0017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17.46,,,,,,,fee schedule,15.8,17.46,
"Injection, aminocaproic acid, 5mg",S0017,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15.8,,,,,,,fee schedule,15.8,17.46,
"Injection, cimetidine HCl, 300 mg",S0023,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.13,,,,,,,fee schedule,0.11,0.13,
"Injection, cimetidine HCl, 300 mg",S0023,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.11,,,,,,,fee schedule,0.11,0.13,
"Injection, famotidine, 20mg",S0028,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.71,,,,,,,fee schedule,1.54,1.71,
"Injection, famotidine, 20mg",S0028,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.54,,,,,,,fee schedule,1.54,1.71,
"Injection, nafcillin sodium, 2 g",S0032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42.85,,,,,,,fee schedule,38.78,42.85,
"Injection, nafcillin sodium, 2 g",S0032,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38.78,,,,,,,fee schedule,38.78,42.85,
"Injection, cefotetan disodium, 500 mg",S0074,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18.23,,,,,,,fee schedule,16.5,18.23,
"Injection, cefotetan disodium, 500 mg",S0074,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16.5,,,,,,,fee schedule,16.5,18.23,
"Injection, pentamidine isethonate, 300 mg",S0080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,235.21,,,,,,,fee schedule,212.88,235.21,
"Injection, pentamidine isethonate, 300 mg",S0080,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,212.88,,,,,,,fee schedule,212.88,235.21,
"Sildenafil citrate, 25 mg",S0090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41.52,,,,,,,fee schedule,37.58,41.52,
"Sildenafil citrate, 25 mg",S0090,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37.58,,,,,,,fee schedule,37.58,41.52,
"Granisetron HCl, 1mg (for circumstances falling under the Medicare Statute, use Q0166)",S0091,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,171.04,,,,,,,fee schedule,154.8,171.04,
"Granisetron HCl, 1mg (for circumstances falling under the Medicare Statute, use Q0166)",S0091,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,154.8,,,,,,,fee schedule,154.8,171.04,
"Zidovudine, oral, 100 mg",S0104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3.21,,,,,,,fee schedule,2.9,3.21,
"Zidovudine, oral, 100 mg",S0104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.9,,,,,,,fee schedule,2.9,3.21,
"Buproprion HCl sustained release tablit, 150 mg, per bottle of 60 tablets",S0106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14.93,,,,,,,fee schedule,13.51,14.93,
"Buproprion HCl sustained release tablit, 150 mg, per bottle of 60 tablets",S0106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13.51,,,,,,,fee schedule,13.51,14.93,
"Mercaptopuine, oral, 50 mg",S0108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11.34,,,,,,,fee schedule,10.27,11.34,
"Mercaptopuine, oral, 50 mg",S0108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10.27,,,,,,,fee schedule,10.27,11.34,
"Methadone, oral, 5 mg",S0109,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.43,,,,,,,fee schedule,0.39,0.43,
"Methadone, oral, 5 mg",S0109,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.39,,,,,,,fee schedule,0.39,0.43,
Description Not Available,S0119,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37.76,,,,,,,fee schedule,34.18,37.76,
Description Not Available,S0119,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,34.18,,,,,,,fee schedule,34.18,37.76,
"Injection, menotropins, 75 IU",S0122,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,460.25,,,,,,,fee schedule,416.56,460.25,
"Injection, menotropins, 75 IU",S0122,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,416.56,,,,,,,fee schedule,416.56,460.25,
"Injection, follitropin alfa, 75 IU",S0126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,457.9,,,,,,,fee schedule,414.43,457.9,
"Injection, follitropin alfa, 75 IU",S0126,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,414.43,,,,,,,fee schedule,414.43,457.9,
"Injection, follitropin beta, 75 IU",S0128,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,412.38,,,,,,,fee schedule,373.23,412.38,
"Injection, follitropin beta, 75 IU",S0128,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,373.23,,,,,,,fee schedule,373.23,412.38,
"Injection, ganirelix acetate, 250 mcg",S0132,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,356.16,,,,,,,fee schedule,322.35,356.16,
"Injection, ganirelix acetate, 250 mcg",S0132,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,322.35,,,,,,,fee schedule,322.35,356.16,
"Clozapine, 25 mg",S0136,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.63,,,,,,,fee schedule,1.47,1.63,
"Clozapine, 25 mg",S0136,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.47,,,,,,,fee schedule,1.47,1.63,
"Didanosine (ddI), 25 mg",S0137,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1.22,,,,,,,fee schedule,1.1,1.22,
"Didanosine (ddI), 25 mg",S0137,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.1,,,,,,,fee schedule,1.1,1.22,
"Finasteride, 5 mg",S0138,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.95,,,,,,,fee schedule,4.48,4.95,
"Finasteride, 5 mg",S0138,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.48,,,,,,,fee schedule,4.48,4.95,
"Minoxidil, 10 mg",S0139,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.04,,,,,,,fee schedule,1.84,2.04,
"Minoxidil, 10 mg",S0139,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1.84,,,,,,,fee schedule,1.84,2.04,
"Saquinavir, 200 mg",S0140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8.26,,,,,,,fee schedule,7.48,8.26,
"Saquinavir, 200 mg",S0140,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7.48,,,,,,,fee schedule,7.48,8.26,
"pegylated interferon alfa-2a, 180 mcg/ ml",S0145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2111.04,,,,,,,fee schedule,1910.62,2111.04,
"pegylated interferon alfa-2a, 180 mcg/ ml",S0145,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1910.62,,,,,,,fee schedule,1910.62,2111.04,
Peg interferon alfa-2B/10,S0148,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,188.1,,,,,,,fee schedule,170.24,188.1,
Peg interferon alfa-2B/10,S0148,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,170.24,,,,,,,fee schedule,170.24,188.1,
"Sterile dilutant for epoprostenol, 50 ml",S0155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22.29,,,,,,,fee schedule,20.18,22.29,
"Sterile dilutant for epoprostenol, 50 ml",S0155,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20.18,,,,,,,fee schedule,20.18,22.29,
"Exemestane, 25 mg",S0156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,31.96,,,,,,,fee schedule,28.93,31.96,
"Exemestane, 25 mg",S0156,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28.93,,,,,,,fee schedule,28.93,31.96,
"Becaplermin gel 0.01%, 0.5 gm",S0157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,81.84,,,,,,,fee schedule,74.07,81.84,
"Becaplermin gel 0.01%, 0.5 gm",S0157,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,74.07,,,,,,,fee schedule,74.07,81.84,
"Dextoamphetamine sulfate, 5 mg",S0160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4.58,,,,,,,fee schedule,4.15,4.58,
"Dextoamphetamine sulfate, 5 mg",S0160,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4.15,,,,,,,fee schedule,4.15,4.58,
"Injection, pantoprazole sodium, 40 mg",S0164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9.62,,,,,,,fee schedule,8.71,9.62,
"Injection, pantoprazole sodium, 40 mg",S0164,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8.71,,,,,,,fee schedule,8.71,9.62,
"Anastrozole, oral, 1 mg",S0170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21.12,,,,,,,fee schedule,19.12,21.12,
"Anastrozole, oral, 1 mg",S0170,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19.12,,,,,,,fee schedule,19.12,21.12,
"Chlorambucil, oral, 2 mg",S0172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1052.39,,,,,,,fee schedule,952.48,1052.39,
"Chlorambucil, oral, 2 mg",S0172,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,952.48,,,,,,,fee schedule,952.48,1052.39,
"Dolasetron mesylate, oral 50 mg (for circumstances falling under the medicare statute, use q0180)",S0174,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,136.61,,,,,,,fee schedule,123.64,136.61,
"Dolasetron mesylate, oral 50 mg (for circumstances falling under the medicare statute, use q0180)",S0174,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,123.64,,,,,,,fee schedule,123.64,136.61,
"Flutamide, oral, 125 mg",S0175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,56.79,,,,,,,fee schedule,51.39,56.79,
"Flutamide, oral, 125 mg",S0175,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51.39,,,,,,,fee schedule,51.39,56.79,
"Hydroxyurea, oral, 500 mg",S0176,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.45,,,,,,,fee schedule,2.22,2.45,
"Hydroxyurea, oral, 500 mg",S0176,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.22,,,,,,,fee schedule,2.22,2.45,
"Lomustine, oral, 10 mg",S0178,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,213.28,,,,,,,fee schedule,193.04,213.28,
"Lomustine, oral, 10 mg",S0178,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,193.04,,,,,,,fee schedule,193.04,213.28,
"Megestrol acetate, oral, 20 mg",S0179,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.54,,,,,,,fee schedule,0.49,0.54,
"Megestrol acetate, oral, 20 mg",S0179,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.49,,,,,,,fee schedule,0.49,0.54,
"Procarbazine HCl, oral, 50 mg",S0182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,245.09,,,,,,,fee schedule,221.82,245.09,
"Procarbazine HCl, oral, 50 mg",S0182,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,221.82,,,,,,,fee schedule,221.82,245.09,
"Prochlorperazine maleate, oral, 5 mg (for circumstances falling under the medicare statute, use q0164)",S0183,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.93,,,,,,,fee schedule,0.84,0.93,
"Prochlorperazine maleate, oral, 5 mg (for circumstances falling under the medicare statute, use q0164)",S0183,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.84,,,,,,,fee schedule,0.84,0.93,
"Tamoxifen citrate, oral, 10 mg",S0187,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.99,,,,,,,fee schedule,2.7,2.99,
"Tamoxifen citrate, oral, 10 mg",S0187,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.7,,,,,,,fee schedule,2.7,2.99,
"testosterone pellet, 75 mg",S0189,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,205.12,,,,,,,fee schedule,185.64,205.12,
"testosterone pellet, 75 mg",S0189,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,185.64,,,,,,,fee schedule,185.64,205.12,
"Mitepristone, oral, 200 mg",S0190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,81.37,,,,,,,fee schedule,73.65,81.37,
"Mitepristone, oral, 200 mg",S0190,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,73.65,,,,,,,fee schedule,73.65,81.37,
"Misoprostol, oral, 200 mcg",S0191,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2.61,,,,,,,fee schedule,2.36,2.61,
"Misoprostol, oral, 200 mcg",S0191,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2.36,,,,,,,fee schedule,2.36,2.61,
Description Not Available,S1091,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3128.4,,,,,,,fee schedule,2831.4,3128.4,
Description Not Available,S1091,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2831.4,,,,,,,fee schedule,2831.4,3128.4,
5% dextrose with potassium,S5012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.43,,,,,,,fee schedule,0.39,0.43,
5% dextrose with potassium,S5012,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.39,,,,,,,fee schedule,0.39,0.43,
Insulin rapid 5 u,S5550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.46,,,,,,,fee schedule,0.41,0.46,
Insulin rapid 5 u,S5550,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.41,,,,,,,fee schedule,0.41,0.46,
Insulin most rapid 5 u,S5551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.66,,,,,,,fee schedule,0.6,0.66,
Insulin most rapid 5 u,S5551,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.6,,,,,,,fee schedule,0.6,0.66,
Insulin intermed 5 u,S5552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.44,,,,,,,fee schedule,0.4,0.44,
Insulin intermed 5 u,S5552,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.4,,,,,,,fee schedule,0.4,0.44,
Insulin long acting 5 u,S5553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,0.62,,,,,,,fee schedule,0.56,0.62,
Insulin long acting 5 u,S5553,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,0.56,,,,,,,fee schedule,0.56,0.62,
Insulin reuse pen 3 ml,S5561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.34,,,,,,,fee schedule,54.61,60.34,
Insulin reuse pen 3 ml,S5561,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,54.61,,,,,,,fee schedule,54.61,60.34,
Insulin dispos pen 3 ml,S5571,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.34,,,,,,,fee schedule,54.61,60.34,
Insulin dispos pen 3 ml,S5571,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,54.61,,,,,,,fee schedule,54.61,60.34,
2019 nCoV diagnostic P,U0001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,125,,,,,,,fee schedule,32.33,135.78,
2019 nCoV diagnostic P,U0001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,135.78,,,,,,,fee schedule,32.33,135.78,
2019 nCoV diagnostic P,U0001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,108.84,,,,,,,fee schedule,32.33,135.78,
2019 nCoV diagnostic P,U0001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,118.9,,,,,,,fee schedule,32.33,135.78,
2019 nCoV diagnostic P,U0001,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,32.33,,,,,,,fee schedule,32.33,135.78,Laboratory
2019 nCoV diagnostic P,U0001,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,37.72,,,,,,,fee schedule,32.33,135.78,APC
2019 nCoV diagnostic P,U0001,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,37.36,,,,,,,fee schedule,32.33,135.78,APC
2019 nCoV diagnostic P,U0001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,35.92,,,,,,,fee schedule,32.33,135.78,APC
2019 nCoV diagnostic P,U0001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,54.96,,,,,,,fee schedule,32.33,135.78,Radiology
2019 nCoV diagnostic P,U0001,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,50.29,,,,,,,fee schedule,32.33,135.78,APC
2019 nCoV diagnostic P,U0001,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,62.86,,,,,,,fee schedule,32.33,135.78,APC
COVID-19 lab test non-CDC,U0002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,178.63,,,,,,,fee schedule,46.18,194.03,
COVID-19 lab test non-CDC,U0002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,194.03,,,,,,,fee schedule,46.18,194.03,
COVID-19 lab test non-CDC,U0002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,155.53,,,,,,,fee schedule,46.18,194.03,
COVID-19 lab test non-CDC,U0002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,169.9,,,,,,,fee schedule,46.18,194.03,
COVID-19 lab test non-CDC,U0002,HCPCS,,,,,,,facility,outpatient,,,,,,Unitedhealthcare,All Commercial Plans,46.18,,,,,,,fee schedule,46.18,194.03,Laboratory
COVID-19 lab test non-CDC,U0002,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,53.88,,,,,,,fee schedule,46.18,194.03,APC
COVID-19 lab test non-CDC,U0002,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,53.36,,,,,,,fee schedule,46.18,194.03,APC
COVID-19 lab test non-CDC,U0002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,51.31,,,,,,,fee schedule,46.18,194.03,APC
COVID-19 lab test non-CDC,U0002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,78.5,,,,,,,fee schedule,46.18,194.03,Radiology
COVID-19 lab test non-CDC,U0002,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,71.83,,,,,,,fee schedule,46.18,194.03,APC
COVID-19 lab test non-CDC,U0002,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,89.79,,,,,,,fee schedule,46.18,194.03,APC
Cov-19 amp prb hgh thruput,U0003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,261,,,,,,,fee schedule,227.25,283.5,
Cov-19 amp prb hgh thruput,U0003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,283.5,,,,,,,fee schedule,227.25,283.5,
Cov-19 amp prb hgh thruput,U0003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,227.25,,,,,,,fee schedule,227.25,283.5,
Cov-19 amp prb hgh thruput,U0003,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,248.25,,,,,,,fee schedule,227.25,283.5,
Cov-19 test non-cdc hgh thru,U0004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,261,,,,,,,fee schedule,227.25,283.5,
Cov-19 test non-cdc hgh thru,U0004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,283.5,,,,,,,fee schedule,227.25,283.5,
Cov-19 test non-cdc hgh thru,U0004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,227.25,,,,,,,fee schedule,227.25,283.5,
Cov-19 test non-cdc hgh thru,U0004,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,248.25,,,,,,,fee schedule,227.25,283.5,
Infec agen detec ampli probe,U0005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,87,,,,,,,fee schedule,75.75,94.5,
Infec agen detec ampli probe,U0005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,94.5,,,,,,,fee schedule,75.75,94.5,
Infec agen detec ampli probe,U0005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,75.75,,,,,,,fee schedule,75.75,94.5,
Infec agen detec ampli probe,U0005,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,82.75,,,,,,,fee schedule,75.75,94.5,
Vision svcs frames purchases,V2020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,211.31,,,,,,,fee schedule,82.43,229.52,
Vision svcs frames purchases,V2020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,229.52,,,,,,,fee schedule,82.43,229.52,
Vision svcs frames purchases,V2020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,183.98,,,,,,,fee schedule,82.43,229.52,
Vision svcs frames purchases,V2020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,200.98,,,,,,,fee schedule,82.43,229.52,
Vision svcs frames purchases,V2020,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,86.55,,,,,,,fee schedule,82.43,229.52,APC
Vision svcs frames purchases,V2020,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,85.73,,,,,,,fee schedule,82.43,229.52,APC
Vision svcs frames purchases,V2020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,82.43,,,,,,,fee schedule,82.43,229.52,APC
Vision svcs frames purchases,V2020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,126.12,,,,,,,fee schedule,82.43,229.52,Radiology
Vision svcs frames purchases,V2020,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,115.4,,,,,,,fee schedule,82.43,229.52,APC
Vision svcs frames purchases,V2020,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,144.25,,,,,,,fee schedule,82.43,229.52,APC
Lens spher single plano 4.00,V2100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,150.82,,,,,,,fee schedule,58.85,163.83,
Lens spher single plano 4.00,V2100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,163.83,,,,,,,fee schedule,58.85,163.83,
Lens spher single plano 4.00,V2100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,131.32,,,,,,,fee schedule,58.85,163.83,
Lens spher single plano 4.00,V2100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,143.46,,,,,,,fee schedule,58.85,163.83,
Lens spher single plano 4.00,V2100,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.79,,,,,,,fee schedule,58.85,163.83,APC
Lens spher single plano 4.00,V2100,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,61.2,,,,,,,fee schedule,58.85,163.83,APC
Lens spher single plano 4.00,V2100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.85,,,,,,,fee schedule,58.85,163.83,APC
Lens spher single plano 4.00,V2100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,90.04,,,,,,,fee schedule,58.85,163.83,Radiology
Lens spher single plano 4.00,V2100,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,82.39,,,,,,,fee schedule,58.85,163.83,APC
Lens spher single plano 4.00,V2100,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.99,,,,,,,fee schedule,58.85,163.83,APC
Single visn sphere 4.12-7.00,V2101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,172.75,,,,,,,fee schedule,67.38,187.64,
Single visn sphere 4.12-7.00,V2101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,187.64,,,,,,,fee schedule,67.38,187.64,
Single visn sphere 4.12-7.00,V2101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,150.41,,,,,,,fee schedule,67.38,187.64,
Single visn sphere 4.12-7.00,V2101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,164.31,,,,,,,fee schedule,67.38,187.64,
Single visn sphere 4.12-7.00,V2101,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,70.75,,,,,,,fee schedule,67.38,187.64,APC
Single visn sphere 4.12-7.00,V2101,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,70.08,,,,,,,fee schedule,67.38,187.64,APC
Single visn sphere 4.12-7.00,V2101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,67.38,,,,,,,fee schedule,67.38,187.64,APC
Single visn sphere 4.12-7.00,V2101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,103.09,,,,,,,fee schedule,67.38,187.64,Radiology
Single visn sphere 4.12-7.00,V2101,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,94.33,,,,,,,fee schedule,67.38,187.64,APC
Single visn sphere 4.12-7.00,V2101,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,117.92,,,,,,,fee schedule,67.38,187.64,APC
Singl visn sphere 7.12-20.00,V2102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,192.03,,,,,,,fee schedule,74.88,208.58,
Singl visn sphere 7.12-20.00,V2102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,208.58,,,,,,,fee schedule,74.88,208.58,
Singl visn sphere 7.12-20.00,V2102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,167.2,,,,,,,fee schedule,74.88,208.58,
Singl visn sphere 7.12-20.00,V2102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,182.65,,,,,,,fee schedule,74.88,208.58,
Singl visn sphere 7.12-20.00,V2102,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,78.62,,,,,,,fee schedule,74.88,208.58,APC
Singl visn sphere 7.12-20.00,V2102,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,77.88,,,,,,,fee schedule,74.88,208.58,APC
Singl visn sphere 7.12-20.00,V2102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,74.88,,,,,,,fee schedule,74.88,208.58,APC
Singl visn sphere 7.12-20.00,V2102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,114.57,,,,,,,fee schedule,74.88,208.58,Radiology
Singl visn sphere 7.12-20.00,V2102,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,104.83,,,,,,,fee schedule,74.88,208.58,APC
Singl visn sphere 7.12-20.00,V2102,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,131.04,,,,,,,fee schedule,74.88,208.58,APC
Spherocylindr 4.00d/12-2.00d,V2103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,114.25,,,,,,,fee schedule,44.55,124.1,
Spherocylindr 4.00d/12-2.00d,V2103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,124.1,,,,,,,fee schedule,44.55,124.1,
Spherocylindr 4.00d/12-2.00d,V2103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,99.47,,,,,,,fee schedule,44.55,124.1,
Spherocylindr 4.00d/12-2.00d,V2103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,108.67,,,,,,,fee schedule,44.55,124.1,
Spherocylindr 4.00d/12-2.00d,V2103,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,46.78,,,,,,,fee schedule,44.55,124.1,APC
Spherocylindr 4.00d/12-2.00d,V2103,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,46.33,,,,,,,fee schedule,44.55,124.1,APC
Spherocylindr 4.00d/12-2.00d,V2103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,44.55,,,,,,,fee schedule,44.55,124.1,APC
Spherocylindr 4.00d/12-2.00d,V2103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,68.16,,,,,,,fee schedule,44.55,124.1,Radiology
Spherocylindr 4.00d/12-2.00d,V2103,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,62.37,,,,,,,fee schedule,44.55,124.1,APC
Spherocylindr 4.00d/12-2.00d,V2103,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,77.96,,,,,,,fee schedule,44.55,124.1,APC
Spherocylindr 4.00d/2.12-4d,V2104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,135.06,,,,,,,fee schedule,52.7,146.7,
Spherocylindr 4.00d/2.12-4d,V2104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,146.7,,,,,,,fee schedule,52.7,146.7,
Spherocylindr 4.00d/2.12-4d,V2104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,117.59,,,,,,,fee schedule,52.7,146.7,
Spherocylindr 4.00d/2.12-4d,V2104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,128.46,,,,,,,fee schedule,52.7,146.7,
Spherocylindr 4.00d/2.12-4d,V2104,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,55.34,,,,,,,fee schedule,52.7,146.7,APC
Spherocylindr 4.00d/2.12-4d,V2104,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,54.81,,,,,,,fee schedule,52.7,146.7,APC
Spherocylindr 4.00d/2.12-4d,V2104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,52.7,,,,,,,fee schedule,52.7,146.7,APC
Spherocylindr 4.00d/2.12-4d,V2104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,80.63,,,,,,,fee schedule,52.7,146.7,Radiology
Spherocylindr 4.00d/2.12-4d,V2104,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,73.78,,,,,,,fee schedule,52.7,146.7,APC
Spherocylindr 4.00d/2.12-4d,V2104,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,92.22,,,,,,,fee schedule,52.7,146.7,APC
Spherocylinder 4.00d/4.25-6d,V2105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,132.27,,,,,,,fee schedule,51.58,143.68,
Spherocylinder 4.00d/4.25-6d,V2105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,143.68,,,,,,,fee schedule,51.58,143.68,
Spherocylinder 4.00d/4.25-6d,V2105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,115.17,,,,,,,fee schedule,51.58,143.68,
Spherocylinder 4.00d/4.25-6d,V2105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,125.81,,,,,,,fee schedule,51.58,143.68,
Spherocylinder 4.00d/4.25-6d,V2105,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,54.16,,,,,,,fee schedule,51.58,143.68,APC
Spherocylinder 4.00d/4.25-6d,V2105,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,53.64,,,,,,,fee schedule,51.58,143.68,APC
Spherocylinder 4.00d/4.25-6d,V2105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,51.58,,,,,,,fee schedule,51.58,143.68,APC
Spherocylinder 4.00d/4.25-6d,V2105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,78.92,,,,,,,fee schedule,51.58,143.68,Radiology
Spherocylinder 4.00d/4.25-6d,V2105,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,72.21,,,,,,,fee schedule,51.58,143.68,APC
Spherocylinder 4.00d/4.25-6d,V2105,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,90.26,,,,,,,fee schedule,51.58,143.68,APC
Spherocylinder 4.00d/>6.00d,V2106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,158.03,,,,,,,fee schedule,61.64,171.65,
Spherocylinder 4.00d/>6.00d,V2106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,171.65,,,,,,,fee schedule,61.64,171.65,
Spherocylinder 4.00d/>6.00d,V2106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,137.59,,,,,,,fee schedule,61.64,171.65,
Spherocylinder 4.00d/>6.00d,V2106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,150.31,,,,,,,fee schedule,61.64,171.65,
Spherocylinder 4.00d/>6.00d,V2106,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,64.72,,,,,,,fee schedule,61.64,171.65,APC
Spherocylinder 4.00d/>6.00d,V2106,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,64.11,,,,,,,fee schedule,61.64,171.65,APC
Spherocylinder 4.00d/>6.00d,V2106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,61.64,,,,,,,fee schedule,61.64,171.65,APC
Spherocylinder 4.00d/>6.00d,V2106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,94.31,,,,,,,fee schedule,61.64,171.65,Radiology
Spherocylinder 4.00d/>6.00d,V2106,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,86.3,,,,,,,fee schedule,61.64,171.65,APC
Spherocylinder 4.00d/>6.00d,V2106,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,107.87,,,,,,,fee schedule,61.64,171.65,APC
Spherocylinder 4.25d/12-2d,V2107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,170.38,,,,,,,fee schedule,66.43,185.07,
Spherocylinder 4.25d/12-2d,V2107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,185.07,,,,,,,fee schedule,66.43,185.07,
Spherocylinder 4.25d/12-2d,V2107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,148.35,,,,,,,fee schedule,66.43,185.07,
Spherocylinder 4.25d/12-2d,V2107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,162.06,,,,,,,fee schedule,66.43,185.07,
Spherocylinder 4.25d/12-2d,V2107,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,69.75,,,,,,,fee schedule,66.43,185.07,APC
Spherocylinder 4.25d/12-2d,V2107,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,69.09,,,,,,,fee schedule,66.43,185.07,APC
Spherocylinder 4.25d/12-2d,V2107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,66.43,,,,,,,fee schedule,66.43,185.07,APC
Spherocylinder 4.25d/12-2d,V2107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,101.64,,,,,,,fee schedule,66.43,185.07,Radiology
Spherocylinder 4.25d/12-2d,V2107,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,93,,,,,,,fee schedule,66.43,185.07,APC
Spherocylinder 4.25d/12-2d,V2107,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,116.25,,,,,,,fee schedule,66.43,185.07,APC
Spherocylinder 4.25d/2.12-4d,V2108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,167.14,,,,,,,fee schedule,65.19,181.55,
Spherocylinder 4.25d/2.12-4d,V2108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,181.55,,,,,,,fee schedule,65.19,181.55,
Spherocylinder 4.25d/2.12-4d,V2108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,145.53,,,,,,,fee schedule,65.19,181.55,
Spherocylinder 4.25d/2.12-4d,V2108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,158.98,,,,,,,fee schedule,65.19,181.55,
Spherocylinder 4.25d/2.12-4d,V2108,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,68.45,,,,,,,fee schedule,65.19,181.55,APC
Spherocylinder 4.25d/2.12-4d,V2108,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,67.8,,,,,,,fee schedule,65.19,181.55,APC
Spherocylinder 4.25d/2.12-4d,V2108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,65.19,,,,,,,fee schedule,65.19,181.55,APC
Spherocylinder 4.25d/2.12-4d,V2108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,99.74,,,,,,,fee schedule,65.19,181.55,Radiology
Spherocylinder 4.25d/2.12-4d,V2108,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,91.27,,,,,,,fee schedule,65.19,181.55,APC
Spherocylinder 4.25d/2.12-4d,V2108,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,114.08,,,,,,,fee schedule,65.19,181.55,APC
Spherocylinder 4.25d/4.25-6d,V2109,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,160.25,,,,,,,fee schedule,62.51,174.07,
Spherocylinder 4.25d/4.25-6d,V2109,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,174.07,,,,,,,fee schedule,62.51,174.07,
Spherocylinder 4.25d/4.25-6d,V2109,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,139.53,,,,,,,fee schedule,62.51,174.07,
Spherocylinder 4.25d/4.25-6d,V2109,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,152.43,,,,,,,fee schedule,62.51,174.07,
Spherocylinder 4.25d/4.25-6d,V2109,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,65.64,,,,,,,fee schedule,62.51,174.07,APC
Spherocylinder 4.25d/4.25-6d,V2109,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,65.01,,,,,,,fee schedule,62.51,174.07,APC
Spherocylinder 4.25d/4.25-6d,V2109,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,62.51,,,,,,,fee schedule,62.51,174.07,APC
Spherocylinder 4.25d/4.25-6d,V2109,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,95.64,,,,,,,fee schedule,62.51,174.07,Radiology
Spherocylinder 4.25d/4.25-6d,V2109,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,87.51,,,,,,,fee schedule,62.51,174.07,APC
Spherocylinder 4.25d/4.25-6d,V2109,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,109.39,,,,,,,fee schedule,62.51,174.07,APC
Spherocylinder 4.25d/over 6d,V2110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,153.92,,,,,,,fee schedule,60.05,167.19,
Spherocylinder 4.25d/over 6d,V2110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,167.19,,,,,,,fee schedule,60.05,167.19,
Spherocylinder 4.25d/over 6d,V2110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,134.02,,,,,,,fee schedule,60.05,167.19,
Spherocylinder 4.25d/over 6d,V2110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,146.4,,,,,,,fee schedule,60.05,167.19,
Spherocylinder 4.25d/over 6d,V2110,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,63.05,,,,,,,fee schedule,60.05,167.19,APC
Spherocylinder 4.25d/over 6d,V2110,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,62.45,,,,,,,fee schedule,60.05,167.19,APC
Spherocylinder 4.25d/over 6d,V2110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,60.05,,,,,,,fee schedule,60.05,167.19,APC
Spherocylinder 4.25d/over 6d,V2110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,91.88,,,,,,,fee schedule,60.05,167.19,Radiology
Spherocylinder 4.25d/over 6d,V2110,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,84.07,,,,,,,fee schedule,60.05,167.19,APC
Spherocylinder 4.25d/over 6d,V2110,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,105.09,,,,,,,fee schedule,60.05,167.19,APC
Spherocylindr 7.25d/.25-2.25,V2111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,180.23,,,,,,,fee schedule,70.28,195.77,
Spherocylindr 7.25d/.25-2.25,V2111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,195.77,,,,,,,fee schedule,70.28,195.77,
Spherocylindr 7.25d/.25-2.25,V2111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,156.92,,,,,,,fee schedule,70.28,195.77,
Spherocylindr 7.25d/.25-2.25,V2111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,171.42,,,,,,,fee schedule,70.28,195.77,
Spherocylindr 7.25d/.25-2.25,V2111,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,73.79,,,,,,,fee schedule,70.28,195.77,APC
Spherocylindr 7.25d/.25-2.25,V2111,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,73.09,,,,,,,fee schedule,70.28,195.77,APC
Spherocylindr 7.25d/.25-2.25,V2111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,70.28,,,,,,,fee schedule,70.28,195.77,APC
Spherocylindr 7.25d/.25-2.25,V2111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,107.53,,,,,,,fee schedule,70.28,195.77,Radiology
Spherocylindr 7.25d/.25-2.25,V2111,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,98.39,,,,,,,fee schedule,70.28,195.77,APC
Spherocylindr 7.25d/.25-2.25,V2111,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,122.99,,,,,,,fee schedule,70.28,195.77,APC
Spherocylindr 7.25d/2.25-4d,V2112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,233.02,,,,,,,fee schedule,90.89,253.11,
Spherocylindr 7.25d/2.25-4d,V2112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,253.11,,,,,,,fee schedule,90.89,253.11,
Spherocylindr 7.25d/2.25-4d,V2112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,202.89,,,,,,,fee schedule,90.89,253.11,
Spherocylindr 7.25d/2.25-4d,V2112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,221.64,,,,,,,fee schedule,90.89,253.11,
Spherocylindr 7.25d/2.25-4d,V2112,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,95.43,,,,,,,fee schedule,90.89,253.11,APC
Spherocylindr 7.25d/2.25-4d,V2112,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,94.53,,,,,,,fee schedule,90.89,253.11,APC
Spherocylindr 7.25d/2.25-4d,V2112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,90.89,,,,,,,fee schedule,90.89,253.11,APC
Spherocylindr 7.25d/2.25-4d,V2112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,139.06,,,,,,,fee schedule,90.89,253.11,Radiology
Spherocylindr 7.25d/2.25-4d,V2112,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,127.25,,,,,,,fee schedule,90.89,253.11,APC
Spherocylindr 7.25d/2.25-4d,V2112,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,159.06,,,,,,,fee schedule,90.89,253.11,APC
Spherocylindr 7.25d/4.25-6d,V2113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,250.77,,,,,,,fee schedule,97.82,272.39,
Spherocylindr 7.25d/4.25-6d,V2113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,272.39,,,,,,,fee schedule,97.82,272.39,
Spherocylindr 7.25d/4.25-6d,V2113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,218.34,,,,,,,fee schedule,97.82,272.39,
Spherocylindr 7.25d/4.25-6d,V2113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,238.52,,,,,,,fee schedule,97.82,272.39,
Spherocylindr 7.25d/4.25-6d,V2113,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,102.71,,,,,,,fee schedule,97.82,272.39,APC
Spherocylindr 7.25d/4.25-6d,V2113,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,101.73,,,,,,,fee schedule,97.82,272.39,APC
Spherocylindr 7.25d/4.25-6d,V2113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,97.82,,,,,,,fee schedule,97.82,272.39,APC
Spherocylindr 7.25d/4.25-6d,V2113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,149.66,,,,,,,fee schedule,97.82,272.39,Radiology
Spherocylindr 7.25d/4.25-6d,V2113,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,136.95,,,,,,,fee schedule,97.82,272.39,APC
Spherocylindr 7.25d/4.25-6d,V2113,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,171.18,,,,,,,fee schedule,97.82,272.39,APC
Spherocylinder over 12.00d,V2114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,284.46,,,,,,,fee schedule,110.95,308.98,
Spherocylinder over 12.00d,V2114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,308.98,,,,,,,fee schedule,110.95,308.98,
Spherocylinder over 12.00d,V2114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,247.67,,,,,,,fee schedule,110.95,308.98,
Spherocylinder over 12.00d,V2114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,270.56,,,,,,,fee schedule,110.95,308.98,
Spherocylinder over 12.00d,V2114,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,116.5,,,,,,,fee schedule,110.95,308.98,APC
Spherocylinder over 12.00d,V2114,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,115.39,,,,,,,fee schedule,110.95,308.98,APC
Spherocylinder over 12.00d,V2114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,110.95,,,,,,,fee schedule,110.95,308.98,APC
Spherocylinder over 12.00d,V2114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,169.75,,,,,,,fee schedule,110.95,308.98,Radiology
Spherocylinder over 12.00d,V2114,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,155.33,,,,,,,fee schedule,110.95,308.98,APC
Spherocylinder over 12.00d,V2114,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,194.16,,,,,,,fee schedule,110.95,308.98,APC
Lens lenticular bifocal,V2115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,309.62,,,,,,,fee schedule,120.75,336.31,
Lens lenticular bifocal,V2115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,336.31,,,,,,,fee schedule,120.75,336.31,
Lens lenticular bifocal,V2115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,269.58,,,,,,,fee schedule,120.75,336.31,
Lens lenticular bifocal,V2115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,294.49,,,,,,,fee schedule,120.75,336.31,
Lens lenticular bifocal,V2115,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,126.79,,,,,,,fee schedule,120.75,336.31,APC
Lens lenticular bifocal,V2115,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,125.58,,,,,,,fee schedule,120.75,336.31,APC
Lens lenticular bifocal,V2115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,120.75,,,,,,,fee schedule,120.75,336.31,APC
Lens lenticular bifocal,V2115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.75,,,,,,,fee schedule,120.75,336.31,Radiology
Lens lenticular bifocal,V2115,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,169.05,,,,,,,fee schedule,120.75,336.31,APC
Lens lenticular bifocal,V2115,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,211.31,,,,,,,fee schedule,120.75,336.31,APC
Lens aniseikonic single,V2118,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,230.2,,,,,,,fee schedule,89.78,250.05,
Lens aniseikonic single,V2118,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,250.05,,,,,,,fee schedule,89.78,250.05,
Lens aniseikonic single,V2118,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,200.43,,,,,,,fee schedule,89.78,250.05,
Lens aniseikonic single,V2118,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,218.96,,,,,,,fee schedule,89.78,250.05,
Lens aniseikonic single,V2118,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,94.27,,,,,,,fee schedule,89.78,250.05,APC
Lens aniseikonic single,V2118,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,93.37,,,,,,,fee schedule,89.78,250.05,APC
Lens aniseikonic single,V2118,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,89.78,,,,,,,fee schedule,89.78,250.05,APC
Lens aniseikonic single,V2118,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,137.36,,,,,,,fee schedule,89.78,250.05,Radiology
Lens aniseikonic single,V2118,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,125.69,,,,,,,fee schedule,89.78,250.05,APC
Lens aniseikonic single,V2118,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,157.12,,,,,,,fee schedule,89.78,250.05,APC
"Lenticular lens, single",V2121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,316.89,,,,,,,fee schedule,123.58,344.21,
"Lenticular lens, single",V2121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,344.21,,,,,,,fee schedule,123.58,344.21,
"Lenticular lens, single",V2121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,275.91,,,,,,,fee schedule,123.58,344.21,
"Lenticular lens, single",V2121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,301.41,,,,,,,fee schedule,123.58,344.21,
"Lenticular lens, single",V2121,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.76,,,,,,,fee schedule,123.58,344.21,APC
"Lenticular lens, single",V2121,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.52,,,,,,,fee schedule,123.58,344.21,APC
"Lenticular lens, single",V2121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.58,,,,,,,fee schedule,123.58,344.21,APC
"Lenticular lens, single",V2121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,189.08,,,,,,,fee schedule,123.58,344.21,Radiology
"Lenticular lens, single",V2121,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,173.01,,,,,,,fee schedule,123.58,344.21,APC
"Lenticular lens, single",V2121,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,216.26,,,,,,,fee schedule,123.58,344.21,APC
Lens spher bifoc plano 4.00d,V2200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,185.87,,,,,,,fee schedule,72.49,201.89,
Lens spher bifoc plano 4.00d,V2200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,201.89,,,,,,,fee schedule,72.49,201.89,
Lens spher bifoc plano 4.00d,V2200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,161.83,,,,,,,fee schedule,72.49,201.89,
Lens spher bifoc plano 4.00d,V2200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,176.79,,,,,,,fee schedule,72.49,201.89,
Lens spher bifoc plano 4.00d,V2200,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,76.11,,,,,,,fee schedule,72.49,201.89,APC
Lens spher bifoc plano 4.00d,V2200,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,75.39,,,,,,,fee schedule,72.49,201.89,APC
Lens spher bifoc plano 4.00d,V2200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,72.49,,,,,,,fee schedule,72.49,201.89,APC
Lens spher bifoc plano 4.00d,V2200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,110.91,,,,,,,fee schedule,72.49,201.89,Radiology
Lens spher bifoc plano 4.00d,V2200,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,101.49,,,,,,,fee schedule,72.49,201.89,APC
Lens spher bifoc plano 4.00d,V2200,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,126.86,,,,,,,fee schedule,72.49,201.89,APC
Lens sphere bifocal 4.12-7.0,V2201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,195.75,,,,,,,fee schedule,76.34,212.63,
Lens sphere bifocal 4.12-7.0,V2201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,212.63,,,,,,,fee schedule,76.34,212.63,
Lens sphere bifocal 4.12-7.0,V2201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,170.44,,,,,,,fee schedule,76.34,212.63,
Lens sphere bifocal 4.12-7.0,V2201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,186.19,,,,,,,fee schedule,76.34,212.63,
Lens sphere bifocal 4.12-7.0,V2201,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,80.16,,,,,,,fee schedule,76.34,212.63,APC
Lens sphere bifocal 4.12-7.0,V2201,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,79.39,,,,,,,fee schedule,76.34,212.63,APC
Lens sphere bifocal 4.12-7.0,V2201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,76.34,,,,,,,fee schedule,76.34,212.63,APC
Lens sphere bifocal 4.12-7.0,V2201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,116.8,,,,,,,fee schedule,76.34,212.63,Radiology
Lens sphere bifocal 4.12-7.0,V2201,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,106.88,,,,,,,fee schedule,76.34,212.63,APC
Lens sphere bifocal 4.12-7.0,V2201,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,133.6,,,,,,,fee schedule,76.34,212.63,APC
Lens sphere bifocal 7.12-20.,V2202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,222.41,,,,,,,fee schedule,86.74,241.58,
Lens sphere bifocal 7.12-20.,V2202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,241.58,,,,,,,fee schedule,86.74,241.58,
Lens sphere bifocal 7.12-20.,V2202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,193.65,,,,,,,fee schedule,86.74,241.58,
Lens sphere bifocal 7.12-20.,V2202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,211.54,,,,,,,fee schedule,86.74,241.58,
Lens sphere bifocal 7.12-20.,V2202,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,91.08,,,,,,,fee schedule,86.74,241.58,APC
Lens sphere bifocal 7.12-20.,V2202,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,90.21,,,,,,,fee schedule,86.74,241.58,APC
Lens sphere bifocal 7.12-20.,V2202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,86.74,,,,,,,fee schedule,86.74,241.58,APC
Lens sphere bifocal 7.12-20.,V2202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,132.71,,,,,,,fee schedule,86.74,241.58,Radiology
Lens sphere bifocal 7.12-20.,V2202,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,121.44,,,,,,,fee schedule,86.74,241.58,APC
Lens sphere bifocal 7.12-20.,V2202,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,151.79,,,,,,,fee schedule,86.74,241.58,APC
Lens sphcyl bifocal 4.00d/.1,V2203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,182.53,,,,,,,fee schedule,71.22,198.26,
Lens sphcyl bifocal 4.00d/.1,V2203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,198.26,,,,,,,fee schedule,71.22,198.26,
Lens sphcyl bifocal 4.00d/.1,V2203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,158.92,,,,,,,fee schedule,71.22,198.26,
Lens sphcyl bifocal 4.00d/.1,V2203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,173.61,,,,,,,fee schedule,71.22,198.26,
Lens sphcyl bifocal 4.00d/.1,V2203,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,74.78,,,,,,,fee schedule,71.22,198.26,APC
Lens sphcyl bifocal 4.00d/.1,V2203,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,74.07,,,,,,,fee schedule,71.22,198.26,APC
Lens sphcyl bifocal 4.00d/.1,V2203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,71.22,,,,,,,fee schedule,71.22,198.26,APC
Lens sphcyl bifocal 4.00d/.1,V2203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,108.97,,,,,,,fee schedule,71.22,198.26,Radiology
Lens sphcyl bifocal 4.00d/.1,V2203,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,99.71,,,,,,,fee schedule,71.22,198.26,APC
Lens sphcyl bifocal 4.00d/.1,V2203,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,124.64,,,,,,,fee schedule,71.22,198.26,APC
Lens sphcy bifocal 4.00d/2.1,V2204,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,185.76,,,,,,,fee schedule,72.45,201.78,
Lens sphcy bifocal 4.00d/2.1,V2204,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,201.78,,,,,,,fee schedule,72.45,201.78,
Lens sphcy bifocal 4.00d/2.1,V2204,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,161.74,,,,,,,fee schedule,72.45,201.78,
Lens sphcy bifocal 4.00d/2.1,V2204,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,176.69,,,,,,,fee schedule,72.45,201.78,
Lens sphcy bifocal 4.00d/2.1,V2204,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,76.07,,,,,,,fee schedule,72.45,201.78,APC
Lens sphcy bifocal 4.00d/2.1,V2204,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,75.35,,,,,,,fee schedule,72.45,201.78,APC
Lens sphcy bifocal 4.00d/2.1,V2204,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,72.45,,,,,,,fee schedule,72.45,201.78,APC
Lens sphcy bifocal 4.00d/2.1,V2204,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,110.85,,,,,,,fee schedule,72.45,201.78,Radiology
Lens sphcy bifocal 4.00d/2.1,V2204,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,101.43,,,,,,,fee schedule,72.45,201.78,APC
Lens sphcy bifocal 4.00d/2.1,V2204,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,126.79,,,,,,,fee schedule,72.45,201.78,APC
Lens sphcy bifocal 4.00d/4.2,V2205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,193.84,,,,,,,fee schedule,75.59,210.55,
Lens sphcy bifocal 4.00d/4.2,V2205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,210.55,,,,,,,fee schedule,75.59,210.55,
Lens sphcy bifocal 4.00d/4.2,V2205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,168.77,,,,,,,fee schedule,75.59,210.55,
Lens sphcy bifocal 4.00d/4.2,V2205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,184.37,,,,,,,fee schedule,75.59,210.55,
Lens sphcy bifocal 4.00d/4.2,V2205,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,79.37,,,,,,,fee schedule,75.59,210.55,APC
Lens sphcy bifocal 4.00d/4.2,V2205,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,78.61,,,,,,,fee schedule,75.59,210.55,APC
Lens sphcy bifocal 4.00d/4.2,V2205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,75.59,,,,,,,fee schedule,75.59,210.55,APC
Lens sphcy bifocal 4.00d/4.2,V2205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,115.65,,,,,,,fee schedule,75.59,210.55,Radiology
Lens sphcy bifocal 4.00d/4.2,V2205,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,105.83,,,,,,,fee schedule,75.59,210.55,APC
Lens sphcy bifocal 4.00d/4.2,V2205,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,132.28,,,,,,,fee schedule,75.59,210.55,APC
Lens sphcy bifocal 4.00d/ove,V2206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,198.15,,,,,,,fee schedule,77.3,215.23,
Lens sphcy bifocal 4.00d/ove,V2206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,215.23,,,,,,,fee schedule,77.3,215.23,
Lens sphcy bifocal 4.00d/ove,V2206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,172.53,,,,,,,fee schedule,77.3,215.23,
Lens sphcy bifocal 4.00d/ove,V2206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,188.47,,,,,,,fee schedule,77.3,215.23,
Lens sphcy bifocal 4.00d/ove,V2206,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,81.17,,,,,,,fee schedule,77.3,215.23,APC
Lens sphcy bifocal 4.00d/ove,V2206,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,80.39,,,,,,,fee schedule,77.3,215.23,APC
Lens sphcy bifocal 4.00d/ove,V2206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,77.3,,,,,,,fee schedule,77.3,215.23,APC
Lens sphcy bifocal 4.00d/ove,V2206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,118.27,,,,,,,fee schedule,77.3,215.23,Radiology
Lens sphcy bifocal 4.00d/ove,V2206,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,108.22,,,,,,,fee schedule,77.3,215.23,APC
Lens sphcy bifocal 4.00d/ove,V2206,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,135.28,,,,,,,fee schedule,77.3,215.23,APC
Lens sphcy bifocal 4.25-7d/.,V2207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,184.61,,,,,,,fee schedule,72.01,200.53,
Lens sphcy bifocal 4.25-7d/.,V2207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,200.53,,,,,,,fee schedule,72.01,200.53,
Lens sphcy bifocal 4.25-7d/.,V2207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,160.74,,,,,,,fee schedule,72.01,200.53,
Lens sphcy bifocal 4.25-7d/.,V2207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,175.6,,,,,,,fee schedule,72.01,200.53,
Lens sphcy bifocal 4.25-7d/.,V2207,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,75.61,,,,,,,fee schedule,72.01,200.53,APC
Lens sphcy bifocal 4.25-7d/.,V2207,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,74.89,,,,,,,fee schedule,72.01,200.53,APC
Lens sphcy bifocal 4.25-7d/.,V2207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,72.01,,,,,,,fee schedule,72.01,200.53,APC
Lens sphcy bifocal 4.25-7d/.,V2207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,110.18,,,,,,,fee schedule,72.01,200.53,Radiology
Lens sphcy bifocal 4.25-7d/.,V2207,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,100.81,,,,,,,fee schedule,72.01,200.53,APC
Lens sphcy bifocal 4.25-7d/.,V2207,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,126.02,,,,,,,fee schedule,72.01,200.53,APC
Lens sphcy bifocal 4.25-7/2.,V2208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,204.9,,,,,,,fee schedule,79.92,222.57,
Lens sphcy bifocal 4.25-7/2.,V2208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,222.57,,,,,,,fee schedule,79.92,222.57,
Lens sphcy bifocal 4.25-7/2.,V2208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,178.41,,,,,,,fee schedule,79.92,222.57,
Lens sphcy bifocal 4.25-7/2.,V2208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,194.89,,,,,,,fee schedule,79.92,222.57,
Lens sphcy bifocal 4.25-7/2.,V2208,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,83.92,,,,,,,fee schedule,79.92,222.57,APC
Lens sphcy bifocal 4.25-7/2.,V2208,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,83.12,,,,,,,fee schedule,79.92,222.57,APC
Lens sphcy bifocal 4.25-7/2.,V2208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,79.92,,,,,,,fee schedule,79.92,222.57,APC
Lens sphcy bifocal 4.25-7/2.,V2208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,122.28,,,,,,,fee schedule,79.92,222.57,Radiology
Lens sphcy bifocal 4.25-7/2.,V2208,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,111.89,,,,,,,fee schedule,79.92,222.57,APC
Lens sphcy bifocal 4.25-7/2.,V2208,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,139.86,,,,,,,fee schedule,79.92,222.57,APC
Lens sphcy bifocal 4.25-7/4.,V2209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,202.68,,,,,,,fee schedule,79.05,220.15,
Lens sphcy bifocal 4.25-7/4.,V2209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,220.15,,,,,,,fee schedule,79.05,220.15,
Lens sphcy bifocal 4.25-7/4.,V2209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,176.47,,,,,,,fee schedule,79.05,220.15,
Lens sphcy bifocal 4.25-7/4.,V2209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,192.77,,,,,,,fee schedule,79.05,220.15,
Lens sphcy bifocal 4.25-7/4.,V2209,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,83,,,,,,,fee schedule,79.05,220.15,APC
Lens sphcy bifocal 4.25-7/4.,V2209,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,82.21,,,,,,,fee schedule,79.05,220.15,APC
Lens sphcy bifocal 4.25-7/4.,V2209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,79.05,,,,,,,fee schedule,79.05,220.15,APC
Lens sphcy bifocal 4.25-7/4.,V2209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,120.95,,,,,,,fee schedule,79.05,220.15,Radiology
Lens sphcy bifocal 4.25-7/4.,V2209,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,110.67,,,,,,,fee schedule,79.05,220.15,APC
Lens sphcy bifocal 4.25-7/4.,V2209,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,138.34,,,,,,,fee schedule,79.05,220.15,APC
Lens sphcy bifocal 4.25-7/ov,V2210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,231.7,,,,,,,fee schedule,90.37,251.67,
Lens sphcy bifocal 4.25-7/ov,V2210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,251.67,,,,,,,fee schedule,90.37,251.67,
Lens sphcy bifocal 4.25-7/ov,V2210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,201.74,,,,,,,fee schedule,90.37,251.67,
Lens sphcy bifocal 4.25-7/ov,V2210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,220.38,,,,,,,fee schedule,90.37,251.67,
Lens sphcy bifocal 4.25-7/ov,V2210,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,94.89,,,,,,,fee schedule,90.37,251.67,APC
Lens sphcy bifocal 4.25-7/ov,V2210,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,93.98,,,,,,,fee schedule,90.37,251.67,APC
Lens sphcy bifocal 4.25-7/ov,V2210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,90.37,,,,,,,fee schedule,90.37,251.67,APC
Lens sphcy bifocal 4.25-7/ov,V2210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,138.27,,,,,,,fee schedule,90.37,251.67,Radiology
Lens sphcy bifocal 4.25-7/ov,V2210,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,126.52,,,,,,,fee schedule,90.37,251.67,APC
Lens sphcy bifocal 4.25-7/ov,V2210,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,158.15,,,,,,,fee schedule,90.37,251.67,APC
Lens sphcy bifo 7.25-12/.25-,V2211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,231.8,,,,,,,fee schedule,90.41,251.79,
Lens sphcy bifo 7.25-12/.25-,V2211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,251.79,,,,,,,fee schedule,90.41,251.79,
Lens sphcy bifo 7.25-12/.25-,V2211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,201.83,,,,,,,fee schedule,90.41,251.79,
Lens sphcy bifo 7.25-12/.25-,V2211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,220.48,,,,,,,fee schedule,90.41,251.79,
Lens sphcy bifo 7.25-12/.25-,V2211,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,94.93,,,,,,,fee schedule,90.41,251.79,APC
Lens sphcy bifo 7.25-12/.25-,V2211,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,94.03,,,,,,,fee schedule,90.41,251.79,APC
Lens sphcy bifo 7.25-12/.25-,V2211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,90.41,,,,,,,fee schedule,90.41,251.79,APC
Lens sphcy bifo 7.25-12/.25-,V2211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,138.33,,,,,,,fee schedule,90.41,251.79,Radiology
Lens sphcy bifo 7.25-12/.25-,V2211,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,126.57,,,,,,,fee schedule,90.41,251.79,APC
Lens sphcy bifo 7.25-12/.25-,V2211,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,158.22,,,,,,,fee schedule,90.41,251.79,APC
Lens sphcyl bifo 7.25-12/2.2,V2212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,239.39,,,,,,,fee schedule,93.36,260.03,
Lens sphcyl bifo 7.25-12/2.2,V2212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,260.03,,,,,,,fee schedule,93.36,260.03,
Lens sphcyl bifo 7.25-12/2.2,V2212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,208.43,,,,,,,fee schedule,93.36,260.03,
Lens sphcyl bifo 7.25-12/2.2,V2212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,227.69,,,,,,,fee schedule,93.36,260.03,
Lens sphcyl bifo 7.25-12/2.2,V2212,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,98.03,,,,,,,fee schedule,93.36,260.03,APC
Lens sphcyl bifo 7.25-12/2.2,V2212,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,97.09,,,,,,,fee schedule,93.36,260.03,APC
Lens sphcyl bifo 7.25-12/2.2,V2212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,93.36,,,,,,,fee schedule,93.36,260.03,APC
Lens sphcyl bifo 7.25-12/2.2,V2212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,142.84,,,,,,,fee schedule,93.36,260.03,Radiology
Lens sphcyl bifo 7.25-12/2.2,V2212,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,130.7,,,,,,,fee schedule,93.36,260.03,APC
Lens sphcyl bifo 7.25-12/2.2,V2212,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,163.38,,,,,,,fee schedule,93.36,260.03,APC
Lens sphcyl bifo 7.25-12/4.2,V2213,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,255.78,,,,,,,fee schedule,99.77,277.83,
Lens sphcyl bifo 7.25-12/4.2,V2213,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,277.83,,,,,,,fee schedule,99.77,277.83,
Lens sphcyl bifo 7.25-12/4.2,V2213,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,222.71,,,,,,,fee schedule,99.77,277.83,
Lens sphcyl bifo 7.25-12/4.2,V2213,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,243.29,,,,,,,fee schedule,99.77,277.83,
Lens sphcyl bifo 7.25-12/4.2,V2213,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,104.76,,,,,,,fee schedule,99.77,277.83,APC
Lens sphcyl bifo 7.25-12/4.2,V2213,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,103.76,,,,,,,fee schedule,99.77,277.83,APC
Lens sphcyl bifo 7.25-12/4.2,V2213,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,99.77,,,,,,,fee schedule,99.77,277.83,APC
Lens sphcyl bifo 7.25-12/4.2,V2213,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,152.65,,,,,,,fee schedule,99.77,277.83,Radiology
Lens sphcyl bifo 7.25-12/4.2,V2213,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,139.68,,,,,,,fee schedule,99.77,277.83,APC
Lens sphcyl bifo 7.25-12/4.2,V2213,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,174.6,,,,,,,fee schedule,99.77,277.83,APC
Lens sphcyl bifocal over 12.,V2214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,262.84,,,,,,,fee schedule,102.51,285.5,
Lens sphcyl bifocal over 12.,V2214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,285.5,,,,,,,fee schedule,102.51,285.5,
Lens sphcyl bifocal over 12.,V2214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,228.86,,,,,,,fee schedule,102.51,285.5,
Lens sphcyl bifocal over 12.,V2214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,250,,,,,,,fee schedule,102.51,285.5,
Lens sphcyl bifocal over 12.,V2214,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,107.64,,,,,,,fee schedule,102.51,285.5,APC
Lens sphcyl bifocal over 12.,V2214,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,106.61,,,,,,,fee schedule,102.51,285.5,APC
Lens sphcyl bifocal over 12.,V2214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,102.51,,,,,,,fee schedule,102.51,285.5,APC
Lens sphcyl bifocal over 12.,V2214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,156.84,,,,,,,fee schedule,102.51,285.5,Radiology
Lens sphcyl bifocal over 12.,V2214,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,143.51,,,,,,,fee schedule,102.51,285.5,APC
Lens sphcyl bifocal over 12.,V2214,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,179.39,,,,,,,fee schedule,102.51,285.5,APC
Lens lenticular bifocal,V2215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,299.73,,,,,,,fee schedule,116.89,325.57,
Lens lenticular bifocal,V2215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,325.57,,,,,,,fee schedule,116.89,325.57,
Lens lenticular bifocal,V2215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,260.97,,,,,,,fee schedule,116.89,325.57,
Lens lenticular bifocal,V2215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,285.09,,,,,,,fee schedule,116.89,325.57,
Lens lenticular bifocal,V2215,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,122.73,,,,,,,fee schedule,116.89,325.57,APC
Lens lenticular bifocal,V2215,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,121.57,,,,,,,fee schedule,116.89,325.57,APC
Lens lenticular bifocal,V2215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,116.89,,,,,,,fee schedule,116.89,325.57,APC
Lens lenticular bifocal,V2215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,178.84,,,,,,,fee schedule,116.89,325.57,Radiology
Lens lenticular bifocal,V2215,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,163.65,,,,,,,fee schedule,116.89,325.57,APC
Lens lenticular bifocal,V2215,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,204.56,,,,,,,fee schedule,116.89,325.57,APC
Lens aniseikonic bifocal,V2218,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,317.52,,,,,,,fee schedule,123.83,344.89,
Lens aniseikonic bifocal,V2218,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,344.89,,,,,,,fee schedule,123.83,344.89,
Lens aniseikonic bifocal,V2218,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,276.46,,,,,,,fee schedule,123.83,344.89,
Lens aniseikonic bifocal,V2218,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,302,,,,,,,fee schedule,123.83,344.89,
Lens aniseikonic bifocal,V2218,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.02,,,,,,,fee schedule,123.83,344.89,APC
Lens aniseikonic bifocal,V2218,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.78,,,,,,,fee schedule,123.83,344.89,APC
Lens aniseikonic bifocal,V2218,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.83,,,,,,,fee schedule,123.83,344.89,APC
Lens aniseikonic bifocal,V2218,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,189.46,,,,,,,fee schedule,123.83,344.89,Radiology
Lens aniseikonic bifocal,V2218,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,173.36,,,,,,,fee schedule,123.83,344.89,APC
Lens aniseikonic bifocal,V2218,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,216.7,,,,,,,fee schedule,123.83,344.89,APC
Lens bifocal seg width over,V2219,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,161.44,,,,,,,fee schedule,62.94,175.35,
Lens bifocal seg width over,V2219,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,175.35,,,,,,,fee schedule,62.94,175.35,
Lens bifocal seg width over,V2219,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,140.56,,,,,,,fee schedule,62.94,175.35,
Lens bifocal seg width over,V2219,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,153.55,,,,,,,fee schedule,62.94,175.35,
Lens bifocal seg width over,V2219,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,66.09,,,,,,,fee schedule,62.94,175.35,APC
Lens bifocal seg width over,V2219,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,65.46,,,,,,,fee schedule,62.94,175.35,APC
Lens bifocal seg width over,V2219,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,62.94,,,,,,,fee schedule,62.94,175.35,APC
Lens bifocal seg width over,V2219,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,96.3,,,,,,,fee schedule,62.94,175.35,Radiology
Lens bifocal seg width over,V2219,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,88.12,,,,,,,fee schedule,62.94,175.35,APC
Lens bifocal seg width over,V2219,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,110.14,,,,,,,fee schedule,62.94,175.35,APC
Lens bifocal add over 3.25d,V2220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,147.73,,,,,,,fee schedule,57.62,160.46,
Lens bifocal add over 3.25d,V2220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,160.46,,,,,,,fee schedule,57.62,160.46,
Lens bifocal add over 3.25d,V2220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,128.62,,,,,,,fee schedule,57.62,160.46,
Lens bifocal add over 3.25d,V2220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,140.51,,,,,,,fee schedule,57.62,160.46,
Lens bifocal add over 3.25d,V2220,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,60.5,,,,,,,fee schedule,57.62,160.46,APC
Lens bifocal add over 3.25d,V2220,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,59.92,,,,,,,fee schedule,57.62,160.46,APC
Lens bifocal add over 3.25d,V2220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,57.62,,,,,,,fee schedule,57.62,160.46,APC
Lens bifocal add over 3.25d,V2220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,88.16,,,,,,,fee schedule,57.62,160.46,Radiology
Lens bifocal add over 3.25d,V2220,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,80.67,,,,,,,fee schedule,57.62,160.46,APC
Lens bifocal add over 3.25d,V2220,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,100.84,,,,,,,fee schedule,57.62,160.46,APC
"Lenticular lens, bifocal",V2221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,315.64,,,,,,,fee schedule,123.13,342.85,
"Lenticular lens, bifocal",V2221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,342.85,,,,,,,fee schedule,123.13,342.85,
"Lenticular lens, bifocal",V2221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,274.82,,,,,,,fee schedule,123.13,342.85,
"Lenticular lens, bifocal",V2221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,300.22,,,,,,,fee schedule,123.13,342.85,
"Lenticular lens, bifocal",V2221,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,129.29,,,,,,,fee schedule,123.13,342.85,APC
"Lenticular lens, bifocal",V2221,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.06,,,,,,,fee schedule,123.13,342.85,APC
"Lenticular lens, bifocal",V2221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.13,,,,,,,fee schedule,123.13,342.85,APC
"Lenticular lens, bifocal",V2221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,188.39,,,,,,,fee schedule,123.13,342.85,Radiology
"Lenticular lens, bifocal",V2221,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,172.38,,,,,,,fee schedule,123.13,342.85,APC
"Lenticular lens, bifocal",V2221,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,215.48,,,,,,,fee schedule,123.13,342.85,APC
Lens sphere trifocal 4.00d,V2300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,242.73,,,,,,,fee schedule,94.67,263.66,
Lens sphere trifocal 4.00d,V2300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,263.66,,,,,,,fee schedule,94.67,263.66,
Lens sphere trifocal 4.00d,V2300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,211.34,,,,,,,fee schedule,94.67,263.66,
Lens sphere trifocal 4.00d,V2300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,230.87,,,,,,,fee schedule,94.67,263.66,
Lens sphere trifocal 4.00d,V2300,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,99.4,,,,,,,fee schedule,94.67,263.66,APC
Lens sphere trifocal 4.00d,V2300,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,98.46,,,,,,,fee schedule,94.67,263.66,APC
Lens sphere trifocal 4.00d,V2300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,94.67,,,,,,,fee schedule,94.67,263.66,APC
Lens sphere trifocal 4.00d,V2300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,144.85,,,,,,,fee schedule,94.67,263.66,Radiology
Lens sphere trifocal 4.00d,V2300,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,132.54,,,,,,,fee schedule,94.67,263.66,APC
Lens sphere trifocal 4.00d,V2300,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,165.67,,,,,,,fee schedule,94.67,263.66,APC
Lens sphere trifocal 4.12-7.,V2301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,317.86,,,,,,,fee schedule,123.97,345.27,
Lens sphere trifocal 4.12-7.,V2301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,345.27,,,,,,,fee schedule,123.97,345.27,
Lens sphere trifocal 4.12-7.,V2301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,276.76,,,,,,,fee schedule,123.97,345.27,
Lens sphere trifocal 4.12-7.,V2301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,302.34,,,,,,,fee schedule,123.97,345.27,
Lens sphere trifocal 4.12-7.,V2301,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.17,,,,,,,fee schedule,123.97,345.27,APC
Lens sphere trifocal 4.12-7.,V2301,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.93,,,,,,,fee schedule,123.97,345.27,APC
Lens sphere trifocal 4.12-7.,V2301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.97,,,,,,,fee schedule,123.97,345.27,APC
Lens sphere trifocal 4.12-7.,V2301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,189.67,,,,,,,fee schedule,123.97,345.27,Radiology
Lens sphere trifocal 4.12-7.,V2301,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,173.56,,,,,,,fee schedule,123.97,345.27,APC
Lens sphere trifocal 4.12-7.,V2301,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,216.95,,,,,,,fee schedule,123.97,345.27,APC
Lens sphere trifocal 7.12-20,V2302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,319.39,,,,,,,fee schedule,124.56,346.93,
Lens sphere trifocal 7.12-20,V2302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,346.93,,,,,,,fee schedule,124.56,346.93,
Lens sphere trifocal 7.12-20,V2302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,278.09,,,,,,,fee schedule,124.56,346.93,
Lens sphere trifocal 7.12-20,V2302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,303.79,,,,,,,fee schedule,124.56,346.93,
Lens sphere trifocal 7.12-20,V2302,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.79,,,,,,,fee schedule,124.56,346.93,APC
Lens sphere trifocal 7.12-20,V2302,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,129.54,,,,,,,fee schedule,124.56,346.93,APC
Lens sphere trifocal 7.12-20,V2302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,124.56,,,,,,,fee schedule,124.56,346.93,APC
Lens sphere trifocal 7.12-20,V2302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,190.58,,,,,,,fee schedule,124.56,346.93,Radiology
Lens sphere trifocal 7.12-20,V2302,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,174.38,,,,,,,fee schedule,124.56,346.93,APC
Lens sphere trifocal 7.12-20,V2302,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,217.98,,,,,,,fee schedule,124.56,346.93,APC
Lens sphcy trifocal 4.0/.12-,V2303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,230.69,,,,,,,fee schedule,89.96,250.58,
Lens sphcy trifocal 4.0/.12-,V2303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,250.58,,,,,,,fee schedule,89.96,250.58,
Lens sphcy trifocal 4.0/.12-,V2303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,200.86,,,,,,,fee schedule,89.96,250.58,
Lens sphcy trifocal 4.0/.12-,V2303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,219.42,,,,,,,fee schedule,89.96,250.58,
Lens sphcy trifocal 4.0/.12-,V2303,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,94.46,,,,,,,fee schedule,89.96,250.58,APC
Lens sphcy trifocal 4.0/.12-,V2303,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,93.56,,,,,,,fee schedule,89.96,250.58,APC
Lens sphcy trifocal 4.0/.12-,V2303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,89.96,,,,,,,fee schedule,89.96,250.58,APC
Lens sphcy trifocal 4.0/.12-,V2303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,137.64,,,,,,,fee schedule,89.96,250.58,Radiology
Lens sphcy trifocal 4.0/.12-,V2303,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,125.94,,,,,,,fee schedule,89.96,250.58,APC
Lens sphcy trifocal 4.0/.12-,V2303,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,157.43,,,,,,,fee schedule,89.96,250.58,APC
Lens sphcy trifocal 4.0/2.25,V2304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,225.19,,,,,,,fee schedule,87.84,244.6,
Lens sphcy trifocal 4.0/2.25,V2304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,244.6,,,,,,,fee schedule,87.84,244.6,
Lens sphcy trifocal 4.0/2.25,V2304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,196.07,,,,,,,fee schedule,87.84,244.6,
Lens sphcy trifocal 4.0/2.25,V2304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,214.19,,,,,,,fee schedule,87.84,244.6,
Lens sphcy trifocal 4.0/2.25,V2304,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,92.23,,,,,,,fee schedule,87.84,244.6,APC
Lens sphcy trifocal 4.0/2.25,V2304,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,91.35,,,,,,,fee schedule,87.84,244.6,APC
Lens sphcy trifocal 4.0/2.25,V2304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,87.84,,,,,,,fee schedule,87.84,244.6,APC
Lens sphcy trifocal 4.0/2.25,V2304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,134.4,,,,,,,fee schedule,87.84,244.6,Radiology
Lens sphcy trifocal 4.0/2.25,V2304,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,122.98,,,,,,,fee schedule,87.84,244.6,APC
Lens sphcy trifocal 4.0/2.25,V2304,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,153.72,,,,,,,fee schedule,87.84,244.6,APC
Lens sphcy trifocal 4.0/4.25,V2305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,279.65,,,,,,,fee schedule,109.09,303.76,
Lens sphcy trifocal 4.0/4.25,V2305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,303.76,,,,,,,fee schedule,109.09,303.76,
Lens sphcy trifocal 4.0/4.25,V2305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,243.49,,,,,,,fee schedule,109.09,303.76,
Lens sphcy trifocal 4.0/4.25,V2305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,265.99,,,,,,,fee schedule,109.09,303.76,
Lens sphcy trifocal 4.0/4.25,V2305,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,114.54,,,,,,,fee schedule,109.09,303.76,APC
Lens sphcy trifocal 4.0/4.25,V2305,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,113.45,,,,,,,fee schedule,109.09,303.76,APC
Lens sphcy trifocal 4.0/4.25,V2305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,109.09,,,,,,,fee schedule,109.09,303.76,APC
Lens sphcy trifocal 4.0/4.25,V2305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,166.91,,,,,,,fee schedule,109.09,303.76,Radiology
Lens sphcy trifocal 4.0/4.25,V2305,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,152.73,,,,,,,fee schedule,109.09,303.76,APC
Lens sphcy trifocal 4.0/4.25,V2305,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,190.91,,,,,,,fee schedule,109.09,303.76,APC
Lens sphcyl trifocal 4.00/>6,V2306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,335.51,,,,,,,fee schedule,130.86,364.43,
Lens sphcyl trifocal 4.00/>6,V2306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,364.43,,,,,,,fee schedule,130.86,364.43,
Lens sphcyl trifocal 4.00/>6,V2306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,292.12,,,,,,,fee schedule,130.86,364.43,
Lens sphcyl trifocal 4.00/>6,V2306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,319.12,,,,,,,fee schedule,130.86,364.43,
Lens sphcyl trifocal 4.00/>6,V2306,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,137.4,,,,,,,fee schedule,130.86,364.43,APC
Lens sphcyl trifocal 4.00/>6,V2306,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.09,,,,,,,fee schedule,130.86,364.43,APC
Lens sphcyl trifocal 4.00/>6,V2306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,130.86,,,,,,,fee schedule,130.86,364.43,APC
Lens sphcyl trifocal 4.00/>6,V2306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,200.22,,,,,,,fee schedule,130.86,364.43,Radiology
Lens sphcyl trifocal 4.00/>6,V2306,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,183.2,,,,,,,fee schedule,130.86,364.43,APC
Lens sphcyl trifocal 4.00/>6,V2306,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,229.01,,,,,,,fee schedule,130.86,364.43,APC
Lens sphcy trifocal 4.25-7/.,V2307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,252.16,,,,,,,fee schedule,98.37,273.9,
Lens sphcy trifocal 4.25-7/.,V2307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,273.9,,,,,,,fee schedule,98.37,273.9,
Lens sphcy trifocal 4.25-7/.,V2307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,219.55,,,,,,,fee schedule,98.37,273.9,
Lens sphcy trifocal 4.25-7/.,V2307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,239.84,,,,,,,fee schedule,98.37,273.9,
Lens sphcy trifocal 4.25-7/.,V2307,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,103.29,,,,,,,fee schedule,98.37,273.9,APC
Lens sphcy trifocal 4.25-7/.,V2307,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,102.3,,,,,,,fee schedule,98.37,273.9,APC
Lens sphcy trifocal 4.25-7/.,V2307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,98.37,,,,,,,fee schedule,98.37,273.9,APC
Lens sphcy trifocal 4.25-7/.,V2307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,150.51,,,,,,,fee schedule,98.37,273.9,Radiology
Lens sphcy trifocal 4.25-7/.,V2307,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,137.72,,,,,,,fee schedule,98.37,273.9,APC
Lens sphcy trifocal 4.25-7/.,V2307,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,172.15,,,,,,,fee schedule,98.37,273.9,APC
Lens sphc trifocal 4.25-7/2.,V2308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,262.36,,,,,,,fee schedule,102.33,284.97,
Lens sphc trifocal 4.25-7/2.,V2308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,284.97,,,,,,,fee schedule,102.33,284.97,
Lens sphc trifocal 4.25-7/2.,V2308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,228.43,,,,,,,fee schedule,102.33,284.97,
Lens sphc trifocal 4.25-7/2.,V2308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,249.54,,,,,,,fee schedule,102.33,284.97,
Lens sphc trifocal 4.25-7/2.,V2308,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,107.45,,,,,,,fee schedule,102.33,284.97,APC
Lens sphc trifocal 4.25-7/2.,V2308,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,106.42,,,,,,,fee schedule,102.33,284.97,APC
Lens sphc trifocal 4.25-7/2.,V2308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,102.33,,,,,,,fee schedule,102.33,284.97,APC
Lens sphc trifocal 4.25-7/2.,V2308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,156.56,,,,,,,fee schedule,102.33,284.97,Radiology
Lens sphc trifocal 4.25-7/2.,V2308,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,143.26,,,,,,,fee schedule,102.33,284.97,APC
Lens sphc trifocal 4.25-7/2.,V2308,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,179.08,,,,,,,fee schedule,102.33,284.97,APC
Lens sphc trifocal 4.25-7/4.,V2309,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,293.43,,,,,,,fee schedule,114.45,318.73,
Lens sphc trifocal 4.25-7/4.,V2309,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,318.73,,,,,,,fee schedule,114.45,318.73,
Lens sphc trifocal 4.25-7/4.,V2309,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,255.49,,,,,,,fee schedule,114.45,318.73,
Lens sphc trifocal 4.25-7/4.,V2309,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,279.1,,,,,,,fee schedule,114.45,318.73,
Lens sphc trifocal 4.25-7/4.,V2309,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,120.17,,,,,,,fee schedule,114.45,318.73,APC
Lens sphc trifocal 4.25-7/4.,V2309,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,119.03,,,,,,,fee schedule,114.45,318.73,APC
Lens sphc trifocal 4.25-7/4.,V2309,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,114.45,,,,,,,fee schedule,114.45,318.73,APC
Lens sphc trifocal 4.25-7/4.,V2309,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,175.11,,,,,,,fee schedule,114.45,318.73,Radiology
Lens sphc trifocal 4.25-7/4.,V2309,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,160.23,,,,,,,fee schedule,114.45,318.73,APC
Lens sphc trifocal 4.25-7/4.,V2309,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,200.29,,,,,,,fee schedule,114.45,318.73,APC
Lens sphc trifocal 4.25-7/>6,V2310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,268.76,,,,,,,fee schedule,104.83,291.93,
Lens sphc trifocal 4.25-7/>6,V2310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,291.93,,,,,,,fee schedule,104.83,291.93,
Lens sphc trifocal 4.25-7/>6,V2310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,234.01,,,,,,,fee schedule,104.83,291.93,
Lens sphc trifocal 4.25-7/>6,V2310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,255.63,,,,,,,fee schedule,104.83,291.93,
Lens sphc trifocal 4.25-7/>6,V2310,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,110.07,,,,,,,fee schedule,104.83,291.93,APC
Lens sphc trifocal 4.25-7/>6,V2310,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,109.02,,,,,,,fee schedule,104.83,291.93,APC
Lens sphc trifocal 4.25-7/>6,V2310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,104.83,,,,,,,fee schedule,104.83,291.93,APC
Lens sphc trifocal 4.25-7/>6,V2310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,160.39,,,,,,,fee schedule,104.83,291.93,Radiology
Lens sphc trifocal 4.25-7/>6,V2310,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,146.76,,,,,,,fee schedule,104.83,291.93,APC
Lens sphc trifocal 4.25-7/>6,V2310,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,183.45,,,,,,,fee schedule,104.83,291.93,APC
Lens sphc trifo 7.25-12/.25-,V2311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,336.1,,,,,,,fee schedule,131.08,365.07,
Lens sphc trifo 7.25-12/.25-,V2311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,365.07,,,,,,,fee schedule,131.08,365.07,
Lens sphc trifo 7.25-12/.25-,V2311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,292.64,,,,,,,fee schedule,131.08,365.07,
Lens sphc trifo 7.25-12/.25-,V2311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,319.68,,,,,,,fee schedule,131.08,365.07,
Lens sphc trifo 7.25-12/.25-,V2311,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,137.63,,,,,,,fee schedule,131.08,365.07,APC
Lens sphc trifo 7.25-12/.25-,V2311,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.32,,,,,,,fee schedule,131.08,365.07,APC
Lens sphc trifo 7.25-12/.25-,V2311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.08,,,,,,,fee schedule,131.08,365.07,APC
Lens sphc trifo 7.25-12/.25-,V2311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,200.55,,,,,,,fee schedule,131.08,365.07,Radiology
Lens sphc trifo 7.25-12/.25-,V2311,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,183.51,,,,,,,fee schedule,131.08,365.07,APC
Lens sphc trifo 7.25-12/.25-,V2311,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,229.39,,,,,,,fee schedule,131.08,365.07,APC
Lens sphc trifo 7.25-12/2.25,V2312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,317.76,,,,,,,fee schedule,123.93,345.15,
Lens sphc trifo 7.25-12/2.25,V2312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,345.15,,,,,,,fee schedule,123.93,345.15,
Lens sphc trifo 7.25-12/2.25,V2312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,276.67,,,,,,,fee schedule,123.93,345.15,
Lens sphc trifo 7.25-12/2.25,V2312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,302.24,,,,,,,fee schedule,123.93,345.15,
Lens sphc trifo 7.25-12/2.25,V2312,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.13,,,,,,,fee schedule,123.93,345.15,APC
Lens sphc trifo 7.25-12/2.25,V2312,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,128.89,,,,,,,fee schedule,123.93,345.15,APC
Lens sphc trifo 7.25-12/2.25,V2312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,123.93,,,,,,,fee schedule,123.93,345.15,APC
Lens sphc trifo 7.25-12/2.25,V2312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,189.61,,,,,,,fee schedule,123.93,345.15,Radiology
Lens sphc trifo 7.25-12/2.25,V2312,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,173.5,,,,,,,fee schedule,123.93,345.15,APC
Lens sphc trifo 7.25-12/2.25,V2312,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,216.88,,,,,,,fee schedule,123.93,345.15,APC
Lens sphc trifo 7.25-12/4.25,V2313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,331.89,,,,,,,fee schedule,129.43,360.5,
Lens sphc trifo 7.25-12/4.25,V2313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,360.5,,,,,,,fee schedule,129.43,360.5,
Lens sphc trifo 7.25-12/4.25,V2313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,288.97,,,,,,,fee schedule,129.43,360.5,
Lens sphc trifo 7.25-12/4.25,V2313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,315.67,,,,,,,fee schedule,129.43,360.5,
Lens sphc trifo 7.25-12/4.25,V2313,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,135.9,,,,,,,fee schedule,129.43,360.5,APC
Lens sphc trifo 7.25-12/4.25,V2313,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,134.61,,,,,,,fee schedule,129.43,360.5,APC
Lens sphc trifo 7.25-12/4.25,V2313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,129.43,,,,,,,fee schedule,129.43,360.5,APC
Lens sphc trifo 7.25-12/4.25,V2313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,198.03,,,,,,,fee schedule,129.43,360.5,Radiology
Lens sphc trifo 7.25-12/4.25,V2313,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,181.2,,,,,,,fee schedule,129.43,360.5,APC
Lens sphc trifo 7.25-12/4.25,V2313,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,226.5,,,,,,,fee schedule,129.43,360.5,APC
Lens sphcyl trifocal over 12,V2314,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,337.35,,,,,,,fee schedule,131.58,366.43,
Lens sphcyl trifocal over 12,V2314,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,366.43,,,,,,,fee schedule,131.58,366.43,
Lens sphcyl trifocal over 12,V2314,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,293.73,,,,,,,fee schedule,131.58,366.43,
Lens sphcyl trifocal over 12,V2314,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,320.87,,,,,,,fee schedule,131.58,366.43,
Lens sphcyl trifocal over 12,V2314,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,138.16,,,,,,,fee schedule,131.58,366.43,APC
Lens sphcyl trifocal over 12,V2314,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,136.84,,,,,,,fee schedule,131.58,366.43,APC
Lens sphcyl trifocal over 12,V2314,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,131.58,,,,,,,fee schedule,131.58,366.43,APC
Lens sphcyl trifocal over 12,V2314,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,201.32,,,,,,,fee schedule,131.58,366.43,Radiology
Lens sphcyl trifocal over 12,V2314,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,184.21,,,,,,,fee schedule,131.58,366.43,APC
Lens sphcyl trifocal over 12,V2314,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,230.26,,,,,,,fee schedule,131.58,366.43,APC
Lens lenticular trifocal,V2315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,374.55,,,,,,,fee schedule,146.08,406.84,
Lens lenticular trifocal,V2315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,406.84,,,,,,,fee schedule,146.08,406.84,
Lens lenticular trifocal,V2315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,326.12,,,,,,,fee schedule,146.08,406.84,
Lens lenticular trifocal,V2315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,356.26,,,,,,,fee schedule,146.08,406.84,
Lens lenticular trifocal,V2315,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,153.38,,,,,,,fee schedule,146.08,406.84,APC
Lens lenticular trifocal,V2315,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,151.92,,,,,,,fee schedule,146.08,406.84,APC
Lens lenticular trifocal,V2315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,146.08,,,,,,,fee schedule,146.08,406.84,APC
Lens lenticular trifocal,V2315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,223.5,,,,,,,fee schedule,146.08,406.84,Radiology
Lens lenticular trifocal,V2315,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,204.51,,,,,,,fee schedule,146.08,406.84,APC
Lens lenticular trifocal,V2315,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,255.64,,,,,,,fee schedule,146.08,406.84,APC
Lens aniseikonic trifocal,V2318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,460.44,,,,,,,fee schedule,179.58,500.13,
Lens aniseikonic trifocal,V2318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,500.13,,,,,,,fee schedule,179.58,500.13,
Lens aniseikonic trifocal,V2318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,400.9,,,,,,,fee schedule,179.58,500.13,
Lens aniseikonic trifocal,V2318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,437.95,,,,,,,fee schedule,179.58,500.13,
Lens aniseikonic trifocal,V2318,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,188.56,,,,,,,fee schedule,179.58,500.13,APC
Lens aniseikonic trifocal,V2318,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,186.76,,,,,,,fee schedule,179.58,500.13,APC
Lens aniseikonic trifocal,V2318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,179.58,,,,,,,fee schedule,179.58,500.13,APC
Lens aniseikonic trifocal,V2318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,274.76,,,,,,,fee schedule,179.58,500.13,Radiology
Lens aniseikonic trifocal,V2318,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,251.41,,,,,,,fee schedule,179.58,500.13,APC
Lens aniseikonic trifocal,V2318,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,314.27,,,,,,,fee schedule,179.58,500.13,APC
Lens trifocal seg width > 28,V2319,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,175.95,,,,,,,fee schedule,68.64,191.12,
Lens trifocal seg width > 28,V2319,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,191.12,,,,,,,fee schedule,68.64,191.12,
Lens trifocal seg width > 28,V2319,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,153.2,,,,,,,fee schedule,68.64,191.12,
Lens trifocal seg width > 28,V2319,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,167.35,,,,,,,fee schedule,68.64,191.12,
Lens trifocal seg width > 28,V2319,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,72.07,,,,,,,fee schedule,68.64,191.12,APC
Lens trifocal seg width > 28,V2319,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,71.39,,,,,,,fee schedule,68.64,191.12,APC
Lens trifocal seg width > 28,V2319,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,68.64,,,,,,,fee schedule,68.64,191.12,APC
Lens trifocal seg width > 28,V2319,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,105.02,,,,,,,fee schedule,68.64,191.12,Radiology
Lens trifocal seg width > 28,V2319,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,96.1,,,,,,,fee schedule,68.64,191.12,APC
Lens trifocal seg width > 28,V2319,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,120.12,,,,,,,fee schedule,68.64,191.12,APC
Lens trifocal add over 3.25d,V2320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,219.27,,,,,,,fee schedule,85.52,238.18,
Lens trifocal add over 3.25d,V2320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,238.18,,,,,,,fee schedule,85.52,238.18,
Lens trifocal add over 3.25d,V2320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,190.92,,,,,,,fee schedule,85.52,238.18,
Lens trifocal add over 3.25d,V2320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,208.56,,,,,,,fee schedule,85.52,238.18,
Lens trifocal add over 3.25d,V2320,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,89.8,,,,,,,fee schedule,85.52,238.18,APC
Lens trifocal add over 3.25d,V2320,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,88.94,,,,,,,fee schedule,85.52,238.18,APC
Lens trifocal add over 3.25d,V2320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,85.52,,,,,,,fee schedule,85.52,238.18,APC
Lens trifocal add over 3.25d,V2320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,130.85,,,,,,,fee schedule,85.52,238.18,Radiology
Lens trifocal add over 3.25d,V2320,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,119.73,,,,,,,fee schedule,85.52,238.18,APC
Lens trifocal add over 3.25d,V2320,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,149.66,,,,,,,fee schedule,85.52,238.18,APC
"Lenticular lens, trifocal",V2321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,373.4,,,,,,,fee schedule,145.66,405.59,
"Lenticular lens, trifocal",V2321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,405.59,,,,,,,fee schedule,145.66,405.59,
"Lenticular lens, trifocal",V2321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,325.12,,,,,,,fee schedule,145.66,405.59,
"Lenticular lens, trifocal",V2321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,355.16,,,,,,,fee schedule,145.66,405.59,
"Lenticular lens, trifocal",V2321,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,152.94,,,,,,,fee schedule,145.66,405.59,APC
"Lenticular lens, trifocal",V2321,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,151.49,,,,,,,fee schedule,145.66,405.59,APC
"Lenticular lens, trifocal",V2321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,145.66,,,,,,,fee schedule,145.66,405.59,APC
"Lenticular lens, trifocal",V2321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,222.86,,,,,,,fee schedule,145.66,405.59,Radiology
"Lenticular lens, trifocal",V2321,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,203.92,,,,,,,fee schedule,145.66,405.59,APC
"Lenticular lens, trifocal",V2321,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,254.9,,,,,,,fee schedule,145.66,405.59,APC
Lens variab asphericity sing,V2410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,332.06,,,,,,,fee schedule,129.49,360.69,
Lens variab asphericity sing,V2410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,360.69,,,,,,,fee schedule,129.49,360.69,
Lens variab asphericity sing,V2410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,289.12,,,,,,,fee schedule,129.49,360.69,
Lens variab asphericity sing,V2410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,315.84,,,,,,,fee schedule,129.49,360.69,
Lens variab asphericity sing,V2410,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,135.96,,,,,,,fee schedule,129.49,360.69,APC
Lens variab asphericity sing,V2410,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,134.67,,,,,,,fee schedule,129.49,360.69,APC
Lens variab asphericity sing,V2410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,129.49,,,,,,,fee schedule,129.49,360.69,APC
Lens variab asphericity sing,V2410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,198.12,,,,,,,fee schedule,129.49,360.69,Radiology
Lens variab asphericity sing,V2410,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,181.29,,,,,,,fee schedule,129.49,360.69,APC
Lens variab asphericity sing,V2410,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,226.61,,,,,,,fee schedule,129.49,360.69,APC
Lens variable asphericity bi,V2430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,384.61,,,,,,,fee schedule,149.99,417.77,
Lens variable asphericity bi,V2430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,417.77,,,,,,,fee schedule,149.99,417.77,
Lens variable asphericity bi,V2430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,334.88,,,,,,,fee schedule,149.99,417.77,
Lens variable asphericity bi,V2430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,365.82,,,,,,,fee schedule,149.99,417.77,
Lens variable asphericity bi,V2430,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,157.49,,,,,,,fee schedule,149.99,417.77,APC
Lens variable asphericity bi,V2430,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,155.99,,,,,,,fee schedule,149.99,417.77,APC
Lens variable asphericity bi,V2430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,149.99,,,,,,,fee schedule,149.99,417.77,APC
Lens variable asphericity bi,V2430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,229.48,,,,,,,fee schedule,149.99,417.77,Radiology
Lens variable asphericity bi,V2430,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,209.99,,,,,,,fee schedule,149.99,417.77,APC
Lens variable asphericity bi,V2430,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,262.48,,,,,,,fee schedule,149.99,417.77,APC
Contact lens pmma spherical,V2500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,318.91,,,,,,,fee schedule,124.39,346.4,
Contact lens pmma spherical,V2500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,346.4,,,,,,,fee schedule,124.39,346.4,
Contact lens pmma spherical,V2500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,277.67,,,,,,,fee schedule,124.39,346.4,
Contact lens pmma spherical,V2500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,303.33,,,,,,,fee schedule,124.39,346.4,
Contact lens pmma spherical,V2500,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,130.61,,,,,,,fee schedule,124.39,346.4,APC
Contact lens pmma spherical,V2500,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,129.37,,,,,,,fee schedule,124.39,346.4,APC
Contact lens pmma spherical,V2500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,124.39,,,,,,,fee schedule,124.39,346.4,APC
Contact lens pmma spherical,V2500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,190.32,,,,,,,fee schedule,124.39,346.4,Radiology
Contact lens pmma spherical,V2500,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,174.15,,,,,,,fee schedule,124.39,346.4,APC
Contact lens pmma spherical,V2500,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,217.68,,,,,,,fee schedule,124.39,346.4,APC
Cntct lens pmma-toric/prism,V2501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,388.61,,,,,,,fee schedule,151.57,422.11,
Cntct lens pmma-toric/prism,V2501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,422.11,,,,,,,fee schedule,151.57,422.11,
Cntct lens pmma-toric/prism,V2501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,338.36,,,,,,,fee schedule,151.57,422.11,
Cntct lens pmma-toric/prism,V2501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,369.63,,,,,,,fee schedule,151.57,422.11,
Cntct lens pmma-toric/prism,V2501,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,159.15,,,,,,,fee schedule,151.57,422.11,APC
Cntct lens pmma-toric/prism,V2501,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,157.63,,,,,,,fee schedule,151.57,422.11,APC
Cntct lens pmma-toric/prism,V2501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,151.57,,,,,,,fee schedule,151.57,422.11,APC
Cntct lens pmma-toric/prism,V2501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,231.9,,,,,,,fee schedule,151.57,422.11,Radiology
Cntct lens pmma-toric/prism,V2501,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,212.2,,,,,,,fee schedule,151.57,422.11,APC
Cntct lens pmma-toric/prism,V2501,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,265.25,,,,,,,fee schedule,151.57,422.11,APC
Contact lens pmma bifocal,V2502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,478.74,,,,,,,fee schedule,186.72,520.01,
Contact lens pmma bifocal,V2502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,520.01,,,,,,,fee schedule,186.72,520.01,
Contact lens pmma bifocal,V2502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,416.84,,,,,,,fee schedule,186.72,520.01,
Contact lens pmma bifocal,V2502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,455.36,,,,,,,fee schedule,186.72,520.01,
Contact lens pmma bifocal,V2502,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,196.06,,,,,,,fee schedule,186.72,520.01,APC
Contact lens pmma bifocal,V2502,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,194.19,,,,,,,fee schedule,186.72,520.01,APC
Contact lens pmma bifocal,V2502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,186.72,,,,,,,fee schedule,186.72,520.01,APC
Contact lens pmma bifocal,V2502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,285.68,,,,,,,fee schedule,186.72,520.01,Radiology
Contact lens pmma bifocal,V2502,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,261.41,,,,,,,fee schedule,186.72,520.01,APC
Contact lens pmma bifocal,V2502,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,326.76,,,,,,,fee schedule,186.72,520.01,APC
Cntct lens pmma color vision,V2503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,440.92,,,,,,,fee schedule,171.97,478.93,
Cntct lens pmma color vision,V2503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,478.93,,,,,,,fee schedule,171.97,478.93,
Cntct lens pmma color vision,V2503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,383.9,,,,,,,fee schedule,171.97,478.93,
Cntct lens pmma color vision,V2503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,419.38,,,,,,,fee schedule,171.97,478.93,
Cntct lens pmma color vision,V2503,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,180.57,,,,,,,fee schedule,171.97,478.93,APC
Cntct lens pmma color vision,V2503,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,178.85,,,,,,,fee schedule,171.97,478.93,APC
Cntct lens pmma color vision,V2503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,171.97,,,,,,,fee schedule,171.97,478.93,APC
Cntct lens pmma color vision,V2503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,263.11,,,,,,,fee schedule,171.97,478.93,Radiology
Cntct lens pmma color vision,V2503,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,240.76,,,,,,,fee schedule,171.97,478.93,APC
Cntct lens pmma color vision,V2503,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,300.95,,,,,,,fee schedule,171.97,478.93,APC
Cntct gas permeable sphericl,V2510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,460.54,,,,,,,fee schedule,179.61,500.25,
Cntct gas permeable sphericl,V2510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,500.25,,,,,,,fee schedule,179.61,500.25,
Cntct gas permeable sphericl,V2510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,400.99,,,,,,,fee schedule,179.61,500.25,
Cntct gas permeable sphericl,V2510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,438.05,,,,,,,fee schedule,179.61,500.25,
Cntct gas permeable sphericl,V2510,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,188.59,,,,,,,fee schedule,179.61,500.25,APC
Cntct gas permeable sphericl,V2510,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,186.79,,,,,,,fee schedule,179.61,500.25,APC
Cntct gas permeable sphericl,V2510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,179.61,,,,,,,fee schedule,179.61,500.25,APC
Cntct gas permeable sphericl,V2510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,274.8,,,,,,,fee schedule,179.61,500.25,Radiology
Cntct gas permeable sphericl,V2510,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,251.45,,,,,,,fee schedule,179.61,500.25,APC
Cntct gas permeable sphericl,V2510,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,314.32,,,,,,,fee schedule,179.61,500.25,APC
Cntct toric prism ballast,V2511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,597.27,,,,,,,fee schedule,232.93,648.76,
Cntct toric prism ballast,V2511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,648.76,,,,,,,fee schedule,232.93,648.76,
Cntct toric prism ballast,V2511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,520.04,,,,,,,fee schedule,232.93,648.76,
Cntct toric prism ballast,V2511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,568.1,,,,,,,fee schedule,232.93,648.76,
Cntct toric prism ballast,V2511,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,244.58,,,,,,,fee schedule,232.93,648.76,APC
Cntct toric prism ballast,V2511,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,242.25,,,,,,,fee schedule,232.93,648.76,APC
Cntct toric prism ballast,V2511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,232.93,,,,,,,fee schedule,232.93,648.76,APC
Cntct toric prism ballast,V2511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,356.38,,,,,,,fee schedule,232.93,648.76,Radiology
Cntct toric prism ballast,V2511,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,326.1,,,,,,,fee schedule,232.93,648.76,APC
Cntct toric prism ballast,V2511,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,407.63,,,,,,,fee schedule,232.93,648.76,APC
Cntct lens gas permbl bifocl,V2512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,788.43,,,,,,,fee schedule,307.49,856.4,
Cntct lens gas permbl bifocl,V2512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,856.4,,,,,,,fee schedule,307.49,856.4,
Cntct lens gas permbl bifocl,V2512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,686.48,,,,,,,fee schedule,307.49,856.4,
Cntct lens gas permbl bifocl,V2512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,749.91,,,,,,,fee schedule,307.49,856.4,
Cntct lens gas permbl bifocl,V2512,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,322.86,,,,,,,fee schedule,307.49,856.4,APC
Cntct lens gas permbl bifocl,V2512,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,319.79,,,,,,,fee schedule,307.49,856.4,APC
Cntct lens gas permbl bifocl,V2512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,307.49,,,,,,,fee schedule,307.49,856.4,APC
Cntct lens gas permbl bifocl,V2512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,470.46,,,,,,,fee schedule,307.49,856.4,Radiology
Cntct lens gas permbl bifocl,V2512,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,430.49,,,,,,,fee schedule,307.49,856.4,APC
Cntct lens gas permbl bifocl,V2512,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,538.11,,,,,,,fee schedule,307.49,856.4,APC
Contact lens extended wear,V2513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,661.93,,,,,,,fee schedule,258.16,718.99,
Contact lens extended wear,V2513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,718.99,,,,,,,fee schedule,258.16,718.99,
Contact lens extended wear,V2513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,576.34,,,,,,,fee schedule,258.16,718.99,
Contact lens extended wear,V2513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,629.6,,,,,,,fee schedule,258.16,718.99,
Contact lens extended wear,V2513,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,271.07,,,,,,,fee schedule,258.16,718.99,APC
Contact lens extended wear,V2513,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,268.49,,,,,,,fee schedule,258.16,718.99,APC
Contact lens extended wear,V2513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,258.16,,,,,,,fee schedule,258.16,718.99,APC
Contact lens extended wear,V2513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,394.98,,,,,,,fee schedule,258.16,718.99,Radiology
Contact lens extended wear,V2513,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.42,,,,,,,fee schedule,258.16,718.99,APC
Contact lens extended wear,V2513,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,451.78,,,,,,,fee schedule,258.16,718.99,APC
Contact lens hydrophilic,V2520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,396.3,,,,,,,fee schedule,154.56,430.47,
Contact lens hydrophilic,V2520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,430.47,,,,,,,fee schedule,154.56,430.47,
Contact lens hydrophilic,V2520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,345.06,,,,,,,fee schedule,154.56,430.47,
Contact lens hydrophilic,V2520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,376.94,,,,,,,fee schedule,154.56,430.47,
Contact lens hydrophilic,V2520,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,162.29,,,,,,,fee schedule,154.56,430.47,APC
Contact lens hydrophilic,V2520,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,160.74,,,,,,,fee schedule,154.56,430.47,APC
Contact lens hydrophilic,V2520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,154.56,,,,,,,fee schedule,154.56,430.47,APC
Contact lens hydrophilic,V2520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,236.48,,,,,,,fee schedule,154.56,430.47,Radiology
Contact lens hydrophilic,V2520,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,216.38,,,,,,,fee schedule,154.56,430.47,APC
Contact lens hydrophilic,V2520,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,270.48,,,,,,,fee schedule,154.56,430.47,APC
Cntct lens hydrophilic toric,V2521,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,606.01,,,,,,,fee schedule,236.36,658.25,
Cntct lens hydrophilic toric,V2521,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,658.25,,,,,,,fee schedule,236.36,658.25,
Cntct lens hydrophilic toric,V2521,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,527.64,,,,,,,fee schedule,236.36,658.25,
Cntct lens hydrophilic toric,V2521,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,576.4,,,,,,,fee schedule,236.36,658.25,
Cntct lens hydrophilic toric,V2521,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,248.18,,,,,,,fee schedule,236.36,658.25,APC
Cntct lens hydrophilic toric,V2521,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,245.81,,,,,,,fee schedule,236.36,658.25,APC
Cntct lens hydrophilic toric,V2521,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,236.36,,,,,,,fee schedule,236.36,658.25,APC
Cntct lens hydrophilic toric,V2521,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,361.63,,,,,,,fee schedule,236.36,658.25,Radiology
Cntct lens hydrophilic toric,V2521,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,330.9,,,,,,,fee schedule,236.36,658.25,APC
Cntct lens hydrophilic toric,V2521,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,413.63,,,,,,,fee schedule,236.36,658.25,APC
Cntct lens hydrophil bifocl,V2522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,739.53,,,,,,,fee schedule,288.43,803.29,
Cntct lens hydrophil bifocl,V2522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,803.29,,,,,,,fee schedule,288.43,803.29,
Cntct lens hydrophil bifocl,V2522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,643.91,,,,,,,fee schedule,288.43,803.29,
Cntct lens hydrophil bifocl,V2522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,703.41,,,,,,,fee schedule,288.43,803.29,
Cntct lens hydrophil bifocl,V2522,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,302.85,,,,,,,fee schedule,288.43,803.29,APC
Cntct lens hydrophil bifocl,V2522,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,299.97,,,,,,,fee schedule,288.43,803.29,APC
Cntct lens hydrophil bifocl,V2522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,288.43,,,,,,,fee schedule,288.43,803.29,APC
Cntct lens hydrophil bifocl,V2522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,441.3,,,,,,,fee schedule,288.43,803.29,Radiology
Cntct lens hydrophil bifocl,V2522,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,403.8,,,,,,,fee schedule,288.43,803.29,APC
Cntct lens hydrophil bifocl,V2522,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,504.75,,,,,,,fee schedule,288.43,803.29,APC
Cntct lens hydrophil extend,V2523,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,577.71,,,,,,,fee schedule,225.33,627.52,
Cntct lens hydrophil extend,V2523,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,627.52,,,,,,,fee schedule,225.33,627.52,
Cntct lens hydrophil extend,V2523,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,503.01,,,,,,,fee schedule,225.33,627.52,
Cntct lens hydrophil extend,V2523,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,549.49,,,,,,,fee schedule,225.33,627.52,
Cntct lens hydrophil extend,V2523,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,236.6,,,,,,,fee schedule,225.33,627.52,APC
Cntct lens hydrophil extend,V2523,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,234.34,,,,,,,fee schedule,225.33,627.52,APC
Cntct lens hydrophil extend,V2523,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,225.33,,,,,,,fee schedule,225.33,627.52,APC
Cntct lens hydrophil extend,V2523,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,344.75,,,,,,,fee schedule,225.33,627.52,Radiology
Cntct lens hydrophil extend,V2523,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,315.46,,,,,,,fee schedule,225.33,627.52,APC
Cntct lens hydrophil extend,V2523,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,394.33,,,,,,,fee schedule,225.33,627.52,APC
Cntct lens hydrophil photoch,V2524,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,189.13,,,,,,,fee schedule,180.12,315.21,APC
Cntct lens hydrophil photoch,V2524,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,187.32,,,,,,,fee schedule,180.12,315.21,APC
Cntct lens hydrophil photoch,V2524,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,180.12,,,,,,,fee schedule,180.12,315.21,APC
Cntct lens hydrophil photoch,V2524,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,275.58,,,,,,,fee schedule,180.12,315.21,Radiology
Cntct lens hydrophil photoch,V2524,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,252.17,,,,,,,fee schedule,180.12,315.21,APC
Cntct lens hydrophil photoch,V2524,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,315.21,,,,,,,fee schedule,180.12,315.21,APC
Contact lens gas impermeable,V2530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,892.38,,,,,,,fee schedule,348.04,969.31,
Contact lens gas impermeable,V2530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,969.31,,,,,,,fee schedule,348.04,969.31,
Contact lens gas impermeable,V2530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,776.98,,,,,,,fee schedule,348.04,969.31,
Contact lens gas impermeable,V2530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,848.78,,,,,,,fee schedule,348.04,969.31,
Contact lens gas impermeable,V2530,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,365.44,,,,,,,fee schedule,348.04,969.31,APC
Contact lens gas impermeable,V2530,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,361.96,,,,,,,fee schedule,348.04,969.31,APC
Contact lens gas impermeable,V2530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,348.04,,,,,,,fee schedule,348.04,969.31,APC
Contact lens gas impermeable,V2530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,532.5,,,,,,,fee schedule,348.04,969.31,Radiology
Contact lens gas impermeable,V2530,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,487.26,,,,,,,fee schedule,348.04,969.31,APC
Contact lens gas impermeable,V2530,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,609.07,,,,,,,fee schedule,348.04,969.31,APC
Contact lens gas permeable,V2531,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1718.53,,,,,,,fee schedule,670.24,1866.68,
Contact lens gas permeable,V2531,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1866.68,,,,,,,fee schedule,670.24,1866.68,
Contact lens gas permeable,V2531,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1496.3,,,,,,,fee schedule,670.24,1866.68,
Contact lens gas permeable,V2531,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1634.58,,,,,,,fee schedule,670.24,1866.68,
Contact lens gas permeable,V2531,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,703.75,,,,,,,fee schedule,670.24,1866.68,APC
Contact lens gas permeable,V2531,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,697.05,,,,,,,fee schedule,670.24,1866.68,APC
Contact lens gas permeable,V2531,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,670.24,,,,,,,fee schedule,670.24,1866.68,APC
Contact lens gas permeable,V2531,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1025.47,,,,,,,fee schedule,670.24,1866.68,Radiology
Contact lens gas permeable,V2531,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,938.34,,,,,,,fee schedule,670.24,1866.68,APC
Contact lens gas permeable,V2531,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,1172.92,,,,,,,fee schedule,670.24,1866.68,APC
Plastic eye prosth custom,V2623,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,3756.83,,,,,,,fee schedule,1465.24,4080.7,
Plastic eye prosth custom,V2623,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4080.7,,,,,,,fee schedule,1465.24,4080.7,
Plastic eye prosth custom,V2623,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3271.04,,,,,,,fee schedule,1465.24,4080.7,
Plastic eye prosth custom,V2623,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3573.31,,,,,,,fee schedule,1465.24,4080.7,
Plastic eye prosth custom,V2623,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1538.5,,,,,,,fee schedule,1465.24,4080.7,APC
Plastic eye prosth custom,V2623,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1523.85,,,,,,,fee schedule,1465.24,4080.7,APC
Plastic eye prosth custom,V2623,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1465.24,,,,,,,fee schedule,1465.24,4080.7,APC
Plastic eye prosth custom,V2623,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2241.82,,,,,,,fee schedule,1465.24,4080.7,Radiology
Plastic eye prosth custom,V2623,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2051.34,,,,,,,fee schedule,1465.24,4080.7,APC
Plastic eye prosth custom,V2623,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,2564.17,,,,,,,fee schedule,1465.24,4080.7,APC
Polishing artifical eye,V2624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,250.66,,,,,,,fee schedule,97.78,272.27,
Polishing artifical eye,V2624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,272.27,,,,,,,fee schedule,97.78,272.27,
Polishing artifical eye,V2624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,218.25,,,,,,,fee schedule,97.78,272.27,
Polishing artifical eye,V2624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,238.42,,,,,,,fee schedule,97.78,272.27,
Polishing artifical eye,V2624,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,102.67,,,,,,,fee schedule,97.78,272.27,APC
Polishing artifical eye,V2624,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,101.69,,,,,,,fee schedule,97.78,272.27,APC
Polishing artifical eye,V2624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,97.78,,,,,,,fee schedule,97.78,272.27,APC
Polishing artifical eye,V2624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,149.6,,,,,,,fee schedule,97.78,272.27,Radiology
Polishing artifical eye,V2624,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,136.89,,,,,,,fee schedule,97.78,272.27,APC
Polishing artifical eye,V2624,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,171.12,,,,,,,fee schedule,97.78,272.27,APC
Enlargemnt of eye prosthesis,V2625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1204.08,,,,,,,fee schedule,469.62,1307.88,
Enlargemnt of eye prosthesis,V2625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1307.88,,,,,,,fee schedule,469.62,1307.88,
Enlargemnt of eye prosthesis,V2625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1048.38,,,,,,,fee schedule,469.62,1307.88,
Enlargemnt of eye prosthesis,V2625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1145.26,,,,,,,fee schedule,469.62,1307.88,
Enlargemnt of eye prosthesis,V2625,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,493.1,,,,,,,fee schedule,469.62,1307.88,APC
Enlargemnt of eye prosthesis,V2625,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,488.4,,,,,,,fee schedule,469.62,1307.88,APC
Enlargemnt of eye prosthesis,V2625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,469.62,,,,,,,fee schedule,469.62,1307.88,APC
Enlargemnt of eye prosthesis,V2625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,718.52,,,,,,,fee schedule,469.62,1307.88,Radiology
Enlargemnt of eye prosthesis,V2625,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,657.47,,,,,,,fee schedule,469.62,1307.88,APC
Enlargemnt of eye prosthesis,V2625,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,821.84,,,,,,,fee schedule,469.62,1307.88,APC
Reduction of eye prosthesis,V2626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,834.99,,,,,,,fee schedule,325.67,906.97,
Reduction of eye prosthesis,V2626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,906.97,,,,,,,fee schedule,325.67,906.97,
Reduction of eye prosthesis,V2626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,727.02,,,,,,,fee schedule,325.67,906.97,
Reduction of eye prosthesis,V2626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,794.2,,,,,,,fee schedule,325.67,906.97,
Reduction of eye prosthesis,V2626,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,341.95,,,,,,,fee schedule,325.67,906.97,APC
Reduction of eye prosthesis,V2626,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,338.7,,,,,,,fee schedule,325.67,906.97,APC
Reduction of eye prosthesis,V2626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,325.67,,,,,,,fee schedule,325.67,906.97,APC
Reduction of eye prosthesis,V2626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,498.28,,,,,,,fee schedule,325.67,906.97,Radiology
Reduction of eye prosthesis,V2626,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,455.94,,,,,,,fee schedule,325.67,906.97,APC
Reduction of eye prosthesis,V2626,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,569.92,,,,,,,fee schedule,325.67,906.97,APC
Scleral cover shell,V2627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4545.78,,,,,,,fee schedule,1772.96,4937.66,
Scleral cover shell,V2627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,4937.66,,,,,,,fee schedule,1772.96,4937.66,
Scleral cover shell,V2627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,3957.97,,,,,,,fee schedule,1772.96,4937.66,
Scleral cover shell,V2627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4323.72,,,,,,,fee schedule,1772.96,4937.66,
Scleral cover shell,V2627,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,1861.61,,,,,,,fee schedule,1772.96,4937.66,APC
Scleral cover shell,V2627,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,1843.88,,,,,,,fee schedule,1772.96,4937.66,APC
Scleral cover shell,V2627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1772.96,,,,,,,fee schedule,1772.96,4937.66,APC
Scleral cover shell,V2627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2712.63,,,,,,,fee schedule,1772.96,4937.66,Radiology
Scleral cover shell,V2627,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,2482.14,,,,,,,fee schedule,1772.96,4937.66,APC
Scleral cover shell,V2627,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,3102.68,,,,,,,fee schedule,1772.96,4937.66,APC
Fabrication & fitting,V2628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1182.57,,,,,,,fee schedule,461.21,1284.52,
Fabrication & fitting,V2628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,1284.52,,,,,,,fee schedule,461.21,1284.52,
Fabrication & fitting,V2628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1029.65,,,,,,,fee schedule,461.21,1284.52,
Fabrication & fitting,V2628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,1124.8,,,,,,,fee schedule,461.21,1284.52,
Fabrication & fitting,V2628,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,484.27,,,,,,,fee schedule,461.21,1284.52,APC
Fabrication & fitting,V2628,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,479.66,,,,,,,fee schedule,461.21,1284.52,APC
Fabrication & fitting,V2628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,461.21,,,,,,,fee schedule,461.21,1284.52,APC
Fabrication & fitting,V2628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,705.65,,,,,,,fee schedule,461.21,1284.52,Radiology
Fabrication & fitting,V2628,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,645.69,,,,,,,fee schedule,461.21,1284.52,APC
Fabrication & fitting,V2628,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,807.12,,,,,,,fee schedule,461.21,1284.52,APC
Balance lens,V2700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,166.31,,,,,,,fee schedule,64.87,180.65,
Balance lens,V2700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,180.65,,,,,,,fee schedule,64.87,180.65,
Balance lens,V2700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,144.8,,,,,,,fee schedule,64.87,180.65,
Balance lens,V2700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,158.18,,,,,,,fee schedule,64.87,180.65,
Balance lens,V2700,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,68.11,,,,,,,fee schedule,64.87,180.65,APC
Balance lens,V2700,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,67.46,,,,,,,fee schedule,64.87,180.65,APC
Balance lens,V2700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,64.87,,,,,,,fee schedule,64.87,180.65,APC
Balance lens,V2700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,99.25,,,,,,,fee schedule,64.87,180.65,Radiology
Balance lens,V2700,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,90.82,,,,,,,fee schedule,64.87,180.65,APC
Balance lens,V2700,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,113.52,,,,,,,fee schedule,64.87,180.65,APC
Glass/plastic slab off prism,V2710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,249.66,,,,,,,fee schedule,97.39,271.18,
Glass/plastic slab off prism,V2710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,271.18,,,,,,,fee schedule,97.39,271.18,
Glass/plastic slab off prism,V2710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,217.37,,,,,,,fee schedule,97.39,271.18,
Glass/plastic slab off prism,V2710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,237.46,,,,,,,fee schedule,97.39,271.18,
Glass/plastic slab off prism,V2710,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,102.26,,,,,,,fee schedule,97.39,271.18,APC
Glass/plastic slab off prism,V2710,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,101.29,,,,,,,fee schedule,97.39,271.18,APC
Glass/plastic slab off prism,V2710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,97.39,,,,,,,fee schedule,97.39,271.18,APC
Glass/plastic slab off prism,V2710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,149.01,,,,,,,fee schedule,97.39,271.18,Radiology
Glass/plastic slab off prism,V2710,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,136.35,,,,,,,fee schedule,97.39,271.18,APC
Glass/plastic slab off prism,V2710,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,170.43,,,,,,,fee schedule,97.39,271.18,APC
Prism lens/es,V2715,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41.2,,,,,,,fee schedule,16.08,44.76,
Prism lens/es,V2715,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,44.76,,,,,,,fee schedule,16.08,44.76,
Prism lens/es,V2715,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35.88,,,,,,,fee schedule,16.08,44.76,
Prism lens/es,V2715,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39.19,,,,,,,fee schedule,16.08,44.76,
Prism lens/es,V2715,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.88,,,,,,,fee schedule,16.08,44.76,APC
Prism lens/es,V2715,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,16.72,,,,,,,fee schedule,16.08,44.76,APC
Prism lens/es,V2715,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16.08,,,,,,,fee schedule,16.08,44.76,APC
Prism lens/es,V2715,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24.6,,,,,,,fee schedule,16.08,44.76,Radiology
Prism lens/es,V2715,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22.51,,,,,,,fee schedule,16.08,44.76,APC
Prism lens/es,V2715,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,28.14,,,,,,,fee schedule,16.08,44.76,APC
Fresnell prism press-on lens,V2718,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,102.35,,,,,,,fee schedule,39.93,111.17,
Fresnell prism press-on lens,V2718,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,111.17,,,,,,,fee schedule,39.93,111.17,
Fresnell prism press-on lens,V2718,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,89.11,,,,,,,fee schedule,39.93,111.17,
Fresnell prism press-on lens,V2718,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,97.35,,,,,,,fee schedule,39.93,111.17,
Fresnell prism press-on lens,V2718,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,41.93,,,,,,,fee schedule,39.93,111.17,APC
Fresnell prism press-on lens,V2718,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,41.53,,,,,,,fee schedule,39.93,111.17,APC
Fresnell prism press-on lens,V2718,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,39.93,,,,,,,fee schedule,39.93,111.17,APC
Fresnell prism press-on lens,V2718,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,61.09,,,,,,,fee schedule,39.93,111.17,Radiology
Fresnell prism press-on lens,V2718,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,55.9,,,,,,,fee schedule,39.93,111.17,APC
Fresnell prism press-on lens,V2718,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,69.88,,,,,,,fee schedule,39.93,111.17,APC
Special base curve,V2730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,88.25,,,,,,,fee schedule,34.42,95.86,
Special base curve,V2730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,95.86,,,,,,,fee schedule,34.42,95.86,
Special base curve,V2730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,76.84,,,,,,,fee schedule,34.42,95.86,
Special base curve,V2730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,83.94,,,,,,,fee schedule,34.42,95.86,
Special base curve,V2730,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,36.14,,,,,,,fee schedule,34.42,95.86,APC
Special base curve,V2730,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,35.8,,,,,,,fee schedule,34.42,95.86,APC
Special base curve,V2730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,34.42,,,,,,,fee schedule,34.42,95.86,APC
Special base curve,V2730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,52.66,,,,,,,fee schedule,34.42,95.86,Radiology
Special base curve,V2730,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,48.19,,,,,,,fee schedule,34.42,95.86,APC
Special base curve,V2730,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,60.24,,,,,,,fee schedule,34.42,95.86,APC
Tint photochromatic lens/es,V2744,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,65.6,,,,,,,fee schedule,25.56,71.25,
Tint photochromatic lens/es,V2744,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,71.25,,,,,,,fee schedule,25.56,71.25,
Tint photochromatic lens/es,V2744,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57.12,,,,,,,fee schedule,25.56,71.25,
Tint photochromatic lens/es,V2744,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,62.39,,,,,,,fee schedule,25.56,71.25,
Tint photochromatic lens/es,V2744,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,26.84,,,,,,,fee schedule,25.56,71.25,APC
Tint photochromatic lens/es,V2744,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,26.58,,,,,,,fee schedule,25.56,71.25,APC
Tint photochromatic lens/es,V2744,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,25.56,,,,,,,fee schedule,25.56,71.25,APC
Tint photochromatic lens/es,V2744,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,39.11,,,,,,,fee schedule,25.56,71.25,Radiology
Tint photochromatic lens/es,V2744,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,35.78,,,,,,,fee schedule,25.56,71.25,APC
Tint photochromatic lens/es,V2744,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,44.73,,,,,,,fee schedule,25.56,71.25,APC
"Tint, any color/solid/grad",V2745,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42.98,,,,,,,fee schedule,16.76,46.68,
"Tint, any color/solid/grad",V2745,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46.68,,,,,,,fee schedule,16.76,46.68,
"Tint, any color/solid/grad",V2745,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37.42,,,,,,,fee schedule,16.76,46.68,
"Tint, any color/solid/grad",V2745,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40.88,,,,,,,fee schedule,16.76,46.68,
"Tint, any color/solid/grad",V2745,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,17.6,,,,,,,fee schedule,16.76,46.68,APC
"Tint, any color/solid/grad",V2745,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,17.43,,,,,,,fee schedule,16.76,46.68,APC
"Tint, any color/solid/grad",V2745,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16.76,,,,,,,fee schedule,16.76,46.68,APC
"Tint, any color/solid/grad",V2745,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25.64,,,,,,,fee schedule,16.76,46.68,Radiology
"Tint, any color/solid/grad",V2745,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.46,,,,,,,fee schedule,16.76,46.68,APC
"Tint, any color/solid/grad",V2745,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,29.33,,,,,,,fee schedule,16.76,46.68,APC
Anti-reflective coating,V2750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,79.87,,,,,,,fee schedule,31.15,86.75,
Anti-reflective coating,V2750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,86.75,,,,,,,fee schedule,31.15,86.75,
Anti-reflective coating,V2750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,69.54,,,,,,,fee schedule,31.15,86.75,
Anti-reflective coating,V2750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,75.96,,,,,,,fee schedule,31.15,86.75,
Anti-reflective coating,V2750,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,32.71,,,,,,,fee schedule,31.15,86.75,APC
Anti-reflective coating,V2750,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,32.4,,,,,,,fee schedule,31.15,86.75,APC
Anti-reflective coating,V2750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,31.15,,,,,,,fee schedule,31.15,86.75,APC
Anti-reflective coating,V2750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,47.66,,,,,,,fee schedule,31.15,86.75,Radiology
Anti-reflective coating,V2750,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43.61,,,,,,,fee schedule,31.15,86.75,APC
Anti-reflective coating,V2750,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,54.51,,,,,,,fee schedule,31.15,86.75,APC
UV lens/es,V2755,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,69.53,,,,,,,fee schedule,27.11,75.52,
UV lens/es,V2755,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,75.52,,,,,,,fee schedule,27.11,75.52,
UV lens/es,V2755,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,60.54,,,,,,,fee schedule,27.11,75.52,
UV lens/es,V2755,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66.13,,,,,,,fee schedule,27.11,75.52,
UV lens/es,V2755,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,28.47,,,,,,,fee schedule,27.11,75.52,APC
UV lens/es,V2755,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,28.19,,,,,,,fee schedule,27.11,75.52,APC
UV lens/es,V2755,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,27.11,,,,,,,fee schedule,27.11,75.52,APC
UV lens/es,V2755,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,41.48,,,,,,,fee schedule,27.11,75.52,Radiology
UV lens/es,V2755,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,37.95,,,,,,,fee schedule,27.11,75.52,APC
UV lens/es,V2755,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,47.44,,,,,,,fee schedule,27.11,75.52,APC
Scratch resistant coating,V2760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55.68,,,,,,,fee schedule,48.48,60.48,
Scratch resistant coating,V2760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60.48,,,,,,,fee schedule,48.48,60.48,
Scratch resistant coating,V2760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48.48,,,,,,,fee schedule,48.48,60.48,
Scratch resistant coating,V2760,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52.96,,,,,,,fee schedule,48.48,60.48,
"Polarization, any lens",V2762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,189.21,,,,,,,fee schedule,164.74,205.52,
"Polarization, any lens",V2762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,205.52,,,,,,,fee schedule,164.74,205.52,
"Polarization, any lens",V2762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,164.74,,,,,,,fee schedule,164.74,205.52,
"Polarization, any lens",V2762,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,179.96,,,,,,,fee schedule,164.74,205.52,
Occluder lens/es,V2770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,67.16,,,,,,,fee schedule,26.2,72.95,
Occluder lens/es,V2770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,72.95,,,,,,,fee schedule,26.2,72.95,
Occluder lens/es,V2770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,58.48,,,,,,,fee schedule,26.2,72.95,
Occluder lens/es,V2770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,63.88,,,,,,,fee schedule,26.2,72.95,
Occluder lens/es,V2770,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,27.51,,,,,,,fee schedule,26.2,72.95,APC
Occluder lens/es,V2770,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,27.25,,,,,,,fee schedule,26.2,72.95,APC
Occluder lens/es,V2770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,26.2,,,,,,,fee schedule,26.2,72.95,APC
Occluder lens/es,V2770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40.09,,,,,,,fee schedule,26.2,72.95,Radiology
Occluder lens/es,V2770,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,36.68,,,,,,,fee schedule,26.2,72.95,APC
Occluder lens/es,V2770,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,45.85,,,,,,,fee schedule,26.2,72.95,APC
Oversize lens/es,V2780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,39.32,,,,,,,fee schedule,15.34,42.71,
Oversize lens/es,V2780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42.71,,,,,,,fee schedule,15.34,42.71,
Oversize lens/es,V2780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,34.24,,,,,,,fee schedule,15.34,42.71,
Oversize lens/es,V2780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37.4,,,,,,,fee schedule,15.34,42.71,
Oversize lens/es,V2780,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,16.11,,,,,,,fee schedule,15.34,42.71,APC
Oversize lens/es,V2780,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,15.95,,,,,,,fee schedule,15.34,42.71,APC
Oversize lens/es,V2780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,15.34,,,,,,,fee schedule,15.34,42.71,APC
Oversize lens/es,V2780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23.47,,,,,,,fee schedule,15.34,42.71,Radiology
Oversize lens/es,V2780,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21.48,,,,,,,fee schedule,15.34,42.71,APC
Oversize lens/es,V2780,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,26.84,,,,,,,fee schedule,15.34,42.71,APC
"Lens, 1.54-1.65 p/1.60-1.79g",V2782,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,204.31,,,,,,,fee schedule,79.68,221.92,
"Lens, 1.54-1.65 p/1.60-1.79g",V2782,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,221.92,,,,,,,fee schedule,79.68,221.92,
"Lens, 1.54-1.65 p/1.60-1.79g",V2782,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,177.89,,,,,,,fee schedule,79.68,221.92,
"Lens, 1.54-1.65 p/1.60-1.79g",V2782,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,194.33,,,,,,,fee schedule,79.68,221.92,
"Lens, 1.54-1.65 p/1.60-1.79g",V2782,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,83.66,,,,,,,fee schedule,79.68,221.92,APC
"Lens, 1.54-1.65 p/1.60-1.79g",V2782,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,82.87,,,,,,,fee schedule,79.68,221.92,APC
"Lens, 1.54-1.65 p/1.60-1.79g",V2782,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,79.68,,,,,,,fee schedule,79.68,221.92,APC
"Lens, 1.54-1.65 p/1.60-1.79g",V2782,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,121.91,,,,,,,fee schedule,79.68,221.92,Radiology
"Lens, 1.54-1.65 p/1.60-1.79g",V2782,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,111.55,,,,,,,fee schedule,79.68,221.92,APC
"Lens, 1.54-1.65 p/1.60-1.79g",V2782,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,139.44,,,,,,,fee schedule,79.68,221.92,APC
"Lens, >= 1.66 p/>=1.80 g",V2783,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,230.38,,,,,,,fee schedule,89.83,250.24,
"Lens, >= 1.66 p/>=1.80 g",V2783,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,250.24,,,,,,,fee schedule,89.83,250.24,
"Lens, >= 1.66 p/>=1.80 g",V2783,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,200.59,,,,,,,fee schedule,89.83,250.24,
"Lens, >= 1.66 p/>=1.80 g",V2783,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,219.12,,,,,,,fee schedule,89.83,250.24,
"Lens, >= 1.66 p/>=1.80 g",V2783,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,94.32,,,,,,,fee schedule,89.83,250.24,APC
"Lens, >= 1.66 p/>=1.80 g",V2783,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,93.42,,,,,,,fee schedule,89.83,250.24,APC
"Lens, >= 1.66 p/>=1.80 g",V2783,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,89.83,,,,,,,fee schedule,89.83,250.24,APC
"Lens, >= 1.66 p/>=1.80 g",V2783,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,137.44,,,,,,,fee schedule,89.83,250.24,Radiology
"Lens, >= 1.66 p/>=1.80 g",V2783,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,125.76,,,,,,,fee schedule,89.83,250.24,APC
"Lens, >= 1.66 p/>=1.80 g",V2783,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,157.2,,,,,,,fee schedule,89.83,250.24,APC
Lens polycarb or equal,V2784,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,149.85,,,,,,,fee schedule,58.43,162.77,
Lens polycarb or equal,V2784,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,162.77,,,,,,,fee schedule,58.43,162.77,
Lens polycarb or equal,V2784,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,130.47,,,,,,,fee schedule,58.43,162.77,
Lens polycarb or equal,V2784,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,142.53,,,,,,,fee schedule,58.43,162.77,
Lens polycarb or equal,V2784,HCPCS,,,,,,,facility,outpatient,,,,,,Aetna,Medicare Managed Care Plan,61.35,,,,,,,fee schedule,58.43,162.77,APC
Lens polycarb or equal,V2784,HCPCS,,,,,,,facility,outpatient,,,,,,Bcbs,Medicare Managed Care Plan,60.77,,,,,,,fee schedule,58.43,162.77,APC
Lens polycarb or equal,V2784,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,58.43,,,,,,,fee schedule,58.43,162.77,APC
Lens polycarb or equal,V2784,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,89.4,,,,,,,fee schedule,58.43,162.77,Radiology
Lens polycarb or equal,V2784,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,81.8,,,,,,,fee schedule,58.43,162.77,APC
Lens polycarb or equal,V2784,HCPCS,,,,,,,facility,outpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,102.25,,,,,,,fee schedule,58.43,162.77,APC
"Hearing aid, digit, bin, bte",V5261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15312,,,,,,,fee schedule,13332,16632,
"Hearing aid, digit, bin, bte",V5261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16632,,,,,,,fee schedule,13332,16632,
"Hearing aid, digit, bin, bte",V5261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13332,,,,,,,fee schedule,13332,16632,
"Hearing aid, digit, bin, bte",V5261,HCPCS,,,,,,,facility,outpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14564,,,,,,,fee schedule,13332,16632,
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,217336.17,,,,,,,fee schedule,217336.17,653009.82,
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,217336.17,,,,,,,fee schedule,217336.17,653009.82,
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,290957.22,,,,,,,fee schedule,217336.17,653009.82,
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,277102.17,,,,,,,fee schedule,217336.17,653009.82,
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,485335.24,,,,,,,fee schedule,217336.17,653009.82,
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,377148.1,,,,,,,fee schedule,217336.17,653009.82,
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,653009.82,,,,,,,fee schedule,217336.17,653009.82,
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,448908.76,,,,,,,fee schedule,217336.17,653009.82,
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,406553.82,,,,,,,fee schedule,217336.17,653009.82,
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,332984.31,,,,,,,fee schedule,217336.17,653009.82,
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],210093.52,210093.52,210093.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],46609.54,46609.54,46609.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,219929.98,,,,,,,fee schedule,217336.17,653009.82,MSDRG Base Rate
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,217835.4,,,,,,,fee schedule,217336.17,653009.82,MSDRG Base Rate
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,217835.4,,,,,,,fee schedule,217336.17,653009.82,MSDRG Base Rate
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,219929.98,,,,,,,fee schedule,217336.17,653009.82,MSDRG Base Rate
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,217835.4,,,,,,,fee schedule,217336.17,653009.82,MSDRG Base Rate
Heart Transplant Or Implant Of Heart Assist System With Mcc,1,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,366549.96,,,,,,,fee schedule,217336.17,653009.82,MSDRG Base Rate
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,85029.66,,,,,,,fee schedule,85029.66,255480.72,
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,85029.66,,,,,,,fee schedule,85029.66,255480.72,
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,113832.84,,,,,,,fee schedule,85029.66,255480.72,
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,108412.25,,,,,,,fee schedule,85029.66,255480.72,
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,189880.45,,,,,,,fee schedule,85029.66,255480.72,
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,147553.78,,,,,,,fee schedule,85029.66,255480.72,
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,255480.72,,,,,,,fee schedule,85029.66,255480.72,
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,175629.11,,,,,,,fee schedule,85029.66,255480.72,
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,159058.35,,,,,,,fee schedule,85029.66,255480.72,
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,130275.33,,,,,,,fee schedule,85029.66,255480.72,
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,89524.45,,,,,,,fee schedule,85029.66,255480.72,MSDRG Base Rate
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,88671.84,,,,,,,fee schedule,85029.66,255480.72,MSDRG Base Rate
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,88671.84,,,,,,,fee schedule,85029.66,255480.72,MSDRG Base Rate
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,89524.45,,,,,,,fee schedule,85029.66,255480.72,MSDRG Base Rate
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,88671.84,,,,,,,fee schedule,85029.66,255480.72,MSDRG Base Rate
Heart Transplant Or Implant Of Heart Assist System Without Mcc,2,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,149207.42,,,,,,,fee schedule,85029.66,255480.72,MSDRG Base Rate
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,165358.64,,,,,,,fee schedule,165227.03,496837.76,
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,165358.64,,,,,,,fee schedule,165227.03,496837.76,
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,221372.68,,,,,,,fee schedule,165227.03,496837.76,
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,210831.16,,,,,,,fee schedule,165227.03,496837.76,
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,369263.78,,,,,,,fee schedule,165227.03,496837.76,
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,286950.38,,,,,,,fee schedule,165227.03,496837.76,
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,496837.76,,,,,,,fee schedule,165227.03,496837.76,
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,341548.96,,,,,,,fee schedule,165227.03,496837.76,
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,309323.51,,,,,,,fee schedule,165227.03,496837.76,
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,253348.68,,,,,,,fee schedule,165227.03,496837.76,
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],371676.8,347035.15,393884.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],161397,161397,161397,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],311009.27,311009.27,311009.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",131539.69,131539.69,131539.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],160734.13,160709.5,163675.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],228798.1,228798.1,520771.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],156194.47,156194.47,156194.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],100280.2,500,257988.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,166815.75,,,,,,,fee schedule,165227.03,496837.76,MSDRG Base Rate
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,165227.03,,,,,,,fee schedule,165227.03,496837.76,MSDRG Base Rate
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,165227.03,,,,,,,fee schedule,165227.03,496837.76,MSDRG Base Rate
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,166815.75,,,,,,,fee schedule,165227.03,496837.76,MSDRG Base Rate
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,165227.03,,,,,,,fee schedule,165227.03,496837.76,MSDRG Base Rate
"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major",3,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,278026.24,,,,,,,fee schedule,165227.03,496837.76,MSDRG Base Rate
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,109022.26,,,,,,,fee schedule,108168.52,327569.05,
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,109022.26,,,,,,,fee schedule,108168.52,327569.05,
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,145952.76,,,,,,,fee schedule,108168.52,327569.05,
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,139002.65,,,,,,,fee schedule,108168.52,327569.05,
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,243458.52,,,,,,,fee schedule,108168.52,327569.05,
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,189188.65,,,,,,,fee schedule,108168.52,327569.05,
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,327569.05,,,,,,,fee schedule,108168.52,327569.05,
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,225185.92,,,,,,,fee schedule,108168.52,327569.05,
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,203939.43,,,,,,,fee schedule,108168.52,327569.05,
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,167034.79,,,,,,,fee schedule,108168.52,327569.05,
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],106289.76,106289.76,216682.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",83856.02,83856.02,83856.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],107039.78,107039.78,107039.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],107039.76,107039.76,107039.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],119426.63,119426.63,119426.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,109208.6,,,,,,,fee schedule,108168.52,327569.05,MSDRG Base Rate
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,108168.52,,,,,,,fee schedule,108168.52,327569.05,MSDRG Base Rate
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,108168.52,,,,,,,fee schedule,108168.52,327569.05,MSDRG Base Rate
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,109208.6,,,,,,,fee schedule,108168.52,327569.05,MSDRG Base Rate
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,108168.52,,,,,,,fee schedule,108168.52,327569.05,MSDRG Base Rate
"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.",4,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,182014.33,,,,,,,fee schedule,108168.52,327569.05,MSDRG Base Rate
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,82166.19,,,,,,,fee schedule,80769.01,246877.14,
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,82166.19,,,,,,,fee schedule,80769.01,246877.14,
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,109999.4,,,,,,,fee schedule,80769.01,246877.14,
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,104761.35,,,,,,,fee schedule,80769.01,246877.14,
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,183486.03,,,,,,,fee schedule,80769.01,246877.14,
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,142584.75,,,,,,,fee schedule,80769.01,246877.14,
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,246877.14,,,,,,,fee schedule,80769.01,246877.14,
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,169714.62,,,,,,,fee schedule,80769.01,246877.14,
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,153701.89,,,,,,,fee schedule,80769.01,246877.14,
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,125888.18,,,,,,,fee schedule,80769.01,246877.14,
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,81545.64,,,,,,,fee schedule,80769.01,246877.14,MSDRG Base Rate
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,80769.01,,,,,,,fee schedule,80769.01,246877.14,MSDRG Base Rate
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,80769.01,,,,,,,fee schedule,80769.01,246877.14,MSDRG Base Rate
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,81545.64,,,,,,,fee schedule,80769.01,246877.14,MSDRG Base Rate
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,80769.01,,,,,,,fee schedule,80769.01,246877.14,MSDRG Base Rate
Liver Transplant With Mcc Or Intestinal Transplant,5,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,135909.39,,,,,,,fee schedule,80769.01,246877.14,MSDRG Base Rate
Liver Transplant Without Mcc,6,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,37414.84,,,,,,,fee schedule,36867.44,112416.9,
Liver Transplant Without Mcc,6,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,37414.84,,,,,,,fee schedule,36867.44,112416.9,
Liver Transplant Without Mcc,6,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,50088.85,,,,,,,fee schedule,36867.44,112416.9,
Liver Transplant Without Mcc,6,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,47703.67,,,,,,,fee schedule,36867.44,112416.9,
Liver Transplant Without Mcc,6,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,83551.4,,,,,,,fee schedule,36867.44,112416.9,
Liver Transplant Without Mcc,6,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,64926.77,,,,,,,fee schedule,36867.44,112416.9,
Liver Transplant Without Mcc,6,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,112416.9,,,,,,,fee schedule,36867.44,112416.9,
Liver Transplant Without Mcc,6,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,77280.51,,,,,,,fee schedule,36867.44,112416.9,
Liver Transplant Without Mcc,6,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,69989.02,,,,,,,fee schedule,36867.44,112416.9,
Liver Transplant Without Mcc,6,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,57323.89,,,,,,,fee schedule,36867.44,112416.9,
Liver Transplant Without Mcc,6,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant Without Mcc,6,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant Without Mcc,6,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant Without Mcc,6,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant Without Mcc,6,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant Without Mcc,6,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant Without Mcc,6,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant Without Mcc,6,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant Without Mcc,6,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant Without Mcc,6,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant Without Mcc,6,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant Without Mcc,6,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant Without Mcc,6,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant Without Mcc,6,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant Without Mcc,6,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant Without Mcc,6,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant Without Mcc,6,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant Without Mcc,6,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Liver Transplant Without Mcc,6,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,37221.93,,,,,,,fee schedule,36867.44,112416.9,MSDRG Base Rate
Liver Transplant Without Mcc,6,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,36867.44,,,,,,,fee schedule,36867.44,112416.9,MSDRG Base Rate
Liver Transplant Without Mcc,6,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,36867.44,,,,,,,fee schedule,36867.44,112416.9,MSDRG Base Rate
Liver Transplant Without Mcc,6,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,37221.93,,,,,,,fee schedule,36867.44,112416.9,MSDRG Base Rate
Liver Transplant Without Mcc,6,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,36867.44,,,,,,,fee schedule,36867.44,112416.9,MSDRG Base Rate
Liver Transplant Without Mcc,6,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,62036.56,,,,,,,fee schedule,36867.44,112416.9,MSDRG Base Rate
Lung Transplant,7,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,100833.88,,,,,,,fee schedule,100833.88,302966.19,
Lung Transplant,7,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,100833.88,,,,,,,fee schedule,100833.88,302966.19,
Lung Transplant,7,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,134990.62,,,,,,,fee schedule,100833.88,302966.19,
Lung Transplant,7,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,128562.52,,,,,,,fee schedule,100833.88,302966.19,
Lung Transplant,7,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,225172.98,,,,,,,fee schedule,100833.88,302966.19,
Lung Transplant,7,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,174979.18,,,,,,,fee schedule,100833.88,302966.19,
Lung Transplant,7,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,302966.19,,,,,,,fee schedule,100833.88,302966.19,
Lung Transplant,7,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,208272.79,,,,,,,fee schedule,100833.88,302966.19,
Lung Transplant,7,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,188622.07,,,,,,,fee schedule,100833.88,302966.19,
Lung Transplant,7,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,154489.24,,,,,,,fee schedule,100833.88,302966.19,
Lung Transplant,7,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lung Transplant,7,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Lung Transplant,7,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Lung Transplant,7,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lung Transplant,7,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lung Transplant,7,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Lung Transplant,7,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Lung Transplant,7,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Lung Transplant,7,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Lung Transplant,7,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Lung Transplant,7,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lung Transplant,7,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lung Transplant,7,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Lung Transplant,7,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Lung Transplant,7,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lung Transplant,7,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Lung Transplant,7,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lung Transplant,7,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lung Transplant,7,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,102168.06,,,,,,,fee schedule,100833.88,302966.19,MSDRG Base Rate
Lung Transplant,7,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,101195.03,,,,,,,fee schedule,100833.88,302966.19,MSDRG Base Rate
Lung Transplant,7,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,101195.03,,,,,,,fee schedule,100833.88,302966.19,MSDRG Base Rate
Lung Transplant,7,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,102168.06,,,,,,,fee schedule,100833.88,302966.19,MSDRG Base Rate
Lung Transplant,7,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,101195.03,,,,,,,fee schedule,100833.88,302966.19,MSDRG Base Rate
Lung Transplant,7,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,170280.09,,,,,,,fee schedule,100833.88,302966.19,MSDRG Base Rate
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,41982.03,,,,,,,fee schedule,41982.03,126139.51,
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,41982.03,,,,,,,fee schedule,41982.03,126139.51,
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56203.14,,,,,,,fee schedule,41982.03,126139.51,
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,53526.81,,,,,,,fee schedule,41982.03,126139.51,
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,93750.42,,,,,,,fee schedule,41982.03,126139.51,
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,72852.31,,,,,,,fee schedule,41982.03,126139.51,
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,126139.51,,,,,,,fee schedule,41982.03,126139.51,
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,86714.06,,,,,,,fee schedule,41982.03,126139.51,
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,78532.51,,,,,,,fee schedule,41982.03,126139.51,
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,64321.36,,,,,,,fee schedule,41982.03,126139.51,
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,44781.22,,,,,,,fee schedule,41982.03,126139.51,MSDRG Base Rate
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,44354.73,,,,,,,fee schedule,41982.03,126139.51,MSDRG Base Rate
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,44354.73,,,,,,,fee schedule,41982.03,126139.51,MSDRG Base Rate
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,44781.22,,,,,,,fee schedule,41982.03,126139.51,MSDRG Base Rate
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,44354.73,,,,,,,fee schedule,41982.03,126139.51,MSDRG Base Rate
Simultaneous Pancreas And Kidney Transplant,8,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,74635.36,,,,,,,fee schedule,41982.03,126139.51,MSDRG Base Rate
Bone marrow transplant,9,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bone marrow transplant,9,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Bone marrow transplant,9,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Bone marrow transplant,9,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bone marrow transplant,9,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bone marrow transplant,9,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Bone marrow transplant,9,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Bone marrow transplant,9,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Bone marrow transplant,9,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Bone marrow transplant,9,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Bone marrow transplant,9,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bone marrow transplant,9,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bone marrow transplant,9,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Bone marrow transplant,9,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Bone marrow transplant,9,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bone marrow transplant,9,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Bone marrow transplant,9,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bone marrow transplant,9,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pancreas Transplant,10,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,61517.78,,,,,,,fee schedule,56511.92,184836.76,
Pancreas Transplant,10,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,61517.78,,,,,,,fee schedule,56511.92,184836.76,
Pancreas Transplant,10,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,82356.48,,,,,,,fee schedule,56511.92,184836.76,
Pancreas Transplant,10,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,78434.76,,,,,,,fee schedule,56511.92,184836.76,
Pancreas Transplant,10,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,137375.87,,,,,,,fee schedule,56511.92,184836.76,
Pancreas Transplant,10,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,106753.11,,,,,,,fee schedule,56511.92,184836.76,
Pancreas Transplant,10,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,184836.76,,,,,,,fee schedule,56511.92,184836.76,
Pancreas Transplant,10,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,127065.23,,,,,,,fee schedule,56511.92,184836.76,
Pancreas Transplant,10,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,115076.51,,,,,,,fee schedule,56511.92,184836.76,
Pancreas Transplant,10,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,94252.4,,,,,,,fee schedule,56511.92,184836.76,
Pancreas Transplant,10,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pancreas Transplant,10,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Pancreas Transplant,10,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Pancreas Transplant,10,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pancreas Transplant,10,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pancreas Transplant,10,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Pancreas Transplant,10,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Pancreas Transplant,10,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Pancreas Transplant,10,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Pancreas Transplant,10,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Pancreas Transplant,10,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pancreas Transplant,10,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pancreas Transplant,10,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Pancreas Transplant,10,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Pancreas Transplant,10,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pancreas Transplant,10,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Pancreas Transplant,10,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pancreas Transplant,10,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pancreas Transplant,10,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,57055.3,,,,,,,fee schedule,56511.92,184836.76,MSDRG Base Rate
Pancreas Transplant,10,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,56511.92,,,,,,,fee schedule,56511.92,184836.76,MSDRG Base Rate
Pancreas Transplant,10,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,56511.92,,,,,,,fee schedule,56511.92,184836.76,MSDRG Base Rate
Pancreas Transplant,10,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,57055.3,,,,,,,fee schedule,56511.92,184836.76,MSDRG Base Rate
Pancreas Transplant,10,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,56511.92,,,,,,,fee schedule,56511.92,184836.76,MSDRG Base Rate
Pancreas Transplant,10,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,95092.16,,,,,,,fee schedule,56511.92,184836.76,MSDRG Base Rate
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,41633.26,,,,,,,fee schedule,41633.26,125091.59,
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,41633.26,,,,,,,fee schedule,41633.26,125091.59,
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55736.22,,,,,,,fee schedule,41633.26,125091.59,
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,53082.13,,,,,,,fee schedule,41633.26,125091.59,
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,92971.58,,,,,,,fee schedule,41633.26,125091.59,
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,72247.08,,,,,,,fee schedule,41633.26,125091.59,
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,125091.59,,,,,,,fee schedule,41633.26,125091.59,
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,85993.67,,,,,,,fee schedule,41633.26,125091.59,
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,77880.09,,,,,,,fee schedule,41633.26,125091.59,
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,63787,,,,,,,fee schedule,41633.26,125091.59,
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,43605.45,,,,,,,fee schedule,41633.26,125091.59,MSDRG Base Rate
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,43190.16,,,,,,,fee schedule,41633.26,125091.59,MSDRG Base Rate
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,43190.16,,,,,,,fee schedule,41633.26,125091.59,MSDRG Base Rate
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,43605.45,,,,,,,fee schedule,41633.26,125091.59,MSDRG Base Rate
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,43190.16,,,,,,,fee schedule,41633.26,125091.59,MSDRG Base Rate
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc",11,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,72675.75,,,,,,,fee schedule,41633.26,125091.59,MSDRG Base Rate
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,31662.45,,,,,,,fee schedule,31662.45,95133.23,
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,31662.45,,,,,,,fee schedule,31662.45,95133.23,
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42387.88,,,,,,,fee schedule,31662.45,95133.23,
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40369.41,,,,,,,fee schedule,31662.45,95133.23,
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,70705.69,,,,,,,fee schedule,31662.45,95133.23,
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,54944.53,,,,,,,fee schedule,31662.45,95133.23,
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,95133.23,,,,,,,fee schedule,31662.45,95133.23,
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,65398.92,,,,,,,fee schedule,31662.45,95133.23,
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,59228.48,,,,,,,fee schedule,31662.45,95133.23,
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,48510.56,,,,,,,fee schedule,31662.45,95133.23,
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,33932.91,,,,,,,fee schedule,31662.45,95133.23,MSDRG Base Rate
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,33609.74,,,,,,,fee schedule,31662.45,95133.23,MSDRG Base Rate
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,33609.74,,,,,,,fee schedule,31662.45,95133.23,MSDRG Base Rate
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,33932.91,,,,,,,fee schedule,31662.45,95133.23,MSDRG Base Rate
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,33609.74,,,,,,,fee schedule,31662.45,95133.23,MSDRG Base Rate
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc",12,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,56554.86,,,,,,,fee schedule,31662.45,95133.23,MSDRG Base Rate
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,20446.25,,,,,,,fee schedule,20446.25,61432.96,
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,20446.25,,,,,,,fee schedule,20446.25,61432.96,
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,27372.28,,,,,,,fee schedule,20446.25,61432.96,
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26068.84,,,,,,,fee schedule,20446.25,61432.96,
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,45658.7,,,,,,,fee schedule,20446.25,61432.96,
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,35480.82,,,,,,,fee schedule,20446.25,61432.96,
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,61432.96,,,,,,,fee schedule,20446.25,61432.96,
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,42231.82,,,,,,,fee schedule,20446.25,61432.96,
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,38247.21,,,,,,,fee schedule,20446.25,61432.96,
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,31326.04,,,,,,,fee schedule,20446.25,61432.96,
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",15317.53,15317.53,15317.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,23509.59,,,,,,,fee schedule,20446.25,61432.96,MSDRG Base Rate
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,23285.69,,,,,,,fee schedule,20446.25,61432.96,MSDRG Base Rate
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,23285.69,,,,,,,fee schedule,20446.25,61432.96,MSDRG Base Rate
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,23509.59,,,,,,,fee schedule,20446.25,61432.96,MSDRG Base Rate
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,23285.69,,,,,,,fee schedule,20446.25,61432.96,MSDRG Base Rate
"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc",13,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,39182.66,,,,,,,fee schedule,20446.25,61432.96,MSDRG Base Rate
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,101088.51,,,,,,,fee schedule,93980.89,303731.27,
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,101088.51,,,,,,,fee schedule,93980.89,303731.27,
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,135331.51,,,,,,,fee schedule,93980.89,303731.27,
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,128887.18,,,,,,,fee schedule,93980.89,303731.27,
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,225741.61,,,,,,,fee schedule,93980.89,303731.27,
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,175421.05,,,,,,,fee schedule,93980.89,303731.27,
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,303731.27,,,,,,,fee schedule,93980.89,303731.27,
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,208798.74,,,,,,,fee schedule,93980.89,303731.27,
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,189098.39,,,,,,,fee schedule,93980.89,303731.27,
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,154879.36,,,,,,,fee schedule,93980.89,303731.27,
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,94884.55,,,,,,,fee schedule,93980.89,303731.27,MSDRG Base Rate
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,93980.89,,,,,,,fee schedule,93980.89,303731.27,MSDRG Base Rate
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,93980.89,,,,,,,fee schedule,93980.89,303731.27,MSDRG Base Rate
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,94884.55,,,,,,,fee schedule,93980.89,303731.27,MSDRG Base Rate
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,93980.89,,,,,,,fee schedule,93980.89,303731.27,MSDRG Base Rate
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,158140.92,,,,,,,fee schedule,93980.89,303731.27,MSDRG Base Rate
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,46570.82,,,,,,,fee schedule,46570.82,139927.03,
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,46570.82,,,,,,,fee schedule,46570.82,139927.03,
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,62346.35,,,,,,,fee schedule,46570.82,139927.03,
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,59377.49,,,,,,,fee schedule,46570.82,139927.03,
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,103997.7,,,,,,,fee schedule,46570.82,139927.03,
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,80815.35,,,,,,,fee schedule,46570.82,139927.03,
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,139927.03,,,,,,,fee schedule,46570.82,139927.03,
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,96192.23,,,,,,,fee schedule,46570.82,139927.03,
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,87116.41,,,,,,,fee schedule,46570.82,139927.03,
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,71351.92,,,,,,,fee schedule,46570.82,139927.03,
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,47321.03,,,,,,,fee schedule,46570.82,139927.03,MSDRG Base Rate
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,46870.36,,,,,,,fee schedule,46570.82,139927.03,MSDRG Base Rate
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,46870.36,,,,,,,fee schedule,46570.82,139927.03,MSDRG Base Rate
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,47321.03,,,,,,,fee schedule,46570.82,139927.03,MSDRG Base Rate
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,46870.36,,,,,,,fee schedule,46570.82,139927.03,MSDRG Base Rate
Autologous Bone Marrow Transplant With Cc/Mcc,16,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,78868.39,,,,,,,fee schedule,46570.82,139927.03,MSDRG Base Rate
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,46570.82,,,,,,,fee schedule,43021.47,139927.03,
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,46570.82,,,,,,,fee schedule,43021.47,139927.03,
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,62346.35,,,,,,,fee schedule,43021.47,139927.03,
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,59377.49,,,,,,,fee schedule,43021.47,139927.03,
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,103997.7,,,,,,,fee schedule,43021.47,139927.03,
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,80815.35,,,,,,,fee schedule,43021.47,139927.03,
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,139927.03,,,,,,,fee schedule,43021.47,139927.03,
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,96192.23,,,,,,,fee schedule,43021.47,139927.03,
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,87116.41,,,,,,,fee schedule,43021.47,139927.03,
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,71351.92,,,,,,,fee schedule,43021.47,139927.03,
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,43435.14,,,,,,,fee schedule,43021.47,139927.03,MSDRG Base Rate
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,43021.47,,,,,,,fee schedule,43021.47,139927.03,MSDRG Base Rate
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,43021.47,,,,,,,fee schedule,43021.47,139927.03,MSDRG Base Rate
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,43435.14,,,,,,,fee schedule,43021.47,139927.03,MSDRG Base Rate
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,43021.47,,,,,,,fee schedule,43021.47,139927.03,MSDRG Base Rate
Autologous Bone Marrow Transplant Without Cc/Mcc,17,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,72391.9,,,,,,,fee schedule,43021.47,139927.03,MSDRG Base Rate
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,290977.56,,,,,,,fee schedule,290977.56,874273.28,
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,290977.56,,,,,,,fee schedule,290977.56,874273.28,
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,389544.1,,,,,,,fee schedule,290977.56,874273.28,
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,370994.46,,,,,,,fee schedule,290977.56,874273.28,
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,649784.46,,,,,,,fee schedule,290977.56,874273.28,
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,504939.58,,,,,,,fee schedule,290977.56,874273.28,
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,874273.28,,,,,,,fee schedule,290977.56,874273.28,
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,601015.36,,,,,,,fee schedule,290977.56,874273.28,
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,544309.03,,,,,,,fee schedule,290977.56,874273.28,
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,445811.49,,,,,,,fee schedule,290977.56,874273.28,
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,338357.51,,,,,,,fee schedule,290977.56,874273.28,MSDRG Base Rate
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,335135.06,,,,,,,fee schedule,290977.56,874273.28,MSDRG Base Rate
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,335135.06,,,,,,,fee schedule,290977.56,874273.28,MSDRG Base Rate
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,338357.51,,,,,,,fee schedule,290977.56,874273.28,MSDRG Base Rate
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,335135.06,,,,,,,fee schedule,290977.56,874273.28,MSDRG Base Rate
Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies,18,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,563929.19,,,,,,,fee schedule,290977.56,874273.28,MSDRG Base Rate
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,61163.61,,,,,,,fee schedule,56193.88,183772.61,
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,61163.61,,,,,,,fee schedule,56193.88,183772.61,
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,81882.34,,,,,,,fee schedule,56193.88,183772.61,
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,77983.19,,,,,,,fee schedule,56193.88,183772.61,
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,136584.97,,,,,,,fee schedule,56193.88,183772.61,
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,106138.51,,,,,,,fee schedule,56193.88,183772.61,
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,183772.61,,,,,,,fee schedule,56193.88,183772.61,
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,126333.68,,,,,,,fee schedule,56193.88,183772.61,
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,114413.99,,,,,,,fee schedule,56193.88,183772.61,
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,93709.76,,,,,,,fee schedule,56193.88,183772.61,
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,56734.21,,,,,,,fee schedule,56193.88,183772.61,MSDRG Base Rate
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,56193.88,,,,,,,fee schedule,56193.88,183772.61,MSDRG Base Rate
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,56193.88,,,,,,,fee schedule,56193.88,183772.61,MSDRG Base Rate
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,56734.21,,,,,,,fee schedule,56193.88,183772.61,MSDRG Base Rate
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,56193.88,,,,,,,fee schedule,56193.88,183772.61,MSDRG Base Rate
Simultaneous Pancreas And Kidney Transplant With Hemodialysis,19,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,94557.02,,,,,,,fee schedule,56193.88,183772.61,MSDRG Base Rate
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,62196.03,,,,,,,fee schedule,61875.12,186874.63,
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,62196.03,,,,,,,fee schedule,61875.12,186874.63,
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,83264.48,,,,,,,fee schedule,61875.12,186874.63,
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,79299.52,,,,,,,fee schedule,61875.12,186874.63,
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,138890.48,,,,,,,fee schedule,61875.12,186874.63,
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,107930.1,,,,,,,fee schedule,61875.12,186874.63,
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,186874.63,,,,,,,fee schedule,61875.12,186874.63,
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,128466.15,,,,,,,fee schedule,61875.12,186874.63,
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,116345.26,,,,,,,fee schedule,61875.12,186874.63,
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,95291.55,,,,,,,fee schedule,61875.12,186874.63,
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,62470.08,,,,,,,fee schedule,61875.12,186874.63,MSDRG Base Rate
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,61875.12,,,,,,,fee schedule,61875.12,186874.63,MSDRG Base Rate
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,61875.12,,,,,,,fee schedule,61875.12,186874.63,MSDRG Base Rate
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,62470.08,,,,,,,fee schedule,61875.12,186874.63,MSDRG Base Rate
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,61875.12,,,,,,,fee schedule,61875.12,186874.63,MSDRG Base Rate
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc,20,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,104116.79,,,,,,,fee schedule,61875.12,186874.63,MSDRG Base Rate
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,42649.48,,,,,,,fee schedule,41949.76,128144.92,
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,42649.48,,,,,,,fee schedule,41949.76,128144.92,
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57096.68,,,,,,,fee schedule,41949.76,128144.92,
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,54377.8,,,,,,,fee schedule,41949.76,128144.92,
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,95240.91,,,,,,,fee schedule,41949.76,128144.92,
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,74010.55,,,,,,,fee schedule,41949.76,128144.92,
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,128144.92,,,,,,,fee schedule,41949.76,128144.92,
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,88092.67,,,,,,,fee schedule,41949.76,128144.92,
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,79781.05,,,,,,,fee schedule,41949.76,128144.92,
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,65343.96,,,,,,,fee schedule,41949.76,128144.92,
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,42353.13,,,,,,,fee schedule,41949.76,128144.92,MSDRG Base Rate
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,41949.76,,,,,,,fee schedule,41949.76,128144.92,MSDRG Base Rate
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,41949.76,,,,,,,fee schedule,41949.76,128144.92,MSDRG Base Rate
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,42353.13,,,,,,,fee schedule,41949.76,128144.92,MSDRG Base Rate
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,41949.76,,,,,,,fee schedule,41949.76,128144.92,MSDRG Base Rate
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc,21,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,70588.54,,,,,,,fee schedule,41949.76,128144.92,MSDRG Base Rate
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,27241.1,,,,,,,fee schedule,25573.05,81848.79,
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,27241.1,,,,,,,fee schedule,25573.05,81848.79,
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36468.82,,,,,,,fee schedule,25573.05,81848.79,
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,34732.22,,,,,,,fee schedule,25573.05,81848.79,
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,60832.32,,,,,,,fee schedule,25573.05,81848.79,
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,47272.06,,,,,,,fee schedule,25573.05,81848.79,
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,81848.79,,,,,,,fee schedule,25573.05,81848.79,
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,56266.6,,,,,,,fee schedule,25573.05,81848.79,
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,50957.79,,,,,,,fee schedule,25573.05,81848.79,
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41736.53,,,,,,,fee schedule,25573.05,81848.79,
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,25818.94,,,,,,,fee schedule,25573.05,81848.79,MSDRG Base Rate
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,25573.05,,,,,,,fee schedule,25573.05,81848.79,MSDRG Base Rate
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,25573.05,,,,,,,fee schedule,25573.05,81848.79,MSDRG Base Rate
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,25818.94,,,,,,,fee schedule,25573.05,81848.79,MSDRG Base Rate
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,25573.05,,,,,,,fee schedule,25573.05,81848.79,MSDRG Base Rate
Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc,22,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,43031.57,,,,,,,fee schedule,25573.05,81848.79,MSDRG Base Rate
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,44018.32,,,,,,,fee schedule,44018.32,132257.76,
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,44018.32,,,,,,,fee schedule,44018.32,132257.76,
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,58929.21,,,,,,,fee schedule,44018.32,132257.76,
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56123.07,,,,,,,fee schedule,44018.32,132257.76,
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,98297.69,,,,,,,fee schedule,44018.32,132257.76,
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,76385.93,,,,,,,fee schedule,44018.32,132257.76,
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,132257.76,,,,,,,fee schedule,44018.32,132257.76,
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,90920.03,,,,,,,fee schedule,44018.32,132257.76,
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,82341.64,,,,,,,fee schedule,44018.32,132257.76,
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,67441.19,,,,,,,fee schedule,44018.32,132257.76,
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],102437.74,102437.74,102437.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",36259.18,36259.18,36259.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],98151.23,98151.23,98151.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,45763.24,,,,,,,fee schedule,44018.32,132257.76,MSDRG Base Rate
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,45327.4,,,,,,,fee schedule,44018.32,132257.76,MSDRG Base Rate
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,45327.4,,,,,,,fee schedule,44018.32,132257.76,MSDRG Base Rate
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,45763.24,,,,,,,fee schedule,44018.32,132257.76,MSDRG Base Rate
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,45327.4,,,,,,,fee schedule,44018.32,132257.76,MSDRG Base Rate
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla,23,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,76272.07,,,,,,,fee schedule,44018.32,132257.76,MSDRG Base Rate
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,29332.17,,,,,,,fee schedule,29332.17,88131.66,
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,29332.17,,,,,,,fee schedule,29332.17,88131.66,
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39268.23,,,,,,,fee schedule,29332.17,88131.66,
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,37398.33,,,,,,,fee schedule,29332.17,88131.66,
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,65501.92,,,,,,,fee schedule,29332.17,88131.66,
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,50900.75,,,,,,,fee schedule,29332.17,88131.66,
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,88131.66,,,,,,,fee schedule,29332.17,88131.66,
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,60585.72,,,,,,,fee schedule,29332.17,88131.66,
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,54869.41,,,,,,,fee schedule,29332.17,88131.66,
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,44940.3,,,,,,,fee schedule,29332.17,88131.66,
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,31557.15,,,,,,,fee schedule,29332.17,88131.66,MSDRG Base Rate
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,31256.61,,,,,,,fee schedule,29332.17,88131.66,MSDRG Base Rate
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,31256.61,,,,,,,fee schedule,29332.17,88131.66,MSDRG Base Rate
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,31557.15,,,,,,,fee schedule,29332.17,88131.66,MSDRG Base Rate
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,31256.61,,,,,,,fee schedule,29332.17,88131.66,MSDRG Base Rate
Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc,24,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,52595.25,,,,,,,fee schedule,29332.17,88131.66,MSDRG Base Rate
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,34506.62,,,,,,,fee schedule,34506.62,103678.85,
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,34506.62,,,,,,,fee schedule,34506.62,103678.85,
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46195.49,,,,,,,fee schedule,34506.62,103678.85,
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43995.71,,,,,,,fee schedule,34506.62,103678.85,
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,77057.03,,,,,,,fee schedule,34506.62,103678.85,
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,59880.08,,,,,,,fee schedule,34506.62,103678.85,
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,103678.85,,,,,,,fee schedule,34506.62,103678.85,
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,71273.57,,,,,,,fee schedule,34506.62,103678.85,
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,64548.85,,,,,,,fee schedule,34506.62,103678.85,
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,52868.16,,,,,,,fee schedule,34506.62,103678.85,
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],33492.62,33492.62,33492.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],70753.45,70753.45,70753.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],77516.35,71397.8,82424.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],30186.61,15708.07,33187.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],33705.05,33705.05,33705.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],67351.98,67351.98,67351.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",35640.14,35640.14,35640.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],33894.26,32958.8,34397.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],102773.43,102773.43,102773.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],73077.98,59768,85429.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],31500.29,25658.62,35070.38,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],102856.18,102856.18,102856.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,36516.47,,,,,,,fee schedule,34506.62,103678.85,MSDRG Base Rate
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,36168.69,,,,,,,fee schedule,34506.62,103678.85,MSDRG Base Rate
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,36168.69,,,,,,,fee schedule,34506.62,103678.85,MSDRG Base Rate
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,36516.47,,,,,,,fee schedule,34506.62,103678.85,MSDRG Base Rate
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,36168.69,,,,,,,fee schedule,34506.62,103678.85,MSDRG Base Rate
Craniotomy And Endovascular Intracranial Procedures With Mcc,25,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,60860.78,,,,,,,fee schedule,34506.62,103678.85,MSDRG Base Rate
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,23599.07,,,,,,,fee schedule,23599.07,70905.95,
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,23599.07,,,,,,,fee schedule,23599.07,70905.95,
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31593.09,,,,,,,fee schedule,23599.07,70905.95,
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,30088.66,,,,,,,fee schedule,23599.07,70905.95,
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,52699.29,,,,,,,fee schedule,23599.07,70905.95,
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,40951.98,,,,,,,fee schedule,23599.07,70905.95,
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,70905.95,,,,,,,fee schedule,23599.07,70905.95,
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,48743.98,,,,,,,fee schedule,23599.07,70905.95,
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,44144.95,,,,,,,fee schedule,23599.07,70905.95,
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,36156.53,,,,,,,fee schedule,23599.07,70905.95,
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],23419.12,23419.12,23419.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],110502.87,110502.87,110502.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,25286.13,,,,,,,fee schedule,23599.07,70905.95,MSDRG Base Rate
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,25045.31,,,,,,,fee schedule,23599.07,70905.95,MSDRG Base Rate
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,25045.31,,,,,,,fee schedule,23599.07,70905.95,MSDRG Base Rate
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,25286.13,,,,,,,fee schedule,23599.07,70905.95,MSDRG Base Rate
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,25045.31,,,,,,,fee schedule,23599.07,70905.95,MSDRG Base Rate
Craniotomy And Endovascular Intracranial Procedures With Cc,26,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,42143.55,,,,,,,fee schedule,23599.07,70905.95,MSDRG Base Rate
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,19040.37,,,,,,,fee schedule,19040.37,57208.84,
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,19040.37,,,,,,,fee schedule,19040.37,57208.84,
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,25490.16,,,,,,,fee schedule,19040.37,57208.84,
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24276.35,,,,,,,fee schedule,19040.37,57208.84,
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,42519.22,,,,,,,fee schedule,19040.37,57208.84,
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,33041.16,,,,,,,fee schedule,19040.37,57208.84,
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,57208.84,,,,,,,fee schedule,19040.37,57208.84,
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,39327.97,,,,,,,fee schedule,19040.37,57208.84,
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,35617.34,,,,,,,fee schedule,19040.37,57208.84,
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,29172.07,,,,,,,fee schedule,19040.37,57208.84,
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],39331.15,39331.15,39331.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],19003,19003,19003,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],18579.61,18579.61,18579.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,20705.72,,,,,,,fee schedule,19040.37,57208.84,MSDRG Base Rate
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,20508.52,,,,,,,fee schedule,19040.37,57208.84,MSDRG Base Rate
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,20508.52,,,,,,,fee schedule,19040.37,57208.84,MSDRG Base Rate
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,20705.72,,,,,,,fee schedule,19040.37,57208.84,MSDRG Base Rate
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,20508.52,,,,,,,fee schedule,19040.37,57208.84,MSDRG Base Rate
Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc,27,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,34509.53,,,,,,,fee schedule,19040.37,57208.84,MSDRG Base Rate
Spinal Procedures With Mcc,28,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,46907.25,,,,,,,fee schedule,46907.25,140937.85,
Spinal Procedures With Mcc,28,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,46907.25,,,,,,,fee schedule,46907.25,140937.85,
Spinal Procedures With Mcc,28,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,62796.74,,,,,,,fee schedule,46907.25,140937.85,
Spinal Procedures With Mcc,28,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,59806.43,,,,,,,fee schedule,46907.25,140937.85,
Spinal Procedures With Mcc,28,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,104748.97,,,,,,,fee schedule,46907.25,140937.85,
Spinal Procedures With Mcc,28,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,81399.15,,,,,,,fee schedule,46907.25,140937.85,
Spinal Procedures With Mcc,28,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,140937.85,,,,,,,fee schedule,46907.25,140937.85,
Spinal Procedures With Mcc,28,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,96887.12,,,,,,,fee schedule,46907.25,140937.85,
Spinal Procedures With Mcc,28,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,87745.73,,,,,,,fee schedule,46907.25,140937.85,
Spinal Procedures With Mcc,28,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,71867.36,,,,,,,fee schedule,46907.25,140937.85,
Spinal Procedures With Mcc,28,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],77821.74,77821.74,77821.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Spinal Procedures With Mcc,28,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Mcc,28,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Mcc,28,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Mcc,28,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Mcc,28,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Mcc,28,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",50394.03,50394.03,50394.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Spinal Procedures With Mcc,28,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Mcc,28,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Mcc,28,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Mcc,28,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Mcc,28,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Mcc,28,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Mcc,28,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],55080.23,55080.23,55080.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Spinal Procedures With Mcc,28,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],43407.49,43407.49,43407.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Spinal Procedures With Mcc,28,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Mcc,28,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Mcc,28,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],109382.72,109382.72,109382.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Spinal Procedures With Mcc,28,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,47935.09,,,,,,,fee schedule,46907.25,140937.85,MSDRG Base Rate
Spinal Procedures With Mcc,28,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,47478.57,,,,,,,fee schedule,46907.25,140937.85,MSDRG Base Rate
Spinal Procedures With Mcc,28,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,47478.57,,,,,,,fee schedule,46907.25,140937.85,MSDRG Base Rate
Spinal Procedures With Mcc,28,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,47935.09,,,,,,,fee schedule,46907.25,140937.85,MSDRG Base Rate
Spinal Procedures With Mcc,28,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,47478.57,,,,,,,fee schedule,46907.25,140937.85,MSDRG Base Rate
Spinal Procedures With Mcc,28,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,79891.82,,,,,,,fee schedule,46907.25,140937.85,MSDRG Base Rate
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,25899.26,,,,,,,fee schedule,25899.26,77817.1,
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,25899.26,,,,,,,fee schedule,25899.26,77817.1,
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,34672.44,,,,,,,fee schedule,25899.26,77817.1,
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,33021.38,,,,,,,fee schedule,25899.26,77817.1,
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,57835.85,,,,,,,fee schedule,25899.26,77817.1,
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,44943.54,,,,,,,fee schedule,25899.26,77817.1,
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,77817.1,,,,,,,fee schedule,25899.26,77817.1,
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,53495.02,,,,,,,fee schedule,25899.26,77817.1,
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,48447.72,,,,,,,fee schedule,25899.26,77817.1,
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,39680.68,,,,,,,fee schedule,25899.26,77817.1,
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],27012.19,27012.19,27012.19,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],106908.79,106908.79,106908.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],23785.71,23785.71,23785.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],25267.65,25267.65,25267.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],57839.3,57839.3,57839.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,27648.61,,,,,,,fee schedule,25899.26,77817.1,MSDRG Base Rate
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,27385.29,,,,,,,fee schedule,25899.26,77817.1,MSDRG Base Rate
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,27385.29,,,,,,,fee schedule,25899.26,77817.1,MSDRG Base Rate
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,27648.61,,,,,,,fee schedule,25899.26,77817.1,MSDRG Base Rate
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,27385.29,,,,,,,fee schedule,25899.26,77817.1,MSDRG Base Rate
Spinal Procedures With Cc Or Spinal Neurostimulators,29,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,46081.02,,,,,,,fee schedule,25899.26,77817.1,MSDRG Base Rate
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17169.98,,,,,,,fee schedule,17169.98,51589.04,
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,17169.98,,,,,,,fee schedule,17169.98,51589.04,
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22986.18,,,,,,,fee schedule,17169.98,51589.04,
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21891.61,,,,,,,fee schedule,17169.98,51589.04,
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,38342.42,,,,,,,fee schedule,17169.98,51589.04,
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,29795.43,,,,,,,fee schedule,17169.98,51589.04,
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,51589.04,,,,,,,fee schedule,17169.98,51589.04,
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,35464.66,,,,,,,fee schedule,17169.98,51589.04,
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,32118.54,,,,,,,fee schedule,17169.98,51589.04,
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26306.4,,,,,,,fee schedule,17169.98,51589.04,
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],17142.17,17142.17,17142.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],38345.87,38345.87,38345.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,18145.59,,,,,,,fee schedule,17169.98,51589.04,MSDRG Base Rate
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,17972.77,,,,,,,fee schedule,17169.98,51589.04,MSDRG Base Rate
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,17972.77,,,,,,,fee schedule,17169.98,51589.04,MSDRG Base Rate
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,18145.59,,,,,,,fee schedule,17169.98,51589.04,MSDRG Base Rate
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,17972.77,,,,,,,fee schedule,17169.98,51589.04,MSDRG Base Rate
Spinal Procedures Without Cc/Mcc,30,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30242.64,,,,,,,fee schedule,17169.98,51589.04,MSDRG Base Rate
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,32332.98,,,,,,,fee schedule,32332.98,97147.92,
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,32332.98,,,,,,,fee schedule,32332.98,97147.92,
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,43285.55,,,,,,,fee schedule,32332.98,97147.92,
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,41224.34,,,,,,,fee schedule,32332.98,97147.92,
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,72203.06,,,,,,,fee schedule,32332.98,97147.92,
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,56108.12,,,,,,,fee schedule,32332.98,97147.92,
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,97147.92,,,,,,,fee schedule,32332.98,97147.92,
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,66783.91,,,,,,,fee schedule,32332.98,97147.92,
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,60482.79,,,,,,,fee schedule,32332.98,97147.92,
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,49537.89,,,,,,,fee schedule,32332.98,97147.92,
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",135406.54,135406.54,135406.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,35999.29,,,,,,,fee schedule,32332.98,97147.92,MSDRG Base Rate
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,35656.44,,,,,,,fee schedule,32332.98,97147.92,MSDRG Base Rate
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,35656.44,,,,,,,fee schedule,32332.98,97147.92,MSDRG Base Rate
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,35999.29,,,,,,,fee schedule,32332.98,97147.92,MSDRG Base Rate
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,35656.44,,,,,,,fee schedule,32332.98,97147.92,MSDRG Base Rate
Ventricular Shunt Procedures With Mcc,31,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,59998.82,,,,,,,fee schedule,32332.98,97147.92,MSDRG Base Rate
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16477.84,,,,,,,fee schedule,16477.84,49509.43,
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,16477.84,,,,,,,fee schedule,16477.84,49509.43,
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22059.59,,,,,,,fee schedule,16477.84,49509.43,
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21009.13,,,,,,,fee schedule,16477.84,49509.43,
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,36796.8,,,,,,,fee schedule,16477.84,49509.43,
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,28594.35,,,,,,,fee schedule,16477.84,49509.43,
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,49509.43,,,,,,,fee schedule,16477.84,49509.43,
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,34035.04,,,,,,,fee schedule,16477.84,49509.43,
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,30823.81,,,,,,,fee schedule,16477.84,49509.43,
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,25245.97,,,,,,,fee schedule,16477.84,49509.43,
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",13368.04,13368.04,13368.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,17644.03,,,,,,,fee schedule,16477.84,49509.43,MSDRG Base Rate
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,17475.99,,,,,,,fee schedule,16477.84,49509.43,MSDRG Base Rate
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,17475.99,,,,,,,fee schedule,16477.84,49509.43,MSDRG Base Rate
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,17644.03,,,,,,,fee schedule,16477.84,49509.43,MSDRG Base Rate
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,17475.99,,,,,,,fee schedule,16477.84,49509.43,MSDRG Base Rate
Ventricular Shunt Procedures With Cc,32,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,29406.72,,,,,,,fee schedule,16477.84,49509.43,MSDRG Base Rate
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12310.35,,,,,,,fee schedule,12310.35,36987.75,
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,12310.35,,,,,,,fee schedule,12310.35,36987.75,
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16480.39,,,,,,,fee schedule,12310.35,36987.75,
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15695.61,,,,,,,fee schedule,12310.35,36987.75,
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,27490.34,,,,,,,fee schedule,12310.35,36987.75,
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,21362.41,,,,,,,fee schedule,12310.35,36987.75,
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,36987.75,,,,,,,fee schedule,12310.35,36987.75,
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,25427.07,,,,,,,fee schedule,12310.35,36987.75,
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,23028,,,,,,,fee schedule,12310.35,36987.75,
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18860.88,,,,,,,fee schedule,12310.35,36987.75,
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],12249.26,12249.26,12249.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13987.04,,,,,,,fee schedule,12310.35,36987.75,MSDRG Base Rate
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,13853.83,,,,,,,fee schedule,12310.35,36987.75,MSDRG Base Rate
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,13853.83,,,,,,,fee schedule,12310.35,36987.75,MSDRG Base Rate
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,13987.04,,,,,,,fee schedule,12310.35,36987.75,MSDRG Base Rate
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,13853.83,,,,,,,fee schedule,12310.35,36987.75,MSDRG Base Rate
Ventricular Shunt Procedures Without Cc/Mcc,33,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23311.73,,,,,,,fee schedule,12310.35,36987.75,MSDRG Base Rate
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,30004.25,,,,,,,fee schedule,30004.25,90150.98,
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,30004.25,,,,,,,fee schedule,30004.25,90150.98,
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40167.97,,,,,,,fee schedule,30004.25,90150.98,
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,38255.22,,,,,,,fee schedule,30004.25,90150.98,
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,67002.74,,,,,,,fee schedule,30004.25,90150.98,
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,52067.02,,,,,,,fee schedule,30004.25,90150.98,
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,90150.98,,,,,,,fee schedule,30004.25,90150.98,
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,61973.9,,,,,,,fee schedule,30004.25,90150.98,
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,56126.61,,,,,,,fee schedule,30004.25,90150.98,
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45970,,,,,,,fee schedule,30004.25,90150.98,
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],29220.11,29220.11,29220.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],26897.27,26897.27,26897.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,31235.28,,,,,,,fee schedule,30004.25,90150.98,MSDRG Base Rate
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,30937.81,,,,,,,fee schedule,30004.25,90150.98,MSDRG Base Rate
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,30937.81,,,,,,,fee schedule,30004.25,90150.98,MSDRG Base Rate
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,31235.28,,,,,,,fee schedule,30004.25,90150.98,MSDRG Base Rate
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,30937.81,,,,,,,fee schedule,30004.25,90150.98,MSDRG Base Rate
Carotid Artery Stent Procedures With Mcc,34,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,52058.81,,,,,,,fee schedule,30004.25,90150.98,MSDRG Base Rate
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17551.15,,,,,,,fee schedule,17551.15,52734.33,
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,17551.15,,,,,,,fee schedule,17551.15,52734.33,
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23496.48,,,,,,,fee schedule,17551.15,52734.33,
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22377.61,,,,,,,fee schedule,17551.15,52734.33,
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,39193.63,,,,,,,fee schedule,17551.15,52734.33,
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,30456.89,,,,,,,fee schedule,17551.15,52734.33,
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,52734.33,,,,,,,fee schedule,17551.15,52734.33,
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,36251.98,,,,,,,fee schedule,17551.15,52734.33,
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,32831.58,,,,,,,fee schedule,17551.15,52734.33,
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26890.41,,,,,,,fee schedule,17551.15,52734.33,
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,19671.35,,,,,,,fee schedule,17551.15,52734.33,MSDRG Base Rate
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,19484,,,,,,,fee schedule,17551.15,52734.33,MSDRG Base Rate
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,19484,,,,,,,fee schedule,17551.15,52734.33,MSDRG Base Rate
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,19671.35,,,,,,,fee schedule,17551.15,52734.33,MSDRG Base Rate
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,19484,,,,,,,fee schedule,17551.15,52734.33,MSDRG Base Rate
Carotid Artery Stent Procedures With Cc,35,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,32785.58,,,,,,,fee schedule,17551.15,52734.33,MSDRG Base Rate
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14143.7,,,,,,,fee schedule,14143.7,42496.27,
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,14143.7,,,,,,,fee schedule,14143.7,42496.27,
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18934.78,,,,,,,fee schedule,14143.7,42496.27,
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18033.13,,,,,,,fee schedule,14143.7,42496.27,
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,31584.42,,,,,,,fee schedule,14143.7,42496.27,
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,24543.87,,,,,,,fee schedule,14143.7,42496.27,
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,42496.27,,,,,,,fee schedule,14143.7,42496.27,
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,29213.88,,,,,,,fee schedule,14143.7,42496.27,
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,26457.52,,,,,,,fee schedule,14143.7,42496.27,
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21669.8,,,,,,,fee schedule,14143.7,42496.27,
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13487.91,13487.91,13487.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,16173.74,,,,,,,fee schedule,14143.7,42496.27,MSDRG Base Rate
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,16019.7,,,,,,,fee schedule,14143.7,42496.27,MSDRG Base Rate
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,16019.7,,,,,,,fee schedule,14143.7,42496.27,MSDRG Base Rate
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,16173.74,,,,,,,fee schedule,14143.7,42496.27,MSDRG Base Rate
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,16019.7,,,,,,,fee schedule,14143.7,42496.27,MSDRG Base Rate
Carotid Artery Stent Procedures Without Cc/Mcc,36,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,26956.23,,,,,,,fee schedule,14143.7,42496.27,MSDRG Base Rate
Extracranial Procedures With Mcc,37,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,25623.02,,,,,,,fee schedule,25623.02,76987.11,
Extracranial Procedures With Mcc,37,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,25623.02,,,,,,,fee schedule,25623.02,76987.11,
Extracranial Procedures With Mcc,37,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,34302.63,,,,,,,fee schedule,25623.02,76987.11,
Extracranial Procedures With Mcc,37,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,32669.18,,,,,,,fee schedule,25623.02,76987.11,
Extracranial Procedures With Mcc,37,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,57218.98,,,,,,,fee schedule,25623.02,76987.11,
Extracranial Procedures With Mcc,37,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,44464.17,,,,,,,fee schedule,25623.02,76987.11,
Extracranial Procedures With Mcc,37,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,76987.11,,,,,,,fee schedule,25623.02,76987.11,
Extracranial Procedures With Mcc,37,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,52924.45,,,,,,,fee schedule,25623.02,76987.11,
Extracranial Procedures With Mcc,37,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,47930.98,,,,,,,fee schedule,25623.02,76987.11,
Extracranial Procedures With Mcc,37,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,39257.45,,,,,,,fee schedule,25623.02,76987.11,
Extracranial Procedures With Mcc,37,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Mcc,37,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Mcc,37,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],24809.3,24809.3,24809.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Extracranial Procedures With Mcc,37,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Mcc,37,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Mcc,37,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Mcc,37,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Mcc,37,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],74162.29,74162.29,74162.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Extracranial Procedures With Mcc,37,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Mcc,37,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Mcc,37,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Mcc,37,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Mcc,37,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Mcc,37,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],23593.47,23411.22,24658.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Extracranial Procedures With Mcc,37,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",14553.94,14553.94,14553.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Extracranial Procedures With Mcc,37,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Mcc,37,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Mcc,37,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Mcc,37,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,26715.02,,,,,,,fee schedule,25623.02,76987.11,MSDRG Base Rate
Extracranial Procedures With Mcc,37,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,26460.6,,,,,,,fee schedule,25623.02,76987.11,MSDRG Base Rate
Extracranial Procedures With Mcc,37,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,26460.6,,,,,,,fee schedule,25623.02,76987.11,MSDRG Base Rate
Extracranial Procedures With Mcc,37,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,26715.02,,,,,,,fee schedule,25623.02,76987.11,MSDRG Base Rate
Extracranial Procedures With Mcc,37,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,26460.6,,,,,,,fee schedule,25623.02,76987.11,MSDRG Base Rate
Extracranial Procedures With Mcc,37,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,44525.04,,,,,,,fee schedule,25623.02,76987.11,MSDRG Base Rate
Extracranial Procedures With Cc,38,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12431.49,,,,,,,fee schedule,12431.49,37351.74,
Extracranial Procedures With Cc,38,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,12431.49,,,,,,,fee schedule,12431.49,37351.74,
Extracranial Procedures With Cc,38,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16642.57,,,,,,,fee schedule,12431.49,37351.74,
Extracranial Procedures With Cc,38,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15850.07,,,,,,,fee schedule,12431.49,37351.74,
Extracranial Procedures With Cc,38,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,27760.86,,,,,,,fee schedule,12431.49,37351.74,
Extracranial Procedures With Cc,38,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,21572.63,,,,,,,fee schedule,12431.49,37351.74,
Extracranial Procedures With Cc,38,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,37351.74,,,,,,,fee schedule,12431.49,37351.74,
Extracranial Procedures With Cc,38,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,25677.29,,,,,,,fee schedule,12431.49,37351.74,
Extracranial Procedures With Cc,38,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,23254.62,,,,,,,fee schedule,12431.49,37351.74,
Extracranial Procedures With Cc,38,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19046.49,,,,,,,fee schedule,12431.49,37351.74,
Extracranial Procedures With Cc,38,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Cc,38,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Cc,38,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11934.99,11934.99,11934.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Extracranial Procedures With Cc,38,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Cc,38,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Cc,38,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Cc,38,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Cc,38,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",10933.58,10933.58,10933.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Extracranial Procedures With Cc,38,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11492.3,11492.3,11492.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Extracranial Procedures With Cc,38,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Cc,38,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Cc,38,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Cc,38,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Cc,38,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],13164.68,7591.54,13215.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Extracranial Procedures With Cc,38,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Cc,38,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Cc,38,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Cc,38,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures With Cc,38,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13672.21,,,,,,,fee schedule,12431.49,37351.74,MSDRG Base Rate
Extracranial Procedures With Cc,38,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,13542,,,,,,,fee schedule,12431.49,37351.74,MSDRG Base Rate
Extracranial Procedures With Cc,38,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,13542,,,,,,,fee schedule,12431.49,37351.74,MSDRG Base Rate
Extracranial Procedures With Cc,38,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,13672.21,,,,,,,fee schedule,12431.49,37351.74,MSDRG Base Rate
Extracranial Procedures With Cc,38,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,13542,,,,,,,fee schedule,12431.49,37351.74,MSDRG Base Rate
Extracranial Procedures With Cc,38,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22787.01,,,,,,,fee schedule,12431.49,37351.74,MSDRG Base Rate
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8782.52,,,,,,,fee schedule,8782.52,26388.03,
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,8782.52,,,,,,,fee schedule,8782.52,26388.03,
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11757.54,,,,,,,fee schedule,8782.52,26388.03,
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11197.66,,,,,,,fee schedule,8782.52,26388.03,
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,19612.32,,,,,,,fee schedule,8782.52,26388.03,
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,15240.5,,,,,,,fee schedule,8782.52,26388.03,
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,26388.03,,,,,,,fee schedule,8782.52,26388.03,
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,18140.34,,,,,,,fee schedule,8782.52,26388.03,
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,16428.78,,,,,,,fee schedule,8782.52,26388.03,
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13455.85,,,,,,,fee schedule,8782.52,26388.03,
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],18140.34,18140.34,18140.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9791.49,9791.49,9791.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8643.75,8643.75,8643.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],17746.99,17746.99,17746.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],8930.68,6977.54,8949.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10179.28,,,,,,,fee schedule,8782.52,26388.03,MSDRG Base Rate
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,10082.33,,,,,,,fee schedule,8782.52,26388.03,MSDRG Base Rate
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,10082.33,,,,,,,fee schedule,8782.52,26388.03,MSDRG Base Rate
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,10179.28,,,,,,,fee schedule,8782.52,26388.03,MSDRG Base Rate
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,10082.33,,,,,,,fee schedule,8782.52,26388.03,MSDRG Base Rate
Extracranial Procedures Without Cc/Mcc,39,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16965.46,,,,,,,fee schedule,8782.52,26388.03,MSDRG Base Rate
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,29103.77,,,,,,,fee schedule,29103.77,87445.41,
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,29103.77,,,,,,,fee schedule,29103.77,87445.41,
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38962.47,,,,,,,fee schedule,29103.77,87445.41,
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,37107.12,,,,,,,fee schedule,29103.77,87445.41,
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,64991.89,,,,,,,fee schedule,29103.77,87445.41,
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,50504.4,,,,,,,fee schedule,29103.77,87445.41,
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,87445.41,,,,,,,fee schedule,29103.77,87445.41,
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,60113.97,,,,,,,fee schedule,29103.77,87445.41,
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,54442.16,,,,,,,fee schedule,29103.77,87445.41,
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,44590.37,,,,,,,fee schedule,29103.77,87445.41,
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],20264.96,20264.96,20264.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],148565.03,148565.03,148565.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],28424.42,28424.42,28424.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],60979.77,60979.77,60979.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],28575,28575,28575,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],27455.93,27455.93,49213.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,31161.06,,,,,,,fee schedule,29103.77,87445.41,MSDRG Base Rate
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,30864.29,,,,,,,fee schedule,29103.77,87445.41,MSDRG Base Rate
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,30864.29,,,,,,,fee schedule,29103.77,87445.41,MSDRG Base Rate
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,31161.06,,,,,,,fee schedule,29103.77,87445.41,MSDRG Base Rate
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,30864.29,,,,,,,fee schedule,29103.77,87445.41,MSDRG Base Rate
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc",40,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,51935.1,,,,,,,fee schedule,29103.77,87445.41,MSDRG Base Rate
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17427.7,,,,,,,fee schedule,17427.7,52363.38,
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,17427.7,,,,,,,fee schedule,17427.7,52363.38,
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23331.2,,,,,,,fee schedule,17427.7,52363.38,
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22220.2,,,,,,,fee schedule,17427.7,52363.38,
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,38917.94,,,,,,,fee schedule,17427.7,52363.38,
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,30242.65,,,,,,,fee schedule,17427.7,52363.38,
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,52363.38,,,,,,,fee schedule,17427.7,52363.38,
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,35996.98,,,,,,,fee schedule,17427.7,52363.38,
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,32600.63,,,,,,,fee schedule,17427.7,52363.38,
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26701.26,,,,,,,fee schedule,17427.7,52363.38,
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],17919.5,17919.5,17919.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],15795.12,15795.12,15795.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",12582.21,12582.21,12582.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],15840.17,15315.17,17751.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,18172.94,,,,,,,fee schedule,17427.7,52363.38,MSDRG Base Rate
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,17999.86,,,,,,,fee schedule,17427.7,52363.38,MSDRG Base Rate
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,17999.86,,,,,,,fee schedule,17427.7,52363.38,MSDRG Base Rate
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,18172.94,,,,,,,fee schedule,17427.7,52363.38,MSDRG Base Rate
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,17999.86,,,,,,,fee schedule,17427.7,52363.38,MSDRG Base Rate
"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator",41,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30288.23,,,,,,,fee schedule,17427.7,52363.38,MSDRG Base Rate
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13561.13,,,,,,,fee schedule,13561.13,40745.88,
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,13561.13,,,,,,,fee schedule,13561.13,40745.88,
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18154.87,,,,,,,fee schedule,13561.13,40745.88,
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17290.36,,,,,,,fee schedule,13561.13,40745.88,
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,30283.48,,,,,,,fee schedule,13561.13,40745.88,
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,23532.93,,,,,,,fee schedule,13561.13,40745.88,
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,40745.88,,,,,,,fee schedule,13561.13,40745.88,
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,28010.58,,,,,,,fee schedule,13561.13,40745.88,
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,25367.76,,,,,,,fee schedule,13561.13,40745.88,
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20777.24,,,,,,,fee schedule,13561.13,40745.88,
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],80043.59,80043.59,80043.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",10321.85,10321.85,10321.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],19278.42,19278.42,19278.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],45481,45481,45481,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14493.29,,,,,,,fee schedule,13561.13,40745.88,MSDRG Base Rate
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,14355.26,,,,,,,fee schedule,13561.13,40745.88,MSDRG Base Rate
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,14355.26,,,,,,,fee schedule,13561.13,40745.88,MSDRG Base Rate
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,14493.29,,,,,,,fee schedule,13561.13,40745.88,MSDRG Base Rate
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,14355.26,,,,,,,fee schedule,13561.13,40745.88,MSDRG Base Rate
"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc",42,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,24155.48,,,,,,,fee schedule,13561.13,40745.88,MSDRG Base Rate
Hyphema,43,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hyphema,43,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Hyphema,43,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Hyphema,43,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hyphema,43,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hyphema,43,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Hyphema,43,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Hyphema,43,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Hyphema,43,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Hyphema,43,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Hyphema,43,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hyphema,43,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hyphema,43,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Hyphema,43,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Hyphema,43,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hyphema,43,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Hyphema,43,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hyphema,43,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections,44,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections,44,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections,44,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections,44,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections,44,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections,44,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections,44,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections,44,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections,44,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections,44,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections,44,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections,44,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections,44,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections,44,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections,44,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections,44,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections,44,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections,44,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Neurological eye disorders,45,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Neurological eye disorders,45,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Neurological eye disorders,45,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Neurological eye disorders,45,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Neurological eye disorders,45,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Neurological eye disorders,45,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Neurological eye disorders,45,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Neurological eye disorders,45,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Neurological eye disorders,45,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Neurological eye disorders,45,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Neurological eye disorders,45,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Neurological eye disorders,45,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Neurological eye disorders,45,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Neurological eye disorders,45,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Neurological eye disorders,45,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Neurological eye disorders,45,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Neurological eye disorders,45,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Neurological eye disorders,45,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders of the Eye Age >17 w CC,46,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders of the Eye Age >17 w CC,46,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders of the Eye Age >17 w CC,46,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders of the Eye Age >17 w CC,46,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders of the Eye Age >17 w CC,46,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders of the Eye Age >17 w CC,46,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders of the Eye Age >17 w CC,46,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders of the Eye Age >17 w CC,46,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders of the Eye Age >17 w CC,46,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders of the Eye Age >17 w CC,46,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders of the Eye Age >17 w CC,46,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders of the Eye Age >17 w CC,46,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders of the Eye Age >17 w CC,46,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders of the Eye Age >17 w CC,46,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders of the Eye Age >17 w CC,46,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders of the Eye Age >17 w CC,46,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders of the Eye Age >17 w CC,46,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders of the Eye Age >17 w CC,46,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders of the Eye Age >17 w/o CC,47,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders of the Eye Age >17 w/o CC,47,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders of the Eye Age >17 w/o CC,47,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders of the Eye Age >17 w/o CC,47,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders of the Eye Age >17 w/o CC,47,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders of the Eye Age >17 w/o CC,47,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders of the Eye Age >17 w/o CC,47,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders of the Eye Age >17 w/o CC,47,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders of the Eye Age >17 w/o CC,47,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders of the Eye Age >17 w/o CC,47,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders of the Eye Age >17 w/o CC,47,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders of the Eye Age >17 w/o CC,47,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders of the Eye Age >17 w/o CC,47,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders of the Eye Age >17 w/o CC,47,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders of the Eye Age >17 w/o CC,47,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders of the Eye Age >17 w/o CC,47,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders of the Eye Age >17 w/o CC,47,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders of the Eye Age >17 w/o CC,47,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders of the Eye Age 0-17,48,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders of the Eye Age 0-17,48,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders of the Eye Age 0-17,48,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders of the Eye Age 0-17,48,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders of the Eye Age 0-17,48,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders of the Eye Age 0-17,48,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders of the Eye Age 0-17,48,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders of the Eye Age 0-17,48,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders of the Eye Age 0-17,48,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders of the Eye Age 0-17,48,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders of the Eye Age 0-17,48,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders of the Eye Age 0-17,48,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders of the Eye Age 0-17,48,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders of the Eye Age 0-17,48,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders of the Eye Age 0-17,48,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders of the Eye Age 0-17,48,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders of the Eye Age 0-17,48,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders of the Eye Age 0-17,48,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head & Neck Procedures,49,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head & Neck Procedures,49,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Major Head & Neck Procedures,49,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Major Head & Neck Procedures,49,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head & Neck Procedures,49,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head & Neck Procedures,49,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Major Head & Neck Procedures,49,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Head & Neck Procedures,49,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Head & Neck Procedures,49,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Major Head & Neck Procedures,49,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Major Head & Neck Procedures,49,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head & Neck Procedures,49,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head & Neck Procedures,49,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Major Head & Neck Procedures,49,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Major Head & Neck Procedures,49,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head & Neck Procedures,49,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Head & Neck Procedures,49,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head & Neck Procedures,49,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Sialoadenectomy,50,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Sialoadenectomy,50,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Sialoadenectomy,50,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Sialoadenectomy,50,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Sialoadenectomy,50,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Sialoadenectomy,50,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Sialoadenectomy,50,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Sialoadenectomy,50,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Sialoadenectomy,50,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Sialoadenectomy,50,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Sialoadenectomy,50,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Sialoadenectomy,50,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Sialoadenectomy,50,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Sialoadenectomy,50,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Sialoadenectomy,50,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Sialoadenectomy,50,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Sialoadenectomy,50,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Sialoadenectomy,50,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Salivary Gland Procedures Except Sialoadenectomy,51,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Salivary Gland Procedures Except Sialoadenectomy,51,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Salivary Gland Procedures Except Sialoadenectomy,51,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Salivary Gland Procedures Except Sialoadenectomy,51,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Salivary Gland Procedures Except Sialoadenectomy,51,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Salivary Gland Procedures Except Sialoadenectomy,51,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Salivary Gland Procedures Except Sialoadenectomy,51,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Salivary Gland Procedures Except Sialoadenectomy,51,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Salivary Gland Procedures Except Sialoadenectomy,51,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Salivary Gland Procedures Except Sialoadenectomy,51,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Salivary Gland Procedures Except Sialoadenectomy,51,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Salivary Gland Procedures Except Sialoadenectomy,51,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Salivary Gland Procedures Except Sialoadenectomy,51,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Salivary Gland Procedures Except Sialoadenectomy,51,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Salivary Gland Procedures Except Sialoadenectomy,51,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Salivary Gland Procedures Except Sialoadenectomy,51,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Salivary Gland Procedures Except Sialoadenectomy,51,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Salivary Gland Procedures Except Sialoadenectomy,51,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,15527.98,,,,,,,fee schedule,15002.16,46655.48,
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,15527.98,,,,,,,fee schedule,15002.16,46655.48,
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20787.97,,,,,,,fee schedule,15002.16,46655.48,
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19798.07,,,,,,,fee schedule,15002.16,46655.48,
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,34675.66,,,,,,,fee schedule,15002.16,46655.48,
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,26946.04,,,,,,,fee schedule,15002.16,46655.48,
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,46655.48,,,,,,,fee schedule,15002.16,46655.48,
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,32073.11,,,,,,,fee schedule,15002.16,46655.48,
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,29046.98,,,,,,,fee schedule,15002.16,46655.48,
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23790.67,,,,,,,fee schedule,15002.16,46655.48,
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15146.41,,,,,,,fee schedule,15002.16,46655.48,MSDRG Base Rate
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,15002.16,,,,,,,fee schedule,15002.16,46655.48,MSDRG Base Rate
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,15002.16,,,,,,,fee schedule,15002.16,46655.48,MSDRG Base Rate
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,15146.41,,,,,,,fee schedule,15002.16,46655.48,MSDRG Base Rate
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,15002.16,,,,,,,fee schedule,15002.16,46655.48,MSDRG Base Rate
Spinal Disorders And Injuries With Cc/Mcc,52,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,25244.01,,,,,,,fee schedule,15002.16,46655.48,MSDRG Base Rate
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7108.89,,,,,,,fee schedule,7108.89,21359.42,
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,7108.89,,,,,,,fee schedule,7108.89,21359.42,
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9516.97,,,,,,,fee schedule,7108.89,21359.42,
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9063.79,,,,,,,fee schedule,7108.89,21359.42,
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,15874.92,,,,,,,fee schedule,7108.89,21359.42,
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,12336.21,,,,,,,fee schedule,7108.89,21359.42,
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,21359.42,,,,,,,fee schedule,7108.89,21359.42,
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,14683.44,,,,,,,fee schedule,7108.89,21359.42,
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,13298.04,,,,,,,fee schedule,7108.89,21359.42,
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10891.65,,,,,,,fee schedule,7108.89,21359.42,
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8645.7,,,,,,,fee schedule,7108.89,21359.42,MSDRG Base Rate
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,8563.36,,,,,,,fee schedule,7108.89,21359.42,MSDRG Base Rate
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,8563.36,,,,,,,fee schedule,7108.89,21359.42,MSDRG Base Rate
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,8645.7,,,,,,,fee schedule,7108.89,21359.42,MSDRG Base Rate
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,8563.36,,,,,,,fee schedule,7108.89,21359.42,MSDRG Base Rate
Spinal Disorders And Injuries Without Cc/Mcc,53,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14409.5,,,,,,,fee schedule,7108.89,21359.42,MSDRG Base Rate
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11567.28,,,,,,,fee schedule,11567.28,34755.13,
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,11567.28,,,,,,,fee schedule,11567.28,34755.13,
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15485.61,,,,,,,fee schedule,11567.28,34755.13,
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14748.21,,,,,,,fee schedule,11567.28,34755.13,
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,25830.99,,,,,,,fee schedule,11567.28,34755.13,
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,20072.95,,,,,,,fee schedule,11567.28,34755.13,
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,34755.13,,,,,,,fee schedule,11567.28,34755.13,
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,23892.27,,,,,,,fee schedule,11567.28,34755.13,
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,21638.01,,,,,,,fee schedule,11567.28,34755.13,
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17722.42,,,,,,,fee schedule,11567.28,34755.13,
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12140.85,12140.85,12140.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],22506,22506,22506,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],14748.21,14748.21,14748.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11389.72,11389.72,11389.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],14496.35,14496.35,14496.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],25330.99,25151.9,27178.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",7316.05,7316.05,7316.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12924.56,,,,,,,fee schedule,11567.28,34755.13,MSDRG Base Rate
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,12801.46,,,,,,,fee schedule,11567.28,34755.13,MSDRG Base Rate
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,12801.46,,,,,,,fee schedule,11567.28,34755.13,MSDRG Base Rate
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,12924.56,,,,,,,fee schedule,11567.28,34755.13,MSDRG Base Rate
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,12801.46,,,,,,,fee schedule,11567.28,34755.13,MSDRG Base Rate
Nervous System Neoplasms With Mcc,54,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21540.92,,,,,,,fee schedule,11567.28,34755.13,MSDRG Base Rate
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8417.55,,,,,,,fee schedule,8417.55,25291.43,
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,8417.55,,,,,,,fee schedule,8417.55,25291.43,
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11268.93,,,,,,,fee schedule,8417.55,25291.43,
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10732.32,,,,,,,fee schedule,8417.55,25291.43,
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,18797.3,,,,,,,fee schedule,8417.55,25291.43,
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,14607.15,,,,,,,fee schedule,8417.55,25291.43,
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,25291.43,,,,,,,fee schedule,8417.55,25291.43,
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,17386.48,,,,,,,fee schedule,8417.55,25291.43,
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,15746.05,,,,,,,fee schedule,8417.55,25291.43,
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12896.66,,,,,,,fee schedule,8417.55,25291.43,
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],11709.82,11709.82,11709.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",6867.43,6867.43,6867.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],7556.81,7556.81,7556.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],11790.07,11790.07,11790.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],8581.05,8581.05,8581.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",6389.7,6389.7,6389.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8961.32,,,,,,,fee schedule,8417.55,25291.43,MSDRG Base Rate
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,8875.97,,,,,,,fee schedule,8417.55,25291.43,MSDRG Base Rate
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,8875.97,,,,,,,fee schedule,8417.55,25291.43,MSDRG Base Rate
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,8961.32,,,,,,,fee schedule,8417.55,25291.43,MSDRG Base Rate
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,8875.97,,,,,,,fee schedule,8417.55,25291.43,MSDRG Base Rate
Nervous System Neoplasms Without Mcc,55,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14935.53,,,,,,,fee schedule,8417.55,25291.43,MSDRG Base Rate
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,19321.24,,,,,,,fee schedule,18962.47,58052.74,
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,19321.24,,,,,,,fee schedule,18962.47,58052.74,
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,25866.17,,,,,,,fee schedule,18962.47,58052.74,
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24634.45,,,,,,,fee schedule,18962.47,58052.74,
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,43146.42,,,,,,,fee schedule,18962.47,58052.74,
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,33528.56,,,,,,,fee schedule,18962.47,58052.74,
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,58052.74,,,,,,,fee schedule,18962.47,58052.74,
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,39908.1,,,,,,,fee schedule,18962.47,58052.74,
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,36142.74,,,,,,,fee schedule,18962.47,58052.74,
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,29602.39,,,,,,,fee schedule,18962.47,58052.74,
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],18469.75,18112.87,19936.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],39909.69,39909.69,39909.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",6614.06,6614.06,6614.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],17458.8,17458.8,19285.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],18352.2,9161.8,18841.04,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,19144.8,,,,,,,fee schedule,18962.47,58052.74,MSDRG Base Rate
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,18962.47,,,,,,,fee schedule,18962.47,58052.74,MSDRG Base Rate
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,18962.47,,,,,,,fee schedule,18962.47,58052.74,MSDRG Base Rate
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,19144.8,,,,,,,fee schedule,18962.47,58052.74,MSDRG Base Rate
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,18962.47,,,,,,,fee schedule,18962.47,58052.74,MSDRG Base Rate
Degenerative Nervous System Disorders With Mcc,56,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31908,,,,,,,fee schedule,18962.47,58052.74,MSDRG Base Rate
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10298.75,,,,,,,fee schedule,10298.75,30943.68,
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,10298.75,,,,,,,fee schedule,10298.75,30943.68,
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13787.37,,,,,,,fee schedule,10298.75,30943.68,
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13130.83,,,,,,,fee schedule,10298.75,30943.68,
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,22998.22,,,,,,,fee schedule,10298.75,30943.68,
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,17871.63,,,,,,,fee schedule,10298.75,30943.68,
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,30943.68,,,,,,,fee schedule,10298.75,30943.68,
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,21272.1,,,,,,,fee schedule,10298.75,30943.68,
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,19265.06,,,,,,,fee schedule,10298.75,30943.68,
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15778.88,,,,,,,fee schedule,10298.75,30943.68,
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],10042.84,10042.84,10042.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],20567.32,20567.32,78102.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9421.72,9421.72,9421.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],13127.88,13127.88,13127.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4826.16,4826.16,4826.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9806.12,8466.07,10209.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],15775.33,15775.33,15775.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],19637.78,19637.78,19637.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],8289.44,7984.54,10371.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4781.47,4781.47,4781.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],14.54,14.54,14.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11117.55,,,,,,,fee schedule,10298.75,30943.68,MSDRG Base Rate
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,11011.67,,,,,,,fee schedule,10298.75,30943.68,MSDRG Base Rate
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,11011.67,,,,,,,fee schedule,10298.75,30943.68,MSDRG Base Rate
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,11117.55,,,,,,,fee schedule,10298.75,30943.68,MSDRG Base Rate
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,11011.67,,,,,,,fee schedule,10298.75,30943.68,MSDRG Base Rate
Degenerative Nervous System Disorders Without Mcc,57,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18529.24,,,,,,,fee schedule,10298.75,30943.68,MSDRG Base Rate
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14241.7,,,,,,,fee schedule,14214.43,42790.71,
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,14241.7,,,,,,,fee schedule,14214.43,42790.71,
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19065.97,,,,,,,fee schedule,14214.43,42790.71,
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18158.07,,,,,,,fee schedule,14214.43,42790.71,
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,31803.26,,,,,,,fee schedule,14214.43,42790.71,
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,24713.92,,,,,,,fee schedule,14214.43,42790.71,
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,42790.71,,,,,,,fee schedule,14214.43,42790.71,
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,29416.29,,,,,,,fee schedule,14214.43,42790.71,
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,26640.83,,,,,,,fee schedule,14214.43,42790.71,
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21819.94,,,,,,,fee schedule,14214.43,42790.71,
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],24.97,24.97,24.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],18714,18714,18714,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],7471.76,7471.76,7471.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14351.11,,,,,,,fee schedule,14214.43,42790.71,MSDRG Base Rate
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,14214.43,,,,,,,fee schedule,14214.43,42790.71,MSDRG Base Rate
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,14214.43,,,,,,,fee schedule,14214.43,42790.71,MSDRG Base Rate
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,14351.11,,,,,,,fee schedule,14214.43,42790.71,MSDRG Base Rate
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,14214.43,,,,,,,fee schedule,14214.43,42790.71,MSDRG Base Rate
Multiple Sclerosis And Cerebellar Ataxia With Mcc,58,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23918.51,,,,,,,fee schedule,14214.43,42790.71,MSDRG Base Rate
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9440.71,,,,,,,fee schedule,9440.71,28365.62,
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,9440.71,,,,,,,fee schedule,9440.71,28365.62,
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12638.68,,,,,,,fee schedule,9440.71,28365.62,
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12036.84,,,,,,,fee schedule,9440.71,28365.62,
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,21082.13,,,,,,,fee schedule,9440.71,28365.62,
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,16382.67,,,,,,,fee schedule,9440.71,28365.62,
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,28365.62,,,,,,,fee schedule,9440.71,28365.62,
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,19499.82,,,,,,,fee schedule,9440.71,28365.62,
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,17660,,,,,,,fee schedule,9440.71,28365.62,
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14464.27,,,,,,,fee schedule,9440.71,28365.62,
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],13475.62,10173.88,16804.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],19552.97,19552.97,19552.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",6073.26,6073.26,6073.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],20883.85,17375,21083.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],8286.92,8286.92,8286.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",6017.03,6017.03,6017.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10690.21,,,,,,,fee schedule,9440.71,28365.62,MSDRG Base Rate
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,10588.4,,,,,,,fee schedule,9440.71,28365.62,MSDRG Base Rate
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,10588.4,,,,,,,fee schedule,9440.71,28365.62,MSDRG Base Rate
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,10690.21,,,,,,,fee schedule,9440.71,28365.62,MSDRG Base Rate
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,10588.4,,,,,,,fee schedule,9440.71,28365.62,MSDRG Base Rate
Multiple Sclerosis And Cerebellar Ataxia With Cc,59,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,17817.01,,,,,,,fee schedule,9440.71,28365.62,MSDRG Base Rate
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6885.89,,,,,,,fee schedule,6885.89,20689.4,
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,6885.89,,,,,,,fee schedule,6885.89,20689.4,
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9218.44,,,,,,,fee schedule,6885.89,20689.4,
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8779.47,,,,,,,fee schedule,6885.89,20689.4,
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,15376.94,,,,,,,fee schedule,6885.89,20689.4,
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,11949.24,,,,,,,fee schedule,6885.89,20689.4,
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,20689.4,,,,,,,fee schedule,6885.89,20689.4,
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,14222.84,,,,,,,fee schedule,6885.89,20689.4,
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,12880.9,,,,,,,fee schedule,6885.89,20689.4,
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10549.99,,,,,,,fee schedule,6885.89,20689.4,
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],9828.63,9828.63,9828.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4589.29,4589.29,4589.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6775.24,6775.24,6775.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],13474.22,12851.55,16072.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8181.64,,,,,,,fee schedule,6885.89,20689.4,MSDRG Base Rate
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,8103.72,,,,,,,fee schedule,6885.89,20689.4,MSDRG Base Rate
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,8103.72,,,,,,,fee schedule,6885.89,20689.4,MSDRG Base Rate
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,8181.64,,,,,,,fee schedule,6885.89,20689.4,MSDRG Base Rate
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,8103.72,,,,,,,fee schedule,6885.89,20689.4,MSDRG Base Rate
Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc,60,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,13636.07,,,,,,,fee schedule,6885.89,20689.4,MSDRG Base Rate
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,20858.3,,,,,,,fee schedule,20858.3,62670.99,
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,20858.3,,,,,,,fee schedule,20858.3,62670.99,
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,27923.89,,,,,,,fee schedule,20858.3,62670.99,
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26594.19,,,,,,,fee schedule,20858.3,62670.99,
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,46578.84,,,,,,,fee schedule,20858.3,62670.99,
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,36195.85,,,,,,,fee schedule,20858.3,62670.99,
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,62670.99,,,,,,,fee schedule,20858.3,62670.99,
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,43082.9,,,,,,,fee schedule,20858.3,62670.99,
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,39017.99,,,,,,,fee schedule,20858.3,62670.99,
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,31957.34,,,,,,,fee schedule,20858.3,62670.99,
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],19568.18,19568.18,19568.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],41758.92,41758.92,41758.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],20352.43,20352.43,22050.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,22535.38,,,,,,,fee schedule,20858.3,62670.99,MSDRG Base Rate
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,22320.76,,,,,,,fee schedule,20858.3,62670.99,MSDRG Base Rate
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,22320.76,,,,,,,fee schedule,20858.3,62670.99,MSDRG Base Rate
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,22535.38,,,,,,,fee schedule,20858.3,62670.99,MSDRG Base Rate
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,22320.76,,,,,,,fee schedule,20858.3,62670.99,MSDRG Base Rate
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc",61,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,37558.97,,,,,,,fee schedule,20858.3,62670.99,MSDRG Base Rate
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13740.92,,,,,,,fee schedule,13740.92,41286.07,
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,13740.92,,,,,,,fee schedule,13740.92,41286.07,
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18395.56,,,,,,,fee schedule,13740.92,41286.07,
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17519.58,,,,,,,fee schedule,13740.92,41286.07,
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,30684.96,,,,,,,fee schedule,13740.92,41286.07,
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,23844.91,,,,,,,fee schedule,13740.92,41286.07,
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,41286.07,,,,,,,fee schedule,13740.92,41286.07,
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,28381.93,,,,,,,fee schedule,13740.92,41286.07,
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,25704.07,,,,,,,fee schedule,13740.92,41286.07,
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21052.69,,,,,,,fee schedule,13740.92,41286.07,
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],13716.06,13716.06,13716.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13102.03,13102.03,13102.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],10876.74,10876.74,10876.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],14095.98,14095.98,14095.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],20639.09,20639.09,20639.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],17520.57,17520.57,17520.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13144.06,13144.06,13144.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],26040.39,26040.39,26040.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],13600.7,13600.7,13626.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14723.75,,,,,,,fee schedule,13740.92,41286.07,MSDRG Base Rate
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,14583.52,,,,,,,fee schedule,13740.92,41286.07,MSDRG Base Rate
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,14583.52,,,,,,,fee schedule,13740.92,41286.07,MSDRG Base Rate
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,14723.75,,,,,,,fee schedule,13740.92,41286.07,MSDRG Base Rate
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,14583.52,,,,,,,fee schedule,13740.92,41286.07,MSDRG Base Rate
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc",62,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,24539.59,,,,,,,fee schedule,13740.92,41286.07,MSDRG Base Rate
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10838.88,,,,,,,fee schedule,10838.88,32566.56,
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,10838.88,,,,,,,fee schedule,10838.88,32566.56,
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14510.47,,,,,,,fee schedule,10838.88,32566.56,
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13819.49,,,,,,,fee schedule,10838.88,32566.56,
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,24204.39,,,,,,,fee schedule,10838.88,32566.56,
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,18808.93,,,,,,,fee schedule,10838.88,32566.56,
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,32566.56,,,,,,,fee schedule,10838.88,32566.56,
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,22387.74,,,,,,,fee schedule,10838.88,32566.56,
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,20275.44,,,,,,,fee schedule,10838.88,32566.56,
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16606.42,,,,,,,fee schedule,10838.88,32566.56,
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],24206.11,24206.11,24206.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],10880.52,10880.52,10880.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11962.85,,,,,,,fee schedule,10838.88,32566.56,MSDRG Base Rate
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,11848.92,,,,,,,fee schedule,10838.88,32566.56,MSDRG Base Rate
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,11848.92,,,,,,,fee schedule,10838.88,32566.56,MSDRG Base Rate
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,11962.85,,,,,,,fee schedule,10838.88,32566.56,MSDRG Base Rate
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,11848.92,,,,,,,fee schedule,10838.88,32566.56,MSDRG Base Rate
"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc",63,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19938.08,,,,,,,fee schedule,10838.88,32566.56,MSDRG Base Rate
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,15348.19,,,,,,,fee schedule,15348.19,46115.29,
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,15348.19,,,,,,,fee schedule,15348.19,46115.29,
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20547.28,,,,,,,fee schedule,15348.19,46115.29,
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19568.85,,,,,,,fee schedule,15348.19,46115.29,
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,34274.18,,,,,,,fee schedule,15348.19,46115.29,
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,26634.05,,,,,,,fee schedule,15348.19,46115.29,
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,46115.29,,,,,,,fee schedule,15348.19,46115.29,
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,31701.76,,,,,,,fee schedule,15348.19,46115.29,
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,28710.67,,,,,,,fee schedule,15348.19,46115.29,
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23515.22,,,,,,,fee schedule,15348.19,46115.29,
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],13096.1,13096.1,13096.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],14357.54,12877.17,15123.73,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],30294.06,18523.73,32954.45,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7055.22,7055.22,7055.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],28272,28272,108062,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",12281.26,12281.26,12281.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",11533.71,11533.71,11533.71,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],74191.95,74191.95,74191.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],14625.79,14625.79,14625.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],14084.19,13045.62,14398.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],23408.22,23408.22,23408.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],13293.58,8100.24,15253.72,28,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],29820,24455.2,32057,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],29278.89,29278.89,29278.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,16706.54,,,,,,,fee schedule,15348.19,46115.29,MSDRG Base Rate
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,16547.43,,,,,,,fee schedule,15348.19,46115.29,MSDRG Base Rate
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,16547.43,,,,,,,fee schedule,15348.19,46115.29,MSDRG Base Rate
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,16706.54,,,,,,,fee schedule,15348.19,46115.29,MSDRG Base Rate
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,16547.43,,,,,,,fee schedule,15348.19,46115.29,MSDRG Base Rate
Intracranial Hemorrhage Or Cerebral Infarction With Mcc,64,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,27844.23,,,,,,,fee schedule,15348.19,46115.29,MSDRG Base Rate
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7847.32,,,,,,,fee schedule,7847.32,23578.13,
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,7847.32,,,,,,,fee schedule,7847.32,23578.13,
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10505.55,,,,,,,fee schedule,7847.32,23578.13,
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10005.29,,,,,,,fee schedule,7847.32,23578.13,
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,17523.93,,,,,,,fee schedule,7847.32,23578.13,
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,13617.63,,,,,,,fee schedule,7847.32,23578.13,
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,23578.13,,,,,,,fee schedule,7847.32,23578.13,
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,16208.68,,,,,,,fee schedule,7847.32,23578.13,
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,14679.38,,,,,,,fee schedule,7847.32,23578.13,
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12023.01,,,,,,,fee schedule,7847.32,23578.13,
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],8121.54,8121.54,8121.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],19227.13,19227.13,19227.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7746.45,5942.32,7770.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],14760.72,13513.86,24779.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7809.16,7809.16,7809.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],9688.38,9688.38,9688.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",9331.05,9331.05,9331.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],10504.52,10504.52,10504.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",8763.08,8763.08,8763.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],7736.9,7736.9,7812.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7493.5,6968.37,7732.45,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],9617.46,9617.46,9640.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],14356.08,5837,17522.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],7897.38,6191.09,8154.11,26,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],17739.99,17739.99,17739.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8888.67,,,,,,,fee schedule,7847.32,23578.13,MSDRG Base Rate
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,8804.02,,,,,,,fee schedule,7847.32,23578.13,MSDRG Base Rate
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,8804.02,,,,,,,fee schedule,7847.32,23578.13,MSDRG Base Rate
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,8888.67,,,,,,,fee schedule,7847.32,23578.13,MSDRG Base Rate
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,8804.02,,,,,,,fee schedule,7847.32,23578.13,MSDRG Base Rate
Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours,65,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14814.45,,,,,,,fee schedule,7847.32,23578.13,MSDRG Base Rate
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5311.03,,,,,,,fee schedule,5311.03,15957.55,
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,5311.03,,,,,,,fee schedule,5311.03,15957.55,
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7110.1,,,,,,,fee schedule,5311.03,15957.55,
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6771.52,,,,,,,fee schedule,5311.03,15957.55,
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,11860.1,,,,,,,fee schedule,5311.03,15957.55,
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,9216.34,,,,,,,fee schedule,5311.03,15957.55,
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,15957.55,,,,,,,fee schedule,5311.03,15957.55,
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,10969.95,,,,,,,fee schedule,5311.03,15957.55,
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,9934.92,,,,,,,fee schedule,5311.03,15957.55,
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8137.11,,,,,,,fee schedule,5311.03,15957.55,
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],11419.07,11419.07,11419.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],4891.54,4891.54,4891.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],9356.8,9356.8,9356.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],5474.86,5474.86,5474.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],119.31,119.31,119.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],19022.85,19022.85,19022.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],5511.38,5511.38,5511.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],11833.62,11833.62,11833.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],9238.64,9238.64,10050.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],5240.43,4582.21,5674.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",6788.78,6788.78,6788.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,6342.6,,,,,,,fee schedule,5311.03,15957.55,MSDRG Base Rate
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,6282.19,,,,,,,fee schedule,5311.03,15957.55,MSDRG Base Rate
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,6282.19,,,,,,,fee schedule,5311.03,15957.55,MSDRG Base Rate
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,6342.6,,,,,,,fee schedule,5311.03,15957.55,MSDRG Base Rate
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,6282.19,,,,,,,fee schedule,5311.03,15957.55,MSDRG Base Rate
Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc,66,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10571,,,,,,,fee schedule,5311.03,15957.55,MSDRG Base Rate
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11233.17,,,,,,,fee schedule,11233.17,33751.27,
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,11233.17,,,,,,,fee schedule,11233.17,33751.27,
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15038.33,,,,,,,fee schedule,11233.17,33751.27,
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14322.22,,,,,,,fee schedule,11233.17,33751.27,
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,25084.89,,,,,,,fee schedule,11233.17,33751.27,
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,19493.16,,,,,,,fee schedule,11233.17,33751.27,
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,33751.27,,,,,,,fee schedule,11233.17,33751.27,
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,23202.16,,,,,,,fee schedule,11233.17,33751.27,
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,21013.02,,,,,,,fee schedule,11233.17,33751.27,
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17210.53,,,,,,,fee schedule,11233.17,33751.27,
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",12413.56,12413.56,12413.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12469.87,,,,,,,fee schedule,11233.17,33751.27,MSDRG Base Rate
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,12351.11,,,,,,,fee schedule,11233.17,33751.27,MSDRG Base Rate
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,12351.11,,,,,,,fee schedule,11233.17,33751.27,MSDRG Base Rate
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,12469.87,,,,,,,fee schedule,11233.17,33751.27,MSDRG Base Rate
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,12351.11,,,,,,,fee schedule,11233.17,33751.27,MSDRG Base Rate
Precerebral Occlusion Without Infarction With Mcc,67,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20783.12,,,,,,,fee schedule,11233.17,33751.27,MSDRG Base Rate
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6802.56,,,,,,,fee schedule,6802.56,20439.01,
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,6802.56,,,,,,,fee schedule,6802.56,20439.01,
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9106.88,,,,,,,fee schedule,6802.56,20439.01,
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8673.22,,,,,,,fee schedule,6802.56,20439.01,
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,15190.85,,,,,,,fee schedule,6802.56,20439.01,
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,11804.62,,,,,,,fee schedule,6802.56,20439.01,
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,20439.01,,,,,,,fee schedule,6802.56,20439.01,
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,14050.71,,,,,,,fee schedule,6802.56,20439.01,
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,12725.01,,,,,,,fee schedule,6802.56,20439.01,
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10422.31,,,,,,,fee schedule,6802.56,20439.01,
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6805.96,6805.96,6805.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6711.2,6711.2,6711.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],7105.69,7105.69,7105.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7748.83,,,,,,,fee schedule,6802.56,20439.01,MSDRG Base Rate
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,7675.03,,,,,,,fee schedule,6802.56,20439.01,MSDRG Base Rate
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,7675.03,,,,,,,fee schedule,6802.56,20439.01,MSDRG Base Rate
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,7748.83,,,,,,,fee schedule,6802.56,20439.01,MSDRG Base Rate
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,7675.03,,,,,,,fee schedule,6802.56,20439.01,MSDRG Base Rate
Precerebral Occlusion Without Infarction Without Mcc,68,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12914.72,,,,,,,fee schedule,6802.56,20439.01,MSDRG Base Rate
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6174.46,,,,,,,fee schedule,6174.46,18551.84,
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,6174.46,,,,,,,fee schedule,6174.46,18551.84,
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8266.02,,,,,,,fee schedule,6174.46,18551.84,
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7872.4,,,,,,,fee schedule,6174.46,18551.84,
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,13788.25,,,,,,,fee schedule,6174.46,18551.84,
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,10714.68,,,,,,,fee schedule,6174.46,18551.84,
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,18551.84,,,,,,,fee schedule,6174.46,18551.84,
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,12753.38,,,,,,,fee schedule,6174.46,18551.84,
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,11550.09,,,,,,,fee schedule,6174.46,18551.84,
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9460,,,,,,,fee schedule,6174.46,18551.84,
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],6543.96,6543.96,6543.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6235.96,6235.96,6484.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],12751.79,12729.47,21543.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],1116.99,1116.99,1116.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",6013.94,6013.94,6479.19,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],6015.04,6015.04,6015.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6024.77,5579.29,6133.3,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],13424.08,13424.08,13641.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],5807.49,10.83,6535.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",5958.25,5958.25,5958.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7236.34,,,,,,,fee schedule,6174.46,18551.84,MSDRG Base Rate
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,7167.42,,,,,,,fee schedule,6174.46,18551.84,MSDRG Base Rate
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,7167.42,,,,,,,fee schedule,6174.46,18551.84,MSDRG Base Rate
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,7236.34,,,,,,,fee schedule,6174.46,18551.84,MSDRG Base Rate
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,7167.42,,,,,,,fee schedule,6174.46,18551.84,MSDRG Base Rate
Transient Ischemia Without Thrombolytic,69,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12060.56,,,,,,,fee schedule,6174.46,18551.84,MSDRG Base Rate
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13416.07,,,,,,,fee schedule,13416.07,40310.02,
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,13416.07,,,,,,,fee schedule,13416.07,40310.02,
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17960.67,,,,,,,fee schedule,13416.07,40310.02,
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17105.4,,,,,,,fee schedule,13416.07,40310.02,
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,29959.54,,,,,,,fee schedule,13416.07,40310.02,
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,23281.19,,,,,,,fee schedule,13416.07,40310.02,
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,40310.02,,,,,,,fee schedule,13416.07,40310.02,
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,27710.95,,,,,,,fee schedule,13416.07,40310.02,
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,25096.4,,,,,,,fee schedule,13416.07,40310.02,
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20554.98,,,,,,,fee schedule,13416.07,40310.02,
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13326.58,13282.18,24989.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],27712.54,27712.54,27812.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13285.05,13285.05,13285.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",17521.15,17521.15,17521.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",16454.64,16454.64,16454.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13185.56,11773.04,13332.07,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],17874.26,17874.26,17874.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],1173.77,1173.77,1173.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],12396.47,10387.98,13308.49,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",16302.28,16302.28,16302.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],26117.6,26117.6,26117.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14001.89,,,,,,,fee schedule,13416.07,40310.02,MSDRG Base Rate
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,13868.54,,,,,,,fee schedule,13416.07,40310.02,MSDRG Base Rate
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,13868.54,,,,,,,fee schedule,13416.07,40310.02,MSDRG Base Rate
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,14001.89,,,,,,,fee schedule,13416.07,40310.02,MSDRG Base Rate
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,13868.54,,,,,,,fee schedule,13416.07,40310.02,MSDRG Base Rate
Other Cerebrovascular Disorders With Mcc,70,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23336.48,,,,,,,fee schedule,13416.07,40310.02,MSDRG Base Rate
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8131.28,,,,,,,fee schedule,8131.28,24431.3,
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,8131.28,,,,,,,fee schedule,8131.28,24431.3,
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10885.69,,,,,,,fee schedule,8131.28,24431.3,
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10367.33,,,,,,,fee schedule,8131.28,24431.3,
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,18158.03,,,,,,,fee schedule,8131.28,24431.3,
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,14110.38,,,,,,,fee schedule,8131.28,24431.3,
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,24431.3,,,,,,,fee schedule,8131.28,24431.3,
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,16795.19,,,,,,,fee schedule,8131.28,24431.3,
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,15210.55,,,,,,,fee schedule,8131.28,24431.3,
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12458.07,,,,,,,fee schedule,8131.28,24431.3,
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],8100.79,8100.79,8100.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],16796.78,16796.78,16796.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8334.03,6669.35,8507.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],15211.99,15211.99,15211.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7321.37,7321.37,8250.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],10368.31,10368.31,10368.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],8038.9,8038.9,8038.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",10092.72,10092.72,10092.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8012.01,8012.01,8096.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],13534.47,13534.47,13534.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],7629.37,14.26,8710.19,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9011.32,,,,,,,fee schedule,8131.28,24431.3,MSDRG Base Rate
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,8925.5,,,,,,,fee schedule,8131.28,24431.3,MSDRG Base Rate
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,8925.5,,,,,,,fee schedule,8131.28,24431.3,MSDRG Base Rate
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,9011.32,,,,,,,fee schedule,8131.28,24431.3,MSDRG Base Rate
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,8925.5,,,,,,,fee schedule,8131.28,24431.3,MSDRG Base Rate
Other Cerebrovascular Disorders With Cc,71,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15018.87,,,,,,,fee schedule,8131.28,24431.3,MSDRG Base Rate
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5787.88,,,,,,,fee schedule,5787.88,17390.32,
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,5787.88,,,,,,,fee schedule,5787.88,17390.32,
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7748.49,,,,,,,fee schedule,5787.88,17390.32,
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7379.51,,,,,,,fee schedule,5787.88,17390.32,
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,12924.97,,,,,,,fee schedule,5787.88,17390.32,
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,10043.84,,,,,,,fee schedule,5787.88,17390.32,
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,17390.32,,,,,,,fee schedule,5787.88,17390.32,
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,11954.9,,,,,,,fee schedule,5787.88,17390.32,
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,10826.94,,,,,,,fee schedule,5787.88,17390.32,
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8867.71,,,,,,,fee schedule,5787.88,17390.32,
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",6915.42,6915.42,6915.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],7230.5,7230.5,7230.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],5442.05,5442.05,5442.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],10.15,10.15,10.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,6903.53,,,,,,,fee schedule,5787.88,17390.32,MSDRG Base Rate
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,6837.78,,,,,,,fee schedule,5787.88,17390.32,MSDRG Base Rate
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,6837.78,,,,,,,fee schedule,5787.88,17390.32,MSDRG Base Rate
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,6903.53,,,,,,,fee schedule,5787.88,17390.32,MSDRG Base Rate
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,6837.78,,,,,,,fee schedule,5787.88,17390.32,MSDRG Base Rate
Other Cerebrovascular Disorders Without Cc/Mcc,72,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11505.88,,,,,,,fee schedule,5787.88,17390.32,MSDRG Base Rate
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11925.31,,,,,,,fee schedule,11925.31,35830.87,
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,11925.31,,,,,,,fee schedule,11925.31,35830.87,
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15964.92,,,,,,,fee schedule,11925.31,35830.87,
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15204.69,,,,,,,fee schedule,11925.31,35830.87,
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,26630.51,,,,,,,fee schedule,11925.31,35830.87,
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,20694.25,,,,,,,fee schedule,11925.31,35830.87,
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,35830.87,,,,,,,fee schedule,11925.31,35830.87,
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,24631.78,,,,,,,fee schedule,11925.31,35830.87,
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,22307.75,,,,,,,fee schedule,11925.31,35830.87,
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18270.96,,,,,,,fee schedule,11925.31,35830.87,
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],10299.71,10299.71,11913.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],25372.37,25372.37,25372.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4521.37,4521.37,4521.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11708.47,11708.47,11708.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],25932.08,25932.08,25932.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],20.91,20.91,9920.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13529.24,,,,,,,fee schedule,11925.31,35830.87,MSDRG Base Rate
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,13400.39,,,,,,,fee schedule,11925.31,35830.87,MSDRG Base Rate
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,13400.39,,,,,,,fee schedule,11925.31,35830.87,MSDRG Base Rate
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,13529.24,,,,,,,fee schedule,11925.31,35830.87,MSDRG Base Rate
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,13400.39,,,,,,,fee schedule,11925.31,35830.87,MSDRG Base Rate
Cranial And Peripheral Nerve Disorders With Mcc,73,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22548.73,,,,,,,fee schedule,11925.31,35830.87,MSDRG Base Rate
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8043.31,,,,,,,fee schedule,8043.31,24167,
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,8043.31,,,,,,,fee schedule,8043.31,24167,
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10767.93,,,,,,,fee schedule,8043.31,24167,
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10255.17,,,,,,,fee schedule,8043.31,24167,
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,17961.59,,,,,,,fee schedule,8043.31,24167,
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,13957.74,,,,,,,fee schedule,8043.31,24167,
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,24167,,,,,,,fee schedule,8043.31,24167,
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,16613.5,,,,,,,fee schedule,8043.31,24167,
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,15046,,,,,,,fee schedule,8043.31,24167,
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12323.29,,,,,,,fee schedule,8043.31,24167,
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8416.68,8416.68,8416.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],16613.5,16613.5,16613.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],10253.17,10253.17,10253.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4005.5,4005.5,4005.5,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],6254.06,6254.06,6254.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7681.89,7555.36,7896.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],12497.05,12497.05,12497.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],21232.59,21232.59,94136.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],8109.46,6662.92,8934.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3968.42,3968.42,3968.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9048.82,,,,,,,fee schedule,8043.31,24167,MSDRG Base Rate
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,8962.64,,,,,,,fee schedule,8043.31,24167,MSDRG Base Rate
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,8962.64,,,,,,,fee schedule,8043.31,24167,MSDRG Base Rate
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,9048.82,,,,,,,fee schedule,8043.31,24167,MSDRG Base Rate
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,8962.64,,,,,,,fee schedule,8043.31,24167,MSDRG Base Rate
Cranial And Peripheral Nerve Disorders Without Mcc,74,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15081.36,,,,,,,fee schedule,8043.31,24167,MSDRG Base Rate
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13290.3,,,,,,,fee schedule,13290.3,39932.12,
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,13290.3,,,,,,,fee schedule,13290.3,39932.12,
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17792.29,,,,,,,fee schedule,13290.3,39932.12,
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16945.04,,,,,,,fee schedule,13290.3,39932.12,
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,29678.67,,,,,,,fee schedule,13290.3,39932.12,
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,23062.94,,,,,,,fee schedule,13290.3,39932.12,
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,39932.12,,,,,,,fee schedule,13290.3,39932.12,
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,27451.16,,,,,,,fee schedule,13290.3,39932.12,
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,24861.12,,,,,,,fee schedule,13290.3,39932.12,
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20362.28,,,,,,,fee schedule,13290.3,39932.12,
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],24763,24763,24763,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15976.09,,,,,,,fee schedule,13290.3,39932.12,MSDRG Base Rate
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,15823.93,,,,,,,fee schedule,13290.3,39932.12,MSDRG Base Rate
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,15823.93,,,,,,,fee schedule,13290.3,39932.12,MSDRG Base Rate
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,15976.09,,,,,,,fee schedule,13290.3,39932.12,MSDRG Base Rate
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,15823.93,,,,,,,fee schedule,13290.3,39932.12,MSDRG Base Rate
Viral Meningitis With Cc/Mcc,75,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,26626.81,,,,,,,fee schedule,13290.3,39932.12,MSDRG Base Rate
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7074.94,,,,,,,fee schedule,7074.94,21257.41,
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,7074.94,,,,,,,fee schedule,7074.94,21257.41,
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9471.52,,,,,,,fee schedule,7074.94,21257.41,
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9020.5,,,,,,,fee schedule,7074.94,21257.41,
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,15799.1,,,,,,,fee schedule,7074.94,21257.41,
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,12277.29,,,,,,,fee schedule,7074.94,21257.41,
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,21257.41,,,,,,,fee schedule,7074.94,21257.41,
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,14613.31,,,,,,,fee schedule,7074.94,21257.41,
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,13234.53,,,,,,,fee schedule,7074.94,21257.41,
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10839.63,,,,,,,fee schedule,7074.94,21257.41,
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",2976.35,2976.35,2976.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],1523.77,1523.77,1523.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7442.59,,,,,,,fee schedule,7074.94,21257.41,MSDRG Base Rate
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,7371.71,,,,,,,fee schedule,7074.94,21257.41,MSDRG Base Rate
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,7371.71,,,,,,,fee schedule,7074.94,21257.41,MSDRG Base Rate
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,7442.59,,,,,,,fee schedule,7074.94,21257.41,MSDRG Base Rate
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,7371.71,,,,,,,fee schedule,7074.94,21257.41,MSDRG Base Rate
Viral Meningitis Without Cc/Mcc,76,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12404.32,,,,,,,fee schedule,7074.94,21257.41,MSDRG Base Rate
Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11930.71,,,,,,,fee schedule,11930.71,35847.1,
Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,11930.71,,,,,,,fee schedule,11930.71,35847.1,
Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15972.15,,,,,,,fee schedule,11930.71,35847.1,
Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15211.58,,,,,,,fee schedule,11930.71,35847.1,
Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,26642.57,,,,,,,fee schedule,11930.71,35847.1,
Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,20703.62,,,,,,,fee schedule,11930.71,35847.1,
Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,35847.1,,,,,,,fee schedule,11930.71,35847.1,
Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,24642.93,,,,,,,fee schedule,11930.71,35847.1,
Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,22317.85,,,,,,,fee schedule,11930.71,35847.1,
Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18279.24,,,,,,,fee schedule,11930.71,35847.1,
Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11464.88,11464.88,11464.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",5863.05,5863.05,5863.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Mcc,77,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7699.17,,,,,,,fee schedule,7699.17,23133,
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,7699.17,,,,,,,fee schedule,7699.17,23133,
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10307.21,,,,,,,fee schedule,7699.17,23133,
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9816.4,,,,,,,fee schedule,7699.17,23133,
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,17193.09,,,,,,,fee schedule,7699.17,23133,
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,13360.54,,,,,,,fee schedule,7699.17,23133,
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,23133,,,,,,,fee schedule,7699.17,23133,
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,15902.68,,,,,,,fee schedule,7699.17,23133,
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,14402.25,,,,,,,fee schedule,7699.17,23133,
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11796.03,,,,,,,fee schedule,7699.17,23133,
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8066.48,8066.48,8066.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy With Cc,78,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5144.36,,,,,,,fee schedule,5144.36,15456.77,
Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,5144.36,,,,,,,fee schedule,5144.36,15456.77,
Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6886.97,,,,,,,fee schedule,5144.36,15456.77,
Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6559.02,,,,,,,fee schedule,5144.36,15456.77,
Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,11487.91,,,,,,,fee schedule,5144.36,15456.77,
Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,8927.11,,,,,,,fee schedule,5144.36,15456.77,
Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,15456.77,,,,,,,fee schedule,5144.36,15456.77,
Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,10625.69,,,,,,,fee schedule,5144.36,15456.77,
Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,9623.15,,,,,,,fee schedule,5144.36,15456.77,
Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7881.75,,,,,,,fee schedule,5144.36,15456.77,
Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertensive Encephalopathy Without Cc/Mcc,79,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,15338.16,,,,,,,fee schedule,14992.1,46085.16,
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,15338.16,,,,,,,fee schedule,14992.1,46085.16,
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20533.85,,,,,,,fee schedule,14992.1,46085.16,
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19556.06,,,,,,,fee schedule,14992.1,46085.16,
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,34251.78,,,,,,,fee schedule,14992.1,46085.16,
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,26616.64,,,,,,,fee schedule,14992.1,46085.16,
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,46085.16,,,,,,,fee schedule,14992.1,46085.16,
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,31681.04,,,,,,,fee schedule,14992.1,46085.16,
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,28691.91,,,,,,,fee schedule,14992.1,46085.16,
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23499.85,,,,,,,fee schedule,14992.1,46085.16,
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],33528.99,33528.99,33528.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13956.93,13956.93,13956.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],14607.78,14607.78,14607.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],15124.05,15124.05,15124.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15136.25,,,,,,,fee schedule,14992.1,46085.16,MSDRG Base Rate
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,14992.1,,,,,,,fee schedule,14992.1,46085.16,MSDRG Base Rate
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,14992.1,,,,,,,fee schedule,14992.1,46085.16,MSDRG Base Rate
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,15136.25,,,,,,,fee schedule,14992.1,46085.16,MSDRG Base Rate
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,14992.1,,,,,,,fee schedule,14992.1,46085.16,MSDRG Base Rate
Nontraumatic Stupor And Coma With Mcc,80,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,25227.09,,,,,,,fee schedule,14992.1,46085.16,MSDRG Base Rate
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6981.57,,,,,,,fee schedule,6981.57,20976.88,
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,6981.57,,,,,,,fee schedule,6981.57,20976.88,
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9346.53,,,,,,,fee schedule,6981.57,20976.88,
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8901.46,,,,,,,fee schedule,6981.57,20976.88,
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,15590.61,,,,,,,fee schedule,6981.57,20976.88,
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,12115.27,,,,,,,fee schedule,6981.57,20976.88,
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,20976.88,,,,,,,fee schedule,6981.57,20976.88,
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,14420.47,,,,,,,fee schedule,6981.57,20976.88,
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,13059.88,,,,,,,fee schedule,6981.57,20976.88,
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10696.58,,,,,,,fee schedule,6981.57,20976.88,
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7992.58,,,,,,,fee schedule,6981.57,20976.88,MSDRG Base Rate
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,7916.46,,,,,,,fee schedule,6981.57,20976.88,MSDRG Base Rate
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,7916.46,,,,,,,fee schedule,6981.57,20976.88,MSDRG Base Rate
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,7992.58,,,,,,,fee schedule,6981.57,20976.88,MSDRG Base Rate
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,7916.46,,,,,,,fee schedule,6981.57,20976.88,MSDRG Base Rate
Nontraumatic Stupor And Coma Without Mcc,81,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,13320.96,,,,,,,fee schedule,6981.57,20976.88,MSDRG Base Rate
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17902.24,,,,,,,fee schedule,17902.24,53789.2,
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,17902.24,,,,,,,fee schedule,17902.24,53789.2,
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23966.49,,,,,,,fee schedule,17902.24,53789.2,
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22825.24,,,,,,,fee schedule,17902.24,53789.2,
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,39977.64,,,,,,,fee schedule,17902.24,53789.2,
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,31066.14,,,,,,,fee schedule,17902.24,53789.2,
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,53789.2,,,,,,,fee schedule,17902.24,53789.2,
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,36977.15,,,,,,,fee schedule,17902.24,53789.2,
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,33488.32,,,,,,,fee schedule,17902.24,53789.2,
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27428.32,,,,,,,fee schedule,17902.24,53789.2,
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],35610.7,35610.7,35610.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],16891.86,16865.53,18242.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],17708.19,17708.19,17708.19,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],22826.22,22826.22,22826.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",19747.59,19747.59,19747.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],17609.86,17533.23,17719.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],10012.38,35.98,29069.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,18851.84,,,,,,,fee schedule,17902.24,53789.2,MSDRG Base Rate
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,18672.3,,,,,,,fee schedule,17902.24,53789.2,MSDRG Base Rate
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,18672.3,,,,,,,fee schedule,17902.24,53789.2,MSDRG Base Rate
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,18851.84,,,,,,,fee schedule,17902.24,53789.2,MSDRG Base Rate
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,18672.3,,,,,,,fee schedule,17902.24,53789.2,MSDRG Base Rate
Traumatic Stupor And Coma >1 Hour With Mcc,82,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31419.73,,,,,,,fee schedule,17902.24,53789.2,MSDRG Base Rate
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10727.76,,,,,,,fee schedule,10727.76,32232.72,
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,10727.76,,,,,,,fee schedule,10727.76,32232.72,
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14361.72,,,,,,,fee schedule,10727.76,32232.72,
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13677.83,,,,,,,fee schedule,10727.76,32232.72,
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,23956.26,,,,,,,fee schedule,10727.76,32232.72,
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,18616.12,,,,,,,fee schedule,10727.76,32232.72,
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,32232.72,,,,,,,fee schedule,10727.76,32232.72,
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,22158.24,,,,,,,fee schedule,10727.76,32232.72,
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,20067.59,,,,,,,fee schedule,10727.76,32232.72,
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16436.18,,,,,,,fee schedule,10727.76,32232.72,
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],18.81,18.81,18.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],26154.13,26154.13,26154.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],10244.07,10244.07,10244.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",14868.79,14868.79,14868.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],10539.13,10539.13,10539.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],2102.03,2102.03,2102.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],10764.31,10764.31,11200.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11900.35,,,,,,,fee schedule,10727.76,32232.72,MSDRG Base Rate
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,11787.02,,,,,,,fee schedule,10727.76,32232.72,MSDRG Base Rate
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,11787.02,,,,,,,fee schedule,10727.76,32232.72,MSDRG Base Rate
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,11900.35,,,,,,,fee schedule,10727.76,32232.72,MSDRG Base Rate
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,11787.02,,,,,,,fee schedule,10727.76,32232.72,MSDRG Base Rate
Traumatic Stupor And Coma >1 Hour With Cc,83,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19833.92,,,,,,,fee schedule,10727.76,32232.72,MSDRG Base Rate
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7376.64,,,,,,,fee schedule,7376.64,22163.9,
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,7376.64,,,,,,,fee schedule,7376.64,22163.9,
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9875.42,,,,,,,fee schedule,7376.64,22163.9,
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9405.17,,,,,,,fee schedule,7376.64,22163.9,
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,16472.84,,,,,,,fee schedule,7376.64,22163.9,
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,12800.84,,,,,,,fee schedule,7376.64,22163.9,
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,22163.9,,,,,,,fee schedule,7376.64,22163.9,
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,15236.48,,,,,,,fee schedule,7376.64,22163.9,
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,13798.9,,,,,,,fee schedule,7376.64,22163.9,
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11301.87,,,,,,,fee schedule,7376.64,22163.9,
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],13682,13682,13682,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",11839.36,11839.36,11839.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],16024.56,16024.56,16024.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8462.88,,,,,,,fee schedule,7376.64,22163.9,MSDRG Base Rate
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,8382.29,,,,,,,fee schedule,7376.64,22163.9,MSDRG Base Rate
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,8382.29,,,,,,,fee schedule,7376.64,22163.9,MSDRG Base Rate
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,8462.88,,,,,,,fee schedule,7376.64,22163.9,MSDRG Base Rate
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,8382.29,,,,,,,fee schedule,7376.64,22163.9,MSDRG Base Rate
Traumatic Stupor And Coma >1 Hour Without Cc/Mcc,84,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14104.81,,,,,,,fee schedule,7376.64,22163.9,MSDRG Base Rate
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17484.02,,,,,,,fee schedule,17484.02,52532.63,
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,17484.02,,,,,,,fee schedule,17484.02,52532.63,
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23406.61,,,,,,,fee schedule,17484.02,52532.63,
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22292.01,,,,,,,fee schedule,17484.02,52532.63,
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,39043.72,,,,,,,fee schedule,17484.02,52532.63,
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,30340.4,,,,,,,fee schedule,17484.02,52532.63,
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,52532.63,,,,,,,fee schedule,17484.02,52532.63,
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,36113.33,,,,,,,fee schedule,17484.02,52532.63,
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,32706,,,,,,,fee schedule,17484.02,52532.63,
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26787.56,,,,,,,fee schedule,17484.02,52532.63,
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],13885.39,13885.39,13885.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,18744.8,,,,,,,fee schedule,17484.02,52532.63,MSDRG Base Rate
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,18566.28,,,,,,,fee schedule,17484.02,52532.63,MSDRG Base Rate
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,18566.28,,,,,,,fee schedule,17484.02,52532.63,MSDRG Base Rate
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,18744.8,,,,,,,fee schedule,17484.02,52532.63,MSDRG Base Rate
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,18566.28,,,,,,,fee schedule,17484.02,52532.63,MSDRG Base Rate
Traumatic Stupor And Coma <1 Hour With Mcc,85,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31241.33,,,,,,,fee schedule,17484.02,52532.63,MSDRG Base Rate
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10120.5,,,,,,,fee schedule,10120.5,30408.13,
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,10120.5,,,,,,,fee schedule,10120.5,30408.13,
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13548.75,,,,,,,fee schedule,10120.5,30408.13,
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12903.57,,,,,,,fee schedule,10120.5,30408.13,
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,22600.18,,,,,,,fee schedule,10120.5,30408.13,
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,17562.32,,,,,,,fee schedule,10120.5,30408.13,
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,30408.13,,,,,,,fee schedule,10120.5,30408.13,
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,20903.94,,,,,,,fee schedule,10120.5,30408.13,
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,18931.63,,,,,,,fee schedule,10120.5,30408.13,
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15505.79,,,,,,,fee schedule,10120.5,30408.13,
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],19858.74,19858.74,19858.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9793.54,9793.54,9793.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",7265.35,7265.35,7265.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],10038.13,10038.13,10038.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],20916.98,20916.98,20916.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11173.02,,,,,,,fee schedule,10120.5,30408.13,MSDRG Base Rate
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,11066.61,,,,,,,fee schedule,10120.5,30408.13,MSDRG Base Rate
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,11066.61,,,,,,,fee schedule,10120.5,30408.13,MSDRG Base Rate
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,11173.02,,,,,,,fee schedule,10120.5,30408.13,MSDRG Base Rate
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,11066.61,,,,,,,fee schedule,10120.5,30408.13,MSDRG Base Rate
Traumatic Stupor And Coma <1 Hour With Cc,86,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18621.7,,,,,,,fee schedule,10120.5,30408.13,MSDRG Base Rate
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6821.08,,,,,,,fee schedule,6821.08,20494.66,
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,6821.08,,,,,,,fee schedule,6821.08,20494.66,
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9131.67,,,,,,,fee schedule,6821.08,20494.66,
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8696.83,,,,,,,fee schedule,6821.08,20494.66,
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,15232.2,,,,,,,fee schedule,6821.08,20494.66,
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,11836.76,,,,,,,fee schedule,6821.08,20494.66,
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,20494.66,,,,,,,fee schedule,6821.08,20494.66,
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,14088.96,,,,,,,fee schedule,6821.08,20494.66,
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,12759.66,,,,,,,fee schedule,6821.08,20494.66,
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10450.68,,,,,,,fee schedule,6821.08,20494.66,
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8141.79,,,,,,,fee schedule,6821.08,20494.66,MSDRG Base Rate
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,8064.25,,,,,,,fee schedule,6821.08,20494.66,MSDRG Base Rate
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,8064.25,,,,,,,fee schedule,6821.08,20494.66,MSDRG Base Rate
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,8141.79,,,,,,,fee schedule,6821.08,20494.66,MSDRG Base Rate
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,8064.25,,,,,,,fee schedule,6821.08,20494.66,MSDRG Base Rate
Traumatic Stupor And Coma <1 Hour Without Cc/Mcc,87,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,13569.66,,,,,,,fee schedule,6821.08,20494.66,MSDRG Base Rate
Concussion With Mcc,88,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10884.4,,,,,,,fee schedule,10884.4,32703.35,
Concussion With Mcc,88,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,10884.4,,,,,,,fee schedule,10884.4,32703.35,
Concussion With Mcc,88,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14571.41,,,,,,,fee schedule,10884.4,32703.35,
Concussion With Mcc,88,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13877.54,,,,,,,fee schedule,10884.4,32703.35,
Concussion With Mcc,88,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,24306.05,,,,,,,fee schedule,10884.4,32703.35,
Concussion With Mcc,88,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,18887.93,,,,,,,fee schedule,10884.4,32703.35,
Concussion With Mcc,88,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,32703.35,,,,,,,fee schedule,10884.4,32703.35,
Concussion With Mcc,88,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,22481.78,,,,,,,fee schedule,10884.4,32703.35,
Concussion With Mcc,88,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,20360.6,,,,,,,fee schedule,10884.4,32703.35,
Concussion With Mcc,88,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16676.17,,,,,,,fee schedule,10884.4,32703.35,
Concussion With Mcc,88,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Mcc,88,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Mcc,88,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Mcc,88,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Mcc,88,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Mcc,88,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Mcc,88,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Mcc,88,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Mcc,88,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Mcc,88,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Mcc,88,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Mcc,88,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Mcc,88,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Mcc,88,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Mcc,88,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Mcc,88,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Mcc,88,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Mcc,88,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Mcc,88,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11556.6,,,,,,,fee schedule,10884.4,32703.35,MSDRG Base Rate
Concussion With Mcc,88,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,11446.54,,,,,,,fee schedule,10884.4,32703.35,MSDRG Base Rate
Concussion With Mcc,88,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,11446.54,,,,,,,fee schedule,10884.4,32703.35,MSDRG Base Rate
Concussion With Mcc,88,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,11556.6,,,,,,,fee schedule,10884.4,32703.35,MSDRG Base Rate
Concussion With Mcc,88,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,11446.54,,,,,,,fee schedule,10884.4,32703.35,MSDRG Base Rate
Concussion With Mcc,88,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19261.01,,,,,,,fee schedule,10884.4,32703.35,MSDRG Base Rate
Concussion With Cc,89,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8272.48,,,,,,,fee schedule,8272.48,24855.57,
Concussion With Cc,89,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,8272.48,,,,,,,fee schedule,8272.48,24855.57,
Concussion With Cc,89,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11074.73,,,,,,,fee schedule,8272.48,24855.57,
Concussion With Cc,89,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10547.36,,,,,,,fee schedule,8272.48,24855.57,
Concussion With Cc,89,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,18473.36,,,,,,,fee schedule,8272.48,24855.57,
Concussion With Cc,89,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,14355.42,,,,,,,fee schedule,8272.48,24855.57,
Concussion With Cc,89,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,24855.57,,,,,,,fee schedule,8272.48,24855.57,
Concussion With Cc,89,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,17086.85,,,,,,,fee schedule,8272.48,24855.57,
Concussion With Cc,89,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,15474.69,,,,,,,fee schedule,8272.48,24855.57,
Concussion With Cc,89,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12674.41,,,,,,,fee schedule,8272.48,24855.57,
Concussion With Cc,89,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Cc,89,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Cc,89,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6417.31,6417.31,6417.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Concussion With Cc,89,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Cc,89,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Cc,89,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Cc,89,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Cc,89,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Cc,89,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Cc,89,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Cc,89,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Cc,89,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Cc,89,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Cc,89,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Cc,89,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Cc,89,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Cc,89,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Cc,89,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion With Cc,89,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9578.5,,,,,,,fee schedule,8272.48,24855.57,MSDRG Base Rate
Concussion With Cc,89,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,9487.28,,,,,,,fee schedule,8272.48,24855.57,MSDRG Base Rate
Concussion With Cc,89,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,9487.28,,,,,,,fee schedule,8272.48,24855.57,MSDRG Base Rate
Concussion With Cc,89,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,9578.5,,,,,,,fee schedule,8272.48,24855.57,MSDRG Base Rate
Concussion With Cc,89,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,9487.28,,,,,,,fee schedule,8272.48,24855.57,MSDRG Base Rate
Concussion With Cc,89,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15964.16,,,,,,,fee schedule,8272.48,24855.57,MSDRG Base Rate
Concussion Without Cc/Mcc,90,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6614.28,,,,,,,fee schedule,6614.28,19873.32,
Concussion Without Cc/Mcc,90,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,6614.28,,,,,,,fee schedule,6614.28,19873.32,
Concussion Without Cc/Mcc,90,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8854.82,,,,,,,fee schedule,6614.28,19873.32,
Concussion Without Cc/Mcc,90,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8433.17,,,,,,,fee schedule,6614.28,19873.32,
Concussion Without Cc/Mcc,90,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,14770.41,,,,,,,fee schedule,6614.28,19873.32,
Concussion Without Cc/Mcc,90,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,11477.91,,,,,,,fee schedule,6614.28,19873.32,
Concussion Without Cc/Mcc,90,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,19873.32,,,,,,,fee schedule,6614.28,19873.32,
Concussion Without Cc/Mcc,90,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,13661.83,,,,,,,fee schedule,6614.28,19873.32,
Concussion Without Cc/Mcc,90,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,12372.82,,,,,,,fee schedule,6614.28,19873.32,
Concussion Without Cc/Mcc,90,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10133.85,,,,,,,fee schedule,6614.28,19873.32,
Concussion Without Cc/Mcc,90,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion Without Cc/Mcc,90,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Concussion Without Cc/Mcc,90,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],9199.8,9199.8,9199.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Concussion Without Cc/Mcc,90,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion Without Cc/Mcc,90,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion Without Cc/Mcc,90,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Concussion Without Cc/Mcc,90,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Concussion Without Cc/Mcc,90,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Concussion Without Cc/Mcc,90,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Concussion Without Cc/Mcc,90,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Concussion Without Cc/Mcc,90,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion Without Cc/Mcc,90,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion Without Cc/Mcc,90,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Concussion Without Cc/Mcc,90,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Concussion Without Cc/Mcc,90,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion Without Cc/Mcc,90,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Concussion Without Cc/Mcc,90,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion Without Cc/Mcc,90,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concussion Without Cc/Mcc,90,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7426.96,,,,,,,fee schedule,6614.28,19873.32,MSDRG Base Rate
Concussion Without Cc/Mcc,90,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,7356.23,,,,,,,fee schedule,6614.28,19873.32,MSDRG Base Rate
Concussion Without Cc/Mcc,90,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,7356.23,,,,,,,fee schedule,6614.28,19873.32,MSDRG Base Rate
Concussion Without Cc/Mcc,90,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,7426.96,,,,,,,fee schedule,6614.28,19873.32,MSDRG Base Rate
Concussion Without Cc/Mcc,90,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,7356.23,,,,,,,fee schedule,6614.28,19873.32,MSDRG Base Rate
Concussion Without Cc/Mcc,90,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12378.28,,,,,,,fee schedule,6614.28,19873.32,MSDRG Base Rate
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14065,,,,,,,fee schedule,14065,42259.8,
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,14065,,,,,,,fee schedule,14065,42259.8,
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18829.41,,,,,,,fee schedule,14065,42259.8,
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17932.78,,,,,,,fee schedule,14065,42259.8,
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,31408.67,,,,,,,fee schedule,14065,42259.8,
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,24407.29,,,,,,,fee schedule,14065,42259.8,
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,42259.8,,,,,,,fee schedule,14065,42259.8,
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,29051.31,,,,,,,fee schedule,14065,42259.8,
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,26310.3,,,,,,,fee schedule,14065,42259.8,
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21549.21,,,,,,,fee schedule,14065,42259.8,
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12315.49,11716.65,13920.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],24.66,24.66,24.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",55621.15,55621.15,55621.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",7412.37,7412.37,7412.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13420.63,13420.63,13428.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],31410.39,31410.39,31410.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],12131.11,164.66,13897.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",181.94,181.94,181.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14715.94,,,,,,,fee schedule,14065,42259.8,MSDRG Base Rate
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,14575.79,,,,,,,fee schedule,14065,42259.8,MSDRG Base Rate
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,14575.79,,,,,,,fee schedule,14065,42259.8,MSDRG Base Rate
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,14715.94,,,,,,,fee schedule,14065,42259.8,MSDRG Base Rate
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,14575.79,,,,,,,fee schedule,14065,42259.8,MSDRG Base Rate
Other Disorders Of Nervous System With Mcc,91,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,24526.56,,,,,,,fee schedule,14065,42259.8,MSDRG Base Rate
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8169.86,,,,,,,fee schedule,8169.86,24547.22,
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,8169.86,,,,,,,fee schedule,8169.86,24547.22,
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10937.34,,,,,,,fee schedule,8169.86,24547.22,
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10416.52,,,,,,,fee schedule,8169.86,24547.22,
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,18244.18,,,,,,,fee schedule,8169.86,24547.22,
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,14177.33,,,,,,,fee schedule,8169.86,24547.22,
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,24547.22,,,,,,,fee schedule,8169.86,24547.22,
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,16874.88,,,,,,,fee schedule,8169.86,24547.22,
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,15282.72,,,,,,,fee schedule,8169.86,24547.22,
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12517.18,,,,,,,fee schedule,8169.86,24547.22,
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],17012.99,17012.99,17012.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6556.17,6556.17,6556.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],10699.01,10699.01,10699.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",5558.69,5558.69,5558.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],8035.03,8035.03,8035.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6377.55,6377.55,6377.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],12515.99,12515.99,12515.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],14887.87,14887.87,14887.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],1470.79,14.32,7972.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8987.88,,,,,,,fee schedule,8169.86,24547.22,MSDRG Base Rate
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,8902.29,,,,,,,fee schedule,8169.86,24547.22,MSDRG Base Rate
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,8902.29,,,,,,,fee schedule,8169.86,24547.22,MSDRG Base Rate
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,8987.88,,,,,,,fee schedule,8169.86,24547.22,MSDRG Base Rate
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,8902.29,,,,,,,fee schedule,8169.86,24547.22,MSDRG Base Rate
Other Disorders Of Nervous System With Cc,92,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14979.81,,,,,,,fee schedule,8169.86,24547.22,MSDRG Base Rate
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6090.36,,,,,,,fee schedule,6090.36,18299.13,
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,6090.36,,,,,,,fee schedule,6090.36,18299.13,
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8153.42,,,,,,,fee schedule,6090.36,18299.13,
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7765.16,,,,,,,fee schedule,6090.36,18299.13,
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,13600.43,,,,,,,fee schedule,6090.36,18299.13,
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,10568.73,,,,,,,fee schedule,6090.36,18299.13,
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,18299.13,,,,,,,fee schedule,6090.36,18299.13,
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,12579.66,,,,,,,fee schedule,6090.36,18299.13,
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,11392.76,,,,,,,fee schedule,6090.36,18299.13,
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9331.14,,,,,,,fee schedule,6090.36,18299.13,
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],4650,4650,4650,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6408.25,6408.25,6408.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",5300.1,5300.1,5300.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4977.48,4977.48,4977.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],5979.24,5979.24,5991.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],7331.14,7331.14,7331.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],11747.59,11747.59,13221.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4931.39,4931.39,4931.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7216.81,,,,,,,fee schedule,6090.36,18299.13,MSDRG Base Rate
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,7148.08,,,,,,,fee schedule,6090.36,18299.13,MSDRG Base Rate
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,7148.08,,,,,,,fee schedule,6090.36,18299.13,MSDRG Base Rate
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,7216.81,,,,,,,fee schedule,6090.36,18299.13,MSDRG Base Rate
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,7148.08,,,,,,,fee schedule,6090.36,18299.13,MSDRG Base Rate
Other Disorders Of Nervous System Without Cc/Mcc,93,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12028.01,,,,,,,fee schedule,6090.36,18299.13,MSDRG Base Rate
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,28151.6,,,,,,,fee schedule,28151.6,84584.51,
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,28151.6,,,,,,,fee schedule,28151.6,84584.51,
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37687.75,,,,,,,fee schedule,28151.6,84584.51,
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,35893.11,,,,,,,fee schedule,28151.6,84584.51,
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,62865.58,,,,,,,fee schedule,28151.6,84584.51,
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,48852.08,,,,,,,fee schedule,28151.6,84584.51,
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,84584.51,,,,,,,fee schedule,28151.6,84584.51,
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,58147.25,,,,,,,fee schedule,28151.6,84584.51,
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,52661.01,,,,,,,fee schedule,28151.6,84584.51,
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,43131.53,,,,,,,fee schedule,28151.6,84584.51,
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],27142.49,27142.49,27142.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],159292.28,159292.28,159292.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",20925.49,20925.49,20925.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],27640.19,27640.19,27640.19,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],24937.49,24937.49,24937.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],80698.8,80698.8,80698.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,28490.78,,,,,,,fee schedule,28151.6,84584.51,MSDRG Base Rate
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,28219.44,,,,,,,fee schedule,28151.6,84584.51,MSDRG Base Rate
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,28219.44,,,,,,,fee schedule,28151.6,84584.51,MSDRG Base Rate
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,28490.78,,,,,,,fee schedule,28151.6,84584.51,MSDRG Base Rate
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,28219.44,,,,,,,fee schedule,28151.6,84584.51,MSDRG Base Rate
Bacterial And Tuberculous Infections Of Nervous System With Mcc,94,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,47484.64,,,,,,,fee schedule,28151.6,84584.51,MSDRG Base Rate
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18495.61,,,,,,,fee schedule,18495.61,55572.05,
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,18495.61,,,,,,,fee schedule,18495.61,55572.05,
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24760.87,,,,,,,fee schedule,18495.61,55572.05,
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23581.78,,,,,,,fee schedule,18495.61,55572.05,
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,41302.71,,,,,,,fee schedule,18495.61,55572.05,
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,32095.83,,,,,,,fee schedule,18495.61,55572.05,
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,55572.05,,,,,,,fee schedule,18495.61,55572.05,
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,38202.76,,,,,,,fee schedule,18495.61,55572.05,
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,34598.3,,,,,,,fee schedule,18495.61,55572.05,
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,28337.43,,,,,,,fee schedule,18495.61,55572.05,
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],77550.46,77550.46,77550.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",16111.59,16111.59,16111.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],28339.79,28339.79,28339.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],41306.15,41306.15,41306.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],18095.66,18095.66,18095.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,21145.55,,,,,,,fee schedule,18495.61,55572.05,MSDRG Base Rate
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,20944.16,,,,,,,fee schedule,18495.61,55572.05,MSDRG Base Rate
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,20944.16,,,,,,,fee schedule,18495.61,55572.05,MSDRG Base Rate
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,21145.55,,,,,,,fee schedule,18495.61,55572.05,MSDRG Base Rate
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,20944.16,,,,,,,fee schedule,18495.61,55572.05,MSDRG Base Rate
Bacterial And Tuberculous Infections Of Nervous System With Cc,95,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,35242.58,,,,,,,fee schedule,18495.61,55572.05,MSDRG Base Rate
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18495.61,,,,,,,fee schedule,18495.61,55572.05,
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,18495.61,,,,,,,fee schedule,18495.61,55572.05,
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24760.87,,,,,,,fee schedule,18495.61,55572.05,
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23581.78,,,,,,,fee schedule,18495.61,55572.05,
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,41302.71,,,,,,,fee schedule,18495.61,55572.05,
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,32095.83,,,,,,,fee schedule,18495.61,55572.05,
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,55572.05,,,,,,,fee schedule,18495.61,55572.05,
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,38202.76,,,,,,,fee schedule,18495.61,55572.05,
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,34598.3,,,,,,,fee schedule,18495.61,55572.05,
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,28337.43,,,,,,,fee schedule,18495.61,55572.05,
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],20946.89,20946.89,20946.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",12224.97,12224.97,12224.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],40220.22,40220.22,40220.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,21145.55,,,,,,,fee schedule,18495.61,55572.05,MSDRG Base Rate
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,20944.16,,,,,,,fee schedule,18495.61,55572.05,MSDRG Base Rate
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,20944.16,,,,,,,fee schedule,18495.61,55572.05,MSDRG Base Rate
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,21145.55,,,,,,,fee schedule,18495.61,55572.05,MSDRG Base Rate
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,20944.16,,,,,,,fee schedule,18495.61,55572.05,MSDRG Base Rate
Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc,96,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,35242.58,,,,,,,fee schedule,18495.61,55572.05,MSDRG Base Rate
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,27660.85,,,,,,,fee schedule,27660.85,83110,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,27660.85,,,,,,,fee schedule,27660.85,83110,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37030.77,,,,,,,fee schedule,27660.85,83110,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,35267.41,,,,,,,fee schedule,27660.85,83110,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,61769.69,,,,,,,fee schedule,27660.85,83110,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,48000.47,,,,,,,fee schedule,27660.85,83110,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,83110,,,,,,,fee schedule,27660.85,83110,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,57133.61,,,,,,,fee schedule,27660.85,83110,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,51743,,,,,,,fee schedule,27660.85,83110,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42379.65,,,,,,,fee schedule,27660.85,83110,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],20936.21,20936.21,20936.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],57130.42,57130.42,57130.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],24472.32,24472.32,24472.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,29212.65,,,,,,,fee schedule,27660.85,83110,MSDRG Base Rate
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,28934.43,,,,,,,fee schedule,27660.85,83110,MSDRG Base Rate
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,28934.43,,,,,,,fee schedule,27660.85,83110,MSDRG Base Rate
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,29212.65,,,,,,,fee schedule,27660.85,83110,MSDRG Base Rate
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,28934.43,,,,,,,fee schedule,27660.85,83110,MSDRG Base Rate
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc,97,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,48687.75,,,,,,,fee schedule,27660.85,83110,MSDRG Base Rate
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16737.1,,,,,,,fee schedule,16737.1,50288.41,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,16737.1,,,,,,,fee schedule,16737.1,50288.41,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22406.67,,,,,,,fee schedule,16737.1,50288.41,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21339.69,,,,,,,fee schedule,16737.1,50288.41,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,37375.76,,,,,,,fee schedule,16737.1,50288.41,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,29044.25,,,,,,,fee schedule,16737.1,50288.41,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,50288.41,,,,,,,fee schedule,16737.1,50288.41,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,34570.55,,,,,,,fee schedule,16737.1,50288.41,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,31308.79,,,,,,,fee schedule,16737.1,50288.41,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,25643.19,,,,,,,fee schedule,16737.1,50288.41,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],107372.59,107372.59,107372.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],30458.14,30458.14,31713.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],93629.12,93629.12,93629.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],21339.66,21339.66,21339.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",10698.01,10698.01,10698.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],16003.56,16003.56,16003.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],68305.4,68305.4,68305.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],34327,34327,34327,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,18924.49,,,,,,,fee schedule,16737.1,50288.41,MSDRG Base Rate
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,18744.25,,,,,,,fee schedule,16737.1,50288.41,MSDRG Base Rate
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,18744.25,,,,,,,fee schedule,16737.1,50288.41,MSDRG Base Rate
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,18924.49,,,,,,,fee schedule,16737.1,50288.41,MSDRG Base Rate
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,18744.25,,,,,,,fee schedule,16737.1,50288.41,MSDRG Base Rate
Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc,98,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31540.81,,,,,,,fee schedule,16737.1,50288.41,MSDRG Base Rate
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10750.14,,,,,,,fee schedule,10750.14,32299.95,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,10750.14,,,,,,,fee schedule,10750.14,32299.95,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14391.67,,,,,,,fee schedule,10750.14,32299.95,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13706.36,,,,,,,fee schedule,10750.14,32299.95,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,24006.23,,,,,,,fee schedule,10750.14,32299.95,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,18654.95,,,,,,,fee schedule,10750.14,32299.95,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,32299.95,,,,,,,fee schedule,10750.14,32299.95,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,22204.46,,,,,,,fee schedule,10750.14,32299.95,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,20109.45,,,,,,,fee schedule,10750.14,32299.95,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16470.47,,,,,,,fee schedule,10750.14,32299.95,
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],21303.73,21303.73,21303.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],13646.67,13646.67,13646.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",8557.59,8557.59,8557.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],500,500,500,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11639.42,,,,,,,fee schedule,10750.14,32299.95,MSDRG Base Rate
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,11528.57,,,,,,,fee schedule,10750.14,32299.95,MSDRG Base Rate
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,11528.57,,,,,,,fee schedule,10750.14,32299.95,MSDRG Base Rate
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,11639.42,,,,,,,fee schedule,10750.14,32299.95,MSDRG Base Rate
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,11528.57,,,,,,,fee schedule,10750.14,32299.95,MSDRG Base Rate
Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc,99,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19399.03,,,,,,,fee schedule,10750.14,32299.95,MSDRG Base Rate
Seizures With Mcc,100,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,15318.1,,,,,,,fee schedule,15318.1,46024.88,
Seizures With Mcc,100,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,15318.1,,,,,,,fee schedule,15318.1,46024.88,
Seizures With Mcc,100,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20507,,,,,,,fee schedule,15318.1,46024.88,
Seizures With Mcc,100,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19530.48,,,,,,,fee schedule,15318.1,46024.88,
Seizures With Mcc,100,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,34206.98,,,,,,,fee schedule,15318.1,46024.88,
Seizures With Mcc,100,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,26581.83,,,,,,,fee schedule,15318.1,46024.88,
Seizures With Mcc,100,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,46024.88,,,,,,,fee schedule,15318.1,46024.88,
Seizures With Mcc,100,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,31639.6,,,,,,,fee schedule,15318.1,46024.88,
Seizures With Mcc,100,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,28654.38,,,,,,,fee schedule,15318.1,46024.88,
Seizures With Mcc,100,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23469.11,,,,,,,fee schedule,15318.1,46024.88,
Seizures With Mcc,100,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Seizures With Mcc,100,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Seizures With Mcc,100,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],27299.46,8041.6,30539,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Seizures With Mcc,100,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],26528.22,26528.22,26528.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Seizures With Mcc,100,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Seizures With Mcc,100,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Seizures With Mcc,100,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4792.44,4792.44,4792.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Seizures With Mcc,100,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4500.73,4500.73,4500.73,21,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Seizures With Mcc,100,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13606.23,13396.87,14996.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Seizures With Mcc,100,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],23470.3,23470.3,23470.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Seizures With Mcc,100,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Seizures With Mcc,100,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Seizures With Mcc,100,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Seizures With Mcc,100,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],21786,15513.85,34208.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Seizures With Mcc,100,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],14122.91,13013.06,15599.91,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Seizures With Mcc,100,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4459.05,4459.05,4459.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Seizures With Mcc,100,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Seizures With Mcc,100,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Seizures With Mcc,100,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,16126.87,,,,,,,fee schedule,15318.1,46024.88,MSDRG Base Rate
Seizures With Mcc,100,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,15973.28,,,,,,,fee schedule,15318.1,46024.88,MSDRG Base Rate
Seizures With Mcc,100,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,15973.28,,,,,,,fee schedule,15318.1,46024.88,MSDRG Base Rate
Seizures With Mcc,100,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,16126.87,,,,,,,fee schedule,15318.1,46024.88,MSDRG Base Rate
Seizures With Mcc,100,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,15973.28,,,,,,,fee schedule,15318.1,46024.88,MSDRG Base Rate
Seizures With Mcc,100,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,26878.11,,,,,,,fee schedule,15318.1,46024.88,MSDRG Base Rate
Seizures Without Mcc,101,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7111.2,,,,,,,fee schedule,7111.2,21366.37,
Seizures Without Mcc,101,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,7111.2,,,,,,,fee schedule,7111.2,21366.37,
Seizures Without Mcc,101,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9520.07,,,,,,,fee schedule,7111.2,21366.37,
Seizures Without Mcc,101,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9066.74,,,,,,,fee schedule,7111.2,21366.37,
Seizures Without Mcc,101,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,15880.09,,,,,,,fee schedule,7111.2,21366.37,
Seizures Without Mcc,101,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,12340.22,,,,,,,fee schedule,7111.2,21366.37,
Seizures Without Mcc,101,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,21366.37,,,,,,,fee schedule,7111.2,21366.37,
Seizures Without Mcc,101,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,14688.22,,,,,,,fee schedule,7111.2,21366.37,
Seizures Without Mcc,101,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,13302.37,,,,,,,fee schedule,7111.2,21366.37,
Seizures Without Mcc,101,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10895.19,,,,,,,fee schedule,7111.2,21366.37,
Seizures Without Mcc,101,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Seizures Without Mcc,101,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Seizures Without Mcc,101,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7433.27,6602.12,10566.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Seizures Without Mcc,101,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],14001.52,8173.8,14689.81,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Seizures Without Mcc,101,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6164.03,6164.03,6164.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Seizures Without Mcc,101,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],13303.82,13303.82,13303.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Seizures Without Mcc,101,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4116.8,4116.8,4116.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Seizures Without Mcc,101,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],8948.68,8948.68,9067.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Seizures Without Mcc,101,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3866.22,3866.22,3866.22,51,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Seizures Without Mcc,101,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],5339.73,5339.73,7074.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Seizures Without Mcc,101,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],9665.17,9665.17,9665.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Seizures Without Mcc,101,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Seizures Without Mcc,101,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Seizures Without Mcc,101,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],10647,6389,15881.81,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Seizures Without Mcc,101,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],7387.42,6313.94,7777.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Seizures Without Mcc,101,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3830.42,3830.42,4012.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Seizures Without Mcc,101,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Seizures Without Mcc,101,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Seizures Without Mcc,101,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8047.27,,,,,,,fee schedule,7111.2,21366.37,MSDRG Base Rate
Seizures Without Mcc,101,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,7970.63,,,,,,,fee schedule,7111.2,21366.37,MSDRG Base Rate
Seizures Without Mcc,101,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,7970.63,,,,,,,fee schedule,7111.2,21366.37,MSDRG Base Rate
Seizures Without Mcc,101,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,8047.27,,,,,,,fee schedule,7111.2,21366.37,MSDRG Base Rate
Seizures Without Mcc,101,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,7970.63,,,,,,,fee schedule,7111.2,21366.37,MSDRG Base Rate
Seizures Without Mcc,101,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,13412.12,,,,,,,fee schedule,7111.2,21366.37,MSDRG Base Rate
Headaches With Mcc,102,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8946.1,,,,,,,fee schedule,8946.1,26879.53,
Headaches With Mcc,102,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,8946.1,,,,,,,fee schedule,8946.1,26879.53,
Headaches With Mcc,102,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11976.53,,,,,,,fee schedule,8946.1,26879.53,
Headaches With Mcc,102,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11406.22,,,,,,,fee schedule,8946.1,26879.53,
Headaches With Mcc,102,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,19977.62,,,,,,,fee schedule,8946.1,26879.53,
Headaches With Mcc,102,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,15524.37,,,,,,,fee schedule,8946.1,26879.53,
Headaches With Mcc,102,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,26879.53,,,,,,,fee schedule,8946.1,26879.53,
Headaches With Mcc,102,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,18478.22,,,,,,,fee schedule,8946.1,26879.53,
Headaches With Mcc,102,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,16734.78,,,,,,,fee schedule,8946.1,26879.53,
Headaches With Mcc,102,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13706.47,,,,,,,fee schedule,8946.1,26879.53,
Headaches With Mcc,102,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Headaches With Mcc,102,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Headaches With Mcc,102,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Headaches With Mcc,102,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Headaches With Mcc,102,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Headaches With Mcc,102,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Headaches With Mcc,102,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Headaches With Mcc,102,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4112.54,4112.54,4112.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Headaches With Mcc,102,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],13707.66,13707.66,13707.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Headaches With Mcc,102,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Headaches With Mcc,102,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Headaches With Mcc,102,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Headaches With Mcc,102,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Headaches With Mcc,102,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],150.69,150.69,150.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Headaches With Mcc,102,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Headaches With Mcc,102,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Headaches With Mcc,102,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Headaches With Mcc,102,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Headaches With Mcc,102,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9752.72,,,,,,,fee schedule,8946.1,26879.53,MSDRG Base Rate
Headaches With Mcc,102,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,9659.83,,,,,,,fee schedule,8946.1,26879.53,MSDRG Base Rate
Headaches With Mcc,102,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,9659.83,,,,,,,fee schedule,8946.1,26879.53,MSDRG Base Rate
Headaches With Mcc,102,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,9752.72,,,,,,,fee schedule,8946.1,26879.53,MSDRG Base Rate
Headaches With Mcc,102,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,9659.83,,,,,,,fee schedule,8946.1,26879.53,MSDRG Base Rate
Headaches With Mcc,102,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16254.52,,,,,,,fee schedule,8946.1,26879.53,MSDRG Base Rate
Headaches Without Mcc,103,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6560.27,,,,,,,fee schedule,6560.27,19711.04,
Headaches Without Mcc,103,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,6560.27,,,,,,,fee schedule,6560.27,19711.04,
Headaches Without Mcc,103,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8782.51,,,,,,,fee schedule,6560.27,19711.04,
Headaches Without Mcc,103,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8364.3,,,,,,,fee schedule,6560.27,19711.04,
Headaches Without Mcc,103,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,14649.8,,,,,,,fee schedule,6560.27,19711.04,
Headaches Without Mcc,103,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,11384.18,,,,,,,fee schedule,6560.27,19711.04,
Headaches Without Mcc,103,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,19711.04,,,,,,,fee schedule,6560.27,19711.04,
Headaches Without Mcc,103,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,13550.27,,,,,,,fee schedule,6560.27,19711.04,
Headaches Without Mcc,103,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,12271.79,,,,,,,fee schedule,6560.27,19711.04,
Headaches Without Mcc,103,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10051.1,,,,,,,fee schedule,6560.27,19711.04,
Headaches Without Mcc,103,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],7053,7053,7053,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Headaches Without Mcc,103,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Headaches Without Mcc,103,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],13550.27,10650.32,28383.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Headaches Without Mcc,103,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],5191.07,5191.07,5191.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Headaches Without Mcc,103,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],12271.79,10339.31,14094.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Headaches Without Mcc,103,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Headaches Without Mcc,103,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Headaches Without Mcc,103,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],8362.3,8362.3,8362.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Headaches Without Mcc,103,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3253.62,3253.62,3253.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Headaches Without Mcc,103,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],5836.76,5836.76,5836.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Headaches Without Mcc,103,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],6012.57,6012.57,6012.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Headaches Without Mcc,103,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Headaches Without Mcc,103,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Headaches Without Mcc,103,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],6933.66,6933.66,6933.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Headaches Without Mcc,103,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],14077.61,1211.03,20818.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Headaches Without Mcc,103,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Headaches Without Mcc,103,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Headaches Without Mcc,103,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Headaches Without Mcc,103,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7529.31,,,,,,,fee schedule,6560.27,19711.04,MSDRG Base Rate
Headaches Without Mcc,103,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,7457.6,,,,,,,fee schedule,6560.27,19711.04,MSDRG Base Rate
Headaches Without Mcc,103,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,7457.6,,,,,,,fee schedule,6560.27,19711.04,MSDRG Base Rate
Headaches Without Mcc,103,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,7529.31,,,,,,,fee schedule,6560.27,19711.04,MSDRG Base Rate
Headaches Without Mcc,103,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,7457.6,,,,,,,fee schedule,6560.27,19711.04,MSDRG Base Rate
Headaches Without Mcc,103,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12548.85,,,,,,,fee schedule,6560.27,19711.04,MSDRG Base Rate
Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath,104,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath,104,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath,104,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath,104,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath,104,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath,104,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath,104,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath,104,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath,104,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath,104,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath,104,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath,104,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath,104,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath,104,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath,104,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath,104,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath,104,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath,104,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath,105,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath,105,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath,105,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath,105,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath,105,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath,105,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath,105,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath,105,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath,105,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath,105,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath,105,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath,105,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath,105,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath,105,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath,105,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath,105,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath,105,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath,105,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass w PTCA,106,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass w PTCA,106,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass w PTCA,106,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass w PTCA,106,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass w PTCA,106,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass w PTCA,106,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass w PTCA,106,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass w PTCA,106,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass w PTCA,106,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass w PTCA,106,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass w PTCA,106,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass w PTCA,106,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass w PTCA,106,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass w PTCA,106,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass w PTCA,106,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass w PTCA,106,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass w PTCA,106,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass w PTCA,106,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,107,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,107,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,107,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,107,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,107,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,107,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,107,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,107,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,107,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,107,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,107,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,107,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,107,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,107,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,107,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,107,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,107,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,107,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures,108,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures,108,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures,108,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures,108,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures,108,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures,108,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures,108,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures,108,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures,108,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures,108,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures,108,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures,108,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures,108,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures,108,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures,108,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures,108,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures,108,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures,108,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,109,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,109,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,109,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,109,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,109,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,109,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,109,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,109,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,109,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,109,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,109,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,109,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,109,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,109,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,109,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,109,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,109,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,109,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Cardiovascular Procedures w CC,110,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Cardiovascular Procedures w CC,110,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Major Cardiovascular Procedures w CC,110,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Major Cardiovascular Procedures w CC,110,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Cardiovascular Procedures w CC,110,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Cardiovascular Procedures w CC,110,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Major Cardiovascular Procedures w CC,110,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Cardiovascular Procedures w CC,110,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Cardiovascular Procedures w CC,110,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Major Cardiovascular Procedures w CC,110,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Major Cardiovascular Procedures w CC,110,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Cardiovascular Procedures w CC,110,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Cardiovascular Procedures w CC,110,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Major Cardiovascular Procedures w CC,110,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Major Cardiovascular Procedures w CC,110,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Cardiovascular Procedures w CC,110,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Cardiovascular Procedures w CC,110,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Cardiovascular Procedures w CC,110,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Cardiovascular Procedures w/o CC,111,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Cardiovascular Procedures w/o CC,111,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Major Cardiovascular Procedures w/o CC,111,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Major Cardiovascular Procedures w/o CC,111,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Cardiovascular Procedures w/o CC,111,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Cardiovascular Procedures w/o CC,111,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Major Cardiovascular Procedures w/o CC,111,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Cardiovascular Procedures w/o CC,111,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Cardiovascular Procedures w/o CC,111,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Major Cardiovascular Procedures w/o CC,111,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Major Cardiovascular Procedures w/o CC,111,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Cardiovascular Procedures w/o CC,111,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Cardiovascular Procedures w/o CC,111,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Major Cardiovascular Procedures w/o CC,111,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Major Cardiovascular Procedures w/o CC,111,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Cardiovascular Procedures w/o CC,111,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Cardiovascular Procedures w/o CC,111,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Cardiovascular Procedures w/o CC,111,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,112,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,112,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,112,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,112,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,112,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,112,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,112,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,112,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,112,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,112,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,112,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,112,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,112,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,112,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,112,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,112,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,112,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,112,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17412.26,,,,,,,fee schedule,17412.26,52317.01,
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,17412.26,,,,,,,fee schedule,17412.26,52317.01,
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23310.54,,,,,,,fee schedule,17412.26,52317.01,
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22200.52,,,,,,,fee schedule,17412.26,52317.01,
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,38883.47,,,,,,,fee schedule,17412.26,52317.01,
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,30215.87,,,,,,,fee schedule,17412.26,52317.01,
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,52317.01,,,,,,,fee schedule,17412.26,52317.01,
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,35965.1,,,,,,,fee schedule,17412.26,52317.01,
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,32571.76,,,,,,,fee schedule,17412.26,52317.01,
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26677.62,,,,,,,fee schedule,17412.26,52317.01,
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,19363.54,,,,,,,fee schedule,17412.26,52317.01,MSDRG Base Rate
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,19179.13,,,,,,,fee schedule,17412.26,52317.01,MSDRG Base Rate
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,19179.13,,,,,,,fee schedule,17412.26,52317.01,MSDRG Base Rate
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,19363.54,,,,,,,fee schedule,17412.26,52317.01,MSDRG Base Rate
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,19179.13,,,,,,,fee schedule,17412.26,52317.01,MSDRG Base Rate
Orbital Procedures With Cc/Mcc,113,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,32272.57,,,,,,,fee schedule,17412.26,52317.01,MSDRG Base Rate
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9121.26,,,,,,,fee schedule,9121.26,27405.81,
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,9121.26,,,,,,,fee schedule,9121.26,27405.81,
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12211.02,,,,,,,fee schedule,9121.26,27405.81,
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11629.55,,,,,,,fee schedule,9121.26,27405.81,
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,20368.77,,,,,,,fee schedule,9121.26,27405.81,
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,15828.32,,,,,,,fee schedule,9121.26,27405.81,
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,27405.81,,,,,,,fee schedule,9121.26,27405.81,
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,18840,,,,,,,fee schedule,9121.26,27405.81,
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,17062.43,,,,,,,fee schedule,9121.26,27405.81,
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13974.83,,,,,,,fee schedule,9121.26,27405.81,
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11565.98,,,,,,,fee schedule,9121.26,27405.81,MSDRG Base Rate
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,11455.83,,,,,,,fee schedule,9121.26,27405.81,MSDRG Base Rate
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,11455.83,,,,,,,fee schedule,9121.26,27405.81,MSDRG Base Rate
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,11565.98,,,,,,,fee schedule,9121.26,27405.81,MSDRG Base Rate
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,11455.83,,,,,,,fee schedule,9121.26,27405.81,MSDRG Base Rate
Orbital Procedures Without Cc/Mcc,114,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19276.63,,,,,,,fee schedule,9121.26,27405.81,MSDRG Base Rate
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11812.65,,,,,,,fee schedule,11812.65,35492.39,
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,11812.65,,,,,,,fee schedule,11812.65,35492.39,
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15814.11,,,,,,,fee schedule,11812.65,35492.39,
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15061.06,,,,,,,fee schedule,11812.65,35492.39,
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,26378.94,,,,,,,fee schedule,11812.65,35492.39,
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,20498.75,,,,,,,fee schedule,11812.65,35492.39,
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,35492.39,,,,,,,fee schedule,11812.65,35492.39,
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,24399.09,,,,,,,fee schedule,11812.65,35492.39,
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,22097.01,,,,,,,fee schedule,11812.65,35492.39,
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18098.36,,,,,,,fee schedule,11812.65,35492.39,
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12987.05,,,,,,,fee schedule,11812.65,35492.39,MSDRG Base Rate
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,12863.36,,,,,,,fee schedule,11812.65,35492.39,MSDRG Base Rate
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,12863.36,,,,,,,fee schedule,11812.65,35492.39,MSDRG Base Rate
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,12987.05,,,,,,,fee schedule,11812.65,35492.39,MSDRG Base Rate
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,12863.36,,,,,,,fee schedule,11812.65,35492.39,MSDRG Base Rate
Extraocular Procedures Except Orbit,115,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21645.09,,,,,,,fee schedule,11812.65,35492.39,MSDRG Base Rate
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12874.4,,,,,,,fee schedule,12874.4,38682.5,
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,12874.4,,,,,,,fee schedule,12874.4,38682.5,
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17235.5,,,,,,,fee schedule,12874.4,38682.5,
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16414.77,,,,,,,fee schedule,12874.4,38682.5,
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,28749.92,,,,,,,fee schedule,12874.4,38682.5,
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,22341.22,,,,,,,fee schedule,12874.4,38682.5,
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,38682.5,,,,,,,fee schedule,12874.4,38682.5,
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,26592.12,,,,,,,fee schedule,12874.4,38682.5,
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,24083.13,,,,,,,fee schedule,12874.4,38682.5,
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19725.07,,,,,,,fee schedule,12874.4,38682.5,
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15121.41,,,,,,,fee schedule,12874.4,38682.5,MSDRG Base Rate
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,14977.39,,,,,,,fee schedule,12874.4,38682.5,MSDRG Base Rate
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,14977.39,,,,,,,fee schedule,12874.4,38682.5,MSDRG Base Rate
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,15121.41,,,,,,,fee schedule,12874.4,38682.5,MSDRG Base Rate
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,14977.39,,,,,,,fee schedule,12874.4,38682.5,MSDRG Base Rate
Intraocular Procedures With Cc/Mcc,116,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,25202.34,,,,,,,fee schedule,12874.4,38682.5,MSDRG Base Rate
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8322.64,,,,,,,fee schedule,8322.64,25006.26,
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,8322.64,,,,,,,fee schedule,8322.64,25006.26,
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11141.87,,,,,,,fee schedule,8322.64,25006.26,
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10611.31,,,,,,,fee schedule,8322.64,25006.26,
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,18585.36,,,,,,,fee schedule,8322.64,25006.26,
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,14442.45,,,,,,,fee schedule,8322.64,25006.26,
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,25006.26,,,,,,,fee schedule,8322.64,25006.26,
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,17190.45,,,,,,,fee schedule,8322.64,25006.26,
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,15568.51,,,,,,,fee schedule,8322.64,25006.26,
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12751.25,,,,,,,fee schedule,8322.64,25006.26,
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4990.8,4990.8,4990.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9471.47,,,,,,,fee schedule,8322.64,25006.26,MSDRG Base Rate
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,9381.27,,,,,,,fee schedule,8322.64,25006.26,MSDRG Base Rate
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,9381.27,,,,,,,fee schedule,8322.64,25006.26,MSDRG Base Rate
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,9471.47,,,,,,,fee schedule,8322.64,25006.26,MSDRG Base Rate
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,9381.27,,,,,,,fee schedule,8322.64,25006.26,MSDRG Base Rate
Intraocular Procedures Without Cc/Mcc,117,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15785.79,,,,,,,fee schedule,8322.64,25006.26,MSDRG Base Rate
Cardiac Pacemaker Device Replacement,118,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement,118,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement,118,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement,118,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement,118,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement,118,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement,118,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement,118,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement,118,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement,118,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement,118,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement,118,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement,118,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement,118,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement,118,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement,118,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement,118,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement,118,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vein ligation & stripping,119,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vein ligation & stripping,119,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Vein ligation & stripping,119,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Vein ligation & stripping,119,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vein ligation & stripping,119,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vein ligation & stripping,119,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Vein ligation & stripping,119,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Vein ligation & stripping,119,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Vein ligation & stripping,119,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Vein ligation & stripping,119,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Vein ligation & stripping,119,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vein ligation & stripping,119,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vein ligation & stripping,119,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Vein ligation & stripping,119,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Vein ligation & stripping,119,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vein ligation & stripping,119,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Vein ligation & stripping,119,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vein ligation & stripping,119,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other circulatory system O.R. procedures,120,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other circulatory system O.R. procedures,120,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other circulatory system O.R. procedures,120,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Other circulatory system O.R. procedures,120,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other circulatory system O.R. procedures,120,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other circulatory system O.R. procedures,120,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Other circulatory system O.R. procedures,120,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other circulatory system O.R. procedures,120,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other circulatory system O.R. procedures,120,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other circulatory system O.R. procedures,120,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other circulatory system O.R. procedures,120,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other circulatory system O.R. procedures,120,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other circulatory system O.R. procedures,120,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Other circulatory system O.R. procedures,120,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Other circulatory system O.R. procedures,120,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other circulatory system O.R. procedures,120,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other circulatory system O.R. procedures,120,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other circulatory system O.R. procedures,120,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8974.65,,,,,,,fee schedule,8974.65,26965.31,
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,8974.65,,,,,,,fee schedule,8974.65,26965.31,
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12014.75,,,,,,,fee schedule,8974.65,26965.31,
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11442.62,,,,,,,fee schedule,8974.65,26965.31,
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,20041.38,,,,,,,fee schedule,8974.65,26965.31,
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,15573.91,,,,,,,fee schedule,8974.65,26965.31,
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,26965.31,,,,,,,fee schedule,8974.65,26965.31,
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,18537.19,,,,,,,fee schedule,8974.65,26965.31,
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,16788.19,,,,,,,fee schedule,8974.65,26965.31,
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13750.21,,,,,,,fee schedule,8974.65,26965.31,
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],18538.78,18538.78,18538.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],7348.84,7348.84,7348.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3456.96,3456.96,3456.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],9787.74,9787.74,9787.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10083.97,,,,,,,fee schedule,8974.65,26965.31,MSDRG Base Rate
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,9987.93,,,,,,,fee schedule,8974.65,26965.31,MSDRG Base Rate
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,9987.93,,,,,,,fee schedule,8974.65,26965.31,MSDRG Base Rate
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,10083.97,,,,,,,fee schedule,8974.65,26965.31,MSDRG Base Rate
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,9987.93,,,,,,,fee schedule,8974.65,26965.31,MSDRG Base Rate
Acute Major Eye Infections With Cc/Mcc,121,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16806.62,,,,,,,fee schedule,8974.65,26965.31,MSDRG Base Rate
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5233.86,,,,,,,fee schedule,5233.86,15725.71,
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,5233.86,,,,,,,fee schedule,5233.86,15725.71,
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7006.8,,,,,,,fee schedule,5233.86,15725.71,
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6673.14,,,,,,,fee schedule,5233.86,15725.71,
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,11687.79,,,,,,,fee schedule,5233.86,15725.71,
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,9082.44,,,,,,,fee schedule,5233.86,15725.71,
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,15725.71,,,,,,,fee schedule,5233.86,15725.71,
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,10810.57,,,,,,,fee schedule,5233.86,15725.71,
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,9790.58,,,,,,,fee schedule,5233.86,15725.71,
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8018.89,,,,,,,fee schedule,5233.86,15725.71,
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",2748.58,2748.58,2748.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",2581.28,2581.28,2581.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7134.78,,,,,,,fee schedule,5233.86,15725.71,MSDRG Base Rate
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,7066.83,,,,,,,fee schedule,5233.86,15725.71,MSDRG Base Rate
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,7066.83,,,,,,,fee schedule,5233.86,15725.71,MSDRG Base Rate
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,7134.78,,,,,,,fee schedule,5233.86,15725.71,MSDRG Base Rate
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,7066.83,,,,,,,fee schedule,5233.86,15725.71,MSDRG Base Rate
Acute Major Eye Infections Without Cc/Mcc,122,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11891.3,,,,,,,fee schedule,5233.86,15725.71,MSDRG Base Rate
Neurological Eye Disorders,123,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6197.61,,,,,,,fee schedule,6197.61,18621.39,
Neurological Eye Disorders,123,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,6197.61,,,,,,,fee schedule,6197.61,18621.39,
Neurological Eye Disorders,123,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8297.01,,,,,,,fee schedule,6197.61,18621.39,
Neurological Eye Disorders,123,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7901.91,,,,,,,fee schedule,6197.61,18621.39,
Neurological Eye Disorders,123,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,13839.94,,,,,,,fee schedule,6197.61,18621.39,
Neurological Eye Disorders,123,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,10754.85,,,,,,,fee schedule,6197.61,18621.39,
Neurological Eye Disorders,123,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,18621.39,,,,,,,fee schedule,6197.61,18621.39,
Neurological Eye Disorders,123,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,12801.19,,,,,,,fee schedule,6197.61,18621.39,
Neurological Eye Disorders,123,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,11593.39,,,,,,,fee schedule,6197.61,18621.39,
Neurological Eye Disorders,123,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9495.46,,,,,,,fee schedule,6197.61,18621.39,
Neurological Eye Disorders,123,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Neurological Eye Disorders,123,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Neurological Eye Disorders,123,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],7543.58,7543.58,7543.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Neurological Eye Disorders,123,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Neurological Eye Disorders,123,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Neurological Eye Disorders,123,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Neurological Eye Disorders,123,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Neurological Eye Disorders,123,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4083.31,4083.31,4083.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Neurological Eye Disorders,123,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6084.53,6084.53,6084.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Neurological Eye Disorders,123,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],7006.63,7006.63,7006.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Neurological Eye Disorders,123,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Neurological Eye Disorders,123,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Neurological Eye Disorders,123,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Neurological Eye Disorders,123,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Neurological Eye Disorders,123,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Neurological Eye Disorders,123,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Neurological Eye Disorders,123,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Neurological Eye Disorders,123,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],23453.6,23453.6,23453.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Neurological Eye Disorders,123,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7234.78,,,,,,,fee schedule,6197.61,18621.39,MSDRG Base Rate
Neurological Eye Disorders,123,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,7165.88,,,,,,,fee schedule,6197.61,18621.39,MSDRG Base Rate
Neurological Eye Disorders,123,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,7165.88,,,,,,,fee schedule,6197.61,18621.39,MSDRG Base Rate
Neurological Eye Disorders,123,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,7234.78,,,,,,,fee schedule,6197.61,18621.39,MSDRG Base Rate
Neurological Eye Disorders,123,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,7165.88,,,,,,,fee schedule,6197.61,18621.39,MSDRG Base Rate
Neurological Eye Disorders,123,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12057.97,,,,,,,fee schedule,6197.61,18621.39,MSDRG Base Rate
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10060.32,,,,,,,fee schedule,10060.32,30227.3,
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,10060.32,,,,,,,fee schedule,10060.32,30227.3,
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13468.18,,,,,,,fee schedule,10060.32,30227.3,
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12826.84,,,,,,,fee schedule,10060.32,30227.3,
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,22465.78,,,,,,,fee schedule,10060.32,30227.3,
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,17457.88,,,,,,,fee schedule,10060.32,30227.3,
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,30227.3,,,,,,,fee schedule,10060.32,30227.3,
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,20779.63,,,,,,,fee schedule,10060.32,30227.3,
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,18819.05,,,,,,,fee schedule,10060.32,30227.3,
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15413.58,,,,,,,fee schedule,10060.32,30227.3,
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9516.86,9516.86,9516.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4707.94,4707.94,4707.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],10133.09,10133.09,10133.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11332.39,,,,,,,fee schedule,10060.32,30227.3,MSDRG Base Rate
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,11224.46,,,,,,,fee schedule,10060.32,30227.3,MSDRG Base Rate
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,11224.46,,,,,,,fee schedule,10060.32,30227.3,MSDRG Base Rate
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,11332.39,,,,,,,fee schedule,10060.32,30227.3,MSDRG Base Rate
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,11224.46,,,,,,,fee schedule,10060.32,30227.3,MSDRG Base Rate
Other Disorders Of The Eye With Mcc Or Thrombolytic Agent,124,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18887.31,,,,,,,fee schedule,10060.32,30227.3,MSDRG Base Rate
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6371.23,,,,,,,fee schedule,6371.23,19143.03,
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,6371.23,,,,,,,fee schedule,6371.23,19143.03,
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8529.43,,,,,,,fee schedule,6371.23,19143.03,
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8123.27,,,,,,,fee schedule,6371.23,19143.03,
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,14227.64,,,,,,,fee schedule,6371.23,19143.03,
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,11056.12,,,,,,,fee schedule,6371.23,19143.03,
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,19143.03,,,,,,,fee schedule,6371.23,19143.03,
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,13159.79,,,,,,,fee schedule,6371.23,19143.03,
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,11918.15,,,,,,,fee schedule,6371.23,19143.03,
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9761.46,,,,,,,fee schedule,6371.23,19143.03,
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6683.56,6683.56,6683.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],11918.15,11918.15,11918.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3013.75,3013.75,3013.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],5028.16,5028.16,6661.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,6994.16,,,,,,,fee schedule,6371.23,19143.03,MSDRG Base Rate
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,6927.54,,,,,,,fee schedule,6371.23,19143.03,MSDRG Base Rate
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,6927.54,,,,,,,fee schedule,6371.23,19143.03,MSDRG Base Rate
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,6994.16,,,,,,,fee schedule,6371.23,19143.03,MSDRG Base Rate
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,6927.54,,,,,,,fee schedule,6371.23,19143.03,MSDRG Base Rate
Other Disorders Of The Eye Without Mcc,125,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11656.92,,,,,,,fee schedule,6371.23,19143.03,MSDRG Base Rate
Acute & Subacute Endocarditis,126,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute & Subacute Endocarditis,126,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Acute & Subacute Endocarditis,126,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Acute & Subacute Endocarditis,126,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute & Subacute Endocarditis,126,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute & Subacute Endocarditis,126,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Acute & Subacute Endocarditis,126,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Acute & Subacute Endocarditis,126,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Acute & Subacute Endocarditis,126,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Acute & Subacute Endocarditis,126,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Acute & Subacute Endocarditis,126,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute & Subacute Endocarditis,126,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute & Subacute Endocarditis,126,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Acute & Subacute Endocarditis,126,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Acute & Subacute Endocarditis,126,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute & Subacute Endocarditis,126,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Acute & Subacute Endocarditis,126,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute & Subacute Endocarditis,126,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure & Shock,127,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure & Shock,127,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure & Shock,127,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure & Shock,127,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure & Shock,127,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure & Shock,127,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure & Shock,127,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure & Shock,127,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure & Shock,127,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure & Shock,127,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure & Shock,127,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure & Shock,127,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure & Shock,127,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure & Shock,127,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure & Shock,127,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure & Shock,127,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure & Shock,127,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure & Shock,127,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis,128,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis,128,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis,128,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis,128,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis,128,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis,128,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis,128,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis,128,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis,128,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis,128,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis,128,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis,128,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis,128,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis,128,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis,128,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis,128,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis,128,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis,128,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head & Neck Procedures W Cc/Mcc Or Major Device,129,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head & Neck Procedures W Cc/Mcc Or Major Device,129,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Major Head & Neck Procedures W Cc/Mcc Or Major Device,129,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Major Head & Neck Procedures W Cc/Mcc Or Major Device,129,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head & Neck Procedures W Cc/Mcc Or Major Device,129,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head & Neck Procedures W Cc/Mcc Or Major Device,129,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Major Head & Neck Procedures W Cc/Mcc Or Major Device,129,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Head & Neck Procedures W Cc/Mcc Or Major Device,129,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Head & Neck Procedures W Cc/Mcc Or Major Device,129,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Major Head & Neck Procedures W Cc/Mcc Or Major Device,129,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Major Head & Neck Procedures W Cc/Mcc Or Major Device,129,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head & Neck Procedures W Cc/Mcc Or Major Device,129,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head & Neck Procedures W Cc/Mcc Or Major Device,129,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Major Head & Neck Procedures W Cc/Mcc Or Major Device,129,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Major Head & Neck Procedures W Cc/Mcc Or Major Device,129,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head & Neck Procedures W Cc/Mcc Or Major Device,129,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Head & Neck Procedures W Cc/Mcc Or Major Device,129,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head & Neck Procedures W Cc/Mcc Or Major Device,129,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head & Neck Procedures W/O Cc/Mcc,130,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head & Neck Procedures W/O Cc/Mcc,130,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Major Head & Neck Procedures W/O Cc/Mcc,130,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Major Head & Neck Procedures W/O Cc/Mcc,130,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head & Neck Procedures W/O Cc/Mcc,130,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head & Neck Procedures W/O Cc/Mcc,130,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Major Head & Neck Procedures W/O Cc/Mcc,130,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Head & Neck Procedures W/O Cc/Mcc,130,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Head & Neck Procedures W/O Cc/Mcc,130,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Major Head & Neck Procedures W/O Cc/Mcc,130,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Major Head & Neck Procedures W/O Cc/Mcc,130,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head & Neck Procedures W/O Cc/Mcc,130,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head & Neck Procedures W/O Cc/Mcc,130,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Major Head & Neck Procedures W/O Cc/Mcc,130,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Major Head & Neck Procedures W/O Cc/Mcc,130,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head & Neck Procedures W/O Cc/Mcc,130,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Head & Neck Procedures W/O Cc/Mcc,130,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head & Neck Procedures W/O Cc/Mcc,130,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cranial/Facial Procedures W Cc/Mcc,131,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cranial/Facial Procedures W Cc/Mcc,131,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Cranial/Facial Procedures W Cc/Mcc,131,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Cranial/Facial Procedures W Cc/Mcc,131,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cranial/Facial Procedures W Cc/Mcc,131,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cranial/Facial Procedures W Cc/Mcc,131,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Cranial/Facial Procedures W Cc/Mcc,131,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cranial/Facial Procedures W Cc/Mcc,131,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cranial/Facial Procedures W Cc/Mcc,131,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Cranial/Facial Procedures W Cc/Mcc,131,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Cranial/Facial Procedures W Cc/Mcc,131,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cranial/Facial Procedures W Cc/Mcc,131,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cranial/Facial Procedures W Cc/Mcc,131,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Cranial/Facial Procedures W Cc/Mcc,131,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Cranial/Facial Procedures W Cc/Mcc,131,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cranial/Facial Procedures W Cc/Mcc,131,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cranial/Facial Procedures W Cc/Mcc,131,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cranial/Facial Procedures W Cc/Mcc,131,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cranial/Facial Procedures W/O Cc/Mcc,132,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cranial/Facial Procedures W/O Cc/Mcc,132,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Cranial/Facial Procedures W/O Cc/Mcc,132,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Cranial/Facial Procedures W/O Cc/Mcc,132,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cranial/Facial Procedures W/O Cc/Mcc,132,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cranial/Facial Procedures W/O Cc/Mcc,132,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Cranial/Facial Procedures W/O Cc/Mcc,132,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cranial/Facial Procedures W/O Cc/Mcc,132,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cranial/Facial Procedures W/O Cc/Mcc,132,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Cranial/Facial Procedures W/O Cc/Mcc,132,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Cranial/Facial Procedures W/O Cc/Mcc,132,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cranial/Facial Procedures W/O Cc/Mcc,132,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cranial/Facial Procedures W/O Cc/Mcc,132,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Cranial/Facial Procedures W/O Cc/Mcc,132,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Cranial/Facial Procedures W/O Cc/Mcc,132,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cranial/Facial Procedures W/O Cc/Mcc,132,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cranial/Facial Procedures W/O Cc/Mcc,132,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cranial/Facial Procedures W/O Cc/Mcc,132,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc",133,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc",133,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc",133,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc",133,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc",133,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc",133,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc",133,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc",133,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc",133,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc",133,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc",133,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc",133,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc",133,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc",133,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc",133,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc",133,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc",133,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc",133,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc",134,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc",134,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc",134,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc",134,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc",134,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc",134,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc",134,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc",134,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc",134,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc",134,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc",134,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc",134,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc",134,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc",134,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc",134,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc",134,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc",134,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc",134,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18602.87,,,,,,,fee schedule,17777.78,55894.31,
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,18602.87,,,,,,,fee schedule,17777.78,55894.31,
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24904.45,,,,,,,fee schedule,17777.78,55894.31,
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23718.53,,,,,,,fee schedule,17777.78,55894.31,
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,41542.22,,,,,,,fee schedule,17777.78,55894.31,
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,32281.95,,,,,,,fee schedule,17777.78,55894.31,
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,55894.31,,,,,,,fee schedule,17777.78,55894.31,
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,38424.3,,,,,,,fee schedule,17777.78,55894.31,
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,34798.93,,,,,,,fee schedule,17777.78,55894.31,
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,28501.76,,,,,,,fee schedule,17777.78,55894.31,
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,17948.72,,,,,,,fee schedule,17777.78,55894.31,MSDRG Base Rate
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,17777.78,,,,,,,fee schedule,17777.78,55894.31,MSDRG Base Rate
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,17777.78,,,,,,,fee schedule,17777.78,55894.31,MSDRG Base Rate
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,17948.72,,,,,,,fee schedule,17777.78,55894.31,MSDRG Base Rate
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,17777.78,,,,,,,fee schedule,17777.78,55894.31,MSDRG Base Rate
Sinus And Mastoid Procedures With Cc/Mcc,135,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,29914.54,,,,,,,fee schedule,17777.78,55894.31,MSDRG Base Rate
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7547.94,,,,,,,fee schedule,7547.94,22678.59,
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,7547.94,,,,,,,fee schedule,7547.94,22678.59,
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10104.75,,,,,,,fee schedule,7547.94,22678.59,
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9623.57,,,,,,,fee schedule,7547.94,22678.59,
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,16855.36,,,,,,,fee schedule,7547.94,22678.59,
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,13098.1,,,,,,,fee schedule,7547.94,22678.59,
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,22678.59,,,,,,,fee schedule,7547.94,22678.59,
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,15590.3,,,,,,,fee schedule,7547.94,22678.59,
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,14119.34,,,,,,,fee schedule,7547.94,22678.59,
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11564.32,,,,,,,fee schedule,7547.94,22678.59,
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8927.73,,,,,,,fee schedule,7547.94,22678.59,MSDRG Base Rate
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,8842.7,,,,,,,fee schedule,7547.94,22678.59,MSDRG Base Rate
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,8842.7,,,,,,,fee schedule,7547.94,22678.59,MSDRG Base Rate
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,8927.73,,,,,,,fee schedule,7547.94,22678.59,MSDRG Base Rate
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,8842.7,,,,,,,fee schedule,7547.94,22678.59,MSDRG Base Rate
Sinus And Mastoid Procedures Without Cc/Mcc,136,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14879.55,,,,,,,fee schedule,7547.94,22678.59,MSDRG Base Rate
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10791.04,,,,,,,fee schedule,10791.04,32422.82,
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,10791.04,,,,,,,fee schedule,10791.04,32422.82,
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14446.42,,,,,,,fee schedule,10791.04,32422.82,
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13758.5,,,,,,,fee schedule,10791.04,32422.82,
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,24097.55,,,,,,,fee schedule,10791.04,32422.82,
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,18725.92,,,,,,,fee schedule,10791.04,32422.82,
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,32422.82,,,,,,,fee schedule,10791.04,32422.82,
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,22288.93,,,,,,,fee schedule,10791.04,32422.82,
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,20185.95,,,,,,,fee schedule,10791.04,32422.82,
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16533.12,,,,,,,fee schedule,10791.04,32422.82,
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12661.28,,,,,,,fee schedule,10791.04,32422.82,MSDRG Base Rate
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,12540.69,,,,,,,fee schedule,10791.04,32422.82,MSDRG Base Rate
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,12540.69,,,,,,,fee schedule,10791.04,32422.82,MSDRG Base Rate
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,12661.28,,,,,,,fee schedule,10791.04,32422.82,MSDRG Base Rate
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,12540.69,,,,,,,fee schedule,10791.04,32422.82,MSDRG Base Rate
Mouth Procedures With Cc/Mcc,137,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21102.13,,,,,,,fee schedule,10791.04,32422.82,MSDRG Base Rate
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6277.09,,,,,,,fee schedule,6277.09,18860.18,
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,6277.09,,,,,,,fee schedule,6277.09,18860.18,
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8403.41,,,,,,,fee schedule,6277.09,18860.18,
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8003.25,,,,,,,fee schedule,6277.09,18860.18,
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,14017.42,,,,,,,fee schedule,6277.09,18860.18,
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,10892.77,,,,,,,fee schedule,6277.09,18860.18,
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,18860.18,,,,,,,fee schedule,6277.09,18860.18,
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,12965.35,,,,,,,fee schedule,6277.09,18860.18,
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,11742.06,,,,,,,fee schedule,6277.09,18860.18,
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9617.23,,,,,,,fee schedule,6277.09,18860.18,
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7919.14,,,,,,,fee schedule,6277.09,18860.18,MSDRG Base Rate
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,7843.72,,,,,,,fee schedule,6277.09,18860.18,MSDRG Base Rate
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,7843.72,,,,,,,fee schedule,6277.09,18860.18,MSDRG Base Rate
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,7919.14,,,,,,,fee schedule,6277.09,18860.18,MSDRG Base Rate
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,7843.72,,,,,,,fee schedule,6277.09,18860.18,MSDRG Base Rate
Mouth Procedures Without Cc/Mcc,138,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,13198.57,,,,,,,fee schedule,6277.09,18860.18,MSDRG Base Rate
Salivary Gland Procedures,139,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10593.5,,,,,,,fee schedule,10548.16,31829.31,
Salivary Gland Procedures,139,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,10593.5,,,,,,,fee schedule,10548.16,31829.31,
Salivary Gland Procedures,139,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14181.97,,,,,,,fee schedule,10548.16,31829.31,
Salivary Gland Procedures,139,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13506.65,,,,,,,fee schedule,10548.16,31829.31,
Salivary Gland Procedures,139,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,23656.44,,,,,,,fee schedule,10548.16,31829.31,
Salivary Gland Procedures,139,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,18383.13,,,,,,,fee schedule,10548.16,31829.31,
Salivary Gland Procedures,139,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,31829.31,,,,,,,fee schedule,10548.16,31829.31,
Salivary Gland Procedures,139,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,21880.92,,,,,,,fee schedule,10548.16,31829.31,
Salivary Gland Procedures,139,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,19816.44,,,,,,,fee schedule,10548.16,31829.31,
Salivary Gland Procedures,139,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16230.48,,,,,,,fee schedule,10548.16,31829.31,
Salivary Gland Procedures,139,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Salivary Gland Procedures,139,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Salivary Gland Procedures,139,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Salivary Gland Procedures,139,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Salivary Gland Procedures,139,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Salivary Gland Procedures,139,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Salivary Gland Procedures,139,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Salivary Gland Procedures,139,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Salivary Gland Procedures,139,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Salivary Gland Procedures,139,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Salivary Gland Procedures,139,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Salivary Gland Procedures,139,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Salivary Gland Procedures,139,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Salivary Gland Procedures,139,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Salivary Gland Procedures,139,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Salivary Gland Procedures,139,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Salivary Gland Procedures,139,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Salivary Gland Procedures,139,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Salivary Gland Procedures,139,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10649.58,,,,,,,fee schedule,10548.16,31829.31,MSDRG Base Rate
Salivary Gland Procedures,139,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,10548.16,,,,,,,fee schedule,10548.16,31829.31,MSDRG Base Rate
Salivary Gland Procedures,139,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,10548.16,,,,,,,fee schedule,10548.16,31829.31,MSDRG Base Rate
Salivary Gland Procedures,139,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,10649.58,,,,,,,fee schedule,10548.16,31829.31,MSDRG Base Rate
Salivary Gland Procedures,139,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,10548.16,,,,,,,fee schedule,10548.16,31829.31,MSDRG Base Rate
Salivary Gland Procedures,139,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,17749.3,,,,,,,fee schedule,10548.16,31829.31,MSDRG Base Rate
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,32631.6,,,,,,,fee schedule,32631.6,98045.14,
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,32631.6,,,,,,,fee schedule,32631.6,98045.14,
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,43685.32,,,,,,,fee schedule,32631.6,98045.14,
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,41605.07,,,,,,,fee schedule,32631.6,98045.14,
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,72869.9,,,,,,,fee schedule,32631.6,98045.14,
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,56626.31,,,,,,,fee schedule,32631.6,98045.14,
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,98045.14,,,,,,,fee schedule,32631.6,98045.14,
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,67400.7,,,,,,,fee schedule,32631.6,98045.14,
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,61041.39,,,,,,,fee schedule,32631.6,98045.14,
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,49995.41,,,,,,,fee schedule,32631.6,98045.14,
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],65653.89,65653.89,65653.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,34318.06,,,,,,,fee schedule,32631.6,98045.14,MSDRG Base Rate
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,33991.22,,,,,,,fee schedule,32631.6,98045.14,MSDRG Base Rate
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,33991.22,,,,,,,fee schedule,32631.6,98045.14,MSDRG Base Rate
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,34318.06,,,,,,,fee schedule,32631.6,98045.14,MSDRG Base Rate
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,33991.22,,,,,,,fee schedule,32631.6,98045.14,MSDRG Base Rate
Major Head And Neck Procedures With Mcc,140,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,57196.77,,,,,,,fee schedule,32631.6,98045.14,MSDRG Base Rate
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16576.61,,,,,,,fee schedule,16576.61,49806.19,
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,16576.61,,,,,,,fee schedule,16576.61,49806.19,
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22191.81,,,,,,,fee schedule,16576.61,49806.19,
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21135.06,,,,,,,fee schedule,16576.61,49806.19,
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,37017.36,,,,,,,fee schedule,16576.61,49806.19,
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,28765.74,,,,,,,fee schedule,16576.61,49806.19,
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,49806.19,,,,,,,fee schedule,16576.61,49806.19,
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,34239.05,,,,,,,fee schedule,16576.61,49806.19,
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,31008.56,,,,,,,fee schedule,16576.61,49806.19,
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,25397.29,,,,,,,fee schedule,16576.61,49806.19,
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],14468.74,14468.74,14468.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],35348.12,35348.12,35348.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,18035.44,,,,,,,fee schedule,16576.61,49806.19,MSDRG Base Rate
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,17863.67,,,,,,,fee schedule,16576.61,49806.19,MSDRG Base Rate
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,17863.67,,,,,,,fee schedule,16576.61,49806.19,MSDRG Base Rate
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,18035.44,,,,,,,fee schedule,16576.61,49806.19,MSDRG Base Rate
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,17863.67,,,,,,,fee schedule,16576.61,49806.19,MSDRG Base Rate
Major Head And Neck Procedures With Cc,141,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30059.07,,,,,,,fee schedule,16576.61,49806.19,MSDRG Base Rate
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12132.1,,,,,,,fee schedule,12132.1,36452.2,
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,12132.1,,,,,,,fee schedule,12132.1,36452.2,
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16241.76,,,,,,,fee schedule,12132.1,36452.2,
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15468.35,,,,,,,fee schedule,12132.1,36452.2,
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,27092.3,,,,,,,fee schedule,12132.1,36452.2,
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,21053.1,,,,,,,fee schedule,12132.1,36452.2,
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,36452.2,,,,,,,fee schedule,12132.1,36452.2,
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,25058.91,,,,,,,fee schedule,12132.1,36452.2,
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,22694.58,,,,,,,fee schedule,12132.1,36452.2,
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18587.79,,,,,,,fee schedule,12132.1,36452.2,
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13467.52,,,,,,,fee schedule,12132.1,36452.2,MSDRG Base Rate
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,13339.26,,,,,,,fee schedule,12132.1,36452.2,MSDRG Base Rate
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,13339.26,,,,,,,fee schedule,12132.1,36452.2,MSDRG Base Rate
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,13467.52,,,,,,,fee schedule,12132.1,36452.2,MSDRG Base Rate
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,13339.26,,,,,,,fee schedule,12132.1,36452.2,MSDRG Base Rate
Major Head And Neck Procedures Without Cc/Mcc,142,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22445.87,,,,,,,fee schedule,12132.1,36452.2,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,25476.41,,,,,,,fee schedule,25476.41,76546.61,
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,25476.41,,,,,,,fee schedule,25476.41,76546.61,
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,34106.36,,,,,,,fee schedule,25476.41,76546.61,
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,32482.26,,,,,,,fee schedule,25476.41,76546.61,
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,56891.59,,,,,,,fee schedule,25476.41,76546.61,
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,44209.76,,,,,,,fee schedule,25476.41,76546.61,
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,76546.61,,,,,,,fee schedule,25476.41,76546.61,
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,52621.64,,,,,,,fee schedule,25476.41,76546.61,
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,47656.74,,,,,,,fee schedule,25476.41,76546.61,
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,39032.83,,,,,,,fee schedule,25476.41,76546.61,
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,30265.77,,,,,,,fee schedule,25476.41,76546.61,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,29977.52,,,,,,,fee schedule,25476.41,76546.61,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,29977.52,,,,,,,fee schedule,25476.41,76546.61,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,30265.77,,,,,,,fee schedule,25476.41,76546.61,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,29977.52,,,,,,,fee schedule,25476.41,76546.61,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc",143,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,50442.94,,,,,,,fee schedule,25476.41,76546.61,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13554.19,,,,,,,fee schedule,13554.19,40725.01,
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,13554.19,,,,,,,fee schedule,13554.19,40725.01,
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18145.57,,,,,,,fee schedule,13554.19,40725.01,
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17281.5,,,,,,,fee schedule,13554.19,40725.01,
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,30267.97,,,,,,,fee schedule,13554.19,40725.01,
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,23520.87,,,,,,,fee schedule,13554.19,40725.01,
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,40725.01,,,,,,,fee schedule,13554.19,40725.01,
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,27996.23,,,,,,,fee schedule,13554.19,40725.01,
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,25354.76,,,,,,,fee schedule,13554.19,40725.01,
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20766.6,,,,,,,fee schedule,13554.19,40725.01,
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],13123.86,13123.86,13123.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",5375.62,5375.62,5375.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14533.91,,,,,,,fee schedule,13554.19,40725.01,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,14395.49,,,,,,,fee schedule,13554.19,40725.01,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,14395.49,,,,,,,fee schedule,13554.19,40725.01,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,14533.91,,,,,,,fee schedule,13554.19,40725.01,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,14395.49,,,,,,,fee schedule,13554.19,40725.01,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc",144,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,24223.18,,,,,,,fee schedule,13554.19,40725.01,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9141.32,,,,,,,fee schedule,9141.32,27466.08,
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,9141.32,,,,,,,fee schedule,9141.32,27466.08,
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12237.88,,,,,,,fee schedule,9141.32,27466.08,
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11655.13,,,,,,,fee schedule,9141.32,27466.08,
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,20413.57,,,,,,,fee schedule,9141.32,27466.08,
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,15863.13,,,,,,,fee schedule,9141.32,27466.08,
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,27466.08,,,,,,,fee schedule,9141.32,27466.08,
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,18881.44,,,,,,,fee schedule,9141.32,27466.08,
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,17099.96,,,,,,,fee schedule,9141.32,27466.08,
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14005.57,,,,,,,fee schedule,9141.32,27466.08,
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],10360.42,10360.42,10360.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],7652,7652,7652,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3508.98,3508.98,3508.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],19902.22,19902.22,20216.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",181.94,181.94,181.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10388.65,,,,,,,fee schedule,9141.32,27466.08,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,10289.71,,,,,,,fee schedule,9141.32,27466.08,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,10289.71,,,,,,,fee schedule,9141.32,27466.08,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,10388.65,,,,,,,fee schedule,9141.32,27466.08,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,10289.71,,,,,,,fee schedule,9141.32,27466.08,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc",145,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,17314.41,,,,,,,fee schedule,9141.32,27466.08,MSDRG Base Rate
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17700.08,,,,,,,fee schedule,17370.76,53181.78,
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,17700.08,,,,,,,fee schedule,17370.76,53181.78,
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23695.85,,,,,,,fee schedule,17370.76,53181.78,
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22567.48,,,,,,,fee schedule,17370.76,53181.78,
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,39526.19,,,,,,,fee schedule,17370.76,53181.78,
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,30715.32,,,,,,,fee schedule,17370.76,53181.78,
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,53181.78,,,,,,,fee schedule,17370.76,53181.78,
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,36559.58,,,,,,,fee schedule,17370.76,53181.78,
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,33110.15,,,,,,,fee schedule,17370.76,53181.78,
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27118.58,,,,,,,fee schedule,17370.76,53181.78,
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],17357.44,17357.44,17357.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],15242.63,15242.63,16051.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,17537.78,,,,,,,fee schedule,17370.76,53181.78,MSDRG Base Rate
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,17370.76,,,,,,,fee schedule,17370.76,53181.78,MSDRG Base Rate
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,17370.76,,,,,,,fee schedule,17370.76,53181.78,MSDRG Base Rate
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,17537.78,,,,,,,fee schedule,17370.76,53181.78,MSDRG Base Rate
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,17370.76,,,,,,,fee schedule,17370.76,53181.78,MSDRG Base Rate
"Ear, Nose, Mouth And Throat Malignancy With Mcc",146,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,29229.64,,,,,,,fee schedule,17370.76,53181.78,MSDRG Base Rate
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9604.29,,,,,,,fee schedule,9604.29,28857.12,
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,9604.29,,,,,,,fee schedule,9604.29,28857.12,
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12857.68,,,,,,,fee schedule,9604.29,28857.12,
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12245.41,,,,,,,fee schedule,9604.29,28857.12,
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,21447.43,,,,,,,fee schedule,9604.29,28857.12,
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,16666.53,,,,,,,fee schedule,9604.29,28857.12,
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,28857.12,,,,,,,fee schedule,9604.29,28857.12,
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,19837.7,,,,,,,fee schedule,9604.29,28857.12,
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,17966,,,,,,,fee schedule,9604.29,28857.12,
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14714.89,,,,,,,fee schedule,9604.29,28857.12,
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10929.27,,,,,,,fee schedule,9604.29,28857.12,MSDRG Base Rate
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,10825.18,,,,,,,fee schedule,9604.29,28857.12,MSDRG Base Rate
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,10825.18,,,,,,,fee schedule,9604.29,28857.12,MSDRG Base Rate
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,10929.27,,,,,,,fee schedule,9604.29,28857.12,MSDRG Base Rate
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,10825.18,,,,,,,fee schedule,9604.29,28857.12,MSDRG Base Rate
"Ear, Nose, Mouth And Throat Malignancy With Cc",147,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18215.45,,,,,,,fee schedule,9604.29,28857.12,MSDRG Base Rate
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6178.32,,,,,,,fee schedule,6178.32,18563.43,
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,6178.32,,,,,,,fee schedule,6178.32,18563.43,
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8271.18,,,,,,,fee schedule,6178.32,18563.43,
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7877.32,,,,,,,fee schedule,6178.32,18563.43,
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,13796.86,,,,,,,fee schedule,6178.32,18563.43,
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,10721.37,,,,,,,fee schedule,6178.32,18563.43,
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,18563.43,,,,,,,fee schedule,6178.32,18563.43,
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,12761.35,,,,,,,fee schedule,6178.32,18563.43,
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,11557.3,,,,,,,fee schedule,6178.32,18563.43,
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9465.91,,,,,,,fee schedule,6178.32,18563.43,
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],7877.32,7877.32,7877.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7223.07,,,,,,,fee schedule,6178.32,18563.43,MSDRG Base Rate
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,7154.27,,,,,,,fee schedule,6178.32,18563.43,MSDRG Base Rate
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,7154.27,,,,,,,fee schedule,6178.32,18563.43,MSDRG Base Rate
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,7223.07,,,,,,,fee schedule,6178.32,18563.43,MSDRG Base Rate
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,7154.27,,,,,,,fee schedule,6178.32,18563.43,MSDRG Base Rate
"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc",148,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12038.44,,,,,,,fee schedule,6178.32,18563.43,MSDRG Base Rate
Dysequilibrium,149,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5767.82,,,,,,,fee schedule,5767.82,17330.04,
Dysequilibrium,149,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,5767.82,,,,,,,fee schedule,5767.82,17330.04,
Dysequilibrium,149,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7721.63,,,,,,,fee schedule,5767.82,17330.04,
Dysequilibrium,149,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7353.93,,,,,,,fee schedule,5767.82,17330.04,
Dysequilibrium,149,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,12880.17,,,,,,,fee schedule,5767.82,17330.04,
Dysequilibrium,149,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,10009.03,,,,,,,fee schedule,5767.82,17330.04,
Dysequilibrium,149,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,17330.04,,,,,,,fee schedule,5767.82,17330.04,
Dysequilibrium,149,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,11913.46,,,,,,,fee schedule,5767.82,17330.04,
Dysequilibrium,149,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,10789.42,,,,,,,fee schedule,5767.82,17330.04,
Dysequilibrium,149,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8836.97,,,,,,,fee schedule,5767.82,17330.04,
Dysequilibrium,149,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],14823.97,14823.97,14823.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Dysequilibrium,149,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dysequilibrium,149,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],11563.46,11563.46,11563.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Dysequilibrium,149,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dysequilibrium,149,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11.83,11.83,11.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Dysequilibrium,149,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Dysequilibrium,149,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Dysequilibrium,149,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3456.1,3456.1,3456.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Dysequilibrium,149,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],4020.09,4020.09,5702.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Dysequilibrium,149,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],8836.97,8836.97,8836.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Dysequilibrium,149,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Dysequilibrium,149,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Dysequilibrium,149,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dysequilibrium,149,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Dysequilibrium,149,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dysequilibrium,149,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Dysequilibrium,149,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dysequilibrium,149,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dysequilibrium,149,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,6867.6,,,,,,,fee schedule,5767.82,17330.04,MSDRG Base Rate
Dysequilibrium,149,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,6802.19,,,,,,,fee schedule,5767.82,17330.04,MSDRG Base Rate
Dysequilibrium,149,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,6802.19,,,,,,,fee schedule,5767.82,17330.04,MSDRG Base Rate
Dysequilibrium,149,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,6867.6,,,,,,,fee schedule,5767.82,17330.04,MSDRG Base Rate
Dysequilibrium,149,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,6802.19,,,,,,,fee schedule,5767.82,17330.04,MSDRG Base Rate
Dysequilibrium,149,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11446,,,,,,,fee schedule,5767.82,17330.04,MSDRG Base Rate
Epistaxis With Mcc,150,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10664.49,,,,,,,fee schedule,10664.49,32042.61,
Epistaxis With Mcc,150,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,10664.49,,,,,,,fee schedule,10664.49,32042.61,
Epistaxis With Mcc,150,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14277.01,,,,,,,fee schedule,10664.49,32042.61,
Epistaxis With Mcc,150,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13597.16,,,,,,,fee schedule,10664.49,32042.61,
Epistaxis With Mcc,150,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,23814.97,,,,,,,fee schedule,10664.49,32042.61,
Epistaxis With Mcc,150,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,18506.32,,,,,,,fee schedule,10664.49,32042.61,
Epistaxis With Mcc,150,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,32042.61,,,,,,,fee schedule,10664.49,32042.61,
Epistaxis With Mcc,150,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,22027.55,,,,,,,fee schedule,10664.49,32042.61,
Epistaxis With Mcc,150,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,19949.23,,,,,,,fee schedule,10664.49,32042.61,
Epistaxis With Mcc,150,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16339.24,,,,,,,fee schedule,10664.49,32042.61,
Epistaxis With Mcc,150,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis With Mcc,150,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis With Mcc,150,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis With Mcc,150,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis With Mcc,150,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis With Mcc,150,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis With Mcc,150,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis With Mcc,150,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],10183.6,10183.6,10183.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Epistaxis With Mcc,150,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis With Mcc,150,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis With Mcc,150,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis With Mcc,150,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis With Mcc,150,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis With Mcc,150,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis With Mcc,150,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis With Mcc,150,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis With Mcc,150,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis With Mcc,150,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis With Mcc,150,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11398.01,,,,,,,fee schedule,10664.49,32042.61,MSDRG Base Rate
Epistaxis With Mcc,150,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,11289.46,,,,,,,fee schedule,10664.49,32042.61,MSDRG Base Rate
Epistaxis With Mcc,150,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,11289.46,,,,,,,fee schedule,10664.49,32042.61,MSDRG Base Rate
Epistaxis With Mcc,150,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,11398.01,,,,,,,fee schedule,10664.49,32042.61,MSDRG Base Rate
Epistaxis With Mcc,150,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,11289.46,,,,,,,fee schedule,10664.49,32042.61,MSDRG Base Rate
Epistaxis With Mcc,150,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18996.69,,,,,,,fee schedule,10664.49,32042.61,MSDRG Base Rate
Epistaxis Without Mcc,151,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5848.84,,,,,,,fee schedule,5848.84,17573.47,
Epistaxis Without Mcc,151,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,5848.84,,,,,,,fee schedule,5848.84,17573.47,
Epistaxis Without Mcc,151,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7830.09,,,,,,,fee schedule,5848.84,17573.47,
Epistaxis Without Mcc,151,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7457.23,,,,,,,fee schedule,5848.84,17573.47,
Epistaxis Without Mcc,151,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,13061.1,,,,,,,fee schedule,5848.84,17573.47,
Epistaxis Without Mcc,151,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,10149.62,,,,,,,fee schedule,5848.84,17573.47,
Epistaxis Without Mcc,151,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,17573.47,,,,,,,fee schedule,5848.84,17573.47,
Epistaxis Without Mcc,151,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,12080.81,,,,,,,fee schedule,5848.84,17573.47,
Epistaxis Without Mcc,151,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,10940.97,,,,,,,fee schedule,5848.84,17573.47,
Epistaxis Without Mcc,151,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8961.11,,,,,,,fee schedule,5848.84,17573.47,
Epistaxis Without Mcc,151,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis Without Mcc,151,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis Without Mcc,151,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis Without Mcc,151,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis Without Mcc,151,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis Without Mcc,151,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis Without Mcc,151,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis Without Mcc,151,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3368.84,3368.84,3368.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Epistaxis Without Mcc,151,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis Without Mcc,151,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis Without Mcc,151,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis Without Mcc,151,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis Without Mcc,151,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis Without Mcc,151,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis Without Mcc,151,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis Without Mcc,151,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis Without Mcc,151,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis Without Mcc,151,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Epistaxis Without Mcc,151,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,6730.1,,,,,,,fee schedule,5848.84,17573.47,MSDRG Base Rate
Epistaxis Without Mcc,151,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,6666,,,,,,,fee schedule,5848.84,17573.47,MSDRG Base Rate
Epistaxis Without Mcc,151,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,6666,,,,,,,fee schedule,5848.84,17573.47,MSDRG Base Rate
Epistaxis Without Mcc,151,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,6730.1,,,,,,,fee schedule,5848.84,17573.47,MSDRG Base Rate
Epistaxis Without Mcc,151,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,6666,,,,,,,fee schedule,5848.84,17573.47,MSDRG Base Rate
Epistaxis Without Mcc,151,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11216.84,,,,,,,fee schedule,5848.84,17573.47,MSDRG Base Rate
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8755.52,,,,,,,fee schedule,8755.52,26306.88,
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,8755.52,,,,,,,fee schedule,8755.52,26306.88,
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11721.38,,,,,,,fee schedule,8755.52,26306.88,
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11163.22,,,,,,,fee schedule,8755.52,26306.88,
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,19552.02,,,,,,,fee schedule,8755.52,26306.88,
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,15193.63,,,,,,,fee schedule,8755.52,26306.88,
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,26306.88,,,,,,,fee schedule,8755.52,26306.88,
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,18084.55,,,,,,,fee schedule,8755.52,26306.88,
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,16378.26,,,,,,,fee schedule,8755.52,26306.88,
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13414.47,,,,,,,fee schedule,8755.52,26306.88,
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],5731,5731,5731,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3270.39,3270.39,3270.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10231.62,,,,,,,fee schedule,8755.52,26306.88,MSDRG Base Rate
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,10134.18,,,,,,,fee schedule,8755.52,26306.88,MSDRG Base Rate
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,10134.18,,,,,,,fee schedule,8755.52,26306.88,MSDRG Base Rate
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,10231.62,,,,,,,fee schedule,8755.52,26306.88,MSDRG Base Rate
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,10134.18,,,,,,,fee schedule,8755.52,26306.88,MSDRG Base Rate
Otitis Media And Uri With Mcc,152,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,17052.7,,,,,,,fee schedule,8755.52,26306.88,MSDRG Base Rate
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5491.58,,,,,,,fee schedule,5491.58,16500.05,
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,5491.58,,,,,,,fee schedule,5491.58,16500.05,
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7351.82,,,,,,,fee schedule,5491.58,16500.05,
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7001.73,,,,,,,fee schedule,5491.58,16500.05,
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,12263.3,,,,,,,fee schedule,5491.58,16500.05,
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,9529.66,,,,,,,fee schedule,5491.58,16500.05,
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,16500.05,,,,,,,fee schedule,5491.58,16500.05,
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,11342.89,,,,,,,fee schedule,5491.58,16500.05,
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,10272.68,,,,,,,fee schedule,5491.58,16500.05,
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8413.75,,,,,,,fee schedule,5491.58,16500.05,
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],16500.05,16500.05,16500.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],4788.6,4788.6,4788.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],7940.02,5069.53,11711.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],4880.75,4880.75,4880.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3077.37,3077.37,3077.37,24,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],4573.56,4573.56,4573.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],1969.88,1554.89,9366,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3048.88,3048.88,3048.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,6762.91,,,,,,,fee schedule,5491.58,16500.05,MSDRG Base Rate
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,6698.5,,,,,,,fee schedule,5491.58,16500.05,MSDRG Base Rate
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,6698.5,,,,,,,fee schedule,5491.58,16500.05,MSDRG Base Rate
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,6762.91,,,,,,,fee schedule,5491.58,16500.05,MSDRG Base Rate
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,6698.5,,,,,,,fee schedule,5491.58,16500.05,MSDRG Base Rate
Otitis Media And Uri Without Mcc,153,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11271.52,,,,,,,fee schedule,5491.58,16500.05,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12548,,,,,,,fee schedule,12548,37701.82,
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,12548,,,,,,,fee schedule,12548,37701.82,
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16798.55,,,,,,,fee schedule,12548,37701.82,
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15998.62,,,,,,,fee schedule,12548,37701.82,
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,28021.05,,,,,,,fee schedule,12548,37701.82,
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,21774.82,,,,,,,fee schedule,12548,37701.82,
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,37701.82,,,,,,,fee schedule,12548,37701.82,
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,25917.95,,,,,,,fee schedule,12548,37701.82,
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,23472.57,,,,,,,fee schedule,12548,37701.82,
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19225,,,,,,,fee schedule,12548,37701.82,
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11693.15,11693.15,11693.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",5599.44,5599.44,5599.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13210.49,,,,,,,fee schedule,12548,37701.82,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,13084.68,,,,,,,fee schedule,12548,37701.82,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,13084.68,,,,,,,fee schedule,12548,37701.82,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,13210.49,,,,,,,fee schedule,12548,37701.82,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,13084.68,,,,,,,fee schedule,12548,37701.82,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc",154,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22017.48,,,,,,,fee schedule,12548,37701.82,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7203.8,,,,,,,fee schedule,7203.8,21644.58,
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,7203.8,,,,,,,fee schedule,7203.8,21644.58,
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9644.03,,,,,,,fee schedule,7203.8,21644.58,
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9184.79,,,,,,,fee schedule,7203.8,21644.58,
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,16086.86,,,,,,,fee schedule,7203.8,21644.58,
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,12500.9,,,,,,,fee schedule,7203.8,21644.58,
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,21644.58,,,,,,,fee schedule,7203.8,21644.58,
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,14879.47,,,,,,,fee schedule,7203.8,21644.58,
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,13475.58,,,,,,,fee schedule,7203.8,21644.58,
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11037.06,,,,,,,fee schedule,7203.8,21644.58,
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],7325.74,7325.74,7325.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7524.67,7524.67,7524.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4145.64,4145.64,4145.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],6819.66,6819.66,6819.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8155.86,,,,,,,fee schedule,7203.8,21644.58,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,8078.19,,,,,,,fee schedule,7203.8,21644.58,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,8078.19,,,,,,,fee schedule,7203.8,21644.58,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,8155.86,,,,,,,fee schedule,7203.8,21644.58,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,8078.19,,,,,,,fee schedule,7203.8,21644.58,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat Diagnoses With Cc",155,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,13593.11,,,,,,,fee schedule,7203.8,21644.58,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5188.34,,,,,,,fee schedule,5188.34,15588.92,
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,5188.34,,,,,,,fee schedule,5188.34,15588.92,
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6945.85,,,,,,,fee schedule,5188.34,15588.92,
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6615.1,,,,,,,fee schedule,5188.34,15588.92,
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,11586.12,,,,,,,fee schedule,5188.34,15588.92,
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,9003.44,,,,,,,fee schedule,5188.34,15588.92,
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,15588.92,,,,,,,fee schedule,5188.34,15588.92,
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,10716.54,,,,,,,fee schedule,5188.34,15588.92,
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,9705.42,,,,,,,fee schedule,5188.34,15588.92,
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7949.14,,,,,,,fee schedule,5188.34,15588.92,
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3467.28,3467.28,3467.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,6394.94,,,,,,,fee schedule,5188.34,15588.92,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,6334.04,,,,,,,fee schedule,5188.34,15588.92,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,6334.04,,,,,,,fee schedule,5188.34,15588.92,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,6394.94,,,,,,,fee schedule,5188.34,15588.92,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,6334.04,,,,,,,fee schedule,5188.34,15588.92,MSDRG Base Rate
"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc",156,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10658.24,,,,,,,fee schedule,5188.34,15588.92,MSDRG Base Rate
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12634.42,,,,,,,fee schedule,12634.42,37961.48,
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,12634.42,,,,,,,fee schedule,12634.42,37961.48,
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16914.24,,,,,,,fee schedule,12634.42,37961.48,
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16108.81,,,,,,,fee schedule,12634.42,37961.48,
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,28214.04,,,,,,,fee schedule,12634.42,37961.48,
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,21924.79,,,,,,,fee schedule,12634.42,37961.48,
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,37961.48,,,,,,,fee schedule,12634.42,37961.48,
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,26096.46,,,,,,,fee schedule,12634.42,37961.48,
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,23634.23,,,,,,,fee schedule,12634.42,37961.48,
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19357.41,,,,,,,fee schedule,12634.42,37961.48,
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],14327.39,14327.39,14327.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14408.13,,,,,,,fee schedule,12634.42,37961.48,MSDRG Base Rate
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,14270.91,,,,,,,fee schedule,12634.42,37961.48,MSDRG Base Rate
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,14270.91,,,,,,,fee schedule,12634.42,37961.48,MSDRG Base Rate
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,14408.13,,,,,,,fee schedule,12634.42,37961.48,MSDRG Base Rate
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,14270.91,,,,,,,fee schedule,12634.42,37961.48,MSDRG Base Rate
Dental And Oral Diseases With Mcc,157,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,24013.55,,,,,,,fee schedule,12634.42,37961.48,MSDRG Base Rate
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7257.04,,,,,,,fee schedule,7257.04,21804.55,
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,7257.04,,,,,,,fee schedule,7257.04,21804.55,
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9715.31,,,,,,,fee schedule,7257.04,21804.55,
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9252.68,,,,,,,fee schedule,7257.04,21804.55,
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,16205.76,,,,,,,fee schedule,7257.04,21804.55,
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,12593.3,,,,,,,fee schedule,7257.04,21804.55,
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,21804.55,,,,,,,fee schedule,7257.04,21804.55,
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,14989.44,,,,,,,fee schedule,7257.04,21804.55,
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,13575.18,,,,,,,fee schedule,7257.04,21804.55,
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11118.63,,,,,,,fee schedule,7257.04,21804.55,
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],13401.62,13401.62,13401.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],9253.66,9253.66,9253.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3638.81,3638.81,3638.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6989.28,6989.28,6989.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],11119.81,11119.81,11119.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],15081,15081,15081,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],7511.59,7511.59,7511.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8103.52,,,,,,,fee schedule,7257.04,21804.55,MSDRG Base Rate
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,8026.35,,,,,,,fee schedule,7257.04,21804.55,MSDRG Base Rate
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,8026.35,,,,,,,fee schedule,7257.04,21804.55,MSDRG Base Rate
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,8103.52,,,,,,,fee schedule,7257.04,21804.55,MSDRG Base Rate
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,8026.35,,,,,,,fee schedule,7257.04,21804.55,MSDRG Base Rate
Dental And Oral Diseases With Cc,158,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,13505.87,,,,,,,fee schedule,7257.04,21804.55,MSDRG Base Rate
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5089.57,,,,,,,fee schedule,5089.57,15292.17,
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,5089.57,,,,,,,fee schedule,5089.57,15292.17,
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6813.63,,,,,,,fee schedule,5089.57,15292.17,
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6489.17,,,,,,,fee schedule,5089.57,15292.17,
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,11365.57,,,,,,,fee schedule,5089.57,15292.17,
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,8832.04,,,,,,,fee schedule,5089.57,15292.17,
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,15292.17,,,,,,,fee schedule,5089.57,15292.17,
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,10512.53,,,,,,,fee schedule,5089.57,15292.17,
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,9520.67,,,,,,,fee schedule,5089.57,15292.17,
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7797.82,,,,,,,fee schedule,5089.57,15292.17,
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],8357.49,8357.49,8357.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,6530.88,,,,,,,fee schedule,5089.57,15292.17,MSDRG Base Rate
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,6468.69,,,,,,,fee schedule,5089.57,15292.17,MSDRG Base Rate
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,6468.69,,,,,,,fee schedule,5089.57,15292.17,MSDRG Base Rate
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,6530.88,,,,,,,fee schedule,5089.57,15292.17,MSDRG Base Rate
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,6468.69,,,,,,,fee schedule,5089.57,15292.17,MSDRG Base Rate
Dental And Oral Diseases Without Cc/Mcc,159,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10884.81,,,,,,,fee schedule,5089.57,15292.17,MSDRG Base Rate
Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC,160,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC,160,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC,160,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC,160,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC,160,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC,160,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC,160,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC,160,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC,160,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC,160,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC,160,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC,160,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC,160,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC,160,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC,160,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC,160,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC,160,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC,160,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal & Femoral Hernia Procedures Age >17 w CC,161,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal & Femoral Hernia Procedures Age >17 w CC,161,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal & Femoral Hernia Procedures Age >17 w CC,161,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal & Femoral Hernia Procedures Age >17 w CC,161,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal & Femoral Hernia Procedures Age >17 w CC,161,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal & Femoral Hernia Procedures Age >17 w CC,161,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal & Femoral Hernia Procedures Age >17 w CC,161,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Inguinal & Femoral Hernia Procedures Age >17 w CC,161,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Inguinal & Femoral Hernia Procedures Age >17 w CC,161,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal & Femoral Hernia Procedures Age >17 w CC,161,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal & Femoral Hernia Procedures Age >17 w CC,161,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal & Femoral Hernia Procedures Age >17 w CC,161,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal & Femoral Hernia Procedures Age >17 w CC,161,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal & Femoral Hernia Procedures Age >17 w CC,161,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal & Femoral Hernia Procedures Age >17 w CC,161,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal & Femoral Hernia Procedures Age >17 w CC,161,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Inguinal & Femoral Hernia Procedures Age >17 w CC,161,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal & Femoral Hernia Procedures Age >17 w CC,161,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal & Femoral Hernia Procedures Age >17 w/o CC,162,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal & Femoral Hernia Procedures Age >17 w/o CC,162,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal & Femoral Hernia Procedures Age >17 w/o CC,162,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal & Femoral Hernia Procedures Age >17 w/o CC,162,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal & Femoral Hernia Procedures Age >17 w/o CC,162,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal & Femoral Hernia Procedures Age >17 w/o CC,162,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal & Femoral Hernia Procedures Age >17 w/o CC,162,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Inguinal & Femoral Hernia Procedures Age >17 w/o CC,162,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Inguinal & Femoral Hernia Procedures Age >17 w/o CC,162,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal & Femoral Hernia Procedures Age >17 w/o CC,162,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal & Femoral Hernia Procedures Age >17 w/o CC,162,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal & Femoral Hernia Procedures Age >17 w/o CC,162,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal & Femoral Hernia Procedures Age >17 w/o CC,162,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal & Femoral Hernia Procedures Age >17 w/o CC,162,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal & Femoral Hernia Procedures Age >17 w/o CC,162,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal & Femoral Hernia Procedures Age >17 w/o CC,162,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Inguinal & Femoral Hernia Procedures Age >17 w/o CC,162,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal & Femoral Hernia Procedures Age >17 w/o CC,162,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Mcc,163,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,35562.96,,,,,,,fee schedule,35562.96,106852.74,
Major Chest Procedures With Mcc,163,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,35562.96,,,,,,,fee schedule,35562.96,106852.74,
Major Chest Procedures With Mcc,163,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,47609.66,,,,,,,fee schedule,35562.96,106852.74,
Major Chest Procedures With Mcc,163,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,45342.54,,,,,,,fee schedule,35562.96,106852.74,
Major Chest Procedures With Mcc,163,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,79415.96,,,,,,,fee schedule,35562.96,106852.74,
Major Chest Procedures With Mcc,163,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,61713.17,,,,,,,fee schedule,35562.96,106852.74,
Major Chest Procedures With Mcc,163,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,106852.74,,,,,,,fee schedule,35562.96,106852.74,
Major Chest Procedures With Mcc,163,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,73455.45,,,,,,,fee schedule,35562.96,106852.74,
Major Chest Procedures With Mcc,163,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,66524.86,,,,,,,fee schedule,35562.96,106852.74,
Major Chest Procedures With Mcc,163,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,54486.6,,,,,,,fee schedule,35562.96,106852.74,
Major Chest Procedures With Mcc,163,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Mcc,163,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Mcc,163,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],34117.9,34117.9,34117.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Chest Procedures With Mcc,163,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],69787.21,69787.21,69787.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Chest Procedures With Mcc,163,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],36161.66,36161.66,36161.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Chest Procedures With Mcc,163,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Mcc,163,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Mcc,163,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],71658.09,71658.09,110830.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Chest Procedures With Mcc,163,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],43440.91,43440.91,43440.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Chest Procedures With Mcc,163,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",68844.08,68844.08,68844.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Chest Procedures With Mcc,163,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],35377.6,35377.6,35377.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Chest Procedures With Mcc,163,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Mcc,163,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Mcc,163,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],79421.13,79421.13,79421.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Chest Procedures With Mcc,163,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],31964.38,62.36,34148.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Chest Procedures With Mcc,163,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Mcc,163,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Mcc,163,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],68102.64,68102.64,68102.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Chest Procedures With Mcc,163,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,36009.45,,,,,,,fee schedule,35562.96,106852.74,MSDRG Base Rate
Major Chest Procedures With Mcc,163,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,35666.5,,,,,,,fee schedule,35562.96,106852.74,MSDRG Base Rate
Major Chest Procedures With Mcc,163,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,35666.5,,,,,,,fee schedule,35562.96,106852.74,MSDRG Base Rate
Major Chest Procedures With Mcc,163,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,36009.45,,,,,,,fee schedule,35562.96,106852.74,MSDRG Base Rate
Major Chest Procedures With Mcc,163,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,35666.5,,,,,,,fee schedule,35562.96,106852.74,MSDRG Base Rate
Major Chest Procedures With Mcc,163,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,60015.74,,,,,,,fee schedule,35562.96,106852.74,MSDRG Base Rate
Major Chest Procedures With Cc,164,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,19420.01,,,,,,,fee schedule,19420.01,58349.49,
Major Chest Procedures With Cc,164,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,19420.01,,,,,,,fee schedule,19420.01,58349.49,
Major Chest Procedures With Cc,164,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,25998.39,,,,,,,fee schedule,19420.01,58349.49,
Major Chest Procedures With Cc,164,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24760.38,,,,,,,fee schedule,19420.01,58349.49,
Major Chest Procedures With Cc,164,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,43366.98,,,,,,,fee schedule,19420.01,58349.49,
Major Chest Procedures With Cc,164,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,33699.95,,,,,,,fee schedule,19420.01,58349.49,
Major Chest Procedures With Cc,164,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,58349.49,,,,,,,fee schedule,19420.01,58349.49,
Major Chest Procedures With Cc,164,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,40112.1,,,,,,,fee schedule,19420.01,58349.49,
Major Chest Procedures With Cc,164,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,36327.49,,,,,,,fee schedule,19420.01,58349.49,
Major Chest Procedures With Cc,164,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,29753.71,,,,,,,fee schedule,19420.01,58349.49,
Major Chest Procedures With Cc,164,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Cc,164,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Cc,164,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],38282.52,38282.52,38282.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Chest Procedures With Cc,164,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Cc,164,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Cc,164,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Cc,164,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Cc,164,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",18598.07,18598.07,18598.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Chest Procedures With Cc,164,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],19233.12,19233.12,19233.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Chest Procedures With Cc,164,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],88541.41,88541.41,88541.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Chest Procedures With Cc,164,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Cc,164,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Cc,164,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Cc,164,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],43370.43,43370.43,43370.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Chest Procedures With Cc,164,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Cc,164,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Cc,164,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Cc,164,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures With Cc,164,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,20714.31,,,,,,,fee schedule,19420.01,58349.49,MSDRG Base Rate
Major Chest Procedures With Cc,164,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,20517.03,,,,,,,fee schedule,19420.01,58349.49,MSDRG Base Rate
Major Chest Procedures With Cc,164,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,20517.03,,,,,,,fee schedule,19420.01,58349.49,MSDRG Base Rate
Major Chest Procedures With Cc,164,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,20714.31,,,,,,,fee schedule,19420.01,58349.49,MSDRG Base Rate
Major Chest Procedures With Cc,164,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,20517.03,,,,,,,fee schedule,19420.01,58349.49,MSDRG Base Rate
Major Chest Procedures With Cc,164,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,34523.84,,,,,,,fee schedule,19420.01,58349.49,MSDRG Base Rate
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14382.13,,,,,,,fee schedule,14382.13,43212.66,
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,14382.13,,,,,,,fee schedule,14382.13,43212.66,
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19253.98,,,,,,,fee schedule,14382.13,43212.66,
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18337.12,,,,,,,fee schedule,14382.13,43212.66,
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,32116.86,,,,,,,fee schedule,14382.13,43212.66,
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,24957.62,,,,,,,fee schedule,14382.13,43212.66,
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,43212.66,,,,,,,fee schedule,14382.13,43212.66,
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,29706.35,,,,,,,fee schedule,14382.13,43212.66,
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,26903.53,,,,,,,fee schedule,14382.13,43212.66,
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22035.1,,,,,,,fee schedule,14382.13,43212.66,
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],32118.58,32118.58,32118.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15950.3,,,,,,,fee schedule,14382.13,43212.66,MSDRG Base Rate
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,15798.39,,,,,,,fee schedule,14382.13,43212.66,MSDRG Base Rate
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,15798.39,,,,,,,fee schedule,14382.13,43212.66,MSDRG Base Rate
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,15950.3,,,,,,,fee schedule,14382.13,43212.66,MSDRG Base Rate
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,15798.39,,,,,,,fee schedule,14382.13,43212.66,MSDRG Base Rate
Major Chest Procedures Without Cc/Mcc,165,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,26583.83,,,,,,,fee schedule,14382.13,43212.66,MSDRG Base Rate
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,29714.89,,,,,,,fee schedule,29714.89,89281.58,
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,29714.89,,,,,,,fee schedule,29714.89,89281.58,
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39780.6,,,,,,,fee schedule,29714.89,89281.58,
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,37886.29,,,,,,,fee schedule,29714.89,89281.58,
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,66356.58,,,,,,,fee schedule,29714.89,89281.58,
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,51564.89,,,,,,,fee schedule,29714.89,89281.58,
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,89281.58,,,,,,,fee schedule,29714.89,89281.58,
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,61376.24,,,,,,,fee schedule,29714.89,89281.58,
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,55585.33,,,,,,,fee schedule,29714.89,89281.58,
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45526.68,,,,,,,fee schedule,29714.89,89281.58,
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],61069.86,47616,88688.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],60423.66,60423.66,60423.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],84357.53,84357.53,84357.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],28401.2,28401.2,28401.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],43170.11,43170.11,43170.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],43759,43759,43759,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],21524.65,21524.65,26831.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,30196.24,,,,,,,fee schedule,29714.89,89281.58,MSDRG Base Rate
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,29908.65,,,,,,,fee schedule,29714.89,89281.58,MSDRG Base Rate
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,29908.65,,,,,,,fee schedule,29714.89,89281.58,MSDRG Base Rate
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,30196.24,,,,,,,fee schedule,29714.89,89281.58,MSDRG Base Rate
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,29908.65,,,,,,,fee schedule,29714.89,89281.58,MSDRG Base Rate
Other Respiratory System O.R. Procedures With Mcc,166,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,50327.06,,,,,,,fee schedule,29714.89,89281.58,MSDRG Base Rate
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14098.18,,,,,,,fee schedule,14098.18,42359.49,
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,14098.18,,,,,,,fee schedule,14098.18,42359.49,
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18873.83,,,,,,,fee schedule,14098.18,42359.49,
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17975.08,,,,,,,fee schedule,14098.18,42359.49,
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,31482.76,,,,,,,fee schedule,14098.18,42359.49,
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,24464.87,,,,,,,fee schedule,14098.18,42359.49,
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,42359.49,,,,,,,fee schedule,14098.18,42359.49,
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,29119.84,,,,,,,fee schedule,14098.18,42359.49,
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,26372.36,,,,,,,fee schedule,14098.18,42359.49,
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21600.05,,,,,,,fee schedule,14098.18,42359.49,
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],17903.27,17903.27,17903.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12199.21,12199.21,12199.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],13678.72,13678.72,13678.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15084.69,,,,,,,fee schedule,14098.18,42359.49,MSDRG Base Rate
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,14941.02,,,,,,,fee schedule,14098.18,42359.49,MSDRG Base Rate
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,14941.02,,,,,,,fee schedule,14098.18,42359.49,MSDRG Base Rate
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,15084.69,,,,,,,fee schedule,14098.18,42359.49,MSDRG Base Rate
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,14941.02,,,,,,,fee schedule,14098.18,42359.49,MSDRG Base Rate
Other Respiratory System O.R. Procedures With Cc,167,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,25141.15,,,,,,,fee schedule,14098.18,42359.49,MSDRG Base Rate
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10446.12,,,,,,,fee schedule,10446.12,31386.5,
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,10446.12,,,,,,,fee schedule,10446.12,31386.5,
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13984.67,,,,,,,fee schedule,10446.12,31386.5,
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13318.74,,,,,,,fee schedule,10446.12,31386.5,
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,23327.33,,,,,,,fee schedule,10446.12,31386.5,
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,18127.38,,,,,,,fee schedule,10446.12,31386.5,
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,31386.5,,,,,,,fee schedule,10446.12,31386.5,
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,21576.51,,,,,,,fee schedule,10446.12,31386.5,
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,19540.75,,,,,,,fee schedule,10446.12,31386.5,
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16004.68,,,,,,,fee schedule,10446.12,31386.5,
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11670.67,,,,,,,fee schedule,10446.12,31386.5,MSDRG Base Rate
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,11559.52,,,,,,,fee schedule,10446.12,31386.5,MSDRG Base Rate
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,11559.52,,,,,,,fee schedule,10446.12,31386.5,MSDRG Base Rate
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,11670.67,,,,,,,fee schedule,10446.12,31386.5,MSDRG Base Rate
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,11559.52,,,,,,,fee schedule,10446.12,31386.5,MSDRG Base Rate
Other Respiratory System O.R. Procedures Without Cc/Mcc,168,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19451.11,,,,,,,fee schedule,10446.12,31386.5,MSDRG Base Rate
Mouth Procedures w/o CC,169,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures w/o CC,169,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures w/o CC,169,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures w/o CC,169,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures w/o CC,169,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures w/o CC,169,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures w/o CC,169,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures w/o CC,169,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures w/o CC,169,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures w/o CC,169,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures w/o CC,169,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures w/o CC,169,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures w/o CC,169,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures w/o CC,169,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures w/o CC,169,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures w/o CC,169,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures w/o CC,169,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mouth Procedures w/o CC,169,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures w/o CC,171,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures w/o CC,171,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures w/o CC,171,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures w/o CC,171,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures w/o CC,171,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures w/o CC,171,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures w/o CC,171,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures w/o CC,171,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures w/o CC,171,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures w/o CC,171,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures w/o CC,171,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures w/o CC,171,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures w/o CC,171,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures w/o CC,171,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures w/o CC,171,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures w/o CC,171,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures w/o CC,171,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures w/o CC,171,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,23676.23,,,,,,,fee schedule,23676.23,71137.79,
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,23676.23,,,,,,,fee schedule,23676.23,71137.79,
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31696.39,,,,,,,fee schedule,23676.23,71137.79,
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,30187.04,,,,,,,fee schedule,23676.23,71137.79,
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,52871.6,,,,,,,fee schedule,23676.23,71137.79,
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,41085.88,,,,,,,fee schedule,23676.23,71137.79,
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,71137.79,,,,,,,fee schedule,23676.23,71137.79,
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,48903.36,,,,,,,fee schedule,23676.23,71137.79,
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,44289.29,,,,,,,fee schedule,23676.23,71137.79,
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,36274.75,,,,,,,fee schedule,23676.23,71137.79,
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,24248.65,,,,,,,fee schedule,23676.23,71137.79,MSDRG Base Rate
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,24017.71,,,,,,,fee schedule,23676.23,71137.79,MSDRG Base Rate
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,24017.71,,,,,,,fee schedule,23676.23,71137.79,MSDRG Base Rate
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,24248.65,,,,,,,fee schedule,23676.23,71137.79,MSDRG Base Rate
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,24017.71,,,,,,,fee schedule,23676.23,71137.79,MSDRG Base Rate
Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism,173,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,40414.41,,,,,,,fee schedule,23676.23,71137.79,MSDRG Base Rate
G.I. hemorrhage w CC,174,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
G.I. hemorrhage w CC,174,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
G.I. hemorrhage w CC,174,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
G.I. hemorrhage w CC,174,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
G.I. hemorrhage w CC,174,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
G.I. hemorrhage w CC,174,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
G.I. hemorrhage w CC,174,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
G.I. hemorrhage w CC,174,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
G.I. hemorrhage w CC,174,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
G.I. hemorrhage w CC,174,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
G.I. hemorrhage w CC,174,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
G.I. hemorrhage w CC,174,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
G.I. hemorrhage w CC,174,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
G.I. hemorrhage w CC,174,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
G.I. hemorrhage w CC,174,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
G.I. hemorrhage w CC,174,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
G.I. hemorrhage w CC,174,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
G.I. hemorrhage w CC,174,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10872.83,,,,,,,fee schedule,10872.83,32668.57,
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,10872.83,,,,,,,fee schedule,10872.83,32668.57,
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14555.92,,,,,,,fee schedule,10872.83,32668.57,
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13862.78,,,,,,,fee schedule,10872.83,32668.57,
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,24280.2,,,,,,,fee schedule,10872.83,32668.57,
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,18867.85,,,,,,,fee schedule,10872.83,32668.57,
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,32668.57,,,,,,,fee schedule,10872.83,32668.57,
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,22457.87,,,,,,,fee schedule,10872.83,32668.57,
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,20338.95,,,,,,,fee schedule,10872.83,32668.57,
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16658.44,,,,,,,fee schedule,10872.83,32668.57,
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],6659.74,6659.74,6659.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],29216,29216,29216,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],10500.04,9841.61,11109.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],20905,18627,22457.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11349.39,10790.72,12140.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],20338.95,18922.81,22205.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",64886.25,64886.25,64886.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",16353.62,16353.62,16353.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],13732.78,13732.78,13862.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],10471.33,10374.13,10707.94,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],16658.44,16658.44,16658.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],14034.65,13534.65,24280.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],10496.96,5687.09,10913.81,31,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",16202.2,16202.2,16202.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],33057.6,33057.6,33057.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11726.91,,,,,,,fee schedule,10872.83,32668.57,MSDRG Base Rate
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,11615.23,,,,,,,fee schedule,10872.83,32668.57,MSDRG Base Rate
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,11615.23,,,,,,,fee schedule,10872.83,32668.57,MSDRG Base Rate
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,11726.91,,,,,,,fee schedule,10872.83,32668.57,MSDRG Base Rate
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,11615.23,,,,,,,fee schedule,10872.83,32668.57,MSDRG Base Rate
Pulmonary Embolism With Mcc Or Acute Cor Pulmonale,175,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19544.86,,,,,,,fee schedule,10872.83,32668.57,MSDRG Base Rate
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6284.8,,,,,,,fee schedule,6284.8,18883.37,
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,6284.8,,,,,,,fee schedule,6284.8,18883.37,
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8413.74,,,,,,,fee schedule,6284.8,18883.37,
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8013.08,,,,,,,fee schedule,6284.8,18883.37,
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,14034.65,,,,,,,fee schedule,6284.8,18883.37,
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,10906.16,,,,,,,fee schedule,6284.8,18883.37,
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,18883.37,,,,,,,fee schedule,6284.8,18883.37,
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,12981.29,,,,,,,fee schedule,6284.8,18883.37,
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,11756.49,,,,,,,fee schedule,6284.8,18883.37,
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9629.05,,,,,,,fee schedule,6284.8,18883.37,
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],12981.29,12981.29,12981.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6336.62,6336.62,6607.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],31083.62,31083.62,31083.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],8021.91,8021.91,8021.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",11838.5,11838.5,11838.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6190.38,6190.38,6190.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],7466.17,7466.17,7466.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],13459.55,13459.55,13459.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],6589.44,6312.82,6706.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7284.77,,,,,,,fee schedule,6284.8,18883.37,MSDRG Base Rate
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,7215.4,,,,,,,fee schedule,6284.8,18883.37,MSDRG Base Rate
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,7215.4,,,,,,,fee schedule,6284.8,18883.37,MSDRG Base Rate
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,7284.77,,,,,,,fee schedule,6284.8,18883.37,MSDRG Base Rate
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,7215.4,,,,,,,fee schedule,6284.8,18883.37,MSDRG Base Rate
Pulmonary Embolism Without Mcc,176,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12141.29,,,,,,,fee schedule,6284.8,18883.37,MSDRG Base Rate
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12473.16,,,,,,,fee schedule,12473.16,37476.94,
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,12473.16,,,,,,,fee schedule,12473.16,37476.94,
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16698.35,,,,,,,fee schedule,12473.16,37476.94,
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15903.19,,,,,,,fee schedule,12473.16,37476.94,
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,27853.91,,,,,,,fee schedule,12473.16,37476.94,
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,21644.94,,,,,,,fee schedule,12473.16,37476.94,
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,37476.94,,,,,,,fee schedule,12473.16,37476.94,
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,25763.36,,,,,,,fee schedule,12473.16,37476.94,
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,23332.56,,,,,,,fee schedule,12473.16,37476.94,
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19110.33,,,,,,,fee schedule,12473.16,37476.94,
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],11605.18,8243.54,12450.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],2493.56,2493.56,2493.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],23673.99,18637,25763.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11970.45,10914.78,12512.81,25,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],21.87,21.87,21.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],23332.56,23332.56,23332.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",14104.01,14104.01,14104.01,23,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],11933.71,11933.7,12268.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11964.55,11510.58,12279.09,54,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],20961.06,20961.06,20961.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],27121.64,15506.57,27553.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],11708.65,6280.75,12425.17,74,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",13973.42,13973.42,13973.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],19125.55,19125.55,19125.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13204.24,,,,,,,fee schedule,12473.16,37476.94,MSDRG Base Rate
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,13078.49,,,,,,,fee schedule,12473.16,37476.94,MSDRG Base Rate
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,13078.49,,,,,,,fee schedule,12473.16,37476.94,MSDRG Base Rate
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,13204.24,,,,,,,fee schedule,12473.16,37476.94,MSDRG Base Rate
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,13078.49,,,,,,,fee schedule,12473.16,37476.94,MSDRG Base Rate
Respiratory Infections And Inflammations With Mcc,177,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22007.07,,,,,,,fee schedule,12473.16,37476.94,MSDRG Base Rate
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7655.19,,,,,,,fee schedule,7655.19,23000.85,
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,7655.19,,,,,,,fee schedule,7655.19,23000.85,
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10248.33,,,,,,,fee schedule,7655.19,23000.85,
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9760.32,,,,,,,fee schedule,7655.19,23000.85,
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,17094.88,,,,,,,fee schedule,7655.19,23000.85,
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,13284.22,,,,,,,fee schedule,7655.19,23000.85,
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,23000.85,,,,,,,fee schedule,7655.19,23000.85,
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,15811.83,,,,,,,fee schedule,7655.19,23000.85,
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,14319.97,,,,,,,fee schedule,7655.19,23000.85,
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11728.65,,,,,,,fee schedule,7655.19,23000.85,
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",9325.37,9325.37,9325.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7336.73,7336.72,10294.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],7309.1,7309.1,7309.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],13262.7,13262.7,13262.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8620.7,,,,,,,fee schedule,7655.19,23000.85,MSDRG Base Rate
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,8538.6,,,,,,,fee schedule,7655.19,23000.85,MSDRG Base Rate
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,8538.6,,,,,,,fee schedule,7655.19,23000.85,MSDRG Base Rate
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,8620.7,,,,,,,fee schedule,7655.19,23000.85,MSDRG Base Rate
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,8538.6,,,,,,,fee schedule,7655.19,23000.85,MSDRG Base Rate
Respiratory Infections And Inflammations With Cc,178,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14367.83,,,,,,,fee schedule,7655.19,23000.85,MSDRG Base Rate
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5939.12,,,,,,,fee schedule,5939.12,17844.72,
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,5939.12,,,,,,,fee schedule,5939.12,17844.72,
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7950.95,,,,,,,fee schedule,5939.12,17844.72,
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7572.34,,,,,,,fee schedule,5939.12,17844.72,
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,13262.7,,,,,,,fee schedule,5939.12,17844.72,
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,10306.28,,,,,,,fee schedule,5939.12,17844.72,
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,17844.72,,,,,,,fee schedule,5939.12,17844.72,
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,12267.28,,,,,,,fee schedule,5939.12,17844.72,
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,11109.85,,,,,,,fee schedule,5939.12,17844.72,
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9099.42,,,,,,,fee schedule,5939.12,17844.72,
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],5937.11,5937.11,5937.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],7974,7974,7974,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],5761.84,5761.84,5761.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],9099.42,9099.42,9099.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,6894.15,,,,,,,fee schedule,5939.12,17844.72,MSDRG Base Rate
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,6828.49,,,,,,,fee schedule,5939.12,17844.72,MSDRG Base Rate
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,6828.49,,,,,,,fee schedule,5939.12,17844.72,MSDRG Base Rate
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,6894.15,,,,,,,fee schedule,5939.12,17844.72,MSDRG Base Rate
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,6828.49,,,,,,,fee schedule,5939.12,17844.72,MSDRG Base Rate
Respiratory Infections And Inflammations Without Cc/Mcc,179,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11490.26,,,,,,,fee schedule,5939.12,17844.72,MSDRG Base Rate
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13485.52,,,,,,,fee schedule,13485.52,40518.68,
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,13485.52,,,,,,,fee schedule,13485.52,40518.68,
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18053.64,,,,,,,fee schedule,13485.52,40518.68,
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17193.94,,,,,,,fee schedule,13485.52,40518.68,
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,30114.62,,,,,,,fee schedule,13485.52,40518.68,
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,23401.7,,,,,,,fee schedule,13485.52,40518.68,
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,40518.68,,,,,,,fee schedule,13485.52,40518.68,
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,27854.39,,,,,,,fee schedule,13485.52,40518.68,
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,25226.3,,,,,,,fee schedule,13485.52,40518.68,
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20661.38,,,,,,,fee schedule,13485.52,40518.68,
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12026.51,12026.51,12847.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],13845,13845,13845,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13191.17,13191.17,13191.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],13252.22,13252.22,13252.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",12963.09,12963.09,12963.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12867.74,12174.01,13415.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],20662.56,20662.56,20662.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],28059.35,28059.35,28059.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],11612.9,9775.08,13368.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],31342.05,31342.05,31342.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14792.5,,,,,,,fee schedule,13485.52,40518.68,MSDRG Base Rate
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,14651.62,,,,,,,fee schedule,13485.52,40518.68,MSDRG Base Rate
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,14651.62,,,,,,,fee schedule,13485.52,40518.68,MSDRG Base Rate
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,14792.5,,,,,,,fee schedule,13485.52,40518.68,MSDRG Base Rate
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,14651.62,,,,,,,fee schedule,13485.52,40518.68,MSDRG Base Rate
Respiratory Neoplasms With Mcc,180,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,24654.18,,,,,,,fee schedule,13485.52,40518.68,MSDRG Base Rate
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8566.47,,,,,,,fee schedule,8566.47,25738.88,
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,8566.47,,,,,,,fee schedule,8566.47,25738.88,
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11468.3,,,,,,,fee schedule,8566.47,25738.88,
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10922.19,,,,,,,fee schedule,8566.47,25738.88,
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,19129.86,,,,,,,fee schedule,8566.47,25738.88,
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,14865.58,,,,,,,fee schedule,8566.47,25738.88,
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,25738.88,,,,,,,fee schedule,8566.47,25738.88,
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,17694.08,,,,,,,fee schedule,8566.47,25738.88,
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,16024.63,,,,,,,fee schedule,8566.47,25738.88,
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13124.83,,,,,,,fee schedule,8566.47,25738.88,
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7820.8,7820.8,7820.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8532.2,8532.2,8532.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],13126.01,13126.01,13126.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",9254.36,9254.36,9254.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9362.88,,,,,,,fee schedule,8566.47,25738.88,MSDRG Base Rate
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,9273.71,,,,,,,fee schedule,8566.47,25738.88,MSDRG Base Rate
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,9273.71,,,,,,,fee schedule,8566.47,25738.88,MSDRG Base Rate
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,9362.88,,,,,,,fee schedule,8566.47,25738.88,MSDRG Base Rate
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,9273.71,,,,,,,fee schedule,8566.47,25738.88,MSDRG Base Rate
Respiratory Neoplasms With Cc,181,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15604.8,,,,,,,fee schedule,8566.47,25738.88,MSDRG Base Rate
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6462.28,,,,,,,fee schedule,6462.28,19416.6,
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,6462.28,,,,,,,fee schedule,6462.28,19416.6,
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8651.32,,,,,,,fee schedule,6462.28,19416.6,
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8239.36,,,,,,,fee schedule,6462.28,19416.6,
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,14430.96,,,,,,,fee schedule,6462.28,19416.6,
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,11214.13,,,,,,,fee schedule,6462.28,19416.6,
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,19416.6,,,,,,,fee schedule,6462.28,19416.6,
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,13347.86,,,,,,,fee schedule,6462.28,19416.6,
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,12088.48,,,,,,,fee schedule,6462.28,19416.6,
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9900.96,,,,,,,fee schedule,6462.28,19416.6,
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,6884.79,,,,,,,fee schedule,6462.28,19416.6,MSDRG Base Rate
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,6819.22,,,,,,,fee schedule,6462.28,19416.6,MSDRG Base Rate
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,6819.22,,,,,,,fee schedule,6462.28,19416.6,MSDRG Base Rate
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,6884.79,,,,,,,fee schedule,6462.28,19416.6,MSDRG Base Rate
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,6819.22,,,,,,,fee schedule,6462.28,19416.6,MSDRG Base Rate
Respiratory Neoplasms Without Cc/Mcc,182,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11474.64,,,,,,,fee schedule,6462.28,19416.6,MSDRG Base Rate
Major Chest Trauma With Mcc,183,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12247.07,,,,,,,fee schedule,12247.07,36797.64,
Major Chest Trauma With Mcc,183,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,12247.07,,,,,,,fee schedule,12247.07,36797.64,
Major Chest Trauma With Mcc,183,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16395.68,,,,,,,fee schedule,12247.07,36797.64,
Major Chest Trauma With Mcc,183,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15614.94,,,,,,,fee schedule,12247.07,36797.64,
Major Chest Trauma With Mcc,183,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,27349.04,,,,,,,fee schedule,12247.07,36797.64,
Major Chest Trauma With Mcc,183,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,21252.61,,,,,,,fee schedule,12247.07,36797.64,
Major Chest Trauma With Mcc,183,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,36797.64,,,,,,,fee schedule,12247.07,36797.64,
Major Chest Trauma With Mcc,183,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,25296.38,,,,,,,fee schedule,12247.07,36797.64,
Major Chest Trauma With Mcc,183,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,22909.64,,,,,,,fee schedule,12247.07,36797.64,
Major Chest Trauma With Mcc,183,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18763.94,,,,,,,fee schedule,12247.07,36797.64,
Major Chest Trauma With Mcc,183,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Mcc,183,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Mcc,183,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11469.13,11469.13,11469.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Chest Trauma With Mcc,183,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Mcc,183,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12385.87,12385.87,12385.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Chest Trauma With Mcc,183,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Mcc,183,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Mcc,183,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],15615.92,15615.92,15615.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Chest Trauma With Mcc,183,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",8895.48,8895.48,8895.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Chest Trauma With Mcc,183,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11696.58,11696.58,11696.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Chest Trauma With Mcc,183,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Mcc,183,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Mcc,183,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Mcc,183,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],12231.68,12145.55,31359.19,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Chest Trauma With Mcc,183,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Mcc,183,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Mcc,183,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Mcc,183,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Mcc,183,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12947.99,,,,,,,fee schedule,12247.07,36797.64,MSDRG Base Rate
Major Chest Trauma With Mcc,183,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,12824.68,,,,,,,fee schedule,12247.07,36797.64,MSDRG Base Rate
Major Chest Trauma With Mcc,183,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,12824.68,,,,,,,fee schedule,12247.07,36797.64,MSDRG Base Rate
Major Chest Trauma With Mcc,183,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,12947.99,,,,,,,fee schedule,12247.07,36797.64,MSDRG Base Rate
Major Chest Trauma With Mcc,183,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,12824.68,,,,,,,fee schedule,12247.07,36797.64,MSDRG Base Rate
Major Chest Trauma With Mcc,183,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21579.98,,,,,,,fee schedule,12247.07,36797.64,MSDRG Base Rate
Major Chest Trauma With Cc,184,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8240.85,,,,,,,fee schedule,8240.85,24760.51,
Major Chest Trauma With Cc,184,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,8240.85,,,,,,,fee schedule,8240.85,24760.51,
Major Chest Trauma With Cc,184,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11032.38,,,,,,,fee schedule,8240.85,24760.51,
Major Chest Trauma With Cc,184,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10507.03,,,,,,,fee schedule,8240.85,24760.51,
Major Chest Trauma With Cc,184,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,18402.71,,,,,,,fee schedule,8240.85,24760.51,
Major Chest Trauma With Cc,184,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,14300.52,,,,,,,fee schedule,8240.85,24760.51,
Major Chest Trauma With Cc,184,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,24760.51,,,,,,,fee schedule,8240.85,24760.51,
Major Chest Trauma With Cc,184,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,17021.51,,,,,,,fee schedule,8240.85,24760.51,
Major Chest Trauma With Cc,184,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,15415.51,,,,,,,fee schedule,8240.85,24760.51,
Major Chest Trauma With Cc,184,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12625.94,,,,,,,fee schedule,8240.85,24760.51,
Major Chest Trauma With Cc,184,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Cc,184,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Cc,184,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7859.34,7859.34,7859.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Chest Trauma With Cc,184,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Cc,184,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Cc,184,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Cc,184,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Cc,184,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Cc,184,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Cc,184,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Cc,184,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Cc,184,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Cc,184,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Cc,184,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],8232.94,6658.49,8431.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Chest Trauma With Cc,184,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Cc,184,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Cc,184,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Cc,184,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma With Cc,184,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9308.97,,,,,,,fee schedule,8240.85,24760.51,MSDRG Base Rate
Major Chest Trauma With Cc,184,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,9220.32,,,,,,,fee schedule,8240.85,24760.51,MSDRG Base Rate
Major Chest Trauma With Cc,184,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,9220.32,,,,,,,fee schedule,8240.85,24760.51,MSDRG Base Rate
Major Chest Trauma With Cc,184,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,9308.97,,,,,,,fee schedule,8240.85,24760.51,MSDRG Base Rate
Major Chest Trauma With Cc,184,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,9220.32,,,,,,,fee schedule,8240.85,24760.51,MSDRG Base Rate
Major Chest Trauma With Cc,184,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15514.96,,,,,,,fee schedule,8240.85,24760.51,MSDRG Base Rate
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6000.08,,,,,,,fee schedule,6000.08,18027.88,
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,6000.08,,,,,,,fee schedule,6000.08,18027.88,
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8032.56,,,,,,,fee schedule,6000.08,18027.88,
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7650.06,,,,,,,fee schedule,6000.08,18027.88,
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,13398.83,,,,,,,fee schedule,6000.08,18027.88,
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,10412.06,,,,,,,fee schedule,6000.08,18027.88,
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,18027.88,,,,,,,fee schedule,6000.08,18027.88,
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,12393.19,,,,,,,fee schedule,6000.08,18027.88,
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,11223.88,,,,,,,fee schedule,6000.08,18027.88,
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9192.82,,,,,,,fee schedule,6000.08,18027.88,
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7140.25,,,,,,,fee schedule,6000.08,18027.88,MSDRG Base Rate
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,7072.25,,,,,,,fee schedule,6000.08,18027.88,MSDRG Base Rate
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,7072.25,,,,,,,fee schedule,6000.08,18027.88,MSDRG Base Rate
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,7140.25,,,,,,,fee schedule,6000.08,18027.88,MSDRG Base Rate
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,7072.25,,,,,,,fee schedule,6000.08,18027.88,MSDRG Base Rate
Major Chest Trauma Without Cc/Mcc,185,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11900.42,,,,,,,fee schedule,6000.08,18027.88,MSDRG Base Rate
Pleural Effusion With Mcc,186,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12191.52,,,,,,,fee schedule,12191.52,36630.72,
Pleural Effusion With Mcc,186,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,12191.52,,,,,,,fee schedule,12191.52,36630.72,
Pleural Effusion With Mcc,186,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16321.31,,,,,,,fee schedule,12191.52,36630.72,
Pleural Effusion With Mcc,186,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15544.1,,,,,,,fee schedule,12191.52,36630.72,
Pleural Effusion With Mcc,186,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,27224.98,,,,,,,fee schedule,12191.52,36630.72,
Pleural Effusion With Mcc,186,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,21156.2,,,,,,,fee schedule,12191.52,36630.72,
Pleural Effusion With Mcc,186,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,36630.72,,,,,,,fee schedule,12191.52,36630.72,
Pleural Effusion With Mcc,186,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,25181.63,,,,,,,fee schedule,12191.52,36630.72,
Pleural Effusion With Mcc,186,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,22805.72,,,,,,,fee schedule,12191.52,36630.72,
Pleural Effusion With Mcc,186,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18678.82,,,,,,,fee schedule,12191.52,36630.72,
Pleural Effusion With Mcc,186,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Mcc,186,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Mcc,186,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11041.97,11041.97,11041.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pleural Effusion With Mcc,186,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],23922.52,23922.52,24736.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pleural Effusion With Mcc,186,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Mcc,186,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Mcc,186,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Mcc,186,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",9301.73,9301.73,9301.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pleural Effusion With Mcc,186,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11969.06,11969.06,11984.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pleural Effusion With Mcc,186,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Mcc,186,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Mcc,186,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Mcc,186,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Mcc,186,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],24926,24926,24926,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pleural Effusion With Mcc,186,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],11830.17,11830.17,12082.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pleural Effusion With Mcc,186,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Mcc,186,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Mcc,186,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],12355.2,12355.2,12355.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pleural Effusion With Mcc,186,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13171.43,,,,,,,fee schedule,12191.52,36630.72,MSDRG Base Rate
Pleural Effusion With Mcc,186,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,13045.99,,,,,,,fee schedule,12191.52,36630.72,MSDRG Base Rate
Pleural Effusion With Mcc,186,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,13045.99,,,,,,,fee schedule,12191.52,36630.72,MSDRG Base Rate
Pleural Effusion With Mcc,186,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,13171.43,,,,,,,fee schedule,12191.52,36630.72,MSDRG Base Rate
Pleural Effusion With Mcc,186,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,13045.99,,,,,,,fee schedule,12191.52,36630.72,MSDRG Base Rate
Pleural Effusion With Mcc,186,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21952.38,,,,,,,fee schedule,12191.52,36630.72,MSDRG Base Rate
Pleural Effusion With Cc,187,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7746.24,,,,,,,fee schedule,7746.24,23274.42,
Pleural Effusion With Cc,187,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,7746.24,,,,,,,fee schedule,7746.24,23274.42,
Pleural Effusion With Cc,187,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10370.23,,,,,,,fee schedule,7746.24,23274.42,
Pleural Effusion With Cc,187,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9876.41,,,,,,,fee schedule,7746.24,23274.42,
Pleural Effusion With Cc,187,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,17298.2,,,,,,,fee schedule,7746.24,23274.42,
Pleural Effusion With Cc,187,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,13442.22,,,,,,,fee schedule,7746.24,23274.42,
Pleural Effusion With Cc,187,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,23274.42,,,,,,,fee schedule,7746.24,23274.42,
Pleural Effusion With Cc,187,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,15999.9,,,,,,,fee schedule,7746.24,23274.42,
Pleural Effusion With Cc,187,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,14490.29,,,,,,,fee schedule,7746.24,23274.42,
Pleural Effusion With Cc,187,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11868.15,,,,,,,fee schedule,7746.24,23274.42,
Pleural Effusion With Cc,187,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Cc,187,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Cc,187,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Cc,187,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Cc,187,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Cc,187,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Cc,187,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Cc,187,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7089.18,7089.18,7089.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pleural Effusion With Cc,187,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Cc,187,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Cc,187,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Cc,187,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Cc,187,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Cc,187,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],14311.57,14311.57,14311.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pleural Effusion With Cc,187,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],6589.99,6589.99,6589.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pleural Effusion With Cc,187,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Cc,187,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Cc,187,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion With Cc,187,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8723.04,,,,,,,fee schedule,7746.24,23274.42,MSDRG Base Rate
Pleural Effusion With Cc,187,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,8639.97,,,,,,,fee schedule,7746.24,23274.42,MSDRG Base Rate
Pleural Effusion With Cc,187,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,8639.97,,,,,,,fee schedule,7746.24,23274.42,MSDRG Base Rate
Pleural Effusion With Cc,187,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,8723.04,,,,,,,fee schedule,7746.24,23274.42,MSDRG Base Rate
Pleural Effusion With Cc,187,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,8639.97,,,,,,,fee schedule,7746.24,23274.42,MSDRG Base Rate
Pleural Effusion With Cc,187,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14538.4,,,,,,,fee schedule,7746.24,23274.42,MSDRG Base Rate
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5664.43,,,,,,,fee schedule,5664.43,17019.37,
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,5664.43,,,,,,,fee schedule,5664.43,17019.37,
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7583.21,,,,,,,fee schedule,5664.43,17019.37,
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7222.11,,,,,,,fee schedule,5664.43,17019.37,
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,12649.28,,,,,,,fee schedule,5664.43,17019.37,
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,9829.6,,,,,,,fee schedule,5664.43,17019.37,
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,17019.37,,,,,,,fee schedule,5664.43,17019.37,
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,11699.89,,,,,,,fee schedule,5664.43,17019.37,
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,10596,,,,,,,fee schedule,5664.43,17019.37,
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8678.56,,,,,,,fee schedule,5664.43,17019.37,
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],5452,5452,5452,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,6598.85,,,,,,,fee schedule,5664.43,17019.37,MSDRG Base Rate
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,6536,,,,,,,fee schedule,5664.43,17019.37,MSDRG Base Rate
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,6536,,,,,,,fee schedule,5664.43,17019.37,MSDRG Base Rate
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,6598.85,,,,,,,fee schedule,5664.43,17019.37,MSDRG Base Rate
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,6536,,,,,,,fee schedule,5664.43,17019.37,MSDRG Base Rate
Pleural Effusion Without Cc/Mcc,188,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10998.08,,,,,,,fee schedule,5664.43,17019.37,MSDRG Base Rate
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9548.74,,,,,,,fee schedule,9548.74,28690.2,
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,9548.74,,,,,,,fee schedule,9548.74,28690.2,
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12783.3,,,,,,,fee schedule,9548.74,28690.2,
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12174.57,,,,,,,fee schedule,9548.74,28690.2,
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,21323.36,,,,,,,fee schedule,9548.74,28690.2,
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,16570.13,,,,,,,fee schedule,9548.74,28690.2,
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,28690.2,,,,,,,fee schedule,9548.74,28690.2,
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,19722.95,,,,,,,fee schedule,9548.74,28690.2,
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,17862.08,,,,,,,fee schedule,9548.74,28690.2,
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14629.77,,,,,,,fee schedule,9548.74,28690.2,
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],19337.48,10895.33,27056.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],9751.33,9751.33,9751.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8774.59,7467.88,9658.63,26,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],14624.62,8909.82,19318.65,28,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9484.53,713.54,10795.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],13691.21,8041.11,19856.07,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",9591.52,9591.52,9591.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],12120.47,11995.47,12175.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",9007.68,9007.68,9007.68,138,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],7903.74,7903.74,8082.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9198.5,7731.26,9514.64,50,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],14517.41,13932,14628.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],11151.9,1156.39,21321.64,32,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],8556.13,769.44,9668.44,71,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",8924.28,8924.28,11195.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],5450.04,5450.04,5450.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],13465.21,10037.92,38587.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10647.24,,,,,,,fee schedule,9548.74,28690.2,MSDRG Base Rate
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,10545.84,,,,,,,fee schedule,9548.74,28690.2,MSDRG Base Rate
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,10545.84,,,,,,,fee schedule,9548.74,28690.2,MSDRG Base Rate
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,10647.24,,,,,,,fee schedule,9548.74,28690.2,MSDRG Base Rate
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,10545.84,,,,,,,fee schedule,9548.74,28690.2,MSDRG Base Rate
Pulmonary Edema And Respiratory Failure,189,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,17745.4,,,,,,,fee schedule,9548.74,28690.2,MSDRG Base Rate
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8667.55,,,,,,,fee schedule,8667.55,26042.59,
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,8667.55,,,,,,,fee schedule,8667.55,26042.59,
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11603.62,,,,,,,fee schedule,8667.55,26042.59,
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11051.07,,,,,,,fee schedule,8667.55,26042.59,
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,19355.58,,,,,,,fee schedule,8667.55,26042.59,
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,15040.99,,,,,,,fee schedule,8667.55,26042.59,
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,26042.59,,,,,,,fee schedule,8667.55,26042.59,
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,17902.86,,,,,,,fee schedule,8667.55,26042.59,
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,16213.71,,,,,,,fee schedule,8667.55,26042.59,
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13279.7,,,,,,,fee schedule,8667.55,26042.59,
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9071.91,9071.91,9071.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",8622.46,8622.46,8622.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",8097.61,8097.61,8097.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],11048.12,11048.12,11048.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],8513.13,8513.13,8513.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8275.3,7512.98,8506.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],8767.8,8767.8,8767.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],12611,12611,12611,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],7365.83,155.19,8818.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",8022.64,8022.64,8022.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9649.59,,,,,,,fee schedule,8667.55,26042.59,MSDRG Base Rate
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,9557.69,,,,,,,fee schedule,8667.55,26042.59,MSDRG Base Rate
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,9557.69,,,,,,,fee schedule,8667.55,26042.59,MSDRG Base Rate
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,9649.59,,,,,,,fee schedule,8667.55,26042.59,MSDRG Base Rate
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,9557.69,,,,,,,fee schedule,8667.55,26042.59,MSDRG Base Rate
Chronic Obstructive Pulmonary Disease With Mcc,190,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16082.66,,,,,,,fee schedule,8667.55,26042.59,MSDRG Base Rate
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6628.94,,,,,,,fee schedule,6628.94,19917.37,
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,6628.94,,,,,,,fee schedule,6628.94,19917.37,
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8874.45,,,,,,,fee schedule,6628.94,19917.37,
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8451.86,,,,,,,fee schedule,6628.94,19917.37,
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,14803.15,,,,,,,fee schedule,6628.94,19917.37,
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,11503.35,,,,,,,fee schedule,6628.94,19917.37,
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,19917.37,,,,,,,fee schedule,6628.94,19917.37,
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,13692.11,,,,,,,fee schedule,6628.94,19917.37,
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,12400.25,,,,,,,fee schedule,6628.94,19917.37,
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10156.31,,,,,,,fee schedule,6628.94,19917.37,
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6923.45,6923.45,6923.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],6507.98,6507.98,6507.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],5674.42,5674.42,5674.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],6899.43,6899.43,6899.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7581.65,,,,,,,fee schedule,6628.94,19917.37,MSDRG Base Rate
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,7509.44,,,,,,,fee schedule,6628.94,19917.37,MSDRG Base Rate
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,7509.44,,,,,,,fee schedule,6628.94,19917.37,MSDRG Base Rate
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,7581.65,,,,,,,fee schedule,6628.94,19917.37,MSDRG Base Rate
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,7509.44,,,,,,,fee schedule,6628.94,19917.37,MSDRG Base Rate
Chronic Obstructive Pulmonary Disease With Cc,191,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12636.08,,,,,,,fee schedule,6628.94,19917.37,MSDRG Base Rate
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4993.89,,,,,,,fee schedule,4993.89,15004.68,
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,4993.89,,,,,,,fee schedule,4993.89,15004.68,
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6685.54,,,,,,,fee schedule,4993.89,15004.68,
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6367.18,,,,,,,fee schedule,4993.89,15004.68,
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,11151.9,,,,,,,fee schedule,4993.89,15004.68,
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,8666.01,,,,,,,fee schedule,4993.89,15004.68,
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,15004.68,,,,,,,fee schedule,4993.89,15004.68,
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,10314.91,,,,,,,fee schedule,4993.89,15004.68,
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,9341.68,,,,,,,fee schedule,4993.89,15004.68,
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7651.22,,,,,,,fee schedule,4993.89,15004.68,
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",5008.86,5008.86,5008.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],5390.86,5390.86,5390.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,6011.36,,,,,,,fee schedule,4993.89,15004.68,MSDRG Base Rate
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,5954.1,,,,,,,fee schedule,4993.89,15004.68,MSDRG Base Rate
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,5954.1,,,,,,,fee schedule,4993.89,15004.68,MSDRG Base Rate
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,6011.36,,,,,,,fee schedule,4993.89,15004.68,MSDRG Base Rate
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,5954.1,,,,,,,fee schedule,4993.89,15004.68,MSDRG Base Rate
Chronic Obstructive Pulmonary Disease Without Cc/Mcc,192,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10018.93,,,,,,,fee schedule,4993.89,15004.68,MSDRG Base Rate
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10168.34,,,,,,,fee schedule,10168.34,30551.88,
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,10168.34,,,,,,,fee schedule,10168.34,30551.88,
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13612.79,,,,,,,fee schedule,10168.34,30551.88,
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12964.57,,,,,,,fee schedule,10168.34,30551.88,
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,22707.01,,,,,,,fee schedule,10168.34,30551.88,
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,17645.34,,,,,,,fee schedule,10168.34,30551.88,
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,30551.88,,,,,,,fee schedule,10168.34,30551.88,
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,21002.75,,,,,,,fee schedule,10168.34,30551.88,
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,19021.13,,,,,,,fee schedule,10168.34,30551.88,
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15579.08,,,,,,,fee schedule,10168.34,30551.88,
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],10340.7,7697.94,10348.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],12671.98,12671.98,22319,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],15932.94,7940,21001.16,43,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9885.13,8927.8,10999.35,30,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],10418.51,9086.32,10657.24,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],13383.04,10768.4,19019.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",9316,6017,10577.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],13049.14,13049.14,13049.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",9933.66,9933.66,9933.66,106,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],10075.65,9059.56,10095.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9733.87,8530.98,10035.22,67,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],14577.9,12562.32,15577.9,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],14472.27,4428.25,22705.29,31,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],7560.21,17.83,10251.11,87,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",9841.69,9841.69,9841.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],36292.35,36292.35,36292.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11264.42,,,,,,,fee schedule,10168.34,30551.88,MSDRG Base Rate
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,11157.14,,,,,,,fee schedule,10168.34,30551.88,MSDRG Base Rate
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,11157.14,,,,,,,fee schedule,10168.34,30551.88,MSDRG Base Rate
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,11264.42,,,,,,,fee schedule,10168.34,30551.88,MSDRG Base Rate
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,11157.14,,,,,,,fee schedule,10168.34,30551.88,MSDRG Base Rate
Simple Pneumonia And Pleurisy With Mcc,193,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18774.04,,,,,,,fee schedule,10168.34,30551.88,MSDRG Base Rate
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6327.24,,,,,,,fee schedule,6327.24,19010.88,
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,6327.24,,,,,,,fee schedule,6327.24,19010.88,
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8470.55,,,,,,,fee schedule,6327.24,19010.88,
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8067.19,,,,,,,fee schedule,6327.24,19010.88,
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,14129.42,,,,,,,fee schedule,6327.24,19010.88,
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,10979.8,,,,,,,fee schedule,6327.24,19010.88,
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,19010.88,,,,,,,fee schedule,6327.24,19010.88,
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,13068.95,,,,,,,fee schedule,6327.24,19010.88,
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,11835.88,,,,,,,fee schedule,6327.24,19010.88,
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9694.07,,,,,,,fee schedule,6327.24,19010.88,
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],19010.88,19010.88,19010.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6619.39,5683.71,6741.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],10623.26,2437.2,13104.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6758.57,6758.57,6758.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],9633.32,9633.32,11835.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",6633.98,6633.98,6633.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",6230.17,6230.17,6230.17,23,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],8067.19,8067.19,8086.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6211.78,5938.36,6245.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],7420.14,7420.14,7420.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],6325.42,2630.4,11634.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],446.09,26.55,6625.94,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",6172.49,6172.49,6172.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7291.81,,,,,,,fee schedule,6327.24,19010.88,MSDRG Base Rate
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,7222.36,,,,,,,fee schedule,6327.24,19010.88,MSDRG Base Rate
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,7222.36,,,,,,,fee schedule,6327.24,19010.88,MSDRG Base Rate
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,7291.81,,,,,,,fee schedule,6327.24,19010.88,MSDRG Base Rate
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,7222.36,,,,,,,fee schedule,6327.24,19010.88,MSDRG Base Rate
Simple Pneumonia And Pleurisy With Cc,194,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12153.02,,,,,,,fee schedule,6327.24,19010.88,MSDRG Base Rate
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4805.62,,,,,,,fee schedule,4805.62,14439,
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,4805.62,,,,,,,fee schedule,4805.62,14439,
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6433.49,,,,,,,fee schedule,4805.62,14439,
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6127.13,,,,,,,fee schedule,4805.62,14439,
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,10731.47,,,,,,,fee schedule,4805.62,14439,
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,8339.29,,,,,,,fee schedule,4805.62,14439,
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,14439,,,,,,,fee schedule,4805.62,14439,
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,9926.02,,,,,,,fee schedule,4805.62,14439,
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,8989.5,,,,,,,fee schedule,4805.62,14439,
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7362.77,,,,,,,fee schedule,4805.62,14439,
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],3232,3232,3232,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],5417.71,3392,8931.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],7190.44,7190.44,7949,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4314.56,4314.56,4314.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],6114.68,6114.68,6114.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4051.93,4051.93,4051.93,31,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],6553.04,6553.04,6553.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],8586,1123.2,10729.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],5239.2,5239.2,5239.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,5905.89,,,,,,,fee schedule,4805.62,14439,MSDRG Base Rate
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,5849.65,,,,,,,fee schedule,4805.62,14439,MSDRG Base Rate
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,5849.65,,,,,,,fee schedule,4805.62,14439,MSDRG Base Rate
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,5905.89,,,,,,,fee schedule,4805.62,14439,MSDRG Base Rate
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,5849.65,,,,,,,fee schedule,4805.62,14439,MSDRG Base Rate
Simple Pneumonia And Pleurisy Without Cc/Mcc,195,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9843.15,,,,,,,fee schedule,4805.62,14439,MSDRG Base Rate
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14538.77,,,,,,,fee schedule,14538.77,43683.29,
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,14538.77,,,,,,,fee schedule,14538.77,43683.29,
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19463.67,,,,,,,fee schedule,14538.77,43683.29,
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18536.83,,,,,,,fee schedule,14538.77,43683.29,
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,32466.65,,,,,,,fee schedule,14538.77,43683.29,
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,25229.44,,,,,,,fee schedule,14538.77,43683.29,
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,43683.29,,,,,,,fee schedule,14538.77,43683.29,
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,30029.89,,,,,,,fee schedule,14538.77,43683.29,
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,27196.54,,,,,,,fee schedule,14538.77,43683.29,
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22275.09,,,,,,,fee schedule,14538.77,43683.29,
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],28976.88,28976.88,28976.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13663.73,13663.73,13663.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],14878.14,14878.14,14878.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12354.9,12354.89,13763.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],12765.13,6309.36,15126.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15739.36,,,,,,,fee schedule,14538.77,43683.29,MSDRG Base Rate
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,15589.46,,,,,,,fee schedule,14538.77,43683.29,MSDRG Base Rate
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,15589.46,,,,,,,fee schedule,14538.77,43683.29,MSDRG Base Rate
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,15739.36,,,,,,,fee schedule,14538.77,43683.29,MSDRG Base Rate
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,15589.46,,,,,,,fee schedule,14538.77,43683.29,MSDRG Base Rate
Interstitial Lung Disease With Mcc,196,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,26232.27,,,,,,,fee schedule,14538.77,43683.29,MSDRG Base Rate
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7638.22,,,,,,,fee schedule,7638.22,22949.84,
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,7638.22,,,,,,,fee schedule,7638.22,22949.84,
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10225.61,,,,,,,fee schedule,7638.22,22949.84,
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9738.68,,,,,,,fee schedule,7638.22,22949.84,
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,17056.97,,,,,,,fee schedule,7638.22,22949.84,
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,13254.76,,,,,,,fee schedule,7638.22,22949.84,
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,22949.84,,,,,,,fee schedule,7638.22,22949.84,
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,15776.77,,,,,,,fee schedule,7638.22,22949.84,
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,14288.22,,,,,,,fee schedule,7638.22,22949.84,
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11702.64,,,,,,,fee schedule,7638.22,22949.84,
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],9730,9730,9730,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],11245.79,11245.79,11245.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",7839.68,7839.68,7839.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8410.54,,,,,,,fee schedule,7638.22,22949.84,MSDRG Base Rate
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,8330.44,,,,,,,fee schedule,7638.22,22949.84,MSDRG Base Rate
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,8330.44,,,,,,,fee schedule,7638.22,22949.84,MSDRG Base Rate
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,8410.54,,,,,,,fee schedule,7638.22,22949.84,MSDRG Base Rate
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,8330.44,,,,,,,fee schedule,7638.22,22949.84,MSDRG Base Rate
Interstitial Lung Disease With Cc,197,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14017.57,,,,,,,fee schedule,7638.22,22949.84,MSDRG Base Rate
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5404.39,,,,,,,fee schedule,5404.39,16238.07,
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,5404.39,,,,,,,fee schedule,5404.39,16238.07,
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7235.09,,,,,,,fee schedule,5404.39,16238.07,
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6890.56,,,,,,,fee schedule,5404.39,16238.07,
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,12068.59,,,,,,,fee schedule,5404.39,16238.07,
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,9378.36,,,,,,,fee schedule,5404.39,16238.07,
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,16238.07,,,,,,,fee schedule,5404.39,16238.07,
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,11162.79,,,,,,,fee schedule,5404.39,16238.07,
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,10109.57,,,,,,,fee schedule,5404.39,16238.07,
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8280.16,,,,,,,fee schedule,5404.39,16238.07,
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,6591.04,,,,,,,fee schedule,5404.39,16238.07,MSDRG Base Rate
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,6528.27,,,,,,,fee schedule,5404.39,16238.07,MSDRG Base Rate
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,6528.27,,,,,,,fee schedule,5404.39,16238.07,MSDRG Base Rate
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,6591.04,,,,,,,fee schedule,5404.39,16238.07,MSDRG Base Rate
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,6528.27,,,,,,,fee schedule,5404.39,16238.07,MSDRG Base Rate
Interstitial Lung Disease Without Cc/Mcc,198,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10985.06,,,,,,,fee schedule,5404.39,16238.07,MSDRG Base Rate
Pneumothorax With Mcc,199,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13620.55,,,,,,,fee schedule,13620.55,40924.4,
Pneumothorax With Mcc,199,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,13620.55,,,,,,,fee schedule,13620.55,40924.4,
Pneumothorax With Mcc,199,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18234.41,,,,,,,fee schedule,13620.55,40924.4,
Pneumothorax With Mcc,199,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17366.11,,,,,,,fee schedule,13620.55,40924.4,
Pneumothorax With Mcc,199,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,30416.16,,,,,,,fee schedule,13620.55,40924.4,
Pneumothorax With Mcc,199,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,23636.03,,,,,,,fee schedule,13620.55,40924.4,
Pneumothorax With Mcc,199,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,40924.4,,,,,,,fee schedule,13620.55,40924.4,
Pneumothorax With Mcc,199,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,28133.3,,,,,,,fee schedule,13620.55,40924.4,
Pneumothorax With Mcc,199,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,25478.9,,,,,,,fee schedule,13620.55,40924.4,
Pneumothorax With Mcc,199,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20868.27,,,,,,,fee schedule,13620.55,40924.4,
Pneumothorax With Mcc,199,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Mcc,199,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Mcc,199,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13771.07,13771.07,13771.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pneumothorax With Mcc,199,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Mcc,199,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Mcc,199,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Mcc,199,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Mcc,199,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",11510.07,11510.07,11510.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pneumothorax With Mcc,199,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13372.78,13372.78,13372.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pneumothorax With Mcc,199,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Mcc,199,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Mcc,199,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Mcc,199,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Mcc,199,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],30397.21,30397.21,30397.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pneumothorax With Mcc,199,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Mcc,199,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Mcc,199,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Mcc,199,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Mcc,199,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14777.66,,,,,,,fee schedule,13620.55,40924.4,MSDRG Base Rate
Pneumothorax With Mcc,199,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,14636.92,,,,,,,fee schedule,13620.55,40924.4,MSDRG Base Rate
Pneumothorax With Mcc,199,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,14636.92,,,,,,,fee schedule,13620.55,40924.4,MSDRG Base Rate
Pneumothorax With Mcc,199,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,14777.66,,,,,,,fee schedule,13620.55,40924.4,MSDRG Base Rate
Pneumothorax With Mcc,199,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,14636.92,,,,,,,fee schedule,13620.55,40924.4,MSDRG Base Rate
Pneumothorax With Mcc,199,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,24629.43,,,,,,,fee schedule,13620.55,40924.4,MSDRG Base Rate
Pneumothorax With Cc,200,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8544.86,,,,,,,fee schedule,8544.86,25673.96,
Pneumothorax With Cc,200,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,8544.86,,,,,,,fee schedule,8544.86,25673.96,
Pneumothorax With Cc,200,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11439.38,,,,,,,fee schedule,8544.86,25673.96,
Pneumothorax With Cc,200,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10894.65,,,,,,,fee schedule,8544.86,25673.96,
Pneumothorax With Cc,200,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,19081.61,,,,,,,fee schedule,8544.86,25673.96,
Pneumothorax With Cc,200,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,14828.09,,,,,,,fee schedule,8544.86,25673.96,
Pneumothorax With Cc,200,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,25673.96,,,,,,,fee schedule,8544.86,25673.96,
Pneumothorax With Cc,200,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,17649.45,,,,,,,fee schedule,8544.86,25673.96,
Pneumothorax With Cc,200,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,15984.21,,,,,,,fee schedule,8544.86,25673.96,
Pneumothorax With Cc,200,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13091.73,,,,,,,fee schedule,8544.86,25673.96,
Pneumothorax With Cc,200,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Cc,200,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Cc,200,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],17151.05,17151.05,17151.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pneumothorax With Cc,200,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Cc,200,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Cc,200,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Cc,200,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Cc,200,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",7022.46,7022.46,7022.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pneumothorax With Cc,200,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7688.7,7688.7,8158.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pneumothorax With Cc,200,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],10157.94,10157.94,10157.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pneumothorax With Cc,200,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Cc,200,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Cc,200,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Cc,200,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],14965.21,14965.21,14965.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pneumothorax With Cc,200,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],6959.38,6959.38,8712.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pneumothorax With Cc,200,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Cc,200,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Cc,200,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax With Cc,200,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9583.97,,,,,,,fee schedule,8544.86,25673.96,MSDRG Base Rate
Pneumothorax With Cc,200,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,9492.69,,,,,,,fee schedule,8544.86,25673.96,MSDRG Base Rate
Pneumothorax With Cc,200,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,9492.69,,,,,,,fee schedule,8544.86,25673.96,MSDRG Base Rate
Pneumothorax With Cc,200,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,9583.97,,,,,,,fee schedule,8544.86,25673.96,MSDRG Base Rate
Pneumothorax With Cc,200,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,9492.69,,,,,,,fee schedule,8544.86,25673.96,MSDRG Base Rate
Pneumothorax With Cc,200,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15973.28,,,,,,,fee schedule,8544.86,25673.96,MSDRG Base Rate
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5223.06,,,,,,,fee schedule,5223.06,15693.25,
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,5223.06,,,,,,,fee schedule,5223.06,15693.25,
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6992.34,,,,,,,fee schedule,5223.06,15693.25,
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6659.37,,,,,,,fee schedule,5223.06,15693.25,
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,11663.66,,,,,,,fee schedule,5223.06,15693.25,
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,9063.69,,,,,,,fee schedule,5223.06,15693.25,
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,15693.25,,,,,,,fee schedule,5223.06,15693.25,
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,10788.26,,,,,,,fee schedule,5223.06,15693.25,
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,9770.37,,,,,,,fee schedule,5223.06,15693.25,
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8002.34,,,,,,,fee schedule,5223.06,15693.25,
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],5610.87,5610.87,5610.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,6582.44,,,,,,,fee schedule,5223.06,15693.25,MSDRG Base Rate
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,6519.75,,,,,,,fee schedule,5223.06,15693.25,MSDRG Base Rate
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,6519.75,,,,,,,fee schedule,5223.06,15693.25,MSDRG Base Rate
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,6582.44,,,,,,,fee schedule,5223.06,15693.25,MSDRG Base Rate
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,6519.75,,,,,,,fee schedule,5223.06,15693.25,MSDRG Base Rate
Pneumothorax Without Cc/Mcc,201,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10970.73,,,,,,,fee schedule,5223.06,15693.25,MSDRG Base Rate
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7459.2,,,,,,,fee schedule,7459.2,22411.97,
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,7459.2,,,,,,,fee schedule,7459.2,22411.97,
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9985.95,,,,,,,fee schedule,7459.2,22411.97,
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9510.43,,,,,,,fee schedule,7459.2,22411.97,
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,16657.21,,,,,,,fee schedule,7459.2,22411.97,
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,12944.11,,,,,,,fee schedule,7459.2,22411.97,
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,22411.97,,,,,,,fee schedule,7459.2,22411.97,
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,15407.01,,,,,,,fee schedule,7459.2,22411.97,
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,13953.35,,,,,,,fee schedule,7459.2,22411.97,
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11428.37,,,,,,,fee schedule,7459.2,22411.97,
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],7687.8,3946.77,15869.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],8681,8681,9907.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7979.25,7979.25,7979.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4916.49,4916.49,4916.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4617.23,4617.23,4617.23,56,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],9510.43,9510.43,9510.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],5504.64,5504.64,7439.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],11200.17,11200.17,11200.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],11503.11,3584,15960.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],8504.72,8504.72,8504.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4574.47,4574.47,4577.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8583.2,,,,,,,fee schedule,7459.2,22411.97,MSDRG Base Rate
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,8501.46,,,,,,,fee schedule,7459.2,22411.97,MSDRG Base Rate
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,8501.46,,,,,,,fee schedule,7459.2,22411.97,MSDRG Base Rate
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,8583.2,,,,,,,fee schedule,7459.2,22411.97,MSDRG Base Rate
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,8501.46,,,,,,,fee schedule,7459.2,22411.97,MSDRG Base Rate
Bronchitis And Asthma With Cc/Mcc,202,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14305.34,,,,,,,fee schedule,7459.2,22411.97,MSDRG Base Rate
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5372.76,,,,,,,fee schedule,5372.76,16143.02,
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,5372.76,,,,,,,fee schedule,5372.76,16143.02,
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7192.74,,,,,,,fee schedule,5372.76,16143.02,
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6850.23,,,,,,,fee schedule,5372.76,16143.02,
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,11997.95,,,,,,,fee schedule,5372.76,16143.02,
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,9323.46,,,,,,,fee schedule,5372.76,16143.02,
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,16143.02,,,,,,,fee schedule,5372.76,16143.02,
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,11097.45,,,,,,,fee schedule,5372.76,16143.02,
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,10050.39,,,,,,,fee schedule,5372.76,16143.02,
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8231.69,,,,,,,fee schedule,5372.76,16143.02,
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],16149.97,16149.97,16149.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],5942,4111.95,11052.23,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],5340.8,5161,5442.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4150.37,4150.37,4150.37,62,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],6853.18,6853.18,6853.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],6420.77,5821.27,7525.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],5934.6,3511.8,11858,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4111.95,4111.95,4111.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,6230.1,,,,,,,fee schedule,5372.76,16143.02,MSDRG Base Rate
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,6170.77,,,,,,,fee schedule,5372.76,16143.02,MSDRG Base Rate
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,6170.77,,,,,,,fee schedule,5372.76,16143.02,MSDRG Base Rate
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,6230.1,,,,,,,fee schedule,5372.76,16143.02,MSDRG Base Rate
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,6170.77,,,,,,,fee schedule,5372.76,16143.02,MSDRG Base Rate
Bronchitis And Asthma Without Cc/Mcc,203,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10383.5,,,,,,,fee schedule,5372.76,16143.02,MSDRG Base Rate
Respiratory Signs And Symptoms,204,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6257.03,,,,,,,fee schedule,6257.03,18799.91,
Respiratory Signs And Symptoms,204,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,6257.03,,,,,,,fee schedule,6257.03,18799.91,
Respiratory Signs And Symptoms,204,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8376.55,,,,,,,fee schedule,6257.03,18799.91,
Respiratory Signs And Symptoms,204,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7977.67,,,,,,,fee schedule,6257.03,18799.91,
Respiratory Signs And Symptoms,204,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,13972.62,,,,,,,fee schedule,6257.03,18799.91,
Respiratory Signs And Symptoms,204,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,10857.95,,,,,,,fee schedule,6257.03,18799.91,
Respiratory Signs And Symptoms,204,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,18799.91,,,,,,,fee schedule,6257.03,18799.91,
Respiratory Signs And Symptoms,204,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,12923.91,,,,,,,fee schedule,6257.03,18799.91,
Respiratory Signs And Symptoms,204,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,11704.53,,,,,,,fee schedule,6257.03,18799.91,
Respiratory Signs And Symptoms,204,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9586.49,,,,,,,fee schedule,6257.03,18799.91,
Respiratory Signs And Symptoms,204,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],4141.99,4141.99,4141.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Respiratory Signs And Symptoms,204,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Signs And Symptoms,204,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],11069.98,11069.98,11069.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Respiratory Signs And Symptoms,204,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Signs And Symptoms,204,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Signs And Symptoms,204,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Signs And Symptoms,204,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Signs And Symptoms,204,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3950.9,3950.9,3950.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Respiratory Signs And Symptoms,204,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Signs And Symptoms,204,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Signs And Symptoms,204,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Signs And Symptoms,204,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Signs And Symptoms,204,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Signs And Symptoms,204,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],7935,7935,7935,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Respiratory Signs And Symptoms,204,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Signs And Symptoms,204,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Signs And Symptoms,204,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Signs And Symptoms,204,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory Signs And Symptoms,204,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7303.53,,,,,,,fee schedule,6257.03,18799.91,MSDRG Base Rate
Respiratory Signs And Symptoms,204,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,7233.97,,,,,,,fee schedule,6257.03,18799.91,MSDRG Base Rate
Respiratory Signs And Symptoms,204,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,7233.97,,,,,,,fee schedule,6257.03,18799.91,MSDRG Base Rate
Respiratory Signs And Symptoms,204,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,7303.53,,,,,,,fee schedule,6257.03,18799.91,MSDRG Base Rate
Respiratory Signs And Symptoms,204,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,7233.97,,,,,,,fee schedule,6257.03,18799.91,MSDRG Base Rate
Respiratory Signs And Symptoms,204,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12172.54,,,,,,,fee schedule,6257.03,18799.91,MSDRG Base Rate
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14565.78,,,,,,,fee schedule,14565.78,43764.44,
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,14565.78,,,,,,,fee schedule,14565.78,43764.44,
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19499.83,,,,,,,fee schedule,14565.78,43764.44,
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18571.27,,,,,,,fee schedule,14565.78,43764.44,
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,32526.96,,,,,,,fee schedule,14565.78,43764.44,
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,25276.3,,,,,,,fee schedule,14565.78,43764.44,
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,43764.44,,,,,,,fee schedule,14565.78,43764.44,
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,30085.67,,,,,,,fee schedule,14565.78,43764.44,
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,27247.06,,,,,,,fee schedule,14565.78,43764.44,
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22316.46,,,,,,,fee schedule,14565.78,43764.44,
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],9708.65,9708.65,9708.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],14385.68,14385.68,14385.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],16945.05,13398.5,23097.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],16836,16836,16836,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",7830.09,7830.09,7830.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],14307.76,14307.76,14307.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",7353.47,7353.47,7353.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13916.85,12658.28,14391.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],9892.02,6844.92,14510.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],12559.22,12559.22,12559.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15300.31,,,,,,,fee schedule,14565.78,43764.44,MSDRG Base Rate
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,15154.59,,,,,,,fee schedule,14565.78,43764.44,MSDRG Base Rate
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,15154.59,,,,,,,fee schedule,14565.78,43764.44,MSDRG Base Rate
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,15300.31,,,,,,,fee schedule,14565.78,43764.44,MSDRG Base Rate
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,15154.59,,,,,,,fee schedule,14565.78,43764.44,MSDRG Base Rate
Other Respiratory System Diagnoses With Mcc,205,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,25500.51,,,,,,,fee schedule,14565.78,43764.44,MSDRG Base Rate
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6989.29,,,,,,,fee schedule,6989.29,21000.07,
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,6989.29,,,,,,,fee schedule,6989.29,21000.07,
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9356.86,,,,,,,fee schedule,6989.29,21000.07,
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8911.3,,,,,,,fee schedule,6989.29,21000.07,
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,15607.84,,,,,,,fee schedule,6989.29,21000.07,
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,12128.66,,,,,,,fee schedule,6989.29,21000.07,
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,21000.07,,,,,,,fee schedule,6989.29,21000.07,
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,14436.4,,,,,,,fee schedule,6989.29,21000.07,
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,13074.32,,,,,,,fee schedule,6989.29,21000.07,
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10708.4,,,,,,,fee schedule,6989.29,21000.07,
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7259.25,7259.25,7259.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],8911.3,8911.3,8911.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",6268.43,6268.43,6268.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],6266.62,6266.62,6266.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],12978.01,12978.01,12978.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],6885.37,6885.37,6885.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8348.05,,,,,,,fee schedule,6989.29,21000.07,MSDRG Base Rate
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,8268.54,,,,,,,fee schedule,6989.29,21000.07,MSDRG Base Rate
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,8268.54,,,,,,,fee schedule,6989.29,21000.07,MSDRG Base Rate
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,8348.05,,,,,,,fee schedule,6989.29,21000.07,MSDRG Base Rate
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,8268.54,,,,,,,fee schedule,6989.29,21000.07,MSDRG Base Rate
Other Respiratory System Diagnoses Without Mcc,206,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,13913.41,,,,,,,fee schedule,6989.29,21000.07,MSDRG Base Rate
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,49905.74,,,,,,,fee schedule,49905.74,149947.16,
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,49905.74,,,,,,,fee schedule,49905.74,149947.16,
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66810.95,,,,,,,fee schedule,49905.74,149947.16,
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,63629.49,,,,,,,fee schedule,49905.74,149947.16,
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,111444.94,,,,,,,fee schedule,49905.74,149947.16,
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,86602.5,,,,,,,fee schedule,49905.74,149947.16,
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,149947.16,,,,,,,fee schedule,49905.74,149947.16,
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,103080.52,,,,,,,fee schedule,49905.74,149947.16,
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,93354.78,,,,,,,fee schedule,49905.74,149947.16,
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,76461.41,,,,,,,fee schedule,49905.74,149947.16,
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],48160.04,48160.04,48160.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],75343.26,75343.26,75343.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",46291.06,46291.06,156412.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],46909.82,46909.82,46909.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],57022.19,57022.19,57022.19,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],75391.4,75391.4,75391.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],236263.32,236263.32,236263.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],46667.08,46667.08,46667.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",51726.9,51726.9,51726.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],100330.56,100330.56,100330.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,51266.3,,,,,,,fee schedule,49905.74,149947.16,MSDRG Base Rate
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,50778.05,,,,,,,fee schedule,49905.74,149947.16,MSDRG Base Rate
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,50778.05,,,,,,,fee schedule,49905.74,149947.16,MSDRG Base Rate
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,51266.3,,,,,,,fee schedule,49905.74,149947.16,MSDRG Base Rate
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,50778.05,,,,,,,fee schedule,49905.74,149947.16,MSDRG Base Rate
Respiratory System Diagnosis With Ventilator Support >96 Hours,207,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,85443.84,,,,,,,fee schedule,49905.74,149947.16,MSDRG Base Rate
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,20710.92,,,,,,,fee schedule,20710.92,62228.17,
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,20710.92,,,,,,,fee schedule,20710.92,62228.17,
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,27726.59,,,,,,,fee schedule,20710.92,62228.17,
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26406.28,,,,,,,fee schedule,20710.92,62228.17,
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,46249.73,,,,,,,fee schedule,20710.92,62228.17,
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,35940.1,,,,,,,fee schedule,20710.92,62228.17,
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,62228.17,,,,,,,fee schedule,20710.92,62228.17,
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,42778.49,,,,,,,fee schedule,20710.92,62228.17,
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,38742.3,,,,,,,fee schedule,20710.92,62228.17,
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,31731.54,,,,,,,fee schedule,20710.92,62228.17,
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],62221.22,62221.22,62221.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],19276.14,18497.65,20085.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],40635.01,28762,42519.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],20153.69,20153.69,20153.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",21313.62,21313.62,21313.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",20016.27,20016.27,20016.27,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],19859.31,19859.31,19859.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],20052.58,20052.58,20052.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],31727.99,31727.99,31727.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],18580.5,18117.41,20203,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],46244.56,46244.56,46244.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",19830.93,19830.93,19830.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,22469.76,,,,,,,fee schedule,20710.92,62228.17,MSDRG Base Rate
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,22255.76,,,,,,,fee schedule,20710.92,62228.17,MSDRG Base Rate
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,22255.76,,,,,,,fee schedule,20710.92,62228.17,MSDRG Base Rate
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,22469.76,,,,,,,fee schedule,20710.92,62228.17,MSDRG Base Rate
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,22255.76,,,,,,,fee schedule,20710.92,62228.17,MSDRG Base Rate
Respiratory System Diagnosis With Ventilator Support <=96 Hours,208,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,37449.6,,,,,,,fee schedule,20710.92,62228.17,MSDRG Base Rate
Complex Aortic Arch Procedures,209,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complex Aortic Arch Procedures,209,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Complex Aortic Arch Procedures,209,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Complex Aortic Arch Procedures,209,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complex Aortic Arch Procedures,209,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complex Aortic Arch Procedures,209,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Complex Aortic Arch Procedures,209,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Complex Aortic Arch Procedures,209,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Complex Aortic Arch Procedures,209,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Complex Aortic Arch Procedures,209,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Complex Aortic Arch Procedures,209,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complex Aortic Arch Procedures,209,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complex Aortic Arch Procedures,209,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Complex Aortic Arch Procedures,209,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Complex Aortic Arch Procedures,209,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complex Aortic Arch Procedures,209,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Complex Aortic Arch Procedures,209,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complex Aortic Arch Procedures,209,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complex Aortic Arch Procedures,209,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,89422.89,,,,,,,fee schedule,88571.25,149038.16,MSDRG Base Rate
Complex Aortic Arch Procedures,209,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,88571.25,,,,,,,fee schedule,88571.25,149038.16,MSDRG Base Rate
Complex Aortic Arch Procedures,209,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,88571.25,,,,,,,fee schedule,88571.25,149038.16,MSDRG Base Rate
Complex Aortic Arch Procedures,209,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,89422.89,,,,,,,fee schedule,88571.25,149038.16,MSDRG Base Rate
Complex Aortic Arch Procedures,209,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,88571.25,,,,,,,fee schedule,88571.25,149038.16,MSDRG Base Rate
Complex Aortic Arch Procedures,209,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,149038.16,,,,,,,fee schedule,88571.25,149038.16,MSDRG Base Rate
Hip & Femur Procedures Except Major Joint Age >17 w CC,210,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip & Femur Procedures Except Major Joint Age >17 w CC,210,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Hip & Femur Procedures Except Major Joint Age >17 w CC,210,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Hip & Femur Procedures Except Major Joint Age >17 w CC,210,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip & Femur Procedures Except Major Joint Age >17 w CC,210,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip & Femur Procedures Except Major Joint Age >17 w CC,210,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Hip & Femur Procedures Except Major Joint Age >17 w CC,210,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Hip & Femur Procedures Except Major Joint Age >17 w CC,210,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Hip & Femur Procedures Except Major Joint Age >17 w CC,210,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Hip & Femur Procedures Except Major Joint Age >17 w CC,210,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Hip & Femur Procedures Except Major Joint Age >17 w CC,210,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip & Femur Procedures Except Major Joint Age >17 w CC,210,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip & Femur Procedures Except Major Joint Age >17 w CC,210,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Hip & Femur Procedures Except Major Joint Age >17 w CC,210,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Hip & Femur Procedures Except Major Joint Age >17 w CC,210,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip & Femur Procedures Except Major Joint Age >17 w CC,210,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Hip & Femur Procedures Except Major Joint Age >17 w CC,210,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip & Femur Procedures Except Major Joint Age >17 w CC,210,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip & Femur Procedures Except Major Joint Age >17 w/o CC,211,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip & Femur Procedures Except Major Joint Age >17 w/o CC,211,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Hip & Femur Procedures Except Major Joint Age >17 w/o CC,211,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Hip & Femur Procedures Except Major Joint Age >17 w/o CC,211,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip & Femur Procedures Except Major Joint Age >17 w/o CC,211,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip & Femur Procedures Except Major Joint Age >17 w/o CC,211,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Hip & Femur Procedures Except Major Joint Age >17 w/o CC,211,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Hip & Femur Procedures Except Major Joint Age >17 w/o CC,211,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Hip & Femur Procedures Except Major Joint Age >17 w/o CC,211,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Hip & Femur Procedures Except Major Joint Age >17 w/o CC,211,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Hip & Femur Procedures Except Major Joint Age >17 w/o CC,211,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip & Femur Procedures Except Major Joint Age >17 w/o CC,211,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip & Femur Procedures Except Major Joint Age >17 w/o CC,211,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Hip & Femur Procedures Except Major Joint Age >17 w/o CC,211,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Hip & Femur Procedures Except Major Joint Age >17 w/o CC,211,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip & Femur Procedures Except Major Joint Age >17 w/o CC,211,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Hip & Femur Procedures Except Major Joint Age >17 w/o CC,211,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip & Femur Procedures Except Major Joint Age >17 w/o CC,211,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,84052.79,,,,,,,fee schedule,84052.79,252545.63,
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,84052.79,,,,,,,fee schedule,84052.79,252545.63,
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,112525.07,,,,,,,fee schedule,84052.79,252545.63,
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,107166.75,,,,,,,fee schedule,84052.79,252545.63,
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,187699.01,,,,,,,fee schedule,84052.79,252545.63,
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,145858.61,,,,,,,fee schedule,84052.79,252545.63,
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,252545.63,,,,,,,fee schedule,84052.79,252545.63,
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,173611.4,,,,,,,fee schedule,84052.79,252545.63,
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,157231.01,,,,,,,fee schedule,84052.79,252545.63,
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,128778.66,,,,,,,fee schedule,84052.79,252545.63,
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,85948.72,,,,,,,fee schedule,84052.79,252545.63,MSDRG Base Rate
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,85130.16,,,,,,,fee schedule,84052.79,252545.63,MSDRG Base Rate
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,85130.16,,,,,,,fee schedule,84052.79,252545.63,MSDRG Base Rate
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,85948.72,,,,,,,fee schedule,84052.79,252545.63,MSDRG Base Rate
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,85130.16,,,,,,,fee schedule,84052.79,252545.63,MSDRG Base Rate
Concomitant Aortic And Mitral Valve Procedures,212,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,143247.86,,,,,,,fee schedule,84052.79,252545.63,MSDRG Base Rate
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],32899.12,32899.12,32899.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,45580.43,,,,,,,fee schedule,45146.33,75967.38,MSDRG Base Rate
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,45146.33,,,,,,,fee schedule,45146.33,75967.38,MSDRG Base Rate
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,45146.33,,,,,,,fee schedule,45146.33,75967.38,MSDRG Base Rate
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,45580.43,,,,,,,fee schedule,45146.33,75967.38,MSDRG Base Rate
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,45146.33,,,,,,,fee schedule,45146.33,75967.38,MSDRG Base Rate
Endovascular Abdominal Aorta With Iliac Branch Procedures,213,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,75967.38,,,,,,,fee schedule,45146.33,75967.38,MSDRG Base Rate
No Longer Valid,214,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,214,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,214,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,214,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,214,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,214,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,214,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,214,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,214,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,214,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,214,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,214,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,214,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,214,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,214,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,214,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,214,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,214,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Heart Assist System Implant,215,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,81746.44,,,,,,,fee schedule,78033.63,245615.93,
Other Heart Assist System Implant,215,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,81746.44,,,,,,,fee schedule,78033.63,245615.93,
Other Heart Assist System Implant,215,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,109437.45,,,,,,,fee schedule,78033.63,245615.93,
Other Heart Assist System Implant,215,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,104226.16,,,,,,,fee schedule,78033.63,245615.93,
Other Heart Assist System Implant,215,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,182548.66,,,,,,,fee schedule,78033.63,245615.93,
Other Heart Assist System Implant,215,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,141856.34,,,,,,,fee schedule,78033.63,245615.93,
Other Heart Assist System Implant,215,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,245615.93,,,,,,,fee schedule,78033.63,245615.93,
Other Heart Assist System Implant,215,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,168847.61,,,,,,,fee schedule,78033.63,245615.93,
Other Heart Assist System Implant,215,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,152916.68,,,,,,,fee schedule,78033.63,245615.93,
Other Heart Assist System Implant,215,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,125245.06,,,,,,,fee schedule,78033.63,245615.93,
Other Heart Assist System Implant,215,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Heart Assist System Implant,215,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Heart Assist System Implant,215,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],76038.22,76038.22,76038.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Heart Assist System Implant,215,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],159285,159285,159285,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Heart Assist System Implant,215,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],79469.72,79469.72,79469.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Heart Assist System Implant,215,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Other Heart Assist System Implant,215,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Heart Assist System Implant,215,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",57430.77,57430.77,57430.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Heart Assist System Implant,215,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],80292.9,80292.9,80292.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Heart Assist System Implant,215,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],56076.79,56076.79,56076.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Heart Assist System Implant,215,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other Heart Assist System Implant,215,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Heart Assist System Implant,215,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Heart Assist System Implant,215,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],74754.4,74754.4,74754.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Heart Assist System Implant,215,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Other Heart Assist System Implant,215,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Heart Assist System Implant,215,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Heart Assist System Implant,215,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Heart Assist System Implant,215,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,78783.96,,,,,,,fee schedule,78033.63,245615.93,MSDRG Base Rate
Other Heart Assist System Implant,215,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,78033.63,,,,,,,fee schedule,78033.63,245615.93,MSDRG Base Rate
Other Heart Assist System Implant,215,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,78033.63,,,,,,,fee schedule,78033.63,245615.93,MSDRG Base Rate
Other Heart Assist System Implant,215,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,78783.96,,,,,,,fee schedule,78033.63,245615.93,MSDRG Base Rate
Other Heart Assist System Implant,215,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,78033.63,,,,,,,fee schedule,78033.63,245615.93,MSDRG Base Rate
Other Heart Assist System Implant,215,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,131306.6,,,,,,,fee schedule,78033.63,245615.93,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,74463.93,,,,,,,fee schedule,74463.93,223734.87,
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,74463.93,,,,,,,fee schedule,74463.93,223734.87,
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,99688.05,,,,,,,fee schedule,74463.93,223734.87,
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,94941.02,,,,,,,fee schedule,74463.93,223734.87,
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,166286.04,,,,,,,fee schedule,74463.93,223734.87,
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,129218.86,,,,,,,fee schedule,74463.93,223734.87,
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,223734.87,,,,,,,fee schedule,74463.93,223734.87,
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,153805.57,,,,,,,fee schedule,74463.93,223734.87,
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,139293.87,,,,,,,fee schedule,74463.93,223734.87,
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,114087.41,,,,,,,fee schedule,74463.93,223734.87,
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],71122.22,71122.22,71122.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],115240.4,115240.4,115240.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],142620.14,142620.14,142620.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],118276.12,118276.12,118276.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],69454.43,69454.43,69454.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],70730.81,70730.81,70730.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],84472.58,84472.58,84472.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,77423.03,,,,,,,fee schedule,74463.93,223734.87,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,76685.67,,,,,,,fee schedule,74463.93,223734.87,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,76685.67,,,,,,,fee schedule,74463.93,223734.87,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,77423.03,,,,,,,fee schedule,74463.93,223734.87,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,76685.67,,,,,,,fee schedule,74463.93,223734.87,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc,216,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,129038.38,,,,,,,fee schedule,74463.93,223734.87,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,49826.27,,,,,,,fee schedule,49826.27,149708.36,
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,49826.27,,,,,,,fee schedule,49826.27,149708.36,
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,66704.55,,,,,,,fee schedule,49826.27,149708.36,
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,63528.16,,,,,,,fee schedule,49826.27,149708.36,
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,111267.46,,,,,,,fee schedule,49826.27,149708.36,
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,86464.59,,,,,,,fee schedule,49826.27,149708.36,
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,149708.36,,,,,,,fee schedule,49826.27,149708.36,
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,102916.36,,,,,,,fee schedule,49826.27,149708.36,
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,93206.11,,,,,,,fee schedule,49826.27,149708.36,
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,76339.64,,,,,,,fee schedule,49826.27,149708.36,
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,52364.73,,,,,,,fee schedule,49826.27,149708.36,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,51866.02,,,,,,,fee schedule,49826.27,149708.36,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,51866.02,,,,,,,fee schedule,49826.27,149708.36,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,52364.73,,,,,,,fee schedule,49826.27,149708.36,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,51866.02,,,,,,,fee schedule,49826.27,149708.36,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc,217,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,87274.55,,,,,,,fee schedule,49826.27,149708.36,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,45904.15,,,,,,,fee schedule,45904.15,137923.93,
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,45904.15,,,,,,,fee schedule,45904.15,137923.93,
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,61453.85,,,,,,,fee schedule,45904.15,137923.93,
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,58527.48,,,,,,,fee schedule,45904.15,137923.93,
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,102508.94,,,,,,,fee schedule,45904.15,137923.93,
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,79658.45,,,,,,,fee schedule,45904.15,137923.93,
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,137923.93,,,,,,,fee schedule,45904.15,137923.93,
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,94815.21,,,,,,,fee schedule,45904.15,137923.93,
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,85869.31,,,,,,,fee schedule,45904.15,137923.93,
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,70330.5,,,,,,,fee schedule,45904.15,137923.93,
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,52364.73,,,,,,,fee schedule,45904.15,137923.93,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,51866.02,,,,,,,fee schedule,45904.15,137923.93,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,51866.02,,,,,,,fee schedule,45904.15,137923.93,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,52364.73,,,,,,,fee schedule,45904.15,137923.93,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,51866.02,,,,,,,fee schedule,45904.15,137923.93,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc,218,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,87274.55,,,,,,,fee schedule,45904.15,137923.93,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,59699.85,,,,,,,fee schedule,59699.85,179374.61,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,59699.85,,,,,,,fee schedule,59699.85,179374.61,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,79922.75,,,,,,,fee schedule,59699.85,179374.61,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,76116.92,,,,,,,fee schedule,59699.85,179374.61,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,133316.25,,,,,,,fee schedule,59699.85,179374.61,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,103598.43,,,,,,,fee schedule,59699.85,179374.61,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,179374.61,,,,,,,fee schedule,59699.85,179374.61,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,123310.29,,,,,,,fee schedule,59699.85,179374.61,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,111675.86,,,,,,,fee schedule,59699.85,179374.61,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,91467.12,,,,,,,fee schedule,59699.85,179374.61,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],54757.01,54757.01,54757.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],113975.3,113975.3,122735.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],59087.63,59087.63,118178.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],81165.07,81165.07,81165.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",85958.23,85958.23,85958.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],153072.11,153072.11,153072.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],89.28,89.28,89.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",47658.54,47658.54,47658.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],57505.14,57505.14,59535.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],206537.03,206537.03,206537.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],106207.34,91390.06,213771.19,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],55174.91,39205.07,77383.81,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",47217.26,47217.26,47217.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,60981.82,,,,,,,fee schedule,59699.85,179374.61,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,60401.04,,,,,,,fee schedule,59699.85,179374.61,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,60401.04,,,,,,,fee schedule,59699.85,179374.61,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,60981.82,,,,,,,fee schedule,59699.85,179374.61,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,60401.04,,,,,,,fee schedule,59699.85,179374.61,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc,219,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,101636.36,,,,,,,fee schedule,59699.85,179374.61,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,40867.05,,,,,,,fee schedule,40867.05,122789.42,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,40867.05,,,,,,,fee schedule,40867.05,122789.42,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,54710.46,,,,,,,fee schedule,40867.05,122789.42,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,52105.21,,,,,,,fee schedule,40867.05,122789.42,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,91260.55,,,,,,,fee schedule,40867.05,122789.42,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,70917.46,,,,,,,fee schedule,40867.05,122789.42,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,122789.42,,,,,,,fee schedule,40867.05,122789.42,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,84411.05,,,,,,,fee schedule,40867.05,122789.42,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,76446.79,,,,,,,fee schedule,40867.05,122789.42,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,62613.07,,,,,,,fee schedule,40867.05,122789.42,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],39028.24,39028.24,39028.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],92628.58,92628.58,92628.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],38290.81,38290.81,38290.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,42657.8,,,,,,,fee schedule,40867.05,122789.42,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,42251.54,,,,,,,fee schedule,40867.05,122789.42,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,42251.54,,,,,,,fee schedule,40867.05,122789.42,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,42657.8,,,,,,,fee schedule,40867.05,122789.42,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,42251.54,,,,,,,fee schedule,40867.05,122789.42,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc,220,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,71096.34,,,,,,,fee schedule,40867.05,122789.42,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,35434.88,,,,,,,fee schedule,35434.88,106467.88,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,35434.88,,,,,,,fee schedule,35434.88,106467.88,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,47438.18,,,,,,,fee schedule,35434.88,106467.88,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,45179.23,,,,,,,fee schedule,35434.88,106467.88,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,79129.92,,,,,,,fee schedule,35434.88,106467.88,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,61490.9,,,,,,,fee schedule,35434.88,106467.88,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,106467.88,,,,,,,fee schedule,35434.88,106467.88,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,73190.88,,,,,,,fee schedule,35434.88,106467.88,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,66285.26,,,,,,,fee schedule,35434.88,106467.88,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,54290.35,,,,,,,fee schedule,35434.88,106467.88,
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],51630.17,51630.17,51630.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,40371.89,,,,,,,fee schedule,35434.88,106467.88,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,39987.4,,,,,,,fee schedule,35434.88,106467.88,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,39987.4,,,,,,,fee schedule,35434.88,106467.88,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,40371.89,,,,,,,fee schedule,35434.88,106467.88,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,39987.4,,,,,,,fee schedule,35434.88,106467.88,MSDRG Base Rate
Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M,221,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,67286.48,,,,,,,fee schedule,35434.88,106467.88,MSDRG Base Rate
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc",222,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,59079.47,,,,,,,fee schedule,59079.47,177510.61,
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc",222,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,59079.47,,,,,,,fee schedule,59079.47,177510.61,
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc",222,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,75325.94,,,,,,,fee schedule,59079.47,177510.61,
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc",222,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,131930.87,,,,,,,fee schedule,59079.47,177510.61,
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc",222,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,102521.87,,,,,,,fee schedule,59079.47,177510.61,
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc",222,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,177510.61,,,,,,,fee schedule,59079.47,177510.61,
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc",222,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,122028.9,,,,,,,fee schedule,59079.47,177510.61,
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc",222,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,110515.36,,,,,,,fee schedule,59079.47,177510.61,
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc",222,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,90516.63,,,,,,,fee schedule,59079.47,177510.61,
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc",222,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc",222,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc",222,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc",222,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc",222,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc",222,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc",222,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc",222,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc",222,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc",222,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc",222,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc",222,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc",222,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc",222,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc",222,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc",222,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc",222,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc",222,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc",223,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,40268.27,,,,,,,fee schedule,40268.27,120990.34,
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc",223,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,40268.27,,,,,,,fee schedule,40268.27,120990.34,
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc",223,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,51341.78,,,,,,,fee schedule,40268.27,120990.34,
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc",223,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,89923.42,,,,,,,fee schedule,40268.27,120990.34,
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc",223,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,69878.39,,,,,,,fee schedule,40268.27,120990.34,
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc",223,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,120990.34,,,,,,,fee schedule,40268.27,120990.34,
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc",223,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,83174.28,,,,,,,fee schedule,40268.27,120990.34,
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc",223,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,75326.72,,,,,,,fee schedule,40268.27,120990.34,
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc",223,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,61695.68,,,,,,,fee schedule,40268.27,120990.34,
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc",223,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc",223,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc",223,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc",223,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc",223,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc",223,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc",223,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc",223,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc",223,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc",223,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc",223,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc",223,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc",223,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc",223,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc",223,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc",223,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc",223,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc",223,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc",224,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,54701.33,,,,,,,fee schedule,54701.33,164356.01,
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc",224,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,54701.33,,,,,,,fee schedule,54701.33,164356.01,
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc",224,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,69743.83,,,,,,,fee schedule,54701.33,164356.01,
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc",224,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,122154.01,,,,,,,fee schedule,54701.33,164356.01,
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc",224,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,94924.39,,,,,,,fee schedule,54701.33,164356.01,
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc",224,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,164356.01,,,,,,,fee schedule,54701.33,164356.01,
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc",224,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,112985.83,,,,,,,fee schedule,54701.33,164356.01,
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc",224,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,102325.51,,,,,,,fee schedule,54701.33,164356.01,
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc",224,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83808.81,,,,,,,fee schedule,54701.33,164356.01,
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc",224,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc",224,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc",224,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc",224,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc",224,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc",224,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc",224,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc",224,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc",224,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc",224,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc",224,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc",224,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc",224,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc",224,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc",224,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc",224,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc",224,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc",224,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc",225,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,39025.97,,,,,,,fee schedule,39025.97,117257.72,
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc",225,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,39025.97,,,,,,,fee schedule,39025.97,117257.72,
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc",225,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49757.85,,,,,,,fee schedule,39025.97,117257.72,
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc",225,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,87149.23,,,,,,,fee schedule,39025.97,117257.72,
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc",225,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,67722.6,,,,,,,fee schedule,39025.97,117257.72,
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc",225,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,117257.72,,,,,,,fee schedule,39025.97,117257.72,
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc",225,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,80608.31,,,,,,,fee schedule,39025.97,117257.72,
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc",225,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,73002.84,,,,,,,fee schedule,39025.97,117257.72,
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc",225,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59792.33,,,,,,,fee schedule,39025.97,117257.72,
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc",225,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc",225,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc",225,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc",225,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc",225,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc",225,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc",225,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc",225,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc",225,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc",225,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc",225,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc",225,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc",225,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc",225,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc",225,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc",225,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc",225,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc",225,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc,226,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,49390.3,,,,,,,fee schedule,49390.3,148398.47,
Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc,226,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,49390.3,,,,,,,fee schedule,49390.3,148398.47,
Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc,226,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,62972.31,,,,,,,fee schedule,49390.3,148398.47,
Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc,226,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,110293.91,,,,,,,fee schedule,49390.3,148398.47,
Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc,226,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,85708.05,,,,,,,fee schedule,49390.3,148398.47,
Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc,226,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,148398.47,,,,,,,fee schedule,49390.3,148398.47,
Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc,226,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,102015.88,,,,,,,fee schedule,49390.3,148398.47,
Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc,226,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,92390.59,,,,,,,fee schedule,49390.3,148398.47,
Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc,226,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,75671.7,,,,,,,fee schedule,49390.3,148398.47,
Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc,226,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc,226,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc,226,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc,226,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc,226,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc,226,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc,226,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc,226,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc,226,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc,226,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc,226,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc,226,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc,226,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc,226,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc,226,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc,226,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc,226,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc,226,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc,227,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,38740.47,,,,,,,fee schedule,38740.47,116399.91,
Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc,227,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,38740.47,,,,,,,fee schedule,38740.47,116399.91,
Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc,227,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49393.85,,,,,,,fee schedule,38740.47,116399.91,
Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc,227,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,86511.68,,,,,,,fee schedule,38740.47,116399.91,
Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc,227,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,67227.17,,,,,,,fee schedule,38740.47,116399.91,
Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc,227,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,116399.91,,,,,,,fee schedule,38740.47,116399.91,
Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc,227,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,80018.61,,,,,,,fee schedule,38740.47,116399.91,
Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc,227,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,72468.78,,,,,,,fee schedule,38740.47,116399.91,
Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc,227,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59354.92,,,,,,,fee schedule,38740.47,116399.91,
Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc,227,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc,227,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc,227,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc,227,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc,227,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc,227,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc,227,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc,227,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc,227,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc,227,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc,227,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc,227,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc,227,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc,227,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc,227,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc,227,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc,227,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc,227,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,38448.8,,,,,,,fee schedule,38448.8,115523.55,
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,38448.8,,,,,,,fee schedule,38448.8,115523.55,
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51473.06,,,,,,,fee schedule,38448.8,115523.55,
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49021.97,,,,,,,fee schedule,38448.8,115523.55,
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,85860.35,,,,,,,fee schedule,38448.8,115523.55,
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,66721.03,,,,,,,fee schedule,38448.8,115523.55,
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,115523.55,,,,,,,fee schedule,38448.8,115523.55,
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,79416.16,,,,,,,fee schedule,38448.8,115523.55,
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,71923.18,,,,,,,fee schedule,38448.8,115523.55,
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,58908.04,,,,,,,fee schedule,38448.8,115523.55,
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],35394.94,35394.94,58453.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],80500.21,80500.21,80500.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],37256.16,37256.16,60973.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",261478.61,261478.61,261478.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],48348.39,48348.39,48348.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",56328.63,52892.27,139455.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],37750.26,37750.26,37751.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],284696.18,284696.18,284696.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],85867.24,85867.24,85867.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],36827.81,28989.97,38353.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,39646.91,,,,,,,fee schedule,38448.8,115523.55,MSDRG Base Rate
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,39269.32,,,,,,,fee schedule,38448.8,115523.55,MSDRG Base Rate
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,39269.32,,,,,,,fee schedule,38448.8,115523.55,MSDRG Base Rate
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,39646.91,,,,,,,fee schedule,38448.8,115523.55,MSDRG Base Rate
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,39269.32,,,,,,,fee schedule,38448.8,115523.55,MSDRG Base Rate
Other Cardiothoracic Procedures With Mcc,228,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,66078.18,,,,,,,fee schedule,38448.8,115523.55,MSDRG Base Rate
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,23967.13,,,,,,,fee schedule,23967.13,72011.82,
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,23967.13,,,,,,,fee schedule,23967.13,72011.82,
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32085.83,,,,,,,fee schedule,23967.13,72011.82,
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,30557.94,,,,,,,fee schedule,23967.13,72011.82,
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,53521.21,,,,,,,fee schedule,23967.13,72011.82,
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,41590.68,,,,,,,fee schedule,23967.13,72011.82,
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,72011.82,,,,,,,fee schedule,23967.13,72011.82,
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,49504.21,,,,,,,fee schedule,23967.13,72011.82,
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,44833.45,,,,,,,fee schedule,23967.13,72011.82,
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,36720.44,,,,,,,fee schedule,23967.13,72011.82,
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],82356.36,82356.36,82356.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],22362.5,22362.5,22477.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],23832.59,23832.59,23832.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",76379.96,76379.96,76379.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",55010.64,55010.64,69199.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],23707.34,22871.84,23860.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],54269.03,54269.03,98005.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],23213.26,22291.3,30871.33,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],75568.8,75568.8,75568.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,25600.97,,,,,,,fee schedule,23967.13,72011.82,MSDRG Base Rate
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,25357.16,,,,,,,fee schedule,23967.13,72011.82,MSDRG Base Rate
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,25357.16,,,,,,,fee schedule,23967.13,72011.82,MSDRG Base Rate
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,25600.97,,,,,,,fee schedule,23967.13,72011.82,MSDRG Base Rate
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,25357.16,,,,,,,fee schedule,23967.13,72011.82,MSDRG Base Rate
Other Cardiothoracic Procedures Without Mcc,229,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,42668.29,,,,,,,fee schedule,23967.13,72011.82,MSDRG Base Rate
Other cardiothoracic procedures w/o CC/MCC,230,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other cardiothoracic procedures w/o CC/MCC,230,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other cardiothoracic procedures w/o CC/MCC,230,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Other cardiothoracic procedures w/o CC/MCC,230,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other cardiothoracic procedures w/o CC/MCC,230,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other cardiothoracic procedures w/o CC/MCC,230,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Other cardiothoracic procedures w/o CC/MCC,230,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other cardiothoracic procedures w/o CC/MCC,230,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other cardiothoracic procedures w/o CC/MCC,230,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other cardiothoracic procedures w/o CC/MCC,230,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other cardiothoracic procedures w/o CC/MCC,230,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other cardiothoracic procedures w/o CC/MCC,230,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other cardiothoracic procedures w/o CC/MCC,230,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Other cardiothoracic procedures w/o CC/MCC,230,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Other cardiothoracic procedures w/o CC/MCC,230,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other cardiothoracic procedures w/o CC/MCC,230,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other cardiothoracic procedures w/o CC/MCC,230,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other cardiothoracic procedures w/o CC/MCC,230,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,65382.03,,,,,,,fee schedule,65382.03,196447.31,
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,65382.03,,,,,,,fee schedule,65382.03,196447.31,
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,87529.71,,,,,,,fee schedule,65382.03,196447.31,
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,83361.65,,,,,,,fee schedule,65382.03,196447.31,
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,146005.16,,,,,,,fee schedule,65382.03,196447.31,
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,113458.83,,,,,,,fee schedule,65382.03,196447.31,
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,196447.31,,,,,,,fee schedule,65382.03,196447.31,
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,135046.85,,,,,,,fee schedule,65382.03,196447.31,
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,122305.06,,,,,,,fee schedule,65382.03,196447.31,
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,100172.87,,,,,,,fee schedule,65382.03,196447.31,
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],92680.65,92680.65,92680.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],151973.43,151973.43,151973.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,66853.63,,,,,,,fee schedule,65382.03,196447.31,MSDRG Base Rate
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,66216.92,,,,,,,fee schedule,65382.03,196447.31,MSDRG Base Rate
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,66216.92,,,,,,,fee schedule,65382.03,196447.31,MSDRG Base Rate
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,66853.63,,,,,,,fee schedule,65382.03,196447.31,MSDRG Base Rate
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,66216.92,,,,,,,fee schedule,65382.03,196447.31,MSDRG Base Rate
Coronary Bypass With Ptca With Mcc,231,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,111422.71,,,,,,,fee schedule,65382.03,196447.31,MSDRG Base Rate
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,47132.56,,,,,,,fee schedule,47132.56,141614.83,
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,47132.56,,,,,,,fee schedule,47132.56,141614.83,
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,63098.37,,,,,,,fee schedule,47132.56,141614.83,
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,60093.7,,,,,,,fee schedule,47132.56,141614.83,
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,105252.12,,,,,,,fee schedule,47132.56,141614.83,
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,81790.14,,,,,,,fee schedule,47132.56,141614.83,
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,141614.83,,,,,,,fee schedule,47132.56,141614.83,
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,97352.5,,,,,,,fee schedule,47132.56,141614.83,
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,88167.2,,,,,,,fee schedule,47132.56,141614.83,
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,72212.57,,,,,,,fee schedule,47132.56,141614.83,
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,48359.3,,,,,,,fee schedule,47132.56,141614.83,MSDRG Base Rate
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,47898.74,,,,,,,fee schedule,47132.56,141614.83,MSDRG Base Rate
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,47898.74,,,,,,,fee schedule,47132.56,141614.83,MSDRG Base Rate
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,48359.3,,,,,,,fee schedule,47132.56,141614.83,MSDRG Base Rate
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,47898.74,,,,,,,fee schedule,47132.56,141614.83,MSDRG Base Rate
Coronary Bypass With Ptca Without Mcc,232,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,80598.84,,,,,,,fee schedule,47132.56,141614.83,MSDRG Base Rate
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,60307.89,,,,,,,fee schedule,60144.91,181201.51,
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,60307.89,,,,,,,fee schedule,60144.91,181201.51,
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,80736.75,,,,,,,fee schedule,60144.91,181201.51,
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,76892.15,,,,,,,fee schedule,60144.91,181201.51,
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,134674.05,,,,,,,fee schedule,60144.91,181201.51,
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,104653.56,,,,,,,fee schedule,60144.91,181201.51,
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,181201.51,,,,,,,fee schedule,60144.91,181201.51,
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,124566.19,,,,,,,fee schedule,60144.91,181201.51,
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,112813.26,,,,,,,fee schedule,60144.91,181201.51,
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,92398.7,,,,,,,fee schedule,60144.91,181201.51,
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],57966.12,57966.12,57966.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],55220.67,55220.67,55220.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],91707.22,79098.97,235062.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],58267.99,58267.99,58267.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],76054.66,76054.66,76054.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],160332.18,160332.18,160332.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],59212,57569.53,59899.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],141241.66,141241.66,141241.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],116658.71,116658.71,116658.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],54472.33,27815.87,58740.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",41728.58,41728.58,41728.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],82955.2,82955.2,82955.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,60723.22,,,,,,,fee schedule,60144.91,181201.51,MSDRG Base Rate
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,60144.91,,,,,,,fee schedule,60144.91,181201.51,MSDRG Base Rate
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,60144.91,,,,,,,fee schedule,60144.91,181201.51,MSDRG Base Rate
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,60723.22,,,,,,,fee schedule,60144.91,181201.51,MSDRG Base Rate
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,60144.91,,,,,,,fee schedule,60144.91,181201.51,MSDRG Base Rate
Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc,233,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,101205.37,,,,,,,fee schedule,60144.91,181201.51,MSDRG Base Rate
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,41049.15,,,,,,,fee schedule,41049.15,123336.56,
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,41049.15,,,,,,,fee schedule,41049.15,123336.56,
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,54954.25,,,,,,,fee schedule,41049.15,123336.56,
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,52337.39,,,,,,,fee schedule,41049.15,123336.56,
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,91667.2,,,,,,,fee schedule,41049.15,123336.56,
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,71233.46,,,,,,,fee schedule,41049.15,123336.56,
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,123336.56,,,,,,,fee schedule,41049.15,123336.56,
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,84787.18,,,,,,,fee schedule,41049.15,123336.56,
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,76787.44,,,,,,,fee schedule,41049.15,123336.56,
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,62892.07,,,,,,,fee schedule,41049.15,123336.56,
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,43672.64,,,,,,,fee schedule,41049.15,123336.56,MSDRG Base Rate
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,43256.71,,,,,,,fee schedule,41049.15,123336.56,MSDRG Base Rate
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,43256.71,,,,,,,fee schedule,41049.15,123336.56,MSDRG Base Rate
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,43672.64,,,,,,,fee schedule,41049.15,123336.56,MSDRG Base Rate
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,43256.71,,,,,,,fee schedule,41049.15,123336.56,MSDRG Base Rate
Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc,234,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,72787.73,,,,,,,fee schedule,41049.15,123336.56,MSDRG Base Rate
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,45400.28,,,,,,,fee schedule,45400.28,136410.02,
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,45400.28,,,,,,,fee schedule,45400.28,136410.02,
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,60779.3,,,,,,,fee schedule,45400.28,136410.02,
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,57885.06,,,,,,,fee schedule,45400.28,136410.02,
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,101383.76,,,,,,,fee schedule,45400.28,136410.02,
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,78784.08,,,,,,,fee schedule,45400.28,136410.02,
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,136410.02,,,,,,,fee schedule,45400.28,136410.02,
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,93774.47,,,,,,,fee schedule,45400.28,136410.02,
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,84926.77,,,,,,,fee schedule,45400.28,136410.02,
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,69558.52,,,,,,,fee schedule,45400.28,136410.02,
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],37927.33,37927.33,37927.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],56179.78,56179.78,56179.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],89587.62,89587.62,89587.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],43641.69,43641.69,44150.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],91239.97,91239.97,91239.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],91641.22,91641.22,91641.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],679.61,679.61,679.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",39238.31,39238.31,39238.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],43938.36,43484.5,45194.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],83080.02,75104.19,113412.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],41722.8,41468.27,45305.69,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,46843.69,,,,,,,fee schedule,45400.28,136410.02,MSDRG Base Rate
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,46397.56,,,,,,,fee schedule,45400.28,136410.02,MSDRG Base Rate
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,46397.56,,,,,,,fee schedule,45400.28,136410.02,MSDRG Base Rate
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,46843.69,,,,,,,fee schedule,45400.28,136410.02,MSDRG Base Rate
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,46397.56,,,,,,,fee schedule,45400.28,136410.02,MSDRG Base Rate
Coronary Bypass Without Cardiac Catheterization With Mcc,235,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,78072.82,,,,,,,fee schedule,45400.28,136410.02,MSDRG Base Rate
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,31727.27,,,,,,,fee schedule,31727.27,95327.97,
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,31727.27,,,,,,,fee schedule,31727.27,95327.97,
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42474.65,,,,,,,fee schedule,31727.27,95327.97,
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40452.05,,,,,,,fee schedule,31727.27,95327.97,
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,70850.43,,,,,,,fee schedule,31727.27,95327.97,
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,55057,,,,,,,fee schedule,31727.27,95327.97,
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,95327.97,,,,,,,fee schedule,31727.27,95327.97,
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,65532.8,,,,,,,fee schedule,31727.27,95327.97,
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,59349.72,,,,,,,fee schedule,31727.27,95327.97,
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,48609.86,,,,,,,fee schedule,31727.27,95327.97,
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,33720.41,,,,,,,fee schedule,31727.27,95327.97,MSDRG Base Rate
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,33399.27,,,,,,,fee schedule,31727.27,95327.97,MSDRG Base Rate
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,33399.27,,,,,,,fee schedule,31727.27,95327.97,MSDRG Base Rate
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,33720.41,,,,,,,fee schedule,31727.27,95327.97,MSDRG Base Rate
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,33399.27,,,,,,,fee schedule,31727.27,95327.97,MSDRG Base Rate
Coronary Bypass Without Cardiac Catheterization Without Mcc,236,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,56200.69,,,,,,,fee schedule,31727.27,95327.97,MSDRG Base Rate
Major cardiovasc procedures w MCC,237,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major cardiovasc procedures w MCC,237,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Major cardiovasc procedures w MCC,237,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Major cardiovasc procedures w MCC,237,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major cardiovasc procedures w MCC,237,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major cardiovasc procedures w MCC,237,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Major cardiovasc procedures w MCC,237,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major cardiovasc procedures w MCC,237,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major cardiovasc procedures w MCC,237,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Major cardiovasc procedures w MCC,237,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Major cardiovasc procedures w MCC,237,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major cardiovasc procedures w MCC,237,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major cardiovasc procedures w MCC,237,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Major cardiovasc procedures w MCC,237,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Major cardiovasc procedures w MCC,237,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major cardiovasc procedures w MCC,237,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major cardiovasc procedures w MCC,237,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major cardiovasc procedures w MCC,237,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major cardiovasc procedures w/o MCC,238,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major cardiovasc procedures w/o MCC,238,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Major cardiovasc procedures w/o MCC,238,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Major cardiovasc procedures w/o MCC,238,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major cardiovasc procedures w/o MCC,238,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major cardiovasc procedures w/o MCC,238,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Major cardiovasc procedures w/o MCC,238,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major cardiovasc procedures w/o MCC,238,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major cardiovasc procedures w/o MCC,238,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Major cardiovasc procedures w/o MCC,238,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Major cardiovasc procedures w/o MCC,238,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major cardiovasc procedures w/o MCC,238,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major cardiovasc procedures w/o MCC,238,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Major cardiovasc procedures w/o MCC,238,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Major cardiovasc procedures w/o MCC,238,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major cardiovasc procedures w/o MCC,238,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major cardiovasc procedures w/o MCC,238,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major cardiovasc procedures w/o MCC,238,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,38862.39,,,,,,,fee schedule,38862.39,116766.22,
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,38862.39,,,,,,,fee schedule,38862.39,116766.22,
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52026.74,,,,,,,fee schedule,38862.39,116766.22,
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49549.29,,,,,,,fee schedule,38862.39,116766.22,
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,86783.93,,,,,,,fee schedule,38862.39,116766.22,
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,67438.74,,,,,,,fee schedule,38862.39,116766.22,
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,116766.22,,,,,,,fee schedule,38862.39,116766.22,
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,80270.43,,,,,,,fee schedule,38862.39,116766.22,
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,72696.84,,,,,,,fee schedule,38862.39,116766.22,
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59541.7,,,,,,,fee schedule,38862.39,116766.22,
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],29452.84,29452.84,29452.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],112876.25,112876.25,112876.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],72702.61,72702.61,72702.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],37081.09,37081.09,37081.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],36199.51,17917.13,36358.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,39446.13,,,,,,,fee schedule,38862.39,116766.22,MSDRG Base Rate
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,39070.45,,,,,,,fee schedule,38862.39,116766.22,MSDRG Base Rate
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,39070.45,,,,,,,fee schedule,38862.39,116766.22,MSDRG Base Rate
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,39446.13,,,,,,,fee schedule,38862.39,116766.22,MSDRG Base Rate
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,39070.45,,,,,,,fee schedule,38862.39,116766.22,MSDRG Base Rate
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc,239,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,65743.54,,,,,,,fee schedule,38862.39,116766.22,MSDRG Base Rate
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,22469.43,,,,,,,fee schedule,22469.43,67511.81,
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,22469.43,,,,,,,fee schedule,22469.43,67511.81,
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,30080.79,,,,,,,fee schedule,22469.43,67511.81,
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28648.37,,,,,,,fee schedule,22469.43,67511.81,
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,50176.67,,,,,,,fee schedule,22469.43,67511.81,
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,38991.68,,,,,,,fee schedule,22469.43,67511.81,
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,67511.81,,,,,,,fee schedule,22469.43,67511.81,
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,46410.7,,,,,,,fee schedule,22469.43,67511.81,
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,42031.81,,,,,,,fee schedule,22469.43,67511.81,
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,34425.78,,,,,,,fee schedule,22469.43,67511.81,
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],36319.95,36319.95,36319.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],19986.16,19986.16,19986.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],83745.92,83745.92,83745.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],20418.47,20418.47,20418.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],32678.14,32678.14,32678.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],41243.93,41243.93,41243.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],21638.35,20397.48,22484.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,23265.06,,,,,,,fee schedule,22469.43,67511.81,MSDRG Base Rate
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,23043.49,,,,,,,fee schedule,22469.43,67511.81,MSDRG Base Rate
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,23043.49,,,,,,,fee schedule,22469.43,67511.81,MSDRG Base Rate
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,23265.06,,,,,,,fee schedule,22469.43,67511.81,MSDRG Base Rate
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,23043.49,,,,,,,fee schedule,22469.43,67511.81,MSDRG Base Rate
Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc,240,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,38775.1,,,,,,,fee schedule,22469.43,67511.81,MSDRG Base Rate
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11649.84,,,,,,,fee schedule,11649.84,35003.2,
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,11649.84,,,,,,,fee schedule,11649.84,35003.2,
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15596.14,,,,,,,fee schedule,11649.84,35003.2,
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14853.47,,,,,,,fee schedule,11649.84,35003.2,
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,26015.36,,,,,,,fee schedule,11649.84,35003.2,
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,20216.22,,,,,,,fee schedule,11649.84,35003.2,
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,35003.2,,,,,,,fee schedule,11649.84,35003.2,
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,24062.8,,,,,,,fee schedule,11649.84,35003.2,
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,21792.45,,,,,,,fee schedule,11649.84,35003.2,
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17848.92,,,,,,,fee schedule,11649.84,35003.2,
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11811.29,,,,,,,fee schedule,11649.84,35003.2,MSDRG Base Rate
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,11698.8,,,,,,,fee schedule,11649.84,35003.2,MSDRG Base Rate
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,11698.8,,,,,,,fee schedule,11649.84,35003.2,MSDRG Base Rate
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,11811.29,,,,,,,fee schedule,11649.84,35003.2,MSDRG Base Rate
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,11698.8,,,,,,,fee schedule,11649.84,35003.2,MSDRG Base Rate
Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc,241,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19685.49,,,,,,,fee schedule,11649.84,35003.2,MSDRG Base Rate
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,26173.18,,,,,,,fee schedule,25692.21,78640.13,
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,26173.18,,,,,,,fee schedule,25692.21,78640.13,
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35039.16,,,,,,,fee schedule,25692.21,78640.13,
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,33370.63,,,,,,,fee schedule,25692.21,78640.13,
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,58447.55,,,,,,,fee schedule,25692.21,78640.13,
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,45418.88,,,,,,,fee schedule,25692.21,78640.13,
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,78640.13,,,,,,,fee schedule,25692.21,78640.13,
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,54060.81,,,,,,,fee schedule,25692.21,78640.13,
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,48960.13,,,,,,,fee schedule,25692.21,78640.13,
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,40100.36,,,,,,,fee schedule,25692.21,78640.13,
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],54835.07,54835.07,54835.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],45659.42,45659.42,45659.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],23927.19,22349.06,25317.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,25939.25,,,,,,,fee schedule,25692.21,78640.13,MSDRG Base Rate
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,25692.21,,,,,,,fee schedule,25692.21,78640.13,MSDRG Base Rate
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,25692.21,,,,,,,fee schedule,25692.21,78640.13,MSDRG Base Rate
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,25939.25,,,,,,,fee schedule,25692.21,78640.13,MSDRG Base Rate
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,25692.21,,,,,,,fee schedule,25692.21,78640.13,MSDRG Base Rate
Permanent Cardiac Pacemaker Implant With Mcc,242,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,43232.09,,,,,,,fee schedule,25692.21,78640.13,MSDRG Base Rate
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17382.17,,,,,,,fee schedule,17382.17,52226.6,
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,17382.17,,,,,,,fee schedule,17382.17,52226.6,
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23270.26,,,,,,,fee schedule,17382.17,52226.6,
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22162.15,,,,,,,fee schedule,17382.17,52226.6,
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,38816.27,,,,,,,fee schedule,17382.17,52226.6,
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,30163.65,,,,,,,fee schedule,17382.17,52226.6,
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,52226.6,,,,,,,fee schedule,17382.17,52226.6,
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,35902.95,,,,,,,fee schedule,17382.17,52226.6,
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,32515.47,,,,,,,fee schedule,17382.17,52226.6,
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26631.51,,,,,,,fee schedule,17382.17,52226.6,
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],130.48,130.48,130.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],15797.73,15797.73,16524.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],35661.9,35661.9,35661.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],17363.36,17363.36,17363.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],17062.89,17015.86,21978.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,17643.26,,,,,,,fee schedule,17382.17,52226.6,MSDRG Base Rate
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,17475.22,,,,,,,fee schedule,17382.17,52226.6,MSDRG Base Rate
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,17475.22,,,,,,,fee schedule,17382.17,52226.6,MSDRG Base Rate
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,17643.26,,,,,,,fee schedule,17382.17,52226.6,MSDRG Base Rate
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,17475.22,,,,,,,fee schedule,17382.17,52226.6,MSDRG Base Rate
Permanent Cardiac Pacemaker Implant With Cc,243,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,29405.42,,,,,,,fee schedule,17382.17,52226.6,MSDRG Base Rate
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13925.34,,,,,,,fee schedule,13925.34,41840.16,
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,13925.34,,,,,,,fee schedule,13925.34,41840.16,
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18642.44,,,,,,,fee schedule,13925.34,41840.16,
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17754.71,,,,,,,fee schedule,13925.34,41840.16,
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,31096.79,,,,,,,fee schedule,13925.34,41840.16,
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,24164.93,,,,,,,fee schedule,13925.34,41840.16,
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,41840.16,,,,,,,fee schedule,13925.34,41840.16,
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,28762.84,,,,,,,fee schedule,13925.34,41840.16,
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,26049.04,,,,,,,fee schedule,13925.34,41840.16,
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21335.24,,,,,,,fee schedule,13925.34,41840.16,
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",14942.73,14942.73,14942.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13506.74,13506.74,13506.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],13803.55,13803.55,13832.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15116.72,,,,,,,fee schedule,13925.34,41840.16,MSDRG Base Rate
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,14972.76,,,,,,,fee schedule,13925.34,41840.16,MSDRG Base Rate
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,14972.76,,,,,,,fee schedule,13925.34,41840.16,MSDRG Base Rate
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,15116.72,,,,,,,fee schedule,13925.34,41840.16,MSDRG Base Rate
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,14972.76,,,,,,,fee schedule,13925.34,41840.16,MSDRG Base Rate
Permanent Cardiac Pacemaker Implant Without Cc/Mcc,244,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,25194.54,,,,,,,fee schedule,13925.34,41840.16,MSDRG Base Rate
Aicd Generator Procedures,245,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,37704.97,,,,,,,fee schedule,36290.19,113288.62,
Aicd Generator Procedures,245,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,37704.97,,,,,,,fee schedule,36290.19,113288.62,
Aicd Generator Procedures,245,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,50477.25,,,,,,,fee schedule,36290.19,113288.62,
Aicd Generator Procedures,245,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,48073.58,,,,,,,fee schedule,36290.19,113288.62,
Aicd Generator Procedures,245,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,84199.28,,,,,,,fee schedule,36290.19,113288.62,
Aicd Generator Procedures,245,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,65430.24,,,,,,,fee schedule,36290.19,113288.62,
Aicd Generator Procedures,245,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,113288.62,,,,,,,fee schedule,36290.19,113288.62,
Aicd Generator Procedures,245,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,77879.77,,,,,,,fee schedule,36290.19,113288.62,
Aicd Generator Procedures,245,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,70531.74,,,,,,,fee schedule,36290.19,113288.62,
Aicd Generator Procedures,245,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,57768.4,,,,,,,fee schedule,36290.19,113288.62,
Aicd Generator Procedures,245,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aicd Generator Procedures,245,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Aicd Generator Procedures,245,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Aicd Generator Procedures,245,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aicd Generator Procedures,245,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aicd Generator Procedures,245,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Aicd Generator Procedures,245,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Aicd Generator Procedures,245,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],48076.53,48076.53,48076.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Aicd Generator Procedures,245,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Aicd Generator Procedures,245,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Aicd Generator Procedures,245,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aicd Generator Procedures,245,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aicd Generator Procedures,245,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Aicd Generator Procedures,245,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Aicd Generator Procedures,245,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aicd Generator Procedures,245,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Aicd Generator Procedures,245,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aicd Generator Procedures,245,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aicd Generator Procedures,245,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,36639.13,,,,,,,fee schedule,36290.19,113288.62,MSDRG Base Rate
Aicd Generator Procedures,245,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,36290.19,,,,,,,fee schedule,36290.19,113288.62,MSDRG Base Rate
Aicd Generator Procedures,245,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,36290.19,,,,,,,fee schedule,36290.19,113288.62,MSDRG Base Rate
Aicd Generator Procedures,245,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,36639.13,,,,,,,fee schedule,36290.19,113288.62,MSDRG Base Rate
Aicd Generator Procedures,245,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,36290.19,,,,,,,fee schedule,36290.19,113288.62,MSDRG Base Rate
Aicd Generator Procedures,245,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,61065.22,,,,,,,fee schedule,36290.19,113288.62,MSDRG Base Rate
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,246,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,23112.96,,,,,,,fee schedule,23112.96,69445.35,
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,246,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,23112.96,,,,,,,fee schedule,23112.96,69445.35,
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,246,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29468.87,,,,,,,fee schedule,23112.96,69445.35,
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,246,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,51613.74,,,,,,,fee schedule,23112.96,69445.35,
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,246,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,40108.41,,,,,,,fee schedule,23112.96,69445.35,
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,246,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,69445.35,,,,,,,fee schedule,23112.96,69445.35,
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,246,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,47739.91,,,,,,,fee schedule,23112.96,69445.35,
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,246,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,43235.6,,,,,,,fee schedule,23112.96,69445.35,
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,246,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,35411.74,,,,,,,fee schedule,23112.96,69445.35,
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,246,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,246,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,246,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,246,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,246,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,246,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,246,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,246,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,246,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,246,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,246,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,246,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,246,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,246,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,246,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,246,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,246,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,246,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc,247,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14733.99,,,,,,,fee schedule,14733.99,44269.85,
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc,247,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,14733.99,,,,,,,fee schedule,14733.99,44269.85,
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc,247,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18785.74,,,,,,,fee schedule,14733.99,44269.85,
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc,247,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,32902.59,,,,,,,fee schedule,14733.99,44269.85,
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc,247,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,25568.21,,,,,,,fee schedule,14733.99,44269.85,
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc,247,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,44269.85,,,,,,,fee schedule,14733.99,44269.85,
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc,247,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,30433.11,,,,,,,fee schedule,14733.99,44269.85,
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc,247,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,27561.72,,,,,,,fee schedule,14733.99,44269.85,
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc,247,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22574.19,,,,,,,fee schedule,14733.99,44269.85,
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc,247,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc,247,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc,247,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc,247,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc,247,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc,247,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc,247,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc,247,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc,247,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc,247,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc,247,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc,247,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc,247,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc,247,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc,247,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc,247,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc,247,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc,247,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,248,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,23224.07,,,,,,,fee schedule,23224.07,69779.2,
Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,248,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,23224.07,,,,,,,fee schedule,23224.07,69779.2,
Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,248,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29610.53,,,,,,,fee schedule,23224.07,69779.2,
Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,248,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,51861.86,,,,,,,fee schedule,23224.07,69779.2,
Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,248,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,40301.22,,,,,,,fee schedule,23224.07,69779.2,
Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,248,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,69779.2,,,,,,,fee schedule,23224.07,69779.2,
Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,248,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,47969.41,,,,,,,fee schedule,23224.07,69779.2,
Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,248,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,43443.45,,,,,,,fee schedule,23224.07,69779.2,
Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,248,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,35581.98,,,,,,,fee schedule,23224.07,69779.2,
Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,248,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,248,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,248,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,248,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,248,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,248,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,248,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,248,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,248,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,248,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,248,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,248,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,248,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,248,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,248,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,248,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,248,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents,248,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc,249,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14017.93,,,,,,,fee schedule,14017.93,42118.37,
Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc,249,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,14017.93,,,,,,,fee schedule,14017.93,42118.37,
Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc,249,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17872.77,,,,,,,fee schedule,14017.93,42118.37,
Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc,249,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,31303.56,,,,,,,fee schedule,14017.93,42118.37,
Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc,249,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,24325.61,,,,,,,fee schedule,14017.93,42118.37,
Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc,249,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,42118.37,,,,,,,fee schedule,14017.93,42118.37,
Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc,249,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,28954.09,,,,,,,fee schedule,14017.93,42118.37,
Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc,249,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,26222.25,,,,,,,fee schedule,14017.93,42118.37,
Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc,249,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21477.1,,,,,,,fee schedule,14017.93,42118.37,
Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc,249,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc,249,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc,249,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc,249,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc,249,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc,249,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc,249,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc,249,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc,249,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc,249,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc,249,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc,249,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc,249,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc,249,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc,249,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc,249,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc,249,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc,249,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17845.14,,,,,,,fee schedule,17845.14,53617.64,
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,17845.14,,,,,,,fee schedule,17845.14,53617.64,
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23890.05,,,,,,,fee schedule,17845.14,53617.64,
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22752.44,,,,,,,fee schedule,17845.14,53617.64,
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,39850.13,,,,,,,fee schedule,17845.14,53617.64,
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,30967.05,,,,,,,fee schedule,17845.14,53617.64,
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,53617.64,,,,,,,fee schedule,17845.14,53617.64,
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,36859.21,,,,,,,fee schedule,17845.14,53617.64,
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,33381.51,,,,,,,fee schedule,17845.14,53617.64,
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27340.83,,,,,,,fee schedule,17845.14,53617.64,
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",15194.64,15194.64,15194.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],17550.87,17550.87,17550.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],75014.58,75014.58,75014.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],35071.06,35071.06,35071.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,18046.37,,,,,,,fee schedule,17845.14,53617.64,MSDRG Base Rate
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,17874.5,,,,,,,fee schedule,17845.14,53617.64,MSDRG Base Rate
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,17874.5,,,,,,,fee schedule,17845.14,53617.64,MSDRG Base Rate
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,18046.37,,,,,,,fee schedule,17845.14,53617.64,MSDRG Base Rate
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,17874.5,,,,,,,fee schedule,17845.14,53617.64,MSDRG Base Rate
Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc,250,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30077.28,,,,,,,fee schedule,17845.14,53617.64,MSDRG Base Rate
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12056.48,,,,,,,fee schedule,12056.48,36225,
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,12056.48,,,,,,,fee schedule,12056.48,36225,
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16140.53,,,,,,,fee schedule,12056.48,36225,
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15371.94,,,,,,,fee schedule,12056.48,36225,
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,26923.44,,,,,,,fee schedule,12056.48,36225,
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,20921.88,,,,,,,fee schedule,12056.48,36225,
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,36225,,,,,,,fee schedule,12056.48,36225,
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,24902.72,,,,,,,fee schedule,12056.48,36225,
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,22553.13,,,,,,,fee schedule,12056.48,36225,
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18471.94,,,,,,,fee schedule,12056.48,36225,
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],15372.92,15372.92,15372.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],26425.16,26425.16,26925.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",10381.31,10381.31,10381.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12671.43,,,,,,,fee schedule,12056.48,36225,MSDRG Base Rate
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,12550.75,,,,,,,fee schedule,12056.48,36225,MSDRG Base Rate
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,12550.75,,,,,,,fee schedule,12056.48,36225,MSDRG Base Rate
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,12671.43,,,,,,,fee schedule,12056.48,36225,MSDRG Base Rate
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,12550.75,,,,,,,fee schedule,12056.48,36225,MSDRG Base Rate
Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc,251,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21119.05,,,,,,,fee schedule,12056.48,36225,MSDRG Base Rate
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,26467.94,,,,,,,fee schedule,26467.94,79525.76,
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,26467.94,,,,,,,fee schedule,26467.94,79525.76,
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35433.76,,,,,,,fee schedule,26467.94,79525.76,
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,33746.44,,,,,,,fee schedule,26467.94,79525.76,
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,59105.78,,,,,,,fee schedule,26467.94,79525.76,
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,45930.38,,,,,,,fee schedule,26467.94,79525.76,
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,79525.76,,,,,,,fee schedule,26467.94,79525.76,
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,54669.64,,,,,,,fee schedule,26467.94,79525.76,
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,49511.51,,,,,,,fee schedule,26467.94,79525.76,
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,40551.96,,,,,,,fee schedule,26467.94,79525.76,
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],24577.05,24577.05,24577.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],54672.82,54672.82,54672.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],26599.33,26599.33,26599.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",16852.72,16852.72,16852.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],25986.5,25412.3,26221.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],23367.95,19244.07,25645.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",16696.68,16696.68,16696.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,28247.81,,,,,,,fee schedule,26467.94,79525.76,MSDRG Base Rate
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,27978.79,,,,,,,fee schedule,26467.94,79525.76,MSDRG Base Rate
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,27978.79,,,,,,,fee schedule,26467.94,79525.76,MSDRG Base Rate
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,28247.81,,,,,,,fee schedule,26467.94,79525.76,MSDRG Base Rate
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,27978.79,,,,,,,fee schedule,26467.94,79525.76,MSDRG Base Rate
Other Vascular Procedures With Mcc,252,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,47079.69,,,,,,,fee schedule,26467.94,79525.76,MSDRG Base Rate
Other Vascular Procedures With Cc,253,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,19698.56,,,,,,,fee schedule,19698.56,59186.43,
Other Vascular Procedures With Cc,253,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,19698.56,,,,,,,fee schedule,19698.56,59186.43,
Other Vascular Procedures With Cc,253,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26371.3,,,,,,,fee schedule,19698.56,59186.43,
Other Vascular Procedures With Cc,253,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25115.53,,,,,,,fee schedule,19698.56,59186.43,
Other Vascular Procedures With Cc,253,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,43989.02,,,,,,,fee schedule,19698.56,59186.43,
Other Vascular Procedures With Cc,253,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,34183.33,,,,,,,fee schedule,19698.56,59186.43,
Other Vascular Procedures With Cc,253,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,59186.43,,,,,,,fee schedule,19698.56,59186.43,
Other Vascular Procedures With Cc,253,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,40687.46,,,,,,,fee schedule,19698.56,59186.43,
Other Vascular Procedures With Cc,253,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,36848.56,,,,,,,fee schedule,19698.56,59186.43,
Other Vascular Procedures With Cc,253,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30180.49,,,,,,,fee schedule,19698.56,59186.43,
Other Vascular Procedures With Cc,253,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Cc,253,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Cc,253,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],37900.05,37900.05,37900.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Vascular Procedures With Cc,253,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],17692.14,17692.14,17692.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Vascular Procedures With Cc,253,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Cc,253,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Cc,253,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",52729.95,52729.95,52729.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Vascular Procedures With Cc,253,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",13515.07,13515.07,13515.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Vascular Procedures With Cc,253,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],19123.74,17697.39,19296.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Vascular Procedures With Cc,253,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Cc,253,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Cc,253,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Cc,253,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Cc,253,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],39188.7,39188.7,39188.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Vascular Procedures With Cc,253,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],17613.76,17613.76,17707.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Vascular Procedures With Cc,253,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Cc,253,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Cc,253,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures With Cc,253,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,21273.68,,,,,,,fee schedule,19698.56,59186.43,MSDRG Base Rate
Other Vascular Procedures With Cc,253,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,21071.08,,,,,,,fee schedule,19698.56,59186.43,MSDRG Base Rate
Other Vascular Procedures With Cc,253,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,21071.08,,,,,,,fee schedule,19698.56,59186.43,MSDRG Base Rate
Other Vascular Procedures With Cc,253,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,21273.68,,,,,,,fee schedule,19698.56,59186.43,MSDRG Base Rate
Other Vascular Procedures With Cc,253,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,21071.08,,,,,,,fee schedule,19698.56,59186.43,MSDRG Base Rate
Other Vascular Procedures With Cc,253,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,35456.14,,,,,,,fee schedule,19698.56,59186.43,MSDRG Base Rate
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13497.86,,,,,,,fee schedule,13497.86,40555.77,
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,13497.86,,,,,,,fee schedule,13497.86,40555.77,
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18070.16,,,,,,,fee schedule,13497.86,40555.77,
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17209.68,,,,,,,fee schedule,13497.86,40555.77,
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,30142.19,,,,,,,fee schedule,13497.86,40555.77,
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,23423.13,,,,,,,fee schedule,13497.86,40555.77,
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,40555.77,,,,,,,fee schedule,13497.86,40555.77,
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,27879.89,,,,,,,fee schedule,13497.86,40555.77,
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,25249.4,,,,,,,fee schedule,13497.86,40555.77,
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20680.29,,,,,,,fee schedule,13497.86,40555.77,
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14915.16,,,,,,,fee schedule,13497.86,40555.77,MSDRG Base Rate
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,14773.11,,,,,,,fee schedule,13497.86,40555.77,MSDRG Base Rate
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,14773.11,,,,,,,fee schedule,13497.86,40555.77,MSDRG Base Rate
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,14915.16,,,,,,,fee schedule,13497.86,40555.77,MSDRG Base Rate
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,14773.11,,,,,,,fee schedule,13497.86,40555.77,MSDRG Base Rate
Other Vascular Procedures Without Cc/Mcc,254,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,24858.59,,,,,,,fee schedule,13497.86,40555.77,MSDRG Base Rate
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,20187.76,,,,,,,fee schedule,20187.76,60656.3,
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,20187.76,,,,,,,fee schedule,20187.76,60656.3,
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,27026.22,,,,,,,fee schedule,20187.76,60656.3,
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25739.26,,,,,,,fee schedule,20187.76,60656.3,
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,45081.47,,,,,,,fee schedule,20187.76,60656.3,
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,35032.26,,,,,,,fee schedule,20187.76,60656.3,
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,60656.3,,,,,,,fee schedule,20187.76,60656.3,
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,41697.91,,,,,,,fee schedule,20187.76,60656.3,
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,37763.67,,,,,,,fee schedule,20187.76,60656.3,
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30930,,,,,,,fee schedule,20187.76,60656.3,
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],18178.44,18178.44,18178.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,22068.98,,,,,,,fee schedule,20187.76,60656.3,MSDRG Base Rate
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,21858.8,,,,,,,fee schedule,20187.76,60656.3,MSDRG Base Rate
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,21858.8,,,,,,,fee schedule,20187.76,60656.3,MSDRG Base Rate
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,22068.98,,,,,,,fee schedule,20187.76,60656.3,MSDRG Base Rate
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,21858.8,,,,,,,fee schedule,20187.76,60656.3,MSDRG Base Rate
Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc,255,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,36781.64,,,,,,,fee schedule,20187.76,60656.3,MSDRG Base Rate
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13068.07,,,,,,,fee schedule,13068.07,39264.42,
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,13068.07,,,,,,,fee schedule,13068.07,39264.42,
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17494.79,,,,,,,fee schedule,13068.07,39264.42,
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16661.7,,,,,,,fee schedule,13068.07,39264.42,
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,29182.42,,,,,,,fee schedule,13068.07,39264.42,
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,22677.3,,,,,,,fee schedule,13068.07,39264.42,
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,39264.42,,,,,,,fee schedule,13068.07,39264.42,
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,26992.16,,,,,,,fee schedule,13068.07,39264.42,
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,24445.42,,,,,,,fee schedule,13068.07,39264.42,
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20021.81,,,,,,,fee schedule,13068.07,39264.42,
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",10966.15,10966.15,10966.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",10298.64,10298.64,10298.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12830.39,12830.39,12830.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14260.48,,,,,,,fee schedule,13068.07,39264.42,MSDRG Base Rate
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,14124.67,,,,,,,fee schedule,13068.07,39264.42,MSDRG Base Rate
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,14124.67,,,,,,,fee schedule,13068.07,39264.42,MSDRG Base Rate
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,14260.48,,,,,,,fee schedule,13068.07,39264.42,MSDRG Base Rate
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,14124.67,,,,,,,fee schedule,13068.07,39264.42,MSDRG Base Rate
Upper Limb And Toe Amputation For Circulatory System Disorders With Cc,256,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23767.47,,,,,,,fee schedule,13068.07,39264.42,MSDRG Base Rate
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6882.03,,,,,,,fee schedule,6882.03,20677.81,
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,6882.03,,,,,,,fee schedule,6882.03,20677.81,
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9213.27,,,,,,,fee schedule,6882.03,20677.81,
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8774.55,,,,,,,fee schedule,6882.03,20677.81,
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,15368.33,,,,,,,fee schedule,6882.03,20677.81,
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,11942.54,,,,,,,fee schedule,6882.03,20677.81,
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,20677.81,,,,,,,fee schedule,6882.03,20677.81,
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,14214.87,,,,,,,fee schedule,6882.03,20677.81,
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,12873.68,,,,,,,fee schedule,6882.03,20677.81,
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10544.08,,,,,,,fee schedule,6882.03,20677.81,
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9528.5,,,,,,,fee schedule,6882.03,20677.81,MSDRG Base Rate
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,9437.75,,,,,,,fee schedule,6882.03,20677.81,MSDRG Base Rate
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,9437.75,,,,,,,fee schedule,6882.03,20677.81,MSDRG Base Rate
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,9528.5,,,,,,,fee schedule,6882.03,20677.81,MSDRG Base Rate
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,9437.75,,,,,,,fee schedule,6882.03,20677.81,MSDRG Base Rate
Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc,257,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15880.83,,,,,,,fee schedule,6882.03,20677.81,MSDRG Base Rate
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,21646.89,,,,,,,fee schedule,21646.89,65040.39,
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,21646.89,,,,,,,fee schedule,21646.89,65040.39,
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28979.61,,,,,,,fee schedule,21646.89,65040.39,
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27599.64,,,,,,,fee schedule,21646.89,65040.39,
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,48339.85,,,,,,,fee schedule,21646.89,65040.39,
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,37564.31,,,,,,,fee schedule,21646.89,65040.39,
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,65040.39,,,,,,,fee schedule,21646.89,65040.39,
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,44711.74,,,,,,,fee schedule,21646.89,65040.39,
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,40493.14,,,,,,,fee schedule,21646.89,65040.39,
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33165.55,,,,,,,fee schedule,21646.89,65040.39,
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,25543.16,,,,,,,fee schedule,21646.89,65040.39,MSDRG Base Rate
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,25299.89,,,,,,,fee schedule,21646.89,65040.39,MSDRG Base Rate
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,25299.89,,,,,,,fee schedule,21646.89,65040.39,MSDRG Base Rate
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,25543.16,,,,,,,fee schedule,21646.89,65040.39,MSDRG Base Rate
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,25299.89,,,,,,,fee schedule,21646.89,65040.39,MSDRG Base Rate
Cardiac Pacemaker Device Replacement With Mcc,258,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,42571.94,,,,,,,fee schedule,21646.89,65040.39,MSDRG Base Rate
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13561.91,,,,,,,fee schedule,13561.91,40748.2,
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,13561.91,,,,,,,fee schedule,13561.91,40748.2,
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18155.9,,,,,,,fee schedule,13561.91,40748.2,
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17291.34,,,,,,,fee schedule,13561.91,40748.2,
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,30285.21,,,,,,,fee schedule,13561.91,40748.2,
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,23534.26,,,,,,,fee schedule,13561.91,40748.2,
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,40748.2,,,,,,,fee schedule,13561.91,40748.2,
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,28012.17,,,,,,,fee schedule,13561.91,40748.2,
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,25369.2,,,,,,,fee schedule,13561.91,40748.2,
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20778.42,,,,,,,fee schedule,13561.91,40748.2,
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",10231.44,10231.44,10231.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,16793.26,,,,,,,fee schedule,13561.91,40748.2,MSDRG Base Rate
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,16633.32,,,,,,,fee schedule,13561.91,40748.2,MSDRG Base Rate
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,16633.32,,,,,,,fee schedule,13561.91,40748.2,MSDRG Base Rate
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,16793.26,,,,,,,fee schedule,13561.91,40748.2,MSDRG Base Rate
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,16633.32,,,,,,,fee schedule,13561.91,40748.2,MSDRG Base Rate
Cardiac Pacemaker Device Replacement Without Mcc,259,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,27988.76,,,,,,,fee schedule,13561.91,40748.2,MSDRG Base Rate
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,26287.38,,,,,,,fee schedule,26156.49,78983.25,
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,26287.38,,,,,,,fee schedule,26156.49,78983.25,
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35192.04,,,,,,,fee schedule,26156.49,78983.25,
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,33516.23,,,,,,,fee schedule,26156.49,78983.25,
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,58702.57,,,,,,,fee schedule,26156.49,78983.25,
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,45617.05,,,,,,,fee schedule,26156.49,78983.25,
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,78983.25,,,,,,,fee schedule,26156.49,78983.25,
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,54296.69,,,,,,,fee schedule,26156.49,78983.25,
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,49173.75,,,,,,,fee schedule,26156.49,78983.25,
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,40275.33,,,,,,,fee schedule,26156.49,78983.25,
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],22765.68,22765.68,22765.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],25389.65,25389.65,25389.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,26407.99,,,,,,,fee schedule,26156.49,78983.25,MSDRG Base Rate
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,26156.49,,,,,,,fee schedule,26156.49,78983.25,MSDRG Base Rate
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,26156.49,,,,,,,fee schedule,26156.49,78983.25,MSDRG Base Rate
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,26407.99,,,,,,,fee schedule,26156.49,78983.25,MSDRG Base Rate
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,26156.49,,,,,,,fee schedule,26156.49,78983.25,MSDRG Base Rate
Cardiac Pacemaker Revision Except Device Replacement With Mcc,260,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,44013.32,,,,,,,fee schedule,26156.49,78983.25,MSDRG Base Rate
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14640.62,,,,,,,fee schedule,14640.62,43989.32,
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,14640.62,,,,,,,fee schedule,14640.62,43989.32,
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19600.03,,,,,,,fee schedule,14640.62,43989.32,
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18666.7,,,,,,,fee schedule,14640.62,43989.32,
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,32694.1,,,,,,,fee schedule,14640.62,43989.32,
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,25406.19,,,,,,,fee schedule,14640.62,43989.32,
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,43989.32,,,,,,,fee schedule,14640.62,43989.32,
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,30240.27,,,,,,,fee schedule,14640.62,43989.32,
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,27387.07,,,,,,,fee schedule,14640.62,43989.32,
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22431.14,,,,,,,fee schedule,14640.62,43989.32,
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],21365.25,21365.25,21365.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],14445.12,14445.12,14445.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15765.15,,,,,,,fee schedule,14640.62,43989.32,MSDRG Base Rate
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,15615.01,,,,,,,fee schedule,14640.62,43989.32,MSDRG Base Rate
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,15615.01,,,,,,,fee schedule,14640.62,43989.32,MSDRG Base Rate
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,15765.15,,,,,,,fee schedule,14640.62,43989.32,MSDRG Base Rate
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,15615.01,,,,,,,fee schedule,14640.62,43989.32,MSDRG Base Rate
Cardiac Pacemaker Revision Except Device Replacement With Cc,261,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,26275.25,,,,,,,fee schedule,14640.62,43989.32,MSDRG Base Rate
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11710.8,,,,,,,fee schedule,11710.8,35186.36,
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,11710.8,,,,,,,fee schedule,11710.8,35186.36,
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15677.75,,,,,,,fee schedule,11710.8,35186.36,
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14931.19,,,,,,,fee schedule,11710.8,35186.36,
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,26151.49,,,,,,,fee schedule,11710.8,35186.36,
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,20322,,,,,,,fee schedule,11710.8,35186.36,
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,35186.36,,,,,,,fee schedule,11710.8,35186.36,
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,24188.71,,,,,,,fee schedule,11710.8,35186.36,
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,21906.48,,,,,,,fee schedule,11710.8,35186.36,
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17942.31,,,,,,,fee schedule,11710.8,35186.36,
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],11152.62,11152.62,11152.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13729.23,,,,,,,fee schedule,11710.8,35186.36,MSDRG Base Rate
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,13598.48,,,,,,,fee schedule,11710.8,35186.36,MSDRG Base Rate
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,13598.48,,,,,,,fee schedule,11710.8,35186.36,MSDRG Base Rate
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,13729.23,,,,,,,fee schedule,11710.8,35186.36,MSDRG Base Rate
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,13598.48,,,,,,,fee schedule,11710.8,35186.36,MSDRG Base Rate
Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc,262,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22882.06,,,,,,,fee schedule,11710.8,35186.36,MSDRG Base Rate
Vein Ligation And Stripping,263,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,20693.94,,,,,,,fee schedule,20693.94,62177.17,
Vein Ligation And Stripping,263,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,20693.94,,,,,,,fee schedule,20693.94,62177.17,
Vein Ligation And Stripping,263,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,27703.87,,,,,,,fee schedule,20693.94,62177.17,
Vein Ligation And Stripping,263,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26384.64,,,,,,,fee schedule,20693.94,62177.17,
Vein Ligation And Stripping,263,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,46211.82,,,,,,,fee schedule,20693.94,62177.17,
Vein Ligation And Stripping,263,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,35910.64,,,,,,,fee schedule,20693.94,62177.17,
Vein Ligation And Stripping,263,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,62177.17,,,,,,,fee schedule,20693.94,62177.17,
Vein Ligation And Stripping,263,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,42743.42,,,,,,,fee schedule,20693.94,62177.17,
Vein Ligation And Stripping,263,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,38710.54,,,,,,,fee schedule,20693.94,62177.17,
Vein Ligation And Stripping,263,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,31705.53,,,,,,,fee schedule,20693.94,62177.17,
Vein Ligation And Stripping,263,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vein Ligation And Stripping,263,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Vein Ligation And Stripping,263,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Vein Ligation And Stripping,263,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vein Ligation And Stripping,263,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vein Ligation And Stripping,263,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Vein Ligation And Stripping,263,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Vein Ligation And Stripping,263,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],20317.87,20317.87,20317.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Vein Ligation And Stripping,263,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Vein Ligation And Stripping,263,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Vein Ligation And Stripping,263,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Vein Ligation And Stripping,263,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vein Ligation And Stripping,263,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Vein Ligation And Stripping,263,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Vein Ligation And Stripping,263,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vein Ligation And Stripping,263,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Vein Ligation And Stripping,263,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vein Ligation And Stripping,263,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vein Ligation And Stripping,263,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,24881.45,,,,,,,fee schedule,20693.94,62177.17,MSDRG Base Rate
Vein Ligation And Stripping,263,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,24644.48,,,,,,,fee schedule,20693.94,62177.17,MSDRG Base Rate
Vein Ligation And Stripping,263,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,24644.48,,,,,,,fee schedule,20693.94,62177.17,MSDRG Base Rate
Vein Ligation And Stripping,263,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,24881.45,,,,,,,fee schedule,20693.94,62177.17,MSDRG Base Rate
Vein Ligation And Stripping,263,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,24644.48,,,,,,,fee schedule,20693.94,62177.17,MSDRG Base Rate
Vein Ligation And Stripping,263,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,41469.08,,,,,,,fee schedule,20693.94,62177.17,MSDRG Base Rate
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,26967.17,,,,,,,fee schedule,26835.89,81025.76,
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,26967.17,,,,,,,fee schedule,26835.89,81025.76,
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36102.11,,,,,,,fee schedule,26835.89,81025.76,
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,34382.97,,,,,,,fee schedule,26835.89,81025.76,
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,60220.62,,,,,,,fee schedule,26835.89,81025.76,
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,46796.71,,,,,,,fee schedule,26835.89,81025.76,
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,81025.76,,,,,,,fee schedule,26835.89,81025.76,
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,55700.81,,,,,,,fee schedule,26835.89,81025.76,
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,50445.39,,,,,,,fee schedule,26835.89,81025.76,
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41316.85,,,,,,,fee schedule,26835.89,81025.76,
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],26277.61,26277.61,26277.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],52918.78,52918.78,52918.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],24385.32,24385.32,24385.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],15986.93,15986.93,15986.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",13299.76,13299.76,13299.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],34134.93,34134.93,34134.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",12490.21,12490.21,12490.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],26825.3,26825.3,26825.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],23779.05,23779.05,24110.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],58640.79,58640.79,58640.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,27093.93,,,,,,,fee schedule,26835.89,81025.76,MSDRG Base Rate
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,26835.89,,,,,,,fee schedule,26835.89,81025.76,MSDRG Base Rate
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,26835.89,,,,,,,fee schedule,26835.89,81025.76,MSDRG Base Rate
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,27093.93,,,,,,,fee schedule,26835.89,81025.76,MSDRG Base Rate
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,26835.89,,,,,,,fee schedule,26835.89,81025.76,MSDRG Base Rate
Other Circulatory System O.R. Procedures,264,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,45156.55,,,,,,,fee schedule,26835.89,81025.76,MSDRG Base Rate
Aicd Lead Procedures,265,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,27522.74,,,,,,,fee schedule,27522.74,82695.01,
Aicd Lead Procedures,265,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,27522.74,,,,,,,fee schedule,27522.74,82695.01,
Aicd Lead Procedures,265,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36845.86,,,,,,,fee schedule,27522.74,82695.01,
Aicd Lead Procedures,265,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,35091.3,,,,,,,fee schedule,27522.74,82695.01,
Aicd Lead Procedures,265,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,61461.25,,,,,,,fee schedule,27522.74,82695.01,
Aicd Lead Procedures,265,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,47760.79,,,,,,,fee schedule,27522.74,82695.01,
Aicd Lead Procedures,265,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,82695.01,,,,,,,fee schedule,27522.74,82695.01,
Aicd Lead Procedures,265,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,56848.32,,,,,,,fee schedule,27522.74,82695.01,
Aicd Lead Procedures,265,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,51484.63,,,,,,,fee schedule,27522.74,82695.01,
Aicd Lead Procedures,265,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42168.03,,,,,,,fee schedule,27522.74,82695.01,
Aicd Lead Procedures,265,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aicd Lead Procedures,265,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Aicd Lead Procedures,265,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Aicd Lead Procedures,265,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aicd Lead Procedures,265,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aicd Lead Procedures,265,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Aicd Lead Procedures,265,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Aicd Lead Procedures,265,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Aicd Lead Procedures,265,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Aicd Lead Procedures,265,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Aicd Lead Procedures,265,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aicd Lead Procedures,265,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aicd Lead Procedures,265,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Aicd Lead Procedures,265,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Aicd Lead Procedures,265,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aicd Lead Procedures,265,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Aicd Lead Procedures,265,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aicd Lead Procedures,265,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aicd Lead Procedures,265,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,29262.65,,,,,,,fee schedule,27522.74,82695.01,MSDRG Base Rate
Aicd Lead Procedures,265,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,28983.96,,,,,,,fee schedule,27522.74,82695.01,MSDRG Base Rate
Aicd Lead Procedures,265,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,28983.96,,,,,,,fee schedule,27522.74,82695.01,MSDRG Base Rate
Aicd Lead Procedures,265,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,29262.65,,,,,,,fee schedule,27522.74,82695.01,MSDRG Base Rate
Aicd Lead Procedures,265,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,28983.96,,,,,,,fee schedule,27522.74,82695.01,MSDRG Base Rate
Aicd Lead Procedures,265,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,48771.08,,,,,,,fee schedule,27522.74,82695.01,MSDRG Base Rate
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,46222.82,,,,,,,fee schedule,46222.82,138881.43,
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,46222.82,,,,,,,fee schedule,46222.82,138881.43,
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,61880.47,,,,,,,fee schedule,46222.82,138881.43,
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,58933.79,,,,,,,fee schedule,46222.82,138881.43,
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,103220.58,,,,,,,fee schedule,46222.82,138881.43,
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,80211.46,,,,,,,fee schedule,46222.82,138881.43,
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,138881.43,,,,,,,fee schedule,46222.82,138881.43,
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,95473.44,,,,,,,fee schedule,46222.82,138881.43,
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,86465.43,,,,,,,fee schedule,46222.82,138881.43,
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,70818.75,,,,,,,fee schedule,46222.82,138881.43,
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],44555.97,44555.97,44555.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],46089.23,46089.23,46089.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],44817.03,44817.03,44817.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],92792,92792,92792,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],81066.69,81066.69,103227.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],43893.76,34805.88,46583.49,24,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,48873.36,,,,,,,fee schedule,46222.82,138881.43,MSDRG Base Rate
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,48407.9,,,,,,,fee schedule,46222.82,138881.43,MSDRG Base Rate
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,48407.9,,,,,,,fee schedule,46222.82,138881.43,MSDRG Base Rate
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,48873.36,,,,,,,fee schedule,46222.82,138881.43,MSDRG Base Rate
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,48407.9,,,,,,,fee schedule,46222.82,138881.43,MSDRG Base Rate
Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc,266,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,81455.6,,,,,,,fee schedule,46222.82,138881.43,MSDRG Base Rate
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36299.86,,,,,,,fee schedule,36299.86,109066.81,
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,36299.86,,,,,,,fee schedule,36299.86,109066.81,
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48596.17,,,,,,,fee schedule,36299.86,109066.81,
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,46282.08,,,,,,,fee schedule,36299.86,109066.81,
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,81061.52,,,,,,,fee schedule,36299.86,109066.81,
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,62991.92,,,,,,,fee schedule,36299.86,109066.81,
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,109066.81,,,,,,,fee schedule,36299.86,109066.81,
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,74977.5,,,,,,,fee schedule,36299.86,109066.81,
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,67903.31,,,,,,,fee schedule,36299.86,109066.81,
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55615.6,,,,,,,fee schedule,36299.86,109066.81,
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],115043.52,115043.52,115043.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],34453.23,34453.23,34453.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],89419.01,89419.01,89419.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],36252.11,35292.18,36265.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],34754.13,34748.23,34804.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,38189.11,,,,,,,fee schedule,36299.86,109066.81,MSDRG Base Rate
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,37825.4,,,,,,,fee schedule,36299.86,109066.81,MSDRG Base Rate
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,37825.4,,,,,,,fee schedule,36299.86,109066.81,MSDRG Base Rate
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,38189.11,,,,,,,fee schedule,36299.86,109066.81,MSDRG Base Rate
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,37825.4,,,,,,,fee schedule,36299.86,109066.81,MSDRG Base Rate
Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc,267,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,63648.52,,,,,,,fee schedule,36299.86,109066.81,MSDRG Base Rate
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,51445.12,,,,,,,fee schedule,51445.12,154572.36,
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,51445.12,,,,,,,fee schedule,51445.12,154572.36,
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,68871.78,,,,,,,fee schedule,51445.12,154572.36,
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,65592.18,,,,,,,fee schedule,51445.12,154572.36,
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,114882.52,,,,,,,fee schedule,51445.12,154572.36,
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,89273.81,,,,,,,fee schedule,51445.12,154572.36,
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,154572.36,,,,,,,fee schedule,51445.12,154572.36,
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,106260.1,,,,,,,fee schedule,51445.12,154572.36,
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,96234.36,,,,,,,fee schedule,51445.12,154572.36,
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,78819.91,,,,,,,fee schedule,51445.12,154572.36,
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],48825.36,48825.36,48825.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",27797.25,27797.25,27797.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",27539.87,27539.87,27539.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,54728.76,,,,,,,fee schedule,51445.12,154572.36,MSDRG Base Rate
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,54207.54,,,,,,,fee schedule,51445.12,154572.36,MSDRG Base Rate
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,54207.54,,,,,,,fee schedule,51445.12,154572.36,MSDRG Base Rate
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,54728.76,,,,,,,fee schedule,51445.12,154572.36,MSDRG Base Rate
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,54207.54,,,,,,,fee schedule,51445.12,154572.36,MSDRG Base Rate
Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc,268,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,91214.6,,,,,,,fee schedule,51445.12,154572.36,MSDRG Base Rate
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,32102.27,,,,,,,fee schedule,32102.27,96454.71,
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,32102.27,,,,,,,fee schedule,32102.27,96454.71,
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42976.68,,,,,,,fee schedule,32102.27,96454.71,
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40930.18,,,,,,,fee schedule,32102.27,96454.71,
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,71687.85,,,,,,,fee schedule,32102.27,96454.71,
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,55707.76,,,,,,,fee schedule,32102.27,96454.71,
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,96454.71,,,,,,,fee schedule,32102.27,96454.71,
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,66307.37,,,,,,,fee schedule,32102.27,96454.71,
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,60051.21,,,,,,,fee schedule,32102.27,96454.71,
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,49184.42,,,,,,,fee schedule,32102.27,96454.71,
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],62137.63,62137.63,62137.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",46708.7,46708.7,46708.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",11372.5,11372.5,11372.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],31862.12,31862.12,31862.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],48855.26,48855.26,48855.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],30865.11,30655.59,30916.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,33989.16,,,,,,,fee schedule,32102.27,96454.71,MSDRG Base Rate
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,33665.46,,,,,,,fee schedule,32102.27,96454.71,MSDRG Base Rate
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,33665.46,,,,,,,fee schedule,32102.27,96454.71,MSDRG Base Rate
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,33989.16,,,,,,,fee schedule,32102.27,96454.71,MSDRG Base Rate
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,33665.46,,,,,,,fee schedule,32102.27,96454.71,MSDRG Base Rate
Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc,269,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,56648.6,,,,,,,fee schedule,32102.27,96454.71,MSDRG Base Rate
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,39605.45,,,,,,,fee schedule,39605.45,118998.84,
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,39605.45,,,,,,,fee schedule,39605.45,118998.84,
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53021.52,,,,,,,fee schedule,39605.45,118998.84,
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,50496.69,,,,,,,fee schedule,39605.45,118998.84,
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,88443.28,,,,,,,fee schedule,39605.45,118998.84,
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,68728.19,,,,,,,fee schedule,39605.45,118998.84,
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,118998.84,,,,,,,fee schedule,39605.45,118998.84,
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,81805.23,,,,,,,fee schedule,39605.45,118998.84,
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,74086.84,,,,,,,fee schedule,39605.45,118998.84,
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60680.17,,,,,,,fee schedule,39605.45,118998.84,
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],119003.47,119003.47,119003.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],35508.54,35508.54,35508.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],77172.73,72672,153002.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],35335.66,35335.66,36334.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],39369.74,39369.74,39369.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],118141.87,118141.87,118141.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",135500.16,135500.16,135500.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],181843.31,181843.31,181843.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],37153.08,37153.08,37153.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",43154.6,43154.6,43154.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],37970.19,37790.4,38997.11,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],40,40,40,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],109403.57,94978.2,175979.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],37988.36,36544.57,66715.92,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],84642.4,84642.4,84642.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,42216.4,,,,,,,fee schedule,39605.45,118998.84,MSDRG Base Rate
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,41814.34,,,,,,,fee schedule,39605.45,118998.84,MSDRG Base Rate
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,41814.34,,,,,,,fee schedule,39605.45,118998.84,MSDRG Base Rate
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,42216.4,,,,,,,fee schedule,39605.45,118998.84,MSDRG Base Rate
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,41814.34,,,,,,,fee schedule,39605.45,118998.84,MSDRG Base Rate
Other Major Cardiovascular Procedures With Mcc,270,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,70360.68,,,,,,,fee schedule,39605.45,118998.84,MSDRG Base Rate
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,26577.51,,,,,,,fee schedule,26577.51,79854.97,
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,26577.51,,,,,,,fee schedule,26577.51,79854.97,
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35580.45,,,,,,,fee schedule,26577.51,79854.97,
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,33886.14,,,,,,,fee schedule,26577.51,79854.97,
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,59350.46,,,,,,,fee schedule,26577.51,79854.97,
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,46120.52,,,,,,,fee schedule,26577.51,79854.97,
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,79854.97,,,,,,,fee schedule,26577.51,79854.97,
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,54895.95,,,,,,,fee schedule,26577.51,79854.97,
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,49716.47,,,,,,,fee schedule,26577.51,79854.97,
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,40719.83,,,,,,,fee schedule,26577.51,79854.97,
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],23999.73,23999.73,23999.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],26782.37,26782.37,26782.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],54895.95,54720.95,54895.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],28137.76,28137.76,28137.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],73117.93,73117.93,73117.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",81493.45,81493.45,81493.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",19260.53,19260.53,19260.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],26092.55,25445.23,43710.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],40719.83,40719.83,40719.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],57790.14,57790.14,120831.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],24142.38,23425.25,25695.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",19082.19,19082.19,19082.19,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,28779.06,,,,,,,fee schedule,26577.51,79854.97,MSDRG Base Rate
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,28504.98,,,,,,,fee schedule,26577.51,79854.97,MSDRG Base Rate
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,28504.98,,,,,,,fee schedule,26577.51,79854.97,MSDRG Base Rate
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,28779.06,,,,,,,fee schedule,26577.51,79854.97,MSDRG Base Rate
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,28504.98,,,,,,,fee schedule,26577.51,79854.97,MSDRG Base Rate
Other Major Cardiovascular Procedures With Cc,271,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,47965.1,,,,,,,fee schedule,26577.51,79854.97,MSDRG Base Rate
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,19305.81,,,,,,,fee schedule,19305.81,58006.37,
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,19305.81,,,,,,,fee schedule,19305.81,58006.37,
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,25845.51,,,,,,,fee schedule,19305.81,58006.37,
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24614.78,,,,,,,fee schedule,19305.81,58006.37,
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,43111.96,,,,,,,fee schedule,19305.81,58006.37,
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,33501.78,,,,,,,fee schedule,19305.81,58006.37,
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,58006.37,,,,,,,fee schedule,19305.81,58006.37,
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,39876.23,,,,,,,fee schedule,19305.81,58006.37,
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,36113.87,,,,,,,fee schedule,19305.81,58006.37,
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,29578.74,,,,,,,fee schedule,19305.81,58006.37,
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],66289.59,66289.59,66289.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",13961.72,13961.72,13961.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],19291.14,19291.14,19291.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],20249.39,20249.39,20249.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,20940.87,,,,,,,fee schedule,19305.81,58006.37,MSDRG Base Rate
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,20741.44,,,,,,,fee schedule,19305.81,58006.37,MSDRG Base Rate
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,20741.44,,,,,,,fee schedule,19305.81,58006.37,MSDRG Base Rate
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,20940.87,,,,,,,fee schedule,19305.81,58006.37,MSDRG Base Rate
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,20741.44,,,,,,,fee schedule,19305.81,58006.37,MSDRG Base Rate
Other Major Cardiovascular Procedures Without Cc/Mcc,272,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,34901.46,,,,,,,fee schedule,19305.81,58006.37,MSDRG Base Rate
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,30170.15,,,,,,,fee schedule,30170.15,90649.44,
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,30170.15,,,,,,,fee schedule,30170.15,90649.44,
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40390.07,,,,,,,fee schedule,30170.15,90649.44,
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,38466.74,,,,,,,fee schedule,30170.15,90649.44,
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,67373.21,,,,,,,fee schedule,30170.15,90649.44,
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,52354.9,,,,,,,fee schedule,30170.15,90649.44,
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,90649.44,,,,,,,fee schedule,30170.15,90649.44,
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,62316.56,,,,,,,fee schedule,30170.15,90649.44,
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,56436.94,,,,,,,fee schedule,30170.15,90649.44,
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46224.18,,,,,,,fee schedule,30170.15,90649.44,
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],30075.18,30075.18,30075.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],23363.34,250,27547.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],121194.75,121194.75,121194.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,33225.88,,,,,,,fee schedule,30170.15,90649.44,MSDRG Base Rate
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,32909.45,,,,,,,fee schedule,30170.15,90649.44,MSDRG Base Rate
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,32909.45,,,,,,,fee schedule,30170.15,90649.44,MSDRG Base Rate
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,33225.88,,,,,,,fee schedule,30170.15,90649.44,MSDRG Base Rate
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,32909.45,,,,,,,fee schedule,30170.15,90649.44,MSDRG Base Rate
Percutaneous And Other Intracardiac Procedures With Mcc,273,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,55376.48,,,,,,,fee schedule,30170.15,90649.44,MSDRG Base Rate
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,24080.56,,,,,,,fee schedule,24080.56,72352.63,
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,24080.56,,,,,,,fee schedule,24080.56,72352.63,
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32237.68,,,,,,,fee schedule,24080.56,72352.63,
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,30702.56,,,,,,,fee schedule,24080.56,72352.63,
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,53774.5,,,,,,,fee schedule,24080.56,72352.63,
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,41787.51,,,,,,,fee schedule,24080.56,72352.63,
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,72352.63,,,,,,,fee schedule,24080.56,72352.63,
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,49738.5,,,,,,,fee schedule,24080.56,72352.63,
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,45045.63,,,,,,,fee schedule,24080.56,72352.63,
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,36894.22,,,,,,,fee schedule,24080.56,72352.63,
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],23544.88,23544.88,23544.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],103706.46,103706.46,103706.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],24582.95,24582.95,24582.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],76994.41,76994.41,98522.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",37507.15,37507.15,37507.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],23957.04,23633.98,24032.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],36896.59,36896.59,36896.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],58592.26,58592.26,58592.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],23280.7,22843,25839.09,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,26711.9,,,,,,,fee schedule,24080.56,72352.63,MSDRG Base Rate
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,26457.5,,,,,,,fee schedule,24080.56,72352.63,MSDRG Base Rate
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,26457.5,,,,,,,fee schedule,24080.56,72352.63,MSDRG Base Rate
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,26711.9,,,,,,,fee schedule,24080.56,72352.63,MSDRG Base Rate
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,26457.5,,,,,,,fee schedule,24080.56,72352.63,MSDRG Base Rate
Percutaneous And Other Intracardiac Procedures Without Mcc,274,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,44519.82,,,,,,,fee schedule,24080.56,72352.63,MSDRG Base Rate
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,54526.17,,,,,,,fee schedule,54526.17,163829.74,
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,54526.17,,,,,,,fee schedule,54526.17,163829.74,
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,72996.52,,,,,,,fee schedule,54526.17,163829.74,
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,69520.51,,,,,,,fee schedule,54526.17,163829.74,
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,121762.86,,,,,,,fee schedule,54526.17,163829.74,
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,94620.44,,,,,,,fee schedule,54526.17,163829.74,
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,163829.74,,,,,,,fee schedule,54526.17,163829.74,
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,112624.04,,,,,,,fee schedule,54526.17,163829.74,
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,101997.86,,,,,,,fee schedule,54526.17,163829.74,
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83540.45,,,,,,,fee schedule,54526.17,163829.74,
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],63228.98,63228.98,63228.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],94454.31,94454.31,94454.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",51574.82,51574.82,51574.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],95.61,95.61,95.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],162318.96,162318.96,162318.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,56701.4,,,,,,,fee schedule,54526.17,163829.74,MSDRG Base Rate
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,56161.38,,,,,,,fee schedule,54526.17,163829.74,MSDRG Base Rate
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,56161.38,,,,,,,fee schedule,54526.17,163829.74,MSDRG Base Rate
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,56701.4,,,,,,,fee schedule,54526.17,163829.74,MSDRG Base Rate
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,56161.38,,,,,,,fee schedule,54526.17,163829.74,MSDRG Base Rate
Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc,275,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,94502.33,,,,,,,fee schedule,54526.17,163829.74,MSDRG Base Rate
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,47793.83,,,,,,,fee schedule,47465.41,143601.7,
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,47793.83,,,,,,,fee schedule,47465.41,143601.7,
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,63983.65,,,,,,,fee schedule,47465.41,143601.7,
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,60936.82,,,,,,,fee schedule,47465.41,143601.7,
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,106728.81,,,,,,,fee schedule,47465.41,143601.7,
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,82937.66,,,,,,,fee schedule,47465.41,143601.7,
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,143601.7,,,,,,,fee schedule,47465.41,143601.7,
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,98718.36,,,,,,,fee schedule,47465.41,143601.7,
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,89404.2,,,,,,,fee schedule,47465.41,143601.7,
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,73225.72,,,,,,,fee schedule,47465.41,143601.7,
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],40862.93,40862.93,40862.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],93511.13,93511.13,93511.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",41120.36,41120.36,41120.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],45780.66,45780.66,45780.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],123963.69,123963.69,123963.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,47921.81,,,,,,,fee schedule,47465.41,143601.7,MSDRG Base Rate
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,47465.41,,,,,,,fee schedule,47465.41,143601.7,MSDRG Base Rate
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,47465.41,,,,,,,fee schedule,47465.41,143601.7,MSDRG Base Rate
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,47921.81,,,,,,,fee schedule,47465.41,143601.7,MSDRG Base Rate
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,47465.41,,,,,,,fee schedule,47465.41,143601.7,MSDRG Base Rate
Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator,276,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,79869.68,,,,,,,fee schedule,47465.41,143601.7,MSDRG Base Rate
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,35897.07,,,,,,,fee schedule,35897.07,107856.6,
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,35897.07,,,,,,,fee schedule,35897.07,107856.6,
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48056.95,,,,,,,fee schedule,35897.07,107856.6,
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,45768.53,,,,,,,fee schedule,35897.07,107856.6,
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,80162.06,,,,,,,fee schedule,35897.07,107856.6,
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,62292.96,,,,,,,fee schedule,35897.07,107856.6,
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,107856.6,,,,,,,fee schedule,35897.07,107856.6,
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,74145.55,,,,,,,fee schedule,35897.07,107856.6,
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,67149.85,,,,,,,fee schedule,35897.07,107856.6,
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,54998.49,,,,,,,fee schedule,35897.07,107856.6,
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],33335,33335,33335,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],100358.22,100358.22,100358.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],33597.32,33597.32,33597.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],89876.76,89876.76,89876.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],35880.43,35880.43,35880.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,37077.4,,,,,,,fee schedule,35897.07,107856.6,MSDRG Base Rate
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,36724.28,,,,,,,fee schedule,35897.07,107856.6,MSDRG Base Rate
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,36724.28,,,,,,,fee schedule,35897.07,107856.6,MSDRG Base Rate
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,37077.4,,,,,,,fee schedule,35897.07,107856.6,MSDRG Base Rate
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,36724.28,,,,,,,fee schedule,35897.07,107856.6,MSDRG Base Rate
Cardiac Defibrillator Implant Without Mcc,277,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,61795.67,,,,,,,fee schedule,35897.07,107856.6,MSDRG Base Rate
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,38603.13,,,,,,,fee schedule,38603.13,115987.23,
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,38603.13,,,,,,,fee schedule,38603.13,115987.23,
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51679.66,,,,,,,fee schedule,38603.13,115987.23,
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49218.73,,,,,,,fee schedule,38603.13,115987.23,
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,86204.97,,,,,,,fee schedule,38603.13,115987.23,
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,66988.83,,,,,,,fee schedule,38603.13,115987.23,
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,115987.23,,,,,,,fee schedule,38603.13,115987.23,
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,79734.92,,,,,,,fee schedule,38603.13,115987.23,
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,72211.86,,,,,,,fee schedule,38603.13,115987.23,
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59144.48,,,,,,,fee schedule,38603.13,115987.23,
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,44481.22,,,,,,,fee schedule,38603.13,115987.23,MSDRG Base Rate
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,44057.59,,,,,,,fee schedule,38603.13,115987.23,MSDRG Base Rate
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,44057.59,,,,,,,fee schedule,38603.13,115987.23,MSDRG Base Rate
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,44481.22,,,,,,,fee schedule,38603.13,115987.23,MSDRG Base Rate
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,44057.59,,,,,,,fee schedule,38603.13,115987.23,MSDRG Base Rate
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc,278,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,74135.37,,,,,,,fee schedule,38603.13,115987.23,MSDRG Base Rate
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,24724.09,,,,,,,fee schedule,24724.09,74286.17,
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,24724.09,,,,,,,fee schedule,24724.09,74286.17,
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,33099.19,,,,,,,fee schedule,24724.09,74286.17,
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,31523.05,,,,,,,fee schedule,24724.09,74286.17,
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,55211.57,,,,,,,fee schedule,24724.09,74286.17,
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,42904.24,,,,,,,fee schedule,24724.09,74286.17,
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,74286.17,,,,,,,fee schedule,24724.09,74286.17,
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,51067.71,,,,,,,fee schedule,24724.09,74286.17,
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,46249.42,,,,,,,fee schedule,24724.09,74286.17,
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37880.18,,,,,,,fee schedule,24724.09,74286.17,
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],27906.11,27906.11,27906.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,29170.46,,,,,,,fee schedule,24724.09,74286.17,MSDRG Base Rate
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,28892.65,,,,,,,fee schedule,24724.09,74286.17,MSDRG Base Rate
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,28892.65,,,,,,,fee schedule,24724.09,74286.17,MSDRG Base Rate
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,29170.46,,,,,,,fee schedule,24724.09,74286.17,MSDRG Base Rate
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,28892.65,,,,,,,fee schedule,24724.09,74286.17,MSDRG Base Rate
Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc,279,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,48617.43,,,,,,,fee schedule,24724.09,74286.17,MSDRG Base Rate
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12666.06,,,,,,,fee schedule,12666.06,38056.54,
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,12666.06,,,,,,,fee schedule,12666.06,38056.54,
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16956.6,,,,,,,fee schedule,12666.06,38056.54,
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16149.14,,,,,,,fee schedule,12666.06,38056.54,
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,28284.69,,,,,,,fee schedule,12666.06,38056.54,
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,21979.69,,,,,,,fee schedule,12666.06,38056.54,
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,38056.54,,,,,,,fee schedule,12666.06,38056.54,
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,26161.8,,,,,,,fee schedule,12666.06,38056.54,
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,23693.41,,,,,,,fee schedule,12666.06,38056.54,
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19405.88,,,,,,,fee schedule,12666.06,38056.54,
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],11685.96,11685.96,11685.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11813.05,10641.87,12595.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],24410.21,22450.02,26160.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13187.96,13058.17,13193.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],23691.97,23691.97,23691.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",62480.6,62480.6,62480.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",15924.16,15924.16,15924.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],16148.16,16148.16,16148.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12434.2,10964.2,12553.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],19429.7,19429.7,19429.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],25472.82,200,27539.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],11874.48,5402.91,13089.26,20,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13527.68,,,,,,,fee schedule,12666.06,38056.54,MSDRG Base Rate
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,13398.84,,,,,,,fee schedule,12666.06,38056.54,MSDRG Base Rate
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,13398.84,,,,,,,fee schedule,12666.06,38056.54,MSDRG Base Rate
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,13527.68,,,,,,,fee schedule,12666.06,38056.54,MSDRG Base Rate
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,13398.84,,,,,,,fee schedule,12666.06,38056.54,MSDRG Base Rate
"Acute Myocardial Infarction, Discharged Alive With Mcc",280,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22546.12,,,,,,,fee schedule,12666.06,38056.54,MSDRG Base Rate
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7112.75,,,,,,,fee schedule,7112.75,21371.01,
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,7112.75,,,,,,,fee schedule,7112.75,21371.01,
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9522.14,,,,,,,fee schedule,7112.75,21371.01,
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9068.71,,,,,,,fee schedule,7112.75,21371.01,
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,15883.54,,,,,,,fee schedule,7112.75,21371.01,
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,12342.9,,,,,,,fee schedule,7112.75,21371.01,
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,21371.01,,,,,,,fee schedule,7112.75,21371.01,
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,14691.41,,,,,,,fee schedule,7112.75,21371.01,
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,13305.26,,,,,,,fee schedule,7112.75,21371.01,
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10897.56,,,,,,,fee schedule,7112.75,21371.01,
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7386.7,7386.7,7386.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],13072.21,13072.21,14042.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7498.57,7498.57,7498.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],10755.73,10755.73,10755.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],9068.71,9068.71,9068.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",14432.88,14432.88,14432.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7016.49,6991.97,7016.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],8302.9,8302.9,8302.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],14814.73,14814.73,14814.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],7034.68,6012.07,7992.23,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",14299.24,14299.24,14299.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8176.17,,,,,,,fee schedule,7112.75,21371.01,MSDRG Base Rate
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,8098.3,,,,,,,fee schedule,7112.75,21371.01,MSDRG Base Rate
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,8098.3,,,,,,,fee schedule,7112.75,21371.01,MSDRG Base Rate
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,8176.17,,,,,,,fee schedule,7112.75,21371.01,MSDRG Base Rate
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,8098.3,,,,,,,fee schedule,7112.75,21371.01,MSDRG Base Rate
"Acute Myocardial Infarction, Discharged Alive With Cc",281,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,13626.95,,,,,,,fee schedule,7112.75,21371.01,MSDRG Base Rate
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5594.98,,,,,,,fee schedule,5594.98,16810.72,
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,5594.98,,,,,,,fee schedule,5594.98,16810.72,
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7490.24,,,,,,,fee schedule,5594.98,16810.72,
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7133.56,,,,,,,fee schedule,5594.98,16810.72,
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,12494.2,,,,,,,fee schedule,5594.98,16810.72,
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,9709.09,,,,,,,fee schedule,5594.98,16810.72,
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,16810.72,,,,,,,fee schedule,5594.98,16810.72,
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,11556.46,,,,,,,fee schedule,5594.98,16810.72,
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,10466.09,,,,,,,fee schedule,5594.98,16810.72,
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8572.16,,,,,,,fee schedule,5594.98,16810.72,
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],13448.58,13448.58,13448.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],4837.89,4837.89,6490.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],10797.64,9020,11556.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],7466.09,7466.09,9351.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",11681.16,11681.16,11681.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],2909.89,2909.89,2909.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],5526.41,5526.41,5526.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],8572.16,8572.16,8572.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],11584.06,11584.06,11994.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],6174.69,6174.69,6473.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",11573,11573,11573,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,6644.95,,,,,,,fee schedule,5594.98,16810.72,MSDRG Base Rate
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,6581.66,,,,,,,fee schedule,5594.98,16810.72,MSDRG Base Rate
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,6581.66,,,,,,,fee schedule,5594.98,16810.72,MSDRG Base Rate
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,6644.95,,,,,,,fee schedule,5594.98,16810.72,MSDRG Base Rate
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,6581.66,,,,,,,fee schedule,5594.98,16810.72,MSDRG Base Rate
"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc",282,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11074.91,,,,,,,fee schedule,5594.98,16810.72,MSDRG Base Rate
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,15088.16,,,,,,,fee schedule,15088.16,45333.99,
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,15088.16,,,,,,,fee schedule,15088.16,45333.99,
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20199.16,,,,,,,fee schedule,15088.16,45333.99,
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19237.3,,,,,,,fee schedule,15088.16,45333.99,
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,33693.5,,,,,,,fee schedule,15088.16,45333.99,
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,26182.81,,,,,,,fee schedule,15088.16,45333.99,
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,45333.99,,,,,,,fee schedule,15088.16,45333.99,
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,31164.66,,,,,,,fee schedule,15088.16,45333.99,
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,28224.24,,,,,,,fee schedule,15088.16,45333.99,
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23116.82,,,,,,,fee schedule,15088.16,45333.99,
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],126.45,126.45,126.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],14373.41,14373.41,14373.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],14363.53,14363.53,15612.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,16470.6,,,,,,,fee schedule,15088.16,45333.99,MSDRG Base Rate
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,16313.74,,,,,,,fee schedule,15088.16,45333.99,MSDRG Base Rate
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,16313.74,,,,,,,fee schedule,15088.16,45333.99,MSDRG Base Rate
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,16470.6,,,,,,,fee schedule,15088.16,45333.99,MSDRG Base Rate
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,16313.74,,,,,,,fee schedule,15088.16,45333.99,MSDRG Base Rate
"Acute Myocardial Infarction, Expired With Mcc",283,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,27451.01,,,,,,,fee schedule,15088.16,45333.99,MSDRG Base Rate
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5716.9,,,,,,,fee schedule,5716.9,17177.03,
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,5716.9,,,,,,,fee schedule,5716.9,17177.03,
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7653.45,,,,,,,fee schedule,5716.9,17177.03,
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7289,,,,,,,fee schedule,5716.9,17177.03,
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,12766.45,,,,,,,fee schedule,5716.9,17177.03,
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,9920.65,,,,,,,fee schedule,5716.9,17177.03,
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,17177.03,,,,,,,fee schedule,5716.9,17177.03,
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,11808.27,,,,,,,fee schedule,5716.9,17177.03,
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,10694.15,,,,,,,fee schedule,5716.9,17177.03,
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8758.95,,,,,,,fee schedule,5716.9,17177.03,
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,6403.54,,,,,,,fee schedule,5716.9,17177.03,MSDRG Base Rate
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,6342.55,,,,,,,fee schedule,5716.9,17177.03,MSDRG Base Rate
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,6342.55,,,,,,,fee schedule,5716.9,17177.03,MSDRG Base Rate
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,6403.54,,,,,,,fee schedule,5716.9,17177.03,MSDRG Base Rate
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,6342.55,,,,,,,fee schedule,5716.9,17177.03,MSDRG Base Rate
"Acute Myocardial Infarction, Expired With Cc",284,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10672.57,,,,,,,fee schedule,5716.9,17177.03,MSDRG Base Rate
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4331.07,,,,,,,fee schedule,4331.07,13013.18,
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,4331.07,,,,,,,fee schedule,4331.07,13013.18,
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5798.2,,,,,,,fee schedule,4331.07,13013.18,
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5522.09,,,,,,,fee schedule,4331.07,13013.18,
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,9671.76,,,,,,,fee schedule,4331.07,13013.18,
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,7515.81,,,,,,,fee schedule,4331.07,13013.18,
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,13013.18,,,,,,,fee schedule,4331.07,13013.18,
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,8945.85,,,,,,,fee schedule,4331.07,13013.18,
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,8101.8,,,,,,,fee schedule,4331.07,13013.18,
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6635.71,,,,,,,fee schedule,4331.07,13013.18,
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,5674.64,,,,,,,fee schedule,4331.07,13013.18,MSDRG Base Rate
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,5620.6,,,,,,,fee schedule,4331.07,13013.18,MSDRG Base Rate
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,5620.6,,,,,,,fee schedule,4331.07,13013.18,MSDRG Base Rate
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,5674.64,,,,,,,fee schedule,4331.07,13013.18,MSDRG Base Rate
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,5620.6,,,,,,,fee schedule,4331.07,13013.18,MSDRG Base Rate
"Acute Myocardial Infarction, Expired Without Cc/Mcc",285,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9457.74,,,,,,,fee schedule,4331.07,13013.18,MSDRG Base Rate
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17078.15,,,,,,,fee schedule,17078.15,51313.15,
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,17078.15,,,,,,,fee schedule,17078.15,51313.15,
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22863.26,,,,,,,fee schedule,17078.15,51313.15,
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21774.53,,,,,,,fee schedule,17078.15,51313.15,
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,38137.37,,,,,,,fee schedule,17078.15,51313.15,
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,29636.09,,,,,,,fee schedule,17078.15,51313.15,
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,51313.15,,,,,,,fee schedule,17078.15,51313.15,
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,35275,,,,,,,fee schedule,17078.15,51313.15,
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,31946.77,,,,,,,fee schedule,17078.15,51313.15,
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26165.72,,,,,,,fee schedule,17078.15,51313.15,
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],23788.69,23788.69,76661.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],16913.57,16913.57,16913.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],15357.5,10367.64,16999.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],34216.31,24232.62,35275,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],15778.95,29.94,17748.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],31182.26,31182.26,32638.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",44983.25,44983.25,44983.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],62848.17,62848.17,62848.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",9116.88,9116.88,99589.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],15415.21,15415.21,15415.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],16156.49,14695.5,16432.55,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],37134.75,28692,38137.37,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],15353.67,14718.12,16763.27,26,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",1492.61,1492.61,1492.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,18283.09,,,,,,,fee schedule,17078.15,51313.15,MSDRG Base Rate
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,18108.97,,,,,,,fee schedule,17078.15,51313.15,MSDRG Base Rate
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,18108.97,,,,,,,fee schedule,17078.15,51313.15,MSDRG Base Rate
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,18283.09,,,,,,,fee schedule,17078.15,51313.15,MSDRG Base Rate
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,18108.97,,,,,,,fee schedule,17078.15,51313.15,MSDRG Base Rate
"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc",286,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30471.82,,,,,,,fee schedule,17078.15,51313.15,MSDRG Base Rate
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8407.52,,,,,,,fee schedule,8407.52,25261.29,
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,8407.52,,,,,,,fee schedule,8407.52,25261.29,
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11255.5,,,,,,,fee schedule,8407.52,25261.29,
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10719.53,,,,,,,fee schedule,8407.52,25261.29,
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,18774.9,,,,,,,fee schedule,8407.52,25261.29,
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,14589.74,,,,,,,fee schedule,8407.52,25261.29,
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,25261.29,,,,,,,fee schedule,8407.52,25261.29,
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,17365.76,,,,,,,fee schedule,8407.52,25261.29,
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,15727.29,,,,,,,fee schedule,8407.52,25261.29,
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12881.29,,,,,,,fee schedule,8407.52,25261.29,
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7481.48,7481.48,8209.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],17238.26,14282.17,17367.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9297.46,9297.46,9496.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],14608.7,14186.41,15728.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],10720.51,10720.51,10720.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",8064.08,8064.08,8064.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8078.82,8078.82,8374.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],12882.48,12882.48,12882.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],17310.34,15673.06,22188.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],8565.95,7055.97,8594.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9355.85,,,,,,,fee schedule,8407.52,25261.29,MSDRG Base Rate
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,9266.74,,,,,,,fee schedule,8407.52,25261.29,MSDRG Base Rate
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,9266.74,,,,,,,fee schedule,8407.52,25261.29,MSDRG Base Rate
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,9355.85,,,,,,,fee schedule,8407.52,25261.29,MSDRG Base Rate
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,9266.74,,,,,,,fee schedule,8407.52,25261.29,MSDRG Base Rate
"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc",287,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15593.08,,,,,,,fee schedule,8407.52,25261.29,MSDRG Base Rate
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,21075.12,,,,,,,fee schedule,21075.12,63322.46,
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,21075.12,,,,,,,fee schedule,21075.12,63322.46,
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28214.17,,,,,,,fee schedule,21075.12,63322.46,
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26870.64,,,,,,,fee schedule,21075.12,63322.46,
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,47063.03,,,,,,,fee schedule,21075.12,63322.46,
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,36572.11,,,,,,,fee schedule,21075.12,63322.46,
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,63322.46,,,,,,,fee schedule,21075.12,63322.46,
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,43530.75,,,,,,,fee schedule,21075.12,63322.46,
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,39423.58,,,,,,,fee schedule,21075.12,63322.46,
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,32289.54,,,,,,,fee schedule,21075.12,63322.46,
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],32323,32323,32323,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",17953.67,17953.67,17953.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,22137.73,,,,,,,fee schedule,21075.12,63322.46,MSDRG Base Rate
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,21926.89,,,,,,,fee schedule,21075.12,63322.46,MSDRG Base Rate
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,21926.89,,,,,,,fee schedule,21075.12,63322.46,MSDRG Base Rate
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,22137.73,,,,,,,fee schedule,21075.12,63322.46,MSDRG Base Rate
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,21926.89,,,,,,,fee schedule,21075.12,63322.46,MSDRG Base Rate
Acute And Subacute Endocarditis With Mcc,288,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,36896.21,,,,,,,fee schedule,21075.12,63322.46,MSDRG Base Rate
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12165.28,,,,,,,fee schedule,12165.28,36551.89,
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,12165.28,,,,,,,fee schedule,12165.28,36551.89,
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16286.18,,,,,,,fee schedule,12165.28,36551.89,
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15510.65,,,,,,,fee schedule,12165.28,36551.89,
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,27166.39,,,,,,,fee schedule,12165.28,36551.89,
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,21110.67,,,,,,,fee schedule,12165.28,36551.89,
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,36551.89,,,,,,,fee schedule,12165.28,36551.89,
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,25127.44,,,,,,,fee schedule,12165.28,36551.89,
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,22756.64,,,,,,,fee schedule,12165.28,36551.89,
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18638.63,,,,,,,fee schedule,12165.28,36551.89,
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14330.79,,,,,,,fee schedule,12165.28,36551.89,MSDRG Base Rate
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,14194.3,,,,,,,fee schedule,12165.28,36551.89,MSDRG Base Rate
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,14194.3,,,,,,,fee schedule,12165.28,36551.89,MSDRG Base Rate
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,14330.79,,,,,,,fee schedule,12165.28,36551.89,MSDRG Base Rate
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,14194.3,,,,,,,fee schedule,12165.28,36551.89,MSDRG Base Rate
Acute And Subacute Endocarditis With Cc,289,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23884.65,,,,,,,fee schedule,12165.28,36551.89,MSDRG Base Rate
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7554.11,,,,,,,fee schedule,7554.11,22697.14,
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,7554.11,,,,,,,fee schedule,7554.11,22697.14,
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10113.01,,,,,,,fee schedule,7554.11,22697.14,
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9631.44,,,,,,,fee schedule,7554.11,22697.14,
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,16869.15,,,,,,,fee schedule,7554.11,22697.14,
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,13108.81,,,,,,,fee schedule,7554.11,22697.14,
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,22697.14,,,,,,,fee schedule,7554.11,22697.14,
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,15603.05,,,,,,,fee schedule,7554.11,22697.14,
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,14130.89,,,,,,,fee schedule,7554.11,22697.14,
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11573.78,,,,,,,fee schedule,7554.11,22697.14,
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8258.98,,,,,,,fee schedule,7554.11,22697.14,MSDRG Base Rate
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,8180.33,,,,,,,fee schedule,7554.11,22697.14,MSDRG Base Rate
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,8180.33,,,,,,,fee schedule,7554.11,22697.14,MSDRG Base Rate
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,8258.98,,,,,,,fee schedule,7554.11,22697.14,MSDRG Base Rate
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,8180.33,,,,,,,fee schedule,7554.11,22697.14,MSDRG Base Rate
Acute And Subacute Endocarditis Without Cc/Mcc,290,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,13764.98,,,,,,,fee schedule,7554.11,22697.14,MSDRG Base Rate
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10068.8,,,,,,,fee schedule,10068.8,30252.8,
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,10068.8,,,,,,,fee schedule,10068.8,30252.8,
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13479.54,,,,,,,fee schedule,10068.8,30252.8,
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12837.66,,,,,,,fee schedule,10068.8,30252.8,
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,22484.73,,,,,,,fee schedule,10068.8,30252.8,
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,17472.61,,,,,,,fee schedule,10068.8,30252.8,
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,30252.8,,,,,,,fee schedule,10068.8,30252.8,
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,20797.16,,,,,,,fee schedule,10068.8,30252.8,
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,18834.93,,,,,,,fee schedule,10068.8,30252.8,
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15426.58,,,,,,,fee schedule,10068.8,30252.8,
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],10235.88,9096.7,10260.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],17215.3,17215.3,17215.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9290.49,7957.02,10261.15,52,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],17372.07,12177.34,20795.56,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9766.75,142.65,10554.45,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],18833.48,18833.48,21093.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",9013.38,9013.38,9013.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],12836.67,12836.67,12836.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",8464.73,8464.73,8464.73,55,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],8404.01,8046.81,9884.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9606.24,8241.84,9900.19,81,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],14991.21,14340.86,15425.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],21307.56,10487.67,22483.01,19,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],8976.22,17.65,10190.6,153,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",8386.36,8386.36,8386.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],15516.75,11057.21,33067.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11025.36,,,,,,,fee schedule,10068.8,30252.8,MSDRG Base Rate
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,10920.35,,,,,,,fee schedule,10068.8,30252.8,MSDRG Base Rate
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,10920.35,,,,,,,fee schedule,10068.8,30252.8,MSDRG Base Rate
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,11025.36,,,,,,,fee schedule,10068.8,30252.8,MSDRG Base Rate
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,10920.35,,,,,,,fee schedule,10068.8,30252.8,MSDRG Base Rate
Heart Failure And Shock With Mcc,291,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18375.6,,,,,,,fee schedule,10068.8,30252.8,MSDRG Base Rate
Heart Failure And Shock With Cc,292,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6645.92,,,,,,,fee schedule,6645.92,19968.38,
Heart Failure And Shock With Cc,292,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,6645.92,,,,,,,fee schedule,6645.92,19968.38,
Heart Failure And Shock With Cc,292,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8897.18,,,,,,,fee schedule,6645.92,19968.38,
Heart Failure And Shock With Cc,292,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8473.5,,,,,,,fee schedule,6645.92,19968.38,
Heart Failure And Shock With Cc,292,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,14841.06,,,,,,,fee schedule,6645.92,19968.38,
Heart Failure And Shock With Cc,292,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,11532.81,,,,,,,fee schedule,6645.92,19968.38,
Heart Failure And Shock With Cc,292,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,19968.38,,,,,,,fee schedule,6645.92,19968.38,
Heart Failure And Shock With Cc,292,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,13727.18,,,,,,,fee schedule,6645.92,19968.38,
Heart Failure And Shock With Cc,292,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,12432,,,,,,,fee schedule,6645.92,19968.38,
Heart Failure And Shock With Cc,292,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10182.32,,,,,,,fee schedule,6645.92,19968.38,
Heart Failure And Shock With Cc,292,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Cc,292,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Cc,292,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Cc,292,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Cc,292,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Cc,292,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Cc,292,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Cc,292,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",5723.34,5723.34,5723.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Heart Failure And Shock With Cc,292,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],6523.9,6523.9,6523.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Heart Failure And Shock With Cc,292,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Cc,292,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Cc,292,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Cc,292,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Cc,292,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],14612.2,14612.2,14612.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Heart Failure And Shock With Cc,292,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],6535.49,6021.34,6923.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Heart Failure And Shock With Cc,292,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Cc,292,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Cc,292,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock With Cc,292,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7628.52,,,,,,,fee schedule,6645.92,19968.38,MSDRG Base Rate
Heart Failure And Shock With Cc,292,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,7555.87,,,,,,,fee schedule,6645.92,19968.38,MSDRG Base Rate
Heart Failure And Shock With Cc,292,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,7555.87,,,,,,,fee schedule,6645.92,19968.38,MSDRG Base Rate
Heart Failure And Shock With Cc,292,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,7628.52,,,,,,,fee schedule,6645.92,19968.38,MSDRG Base Rate
Heart Failure And Shock With Cc,292,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,7555.87,,,,,,,fee schedule,6645.92,19968.38,MSDRG Base Rate
Heart Failure And Shock With Cc,292,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12714.2,,,,,,,fee schedule,6645.92,19968.38,MSDRG Base Rate
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4236.17,,,,,,,fee schedule,4236.17,12728.02,
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,4236.17,,,,,,,fee schedule,4236.17,12728.02,
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5671.14,,,,,,,fee schedule,4236.17,12728.02,
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5401.08,,,,,,,fee schedule,4236.17,12728.02,
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,9459.82,,,,,,,fee schedule,4236.17,12728.02,
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,7351.11,,,,,,,fee schedule,4236.17,12728.02,
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,12728.02,,,,,,,fee schedule,4236.17,12728.02,
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,8749.82,,,,,,,fee schedule,4236.17,12728.02,
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,7924.27,,,,,,,fee schedule,4236.17,12728.02,
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6490.3,,,,,,,fee schedule,4236.17,12728.02,
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],2124.63,2124.63,2124.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],4351.54,4351.54,4351.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,5417.61,,,,,,,fee schedule,4236.17,12728.02,MSDRG Base Rate
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,5366.02,,,,,,,fee schedule,4236.17,12728.02,MSDRG Base Rate
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,5366.02,,,,,,,fee schedule,4236.17,12728.02,MSDRG Base Rate
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,5417.61,,,,,,,fee schedule,4236.17,12728.02,MSDRG Base Rate
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,5366.02,,,,,,,fee schedule,4236.17,12728.02,MSDRG Base Rate
Heart Failure And Shock Without Cc/Mcc,293,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9029.35,,,,,,,fee schedule,4236.17,12728.02,MSDRG Base Rate
Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9474.66,,,,,,,fee schedule,9474.66,28467.63,
Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,9474.66,,,,,,,fee schedule,9474.66,28467.63,
Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12684.13,,,,,,,fee schedule,9474.66,28467.63,
Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12080.13,,,,,,,fee schedule,9474.66,28467.63,
Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,21157.94,,,,,,,fee schedule,9474.66,28467.63,
Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,16441.58,,,,,,,fee schedule,9474.66,28467.63,
Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,28467.63,,,,,,,fee schedule,9474.66,28467.63,
Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,19569.95,,,,,,,fee schedule,9474.66,28467.63,
Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,17723.51,,,,,,,fee schedule,9474.66,28467.63,
Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14516.28,,,,,,,fee schedule,9474.66,28467.63,
Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],14342,14342,14342,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],7642.28,7642.28,7642.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis With Cc/Mcc,294,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6094.22,,,,,,,fee schedule,6094.22,18310.72,
Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,6094.22,,,,,,,fee schedule,6094.22,18310.72,
Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8158.59,,,,,,,fee schedule,6094.22,18310.72,
Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7770.08,,,,,,,fee schedule,6094.22,18310.72,
Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,13609.04,,,,,,,fee schedule,6094.22,18310.72,
Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,10575.42,,,,,,,fee schedule,6094.22,18310.72,
Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,18310.72,,,,,,,fee schedule,6094.22,18310.72,
Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,12587.63,,,,,,,fee schedule,6094.22,18310.72,
Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,11399.97,,,,,,,fee schedule,6094.22,18310.72,
Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9337.05,,,,,,,fee schedule,6094.22,18310.72,
Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Deep Vein Thrombophlebitis Without Cc/Mcc,295,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12641.37,,,,,,,fee schedule,12641.37,37982.35,
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,12641.37,,,,,,,fee schedule,12641.37,37982.35,
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16923.54,,,,,,,fee schedule,12641.37,37982.35,
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16117.66,,,,,,,fee schedule,12641.37,37982.35,
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,28229.55,,,,,,,fee schedule,12641.37,37982.35,
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,21936.84,,,,,,,fee schedule,12641.37,37982.35,
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,37982.35,,,,,,,fee schedule,12641.37,37982.35,
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,26110.8,,,,,,,fee schedule,12641.37,37982.35,
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,23647.22,,,,,,,fee schedule,12641.37,37982.35,
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19368.05,,,,,,,fee schedule,12641.37,37982.35,
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",13090.77,13090.77,13090.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12444.99,12444.99,12444.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],16105,16105,16105,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13198,,,,,,,fee schedule,12641.37,37982.35,MSDRG Base Rate
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,13072.3,,,,,,,fee schedule,12641.37,37982.35,MSDRG Base Rate
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,13072.3,,,,,,,fee schedule,12641.37,37982.35,MSDRG Base Rate
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,13198,,,,,,,fee schedule,12641.37,37982.35,MSDRG Base Rate
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,13072.3,,,,,,,fee schedule,12641.37,37982.35,MSDRG Base Rate
"Cardiac Arrest, Unexplained With Mcc",296,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21996.66,,,,,,,fee schedule,12641.37,37982.35,MSDRG Base Rate
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5435.26,,,,,,,fee schedule,5435.26,16330.81,
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,5435.26,,,,,,,fee schedule,5435.26,16330.81,
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7276.41,,,,,,,fee schedule,5435.26,16330.81,
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6929.92,,,,,,,fee schedule,5435.26,16330.81,
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,12137.52,,,,,,,fee schedule,5435.26,16330.81,
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,9431.92,,,,,,,fee schedule,5435.26,16330.81,
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,16330.81,,,,,,,fee schedule,5435.26,16330.81,
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,11226.54,,,,,,,fee schedule,5435.26,16330.81,
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,10167.31,,,,,,,fee schedule,5435.26,16330.81,
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8327.44,,,,,,,fee schedule,5435.26,16330.81,
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,5948.86,,,,,,,fee schedule,5435.26,16330.81,MSDRG Base Rate
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,5892.2,,,,,,,fee schedule,5435.26,16330.81,MSDRG Base Rate
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,5892.2,,,,,,,fee schedule,5435.26,16330.81,MSDRG Base Rate
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,5948.86,,,,,,,fee schedule,5435.26,16330.81,MSDRG Base Rate
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,5892.2,,,,,,,fee schedule,5435.26,16330.81,MSDRG Base Rate
"Cardiac Arrest, Unexplained With Cc",297,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9914.76,,,,,,,fee schedule,5435.26,16330.81,MSDRG Base Rate
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,3407.45,,,,,,,fee schedule,3407.45,10238.05,
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,3407.45,,,,,,,fee schedule,3407.45,10238.05,
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,4561.7,,,,,,,fee schedule,3407.45,10238.05,
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,4344.48,,,,,,,fee schedule,3407.45,10238.05,
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,7609.21,,,,,,,fee schedule,3407.45,10238.05,
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,5913.02,,,,,,,fee schedule,3407.45,10238.05,
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,10238.05,,,,,,,fee schedule,3407.45,10238.05,
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,7038.11,,,,,,,fee schedule,3407.45,10238.05,
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,6374.05,,,,,,,fee schedule,3407.45,10238.05,
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,5220.61,,,,,,,fee schedule,3407.45,10238.05,
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,4551.21,,,,,,,fee schedule,3407.45,10238.05,MSDRG Base Rate
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,4507.87,,,,,,,fee schedule,3407.45,10238.05,MSDRG Base Rate
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,4507.87,,,,,,,fee schedule,3407.45,10238.05,MSDRG Base Rate
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,4551.21,,,,,,,fee schedule,3407.45,10238.05,MSDRG Base Rate
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,4507.87,,,,,,,fee schedule,3407.45,10238.05,MSDRG Base Rate
"Cardiac Arrest, Unexplained Without Cc/Mcc",298,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,7585.36,,,,,,,fee schedule,3407.45,10238.05,MSDRG Base Rate
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12482.42,,,,,,,fee schedule,12482.42,37504.76,
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,12482.42,,,,,,,fee schedule,12482.42,37504.76,
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16710.74,,,,,,,fee schedule,12482.42,37504.76,
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15915,,,,,,,fee schedule,12482.42,37504.76,
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,27874.59,,,,,,,fee schedule,12482.42,37504.76,
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,21661,,,,,,,fee schedule,12482.42,37504.76,
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,37504.76,,,,,,,fee schedule,12482.42,37504.76,
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,25782.48,,,,,,,fee schedule,12482.42,37504.76,
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,23349.88,,,,,,,fee schedule,12482.42,37504.76,
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19124.51,,,,,,,fee schedule,12482.42,37504.76,
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],23601.84,16695.39,99197.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12192.55,11835.48,23815.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9370.2,9370.2,11555.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],18486,18486,18486,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],15914.01,15914.01,15914.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",9348.59,9348.59,9348.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12000.08,11449.4,12253.89,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],5405.36,5405.36,5405.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],24612.1,20326,27140.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],11332.68,8189.88,13294.9,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",9262.03,9262.03,9262.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],9733.6,9733.6,9733.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13751.12,,,,,,,fee schedule,12482.42,37504.76,MSDRG Base Rate
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,13620.15,,,,,,,fee schedule,12482.42,37504.76,MSDRG Base Rate
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,13620.15,,,,,,,fee schedule,12482.42,37504.76,MSDRG Base Rate
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,13751.12,,,,,,,fee schedule,12482.42,37504.76,MSDRG Base Rate
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,13620.15,,,,,,,fee schedule,12482.42,37504.76,MSDRG Base Rate
Peripheral Vascular Disorders With Mcc,299,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22918.52,,,,,,,fee schedule,12482.42,37504.76,MSDRG Base Rate
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8260.14,,,,,,,fee schedule,8260.14,24818.47,
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,8260.14,,,,,,,fee schedule,8260.14,24818.47,
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11058.2,,,,,,,fee schedule,8260.14,24818.47,
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10531.62,,,,,,,fee schedule,8260.14,24818.47,
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,18445.79,,,,,,,fee schedule,8260.14,24818.47,
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,14334,,,,,,,fee schedule,8260.14,24818.47,
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,24818.47,,,,,,,fee schedule,8260.14,24818.47,
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,17061.35,,,,,,,fee schedule,8260.14,24818.47,
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,15451.6,,,,,,,fee schedule,8260.14,24818.47,
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12655.49,,,,,,,fee schedule,8260.14,24818.47,
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],4611.7,4611.7,4611.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],24413.43,24413.43,24413.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6790.54,6790.54,8433.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],16812.94,16022.15,17062.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8783.81,8783.81,8783.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],17307.32,17307.32,17307.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",6504.87,6504.87,6504.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],10532.61,10532.61,10532.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7855.57,6467.69,8220.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],5570.28,5570.28,5570.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],13862.26,13862.26,17947.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],7791.21,14.48,8524.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",6444.64,6444.64,6444.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9335.54,,,,,,,fee schedule,8260.14,24818.47,MSDRG Base Rate
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,9246.63,,,,,,,fee schedule,8260.14,24818.47,MSDRG Base Rate
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,9246.63,,,,,,,fee schedule,8260.14,24818.47,MSDRG Base Rate
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,9335.54,,,,,,,fee schedule,8260.14,24818.47,MSDRG Base Rate
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,9246.63,,,,,,,fee schedule,8260.14,24818.47,MSDRG Base Rate
Peripheral Vascular Disorders With Cc,300,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15559.23,,,,,,,fee schedule,8260.14,24818.47,MSDRG Base Rate
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5503.93,,,,,,,fee schedule,5503.93,16537.15,
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,5503.93,,,,,,,fee schedule,5503.93,16537.15,
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7368.35,,,,,,,fee schedule,5503.93,16537.15,
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7017.47,,,,,,,fee schedule,5503.93,16537.15,
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,12290.87,,,,,,,fee schedule,5503.93,16537.15,
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,9551.09,,,,,,,fee schedule,5503.93,16537.15,
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,16537.15,,,,,,,fee schedule,5503.93,16537.15,
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,11368.39,,,,,,,fee schedule,5503.93,16537.15,
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,10295.77,,,,,,,fee schedule,5503.93,16537.15,
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8432.66,,,,,,,fee schedule,5503.93,16537.15,
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4293.53,4293.53,4293.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],5404.25,5404.25,5404.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4253.77,4253.77,4253.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,6618.38,,,,,,,fee schedule,5503.93,16537.15,MSDRG Base Rate
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,6555.35,,,,,,,fee schedule,5503.93,16537.15,MSDRG Base Rate
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,6555.35,,,,,,,fee schedule,5503.93,16537.15,MSDRG Base Rate
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,6618.38,,,,,,,fee schedule,5503.93,16537.15,MSDRG Base Rate
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,6555.35,,,,,,,fee schedule,5503.93,16537.15,MSDRG Base Rate
Peripheral Vascular Disorders Without Cc/Mcc,301,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11030.64,,,,,,,fee schedule,5503.93,16537.15,MSDRG Base Rate
Atherosclerosis With Mcc,302,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8975.43,,,,,,,fee schedule,8975.43,26967.63,
Atherosclerosis With Mcc,302,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,8975.43,,,,,,,fee schedule,8975.43,26967.63,
Atherosclerosis With Mcc,302,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12015.79,,,,,,,fee schedule,8975.43,26967.63,
Atherosclerosis With Mcc,302,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11443.61,,,,,,,fee schedule,8975.43,26967.63,
Atherosclerosis With Mcc,302,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,20043.1,,,,,,,fee schedule,8975.43,26967.63,
Atherosclerosis With Mcc,302,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,15575.25,,,,,,,fee schedule,8975.43,26967.63,
Atherosclerosis With Mcc,302,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,26967.63,,,,,,,fee schedule,8975.43,26967.63,
Atherosclerosis With Mcc,302,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,18538.78,,,,,,,fee schedule,8975.43,26967.63,
Atherosclerosis With Mcc,302,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,16789.63,,,,,,,fee schedule,8975.43,26967.63,
Atherosclerosis With Mcc,302,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13751.4,,,,,,,fee schedule,8975.43,26967.63,
Atherosclerosis With Mcc,302,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis With Mcc,302,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis With Mcc,302,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7463.26,7463.26,7463.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Atherosclerosis With Mcc,302,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis With Mcc,302,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis With Mcc,302,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis With Mcc,302,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis With Mcc,302,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",5753.43,5753.43,5753.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Atherosclerosis With Mcc,302,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis With Mcc,302,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis With Mcc,302,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis With Mcc,302,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis With Mcc,302,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis With Mcc,302,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],7299.83,7299.83,7299.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Atherosclerosis With Mcc,302,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis With Mcc,302,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis With Mcc,302,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis With Mcc,302,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis With Mcc,302,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10344.12,,,,,,,fee schedule,8975.43,26967.63,MSDRG Base Rate
Atherosclerosis With Mcc,302,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,10245.6,,,,,,,fee schedule,8975.43,26967.63,MSDRG Base Rate
Atherosclerosis With Mcc,302,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,10245.6,,,,,,,fee schedule,8975.43,26967.63,MSDRG Base Rate
Atherosclerosis With Mcc,302,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,10344.12,,,,,,,fee schedule,8975.43,26967.63,MSDRG Base Rate
Atherosclerosis With Mcc,302,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,10245.6,,,,,,,fee schedule,8975.43,26967.63,MSDRG Base Rate
Atherosclerosis With Mcc,302,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,17240.2,,,,,,,fee schedule,8975.43,26967.63,MSDRG Base Rate
Atherosclerosis Without Mcc,303,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5188.34,,,,,,,fee schedule,5188.34,15588.92,
Atherosclerosis Without Mcc,303,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,5188.34,,,,,,,fee schedule,5188.34,15588.92,
Atherosclerosis Without Mcc,303,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6945.85,,,,,,,fee schedule,5188.34,15588.92,
Atherosclerosis Without Mcc,303,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6615.1,,,,,,,fee schedule,5188.34,15588.92,
Atherosclerosis Without Mcc,303,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,11586.12,,,,,,,fee schedule,5188.34,15588.92,
Atherosclerosis Without Mcc,303,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,9003.44,,,,,,,fee schedule,5188.34,15588.92,
Atherosclerosis Without Mcc,303,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,15588.92,,,,,,,fee schedule,5188.34,15588.92,
Atherosclerosis Without Mcc,303,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,10716.54,,,,,,,fee schedule,5188.34,15588.92,
Atherosclerosis Without Mcc,303,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,9705.42,,,,,,,fee schedule,5188.34,15588.92,
Atherosclerosis Without Mcc,303,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7949.14,,,,,,,fee schedule,5188.34,15588.92,
Atherosclerosis Without Mcc,303,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis Without Mcc,303,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis Without Mcc,303,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],10716.54,10716.54,10716.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Atherosclerosis Without Mcc,303,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis Without Mcc,303,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis Without Mcc,303,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis Without Mcc,303,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis Without Mcc,303,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],261.89,261.89,261.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Atherosclerosis Without Mcc,303,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis Without Mcc,303,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis Without Mcc,303,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis Without Mcc,303,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis Without Mcc,303,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis Without Mcc,303,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],5355.89,5355.89,5355.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Atherosclerosis Without Mcc,303,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis Without Mcc,303,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis Without Mcc,303,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis Without Mcc,303,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Atherosclerosis Without Mcc,303,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,6255.1,,,,,,,fee schedule,5188.34,15588.92,MSDRG Base Rate
Atherosclerosis Without Mcc,303,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,6195.53,,,,,,,fee schedule,5188.34,15588.92,MSDRG Base Rate
Atherosclerosis Without Mcc,303,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,6195.53,,,,,,,fee schedule,5188.34,15588.92,MSDRG Base Rate
Atherosclerosis Without Mcc,303,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,6255.1,,,,,,,fee schedule,5188.34,15588.92,MSDRG Base Rate
Atherosclerosis Without Mcc,303,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,6195.53,,,,,,,fee schedule,5188.34,15588.92,MSDRG Base Rate
Atherosclerosis Without Mcc,303,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10425.17,,,,,,,fee schedule,5188.34,15588.92,MSDRG Base Rate
Hypertension With Mcc,304,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9064.93,,,,,,,fee schedule,9064.93,27236.56,
Hypertension With Mcc,304,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,9064.93,,,,,,,fee schedule,9064.93,27236.56,
Hypertension With Mcc,304,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12135.61,,,,,,,fee schedule,9064.93,27236.56,
Hypertension With Mcc,304,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11557.73,,,,,,,fee schedule,9064.93,27236.56,
Hypertension With Mcc,304,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,20242.98,,,,,,,fee schedule,9064.93,27236.56,
Hypertension With Mcc,304,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,15730.57,,,,,,,fee schedule,9064.93,27236.56,
Hypertension With Mcc,304,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,27236.56,,,,,,,fee schedule,9064.93,27236.56,
Hypertension With Mcc,304,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,18723.66,,,,,,,fee schedule,9064.93,27236.56,
Hypertension With Mcc,304,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,16957.06,,,,,,,fee schedule,9064.93,27236.56,
Hypertension With Mcc,304,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13888.53,,,,,,,fee schedule,9064.93,27236.56,
Hypertension With Mcc,304,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertension With Mcc,304,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Hypertension With Mcc,304,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8961.69,8961.69,8961.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hypertension With Mcc,304,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],17787.47,17787.47,17787.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hypertension With Mcc,304,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertension With Mcc,304,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Hypertension With Mcc,304,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",5920.35,5920.35,5920.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hypertension With Mcc,304,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",5559.98,5559.98,5559.98,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hypertension With Mcc,304,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8113.05,7257.05,8835.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hypertension With Mcc,304,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],78359.4,78359.4,78359.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hypertension With Mcc,304,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Hypertension With Mcc,304,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Hypertension With Mcc,304,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertension With Mcc,304,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],8989.09,8861.9,9201.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hypertension With Mcc,304,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],20242.98,20242.98,20504.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hypertension With Mcc,304,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Hypertension With Mcc,304,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertension With Mcc,304,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],73597.57,73597.57,73597.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hypertension With Mcc,304,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10292.55,,,,,,,fee schedule,9064.93,27236.56,MSDRG Base Rate
Hypertension With Mcc,304,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,10194.53,,,,,,,fee schedule,9064.93,27236.56,MSDRG Base Rate
Hypertension With Mcc,304,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,10194.53,,,,,,,fee schedule,9064.93,27236.56,MSDRG Base Rate
Hypertension With Mcc,304,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,10292.55,,,,,,,fee schedule,9064.93,27236.56,MSDRG Base Rate
Hypertension With Mcc,304,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,10194.53,,,,,,,fee schedule,9064.93,27236.56,MSDRG Base Rate
Hypertension With Mcc,304,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,17154.25,,,,,,,fee schedule,9064.93,27236.56,MSDRG Base Rate
Hypertension Without Mcc,305,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5792.51,,,,,,,fee schedule,5792.51,17404.23,
Hypertension Without Mcc,305,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,5792.51,,,,,,,fee schedule,5792.51,17404.23,
Hypertension Without Mcc,305,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7754.69,,,,,,,fee schedule,5792.51,17404.23,
Hypertension Without Mcc,305,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7385.42,,,,,,,fee schedule,5792.51,17404.23,
Hypertension Without Mcc,305,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,12935.31,,,,,,,fee schedule,5792.51,17404.23,
Hypertension Without Mcc,305,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,10051.87,,,,,,,fee schedule,5792.51,17404.23,
Hypertension Without Mcc,305,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,17404.23,,,,,,,fee schedule,5792.51,17404.23,
Hypertension Without Mcc,305,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,11964.46,,,,,,,fee schedule,5792.51,17404.23,
Hypertension Without Mcc,305,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,10835.6,,,,,,,fee schedule,5792.51,17404.23,
Hypertension Without Mcc,305,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8874.81,,,,,,,fee schedule,5792.51,17404.23,
Hypertension Without Mcc,305,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertension Without Mcc,305,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Hypertension Without Mcc,305,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],11291.24,11291.24,11964.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hypertension Without Mcc,305,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertension Without Mcc,305,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],9752.05,9752.05,9752.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hypertension Without Mcc,305,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertension Without Mcc,305,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4521.46,4521.46,4521.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hypertension Without Mcc,305,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4246.24,4246.24,4246.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hypertension Without Mcc,305,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],7385.42,7385.42,7385.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hypertension Without Mcc,305,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],4256.39,4044.33,5724.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hypertension Without Mcc,305,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],8874.81,8874.81,8874.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hypertension Without Mcc,305,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Hypertension Without Mcc,305,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertension Without Mcc,305,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],5767.35,5767.35,5767.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hypertension Without Mcc,305,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],6589.58,5425.48,6666.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hypertension Without Mcc,305,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Hypertension Without Mcc,305,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hypertension Without Mcc,305,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],11795.28,11795.28,11795.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hypertension Without Mcc,305,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,6894.94,,,,,,,fee schedule,5792.51,17404.23,MSDRG Base Rate
Hypertension Without Mcc,305,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,6829.27,,,,,,,fee schedule,5792.51,17404.23,MSDRG Base Rate
Hypertension Without Mcc,305,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,6829.27,,,,,,,fee schedule,5792.51,17404.23,MSDRG Base Rate
Hypertension Without Mcc,305,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,6894.94,,,,,,,fee schedule,5792.51,17404.23,MSDRG Base Rate
Hypertension Without Mcc,305,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,6829.27,,,,,,,fee schedule,5792.51,17404.23,MSDRG Base Rate
Hypertension Without Mcc,305,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11491.57,,,,,,,fee schedule,5792.51,17404.23,MSDRG Base Rate
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11554.16,,,,,,,fee schedule,11554.16,34715.72,
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,11554.16,,,,,,,fee schedule,11554.16,34715.72,
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15468.05,,,,,,,fee schedule,11554.16,34715.72,
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14731.48,,,,,,,fee schedule,11554.16,34715.72,
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,25801.7,,,,,,,fee schedule,11554.16,34715.72,
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,20050.19,,,,,,,fee schedule,11554.16,34715.72,
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,34715.72,,,,,,,fee schedule,11554.16,34715.72,
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,23865.17,,,,,,,fee schedule,11554.16,34715.72,
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,21613.47,,,,,,,fee schedule,11554.16,34715.72,
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17702.32,,,,,,,fee schedule,11554.16,34715.72,
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],9736.8,9736.8,9736.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",16781.36,16781.36,16781.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],24990.61,24990.61,24990.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],10821.38,7136.14,11548.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",16625.98,16625.98,16625.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13306.59,,,,,,,fee schedule,11554.16,34715.72,MSDRG Base Rate
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,13179.86,,,,,,,fee schedule,11554.16,34715.72,MSDRG Base Rate
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,13179.86,,,,,,,fee schedule,11554.16,34715.72,MSDRG Base Rate
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,13306.59,,,,,,,fee schedule,11554.16,34715.72,MSDRG Base Rate
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,13179.86,,,,,,,fee schedule,11554.16,34715.72,MSDRG Base Rate
Cardiac Congenital And Valvular Disorders With Mcc,306,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22177.64,,,,,,,fee schedule,11554.16,34715.72,MSDRG Base Rate
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7147.47,,,,,,,fee schedule,7147.47,21475.34,
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,7147.47,,,,,,,fee schedule,7147.47,21475.34,
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9568.62,,,,,,,fee schedule,7147.47,21475.34,
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9112.98,,,,,,,fee schedule,7147.47,21475.34,
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,15961.08,,,,,,,fee schedule,7147.47,21475.34,
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,12403.16,,,,,,,fee schedule,7147.47,21475.34,
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,21475.34,,,,,,,fee schedule,7147.47,21475.34,
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,14763.13,,,,,,,fee schedule,7147.47,21475.34,
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,13370.21,,,,,,,fee schedule,7147.47,21475.34,
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10950.76,,,,,,,fee schedule,7147.47,21475.34,
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7972.41,7972.41,7972.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],11071,11071,14378.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],10.57,10.57,10.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",22003.65,22003.65,22003.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],5622.53,5622.53,5622.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8130.08,,,,,,,fee schedule,7147.47,21475.34,MSDRG Base Rate
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,8052.65,,,,,,,fee schedule,7147.47,21475.34,MSDRG Base Rate
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,8052.65,,,,,,,fee schedule,7147.47,21475.34,MSDRG Base Rate
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,8130.08,,,,,,,fee schedule,7147.47,21475.34,MSDRG Base Rate
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,8052.65,,,,,,,fee schedule,7147.47,21475.34,MSDRG Base Rate
Cardiac Congenital And Valvular Disorders Without Mcc,307,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,13550.13,,,,,,,fee schedule,7147.47,21475.34,MSDRG Base Rate
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9305.68,,,,,,,fee schedule,9305.68,27959.9,
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,9305.68,,,,,,,fee schedule,9305.68,27959.9,
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12457.91,,,,,,,fee schedule,9305.68,27959.9,
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11864.68,,,,,,,fee schedule,9305.68,27959.9,
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,20780.59,,,,,,,fee schedule,9305.68,27959.9,
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,16148.34,,,,,,,fee schedule,9305.68,27959.9,
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,27959.9,,,,,,,fee schedule,9305.68,27959.9,
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,19220.91,,,,,,,fee schedule,9305.68,27959.9,
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,17407.4,,,,,,,fee schedule,9305.68,27959.9,
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14257.38,,,,,,,fee schedule,9305.68,27959.9,
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],9507.03,9507.03,9507.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9429.68,9428.9,9992.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],17021,17021,17021,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9953.28,9953.28,9953.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],17405.96,17405.96,17405.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",7720.69,7720.69,7720.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",7250.73,7250.73,7250.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],8903.14,8903.14,8903.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8455.83,7239.87,9230.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],20348.31,12676.85,20778.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],9078.92,7453.36,10055.29,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",7183.59,7183.59,7183.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10401.93,,,,,,,fee schedule,9305.68,27959.9,MSDRG Base Rate
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,10302.86,,,,,,,fee schedule,9305.68,27959.9,MSDRG Base Rate
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,10302.86,,,,,,,fee schedule,9305.68,27959.9,MSDRG Base Rate
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,10401.93,,,,,,,fee schedule,9305.68,27959.9,MSDRG Base Rate
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,10302.86,,,,,,,fee schedule,9305.68,27959.9,MSDRG Base Rate
Cardiac Arrhythmia And Conduction Disorders With Mcc,308,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,17336.55,,,,,,,fee schedule,9305.68,27959.9,MSDRG Base Rate
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5704.55,,,,,,,fee schedule,5704.55,17139.93,
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,5704.55,,,,,,,fee schedule,5704.55,17139.93,
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7636.92,,,,,,,fee schedule,5704.55,17139.93,
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7273.26,,,,,,,fee schedule,5704.55,17139.93,
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,12738.88,,,,,,,fee schedule,5704.55,17139.93,
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,9899.23,,,,,,,fee schedule,5704.55,17139.93,
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,17139.93,,,,,,,fee schedule,5704.55,17139.93,
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,11782.77,,,,,,,fee schedule,5704.55,17139.93,
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,10671.06,,,,,,,fee schedule,5704.55,17139.93,
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8740.03,,,,,,,fee schedule,5704.55,17139.93,
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],5978.74,5978.74,5978.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],16640.9,16640.9,16640.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],11782.77,9992.51,12455.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6028.75,5047.62,6628.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11.58,11.58,11.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],10671.06,10671.06,10671.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3921.34,3921.34,3921.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",5121.92,5121.92,5121.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],5447.67,5447.67,5447.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],5557.35,5131.93,5664.5,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],6692.96,6692.96,6692.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],12176.85,1570.77,12738.88,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],5400.8,4736.86,6068.75,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,6743.38,,,,,,,fee schedule,5704.55,17139.93,MSDRG Base Rate
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,6679.16,,,,,,,fee schedule,5704.55,17139.93,MSDRG Base Rate
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,6679.16,,,,,,,fee schedule,5704.55,17139.93,MSDRG Base Rate
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,6743.38,,,,,,,fee schedule,5704.55,17139.93,MSDRG Base Rate
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,6679.16,,,,,,,fee schedule,5704.55,17139.93,MSDRG Base Rate
Cardiac Arrhythmia And Conduction Disorders With Cc,309,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11238.97,,,,,,,fee schedule,5704.55,17139.93,MSDRG Base Rate
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4317.19,,,,,,,fee schedule,4317.19,12971.45,
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,4317.19,,,,,,,fee schedule,4317.19,12971.45,
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5779.6,,,,,,,fee schedule,4317.19,12971.45,
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5504.38,,,,,,,fee schedule,4317.19,12971.45,
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,9640.74,,,,,,,fee schedule,4317.19,12971.45,
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,7491.71,,,,,,,fee schedule,4317.19,12971.45,
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,12971.45,,,,,,,fee schedule,4317.19,12971.45,
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,8917.17,,,,,,,fee schedule,4317.19,12971.45,
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,8075.82,,,,,,,fee schedule,4317.19,12971.45,
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6614.43,,,,,,,fee schedule,4317.19,12971.45,
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7.57,7.57,7.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],8297.89,7003,8917.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],4159.35,4159.35,4159.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],9151.57,9151.57,9151.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3682.65,3682.65,3682.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],4245.42,4244.42,4274.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],9387.29,9387.29,9640.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],4727.42,8.91,4728.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,5418.39,,,,,,,fee schedule,4317.19,12971.45,MSDRG Base Rate
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,5366.78,,,,,,,fee schedule,4317.19,12971.45,MSDRG Base Rate
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,5366.78,,,,,,,fee schedule,4317.19,12971.45,MSDRG Base Rate
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,5418.39,,,,,,,fee schedule,4317.19,12971.45,MSDRG Base Rate
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,5366.78,,,,,,,fee schedule,4317.19,12971.45,MSDRG Base Rate
Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc,310,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9030.65,,,,,,,fee schedule,4317.19,12971.45,MSDRG Base Rate
Angina Pectoris,311,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5389.73,,,,,,,fee schedule,5389.73,16194.02,
Angina Pectoris,311,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,5389.73,,,,,,,fee schedule,5389.73,16194.02,
Angina Pectoris,311,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7215.46,,,,,,,fee schedule,5389.73,16194.02,
Angina Pectoris,311,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6871.87,,,,,,,fee schedule,5389.73,16194.02,
Angina Pectoris,311,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,12035.85,,,,,,,fee schedule,5389.73,16194.02,
Angina Pectoris,311,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,9352.92,,,,,,,fee schedule,5389.73,16194.02,
Angina Pectoris,311,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,16194.02,,,,,,,fee schedule,5389.73,16194.02,
Angina Pectoris,311,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,11132.51,,,,,,,fee schedule,5389.73,16194.02,
Angina Pectoris,311,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,10082.15,,,,,,,fee schedule,5389.73,16194.02,
Angina Pectoris,311,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8257.69,,,,,,,fee schedule,5389.73,16194.02,
Angina Pectoris,311,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Angina Pectoris,311,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Angina Pectoris,311,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Angina Pectoris,311,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Angina Pectoris,311,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],10079.26,10079.26,10079.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Angina Pectoris,311,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Angina Pectoris,311,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Angina Pectoris,311,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],134.45,134.45,134.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Angina Pectoris,311,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],4525.66,4525.66,4525.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Angina Pectoris,311,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],6869.9,6869.9,6869.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Angina Pectoris,311,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Angina Pectoris,311,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Angina Pectoris,311,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Angina Pectoris,311,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Angina Pectoris,311,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Angina Pectoris,311,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Angina Pectoris,311,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Angina Pectoris,311,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Angina Pectoris,311,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,6479.32,,,,,,,fee schedule,5389.73,16194.02,MSDRG Base Rate
Angina Pectoris,311,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,6417.61,,,,,,,fee schedule,5389.73,16194.02,MSDRG Base Rate
Angina Pectoris,311,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,6417.61,,,,,,,fee schedule,5389.73,16194.02,MSDRG Base Rate
Angina Pectoris,311,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,6479.32,,,,,,,fee schedule,5389.73,16194.02,MSDRG Base Rate
Angina Pectoris,311,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,6417.61,,,,,,,fee schedule,5389.73,16194.02,MSDRG Base Rate
Angina Pectoris,311,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10798.86,,,,,,,fee schedule,5389.73,16194.02,MSDRG Base Rate
Syncope And Collapse,312,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6723.08,,,,,,,fee schedule,6723.08,20200.22,
Syncope And Collapse,312,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,6723.08,,,,,,,fee schedule,6723.08,20200.22,
Syncope And Collapse,312,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9000.48,,,,,,,fee schedule,6723.08,20200.22,
Syncope And Collapse,312,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8571.88,,,,,,,fee schedule,6723.08,20200.22,
Syncope And Collapse,312,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,15013.37,,,,,,,fee schedule,6723.08,20200.22,
Syncope And Collapse,312,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,11666.71,,,,,,,fee schedule,6723.08,20200.22,
Syncope And Collapse,312,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,20200.22,,,,,,,fee schedule,6723.08,20200.22,
Syncope And Collapse,312,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,13886.55,,,,,,,fee schedule,6723.08,20200.22,
Syncope And Collapse,312,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,12576.34,,,,,,,fee schedule,6723.08,20200.22,
Syncope And Collapse,312,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10300.54,,,,,,,fee schedule,6723.08,20200.22,
Syncope And Collapse,312,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],7077.48,7077.48,7077.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Syncope And Collapse,312,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Syncope And Collapse,312,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6997.34,5332.39,7774.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Syncope And Collapse,312,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],13037.93,13037.93,13192.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Syncope And Collapse,312,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],5931.92,5931.92,5931.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Syncope And Collapse,312,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Syncope And Collapse,312,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Syncope And Collapse,312,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3827.1,3827.1,3827.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Syncope And Collapse,312,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6436.35,4957.93,6865.05,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Syncope And Collapse,312,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],10300.54,10300.54,10300.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Syncope And Collapse,312,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Syncope And Collapse,312,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Syncope And Collapse,312,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Syncope And Collapse,312,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],15013.37,15013.37,15013.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Syncope And Collapse,312,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],5516.66,282.43,6993.66,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Syncope And Collapse,312,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Syncope And Collapse,312,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Syncope And Collapse,312,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Syncope And Collapse,312,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7805.08,,,,,,,fee schedule,6723.08,20200.22,MSDRG Base Rate
Syncope And Collapse,312,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,7730.75,,,,,,,fee schedule,6723.08,20200.22,MSDRG Base Rate
Syncope And Collapse,312,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,7730.75,,,,,,,fee schedule,6723.08,20200.22,MSDRG Base Rate
Syncope And Collapse,312,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,7805.08,,,,,,,fee schedule,6723.08,20200.22,MSDRG Base Rate
Syncope And Collapse,312,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,7730.75,,,,,,,fee schedule,6723.08,20200.22,MSDRG Base Rate
Syncope And Collapse,312,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,13008.47,,,,,,,fee schedule,6723.08,20200.22,MSDRG Base Rate
Chest Pain,313,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5503.93,,,,,,,fee schedule,5503.93,16537.15,
Chest Pain,313,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,5503.93,,,,,,,fee schedule,5503.93,16537.15,
Chest Pain,313,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7368.35,,,,,,,fee schedule,5503.93,16537.15,
Chest Pain,313,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7017.47,,,,,,,fee schedule,5503.93,16537.15,
Chest Pain,313,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,12290.87,,,,,,,fee schedule,5503.93,16537.15,
Chest Pain,313,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,9551.09,,,,,,,fee schedule,5503.93,16537.15,
Chest Pain,313,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,16537.15,,,,,,,fee schedule,5503.93,16537.15,
Chest Pain,313,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,11368.39,,,,,,,fee schedule,5503.93,16537.15,
Chest Pain,313,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,10295.77,,,,,,,fee schedule,5503.93,16537.15,
Chest Pain,313,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8432.66,,,,,,,fee schedule,5503.93,16537.15,
Chest Pain,313,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],16539.47,16539.47,16539.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Chest Pain,313,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chest Pain,313,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6238.93,6238.93,6238.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Chest Pain,313,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],9175,9175,9175,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Chest Pain,313,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],6265.85,6265.85,6265.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Chest Pain,313,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chest Pain,313,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Chest Pain,313,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3775.94,3775.94,3775.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Chest Pain,313,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],6816.46,6816.46,6816.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Chest Pain,313,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],5189.23,3862.67,5312.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Chest Pain,313,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],8283.84,8283.84,8433.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Chest Pain,313,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Chest Pain,313,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chest Pain,313,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],1600,1600,1600,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Chest Pain,313,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],6450.56,6450.56,6450.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Chest Pain,313,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Chest Pain,313,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chest Pain,313,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chest Pain,313,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,6620.72,,,,,,,fee schedule,5503.93,16537.15,MSDRG Base Rate
Chest Pain,313,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,6557.67,,,,,,,fee schedule,5503.93,16537.15,MSDRG Base Rate
Chest Pain,313,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,6557.67,,,,,,,fee schedule,5503.93,16537.15,MSDRG Base Rate
Chest Pain,313,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,6620.72,,,,,,,fee schedule,5503.93,16537.15,MSDRG Base Rate
Chest Pain,313,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,6557.67,,,,,,,fee schedule,5503.93,16537.15,MSDRG Base Rate
Chest Pain,313,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11034.54,,,,,,,fee schedule,5503.93,16537.15,MSDRG Base Rate
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16615.96,,,,,,,fee schedule,16615.96,49924.43,
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,16615.96,,,,,,,fee schedule,16615.96,49924.43,
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22244.49,,,,,,,fee schedule,16615.96,49924.43,
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21185.24,,,,,,,fee schedule,16615.96,49924.43,
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,37105.24,,,,,,,fee schedule,16615.96,49924.43,
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,28834.03,,,,,,,fee schedule,16615.96,49924.43,
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,49924.43,,,,,,,fee schedule,16615.96,49924.43,
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,34320.33,,,,,,,fee schedule,16615.96,49924.43,
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,31082.18,,,,,,,fee schedule,16615.96,49924.43,
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,25457.58,,,,,,,fee schedule,16615.96,49924.43,
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],16459.09,16459.09,16459.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],15691.58,29.14,16521.94,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],33365.66,26017,34321.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],29.14,29.14,29.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],33709.34,33709.34,33709.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",9778.9,9778.9,9778.9,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],21186.22,21186.22,21186.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],16085.33,15850.79,16372.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],16313.53,14671.06,16445.81,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],24246.45,24246.45,132034.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],37106.96,22483.01,95426.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],14416.74,9863.79,16330.08,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",9688.36,9688.36,9688.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,17286.22,,,,,,,fee schedule,16615.96,49924.43,MSDRG Base Rate
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,17121.59,,,,,,,fee schedule,16615.96,49924.43,MSDRG Base Rate
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,17121.59,,,,,,,fee schedule,16615.96,49924.43,MSDRG Base Rate
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,17286.22,,,,,,,fee schedule,16615.96,49924.43,MSDRG Base Rate
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,17121.59,,,,,,,fee schedule,16615.96,49924.43,MSDRG Base Rate
Other Circulatory System Diagnoses With Mcc,314,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,28810.37,,,,,,,fee schedule,16615.96,49924.43,MSDRG Base Rate
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7425.25,,,,,,,fee schedule,7425.25,22309.96,
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,7425.25,,,,,,,fee schedule,7425.25,22309.96,
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9940.5,,,,,,,fee schedule,7425.25,22309.96,
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9467.15,,,,,,,fee schedule,7425.25,22309.96,
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,16581.39,,,,,,,fee schedule,7425.25,22309.96,
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,12885.2,,,,,,,fee schedule,7425.25,22309.96,
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,22309.96,,,,,,,fee schedule,7425.25,22309.96,
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,15336.89,,,,,,,fee schedule,7425.25,22309.96,
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,13889.84,,,,,,,fee schedule,7425.25,22309.96,
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11376.35,,,,,,,fee schedule,7425.25,22309.96,
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],7748.85,7748.85,7748.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],22309.96,22309.96,22309.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7658.83,7658.83,7658.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],15336.89,15336.89,22342.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],13889.84,13889.84,13889.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",7359.06,7359.06,7359.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7300.75,6906.5,7414.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],283.65,15.16,8236.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8521.48,,,,,,,fee schedule,7425.25,22309.96,MSDRG Base Rate
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,8440.33,,,,,,,fee schedule,7425.25,22309.96,MSDRG Base Rate
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,8440.33,,,,,,,fee schedule,7425.25,22309.96,MSDRG Base Rate
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,8521.48,,,,,,,fee schedule,7425.25,22309.96,MSDRG Base Rate
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,8440.33,,,,,,,fee schedule,7425.25,22309.96,MSDRG Base Rate
Other Circulatory System Diagnoses With Cc,315,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14202.48,,,,,,,fee schedule,7425.25,22309.96,MSDRG Base Rate
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5267.04,,,,,,,fee schedule,5267.04,15825.4,
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,5267.04,,,,,,,fee schedule,5267.04,15825.4,
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7051.22,,,,,,,fee schedule,5267.04,15825.4,
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6715.45,,,,,,,fee schedule,5267.04,15825.4,
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,11761.88,,,,,,,fee schedule,5267.04,15825.4,
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,9140.01,,,,,,,fee schedule,5267.04,15825.4,
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,15825.4,,,,,,,fee schedule,5267.04,15825.4,
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,10879.1,,,,,,,fee schedule,5267.04,15825.4,
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,9852.65,,,,,,,fee schedule,5267.04,15825.4,
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8069.72,,,,,,,fee schedule,5267.04,15825.4,
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],9254,9254,9254,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],10880.7,10880.7,10880.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],9854.09,9854.09,9854.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",7341.01,7341.01,7341.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],5198.69,5198.69,5198.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],9914.27,9914.27,9914.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],939.02,939.02,939.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],5623.87,5623.87,5623.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,6324.63,,,,,,,fee schedule,5267.04,15825.4,MSDRG Base Rate
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,6264.4,,,,,,,fee schedule,5267.04,15825.4,MSDRG Base Rate
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,6264.4,,,,,,,fee schedule,5267.04,15825.4,MSDRG Base Rate
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,6324.63,,,,,,,fee schedule,5267.04,15825.4,MSDRG Base Rate
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,6264.4,,,,,,,fee schedule,5267.04,15825.4,MSDRG Base Rate
Other Circulatory System Diagnoses Without Cc/Mcc,316,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10541.06,,,,,,,fee schedule,5267.04,15825.4,MSDRG Base Rate
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,47732.1,,,,,,,fee schedule,47732.1,143416.22,
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,47732.1,,,,,,,fee schedule,47732.1,143416.22,
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,63901.01,,,,,,,fee schedule,47732.1,143416.22,
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,60858.12,,,,,,,fee schedule,47732.1,143416.22,
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,106590.97,,,,,,,fee schedule,47732.1,143416.22,
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,82830.54,,,,,,,fee schedule,47732.1,143416.22,
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,143416.22,,,,,,,fee schedule,47732.1,143416.22,
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,98590.86,,,,,,,fee schedule,47732.1,143416.22,
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,89288.72,,,,,,,fee schedule,47732.1,143416.22,
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,73131.14,,,,,,,fee schedule,47732.1,143416.22,
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,53233.47,,,,,,,fee schedule,47732.1,143416.22,MSDRG Base Rate
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,52726.48,,,,,,,fee schedule,47732.1,143416.22,MSDRG Base Rate
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,52726.48,,,,,,,fee schedule,47732.1,143416.22,MSDRG Base Rate
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,53233.47,,,,,,,fee schedule,47732.1,143416.22,MSDRG Base Rate
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,52726.48,,,,,,,fee schedule,47732.1,143416.22,MSDRG Base Rate
Concomitant Left Atrial Appendage Closure And Cardiac Ablation,317,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,88722.44,,,,,,,fee schedule,47732.1,143416.22,MSDRG Base Rate
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],17618.49,17618.49,17618.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,19919,,,,,,,fee schedule,19729.3,33198.34,MSDRG Base Rate
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,19729.3,,,,,,,fee schedule,19729.3,33198.34,MSDRG Base Rate
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,19729.3,,,,,,,fee schedule,19729.3,33198.34,MSDRG Base Rate
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,19919,,,,,,,fee schedule,19729.3,33198.34,MSDRG Base Rate
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,19729.3,,,,,,,fee schedule,19729.3,33198.34,MSDRG Base Rate
Percutaneous Coronary Atherectomy Without Intraluminal Device,318,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,33198.34,,,,,,,fee schedule,19729.3,33198.34,MSDRG Base Rate
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,33893.19,,,,,,,fee schedule,33893.19,101835.72,
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,33893.19,,,,,,,fee schedule,33893.19,101835.72,
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,45374.26,,,,,,,fee schedule,33893.19,101835.72,
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43213.59,,,,,,,fee schedule,33893.19,101835.72,
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,75687.17,,,,,,,fee schedule,33893.19,101835.72,
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,58815.58,,,,,,,fee schedule,33893.19,101835.72,
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,101835.72,,,,,,,fee schedule,33893.19,101835.72,
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,70006.52,,,,,,,fee schedule,33893.19,101835.72,
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,63401.35,,,,,,,fee schedule,33893.19,101835.72,
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,51928.31,,,,,,,fee schedule,33893.19,101835.72,
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",46150.92,46150.92,46150.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],51931.86,51931.86,51931.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,35861.79,,,,,,,fee schedule,33893.19,101835.72,MSDRG Base Rate
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,35520.25,,,,,,,fee schedule,33893.19,101835.72,MSDRG Base Rate
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,35520.25,,,,,,,fee schedule,33893.19,101835.72,MSDRG Base Rate
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,35861.79,,,,,,,fee schedule,33893.19,101835.72,MSDRG Base Rate
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,35520.25,,,,,,,fee schedule,33893.19,101835.72,MSDRG Base Rate
Other Endovascular Cardiac Valve Procedures With Mcc,319,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,59769.66,,,,,,,fee schedule,33893.19,101835.72,MSDRG Base Rate
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17859.8,,,,,,,fee schedule,17859.8,53661.69,
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,17859.8,,,,,,,fee schedule,17859.8,53661.69,
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23909.68,,,,,,,fee schedule,17859.8,53661.69,
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22771.13,,,,,,,fee schedule,17859.8,53661.69,
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,39882.87,,,,,,,fee schedule,17859.8,53661.69,
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,30992.49,,,,,,,fee schedule,17859.8,53661.69,
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,53661.69,,,,,,,fee schedule,17859.8,53661.69,
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,36889.49,,,,,,,fee schedule,17859.8,53661.69,
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,33408.94,,,,,,,fee schedule,17859.8,53661.69,
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27363.29,,,,,,,fee schedule,17859.8,53661.69,
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,19786.98,,,,,,,fee schedule,17859.8,53661.69,MSDRG Base Rate
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,19598.53,,,,,,,fee schedule,17859.8,53661.69,MSDRG Base Rate
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,19598.53,,,,,,,fee schedule,17859.8,53661.69,MSDRG Base Rate
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,19786.98,,,,,,,fee schedule,17859.8,53661.69,MSDRG Base Rate
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,19598.53,,,,,,,fee schedule,17859.8,53661.69,MSDRG Base Rate
Other Endovascular Cardiac Valve Procedures Without Mcc,320,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,32978.3,,,,,,,fee schedule,17859.8,53661.69,MSDRG Base Rate
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,21965.56,,,,,,,fee schedule,21965.56,65997.89,
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,21965.56,,,,,,,fee schedule,21965.56,65997.89,
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29406.24,,,,,,,fee schedule,21965.56,65997.89,
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28005.95,,,,,,,fee schedule,21965.56,65997.89,
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,49051.49,,,,,,,fee schedule,21965.56,65997.89,
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,38117.31,,,,,,,fee schedule,21965.56,65997.89,
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,65997.89,,,,,,,fee schedule,21965.56,65997.89,
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,45369.96,,,,,,,fee schedule,21965.56,65997.89,
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,41089.27,,,,,,,fee schedule,21965.56,65997.89,
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33653.8,,,,,,,fee schedule,21965.56,65997.89,
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],21535.69,21535.69,21535.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],66000.21,66000.21,66000.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],20555.92,19642.04,21362.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],42761.1,28834.56,85372.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],21070.37,20362.46,22469.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],41090.71,41090.71,44566.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",48393.22,48393.22,48393.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],28006.93,28006.93,28006.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],21226.9,21226.9,21226.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],21603.03,21603.03,21603.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],21599.04,20991.47,21639.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],33654.98,33654.98,33654.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],45067.28,24231.96,46063.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],21323.04,19740.9,21907.9,19,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",47945.13,47945.13,47945.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,22251.79,,,,,,,fee schedule,21965.56,65997.89,MSDRG Base Rate
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,22039.87,,,,,,,fee schedule,21965.56,65997.89,MSDRG Base Rate
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,22039.87,,,,,,,fee schedule,21965.56,65997.89,MSDRG Base Rate
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,22251.79,,,,,,,fee schedule,21965.56,65997.89,MSDRG Base Rate
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,22039.87,,,,,,,fee schedule,21965.56,65997.89,MSDRG Base Rate
Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal,321,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,37086.32,,,,,,,fee schedule,21965.56,65997.89,MSDRG Base Rate
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13959.29,,,,,,,fee schedule,13959.29,41942.17,
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,13959.29,,,,,,,fee schedule,13959.29,41942.17,
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18687.89,,,,,,,fee schedule,13959.29,41942.17,
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17798,,,,,,,fee schedule,13959.29,41942.17,
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,31172.6,,,,,,,fee schedule,13959.29,41942.17,
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,24223.85,,,,,,,fee schedule,13959.29,41942.17,
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,41942.17,,,,,,,fee schedule,13959.29,41942.17,
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,28832.97,,,,,,,fee schedule,13959.29,41942.17,
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,26112.55,,,,,,,fee schedule,13959.29,41942.17,
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21387.25,,,,,,,fee schedule,13959.29,41942.17,
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],13961.27,13961.27,13961.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],40873.39,40873.39,40971.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13287.54,12826.15,13826.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],27097.7,24580.4,28834.56,32,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],14043.52,14043.52,14183.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],26113.99,24473.18,27663.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",36349.86,36349.86,36349.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",34137.25,34137.25,34137.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],17798.98,17798.98,17798.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],17798.98,17798.98,17798.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],13888.1,13888.1,13888.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13738.86,13704.1,13834.36,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],19520.23,19520.23,19520.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],30176.33,26498.2,31174.33,25,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],13670.98,13023.9,14206.01,28,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],2828.8,2828.8,2828.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14769.07,,,,,,,fee schedule,13959.29,41942.17,MSDRG Base Rate
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,14628.41,,,,,,,fee schedule,13959.29,41942.17,MSDRG Base Rate
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,14628.41,,,,,,,fee schedule,13959.29,41942.17,MSDRG Base Rate
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,14769.07,,,,,,,fee schedule,13959.29,41942.17,MSDRG Base Rate
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,14628.41,,,,,,,fee schedule,13959.29,41942.17,MSDRG Base Rate
Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc,322,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,24615.12,,,,,,,fee schedule,13959.29,41942.17,MSDRG Base Rate
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,32864.63,,,,,,,fee schedule,32864.63,98745.29,
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,32864.63,,,,,,,fee schedule,32864.63,98745.29,
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,43997.28,,,,,,,fee schedule,32864.63,98745.29,
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,41902.18,,,,,,,fee schedule,32864.63,98745.29,
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,73390.28,,,,,,,fee schedule,32864.63,98745.29,
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,57030.69,,,,,,,fee schedule,32864.63,98745.29,
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,98745.29,,,,,,,fee schedule,32864.63,98745.29,
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,67882.02,,,,,,,fee schedule,32864.63,98745.29,
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,61477.29,,,,,,,fee schedule,32864.63,98745.29,
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,50352.43,,,,,,,fee schedule,32864.63,98745.29,
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],32797.37,32797.37,32797.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],72089.89,72089.89,72089.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],30389.77,30389.77,30389.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,34803.21,,,,,,,fee schedule,32864.63,98745.29,MSDRG Base Rate
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,34471.75,,,,,,,fee schedule,32864.63,98745.29,MSDRG Base Rate
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,34471.75,,,,,,,fee schedule,32864.63,98745.29,MSDRG Base Rate
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,34803.21,,,,,,,fee schedule,32864.63,98745.29,MSDRG Base Rate
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,34471.75,,,,,,,fee schedule,32864.63,98745.29,MSDRG Base Rate
Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc,323,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,58005.34,,,,,,,fee schedule,32864.63,98745.29,MSDRG Base Rate
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,24653.1,,,,,,,fee schedule,24653.1,74072.88,
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,24653.1,,,,,,,fee schedule,24653.1,74072.88,
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,33004.16,,,,,,,fee schedule,24653.1,74072.88,
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,31432.54,,,,,,,fee schedule,24653.1,74072.88,
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,55053.05,,,,,,,fee schedule,24653.1,74072.88,
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,42781.05,,,,,,,fee schedule,24653.1,74072.88,
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,74072.88,,,,,,,fee schedule,24653.1,74072.88,
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,50921.08,,,,,,,fee schedule,24653.1,74072.88,
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,46116.63,,,,,,,fee schedule,24653.1,74072.88,
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37771.42,,,,,,,fee schedule,24653.1,74072.88,
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],23586.81,23586.81,23586.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],50922.67,50922.67,50922.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],49357.73,49357.73,49357.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,25612.69,,,,,,,fee schedule,24653.1,74072.88,MSDRG Base Rate
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,25368.76,,,,,,,fee schedule,24653.1,74072.88,MSDRG Base Rate
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,25368.76,,,,,,,fee schedule,24653.1,74072.88,MSDRG Base Rate
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,25612.69,,,,,,,fee schedule,24653.1,74072.88,MSDRG Base Rate
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,25368.76,,,,,,,fee schedule,24653.1,74072.88,MSDRG Base Rate
Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc,324,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,42687.82,,,,,,,fee schedule,24653.1,74072.88,MSDRG Base Rate
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,22083.62,,,,,,,fee schedule,22083.62,66352.61,
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,22083.62,,,,,,,fee schedule,22083.62,66352.61,
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29564.29,,,,,,,fee schedule,22083.62,66352.61,
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28156.47,,,,,,,fee schedule,22083.62,66352.61,
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,49315.12,,,,,,,fee schedule,22083.62,66352.61,
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,38322.18,,,,,,,fee schedule,22083.62,66352.61,
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,66352.61,,,,,,,fee schedule,22083.62,66352.61,
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,45613.81,,,,,,,fee schedule,22083.62,66352.61,
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,41310.11,,,,,,,fee schedule,22083.62,66352.61,
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33834.68,,,,,,,fee schedule,22083.62,66352.61,
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],38.72,38.72,38.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,26076.75,,,,,,,fee schedule,22083.62,66352.61,MSDRG Base Rate
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,25828.4,,,,,,,fee schedule,22083.62,66352.61,MSDRG Base Rate
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,25828.4,,,,,,,fee schedule,22083.62,66352.61,MSDRG Base Rate
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,26076.75,,,,,,,fee schedule,22083.62,66352.61,MSDRG Base Rate
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,25828.4,,,,,,,fee schedule,22083.62,66352.61,MSDRG Base Rate
Coronary Intravascular Lithotripsy Without Intraluminal Device,325,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,43461.25,,,,,,,fee schedule,22083.62,66352.61,MSDRG Base Rate
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,39188.01,,,,,,,fee schedule,39188.01,117744.58,
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,39188.01,,,,,,,fee schedule,39188.01,117744.58,
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52462.67,,,,,,,fee schedule,39188.01,117744.58,
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49964.45,,,,,,,fee schedule,39188.01,117744.58,
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,87511.08,,,,,,,fee schedule,39188.01,117744.58,
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,68003.79,,,,,,,fee schedule,39188.01,117744.58,
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,117744.58,,,,,,,fee schedule,39188.01,117744.58,
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,80943,,,,,,,fee schedule,39188.01,117744.58,
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,73305.96,,,,,,,fee schedule,39188.01,117744.58,
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60040.59,,,,,,,fee schedule,39188.01,117744.58,
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],23310.46,23310.46,23310.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],36081.78,36081.78,37633.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],129560.79,129560.79,227142.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],124031.32,124031.32,124031.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],38056.98,38056.98,38056.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",23255.05,23255.05,23255.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],37825.06,37825.06,38475.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],59749.82,59749.82,59749.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],35787.7,35248.59,69500.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",23039.73,23039.73,23039.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,39959.4,,,,,,,fee schedule,39188.01,117744.58,MSDRG Base Rate
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,39578.83,,,,,,,fee schedule,39188.01,117744.58,MSDRG Base Rate
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,39578.83,,,,,,,fee schedule,39188.01,117744.58,MSDRG Base Rate
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,39959.4,,,,,,,fee schedule,39188.01,117744.58,MSDRG Base Rate
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,39578.83,,,,,,,fee schedule,39188.01,117744.58,MSDRG Base Rate
"Stomach, Esophageal And Duodenal Procedures With Mcc",326,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,66599,,,,,,,fee schedule,39188.01,117744.58,MSDRG Base Rate
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18735.58,,,,,,,fee schedule,18735.58,56293.07,
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,18735.58,,,,,,,fee schedule,18735.58,56293.07,
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,25082.13,,,,,,,fee schedule,18735.58,56293.07,
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23887.74,,,,,,,fee schedule,18735.58,56293.07,
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,41838.59,,,,,,,fee schedule,18735.58,56293.07,
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,32512.26,,,,,,,fee schedule,18735.58,56293.07,
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,56293.07,,,,,,,fee schedule,18735.58,56293.07,
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,38698.43,,,,,,,fee schedule,18735.58,56293.07,
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,35047.2,,,,,,,fee schedule,18735.58,56293.07,
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,28705.1,,,,,,,fee schedule,18735.58,56293.07,
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],32.85,32.85,32.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],36943.7,36943.7,36943.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],36623.67,36623.67,36623.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],18088.74,18088.74,18088.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],21907.74,21907.74,21907.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],28569.29,28569.29,28569.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,20090.88,,,,,,,fee schedule,18735.58,56293.07,MSDRG Base Rate
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,19899.54,,,,,,,fee schedule,18735.58,56293.07,MSDRG Base Rate
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,19899.54,,,,,,,fee schedule,18735.58,56293.07,MSDRG Base Rate
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,20090.88,,,,,,,fee schedule,18735.58,56293.07,MSDRG Base Rate
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,19899.54,,,,,,,fee schedule,18735.58,56293.07,MSDRG Base Rate
"Stomach, Esophageal And Duodenal Procedures With Cc",327,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,33484.8,,,,,,,fee schedule,18735.58,56293.07,MSDRG Base Rate
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12294.91,,,,,,,fee schedule,12294.91,36941.39,
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,12294.91,,,,,,,fee schedule,12294.91,36941.39,
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16459.73,,,,,,,fee schedule,12294.91,36941.39,
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15675.93,,,,,,,fee schedule,12294.91,36941.39,
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,27455.88,,,,,,,fee schedule,12294.91,36941.39,
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,21335.63,,,,,,,fee schedule,12294.91,36941.39,
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,36941.39,,,,,,,fee schedule,12294.91,36941.39,
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,25395.19,,,,,,,fee schedule,12294.91,36941.39,
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,22999.14,,,,,,,fee schedule,12294.91,36941.39,
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18837.24,,,,,,,fee schedule,12294.91,36941.39,
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",10890.17,10890.17,10890.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],10428.86,10428.86,10428.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],27457.6,27457.6,27457.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],21.56,21.56,21.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13513.62,,,,,,,fee schedule,12294.91,36941.39,MSDRG Base Rate
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,13384.91,,,,,,,fee schedule,12294.91,36941.39,MSDRG Base Rate
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,13384.91,,,,,,,fee schedule,12294.91,36941.39,MSDRG Base Rate
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,13513.62,,,,,,,fee schedule,12294.91,36941.39,MSDRG Base Rate
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,13384.91,,,,,,,fee schedule,12294.91,36941.39,MSDRG Base Rate
"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc",328,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22522.69,,,,,,,fee schedule,12294.91,36941.39,MSDRG Base Rate
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,35430.25,,,,,,,fee schedule,35430.25,106453.97,
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,35430.25,,,,,,,fee schedule,35430.25,106453.97,
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,47431.99,,,,,,,fee schedule,35430.25,106453.97,
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,45173.33,,,,,,,fee schedule,35430.25,106453.97,
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,79119.58,,,,,,,fee schedule,35430.25,106453.97,
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,61482.86,,,,,,,fee schedule,35430.25,106453.97,
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,106453.97,,,,,,,fee schedule,35430.25,106453.97,
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,73181.32,,,,,,,fee schedule,35430.25,106453.97,
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,66276.6,,,,,,,fee schedule,35430.25,106453.97,
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,54283.26,,,,,,,fee schedule,35430.25,106453.97,
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],70095.45,58392.94,72884.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],32790.9,12979.37,250480.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],34207.62,34207.62,34207.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],66279.48,64825.53,72344.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",50962.87,50962.87,50962.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",20341.27,20341.27,127481.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],35460.99,35460.99,35460.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],33796.33,32196.97,34678.53,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],54285.63,54285.63,54285.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],60236.82,47785.03,157098.19,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],32132.63,17479.8,45350.7,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",20152.93,20152.93,20152.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,36905.53,,,,,,,fee schedule,35430.25,106453.97,MSDRG Base Rate
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,36554.04,,,,,,,fee schedule,35430.25,106453.97,MSDRG Base Rate
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,36554.04,,,,,,,fee schedule,35430.25,106453.97,MSDRG Base Rate
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,36905.53,,,,,,,fee schedule,35430.25,106453.97,MSDRG Base Rate
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,36554.04,,,,,,,fee schedule,35430.25,106453.97,MSDRG Base Rate
Major Small And Large Bowel Procedures With Mcc,329,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,61509.21,,,,,,,fee schedule,35430.25,106453.97,MSDRG Base Rate
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18238.66,,,,,,,fee schedule,18238.66,54800.02,
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,18238.66,,,,,,,fee schedule,18238.66,54800.02,
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24416.88,,,,,,,fee schedule,18238.66,54800.02,
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23254.18,,,,,,,fee schedule,18238.66,54800.02,
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,40728.91,,,,,,,fee schedule,18238.66,54800.02,
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,31649.94,,,,,,,fee schedule,18238.66,54800.02,
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,54800.02,,,,,,,fee schedule,18238.66,54800.02,
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,37672.04,,,,,,,fee schedule,18238.66,54800.02,
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,34117.65,,,,,,,fee schedule,18238.66,54800.02,
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27943.76,,,,,,,fee schedule,18238.66,54800.02,
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],54796.64,54796.64,54796.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],17846.1,17846.1,17846.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],34514.66,34461.47,73184.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],18522.8,17972,18558.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],23336.81,23336.81,23336.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",17118.82,17118.82,17118.82,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],17920.87,17920.87,17920.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],17986.18,16263.39,19306.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],26613.11,26613.11,26613.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],40228.91,33462.15,41306.15,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],17424.5,15883.61,17869.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,19723.69,,,,,,,fee schedule,18238.66,54800.02,MSDRG Base Rate
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,19535.85,,,,,,,fee schedule,18238.66,54800.02,MSDRG Base Rate
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,19535.85,,,,,,,fee schedule,18238.66,54800.02,MSDRG Base Rate
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,19723.69,,,,,,,fee schedule,18238.66,54800.02,MSDRG Base Rate
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,19535.85,,,,,,,fee schedule,18238.66,54800.02,MSDRG Base Rate
Major Small And Large Bowel Procedures With Cc,330,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,32872.82,,,,,,,fee schedule,18238.66,54800.02,MSDRG Base Rate
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12739.36,,,,,,,fee schedule,12739.36,38276.78,
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,12739.36,,,,,,,fee schedule,12739.36,38276.78,
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17054.73,,,,,,,fee schedule,12739.36,38276.78,
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16242.6,,,,,,,fee schedule,12739.36,38276.78,
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,28448.38,,,,,,,fee schedule,12739.36,38276.78,
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,22106.89,,,,,,,fee schedule,12739.36,38276.78,
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,38276.78,,,,,,,fee schedule,12739.36,38276.78,
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,26313.21,,,,,,,fee schedule,12739.36,38276.78,
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,23830.53,,,,,,,fee schedule,12739.36,38276.78,
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19518.19,,,,,,,fee schedule,12739.36,38276.78,
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],11754.24,11754.24,11754.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],26430.5,26430.5,27205.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],16242.6,16242.6,16242.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",11283.08,11283.08,11283.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12722.05,12722.05,12722.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],16976.59,16976.59,16976.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],28448.38,24978.85,28448.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],12665.24,12665.24,13969.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",11178.61,11178.61,11178.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14143.29,,,,,,,fee schedule,12739.36,38276.78,MSDRG Base Rate
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,14008.59,,,,,,,fee schedule,12739.36,38276.78,MSDRG Base Rate
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,14008.59,,,,,,,fee schedule,12739.36,38276.78,MSDRG Base Rate
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,14143.29,,,,,,,fee schedule,12739.36,38276.78,MSDRG Base Rate
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,14008.59,,,,,,,fee schedule,12739.36,38276.78,MSDRG Base Rate
Major Small And Large Bowel Procedures Without Cc/Mcc,331,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23572.15,,,,,,,fee schedule,12739.36,38276.78,MSDRG Base Rate
Rectal Resection With Mcc,332,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,26763.47,,,,,,,fee schedule,26763.47,80413.7,
Rectal Resection With Mcc,332,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,26763.47,,,,,,,fee schedule,26763.47,80413.7,
Rectal Resection With Mcc,332,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35829.4,,,,,,,fee schedule,26763.47,80413.7,
Rectal Resection With Mcc,332,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,34123.24,,,,,,,fee schedule,26763.47,80413.7,
Rectal Resection With Mcc,332,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,59765.72,,,,,,,fee schedule,26763.47,80413.7,
Rectal Resection With Mcc,332,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,46443.22,,,,,,,fee schedule,26763.47,80413.7,
Rectal Resection With Mcc,332,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,80413.7,,,,,,,fee schedule,26763.47,80413.7,
Rectal Resection With Mcc,332,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,55280.05,,,,,,,fee schedule,26763.47,80413.7,
Rectal Resection With Mcc,332,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,50064.33,,,,,,,fee schedule,26763.47,80413.7,
Rectal Resection With Mcc,332,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41004.75,,,,,,,fee schedule,26763.47,80413.7,
Rectal Resection With Mcc,332,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Mcc,332,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Mcc,332,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Mcc,332,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Mcc,332,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Mcc,332,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Mcc,332,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Mcc,332,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Mcc,332,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Mcc,332,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Mcc,332,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Mcc,332,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Mcc,332,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Mcc,332,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Mcc,332,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Mcc,332,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Mcc,332,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Mcc,332,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Mcc,332,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,29282.18,,,,,,,fee schedule,26763.47,80413.7,MSDRG Base Rate
Rectal Resection With Mcc,332,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,29003.3,,,,,,,fee schedule,26763.47,80413.7,MSDRG Base Rate
Rectal Resection With Mcc,332,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,29003.3,,,,,,,fee schedule,26763.47,80413.7,MSDRG Base Rate
Rectal Resection With Mcc,332,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,29282.18,,,,,,,fee schedule,26763.47,80413.7,MSDRG Base Rate
Rectal Resection With Mcc,332,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,29003.3,,,,,,,fee schedule,26763.47,80413.7,MSDRG Base Rate
Rectal Resection With Mcc,332,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,48803.63,,,,,,,fee schedule,26763.47,80413.7,MSDRG Base Rate
Rectal Resection With Cc,333,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16397.59,,,,,,,fee schedule,16397.59,49268.32,
Rectal Resection With Cc,333,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,16397.59,,,,,,,fee schedule,16397.59,49268.32,
Rectal Resection With Cc,333,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21952.16,,,,,,,fee schedule,16397.59,49268.32,
Rectal Resection With Cc,333,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20906.82,,,,,,,fee schedule,16397.59,49268.32,
Rectal Resection With Cc,333,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,36617.6,,,,,,,fee schedule,16397.59,49268.32,
Rectal Resection With Cc,333,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,28455.09,,,,,,,fee schedule,16397.59,49268.32,
Rectal Resection With Cc,333,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,49268.32,,,,,,,fee schedule,16397.59,49268.32,
Rectal Resection With Cc,333,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,33869.29,,,,,,,fee schedule,16397.59,49268.32,
Rectal Resection With Cc,333,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,30673.69,,,,,,,fee schedule,16397.59,49268.32,
Rectal Resection With Cc,333,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,25123.02,,,,,,,fee schedule,16397.59,49268.32,
Rectal Resection With Cc,333,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Cc,333,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Cc,333,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],14206.35,14206.35,14206.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Rectal Resection With Cc,333,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Cc,333,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Cc,333,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Cc,333,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Cc,333,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Cc,333,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Cc,333,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Cc,333,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Cc,333,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Cc,333,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Cc,333,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Cc,333,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Cc,333,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Cc,333,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Cc,333,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection With Cc,333,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,19294.01,,,,,,,fee schedule,16397.59,49268.32,MSDRG Base Rate
Rectal Resection With Cc,333,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,19110.26,,,,,,,fee schedule,16397.59,49268.32,MSDRG Base Rate
Rectal Resection With Cc,333,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,19110.26,,,,,,,fee schedule,16397.59,49268.32,MSDRG Base Rate
Rectal Resection With Cc,333,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,19294.01,,,,,,,fee schedule,16397.59,49268.32,MSDRG Base Rate
Rectal Resection With Cc,333,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,19110.26,,,,,,,fee schedule,16397.59,49268.32,MSDRG Base Rate
Rectal Resection With Cc,333,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,32156.69,,,,,,,fee schedule,16397.59,49268.32,MSDRG Base Rate
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12796.46,,,,,,,fee schedule,12796.46,38448.35,
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,12796.46,,,,,,,fee schedule,12796.46,38448.35,
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17131.17,,,,,,,fee schedule,12796.46,38448.35,
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16315.41,,,,,,,fee schedule,12796.46,38448.35,
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,28575.89,,,,,,,fee schedule,12796.46,38448.35,
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,22205.98,,,,,,,fee schedule,12796.46,38448.35,
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,38448.35,,,,,,,fee schedule,12796.46,38448.35,
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,26431.15,,,,,,,fee schedule,12796.46,38448.35,
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,23937.35,,,,,,,fee schedule,12796.46,38448.35,
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19605.67,,,,,,,fee schedule,12796.46,38448.35,
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13791.74,,,,,,,fee schedule,12796.46,38448.35,MSDRG Base Rate
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,13660.39,,,,,,,fee schedule,12796.46,38448.35,MSDRG Base Rate
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,13660.39,,,,,,,fee schedule,12796.46,38448.35,MSDRG Base Rate
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,13791.74,,,,,,,fee schedule,12796.46,38448.35,MSDRG Base Rate
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,13660.39,,,,,,,fee schedule,12796.46,38448.35,MSDRG Base Rate
Rectal Resection Without Cc/Mcc,334,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22986.23,,,,,,,fee schedule,12796.46,38448.35,MSDRG Base Rate
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,27962.56,,,,,,,fee schedule,27962.56,84016.5,
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,27962.56,,,,,,,fee schedule,27962.56,84016.5,
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37434.67,,,,,,,fee schedule,27962.56,84016.5,
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,35652.07,,,,,,,fee schedule,27962.56,84016.5,
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,62443.42,,,,,,,fee schedule,27962.56,84016.5,
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,48524.02,,,,,,,fee schedule,27962.56,84016.5,
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,84016.5,,,,,,,fee schedule,27962.56,84016.5,
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,57756.78,,,,,,,fee schedule,27962.56,84016.5,
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,52307.37,,,,,,,fee schedule,27962.56,84016.5,
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42841.89,,,,,,,fee schedule,27962.56,84016.5,
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],26499.86,26499.86,26499.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],26179.53,26179.53,27047.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],51191.82,51191.82,51191.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",20128.04,20128.04,20128.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],27849.56,27849.56,27849.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],62434.81,62434.81,62434.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],25288.26,24900.89,26994.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",19941.68,19941.68,19941.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,28893.12,,,,,,,fee schedule,27962.56,84016.5,MSDRG Base Rate
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,28617.95,,,,,,,fee schedule,27962.56,84016.5,MSDRG Base Rate
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,28617.95,,,,,,,fee schedule,27962.56,84016.5,MSDRG Base Rate
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,28893.12,,,,,,,fee schedule,27962.56,84016.5,MSDRG Base Rate
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,28617.95,,,,,,,fee schedule,27962.56,84016.5,MSDRG Base Rate
Peritoneal Adhesiolysis With Mcc,335,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,48155.2,,,,,,,fee schedule,27962.56,84016.5,MSDRG Base Rate
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16299.6,,,,,,,fee schedule,16299.6,48973.88,
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,16299.6,,,,,,,fee schedule,16299.6,48973.88,
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21820.97,,,,,,,fee schedule,16299.6,48973.88,
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20781.88,,,,,,,fee schedule,16299.6,48973.88,
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,36398.76,,,,,,,fee schedule,16299.6,48973.88,
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,28285.04,,,,,,,fee schedule,16299.6,48973.88,
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,48973.88,,,,,,,fee schedule,16299.6,48973.88,
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,33666.88,,,,,,,fee schedule,16299.6,48973.88,
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,30490.38,,,,,,,fee schedule,16299.6,48973.88,
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24972.88,,,,,,,fee schedule,16299.6,48973.88,
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8209.81,8209.81,8209.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],16295.24,16295.24,16295.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",15102.64,15102.64,15102.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],16137.94,16137.94,16137.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],23703.76,23703.76,23703.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],14927.73,10452.42,16013.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,17469.82,,,,,,,fee schedule,16299.6,48973.88,MSDRG Base Rate
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,17303.44,,,,,,,fee schedule,16299.6,48973.88,MSDRG Base Rate
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,17303.44,,,,,,,fee schedule,16299.6,48973.88,MSDRG Base Rate
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,17469.82,,,,,,,fee schedule,16299.6,48973.88,MSDRG Base Rate
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,17303.44,,,,,,,fee schedule,16299.6,48973.88,MSDRG Base Rate
Peritoneal Adhesiolysis With Cc,336,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,29116.36,,,,,,,fee schedule,16299.6,48973.88,MSDRG Base Rate
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11844.29,,,,,,,fee schedule,11844.29,35587.44,
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,11844.29,,,,,,,fee schedule,11844.29,35587.44,
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15856.46,,,,,,,fee schedule,11844.29,35587.44,
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15101.39,,,,,,,fee schedule,11844.29,35587.44,
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,26449.59,,,,,,,fee schedule,11844.29,35587.44,
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,20553.65,,,,,,,fee schedule,11844.29,35587.44,
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,35587.44,,,,,,,fee schedule,11844.29,35587.44,
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,24464.43,,,,,,,fee schedule,11844.29,35587.44,
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,22156.19,,,,,,,fee schedule,11844.29,35587.44,
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18146.83,,,,,,,fee schedule,11844.29,35587.44,
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],10914.1,10914.1,10914.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],19716.87,19716.87,19716.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",10696.07,10696.07,10696.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],27323,27323,27323,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],11827.53,11827.53,11827.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12987.84,,,,,,,fee schedule,11844.29,35587.44,MSDRG Base Rate
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,12864.14,,,,,,,fee schedule,11844.29,35587.44,MSDRG Base Rate
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,12864.14,,,,,,,fee schedule,11844.29,35587.44,MSDRG Base Rate
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,12987.84,,,,,,,fee schedule,11844.29,35587.44,MSDRG Base Rate
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,12864.14,,,,,,,fee schedule,11844.29,35587.44,MSDRG Base Rate
Peritoneal Adhesiolysis Without Cc/Mcc,337,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21646.4,,,,,,,fee schedule,11844.29,35587.44,MSDRG Base Rate
Appendectomy With Complicated Principal Diagnosis With Mcc,338,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,20497.95,,,,,,,fee schedule,20497.95,61588.3,
Appendectomy With Complicated Principal Diagnosis With Mcc,338,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,20497.95,,,,,,,fee schedule,20497.95,61588.3,
Appendectomy With Complicated Principal Diagnosis With Mcc,338,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26134.75,,,,,,,fee schedule,20497.95,61588.3,
Appendectomy With Complicated Principal Diagnosis With Mcc,338,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,45774.15,,,,,,,fee schedule,20497.95,61588.3,
Appendectomy With Complicated Principal Diagnosis With Mcc,338,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,35570.54,,,,,,,fee schedule,20497.95,61588.3,
Appendectomy With Complicated Principal Diagnosis With Mcc,338,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,61588.3,,,,,,,fee schedule,20497.95,61588.3,
Appendectomy With Complicated Principal Diagnosis With Mcc,338,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,42338.61,,,,,,,fee schedule,20497.95,61588.3,
Appendectomy With Complicated Principal Diagnosis With Mcc,338,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,38343.92,,,,,,,fee schedule,20497.95,61588.3,
Appendectomy With Complicated Principal Diagnosis With Mcc,338,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,31405.25,,,,,,,fee schedule,20497.95,61588.3,
Appendectomy With Complicated Principal Diagnosis With Mcc,338,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy With Complicated Principal Diagnosis With Mcc,338,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy With Complicated Principal Diagnosis With Mcc,338,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy With Complicated Principal Diagnosis With Mcc,338,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy With Complicated Principal Diagnosis With Mcc,338,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy With Complicated Principal Diagnosis With Mcc,338,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy With Complicated Principal Diagnosis With Mcc,338,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy With Complicated Principal Diagnosis With Mcc,338,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy With Complicated Principal Diagnosis With Mcc,338,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy With Complicated Principal Diagnosis With Mcc,338,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy With Complicated Principal Diagnosis With Mcc,338,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy With Complicated Principal Diagnosis With Mcc,338,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy With Complicated Principal Diagnosis With Mcc,338,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy With Complicated Principal Diagnosis With Mcc,338,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy With Complicated Principal Diagnosis With Mcc,338,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy With Complicated Principal Diagnosis With Mcc,338,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy With Complicated Principal Diagnosis With Mcc,338,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy With Complicated Principal Diagnosis With Mcc,338,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy With Complicated Principal Diagnosis With Cc,339,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12564.98,,,,,,,fee schedule,12564.98,37752.83,
Appendectomy With Complicated Principal Diagnosis With Cc,339,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,12564.98,,,,,,,fee schedule,12564.98,37752.83,
Appendectomy With Complicated Principal Diagnosis With Cc,339,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16020.26,,,,,,,fee schedule,12564.98,37752.83,
Appendectomy With Complicated Principal Diagnosis With Cc,339,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,28058.96,,,,,,,fee schedule,12564.98,37752.83,
Appendectomy With Complicated Principal Diagnosis With Cc,339,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,21804.28,,,,,,,fee schedule,12564.98,37752.83,
Appendectomy With Complicated Principal Diagnosis With Cc,339,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,37752.83,,,,,,,fee schedule,12564.98,37752.83,
Appendectomy With Complicated Principal Diagnosis With Cc,339,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,25953.02,,,,,,,fee schedule,12564.98,37752.83,
Appendectomy With Complicated Principal Diagnosis With Cc,339,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,23504.33,,,,,,,fee schedule,12564.98,37752.83,
Appendectomy With Complicated Principal Diagnosis With Cc,339,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19251.01,,,,,,,fee schedule,12564.98,37752.83,
Appendectomy With Complicated Principal Diagnosis With Cc,339,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy With Complicated Principal Diagnosis With Cc,339,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy With Complicated Principal Diagnosis With Cc,339,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy With Complicated Principal Diagnosis With Cc,339,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy With Complicated Principal Diagnosis With Cc,339,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy With Complicated Principal Diagnosis With Cc,339,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy With Complicated Principal Diagnosis With Cc,339,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy With Complicated Principal Diagnosis With Cc,339,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy With Complicated Principal Diagnosis With Cc,339,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy With Complicated Principal Diagnosis With Cc,339,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy With Complicated Principal Diagnosis With Cc,339,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy With Complicated Principal Diagnosis With Cc,339,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy With Complicated Principal Diagnosis With Cc,339,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy With Complicated Principal Diagnosis With Cc,339,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy With Complicated Principal Diagnosis With Cc,339,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy With Complicated Principal Diagnosis With Cc,339,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy With Complicated Principal Diagnosis With Cc,339,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy With Complicated Principal Diagnosis With Cc,339,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc,340,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9258.61,,,,,,,fee schedule,9258.61,27818.48,
Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc,340,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,9258.61,,,,,,,fee schedule,9258.61,27818.48,
Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc,340,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11804.66,,,,,,,fee schedule,9258.61,27818.48,
Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc,340,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,20675.48,,,,,,,fee schedule,9258.61,27818.48,
Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc,340,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,16066.66,,,,,,,fee schedule,9258.61,27818.48,
Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc,340,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,27818.48,,,,,,,fee schedule,9258.61,27818.48,
Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc,340,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,19123.69,,,,,,,fee schedule,9258.61,27818.48,
Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc,340,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,17319.36,,,,,,,fee schedule,9258.61,27818.48,
Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc,340,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14185.27,,,,,,,fee schedule,9258.61,27818.48,
Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc,340,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc,340,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc,340,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc,340,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc,340,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc,340,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc,340,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc,340,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc,340,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc,340,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc,340,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc,340,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc,340,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc,340,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc,340,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc,340,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc,340,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc,340,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy Without Complicated Principal Diagnosis With Mcc,341,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17430.78,,,,,,,fee schedule,17430.78,52372.66,
Appendectomy Without Complicated Principal Diagnosis With Mcc,341,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,17430.78,,,,,,,fee schedule,17430.78,52372.66,
Appendectomy Without Complicated Principal Diagnosis With Mcc,341,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22224.13,,,,,,,fee schedule,17430.78,52372.66,
Appendectomy Without Complicated Principal Diagnosis With Mcc,341,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,38924.83,,,,,,,fee schedule,17430.78,52372.66,
Appendectomy Without Complicated Principal Diagnosis With Mcc,341,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,30248.01,,,,,,,fee schedule,17430.78,52372.66,
Appendectomy Without Complicated Principal Diagnosis With Mcc,341,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,52372.66,,,,,,,fee schedule,17430.78,52372.66,
Appendectomy Without Complicated Principal Diagnosis With Mcc,341,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,36003.35,,,,,,,fee schedule,17430.78,52372.66,
Appendectomy Without Complicated Principal Diagnosis With Mcc,341,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,32606.41,,,,,,,fee schedule,17430.78,52372.66,
Appendectomy Without Complicated Principal Diagnosis With Mcc,341,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26705.99,,,,,,,fee schedule,17430.78,52372.66,
Appendectomy Without Complicated Principal Diagnosis With Mcc,341,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy Without Complicated Principal Diagnosis With Mcc,341,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy Without Complicated Principal Diagnosis With Mcc,341,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy Without Complicated Principal Diagnosis With Mcc,341,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy Without Complicated Principal Diagnosis With Mcc,341,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy Without Complicated Principal Diagnosis With Mcc,341,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy Without Complicated Principal Diagnosis With Mcc,341,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy Without Complicated Principal Diagnosis With Mcc,341,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy Without Complicated Principal Diagnosis With Mcc,341,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy Without Complicated Principal Diagnosis With Mcc,341,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy Without Complicated Principal Diagnosis With Mcc,341,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy Without Complicated Principal Diagnosis With Mcc,341,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy Without Complicated Principal Diagnosis With Mcc,341,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy Without Complicated Principal Diagnosis With Mcc,341,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy Without Complicated Principal Diagnosis With Mcc,341,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy Without Complicated Principal Diagnosis With Mcc,341,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy Without Complicated Principal Diagnosis With Mcc,341,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy Without Complicated Principal Diagnosis With Mcc,341,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy Without Complicated Principal Diagnosis With Cc,342,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11213.11,,,,,,,fee schedule,11213.11,33690.99,
Appendectomy Without Complicated Principal Diagnosis With Cc,342,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,11213.11,,,,,,,fee schedule,11213.11,33690.99,
Appendectomy Without Complicated Principal Diagnosis With Cc,342,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14296.64,,,,,,,fee schedule,11213.11,33690.99,
Appendectomy Without Complicated Principal Diagnosis With Cc,342,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,25040.09,,,,,,,fee schedule,11213.11,33690.99,
Appendectomy Without Complicated Principal Diagnosis With Cc,342,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,19458.35,,,,,,,fee schedule,11213.11,33690.99,
Appendectomy Without Complicated Principal Diagnosis With Cc,342,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,33690.99,,,,,,,fee schedule,11213.11,33690.99,
Appendectomy Without Complicated Principal Diagnosis With Cc,342,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,23160.72,,,,,,,fee schedule,11213.11,33690.99,
Appendectomy Without Complicated Principal Diagnosis With Cc,342,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,20975.49,,,,,,,fee schedule,11213.11,33690.99,
Appendectomy Without Complicated Principal Diagnosis With Cc,342,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17179.79,,,,,,,fee schedule,11213.11,33690.99,
Appendectomy Without Complicated Principal Diagnosis With Cc,342,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy Without Complicated Principal Diagnosis With Cc,342,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy Without Complicated Principal Diagnosis With Cc,342,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy Without Complicated Principal Diagnosis With Cc,342,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy Without Complicated Principal Diagnosis With Cc,342,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy Without Complicated Principal Diagnosis With Cc,342,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy Without Complicated Principal Diagnosis With Cc,342,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy Without Complicated Principal Diagnosis With Cc,342,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy Without Complicated Principal Diagnosis With Cc,342,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy Without Complicated Principal Diagnosis With Cc,342,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy Without Complicated Principal Diagnosis With Cc,342,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy Without Complicated Principal Diagnosis With Cc,342,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy Without Complicated Principal Diagnosis With Cc,342,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy Without Complicated Principal Diagnosis With Cc,342,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy Without Complicated Principal Diagnosis With Cc,342,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy Without Complicated Principal Diagnosis With Cc,342,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy Without Complicated Principal Diagnosis With Cc,342,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy Without Complicated Principal Diagnosis With Cc,342,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc,343,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8431.44,,,,,,,fee schedule,8431.44,25333.16,
Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc,343,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,8431.44,,,,,,,fee schedule,8431.44,25333.16,
Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc,343,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10750.03,,,,,,,fee schedule,8431.44,25333.16,
Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc,343,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,18828.31,,,,,,,fee schedule,8431.44,25333.16,
Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc,343,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,14631.25,,,,,,,fee schedule,8431.44,25333.16,
Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc,343,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,25333.16,,,,,,,fee schedule,8431.44,25333.16,
Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc,343,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,17415.17,,,,,,,fee schedule,8431.44,25333.16,
Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc,343,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,15772.03,,,,,,,fee schedule,8431.44,25333.16,
Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc,343,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12917.94,,,,,,,fee schedule,8431.44,25333.16,
Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc,343,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc,343,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc,343,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc,343,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc,343,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc,343,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc,343,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc,343,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc,343,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc,343,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc,343,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc,343,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc,343,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc,343,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc,343,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc,343,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc,343,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc,343,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,20790.39,,,,,,,fee schedule,20790.39,62466.97,
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,20790.39,,,,,,,fee schedule,20790.39,62466.97,
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,27832.99,,,,,,,fee schedule,20790.39,62466.97,
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26507.61,,,,,,,fee schedule,20790.39,62466.97,
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,46427.21,,,,,,,fee schedule,20790.39,62466.97,
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,36078.02,,,,,,,fee schedule,20790.39,62466.97,
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,62466.97,,,,,,,fee schedule,20790.39,62466.97,
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,42942.65,,,,,,,fee schedule,20790.39,62466.97,
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,38890.97,,,,,,,fee schedule,20790.39,62466.97,
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,31853.3,,,,,,,fee schedule,20790.39,62466.97,
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],19935.59,19935.59,19935.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],20411.83,20411.83,20411.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,21173.68,,,,,,,fee schedule,20790.39,62466.97,MSDRG Base Rate
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,20972.03,,,,,,,fee schedule,20790.39,62466.97,MSDRG Base Rate
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,20972.03,,,,,,,fee schedule,20790.39,62466.97,MSDRG Base Rate
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,21173.68,,,,,,,fee schedule,20790.39,62466.97,MSDRG Base Rate
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,20972.03,,,,,,,fee schedule,20790.39,62466.97,MSDRG Base Rate
Minor Small And Large Bowel Procedures With Mcc,344,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,35289.47,,,,,,,fee schedule,20790.39,62466.97,MSDRG Base Rate
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11490.89,,,,,,,fee schedule,11490.89,34525.61,
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,11490.89,,,,,,,fee schedule,11490.89,34525.61,
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15383.35,,,,,,,fee schedule,11490.89,34525.61,
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14650.81,,,,,,,fee schedule,11490.89,34525.61,
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,25660.41,,,,,,,fee schedule,11490.89,34525.61,
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,19940.39,,,,,,,fee schedule,11490.89,34525.61,
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,34525.61,,,,,,,fee schedule,11490.89,34525.61,
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,23734.48,,,,,,,fee schedule,11490.89,34525.61,
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,21495.11,,,,,,,fee schedule,11490.89,34525.61,
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17605.38,,,,,,,fee schedule,11490.89,34525.61,
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],25324.67,25324.67,25324.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11214.17,11214.17,11214.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],17599.47,17599.47,17599.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],23748.8,23748.8,23748.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12751.13,,,,,,,fee schedule,11490.89,34525.61,MSDRG Base Rate
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,12629.69,,,,,,,fee schedule,11490.89,34525.61,MSDRG Base Rate
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,12629.69,,,,,,,fee schedule,11490.89,34525.61,MSDRG Base Rate
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,12751.13,,,,,,,fee schedule,11490.89,34525.61,MSDRG Base Rate
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,12629.69,,,,,,,fee schedule,11490.89,34525.61,MSDRG Base Rate
Minor Small And Large Bowel Procedures With Cc,345,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21251.88,,,,,,,fee schedule,11490.89,34525.61,MSDRG Base Rate
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9608.15,,,,,,,fee schedule,9608.15,28868.72,
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,9608.15,,,,,,,fee schedule,9608.15,28868.72,
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12862.84,,,,,,,fee schedule,9608.15,28868.72,
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12250.33,,,,,,,fee schedule,9608.15,28868.72,
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,21456.04,,,,,,,fee schedule,9608.15,28868.72,
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,16673.23,,,,,,,fee schedule,9608.15,28868.72,
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,28868.72,,,,,,,fee schedule,9608.15,28868.72,
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,19845.67,,,,,,,fee schedule,9608.15,28868.72,
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,17973.22,,,,,,,fee schedule,9608.15,28868.72,
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14720.8,,,,,,,fee schedule,9608.15,28868.72,
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],19089.73,19089.73,19089.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],13579.75,13579.75,13579.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",13452.26,13452.26,13452.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],12863.87,12863.87,12863.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9175.71,9175.71,9175.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],20992.89,20992.89,20992.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10262.87,,,,,,,fee schedule,9608.15,28868.72,MSDRG Base Rate
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,10165.13,,,,,,,fee schedule,9608.15,28868.72,MSDRG Base Rate
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,10165.13,,,,,,,fee schedule,9608.15,28868.72,MSDRG Base Rate
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,10262.87,,,,,,,fee schedule,9608.15,28868.72,MSDRG Base Rate
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,10165.13,,,,,,,fee schedule,9608.15,28868.72,MSDRG Base Rate
Minor Small And Large Bowel Procedures Without Cc/Mcc,346,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,17104.78,,,,,,,fee schedule,9608.15,28868.72,MSDRG Base Rate
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18261.04,,,,,,,fee schedule,18261.04,54867.25,
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,18261.04,,,,,,,fee schedule,18261.04,54867.25,
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24446.84,,,,,,,fee schedule,18261.04,54867.25,
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23282.71,,,,,,,fee schedule,18261.04,54867.25,
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,40778.88,,,,,,,fee schedule,18261.04,54867.25,
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,31688.77,,,,,,,fee schedule,18261.04,54867.25,
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,54867.25,,,,,,,fee schedule,18261.04,54867.25,
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,37718.26,,,,,,,fee schedule,18261.04,54867.25,
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,34159.5,,,,,,,fee schedule,18261.04,54867.25,
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27978.04,,,,,,,fee schedule,18261.04,54867.25,
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],33777.49,33777.49,33777.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],1173.77,1173.77,1173.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],15697.15,15697.15,15697.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,18929.96,,,,,,,fee schedule,18261.04,54867.25,MSDRG Base Rate
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,18749.67,,,,,,,fee schedule,18261.04,54867.25,MSDRG Base Rate
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,18749.67,,,,,,,fee schedule,18261.04,54867.25,MSDRG Base Rate
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,18929.96,,,,,,,fee schedule,18261.04,54867.25,MSDRG Base Rate
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,18749.67,,,,,,,fee schedule,18261.04,54867.25,MSDRG Base Rate
Anal And Stomal Procedures With Mcc,347,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31549.93,,,,,,,fee schedule,18261.04,54867.25,MSDRG Base Rate
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9713.09,,,,,,,fee schedule,9713.09,29184.02,
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,9713.09,,,,,,,fee schedule,9713.09,29184.02,
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13003.33,,,,,,,fee schedule,9713.09,29184.02,
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12384.12,,,,,,,fee schedule,9713.09,29184.02,
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,21690.38,,,,,,,fee schedule,9713.09,29184.02,
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,16855.33,,,,,,,fee schedule,9713.09,29184.02,
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,29184.02,,,,,,,fee schedule,9713.09,29184.02,
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,20062.43,,,,,,,fee schedule,9713.09,29184.02,
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,18169.52,,,,,,,fee schedule,9713.09,29184.02,
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14881.58,,,,,,,fee schedule,9713.09,29184.02,
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],16221.05,16221.05,16221.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11220.67,,,,,,,fee schedule,9713.09,29184.02,MSDRG Base Rate
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,11113.8,,,,,,,fee schedule,9713.09,29184.02,MSDRG Base Rate
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,11113.8,,,,,,,fee schedule,9713.09,29184.02,MSDRG Base Rate
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,11220.67,,,,,,,fee schedule,9713.09,29184.02,MSDRG Base Rate
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,11113.8,,,,,,,fee schedule,9713.09,29184.02,MSDRG Base Rate
Anal And Stomal Procedures With Cc,348,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18701.11,,,,,,,fee schedule,9713.09,29184.02,MSDRG Base Rate
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6797.16,,,,,,,fee schedule,6797.16,20422.79,
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,6797.16,,,,,,,fee schedule,6797.16,20422.79,
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9099.64,,,,,,,fee schedule,6797.16,20422.79,
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8666.33,,,,,,,fee schedule,6797.16,20422.79,
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,15178.79,,,,,,,fee schedule,6797.16,20422.79,
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,11795.25,,,,,,,fee schedule,6797.16,20422.79,
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,20422.79,,,,,,,fee schedule,6797.16,20422.79,
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,14039.56,,,,,,,fee schedule,6797.16,20422.79,
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,12714.91,,,,,,,fee schedule,6797.16,20422.79,
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10414.04,,,,,,,fee schedule,6797.16,20422.79,
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],14918.03,14918.03,14918.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7797.27,,,,,,,fee schedule,6797.16,20422.79,MSDRG Base Rate
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,7723.01,,,,,,,fee schedule,6797.16,20422.79,MSDRG Base Rate
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,7723.01,,,,,,,fee schedule,6797.16,20422.79,MSDRG Base Rate
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,7797.27,,,,,,,fee schedule,6797.16,20422.79,MSDRG Base Rate
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,7723.01,,,,,,,fee schedule,6797.16,20422.79,MSDRG Base Rate
Anal And Stomal Procedures Without Cc/Mcc,349,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12995.45,,,,,,,fee schedule,6797.16,20422.79,MSDRG Base Rate
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18671.54,,,,,,,fee schedule,18671.54,56100.64,
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,18671.54,,,,,,,fee schedule,18671.54,56100.64,
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24996.39,,,,,,,fee schedule,18671.54,56100.64,
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23806.09,,,,,,,fee schedule,18671.54,56100.64,
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,41695.57,,,,,,,fee schedule,18671.54,56100.64,
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,32401.12,,,,,,,fee schedule,18671.54,56100.64,
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,56100.64,,,,,,,fee schedule,18671.54,56100.64,
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,38566.14,,,,,,,fee schedule,18671.54,56100.64,
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,34927.39,,,,,,,fee schedule,18671.54,56100.64,
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,28606.97,,,,,,,fee schedule,18671.54,56100.64,
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],17264.13,17264.13,17264.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],17657.5,17657.5,17657.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",5331.71,5331.71,5331.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],18226.78,18226.78,18226.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,20463.53,,,,,,,fee schedule,18671.54,56100.64,MSDRG Base Rate
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,20268.64,,,,,,,fee schedule,18671.54,56100.64,MSDRG Base Rate
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,20268.64,,,,,,,fee schedule,18671.54,56100.64,MSDRG Base Rate
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,20463.53,,,,,,,fee schedule,18671.54,56100.64,MSDRG Base Rate
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,20268.64,,,,,,,fee schedule,18671.54,56100.64,MSDRG Base Rate
Inguinal And Femoral Hernia Procedures With Mcc,350,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,34105.89,,,,,,,fee schedule,18671.54,56100.64,MSDRG Base Rate
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11610.49,,,,,,,fee schedule,11610.49,34884.96,
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,11610.49,,,,,,,fee schedule,11610.49,34884.96,
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15543.46,,,,,,,fee schedule,11610.49,34884.96,
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14803.3,,,,,,,fee schedule,11610.49,34884.96,
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,25927.49,,,,,,,fee schedule,11610.49,34884.96,
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,20147.93,,,,,,,fee schedule,11610.49,34884.96,
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,34884.96,,,,,,,fee schedule,11610.49,34884.96,
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,23981.52,,,,,,,fee schedule,11610.49,34884.96,
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,21718.84,,,,,,,fee schedule,11610.49,34884.96,
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17788.62,,,,,,,fee schedule,11610.49,34884.96,
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],11398.36,11398.36,11398.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],17674.95,17674.95,17674.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12056.46,12056.46,12056.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4157.68,4157.68,4157.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],11846.03,11846.03,11846.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12905.8,,,,,,,fee schedule,11610.49,34884.96,MSDRG Base Rate
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,12782.89,,,,,,,fee schedule,11610.49,34884.96,MSDRG Base Rate
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,12782.89,,,,,,,fee schedule,11610.49,34884.96,MSDRG Base Rate
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,12905.8,,,,,,,fee schedule,11610.49,34884.96,MSDRG Base Rate
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,12782.89,,,,,,,fee schedule,11610.49,34884.96,MSDRG Base Rate
Inguinal And Femoral Hernia Procedures With Cc,351,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21509.67,,,,,,,fee schedule,11610.49,34884.96,MSDRG Base Rate
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8507.06,,,,,,,fee schedule,8507.06,25560.36,
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,8507.06,,,,,,,fee schedule,8507.06,25560.36,
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11388.76,,,,,,,fee schedule,8507.06,25560.36,
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10846.44,,,,,,,fee schedule,8507.06,25560.36,
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,18997.18,,,,,,,fee schedule,8507.06,25560.36,
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,14762.48,,,,,,,fee schedule,8507.06,25560.36,
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,25560.36,,,,,,,fee schedule,8507.06,25560.36,
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,17571.36,,,,,,,fee schedule,8507.06,25560.36,
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,15913.49,,,,,,,fee schedule,8507.06,25560.36,
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13033.8,,,,,,,fee schedule,8507.06,25560.36,
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],16791.2,16791.2,16791.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10119.12,,,,,,,fee schedule,8507.06,25560.36,MSDRG Base Rate
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,10022.75,,,,,,,fee schedule,8507.06,25560.36,MSDRG Base Rate
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,10022.75,,,,,,,fee schedule,8507.06,25560.36,MSDRG Base Rate
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,10119.12,,,,,,,fee schedule,8507.06,25560.36,MSDRG Base Rate
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,10022.75,,,,,,,fee schedule,8507.06,25560.36,MSDRG Base Rate
Inguinal And Femoral Hernia Procedures Without Cc/Mcc,352,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16865.21,,,,,,,fee schedule,8507.06,25560.36,MSDRG Base Rate
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,22629.92,,,,,,,fee schedule,22629.92,67994.04,
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,22629.92,,,,,,,fee schedule,22629.92,67994.04,
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,30295.65,,,,,,,fee schedule,22629.92,67994.04,
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28853,,,,,,,fee schedule,22629.92,67994.04,
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,50535.08,,,,,,,fee schedule,22629.92,67994.04,
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,39270.19,,,,,,,fee schedule,22629.92,67994.04,
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,67994.04,,,,,,,fee schedule,22629.92,67994.04,
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,46742.2,,,,,,,fee schedule,22629.92,67994.04,
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,42332.04,,,,,,,fee schedule,22629.92,67994.04,
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,34671.68,,,,,,,fee schedule,22629.92,67994.04,
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",11848.82,11848.82,11848.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],21710.02,21710.02,22218.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],35586.74,35586.74,35586.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,23667.4,,,,,,,fee schedule,22629.92,67994.04,MSDRG Base Rate
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,23442,,,,,,,fee schedule,22629.92,67994.04,MSDRG Base Rate
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,23442,,,,,,,fee schedule,22629.92,67994.04,MSDRG Base Rate
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,23667.4,,,,,,,fee schedule,22629.92,67994.04,MSDRG Base Rate
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,23442,,,,,,,fee schedule,22629.92,67994.04,MSDRG Base Rate
Hernia Procedures Except Inguinal And Femoral With Mcc,353,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,39445.66,,,,,,,fee schedule,22629.92,67994.04,MSDRG Base Rate
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13125.94,,,,,,,fee schedule,13125.94,39438.3,
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,13125.94,,,,,,,fee schedule,13125.94,39438.3,
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17572.26,,,,,,,fee schedule,13125.94,39438.3,
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16735.49,,,,,,,fee schedule,13125.94,39438.3,
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,29311.65,,,,,,,fee schedule,13125.94,39438.3,
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,22777.73,,,,,,,fee schedule,13125.94,39438.3,
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,39438.3,,,,,,,fee schedule,13125.94,39438.3,
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,27111.69,,,,,,,fee schedule,13125.94,39438.3,
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,24553.68,,,,,,,fee schedule,13125.94,39438.3,
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20110.47,,,,,,,fee schedule,13125.94,39438.3,
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],27111.69,27111.69,27111.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",6229.31,6229.31,6229.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],16735.49,16735.49,16735.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11243.95,11243.95,11243.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],28766.42,28766.42,28766.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",6171.63,6171.63,6171.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14139.38,,,,,,,fee schedule,13125.94,39438.3,MSDRG Base Rate
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,14004.72,,,,,,,fee schedule,13125.94,39438.3,MSDRG Base Rate
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,14004.72,,,,,,,fee schedule,13125.94,39438.3,MSDRG Base Rate
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,14139.38,,,,,,,fee schedule,13125.94,39438.3,MSDRG Base Rate
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,14004.72,,,,,,,fee schedule,13125.94,39438.3,MSDRG Base Rate
Hernia Procedures Except Inguinal And Femoral With Cc,354,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23565.64,,,,,,,fee schedule,13125.94,39438.3,MSDRG Base Rate
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10286.4,,,,,,,fee schedule,10286.4,30906.59,
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,10286.4,,,,,,,fee schedule,10286.4,30906.59,
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13770.84,,,,,,,fee schedule,10286.4,30906.59,
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13115.09,,,,,,,fee schedule,10286.4,30906.59,
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,22970.65,,,,,,,fee schedule,10286.4,30906.59,
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,17850.21,,,,,,,fee schedule,10286.4,30906.59,
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,30906.59,,,,,,,fee schedule,10286.4,30906.59,
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,21246.6,,,,,,,fee schedule,10286.4,30906.59,
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,19241.97,,,,,,,fee schedule,10286.4,30906.59,
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15759.96,,,,,,,fee schedule,10286.4,30906.59,
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],13116.07,13116.07,13116.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],10392.14,10392.14,10392.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],20485.01,20485.01,20485.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11503.47,,,,,,,fee schedule,10286.4,30906.59,MSDRG Base Rate
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,11393.92,,,,,,,fee schedule,10286.4,30906.59,MSDRG Base Rate
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,11393.92,,,,,,,fee schedule,10286.4,30906.59,MSDRG Base Rate
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,11503.47,,,,,,,fee schedule,10286.4,30906.59,MSDRG Base Rate
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,11393.92,,,,,,,fee schedule,10286.4,30906.59,MSDRG Base Rate
Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc,355,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19172.46,,,,,,,fee schedule,10286.4,30906.59,MSDRG Base Rate
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,32912.47,,,,,,,fee schedule,32912.47,98889.03,
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,32912.47,,,,,,,fee schedule,32912.47,98889.03,
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,44061.33,,,,,,,fee schedule,32912.47,98889.03,
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,41963.18,,,,,,,fee schedule,32912.47,98889.03,
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,73497.11,,,,,,,fee schedule,32912.47,98889.03,
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,57113.71,,,,,,,fee schedule,32912.47,98889.03,
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,98889.03,,,,,,,fee schedule,32912.47,98889.03,
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,67980.84,,,,,,,fee schedule,32912.47,98889.03,
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,61566.78,,,,,,,fee schedule,32912.47,98889.03,
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,50425.73,,,,,,,fee schedule,32912.47,98889.03,
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],46645,46645,46645,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",25822.35,25822.35,25822.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],32655.47,32655.47,32655.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],16880.51,16880.51,16880.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,35314.15,,,,,,,fee schedule,32912.47,98889.03,MSDRG Base Rate
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,34977.82,,,,,,,fee schedule,32912.47,98889.03,MSDRG Base Rate
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,34977.82,,,,,,,fee schedule,32912.47,98889.03,MSDRG Base Rate
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,35314.15,,,,,,,fee schedule,32912.47,98889.03,MSDRG Base Rate
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,34977.82,,,,,,,fee schedule,32912.47,98889.03,MSDRG Base Rate
Other Digestive System O.R. Procedures With Mcc,356,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,58856.91,,,,,,,fee schedule,32912.47,98889.03,MSDRG Base Rate
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17376,,,,,,,fee schedule,17376,52208.05,
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,17376,,,,,,,fee schedule,17376,52208.05,
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23261.99,,,,,,,fee schedule,17376,52208.05,
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22154.28,,,,,,,fee schedule,17376,52208.05,
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,38802.49,,,,,,,fee schedule,17376,52208.05,
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,30152.94,,,,,,,fee schedule,17376,52208.05,
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,52208.05,,,,,,,fee schedule,17376,52208.05,
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,35890.2,,,,,,,fee schedule,17376,52208.05,
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,32503.92,,,,,,,fee schedule,17376,52208.05,
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26622.05,,,,,,,fee schedule,17376,52208.05,
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],36063.95,36063.95,36063.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",15257.4,15257.4,15257.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],15417.22,15417.22,15417.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],15104.1,15104.1,15104.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,19163.55,,,,,,,fee schedule,17376,52208.05,MSDRG Base Rate
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,18981.04,,,,,,,fee schedule,17376,52208.05,MSDRG Base Rate
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,18981.04,,,,,,,fee schedule,17376,52208.05,MSDRG Base Rate
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,19163.55,,,,,,,fee schedule,17376,52208.05,MSDRG Base Rate
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,18981.04,,,,,,,fee schedule,17376,52208.05,MSDRG Base Rate
Other Digestive System O.R. Procedures With Cc,357,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31939.25,,,,,,,fee schedule,17376,52208.05,MSDRG Base Rate
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10455.38,,,,,,,fee schedule,10455.38,31414.32,
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,10455.38,,,,,,,fee schedule,10455.38,31414.32,
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13997.07,,,,,,,fee schedule,10455.38,31414.32,
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13330.54,,,,,,,fee schedule,10455.38,31414.32,
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,23348.01,,,,,,,fee schedule,10455.38,31414.32,
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,18143.45,,,,,,,fee schedule,10455.38,31414.32,
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,31414.32,,,,,,,fee schedule,10455.38,31414.32,
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,21595.64,,,,,,,fee schedule,10455.38,31414.32,
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,19558.07,,,,,,,fee schedule,10455.38,31414.32,
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16018.86,,,,,,,fee schedule,10455.38,31414.32,
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],16965.13,16965.13,16965.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],16020.05,16020.05,16020.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],19727.82,19727.82,19727.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11916.75,,,,,,,fee schedule,10455.38,31414.32,MSDRG Base Rate
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,11803.26,,,,,,,fee schedule,10455.38,31414.32,MSDRG Base Rate
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,11803.26,,,,,,,fee schedule,10455.38,31414.32,MSDRG Base Rate
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,11916.75,,,,,,,fee schedule,10455.38,31414.32,MSDRG Base Rate
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,11803.26,,,,,,,fee schedule,10455.38,31414.32,MSDRG Base Rate
Other Digestive System O.R. Procedures Without Cc/Mcc,358,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19861.26,,,,,,,fee schedule,10455.38,31414.32,MSDRG Base Rate
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],200,200,200,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,27859.54,,,,,,,fee schedule,27594.22,46432.58,MSDRG Base Rate
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,27594.22,,,,,,,fee schedule,27594.22,46432.58,MSDRG Base Rate
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,27594.22,,,,,,,fee schedule,27594.22,46432.58,MSDRG Base Rate
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,27859.54,,,,,,,fee schedule,27594.22,46432.58,MSDRG Base Rate
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,27594.22,,,,,,,fee schedule,27594.22,46432.58,MSDRG Base Rate
Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc,359,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,46432.58,,,,,,,fee schedule,27594.22,46432.58,MSDRG Base Rate
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],18708.83,18708.83,18708.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,19857.28,,,,,,,fee schedule,19668.17,33095.48,MSDRG Base Rate
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,19668.17,,,,,,,fee schedule,19668.17,33095.48,MSDRG Base Rate
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,19668.17,,,,,,,fee schedule,19668.17,33095.48,MSDRG Base Rate
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,19857.28,,,,,,,fee schedule,19668.17,33095.48,MSDRG Base Rate
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,19668.17,,,,,,,fee schedule,19668.17,33095.48,MSDRG Base Rate
Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc,360,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,33095.48,,,,,,,fee schedule,19668.17,33095.48,MSDRG Base Rate
Laparoscopy & Incisional Tubal Interruption,361,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopy & Incisional Tubal Interruption,361,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopy & Incisional Tubal Interruption,361,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopy & Incisional Tubal Interruption,361,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopy & Incisional Tubal Interruption,361,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopy & Incisional Tubal Interruption,361,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopy & Incisional Tubal Interruption,361,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopy & Incisional Tubal Interruption,361,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopy & Incisional Tubal Interruption,361,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopy & Incisional Tubal Interruption,361,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopy & Incisional Tubal Interruption,361,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopy & Incisional Tubal Interruption,361,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopy & Incisional Tubal Interruption,361,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopy & Incisional Tubal Interruption,361,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopy & Incisional Tubal Interruption,361,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopy & Incisional Tubal Interruption,361,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopy & Incisional Tubal Interruption,361,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopy & Incisional Tubal Interruption,361,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endoscopic Tubal Interruption,362,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endoscopic Tubal Interruption,362,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Endoscopic Tubal Interruption,362,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Endoscopic Tubal Interruption,362,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endoscopic Tubal Interruption,362,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endoscopic Tubal Interruption,362,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Endoscopic Tubal Interruption,362,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Endoscopic Tubal Interruption,362,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Endoscopic Tubal Interruption,362,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Endoscopic Tubal Interruption,362,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Endoscopic Tubal Interruption,362,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endoscopic Tubal Interruption,362,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endoscopic Tubal Interruption,362,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Endoscopic Tubal Interruption,362,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Endoscopic Tubal Interruption,362,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endoscopic Tubal Interruption,362,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Endoscopic Tubal Interruption,362,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endoscopic Tubal Interruption,362,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization & Radio-Implant, for Malignancy",363,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization & Radio-Implant, for Malignancy",363,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization & Radio-Implant, for Malignancy",363,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization & Radio-Implant, for Malignancy",363,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization & Radio-Implant, for Malignancy",363,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization & Radio-Implant, for Malignancy",363,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization & Radio-Implant, for Malignancy",363,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization & Radio-Implant, for Malignancy",363,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization & Radio-Implant, for Malignancy",363,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization & Radio-Implant, for Malignancy",363,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization & Radio-Implant, for Malignancy",363,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization & Radio-Implant, for Malignancy",363,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization & Radio-Implant, for Malignancy",363,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization & Radio-Implant, for Malignancy",363,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization & Radio-Implant, for Malignancy",363,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization & Radio-Implant, for Malignancy",363,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization & Radio-Implant, for Malignancy",363,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization & Radio-Implant, for Malignancy",363,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization Except for Malignancy",364,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization Except for Malignancy",364,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization Except for Malignancy",364,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization Except for Malignancy",364,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization Except for Malignancy",364,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization Except for Malignancy",364,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization Except for Malignancy",364,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization Except for Malignancy",364,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization Except for Malignancy",364,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization Except for Malignancy",364,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization Except for Malignancy",364,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization Except for Malignancy",364,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization Except for Malignancy",364,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization Except for Malignancy",364,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization Except for Malignancy",364,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization Except for Malignancy",364,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization Except for Malignancy",364,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization Except for Malignancy",364,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures,365,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures,365,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures,365,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures,365,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures,365,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures,365,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures,365,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures,365,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures,365,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures,365,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures,365,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures,365,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures,365,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures,365,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures,365,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures,365,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures,365,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures,365,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, female reproductive system w CC",366,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, female reproductive system w CC",366,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, female reproductive system w CC",366,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, female reproductive system w CC",366,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, female reproductive system w CC",366,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, female reproductive system w CC",366,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, female reproductive system w CC",366,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, female reproductive system w CC",366,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, female reproductive system w CC",366,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, female reproductive system w CC",366,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, female reproductive system w CC",366,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, female reproductive system w CC",366,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, female reproductive system w CC",366,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, female reproductive system w CC",366,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, female reproductive system w CC",366,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, female reproductive system w CC",366,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, female reproductive system w CC",366,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, female reproductive system w CC",366,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System w/o CC",367,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System w/o CC",367,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System w/o CC",367,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System w/o CC",367,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System w/o CC",367,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System w/o CC",367,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System w/o CC",367,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System w/o CC",367,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System w/o CC",367,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System w/o CC",367,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System w/o CC",367,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System w/o CC",367,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System w/o CC",367,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System w/o CC",367,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System w/o CC",367,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System w/o CC",367,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System w/o CC",367,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System w/o CC",367,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12885.2,,,,,,,fee schedule,12885.2,38714.96,
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,12885.2,,,,,,,fee schedule,12885.2,38714.96,
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17249.97,,,,,,,fee schedule,12885.2,38714.96,
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16428.54,,,,,,,fee schedule,12885.2,38714.96,
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,28774.05,,,,,,,fee schedule,12885.2,38714.96,
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,22359.96,,,,,,,fee schedule,12885.2,38714.96,
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,38714.96,,,,,,,fee schedule,12885.2,38714.96,
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,26614.43,,,,,,,fee schedule,12885.2,38714.96,
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,24103.34,,,,,,,fee schedule,12885.2,38714.96,
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19741.62,,,,,,,fee schedule,12885.2,38714.96,
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],20124.28,20124.28,20124.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",7183.67,7183.67,7183.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],10563.31,10563.31,10563.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],20736,20736,20736,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],12437.92,12437.92,12782.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13432.37,,,,,,,fee schedule,12885.2,38714.96,MSDRG Base Rate
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,13304.44,,,,,,,fee schedule,12885.2,38714.96,MSDRG Base Rate
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,13304.44,,,,,,,fee schedule,12885.2,38714.96,MSDRG Base Rate
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,13432.37,,,,,,,fee schedule,12885.2,38714.96,MSDRG Base Rate
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,13304.44,,,,,,,fee schedule,12885.2,38714.96,MSDRG Base Rate
Major Esophageal Disorders With Mcc,368,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22387.28,,,,,,,fee schedule,12885.2,38714.96,MSDRG Base Rate
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7851.95,,,,,,,fee schedule,7851.95,23592.04,
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,7851.95,,,,,,,fee schedule,7851.95,23592.04,
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10511.75,,,,,,,fee schedule,7851.95,23592.04,
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10011.19,,,,,,,fee schedule,7851.95,23592.04,
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,17534.27,,,,,,,fee schedule,7851.95,23592.04,
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,13625.66,,,,,,,fee schedule,7851.95,23592.04,
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,23592.04,,,,,,,fee schedule,7851.95,23592.04,
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,16218.24,,,,,,,fee schedule,7851.95,23592.04,
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,14688.04,,,,,,,fee schedule,7851.95,23592.04,
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12030.11,,,,,,,fee schedule,7851.95,23592.04,
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],2221.74,2221.74,2221.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",5180.82,5180.82,5180.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7720.68,7720.68,7720.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],17234.45,17234.45,17234.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],7586.25,7482.65,8060.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],13578,13578,13578,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8809.76,,,,,,,fee schedule,7851.95,23592.04,MSDRG Base Rate
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,8725.86,,,,,,,fee schedule,7851.95,23592.04,MSDRG Base Rate
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,8725.86,,,,,,,fee schedule,7851.95,23592.04,MSDRG Base Rate
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,8809.76,,,,,,,fee schedule,7851.95,23592.04,MSDRG Base Rate
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,8725.86,,,,,,,fee schedule,7851.95,23592.04,MSDRG Base Rate
Major Esophageal Disorders With Cc,369,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14682.94,,,,,,,fee schedule,7851.95,23592.04,MSDRG Base Rate
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5385.1,,,,,,,fee schedule,5385.1,16180.11,
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,5385.1,,,,,,,fee schedule,5385.1,16180.11,
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7209.27,,,,,,,fee schedule,5385.1,16180.11,
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6865.97,,,,,,,fee schedule,5385.1,16180.11,
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,12025.51,,,,,,,fee schedule,5385.1,16180.11,
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,9344.88,,,,,,,fee schedule,5385.1,16180.11,
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,16180.11,,,,,,,fee schedule,5385.1,16180.11,
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,11122.95,,,,,,,fee schedule,5385.1,16180.11,
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,10073.49,,,,,,,fee schedule,5385.1,16180.11,
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8250.6,,,,,,,fee schedule,5385.1,16180.11,
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],10074.93,10074.93,10074.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,6470.73,,,,,,,fee schedule,5385.1,16180.11,MSDRG Base Rate
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,6409.1,,,,,,,fee schedule,5385.1,16180.11,MSDRG Base Rate
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,6409.1,,,,,,,fee schedule,5385.1,16180.11,MSDRG Base Rate
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,6470.73,,,,,,,fee schedule,5385.1,16180.11,MSDRG Base Rate
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,6409.1,,,,,,,fee schedule,5385.1,16180.11,MSDRG Base Rate
Major Esophageal Disorders Without Cc/Mcc,370,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10784.55,,,,,,,fee schedule,5385.1,16180.11,MSDRG Base Rate
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13490.15,,,,,,,fee schedule,13490.15,40532.59,
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,13490.15,,,,,,,fee schedule,13490.15,40532.59,
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18059.83,,,,,,,fee schedule,13490.15,40532.59,
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17199.85,,,,,,,fee schedule,13490.15,40532.59,
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,30124.96,,,,,,,fee schedule,13490.15,40532.59,
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,23409.74,,,,,,,fee schedule,13490.15,40532.59,
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,40532.59,,,,,,,fee schedule,13490.15,40532.59,
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,27863.95,,,,,,,fee schedule,13490.15,40532.59,
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,25234.96,,,,,,,fee schedule,13490.15,40532.59,
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20668.47,,,,,,,fee schedule,13490.15,40532.59,
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],27859.17,27859.17,27859.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],10321,10321,10321,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],15126.43,15126.43,15126.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",78986.7,78986.7,78986.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],17196.89,17196.89,17196.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",8518.9,8518.9,8518.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11995.18,11599.24,13411.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],11165.35,8155.62,13643.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",8440.02,8440.02,8440.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],31496,31496,31496,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14847.98,,,,,,,fee schedule,13490.15,40532.59,MSDRG Base Rate
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,14706.57,,,,,,,fee schedule,13490.15,40532.59,MSDRG Base Rate
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,14706.57,,,,,,,fee schedule,13490.15,40532.59,MSDRG Base Rate
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,14847.98,,,,,,,fee schedule,13490.15,40532.59,MSDRG Base Rate
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,14706.57,,,,,,,fee schedule,13490.15,40532.59,MSDRG Base Rate
Major Gastrointestinal Disorders And Peritoneal Infections With Mcc,371,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,24746.63,,,,,,,fee schedule,13490.15,40532.59,MSDRG Base Rate
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7942.23,,,,,,,fee schedule,7942.23,23863.29,
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,7942.23,,,,,,,fee schedule,7942.23,23863.29,
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10632.61,,,,,,,fee schedule,7942.23,23863.29,
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10126.29,,,,,,,fee schedule,7942.23,23863.29,
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,17735.87,,,,,,,fee schedule,7942.23,23863.29,
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,13782.33,,,,,,,fee schedule,7942.23,23863.29,
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,23863.29,,,,,,,fee schedule,7942.23,23863.29,
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,16404.72,,,,,,,fee schedule,7942.23,23863.29,
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,14856.92,,,,,,,fee schedule,7942.23,23863.29,
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12168.43,,,,,,,fee schedule,7942.23,23863.29,
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7843.13,7843.13,7843.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],16404.72,16404.72,16404.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],14856.92,14856.92,14856.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",6492.99,6492.99,6492.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],8203.35,8203.35,8203.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",6097.77,6097.77,6097.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7797.31,6154.84,7797.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],20209.18,20209.18,20209.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],7174.03,16.07,8700.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",6041.31,6041.31,6041.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8972.26,,,,,,,fee schedule,7942.23,23863.29,MSDRG Base Rate
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,8886.81,,,,,,,fee schedule,7942.23,23863.29,MSDRG Base Rate
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,8886.81,,,,,,,fee schedule,7942.23,23863.29,MSDRG Base Rate
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,8972.26,,,,,,,fee schedule,7942.23,23863.29,MSDRG Base Rate
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,8886.81,,,,,,,fee schedule,7942.23,23863.29,MSDRG Base Rate
Major Gastrointestinal Disorders And Peritoneal Infections With Cc,372,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14953.77,,,,,,,fee schedule,7942.23,23863.29,MSDRG Base Rate
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5596.52,,,,,,,fee schedule,5596.52,16815.36,
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,5596.52,,,,,,,fee schedule,5596.52,16815.36,
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7492.31,,,,,,,fee schedule,5596.52,16815.36,
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7135.53,,,,,,,fee schedule,5596.52,16815.36,
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,12497.64,,,,,,,fee schedule,5596.52,16815.36,
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,9711.77,,,,,,,fee schedule,5596.52,16815.36,
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,16815.36,,,,,,,fee schedule,5596.52,16815.36,
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,11559.64,,,,,,,fee schedule,5596.52,16815.36,
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,10468.98,,,,,,,fee schedule,5596.52,16815.36,
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8574.53,,,,,,,fee schedule,5596.52,16815.36,
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],5430.99,5430.99,5430.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],9977.06,9977.06,9977.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],7136.51,7136.51,7136.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4759.52,4759.52,4759.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],8575.71,8575.71,8575.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],5972.85,5972.85,5972.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,6678.54,,,,,,,fee schedule,5596.52,16815.36,MSDRG Base Rate
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,6614.93,,,,,,,fee schedule,5596.52,16815.36,MSDRG Base Rate
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,6614.93,,,,,,,fee schedule,5596.52,16815.36,MSDRG Base Rate
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,6678.54,,,,,,,fee schedule,5596.52,16815.36,MSDRG Base Rate
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,6614.93,,,,,,,fee schedule,5596.52,16815.36,MSDRG Base Rate
Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc,373,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11130.89,,,,,,,fee schedule,5596.52,16815.36,MSDRG Base Rate
Digestive Malignancy With Mcc,374,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16292.65,,,,,,,fee schedule,16292.65,48953.02,
Digestive Malignancy With Mcc,374,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,16292.65,,,,,,,fee schedule,16292.65,48953.02,
Digestive Malignancy With Mcc,374,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21811.67,,,,,,,fee schedule,16292.65,48953.02,
Digestive Malignancy With Mcc,374,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20773.02,,,,,,,fee schedule,16292.65,48953.02,
Digestive Malignancy With Mcc,374,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,36383.26,,,,,,,fee schedule,16292.65,48953.02,
Digestive Malignancy With Mcc,374,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,28272.99,,,,,,,fee schedule,16292.65,48953.02,
Digestive Malignancy With Mcc,374,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,48953.02,,,,,,,fee schedule,16292.65,48953.02,
Digestive Malignancy With Mcc,374,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,33652.54,,,,,,,fee schedule,16292.65,48953.02,
Digestive Malignancy With Mcc,374,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,30477.39,,,,,,,fee schedule,16292.65,48953.02,
Digestive Malignancy With Mcc,374,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24962.24,,,,,,,fee schedule,16292.65,48953.02,
Digestive Malignancy With Mcc,374,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],13840.89,13840.89,13840.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Digestive Malignancy With Mcc,374,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy With Mcc,374,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],29349.01,29349.01,29349.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Digestive Malignancy With Mcc,374,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],27702,27702,32250.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Digestive Malignancy With Mcc,374,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy With Mcc,374,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy With Mcc,374,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",67250.29,67250.29,67250.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Digestive Malignancy With Mcc,374,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",12004.44,12004.44,12004.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Digestive Malignancy With Mcc,374,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],157076.01,157076.01,157076.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Digestive Malignancy With Mcc,374,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],15457.22,15453.52,15994.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Digestive Malignancy With Mcc,374,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy With Mcc,374,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy With Mcc,374,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy With Mcc,374,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],20776.54,20776.54,20776.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Digestive Malignancy With Mcc,374,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],13994.37,28.57,14699.36,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Digestive Malignancy With Mcc,374,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy With Mcc,374,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy With Mcc,374,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy With Mcc,374,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,17704.19,,,,,,,fee schedule,16292.65,48953.02,MSDRG Base Rate
Digestive Malignancy With Mcc,374,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,17535.58,,,,,,,fee schedule,16292.65,48953.02,MSDRG Base Rate
Digestive Malignancy With Mcc,374,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,17535.58,,,,,,,fee schedule,16292.65,48953.02,MSDRG Base Rate
Digestive Malignancy With Mcc,374,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,17704.19,,,,,,,fee schedule,16292.65,48953.02,MSDRG Base Rate
Digestive Malignancy With Mcc,374,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,17535.58,,,,,,,fee schedule,16292.65,48953.02,MSDRG Base Rate
Digestive Malignancy With Mcc,374,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,29506.98,,,,,,,fee schedule,16292.65,48953.02,MSDRG Base Rate
Digestive Malignancy With Cc,375,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9480.83,,,,,,,fee schedule,9480.83,28486.18,
Digestive Malignancy With Cc,375,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,9480.83,,,,,,,fee schedule,9480.83,28486.18,
Digestive Malignancy With Cc,375,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12692.4,,,,,,,fee schedule,9480.83,28486.18,
Digestive Malignancy With Cc,375,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12088,,,,,,,fee schedule,9480.83,28486.18,
Digestive Malignancy With Cc,375,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,21171.73,,,,,,,fee schedule,9480.83,28486.18,
Digestive Malignancy With Cc,375,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,16452.29,,,,,,,fee schedule,9480.83,28486.18,
Digestive Malignancy With Cc,375,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,28486.18,,,,,,,fee schedule,9480.83,28486.18,
Digestive Malignancy With Cc,375,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,19582.7,,,,,,,fee schedule,9480.83,28486.18,
Digestive Malignancy With Cc,375,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,17735.06,,,,,,,fee schedule,9480.83,28486.18,
Digestive Malignancy With Cc,375,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14525.74,,,,,,,fee schedule,9480.83,28486.18,
Digestive Malignancy With Cc,375,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],14754.3,14754.3,14754.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Digestive Malignancy With Cc,375,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy With Cc,375,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9585.35,9585.35,9585.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Digestive Malignancy With Cc,375,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],16356.76,16356.76,16356.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Digestive Malignancy With Cc,375,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],17735.06,17735.06,17735.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Digestive Malignancy With Cc,375,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9969.79,9969.79,9969.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Digestive Malignancy With Cc,375,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy With Cc,375,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",8494.83,8494.83,8494.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Digestive Malignancy With Cc,375,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9046.01,9046.01,9046.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Digestive Malignancy With Cc,375,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy With Cc,375,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy With Cc,375,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy With Cc,375,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy With Cc,375,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],21171.73,21171.73,21171.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Digestive Malignancy With Cc,375,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],8479.38,6435.21,9613.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Digestive Malignancy With Cc,375,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy With Cc,375,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy With Cc,375,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy With Cc,375,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10445.68,,,,,,,fee schedule,9480.83,28486.18,MSDRG Base Rate
Digestive Malignancy With Cc,375,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,10346.2,,,,,,,fee schedule,9480.83,28486.18,MSDRG Base Rate
Digestive Malignancy With Cc,375,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,10346.2,,,,,,,fee schedule,9480.83,28486.18,MSDRG Base Rate
Digestive Malignancy With Cc,375,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,10445.68,,,,,,,fee schedule,9480.83,28486.18,MSDRG Base Rate
Digestive Malignancy With Cc,375,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,10346.2,,,,,,,fee schedule,9480.83,28486.18,MSDRG Base Rate
Digestive Malignancy With Cc,375,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,17409.47,,,,,,,fee schedule,9480.83,28486.18,MSDRG Base Rate
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6812.59,,,,,,,fee schedule,6812.59,20469.15,
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,6812.59,,,,,,,fee schedule,6812.59,20469.15,
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9120.3,,,,,,,fee schedule,6812.59,20469.15,
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8686.01,,,,,,,fee schedule,6812.59,20469.15,
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,15213.25,,,,,,,fee schedule,6812.59,20469.15,
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,11822.03,,,,,,,fee schedule,6812.59,20469.15,
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,20469.15,,,,,,,fee schedule,6812.59,20469.15,
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,14071.43,,,,,,,fee schedule,6812.59,20469.15,
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,12743.78,,,,,,,fee schedule,6812.59,20469.15,
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10437.68,,,,,,,fee schedule,6812.59,20469.15,
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],8686.99,8686.99,8686.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8216.8,,,,,,,fee schedule,6812.59,20469.15,MSDRG Base Rate
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,8138.54,,,,,,,fee schedule,6812.59,20469.15,MSDRG Base Rate
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,8138.54,,,,,,,fee schedule,6812.59,20469.15,MSDRG Base Rate
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,8216.8,,,,,,,fee schedule,6812.59,20469.15,MSDRG Base Rate
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,8138.54,,,,,,,fee schedule,6812.59,20469.15,MSDRG Base Rate
Digestive Malignancy Without Cc/Mcc,376,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,13694.66,,,,,,,fee schedule,6812.59,20469.15,MSDRG Base Rate
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14028.73,,,,,,,fee schedule,14028.73,42150.83,
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,14028.73,,,,,,,fee schedule,14028.73,42150.83,
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18780.86,,,,,,,fee schedule,14028.73,42150.83,
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17886.54,,,,,,,fee schedule,14028.73,42150.83,
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,31327.68,,,,,,,fee schedule,14028.73,42150.83,
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,24344.36,,,,,,,fee schedule,14028.73,42150.83,
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,42150.83,,,,,,,fee schedule,14028.73,42150.83,
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,28976.41,,,,,,,fee schedule,14028.73,42150.83,
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,26242.46,,,,,,,fee schedule,14028.73,42150.83,
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21493.65,,,,,,,fee schedule,14028.73,42150.83,
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],8012.22,8012.22,8012.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],27106.66,15713.02,28978,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12704.96,12215.93,25188.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13355.2,13355.2,13355.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",9445.49,9445.49,9445.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],17887.52,17887.52,17887.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",8870.55,8870.55,8870.55,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12926.43,12131.02,13773.51,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],17889.52,17889.52,19175.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],29348.41,29348.41,31498.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],12352.84,28.77,14579.63,29,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],16059.05,16059.05,16059.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15276.87,,,,,,,fee schedule,14028.73,42150.83,MSDRG Base Rate
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,15131.38,,,,,,,fee schedule,14028.73,42150.83,MSDRG Base Rate
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,15131.38,,,,,,,fee schedule,14028.73,42150.83,MSDRG Base Rate
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,15276.87,,,,,,,fee schedule,14028.73,42150.83,MSDRG Base Rate
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,15131.38,,,,,,,fee schedule,14028.73,42150.83,MSDRG Base Rate
Gastrointestinal Hemorrhage With Mcc,377,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,25461.45,,,,,,,fee schedule,14028.73,42150.83,MSDRG Base Rate
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7607.35,,,,,,,fee schedule,7607.35,22857.11,
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,7607.35,,,,,,,fee schedule,7607.35,22857.11,
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10184.29,,,,,,,fee schedule,7607.35,22857.11,
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9699.32,,,,,,,fee schedule,7607.35,22857.11,
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,16988.04,,,,,,,fee schedule,7607.35,22857.11,
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,13201.2,,,,,,,fee schedule,7607.35,22857.11,
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,22857.11,,,,,,,fee schedule,7607.35,22857.11,
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,15713.02,,,,,,,fee schedule,7607.35,22857.11,
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,14230.48,,,,,,,fee schedule,7607.35,22857.11,
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11655.35,,,,,,,fee schedule,7607.35,22857.11,
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],7893.37,7681.06,7930.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7642.65,6791.6,14480.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],14852.36,12570.42,15679.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7185.12,7185.12,8140.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],10504.28,10504.28,10504.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",5258.43,5258.43,5258.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4938.36,4938.36,4938.36,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],10184.29,10184.29,10184.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],9678.66,9678.66,9678.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],6001.06,6001.06,6001.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7108.54,5826.06,7533.33,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],11076.69,11038.48,11655.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],16467.91,1144.88,16488.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],6415.63,15.43,7828.83,19,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8657.42,,,,,,,fee schedule,7607.35,22857.11,MSDRG Base Rate
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,8574.97,,,,,,,fee schedule,7607.35,22857.11,MSDRG Base Rate
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,8574.97,,,,,,,fee schedule,7607.35,22857.11,MSDRG Base Rate
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,8657.42,,,,,,,fee schedule,7607.35,22857.11,MSDRG Base Rate
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,8574.97,,,,,,,fee schedule,7607.35,22857.11,MSDRG Base Rate
Gastrointestinal Hemorrhage With Cc,378,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14429.03,,,,,,,fee schedule,7607.35,22857.11,MSDRG Base Rate
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4912.1,,,,,,,fee schedule,4912.1,14758.93,
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,4912.1,,,,,,,fee schedule,4912.1,14758.93,
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6576.04,,,,,,,fee schedule,4912.1,14758.93,
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6262.9,,,,,,,fee schedule,4912.1,14758.93,
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,10969.25,,,,,,,fee schedule,4912.1,14758.93,
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,8524.07,,,,,,,fee schedule,4912.1,14758.93,
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,14758.93,,,,,,,fee schedule,4912.1,14758.93,
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,10145.97,,,,,,,fee schedule,4912.1,14758.93,
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,9188.68,,,,,,,fee schedule,4912.1,14758.93,
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7525.91,,,,,,,fee schedule,4912.1,14758.93,
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],3699.43,3699.43,3699.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],9640.18,9640.18,10147.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],7380.2,7380.2,7380.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],6263.88,6263.88,6263.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3690.82,3690.82,3690.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],3699.43,3699.43,3699.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],5296.96,5296.96,5296.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,5920.73,,,,,,,fee schedule,4912.1,14758.93,MSDRG Base Rate
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,5864.34,,,,,,,fee schedule,4912.1,14758.93,MSDRG Base Rate
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,5864.34,,,,,,,fee schedule,4912.1,14758.93,MSDRG Base Rate
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,5920.73,,,,,,,fee schedule,4912.1,14758.93,MSDRG Base Rate
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,5864.34,,,,,,,fee schedule,4912.1,14758.93,MSDRG Base Rate
Gastrointestinal Hemorrhage Without Cc/Mcc,379,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9867.88,,,,,,,fee schedule,4912.1,14758.93,MSDRG Base Rate
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14848.19,,,,,,,fee schedule,14848.19,44612.97,
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,14848.19,,,,,,,fee schedule,14848.19,44612.97,
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19877.9,,,,,,,fee schedule,14848.19,44612.97,
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18931.34,,,,,,,fee schedule,14848.19,44612.97,
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,33157.61,,,,,,,fee schedule,14848.19,44612.97,
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,25766.38,,,,,,,fee schedule,14848.19,44612.97,
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,44612.97,,,,,,,fee schedule,14848.19,44612.97,
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,30668.99,,,,,,,fee schedule,14848.19,44612.97,
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,27775.35,,,,,,,fee schedule,14848.19,44612.97,
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22749.15,,,,,,,fee schedule,14848.19,44612.97,
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13608.04,13608.04,13608.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],30668.99,30668.99,30668.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13891.48,13891.48,13891.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",9519.68,9519.68,9519.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],14592.25,14592.25,14592.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],18856.34,18856.34,18856.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],18766.28,18766.28,32757.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],6067.71,6067.71,8290.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",9431.54,9431.54,9431.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],51651.6,51651.6,51651.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,16325.3,,,,,,,fee schedule,14848.19,44612.97,MSDRG Base Rate
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,16169.82,,,,,,,fee schedule,14848.19,44612.97,MSDRG Base Rate
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,16169.82,,,,,,,fee schedule,14848.19,44612.97,MSDRG Base Rate
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,16325.3,,,,,,,fee schedule,14848.19,44612.97,MSDRG Base Rate
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,16169.82,,,,,,,fee schedule,14848.19,44612.97,MSDRG Base Rate
Complicated Peptic Ulcer With Mcc,380,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,27208.82,,,,,,,fee schedule,14848.19,44612.97,MSDRG Base Rate
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8403.66,,,,,,,fee schedule,8403.66,25249.69,
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,8403.66,,,,,,,fee schedule,8403.66,25249.69,
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11250.34,,,,,,,fee schedule,8403.66,25249.69,
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10714.61,,,,,,,fee schedule,8403.66,25249.69,
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,18766.28,,,,,,,fee schedule,8403.66,25249.69,
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,14583.05,,,,,,,fee schedule,8403.66,25249.69,
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,25249.69,,,,,,,fee schedule,8403.66,25249.69,
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,17357.79,,,,,,,fee schedule,8403.66,25249.69,
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,15720.07,,,,,,,fee schedule,8403.66,25249.69,
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12875.38,,,,,,,fee schedule,8403.66,25249.69,
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],17357.79,17357.79,17357.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",5779.65,5779.65,5779.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],10714.61,10714.61,10714.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8052.13,8052.13,8052.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],11737.27,11737.27,11737.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],5738.4,5738.4,5738.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",5726.14,5726.14,5726.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9460.53,,,,,,,fee schedule,8403.66,25249.69,MSDRG Base Rate
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,9370.43,,,,,,,fee schedule,8403.66,25249.69,MSDRG Base Rate
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,9370.43,,,,,,,fee schedule,8403.66,25249.69,MSDRG Base Rate
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,9460.53,,,,,,,fee schedule,8403.66,25249.69,MSDRG Base Rate
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,9370.43,,,,,,,fee schedule,8403.66,25249.69,MSDRG Base Rate
Complicated Peptic Ulcer With Cc,381,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15767.55,,,,,,,fee schedule,8403.66,25249.69,MSDRG Base Rate
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5781.71,,,,,,,fee schedule,5781.71,17371.77,
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,5781.71,,,,,,,fee schedule,5781.71,17371.77,
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7740.22,,,,,,,fee schedule,5781.71,17371.77,
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7371.64,,,,,,,fee schedule,5781.71,17371.77,
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,12911.19,,,,,,,fee schedule,5781.71,17371.77,
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,10033.13,,,,,,,fee schedule,5781.71,17371.77,
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,17371.77,,,,,,,fee schedule,5781.71,17371.77,
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,11942.15,,,,,,,fee schedule,5781.71,17371.77,
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,10815.4,,,,,,,fee schedule,5781.71,17371.77,
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8858.25,,,,,,,fee schedule,5781.71,17371.77,
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],5816.48,5816.48,5816.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],19183,19183,19183,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7250.41,,,,,,,fee schedule,5781.71,17371.77,MSDRG Base Rate
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,7181.36,,,,,,,fee schedule,5781.71,17371.77,MSDRG Base Rate
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,7181.36,,,,,,,fee schedule,5781.71,17371.77,MSDRG Base Rate
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,7250.41,,,,,,,fee schedule,5781.71,17371.77,MSDRG Base Rate
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,7181.36,,,,,,,fee schedule,5781.71,17371.77,MSDRG Base Rate
Complicated Peptic Ulcer Without Cc/Mcc,382,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12084.01,,,,,,,fee schedule,5781.71,17371.77,MSDRG Base Rate
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9754.76,,,,,,,fee schedule,9754.76,29309.21,
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,9754.76,,,,,,,fee schedule,9754.76,29309.21,
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13059.11,,,,,,,fee schedule,9754.76,29309.21,
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12437.25,,,,,,,fee schedule,9754.76,29309.21,
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,21783.43,,,,,,,fee schedule,9754.76,29309.21,
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,16927.64,,,,,,,fee schedule,9754.76,29309.21,
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,29309.21,,,,,,,fee schedule,9754.76,29309.21,
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,20148.49,,,,,,,fee schedule,9754.76,29309.21,
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,18247.46,,,,,,,fee schedule,9754.76,29309.21,
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14945.42,,,,,,,fee schedule,9754.76,29309.21,
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11782.39,,,,,,,fee schedule,9754.76,29309.21,MSDRG Base Rate
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,11670.17,,,,,,,fee schedule,9754.76,29309.21,MSDRG Base Rate
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,11670.17,,,,,,,fee schedule,9754.76,29309.21,MSDRG Base Rate
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,11782.39,,,,,,,fee schedule,9754.76,29309.21,MSDRG Base Rate
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,11670.17,,,,,,,fee schedule,9754.76,29309.21,MSDRG Base Rate
Uncomplicated Peptic Ulcer With Mcc,383,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19637.31,,,,,,,fee schedule,9754.76,29309.21,MSDRG Base Rate
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6709.96,,,,,,,fee schedule,6709.96,20160.81,
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,6709.96,,,,,,,fee schedule,6709.96,20160.81,
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8982.92,,,,,,,fee schedule,6709.96,20160.81,
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8555.16,,,,,,,fee schedule,6709.96,20160.81,
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,14984.08,,,,,,,fee schedule,6709.96,20160.81,
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,11643.94,,,,,,,fee schedule,6709.96,20160.81,
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,20160.81,,,,,,,fee schedule,6709.96,20160.81,
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,13859.46,,,,,,,fee schedule,6709.96,20160.81,
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,12551.81,,,,,,,fee schedule,6709.96,20160.81,
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10280.45,,,,,,,fee schedule,6709.96,20160.81,
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],6369.08,6369.08,6369.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],14984.08,14984.08,14984.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],6979.34,6979.34,6979.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7673.84,,,,,,,fee schedule,6709.96,20160.81,MSDRG Base Rate
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,7600.76,,,,,,,fee schedule,6709.96,20160.81,MSDRG Base Rate
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,7600.76,,,,,,,fee schedule,6709.96,20160.81,MSDRG Base Rate
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,7673.84,,,,,,,fee schedule,6709.96,20160.81,MSDRG Base Rate
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,7600.76,,,,,,,fee schedule,6709.96,20160.81,MSDRG Base Rate
Uncomplicated Peptic Ulcer Without Mcc,384,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12789.74,,,,,,,fee schedule,6709.96,20160.81,MSDRG Base Rate
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12536.43,,,,,,,fee schedule,12536.43,37667.04,
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,12536.43,,,,,,,fee schedule,12536.43,37667.04,
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16783.05,,,,,,,fee schedule,12536.43,37667.04,
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15983.86,,,,,,,fee schedule,12536.43,37667.04,
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,27995.21,,,,,,,fee schedule,12536.43,37667.04,
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,21754.73,,,,,,,fee schedule,12536.43,37667.04,
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,37667.04,,,,,,,fee schedule,12536.43,37667.04,
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,25894.05,,,,,,,fee schedule,12536.43,37667.04,
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,23450.92,,,,,,,fee schedule,12536.43,37667.04,
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19207.27,,,,,,,fee schedule,12536.43,37667.04,
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13492,13492,13492,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],15984.85,15984.85,15984.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],10362.81,10362.81,10362.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],19208.45,19208.45,19208.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],27996.93,27996.93,27996.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],12578.61,12578.61,12578.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",7924.25,7924.25,7924.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13357.36,,,,,,,fee schedule,12536.43,37667.04,MSDRG Base Rate
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,13230.15,,,,,,,fee schedule,12536.43,37667.04,MSDRG Base Rate
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,13230.15,,,,,,,fee schedule,12536.43,37667.04,MSDRG Base Rate
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,13357.36,,,,,,,fee schedule,12536.43,37667.04,MSDRG Base Rate
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,13230.15,,,,,,,fee schedule,12536.43,37667.04,MSDRG Base Rate
Inflammatory Bowel Disease With Mcc,385,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22262.28,,,,,,,fee schedule,12536.43,37667.04,MSDRG Base Rate
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7657.51,,,,,,,fee schedule,7657.51,23007.8,
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,7657.51,,,,,,,fee schedule,7657.51,23007.8,
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10251.43,,,,,,,fee schedule,7657.51,23007.8,
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9763.27,,,,,,,fee schedule,7657.51,23007.8,
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,17100.04,,,,,,,fee schedule,7657.51,23007.8,
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,13288.24,,,,,,,fee schedule,7657.51,23007.8,
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,23007.8,,,,,,,fee schedule,7657.51,23007.8,
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,15816.61,,,,,,,fee schedule,7657.51,23007.8,
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,14324.3,,,,,,,fee schedule,7657.51,23007.8,
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11732.19,,,,,,,fee schedule,7657.51,23007.8,
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],11611.99,11611.99,11611.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],6561,6561,6561,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8039.4,8039.4,8039.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],15921.95,15921.95,15921.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",5756.44,5756.44,5756.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7312.03,7312.03,7312.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],7323.78,6424.69,7893.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],17101.77,15310.47,17201.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8623.04,,,,,,,fee schedule,7657.51,23007.8,MSDRG Base Rate
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,8540.92,,,,,,,fee schedule,7657.51,23007.8,MSDRG Base Rate
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,8540.92,,,,,,,fee schedule,7657.51,23007.8,MSDRG Base Rate
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,8623.04,,,,,,,fee schedule,7657.51,23007.8,MSDRG Base Rate
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,8540.92,,,,,,,fee schedule,7657.51,23007.8,MSDRG Base Rate
Inflammatory Bowel Disease With Cc,386,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14371.74,,,,,,,fee schedule,7657.51,23007.8,MSDRG Base Rate
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5172.14,,,,,,,fee schedule,5172.14,15540.24,
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,5172.14,,,,,,,fee schedule,5172.14,15540.24,
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6924.16,,,,,,,fee schedule,5172.14,15540.24,
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6594.44,,,,,,,fee schedule,5172.14,15540.24,
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,11549.94,,,,,,,fee schedule,5172.14,15540.24,
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,8975.32,,,,,,,fee schedule,5172.14,15540.24,
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,15540.24,,,,,,,fee schedule,5172.14,15540.24,
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,10683.07,,,,,,,fee schedule,5172.14,15540.24,
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,9675.11,,,,,,,fee schedule,5172.14,15540.24,
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7924.31,,,,,,,fee schedule,5172.14,15540.24,
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],10683.07,10683.07,10683.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,6318.39,,,,,,,fee schedule,5172.14,15540.24,MSDRG Base Rate
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,6258.21,,,,,,,fee schedule,5172.14,15540.24,MSDRG Base Rate
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,6258.21,,,,,,,fee schedule,5172.14,15540.24,MSDRG Base Rate
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,6318.39,,,,,,,fee schedule,5172.14,15540.24,MSDRG Base Rate
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,6258.21,,,,,,,fee schedule,5172.14,15540.24,MSDRG Base Rate
Inflammatory Bowel Disease Without Cc/Mcc,387,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10530.64,,,,,,,fee schedule,5172.14,15540.24,MSDRG Base Rate
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11342.74,,,,,,,fee schedule,11342.74,34080.48,
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,11342.74,,,,,,,fee schedule,11342.74,34080.48,
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15185.01,,,,,,,fee schedule,11342.74,34080.48,
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14461.92,,,,,,,fee schedule,11342.74,34080.48,
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,25329.57,,,,,,,fee schedule,11342.74,34080.48,
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,19683.3,,,,,,,fee schedule,11342.74,34080.48,
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,34080.48,,,,,,,fee schedule,11342.74,34080.48,
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,23428.48,,,,,,,fee schedule,11342.74,34080.48,
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,21217.98,,,,,,,fee schedule,11342.74,34080.48,
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17378.4,,,,,,,fee schedule,11342.74,34080.48,
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9149.04,9149.04,9149.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],14524,12058.17,23426.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11115.7,11115.7,11115.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",7723.88,7723.88,7723.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",7253.74,7253.74,7253.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],14210.93,14210.93,14210.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],10796.47,9492.53,11261.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],15197.74,15197.74,16549.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],25446.74,25446.74,25446.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],10074.9,19.88,11354.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],9795.1,9795.1,9795.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12533.16,,,,,,,fee schedule,11342.74,34080.48,MSDRG Base Rate
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,12413.79,,,,,,,fee schedule,11342.74,34080.48,MSDRG Base Rate
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,12413.79,,,,,,,fee schedule,11342.74,34080.48,MSDRG Base Rate
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,12533.16,,,,,,,fee schedule,11342.74,34080.48,MSDRG Base Rate
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,12413.79,,,,,,,fee schedule,11342.74,34080.48,MSDRG Base Rate
Gastrointestinal Obstruction With Mcc,388,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20888.6,,,,,,,fee schedule,11342.74,34080.48,MSDRG Base Rate
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6186.04,,,,,,,fee schedule,6186.04,18586.61,
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,6186.04,,,,,,,fee schedule,6186.04,18586.61,
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8281.51,,,,,,,fee schedule,6186.04,18586.61,
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7887.16,,,,,,,fee schedule,6186.04,18586.61,
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,13814.09,,,,,,,fee schedule,6186.04,18586.61,
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,10734.76,,,,,,,fee schedule,6186.04,18586.61,
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,18586.61,,,,,,,fee schedule,6186.04,18586.61,
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,12777.29,,,,,,,fee schedule,6186.04,18586.61,
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,11571.74,,,,,,,fee schedule,6186.04,18586.61,
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9477.73,,,,,,,fee schedule,6186.04,18586.61,
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],6451.69,6451.69,6451.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],15124,15124,15124,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6492.2,5863.55,6496.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],10859.41,10135.2,12775.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],12255.21,12255.21,12255.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4689,4689,4689,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4403.58,4403.58,4403.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],7761.17,7761.17,7835.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],5405.16,5405.16,5405.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],5885.8,4429.93,6096,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],9476.55,9476.55,9476.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],13812.37,13812.37,13912.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],6351.33,4649.79,6490.68,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4362.81,4362.81,4362.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7166.03,,,,,,,fee schedule,6186.04,18586.61,MSDRG Base Rate
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,7097.78,,,,,,,fee schedule,6186.04,18586.61,MSDRG Base Rate
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,7097.78,,,,,,,fee schedule,6186.04,18586.61,MSDRG Base Rate
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,7166.03,,,,,,,fee schedule,6186.04,18586.61,MSDRG Base Rate
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,7097.78,,,,,,,fee schedule,6186.04,18586.61,MSDRG Base Rate
Gastrointestinal Obstruction With Cc,389,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11943.38,,,,,,,fee schedule,6186.04,18586.61,MSDRG Base Rate
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4221.51,,,,,,,fee schedule,4221.51,12683.97,
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,4221.51,,,,,,,fee schedule,4221.51,12683.97,
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5651.51,,,,,,,fee schedule,4221.51,12683.97,
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5382.39,,,,,,,fee schedule,4221.51,12683.97,
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,9427.08,,,,,,,fee schedule,4221.51,12683.97,
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,7325.67,,,,,,,fee schedule,4221.51,12683.97,
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,12683.97,,,,,,,fee schedule,4221.51,12683.97,
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,8719.54,,,,,,,fee schedule,4221.51,12683.97,
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,7896.84,,,,,,,fee schedule,4221.51,12683.97,
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6467.84,,,,,,,fee schedule,4221.51,12683.97,
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],8323.2,8323.2,8323.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],4345.54,4345.54,4345.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],8721.13,7288.1,11340.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],7655.22,7340.44,8846.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],4554.96,4554.96,4554.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],5385.38,5385.38,5385.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3104.02,3104.02,3104.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],4179.62,4178.75,4190.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],5969.02,5969.02,5969.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],9428.8,8976,9428.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],7.4,7.4,7.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,5245.74,,,,,,,fee schedule,4221.51,12683.97,MSDRG Base Rate
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,5195.78,,,,,,,fee schedule,4221.51,12683.97,MSDRG Base Rate
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,5195.78,,,,,,,fee schedule,4221.51,12683.97,MSDRG Base Rate
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,5245.74,,,,,,,fee schedule,4221.51,12683.97,MSDRG Base Rate
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,5195.78,,,,,,,fee schedule,4221.51,12683.97,MSDRG Base Rate
Gastrointestinal Obstruction Without Cc/Mcc,390,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8742.89,,,,,,,fee schedule,4221.51,12683.97,MSDRG Base Rate
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9914.48,,,,,,,fee schedule,9914.48,29789.12,
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,9914.48,,,,,,,fee schedule,9914.48,29789.12,
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13272.94,,,,,,,fee schedule,9914.48,29789.12,
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12640.9,,,,,,,fee schedule,9914.48,29789.12,
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,22140.11,,,,,,,fee schedule,9914.48,29789.12,
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,17204.81,,,,,,,fee schedule,9914.48,29789.12,
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,29789.12,,,,,,,fee schedule,9914.48,29789.12,
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,20478.4,,,,,,,fee schedule,9914.48,29789.12,
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,18546.25,,,,,,,fee schedule,9914.48,29789.12,
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15190.14,,,,,,,fee schedule,9914.48,29789.12,
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],12428.2,12428.2,12428.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],2396,2396,9071,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9967.93,8342.83,10188.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],13150.65,11814.41,20260.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],23402.16,23402.16,23402.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3702.54,3702.54,3702.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3888.14,3888.14,4369.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],12596.96,12596.96,12596.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],9738.04,9738.04,9738.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9392.14,8088.06,9576.81,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],11235.68,11235.68,11235.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],15610.84,9001.8,21972.22,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],9985.31,7069.81,10012.84,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3852.14,3852.14,3852.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],15823.2,15823.2,15823.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10904.27,,,,,,,fee schedule,9914.48,29789.12,MSDRG Base Rate
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,10800.42,,,,,,,fee schedule,9914.48,29789.12,MSDRG Base Rate
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,10800.42,,,,,,,fee schedule,9914.48,29789.12,MSDRG Base Rate
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,10904.27,,,,,,,fee schedule,9914.48,29789.12,MSDRG Base Rate
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,10800.42,,,,,,,fee schedule,9914.48,29789.12,MSDRG Base Rate
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc",391,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18173.78,,,,,,,fee schedule,9914.48,29789.12,MSDRG Base Rate
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6020.91,,,,,,,fee schedule,6020.91,18090.48,
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,6020.91,,,,,,,fee schedule,6020.91,18090.48,
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8060.45,,,,,,,fee schedule,6020.91,18090.48,
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7676.62,,,,,,,fee schedule,6020.91,18090.48,
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,13445.35,,,,,,,fee schedule,6020.91,18090.48,
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,10448.22,,,,,,,fee schedule,6020.91,18090.48,
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,18090.48,,,,,,,fee schedule,6020.91,18090.48,
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,12436.22,,,,,,,fee schedule,6020.91,18090.48,
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,11262.85,,,,,,,fee schedule,6020.91,18090.48,
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9224.74,,,,,,,fee schedule,6020.91,18090.48,
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],17054.38,17054.38,17704.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],5205.71,1242.9,6107.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],11342.66,8420.49,12183.4,34,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],5510.78,5510.78,5510.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],9937.12,6612.45,11262.85,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3702.54,3702.54,3702.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],7728.76,7676.62,7728.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3477.17,3477.17,3477.17,61,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],4685.23,4685.23,4685.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],4268.56,4145.4,6011.64,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],7845.14,6545.75,9224.74,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],11271,1616.32,13183.29,26,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],4843.05,17.38,6365.82,23,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3444.97,3444.97,3444.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],9384.4,9384.4,11955.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7086.34,,,,,,,fee schedule,6020.91,18090.48,MSDRG Base Rate
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,7018.86,,,,,,,fee schedule,6020.91,18090.48,MSDRG Base Rate
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,7018.86,,,,,,,fee schedule,6020.91,18090.48,MSDRG Base Rate
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,7086.34,,,,,,,fee schedule,6020.91,18090.48,MSDRG Base Rate
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,7018.86,,,,,,,fee schedule,6020.91,18090.48,MSDRG Base Rate
"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc",392,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11810.58,,,,,,,fee schedule,6020.91,18090.48,MSDRG Base Rate
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12777.17,,,,,,,fee schedule,12777.17,38390.39,
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,12777.17,,,,,,,fee schedule,12777.17,38390.39,
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17105.35,,,,,,,fee schedule,12777.17,38390.39,
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16290.81,,,,,,,fee schedule,12777.17,38390.39,
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,28532.81,,,,,,,fee schedule,12777.17,38390.39,
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,22172.5,,,,,,,fee schedule,12777.17,38390.39,
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,38390.39,,,,,,,fee schedule,12777.17,38390.39,
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,26391.3,,,,,,,fee schedule,12777.17,38390.39,
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,23901.26,,,,,,,fee schedule,12777.17,38390.39,
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19576.12,,,,,,,fee schedule,12777.17,38390.39,
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],12446.38,12446.38,12446.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],25073.25,18115,26392.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],10899.34,10721.56,11400,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],21729.6,17643.6,23902.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12356.7,12356.7,12356.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",6099.92,6099.92,6099.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12227.03,10902.29,12379.27,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],19577.3,19577.3,19577.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],28534.54,28534.54,83568.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],10000.83,292.04,12756.31,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",6043.43,6043.43,6043.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],47132.33,47132.33,47132.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13490.18,,,,,,,fee schedule,12777.17,38390.39,MSDRG Base Rate
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,13361.7,,,,,,,fee schedule,12777.17,38390.39,MSDRG Base Rate
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,13361.7,,,,,,,fee schedule,12777.17,38390.39,MSDRG Base Rate
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,13490.18,,,,,,,fee schedule,12777.17,38390.39,MSDRG Base Rate
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,13361.7,,,,,,,fee schedule,12777.17,38390.39,MSDRG Base Rate
Other Digestive System Diagnoses With Mcc,393,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22483.63,,,,,,,fee schedule,12777.17,38390.39,MSDRG Base Rate
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7263.21,,,,,,,fee schedule,7263.21,21823.1,
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,7263.21,,,,,,,fee schedule,7263.21,21823.1,
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9723.57,,,,,,,fee schedule,7263.21,21823.1,
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9260.55,,,,,,,fee schedule,7263.21,21823.1,
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,16219.54,,,,,,,fee schedule,7263.21,21823.1,
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,12604.01,,,,,,,fee schedule,7263.21,21823.1,
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,21823.1,,,,,,,fee schedule,7263.21,21823.1,
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,15002.19,,,,,,,fee schedule,7263.21,21823.1,
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,13586.72,,,,,,,fee schedule,7263.21,21823.1,
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11128.09,,,,,,,fee schedule,7263.21,21823.1,
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],20095.48,20095.48,20095.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8027.82,8027.82,8027.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],14163.1,13156,15002.19,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],13586.72,13172.21,13856.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",5038.71,5038.71,5038.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],9260.55,9260.55,9260.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4732.01,4732.01,4732.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6941.13,5298.38,7164.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],11128.09,11128.09,11128.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],5296.61,5296.61,5957.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],14041.61,1173.77,16219.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4688.19,4688.19,4688.19,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],23731.6,23731.6,23731.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8305.86,,,,,,,fee schedule,7263.21,21823.1,MSDRG Base Rate
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,8226.75,,,,,,,fee schedule,7263.21,21823.1,MSDRG Base Rate
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,8226.75,,,,,,,fee schedule,7263.21,21823.1,MSDRG Base Rate
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,8305.86,,,,,,,fee schedule,7263.21,21823.1,MSDRG Base Rate
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,8226.75,,,,,,,fee schedule,7263.21,21823.1,MSDRG Base Rate
Other Digestive System Diagnoses With Cc,394,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,13843.1,,,,,,,fee schedule,7263.21,21823.1,MSDRG Base Rate
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4910.56,,,,,,,fee schedule,4910.56,14754.3,
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,4910.56,,,,,,,fee schedule,4910.56,14754.3,
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6573.97,,,,,,,fee schedule,4910.56,14754.3,
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6260.93,,,,,,,fee schedule,4910.56,14754.3,
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,10965.81,,,,,,,fee schedule,4910.56,14754.3,
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,8521.4,,,,,,,fee schedule,4910.56,14754.3,
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,14754.3,,,,,,,fee schedule,4910.56,14754.3,
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,10142.78,,,,,,,fee schedule,4910.56,14754.3,
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,9185.8,,,,,,,fee schedule,4910.56,14754.3,
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7523.55,,,,,,,fee schedule,4910.56,14754.3,
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],7514.28,4800.8,10142.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],8127.77,8127.77,8127.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],6260.93,6260.93,6260.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4079.87,4079.87,4079.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],5219.38,5219.38,5219.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],10602.52,10602.52,10602.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],5299.8,5299.8,5299.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,6066.04,,,,,,,fee schedule,4910.56,14754.3,MSDRG Base Rate
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,6008.27,,,,,,,fee schedule,4910.56,14754.3,MSDRG Base Rate
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,6008.27,,,,,,,fee schedule,4910.56,14754.3,MSDRG Base Rate
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,6066.04,,,,,,,fee schedule,4910.56,14754.3,MSDRG Base Rate
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,6008.27,,,,,,,fee schedule,4910.56,14754.3,MSDRG Base Rate
Other Digestive System Diagnoses Without Cc/Mcc,395,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10110.06,,,,,,,fee schedule,4910.56,14754.3,MSDRG Base Rate
Red Blood Cell Disorders Age 0-17,396,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders Age 0-17,396,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders Age 0-17,396,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders Age 0-17,396,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders Age 0-17,396,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders Age 0-17,396,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders Age 0-17,396,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders Age 0-17,396,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders Age 0-17,396,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders Age 0-17,396,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders Age 0-17,396,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders Age 0-17,396,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders Age 0-17,396,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders Age 0-17,396,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders Age 0-17,396,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders Age 0-17,396,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders Age 0-17,396,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders Age 0-17,396,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Mcc,397,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,19117.53,,,,,,,fee schedule,19117.53,57440.68,
Appendix Procedures With Mcc,397,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,19117.53,,,,,,,fee schedule,19117.53,57440.68,
Appendix Procedures With Mcc,397,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,25593.46,,,,,,,fee schedule,19117.53,57440.68,
Appendix Procedures With Mcc,397,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24374.73,,,,,,,fee schedule,19117.53,57440.68,
Appendix Procedures With Mcc,397,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,42691.53,,,,,,,fee schedule,19117.53,57440.68,
Appendix Procedures With Mcc,397,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,33175.06,,,,,,,fee schedule,19117.53,57440.68,
Appendix Procedures With Mcc,397,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,57440.68,,,,,,,fee schedule,19117.53,57440.68,
Appendix Procedures With Mcc,397,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,39487.34,,,,,,,fee schedule,19117.53,57440.68,
Appendix Procedures With Mcc,397,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,35761.68,,,,,,,fee schedule,19117.53,57440.68,
Appendix Procedures With Mcc,397,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,29290.29,,,,,,,fee schedule,19117.53,57440.68,
Appendix Procedures With Mcc,397,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Mcc,397,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Mcc,397,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],204501.77,204501.77,204501.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Appendix Procedures With Mcc,397,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Mcc,397,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],37910.62,37910.62,37910.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Appendix Procedures With Mcc,397,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Mcc,397,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Mcc,397,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],24376.7,24376.7,24376.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Appendix Procedures With Mcc,397,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",9418.66,9418.66,9418.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Appendix Procedures With Mcc,397,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Mcc,397,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Mcc,397,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Mcc,397,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Mcc,397,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],18645.2,18645.2,18645.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Appendix Procedures With Mcc,397,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],42694.97,42694.97,42694.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Appendix Procedures With Mcc,397,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Mcc,397,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Mcc,397,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Mcc,397,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,19705.73,,,,,,,fee schedule,19117.53,57440.68,MSDRG Base Rate
Appendix Procedures With Mcc,397,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,19518.05,,,,,,,fee schedule,19117.53,57440.68,MSDRG Base Rate
Appendix Procedures With Mcc,397,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,19518.05,,,,,,,fee schedule,19117.53,57440.68,MSDRG Base Rate
Appendix Procedures With Mcc,397,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,19705.73,,,,,,,fee schedule,19117.53,57440.68,MSDRG Base Rate
Appendix Procedures With Mcc,397,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,19518.05,,,,,,,fee schedule,19117.53,57440.68,MSDRG Base Rate
Appendix Procedures With Mcc,397,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,32842.88,,,,,,,fee schedule,19117.53,57440.68,MSDRG Base Rate
Appendix Procedures With Cc,398,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11676.85,,,,,,,fee schedule,11676.85,35084.35,
Appendix Procedures With Cc,398,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,11676.85,,,,,,,fee schedule,11676.85,35084.35,
Appendix Procedures With Cc,398,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15632.3,,,,,,,fee schedule,11676.85,35084.35,
Appendix Procedures With Cc,398,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14887.91,,,,,,,fee schedule,11676.85,35084.35,
Appendix Procedures With Cc,398,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,26075.67,,,,,,,fee schedule,11676.85,35084.35,
Appendix Procedures With Cc,398,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,20263.09,,,,,,,fee schedule,11676.85,35084.35,
Appendix Procedures With Cc,398,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,35084.35,,,,,,,fee schedule,11676.85,35084.35,
Appendix Procedures With Cc,398,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,24118.58,,,,,,,fee schedule,11676.85,35084.35,
Appendix Procedures With Cc,398,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,21842.97,,,,,,,fee schedule,11676.85,35084.35,
Appendix Procedures With Cc,398,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17890.29,,,,,,,fee schedule,11676.85,35084.35,
Appendix Procedures With Cc,398,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Cc,398,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Cc,398,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11203.88,11203.88,11203.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Appendix Procedures With Cc,398,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],23066.99,23066.99,24116.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Appendix Procedures With Cc,398,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],21841.53,21497.15,21841.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Appendix Procedures With Cc,398,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Cc,398,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Cc,398,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",7080.92,7080.92,7080.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Appendix Procedures With Cc,398,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],14887.91,14887.91,14887.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Appendix Procedures With Cc,398,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],227.89,227.89,227.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Appendix Procedures With Cc,398,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Cc,398,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Cc,398,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Cc,398,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],25424.25,25424.25,25424.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Appendix Procedures With Cc,398,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],11680.38,11680.38,11680.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Appendix Procedures With Cc,398,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Cc,398,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Cc,398,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures With Cc,398,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12820.65,,,,,,,fee schedule,11676.85,35084.35,MSDRG Base Rate
Appendix Procedures With Cc,398,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,12698.55,,,,,,,fee schedule,11676.85,35084.35,MSDRG Base Rate
Appendix Procedures With Cc,398,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,12698.55,,,,,,,fee schedule,11676.85,35084.35,MSDRG Base Rate
Appendix Procedures With Cc,398,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,12820.65,,,,,,,fee schedule,11676.85,35084.35,MSDRG Base Rate
Appendix Procedures With Cc,398,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,12698.55,,,,,,,fee schedule,11676.85,35084.35,MSDRG Base Rate
Appendix Procedures With Cc,398,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21367.74,,,,,,,fee schedule,11676.85,35084.35,MSDRG Base Rate
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8673.72,,,,,,,fee schedule,8673.72,26061.13,
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,8673.72,,,,,,,fee schedule,8673.72,26061.13,
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11611.89,,,,,,,fee schedule,8673.72,26061.13,
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11058.94,,,,,,,fee schedule,8673.72,26061.13,
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,19369.37,,,,,,,fee schedule,8673.72,26061.13,
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,15051.7,,,,,,,fee schedule,8673.72,26061.13,
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,26061.13,,,,,,,fee schedule,8673.72,26061.13,
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,17915.61,,,,,,,fee schedule,8673.72,26061.13,
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,16225.26,,,,,,,fee schedule,8673.72,26061.13,
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13289.16,,,,,,,fee schedule,8673.72,26061.13,
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8492.46,8492.46,8492.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],16533.78,250,17910.83,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",5688.27,5688.27,5688.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],11035.99,11035.99,11035.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],10950.72,10950.72,10950.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",5342.02,5342.02,5342.02,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],13285.61,13285.61,13285.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],18274.56,16617.21,19064.2,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9938.65,,,,,,,fee schedule,8673.72,26061.13,MSDRG Base Rate
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,9844,,,,,,,fee schedule,8673.72,26061.13,MSDRG Base Rate
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,9844,,,,,,,fee schedule,8673.72,26061.13,MSDRG Base Rate
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,9938.65,,,,,,,fee schedule,8673.72,26061.13,MSDRG Base Rate
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,9844,,,,,,,fee schedule,8673.72,26061.13,MSDRG Base Rate
Appendix Procedures Without Cc/Mcc,399,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16564.41,,,,,,,fee schedule,8673.72,26061.13,MSDRG Base Rate
No Longer Valid,400,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,400,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,400,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,400,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,400,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,400,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,400,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,400,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,400,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,400,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,400,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,400,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,400,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,400,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,400,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,400,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,400,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,400,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma & non-acute leukemia w other O.R. proc w CC,401,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma & non-acute leukemia w other O.R. proc w CC,401,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma & non-acute leukemia w other O.R. proc w CC,401,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma & non-acute leukemia w other O.R. proc w CC,401,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma & non-acute leukemia w other O.R. proc w CC,401,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma & non-acute leukemia w other O.R. proc w CC,401,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma & non-acute leukemia w other O.R. proc w CC,401,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma & non-acute leukemia w other O.R. proc w CC,401,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma & non-acute leukemia w other O.R. proc w CC,401,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma & non-acute leukemia w other O.R. proc w CC,401,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma & non-acute leukemia w other O.R. proc w CC,401,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma & non-acute leukemia w other O.R. proc w CC,401,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma & non-acute leukemia w other O.R. proc w CC,401,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma & non-acute leukemia w other O.R. proc w CC,401,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma & non-acute leukemia w other O.R. proc w CC,401,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma & non-acute leukemia w other O.R. proc w CC,401,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma & non-acute leukemia w other O.R. proc w CC,401,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma & non-acute leukemia w other O.R. proc w CC,401,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,30318.3,,,,,,,fee schedule,30318.3,91094.57,
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,30318.3,,,,,,,fee schedule,30318.3,91094.57,
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40588.4,,,,,,,fee schedule,30318.3,91094.57,
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,38655.63,,,,,,,fee schedule,30318.3,91094.57,
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,67704.05,,,,,,,fee schedule,30318.3,91094.57,
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,52611.99,,,,,,,fee schedule,30318.3,91094.57,
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,91094.57,,,,,,,fee schedule,30318.3,91094.57,
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,62622.57,,,,,,,fee schedule,30318.3,91094.57,
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,56714.07,,,,,,,fee schedule,30318.3,91094.57,
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46451.16,,,,,,,fee schedule,30318.3,91094.57,
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],90700.44,90700.44,90700.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],30180.99,30180.99,30180.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],63614.5,63614.5,63614.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],81677.42,81677.42,81677.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],29652.73,28810.08,30160.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],67411.12,67411.12,67411.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],29068.74,29068.74,29068.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,32405.58,,,,,,,fee schedule,30318.3,91094.57,MSDRG Base Rate
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,32096.96,,,,,,,fee schedule,30318.3,91094.57,MSDRG Base Rate
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,32096.96,,,,,,,fee schedule,30318.3,91094.57,MSDRG Base Rate
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,32405.58,,,,,,,fee schedule,30318.3,91094.57,MSDRG Base Rate
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,32096.96,,,,,,,fee schedule,30318.3,91094.57,MSDRG Base Rate
Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical,402,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,54009.3,,,,,,,fee schedule,30318.3,91094.57,MSDRG Base Rate
Lymphoma & non-acute leukemia w CC,403,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma & non-acute leukemia w CC,403,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma & non-acute leukemia w CC,403,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma & non-acute leukemia w CC,403,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma & non-acute leukemia w CC,403,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma & non-acute leukemia w CC,403,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma & non-acute leukemia w CC,403,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma & non-acute leukemia w CC,403,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma & non-acute leukemia w CC,403,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma & non-acute leukemia w CC,403,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma & non-acute leukemia w CC,403,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma & non-acute leukemia w CC,403,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma & non-acute leukemia w CC,403,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma & non-acute leukemia w CC,403,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma & non-acute leukemia w CC,403,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma & non-acute leukemia w CC,403,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma & non-acute leukemia w CC,403,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma & non-acute leukemia w CC,403,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma & Non-Acute Leukemia w/o CC,404,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma & Non-Acute Leukemia w/o CC,404,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma & Non-Acute Leukemia w/o CC,404,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma & Non-Acute Leukemia w/o CC,404,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma & Non-Acute Leukemia w/o CC,404,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma & Non-Acute Leukemia w/o CC,404,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma & Non-Acute Leukemia w/o CC,404,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma & Non-Acute Leukemia w/o CC,404,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma & Non-Acute Leukemia w/o CC,404,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma & Non-Acute Leukemia w/o CC,404,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma & Non-Acute Leukemia w/o CC,404,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma & Non-Acute Leukemia w/o CC,404,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma & Non-Acute Leukemia w/o CC,404,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma & Non-Acute Leukemia w/o CC,404,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma & Non-Acute Leukemia w/o CC,404,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma & Non-Acute Leukemia w/o CC,404,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma & Non-Acute Leukemia w/o CC,404,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma & Non-Acute Leukemia w/o CC,404,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,41886.35,,,,,,,fee schedule,41886.35,125852.03,
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,41886.35,,,,,,,fee schedule,41886.35,125852.03,
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56075.05,,,,,,,fee schedule,41886.35,125852.03,
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,53404.82,,,,,,,fee schedule,41886.35,125852.03,
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,93536.76,,,,,,,fee schedule,41886.35,125852.03,
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,72686.28,,,,,,,fee schedule,41886.35,125852.03,
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,125852.03,,,,,,,fee schedule,41886.35,125852.03,
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,86516.43,,,,,,,fee schedule,41886.35,125852.03,
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,78353.53,,,,,,,fee schedule,41886.35,125852.03,
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,64174.76,,,,,,,fee schedule,41886.35,125852.03,
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",69574.5,69574.5,69574.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",20264.75,20264.75,20264.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],37995.15,37995.15,37995.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,43733.57,,,,,,,fee schedule,41886.35,125852.03,MSDRG Base Rate
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,43317.06,,,,,,,fee schedule,41886.35,125852.03,MSDRG Base Rate
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,43317.06,,,,,,,fee schedule,41886.35,125852.03,MSDRG Base Rate
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,43733.57,,,,,,,fee schedule,41886.35,125852.03,MSDRG Base Rate
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,43317.06,,,,,,,fee schedule,41886.35,125852.03,MSDRG Base Rate
"Pancreas, Liver And Shunt Procedures With Mcc",405,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,72889.28,,,,,,,fee schedule,41886.35,125852.03,MSDRG Base Rate
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,21668.49,,,,,,,fee schedule,21668.49,65105.31,
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,21668.49,,,,,,,fee schedule,21668.49,65105.31,
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29008.54,,,,,,,fee schedule,21668.49,65105.31,
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27627.18,,,,,,,fee schedule,21668.49,65105.31,
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,48388.09,,,,,,,fee schedule,21668.49,65105.31,
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,37601.8,,,,,,,fee schedule,21668.49,65105.31,
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,65105.31,,,,,,,fee schedule,21668.49,65105.31,
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,44756.36,,,,,,,fee schedule,21668.49,65105.31,
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,40533.56,,,,,,,fee schedule,21668.49,65105.31,
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33198.65,,,,,,,fee schedule,21668.49,65105.31,
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,23653.34,,,,,,,fee schedule,21668.49,65105.31,MSDRG Base Rate
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,23428.07,,,,,,,fee schedule,21668.49,65105.31,MSDRG Base Rate
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,23428.07,,,,,,,fee schedule,21668.49,65105.31,MSDRG Base Rate
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,23653.34,,,,,,,fee schedule,21668.49,65105.31,MSDRG Base Rate
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,23428.07,,,,,,,fee schedule,21668.49,65105.31,MSDRG Base Rate
"Pancreas, Liver And Shunt Procedures With Cc",406,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,39422.23,,,,,,,fee schedule,21668.49,65105.31,MSDRG Base Rate
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16478.61,,,,,,,fee schedule,16478.61,49511.75,
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,16478.61,,,,,,,fee schedule,16478.61,49511.75,
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22060.62,,,,,,,fee schedule,16478.61,49511.75,
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21010.12,,,,,,,fee schedule,16478.61,49511.75,
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,36798.52,,,,,,,fee schedule,16478.61,49511.75,
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,28595.68,,,,,,,fee schedule,16478.61,49511.75,
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,49511.75,,,,,,,fee schedule,16478.61,49511.75,
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,34036.64,,,,,,,fee schedule,16478.61,49511.75,
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,30825.25,,,,,,,fee schedule,16478.61,49511.75,
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,25247.15,,,,,,,fee schedule,16478.61,49511.75,
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,18336.21,,,,,,,fee schedule,16478.61,49511.75,MSDRG Base Rate
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,18161.58,,,,,,,fee schedule,16478.61,49511.75,MSDRG Base Rate
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,18161.58,,,,,,,fee schedule,16478.61,49511.75,MSDRG Base Rate
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,18336.21,,,,,,,fee schedule,16478.61,49511.75,MSDRG Base Rate
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,18161.58,,,,,,,fee schedule,16478.61,49511.75,MSDRG Base Rate
"Pancreas, Liver And Shunt Procedures Without Cc/Mcc",407,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30560.36,,,,,,,fee schedule,16478.61,49511.75,MSDRG Base Rate
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,27015.01,,,,,,,fee schedule,27015.01,81169.5,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,27015.01,,,,,,,fee schedule,27015.01,81169.5,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36166.15,,,,,,,fee schedule,27015.01,81169.5,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,34443.96,,,,,,,fee schedule,27015.01,81169.5,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,60327.45,,,,,,,fee schedule,27015.01,81169.5,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,46879.73,,,,,,,fee schedule,27015.01,81169.5,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,81169.5,,,,,,,fee schedule,27015.01,81169.5,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,55799.62,,,,,,,fee schedule,27015.01,81169.5,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,50534.88,,,,,,,fee schedule,27015.01,81169.5,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41390.14,,,,,,,fee schedule,27015.01,81169.5,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],26115.69,26115.69,26115.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,28851.72,,,,,,,fee schedule,27015.01,81169.5,MSDRG Base Rate
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,28576.94,,,,,,,fee schedule,27015.01,81169.5,MSDRG Base Rate
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,28576.94,,,,,,,fee schedule,27015.01,81169.5,MSDRG Base Rate
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,28851.72,,,,,,,fee schedule,27015.01,81169.5,MSDRG Base Rate
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,28576.94,,,,,,,fee schedule,27015.01,81169.5,MSDRG Base Rate
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc,408,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,48086.2,,,,,,,fee schedule,27015.01,81169.5,MSDRG Base Rate
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16175.37,,,,,,,fee schedule,16175.37,48600.62,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,16175.37,,,,,,,fee schedule,16175.37,48600.62,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21654.65,,,,,,,fee schedule,16175.37,48600.62,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20623.48,,,,,,,fee schedule,16175.37,48600.62,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,36121.35,,,,,,,fee schedule,16175.37,48600.62,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,28069.46,,,,,,,fee schedule,16175.37,48600.62,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,48600.62,,,,,,,fee schedule,16175.37,48600.62,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,33410.28,,,,,,,fee schedule,16175.37,48600.62,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,30257.99,,,,,,,fee schedule,16175.37,48600.62,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24782.54,,,,,,,fee schedule,16175.37,48600.62,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",15974.89,15974.89,15974.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,18005.75,,,,,,,fee schedule,16175.37,48600.62,MSDRG Base Rate
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,17834.26,,,,,,,fee schedule,16175.37,48600.62,MSDRG Base Rate
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,17834.26,,,,,,,fee schedule,16175.37,48600.62,MSDRG Base Rate
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,18005.75,,,,,,,fee schedule,16175.37,48600.62,MSDRG Base Rate
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,17834.26,,,,,,,fee schedule,16175.37,48600.62,MSDRG Base Rate
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc,409,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30009.58,,,,,,,fee schedule,16175.37,48600.62,MSDRG Base Rate
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11967.75,,,,,,,fee schedule,11967.75,35958.38,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,11967.75,,,,,,,fee schedule,11967.75,35958.38,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16021.74,,,,,,,fee schedule,11967.75,35958.38,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15258.8,,,,,,,fee schedule,11967.75,35958.38,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,26725.28,,,,,,,fee schedule,11967.75,35958.38,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,20767.89,,,,,,,fee schedule,11967.75,35958.38,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,35958.38,,,,,,,fee schedule,11967.75,35958.38,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,24719.43,,,,,,,fee schedule,11967.75,35958.38,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,22387.13,,,,,,,fee schedule,11967.75,35958.38,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18335.98,,,,,,,fee schedule,11967.75,35958.38,
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13399.55,,,,,,,fee schedule,11967.75,35958.38,MSDRG Base Rate
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,13271.94,,,,,,,fee schedule,11967.75,35958.38,MSDRG Base Rate
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,13271.94,,,,,,,fee schedule,11967.75,35958.38,MSDRG Base Rate
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,13399.55,,,,,,,fee schedule,11967.75,35958.38,MSDRG Base Rate
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,13271.94,,,,,,,fee schedule,11967.75,35958.38,MSDRG Base Rate
Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc,410,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22332.59,,,,,,,fee schedule,11967.75,35958.38,MSDRG Base Rate
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,21114.47,,,,,,,fee schedule,21114.47,63440.7,
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,21114.47,,,,,,,fee schedule,21114.47,63440.7,
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28266.85,,,,,,,fee schedule,21114.47,63440.7,
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26920.81,,,,,,,fee schedule,21114.47,63440.7,
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,47150.91,,,,,,,fee schedule,21114.47,63440.7,
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,36640.4,,,,,,,fee schedule,21114.47,63440.7,
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,63440.7,,,,,,,fee schedule,21114.47,63440.7,
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,43612.03,,,,,,,fee schedule,21114.47,63440.7,
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,39497.2,,,,,,,fee schedule,21114.47,63440.7,
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,32349.83,,,,,,,fee schedule,21114.47,63440.7,
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,26802.52,,,,,,,fee schedule,21114.47,63440.7,MSDRG Base Rate
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,26547.26,,,,,,,fee schedule,21114.47,63440.7,MSDRG Base Rate
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,26547.26,,,,,,,fee schedule,21114.47,63440.7,MSDRG Base Rate
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,26802.52,,,,,,,fee schedule,21114.47,63440.7,MSDRG Base Rate
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,26547.26,,,,,,,fee schedule,21114.47,63440.7,MSDRG Base Rate
Cholecystectomy With C.D.E. With Mcc,411,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,44670.87,,,,,,,fee schedule,21114.47,63440.7,MSDRG Base Rate
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16446.97,,,,,,,fee schedule,16446.97,49416.7,
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,16446.97,,,,,,,fee schedule,16446.97,49416.7,
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22018.27,,,,,,,fee schedule,16446.97,49416.7,
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20969.78,,,,,,,fee schedule,16446.97,49416.7,
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,36727.88,,,,,,,fee schedule,16446.97,49416.7,
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,28540.79,,,,,,,fee schedule,16446.97,49416.7,
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,49416.7,,,,,,,fee schedule,16446.97,49416.7,
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,33971.29,,,,,,,fee schedule,16446.97,49416.7,
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,30766.07,,,,,,,fee schedule,16446.97,49416.7,
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,25198.68,,,,,,,fee schedule,16446.97,49416.7,
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",10197.62,10197.62,10197.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,17421.38,,,,,,,fee schedule,16446.97,49416.7,MSDRG Base Rate
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,17255.46,,,,,,,fee schedule,16446.97,49416.7,MSDRG Base Rate
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,17255.46,,,,,,,fee schedule,16446.97,49416.7,MSDRG Base Rate
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,17421.38,,,,,,,fee schedule,16446.97,49416.7,MSDRG Base Rate
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,17255.46,,,,,,,fee schedule,16446.97,49416.7,MSDRG Base Rate
Cholecystectomy With C.D.E. With Cc,412,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,29035.63,,,,,,,fee schedule,16446.97,49416.7,MSDRG Base Rate
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12827.33,,,,,,,fee schedule,12827.33,38541.08,
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,12827.33,,,,,,,fee schedule,12827.33,38541.08,
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17172.49,,,,,,,fee schedule,12827.33,38541.08,
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16354.76,,,,,,,fee schedule,12827.33,38541.08,
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,28644.81,,,,,,,fee schedule,12827.33,38541.08,
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,22259.54,,,,,,,fee schedule,12827.33,38541.08,
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,38541.08,,,,,,,fee schedule,12827.33,38541.08,
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,26494.9,,,,,,,fee schedule,12827.33,38541.08,
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,23995.08,,,,,,,fee schedule,12827.33,38541.08,
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19652.96,,,,,,,fee schedule,12827.33,38541.08,
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13968.3,,,,,,,fee schedule,12827.33,38541.08,MSDRG Base Rate
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,13835.27,,,,,,,fee schedule,12827.33,38541.08,MSDRG Base Rate
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,13835.27,,,,,,,fee schedule,12827.33,38541.08,MSDRG Base Rate
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,13968.3,,,,,,,fee schedule,12827.33,38541.08,MSDRG Base Rate
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,13835.27,,,,,,,fee schedule,12827.33,38541.08,MSDRG Base Rate
Cholecystectomy With C.D.E. Without Cc/Mcc,413,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23280.5,,,,,,,fee schedule,12827.33,38541.08,MSDRG Base Rate
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,27034.3,,,,,,,fee schedule,27034.3,81227.46,
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,27034.3,,,,,,,fee schedule,27034.3,81227.46,
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36191.98,,,,,,,fee schedule,27034.3,81227.46,
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,34468.56,,,,,,,fee schedule,27034.3,81227.46,
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,60370.53,,,,,,,fee schedule,27034.3,81227.46,
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,46913.2,,,,,,,fee schedule,27034.3,81227.46,
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,81227.46,,,,,,,fee schedule,27034.3,81227.46,
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,55839.47,,,,,,,fee schedule,27034.3,81227.46,
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,50570.96,,,,,,,fee schedule,27034.3,81227.46,
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41419.7,,,,,,,fee schedule,27034.3,81227.46,
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,28828.28,,,,,,,fee schedule,27034.3,81227.46,MSDRG Base Rate
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,28553.72,,,,,,,fee schedule,27034.3,81227.46,MSDRG Base Rate
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,28553.72,,,,,,,fee schedule,27034.3,81227.46,MSDRG Base Rate
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,28828.28,,,,,,,fee schedule,27034.3,81227.46,MSDRG Base Rate
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,28553.72,,,,,,,fee schedule,27034.3,81227.46,MSDRG Base Rate
Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc,414,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,48047.12,,,,,,,fee schedule,27034.3,81227.46,MSDRG Base Rate
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,15262.54,,,,,,,fee schedule,15262.54,45857.95,
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,15262.54,,,,,,,fee schedule,15262.54,45857.95,
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20432.62,,,,,,,fee schedule,15262.54,45857.95,
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19459.64,,,,,,,fee schedule,15262.54,45857.95,
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,34082.92,,,,,,,fee schedule,15262.54,45857.95,
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,26485.42,,,,,,,fee schedule,15262.54,45857.95,
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,45857.95,,,,,,,fee schedule,15262.54,45857.95,
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,31524.85,,,,,,,fee schedule,15262.54,45857.95,
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,28550.45,,,,,,,fee schedule,15262.54,45857.95,
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23384,,,,,,,fee schedule,15262.54,45857.95,
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,17141.69,,,,,,,fee schedule,15262.54,45857.95,MSDRG Base Rate
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,16978.44,,,,,,,fee schedule,15262.54,45857.95,MSDRG Base Rate
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,16978.44,,,,,,,fee schedule,15262.54,45857.95,MSDRG Base Rate
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,17141.69,,,,,,,fee schedule,15262.54,45857.95,MSDRG Base Rate
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,16978.44,,,,,,,fee schedule,15262.54,45857.95,MSDRG Base Rate
Cholecystectomy Except By Laparoscope Without C.D.E. With Cc,415,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,28569.48,,,,,,,fee schedule,15262.54,45857.95,MSDRG Base Rate
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10572.67,,,,,,,fee schedule,10572.67,31766.72,
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,10572.67,,,,,,,fee schedule,10572.67,31766.72,
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14154.08,,,,,,,fee schedule,10572.67,31766.72,
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13480.08,,,,,,,fee schedule,10572.67,31766.72,
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,23609.92,,,,,,,fee schedule,10572.67,31766.72,
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,18346.98,,,,,,,fee schedule,10572.67,31766.72,
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,31766.72,,,,,,,fee schedule,10572.67,31766.72,
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,21837.89,,,,,,,fee schedule,10572.67,31766.72,
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,19777.47,,,,,,,fee schedule,10572.67,31766.72,
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16198.56,,,,,,,fee schedule,10572.67,31766.72,
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11646.44,,,,,,,fee schedule,10572.67,31766.72,MSDRG Base Rate
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,11535.52,,,,,,,fee schedule,10572.67,31766.72,MSDRG Base Rate
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,11535.52,,,,,,,fee schedule,10572.67,31766.72,MSDRG Base Rate
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,11646.44,,,,,,,fee schedule,10572.67,31766.72,MSDRG Base Rate
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,11535.52,,,,,,,fee schedule,10572.67,31766.72,MSDRG Base Rate
Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc,416,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19410.74,,,,,,,fee schedule,10572.67,31766.72,MSDRG Base Rate
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18337.43,,,,,,,fee schedule,18337.43,55096.78,
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,18337.43,,,,,,,fee schedule,18337.43,55096.78,
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24549.1,,,,,,,fee schedule,18337.43,55096.78,
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23380.1,,,,,,,fee schedule,18337.43,55096.78,
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,40949.47,,,,,,,fee schedule,18337.43,55096.78,
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,31821.34,,,,,,,fee schedule,18337.43,55096.78,
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,55096.78,,,,,,,fee schedule,18337.43,55096.78,
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,37876.04,,,,,,,fee schedule,18337.43,55096.78,
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,34302.4,,,,,,,fee schedule,18337.43,55096.78,
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,28095.08,,,,,,,fee schedule,18337.43,55096.78,
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],30547.24,30547.24,30547.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],18453.07,18453.07,18453.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],32022.08,26053.42,35982.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],17634.64,17304.87,19831.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],30561.59,30561.59,38578.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",9823.61,9823.61,9823.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],18002.83,16360.35,18002.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],28095.08,28095.08,28095.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],36274.99,27698.08,40449.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],16089.96,12731.74,17221.89,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",9732.66,9732.66,9732.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,19639.33,,,,,,,fee schedule,18337.43,55096.78,MSDRG Base Rate
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,19452.28,,,,,,,fee schedule,18337.43,55096.78,MSDRG Base Rate
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,19452.28,,,,,,,fee schedule,18337.43,55096.78,MSDRG Base Rate
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,19639.33,,,,,,,fee schedule,18337.43,55096.78,MSDRG Base Rate
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,19452.28,,,,,,,fee schedule,18337.43,55096.78,MSDRG Base Rate
Laparoscopic Cholecystectomy Without C.D.E. With Mcc,417,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,32732.21,,,,,,,fee schedule,18337.43,55096.78,MSDRG Base Rate
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12797.23,,,,,,,fee schedule,12797.23,38450.66,
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,12797.23,,,,,,,fee schedule,12797.23,38450.66,
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17132.21,,,,,,,fee schedule,12797.23,38450.66,
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16316.39,,,,,,,fee schedule,12797.23,38450.66,
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,28577.61,,,,,,,fee schedule,12797.23,38450.66,
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,22207.32,,,,,,,fee schedule,12797.23,38450.66,
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,38450.66,,,,,,,fee schedule,12797.23,38450.66,
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,26432.74,,,,,,,fee schedule,12797.23,38450.66,
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,23938.79,,,,,,,fee schedule,12797.23,38450.66,
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19606.85,,,,,,,fee schedule,12797.23,38450.66,
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],12602.43,12602.43,12602.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],30547.24,30547.24,30547.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12748.63,12748.63,13191.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],25382.78,24729.66,26524.08,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13888.27,13888.27,13888.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],27346.41,27346.41,27346.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",7517.26,7517.26,7517.26,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],16265.41,16265.41,16265.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],12398.2,12398.2,12398.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12739.61,12417.37,12759.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],17605.67,16697.16,19605.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],28575.89,28275.89,28647.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],12188.72,10861.2,12709.21,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",7447.66,7447.66,7447.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14211.26,,,,,,,fee schedule,12797.23,38450.66,MSDRG Base Rate
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,14075.91,,,,,,,fee schedule,12797.23,38450.66,MSDRG Base Rate
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,14075.91,,,,,,,fee schedule,12797.23,38450.66,MSDRG Base Rate
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,14211.26,,,,,,,fee schedule,12797.23,38450.66,MSDRG Base Rate
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,14075.91,,,,,,,fee schedule,12797.23,38450.66,MSDRG Base Rate
Laparoscopic Cholecystectomy Without C.D.E. With Cc,418,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23685.43,,,,,,,fee schedule,12797.23,38450.66,MSDRG Base Rate
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10166.8,,,,,,,fee schedule,10166.8,30547.24,
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,10166.8,,,,,,,fee schedule,10166.8,30547.24,
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13610.73,,,,,,,fee schedule,10166.8,30547.24,
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12962.6,,,,,,,fee schedule,10166.8,30547.24,
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,22703.57,,,,,,,fee schedule,10166.8,30547.24,
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,17642.66,,,,,,,fee schedule,10166.8,30547.24,
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,30547.24,,,,,,,fee schedule,10166.8,30547.24,
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,20999.57,,,,,,,fee schedule,10166.8,30547.24,
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,19018.24,,,,,,,fee schedule,10166.8,30547.24,
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15576.72,,,,,,,fee schedule,10166.8,30547.24,
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],30397.24,30397.24,30547.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],19848.41,17149.47,20929.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9844.9,9844.9,9844.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],17606.42,17606.42,18677.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",6829.87,6829.87,6829.87,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],12919.31,12919.31,12919.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8338.81,8338.81,8338.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],13701.4,13701.4,14834.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],22403.57,21967.65,32653.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],9181.81,9181.81,9181.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],36351.15,36351.15,36351.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11665.97,,,,,,,fee schedule,10166.8,30547.24,MSDRG Base Rate
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,11554.87,,,,,,,fee schedule,10166.8,30547.24,MSDRG Base Rate
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,11554.87,,,,,,,fee schedule,10166.8,30547.24,MSDRG Base Rate
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,11665.97,,,,,,,fee schedule,10166.8,30547.24,MSDRG Base Rate
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,11554.87,,,,,,,fee schedule,10166.8,30547.24,MSDRG Base Rate
Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc,419,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19443.29,,,,,,,fee schedule,10166.8,30547.24,MSDRG Base Rate
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,27231.84,,,,,,,fee schedule,27231.84,81820.97,
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,27231.84,,,,,,,fee schedule,27231.84,81820.97,
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36456.42,,,,,,,fee schedule,27231.84,81820.97,
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,34720.41,,,,,,,fee schedule,27231.84,81820.97,
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,60811.65,,,,,,,fee schedule,27231.84,81820.97,
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,47255.99,,,,,,,fee schedule,27231.84,81820.97,
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,81820.97,,,,,,,fee schedule,27231.84,81820.97,
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,56247.47,,,,,,,fee schedule,27231.84,81820.97,
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,50940.47,,,,,,,fee schedule,27231.84,81820.97,
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41722.34,,,,,,,fee schedule,27231.84,81820.97,
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",19652.16,19652.16,19652.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],52767.7,52767.7,52767.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],24598.16,24598.16,24598.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,27613.45,,,,,,,fee schedule,27231.84,81820.97,MSDRG Base Rate
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,27350.46,,,,,,,fee schedule,27231.84,81820.97,MSDRG Base Rate
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,27350.46,,,,,,,fee schedule,27231.84,81820.97,MSDRG Base Rate
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,27613.45,,,,,,,fee schedule,27231.84,81820.97,MSDRG Base Rate
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,27350.46,,,,,,,fee schedule,27231.84,81820.97,MSDRG Base Rate
Hepatobiliary Diagnostic Procedures With Mcc,420,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,46022.41,,,,,,,fee schedule,27231.84,81820.97,MSDRG Base Rate
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12635.2,,,,,,,fee schedule,12635.2,37963.8,
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,12635.2,,,,,,,fee schedule,12635.2,37963.8,
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16915.28,,,,,,,fee schedule,12635.2,37963.8,
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16109.79,,,,,,,fee schedule,12635.2,37963.8,
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,28215.76,,,,,,,fee schedule,12635.2,37963.8,
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,21926.13,,,,,,,fee schedule,12635.2,37963.8,
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,37963.8,,,,,,,fee schedule,12635.2,37963.8,
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,26098.05,,,,,,,fee schedule,12635.2,37963.8,
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,23635.68,,,,,,,fee schedule,12635.2,37963.8,
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19358.59,,,,,,,fee schedule,12635.2,37963.8,
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14569.85,,,,,,,fee schedule,12635.2,37963.8,MSDRG Base Rate
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,14431.09,,,,,,,fee schedule,12635.2,37963.8,MSDRG Base Rate
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,14431.09,,,,,,,fee schedule,12635.2,37963.8,MSDRG Base Rate
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,14569.85,,,,,,,fee schedule,12635.2,37963.8,MSDRG Base Rate
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,14431.09,,,,,,,fee schedule,12635.2,37963.8,MSDRG Base Rate
Hepatobiliary Diagnostic Procedures With Cc,421,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,24283.09,,,,,,,fee schedule,12635.2,37963.8,MSDRG Base Rate
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11337.34,,,,,,,fee schedule,11337.34,34064.25,
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,11337.34,,,,,,,fee schedule,11337.34,34064.25,
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15177.78,,,,,,,fee schedule,11337.34,34064.25,
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14455.03,,,,,,,fee schedule,11337.34,34064.25,
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,25317.51,,,,,,,fee schedule,11337.34,34064.25,
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,19673.93,,,,,,,fee schedule,11337.34,34064.25,
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,34064.25,,,,,,,fee schedule,11337.34,34064.25,
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,23417.32,,,,,,,fee schedule,11337.34,34064.25,
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,21207.88,,,,,,,fee schedule,11337.34,34064.25,
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17370.12,,,,,,,fee schedule,11337.34,34064.25,
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11929.26,,,,,,,fee schedule,11337.34,34064.25,MSDRG Base Rate
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,11815.65,,,,,,,fee schedule,11337.34,34064.25,MSDRG Base Rate
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,11815.65,,,,,,,fee schedule,11337.34,34064.25,MSDRG Base Rate
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,11929.26,,,,,,,fee schedule,11337.34,34064.25,MSDRG Base Rate
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,11815.65,,,,,,,fee schedule,11337.34,34064.25,MSDRG Base Rate
Hepatobiliary Diagnostic Procedures Without Cc/Mcc,422,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19882.1,,,,,,,fee schedule,11337.34,34064.25,MSDRG Base Rate
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,31382.35,,,,,,,fee schedule,31382.35,94291.65,
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,31382.35,,,,,,,fee schedule,31382.35,94291.65,
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42012.9,,,,,,,fee schedule,31382.35,94291.65,
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40012.29,,,,,,,fee schedule,31382.35,94291.65,
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,70080.2,,,,,,,fee schedule,31382.35,94291.65,
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,54458.47,,,,,,,fee schedule,31382.35,94291.65,
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,94291.65,,,,,,,fee schedule,31382.35,94291.65,
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,64820.38,,,,,,,fee schedule,31382.35,94291.65,
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,58704.52,,,,,,,fee schedule,31382.35,94291.65,
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,48081.42,,,,,,,fee schedule,31382.35,94291.65,
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],54386,54386,54386,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],27552.35,27552.35,27552.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],34955,34955,34955,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],29717.37,29717.37,29717.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",24862.62,24862.62,24862.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,33440.73,,,,,,,fee schedule,31382.35,94291.65,MSDRG Base Rate
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,33122.24,,,,,,,fee schedule,31382.35,94291.65,MSDRG Base Rate
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,33122.24,,,,,,,fee schedule,31382.35,94291.65,MSDRG Base Rate
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,33440.73,,,,,,,fee schedule,31382.35,94291.65,MSDRG Base Rate
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,33122.24,,,,,,,fee schedule,31382.35,94291.65,MSDRG Base Rate
Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc,423,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,55734.54,,,,,,,fee schedule,31382.35,94291.65,MSDRG Base Rate
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17616.74,,,,,,,fee schedule,17616.74,52931.39,
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,17616.74,,,,,,,fee schedule,17616.74,52931.39,
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23584.29,,,,,,,fee schedule,17616.74,52931.39,
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22461.23,,,,,,,fee schedule,17616.74,52931.39,
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,39340.1,,,,,,,fee schedule,17616.74,52931.39,
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,30570.71,,,,,,,fee schedule,17616.74,52931.39,
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,52931.39,,,,,,,fee schedule,17616.74,52931.39,
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,36387.45,,,,,,,fee schedule,17616.74,52931.39,
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,32954.27,,,,,,,fee schedule,17616.74,52931.39,
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26990.9,,,,,,,fee schedule,17616.74,52931.39,
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],51394.8,51394.8,51394.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],17471.69,17471.69,17471.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],15927.8,15927.8,15927.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,18088.56,,,,,,,fee schedule,17616.74,52931.39,MSDRG Base Rate
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,17916.29,,,,,,,fee schedule,17616.74,52931.39,MSDRG Base Rate
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,17916.29,,,,,,,fee schedule,17616.74,52931.39,MSDRG Base Rate
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,18088.56,,,,,,,fee schedule,17616.74,52931.39,MSDRG Base Rate
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,17916.29,,,,,,,fee schedule,17616.74,52931.39,MSDRG Base Rate
Other Hepatobiliary Or Pancreas O.R. Procedures With Cc,424,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30147.6,,,,,,,fee schedule,17616.74,52931.39,MSDRG Base Rate
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11926.85,,,,,,,fee schedule,11926.85,35835.51,
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,11926.85,,,,,,,fee schedule,11926.85,35835.51,
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15966.99,,,,,,,fee schedule,11926.85,35835.51,
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15206.66,,,,,,,fee schedule,11926.85,35835.51,
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,26633.96,,,,,,,fee schedule,11926.85,35835.51,
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,20696.92,,,,,,,fee schedule,11926.85,35835.51,
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,35835.51,,,,,,,fee schedule,11926.85,35835.51,
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,24634.96,,,,,,,fee schedule,11926.85,35835.51,
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,22310.63,,,,,,,fee schedule,11926.85,35835.51,
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18273.33,,,,,,,fee schedule,11926.85,35835.51,
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12716.75,,,,,,,fee schedule,11926.85,35835.51,MSDRG Base Rate
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,12595.64,,,,,,,fee schedule,11926.85,35835.51,MSDRG Base Rate
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,12595.64,,,,,,,fee schedule,11926.85,35835.51,MSDRG Base Rate
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,12716.75,,,,,,,fee schedule,11926.85,35835.51,MSDRG Base Rate
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,12595.64,,,,,,,fee schedule,11926.85,35835.51,MSDRG Base Rate
Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc,425,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21194.58,,,,,,,fee schedule,11926.85,35835.51,MSDRG Base Rate
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,80877.6,,,,,,,fee schedule,80877.6,243005.41,
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,80877.6,,,,,,,fee schedule,80877.6,243005.41,
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,108274.3,,,,,,,fee schedule,80877.6,243005.41,
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,103118.4,,,,,,,fee schedule,80877.6,243005.41,
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,180608.45,,,,,,,fee schedule,80877.6,243005.41,
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,140348.62,,,,,,,fee schedule,80877.6,243005.41,
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,243005.41,,,,,,,fee schedule,80877.6,243005.41,
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,167053.02,,,,,,,fee schedule,80877.6,243005.41,
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,151291.41,,,,,,,fee schedule,80877.6,243005.41,
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,123913.89,,,,,,,fee schedule,80877.6,243005.41,
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],80713.84,80713.84,80713.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],132.26,132.26,132.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,87097.92,,,,,,,fee schedule,80877.6,243005.41,MSDRG Base Rate
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,86268.42,,,,,,,fee schedule,80877.6,243005.41,MSDRG Base Rate
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,86268.42,,,,,,,fee schedule,80877.6,243005.41,MSDRG Base Rate
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,87097.92,,,,,,,fee schedule,80877.6,243005.41,MSDRG Base Rate
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,86268.42,,,,,,,fee schedule,80877.6,243005.41,MSDRG Base Rate
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made,426,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,145163.2,,,,,,,fee schedule,80877.6,243005.41,MSDRG Base Rate
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,54774.63,,,,,,,fee schedule,54774.63,164576.26,
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,54774.63,,,,,,,fee schedule,54774.63,164576.26,
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,73329.15,,,,,,,fee schedule,54774.63,164576.26,
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,69837.29,,,,,,,fee schedule,54774.63,164576.26,
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,122317.7,,,,,,,fee schedule,54774.63,164576.26,
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,95051.59,,,,,,,fee schedule,54774.63,164576.26,
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,164576.26,,,,,,,fee schedule,54774.63,164576.26,
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,113137.23,,,,,,,fee schedule,54774.63,164576.26,
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,102462.64,,,,,,,fee schedule,54774.63,164576.26,
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,83921.12,,,,,,,fee schedule,54774.63,164576.26,
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],52889.77,52889.77,52889.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],111056.55,111056.55,111056.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],52208.46,52208.46,52208.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,57390.45,,,,,,,fee schedule,54774.63,164576.26,MSDRG Base Rate
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,56843.87,,,,,,,fee schedule,54774.63,164576.26,MSDRG Base Rate
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,56843.87,,,,,,,fee schedule,54774.63,164576.26,MSDRG Base Rate
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,57390.45,,,,,,,fee schedule,54774.63,164576.26,MSDRG Base Rate
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,56843.87,,,,,,,fee schedule,54774.63,164576.26,MSDRG Base Rate
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc,427,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,95650.75,,,,,,,fee schedule,54774.63,164576.26,MSDRG Base Rate
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,42478.95,,,,,,,fee schedule,42478.95,127632.56,
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,42478.95,,,,,,,fee schedule,42478.95,127632.56,
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56868.39,,,,,,,fee schedule,42478.95,127632.56,
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,54160.38,,,,,,,fee schedule,42478.95,127632.56,
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,94860.1,,,,,,,fee schedule,42478.95,127632.56,
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,73714.63,,,,,,,fee schedule,42478.95,127632.56,
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,127632.56,,,,,,,fee schedule,42478.95,127632.56,
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,87740.45,,,,,,,fee schedule,42478.95,127632.56,
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,79462.06,,,,,,,fee schedule,42478.95,127632.56,
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,65082.69,,,,,,,fee schedule,42478.95,127632.56,
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],44240.34,44240.34,44240.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],71224.83,71224.83,71224.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],40684.71,40684.71,40684.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],98474.59,98474.59,98474.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,44917.15,,,,,,,fee schedule,42478.95,127632.56,MSDRG Base Rate
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,44489.37,,,,,,,fee schedule,42478.95,127632.56,MSDRG Base Rate
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,44489.37,,,,,,,fee schedule,42478.95,127632.56,MSDRG Base Rate
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,44917.15,,,,,,,fee schedule,42478.95,127632.56,MSDRG Base Rate
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,44489.37,,,,,,,fee schedule,42478.95,127632.56,MSDRG Base Rate
Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc,428,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,74861.92,,,,,,,fee schedule,42478.95,127632.56,MSDRG Base Rate
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,64352.69,,,,,,,fee schedule,64352.69,193354.56,
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,64352.69,,,,,,,fee schedule,64352.69,193354.56,
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,86151.7,,,,,,,fee schedule,64352.69,193354.56,
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,82049.25,,,,,,,fee schedule,64352.69,193354.56,
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,143706.54,,,,,,,fee schedule,64352.69,193354.56,
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,111672.6,,,,,,,fee schedule,64352.69,193354.56,
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,193354.56,,,,,,,fee schedule,64352.69,193354.56,
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,132920.75,,,,,,,fee schedule,64352.69,193354.56,
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,120379.56,,,,,,,fee schedule,64352.69,193354.56,
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,98595.81,,,,,,,fee schedule,64352.69,193354.56,
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],62312.84,62312.84,62312.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],106125.6,106125.6,106125.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],59839.01,59839.01,59839.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,71382.48,,,,,,,fee schedule,64352.69,193354.56,MSDRG Base Rate
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,70702.64,,,,,,,fee schedule,64352.69,193354.56,MSDRG Base Rate
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,70702.64,,,,,,,fee schedule,64352.69,193354.56,MSDRG Base Rate
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,71382.48,,,,,,,fee schedule,64352.69,193354.56,MSDRG Base Rate
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,70702.64,,,,,,,fee schedule,64352.69,193354.56,MSDRG Base Rate
Combined Anterior And Posterior Cervical Spinal Fusion With Mcc,429,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,118970.79,,,,,,,fee schedule,64352.69,193354.56,MSDRG Base Rate
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,42208.11,,,,,,,fee schedule,42208.11,126818.8,
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,42208.11,,,,,,,fee schedule,42208.11,126818.8,
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,56505.8,,,,,,,fee schedule,42208.11,126818.8,
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,53815.06,,,,,,,fee schedule,42208.11,126818.8,
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,94255.29,,,,,,,fee schedule,42208.11,126818.8,
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,73244.64,,,,,,,fee schedule,42208.11,126818.8,
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,126818.8,,,,,,,fee schedule,42208.11,126818.8,
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,87181.03,,,,,,,fee schedule,42208.11,126818.8,
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,78955.42,,,,,,,fee schedule,42208.11,126818.8,
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,64667.74,,,,,,,fee schedule,42208.11,126818.8,
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],77996.31,77996.31,77996.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",24642.3,24642.3,24642.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],42245.57,42245.57,42245.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],42332.68,42332.68,42332.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,46050.73,,,,,,,fee schedule,42208.11,126818.8,MSDRG Base Rate
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,45612.15,,,,,,,fee schedule,42208.11,126818.8,MSDRG Base Rate
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,45612.15,,,,,,,fee schedule,42208.11,126818.8,MSDRG Base Rate
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,46050.73,,,,,,,fee schedule,42208.11,126818.8,MSDRG Base Rate
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,45612.15,,,,,,,fee schedule,42208.11,126818.8,MSDRG Base Rate
Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc,430,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,76751.22,,,,,,,fee schedule,42208.11,126818.8,MSDRG Base Rate
Childhood Mental Disorders,431,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Childhood Mental Disorders,431,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Childhood Mental Disorders,431,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Childhood Mental Disorders,431,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Childhood Mental Disorders,431,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Childhood Mental Disorders,431,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Childhood Mental Disorders,431,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Childhood Mental Disorders,431,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Childhood Mental Disorders,431,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Childhood Mental Disorders,431,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Childhood Mental Disorders,431,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Childhood Mental Disorders,431,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Childhood Mental Disorders,431,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Childhood Mental Disorders,431,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Childhood Mental Disorders,431,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Childhood Mental Disorders,431,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Childhood Mental Disorders,431,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Childhood Mental Disorders,431,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,15116.71,,,,,,,fee schedule,15116.71,45419.77,
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,15116.71,,,,,,,fee schedule,15116.71,45419.77,
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20237.39,,,,,,,fee schedule,15116.71,45419.77,
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19273.7,,,,,,,fee schedule,15116.71,45419.77,
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,33757.25,,,,,,,fee schedule,15116.71,45419.77,
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,26232.35,,,,,,,fee schedule,15116.71,45419.77,
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,45419.77,,,,,,,fee schedule,15116.71,45419.77,
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,31223.63,,,,,,,fee schedule,15116.71,45419.77,
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,28277.65,,,,,,,fee schedule,15116.71,45419.77,
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23160.56,,,,,,,fee schedule,15116.71,45419.77,
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],6063.84,6063.84,6063.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],30552.62,30552.62,30552.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],14309.6,12845.6,15989.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],29141.81,17050.19,88858.26,28,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],26.5,26.5,26.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],28277.65,22849.87,28638.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",11785.52,11785.52,52361.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],19198.7,19023.7,19273.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",11068.14,11068.14,11068.14,65,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],15418.96,15418.96,15418.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],12299.88,12299.88,12299.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],14565.5,13198.4,14957.53,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],23160.56,22953.64,23160.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],32869.78,26504.2,33914.05,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],12961.6,30.98,15375.99,23,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",10965.66,6103.91,10965.66,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,16372.18,,,,,,,fee schedule,15116.71,45419.77,MSDRG Base Rate
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,16216.25,,,,,,,fee schedule,15116.71,45419.77,MSDRG Base Rate
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,16216.25,,,,,,,fee schedule,15116.71,45419.77,MSDRG Base Rate
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,16372.18,,,,,,,fee schedule,15116.71,45419.77,MSDRG Base Rate
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,16216.25,,,,,,,fee schedule,15116.71,45419.77,MSDRG Base Rate
Cirrhosis And Alcoholic Hepatitis With Mcc,432,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,27286.96,,,,,,,fee schedule,15116.71,45419.77,MSDRG Base Rate
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8253.97,,,,,,,fee schedule,8253.97,24799.92,
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,8253.97,,,,,,,fee schedule,8253.97,24799.92,
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11049.94,,,,,,,fee schedule,8253.97,24799.92,
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10523.75,,,,,,,fee schedule,8253.97,24799.92,
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,18432,,,,,,,fee schedule,8253.97,24799.92,
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,14323.28,,,,,,,fee schedule,8253.97,24799.92,
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,24799.92,,,,,,,fee schedule,8253.97,24799.92,
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,17048.6,,,,,,,fee schedule,8253.97,24799.92,
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,15440.05,,,,,,,fee schedule,8253.97,24799.92,
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12646.04,,,,,,,fee schedule,8253.97,24799.92,
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],14041.75,14041.75,14041.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],8284.4,8284.4,8284.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7215.52,6516.86,8116.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],16197.68,15109.28,17050.19,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8761.56,8761.56,8761.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],17074.53,16776.63,17494.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",6560.28,6560.28,6560.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",6160.96,6160.96,6160.96,25,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],10524.74,10524.74,10524.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8113.12,6276.77,8132.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],12647.22,12647.22,12647.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],17373.54,12001.39,18433.72,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],7345.76,990.94,9488.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",6103.91,6103.91,6103.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9247.26,,,,,,,fee schedule,8253.97,24799.92,MSDRG Base Rate
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,9159.19,,,,,,,fee schedule,8253.97,24799.92,MSDRG Base Rate
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,9159.19,,,,,,,fee schedule,8253.97,24799.92,MSDRG Base Rate
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,9247.26,,,,,,,fee schedule,8253.97,24799.92,MSDRG Base Rate
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,9159.19,,,,,,,fee schedule,8253.97,24799.92,MSDRG Base Rate
Cirrhosis And Alcoholic Hepatitis With Cc,433,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15412.09,,,,,,,fee schedule,8253.97,24799.92,MSDRG Base Rate
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5373.53,,,,,,,fee schedule,5373.53,16145.34,
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,5373.53,,,,,,,fee schedule,5373.53,16145.34,
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7193.77,,,,,,,fee schedule,5373.53,16145.34,
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6851.21,,,,,,,fee schedule,5373.53,16145.34,
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,11999.67,,,,,,,fee schedule,5373.53,16145.34,
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,9324.8,,,,,,,fee schedule,5373.53,16145.34,
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,16145.34,,,,,,,fee schedule,5373.53,16145.34,
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,11099.04,,,,,,,fee schedule,5373.53,16145.34,
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,10051.84,,,,,,,fee schedule,5373.53,16145.34,
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8232.87,,,,,,,fee schedule,5373.53,16145.34,
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3770.35,3770.35,3770.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,6562.13,,,,,,,fee schedule,5373.53,16145.34,MSDRG Base Rate
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,6499.64,,,,,,,fee schedule,5373.53,16145.34,MSDRG Base Rate
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,6499.64,,,,,,,fee schedule,5373.53,16145.34,MSDRG Base Rate
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,6562.13,,,,,,,fee schedule,5373.53,16145.34,MSDRG Base Rate
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,6499.64,,,,,,,fee schedule,5373.53,16145.34,MSDRG Base Rate
Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc,434,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10936.89,,,,,,,fee schedule,5373.53,16145.34,MSDRG Base Rate
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14078.12,,,,,,,fee schedule,14078.12,42299.21,
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,14078.12,,,,,,,fee schedule,14078.12,42299.21,
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18846.98,,,,,,,fee schedule,14078.12,42299.21,
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17949.5,,,,,,,fee schedule,14078.12,42299.21,
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,31437.96,,,,,,,fee schedule,14078.12,42299.21,
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,24430.06,,,,,,,fee schedule,14078.12,42299.21,
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,42299.21,,,,,,,fee schedule,14078.12,42299.21,
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,29078.41,,,,,,,fee schedule,14078.12,42299.21,
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,26334.83,,,,,,,fee schedule,14078.12,42299.21,
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21569.31,,,,,,,fee schedule,14078.12,42299.21,
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],13732.59,13732.59,14013.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],41069.92,41069.92,41069.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13904.87,13371.02,13927.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],27625.99,20758,29080,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13403.52,13403.52,13403.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],26336.28,26336.28,26336.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",9493.46,9493.46,9493.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13160.5,12179.52,13645.84,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],17527.89,17527.89,17527.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],29577.56,29577.56,29577.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],13192.21,24.69,15018.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",9405.56,9405.56,9405.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15344.84,,,,,,,fee schedule,14078.12,42299.21,MSDRG Base Rate
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,15198.7,,,,,,,fee schedule,14078.12,42299.21,MSDRG Base Rate
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,15198.7,,,,,,,fee schedule,14078.12,42299.21,MSDRG Base Rate
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,15344.84,,,,,,,fee schedule,14078.12,42299.21,MSDRG Base Rate
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,15198.7,,,,,,,fee schedule,14078.12,42299.21,MSDRG Base Rate
Malignancy Of Hepatobiliary System Or Pancreas With Mcc,435,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,25574.73,,,,,,,fee schedule,14078.12,42299.21,MSDRG Base Rate
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8700.73,,,,,,,fee schedule,8700.73,26142.28,
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,8700.73,,,,,,,fee schedule,8700.73,26142.28,
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11648.04,,,,,,,fee schedule,8700.73,26142.28,
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11093.37,,,,,,,fee schedule,8700.73,26142.28,
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,19429.68,,,,,,,fee schedule,8700.73,26142.28,
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,15098.56,,,,,,,fee schedule,8700.73,26142.28,
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,26142.28,,,,,,,fee schedule,8700.73,26142.28,
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,17971.4,,,,,,,fee schedule,8700.73,26142.28,
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,16275.78,,,,,,,fee schedule,8700.73,26142.28,
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13330.53,,,,,,,fee schedule,8700.73,26142.28,
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],17972.99,17972.99,17972.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8520.97,8520.97,8520.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",7576.04,7576.04,7576.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",7114.88,7114.88,7114.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8576.25,8576.25,8576.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],8832.14,7189.89,8873,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9832.41,,,,,,,fee schedule,8700.73,26142.28,MSDRG Base Rate
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,9738.77,,,,,,,fee schedule,8700.73,26142.28,MSDRG Base Rate
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,9738.77,,,,,,,fee schedule,8700.73,26142.28,MSDRG Base Rate
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,9832.41,,,,,,,fee schedule,8700.73,26142.28,MSDRG Base Rate
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,9738.77,,,,,,,fee schedule,8700.73,26142.28,MSDRG Base Rate
Malignancy Of Hepatobiliary System Or Pancreas With Cc,436,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16387.35,,,,,,,fee schedule,8700.73,26142.28,MSDRG Base Rate
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6057.95,,,,,,,fee schedule,6057.95,18201.76,
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,6057.95,,,,,,,fee schedule,6057.95,18201.76,
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8110.04,,,,,,,fee schedule,6057.95,18201.76,
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7723.85,,,,,,,fee schedule,6057.95,18201.76,
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,13528.06,,,,,,,fee schedule,6057.95,18201.76,
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,10512.49,,,,,,,fee schedule,6057.95,18201.76,
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,18201.76,,,,,,,fee schedule,6057.95,18201.76,
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,12512.72,,,,,,,fee schedule,6057.95,18201.76,
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,11332.13,,,,,,,fee schedule,6057.95,18201.76,
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9281.48,,,,,,,fee schedule,6057.95,18201.76,
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],8490.64,8490.64,8490.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7662.11,,,,,,,fee schedule,6057.95,18201.76,MSDRG Base Rate
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,7589.14,,,,,,,fee schedule,6057.95,18201.76,MSDRG Base Rate
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,7589.14,,,,,,,fee schedule,6057.95,18201.76,MSDRG Base Rate
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,7662.11,,,,,,,fee schedule,6057.95,18201.76,MSDRG Base Rate
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,7589.14,,,,,,,fee schedule,6057.95,18201.76,MSDRG Base Rate
Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc,437,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12770.19,,,,,,,fee schedule,6057.95,18201.76,MSDRG Base Rate
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12838.13,,,,,,,fee schedule,12838.13,38573.54,
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,12838.13,,,,,,,fee schedule,12838.13,38573.54,
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17186.95,,,,,,,fee schedule,12838.13,38573.54,
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16368.53,,,,,,,fee schedule,12838.13,38573.54,
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,28668.94,,,,,,,fee schedule,12838.13,38573.54,
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,22278.28,,,,,,,fee schedule,12838.13,38573.54,
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,38573.54,,,,,,,fee schedule,12838.13,38573.54,
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,26517.21,,,,,,,fee schedule,12838.13,38573.54,
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,24015.29,,,,,,,fee schedule,12838.13,38573.54,
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19669.51,,,,,,,fee schedule,12838.13,38573.54,
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],34358.16,34358.16,34358.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12248.17,12248.17,12248.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],26515.62,25189.83,66238.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],26895.37,14199,108012.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",9083.41,9083.41,9083.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",8530.51,8530.51,8530.51,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],140457.24,140457.24,140457.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],10960.64,10960.64,12077.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],24617.42,24617.42,24617.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],27040.15,2455.26,28667.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],12737.2,10998.67,27192.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",8451.52,8451.52,8451.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13731.57,,,,,,,fee schedule,12838.13,38573.54,MSDRG Base Rate
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,13600.8,,,,,,,fee schedule,12838.13,38573.54,MSDRG Base Rate
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,13600.8,,,,,,,fee schedule,12838.13,38573.54,MSDRG Base Rate
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,13731.57,,,,,,,fee schedule,12838.13,38573.54,MSDRG Base Rate
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,13600.8,,,,,,,fee schedule,12838.13,38573.54,MSDRG Base Rate
Disorders Of Pancreas Except Malignancy With Mcc,438,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22885.96,,,,,,,fee schedule,12838.13,38573.54,MSDRG Base Rate
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6637.43,,,,,,,fee schedule,6637.43,19942.88,
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,6637.43,,,,,,,fee schedule,6637.43,19942.88,
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8885.81,,,,,,,fee schedule,6637.43,19942.88,
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8462.68,,,,,,,fee schedule,6637.43,19942.88,
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,14822.11,,,,,,,fee schedule,6637.43,19942.88,
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,11518.08,,,,,,,fee schedule,6637.43,19942.88,
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,19942.88,,,,,,,fee schedule,6637.43,19942.88,
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,13709.64,,,,,,,fee schedule,6637.43,19942.88,
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,12416.13,,,,,,,fee schedule,6637.43,19942.88,
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10169.32,,,,,,,fee schedule,6637.43,19942.88,
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],14260.48,14260.48,18321,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6672.08,5818.31,6948.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],9803.3,9254.5,13359.64,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7002.26,7002.26,7002.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],12416.13,10057.92,12416.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",6816.63,6816.63,49063.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",6401.7,6401.7,6401.7,26,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6332.99,6332.99,6332.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],9628.77,9628.77,10169.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],13050.54,3010,14494.72,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],5939.13,5760.25,6916.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",6342.43,6342.43,6342.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7567.59,,,,,,,fee schedule,6637.43,19942.88,MSDRG Base Rate
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,7495.52,,,,,,,fee schedule,6637.43,19942.88,MSDRG Base Rate
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,7495.52,,,,,,,fee schedule,6637.43,19942.88,MSDRG Base Rate
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,7567.59,,,,,,,fee schedule,6637.43,19942.88,MSDRG Base Rate
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,7495.52,,,,,,,fee schedule,6637.43,19942.88,MSDRG Base Rate
Disorders Of Pancreas Except Malignancy With Cc,439,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12612.65,,,,,,,fee schedule,6637.43,19942.88,MSDRG Base Rate
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4746.2,,,,,,,fee schedule,4746.2,14260.48,
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,4746.2,,,,,,,fee schedule,4746.2,14260.48,
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6353.95,,,,,,,fee schedule,4746.2,14260.48,
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6051.38,,,,,,,fee schedule,4746.2,14260.48,
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,10598.79,,,,,,,fee schedule,4746.2,14260.48,
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,8236.19,,,,,,,fee schedule,4746.2,14260.48,
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,14260.48,,,,,,,fee schedule,4746.2,14260.48,
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,9803.3,,,,,,,fee schedule,4746.2,14260.48,
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,8878.35,,,,,,,fee schedule,4746.2,14260.48,
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7271.74,,,,,,,fee schedule,4746.2,14260.48,
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],11961.81,11961.81,11961.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],8515.76,2872.26,9561.27,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],5415.12,5415.12,5415.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],7954.97,7954.97,7954.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",5142.13,5142.13,5142.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],6051.38,6051.38,6051.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],7021.74,7021.74,7021.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],355.82,355.82,355.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],4708.52,4549.22,5143.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,5850.42,,,,,,,fee schedule,4746.2,14260.48,MSDRG Base Rate
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,5794.7,,,,,,,fee schedule,4746.2,14260.48,MSDRG Base Rate
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,5794.7,,,,,,,fee schedule,4746.2,14260.48,MSDRG Base Rate
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,5850.42,,,,,,,fee schedule,4746.2,14260.48,MSDRG Base Rate
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,5794.7,,,,,,,fee schedule,4746.2,14260.48,MSDRG Base Rate
Disorders Of Pancreas Except Malignancy Without Cc/Mcc,440,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9750.7,,,,,,,fee schedule,4746.2,14260.48,MSDRG Base Rate
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14585.84,,,,,,,fee schedule,14585.84,43824.72,
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,14585.84,,,,,,,fee schedule,14585.84,43824.72,
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19526.69,,,,,,,fee schedule,14585.84,43824.72,
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18596.85,,,,,,,fee schedule,14585.84,43824.72,
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,32571.76,,,,,,,fee schedule,14585.84,43824.72,
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,25311.12,,,,,,,fee schedule,14585.84,43824.72,
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,43824.72,,,,,,,fee schedule,14585.84,43824.72,
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,30127.11,,,,,,,fee schedule,14585.84,43824.72,
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,27284.59,,,,,,,fee schedule,14585.84,43824.72,
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22347.2,,,,,,,fee schedule,14585.84,43824.72,
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],13991.89,13991.89,13991.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13852.44,12926.47,26320.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],29628.7,29628.7,29628.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11930.62,11930.62,11930.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",7931.67,7931.67,7931.67,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13917.6,13790.15,14320.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],13545.57,13545.57,13545.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],22132,22132,23930.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],13132.85,12666.01,15283.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",7858.23,7858.23,7858.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15016.72,,,,,,,fee schedule,14585.84,43824.72,MSDRG Base Rate
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,14873.71,,,,,,,fee schedule,14585.84,43824.72,MSDRG Base Rate
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,14873.71,,,,,,,fee schedule,14585.84,43824.72,MSDRG Base Rate
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,15016.72,,,,,,,fee schedule,14585.84,43824.72,MSDRG Base Rate
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,14873.71,,,,,,,fee schedule,14585.84,43824.72,MSDRG Base Rate
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc",441,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,25027.87,,,,,,,fee schedule,14585.84,43824.72,MSDRG Base Rate
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7455.34,,,,,,,fee schedule,7455.34,22400.38,
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,7455.34,,,,,,,fee schedule,7455.34,22400.38,
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9980.79,,,,,,,fee schedule,7455.34,22400.38,
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9505.51,,,,,,,fee schedule,7455.34,22400.38,
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,16648.59,,,,,,,fee schedule,7455.34,22400.38,
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,12937.42,,,,,,,fee schedule,7455.34,22400.38,
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,22400.38,,,,,,,fee schedule,7455.34,22400.38,
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,15399.04,,,,,,,fee schedule,7455.34,22400.38,
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,13946.13,,,,,,,fee schedule,7455.34,22400.38,
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11422.46,,,,,,,fee schedule,7455.34,22400.38,
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8236.29,6498.67,8334.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],10754,10754,15861.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],15255.04,15255.04,15255.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",5873.8,5873.8,5873.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7126.49,6461.65,7156.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],9289.22,9289.22,9289.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],16171.17,16171.17,16648.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],7344.96,138.07,7883.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],12728.11,12728.11,12728.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8537.11,,,,,,,fee schedule,7455.34,22400.38,MSDRG Base Rate
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,8455.8,,,,,,,fee schedule,7455.34,22400.38,MSDRG Base Rate
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,8455.8,,,,,,,fee schedule,7455.34,22400.38,MSDRG Base Rate
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,8537.11,,,,,,,fee schedule,7455.34,22400.38,MSDRG Base Rate
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,8455.8,,,,,,,fee schedule,7455.34,22400.38,MSDRG Base Rate
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc",442,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14228.52,,,,,,,fee schedule,7455.34,22400.38,MSDRG Base Rate
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5421.37,,,,,,,fee schedule,5421.37,16289.08,
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,5421.37,,,,,,,fee schedule,5421.37,16289.08,
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7257.82,,,,,,,fee schedule,5421.37,16289.08,
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6912.21,,,,,,,fee schedule,5421.37,16289.08,
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,12106.5,,,,,,,fee schedule,5421.37,16289.08,
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,9407.81,,,,,,,fee schedule,5421.37,16289.08,
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,16289.08,,,,,,,fee schedule,5421.37,16289.08,
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,11197.86,,,,,,,fee schedule,5421.37,16289.08,
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,10141.33,,,,,,,fee schedule,5421.37,16289.08,
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8306.17,,,,,,,fee schedule,5421.37,16289.08,
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4877.74,4877.74,4877.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],12108.22,12108.22,12108.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],3803.14,3803.14,3803.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4832.58,4832.58,4832.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,6462.13,,,,,,,fee schedule,5421.37,16289.08,MSDRG Base Rate
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,6400.59,,,,,,,fee schedule,5421.37,16289.08,MSDRG Base Rate
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,6400.59,,,,,,,fee schedule,5421.37,16289.08,MSDRG Base Rate
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,6462.13,,,,,,,fee schedule,5421.37,16289.08,MSDRG Base Rate
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,6400.59,,,,,,,fee schedule,5421.37,16289.08,MSDRG Base Rate
"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc",443,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10770.22,,,,,,,fee schedule,5421.37,16289.08,MSDRG Base Rate
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12997.85,,,,,,,fee schedule,12997.85,39053.45,
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,12997.85,,,,,,,fee schedule,12997.85,39053.45,
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17400.78,,,,,,,fee schedule,12997.85,39053.45,
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16572.18,,,,,,,fee schedule,12997.85,39053.45,
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,29025.62,,,,,,,fee schedule,12997.85,39053.45,
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,22555.46,,,,,,,fee schedule,12997.85,39053.45,
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,39053.45,,,,,,,fee schedule,12997.85,39053.45,
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,26847.12,,,,,,,fee schedule,12997.85,39053.45,
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,24314.07,,,,,,,fee schedule,12997.85,39053.45,
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19914.23,,,,,,,fee schedule,12997.85,39053.45,
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],39051.13,39051.13,39051.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11914.77,11914.77,13275.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],20085,20085,20085,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12059.18,12059.18,12333.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],12797.43,12797.43,12797.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",5625.75,5625.75,5625.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12759.92,12759.92,12759.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],28791.28,28791.28,28791.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],12887.39,11143.09,12903.09,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14049.55,,,,,,,fee schedule,12997.85,39053.45,MSDRG Base Rate
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,13915.74,,,,,,,fee schedule,12997.85,39053.45,MSDRG Base Rate
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,13915.74,,,,,,,fee schedule,12997.85,39053.45,MSDRG Base Rate
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,14049.55,,,,,,,fee schedule,12997.85,39053.45,MSDRG Base Rate
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,13915.74,,,,,,,fee schedule,12997.85,39053.45,MSDRG Base Rate
Disorders Of The Biliary Tract With Mcc,444,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23415.91,,,,,,,fee schedule,12997.85,39053.45,MSDRG Base Rate
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8367.39,,,,,,,fee schedule,8367.39,25140.73,
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,8367.39,,,,,,,fee schedule,8367.39,25140.73,
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11201.79,,,,,,,fee schedule,8367.39,25140.73,
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10668.37,,,,,,,fee schedule,8367.39,25140.73,
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,18685.3,,,,,,,fee schedule,8367.39,25140.73,
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,14520.12,,,,,,,fee schedule,8367.39,25140.73,
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,25140.73,,,,,,,fee schedule,8367.39,25140.73,
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,17282.89,,,,,,,fee schedule,8367.39,25140.73,
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,15652.23,,,,,,,fee schedule,8367.39,25140.73,
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12819.82,,,,,,,fee schedule,8367.39,25140.73,
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],10887,10887,10887,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8236.22,8013.72,8538.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],16529,16345.25,22972.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],17692.07,17692.07,17692.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4330.5,4330.5,4330.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7984.35,7984.35,8223.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],15400.28,14395.65,18687.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],8356.16,8117.38,8557.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9545.69,,,,,,,fee schedule,8367.39,25140.73,MSDRG Base Rate
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,9454.78,,,,,,,fee schedule,8367.39,25140.73,MSDRG Base Rate
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,9454.78,,,,,,,fee schedule,8367.39,25140.73,MSDRG Base Rate
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,9545.69,,,,,,,fee schedule,8367.39,25140.73,MSDRG Base Rate
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,9454.78,,,,,,,fee schedule,8367.39,25140.73,MSDRG Base Rate
Disorders Of The Biliary Tract With Cc,445,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15909.48,,,,,,,fee schedule,8367.39,25140.73,MSDRG Base Rate
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6151.31,,,,,,,fee schedule,6151.31,18482.28,
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,6151.31,,,,,,,fee schedule,6151.31,18482.28,
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8235.03,,,,,,,fee schedule,6151.31,18482.28,
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7842.89,,,,,,,fee schedule,6151.31,18482.28,
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,13736.55,,,,,,,fee schedule,6151.31,18482.28,
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,10674.51,,,,,,,fee schedule,6151.31,18482.28,
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,18482.28,,,,,,,fee schedule,6151.31,18482.28,
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,12705.57,,,,,,,fee schedule,6151.31,18482.28,
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,11506.78,,,,,,,fee schedule,6151.31,18482.28,
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9424.53,,,,,,,fee schedule,6151.31,18482.28,
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],1876.64,1876.64,1876.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],11120.71,7411.6,12707.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],12889.15,12889.15,12889.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],7841.87,7841.87,7841.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3429.45,3429.45,3429.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],4301.43,4301.43,4301.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],9275.71,9275.71,9275.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],13049.2,13049.2,13049.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],6841.15,6841.15,7067.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7458.99,,,,,,,fee schedule,6151.31,18482.28,MSDRG Base Rate
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,7387.95,,,,,,,fee schedule,6151.31,18482.28,MSDRG Base Rate
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,7387.95,,,,,,,fee schedule,6151.31,18482.28,MSDRG Base Rate
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,7458.99,,,,,,,fee schedule,6151.31,18482.28,MSDRG Base Rate
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,7387.95,,,,,,,fee schedule,6151.31,18482.28,MSDRG Base Rate
Disorders Of The Biliary Tract Without Cc/Mcc,446,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12431.65,,,,,,,fee schedule,6151.31,18482.28,MSDRG Base Rate
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,51730.61,,,,,,,fee schedule,51730.61,155430.17,
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,51730.61,,,,,,,fee schedule,51730.61,155430.17,
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,69253.98,,,,,,,fee schedule,51730.61,155430.17,
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,65956.19,,,,,,,fee schedule,51730.61,155430.17,
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,115520.07,,,,,,,fee schedule,51730.61,155430.17,
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,89769.24,,,,,,,fee schedule,51730.61,155430.17,
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,155430.17,,,,,,,fee schedule,51730.61,155430.17,
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,106849.8,,,,,,,fee schedule,51730.61,155430.17,
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,96768.42,,,,,,,fee schedule,51730.61,155430.17,
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,79257.32,,,,,,,fee schedule,51730.61,155430.17,
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],85.03,85.03,85.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],49617.49,49617.49,49617.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],51454.37,51454.37,51454.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,53195.18,,,,,,,fee schedule,51730.61,155430.17,MSDRG Base Rate
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,52688.56,,,,,,,fee schedule,51730.61,155430.17,MSDRG Base Rate
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,52688.56,,,,,,,fee schedule,51730.61,155430.17,MSDRG Base Rate
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,53195.18,,,,,,,fee schedule,51730.61,155430.17,MSDRG Base Rate
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,52688.56,,,,,,,fee schedule,51730.61,155430.17,MSDRG Base Rate
Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody,447,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,88658.64,,,,,,,fee schedule,51730.61,155430.17,MSDRG Base Rate
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,31506.58,,,,,,,fee schedule,31506.58,94664.91,
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,31506.58,,,,,,,fee schedule,31506.58,94664.91,
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42179.21,,,,,,,fee schedule,31506.58,94664.91,
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40170.68,,,,,,,fee schedule,31506.58,94664.91,
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,70357.62,,,,,,,fee schedule,31506.58,94664.91,
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,54674.05,,,,,,,fee schedule,31506.58,94664.91,
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,94664.91,,,,,,,fee schedule,31506.58,94664.91,
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,65076.98,,,,,,,fee schedule,31506.58,94664.91,
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,58936.91,,,,,,,fee schedule,31506.58,94664.91,
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,48271.75,,,,,,,fee schedule,31506.58,94664.91,
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],87004.11,87004.11,87004.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],58897.05,58897.05,58897.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",18134.22,18134.22,18134.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],56852,56852,56852,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],30309.67,30304.88,30347.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,34126.66,,,,,,,fee schedule,31506.58,94664.91,MSDRG Base Rate
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,33801.64,,,,,,,fee schedule,31506.58,94664.91,MSDRG Base Rate
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,33801.64,,,,,,,fee schedule,31506.58,94664.91,MSDRG Base Rate
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,34126.66,,,,,,,fee schedule,31506.58,94664.91,MSDRG Base Rate
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,33801.64,,,,,,,fee schedule,31506.58,94664.91,MSDRG Base Rate
Multiple Level Spinal Fusion Except Cervical Without Mcc,448,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,56877.76,,,,,,,fee schedule,31506.58,94664.91,MSDRG Base Rate
Poisoning & toxic Effects of Drugs Age >17 w CC,449,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Poisoning & toxic Effects of Drugs Age >17 w CC,449,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Poisoning & toxic Effects of Drugs Age >17 w CC,449,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Poisoning & toxic Effects of Drugs Age >17 w CC,449,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Poisoning & toxic Effects of Drugs Age >17 w CC,449,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Poisoning & toxic Effects of Drugs Age >17 w CC,449,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Poisoning & toxic Effects of Drugs Age >17 w CC,449,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Poisoning & toxic Effects of Drugs Age >17 w CC,449,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Poisoning & toxic Effects of Drugs Age >17 w CC,449,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Poisoning & toxic Effects of Drugs Age >17 w CC,449,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Poisoning & toxic Effects of Drugs Age >17 w CC,449,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Poisoning & toxic Effects of Drugs Age >17 w CC,449,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Poisoning & toxic Effects of Drugs Age >17 w CC,449,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Poisoning & toxic Effects of Drugs Age >17 w CC,449,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Poisoning & toxic Effects of Drugs Age >17 w CC,449,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Poisoning & toxic Effects of Drugs Age >17 w CC,449,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Poisoning & toxic Effects of Drugs Age >17 w CC,449,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Poisoning & toxic Effects of Drugs Age >17 w CC,449,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,39735.86,,,,,,,fee schedule,39735.86,119390.64,
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,39735.86,,,,,,,fee schedule,39735.86,119390.64,
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,53196.09,,,,,,,fee schedule,39735.86,119390.64,
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,50662.95,,,,,,,fee schedule,39735.86,119390.64,
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,88734.48,,,,,,,fee schedule,39735.86,119390.64,
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,68954.48,,,,,,,fee schedule,39735.86,119390.64,
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,119390.64,,,,,,,fee schedule,39735.86,119390.64,
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,82074.58,,,,,,,fee schedule,39735.86,119390.64,
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,74330.77,,,,,,,fee schedule,39735.86,119390.64,
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60879.96,,,,,,,fee schedule,39735.86,119390.64,
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],94179.42,94179.42,94179.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],42192.8,42192.8,42192.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],37371.36,37371.36,37371.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,42632.8,,,,,,,fee schedule,39735.86,119390.64,MSDRG Base Rate
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,42226.78,,,,,,,fee schedule,39735.86,119390.64,MSDRG Base Rate
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,42226.78,,,,,,,fee schedule,39735.86,119390.64,MSDRG Base Rate
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,42632.8,,,,,,,fee schedule,39735.86,119390.64,MSDRG Base Rate
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,42226.78,,,,,,,fee schedule,39735.86,119390.64,MSDRG Base Rate
Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F,450,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,71054.67,,,,,,,fee schedule,39735.86,119390.64,MSDRG Base Rate
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,23810.5,,,,,,,fee schedule,23810.5,71541.19,
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,23810.5,,,,,,,fee schedule,23810.5,71541.19,
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31876.13,,,,,,,fee schedule,23810.5,71541.19,
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,30358.22,,,,,,,fee schedule,23810.5,71541.19,
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,53171.42,,,,,,,fee schedule,23810.5,71541.19,
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,41318.86,,,,,,,fee schedule,23810.5,71541.19,
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,71541.19,,,,,,,fee schedule,23810.5,71541.19,
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,49180.68,,,,,,,fee schedule,23810.5,71541.19,
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,44540.44,,,,,,,fee schedule,23810.5,71541.19,
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,36480.45,,,,,,,fee schedule,23810.5,71541.19,
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],30360.19,30360.19,30360.19,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],21735.07,21120.53,23053.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],72375.44,72375.44,72375.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],22229.43,22229.43,22229.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,26233,,,,,,,fee schedule,23810.5,71541.19,MSDRG Base Rate
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,25983.16,,,,,,,fee schedule,23810.5,71541.19,MSDRG Base Rate
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,25983.16,,,,,,,fee schedule,23810.5,71541.19,MSDRG Base Rate
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,26233,,,,,,,fee schedule,23810.5,71541.19,MSDRG Base Rate
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,25983.16,,,,,,,fee schedule,23810.5,71541.19,MSDRG Base Rate
Single Level Spinal Fusion Except Cervical Without Mcc,451,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,43721.67,,,,,,,fee schedule,23810.5,71541.19,MSDRG Base Rate
Complications of treatment w CC,452,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complications of treatment w CC,452,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Complications of treatment w CC,452,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Complications of treatment w CC,452,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complications of treatment w CC,452,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complications of treatment w CC,452,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Complications of treatment w CC,452,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Complications of treatment w CC,452,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Complications of treatment w CC,452,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Complications of treatment w CC,452,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Complications of treatment w CC,452,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complications of treatment w CC,452,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complications of treatment w CC,452,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Complications of treatment w CC,452,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Complications of treatment w CC,452,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complications of treatment w CC,452,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Complications of treatment w CC,452,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complications of treatment w CC,452,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,68375.89,,,,,,,fee schedule,68375.89,205442.7,
Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,68375.89,,,,,,,fee schedule,68375.89,205442.7,
Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,87178.81,,,,,,,fee schedule,68375.89,205442.7,
Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,152690.78,,,,,,,fee schedule,68375.89,205442.7,
Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,118654.15,,,,,,,fee schedule,68375.89,205442.7,
Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,205442.7,,,,,,,fee schedule,68375.89,205442.7,
Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,141230.69,,,,,,,fee schedule,68375.89,205442.7,
Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,127905.45,,,,,,,fee schedule,68375.89,205442.7,
Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,104759.83,,,,,,,fee schedule,68375.89,205442.7,
Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Mcc,453,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,47194.29,,,,,,,fee schedule,47194.29,141800.3,
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,47194.29,,,,,,,fee schedule,47194.29,141800.3,
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,60172.4,,,,,,,fee schedule,47194.29,141800.3,
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,105389.97,,,,,,,fee schedule,47194.29,141800.3,
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,81897.26,,,,,,,fee schedule,47194.29,141800.3,
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,141800.3,,,,,,,fee schedule,47194.29,141800.3,
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,97480,,,,,,,fee schedule,47194.29,141800.3,
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,88282.67,,,,,,,fee schedule,47194.29,141800.3,
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,72307.14,,,,,,,fee schedule,47194.29,141800.3,
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion With Cc,454,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,35537.5,,,,,,,fee schedule,35537.5,106776.23,
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,35537.5,,,,,,,fee schedule,35537.5,106776.23,
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,45310.08,,,,,,,fee schedule,35537.5,106776.23,
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,79359.09,,,,,,,fee schedule,35537.5,106776.23,
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,61668.98,,,,,,,fee schedule,35537.5,106776.23,
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,106776.23,,,,,,,fee schedule,35537.5,106776.23,
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,73402.86,,,,,,,fee schedule,35537.5,106776.23,
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,66477.23,,,,,,,fee schedule,35537.5,106776.23,
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,54447.59,,,,,,,fee schedule,35537.5,106776.23,
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc,455,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,65344.99,,,,,,,fee schedule,65344.99,196336.02,
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,65344.99,,,,,,,fee schedule,65344.99,196336.02,
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,87480.13,,,,,,,fee schedule,65344.99,196336.02,
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,83314.43,,,,,,,fee schedule,65344.99,196336.02,
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,145922.45,,,,,,,fee schedule,65344.99,196336.02,
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,113394.55,,,,,,,fee schedule,65344.99,196336.02,
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,196336.02,,,,,,,fee schedule,65344.99,196336.02,
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,134970.34,,,,,,,fee schedule,65344.99,196336.02,
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,122235.77,,,,,,,fee schedule,65344.99,196336.02,
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,100116.13,,,,,,,fee schedule,65344.99,196336.02,
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],64160.28,64160.28,64160.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,66646.6,,,,,,,fee schedule,65344.99,196336.02,MSDRG Base Rate
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,66011.87,,,,,,,fee schedule,65344.99,196336.02,MSDRG Base Rate
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,66011.87,,,,,,,fee schedule,65344.99,196336.02,MSDRG Base Rate
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,66646.6,,,,,,,fee schedule,65344.99,196336.02,MSDRG Base Rate
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,66011.87,,,,,,,fee schedule,65344.99,196336.02,MSDRG Base Rate
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",456,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,111077.66,,,,,,,fee schedule,65344.99,196336.02,MSDRG Base Rate
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,44282.98,,,,,,,fee schedule,44282.98,133052.98,
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,44282.98,,,,,,,fee schedule,44282.98,133052.98,
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,59283.53,,,,,,,fee schedule,44282.98,133052.98,
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,56460.51,,,,,,,fee schedule,44282.98,133052.98,
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,98888.71,,,,,,,fee schedule,44282.98,133052.98,
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,76845.21,,,,,,,fee schedule,44282.98,133052.98,
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,133052.98,,,,,,,fee schedule,44282.98,133052.98,
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,91466.69,,,,,,,fee schedule,44282.98,133052.98,
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,82836.73,,,,,,,fee schedule,44282.98,133052.98,
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,67846.69,,,,,,,fee schedule,44282.98,133052.98,
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",26294.36,26294.36,26294.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],41835.52,41835.52,41835.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],109285.04,109285.04,109285.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,47581.97,,,,,,,fee schedule,44282.98,133052.98,MSDRG Base Rate
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,47128.81,,,,,,,fee schedule,44282.98,133052.98,MSDRG Base Rate
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,47128.81,,,,,,,fee schedule,44282.98,133052.98,MSDRG Base Rate
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,47581.97,,,,,,,fee schedule,44282.98,133052.98,MSDRG Base Rate
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,47128.81,,,,,,,fee schedule,44282.98,133052.98,MSDRG Base Rate
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",457,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,79303.28,,,,,,,fee schedule,44282.98,133052.98,MSDRG Base Rate
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,33316.02,,,,,,,fee schedule,33273.91,100101.56,
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,33316.02,,,,,,,fee schedule,33273.91,100101.56,
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,44601.58,,,,,,,fee schedule,33273.91,100101.56,
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,42477.71,,,,,,,fee schedule,33273.91,100101.56,
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,74398.29,,,,,,,fee schedule,33273.91,100101.56,
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,57814,,,,,,,fee schedule,33273.91,100101.56,
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,100101.56,,,,,,,fee schedule,33273.91,100101.56,
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,68814.38,,,,,,,fee schedule,33273.91,100101.56,
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,62321.68,,,,,,,fee schedule,33273.91,100101.56,
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,51044.02,,,,,,,fee schedule,33273.91,100101.56,
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,33593.85,,,,,,,fee schedule,33273.91,100101.56,MSDRG Base Rate
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,33273.91,,,,,,,fee schedule,33273.91,100101.56,MSDRG Base Rate
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,33273.91,,,,,,,fee schedule,33273.91,100101.56,MSDRG Base Rate
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,33593.85,,,,,,,fee schedule,33273.91,100101.56,MSDRG Base Rate
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,33273.91,,,,,,,fee schedule,33273.91,100101.56,MSDRG Base Rate
"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With",458,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,55989.74,,,,,,,fee schedule,33273.91,100101.56,MSDRG Base Rate
Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,51175.82,,,,,,,fee schedule,51175.82,153763.24,
Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,51175.82,,,,,,,fee schedule,51175.82,153763.24,
Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,65248.83,,,,,,,fee schedule,51175.82,153763.24,
Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,114281.16,,,,,,,fee schedule,51175.82,153763.24,
Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,88806.5,,,,,,,fee schedule,51175.82,153763.24,
Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,153763.24,,,,,,,fee schedule,51175.82,153763.24,
Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,105703.87,,,,,,,fee schedule,51175.82,153763.24,
Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,95730.62,,,,,,,fee schedule,51175.82,153763.24,
Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,78407.32,,,,,,,fee schedule,51175.82,153763.24,
Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical With Mcc,459,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,28224.91,,,,,,,fee schedule,28224.91,84804.75,
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,28224.91,,,,,,,fee schedule,28224.91,84804.75,
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,35986.57,,,,,,,fee schedule,28224.91,84804.75,
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,63029.27,,,,,,,fee schedule,28224.91,84804.75,
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,48979.28,,,,,,,fee schedule,28224.91,84804.75,
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,84804.75,,,,,,,fee schedule,28224.91,84804.75,
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,58298.66,,,,,,,fee schedule,28224.91,84804.75,
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,52798.13,,,,,,,fee schedule,28224.91,84804.75,
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,43243.84,,,,,,,fee schedule,28224.91,84804.75,
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Fusion Except Cervical Without Mcc,460,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,47351.7,,,,,,,fee schedule,43723.32,142273.25,
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,47351.7,,,,,,,fee schedule,43723.32,142273.25,
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,63391.74,,,,,,,fee schedule,43723.32,142273.25,
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,60373.1,,,,,,,fee schedule,43723.32,142273.25,
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,105741.48,,,,,,,fee schedule,43723.32,142273.25,
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,82170.41,,,,,,,fee schedule,43723.32,142273.25,
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,142273.25,,,,,,,fee schedule,43723.32,142273.25,
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,97805.13,,,,,,,fee schedule,43723.32,142273.25,
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,88577.13,,,,,,,fee schedule,43723.32,142273.25,
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,72548.31,,,,,,,fee schedule,43723.32,142273.25,
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,44143.73,,,,,,,fee schedule,43723.32,142273.25,MSDRG Base Rate
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,43723.32,,,,,,,fee schedule,43723.32,142273.25,MSDRG Base Rate
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,43723.32,,,,,,,fee schedule,43723.32,142273.25,MSDRG Base Rate
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,44143.73,,,,,,,fee schedule,43723.32,142273.25,MSDRG Base Rate
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,43723.32,,,,,,,fee schedule,43723.32,142273.25,MSDRG Base Rate
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc,461,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,73572.89,,,,,,,fee schedule,43723.32,142273.25,MSDRG Base Rate
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,22095.97,,,,,,,fee schedule,21569.4,66389.7,
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,22095.97,,,,,,,fee schedule,21569.4,66389.7,
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29580.82,,,,,,,fee schedule,21569.4,66389.7,
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28172.21,,,,,,,fee schedule,21569.4,66389.7,
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,49342.69,,,,,,,fee schedule,21569.4,66389.7,
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,38343.6,,,,,,,fee schedule,21569.4,66389.7,
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,66389.7,,,,,,,fee schedule,21569.4,66389.7,
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,45639.31,,,,,,,fee schedule,21569.4,66389.7,
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,41333.2,,,,,,,fee schedule,21569.4,66389.7,
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33853.59,,,,,,,fee schedule,21569.4,66389.7,
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,21776.8,,,,,,,fee schedule,21569.4,66389.7,MSDRG Base Rate
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,21569.4,,,,,,,fee schedule,21569.4,66389.7,MSDRG Base Rate
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,21569.4,,,,,,,fee schedule,21569.4,66389.7,MSDRG Base Rate
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,21776.8,,,,,,,fee schedule,21569.4,66389.7,MSDRG Base Rate
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,21569.4,,,,,,,fee schedule,21569.4,66389.7,MSDRG Base Rate
Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc,462,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,36294.67,,,,,,,fee schedule,21569.4,66389.7,MSDRG Base Rate
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,41672.61,,,,,,,fee schedule,41672.61,125209.83,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,41672.61,,,,,,,fee schedule,41672.61,125209.83,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55788.91,,,,,,,fee schedule,41672.61,125209.83,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,53132.3,,,,,,,fee schedule,41672.61,125209.83,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,93059.46,,,,,,,fee schedule,41672.61,125209.83,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,72315.37,,,,,,,fee schedule,41672.61,125209.83,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,125209.83,,,,,,,fee schedule,41672.61,125209.83,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,86074.95,,,,,,,fee schedule,41672.61,125209.83,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,77953.7,,,,,,,fee schedule,41672.61,125209.83,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,63847.29,,,,,,,fee schedule,41672.61,125209.83,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],100934.43,100934.43,100934.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],38438.84,38438.84,38438.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],40096.3,40096.3,40096.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],39012.4,39012.4,39012.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],73200.57,73200.57,73200.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],38354.34,32950.21,39925.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,45522.61,,,,,,,fee schedule,41672.61,125209.83,MSDRG Base Rate
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,45089.06,,,,,,,fee schedule,41672.61,125209.83,MSDRG Base Rate
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,45089.06,,,,,,,fee schedule,41672.61,125209.83,MSDRG Base Rate
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,45522.61,,,,,,,fee schedule,41672.61,125209.83,MSDRG Base Rate
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,45089.06,,,,,,,fee schedule,41672.61,125209.83,MSDRG Base Rate
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,463,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,75871.02,,,,,,,fee schedule,41672.61,125209.83,MSDRG Base Rate
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,22751.84,,,,,,,fee schedule,22751.84,68360.34,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,22751.84,,,,,,,fee schedule,22751.84,68360.34,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,30458.86,,,,,,,fee schedule,22751.84,68360.34,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29008.44,,,,,,,fee schedule,22751.84,68360.34,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,50807.33,,,,,,,fee schedule,22751.84,68360.34,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,39481.75,,,,,,,fee schedule,22751.84,68360.34,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,68360.34,,,,,,,fee schedule,22751.84,68360.34,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,46994.02,,,,,,,fee schedule,22751.84,68360.34,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,42560.09,,,,,,,fee schedule,22751.84,68360.34,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,34858.47,,,,,,,fee schedule,22751.84,68360.34,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],38773.68,38773.68,38773.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],19691.34,19691.34,19691.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",43006.65,43006.65,43006.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],29008.44,29008.44,29008.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",17176.86,17176.86,17176.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],20092.56,20092.56,20092.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],29914.74,29914.74,29914.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],23230.94,23230.94,23230.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,25329.1,,,,,,,fee schedule,22751.84,68360.34,MSDRG Base Rate
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,25087.87,,,,,,,fee schedule,22751.84,68360.34,MSDRG Base Rate
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,25087.87,,,,,,,fee schedule,22751.84,68360.34,MSDRG Base Rate
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,25329.1,,,,,,,fee schedule,22751.84,68360.34,MSDRG Base Rate
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,25087.87,,,,,,,fee schedule,22751.84,68360.34,MSDRG Base Rate
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,464,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,42215.16,,,,,,,fee schedule,22751.84,68360.34,MSDRG Base Rate
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13394.46,,,,,,,fee schedule,13394.46,40245.11,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,13394.46,,,,,,,fee schedule,13394.46,40245.11,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17931.74,,,,,,,fee schedule,13394.46,40245.11,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17077.85,,,,,,,fee schedule,13394.46,40245.11,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,29911.29,,,,,,,fee schedule,13394.46,40245.11,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,23243.7,,,,,,,fee schedule,13394.46,40245.11,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,40245.11,,,,,,,fee schedule,13394.46,40245.11,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,27666.32,,,,,,,fee schedule,13394.46,40245.11,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,25055.98,,,,,,,fee schedule,13394.46,40245.11,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20521.88,,,,,,,fee schedule,13394.46,40245.11,
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],13286.2,13273.11,13294.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15243.28,,,,,,,fee schedule,13394.46,40245.11,MSDRG Base Rate
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,15098.11,,,,,,,fee schedule,13394.46,40245.11,MSDRG Base Rate
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,15098.11,,,,,,,fee schedule,13394.46,40245.11,MSDRG Base Rate
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,15243.28,,,,,,,fee schedule,13394.46,40245.11,MSDRG Base Rate
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,15098.11,,,,,,,fee schedule,13394.46,40245.11,MSDRG Base Rate
Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit,465,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,25405.47,,,,,,,fee schedule,13394.46,40245.11,MSDRG Base Rate
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,39308.38,,,,,,,fee schedule,39308.38,118106.25,
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,39308.38,,,,,,,fee schedule,39308.38,118106.25,
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,52623.81,,,,,,,fee schedule,39308.38,118106.25,
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,50117.93,,,,,,,fee schedule,39308.38,118106.25,
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,87779.88,,,,,,,fee schedule,39308.38,118106.25,
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,68212.68,,,,,,,fee schedule,39308.38,118106.25,
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,118106.25,,,,,,,fee schedule,39308.38,118106.25,
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,81191.63,,,,,,,fee schedule,39308.38,118106.25,
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,73531.13,,,,,,,fee schedule,39308.38,118106.25,
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,60225.02,,,,,,,fee schedule,39308.38,118106.25,
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],35725.33,35725.33,35725.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],37540.33,37540.33,37540.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],36619.11,36619.11,36619.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,41662.51,,,,,,,fee schedule,39308.38,118106.25,MSDRG Base Rate
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,41265.72,,,,,,,fee schedule,39308.38,118106.25,MSDRG Base Rate
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,41265.72,,,,,,,fee schedule,39308.38,118106.25,MSDRG Base Rate
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,41662.51,,,,,,,fee schedule,39308.38,118106.25,MSDRG Base Rate
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,41265.72,,,,,,,fee schedule,39308.38,118106.25,MSDRG Base Rate
Revision Of Hip Or Knee Replacement With Mcc,466,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,69437.52,,,,,,,fee schedule,39308.38,118106.25,MSDRG Base Rate
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,26427.04,,,,,,,fee schedule,26427.04,79402.88,
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,26427.04,,,,,,,fee schedule,26427.04,79402.88,
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35379.01,,,,,,,fee schedule,26427.04,79402.88,
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,33694.3,,,,,,,fee schedule,26427.04,79402.88,
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,59014.45,,,,,,,fee schedule,26427.04,79402.88,
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,45859.41,,,,,,,fee schedule,26427.04,79402.88,
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,79402.88,,,,,,,fee schedule,26427.04,79402.88,
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,54585.17,,,,,,,fee schedule,26427.04,79402.88,
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,49435.01,,,,,,,fee schedule,26427.04,79402.88,
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,40489.3,,,,,,,fee schedule,26427.04,79402.88,
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],79409.84,79409.84,79409.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],55089.95,55089.95,55089.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],25582.93,25582.93,25582.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],27632.35,27632.35,27632.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],48141.54,48141.54,48141.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",27078.48,27078.48,27078.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],26171.21,24724.86,26533.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],59019.62,59019.62,98751.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],25562.49,19778.06,25912.48,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,28547.03,,,,,,,fee schedule,26427.04,79402.88,MSDRG Base Rate
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,28275.16,,,,,,,fee schedule,26427.04,79402.88,MSDRG Base Rate
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,28275.16,,,,,,,fee schedule,26427.04,79402.88,MSDRG Base Rate
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,28547.03,,,,,,,fee schedule,26427.04,79402.88,MSDRG Base Rate
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,28275.16,,,,,,,fee schedule,26427.04,79402.88,MSDRG Base Rate
Revision Of Hip Or Knee Replacement With Cc,467,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,47578.39,,,,,,,fee schedule,26427.04,79402.88,MSDRG Base Rate
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,20241,,,,,,,fee schedule,20241,60816.27,
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,20241,,,,,,,fee schedule,20241,60816.27,
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,27097.5,,,,,,,fee schedule,20241,60816.27,
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25807.15,,,,,,,fee schedule,20241,60816.27,
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,45200.36,,,,,,,fee schedule,20241,60816.27,
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,35124.65,,,,,,,fee schedule,20241,60816.27,
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,60816.27,,,,,,,fee schedule,20241,60816.27,
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,41807.88,,,,,,,fee schedule,20241,60816.27,
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,37863.27,,,,,,,fee schedule,20241,60816.27,
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,31011.58,,,,,,,fee schedule,20241,60816.27,
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],19854.69,19854.69,19854.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],19739.12,19739.12,19739.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],31182.6,31182.6,31182.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],60698.63,60698.63,60698.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],27098.53,27098.53,27098.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],20257.45,20257.45,20257.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],41897.33,40800.61,45202.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],19708.59,19001.11,21941.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,22464.29,,,,,,,fee schedule,20241,60816.27,MSDRG Base Rate
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,22250.34,,,,,,,fee schedule,20241,60816.27,MSDRG Base Rate
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,22250.34,,,,,,,fee schedule,20241,60816.27,MSDRG Base Rate
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,22464.29,,,,,,,fee schedule,20241,60816.27,MSDRG Base Rate
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,22250.34,,,,,,,fee schedule,20241,60816.27,MSDRG Base Rate
Revision Of Hip Or Knee Replacement Without Cc/Mcc,468,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,37440.48,,,,,,,fee schedule,20241,60816.27,MSDRG Base Rate
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,25220.24,,,,,,,fee schedule,24457.22,75776.9,
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,25220.24,,,,,,,fee schedule,24457.22,75776.9,
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,33763.41,,,,,,,fee schedule,24457.22,75776.9,
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,32155.63,,,,,,,fee schedule,24457.22,75776.9,
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,56319.52,,,,,,,fee schedule,24457.22,75776.9,
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,43765.22,,,,,,,fee schedule,24457.22,75776.9,
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,75776.9,,,,,,,fee schedule,24457.22,75776.9,
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,52092.5,,,,,,,fee schedule,24457.22,75776.9,
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,47177.53,,,,,,,fee schedule,24457.22,75776.9,
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,38640.34,,,,,,,fee schedule,24457.22,75776.9,
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",26225.58,26225.58,26225.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],23304.8,21010.04,24389.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,24692.39,,,,,,,fee schedule,24457.22,75776.9,MSDRG Base Rate
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,24457.22,,,,,,,fee schedule,24457.22,75776.9,MSDRG Base Rate
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,24457.22,,,,,,,fee schedule,24457.22,75776.9,MSDRG Base Rate
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,24692.39,,,,,,,fee schedule,24457.22,75776.9,MSDRG Base Rate
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,24457.22,,,,,,,fee schedule,24457.22,75776.9,MSDRG Base Rate
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl,469,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,41153.98,,,,,,,fee schedule,24457.22,75776.9,MSDRG Base Rate
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14548.8,,,,,,,fee schedule,14548.8,43713.43,
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,14548.8,,,,,,,fee schedule,14548.8,43713.43,
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19477.1,,,,,,,fee schedule,14548.8,43713.43,
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18549.62,,,,,,,fee schedule,14548.8,43713.43,
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,32489.05,,,,,,,fee schedule,14548.8,43713.43,
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,25246.85,,,,,,,fee schedule,14548.8,43713.43,
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,43713.43,,,,,,,fee schedule,14548.8,43713.43,
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,30050.61,,,,,,,fee schedule,14548.8,43713.43,
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,27215.31,,,,,,,fee schedule,14548.8,43713.43,
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22290.46,,,,,,,fee schedule,14548.8,43713.43,
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],58968.79,58968.79,58968.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],28082.29,28082.29,28082.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12758.65,12758.65,12758.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",17836.31,17836.31,17836.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],14558.99,14558.99,14558.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],14316.86,14095.15,14534.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],14373.41,14352.7,23411.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,16065.15,,,,,,,fee schedule,14548.8,43713.43,MSDRG Base Rate
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,15912.15,,,,,,,fee schedule,14548.8,43713.43,MSDRG Base Rate
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,15912.15,,,,,,,fee schedule,14548.8,43713.43,MSDRG Base Rate
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,16065.15,,,,,,,fee schedule,14548.8,43713.43,MSDRG Base Rate
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,15912.15,,,,,,,fee schedule,14548.8,43713.43,MSDRG Base Rate
Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc,470,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,26775.24,,,,,,,fee schedule,14548.8,43713.43,MSDRG Base Rate
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,37477.34,,,,,,,fee schedule,37477.34,112604.69,
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,37477.34,,,,,,,fee schedule,37477.34,112604.69,
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,50172.52,,,,,,,fee schedule,37477.34,112604.69,
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,47783.36,,,,,,,fee schedule,37477.34,112604.69,
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,83690.97,,,,,,,fee schedule,37477.34,112604.69,
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,65035.23,,,,,,,fee schedule,37477.34,112604.69,
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,112604.69,,,,,,,fee schedule,37477.34,112604.69,
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,77409.6,,,,,,,fee schedule,37477.34,112604.69,
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,70105.94,,,,,,,fee schedule,37477.34,112604.69,
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,57419.65,,,,,,,fee schedule,37477.34,112604.69,
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],63490.4,63490.4,63490.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],33767.9,33546.83,37456.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,38719.57,,,,,,,fee schedule,37477.34,112604.69,MSDRG Base Rate
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,38350.81,,,,,,,fee schedule,37477.34,112604.69,MSDRG Base Rate
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,38350.81,,,,,,,fee schedule,37477.34,112604.69,MSDRG Base Rate
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,38719.57,,,,,,,fee schedule,37477.34,112604.69,MSDRG Base Rate
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,38350.81,,,,,,,fee schedule,37477.34,112604.69,MSDRG Base Rate
Cervical Spinal Fusion With Mcc,471,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64532.62,,,,,,,fee schedule,37477.34,112604.69,MSDRG Base Rate
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,22353.69,,,,,,,fee schedule,22353.69,67164.05,
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,22353.69,,,,,,,fee schedule,22353.69,67164.05,
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29925.84,,,,,,,fee schedule,22353.69,67164.05,
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28500.8,,,,,,,fee schedule,22353.69,67164.05,
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,49918.21,,,,,,,fee schedule,22353.69,67164.05,
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,38790.83,,,,,,,fee schedule,22353.69,67164.05,
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,67164.05,,,,,,,fee schedule,22353.69,67164.05,
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,46171.63,,,,,,,fee schedule,22353.69,67164.05,
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,41815.3,,,,,,,fee schedule,22353.69,67164.05,
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,34248.45,,,,,,,fee schedule,22353.69,67164.05,
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],23852.06,23852.06,23852.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],28502.77,28502.77,28502.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",12530.62,12530.62,12530.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],19606.62,12685.16,23262.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],48138.88,48138.88,48138.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,24011.92,,,,,,,fee schedule,22353.69,67164.05,MSDRG Base Rate
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,23783.24,,,,,,,fee schedule,22353.69,67164.05,MSDRG Base Rate
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,23783.24,,,,,,,fee schedule,22353.69,67164.05,MSDRG Base Rate
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,24011.92,,,,,,,fee schedule,22353.69,67164.05,MSDRG Base Rate
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,23783.24,,,,,,,fee schedule,22353.69,67164.05,MSDRG Base Rate
Cervical Spinal Fusion With Cc,472,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,40019.88,,,,,,,fee schedule,22353.69,67164.05,MSDRG Base Rate
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18265.67,,,,,,,fee schedule,18265.67,54881.16,
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,18265.67,,,,,,,fee schedule,18265.67,54881.16,
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24453.03,,,,,,,fee schedule,18265.67,54881.16,
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23288.61,,,,,,,fee schedule,18265.67,54881.16,
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,40789.22,,,,,,,fee schedule,18265.67,54881.16,
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,31696.81,,,,,,,fee schedule,18265.67,54881.16,
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,54881.16,,,,,,,fee schedule,18265.67,54881.16,
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,37727.82,,,,,,,fee schedule,18265.67,54881.16,
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,34168.16,,,,,,,fee schedule,18265.67,54881.16,
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27985.13,,,,,,,fee schedule,18265.67,54881.16,
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],17858.81,17858.81,17858.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],32866.81,32866.81,32866.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],17743.79,17743.79,17743.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],17876.49,17876.49,17876.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,20068.22,,,,,,,fee schedule,18265.67,54881.16,MSDRG Base Rate
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,19877.09,,,,,,,fee schedule,18265.67,54881.16,MSDRG Base Rate
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,19877.09,,,,,,,fee schedule,18265.67,54881.16,MSDRG Base Rate
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,20068.22,,,,,,,fee schedule,18265.67,54881.16,MSDRG Base Rate
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,19877.09,,,,,,,fee schedule,18265.67,54881.16,MSDRG Base Rate
Cervical Spinal Fusion Without Cc/Mcc,473,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,33447.03,,,,,,,fee schedule,18265.67,54881.16,MSDRG Base Rate
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,34602.3,,,,,,,fee schedule,34204.79,103966.33,
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,34602.3,,,,,,,fee schedule,34204.79,103966.33,
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46323.58,,,,,,,fee schedule,34204.79,103966.33,
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,44117.71,,,,,,,fee schedule,34204.79,103966.33,
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,77270.7,,,,,,,fee schedule,34204.79,103966.33,
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,60046.12,,,,,,,fee schedule,34204.79,103966.33,
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,103966.33,,,,,,,fee schedule,34204.79,103966.33,
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,71471.2,,,,,,,fee schedule,34204.79,103966.33,
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,64727.83,,,,,,,fee schedule,34204.79,103966.33,
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,53014.76,,,,,,,fee schedule,34204.79,103966.33,
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],31999.3,31999.3,31999.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",23442.16,23442.16,23442.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",22015.25,22015.25,22015.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],34042.41,34042.41,34042.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],31660.15,31660.15,31660.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],31474.81,31304.36,31529.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,34533.68,,,,,,,fee schedule,34204.79,103966.33,MSDRG Base Rate
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,34204.79,,,,,,,fee schedule,34204.79,103966.33,MSDRG Base Rate
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,34204.79,,,,,,,fee schedule,34204.79,103966.33,MSDRG Base Rate
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,34533.68,,,,,,,fee schedule,34204.79,103966.33,MSDRG Base Rate
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,34204.79,,,,,,,fee schedule,34204.79,103966.33,MSDRG Base Rate
Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc,474,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,57556.14,,,,,,,fee schedule,34204.79,103966.33,MSDRG Base Rate
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16644.51,,,,,,,fee schedule,16644.51,50010.21,
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,16644.51,,,,,,,fee schedule,16644.51,50010.21,
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22282.71,,,,,,,fee schedule,16644.51,50010.21,
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21221.64,,,,,,,fee schedule,16644.51,50010.21,
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,37168.99,,,,,,,fee schedule,16644.51,50010.21,
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,28883.57,,,,,,,fee schedule,16644.51,50010.21,
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,50010.21,,,,,,,fee schedule,16644.51,50010.21,
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,34379.3,,,,,,,fee schedule,16644.51,50010.21,
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,31135.58,,,,,,,fee schedule,16644.51,50010.21,
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,25501.32,,,,,,,fee schedule,16644.51,50010.21,
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],14503.61,14503.61,14503.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],15718.14,15718.14,16468.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",11169.59,11169.59,11169.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],16342.31,16342.31,16342.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],25503.69,25503.69,25503.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,18774.49,,,,,,,fee schedule,16644.51,50010.21,MSDRG Base Rate
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,18595.69,,,,,,,fee schedule,16644.51,50010.21,MSDRG Base Rate
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,18595.69,,,,,,,fee schedule,16644.51,50010.21,MSDRG Base Rate
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,18774.49,,,,,,,fee schedule,16644.51,50010.21,MSDRG Base Rate
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,18595.69,,,,,,,fee schedule,16644.51,50010.21,MSDRG Base Rate
Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc,475,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31290.82,,,,,,,fee schedule,16644.51,50010.21,MSDRG Base Rate
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8973.88,,,,,,,fee schedule,8973.88,26962.99,
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,8973.88,,,,,,,fee schedule,8973.88,26962.99,
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12013.72,,,,,,,fee schedule,8973.88,26962.99,
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11441.64,,,,,,,fee schedule,8973.88,26962.99,
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,20039.65,,,,,,,fee schedule,8973.88,26962.99,
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,15572.57,,,,,,,fee schedule,8973.88,26962.99,
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,26962.99,,,,,,,fee schedule,8973.88,26962.99,
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,18535.59,,,,,,,fee schedule,8973.88,26962.99,
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,16786.74,,,,,,,fee schedule,8973.88,26962.99,
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13749.03,,,,,,,fee schedule,8973.88,26962.99,
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10216,,,,,,,fee schedule,8973.88,26962.99,MSDRG Base Rate
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,10118.7,,,,,,,fee schedule,8973.88,26962.99,MSDRG Base Rate
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,10118.7,,,,,,,fee schedule,8973.88,26962.99,MSDRG Base Rate
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,10216,,,,,,,fee schedule,8973.88,26962.99,MSDRG Base Rate
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,10118.7,,,,,,,fee schedule,8973.88,26962.99,MSDRG Base Rate
Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc,476,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,17026.66,,,,,,,fee schedule,8973.88,26962.99,MSDRG Base Rate
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,26534.3,,,,,,,fee schedule,26534.3,79725.14,
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,26534.3,,,,,,,fee schedule,26534.3,79725.14,
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35522.6,,,,,,,fee schedule,26534.3,79725.14,
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,33831.05,,,,,,,fee schedule,26534.3,79725.14,
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,59253.96,,,,,,,fee schedule,26534.3,79725.14,
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,46045.53,,,,,,,fee schedule,26534.3,79725.14,
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,79725.14,,,,,,,fee schedule,26534.3,79725.14,
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,54806.7,,,,,,,fee schedule,26534.3,79725.14,
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,49635.64,,,,,,,fee schedule,26534.3,79725.14,
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,40653.63,,,,,,,fee schedule,26534.3,79725.14,
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],25782.8,25782.8,25782.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",16288.28,16288.28,16288.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],24409.17,24409.17,24409.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],40656,40656,40656,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],17767.12,17767.12,17767.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,27984.54,,,,,,,fee schedule,26534.3,79725.14,MSDRG Base Rate
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,27718.02,,,,,,,fee schedule,26534.3,79725.14,MSDRG Base Rate
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,27718.02,,,,,,,fee schedule,26534.3,79725.14,MSDRG Base Rate
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,27984.54,,,,,,,fee schedule,26534.3,79725.14,MSDRG Base Rate
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,27718.02,,,,,,,fee schedule,26534.3,79725.14,MSDRG Base Rate
Biopsies Of Musculoskeletal System And Connective Tissue With Mcc,477,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,46640.9,,,,,,,fee schedule,26534.3,79725.14,MSDRG Base Rate
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18043.45,,,,,,,fee schedule,18043.45,54213.47,
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,18043.45,,,,,,,fee schedule,18043.45,54213.47,
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24155.53,,,,,,,fee schedule,18043.45,54213.47,
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23005.27,,,,,,,fee schedule,18043.45,54213.47,
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,40292.97,,,,,,,fee schedule,18043.45,54213.47,
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,31311.18,,,,,,,fee schedule,18043.45,54213.47,
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,54213.47,,,,,,,fee schedule,18043.45,54213.47,
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,37268.81,,,,,,,fee schedule,18043.45,54213.47,
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,33752.47,,,,,,,fee schedule,18043.45,54213.47,
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27644.66,,,,,,,fee schedule,18043.45,54213.47,
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],17658.59,17658.59,17658.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],35408.39,35408.39,35408.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",11924.48,11924.48,11924.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],17684.09,17526.38,18036.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],39306.95,39306.95,39306.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],17053.61,15708.44,17699.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,20208.07,,,,,,,fee schedule,18043.45,54213.47,MSDRG Base Rate
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,20015.61,,,,,,,fee schedule,18043.45,54213.47,MSDRG Base Rate
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,20015.61,,,,,,,fee schedule,18043.45,54213.47,MSDRG Base Rate
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,20208.07,,,,,,,fee schedule,18043.45,54213.47,MSDRG Base Rate
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,20015.61,,,,,,,fee schedule,18043.45,54213.47,MSDRG Base Rate
Biopsies Of Musculoskeletal System And Connective Tissue With Cc,478,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,33680.12,,,,,,,fee schedule,18043.45,54213.47,MSDRG Base Rate
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13701.57,,,,,,,fee schedule,13701.57,41167.83,
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,13701.57,,,,,,,fee schedule,13701.57,41167.83,
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18342.87,,,,,,,fee schedule,13701.57,41167.83,
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17469.41,,,,,,,fee schedule,13701.57,41167.83,
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,30597.09,,,,,,,fee schedule,13701.57,41167.83,
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,23776.62,,,,,,,fee schedule,13701.57,41167.83,
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,41167.83,,,,,,,fee schedule,13701.57,41167.83,
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,28300.64,,,,,,,fee schedule,13701.57,41167.83,
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,25630.45,,,,,,,fee schedule,13701.57,41167.83,
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20992.4,,,,,,,fee schedule,13701.57,41167.83,
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],13191.96,13191.96,13789.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15518.28,,,,,,,fee schedule,13701.57,41167.83,MSDRG Base Rate
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,15370.48,,,,,,,fee schedule,13701.57,41167.83,MSDRG Base Rate
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,15370.48,,,,,,,fee schedule,13701.57,41167.83,MSDRG Base Rate
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,15518.28,,,,,,,fee schedule,13701.57,41167.83,MSDRG Base Rate
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,15370.48,,,,,,,fee schedule,13701.57,41167.83,MSDRG Base Rate
Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc,479,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,25863.79,,,,,,,fee schedule,13701.57,41167.83,MSDRG Base Rate
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,22693.2,,,,,,,fee schedule,22693.2,68184.14,
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,22693.2,,,,,,,fee schedule,22693.2,68184.14,
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,30380.35,,,,,,,fee schedule,22693.2,68184.14,
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28933.68,,,,,,,fee schedule,22693.2,68184.14,
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,50676.37,,,,,,,fee schedule,22693.2,68184.14,
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,39379.99,,,,,,,fee schedule,22693.2,68184.14,
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,68184.14,,,,,,,fee schedule,22693.2,68184.14,
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,46872.89,,,,,,,fee schedule,22693.2,68184.14,
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,42450.39,,,,,,,fee schedule,22693.2,68184.14,
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,34768.62,,,,,,,fee schedule,22693.2,68184.14,
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],22254.25,22254.25,22254.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],34915.64,34915.64,34915.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],19867.09,15272.59,22051.05,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],19539.5,19539.5,23846.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],41.98,41.98,41.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],20635.71,20635.71,20635.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",18305.31,18305.31,18305.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],21878.68,21652.36,22519.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],67549.84,67549.84,67549.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],22006.65,19912.27,22067.15,22,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],20980.09,20980.09,20980.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,23747.87,,,,,,,fee schedule,22693.2,68184.14,MSDRG Base Rate
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,23521.7,,,,,,,fee schedule,22693.2,68184.14,MSDRG Base Rate
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,23521.7,,,,,,,fee schedule,22693.2,68184.14,MSDRG Base Rate
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,23747.87,,,,,,,fee schedule,22693.2,68184.14,MSDRG Base Rate
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,23521.7,,,,,,,fee schedule,22693.2,68184.14,MSDRG Base Rate
Hip And Femur Procedures Except Major Joint With Mcc,480,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,39579.79,,,,,,,fee schedule,22693.2,68184.14,MSDRG Base Rate
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16010.24,,,,,,,fee schedule,16010.24,48104.48,
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,16010.24,,,,,,,fee schedule,16010.24,48104.48,
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21433.59,,,,,,,fee schedule,16010.24,48104.48,
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20412.95,,,,,,,fee schedule,16010.24,48104.48,
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,35752.6,,,,,,,fee schedule,16010.24,48104.48,
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,27782.91,,,,,,,fee schedule,16010.24,48104.48,
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,48104.48,,,,,,,fee schedule,16010.24,48104.48,
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,33069.22,,,,,,,fee schedule,16010.24,48104.48,
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,29949.11,,,,,,,fee schedule,16010.24,48104.48,
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24529.55,,,,,,,fee schedule,16010.24,48104.48,
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],15569.85,15569.85,15569.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],31566.71,31566.71,33069.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],15141.7,15058.38,16552.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],15258.26,15258.26,15258.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],20412.95,20412.95,20412.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],15570.78,15570.78,15570.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",13296.25,13296.25,13296.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],15496.98,13675.28,15977.57,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],32036.07,30064.69,35752.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],14890.81,12334.95,15878.64,27,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",13864.57,13864.57,13864.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,17358.88,,,,,,,fee schedule,16010.24,48104.48,MSDRG Base Rate
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,17193.56,,,,,,,fee schedule,16010.24,48104.48,MSDRG Base Rate
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,17193.56,,,,,,,fee schedule,16010.24,48104.48,MSDRG Base Rate
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,17358.88,,,,,,,fee schedule,16010.24,48104.48,MSDRG Base Rate
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,17193.56,,,,,,,fee schedule,16010.24,48104.48,MSDRG Base Rate
Hip And Femur Procedures Except Major Joint With Cc,481,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,28931.47,,,,,,,fee schedule,16010.24,48104.48,MSDRG Base Rate
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12240.9,,,,,,,fee schedule,12240.9,36779.1,
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,12240.9,,,,,,,fee schedule,12240.9,36779.1,
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16387.42,,,,,,,fee schedule,12240.9,36779.1,
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15607.07,,,,,,,fee schedule,12240.9,36779.1,
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,27335.26,,,,,,,fee schedule,12240.9,36779.1,
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,21241.9,,,,,,,fee schedule,12240.9,36779.1,
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,36779.1,,,,,,,fee schedule,12240.9,36779.1,
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,25283.63,,,,,,,fee schedule,12240.9,36779.1,
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,22898.1,,,,,,,fee schedule,12240.9,36779.1,
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18754.48,,,,,,,fee schedule,12240.9,36779.1,
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],12059.32,12059.32,12059.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11744.72,11715.72,11773.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],23854.32,23854.32,23854.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12685.48,12685.48,12685.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],25645.74,25645.74,25645.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11856.42,10860.04,12222.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],18698.08,18698.08,18698.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],26616.62,26616.62,26616.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],12002.66,11497.01,12325.28,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13737.83,,,,,,,fee schedule,12240.9,36779.1,MSDRG Base Rate
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,13607,,,,,,,fee schedule,12240.9,36779.1,MSDRG Base Rate
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,13607,,,,,,,fee schedule,12240.9,36779.1,MSDRG Base Rate
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,13737.83,,,,,,,fee schedule,12240.9,36779.1,MSDRG Base Rate
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,13607,,,,,,,fee schedule,12240.9,36779.1,MSDRG Base Rate
Hip And Femur Procedures Except Major Joint Without Cc/Mcc,482,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22896.39,,,,,,,fee schedule,12240.9,36779.1,MSDRG Base Rate
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,19661.52,,,,,,,fee schedule,19661.52,59075.15,
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,19661.52,,,,,,,fee schedule,19661.52,59075.15,
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26321.72,,,,,,,fee schedule,19661.52,59075.15,
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25068.31,,,,,,,fee schedule,19661.52,59075.15,
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,43906.31,,,,,,,fee schedule,19661.52,59075.15,
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,34119.06,,,,,,,fee schedule,19661.52,59075.15,
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,59075.15,,,,,,,fee schedule,19661.52,59075.15,
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,40610.96,,,,,,,fee schedule,19661.52,59075.15,
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,36779.28,,,,,,,fee schedule,19661.52,59075.15,
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30123.74,,,,,,,fee schedule,19661.52,59075.15,
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],20577.68,20577.68,20577.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],24319.29,24319.29,24319.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",11138.64,11138.64,11138.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],42753.7,42753.7,42753.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],19163.56,19163.56,19163.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,22651.01,,,,,,,fee schedule,19661.52,59075.15,MSDRG Base Rate
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,22435.29,,,,,,,fee schedule,19661.52,59075.15,MSDRG Base Rate
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,22435.29,,,,,,,fee schedule,19661.52,59075.15,MSDRG Base Rate
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,22651.01,,,,,,,fee schedule,19661.52,59075.15,MSDRG Base Rate
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,22435.29,,,,,,,fee schedule,19661.52,59075.15,MSDRG Base Rate
Major Joint Or Limb Reattachment Procedures Of Upper Extremities,483,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,37751.68,,,,,,,fee schedule,19661.52,59075.15,MSDRG Base Rate
Major joint & limb reattachment proc of upper extremity w/o CC/MCC,484,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major joint & limb reattachment proc of upper extremity w/o CC/MCC,484,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Major joint & limb reattachment proc of upper extremity w/o CC/MCC,484,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Major joint & limb reattachment proc of upper extremity w/o CC/MCC,484,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major joint & limb reattachment proc of upper extremity w/o CC/MCC,484,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major joint & limb reattachment proc of upper extremity w/o CC/MCC,484,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Major joint & limb reattachment proc of upper extremity w/o CC/MCC,484,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major joint & limb reattachment proc of upper extremity w/o CC/MCC,484,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major joint & limb reattachment proc of upper extremity w/o CC/MCC,484,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Major joint & limb reattachment proc of upper extremity w/o CC/MCC,484,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Major joint & limb reattachment proc of upper extremity w/o CC/MCC,484,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major joint & limb reattachment proc of upper extremity w/o CC/MCC,484,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major joint & limb reattachment proc of upper extremity w/o CC/MCC,484,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Major joint & limb reattachment proc of upper extremity w/o CC/MCC,484,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Major joint & limb reattachment proc of upper extremity w/o CC/MCC,484,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major joint & limb reattachment proc of upper extremity w/o CC/MCC,484,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major joint & limb reattachment proc of upper extremity w/o CC/MCC,484,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major joint & limb reattachment proc of upper extremity w/o CC/MCC,484,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,24873.78,,,,,,,fee schedule,24873.78,74735.94,
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,24873.78,,,,,,,fee schedule,24873.78,74735.94,
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,33299.59,,,,,,,fee schedule,24873.78,74735.94,
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,31713.91,,,,,,,fee schedule,24873.78,74735.94,
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,55545.85,,,,,,,fee schedule,24873.78,74735.94,
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,43164,,,,,,,fee schedule,24873.78,74735.94,
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,74735.94,,,,,,,fee schedule,24873.78,74735.94,
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,51376.9,,,,,,,fee schedule,24873.78,74735.94,
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,46529.44,,,,,,,fee schedule,24873.78,74735.94,
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,38109.53,,,,,,,fee schedule,24873.78,74735.94,
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],23170.24,23170.24,23170.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],23708.77,23708.77,23708.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],26094.02,26094.02,26094.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],36545.23,36545.23,36545.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,26207.21,,,,,,,fee schedule,24873.78,74735.94,MSDRG Base Rate
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,25957.62,,,,,,,fee schedule,24873.78,74735.94,MSDRG Base Rate
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,25957.62,,,,,,,fee schedule,24873.78,74735.94,MSDRG Base Rate
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,26207.21,,,,,,,fee schedule,24873.78,74735.94,MSDRG Base Rate
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,25957.62,,,,,,,fee schedule,24873.78,74735.94,MSDRG Base Rate
Knee Procedures With Principal Diagnosis Of Infection With Mcc,485,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,43678.69,,,,,,,fee schedule,24873.78,74735.94,MSDRG Base Rate
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16363.64,,,,,,,fee schedule,16363.64,49166.31,
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,16363.64,,,,,,,fee schedule,16363.64,49166.31,
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21906.7,,,,,,,fee schedule,16363.64,49166.31,
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20863.53,,,,,,,fee schedule,16363.64,49166.31,
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,36541.78,,,,,,,fee schedule,16363.64,49166.31,
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,28396.17,,,,,,,fee schedule,16363.64,49166.31,
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,49166.31,,,,,,,fee schedule,16363.64,49166.31,
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,33799.17,,,,,,,fee schedule,16363.64,49166.31,
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,30610.18,,,,,,,fee schedule,16363.64,49166.31,
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,25071,,,,,,,fee schedule,16363.64,49166.31,
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],52675.64,52675.64,52675.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],16123.11,16123.11,16123.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],31584.57,31584.57,33802.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],20865.5,20865.5,20865.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",12026.79,12026.79,12026.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],15614.58,15614.58,15614.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],14743.8,14743.8,15713.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,17332.32,,,,,,,fee schedule,16363.64,49166.31,MSDRG Base Rate
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,17167.25,,,,,,,fee schedule,16363.64,49166.31,MSDRG Base Rate
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,17167.25,,,,,,,fee schedule,16363.64,49166.31,MSDRG Base Rate
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,17332.32,,,,,,,fee schedule,16363.64,49166.31,MSDRG Base Rate
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,17167.25,,,,,,,fee schedule,16363.64,49166.31,MSDRG Base Rate
Knee Procedures With Principal Diagnosis Of Infection With Cc,486,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,28887.2,,,,,,,fee schedule,16363.64,49166.31,MSDRG Base Rate
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12192.29,,,,,,,fee schedule,12192.29,36633.04,
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,12192.29,,,,,,,fee schedule,12192.29,36633.04,
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16322.34,,,,,,,fee schedule,12192.29,36633.04,
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15545.09,,,,,,,fee schedule,12192.29,36633.04,
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,27226.7,,,,,,,fee schedule,12192.29,36633.04,
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,21157.54,,,,,,,fee schedule,12192.29,36633.04,
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,36633.04,,,,,,,fee schedule,12192.29,36633.04,
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,25183.22,,,,,,,fee schedule,12192.29,36633.04,
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,22807.16,,,,,,,fee schedule,12192.29,36633.04,
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18680.01,,,,,,,fee schedule,12192.29,36633.04,
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],35743.92,35743.92,35743.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],25184.82,25184.82,25184.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13231.59,,,,,,,fee schedule,12192.29,36633.04,MSDRG Base Rate
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,13105.57,,,,,,,fee schedule,12192.29,36633.04,MSDRG Base Rate
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,13105.57,,,,,,,fee schedule,12192.29,36633.04,MSDRG Base Rate
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,13231.59,,,,,,,fee schedule,12192.29,36633.04,MSDRG Base Rate
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,13105.57,,,,,,,fee schedule,12192.29,36633.04,MSDRG Base Rate
Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc,487,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22052.64,,,,,,,fee schedule,12192.29,36633.04,MSDRG Base Rate
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,15164.55,,,,,,,fee schedule,14674.07,45563.52,
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,15164.55,,,,,,,fee schedule,14674.07,45563.52,
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20301.43,,,,,,,fee schedule,14674.07,45563.52,
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19334.7,,,,,,,fee schedule,14674.07,45563.52,
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,33864.08,,,,,,,fee schedule,14674.07,45563.52,
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,26315.37,,,,,,,fee schedule,14674.07,45563.52,
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,45563.52,,,,,,,fee schedule,14674.07,45563.52,
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,31322.44,,,,,,,fee schedule,14674.07,45563.52,
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,28367.14,,,,,,,fee schedule,14674.07,45563.52,
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23233.86,,,,,,,fee schedule,14674.07,45563.52,
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],31324.03,31324.03,31324.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",9559.23,9559.23,9559.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13246.13,13246.13,13246.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],40901.08,40901.08,40901.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14815.16,,,,,,,fee schedule,14674.07,45563.52,MSDRG Base Rate
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,14674.07,,,,,,,fee schedule,14674.07,45563.52,MSDRG Base Rate
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,14674.07,,,,,,,fee schedule,14674.07,45563.52,MSDRG Base Rate
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,14815.16,,,,,,,fee schedule,14674.07,45563.52,MSDRG Base Rate
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,14674.07,,,,,,,fee schedule,14674.07,45563.52,MSDRG Base Rate
Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc,488,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,24691.94,,,,,,,fee schedule,14674.07,45563.52,MSDRG Base Rate
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9557.22,,,,,,,fee schedule,9557.22,28715.7,
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,9557.22,,,,,,,fee schedule,9557.22,28715.7,
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12794.66,,,,,,,fee schedule,9557.22,28715.7,
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12185.4,,,,,,,fee schedule,9557.22,28715.7,
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,21342.32,,,,,,,fee schedule,9557.22,28715.7,
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,16584.85,,,,,,,fee schedule,9557.22,28715.7,
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,28715.7,,,,,,,fee schedule,9557.22,28715.7,
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,19740.48,,,,,,,fee schedule,9557.22,28715.7,
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,17877.95,,,,,,,fee schedule,9557.22,28715.7,
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14642.78,,,,,,,fee schedule,9557.22,28715.7,
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9701.82,9701.82,9701.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],17875.07,17875.07,17875.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9552.62,9552.62,9552.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],9674.42,9674.42,9674.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9720.69,,,,,,,fee schedule,9557.22,28715.7,MSDRG Base Rate
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,9628.11,,,,,,,fee schedule,9557.22,28715.7,MSDRG Base Rate
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,9628.11,,,,,,,fee schedule,9557.22,28715.7,MSDRG Base Rate
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,9720.69,,,,,,,fee schedule,9557.22,28715.7,MSDRG Base Rate
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,9628.11,,,,,,,fee schedule,9557.22,28715.7,MSDRG Base Rate
Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc,489,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16201.15,,,,,,,fee schedule,9557.22,28715.7,MSDRG Base Rate
Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim,490,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim,490,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim,490,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim,490,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim,490,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim,490,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim,490,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim,490,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim,490,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim,490,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim,490,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim,490,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim,490,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim,490,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim,490,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim,490,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim,490,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim,490,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back & neck proc exc spinal fusion w/o CC/MCC,491,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back & neck proc exc spinal fusion w/o CC/MCC,491,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Back & neck proc exc spinal fusion w/o CC/MCC,491,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Back & neck proc exc spinal fusion w/o CC/MCC,491,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back & neck proc exc spinal fusion w/o CC/MCC,491,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back & neck proc exc spinal fusion w/o CC/MCC,491,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Back & neck proc exc spinal fusion w/o CC/MCC,491,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Back & neck proc exc spinal fusion w/o CC/MCC,491,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Back & neck proc exc spinal fusion w/o CC/MCC,491,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Back & neck proc exc spinal fusion w/o CC/MCC,491,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Back & neck proc exc spinal fusion w/o CC/MCC,491,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back & neck proc exc spinal fusion w/o CC/MCC,491,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back & neck proc exc spinal fusion w/o CC/MCC,491,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Back & neck proc exc spinal fusion w/o CC/MCC,491,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Back & neck proc exc spinal fusion w/o CC/MCC,491,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back & neck proc exc spinal fusion w/o CC/MCC,491,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Back & neck proc exc spinal fusion w/o CC/MCC,491,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back & neck proc exc spinal fusion w/o CC/MCC,491,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,27400.05,,,,,,,fee schedule,27400.05,82326.38,
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,27400.05,,,,,,,fee schedule,27400.05,82326.38,
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36681.62,,,,,,,fee schedule,27400.05,82326.38,
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,34934.88,,,,,,,fee schedule,27400.05,82326.38,
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,61187.28,,,,,,,fee schedule,27400.05,82326.38,
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,47547.89,,,,,,,fee schedule,27400.05,82326.38,
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,82326.38,,,,,,,fee schedule,27400.05,82326.38,
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,56594.91,,,,,,,fee schedule,27400.05,82326.38,
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,51255.13,,,,,,,fee schedule,27400.05,82326.38,
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41980.06,,,,,,,fee schedule,27400.05,82326.38,
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],55391.9,55391.9,55391.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],25420.03,25420.03,25420.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",11178.62,11178.62,11178.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],25300.05,25300.05,26902.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],41371.63,41371.63,41371.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],26531.03,26531.03,26531.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,29679.84,,,,,,,fee schedule,27400.05,82326.38,MSDRG Base Rate
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,29397.17,,,,,,,fee schedule,27400.05,82326.38,MSDRG Base Rate
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,29397.17,,,,,,,fee schedule,27400.05,82326.38,MSDRG Base Rate
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,29679.84,,,,,,,fee schedule,27400.05,82326.38,MSDRG Base Rate
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,29397.17,,,,,,,fee schedule,27400.05,82326.38,MSDRG Base Rate
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc",492,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,49466.39,,,,,,,fee schedule,27400.05,82326.38,MSDRG Base Rate
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18526.48,,,,,,,fee schedule,18526.48,55664.78,
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,18526.48,,,,,,,fee schedule,18526.48,55664.78,
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24802.19,,,,,,,fee schedule,18526.48,55664.78,
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23621.13,,,,,,,fee schedule,18526.48,55664.78,
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,41371.63,,,,,,,fee schedule,18526.48,55664.78,
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,32149.39,,,,,,,fee schedule,18526.48,55664.78,
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,55664.78,,,,,,,fee schedule,18526.48,55664.78,
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,38266.51,,,,,,,fee schedule,18526.48,55664.78,
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,34656.03,,,,,,,fee schedule,18526.48,55664.78,
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,28384.72,,,,,,,fee schedule,18526.48,55664.78,
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],18173.97,18173.97,18173.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],17417.4,17402.61,25171.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],36927.83,36927.83,36927.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",8425.16,8425.16,8425.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",7912.33,7912.33,7912.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],23482.33,23482.33,23482.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],17266.75,16545.95,18538,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],41371.63,41371.63,41371.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],18127.74,17303.79,20246.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,20808.84,,,,,,,fee schedule,18526.48,55664.78,MSDRG Base Rate
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,20610.66,,,,,,,fee schedule,18526.48,55664.78,MSDRG Base Rate
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,20610.66,,,,,,,fee schedule,18526.48,55664.78,MSDRG Base Rate
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,20808.84,,,,,,,fee schedule,18526.48,55664.78,MSDRG Base Rate
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,20610.66,,,,,,,fee schedule,18526.48,55664.78,MSDRG Base Rate
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc",493,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,34681.39,,,,,,,fee schedule,18526.48,55664.78,MSDRG Base Rate
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14548.8,,,,,,,fee schedule,14548.8,43713.43,
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,14548.8,,,,,,,fee schedule,14548.8,43713.43,
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19477.1,,,,,,,fee schedule,14548.8,43713.43,
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18549.62,,,,,,,fee schedule,14548.8,43713.43,
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,32489.05,,,,,,,fee schedule,14548.8,43713.43,
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,25246.85,,,,,,,fee schedule,14548.8,43713.43,
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,43713.43,,,,,,,fee schedule,14548.8,43713.43,
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,30050.61,,,,,,,fee schedule,14548.8,43713.43,
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,27215.31,,,,,,,fee schedule,14548.8,43713.43,
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22290.46,,,,,,,fee schedule,14548.8,43713.43,
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7309.05,7309.05,7309.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],19903.16,19903.16,19903.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],27213.86,27213.86,27213.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],18546.64,18546.64,18546.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],19481.24,19481.24,19481.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],14379.68,14379.68,14379.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",6683.57,6683.57,6683.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,16671.39,,,,,,,fee schedule,14548.8,43713.43,MSDRG Base Rate
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,16512.61,,,,,,,fee schedule,14548.8,43713.43,MSDRG Base Rate
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,16512.61,,,,,,,fee schedule,14548.8,43713.43,MSDRG Base Rate
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,16671.39,,,,,,,fee schedule,14548.8,43713.43,MSDRG Base Rate
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,16512.61,,,,,,,fee schedule,14548.8,43713.43,MSDRG Base Rate
"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc",494,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,27785.64,,,,,,,fee schedule,14548.8,43713.43,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,27163.16,,,,,,,fee schedule,27163.16,81614.64,
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,27163.16,,,,,,,fee schedule,27163.16,81614.64,
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36364.49,,,,,,,fee schedule,27163.16,81614.64,
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,34632.85,,,,,,,fee schedule,27163.16,81614.64,
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,60658.29,,,,,,,fee schedule,27163.16,81614.64,
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,47136.82,,,,,,,fee schedule,27163.16,81614.64,
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,81614.64,,,,,,,fee schedule,27163.16,81614.64,
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,56105.63,,,,,,,fee schedule,27163.16,81614.64,
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,50812.01,,,,,,,fee schedule,27163.16,81614.64,
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41617.13,,,,,,,fee schedule,27163.16,81614.64,
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],23755.23,23755.23,23755.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",20711.4,20711.4,20711.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],306.9,306.9,306.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,29321.24,,,,,,,fee schedule,27163.16,81614.64,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,29041.99,,,,,,,fee schedule,27163.16,81614.64,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,29041.99,,,,,,,fee schedule,27163.16,81614.64,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,29321.24,,,,,,,fee schedule,27163.16,81614.64,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,29041.99,,,,,,,fee schedule,27163.16,81614.64,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc,495,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,48868.73,,,,,,,fee schedule,27163.16,81614.64,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,15223.19,,,,,,,fee schedule,14944.89,45739.71,
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,15223.19,,,,,,,fee schedule,14944.89,45739.71,
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20379.94,,,,,,,fee schedule,14944.89,45739.71,
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19409.47,,,,,,,fee schedule,14944.89,45739.71,
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,33995.04,,,,,,,fee schedule,14944.89,45739.71,
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,26417.13,,,,,,,fee schedule,14944.89,45739.71,
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,45739.71,,,,,,,fee schedule,14944.89,45739.71,
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,31443.57,,,,,,,fee schedule,14944.89,45739.71,
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,28476.84,,,,,,,fee schedule,14944.89,45739.71,
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23323.7,,,,,,,fee schedule,14944.89,45739.71,
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],19410.45,19410.45,19410.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],31083,31083,31083,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],14981.8,14981.8,14981.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15088.59,,,,,,,fee schedule,14944.89,45739.71,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,14944.89,,,,,,,fee schedule,14944.89,45739.71,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,14944.89,,,,,,,fee schedule,14944.89,45739.71,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,15088.59,,,,,,,fee schedule,14944.89,45739.71,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,14944.89,,,,,,,fee schedule,14944.89,45739.71,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc,496,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,25147.66,,,,,,,fee schedule,14944.89,45739.71,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10362.79,,,,,,,fee schedule,10336.13,31136.11,
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,10362.79,,,,,,,fee schedule,10336.13,31136.11,
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13873.11,,,,,,,fee schedule,10336.13,31136.11,
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13212.49,,,,,,,fee schedule,10336.13,31136.11,
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,23141.23,,,,,,,fee schedule,10336.13,31136.11,
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,17982.77,,,,,,,fee schedule,10336.13,31136.11,
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,31136.11,,,,,,,fee schedule,10336.13,31136.11,
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,21404.38,,,,,,,fee schedule,10336.13,31136.11,
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,19384.86,,,,,,,fee schedule,10336.13,31136.11,
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15877,,,,,,,fee schedule,10336.13,31136.11,
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],168.16,168.16,168.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10435.52,,,,,,,fee schedule,10336.13,31136.11,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,10336.13,,,,,,,fee schedule,10336.13,31136.11,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,10336.13,,,,,,,fee schedule,10336.13,31136.11,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,10435.52,,,,,,,fee schedule,10336.13,31136.11,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,10336.13,,,,,,,fee schedule,10336.13,31136.11,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc,497,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,17392.53,,,,,,,fee schedule,10336.13,31136.11,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,19480.96,,,,,,,fee schedule,19480.96,58532.64,
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,19480.96,,,,,,,fee schedule,19480.96,58532.64,
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26080,,,,,,,fee schedule,19480.96,58532.64,
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24838.1,,,,,,,fee schedule,19480.96,58532.64,
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,43503.11,,,,,,,fee schedule,19480.96,58532.64,
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,33805.73,,,,,,,fee schedule,19480.96,58532.64,
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,58532.64,,,,,,,fee schedule,19480.96,58532.64,
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,40238.01,,,,,,,fee schedule,19480.96,58532.64,
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,36441.52,,,,,,,fee schedule,19480.96,58532.64,
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,29847.1,,,,,,,fee schedule,19480.96,58532.64,
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",5833.82,5833.82,5833.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,24564.27,,,,,,,fee schedule,19480.96,58532.64,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,24330.32,,,,,,,fee schedule,19480.96,58532.64,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,24330.32,,,,,,,fee schedule,19480.96,58532.64,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,24564.27,,,,,,,fee schedule,19480.96,58532.64,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,24330.32,,,,,,,fee schedule,19480.96,58532.64,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc,498,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,40940.44,,,,,,,fee schedule,19480.96,58532.64,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8956.91,,,,,,,fee schedule,8956.91,27893.72,
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,8956.91,,,,,,,fee schedule,8956.91,27893.72,
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11990.99,,,,,,,fee schedule,8956.91,27893.72,
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11420,,,,,,,fee schedule,8956.91,27893.72,
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,20001.74,,,,,,,fee schedule,8956.91,27893.72,
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,15543.11,,,,,,,fee schedule,8956.91,27893.72,
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,26911.99,,,,,,,fee schedule,8956.91,27893.72,
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,18500.53,,,,,,,fee schedule,8956.91,27893.72,
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,16754.99,,,,,,,fee schedule,8956.91,27893.72,
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13723.02,,,,,,,fee schedule,8956.91,27893.72,
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,16736.23,,,,,,,fee schedule,8956.91,27893.72,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,16576.84,,,,,,,fee schedule,8956.91,27893.72,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,16576.84,,,,,,,fee schedule,8956.91,27893.72,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,16736.23,,,,,,,fee schedule,8956.91,27893.72,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,16576.84,,,,,,,fee schedule,8956.91,27893.72,MSDRG Base Rate
Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc,499,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,27893.72,,,,,,,fee schedule,8956.91,27893.72,MSDRG Base Rate
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,24448.62,,,,,,,fee schedule,24448.62,73458.5,
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,24448.62,,,,,,,fee schedule,24448.62,73458.5,
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32730.41,,,,,,,fee schedule,24448.62,73458.5,
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,31171.83,,,,,,,fee schedule,24448.62,73458.5,
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,54596.42,,,,,,,fee schedule,24448.62,73458.5,
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,42426.22,,,,,,,fee schedule,24448.62,73458.5,
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,73458.5,,,,,,,fee schedule,24448.62,73458.5,
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,50498.73,,,,,,,fee schedule,24448.62,73458.5,
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,45734.13,,,,,,,fee schedule,24448.62,73458.5,
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37458.13,,,,,,,fee schedule,24448.62,73458.5,
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],23996.69,23996.69,23996.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],21877.31,21877.31,21877.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,25720.51,,,,,,,fee schedule,24448.62,73458.5,MSDRG Base Rate
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,25475.55,,,,,,,fee schedule,24448.62,73458.5,MSDRG Base Rate
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,25475.55,,,,,,,fee schedule,24448.62,73458.5,MSDRG Base Rate
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,25720.51,,,,,,,fee schedule,24448.62,73458.5,MSDRG Base Rate
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,25475.55,,,,,,,fee schedule,24448.62,73458.5,MSDRG Base Rate
Soft Tissue Procedures With Mcc,500,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,42867.51,,,,,,,fee schedule,24448.62,73458.5,MSDRG Base Rate
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13772.56,,,,,,,fee schedule,13772.56,41381.12,
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,13772.56,,,,,,,fee schedule,13772.56,41381.12,
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18437.91,,,,,,,fee schedule,13772.56,41381.12,
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17559.92,,,,,,,fee schedule,13772.56,41381.12,
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,30755.61,,,,,,,fee schedule,13772.56,41381.12,
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,23899.81,,,,,,,fee schedule,13772.56,41381.12,
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,41381.12,,,,,,,fee schedule,13772.56,41381.12,
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,28447.27,,,,,,,fee schedule,13772.56,41381.12,
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,25763.25,,,,,,,fee schedule,13772.56,41381.12,
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21101.16,,,,,,,fee schedule,13772.56,41381.12,
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12637.58,12637.58,12637.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],28444.08,28444.08,28444.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],17557.95,17557.95,17557.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",5831.67,5831.67,5831.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],500,500,500,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],13625.78,13625.78,13625.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14652.67,,,,,,,fee schedule,13772.56,41381.12,MSDRG Base Rate
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,14513.12,,,,,,,fee schedule,13772.56,41381.12,MSDRG Base Rate
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,14513.12,,,,,,,fee schedule,13772.56,41381.12,MSDRG Base Rate
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,14652.67,,,,,,,fee schedule,13772.56,41381.12,MSDRG Base Rate
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,14513.12,,,,,,,fee schedule,13772.56,41381.12,MSDRG Base Rate
Soft Tissue Procedures With Cc,501,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,24421.11,,,,,,,fee schedule,13772.56,41381.12,MSDRG Base Rate
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10780.23,,,,,,,fee schedule,10780.23,32390.37,
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,10780.23,,,,,,,fee schedule,10780.23,32390.37,
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14431.96,,,,,,,fee schedule,10780.23,32390.37,
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13744.73,,,,,,,fee schedule,10780.23,32390.37,
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,24073.43,,,,,,,fee schedule,10780.23,32390.37,
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,18707.17,,,,,,,fee schedule,10780.23,32390.37,
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,32390.37,,,,,,,fee schedule,10780.23,32390.37,
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,22266.62,,,,,,,fee schedule,10780.23,32390.37,
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,20165.74,,,,,,,fee schedule,10780.23,32390.37,
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16516.57,,,,,,,fee schedule,10780.23,32390.37,
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4374.34,4374.34,4374.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11510.51,,,,,,,fee schedule,10780.23,32390.37,MSDRG Base Rate
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,11400.89,,,,,,,fee schedule,10780.23,32390.37,MSDRG Base Rate
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,11400.89,,,,,,,fee schedule,10780.23,32390.37,MSDRG Base Rate
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,11510.51,,,,,,,fee schedule,10780.23,32390.37,MSDRG Base Rate
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,11400.89,,,,,,,fee schedule,10780.23,32390.37,MSDRG Base Rate
Soft Tissue Procedures Without Cc/Mcc,502,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19184.18,,,,,,,fee schedule,10780.23,32390.37,MSDRG Base Rate
Foot Procedures With Mcc,503,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,20420.79,,,,,,,fee schedule,20420.79,61356.46,
Foot Procedures With Mcc,503,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,20420.79,,,,,,,fee schedule,20420.79,61356.46,
Foot Procedures With Mcc,503,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,27338.19,,,,,,,fee schedule,20420.79,61356.46,
Foot Procedures With Mcc,503,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26036.37,,,,,,,fee schedule,20420.79,61356.46,
Foot Procedures With Mcc,503,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,45601.84,,,,,,,fee schedule,20420.79,61356.46,
Foot Procedures With Mcc,503,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,35436.64,,,,,,,fee schedule,20420.79,61356.46,
Foot Procedures With Mcc,503,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,61356.46,,,,,,,fee schedule,20420.79,61356.46,
Foot Procedures With Mcc,503,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,42179.23,,,,,,,fee schedule,20420.79,61356.46,
Foot Procedures With Mcc,503,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,38199.58,,,,,,,fee schedule,20420.79,61356.46,
Foot Procedures With Mcc,503,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,31287.03,,,,,,,fee schedule,20420.79,61356.46,
Foot Procedures With Mcc,503,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Mcc,503,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Mcc,503,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],19902.6,19902.6,19902.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Foot Procedures With Mcc,503,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Mcc,503,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Mcc,503,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Mcc,503,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Mcc,503,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",9797.39,9797.39,9797.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Foot Procedures With Mcc,503,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Mcc,503,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Mcc,503,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Mcc,503,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Mcc,503,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Mcc,503,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Mcc,503,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Mcc,503,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Mcc,503,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Mcc,503,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Mcc,503,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,22801,,,,,,,fee schedule,20420.79,61356.46,MSDRG Base Rate
Foot Procedures With Mcc,503,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,22583.85,,,,,,,fee schedule,20420.79,61356.46,MSDRG Base Rate
Foot Procedures With Mcc,503,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,22583.85,,,,,,,fee schedule,20420.79,61356.46,MSDRG Base Rate
Foot Procedures With Mcc,503,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,22801,,,,,,,fee schedule,20420.79,61356.46,MSDRG Base Rate
Foot Procedures With Mcc,503,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,22583.85,,,,,,,fee schedule,20420.79,61356.46,MSDRG Base Rate
Foot Procedures With Mcc,503,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,38001.67,,,,,,,fee schedule,20420.79,61356.46,MSDRG Base Rate
Foot Procedures With Cc,504,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13546.47,,,,,,,fee schedule,13546.47,40701.83,
Foot Procedures With Cc,504,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,13546.47,,,,,,,fee schedule,13546.47,40701.83,
Foot Procedures With Cc,504,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18135.24,,,,,,,fee schedule,13546.47,40701.83,
Foot Procedures With Cc,504,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17271.66,,,,,,,fee schedule,13546.47,40701.83,
Foot Procedures With Cc,504,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,30250.74,,,,,,,fee schedule,13546.47,40701.83,
Foot Procedures With Cc,504,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,23507.48,,,,,,,fee schedule,13546.47,40701.83,
Foot Procedures With Cc,504,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,40701.83,,,,,,,fee schedule,13546.47,40701.83,
Foot Procedures With Cc,504,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,27980.3,,,,,,,fee schedule,13546.47,40701.83,
Foot Procedures With Cc,504,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,25340.33,,,,,,,fee schedule,13546.47,40701.83,
Foot Procedures With Cc,504,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20754.77,,,,,,,fee schedule,13546.47,40701.83,
Foot Procedures With Cc,504,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Cc,504,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Cc,504,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],26149.76,26149.76,26149.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Foot Procedures With Cc,504,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Cc,504,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Cc,504,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Cc,504,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Cc,504,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",6564.2,6564.2,6564.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Foot Procedures With Cc,504,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],16077.67,16077.67,16077.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Foot Procedures With Cc,504,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Cc,504,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Cc,504,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Cc,504,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Cc,504,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Cc,504,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Cc,504,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Cc,504,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Cc,504,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures With Cc,504,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15598.75,,,,,,,fee schedule,13546.47,40701.83,MSDRG Base Rate
Foot Procedures With Cc,504,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,15450.19,,,,,,,fee schedule,13546.47,40701.83,MSDRG Base Rate
Foot Procedures With Cc,504,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,15450.19,,,,,,,fee schedule,13546.47,40701.83,MSDRG Base Rate
Foot Procedures With Cc,504,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,15598.75,,,,,,,fee schedule,13546.47,40701.83,MSDRG Base Rate
Foot Procedures With Cc,504,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,15450.19,,,,,,,fee schedule,13546.47,40701.83,MSDRG Base Rate
Foot Procedures With Cc,504,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,25997.91,,,,,,,fee schedule,13546.47,40701.83,MSDRG Base Rate
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13546.47,,,,,,,fee schedule,13546.47,40701.83,
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,13546.47,,,,,,,fee schedule,13546.47,40701.83,
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18135.24,,,,,,,fee schedule,13546.47,40701.83,
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17271.66,,,,,,,fee schedule,13546.47,40701.83,
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,30250.74,,,,,,,fee schedule,13546.47,40701.83,
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,23507.48,,,,,,,fee schedule,13546.47,40701.83,
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,40701.83,,,,,,,fee schedule,13546.47,40701.83,
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,27980.3,,,,,,,fee schedule,13546.47,40701.83,
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,25340.33,,,,,,,fee schedule,13546.47,40701.83,
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20754.77,,,,,,,fee schedule,13546.47,40701.83,
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],20747.68,20747.68,20747.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15001.88,,,,,,,fee schedule,13546.47,40701.83,MSDRG Base Rate
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,14859,,,,,,,fee schedule,13546.47,40701.83,MSDRG Base Rate
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,14859,,,,,,,fee schedule,13546.47,40701.83,MSDRG Base Rate
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,15001.88,,,,,,,fee schedule,13546.47,40701.83,MSDRG Base Rate
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,14859,,,,,,,fee schedule,13546.47,40701.83,MSDRG Base Rate
Foot Procedures Without Cc/Mcc,505,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,25003.12,,,,,,,fee schedule,13546.47,40701.83,MSDRG Base Rate
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11566.51,,,,,,,fee schedule,11426.42,34752.82,
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,11566.51,,,,,,,fee schedule,11426.42,34752.82,
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15484.58,,,,,,,fee schedule,11426.42,34752.82,
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14747.22,,,,,,,fee schedule,11426.42,34752.82,
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,25829.27,,,,,,,fee schedule,11426.42,34752.82,
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,20071.61,,,,,,,fee schedule,11426.42,34752.82,
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,34752.82,,,,,,,fee schedule,11426.42,34752.82,
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,23890.67,,,,,,,fee schedule,11426.42,34752.82,
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,21636.57,,,,,,,fee schedule,11426.42,34752.82,
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17721.24,,,,,,,fee schedule,11426.42,34752.82,
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",6922.29,6922.29,6922.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],9847.03,9847.03,9847.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",6858.2,6858.2,6858.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11536.29,,,,,,,fee schedule,11426.42,34752.82,MSDRG Base Rate
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,11426.42,,,,,,,fee schedule,11426.42,34752.82,MSDRG Base Rate
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,11426.42,,,,,,,fee schedule,11426.42,34752.82,MSDRG Base Rate
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,11536.29,,,,,,,fee schedule,11426.42,34752.82,MSDRG Base Rate
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,11426.42,,,,,,,fee schedule,11426.42,34752.82,MSDRG Base Rate
Major Thumb Or Joint Procedures,506,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19227.14,,,,,,,fee schedule,11426.42,34752.82,MSDRG Base Rate
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14954.67,,,,,,,fee schedule,14954.67,44932.91,
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,14954.67,,,,,,,fee schedule,14954.67,44932.91,
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20020.46,,,,,,,fee schedule,14954.67,44932.91,
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19067.11,,,,,,,fee schedule,14954.67,44932.91,
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,33395.4,,,,,,,fee schedule,14954.67,44932.91,
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,25951.16,,,,,,,fee schedule,14954.67,44932.91,
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,44932.91,,,,,,,fee schedule,14954.67,44932.91,
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,30888.93,,,,,,,fee schedule,14954.67,44932.91,
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,27974.54,,,,,,,fee schedule,14954.67,44932.91,
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22912.3,,,,,,,fee schedule,14954.67,44932.91,
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],14163.76,14163.76,14163.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],30850.92,30850.92,30850.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],14288.51,14288.51,14288.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15108.12,,,,,,,fee schedule,14954.67,44932.91,MSDRG Base Rate
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,14964.24,,,,,,,fee schedule,14954.67,44932.91,MSDRG Base Rate
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,14964.24,,,,,,,fee schedule,14954.67,44932.91,MSDRG Base Rate
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,15108.12,,,,,,,fee schedule,14954.67,44932.91,MSDRG Base Rate
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,14964.24,,,,,,,fee schedule,14954.67,44932.91,MSDRG Base Rate
Major Shoulder Or Elbow Joint Procedures With Cc/Mcc,507,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,25180.21,,,,,,,fee schedule,14954.67,44932.91,MSDRG Base Rate
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9958.46,,,,,,,fee schedule,9958.46,29921.27,
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,9958.46,,,,,,,fee schedule,9958.46,29921.27,
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13331.82,,,,,,,fee schedule,9958.46,29921.27,
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12696.97,,,,,,,fee schedule,9958.46,29921.27,
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,22238.33,,,,,,,fee schedule,9958.46,29921.27,
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,17281.13,,,,,,,fee schedule,9958.46,29921.27,
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,29921.27,,,,,,,fee schedule,9958.46,29921.27,
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,20569.25,,,,,,,fee schedule,9958.46,29921.27,
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,18628.52,,,,,,,fee schedule,9958.46,29921.27,
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15257.52,,,,,,,fee schedule,9958.46,29921.27,
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12826.9,,,,,,,fee schedule,9958.46,29921.27,MSDRG Base Rate
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,12704.74,,,,,,,fee schedule,9958.46,29921.27,MSDRG Base Rate
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,12704.74,,,,,,,fee schedule,9958.46,29921.27,MSDRG Base Rate
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,12826.9,,,,,,,fee schedule,9958.46,29921.27,MSDRG Base Rate
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,12704.74,,,,,,,fee schedule,9958.46,29921.27,MSDRG Base Rate
Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc,508,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21378.18,,,,,,,fee schedule,9958.46,29921.27,MSDRG Base Rate
Arthroscopy,509,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13553.42,,,,,,,fee schedule,13553.42,40722.7,
Arthroscopy,509,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,13553.42,,,,,,,fee schedule,13553.42,40722.7,
Arthroscopy,509,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18144.54,,,,,,,fee schedule,13553.42,40722.7,
Arthroscopy,509,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17280.52,,,,,,,fee schedule,13553.42,40722.7,
Arthroscopy,509,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,30266.25,,,,,,,fee schedule,13553.42,40722.7,
Arthroscopy,509,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,23519.54,,,,,,,fee schedule,13553.42,40722.7,
Arthroscopy,509,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,40722.7,,,,,,,fee schedule,13553.42,40722.7,
Arthroscopy,509,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,27994.64,,,,,,,fee schedule,13553.42,40722.7,
Arthroscopy,509,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,25353.32,,,,,,,fee schedule,13553.42,40722.7,
Arthroscopy,509,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20765.41,,,,,,,fee schedule,13553.42,40722.7,
Arthroscopy,509,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Arthroscopy,509,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Arthroscopy,509,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Arthroscopy,509,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Arthroscopy,509,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Arthroscopy,509,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Arthroscopy,509,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Arthroscopy,509,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Arthroscopy,509,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Arthroscopy,509,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Arthroscopy,509,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Arthroscopy,509,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Arthroscopy,509,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Arthroscopy,509,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Arthroscopy,509,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Arthroscopy,509,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Arthroscopy,509,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Arthroscopy,509,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,22052.76,,,,,,,fee schedule,22052.76,66259.87,
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,22052.76,,,,,,,fee schedule,22052.76,66259.87,
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29522.97,,,,,,,fee schedule,22052.76,66259.87,
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28117.12,,,,,,,fee schedule,22052.76,66259.87,
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,49246.2,,,,,,,fee schedule,22052.76,66259.87,
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,38268.62,,,,,,,fee schedule,22052.76,66259.87,
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,66259.87,,,,,,,fee schedule,22052.76,66259.87,
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,45550.06,,,,,,,fee schedule,22052.76,66259.87,
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,41252.37,,,,,,,fee schedule,22052.76,66259.87,
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33787.39,,,,,,,fee schedule,22052.76,66259.87,
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,24593.17,,,,,,,fee schedule,22052.76,66259.87,MSDRG Base Rate
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,24358.95,,,,,,,fee schedule,22052.76,66259.87,MSDRG Base Rate
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,24358.95,,,,,,,fee schedule,22052.76,66259.87,MSDRG Base Rate
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,24593.17,,,,,,,fee schedule,22052.76,66259.87,MSDRG Base Rate
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,24358.95,,,,,,,fee schedule,22052.76,66259.87,MSDRG Base Rate
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc",510,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,40988.62,,,,,,,fee schedule,22052.76,66259.87,MSDRG Base Rate
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,15134.46,,,,,,,fee schedule,15134.46,45473.1,
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,15134.46,,,,,,,fee schedule,15134.46,45473.1,
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20261.14,,,,,,,fee schedule,15134.46,45473.1,
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19296.33,,,,,,,fee schedule,15134.46,45473.1,
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,33796.88,,,,,,,fee schedule,15134.46,45473.1,
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,26263.15,,,,,,,fee schedule,15134.46,45473.1,
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,45473.1,,,,,,,fee schedule,15134.46,45473.1,
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,31260.28,,,,,,,fee schedule,15134.46,45473.1,
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,28310.85,,,,,,,fee schedule,15134.46,45473.1,
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23187.75,,,,,,,fee schedule,15134.46,45473.1,
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],12691.17,12691.17,12691.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,17240.92,,,,,,,fee schedule,15134.46,45473.1,MSDRG Base Rate
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,17076.72,,,,,,,fee schedule,15134.46,45473.1,MSDRG Base Rate
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,17076.72,,,,,,,fee schedule,15134.46,45473.1,MSDRG Base Rate
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,17240.92,,,,,,,fee schedule,15134.46,45473.1,MSDRG Base Rate
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,17076.72,,,,,,,fee schedule,15134.46,45473.1,MSDRG Base Rate
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc",511,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,28734.86,,,,,,,fee schedule,15134.46,45473.1,MSDRG Base Rate
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12405.25,,,,,,,fee schedule,12405.25,37272.92,
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,12405.25,,,,,,,fee schedule,12405.25,37272.92,
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16607.44,,,,,,,fee schedule,12405.25,37272.92,
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15816.62,,,,,,,fee schedule,12405.25,37272.92,
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,27702.28,,,,,,,fee schedule,12405.25,37272.92,
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,21527.1,,,,,,,fee schedule,12405.25,37272.92,
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,37272.92,,,,,,,fee schedule,12405.25,37272.92,
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,25623.1,,,,,,,fee schedule,12405.25,37272.92,
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,23205.54,,,,,,,fee schedule,12405.25,37272.92,
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19006.29,,,,,,,fee schedule,12405.25,37272.92,
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13928.45,,,,,,,fee schedule,12405.25,37272.92,MSDRG Base Rate
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,13795.8,,,,,,,fee schedule,12405.25,37272.92,MSDRG Base Rate
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,13795.8,,,,,,,fee schedule,12405.25,37272.92,MSDRG Base Rate
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,13928.45,,,,,,,fee schedule,12405.25,37272.92,MSDRG Base Rate
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,13795.8,,,,,,,fee schedule,12405.25,37272.92,MSDRG Base Rate
"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc",512,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23214.08,,,,,,,fee schedule,12405.25,37272.92,MSDRG Base Rate
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11616.66,,,,,,,fee schedule,11616.66,34903.51,
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,11616.66,,,,,,,fee schedule,11616.66,34903.51,
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15551.72,,,,,,,fee schedule,11616.66,34903.51,
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14811.17,,,,,,,fee schedule,11616.66,34903.51,
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,25941.27,,,,,,,fee schedule,11616.66,34903.51,
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,20158.65,,,,,,,fee schedule,11616.66,34903.51,
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,34903.51,,,,,,,fee schedule,11616.66,34903.51,
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,23994.27,,,,,,,fee schedule,11616.66,34903.51,
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,21730.39,,,,,,,fee schedule,11616.66,34903.51,
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17798.08,,,,,,,fee schedule,11616.66,34903.51,
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",6451.34,6451.34,6451.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",6058.65,6058.65,6058.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",6002.55,6002.55,6002.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13294.87,,,,,,,fee schedule,11616.66,34903.51,MSDRG Base Rate
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,13168.25,,,,,,,fee schedule,11616.66,34903.51,MSDRG Base Rate
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,13168.25,,,,,,,fee schedule,11616.66,34903.51,MSDRG Base Rate
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,13294.87,,,,,,,fee schedule,11616.66,34903.51,MSDRG Base Rate
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,13168.25,,,,,,,fee schedule,11616.66,34903.51,MSDRG Base Rate
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc",513,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22158.12,,,,,,,fee schedule,11616.66,34903.51,MSDRG Base Rate
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7867.39,,,,,,,fee schedule,7867.39,23638.41,
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,7867.39,,,,,,,fee schedule,7867.39,23638.41,
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10532.41,,,,,,,fee schedule,7867.39,23638.41,
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10030.87,,,,,,,fee schedule,7867.39,23638.41,
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,17568.73,,,,,,,fee schedule,7867.39,23638.41,
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,13652.44,,,,,,,fee schedule,7867.39,23638.41,
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,23638.41,,,,,,,fee schedule,7867.39,23638.41,
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,16250.12,,,,,,,fee schedule,7867.39,23638.41,
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,14716.91,,,,,,,fee schedule,7867.39,23638.41,
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12053.75,,,,,,,fee schedule,7867.39,23638.41,
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7558.34,7558.34,7558.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8982.41,,,,,,,fee schedule,7867.39,23638.41,MSDRG Base Rate
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,8896.87,,,,,,,fee schedule,7867.39,23638.41,MSDRG Base Rate
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,8896.87,,,,,,,fee schedule,7867.39,23638.41,MSDRG Base Rate
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,8982.41,,,,,,,fee schedule,7867.39,23638.41,MSDRG Base Rate
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,8896.87,,,,,,,fee schedule,7867.39,23638.41,MSDRG Base Rate
"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc",514,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14970.69,,,,,,,fee schedule,7867.39,23638.41,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,23859.88,,,,,,,fee schedule,23859.88,71689.56,
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,23859.88,,,,,,,fee schedule,23859.88,71689.56,
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31942.24,,,,,,,fee schedule,23859.88,71689.56,
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,30421.19,,,,,,,fee schedule,23859.88,71689.56,
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,53281.7,,,,,,,fee schedule,23859.88,71689.56,
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,41404.56,,,,,,,fee schedule,23859.88,71689.56,
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,71689.56,,,,,,,fee schedule,23859.88,71689.56,
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,49282.68,,,,,,,fee schedule,23859.88,71689.56,
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,44632.81,,,,,,,fee schedule,23859.88,71689.56,
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,36556.11,,,,,,,fee schedule,23859.88,71689.56,
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],19385.11,19385.11,19385.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],22669.42,22669.42,22669.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",20773.73,20773.73,20773.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],22774.5,22774.5,22774.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],21303.87,21303.87,21303.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],23148.27,23103.36,31947.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,25893.16,,,,,,,fee schedule,23859.88,71689.56,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,25646.56,,,,,,,fee schedule,23859.88,71689.56,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,25646.56,,,,,,,fee schedule,23859.88,71689.56,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,25893.16,,,,,,,fee schedule,23859.88,71689.56,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,25646.56,,,,,,,fee schedule,23859.88,71689.56,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc,515,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,43155.26,,,,,,,fee schedule,23859.88,71689.56,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,15521.81,,,,,,,fee schedule,15521.81,46636.93,
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,15521.81,,,,,,,fee schedule,15521.81,46636.93,
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20779.71,,,,,,,fee schedule,15521.81,46636.93,
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19790.2,,,,,,,fee schedule,15521.81,46636.93,
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,34661.88,,,,,,,fee schedule,15521.81,46636.93,
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,26935.32,,,,,,,fee schedule,15521.81,46636.93,
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,46636.93,,,,,,,fee schedule,15521.81,46636.93,
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,32060.36,,,,,,,fee schedule,15521.81,46636.93,
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,29035.43,,,,,,,fee schedule,15521.81,46636.93,
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23781.22,,,,,,,fee schedule,15521.81,46636.93,
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],32435.73,32435.73,32435.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],14145.12,14145.12,14145.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],15401.95,13438.45,15529.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],35807.74,35807.74,35807.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],13450.86,13450.86,13606.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",11299.57,11299.57,11299.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,17230.75,,,,,,,fee schedule,15521.81,46636.93,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,17066.65,,,,,,,fee schedule,15521.81,46636.93,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,17066.65,,,,,,,fee schedule,15521.81,46636.93,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,17230.75,,,,,,,fee schedule,15521.81,46636.93,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,17066.65,,,,,,,fee schedule,15521.81,46636.93,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc,516,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,28717.92,,,,,,,fee schedule,15521.81,46636.93,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11517.13,,,,,,,fee schedule,11517.13,34604.44,
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,11517.13,,,,,,,fee schedule,11517.13,34604.44,
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15418.47,,,,,,,fee schedule,11517.13,34604.44,
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14684.26,,,,,,,fee schedule,11517.13,34604.44,
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,25718.99,,,,,,,fee schedule,11517.13,34604.44,
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,19985.91,,,,,,,fee schedule,11517.13,34604.44,
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,34604.44,,,,,,,fee schedule,11517.13,34604.44,
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,23788.67,,,,,,,fee schedule,11517.13,34604.44,
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,21544.19,,,,,,,fee schedule,11517.13,34604.44,
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17645.58,,,,,,,fee schedule,11517.13,34604.44,
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],21525.73,21525.73,21525.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11458.82,11152.53,11518.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],10524.62,10524.62,10524.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13001.12,,,,,,,fee schedule,11517.13,34604.44,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,12877.3,,,,,,,fee schedule,11517.13,34604.44,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,12877.3,,,,,,,fee schedule,11517.13,34604.44,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,13001.12,,,,,,,fee schedule,11517.13,34604.44,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,12877.3,,,,,,,fee schedule,11517.13,34604.44,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc,517,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21668.54,,,,,,,fee schedule,11517.13,34604.44,MSDRG Base Rate
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,27653.14,,,,,,,fee schedule,27653.14,83086.82,
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,27653.14,,,,,,,fee schedule,27653.14,83086.82,
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37020.44,,,,,,,fee schedule,27653.14,83086.82,
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,35257.57,,,,,,,fee schedule,27653.14,83086.82,
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,61752.46,,,,,,,fee schedule,27653.14,83086.82,
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,47987.08,,,,,,,fee schedule,27653.14,83086.82,
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,83086.82,,,,,,,fee schedule,27653.14,83086.82,
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,57117.67,,,,,,,fee schedule,27653.14,83086.82,
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,51728.57,,,,,,,fee schedule,27653.14,83086.82,
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42367.83,,,,,,,fee schedule,27653.14,83086.82,
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],35259.54,35259.54,35259.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",13987.08,13987.08,13987.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],27581.25,27581.25,27581.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],24419.48,24419.48,29248.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,30193.11,,,,,,,fee schedule,27653.14,83086.82,MSDRG Base Rate
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,29905.55,,,,,,,fee schedule,27653.14,83086.82,MSDRG Base Rate
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,29905.55,,,,,,,fee schedule,27653.14,83086.82,MSDRG Base Rate
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,30193.11,,,,,,,fee schedule,27653.14,83086.82,MSDRG Base Rate
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,29905.55,,,,,,,fee schedule,27653.14,83086.82,MSDRG Base Rate
Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator,518,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,50321.84,,,,,,,fee schedule,27653.14,83086.82,MSDRG Base Rate
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,15213.93,,,,,,,fee schedule,15213.93,45711.89,
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,15213.93,,,,,,,fee schedule,15213.93,45711.89,
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20367.54,,,,,,,fee schedule,15213.93,45711.89,
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19397.66,,,,,,,fee schedule,15213.93,45711.89,
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,33974.36,,,,,,,fee schedule,15213.93,45711.89,
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,26401.06,,,,,,,fee schedule,15213.93,45711.89,
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,45711.89,,,,,,,fee schedule,15213.93,45711.89,
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,31424.44,,,,,,,fee schedule,15213.93,45711.89,
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,28459.52,,,,,,,fee schedule,15213.93,45711.89,
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23309.52,,,,,,,fee schedule,15213.93,45711.89,
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],31427.63,31427.63,31427.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],25720.42,25720.42,25720.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",54489.62,54489.62,54489.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],14983.8,14983.8,14983.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",8714.07,8714.07,8714.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13295.37,13294.53,14729.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],78160.15,78160.15,78160.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],14156.04,13642.97,15226.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",8633.38,8633.38,8633.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,16622.17,,,,,,,fee schedule,15213.93,45711.89,MSDRG Base Rate
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,16463.87,,,,,,,fee schedule,15213.93,45711.89,MSDRG Base Rate
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,16463.87,,,,,,,fee schedule,15213.93,45711.89,MSDRG Base Rate
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,16622.17,,,,,,,fee schedule,15213.93,45711.89,MSDRG Base Rate
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,16463.87,,,,,,,fee schedule,15213.93,45711.89,MSDRG Base Rate
Back And Neck Procedures Except Spinal Fusion With Cc,519,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,27703.62,,,,,,,fee schedule,15213.93,45711.89,MSDRG Base Rate
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11058.01,,,,,,,fee schedule,11058.01,33224.99,
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,11058.01,,,,,,,fee schedule,11058.01,33224.99,
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14803.84,,,,,,,fee schedule,11058.01,33224.99,
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14098.9,,,,,,,fee schedule,11058.01,33224.99,
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,24693.75,,,,,,,fee schedule,11058.01,33224.99,
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,19189.21,,,,,,,fee schedule,11058.01,33224.99,
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,33224.99,,,,,,,fee schedule,11058.01,33224.99,
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,22840.38,,,,,,,fee schedule,11058.01,33224.99,
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,20685.37,,,,,,,fee schedule,11058.01,33224.99,
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16942.17,,,,,,,fee schedule,11058.01,33224.99,
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],1093.18,1093.18,1093.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11307.75,11307.75,11307.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],22387.56,22387.56,22387.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],14059.88,14059.88,14059.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",7764.02,7764.02,7764.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],10735.43,10655.67,10925.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],24695.47,24695.47,24695.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],11065.94,11065.94,11065.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12666.75,,,,,,,fee schedule,11058.01,33224.99,MSDRG Base Rate
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,12546.11,,,,,,,fee schedule,11058.01,33224.99,MSDRG Base Rate
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,12546.11,,,,,,,fee schedule,11058.01,33224.99,MSDRG Base Rate
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,12666.75,,,,,,,fee schedule,11058.01,33224.99,MSDRG Base Rate
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,12546.11,,,,,,,fee schedule,11058.01,33224.99,MSDRG Base Rate
Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc,520,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21111.25,,,,,,,fee schedule,11058.01,33224.99,MSDRG Base Rate
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,22489.49,,,,,,,fee schedule,22489.49,67572.09,
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,22489.49,,,,,,,fee schedule,22489.49,67572.09,
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,30107.64,,,,,,,fee schedule,22489.49,67572.09,
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28673.95,,,,,,,fee schedule,22489.49,67572.09,
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,50221.47,,,,,,,fee schedule,22489.49,67572.09,
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,39026.49,,,,,,,fee schedule,22489.49,67572.09,
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,67572.09,,,,,,,fee schedule,22489.49,67572.09,
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,46452.14,,,,,,,fee schedule,22489.49,67572.09,
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,42069.34,,,,,,,fee schedule,22489.49,67572.09,
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,34456.52,,,,,,,fee schedule,22489.49,67572.09,
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],20990.75,20990.75,20990.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],18803.6,18803.6,18803.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],82363.02,82363.02,82363.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",28934.31,28934.31,28934.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],22106.41,21491.39,22446.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],1173.77,1173.77,1173.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],20882.43,17673,21854.02,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,23418.97,,,,,,,fee schedule,22489.49,67572.09,MSDRG Base Rate
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,23195.93,,,,,,,fee schedule,22489.49,67572.09,MSDRG Base Rate
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,23195.93,,,,,,,fee schedule,22489.49,67572.09,MSDRG Base Rate
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,23418.97,,,,,,,fee schedule,22489.49,67572.09,MSDRG Base Rate
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,23195.93,,,,,,,fee schedule,22489.49,67572.09,MSDRG Base Rate
Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc,521,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,39031.62,,,,,,,fee schedule,22489.49,67572.09,MSDRG Base Rate
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16267.19,,,,,,,fee schedule,16267.19,48876.51,
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,16267.19,,,,,,,fee schedule,16267.19,48876.51,
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21777.58,,,,,,,fee schedule,16267.19,48876.51,
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20740.56,,,,,,,fee schedule,16267.19,48876.51,
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,36326.39,,,,,,,fee schedule,16267.19,48876.51,
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,28228.8,,,,,,,fee schedule,16267.19,48876.51,
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,48876.51,,,,,,,fee schedule,16267.19,48876.51,
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,33599.94,,,,,,,fee schedule,16267.19,48876.51,
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,30429.76,,,,,,,fee schedule,16267.19,48876.51,
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24923.22,,,,,,,fee schedule,16267.19,48876.51,
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],15361.9,14198.23,16351.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],33416.11,33416.11,33416.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],16628.89,16628.89,16628.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],15112.76,15112.76,15112.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",21461.56,21461.56,21461.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],16003.12,15775.55,16251.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],23781.45,23781.45,23781.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],32990.89,32990.89,32990.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],15399.73,14644.29,16872.27,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,17540.12,,,,,,,fee schedule,16267.19,48876.51,MSDRG Base Rate
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,17373.08,,,,,,,fee schedule,16267.19,48876.51,MSDRG Base Rate
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,17373.08,,,,,,,fee schedule,16267.19,48876.51,MSDRG Base Rate
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,17540.12,,,,,,,fee schedule,16267.19,48876.51,MSDRG Base Rate
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,17373.08,,,,,,,fee schedule,16267.19,48876.51,MSDRG Base Rate
Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc,522,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,29233.54,,,,,,,fee schedule,16267.19,48876.51,MSDRG Base Rate
Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC,523,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC,523,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC,523,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC,523,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC,523,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC,523,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC,523,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC,523,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC,523,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC,523,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC,523,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC,523,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC,523,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC,523,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC,523,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC,523,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC,523,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC,523,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transient ischemia,524,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transient ischemia,524,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Transient ischemia,524,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Transient ischemia,524,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transient ischemia,524,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transient ischemia,524,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Transient ischemia,524,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Transient ischemia,524,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Transient ischemia,524,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Transient ischemia,524,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Transient ischemia,524,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transient ischemia,524,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transient ischemia,524,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Transient ischemia,524,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Transient ischemia,524,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transient ischemia,524,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Transient ischemia,524,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transient ischemia,524,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other heart assist system implant,525,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other heart assist system implant,525,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other heart assist system implant,525,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Other heart assist system implant,525,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other heart assist system implant,525,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other heart assist system implant,525,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Other heart assist system implant,525,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other heart assist system implant,525,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other heart assist system implant,525,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other heart assist system implant,525,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other heart assist system implant,525,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other heart assist system implant,525,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other heart assist system implant,525,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Other heart assist system implant,525,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Other heart assist system implant,525,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other heart assist system implant,525,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other heart assist system implant,525,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other heart assist system implant,525,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,526,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,526,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,526,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,526,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,526,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,526,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,526,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,526,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,526,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,526,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,526,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,526,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,526,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,526,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,526,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,526,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,526,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,526,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,527,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,527,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,527,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,527,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,527,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,527,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,527,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,527,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,527,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,527,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,527,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,527,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,527,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,527,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,527,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,527,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,527,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
No Longer Valid,527,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Proc w Pdx Hemorrhage,528,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Proc w Pdx Hemorrhage,528,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Proc w Pdx Hemorrhage,528,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Proc w Pdx Hemorrhage,528,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Proc w Pdx Hemorrhage,528,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Proc w Pdx Hemorrhage,528,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Proc w Pdx Hemorrhage,528,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Proc w Pdx Hemorrhage,528,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Proc w Pdx Hemorrhage,528,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Proc w Pdx Hemorrhage,528,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Proc w Pdx Hemorrhage,528,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Proc w Pdx Hemorrhage,528,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Proc w Pdx Hemorrhage,528,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Proc w Pdx Hemorrhage,528,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Proc w Pdx Hemorrhage,528,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Proc w Pdx Hemorrhage,528,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Proc w Pdx Hemorrhage,528,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Intracranial Vascular Proc w Pdx Hemorrhage,528,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular shunt procedures w CC,529,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular shunt procedures w CC,529,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular shunt procedures w CC,529,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular shunt procedures w CC,529,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular shunt procedures w CC,529,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular shunt procedures w CC,529,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular shunt procedures w CC,529,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Ventricular shunt procedures w CC,529,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Ventricular shunt procedures w CC,529,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular shunt procedures w CC,529,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular shunt procedures w CC,529,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular shunt procedures w CC,529,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular shunt procedures w CC,529,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular shunt procedures w CC,529,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular shunt procedures w CC,529,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular shunt procedures w CC,529,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Ventricular shunt procedures w CC,529,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular shunt procedures w CC,529,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures w/o CC,530,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures w/o CC,530,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures w/o CC,530,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures w/o CC,530,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures w/o CC,530,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures w/o CC,530,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures w/o CC,530,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures w/o CC,530,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures w/o CC,530,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures w/o CC,530,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures w/o CC,530,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures w/o CC,530,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures w/o CC,530,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures w/o CC,530,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures w/o CC,530,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures w/o CC,530,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures w/o CC,530,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ventricular Shunt Procedures w/o CC,530,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures w CC,531,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures w CC,531,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures w CC,531,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures w CC,531,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures w CC,531,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures w CC,531,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures w CC,531,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures w CC,531,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures w CC,531,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures w CC,531,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures w CC,531,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures w CC,531,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures w CC,531,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures w CC,531,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures w CC,531,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures w CC,531,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures w CC,531,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures w CC,531,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures w/o CC,532,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures w/o CC,532,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures w/o CC,532,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures w/o CC,532,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures w/o CC,532,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures w/o CC,532,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures w/o CC,532,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures w/o CC,532,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures w/o CC,532,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures w/o CC,532,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures w/o CC,532,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures w/o CC,532,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures w/o CC,532,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures w/o CC,532,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures w/o CC,532,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures w/o CC,532,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures w/o CC,532,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Spinal Procedures w/o CC,532,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur With Mcc,533,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11765.59,,,,,,,fee schedule,11765.59,35350.96,
Fractures Of Femur With Mcc,533,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,11765.59,,,,,,,fee schedule,11765.59,35350.96,
Fractures Of Femur With Mcc,533,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15751.09,,,,,,,fee schedule,11765.59,35350.96,
Fractures Of Femur With Mcc,533,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15001.04,,,,,,,fee schedule,11765.59,35350.96,
Fractures Of Femur With Mcc,533,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,26273.83,,,,,,,fee schedule,11765.59,35350.96,
Fractures Of Femur With Mcc,533,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,20417.07,,,,,,,fee schedule,11765.59,35350.96,
Fractures Of Femur With Mcc,533,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,35350.96,,,,,,,fee schedule,11765.59,35350.96,
Fractures Of Femur With Mcc,533,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,24301.87,,,,,,,fee schedule,11765.59,35350.96,
Fractures Of Femur With Mcc,533,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,22008.96,,,,,,,fee schedule,11765.59,35350.96,
Fractures Of Femur With Mcc,533,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18026.25,,,,,,,fee schedule,11765.59,35350.96,
Fractures Of Femur With Mcc,533,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur With Mcc,533,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur With Mcc,533,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur With Mcc,533,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur With Mcc,533,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur With Mcc,533,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur With Mcc,533,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur With Mcc,533,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur With Mcc,533,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur With Mcc,533,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur With Mcc,533,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur With Mcc,533,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur With Mcc,533,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur With Mcc,533,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur With Mcc,533,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur With Mcc,533,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur With Mcc,533,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur With Mcc,533,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur With Mcc,533,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13243.3,,,,,,,fee schedule,11765.59,35350.96,MSDRG Base Rate
Fractures Of Femur With Mcc,533,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,13117.18,,,,,,,fee schedule,11765.59,35350.96,MSDRG Base Rate
Fractures Of Femur With Mcc,533,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,13117.18,,,,,,,fee schedule,11765.59,35350.96,MSDRG Base Rate
Fractures Of Femur With Mcc,533,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,13243.3,,,,,,,fee schedule,11765.59,35350.96,MSDRG Base Rate
Fractures Of Femur With Mcc,533,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,13117.18,,,,,,,fee schedule,11765.59,35350.96,MSDRG Base Rate
Fractures Of Femur With Mcc,533,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22072.17,,,,,,,fee schedule,11765.59,35350.96,MSDRG Base Rate
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6280.17,,,,,,,fee schedule,6280.17,18869.46,
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,6280.17,,,,,,,fee schedule,6280.17,18869.46,
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8407.54,,,,,,,fee schedule,6280.17,18869.46,
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8007.18,,,,,,,fee schedule,6280.17,18869.46,
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,14024.31,,,,,,,fee schedule,6280.17,18869.46,
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,10898.12,,,,,,,fee schedule,6280.17,18869.46,
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,18869.46,,,,,,,fee schedule,6280.17,18869.46,
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,12971.73,,,,,,,fee schedule,6280.17,18869.46,
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,11747.83,,,,,,,fee schedule,6280.17,18869.46,
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9621.96,,,,,,,fee schedule,6280.17,18869.46,
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",5600.82,5600.82,5600.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],121.02,121.02,121.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7293.37,,,,,,,fee schedule,6280.17,18869.46,MSDRG Base Rate
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,7223.91,,,,,,,fee schedule,6280.17,18869.46,MSDRG Base Rate
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,7223.91,,,,,,,fee schedule,6280.17,18869.46,MSDRG Base Rate
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,7293.37,,,,,,,fee schedule,6280.17,18869.46,MSDRG Base Rate
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,7223.91,,,,,,,fee schedule,6280.17,18869.46,MSDRG Base Rate
Fractures Of Femur Without Mcc,534,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12155.62,,,,,,,fee schedule,6280.17,18869.46,MSDRG Base Rate
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10261.71,,,,,,,fee schedule,10261.71,30832.4,
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,10261.71,,,,,,,fee schedule,10261.71,30832.4,
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13737.79,,,,,,,fee schedule,10261.71,30832.4,
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13083.61,,,,,,,fee schedule,10261.71,30832.4,
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,22915.51,,,,,,,fee schedule,10261.71,30832.4,
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,17807.36,,,,,,,fee schedule,10261.71,30832.4,
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,30832.4,,,,,,,fee schedule,10261.71,30832.4,
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,21195.6,,,,,,,fee schedule,10261.71,30832.4,
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,19195.78,,,,,,,fee schedule,10261.71,30832.4,
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15722.13,,,,,,,fee schedule,10261.71,30832.4,
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9371.23,9371.23,9371.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11424.35,11424.35,11424.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9791.05,9791.05,9791.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],8443.55,8443.55,10319.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11011.3,,,,,,,fee schedule,10261.71,30832.4,MSDRG Base Rate
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,10906.43,,,,,,,fee schedule,10261.71,30832.4,MSDRG Base Rate
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,10906.43,,,,,,,fee schedule,10261.71,30832.4,MSDRG Base Rate
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,11011.3,,,,,,,fee schedule,10261.71,30832.4,MSDRG Base Rate
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,10906.43,,,,,,,fee schedule,10261.71,30832.4,MSDRG Base Rate
Fractures Of Hip And Pelvis With Mcc,535,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18352.16,,,,,,,fee schedule,10261.71,30832.4,MSDRG Base Rate
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6257.03,,,,,,,fee schedule,6257.03,18799.91,
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,6257.03,,,,,,,fee schedule,6257.03,18799.91,
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8376.55,,,,,,,fee schedule,6257.03,18799.91,
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7977.67,,,,,,,fee schedule,6257.03,18799.91,
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,13972.62,,,,,,,fee schedule,6257.03,18799.91,
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,10857.95,,,,,,,fee schedule,6257.03,18799.91,
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,18799.91,,,,,,,fee schedule,6257.03,18799.91,
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,12923.91,,,,,,,fee schedule,6257.03,18799.91,
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,11704.53,,,,,,,fee schedule,6257.03,18799.91,
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9586.49,,,,,,,fee schedule,6257.03,18799.91,
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],12646.05,12646.05,12646.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6332.92,6332.92,6332.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4288.8,4288.8,4288.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6151.86,6151.86,6245.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7305.09,,,,,,,fee schedule,6257.03,18799.91,MSDRG Base Rate
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,7235.52,,,,,,,fee schedule,6257.03,18799.91,MSDRG Base Rate
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,7235.52,,,,,,,fee schedule,6257.03,18799.91,MSDRG Base Rate
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,7305.09,,,,,,,fee schedule,6257.03,18799.91,MSDRG Base Rate
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,7235.52,,,,,,,fee schedule,6257.03,18799.91,MSDRG Base Rate
Fractures Of Hip And Pelvis Without Mcc,536,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12175.15,,,,,,,fee schedule,6257.03,18799.91,MSDRG Base Rate
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7090.37,,,,,,,fee schedule,7090.37,21303.78,
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,7090.37,,,,,,,fee schedule,7090.37,21303.78,
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9492.18,,,,,,,fee schedule,7090.37,21303.78,
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9040.17,,,,,,,fee schedule,7090.37,21303.78,
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,15833.57,,,,,,,fee schedule,7090.37,21303.78,
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,12304.07,,,,,,,fee schedule,7090.37,21303.78,
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,21303.78,,,,,,,fee schedule,7090.37,21303.78,
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,14645.19,,,,,,,fee schedule,7090.37,21303.78,
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,13263.4,,,,,,,fee schedule,7090.37,21303.78,
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10863.27,,,,,,,fee schedule,7090.37,21303.78,
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8451.17,,,,,,,fee schedule,7090.37,21303.78,MSDRG Base Rate
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,8370.68,,,,,,,fee schedule,7090.37,21303.78,MSDRG Base Rate
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,8370.68,,,,,,,fee schedule,7090.37,21303.78,MSDRG Base Rate
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,8451.17,,,,,,,fee schedule,7090.37,21303.78,MSDRG Base Rate
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,8370.68,,,,,,,fee schedule,7090.37,21303.78,MSDRG Base Rate
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc",537,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14085.28,,,,,,,fee schedule,7090.37,21303.78,MSDRG Base Rate
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5181.39,,,,,,,fee schedule,5181.39,15568.06,
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,5181.39,,,,,,,fee schedule,5181.39,15568.06,
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6936.55,,,,,,,fee schedule,5181.39,15568.06,
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6606.24,,,,,,,fee schedule,5181.39,15568.06,
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,11570.62,,,,,,,fee schedule,5181.39,15568.06,
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,8991.39,,,,,,,fee schedule,5181.39,15568.06,
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,15568.06,,,,,,,fee schedule,5181.39,15568.06,
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,10702.19,,,,,,,fee schedule,5181.39,15568.06,
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,9692.43,,,,,,,fee schedule,5181.39,15568.06,
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7938.5,,,,,,,fee schedule,5181.39,15568.06,
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,6623.06,,,,,,,fee schedule,5181.39,15568.06,MSDRG Base Rate
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,6559.99,,,,,,,fee schedule,5181.39,15568.06,MSDRG Base Rate
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,6559.99,,,,,,,fee schedule,5181.39,15568.06,MSDRG Base Rate
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,6623.06,,,,,,,fee schedule,5181.39,15568.06,MSDRG Base Rate
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,6559.99,,,,,,,fee schedule,5181.39,15568.06,MSDRG Base Rate
"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc",538,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11038.44,,,,,,,fee schedule,5181.39,15568.06,MSDRG Base Rate
Osteomyelitis With Mcc,539,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,15607.46,,,,,,,fee schedule,15607.46,46894.28,
Osteomyelitis With Mcc,539,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,15607.46,,,,,,,fee schedule,15607.46,46894.28,
Osteomyelitis With Mcc,539,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20894.37,,,,,,,fee schedule,15607.46,46894.28,
Osteomyelitis With Mcc,539,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19899.4,,,,,,,fee schedule,15607.46,46894.28,
Osteomyelitis With Mcc,539,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,34853.14,,,,,,,fee schedule,15607.46,46894.28,
Osteomyelitis With Mcc,539,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,27083.95,,,,,,,fee schedule,15607.46,46894.28,
Osteomyelitis With Mcc,539,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,46894.28,,,,,,,fee schedule,15607.46,46894.28,
Osteomyelitis With Mcc,539,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,32237.27,,,,,,,fee schedule,15607.46,46894.28,
Osteomyelitis With Mcc,539,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,29195.65,,,,,,,fee schedule,15607.46,46894.28,
Osteomyelitis With Mcc,539,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23912.44,,,,,,,fee schedule,15607.46,46894.28,
Osteomyelitis With Mcc,539,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Mcc,539,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Mcc,539,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],32232.49,32232.49,32232.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Osteomyelitis With Mcc,539,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],14775.14,14775.14,14775.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Osteomyelitis With Mcc,539,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],15981.97,15981.97,15981.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Osteomyelitis With Mcc,539,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Mcc,539,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Mcc,539,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",11688.04,11688.04,11688.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Osteomyelitis With Mcc,539,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Mcc,539,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Mcc,539,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Mcc,539,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Mcc,539,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Mcc,539,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Mcc,539,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Mcc,539,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Mcc,539,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Mcc,539,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Mcc,539,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,16383.9,,,,,,,fee schedule,15607.46,46894.28,MSDRG Base Rate
Osteomyelitis With Mcc,539,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,16227.86,,,,,,,fee schedule,15607.46,46894.28,MSDRG Base Rate
Osteomyelitis With Mcc,539,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,16227.86,,,,,,,fee schedule,15607.46,46894.28,MSDRG Base Rate
Osteomyelitis With Mcc,539,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,16383.9,,,,,,,fee schedule,15607.46,46894.28,MSDRG Base Rate
Osteomyelitis With Mcc,539,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,16227.86,,,,,,,fee schedule,15607.46,46894.28,MSDRG Base Rate
Osteomyelitis With Mcc,539,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,27306.49,,,,,,,fee schedule,15607.46,46894.28,MSDRG Base Rate
Osteomyelitis With Cc,540,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9987.78,,,,,,,fee schedule,9987.78,30009.37,
Osteomyelitis With Cc,540,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,9987.78,,,,,,,fee schedule,9987.78,30009.37,
Osteomyelitis With Cc,540,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13371.07,,,,,,,fee schedule,9987.78,30009.37,
Osteomyelitis With Cc,540,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12734.36,,,,,,,fee schedule,9987.78,30009.37,
Osteomyelitis With Cc,540,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,22303.81,,,,,,,fee schedule,9987.78,30009.37,
Osteomyelitis With Cc,540,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,17332.02,,,,,,,fee schedule,9987.78,30009.37,
Osteomyelitis With Cc,540,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,30009.37,,,,,,,fee schedule,9987.78,30009.37,
Osteomyelitis With Cc,540,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,20629.81,,,,,,,fee schedule,9987.78,30009.37,
Osteomyelitis With Cc,540,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,18683.37,,,,,,,fee schedule,9987.78,30009.37,
Osteomyelitis With Cc,540,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15302.45,,,,,,,fee schedule,9987.78,30009.37,
Osteomyelitis With Cc,540,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Cc,540,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Cc,540,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8092.29,8092.29,8092.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Osteomyelitis With Cc,540,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Cc,540,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Cc,540,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Cc,540,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Cc,540,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",8897.63,8897.63,8897.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Osteomyelitis With Cc,540,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9798.26,9798.26,9798.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Osteomyelitis With Cc,540,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Cc,540,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Cc,540,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Cc,540,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Cc,540,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],8915.13,7049.96,10065.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Osteomyelitis With Cc,540,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",8815.25,8815.25,8815.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Osteomyelitis With Cc,540,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Cc,540,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Cc,540,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis With Cc,540,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11123.02,,,,,,,fee schedule,9987.78,30009.37,MSDRG Base Rate
Osteomyelitis With Cc,540,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,11017.08,,,,,,,fee schedule,9987.78,30009.37,MSDRG Base Rate
Osteomyelitis With Cc,540,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,11017.08,,,,,,,fee schedule,9987.78,30009.37,MSDRG Base Rate
Osteomyelitis With Cc,540,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,11123.02,,,,,,,fee schedule,9987.78,30009.37,MSDRG Base Rate
Osteomyelitis With Cc,540,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,11017.08,,,,,,,fee schedule,9987.78,30009.37,MSDRG Base Rate
Osteomyelitis With Cc,540,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18538.36,,,,,,,fee schedule,9987.78,30009.37,MSDRG Base Rate
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6750.09,,,,,,,fee schedule,6750.09,20281.36,
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,6750.09,,,,,,,fee schedule,6750.09,20281.36,
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9036.63,,,,,,,fee schedule,6750.09,20281.36,
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8606.32,,,,,,,fee schedule,6750.09,20281.36,
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,15073.68,,,,,,,fee schedule,6750.09,20281.36,
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,11713.57,,,,,,,fee schedule,6750.09,20281.36,
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,20281.36,,,,,,,fee schedule,6750.09,20281.36,
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,13942.33,,,,,,,fee schedule,6750.09,20281.36,
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,12626.86,,,,,,,fee schedule,6750.09,20281.36,
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10341.92,,,,,,,fee schedule,6750.09,20281.36,
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",6776.13,6776.13,6776.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],6789.32,6789.32,6789.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],6763.86,6763.86,6763.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7147.28,,,,,,,fee schedule,6750.09,20281.36,MSDRG Base Rate
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,7079.21,,,,,,,fee schedule,6750.09,20281.36,MSDRG Base Rate
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,7079.21,,,,,,,fee schedule,6750.09,20281.36,MSDRG Base Rate
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,7147.28,,,,,,,fee schedule,6750.09,20281.36,MSDRG Base Rate
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,7079.21,,,,,,,fee schedule,6750.09,20281.36,MSDRG Base Rate
Osteomyelitis Without Cc/Mcc,541,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11912.13,,,,,,,fee schedule,6750.09,20281.36,MSDRG Base Rate
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14389.85,,,,,,,fee schedule,14389.85,43235.84,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,14389.85,,,,,,,fee schedule,14389.85,43235.84,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19264.31,,,,,,,fee schedule,14389.85,43235.84,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18346.96,,,,,,,fee schedule,14389.85,43235.84,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,32134.09,,,,,,,fee schedule,14389.85,43235.84,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,24971.01,,,,,,,fee schedule,14389.85,43235.84,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,43235.84,,,,,,,fee schedule,14389.85,43235.84,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,29722.29,,,,,,,fee schedule,14389.85,43235.84,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,26917.97,,,,,,,fee schedule,14389.85,43235.84,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22046.92,,,,,,,fee schedule,14389.85,43235.84,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],8665.37,8665.37,8665.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13251.52,13251.52,16278.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],15988,15988,15988,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13760.24,13760.24,13760.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",13154.19,13154.19,13154.19,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],14152.09,14152.09,14316.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],13629.42,13629.42,13629.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],8277.02,5917.99,14243.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14796.41,,,,,,,fee schedule,14389.85,43235.84,MSDRG Base Rate
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,14655.49,,,,,,,fee schedule,14389.85,43235.84,MSDRG Base Rate
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,14655.49,,,,,,,fee schedule,14389.85,43235.84,MSDRG Base Rate
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,14796.41,,,,,,,fee schedule,14389.85,43235.84,MSDRG Base Rate
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,14655.49,,,,,,,fee schedule,14389.85,43235.84,MSDRG Base Rate
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc,542,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,24660.68,,,,,,,fee schedule,14389.85,43235.84,MSDRG Base Rate
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8185.29,,,,,,,fee schedule,8185.29,24593.59,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,8185.29,,,,,,,fee schedule,8185.29,24593.59,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10958,,,,,,,fee schedule,8185.29,24593.59,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10436.19,,,,,,,fee schedule,8185.29,24593.59,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,18278.64,,,,,,,fee schedule,8185.29,24593.59,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,14204.11,,,,,,,fee schedule,8185.29,24593.59,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,24593.59,,,,,,,fee schedule,8185.29,24593.59,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,16906.75,,,,,,,fee schedule,8185.29,24593.59,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,15311.59,,,,,,,fee schedule,8185.29,24593.59,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12540.82,,,,,,,fee schedule,8185.29,24593.59,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7062.42,6865.54,9090.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7964.11,7964.11,7964.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8070.22,8070.22,8070.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],5432.26,5432.26,5432.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],8172.97,7480.63,8738.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9026.94,,,,,,,fee schedule,8185.29,24593.59,MSDRG Base Rate
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,8940.97,,,,,,,fee schedule,8185.29,24593.59,MSDRG Base Rate
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,8940.97,,,,,,,fee schedule,8185.29,24593.59,MSDRG Base Rate
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,9026.94,,,,,,,fee schedule,8185.29,24593.59,MSDRG Base Rate
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,8940.97,,,,,,,fee schedule,8185.29,24593.59,MSDRG Base Rate
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc,543,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15044.91,,,,,,,fee schedule,8185.29,24593.59,MSDRG Base Rate
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5831.09,,,,,,,fee schedule,5831.09,17520.15,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,5831.09,,,,,,,fee schedule,5831.09,17520.15,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7806.34,,,,,,,fee schedule,5831.09,17520.15,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7434.61,,,,,,,fee schedule,5831.09,17520.15,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,13021.47,,,,,,,fee schedule,5831.09,17520.15,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,10118.82,,,,,,,fee schedule,5831.09,17520.15,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,17520.15,,,,,,,fee schedule,5831.09,17520.15,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,12044.15,,,,,,,fee schedule,5831.09,17520.15,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,10907.77,,,,,,,fee schedule,5831.09,17520.15,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8933.92,,,,,,,fee schedule,5831.09,17520.15,
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],4806.49,4806.49,4806.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],5596.92,5596.92,5596.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,6891.03,,,,,,,fee schedule,5831.09,17520.15,MSDRG Base Rate
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,6825.41,,,,,,,fee schedule,5831.09,17520.15,MSDRG Base Rate
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,6825.41,,,,,,,fee schedule,5831.09,17520.15,MSDRG Base Rate
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,6891.03,,,,,,,fee schedule,5831.09,17520.15,MSDRG Base Rate
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,6825.41,,,,,,,fee schedule,5831.09,17520.15,MSDRG Base Rate
Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc,544,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11485.06,,,,,,,fee schedule,5831.09,17520.15,MSDRG Base Rate
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,19496.4,,,,,,,fee schedule,19496.4,58579.01,
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,19496.4,,,,,,,fee schedule,19496.4,58579.01,
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26100.66,,,,,,,fee schedule,19496.4,58579.01,
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24857.78,,,,,,,fee schedule,19496.4,58579.01,
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,43537.57,,,,,,,fee schedule,19496.4,58579.01,
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,33832.51,,,,,,,fee schedule,19496.4,58579.01,
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,58579.01,,,,,,,fee schedule,19496.4,58579.01,
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,40269.89,,,,,,,fee schedule,19496.4,58579.01,
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,36470.39,,,,,,,fee schedule,19496.4,58579.01,
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,29870.75,,,,,,,fee schedule,19496.4,58579.01,
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],9129.87,9129.87,85975.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],40119.16,40119.16,40119.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",12107.18,12107.18,12107.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],18517.42,18517.42,18517.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],43541.01,43541.01,43541.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],18611.55,18511.5,19712.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],58538.65,58538.65,58538.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,20383.85,,,,,,,fee schedule,19496.4,58579.01,MSDRG Base Rate
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,20189.72,,,,,,,fee schedule,19496.4,58579.01,MSDRG Base Rate
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,20189.72,,,,,,,fee schedule,19496.4,58579.01,MSDRG Base Rate
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,20383.85,,,,,,,fee schedule,19496.4,58579.01,MSDRG Base Rate
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,20189.72,,,,,,,fee schedule,19496.4,58579.01,MSDRG Base Rate
Connective Tissue Disorders With Mcc,545,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,33973.08,,,,,,,fee schedule,19496.4,58579.01,MSDRG Base Rate
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8932.99,,,,,,,fee schedule,8932.99,26840.12,
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,8932.99,,,,,,,fee schedule,8932.99,26840.12,
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11958.97,,,,,,,fee schedule,8932.99,26840.12,
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11389.5,,,,,,,fee schedule,8932.99,26840.12,
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,19948.33,,,,,,,fee schedule,8932.99,26840.12,
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,15501.6,,,,,,,fee schedule,8932.99,26840.12,
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,26840.12,,,,,,,fee schedule,8932.99,26840.12,
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,18451.12,,,,,,,fee schedule,8932.99,26840.12,
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,16710.24,,,,,,,fee schedule,8932.99,26840.12,
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13686.38,,,,,,,fee schedule,8932.99,26840.12,
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],15.66,15.66,15.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],19004.65,16068.37,19114.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",5629.68,5629.68,5629.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",5287,5287,5287,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7127.51,7127.51,7127.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],13034.65,13034.65,13034.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],1038.94,1038.94,1038.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10006.63,,,,,,,fee schedule,8932.99,26840.12,MSDRG Base Rate
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,9911.32,,,,,,,fee schedule,8932.99,26840.12,MSDRG Base Rate
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,9911.32,,,,,,,fee schedule,8932.99,26840.12,MSDRG Base Rate
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,10006.63,,,,,,,fee schedule,8932.99,26840.12,MSDRG Base Rate
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,9911.32,,,,,,,fee schedule,8932.99,26840.12,MSDRG Base Rate
Connective Tissue Disorders With Cc,546,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16677.71,,,,,,,fee schedule,8932.99,26840.12,MSDRG Base Rate
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5757.79,,,,,,,fee schedule,5757.79,17299.9,
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,5757.79,,,,,,,fee schedule,5757.79,17299.9,
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7708.2,,,,,,,fee schedule,5757.79,17299.9,
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7341.15,,,,,,,fee schedule,5757.79,17299.9,
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,12857.77,,,,,,,fee schedule,5757.79,17299.9,
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,9991.62,,,,,,,fee schedule,5757.79,17299.9,
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,17299.9,,,,,,,fee schedule,5757.79,17299.9,
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,11892.74,,,,,,,fee schedule,5757.79,17299.9,
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,10770.65,,,,,,,fee schedule,5757.79,17299.9,
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8821.61,,,,,,,fee schedule,5757.79,17299.9,
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7528.52,,,,,,,fee schedule,5757.79,17299.9,MSDRG Base Rate
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,7456.82,,,,,,,fee schedule,5757.79,17299.9,MSDRG Base Rate
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,7456.82,,,,,,,fee schedule,5757.79,17299.9,MSDRG Base Rate
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,7528.52,,,,,,,fee schedule,5757.79,17299.9,MSDRG Base Rate
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,7456.82,,,,,,,fee schedule,5757.79,17299.9,MSDRG Base Rate
Connective Tissue Disorders Without Cc/Mcc,547,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12547.54,,,,,,,fee schedule,5757.79,17299.9,MSDRG Base Rate
Septic Arthritis With Mcc,548,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,15544.18,,,,,,,fee schedule,15544.18,46704.17,
Septic Arthritis With Mcc,548,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,15544.18,,,,,,,fee schedule,15544.18,46704.17,
Septic Arthritis With Mcc,548,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20809.66,,,,,,,fee schedule,15544.18,46704.17,
Septic Arthritis With Mcc,548,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19818.73,,,,,,,fee schedule,15544.18,46704.17,
Septic Arthritis With Mcc,548,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,34711.85,,,,,,,fee schedule,15544.18,46704.17,
Septic Arthritis With Mcc,548,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,26974.16,,,,,,,fee schedule,15544.18,46704.17,
Septic Arthritis With Mcc,548,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,46704.17,,,,,,,fee schedule,15544.18,46704.17,
Septic Arthritis With Mcc,548,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,32106.58,,,,,,,fee schedule,15544.18,46704.17,
Septic Arthritis With Mcc,548,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,29077.29,,,,,,,fee schedule,15544.18,46704.17,
Septic Arthritis With Mcc,548,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23815.5,,,,,,,fee schedule,15544.18,46704.17,
Septic Arthritis With Mcc,548,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Mcc,548,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Mcc,548,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13054.42,13054.42,13054.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Septic Arthritis With Mcc,548,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Mcc,548,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Mcc,548,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Mcc,548,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Mcc,548,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],15218.19,15218.19,15218.19,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Septic Arthritis With Mcc,548,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Mcc,548,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Mcc,548,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Mcc,548,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Mcc,548,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Mcc,548,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],15318.87,15318.87,15318.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Septic Arthritis With Mcc,548,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Mcc,548,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Mcc,548,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Mcc,548,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Mcc,548,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,16080.77,,,,,,,fee schedule,15544.18,46704.17,MSDRG Base Rate
Septic Arthritis With Mcc,548,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,15927.62,,,,,,,fee schedule,15544.18,46704.17,MSDRG Base Rate
Septic Arthritis With Mcc,548,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,15927.62,,,,,,,fee schedule,15544.18,46704.17,MSDRG Base Rate
Septic Arthritis With Mcc,548,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,16080.77,,,,,,,fee schedule,15544.18,46704.17,MSDRG Base Rate
Septic Arthritis With Mcc,548,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,15927.62,,,,,,,fee schedule,15544.18,46704.17,MSDRG Base Rate
Septic Arthritis With Mcc,548,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,26801.28,,,,,,,fee schedule,15544.18,46704.17,MSDRG Base Rate
Septic Arthritis With Cc,549,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9297.96,,,,,,,fee schedule,9297.96,27936.72,
Septic Arthritis With Cc,549,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,9297.96,,,,,,,fee schedule,9297.96,27936.72,
Septic Arthritis With Cc,549,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12447.58,,,,,,,fee schedule,9297.96,27936.72,
Septic Arthritis With Cc,549,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11854.84,,,,,,,fee schedule,9297.96,27936.72,
Septic Arthritis With Cc,549,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,20763.36,,,,,,,fee schedule,9297.96,27936.72,
Septic Arthritis With Cc,549,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,16134.95,,,,,,,fee schedule,9297.96,27936.72,
Septic Arthritis With Cc,549,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,27936.72,,,,,,,fee schedule,9297.96,27936.72,
Septic Arthritis With Cc,549,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,19204.98,,,,,,,fee schedule,9297.96,27936.72,
Septic Arthritis With Cc,549,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,17392.97,,,,,,,fee schedule,9297.96,27936.72,
Septic Arthritis With Cc,549,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14245.56,,,,,,,fee schedule,9297.96,27936.72,
Septic Arthritis With Cc,549,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Cc,549,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Cc,549,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8050.04,8050.04,8050.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Septic Arthritis With Cc,549,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Cc,549,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Cc,549,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Cc,549,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Cc,549,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",8290.63,8290.63,8290.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Septic Arthritis With Cc,549,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Cc,549,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Cc,549,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Cc,549,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Cc,549,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Cc,549,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],15494,15494,15494,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Septic Arthritis With Cc,549,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],9409.09,9409.09,9409.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Septic Arthritis With Cc,549,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Cc,549,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Cc,549,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis With Cc,549,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10426.93,,,,,,,fee schedule,9297.96,27936.72,MSDRG Base Rate
Septic Arthritis With Cc,549,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,10327.63,,,,,,,fee schedule,9297.96,27936.72,MSDRG Base Rate
Septic Arthritis With Cc,549,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,10327.63,,,,,,,fee schedule,9297.96,27936.72,MSDRG Base Rate
Septic Arthritis With Cc,549,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,10426.93,,,,,,,fee schedule,9297.96,27936.72,MSDRG Base Rate
Septic Arthritis With Cc,549,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,10327.63,,,,,,,fee schedule,9297.96,27936.72,MSDRG Base Rate
Septic Arthritis With Cc,549,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,17378.22,,,,,,,fee schedule,9297.96,27936.72,MSDRG Base Rate
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6652.09,,,,,,,fee schedule,6652.09,19986.93,
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,6652.09,,,,,,,fee schedule,6652.09,19986.93,
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8905.44,,,,,,,fee schedule,6652.09,19986.93,
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8481.37,,,,,,,fee schedule,6652.09,19986.93,
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,14854.85,,,,,,,fee schedule,6652.09,19986.93,
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,11543.52,,,,,,,fee schedule,6652.09,19986.93,
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,19986.93,,,,,,,fee schedule,6652.09,19986.93,
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,13739.93,,,,,,,fee schedule,6652.09,19986.93,
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,12443.55,,,,,,,fee schedule,6652.09,19986.93,
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10191.78,,,,,,,fee schedule,6652.09,19986.93,
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],11841.07,11841.07,11841.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7824.62,,,,,,,fee schedule,6652.09,19986.93,MSDRG Base Rate
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,7750.1,,,,,,,fee schedule,6652.09,19986.93,MSDRG Base Rate
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,7750.1,,,,,,,fee schedule,6652.09,19986.93,MSDRG Base Rate
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,7824.62,,,,,,,fee schedule,6652.09,19986.93,MSDRG Base Rate
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,7750.1,,,,,,,fee schedule,6652.09,19986.93,MSDRG Base Rate
Septic Arthritis Without Cc/Mcc,550,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,13041.04,,,,,,,fee schedule,6652.09,19986.93,MSDRG Base Rate
Medical Back Problems With Mcc,551,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13166.07,,,,,,,fee schedule,13166.07,39558.86,
Medical Back Problems With Mcc,551,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,13166.07,,,,,,,fee schedule,13166.07,39558.86,
Medical Back Problems With Mcc,551,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17625.98,,,,,,,fee schedule,13166.07,39558.86,
Medical Back Problems With Mcc,551,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16786.65,,,,,,,fee schedule,13166.07,39558.86,
Medical Back Problems With Mcc,551,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,29401.26,,,,,,,fee schedule,13166.07,39558.86,
Medical Back Problems With Mcc,551,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,22847.36,,,,,,,fee schedule,13166.07,39558.86,
Medical Back Problems With Mcc,551,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,39558.86,,,,,,,fee schedule,13166.07,39558.86,
Medical Back Problems With Mcc,551,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,27194.57,,,,,,,fee schedule,13166.07,39558.86,
Medical Back Problems With Mcc,551,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,24628.73,,,,,,,fee schedule,13166.07,39558.86,
Medical Back Problems With Mcc,551,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20171.95,,,,,,,fee schedule,13166.07,39558.86,
Medical Back Problems With Mcc,551,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],10835.02,10835.02,10835.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Medical Back Problems With Mcc,551,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Medical Back Problems With Mcc,551,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12546.15,12546.15,12546.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Medical Back Problems With Mcc,551,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Medical Back Problems With Mcc,551,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],23.09,23.09,23.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Medical Back Problems With Mcc,551,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Medical Back Problems With Mcc,551,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Medical Back Problems With Mcc,551,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4979.63,4979.63,4979.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Medical Back Problems With Mcc,551,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11284.12,11284.12,12926.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Medical Back Problems With Mcc,551,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Medical Back Problems With Mcc,551,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Medical Back Problems With Mcc,551,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Medical Back Problems With Mcc,551,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Medical Back Problems With Mcc,551,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],11355.69,11355.69,13047.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Medical Back Problems With Mcc,551,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4933.52,4933.52,4933.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Medical Back Problems With Mcc,551,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Medical Back Problems With Mcc,551,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Medical Back Problems With Mcc,551,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Medical Back Problems With Mcc,551,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14090.17,,,,,,,fee schedule,13166.07,39558.86,MSDRG Base Rate
Medical Back Problems With Mcc,551,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,13955.98,,,,,,,fee schedule,13166.07,39558.86,MSDRG Base Rate
Medical Back Problems With Mcc,551,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,13955.98,,,,,,,fee schedule,13166.07,39558.86,MSDRG Base Rate
Medical Back Problems With Mcc,551,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,14090.17,,,,,,,fee schedule,13166.07,39558.86,MSDRG Base Rate
Medical Back Problems With Mcc,551,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,13955.98,,,,,,,fee schedule,13166.07,39558.86,MSDRG Base Rate
Medical Back Problems With Mcc,551,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23483.62,,,,,,,fee schedule,13166.07,39558.86,MSDRG Base Rate
Medical Back Problems Without Mcc,552,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7436.83,,,,,,,fee schedule,7436.83,22344.74,
Medical Back Problems Without Mcc,552,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,7436.83,,,,,,,fee schedule,7436.83,22344.74,
Medical Back Problems Without Mcc,552,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9956,,,,,,,fee schedule,7436.83,22344.74,
Medical Back Problems Without Mcc,552,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9481.9,,,,,,,fee schedule,7436.83,22344.74,
Medical Back Problems Without Mcc,552,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,16607.24,,,,,,,fee schedule,7436.83,22344.74,
Medical Back Problems Without Mcc,552,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,12905.28,,,,,,,fee schedule,7436.83,22344.74,
Medical Back Problems Without Mcc,552,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,22344.74,,,,,,,fee schedule,7436.83,22344.74,
Medical Back Problems Without Mcc,552,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,15360.79,,,,,,,fee schedule,7436.83,22344.74,
Medical Back Problems Without Mcc,552,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,13911.49,,,,,,,fee schedule,7436.83,22344.74,
Medical Back Problems Without Mcc,552,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11394.08,,,,,,,fee schedule,7436.83,22344.74,
Medical Back Problems Without Mcc,552,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Medical Back Problems Without Mcc,552,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Medical Back Problems Without Mcc,552,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],14423.16,14272.79,14660.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Medical Back Problems Without Mcc,552,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Medical Back Problems Without Mcc,552,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6905.83,6905.83,6905.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Medical Back Problems Without Mcc,552,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],13911.49,13911.49,13911.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Medical Back Problems Without Mcc,552,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Medical Back Problems Without Mcc,552,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3594.96,3594.96,3594.96,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Medical Back Problems Without Mcc,552,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],9441.9,9441.9,9441.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Medical Back Problems Without Mcc,552,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7203.63,7203.63,7238.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Medical Back Problems Without Mcc,552,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],15721.08,15721.08,15721.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Medical Back Problems Without Mcc,552,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Medical Back Problems Without Mcc,552,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Medical Back Problems Without Mcc,552,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],90092.4,90092.4,90092.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Medical Back Problems Without Mcc,552,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],6114.39,15.13,7708.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Medical Back Problems Without Mcc,552,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Medical Back Problems Without Mcc,552,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Medical Back Problems Without Mcc,552,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Medical Back Problems Without Mcc,552,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8505.86,,,,,,,fee schedule,7436.83,22344.74,MSDRG Base Rate
Medical Back Problems Without Mcc,552,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,8424.85,,,,,,,fee schedule,7436.83,22344.74,MSDRG Base Rate
Medical Back Problems Without Mcc,552,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,8424.85,,,,,,,fee schedule,7436.83,22344.74,MSDRG Base Rate
Medical Back Problems Without Mcc,552,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,8505.86,,,,,,,fee schedule,7436.83,22344.74,MSDRG Base Rate
Medical Back Problems Without Mcc,552,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,8424.85,,,,,,,fee schedule,7436.83,22344.74,MSDRG Base Rate
Medical Back Problems Without Mcc,552,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14176.44,,,,,,,fee schedule,7436.83,22344.74,MSDRG Base Rate
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10079.61,,,,,,,fee schedule,10079.61,30285.26,
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,10079.61,,,,,,,fee schedule,10079.61,30285.26,
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13494,,,,,,,fee schedule,10079.61,30285.26,
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12851.43,,,,,,,fee schedule,10079.61,30285.26,
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,22508.86,,,,,,,fee schedule,10079.61,30285.26,
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,17491.36,,,,,,,fee schedule,10079.61,30285.26,
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,30285.26,,,,,,,fee schedule,10079.61,30285.26,
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,20819.47,,,,,,,fee schedule,10079.61,30285.26,
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,18855.13,,,,,,,fee schedule,10079.61,30285.26,
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15443.13,,,,,,,fee schedule,10079.61,30285.26,
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],10557.7,10557.7,10557.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11123.02,,,,,,,fee schedule,10079.61,30285.26,MSDRG Base Rate
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,11017.08,,,,,,,fee schedule,10079.61,30285.26,MSDRG Base Rate
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,11017.08,,,,,,,fee schedule,10079.61,30285.26,MSDRG Base Rate
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,11123.02,,,,,,,fee schedule,10079.61,30285.26,MSDRG Base Rate
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,11017.08,,,,,,,fee schedule,10079.61,30285.26,MSDRG Base Rate
Bone Diseases And Arthropathies With Mcc,553,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18538.36,,,,,,,fee schedule,10079.61,30285.26,MSDRG Base Rate
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6439.9,,,,,,,fee schedule,6439.9,19349.37,
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,6439.9,,,,,,,fee schedule,6439.9,19349.37,
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8621.37,,,,,,,fee schedule,6439.9,19349.37,
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8210.83,,,,,,,fee schedule,6439.9,19349.37,
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,14380.99,,,,,,,fee schedule,6439.9,19349.37,
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,11175.29,,,,,,,fee schedule,6439.9,19349.37,
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,19349.37,,,,,,,fee schedule,6439.9,19349.37,
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,13301.64,,,,,,,fee schedule,6439.9,19349.37,
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,12046.62,,,,,,,fee schedule,6439.9,19349.37,
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9866.67,,,,,,,fee schedule,6439.9,19349.37,
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],11.29,11.29,11.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],11551.64,11551.64,11551.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],13492.14,13492.14,13492.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6083.1,6083.1,6083.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],14162,14162,14162,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],6735.56,6610.97,6977.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7480.87,,,,,,,fee schedule,6439.9,19349.37,MSDRG Base Rate
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,7409.63,,,,,,,fee schedule,6439.9,19349.37,MSDRG Base Rate
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,7409.63,,,,,,,fee schedule,6439.9,19349.37,MSDRG Base Rate
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,7480.87,,,,,,,fee schedule,6439.9,19349.37,MSDRG Base Rate
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,7409.63,,,,,,,fee schedule,6439.9,19349.37,MSDRG Base Rate
Bone Diseases And Arthropathies Without Mcc,554,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12468.12,,,,,,,fee schedule,6439.9,19349.37,MSDRG Base Rate
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10389.8,,,,,,,fee schedule,10389.8,31217.26,
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,10389.8,,,,,,,fee schedule,10389.8,31217.26,
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13909.26,,,,,,,fee schedule,10389.8,31217.26,
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13246.92,,,,,,,fee schedule,10389.8,31217.26,
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,23201.54,,,,,,,fee schedule,10389.8,31217.26,
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,18029.64,,,,,,,fee schedule,10389.8,31217.26,
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,31217.26,,,,,,,fee schedule,10389.8,31217.26,
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,21460.17,,,,,,,fee schedule,10389.8,31217.26,
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,19435.38,,,,,,,fee schedule,10389.8,31217.26,
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15918.38,,,,,,,fee schedule,10389.8,31217.26,
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11322.23,,,,,,,fee schedule,10389.8,31217.26,MSDRG Base Rate
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,11214.4,,,,,,,fee schedule,10389.8,31217.26,MSDRG Base Rate
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,11214.4,,,,,,,fee schedule,10389.8,31217.26,MSDRG Base Rate
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,11322.23,,,,,,,fee schedule,10389.8,31217.26,MSDRG Base Rate
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,11214.4,,,,,,,fee schedule,10389.8,31217.26,MSDRG Base Rate
Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc,555,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18870.39,,,,,,,fee schedule,10389.8,31217.26,MSDRG Base Rate
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6300.24,,,,,,,fee schedule,6300.24,18929.74,
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,6300.24,,,,,,,fee schedule,6300.24,18929.74,
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8434.4,,,,,,,fee schedule,6300.24,18929.74,
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8032.76,,,,,,,fee schedule,6300.24,18929.74,
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,14069.11,,,,,,,fee schedule,6300.24,18929.74,
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,10932.94,,,,,,,fee schedule,6300.24,18929.74,
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,18929.74,,,,,,,fee schedule,6300.24,18929.74,
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,13013.16,,,,,,,fee schedule,6300.24,18929.74,
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,11785.36,,,,,,,fee schedule,6300.24,18929.74,
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9652.7,,,,,,,fee schedule,6300.24,18929.74,
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],11126.33,11126.33,11126.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3070.39,3070.39,3070.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",2883.49,2883.49,2883.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7484.78,,,,,,,fee schedule,6300.24,18929.74,MSDRG Base Rate
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,7413.49,,,,,,,fee schedule,6300.24,18929.74,MSDRG Base Rate
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,7413.49,,,,,,,fee schedule,6300.24,18929.74,MSDRG Base Rate
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,7484.78,,,,,,,fee schedule,6300.24,18929.74,MSDRG Base Rate
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,7413.49,,,,,,,fee schedule,6300.24,18929.74,MSDRG Base Rate
Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc,556,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12474.63,,,,,,,fee schedule,6300.24,18929.74,MSDRG Base Rate
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11957.72,,,,,,,fee schedule,11957.72,35928.24,
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,11957.72,,,,,,,fee schedule,11957.72,35928.24,
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16008.31,,,,,,,fee schedule,11957.72,35928.24,
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15246.01,,,,,,,fee schedule,11957.72,35928.24,
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,26702.88,,,,,,,fee schedule,11957.72,35928.24,
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,20750.48,,,,,,,fee schedule,11957.72,35928.24,
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,35928.24,,,,,,,fee schedule,11957.72,35928.24,
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,24698.72,,,,,,,fee schedule,11957.72,35928.24,
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,22368.37,,,,,,,fee schedule,11957.72,35928.24,
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18320.62,,,,,,,fee schedule,11957.72,35928.24,
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],52021.8,52021.8,52021.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],16404.72,16404.72,16404.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],10702.02,10702.02,10702.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],10097.04,10097.04,10097.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],14884.14,14884.14,14884.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],11656.4,11656.4,11656.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12612.06,,,,,,,fee schedule,11957.72,35928.24,MSDRG Base Rate
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,12491.95,,,,,,,fee schedule,11957.72,35928.24,MSDRG Base Rate
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,12491.95,,,,,,,fee schedule,11957.72,35928.24,MSDRG Base Rate
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,12612.06,,,,,,,fee schedule,11957.72,35928.24,MSDRG Base Rate
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,12491.95,,,,,,,fee schedule,11957.72,35928.24,MSDRG Base Rate
"Tendonitis, Myositis And Bursitis With Mcc",557,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21020.11,,,,,,,fee schedule,11957.72,35928.24,MSDRG Base Rate
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6665.21,,,,,,,fee schedule,6665.21,20026.34,
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,6665.21,,,,,,,fee schedule,6665.21,20026.34,
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8923,,,,,,,fee schedule,6665.21,20026.34,
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8498.1,,,,,,,fee schedule,6665.21,20026.34,
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,14884.14,,,,,,,fee schedule,6665.21,20026.34,
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,11566.28,,,,,,,fee schedule,6665.21,20026.34,
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,20026.34,,,,,,,fee schedule,6665.21,20026.34,
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,13767.02,,,,,,,fee schedule,6665.21,20026.34,
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,12468.09,,,,,,,fee schedule,6665.21,20026.34,
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10211.88,,,,,,,fee schedule,6665.21,20026.34,
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],20026.34,20026.34,20026.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7942.91,7942.91,7942.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],9868.64,9868.64,13597.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],6794.82,6794.82,6794.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4174.48,4174.48,4174.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3920.38,3920.38,3920.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],8498.1,8498.1,8498.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],5683.45,5683.45,5683.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],8232.35,8232.35,8232.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],15898.96,15898.96,15898.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7973.84,,,,,,,fee schedule,6665.21,20026.34,MSDRG Base Rate
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,7897.9,,,,,,,fee schedule,6665.21,20026.34,MSDRG Base Rate
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,7897.9,,,,,,,fee schedule,6665.21,20026.34,MSDRG Base Rate
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,7973.84,,,,,,,fee schedule,6665.21,20026.34,MSDRG Base Rate
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,7897.9,,,,,,,fee schedule,6665.21,20026.34,MSDRG Base Rate
"Tendonitis, Myositis And Bursitis Without Mcc",558,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,13289.73,,,,,,,fee schedule,6665.21,20026.34,MSDRG Base Rate
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14321.95,,,,,,,fee schedule,14321.95,43031.82,
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,14321.95,,,,,,,fee schedule,14321.95,43031.82,
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19173.4,,,,,,,fee schedule,14321.95,43031.82,
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18260.39,,,,,,,fee schedule,14321.95,43031.82,
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,31982.46,,,,,,,fee schedule,14321.95,43031.82,
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,24853.18,,,,,,,fee schedule,14321.95,43031.82,
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,43031.82,,,,,,,fee schedule,14321.95,43031.82,
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,29582.04,,,,,,,fee schedule,14321.95,43031.82,
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,26790.95,,,,,,,fee schedule,14321.95,43031.82,
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21942.89,,,,,,,fee schedule,14321.95,43031.82,
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12612.76,12612.76,12612.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],14060.72,14060.72,14060.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15565.15,,,,,,,fee schedule,14321.95,43031.82,MSDRG Base Rate
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,15416.91,,,,,,,fee schedule,14321.95,43031.82,MSDRG Base Rate
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,15416.91,,,,,,,fee schedule,14321.95,43031.82,MSDRG Base Rate
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,15565.15,,,,,,,fee schedule,14321.95,43031.82,MSDRG Base Rate
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,15416.91,,,,,,,fee schedule,14321.95,43031.82,MSDRG Base Rate
"Aftercare, Musculoskeletal System And Connective Tissue With Mcc",559,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,25941.91,,,,,,,fee schedule,14321.95,43031.82,MSDRG Base Rate
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8787.15,,,,,,,fee schedule,8787.15,26401.94,
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,8787.15,,,,,,,fee schedule,8787.15,26401.94,
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11763.74,,,,,,,fee schedule,8787.15,26401.94,
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11203.56,,,,,,,fee schedule,8787.15,26401.94,
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,19622.66,,,,,,,fee schedule,8787.15,26401.94,
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,15248.53,,,,,,,fee schedule,8787.15,26401.94,
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,26401.94,,,,,,,fee schedule,8787.15,26401.94,
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,18149.9,,,,,,,fee schedule,8787.15,26401.94,
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,16437.44,,,,,,,fee schedule,8787.15,26401.94,
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13462.94,,,,,,,fee schedule,8787.15,26401.94,
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],25711,25711,25711,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7180.04,7180.04,9107.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8729.57,8729.57,8729.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9793.34,,,,,,,fee schedule,8787.15,26401.94,MSDRG Base Rate
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,9700.07,,,,,,,fee schedule,8787.15,26401.94,MSDRG Base Rate
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,9700.07,,,,,,,fee schedule,8787.15,26401.94,MSDRG Base Rate
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,9793.34,,,,,,,fee schedule,8787.15,26401.94,MSDRG Base Rate
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,9700.07,,,,,,,fee schedule,8787.15,26401.94,MSDRG Base Rate
"Aftercare, Musculoskeletal System And Connective Tissue With Cc",560,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16322.23,,,,,,,fee schedule,8787.15,26401.94,MSDRG Base Rate
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6308.72,,,,,,,fee schedule,6308.72,18955.24,
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,6308.72,,,,,,,fee schedule,6308.72,18955.24,
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8445.76,,,,,,,fee schedule,6308.72,18955.24,
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8043.58,,,,,,,fee schedule,6308.72,18955.24,
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,14088.07,,,,,,,fee schedule,6308.72,18955.24,
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,10947.66,,,,,,,fee schedule,6308.72,18955.24,
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,18955.24,,,,,,,fee schedule,6308.72,18955.24,
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,13030.7,,,,,,,fee schedule,6308.72,18955.24,
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,11801.24,,,,,,,fee schedule,6308.72,18955.24,
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9665.7,,,,,,,fee schedule,6308.72,18955.24,
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],14188.07,14188.07,14188.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7276.18,,,,,,,fee schedule,6308.72,18955.24,MSDRG Base Rate
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,7206.89,,,,,,,fee schedule,6308.72,18955.24,MSDRG Base Rate
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,7206.89,,,,,,,fee schedule,6308.72,18955.24,MSDRG Base Rate
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,7276.18,,,,,,,fee schedule,6308.72,18955.24,MSDRG Base Rate
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,7206.89,,,,,,,fee schedule,6308.72,18955.24,MSDRG Base Rate
"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc",561,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12126.98,,,,,,,fee schedule,6308.72,18955.24,MSDRG Base Rate
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11294.13,,,,,,,fee schedule,11294.13,33934.42,
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,11294.13,,,,,,,fee schedule,11294.13,33934.42,
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15119.93,,,,,,,fee schedule,11294.13,33934.42,
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14399.94,,,,,,,fee schedule,11294.13,33934.42,
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,25221.01,,,,,,,fee schedule,11294.13,33934.42,
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,19598.94,,,,,,,fee schedule,11294.13,33934.42,
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,33934.42,,,,,,,fee schedule,11294.13,33934.42,
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,23328.07,,,,,,,fee schedule,11294.13,33934.42,
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,21127.05,,,,,,,fee schedule,11294.13,33934.42,
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17303.92,,,,,,,fee schedule,11294.13,33934.42,
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],10234.37,10234.37,11414.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9444.06,9444.06,9444.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],10362.71,6845.67,11186.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12126.91,,,,,,,fee schedule,11294.13,33934.42,MSDRG Base Rate
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,12011.42,,,,,,,fee schedule,11294.13,33934.42,MSDRG Base Rate
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,12011.42,,,,,,,fee schedule,11294.13,33934.42,MSDRG Base Rate
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,12126.91,,,,,,,fee schedule,11294.13,33934.42,MSDRG Base Rate
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,12011.42,,,,,,,fee schedule,11294.13,33934.42,MSDRG Base Rate
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc",562,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20211.52,,,,,,,fee schedule,11294.13,33934.42,MSDRG Base Rate
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6895.92,,,,,,,fee schedule,6895.92,20719.54,
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,6895.92,,,,,,,fee schedule,6895.92,20719.54,
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9231.87,,,,,,,fee schedule,6895.92,20719.54,
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8792.26,,,,,,,fee schedule,6895.92,20719.54,
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,15399.34,,,,,,,fee schedule,6895.92,20719.54,
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,11966.64,,,,,,,fee schedule,6895.92,20719.54,
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,20719.54,,,,,,,fee schedule,6895.92,20719.54,
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,14243.56,,,,,,,fee schedule,6895.92,20719.54,
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,12899.67,,,,,,,fee schedule,6895.92,20719.54,
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10565.36,,,,,,,fee schedule,6895.92,20719.54,
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7172.72,7172.72,7172.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],8490.48,8490.48,8490.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],10188.99,10188.99,10188.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3363.68,3363.68,3363.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],5128.37,5128.37,5128.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],15334.79,15334.79,15334.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],7160.46,5764,7165.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",181.94,181.94,3332.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7991.8,,,,,,,fee schedule,6895.92,20719.54,MSDRG Base Rate
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,7915.69,,,,,,,fee schedule,6895.92,20719.54,MSDRG Base Rate
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,7915.69,,,,,,,fee schedule,6895.92,20719.54,MSDRG Base Rate
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,7991.8,,,,,,,fee schedule,6895.92,20719.54,MSDRG Base Rate
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,7915.69,,,,,,,fee schedule,6895.92,20719.54,MSDRG Base Rate
"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc",563,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,13319.67,,,,,,,fee schedule,6895.92,20719.54,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12108.18,,,,,,,fee schedule,12108.18,36380.33,
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,12108.18,,,,,,,fee schedule,12108.18,36380.33,
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16209.74,,,,,,,fee schedule,12108.18,36380.33,
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15437.85,,,,,,,fee schedule,12108.18,36380.33,
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,27038.89,,,,,,,fee schedule,12108.18,36380.33,
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,21011.59,,,,,,,fee schedule,12108.18,36380.33,
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,36380.33,,,,,,,fee schedule,12108.18,36380.33,
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,25009.5,,,,,,,fee schedule,12108.18,36380.33,
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,22649.83,,,,,,,fee schedule,12108.18,36380.33,
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18551.15,,,,,,,fee schedule,12108.18,36380.33,
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",7034.07,7034.07,7034.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],11592.13,11592.13,11592.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],10237.49,10237.49,10237.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],11819.74,11819.74,11819.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13055.03,,,,,,,fee schedule,12108.18,36380.33,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,12930.69,,,,,,,fee schedule,12108.18,36380.33,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,12930.69,,,,,,,fee schedule,12108.18,36380.33,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,13055.03,,,,,,,fee schedule,12108.18,36380.33,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,12930.69,,,,,,,fee schedule,12108.18,36380.33,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc,564,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21758.38,,,,,,,fee schedule,12108.18,36380.33,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7867.39,,,,,,,fee schedule,7867.39,23638.41,
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,7867.39,,,,,,,fee schedule,7867.39,23638.41,
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10532.41,,,,,,,fee schedule,7867.39,23638.41,
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10030.87,,,,,,,fee schedule,7867.39,23638.41,
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,17568.73,,,,,,,fee schedule,7867.39,23638.41,
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,13652.44,,,,,,,fee schedule,7867.39,23638.41,
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,23638.41,,,,,,,fee schedule,7867.39,23638.41,
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,16250.12,,,,,,,fee schedule,7867.39,23638.41,
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,14716.91,,,,,,,fee schedule,7867.39,23638.41,
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12053.75,,,,,,,fee schedule,7867.39,23638.41,
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6884.03,6884.03,6884.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4712.24,4712.24,4712.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7758.12,7758.12,7758.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],8068.63,6516.53,8086.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8608.2,,,,,,,fee schedule,7867.39,23638.41,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,8526.22,,,,,,,fee schedule,7867.39,23638.41,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,8526.22,,,,,,,fee schedule,7867.39,23638.41,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,8608.2,,,,,,,fee schedule,7867.39,23638.41,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,8526.22,,,,,,,fee schedule,7867.39,23638.41,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue Diagnoses With Cc,565,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14347.01,,,,,,,fee schedule,7867.39,23638.41,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5771.68,,,,,,,fee schedule,5771.68,17341.63,
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,5771.68,,,,,,,fee schedule,5771.68,17341.63,
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7726.8,,,,,,,fee schedule,5771.68,17341.63,
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7358.85,,,,,,,fee schedule,5771.68,17341.63,
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,12888.79,,,,,,,fee schedule,5771.68,17341.63,
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,10015.72,,,,,,,fee schedule,5771.68,17341.63,
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,17341.63,,,,,,,fee schedule,5771.68,17341.63,
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,11921.43,,,,,,,fee schedule,5771.68,17341.63,
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,10796.63,,,,,,,fee schedule,5771.68,17341.63,
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8842.89,,,,,,,fee schedule,5771.68,17341.63,
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,6849.62,,,,,,,fee schedule,5771.68,17341.63,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,6784.39,,,,,,,fee schedule,5771.68,17341.63,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,6784.39,,,,,,,fee schedule,5771.68,17341.63,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,6849.62,,,,,,,fee schedule,5771.68,17341.63,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,6784.39,,,,,,,fee schedule,5771.68,17341.63,MSDRG Base Rate
Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc,566,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11416.04,,,,,,,fee schedule,5771.68,17341.63,MSDRG Base Rate
"Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx",567,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx",567,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx",567,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx",567,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx",567,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx",567,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx",567,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx",567,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx",567,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx",567,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx",567,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx",567,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx",567,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx",567,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx",567,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx",567,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx",567,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx",567,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx",568,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx",568,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx",568,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx",568,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx",568,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx",568,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx",568,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx",568,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx",568,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx",568,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx",568,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx",568,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx",568,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx",568,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx",568,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx",568,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx",568,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx",568,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Small & Large Bowel Procedures w CC w Major Gi Dx,569,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Small & Large Bowel Procedures w CC w Major Gi Dx,569,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Major Small & Large Bowel Procedures w CC w Major Gi Dx,569,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Major Small & Large Bowel Procedures w CC w Major Gi Dx,569,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Small & Large Bowel Procedures w CC w Major Gi Dx,569,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Small & Large Bowel Procedures w CC w Major Gi Dx,569,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Major Small & Large Bowel Procedures w CC w Major Gi Dx,569,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Small & Large Bowel Procedures w CC w Major Gi Dx,569,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Small & Large Bowel Procedures w CC w Major Gi Dx,569,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Major Small & Large Bowel Procedures w CC w Major Gi Dx,569,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Major Small & Large Bowel Procedures w CC w Major Gi Dx,569,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Small & Large Bowel Procedures w CC w Major Gi Dx,569,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Small & Large Bowel Procedures w CC w Major Gi Dx,569,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Major Small & Large Bowel Procedures w CC w Major Gi Dx,569,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Major Small & Large Bowel Procedures w CC w Major Gi Dx,569,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Small & Large Bowel Procedures w CC w Major Gi Dx,569,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Small & Large Bowel Procedures w CC w Major Gi Dx,569,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Small & Large Bowel Procedures w CC w Major Gi Dx,569,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Mcc,570,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,23228.7,,,,,,,fee schedule,23228.7,69793.11,
Skin Debridement With Mcc,570,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,23228.7,,,,,,,fee schedule,23228.7,69793.11,
Skin Debridement With Mcc,570,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31097.25,,,,,,,fee schedule,23228.7,69793.11,
Skin Debridement With Mcc,570,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29616.44,,,,,,,fee schedule,23228.7,69793.11,
Skin Debridement With Mcc,570,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,51872.2,,,,,,,fee schedule,23228.7,69793.11,
Skin Debridement With Mcc,570,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,40309.26,,,,,,,fee schedule,23228.7,69793.11,
Skin Debridement With Mcc,570,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,69793.11,,,,,,,fee schedule,23228.7,69793.11,
Skin Debridement With Mcc,570,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,47978.97,,,,,,,fee schedule,23228.7,69793.11,
Skin Debridement With Mcc,570,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,43452.11,,,,,,,fee schedule,23228.7,69793.11,
Skin Debridement With Mcc,570,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,35589.07,,,,,,,fee schedule,23228.7,69793.11,
Skin Debridement With Mcc,570,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Mcc,570,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Mcc,570,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Mcc,570,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Mcc,570,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Mcc,570,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Mcc,570,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Mcc,570,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",16983.41,16983.41,16983.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Skin Debridement With Mcc,570,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],29539.47,29539.47,29539.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Skin Debridement With Mcc,570,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],22161.83,22161.83,22161.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Skin Debridement With Mcc,570,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Mcc,570,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Mcc,570,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Mcc,570,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Mcc,570,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Mcc,570,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Mcc,570,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Mcc,570,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Mcc,570,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,23972.86,,,,,,,fee schedule,23228.7,69793.11,MSDRG Base Rate
Skin Debridement With Mcc,570,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,23744.55,,,,,,,fee schedule,23228.7,69793.11,MSDRG Base Rate
Skin Debridement With Mcc,570,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,23744.55,,,,,,,fee schedule,23228.7,69793.11,MSDRG Base Rate
Skin Debridement With Mcc,570,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,23972.86,,,,,,,fee schedule,23228.7,69793.11,MSDRG Base Rate
Skin Debridement With Mcc,570,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,23744.55,,,,,,,fee schedule,23228.7,69793.11,MSDRG Base Rate
Skin Debridement With Mcc,570,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,39954.78,,,,,,,fee schedule,23228.7,69793.11,MSDRG Base Rate
Skin Debridement With Cc,571,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12923.01,,,,,,,fee schedule,12923.01,38828.56,
Skin Debridement With Cc,571,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,12923.01,,,,,,,fee schedule,12923.01,38828.56,
Skin Debridement With Cc,571,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17300.58,,,,,,,fee schedule,12923.01,38828.56,
Skin Debridement With Cc,571,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16476.75,,,,,,,fee schedule,12923.01,38828.56,
Skin Debridement With Cc,571,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,28858.48,,,,,,,fee schedule,12923.01,38828.56,
Skin Debridement With Cc,571,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,22425.57,,,,,,,fee schedule,12923.01,38828.56,
Skin Debridement With Cc,571,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,38828.56,,,,,,,fee schedule,12923.01,38828.56,
Skin Debridement With Cc,571,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,26692.53,,,,,,,fee schedule,12923.01,38828.56,
Skin Debridement With Cc,571,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,24174.06,,,,,,,fee schedule,12923.01,38828.56,
Skin Debridement With Cc,571,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19799.55,,,,,,,fee schedule,12923.01,38828.56,
Skin Debridement With Cc,571,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Cc,571,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Cc,571,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Cc,571,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Cc,571,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Cc,571,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Cc,571,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Cc,571,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11556.61,11556.61,11556.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Skin Debridement With Cc,571,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Cc,571,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Cc,571,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Cc,571,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Cc,571,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Cc,571,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],11921.59,11921.59,11921.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Skin Debridement With Cc,571,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Cc,571,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Cc,571,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Cc,571,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement With Cc,571,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14194.86,,,,,,,fee schedule,12923.01,38828.56,MSDRG Base Rate
Skin Debridement With Cc,571,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,14059.67,,,,,,,fee schedule,12923.01,38828.56,MSDRG Base Rate
Skin Debridement With Cc,571,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,14059.67,,,,,,,fee schedule,12923.01,38828.56,MSDRG Base Rate
Skin Debridement With Cc,571,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,14194.86,,,,,,,fee schedule,12923.01,38828.56,MSDRG Base Rate
Skin Debridement With Cc,571,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,14059.67,,,,,,,fee schedule,12923.01,38828.56,MSDRG Base Rate
Skin Debridement With Cc,571,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23658.09,,,,,,,fee schedule,12923.01,38828.56,MSDRG Base Rate
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8814.93,,,,,,,fee schedule,8814.93,26485.4,
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,8814.93,,,,,,,fee schedule,8814.93,26485.4,
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11800.92,,,,,,,fee schedule,8814.93,26485.4,
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11238.98,,,,,,,fee schedule,8814.93,26485.4,
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,19684.69,,,,,,,fee schedule,8814.93,26485.4,
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,15296.74,,,,,,,fee schedule,8814.93,26485.4,
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,26485.4,,,,,,,fee schedule,8814.93,26485.4,
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,18207.27,,,,,,,fee schedule,8814.93,26485.4,
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,16489.4,,,,,,,fee schedule,8814.93,26485.4,
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13505.5,,,,,,,fee schedule,8814.93,26485.4,
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",6901.31,6901.31,6901.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],7093.47,7093.47,7093.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9951.15,,,,,,,fee schedule,8814.93,26485.4,MSDRG Base Rate
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,9856.38,,,,,,,fee schedule,8814.93,26485.4,MSDRG Base Rate
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,9856.38,,,,,,,fee schedule,8814.93,26485.4,MSDRG Base Rate
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,9951.15,,,,,,,fee schedule,8814.93,26485.4,MSDRG Base Rate
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,9856.38,,,,,,,fee schedule,8814.93,26485.4,MSDRG Base Rate
Skin Debridement Without Cc/Mcc,572,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16585.26,,,,,,,fee schedule,8814.93,26485.4,MSDRG Base Rate
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,47514.51,,,,,,,fee schedule,47514.51,142762.44,
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,47514.51,,,,,,,fee schedule,47514.51,142762.44,
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,63609.7,,,,,,,fee schedule,47514.51,142762.44,
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,60580.68,,,,,,,fee schedule,47514.51,142762.44,
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,106105.05,,,,,,,fee schedule,47514.51,142762.44,
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,82452.94,,,,,,,fee schedule,47514.51,142762.44,
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,142762.44,,,,,,,fee schedule,47514.51,142762.44,
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,98141.42,,,,,,,fee schedule,47514.51,142762.44,
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,88881.69,,,,,,,fee schedule,47514.51,142762.44,
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,72797.76,,,,,,,fee schedule,47514.51,142762.44,
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",32394.91,32394.91,32394.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],250,250,250,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],45058.01,45058.01,45058.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,52178.01,,,,,,,fee schedule,47514.51,142762.44,MSDRG Base Rate
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,51681.07,,,,,,,fee schedule,47514.51,142762.44,MSDRG Base Rate
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,51681.07,,,,,,,fee schedule,47514.51,142762.44,MSDRG Base Rate
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,52178.01,,,,,,,fee schedule,47514.51,142762.44,MSDRG Base Rate
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,51681.07,,,,,,,fee schedule,47514.51,142762.44,MSDRG Base Rate
Skin Graft For Skin Ulcer Or Cellulitis With Mcc,573,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,86963.34,,,,,,,fee schedule,47514.51,142762.44,MSDRG Base Rate
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,26734.14,,,,,,,fee schedule,26734.14,80325.6,
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,26734.14,,,,,,,fee schedule,26734.14,80325.6,
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35790.14,,,,,,,fee schedule,26734.14,80325.6,
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,34085.86,,,,,,,fee schedule,26734.14,80325.6,
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,59700.25,,,,,,,fee schedule,26734.14,80325.6,
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,46392.33,,,,,,,fee schedule,26734.14,80325.6,
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,80325.6,,,,,,,fee schedule,26734.14,80325.6,
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,55219.49,,,,,,,fee schedule,26734.14,80325.6,
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,50009.48,,,,,,,fee schedule,26734.14,80325.6,
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,40959.82,,,,,,,fee schedule,26734.14,80325.6,
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],25200.08,25200.08,25200.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],44836.72,44836.72,44836.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",53245.13,53245.13,53245.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",17401.69,17401.69,17401.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,28115.79,,,,,,,fee schedule,26734.14,80325.6,MSDRG Base Rate
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,27848.02,,,,,,,fee schedule,26734.14,80325.6,MSDRG Base Rate
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,27848.02,,,,,,,fee schedule,26734.14,80325.6,MSDRG Base Rate
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,28115.79,,,,,,,fee schedule,26734.14,80325.6,MSDRG Base Rate
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,27848.02,,,,,,,fee schedule,26734.14,80325.6,MSDRG Base Rate
Skin Graft For Skin Ulcer Or Cellulitis With Cc,574,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,46859.64,,,,,,,fee schedule,26734.14,80325.6,MSDRG Base Rate
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,15405.29,,,,,,,fee schedule,14891.5,46286.86,
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,15405.29,,,,,,,fee schedule,14891.5,46286.86,
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20623.73,,,,,,,fee schedule,14891.5,46286.86,
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19641.65,,,,,,,fee schedule,14891.5,46286.86,
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,34401.69,,,,,,,fee schedule,14891.5,46286.86,
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,26733.14,,,,,,,fee schedule,14891.5,46286.86,
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,46286.86,,,,,,,fee schedule,14891.5,46286.86,
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,31819.7,,,,,,,fee schedule,14891.5,46286.86,
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,28817.48,,,,,,,fee schedule,14891.5,46286.86,
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23602.7,,,,,,,fee schedule,14891.5,46286.86,
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15034.69,,,,,,,fee schedule,14891.5,46286.86,MSDRG Base Rate
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,14891.5,,,,,,,fee schedule,14891.5,46286.86,MSDRG Base Rate
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,14891.5,,,,,,,fee schedule,14891.5,46286.86,MSDRG Base Rate
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,15034.69,,,,,,,fee schedule,14891.5,46286.86,MSDRG Base Rate
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,14891.5,,,,,,,fee schedule,14891.5,46286.86,MSDRG Base Rate
Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc,575,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,25057.81,,,,,,,fee schedule,14891.5,46286.86,MSDRG Base Rate
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,41627.86,,,,,,,fee schedule,38911.82,125075.36,
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,41627.86,,,,,,,fee schedule,38911.82,125075.36,
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,55728.99,,,,,,,fee schedule,38911.82,125075.36,
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,53075.24,,,,,,,fee schedule,38911.82,125075.36,
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,92959.52,,,,,,,fee schedule,38911.82,125075.36,
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,72237.71,,,,,,,fee schedule,38911.82,125075.36,
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,125075.36,,,,,,,fee schedule,38911.82,125075.36,
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,85982.51,,,,,,,fee schedule,38911.82,125075.36,
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,77869.99,,,,,,,fee schedule,38911.82,125075.36,
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,63778.72,,,,,,,fee schedule,38911.82,125075.36,
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],20064.69,20064.69,20064.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,39285.97,,,,,,,fee schedule,38911.82,125075.36,MSDRG Base Rate
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,38911.82,,,,,,,fee schedule,38911.82,125075.36,MSDRG Base Rate
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,38911.82,,,,,,,fee schedule,38911.82,125075.36,MSDRG Base Rate
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,39285.97,,,,,,,fee schedule,38911.82,125075.36,MSDRG Base Rate
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,38911.82,,,,,,,fee schedule,38911.82,125075.36,MSDRG Base Rate
Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc,576,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,65476.62,,,,,,,fee schedule,38911.82,125075.36,MSDRG Base Rate
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,20545.02,,,,,,,fee schedule,20545.02,61729.72,
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,20545.02,,,,,,,fee schedule,20545.02,61729.72,
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,27504.5,,,,,,,fee schedule,20545.02,61729.72,
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26194.77,,,,,,,fee schedule,20545.02,61729.72,
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,45879.26,,,,,,,fee schedule,20545.02,61729.72,
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,35652.21,,,,,,,fee schedule,20545.02,61729.72,
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,61729.72,,,,,,,fee schedule,20545.02,61729.72,
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,42435.83,,,,,,,fee schedule,20545.02,61729.72,
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,38431.97,,,,,,,fee schedule,20545.02,61729.72,
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,31477.36,,,,,,,fee schedule,20545.02,61729.72,
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],20542.94,20542.94,20542.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,21704.14,,,,,,,fee schedule,20545.02,61729.72,MSDRG Base Rate
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,21497.43,,,,,,,fee schedule,20545.02,61729.72,MSDRG Base Rate
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,21497.43,,,,,,,fee schedule,20545.02,61729.72,MSDRG Base Rate
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,21704.14,,,,,,,fee schedule,20545.02,61729.72,MSDRG Base Rate
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,21497.43,,,,,,,fee schedule,20545.02,61729.72,MSDRG Base Rate
Skin Graft Except For Skin Ulcer Or Cellulitis With Cc,577,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,36173.57,,,,,,,fee schedule,20545.02,61729.72,MSDRG Base Rate
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13042.61,,,,,,,fee schedule,13042.61,39187.92,
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,13042.61,,,,,,,fee schedule,13042.61,39187.92,
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17460.7,,,,,,,fee schedule,13042.61,39187.92,
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16629.24,,,,,,,fee schedule,13042.61,39187.92,
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,29125.56,,,,,,,fee schedule,13042.61,39187.92,
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,22633.12,,,,,,,fee schedule,13042.61,39187.92,
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,39187.92,,,,,,,fee schedule,13042.61,39187.92,
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,26939.56,,,,,,,fee schedule,13042.61,39187.92,
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,24397.79,,,,,,,fee schedule,13042.61,39187.92,
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19982.79,,,,,,,fee schedule,13042.61,39187.92,
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13545.64,,,,,,,fee schedule,13042.61,39187.92,MSDRG Base Rate
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,13416.63,,,,,,,fee schedule,13042.61,39187.92,MSDRG Base Rate
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,13416.63,,,,,,,fee schedule,13042.61,39187.92,MSDRG Base Rate
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,13545.64,,,,,,,fee schedule,13042.61,39187.92,MSDRG Base Rate
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,13416.63,,,,,,,fee schedule,13042.61,39187.92,MSDRG Base Rate
Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc,578,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22576.07,,,,,,,fee schedule,13042.61,39187.92,MSDRG Base Rate
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,25147.7,,,,,,,fee schedule,25147.7,75558.97,
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,25147.7,,,,,,,fee schedule,25147.7,75558.97,
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,33666.31,,,,,,,fee schedule,25147.7,75558.97,
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,32063.16,,,,,,,fee schedule,25147.7,75558.97,
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,56157.55,,,,,,,fee schedule,25147.7,75558.97,
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,43639.35,,,,,,,fee schedule,25147.7,75558.97,
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,75558.97,,,,,,,fee schedule,25147.7,75558.97,
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,51942.69,,,,,,,fee schedule,25147.7,75558.97,
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,47041.85,,,,,,,fee schedule,25147.7,75558.97,
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,38529.21,,,,,,,fee schedule,25147.7,75558.97,
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],17381.58,17381.58,17381.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",11889.23,11889.23,11889.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],38532.76,38532.76,38532.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],45706.37,45706.37,45706.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],23814.33,22134.21,24317.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",11779.14,11779.14,11779.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,26296.27,,,,,,,fee schedule,25147.7,75558.97,MSDRG Base Rate
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,26045.83,,,,,,,fee schedule,25147.7,75558.97,MSDRG Base Rate
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,26045.83,,,,,,,fee schedule,25147.7,75558.97,MSDRG Base Rate
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,26296.27,,,,,,,fee schedule,25147.7,75558.97,MSDRG Base Rate
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,26045.83,,,,,,,fee schedule,25147.7,75558.97,MSDRG Base Rate
"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc",579,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,43827.12,,,,,,,fee schedule,25147.7,75558.97,MSDRG Base Rate
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13679.96,,,,,,,fee schedule,13679.96,41102.91,
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,13679.96,,,,,,,fee schedule,13679.96,41102.91,
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18313.95,,,,,,,fee schedule,13679.96,41102.91,
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17441.86,,,,,,,fee schedule,13679.96,41102.91,
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,30548.84,,,,,,,fee schedule,13679.96,41102.91,
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,23739.13,,,,,,,fee schedule,13679.96,41102.91,
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,41102.91,,,,,,,fee schedule,13679.96,41102.91,
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,28256.02,,,,,,,fee schedule,13679.96,41102.91,
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,25590.04,,,,,,,fee schedule,13679.96,41102.91,
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20959.29,,,,,,,fee schedule,13679.96,41102.91,
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],16456.23,16456.23,16456.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11267.78,11267.78,11599.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",6984.16,6984.16,6984.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",6559.04,6559.04,6559.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13043.77,13043.77,13043.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],841.51,841.51,841.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",6498.3,6498.3,6498.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14495.63,,,,,,,fee schedule,13679.96,41102.91,MSDRG Base Rate
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,14357.57,,,,,,,fee schedule,13679.96,41102.91,MSDRG Base Rate
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,14357.57,,,,,,,fee schedule,13679.96,41102.91,MSDRG Base Rate
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,14495.63,,,,,,,fee schedule,13679.96,41102.91,MSDRG Base Rate
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,14357.57,,,,,,,fee schedule,13679.96,41102.91,MSDRG Base Rate
"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc",580,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,24159.38,,,,,,,fee schedule,13679.96,41102.91,MSDRG Base Rate
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11104.31,,,,,,,fee schedule,11104.31,33364.09,
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,11104.31,,,,,,,fee schedule,11104.31,33364.09,
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14865.82,,,,,,,fee schedule,11104.31,33364.09,
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14157.92,,,,,,,fee schedule,11104.31,33364.09,
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,24797.13,,,,,,,fee schedule,11104.31,33364.09,
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,19269.55,,,,,,,fee schedule,11104.31,33364.09,
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,33364.09,,,,,,,fee schedule,11104.31,33364.09,
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,22936,,,,,,,fee schedule,11104.31,33364.09,
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,20771.97,,,,,,,fee schedule,11104.31,33364.09,
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17013.1,,,,,,,fee schedule,11104.31,33364.09,
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],22196.78,22196.78,22196.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],22937.6,22937.6,22937.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],14158.91,14158.91,14158.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",5048.84,5048.84,5048.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],26787.16,26787.16,26787.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12269.88,,,,,,,fee schedule,11104.31,33364.09,MSDRG Base Rate
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,12153.02,,,,,,,fee schedule,11104.31,33364.09,MSDRG Base Rate
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,12153.02,,,,,,,fee schedule,11104.31,33364.09,MSDRG Base Rate
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,12269.88,,,,,,,fee schedule,11104.31,33364.09,MSDRG Base Rate
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,12153.02,,,,,,,fee schedule,11104.31,33364.09,MSDRG Base Rate
"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc",581,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20449.8,,,,,,,fee schedule,11104.31,33364.09,MSDRG Base Rate
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13511.75,,,,,,,fee schedule,13511.75,40597.5,
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,13511.75,,,,,,,fee schedule,13511.75,40597.5,
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18088.76,,,,,,,fee schedule,13511.75,40597.5,
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17227.39,,,,,,,fee schedule,13511.75,40597.5,
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,30173.2,,,,,,,fee schedule,13511.75,40597.5,
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,23447.23,,,,,,,fee schedule,13511.75,40597.5,
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,40597.5,,,,,,,fee schedule,13511.75,40597.5,
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,27908.58,,,,,,,fee schedule,13511.75,40597.5,
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,25275.38,,,,,,,fee schedule,13511.75,40597.5,
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20701.57,,,,,,,fee schedule,13511.75,40597.5,
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],13399.51,13399.51,13399.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,16047.18,,,,,,,fee schedule,13511.75,40597.5,MSDRG Base Rate
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,15894.35,,,,,,,fee schedule,13511.75,40597.5,MSDRG Base Rate
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,15894.35,,,,,,,fee schedule,13511.75,40597.5,MSDRG Base Rate
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,16047.18,,,,,,,fee schedule,13511.75,40597.5,MSDRG Base Rate
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,15894.35,,,,,,,fee schedule,13511.75,40597.5,MSDRG Base Rate
Mastectomy For Malignancy With Cc/Mcc,582,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,26745.3,,,,,,,fee schedule,13511.75,40597.5,MSDRG Base Rate
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12673.78,,,,,,,fee schedule,12673.78,38079.72,
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,12673.78,,,,,,,fee schedule,12673.78,38079.72,
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16966.93,,,,,,,fee schedule,12673.78,38079.72,
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16158.98,,,,,,,fee schedule,12673.78,38079.72,
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,28301.92,,,,,,,fee schedule,12673.78,38079.72,
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,21993.08,,,,,,,fee schedule,12673.78,38079.72,
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,38079.72,,,,,,,fee schedule,12673.78,38079.72,
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,26177.74,,,,,,,fee schedule,12673.78,38079.72,
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,23707.85,,,,,,,fee schedule,12673.78,38079.72,
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19417.7,,,,,,,fee schedule,12673.78,38079.72,
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14467.51,,,,,,,fee schedule,12673.78,38079.72,MSDRG Base Rate
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,14329.72,,,,,,,fee schedule,12673.78,38079.72,MSDRG Base Rate
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,14329.72,,,,,,,fee schedule,12673.78,38079.72,MSDRG Base Rate
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,14467.51,,,,,,,fee schedule,12673.78,38079.72,MSDRG Base Rate
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,14329.72,,,,,,,fee schedule,12673.78,38079.72,MSDRG Base Rate
Mastectomy For Malignancy Without Cc/Mcc,583,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,24112.52,,,,,,,fee schedule,12673.78,38079.72,MSDRG Base Rate
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,15797.27,,,,,,,fee schedule,15797.27,47464.6,
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,15797.27,,,,,,,fee schedule,15797.27,47464.6,
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21148.49,,,,,,,fee schedule,15797.27,47464.6,
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20141.42,,,,,,,fee schedule,15797.27,47464.6,
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,35277.03,,,,,,,fee schedule,15797.27,47464.6,
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,27413.35,,,,,,,fee schedule,15797.27,47464.6,
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,47464.6,,,,,,,fee schedule,15797.27,47464.6,
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,32629.34,,,,,,,fee schedule,15797.27,47464.6,
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,29550.73,,,,,,,fee schedule,15797.27,47464.6,
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24203.26,,,,,,,fee schedule,15797.27,47464.6,
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],15592.68,15592.68,15592.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,17719.81,,,,,,,fee schedule,15797.27,47464.6,MSDRG Base Rate
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,17551.05,,,,,,,fee schedule,15797.27,47464.6,MSDRG Base Rate
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,17551.05,,,,,,,fee schedule,15797.27,47464.6,MSDRG Base Rate
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,17719.81,,,,,,,fee schedule,15797.27,47464.6,MSDRG Base Rate
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,17551.05,,,,,,,fee schedule,15797.27,47464.6,MSDRG Base Rate
"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc",584,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,29533.02,,,,,,,fee schedule,15797.27,47464.6,MSDRG Base Rate
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,15316.56,,,,,,,fee schedule,15316.56,46020.24,
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,15316.56,,,,,,,fee schedule,15316.56,46020.24,
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20504.93,,,,,,,fee schedule,15316.56,46020.24,
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19528.51,,,,,,,fee schedule,15316.56,46020.24,
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,34203.54,,,,,,,fee schedule,15316.56,46020.24,
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,26579.15,,,,,,,fee schedule,15316.56,46020.24,
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,46020.24,,,,,,,fee schedule,15316.56,46020.24,
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,31636.41,,,,,,,fee schedule,15316.56,46020.24,
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,28651.49,,,,,,,fee schedule,15316.56,46020.24,
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23466.75,,,,,,,fee schedule,15316.56,46020.24,
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,16066.71,,,,,,,fee schedule,15316.56,46020.24,MSDRG Base Rate
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,15913.7,,,,,,,fee schedule,15316.56,46020.24,MSDRG Base Rate
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,15913.7,,,,,,,fee schedule,15316.56,46020.24,MSDRG Base Rate
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,16066.71,,,,,,,fee schedule,15316.56,46020.24,MSDRG Base Rate
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,15913.7,,,,,,,fee schedule,15316.56,46020.24,MSDRG Base Rate
"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc",585,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,26777.85,,,,,,,fee schedule,15316.56,46020.24,MSDRG Base Rate
Skin Ulcers With Mcc,592,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,15865.95,,,,,,,fee schedule,15865.95,47670.94,
Skin Ulcers With Mcc,592,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,15865.95,,,,,,,fee schedule,15865.95,47670.94,
Skin Ulcers With Mcc,592,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21240.42,,,,,,,fee schedule,15865.95,47670.94,
Skin Ulcers With Mcc,592,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20228.98,,,,,,,fee schedule,15865.95,47670.94,
Skin Ulcers With Mcc,592,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,35430.38,,,,,,,fee schedule,15865.95,47670.94,
Skin Ulcers With Mcc,592,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,27532.52,,,,,,,fee schedule,15865.95,47670.94,
Skin Ulcers With Mcc,592,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,47670.94,,,,,,,fee schedule,15865.95,47670.94,
Skin Ulcers With Mcc,592,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,32771.18,,,,,,,fee schedule,15865.95,47670.94,
Skin Ulcers With Mcc,592,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,29679.19,,,,,,,fee schedule,15865.95,47670.94,
Skin Ulcers With Mcc,592,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24308.48,,,,,,,fee schedule,15865.95,47670.94,
Skin Ulcers With Mcc,592,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],27.82,27.82,27.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Skin Ulcers With Mcc,592,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Mcc,592,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Mcc,592,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Mcc,592,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Mcc,592,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Mcc,592,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",9859.3,9859.3,9859.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Skin Ulcers With Mcc,592,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",9259.17,9259.17,9259.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Skin Ulcers With Mcc,592,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],14856.17,14856.17,14856.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Skin Ulcers With Mcc,592,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Mcc,592,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Mcc,592,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Mcc,592,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Mcc,592,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],15645,13552.75,20714.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Skin Ulcers With Mcc,592,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Mcc,592,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Mcc,592,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Mcc,592,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Mcc,592,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,16115.15,,,,,,,fee schedule,15865.95,47670.94,MSDRG Base Rate
Skin Ulcers With Mcc,592,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,15961.67,,,,,,,fee schedule,15865.95,47670.94,MSDRG Base Rate
Skin Ulcers With Mcc,592,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,15961.67,,,,,,,fee schedule,15865.95,47670.94,MSDRG Base Rate
Skin Ulcers With Mcc,592,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,16115.15,,,,,,,fee schedule,15865.95,47670.94,MSDRG Base Rate
Skin Ulcers With Mcc,592,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,15961.67,,,,,,,fee schedule,15865.95,47670.94,MSDRG Base Rate
Skin Ulcers With Mcc,592,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,26858.58,,,,,,,fee schedule,15865.95,47670.94,MSDRG Base Rate
Skin Ulcers With Cc,593,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9433.76,,,,,,,fee schedule,9433.76,28344.76,
Skin Ulcers With Cc,593,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,9433.76,,,,,,,fee schedule,9433.76,28344.76,
Skin Ulcers With Cc,593,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12629.38,,,,,,,fee schedule,9433.76,28344.76,
Skin Ulcers With Cc,593,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12027.99,,,,,,,fee schedule,9433.76,28344.76,
Skin Ulcers With Cc,593,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,21066.62,,,,,,,fee schedule,9433.76,28344.76,
Skin Ulcers With Cc,593,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,16370.61,,,,,,,fee schedule,9433.76,28344.76,
Skin Ulcers With Cc,593,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,28344.76,,,,,,,fee schedule,9433.76,28344.76,
Skin Ulcers With Cc,593,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,19485.48,,,,,,,fee schedule,9433.76,28344.76,
Skin Ulcers With Cc,593,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,17647.01,,,,,,,fee schedule,9433.76,28344.76,
Skin Ulcers With Cc,593,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14453.63,,,,,,,fee schedule,9433.76,28344.76,
Skin Ulcers With Cc,593,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Cc,593,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Cc,593,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],13308,13308,13308,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Skin Ulcers With Cc,593,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Cc,593,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Cc,593,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Cc,593,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Cc,593,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4886.34,4886.34,4886.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Skin Ulcers With Cc,593,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9219.31,9219.31,9219.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Skin Ulcers With Cc,593,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Cc,593,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Cc,593,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Cc,593,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Cc,593,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],232.56,232.56,232.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Skin Ulcers With Cc,593,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Cc,593,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Cc,593,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Cc,593,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers With Cc,593,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10263.64,,,,,,,fee schedule,9433.76,28344.76,MSDRG Base Rate
Skin Ulcers With Cc,593,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,10165.9,,,,,,,fee schedule,9433.76,28344.76,MSDRG Base Rate
Skin Ulcers With Cc,593,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,10165.9,,,,,,,fee schedule,9433.76,28344.76,MSDRG Base Rate
Skin Ulcers With Cc,593,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,10263.64,,,,,,,fee schedule,9433.76,28344.76,MSDRG Base Rate
Skin Ulcers With Cc,593,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,10165.9,,,,,,,fee schedule,9433.76,28344.76,MSDRG Base Rate
Skin Ulcers With Cc,593,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,17106.08,,,,,,,fee schedule,9433.76,28344.76,MSDRG Base Rate
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6547.92,,,,,,,fee schedule,6547.92,19673.94,
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,6547.92,,,,,,,fee schedule,6547.92,19673.94,
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8765.99,,,,,,,fee schedule,6547.92,19673.94,
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8348.56,,,,,,,fee schedule,6547.92,19673.94,
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,14622.23,,,,,,,fee schedule,6547.92,19673.94,
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,11362.75,,,,,,,fee schedule,6547.92,19673.94,
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,19673.94,,,,,,,fee schedule,6547.92,19673.94,
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,13524.77,,,,,,,fee schedule,6547.92,19673.94,
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,12248.69,,,,,,,fee schedule,6547.92,19673.94,
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10032.18,,,,,,,fee schedule,6547.92,19673.94,
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7767.58,,,,,,,fee schedule,6547.92,19673.94,MSDRG Base Rate
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,7693.61,,,,,,,fee schedule,6547.92,19673.94,MSDRG Base Rate
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,7693.61,,,,,,,fee schedule,6547.92,19673.94,MSDRG Base Rate
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,7767.58,,,,,,,fee schedule,6547.92,19673.94,MSDRG Base Rate
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,7693.61,,,,,,,fee schedule,6547.92,19673.94,MSDRG Base Rate
Skin Ulcers Without Cc/Mcc,594,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12945.98,,,,,,,fee schedule,6547.92,19673.94,MSDRG Base Rate
Major Skin Disorders With Mcc,595,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16319.66,,,,,,,fee schedule,16319.66,49034.16,
Major Skin Disorders With Mcc,595,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,16319.66,,,,,,,fee schedule,16319.66,49034.16,
Major Skin Disorders With Mcc,595,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21847.82,,,,,,,fee schedule,16319.66,49034.16,
Major Skin Disorders With Mcc,595,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20807.45,,,,,,,fee schedule,16319.66,49034.16,
Major Skin Disorders With Mcc,595,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,36443.57,,,,,,,fee schedule,16319.66,49034.16,
Major Skin Disorders With Mcc,595,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,28319.85,,,,,,,fee schedule,16319.66,49034.16,
Major Skin Disorders With Mcc,595,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,49034.16,,,,,,,fee schedule,16319.66,49034.16,
Major Skin Disorders With Mcc,595,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,33708.32,,,,,,,fee schedule,16319.66,49034.16,
Major Skin Disorders With Mcc,595,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,30527.91,,,,,,,fee schedule,16319.66,49034.16,
Major Skin Disorders With Mcc,595,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,25003.61,,,,,,,fee schedule,16319.66,49034.16,
Major Skin Disorders With Mcc,595,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders With Mcc,595,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders With Mcc,595,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],10688.94,10688.94,10688.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Skin Disorders With Mcc,595,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders With Mcc,595,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders With Mcc,595,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders With Mcc,595,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders With Mcc,595,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",18769.59,18769.59,18769.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Skin Disorders With Mcc,595,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders With Mcc,595,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders With Mcc,595,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders With Mcc,595,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders With Mcc,595,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders With Mcc,595,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders With Mcc,595,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders With Mcc,595,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders With Mcc,595,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders With Mcc,595,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders With Mcc,595,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,17563.57,,,,,,,fee schedule,16319.66,49034.16,MSDRG Base Rate
Major Skin Disorders With Mcc,595,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,17396.3,,,,,,,fee schedule,16319.66,49034.16,MSDRG Base Rate
Major Skin Disorders With Mcc,595,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,17396.3,,,,,,,fee schedule,16319.66,49034.16,MSDRG Base Rate
Major Skin Disorders With Mcc,595,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,17563.57,,,,,,,fee schedule,16319.66,49034.16,MSDRG Base Rate
Major Skin Disorders With Mcc,595,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,17396.3,,,,,,,fee schedule,16319.66,49034.16,MSDRG Base Rate
Major Skin Disorders With Mcc,595,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,29272.62,,,,,,,fee schedule,16319.66,49034.16,MSDRG Base Rate
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8341.16,,,,,,,fee schedule,8341.16,25061.9,
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,8341.16,,,,,,,fee schedule,8341.16,25061.9,
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11166.67,,,,,,,fee schedule,8341.16,25061.9,
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10634.92,,,,,,,fee schedule,8341.16,25061.9,
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,18626.71,,,,,,,fee schedule,8341.16,25061.9,
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,14474.59,,,,,,,fee schedule,8341.16,25061.9,
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,25061.9,,,,,,,fee schedule,8341.16,25061.9,
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,17228.7,,,,,,,fee schedule,8341.16,25061.9,
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,15603.15,,,,,,,fee schedule,8341.16,25061.9,
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12779.63,,,,,,,fee schedule,8341.16,25061.9,
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],12480.83,12480.83,12480.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",5556.11,5556.11,5556.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],6547.23,6547.23,6547.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],12780.81,12780.81,12780.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9452.72,,,,,,,fee schedule,8341.16,25061.9,MSDRG Base Rate
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,9362.69,,,,,,,fee schedule,8341.16,25061.9,MSDRG Base Rate
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,9362.69,,,,,,,fee schedule,8341.16,25061.9,MSDRG Base Rate
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,9452.72,,,,,,,fee schedule,8341.16,25061.9,MSDRG Base Rate
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,9362.69,,,,,,,fee schedule,8341.16,25061.9,MSDRG Base Rate
Major Skin Disorders Without Mcc,596,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15754.53,,,,,,,fee schedule,8341.16,25061.9,MSDRG Base Rate
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13553.42,,,,,,,fee schedule,13553.42,40722.7,
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,13553.42,,,,,,,fee schedule,13553.42,40722.7,
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18144.54,,,,,,,fee schedule,13553.42,40722.7,
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17280.52,,,,,,,fee schedule,13553.42,40722.7,
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,30266.25,,,,,,,fee schedule,13553.42,40722.7,
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,23519.54,,,,,,,fee schedule,13553.42,40722.7,
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,40722.7,,,,,,,fee schedule,13553.42,40722.7,
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,27994.64,,,,,,,fee schedule,13553.42,40722.7,
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,25353.32,,,,,,,fee schedule,13553.42,40722.7,
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20765.41,,,,,,,fee schedule,13553.42,40722.7,
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",6752.92,6752.92,6752.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],18061.78,18061.78,30269.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14019.85,,,,,,,fee schedule,13553.42,40722.7,MSDRG Base Rate
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,13886.33,,,,,,,fee schedule,13553.42,40722.7,MSDRG Base Rate
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,13886.33,,,,,,,fee schedule,13553.42,40722.7,MSDRG Base Rate
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,14019.85,,,,,,,fee schedule,13553.42,40722.7,MSDRG Base Rate
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,13886.33,,,,,,,fee schedule,13553.42,40722.7,MSDRG Base Rate
Malignant Breast Disorders With Mcc,597,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23366.42,,,,,,,fee schedule,13553.42,40722.7,MSDRG Base Rate
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8324.95,,,,,,,fee schedule,8324.95,25013.22,
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,8324.95,,,,,,,fee schedule,8324.95,25013.22,
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11144.97,,,,,,,fee schedule,8324.95,25013.22,
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10614.26,,,,,,,fee schedule,8324.95,25013.22,
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,18590.53,,,,,,,fee schedule,8324.95,25013.22,
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,14446.47,,,,,,,fee schedule,8324.95,25013.22,
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,25013.22,,,,,,,fee schedule,8324.95,25013.22,
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,17195.23,,,,,,,fee schedule,8324.95,25013.22,
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,15572.84,,,,,,,fee schedule,8324.95,25013.22,
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12754.8,,,,,,,fee schedule,8324.95,25013.22,
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9833.96,,,,,,,fee schedule,8324.95,25013.22,MSDRG Base Rate
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,9740.31,,,,,,,fee schedule,8324.95,25013.22,MSDRG Base Rate
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,9740.31,,,,,,,fee schedule,8324.95,25013.22,MSDRG Base Rate
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,9833.96,,,,,,,fee schedule,8324.95,25013.22,MSDRG Base Rate
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,9740.31,,,,,,,fee schedule,8324.95,25013.22,MSDRG Base Rate
Malignant Breast Disorders With Cc,598,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16389.94,,,,,,,fee schedule,8324.95,25013.22,MSDRG Base Rate
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6596.54,,,,,,,fee schedule,6596.54,19820,
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,6596.54,,,,,,,fee schedule,6596.54,19820,
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8831.07,,,,,,,fee schedule,6596.54,19820,
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8410.54,,,,,,,fee schedule,6596.54,19820,
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,14730.78,,,,,,,fee schedule,6596.54,19820,
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,11447.11,,,,,,,fee schedule,6596.54,19820,
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,19820,,,,,,,fee schedule,6596.54,19820,
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,13625.17,,,,,,,fee schedule,6596.54,19820,
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,12339.63,,,,,,,fee schedule,6596.54,19820,
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10106.66,,,,,,,fee schedule,6596.54,19820,
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7006.66,,,,,,,fee schedule,6596.54,19820,MSDRG Base Rate
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,6939.93,,,,,,,fee schedule,6596.54,19820,MSDRG Base Rate
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,6939.93,,,,,,,fee schedule,6596.54,19820,MSDRG Base Rate
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,7006.66,,,,,,,fee schedule,6596.54,19820,MSDRG Base Rate
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,6939.93,,,,,,,fee schedule,6596.54,19820,MSDRG Base Rate
Malignant Breast Disorders Without Cc/Mcc,599,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11677.77,,,,,,,fee schedule,6596.54,19820,MSDRG Base Rate
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7385.9,,,,,,,fee schedule,7385.9,22191.72,
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,7385.9,,,,,,,fee schedule,7385.9,22191.72,
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9887.82,,,,,,,fee schedule,7385.9,22191.72,
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9416.97,,,,,,,fee schedule,7385.9,22191.72,
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,16493.51,,,,,,,fee schedule,7385.9,22191.72,
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,12816.91,,,,,,,fee schedule,7385.9,22191.72,
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,22191.72,,,,,,,fee schedule,7385.9,22191.72,
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,15255.6,,,,,,,fee schedule,7385.9,22191.72,
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,13816.22,,,,,,,fee schedule,7385.9,22191.72,
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11316.06,,,,,,,fee schedule,7385.9,22191.72,
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9133.19,,,,,,,fee schedule,7385.9,22191.72,MSDRG Base Rate
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,9046.21,,,,,,,fee schedule,7385.9,22191.72,MSDRG Base Rate
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,9046.21,,,,,,,fee schedule,7385.9,22191.72,MSDRG Base Rate
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,9133.19,,,,,,,fee schedule,7385.9,22191.72,MSDRG Base Rate
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,9046.21,,,,,,,fee schedule,7385.9,22191.72,MSDRG Base Rate
Non-Malignant Breast Disorders With Cc/Mcc,600,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15221.99,,,,,,,fee schedule,7385.9,22191.72,MSDRG Base Rate
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4625.83,,,,,,,fee schedule,4625.83,13898.81,
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,4625.83,,,,,,,fee schedule,4625.83,13898.81,
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6192.8,,,,,,,fee schedule,4625.83,13898.81,
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5897.9,,,,,,,fee schedule,4625.83,13898.81,
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,10329.98,,,,,,,fee schedule,4625.83,13898.81,
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,8027.31,,,,,,,fee schedule,4625.83,13898.81,
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,13898.81,,,,,,,fee schedule,4625.83,13898.81,
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,9554.68,,,,,,,fee schedule,4625.83,13898.81,
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,8653.18,,,,,,,fee schedule,4625.83,13898.81,
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7087.31,,,,,,,fee schedule,4625.83,13898.81,
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,5722.3,,,,,,,fee schedule,4625.83,13898.81,MSDRG Base Rate
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,5667.8,,,,,,,fee schedule,4625.83,13898.81,MSDRG Base Rate
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,5667.8,,,,,,,fee schedule,4625.83,13898.81,MSDRG Base Rate
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,5722.3,,,,,,,fee schedule,4625.83,13898.81,MSDRG Base Rate
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,5667.8,,,,,,,fee schedule,4625.83,13898.81,MSDRG Base Rate
Non-Malignant Breast Disorders Without Cc/Mcc,601,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9537.17,,,,,,,fee schedule,4625.83,13898.81,MSDRG Base Rate
Cellulitis With Mcc,602,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11338.11,,,,,,,fee schedule,11338.11,34066.57,
Cellulitis With Mcc,602,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,11338.11,,,,,,,fee schedule,11338.11,34066.57,
Cellulitis With Mcc,602,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15178.81,,,,,,,fee schedule,11338.11,34066.57,
Cellulitis With Mcc,602,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14456.02,,,,,,,fee schedule,11338.11,34066.57,
Cellulitis With Mcc,602,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,25319.23,,,,,,,fee schedule,11338.11,34066.57,
Cellulitis With Mcc,602,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,19675.27,,,,,,,fee schedule,11338.11,34066.57,
Cellulitis With Mcc,602,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,34066.57,,,,,,,fee schedule,11338.11,34066.57,
Cellulitis With Mcc,602,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,23418.92,,,,,,,fee schedule,11338.11,34066.57,
Cellulitis With Mcc,602,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,21209.32,,,,,,,fee schedule,11338.11,34066.57,
Cellulitis With Mcc,602,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17371.31,,,,,,,fee schedule,11338.11,34066.57,
Cellulitis With Mcc,602,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],7620.75,7620.75,7620.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cellulitis With Mcc,602,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Cellulitis With Mcc,602,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11227.51,9985.63,11355.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cellulitis With Mcc,602,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],22244.94,22244.94,22244.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cellulitis With Mcc,602,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],10702.11,10702.11,10702.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cellulitis With Mcc,602,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Cellulitis With Mcc,602,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",8654.5,8654.5,8654.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cellulitis With Mcc,602,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",8127.7,8127.7,8127.7,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cellulitis With Mcc,602,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],14414.05,14414.05,14414.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cellulitis With Mcc,602,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],10951.08,9217.25,11144.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cellulitis With Mcc,602,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Cellulitis With Mcc,602,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cellulitis With Mcc,602,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Cellulitis With Mcc,602,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],9976.47,9976.47,24815.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cellulitis With Mcc,602,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],9223.69,26.55,11520.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cellulitis With Mcc,602,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cellulitis With Mcc,602,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cellulitis With Mcc,602,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],20164.2,20164.2,20164.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cellulitis With Mcc,602,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12099.57,,,,,,,fee schedule,11338.11,34066.57,MSDRG Base Rate
Cellulitis With Mcc,602,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,11984.34,,,,,,,fee schedule,11338.11,34066.57,MSDRG Base Rate
Cellulitis With Mcc,602,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,11984.34,,,,,,,fee schedule,11338.11,34066.57,MSDRG Base Rate
Cellulitis With Mcc,602,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,12099.57,,,,,,,fee schedule,11338.11,34066.57,MSDRG Base Rate
Cellulitis With Mcc,602,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,11984.34,,,,,,,fee schedule,11338.11,34066.57,MSDRG Base Rate
Cellulitis With Mcc,602,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20165.95,,,,,,,fee schedule,11338.11,34066.57,MSDRG Base Rate
Cellulitis Without Mcc,603,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6797.16,,,,,,,fee schedule,6797.16,20422.79,
Cellulitis Without Mcc,603,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,6797.16,,,,,,,fee schedule,6797.16,20422.79,
Cellulitis Without Mcc,603,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9099.64,,,,,,,fee schedule,6797.16,20422.79,
Cellulitis Without Mcc,603,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8666.33,,,,,,,fee schedule,6797.16,20422.79,
Cellulitis Without Mcc,603,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,15178.79,,,,,,,fee schedule,6797.16,20422.79,
Cellulitis Without Mcc,603,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,11795.25,,,,,,,fee schedule,6797.16,20422.79,
Cellulitis Without Mcc,603,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,20422.79,,,,,,,fee schedule,6797.16,20422.79,
Cellulitis Without Mcc,603,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,14039.56,,,,,,,fee schedule,6797.16,20422.79,
Cellulitis Without Mcc,603,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,12714.91,,,,,,,fee schedule,6797.16,20422.79,
Cellulitis Without Mcc,603,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10414.04,,,,,,,fee schedule,6797.16,20422.79,
Cellulitis Without Mcc,603,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],20370.47,20370.47,20370.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cellulitis Without Mcc,603,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cellulitis Without Mcc,603,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6784.69,5142.21,6891.58,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cellulitis Without Mcc,603,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],13095,8061,15430.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cellulitis Without Mcc,603,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],12579,6731.78,12713.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cellulitis Without Mcc,603,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6543.93,6543.93,6543.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cellulitis Without Mcc,603,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4381.39,4381.39,4381.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cellulitis Without Mcc,603,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4114.69,4114.69,4114.69,59,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cellulitis Without Mcc,603,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],8665.35,8665.35,8703.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cellulitis Without Mcc,603,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],6672.37,6672.37,6757.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cellulitis Without Mcc,603,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6576.13,5028.58,6788.84,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cellulitis Without Mcc,603,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],8665.35,8665.35,8665.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cellulitis Without Mcc,603,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Cellulitis Without Mcc,603,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],11327.8,2397,15177.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cellulitis Without Mcc,603,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],5688.12,11.92,7075.44,26,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cellulitis Without Mcc,603,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4076.59,181.94,4076.59,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cellulitis Without Mcc,603,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cellulitis Without Mcc,603,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],8231.4,8231.4,8231.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cellulitis Without Mcc,603,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7799.62,,,,,,,fee schedule,6797.16,20422.79,MSDRG Base Rate
Cellulitis Without Mcc,603,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,7725.34,,,,,,,fee schedule,6797.16,20422.79,MSDRG Base Rate
Cellulitis Without Mcc,603,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,7725.34,,,,,,,fee schedule,6797.16,20422.79,MSDRG Base Rate
Cellulitis Without Mcc,603,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,7799.62,,,,,,,fee schedule,6797.16,20422.79,MSDRG Base Rate
Cellulitis Without Mcc,603,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,7725.34,,,,,,,fee schedule,6797.16,20422.79,MSDRG Base Rate
Cellulitis Without Mcc,603,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12999.37,,,,,,,fee schedule,6797.16,20422.79,MSDRG Base Rate
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11463.88,,,,,,,fee schedule,11463.88,34444.47,
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,11463.88,,,,,,,fee schedule,11463.88,34444.47,
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15347.19,,,,,,,fee schedule,11463.88,34444.47,
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14616.38,,,,,,,fee schedule,11463.88,34444.47,
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,25600.1,,,,,,,fee schedule,11463.88,34444.47,
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,19893.52,,,,,,,fee schedule,11463.88,34444.47,
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,34444.47,,,,,,,fee schedule,11463.88,34444.47,
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,23678.7,,,,,,,fee schedule,11463.88,34444.47,
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,21444.59,,,,,,,fee schedule,11463.88,34444.47,
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17564,,,,,,,fee schedule,11463.88,34444.47,
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9802.94,9802.94,9802.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3818.93,3818.93,3818.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],11347.43,11347.43,11347.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],23491.2,23491.2,23491.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12496.44,,,,,,,fee schedule,11463.88,34444.47,MSDRG Base Rate
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,12377.42,,,,,,,fee schedule,11463.88,34444.47,MSDRG Base Rate
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,12377.42,,,,,,,fee schedule,11463.88,34444.47,MSDRG Base Rate
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,12496.44,,,,,,,fee schedule,11463.88,34444.47,MSDRG Base Rate
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,12377.42,,,,,,,fee schedule,11463.88,34444.47,MSDRG Base Rate
"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc",604,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20827.4,,,,,,,fee schedule,11463.88,34444.47,MSDRG Base Rate
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7127.41,,,,,,,fee schedule,7127.41,21415.06,
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,7127.41,,,,,,,fee schedule,7127.41,21415.06,
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9541.77,,,,,,,fee schedule,7127.41,21415.06,
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9087.4,,,,,,,fee schedule,7127.41,21415.06,
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,15916.27,,,,,,,fee schedule,7127.41,21415.06,
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,12368.34,,,,,,,fee schedule,7127.41,21415.06,
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,21415.06,,,,,,,fee schedule,7127.41,21415.06,
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,14721.69,,,,,,,fee schedule,7127.41,21415.06,
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,13332.69,,,,,,,fee schedule,7127.41,21415.06,
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10920.02,,,,,,,fee schedule,7127.41,21415.06,
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],8582.01,8582.01,8582.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],13332.69,13332.69,13332.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",2743.78,2743.78,2743.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6833.13,6833.13,6833.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],7366.94,7366.94,7366.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8151.96,,,,,,,fee schedule,7127.41,21415.06,MSDRG Base Rate
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,8074.32,,,,,,,fee schedule,7127.41,21415.06,MSDRG Base Rate
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,8074.32,,,,,,,fee schedule,7127.41,21415.06,MSDRG Base Rate
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,8151.96,,,,,,,fee schedule,7127.41,21415.06,MSDRG Base Rate
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,8074.32,,,,,,,fee schedule,7127.41,21415.06,MSDRG Base Rate
"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc",605,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,13586.6,,,,,,,fee schedule,7127.41,21415.06,MSDRG Base Rate
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12423.77,,,,,,,fee schedule,12423.77,37328.56,
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,12423.77,,,,,,,fee schedule,12423.77,37328.56,
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16632.24,,,,,,,fee schedule,12423.77,37328.56,
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15840.23,,,,,,,fee schedule,12423.77,37328.56,
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,27743.63,,,,,,,fee schedule,12423.77,37328.56,
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,21559.24,,,,,,,fee schedule,12423.77,37328.56,
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,37328.56,,,,,,,fee schedule,12423.77,37328.56,
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,25661.36,,,,,,,fee schedule,12423.77,37328.56,
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,23240.18,,,,,,,fee schedule,12423.77,37328.56,
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19034.67,,,,,,,fee schedule,12423.77,37328.56,
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",5469.27,5469.27,5469.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],10256.06,10256.06,10256.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],12379.9,12379.9,12379.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12817.53,,,,,,,fee schedule,12423.77,37328.56,MSDRG Base Rate
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,12695.46,,,,,,,fee schedule,12423.77,37328.56,MSDRG Base Rate
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,12695.46,,,,,,,fee schedule,12423.77,37328.56,MSDRG Base Rate
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,12817.53,,,,,,,fee schedule,12423.77,37328.56,MSDRG Base Rate
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,12695.46,,,,,,,fee schedule,12423.77,37328.56,MSDRG Base Rate
Minor Skin Disorders With Mcc,606,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21362.55,,,,,,,fee schedule,12423.77,37328.56,MSDRG Base Rate
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6669.07,,,,,,,fee schedule,6669.07,20037.93,
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,6669.07,,,,,,,fee schedule,6669.07,20037.93,
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8928.17,,,,,,,fee schedule,6669.07,20037.93,
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8503.02,,,,,,,fee schedule,6669.07,20037.93,
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,14892.75,,,,,,,fee schedule,6669.07,20037.93,
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,11572.98,,,,,,,fee schedule,6669.07,20037.93,
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,20037.93,,,,,,,fee schedule,6669.07,20037.93,
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,13774.99,,,,,,,fee schedule,6669.07,20037.93,
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,12475.31,,,,,,,fee schedule,6669.07,20037.93,
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10217.79,,,,,,,fee schedule,6669.07,20037.93,
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],13479.86,13479.86,13479.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3110.47,3110.47,3110.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],6761,6761,6761,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],3583.24,3583.24,3583.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8076.96,,,,,,,fee schedule,6669.07,20037.93,MSDRG Base Rate
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,8000.03,,,,,,,fee schedule,6669.07,20037.93,MSDRG Base Rate
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,8000.03,,,,,,,fee schedule,6669.07,20037.93,MSDRG Base Rate
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,8076.96,,,,,,,fee schedule,6669.07,20037.93,MSDRG Base Rate
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,8000.03,,,,,,,fee schedule,6669.07,20037.93,MSDRG Base Rate
Minor Skin Disorders Without Mcc,607,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,13461.6,,,,,,,fee schedule,6669.07,20037.93,MSDRG Base Rate
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17583.56,,,,,,,fee schedule,17583.56,52831.7,
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,17583.56,,,,,,,fee schedule,17583.56,52831.7,
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23539.87,,,,,,,fee schedule,17583.56,52831.7,
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22418.93,,,,,,,fee schedule,17583.56,52831.7,
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,39266,,,,,,,fee schedule,17583.56,52831.7,
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,30513.13,,,,,,,fee schedule,17583.56,52831.7,
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,52831.7,,,,,,,fee schedule,17583.56,52831.7,
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,36318.92,,,,,,,fee schedule,17583.56,52831.7,
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,32892.2,,,,,,,fee schedule,17583.56,52831.7,
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26940.06,,,,,,,fee schedule,17583.56,52831.7,
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",72984.65,72984.65,72984.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",12543.09,12543.09,12543.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],17530.39,17530.39,17530.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],32637.72,32637.72,32637.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,18119.03,,,,,,,fee schedule,17583.56,52831.7,MSDRG Base Rate
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,17946.47,,,,,,,fee schedule,17583.56,52831.7,MSDRG Base Rate
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,17946.47,,,,,,,fee schedule,17583.56,52831.7,MSDRG Base Rate
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,18119.03,,,,,,,fee schedule,17583.56,52831.7,MSDRG Base Rate
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,17946.47,,,,,,,fee schedule,17583.56,52831.7,MSDRG Base Rate
Adrenal And Pituitary Procedures With Cc/Mcc,614,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30198.38,,,,,,,fee schedule,17583.56,52831.7,MSDRG Base Rate
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11056.47,,,,,,,fee schedule,11056.47,33220.35,
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,11056.47,,,,,,,fee schedule,11056.47,33220.35,
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14801.77,,,,,,,fee schedule,11056.47,33220.35,
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14096.93,,,,,,,fee schedule,11056.47,33220.35,
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,24690.3,,,,,,,fee schedule,11056.47,33220.35,
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,19186.53,,,,,,,fee schedule,11056.47,33220.35,
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,33220.35,,,,,,,fee schedule,11056.47,33220.35,
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,22837.19,,,,,,,fee schedule,11056.47,33220.35,
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,20682.48,,,,,,,fee schedule,11056.47,33220.35,
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16939.8,,,,,,,fee schedule,11056.47,33220.35,
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],32584.27,32584.27,32584.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],10594.74,10594.74,10594.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],24692.02,24692.02,24692.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11927.7,,,,,,,fee schedule,11056.47,33220.35,MSDRG Base Rate
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,11814.1,,,,,,,fee schedule,11056.47,33220.35,MSDRG Base Rate
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,11814.1,,,,,,,fee schedule,11056.47,33220.35,MSDRG Base Rate
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,11927.7,,,,,,,fee schedule,11056.47,33220.35,MSDRG Base Rate
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,11814.1,,,,,,,fee schedule,11056.47,33220.35,MSDRG Base Rate
Adrenal And Pituitary Procedures Without Cc/Mcc,615,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19879.49,,,,,,,fee schedule,11056.47,33220.35,MSDRG Base Rate
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,29822.15,,,,,,,fee schedule,27971.83,89603.84,
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,29822.15,,,,,,,fee schedule,27971.83,89603.84,
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39924.19,,,,,,,fee schedule,27971.83,89603.84,
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,38023.04,,,,,,,fee schedule,27971.83,89603.84,
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,66596.09,,,,,,,fee schedule,27971.83,89603.84,
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,51751.01,,,,,,,fee schedule,27971.83,89603.84,
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,89603.84,,,,,,,fee schedule,27971.83,89603.84,
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,61597.77,,,,,,,fee schedule,27971.83,89603.84,
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,55785.97,,,,,,,fee schedule,27971.83,89603.84,
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45691,,,,,,,fee schedule,27971.83,89603.84,
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],36082.53,36082.53,36082.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],29721.72,29721.72,29721.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],26848.55,26848.55,26848.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,28240.79,,,,,,,fee schedule,27971.83,89603.84,MSDRG Base Rate
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,27971.83,,,,,,,fee schedule,27971.83,89603.84,MSDRG Base Rate
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,27971.83,,,,,,,fee schedule,27971.83,89603.84,MSDRG Base Rate
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,28240.79,,,,,,,fee schedule,27971.83,89603.84,MSDRG Base Rate
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,27971.83,,,,,,,fee schedule,27971.83,89603.84,MSDRG Base Rate
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc",616,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,47067.98,,,,,,,fee schedule,27971.83,89603.84,MSDRG Base Rate
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14909.15,,,,,,,fee schedule,14909.15,44796.12,
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,14909.15,,,,,,,fee schedule,14909.15,44796.12,
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19959.51,,,,,,,fee schedule,14909.15,44796.12,
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19009.06,,,,,,,fee schedule,14909.15,44796.12,
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,33293.74,,,,,,,fee schedule,14909.15,44796.12,
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,25872.16,,,,,,,fee schedule,14909.15,44796.12,
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,44796.12,,,,,,,fee schedule,14909.15,44796.12,
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,30794.9,,,,,,,fee schedule,14909.15,44796.12,
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,27889.37,,,,,,,fee schedule,14909.15,44796.12,
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22842.55,,,,,,,fee schedule,14909.15,44796.12,
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],14193.04,14193.04,14193.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],35498.46,35498.46,35498.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],14140.45,13814.06,14153.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],29246.07,29246.07,29246.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],27287.24,27287.24,27287.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",11610.23,11610.23,11610.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],13686.2,13686.2,13686.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],14220.91,14220.91,14220.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],32408.38,28913.66,32783.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],12952.5,12868.2,14383.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",11502.72,11502.72,11502.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],32583.06,32583.06,32583.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15607.34,,,,,,,fee schedule,14909.15,44796.12,MSDRG Base Rate
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,15458.7,,,,,,,fee schedule,14909.15,44796.12,MSDRG Base Rate
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,15458.7,,,,,,,fee schedule,14909.15,44796.12,MSDRG Base Rate
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,15607.34,,,,,,,fee schedule,14909.15,44796.12,MSDRG Base Rate
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,15458.7,,,,,,,fee schedule,14909.15,44796.12,MSDRG Base Rate
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc",617,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,26012.23,,,,,,,fee schedule,14909.15,44796.12,MSDRG Base Rate
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9606.61,,,,,,,fee schedule,9606.61,28864.08,
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,9606.61,,,,,,,fee schedule,9606.61,28864.08,
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12860.78,,,,,,,fee schedule,9606.61,28864.08,
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12248.36,,,,,,,fee schedule,9606.61,28864.08,
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,21452.6,,,,,,,fee schedule,9606.61,28864.08,
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,16670.55,,,,,,,fee schedule,9606.61,28864.08,
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,28864.08,,,,,,,fee schedule,9606.61,28864.08,
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,19842.49,,,,,,,fee schedule,9606.61,28864.08,
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,17970.33,,,,,,,fee schedule,9606.61,28864.08,
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14718.44,,,,,,,fee schedule,9606.61,28864.08,
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12076.13,,,,,,,fee schedule,9606.61,28864.08,MSDRG Base Rate
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,11961.12,,,,,,,fee schedule,9606.61,28864.08,MSDRG Base Rate
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,11961.12,,,,,,,fee schedule,9606.61,28864.08,MSDRG Base Rate
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,12076.13,,,,,,,fee schedule,9606.61,28864.08,MSDRG Base Rate
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,11961.12,,,,,,,fee schedule,9606.61,28864.08,MSDRG Base Rate
"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",618,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20126.89,,,,,,,fee schedule,9606.61,28864.08,MSDRG Base Rate
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,21037.31,,,,,,,fee schedule,21037.31,63208.86,
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,21037.31,,,,,,,fee schedule,21037.31,63208.86,
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28163.55,,,,,,,fee schedule,21037.31,63208.86,
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26822.43,,,,,,,fee schedule,21037.31,63208.86,
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,46978.6,,,,,,,fee schedule,21037.31,63208.86,
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,36506.5,,,,,,,fee schedule,21037.31,63208.86,
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,63208.86,,,,,,,fee schedule,21037.31,63208.86,
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,43452.65,,,,,,,fee schedule,21037.31,63208.86,
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,39352.86,,,,,,,fee schedule,21037.31,63208.86,
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,32231.61,,,,,,,fee schedule,21037.31,63208.86,
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],20669.19,20669.19,20669.19,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,23553.34,,,,,,,fee schedule,21037.31,63208.86,MSDRG Base Rate
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,23329.02,,,,,,,fee schedule,21037.31,63208.86,MSDRG Base Rate
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,23329.02,,,,,,,fee schedule,21037.31,63208.86,MSDRG Base Rate
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,23553.34,,,,,,,fee schedule,21037.31,63208.86,MSDRG Base Rate
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,23329.02,,,,,,,fee schedule,21037.31,63208.86,MSDRG Base Rate
O.R. Procedures For Obesity With Mcc,619,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,39255.56,,,,,,,fee schedule,21037.31,63208.86,MSDRG Base Rate
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12321.92,,,,,,,fee schedule,12321.92,37022.53,
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,12321.92,,,,,,,fee schedule,12321.92,37022.53,
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16495.88,,,,,,,fee schedule,12321.92,37022.53,
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15710.37,,,,,,,fee schedule,12321.92,37022.53,
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,27516.18,,,,,,,fee schedule,12321.92,37022.53,
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,21382.49,,,,,,,fee schedule,12321.92,37022.53,
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,37022.53,,,,,,,fee schedule,12321.92,37022.53,
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,25450.98,,,,,,,fee schedule,12321.92,37022.53,
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,23049.65,,,,,,,fee schedule,12321.92,37022.53,
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18878.62,,,,,,,fee schedule,12321.92,37022.53,
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",12927.38,12927.38,12927.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],20817.56,20817.56,22273.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],10293.14,10293.14,10293.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],28485.34,28485.34,28485.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],23435.63,23435.63,23435.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13497.99,,,,,,,fee schedule,12321.92,37022.53,MSDRG Base Rate
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,13369.44,,,,,,,fee schedule,12321.92,37022.53,MSDRG Base Rate
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,13369.44,,,,,,,fee schedule,12321.92,37022.53,MSDRG Base Rate
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,13497.99,,,,,,,fee schedule,12321.92,37022.53,MSDRG Base Rate
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,13369.44,,,,,,,fee schedule,12321.92,37022.53,MSDRG Base Rate
O.R. Procedures For Obesity With Cc,620,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22496.65,,,,,,,fee schedule,12321.92,37022.53,MSDRG Base Rate
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11278.7,,,,,,,fee schedule,11278.7,33888.05,
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,11278.7,,,,,,,fee schedule,11278.7,33888.05,
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15099.27,,,,,,,fee schedule,11278.7,33888.05,
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14380.26,,,,,,,fee schedule,11278.7,33888.05,
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,25186.55,,,,,,,fee schedule,11278.7,33888.05,
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,19572.16,,,,,,,fee schedule,11278.7,33888.05,
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,33888.05,,,,,,,fee schedule,11278.7,33888.05,
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,23296.19,,,,,,,fee schedule,11278.7,33888.05,
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,21098.18,,,,,,,fee schedule,11278.7,33888.05,
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17280.28,,,,,,,fee schedule,11278.7,33888.05,
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],32903.66,32903.66,32903.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],24182.33,24182.33,24182.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],12774.67,12774.67,12774.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",12927.38,12927.38,12927.38,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],18535.67,18460.67,18535.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],15569.96,15569.96,15569.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11107.18,11107.18,11107.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],21203.24,19003.02,22273.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],25042.94,21440.23,25327.71,21,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],12137.14,12137.14,12137.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12780.02,,,,,,,fee schedule,11278.7,33888.05,MSDRG Base Rate
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,12658.31,,,,,,,fee schedule,11278.7,33888.05,MSDRG Base Rate
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,12658.31,,,,,,,fee schedule,11278.7,33888.05,MSDRG Base Rate
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,12780.02,,,,,,,fee schedule,11278.7,33888.05,MSDRG Base Rate
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,12658.31,,,,,,,fee schedule,11278.7,33888.05,MSDRG Base Rate
O.R. Procedures For Obesity Without Cc/Mcc,621,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21300.04,,,,,,,fee schedule,11278.7,33888.05,MSDRG Base Rate
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,28889.27,,,,,,,fee schedule,28527.42,86800.9,
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,28889.27,,,,,,,fee schedule,28527.42,86800.9,
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,38675.3,,,,,,,fee schedule,28527.42,86800.9,
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,36833.62,,,,,,,fee schedule,28527.42,86800.9,
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,64512.86,,,,,,,fee schedule,28527.42,86800.9,
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,50132.16,,,,,,,fee schedule,28527.42,86800.9,
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,86800.9,,,,,,,fee schedule,28527.42,86800.9,
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,59670.9,,,,,,,fee schedule,28527.42,86800.9,
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,54040.9,,,,,,,fee schedule,28527.42,86800.9,
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,44261.72,,,,,,,fee schedule,28527.42,86800.9,
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],57922.84,57922.84,57922.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",19601.86,19601.86,19601.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],27793.71,27793.71,27793.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],27912.55,27912.55,27912.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],58278.91,58278.91,58278.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,28801.72,,,,,,,fee schedule,28527.42,86800.9,MSDRG Base Rate
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,28527.42,,,,,,,fee schedule,28527.42,86800.9,MSDRG Base Rate
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,28527.42,,,,,,,fee schedule,28527.42,86800.9,MSDRG Base Rate
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,28801.72,,,,,,,fee schedule,28527.42,86800.9,MSDRG Base Rate
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,28527.42,,,,,,,fee schedule,28527.42,86800.9,MSDRG Base Rate
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc",622,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,48002.87,,,,,,,fee schedule,28527.42,86800.9,MSDRG Base Rate
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14768.71,,,,,,,fee schedule,14768.71,44374.18,
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,14768.71,,,,,,,fee schedule,14768.71,44374.18,
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19771.51,,,,,,,fee schedule,14768.71,44374.18,
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18830.01,,,,,,,fee schedule,14768.71,44374.18,
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,32980.13,,,,,,,fee schedule,14768.71,44374.18,
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,25628.46,,,,,,,fee schedule,14768.71,44374.18,
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,44374.18,,,,,,,fee schedule,14768.71,44374.18,
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,30504.83,,,,,,,fee schedule,14768.71,44374.18,
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,27626.68,,,,,,,fee schedule,14768.71,44374.18,
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22627.38,,,,,,,fee schedule,14768.71,44374.18,
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],28170.72,28170.72,28170.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12476.43,12476.43,12476.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],22613.2,22613.2,22613.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],29974.29,29974.29,29974.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15010.47,,,,,,,fee schedule,14768.71,44374.18,MSDRG Base Rate
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,14867.52,,,,,,,fee schedule,14768.71,44374.18,MSDRG Base Rate
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,14867.52,,,,,,,fee schedule,14768.71,44374.18,MSDRG Base Rate
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,15010.47,,,,,,,fee schedule,14768.71,44374.18,MSDRG Base Rate
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,14867.52,,,,,,,fee schedule,14768.71,44374.18,MSDRG Base Rate
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc",623,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,25017.46,,,,,,,fee schedule,14768.71,44374.18,MSDRG Base Rate
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7740.07,,,,,,,fee schedule,7740.07,23255.87,
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,7740.07,,,,,,,fee schedule,7740.07,23255.87,
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10361.96,,,,,,,fee schedule,7740.07,23255.87,
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9868.54,,,,,,,fee schedule,7740.07,23255.87,
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,17284.42,,,,,,,fee schedule,7740.07,23255.87,
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,13431.51,,,,,,,fee schedule,7740.07,23255.87,
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,23255.87,,,,,,,fee schedule,7740.07,23255.87,
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,15987.15,,,,,,,fee schedule,7740.07,23255.87,
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,14478.75,,,,,,,fee schedule,7740.07,23255.87,
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11858.69,,,,,,,fee schedule,7740.07,23255.87,
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10776.14,,,,,,,fee schedule,7740.07,23255.87,MSDRG Base Rate
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,10673.51,,,,,,,fee schedule,7740.07,23255.87,MSDRG Base Rate
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,10673.51,,,,,,,fee schedule,7740.07,23255.87,MSDRG Base Rate
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,10776.14,,,,,,,fee schedule,7740.07,23255.87,MSDRG Base Rate
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,10673.51,,,,,,,fee schedule,7740.07,23255.87,MSDRG Base Rate
"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc",624,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,17960.23,,,,,,,fee schedule,7740.07,23255.87,MSDRG Base Rate
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,22121.43,,,,,,,fee schedule,22121.43,66466.21,
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,22121.43,,,,,,,fee schedule,22121.43,66466.21,
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29614.9,,,,,,,fee schedule,22121.43,66466.21,
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28204.68,,,,,,,fee schedule,22121.43,66466.21,
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,49399.55,,,,,,,fee schedule,22121.43,66466.21,
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,38387.79,,,,,,,fee schedule,22121.43,66466.21,
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,66466.21,,,,,,,fee schedule,22121.43,66466.21,
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,45691.91,,,,,,,fee schedule,22121.43,66466.21,
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,41380.83,,,,,,,fee schedule,22121.43,66466.21,
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33892.61,,,,,,,fee schedule,22121.43,66466.21,
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,24590.04,,,,,,,fee schedule,22121.43,66466.21,MSDRG Base Rate
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,24355.85,,,,,,,fee schedule,22121.43,66466.21,MSDRG Base Rate
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,24355.85,,,,,,,fee schedule,22121.43,66466.21,MSDRG Base Rate
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,24590.04,,,,,,,fee schedule,22121.43,66466.21,MSDRG Base Rate
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,24355.85,,,,,,,fee schedule,22121.43,66466.21,MSDRG Base Rate
"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc",625,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,40983.41,,,,,,,fee schedule,22121.43,66466.21,MSDRG Base Rate
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11645.21,,,,,,,fee schedule,11645.21,34989.29,
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,11645.21,,,,,,,fee schedule,11645.21,34989.29,
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15589.95,,,,,,,fee schedule,11645.21,34989.29,
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14847.57,,,,,,,fee schedule,11645.21,34989.29,
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,26005.03,,,,,,,fee schedule,11645.21,34989.29,
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,20208.19,,,,,,,fee schedule,11645.21,34989.29,
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,34989.29,,,,,,,fee schedule,11645.21,34989.29,
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,24053.24,,,,,,,fee schedule,11645.21,34989.29,
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,21783.79,,,,,,,fee schedule,11645.21,34989.29,
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17841.82,,,,,,,fee schedule,11645.21,34989.29,
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],9791.01,9791.01,9791.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12709.71,,,,,,,fee schedule,11645.21,34989.29,MSDRG Base Rate
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,12588.67,,,,,,,fee schedule,11645.21,34989.29,MSDRG Base Rate
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,12588.67,,,,,,,fee schedule,11645.21,34989.29,MSDRG Base Rate
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,12709.71,,,,,,,fee schedule,11645.21,34989.29,MSDRG Base Rate
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,12588.67,,,,,,,fee schedule,11645.21,34989.29,MSDRG Base Rate
"Thyroid, Parathyroid And Thyroglossal Procedures With Cc",626,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21182.86,,,,,,,fee schedule,11645.21,34989.29,MSDRG Base Rate
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9774.82,,,,,,,fee schedule,9774.82,29369.49,
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,9774.82,,,,,,,fee schedule,9774.82,29369.49,
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13085.97,,,,,,,fee schedule,9774.82,29369.49,
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12462.83,,,,,,,fee schedule,9774.82,29369.49,
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,21828.23,,,,,,,fee schedule,9774.82,29369.49,
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,16962.45,,,,,,,fee schedule,9774.82,29369.49,
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,29369.49,,,,,,,fee schedule,9774.82,29369.49,
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,20189.93,,,,,,,fee schedule,9774.82,29369.49,
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,18284.99,,,,,,,fee schedule,9774.82,29369.49,
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14976.16,,,,,,,fee schedule,9774.82,29369.49,
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9622.91,9622.91,9622.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11373.01,,,,,,,fee schedule,9774.82,29369.49,MSDRG Base Rate
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,11264.7,,,,,,,fee schedule,9774.82,29369.49,MSDRG Base Rate
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,11264.7,,,,,,,fee schedule,9774.82,29369.49,MSDRG Base Rate
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,11373.01,,,,,,,fee schedule,9774.82,29369.49,MSDRG Base Rate
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,11264.7,,,,,,,fee schedule,9774.82,29369.49,MSDRG Base Rate
"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc",627,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18955.02,,,,,,,fee schedule,9774.82,29369.49,MSDRG Base Rate
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,30450.24,,,,,,,fee schedule,29824.31,91491.02,
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,30450.24,,,,,,,fee schedule,29824.31,91491.02,
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40765.04,,,,,,,fee schedule,29824.31,91491.02,
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,38823.86,,,,,,,fee schedule,29824.31,91491.02,
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,67998.7,,,,,,,fee schedule,29824.31,91491.02,
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,52840.96,,,,,,,fee schedule,29824.31,91491.02,
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,91491.02,,,,,,,fee schedule,29824.31,91491.02,
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,62895.1,,,,,,,fee schedule,29824.31,91491.02,
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,56960.89,,,,,,,fee schedule,29824.31,91491.02,
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46653.32,,,,,,,fee schedule,29824.31,91491.02,
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],51439.99,51439.99,51439.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],67988.36,67988.36,67988.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],26020.89,26020.89,26020.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],40024,40024,40024,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,30111.08,,,,,,,fee schedule,29824.31,91491.02,MSDRG Base Rate
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,29824.31,,,,,,,fee schedule,29824.31,91491.02,MSDRG Base Rate
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,29824.31,,,,,,,fee schedule,29824.31,91491.02,MSDRG Base Rate
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,30111.08,,,,,,,fee schedule,29824.31,91491.02,MSDRG Base Rate
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,29824.31,,,,,,,fee schedule,29824.31,91491.02,MSDRG Base Rate
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc",628,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,50185.14,,,,,,,fee schedule,29824.31,91491.02,MSDRG Base Rate
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17362.11,,,,,,,fee schedule,17362.11,52166.32,
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,17362.11,,,,,,,fee schedule,17362.11,52166.32,
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23243.4,,,,,,,fee schedule,17362.11,52166.32,
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22136.57,,,,,,,fee schedule,17362.11,52166.32,
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,38771.47,,,,,,,fee schedule,17362.11,52166.32,
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,30128.84,,,,,,,fee schedule,17362.11,52166.32,
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,52166.32,,,,,,,fee schedule,17362.11,52166.32,
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,35861.51,,,,,,,fee schedule,17362.11,52166.32,
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,32477.94,,,,,,,fee schedule,17362.11,52166.32,
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26600.77,,,,,,,fee schedule,17362.11,52166.32,
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],15407.28,15407.28,15407.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],29176.84,29176.84,29176.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",11231.93,11231.93,11231.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],16558.43,16558.43,17071.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],38254.24,38254.24,38754.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],15067.09,15067.09,17034.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],24610.5,24610.5,24610.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,18017.46,,,,,,,fee schedule,17362.11,52166.32,MSDRG Base Rate
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,17845.87,,,,,,,fee schedule,17362.11,52166.32,MSDRG Base Rate
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,17845.87,,,,,,,fee schedule,17362.11,52166.32,MSDRG Base Rate
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,18017.46,,,,,,,fee schedule,17362.11,52166.32,MSDRG Base Rate
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,17845.87,,,,,,,fee schedule,17362.11,52166.32,MSDRG Base Rate
"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc",629,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30029.11,,,,,,,fee schedule,17362.11,52166.32,MSDRG Base Rate
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10811.87,,,,,,,fee schedule,10811.87,32485.42,
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,10811.87,,,,,,,fee schedule,10811.87,32485.42,
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14474.31,,,,,,,fee schedule,10811.87,32485.42,
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13785.06,,,,,,,fee schedule,10811.87,32485.42,
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,24144.08,,,,,,,fee schedule,10811.87,32485.42,
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,18762.07,,,,,,,fee schedule,10811.87,32485.42,
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,32485.42,,,,,,,fee schedule,10811.87,32485.42,
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,22331.96,,,,,,,fee schedule,10811.87,32485.42,
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,20224.92,,,,,,,fee schedule,10811.87,32485.42,
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16565.04,,,,,,,fee schedule,10811.87,32485.42,
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12398,,,,,,,fee schedule,10811.87,32485.42,MSDRG Base Rate
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,12279.92,,,,,,,fee schedule,10811.87,32485.42,MSDRG Base Rate
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,12279.92,,,,,,,fee schedule,10811.87,32485.42,MSDRG Base Rate
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,12398,,,,,,,fee schedule,10811.87,32485.42,MSDRG Base Rate
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,12279.92,,,,,,,fee schedule,10811.87,32485.42,MSDRG Base Rate
"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc",630,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20663.34,,,,,,,fee schedule,10811.87,32485.42,MSDRG Base Rate
Diabetes With Mcc,637,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11237.03,,,,,,,fee schedule,11237.03,33762.86,
Diabetes With Mcc,637,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,11237.03,,,,,,,fee schedule,11237.03,33762.86,
Diabetes With Mcc,637,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15043.49,,,,,,,fee schedule,11237.03,33762.86,
Diabetes With Mcc,637,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14327.14,,,,,,,fee schedule,11237.03,33762.86,
Diabetes With Mcc,637,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,25093.51,,,,,,,fee schedule,11237.03,33762.86,
Diabetes With Mcc,637,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,19499.86,,,,,,,fee schedule,11237.03,33762.86,
Diabetes With Mcc,637,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,33762.86,,,,,,,fee schedule,11237.03,33762.86,
Diabetes With Mcc,637,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,23210.13,,,,,,,fee schedule,11237.03,33762.86,
Diabetes With Mcc,637,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,21020.23,,,,,,,fee schedule,11237.03,33762.86,
Diabetes With Mcc,637,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17216.44,,,,,,,fee schedule,11237.03,33762.86,
Diabetes With Mcc,637,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],1447.8,1447.8,1447.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Diabetes With Mcc,637,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],11357.88,11357.88,11357.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Diabetes With Mcc,637,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],10800.82,10688.32,11232.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Diabetes With Mcc,637,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],18167,11287,22156.9,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Diabetes With Mcc,637,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],21090.23,19144.96,23225.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Diabetes With Mcc,637,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11473.45,11473.45,11473.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Diabetes With Mcc,637,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",6892.16,6892.16,6892.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Diabetes With Mcc,637,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],14258.27,14258.27,14258.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Diabetes With Mcc,637,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",6472.63,6472.63,6472.63,30,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Diabetes With Mcc,637,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],10385.3,9070.83,11031.99,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Diabetes With Mcc,637,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],17216.44,17216.44,17216.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Diabetes With Mcc,637,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Diabetes With Mcc,637,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Diabetes With Mcc,637,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],21641,6472.63,30038.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Diabetes With Mcc,637,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],10514.9,10216.91,11069.01,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Diabetes With Mcc,637,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",6412.7,6412.7,6412.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Diabetes With Mcc,637,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Diabetes With Mcc,637,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],30397.75,30397.75,30397.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Diabetes With Mcc,637,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12219.88,,,,,,,fee schedule,11237.03,33762.86,MSDRG Base Rate
Diabetes With Mcc,637,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,12103.5,,,,,,,fee schedule,11237.03,33762.86,MSDRG Base Rate
Diabetes With Mcc,637,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,12103.5,,,,,,,fee schedule,11237.03,33762.86,MSDRG Base Rate
Diabetes With Mcc,637,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,12219.88,,,,,,,fee schedule,11237.03,33762.86,MSDRG Base Rate
Diabetes With Mcc,637,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,12103.5,,,,,,,fee schedule,11237.03,33762.86,MSDRG Base Rate
Diabetes With Mcc,637,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20366.46,,,,,,,fee schedule,11237.03,33762.86,MSDRG Base Rate
Diabetes With Cc,638,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7077.25,,,,,,,fee schedule,7077.25,21264.36,
Diabetes With Cc,638,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,7077.25,,,,,,,fee schedule,7077.25,21264.36,
Diabetes With Cc,638,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9474.62,,,,,,,fee schedule,7077.25,21264.36,
Diabetes With Cc,638,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9023.45,,,,,,,fee schedule,7077.25,21264.36,
Diabetes With Cc,638,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,15804.27,,,,,,,fee schedule,7077.25,21264.36,
Diabetes With Cc,638,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,12281.31,,,,,,,fee schedule,7077.25,21264.36,
Diabetes With Cc,638,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,21264.36,,,,,,,fee schedule,7077.25,21264.36,
Diabetes With Cc,638,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,14618.1,,,,,,,fee schedule,7077.25,21264.36,
Diabetes With Cc,638,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,13238.86,,,,,,,fee schedule,7077.25,21264.36,
Diabetes With Cc,638,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10843.18,,,,,,,fee schedule,7077.25,21264.36,
Diabetes With Cc,638,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Diabetes With Cc,638,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Diabetes With Cc,638,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6156.72,5668.56,7049.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Diabetes With Cc,638,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],13006.94,9723.01,19090.99,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Diabetes With Cc,638,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7752.82,7752.82,7752.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Diabetes With Cc,638,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],13215.44,13215.44,13215.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Diabetes With Cc,638,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Diabetes With Cc,638,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],9023.45,9023.45,9023.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Diabetes With Cc,638,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4283.21,4283.21,4283.21,47,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Diabetes With Cc,638,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],5305.63,5305.63,5305.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Diabetes With Cc,638,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],5328.96,5305.63,9920.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Diabetes With Cc,638,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],9246.16,9246.16,9246.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Diabetes With Cc,638,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Diabetes With Cc,638,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],14119.62,12643.42,15317.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Diabetes With Cc,638,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],5800.03,12.41,7151.1,19,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Diabetes With Cc,638,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4243.55,4243.55,4243.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Diabetes With Cc,638,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Diabetes With Cc,638,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Diabetes With Cc,638,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7997.27,,,,,,,fee schedule,7077.25,21264.36,MSDRG Base Rate
Diabetes With Cc,638,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,7921.11,,,,,,,fee schedule,7077.25,21264.36,MSDRG Base Rate
Diabetes With Cc,638,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,7921.11,,,,,,,fee schedule,7077.25,21264.36,MSDRG Base Rate
Diabetes With Cc,638,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,7997.27,,,,,,,fee schedule,7077.25,21264.36,MSDRG Base Rate
Diabetes With Cc,638,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,7921.11,,,,,,,fee schedule,7077.25,21264.36,MSDRG Base Rate
Diabetes With Cc,638,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,13328.79,,,,,,,fee schedule,7077.25,21264.36,MSDRG Base Rate
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4834.94,,,,,,,fee schedule,4834.94,14527.09,
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,4834.94,,,,,,,fee schedule,4834.94,14527.09,
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6472.74,,,,,,,fee schedule,4834.94,14527.09,
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6164.52,,,,,,,fee schedule,4834.94,14527.09,
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,10796.94,,,,,,,fee schedule,4834.94,14527.09,
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,8390.17,,,,,,,fee schedule,4834.94,14527.09,
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,14527.09,,,,,,,fee schedule,4834.94,14527.09,
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,9986.59,,,,,,,fee schedule,4834.94,14527.09,
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,9044.34,,,,,,,fee schedule,4834.94,14527.09,
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7407.69,,,,,,,fee schedule,4834.94,14527.09,
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],8674,8674,8674,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],8950.86,6046.08,10286.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],5222.65,5222.65,5222.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],9044.34,5818.11,9344.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],6164.52,6164.52,6264.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3472.01,3472.01,3472.01,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],3104.24,3104.24,3480.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],7407.69,7407.69,7407.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],8759.1,6294.41,10796.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3439.86,3439.86,3439.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,5848.86,,,,,,,fee schedule,4834.94,14527.09,MSDRG Base Rate
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,5793.15,,,,,,,fee schedule,4834.94,14527.09,MSDRG Base Rate
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,5793.15,,,,,,,fee schedule,4834.94,14527.09,MSDRG Base Rate
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,5848.86,,,,,,,fee schedule,4834.94,14527.09,MSDRG Base Rate
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,5793.15,,,,,,,fee schedule,4834.94,14527.09,MSDRG Base Rate
Diabetes Without Cc/Mcc,639,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9748.1,,,,,,,fee schedule,4834.94,14527.09,MSDRG Base Rate
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10247.82,,,,,,,fee schedule,10247.82,30790.67,
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,10247.82,,,,,,,fee schedule,10247.82,30790.67,
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13719.19,,,,,,,fee schedule,10247.82,30790.67,
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13065.9,,,,,,,fee schedule,10247.82,30790.67,
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,22884.49,,,,,,,fee schedule,10247.82,30790.67,
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,17783.26,,,,,,,fee schedule,10247.82,30790.67,
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,30790.67,,,,,,,fee schedule,10247.82,30790.67,
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,21166.91,,,,,,,fee schedule,10247.82,30790.67,
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,19169.8,,,,,,,fee schedule,10247.82,30790.67,
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15700.85,,,,,,,fee schedule,10247.82,30790.67,
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],10300.98,9941.48,11049.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],21165.32,21165.32,21165.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",9773.7,9773.7,9773.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",9178.78,9178.78,9178.78,27,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9970.13,9414,10060.07,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],15103.56,15103.56,15103.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],22382.77,22382.77,22938.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],8671.61,17.96,10339.74,29,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",9093.79,9093.79,9093.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11430.05,,,,,,,fee schedule,10247.82,30790.67,MSDRG Base Rate
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,11321.19,,,,,,,fee schedule,10247.82,30790.67,MSDRG Base Rate
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,11321.19,,,,,,,fee schedule,10247.82,30790.67,MSDRG Base Rate
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,11430.05,,,,,,,fee schedule,10247.82,30790.67,MSDRG Base Rate
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,11321.19,,,,,,,fee schedule,10247.82,30790.67,MSDRG Base Rate
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc",640,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19050.08,,,,,,,fee schedule,10247.82,30790.67,MSDRG Base Rate
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6030.17,,,,,,,fee schedule,6030.17,18118.3,
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,6030.17,,,,,,,fee schedule,6030.17,18118.3,
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8072.85,,,,,,,fee schedule,6030.17,18118.3,
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7688.43,,,,,,,fee schedule,6030.17,18118.3,
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,13466.03,,,,,,,fee schedule,6030.17,18118.3,
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,10464.29,,,,,,,fee schedule,6030.17,18118.3,
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,18118.3,,,,,,,fee schedule,6030.17,18118.3,
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,12455.34,,,,,,,fee schedule,6030.17,18118.3,
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,11280.17,,,,,,,fee schedule,6030.17,18118.3,
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9238.92,,,,,,,fee schedule,6030.17,18118.3,
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6348.83,6215.14,6837.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],10546.9,6020,11953.75,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],11058,7629,11278.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4745.75,4745.75,4745.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],7687.44,7687.44,7687.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4456.88,4456.88,4456.88,37,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],4467.45,4465.01,5934.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],9237.74,7390.19,9237.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],10751.44,1053.9,13464.3,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],6337.77,4841.55,6399.84,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4415.61,4415.61,4415.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],6362.01,6362.01,6362.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7075.4,,,,,,,fee schedule,6030.17,18118.3,MSDRG Base Rate
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,7008.02,,,,,,,fee schedule,6030.17,18118.3,MSDRG Base Rate
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,7008.02,,,,,,,fee schedule,6030.17,18118.3,MSDRG Base Rate
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,7075.4,,,,,,,fee schedule,6030.17,18118.3,MSDRG Base Rate
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,7008.02,,,,,,,fee schedule,6030.17,18118.3,MSDRG Base Rate
"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc",641,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11792.34,,,,,,,fee schedule,6030.17,18118.3,MSDRG Base Rate
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9576.51,,,,,,,fee schedule,9576.51,28773.66,
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,9576.51,,,,,,,fee schedule,9576.51,28773.66,
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12820.49,,,,,,,fee schedule,9576.51,28773.66,
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12209.99,,,,,,,fee schedule,9576.51,28773.66,
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,21385.39,,,,,,,fee schedule,9576.51,28773.66,
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,16618.33,,,,,,,fee schedule,9576.51,28773.66,
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,28773.66,,,,,,,fee schedule,9576.51,28773.66,
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,19780.33,,,,,,,fee schedule,9576.51,28773.66,
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,17914.04,,,,,,,fee schedule,9576.51,28773.66,
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14672.33,,,,,,,fee schedule,9576.51,28773.66,
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11254.16,11254.16,11254.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",7187.54,7187.54,7187.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],6629.17,6629.17,6629.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],10107.35,10107.35,10107.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12105.82,,,,,,,fee schedule,9576.51,28773.66,MSDRG Base Rate
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,11990.52,,,,,,,fee schedule,9576.51,28773.66,MSDRG Base Rate
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,11990.52,,,,,,,fee schedule,9576.51,28773.66,MSDRG Base Rate
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,12105.82,,,,,,,fee schedule,9576.51,28773.66,MSDRG Base Rate
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,11990.52,,,,,,,fee schedule,9576.51,28773.66,MSDRG Base Rate
Inborn And Other Disorders Of Metabolism,642,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20176.36,,,,,,,fee schedule,9576.51,28773.66,MSDRG Base Rate
Endocrine Disorders With Mcc,643,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12787.98,,,,,,,fee schedule,12787.98,38422.84,
Endocrine Disorders With Mcc,643,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,12787.98,,,,,,,fee schedule,12787.98,38422.84,
Endocrine Disorders With Mcc,643,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17119.81,,,,,,,fee schedule,12787.98,38422.84,
Endocrine Disorders With Mcc,643,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16304.58,,,,,,,fee schedule,12787.98,38422.84,
Endocrine Disorders With Mcc,643,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,28556.94,,,,,,,fee schedule,12787.98,38422.84,
Endocrine Disorders With Mcc,643,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,22191.25,,,,,,,fee schedule,12787.98,38422.84,
Endocrine Disorders With Mcc,643,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,38422.84,,,,,,,fee schedule,12787.98,38422.84,
Endocrine Disorders With Mcc,643,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,26413.62,,,,,,,fee schedule,12787.98,38422.84,
Endocrine Disorders With Mcc,643,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,23921.47,,,,,,,fee schedule,12787.98,38422.84,
Endocrine Disorders With Mcc,643,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19592.67,,,,,,,fee schedule,12787.98,38422.84,
Endocrine Disorders With Mcc,643,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders With Mcc,643,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders With Mcc,643,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11369.29,11369.29,11369.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Endocrine Disorders With Mcc,643,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],22920.95,22417.24,25092.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Endocrine Disorders With Mcc,643,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders With Mcc,643,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders With Mcc,643,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",8049.34,8049.34,8049.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Endocrine Disorders With Mcc,643,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",7559.39,7559.39,7559.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Endocrine Disorders With Mcc,643,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12119.29,10912.17,12554.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Endocrine Disorders With Mcc,643,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],17188.7,17188.7,17188.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Endocrine Disorders With Mcc,643,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders With Mcc,643,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders With Mcc,643,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders With Mcc,643,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],28363.95,28363.95,28363.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Endocrine Disorders With Mcc,643,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],12464.99,10954,12692.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Endocrine Disorders With Mcc,643,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders With Mcc,643,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders With Mcc,643,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders With Mcc,643,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13855.8,,,,,,,fee schedule,12787.98,38422.84,MSDRG Base Rate
Endocrine Disorders With Mcc,643,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,13723.84,,,,,,,fee schedule,12787.98,38422.84,MSDRG Base Rate
Endocrine Disorders With Mcc,643,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,13723.84,,,,,,,fee schedule,12787.98,38422.84,MSDRG Base Rate
Endocrine Disorders With Mcc,643,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,13855.8,,,,,,,fee schedule,12787.98,38422.84,MSDRG Base Rate
Endocrine Disorders With Mcc,643,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,13723.84,,,,,,,fee schedule,12787.98,38422.84,MSDRG Base Rate
Endocrine Disorders With Mcc,643,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23093,,,,,,,fee schedule,12787.98,38422.84,MSDRG Base Rate
Endocrine Disorders With Cc,644,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7974.64,,,,,,,fee schedule,7974.64,23960.66,
Endocrine Disorders With Cc,644,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,7974.64,,,,,,,fee schedule,7974.64,23960.66,
Endocrine Disorders With Cc,644,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10675.99,,,,,,,fee schedule,7974.64,23960.66,
Endocrine Disorders With Cc,644,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10167.61,,,,,,,fee schedule,7974.64,23960.66,
Endocrine Disorders With Cc,644,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,17808.24,,,,,,,fee schedule,7974.64,23960.66,
Endocrine Disorders With Cc,644,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,13838.57,,,,,,,fee schedule,7974.64,23960.66,
Endocrine Disorders With Cc,644,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,23960.66,,,,,,,fee schedule,7974.64,23960.66,
Endocrine Disorders With Cc,644,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,16471.65,,,,,,,fee schedule,7974.64,23960.66,
Endocrine Disorders With Cc,644,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,14917.54,,,,,,,fee schedule,7974.64,23960.66,
Endocrine Disorders With Cc,644,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12218.08,,,,,,,fee schedule,7974.64,23960.66,
Endocrine Disorders With Cc,644,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],18115.98,18115.98,18115.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Endocrine Disorders With Cc,644,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders With Cc,644,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6207.15,6207.15,6207.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Endocrine Disorders With Cc,644,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],4435.23,4435.23,4435.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Endocrine Disorders With Cc,644,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7388.55,7388.55,7388.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Endocrine Disorders With Cc,644,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],16705.94,16705.94,16705.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Endocrine Disorders With Cc,644,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders With Cc,644,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],10166.63,10166.63,10166.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Endocrine Disorders With Cc,644,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",5471.42,5471.42,5471.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Endocrine Disorders With Cc,644,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],7828.37,7828.37,7828.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Endocrine Disorders With Cc,644,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7640.79,7615.64,7814.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Endocrine Disorders With Cc,644,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders With Cc,644,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders With Cc,644,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],8172.86,6987.06,8457.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Endocrine Disorders With Cc,644,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders With Cc,644,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders With Cc,644,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders With Cc,644,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders With Cc,644,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9003.51,,,,,,,fee schedule,7974.64,23960.66,MSDRG Base Rate
Endocrine Disorders With Cc,644,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,8917.76,,,,,,,fee schedule,7974.64,23960.66,MSDRG Base Rate
Endocrine Disorders With Cc,644,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,8917.76,,,,,,,fee schedule,7974.64,23960.66,MSDRG Base Rate
Endocrine Disorders With Cc,644,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,9003.51,,,,,,,fee schedule,7974.64,23960.66,MSDRG Base Rate
Endocrine Disorders With Cc,644,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,8917.76,,,,,,,fee schedule,7974.64,23960.66,MSDRG Base Rate
Endocrine Disorders With Cc,644,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15005.85,,,,,,,fee schedule,7974.64,23960.66,MSDRG Base Rate
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6010.88,,,,,,,fee schedule,6010.88,18060.34,
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,6010.88,,,,,,,fee schedule,6010.88,18060.34,
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8047.02,,,,,,,fee schedule,6010.88,18060.34,
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7663.83,,,,,,,fee schedule,6010.88,18060.34,
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,13422.95,,,,,,,fee schedule,6010.88,18060.34,
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,10430.81,,,,,,,fee schedule,6010.88,18060.34,
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,18060.34,,,,,,,fee schedule,6010.88,18060.34,
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,12415.5,,,,,,,fee schedule,6010.88,18060.34,
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,11244.09,,,,,,,fee schedule,6010.88,18060.34,
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9209.37,,,,,,,fee schedule,6010.88,18060.34,
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],6410,6410,6410,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],7585.88,7585.88,7585.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4885.48,4885.48,4885.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],13065.03,13065.03,13065.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],6338.15,6338.15,6338.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,6998.06,,,,,,,fee schedule,6010.88,18060.34,MSDRG Base Rate
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,6931.41,,,,,,,fee schedule,6010.88,18060.34,MSDRG Base Rate
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,6931.41,,,,,,,fee schedule,6010.88,18060.34,MSDRG Base Rate
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,6998.06,,,,,,,fee schedule,6010.88,18060.34,MSDRG Base Rate
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,6931.41,,,,,,,fee schedule,6010.88,18060.34,MSDRG Base Rate
Endocrine Disorders Without Cc/Mcc,645,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11663.44,,,,,,,fee schedule,6010.88,18060.34,MSDRG Base Rate
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,35548.3,,,,,,,fee schedule,35548.3,106808.69,
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,35548.3,,,,,,,fee schedule,35548.3,106808.69,
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,47590.03,,,,,,,fee schedule,35548.3,106808.69,
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,45323.85,,,,,,,fee schedule,35548.3,106808.69,
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,79383.22,,,,,,,fee schedule,35548.3,106808.69,
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,61687.73,,,,,,,fee schedule,35548.3,106808.69,
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,106808.69,,,,,,,fee schedule,35548.3,106808.69,
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,73425.17,,,,,,,fee schedule,35548.3,106808.69,
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,66497.44,,,,,,,fee schedule,35548.3,106808.69,
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,54464.14,,,,,,,fee schedule,35548.3,106808.69,
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],31923.53,31923.53,31923.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],23300.47,23300.47,23300.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,37725.05,,,,,,,fee schedule,35548.3,106808.69,MSDRG Base Rate
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,37365.76,,,,,,,fee schedule,35548.3,106808.69,MSDRG Base Rate
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,37365.76,,,,,,,fee schedule,35548.3,106808.69,MSDRG Base Rate
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,37725.05,,,,,,,fee schedule,35548.3,106808.69,MSDRG Base Rate
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,37365.76,,,,,,,fee schedule,35548.3,106808.69,MSDRG Base Rate
Kidney Transplant With Hemodialysis With Mcc,650,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,62875.09,,,,,,,fee schedule,35548.3,106808.69,MSDRG Base Rate
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,26792.02,,,,,,,fee schedule,26792.02,80499.48,
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,26792.02,,,,,,,fee schedule,26792.02,80499.48,
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35867.62,,,,,,,fee schedule,26792.02,80499.48,
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,34159.64,,,,,,,fee schedule,26792.02,80499.48,
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,59829.48,,,,,,,fee schedule,26792.02,80499.48,
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,46492.76,,,,,,,fee schedule,26792.02,80499.48,
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,80499.48,,,,,,,fee schedule,26792.02,80499.48,
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,55339.02,,,,,,,fee schedule,26792.02,80499.48,
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,50117.73,,,,,,,fee schedule,26792.02,80499.48,
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41048.49,,,,,,,fee schedule,26792.02,80499.48,
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,29947.02,,,,,,,fee schedule,26792.02,80499.48,MSDRG Base Rate
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,29661.81,,,,,,,fee schedule,26792.02,80499.48,MSDRG Base Rate
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,29661.81,,,,,,,fee schedule,26792.02,80499.48,MSDRG Base Rate
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,29947.02,,,,,,,fee schedule,26792.02,80499.48,MSDRG Base Rate
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,29661.81,,,,,,,fee schedule,26792.02,80499.48,MSDRG Base Rate
Kidney Transplant With Hemodialysis Without Mcc,651,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,49911.7,,,,,,,fee schedule,26792.02,80499.48,MSDRG Base Rate
Kidney Transplant,652,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,23697.84,,,,,,,fee schedule,23697.84,71202.7,
Kidney Transplant,652,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,23697.84,,,,,,,fee schedule,23697.84,71202.7,
Kidney Transplant,652,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31725.31,,,,,,,fee schedule,23697.84,71202.7,
Kidney Transplant,652,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,30214.59,,,,,,,fee schedule,23697.84,71202.7,
Kidney Transplant,652,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,52919.85,,,,,,,fee schedule,23697.84,71202.7,
Kidney Transplant,652,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,41123.37,,,,,,,fee schedule,23697.84,71202.7,
Kidney Transplant,652,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,71202.7,,,,,,,fee schedule,23697.84,71202.7,
Kidney Transplant,652,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,48947.99,,,,,,,fee schedule,23697.84,71202.7,
Kidney Transplant,652,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,44329.7,,,,,,,fee schedule,23697.84,71202.7,
Kidney Transplant,652,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,36307.85,,,,,,,fee schedule,23697.84,71202.7,
Kidney Transplant,652,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant,652,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant,652,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],241691.67,241691.67,241691.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney Transplant,652,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant,652,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant,652,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant,652,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant,652,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],23439.05,23439.05,23439.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney Transplant,652,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant,652,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant,652,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant,652,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant,652,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant,652,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant,652,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant,652,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant,652,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant,652,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney Transplant,652,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,26225.97,,,,,,,fee schedule,23697.84,71202.7,MSDRG Base Rate
Kidney Transplant,652,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,25976.19,,,,,,,fee schedule,23697.84,71202.7,MSDRG Base Rate
Kidney Transplant,652,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,25976.19,,,,,,,fee schedule,23697.84,71202.7,MSDRG Base Rate
Kidney Transplant,652,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,26225.97,,,,,,,fee schedule,23697.84,71202.7,MSDRG Base Rate
Kidney Transplant,652,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,25976.19,,,,,,,fee schedule,23697.84,71202.7,MSDRG Base Rate
Kidney Transplant,652,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,43709.94,,,,,,,fee schedule,23697.84,71202.7,MSDRG Base Rate
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,43011.36,,,,,,,fee schedule,41196.07,129232.25,
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,43011.36,,,,,,,fee schedule,41196.07,129232.25,
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57581.15,,,,,,,fee schedule,41196.07,129232.25,
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,54839.2,,,,,,,fee schedule,41196.07,129232.25,
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,96049.04,,,,,,,fee schedule,41196.07,129232.25,
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,74638.54,,,,,,,fee schedule,41196.07,129232.25,
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,129232.25,,,,,,,fee schedule,41196.07,129232.25,
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,88840.15,,,,,,,fee schedule,41196.07,129232.25,
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,80458,,,,,,,fee schedule,41196.07,129232.25,
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,65898.42,,,,,,,fee schedule,41196.07,129232.25,
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],24986.11,24986.11,24986.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],39207.91,39207.91,39207.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,41592.19,,,,,,,fee schedule,41196.07,129232.25,MSDRG Base Rate
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,41196.07,,,,,,,fee schedule,41196.07,129232.25,MSDRG Base Rate
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,41196.07,,,,,,,fee schedule,41196.07,129232.25,MSDRG Base Rate
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,41592.19,,,,,,,fee schedule,41196.07,129232.25,MSDRG Base Rate
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,41196.07,,,,,,,fee schedule,41196.07,129232.25,MSDRG Base Rate
Major Bladder Procedures With Mcc,653,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,69320.32,,,,,,,fee schedule,41196.07,129232.25,MSDRG Base Rate
Major Bladder Procedures With Cc,654,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,21774.2,,,,,,,fee schedule,21774.2,65422.93,
Major Bladder Procedures With Cc,654,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,21774.2,,,,,,,fee schedule,21774.2,65422.93,
Major Bladder Procedures With Cc,654,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,29150.06,,,,,,,fee schedule,21774.2,65422.93,
Major Bladder Procedures With Cc,654,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,27761.97,,,,,,,fee schedule,21774.2,65422.93,
Major Bladder Procedures With Cc,654,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,48624.16,,,,,,,fee schedule,21774.2,65422.93,
Major Bladder Procedures With Cc,654,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,37785.24,,,,,,,fee schedule,21774.2,65422.93,
Major Bladder Procedures With Cc,654,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,65422.93,,,,,,,fee schedule,21774.2,65422.93,
Major Bladder Procedures With Cc,654,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,44974.71,,,,,,,fee schedule,21774.2,65422.93,
Major Bladder Procedures With Cc,654,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,40731.3,,,,,,,fee schedule,21774.2,65422.93,
Major Bladder Procedures With Cc,654,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,33360.61,,,,,,,fee schedule,21774.2,65422.93,
Major Bladder Procedures With Cc,654,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Cc,654,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Cc,654,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Cc,654,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Cc,654,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Cc,654,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Cc,654,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Cc,654,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],21685.17,21685.17,21685.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Bladder Procedures With Cc,654,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Cc,654,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Cc,654,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Cc,654,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Cc,654,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Cc,654,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],48627.61,48627.61,48627.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Bladder Procedures With Cc,654,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Cc,654,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Cc,654,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Cc,654,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures With Cc,654,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,22865.06,,,,,,,fee schedule,21774.2,65422.93,MSDRG Base Rate
Major Bladder Procedures With Cc,654,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,22647.3,,,,,,,fee schedule,21774.2,65422.93,MSDRG Base Rate
Major Bladder Procedures With Cc,654,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,22647.3,,,,,,,fee schedule,21774.2,65422.93,MSDRG Base Rate
Major Bladder Procedures With Cc,654,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,22865.06,,,,,,,fee schedule,21774.2,65422.93,MSDRG Base Rate
Major Bladder Procedures With Cc,654,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,22647.3,,,,,,,fee schedule,21774.2,65422.93,MSDRG Base Rate
Major Bladder Procedures With Cc,654,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,38108.44,,,,,,,fee schedule,21774.2,65422.93,MSDRG Base Rate
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16027.99,,,,,,,fee schedule,16027.99,48157.8,
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,16027.99,,,,,,,fee schedule,16027.99,48157.8,
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21457.35,,,,,,,fee schedule,16027.99,48157.8,
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20435.58,,,,,,,fee schedule,16027.99,48157.8,
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,35792.23,,,,,,,fee schedule,16027.99,48157.8,
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,27813.71,,,,,,,fee schedule,16027.99,48157.8,
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,48157.8,,,,,,,fee schedule,16027.99,48157.8,
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,33105.87,,,,,,,fee schedule,16027.99,48157.8,
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,29982.3,,,,,,,fee schedule,16027.99,48157.8,
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24556.74,,,,,,,fee schedule,16027.99,48157.8,
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],36471.13,36471.13,36471.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,17531.54,,,,,,,fee schedule,16027.99,48157.8,MSDRG Base Rate
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,17364.57,,,,,,,fee schedule,16027.99,48157.8,MSDRG Base Rate
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,17364.57,,,,,,,fee schedule,16027.99,48157.8,MSDRG Base Rate
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,17531.54,,,,,,,fee schedule,16027.99,48157.8,MSDRG Base Rate
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,17364.57,,,,,,,fee schedule,16027.99,48157.8,MSDRG Base Rate
Major Bladder Procedures Without Cc/Mcc,655,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,29219.22,,,,,,,fee schedule,16027.99,48157.8,MSDRG Base Rate
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,25136.9,,,,,,,fee schedule,25136.9,75526.52,
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,25136.9,,,,,,,fee schedule,25136.9,75526.52,
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,33651.85,,,,,,,fee schedule,25136.9,75526.52,
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,32049.38,,,,,,,fee schedule,25136.9,75526.52,
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,56133.43,,,,,,,fee schedule,25136.9,75526.52,
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,43620.6,,,,,,,fee schedule,25136.9,75526.52,
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,75526.52,,,,,,,fee schedule,25136.9,75526.52,
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,51920.38,,,,,,,fee schedule,25136.9,75526.52,
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,47021.64,,,,,,,fee schedule,25136.9,75526.52,
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,38512.66,,,,,,,fee schedule,25136.9,75526.52,
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],24307.16,24307.16,26624.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,25868.93,,,,,,,fee schedule,25136.9,75526.52,MSDRG Base Rate
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,25622.56,,,,,,,fee schedule,25136.9,75526.52,MSDRG Base Rate
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,25622.56,,,,,,,fee schedule,25136.9,75526.52,MSDRG Base Rate
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,25868.93,,,,,,,fee schedule,25136.9,75526.52,MSDRG Base Rate
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,25622.56,,,,,,,fee schedule,25136.9,75526.52,MSDRG Base Rate
Kidney And Ureter Procedures For Neoplasm With Mcc,656,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,43114.89,,,,,,,fee schedule,25136.9,75526.52,MSDRG Base Rate
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14105.12,,,,,,,fee schedule,14105.12,42380.35,
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,14105.12,,,,,,,fee schedule,14105.12,42380.35,
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18883.13,,,,,,,fee schedule,14105.12,42380.35,
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17983.94,,,,,,,fee schedule,14105.12,42380.35,
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,31498.27,,,,,,,fee schedule,14105.12,42380.35,
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,24476.92,,,,,,,fee schedule,14105.12,42380.35,
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,42380.35,,,,,,,fee schedule,14105.12,42380.35,
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,29134.19,,,,,,,fee schedule,14105.12,42380.35,
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,26385.35,,,,,,,fee schedule,14105.12,42380.35,
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21610.69,,,,,,,fee schedule,14105.12,42380.35,
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],11712.35,11712.35,11712.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],26386.8,26386.8,26386.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],17984.92,17984.92,17984.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",12651.85,12651.85,12651.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],14111.31,14111.31,14111.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],29099.32,29099.32,29099.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],11604.54,11604.54,11604.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15292.49,,,,,,,fee schedule,14105.12,42380.35,MSDRG Base Rate
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,15146.85,,,,,,,fee schedule,14105.12,42380.35,MSDRG Base Rate
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,15146.85,,,,,,,fee schedule,14105.12,42380.35,MSDRG Base Rate
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,15292.49,,,,,,,fee schedule,14105.12,42380.35,MSDRG Base Rate
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,15146.85,,,,,,,fee schedule,14105.12,42380.35,MSDRG Base Rate
Kidney And Ureter Procedures For Neoplasm With Cc,657,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,25487.49,,,,,,,fee schedule,14105.12,42380.35,MSDRG Base Rate
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11604.32,,,,,,,fee schedule,11604.32,34866.42,
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,11604.32,,,,,,,fee schedule,11604.32,34866.42,
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15535.2,,,,,,,fee schedule,11604.32,34866.42,
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14795.43,,,,,,,fee schedule,11604.32,34866.42,
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,25913.7,,,,,,,fee schedule,11604.32,34866.42,
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,20137.22,,,,,,,fee schedule,11604.32,34866.42,
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,34866.42,,,,,,,fee schedule,11604.32,34866.42,
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,23968.77,,,,,,,fee schedule,11604.32,34866.42,
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,21707.29,,,,,,,fee schedule,11604.32,34866.42,
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17779.17,,,,,,,fee schedule,11604.32,34866.42,
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],11694.85,11694.85,11694.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11787.13,11787.13,11787.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],21708.74,21708.74,21708.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],14796.41,14796.41,14796.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],11233.55,11233.55,11233.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",10198.91,10198.91,10198.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],10844.79,10844.79,10844.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],16147.46,16147.46,16147.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],25741.9,25741.9,26664.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],12688.56,11585.71,12698.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],22979.46,22979.46,22979.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13119.09,,,,,,,fee schedule,11604.32,34866.42,MSDRG Base Rate
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,12994.14,,,,,,,fee schedule,11604.32,34866.42,MSDRG Base Rate
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,12994.14,,,,,,,fee schedule,11604.32,34866.42,MSDRG Base Rate
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,13119.09,,,,,,,fee schedule,11604.32,34866.42,MSDRG Base Rate
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,12994.14,,,,,,,fee schedule,11604.32,34866.42,MSDRG Base Rate
Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc,658,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21865.15,,,,,,,fee schedule,11604.32,34866.42,MSDRG Base Rate
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,19940.07,,,,,,,fee schedule,19940.07,59912.09,
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,19940.07,,,,,,,fee schedule,19940.07,59912.09,
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26694.63,,,,,,,fee schedule,19940.07,59912.09,
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25423.46,,,,,,,fee schedule,19940.07,59912.09,
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,44528.35,,,,,,,fee schedule,19940.07,59912.09,
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,34602.44,,,,,,,fee schedule,19940.07,59912.09,
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,59912.09,,,,,,,fee schedule,19940.07,59912.09,
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,41186.31,,,,,,,fee schedule,19940.07,59912.09,
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,37300.34,,,,,,,fee schedule,19940.07,59912.09,
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30550.52,,,,,,,fee schedule,19940.07,59912.09,
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],10523.59,10523.59,10523.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],17741.71,17741.71,17741.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],39.99,39.99,39.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],37276.73,37276.73,37276.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],18957.77,18957.77,18957.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",15712.23,15712.23,15712.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],18353.57,18353.57,18353.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],19228.84,19190.53,19712.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],44530.07,44530.07,44530.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],18094.7,9192.68,19428.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],25020.35,25020.35,25020.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,20846.34,,,,,,,fee schedule,19940.07,59912.09,MSDRG Base Rate
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,20647.81,,,,,,,fee schedule,19940.07,59912.09,MSDRG Base Rate
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,20647.81,,,,,,,fee schedule,19940.07,59912.09,MSDRG Base Rate
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,20846.34,,,,,,,fee schedule,19940.07,59912.09,MSDRG Base Rate
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,20647.81,,,,,,,fee schedule,19940.07,59912.09,MSDRG Base Rate
Kidney And Ureter Procedures For Non-Neoplasm With Mcc,659,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,34743.9,,,,,,,fee schedule,19940.07,59912.09,MSDRG Base Rate
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10338.87,,,,,,,fee schedule,10338.87,31064.24,
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,10338.87,,,,,,,fee schedule,10338.87,31064.24,
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13841.09,,,,,,,fee schedule,10338.87,31064.24,
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13181.99,,,,,,,fee schedule,10338.87,31064.24,
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,23087.82,,,,,,,fee schedule,10338.87,31064.24,
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,17941.26,,,,,,,fee schedule,10338.87,31064.24,
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,31064.24,,,,,,,fee schedule,10338.87,31064.24,
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,21354.98,,,,,,,fee schedule,10338.87,31064.24,
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,19340.12,,,,,,,fee schedule,10338.87,31064.24,
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15840.35,,,,,,,fee schedule,10338.87,31064.24,
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],18.13,18.13,18.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],22860.57,19838.56,23800.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],10944.73,10944.73,10944.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],17032.38,14791.46,19177.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],18720.21,17182.41,19341.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",11463.26,11463.26,11463.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],13197.18,13197.18,13197.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",10765.5,10765.5,11254.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],12307.73,12307.73,12307.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],10147.85,9986.18,10257.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],15153.61,15153.61,15153.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],14923.72,14923.72,14923.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],10058.58,7816.91,10414.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",22482.52,22482.52,22482.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],39408.63,39408.63,39408.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11321.45,,,,,,,fee schedule,10338.87,31064.24,MSDRG Base Rate
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,11213.62,,,,,,,fee schedule,10338.87,31064.24,MSDRG Base Rate
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,11213.62,,,,,,,fee schedule,10338.87,31064.24,MSDRG Base Rate
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,11321.45,,,,,,,fee schedule,10338.87,31064.24,MSDRG Base Rate
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,11213.62,,,,,,,fee schedule,10338.87,31064.24,MSDRG Base Rate
Kidney And Ureter Procedures For Non-Neoplasm With Cc,660,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18869.08,,,,,,,fee schedule,10338.87,31064.24,MSDRG Base Rate
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7921.4,,,,,,,fee schedule,7921.4,23800.69,
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,7921.4,,,,,,,fee schedule,7921.4,23800.69,
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10604.72,,,,,,,fee schedule,7921.4,23800.69,
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10099.73,,,,,,,fee schedule,7921.4,23800.69,
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,17689.34,,,,,,,fee schedule,7921.4,23800.69,
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,13746.17,,,,,,,fee schedule,7921.4,23800.69,
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,23800.69,,,,,,,fee schedule,7921.4,23800.69,
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,16361.68,,,,,,,fee schedule,7921.4,23800.69,
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,14817.94,,,,,,,fee schedule,7921.4,23800.69,
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12136.51,,,,,,,fee schedule,7921.4,23800.69,
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],8045.04,8045.04,8045.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],23800.69,23800.69,23800.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],14096.68,10451.52,16361.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7535.5,7535.5,7535.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8267.4,7366.83,8443.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],10099.73,10099.73,10099.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",7758,7758,14305.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],11986.34,11986.34,11986.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],17689.34,17689.34,17840.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],7399.84,7399.84,7399.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9084.76,,,,,,,fee schedule,7921.4,23800.69,MSDRG Base Rate
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,8998.24,,,,,,,fee schedule,7921.4,23800.69,MSDRG Base Rate
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,8998.24,,,,,,,fee schedule,7921.4,23800.69,MSDRG Base Rate
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,9084.76,,,,,,,fee schedule,7921.4,23800.69,MSDRG Base Rate
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,8998.24,,,,,,,fee schedule,7921.4,23800.69,MSDRG Base Rate
Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc,661,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15141.26,,,,,,,fee schedule,7921.4,23800.69,MSDRG Base Rate
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,24069.76,,,,,,,fee schedule,24069.76,72320.17,
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,24069.76,,,,,,,fee schedule,24069.76,72320.17,
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32223.21,,,,,,,fee schedule,24069.76,72320.17,
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,30688.78,,,,,,,fee schedule,24069.76,72320.17,
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,53750.38,,,,,,,fee schedule,24069.76,72320.17,
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,41768.77,,,,,,,fee schedule,24069.76,72320.17,
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,72320.17,,,,,,,fee schedule,24069.76,72320.17,
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,49716.19,,,,,,,fee schedule,24069.76,72320.17,
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,45025.42,,,,,,,fee schedule,24069.76,72320.17,
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,36877.67,,,,,,,fee schedule,24069.76,72320.17,
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],42.2,42.2,42.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,24913.48,,,,,,,fee schedule,24069.76,72320.17,MSDRG Base Rate
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,24676.2,,,,,,,fee schedule,24069.76,72320.17,MSDRG Base Rate
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,24676.2,,,,,,,fee schedule,24069.76,72320.17,MSDRG Base Rate
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,24913.48,,,,,,,fee schedule,24069.76,72320.17,MSDRG Base Rate
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,24676.2,,,,,,,fee schedule,24069.76,72320.17,MSDRG Base Rate
Minor Bladder Procedures With Mcc,662,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,41522.46,,,,,,,fee schedule,24069.76,72320.17,MSDRG Base Rate
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11784.88,,,,,,,fee schedule,11784.88,35408.92,
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,11784.88,,,,,,,fee schedule,11784.88,35408.92,
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15776.92,,,,,,,fee schedule,11784.88,35408.92,
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15025.64,,,,,,,fee schedule,11784.88,35408.92,
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,26316.91,,,,,,,fee schedule,11784.88,35408.92,
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,20450.55,,,,,,,fee schedule,11784.88,35408.92,
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,35408.92,,,,,,,fee schedule,11784.88,35408.92,
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,24341.71,,,,,,,fee schedule,11784.88,35408.92,
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,22045.05,,,,,,,fee schedule,11784.88,35408.92,
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18055.8,,,,,,,fee schedule,11784.88,35408.92,
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11934.5,11934.5,11934.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11585.64,11585.64,11585.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12872.21,,,,,,,fee schedule,11784.88,35408.92,MSDRG Base Rate
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,12749.62,,,,,,,fee schedule,11784.88,35408.92,MSDRG Base Rate
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,12749.62,,,,,,,fee schedule,11784.88,35408.92,MSDRG Base Rate
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,12872.21,,,,,,,fee schedule,11784.88,35408.92,MSDRG Base Rate
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,12749.62,,,,,,,fee schedule,11784.88,35408.92,MSDRG Base Rate
Minor Bladder Procedures With Cc,663,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21453.69,,,,,,,fee schedule,11784.88,35408.92,MSDRG Base Rate
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8331.9,,,,,,,fee schedule,8331.9,25034.08,
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,8331.9,,,,,,,fee schedule,8331.9,25034.08,
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11154.27,,,,,,,fee schedule,8331.9,25034.08,
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10623.12,,,,,,,fee schedule,8331.9,25034.08,
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,18606.03,,,,,,,fee schedule,8331.9,25034.08,
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,14458.52,,,,,,,fee schedule,8331.9,25034.08,
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,25034.08,,,,,,,fee schedule,8331.9,25034.08,
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,17209.57,,,,,,,fee schedule,8331.9,25034.08,
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,15585.83,,,,,,,fee schedule,8331.9,25034.08,
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12765.44,,,,,,,fee schedule,8331.9,25034.08,
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],16783.47,16783.47,16783.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4804.66,4804.66,4804.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9174.6,,,,,,,fee schedule,8331.9,25034.08,MSDRG Base Rate
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,9087.22,,,,,,,fee schedule,8331.9,25034.08,MSDRG Base Rate
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,9087.22,,,,,,,fee schedule,8331.9,25034.08,MSDRG Base Rate
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,9174.6,,,,,,,fee schedule,8331.9,25034.08,MSDRG Base Rate
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,9087.22,,,,,,,fee schedule,8331.9,25034.08,MSDRG Base Rate
Minor Bladder Procedures Without Cc/Mcc,664,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15290.99,,,,,,,fee schedule,8331.9,25034.08,MSDRG Base Rate
Prostatectomy With Mcc,665,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,26492.63,,,,,,,fee schedule,25138.17,79599.95,
Prostatectomy With Mcc,665,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,26492.63,,,,,,,fee schedule,25138.17,79599.95,
Prostatectomy With Mcc,665,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,35466.82,,,,,,,fee schedule,25138.17,79599.95,
Prostatectomy With Mcc,665,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,33777.93,,,,,,,fee schedule,25138.17,79599.95,
Prostatectomy With Mcc,665,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,59160.92,,,,,,,fee schedule,25138.17,79599.95,
Prostatectomy With Mcc,665,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,45973.23,,,,,,,fee schedule,25138.17,79599.95,
Prostatectomy With Mcc,665,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,79599.95,,,,,,,fee schedule,25138.17,79599.95,
Prostatectomy With Mcc,665,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,54720.64,,,,,,,fee schedule,25138.17,79599.95,
Prostatectomy With Mcc,665,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,49557.7,,,,,,,fee schedule,25138.17,79599.95,
Prostatectomy With Mcc,665,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,40589.79,,,,,,,fee schedule,25138.17,79599.95,
Prostatectomy With Mcc,665,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Mcc,665,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Mcc,665,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Mcc,665,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Mcc,665,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Mcc,665,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Mcc,665,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Mcc,665,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],25527.02,25527.02,25527.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Prostatectomy With Mcc,665,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Mcc,665,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Mcc,665,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Mcc,665,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Mcc,665,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Mcc,665,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],11194.71,11194.71,11194.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Prostatectomy With Mcc,665,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Mcc,665,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Mcc,665,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Mcc,665,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Mcc,665,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,25379.89,,,,,,,fee schedule,25138.17,79599.95,MSDRG Base Rate
Prostatectomy With Mcc,665,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,25138.17,,,,,,,fee schedule,25138.17,79599.95,MSDRG Base Rate
Prostatectomy With Mcc,665,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,25138.17,,,,,,,fee schedule,25138.17,79599.95,MSDRG Base Rate
Prostatectomy With Mcc,665,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,25379.89,,,,,,,fee schedule,25138.17,79599.95,MSDRG Base Rate
Prostatectomy With Mcc,665,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,25138.17,,,,,,,fee schedule,25138.17,79599.95,MSDRG Base Rate
Prostatectomy With Mcc,665,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,42299.81,,,,,,,fee schedule,25138.17,79599.95,MSDRG Base Rate
Prostatectomy With Cc,666,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12710.04,,,,,,,fee schedule,12710.04,38188.68,
Prostatectomy With Cc,666,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,12710.04,,,,,,,fee schedule,12710.04,38188.68,
Prostatectomy With Cc,666,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17015.48,,,,,,,fee schedule,12710.04,38188.68,
Prostatectomy With Cc,666,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16205.22,,,,,,,fee schedule,12710.04,38188.68,
Prostatectomy With Cc,666,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,28382.9,,,,,,,fee schedule,12710.04,38188.68,
Prostatectomy With Cc,666,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,22056.01,,,,,,,fee schedule,12710.04,38188.68,
Prostatectomy With Cc,666,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,38188.68,,,,,,,fee schedule,12710.04,38188.68,
Prostatectomy With Cc,666,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,26252.65,,,,,,,fee schedule,12710.04,38188.68,
Prostatectomy With Cc,666,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,23775.68,,,,,,,fee schedule,12710.04,38188.68,
Prostatectomy With Cc,666,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19473.26,,,,,,,fee schedule,12710.04,38188.68,
Prostatectomy With Cc,666,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Cc,666,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Cc,666,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Cc,666,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Cc,666,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Cc,666,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Cc,666,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Cc,666,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],14906.2,14906.2,14906.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Prostatectomy With Cc,666,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Cc,666,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Cc,666,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Cc,666,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Cc,666,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Cc,666,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Cc,666,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Cc,666,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Cc,666,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Cc,666,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy With Cc,666,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14662.03,,,,,,,fee schedule,12710.04,38188.68,MSDRG Base Rate
Prostatectomy With Cc,666,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,14522.39,,,,,,,fee schedule,12710.04,38188.68,MSDRG Base Rate
Prostatectomy With Cc,666,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,14522.39,,,,,,,fee schedule,12710.04,38188.68,MSDRG Base Rate
Prostatectomy With Cc,666,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,14662.03,,,,,,,fee schedule,12710.04,38188.68,MSDRG Base Rate
Prostatectomy With Cc,666,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,14522.39,,,,,,,fee schedule,12710.04,38188.68,MSDRG Base Rate
Prostatectomy With Cc,666,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,24436.72,,,,,,,fee schedule,12710.04,38188.68,MSDRG Base Rate
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7929.89,,,,,,,fee schedule,7929.89,23826.2,
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,7929.89,,,,,,,fee schedule,7929.89,23826.2,
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10616.08,,,,,,,fee schedule,7929.89,23826.2,
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10110.55,,,,,,,fee schedule,7929.89,23826.2,
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,17708.3,,,,,,,fee schedule,7929.89,23826.2,
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,13760.9,,,,,,,fee schedule,7929.89,23826.2,
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,23826.2,,,,,,,fee schedule,7929.89,23826.2,
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,16379.22,,,,,,,fee schedule,7929.89,23826.2,
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,14833.82,,,,,,,fee schedule,7929.89,23826.2,
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12149.51,,,,,,,fee schedule,7929.89,23826.2,
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9637.88,,,,,,,fee schedule,7929.89,23826.2,MSDRG Base Rate
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,9546.09,,,,,,,fee schedule,7929.89,23826.2,MSDRG Base Rate
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,9546.09,,,,,,,fee schedule,7929.89,23826.2,MSDRG Base Rate
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,9637.88,,,,,,,fee schedule,7929.89,23826.2,MSDRG Base Rate
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,9546.09,,,,,,,fee schedule,7929.89,23826.2,MSDRG Base Rate
Prostatectomy Without Cc/Mcc,667,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16063.13,,,,,,,fee schedule,7929.89,23826.2,MSDRG Base Rate
Transurethral Procedures With Mcc,668,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,22501.07,,,,,,,fee schedule,22501.07,67606.86,
Transurethral Procedures With Mcc,668,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,22501.07,,,,,,,fee schedule,22501.07,67606.86,
Transurethral Procedures With Mcc,668,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,30123.14,,,,,,,fee schedule,22501.07,67606.86,
Transurethral Procedures With Mcc,668,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28688.71,,,,,,,fee schedule,22501.07,67606.86,
Transurethral Procedures With Mcc,668,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,50247.32,,,,,,,fee schedule,22501.07,67606.86,
Transurethral Procedures With Mcc,668,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,39046.58,,,,,,,fee schedule,22501.07,67606.86,
Transurethral Procedures With Mcc,668,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,67606.86,,,,,,,fee schedule,22501.07,67606.86,
Transurethral Procedures With Mcc,668,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,46476.04,,,,,,,fee schedule,22501.07,67606.86,
Transurethral Procedures With Mcc,668,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,42090.99,,,,,,,fee schedule,22501.07,67606.86,
Transurethral Procedures With Mcc,668,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,34474.25,,,,,,,fee schedule,22501.07,67606.86,
Transurethral Procedures With Mcc,668,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Mcc,668,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Mcc,668,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Mcc,668,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Mcc,668,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Mcc,668,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Mcc,668,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Mcc,668,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Mcc,668,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Mcc,668,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Mcc,668,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Mcc,668,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Mcc,668,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Mcc,668,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],21413.39,21413.39,21413.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Transurethral Procedures With Mcc,668,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Mcc,668,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Mcc,668,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Mcc,668,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Mcc,668,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,23808.03,,,,,,,fee schedule,22501.07,67606.86,MSDRG Base Rate
Transurethral Procedures With Mcc,668,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,23581.28,,,,,,,fee schedule,22501.07,67606.86,MSDRG Base Rate
Transurethral Procedures With Mcc,668,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,23581.28,,,,,,,fee schedule,22501.07,67606.86,MSDRG Base Rate
Transurethral Procedures With Mcc,668,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,23808.03,,,,,,,fee schedule,22501.07,67606.86,MSDRG Base Rate
Transurethral Procedures With Mcc,668,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,23581.28,,,,,,,fee schedule,22501.07,67606.86,MSDRG Base Rate
Transurethral Procedures With Mcc,668,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,39680.04,,,,,,,fee schedule,22501.07,67606.86,MSDRG Base Rate
Transurethral Procedures With Cc,669,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11940.74,,,,,,,fee schedule,11940.74,35877.24,
Transurethral Procedures With Cc,669,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,11940.74,,,,,,,fee schedule,11940.74,35877.24,
Transurethral Procedures With Cc,669,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15985.58,,,,,,,fee schedule,11940.74,35877.24,
Transurethral Procedures With Cc,669,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15224.37,,,,,,,fee schedule,11940.74,35877.24,
Transurethral Procedures With Cc,669,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,26664.97,,,,,,,fee schedule,11940.74,35877.24,
Transurethral Procedures With Cc,669,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,20721.03,,,,,,,fee schedule,11940.74,35877.24,
Transurethral Procedures With Cc,669,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,35877.24,,,,,,,fee schedule,11940.74,35877.24,
Transurethral Procedures With Cc,669,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,24663.65,,,,,,,fee schedule,11940.74,35877.24,
Transurethral Procedures With Cc,669,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,22336.62,,,,,,,fee schedule,11940.74,35877.24,
Transurethral Procedures With Cc,669,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18294.61,,,,,,,fee schedule,11940.74,35877.24,
Transurethral Procedures With Cc,669,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Cc,669,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Cc,669,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Cc,669,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Cc,669,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Cc,669,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Cc,669,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Cc,669,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Cc,669,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Cc,669,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Cc,669,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Cc,669,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Cc,669,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Cc,669,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Cc,669,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Cc,669,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Cc,669,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Cc,669,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures With Cc,669,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13120.65,,,,,,,fee schedule,11940.74,35877.24,MSDRG Base Rate
Transurethral Procedures With Cc,669,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,12995.69,,,,,,,fee schedule,11940.74,35877.24,MSDRG Base Rate
Transurethral Procedures With Cc,669,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,12995.69,,,,,,,fee schedule,11940.74,35877.24,MSDRG Base Rate
Transurethral Procedures With Cc,669,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,13120.65,,,,,,,fee schedule,11940.74,35877.24,MSDRG Base Rate
Transurethral Procedures With Cc,669,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,12995.69,,,,,,,fee schedule,11940.74,35877.24,MSDRG Base Rate
Transurethral Procedures With Cc,669,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21867.76,,,,,,,fee schedule,11940.74,35877.24,MSDRG Base Rate
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7373.55,,,,,,,fee schedule,7373.55,22154.63,
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,7373.55,,,,,,,fee schedule,7373.55,22154.63,
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9871.29,,,,,,,fee schedule,7373.55,22154.63,
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9401.23,,,,,,,fee schedule,7373.55,22154.63,
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,16465.94,,,,,,,fee schedule,7373.55,22154.63,
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,12795.48,,,,,,,fee schedule,7373.55,22154.63,
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,22154.63,,,,,,,fee schedule,7373.55,22154.63,
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,15230.1,,,,,,,fee schedule,7373.55,22154.63,
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,13793.13,,,,,,,fee schedule,7373.55,22154.63,
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11297.14,,,,,,,fee schedule,7373.55,22154.63,
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8630.85,,,,,,,fee schedule,7373.55,22154.63,MSDRG Base Rate
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,8548.65,,,,,,,fee schedule,7373.55,22154.63,MSDRG Base Rate
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,8548.65,,,,,,,fee schedule,7373.55,22154.63,MSDRG Base Rate
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,8630.85,,,,,,,fee schedule,7373.55,22154.63,MSDRG Base Rate
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,8548.65,,,,,,,fee schedule,7373.55,22154.63,MSDRG Base Rate
Transurethral Procedures Without Cc/Mcc,670,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14384.76,,,,,,,fee schedule,7373.55,22154.63,MSDRG Base Rate
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13299.56,,,,,,,fee schedule,13299.56,39959.94,
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,13299.56,,,,,,,fee schedule,13299.56,39959.94,
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17804.68,,,,,,,fee schedule,13299.56,39959.94,
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16956.85,,,,,,,fee schedule,13299.56,39959.94,
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,29699.35,,,,,,,fee schedule,13299.56,39959.94,
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,23079,,,,,,,fee schedule,13299.56,39959.94,
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,39959.94,,,,,,,fee schedule,13299.56,39959.94,
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,27470.29,,,,,,,fee schedule,13299.56,39959.94,
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,24878.44,,,,,,,fee schedule,13299.56,39959.94,
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20376.47,,,,,,,fee schedule,13299.56,39959.94,
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15019.06,,,,,,,fee schedule,13299.56,39959.94,MSDRG Base Rate
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,14876.02,,,,,,,fee schedule,13299.56,39959.94,MSDRG Base Rate
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,14876.02,,,,,,,fee schedule,13299.56,39959.94,MSDRG Base Rate
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,15019.06,,,,,,,fee schedule,13299.56,39959.94,MSDRG Base Rate
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,14876.02,,,,,,,fee schedule,13299.56,39959.94,MSDRG Base Rate
Urethral Procedures With Cc/Mcc,671,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,25031.77,,,,,,,fee schedule,13299.56,39959.94,MSDRG Base Rate
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8443.78,,,,,,,fee schedule,8443.78,25370.25,
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,8443.78,,,,,,,fee schedule,8443.78,25370.25,
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11304.05,,,,,,,fee schedule,8443.78,25370.25,
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10765.77,,,,,,,fee schedule,8443.78,25370.25,
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,18855.88,,,,,,,fee schedule,8443.78,25370.25,
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,14652.68,,,,,,,fee schedule,8443.78,25370.25,
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,25370.25,,,,,,,fee schedule,8443.78,25370.25,
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,17440.67,,,,,,,fee schedule,8443.78,25370.25,
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,15795.13,,,,,,,fee schedule,8443.78,25370.25,
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12936.86,,,,,,,fee schedule,8443.78,25370.25,
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9429.28,,,,,,,fee schedule,8443.78,25370.25,MSDRG Base Rate
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,9339.48,,,,,,,fee schedule,8443.78,25370.25,MSDRG Base Rate
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,9339.48,,,,,,,fee schedule,8443.78,25370.25,MSDRG Base Rate
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,9429.28,,,,,,,fee schedule,8443.78,25370.25,MSDRG Base Rate
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,9339.48,,,,,,,fee schedule,8443.78,25370.25,MSDRG Base Rate
Urethral Procedures Without Cc/Mcc,672,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15715.47,,,,,,,fee schedule,8443.78,25370.25,MSDRG Base Rate
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,32330.67,,,,,,,fee schedule,32330.67,97140.96,
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,32330.67,,,,,,,fee schedule,32330.67,97140.96,
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,43282.45,,,,,,,fee schedule,32330.67,97140.96,
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,41221.39,,,,,,,fee schedule,32330.67,97140.96,
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,72197.89,,,,,,,fee schedule,32330.67,97140.96,
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,56104.1,,,,,,,fee schedule,32330.67,97140.96,
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,97140.96,,,,,,,fee schedule,32330.67,97140.96,
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,66779.13,,,,,,,fee schedule,32330.67,97140.96,
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,60478.46,,,,,,,fee schedule,32330.67,97140.96,
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,49534.35,,,,,,,fee schedule,32330.67,97140.96,
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],97181.69,97181.69,97181.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],42268,42268,42268,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],32751.93,29924.46,83041.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],67923.07,67923.07,67923.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",14874.43,14874.43,14874.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",13969.03,13969.03,14144.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],31737.71,31737.7,32285.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],43829.6,43829.6,72191,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],30202.59,56.68,39472.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,33820.41,,,,,,,fee schedule,32330.67,97140.96,MSDRG Base Rate
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,33498.31,,,,,,,fee schedule,32330.67,97140.96,MSDRG Base Rate
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,33498.31,,,,,,,fee schedule,32330.67,97140.96,MSDRG Base Rate
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,33820.41,,,,,,,fee schedule,32330.67,97140.96,MSDRG Base Rate
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,33498.31,,,,,,,fee schedule,32330.67,97140.96,MSDRG Base Rate
Other Kidney And Urinary Tract Procedures With Mcc,673,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,56367.34,,,,,,,fee schedule,32330.67,97140.96,MSDRG Base Rate
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17811.19,,,,,,,fee schedule,17811.19,53515.63,
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,17811.19,,,,,,,fee schedule,17811.19,53515.63,
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23844.6,,,,,,,fee schedule,17811.19,53515.63,
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22709.15,,,,,,,fee schedule,17811.19,53515.63,
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,39774.32,,,,,,,fee schedule,17811.19,53515.63,
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,30908.14,,,,,,,fee schedule,17811.19,53515.63,
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,53515.63,,,,,,,fee schedule,17811.19,53515.63,
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,36789.09,,,,,,,fee schedule,17811.19,53515.63,
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,33318,,,,,,,fee schedule,17811.19,53515.63,
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27288.81,,,,,,,fee schedule,17811.19,53515.63,
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],17263.56,17263.56,17263.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],34909.97,32929.66,107046.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],16220.83,16220.83,16220.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",8855.93,8855.93,8855.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],17257.43,17257.43,17257.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],16772.7,16772.7,17457.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],35055.7,32146.8,39776.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],34180.41,34180.41,54125.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,19265.89,,,,,,,fee schedule,17811.19,53515.63,MSDRG Base Rate
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,19082.41,,,,,,,fee schedule,17811.19,53515.63,MSDRG Base Rate
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,19082.41,,,,,,,fee schedule,17811.19,53515.63,MSDRG Base Rate
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,19265.89,,,,,,,fee schedule,17811.19,53515.63,MSDRG Base Rate
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,19082.41,,,,,,,fee schedule,17811.19,53515.63,MSDRG Base Rate
Other Kidney And Urinary Tract Procedures With Cc,674,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,32109.82,,,,,,,fee schedule,17811.19,53515.63,MSDRG Base Rate
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12077.32,,,,,,,fee schedule,12077.32,36287.6,
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,12077.32,,,,,,,fee schedule,12077.32,36287.6,
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16168.42,,,,,,,fee schedule,12077.32,36287.6,
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15398.5,,,,,,,fee schedule,12077.32,36287.6,
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,26969.96,,,,,,,fee schedule,12077.32,36287.6,
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,20958.03,,,,,,,fee schedule,12077.32,36287.6,
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,36287.6,,,,,,,fee schedule,12077.32,36287.6,
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,24945.75,,,,,,,fee schedule,12077.32,36287.6,
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,22592.1,,,,,,,fee schedule,12077.32,36287.6,
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18503.86,,,,,,,fee schedule,12077.32,36287.6,
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13819.08,,,,,,,fee schedule,12077.32,36287.6,MSDRG Base Rate
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,13687.47,,,,,,,fee schedule,12077.32,36287.6,MSDRG Base Rate
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,13687.47,,,,,,,fee schedule,12077.32,36287.6,MSDRG Base Rate
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,13819.08,,,,,,,fee schedule,12077.32,36287.6,MSDRG Base Rate
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,13687.47,,,,,,,fee schedule,12077.32,36287.6,MSDRG Base Rate
Other Kidney And Urinary Tract Procedures Without Cc/Mcc,675,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23031.8,,,,,,,fee schedule,12077.32,36287.6,MSDRG Base Rate
Renal Failure With Mcc,682,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11589.66,,,,,,,fee schedule,11589.66,34822.37,
Renal Failure With Mcc,682,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,11589.66,,,,,,,fee schedule,11589.66,34822.37,
Renal Failure With Mcc,682,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15515.57,,,,,,,fee schedule,11589.66,34822.37,
Renal Failure With Mcc,682,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14776.74,,,,,,,fee schedule,11589.66,34822.37,
Renal Failure With Mcc,682,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,25880.96,,,,,,,fee schedule,11589.66,34822.37,
Renal Failure With Mcc,682,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,20111.78,,,,,,,fee schedule,11589.66,34822.37,
Renal Failure With Mcc,682,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,34822.37,,,,,,,fee schedule,11589.66,34822.37,
Renal Failure With Mcc,682,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,23938.49,,,,,,,fee schedule,11589.66,34822.37,
Renal Failure With Mcc,682,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,21679.87,,,,,,,fee schedule,11589.66,34822.37,
Renal Failure With Mcc,682,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17756.7,,,,,,,fee schedule,11589.66,34822.37,
Renal Failure With Mcc,682,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],10090.33,10090.33,10090.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Renal Failure With Mcc,682,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Renal Failure With Mcc,682,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11131.03,9669.53,11336.38,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Renal Failure With Mcc,682,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],22740.04,22740.04,22740.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Renal Failure With Mcc,682,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11213.13,10703.04,11477.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Renal Failure With Mcc,682,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],12412,12412,12412,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Renal Failure With Mcc,682,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Renal Failure With Mcc,682,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",17344.94,17344.94,17344.94,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Renal Failure With Mcc,682,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],9091.16,9091.16,9091.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Renal Failure With Mcc,682,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11143.15,10694.61,11509.09,26,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Renal Failure With Mcc,682,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Renal Failure With Mcc,682,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Renal Failure With Mcc,682,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Renal Failure With Mcc,682,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],25269.11,23899.67,25879.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Renal Failure With Mcc,682,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],10409.37,20.32,11573.48,37,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Renal Failure With Mcc,682,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",17184.34,17184.34,17184.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Renal Failure With Mcc,682,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Renal Failure With Mcc,682,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Renal Failure With Mcc,682,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12565.97,,,,,,,fee schedule,11589.66,34822.37,MSDRG Base Rate
Renal Failure With Mcc,682,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,12446.29,,,,,,,fee schedule,11589.66,34822.37,MSDRG Base Rate
Renal Failure With Mcc,682,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,12446.29,,,,,,,fee schedule,11589.66,34822.37,MSDRG Base Rate
Renal Failure With Mcc,682,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,12565.97,,,,,,,fee schedule,11589.66,34822.37,MSDRG Base Rate
Renal Failure With Mcc,682,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,12446.29,,,,,,,fee schedule,11589.66,34822.37,MSDRG Base Rate
Renal Failure With Mcc,682,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20943.28,,,,,,,fee schedule,11589.66,34822.37,MSDRG Base Rate
Renal Failure With Cc,683,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6858.89,,,,,,,fee schedule,6858.89,20608.26,
Renal Failure With Cc,683,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,6858.89,,,,,,,fee schedule,6858.89,20608.26,
Renal Failure With Cc,683,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9182.28,,,,,,,fee schedule,6858.89,20608.26,
Renal Failure With Cc,683,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8745.03,,,,,,,fee schedule,6858.89,20608.26,
Renal Failure With Cc,683,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,15316.64,,,,,,,fee schedule,6858.89,20608.26,
Renal Failure With Cc,683,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,11902.37,,,,,,,fee schedule,6858.89,20608.26,
Renal Failure With Cc,683,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,20608.26,,,,,,,fee schedule,6858.89,20608.26,
Renal Failure With Cc,683,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,14167.06,,,,,,,fee schedule,6858.89,20608.26,
Renal Failure With Cc,683,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,12830.38,,,,,,,fee schedule,6858.89,20608.26,
Renal Failure With Cc,683,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10508.61,,,,,,,fee schedule,6858.89,20608.26,
Renal Failure With Cc,683,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],582.78,582.78,582.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Renal Failure With Cc,683,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],6411.18,6411.18,6411.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Renal Failure With Cc,683,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6996.96,5209.22,7142.99,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Renal Failure With Cc,683,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],12791.63,4211,14356.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Renal Failure With Cc,683,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6329.18,6329.18,7386.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Renal Failure With Cc,683,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],12558.06,12558.06,12558.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Renal Failure With Cc,683,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",11841.83,11841.83,11841.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Renal Failure With Cc,683,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",11121.02,11121.02,11121.02,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Renal Failure With Cc,683,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],8745.03,8745.03,8745.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Renal Failure With Cc,683,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],6774.47,6774.47,6774.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Renal Failure With Cc,683,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6734.61,6235.27,6826.85,25,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Renal Failure With Cc,683,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Renal Failure With Cc,683,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Renal Failure With Cc,683,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],12253.31,12152.79,15316.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Renal Failure With Cc,683,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],6499.1,4385.28,7580.16,21,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Renal Failure With Cc,683,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",11018.05,11018.05,11018.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Renal Failure With Cc,683,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Renal Failure With Cc,683,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],28142.4,28142.4,28142.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Renal Failure With Cc,683,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7837.89,,,,,,,fee schedule,6858.89,20608.26,MSDRG Base Rate
Renal Failure With Cc,683,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,7763.25,,,,,,,fee schedule,6858.89,20608.26,MSDRG Base Rate
Renal Failure With Cc,683,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,7763.25,,,,,,,fee schedule,6858.89,20608.26,MSDRG Base Rate
Renal Failure With Cc,683,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,7837.89,,,,,,,fee schedule,6858.89,20608.26,MSDRG Base Rate
Renal Failure With Cc,683,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,7763.25,,,,,,,fee schedule,6858.89,20608.26,MSDRG Base Rate
Renal Failure With Cc,683,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,13063.16,,,,,,,fee schedule,6858.89,20608.26,MSDRG Base Rate
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4687.56,,,,,,,fee schedule,4687.56,14084.28,
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,4687.56,,,,,,,fee schedule,4687.56,14084.28,
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6275.44,,,,,,,fee schedule,4687.56,14084.28,
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5976.61,,,,,,,fee schedule,4687.56,14084.28,
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,10467.83,,,,,,,fee schedule,4687.56,14084.28,
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,8134.43,,,,,,,fee schedule,4687.56,14084.28,
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,14084.28,,,,,,,fee schedule,4687.56,14084.28,
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,9682.18,,,,,,,fee schedule,4687.56,14084.28,
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,8768.66,,,,,,,fee schedule,4687.56,14084.28,
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7181.89,,,,,,,fee schedule,4687.56,14084.28,
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],6119,6119,6119,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],9680.58,9680.58,9680.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],5105.05,5105.05,5105.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],1586.08,1586.08,1586.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",7329.83,7329.83,7329.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],4634.78,4634.78,4634.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],7180.71,7180.71,7180.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],9966.11,9966.11,9966.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],5076.53,5025.48,5204.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,5685.58,,,,,,,fee schedule,4687.56,14084.28,MSDRG Base Rate
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,5631.43,,,,,,,fee schedule,4687.56,14084.28,MSDRG Base Rate
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,5631.43,,,,,,,fee schedule,4687.56,14084.28,MSDRG Base Rate
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,5685.58,,,,,,,fee schedule,4687.56,14084.28,MSDRG Base Rate
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,5631.43,,,,,,,fee schedule,4687.56,14084.28,MSDRG Base Rate
Renal Failure Without Cc/Mcc,684,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9475.97,,,,,,,fee schedule,4687.56,14084.28,MSDRG Base Rate
Admit For Renal Dialysis,685,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Admit For Renal Dialysis,685,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Admit For Renal Dialysis,685,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Admit For Renal Dialysis,685,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Admit For Renal Dialysis,685,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Admit For Renal Dialysis,685,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Admit For Renal Dialysis,685,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Admit For Renal Dialysis,685,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Admit For Renal Dialysis,685,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Admit For Renal Dialysis,685,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Admit For Renal Dialysis,685,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Admit For Renal Dialysis,685,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Admit For Renal Dialysis,685,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Admit For Renal Dialysis,685,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Admit For Renal Dialysis,685,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Admit For Renal Dialysis,685,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Admit For Renal Dialysis,685,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Admit For Renal Dialysis,685,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14549.57,,,,,,,fee schedule,14549.57,43715.75,
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,14549.57,,,,,,,fee schedule,14549.57,43715.75,
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19478.13,,,,,,,fee schedule,14549.57,43715.75,
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18550.61,,,,,,,fee schedule,14549.57,43715.75,
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,32490.77,,,,,,,fee schedule,14549.57,43715.75,
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,25248.18,,,,,,,fee schedule,14549.57,43715.75,
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,43715.75,,,,,,,fee schedule,14549.57,43715.75,
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,30052.2,,,,,,,fee schedule,14549.57,43715.75,
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,27216.75,,,,,,,fee schedule,14549.57,43715.75,
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22291.64,,,,,,,fee schedule,14549.57,43715.75,
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],14353.26,14353.26,14353.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],18551.59,18551.59,18551.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13915.62,13915.62,14476.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],32492.5,32492.5,32492.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],14348.26,14348.26,14348.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15087.03,,,,,,,fee schedule,14549.57,43715.75,MSDRG Base Rate
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,14943.34,,,,,,,fee schedule,14549.57,43715.75,MSDRG Base Rate
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,14943.34,,,,,,,fee schedule,14549.57,43715.75,MSDRG Base Rate
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,15087.03,,,,,,,fee schedule,14549.57,43715.75,MSDRG Base Rate
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,14943.34,,,,,,,fee schedule,14549.57,43715.75,MSDRG Base Rate
Kidney And Urinary Tract Neoplasms With Mcc,686,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,25145.05,,,,,,,fee schedule,14549.57,43715.75,MSDRG Base Rate
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8122.02,,,,,,,fee schedule,8122.02,24403.48,
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,8122.02,,,,,,,fee schedule,8122.02,24403.48,
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10873.29,,,,,,,fee schedule,8122.02,24403.48,
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10355.52,,,,,,,fee schedule,8122.02,24403.48,
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,18137.35,,,,,,,fee schedule,8122.02,24403.48,
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,14094.31,,,,,,,fee schedule,8122.02,24403.48,
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,24403.48,,,,,,,fee schedule,8122.02,24403.48,
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,16776.07,,,,,,,fee schedule,8122.02,24403.48,
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,15193.23,,,,,,,fee schedule,8122.02,24403.48,
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12443.88,,,,,,,fee schedule,8122.02,24403.48,
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7857.55,7857.55,7857.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],8326.71,8326.71,8326.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9181.63,,,,,,,fee schedule,8122.02,24403.48,MSDRG Base Rate
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,9094.19,,,,,,,fee schedule,8122.02,24403.48,MSDRG Base Rate
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,9094.19,,,,,,,fee schedule,8122.02,24403.48,MSDRG Base Rate
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,9181.63,,,,,,,fee schedule,8122.02,24403.48,MSDRG Base Rate
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,9094.19,,,,,,,fee schedule,8122.02,24403.48,MSDRG Base Rate
Kidney And Urinary Tract Neoplasms With Cc,687,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15302.72,,,,,,,fee schedule,8122.02,24403.48,MSDRG Base Rate
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5588.04,,,,,,,fee schedule,5588.04,16789.85,
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,5588.04,,,,,,,fee schedule,5588.04,16789.85,
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7480.94,,,,,,,fee schedule,5588.04,16789.85,
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7124.71,,,,,,,fee schedule,5588.04,16789.85,
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,12478.69,,,,,,,fee schedule,5588.04,16789.85,
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,9697.04,,,,,,,fee schedule,5588.04,16789.85,
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,16789.85,,,,,,,fee schedule,5588.04,16789.85,
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,11542.11,,,,,,,fee schedule,5588.04,16789.85,
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,10453.1,,,,,,,fee schedule,5588.04,16789.85,
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8561.52,,,,,,,fee schedule,5588.04,16789.85,
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7169.94,,,,,,,fee schedule,5588.04,16789.85,MSDRG Base Rate
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,7101.65,,,,,,,fee schedule,5588.04,16789.85,MSDRG Base Rate
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,7101.65,,,,,,,fee schedule,5588.04,16789.85,MSDRG Base Rate
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,7169.94,,,,,,,fee schedule,5588.04,16789.85,MSDRG Base Rate
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,7101.65,,,,,,,fee schedule,5588.04,16789.85,MSDRG Base Rate
Kidney And Urinary Tract Neoplasms Without Cc/Mcc,688,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11949.89,,,,,,,fee schedule,5588.04,16789.85,MSDRG Base Rate
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9030.98,,,,,,,fee schedule,9030.98,27134.55,
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,9030.98,,,,,,,fee schedule,9030.98,27134.55,
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12090.16,,,,,,,fee schedule,9030.98,27134.55,
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11514.44,,,,,,,fee schedule,9030.98,27134.55,
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,20167.16,,,,,,,fee schedule,9030.98,27134.55,
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,15671.66,,,,,,,fee schedule,9030.98,27134.55,
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,27134.55,,,,,,,fee schedule,9030.98,27134.55,
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,18653.53,,,,,,,fee schedule,9030.98,27134.55,
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,16893.55,,,,,,,fee schedule,9030.98,27134.55,
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13836.52,,,,,,,fee schedule,9030.98,27134.55,
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],9244.45,9244.45,9244.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8230.78,7096.7,9828.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],12884.63,12884.63,12884.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9149.22,9149.22,9149.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",7057.71,7057.71,7057.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],7215.46,7215.46,7215.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7846.05,7222.97,8865.45,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],13835.33,13835.33,13835.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],15.84,15.84,15.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],8083.96,15.84,9210.57,21,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",6992.36,6992.36,6992.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10060.52,,,,,,,fee schedule,9030.98,27134.55,MSDRG Base Rate
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,9964.71,,,,,,,fee schedule,9030.98,27134.55,MSDRG Base Rate
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,9964.71,,,,,,,fee schedule,9030.98,27134.55,MSDRG Base Rate
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,10060.52,,,,,,,fee schedule,9030.98,27134.55,MSDRG Base Rate
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,9964.71,,,,,,,fee schedule,9030.98,27134.55,MSDRG Base Rate
Kidney And Urinary Tract Infections With Mcc,689,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16767.54,,,,,,,fee schedule,9030.98,27134.55,MSDRG Base Rate
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6192.98,,,,,,,fee schedule,6192.98,18607.48,
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,6192.98,,,,,,,fee schedule,6192.98,18607.48,
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8290.81,,,,,,,fee schedule,6192.98,18607.48,
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7896.01,,,,,,,fee schedule,6192.98,18607.48,
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,13829.6,,,,,,,fee schedule,6192.98,18607.48,
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,10746.81,,,,,,,fee schedule,6192.98,18607.48,
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,18607.48,,,,,,,fee schedule,6192.98,18607.48,
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,12791.63,,,,,,,fee schedule,6192.98,18607.48,
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,11584.73,,,,,,,fee schedule,6192.98,18607.48,
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9488.37,,,,,,,fee schedule,6192.98,18607.48,
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],7214.03,7214.03,12825.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],14189.32,14189.32,24961.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],5502.96,5262.99,7074.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],10008.84,6427,10939.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],5953.64,5953.64,5953.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],7945,7945,7945,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],7896.01,7896.01,7896.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4250.97,4250.97,4250.97,23,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],4541.64,4434.39,6113.5,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],8563.3,7896.01,9365.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],12553.64,12553.64,13829.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],5418.95,1260.86,7153.81,19,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],14188.19,14188.19,14188.19,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7319.94,,,,,,,fee schedule,6192.98,18607.48,MSDRG Base Rate
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,7250.22,,,,,,,fee schedule,6192.98,18607.48,MSDRG Base Rate
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,7250.22,,,,,,,fee schedule,6192.98,18607.48,MSDRG Base Rate
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,7319.94,,,,,,,fee schedule,6192.98,18607.48,MSDRG Base Rate
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,7250.22,,,,,,,fee schedule,6192.98,18607.48,MSDRG Base Rate
Kidney And Urinary Tract Infections Without Mcc,690,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12199.9,,,,,,,fee schedule,6192.98,18607.48,MSDRG Base Rate
Urinary Stones W Esw Lithotripsy W Cc/Mcc,691,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones W Esw Lithotripsy W Cc/Mcc,691,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones W Esw Lithotripsy W Cc/Mcc,691,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones W Esw Lithotripsy W Cc/Mcc,691,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones W Esw Lithotripsy W Cc/Mcc,691,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones W Esw Lithotripsy W Cc/Mcc,691,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones W Esw Lithotripsy W Cc/Mcc,691,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones W Esw Lithotripsy W Cc/Mcc,691,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones W Esw Lithotripsy W Cc/Mcc,691,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones W Esw Lithotripsy W Cc/Mcc,691,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones W Esw Lithotripsy W Cc/Mcc,691,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones W Esw Lithotripsy W Cc/Mcc,691,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones W Esw Lithotripsy W Cc/Mcc,691,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones W Esw Lithotripsy W Cc/Mcc,691,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones W Esw Lithotripsy W Cc/Mcc,691,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones W Esw Lithotripsy W Cc/Mcc,691,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones W Esw Lithotripsy W Cc/Mcc,691,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones W Esw Lithotripsy W Cc/Mcc,691,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones W Esw Lithotripsy W/O Cc/Mcc,692,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones W Esw Lithotripsy W/O Cc/Mcc,692,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones W Esw Lithotripsy W/O Cc/Mcc,692,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones W Esw Lithotripsy W/O Cc/Mcc,692,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones W Esw Lithotripsy W/O Cc/Mcc,692,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones W Esw Lithotripsy W/O Cc/Mcc,692,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones W Esw Lithotripsy W/O Cc/Mcc,692,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones W Esw Lithotripsy W/O Cc/Mcc,692,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones W Esw Lithotripsy W/O Cc/Mcc,692,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones W Esw Lithotripsy W/O Cc/Mcc,692,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones W Esw Lithotripsy W/O Cc/Mcc,692,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones W Esw Lithotripsy W/O Cc/Mcc,692,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones W Esw Lithotripsy W/O Cc/Mcc,692,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones W Esw Lithotripsy W/O Cc/Mcc,692,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones W Esw Lithotripsy W/O Cc/Mcc,692,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones W Esw Lithotripsy W/O Cc/Mcc,692,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones W Esw Lithotripsy W/O Cc/Mcc,692,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones W Esw Lithotripsy W/O Cc/Mcc,692,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones With Mcc,693,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11345.06,,,,,,,fee schedule,11345.06,34087.44,
Urinary Stones With Mcc,693,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,11345.06,,,,,,,fee schedule,11345.06,34087.44,
Urinary Stones With Mcc,693,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15188.11,,,,,,,fee schedule,11345.06,34087.44,
Urinary Stones With Mcc,693,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14464.87,,,,,,,fee schedule,11345.06,34087.44,
Urinary Stones With Mcc,693,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,25334.74,,,,,,,fee schedule,11345.06,34087.44,
Urinary Stones With Mcc,693,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,19687.32,,,,,,,fee schedule,11345.06,34087.44,
Urinary Stones With Mcc,693,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,34087.44,,,,,,,fee schedule,11345.06,34087.44,
Urinary Stones With Mcc,693,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,23433.26,,,,,,,fee schedule,11345.06,34087.44,
Urinary Stones With Mcc,693,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,21222.31,,,,,,,fee schedule,11345.06,34087.44,
Urinary Stones With Mcc,693,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17381.95,,,,,,,fee schedule,11345.06,34087.44,
Urinary Stones With Mcc,693,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones With Mcc,693,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones With Mcc,693,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones With Mcc,693,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones With Mcc,693,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones With Mcc,693,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones With Mcc,693,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones With Mcc,693,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],10847.95,10847.95,10847.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Urinary Stones With Mcc,693,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones With Mcc,693,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones With Mcc,693,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones With Mcc,693,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones With Mcc,693,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones With Mcc,693,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones With Mcc,693,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones With Mcc,693,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones With Mcc,693,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones With Mcc,693,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones With Mcc,693,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11499.57,,,,,,,fee schedule,11345.06,34087.44,MSDRG Base Rate
Urinary Stones With Mcc,693,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,11390.05,,,,,,,fee schedule,11345.06,34087.44,MSDRG Base Rate
Urinary Stones With Mcc,693,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,11390.05,,,,,,,fee schedule,11345.06,34087.44,MSDRG Base Rate
Urinary Stones With Mcc,693,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,11499.57,,,,,,,fee schedule,11345.06,34087.44,MSDRG Base Rate
Urinary Stones With Mcc,693,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,11390.05,,,,,,,fee schedule,11345.06,34087.44,MSDRG Base Rate
Urinary Stones With Mcc,693,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19165.95,,,,,,,fee schedule,11345.06,34087.44,MSDRG Base Rate
Urinary Stones Without Mcc,694,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6029.4,,,,,,,fee schedule,6029.4,18115.98,
Urinary Stones Without Mcc,694,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,6029.4,,,,,,,fee schedule,6029.4,18115.98,
Urinary Stones Without Mcc,694,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8071.82,,,,,,,fee schedule,6029.4,18115.98,
Urinary Stones Without Mcc,694,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7687.44,,,,,,,fee schedule,6029.4,18115.98,
Urinary Stones Without Mcc,694,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,13464.3,,,,,,,fee schedule,6029.4,18115.98,
Urinary Stones Without Mcc,694,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,10462.95,,,,,,,fee schedule,6029.4,18115.98,
Urinary Stones Without Mcc,694,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,18115.98,,,,,,,fee schedule,6029.4,18115.98,
Urinary Stones Without Mcc,694,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,12453.75,,,,,,,fee schedule,6029.4,18115.98,
Urinary Stones Without Mcc,694,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,11278.73,,,,,,,fee schedule,6029.4,18115.98,
Urinary Stones Without Mcc,694,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9237.74,,,,,,,fee schedule,6029.4,18115.98,
Urinary Stones Without Mcc,694,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],8295.72,8295.72,8295.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Urinary Stones Without Mcc,694,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones Without Mcc,694,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],12474.47,12474.47,12474.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Urinary Stones Without Mcc,694,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones Without Mcc,694,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],11278.73,11278.73,11278.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Urinary Stones Without Mcc,694,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones Without Mcc,694,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4042.19,4042.19,4042.19,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Urinary Stones Without Mcc,694,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],7700.23,7700.23,7700.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Urinary Stones Without Mcc,694,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3796.14,3796.14,3796.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Urinary Stones Without Mcc,694,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],5752.86,5752.86,5752.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Urinary Stones Without Mcc,694,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],8797.85,8797.85,8797.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Urinary Stones Without Mcc,694,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones Without Mcc,694,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones Without Mcc,694,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],13464.3,13464.3,13464.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Urinary Stones Without Mcc,694,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],7074.35,7074.35,7074.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Urinary Stones Without Mcc,694,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones Without Mcc,694,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones Without Mcc,694,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urinary Stones Without Mcc,694,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7102.75,,,,,,,fee schedule,6029.4,18115.98,MSDRG Base Rate
Urinary Stones Without Mcc,694,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,7035.1,,,,,,,fee schedule,6029.4,18115.98,MSDRG Base Rate
Urinary Stones Without Mcc,694,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,7035.1,,,,,,,fee schedule,6029.4,18115.98,MSDRG Base Rate
Urinary Stones Without Mcc,694,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,7102.75,,,,,,,fee schedule,6029.4,18115.98,MSDRG Base Rate
Urinary Stones Without Mcc,694,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,7035.1,,,,,,,fee schedule,6029.4,18115.98,MSDRG Base Rate
Urinary Stones Without Mcc,694,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11837.91,,,,,,,fee schedule,6029.4,18115.98,MSDRG Base Rate
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8701.5,,,,,,,fee schedule,8701.5,26144.6,
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,8701.5,,,,,,,fee schedule,8701.5,26144.6,
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11649.07,,,,,,,fee schedule,8701.5,26144.6,
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11094.36,,,,,,,fee schedule,8701.5,26144.6,
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,19431.4,,,,,,,fee schedule,8701.5,26144.6,
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,15099.9,,,,,,,fee schedule,8701.5,26144.6,
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,26144.6,,,,,,,fee schedule,8701.5,26144.6,
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,17972.99,,,,,,,fee schedule,8701.5,26144.6,
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,16277.22,,,,,,,fee schedule,8701.5,26144.6,
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13331.71,,,,,,,fee schedule,8701.5,26144.6,
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9931.62,,,,,,,fee schedule,8701.5,26144.6,MSDRG Base Rate
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,9837.04,,,,,,,fee schedule,8701.5,26144.6,MSDRG Base Rate
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,9837.04,,,,,,,fee schedule,8701.5,26144.6,MSDRG Base Rate
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,9931.62,,,,,,,fee schedule,8701.5,26144.6,MSDRG Base Rate
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,9837.04,,,,,,,fee schedule,8701.5,26144.6,MSDRG Base Rate
Kidney And Urinary Tract Signs And Symptoms With Mcc,695,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16552.71,,,,,,,fee schedule,8701.5,26144.6,MSDRG Base Rate
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5337.26,,,,,,,fee schedule,5337.26,16036.37,
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,5337.26,,,,,,,fee schedule,5337.26,16036.37,
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7145.22,,,,,,,fee schedule,5337.26,16036.37,
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6804.97,,,,,,,fee schedule,5337.26,16036.37,
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,11918.68,,,,,,,fee schedule,5337.26,16036.37,
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,9261.86,,,,,,,fee schedule,5337.26,16036.37,
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,16036.37,,,,,,,fee schedule,5337.26,16036.37,
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,11024.13,,,,,,,fee schedule,5337.26,16036.37,
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,9984,,,,,,,fee schedule,5337.26,16036.37,
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8177.31,,,,,,,fee schedule,5337.26,16036.37,
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3712.32,3712.32,3712.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],5093.2,5093.2,5093.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],11207.97,11207.97,11207.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,6378.54,,,,,,,fee schedule,5337.26,16036.37,MSDRG Base Rate
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,6317.79,,,,,,,fee schedule,5337.26,16036.37,MSDRG Base Rate
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,6317.79,,,,,,,fee schedule,5337.26,16036.37,MSDRG Base Rate
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,6378.54,,,,,,,fee schedule,5337.26,16036.37,MSDRG Base Rate
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,6317.79,,,,,,,fee schedule,5337.26,16036.37,MSDRG Base Rate
Kidney And Urinary Tract Signs And Symptoms Without Mcc,696,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10630.9,,,,,,,fee schedule,5337.26,16036.37,MSDRG Base Rate
Urethral Stricture,697,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7730.04,,,,,,,fee schedule,7730.04,23225.73,
Urethral Stricture,697,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,7730.04,,,,,,,fee schedule,7730.04,23225.73,
Urethral Stricture,697,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10348.53,,,,,,,fee schedule,7730.04,23225.73,
Urethral Stricture,697,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9855.75,,,,,,,fee schedule,7730.04,23225.73,
Urethral Stricture,697,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,17262.02,,,,,,,fee schedule,7730.04,23225.73,
Urethral Stricture,697,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,13414.1,,,,,,,fee schedule,7730.04,23225.73,
Urethral Stricture,697,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,23225.73,,,,,,,fee schedule,7730.04,23225.73,
Urethral Stricture,697,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,15966.43,,,,,,,fee schedule,7730.04,23225.73,
Urethral Stricture,697,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,14459.98,,,,,,,fee schedule,7730.04,23225.73,
Urethral Stricture,697,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11843.32,,,,,,,fee schedule,7730.04,23225.73,
Urethral Stricture,697,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Stricture,697,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Stricture,697,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],10480.54,10480.54,10480.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Urethral Stricture,697,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Stricture,697,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Stricture,697,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Stricture,697,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Urethral Stricture,697,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Urethral Stricture,697,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Stricture,697,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Stricture,697,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Stricture,697,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Stricture,697,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Stricture,697,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Stricture,697,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Stricture,697,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Urethral Stricture,697,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Stricture,697,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Urethral Stricture,697,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9416,,,,,,,fee schedule,7730.04,23225.73,MSDRG Base Rate
Urethral Stricture,697,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,9326.32,,,,,,,fee schedule,7730.04,23225.73,MSDRG Base Rate
Urethral Stricture,697,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,9326.32,,,,,,,fee schedule,7730.04,23225.73,MSDRG Base Rate
Urethral Stricture,697,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,9416,,,,,,,fee schedule,7730.04,23225.73,MSDRG Base Rate
Urethral Stricture,697,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,9326.32,,,,,,,fee schedule,7730.04,23225.73,MSDRG Base Rate
Urethral Stricture,697,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15693.34,,,,,,,fee schedule,7730.04,23225.73,MSDRG Base Rate
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12970.08,,,,,,,fee schedule,12970.08,38969.99,
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,12970.08,,,,,,,fee schedule,12970.08,38969.99,
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17363.6,,,,,,,fee schedule,12970.08,38969.99,
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16536.76,,,,,,,fee schedule,12970.08,38969.99,
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,28963.59,,,,,,,fee schedule,12970.08,38969.99,
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,22507.25,,,,,,,fee schedule,12970.08,38969.99,
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,38969.99,,,,,,,fee schedule,12970.08,38969.99,
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,26789.75,,,,,,,fee schedule,12970.08,38969.99,
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,24262.11,,,,,,,fee schedule,12970.08,38969.99,
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19871.67,,,,,,,fee schedule,12970.08,38969.99,
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],7260.46,7260.46,7260.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],38969.99,38969.99,38969.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12368.18,10604.18,13458.87,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],19237.35,9272.5,26789.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12562.02,12562.02,12562.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],24462.11,24462.11,24462.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",9873.49,9873.49,9873.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",9272.5,9272.5,9272.5,20,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],16536.76,16536.76,16536.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],12763.42,11727.35,12885.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12377.07,11090.94,12748.44,27,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],27711.22,21325.53,111157.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],11118.68,7828.16,12912.79,43,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],41020,41020,41020,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13920.64,,,,,,,fee schedule,12970.08,38969.99,MSDRG Base Rate
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,13788.06,,,,,,,fee schedule,12970.08,38969.99,MSDRG Base Rate
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,13788.06,,,,,,,fee schedule,12970.08,38969.99,MSDRG Base Rate
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,13920.64,,,,,,,fee schedule,12970.08,38969.99,MSDRG Base Rate
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,13788.06,,,,,,,fee schedule,12970.08,38969.99,MSDRG Base Rate
Other Kidney And Urinary Tract Diagnoses With Mcc,698,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23201.06,,,,,,,fee schedule,12970.08,38969.99,MSDRG Base Rate
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7868.93,,,,,,,fee schedule,7868.93,23643.04,
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,7868.93,,,,,,,fee schedule,7868.93,23643.04,
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10534.47,,,,,,,fee schedule,7868.93,23643.04,
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10032.83,,,,,,,fee schedule,7868.93,23643.04,
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,17572.17,,,,,,,fee schedule,7868.93,23643.04,
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,13655.12,,,,,,,fee schedule,7868.93,23643.04,
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,23643.04,,,,,,,fee schedule,7868.93,23643.04,
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,16253.31,,,,,,,fee schedule,7868.93,23643.04,
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,14719.79,,,,,,,fee schedule,7868.93,23643.04,
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12056.12,,,,,,,fee schedule,7868.93,23643.04,
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],18925.8,18925.8,18925.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8065.07,8065.07,8089.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],11117.23,11117.23,11117.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12830.38,12830.38,12830.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",7512.41,7512.41,7512.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],10042.67,10042.67,10042.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",7055.13,7055.13,7055.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],7725.94,7725.94,7725.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7712.31,6312.71,7735.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],12057.3,12057.3,12057.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],9819.41,9819.41,9819.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],8086.5,284.44,8553.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],22558.31,14769.6,38234.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8925.39,,,,,,,fee schedule,7868.93,23643.04,MSDRG Base Rate
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,8840.38,,,,,,,fee schedule,7868.93,23643.04,MSDRG Base Rate
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,8840.38,,,,,,,fee schedule,7868.93,23643.04,MSDRG Base Rate
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,8925.39,,,,,,,fee schedule,7868.93,23643.04,MSDRG Base Rate
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,8840.38,,,,,,,fee schedule,7868.93,23643.04,MSDRG Base Rate
Other Kidney And Urinary Tract Diagnoses With Cc,699,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14875.65,,,,,,,fee schedule,7868.93,23643.04,MSDRG Base Rate
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5355.78,,,,,,,fee schedule,5355.78,16092.01,
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,5355.78,,,,,,,fee schedule,5355.78,16092.01,
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7170.01,,,,,,,fee schedule,5355.78,16092.01,
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6828.58,,,,,,,fee schedule,5355.78,16092.01,
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,11960.04,,,,,,,fee schedule,5355.78,16092.01,
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,9294,,,,,,,fee schedule,5355.78,16092.01,
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,16092.01,,,,,,,fee schedule,5355.78,16092.01,
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,11062.39,,,,,,,fee schedule,5355.78,16092.01,
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,10018.64,,,,,,,fee schedule,5355.78,16092.01,
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8205.68,,,,,,,fee schedule,5355.78,16092.01,
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],10997,10997,10997,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4872.16,4872.16,4872.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,6385.58,,,,,,,fee schedule,5355.78,16092.01,MSDRG Base Rate
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,6324.76,,,,,,,fee schedule,5355.78,16092.01,MSDRG Base Rate
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,6324.76,,,,,,,fee schedule,5355.78,16092.01,MSDRG Base Rate
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,6385.58,,,,,,,fee schedule,5355.78,16092.01,MSDRG Base Rate
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,6324.76,,,,,,,fee schedule,5355.78,16092.01,MSDRG Base Rate
Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc,700,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10642.62,,,,,,,fee schedule,5355.78,16092.01,MSDRG Base Rate
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14973.19,,,,,,,fee schedule,14973.19,44988.55,
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,14973.19,,,,,,,fee schedule,14973.19,44988.55,
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20045.25,,,,,,,fee schedule,14973.19,44988.55,
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19090.72,,,,,,,fee schedule,14973.19,44988.55,
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,33436.76,,,,,,,fee schedule,14973.19,44988.55,
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,25983.3,,,,,,,fee schedule,14973.19,44988.55,
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,44988.55,,,,,,,fee schedule,14973.19,44988.55,
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,30927.18,,,,,,,fee schedule,14973.19,44988.55,
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,28009.18,,,,,,,fee schedule,14973.19,44988.55,
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22940.67,,,,,,,fee schedule,14973.19,44988.55,
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],19091.7,19091.7,19091.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],13223.19,13223.19,13223.19,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,16622.95,,,,,,,fee schedule,14973.19,44988.55,MSDRG Base Rate
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,16464.64,,,,,,,fee schedule,14973.19,44988.55,MSDRG Base Rate
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,16464.64,,,,,,,fee schedule,14973.19,44988.55,MSDRG Base Rate
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,16622.95,,,,,,,fee schedule,14973.19,44988.55,MSDRG Base Rate
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,16464.64,,,,,,,fee schedule,14973.19,44988.55,MSDRG Base Rate
Major Male Pelvic Procedures With Cc/Mcc,707,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,27704.91,,,,,,,fee schedule,14973.19,44988.55,MSDRG Base Rate
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11438.42,,,,,,,fee schedule,11438.42,34367.96,
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,11438.42,,,,,,,fee schedule,11438.42,34367.96,
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15313.1,,,,,,,fee schedule,11438.42,34367.96,
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14583.91,,,,,,,fee schedule,11438.42,34367.96,
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,25543.23,,,,,,,fee schedule,11438.42,34367.96,
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,19849.34,,,,,,,fee schedule,11438.42,34367.96,
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,34367.96,,,,,,,fee schedule,11438.42,34367.96,
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,23626.11,,,,,,,fee schedule,11438.42,34367.96,
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,21396.96,,,,,,,fee schedule,11438.42,34367.96,
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17524.99,,,,,,,fee schedule,11438.42,34367.96,
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],14584.59,14584.59,14584.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],24873.38,24873.38,24873.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12981.59,,,,,,,fee schedule,11438.42,34367.96,MSDRG Base Rate
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,12857.96,,,,,,,fee schedule,11438.42,34367.96,MSDRG Base Rate
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,12857.96,,,,,,,fee schedule,11438.42,34367.96,MSDRG Base Rate
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,12981.59,,,,,,,fee schedule,11438.42,34367.96,MSDRG Base Rate
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,12857.96,,,,,,,fee schedule,11438.42,34367.96,MSDRG Base Rate
Major Male Pelvic Procedures Without Cc/Mcc,708,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21635.98,,,,,,,fee schedule,11438.42,34367.96,MSDRG Base Rate
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17338.19,,,,,,,fee schedule,17338.19,52094.45,
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,17338.19,,,,,,,fee schedule,17338.19,52094.45,
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23211.38,,,,,,,fee schedule,17338.19,52094.45,
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22106.08,,,,,,,fee schedule,17338.19,52094.45,
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,38718.06,,,,,,,fee schedule,17338.19,52094.45,
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,30087.33,,,,,,,fee schedule,17338.19,52094.45,
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,52094.45,,,,,,,fee schedule,17338.19,52094.45,
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,35812.1,,,,,,,fee schedule,17338.19,52094.45,
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,32433.2,,,,,,,fee schedule,17338.19,52094.45,
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26564.12,,,,,,,fee schedule,17338.19,52094.45,
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,19176.05,,,,,,,fee schedule,17338.19,52094.45,MSDRG Base Rate
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,18993.42,,,,,,,fee schedule,17338.19,52094.45,MSDRG Base Rate
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,18993.42,,,,,,,fee schedule,17338.19,52094.45,MSDRG Base Rate
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,19176.05,,,,,,,fee schedule,17338.19,52094.45,MSDRG Base Rate
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,18993.42,,,,,,,fee schedule,17338.19,52094.45,MSDRG Base Rate
Penis Procedures With Cc/Mcc,709,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31960.08,,,,,,,fee schedule,17338.19,52094.45,MSDRG Base Rate
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11584.26,,,,,,,fee schedule,11584.26,34806.14,
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,11584.26,,,,,,,fee schedule,11584.26,34806.14,
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15508.34,,,,,,,fee schedule,11584.26,34806.14,
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14769.85,,,,,,,fee schedule,11584.26,34806.14,
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,25868.9,,,,,,,fee schedule,11584.26,34806.14,
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,20102.41,,,,,,,fee schedule,11584.26,34806.14,
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,34806.14,,,,,,,fee schedule,11584.26,34806.14,
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,23927.33,,,,,,,fee schedule,11584.26,34806.14,
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,21669.76,,,,,,,fee schedule,11584.26,34806.14,
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17748.43,,,,,,,fee schedule,11584.26,34806.14,
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11942.53,,,,,,,fee schedule,11584.26,34806.14,MSDRG Base Rate
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,11828.79,,,,,,,fee schedule,11584.26,34806.14,MSDRG Base Rate
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,11828.79,,,,,,,fee schedule,11584.26,34806.14,MSDRG Base Rate
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,11942.53,,,,,,,fee schedule,11584.26,34806.14,MSDRG Base Rate
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,11828.79,,,,,,,fee schedule,11584.26,34806.14,MSDRG Base Rate
Penis Procedures Without Cc/Mcc,710,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19904.22,,,,,,,fee schedule,11584.26,34806.14,MSDRG Base Rate
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14742.48,,,,,,,fee schedule,14742.48,44295.35,
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,14742.48,,,,,,,fee schedule,14742.48,44295.35,
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19736.38,,,,,,,fee schedule,14742.48,44295.35,
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18796.56,,,,,,,fee schedule,14742.48,44295.35,
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,32921.55,,,,,,,fee schedule,14742.48,44295.35,
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,25582.93,,,,,,,fee schedule,14742.48,44295.35,
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,44295.35,,,,,,,fee schedule,14742.48,44295.35,
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,30450.65,,,,,,,fee schedule,14742.48,44295.35,
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,27577.6,,,,,,,fee schedule,14742.48,44295.35,
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22587.19,,,,,,,fee schedule,14742.48,44295.35,
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",7052.12,7052.12,7052.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,17275.29,,,,,,,fee schedule,14742.48,44295.35,MSDRG Base Rate
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,17110.77,,,,,,,fee schedule,14742.48,44295.35,MSDRG Base Rate
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,17110.77,,,,,,,fee schedule,14742.48,44295.35,MSDRG Base Rate
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,17275.29,,,,,,,fee schedule,14742.48,44295.35,MSDRG Base Rate
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,17110.77,,,,,,,fee schedule,14742.48,44295.35,MSDRG Base Rate
Testes Procedures With Cc/Mcc,711,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,28792.16,,,,,,,fee schedule,14742.48,44295.35,MSDRG Base Rate
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8253.19,,,,,,,fee schedule,8253.19,24797.61,
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,8253.19,,,,,,,fee schedule,8253.19,24797.61,
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11048.9,,,,,,,fee schedule,8253.19,24797.61,
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10522.77,,,,,,,fee schedule,8253.19,24797.61,
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,18430.28,,,,,,,fee schedule,8253.19,24797.61,
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,14321.94,,,,,,,fee schedule,8253.19,24797.61,
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,24797.61,,,,,,,fee schedule,8253.19,24797.61,
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,17047.01,,,,,,,fee schedule,8253.19,24797.61,
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,15438.61,,,,,,,fee schedule,8253.19,24797.61,
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12644.85,,,,,,,fee schedule,8253.19,24797.61,
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",5328.7,5328.7,5328.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9587.1,,,,,,,fee schedule,8253.19,24797.61,MSDRG Base Rate
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,9495.79,,,,,,,fee schedule,8253.19,24797.61,MSDRG Base Rate
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,9495.79,,,,,,,fee schedule,8253.19,24797.61,MSDRG Base Rate
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,9587.1,,,,,,,fee schedule,8253.19,24797.61,MSDRG Base Rate
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,9495.79,,,,,,,fee schedule,8253.19,24797.61,MSDRG Base Rate
Testes Procedures Without Cc/Mcc,712,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15978.5,,,,,,,fee schedule,8253.19,24797.61,MSDRG Base Rate
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11156.78,,,,,,,fee schedule,11156.78,33521.75,
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,11156.78,,,,,,,fee schedule,11156.78,33521.75,
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14936.06,,,,,,,fee schedule,11156.78,33521.75,
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14224.82,,,,,,,fee schedule,11156.78,33521.75,
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,24914.3,,,,,,,fee schedule,11156.78,33521.75,
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,19360.6,,,,,,,fee schedule,11156.78,33521.75,
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,33521.75,,,,,,,fee schedule,11156.78,33521.75,
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,23044.38,,,,,,,fee schedule,11156.78,33521.75,
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,20870.12,,,,,,,fee schedule,11156.78,33521.75,
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17093.49,,,,,,,fee schedule,11156.78,33521.75,
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],11052.53,11052.53,11052.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],10242.21,10242.21,10242.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],11180.02,11180.02,11180.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12740.96,,,,,,,fee schedule,11156.78,33521.75,MSDRG Base Rate
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,12619.62,,,,,,,fee schedule,11156.78,33521.75,MSDRG Base Rate
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,12619.62,,,,,,,fee schedule,11156.78,33521.75,MSDRG Base Rate
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,12740.96,,,,,,,fee schedule,11156.78,33521.75,MSDRG Base Rate
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,12619.62,,,,,,,fee schedule,11156.78,33521.75,MSDRG Base Rate
Transurethral Prostatectomy With Cc/Mcc,713,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21234.94,,,,,,,fee schedule,11156.78,33521.75,MSDRG Base Rate
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7250.09,,,,,,,fee schedule,7250.09,21783.69,
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,7250.09,,,,,,,fee schedule,7250.09,21783.69,
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9706.01,,,,,,,fee schedule,7250.09,21783.69,
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9243.82,,,,,,,fee schedule,7250.09,21783.69,
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,16190.25,,,,,,,fee schedule,7250.09,21783.69,
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,12581.24,,,,,,,fee schedule,7250.09,21783.69,
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,21783.69,,,,,,,fee schedule,7250.09,21783.69,
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,14975.1,,,,,,,fee schedule,7250.09,21783.69,
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,13562.19,,,,,,,fee schedule,7250.09,21783.69,
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11107.99,,,,,,,fee schedule,7250.09,21783.69,
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],15688.81,15688.81,15688.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9256.63,,,,,,,fee schedule,7250.09,21783.69,MSDRG Base Rate
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,9168.47,,,,,,,fee schedule,7250.09,21783.69,MSDRG Base Rate
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,9168.47,,,,,,,fee schedule,7250.09,21783.69,MSDRG Base Rate
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,9256.63,,,,,,,fee schedule,7250.09,21783.69,MSDRG Base Rate
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,9168.47,,,,,,,fee schedule,7250.09,21783.69,MSDRG Base Rate
Transurethral Prostatectomy Without Cc/Mcc,714,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15427.72,,,,,,,fee schedule,7250.09,21783.69,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17424.61,,,,,,,fee schedule,17424.61,52354.11,
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,17424.61,,,,,,,fee schedule,17424.61,52354.11,
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23327.07,,,,,,,fee schedule,17424.61,52354.11,
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22216.26,,,,,,,fee schedule,17424.61,52354.11,
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,38911.04,,,,,,,fee schedule,17424.61,52354.11,
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,30237.3,,,,,,,fee schedule,17424.61,52354.11,
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,52354.11,,,,,,,fee schedule,17424.61,52354.11,
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,35990.6,,,,,,,fee schedule,17424.61,52354.11,
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,32594.86,,,,,,,fee schedule,17424.61,52354.11,
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26696.53,,,,,,,fee schedule,17424.61,52354.11,
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],17079.55,17079.55,17079.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,18474.5,,,,,,,fee schedule,17424.61,52354.11,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,18298.55,,,,,,,fee schedule,17424.61,52354.11,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,18298.55,,,,,,,fee schedule,17424.61,52354.11,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,18474.5,,,,,,,fee schedule,17424.61,52354.11,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,18298.55,,,,,,,fee schedule,17424.61,52354.11,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc,715,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30790.83,,,,,,,fee schedule,17424.61,52354.11,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10950.76,,,,,,,fee schedule,10950.76,32902.73,
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,10950.76,,,,,,,fee schedule,10950.76,32902.73,
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14660.25,,,,,,,fee schedule,10950.76,32902.73,
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13962.15,,,,,,,fee schedule,10950.76,32902.73,
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,24454.24,,,,,,,fee schedule,10950.76,32902.73,
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,19003.09,,,,,,,fee schedule,10950.76,32902.73,
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,32902.73,,,,,,,fee schedule,10950.76,32902.73,
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,22618.84,,,,,,,fee schedule,10950.76,32902.73,
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,20484.73,,,,,,,fee schedule,10950.76,32902.73,
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16777.84,,,,,,,fee schedule,10950.76,32902.73,
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12487.84,,,,,,,fee schedule,10950.76,32902.73,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,12368.91,,,,,,,fee schedule,10950.76,32902.73,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,12368.91,,,,,,,fee schedule,10950.76,32902.73,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,12487.84,,,,,,,fee schedule,10950.76,32902.73,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,12368.91,,,,,,,fee schedule,10950.76,32902.73,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc,716,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20813.07,,,,,,,fee schedule,10950.76,32902.73,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14316.54,,,,,,,fee schedule,14316.54,43015.59,
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,14316.54,,,,,,,fee schedule,14316.54,43015.59,
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19166.17,,,,,,,fee schedule,14316.54,43015.59,
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18253.5,,,,,,,fee schedule,14316.54,43015.59,
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,31970.4,,,,,,,fee schedule,14316.54,43015.59,
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,24843.81,,,,,,,fee schedule,14316.54,43015.59,
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,43015.59,,,,,,,fee schedule,14316.54,43015.59,
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,29570.88,,,,,,,fee schedule,14316.54,43015.59,
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,26780.84,,,,,,,fee schedule,14316.54,43015.59,
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21934.61,,,,,,,fee schedule,14316.54,43015.59,
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],29621.82,29621.82,29621.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13348.54,13348.54,13348.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",6393.53,6393.53,6393.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],12291.58,12291.58,12291.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15765.15,,,,,,,fee schedule,14316.54,43015.59,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,15615.01,,,,,,,fee schedule,14316.54,43015.59,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,15615.01,,,,,,,fee schedule,14316.54,43015.59,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,15765.15,,,,,,,fee schedule,14316.54,43015.59,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,15615.01,,,,,,,fee schedule,14316.54,43015.59,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc,717,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,26275.25,,,,,,,fee schedule,14316.54,43015.59,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9504.75,,,,,,,fee schedule,9504.75,28558.05,
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,9504.75,,,,,,,fee schedule,9504.75,28558.05,
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12724.42,,,,,,,fee schedule,9504.75,28558.05,
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12118.5,,,,,,,fee schedule,9504.75,28558.05,
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,21225.15,,,,,,,fee schedule,9504.75,28558.05,
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,16493.8,,,,,,,fee schedule,9504.75,28558.05,
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,28558.05,,,,,,,fee schedule,9504.75,28558.05,
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,19632.11,,,,,,,fee schedule,9504.75,28558.05,
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,17779.8,,,,,,,fee schedule,9504.75,28558.05,
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14562.39,,,,,,,fee schedule,9504.75,28558.05,
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],13313.07,13313.07,13313.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11488.64,,,,,,,fee schedule,9504.75,28558.05,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,11379.22,,,,,,,fee schedule,9504.75,28558.05,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,11379.22,,,,,,,fee schedule,9504.75,28558.05,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,11488.64,,,,,,,fee schedule,9504.75,28558.05,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,11379.22,,,,,,,fee schedule,9504.75,28558.05,MSDRG Base Rate
Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc,718,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19147.73,,,,,,,fee schedule,9504.75,28558.05,MSDRG Base Rate
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13339.68,,,,,,,fee schedule,13339.68,40080.5,
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,13339.68,,,,,,,fee schedule,13339.68,40080.5,
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17858.4,,,,,,,fee schedule,13339.68,40080.5,
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17008,,,,,,,fee schedule,13339.68,40080.5,
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,29788.95,,,,,,,fee schedule,13339.68,40080.5,
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,23148.63,,,,,,,fee schedule,13339.68,40080.5,
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,40080.5,,,,,,,fee schedule,13339.68,40080.5,
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,27553.16,,,,,,,fee schedule,13339.68,40080.5,
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,24953.5,,,,,,,fee schedule,13339.68,40080.5,
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20437.94,,,,,,,fee schedule,13339.68,40080.5,
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13163.6,13163.6,13163.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15133.9,,,,,,,fee schedule,13339.68,40080.5,MSDRG Base Rate
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,14989.77,,,,,,,fee schedule,13339.68,40080.5,MSDRG Base Rate
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,14989.77,,,,,,,fee schedule,13339.68,40080.5,MSDRG Base Rate
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,15133.9,,,,,,,fee schedule,13339.68,40080.5,MSDRG Base Rate
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,14989.77,,,,,,,fee schedule,13339.68,40080.5,MSDRG Base Rate
"Malignancy, Male Reproductive System With Mcc",722,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,25223.17,,,,,,,fee schedule,13339.68,40080.5,MSDRG Base Rate
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8664.46,,,,,,,fee schedule,8664.46,26033.31,
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,8664.46,,,,,,,fee schedule,8664.46,26033.31,
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11599.49,,,,,,,fee schedule,8664.46,26033.31,
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11047.14,,,,,,,fee schedule,8664.46,26033.31,
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,19348.69,,,,,,,fee schedule,8664.46,26033.31,
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,15035.63,,,,,,,fee schedule,8664.46,26033.31,
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,26033.31,,,,,,,fee schedule,8664.46,26033.31,
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,17896.49,,,,,,,fee schedule,8664.46,26033.31,
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,16207.94,,,,,,,fee schedule,8664.46,26033.31,
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13274.97,,,,,,,fee schedule,8664.46,26033.31,
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9923.02,,,,,,,fee schedule,8664.46,26033.31,MSDRG Base Rate
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,9828.52,,,,,,,fee schedule,8664.46,26033.31,MSDRG Base Rate
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,9828.52,,,,,,,fee schedule,8664.46,26033.31,MSDRG Base Rate
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,9923.02,,,,,,,fee schedule,8664.46,26033.31,MSDRG Base Rate
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,9828.52,,,,,,,fee schedule,8664.46,26033.31,MSDRG Base Rate
"Malignancy, Male Reproductive System With Cc",723,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16538.38,,,,,,,fee schedule,8664.46,26033.31,MSDRG Base Rate
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5621.99,,,,,,,fee schedule,5621.99,16891.86,
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,5621.99,,,,,,,fee schedule,5621.99,16891.86,
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7526.39,,,,,,,fee schedule,5621.99,16891.86,
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7168,,,,,,,fee schedule,5621.99,16891.86,
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,12554.51,,,,,,,fee schedule,5621.99,16891.86,
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,9755.95,,,,,,,fee schedule,5621.99,16891.86,
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,16891.86,,,,,,,fee schedule,5621.99,16891.86,
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,11612.24,,,,,,,fee schedule,5621.99,16891.86,
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,10516.61,,,,,,,fee schedule,5621.99,16891.86,
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8613.54,,,,,,,fee schedule,5621.99,16891.86,
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,6118.38,,,,,,,fee schedule,5621.99,16891.86,MSDRG Base Rate
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,6060.11,,,,,,,fee schedule,5621.99,16891.86,MSDRG Base Rate
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,6060.11,,,,,,,fee schedule,5621.99,16891.86,MSDRG Base Rate
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,6118.38,,,,,,,fee schedule,5621.99,16891.86,MSDRG Base Rate
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,6060.11,,,,,,,fee schedule,5621.99,16891.86,MSDRG Base Rate
"Malignancy, Male Reproductive System Without Cc/Mcc",724,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10197.3,,,,,,,fee schedule,5621.99,16891.86,MSDRG Base Rate
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9746.27,,,,,,,fee schedule,9746.27,29283.71,
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,9746.27,,,,,,,fee schedule,9746.27,29283.71,
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13047.75,,,,,,,fee schedule,9746.27,29283.71,
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12426.43,,,,,,,fee schedule,9746.27,29283.71,
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,21764.48,,,,,,,fee schedule,9746.27,29283.71,
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,16912.91,,,,,,,fee schedule,9746.27,29283.71,
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,29283.71,,,,,,,fee schedule,9746.27,29283.71,
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,20130.96,,,,,,,fee schedule,9746.27,29283.71,
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,18231.59,,,,,,,fee schedule,9746.27,29283.71,
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14932.42,,,,,,,fee schedule,9746.27,29283.71,
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10137.87,,,,,,,fee schedule,9746.27,29283.71,MSDRG Base Rate
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,10041.31,,,,,,,fee schedule,9746.27,29283.71,MSDRG Base Rate
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,10041.31,,,,,,,fee schedule,9746.27,29283.71,MSDRG Base Rate
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,10137.87,,,,,,,fee schedule,9746.27,29283.71,MSDRG Base Rate
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,10041.31,,,,,,,fee schedule,9746.27,29283.71,MSDRG Base Rate
Benign Prostatic Hypertrophy With Mcc,725,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16896.44,,,,,,,fee schedule,9746.27,29283.71,MSDRG Base Rate
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5743.13,,,,,,,fee schedule,5743.13,17255.85,
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,5743.13,,,,,,,fee schedule,5743.13,17255.85,
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7688.57,,,,,,,fee schedule,5743.13,17255.85,
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7322.45,,,,,,,fee schedule,5743.13,17255.85,
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,12825.03,,,,,,,fee schedule,5743.13,17255.85,
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,9966.18,,,,,,,fee schedule,5743.13,17255.85,
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,17255.85,,,,,,,fee schedule,5743.13,17255.85,
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,11862.46,,,,,,,fee schedule,5743.13,17255.85,
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,10743.23,,,,,,,fee schedule,5743.13,17255.85,
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8799.14,,,,,,,fee schedule,5743.13,17255.85,
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],3996.61,3996.61,3996.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],1139.02,1139.02,1139.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],280.07,280.07,280.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,6636.35,,,,,,,fee schedule,5743.13,17255.85,MSDRG Base Rate
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,6573.14,,,,,,,fee schedule,5743.13,17255.85,MSDRG Base Rate
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,6573.14,,,,,,,fee schedule,5743.13,17255.85,MSDRG Base Rate
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,6636.35,,,,,,,fee schedule,5743.13,17255.85,MSDRG Base Rate
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,6573.14,,,,,,,fee schedule,5743.13,17255.85,MSDRG Base Rate
Benign Prostatic Hypertrophy Without Mcc,726,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11060.58,,,,,,,fee schedule,5743.13,17255.85,MSDRG Base Rate
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11337.34,,,,,,,fee schedule,11337.34,34064.25,
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,11337.34,,,,,,,fee schedule,11337.34,34064.25,
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15177.78,,,,,,,fee schedule,11337.34,34064.25,
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14455.03,,,,,,,fee schedule,11337.34,34064.25,
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,25317.51,,,,,,,fee schedule,11337.34,34064.25,
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,19673.93,,,,,,,fee schedule,11337.34,34064.25,
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,34064.25,,,,,,,fee schedule,11337.34,34064.25,
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,23417.32,,,,,,,fee schedule,11337.34,34064.25,
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,21207.88,,,,,,,fee schedule,11337.34,34064.25,
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17370.12,,,,,,,fee schedule,11337.34,34064.25,
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],9489.98,9489.98,9489.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],10446.47,10446.47,10446.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12580.81,,,,,,,fee schedule,11337.34,34064.25,MSDRG Base Rate
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,12460.99,,,,,,,fee schedule,11337.34,34064.25,MSDRG Base Rate
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,12460.99,,,,,,,fee schedule,11337.34,34064.25,MSDRG Base Rate
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,12580.81,,,,,,,fee schedule,11337.34,34064.25,MSDRG Base Rate
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,12460.99,,,,,,,fee schedule,11337.34,34064.25,MSDRG Base Rate
Inflammation Of The Male Reproductive System With Mcc,727,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20968.01,,,,,,,fee schedule,11337.34,34064.25,MSDRG Base Rate
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6304.87,,,,,,,fee schedule,6304.87,18943.65,
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,6304.87,,,,,,,fee schedule,6304.87,18943.65,
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8440.59,,,,,,,fee schedule,6304.87,18943.65,
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8038.66,,,,,,,fee schedule,6304.87,18943.65,
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,14079.45,,,,,,,fee schedule,6304.87,18943.65,
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,10940.97,,,,,,,fee schedule,6304.87,18943.65,
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,18943.65,,,,,,,fee schedule,6304.87,18943.65,
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,13022.73,,,,,,,fee schedule,6304.87,18943.65,
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,11794.02,,,,,,,fee schedule,6304.87,18943.65,
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9659.79,,,,,,,fee schedule,6304.87,18943.65,
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3610,3610,3610,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],6613.85,6613.85,6613.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7333.21,,,,,,,fee schedule,6304.87,18943.65,MSDRG Base Rate
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,7263.37,,,,,,,fee schedule,6304.87,18943.65,MSDRG Base Rate
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,7263.37,,,,,,,fee schedule,6304.87,18943.65,MSDRG Base Rate
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,7333.21,,,,,,,fee schedule,6304.87,18943.65,MSDRG Base Rate
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,7263.37,,,,,,,fee schedule,6304.87,18943.65,MSDRG Base Rate
Inflammation Of The Male Reproductive System Without Mcc,728,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12222.02,,,,,,,fee schedule,6304.87,18943.65,MSDRG Base Rate
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8493.94,,,,,,,fee schedule,8493.94,25520.95,
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,8493.94,,,,,,,fee schedule,8493.94,25520.95,
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11371.2,,,,,,,fee schedule,8493.94,25520.95,
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10829.71,,,,,,,fee schedule,8493.94,25520.95,
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,18967.88,,,,,,,fee schedule,8493.94,25520.95,
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,14739.71,,,,,,,fee schedule,8493.94,25520.95,
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,25520.95,,,,,,,fee schedule,8493.94,25520.95,
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,17544.26,,,,,,,fee schedule,8493.94,25520.95,
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,15888.95,,,,,,,fee schedule,8493.94,25520.95,
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13013.7,,,,,,,fee schedule,8493.94,25520.95,
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9266.79,,,,,,,fee schedule,8493.94,25520.95,MSDRG Base Rate
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,9178.53,,,,,,,fee schedule,8493.94,25520.95,MSDRG Base Rate
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,9178.53,,,,,,,fee schedule,8493.94,25520.95,MSDRG Base Rate
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,9266.79,,,,,,,fee schedule,8493.94,25520.95,MSDRG Base Rate
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,9178.53,,,,,,,fee schedule,8493.94,25520.95,MSDRG Base Rate
Other Male Reproductive System Diagnoses With Cc/Mcc,729,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15444.64,,,,,,,fee schedule,8493.94,25520.95,MSDRG Base Rate
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4682.93,,,,,,,fee schedule,4682.93,14070.37,
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,4682.93,,,,,,,fee schedule,4682.93,14070.37,
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6269.24,,,,,,,fee schedule,4682.93,14070.37,
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5970.71,,,,,,,fee schedule,4682.93,14070.37,
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,10457.49,,,,,,,fee schedule,4682.93,14070.37,
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,8126.39,,,,,,,fee schedule,4682.93,14070.37,
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,14070.37,,,,,,,fee schedule,4682.93,14070.37,
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,9672.61,,,,,,,fee schedule,4682.93,14070.37,
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,8759.99,,,,,,,fee schedule,4682.93,14070.37,
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7174.8,,,,,,,fee schedule,4682.93,14070.37,
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,6245.73,,,,,,,fee schedule,4682.93,14070.37,MSDRG Base Rate
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,6186.24,,,,,,,fee schedule,4682.93,14070.37,MSDRG Base Rate
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,6186.24,,,,,,,fee schedule,4682.93,14070.37,MSDRG Base Rate
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,6245.73,,,,,,,fee schedule,4682.93,14070.37,MSDRG Base Rate
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,6186.24,,,,,,,fee schedule,4682.93,14070.37,MSDRG Base Rate
Other Male Reproductive System Diagnoses Without Cc/Mcc,730,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10409.54,,,,,,,fee schedule,4682.93,14070.37,MSDRG Base Rate
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16224.75,,,,,,,fee schedule,16224.75,48749,
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,16224.75,,,,,,,fee schedule,16224.75,48749,
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21720.76,,,,,,,fee schedule,16224.75,48749,
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20686.45,,,,,,,fee schedule,16224.75,48749,
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,36231.62,,,,,,,fee schedule,16224.75,48749,
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,28155.15,,,,,,,fee schedule,16224.75,48749,
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,48749,,,,,,,fee schedule,16224.75,48749,
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,33512.29,,,,,,,fee schedule,16224.75,48749,
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,30350.37,,,,,,,fee schedule,16224.75,48749,
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24858.2,,,,,,,fee schedule,16224.75,48749,
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],33513.88,33513.88,33513.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],33.53,33.53,33.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,17636.22,,,,,,,fee schedule,16224.75,48749,MSDRG Base Rate
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,17468.26,,,,,,,fee schedule,16224.75,48749,MSDRG Base Rate
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,17468.26,,,,,,,fee schedule,16224.75,48749,MSDRG Base Rate
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,17636.22,,,,,,,fee schedule,16224.75,48749,MSDRG Base Rate
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,17468.26,,,,,,,fee schedule,16224.75,48749,MSDRG Base Rate
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc",734,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,29393.7,,,,,,,fee schedule,16224.75,48749,MSDRG Base Rate
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9365.86,,,,,,,fee schedule,9365.86,28140.74,
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,9365.86,,,,,,,fee schedule,9365.86,28140.74,
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12538.48,,,,,,,fee schedule,9365.86,28140.74,
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11941.41,,,,,,,fee schedule,9365.86,28140.74,
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,20914.99,,,,,,,fee schedule,9365.86,28140.74,
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,16252.78,,,,,,,fee schedule,9365.86,28140.74,
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,28140.74,,,,,,,fee schedule,9365.86,28140.74,
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,19345.23,,,,,,,fee schedule,9365.86,28140.74,
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,17519.99,,,,,,,fee schedule,9365.86,28140.74,
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14349.59,,,,,,,fee schedule,9365.86,28140.74,
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11507.39,,,,,,,fee schedule,9365.86,28140.74,MSDRG Base Rate
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,11397.8,,,,,,,fee schedule,9365.86,28140.74,MSDRG Base Rate
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,11397.8,,,,,,,fee schedule,9365.86,28140.74,MSDRG Base Rate
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,11507.39,,,,,,,fee schedule,9365.86,28140.74,MSDRG Base Rate
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,11397.8,,,,,,,fee schedule,9365.86,28140.74,MSDRG Base Rate
"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc",735,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19178.98,,,,,,,fee schedule,9365.86,28140.74,MSDRG Base Rate
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,30380.8,,,,,,,fee schedule,28645.8,91282.36,
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,30380.8,,,,,,,fee schedule,28645.8,91282.36,
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40672.07,,,,,,,fee schedule,28645.8,91282.36,
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,38735.31,,,,,,,fee schedule,28645.8,91282.36,
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,67843.62,,,,,,,fee schedule,28645.8,91282.36,
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,52720.45,,,,,,,fee schedule,28645.8,91282.36,
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,91282.36,,,,,,,fee schedule,28645.8,91282.36,
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,62751.66,,,,,,,fee schedule,28645.8,91282.36,
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,56830.99,,,,,,,fee schedule,28645.8,91282.36,
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46546.92,,,,,,,fee schedule,28645.8,91282.36,
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],26608.13,26608.13,26608.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],29444.93,29444.93,29444.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],67848.79,67848.79,67848.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],28947.8,28947.8,28947.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,28921.24,,,,,,,fee schedule,28645.8,91282.36,MSDRG Base Rate
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,28645.8,,,,,,,fee schedule,28645.8,91282.36,MSDRG Base Rate
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,28645.8,,,,,,,fee schedule,28645.8,91282.36,MSDRG Base Rate
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,28921.24,,,,,,,fee schedule,28645.8,91282.36,MSDRG Base Rate
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,28645.8,,,,,,,fee schedule,28645.8,91282.36,MSDRG Base Rate
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc,736,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,48202.07,,,,,,,fee schedule,28645.8,91282.36,MSDRG Base Rate
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,15419.18,,,,,,,fee schedule,15419.18,46328.59,
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,15419.18,,,,,,,fee schedule,15419.18,46328.59,
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20642.32,,,,,,,fee schedule,15419.18,46328.59,
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19659.36,,,,,,,fee schedule,15419.18,46328.59,
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,34432.71,,,,,,,fee schedule,15419.18,46328.59,
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,26757.24,,,,,,,fee schedule,15419.18,46328.59,
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,46328.59,,,,,,,fee schedule,15419.18,46328.59,
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,31848.39,,,,,,,fee schedule,15419.18,46328.59,
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,28843.46,,,,,,,fee schedule,15419.18,46328.59,
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23623.98,,,,,,,fee schedule,15419.18,46328.59,
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],28844.91,28844.91,33311.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13426.47,13426.47,13426.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],23732.34,23732.34,23732.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],45658.54,45658.54,45658.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,17094.04,,,,,,,fee schedule,15419.18,46328.59,MSDRG Base Rate
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,16931.24,,,,,,,fee schedule,15419.18,46328.59,MSDRG Base Rate
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,16931.24,,,,,,,fee schedule,15419.18,46328.59,MSDRG Base Rate
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,17094.04,,,,,,,fee schedule,15419.18,46328.59,MSDRG Base Rate
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,16931.24,,,,,,,fee schedule,15419.18,46328.59,MSDRG Base Rate
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc,737,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,28490.07,,,,,,,fee schedule,15419.18,46328.59,MSDRG Base Rate
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11703.86,,,,,,,fee schedule,11703.86,35165.49,
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,11703.86,,,,,,,fee schedule,11703.86,35165.49,
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15668.45,,,,,,,fee schedule,11703.86,35165.49,
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14922.34,,,,,,,fee schedule,11703.86,35165.49,
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,26135.98,,,,,,,fee schedule,11703.86,35165.49,
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,20309.95,,,,,,,fee schedule,11703.86,35165.49,
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,35165.49,,,,,,,fee schedule,11703.86,35165.49,
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,24174.36,,,,,,,fee schedule,11703.86,35165.49,
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,21893.49,,,,,,,fee schedule,11703.86,35165.49,
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17931.67,,,,,,,fee schedule,11703.86,35165.49,
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],34326.45,34326.45,34326.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],24901.23,24901.23,24901.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12468.31,,,,,,,fee schedule,11703.86,35165.49,MSDRG Base Rate
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,12349.56,,,,,,,fee schedule,11703.86,35165.49,MSDRG Base Rate
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,12349.56,,,,,,,fee schedule,11703.86,35165.49,MSDRG Base Rate
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,12468.31,,,,,,,fee schedule,11703.86,35165.49,MSDRG Base Rate
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,12349.56,,,,,,,fee schedule,11703.86,35165.49,MSDRG Base Rate
Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc,738,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20780.52,,,,,,,fee schedule,11703.86,35165.49,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,30715.68,,,,,,,fee schedule,28710.03,92288.55,
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,30715.68,,,,,,,fee schedule,28710.03,92288.55,
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,41120.39,,,,,,,fee schedule,28710.03,92288.55,
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,39162.29,,,,,,,fee schedule,28710.03,92288.55,
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,68591.44,,,,,,,fee schedule,28710.03,92288.55,
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,53301.57,,,,,,,fee schedule,28710.03,92288.55,
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,92288.55,,,,,,,fee schedule,28710.03,92288.55,
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,63443.36,,,,,,,fee schedule,28710.03,92288.55,
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,57457.42,,,,,,,fee schedule,28710.03,92288.55,
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,47059.99,,,,,,,fee schedule,28710.03,92288.55,
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,28986.09,,,,,,,fee schedule,28710.03,92288.55,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,28710.03,,,,,,,fee schedule,28710.03,92288.55,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,28710.03,,,,,,,fee schedule,28710.03,92288.55,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,28986.09,,,,,,,fee schedule,28710.03,92288.55,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,28710.03,,,,,,,fee schedule,28710.03,92288.55,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc,739,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,48310.15,,,,,,,fee schedule,28710.03,92288.55,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14029.5,,,,,,,fee schedule,14029.5,42153.15,
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,14029.5,,,,,,,fee schedule,14029.5,42153.15,
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18781.9,,,,,,,fee schedule,14029.5,42153.15,
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17887.52,,,,,,,fee schedule,14029.5,42153.15,
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,31329.4,,,,,,,fee schedule,14029.5,42153.15,
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,24345.7,,,,,,,fee schedule,14029.5,42153.15,
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,42153.15,,,,,,,fee schedule,14029.5,42153.15,
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,28978,,,,,,,fee schedule,14029.5,42153.15,
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,26243.9,,,,,,,fee schedule,14029.5,42153.15,
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21494.83,,,,,,,fee schedule,14029.5,42153.15,
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],10534.54,10534.54,10534.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13259.66,13259.66,13259.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13394.27,13394.27,13394.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],31331.13,31331.13,31331.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15133.12,,,,,,,fee schedule,14029.5,42153.15,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,14989,,,,,,,fee schedule,14029.5,42153.15,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,14989,,,,,,,fee schedule,14029.5,42153.15,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,15133.12,,,,,,,fee schedule,14029.5,42153.15,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,14989,,,,,,,fee schedule,14029.5,42153.15,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc,740,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,25221.88,,,,,,,fee schedule,14029.5,42153.15,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10598.13,,,,,,,fee schedule,10598.13,31843.22,
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,10598.13,,,,,,,fee schedule,10598.13,31843.22,
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14188.17,,,,,,,fee schedule,10598.13,31843.22,
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13512.55,,,,,,,fee schedule,10598.13,31843.22,
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,23666.78,,,,,,,fee schedule,10598.13,31843.22,
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,18391.17,,,,,,,fee schedule,10598.13,31843.22,
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,31843.22,,,,,,,fee schedule,10598.13,31843.22,
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,21890.49,,,,,,,fee schedule,10598.13,31843.22,
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,19825.1,,,,,,,fee schedule,10598.13,31843.22,
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16237.57,,,,,,,fee schedule,10598.13,31843.22,
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],10635.41,10635.41,10635.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12137.07,,,,,,,fee schedule,10598.13,31843.22,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,12021.47,,,,,,,fee schedule,10598.13,31843.22,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,12021.47,,,,,,,fee schedule,10598.13,31843.22,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,12137.07,,,,,,,fee schedule,10598.13,31843.22,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,12021.47,,,,,,,fee schedule,10598.13,31843.22,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc,741,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20228.44,,,,,,,fee schedule,10598.13,31843.22,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14094.32,,,,,,,fee schedule,14094.32,42347.89,
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,14094.32,,,,,,,fee schedule,14094.32,42347.89,
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18868.67,,,,,,,fee schedule,14094.32,42347.89,
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17970.16,,,,,,,fee schedule,14094.32,42347.89,
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,31474.14,,,,,,,fee schedule,14094.32,42347.89,
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,24458.17,,,,,,,fee schedule,14094.32,42347.89,
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,42347.89,,,,,,,fee schedule,14094.32,42347.89,
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,29111.88,,,,,,,fee schedule,14094.32,42347.89,
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,26365.14,,,,,,,fee schedule,14094.32,42347.89,
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21594.14,,,,,,,fee schedule,14094.32,42347.89,
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],28387.1,19026.8,29236.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],26366.59,26366.59,26507.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",7110.16,7110.16,7110.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],17971.15,17971.15,17971.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12195.43,12195.43,12195.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],20605.77,20605.77,20605.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],29016.74,29016.74,30818.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],13938.99,13938.99,38069.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],44095.44,44095.44,44095.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15330,,,,,,,fee schedule,14094.32,42347.89,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,15184,,,,,,,fee schedule,14094.32,42347.89,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,15184,,,,,,,fee schedule,14094.32,42347.89,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,15330,,,,,,,fee schedule,14094.32,42347.89,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,15184,,,,,,,fee schedule,14094.32,42347.89,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc,742,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,25550,,,,,,,fee schedule,14094.32,42347.89,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9248.58,,,,,,,fee schedule,9248.58,27788.34,
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,9248.58,,,,,,,fee schedule,9248.58,27788.34,
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12381.47,,,,,,,fee schedule,9248.58,27788.34,
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11791.87,,,,,,,fee schedule,9248.58,27788.34,
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,20653.08,,,,,,,fee schedule,9248.58,27788.34,
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,16049.25,,,,,,,fee schedule,9248.58,27788.34,
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,27788.34,,,,,,,fee schedule,9248.58,27788.34,
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,19102.98,,,,,,,fee schedule,9248.58,27788.34,
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,17300.59,,,,,,,fee schedule,9248.58,27788.34,
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14169.9,,,,,,,fee schedule,9248.58,27788.34,
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],17782.9,17782.9,17782.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],20057.16,20057.16,20057.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],11792.86,11792.86,11792.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",5723.76,5723.76,5723.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7225.77,7225.77,7225.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],13633.77,13496.27,14171.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],18766.13,17170.57,20111.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],9383.82,9383.82,9383.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],15213.55,15213.55,15213.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10688.64,,,,,,,fee schedule,9248.58,27788.34,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,10586.85,,,,,,,fee schedule,9248.58,27788.34,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,10586.85,,,,,,,fee schedule,9248.58,27788.34,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,10688.64,,,,,,,fee schedule,9248.58,27788.34,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,10586.85,,,,,,,fee schedule,9248.58,27788.34,MSDRG Base Rate
Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc,743,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,17814.4,,,,,,,fee schedule,9248.58,27788.34,MSDRG Base Rate
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,15076.59,,,,,,,fee schedule,15076.59,45299.22,
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,15076.59,,,,,,,fee schedule,15076.59,45299.22,
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20183.67,,,,,,,fee schedule,15076.59,45299.22,
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19222.55,,,,,,,fee schedule,15076.59,45299.22,
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,33667.65,,,,,,,fee schedule,15076.59,45299.22,
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,26162.72,,,,,,,fee schedule,15076.59,45299.22,
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,45299.22,,,,,,,fee schedule,15076.59,45299.22,
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,31140.75,,,,,,,fee schedule,15076.59,45299.22,
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,28202.59,,,,,,,fee schedule,15076.59,45299.22,
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23099.08,,,,,,,fee schedule,15076.59,45299.22,
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],31142.34,31142.34,31142.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],12907.84,12907.84,12907.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,17004.19,,,,,,,fee schedule,15076.59,45299.22,MSDRG Base Rate
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,16842.25,,,,,,,fee schedule,15076.59,45299.22,MSDRG Base Rate
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,16842.25,,,,,,,fee schedule,15076.59,45299.22,MSDRG Base Rate
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,17004.19,,,,,,,fee schedule,15076.59,45299.22,MSDRG Base Rate
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,16842.25,,,,,,,fee schedule,15076.59,45299.22,MSDRG Base Rate
"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc",744,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,28340.32,,,,,,,fee schedule,15076.59,45299.22,MSDRG Base Rate
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7907.51,,,,,,,fee schedule,7907.51,23758.96,
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,7907.51,,,,,,,fee schedule,7907.51,23758.96,
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10586.12,,,,,,,fee schedule,7907.51,23758.96,
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10082.02,,,,,,,fee schedule,7907.51,23758.96,
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,17658.33,,,,,,,fee schedule,7907.51,23758.96,
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,13722.07,,,,,,,fee schedule,7907.51,23758.96,
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,23758.96,,,,,,,fee schedule,7907.51,23758.96,
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,16333,,,,,,,fee schedule,7907.51,23758.96,
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,14791.96,,,,,,,fee schedule,7907.51,23758.96,
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12115.23,,,,,,,fee schedule,7907.51,23758.96,
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9882.4,,,,,,,fee schedule,7907.51,23758.96,MSDRG Base Rate
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,9788.28,,,,,,,fee schedule,7907.51,23758.96,MSDRG Base Rate
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,9788.28,,,,,,,fee schedule,7907.51,23758.96,MSDRG Base Rate
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,9882.4,,,,,,,fee schedule,7907.51,23758.96,MSDRG Base Rate
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,9788.28,,,,,,,fee schedule,7907.51,23758.96,MSDRG Base Rate
"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc",745,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16470.67,,,,,,,fee schedule,7907.51,23758.96,MSDRG Base Rate
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12920.69,,,,,,,fee schedule,12920.69,38821.61,
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,12920.69,,,,,,,fee schedule,12920.69,38821.61,
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17297.48,,,,,,,fee schedule,12920.69,38821.61,
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16473.8,,,,,,,fee schedule,12920.69,38821.61,
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,28853.31,,,,,,,fee schedule,12920.69,38821.61,
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,22421.56,,,,,,,fee schedule,12920.69,38821.61,
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,38821.61,,,,,,,fee schedule,12920.69,38821.61,
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,26687.75,,,,,,,fee schedule,12920.69,38821.61,
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,24169.73,,,,,,,fee schedule,12920.69,38821.61,
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19796.01,,,,,,,fee schedule,12920.69,38821.61,
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],1931.92,1931.92,1931.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",7380.89,7380.89,7380.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14566.72,,,,,,,fee schedule,12920.69,38821.61,MSDRG Base Rate
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,14427.99,,,,,,,fee schedule,12920.69,38821.61,MSDRG Base Rate
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,14427.99,,,,,,,fee schedule,12920.69,38821.61,MSDRG Base Rate
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,14566.72,,,,,,,fee schedule,12920.69,38821.61,MSDRG Base Rate
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,14427.99,,,,,,,fee schedule,12920.69,38821.61,MSDRG Base Rate
"Vagina, Cervix And Vulva Procedures With Cc/Mcc",746,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,24277.87,,,,,,,fee schedule,12920.69,38821.61,MSDRG Base Rate
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7369.69,,,,,,,fee schedule,7369.69,22143.04,
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,7369.69,,,,,,,fee schedule,7369.69,22143.04,
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9866.13,,,,,,,fee schedule,7369.69,22143.04,
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9396.31,,,,,,,fee schedule,7369.69,22143.04,
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,16457.33,,,,,,,fee schedule,7369.69,22143.04,
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,12788.79,,,,,,,fee schedule,7369.69,22143.04,
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,22143.04,,,,,,,fee schedule,7369.69,22143.04,
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,15222.14,,,,,,,fee schedule,7369.69,22143.04,
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,13785.91,,,,,,,fee schedule,7369.69,22143.04,
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11291.23,,,,,,,fee schedule,7369.69,22143.04,
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],7614.35,7614.35,7614.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7712.11,,,,,,,fee schedule,7369.69,22143.04,MSDRG Base Rate
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,7638.66,,,,,,,fee schedule,7369.69,22143.04,MSDRG Base Rate
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,7638.66,,,,,,,fee schedule,7369.69,22143.04,MSDRG Base Rate
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,7712.11,,,,,,,fee schedule,7369.69,22143.04,MSDRG Base Rate
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,7638.66,,,,,,,fee schedule,7369.69,22143.04,MSDRG Base Rate
"Vagina, Cervix And Vulva Procedures Without Cc/Mcc",747,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12853.52,,,,,,,fee schedule,7369.69,22143.04,MSDRG Base Rate
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10510.94,,,,,,,fee schedule,10510.94,31581.24,
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,10510.94,,,,,,,fee schedule,10510.94,31581.24,
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14071.44,,,,,,,fee schedule,10510.94,31581.24,
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13401.38,,,,,,,fee schedule,10510.94,31581.24,
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,23472.07,,,,,,,fee schedule,10510.94,31581.24,
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,18239.86,,,,,,,fee schedule,10510.94,31581.24,
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,31581.24,,,,,,,fee schedule,10510.94,31581.24,
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,21710.39,,,,,,,fee schedule,10510.94,31581.24,
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,19661.99,,,,,,,fee schedule,10510.94,31581.24,
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16103.98,,,,,,,fee schedule,10510.94,31581.24,
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],10570.11,10570.11,10570.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11833.94,,,,,,,fee schedule,10510.94,31581.24,MSDRG Base Rate
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,11721.24,,,,,,,fee schedule,10510.94,31581.24,MSDRG Base Rate
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,11721.24,,,,,,,fee schedule,10510.94,31581.24,MSDRG Base Rate
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,11833.94,,,,,,,fee schedule,10510.94,31581.24,MSDRG Base Rate
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,11721.24,,,,,,,fee schedule,10510.94,31581.24,MSDRG Base Rate
Female Reproductive System Reconstructive Procedures,748,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19723.24,,,,,,,fee schedule,10510.94,31581.24,MSDRG Base Rate
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,19972.48,,,,,,,fee schedule,19972.48,60009.47,
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,19972.48,,,,,,,fee schedule,19972.48,60009.47,
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26738.02,,,,,,,fee schedule,19972.48,60009.47,
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25464.78,,,,,,,fee schedule,19972.48,60009.47,
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,44600.72,,,,,,,fee schedule,19972.48,60009.47,
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,34658.68,,,,,,,fee schedule,19972.48,60009.47,
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,60009.47,,,,,,,fee schedule,19972.48,60009.47,
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,41253.25,,,,,,,fee schedule,19972.48,60009.47,
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,37360.97,,,,,,,fee schedule,19972.48,60009.47,
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30600.17,,,,,,,fee schedule,19972.48,60009.47,
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",11058.25,11058.25,11058.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],44604.17,44604.17,44604.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,21054.94,,,,,,,fee schedule,19972.48,60009.47,MSDRG Base Rate
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,20854.41,,,,,,,fee schedule,19972.48,60009.47,MSDRG Base Rate
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,20854.41,,,,,,,fee schedule,19972.48,60009.47,MSDRG Base Rate
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,21054.94,,,,,,,fee schedule,19972.48,60009.47,MSDRG Base Rate
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,20854.41,,,,,,,fee schedule,19972.48,60009.47,MSDRG Base Rate
Other Female Reproductive System O.R. Procedures With Cc/Mcc,749,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,35091.56,,,,,,,fee schedule,19972.48,60009.47,MSDRG Base Rate
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9949.98,,,,,,,fee schedule,9949.98,29895.77,
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,9949.98,,,,,,,fee schedule,9949.98,29895.77,
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13320.46,,,,,,,fee schedule,9949.98,29895.77,
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12686.15,,,,,,,fee schedule,9949.98,29895.77,
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,22219.37,,,,,,,fee schedule,9949.98,29895.77,
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,17266.41,,,,,,,fee schedule,9949.98,29895.77,
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,29895.77,,,,,,,fee schedule,9949.98,29895.77,
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,20551.72,,,,,,,fee schedule,9949.98,29895.77,
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,18612.64,,,,,,,fee schedule,9949.98,29895.77,
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15244.52,,,,,,,fee schedule,9949.98,29895.77,
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12525.34,,,,,,,fee schedule,9949.98,29895.77,MSDRG Base Rate
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,12406.06,,,,,,,fee schedule,9949.98,29895.77,MSDRG Base Rate
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,12406.06,,,,,,,fee schedule,9949.98,29895.77,MSDRG Base Rate
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,12525.34,,,,,,,fee schedule,9949.98,29895.77,MSDRG Base Rate
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,12406.06,,,,,,,fee schedule,9949.98,29895.77,MSDRG Base Rate
Other Female Reproductive System O.R. Procedures Without Cc/Mcc,750,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20875.58,,,,,,,fee schedule,9949.98,29895.77,MSDRG Base Rate
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13960.06,,,,,,,fee schedule,13960.06,41944.49,
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,13960.06,,,,,,,fee schedule,13960.06,41944.49,
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18688.93,,,,,,,fee schedule,13960.06,41944.49,
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17798.98,,,,,,,fee schedule,13960.06,41944.49,
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,31174.33,,,,,,,fee schedule,13960.06,41944.49,
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,24225.19,,,,,,,fee schedule,13960.06,41944.49,
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,41944.49,,,,,,,fee schedule,13960.06,41944.49,
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,28834.56,,,,,,,fee schedule,13960.06,41944.49,
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,26113.99,,,,,,,fee schedule,13960.06,41944.49,
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21388.43,,,,,,,fee schedule,13960.06,41944.49,
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13231.77,13231.77,13231.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],28836.15,28836.15,28836.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],13440,13440,13440,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",8394.66,8394.66,8394.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],12081.31,12081.31,12081.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15383.91,,,,,,,fee schedule,13960.06,41944.49,MSDRG Base Rate
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,15237.39,,,,,,,fee schedule,13960.06,41944.49,MSDRG Base Rate
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,15237.39,,,,,,,fee schedule,13960.06,41944.49,MSDRG Base Rate
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,15383.91,,,,,,,fee schedule,13960.06,41944.49,MSDRG Base Rate
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,15237.39,,,,,,,fee schedule,13960.06,41944.49,MSDRG Base Rate
"Malignancy, Female Reproductive System With Mcc",754,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,25639.84,,,,,,,fee schedule,13960.06,41944.49,MSDRG Base Rate
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8565.7,,,,,,,fee schedule,8565.7,25736.56,
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,8565.7,,,,,,,fee schedule,8565.7,25736.56,
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11467.27,,,,,,,fee schedule,8565.7,25736.56,
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10921.21,,,,,,,fee schedule,8565.7,25736.56,
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,19128.13,,,,,,,fee schedule,8565.7,25736.56,
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,14864.24,,,,,,,fee schedule,8565.7,25736.56,
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,25736.56,,,,,,,fee schedule,8565.7,25736.56,
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,17692.49,,,,,,,fee schedule,8565.7,25736.56,
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,16023.18,,,,,,,fee schedule,8565.7,25736.56,
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13123.65,,,,,,,fee schedule,8565.7,25736.56,
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],17883.4,17883.4,17883.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],12818.57,12818.57,12818.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",5339.01,5339.01,5339.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6573.46,6573.46,6573.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9494.13,,,,,,,fee schedule,8565.7,25736.56,MSDRG Base Rate
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,9403.71,,,,,,,fee schedule,8565.7,25736.56,MSDRG Base Rate
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,9403.71,,,,,,,fee schedule,8565.7,25736.56,MSDRG Base Rate
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,9494.13,,,,,,,fee schedule,8565.7,25736.56,MSDRG Base Rate
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,9403.71,,,,,,,fee schedule,8565.7,25736.56,MSDRG Base Rate
"Malignancy, Female Reproductive System With Cc",755,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15823.55,,,,,,,fee schedule,8565.7,25736.56,MSDRG Base Rate
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7368.15,,,,,,,fee schedule,7368.15,22138.4,
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,7368.15,,,,,,,fee schedule,7368.15,22138.4,
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9864.06,,,,,,,fee schedule,7368.15,22138.4,
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9394.34,,,,,,,fee schedule,7368.15,22138.4,
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,16453.88,,,,,,,fee schedule,7368.15,22138.4,
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,12786.11,,,,,,,fee schedule,7368.15,22138.4,
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,22138.4,,,,,,,fee schedule,7368.15,22138.4,
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,15218.95,,,,,,,fee schedule,7368.15,22138.4,
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,13783.03,,,,,,,fee schedule,7368.15,22138.4,
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11288.87,,,,,,,fee schedule,7368.15,22138.4,
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3167.65,3167.65,3167.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8499.6,,,,,,,fee schedule,7368.15,22138.4,MSDRG Base Rate
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,8418.65,,,,,,,fee schedule,7368.15,22138.4,MSDRG Base Rate
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,8418.65,,,,,,,fee schedule,7368.15,22138.4,MSDRG Base Rate
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,8499.6,,,,,,,fee schedule,7368.15,22138.4,MSDRG Base Rate
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,8418.65,,,,,,,fee schedule,7368.15,22138.4,MSDRG Base Rate
"Malignancy, Female Reproductive System Without Cc/Mcc",756,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14166,,,,,,,fee schedule,7368.15,22138.4,MSDRG Base Rate
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10919.9,,,,,,,fee schedule,10919.9,32810,
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,10919.9,,,,,,,fee schedule,10919.9,32810,
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14618.93,,,,,,,fee schedule,10919.9,32810,
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13922.79,,,,,,,fee schedule,10919.9,32810,
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,24385.31,,,,,,,fee schedule,10919.9,32810,
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,18949.53,,,,,,,fee schedule,10919.9,32810,
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,32810,,,,,,,fee schedule,10919.9,32810,
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,22555.09,,,,,,,fee schedule,10919.9,32810,
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,20427,,,,,,,fee schedule,10919.9,32810,
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16730.55,,,,,,,fee schedule,10919.9,32810,
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],19.15,19.15,19.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12182.37,,,,,,,fee schedule,10919.9,32810,MSDRG Base Rate
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,12066.35,,,,,,,fee schedule,10919.9,32810,MSDRG Base Rate
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,12066.35,,,,,,,fee schedule,10919.9,32810,MSDRG Base Rate
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,12182.37,,,,,,,fee schedule,10919.9,32810,MSDRG Base Rate
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,12066.35,,,,,,,fee schedule,10919.9,32810,MSDRG Base Rate
"Infections, Female Reproductive System With Mcc",757,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20303.96,,,,,,,fee schedule,10919.9,32810,MSDRG Base Rate
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7865.07,,,,,,,fee schedule,7865.07,23631.45,
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,7865.07,,,,,,,fee schedule,7865.07,23631.45,
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10529.31,,,,,,,fee schedule,7865.07,23631.45,
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10027.91,,,,,,,fee schedule,7865.07,23631.45,
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,17563.56,,,,,,,fee schedule,7865.07,23631.45,
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,13648.43,,,,,,,fee schedule,7865.07,23631.45,
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,23631.45,,,,,,,fee schedule,7865.07,23631.45,
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,16245.34,,,,,,,fee schedule,7865.07,23631.45,
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,14712.58,,,,,,,fee schedule,7865.07,23631.45,
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12050.21,,,,,,,fee schedule,7865.07,23631.45,
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4093.46,4093.46,4093.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],17563.56,17563.56,17563.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3808.7,3808.7,3808.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8644.14,,,,,,,fee schedule,7865.07,23631.45,MSDRG Base Rate
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,8561.81,,,,,,,fee schedule,7865.07,23631.45,MSDRG Base Rate
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,8561.81,,,,,,,fee schedule,7865.07,23631.45,MSDRG Base Rate
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,8644.14,,,,,,,fee schedule,7865.07,23631.45,MSDRG Base Rate
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,8561.81,,,,,,,fee schedule,7865.07,23631.45,MSDRG Base Rate
"Infections, Female Reproductive System With Cc",758,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14406.89,,,,,,,fee schedule,7865.07,23631.45,MSDRG Base Rate
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4937.56,,,,,,,fee schedule,4937.56,14835.44,
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,4937.56,,,,,,,fee schedule,4937.56,14835.44,
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6610.13,,,,,,,fee schedule,4937.56,14835.44,
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6295.36,,,,,,,fee schedule,4937.56,14835.44,
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,11026.12,,,,,,,fee schedule,4937.56,14835.44,
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,8568.26,,,,,,,fee schedule,4937.56,14835.44,
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,14835.44,,,,,,,fee schedule,4937.56,14835.44,
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,10198.56,,,,,,,fee schedule,4937.56,14835.44,
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,9236.32,,,,,,,fee schedule,4937.56,14835.44,
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7564.92,,,,,,,fee schedule,4937.56,14835.44,
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],9343.62,9343.62,9343.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3117.78,3117.78,3117.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],8429.49,8429.49,8429.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,6180.1,,,,,,,fee schedule,4937.56,14835.44,MSDRG Base Rate
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,6121.24,,,,,,,fee schedule,4937.56,14835.44,MSDRG Base Rate
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,6121.24,,,,,,,fee schedule,4937.56,14835.44,MSDRG Base Rate
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,6180.1,,,,,,,fee schedule,4937.56,14835.44,MSDRG Base Rate
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,6121.24,,,,,,,fee schedule,4937.56,14835.44,MSDRG Base Rate
"Infections, Female Reproductive System Without Cc/Mcc",759,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10300.17,,,,,,,fee schedule,4937.56,14835.44,MSDRG Base Rate
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7604.27,,,,,,,fee schedule,7604.27,22847.83,
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,7604.27,,,,,,,fee schedule,7604.27,22847.83,
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10180.16,,,,,,,fee schedule,7604.27,22847.83,
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9695.39,,,,,,,fee schedule,7604.27,22847.83,
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,16981.15,,,,,,,fee schedule,7604.27,22847.83,
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,13195.85,,,,,,,fee schedule,7604.27,22847.83,
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,22847.83,,,,,,,fee schedule,7604.27,22847.83,
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,15706.64,,,,,,,fee schedule,7604.27,22847.83,
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,14224.71,,,,,,,fee schedule,7604.27,22847.83,
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11650.62,,,,,,,fee schedule,7604.27,22847.83,
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],13513.22,13513.22,14034,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4387.24,4387.24,4387.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],8723.85,8723.85,8723.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8866.79,,,,,,,fee schedule,7604.27,22847.83,MSDRG Base Rate
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,8782.34,,,,,,,fee schedule,7604.27,22847.83,MSDRG Base Rate
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,8782.34,,,,,,,fee schedule,7604.27,22847.83,MSDRG Base Rate
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,8866.79,,,,,,,fee schedule,7604.27,22847.83,MSDRG Base Rate
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,8782.34,,,,,,,fee schedule,7604.27,22847.83,MSDRG Base Rate
Menstrual And Other Female Reproductive System Disorders With Cc/Mcc,760,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14777.98,,,,,,,fee schedule,7604.27,22847.83,MSDRG Base Rate
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4891.27,,,,,,,fee schedule,4891.27,14696.34,
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,4891.27,,,,,,,fee schedule,4891.27,14696.34,
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6548.15,,,,,,,fee schedule,4891.27,14696.34,
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6236.33,,,,,,,fee schedule,4891.27,14696.34,
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,10922.73,,,,,,,fee schedule,4891.27,14696.34,
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,8487.92,,,,,,,fee schedule,4891.27,14696.34,
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,14696.34,,,,,,,fee schedule,4891.27,14696.34,
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,10102.93,,,,,,,fee schedule,4891.27,14696.34,
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,9149.71,,,,,,,fee schedule,4891.27,14696.34,
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7493.99,,,,,,,fee schedule,4891.27,14696.34,
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3269.1,3269.1,3269.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],1401,1401,1401,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,5452.77,,,,,,,fee schedule,4891.27,14696.34,MSDRG Base Rate
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,5400.83,,,,,,,fee schedule,4891.27,14696.34,MSDRG Base Rate
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,5400.83,,,,,,,fee schedule,4891.27,14696.34,MSDRG Base Rate
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,5452.77,,,,,,,fee schedule,4891.27,14696.34,MSDRG Base Rate
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,5400.83,,,,,,,fee schedule,4891.27,14696.34,MSDRG Base Rate
Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc,761,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9087.94,,,,,,,fee schedule,4891.27,14696.34,MSDRG Base Rate
Cesarean Section W Cc/Mcc,765,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section W Cc/Mcc,765,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section W Cc/Mcc,765,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section W Cc/Mcc,765,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section W Cc/Mcc,765,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section W Cc/Mcc,765,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section W Cc/Mcc,765,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section W Cc/Mcc,765,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section W Cc/Mcc,765,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section W Cc/Mcc,765,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section W Cc/Mcc,765,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section W Cc/Mcc,765,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section W Cc/Mcc,765,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section W Cc/Mcc,765,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section W Cc/Mcc,765,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section W Cc/Mcc,765,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section W Cc/Mcc,765,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section W Cc/Mcc,765,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section W/O Cc/Mcc,766,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section W/O Cc/Mcc,766,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section W/O Cc/Mcc,766,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section W/O Cc/Mcc,766,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section W/O Cc/Mcc,766,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section W/O Cc/Mcc,766,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section W/O Cc/Mcc,766,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section W/O Cc/Mcc,766,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section W/O Cc/Mcc,766,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section W/O Cc/Mcc,766,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section W/O Cc/Mcc,766,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section W/O Cc/Mcc,766,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section W/O Cc/Mcc,766,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section W/O Cc/Mcc,766,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section W/O Cc/Mcc,766,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section W/O Cc/Mcc,766,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section W/O Cc/Mcc,766,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section W/O Cc/Mcc,766,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery W Sterilization &/Or D&C,767,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery W Sterilization &/Or D&C,767,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery W Sterilization &/Or D&C,767,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery W Sterilization &/Or D&C,767,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery W Sterilization &/Or D&C,767,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery W Sterilization &/Or D&C,767,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery W Sterilization &/Or D&C,767,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery W Sterilization &/Or D&C,767,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery W Sterilization &/Or D&C,767,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery W Sterilization &/Or D&C,767,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery W Sterilization &/Or D&C,767,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery W Sterilization &/Or D&C,767,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery W Sterilization &/Or D&C,767,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery W Sterilization &/Or D&C,767,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery W Sterilization &/Or D&C,767,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery W Sterilization &/Or D&C,767,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery W Sterilization &/Or D&C,767,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery W Sterilization &/Or D&C,767,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8459.22,,,,,,,fee schedule,8459.22,25416.62,
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,8459.22,,,,,,,fee schedule,8459.22,25416.62,
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11324.71,,,,,,,fee schedule,8459.22,25416.62,
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10785.44,,,,,,,fee schedule,8459.22,25416.62,
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,18890.35,,,,,,,fee schedule,8459.22,25416.62,
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,14679.46,,,,,,,fee schedule,8459.22,25416.62,
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,25416.62,,,,,,,fee schedule,8459.22,25416.62,
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,17472.54,,,,,,,fee schedule,8459.22,25416.62,
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,15823.99,,,,,,,fee schedule,8459.22,25416.62,
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12960.5,,,,,,,fee schedule,8459.22,25416.62,
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],14121,14121,22161.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],14440.64,14440.64,14440.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],13482,11114,17323.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",5333.06,5333.06,5333.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",5008.43,5008.43,5121.04,24,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],12343.34,12265.91,12960.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],6875,5550,9708.43,29,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4962.06,4962.06,4962.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9367.56,,,,,,,fee schedule,8459.22,25416.62,MSDRG Base Rate
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,9278.35,,,,,,,fee schedule,8459.22,25416.62,MSDRG Base Rate
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,9278.35,,,,,,,fee schedule,8459.22,25416.62,MSDRG Base Rate
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,9367.56,,,,,,,fee schedule,8459.22,25416.62,MSDRG Base Rate
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,9278.35,,,,,,,fee schedule,8459.22,25416.62,MSDRG Base Rate
Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C,768,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15612.61,,,,,,,fee schedule,8459.22,25416.62,MSDRG Base Rate
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10721.59,,,,,,,fee schedule,10721.59,32214.17,
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,10721.59,,,,,,,fee schedule,10721.59,32214.17,
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14353.45,,,,,,,fee schedule,10721.59,32214.17,
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13669.96,,,,,,,fee schedule,10721.59,32214.17,
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,23942.47,,,,,,,fee schedule,10721.59,32214.17,
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,18605.41,,,,,,,fee schedule,10721.59,32214.17,
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,32214.17,,,,,,,fee schedule,10721.59,32214.17,
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,22145.49,,,,,,,fee schedule,10721.59,32214.17,
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,20056.04,,,,,,,fee schedule,10721.59,32214.17,
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16426.72,,,,,,,fee schedule,10721.59,32214.17,
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],18790.31,18790.31,18790.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],20056.04,20056.04,20056.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",5100.43,5100.43,5100.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],16426.72,16426.72,16426.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],23313.3,23313.3,23942.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14197.2,,,,,,,fee schedule,10721.59,32214.17,MSDRG Base Rate
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,14061.99,,,,,,,fee schedule,10721.59,32214.17,MSDRG Base Rate
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,14061.99,,,,,,,fee schedule,10721.59,32214.17,MSDRG Base Rate
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,14197.2,,,,,,,fee schedule,10721.59,32214.17,MSDRG Base Rate
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,14061.99,,,,,,,fee schedule,10721.59,32214.17,MSDRG Base Rate
Postpartum And Post Abortion Diagnoses With O.R. Procedures,769,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23662,,,,,,,fee schedule,10721.59,32214.17,MSDRG Base Rate
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8301.81,,,,,,,fee schedule,8301.81,24943.67,
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,8301.81,,,,,,,fee schedule,8301.81,24943.67,
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11113.98,,,,,,,fee schedule,8301.81,24943.67,
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10584.75,,,,,,,fee schedule,8301.81,24943.67,
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,18538.83,,,,,,,fee schedule,8301.81,24943.67,
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,14406.3,,,,,,,fee schedule,8301.81,24943.67,
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,24943.67,,,,,,,fee schedule,8301.81,24943.67,
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,17147.41,,,,,,,fee schedule,8301.81,24943.67,
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,15529.54,,,,,,,fee schedule,8301.81,24943.67,
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12719.33,,,,,,,fee schedule,8301.81,24943.67,
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],24219.68,24219.68,24219.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],17394.62,17394.62,17394.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3205.05,3205.05,3205.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],20066.79,20066.79,20066.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8829.29,,,,,,,fee schedule,8301.81,24943.67,MSDRG Base Rate
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,8745.2,,,,,,,fee schedule,8301.81,24943.67,MSDRG Base Rate
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,8745.2,,,,,,,fee schedule,8301.81,24943.67,MSDRG Base Rate
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,8829.29,,,,,,,fee schedule,8301.81,24943.67,MSDRG Base Rate
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,8745.2,,,,,,,fee schedule,8301.81,24943.67,MSDRG Base Rate
"Abortion With D&C, Aspiration Curettage Or Hysterotomy",770,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14715.49,,,,,,,fee schedule,8301.81,24943.67,MSDRG Base Rate
Vaginal Delivery W Complicating Diagnoses,774,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery W Complicating Diagnoses,774,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery W Complicating Diagnoses,774,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery W Complicating Diagnoses,774,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery W Complicating Diagnoses,774,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery W Complicating Diagnoses,774,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery W Complicating Diagnoses,774,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery W Complicating Diagnoses,774,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery W Complicating Diagnoses,774,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery W Complicating Diagnoses,774,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery W Complicating Diagnoses,774,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery W Complicating Diagnoses,774,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery W Complicating Diagnoses,774,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery W Complicating Diagnoses,774,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery W Complicating Diagnoses,774,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery W Complicating Diagnoses,774,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery W Complicating Diagnoses,774,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery W Complicating Diagnoses,774,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery W/O Complicating Diagnoses,775,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery W/O Complicating Diagnoses,775,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery W/O Complicating Diagnoses,775,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery W/O Complicating Diagnoses,775,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery W/O Complicating Diagnoses,775,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery W/O Complicating Diagnoses,775,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery W/O Complicating Diagnoses,775,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery W/O Complicating Diagnoses,775,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery W/O Complicating Diagnoses,775,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery W/O Complicating Diagnoses,775,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery W/O Complicating Diagnoses,775,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery W/O Complicating Diagnoses,775,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery W/O Complicating Diagnoses,775,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery W/O Complicating Diagnoses,775,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery W/O Complicating Diagnoses,775,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery W/O Complicating Diagnoses,775,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery W/O Complicating Diagnoses,775,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery W/O Complicating Diagnoses,775,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5504.7,,,,,,,fee schedule,5504.7,16539.47,
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,5504.7,,,,,,,fee schedule,5504.7,16539.47,
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7369.38,,,,,,,fee schedule,5504.7,16539.47,
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7018.46,,,,,,,fee schedule,5504.7,16539.47,
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,12292.6,,,,,,,fee schedule,5504.7,16539.47,
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,9552.43,,,,,,,fee schedule,5504.7,16539.47,
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,16539.47,,,,,,,fee schedule,5504.7,16539.47,
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,11369.98,,,,,,,fee schedule,5504.7,16539.47,
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,10297.22,,,,,,,fee schedule,5504.7,16539.47,
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8433.84,,,,,,,fee schedule,5504.7,16539.47,
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],10925,10925,10925,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],10803,10696.58,11355,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],7813,7813,10298.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3002.14,3002.14,3002.14,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],6769.44,6769.44,6769.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],7428.72,7428.72,8435.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],10201.2,5024,12294.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",2974.34,2974.34,2974.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,6110.57,,,,,,,fee schedule,5504.7,16539.47,MSDRG Base Rate
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,6052.37,,,,,,,fee schedule,5504.7,16539.47,MSDRG Base Rate
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,6052.37,,,,,,,fee schedule,5504.7,16539.47,MSDRG Base Rate
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,6110.57,,,,,,,fee schedule,5504.7,16539.47,MSDRG Base Rate
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,6052.37,,,,,,,fee schedule,5504.7,16539.47,MSDRG Base Rate
Postpartum And Post Abortion Diagnoses Without O.R. Procedures,776,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10184.28,,,,,,,fee schedule,5504.7,16539.47,MSDRG Base Rate
Ectopic Pregnancy,777,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ectopic Pregnancy,777,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Ectopic Pregnancy,777,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Ectopic Pregnancy,777,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ectopic Pregnancy,777,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ectopic Pregnancy,777,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Ectopic Pregnancy,777,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Ectopic Pregnancy,777,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Ectopic Pregnancy,777,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Ectopic Pregnancy,777,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Ectopic Pregnancy,777,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ectopic Pregnancy,777,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ectopic Pregnancy,777,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Ectopic Pregnancy,777,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Ectopic Pregnancy,777,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ectopic Pregnancy,777,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Ectopic Pregnancy,777,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ectopic Pregnancy,777,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Threatened Abortion,778,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Threatened Abortion,778,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Threatened Abortion,778,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Threatened Abortion,778,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Threatened Abortion,778,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Threatened Abortion,778,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Threatened Abortion,778,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Threatened Abortion,778,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Threatened Abortion,778,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Threatened Abortion,778,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Threatened Abortion,778,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Threatened Abortion,778,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Threatened Abortion,778,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Threatened Abortion,778,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Threatened Abortion,778,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Threatened Abortion,778,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Threatened Abortion,778,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Threatened Abortion,778,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Abortion Without D&C,779,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7212.29,,,,,,,fee schedule,7212.29,21670.08,
Abortion Without D&C,779,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,7212.29,,,,,,,fee schedule,7212.29,21670.08,
Abortion Without D&C,779,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9655.39,,,,,,,fee schedule,7212.29,21670.08,
Abortion Without D&C,779,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9195.62,,,,,,,fee schedule,7212.29,21670.08,
Abortion Without D&C,779,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,16105.82,,,,,,,fee schedule,7212.29,21670.08,
Abortion Without D&C,779,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,12515.63,,,,,,,fee schedule,7212.29,21670.08,
Abortion Without D&C,779,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,21670.08,,,,,,,fee schedule,7212.29,21670.08,
Abortion Without D&C,779,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,14897.01,,,,,,,fee schedule,7212.29,21670.08,
Abortion Without D&C,779,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,13491.46,,,,,,,fee schedule,7212.29,21670.08,
Abortion Without D&C,779,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11050.06,,,,,,,fee schedule,7212.29,21670.08,
Abortion Without D&C,779,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Abortion Without D&C,779,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Abortion Without D&C,779,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Abortion Without D&C,779,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Abortion Without D&C,779,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Abortion Without D&C,779,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Abortion Without D&C,779,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Abortion Without D&C,779,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",2523.24,2523.24,2523.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Abortion Without D&C,779,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Abortion Without D&C,779,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Abortion Without D&C,779,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Abortion Without D&C,779,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Abortion Without D&C,779,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Abortion Without D&C,779,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],8653,8653,8653,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Abortion Without D&C,779,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",2499.88,2499.88,2499.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Abortion Without D&C,779,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Abortion Without D&C,779,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Abortion Without D&C,779,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Abortion Without D&C,779,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7568.37,,,,,,,fee schedule,7212.29,21670.08,MSDRG Base Rate
Abortion Without D&C,779,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,7496.29,,,,,,,fee schedule,7212.29,21670.08,MSDRG Base Rate
Abortion Without D&C,779,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,7496.29,,,,,,,fee schedule,7212.29,21670.08,MSDRG Base Rate
Abortion Without D&C,779,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,7568.37,,,,,,,fee schedule,7212.29,21670.08,MSDRG Base Rate
Abortion Without D&C,779,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,7496.29,,,,,,,fee schedule,7212.29,21670.08,MSDRG Base Rate
Abortion Without D&C,779,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12613.95,,,,,,,fee schedule,7212.29,21670.08,MSDRG Base Rate
False Labor,780,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
False Labor,780,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
False Labor,780,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
False Labor,780,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
False Labor,780,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
False Labor,780,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
False Labor,780,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
False Labor,780,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
False Labor,780,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
False Labor,780,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
False Labor,780,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
False Labor,780,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
False Labor,780,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
False Labor,780,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
False Labor,780,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
False Labor,780,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
False Labor,780,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
False Labor,780,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses W Medical Complications,781,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses W Medical Complications,781,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses W Medical Complications,781,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses W Medical Complications,781,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses W Medical Complications,781,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses W Medical Complications,781,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses W Medical Complications,781,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses W Medical Complications,781,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses W Medical Complications,781,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses W Medical Complications,781,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses W Medical Complications,781,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses W Medical Complications,781,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses W Medical Complications,781,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses W Medical Complications,781,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses W Medical Complications,781,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses W Medical Complications,781,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses W Medical Complications,781,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses W Medical Complications,781,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses W/O Medical Complications,782,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses W/O Medical Complications,782,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses W/O Medical Complications,782,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses W/O Medical Complications,782,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses W/O Medical Complications,782,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses W/O Medical Complications,782,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses W/O Medical Complications,782,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses W/O Medical Complications,782,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses W/O Medical Complications,782,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses W/O Medical Complications,782,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses W/O Medical Complications,782,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses W/O Medical Complications,782,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses W/O Medical Complications,782,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses W/O Medical Complications,782,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses W/O Medical Complications,782,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses W/O Medical Complications,782,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses W/O Medical Complications,782,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses W/O Medical Complications,782,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14213.15,,,,,,,fee schedule,14213.15,42704.93,
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,14213.15,,,,,,,fee schedule,14213.15,42704.93,
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19027.75,,,,,,,fee schedule,14213.15,42704.93,
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18121.67,,,,,,,fee schedule,14213.15,42704.93,
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,31739.5,,,,,,,fee schedule,14213.15,42704.93,
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,24664.38,,,,,,,fee schedule,14213.15,42704.93,
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,42704.93,,,,,,,fee schedule,14213.15,42704.93,
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,29357.32,,,,,,,fee schedule,14213.15,42704.93,
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,26587.43,,,,,,,fee schedule,14213.15,42704.93,
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21776.2,,,,,,,fee schedule,14213.15,42704.93,
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],84645.13,84645.13,84645.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],19948.9,19948.9,19948.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",7610.55,7610.55,7610.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],13105.46,13105.46,13105.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,20176.03,,,,,,,fee schedule,14213.15,42704.93,MSDRG Base Rate
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,19983.88,,,,,,,fee schedule,14213.15,42704.93,MSDRG Base Rate
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,19983.88,,,,,,,fee schedule,14213.15,42704.93,MSDRG Base Rate
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,20176.03,,,,,,,fee schedule,14213.15,42704.93,MSDRG Base Rate
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,19983.88,,,,,,,fee schedule,14213.15,42704.93,MSDRG Base Rate
Cesarean Section With Sterilization With Mcc,783,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,33626.72,,,,,,,fee schedule,14213.15,42704.93,MSDRG Base Rate
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8356.59,,,,,,,fee schedule,8356.59,25108.27,
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,8356.59,,,,,,,fee schedule,8356.59,25108.27,
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11187.33,,,,,,,fee schedule,8356.59,25108.27,
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10654.6,,,,,,,fee schedule,8356.59,25108.27,
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,18661.17,,,,,,,fee schedule,8356.59,25108.27,
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,14501.37,,,,,,,fee schedule,8356.59,25108.27,
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,25108.27,,,,,,,fee schedule,8356.59,25108.27,
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,17260.57,,,,,,,fee schedule,8356.59,25108.27,
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,15632.02,,,,,,,fee schedule,8356.59,25108.27,
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12803.27,,,,,,,fee schedule,8356.59,25108.27,
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],19603.69,19603.69,25108.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],16221.55,13702.49,16910.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],15632.02,14934.54,16465.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",5197.58,5197.58,5310.19,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],12803.27,12803.27,16370.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],11026,10363.8,101358,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",5149.46,5149.46,5149.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],24376.19,24376.19,24376.19,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9277.73,,,,,,,fee schedule,8356.59,25108.27,MSDRG Base Rate
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,9189.37,,,,,,,fee schedule,8356.59,25108.27,MSDRG Base Rate
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,9189.37,,,,,,,fee schedule,8356.59,25108.27,MSDRG Base Rate
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,9277.73,,,,,,,fee schedule,8356.59,25108.27,MSDRG Base Rate
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,9189.37,,,,,,,fee schedule,8356.59,25108.27,MSDRG Base Rate
Cesarean Section With Sterilization With Cc,784,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15462.88,,,,,,,fee schedule,8356.59,25108.27,MSDRG Base Rate
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6750.86,,,,,,,fee schedule,6750.86,20283.68,
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,6750.86,,,,,,,fee schedule,6750.86,20283.68,
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9037.66,,,,,,,fee schedule,6750.86,20283.68,
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8607.3,,,,,,,fee schedule,6750.86,20283.68,
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,15075.4,,,,,,,fee schedule,6750.86,20283.68,
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,11714.91,,,,,,,fee schedule,6750.86,20283.68,
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,20283.68,,,,,,,fee schedule,6750.86,20283.68,
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,13943.93,,,,,,,fee schedule,6750.86,20283.68,
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,12628.31,,,,,,,fee schedule,6750.86,20283.68,
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10343.1,,,,,,,fee schedule,6750.86,20283.68,
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],18415.25,18415.25,18415.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],13225.53,13225.53,13225.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],12411.65,10182.47,14679.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",5052.9,5052.9,5052.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4745.34,4745.34,4745.34,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],5263.52,5263.52,5263.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],7877.01,6977.86,9108.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],11026,9322.45,12405.25,29,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4701.4,4701.4,4701.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8478.52,,,,,,,fee schedule,6750.86,20283.68,MSDRG Base Rate
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,8397.77,,,,,,,fee schedule,6750.86,20283.68,MSDRG Base Rate
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,8397.77,,,,,,,fee schedule,6750.86,20283.68,MSDRG Base Rate
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,8478.52,,,,,,,fee schedule,6750.86,20283.68,MSDRG Base Rate
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,8397.77,,,,,,,fee schedule,6750.86,20283.68,MSDRG Base Rate
Cesarean Section With Sterilization Without Cc/Mcc,785,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14130.86,,,,,,,fee schedule,6750.86,20283.68,MSDRG Base Rate
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12467.76,,,,,,,fee schedule,12467.76,37460.71,
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,12467.76,,,,,,,fee schedule,12467.76,37460.71,
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16691.12,,,,,,,fee schedule,12467.76,37460.71,
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15896.31,,,,,,,fee schedule,12467.76,37460.71,
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,27841.85,,,,,,,fee schedule,12467.76,37460.71,
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,21635.56,,,,,,,fee schedule,12467.76,37460.71,
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,37460.71,,,,,,,fee schedule,12467.76,37460.71,
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,25752.2,,,,,,,fee schedule,12467.76,37460.71,
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,23322.46,,,,,,,fee schedule,12467.76,37460.71,
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19102.05,,,,,,,fee schedule,12467.76,37460.71,
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],27331.65,27331.65,57963.22,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],25753.79,21071.6,26746.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],20214.28,20089.33,26122.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",7750.9,7750.9,7750.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",7279.1,7279.1,7279.1,22,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],13897.29,13897.29,13897.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],12046,11026,21196,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",7211.7,7211.7,7211.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],12202.2,12202.2,12202.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13882.35,,,,,,,fee schedule,12467.76,37460.71,MSDRG Base Rate
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,13750.14,,,,,,,fee schedule,12467.76,37460.71,MSDRG Base Rate
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,13750.14,,,,,,,fee schedule,12467.76,37460.71,MSDRG Base Rate
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,13882.35,,,,,,,fee schedule,12467.76,37460.71,MSDRG Base Rate
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,13750.14,,,,,,,fee schedule,12467.76,37460.71,MSDRG Base Rate
Cesarean Section Without Sterilization With Mcc,786,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23137.26,,,,,,,fee schedule,12467.76,37460.71,MSDRG Base Rate
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8193.01,,,,,,,fee schedule,8193.01,24616.77,
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,8193.01,,,,,,,fee schedule,8193.01,24616.77,
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10968.33,,,,,,,fee schedule,8193.01,24616.77,
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10446.03,,,,,,,fee schedule,8193.01,24616.77,
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,18295.88,,,,,,,fee schedule,8193.01,24616.77,
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,14217.5,,,,,,,fee schedule,8193.01,24616.77,
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,24616.77,,,,,,,fee schedule,8193.01,24616.77,
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,16922.69,,,,,,,fee schedule,8193.01,24616.77,
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,15326.02,,,,,,,fee schedule,8193.01,24616.77,
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12552.64,,,,,,,fee schedule,8193.01,24616.77,
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],20441.14,20073.96,24616.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],16572.69,14068.87,16922.69,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],15326.02,13736.02,18016.78,24,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",5732.67,5732.67,5732.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],10180.13,10180.13,10446.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",5383.72,5383.72,5383.72,72,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],9310.94,9310.94,9310.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7817.24,7817.24,7817.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],12552.64,9521.05,16936.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],11026,9320.8,16044.72,51,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],6539.29,6539.29,6539.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",5333.88,4856.86,5333.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],28964.8,28964.8,28964.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9720.69,,,,,,,fee schedule,8193.01,24616.77,MSDRG Base Rate
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,9628.11,,,,,,,fee schedule,8193.01,24616.77,MSDRG Base Rate
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,9628.11,,,,,,,fee schedule,8193.01,24616.77,MSDRG Base Rate
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,9720.69,,,,,,,fee schedule,8193.01,24616.77,MSDRG Base Rate
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,9628.11,,,,,,,fee schedule,8193.01,24616.77,MSDRG Base Rate
Cesarean Section Without Sterilization With Cc,787,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16201.15,,,,,,,fee schedule,8193.01,24616.77,MSDRG Base Rate
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6983.12,,,,,,,fee schedule,6983.12,20981.52,
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,6983.12,,,,,,,fee schedule,6983.12,20981.52,
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9348.6,,,,,,,fee schedule,6983.12,20981.52,
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8903.43,,,,,,,fee schedule,6983.12,20981.52,
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,15594.06,,,,,,,fee schedule,6983.12,20981.52,
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,12117.95,,,,,,,fee schedule,6983.12,20981.52,
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,20981.52,,,,,,,fee schedule,6983.12,20981.52,
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,14423.65,,,,,,,fee schedule,6983.12,20981.52,
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,13062.77,,,,,,,fee schedule,6983.12,20981.52,
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10698.95,,,,,,,fee schedule,6983.12,20981.52,
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],19211.4,18102.7,20974.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],13308.3,12867.96,14012.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],13058.44,10703.74,15499.96,28,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",5219.99,5219.99,5219.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],8900.47,8454.77,9013.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4902.25,4902.25,4902.25,43,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],10695.4,10186.1,10924.06,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],11026,9166.96,11390,89,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4856.86,4856.86,4856.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],21907.58,21907.58,21907.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8486.33,,,,,,,fee schedule,6983.12,20981.52,MSDRG Base Rate
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,8405.51,,,,,,,fee schedule,6983.12,20981.52,MSDRG Base Rate
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,8405.51,,,,,,,fee schedule,6983.12,20981.52,MSDRG Base Rate
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,8486.33,,,,,,,fee schedule,6983.12,20981.52,MSDRG Base Rate
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,8405.51,,,,,,,fee schedule,6983.12,20981.52,MSDRG Base Rate
Cesarean Section Without Sterilization Without Cc/Mcc,788,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14143.88,,,,,,,fee schedule,6983.12,20981.52,MSDRG Base Rate
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13909.9,,,,,,,fee schedule,13909.9,41793.8,
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,13909.9,,,,,,,fee schedule,13909.9,41793.8,
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18621.78,,,,,,,fee schedule,13909.9,41793.8,
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17735.03,,,,,,,fee schedule,13909.9,41793.8,
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,31062.32,,,,,,,fee schedule,13909.9,41793.8,
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,24138.15,,,,,,,fee schedule,13909.9,41793.8,
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,41793.8,,,,,,,fee schedule,13909.9,41793.8,
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,28730.96,,,,,,,fee schedule,13909.9,41793.8,
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,26020.17,,,,,,,fee schedule,13909.9,41793.8,
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21311.59,,,,,,,fee schedule,13909.9,41793.8,
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],26443,26443,26443,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],29017.1,29017.1,29017.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],295204.77,295204.77,295204.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",157068.32,13658.22,484819.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",316734.32,316734.32,316734.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15075.31,,,,,,,fee schedule,13909.9,41793.8,MSDRG Base Rate
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,14931.74,,,,,,,fee schedule,13909.9,41793.8,MSDRG Base Rate
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,14931.74,,,,,,,fee schedule,13909.9,41793.8,MSDRG Base Rate
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,15075.31,,,,,,,fee schedule,13909.9,41793.8,MSDRG Base Rate
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,14931.74,,,,,,,fee schedule,13909.9,41793.8,MSDRG Base Rate
"Neonates, Died Or Transferred To Another Acute Care Facility",789,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,25125.52,,,,,,,fee schedule,13909.9,41793.8,MSDRG Base Rate
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,45872.51,,,,,,,fee schedule,45872.51,137828.88,
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,45872.51,,,,,,,fee schedule,45872.51,137828.88,
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,61411.49,,,,,,,fee schedule,45872.51,137828.88,
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,58487.15,,,,,,,fee schedule,45872.51,137828.88,
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,102438.3,,,,,,,fee schedule,45872.51,137828.88,
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,79603.55,,,,,,,fee schedule,45872.51,137828.88,
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,137828.88,,,,,,,fee schedule,45872.51,137828.88,
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,94749.86,,,,,,,fee schedule,45872.51,137828.88,
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,85810.13,,,,,,,fee schedule,45872.51,137828.88,
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,70282.03,,,,,,,fee schedule,45872.51,137828.88,
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],89543.49,67668,211013.74,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],85807.24,33077.5,360694.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",81451.5,49429.55,226784.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",66892.2,29276.5,300338.2,44,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],80940.32,70279.66,158946.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],98382,45643,113939.4,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",83627.64,50450.29,103061.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,47428.85,,,,,,,fee schedule,45872.51,137828.88,MSDRG Base Rate
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,46977.14,,,,,,,fee schedule,45872.51,137828.88,MSDRG Base Rate
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,46977.14,,,,,,,fee schedule,45872.51,137828.88,MSDRG Base Rate
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,47428.85,,,,,,,fee schedule,45872.51,137828.88,MSDRG Base Rate
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,46977.14,,,,,,,fee schedule,45872.51,137828.88,MSDRG Base Rate
"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate",790,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,79048.08,,,,,,,fee schedule,45872.51,137828.88,MSDRG Base Rate
Prematurity With Major Problems,791,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,31328.34,,,,,,,fee schedule,31328.34,94129.36,
Prematurity With Major Problems,791,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,31328.34,,,,,,,fee schedule,31328.34,94129.36,
Prematurity With Major Problems,791,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,41940.59,,,,,,,fee schedule,31328.34,94129.36,
Prematurity With Major Problems,791,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,39943.43,,,,,,,fee schedule,31328.34,94129.36,
Prematurity With Major Problems,791,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,69959.58,,,,,,,fee schedule,31328.34,94129.36,
Prematurity With Major Problems,791,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,54364.74,,,,,,,fee schedule,31328.34,94129.36,
Prematurity With Major Problems,791,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,94129.36,,,,,,,fee schedule,31328.34,94129.36,
Prematurity With Major Problems,791,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,64708.82,,,,,,,fee schedule,31328.34,94129.36,
Prematurity With Major Problems,791,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,58603.48,,,,,,,fee schedule,31328.34,94129.36,
Prematurity With Major Problems,791,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,47998.66,,,,,,,fee schedule,31328.34,94129.36,
Prematurity With Major Problems,791,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prematurity With Major Problems,791,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Prematurity With Major Problems,791,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],35401,7791,75253.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Prematurity With Major Problems,791,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prematurity With Major Problems,791,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],23275.99,23275.99,40724,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Prematurity With Major Problems,791,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prematurity With Major Problems,791,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",40455.35,40455.35,42960.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Prematurity With Major Problems,791,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",14592.37,14592.37,62882.63,30,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Prematurity With Major Problems,791,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],21967.13,21967.13,21967.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Prematurity With Major Problems,791,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],47996.3,47996.3,69944.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Prematurity With Major Problems,791,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Prematurity With Major Problems,791,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prematurity With Major Problems,791,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prematurity With Major Problems,791,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],61373,21157,111941,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Prematurity With Major Problems,791,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",14457.25,14457.25,14457.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Prematurity With Major Problems,791,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prematurity With Major Problems,791,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prematurity With Major Problems,791,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prematurity With Major Problems,791,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,32706.36,,,,,,,fee schedule,31328.34,94129.36,MSDRG Base Rate
Prematurity With Major Problems,791,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,32394.87,,,,,,,fee schedule,31328.34,94129.36,MSDRG Base Rate
Prematurity With Major Problems,791,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,32394.87,,,,,,,fee schedule,31328.34,94129.36,MSDRG Base Rate
Prematurity With Major Problems,791,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,32706.36,,,,,,,fee schedule,31328.34,94129.36,MSDRG Base Rate
Prematurity With Major Problems,791,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,32394.87,,,,,,,fee schedule,31328.34,94129.36,MSDRG Base Rate
Prematurity With Major Problems,791,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,54510.59,,,,,,,fee schedule,31328.34,94129.36,MSDRG Base Rate
Prematurity Without Major Problems,792,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18903.02,,,,,,,fee schedule,18903.02,56796.16,
Prematurity Without Major Problems,792,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,18903.02,,,,,,,fee schedule,18903.02,56796.16,
Prematurity Without Major Problems,792,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,25306.29,,,,,,,fee schedule,18903.02,56796.16,
Prematurity Without Major Problems,792,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24101.23,,,,,,,fee schedule,18903.02,56796.16,
Prematurity Without Major Problems,792,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,42212.5,,,,,,,fee schedule,18903.02,56796.16,
Prematurity Without Major Problems,792,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,32802.82,,,,,,,fee schedule,18903.02,56796.16,
Prematurity Without Major Problems,792,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,56796.16,,,,,,,fee schedule,18903.02,56796.16,
Prematurity Without Major Problems,792,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,39044.28,,,,,,,fee schedule,18903.02,56796.16,
Prematurity Without Major Problems,792,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,35360.41,,,,,,,fee schedule,18903.02,56796.16,
Prematurity Without Major Problems,792,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,28961.63,,,,,,,fee schedule,18903.02,56796.16,
Prematurity Without Major Problems,792,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],29562,29562,29562,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Prematurity Without Major Problems,792,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prematurity Without Major Problems,792,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],16179.68,5398.43,39042.68,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Prematurity Without Major Problems,792,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prematurity Without Major Problems,792,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],8908.28,4408,29134.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Prematurity Without Major Problems,792,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prematurity Without Major Problems,792,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",43162.93,43162.93,43162.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Prematurity Without Major Problems,792,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3512.42,3512.42,3862.42,62,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Prematurity Without Major Problems,792,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],28960.45,25255.76,28960.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Prematurity Without Major Problems,792,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Prematurity Without Major Problems,792,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Prematurity Without Major Problems,792,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prematurity Without Major Problems,792,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prematurity Without Major Problems,792,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],2418,2326.2,29132,22,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Prematurity Without Major Problems,792,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3479.9,3479.9,36134.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Prematurity Without Major Problems,792,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prematurity Without Major Problems,792,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prematurity Without Major Problems,792,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prematurity Without Major Problems,792,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,20129.94,,,,,,,fee schedule,18903.02,56796.16,MSDRG Base Rate
Prematurity Without Major Problems,792,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,19938.22,,,,,,,fee schedule,18903.02,56796.16,MSDRG Base Rate
Prematurity Without Major Problems,792,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,19938.22,,,,,,,fee schedule,18903.02,56796.16,MSDRG Base Rate
Prematurity Without Major Problems,792,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,20129.94,,,,,,,fee schedule,18903.02,56796.16,MSDRG Base Rate
Prematurity Without Major Problems,792,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,19938.22,,,,,,,fee schedule,18903.02,56796.16,MSDRG Base Rate
Prematurity Without Major Problems,792,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,33549.9,,,,,,,fee schedule,18903.02,56796.16,MSDRG Base Rate
Full Term Neonate With Major Problems,793,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,32180.98,,,,,,,fee schedule,32180.98,96691.19,
Full Term Neonate With Major Problems,793,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,32180.98,,,,,,,fee schedule,32180.98,96691.19,
Full Term Neonate With Major Problems,793,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,43082.05,,,,,,,fee schedule,32180.98,96691.19,
Full Term Neonate With Major Problems,793,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,41030.53,,,,,,,fee schedule,32180.98,96691.19,
Full Term Neonate With Major Problems,793,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,71863.61,,,,,,,fee schedule,32180.98,96691.19,
Full Term Neonate With Major Problems,793,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,55844.33,,,,,,,fee schedule,32180.98,96691.19,
Full Term Neonate With Major Problems,793,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,96691.19,,,,,,,fee schedule,32180.98,96691.19,
Full Term Neonate With Major Problems,793,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,66469.94,,,,,,,fee schedule,32180.98,96691.19,
Full Term Neonate With Major Problems,793,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,60198.44,,,,,,,fee schedule,32180.98,96691.19,
Full Term Neonate With Major Problems,793,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,49305,,,,,,,fee schedule,32180.98,96691.19,
Full Term Neonate With Major Problems,793,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],7282,7282,10997,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Full Term Neonate With Major Problems,793,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Term Neonate With Major Problems,793,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],23115,14926.41,63653,25,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Full Term Neonate With Major Problems,793,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Term Neonate With Major Problems,793,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],10439.35,4048,27806.33,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Full Term Neonate With Major Problems,793,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Term Neonate With Major Problems,793,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4232.16,4232.16,39317.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Full Term Neonate With Major Problems,793,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3974.55,3974.55,3974.55,68,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Full Term Neonate With Major Problems,793,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],41029.55,41029.55,41029.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Full Term Neonate With Major Problems,793,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],46956.03,46956.03,49303.82,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Full Term Neonate With Major Problems,793,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Full Term Neonate With Major Problems,793,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Term Neonate With Major Problems,793,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Term Neonate With Major Problems,793,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],3627,1209,34584,26,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Full Term Neonate With Major Problems,793,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3937.75,3937.75,181910.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Full Term Neonate With Major Problems,793,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Term Neonate With Major Problems,793,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Term Neonate With Major Problems,793,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Term Neonate With Major Problems,793,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,33570.41,,,,,,,fee schedule,32180.98,96691.19,MSDRG Base Rate
Full Term Neonate With Major Problems,793,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,33250.69,,,,,,,fee schedule,32180.98,96691.19,MSDRG Base Rate
Full Term Neonate With Major Problems,793,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,33250.69,,,,,,,fee schedule,32180.98,96691.19,MSDRG Base Rate
Full Term Neonate With Major Problems,793,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,33570.41,,,,,,,fee schedule,32180.98,96691.19,MSDRG Base Rate
Full Term Neonate With Major Problems,793,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,33250.69,,,,,,,fee schedule,32180.98,96691.19,MSDRG Base Rate
Full Term Neonate With Major Problems,793,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,55950.68,,,,,,,fee schedule,32180.98,96691.19,MSDRG Base Rate
Neonate With Other Significant Problems,794,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11390.58,,,,,,,fee schedule,11390.58,34224.22,
Neonate With Other Significant Problems,794,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,11390.58,,,,,,,fee schedule,11390.58,34224.22,
Neonate With Other Significant Problems,794,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15249.06,,,,,,,fee schedule,11390.58,34224.22,
Neonate With Other Significant Problems,794,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14522.91,,,,,,,fee schedule,11390.58,34224.22,
Neonate With Other Significant Problems,794,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,25436.4,,,,,,,fee schedule,11390.58,34224.22,
Neonate With Other Significant Problems,794,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,19766.32,,,,,,,fee schedule,11390.58,34224.22,
Neonate With Other Significant Problems,794,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,34224.22,,,,,,,fee schedule,11390.58,34224.22,
Neonate With Other Significant Problems,794,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,23527.29,,,,,,,fee schedule,11390.58,34224.22,
Neonate With Other Significant Problems,794,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,21307.47,,,,,,,fee schedule,11390.58,34224.22,
Neonate With Other Significant Problems,794,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17451.7,,,,,,,fee schedule,11390.58,34224.22,
Neonate With Other Significant Problems,794,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],3714,1867.2,6984,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Neonate With Other Significant Problems,794,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Neonate With Other Significant Problems,794,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],5023,2684,15938,29,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Neonate With Other Significant Problems,794,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Neonate With Other Significant Problems,794,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],4538,2259,7723,39,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Neonate With Other Significant Problems,794,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Neonate With Other Significant Problems,794,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",996.31,996.31,1621.14,25,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Neonate With Other Significant Problems,794,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],14657.7,14657.7,14657.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Neonate With Other Significant Problems,794,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",1522.46,1522.46,1522.46,280,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Neonate With Other Significant Problems,794,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],15249.06,15249.06,15249.06,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Neonate With Other Significant Problems,794,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],17451.7,14522.91,17451.7,46,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Neonate With Other Significant Problems,794,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Neonate With Other Significant Problems,794,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Neonate With Other Significant Problems,794,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],2176.2,1178,3031.6,150,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Neonate With Other Significant Problems,794,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",1508.37,927.01,1508.37,39,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Neonate With Other Significant Problems,794,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Neonate With Other Significant Problems,794,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Neonate With Other Significant Problems,794,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Neonate With Other Significant Problems,794,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12526.12,,,,,,,fee schedule,11390.58,34224.22,MSDRG Base Rate
Neonate With Other Significant Problems,794,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,12406.83,,,,,,,fee schedule,11390.58,34224.22,MSDRG Base Rate
Neonate With Other Significant Problems,794,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,12406.83,,,,,,,fee schedule,11390.58,34224.22,MSDRG Base Rate
Neonate With Other Significant Problems,794,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,12526.12,,,,,,,fee schedule,11390.58,34224.22,MSDRG Base Rate
Neonate With Other Significant Problems,794,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,12406.83,,,,,,,fee schedule,11390.58,34224.22,MSDRG Base Rate
Neonate With Other Significant Problems,794,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20876.87,,,,,,,fee schedule,11390.58,34224.22,MSDRG Base Rate
Normal Newborn,795,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,1541.69,,,,,,,fee schedule,1541.69,4632.16,
Normal Newborn,795,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,1541.69,,,,,,,fee schedule,1541.69,4632.16,
Normal Newborn,795,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,2063.92,,,,,,,fee schedule,1541.69,4632.16,
Normal Newborn,795,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,1965.64,,,,,,,fee schedule,1541.69,4632.16,
Normal Newborn,795,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,3442.75,,,,,,,fee schedule,1541.69,4632.16,
Normal Newborn,795,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,2675.32,,,,,,,fee schedule,1541.69,4632.16,
Normal Newborn,795,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,4632.16,,,,,,,fee schedule,1541.69,4632.16,
Normal Newborn,795,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,3184.36,,,,,,,fee schedule,1541.69,4632.16,
Normal Newborn,795,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,2883.91,,,,,,,fee schedule,1541.69,4632.16,
Normal Newborn,795,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,2362.04,,,,,,,fee schedule,1541.69,4632.16,
Normal Newborn,795,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],3661,1634.41,4333.94,24,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Normal Newborn,795,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Normal Newborn,795,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],2323,1207.38,3184.36,33,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Normal Newborn,795,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Normal Newborn,795,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],2883.91,1690.4,3229.97,59,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Normal Newborn,795,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Normal Newborn,795,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",996.31,996.31,996.31,25,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Normal Newborn,795,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",935.67,935.67,935.67,428,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Normal Newborn,795,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],1965.64,1965.64,1965.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Normal Newborn,795,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],2063.92,2063.92,2063.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Normal Newborn,795,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],2362.04,2249.57,2362.04,66,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Normal Newborn,795,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Normal Newborn,795,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Normal Newborn,795,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],1209,999.2,2418,238,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Normal Newborn,795,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",927.01,927.01,927.01,50,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Normal Newborn,795,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Normal Newborn,795,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Normal Newborn,795,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],4300,4300,4300,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Normal Newborn,795,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,2556.71,,,,,,,fee schedule,1541.69,4632.16,MSDRG Base Rate
Normal Newborn,795,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,2532.36,,,,,,,fee schedule,1541.69,4632.16,MSDRG Base Rate
Normal Newborn,795,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,2532.36,,,,,,,fee schedule,1541.69,4632.16,MSDRG Base Rate
Normal Newborn,795,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,2556.71,,,,,,,fee schedule,1541.69,4632.16,MSDRG Base Rate
Normal Newborn,795,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,2532.36,,,,,,,fee schedule,1541.69,4632.16,MSDRG Base Rate
Normal Newborn,795,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,4261.18,,,,,,,fee schedule,1541.69,4632.16,MSDRG Base Rate
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9850.44,,,,,,,fee schedule,9850.44,29596.69,
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,9850.44,,,,,,,fee schedule,9850.44,29596.69,
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13187.2,,,,,,,fee schedule,9850.44,29596.69,
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12559.24,,,,,,,fee schedule,9850.44,29596.69,
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,21997.09,,,,,,,fee schedule,9850.44,29596.69,
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,17093.67,,,,,,,fee schedule,9850.44,29596.69,
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,29596.69,,,,,,,fee schedule,9850.44,29596.69,
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,20346.12,,,,,,,fee schedule,9850.44,29596.69,
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,18426.44,,,,,,,fee schedule,9850.44,29596.69,
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15092.02,,,,,,,fee schedule,9850.44,29596.69,
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],16909.94,16909.94,16909.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4582.41,4582.41,4582.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],6187.5,6187.5,6187.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10112.88,,,,,,,fee schedule,9850.44,29596.69,MSDRG Base Rate
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,10016.56,,,,,,,fee schedule,9850.44,29596.69,MSDRG Base Rate
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,10016.56,,,,,,,fee schedule,9850.44,29596.69,MSDRG Base Rate
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,10112.88,,,,,,,fee schedule,9850.44,29596.69,MSDRG Base Rate
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,10016.56,,,,,,,fee schedule,9850.44,29596.69,MSDRG Base Rate
Vaginal Delivery With Sterilization And/Or D&C With Mcc,796,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16854.79,,,,,,,fee schedule,9850.44,29596.69,MSDRG Base Rate
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7470.78,,,,,,,fee schedule,7470.78,22446.75,
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,7470.78,,,,,,,fee schedule,7470.78,22446.75,
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10001.45,,,,,,,fee schedule,7470.78,22446.75,
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9525.19,,,,,,,fee schedule,7470.78,22446.75,
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,16683.05,,,,,,,fee schedule,7470.78,22446.75,
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,12964.2,,,,,,,fee schedule,7470.78,22446.75,
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,22446.75,,,,,,,fee schedule,7470.78,22446.75,
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,15430.92,,,,,,,fee schedule,7470.78,22446.75,
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,13975,,,,,,,fee schedule,7470.78,22446.75,
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11446.1,,,,,,,fee schedule,7470.78,22446.75,
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],14659.37,14659.37,14659.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3480.18,3480.18,3480.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],6875,6875,6875,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8811.33,,,,,,,fee schedule,7470.78,22446.75,MSDRG Base Rate
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,8727.41,,,,,,,fee schedule,7470.78,22446.75,MSDRG Base Rate
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,8727.41,,,,,,,fee schedule,7470.78,22446.75,MSDRG Base Rate
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,8811.33,,,,,,,fee schedule,7470.78,22446.75,MSDRG Base Rate
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,8727.41,,,,,,,fee schedule,7470.78,22446.75,MSDRG Base Rate
Vaginal Delivery With Sterilization And/Or D&C With Cc,797,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14685.54,,,,,,,fee schedule,7470.78,22446.75,MSDRG Base Rate
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7470.78,,,,,,,fee schedule,7470.78,22446.75,
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,7470.78,,,,,,,fee schedule,7470.78,22446.75,
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10001.45,,,,,,,fee schedule,7470.78,22446.75,
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9525.19,,,,,,,fee schedule,7470.78,22446.75,
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,16683.05,,,,,,,fee schedule,7470.78,22446.75,
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,12964.2,,,,,,,fee schedule,7470.78,22446.75,
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,22446.75,,,,,,,fee schedule,7470.78,22446.75,
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,15430.92,,,,,,,fee schedule,7470.78,22446.75,
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,13975,,,,,,,fee schedule,7470.78,22446.75,
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11446.1,,,,,,,fee schedule,7470.78,22446.75,
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3195.59,3195.59,3195.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3166,3166,3166,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8473.05,,,,,,,fee schedule,7470.78,22446.75,MSDRG Base Rate
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,8392.35,,,,,,,fee schedule,7470.78,22446.75,MSDRG Base Rate
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,8392.35,,,,,,,fee schedule,7470.78,22446.75,MSDRG Base Rate
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,8473.05,,,,,,,fee schedule,7470.78,22446.75,MSDRG Base Rate
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,8392.35,,,,,,,fee schedule,7470.78,22446.75,MSDRG Base Rate
Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc,798,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14121.75,,,,,,,fee schedule,7470.78,22446.75,MSDRG Base Rate
Splenic Procedures With Mcc,799,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36686.44,,,,,,,fee schedule,36030.96,110228.33,
Splenic Procedures With Mcc,799,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,36686.44,,,,,,,fee schedule,36030.96,110228.33,
Splenic Procedures With Mcc,799,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,49113.7,,,,,,,fee schedule,36030.96,110228.33,
Splenic Procedures With Mcc,799,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,46774.96,,,,,,,fee schedule,36030.96,110228.33,
Splenic Procedures With Mcc,799,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,81924.79,,,,,,,fee schedule,36030.96,110228.33,
Splenic Procedures With Mcc,799,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,63662.76,,,,,,,fee schedule,36030.96,110228.33,
Splenic Procedures With Mcc,799,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,110228.33,,,,,,,fee schedule,36030.96,110228.33,
Splenic Procedures With Mcc,799,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,75775.98,,,,,,,fee schedule,36030.96,110228.33,
Splenic Procedures With Mcc,799,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,68626.45,,,,,,,fee schedule,36030.96,110228.33,
Splenic Procedures With Mcc,799,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,56207.89,,,,,,,fee schedule,36030.96,110228.33,
Splenic Procedures With Mcc,799,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Mcc,799,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Mcc,799,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Mcc,799,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Mcc,799,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Mcc,799,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Mcc,799,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Mcc,799,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Mcc,799,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Mcc,799,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Mcc,799,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Mcc,799,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Mcc,799,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Mcc,799,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Mcc,799,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Mcc,799,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Mcc,799,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Mcc,799,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Mcc,799,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,36377.41,,,,,,,fee schedule,36030.96,110228.33,MSDRG Base Rate
Splenic Procedures With Mcc,799,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,36030.96,,,,,,,fee schedule,36030.96,110228.33,MSDRG Base Rate
Splenic Procedures With Mcc,799,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,36030.96,,,,,,,fee schedule,36030.96,110228.33,MSDRG Base Rate
Splenic Procedures With Mcc,799,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,36377.41,,,,,,,fee schedule,36030.96,110228.33,MSDRG Base Rate
Splenic Procedures With Mcc,799,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,36030.96,,,,,,,fee schedule,36030.96,110228.33,MSDRG Base Rate
Splenic Procedures With Mcc,799,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,60629.01,,,,,,,fee schedule,36030.96,110228.33,MSDRG Base Rate
Splenic Procedures With Cc,800,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,22481.77,,,,,,,fee schedule,22481.77,67548.9,
Splenic Procedures With Cc,800,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,22481.77,,,,,,,fee schedule,22481.77,67548.9,
Splenic Procedures With Cc,800,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,30097.31,,,,,,,fee schedule,22481.77,67548.9,
Splenic Procedures With Cc,800,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,28664.11,,,,,,,fee schedule,22481.77,67548.9,
Splenic Procedures With Cc,800,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,50204.24,,,,,,,fee schedule,22481.77,67548.9,
Splenic Procedures With Cc,800,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,39013.1,,,,,,,fee schedule,22481.77,67548.9,
Splenic Procedures With Cc,800,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,67548.9,,,,,,,fee schedule,22481.77,67548.9,
Splenic Procedures With Cc,800,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,46436.2,,,,,,,fee schedule,22481.77,67548.9,
Splenic Procedures With Cc,800,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,42054.9,,,,,,,fee schedule,22481.77,67548.9,
Splenic Procedures With Cc,800,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,34444.7,,,,,,,fee schedule,22481.77,67548.9,
Splenic Procedures With Cc,800,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Cc,800,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Cc,800,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Cc,800,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Cc,800,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Cc,800,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Cc,800,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Cc,800,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Cc,800,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Cc,800,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Cc,800,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Cc,800,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Cc,800,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Cc,800,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Cc,800,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Cc,800,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Cc,800,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Cc,800,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures With Cc,800,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,22943.97,,,,,,,fee schedule,22481.77,67548.9,MSDRG Base Rate
Splenic Procedures With Cc,800,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,22725.46,,,,,,,fee schedule,22481.77,67548.9,MSDRG Base Rate
Splenic Procedures With Cc,800,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,22725.46,,,,,,,fee schedule,22481.77,67548.9,MSDRG Base Rate
Splenic Procedures With Cc,800,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,22943.97,,,,,,,fee schedule,22481.77,67548.9,MSDRG Base Rate
Splenic Procedures With Cc,800,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,22725.46,,,,,,,fee schedule,22481.77,67548.9,MSDRG Base Rate
Splenic Procedures With Cc,800,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,38239.95,,,,,,,fee schedule,22481.77,67548.9,MSDRG Base Rate
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12667.6,,,,,,,fee schedule,12667.6,38061.17,
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,12667.6,,,,,,,fee schedule,12667.6,38061.17,
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16958.66,,,,,,,fee schedule,12667.6,38061.17,
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16151.11,,,,,,,fee schedule,12667.6,38061.17,
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,28288.13,,,,,,,fee schedule,12667.6,38061.17,
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,21982.36,,,,,,,fee schedule,12667.6,38061.17,
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,38061.17,,,,,,,fee schedule,12667.6,38061.17,
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,26164.99,,,,,,,fee schedule,12667.6,38061.17,
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,23696.3,,,,,,,fee schedule,12667.6,38061.17,
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19408.24,,,,,,,fee schedule,12667.6,38061.17,
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15908.9,,,,,,,fee schedule,12667.6,38061.17,MSDRG Base Rate
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,15757.38,,,,,,,fee schedule,12667.6,38061.17,MSDRG Base Rate
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,15757.38,,,,,,,fee schedule,12667.6,38061.17,MSDRG Base Rate
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,15908.9,,,,,,,fee schedule,12667.6,38061.17,MSDRG Base Rate
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,15757.38,,,,,,,fee schedule,12667.6,38061.17,MSDRG Base Rate
Splenic Procedures Without Cc/Mcc,801,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,26514.83,,,,,,,fee schedule,12667.6,38061.17,MSDRG Base Rate
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,27659.31,,,,,,,fee schedule,27659.31,83105.37,
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,27659.31,,,,,,,fee schedule,27659.31,83105.37,
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,37028.7,,,,,,,fee schedule,27659.31,83105.37,
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,35265.44,,,,,,,fee schedule,27659.31,83105.37,
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,61766.24,,,,,,,fee schedule,27659.31,83105.37,
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,47997.79,,,,,,,fee schedule,27659.31,83105.37,
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,83105.37,,,,,,,fee schedule,27659.31,83105.37,
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,57130.42,,,,,,,fee schedule,27659.31,83105.37,
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,51740.12,,,,,,,fee schedule,27659.31,83105.37,
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,42377.28,,,,,,,fee schedule,27659.31,83105.37,
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],53281,53281,53281,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],86317.77,86317.77,86317.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],26678.77,26678.77,26678.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,32121.21,,,,,,,fee schedule,27659.31,83105.37,MSDRG Base Rate
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,31815.3,,,,,,,fee schedule,27659.31,83105.37,MSDRG Base Rate
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,31815.3,,,,,,,fee schedule,27659.31,83105.37,MSDRG Base Rate
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,32121.21,,,,,,,fee schedule,27659.31,83105.37,MSDRG Base Rate
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,31815.3,,,,,,,fee schedule,27659.31,83105.37,MSDRG Base Rate
Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc,802,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,53535.35,,,,,,,fee schedule,27659.31,83105.37,MSDRG Base Rate
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13733.98,,,,,,,fee schedule,13733.98,41265.2,
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,13733.98,,,,,,,fee schedule,13733.98,41265.2,
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18386.26,,,,,,,fee schedule,13733.98,41265.2,
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17510.73,,,,,,,fee schedule,13733.98,41265.2,
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,30669.46,,,,,,,fee schedule,13733.98,41265.2,
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,23832.86,,,,,,,fee schedule,13733.98,41265.2,
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,41265.2,,,,,,,fee schedule,13733.98,41265.2,
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,28367.58,,,,,,,fee schedule,13733.98,41265.2,
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,25691.08,,,,,,,fee schedule,13733.98,41265.2,
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21042.05,,,,,,,fee schedule,13733.98,41265.2,
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],16401.43,16401.43,16401.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15518.28,,,,,,,fee schedule,13733.98,41265.2,MSDRG Base Rate
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,15370.48,,,,,,,fee schedule,13733.98,41265.2,MSDRG Base Rate
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,15370.48,,,,,,,fee schedule,13733.98,41265.2,MSDRG Base Rate
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,15518.28,,,,,,,fee schedule,13733.98,41265.2,MSDRG Base Rate
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,15370.48,,,,,,,fee schedule,13733.98,41265.2,MSDRG Base Rate
Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc,803,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,25863.79,,,,,,,fee schedule,13733.98,41265.2,MSDRG Base Rate
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8530.2,,,,,,,fee schedule,8530.2,25629.91,
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,8530.2,,,,,,,fee schedule,8530.2,25629.91,
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11419.75,,,,,,,fee schedule,8530.2,25629.91,
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10875.95,,,,,,,fee schedule,8530.2,25629.91,
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,19048.87,,,,,,,fee schedule,8530.2,25629.91,
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,14802.65,,,,,,,fee schedule,8530.2,25629.91,
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,25629.91,,,,,,,fee schedule,8530.2,25629.91,
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,17619.17,,,,,,,fee schedule,8530.2,25629.91,
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,15956.79,,,,,,,fee schedule,8530.2,25629.91,
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13069.27,,,,,,,fee schedule,8530.2,25629.91,
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11589.42,,,,,,,fee schedule,8530.2,25629.91,MSDRG Base Rate
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,11479.04,,,,,,,fee schedule,8530.2,25629.91,MSDRG Base Rate
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,11479.04,,,,,,,fee schedule,8530.2,25629.91,MSDRG Base Rate
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,11589.42,,,,,,,fee schedule,8530.2,25629.91,MSDRG Base Rate
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,11479.04,,,,,,,fee schedule,8530.2,25629.91,MSDRG Base Rate
Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc,804,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19315.7,,,,,,,fee schedule,8530.2,25629.91,MSDRG Base Rate
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7699.95,,,,,,,fee schedule,7699.95,23135.31,
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,7699.95,,,,,,,fee schedule,7699.95,23135.31,
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10308.25,,,,,,,fee schedule,7699.95,23135.31,
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9817.38,,,,,,,fee schedule,7699.95,23135.31,
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,17194.81,,,,,,,fee schedule,7699.95,23135.31,
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,13361.88,,,,,,,fee schedule,7699.95,23135.31,
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,23135.31,,,,,,,fee schedule,7699.95,23135.31,
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,15904.27,,,,,,,fee schedule,7699.95,23135.31,
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,14403.69,,,,,,,fee schedule,7699.95,23135.31,
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11797.21,,,,,,,fee schedule,7699.95,23135.31,
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],13591.87,13591.87,13591.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],12928,9637.6,15110.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],14405.13,11332.16,26403.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3401.79,3401.79,3401.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],9918.71,9918.71,9918.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],9323.53,9323.53,9323.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3194.73,3194.73,3194.73,19,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],11798.4,11798.4,11823.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],5325.85,5325.85,5325.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],8570,6694,11960,22,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3165.15,3165.15,3165.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],15132.8,15132.8,15132.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9426.94,,,,,,,fee schedule,7699.95,23135.31,MSDRG Base Rate
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,9337.16,,,,,,,fee schedule,7699.95,23135.31,MSDRG Base Rate
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,9337.16,,,,,,,fee schedule,7699.95,23135.31,MSDRG Base Rate
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,9426.94,,,,,,,fee schedule,7699.95,23135.31,MSDRG Base Rate
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,9337.16,,,,,,,fee schedule,7699.95,23135.31,MSDRG Base Rate
Vaginal Delivery Without Sterilization Or D&C With Mcc,805,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15711.57,,,,,,,fee schedule,7699.95,23135.31,MSDRG Base Rate
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5582.63,,,,,,,fee schedule,5582.63,16773.62,
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,5582.63,,,,,,,fee schedule,5582.63,16773.62,
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7473.71,,,,,,,fee schedule,5582.63,16773.62,
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7117.82,,,,,,,fee schedule,5582.63,16773.62,
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,12466.63,,,,,,,fee schedule,5582.63,16773.62,
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,9687.67,,,,,,,fee schedule,5582.63,16773.62,
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,16773.62,,,,,,,fee schedule,5582.63,16773.62,
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,11530.95,,,,,,,fee schedule,5582.63,16773.62,
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,10443,,,,,,,fee schedule,5582.63,16773.62,
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8553.25,,,,,,,fee schedule,5582.63,16773.62,
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],12257.38,10549,15510.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],10783.05,7137.65,12643.25,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],10444.44,8782,12189.16,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",2640.1,2640.1,2640.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",2479.4,2479.4,2479.4,84,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],7186.98,7186.98,7186.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],8073.43,5499.9,8554.43,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],6875,5300,8854.4,68,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",2456.44,2456.44,2456.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],8420.88,8420.88,8420.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,6886.34,,,,,,,fee schedule,5582.63,16773.62,MSDRG Base Rate
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,6820.76,,,,,,,fee schedule,5582.63,16773.62,MSDRG Base Rate
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,6820.76,,,,,,,fee schedule,5582.63,16773.62,MSDRG Base Rate
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,6886.34,,,,,,,fee schedule,5582.63,16773.62,MSDRG Base Rate
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,6820.76,,,,,,,fee schedule,5582.63,16773.62,MSDRG Base Rate
Vaginal Delivery Without Sterilization Or D&C With Cc,806,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11477.24,,,,,,,fee schedule,5582.63,16773.62,MSDRG Base Rate
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4916.73,,,,,,,fee schedule,4916.73,14772.84,
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,4916.73,,,,,,,fee schedule,4916.73,14772.84,
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6582.24,,,,,,,fee schedule,4916.73,14772.84,
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6268.8,,,,,,,fee schedule,4916.73,14772.84,
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,10979.59,,,,,,,fee schedule,4916.73,14772.84,
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,8532.11,,,,,,,fee schedule,4916.73,14772.84,
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,14772.84,,,,,,,fee schedule,4916.73,14772.84,
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,10155.53,,,,,,,fee schedule,4916.73,14772.84,
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,9197.34,,,,,,,fee schedule,4916.73,14772.84,
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7533,,,,,,,fee schedule,4916.73,14772.84,
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],11893.5,8501.28,13936,26,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],10002.94,3458.04,11314.09,26,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],8948.79,6886.21,10357.59,103,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",2394.29,2394.29,2394.29,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],6269.78,5256.52,6269.78,23,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",2248.55,2248.55,2248.55,281,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],4301.27,4301.27,5443.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],3862.91,3862.91,3862.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],6393.19,4829.74,7534.19,45,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],6875,5465.47,8500,286,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",2227.73,2227.73,2227.73,32,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],7714.56,4780.46,23029.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,6262.91,,,,,,,fee schedule,4916.73,14772.84,MSDRG Base Rate
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,6203.27,,,,,,,fee schedule,4916.73,14772.84,MSDRG Base Rate
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,6203.27,,,,,,,fee schedule,4916.73,14772.84,MSDRG Base Rate
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,6262.91,,,,,,,fee schedule,4916.73,14772.84,MSDRG Base Rate
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,6203.27,,,,,,,fee schedule,4916.73,14772.84,MSDRG Base Rate
Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc,807,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10438.19,,,,,,,fee schedule,4916.73,14772.84,MSDRG Base Rate
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17673.07,,,,,,,fee schedule,17673.07,53100.63,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,17673.07,,,,,,,fee schedule,17673.07,53100.63,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23659.69,,,,,,,fee schedule,17673.07,53100.63,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,22533.05,,,,,,,fee schedule,17673.07,53100.63,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,39465.88,,,,,,,fee schedule,17673.07,53100.63,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,30668.46,,,,,,,fee schedule,17673.07,53100.63,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,53100.63,,,,,,,fee schedule,17673.07,53100.63,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,36503.8,,,,,,,fee schedule,17673.07,53100.63,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,33059.63,,,,,,,fee schedule,17673.07,53100.63,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27077.2,,,,,,,fee schedule,17673.07,53100.63,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],17062.57,17062.57,17450.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],34.75,34.75,34.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],19111.48,19111.48,19111.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],18112,18112,18112,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",12617.54,12617.54,12617.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],17452.99,17452.99,17452.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],122920.99,122920.99,122920.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],215680.37,215680.37,233835.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,18244.81,,,,,,,fee schedule,17673.07,53100.63,MSDRG Base Rate
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,18071.05,,,,,,,fee schedule,17673.07,53100.63,MSDRG Base Rate
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,18071.05,,,,,,,fee schedule,17673.07,53100.63,MSDRG Base Rate
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,18244.81,,,,,,,fee schedule,17673.07,53100.63,MSDRG Base Rate
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,18071.05,,,,,,,fee schedule,17673.07,53100.63,MSDRG Base Rate
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,808,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30408.02,,,,,,,fee schedule,17673.07,53100.63,MSDRG Base Rate
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9556.45,,,,,,,fee schedule,9556.45,28713.38,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,9556.45,,,,,,,fee schedule,9556.45,28713.38,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12793.63,,,,,,,fee schedule,9556.45,28713.38,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12184.41,,,,,,,fee schedule,9556.45,28713.38,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,21340.59,,,,,,,fee schedule,9556.45,28713.38,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,16583.52,,,,,,,fee schedule,9556.45,28713.38,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,28713.38,,,,,,,fee schedule,9556.45,28713.38,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,19738.89,,,,,,,fee schedule,9556.45,28713.38,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,17876.51,,,,,,,fee schedule,9556.45,28713.38,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14641.6,,,,,,,fee schedule,9556.45,28713.38,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],17649.66,10599.3,18751.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],15053,15053,15053,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",6633.41,6633.41,6633.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],13944.38,13944.38,13944.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],10041,10041,10041,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],8886.57,16.76,10523.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10885.52,,,,,,,fee schedule,9556.45,28713.38,MSDRG Base Rate
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,10781.85,,,,,,,fee schedule,9556.45,28713.38,MSDRG Base Rate
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,10781.85,,,,,,,fee schedule,9556.45,28713.38,MSDRG Base Rate
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,10885.52,,,,,,,fee schedule,9556.45,28713.38,MSDRG Base Rate
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,10781.85,,,,,,,fee schedule,9556.45,28713.38,MSDRG Base Rate
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,809,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18142.53,,,,,,,fee schedule,9556.45,28713.38,MSDRG Base Rate
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7343.46,,,,,,,fee schedule,7343.46,22064.21,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,7343.46,,,,,,,fee schedule,7343.46,22064.21,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9831,,,,,,,fee schedule,7343.46,22064.21,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9362.86,,,,,,,fee schedule,7343.46,22064.21,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,16398.74,,,,,,,fee schedule,7343.46,22064.21,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,12743.26,,,,,,,fee schedule,7343.46,22064.21,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,22064.21,,,,,,,fee schedule,7343.46,22064.21,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,15167.95,,,,,,,fee schedule,7343.46,22064.21,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,13736.84,,,,,,,fee schedule,7343.46,22064.21,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11251.04,,,,,,,fee schedule,7343.46,22064.21,
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9172.25,,,,,,,fee schedule,7343.46,22064.21,MSDRG Base Rate
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,9084.9,,,,,,,fee schedule,7343.46,22064.21,MSDRG Base Rate
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,9084.9,,,,,,,fee schedule,7343.46,22064.21,MSDRG Base Rate
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,9172.25,,,,,,,fee schedule,7343.46,22064.21,MSDRG Base Rate
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,9084.9,,,,,,,fee schedule,7343.46,22064.21,MSDRG Base Rate
Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ,810,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15287.09,,,,,,,fee schedule,7343.46,22064.21,MSDRG Base Rate
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10855.08,,,,,,,fee schedule,10855.08,32615.25,
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,10855.08,,,,,,,fee schedule,10855.08,32615.25,
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14532.16,,,,,,,fee schedule,10855.08,32615.25,
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13840.15,,,,,,,fee schedule,10855.08,32615.25,
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,24240.57,,,,,,,fee schedule,10855.08,32615.25,
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,18837.05,,,,,,,fee schedule,10855.08,32615.25,
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,32615.25,,,,,,,fee schedule,10855.08,32615.25,
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,22421.21,,,,,,,fee schedule,10855.08,32615.25,
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,20305.75,,,,,,,fee schedule,10855.08,32615.25,
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16631.25,,,,,,,fee schedule,10855.08,32615.25,
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],32617.57,32617.57,32617.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9291.44,8873.29,10620.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],23104.71,23104.71,23104.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],10779.74,10779.74,10779.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",6295.95,6295.95,6295.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],9015.28,9015.28,9015.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],10724.7,9015.28,10838.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],16502.43,16502.43,16502.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],22216.03,22216.03,24041.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],9517.6,5633.08,10873.56,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11966.76,,,,,,,fee schedule,10855.08,32615.25,MSDRG Base Rate
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,11852.79,,,,,,,fee schedule,10855.08,32615.25,MSDRG Base Rate
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,11852.79,,,,,,,fee schedule,10855.08,32615.25,MSDRG Base Rate
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,11966.76,,,,,,,fee schedule,10855.08,32615.25,MSDRG Base Rate
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,11852.79,,,,,,,fee schedule,10855.08,32615.25,MSDRG Base Rate
Red Blood Cell Disorders With Mcc,811,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19944.59,,,,,,,fee schedule,10855.08,32615.25,MSDRG Base Rate
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7121.23,,,,,,,fee schedule,7121.23,21396.51,
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,7121.23,,,,,,,fee schedule,7121.23,21396.51,
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9533.5,,,,,,,fee schedule,7121.23,21396.51,
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9079.53,,,,,,,fee schedule,7121.23,21396.51,
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,15902.49,,,,,,,fee schedule,7121.23,21396.51,
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,12357.63,,,,,,,fee schedule,7121.23,21396.51,
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,21396.51,,,,,,,fee schedule,7121.23,21396.51,
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,14708.94,,,,,,,fee schedule,7121.23,21396.51,
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,13321.14,,,,,,,fee schedule,7121.23,21396.51,
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10910.56,,,,,,,fee schedule,7121.23,21396.51,
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],13652,13652,13652,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],13973.49,11142,14708.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],282.49,282.49,282.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4269.24,4269.24,4269.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],9077.53,9077.53,9077.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4009.37,4009.37,6991.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],5348.82,5310.26,6882.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],15106.07,15106.07,15106.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],5829,910.77,7371.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8169.15,,,,,,,fee schedule,7121.23,21396.51,MSDRG Base Rate
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,8091.35,,,,,,,fee schedule,7121.23,21396.51,MSDRG Base Rate
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,8091.35,,,,,,,fee schedule,7121.23,21396.51,MSDRG Base Rate
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,8169.15,,,,,,,fee schedule,7121.23,21396.51,MSDRG Base Rate
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,8091.35,,,,,,,fee schedule,7121.23,21396.51,MSDRG Base Rate
Red Blood Cell Disorders Without Mcc,812,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,13615.24,,,,,,,fee schedule,7121.23,21396.51,MSDRG Base Rate
Coagulation Disorders,813,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11943.83,,,,,,,fee schedule,11943.83,35886.51,
Coagulation Disorders,813,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,11943.83,,,,,,,fee schedule,11943.83,35886.51,
Coagulation Disorders,813,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15989.71,,,,,,,fee schedule,11943.83,35886.51,
Coagulation Disorders,813,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15228.3,,,,,,,fee schedule,11943.83,35886.51,
Coagulation Disorders,813,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,26671.86,,,,,,,fee schedule,11943.83,35886.51,
Coagulation Disorders,813,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,20726.38,,,,,,,fee schedule,11943.83,35886.51,
Coagulation Disorders,813,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,35886.51,,,,,,,fee schedule,11943.83,35886.51,
Coagulation Disorders,813,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,24670.03,,,,,,,fee schedule,11943.83,35886.51,
Coagulation Disorders,813,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,22342.39,,,,,,,fee schedule,11943.83,35886.51,
Coagulation Disorders,813,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18299.34,,,,,,,fee schedule,11943.83,35886.51,
Coagulation Disorders,813,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],31579.98,31579.98,31579.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Coagulation Disorders,813,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],10443.03,10443.03,10443.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Coagulation Disorders,813,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11925.53,11897.53,24225.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Coagulation Disorders,813,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],24651.62,24651.62,24651.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Coagulation Disorders,813,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11428.83,11428.83,11428.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Coagulation Disorders,813,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Coagulation Disorders,813,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Coagulation Disorders,813,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],73862.57,73862.57,73862.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Coagulation Disorders,813,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4623.25,4623.25,4623.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Coagulation Disorders,813,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],11726.65,11726.65,11726.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Coagulation Disorders,813,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11726.65,10773.64,11865.42,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Coagulation Disorders,813,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],4623.25,4623.25,4623.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Coagulation Disorders,813,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Coagulation Disorders,813,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],25807.31,23752.63,26673.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Coagulation Disorders,813,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],11177.79,7848.5,12631.9,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Coagulation Disorders,813,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4580.45,4580.45,4580.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Coagulation Disorders,813,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coagulation Disorders,813,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Coagulation Disorders,813,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12912.06,,,,,,,fee schedule,11943.83,35886.51,MSDRG Base Rate
Coagulation Disorders,813,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,12789.09,,,,,,,fee schedule,11943.83,35886.51,MSDRG Base Rate
Coagulation Disorders,813,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,12789.09,,,,,,,fee schedule,11943.83,35886.51,MSDRG Base Rate
Coagulation Disorders,813,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,12912.06,,,,,,,fee schedule,11943.83,35886.51,MSDRG Base Rate
Coagulation Disorders,813,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,12789.09,,,,,,,fee schedule,11943.83,35886.51,MSDRG Base Rate
Coagulation Disorders,813,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21520.1,,,,,,,fee schedule,11943.83,35886.51,MSDRG Base Rate
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16129.07,,,,,,,fee schedule,16129.07,48461.52,
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,16129.07,,,,,,,fee schedule,16129.07,48461.52,
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21592.67,,,,,,,fee schedule,16129.07,48461.52,
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20564.46,,,,,,,fee schedule,16129.07,48461.52,
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,36017.96,,,,,,,fee schedule,16129.07,48461.52,
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,27989.12,,,,,,,fee schedule,16129.07,48461.52,
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,48461.52,,,,,,,fee schedule,16129.07,48461.52,
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,33314.66,,,,,,,fee schedule,16129.07,48461.52,
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,30171.39,,,,,,,fee schedule,16129.07,48461.52,
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24711.61,,,,,,,fee schedule,16129.07,48461.52,
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],22906.59,22906.59,22906.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],14760.17,14760.17,14760.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],23498.01,23498.01,23498.01,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12000.08,12000.08,12000.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],17522.2,17522.2,17522.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],15839.52,15839.52,15839.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,17610.44,,,,,,,fee schedule,16129.07,48461.52,MSDRG Base Rate
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,17442.72,,,,,,,fee schedule,16129.07,48461.52,MSDRG Base Rate
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,17442.72,,,,,,,fee schedule,16129.07,48461.52,MSDRG Base Rate
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,17610.44,,,,,,,fee schedule,16129.07,48461.52,MSDRG Base Rate
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,17442.72,,,,,,,fee schedule,16129.07,48461.52,MSDRG Base Rate
Reticuloendothelial And Immunity Disorders With Mcc,814,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,29350.74,,,,,,,fee schedule,16129.07,48461.52,MSDRG Base Rate
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7840.38,,,,,,,fee schedule,7840.38,23557.26,
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,7840.38,,,,,,,fee schedule,7840.38,23557.26,
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10496.25,,,,,,,fee schedule,7840.38,23557.26,
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9996.43,,,,,,,fee schedule,7840.38,23557.26,
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,17508.42,,,,,,,fee schedule,7840.38,23557.26,
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,13605.58,,,,,,,fee schedule,7840.38,23557.26,
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,23557.26,,,,,,,fee schedule,7840.38,23557.26,
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,16194.34,,,,,,,fee schedule,7840.38,23557.26,
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,14666.39,,,,,,,fee schedule,7840.38,23557.26,
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12012.37,,,,,,,fee schedule,7840.38,23557.26,
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],8129.66,8129.66,8129.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8037.5,8037.5,8037.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],16194.34,16194.34,16194.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13.75,13.75,13.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",5325.26,5325.26,5325.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],17508.42,17508.42,17508.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8917.58,,,,,,,fee schedule,7840.38,23557.26,MSDRG Base Rate
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,8832.65,,,,,,,fee schedule,7840.38,23557.26,MSDRG Base Rate
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,8832.65,,,,,,,fee schedule,7840.38,23557.26,MSDRG Base Rate
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,8917.58,,,,,,,fee schedule,7840.38,23557.26,MSDRG Base Rate
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,8832.65,,,,,,,fee schedule,7840.38,23557.26,MSDRG Base Rate
Reticuloendothelial And Immunity Disorders With Cc,815,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14862.63,,,,,,,fee schedule,7840.38,23557.26,MSDRG Base Rate
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5088.03,,,,,,,fee schedule,5088.03,15287.53,
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,5088.03,,,,,,,fee schedule,5088.03,15287.53,
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6811.56,,,,,,,fee schedule,5088.03,15287.53,
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6487.2,,,,,,,fee schedule,5088.03,15287.53,
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,11362.12,,,,,,,fee schedule,5088.03,15287.53,
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,8829.37,,,,,,,fee schedule,5088.03,15287.53,
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,15287.53,,,,,,,fee schedule,5088.03,15287.53,
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,10509.35,,,,,,,fee schedule,5088.03,15287.53,
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,9517.78,,,,,,,fee schedule,5088.03,15287.53,
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7795.45,,,,,,,fee schedule,5088.03,15287.53,
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],9887.52,9887.52,9887.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,5933.24,,,,,,,fee schedule,5088.03,15287.53,MSDRG Base Rate
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,5876.73,,,,,,,fee schedule,5088.03,15287.53,MSDRG Base Rate
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,5876.73,,,,,,,fee schedule,5088.03,15287.53,MSDRG Base Rate
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,5933.24,,,,,,,fee schedule,5088.03,15287.53,MSDRG Base Rate
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,5876.73,,,,,,,fee schedule,5088.03,15287.53,MSDRG Base Rate
Reticuloendothelial And Immunity Disorders Without Cc/Mcc,816,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9888.72,,,,,,,fee schedule,5088.03,15287.53,MSDRG Base Rate
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,19561.21,,,,,,,fee schedule,18641.33,58773.76,
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,19561.21,,,,,,,fee schedule,18641.33,58773.76,
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26187.43,,,,,,,fee schedule,18641.33,58773.76,
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24940.42,,,,,,,fee schedule,18641.33,58773.76,
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,43682.31,,,,,,,fee schedule,18641.33,58773.76,
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,33944.99,,,,,,,fee schedule,18641.33,58773.76,
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,58773.76,,,,,,,fee schedule,18641.33,58773.76,
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,40403.76,,,,,,,fee schedule,18641.33,58773.76,
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,36591.63,,,,,,,fee schedule,18641.33,58773.76,
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,29970.05,,,,,,,fee schedule,18641.33,58773.76,
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],34838.31,34838.31,34838.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",6113.67,6113.67,6113.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],43682.31,43682.31,43682.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,18820.58,,,,,,,fee schedule,18641.33,58773.76,MSDRG Base Rate
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,18641.33,,,,,,,fee schedule,18641.33,58773.76,MSDRG Base Rate
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,18641.33,,,,,,,fee schedule,18641.33,58773.76,MSDRG Base Rate
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,18820.58,,,,,,,fee schedule,18641.33,58773.76,MSDRG Base Rate
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,18641.33,,,,,,,fee schedule,18641.33,58773.76,MSDRG Base Rate
Other Antepartum Diagnoses With O.R. Procedures With Mcc,817,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31367.63,,,,,,,fee schedule,18641.33,58773.76,MSDRG Base Rate
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9938.4,,,,,,,fee schedule,9938.4,29860.99,
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,9938.4,,,,,,,fee schedule,9938.4,29860.99,
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13304.96,,,,,,,fee schedule,9938.4,29860.99,
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12671.4,,,,,,,fee schedule,9938.4,29860.99,
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,22193.53,,,,,,,fee schedule,9938.4,29860.99,
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,17246.32,,,,,,,fee schedule,9938.4,29860.99,
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,29860.99,,,,,,,fee schedule,9938.4,29860.99,
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,20527.81,,,,,,,fee schedule,9938.4,29860.99,
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,18590.99,,,,,,,fee schedule,9938.4,29860.99,
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15226.79,,,,,,,fee schedule,9938.4,29860.99,
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4879.89,4879.89,6113.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],8570,8570,8570,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10051.93,,,,,,,fee schedule,9938.4,29860.99,MSDRG Base Rate
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,9956.2,,,,,,,fee schedule,9938.4,29860.99,MSDRG Base Rate
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,9956.2,,,,,,,fee schedule,9938.4,29860.99,MSDRG Base Rate
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,10051.93,,,,,,,fee schedule,9938.4,29860.99,MSDRG Base Rate
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,9956.2,,,,,,,fee schedule,9938.4,29860.99,MSDRG Base Rate
Other Antepartum Diagnoses With O.R. Procedures With Cc,818,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16753.22,,,,,,,fee schedule,9938.4,29860.99,MSDRG Base Rate
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6300.24,,,,,,,fee schedule,6300.24,18929.74,
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,6300.24,,,,,,,fee schedule,6300.24,18929.74,
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8434.4,,,,,,,fee schedule,6300.24,18929.74,
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8032.76,,,,,,,fee schedule,6300.24,18929.74,
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,14069.11,,,,,,,fee schedule,6300.24,18929.74,
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,10932.94,,,,,,,fee schedule,6300.24,18929.74,
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,18929.74,,,,,,,fee schedule,6300.24,18929.74,
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,13013.16,,,,,,,fee schedule,6300.24,18929.74,
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,11785.36,,,,,,,fee schedule,6300.24,18929.74,
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9652.7,,,,,,,fee schedule,6300.24,18929.74,
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],10226.13,10226.13,10226.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4113.4,4113.4,4113.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7713.68,,,,,,,fee schedule,6300.24,18929.74,MSDRG Base Rate
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,7640.21,,,,,,,fee schedule,6300.24,18929.74,MSDRG Base Rate
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,7640.21,,,,,,,fee schedule,6300.24,18929.74,MSDRG Base Rate
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,7713.68,,,,,,,fee schedule,6300.24,18929.74,MSDRG Base Rate
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,7640.21,,,,,,,fee schedule,6300.24,18929.74,MSDRG Base Rate
Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc,819,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12856.13,,,,,,,fee schedule,6300.24,18929.74,MSDRG Base Rate
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,44922.65,,,,,,,fee schedule,44922.65,134974.93,
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,44922.65,,,,,,,fee schedule,44922.65,134974.93,
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,60139.88,,,,,,,fee schedule,44922.65,134974.93,
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,57276.09,,,,,,,fee schedule,44922.65,134974.93,
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,100317.16,,,,,,,fee schedule,44922.65,134974.93,
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,77955.24,,,,,,,fee schedule,44922.65,134974.93,
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,134974.93,,,,,,,fee schedule,44922.65,134974.93,
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,92787.93,,,,,,,fee schedule,44922.65,134974.93,
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,84033.3,,,,,,,fee schedule,44922.65,134974.93,
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,68826.73,,,,,,,fee schedule,44922.65,134974.93,
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],48081.87,48081.87,48081.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],41027.8,41027.8,41027.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,46814.01,,,,,,,fee schedule,44922.65,134974.93,MSDRG Base Rate
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,46368.16,,,,,,,fee schedule,44922.65,134974.93,MSDRG Base Rate
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,46368.16,,,,,,,fee schedule,44922.65,134974.93,MSDRG Base Rate
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,46814.01,,,,,,,fee schedule,44922.65,134974.93,MSDRG Base Rate
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,46368.16,,,,,,,fee schedule,44922.65,134974.93,MSDRG Base Rate
Lymphoma And Leukemia With Major O.R. Procedures With Mcc,820,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,78023.35,,,,,,,fee schedule,44922.65,134974.93,MSDRG Base Rate
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,17223.99,,,,,,,fee schedule,17223.99,51751.32,
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,17223.99,,,,,,,fee schedule,17223.99,51751.32,
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,23058.49,,,,,,,fee schedule,17223.99,51751.32,
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21960.47,,,,,,,fee schedule,17223.99,51751.32,
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,38463.04,,,,,,,fee schedule,17223.99,51751.32,
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,29889.16,,,,,,,fee schedule,17223.99,51751.32,
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,51751.32,,,,,,,fee schedule,17223.99,51751.32,
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,35576.22,,,,,,,fee schedule,17223.99,51751.32,
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,32219.57,,,,,,,fee schedule,17223.99,51751.32,
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26389.16,,,,,,,fee schedule,17223.99,51751.32,
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,18484.65,,,,,,,fee schedule,17223.99,51751.32,MSDRG Base Rate
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,18308.61,,,,,,,fee schedule,17223.99,51751.32,MSDRG Base Rate
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,18308.61,,,,,,,fee schedule,17223.99,51751.32,MSDRG Base Rate
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,18484.65,,,,,,,fee schedule,17223.99,51751.32,MSDRG Base Rate
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,18308.61,,,,,,,fee schedule,17223.99,51751.32,MSDRG Base Rate
Lymphoma And Leukemia With Major O.R. Procedures With Cc,821,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30807.75,,,,,,,fee schedule,17223.99,51751.32,MSDRG Base Rate
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8824.19,,,,,,,fee schedule,8824.19,26513.22,
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,8824.19,,,,,,,fee schedule,8824.19,26513.22,
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11813.32,,,,,,,fee schedule,8824.19,26513.22,
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11250.78,,,,,,,fee schedule,8824.19,26513.22,
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,19705.37,,,,,,,fee schedule,8824.19,26513.22,
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,15312.8,,,,,,,fee schedule,8824.19,26513.22,
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,26513.22,,,,,,,fee schedule,8824.19,26513.22,
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,18226.4,,,,,,,fee schedule,8824.19,26513.22,
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,16506.72,,,,,,,fee schedule,8824.19,26513.22,
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13519.68,,,,,,,fee schedule,8824.19,26513.22,
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10401.93,,,,,,,fee schedule,8824.19,26513.22,MSDRG Base Rate
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,10302.86,,,,,,,fee schedule,8824.19,26513.22,MSDRG Base Rate
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,10302.86,,,,,,,fee schedule,8824.19,26513.22,MSDRG Base Rate
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,10401.93,,,,,,,fee schedule,8824.19,26513.22,MSDRG Base Rate
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,10302.86,,,,,,,fee schedule,8824.19,26513.22,MSDRG Base Rate
Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc,822,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,17336.55,,,,,,,fee schedule,8824.19,26513.22,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36105.41,,,,,,,fee schedule,36105.41,108482.57,
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,36105.41,,,,,,,fee schedule,36105.41,108482.57,
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,48335.86,,,,,,,fee schedule,36105.41,108482.57,
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,46034.16,,,,,,,fee schedule,36105.41,108482.57,
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,80627.3,,,,,,,fee schedule,36105.41,108482.57,
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,62654.49,,,,,,,fee schedule,36105.41,108482.57,
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,108482.57,,,,,,,fee schedule,36105.41,108482.57,
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,74575.87,,,,,,,fee schedule,36105.41,108482.57,
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,67539.57,,,,,,,fee schedule,36105.41,108482.57,
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,55317.69,,,,,,,fee schedule,36105.41,108482.57,
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],31790.79,31790.79,31790.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",75194.6,75194.6,75194.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],34462.12,34462.12,34462.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],34713.42,34713.42,34713.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,36814.12,,,,,,,fee schedule,36105.41,108482.57,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,36463.51,,,,,,,fee schedule,36105.41,108482.57,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,36463.51,,,,,,,fee schedule,36105.41,108482.57,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,36814.12,,,,,,,fee schedule,36105.41,108482.57,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,36463.51,,,,,,,fee schedule,36105.41,108482.57,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc,823,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,61356.87,,,,,,,fee schedule,36105.41,108482.57,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16970.13,,,,,,,fee schedule,16970.13,50988.57,
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,16970.13,,,,,,,fee schedule,16970.13,50988.57,
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22718.64,,,,,,,fee schedule,16970.13,50988.57,
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21636.8,,,,,,,fee schedule,16970.13,50988.57,
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,37896.14,,,,,,,fee schedule,16970.13,50988.57,
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,29448.63,,,,,,,fee schedule,16970.13,50988.57,
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,50988.57,,,,,,,fee schedule,16970.13,50988.57,
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,35051.87,,,,,,,fee schedule,16970.13,50988.57,
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,31744.7,,,,,,,fee schedule,16970.13,50988.57,
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,26000.21,,,,,,,fee schedule,16970.13,50988.57,
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],16137.23,16137.23,16137.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,18695.59,,,,,,,fee schedule,16970.13,50988.57,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,18517.53,,,,,,,fee schedule,16970.13,50988.57,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,18517.53,,,,,,,fee schedule,16970.13,50988.57,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,18695.59,,,,,,,fee schedule,16970.13,50988.57,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,18517.53,,,,,,,fee schedule,16970.13,50988.57,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Other Procedures With Cc,824,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31159.31,,,,,,,fee schedule,16970.13,50988.57,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9496.27,,,,,,,fee schedule,9496.27,28532.55,
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,9496.27,,,,,,,fee schedule,9496.27,28532.55,
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12713.06,,,,,,,fee schedule,9496.27,28532.55,
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12107.68,,,,,,,fee schedule,9496.27,28532.55,
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,21206.19,,,,,,,fee schedule,9496.27,28532.55,
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,16479.07,,,,,,,fee schedule,9496.27,28532.55,
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,28532.55,,,,,,,fee schedule,9496.27,28532.55,
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,19614.58,,,,,,,fee schedule,9496.27,28532.55,
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,17763.92,,,,,,,fee schedule,9496.27,28532.55,
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14549.38,,,,,,,fee schedule,9496.27,28532.55,
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],19616.17,19616.17,19616.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],13857.69,13857.69,13857.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11537.85,,,,,,,fee schedule,9496.27,28532.55,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,11427.97,,,,,,,fee schedule,9496.27,28532.55,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,11427.97,,,,,,,fee schedule,9496.27,28532.55,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,11537.85,,,,,,,fee schedule,9496.27,28532.55,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,11427.97,,,,,,,fee schedule,9496.27,28532.55,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc,825,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19229.75,,,,,,,fee schedule,9496.27,28532.55,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36846.16,,,,,,,fee schedule,36846.16,110708.24,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,36846.16,,,,,,,fee schedule,36846.16,110708.24,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,49327.53,,,,,,,fee schedule,36846.16,110708.24,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,46978.61,,,,,,,fee schedule,36846.16,110708.24,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,82281.47,,,,,,,fee schedule,36846.16,110708.24,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,63939.93,,,,,,,fee schedule,36846.16,110708.24,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,110708.24,,,,,,,fee schedule,36846.16,110708.24,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,76105.9,,,,,,,fee schedule,36846.16,110708.24,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,68925.24,,,,,,,fee schedule,36846.16,110708.24,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,56452.61,,,,,,,fee schedule,36846.16,110708.24,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],83264.84,83264.84,83264.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],35319.77,35319.77,35319.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,37540.68,,,,,,,fee schedule,36846.16,110708.24,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,37183.15,,,,,,,fee schedule,36846.16,110708.24,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,37183.15,,,,,,,fee schedule,36846.16,110708.24,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,37540.68,,,,,,,fee schedule,36846.16,110708.24,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,37183.15,,,,,,,fee schedule,36846.16,110708.24,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc,826,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,62567.8,,,,,,,fee schedule,36846.16,110708.24,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18207.8,,,,,,,fee schedule,18207.8,54707.28,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,18207.8,,,,,,,fee schedule,18207.8,54707.28,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,24375.56,,,,,,,fee schedule,18207.8,54707.28,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,23214.82,,,,,,,fee schedule,18207.8,54707.28,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,40659.99,,,,,,,fee schedule,18207.8,54707.28,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,31596.38,,,,,,,fee schedule,18207.8,54707.28,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,54707.28,,,,,,,fee schedule,18207.8,54707.28,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,37608.29,,,,,,,fee schedule,18207.8,54707.28,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,34059.91,,,,,,,fee schedule,18207.8,54707.28,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,27896.47,,,,,,,fee schedule,18207.8,54707.28,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,19051.83,,,,,,,fee schedule,18207.8,54707.28,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,18870.38,,,,,,,fee schedule,18207.8,54707.28,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,18870.38,,,,,,,fee schedule,18207.8,54707.28,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,19051.83,,,,,,,fee schedule,18207.8,54707.28,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,18870.38,,,,,,,fee schedule,18207.8,54707.28,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc,827,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,31753.05,,,,,,,fee schedule,18207.8,54707.28,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12367.45,,,,,,,fee schedule,12367.45,37159.32,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,12367.45,,,,,,,fee schedule,12367.45,37159.32,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16556.83,,,,,,,fee schedule,12367.45,37159.32,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15768.41,,,,,,,fee schedule,12367.45,37159.32,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,27617.85,,,,,,,fee schedule,12367.45,37159.32,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,21461.49,,,,,,,fee schedule,12367.45,37159.32,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,37159.32,,,,,,,fee schedule,12367.45,37159.32,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,25545.01,,,,,,,fee schedule,12367.45,37159.32,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,23134.82,,,,,,,fee schedule,12367.45,37159.32,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18948.37,,,,,,,fee schedule,12367.45,37159.32,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",9637.04,9637.04,9637.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14306.58,,,,,,,fee schedule,12367.45,37159.32,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,14170.32,,,,,,,fee schedule,12367.45,37159.32,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,14170.32,,,,,,,fee schedule,12367.45,37159.32,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,14306.58,,,,,,,fee schedule,12367.45,37159.32,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,14170.32,,,,,,,fee schedule,12367.45,37159.32,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C,828,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23844.29,,,,,,,fee schedule,12367.45,37159.32,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,23793.52,,,,,,,fee schedule,23793.52,71490.18,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,23793.52,,,,,,,fee schedule,23793.52,71490.18,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,31853.4,,,,,,,fee schedule,23793.52,71490.18,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,30336.58,,,,,,,fee schedule,23793.52,71490.18,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,53133.51,,,,,,,fee schedule,23793.52,71490.18,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,41289.4,,,,,,,fee schedule,23793.52,71490.18,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,71490.18,,,,,,,fee schedule,23793.52,71490.18,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,49145.62,,,,,,,fee schedule,23793.52,71490.18,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,44508.68,,,,,,,fee schedule,23793.52,71490.18,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,36454.44,,,,,,,fee schedule,23793.52,71490.18,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],91095.66,91095.66,131123.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],22950.65,22950.65,22950.65,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],36456.81,36456.81,36456.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],53136.96,53136.96,53136.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],22221.48,22221.48,22221.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,25683,,,,,,,fee schedule,23793.52,71490.18,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,25438.4,,,,,,,fee schedule,23793.52,71490.18,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,25438.4,,,,,,,fee schedule,23793.52,71490.18,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,25683,,,,,,,fee schedule,23793.52,71490.18,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,25438.4,,,,,,,fee schedule,23793.52,71490.18,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc,829,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,42805,,,,,,,fee schedule,23793.52,71490.18,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11284.1,,,,,,,fee schedule,11284.1,33904.28,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,11284.1,,,,,,,fee schedule,11284.1,33904.28,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15106.5,,,,,,,fee schedule,11284.1,33904.28,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14387.15,,,,,,,fee schedule,11284.1,33904.28,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,25198.61,,,,,,,fee schedule,11284.1,33904.28,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,19581.54,,,,,,,fee schedule,11284.1,33904.28,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,33904.28,,,,,,,fee schedule,11284.1,33904.28,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,23307.35,,,,,,,fee schedule,11284.1,33904.28,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,21108.28,,,,,,,fee schedule,11284.1,33904.28,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17288.55,,,,,,,fee schedule,11284.1,33904.28,
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12753.47,,,,,,,fee schedule,11284.1,33904.28,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,12632.01,,,,,,,fee schedule,11284.1,33904.28,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,12632.01,,,,,,,fee schedule,11284.1,33904.28,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,12753.47,,,,,,,fee schedule,11284.1,33904.28,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,12632.01,,,,,,,fee schedule,11284.1,33904.28,MSDRG Base Rate
Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc,830,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21255.78,,,,,,,fee schedule,11284.1,33904.28,MSDRG Base Rate
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8880.52,,,,,,,fee schedule,8880.52,26682.47,
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,8880.52,,,,,,,fee schedule,8880.52,26682.47,
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11888.73,,,,,,,fee schedule,8880.52,26682.47,
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11322.6,,,,,,,fee schedule,8880.52,26682.47,
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,19831.16,,,,,,,fee schedule,8880.52,26682.47,
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,15410.55,,,,,,,fee schedule,8880.52,26682.47,
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,26682.47,,,,,,,fee schedule,8880.52,26682.47,
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,18342.74,,,,,,,fee schedule,8880.52,26682.47,
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,16612.09,,,,,,,fee schedule,8880.52,26682.47,
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13605.99,,,,,,,fee schedule,8880.52,26682.47,
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],5945,5945,5945,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],18344.34,14656,21656.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8082.3,8082.3,8082.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4042.04,4042.04,4042.04,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],19832.88,19832.88,19832.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4004.61,4004.61,4004.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10390.21,,,,,,,fee schedule,8880.52,26682.47,MSDRG Base Rate
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,10291.26,,,,,,,fee schedule,8880.52,26682.47,MSDRG Base Rate
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,10291.26,,,,,,,fee schedule,8880.52,26682.47,MSDRG Base Rate
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,10390.21,,,,,,,fee schedule,8880.52,26682.47,MSDRG Base Rate
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,10291.26,,,,,,,fee schedule,8880.52,26682.47,MSDRG Base Rate
Other Antepartum Diagnoses Without O.R. Procedures With Mcc,831,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,17317.02,,,,,,,fee schedule,8880.52,26682.47,MSDRG Base Rate
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5766.28,,,,,,,fee schedule,5766.28,17325.4,
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,5766.28,,,,,,,fee schedule,5766.28,17325.4,
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7719.56,,,,,,,fee schedule,5766.28,17325.4,
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7351.97,,,,,,,fee schedule,5766.28,17325.4,
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,12876.73,,,,,,,fee schedule,5766.28,17325.4,
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,10006.35,,,,,,,fee schedule,5766.28,17325.4,
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,17325.4,,,,,,,fee schedule,5766.28,17325.4,
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,11910.27,,,,,,,fee schedule,5766.28,17325.4,
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,10786.53,,,,,,,fee schedule,5766.28,17325.4,
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8834.61,,,,,,,fee schedule,5766.28,17325.4,
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],6037.6,3826.2,11911.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],3734.23,3734.23,5797,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",2955.03,2955.03,2955.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",2775.16,2775.16,2887.77,28,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],7202.95,7202.95,7202.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],8835.79,8835.79,8835.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],6915.16,4537,12878.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",2749.46,2749.46,2749.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],11911.2,11911.2,11911.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,6633.23,,,,,,,fee schedule,5766.28,17325.4,MSDRG Base Rate
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,6570.05,,,,,,,fee schedule,5766.28,17325.4,MSDRG Base Rate
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,6570.05,,,,,,,fee schedule,5766.28,17325.4,MSDRG Base Rate
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,6633.23,,,,,,,fee schedule,5766.28,17325.4,MSDRG Base Rate
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,6570.05,,,,,,,fee schedule,5766.28,17325.4,MSDRG Base Rate
Other Antepartum Diagnoses Without O.R. Procedures With Cc,832,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11055.38,,,,,,,fee schedule,5766.28,17325.4,MSDRG Base Rate
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4010.85,,,,,,,fee schedule,4010.85,12051.04,
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,4010.85,,,,,,,fee schedule,4010.85,12051.04,
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5369.5,,,,,,,fee schedule,4010.85,12051.04,
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5113.81,,,,,,,fee schedule,4010.85,12051.04,
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,8956.67,,,,,,,fee schedule,4010.85,12051.04,
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,6960.12,,,,,,,fee schedule,4010.85,12051.04,
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,12051.04,,,,,,,fee schedule,4010.85,12051.04,
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,8284.44,,,,,,,fee schedule,4010.85,12051.04,
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,7502.79,,,,,,,fee schedule,4010.85,12051.04,
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6145.1,,,,,,,fee schedule,4010.85,12051.04,
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],6928.54,6911.16,8143,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],6762.65,6518.26,7502.79,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",2076.59,2076.59,2076.59,30,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],4314.82,4314.82,4314.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],3792.27,3792.27,3792.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],4513.66,1956.04,8721.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,5080.9,,,,,,,fee schedule,4010.85,12051.04,MSDRG Base Rate
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,5032.51,,,,,,,fee schedule,4010.85,12051.04,MSDRG Base Rate
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,5032.51,,,,,,,fee schedule,4010.85,12051.04,MSDRG Base Rate
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,5080.9,,,,,,,fee schedule,4010.85,12051.04,MSDRG Base Rate
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,5032.51,,,,,,,fee schedule,4010.85,12051.04,MSDRG Base Rate
Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc,833,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8468.16,,,,,,,fee schedule,4010.85,12051.04,MSDRG Base Rate
Acute Leukemia With Mcc,834,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,42646.39,,,,,,,fee schedule,42646.39,128135.65,
Acute Leukemia With Mcc,834,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,42646.39,,,,,,,fee schedule,42646.39,128135.65,
Acute Leukemia With Mcc,834,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,57092.55,,,,,,,fee schedule,42646.39,128135.65,
Acute Leukemia With Mcc,834,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,54373.86,,,,,,,fee schedule,42646.39,128135.65,
Acute Leukemia With Mcc,834,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,95234.01,,,,,,,fee schedule,42646.39,128135.65,
Acute Leukemia With Mcc,834,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,74005.19,,,,,,,fee schedule,42646.39,128135.65,
Acute Leukemia With Mcc,834,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,128135.65,,,,,,,fee schedule,42646.39,128135.65,
Acute Leukemia With Mcc,834,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,88086.3,,,,,,,fee schedule,42646.39,128135.65,
Acute Leukemia With Mcc,834,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,79775.27,,,,,,,fee schedule,42646.39,128135.65,
Acute Leukemia With Mcc,834,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,65339.23,,,,,,,fee schedule,42646.39,128135.65,
Acute Leukemia With Mcc,834,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Mcc,834,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Mcc,834,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],281363.24,281363.24,281363.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Acute Leukemia With Mcc,834,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Mcc,834,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Mcc,834,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Mcc,834,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Mcc,834,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],41890.29,41136.4,42087.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Acute Leukemia With Mcc,834,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Mcc,834,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Mcc,834,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Mcc,834,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Mcc,834,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Mcc,834,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],102948,102948,102948,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Acute Leukemia With Mcc,834,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],40328.85,38789.88,40878.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Acute Leukemia With Mcc,834,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Mcc,834,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Mcc,834,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Mcc,834,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,43885.14,,,,,,,fee schedule,42646.39,128135.65,MSDRG Base Rate
Acute Leukemia With Mcc,834,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,43467.18,,,,,,,fee schedule,42646.39,128135.65,MSDRG Base Rate
Acute Leukemia With Mcc,834,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,43467.18,,,,,,,fee schedule,42646.39,128135.65,MSDRG Base Rate
Acute Leukemia With Mcc,834,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,43885.14,,,,,,,fee schedule,42646.39,128135.65,MSDRG Base Rate
Acute Leukemia With Mcc,834,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,43467.18,,,,,,,fee schedule,42646.39,128135.65,MSDRG Base Rate
Acute Leukemia With Mcc,834,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,73141.9,,,,,,,fee schedule,42646.39,128135.65,MSDRG Base Rate
Acute Leukemia With Cc,835,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16480.15,,,,,,,fee schedule,16480.15,49516.39,
Acute Leukemia With Cc,835,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,16480.15,,,,,,,fee schedule,16480.15,49516.39,
Acute Leukemia With Cc,835,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22062.69,,,,,,,fee schedule,16480.15,49516.39,
Acute Leukemia With Cc,835,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21012.09,,,,,,,fee schedule,16480.15,49516.39,
Acute Leukemia With Cc,835,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,36801.97,,,,,,,fee schedule,16480.15,49516.39,
Acute Leukemia With Cc,835,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,28598.36,,,,,,,fee schedule,16480.15,49516.39,
Acute Leukemia With Cc,835,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,49516.39,,,,,,,fee schedule,16480.15,49516.39,
Acute Leukemia With Cc,835,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,34039.83,,,,,,,fee schedule,16480.15,49516.39,
Acute Leukemia With Cc,835,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,30828.14,,,,,,,fee schedule,16480.15,49516.39,
Acute Leukemia With Cc,835,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,25249.51,,,,,,,fee schedule,16480.15,49516.39,
Acute Leukemia With Cc,835,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Cc,835,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Cc,835,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Cc,835,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Cc,835,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Cc,835,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Cc,835,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Cc,835,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",25879.95,25879.95,25879.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Acute Leukemia With Cc,835,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Cc,835,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Cc,835,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Cc,835,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Cc,835,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Cc,835,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],13248.47,13248.47,13248.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Acute Leukemia With Cc,835,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Cc,835,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Cc,835,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Cc,835,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Cc,835,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,17290.92,,,,,,,fee schedule,16480.15,49516.39,MSDRG Base Rate
Acute Leukemia With Cc,835,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,17126.24,,,,,,,fee schedule,16480.15,49516.39,MSDRG Base Rate
Acute Leukemia With Cc,835,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,17126.24,,,,,,,fee schedule,16480.15,49516.39,MSDRG Base Rate
Acute Leukemia With Cc,835,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,17290.92,,,,,,,fee schedule,16480.15,49516.39,MSDRG Base Rate
Acute Leukemia With Cc,835,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,17126.24,,,,,,,fee schedule,16480.15,49516.39,MSDRG Base Rate
Acute Leukemia With Cc,835,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,28818.2,,,,,,,fee schedule,16480.15,49516.39,MSDRG Base Rate
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9804.91,,,,,,,fee schedule,9804.91,29459.91,
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,9804.91,,,,,,,fee schedule,9804.91,29459.91,
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13126.25,,,,,,,fee schedule,9804.91,29459.91,
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12501.2,,,,,,,fee schedule,9804.91,29459.91,
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,21895.43,,,,,,,fee schedule,9804.91,29459.91,
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,17014.67,,,,,,,fee schedule,9804.91,29459.91,
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,29459.91,,,,,,,fee schedule,9804.91,29459.91,
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,20252.09,,,,,,,fee schedule,9804.91,29459.91,
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,18341.28,,,,,,,fee schedule,9804.91,29459.91,
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15022.27,,,,,,,fee schedule,9804.91,29459.91,
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10523.03,,,,,,,fee schedule,9804.91,29459.91,MSDRG Base Rate
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,10422.81,,,,,,,fee schedule,9804.91,29459.91,MSDRG Base Rate
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,10422.81,,,,,,,fee schedule,9804.91,29459.91,MSDRG Base Rate
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,10523.03,,,,,,,fee schedule,9804.91,29459.91,MSDRG Base Rate
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,10422.81,,,,,,,fee schedule,9804.91,29459.91,MSDRG Base Rate
Acute Leukemia Without Cc/Mcc,836,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,17538.38,,,,,,,fee schedule,9804.91,29459.91,MSDRG Base Rate
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,38633.22,,,,,,,fee schedule,38162.01,116077.65,
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,38633.22,,,,,,,fee schedule,38162.01,116077.65,
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51719.94,,,,,,,fee schedule,38162.01,116077.65,
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49257.1,,,,,,,fee schedule,38162.01,116077.65,
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,86272.17,,,,,,,fee schedule,38162.01,116077.65,
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,67041.05,,,,,,,fee schedule,38162.01,116077.65,
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,116077.65,,,,,,,fee schedule,38162.01,116077.65,
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,79797.08,,,,,,,fee schedule,38162.01,116077.65,
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,72268.15,,,,,,,fee schedule,38162.01,116077.65,
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59190.59,,,,,,,fee schedule,38162.01,116077.65,
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],75838.26,75838.26,75838.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",14369.25,14369.25,14369.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],38560.29,38560.29,38560.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],13804,13804,13804,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],37001.25,37001.25,37001.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,38528.95,,,,,,,fee schedule,38162.01,116077.65,MSDRG Base Rate
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,38162.01,,,,,,,fee schedule,38162.01,116077.65,MSDRG Base Rate
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,38162.01,,,,,,,fee schedule,38162.01,116077.65,MSDRG Base Rate
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,38528.95,,,,,,,fee schedule,38162.01,116077.65,MSDRG Base Rate
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,38162.01,,,,,,,fee schedule,38162.01,116077.65,MSDRG Base Rate
Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc,837,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,64214.92,,,,,,,fee schedule,38162.01,116077.65,MSDRG Base Rate
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,15649.12,,,,,,,fee schedule,15649.12,47019.47,
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,15649.12,,,,,,,fee schedule,15649.12,47019.47,
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20950.15,,,,,,,fee schedule,15649.12,47019.47,
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19952.53,,,,,,,fee schedule,15649.12,47019.47,
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,34946.19,,,,,,,fee schedule,15649.12,47019.47,
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,27156.26,,,,,,,fee schedule,15649.12,47019.47,
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,47019.47,,,,,,,fee schedule,15649.12,47019.47,
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,32323.33,,,,,,,fee schedule,15649.12,47019.47,
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,29273.6,,,,,,,fee schedule,15649.12,47019.47,
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23976.28,,,,,,,fee schedule,15649.12,47019.47,
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],259637.77,259637.77,259637.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",9755.26,9755.26,9755.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],15404.67,15404.67,15404.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],25264.02,25264.02,25264.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,17303.41,,,,,,,fee schedule,15649.12,47019.47,MSDRG Base Rate
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,17138.62,,,,,,,fee schedule,15649.12,47019.47,MSDRG Base Rate
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,17138.62,,,,,,,fee schedule,15649.12,47019.47,MSDRG Base Rate
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,17303.41,,,,,,,fee schedule,15649.12,47019.47,MSDRG Base Rate
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,17138.62,,,,,,,fee schedule,15649.12,47019.47,MSDRG Base Rate
Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent,838,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,28839.02,,,,,,,fee schedule,15649.12,47019.47,MSDRG Base Rate
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10573.44,,,,,,,fee schedule,10573.44,31769.04,
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,10573.44,,,,,,,fee schedule,10573.44,31769.04,
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14155.12,,,,,,,fee schedule,10573.44,31769.04,
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13481.07,,,,,,,fee schedule,10573.44,31769.04,
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,23611.64,,,,,,,fee schedule,10573.44,31769.04,
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,18348.32,,,,,,,fee schedule,10573.44,31769.04,
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,31769.04,,,,,,,fee schedule,10573.44,31769.04,
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,21839.49,,,,,,,fee schedule,10573.44,31769.04,
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,19778.91,,,,,,,fee schedule,10573.44,31769.04,
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16199.74,,,,,,,fee schedule,10573.44,31769.04,
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],21841.08,21841.08,21841.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],13482.05,13482.05,13482.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9646.28,9646.28,9646.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12276.13,,,,,,,fee schedule,10573.44,31769.04,MSDRG Base Rate
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,12159.21,,,,,,,fee schedule,10573.44,31769.04,MSDRG Base Rate
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,12159.21,,,,,,,fee schedule,10573.44,31769.04,MSDRG Base Rate
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,12276.13,,,,,,,fee schedule,10573.44,31769.04,MSDRG Base Rate
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,12159.21,,,,,,,fee schedule,10573.44,31769.04,MSDRG Base Rate
Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,839,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20460.21,,,,,,,fee schedule,10573.44,31769.04,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,24609.89,,,,,,,fee schedule,24609.89,73943.05,
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,24609.89,,,,,,,fee schedule,24609.89,73943.05,
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32946.31,,,,,,,fee schedule,24609.89,73943.05,
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,31377.44,,,,,,,fee schedule,24609.89,73943.05,
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,54956.55,,,,,,,fee schedule,24609.89,73943.05,
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,42706.07,,,,,,,fee schedule,24609.89,73943.05,
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,73943.05,,,,,,,fee schedule,24609.89,73943.05,
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,50831.83,,,,,,,fee schedule,24609.89,73943.05,
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,46035.8,,,,,,,fee schedule,24609.89,73943.05,
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37705.21,,,,,,,fee schedule,24609.89,73943.05,
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],90932.95,90932.95,90932.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],22961.81,22541.21,47528.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],23397.39,23397.39,23397.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],22169,22169,22169,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",17956.24,17956.24,17956.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],24493.28,24493.28,24493.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],23380.99,21993.29,25658.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,26268.15,,,,,,,fee schedule,24609.89,73943.05,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,26017.98,,,,,,,fee schedule,24609.89,73943.05,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,26017.98,,,,,,,fee schedule,24609.89,73943.05,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,26268.15,,,,,,,fee schedule,24609.89,73943.05,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,26017.98,,,,,,,fee schedule,24609.89,73943.05,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Mcc,840,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,43780.26,,,,,,,fee schedule,24609.89,73943.05,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12098.15,,,,,,,fee schedule,12098.15,36350.19,
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,12098.15,,,,,,,fee schedule,12098.15,36350.19,
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16196.31,,,,,,,fee schedule,12098.15,36350.19,
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15425.06,,,,,,,fee schedule,12098.15,36350.19,
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,27016.48,,,,,,,fee schedule,12098.15,36350.19,
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,20994.18,,,,,,,fee schedule,12098.15,36350.19,
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,36350.19,,,,,,,fee schedule,12098.15,36350.19,
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,24988.78,,,,,,,fee schedule,12098.15,36350.19,
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,22631.07,,,,,,,fee schedule,12098.15,36350.19,
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18535.78,,,,,,,fee schedule,12098.15,36350.19,
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],19425,19425,19425,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],24064.16,24064.16,24064.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12611.11,12611.11,12611.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",13320.76,13320.76,13320.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],27018.21,27018.21,27018.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],12042.7,12042.7,12042.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13740.95,,,,,,,fee schedule,12098.15,36350.19,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,13610.08,,,,,,,fee schedule,12098.15,36350.19,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,13610.08,,,,,,,fee schedule,12098.15,36350.19,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,13740.95,,,,,,,fee schedule,12098.15,36350.19,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,13610.08,,,,,,,fee schedule,12098.15,36350.19,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia With Cc,841,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22901.59,,,,,,,fee schedule,12098.15,36350.19,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8115.85,,,,,,,fee schedule,8115.85,24384.93,
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,8115.85,,,,,,,fee schedule,8115.85,24384.93,
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10865.03,,,,,,,fee schedule,8115.85,24384.93,
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10347.65,,,,,,,fee schedule,8115.85,24384.93,
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,18123.57,,,,,,,fee schedule,8115.85,24384.93,
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,14083.6,,,,,,,fee schedule,8115.85,24384.93,
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,24384.93,,,,,,,fee schedule,8115.85,24384.93,
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,16763.31,,,,,,,fee schedule,8115.85,24384.93,
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,15181.68,,,,,,,fee schedule,8115.85,24384.93,
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12434.42,,,,,,,fee schedule,8115.85,24384.93,
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8229.7,8229.7,8229.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],18125.29,18125.29,18125.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8889.45,,,,,,,fee schedule,8115.85,24384.93,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,8804.79,,,,,,,fee schedule,8115.85,24384.93,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,8804.79,,,,,,,fee schedule,8115.85,24384.93,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,8889.45,,,,,,,fee schedule,8115.85,24384.93,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,8804.79,,,,,,,fee schedule,8115.85,24384.93,MSDRG Base Rate
Lymphoma And Non-Acute Leukemia Without Cc/Mcc,842,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14815.74,,,,,,,fee schedule,8115.85,24384.93,MSDRG Base Rate
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14607.44,,,,,,,fee schedule,14607.44,43889.63,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,14607.44,,,,,,,fee schedule,14607.44,43889.63,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19555.61,,,,,,,fee schedule,14607.44,43889.63,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18624.39,,,,,,,fee schedule,14607.44,43889.63,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,32620.01,,,,,,,fee schedule,14607.44,43889.63,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,25348.61,,,,,,,fee schedule,14607.44,43889.63,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,43889.63,,,,,,,fee schedule,14607.44,43889.63,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,30171.74,,,,,,,fee schedule,14607.44,43889.63,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,27325.01,,,,,,,fee schedule,14607.44,43889.63,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22380.3,,,,,,,fee schedule,14607.44,43889.63,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13938.94,13938.94,14375.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,16579.98,,,,,,,fee schedule,14607.44,43889.63,MSDRG Base Rate
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,16422.08,,,,,,,fee schedule,14607.44,43889.63,MSDRG Base Rate
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,16422.08,,,,,,,fee schedule,14607.44,43889.63,MSDRG Base Rate
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,16579.98,,,,,,,fee schedule,14607.44,43889.63,MSDRG Base Rate
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,16422.08,,,,,,,fee schedule,14607.44,43889.63,MSDRG Base Rate
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc,843,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,27633.3,,,,,,,fee schedule,14607.44,43889.63,MSDRG Base Rate
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9221.57,,,,,,,fee schedule,9221.57,27707.2,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,9221.57,,,,,,,fee schedule,9221.57,27707.2,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12345.31,,,,,,,fee schedule,9221.57,27707.2,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11757.44,,,,,,,fee schedule,9221.57,27707.2,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,20592.77,,,,,,,fee schedule,9221.57,27707.2,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,16002.39,,,,,,,fee schedule,9221.57,27707.2,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,27707.2,,,,,,,fee schedule,9221.57,27707.2,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,19047.19,,,,,,,fee schedule,9221.57,27707.2,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,17250.07,,,,,,,fee schedule,9221.57,27707.2,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14128.52,,,,,,,fee schedule,9221.57,27707.2,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],119.16,119.16,119.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",7576.04,7576.04,7576.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",9405.76,9405.76,9405.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],13406.86,13406.86,13406.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],9347.75,9347.75,9347.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10506.62,,,,,,,fee schedule,9221.57,27707.2,MSDRG Base Rate
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,10406.55,,,,,,,fee schedule,9221.57,27707.2,MSDRG Base Rate
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,10406.55,,,,,,,fee schedule,9221.57,27707.2,MSDRG Base Rate
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,10506.62,,,,,,,fee schedule,9221.57,27707.2,MSDRG Base Rate
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,10406.55,,,,,,,fee schedule,9221.57,27707.2,MSDRG Base Rate
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc,844,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,17511.02,,,,,,,fee schedule,9221.57,27707.2,MSDRG Base Rate
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6456.1,,,,,,,fee schedule,6456.1,19398.05,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,6456.1,,,,,,,fee schedule,6456.1,19398.05,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8643.06,,,,,,,fee schedule,6456.1,19398.05,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8231.49,,,,,,,fee schedule,6456.1,19398.05,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,14417.18,,,,,,,fee schedule,6456.1,19398.05,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,11203.41,,,,,,,fee schedule,6456.1,19398.05,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,19398.05,,,,,,,fee schedule,6456.1,19398.05,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,13335.11,,,,,,,fee schedule,6456.1,19398.05,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,12076.93,,,,,,,fee schedule,6456.1,19398.05,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9891.5,,,,,,,fee schedule,6456.1,19398.05,
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7648.84,,,,,,,fee schedule,6456.1,19398.05,MSDRG Base Rate
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,7575.99,,,,,,,fee schedule,6456.1,19398.05,MSDRG Base Rate
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,7575.99,,,,,,,fee schedule,6456.1,19398.05,MSDRG Base Rate
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,7648.84,,,,,,,fee schedule,6456.1,19398.05,MSDRG Base Rate
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,7575.99,,,,,,,fee schedule,6456.1,19398.05,MSDRG Base Rate
Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc,845,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12748.07,,,,,,,fee schedule,6456.1,19398.05,MSDRG Base Rate
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,19703.96,,,,,,,fee schedule,19703.96,59202.66,
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,19703.96,,,,,,,fee schedule,19703.96,59202.66,
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,26378.53,,,,,,,fee schedule,19703.96,59202.66,
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,25122.42,,,,,,,fee schedule,19703.96,59202.66,
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,44001.08,,,,,,,fee schedule,19703.96,59202.66,
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,34192.7,,,,,,,fee schedule,19703.96,59202.66,
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,59202.66,,,,,,,fee schedule,19703.96,59202.66,
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,40698.61,,,,,,,fee schedule,19703.96,59202.66,
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,36858.66,,,,,,,fee schedule,19703.96,59202.66,
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,30188.76,,,,,,,fee schedule,19703.96,59202.66,
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],20252.09,20252.09,20252.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],35296,35296,35296,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],24974.39,24974.39,25124.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],19345.91,17703.45,19345.93,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],29852.9,29852.9,29852.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],42599,30352,44004.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],17332.62,8815.56,19196.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,21249.46,,,,,,,fee schedule,19703.96,59202.66,MSDRG Base Rate
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,21047.08,,,,,,,fee schedule,19703.96,59202.66,MSDRG Base Rate
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,21047.08,,,,,,,fee schedule,19703.96,59202.66,MSDRG Base Rate
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,21249.46,,,,,,,fee schedule,19703.96,59202.66,MSDRG Base Rate
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,21047.08,,,,,,,fee schedule,19703.96,59202.66,MSDRG Base Rate
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc,846,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,35415.76,,,,,,,fee schedule,19703.96,59202.66,MSDRG Base Rate
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9804.14,,,,,,,fee schedule,9804.14,29457.59,
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,9804.14,,,,,,,fee schedule,9804.14,29457.59,
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13125.22,,,,,,,fee schedule,9804.14,29457.59,
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12500.21,,,,,,,fee schedule,9804.14,29457.59,
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,21893.71,,,,,,,fee schedule,9804.14,29457.59,
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,17013.33,,,,,,,fee schedule,9804.14,29457.59,
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,29457.59,,,,,,,fee schedule,9804.14,29457.59,
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,20250.49,,,,,,,fee schedule,9804.14,29457.59,
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,18339.84,,,,,,,fee schedule,9804.14,29457.59,
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15021.08,,,,,,,fee schedule,9804.14,29457.59,
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],29459.91,29459.91,29459.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],20252.09,20252.09,20252.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],17971.28,17971.28,21148.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6905.11,6905.11,6905.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",12501.2,12501.2,12501.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],12501.2,12501.2,12501.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",6495.41,6495.41,6495.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9355.2,9355.2,9626,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],15022.27,13888.95,15022.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],21319.8,19956,21895.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],9033.41,8559.64,16361.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11215.98,,,,,,,fee schedule,9804.14,29457.59,MSDRG Base Rate
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,11109.17,,,,,,,fee schedule,9804.14,29457.59,MSDRG Base Rate
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,11109.17,,,,,,,fee schedule,9804.14,29457.59,MSDRG Base Rate
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,11215.98,,,,,,,fee schedule,9804.14,29457.59,MSDRG Base Rate
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,11109.17,,,,,,,fee schedule,9804.14,29457.59,MSDRG Base Rate
Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc,847,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18693.31,,,,,,,fee schedule,9804.14,29457.59,MSDRG Base Rate
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6318.76,,,,,,,fee schedule,6318.76,18985.38,
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,6318.76,,,,,,,fee schedule,6318.76,18985.38,
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8459.19,,,,,,,fee schedule,6318.76,18985.38,
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8056.37,,,,,,,fee schedule,6318.76,18985.38,
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,14110.47,,,,,,,fee schedule,6318.76,18985.38,
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,10965.07,,,,,,,fee schedule,6318.76,18985.38,
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,18985.38,,,,,,,fee schedule,6318.76,18985.38,
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,13051.42,,,,,,,fee schedule,6318.76,18985.38,
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,11820,,,,,,,fee schedule,6318.76,18985.38,
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9681.07,,,,,,,fee schedule,6318.76,18985.38,
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7631.65,,,,,,,fee schedule,6318.76,18985.38,MSDRG Base Rate
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,7558.97,,,,,,,fee schedule,6318.76,18985.38,MSDRG Base Rate
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,7558.97,,,,,,,fee schedule,6318.76,18985.38,MSDRG Base Rate
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,7631.65,,,,,,,fee schedule,6318.76,18985.38,MSDRG Base Rate
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,7558.97,,,,,,,fee schedule,6318.76,18985.38,MSDRG Base Rate
Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc,848,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12719.42,,,,,,,fee schedule,6318.76,18985.38,MSDRG Base Rate
Radiotherapy,849,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,20609.07,,,,,,,fee schedule,20609.07,61922.15,
Radiotherapy,849,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,20609.07,,,,,,,fee schedule,20609.07,61922.15,
Radiotherapy,849,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,27590.24,,,,,,,fee schedule,20609.07,61922.15,
Radiotherapy,849,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26276.42,,,,,,,fee schedule,20609.07,61922.15,
Radiotherapy,849,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,46022.28,,,,,,,fee schedule,20609.07,61922.15,
Radiotherapy,849,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,35763.35,,,,,,,fee schedule,20609.07,61922.15,
Radiotherapy,849,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,61922.15,,,,,,,fee schedule,20609.07,61922.15,
Radiotherapy,849,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,42568.11,,,,,,,fee schedule,20609.07,61922.15,
Radiotherapy,849,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,38551.77,,,,,,,fee schedule,20609.07,61922.15,
Radiotherapy,849,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,31575.49,,,,,,,fee schedule,20609.07,61922.15,
Radiotherapy,849,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Radiotherapy,849,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Radiotherapy,849,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Radiotherapy,849,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Radiotherapy,849,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Radiotherapy,849,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Radiotherapy,849,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Radiotherapy,849,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Radiotherapy,849,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Radiotherapy,849,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Radiotherapy,849,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Radiotherapy,849,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Radiotherapy,849,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Radiotherapy,849,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Radiotherapy,849,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Radiotherapy,849,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Radiotherapy,849,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Radiotherapy,849,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Radiotherapy,849,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,22163.52,,,,,,,fee schedule,20609.07,61922.15,MSDRG Base Rate
Radiotherapy,849,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,21952.43,,,,,,,fee schedule,20609.07,61922.15,MSDRG Base Rate
Radiotherapy,849,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,21952.43,,,,,,,fee schedule,20609.07,61922.15,MSDRG Base Rate
Radiotherapy,849,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,22163.52,,,,,,,fee schedule,20609.07,61922.15,MSDRG Base Rate
Radiotherapy,849,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,21952.43,,,,,,,fee schedule,20609.07,61922.15,MSDRG Base Rate
Radiotherapy,849,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,36939.19,,,,,,,fee schedule,20609.07,61922.15,MSDRG Base Rate
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,71075.77,,,,,,,fee schedule,67993.57,213554.78,
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,71075.77,,,,,,,fee schedule,67993.57,213554.78,
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,95152.18,,,,,,,fee schedule,67993.57,213554.78,
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,90621.14,,,,,,,fee schedule,67993.57,213554.78,
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,158719.91,,,,,,,fee schedule,67993.57,213554.78,
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,123339.31,,,,,,,fee schedule,67993.57,213554.78,
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,213554.78,,,,,,,fee schedule,67993.57,213554.78,
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,146807.3,,,,,,,fee schedule,67993.57,213554.78,
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,132955.9,,,,,,,fee schedule,67993.57,213554.78,
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,108896.36,,,,,,,fee schedule,67993.57,213554.78,
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],243634.42,243634.42,243634.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,68647.35,,,,,,,fee schedule,67993.57,213554.78,MSDRG Base Rate
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,67993.57,,,,,,,fee schedule,67993.57,213554.78,MSDRG Base Rate
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,67993.57,,,,,,,fee schedule,67993.57,213554.78,MSDRG Base Rate
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,68647.35,,,,,,,fee schedule,67993.57,213554.78,MSDRG Base Rate
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,67993.57,,,,,,,fee schedule,67993.57,213554.78,MSDRG Base Rate
Acute Leukemia With Other Procedures,850,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,114412.25,,,,,,,fee schedule,67993.57,213554.78,MSDRG Base Rate
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,38592.32,,,,,,,fee schedule,38592.32,115954.78,
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,38592.32,,,,,,,fee schedule,38592.32,115954.78,
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,51665.19,,,,,,,fee schedule,38592.32,115954.78,
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,49204.96,,,,,,,fee schedule,38592.32,115954.78,
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,86180.85,,,,,,,fee schedule,38592.32,115954.78,
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,66970.09,,,,,,,fee schedule,38592.32,115954.78,
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,115954.78,,,,,,,fee schedule,38592.32,115954.78,
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,79712.61,,,,,,,fee schedule,38592.32,115954.78,
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,72191.65,,,,,,,fee schedule,38592.32,115954.78,
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,59127.93,,,,,,,fee schedule,38592.32,115954.78,
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],100216.01,93445.08,115950.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],26644.96,26644.96,37335.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],72002.33,40795.25,139050.28,40,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],35536.21,15271.95,37028.7,24,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],37190.66,37190.66,37190.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],69067.26,45891.74,84952.92,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",31106.76,13532.76,83267.32,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",29213.31,29213.31,29213.31,41,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],49202.99,48933.31,306346.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],38417.34,38417.34,38417.34,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],36373.93,35206.74,38336.75,36,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],191957.67,191957.67,191957.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],77581.35,28588.38,85927.4,34,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],34900.41,362.66,37090.88,88,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",28942.82,28942.82,28942.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],100983.44,41590.4,168456.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,39578.15,,,,,,,fee schedule,38592.32,115954.78,MSDRG Base Rate
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,39201.22,,,,,,,fee schedule,38592.32,115954.78,MSDRG Base Rate
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,39201.22,,,,,,,fee schedule,38592.32,115954.78,MSDRG Base Rate
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,39578.15,,,,,,,fee schedule,38592.32,115954.78,MSDRG Base Rate
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,39201.22,,,,,,,fee schedule,38592.32,115954.78,MSDRG Base Rate
Infectious And Parasitic Diseases With O.R. Procedures With Mcc,853,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,65963.59,,,,,,,fee schedule,38592.32,115954.78,MSDRG Base Rate
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,15418.41,,,,,,,fee schedule,15418.41,46326.27,
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,15418.41,,,,,,,fee schedule,15418.41,46326.27,
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20641.29,,,,,,,fee schedule,15418.41,46326.27,
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19658.37,,,,,,,fee schedule,15418.41,46326.27,
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,34430.98,,,,,,,fee schedule,15418.41,46326.27,
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,26755.9,,,,,,,fee schedule,15418.41,46326.27,
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,46326.27,,,,,,,fee schedule,15418.41,46326.27,
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,31846.79,,,,,,,fee schedule,15418.41,46326.27,
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,28842.02,,,,,,,fee schedule,15418.41,46326.27,
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23622.8,,,,,,,fee schedule,15418.41,46326.27,
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],44660.68,44660.68,44660.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],14544.87,14307.93,15125.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],26637.12,16361.68,32461.8,25,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],27303.2,23206.85,28840.58,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],16046.75,16046.75,16046.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",79678.85,79678.85,79678.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",15595.3,15595.3,15595.3,32,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],19657.39,19608.01,64299.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],15223.37,15223.37,15223.37,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],14935.21,14743.14,15151.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],22948.28,22496.79,23621.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],26995.18,14678.79,34353.17,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],13342.72,102.03,15208.96,20,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",15450.9,15450.9,15450.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],19598.32,19426.8,33109.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,16605.76,,,,,,,fee schedule,15418.41,46326.27,MSDRG Base Rate
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,16447.61,,,,,,,fee schedule,15418.41,46326.27,MSDRG Base Rate
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,16447.61,,,,,,,fee schedule,15418.41,46326.27,MSDRG Base Rate
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,16605.76,,,,,,,fee schedule,15418.41,46326.27,MSDRG Base Rate
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,16447.61,,,,,,,fee schedule,15418.41,46326.27,MSDRG Base Rate
Infectious And Parasitic Diseases With O.R. Procedures With Cc,854,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,27676.27,,,,,,,fee schedule,15418.41,46326.27,MSDRG Base Rate
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12542.6,,,,,,,fee schedule,12542.6,37685.59,
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,12542.6,,,,,,,fee schedule,12542.6,37685.59,
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16791.32,,,,,,,fee schedule,12542.6,37685.59,
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15991.73,,,,,,,fee schedule,12542.6,37685.59,
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,28008.99,,,,,,,fee schedule,12542.6,37685.59,
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,21765.45,,,,,,,fee schedule,12542.6,37685.59,
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,37685.59,,,,,,,fee schedule,12542.6,37685.59,
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,25906.8,,,,,,,fee schedule,12542.6,37685.59,
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,23462.47,,,,,,,fee schedule,12542.6,37685.59,
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19216.73,,,,,,,fee schedule,12542.6,37685.59,
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",15595.3,15595.3,15595.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],18176.98,18176.98,18176.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12692.53,,,,,,,fee schedule,12542.6,37685.59,MSDRG Base Rate
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,12571.64,,,,,,,fee schedule,12542.6,37685.59,MSDRG Base Rate
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,12571.64,,,,,,,fee schedule,12542.6,37685.59,MSDRG Base Rate
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,12692.53,,,,,,,fee schedule,12542.6,37685.59,MSDRG Base Rate
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,12571.64,,,,,,,fee schedule,12542.6,37685.59,MSDRG Base Rate
Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc,855,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21154.21,,,,,,,fee schedule,12542.6,37685.59,MSDRG Base Rate
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,34809.87,,,,,,,fee schedule,34809.87,104589.98,
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,34809.87,,,,,,,fee schedule,34809.87,104589.98,
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,46601.46,,,,,,,fee schedule,34809.87,104589.98,
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,44382.35,,,,,,,fee schedule,34809.87,104589.98,
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,77734.21,,,,,,,fee schedule,34809.87,104589.98,
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,60406.31,,,,,,,fee schedule,34809.87,104589.98,
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,104589.98,,,,,,,fee schedule,34809.87,104589.98,
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,71899.93,,,,,,,fee schedule,34809.87,104589.98,
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,65116.1,,,,,,,fee schedule,34809.87,104589.98,
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,53332.77,,,,,,,fee schedule,34809.87,104589.98,
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],32175.33,32175.33,32175.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],45371.89,45371.89,45371.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",23860.76,23860.76,23860.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],31623,31623,31623,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],33215.5,33215.5,33215.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],31793.9,16540.28,33243.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],47349.65,35902.72,78297.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,36532.09,,,,,,,fee schedule,34809.87,104589.98,MSDRG Base Rate
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,36184.17,,,,,,,fee schedule,34809.87,104589.98,MSDRG Base Rate
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,36184.17,,,,,,,fee schedule,34809.87,104589.98,MSDRG Base Rate
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,36532.09,,,,,,,fee schedule,34809.87,104589.98,MSDRG Base Rate
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,36184.17,,,,,,,fee schedule,34809.87,104589.98,MSDRG Base Rate
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc,856,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,60886.82,,,,,,,fee schedule,34809.87,104589.98,MSDRG Base Rate
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16812.72,,,,,,,fee schedule,16812.72,50515.62,
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,16812.72,,,,,,,fee schedule,16812.72,50515.62,
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22507.91,,,,,,,fee schedule,16812.72,50515.62,
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21436.11,,,,,,,fee schedule,16812.72,50515.62,
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,37544.63,,,,,,,fee schedule,16812.72,50515.62,
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,29175.47,,,,,,,fee schedule,16812.72,50515.62,
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,50515.62,,,,,,,fee schedule,16812.72,50515.62,
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,34726.74,,,,,,,fee schedule,16812.72,50515.62,
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,31450.24,,,,,,,fee schedule,16812.72,50515.62,
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,25759.04,,,,,,,fee schedule,16812.72,50515.62,
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],31352.67,31352.67,31352.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],20947.17,20947.17,20947.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],31819.97,31819.97,31819.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",9238.53,9238.53,9238.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],16505.95,16249.57,16505.95,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],65016.91,65016.91,65016.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],33192.06,27649.73,37544.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],16476.03,15888.03,17319.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],33598.55,33598.55,33598.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,17726.07,,,,,,,fee schedule,16812.72,50515.62,MSDRG Base Rate
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,17557.25,,,,,,,fee schedule,16812.72,50515.62,MSDRG Base Rate
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,17557.25,,,,,,,fee schedule,16812.72,50515.62,MSDRG Base Rate
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,17726.07,,,,,,,fee schedule,16812.72,50515.62,MSDRG Base Rate
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,17557.25,,,,,,,fee schedule,16812.72,50515.62,MSDRG Base Rate
Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc,857,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,29543.45,,,,,,,fee schedule,16812.72,50515.62,MSDRG Base Rate
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9941.49,,,,,,,fee schedule,9941.49,29870.27,
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,9941.49,,,,,,,fee schedule,9941.49,29870.27,
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13309.09,,,,,,,fee schedule,9941.49,29870.27,
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12675.33,,,,,,,fee schedule,9941.49,29870.27,
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,22200.42,,,,,,,fee schedule,9941.49,29870.27,
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,17251.68,,,,,,,fee schedule,9941.49,29870.27,
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,29870.27,,,,,,,fee schedule,9941.49,29870.27,
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,20534.18,,,,,,,fee schedule,9941.49,29870.27,
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,18596.77,,,,,,,fee schedule,9941.49,29870.27,
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15231.52,,,,,,,fee schedule,9941.49,29870.27,
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11877.69,,,,,,,fee schedule,9941.49,29870.27,MSDRG Base Rate
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,11764.57,,,,,,,fee schedule,9941.49,29870.27,MSDRG Base Rate
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,11764.57,,,,,,,fee schedule,9941.49,29870.27,MSDRG Base Rate
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,11877.69,,,,,,,fee schedule,9941.49,29870.27,MSDRG Base Rate
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,11764.57,,,,,,,fee schedule,9941.49,29870.27,MSDRG Base Rate
Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc,858,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19796.16,,,,,,,fee schedule,9941.49,29870.27,MSDRG Base Rate
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14186.91,,,,,,,fee schedule,14186.91,42626.1,
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,14186.91,,,,,,,fee schedule,14186.91,42626.1,
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18992.63,,,,,,,fee schedule,14186.91,42626.1,
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18088.22,,,,,,,fee schedule,14186.91,42626.1,
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,31680.92,,,,,,,fee schedule,14186.91,42626.1,
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,24618.85,,,,,,,fee schedule,14186.91,42626.1,
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,42626.1,,,,,,,fee schedule,14186.91,42626.1,
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,29303.13,,,,,,,fee schedule,14186.91,42626.1,
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,26538.35,,,,,,,fee schedule,14186.91,42626.1,
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21736,,,,,,,fee schedule,14186.91,42626.1,
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13820.54,13513.8,14182.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],26534,26534,29108.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],14568.34,14568.34,15057.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],26539.8,26539.8,26539.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",8908.38,8908.38,8908.38,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13593.2,12835.36,14149.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],20739.24,20739.24,20739.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],21220.44,9769.98,31682.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],12295.1,11021.18,14065.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15243.28,,,,,,,fee schedule,14186.91,42626.1,MSDRG Base Rate
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,15098.11,,,,,,,fee schedule,14186.91,42626.1,MSDRG Base Rate
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,15098.11,,,,,,,fee schedule,14186.91,42626.1,MSDRG Base Rate
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,15243.28,,,,,,,fee schedule,14186.91,42626.1,MSDRG Base Rate
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,15098.11,,,,,,,fee schedule,14186.91,42626.1,MSDRG Base Rate
Postoperative And Post-Traumatic Infections With Mcc,862,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,25405.47,,,,,,,fee schedule,14186.91,42626.1,MSDRG Base Rate
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7715.38,,,,,,,fee schedule,7715.38,23181.68,
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,7715.38,,,,,,,fee schedule,7715.38,23181.68,
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10328.91,,,,,,,fee schedule,7715.38,23181.68,
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9837.06,,,,,,,fee schedule,7715.38,23181.68,
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,17229.28,,,,,,,fee schedule,7715.38,23181.68,
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,13388.66,,,,,,,fee schedule,7715.38,23181.68,
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,23181.68,,,,,,,fee schedule,7715.38,23181.68,
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,15936.15,,,,,,,fee schedule,7715.38,23181.68,
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,14432.56,,,,,,,fee schedule,7715.38,23181.68,
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11820.86,,,,,,,fee schedule,7715.38,23181.68,
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6340.78,6340.78,6340.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7480.62,7480.62,7480.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],16132.05,16132.05,16132.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4250.11,4250.11,4250.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7574.59,7574.59,7589.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],11820.86,11820.86,11820.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],17229.28,17229.28,17229.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],6366.33,6366.33,6366.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8791.8,,,,,,,fee schedule,7715.38,23181.68,MSDRG Base Rate
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,8708.07,,,,,,,fee schedule,7715.38,23181.68,MSDRG Base Rate
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,8708.07,,,,,,,fee schedule,7715.38,23181.68,MSDRG Base Rate
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,8791.8,,,,,,,fee schedule,7715.38,23181.68,MSDRG Base Rate
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,8708.07,,,,,,,fee schedule,7715.38,23181.68,MSDRG Base Rate
Postoperative And Post-Traumatic Infections Without Mcc,863,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14653,,,,,,,fee schedule,7715.38,23181.68,MSDRG Base Rate
Fever And Inflammatory Conditions,864,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6928.33,,,,,,,fee schedule,6928.33,20816.91,
Fever And Inflammatory Conditions,864,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,6928.33,,,,,,,fee schedule,6928.33,20816.91,
Fever And Inflammatory Conditions,864,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9275.25,,,,,,,fee schedule,6928.33,20816.91,
Fever And Inflammatory Conditions,864,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8833.58,,,,,,,fee schedule,6928.33,20816.91,
Fever And Inflammatory Conditions,864,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,15471.71,,,,,,,fee schedule,6928.33,20816.91,
Fever And Inflammatory Conditions,864,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,12022.88,,,,,,,fee schedule,6928.33,20816.91,
Fever And Inflammatory Conditions,864,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,20816.91,,,,,,,fee schedule,6928.33,20816.91,
Fever And Inflammatory Conditions,864,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,14310.5,,,,,,,fee schedule,6928.33,20816.91,
Fever And Inflammatory Conditions,864,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,12960.29,,,,,,,fee schedule,6928.33,20816.91,
Fever And Inflammatory Conditions,864,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10615.01,,,,,,,fee schedule,6928.33,20816.91,
Fever And Inflammatory Conditions,864,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fever And Inflammatory Conditions,864,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Fever And Inflammatory Conditions,864,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],14312.09,14312.09,14312.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Fever And Inflammatory Conditions,864,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fever And Inflammatory Conditions,864,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fever And Inflammatory Conditions,864,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Fever And Inflammatory Conditions,864,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Fever And Inflammatory Conditions,864,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",5420.26,5420.26,5420.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Fever And Inflammatory Conditions,864,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],10110.66,10110.66,10110.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Fever And Inflammatory Conditions,864,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Fever And Inflammatory Conditions,864,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Fever And Inflammatory Conditions,864,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fever And Inflammatory Conditions,864,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fever And Inflammatory Conditions,864,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Fever And Inflammatory Conditions,864,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fever And Inflammatory Conditions,864,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Fever And Inflammatory Conditions,864,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fever And Inflammatory Conditions,864,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Fever And Inflammatory Conditions,864,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7930.86,,,,,,,fee schedule,6928.33,20816.91,MSDRG Base Rate
Fever And Inflammatory Conditions,864,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,7855.33,,,,,,,fee schedule,6928.33,20816.91,MSDRG Base Rate
Fever And Inflammatory Conditions,864,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,7855.33,,,,,,,fee schedule,6928.33,20816.91,MSDRG Base Rate
Fever And Inflammatory Conditions,864,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,7930.86,,,,,,,fee schedule,6928.33,20816.91,MSDRG Base Rate
Fever And Inflammatory Conditions,864,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,7855.33,,,,,,,fee schedule,6928.33,20816.91,MSDRG Base Rate
Fever And Inflammatory Conditions,864,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,13218.1,,,,,,,fee schedule,6928.33,20816.91,MSDRG Base Rate
Viral Illness With Mcc,865,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11388.27,,,,,,,fee schedule,11388.27,34217.27,
Viral Illness With Mcc,865,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,11388.27,,,,,,,fee schedule,11388.27,34217.27,
Viral Illness With Mcc,865,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15245.96,,,,,,,fee schedule,11388.27,34217.27,
Viral Illness With Mcc,865,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14519.96,,,,,,,fee schedule,11388.27,34217.27,
Viral Illness With Mcc,865,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,25431.23,,,,,,,fee schedule,11388.27,34217.27,
Viral Illness With Mcc,865,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,19762.3,,,,,,,fee schedule,11388.27,34217.27,
Viral Illness With Mcc,865,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,34217.27,,,,,,,fee schedule,11388.27,34217.27,
Viral Illness With Mcc,865,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,23522.51,,,,,,,fee schedule,11388.27,34217.27,
Viral Illness With Mcc,865,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,21303.14,,,,,,,fee schedule,11388.27,34217.27,
Viral Illness With Mcc,865,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17448.15,,,,,,,fee schedule,11388.27,34217.27,
Viral Illness With Mcc,865,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Illness With Mcc,865,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Viral Illness With Mcc,865,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11413.58,11413.58,11413.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Viral Illness With Mcc,865,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Viral Illness With Mcc,865,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Illness With Mcc,865,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Viral Illness With Mcc,865,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Viral Illness With Mcc,865,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],14519.96,14519.96,14519.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Viral Illness With Mcc,865,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],9537.99,9537.99,9537.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Viral Illness With Mcc,865,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3825.81,3825.81,3825.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Viral Illness With Mcc,865,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],17448.15,17448.15,17448.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Viral Illness With Mcc,865,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Viral Illness With Mcc,865,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Illness With Mcc,865,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],13067.46,13067.46,13067.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Viral Illness With Mcc,865,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Illness With Mcc,865,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Viral Illness With Mcc,865,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Illness With Mcc,865,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Illness With Mcc,865,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12701.13,,,,,,,fee schedule,11388.27,34217.27,MSDRG Base Rate
Viral Illness With Mcc,865,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,12580.16,,,,,,,fee schedule,11388.27,34217.27,MSDRG Base Rate
Viral Illness With Mcc,865,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,12580.16,,,,,,,fee schedule,11388.27,34217.27,MSDRG Base Rate
Viral Illness With Mcc,865,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,12701.13,,,,,,,fee schedule,11388.27,34217.27,MSDRG Base Rate
Viral Illness With Mcc,865,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,12580.16,,,,,,,fee schedule,11388.27,34217.27,MSDRG Base Rate
Viral Illness With Mcc,865,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21168.54,,,,,,,fee schedule,11388.27,34217.27,MSDRG Base Rate
Viral Illness Without Mcc,866,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6826.48,,,,,,,fee schedule,6826.48,20510.88,
Viral Illness Without Mcc,866,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,6826.48,,,,,,,fee schedule,6826.48,20510.88,
Viral Illness Without Mcc,866,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9138.9,,,,,,,fee schedule,6826.48,20510.88,
Viral Illness Without Mcc,866,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8703.71,,,,,,,fee schedule,6826.48,20510.88,
Viral Illness Without Mcc,866,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,15244.27,,,,,,,fee schedule,6826.48,20510.88,
Viral Illness Without Mcc,866,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,11846.13,,,,,,,fee schedule,6826.48,20510.88,
Viral Illness Without Mcc,866,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,20510.88,,,,,,,fee schedule,6826.48,20510.88,
Viral Illness Without Mcc,866,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,14100.12,,,,,,,fee schedule,6826.48,20510.88,
Viral Illness Without Mcc,866,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,12769.76,,,,,,,fee schedule,6826.48,20510.88,
Viral Illness Without Mcc,866,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10458.96,,,,,,,fee schedule,6826.48,20510.88,
Viral Illness Without Mcc,866,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],17573.39,17573.39,17573.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Viral Illness Without Mcc,866,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Illness Without Mcc,866,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],3633.91,3633.91,3633.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Viral Illness Without Mcc,866,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6440.49,6440.49,6440.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Viral Illness Without Mcc,866,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Illness Without Mcc,866,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Viral Illness Without Mcc,866,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Viral Illness Without Mcc,866,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",2926.48,2926.48,2926.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Viral Illness Without Mcc,866,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Viral Illness Without Mcc,866,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Viral Illness Without Mcc,866,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Illness Without Mcc,866,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Illness Without Mcc,866,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Viral Illness Without Mcc,866,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],15245.99,15245.99,15245.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Viral Illness Without Mcc,866,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],7130.97,7130.97,7130.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Viral Illness Without Mcc,866,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Viral Illness Without Mcc,866,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Illness Without Mcc,866,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Viral Illness Without Mcc,866,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7789.46,,,,,,,fee schedule,6826.48,20510.88,MSDRG Base Rate
Viral Illness Without Mcc,866,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,7715.27,,,,,,,fee schedule,6826.48,20510.88,MSDRG Base Rate
Viral Illness Without Mcc,866,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,7715.27,,,,,,,fee schedule,6826.48,20510.88,MSDRG Base Rate
Viral Illness Without Mcc,866,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,7789.46,,,,,,,fee schedule,6826.48,20510.88,MSDRG Base Rate
Viral Illness Without Mcc,866,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,7715.27,,,,,,,fee schedule,6826.48,20510.88,MSDRG Base Rate
Viral Illness Without Mcc,866,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12982.43,,,,,,,fee schedule,6826.48,20510.88,MSDRG Base Rate
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16544.97,,,,,,,fee schedule,16544.97,49711.13,
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,16544.97,,,,,,,fee schedule,16544.97,49711.13,
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22149.46,,,,,,,fee schedule,16544.97,49711.13,
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21094.73,,,,,,,fee schedule,16544.97,49711.13,
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,36946.71,,,,,,,fee schedule,16544.97,49711.13,
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,28710.84,,,,,,,fee schedule,16544.97,49711.13,
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,49711.13,,,,,,,fee schedule,16544.97,49711.13,
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,34173.7,,,,,,,fee schedule,16544.97,49711.13,
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,30949.38,,,,,,,fee schedule,16544.97,49711.13,
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,25348.82,,,,,,,fee schedule,16544.97,49711.13,
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",10049.3,10049.3,10049.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],16243.83,16243.83,16243.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],16187.41,16187.41,16187.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],14352.51,14352.51,14352.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",9956.25,9956.25,9956.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,17348.72,,,,,,,fee schedule,16544.97,49711.13,MSDRG Base Rate
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,17183.49,,,,,,,fee schedule,16544.97,49711.13,MSDRG Base Rate
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,17183.49,,,,,,,fee schedule,16544.97,49711.13,MSDRG Base Rate
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,17348.72,,,,,,,fee schedule,16544.97,49711.13,MSDRG Base Rate
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,17183.49,,,,,,,fee schedule,16544.97,49711.13,MSDRG Base Rate
Other Infectious And Parasitic Diseases Diagnoses With Mcc,867,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,28914.53,,,,,,,fee schedule,16544.97,49711.13,MSDRG Base Rate
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8101.96,,,,,,,fee schedule,8101.96,24343.2,
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,8101.96,,,,,,,fee schedule,8101.96,24343.2,
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10846.44,,,,,,,fee schedule,8101.96,24343.2,
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10329.94,,,,,,,fee schedule,8101.96,24343.2,
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,18092.55,,,,,,,fee schedule,8101.96,24343.2,
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,14059.5,,,,,,,fee schedule,8101.96,24343.2,
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,24343.2,,,,,,,fee schedule,8101.96,24343.2,
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,16734.63,,,,,,,fee schedule,8101.96,24343.2,
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,15155.7,,,,,,,fee schedule,8101.96,24343.2,
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12413.14,,,,,,,fee schedule,8101.96,24343.2,
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7418.67,7418.67,7418.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],7825.94,7825.94,7825.94,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],12414.32,12414.32,12414.32,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],7646.23,7646.23,7646.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9051.17,,,,,,,fee schedule,8101.96,24343.2,MSDRG Base Rate
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,8964.97,,,,,,,fee schedule,8101.96,24343.2,MSDRG Base Rate
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,8964.97,,,,,,,fee schedule,8101.96,24343.2,MSDRG Base Rate
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,9051.17,,,,,,,fee schedule,8101.96,24343.2,MSDRG Base Rate
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,8964.97,,,,,,,fee schedule,8101.96,24343.2,MSDRG Base Rate
Other Infectious And Parasitic Diseases Diagnoses With Cc,868,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15085.28,,,,,,,fee schedule,8101.96,24343.2,MSDRG Base Rate
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5551.77,,,,,,,fee schedule,5551.77,16680.89,
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,5551.77,,,,,,,fee schedule,5551.77,16680.89,
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7432.39,,,,,,,fee schedule,5551.77,16680.89,
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7078.47,,,,,,,fee schedule,5551.77,16680.89,
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,12397.7,,,,,,,fee schedule,5551.77,16680.89,
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,9634.11,,,,,,,fee schedule,5551.77,16680.89,
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,16680.89,,,,,,,fee schedule,5551.77,16680.89,
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,11467.2,,,,,,,fee schedule,5551.77,16680.89,
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,10385.26,,,,,,,fee schedule,5551.77,16680.89,
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8505.96,,,,,,,fee schedule,5551.77,16680.89,
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,6696.5,,,,,,,fee schedule,5551.77,16680.89,MSDRG Base Rate
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,6632.72,,,,,,,fee schedule,5551.77,16680.89,MSDRG Base Rate
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,6632.72,,,,,,,fee schedule,5551.77,16680.89,MSDRG Base Rate
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,6696.5,,,,,,,fee schedule,5551.77,16680.89,MSDRG Base Rate
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,6632.72,,,,,,,fee schedule,5551.77,16680.89,MSDRG Base Rate
Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc,869,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,11160.84,,,,,,,fee schedule,5551.77,16680.89,MSDRG Base Rate
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,53677.4,,,,,,,fee schedule,53677.4,161279.5,
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,53677.4,,,,,,,fee schedule,53677.4,161279.5,
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,71860.23,,,,,,,fee schedule,53677.4,161279.5,
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,68438.33,,,,,,,fee schedule,53677.4,161279.5,
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,119867.45,,,,,,,fee schedule,53677.4,161279.5,
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,93147.54,,,,,,,fee schedule,53677.4,161279.5,
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,161279.5,,,,,,,fee schedule,53677.4,161279.5,
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,110870.89,,,,,,,fee schedule,53677.4,161279.5,
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,100410.12,,,,,,,fee schedule,53677.4,161279.5,
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,82240.02,,,,,,,fee schedule,53677.4,161279.5,
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],118218.76,115061.92,132046.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],62357.97,62357.97,106506.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],162411.24,162411.24,162411.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",67844.4,67844.4,67844.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",36302.17,36302.17,36302.17,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],49677.82,49677.82,49677.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],51055.49,51055.49,51215.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],120488.9,120488.9,120488.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],118412.84,118412.84,147147,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],50272.44,12966.75,55654.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,54993.6,,,,,,,fee schedule,53677.4,161279.5,MSDRG Base Rate
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,54469.85,,,,,,,fee schedule,53677.4,161279.5,MSDRG Base Rate
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,54469.85,,,,,,,fee schedule,53677.4,161279.5,MSDRG Base Rate
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,54993.6,,,,,,,fee schedule,53677.4,161279.5,MSDRG Base Rate
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,54469.85,,,,,,,fee schedule,53677.4,161279.5,MSDRG Base Rate
Septicemia Or Severe Sepsis With Mv >96 Hours,870,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,91656,,,,,,,fee schedule,53677.4,161279.5,MSDRG Base Rate
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,15141.4,,,,,,,fee schedule,15141.4,45493.96,
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,15141.4,,,,,,,fee schedule,15141.4,45493.96,
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20270.44,,,,,,,fee schedule,15141.4,45493.96,
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19305.19,,,,,,,fee schedule,15141.4,45493.96,
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,33812.39,,,,,,,fee schedule,15141.4,45493.96,
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,26275.2,,,,,,,fee schedule,15141.4,45493.96,
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,45493.96,,,,,,,fee schedule,15141.4,45493.96,
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,31274.63,,,,,,,fee schedule,15141.4,45493.96,
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,28323.84,,,,,,,fee schedule,15141.4,45493.96,
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23198.39,,,,,,,fee schedule,15141.4,45493.96,
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],13869.76,10333.12,15073.39,25,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],24322.65,19010.88,35196,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13859.78,11815.23,15206.31,132,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],24893.04,11139.48,31271.44,129,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],14431.87,9253.81,15521.44,32,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],27320.95,18211,31402.46,34,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",11671.09,9591.52,51851.15,23,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",10960.67,10960.67,10960.67,342,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],19303.22,19053.22,78171.03,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],14112.22,12756.03,15061.99,19,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],14440.59,12846.11,14916.11,271,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],23025.42,20428.64,24196.02,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],22345,10346.74,33808.95,130,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],13081.05,26.55,14938.76,424,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",10859.18,9841.69,10859.18,44,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],38914.4,27580,56912.8,11,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,16171.4,,,,,,,fee schedule,15141.4,45493.96,MSDRG Base Rate
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,16017.38,,,,,,,fee schedule,15141.4,45493.96,MSDRG Base Rate
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,16017.38,,,,,,,fee schedule,15141.4,45493.96,MSDRG Base Rate
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,16171.4,,,,,,,fee schedule,15141.4,45493.96,MSDRG Base Rate
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,16017.38,,,,,,,fee schedule,15141.4,45493.96,MSDRG Base Rate
Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc,871,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,26952.33,,,,,,,fee schedule,15141.4,45493.96,MSDRG Base Rate
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7955.35,,,,,,,fee schedule,7955.35,23902.7,
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,7955.35,,,,,,,fee schedule,7955.35,23902.7,
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10650.17,,,,,,,fee schedule,7955.35,23902.7,
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10143.02,,,,,,,fee schedule,7955.35,23902.7,
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,17765.16,,,,,,,fee schedule,7955.35,23902.7,
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,13805.09,,,,,,,fee schedule,7955.35,23902.7,
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,23902.7,,,,,,,fee schedule,7955.35,23902.7,
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,16431.81,,,,,,,fee schedule,7955.35,23902.7,
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,14881.45,,,,,,,fee schedule,7955.35,23902.7,
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12188.52,,,,,,,fee schedule,7955.35,23902.7,
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],6445.72,6445.72,8210.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],16358.67,9287.2,23902.7,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],12152.05,7061.82,15745.11,45,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7134.9,6304.86,8236.81,21,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7135.38,138.95,8469.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],13361.28,9802.65,16551.19,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",7234.55,4269.24,7234.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",6794.19,6794.19,6794.19,144,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],10141.02,10130.2,10143.02,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],7938.66,7938.66,7938.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7248.5,6304.86,7890.02,43,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],10834.95,9705.74,11768.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],13948.49,976,17765.16,45,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],6005.02,13.95,7546.46,48,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",6731.27,4076.59,6731.27,17,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],11866.4,9592.4,26261.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8990.23,,,,,,,fee schedule,7955.35,23902.7,MSDRG Base Rate
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,8904.6,,,,,,,fee schedule,7955.35,23902.7,MSDRG Base Rate
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,8904.6,,,,,,,fee schedule,7955.35,23902.7,MSDRG Base Rate
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,8990.23,,,,,,,fee schedule,7955.35,23902.7,MSDRG Base Rate
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,8904.6,,,,,,,fee schedule,7955.35,23902.7,MSDRG Base Rate
Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc,872,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14983.71,,,,,,,fee schedule,7955.35,23902.7,MSDRG Base Rate
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,30319.84,,,,,,,fee schedule,30319.84,91099.21,
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,30319.84,,,,,,,fee schedule,30319.84,91099.21,
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,40590.47,,,,,,,fee schedule,30319.84,91099.21,
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,38657.59,,,,,,,fee schedule,30319.84,91099.21,
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,67707.49,,,,,,,fee schedule,30319.84,91099.21,
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,52614.67,,,,,,,fee schedule,30319.84,91099.21,
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,91099.21,,,,,,,fee schedule,30319.84,91099.21,
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,62625.76,,,,,,,fee schedule,30319.84,91099.21,
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,56716.96,,,,,,,fee schedule,30319.84,91099.21,
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,46453.52,,,,,,,fee schedule,30319.84,91099.21,
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",11693.2,11693.2,11693.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],27331.31,27331.31,27331.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,31189.97,,,,,,,fee schedule,30319.84,91099.21,MSDRG Base Rate
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,30892.92,,,,,,,fee schedule,30319.84,91099.21,MSDRG Base Rate
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,30892.92,,,,,,,fee schedule,30319.84,91099.21,MSDRG Base Rate
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,31189.97,,,,,,,fee schedule,30319.84,91099.21,MSDRG Base Rate
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,30892.92,,,,,,,fee schedule,30319.84,91099.21,MSDRG Base Rate
O.R. Procedures With Principal Diagnosis Of Mental Illness,876,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,51983.28,,,,,,,fee schedule,30319.84,91099.21,MSDRG Base Rate
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7396.7,,,,,,,fee schedule,7396.7,22224.18,
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,7396.7,,,,,,,fee schedule,7396.7,22224.18,
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9902.28,,,,,,,fee schedule,7396.7,22224.18,
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9430.75,,,,,,,fee schedule,7396.7,22224.18,
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,16517.64,,,,,,,fee schedule,7396.7,22224.18,
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,12835.65,,,,,,,fee schedule,7396.7,22224.18,
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,22224.18,,,,,,,fee schedule,7396.7,22224.18,
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,15277.92,,,,,,,fee schedule,7396.7,22224.18,
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,13836.43,,,,,,,fee schedule,7396.7,22224.18,
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11332.61,,,,,,,fee schedule,7396.7,22224.18,
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],4206.62,2799.98,19167.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",7500,7500,7500,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3822.37,3451.35,4141.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7359.61,7359.61,7359.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],6078.13,5806.28,6727.76,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],7560,7560,8400,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8497.26,,,,,,,fee schedule,7396.7,22224.18,MSDRG Base Rate
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,8416.34,,,,,,,fee schedule,7396.7,22224.18,MSDRG Base Rate
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,8416.34,,,,,,,fee schedule,7396.7,22224.18,MSDRG Base Rate
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,8497.26,,,,,,,fee schedule,7396.7,22224.18,MSDRG Base Rate
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,8416.34,,,,,,,fee schedule,7396.7,22224.18,MSDRG Base Rate
Acute Adjustment Reaction And Psychosocial Dysfunction,880,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14162.1,,,,,,,fee schedule,7396.7,22224.18,MSDRG Base Rate
Depressive Neuroses,881,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7053.33,,,,,,,fee schedule,7053.33,21192.49,
Depressive Neuroses,881,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,7053.33,,,,,,,fee schedule,7053.33,21192.49,
Depressive Neuroses,881,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9442.6,,,,,,,fee schedule,7053.33,21192.49,
Depressive Neuroses,881,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8992.95,,,,,,,fee schedule,7053.33,21192.49,
Depressive Neuroses,881,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,15750.86,,,,,,,fee schedule,7053.33,21192.49,
Depressive Neuroses,881,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,12239.8,,,,,,,fee schedule,7053.33,21192.49,
Depressive Neuroses,881,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,21192.49,,,,,,,fee schedule,7053.33,21192.49,
Depressive Neuroses,881,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,14568.69,,,,,,,fee schedule,7053.33,21192.49,
Depressive Neuroses,881,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,13194.12,,,,,,,fee schedule,7053.33,21192.49,
Depressive Neuroses,881,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10806.53,,,,,,,fee schedule,7053.33,21192.49,
Depressive Neuroses,881,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Depressive Neuroses,881,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Depressive Neuroses,881,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6040.25,6040.25,6040.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Depressive Neuroses,881,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],8201.93,5608.83,13138.81,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Depressive Neuroses,881,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],3530.02,3530.02,6503,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Depressive Neuroses,881,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Depressive Neuroses,881,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Depressive Neuroses,881,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],5540.4,4653.92,6980.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Depressive Neuroses,881,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3275,2070.81,6212.43,18,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Depressive Neuroses,881,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Depressive Neuroses,881,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Depressive Neuroses,881,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Depressive Neuroses,881,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Depressive Neuroses,881,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],3360,2940,4200,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Depressive Neuroses,881,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Depressive Neuroses,881,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Depressive Neuroses,881,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Depressive Neuroses,881,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Depressive Neuroses,881,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8346.48,,,,,,,fee schedule,7053.33,21192.49,MSDRG Base Rate
Depressive Neuroses,881,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,8266.99,,,,,,,fee schedule,7053.33,21192.49,MSDRG Base Rate
Depressive Neuroses,881,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,8266.99,,,,,,,fee schedule,7053.33,21192.49,MSDRG Base Rate
Depressive Neuroses,881,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,8346.48,,,,,,,fee schedule,7053.33,21192.49,MSDRG Base Rate
Depressive Neuroses,881,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,8266.99,,,,,,,fee schedule,7053.33,21192.49,MSDRG Base Rate
Depressive Neuroses,881,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,13910.8,,,,,,,fee schedule,7053.33,21192.49,MSDRG Base Rate
Neuroses Except Depressive,882,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7422.16,,,,,,,fee schedule,7422.16,22300.69,
Neuroses Except Depressive,882,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,7422.16,,,,,,,fee schedule,7422.16,22300.69,
Neuroses Except Depressive,882,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9936.37,,,,,,,fee schedule,7422.16,22300.69,
Neuroses Except Depressive,882,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9463.21,,,,,,,fee schedule,7422.16,22300.69,
Neuroses Except Depressive,882,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,16574.5,,,,,,,fee schedule,7422.16,22300.69,
Neuroses Except Depressive,882,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,12879.84,,,,,,,fee schedule,7422.16,22300.69,
Neuroses Except Depressive,882,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,22300.69,,,,,,,fee schedule,7422.16,22300.69,
Neuroses Except Depressive,882,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,15330.51,,,,,,,fee schedule,7422.16,22300.69,
Neuroses Except Depressive,882,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,13884.06,,,,,,,fee schedule,7422.16,22300.69,
Neuroses Except Depressive,882,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11371.62,,,,,,,fee schedule,7422.16,22300.69,
Neuroses Except Depressive,882,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Neuroses Except Depressive,882,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Neuroses Except Depressive,882,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],4190.36,4190.36,13772,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Neuroses Except Depressive,882,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Neuroses Except Depressive,882,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],5545.89,5545.89,5545.89,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Neuroses Except Depressive,882,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Neuroses Except Depressive,882,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Neuroses Except Depressive,882,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",2761.08,2070.81,6212.43,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Neuroses Except Depressive,882,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],2352,2352,2352,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Neuroses Except Depressive,882,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Neuroses Except Depressive,882,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Neuroses Except Depressive,882,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Neuroses Except Depressive,882,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Neuroses Except Depressive,882,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],6212.43,6212.43,6212.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Neuroses Except Depressive,882,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Neuroses Except Depressive,882,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Neuroses Except Depressive,882,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Neuroses Except Depressive,882,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Neuroses Except Depressive,882,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9384.75,,,,,,,fee schedule,7422.16,22300.69,MSDRG Base Rate
Neuroses Except Depressive,882,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,9295.37,,,,,,,fee schedule,7422.16,22300.69,MSDRG Base Rate
Neuroses Except Depressive,882,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,9295.37,,,,,,,fee schedule,7422.16,22300.69,MSDRG Base Rate
Neuroses Except Depressive,882,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,9384.75,,,,,,,fee schedule,7422.16,22300.69,MSDRG Base Rate
Neuroses Except Depressive,882,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,9295.37,,,,,,,fee schedule,7422.16,22300.69,MSDRG Base Rate
Neuroses Except Depressive,882,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15641.26,,,,,,,fee schedule,7422.16,22300.69,MSDRG Base Rate
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14324.26,,,,,,,fee schedule,14324.26,43038.78,
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,14324.26,,,,,,,fee schedule,14324.26,43038.78,
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19176.5,,,,,,,fee schedule,14324.26,43038.78,
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18263.34,,,,,,,fee schedule,14324.26,43038.78,
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,31987.63,,,,,,,fee schedule,14324.26,43038.78,
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,24857.2,,,,,,,fee schedule,14324.26,43038.78,
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,43038.78,,,,,,,fee schedule,14324.26,43038.78,
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,29586.82,,,,,,,fee schedule,14324.26,43038.78,
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,26795.28,,,,,,,fee schedule,14324.26,43038.78,
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21946.44,,,,,,,fee schedule,14324.26,43038.78,
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12841.69,12841.69,12841.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],9444.55,9348,23582.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",2761.08,2761.08,6726.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],2940,2940,2940,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],4200,4200,4200,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,16357.33,,,,,,,fee schedule,14324.26,43038.78,MSDRG Base Rate
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,16201.55,,,,,,,fee schedule,14324.26,43038.78,MSDRG Base Rate
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,16201.55,,,,,,,fee schedule,14324.26,43038.78,MSDRG Base Rate
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,16357.33,,,,,,,fee schedule,14324.26,43038.78,MSDRG Base Rate
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,16201.55,,,,,,,fee schedule,14324.26,43038.78,MSDRG Base Rate
Disorders Of Personality And Impulse Control,883,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,27262.22,,,,,,,fee schedule,14324.26,43038.78,MSDRG Base Rate
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12886.74,,,,,,,fee schedule,12886.74,38719.6,
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,12886.74,,,,,,,fee schedule,12886.74,38719.6,
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17252.03,,,,,,,fee schedule,12886.74,38719.6,
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16430.51,,,,,,,fee schedule,12886.74,38719.6,
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,28777.49,,,,,,,fee schedule,12886.74,38719.6,
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,22362.64,,,,,,,fee schedule,12886.74,38719.6,
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,38719.6,,,,,,,fee schedule,12886.74,38719.6,
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,26617.62,,,,,,,fee schedule,12886.74,38719.6,
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,24106.22,,,,,,,fee schedule,12886.74,38719.6,
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19743.99,,,,,,,fee schedule,12886.74,38719.6,
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],2753.14,2753.14,2753.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],31889.45,31889.45,31889.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12828.76,11999.52,13022.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],23370,23370,23370,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",8283.24,6008.35,9663.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],11009.88,11009.88,11009.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],11928.93,11011.95,18617.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],12644.6,11436.02,19112.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13565.17,,,,,,,fee schedule,12886.74,38719.6,MSDRG Base Rate
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,13435.98,,,,,,,fee schedule,12886.74,38719.6,MSDRG Base Rate
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,13435.98,,,,,,,fee schedule,12886.74,38719.6,MSDRG Base Rate
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,13565.17,,,,,,,fee schedule,12886.74,38719.6,MSDRG Base Rate
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,13435.98,,,,,,,fee schedule,12886.74,38719.6,MSDRG Base Rate
Organic Disturbances And Intellectual Disability,884,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22608.62,,,,,,,fee schedule,12886.74,38719.6,MSDRG Base Rate
Psychoses,885,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10875.91,,,,,,,fee schedule,10875.91,32677.85,
Psychoses,885,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,10875.91,,,,,,,fee schedule,10875.91,32677.85,
Psychoses,885,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14560.05,,,,,,,fee schedule,10875.91,32677.85,
Psychoses,885,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13866.72,,,,,,,fee schedule,10875.91,32677.85,
Psychoses,885,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,24287.09,,,,,,,fee schedule,10875.91,32677.85,
Psychoses,885,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,18873.21,,,,,,,fee schedule,10875.91,32677.85,
Psychoses,885,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,32677.85,,,,,,,fee schedule,10875.91,32677.85,
Psychoses,885,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,22464.24,,,,,,,fee schedule,10875.91,32677.85,
Psychoses,885,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,20344.72,,,,,,,fee schedule,10875.91,32677.85,
Psychoses,885,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16663.17,,,,,,,fee schedule,10875.91,32677.85,
Psychoses,885,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],9759,9759,11299.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Psychoses,885,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],19872,6947,22356,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Psychoses,885,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],5699.49,5699.49,7913.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Psychoses,885,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],9270.05,4674,21514.07,110,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Psychoses,885,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],4942.11,4942.11,4942.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Psychoses,885,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],5574,2787,12077,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Psychoses,885,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",7500,3750,11250,21,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Psychoses,885,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],8144.36,4753.92,11644.8,14,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Psychoses,885,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],5540.4,5540.4,5540.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Psychoses,885,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4831.89,2761.08,9663.78,160,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Psychoses,885,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],4574.15,2352,16356,20,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Psychoses,885,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],5817.4,3490.44,11080.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Psychoses,885,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Psychoses,885,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],4998,1524.27,13440,46,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Psychoses,885,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],10143.02,7473,11746.25,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Psychoses,885,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Psychoses,885,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Psychoses,885,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],12684,12684,12684,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Psychoses,885,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11908.17,,,,,,,fee schedule,10875.91,32677.85,MSDRG Base Rate
Psychoses,885,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,11794.75,,,,,,,fee schedule,10875.91,32677.85,MSDRG Base Rate
Psychoses,885,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,11794.75,,,,,,,fee schedule,10875.91,32677.85,MSDRG Base Rate
Psychoses,885,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,11908.17,,,,,,,fee schedule,10875.91,32677.85,MSDRG Base Rate
Psychoses,885,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,11794.75,,,,,,,fee schedule,10875.91,32677.85,MSDRG Base Rate
Psychoses,885,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,19846.94,,,,,,,fee schedule,10875.91,32677.85,MSDRG Base Rate
Behavioral And Developmental Disorders,886,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13861.29,,,,,,,fee schedule,13861.29,41647.74,
Behavioral And Developmental Disorders,886,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,13861.29,,,,,,,fee schedule,13861.29,41647.74,
Behavioral And Developmental Disorders,886,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18556.7,,,,,,,fee schedule,13861.29,41647.74,
Behavioral And Developmental Disorders,886,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17673.06,,,,,,,fee schedule,13861.29,41647.74,
Behavioral And Developmental Disorders,886,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,30953.77,,,,,,,fee schedule,13861.29,41647.74,
Behavioral And Developmental Disorders,886,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,24053.8,,,,,,,fee schedule,13861.29,41647.74,
Behavioral And Developmental Disorders,886,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,41647.74,,,,,,,fee schedule,13861.29,41647.74,
Behavioral And Developmental Disorders,886,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,28630.56,,,,,,,fee schedule,13861.29,41647.74,
Behavioral And Developmental Disorders,886,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,25929.24,,,,,,,fee schedule,13861.29,41647.74,
Behavioral And Developmental Disorders,886,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21237.11,,,,,,,fee schedule,13861.29,41647.74,
Behavioral And Developmental Disorders,886,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],10253,10253,10253,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Behavioral And Developmental Disorders,886,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Behavioral And Developmental Disorders,886,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],10285.7,10285.7,10285.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Behavioral And Developmental Disorders,886,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12762.29,12762.29,12762.29,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Behavioral And Developmental Disorders,886,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],2373.16,2373.16,2373.16,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Behavioral And Developmental Disorders,886,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Behavioral And Developmental Disorders,886,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Behavioral And Developmental Disorders,886,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4831.89,3451.35,9663.78,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Behavioral And Developmental Disorders,886,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],2493.18,2493.18,2493.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Behavioral And Developmental Disorders,886,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Behavioral And Developmental Disorders,886,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Behavioral And Developmental Disorders,886,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Behavioral And Developmental Disorders,886,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Behavioral And Developmental Disorders,886,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],4200,4200,4200,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Behavioral And Developmental Disorders,886,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Behavioral And Developmental Disorders,886,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Behavioral And Developmental Disorders,886,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Behavioral And Developmental Disorders,886,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Behavioral And Developmental Disorders,886,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,17208.88,,,,,,,fee schedule,13861.29,41647.74,MSDRG Base Rate
Behavioral And Developmental Disorders,886,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,17044.99,,,,,,,fee schedule,13861.29,41647.74,MSDRG Base Rate
Behavioral And Developmental Disorders,886,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,17044.99,,,,,,,fee schedule,13861.29,41647.74,MSDRG Base Rate
Behavioral And Developmental Disorders,886,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,17208.88,,,,,,,fee schedule,13861.29,41647.74,MSDRG Base Rate
Behavioral And Developmental Disorders,886,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,17044.99,,,,,,,fee schedule,13861.29,41647.74,MSDRG Base Rate
Behavioral And Developmental Disorders,886,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,28681.47,,,,,,,fee schedule,13861.29,41647.74,MSDRG Base Rate
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9176.82,,,,,,,fee schedule,9176.82,27572.73,
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,9176.82,,,,,,,fee schedule,9176.82,27572.73,
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12285.4,,,,,,,fee schedule,9176.82,27572.73,
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11700.38,,,,,,,fee schedule,9176.82,27572.73,
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,20492.83,,,,,,,fee schedule,9176.82,27572.73,
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,15924.73,,,,,,,fee schedule,9176.82,27572.73,
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,27572.73,,,,,,,fee schedule,9176.82,27572.73,
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,18954.75,,,,,,,fee schedule,9176.82,27572.73,
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,17166.36,,,,,,,fee schedule,9176.82,27572.73,
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14059.95,,,,,,,fee schedule,9176.82,27572.73,
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9362.09,,,,,,,fee schedule,9176.82,27572.73,MSDRG Base Rate
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,9272.93,,,,,,,fee schedule,9176.82,27572.73,MSDRG Base Rate
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,9272.93,,,,,,,fee schedule,9176.82,27572.73,MSDRG Base Rate
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,9362.09,,,,,,,fee schedule,9176.82,27572.73,MSDRG Base Rate
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,9272.93,,,,,,,fee schedule,9176.82,27572.73,MSDRG Base Rate
Other Mental Disorder Diagnoses,887,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,15603.49,,,,,,,fee schedule,9176.82,27572.73,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4815.65,,,,,,,fee schedule,4815.65,14469.13,
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,4815.65,,,,,,,fee schedule,4815.65,14469.13,
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6446.92,,,,,,,fee schedule,4815.65,14469.13,
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6139.92,,,,,,,fee schedule,4815.65,14469.13,
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,10753.87,,,,,,,fee schedule,4815.65,14469.13,
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,8356.7,,,,,,,fee schedule,4815.65,14469.13,
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,14469.13,,,,,,,fee schedule,4815.65,14469.13,
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,9946.74,,,,,,,fee schedule,4815.65,14469.13,
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,9008.26,,,,,,,fee schedule,4815.65,14469.13,
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7378.14,,,,,,,fee schedule,4815.65,14469.13,
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],9151.27,8282.96,9946.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",2364.62,2364.62,2364.62,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],6137.92,6137.92,6139.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],5902.51,5902.51,5902.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],8805,8805,8805,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],4542.41,4542.41,5402.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",2342.72,2342.72,2342.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,5815.27,,,,,,,fee schedule,4815.65,14469.13,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,5759.88,,,,,,,fee schedule,4815.65,14469.13,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,5759.88,,,,,,,fee schedule,4815.65,14469.13,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,5815.27,,,,,,,fee schedule,4815.65,14469.13,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,5759.88,,,,,,,fee schedule,4815.65,14469.13,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence, Left Ama",894,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9692.11,,,,,,,fee schedule,4815.65,14469.13,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11172.21,,,,,,,fee schedule,11172.21,33568.11,
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,11172.21,,,,,,,fee schedule,11172.21,33568.11,
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14956.72,,,,,,,fee schedule,11172.21,33568.11,
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14244.5,,,,,,,fee schedule,11172.21,33568.11,
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,24948.76,,,,,,,fee schedule,11172.21,33568.11,
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,19387.38,,,,,,,fee schedule,11172.21,33568.11,
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,33568.11,,,,,,,fee schedule,11172.21,33568.11,
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,23076.25,,,,,,,fee schedule,11172.21,33568.11,
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,20898.99,,,,,,,fee schedule,11172.21,33568.11,
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17117.13,,,,,,,fee schedule,11172.21,33568.11,
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12055.04,,,,,,,fee schedule,11172.21,33568.11,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,11940.23,,,,,,,fee schedule,11172.21,33568.11,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,11940.23,,,,,,,fee schedule,11172.21,33568.11,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,12055.04,,,,,,,fee schedule,11172.21,33568.11,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,11940.23,,,,,,,fee schedule,11172.21,33568.11,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy",895,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20091.73,,,,,,,fee schedule,11172.21,33568.11,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13740.92,,,,,,,fee schedule,13740.92,41286.07,
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,13740.92,,,,,,,fee schedule,13740.92,41286.07,
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18395.56,,,,,,,fee schedule,13740.92,41286.07,
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17519.58,,,,,,,fee schedule,13740.92,41286.07,
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,30684.96,,,,,,,fee schedule,13740.92,41286.07,
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,23844.91,,,,,,,fee schedule,13740.92,41286.07,
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,41286.07,,,,,,,fee schedule,13740.92,41286.07,
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,28381.93,,,,,,,fee schedule,13740.92,41286.07,
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,25704.07,,,,,,,fee schedule,13740.92,41286.07,
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21052.69,,,,,,,fee schedule,13740.92,41286.07,
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],38374.06,34617.95,40436.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12131.31,11422.86,14301.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],19047,8425,28581.12,20,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],17981.88,16337.02,23286.13,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13072.9,13072.9,13072.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",5447.49,5447.49,5450.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",5115.9,5115.9,5115.9,66,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],17493.02,17493.02,17519.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],12326.57,12326.57,12326.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12796.14,11847.71,13651.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],21052.69,21052.69,21052.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],26063.66,14683.17,30834.96,13,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],11863.47,11815.84,13587,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",5068.54,5068.54,5068.54,15,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],25294.62,25294.62,25294.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14629.22,,,,,,,fee schedule,13740.92,41286.07,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,14489.89,,,,,,,fee schedule,13740.92,41286.07,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,14489.89,,,,,,,fee schedule,13740.92,41286.07,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,14629.22,,,,,,,fee schedule,13740.92,41286.07,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,14489.89,,,,,,,fee schedule,13740.92,41286.07,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc",896,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,24382.03,,,,,,,fee schedule,13740.92,41286.07,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6807.19,,,,,,,fee schedule,6807.19,20452.92,
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,6807.19,,,,,,,fee schedule,6807.19,20452.92,
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9113.07,,,,,,,fee schedule,6807.19,20452.92,
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8679.12,,,,,,,fee schedule,6807.19,20452.92,
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,15201.19,,,,,,,fee schedule,6807.19,20452.92,
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,11812.66,,,,,,,fee schedule,6807.19,20452.92,
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,20452.92,,,,,,,fee schedule,6807.19,20452.92,
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,14060.27,,,,,,,fee schedule,6807.19,20452.92,
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,12733.67,,,,,,,fee schedule,6807.19,20452.92,
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10429.4,,,,,,,fee schedule,6807.19,20452.92,
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],2075.69,2075.69,2075.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],9229.68,6306.9,14060.27,42,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7354.82,7354.82,7354.82,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],5925.56,5925.56,7083.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],12283.67,11493,12733.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3936.45,3936.45,5000,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3696.84,3696.84,3696.84,134,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],8604.12,8385.92,8679.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6494.98,6494.97,6716.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],11467.81,11467.81,11467.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],9492.39,3360,15211.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],5909.37,3751.18,7133.31,20,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3662.61,3662.61,5068.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],5380.4,5380.4,5380.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7892.59,,,,,,,fee schedule,6807.19,20452.92,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,7817.42,,,,,,,fee schedule,6807.19,20452.92,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,7817.42,,,,,,,fee schedule,6807.19,20452.92,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,7892.59,,,,,,,fee schedule,6807.19,20452.92,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,7817.42,,,,,,,fee schedule,6807.19,20452.92,MSDRG Base Rate
"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc",897,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,13154.31,,,,,,,fee schedule,6807.19,20452.92,MSDRG Base Rate
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,34184.09,,,,,,,fee schedule,33459.62,102709.76,
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,34184.09,,,,,,,fee schedule,33459.62,102709.76,
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,45763.7,,,,,,,fee schedule,33459.62,102709.76,
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,43584.48,,,,,,,fee schedule,33459.62,102709.76,
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,76336.78,,,,,,,fee schedule,33459.62,102709.76,
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,59320.38,,,,,,,fee schedule,33459.62,102709.76,
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,102709.76,,,,,,,fee schedule,33459.62,102709.76,
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,70607.38,,,,,,,fee schedule,33459.62,102709.76,
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,63945.51,,,,,,,fee schedule,33459.62,102709.76,
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,52374,,,,,,,fee schedule,33459.62,102709.76,
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",33466.63,33466.63,33466.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],33562.61,33562.61,33562.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,33781.35,,,,,,,fee schedule,33459.62,102709.76,MSDRG Base Rate
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,33459.62,,,,,,,fee schedule,33459.62,102709.76,MSDRG Base Rate
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,33459.62,,,,,,,fee schedule,33459.62,102709.76,MSDRG Base Rate
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,33781.35,,,,,,,fee schedule,33459.62,102709.76,MSDRG Base Rate
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,33459.62,,,,,,,fee schedule,33459.62,102709.76,MSDRG Base Rate
Wound Debridements For Injuries With Mcc,901,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,56302.24,,,,,,,fee schedule,33459.62,102709.76,MSDRG Base Rate
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14640.62,,,,,,,fee schedule,14640.62,43989.32,
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,14640.62,,,,,,,fee schedule,14640.62,43989.32,
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,19600.03,,,,,,,fee schedule,14640.62,43989.32,
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,18666.7,,,,,,,fee schedule,14640.62,43989.32,
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,32694.1,,,,,,,fee schedule,14640.62,43989.32,
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,25406.19,,,,,,,fee schedule,14640.62,43989.32,
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,43989.32,,,,,,,fee schedule,14640.62,43989.32,
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,30240.27,,,,,,,fee schedule,14640.62,43989.32,
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,27387.07,,,,,,,fee schedule,14640.62,43989.32,
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,22431.14,,,,,,,fee schedule,14640.62,43989.32,
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],25.68,25.68,25.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15952.65,,,,,,,fee schedule,14640.62,43989.32,MSDRG Base Rate
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,15800.72,,,,,,,fee schedule,14640.62,43989.32,MSDRG Base Rate
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,15800.72,,,,,,,fee schedule,14640.62,43989.32,MSDRG Base Rate
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,15952.65,,,,,,,fee schedule,14640.62,43989.32,MSDRG Base Rate
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,15800.72,,,,,,,fee schedule,14640.62,43989.32,MSDRG Base Rate
Wound Debridements For Injuries With Cc,902,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,26587.75,,,,,,,fee schedule,14640.62,43989.32,MSDRG Base Rate
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9405.99,,,,,,,fee schedule,9405.99,28261.3,
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,9405.99,,,,,,,fee schedule,9405.99,28261.3,
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,12592.2,,,,,,,fee schedule,9405.99,28261.3,
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11992.57,,,,,,,fee schedule,9405.99,28261.3,
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,21004.59,,,,,,,fee schedule,9405.99,28261.3,
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,16322.41,,,,,,,fee schedule,9405.99,28261.3,
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,28261.3,,,,,,,fee schedule,9405.99,28261.3,
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,19428.11,,,,,,,fee schedule,9405.99,28261.3,
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,17595.05,,,,,,,fee schedule,9405.99,28261.3,
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14411.07,,,,,,,fee schedule,9405.99,28261.3,
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",5452.28,5452.28,5452.28,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10133.18,,,,,,,fee schedule,9405.99,28261.3,MSDRG Base Rate
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,10036.68,,,,,,,fee schedule,9405.99,28261.3,MSDRG Base Rate
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,10036.68,,,,,,,fee schedule,9405.99,28261.3,MSDRG Base Rate
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,10133.18,,,,,,,fee schedule,9405.99,28261.3,MSDRG Base Rate
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,10036.68,,,,,,,fee schedule,9405.99,28261.3,MSDRG Base Rate
Wound Debridements For Injuries Without Cc/Mcc,903,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16888.64,,,,,,,fee schedule,9405.99,28261.3,MSDRG Base Rate
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,29791.28,,,,,,,fee schedule,29408.78,89511.11,
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,29791.28,,,,,,,fee schedule,29408.78,89511.11,
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39882.87,,,,,,,fee schedule,29408.78,89511.11,
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,37983.69,,,,,,,fee schedule,29408.78,89511.11,
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,66527.17,,,,,,,fee schedule,29408.78,89511.11,
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,51697.45,,,,,,,fee schedule,29408.78,89511.11,
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,89511.11,,,,,,,fee schedule,29408.78,89511.11,
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,61534.02,,,,,,,fee schedule,29408.78,89511.11,
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,55728.23,,,,,,,fee schedule,29408.78,89511.11,
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45643.71,,,,,,,fee schedule,29408.78,89511.11,
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],28267.4,28267.4,28267.4,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,29691.55,,,,,,,fee schedule,29408.78,89511.11,MSDRG Base Rate
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,29408.78,,,,,,,fee schedule,29408.78,89511.11,MSDRG Base Rate
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,29408.78,,,,,,,fee schedule,29408.78,89511.11,MSDRG Base Rate
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,29691.55,,,,,,,fee schedule,29408.78,89511.11,MSDRG Base Rate
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,29408.78,,,,,,,fee schedule,29408.78,89511.11,MSDRG Base Rate
Skin Grafts For Injuries With Cc/Mcc,904,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,49485.92,,,,,,,fee schedule,29408.78,89511.11,MSDRG Base Rate
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12716.99,,,,,,,fee schedule,12464.86,38209.55,
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,12716.99,,,,,,,fee schedule,12464.86,38209.55,
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17024.77,,,,,,,fee schedule,12464.86,38209.55,
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16214.07,,,,,,,fee schedule,12464.86,38209.55,
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,28398.41,,,,,,,fee schedule,12464.86,38209.55,
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,22068.06,,,,,,,fee schedule,12464.86,38209.55,
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,38209.55,,,,,,,fee schedule,12464.86,38209.55,
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,26266.99,,,,,,,fee schedule,12464.86,38209.55,
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,23788.68,,,,,,,fee schedule,12464.86,38209.55,
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19483.9,,,,,,,fee schedule,12464.86,38209.55,
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12584.71,,,,,,,fee schedule,12464.86,38209.55,MSDRG Base Rate
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,12464.86,,,,,,,fee schedule,12464.86,38209.55,MSDRG Base Rate
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,12464.86,,,,,,,fee schedule,12464.86,38209.55,MSDRG Base Rate
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,12584.71,,,,,,,fee schedule,12464.86,38209.55,MSDRG Base Rate
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,12464.86,,,,,,,fee schedule,12464.86,38209.55,MSDRG Base Rate
Skin Grafts For Injuries Without Cc/Mcc,905,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,20974.52,,,,,,,fee schedule,12464.86,38209.55,MSDRG Base Rate
Hand Procedures For Injuries,906,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16839.73,,,,,,,fee schedule,16186.07,50596.76,
Hand Procedures For Injuries,906,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,16839.73,,,,,,,fee schedule,16186.07,50596.76,
Hand Procedures For Injuries,906,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22544.06,,,,,,,fee schedule,16186.07,50596.76,
Hand Procedures For Injuries,906,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21470.54,,,,,,,fee schedule,16186.07,50596.76,
Hand Procedures For Injuries,906,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,37604.93,,,,,,,fee schedule,16186.07,50596.76,
Hand Procedures For Injuries,906,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,29222.34,,,,,,,fee schedule,16186.07,50596.76,
Hand Procedures For Injuries,906,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,50596.76,,,,,,,fee schedule,16186.07,50596.76,
Hand Procedures For Injuries,906,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,34782.52,,,,,,,fee schedule,16186.07,50596.76,
Hand Procedures For Injuries,906,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,31500.76,,,,,,,fee schedule,16186.07,50596.76,
Hand Procedures For Injuries,906,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,25800.42,,,,,,,fee schedule,16186.07,50596.76,
Hand Procedures For Injuries,906,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hand Procedures For Injuries,906,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Hand Procedures For Injuries,906,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Hand Procedures For Injuries,906,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hand Procedures For Injuries,906,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hand Procedures For Injuries,906,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Hand Procedures For Injuries,906,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Hand Procedures For Injuries,906,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Hand Procedures For Injuries,906,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Hand Procedures For Injuries,906,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Hand Procedures For Injuries,906,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hand Procedures For Injuries,906,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hand Procedures For Injuries,906,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Hand Procedures For Injuries,906,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Hand Procedures For Injuries,906,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hand Procedures For Injuries,906,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Hand Procedures For Injuries,906,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hand Procedures For Injuries,906,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hand Procedures For Injuries,906,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,16341.71,,,,,,,fee schedule,16186.07,50596.76,MSDRG Base Rate
Hand Procedures For Injuries,906,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,16186.07,,,,,,,fee schedule,16186.07,50596.76,MSDRG Base Rate
Hand Procedures For Injuries,906,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,16186.07,,,,,,,fee schedule,16186.07,50596.76,MSDRG Base Rate
Hand Procedures For Injuries,906,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,16341.71,,,,,,,fee schedule,16186.07,50596.76,MSDRG Base Rate
Hand Procedures For Injuries,906,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,16186.07,,,,,,,fee schedule,16186.07,50596.76,MSDRG Base Rate
Hand Procedures For Injuries,906,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,27236.18,,,,,,,fee schedule,16186.07,50596.76,MSDRG Base Rate
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,30737.28,,,,,,,fee schedule,30694.83,92353.46,
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,30737.28,,,,,,,fee schedule,30694.83,92353.46,
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,41149.32,,,,,,,fee schedule,30694.83,92353.46,
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,39189.83,,,,,,,fee schedule,30694.83,92353.46,
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,68639.69,,,,,,,fee schedule,30694.83,92353.46,
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,53339.07,,,,,,,fee schedule,30694.83,92353.46,
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,92353.46,,,,,,,fee schedule,30694.83,92353.46,
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,63487.99,,,,,,,fee schedule,30694.83,92353.46,
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,57497.84,,,,,,,fee schedule,30694.83,92353.46,
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,47093.1,,,,,,,fee schedule,30694.83,92353.46,
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],28023.05,28023.05,28023.05,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],59178.04,59178.04,59178.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",20374.8,20374.8,20374.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],39191.8,39191.8,39191.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],30211.46,30211.46,30211.46,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],66838.52,66838.52,66838.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],28838.61,28838.61,28838.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",56119.71,56119.71,56119.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,30989.97,,,,,,,fee schedule,30694.83,92353.46,MSDRG Base Rate
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,30694.83,,,,,,,fee schedule,30694.83,92353.46,MSDRG Base Rate
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,30694.83,,,,,,,fee schedule,30694.83,92353.46,MSDRG Base Rate
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,30989.97,,,,,,,fee schedule,30694.83,92353.46,MSDRG Base Rate
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,30694.83,,,,,,,fee schedule,30694.83,92353.46,MSDRG Base Rate
Other O.R. Procedures For Injuries With Mcc,907,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,51649.95,,,,,,,fee schedule,30694.83,92353.46,MSDRG Base Rate
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,15563.47,,,,,,,fee schedule,15563.47,46762.13,
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,15563.47,,,,,,,fee schedule,15563.47,46762.13,
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20835.49,,,,,,,fee schedule,15563.47,46762.13,
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19843.33,,,,,,,fee schedule,15563.47,46762.13,
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,34754.93,,,,,,,fee schedule,15563.47,46762.13,
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,27007.63,,,,,,,fee schedule,15563.47,46762.13,
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,46762.13,,,,,,,fee schedule,15563.47,46762.13,
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,32146.42,,,,,,,fee schedule,15563.47,46762.13,
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,29113.38,,,,,,,fee schedule,15563.47,46762.13,
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23845.05,,,,,,,fee schedule,15563.47,46762.13,
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],13503.86,13503.86,13503.86,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],29346.7,29346.7,29346.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],19751.74,19751.74,19751.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],15297.77,15297.77,15306.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],32358.44,32358.44,32358.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],19716.42,19716.42,19716.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],15289.25,15289.25,15289.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",9208.44,9208.44,9208.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],15279.18,15279.18,15279.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],22217.44,22217.44,22217.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],53285.91,53285.91,53285.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],13488.62,13488.62,13488.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,16583.11,,,,,,,fee schedule,15563.47,46762.13,MSDRG Base Rate
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,16425.18,,,,,,,fee schedule,15563.47,46762.13,MSDRG Base Rate
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,16425.18,,,,,,,fee schedule,15563.47,46762.13,MSDRG Base Rate
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,16583.11,,,,,,,fee schedule,15563.47,46762.13,MSDRG Base Rate
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,16425.18,,,,,,,fee schedule,15563.47,46762.13,MSDRG Base Rate
Other O.R. Procedures For Injuries With Cc,908,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,27638.52,,,,,,,fee schedule,15563.47,46762.13,MSDRG Base Rate
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9785.62,,,,,,,fee schedule,9785.62,29401.95,
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,9785.62,,,,,,,fee schedule,9785.62,29401.95,
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13100.43,,,,,,,fee schedule,9785.62,29401.95,
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12476.6,,,,,,,fee schedule,9785.62,29401.95,
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,21852.35,,,,,,,fee schedule,9785.62,29401.95,
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,16981.2,,,,,,,fee schedule,9785.62,29401.95,
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,29401.95,,,,,,,fee schedule,9785.62,29401.95,
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,20212.24,,,,,,,fee schedule,9785.62,29401.95,
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,18305.2,,,,,,,fee schedule,9785.62,29401.95,
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,14992.71,,,,,,,fee schedule,9785.62,29401.95,
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],10257.41,10257.41,10257.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],11977.59,11977.59,11977.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9337.54,9337.54,9337.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],9890.24,9890.24,9890.24,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11251.14,,,,,,,fee schedule,9785.62,29401.95,MSDRG Base Rate
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,11143.98,,,,,,,fee schedule,9785.62,29401.95,MSDRG Base Rate
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,11143.98,,,,,,,fee schedule,9785.62,29401.95,MSDRG Base Rate
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,11251.14,,,,,,,fee schedule,9785.62,29401.95,MSDRG Base Rate
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,11143.98,,,,,,,fee schedule,9785.62,29401.95,MSDRG Base Rate
Other O.R. Procedures For Injuries Without Cc/Mcc,909,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18751.9,,,,,,,fee schedule,9785.62,29401.95,MSDRG Base Rate
Traumatic Injury With Mcc,913,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12486.27,,,,,,,fee schedule,12486.27,37516.35,
Traumatic Injury With Mcc,913,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,12486.27,,,,,,,fee schedule,12486.27,37516.35,
Traumatic Injury With Mcc,913,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16715.91,,,,,,,fee schedule,12486.27,37516.35,
Traumatic Injury With Mcc,913,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15919.92,,,,,,,fee schedule,12486.27,37516.35,
Traumatic Injury With Mcc,913,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,27883.2,,,,,,,fee schedule,12486.27,37516.35,
Traumatic Injury With Mcc,913,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,21667.7,,,,,,,fee schedule,12486.27,37516.35,
Traumatic Injury With Mcc,913,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,37516.35,,,,,,,fee schedule,12486.27,37516.35,
Traumatic Injury With Mcc,913,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,25790.45,,,,,,,fee schedule,12486.27,37516.35,
Traumatic Injury With Mcc,913,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,23357.1,,,,,,,fee schedule,12486.27,37516.35,
Traumatic Injury With Mcc,913,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19130.43,,,,,,,fee schedule,12486.27,37516.35,
Traumatic Injury With Mcc,913,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury With Mcc,913,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury With Mcc,913,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],25680.59,25680.59,25680.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Traumatic Injury With Mcc,913,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury With Mcc,913,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury With Mcc,913,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury With Mcc,913,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury With Mcc,913,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury With Mcc,913,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury With Mcc,913,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury With Mcc,913,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury With Mcc,913,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury With Mcc,913,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury With Mcc,913,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],11677.85,11677.85,11677.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Traumatic Injury With Mcc,913,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury With Mcc,913,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury With Mcc,913,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury With Mcc,913,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury With Mcc,913,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13765.95,,,,,,,fee schedule,12486.27,37516.35,MSDRG Base Rate
Traumatic Injury With Mcc,913,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,13634.85,,,,,,,fee schedule,12486.27,37516.35,MSDRG Base Rate
Traumatic Injury With Mcc,913,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,13634.85,,,,,,,fee schedule,12486.27,37516.35,MSDRG Base Rate
Traumatic Injury With Mcc,913,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,13765.95,,,,,,,fee schedule,12486.27,37516.35,MSDRG Base Rate
Traumatic Injury With Mcc,913,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,13634.85,,,,,,,fee schedule,12486.27,37516.35,MSDRG Base Rate
Traumatic Injury With Mcc,913,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22943.25,,,,,,,fee schedule,12486.27,37516.35,MSDRG Base Rate
Traumatic Injury Without Mcc,914,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7070.31,,,,,,,fee schedule,7070.31,21243.5,
Traumatic Injury Without Mcc,914,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,7070.31,,,,,,,fee schedule,7070.31,21243.5,
Traumatic Injury Without Mcc,914,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9465.32,,,,,,,fee schedule,7070.31,21243.5,
Traumatic Injury Without Mcc,914,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9014.6,,,,,,,fee schedule,7070.31,21243.5,
Traumatic Injury Without Mcc,914,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,15788.77,,,,,,,fee schedule,7070.31,21243.5,
Traumatic Injury Without Mcc,914,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,12269.26,,,,,,,fee schedule,7070.31,21243.5,
Traumatic Injury Without Mcc,914,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,21243.5,,,,,,,fee schedule,7070.31,21243.5,
Traumatic Injury Without Mcc,914,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,14603.75,,,,,,,fee schedule,7070.31,21243.5,
Traumatic Injury Without Mcc,914,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,13225.87,,,,,,,fee schedule,7070.31,21243.5,
Traumatic Injury Without Mcc,914,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10832.54,,,,,,,fee schedule,7070.31,21243.5,
Traumatic Injury Without Mcc,914,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury Without Mcc,914,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury Without Mcc,914,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury Without Mcc,914,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury Without Mcc,914,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury Without Mcc,914,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury Without Mcc,914,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury Without Mcc,914,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6715.47,6715.47,6715.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Traumatic Injury Without Mcc,914,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury Without Mcc,914,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury Without Mcc,914,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury Without Mcc,914,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury Without Mcc,914,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury Without Mcc,914,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],9908.61,9908.61,9908.61,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Traumatic Injury Without Mcc,914,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",170.04,170.04,170.04,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Traumatic Injury Without Mcc,914,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury Without Mcc,914,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury Without Mcc,914,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Traumatic Injury Without Mcc,914,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7913.68,,,,,,,fee schedule,7070.31,21243.5,MSDRG Base Rate
Traumatic Injury Without Mcc,914,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,7838.31,,,,,,,fee schedule,7070.31,21243.5,MSDRG Base Rate
Traumatic Injury Without Mcc,914,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,7838.31,,,,,,,fee schedule,7070.31,21243.5,MSDRG Base Rate
Traumatic Injury Without Mcc,914,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,7913.68,,,,,,,fee schedule,7070.31,21243.5,MSDRG Base Rate
Traumatic Injury Without Mcc,914,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,7838.31,,,,,,,fee schedule,7070.31,21243.5,MSDRG Base Rate
Traumatic Injury Without Mcc,914,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,13189.47,,,,,,,fee schedule,7070.31,21243.5,MSDRG Base Rate
Allergic Reactions With Mcc,915,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13409.13,,,,,,,fee schedule,13409.13,40289.16,
Allergic Reactions With Mcc,915,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,13409.13,,,,,,,fee schedule,13409.13,40289.16,
Allergic Reactions With Mcc,915,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17951.37,,,,,,,fee schedule,13409.13,40289.16,
Allergic Reactions With Mcc,915,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17096.55,,,,,,,fee schedule,13409.13,40289.16,
Allergic Reactions With Mcc,915,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,29944.03,,,,,,,fee schedule,13409.13,40289.16,
Allergic Reactions With Mcc,915,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,23269.14,,,,,,,fee schedule,13409.13,40289.16,
Allergic Reactions With Mcc,915,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,40289.16,,,,,,,fee schedule,13409.13,40289.16,
Allergic Reactions With Mcc,915,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,27696.6,,,,,,,fee schedule,13409.13,40289.16,
Allergic Reactions With Mcc,915,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,25083.41,,,,,,,fee schedule,13409.13,40289.16,
Allergic Reactions With Mcc,915,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20544.34,,,,,,,fee schedule,13409.13,40289.16,
Allergic Reactions With Mcc,915,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],40291.47,40291.47,40291.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Allergic Reactions With Mcc,915,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions With Mcc,915,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],23.51,23.51,23.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Allergic Reactions With Mcc,915,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions With Mcc,915,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions With Mcc,915,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions With Mcc,915,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions With Mcc,915,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4342.96,4342.96,4342.96,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Allergic Reactions With Mcc,915,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],18098.25,18098.25,18098.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Allergic Reactions With Mcc,915,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions With Mcc,915,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions With Mcc,915,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions With Mcc,915,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions With Mcc,915,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],28286,28286,28286,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Allergic Reactions With Mcc,915,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions With Mcc,915,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions With Mcc,915,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions With Mcc,915,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions With Mcc,915,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14133.14,,,,,,,fee schedule,13409.13,40289.16,MSDRG Base Rate
Allergic Reactions With Mcc,915,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,13998.54,,,,,,,fee schedule,13409.13,40289.16,MSDRG Base Rate
Allergic Reactions With Mcc,915,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,13998.54,,,,,,,fee schedule,13409.13,40289.16,MSDRG Base Rate
Allergic Reactions With Mcc,915,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,14133.14,,,,,,,fee schedule,13409.13,40289.16,MSDRG Base Rate
Allergic Reactions With Mcc,915,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,13998.54,,,,,,,fee schedule,13409.13,40289.16,MSDRG Base Rate
Allergic Reactions With Mcc,915,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23555.23,,,,,,,fee schedule,13409.13,40289.16,MSDRG Base Rate
Allergic Reactions Without Mcc,916,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5123.52,,,,,,,fee schedule,5123.52,15394.18,
Allergic Reactions Without Mcc,916,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,5123.52,,,,,,,fee schedule,5123.52,15394.18,
Allergic Reactions Without Mcc,916,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6859.08,,,,,,,fee schedule,5123.52,15394.18,
Allergic Reactions Without Mcc,916,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6532.46,,,,,,,fee schedule,5123.52,15394.18,
Allergic Reactions Without Mcc,916,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,11441.38,,,,,,,fee schedule,5123.52,15394.18,
Allergic Reactions Without Mcc,916,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,8890.96,,,,,,,fee schedule,5123.52,15394.18,
Allergic Reactions Without Mcc,916,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,15394.18,,,,,,,fee schedule,5123.52,15394.18,
Allergic Reactions Without Mcc,916,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,10582.66,,,,,,,fee schedule,5123.52,15394.18,
Allergic Reactions Without Mcc,916,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,9584.18,,,,,,,fee schedule,5123.52,15394.18,
Allergic Reactions Without Mcc,916,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,7849.83,,,,,,,fee schedule,5123.52,15394.18,
Allergic Reactions Without Mcc,916,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions Without Mcc,916,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions Without Mcc,916,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],5120.41,5120.41,5120.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Allergic Reactions Without Mcc,916,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],8235.66,8235.66,8235.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Allergic Reactions Without Mcc,916,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions Without Mcc,916,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions Without Mcc,916,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions Without Mcc,916,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3144.43,3144.43,3144.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Allergic Reactions Without Mcc,916,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],5060.99,5060.99,5060.99,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Allergic Reactions Without Mcc,916,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions Without Mcc,916,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions Without Mcc,916,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions Without Mcc,916,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions Without Mcc,916,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],10204.27,10204.27,10204.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Allergic Reactions Without Mcc,916,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],4512.44,4512.44,4512.44,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Allergic Reactions Without Mcc,916,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions Without Mcc,916,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions Without Mcc,916,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Allergic Reactions Without Mcc,916,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,6201.2,,,,,,,fee schedule,5123.52,15394.18,MSDRG Base Rate
Allergic Reactions Without Mcc,916,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,6142.14,,,,,,,fee schedule,5123.52,15394.18,MSDRG Base Rate
Allergic Reactions Without Mcc,916,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,6142.14,,,,,,,fee schedule,5123.52,15394.18,MSDRG Base Rate
Allergic Reactions Without Mcc,916,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,6201.2,,,,,,,fee schedule,5123.52,15394.18,MSDRG Base Rate
Allergic Reactions Without Mcc,916,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,6142.14,,,,,,,fee schedule,5123.52,15394.18,MSDRG Base Rate
Allergic Reactions Without Mcc,916,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10335.32,,,,,,,fee schedule,5123.52,15394.18,MSDRG Base Rate
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12651.4,,,,,,,fee schedule,12651.4,38012.49,
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,12651.4,,,,,,,fee schedule,12651.4,38012.49,
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,16936.97,,,,,,,fee schedule,12651.4,38012.49,
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16130.45,,,,,,,fee schedule,12651.4,38012.49,
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,28251.95,,,,,,,fee schedule,12651.4,38012.49,
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,21954.24,,,,,,,fee schedule,12651.4,38012.49,
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,38012.49,,,,,,,fee schedule,12651.4,38012.49,
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,26131.52,,,,,,,fee schedule,12651.4,38012.49,
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,23665.99,,,,,,,fee schedule,12651.4,38012.49,
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19383.42,,,,,,,fee schedule,12651.4,38012.49,
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12590.5,10920.54,22928.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],19129.61,2960.2,26134.31,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],4818.45,4818.45,4818.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],23667.43,23667.43,23667.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4762.23,4762.23,4762.23,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4472.36,4472.36,4472.36,28,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],16131.43,16131.43,16131.43,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],10778.83,10756.65,12762.15,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],16345.36,16345.36,16345.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],28253.67,4610.77,123614.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],11456.62,10603.02,12564.03,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4430.94,4430.94,10481.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],14707.73,14707.73,14707.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13248.77,,,,,,,fee schedule,12651.4,38012.49,MSDRG Base Rate
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,13122.6,,,,,,,fee schedule,12651.4,38012.49,MSDRG Base Rate
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,13122.6,,,,,,,fee schedule,12651.4,38012.49,MSDRG Base Rate
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,13248.77,,,,,,,fee schedule,12651.4,38012.49,MSDRG Base Rate
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,13122.6,,,,,,,fee schedule,12651.4,38012.49,MSDRG Base Rate
Poisoning And Toxic Effects Of Drugs With Mcc,917,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,22081.29,,,,,,,fee schedule,12651.4,38012.49,MSDRG Base Rate
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6824.16,,,,,,,fee schedule,6824.16,20503.93,
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,6824.16,,,,,,,fee schedule,6824.16,20503.93,
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9135.8,,,,,,,fee schedule,6824.16,20503.93,
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8700.76,,,,,,,fee schedule,6824.16,20503.93,
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,15239.1,,,,,,,fee schedule,6824.16,20503.93,
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,11842.12,,,,,,,fee schedule,6824.16,20503.93,
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,20503.93,,,,,,,fee schedule,6824.16,20503.93,
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,14095.34,,,,,,,fee schedule,6824.16,20503.93,
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,12765.43,,,,,,,fee schedule,6824.16,20503.93,
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10455.41,,,,,,,fee schedule,6824.16,20503.93,
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],18836,18836,18836,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],5440.7,5440.7,5440.7,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],11344,7976,96094.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],10597.52,10597.52,10597.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3729.51,3729.51,3729.51,16,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],5058.69,5058.69,5058.69,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],13520.23,13520.23,14710.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],6932.51,6233.47,6943.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3694.98,3694.98,3694.98,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7691.81,,,,,,,fee schedule,6824.16,20503.93,MSDRG Base Rate
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,7618.55,,,,,,,fee schedule,6824.16,20503.93,MSDRG Base Rate
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,7618.55,,,,,,,fee schedule,6824.16,20503.93,MSDRG Base Rate
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,7691.81,,,,,,,fee schedule,6824.16,20503.93,MSDRG Base Rate
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,7618.55,,,,,,,fee schedule,6824.16,20503.93,MSDRG Base Rate
Poisoning And Toxic Effects Of Drugs Without Mcc,918,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12819.68,,,,,,,fee schedule,6824.16,20503.93,MSDRG Base Rate
Complications Of Treatment With Mcc,919,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,14069.63,,,,,,,fee schedule,14069.63,42273.71,
Complications Of Treatment With Mcc,919,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,14069.63,,,,,,,fee schedule,14069.63,42273.71,
Complications Of Treatment With Mcc,919,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,18835.61,,,,,,,fee schedule,14069.63,42273.71,
Complications Of Treatment With Mcc,919,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,17938.68,,,,,,,fee schedule,14069.63,42273.71,
Complications Of Treatment With Mcc,919,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,31419.01,,,,,,,fee schedule,14069.63,42273.71,
Complications Of Treatment With Mcc,919,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,24415.33,,,,,,,fee schedule,14069.63,42273.71,
Complications Of Treatment With Mcc,919,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,42273.71,,,,,,,fee schedule,14069.63,42273.71,
Complications Of Treatment With Mcc,919,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,29060.88,,,,,,,fee schedule,14069.63,42273.71,
Complications Of Treatment With Mcc,919,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,26318.96,,,,,,,fee schedule,14069.63,42273.71,
Complications Of Treatment With Mcc,919,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,21556.31,,,,,,,fee schedule,14069.63,42273.71,
Complications Of Treatment With Mcc,919,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],15112.14,15112.14,15112.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Complications Of Treatment With Mcc,919,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment With Mcc,919,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],15422.77,13635.22,27402.56,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Complications Of Treatment With Mcc,919,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12320.58,12277.46,14791.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Complications Of Treatment With Mcc,919,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13108.17,13108.17,13108.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Complications Of Treatment With Mcc,919,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],12845.72,12845.72,12845.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Complications Of Treatment With Mcc,919,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment With Mcc,919,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",5552.67,5552.67,5552.67,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Complications Of Treatment With Mcc,919,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],17951.47,17951.47,17951.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Complications Of Treatment With Mcc,919,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13773.66,13773.66,13773.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Complications Of Treatment With Mcc,919,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],86777.33,86777.33,86777.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Complications Of Treatment With Mcc,919,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment With Mcc,919,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment With Mcc,919,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],15254,12734,31422.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Complications Of Treatment With Mcc,919,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],13897.59,13294.72,14951,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Complications Of Treatment With Mcc,919,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",5501.26,5501.26,5501.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Complications Of Treatment With Mcc,919,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment With Mcc,919,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],20216.8,20216.8,20216.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Complications Of Treatment With Mcc,919,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,15298.75,,,,,,,fee schedule,14069.63,42273.71,MSDRG Base Rate
Complications Of Treatment With Mcc,919,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,15153.05,,,,,,,fee schedule,14069.63,42273.71,MSDRG Base Rate
Complications Of Treatment With Mcc,919,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,15153.05,,,,,,,fee schedule,14069.63,42273.71,MSDRG Base Rate
Complications Of Treatment With Mcc,919,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,15298.75,,,,,,,fee schedule,14069.63,42273.71,MSDRG Base Rate
Complications Of Treatment With Mcc,919,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,15153.05,,,,,,,fee schedule,14069.63,42273.71,MSDRG Base Rate
Complications Of Treatment With Mcc,919,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,25497.92,,,,,,,fee schedule,14069.63,42273.71,MSDRG Base Rate
Complications Of Treatment With Cc,920,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7838.07,,,,,,,fee schedule,7838.07,23550.31,
Complications Of Treatment With Cc,920,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,7838.07,,,,,,,fee schedule,7838.07,23550.31,
Complications Of Treatment With Cc,920,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10493.15,,,,,,,fee schedule,7838.07,23550.31,
Complications Of Treatment With Cc,920,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9993.48,,,,,,,fee schedule,7838.07,23550.31,
Complications Of Treatment With Cc,920,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,17503.25,,,,,,,fee schedule,7838.07,23550.31,
Complications Of Treatment With Cc,920,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,13601.56,,,,,,,fee schedule,7838.07,23550.31,
Complications Of Treatment With Cc,920,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,23550.31,,,,,,,fee schedule,7838.07,23550.31,
Complications Of Treatment With Cc,920,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,16189.56,,,,,,,fee schedule,7838.07,23550.31,
Complications Of Treatment With Cc,920,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,14662.06,,,,,,,fee schedule,7838.07,23550.31,
Complications Of Treatment With Cc,920,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12008.83,,,,,,,fee schedule,7838.07,23550.31,
Complications Of Treatment With Cc,920,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment With Cc,920,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment With Cc,920,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],14323,14323,14323,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Complications Of Treatment With Cc,920,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment With Cc,920,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],8366.17,8366.17,8366.17,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Complications Of Treatment With Cc,920,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment With Cc,920,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment With Cc,920,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4228.18,4228.18,4228.18,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Complications Of Treatment With Cc,920,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],7716.02,6055.54,7810.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Complications Of Treatment With Cc,920,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment With Cc,920,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment With Cc,920,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment With Cc,920,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment With Cc,920,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],17044.77,17044.77,17504.97,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Complications Of Treatment With Cc,920,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],6664.03,6578.47,8039.53,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Complications Of Treatment With Cc,920,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4189.03,4189.03,4189.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Complications Of Treatment With Cc,920,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment With Cc,920,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment With Cc,920,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8826.16,,,,,,,fee schedule,7838.07,23550.31,MSDRG Base Rate
Complications Of Treatment With Cc,920,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,8742.1,,,,,,,fee schedule,7838.07,23550.31,MSDRG Base Rate
Complications Of Treatment With Cc,920,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,8742.1,,,,,,,fee schedule,7838.07,23550.31,MSDRG Base Rate
Complications Of Treatment With Cc,920,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,8826.16,,,,,,,fee schedule,7838.07,23550.31,MSDRG Base Rate
Complications Of Treatment With Cc,920,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,8742.1,,,,,,,fee schedule,7838.07,23550.31,MSDRG Base Rate
Complications Of Treatment With Cc,920,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14710.27,,,,,,,fee schedule,7838.07,23550.31,MSDRG Base Rate
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,5305.62,,,,,,,fee schedule,5305.62,15941.32,
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,5305.62,,,,,,,fee schedule,5305.62,15941.32,
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,7102.87,,,,,,,fee schedule,5305.62,15941.32,
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,6764.64,,,,,,,fee schedule,5305.62,15941.32,
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,11848.04,,,,,,,fee schedule,5305.62,15941.32,
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,9206.96,,,,,,,fee schedule,5305.62,15941.32,
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,15941.32,,,,,,,fee schedule,5305.62,15941.32,
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,10958.79,,,,,,,fee schedule,5305.62,15941.32,
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,9924.82,,,,,,,fee schedule,5305.62,15941.32,
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,8128.83,,,,,,,fee schedule,5305.62,15941.32,
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3464.27,3464.27,3464.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],7742.88,7742.88,7742.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],4192.68,4192.68,4192.68,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3432.2,3432.2,3432.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,6373.85,,,,,,,fee schedule,5305.62,15941.32,MSDRG Base Rate
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,6313.14,,,,,,,fee schedule,5305.62,15941.32,MSDRG Base Rate
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,6313.14,,,,,,,fee schedule,5305.62,15941.32,MSDRG Base Rate
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,6373.85,,,,,,,fee schedule,5305.62,15941.32,MSDRG Base Rate
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,6313.14,,,,,,,fee schedule,5305.62,15941.32,MSDRG Base Rate
Complications Of Treatment Without Cc/Mcc,921,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,10623.08,,,,,,,fee schedule,5305.62,15941.32,MSDRG Base Rate
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13034.12,,,,,,,fee schedule,13034.12,39162.41,
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,13034.12,,,,,,,fee schedule,13034.12,39162.41,
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17449.33,,,,,,,fee schedule,13034.12,39162.41,
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16618.42,,,,,,,fee schedule,13034.12,39162.41,
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,29106.61,,,,,,,fee schedule,13034.12,39162.41,
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,22618.39,,,,,,,fee schedule,13034.12,39162.41,
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,39162.41,,,,,,,fee schedule,13034.12,39162.41,
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,26922.03,,,,,,,fee schedule,13034.12,39162.41,
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,24381.91,,,,,,,fee schedule,13034.12,39162.41,
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19969.79,,,,,,,fee schedule,13034.12,39162.41,
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],22.85,22.85,22.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",6990.11,6990.11,6990.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",6564.63,6564.63,6564.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],9902.41,9902.41,9902.41,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",6503.85,6503.85,6503.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14662.82,,,,,,,fee schedule,13034.12,39162.41,MSDRG Base Rate
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,14523.17,,,,,,,fee schedule,13034.12,39162.41,MSDRG Base Rate
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,14523.17,,,,,,,fee schedule,13034.12,39162.41,MSDRG Base Rate
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,14662.82,,,,,,,fee schedule,13034.12,39162.41,MSDRG Base Rate
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,14523.17,,,,,,,fee schedule,13034.12,39162.41,MSDRG Base Rate
"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc",922,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,24438.03,,,,,,,fee schedule,13034.12,39162.41,MSDRG Base Rate
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7868.93,,,,,,,fee schedule,7868.93,23643.04,
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,7868.93,,,,,,,fee schedule,7868.93,23643.04,
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10534.47,,,,,,,fee schedule,7868.93,23643.04,
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10032.83,,,,,,,fee schedule,7868.93,23643.04,
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,17572.17,,,,,,,fee schedule,7868.93,23643.04,
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,13655.12,,,,,,,fee schedule,7868.93,23643.04,
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,23643.04,,,,,,,fee schedule,7868.93,23643.04,
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,16253.31,,,,,,,fee schedule,7868.93,23643.04,
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,14719.79,,,,,,,fee schedule,7868.93,23643.04,
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12056.12,,,,,,,fee schedule,7868.93,23643.04,
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],20045,20045,20045,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6977.27,6977.27,6977.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],10888,10888,11663.2,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4218.3,4218.3,4218.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],16862,16862,16862,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],8999.36,8999.36,8999.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8946.48,,,,,,,fee schedule,7868.93,23643.04,MSDRG Base Rate
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,8861.28,,,,,,,fee schedule,7868.93,23643.04,MSDRG Base Rate
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,8861.28,,,,,,,fee schedule,7868.93,23643.04,MSDRG Base Rate
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,8946.48,,,,,,,fee schedule,7868.93,23643.04,MSDRG Base Rate
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,8861.28,,,,,,,fee schedule,7868.93,23643.04,MSDRG Base Rate
"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc",923,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,14910.8,,,,,,,fee schedule,7868.93,23643.04,MSDRG Base Rate
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,183048.68,,,,,,,fee schedule,166196.6,549989.4,
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,183048.68,,,,,,,fee schedule,166196.6,549989.4,
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,245055.1,,,,,,,fee schedule,166196.6,549989.4,
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,233385.86,,,,,,,fee schedule,166196.6,549989.4,
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,408767.57,,,,,,,fee schedule,166196.6,549989.4,
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,317648.29,,,,,,,fee schedule,166196.6,549989.4,
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,549989.4,,,,,,,fee schedule,166196.6,549989.4,
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,378087.82,,,,,,,fee schedule,166196.6,549989.4,
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,342414.9,,,,,,,fee schedule,166196.6,549989.4,
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,280451.89,,,,,,,fee schedule,166196.6,549989.4,
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,167794.64,,,,,,,fee schedule,166196.6,549989.4,MSDRG Base Rate
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,166196.6,,,,,,,fee schedule,166196.6,549989.4,MSDRG Base Rate
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,166196.6,,,,,,,fee schedule,166196.6,549989.4,MSDRG Base Rate
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,167794.64,,,,,,,fee schedule,166196.6,549989.4,MSDRG Base Rate
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,166196.6,,,,,,,fee schedule,166196.6,549989.4,MSDRG Base Rate
Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft,927,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,279657.74,,,,,,,fee schedule,166196.6,549989.4,MSDRG Base Rate
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,51532.31,,,,,,,fee schedule,51532.31,154834.34,
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,51532.31,,,,,,,fee schedule,51532.31,154834.34,
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,68988.5,,,,,,,fee schedule,51532.31,154834.34,
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,65703.35,,,,,,,fee schedule,51532.31,154834.34,
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,115077.23,,,,,,,fee schedule,51532.31,154834.34,
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,89425.12,,,,,,,fee schedule,51532.31,154834.34,
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,154834.34,,,,,,,fee schedule,51532.31,154834.34,
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,106440.2,,,,,,,fee schedule,51532.31,154834.34,
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,96397.47,,,,,,,fee schedule,51532.31,154834.34,
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,78953.49,,,,,,,fee schedule,51532.31,154834.34,
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,57031.86,,,,,,,fee schedule,51532.31,154834.34,MSDRG Base Rate
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,56488.7,,,,,,,fee schedule,51532.31,154834.34,MSDRG Base Rate
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,56488.7,,,,,,,fee schedule,51532.31,154834.34,MSDRG Base Rate
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,57031.86,,,,,,,fee schedule,51532.31,154834.34,MSDRG Base Rate
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,56488.7,,,,,,,fee schedule,51532.31,154834.34,MSDRG Base Rate
Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc,928,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,95053.1,,,,,,,fee schedule,51532.31,154834.34,MSDRG Base Rate
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,24538.9,,,,,,,fee schedule,24538.9,73729.76,
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,24538.9,,,,,,,fee schedule,24538.9,73729.76,
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32851.28,,,,,,,fee schedule,24538.9,73729.76,
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,31286.93,,,,,,,fee schedule,24538.9,73729.76,
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,54798.03,,,,,,,fee schedule,24538.9,73729.76,
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,42582.88,,,,,,,fee schedule,24538.9,73729.76,
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,73729.76,,,,,,,fee schedule,24538.9,73729.76,
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,50685.2,,,,,,,fee schedule,24538.9,73729.76,
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,45903.01,,,,,,,fee schedule,24538.9,73729.76,
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37596.45,,,,,,,fee schedule,24538.9,73729.76,
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,26158,,,,,,,fee schedule,24538.9,73729.76,MSDRG Base Rate
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,25908.88,,,,,,,fee schedule,24538.9,73729.76,MSDRG Base Rate
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,25908.88,,,,,,,fee schedule,24538.9,73729.76,MSDRG Base Rate
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,26158,,,,,,,fee schedule,24538.9,73729.76,MSDRG Base Rate
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,25908.88,,,,,,,fee schedule,24538.9,73729.76,MSDRG Base Rate
Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc,929,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,43596.66,,,,,,,fee schedule,24538.9,73729.76,MSDRG Base Rate
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,33385.47,,,,,,,fee schedule,31119.65,100310.21,
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,33385.47,,,,,,,fee schedule,31119.65,100310.21,
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,44694.55,,,,,,,fee schedule,31119.65,100310.21,
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,42566.25,,,,,,,fee schedule,31119.65,100310.21,
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,74553.37,,,,,,,fee schedule,31119.65,100310.21,
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,57934.51,,,,,,,fee schedule,31119.65,100310.21,
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,100310.21,,,,,,,fee schedule,31119.65,100310.21,
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,68957.82,,,,,,,fee schedule,31119.65,100310.21,
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,62451.59,,,,,,,fee schedule,31119.65,100310.21,
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,51150.42,,,,,,,fee schedule,31119.65,100310.21,
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,31418.88,,,,,,,fee schedule,31119.65,100310.21,MSDRG Base Rate
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,31119.65,,,,,,,fee schedule,31119.65,100310.21,MSDRG Base Rate
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,31119.65,,,,,,,fee schedule,31119.65,100310.21,MSDRG Base Rate
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,31418.88,,,,,,,fee schedule,31119.65,100310.21,MSDRG Base Rate
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,31119.65,,,,,,,fee schedule,31119.65,100310.21,MSDRG Base Rate
Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft,933,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,52364.8,,,,,,,fee schedule,31119.65,100310.21,MSDRG Base Rate
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16556.54,,,,,,,fee schedule,16556.54,49745.91,
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,16556.54,,,,,,,fee schedule,16556.54,49745.91,
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22164.95,,,,,,,fee schedule,16556.54,49745.91,
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21109.48,,,,,,,fee schedule,16556.54,49745.91,
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,36972.56,,,,,,,fee schedule,16556.54,49745.91,
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,28730.92,,,,,,,fee schedule,16556.54,49745.91,
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,49745.91,,,,,,,fee schedule,16556.54,49745.91,
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,34197.61,,,,,,,fee schedule,16556.54,49745.91,
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,30971.03,,,,,,,fee schedule,16556.54,49745.91,
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,25366.55,,,,,,,fee schedule,16556.54,49745.91,
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",7455.36,7455.36,7455.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,18265.9,,,,,,,fee schedule,16556.54,49745.91,MSDRG Base Rate
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,18091.94,,,,,,,fee schedule,16556.54,49745.91,MSDRG Base Rate
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,18091.94,,,,,,,fee schedule,16556.54,49745.91,MSDRG Base Rate
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,18265.9,,,,,,,fee schedule,16556.54,49745.91,MSDRG Base Rate
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,18091.94,,,,,,,fee schedule,16556.54,49745.91,MSDRG Base Rate
Full Thickness Burn Without Skin Graft Or Inhalation Injury,934,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,30443.17,,,,,,,fee schedule,16556.54,49745.91,MSDRG Base Rate
Non-Extensive Burns,935,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16946.98,,,,,,,fee schedule,16926.59,50919.02,
Non-Extensive Burns,935,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,16946.98,,,,,,,fee schedule,16926.59,50919.02,
Non-Extensive Burns,935,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,22687.65,,,,,,,fee schedule,16926.59,50919.02,
Non-Extensive Burns,935,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,21607.29,,,,,,,fee schedule,16926.59,50919.02,
Non-Extensive Burns,935,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,37844.45,,,,,,,fee schedule,16926.59,50919.02,
Non-Extensive Burns,935,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,29408.46,,,,,,,fee schedule,16926.59,50919.02,
Non-Extensive Burns,935,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,50919.02,,,,,,,fee schedule,16926.59,50919.02,
Non-Extensive Burns,935,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,35004.06,,,,,,,fee schedule,16926.59,50919.02,
Non-Extensive Burns,935,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,31701.39,,,,,,,fee schedule,16926.59,50919.02,
Non-Extensive Burns,935,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,25964.75,,,,,,,fee schedule,16926.59,50919.02,
Non-Extensive Burns,935,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive Burns,935,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive Burns,935,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive Burns,935,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive Burns,935,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive Burns,935,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive Burns,935,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive Burns,935,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive Burns,935,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive Burns,935,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive Burns,935,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive Burns,935,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive Burns,935,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive Burns,935,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],14716.11,14716.11,14716.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Non-Extensive Burns,935,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",3499.92,3499.92,3499.92,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Non-Extensive Burns,935,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive Burns,935,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive Burns,935,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive Burns,935,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,17089.35,,,,,,,fee schedule,16926.59,50919.02,MSDRG Base Rate
Non-Extensive Burns,935,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,16926.59,,,,,,,fee schedule,16926.59,50919.02,MSDRG Base Rate
Non-Extensive Burns,935,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,16926.59,,,,,,,fee schedule,16926.59,50919.02,MSDRG Base Rate
Non-Extensive Burns,935,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,17089.35,,,,,,,fee schedule,16926.59,50919.02,MSDRG Base Rate
Non-Extensive Burns,935,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,16926.59,,,,,,,fee schedule,16926.59,50919.02,MSDRG Base Rate
Non-Extensive Burns,935,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,28482.25,,,,,,,fee schedule,16926.59,50919.02,MSDRG Base Rate
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,24489.52,,,,,,,fee schedule,24489.52,73581.38,
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,24489.52,,,,,,,fee schedule,24489.52,73581.38,
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,32785.16,,,,,,,fee schedule,24489.52,73581.38,
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,31223.97,,,,,,,fee schedule,24489.52,73581.38,
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,54687.75,,,,,,,fee schedule,24489.52,73581.38,
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,42497.18,,,,,,,fee schedule,24489.52,73581.38,
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,73581.38,,,,,,,fee schedule,24489.52,73581.38,
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,50583.2,,,,,,,fee schedule,24489.52,73581.38,
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,45810.63,,,,,,,fee schedule,24489.52,73581.38,
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,37520.79,,,,,,,fee schedule,24489.52,73581.38,
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,29343.12,,,,,,,fee schedule,24489.52,73581.38,MSDRG Base Rate
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,29063.66,,,,,,,fee schedule,24489.52,73581.38,MSDRG Base Rate
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,29063.66,,,,,,,fee schedule,24489.52,73581.38,MSDRG Base Rate
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,29343.12,,,,,,,fee schedule,24489.52,73581.38,MSDRG Base Rate
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,29063.66,,,,,,,fee schedule,24489.52,73581.38,MSDRG Base Rate
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc,939,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,48905.2,,,,,,,fee schedule,24489.52,73581.38,MSDRG Base Rate
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,16291.11,,,,,,,fee schedule,16291.11,48948.38,
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,16291.11,,,,,,,fee schedule,16291.11,48948.38,
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,21809.6,,,,,,,fee schedule,16291.11,48948.38,
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,20771.05,,,,,,,fee schedule,16291.11,48948.38,
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,36379.81,,,,,,,fee schedule,16291.11,48948.38,
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,28270.31,,,,,,,fee schedule,16291.11,48948.38,
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,48948.38,,,,,,,fee schedule,16291.11,48948.38,
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,33649.35,,,,,,,fee schedule,16291.11,48948.38,
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,30474.5,,,,,,,fee schedule,16291.11,48948.38,
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,24959.87,,,,,,,fee schedule,16291.11,48948.38,
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,19252.61,,,,,,,fee schedule,16291.11,48948.38,MSDRG Base Rate
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,19069.25,,,,,,,fee schedule,16291.11,48948.38,MSDRG Base Rate
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,19069.25,,,,,,,fee schedule,16291.11,48948.38,MSDRG Base Rate
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,19252.61,,,,,,,fee schedule,16291.11,48948.38,MSDRG Base Rate
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,19069.25,,,,,,,fee schedule,16291.11,48948.38,MSDRG Base Rate
O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc,940,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,32087.68,,,,,,,fee schedule,16291.11,48948.38,MSDRG Base Rate
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,15078.9,,,,,,,fee schedule,15078.9,45306.17,
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,15078.9,,,,,,,fee schedule,15078.9,45306.17,
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,20186.77,,,,,,,fee schedule,15078.9,45306.17,
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,19225.5,,,,,,,fee schedule,15078.9,45306.17,
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,33672.82,,,,,,,fee schedule,15078.9,45306.17,
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,26166.74,,,,,,,fee schedule,15078.9,45306.17,
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,45306.17,,,,,,,fee schedule,15078.9,45306.17,
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,31145.53,,,,,,,fee schedule,15078.9,45306.17,
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,28206.92,,,,,,,fee schedule,15078.9,45306.17,
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,23102.63,,,,,,,fee schedule,15078.9,45306.17,
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,16837.01,,,,,,,fee schedule,15078.9,45306.17,MSDRG Base Rate
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,16676.66,,,,,,,fee schedule,15078.9,45306.17,MSDRG Base Rate
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,16676.66,,,,,,,fee schedule,15078.9,45306.17,MSDRG Base Rate
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,16837.01,,,,,,,fee schedule,15078.9,45306.17,MSDRG Base Rate
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,16676.66,,,,,,,fee schedule,15078.9,45306.17,MSDRG Base Rate
O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc,941,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,28061.69,,,,,,,fee schedule,15078.9,45306.17,MSDRG Base Rate
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11777.93,,,,,,,fee schedule,11777.93,35388.06,
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,11777.93,,,,,,,fee schedule,11777.93,35388.06,
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15767.62,,,,,,,fee schedule,11777.93,35388.06,
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,15016.78,,,,,,,fee schedule,11777.93,35388.06,
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,26301.4,,,,,,,fee schedule,11777.93,35388.06,
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,20438.5,,,,,,,fee schedule,11777.93,35388.06,
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,35388.06,,,,,,,fee schedule,11777.93,35388.06,
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,24327.37,,,,,,,fee schedule,11777.93,35388.06,
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,22032.06,,,,,,,fee schedule,11777.93,35388.06,
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,18045.16,,,,,,,fee schedule,11777.93,35388.06,
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13094.09,,,,,,,fee schedule,11777.93,35388.06,MSDRG Base Rate
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,12969.38,,,,,,,fee schedule,11777.93,35388.06,MSDRG Base Rate
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,12969.38,,,,,,,fee schedule,11777.93,35388.06,MSDRG Base Rate
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,13094.09,,,,,,,fee schedule,11777.93,35388.06,MSDRG Base Rate
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,12969.38,,,,,,,fee schedule,11777.93,35388.06,MSDRG Base Rate
Rehabilitation With Cc/Mcc,945,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21823.48,,,,,,,fee schedule,11777.93,35388.06,MSDRG Base Rate
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8614.31,,,,,,,fee schedule,8614.31,25882.62,
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,8614.31,,,,,,,fee schedule,8614.31,25882.62,
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11532.35,,,,,,,fee schedule,8614.31,25882.62,
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10983.19,,,,,,,fee schedule,8614.31,25882.62,
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,19236.69,,,,,,,fee schedule,8614.31,25882.62,
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,14948.6,,,,,,,fee schedule,8614.31,25882.62,
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,25882.62,,,,,,,fee schedule,8614.31,25882.62,
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,17792.89,,,,,,,fee schedule,8614.31,25882.62,
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,16114.12,,,,,,,fee schedule,8614.31,25882.62,
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13198.13,,,,,,,fee schedule,8614.31,25882.62,
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,9955.06,,,,,,,fee schedule,8614.31,25882.62,MSDRG Base Rate
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,9860.25,,,,,,,fee schedule,8614.31,25882.62,MSDRG Base Rate
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,9860.25,,,,,,,fee schedule,8614.31,25882.62,MSDRG Base Rate
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,9955.06,,,,,,,fee schedule,8614.31,25882.62,MSDRG Base Rate
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,9860.25,,,,,,,fee schedule,8614.31,25882.62,MSDRG Base Rate
Rehabilitation Without Cc/Mcc,946,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,16591.77,,,,,,,fee schedule,8614.31,25882.62,MSDRG Base Rate
Signs And Symptoms With Mcc,947,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,9923.74,,,,,,,fee schedule,9923.74,29816.94,
Signs And Symptoms With Mcc,947,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,9923.74,,,,,,,fee schedule,9923.74,29816.94,
Signs And Symptoms With Mcc,947,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,13285.34,,,,,,,fee schedule,9923.74,29816.94,
Signs And Symptoms With Mcc,947,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,12652.7,,,,,,,fee schedule,9923.74,29816.94,
Signs And Symptoms With Mcc,947,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,22160.79,,,,,,,fee schedule,9923.74,29816.94,
Signs And Symptoms With Mcc,947,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,17220.88,,,,,,,fee schedule,9923.74,29816.94,
Signs And Symptoms With Mcc,947,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,29816.94,,,,,,,fee schedule,9923.74,29816.94,
Signs And Symptoms With Mcc,947,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,20497.53,,,,,,,fee schedule,9923.74,29816.94,
Signs And Symptoms With Mcc,947,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,18563.57,,,,,,,fee schedule,9923.74,29816.94,
Signs And Symptoms With Mcc,947,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,15204.33,,,,,,,fee schedule,9923.74,29816.94,
Signs And Symptoms With Mcc,947,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms With Mcc,947,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms With Mcc,947,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],10013.39,10013.39,10013.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Signs And Symptoms With Mcc,947,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],21414.09,21414.09,21414.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Signs And Symptoms With Mcc,947,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms With Mcc,947,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms With Mcc,947,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms With Mcc,947,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",6366.02,6366.02,6366.02,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Signs And Symptoms With Mcc,947,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms With Mcc,947,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms With Mcc,947,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms With Mcc,947,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms With Mcc,947,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms With Mcc,947,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],13440,13440,13440,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Signs And Symptoms With Mcc,947,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],9997.64,9997.64,10013.39,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Signs And Symptoms With Mcc,947,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",6307.07,6307.07,6307.07,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Signs And Symptoms With Mcc,947,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms With Mcc,947,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms With Mcc,947,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10912.86,,,,,,,fee schedule,9923.74,29816.94,MSDRG Base Rate
Signs And Symptoms With Mcc,947,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,10808.93,,,,,,,fee schedule,9923.74,29816.94,MSDRG Base Rate
Signs And Symptoms With Mcc,947,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,10808.93,,,,,,,fee schedule,9923.74,29816.94,MSDRG Base Rate
Signs And Symptoms With Mcc,947,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,10912.86,,,,,,,fee schedule,9923.74,29816.94,MSDRG Base Rate
Signs And Symptoms With Mcc,947,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,10808.93,,,,,,,fee schedule,9923.74,29816.94,MSDRG Base Rate
Signs And Symptoms With Mcc,947,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18188.1,,,,,,,fee schedule,9923.74,29816.94,MSDRG Base Rate
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,6130.48,,,,,,,fee schedule,6130.48,18419.69,
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,6130.48,,,,,,,fee schedule,6130.48,18419.69,
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,8207.14,,,,,,,fee schedule,6130.48,18419.69,
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,7816.32,,,,,,,fee schedule,6130.48,18419.69,
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,13690.03,,,,,,,fee schedule,6130.48,18419.69,
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,10638.36,,,,,,,fee schedule,6130.48,18419.69,
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,18419.69,,,,,,,fee schedule,6130.48,18419.69,
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,12662.53,,,,,,,fee schedule,6130.48,18419.69,
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,11467.81,,,,,,,fee schedule,6130.48,18419.69,
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,9392.61,,,,,,,fee schedule,6130.48,18419.69,
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],6554.66,6554.66,6554.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4658.33,4658.33,4658.33,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4374.77,4374.77,4897.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],4376.14,4376.14,4376.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],13690.03,13690.03,13690.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],5562.04,5282.66,6451.84,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4334.27,4334.27,4334.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,7249.62,,,,,,,fee schedule,6130.48,18419.69,MSDRG Base Rate
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,7180.58,,,,,,,fee schedule,6130.48,18419.69,MSDRG Base Rate
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,7180.58,,,,,,,fee schedule,6130.48,18419.69,MSDRG Base Rate
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,7249.62,,,,,,,fee schedule,6130.48,18419.69,MSDRG Base Rate
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,7180.58,,,,,,,fee schedule,6130.48,18419.69,MSDRG Base Rate
Signs And Symptoms Without Mcc,948,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,12082.7,,,,,,,fee schedule,6130.48,18419.69,MSDRG Base Rate
Aftercare With Cc/Mcc,949,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8324.95,,,,,,,fee schedule,8324.95,25013.22,
Aftercare With Cc/Mcc,949,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,8324.95,,,,,,,fee schedule,8324.95,25013.22,
Aftercare With Cc/Mcc,949,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11144.97,,,,,,,fee schedule,8324.95,25013.22,
Aftercare With Cc/Mcc,949,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,10614.26,,,,,,,fee schedule,8324.95,25013.22,
Aftercare With Cc/Mcc,949,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,18590.53,,,,,,,fee schedule,8324.95,25013.22,
Aftercare With Cc/Mcc,949,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,14446.47,,,,,,,fee schedule,8324.95,25013.22,
Aftercare With Cc/Mcc,949,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,25013.22,,,,,,,fee schedule,8324.95,25013.22,
Aftercare With Cc/Mcc,949,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,17195.23,,,,,,,fee schedule,8324.95,25013.22,
Aftercare With Cc/Mcc,949,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,15572.84,,,,,,,fee schedule,8324.95,25013.22,
Aftercare With Cc/Mcc,949,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,12754.8,,,,,,,fee schedule,8324.95,25013.22,
Aftercare With Cc/Mcc,949,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aftercare With Cc/Mcc,949,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Aftercare With Cc/Mcc,949,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Aftercare With Cc/Mcc,949,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aftercare With Cc/Mcc,949,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aftercare With Cc/Mcc,949,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Aftercare With Cc/Mcc,949,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Aftercare With Cc/Mcc,949,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Aftercare With Cc/Mcc,949,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Aftercare With Cc/Mcc,949,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Aftercare With Cc/Mcc,949,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aftercare With Cc/Mcc,949,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aftercare With Cc/Mcc,949,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Aftercare With Cc/Mcc,949,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Aftercare With Cc/Mcc,949,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aftercare With Cc/Mcc,949,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Aftercare With Cc/Mcc,949,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aftercare With Cc/Mcc,949,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aftercare With Cc/Mcc,949,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10290.21,,,,,,,fee schedule,8324.95,25013.22,MSDRG Base Rate
Aftercare With Cc/Mcc,949,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,10192.21,,,,,,,fee schedule,8324.95,25013.22,MSDRG Base Rate
Aftercare With Cc/Mcc,949,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,10192.21,,,,,,,fee schedule,8324.95,25013.22,MSDRG Base Rate
Aftercare With Cc/Mcc,949,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,10290.21,,,,,,,fee schedule,8324.95,25013.22,MSDRG Base Rate
Aftercare With Cc/Mcc,949,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,10192.21,,,,,,,fee schedule,8324.95,25013.22,MSDRG Base Rate
Aftercare With Cc/Mcc,949,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,17150.35,,,,,,,fee schedule,8324.95,25013.22,MSDRG Base Rate
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4522.44,,,,,,,fee schedule,4522.44,13588.14,
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,4522.44,,,,,,,fee schedule,4522.44,13588.14,
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,6054.38,,,,,,,fee schedule,4522.44,13588.14,
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5766.08,,,,,,,fee schedule,4522.44,13588.14,
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,10099.09,,,,,,,fee schedule,4522.44,13588.14,
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,7847.88,,,,,,,fee schedule,4522.44,13588.14,
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,13588.14,,,,,,,fee schedule,4522.44,13588.14,
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,9341.11,,,,,,,fee schedule,4522.44,13588.14,
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,8459.77,,,,,,,fee schedule,4522.44,13588.14,
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6928.9,,,,,,,fee schedule,4522.44,13588.14,
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,5899.64,,,,,,,fee schedule,4522.44,13588.14,MSDRG Base Rate
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,5843.45,,,,,,,fee schedule,4522.44,13588.14,MSDRG Base Rate
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,5843.45,,,,,,,fee schedule,4522.44,13588.14,MSDRG Base Rate
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,5899.64,,,,,,,fee schedule,4522.44,13588.14,MSDRG Base Rate
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,5843.45,,,,,,,fee schedule,4522.44,13588.14,MSDRG Base Rate
Aftercare Without Cc/Mcc,950,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,9832.72,,,,,,,fee schedule,4522.44,13588.14,MSDRG Base Rate
Other Factors Influencing Health Status,951,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,4374.29,,,,,,,fee schedule,4374.29,13143.01,
Other Factors Influencing Health Status,951,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,4374.29,,,,,,,fee schedule,4374.29,13143.01,
Other Factors Influencing Health Status,951,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,5856.04,,,,,,,fee schedule,4374.29,13143.01,
Other Factors Influencing Health Status,951,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,5577.18,,,,,,,fee schedule,4374.29,13143.01,
Other Factors Influencing Health Status,951,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,9768.25,,,,,,,fee schedule,4374.29,13143.01,
Other Factors Influencing Health Status,951,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,7590.79,,,,,,,fee schedule,4374.29,13143.01,
Other Factors Influencing Health Status,951,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,13143.01,,,,,,,fee schedule,4374.29,13143.01,
Other Factors Influencing Health Status,951,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,9035.1,,,,,,,fee schedule,4374.29,13143.01,
Other Factors Influencing Health Status,951,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,8182.63,,,,,,,fee schedule,4374.29,13143.01,
Other Factors Influencing Health Status,951,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,6701.91,,,,,,,fee schedule,4374.29,13143.01,
Other Factors Influencing Health Status,951,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Factors Influencing Health Status,951,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Factors Influencing Health Status,951,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Other Factors Influencing Health Status,951,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Factors Influencing Health Status,951,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Factors Influencing Health Status,951,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Other Factors Influencing Health Status,951,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Factors Influencing Health Status,951,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",2388.26,2388.26,2388.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Factors Influencing Health Status,951,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],2575.03,2575.03,2575.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Factors Influencing Health Status,951,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other Factors Influencing Health Status,951,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Factors Influencing Health Status,951,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Factors Influencing Health Status,951,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Other Factors Influencing Health Status,951,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",2366.14,2366.14,2366.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Factors Influencing Health Status,951,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Other Factors Influencing Health Status,951,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Factors Influencing Health Status,951,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Factors Influencing Health Status,951,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Factors Influencing Health Status,951,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,5339.49,,,,,,,fee schedule,4374.29,13143.01,MSDRG Base Rate
Other Factors Influencing Health Status,951,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,5288.64,,,,,,,fee schedule,4374.29,13143.01,MSDRG Base Rate
Other Factors Influencing Health Status,951,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,5288.64,,,,,,,fee schedule,4374.29,13143.01,MSDRG Base Rate
Other Factors Influencing Health Status,951,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,5339.49,,,,,,,fee schedule,4374.29,13143.01,MSDRG Base Rate
Other Factors Influencing Health Status,951,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,5288.64,,,,,,,fee schedule,4374.29,13143.01,MSDRG Base Rate
Other Factors Influencing Health Status,951,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,8899.15,,,,,,,fee schedule,4374.29,13143.01,MSDRG Base Rate
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,52685.1,,,,,,,fee schedule,52685.1,158298.03,
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,52685.1,,,,,,,fee schedule,52685.1,158298.03,
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,70531.8,,,,,,,fee schedule,52685.1,158298.03,
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,67173.15,,,,,,,fee schedule,52685.1,158298.03,
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,117651.54,,,,,,,fee schedule,52685.1,158298.03,
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,91425.58,,,,,,,fee schedule,52685.1,158298.03,
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,158298.03,,,,,,,fee schedule,52685.1,158298.03,
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,108821.29,,,,,,,fee schedule,52685.1,158298.03,
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,98553.91,,,,,,,fee schedule,52685.1,158298.03,
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,80719.71,,,,,,,fee schedule,52685.1,158298.03,
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,53581.9,,,,,,,fee schedule,52685.1,158298.03,MSDRG Base Rate
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,53071.6,,,,,,,fee schedule,52685.1,158298.03,MSDRG Base Rate
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,53071.6,,,,,,,fee schedule,52685.1,158298.03,MSDRG Base Rate
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,53581.9,,,,,,,fee schedule,52685.1,158298.03,MSDRG Base Rate
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,53071.6,,,,,,,fee schedule,52685.1,158298.03,MSDRG Base Rate
Craniotomy For Multiple Significant Trauma,955,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,89303.16,,,,,,,fee schedule,52685.1,158298.03,MSDRG Base Rate
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,29492.67,,,,,,,fee schedule,29492.67,88613.88,
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,29492.67,,,,,,,fee schedule,29492.67,88613.88,
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,39483.1,,,,,,,fee schedule,29492.67,88613.88,
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,37602.96,,,,,,,fee schedule,29492.67,88613.88,
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,65860.33,,,,,,,fee schedule,29492.67,88613.88,
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,51179.26,,,,,,,fee schedule,29492.67,88613.88,
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,88613.88,,,,,,,fee schedule,29492.67,88613.88,
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,60917.23,,,,,,,fee schedule,29492.67,88613.88,
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,55169.63,,,,,,,fee schedule,29492.67,88613.88,
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,45186.2,,,,,,,fee schedule,29492.67,88613.88,
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],28264.88,28264.88,28264.88,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],28344.1,28344.1,28344.1,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],28989.54,28989.54,28989.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],28403.05,26723.04,28484.11,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,30393.89,,,,,,,fee schedule,29492.67,88613.88,MSDRG Base Rate
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,30104.42,,,,,,,fee schedule,29492.67,88613.88,MSDRG Base Rate
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,30104.42,,,,,,,fee schedule,29492.67,88613.88,MSDRG Base Rate
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,30393.89,,,,,,,fee schedule,29492.67,88613.88,MSDRG Base Rate
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,30104.42,,,,,,,fee schedule,29492.67,88613.88,MSDRG Base Rate
"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma",956,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,50656.48,,,,,,,fee schedule,29492.67,88613.88,MSDRG Base Rate
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,57591.03,,,,,,,fee schedule,57591.03,173038.42,
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,57591.03,,,,,,,fee schedule,57591.03,173038.42,
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,77099.57,,,,,,,fee schedule,57591.03,173038.42,
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,73428.18,,,,,,,fee schedule,57591.03,173038.42,
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,128607.01,,,,,,,fee schedule,57591.03,173038.42,
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,99938.94,,,,,,,fee schedule,57591.03,173038.42,
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,173038.42,,,,,,,fee schedule,57591.03,173038.42,
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,118954.51,,,,,,,fee schedule,57591.03,173038.42,
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,107731.05,,,,,,,fee schedule,57591.03,173038.42,
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,88236.16,,,,,,,fee schedule,57591.03,173038.42,
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,60525.57,,,,,,,fee schedule,57591.03,173038.42,MSDRG Base Rate
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,59949.14,,,,,,,fee schedule,57591.03,173038.42,MSDRG Base Rate
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,59949.14,,,,,,,fee schedule,57591.03,173038.42,MSDRG Base Rate
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,60525.57,,,,,,,fee schedule,57591.03,173038.42,MSDRG Base Rate
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,59949.14,,,,,,,fee schedule,57591.03,173038.42,MSDRG Base Rate
Other O.R. Procedures For Multiple Significant Trauma With Mcc,957,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,100875.95,,,,,,,fee schedule,57591.03,173038.42,MSDRG Base Rate
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,31709.52,,,,,,,fee schedule,31709.52,95274.65,
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,31709.52,,,,,,,fee schedule,31709.52,95274.65,
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,42450.89,,,,,,,fee schedule,31709.52,95274.65,
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,40429.43,,,,,,,fee schedule,31709.52,95274.65,
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,70810.79,,,,,,,fee schedule,31709.52,95274.65,
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,55026.21,,,,,,,fee schedule,31709.52,95274.65,
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,95274.65,,,,,,,fee schedule,31709.52,95274.65,
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,65496.14,,,,,,,fee schedule,31709.52,95274.65,
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,59316.52,,,,,,,fee schedule,31709.52,95274.65,
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,48582.67,,,,,,,fee schedule,31709.52,95274.65,
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],28068.72,28068.72,28068.72,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,33916.5,,,,,,,fee schedule,31709.52,95274.65,MSDRG Base Rate
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,33593.49,,,,,,,fee schedule,31709.52,95274.65,MSDRG Base Rate
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,33593.49,,,,,,,fee schedule,31709.52,95274.65,MSDRG Base Rate
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,33916.5,,,,,,,fee schedule,31709.52,95274.65,MSDRG Base Rate
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,33593.49,,,,,,,fee schedule,31709.52,95274.65,MSDRG Base Rate
Other O.R. Procedures For Multiple Significant Trauma With Cc,958,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,56527.5,,,,,,,fee schedule,31709.52,95274.65,MSDRG Base Rate
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,20399.19,,,,,,,fee schedule,20399.19,61291.54,
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,20399.19,,,,,,,fee schedule,20399.19,61291.54,
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,27309.26,,,,,,,fee schedule,20399.19,61291.54,
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26008.83,,,,,,,fee schedule,20399.19,61291.54,
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,45553.59,,,,,,,fee schedule,20399.19,61291.54,
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,35399.14,,,,,,,fee schedule,20399.19,61291.54,
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,61291.54,,,,,,,fee schedule,20399.19,61291.54,
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,42134.6,,,,,,,fee schedule,20399.19,61291.54,
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,38159.17,,,,,,,fee schedule,20399.19,61291.54,
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,31253.93,,,,,,,fee schedule,20399.19,61291.54,
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,23996.3,,,,,,,fee schedule,20399.19,61291.54,MSDRG Base Rate
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,23767.76,,,,,,,fee schedule,20399.19,61291.54,MSDRG Base Rate
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,23767.76,,,,,,,fee schedule,20399.19,61291.54,MSDRG Base Rate
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,23996.3,,,,,,,fee schedule,20399.19,61291.54,MSDRG Base Rate
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,23767.76,,,,,,,fee schedule,20399.19,61291.54,MSDRG Base Rate
Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc,959,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,39993.84,,,,,,,fee schedule,20399.19,61291.54,MSDRG Base Rate
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,20961.69,,,,,,,fee schedule,20961.69,62981.65,
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,20961.69,,,,,,,fee schedule,20961.69,62981.65,
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,28062.32,,,,,,,fee schedule,20961.69,62981.65,
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26726.02,,,,,,,fee schedule,20961.69,62981.65,
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,46809.73,,,,,,,fee schedule,20961.69,62981.65,
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,36375.27,,,,,,,fee schedule,20961.69,62981.65,
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,62981.65,,,,,,,fee schedule,20961.69,62981.65,
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,43296.46,,,,,,,fee schedule,20961.69,62981.65,
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,39211.4,,,,,,,fee schedule,20961.69,62981.65,
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,32115.75,,,,,,,fee schedule,20961.69,62981.65,
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],29780.58,29780.58,29780.58,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,22353.36,,,,,,,fee schedule,20961.69,62981.65,MSDRG Base Rate
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,22140.47,,,,,,,fee schedule,20961.69,62981.65,MSDRG Base Rate
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,22140.47,,,,,,,fee schedule,20961.69,62981.65,MSDRG Base Rate
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,22353.36,,,,,,,fee schedule,20961.69,62981.65,MSDRG Base Rate
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,22140.47,,,,,,,fee schedule,20961.69,62981.65,MSDRG Base Rate
Other Multiple Significant Trauma With Mcc,963,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,37255.59,,,,,,,fee schedule,20961.69,62981.65,MSDRG Base Rate
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11575.77,,,,,,,fee schedule,11575.77,34780.64,
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,11575.77,,,,,,,fee schedule,11575.77,34780.64,
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,15496.98,,,,,,,fee schedule,11575.77,34780.64,
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14759.03,,,,,,,fee schedule,11575.77,34780.64,
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,25849.95,,,,,,,fee schedule,11575.77,34780.64,
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,20087.68,,,,,,,fee schedule,11575.77,34780.64,
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,34780.64,,,,,,,fee schedule,11575.77,34780.64,
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,23909.8,,,,,,,fee schedule,11575.77,34780.64,
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,21653.89,,,,,,,fee schedule,11575.77,34780.64,
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17735.42,,,,,,,fee schedule,11575.77,34780.64,
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],10812.48,10812.48,10812.48,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],9451.36,9451.36,9451.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,12969.09,,,,,,,fee schedule,11575.77,34780.64,MSDRG Base Rate
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,12845.57,,,,,,,fee schedule,11575.77,34780.64,MSDRG Base Rate
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,12845.57,,,,,,,fee schedule,11575.77,34780.64,MSDRG Base Rate
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,12969.09,,,,,,,fee schedule,11575.77,34780.64,MSDRG Base Rate
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,12845.57,,,,,,,fee schedule,11575.77,34780.64,MSDRG Base Rate
Other Multiple Significant Trauma With Cc,964,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,21615.14,,,,,,,fee schedule,11575.77,34780.64,MSDRG Base Rate
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7040.99,,,,,,,fee schedule,7040.99,21155.4,
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,7040.99,,,,,,,fee schedule,7040.99,21155.4,
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,9426.07,,,,,,,fee schedule,7040.99,21155.4,
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,8977.21,,,,,,,fee schedule,7040.99,21155.4,
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,15723.29,,,,,,,fee schedule,7040.99,21155.4,
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,12218.38,,,,,,,fee schedule,7040.99,21155.4,
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,21155.4,,,,,,,fee schedule,7040.99,21155.4,
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,14543.19,,,,,,,fee schedule,7040.99,21155.4,
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,13171.03,,,,,,,fee schedule,7040.99,21155.4,
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,10787.61,,,,,,,fee schedule,7040.99,21155.4,
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8343.36,,,,,,,fee schedule,7040.99,21155.4,MSDRG Base Rate
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,8263.9,,,,,,,fee schedule,7040.99,21155.4,MSDRG Base Rate
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,8263.9,,,,,,,fee schedule,7040.99,21155.4,MSDRG Base Rate
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,8343.36,,,,,,,fee schedule,7040.99,21155.4,MSDRG Base Rate
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,8263.9,,,,,,,fee schedule,7040.99,21155.4,MSDRG Base Rate
Other Multiple Significant Trauma Without Cc/Mcc,965,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,13905.61,,,,,,,fee schedule,7040.99,21155.4,MSDRG Base Rate
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,48796.16,,,,,,,fee schedule,48352.96,146613.3,
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,48796.16,,,,,,,fee schedule,48352.96,146613.3,
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,65325.51,,,,,,,fee schedule,48352.96,146613.3,
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,62214.78,,,,,,,fee schedule,48352.96,146613.3,
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,108967.12,,,,,,,fee schedule,48352.96,146613.3,
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,84677.02,,,,,,,fee schedule,48352.96,146613.3,
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,146613.3,,,,,,,fee schedule,48352.96,146613.3,
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,100788.67,,,,,,,fee schedule,48352.96,146613.3,
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,91279.17,,,,,,,fee schedule,48352.96,146613.3,
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,74761.4,,,,,,,fee schedule,48352.96,146613.3,
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,48817.89,,,,,,,fee schedule,48352.96,146613.3,MSDRG Base Rate
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,48352.96,,,,,,,fee schedule,48352.96,146613.3,MSDRG Base Rate
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,48352.96,,,,,,,fee schedule,48352.96,146613.3,MSDRG Base Rate
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,48817.89,,,,,,,fee schedule,48352.96,146613.3,MSDRG Base Rate
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,48352.96,,,,,,,fee schedule,48352.96,146613.3,MSDRG Base Rate
Hiv With Extensive O.R. Procedures With Mcc,969,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,81363.15,,,,,,,fee schedule,48352.96,146613.3,MSDRG Base Rate
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,20472.49,,,,,,,fee schedule,20472.49,61511.79,
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,20472.49,,,,,,,fee schedule,20472.49,61511.79,
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,27407.4,,,,,,,fee schedule,20472.49,61511.79,
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,26102.29,,,,,,,fee schedule,20472.49,61511.79,
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,45717.29,,,,,,,fee schedule,20472.49,61511.79,
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,35526.35,,,,,,,fee schedule,20472.49,61511.79,
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,61511.79,,,,,,,fee schedule,20472.49,61511.79,
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,42286.01,,,,,,,fee schedule,20472.49,61511.79,
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,38296.29,,,,,,,fee schedule,20472.49,61511.79,
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,31366.24,,,,,,,fee schedule,20472.49,61511.79,
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,21600.24,,,,,,,fee schedule,20472.49,61511.79,MSDRG Base Rate
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,21394.53,,,,,,,fee schedule,20472.49,61511.79,MSDRG Base Rate
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,21394.53,,,,,,,fee schedule,20472.49,61511.79,MSDRG Base Rate
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,21600.24,,,,,,,fee schedule,20472.49,61511.79,MSDRG Base Rate
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,21394.53,,,,,,,fee schedule,20472.49,61511.79,MSDRG Base Rate
Hiv With Extensive O.R. Procedures Without Mcc,970,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,36000.4,,,,,,,fee schedule,20472.49,61511.79,MSDRG Base Rate
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,23040.42,,,,,,,fee schedule,23040.42,69227.42,
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,23040.42,,,,,,,fee schedule,23040.42,69227.42,
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,30845.2,,,,,,,fee schedule,23040.42,69227.42,
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,29376.39,,,,,,,fee schedule,23040.42,69227.42,
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,51451.77,,,,,,,fee schedule,23040.42,69227.42,
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,39982.54,,,,,,,fee schedule,23040.42,69227.42,
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,69227.42,,,,,,,fee schedule,23040.42,69227.42,
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,47590.09,,,,,,,fee schedule,23040.42,69227.42,
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,43099.92,,,,,,,fee schedule,23040.42,69227.42,
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,35300.61,,,,,,,fee schedule,23040.42,69227.42,
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],46482.42,44587.45,81261.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],24492.14,24492.14,24492.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,23542.41,,,,,,,fee schedule,23040.42,69227.42,MSDRG Base Rate
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,23318.19,,,,,,,fee schedule,23040.42,69227.42,MSDRG Base Rate
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,23318.19,,,,,,,fee schedule,23040.42,69227.42,MSDRG Base Rate
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,23542.41,,,,,,,fee schedule,23040.42,69227.42,MSDRG Base Rate
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,23318.19,,,,,,,fee schedule,23040.42,69227.42,MSDRG Base Rate
Hiv With Major Related Condition With Mcc,974,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,39237.34,,,,,,,fee schedule,23040.42,69227.42,MSDRG Base Rate
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,10966.96,,,,,,,fee schedule,10966.96,32951.42,
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,10966.96,,,,,,,fee schedule,10966.96,32951.42,
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14681.94,,,,,,,fee schedule,10966.96,32951.42,
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,13982.81,,,,,,,fee schedule,10966.96,32951.42,
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,24490.42,,,,,,,fee schedule,10966.96,32951.42,
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,19031.21,,,,,,,fee schedule,10966.96,32951.42,
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,32951.42,,,,,,,fee schedule,10966.96,32951.42,
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,22652.31,,,,,,,fee schedule,10966.96,32951.42,
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,20515.04,,,,,,,fee schedule,10966.96,32951.42,
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,16802.67,,,,,,,fee schedule,10966.96,32951.42,
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],10767.62,10767.62,10767.62,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],9261.6,9261.6,9261.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11112.86,,,,,,,fee schedule,10966.96,32951.42,MSDRG Base Rate
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,11007.03,,,,,,,fee schedule,10966.96,32951.42,MSDRG Base Rate
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,11007.03,,,,,,,fee schedule,10966.96,32951.42,MSDRG Base Rate
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,11112.86,,,,,,,fee schedule,10966.96,32951.42,MSDRG Base Rate
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,11007.03,,,,,,,fee schedule,10966.96,32951.42,MSDRG Base Rate
Hiv With Major Related Condition With Cc,975,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18521.44,,,,,,,fee schedule,10966.96,32951.42,MSDRG Base Rate
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,7738.53,,,,,,,fee schedule,7738.53,23251.23,
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,7738.53,,,,,,,fee schedule,7738.53,23251.23,
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,10359.9,,,,,,,fee schedule,7738.53,23251.23,
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,9866.57,,,,,,,fee schedule,7738.53,23251.23,
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,17280.97,,,,,,,fee schedule,7738.53,23251.23,
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,13428.83,,,,,,,fee schedule,7738.53,23251.23,
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,23251.23,,,,,,,fee schedule,7738.53,23251.23,
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,15983.96,,,,,,,fee schedule,7738.53,23251.23,
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,14475.86,,,,,,,fee schedule,7738.53,23251.23,
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,11856.32,,,,,,,fee schedule,7738.53,23251.23,
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,8048.05,,,,,,,fee schedule,7738.53,23251.23,MSDRG Base Rate
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,7971.4,,,,,,,fee schedule,7738.53,23251.23,MSDRG Base Rate
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,7971.4,,,,,,,fee schedule,7738.53,23251.23,MSDRG Base Rate
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,8048.05,,,,,,,fee schedule,7738.53,23251.23,MSDRG Base Rate
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,7971.4,,,,,,,fee schedule,7738.53,23251.23,MSDRG Base Rate
Hiv With Major Related Condition Without Cc/Mcc,976,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,13413.42,,,,,,,fee schedule,7738.53,23251.23,MSDRG Base Rate
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,11125.15,,,,,,,fee schedule,11027.91,33426.69,
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,11125.15,,,,,,,fee schedule,11027.91,33426.69,
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,14893.71,,,,,,,fee schedule,11027.91,33426.69,
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,14184.49,,,,,,,fee schedule,11027.91,33426.69,
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,24843.66,,,,,,,fee schedule,11027.91,33426.69,
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,19305.7,,,,,,,fee schedule,11027.91,33426.69,
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,33426.69,,,,,,,fee schedule,11027.91,33426.69,
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,22979.03,,,,,,,fee schedule,11027.91,33426.69,
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,20810.94,,,,,,,fee schedule,11027.91,33426.69,
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,17045.02,,,,,,,fee schedule,11027.91,33426.69,
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],67930.83,67930.83,67930.83,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",6411.51,6411.51,6411.51,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,11133.95,,,,,,,fee schedule,11027.91,33426.69,MSDRG Base Rate
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,11027.91,,,,,,,fee schedule,11027.91,33426.69,MSDRG Base Rate
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,11027.91,,,,,,,fee schedule,11027.91,33426.69,MSDRG Base Rate
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,11133.95,,,,,,,fee schedule,11027.91,33426.69,MSDRG Base Rate
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,11027.91,,,,,,,fee schedule,11027.91,33426.69,MSDRG Base Rate
Hiv With Or Without Other Related Condition,977,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,18556.58,,,,,,,fee schedule,11027.91,33426.69,MSDRG Base Rate
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,36684.89,,,,,,,fee schedule,36684.89,110223.69,
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,36684.89,,,,,,,fee schedule,36684.89,110223.69,
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,49111.63,,,,,,,fee schedule,36684.89,110223.69,
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,46772.99,,,,,,,fee schedule,36684.89,110223.69,
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,81921.34,,,,,,,fee schedule,36684.89,110223.69,
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,63660.08,,,,,,,fee schedule,36684.89,110223.69,
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,110223.69,,,,,,,fee schedule,36684.89,110223.69,
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,75772.8,,,,,,,fee schedule,36684.89,110223.69,
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,68623.57,,,,,,,fee schedule,36684.89,110223.69,
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,56205.52,,,,,,,fee schedule,36684.89,110223.69,
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],34695.55,34695.55,34695.55,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],73235.03,73235.03,107500.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],35098.71,34603.3,36783.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],74374.27,74374.27,74374.27,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],35250.45,35250.45,35250.45,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",99977.74,99977.74,99977.74,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",21580.64,21580.64,21580.64,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],36311.21,36311.21,36311.21,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],34982.44,34364.81,35992.52,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],81914.45,81414.45,89535.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],32763.43,18058.31,35221.27,12,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",115430.5,115430.5,115430.5,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],113161.14,113161.14,113161.14,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,37650.05,,,,,,,fee schedule,36684.89,110223.69,MSDRG Base Rate
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,37291.48,,,,,,,fee schedule,36684.89,110223.69,MSDRG Base Rate
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,37291.48,,,,,,,fee schedule,36684.89,110223.69,MSDRG Base Rate
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,37650.05,,,,,,,fee schedule,36684.89,110223.69,MSDRG Base Rate
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,37291.48,,,,,,,fee schedule,36684.89,110223.69,MSDRG Base Rate
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,981,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,62750.08,,,,,,,fee schedule,36684.89,110223.69,MSDRG Base Rate
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,18892.99,,,,,,,fee schedule,18892.99,56766.02,
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,18892.99,,,,,,,fee schedule,18892.99,56766.02,
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,25292.86,,,,,,,fee schedule,18892.99,56766.02,
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,24088.44,,,,,,,fee schedule,18892.99,56766.02,
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,42190.1,,,,,,,fee schedule,18892.99,56766.02,
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,32785.42,,,,,,,fee schedule,18892.99,56766.02,
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,56766.02,,,,,,,fee schedule,18892.99,56766.02,
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,39023.56,,,,,,,fee schedule,18892.99,56766.02,
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,35341.65,,,,,,,fee schedule,18892.99,56766.02,
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,28946.26,,,,,,,fee schedule,18892.99,56766.02,
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],2140.6,2140.6,2140.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],16220.35,16220.35,16220.35,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],19040.26,19040.26,19040.26,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],24086.47,24086.47,24086.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],18331.2,18110.58,18825.47,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],27943.9,27943.9,27943.9,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],95006.8,95006.8,95006.8,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],18453.59,17328.59,18497.09,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",11094.71,11094.71,11094.71,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,20202.6,,,,,,,fee schedule,18892.99,56766.02,MSDRG Base Rate
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,20010.19,,,,,,,fee schedule,18892.99,56766.02,MSDRG Base Rate
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,20010.19,,,,,,,fee schedule,18892.99,56766.02,MSDRG Base Rate
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,20202.6,,,,,,,fee schedule,18892.99,56766.02,MSDRG Base Rate
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,20010.19,,,,,,,fee schedule,18892.99,56766.02,MSDRG Base Rate
Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,982,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,33671,,,,,,,fee schedule,18892.99,56766.02,MSDRG Base Rate
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,12871.31,,,,,,,fee schedule,12871.31,38673.23,
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,12871.31,,,,,,,fee schedule,12871.31,38673.23,
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17231.37,,,,,,,fee schedule,12871.31,38673.23,
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16410.83,,,,,,,fee schedule,12871.31,38673.23,
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,28743.03,,,,,,,fee schedule,12871.31,38673.23,
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,22335.86,,,,,,,fee schedule,12871.31,38673.23,
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,38673.23,,,,,,,fee schedule,12871.31,38673.23,
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,26585.74,,,,,,,fee schedule,12871.31,38673.23,
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,24077.36,,,,,,,fee schedule,12871.31,38673.23,
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,19720.34,,,,,,,fee schedule,12871.31,38673.23,
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],32859.3,32859.3,32859.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],12550.77,12550.77,12550.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],28369.75,28369.75,28369.75,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],12094.46,12094.46,12777.85,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,14386.26,,,,,,,fee schedule,12871.31,38673.23,MSDRG Base Rate
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,14249.25,,,,,,,fee schedule,12871.31,38673.23,MSDRG Base Rate
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,14249.25,,,,,,,fee schedule,12871.31,38673.23,MSDRG Base Rate
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,14386.26,,,,,,,fee schedule,12871.31,38673.23,MSDRG Base Rate
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,14249.25,,,,,,,fee schedule,12871.31,38673.23,MSDRG Base Rate
Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,983,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23977.1,,,,,,,fee schedule,12871.31,38673.23,MSDRG Base Rate
Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc,984,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc,984,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc,984,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc,984,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc,984,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc,984,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc,984,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc,984,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc,984,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc,984,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc,984,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc,984,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc,984,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc,984,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc,984,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc,984,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc,984,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc,984,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc,985,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc,985,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc,985,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc,985,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc,985,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc,985,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc,985,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc,985,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc,985,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc,985,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc,985,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc,985,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc,985,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc,985,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc,985,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc,985,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc,985,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc,985,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc,986,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc,986,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc,986,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc,986,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc,986,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc,986,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc,986,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc,986,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc,986,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc,986,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc,986,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc,986,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc,986,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc,986,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc,986,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc,986,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc,986,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc,986,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,27029.67,,,,,,,fee schedule,27029.67,81213.55,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,27029.67,,,,,,,fee schedule,27029.67,81213.55,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,36185.78,,,,,,,fee schedule,27029.67,81213.55,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,34462.65,,,,,,,fee schedule,27029.67,81213.55,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,60360.19,,,,,,,fee schedule,27029.67,81213.55,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,46905.17,,,,,,,fee schedule,27029.67,81213.55,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,81213.55,,,,,,,fee schedule,27029.67,81213.55,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,55829.9,,,,,,,fee schedule,27029.67,81213.55,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,50562.3,,,,,,,fee schedule,27029.67,81213.55,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,41412.61,,,,,,,fee schedule,27029.67,81213.55,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],26333.3,26333.3,26333.3,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],25091.59,25091.59,25091.59,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],53699.49,53699.49,53699.49,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],26572.81,26572.81,26572.81,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",13474.66,13474.66,14996.91,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],24885.36,24885.36,24885.36,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],55745.6,55745.6,55745.6,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],26097.95,20981.5,26127.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],58216.54,58216.54,58216.54,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,27779.85,,,,,,,fee schedule,27029.67,81213.55,MSDRG Base Rate
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,27515.28,,,,,,,fee schedule,27029.67,81213.55,MSDRG Base Rate
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,27515.28,,,,,,,fee schedule,27029.67,81213.55,MSDRG Base Rate
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,27779.85,,,,,,,fee schedule,27029.67,81213.55,MSDRG Base Rate
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,27515.28,,,,,,,fee schedule,27029.67,81213.55,MSDRG Base Rate
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc,987,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,46299.75,,,,,,,fee schedule,27029.67,81213.55,MSDRG Base Rate
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,13240.91,,,,,,,fee schedule,13240.91,39783.74,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,13240.91,,,,,,,fee schedule,13240.91,39783.74,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,17726.18,,,,,,,fee schedule,13240.91,39783.74,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,16882.08,,,,,,,fee schedule,13240.91,39783.74,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,29568.4,,,,,,,fee schedule,13240.91,39783.74,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,22977.24,,,,,,,fee schedule,13240.91,39783.74,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,39783.74,,,,,,,fee schedule,13240.91,39783.74,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,27349.16,,,,,,,fee schedule,13240.91,39783.74,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,24768.74,,,,,,,fee schedule,13240.91,39783.74,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,20286.62,,,,,,,fee schedule,13240.91,39783.74,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],21356.57,21356.57,21356.57,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],13625.73,13625.73,13625.73,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],16882.08,16882.08,16882.08,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",6714.66,6714.66,6714.66,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],12641.12,12641.12,12641.12,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],15301.57,15301.57,18201.63,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],11784.75,11784.75,13137.77,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,13836.27,,,,,,,fee schedule,13240.91,39783.74,MSDRG Base Rate
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,13704.5,,,,,,,fee schedule,13240.91,39783.74,MSDRG Base Rate
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,13704.5,,,,,,,fee schedule,13240.91,39783.74,MSDRG Base Rate
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,13836.27,,,,,,,fee schedule,13240.91,39783.74,MSDRG Base Rate
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,13704.5,,,,,,,fee schedule,13240.91,39783.74,MSDRG Base Rate
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc,988,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,23060.45,,,,,,,fee schedule,13240.91,39783.74,MSDRG Base Rate
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,8915.24,,,,,,,fee schedule,8915.24,26786.79,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,8915.24,,,,,,,fee schedule,8915.24,26786.79,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,11935.21,,,,,,,fee schedule,8915.24,26786.79,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,11366.87,,,,,,,fee schedule,8915.24,26786.79,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,19908.7,,,,,,,fee schedule,8915.24,26786.79,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,15470.81,,,,,,,fee schedule,8915.24,26786.79,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,26786.79,,,,,,,fee schedule,8915.24,26786.79,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,18414.46,,,,,,,fee schedule,8915.24,26786.79,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,16677.04,,,,,,,fee schedule,8915.24,26786.79,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,13659.19,,,,,,,fee schedule,8915.24,26786.79,
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",4180.03,4180.03,4180.03,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],5590.25,5590.25,5590.25,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],20663.42,20663.42,20663.42,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],20634.87,20634.87,20634.87,1 through 10,other,,,"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,10364.43,,,,,,,fee schedule,8915.24,26786.79,MSDRG Base Rate
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,10265.73,,,,,,,fee schedule,8915.24,26786.79,MSDRG Base Rate
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,,,facility,inpatient,,,,,,Care Improvement Plus,Medicare Managed Care Plan,10265.73,,,,,,,fee schedule,8915.24,26786.79,MSDRG Base Rate
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,10364.43,,,,,,,fee schedule,8915.24,26786.79,MSDRG Base Rate
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,10265.73,,,,,,,fee schedule,8915.24,26786.79,MSDRG Base Rate
Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc,989,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,17274.06,,,,,,,fee schedule,8915.24,26786.79,MSDRG Base Rate
Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Principal Diagnosis Invalid As Discharge Diagnosis,998,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ungroupable,999,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ungroupable,999,MS-DRG,,,,,,,facility,inpatient,,,,,,Aetna,All Commercial Plans,,,[Stop Loss: Total Charges > BasePayment * 2.95 | Excess % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1326.88],,,,0,other,,,No services performed during 15-month lookback period.
Ungroupable,999,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,All Commercial Plans,,,[Stop Loss: Total Charges > 95524 | Total % of Charge: 79] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 1558] [Psych-Per Diem: 1558] [Kidney Transplant (%BC): 75],,,,0,other,,,No services performed during 15-month lookback period.
Ungroupable,999,MS-DRG,,,,,,,facility,inpatient,,,,,,Bcbs,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ungroupable,999,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,Healthspring Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ungroupable,999,MS-DRG,,,,,,,facility,inpatient,,,,,,Cigna,All Commercial Plans,,,[Stop Loss: Total Charges > 100000 | Total % of Charge: 71] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Rehab-Per Diem: 1500],,,,0,other,,,No services performed during 15-month lookback period.
Ungroupable,999,MS-DRG,,,,,,,facility,inpatient,,,,,,Molina Healthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Ungroupable,999,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Centennial Care Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Ungroupable,999,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Select/Select Silver Other Commercial Plan,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 16960.74],,,,0,other,,,No services performed during 15-month lookback period.
Ungroupable,999,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Engage Other Commercial Plan,,,[Stop Loss: Total Charges > 89130.13 | Total % of Charge: 63] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 19462.45],,,,0,other,,,No services performed during 15-month lookback period.
Ungroupable,999,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care - Hmo,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ungroupable,999,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,Medicare Managed Care Plan,,,[MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ungroupable,999,MS-DRG,,,,,,,facility,inpatient,,,,,,Presbyterian Health Plan,All Commercial Plans,,,[Stop Loss: Total Charges > 91804.04 | Total % of Charge: 70] [MSDRG Base Rate: FEE SCHEDULE] [Psych-Per Diem: 1163.48] [Bariatric Surgery-Case Rate: 22273.68],,,,0,other,,,No services performed during 15-month lookback period.
Ungroupable,999,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,All Commercial Plans,,,[Stop Loss: Total Charges > 133900 | Total % of Charge: 60] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11026 Days: 4 Additional Days: 1695] [Normal vag. Del. 2 day stay-Case Rate: 6875 Days: 2 Additional Days: 1695] [Nursery  Level 1- Boarder-Per Diem: 1209] [Nursery  Level 2-Per Diem: 3662] [Nursery  Level 3-Per Diem: 5452] [Nursery  Level 4-NICU-Per Diem: 5452] [Alcohol/ Chemical Dependency-Per Diem: 874] [Psych-Per Diem: 874] [Rehab-Per Diem: 1585] [SNF-Per Diem: 1007],,,,0,other,,,No services performed during 15-month lookback period.
Ungroupable,999,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ungroupable,999,MS-DRG,,,,,,,facility,inpatient,,,,,,Unitedhealthcare,Medicaid Managed Care Plan,,,"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://nmmedicaid.portal.conduent.com/static/ProviderInformation.htm]",,,,0,other,,,No services performed during 15-month lookback period.
Ungroupable,999,MS-DRG,,,,,,,facility,inpatient,,,,,,Wellpoint,Formerly Amerigroup Medicare Managed Care Plan,,,[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.
Ungroupable,999,MS-DRG,,,,,,,facility,inpatient,,,,,,Zelis,All Commercial Plans,,,[Stop Loss: Total Charges > 50000 | Total % of Charge: 80] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE],,,,0,other,,,No services performed during 15-month lookback period.